Az Essential RX List

Arizona
Essential Rx Drug List

The Essential Rx Drug List includes a list of drugs covered by Health Net. This drug list is for Arizona. The
drug list is updated often and may change. To get the most up-to-date information, you may view the latest
drug list on our website at www.healthnet.com/azdruglistpdf or call us at the toll-free telephone number on
your Health Net ID card.
Welcome to Health Net
What is the Essential Rx Drug List?
The Essential Rx Drug List or formulary is a list of covered drugs used to treat common diseases or health
problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide
which drugs should be included. The committee reviews new drugs and new information about existing
drugs and chooses drugs based on:
 Safety;
 Effectiveness;
 Side effects; and
 Value (If two drugs are equally effective, the less costly drug will be preferred)
How much will I pay for my drugs?

To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier
column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not
know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan
documents.
Abbreviation Description
1 Generic drugs
2 Preferred brand drugs
3 Non-preferred brand drugs, covered drugs not on the
drug list and covered brand drugs that are approved
for medical necessity by Health Net.
GP Brand drugs with an available generic version. You
may be responsible for your copayment plus the
difference in cost between the brand and generic
drugs if you or your doctor requests the brand drug.
Prior Authorization may be required for some drugs.
AC Oral or patient-administered cancer treatment drugs.
PV Preventive benefit drugs. These drugs must be
covered at no cost to members under the Affordable
Care Act. A deductible does not apply. To get a
brand drug that has a generic available, you pay the
difference in cost between the brand and generic
drugs.
SP Specialty drugs and covered injectable drugs. You
may be required to obtain some drugs from a
Specialty Pharmacy. Prior authorization may be
required.
How do I use the drug list?

Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list.
Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page
number where you can find your drug.
What if my drug is not on the drug list?

ii
If your drug is not on the drug list, call us at the telephone number on your Health Net ID card and ask if
your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is
covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask us to make
an exception.
What are generic drugs?

A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic
drugs are safe and effective, and generally cost less.
Generic drugs are available on the drug list at Tier 1. If you request a brand name drug that has an available
generic version, you may pay a higher cost share.
Are there any limits on my drug coverage?

Some drugs have limits on coverage. The table below provides a description of abbreviations that may
appear in the Limits column on the drug list:
Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does
not fall within manufacturer, FDA, or clinical recommendations.
PA Prior Authorization These drugs require prior authorization for coverage,
effectiveness, or safety reasons. This means that your doctor
must request approval from Health Net before the drug will be
covered.
QL Quantity Limit These drugs have a limit on the amount that will be covered.
Your doctor must request approval for a higher quantity of the
drug from Health Net.
RX/OTC Prescription & Certain drugs are available both in a prescription form and in an
Over-the-Counter OTC form. Only prescription drugs are covered by your plan
(OTC) with the exception of some insulins, insulin supplies and some
covered preventive drugs.
ST Step Therapy You must first try another specific drug(s) before these drugs will
be covered.
How can I get an exception to the rules for drug coverage?

Your doctor can ask for an exception to our rules for drug coverage.
 Your doctor can ask us to cover your drug even if it is not on the drug list. If we approve an exception
request for a drug not on the drug list, the non-preferred brand tier (Tier 3) or Specialty
copayment/coinsurance will apply.
 Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a
quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To request an exception, your doctor can fax a prior authorization form along with a written statement
supporting the request to us at 1-800-977-4170.
Can I go to any pharmacy?

iii
To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract
with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a
pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your
Health Net ID card.
If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill
Health Net online so you may have to pay the full cost of your drug. Unless it is an emergency, your out-of-
network prescription drug may not be covered.
Some injectable and high cost drugs may be considered “specialty drugs”. Unless otherwise noted, these
drugs must be obtained from one of Health Net’s Specialty Pharmacies.
Can I use a mail order pharmacy?

You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs.
Maintenance drugs are those that you take daily and are needed for a long term condition. To use the mail
order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug.
Mail order forms are available on our website at www.healthnet.com or you may call us at the telephone
number on your Health Net ID card to request a form.
How can I save money on my prescription drugs?

You can save time and money with these simple steps:
 Ask your doctor about generic drugs that may work for you.
 Fill prescriptions at Health Net participating pharmacies.
 Be sure your doctor prescribes drugs on the drug list
iv
Health Net of Arizona, Inc. and Health Net Life Insurance Company (“Health Net”) complies
with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. Health Net does not exclude people or treat them
differently because of race, color, national origin, age, disability, or sex.
Health Net:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters and written information in other formats (large print,
accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as
qualified interpreters and information written in other languages.
If you need these services, contact Health Net's Customer Contact Center at 1-888-926-5057
(TTY: 711).
If you believe that Health Net has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by
calling the number above and telling them you need help filing a grievance; Health Net's
Customer Contact Center is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.
Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH
Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent
to you in your language. For help, call us at the number listed on your ID card. Individual & Family Plan
members please call 1-888-926-5057 (TTY: 711); Small Business members please call
1-888-926-5122 (TTY: 711). Employer group members please call 1-800-289-2818 (TTY: 711).
Arabic
‫ اتصل بنا على‬،‫ للحصول على المساعدة‬.‫ ويمكنك الحصول على وثائق مقروءة لك‬.‫ يمكنك الحصول على مترجم فوري‬.‫خدمات اللغة مجانية‬
‫)؛ ويرجى‬TTY: 711) 1-888-926-5057 ‫ يرجى من أعضاء خطة األفراد والعائلة االتصال على الرقم‬.‫الرقم الموجود على بطاقة الهوية‬
‫ يرجى من أعضاء مجموعة أصحاب العمل االتصال‬.)TTY: 711) 1-888-926-5122 ‫من أعضاء األعمال الصغيرة االتصال على الرقم‬
.)TTY: 711) 1-800-289-2818 ‫على الرقم‬
Chinese
免費語言服務。您可使用口譯員。您可請人將文件內容唸給您聽。如需協助，請致電您會員卡上所列
的電話號碼與我們聯絡。個人與家庭計畫的會員請致電 1-888-926-5057 (TTY: 711) 小型企業的會員請致
電 1-888-926-5122 (TTY: 711) 。雇主團體的會員請致電 1-800-289-2818 (TTY: 711) 。
French
Aucun service linguistique avec coût. Vous pouvez obtenir un interprète. Les documents peuvent être lus
pour vous. Pour obtenir de l’aide, appelez-nous au numéro figurant sur votre carte d’identité. Membres des
programmes pour particuliers et familles, veuillez composer le 1-888-926-5057 (TTY: 711). Membres des
programmes pour petites entreprises, veuillez composer le 1-888-926-5122 (TTY: 711). Membres du groupe
d’employeurs, veuillez composer le 1-800-289-2818 (TTY: 711).
German
Kostenloser Sprachendienst. Dolmetscher sind verfügbar. Dokumente können Ihnen vorgelesen werden.
Wenn Sie Hilfe benötigen, rufen Sie uns unter der Nummer auf Ihrer ID-Karte an. Mitglieder von Einzel-
und Familienpolicen rufen bitte unter 1-888-926-5057 (TTY: 711) an; Kleinunternehmen-Mitglieder
rufen bitte unter 1-888-926-5122 (TTY: 711) an. Arbeitgeber-Gruppenmitglieder rufen bitte unter
1-800-289-2818 (TTY: 711) an.
Japanese
無料の言語サービス。通訳をご利用いただけます。文書をお読みします。援助が必要な場合は、
IDカードに記載されている番号までお電話ください。個人および家族向けプランのメンバーの方は
1-888-926-5057 (TTY: 711) まで、小規模企業メンバーの方は1-888-926-5122 (TTY: 711)までお電
話ください。雇用主を通じた団体保険のメンバーの方は、1-800-289-2818 (TTY: 711) までお電話
ください。
Korean
무료 언어 서비스. 통역 서비스를 받을 수 있습니다. 문서 낭독 서비스를 받으실 수 있습니다.
도움을 원하시면, 보험 ID에 수록된 번호로 전화해 주십시오. 개인 및 가족 계획가입자분은
1-888-926-5057 (TTY: 711)번으로 전화해 주시고, 소기업가입자분은 1-888-926-5122 (TTY: 711)번으로
전화해 주십시오. 고용주 그룹 가입자분은 1-800-289-2818 (TTY: 711)번으로 전화해 주십시오.
Navajo
Saad Bee !k1 E’eyeed T’11 J77k’e. Ata’ halne’7g77 h0l=. T’11 h0 hazaad k’ehj7 naaltsoos hach’8’
w0ltah d00 [a’ da hach’8’ 4l’88h.Sh7k1 a’doowo[ n7n7zingo naaltsoos bee n47ho’d0lzin7g77 bik1a’gi b44sh
bee hane’7 bik11’ 1aj8’ hod77lnih. T’11 h0 d00 ha’1[ch7n7 bi[ hak’4’4sti’7g77 koj8’ hojilnih
1-888-926-5057 (TTY: 711); Small business dei[n7n7j7 atah n7l98go 47 koj8’ h0lne’
1-888-926-5122 (TTY: 711). Employer group-j7 atah n7l98go 47 koj8’ hod77lnih 1-800-289-2818 (TTY: 711).
Persian (Farsi)
‫ اعضای برنامه انفرادی و خانواده لطفا ً با شماره‬.‫ با ما به شماره ای که در کارت شناسايی شما قيد شده تماس بگيريد‬،‫کسب اطالعات‬
‫) تماس بگيريد؛ اعضای واحد بازرگانی کوچک با شماره‬TTY: 711) 1-888-926-5057
‫) تماس‬TTY: 711) 1-800-289-2818 ‫ اعضای گروه کارفرما لطفا ً با شماره‬.‫) تماس بگيريد‬TTY: 711) 1-888-926-5122
.‫بگيريد‬
Russian
Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут
прочитать документы. За помощью обращайтесь к нам по телефону, приведенному на вашей
идентификационной карточке участника плана. Участники планов для семей и частных лиц: звоните по
телефону 1-888-926-5057 (TTY: 711). Участники планов для малых предприятий: звоните по телефону
1-888-926-5122 (TTY: 711). Участники групповых планов, предоставляемых работодателем: звоните по
телефону 1-800-289-2818 (TTY: 711).
Serbo-Croatian
Besplatne jezičke usluge. Možemo vam obezbediti tumača. Možemo vam pročitati vaše dokumente. Ukoliko
vam je potrebna pomoć, nazovite broj napisan na vašoj zdravstvenoj kartici. Molimo članove individualnog i
porodičnog plana da nazovu 1-888-926-5057 (TTY: 711); molimo članove malog preduzeća da nazovu
1-888-926-5122 (TTY: 711). Molimo članove grupe osigurane preko poslodavca da nazovu
1-800-289-2818 (TTY: 711).
Spanish
Servicios de idiomas sin costo. Puede solicitar un intérprete. Puede obtener el servicio de lectura de
documentos. Para obtener ayuda, llámenos al número que aparece en su tarjeta de identificación. Los afiliados
de planes individuales y familiares deben llamar al 1-888-926-5057 (TTY: 711); los afiliados de pequeñas
empresas deben llamar al 1-888-926-5122 (TTY: 711). Los afiliados del grupo del empleador deben llamar al
1-800-289-2818 (TTY: 711).
Syriac (Assyrian)
ܵ ‫ ܵܩܐ ܲܗ ܲܝ‬.‫ܕܛܠܒܬ ܕܐܫ ܵܛܪܐ ܵܦܝܫܝ ܩܪܝܐ ܵܩܬܘܟ‬ ܵ ‫ ܵܡܬܨܬ‬.‫ܕܗܘܐܠܘܟ ܲܚ ݇ܕ ܲܬܪܓ ܵܡ ܵܢܐ‬ ܵ ܵ ܵ ‫(ܕܠ ܦܘ‬ ܵ ܲ ܲ ܵܵ ܲ
،‫ܪܬܐ‬ � � ̣ � ܹ ܸ � ܹ ܸ ܸ ܸ ̰ܸ � � ̣ � ܹ ‫ܨܬ‬ ܸ ‫ ܵܡ‬.)‫ܪܥܢܐ‬ � ‫ܓܢ‬
� ‫ܸܚܠ �ܡܹܬܐ ܸܠܫܢܹܝܐ �ܡ‬
ܵ ܲ ܲ ܵ ܵ ܵ ܵ ܲ ܵ ܲ ܲ ܲ ܵ ܲ ܵ ܵ ܲ ܲ
‫ܪܝܡ �ܘܢ �ܥܠ ܸܡܢ ܵܝܢܐ‬
� ‫ܘܟܘܢ ܩ‬ ̣ ‫ܐܢ ܒܣܡܐ ܠ‬ ܸ ‫ܬܘܬܐ‬ � ‫ �ܦܪܨܘܹܦܐ ܲ �ܝܢ �ܗܕܹܡܐ‬.‫ܟ‬
� ‫ܕܒܝ‬ ̣ ‫ܬܘ‬ �ܵ ‫ܩ �ܪܝ �ܠܢ �ܥܠ ܸܡܢ ܵܝܢܐ ܪܫ�ܝܡܐ �ܥܠ ܸܦܬܩܐ‬
� ‫ܕܗܝܝ�ܘ‬
ܲ ܵ ܵ ܵ ܵ ܲ ܵ ܲ ܵܵ
.)TTY: 711( 1-888-926-5122 ‫ܪܝܡ �ܘܢ �ܥܠ‬ ܲ � ‫ܘܟܘܢ ܩ‬ ̣ ‫ܐܢ ܒܣܡܐ ܠ‬ ܸ ‫ܪܘܬܐ ܙܥܘܪܬܐ‬
ܵ
� ‫ܕܬܓ‬ � ‫); ܵܡܪܘ ܹܬܐ‬TTY: 711( 1-888-926-5057
.)TTY: 711( 1-800-289-2818 ‫ܪܝܡ �ܘܢ ܲ�ܥܠ ܸܡܢ ܵܝ ܵܢܐ‬ ܲ ‫ܕܦ ܵܠܚܐ ܐܢ ܵܒܣ ܵܡܐ ܵܠ‬ ܲ ܵ ܲ ‫ܲܗ ܵܕܡܐ‬
� ‫ܘܟܘܢ ܩ‬̣ ܸ ܹ � ‫ܕܡܦܸܠ ܵܚܹܢܐ‬ � ܲ ‫ܕܕܣܬܐ‬ � ܹ �
Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga
dokumento na babasahin sa inyo. Para sa tulong, tawagan kami sa nakalistang numero sa inyong ID card.
Para sa mga miyembro ng Plano para sa Indibiduwal at Pamilya mangyaring tawagan ang
1-888-926-5057 (TTY: 711); Para sa mga miyembro na Maliit na Negosyo, mangyaring tawagan ang
1-888-926-5122 (TTY: 711). Para sa mga miyembro ng grupo ng empleyado, mangyaring tawagan ang
1-800-289-2818 (TTY: 711).
Thai
ไม่มคี า่ บริการด้านภาษา คุณสามารถใช้ลา่ มได้ คุณสามารถให้อา่ นเอกสารให้ฟงั ได้ ส�าหรับความช่วยเหลือ โทรหาเราตาม
หมายเลขท่ใี ห้ไว้บนบัตรประจ�าตัวของคุณ สมาชิกแผนบุคคลและครอบครัว กรุณาโทร 1-888-926-5057 (TTY: 711); สมาชิก
ธุรกิจขนาดเล็ก กรุณาโทร 1-888-926-5122 (TTY: 711) สมาชิกกลุม่ นายจ้าง กรุณาโทร 1-800-289-2818 (TTY: 711)
Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho
nghe tài liệu. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID của quý vị. Các thành
viên của Chương Trình Cá Nhân & Gia Đình vui lòng gọi số 1-888-926-5057 (TTY: 711); Các thành viên
thuộc Doanh Nghiệp Nhỏ vui lòng gọi số 1-888-926-5122 (TTY: 711). Các thành viên thuộc chương trình
theo nhóm của chủ sử dụng lao động vui lòng gọi số 1-800-289-2818 (TTY: 711).
Health Net of Arizona, Inc. underwrites benefits for HMO plans, and Health Net Life Insurance Company
underwrites benefits for PPO and indemnity plans and for life insurance coverage. Health Net of Arizona, Inc.
and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. All rights reserved.
AZ Commercial On and Off-Exchange Member Notice of Language Assistance
FLY007786EH00 (06/16)
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTI- methamphetamine hcl tabs 1 PA
OBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders PROCENTRA SOLN (Use
Dextroamphetamine GP
Amphetamines Sulfate)
ADDERALL TABS (Use QL(1 ea daily)
Amphetamine- GP VYVANSE CAPS 2
Dextroamphetamine) QL(1 ea daily)
ADDERALL XR CP24 (Use QL(1 ea daily) VYVANSE CHEW 2
Amphetamine- GP Analeptics
Dextroamphetamine)
PA caffeine citrate soln 1
ADZENYS XR-ODT TBED 3
amphetamine- QL(1 ea daily) Anorexiants Non-Amphetamine
dextroamphetamine cp24 ADIPEX-P CAPS (Use GP PA
5mg-5mg-5mg-5mg, Phentermine HCl)
2.5mg-2.5mg-2.5mg- ADIPEX-P TABS (Use
2.5mg, 7.5mg-7.5mg- GP PA
1 Phentermine HCl)
7.5mg-7.5mg, 1.25mg- phendimetrazine tartrate
1.25mg-1.25mg-1.25mg, 1 PA
3.75mg-3.75mg-3.75mg- tabs
3.75mg, 6.25mg-6.25mg- phentermine hcl caps 1 PA
6.25mg-6.25mg
amphetamine- phentermine hcl tabs 1 PA
dextroamphetamine tabs
5mg-5mg-5mg-5mg, QSYMIA CP24 3 PA
2.5mg-2.5mg-2.5mg-
2.5mg, 7.5mg-7.5mg- Anti-Obesity Agents
7.5mg-7.5mg, 1.25mg- PA
1.25mg-1.25mg-1.25mg, 1 BELVIQ TABS 3
3.75mg-3.75mg-3.75mg- PA
3.75mg, 1.875mg- BELVIQ XR TB24 3
1.875mg-1.875mg- PA
1.875mg, 3.125mg- CONTRAVE TB12 3
3.125mg-3.125mg- PA
3.125mg XENICAL CAPS 2
DESOXYN TABS (Use GP PA
Methamphetamine HCl) Attention-Deficit/Hyperactivity Disorder (ADHD)
DEXEDRINE CP24 (Use atomoxetine hcl caps 10 1 QL(2 ea daily)
Dextroamphetamine GP mg, 18 mg, 25 mg, 40 mg
Sulfate) atomoxetine hcl caps 60 1 QL(1 ea daily)
dextroamphetamine sulfate mg, 80 mg, 100 mg
1
cp24 clonidine hcl (adhd) tb12 1 QL(4 ea daily)
dextroamphetamine sulfate 1
soln guanfacine hcl (adhd) tb24 1 QL(1 ea daily)
dextroamphetamine sulfate INTUNIV TB24 (Use
tabs 1 GP QL(1 ea daily)
Guanfacine HCl (ADHD))
PA; QL(8 ml KAPVAY TB12 (Use
DYANAVEL XR SUER 3
daily) GP QL(4 ea daily)
Clonidine HCl (ADHD))
You can find information on what the symbols and abbreviations on this table mean by going to
page ii-iii.
AZ Essential Rx Drug List Updated: September 1, 2019
1
STRATTERA CAPS 10 QL(2 ea daily) methylphenidate hcl tb24
MG, 18 MG, 25 MG, 40 MG GP 18 mg, 27 mg, 36 mg, 54 1
(Use Atomoxetine HCl) mg
STRATTERA CAPS 60 QL(1 ea daily) methylphenidate hcl tbcr 10 1 QL(1 ea daily)
MG, 80 MG, 100 MG (Use GP mg
Atomoxetine HCl) methylphenidate hcl tbcr 18
Stimulants - Misc. mg, 20 mg, 27 mg, 36 mg, 1
PA 54 mg
armodafinil tabs 1 METHYLPHENIDATE QL(1 ea daily)
CONCERTA TBCR (Use HYDROCHLORIDE ER 3
GP (LA) CP24
Methylphenidate HCl)
QL(1 ea daily) ST; QL(1 ea
DAYTRANA PTCH 3 modafinil tabs 1
daily)
dexmethylphenidate hcl NUVIGIL TABS (Use GP PA
1 Armodafinil)
cp24 25 mg, 35 mg
dexmethylphenidate hcl QL(1 ea daily) PROVIGIL TABS (Use GP ST; QL(1 ea
cp24 5 mg, 10 mg, 15 mg, 1 Modafinil) daily)
20 mg, 30 mg, 40 mg
QUILLIVANT XR SUSR 3 PA; QL(12 ml
dexmethylphenidate hcl daily)
1
tabs 5 mg, 10 mg, 2.5 mg RITALIN LA CP24 (Use GP QL(1 ea daily)
FOCALIN TABS (Use Methylphenidate HCl)
GP
Dexmethylphenidate HCl) RITALIN TABS (Use GP
FOCALIN XR CP24 25 Methylphenidate HCl)
MG, 35 MG (Use GP
Dexmethylphenidate HCl) ALLERGENIC EXTRACTS/BIOLOGICALS MISC
FOCALIN XR CP24 5 MG, QL(1 ea daily) Allergenic Extracts
10 MG, 15 MG, 20 MG, 30 GP PA
MG, 40 MG (Use GRASTEK SUBL 3
Dexmethylphenidate HCl)
ORALAIR ADULT SAMPLE 3 PA
METHYLIN SOLN (Use GP KIT SUBL
Methylphenidate HCl)
ORALAIR ADULT 3 PA
methylphenidate hcl chew 1 STARTER PACK SUBL
5 mg, 10 mg, 2.5 mg
ORALAIR PA
methylphenidate hcl cp24 QL(1 ea daily) CHILDREN/ADOLESCENT 3
10 mg, 20 mg, 30 mg, 40 1 S SAMPLE KIT THPK
mg
ORALAIR PA
methylphenidate hcl cpcr CHILDREN/ADOLESCENT 3
10 mg, 40 mg, 50 mg, 60 1 S STARTER PACK SUBL
mg
ORALAIR SUBL 3 PA
methylphenidate hcl cpcr 1 QL(2 ea daily)
20 mg, 30 mg PA
RAGWITEK SUBL 3
methylphenidate hcl soln 5 1
mg/5ml, 10 mg/5ml Biologicals Misc
methylphenidate hcl tabs 5
mg, 10 mg, 20 mg 1 ADAGEN SOLN SP PA
page ii-iii.
2
AMINOGLYCOSIDES - Drugs to Treat Bacterial HUMIRA PEN-CD/UC/HS SP PA
Infections STARTER PNKT
Aminoglycosides HUMIRA PEN-PS/UV SP PA
STARTER PNKT
amikacin sulfate soln SP PA
HUMIRA PSKT SP PA
ARIKAYCE SUSP SP PA
SIMPONI SOAJ SP PA
BETHKIS NEBU SP
SIMPONI SOSY SP PA
gentamicin in saline soln SP PA Antirheumatic - Enzyme Inhibitors
gentamicin sulfate soln SP PA XELJANZ TABS SP PA
GENTAMICIN PA XELJANZ XR TB24 SP PA
SULFATE/0.9% SODIUM SP
CHLORIDE SOLN Antirheumatic Antimetabolites
ISOTONIC GENTAMICIN SP PA
SOLN METHOTREXATE TABS AC
KITABIS PAK NEBU SP OTREXUP SOAJ SP PA
neomycin sulfate tabs 1 RASUVO SOAJ SP PA
paromomycin sulfate caps 1 Gold Compounds

STREPTOMYCIN RIDAURA CAPS 2
SP PA
SULFATE SOLR
TOBI NEBU (Use Interleukin-1 Blockers
SP
Tobramycin) ARCALYST SOLR SP PA
TOBI PODHALER CAPS SP PA Interleukin-1 Receptor Antagonist (IL-1Ra)
TOBRAMYCIN NEBU SP KINERET SOSY SP PA
tobramycin nebu SP Interleukin-1beta Blockers

TOBRAMYCIN SULFATE ILARIS SOLN SP PA
SP PA
SOLN 10 MG/ML
Interleukin-6 Receptor Inhibitors
tobramycin sulfate soln 40 SP PA
mg/ml, 80 mg/2ml ACTEMRA SOLN SP PA
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint ACTEMRA SOSY SP PA
Conditions
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
Anti-TNF-alpha - Monoclonal Antibodies ANAPROX DS TABS (Use GP
HUMIRA PEDIATRIC PA Naproxen Sodium)
CROHNS DISEASE SP ARTHROTEC 50 TBEC
STARTER PACK PSKT (Use Diclofenac w/ GP
HUMIRA PEN PNKT SP PA Misoprostol)
page ii-iii.
3
ARTHROTEC 75 TBEC indomethacin cpcr 1
(Use Diclofenac w/ GP
Misoprostol) ketoprofen caps 50 mg, 75 1
CELEBREX CAPS (Use mg
GP AL(At least 60
Celecoxib) yrs old) KETOPROFEN CAPS 50 2
MG, 75 MG
celecoxib caps 1 AL(At least 60
yrs old) ketoprofen cp24 200 mg 1
DAYPRO TABS (Use GP
Oxaprozin) Limit 20 per
ketorolac tromethamine 1 month;QL(0.67
diclofenac potassium tabs 1 tabs ea daily)
LODINE TABS (Use GP
diclofenac sodium tb24 1 Etodolac)
diclofenac sodium tbec 1 meclofenamate sodium 1
caps
diclofenac w/ misoprostol 1
tbec mefenamic acid caps 1
EC-NAPROSYN TBEC GP meloxicam tabs 15 mg 1 QL(1 ea daily)
(Use Naproxen)
EC-NAPROXEN TBEC meloxicam tabs 7.5 mg 1 QL(2 ea daily)
GP
(Use Naproxen)
etodolac caps 200 mg, 300 MOBIC TABS 15 MG (Use GP QL(1 ea daily)
1 Meloxicam)
mg
etodolac tabs 400 mg, 500 MOBIC TABS 7.5 MG (Use GP QL(2 ea daily)
1 Meloxicam)
mg
etodolac tb24 400 mg, 500 QL(2 ea daily) nabumetone tabs 500 mg 1 QL(4 ea daily)
1
mg, 600 mg
nabumetone tabs 750 mg 1 QL(3 ea daily)
FELDENE CAPS (Use GP
Piroxicam)
FENOPROFEN CALCIUM NALFON CAPS 400 MG 3
2
CAPS 200 MG NALFON TABS 600 MG
FENOPROFEN CALCIUM NF
3 (Use Fenoprofen Calcium)
CAPS 400 MG NAPRELAN TB24 375 MG,
fenoprofen calcium tabs 1 500 MG (Use Naproxen GP
600 mg Sodium)
FENORTHO CAPS 2 NAPRELAN TB24 750 MG 3
flurbiprofen tabs 1 NAPROSYN SUSP (Use GP

Naproxen)
ibuprofen tabs 1 NAPROSYN TABS (Use GP
Naproxen)
INDOCIN SUPP RE 50 MG 3 naproxen sodium tabs 1
INDOCIN SUSP OR 25 2
MG/5ML naproxen sodium tb24 1
indomethacin caps 1 naproxen susp 1
page ii-iii.
4
naproxen tabs 1 ORENCIA SOLR SP PA
naproxen tbec 1 ORENCIA SOSY SP PA
oxaprozin tabs 1 Soluble Tumor Necrosis Factor Receptor Agents

ENBREL SOLR SP PA
piroxicam caps 1
PONSTEL CAPS (Use ENBREL SOSY SP PA
GP
Mefenamic Acid) ENBREL SURECLICK
QL(1 ea daily,5 SP PA
SPRIX SOLN 3 SOAJ
day(s) limit)
ANALGESICS - NonNarcotic - Drugs to Treat
sulindac tabs 1 Pain, Muscle and Joint Conditions
ST; QL(3 ea Analgesic Combinations
TIVORBEX CAPS 3
daily) butalbital-acetaminophen 1
TOLMETIN SODIUM tabs
2
CAPS 400 MG butalbital-acetaminophen- 1
tolmetin sodium tabs 200 caffeine caps
1
mg, 600 mg butalbital-acetaminophen- 1
PA caffeine tabs
VIMOVO TBEC 3
butalbital-aspirin-caffeine 1
VIVLODEX CAPS 3 PA caps
BUTALBITAL/ASPIRIN/CA 2
ST; QL(4 ea FFEINE TABS
ZIPSOR CAPS 3 daily,7 day(s)
limit) DURAXIN CAPS 3
ST; QL(3 ea ESGIC TABS (Use
ZORVOLEX CAPS 3
daily) Butalbital-Acetaminophen- GP
Phosphodiesterase 4 (PDE4) Inhibitors Caffeine)
OTEZLA TABS SP PA FIORICET CAPS 3
FIORINAL CAPS (Use
OTEZLA TBPK SP PA Butalbital-Aspirin-Caffeine) GP
Pyrimidine Synthesis Inhibitors TENCON TABS 3
ARAVA TABS 10 MG (Use GP QL(2 ea daily)
Leflunomide) VANATOL LQ SOLN 3
ARAVA TABS 20 MG (Use GP QL(1 ea daily)
Leflunomide) VANATOL S SOLN 3
leflunomide tabs 10 mg 1 QL(2 ea daily) Salicylates
leflunomide tabs 20 mg 1 QL(1 ea daily) ASCRIPTIN TABS PV PV
Selective Costimulation Modulators aspirin chew PV PV

ORENCIA CLICKJECT SP PA
SOAJ aspirin tabs PV PV
page ii-iii.
5
aspirin tbec PV PV fentanyl citrate lpop bu 200 PA
mcg, 400 mcg, 600 mcg, 1
choline & mag salicylate 800 mcg, 1200 mcg, 1600
1 mcg
liqd
diflunisal tabs 1 FENTANYL CITRATE PA; QL(3 ea
TABS BU 100 MCG, 200 3 daily)
ECOTRIN REGULAR PV MCG, 400 MCG, 600 MCG,
STRENGTH TBEC (Use GP 800 MCG
Aspirin) fentanyl pt72 12 mcg/hr, 25 Limit 15 per
mcg/hr, 50 mcg/hr, 75 1 month;QL(0.5
salsalate tabs 1 mcg/hr, 100 mcg/hr ea daily)
ANALGESICS - OPIOID - Drugs to Treat Pain, fentanyl pt72 37.5 mcg/hr 1 QL(0.34 ea
Muscle and Joint Conditions daily)
Opioid Agonists FENTORA TABS 100 PA; QL(3 ea
MCG, 200 MCG, 400 MCG, 3 daily)
ABSTRAL SUBL 3 PA 600 MCG, 800 MCG
New starts
ACTIQ LPOP (Use hydromorphone hcl liqd 1
GP PA mg/ml 1 limited to 7
Fentanyl Citrate) days.
New starts hydromorphone hcl t24a 32 1 QL(2 ea daily)
codeine sulfate tabs 15 mg,
limited to 7
1
30 mg, 60 mg mg
days.
hydromorphone hcl t24a 8 1 QL(4 ea daily)
CODEINE SULFATE TABS New starts mg, 12 mg, 16 mg
30 MG (Use Codeine GP limited to 7
Sulfate) days. New starts
hydromorphone hcl tabs 2 1 limited to 7
CONZIP CP24 3 mg, 4 mg, 8 mg days.
DEMEROL TABS (Use New starts HYSINGLA ER T24A 3 PA

GP limited to 7
Meperidine HCl) days. PA
IONSYS PTCH 3
New starts
DILAUDID LIQD (Use GP limited to 7 KADIAN CP24 10 MG, 20 QL(1 ea daily)
Hydromorphone HCl) days. MG, 30 MG, 50 MG, 60 GP
MG, 80 MG, 100 MG (Use
New starts Morphine Sulfate)
DILAUDID TABS (Use GP limited to 7
Hydromorphone HCl) days. LAZANDA SOLN 3 PA
DOLOPHINE TABS (Use GP QL(12 ea daily) PA; New starts
Methadone HCl) levorphanol tartrate tabs 2 1 limited to 7
Limit 15 per mg days.
DURAGESIC PT72 (Use GP month;QL(0.5
Fentanyl) New starts
ea daily) meperidine hcl soln 50 1 limited to 7
mg/5ml
EMBEDA CPCR 3 PA days.
New starts
EXALGO T24A 32 MG MEPERIDINE HCL TABS
GP QL(2 ea daily) 50 MG, 100 MG
2 limited to 7
(Use Hydromorphone HCl) days.
EXALGO T24A 8 MG, 12 QL(4 ea daily) New starts
MG, 16 MG (Use GP meperidine hcl tabs 50 mg, 1 limited to 7
Hydromorphone HCl) 100 mg days.
page ii-iii.
6
methadone hcl conc 10 1 OXAYDO TABA 3 QL(4 ea daily)
mg/ml
methadone hcl soln 5 New starts
1 oxycodone hcl caps 1 limited to 7
mg/5ml, 10 mg/5ml
methadone hcl tabs 5 mg, QL(12 ea daily) days.
1 New starts
10 mg
oxycodone hcl conc 1 limited to 7
methadone hcl tbso 40 mg 1 days.
METHADOSE CONC (Use OXYCODONE HCL ER 3 QL(3 ea daily)
GP T12A
Methadone HCl)
METHADOSE SUGAR- New starts
FREE CONC (Use GP oxycodone hcl soln 1 limited to 7
Methadone HCl) days.
morphine sulfate cp24 or QL(1 ea daily) New starts
10 mg, 20 mg, 30 mg, 50 1 oxycodone hcl tabs 1 limited to 7
mg, 60 mg, 80 mg, 100 mg days.
MORPHINE SULFATE ER QL(1 ea daily) OXYCODONE QL(3 ea daily)
2 HYDROCHLORIDE ER 3
CP24
T12A
morphine sulfate soln ij 0.5 SP PA
mg/ml, 1 mg/ml OXYCONTIN T12A 3 QL(3 ea daily)
morphine sulfate soln or 20 New starts
mg/ml, 10 mg/5ml, 20 1 limited to 7 New starts
oxymorphone hcl tabs 5 1 limited to 7
mg/5ml, 100 mg/5ml days. mg, 10 mg days.
New starts
morphine sulfate supp re 1 limited to 7 oxymorphone hcl tb12 5 QL(2 ea daily)
10 mg, 20 mg days. mg, 10 mg, 15 mg, 20 mg, 1
30 mg, 40 mg, 7.5 mg
New starts
MORPHINE SULFATE New starts
2 limited to 7 ROXICODONE TABS (Use
SUPP RE 5 MG, 30 MG GP limited to 7
days. Oxycodone HCl) days.
New starts
morphine sulfate tabs or 15 1 limited to 7 ROXYBOND TABA 3 QL(4 ea daily)
mg, 30 mg days.
SUBSYS LIQD 3 PA
morphine sulfate tbcr or 15
mg, 30 mg, 60 mg, 100 mg, 1
200 mg TRAMADOL HCL ER CP24 3
MS CONTIN TBCR (Use GP New starts
Morphine Sulfate) limited to 7
tramadol hcl tabs 50 mg 1
days.;QL(8 ea
NUCYNTA ER TB12 2 QL(2 ea daily)
daily)
New starts tramadol hcl tb24 100 mg,
NUCYNTA TABS 2 limited to 7 1
200 mg, 300 mg
days. New starts
OPANA ER (CRUSH QL(2 ea daily) ULTRAM TABS (Use
RESISTANT) T12A 2 GP limited to 7
Tramadol HCl) days.;QL(8 ea
New starts daily)
OPANA TABS (Use GP limited to 7
Oxymorphone HCl) days. ZOHYDRO ER C12A 3 PA
page ii-iii.
7
Opioid Combinations New starts
New starts oxycodone-aspirin tabs 1 limited to 7
acetaminophen w/ codeine 1 limited to 7 days.
soln days. New starts
OXYCODONE/ACETAMIN 2 limited to 7
New starts OPHEN SOLN
acetaminophen w/ codeine 1 limited to 7 days.
tabs days. New starts
OXYCODONE/ASPIRIN 3 limited to 7
New starts TABS
ASPIRIN-CAFFEINE- 3 limited to 7 days.
DIHYDROCODEINE CAPS New starts
days.
New starts OXYCODONE/IBUPROFE 3 limited to 7
butalbital-acetaminophen- 1 limited to 7 N TABS days.;QL(4 ea
caffeine w/ codeine caps days. daily)
New starts PERCOCET TABS (Use New starts
butalbital-aspirin-caffeine 1 limited to 7 Oxycodone w/ GP limited to 7
w/cod caps days. Acetaminophen) days.
FIORICET/CODEINE New starts New starts
CAPS (Use Butalbital- PRIMLEV TABS 3 limited to 7
GP limited to 7 days.
Acetaminophen-Caffeine days.
w/ Codeine) New starts
FIORINAL/CODEINE #3 New starts SYNALGOS-DC CAPS 3 limited to 7
CAPS (Use Butalbital- GP limited to 7 days.
Aspirin-Caffeine w/Cod) days. New starts
tramadol-acetaminophen 1 limited to 7
HYDROCODONE New starts tabs days.
BITARTRATE/ACETAMIN 3 limited to 7
OPHEN SOLN days. TYLENOL/CODEINE #3 New starts
New starts TABS (Use Acetaminophen GP limited to 7
hydrocodone- 1 limited to 7 w/ Codeine) days.
acetaminophen soln days. TYLENOL/CODEINE #4 New starts
New starts TABS (Use Acetaminophen GP limited to 7
hydrocodone- 1 limited to 7 w/ Codeine) days.
acetaminophen tabs days. New starts
ULTRACET TABS (Use GP limited to 7
hydrocodone-ibuprofen New starts Tramadol-Acetaminophen) days.
1 limited to 7
tabs days. XODOL TABS (Use New starts
New starts
Hydrocodone- GP limited to 7
LORTAB ELIX 3 limited to 7 Acetaminophen) days.
days. New starts
ZAMICET SOLN 3 limited to 7
MEPERIDINE New starts days.
HCL/PROMETHAZINE 3 limited to 7
HCL CAPS days. Opioid Partial Agonists
NORCO TABS (Use New starts BELBUCA FILM 3 QL(2 ea daily)
Hydrocodone- GP limited to 7
Acetaminophen) days. BUNAVAIL FILM 3 PA
New starts
oxycodone w/ 1 limited to 7 PA
acetaminophen tabs buprenorphine hcl subl 1
days.
page ii-iii.
8
buprenorphine hcl- 1 PA oxandrolone tabs 1
naloxone hcl dihydrate film
buprenorphine hcl- 1 PA Androgens
naloxone hcl dihydrate subl ST; QL(1 ea
buprenorphine ptwk 15 ANDRODERM PT24 3
1 daily)
mcg/hr ANDROGEL GEL 25 QL(10 gm
BUPRENORPHINE PTWK 3 MG/2.5GM, 40.5 daily)
15 MCG/HR MG/2.5GM, 20.25 GP
buprenorphine ptwk 5 Limit 4 per MG/1.25GM (Use
mcg/hr, 10 mcg/hr, 20 1 month;QL(0.15 Testosterone)
mcg/hr ea daily) ANDROGEL GEL 50 QL(10 gm
2
BUPRENORPHINE PTWK Limit 4 per MG/5GM daily)
5 MCG/HR, 10 MCG/HR, 3 month;QL(0.15 ANDROGEL PUMP GEL
20 MCG/HR, 7.5 MCG/HR ea daily) GP QL(10 gm
(Use Testosterone) daily)
New starts ANDROID CAPS (Use
limited to 7 GP
butorphanol tartrate soln 1 Methyltestosterone)
days.;QL(0.25
ml daily) ANDROXY TABS 2
BUTRANS PTWK 15 AXIRON SOLN (Use
MCG/HR (Use GP GP QL(6 ml daily);
Testosterone) GL
Buprenorphine)
BUTRANS PTWK 5 Limit 4 per danazol caps 1
MCG/HR, 10 MCG/HR, 20 GP month;QL(0.15 FORTESTA GEL (Use
MCG/HR (Use ea daily) GP QL(3.5 gm
Testosterone) daily)
Buprenorphine)
Limit 4 per METHITEST TABS 2
BUTRANS PTWK 7.5 3 month;QL(0.15
MCG/HR METHYLTESTOSTERONE 3
ea daily) CAPS
nalbuphine hcl soln SP PA STRIANT MISC 3 QL(2 ea daily)
New starts TESTIM GEL (Use
pentazocine w/ naloxone 1 limited to 7 NF QL(10 gm
tabs Testosterone) daily)
days.
SUBOXONE FILM (Use PA TESTONE CIK KIT SP PA
Buprenorphine HCl- GP testosterone gel 1 %, 1.62 QL(10 gm
Naloxone HCl Dihydrate) %, 50 mg/5gm, 25 daily)
1
TALWIN SOLN SP PA mg/2.5gm, 40.5 mg/2.5gm,
20.25 mg/1.25gm
ZUBSOLV SUBL 3 PA QL(3.5 gm
testosterone gel 10 mg/act 1
daily)
ANDROGENS-ANABOLIC - Drugs to Regulate QL(6 ml daily);
Hormones testosterone soln 30 mg/act 1
GL
Anabolic Steroids TESTRED CAPS (Use GP
Methyltestosterone)
ANADROL-50 TABS 3
ANORECTAL AGENTS - Rectal Drugs to Treat
OXANDRIN TABS (Use GP Pain, Swelling and Itching
Oxandrolone)
page ii-iii.
9
Intrarectal Steroids RECTIV OINT 3
CORTENEMA ENEM (Use
Hydrocortisone GP ANTHELMINTICS - Drugs to Treat Worm
(Intrarectal)) Infections
CORTIFOAM FOAM 2 Anthelmintics
hydrocortisone (intrarectal) albendazole tabs 1
1
enem ALBENZA TABS (Use
UCERIS FOAM RE 2 PA GP
3 Albendazole)
MG/ACT BILTRICIDE TABS (Use GP
Rectal Combinations Praziquantel)
ANALPRAM HC CREA ivermectin tabs 1
(Use Hydrocortisone GP
Acetate w/ Pramoxine) praziquantel tabs 1
ANALPRAM HC SINGLES
CREA (Use Hydrocortisone GP STROMECTOL TABS (Use GP
Acetate w/ Pramoxine) Ivermectin)
ANALPRAM-HC CREA ANTI-INFECTIVE AGENTS - MISC. - Drugs to
1%-1% (Use Treat Bacterial Infections
GP
Hydrocortisone Acetate w/ Anti-infective Agents - Misc.
Pramoxine)
bacitracin solr im 50000 SP PA
ANALPRAM-HC LOTN 3 unit
1%-2.5%
FLAGYL CAPS (Use
hydrocortisone acetate w/ 1 Metronidazole) GP
pramoxine crea
FLAGYL TABS (Use
lidocaine-hydrocortisone 1 Metronidazole) GP
acetate (rectal) kit
IMPAVIDO CAPS SP
PROCORT CREA 3
metronidazole caps 1
PROCTOFOAM HC FOAM 2
Rectal Steroids metronidazole in nacl soln SP PA
ANUSOL-HC CREA (Use GP metronidazole tabs 1
Hydrocortisone (Rectal))
hydrocortisone (rectal) crea 1 NEBUPENT SOLR 2
hydrocortisone acetate 1 PRIMSOL SOLN 2
(rectal) supp
PROCTOCORT CREA TINDAMAX TABS (Use GP
(Use Hydrocortisone GP Tinidazole)
(Rectal)) tinidazole tabs 1
PROCTOCORT SUPP
(Use Hydrocortisone GP trimethoprim tabs 1
Acetate (Rectal))
Vasodilating Agents TRIMPEX SOLN 2
page ii-iii.
10
XIFAXAN TABS 3 PA daptomycin solr SP PA
Anti-infective Misc. - Combinations Leprostatics
BACTRIM DS TABS (Use dapsone tabs 1
Sulfamethoxazole- GP
Trimethoprim) Lincosamides
BACTRIM TABS (Use CLEOCIN CAPS OR 75
Sulfamethoxazole- GP MG, 150 MG, 300 MG (Use GP
Trimethoprim) Clindamycin HCl)
sulfamethoxazole- 1 CLEOCIN IN D5W SOLN PA
trimethoprim susp (Use Clindamycin SP
sulfamethoxazole- 1 Phosphate in D5W)
trimethoprim tabs CLEOCIN PEDIATRIC
Antiprotozoal Agents GRANULES SOLR (Use GP
Clindamycin Palmitate
ALINIA SUSR 3 Hydrochloride)
CLEOCIN PHOSPHATE PA
ALINIA TABS 3 SOLN (Use Clindamycin SP
Phosphate in D5W)
atovaquone susp 1
CLEOCIN PHOSPHATE PA
MEPRON SUSP (Use SOLN (Use Clindamycin SP
GP Phosphate)
Atovaquone)
Carbapenems clindamycin hcl caps 1
DORIBAX SOLR SP PA clindamycin palmitate 1
hydrochloride solr
DORIPENEM SOLR SP PA clindamycin phosphate in SP PA
d5w soln
ertapenem sodium solr SP PA clindamycin phosphate soln PA
INVANZ SOLR IJ (Use ij 9 gm/60ml, 300 mg/2ml,
SP PA 600 mg/4ml, 900 mg/6ml, SP
Ertapenem Sodium)
9000 mg/60ml
INVANZ SOLR IV SP PA clindamycin phosphate soln SP PA
iv 300 mg/2ml, 600 mg/4ml
meropenem solr SP PA LINCOCIN SOLN (Use SP PA
MERREM SOLR (Use Lincomycin HCl)
SP PA
Meropenem) lincomycin hcl soln SP PA
Chloramphenicols
CHLORAMPHENICOL PA Oxazolidinones
SODIUM SUCCINATE SP linezolid susr 1
SOLR
Cyclic Lipopeptides linezolid tabs 1
CUBICIN RF SOLR (Use SP PA QL(6 ea per 90
Daptomycin) SIVEXTRO TABS 2
days retail)
CUBICIN SOLR (Use SP PA ZYVOX SUSR (Use
Daptomycin) GP
Linezolid)
page ii-iii.
11
ZYVOX TABS (Use GP nitroglycerin cpcr or 9 mg, 1
Linezolid) 2.5 mg
Polymyxins nitroglycerin pt24 td 0.1 QL(1 ea daily)
mg/hr, 0.2 mg/hr, 0.4 1
polymyxin b sulfate solr SP PA mg/hr, 0.6 mg/hr
nitroglycerin soln tl 0.4 1
ANTIANGINAL AGENTS - Drugs to Treat Chest mg/spray
Pain
nitroglycerin subl sl 0.3 mg, 1
Antianginals-Other 0.4 mg, 0.6 mg
RANEXA TB12 1000 MG GP NITROLINGUAL
(Use Ranolazine) PUMPSPRAY SOLN (Use GP
RANEXA TB12 500 MG Nitroglycerin)
GP QL(4 ea daily)
(Use Ranolazine)
NITROMIST AERS 3
ranolazine tb12 1000 mg 1
NITROSTAT SUBL (Use GP
ranolazine tb12 500 mg 1 QL(4 ea daily) Nitroglycerin)
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Nitrates
DILATRATE SR CPCR 3 Antianxiety Agents - Misc.
ISORDIL TITRADOSE buspirone hcl tabs 1

2
TABS 40 MG
hydroxyzine hcl syrp 1
ISORDIL TITRADOSE
TABS 5 MG (Use GP hydroxyzine hcl tabs 1
Isosorbide Dinitrate)
ISOSORBIDE DINITRATE 2 hydroxyzine pamoate caps 1
ER TBCR
ISOSORBIDE DINITRATE 2 meprobamate tabs 1
TABS 30 MG
VISTARIL CAPS (Use GP
isosorbide dinitrate tabs 5 1 Hydroxyzine Pamoate)
mg, 10 mg, 20 mg
isosorbide mononitrate Benzodiazepines
1 ALPRAZOLAM INTENSOL
tabs 3
isosorbide mononitrate CONC
1
tb24 alprazolam tabs 1
NITRO-BID OINT 2
alprazolam tb24 1
NITRO-DUR PT24 0.1 QL(1 ea daily)
MG/HR, 0.2 MG/HR, 0.4 GP alprazolam tbdp 1
MG/HR, 0.6 MG/HR (Use
Nitroglycerin) ATIVAN TABS (Use GP
NITRO-DUR PT24 0.3 QL(1 ea daily) Lorazepam)
2
MG/HR, 0.8 MG/HR chlordiazepoxide hcl caps 1
NITRO-TIME CPCR 2 clorazepate dipotassium 1
nitroglycerin aers tl 400 tabs
1
mcg/spray
page ii-iii.
12
diazepam conc 1 propafenone hcl tabs 150 1 QL(6 ea daily)
mg
diazepam soln 1 propafenone hcl tabs 225 1 QL(3 ea daily)
mg, 300 mg
diazepam tabs 1 RYTHMOL SR CP12 (Use GP
Propafenone HCl)
lorazepam conc 1 Antiarrhythmics Type III
lorazepam tabs 1 amiodarone hcl tabs 1
oxazepam caps 10 mg, 15 1 dofetilide caps 1
mg, 30 mg
OXAZEPAM CAPS 10 MG, 2 MULTAQ TABS 2
30 MG
TRANXENE T TABS (Use TIKOSYN CAPS (Use GP
GP Dofetilide)
Clorazepate Dipotassium)
VALIUM TABS (Use ANTIASTHMATIC AND BRONCHODILATOR
GP AGENTS - Drugs to Treat Lung Conditions
Diazepam)
XANAX TABS (Use GP Anti-Inflammatory Agents
Alprazolam)
XANAX XR TB24 (Use
cromolyn sodium nebu 1
GP
Alprazolam) Antiasthmatic - Monoclonal Antibodies
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms NUCALA SOLR SP PA
Antiarrhythmics Type I-A XOLAIR SOLR SP PA
disopyramide phosphate 1
caps Bronchodilators - Anticholinergics
NORPACE CAPS (Use Limit 2 inhalers
GP per
Disopyramide Phosphate) ATROVENT HFA AERS 2
month;QL(0.86
NORPACE CR CP12 2 gm daily)
INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)
quinidine gluconate tbcr 1
QUINIDINE SULFATE 2 ipratropium bromide soln 1
TABS
SEEBRI NEOHALER 3 QL(2 ea daily)
Antiarrhythmics Type I-B CAPS
MEXILETINE HCL CAPS 3 SPIRIVA HANDIHALER QL(1 ea daily)
150 MG, 200 MG 2
CAPS
MEXILETINE HCL CAPS 1 Limit 1 inhaler
250 MG SPIRIVA RESPIMAT per
2
Antiarrhythmics Type I-C AERS month;QL(0.14
gm daily)
flecainide acetate tabs 1 ST; Limit 1
propafenone hcl cp12 225 TUDORZA PRESSAIR 3 inhaler per
1 AEPB month;QL(0.04
mg, 325 mg, 425 mg
ea daily)
page ii-iii.
13
Leukotriene Modulators Limit 1 inhaler
ASMANEX TWISTHALER
ACCOLATE TABS (Use 14 METERED DOSES 2 per
GP month;QL(0.04
Zafirlukast) AEPB ea daily)
montelukast sodium chew 1 QL(1 ea daily)
Limit 1 inhaler
ASMANEX TWISTHALER
montelukast sodium pack 1 QL(1 ea daily) 30 METERED DOSES 2 per
month;QL(0.04
AEPB ea daily)
montelukast sodium tabs 1 QL(1 ea daily)
Limit 1 inhaler
ASMANEX TWISTHALER
SINGULAIR CHEW (Use GP QL(1 ea daily) 60 METERED DOSES 2 per
Montelukast Sodium) month;QL(0.04
AEPB ea daily)
SINGULAIR PACK (Use GP QL(1 ea daily)
Montelukast Sodium) Limit 1 inhaler
ASMANEX TWISTHALER
SINGULAIR TABS (Use 7 METERED DOSES 2 per
GP QL(1 ea daily) AEPB month;QL(0.04
Montelukast Sodium) ea daily)
zafirlukast tabs 1 budesonide (inhalation) 1 QL(8 ml daily)
susp 0.25 mg/2ml
zileuton tb12 1 ST budesonide (inhalation) QL(4 ml daily)
1
susp 0.5 mg/2ml, 1 mg/2ml
ZYFLO CR TB12 (Use GP ST
Zileuton) FLOVENT DISKUS AEPB 2 QL(20 ea daily)
100 MCG/BLIST
ZYFLO TABS 3 ST
FLOVENT DISKUS AEPB 2 QL(8 ea daily)
250 MCG/BLIST
Selective Phosphodiesterase 4 (PDE4) Inhibitors
FLOVENT DISKUS AEPB 2 QL(40 ea daily)
DALIRESP TABS 3 QL(1 ea daily) 50 MCG/BLIST
Limit 2 inhalers
Steroid Inhalants FLOVENT HFA AERO 110 per
Limit 2 inhalers 2
MCG/ACT, 220 MCG/ACT month;QL(0.8
per gm daily)
AEROSPAN AERS 2
month;QL(0.6 Limit 1 inhaler
gm daily) FLOVENT HFA AERO 44 per
Limit 2 inhalers 2
MCG/ACT month;QL(0.36
per gm daily)
ALVESCO AERS 3
month;QL(0.41 Limit 2 inhalers
gm daily) PULMICORT FLEXHALER per
QL(1 ea daily) 2
ARNUITY ELLIPTA AEPB 2 AEPB 180 MCG/ACT month;QL(0.07
ea daily)
Limit 1 inhaler Limit 2 inhalers
per PULMICORT FLEXHALER per
ASMANEX HFA AERO 2 2
month;QL(0.44 AEPB 90 MCG/ACT month;QL(0.27
gm daily) ea daily)
Limit 1 inhaler PULMICORT SUSP 0.25 QL(8 ml daily)
ASMANEX TWISTHALER per MG/2ML (Use Budesonide GP
120 METERED DOSES 2
month;QL(0.04 (Inhalation))
AEPB ea daily) PULMICORT SUSP 0.5 QL(4 ml daily)
MG/2ML, 1 MG/2ML (Use GP
Budesonide (Inhalation))
page ii-iii.
14
Limit 8.7gms Limit 6 per
COMBIVENT RESPIMAT
2 per 3 month;QL(0.2
QVAR AERS 40 MCG/ACT AERS
month;QL(0.58 gm daily)
gm daily) PA; Limit 1
Limit 8.7gms 3 inhaler per
DULERA AERO
QVAR AERS 80 MCG/ACT 2 per month;QL(0.45
month;QL(0.29 gm daily)
gm daily) QL(2 ea daily)
fluticasone-salmeterol aepb 1
Limit 1 inhaler
QVAR REDIHALER AERB 2 per ipratropium-albuterol soln 1
40 MCG/ACT month;QL(0.36
gm daily)
levalbuterol hcl nebu 1
Limit 2 Inhalers
QVAR REDIHALER AERB Limit 30 per
2 per levalbuterol tartrate aero 2 month;QL(0.9
80 MCG/ACT month;QL(0.72
gm daily) gm daily)
Sympathomimetics metaproterenol sulfate syrp 1
ADVAIR DISKUS AEPB QL(2 ea daily)
(Use Fluticasone- GP metaproterenol sulfate tabs 1
Salmeterol)
PERFOROMIST NEBU 3 QL(4 ml daily)
Limit 1 inhaler
per Limit 2 inhalers
ADVAIR HFA AERO 2
month;QL(0.4 PROAIR HFA AERS (Use
gm daily) NF per
Albuterol Sulfate) month;QL(0.57
albuterol sulfate aers in 1 QL(0.45 gm gm daily)
108 mcg/act daily) Limit 2 inhalers
ALBUTEROL SULFATE QL(2 ea daily) PROAIR RESPICLICK
ER TB12
2 3 per
AEPB month;QL(0.07
albuterol sulfate nebu in ea daily)
0.63 mg/3ml, 0.083 %, 0.5 1 Limit 2 inhalers
%, 1.25 mg/3ml PROVENTIL HFA AERS NF per
albuterol sulfate syrp or 2 (Use Albuterol Sulfate) month;QL(0.45
1 gm daily)
mg/5ml
albuterol sulfate tabs or 2 SEREVENT DISKUS 2 QL(2 ea daily)
1 AEPB
mg, 4 mg
albuterol sulfate tb12 or 4 QL(2 ea daily) Limit 1 inhaler
1 STIOLTO RESPIMAT per
mg, 8 mg 2
QL(2 ea daily) AERS month;QL(0.14
ANORO ELLIPTA AEPB 2 gm daily)
ARCAPTA NEOHALER QL(1 ea daily) Limit 1 inhaler
3 STRIVERDI RESPIMAT per
CAPS 2
BEVESPI AEROSPHERE QL(0.36 gm AERS month;QL(0.14
3 gm daily)
AERO daily)
QL(2 ea daily) Limit 1 inhaler
BREO ELLIPTA AEPB 2 per
SYMBICORT AERO 2
month;QL(0.34
BROVANA NEBU 3 gm daily)
page ii-iii.
15
terbutaline sulfate tabs 1 XARELTO TABS 2
Limit 2 inhalers Heparins And Heparinoid-Like Agents
VENTOLIN HFA AERS NF per ARIXTRA SOLN (Use SP QL(20 ml per
(Use Albuterol Sulfate) month;QL(1.2
gm daily) Fondaparinux Sodium) 10 days retail)
QL(20 ml per
Limit 2 inhalers enoxaparin sodium soln SP
10 days retail)
VENTOLIN HFA AERS NF per
(Use Albuterol Sulfate) month;QL(0.54 fondaparinux sodium soln SP QL(20 ml per
gm daily) 10 days retail)
VOSPIRE ER TB12 (Use GP QL(2 ea daily) FRAGMIN SOLN SP QL(20 ml per
Albuterol Sulfate) 10 days retail)
XOPENEX HEPARIN LOCK FLUSH SP PA
CONCENTRATE NEBU GP SOLN
(Use Levalbuterol HCl) heparin sod (porcine) in SP PA
Limit 30 per d5w soln
XOPENEX HFA AERO 2
month heparin sodium (porcine) SP PA
XOPENEX NEBU (Use lock flush soln
GP
Levalbuterol HCl) heparin sodium (porcine) SP PA
Xanthines soln
ELIXOPHYLLIN ELIX 3 HEPARIN SODIUM SOSY SP PA

HEPARIN SODIUM/D5W SP PA
THEO-24 CP24 2 SOLN
HEPARIN PA
theophylline soln 1 SODIUM/DEXTROSE SP
SOLN
theophylline tb12 1
LOVENOX SOLN (Use SP QL(20 ml per
Enoxaparin Sodium) 10 days retail)
theophylline tb24 1
Thrombin Inhibitors
ANTICOAGULANTS - Blood Thinners PRADAXA CAPS 3
Coumarin Anticoagulants
COUMADIN TABS (Use ANTICONVULSANTS - Drugs to Treat Seizures
3
Warfarin Sodium) AMPA Glutamate Receptor Antagonists
warfarin sodium tabs 1 FYCOMPA SUSP 3
Direct Factor Xa Inhibitors FYCOMPA TABS 3
ELIQUIS STARTER PACK 2
TABS Anticonvulsants - Benzodiazepines
ELIQUIS TABS 2 clobazam susp 1
SAVAYSA TABS 3 clobazam tabs 1
XARELTO STARTER 2
PACK TBPK clonazepam tabs 1
page ii-iii.
16
clonazepam tbdp 1 carbamazepine tb12 1
Limit 4 boxes CARBATROL CP12 (Use
DIASTAT ACUDIAL GEL 3
10 MG
2 (8 syringes) per Carbamazepine)
30 days
EPIDIOLEX SOLN SP PA
Limit 4 boxes
(8 syringes) per gabapentin caps 1
DIASTAT ACUDIAL GEL 2 30 days;QL(4
20 MG ea per 30 days
retail) gabapentin soln 1
Limit 4 boxes gabapentin tabs 1
(8 syringes) per
DIASTAT PEDIATRIC GEL 2 30 days;QL(4 KEPPRA SOLN (Use
ea per 30 days 3
Levetiracetam)
retail) KEPPRA TABS (Use
Limit 4 boxes 3
Levetiracetam)
(8 syringes) per KEPPRA XR TB24 (Use
diazepam (anticonvulsant) 2 30 days;QL(4 3
gel Levetiracetam)
ea per 30 days
retail) LAMICTAL CHEWABLE
DISPERSIBLE CHEW (Use 3
Limit 4 boxes Lamotrigine)
(8 syringes) per
DIAZEPAM RECTAL GEL PA
2 30 days;QL(4 LAMICTAL ODT KIT 3
GEL ea per 30 days
retail) LAMICTAL ODT TBDP 25 PA
MG, 50 MG, 100 MG, 200 3
KLONOPIN TABS (Use GP MG (Use Lamotrigine)
Clonazepam)
LAMICTAL STARTER/NOT
ONFI SUSP (Use GP TAKING
Clobazam) GP
CARBAMAZEPINE KIT
ONFI TABS (Use GP (Use Lamotrigine)
Clobazam) LAMICTAL
Anticonvulsants - Misc. STARTER/TAKING
APTIOM TABS 200 MG, QL(2 ea daily) CARBAMAZEPINE/NOT GP
3 TAKING VALPROATE KIT
400 MG, 600 MG
(Use Lamotrigine)
APTIOM TABS 800 MG 3 QL(1 ea daily)
LAMICTAL
STARTER/TAKING GP
BANZEL SUSP 2 VALPROATE KIT (Use
Lamotrigine)
BANZEL TABS 2 LAMICTAL TABS (Use 3
Lamotrigine)
carbamazepine chew 1
LAMICTAL XR KIT 3 PA
carbamazepine cp12 1
LAMICTAL XR TB24 25 PA; QL(1 ea
MG, 50 MG, 100 MG, 200 3 daily)
carbamazepine susp 1 MG (Use Lamotrigine)
carbamazepine tabs 1
page ii-iii.
17
LAMICTAL XR TB24 250 PA pregabalin caps 25 mg, 50 PA; QL(3 ea
MG, 300 MG (Use 3 mg, 75 mg, 100 mg, 200 1 daily)
Lamotrigine) mg
lamotrigine chew 5 mg, 25 1 pregabalin soln 20 mg/ml 1 PA
mg
lamotrigine kit 1 PA primidone tabs 1
QUDEXY XR CS24 3 PA
lamotrigine kit 25 mg, 1
lamotrigine tabs 25 mg, SPRITAM TB3D 3 PA
1
100 mg, 150 mg, 200 mg
lamotrigine tb24 25 mg, 50 PA; QL(1 ea TEGRETOL SUSP (Use 3
1 Carbamazepine)
mg, 100 mg, 200 mg daily)
lamotrigine tb24 250 mg, PA TEGRETOL TABS (Use 3
1 Carbamazepine)
300 mg
lamotrigine tbdp 25 mg, 50 PA TEGRETOL-XR TB12 100 GP
1 MG (Use Carbamazepine)
mg, 100 mg, 200 mg
TEGRETOL-XR TB12 200
levetiracetam soln 1 MG, 400 MG (Use 3
Carbamazepine)
levetiracetam tabs 1 TOPAMAX SPRINKLE 3
CPSP (Use Topiramate)
levetiracetam tb24 1
TOPAMAX TABS (Use 3
LYRICA CAPS 150 MG, PA; QL(2 ea Topiramate)
225 MG, 300 MG (Use 3 daily)
Pregabalin) topiramate cpsp 1
LYRICA CAPS 25 MG, 50 PA; QL(3 ea TOPIRAMATE ER CS24 3 PA
MG, 75 MG, 100 MG, 200 3 daily)
MG (Use Pregabalin) topiramate tabs 1
LYRICA SOLN 20 MG/ML 3 PA
(Use Pregabalin) TRILEPTAL SUSP 300
MYSOLINE TABS (Use MG/5ML (Use 3
3 Oxcarbazepine)
Primidone)
NEURONTIN CAPS (Use TRILEPTAL TABS 150
3 MG, 300 MG (Use 3
Gabapentin)
Oxcarbazepine)
NEURONTIN SOLN (Use 3
Gabapentin) TRILEPTAL TABS 600 MG GP
(Use Oxcarbazepine)
NEURONTIN TABS (Use 3
Gabapentin) TROKENDI XR CP24 3 PA
oxcarbazepine susp 1 VIMPAT SOLN 2

oxcarbazepine tabs 1 VIMPAT TABS 2
OXTELLAR XR TB24 3 ST ZONEGRAN CAPS (Use 3
Zonisamide)
pregabalin caps 150 mg, 1 PA; QL(2 ea
225 mg, 300 mg daily) zonisamide caps 1
page ii-iii.
18
Carbamates phenytoin susp 1
felbamate susp 1 Succinimides
felbamate tabs 1 CELONTIN CAPS 2
FELBATOL SUSP (Use 3 ethosuximide caps 1
Felbamate)
FELBATOL TABS (Use 3 ethosuximide soln 1
Felbamate)
ZARONTIN CAPS (Use 3
GABA Modulators Ethosuximide)
GABITRIL TABS (Use 3 ZARONTIN SOLN (Use
Tiagabine HCl) 3
Ethosuximide)
SABRIL PACK (Use GP
Vigabatrin) Valproic Acid
SABRIL TABS (Use DEPAKENE CAPS 250 MG 3
GP (Use Valproic Acid)
Vigabatrin)
DEPAKENE SOLN 250
tiagabine hcl tabs 1 MG/5ML (Use Valproate GP
Sodium)
vigabatrin pack 1 DEPAKOTE ER TB24 (Use 3
Divalproex Sodium)
vigabatrin tabs 1
DEPAKOTE SPRINKLES
Hydantoins CSDR (Use Divalproex 3
Sodium)
CEREBYX SOLN (Use SP PA
Fosphenytoin Sodium) DEPAKOTE TBEC (Use 3
Divalproex Sodium)
DILANTIN CAPS 100 MG
(Use Phenytoin Sodium 3 divalproex sodium csdr 1
Extended)
DILANTIN CAPS 30 MG 2 divalproex sodium tb24 1
DILANTIN INFATABS divalproex sodium tbec 1

3
CHEW (Use Phenytoin)
DILANTIN-125 SUSP (Use valproate sodium soln 1
3
Phenytoin)
valproic acid caps 1
fosphenytoin sodium soln SP PA
ANTIDEPRESSANTS - Drugs to Treat
PEGANONE TABS 3 Depression
PHENYTEK CAPS (Use Alpha-2 Receptor Antagonists (Tetracyclics)
Phenytoin Sodium 3 mirtazapine tabs 1
Extended)
phenytoin chew 1 mirtazapine tbdp 1
phenytoin sodium extended REMERON SOLTAB TBDP GP
1 (Use Mirtazapine)
caps
REMERON TABS (Use
phenytoin sodium soln SP PA Mirtazapine) GP
page ii-iii.
19
Antidepressants - Misc. citalopram hydrobromide 1 QL(2 ea daily)
bupropion hcl tabs 75 mg, tabs 20 mg
1 citalopram hydrobromide QL(1 ea daily)
100 mg 1
bupropion hcl tb12 100 mg, tabs 40 mg
1
150 mg, 200 mg escitalopram oxalate soln 1
bupropion hcl tb24 150 mg, 1 QL(1 ea daily)
300 mg escitalopram oxalate tabs 1
BUPROPION ST; QL(1 ea
HYDROCHLORIDE ER 3 daily) FLUOXETINE DR CPDR 3
(XL) TB24 fluoxetine hcl caps 10 mg,
ST; QL(1 ea 1
FORFIVO XL TB24 3 20 mg, 40 mg
daily) fluoxetine hcl soln 20 1
maprotiline hcl tabs 1 mg/5ml
fluoxetine hcl tabs 10 mg, 1
WELLBUTRIN SR TB12 GP 20 mg
(Use Bupropion HCl)
ST; QL(1 ea
WELLBUTRIN XL TB24 fluoxetine hcl tabs 60 mg 1
GP QL(1 ea daily) daily)
(Use Bupropion HCl)
FLUOXETINE 3 ST; QL(1 ea
Monoamine Oxidase Inhibitors (MAOIs) HYDROCHLORIDE TABS daily)
EMSAM PT24 3 QL(1 ea daily) FLUOXETINE ST; QL(1 ea
HYDROCHLORIDE TABS GP daily)
MARPLAN TABS 2 (Use Fluoxetine HCl)
NARDIL TABS (Use fluvoxamine maleate cp24 1
GP
Phenelzine Sulfate)
PARNATE TABS (Use
fluvoxamine maleate tabs 1
GP
Tranylcypromine Sulfate) LEXAPRO TABS (Use GP
phenelzine sulfate tabs 1
Escitalopram Oxalate)
tranylcypromine sulfate paroxetine hcl tabs 1

1
tabs
paroxetine hcl tb24 1
Selective Serotonin Reuptake Inhibitors (SSRIs)
PAXIL CR TB24 (Use GP
CELEXA TABS 10 MG QL(4 ea daily) Paroxetine HCl)
(Use Citalopram GP
Hydrobromide) PAXIL SUSP 10 MG/5ML 2
CELEXA TABS 20 MG QL(2 ea daily)
(Use Citalopram GP PAXIL TABS 10 MG, 20
Hydrobromide) MG, 30 MG, 40 MG (Use GP
Paroxetine HCl)
CELEXA TABS 40 MG QL(1 ea daily)
(Use Citalopram GP PEXEVA TABS 3
Hydrobromide)
PROZAC CAPS (Use GP
citalopram hydrobromide 1 QL(20 ml daily) Fluoxetine HCl)
soln 10 mg/5ml
citalopram hydrobromide sertraline hcl conc 1
1 QL(4 ea daily)
tabs 10 mg
sertraline hcl tabs 1
page ii-iii.
20
ZOLOFT CONC (Use GP venlafaxine hcl cp24 150 1 QL(2 ea daily)
Sertraline HCl) mg
ZOLOFT TABS (Use GP venlafaxine hcl cp24 75 1 QL(1 ea daily)
Sertraline HCl) mg, 37.5 mg
Serotonin Modulators venlafaxine hcl tabs 25 mg,
50 mg, 75 mg, 100 mg, 1
nefazodone hcl tabs 1 37.5 mg
NEFAZODONE venlafaxine hcl tb24 75 mg, 1
HYDROCHLORIDE TABS 3 150 mg, 37.5 mg
250 MG Tricyclic Agents
NEFAZODONE
HYDROCHLORIDE TABS 2 amitriptyline hcl tabs 1
50 MG
AMOXAPINE TABS 2
trazodone hcl tabs 1
ANAFRANIL CAPS (Use GP
TRINTELLIX TABS 3 ST; QL(1 ea Clomipramine HCl)
daily)
clomipramine hcl caps 1
VIIBRYD STARTER PACK 3 PA
KIT desipramine hcl tabs 1
VIIBRYD TABS 3 ST
doxepin hcl caps 10 mg, 25 1
Serotonin-Norepinephrine Reuptake Inhibitors mg, 50 mg, 75 mg, 100 mg
CYMBALTA CPEP (Use DOXEPIN HCL CAPS 150
GP QL(2 ea daily) MG
2
Duloxetine HCl)
DESVENLAFAXINE ER doxepin hcl caps 75 mg 1 MO
3 ST; QL(1 ea
TB24 50 MG, 100 MG daily)
desvenlafaxine succinate doxepin hcl conc 10 mg/ml 1
1
tb24 ELAVIL TABS (Use
duloxetine hcl cpep 20 mg, GP
1 QL(2 ea daily) Amitriptyline HCl)
30 mg, 60 mg
EFFEXOR XR CP24 150 imipramine hcl tabs 1
GP QL(2 ea daily)
MG (Use Venlafaxine HCl)
imipramine pamoate caps 1
EFFEXOR XR CP24 75 QL(1 ea daily)
MG, 37.5 MG (Use GP NORPRAMIN TABS (Use
Venlafaxine HCl) GP
Desipramine HCl)
FETZIMA CP24 20 MG 3 ST; QL(2 ea nortriptyline hcl caps 1
daily)
FETZIMA CP24 40 MG, 80 3 ST; QL(1 ea nortriptyline hcl soln 1
MG, 120 MG daily)
FETZIMA TITRATION PAMELOR CAPS (Use
3 ST Nortriptyline HCl) GP
PACK C4PK
KHEDEZLA TB24 3 ST; QL(1 ea protriptyline hcl tabs 1
daily)
PRISTIQ TB24 (Use SURMONTIL CAPS (Use GP
Desvenlafaxine Succinate) GP Trimipramine Maleate)
page ii-iii.
21
TOFRANIL TABS (Use GP JANUMET XR TB24 2
Imipramine HCl)
JENTADUETO TABS 3 PA
trimipramine maleate caps 1
ANTIDIABETICS - Drugs to Regulate Blood JENTADUETO XR TB24 3 PA
Sugar
KAZANO TABS 3 PA
Alpha-Glucosidase Inhibitors
acarbose tabs 1 KOMBIGLYZE XR TB24 3 PA
GLYSET TABS (Use OSENI TABS 3 PA

GP
Miglitol)
pioglitazone hcl-glimepiride 1
miglitol tabs 1 tabs
PRECOSE TABS (Use pioglitazone hcl-metformin 1
GP hcl tabs
Acarbose)
Antidiabetic - Amylin Analogs REPAGLINIDE/METFORM
IN HYDROCHLORIDE 3
SYMLINPEN 120 SOPN SP PA TABS
SYMLINPEN 60 SOPN SP PA SEGLUROMET TABS 3
Antidiabetic Combinations SYNJARDY TABS 2

ACTOPLUS MET TABS
(Use Pioglitazone HCl- GP XIGDUO XR TB24 3
Metformin HCl)
Biguanides
ACTOPLUS MET XR TB24 3 GLUCOPHAGE TABS GP PV
(Use Metformin HCl)
ALOGLIPTIN/METFORMIN 3 PA
HCL TABS GLUCOPHAGE XR TB24 GP
(Use Metformin HCl)
ALOGLIPTIN/PIOGLITAZO 3 PA
NE TABS GLUMETZA TB24 (Use GP PA
Metformin HCl)
DUETACT TABS (Use
Pioglitazone HCl- GP metformin hcl tabs 500 mg, PV PV
Glimepiride) 850 mg, 1000 mg
metformin hcl tb24 500 mg, 1 PA
glipizide-metformin hcl tabs 1 1000 mg
GLUCOVANCE TABS (Use GP metformin hcl tb24 500 mg, 1
Glyburide-Metformin) 750 mg
glyburide-metformin tabs 1 METFORMIN 3
HYDROCHLORIDE SOLN
GLYXAMBI TABS 2 RIOMET SOLN 3
INVOKAMET TABS 2 Diabetic Other
GLUCAGEN HYPOKIT SP
INVOKAMET XR TB24 2 SOLR
JANUMET TABS 2
page ii-iii.
22
Limit 1 per ADMELOG SOLOSTAR 3 PA; QL(1.5 ml
GLUCAGON SP year;QL(0.04 SOPN daily)
EMERGENCY KIT KIT ea daily)
AFREZZA POWD 3 PA
KORLYM TABS 3 PA
AFREZZA POWD 4 UNIT, 3 PA; QL(3 ea
PROGLYCEM SUSP 3 8 UNIT, 12 UNIT daily)
PA; Limit 45mls
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors per
APIDRA SOLN 3
month;QL(1.5
ALOGLIPTIN TABS 3 PA ml daily)
PA; Limit 45mls
JANUVIA TABS 2 APIDRA SOLOSTAR per
3
PA SOPN month;QL(1.5
NESINA TABS 3 ml daily)
ONGLYZA TABS 3 PA BASAGLAR KWIKPEN 3 PA
SOPN
TRADJENTA TABS 3 PA PA; Limit 45mls
FIASP FLEXTOUCH 3 per
Dopamine Receptor Agonists - Antidiabetic SOPN month;QL(1.5
ml daily)
CYCLOSET TABS 3 PA; Limit 40mls
Incretin Mimetic Agents (GLP-1 Receptor per
FIASP SOLN 3
month;QL(1.33
BYDUREON PEN PEN SP PA ml daily)
Limit 45mls per
BYDUREON SRER SP PA HUMALOG JUNIOR 2 month;QL(1.5
KWIKPEN SOPN ml daily)
BYETTA SOPN SP PA Limit 45mls per
HUMALOG KWIKPEN 2 month;QL(1.5
TANZEUM PEN SP PA SOPN 100 UNIT/ML ml daily)
Limit 24mls per
TRULICITY SOPN SP PA HUMALOG KWIKPEN 2 month;QL(0.8
SOPN 200 UNIT/ML ml daily)
VICTOZA SOPN SP PA
Limit 45mls per
HUMALOG MIX 50/50
Insulin Sensitizing Agents 2 month;QL(1.5
KWIKPEN SUPN ml daily)
ACTOS TABS (Use GP
Pioglitazone HCl) Limit 40mls per
HUMALOG MIX 50/50 2 month;QL(1.34
SUSP
AVANDIA TABS 2 ml daily)
Limit 45mls per
pioglitazone hcl tabs 1 HUMALOG MIX 75/25 2 month;QL(1.5
KWIKPEN SUPN ml daily)
Insulin Limit 40mls per
PA; Limit 45mls HUMALOG MIX 75/25 2 month;QL(1.34
per SUSP
ADMELOG SOLN 3 ml daily)
month;QL(1.5
ml daily) Limit 45mls per
HUMALOG SOCT 2 month;QL(1.5
ml daily)
page ii-iii.
23
Limit 45mls per PA; Limit 45mls
HUMALOG SOLN 2 month;QL(1.5
3 per
ml daily) NOVOLIN N SUSP month;QL(1.5
HUMULIN 70/30 KWIKPEN ml daily)
2
SUPN PA; Limit 45mls
Limit 45mls per NOVOLIN R RELION 3 per
HUMULIN 70/30 SUSP 2 month;QL(1.5 SOLN month;QL(1.5
ml daily) ml daily)
HUMULIN N KWIKPEN
SUPN
2 month;QL(1.5 NOVOLIN R SOLN 3 per
ml daily) month;QL(1.5
ml daily)
Limit 40mls per
HUMULIN N SUSP 2 month;QL(1.5 PA; Limit 45mls
ml daily) NOVOLOG FLEXPEN 3 per
SOPN month;QL(1.5
Limit 45mls per ml daily)
HUMULIN R SOLN 2 month;QL(1.5
ml daily) PA; Limit 45mls
NOVOLOG MIX 70/30
Limit 40mls per PREFILLED FLEXPEN 3 per
HUMULIN R U-500 month;QL(1.5
2 month;QL(1.34 SUPN
(CONCENTRATED) SOLN ml daily)
ml daily)
PA; Limit 45mls
Limit 40mls per NOVOLOG MIX 70/30
HUMULIN R U-500 2 month;QL(1.34 3 per
KWIKPEN SOPN SUSP month;QL(1.5
ml daily) ml daily)
LANTUS SOLN 2 month;QL(1.34 NOVOLOG PENFILL
ml daily) 3 per
SOCT month;QL(1.5
Limit 45mls per ml daily)
LANTUS SOLOSTAR 2 month;QL(1.5 PA; Limit 40mls
SOPN ml daily)
Limit 45mls per NOVOLOG SOLN 3 per
LEVEMIR FLEXTOUCH month;QL(1.33
2 month;QL(1.5 ml daily)
SOPN ml daily) Limit 3 boxes
Limit 45mls per TOUJEO MAX SOLOSTAR 2 per
LEVEMIR SOLN 2 month;QL(1.5 SOPN month;QL(0.5
ml daily) ml daily)
PA; Limit 45mls Limit 3 boxes
NOVOLIN 70/30 RELION per TOUJEO SOLOSTAR
SUSP
3
month;QL(1.5 2 per
SOPN month;QL(0.5
ml daily) ml daily)
PA; Limit 45mls Limit 45mls per
per TRESIBA FLEXTOUCH 2 month;QL(1.5
NOVOLIN 70/30 SUSP 3 SOPN 100 UNIT/ML
month;QL(1.5 ml daily)
ml daily) Limit 27mls per
PA; Limit 45mls TRESIBA FLEXTOUCH 2 month;QL(0.9
NOVOLIN N RELION per SOPN 200 UNIT/ML
3 ml daily)
SUSP month;QL(1.5
ml daily) Meglitinide Analogues
page ii-iii.
24
nateglinide tabs 1 MYTESI TBEC 3 PA; QL(2 ea
daily)
PRANDIN TABS (Use GP Antiperistaltic Agents
Repaglinide)
diphenoxylate w/ atropine 1
repaglinide tabs 1 liqd
STARLIX TABS (Use diphenoxylate w/ atropine 1
GP tabs
Nateglinide)
IMODIUM A-D CAPS (Use GP RX/OTC
Sodium-Glucose Co-Transporter 2 (SGLT2) Loperamide HCl)
FARXIGA TABS 3 LOMOTIL TABS (Use GP
Diphenoxylate w/ Atropine)
INVOKANA TABS 2 RX/OTC
loperamide hcl caps 1
JARDIANCE TABS 2
MOTOFEN TABS 2
STEGLATRO TABS 3
opium tincture tinc 1
Sulfonylureas
paregoric tinc 1
AMARYL TABS (Use GP
Glimepiride)
ANTIDOTES AND SPECIFIC ANTAGONISTS
chlorpropamide tabs 1
Antidotes - Chelating Agents
glimepiride tabs 1 CHEMET CAPS 2
glipizide tabs 1 deferasirox tbso SP PA
glipizide tb24 1 EXJADE TBSO (Use SP PA
Deferasirox)
GLUCOTROL TABS (Use GP
Glipizide) FERRIPROX SOLN 100 SP PA
MG/ML
GLUCOTROL XL TB24 GP
(Use Glipizide) FERRIPROX TABS 500 SP PA
MG
glyburide micronized tabs 1
JADENU SPRINKLE PACK SP PA
glyburide tabs 1
JADENU TABS SP PA
GLYNASE TABS (Use GP
Glyburide Micronized) Antidotes and Specific Antagonists
TOLAZAMIDE TABS 250 RADIOGARDASE CAPS 3 PA
2
MG
tolazamide tabs 500 mg 1 VISTOGARD PACK SP
Opioid Antagonists
tolbutamide tabs 1
EVZIO SOAJ SP PA
ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs
to Treat Diarrhea NALOXONE HCL SOCT SP
0.4 MG/ML
Antidiarrheal - Chloride Channel Antagonists
page ii-iii.
25
naloxone hcl soln 0.4 SP Limit 20 per
mg/ml, 4 mg/10ml ZUPLENZ FILM 3 month;QL(0.67
NALOXONE HCL SOSY 2 ea daily)
SP
MG/2ML Antiemetics - Anticholinergic
naltrexone hcl tabs 1 meclizine hcl tabs 1 RX/OTC
QL(4 ea per 30
NARCAN LIQD 3 scopolamine pt72 1
days retail)
VIVITROL SUSR SP PA TIGAN CAPS (Use GP
Trimethobenzamide HCl)
ANTIEMETICS - Drugs to Treat Nausea and TRANSDERM SCOP PT72 GP
Vomiting (Use Scopolamine)
5-HT3 Receptor Antagonists TRANSDERM-SCOP PT72 GP
(Use Scopolamine)
ALOXI SOLN (Use SP PA
Palonosetron HCl) trimethobenzamide hcl 1
caps
PA; Limit 2 per
ANZEMET TABS 3 month;QL(0.07 Antiemetics - Miscellaneous
ea daily) QL(2 ea per 28
AKYNZEO CAPS 3
PA; QL(2 ea days retail)
granisetron hcl tabs 1
daily)
CESAMET CAPS 3 PA; QL(2 ea
ondansetron hcl soln 4 daily)
1 QL(5 ml daily)
mg/5ml DICLEGIS TBEC (Use GP QL(4 ea daily)
QL(30 ea per Doxylamine-Pyridoxine)
ondansetron hcl tabs 4 mg, 1 30 days QL(4 ea daily)
8 mg retail,90 ea per doxylamine-pyridoxine tbec 1
90 days mail) PA
dronabinol caps 1
QL(30 ea per
ondansetron tbdp 1 30 days MARINOL CAPS (Use GP PA
retail,90 ea per Dronabinol)
90 days mail)
Substance P/Neurokinin 1 (NK1) Receptor
palonosetron hcl soln SP PA Limit 3 per
PALONOSETRON aprepitant caps 1 month;QL(0.1
SP PA ea daily)
HYDROCHLORIDE SOLN
PA Limit 2 per
SANCUSO PTCH 3 aprepitant caps 40 mg 1 month;QL(0.07
ea daily)
QL(30 ea per
ZOFRAN ODT TBDP (Use Limit 1 per
GP 30 days aprepitant caps 80 mg, 125 1 month;QL(0.04
Ondansetron) retail,90 ea per mg
90 days mail) ea daily)
EMEND CAPS 40 MG (Use GP Limit
ZOFRAN SOLN 4 MG/5ML 2 per
GP QL(5 ml daily) month;QL(0.07
(Use Ondansetron HCl) Aprepitant) ea daily)
QL(30 ea per
ZOFRAN TABS 4 MG, 8 Limit 1 per
MG (Use Ondansetron GP 30 days EMEND CAPS 80 MG, 125 GP month;QL(0.04
retail,90 ea per MG (Use Aprepitant)
HCl) 90 days mail) ea daily)
page ii-iii.
26
EMEND SUSR 125 MG 3 PA itraconazole caps 1 PA
EMEND TRIPACK CAPS Limit 3 per itraconazole soln 1 PA

GP month;QL(0.1
(Use Aprepitant)
ea daily) ketoconazole tabs 1
VARUBI TABS 3 QL(4 ea per fill
retail) NOXAFIL SUSP 3
ANTIFUNGALS - Drugs to Treat Fungal Infections
NOXAFIL TBEC 3
Antifungals PA
ONMEL TABS 3
AMPHOTERICIN B SOLR SP PA
SPORANOX CAPS (Use GP PA
ANCOBON CAPS (Use GP Itraconazole)
Flucytosine) SPORANOX PULSEPAK GP PA
BIO-STATIN CAPS 3 CAPS (Use Itraconazole)
SPORANOX SOLN (Use GP PA
flucytosine caps 1 Itraconazole)
GRIS-PEG TABS (Use VFEND IV SOLR (Use SP PA
Griseofulvin Ultramicrosize) GP Voriconazole)
griseofulvin microsize susp 1 VFEND SUSR 40 MG/ML 2

VFEND TABS 50 MG, 200 GP
griseofulvin microsize tabs 1 MG (Use Voriconazole)
griseofulvin ultramicrosize 1 voriconazole solr iv 200 mg SP PA
tabs
LAMISIL TABS (Use voriconazole susr or 40
GP QL(90 ea per mg/ml 1
Terbinafine HCl) 365 days retail)
voriconazole tabs or 50 mg, 1
nystatin powd 1 200 mg
nystatin tabs 1 ANTIHISTAMINES - Drugs to Treat Allergies
QL(90 ea per Antihistamines - Alkylamines
terbinafine hcl tabs 1
365 days retail) BROMPHENIRAMINE 3
Imidazole-Related Antifungals TANNATE CHEW
DEXCHLORPHENIRAMIN 2
CRESEMBA CAPS 3 E MALEATE SOLN
DIFLUCAN SUSR (Use GP RYCLORA SOLN 2
Fluconazole)
DIFLUCAN TABS (Use GP Antihistamines - Ethanolamines
Fluconazole) carbinoxamine maleate 1
fluconazole in dextrose SP PA soln
soln carbinoxamine maleate 1
fluconazole susr 1 tabs
CLEMASTINE FUMARATE 2
fluconazole tabs 1 TABS
page ii-iii.
27
diphenhydramine hcl caps 1 ANTIHYPERLIPIDEMICS - Drugs to Treat High
50 mg Cholesterol
diphenhydramine hcl elix 1 RX/OTC
Antihyperlipidemics - Combinations
12.5 mg/5ml
Antihistamines - Non-Sedating ezetimibe-simvastatin tabs 1 QL(1 ea daily)
RX/OTC VYTORIN TABS (Use
cetirizine hcl soln 1 GP QL(1 ea daily)
Ezetimibe-Simvastatin)
cetirizine hcl syrp 1 RX/OTC
Antihyperlipidemics - Misc.
CLARINEX SYRP 0.5 3 KYNAMRO SOSY SP PA
MG/ML
LOVAZA CAPS (Use
CLARINEX TABS 5 MG GP Omega-3-acid Ethyl Esters) GP
(Use Desloratadine)
omega-3-acid ethyl esters 1
DESLORATADINE ODT 3 caps
TBDP
VASCEPA CAPS 3 ST
desloratadine tabs 1
levocetirizine RX/OTC Bile Acid Sequestrants
1
dihydrochloride soln cholestyramine light pack 1
levocetirizine 1 RX/OTC
dihydrochloride tabs cholestyramine light powd 1
XYZAL ALLERGY 24HR RX/OTC
CHILDRENS SOLN (Use GP cholestyramine pack 1
Levocetirizine
Dihydrochloride) cholestyramine powd 1
XYZAL ALLERGY 24HR RX/OTC
TABS (Use Levocetirizine GP colesevelam hcl pack 1
Dihydrochloride)
ZYRTEC CHILDRENS RX/OTC colesevelam hcl tabs 1
ALLERGY SOLN (Use GP COLESTID FLAVORED
Cetirizine HCl) GP
GRAN (Use Colestipol HCl)
Antihistamines - Phenothiazines COLESTID FLAVORED GP
promethazine hcl soln or PACK (Use Colestipol HCl)
1
6.25 mg/5ml COLESTID GRAN (Use GP
promethazine hcl supp re Colestipol HCl)
1
25 mg, 50 mg, 12.5 mg COLESTID PACK (Use GP
promethazine hcl syrp or Colestipol HCl)
1
6.25 mg/5ml COLESTID TABS (Use GP
promethazine hcl tabs or Colestipol HCl)
1
25 mg, 50 mg, 12.5 mg
colestipol hcl gran 1
Antihistamines - Piperidines
colestipol hcl pack 1
cyproheptadine hcl syrp 1
colestipol hcl tabs 1
cyproheptadine hcl tabs 1
QUESTRAN LIGHT POWD GP
(Use Cholestyramine Light)
page ii-iii.
28
QUESTRAN PACK (Use GP atorvastatin calcium tabs 1 QL(1 ea daily)
Cholestyramine)
QUESTRAN POWD (Use CRESTOR TABS (Use GP QL(1 ea daily)
GP Rosuvastatin Calcium)
Cholestyramine)
WELCHOL PACK (Use fluvastatin sodium caps 1 QL(1 ea daily)
GP
Colesevelam HCl)
WELCHOL TABS (Use fluvastatin sodium tb24 1 QL(1 ea daily)
GP
Colesevelam HCl)
LESCOL XL TB24 (Use GP QL(1 ea daily)
Fibric Acid Derivatives Fluvastatin Sodium)
ANTARA CAPS 3 LIPITOR TABS (Use GP QL(1 ea daily)
Atorvastatin Calcium)
choline fenofibrate cpdr 1 LIVALO TABS 3 ST; QL(1 ea
daily)
FENOFIBRATE CAPS 50 3
MG, 150 MG $0 copay for
Generic only,
lovastatin tabs 1
age 40 to
fenofibrate micronized caps 1
75;PV
FENOFIBRATE TABS 160 PRAVACHOL TABS 20
2 QL(1 ea daily)
MG MG, 80 MG (Use GP
fenofibrate tabs 40 mg, 120 1 PA Pravastatin Sodium)
mg PRAVACHOL TABS 40 QL(2 ea daily)
fenofibrate tabs 48 mg, 54 1 MG (Use Pravastatin GP
mg, 145 mg, 160 mg Sodium)
fenofibric acid tabs 1 pravastatin sodium tabs 10 1 QL(1 ea daily)
mg, 20 mg, 80 mg
FENOGLIDE TABS (Use GP PA pravastatin sodium tabs 40 QL(2 ea daily)
Fenofibrate) 1
mg
FIBRICOR TABS (Use GP QL(1 ea daily)
Fenofibric Acid) rosuvastatin calcium tabs 1
gemfibrozil tabs 1 simvastatin tabs 5 mg, 10 1 QL(1 ea daily)
mg, 20 mg, 40 mg
LIPOFEN CAPS 3 simvastatin tabs 80 mg 1
LOFIBRA CAPS (Use GP ZOCOR TABS 5 MG, 10 QL(1 ea daily)
Fenofibrate Micronized) MG, 20 MG, 40 MG (Use GP
LOPID TABS (Use GP Simvastatin)
Gemfibrozil) ZOCOR TABS 80 MG (Use
TRICOR TABS (Use GP
GP Simvastatin)
Fenofibrate)
Intestinal Cholesterol Absorption Inhibitors
TRIGLIDE TABS 2
ezetimibe tabs 1
TRILIPIX CPDR (Use GP
Choline Fenofibrate) ZETIA TABS (Use GP
Ezetimibe)
HMG CoA Reductase Inhibitors
Microsomal Triglyceride Transfer Protein (MTP)
ALTOPREV TB24 3
JUXTAPID CAPS SP PA
page ii-iii.
29
Nicotinic Acid Derivatives VASOTEC TABS (Use GP QL(2 ea daily)
niacin (antihyperlipidemic) Enalapril Maleate)
1 ZESTRIL TABS (Use
tbcr GP
Lisinopril)
NIASPAN TBCR 2
Agents for Pheochromocytoma
Proprotein Convertase Subtilisin/Kexin Type 9 DEMSER CAPS 3
PRALUENT SOPN SP PA DIBENZYLINE CAPS (Use GP
REPATHA PUSHTRONEX Phenoxybenzamine HCl)
SP PA phenoxybenzamine hcl
SYSTEM SOCT 1
caps
REPATHA SOSY SP PA
Angiotensin II Receptor Antagonists
REPATHA SURECLICK SP PA ATACAND TABS (Use
SOAJ GP
Candesartan Cilexetil)
ANTIHYPERTENSIVES - Drugs to Treat High AVAPRO TABS (Use
Blood Pressure GP
Irbesartan)
ACE Inhibitors BENICAR TABS (Use GP
ACCUPRIL TABS (Use Olmesartan Medoxomil)
GP
Quinapril HCl) candesartan cilexetil tabs 1
ACEON TABS (Use GP
Perindopril Erbumine) COZAAR TABS (Use GP
Losartan Potassium)
ALTACE CAPS (Use GP
Ramipril) DIOVAN TABS (Use GP
Valsartan)
benazepril hcl tabs 1
EDARBI TABS 3
captopril tabs 1 EPROSARTAN 2
QL(2 ea daily) MESYLATE TABS
enalapril maleate tabs 1
irbesartan tabs 1
fosinopril sodium tabs 1
losartan potassium tabs 1
lisinopril tabs 1 MICARDIS TABS (Use GP
LOTENSIN TABS (Use Telmisartan)
GP
Benazepril HCl) olmesartan medoxomil tabs 1
moexipril hcl tabs 1
telmisartan tabs 1
perindopril erbumine tabs 1
valsartan tabs 1
PRINIVIL TABS (Use GP
Lisinopril) Antiadrenergic Antihypertensives
quinapril hcl tabs 1 CARDURA TABS (Use GP
Doxazosin Mesylate)
ramipril caps 1 CATAPRES TABS (Use GP
Clonidine HCl)
trandolapril tabs 1
page ii-iii.
30
clonidine hcl tabs 1 BYVALSON TABS 3
doxazosin mesylate tabs 1 candesartan cilexetil- 1

hydrochlorothiazide tabs
guanfacine hcl tabs 1 captopril & 1
methyldopa tabs 1 clonidine & chlorthalidone 1
tabs
METHYLDOPATE HCL SP PA
SOLN CLORPRES TABS 2
MINIPRESS CAPS (Use GP CORZIDE TABS 40MG-
Prazosin HCl) 5MG (Use Nadolol & GP
prazosin hcl caps 1 Bendroflumethiazide)
CORZIDE TABS 80MG- 2
terazosin hcl caps 1 5MG
DIOVAN HCT TABS (Use
Antihypertensive Combinations Valsartan- GP
ACCURETIC TABS (Use Hydrochlorothiazide)
Quinapril- GP
Hydrochlorothiazide) DUTOPROL TB24 3
amlodipine besylate- 1 EDARBYCLOR TABS 3
benazepril hcl caps
amlodipine besylate- ST enalapril maleate & 1
olmesartan medoxomil tabs 1 hydrochlorothiazide tabs
amlodipine besylate- EXFORGE HCT TABS
1 (Use Amlodipine-Valsartan- GP
valsartan tabs
amlodipine-valsartan- Hydrochlorothiazide)
1 EXFORGE TABS (Use
ATACAND HCT TABS Amlodipine Besylate- GP
(Use Candesartan Cilexetil- GP Valsartan)
Hydrochlorothiazide) fosinopril sodium & 1
atenolol & chlorthalidone hydrochlorothiazide tabs
1 HYZAAR TABS (Use
tabs
AVALIDE TABS (Use Losartan Potassium & GP
Irbesartan- GP Hydrochlorothiazide)
Hydrochlorothiazide) irbesartan- 1
AZOR TABS (Use ST hydrochlorothiazide tabs
Amlodipine Besylate- GP lisinopril & 1
Olmesartan Medoxomil) hydrochlorothiazide tabs
benazepril & LOPRESSOR HCT TABS
1 (Use Metoprolol & GP
BENICAR HCT TABS (Use Hydrochlorothiazide)
Olmesartan Medoxomil- GP losartan potassium & 1
Hydrochlorothiazide) hydrochlorothiazide tabs
bisoprolol & LOTENSIN HCT TABS
1 (Use Benazepril & GP
Hydrochlorothiazide)
page ii-iii.
31
LOTREL CAPS (Use trandolapril-verapamil hcl 1
Amlodipine Besylate- GP tbcr
Benazepril HCl) TRANDOLAPRIL/VERAPA 3
methyldopa & 1 MIL HCL ER TBCR
hydrochlorothiazide tabs TRIBENZOR TABS (Use ST
metoprolol & 1 Olmesartan Medoxomil- GP
hydrochlorothiazide tabs Amlodipine-
METOPROLOL Hydrochlorothiazide)
SUCCINATE 3 TWYNSTA TABS (Use GP
ER/HYDROCHLOROTHIA Telmisartan-Amlodipine)
ZIDE TB24 valsartan- 1
METOPROLOL/HYDROCH 2 hydrochlorothiazide tabs
LOROTHIAZIDE TABS VASERETIC TABS (Use
MICARDIS HCT TABS Enalapril Maleate & GP
(Use Telmisartan- GP Hydrochlorothiazide)
Hydrochlorothiazide) ZESTORETIC TABS (Use
moexipril- 1 Lisinopril & GP
hydrochlorothiazide tabs Hydrochlorothiazide)
nadolol & 1 ZIAC TABS (Use Bisoprolol GP
bendroflumethiazide tabs & Hydrochlorothiazide)
NADOLOL/BENDROFLUM 2 Antihypertensives - Misc.
ETHIAZIDE TABS
olmesartan medoxomil- ST VECAMYL TABS 3
amlodipine- 1
hydrochlorothiazide tabs Direct Renin Inhibitors
olmesartan medoxomil- aliskiren fumarate tabs 1 ST
1
TEKTURNA TABS 150 3 ST
propranolol & 1 MG, 300 MG
TEKTURNA TABS 150 ST
quinapril- 1 MG, 300 MG (Use Aliskiren GP
hydrochlorothiazide tabs Fumarate)
TARKA TBCR (Use
Trandolapril-Verapamil GP Selective Aldosterone Receptor Antagonists
HCl) eplerenone tabs 1
TEKTURNA HCT TABS 3 ST INSPRA TABS (Use GP
Eplerenone)
telmisartan-amlodipine tabs 1
Vasodilators
telmisartan- 1
hydrochlorothiazide tabs hydralazine hcl tabs 1
TENORETIC 100 TABS minoxidil tabs 1
(Use Atenolol & GP
Chlorthalidone) ANTIMALARIALS - Drugs to Treat Malaria
TENORETIC 50 TABS (Parasitic Infections)
(Use Atenolol & GP
Chlorthalidone) Antimalarial Combinations
page ii-iii.
32
atovaquone-proguanil hcl 1 MESTINON TABS 60 MG
tabs (Use Pyridostigmine GP
Limit 24 per Bromide)
COARTEM TABS 2 month;QL(0.8 MESTINON TIMESPAN
ea daily) TBCR (Use Pyridostigmine GP
MALARONE TABS (Use Bromide)
GP
Atovaquone-Proguanil HCl) pyridostigmine bromide 1 PA
soln 60 mg/5ml
Antimalarials
CHLOROQUINE pyridostigmine bromide 1 PA
PHOSPHATE TABS 250 2 syrp 60 mg/5ml
MG pyridostigmine bromide 1
chloroquine phosphate tabs 60 mg
1 pyridostigmine bromide tbcr 1
tabs 500 mg
PA 180 mg
DARAPRIM TABS 2
ANTIMYCOBACTERIAL AGENTS - Drugs to
hydroxychloroquine sulfate Treat Tuberculosis (Bacterial Infections)
1
tabs Anti TB Combinations
QL(2 ea per 30
KRINTAFEL TABS 2 RIFAMATE CAPS 2
days retail)
QL(6 ea per fill
mefloquine hcl tabs 1 retail,6 ea per RIFATER TABS 2
fill mail)
Antimycobacterial Agents
QL(6 ea per fill
MEFLOQUINE HCL TABS 2 retail,6 ea per CAPASTAT SULFATE SP PA
fill mail) SOLR
PLAQUENIL TABS (Use cycloserine caps 1
Hydroxychloroquine GP
Sulfate) ethambutol hcl tabs 1
primaquine phosphate tabs 1 ISONIAZID SOLN IJ 100 SP PA
MG/ML
PRIMAQUINE
PHOSPHATE TABS (Use GP isoniazid syrp or 50 mg/5ml 1
Primaquine Phosphate)
isoniazid tabs or 100 mg, 1
QUALAQUIN CAPS (Use GP PA; QL(2 ea 300 mg
Quinine Sulfate) daily)
MYAMBUTOL TABS (Use GP
quinine sulfate caps 1 PA; QL(2 ea Ethambutol HCl)
daily)
MYCOBUTIN CAPS (Use GP
ANTIMYASTHENIC/CHOLINERGIC AGENTS Rifabutin)
Antimyasthenic/Cholinergic Agents PASER PACK 3
FIRDAPSE TABS SP PA PRIFTIN TABS 3
GUANIDINE HCL TABS 2 pyrazinamide tabs 1
MESTINON SYRP 60 PA
MG/5ML (Use GP rifabutin caps 1
Pyridostigmine Bromide)
page ii-iii.
33
RIFADIN CAPS OR 150 GLIADEL WAFER WAFR AC
MG, 300 MG (Use GP
Rifampin) HEXALEN CAPS AC
RIFADIN SOLR IV 600 MG SP PA
(Use Rifampin) IFEX SOLR 1 GM (Use AC
rifampin caps or 150 mg, Ifosfamide)
1
300 mg IFEX SOLR 3 GM AC
rifampin solr iv 600 mg SP PA ifosfamide soln 1 gm/20ml, AC
3 gm/60ml
SIRTURO TABS SP
ifosfamide solr 1 gm AC
TRECATOR TABS 2
IFOSFAMIDE SOLR 3 GM AC
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer LEUKERAN TABS AC
Alkylating Agents
melphalan hcl solr AC PA
ALKERAN SOLR IV 50 MG AC PA
(Use Melphalan HCl) melphalan tabs AC
ALKERAN TABS OR 2 MG AC
(Use Melphalan) MUSTARGEN SOLR AC
BICNU SOLR (Use AC
Carmustine) MYLERAN TABS AC
busulfan soln AC PA oxaliplatin soln AC
BUSULFEX SOLN (Use AC PA
Busulfan) oxaliplatin solr AC
carboplatin soln AC TEMODAR CAPS OR 5
MG, 20 MG, 100 MG, 140 AC
carmustine solr AC MG, 180 MG, 250 MG (Use
Temozolomide)
CISPLATIN SOLN 200 AC TEMODAR SOLR IV 100
MG/200ML AC
MG
cisplatin soln 50 mg/50ml, AC
100 mg/100ml temozolomide caps AC
cyclophosphamide caps or AC
25 mg, 50 mg TEPADINA SOLR AC
CYCLOPHOSPHAMIDE thiotepa solr AC
CAPS OR 25 MG, 50 MG AC
(Use Cyclophosphamide)
TREANDA SOLR AC
cyclophosphamide solr ij 1 AC
gm, 2 gm, 500 mg ZANOSAR SOLR AC PA
GLEOSTINE CAPS 10 MG,
40 MG, 100 MG (Use GP Antimetabolites
Lomustine)
ALIMTA SOLR AC PA
GLEOSTINE CAPS 5 MG 3
azacitidine susr AC PA
page ii-iii.
34
capecitabine tabs AC methotrexate sodium tabs AC
or 2.5 mg
cladribine soln AC PA PURIXAN SUSP AC AL(Up to 13 yrs
old )
clofarabine soln AC PA TABLOID TABS AC
CLOLAR SOLN (Use AC PA
Clofarabine) TREXALL TABS AC
cytarabine soln AC PA VIDAZA SUSR (Use AC PA
Azacitidine)
CYTARABINEAQUEOUS AC PA XELODA TABS (Use
SOLN AC
Capecitabine)
DACOGEN SOLR (Use AC PA
Decitabine) Antineoplastic - Angiogenesis Inhibitors
decitabine solr AC PA AVASTIN SOLN AC
floxuridine solr AC PA CYRAMZA SOLN AC
fludarabine phosphate soln AC PA ZALTRAP SOLN AC

Antineoplastic - Antibodies
fludarabine phosphate solr AC PA
ADCETRIS SOLR AC PA
fluorouracil soln iv 1 PA
gm/20ml, 5 gm/100ml, 2.5 AC
ARZERRA CONC AC PA
gm/50ml, 500 mg/10ml
FOLOTYN SOLN AC BLINCYTO SOLR AC
gemcitabine hcl soln AC PA CAMPATH SOLN AC PA
gemcitabine hcl solr AC PA ERBITUX SOLN AC PA

GEMCITABINE SOLN (Use AC PA GAZYVA SOLN AC
Gemcitabine HCl)
GEMZAR SOLR (Use AC PA HERCEPTIN SOLR AC
Gemcitabine HCl)
mercaptopurine tabs AC KADCYLA SOLR AC
METHOTREXATE POWD AC KEYTRUDA SOLN AC PA
methotrexate sodium soln ij PA OPDIVO SOLN AC PA

1 gm/40ml, 50 mg/2ml, 250 AC
mg/10ml PERJETA SOLN AC PA
METHOTREXATE PA
SODIUM SOLN IJ 250 AC RITUXAN SOLN AC PA
MG/10ML
methotrexate sodium solr ij VECTIBIX SOLN AC
AC PA
1 gm
YERVOY SOLN AC PA
page ii-iii.
35
ZEVALIN Y-90 KIT AC flutamide caps AC
Antineoplastic - BCL-2 Inhibitors FULVESTRANT SOLN AC
VENCLEXTA STARTING AC
PACK TBPK fulvestrant soln AC
VENCLEXTA TABS AC HYDROXYPROGESTERO PA
NE CAPROATE SOLN SP
Antineoplastic - Cellular Immunotherapy 1.25 GM/5ML
PROVENGE SUSP AC letrozole tabs AC
Antineoplastic - Hedgehog Pathway Inhibitors leuprolide acetate kit AC PA
DAURISMO TABS AC PA LUPRON DEPOT (1- AC PA
MONTH) KIT
ERIVEDGE CAPS AC LUPRON DEPOT (3- AC PA;
MONTH) KIT
ODOMZO CAPS AC
LUPRON DEPOT (4- AC PA
Antineoplastic - Hormonal and Related Agents MONTH) KIT
abiraterone acetate tabs AC PA LYSODREN TABS AC
MEGESTROL ACETATE AC
anastrozole tabs AC POWD XX
ARIMIDEX TABS (Use megestrol acetate susp or AC
AC 40 mg/ml, 400 mg/10ml
Anastrozole)
AROMASIN TABS (Use megestrol acetate tabs or AC
AC 20 mg, 40 mg
Exemestane)
bicalutamide tabs AC NILANDRON TABS (Use AC
Nilutamide)
CASODEX TABS (Use
Bicalutamide) AC nilutamide tabs AC
DEPO-PROVERA SUSP AC PA SOLTAMOX SOLN AC
ELIGARD KIT AC PA tamoxifen citrate tabs PV PV
EMCYT CAPS AC toremifene citrate tabs AC
exemestane tabs AC TRELSTAR MIXJECT AC PA

SUSR
FARESTON TABS (Use AC
Toremifene Citrate) VANTAS KIT AC
FASLODEX SOLN (Use AC XTANDI CAPS AC PA
Fulvestrant)
FEMARA TABS (Use AC ZOLADEX IMPL AC
Letrozole)
ZYTIGA TABS (Use AC PA
FIRMAGON SOLR AC PA Abiraterone Acetate)
Antineoplastic - Immunomodulators
page ii-iii.
36
LEVAMISOLE HCL POWD AC Antineoplastic Enzyme Inhibitors
AFINITOR DISPERZ TBSO AC PA
POMALYST CAPS AC PA
Antineoplastic Antibiotics AFINITOR TABS AC PA
ADRIAMYCIN SOLR AC ALECENSA CAPS AC PA
bleomycin sulfate solr AC BELEODAQ SOLR AC

COSMEGEN SOLR (Use AC BOSULIF TABS AC PA
Dactinomycin)
dactinomycin solr AC BRAFTOVI CAPS AC PA
DOXIL INJ (Use CABOMETYX TABS AC PA
Doxorubicin HCl AC
Liposomal) CAPRELSA TABS AC PA
doxorubicin hcl liposomal AC
inj COMETRIQ KIT AC PA
doxorubicin hcl soln AC
COPIKTRA CAPS AC PA
doxorubicin hcl solr AC
COTELLIC TABS AC PA
ELLENCE SOLN (Use AC
Epirubicin HCl) erlotinib hcl tabs AC PA
epirubicin hcl soln AC FARYDAK CAPS AC PA
IDAMYCIN PFS SOLN
(Use Idarubicin HCl)
AC GILOTRIF TABS AC PA
idarubicin hcl soln AC GLEEVEC TABS (Use AC
Imatinib Mesylate)
mitomycin solr AC IBRANCE CAPS AC PA
mitoxantrone hcl conc AC PA ICLUSIG TABS AC PA
valrubicin soln AC imatinib mesylate tabs AC
VALSTAR SOLN (Use IMBRUVICA CAPS 70 MG,
Valrubicin) AC AC PA
140 MG
Antineoplastic Combinations IMBRUVICA TABS 140 PA; QL(1 ea
KISQALI FEMARA 200 MG, 280 MG, 420 MG, 560 AC daily)
AC PA MG
DOSE TBPK
KISQALI FEMARA 400 AC PA INLYTA TABS AC PA
DOSE TBPK
KISQALI FEMARA 600 AC PA IRESSA TABS SP
DOSE TBPK
ISTODAX (OVERFILL) AC PA
LONSURF TABS AC PA SOLR
page ii-iii.
37
JAKAFI TABS AC PA TARCEVA TABS (Use AC PA
Erlotinib HCl)
KISQALI TBPK AC PA TASIGNA CAPS AC PA
KYPROLIS SOLR AC temsirolimus soln AC PA
LENVIMA 10 MG DAILY AC PA
DOSE CPPK TIBSOVO TABS AC PA
LENVIMA 14 MG DAILY AC PA TORISEL SOLN (Use AC PA
DOSE CPPK Temsirolimus)
LENVIMA 18 MG DAILY SP PA TYKERB TABS AC
DOSE CPPK
LENVIMA 20 MG DAILY AC PA VELCADE SOLR AC PA
DOSE CPPK
LENVIMA 24 MG DAILY AC PA VITRAKVI CAPS AC PA
DOSE CPPK
LENVIMA 8 MG DAILY VITRAKVI SOLN AC PA
SP PA
DOSE CPPK
VIZIMPRO TABS AC PA
LORBRENA TABS AC PA
VOTRIENT TABS AC
LYNPARZA CAPS AC PA
XALKORI CAPS AC PA
LYNPARZA TABS AC PA
XOSPATA TABS AC PA
MEKINIST TABS AC PA
ZELBORAF TABS AC PA
MEKTOVI TABS AC PA
ZOLINZA CAPS AC PA
NEXAVAR TABS AC PA
ZYDELIG TABS AC PA
NINLARO CAPS SP PA
ZYKADIA CAPS AC PA
ROMIDEPSIN SOLR AC PA
Antineoplastic Enzymes
RUBRACA TABS AC PA
ERWINAZE SOLR AC
SPRYCEL TABS AC PA
ONCASPAR SOLN AC
STIVARGA TABS AC PA; SP
Antineoplastic Radiopharmaceuticals
SUTENT CAPS AC METASTRON SOLN AC
TAFINLAR CAPS AC PA QUADRAMET SOLN AC
TAGRISSO TABS AC PA XOFIGO SOLN AC
TALZENNA CAPS AC PA Antineoplastics Misc.
page ii-iii.
38
ACTIMMUNE SOLN AC PA Chemotherapy Rescue/Antidote Agents
dexrazoxane hcl solr AC
ALFERON N SOLN AC PA
FUSILEV SOLR (Use AC
arsenic trioxide soln AC Levoleucovorin Calcium)
leucovorin calcium solr ij AC PA
bexarotene caps AC PA 100 mg, 200 mg, 350 mg
DACARBAZINE SOLR 100 leucovorin calcium solr ij 50 AC
AC mg, 500 mg
MG
LEUCOVORIN CALCIUM AC
dacarbazine solr 200 mg AC TABS OR 10 MG, 15 MG
HYDREA CAPS (Use leucovorin calcium tabs or AC
AC 5 mg, 25 mg
Hydroxyurea)
hydroxyurea caps AC levoleucovorin calcium soln AC
INTRON A SOLN AC PA levoleucovorin calcium solr AC
INTRON A SOLR AC PA mesna soln AC

INTRON A W/DILUENT MESNEX SOLN IV 100
AC PA MG/ML (Use Mesna)
AC
SOLR
MATULANE CAPS AC PA MESNEX TABS OR 400 AC
MG
NIPENT SOLR AC TOTECT SOLR AC
PHOTOFRIN SOLR AC VORAXAZE SOLR AC
PROLEUKIN SOLR AC ZINECARD SOLR (Use AC
Dexrazoxane HCl)
SYLATRON KIT AC PA Mitotic Inhibitors
SYNRIBO SOLR AC PA ABRAXANE SUSR AC
TARGRETIN CAPS OR 75 DOCETAXEL CONC 160
AC PA MG/8ML (Use Docetaxel)
AC
MG (Use Bexarotene)
DOCETAXEL CONC 20
TICE BCG SUSR AC MG/ML, 80 MG/2ML, 80 AC
tretinoin (chemotherapy) MG/4ML, 160 MG/8ML, 20
AC MG/0.5ML
caps
docetaxel conc 20 mg/ml, AC
TRISENOX SOLN AC 80 mg/4ml, 160 mg/8ml
DOCETAXEL SOLN 20
UVADEX SOLN AC PA MG/2ML, 80 MG/8ML, 160 AC
Chemotherapy Adjuncts MG/16ML
docetaxel soln 20 mg/2ml, AC
ELITEK SOLR AC 80 mg/8ml, 160 mg/16ml
KEPIVANCE SOLR AC PA
page ii-iii.
39
DOCETAXEL SOLN 20 HYCAMTIN SOLR IV 4 MG AC PA
MG/2ML, 80 MG/8ML, 160 AC (Use Topotecan HCl)
MG/16ML (Use Docetaxel)
irinotecan hcl soln AC
ETOPOPHOS SOLR AC PA
IRINOTECAN SOLN AC
etoposide caps or 50 mg AC
TOPOTECAN HCL SOLN AC
etoposide soln iv 1 PA 4 MG/4ML
gm/50ml, 100 mg/5ml, 500 AC topotecan hcl soln 4
mg/25ml AC
mg/4ml
HALAVEN SOLN AC TOPOTECAN HCL SOLN
4 MG/4ML (Use Topotecan AC
IXEMPRA KIT SOLR AC HCl)
topotecan hcl solr 4 mg AC PA
JEVTANA SOLN AC
ANTIPARKINSON AND RELATED THERAPY
MARQIBO SUSP AC AGENTS - Drugs to Treat Parkinson's Disease
NAVELBINE SOLN (Use AC Antiparkinson Adjuvants
Vinorelbine Tartrate)
carbidopa tabs 1
PACLITAXEL CONC 150 AC
MG/25ML LODOSYN TABS (Use GP
paclitaxel conc 30 mg/5ml, Carbidopa)
300 mg/50ml, 100 AC Antiparkinson Anticholinergics
mg/16.7ml
benztropine mesylate soln SP PA
TAXOL CONC (Use AC ij 1 mg/ml
Paclitaxel)
benztropine mesylate tabs 1
TAXOTERE CONC (Use AC or 0.5 mg, 1 mg, 2 mg
Docetaxel)
COGENTIN SOLN (Use SP PA
TENIPOSIDE SOLN AC Benztropine Mesylate)
VINBLASTINE SULFATE trihexyphenidyl hcl soln 1
AC
SOLN
VINCRISTINE SULFATE trihexyphenidyl hcl tabs 1
AC
SOLN
Antiparkinson COMT Inhibitors
vincristine sulfate soln AC COMTAN TABS (Use GP
Entacapone)
vinorelbine tartrate soln AC
entacapone tabs 1
Topoisomerase I Inhibitors
TASMAR TABS (Use GP
CAMPTOSAR SOLN 300 AC Tolcapone)
MG/15ML
CAMPTOSAR SOLN 40 tolcapone tabs 1
MG/2ML, 100 MG/5ML AC
(Use Irinotecan HCl) Antiparkinson Dopaminergics
HYCAMTIN CAPS OR 0.25 AC PA amantadine hcl caps 1
MG, 1 MG
page ii-iii.
40
amantadine hcl syrp 1 RYTARY CPCR 3 PA
amantadine hcl tabs 1 SINEMET CR TBCR (Use GP

Carbidopa-Levodopa)
bromocriptine mesylate 1 SINEMET TABS (Use
caps GP
Carbidopa-Levodopa)
bromocriptine mesylate 1 STALEVO 100 TABS (Use
tabs Carbidopa-Levodopa- GP
carbidopa-levodopa tabs 1 Entacapone)
STALEVO 125 TABS (Use
carbidopa-levodopa tbcr 1 Carbidopa-Levodopa- GP
Entacapone)
carbidopa-levodopa tbdp 1 STALEVO 150 TABS (Use
Carbidopa-Levodopa- GP
carbidopa-levodopa- 1 Entacapone)
entacapone tabs STALEVO 200 TABS (Use
DUOPA SUSP SP Carbidopa-Levodopa- GP
Entacapone)
MIRAPEX ER TB24 (Use STALEVO 50 TABS (Use
Pramipexole GP Carbidopa-Levodopa- GP
Dihydrochloride) Entacapone)
MIRAPEX TABS (Use STALEVO 75 TABS (Use
Pramipexole GP Carbidopa-Levodopa- GP
Dihydrochloride) Entacapone)
NEUPRO PT24 1
MG/24HR, 3 MG/24HR, 8 3 Antiparkinson Monoamine Oxidase Inhibitors
MG/24HR AZILECT TABS (Use GP
NEUPRO PT24 2 QL(3 ea daily) Rasagiline Mesylate)
3 ELDEPRYL CAPS (Use
MG/24HR GP
NEUPRO PT24 4 QL(1 ea daily) Selegiline HCl)
3
MG/24HR, 6 MG/24HR rasagiline mesylate tabs 1
PARLODEL CAPS (Use GP
Bromocriptine Mesylate) selegiline hcl caps 1
PARLODEL TABS (Use GP
Bromocriptine Mesylate) SELEGILINE HCL TABS 2
pramipexole 1
dihydrochloride tabs selegiline hcl tabs 1
pramipexole 1
dihydrochloride tb24 ZELAPAR TBDP 3
REQUIP TABS (Use GP ANTIPSYCHOTICS/ANTIMANIC AGENTS -
Ropinirole Hydrochloride) Drugs to Treat Mood Disorders
REQUIP XL TB24 (Use GP Antimanic Agents
Ropinirole Hydrochloride)
ropinirole hydrochloride lithium carbonate caps 1
1
tabs
ropinirole hydrochloride lithium carbonate tabs 1
1
tb24
page ii-iii.
41
lithium carbonate tbcr 1 RISPERDAL TABS (Use GP
Risperidone)
LITHIUM SOLN 3 RISPERIDONE ODT TBDP 3
LITHOBID TBCR (Use 3
Lithium Carbonate) risperidone soln 1
Antipsychotics - Misc. risperidone tabs 1
EQUETRO CP12 3
risperidone tbdp 1
GEODON CAPS OR 20
MG, 40 MG, 60 MG, 80 MG GP Butyrophenones
(Use Ziprasidone HCl) haloperidol lactate conc 1
GEODON SOLR IM 20 MG SP PA
haloperidol tabs 1
LATUDA TABS 3 PA
Dibenzapines
PA; QL(1 ea
NUPLAZID CAPS 3 CLOZAPINE ODT TBDP 3
daily)
PA; QL(1 ea clozapine tabs 25 mg, 50
NUPLAZID TABS 3 1
daily) mg, 100 mg, 200 mg
VRAYLAR CAPS 3 PA CLOZAPINE TABS 50 MG, GP
200 MG (Use Clozapine)
VRAYLAR CPPK 3 PA clozapine tbdp 25 mg, 100 1
mg, 12.5 mg
ziprasidone hcl caps 1 CLOZARIL TABS (Use GP
Clozapine)
Benzisoxazoles FAZACLO TBDP 150 MG,
PA 3
FANAPT TABS 3 200 MG
FAZACLO TBDP 25 MG,
FANAPT TITRATION 3 PA 100 MG, 12.5 MG (Use GP
PACK TABS Clozapine)
INVEGA SUSTENNA SP PA
SUSY loxapine succinate caps 1
INVEGA TB24 (Use
Paliperidone) GP olanzapine solr im 10 mg SP PA
INVEGA TRINZA SUSY SP PA olanzapine tabs or 5 mg,

10 mg, 15 mg, 20 mg, 2.5 1
paliperidone tb24 1 mg, 7.5 mg
olanzapine tbdp or 5 mg, 1
PERSERIS PRSY SP PA 10 mg, 15 mg, 20 mg
quetiapine fumarate tabs
RISPERDAL CONSTA SP PA 25 mg, 50 mg, 100 mg, 200 1
SUSR mg, 300 mg, 400 mg
RISPERDAL M-TAB TBDP GP quetiapine fumarate tb24 PA
(Use Risperidone) 50 mg, 150 mg, 200 mg, 1
RISPERDAL SOLN (Use GP 300 mg, 400 mg
Risperidone)
page ii-iii.
42
SAPHRIS SUBL 3 PA Quinolinone Derivatives
ABILIFY TABS (Use GP
SEROQUEL TABS (Use GP Aripiprazole)
Quetiapine Fumarate)
SEROQUEL XR TB24 (Use GP PA aripiprazole soln 1 mg/ml 1
Quetiapine Fumarate) aripiprazole tabs 2 mg, 5
VERSACLOZ SUSP 3 QL(18 ml daily) mg, 10 mg, 15 mg, 20 mg, 1
30 mg
ZYPREXA SOLR IM 10 SP PA aripiprazole tbdp 10 mg, 15 PA
MG (Use Olanzapine) 1
mg
ZYPREXA TABS OR 5 PA
MG, 10 MG, 15 MG, 20 REXULTI TABS 3
GP
MG, 2.5 MG, 7.5 MG (Use
Olanzapine) Thioxanthenes
ZYPREXA ZYDIS TBDP GP thiothixene caps 1
(Use Olanzapine)
Dihydroindolones ANTISEPTICS & DISINFECTANTS
MOLINDONE 2 Antiseptics & Disinfectants
HYDROCHLORIDE TABS
FORMALDEHYDE SOLN 3
Phenothiazines 10 %
chlorpromazine hcl tabs 1 formaldehyde soln 10%, 10 1
%
fluphenazine hcl conc 5 1
mg/ml ANTIVIRALS - Drugs to Treat Viral Infections
fluphenazine hcl elix 2.5 1 Antiretrovirals
mg/5ml
fluphenazine hcl tabs 1 mg, abacavir sulfate soln 1
1
5 mg, 10 mg, 2.5 mg
FLUPHENAZINE HCL abacavir sulfate tabs 1
TABS 1 MG, 5 MG, 10 MG, 2 abacavir sulfate-lamivudine
2.5 MG 1
tabs
perphenazine tabs 1 abacavir sulfate- 1
lamivudine-zidovudine tabs
prochlorperazine edisylate SP PA
soln 10 mg/2ml APTIVUS CAPS 2
PROCHLORPERAZINE PA
EDISYLATE SOLN 50 SP APTIVUS SOLN 2
MG/10ML
atazanavir sulfate caps 1
prochlorperazine maleate 1
tabs ST
ATRIPLA TABS 2
prochlorperazine supp 1
COMBIVIR TABS (Use GP
Lamivudine-Zidovudine)
thioridazine hcl tabs 1
COMPLERA TABS 2 ST
trifluoperazine hcl tabs 1
CRIXIVAN CAPS 2
page ii-iii.
43
DELSTRIGO TABS 3 ST lamivudine soln 1
DESCOVY TABS 2 lamivudine tabs 1
didanosine cpdr 1 lamivudine-zidovudine tabs 1
EDURANT TABS 2 LEXIVA SUSP 50 MG/ML 2
efavirenz caps 1 LEXIVA TABS 700 MG

(Use Fosamprenavir GP
efavirenz tabs 1 Calcium)
lopinavir-ritonavir soln 1
EMTRIVA CAPS 2
nevirapine tabs 1
EMTRIVA SOLN 2
EPIVIR SOLN (Use nevirapine tb24 1
GP
Lamivudine)
NORVIR CAPS 100 MG 2
EPIVIR TABS (Use GP
Lamivudine) NORVIR PACK 100 MG 3
EPZICOM TABS (Use
Abacavir Sulfate- GP NORVIR SOLN 80 MG/ML 2
Lamivudine)
NORVIR TABS 100 MG GP
EVOTAZ TABS 2 (Use Ritonavir)
fosamprenavir calcium tabs 1 PIFELTRO TABS 2
FUZEON SOLR SP PA PREZCOBIX TABS 2

PREZISTA SUSP 100 3
GENVOYA TABS 2 MG/ML
INTELENCE TABS 2 PREZISTA TABS 75 MG, 2
150 MG, 600 MG, 800 MG
INVIRASE CAPS 2 RESCRIPTOR TABS 2
INVIRASE TABS 2 RETROVIR CAPS (Use GP
Zidovudine)
ISENTRESS CHEW 2 RETROVIR SYRP (Use GP
Zidovudine)
ISENTRESS PACK 2 REYATAZ CAPS 150 MG,
200 MG, 300 MG (Use GP
ISENTRESS TABS 2 Atazanavir Sulfate)
KALETRA SOLN REYATAZ PACK 50 MG 2
400MG/5ML-100MG/5ML GP
(Use Lopinavir-Ritonavir) ritonavir tabs 1
KALETRA TABS 100MG- 2
25MG, 200MG-50MG SELZENTRY TABS 2
page ii-iii.
44
stavudine caps 1 ZIAGEN SOLN (Use GP
Abacavir Sulfate)
STRIBILD TABS 2 ZIAGEN TABS (Use GP
Abacavir Sulfate)
SUSTIVA CAPS (Use GP
Efavirenz) zidovudine caps 1
SUSTIVA TABS (Use GP
Efavirenz) zidovudine syrp 1
SYMTUZA TABS 3 ST zidovudine tabs 1

tenofovir disoproxil 1 CMV Agents
fumarate tabs
cidofovir soln SP PA
TIVICAY TABS 2
FOSCAVIR SOLN SP PA
TRIUMEQ TABS 2
TRIZIVIR TABS (Use PREVYMIS TABS SP PA; SP
Abacavir Sulfate- GP VALCYTE SOLR 50 QL(21 ml daily)
Lamivudine-Zidovudine) MG/ML (Use Valganciclovir GP
TRUVADA TABS 2 HCl)
VALCYTE TABS 450 MG GP
TYBOST TABS 2 (Use Valganciclovir HCl)
valganciclovir hcl solr 50 1 QL(21 ml daily)
VIDEX EC CPDR 125 MG 2 mg/ml
VIDEX EC CPDR 200 MG, valganciclovir hcl tabs 450 1
250 MG, 400 MG (Use GP mg
Didanosine) Hepatitis Agents
VIDEXPEDIATRIC SOLR 2 adefovir dipivoxil tabs 1
VIRACEPT TABS 2 BARACLUDE SOLN 0.05 2
MG/ML
VIRAMUNE TABS (Use BARACLUDE TABS 0.5
Nevirapine) GP GP PA
MG, 1 MG (Use Entecavir)
VIRAMUNE XR TB24 (Use COPEGUS TABS (Use
Nevirapine) GP GP PA
Ribavirin (Hepatitis C))
VIREAD POWD 40 MG/GM 2 DAKLINZA TABS SP PA
VIREAD TABS 150 MG, 2
200 MG, 250 MG entecavir tabs 1
VIREAD TABS 300 MG
(Use Tenofovir Disoproxil GP EPCLUSA TABS SP PA
Fumarate) EPIVIR HBV SOLN 5 3
ZERIT CAPS 15 MG, 20 MG/ML
MG, 30 MG, 40 MG (Use GP EPIVIR HBV TABS 100
Stavudine) MG (Use Lamivudine GP
ZERIT SOLR 1 MG/ML 2 (HBV))
page ii-iii.
45
HARVONI TABS SP PA Herpes Agents
acyclovir caps 1
HEPSERA TABS 2
acyclovir susp 1
lamivudine (hbv) tabs 1
LEDIPASVIR/SOFOSBUVI acyclovir tabs 1
SP PA
R TABS
famciclovir tabs 1
MAVYRET TABS SP PA
MODERIBA 1200 DOSE PA valacyclovir hcl tabs 1
PACK TABS (Use Ribavirin 3 VALTREX TABS (Use
(Hepatitis C)) GP
Valacyclovir HCl)
MODERIBA 800 DOSE PA ZOVIRAX CAPS OR 200
PACK TABS (Use Ribavirin 3 GP
MG (Use Acyclovir)
(Hepatitis C))
ZOVIRAX SUSP OR 200 GP
OLYSIO CAPS SP PA MG/5ML (Use Acyclovir)
PEGASYS PROCLICK ZOVIRAX TABS OR 400
SP PA MG, 800 MG (Use GP
SOLN
Acyclovir)
PEGASYS SOLN SP PA Influenza Agents
PEGINTRON KIT SP PA FLUMADINE TABS (Use
Rimantadine GP
REBETOL CAPS 200 MG PA Hydrochloride)
(Use Ribavirin (Hepatitis GP QL(10 ea per
C)) fill retail,10 ea
oseltamivir phosphate caps 1 per fill mail);
REBETOL SOLN 40 2 PA 30 mg, 45 mg
MG/ML AL(At least 1
RIBASPHERE RIBAPAK PA yrs old)
2 oseltamivir phosphate caps
TABS 1
PA 75 mg
RIBASPHERE TABS 2 QL(120 ml per
PA 30 days retail);
ribavirin (hepatitis c) caps 1 oseltamivir phosphate susr 1 AL(At least 1
6 mg/ml yrs old - Up to
ribavirin (hepatitis c) tabs 1 PA
12 yrs old)
SOFOSBUVIR/VELPATAS Limit 20 per
SP PA RELENZA DISKHALER 3 month;QL(0.67
VIR TABS AEPB ea daily)
SOVALDI TABS SP PA rimantadine hydrochloride 1
tabs
TECHNIVIE TABS SP PA
QL(10 ea per
VIEKIRA PAK TBPK SP PA TAMIFLU CAPS 30 MG, 45 fill retail,10 ea
MG (Use Oseltamivir GP per fill mail);
Phosphate) AL(At least 1
VIEKIRA XR TB24 SP PA yrs old)
ZEPATIER TABS SP PA
page ii-iii.
46
TAMIFLU CAPS 75 MG metoprolol tartrate tabs 25 1
(Use Oseltamivir GP mg, 50 mg, 100 mg
Phosphate) METOPROLOL PA
QL(120 ml per TARTRATE TABS 75 MG, 3
TAMIFLU SUSR 6 MG/ML 30 days retail); 37.5 MG
(Use Oseltamivir GP AL(At least 1 TENORMIN TABS (Use
Phosphate) yrs old - Up to GP
Atenolol)
12 yrs old)
TOPROL XL TB24 (Use GP
Respiratory Syncytial Virus (RSV) Agents Metoprolol Succinate)
ribavirin solr 1 Beta Blockers Non-Selective
BETAPACE AF TABS (Use GP
VIRAZOLE SOLR (Use GP Sotalol HCl (AFIB/AFL))
Ribavirin)
BETAPACE TABS (Use GP
BETA BLOCKERS - Drugs to Treat High Blood Sotalol HCl)
Pressure CORGARD TABS (Use GP
Alpha-Beta Blockers Nadolol)
carvedilol phosphate cp24 1 AL(Up to 1 yrs
HEMANGEOL SOLN 3
old )
carvedilol tabs 25 mg, 12.5 1 INDERAL LA CP24 (Use
mg, 6.25 mg GP
Propranolol HCl)
carvedilol tabs 3.125 mg 1 QL(2 ea daily)
INDERAL XL CP24 3
COREG CR CP24 (Use GP
Carvedilol Phosphate) INNOPRAN XL CP24 3
COREG TABS 25 MG, nadolol tabs 1
12.5 MG, 6.25 MG (Use GP
Carvedilol) pindolol tabs 1
COREG TABS 3.125 MG GP QL(2 ea daily)
(Use Carvedilol) propranolol hcl cp24 1
labetalol hcl tabs 1
propranolol hcl soln 1
Beta Blockers Cardio-Selective
propranolol hcl tabs 1
acebutolol hcl caps 1
sotalol hcl (afib/afl) tabs 1
atenolol tabs 1
sotalol hcl tabs 1
betaxolol hcl tabs 1
QL(1 ea daily) SOTYLIZE SOLN 3
bisoprolol fumarate tabs 1
timolol maleate tabs 1 QL(2 ea daily)
BYSTOLIC TABS 3
CALCIUM CHANNEL BLOCKERS - Drugs to
LOPRESSOR TABS (Use GP Treat High Blood Pressure
Metoprolol Tartrate)
Calcium Channel Blockers
metoprolol succinate tb24 1
ADALAT CC TB24 30 MG, GP
60 MG (Use Nifedipine)
page ii-iii.
47
ADALAT CC TB24 90 MG GP QL(1 ea daily) nimodipine caps 1
(Use Nifedipine)
amlodipine besylate tabs 1 QL(2 ea daily) nisoldipine tb24 1
CALAN SR TBCR (Use NORVASC TABS (Use GP QL(2 ea daily)
GP Amlodipine Besylate)
Verapamil HCl)
CALAN TABS (Use GP NYMALIZE SOLN 3
Verapamil HCl)
CARDIZEM CD CP24 (Use QL(1 ea daily) PROCARDIA CAPS (Use GP
Diltiazem HCl Coated GP Nifedipine)
Beads) PROCARDIA XL TB24 GP QL(1 ea daily)
CARDIZEM LA TB24 120 (Use Nifedipine)
2 SULAR TB24 (Use
MG GP
CARDIZEM LA TB24 180 Nisoldipine)
MG, 240 MG, 300 MG, 360 TIAZAC CP24 (Use
MG, 420 MG (Use GP Diltiazem HCl Extended GP
Diltiazem HCl Coated Release Beads)
Beads)
verapamil hcl cp24 1
CARDIZEM TABS (Use GP
Diltiazem HCl) VERAPAMIL HCL ER 3
CP24
DILT-XR CP24 2
VERAPAMIL HCL SR 2
diltiazem hcl coated beads QL(1 ea daily) CP24
cp24 120 mg, 180 mg, 240 1
mg, 300 mg, 360 mg verapamil hcl tabs 1
diltiazem hcl coated beads verapamil hcl tbcr 1
tb24 180 mg, 240 mg, 300 1
mg, 360 mg, 420 mg VERELAN CP24 120 MG,
180 MG, 240 MG (Use GP
diltiazem hcl cp12 1 Verapamil HCl)
diltiazem hcl cp24 1 VERELAN CP24 360 MG 2
diltiazem hcl extended VERELAN PM CP24 100 3
1 MG, 300 MG
release beads cp24
diltiazem hcl tabs 1 VERELAN PM CP24 200 GP
MG (Use Verapamil HCl)
felodipine tb24 1 CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
isradipine caps 1 Cardiac Glycosides
nicardipine hcl caps 1 digoxin soln 1
nifedipine caps 10 mg, 20 1 digoxin tabs 1
mg
nifedipine tb24 30 mg, 60 LANOXIN TABS 125 MCG, 3
1 250 MCG (Use Digoxin)
mg
nifedipine tb24 30 mg, 60 QL(1 ea daily) LANOXIN TABS 62.5 3
1 MCG, 187.5 MCG
mg, 90 mg
page ii-iii.
48
CARDIOVASCULAR AGENTS - MISC. - Drugs to VENTAVIS SOLN SP PA
Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations Pulmonary Hypertension - Endothelin Receptor
amlodipine besylate- ambrisentan tabs SP PA
1
atorvastatin calcium tabs
PA; PA
BIDIL TABS 3 Required to
bosentan tabs SP direct to
CADUET TABS (Use Caremark
Amlodipine Besylate- GP Specialty
Atorvastatin Calcium)
LETAIRIS TABS (Use SP PA
ENTRESTO TABS 3 PA Ambrisentan)
Impotence Agents OPSUMIT TABS SP PA
PA; Limited to PA; PA
6 per Required to
TRACLEER TABS (Use
sildenafil citrate tabs 1 month;QL(6 ea Bosentan) SP direct to
per 30 days Caremark
retail,18 ea per Specialty
90 days mail)
Pulmonary Hypertension - Phosphodiesterase
PA; Limited to
6 per ADCIRCA TABS (Use PA
VIAGRA TABS (Use Tadalafil (Pulmonary SP
GP month;QL(6 ea Hypertension))
Sildenafil Citrate) per 30 days
retail,18 ea per REVATIO SOLN (Use PA
90 days mail) Sildenafil Citrate SP
(Pulmonary Hypertension))
Peripheral Vasodilators
REVATIO SUSR (Use PA
isoxsuprine hcl tabs 1 Sildenafil Citrate SP
Prostaglandin Vasodilators REVATIO TABS (Use PA
epoprostenol sodium solr SP PA Sildenafil Citrate SP
FLOLAN SOLR (Use SP PA sildenafil citrate (pulmonary SP PA
Epoprostenol Sodium) hypertension) soln
ORENITRAM TBCR SP PA sildenafil citrate (pulmonary SP PA
hypertension) susr
REMODULIN SOLN (Use SP PA sildenafil citrate (pulmonary SP PA
Treprostinil) hypertension) tabs
treprostinil soln SP PA tadalafil (pulmonary SP PA
hypertension) tabs
TYVASO REFILL SOLN SP PA Pulmonary Hypertension - Prostacyclin Receptor
TYVASO SOLN SP PA UPTRAVI TABS SP PA
TYVASO STARTER SOLN SP PA UPTRAVI TBPK SP PA
VELETRI SOLR SP PA Pulmonary Hypertension - Sol Guanylate Cyclase
page ii-iii.
49
ADEMPAS TABS SP PA cefprozil tabs 1
Sinus Node Inhibitors CEFTIN SUSR 2
CORLANOR TABS 5 MG, 3 ST
7.5 MG cefuroxime axetil tabs 1
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections cefuroxime sodium solr SP PA
Cephalosporins - 1st Generation Cephalosporins - 3rd Generation
cefadroxil caps 1 CEDAX CAPS 3
cefadroxil susr 1 CEDAX SUSR 3
cefadroxil tabs 1 cefdinir caps 1

cefazolin sodium solr 1 gm, SP PA cefdinir susr 1
10 gm, 500 mg
CEFAZOLIN SODIUM SP PA cefditoren pivoxil tabs 1
SOLR 20 GM
cephalexin caps 1 cefixime caps 1
cephalexin susr 1 cefixime susr 1
cephalexin tabs 1 cefpodoxime proxetil susr 1
KEFLEX CAPS (Use cefpodoxime proxetil tabs 1

GP
Cephalexin)
Cephalosporins - 2nd Generation ceftazidime solr SP PA
cefaclor caps 250 mg, 500 1 CEFTIBUTEN CAPS 3
mg
CEFACLOR ER TB12 3 CEFTIBUTEN SUSR 3
CEFACLOR SUSR 125 ceftriaxone sodium solr SP PA
MG/5ML, 250 MG/5ML, 2
375 MG/5ML SPECTRACEF TABS (Use GP
cefaclor susr 125 mg/5ml, Cefditoren Pivoxil)
1 SUPRAX CAPS 400 MG
375 mg/5ml GP
CEFOTAN SOLR (Use (Use Cefixime)
SP PA SUPRAX CHEW 100 MG,
Cefotetan Disodium) 3
200 MG
cefotetan disodium solr SP PA SUPRAX SUSR 100
MG/5ML, 200 MG/5ML GP
CEFOTETAN SOLR SP PA (Use Cefixime)
cefoxitin sodium solr SP PA SUPRAX SUSR 500 3
MG/5ML
cefprozil susr 1 Cephalosporins - 4th Generation
page ii-iii.
50
cefepime hcl solr SP PA ESTROSTEP FE TABS PV
(Use Norethindrone GP
CEFEPIME SOLN SP PA Acetate-Ethinyl Estradiol-
Fe)
CEFEPIME/DEXTROSE SP PA ethynodiol diacet & eth
SOLR PV PV
estrad tabs
MAXIPIME SOLR (Use SP PA GENERESS FE CHEW QL(1 ea daily);
Cefepime HCl) (Use Norethindrone & GP PV
Cephalosporins - 5th Generation Ethinyl Estradiol-Fe)
levonorgestrel & eth PV PV
TEFLARO SOLR SP PA estradiol tabs
levonorgestrel-eth estradiol PV PV
CHEMICALS (triphasic) tabs
Bulk Chemicals - H's QL(91 ea per
levonorgestrel-ethinyl PV fill retail,91 ea
HEPARIN SODIUM POWD SP PA estradiol (91-day) tabs per 91 days
retail); PV
CONTRACEPTIVES - Drugs to Prevent levonorgestrel-ethinyl
Pregnancy PV QL(1 ea daily);
estradiol (91-day) tabs PV
Combination Contraceptives - Oral levonorgestrel-ethinyl PV PV
BEYAZ TABS (Use QL(1 ea daily); estradiol (continuous) tabs
Drospirenone-Ethinyl GP PV
Estradiol-Levomefolate LO LOESTRIN FE TABS PV QL(1 ea daily);
PV
Calcium) LOESTRIN 1.5/30-21 PV
BREVICON-28 TABS (Use PV TABS (Use Norethindrone GP
Norethindrone & Eth GP Acet & Eth Estra)
Estradiol) LOESTRIN 1/20-21 TABS PV
CYCLESSA TABS (Use PV (Use Norethindrone Acet & GP
Desogestrel-Ethinyl GP Eth Estra)
Estradiol (Triphasic)) LOESTRIN FE 1.5/30 PV
DESOGEN TABS (Use PV TABS (Use Norethin Acet & GP
Desogestrel & Ethinyl GP Estrad-Fe)
Estradiol) LOESTRIN FE 1/20 TABS PV
desogestrel & ethinyl PV PV (Use Norethin Acet & GP
estradiol tabs Estrad-Fe)
desogestrel-ethinyl PV PV LOSEASONIQUE TABS QL(1 ea daily);
estradiol (biphasic) tabs (Use Levonorgestrel- GP PV
desogestrel-ethinyl Ethinyl Estradiol (91-Day))
PV PV
estradiol (triphasic) tabs MINASTRIN 24 FE CHEW PV
drospirenone-ethinyl (Use Norethin Acet & GP
PV QL(1 ea daily); Estrad-Fe)
estradiol tabs PV
drospirenone-ethinyl QL(1 ea daily); MIRCETTE TABS (Use PV
estradiol-levomefolate PV PV Desogestrel-Ethinyl GP
calcium tabs Estradiol (Biphasic))
NATAZIA TABS PV QL(1 ea daily);
PV
page ii-iii.
51
NECON 1/50-28 TABS PV PV QUARTETTE TABS (Use
QL(91 ea per
Levonorgestrel-Ethinyl GP fill retail,91 ea
norethin acet & estrad-fe per 91 days
PV PV Estradiol (91-Day)) retail); PV
chew
norethin acet & estrad-fe SAFYRAL TABS (Use QL(1 ea daily);
PV PV Drospirenone-Ethinyl
tabs GP PV
norethindrone & eth Estradiol-Levomefolate
PV PV Calcium)
estradiol tabs
norethindrone & ethinyl PV SEASONIQUE TABS (Use QL(1 ea daily);
estradiol-fe chew 0.4mg- PV Levonorgestrel-Ethinyl GP PV
35mcg Estradiol (91-Day))
norethindrone & ethinyl QL(1 ea daily); TAYTULLA CAPS PV PA; PV
estradiol-fe chew 75mg- PV PV
0.8mg-25mcg TRI-NORINYL 28 TABS PV
(Use Norethindrone-Eth GP
norethindrone acet & eth PV PV Estradiol (Triphasic))
estra tabs
YASMIN 28 TABS (Use QL(1 ea daily);
norethindrone acetate- PV PV Drospirenone-Ethinyl GP PV
ethinyl estradiol-fe tabs Estradiol)
norethindrone-eth estradiol PV PV YAZ TABS (Use QL(1 ea daily);
(triphasic) tabs Drospirenone-Ethinyl GP PV
norethindrone-eth estradiol PV QL(1 ea daily); Estradiol)
(triphasic) tabs PV
Combination Contraceptives - Transdermal
norgestimate-ethinyl PV PV
estradiol (triphasic) tabs XULANE PTWK PV PV
norgestimate-ethinyl PV QL(1 ea daily);
estradiol (triphasic) tabs PV Combination Contraceptives - Vaginal
norgestimate-ethinyl Limit 1 per
PV QL(1 ea daily); NUVARING RING PV month;QL(0.04
estradiol tabs PV
ea daily); PV
norgestrel & ethinyl PV PV
estradiol tabs Copper Contraceptives - IUD
ORTHO TRI-CYCLEN LO PV PARAGARD PV
TABS (Use Norgestimate- INTRAUTERINE COPPER PV
GP CONTRACEPTIVE T380A
Ethinyl Estradiol
(Triphasic)) IUD
ORTHO TRI-CYCLEN QL(1 ea daily); Emergency Contraceptives
TABS (Use Norgestimate- GP PV
Ethinyl Estradiol ELLA TABS PV PV
(Triphasic))
levonorgestrel (emergency PV PV
ORTHO-CYCLEN TABS QL(1 ea daily); oc) tabs
(Use Norgestimate-Ethinyl GP PV
Estradiol) PLAN B ONE-STEP TABS PV
(Use Levonorgestrel GP
ORTHO-NOVUM 1/35 PV (Emergency OC))
TABS (Use Norethindrone GP
& Eth Estradiol) Progestin Contraceptives - IUD
ORTHO-NOVUM 7/7/7 QL(1 ea daily); QL(1 ea per
TABS (Use Norethindrone- GP PV LILETTA IUD PV 365 days
Eth Estradiol (Triphasic)) retail); PV
page ii-iii.
52
MIRENA IUD PV PV DEXAMETHASONE PA
SODIUM PHOSPHATE SP
SKYLA IUD PV PV SOLN IJ 10 MG/ML
DEXAMETHASONE PA
Progestin Contraceptives - Implants SODIUM PHOSPHATE
SOLN IJ 10 MG/ML (Use SP
NEXPLANON IMPL PV PV Dexamethasone Sodium
Phosphate)
Progestin Contraceptives - Injectable
dexamethasone sodium PA
DEPO-PROVERA QL(1 ml per 90 phosphate soln ij 4 mg/ml,
CONTRACEPTIVE SUSP SP
GP days retail); PV 10 mg/ml, 20 mg/5ml, 100
(Use Medroxyprogesterone mg/10ml, 120 mg/30ml
Acetate (Contraceptive))
DEPO-PROVERA QL(1 ml per 90 dexamethasone soln 1
CONTRACEPTIVE SUSY GP days retail); PV
(Use Medroxyprogesterone dexamethasone tabs 1
Acetate (Contraceptive))
DEPO-SUBQ PROVERA dexamethasone tbpk 1
PV PV
104 SUSY
EMFLAZA SUSP SP PA
medroxyprogesterone QL(1 ml per 90
acetate (contraceptive) PV days retail); PV EMFLAZA TABS SP PA
susp
medroxyprogesterone QL(1 ml per 90 ENTOCORT EC CPEP GP
acetate (contraceptive) PV days retail); PV (Use Budesonide)
susy
hydrocortisone tabs 1
Progestin Contraceptives - Oral
MEDROL DOSEPAK TBPK GP
norethindrone PV QL(1 ea daily); (Use Methylprednisolone)
(contraceptive) tabs PV
ORTHO MICRONOR QL(1 ea daily); MEDROL TABS 2 MG 2
TABS (Use Norethindrone GP PV
(Contraceptive)) MEDROL TABS 4 MG, 8
MG, 16 MG, 32 MG (Use GP
CORTICOSTEROIDS - Steroid Hormone Drugs to Methylprednisolone)
Treat Systemic Swelling Conditions
methylprednisolone tabs 1
Glucocorticosteroids
budesonide cpep 3 mg 1 methylprednisolone tbpk 1
budesonide tb24 9 mg 1 PA MILLIPRED DP TBPK 3
CORTEF TABS (Use MILLIPRED SOLN 10

GP MG/5ML (Use
Hydrocortisone) GP
Prednisolone Sodium
cortisone acetate tabs 1 Phosphate)
dexamethasone elix 1 MILLIPRED TABS 5 MG 2
DEXAMETHASONE ORAPRED ODT TBDP

2 (Use Prednisolone Sodium GP
INTENSOL CONC
Phosphate)
page ii-iii.
53
PEDIAPRED SOLN (Use benzonatate caps 1
Prednisolone Sodium GP
Phosphate) hydrocodone w/ 1
PREDNISOLONE SODIUM homatropine syrp
PHOSPHATE SOLN OR 3 hydrocodone w/
25 MG/5ML 1
homatropine tabs
prednisolone sodium TESSALON PERLES
phosphate soln or 5 GP
1 CAPS (Use Benzonatate)
mg/5ml, 10 mg/5ml, 15
mg/5ml, 20 mg/5ml Cough/Cold/Allergy Combinations
prednisolone sodium ACTIDOM DMX LIQD 3
phosphate tbdp or 10 mg, 1
15 mg, 30 mg CLARINEX-D 12 HOUR 3
TB12
prednisolone soln 1
CODITUSSIN AC LIQD 3
PREDNISOLONE SOLN 2
DECON-G LIQD 3
prednisolone syrp 1
DOMETUSS-DMX LIQD 3
PREDNISONE INTENSOL 2
CONC guaifenesin-codeine soln 1
prednisone soln 1 guaifenesin-codeine syrp 1
prednisone tabs 1 HYCOFENIX SOLN 3 PA
prednisone tbpk 1 HYDROCODONE

BITARTRATE/CHLORPHE 3
RAYOS TBEC 3 PA NIRAMINE MALEATE/PSE
SOLN
SOLU-CORTEF SOLR SP PA hydrocodone polistirex-
chlorpheniramine polistirex 1
TAPERDEX 12-DAY TBPK 3 suer
UCERIS TB24 OR 9 MG MUCINEX D TB12 (Use
GP PA Pseudoephedrine- GP
(Use Budesonide)
Guaifenesin)
VERIPRED 20 SOLN (Use
Prednisolone Sodium GP NEOTUSS PLUS LIQD 3
Phosphate)
PRO-RED AC SYRP 3
ZODEX 12-DAY TBPK 3
promethazine & 1
Mineralocorticoids phenylephrine soln
fludrocortisone acetate 1 promethazine w/codeine
tabs 1
soln
COUGH/COLD/ALLERGY - Drugs to Treat promethazine w/codeine
Cough, Cold and Allergy Symptoms 1
syrp
Antitussives promethazine- 1
phenylephrine-codeine syrp
page ii-iii.
54
PROMETHAZINE/DEXTR 2 Mucolytics
OMETHORPHAN SOLN
PROMETHAZINE/DEXTR acetylcysteine soln 1
2
OMETHORPHAN SYRP
DERMATOLOGICALS - Drugs to Treat Skin
PROMETHAZINE/PHENYL 2 Conditions
EPHRINE SYRP
PROMETHAZINE/PHENYL Acne Products
2 PA
EPHRINE/CODEINE SYRP ABSORICA CAPS 3
pseudoephed-cpm w/ 1
hydrocod soln ACANYA GEL (Use PA
Clindamycin Phosphate- GP
pseudoephedrine w/ 1 Benzoyl Peroxide)
codeine-gg soln
ACZONE GEL 5 % (Use GP PA
pseudoephedrine- 1 Dapsone (Topical))
guaifenesin tb12
PA; QL(2 gm
ACZONE GEL 7.5 % 3
REZIRA SOLN 3 daily)
Limit 45gms
SEMPREX-D CAPS 3 per
adapalene crea 0.1 % 1
month;QL(1.5
TUSNEL TABS 3 gm daily)
Limit 45gms
TUSSICAPS CP12 3 per
TUSSIONEX adapalene gel 0.1 % 1 month;QL(1.5
PENNKINETIC gm daily);
EXTENDED RELEASE RX/OTC
SUER (Use Hydrocodone GP adapalene gel 0.3 % 1
Polistirex-
Chlorpheniramine ADAPALENE LOTN 0.1 % 3
Polistirex)
PA adapalene-benzoyl 1
TUZISTRA XR SUER 3 peroxide gel
PA ATRALIN GEL (Use GP
VITUZ SOLN 3 Tretinoin)
ZUTRIPRO SOLN (Use AZELEX CREA 2
Pseudoephed-CPM w/ GP
Hydrocod) BENZACLIN GEL (Use
Misc. Respiratory Inhalants Clindamycin Phosphate- GP
Benzoyl Peroxide)
HYPER-SAL NEBU (Use
Sodium Chloride (Inhalant)) GP BENZACLIN WITH PUMP
GEL (Use Clindamycin GP
HYPERSAL NEBU 3.5 % 3 Phosphate-Benzoyl
Peroxide)
HYPERSAL NEBU 7 %
(Use Sodium Chloride GP BENZAMYCIN GEL (Use
(Inhalant)) Benzoyl Peroxide- GP
Erythromycin)
NEBUSAL NEBU 3
benzoyl peroxide liqd 1
sodium chloride (inhalant) 1
nebu
page ii-iii.
55
benzoyl peroxide- 1 clindamycin phosphate- 1
erythromycin gel tretinoin gel
BP CLEANSING WASH 2 dapsone (topical) gel 1 PA
EMUL
CLEOCIN-T GEL (Use Limit 45gms
Clindamycin Phosphate GP DIFFERIN CREA 0.1 % GP per
(Topical)) (Use Adapalene) month;QL(1.5
CLEOCIN-T LOTN (Use gm daily)
Clindamycin Phosphate GP Limit 45gms
(Topical)) per
DIFFERIN GEL 0.1 % (Use GP month;QL(1.5
CLEOCIN-T SOLN (Use Adapalene)
Clindamycin Phosphate GP gm daily);
(Topical)) RX/OTC
CLEOCIN-T SWAB (Use DIFFERIN GEL 0.3 % (Use GP
Clindamycin Phosphate GP Adapalene)
(Topical)) DIFFERIN LOTN 0.1 % 3
CLINDACIN ETZ KIT 3 DUAC GEL (Use
CLINDACIN ETZ Clindamycin Phosphate- GP
3 Benzoyl Peroxide
PLEDGETS SWAB
(Refrigerate))
CLINDACIN PAC KIT 3 EPIDUO GEL (Use
Adapalene-Benzoyl GP
CLINDACIN-P SWAB 3 Peroxide)
clindamycin phosphate ERYGEL GEL (Use NF
1 Erythromycin (Acne Aid))
(topical) foam
clindamycin phosphate 1 erythromycin (acne aid) gel 1
(topical) gel
erythromycin (acne aid) 1
clindamycin phosphate 1 pads
(topical) lotn
erythromycin (acne aid) 1
clindamycin phosphate 1 soln
(topical) soln
EVOCLIN FOAM (Use
clindamycin phosphate 1 Clindamycin Phosphate GP
(topical) swab (Topical))
CLINDAMYCIN Limit 50gms
PHOSPHATE SWAB EX 1 3 per
% month;QL(1.67
clindamycin phosphate- FABIOR FOAM 3
gm daily);
benzoyl peroxide 1 AL(Up to 46 yrs
(refrigerate) gel old )
clindamycin phosphate-
benzoyl peroxide gel 1%- 1 isotretinoin caps 1
5% KLARON LOTN (Use
clindamycin phosphate- PA Sulfacetamide Sodium GP
benzoyl peroxide gel 1.2%- 1 (Acne))
2.5% RETIN-A CREA (Use GP AL(Up to 46 yrs
Tretinoin) old )
page ii-iii.
56
RETIN-A GEL (Use GP AL(Up to 46 yrs TRETIN-X CREA 3 PA
Tretinoin) old )
RETIN-A MICRO GEL (Use GP AL(Up to 46 yrs tretinoin crea 0.025 %, 0.05 1 AL(Up to 46 yrs
Tretinoin Microsphere) old ) %, 0.1 % old )
RETIN-A MICRO PUMP AL(Up to 46 yrs tretinoin gel 0.025 %, 0.01 1 AL(Up to 46 yrs
GEL 0.04 %, 0.1 % (Use GP old ) % old )
Tretinoin Microsphere) tretinoin gel 0.05 % 1
RIAX FOAM 3 AL(Up to 46 yrs
tretinoin microsphere gel 1
old )
SODIUM
SULFACETAMIDE/SULFU 3 VELTIN GEL 3
R CLEANSER IN UREA
EMUL ZIANA GEL (Use
SODIUM QL(1 gm daily) Clindamycin Phosphate- GP
SULFACETAMIDE/SULFU 2 Tretinoin)
R LOTN Agents for External Genital and Perianal Warts
SODIUM Limit 30gms
SULFACETAMIDE/SULFU 3 VEREGEN OINT 3 per month;QL(1
R SUSP gm daily)
SSS 10-5 FOAM 2 Anti-inflammatory Agents - Topical
sulfacetamide sodium DICLOFENAC 3
1 EPOLAMINE PTCH
(acne) lotn
sulfacetamide sodium w/ diclofenac sodium (topical) 1
1 gel 1 %
sulfur crea
sulfacetamide sodium w/ diclofenac sodium (topical) 1 QL(5 ml daily)
1 soln 1.5 %
sulfur emul
sulfacetamide sodium w/ ENOVARX-IBUPROFEN 3 PA
1 CREA
sulfur liqd
sulfacetamide sodium w/ 1 FLECTOR PTCH 3
sulfur pads
sulfacetamide sodium w/ PA; QL(4 gm
1 PENNSAID SOLN 3
sulfur susp daily)
sulfacetamide sodium- REXAPHENAC CREA 3 PA
1
sulfur in urea vehicle gel
VOLTAREN GEL (Use
SUMADAN WASH LIQD Diclofenac Sodium GP
(Use Sulfacetamide GP (Topical))
Sodium w/ Sulfur)
SUMAXIN PADS (Use Antibiotics - Topical
Sulfacetamide Sodium w/ GP ALTABAX OINT 3
Sulfur)
SUMAXIN TS SUSP (Use BACTROBAN CREA (Use
Sulfacetamide Sodium w/ GP Mupirocin Calcium GP
Sulfur) (Topical))
SUMAXIN WASH LIQD CENTANY AT KIT 3
(Use Sulfacetamide GP
Sodium w/ Sulfur) CENTANY OINT 2
page ii-iii.
57
CORTISPORIN CREA 3 EXODERM LOTN 3
CORTISPORIN OINT 3 EXTINA FOAM (Use GP

Ketoconazole (Topical))
gentamicin sulfate (topical) 1
crea HALOTIN CREA 3
gentamicin sulfate (topical) 1 iodoquinol-hc crea 1
oint
mupirocin calcium (topical) iodoquinol-hydrocortisone 1
1 in aloe vehicle crea
crea
PA; Limit 4mls
MUPIROCIN CREA 3 per
JUBLIA SOLN 2
month;QL(0.15
mupirocin oint 1 ml daily)
NEO-SYNALAR CREA 2 ketoconazole (topical) crea 1 QL(2 gm daily)
Antifungals - Topical ketoconazole (topical) foam 1

ALA-QUIN CREA 3 ketoconazole (topical) 1
sham
ALOQUIN GEL 3 LOPROX CREA (Use GP
RX/OTC Ciclopirox Olamine)
butenafine hcl crea 1 LOPROX SHAMPOO GP
SHAM (Use Ciclopirox)
ciclopirox gel 1
LOPROX SUSP (Use GP
ciclopirox olamine crea 1 Ciclopirox Olamine)
LOTRIMIN ULTRA CREA 2 RX/OTC
ciclopirox olamine susp 1
LOTRIMIN ULTRA CREA GP RX/OTC
ciclopirox sham 1 (Use Butenafine HCl)
LOTRISONE CREA (Use Limit 1 tube per
ciclopirox soln 1 Clotrimazole w/ GP month;QL(1.5
Betamethasone) gm daily)
clotrimazole (topical) soln 1 RX/OTC
LULICONAZOLE CREA 2
Limit 1 tube per
clotrimazole w/ 1 month;QL(1.5 LUZU CREA 2
betamethasone crea gm daily)
MENTAX CREA 2 RX/OTC
clotrimazole w/ 1 QL(2 ml daily)
betamethasone lotn MICONAZOLE
econazole nitrate crea 1 NITRATE/ZINC 3
OXIDE/WHITE
ERTACZO CREA 3 PA PETROLATUM OINT
naftifine hcl crea 1
EXELDERM CREA 3
naftifine hcl gel 1
EXELDERM SOLN 2
page ii-iii.
58
NAFTIN CREA 2 % (Use GP LEVULAN KERASTICK AC
Naftifine HCl) SOLR
NAFTIN GEL 1 %, 2 % 3 PANRETIN GEL AC PA
NIZORAL SHAM (Use GP PICATO GEL AC
Ketoconazole (Topical))
nystatin (topical) crea 1 TARGRETIN GEL EX 1 % AC PA
nystatin (topical) oint 1 VALCHLOR GEL AC PA
nystatin (topical) powd 1 Antipruritics - Topical

doxepin hcl (antipruritic) 1
nystatin-triamcinolone crea 1 crea
ZONALON CREA (Use GP
nystatin-triamcinolone oint 1 Doxepin HCl (Antipruritic))
Antipsoriatics
oxiconazole nitrate crea 1
acitretin caps 10 mg 1 QL(1 ea daily)
OXISTAT CREA (Use GP
Oxiconazole Nitrate) acitretin caps 17.5 mg 1
OXISTAT LOTN 3
acitretin caps 25 mg 1 QL(2 ea daily)
PENLAC NAIL LACQUER GP
SOLN (Use Ciclopirox) calcipotriene crea 1
QUINJA GEL 3
calcipotriene oint 1
VUSION OINT 3
calcipotriene soln 1
VYTONE CREA (Use
Iodoquinol-Hydrocortisone GP Limit 100gms
in Aloe Vehicle) calcitriol (topical) oint 1 per
month;QL(3.4
XOLEGEL GEL 3 gm daily)
COSENTYX SP PA
Antineoplastic or Premalignant Lesion Agents - SENSOREADY PEN SOAJ
CARAC CREA AC COSENTYX SOSY SP PA
diclofenac sodium (actinic AC PA DOVONEX CREA (Use
keratoses) gel GP
Calcipotriene)
EFUDEX CREA (Use
Fluorouracil (Topical)) AC ILUMYA SOSY SP PA
FLUOROPLEX CREA AC methoxsalen rapid caps 1
fluorouracil (topical) crea AC OXSORALEN ULTRA
CAPS (Use Methoxsalen GP
FLUOROURACIL CREA AC Rapid)
EX 0.5 % SORIATANE CAPS 10 MG
FLUOROURACIL SOLN GP QL(1 ea daily)
AC (Use Acitretin)
EX 2 %, 5 %
page ii-iii.
59
SORIATANE CAPS 17.5 GP SULFAMYLON CREA 85 3
MG (Use Acitretin) MG/GM
SORIATANE CAPS 25 MG GP QL(2 ea daily) SULFAMYLON PACK 5 % GP
(Use Acitretin) (Use Mafenide Acetate)
SORILUX FOAM 3 QL(4 gm daily) Cauterizing Agents
silver nitrate-potassium 1
STELARA SOLN SP PA nitrate misc
Corticosteroids - Topical
STELARA SOSY SP PA
ALA SCALP LOTN 3
TALTZ SOAJ SP PA
alclometasone dipropionate 1
TALTZ SOSY SP PA crea
alclometasone dipropionate 1
AL(Up to 46 yrs oint
tazarotene crea 1
old )
AL(Up to 46 yrs AMCINONIDE CREA 2
TAZORAC CREA 0.05 % 2
old )
amcinonide lotn 1
TAZORAC CREA 0.1 % GP AL(Up to 46 yrs
(Use Tazarotene) old )
AMCINONIDE OINT 3
TAZORAC GEL 0.05 %, 2 AL(Up to 46 yrs
0.1 % old ) APEXICON E CREA 2
Antiseborrheic Products AUGMENTED
selenium sulfide lotn 2.5 % 1 BETAMETHASONE 2
DIPROPIONATE GEL
SELENIUM SULFIDE 2 MO betamethasone
SHAM 2.25 % 1
dipropionate (topical) crea
SODIUM betamethasone
SULFACETAMIDE WASH 3 1
dipropionate (topical) lotn
LIQD
betamethasone 1
Antivirals - Topical dipropionate (topical) oint
acyclovir topical oint 1 QL(1 gm daily) betamethasone
dipropionate augmented 1
Limit 5gms per crea
DENAVIR CREA 3 month;QL(0.17 betamethasone
gm daily) dipropionate augmented 1
ZOVIRAX OINT EX 5 % GP QL(1 gm daily) gel
(Use Acyclovir Topical) betamethasone
Burn Products dipropionate augmented 1
lotn
mafenide acetate pack 1 betamethasone
SILVADENE CREA (Use dipropionate augmented 1
GP oint
Silver Sulfadiazine)
betamethasone valerate 1
silver sulfadiazine crea 1 crea
page ii-iii.
60
betamethasone valerate 1 CORDRAN LOTN 0.05 % GP PA
foam (Use Flurandrenolide)
betamethasone valerate 1 CORDRAN OINT 0.05 % GP PA
lotn (Use Flurandrenolide)
betamethasone valerate 1 CORDRAN TAPE 4 2
oint MCG/SQCM
calcipotriene- ST CORTANE-B LOTN 3
betamethasone 1
dipropionate oint CUTIVATE LOTN (Use GP
Fluticasone Propionate)
CAPEX SHAM 2
DERMA-SMOOTHE/FS
clobetasol propionate crea 1 BODY OIL (Use GP
Fluocinolone Acetonide)
clobetasol propionate 1 DERMA-SMOOTHE/FS
emollient base crea SCALP OIL (Use GP
clobetasol propionate Fluocinolone Acetonide)
1
emulsion foam
DERMASORB TA KIT 3
clobetasol propionate foam 1
DERMATOP OINT (Use GP
clobetasol propionate gel 1 Prednicarbate)
DESONATE GEL 3
clobetasol propionate liqd 1
desonide crea 1
clobetasol propionate lotn 1
desonide lotn 1
clobetasol propionate oint 1
desonide oint 1
clobetasol propionate sham 1
DESOWEN CREA (Use GP
clobetasol propionate soln 1 Desonide)
DESOWEN LOTN (Use GP
CLOBEX LIQD (Use GP Desonide)
Clobetasol Propionate)
desoximetasone crea 0.05 1
CLOBEX LOTN (Use GP %, 0.25 %
CLOBEX SHAM (Use desoximetasone gel 0.05 % 1
GP
Clobetasol Propionate) desoximetasone liqd 0.25 ST
CLOCORTOLONE 1
3 %
PIVALATE CREA desoximetasone oint 0.05
CLOCORTOLONE 1
3 %, 0.25 %
PIVALATE PUMP CREA
diflorasone diacetate crea 1
CLODERM CREA 3
diflorasone diacetate oint 1
CLODERM PUMP CREA 3
DIPROLENE AF CREA
CORDRAN CREA 0.05 % GP (Use Betamethasone GP
(Use Flurandrenolide) Dipropionate Augmented)
page ii-iii.
61
DIPROLENE OINT (Use HALOG CREA (Use GP
Betamethasone GP Halcinonide)
Dipropionate Augmented)
HALOG OINT 3
ELOCON CREA (Use GP
Mometasone Furoate) hydrocortisone (topical) RX/OTC
1
ELOCON OINT (Use crea 1 %
GP
Mometasone Furoate) hydrocortisone (topical) 1
PA crea 2.5 %
ENSTILAR FOAM 3
hydrocortisone (topical) lotn 1
EPIFOAM FOAM 3 2.5 %
hydrocortisone (topical) oint 1 RX/OTC
fluocinolone acetonide crea 1 1%
hydrocortisone (topical) oint 1
fluocinolone acetonide oil 1 2.5 %
hydrocortisone butyrate 1
fluocinolone acetonide oint 1 crea
hydrocortisone butyrate 1
fluocinolone acetonide soln 1 hydrophilic lipo base crea
fluocinonide crea 1 hydrocortisone butyrate 1
oint
fluocinonide emulsified 1 hydrocortisone butyrate
base crea 1
soln
fluocinonide gel 1 hydrocortisone valerate 1
crea
fluocinonide oint 1 hydrocortisone valerate oint 1
fluocinonide soln 1 KENALOG AERS (Use
Triamcinolone Acetonide GP
flurandrenolide crea 1 (Topical))
LOCOID CREA (Use GP
flurandrenolide lotn 1 PA Hydrocortisone Butyrate)
PA LOCOID LIPOCREAM
flurandrenolide oint 1 CREA (Use Hydrocortisone GP
Butyrate Hydrophilic Lipo
fluticasone propionate crea 1 Base)
LOCOID OINT (Use GP
fluticasone propionate lotn 1 Hydrocortisone Butyrate)
fluticasone propionate oint 1 LOCOID SOLN (Use GP
Hydrocortisone Butyrate)
HALAC KIT 3 LUXIQ FOAM (Use GP
Betamethasone Valerate)
halcinonide crea 1 mometasone furoate crea 1
halobetasol propionate 1
crea mometasone furoate oint 1
halobetasol propionate oint 1 mometasone furoate soln 1
page ii-iii.
62
MONISTAT SOOTHING RX/OTC TEMOVATE CREA (Use GP
CARE ITCH RELIEF CREA GP Clobetasol Propionate)
(Use Hydrocortisone TEMOVATE OINT (Use
(Topical)) GP
NUCORT LOTN 3 TEXACORT SOLN 3
OLUX FOAM (Use GP TOPICORT CREA 0.05 %,
Clobetasol Propionate) 0.25 % (Use GP
OLUX-E FOAM (Use Desoximetasone)
Clobetasol Propionate GP TOPICORT GEL 0.05 %
Emulsion) GP
(Use Desoximetasone)
PANDEL CREA 3 TOPICORT LIQD 0.25 % GP ST
(Use Desoximetasone)
PRAMOSONE CREA 1%- 2 TOPICORT OINT 0.05 %,
1% 0.25 % (Use GP
PRAMOSONE CREA 1%- GP Desoximetasone)
2.5% (Use Pramoxine-HC) triamcinolone acetonide 1
PRAMOSONE E CREA 3 (topical) aers
triamcinolone acetonide 1
PRAMOSONE LOTN 1%- 3 (topical) crea
1%, 1%-2.5%
PRAMOSONE OINT 1%- 3 (topical) lotn
1%, 1%-2.5%
pramoxine-hc crea 1 (topical) oint
PREDNICARBATE CREA 2 TRIANEX OINT 2

TRIDESILON CREA (Use GP
prednicarbate crea 1 Desonide)
ULTRAVATE CREA (Use GP
PREDNICARBATE OINT 3 Halobetasol Propionate)
PSORCON CREA (Use ULTRAVATE LOTN 3 PA
GP
Diflorasone Diacetate)
PA ULTRAVATE OINT (Use GP
SERNIVO EMUL 3 Halobetasol Propionate)
SYNALAR CREA (Use GP ULTRAVATE X KIT 3
SYNALAR OINT (Use VANOS CREA (Use GP
GP Fluocinonide)
SYNALAR SOLN (Use GP VERDESO FOAM 3
TACLONEX OINT (Use ST WESTCORT OINT (Use GP
Calcipotriene- Hydrocortisone Valerate)
GP
Betamethasone Emollient/Keratolytic Agents
Dipropionate)
CEM-UREA SOLN 3
ST; QL(2 gm
TACLONEX SUSP 3
daily)
GORDONS UREA OINT 3
page ii-iii.
63
HYDRO 35 FOAM (Use GP hyaluronate sodium 1
Urea in Lactic Acid Vehicle) (emollient) gel
HYDRO 40 FOAM FOAM GP HYLIRA GEL 0.2 % (Use
(Use Urea) Hyaluronate Sodium GP
KERALAC CREA (Use (Emollient))
GP PA
Urea) HYLIRA LOTN 0.1 % 3
URAMAXIN CREA 45 % GP
(Use Urea) LAC-HYDRIN CREA (Use RX/OTC
Lactic Acid (Ammonium GP
URAMAXIN FOAM 20% 3 Lactate))
URAMAXIN GEL 45 % LAC-HYDRIN LOTN (Use RX/OTC
GP Lactic Acid (Ammonium GP
(Use Urea)
Lactate))
URAMAXIN GT GEL (Use GP
Urea) LAC-HYDRIN TWELVE RX/OTC
LOTN (Use Lactic Acid GP
URAMAXIN LOTN 45 % GP (Ammonium Lactate))
(Use Urea)
lactic acid (ammonium 1 RX/OTC
URE-K CREA 3 lactate) crea 12 %
urea crea 39 %, 41 %, 50 lactic acid (ammonium 1
1 lactate) lotn 10 %
%
RX/OTC lactic acid (ammonium 1 RX/OTC
urea crea 40 % 1 lactate) lotn 12 %
UREA CREA 45 % 3 Enzymes - Topical
PA SANTYL OINT 3
urea crea 47 % 1
TBC AERS 3
urea foam 40 % 1
Immunomodulating Agents - Topical
urea gel 45 % 1 ALDARA CREA (Use GP
urea in lactic acid vehicle Imiquimod)
1
foam imiquimod crea 1
UREA IN ZINC
UNDECYLENATE/LACTIC 3 Immunosuppressive Agents - Topical
ACID VEHICLE EMUL ELIDEL CREA (Use GP QL(2 gm daily)
urea lotn 40 % 1 Pimecrolimus)
pimecrolimus crea 1 QL(2 gm daily)
UREA LOTN 45 % 3
PROTOPIC OINT (Use QL(2 gm daily);
UREA NAIL STCK 3 GP AL(At least 2
Tacrolimus (Topical)) yrs old)
UREA TOPICAL SUSP 3 QL(2 gm daily);
tacrolimus (topical) oint 1 AL(At least 2
UTOPIC CREA (Use Urea) GP yrs old)
Keratolytic/Antimitotic Agents
Emollients
BENSAL HP OINT 3
page ii-iii.
64
CONDYLOX GEL 2 ETHYL CHLORIDE/MIST 3
AERO
PODOCON 25 IN RX/OTC
BENZOIN TINCTURE 3 lidocaine hcl crea ex 3 % 1
SOLN
lidocaine hcl gel ex 2 % 1
podofilox soln 1
lidocaine hcl gel ex 2 % 1 RX/OTC
SALEX LOTION KIT (Use GP
Salicylic Acid w/ Cleanser) lidocaine hcl soln ex 4 % 1
SALEX SHAM (Use GP
Salicylic Acid) lidocaine oint 1
salicylic acid crea 6 % 1 QL(3 ea daily)
lidocaine ptch 1
salicylic acid liqd 26 %, 1
27.5 % lidocaine-prilocaine crea 1
SALICYLIC ACID LOTION 3
KIT lidocaine-prilocaine kit 1
salicylic acid lotn 6 % 1 LIDODERM PTCH (Use GP QL(3 ea daily)
Lidocaine)
salicylic acid sham 6 % 1
SYNERA PTCH 3
salicylic acid soln 26 % 1 Misc. Topical
SALICYLIC ACID SOLN 26 3 DRYSOL SOLN 2
%
VIRASAL LIQD (Use GP XERAC AC SOLN 3
Salicylic Acid)
Liniments Rosacea Agents
MEDROX-RX OINT 3 PA azelaic acid gel 1
DOXYCYCLINE CPDR 3 PA
Local Anesthetics - Topical
CETACAINE AERO 3 FINACEA FOAM 3
COCAINE HCL SOLN 3 FINACEA GEL (Use GP
Azelaic Acid)
ETHYL CHLORIDE AERO 3 METROCREAM CREA
(Use Metronidazole GP
ETHYL CHLORIDE/FINE 3 (Topical))
PINPOINT AERO
METROGEL GEL (Use GP
ETHYL CHLORIDE/FINE 3 Metronidazole (Topical))
STREAM AERO
METROLOTION LOTN QL(2 ml daily)
ETHYL (Use Metronidazole GP
CHLORIDE/MEDIUM JET 3 (Topical))
STREAM AERO
metronidazole (topical) 1
ETHYL crea 0.75 %
CHLORIDE/MEDIUM 3
STREAM AERO
page ii-iii.
65
Limit 45gms
metronidazole (topical) gel DIAGNOSTIC PRODUCTS
1 per
0.75 % month;QL(1.5 Diagnostic Drugs
gm daily)
GLUCAGEN DIAGNOSTIC SP
metronidazole (topical) gel 1 SOLR
1%
Limit 1 per
metronidazole (topical) lotn QL(2 ml daily) GLUCAGON HCL SP year;QL(0.04
1 DIAGNOSTIC SOLR
0.75 % ea daily)
MIRVASO GEL 3 PA Limit 1 per
GLUCAGON SOLR SP year;QL(0.04
NORITATE CREA 3 PA ea daily)
PA METOPIRONE CAPS 3
ORACEA CPDR 3
PA Diagnostic Tests
SOOLANTRA CREA 3
CHEK-STIX COMBO PAK
Scabicides & Pediculicides URINALYSIS CONTROL 2
STRP
crotamiton lotn 1 CHEK-STIX CONTROL 2
ELIMITE CREA (Use STRP
GP QL(120 gm per
Permethrin) 14 days retail) CHEMSTRIP-K STRP 2
EURAX CREA 2
KETONE STRP 2
EURAX LOTN (Use GP
Crotamiton) KETONE TEST STRIPS 2
STRP
LINDANE SHAM 2
KETOSTIX STRP 2
malathion lotn 1
RELION KETONE STRP 2
AL(At least 4
NATROBA SUSP 3 RELION KETONE TEST
yrs old) 2
STRIPS STRP
OVIDE LOTN (Use GP
Malathion) DIETARY PRODUCTS/DIETARY MANAGEMENT
QL(120 gm per PRODUCTS
permethrin crea 1
14 days retail) Dietary Management Products
SKLICE LOTN 3 folic acid-pyridoxine- 1
cyanocobalamin tabs
AL(At least 4
SPINOSAD SUSP 3 DIGESTIVE AIDS - Drugs to Treat Low Digestive
yrs old)
Enzymes
ULESFIA LOTN 3 Digestive Enzymes
Wound Care Products CREON CPEP 2
Limit 15gms
per PANCREAZE CPEP 3
REGRANEX GEL 3
month;QL(0.5
gm daily) PERTZYE CPEP 3
page ii-iii.
66
SUCRAID SOLN SP PA MAXZIDE-25 TABS (Use
Triamterene & GP
VIOKACE TABS 3 Hydrochlorothiazide)
spironolactone & 1
ZENPEP CPEP hydrochlorothiazide tabs
10000UNIT-3000UNIT- triamterene &
14000UNIT, 17000UNIT- 1
hydrochlorothiazide caps
5000UNIT-24000UNIT,
47000UNIT-15000UNIT- triamterene & 1
2 hydrochlorothiazide tabs
63000UNIT, 63000UNIT-
20000UNIT-84000UNIT, Loop Diuretics
79000UNIT-25000UNIT-
105000UNIT, 126000UNIT- bumetanide tabs 1
40000UNIT-168000UNIT
BUMEX TABS (Use GP
ZENPEP CPEP Bumetanide)
32000UNIT-10000UNIT- 3
42000UNIT DEMADEX TABS (Use GP
Torsemide)
DIURETICS - Drugs to Treat Heart, Circulation EDECRIN TABS (Use
Conditions and Blood Pressure GP ST
Ethacrynic Acid)
Carbonic Anhydrase Inhibitors ethacrynic acid tabs 1 ST
acetazolamide cp12 1
furosemide soln 10 mg/ml 1
acetazolamide tabs 1 FUROSEMIDE SOLN 8 2
DIAMOX CP12 (Use MG/ML
GP
Acetazolamide) furosemide tabs 20 mg, 40 1
mg, 80 mg
KEVEYIS TABS SP PA
LASIX TABS (Use GP
methazolamide tabs 1 Furosemide)
NEPTAZANE TABS (Use torsemide tabs 1

GP
Methazolamide) Potassium Sparing Diuretics
Diuretic Combinations ALDACTONE TABS (Use GP
ALDACTAZIDE TABS Spironolactone)
25MG-25MG (Use GP
Spironolactone & amiloride hcl tabs 1
Hydrochlorothiazide) DYRENIUM CAPS (Use
ALDACTAZIDE TABS GP
2 Triamterene)
50MG-50MG
spironolactone tabs 1
amiloride & 1
triamterene caps 1
DYAZIDE CAPS (Use
Triamterene & GP Thiazides and Thiazide-Like Diuretics
Hydrochlorothiazide) CHLOROTHIAZIDE TABS
MAXZIDE TABS (Use 3
250 MG
Triamterene & GP
Hydrochlorothiazide) chlorothiazide tabs 500 mg 1
page ii-iii.
67
chlorthalidone tabs 1 FORTEO SOLN SP PA
DIURIL SUSP 3 PA; Limit 4 per

FOSAMAX PLUS D TABS 3 month;QL(0.15
hydrochlorothiazide caps 1 ea daily)
FOSAMAX TABS (Use Limit 4 per
hydrochlorothiazide tabs 1 GP month;QL(0.15
Alendronate Sodium) ea daily)
indapamide tabs 1 ibandronate sodium soln iv SP PA
3 mg/3ml
methyclothiazide tabs 1 ibandronate sodium tabs or 1
150 mg
metolazone tabs 1
MIACALCIN SOLN SP PA
MICROZIDE CAPS (Use GP
Hydrochlorothiazide) NATPARA CART SP PA
ENDOCRINE AND METABOLIC AGENTS - pamidronate disodium soln
MISC. - Drugs to Treat Bone Disease and SP PA
30 mg/10ml, 90 mg/10ml
Regulate Hormones
PAMIDRONATE PA
Bone Density Regulators DISODIUM SOLN 6 SP
ACTONEL TABS (Use MG/ML
GP ST
Risedronate Sodium) PROLIA SOSY SP PA
alendronate sodium soln 1
70 mg/75ml RECLAST SOLN (Use SP PA
Limit 4 per Zoledronic Acid)
alendronate sodium tabs 1 month;QL(0.15 risedronate sodium tabs 5 ST
35 mg, 70 mg 1
ea daily) mg, 30 mg, 35 mg, 150 mg
alendronate sodium tabs Limit 4 per
1 risedronate sodium tbec 35 1 month;QL(0.15
40 mg mg
ALENDRONATE SODIUM QL(1 ea daily) ea daily)
2
TABS 5 MG XGEVA SOLN SP PA
alendronate sodium tabs 5 1 QL(1 ea daily)
mg, 10 mg zoledronic acid conc 4 SP PA
mg/5ml
Limit 4 per
ATELVIA TBEC (Use ZOLEDRONIC ACID SOLN
Risedronate Sodium) GP month;QL(0.15 SP PA
ea daily) 4 MG/100ML
zoledronic acid soln 5 SP PA
BINOSTO TBEF 3 mg/100ml
BONIVA SOLN IV 3 PA ZOMETA CONC 4 PA
MG/3ML (Use Ibandronate SP MG/5ML (Use Zoledronic SP
Sodium) Acid)
BONIVA TABS OR 150 MG GP ZOMETA SOLN 4 SP PA
(Use Ibandronate Sodium) MG/100ML
calcitonin (salmon) soln 1 Corticotropin
ACTHAR GEL SP PA
etidronate disodium tabs 1
Fertility Regulators
page ii-iii.
68
CHORIONIC SP PA OSPHENA TABS 3
GONADOTROPIN SOLR
NOVAREL SOLR SP PA raloxifene hcl tabs PV QL(1 ea daily);
PV
PREGNYL W/DILUENT PA Insulin-Like Growth Factors (Somatomedins)
BENZYLALCOHOL/NACL SP
SOLR INCRELEX SOLN SP PA
Growth Hormone Receptor Antagonists LHRH/GnRH Agonist Analog Pituitary
SOMAVERT SOLR SP PA LUPANETA PACK KIT 3 PA
Growth Hormones LUPRON DEPOT-PED (1- AC PA
GENOTROPIN MINIQUICK SP PA MONTH) KIT
SOLR LUPRON DEPOT-PED (3- AC PA
MONTH) KIT
GENOTROPIN SOLR SP PA
SYNAREL SOLN 2
HUMATROPE COMBO SP PA; Preferred
PACK SOLR Metabolic Modifiers
HUMATROPE SOLR SP PA; Preferred ALDURAZYME SOLN SP PA
NORDITROPIN FLEXPRO SP PA; Preferred BUPHENYL POWD (Use
SOLN GP
Sodium Phenylbutyrate)
NUTROPIN AQ NUSPIN SP PA BUPHENYL TABS (Use
10 SOLN GP
Sodium Phenylbutyrate)
NUTROPIN AQ NUSPIN SP PA calcitriol caps or 0.25 mcg,
20 SOLN 1
0.5 mcg
NUTROPIN AQ NUSPIN 5 SP PA
SOLN calcitriol soln iv 1 mcg/ml SP PA
OMNITROPE SOLN SP PA CALCITRIOL SOLN IV 1 SP PA
MCG/ML
OMNITROPE SOLR SP PA calcitriol soln or 1 mcg/ml 1
SAIZEN CLICK.EASY SP PA
SOLR CARBAGLU TABS SP PA
SAIZEN SOLR SP PA CARNITOR SF SOLN (Use
Levocarnitine (Metabolic GP
SAIZENPREP PA Modifiers))
RECONSTITUTIONKIT SP CARNITOR SOLN 1
SOLR GM/10ML (Use GP
SEROSTIM SOLR SP PA Levocarnitine (Metabolic
Modifiers))
ZOMACTON SOLR SP PA CARNITOR TABS 330 MG RX/OTC
(Use Levocarnitine GP
ZORBTIVE SOLR SP PA (Metabolic Modifiers))
cinacalcet hcl tabs 1
Hormone Receptor Modulators
EVISTA TABS (Use GP QL(1 ea daily); CYSTADANE POWD SP PA
Raloxifene HCl) PV
page ii-iii.
69
doxercalciferol caps 1 ZEMPLAR CAPS OR 1
MCG, 2 MCG (Use GP
ELAPRASE SOLN SP PA Paricalcitol)
ZEMPLAR SOLN IV 2 PA
FABRAZYME SOLR SP PA MCG/ML, 5 MCG/ML (Use SP
Paricalcitol)
GALAFOLD CAPS SP PA; QL(0.5 ea Posterior Pituitary Hormones
daily)
HECTOROL CAPS (Use DDAVP SOLN IJ 4 PA
Doxercalciferol) GP MCG/ML (Use SP
Desmopressin Acetate)
KUVAN PACK SP
DDAVP SOLN NA 0.01 % 2
KUVAN TBSO SP DDAVP SOLN NA 0.01 %
(Use Desmopressin GP
levocarnitine (metabolic 1 Acetate Spray)
modifiers) soln 1 gm/10ml
DDAVP TABS OR 0.1 MG,
levocarnitine (metabolic 1 RX/OTC 0.2 MG (Use GP
modifiers) tabs 330 mg Desmopressin Acetate)
LUMIZYME SOLR SP PA desmopressin acetate soln SP PA
ij 4 mcg/ml
MYALEPT SOLR SP PA desmopressin acetate 1
spray refrigerated soln
NAGLAZYME SOLN SP PA desmopressin acetate 1
spray soln
ORFADIN CAPS SP PA
desmopressin acetate tabs 1
ORFADIN SUSP SP PA or 0.1 mg, 0.2 mg
paricalcitol caps or 1 mcg, STIMATE SOLN 3

1
2 mcg, 4 mcg Prolactin Inhibitors
paricalcitol soln iv 2 SP PA
mcg/ml, 5 mcg/ml cabergoline tabs 1
RAVICTI LIQD SP PA Somatostatic Agents
ROCALTROL CAPS (Use GP octreotide acetate soln SP PA
Calcitriol)
SANDOSTATIN LAR SP PA
ROCALTROL SOLN (Use GP DEPOT KIT
Calcitriol)
SANDOSTATIN SOLN SP PA
SENSIPAR TABS (Use GP (Use Octreotide Acetate)
Cinacalcet HCl)
sodium phenylbutyrate SIGNIFOR SOLN SP PA
1
powd
SOMATULINE DEPOT SP PA
sodium phenylbutyrate tabs 1 SOLN
Vasopressin Receptor Antagonists
STRENSIQ SOLN SP PA
JYNARQUE TABS 15 MG, SP PA; QL(1 ea
30 MG daily)
XURIDEN PACK SP
page ii-iii.
70
JYNARQUE TBPK SP PA; SP DIVIGEL GEL 3
SAMSCA TABS SP PA; QL(1 ea ELESTRIN GEL 3

daily)
ESTROGENS - Hormone Replacement/Modifying ESTRACE TABS (Use GP
Drugs Estradiol)
estradiol pttw td 0.0375 Limit 8 per
Estrogen Combinations mg/24hr, 0.025 mg/24hr, month;QL(0.29
ACTIVELLA TABS (Use 1
0.075 mg/24hr, 0.05 ea daily)
Estradiol & Norethindrone GP mg/24hr, 0.1 mg/24hr
Acetate) estradiol ptwk td 0.025 Limit 4 per
ANGELIQ TABS 3 mg/24hr, 0.075 mg/24hr, month;QL(0.15
0.05 mg/24hr, 0.06 1 ea daily)
CLIMARA PRO PTWK 2 mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
COMBIPATCH PTTW 3 estradiol tabs or 0.5 mg, 1 1
mg, 2 mg
DUAVEE TABS 3 estradiol valerate oil SP PA
esterified estrogens & 1 QL(1 ea daily) Limit 50gms
methyltestosterone tabs per
estradiol & norethindrone ESTROGEL GEL 3
month;QL(1.67
1
acetate tabs gm daily)
FEMHRT LOW DOSE ESTROPIPATE TABS 0.75
TABS (Use Norethindrone GP 2
MG, 1.5 MG
Acetate-Ethinyl Estradiol)
norethindrone acetate- estropipate tabs 3 mg 1
1
ethinyl estradiol tabs
EVAMIST SOLN 3
PREFEST TABS 3
MENEST TABS 2
PREMPHASE TABS 2 QL(1 ea daily)
Limit 4 per
QL(1 ea daily) MENOSTAR PTWK 3 month;QL(0.14
PREMPRO TABS 2 ea daily)
Estrogens Limit 8 per
MINIVELLE PTTW (Use GP month;QL(0.29
Limit 8 per Estradiol)
ALORA PTTW 2 month;QL(0.29 ea daily)
ea daily) PREMARIN SOLR IJ 25 SP PA
Limit 4 per MG
CLIMARA PTWK (Use GP month;QL(0.15 PREMARIN TABS OR
Estradiol) ea daily) 0.625 MG, 0.45 MG, 0.3 2
DELESTROGEN OIL 10 MG, 0.9 MG, 1.25 MG
SP PA Limit 8 per
MG/ML VIVELLE-DOT PTTW (Use
DELESTROGEN OIL 20 PA GP month;QL(0.29
Estradiol) ea daily)
MG/ML, 40 MG/ML (Use SP
Estradiol Valerate) FLUOROQUINOLONES - Drugs to Treat Bacterial
Infections
DEPO-ESTRADIOL OIL SP PA
page ii-iii.
71
Fluoroquinolones CHOLBAM CAPS SP PA
AVELOX TABS (Use GP
Moxifloxacin HCl) Farnesoid X Receptor (FXR) Agonists
BAXDELA TABS 3 ST OCALIVA TABS SP PA
CIPRO SUSR 5 2 Gallstone Solubilizing Agents
GM/100ML ACTIGALL CAPS (Use
CIPRO SUSR 500 GP
Ursodiol)
MG/5ML (Use GP PA
Ciprofloxacin) CHENODAL TABS 3
CIPRO TABS 250 MG, 500 URSO 250 TABS (Use
MG (Use Ciprofloxacin GP GP
Ursodiol)
HCl) URSO FORTE TABS (Use
QL(14 ea per GP
CIPROFLOXACIN ER Ursodiol)
2 fill retail,14 ea
TB24 1000MG ursodiol caps 1
per fill mail)
QL(3 ea per fill
CIPROFLOXACIN ER ursodiol tabs 1
2 retail,3 ea per
TB24 500MG fill mail)
Gastrointestinal Antiallergy Agents
CIPROFLOXACIN HCL
TABS 100 MG
2 cromolyn sodium 1
(mastocytosis) conc
ciprofloxacin hcl tabs 250 1
mg, 500 mg, 750 mg GASTROCROM CONC
(Use Cromolyn Sodium GP
ciprofloxacin susr 1 (Mastocytosis))
LEVAQUIN TABS (Use Gastrointestinal Chloride Channel Activators
GP QL(14 ea per
Levofloxacin) fill retail) AMITIZA CAPS 2
levofloxacin soln 25 mg/ml 1
Gastrointestinal Stimulants
levofloxacin tabs 250 mg, 1 QL(14 ea per
500 mg, 750 mg fill retail) metoclopramide hcl soln 1
moxifloxacin hcl tabs 1 metoclopramide hcl tabs 1

OFLOXACIN TABS 300 METOCLOPRAMIDE ODT 3
3 TBDP
MG
QL(28 ea per REGLAN TABS (Use GP
90 days Metoclopramide HCl)
ofloxacin tabs 400 mg 1
retail,28 ea per Inflammatory Bowel Agents
90 days mail)
APRISO CP24 3 PA
GASTROINTESTINAL AGENTS - MISC. -
Miscellaneous Gastrointestinal Drugs ASACOL HD TBEC (Use PA
3
Agents for Chronic Idiopathic Constipation (CIC) Mesalamine)
AZULFIDINE EN-TABS
TRULANCE TABS 3 PA TBEC (Use Sulfasalazine)
GP
Bile Acid Synthesis Disorder Agents AZULFIDINE TABS (Use GP

Sulfasalazine)
page ii-iii.
72
Limit 280 per LOTRONEX TABS (Use GP
balsalazide disodium caps 1 month;QL(9.4 Alosetron HCl)
ea daily) PA
VIBERZI TABS 3
CANASA SUPP (Use GP
Mesalamine) Peripheral Opioid Receptor Antagonists
CIMZIA KIT SP PA ENTEREG CAPS 3
COLAZAL CAPS (Use Limit 280 per
GP month;QL(9.4 MOVANTIK TABS 3
Balsalazide Disodium) ea daily)
DELZICOL CPDR (Use RELISTOR SOLN SP PA
GP PA
Mesalamine)
RELISTOR TABS SP PA
DIPENTUM CAPS 3
Phosphate Binder Agents
ST; QL(6 ea calcium acetate (phosphate
GIAZO TABS 3
daily) 1
binder) caps
LIALDA TBEC (Use GP calcium acetate (phosphate RX/OTC
Mesalamine) 1
binder) tabs
mesalamine cpdr or 400 1 PA ELIPHOS TABS (Use RX/OTC
mg Calcium Acetate GP
mesalamine enem re 4 gm 1 (Phosphate Binder))
FOSRENOL CHEW 500
mesalamine supp re 1000 1 MG, 750 MG, 1000 MG
mg GP
(Use Lanthanum
mesalamine tbec or 1.2 1 Carbonate)
gm, 800 mg FOSRENOL PACK 750
PA 3
PENTASA CPCR 3 MG, 1000 MG
lanthanum carbonate chew 1
REMICADE SOLR SP PA
PHOSLYRA SOLN 3
SFROWASA ENEM 2
RENAGEL TABS 400 MG 3 PA
STELARA SOLN SP PA
RENAGEL TABS 800 MG GP PA
sulfasalazine tabs 1 (Use Sevelamer HCl)
RENVELA PACK (Use GP
sulfasalazine tbec 1 Sevelamer Carbonate)
RENVELA TABS (Use GP
Intestinal Acidifiers Sevelamer Carbonate)
lactulose (encephalopathy) 1
soln sevelamer carbonate pack 1
Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate tabs 1
alosetron hcl tabs 1 PA
sevelamer hcl tabs 1
LINZESS CAPS 2 SEVELAMER PA
3
HYDROCHLORIDE TABS
page ii-iii.
73
VELPHORO CHEW 3 PA NEOMYCIN/POLYMYXIN 3
B SULFATES SOLN
Short Bowel Syndrome (SBS) Agents NEOSPORIN GU
IRRIGANT SOLN (Use
GATTEX KIT SP PA Neomycin/Polymyxin B GP
GU)
GENITOURINARY AGENTS - MISCELLANEOUS
- Miscellaneous Drugs to Treat Reproductive sodium chloride (gu 1
Organs and Urinary System irrigant) soln
Acidifiers Interstitial Cystitis Agents
ELMIRON CAPS 3 QL(3 ea daily)
K-PHOS NO 2 TABS 2
Alkalinizers Prostatic Hypertrophy Agents
alfuzosin hcl tb24 1 QL(1 ea daily)
ORACIT SOLN 2
pot & sod citrates w/citric AVODART CAPS (Use GP AL(At least 40
1 Dutasteride) yrs old)
ac soln
pot & sod citrates w/citric 1 CARDURA XL TB24 3
ac syrp
AL(At least 40
potassium citrate dutasteride caps 1
yrs old)
1
(alkalinizer) tbcr
dutasteride-tamsulosin hcl 1
potassium citrate-citric acid 1 caps
pack 3300mg-1002mg
QL(1 ea daily);
potassium citrate-citric acid RX/OTC finasteride tabs 1 AL(At least 40
soln 1100mg/5ml- yrs old)
334mg/5ml, 1100mg/5ml- 1
1100mg/5ml-334mg/5ml- FLOMAX CAPS (Use GP QL(2 ea daily)
334mg/5ml Tamsulosin HCl)
sodium citrate & citric acid RX/OTC JALYN CAPS (Use
1 Dutasteride-Tamsulosin GP
soln
HCl)
UROCIT-K 10 TBCR (Use
Potassium Citrate GP QL(1 ea daily);
PROSCAR TABS (Use GP AL(At least 40
(Alkalinizer)) Finasteride) yrs old)
UROCIT-K 15 TBCR (Use
Potassium Citrate GP RAPAFLO CAPS 4 MG 3
(Alkalinizer))
UROCIT-K 5 TBCR (Use RAPAFLO CAPS 4 MG, 8 GP
Potassium Citrate GP MG (Use Silodosin)
(Alkalinizer)) silodosin caps 1
Cystinosis Agents QL(2 ea daily)
tamsulosin hcl caps 1
CYSTAGON CAPS 3
UROXATRAL TB24 (Use GP QL(1 ea daily)
PROCYSBI CPDR 3 PA Alfuzosin HCl)
Urinary Analgesics
Genitourinary Irrigants
neomycin/polymyxin b gu phenazopyridine hcl tabs 1
1
soln
page ii-iii.
74
PYRIDIUM TABS (Use GP ELOCTATE SOLR SP PA
Phenazopyridine HCl)
Urinary Stone Agents HELIXATE FS KIT SP PA
LITHOSTAT TABS 3 IDELVION SOLR SP PA
GOUT AGENTS - Drugs to Treat Gout IXINITY SOLR SP PA
Gout Agent Combinations KOGENATE FS BIO-SET SP PA
colchicine w/ probenecid KIT
1
tabs
KOGENATE FS KIT SP PA
Gout Agents
KOVALTRY SOLR SP PA
allopurinol tabs 1
NOVOEIGHT SOLR SP PA
COLCHICINE CAPS 3
OBIZUR SOLR SP PA
colchicine tabs 2
RIXUBIS SOLR SP PA
COLCRYS TABS 2
WILATE KIT SP PA
febuxostat tabs 1
Bradykinin B2 Receptor Antagonists
MITIGARE CAPS 3
FIRAZYR SOLN (Use
SP PA
ULORIC TABS (Use Icatibant Acetate)
GP
Febuxostat)
icatibant acetate soln SP PA
ZYLOPRIM TABS (Use GP
Allopurinol) Complement Inhibitors
Uricosurics CINRYZE SOLR SP PA
probenecid tabs 1
RUCONEST SOLR SP PA
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders Hematorheologic Agents
Antihemophilic Products pentoxifylline tbcr 1
ADVATE SOLR SP PA Platelet Aggregation Inhibitors
ALPHANATE/VON PA AGGRENOX CP12 (Use GP
WILLEBRANDFACTOR SP Aspirin-Dipyridamole)
COMPLEX/HUMAN SOLR AGRYLIN CAPS (Use GP
Anagrelide HCl)
ALPHANINE SD SOLR SP PA
anagrelide hcl caps 1
ALPROLIX SOLR SP PA
aspirin-dipyridamole cp12 1
BENEFIX KIT SP PA
BRILINTA TABS 2
CORIFACT KIT SP PA
page ii-iii.
75
cilostazol tabs 1 QL(2 ea daily) ARANESP ALBUMIN SP PA
FREE SOSY
QL(2 ea daily)
clopidogrel bisulfate tabs 1 EPOGEN SOLN SP PA
dipyridamole tabs 1 GRANIX SOSY SP PA
EFFIENT TABS (Use
Prasugrel HCl) GP LEUKINE SOLR SP PA
PLAVIX TABS (Use GP QL(2 ea daily) MIRCERA SOSY SP PA
Clopidogrel Bisulfate)
prasugrel hcl tabs 1 MULPLETA TABS SP PA
NEULASTA ONPRO KIT SP PA
ZONTIVITY TABS 2 PSKT
HEMATOPOIETIC AGENTS - Drugs to Treat NEULASTA SOSY SP PA
Blood Disorders
Agents for Gaucher Disease NEUPOGEN SOLN SP PA
CERDELGA CAPS SP PA NEUPOGEN SOSY SP PA
CEREZYME SOLR SP PA NIVESTYM SOSY SP PA
ELELYSO SOLR SP PA PROCRIT SOLN 2000 PA
UNIT/ML, 3000 UNIT/ML,
miglustat caps SP PA 4000 UNIT/ML, 10000 SP
UNIT/ML, 20000 UNIT/ML,
VPRIV SOLR SP PA 40000 UNIT/ML
PROMACTA PACK 12.5 SP PA
ZAVESCA CAPS (Use SP PA MG
Miglustat) PROMACTA TABS 25 MG, SP PA
Agents for Sickle Cell Anemia 50 MG, 12.5 MG
DROXIA CAPS 2 PROMACTA TABS 75 MG SP PA; QL(1 ea
daily)
SIKLOS TABS SP PA ZARXIO SOSY SP PA
Cobalamins Hematopoietic Mixtures
cyanocobalamin soln 1000 SP PA
mcg/ml FOLIVANE-F CAPS 2
Folic Acid/Folates INTEGRA F CAPS 2
folic acid tabs 1 mg 1 RX/OTC
Iron
folic acid tabs 400 mcg, PV PV carbonyl iron susp PV PV
800 mcg
FER-IN-SOL SOLN (Use GP PV
Hematopoietic Growth Factors Ferrous Sulfate)
ARANESP ALBUMIN SP PA
FREE SOLN ferrous sulfate elix 220 PV PV
mg/5ml
page ii-iii.
76
ferrous sulfate soln 15 PV PV phenobarbital tabs 15 mg,
mg/ml 30 mg, 60 mg, 100 mg, 1
FERROUS SULFATE 16.2 mg, 32.4 mg, 64.8 mg,
PV PV 97.2 mg
SYRP 300 MG/5ML
ICAR PEDIATRIC SUSP GP PV SECONAL SODIUM CAPS 3
(Use Carbonyl Iron)
Stem Cell Mobilizers Hypnotics - Tricyclic Agents
ST; QL(1 ea
MOZOBIL SOLN SP PA SILENOR TABS 3
daily)
HEMOSTATICS - Drugs to Stop Bleeding/Treat Non-Barbiturate Hypnotics
Blood Disorders AMBIEN CR TBCR (Use GP QL(1 ea daily)
Zolpidem Tartrate)
Hemostatics - Systemic
AMBIEN TABS (Use GP QL(1 ea daily)
AMICAR SOLN 0.25 3 Zolpidem Tartrate)
GM/ML
AMICAR TABS 500 MG, DORAL TABS 3
1000 MG (Use GP
Aminocaproic Acid) ST; QL(1 ea
EDLUAR SUBL 3
daily)
aminocaproic acid tabs 1
estazolam tabs 1
CYKLOKAPRON SOLN SP PA
(Use Tranexamic Acid) eszopiclone tabs 1 QL(1 ea daily)
LYSTEDA TABS (Use GP QL(6 ea daily,5
Tranexamic Acid) day(s) limit) flurazepam hcl caps 1
tranexamic acid soln iv SP PA HALCION TABS (Use
1000 mg/10ml GP
Triazolam)
tranexamic acid tabs or QL(6 ea daily,5 INTERMEZZO SUBL (Use
650 mg 1
day(s) limit) GP PA
Zolpidem Tartrate)
HYPNOTICS/SEDATIVES/SLEEP DISORDER LUNESTA TABS (Use GP QL(1 ea daily)
AGENTS Eszopiclone)
Antihistamine Hypnotics midazolam hcl syrp 1
diphenhydramine hcl 1
(sleep) caps QUAZEPAM TABS 1
UNISOM SLEEPGELS
CAPS (Use quazepam tabs 1
GP
Diphenhydramine HCl RESTORIL CAPS (Use
(Sleep)) GP
Temazepam)
Barbiturate Hypnotics SONATA CAPS (Use GP QL(1 ea daily)
BUTISOL SODIUM TABS 3 Zaleplon)
phenobarbital elix 20 temazepam caps 1

1
mg/5ml
triazolam tabs 1
phenobarbital soln 20 1
mg/5ml zaleplon caps 1 QL(1 ea daily)
page ii-iii.
77
zolpidem tartrate subl sl 3.5 1 PA PA; AL(At least
mg, 1.75 mg MOVIPREP SOLR PV 50 yrs old - Up
zolpidem tartrate tabs or 5 to 74 yrs old);
1 QL(1 ea daily) PV
mg, 10 mg
zolpidem tartrate tbcr or NULYTELY/FLAVOR AL(At least 50
1 QL(1 ea daily) PACKS SOLR (Use PEG yrs old - Up to
12.5 mg, 6.25 mg
3350-Potassium Chloride- GP 74 yrs old); PV
ST; Limit Sod Bicarbonate-Sod
ZOLPIMIST SOLN 3 7.7mls per Chloride)
month;QL(0.26
ml daily) QL(4000 ml per
fill retail,4000
Orexin Receptor Antagonists peg 3350-kcl-sod bicarb- ml per fill mail);
sod chloride-sod sulfate PV
AL(At least 50
ST; QL(1 ea solr
BELSOMRA TABS 2
daily) yrs old - Up to
74 yrs old); PV
Selective Melatonin Receptor Agonists
peg 3350-potassium AL(At least 50
HETLIOZ CAPS SP PA chloride-sod bicarbonate- PV yrs old - Up to
sod chloride solr 74 yrs old); PV
ST; QL(1 ea
ramelteon tabs 1
daily) PA; AL(At least
50 yrs old - Up
ROZEREM TABS (Use PLENVU SOLR PV
GP ST; QL(1 ea to 74 yrs old);
Ramelteon) daily) PV
LAXATIVES - Bowel Treatment Drugs PA; AL(At least
50 yrs old - Up
Laxative Combinations PREPOPIK PACK PV
to 74 yrs old);
QL(1 ea per fill PV
retail,1 ea per AL(At least 50
bisacodyl-peg 3350-pot fill mail); AL(At SUPREP BOWEL PREP
chloride-sod bicarb-sod PV PV yrs old - Up to
least 50 yrs old KIT SOLN
chloride kit 74 yrs old); PV
- Up to 74 yrs
old); PV Laxatives - Miscellaneous
QL(4000 ml per KRISTALOSE PACK 10 2
COLYTE-FLAVOR PACKS fill retail,4000 GM, 20 GM
SOLR (Use PEG 3350- GP ml per fill mail); LACTULOSE PACK 10 GM 2
KCl-Sod Bicarb-Sod AL(At least 50
Chloride-Sod Sulfate) yrs old - Up to lactulose soln 10 gm/15ml, 1
74 yrs old); PV 20 gm/30ml
PA; QL(4000 MACROLIDES - Drugs to Treat Bacterial
GOLYTELY SOLR ea per fill Infections
227.1GM-21.5GM-5.53GM- PV
retail,4000 ea
2.82GM-6.36GM Azithromycin
per fill mail); PV
GOLYTELY SOLR 236GM- QL(4000 ml per azithromycin pack 1 gm 1
22.74GM-5.86GM-2.97GM- fill retail,4000
ml per fill mail); azithromycin susr 100 1
6.74GM (Use PEG 3350- GP mg/5ml, 200 mg/5ml
AL(At least 50
KCl-Sod Bicarb-Sod yrs old - Up to
Chloride-Sod Sulfate) QL(6 ea per fill
74 yrs old); PV azithromycin tabs 250 mg 1 retail,6 ea per
fill mail)
page ii-iii.
78
azithromycin tabs 500 mg 1 QL(3 ea daily) erythromycin base tabs 1
QL(10 ea per erythromycin base tbec 1
azithromycin tabs 600 mg 1 fill retail,10 ea
per fill mail) erythromycin 1
ZITHROMAX PACK 1 GM ethylsuccinate susr
GP
(Use Azithromycin) erythromycin 1
ZITHROMAX SUSR 100 ethylsuccinate tabs
MG/5ML, 200 MG/5ML GP PCE TBEC 2
(Use Azithromycin)
QL(6 ea per fill Fidaxomicin
ZITHROMAX TABS 250 GP retail,6 ea per
MG (Use Azithromycin) DIFICID TABS 3
fill mail)
ZITHROMAX TABS 500 GP QL(3 ea daily)
MG (Use Azithromycin) MEDICAL DEVICES AND SUPPLIES
QL(10 ea per Contraceptives
ZITHROMAX TABS 600 GP fill retail,10 ea
MG (Use Azithromycin) per fill mail) CAYA DPRH PV PV
ZITHROMAX TRI-PAK GP QL(3 ea daily) FC FEMALE CONDOM
TABS (Use Azithromycin) PV PV
MISC
QL(6 ea per fill FC2 FEMALE CONDOM
ZITHROMAX Z-PAK TABS GP retail,6 ea per PV PV
(Use Azithromycin) MISC
fill mail)
FEMCAP DEVI PV PV
ZMAX SUSR 2 QL(2 ea daily)
OMNIFLEX DIAPHRAGM PV PV
Clarithromycin DPRH
clarithromycin susr 125 1 WIDE-SEAL SILICONE PV
mg/5ml, 250 mg/5ml DIAPHRAGM KIT 60 PV
CLARITHROMYCIN SUSR DPRH
2
125 MG/5ML, 250 MG/5ML WIDE-SEAL SILICONE PV
clarithromycin tabs 250 mg, DIAPHRAGM KIT 65 PV
1 DPRH
500 mg
QL(14 ea per WIDE-SEAL SILICONE PV
clarithromycin tb24 500 mg 1 fill retail,14 ea DIAPHRAGM KIT 70 PV
per fill mail) DPRH
Erythromycins WIDE-SEAL SILICONE PV
DIAPHRAGM KIT 75 PV
E.E.S. GRANULES SUSR DPRH
(Use Erythromycin GP
Ethylsuccinate) WIDE-SEAL SILICONE PV
DIAPHRAGM KIT 80 PV
ERYPED 200 SUSR (Use DPRH
Erythromycin GP
DIAPHRAGM KIT 85 PV
ERYPED 400 SUSR (Use DPRH
Erythromycin GP
DIAPHRAGM KIT 90 PV
erythromycin base cpep 1 DPRH
page ii-iii.
79
WIDE-SEAL SILICONE PV ONETOUCH VERIO SYNC RX/OTC
DIAPHRAGM KIT 95 PV BLOODGLUCOSE 2
DPRH MONITORING SYSTEM
KIT
Diabetic Supplies
QL(1 ea per PRECISION XTRA DEVI 2
365 days
FREESTYLE FREEDOM Parenteral Therapy Supplies
2 retail,1 ea per
LITE KIT 365 days mail); BD ECLIPSE NEEDLE
RX/OTC 2
30G X1/2" MISC
QL(1 ea per BD NEEDLE/30G X 1/2"
FREESTYLE INSULINX 2
365 days MISC
BLOODGLUCOSE 2 retail,1 ea per EASY TOUCH FLIPLOCK
MONITORING SYSTEM 2
365 days mail); NEEDLES 30GX1/2" MISC
KIT RX/OTC
EASY TOUCH
FREESTYLE LITE BLOOD HYPODERMIC NEEDLES 2
GLUCOSE MONITORING 2 30GX1/2" MISC
SYSTEM DEVI
HUMAPEN LUXURA HD 2 RX/OTC
FREESTYLE PRECISION RX/OTC DEVI
NEO BLOOD GLUCOSE 2
MONITORING SYSTEM HYPODERMIC NEEDLE 2
KIT 30GX1/2" MISC
LANCETS AND LANCET INSULIN SYRINGES AND 2 MO
2 PEN NEEDLES
DEVICES
QL(1 ea per POLY HUB NEEDLE/30G 2
365 days X 1/2" MISC
ONETOUCH ULTRA 2 KIT 2 retail,1 ea per Respiratory Therapy Supplies
365 days mail); QL(2 ea per
RX/OTC AEROCHAMBER MINI 365 days
QL(1 ea per AEROSOLCHAMBER 2 retail,2 ea per
365 days DEVI 365 days mail);
ONETOUCH ULTRA MINI 2 retail,1 ea per RX/OTC
KIT 365 days mail); QL(2 ea per
RX/OTC AEROVENT PLUS 365 days
ONETOUCH VERIO FLEX RX/OTC HOLDING 2 retail,2 ea per
BLOOD GLUCOSE CHAMBER/COLLAPSIBLE
2 365 days mail);
MONITORING SYSTEM DEVI RX/OTC
KIT QL(2 ea per
QL(1 ea per 365 days
ONETOUCH VERIO IQ 365 days ARIAL CHAMBER DEVI 2 retail,2 ea per
BLOOD GLUCOSE 2 retail,1 ea per 365 days mail);
MONITORING SYSTEM 365 days mail); RX/OTC
KIT RX/OTC QL(2 ea per
QL(1 ea per 365 days
ONETOUCH VERIO KIT 2 365 days BREATHE EASE/LARGE 2 retail,2 ea per
retail); RX/OTC MASK DEVI 365 days mail);
RX/OTC
page ii-iii.
80
QL(2 ea per Limited to 1
365 days every 6
BREATHE EASE/MEDIUM 2 retail,2 ea per
MASK DEVI INSPIRACHAMBER/LARG 2 months;QL(2
365 days mail); E DEVI ea per 365
RX/OTC days retail);
QL(2 ea per RX/OTC
365 days QL(2 ea per
BREATHE EASE/SMALL 2 retail,2 ea per
MASK DEVI 365 days
365 days mail); OPTICHAMBER 2 retail,2 ea per
RX/OTC DIAMOND MISC 365 days mail);
CLEVER CHOICE ANTI- Limit 1 every 6 RX/OTC
STATICVALVED months;QL(2 QL(2 ea per
HOLDING 2 ea per 365 OPTICHAMBER 365 days
CHAMBER/ADULT LARGE days retail); DIAMOND/LARGEFACE 2 retail,2 ea per
DEVI RX/OTC MASK DEVI 365 days mail);
CLEVER CHOICE ANTI- QL(2 ea per RX/OTC
STATICVALVED 2 365 days QL(2 ea per
HOLDING retail); RX/OTC OPTICHAMBER 365 days
CHAMBER/MEDIUM DEVI DIAMOND/MEDIUM FACE 2 retail,2 ea per
CLEVER CHOICE ANTI- QL(2 ea per MASK MISC 365 days mail);
STATICVALVED RX/OTC
2 365 days
HOLDING retail); RX/OTC QL(2 ea per
CHAMBER/SMALL DEVI OPTICHAMBER 365 days
Limit 1 every 6 DIAMOND/SMALLFACE 2 retail,2 ea per
COMPACT SPACE months;QL(1 MASK MISC 365 days mail);
CHAMBER/ANTI-STATIC 2 ea per 180 RX/OTC
DEVI days retail); QL(2 ea per
RX/OTC 365 days
spacer/aerosol-holding 1 retail,2 ea per
Limit 1 every 6 chambers devi
COMPACT SPACE 365 days mail);
months;QL(1
CHAMBER/ANTI- 2 ea per 180 RX/OTC
STATIC/LARGE MASK QL(2 ea per
days retail);
DEVI 365 days
RX/OTC spacer/aerosol-holding
Limit 1 every 6 1 retail,2 ea per
COMPACT SPACE chambers misc 365 days mail);
months;QL(1
STATIC/MEDIUM MASK QL(2 ea per
days retail);
DEVI 365 days
RX/OTC VALVED HOLDING
Limit 1 every 6 2 retail,2 ea per
COMPACT SPACE CHAMBER DEVI
months;QL(1 365 days mail);
STATIC/SMALL MASK days retail); MIGRAINE PRODUCTS - Drugs to Treat Migraine
DEVI RX/OTC Headaches
QL(2 ea per Migraine Combinations
365 days
FLEXICHAMBER DEVI 1 retail,2 ea per CAFERGOT TABS (Use GP
365 days mail); Ergotamine w/ Caffeine)
RX/OTC ergotamine w/ caffeine tabs 1
page ii-iii.
81
ISOMETHEPTENE Limit 6 tabs per
MUCATE/CAFFEINE/ACE 3 eletriptan hydrobromide 1 month;QL(0.2
TAMINOPHEN TABS
tabs ea daily)
isometheptene- FROVA TABS (Use Limit 9 per
dichloralphenazone- 1
Frovatriptan Succinate) GP month;QL(0.3
acetaminophen caps ea daily)
ISOMETHEPTENE/DICHL Limit 9 per
ORALPHENAZONE/ACET 2 frovatriptan succinate tabs 1 month;QL(0.3
AMINOPHEN CAPS ea daily)
MIGERGOT SUPP 2 Limit 1 inhaler
IMITREX SOLN NA 20 GP per
PRODRIN TABS (Use MG/ACT (Use Sumatriptan) month;QL(0.23
Isometheptene-Caffeine- GP ea daily)
Acetaminophen) Limit 6 sprays
PA; Limit 9 per IMITREX SOLN NA 5 GP per
sumatriptan-naproxen 1 month;QL(0.3 MG/ACT (Use Sumatriptan) month;QL(0.2
sodium tabs ea daily) ea daily)
TREXIMET TABS 10MG- PA IMITREX SOLN SC 6 PA; Limit 2mls
3
60MG MG/0.5ML (Use SP per
TREXIMET TABS 85MG- PA; Limit 9 per month;QL(0.07
Sumatriptan Succinate) ml daily)
500MG (Use Sumatriptan- GP month;QL(0.3
Naproxen Sodium) ea daily) IMITREX STATDOSE PA
REFILL SOCT (Use SP
Migraine Products - NSAIDs Sumatriptan Succinate)
PA; Limit 9 per IMITREX STATDOSE PA
CAMBIA PACK 3 month;QL(0.3 SYSTEM SOAJ (Use SP
ea daily) Sumatriptan Succinate)
Migraine Products IMITREX TABS OR 25 MG, Limit 9 per
QL(8 ml per fill 50 MG, 100 MG (Use GP month;QL(0.3
dihydroergotamine 1 retail,8 ml per Sumatriptan Succinate) ea daily)
mesylate soln fill mail) Limit 9 per
MAXALT TABS (Use GP month;QL(0.3
ERGOMAR SUBL 2 Rizatriptan Benzoate) ea daily)
MIGRANAL SOLN (Use QL(8 ml per fill Limit 9 per
Dihydroergotamine GP retail,8 ml per MAXALT-MLT TBDP (Use GP month;QL(0.3
Mesylate) fill mail) Rizatriptan Benzoate) ea daily)
Serotonin Agonists Limit 9 per
Limit 6 tabs per naratriptan hcl tabs 1 month;QL(0.3
almotriptan malate tabs 1 month;QL(0.2 ea daily)
ea daily) Limit 6 tabs per
RELPAX TABS (Use GP month;QL(0.2
Limit 9 per Eletriptan Hydrobromide)
AMERGE TABS (Use GP month;QL(0.3 ea daily)
Naratriptan HCl) ea daily) Limit 9 per
Limit 6 tabs per rizatriptan benzoate tabs 1 month;QL(0.3
AXERT TABS (Use GP month;QL(0.2 ea daily)
Almotriptan Malate) ea daily) Limit 9 per
rizatriptan benzoate tbdp 1 month;QL(0.3
ea daily)
page ii-iii.
82
Limit 1 inhaler NORMOSOL -R SOLN SP PA
sumatriptan soln 20 mg/act 1 per
month;QL(0.23 NORMOSOL-R SOLN SP PA
ea daily)
sumatriptan soln 5 mg/act 1 QL(0.23 ea PLASMA-LYTE A SOLN SP PA
daily)
Limit 6 per PLASMA-LYTE-148 SOLN SP PA
sumatriptan soln 5 mg/act 1 month;QL(0.2
ea daily) potassium chloride in nacl SP PA
sumatriptan succinate soaj SP PA soln
sc 4 mg/0.5ml, 6 mg/0.5ml Fluoride
sumatriptan succinate soct SP PA FLUORABON SOLN PV PV
sc 4 mg/0.5ml, 6 mg/0.5ml
PA; Limit 2mls FLURA-DROPS SOLN PV PV
sumatriptan succinate soln SP per
sc 6 mg/0.5ml month;QL(0.07 LOZI-FLUR LOZG 2
ml daily)
SUMATRIPTAN PA sodium fluoride chew 0.25 PV PV
SUCCINATE SOSY SC 6 SP mg, 0.5 mg, 1 mg, 2.2 mg
MG/0.5ML sodium fluoride soln 0.125 PV PV
Limit 9 per mg/drop, 0.5 mg/ml
sumatriptan succinate tabs SODIUM FLUORIDE TABS
or 25 mg, 50 mg, 100 mg 1 month;QL(0.3 PV PV
ea daily) 0.5 MG, 1 MG
SUMAVEL DOSEPRO SP PA Magnesium
SOTJ MAGNESIUM SULFATE
ZEMBRACE SYMTOUCH SP PA
SP PA SOLN IJ 50 %
SOAJ magnesium sulfate soln ij
zolmitriptan tabs 5 mg, 2.5 SP PA
1 QL(0.2 ea 50 %
mg daily) magnesium sulfate soln iv PA
Limit 6 tabs per 2 gm/50ml, 4 gm/100ml, 20 SP
zolmitriptan tbdp 5 mg, 2.5 1 month;QL(0.2
mg gm/500ml, 40 gm/1000ml
ea daily) MAGNESIUM SULFATE PA
QL(6 ea per 30 SOLN IV 2 GM/50ML, 4
ZOMIG SOLN NA 5 MG, 3 days retail,18 GM/100ML, 20 GM/500ML, SP
2.5 MG ea per 90 days 40 GM/1000ML (Use
mail) Magnesium Sulfate)
ZOMIG TABS OR 5 MG, GP QL(0.2 ea Phosphate
2.5 MG (Use Zolmitriptan) daily)
K-PHOS NEUTRAL TABS
Limit 6 tabs per (Use Pot Phosphate
ZOMIG ZMT TBDP (Use GP month;QL(0.2
Zolmitriptan) Monobasic w/ Sod GP
ea daily) Phosphate Dibasic &
MINERALS & ELECTROLYTES Monobasic)
Electrolyte Mixtures K-PHOS TABS 2
ISOLYTE-S SOLN SP PA pot phosphate monobasic

w/ sod phosphate dibasic & 1
monobasic tabs
page ii-iii.
83
Potassium SODIUM CHLORIDE SP PA
SOLN IV 0.9 %, 23.4 %
EFFERVESCENT
POTASSIUM/CHLORIDE 2 MISCELLANEOUS THERAPEUTIC CLASSES
TBEF
K-TAB TBCR 10 MEQ (Use GP Chelating Agents
Potassium Chloride) CUPRIMINE CAPS (Use GP PA
Penicillamine)
K-TAB TBCR 20 MEQ 3
DEPEN TITRATABS TABS 2
K-TAB TBCR 8 MEQ 2
penicillamine caps 1 PA
KLOR-CON M15 TBCR 2
SYPRINE CAPS (Use SP PA
potassium bicarb & 1 Trientine HCl)
chloride tbef
trientine hcl caps SP PA
potassium bicarbonate tbef 1
Enzymes
potassium chloride cpcr or
8 meq, 10 meq 1 XIAFLEX SOLR SP PA
POTASSIUM CHLORIDE 3
ER TBCR 20 MEQ Immunomodulators
POTASSIUM CHLORIDE REVLIMID CAPS AC PA
2
ER TBCR 8 MEQ
potassium chloride THALOMID CAPS SP
microencapsulated crystals 1
er tbcr Immunosuppressive Agents
potassium chloride pack or ASTAGRAF XL CP24 3 ST
1
20 meq
potassium chloride soln iv PA ATGAM INJ SP PA
0.4 meq/ml, 2 meq/ml, 20 SP
meq/50ml, 10 meq/100ml, AZASAN TABS 3
20 meq/100ml
AZATHIOPRINE SOLR IJ SP PA
POTASSIUM CHLORIDE PA 100 MG
SOLN IV 2 MEQ/ML, 10 SP
MEQ/50ML, 20 azathioprine tabs or 50 mg 1
MEQ/100ML
CELLCEPT CAPS (Use GP
potassium chloride soln or 1 Mycophenolate Mofetil)
10 %, 20 %
CELLCEPT PA
potassium chloride tbcr or 1 INTRAVENOUS SOLR
8 meq, 10 meq SP
(Use Mycophenolate
Sodium Mofetil HCl)
SODIUM CHLORIDE CELLCEPT SUSR (Use
SP PA Mycophenolate Mofetil) GP
SOLN IJ 0.9 %
sodium chloride soln ij 0.9 CELLCEPT TABS (Use
SP PA Mycophenolate Mofetil) GP
%, 2.5 meq/ml
sodium chloride soln iv PA cyclosporine caps or 25 1
0.45 %, 0.9 %, 3 %, 5 %, 4 SP mg, 100 mg
meq/ml
page ii-iii.
84
cyclosporine modified (for 1 SIMULECT SOLR SP PA
microemulsion) caps
cyclosporine modified (for 1 sirolimus soln 1
microemulsion) soln
cyclosporine soln iv 50 SP PA sirolimus tabs 1
mg/ml
ST tacrolimus caps 1
ENVARSUS XR TB24 3
IMURAN TABS (Use THYMOGLOBULIN SOLR SP PA
GP
Azathioprine)
ZORTRESS TABS 2 PA
mycophenolate mofetil 1
caps
Irrigation Solutions
mycophenolate mofetil hcl SP PA
solr irrigation solutions, 1
physiological soln
mycophenolate mofetil susr 1 lactated ringer's (irrigation) 1
soln
mycophenolate mofetil tabs 1
ringer's irrigation soln 1
mycophenolate sodium 1
tbec water for irrigation, sterile 1
soln
MYFORTIC TBEC (Use GP
Mycophenolate Sodium) Lymphatic Agents
NEORAL CAPS (Use SYLVANT SOLR AC
Cyclosporine Modified (For 3
Microemulsion)) Miscellaneous Therapeutic Classes
NEORAL SOLN (Use
Cyclosporine Modified (For 3 Compounded Drug 3 PA
Microemulsion))
Potassium Removing Agents
NULOJIX SOLR SP PA ST
LOKELMA PACK 3
PROGRAF CAPS 0.5 MG,
1 MG, 5 MG (Use 3 sodium polystyrene 1
Tacrolimus) sulfonate powd
PROGRAF PACK 0.2 MG, sodium polystyrene
SP PA sulfonate susp 1
1 MG
RAPAMUNE SOLN (Use VELTASSA PACK 3 ST
GP
Sirolimus)
RAPAMUNE TABS (Use Systemic Lupus Erythematosus Agents
GP
Sirolimus) BENLYSTA SOLR SP PA
SANDIMMUNE CAPS OR
25 MG, 100 MG (Use GP MOUTH/THROAT/DENTAL AGENTS
Cyclosporine)
SANDIMMUNE SOLN IV PA Anesthetics Topical Oral
50 MG/ML (Use SP FIRST-MOUTHWASH BLM
Cyclosporine) 3
SUSP
SANDIMMUNE SOLN OR 2 lidocaine hcl (mouth-throat)
100 MG/ML 1
soln
page ii-iii.
85
LIDOCAINE HCL SOLN 3 POLY-VI-FLOR FS STRP 3
MT 4 %
Anti-infectives - Throat POLY-VI-FLOR SUSP 3
clotrimazole lozg 1 QUFLORA PEDIATRIC 2 AL(Up to 6 yrs
CHEW old )
clotrimazole troc 1 QUFLORA PEDIATRIC AL(Up to 6 yrs
2
nystatin (mouth-throat) SOLN old )
1
susp TRI-VI-FLOR SUSP 3
ORAVIG TABS 3
TRI-VI-FLORO SUSP 3
Antiseptics - Mouth/Throat
Ped Multi Vitamins w/Fl & FE
chlorhexidine gluconate 1
(mouth-throat) soln ped multivitamins w/fl & 1
iron liqd
PERIDEX SOLN (Use
Chlorhexidine Gluconate GP pediatric vitamins acd 1 AL(Up to 6 yrs
(Mouth-Throat)) fluoride & iron soln old )
POLY-VI-FLOR/IRON AL(Up to 6 yrs
Steroids - Mouth/Throat/Dental CHEW 200MCG-0.5MG- 3 old )
triamcinolone acetonide 1 10MG-15UNIT-400UNIT
(mouth) pste POLY-VI-FLOR/IRON
Throat Products - Misc. SUSP 200MCG/ML- 3
7MG/ML-0.25MG/ML
cevimeline hcl caps 1
Prenatal Vitamins
EVOXAC CAPS (Use GP
Cevimeline HCl) ACTIVE OB CAPS 3
GELCLAIR GEL 3 ATABEX EC TBEC 2
GELX GEL 3 PA BAL-CARE DHA MISC 2
pilocarpine hcl (oral) tabs 1 BP MULTINATAL PLUS 2

TABS
SALAGEN TABS (Use GP
Pilocarpine HCl (Oral)) C-NATE DHA CAPS 3
MULTIVITAMINS CALCIUM PNV CAPS 3

Ped MV w/ Fluoride CITRANATAL 90 DHA 2
AL(Up to 6 yrs MISC
FLORIVA PLUS SOLN 2 CITRANATAL ASSURE
old ) 3
MULTIVITAMIN/FLUORID AL(Up to 6 yrs MISC
2 CITRANATAL B-CALM
E CHEW old ) 3
pediatric multivitamins w/fl AL(Up to 6 yrs MISC
1 CITRANATAL BLOOM
chew old ) 2
pediatric multivitamins w/fl AL(Up to 6 yrs DHA MISC
1
soln old ) CITRANATAL DHA MISC 2
pediatric vitamins acd w/ 1 AL(Up to 6 yrs
fluoride soln old )
page ii-iii.
86
CITRANATAL HARMONY 3 NESTABS DHA MISC 2
CAPS
CITRANATAL RX TABS 3 NESTABS TABS 3
CONCEPT DHA CAPS 2 NEXA PLUS CAPS 3

OB COMPLETE ONE 3
CONCEPT OB CAPS 2 CAPS
DOTHELLE DHA CAPS 2 OB COMPLETE PETITE 3
CAPS
DUET DHA 400 MISC 3 OB COMPLETE PREMIER 3
TABS
DUET DHA BALANCED 3 OB COMPLETE/DHA
MISC 3
CAPS
FOCALGIN 90 DHA MISC 2 OBSTETRIX DHA MISC 2 RX/OTC
FOCALGIN CA MISC 3 OBTREX DHA MISC 2 RX/OTC
FOLCAL DHA CAPS 3 PNV OB+DHA MISC 2

FOLCAPS OMEGA 3 3 PNV-DHA+DOCUSATE
CAPS 3
CAPS
FOLET DHA THPK 3 PNV-OMEGA CAPS 3
FOLIVANE-OB CAPS 2 PNV-SELECT TABS 3
HEMENATAL OB + DHA 2
MISC PNV-TOTAL CAPS 3
HEMENATAL OB TABS 3 PNV-VP-U CAPS 2
INFANATE BALANCE 3
CAPS PR NATAL 400 EC MISC 3
MARNATAL-F CAPS 2 PR NATAL 400 MISC 3

MYNATAL ADVANCE 2 PR NATAL 430 EC MISC 2
TABS
MYNATAL ULTRACAPLET 2 PR NATAL 430 MISC 2
TABS
MYNATE 90 PLUS TBCR 2 PRENA1 PEARL CPCR 3
PRENAISSANCE 3
NATACHEW CHEW 3 BALANCE CAPS
PRENAISSANCE 3
NATELLE ONE CAPS 3 HARMONY DHA MISC
NEEVO DHA CAPS 3 PRENAISSANCE NEXT 3
TABS
NESTABS ABC MISC 3 PRENAISSANCE NEXT-B 3
TABS
page ii-iii.
87
PRENAISSANCE PLUS 3 TARON-C DHA CAPS 2
CAPS
PRENATA CHEW 2 TARON-PREX CAPS 3
PRENATAL 19 TABS 3 THRIVITE 19 TABS 3

prenatal vit w/ docusate-fe 1 TL FOLATE TABS 3
fumarate-folic acid tabs
prenatal vit w/ docusate- 1 TL-CARE DHA CAPS 3
iron carbonyl-folic acid tabs
prenatal vit w/ ferrous TRI-TABS DHA MISC 2
fumarate-l methylfolate- 1
folic acid tabs TRICARE PRENATAL 3
DHA ONE CAPS
prenatal without a w/ fe
fumarate-l methylfolate-fa- 1 TRINATAL GT TABS 2
dha caps
TRIVEEN-DUO DHA MISC 3
PRENATAL-U CAPS 2
QL(1 ea daily) TRIVEEN-PRX RNF CAPS 3
PRENATE DHA CAPS 2
ULTIMATECARE ONE 3
PRENATE ELITE TABS 2 CAPS
PRENATE ENHANCE ULTIMATECARE ONE NF 3
3 CAPS
CAPS
PRENATE ESSENTIAL VEMAVITE-PRX 2 CAPS 3
3
CAPS
VENA-BAL DHA MISC 2
PRENATE MINI CAPS 3
VINATE DHA RF CAPS 3
PRENATE PIXIE CAPS 3
PRENATE RESTORE VIRT-ADVANCE TABS 2
3
CAPS
VIRT-C DHA CAPS 2
R-NATAL OB CAPS 3
VIRT-NATE DHA CAPS 3
RELNATE DHA CAPS 3
VIRT-PN DHA CAPS 3
SE-NATAL 19 TABS 3
SELECT-OB CHEW VIRT-PN PLUS CAPS 3
1700UNIT-29MG-30UNIT-
15MG-25MG-1.6MG- VIRT-PN TABS 3
3
15MG-1.8MG-5MCG-
400UNIT-1MG-2.5MG- VIRT-VITE GT TABS 2
60MG
VIRTPREX CAPS 3
SELECT-OB+DHA MISC 3
VITAFOL ULTRA CAPS 2
TARON-BC MISC 3
page ii-iii.
88
VITAFOL-NANO TABS 3 LIORESAL INTRATHECAL PA
SOLN 0.05 MG/ML, 10 SP
VITAFOL-ONE CAPS 3 MG/5ML, 10 MG/20ML
LIORESAL INTRATHECAL PA
VITAPEARL CPCR 3 SOLN 10 MG/20ML, 40 SP
MG/20ML (Use Baclofen)
VIVA DHA CAPS 3 LORZONE TABS 3
VP-CH PLUS CAPS 3 metaxalone tabs 1
VP-CH-PNV CAPS 3 methocarbamol tabs 1
VP-GGR-B6 PRENATAL 3
TABS orphenadrine citrate tb12 1
VP-HEME OB + DHA 2 PARAFON FORTE DSC
MISC GP
TABS (Use Chlorzoxazone)
VP-HEME OB TABS 3 ROBAXIN TABS (Use GP
Methocarbamol)
VP-PNV-DHA CAPS 3 ROBAXIN-750 TABS (Use GP
Methocarbamol)
ZATEAN-PN DHA CAPS 3 SKELAXIN TABS (Use GP
Metaxalone)
ZATEAN-PN PLUS CAPS 3 SOMA TABS (Use GP
Carisoprodol)
MUSCULOSKELETAL THERAPY AGENTS -
Drugs to Treat Spasms tizanidine hcl caps 1
Central Muscle Relaxants
tizanidine hcl tabs 1
AMRIX CP24 (Use GP ST; QL(1 ea
Cyclobenzaprine HCl) daily) ZANAFLEX CAPS (Use GP
baclofen soln it 40 Tizanidine HCl)
SP PA
mg/20ml, 500 mcg/ml ZANAFLEX TABS (Use GP
baclofen tabs or 10 mg, 20 Tizanidine HCl)
1
mg Direct Muscle Relaxants
BACLOFEN TABS OR 5 3 DANTRIUM CAPS (Use
MG GP
Dantrolene Sodium)
carisoprodol tabs 1 dantrolene sodium caps 1
CHLORZOXAZONE TABS 3 Muscle Relaxant Combinations
375 MG, 500 MG, 750 MG
carisoprodol w/ aspirin & 1
cyclobenzaprine hcl cp24 1 ST; QL(1 ea codeine tabs
15 mg, 30 mg daily)
cyclobenzaprine hcl tabs 5 carisoprodol w/ aspirin tabs 1
1
mg, 10 mg, 7.5 mg
CYCLO/GABA10/300 3 PA
FEXMID TABS (Use GP PACK THPK
Cyclobenzaprine HCl)
Viscosupplements
GABLOFEN SOLN SP PA
page ii-iii.
89
EUFLEXXA SOSY SP PA Limit 2 inhalers
per
HYALGAN SOSY SP PA budesonide (nasal) susp 1 month;QL(0.6
ml daily);
RX/OTC
ORTHOVISC SOSY SP PA
Limit 2 inhalers
SODIUM HYALURONATE FLONASE ALLERGY
SP PA RELIEF CHILDRENS per
SOSY GP month;QL(1.2
SUSP (Use Fluticasone ml daily);
SYNVISC ONE SOSY SP PA Propionate (Nasal)) RX/OTC
SYNVISC SOSY SP PA Limit 2 inhalers
FLONASE ALLERGY per
RELIEF SUSP (Use GP month;QL(1.2
NASAL AGENTS - SYSTEMIC AND TOPICAL - Fluticasone Propionate
Drugs to treat the Nose or Sinus ml daily);
(Nasal)) RX/OTC
Nasal Agent Combinations Limit 1 inhaler
Limit 1 inhaler FLONASE SENSIMIST
per 3 per
DYMISTA SUSP 3 SUSP month;QL(0.34
month;QL(0.77 ml daily)
gm daily)
FLUNISOLIDE SOLN 3
Nasal Agents - Misc.
PA Limit 2 inhalers
TICASPRAY THPK 3 per
fluticasone propionate 1 month;QL(1.2
Nasal Anti-infectives (nasal) susp ml daily);
BACTROBAN NASAL 2 RX/OTC
OINT Limit 2 inhalers
Nasal Antiallergy mometasone furoate 1 per
ASTEPRO SOLN (Use (nasal) susp month;QL(1.2
GP QL(1 ml daily) gm daily)
Azelastine HCl)
Limit 30mls per NASACORT ALLERGY 3 RX/OTC
azelastine hcl soln 0.1 %, 1 month;QL(1.2 24HR AERO
137 mcg/spray ml daily) NASACORT ALLERGY RX/OTC
QL(1 ml daily) 24HR AERO (Use GP
azelastine hcl soln 0.15 % 1 Triamcinolone Acetonide
(Nasal))
olopatadine hcl (nasal) soln 1 NASACORT ALLERGY RX/OTC
PATANASE SOLN (Use 24HR CHILDRENS AERO GP
GP (Use Triamcinolone
Olopatadine HCl (Nasal))
Acetonide (Nasal))
Nasal Anticholinergics Limit 2 inhalers
ipratropium bromide (nasal) NASONEX SUSP (Use
soln 1 Mometasone Furoate GP per
month;QL(1.2
(Nasal)) gm daily)
Nasal Steroids
Limit 2 inhalers Limit 1 inhaler
BECONASE AQ SUSP 3 per OMNARIS SUSP 3 per
month;QL(1.67 month;QL(0.42
gm daily) gm daily)
page ii-iii.
90
Limit 1 inhaler COSOPT PF SOLN (Use
QNASL AERS 3 per Dorzolamide HCl-Timolol GP
month;QL(0.29 Maleate)
gm daily) COSOPT SOLN (Use
QNASL CHILDRENS 3 QL(0.23 gm Dorzolamide HCl-Timolol GP
AERS daily) Maleate)
triamcinolone acetonide 1 RX/OTC dorzolamide hcl-timolol 1
(nasal) aero maleate soln
Limit 1 inhaler DORZOLAMIDE
per HCL/TIMOLOL MALEATE 2
ZETONNA AERS 3
month;QL(0.3 SOLN
gm daily) ISTALOL SOLN (Use GP
Sympathomimetic Decongestants Timolol Maleate (Ophth))
ADRENALIN SOLN 3 levobunolol hcl soln 1
NEUROMUSCULAR AGENTS - Drugs to METIPRANOLOL SOLN 3

Relax/Paralyze Muscles
ALS Agents
timolol maleate (ophth) soln 1
RILUTEK TABS (Use TIMOLOL MALEATE
GP OPHTHALMIC GEL 2
Riluzole)
FORMING SOLG
riluzole tabs 1
TIMOPTIC OCUDOSE 3
Neuromuscular Blocking Agent - Neurotoxins SOLN
TIMOPTIC SOLN (Use
BOTOX SOLR SP PA Timolol Maleate (Ophth)) GP
TIMOPTIC-XE SOLG 0.25
OPHTHALMIC AGENTS - Drugs to Treat the Eye % (Use Timolol Maleate GP
(Ophth))
Artificial Tears and Lubricants
TIMOPTIC-XE SOLG 0.25 2
LACRISERT INST 3 %, 0.5 %
Beta-blockers - Ophthalmic Cycloplegic Mydriatics
BETAGAN SOLN (Use ATROPINE SULFATE 2
GP OINT OP 1 %
Levobunolol HCl)
ATROPINE SULFATE 2
betaxolol hcl (ophth) soln 1 SOLN OP 1 %
CYCLOGYL SOLN (Use GP
BETIMOL SOLN 2 Cyclopentolate HCl)
BETOPTIC-S SUSP 2 CYCLOMYDRIL SOLN 3
carteolol hcl (ophth) soln 1 cyclopentolate hcl soln 1
CARTEOLOL HCL SOLN 3 homatropine hbr soln 1
COMBIGAN SOLN 3 ISOPTO ATROPINE SOLN 2
page ii-iii.
91
MYDRIACYL SOLN (Use GP CILOXAN SOLN (Use GP
Tropicamide) Ciprofloxacin HCl (Ophth))
tropicamide soln 1 ciprofloxacin hcl (ophth) 1
soln
Miotics erythromycin (ophth) oint 1
ISOPTO CARPINE SOLN GP
(Use Pilocarpine HCl) gatifloxacin (ophth) soln 1
PHOSPHOLINE IODIDE 2
SOLR GENTAK OINT 2
pilocarpine hcl soln 1 gentamicin sulfate (ophth) 1
soln
Ophthalmic - Angiogenesis Inhibitors Limit 5mls per
LUCENTIS SOSY SP PA KLARITY-A SOLN 3 month;QL(0.17
ml daily)
Ophthalmic Adrenergic Agents levofloxacin (ophth) soln 1
ALPHAGAN P SOLN 0.1 % 2
MOXEZA SOLN 2
ALPHAGAN P SOLN 0.15
% (Use Brimonidine GP moxifloxacin hcl (ophth) 1
Tartrate) soln
apraclonidine hcl soln 1 NATACYN SUSP 2
neomycin-bacitracin zn- 1
brimonidine tartrate soln 1 polymyxin oint
IOPIDINE SOLN 0.5 % GP NEOMYCIN/POLYMYXIN/
(Use Apraclonidine HCl) 2
GRAMICIDIN SOLN
IOPIDINE SOLN 1 % 3 NEOSPORIN SOLN (Use
Neomycin-Polymyxin- GP
SIMBRINZA SUSP 3 Gramicidin)
QL(5 ml per fill
OCUFLOX SOLN (Use GP retail,5 ml per
Ophthalmic Anti-infectives Ofloxacin (Ophth))
Limit 5mls per fill mail)
AZASITE SOLN 3 month;QL(0.17 QL(5 ml per fill
ml daily) ofloxacin (ophth) soln 1 retail,5 ml per
BACITRACIN OINT OP fill mail)
2 polymyxin b-trimethoprim
500 UNIT/GM 1
bacitracin-polymyxin b soln
1 POLYTRIM SOLN (Use
(ophth) oint GP
Polymyxin B-Trimethoprim)
BESIVANCE SUSP 3
sulfacetamide sodium 1
BLEPH-10 SOLN (Use (ophth) oint
Sulfacetamide Sodium GP sulfacetamide sodium
(Ophth)) 1
(ophth) soln
CILOXAN OINT 2 tobramycin (ophth) soln 1
TOBREX OINT 2
page ii-iii.
92
TOBREX SOLN (Use GP DEXAMETHASONE
Tobramycin (Ophth)) SODIUM PHOSPHATE 2
SOLN OP 0.1 %
TRIFLURIDINE SOLN 2
DUREZOL EMUL 3
trifluridine soln 1
FLAREX SUSP 2
VIGAMOX SOLN (Use GP
Moxifloxacin HCl (Ophth)) fluorometholone (ophth) 1
VIROPTIC SOLN (Use susp
GP
Trifluridine) FML FORTE SUSP 2
ZIRGAN GEL 3 FML LIQUIFILM SUSP
ZYMAXID SOLN (Use (Use Fluorometholone GP
GP (Ophth))
Gatifloxacin (Ophth))
Ophthalmic Decongestants FML OINT 2
phenylephrine hcl (ophth) 1
soln LOTEMAX GEL 3
Ophthalmic Immunomodulators LOTEMAX OINT 3
Limit 60 per
RESTASIS EMUL 3 month;QL(2.14 LOTEMAX SUSP (Use GP
ml daily) Loteprednol Etabonate)
Limit 60 per loteprednol etabonate susp 1
RESTASIS MULTIDOSE 3 month;QL(2.14
EMUL ml daily) MAXIDEX SUSP 2
Ophthalmic Local Anesthetics MAXITROL OINT (Use
AKTEN GEL 3 Neomycin-Polymy- GP
Dexameth)
ALCAINE SOLN (Use GP MAXITROL SUSP (Use
Proparacaine HCl) Neomycin-Polymy- GP
proparacaine hcl soln 1 Dexameth)
neomycin-polymy- 1
tetracaine hcl (ophth) soln 1 dexameth oint
neomycin-polymy- 1
Ophthalmic Nerve Growth Factors dexameth susp
OXERVATE SOLN SP PA neomycin-polymyxin-hc 1
(ophth) susp
Ophthalmic Steroids OMNIPRED SUSP (Use
Prednisolone Acetate GP
ALREX SUSP 3 (Ophth))
QL(4 gm per fill PRED FORTE SUSP 2
bacitracin-poly-neomycin- 1 retail,4 gm per
hc oint fill mail)
PRED MILD SUSP 2
BLEPHAMIDE S.O.P. 2
OINT PRED-G S.O.P. OINT 3
BLEPHAMIDE SUSP 2
page ii-iii.
93
PRED-G SUSP 3 ACULAR SOLN (Use
Ketorolac Tromethamine GP
PREDNISOLONE (Ophth))
2
ACETATE P-F SUSP
ACUVAIL SOLN 3
PREDNISOLONE 2
ACETATE SUSP ALOCRIL SOLN 3
PREDNISOLONE SODIUM
PHOSPHATE SOLN OP 1 2 ALOMIDE SOLN 2
%
PREDNISOLONE SODIUM PA azelastine hcl (ophth) soln 1
PHOSPHATE/MOXIFLOXA 3
CIN SOLN Limit 10mls per
AZOPT SUSP 2 month;QL(0.4
PREDNISOLONE/MOXIFL 3 PA ml daily)
OXACIN SOLN
ST; Limit 10mls
PREDNISOLONE/MOXIFL PA per
OXACIN/BROMFENAC 3 BEPREVE SOLN 3
month;QL(0.34
SOLN ml daily)
PREDNISOLONE/MOXIFL PA bromfenac sodium (ophth)
OXACIN/KETOROLAC 3 1
soln
SOLN
sulfacetamide sod- BROMFENAC SOLN 3
1
prednisolone soln
cromolyn sodium (ophth) 1
SULFACETAMIDE soln
SODIUM/PREDNISOLONE 2
SODIUM PHOSPHATE CYSTARAN SOLN SP PA
SOLN
diclofenac sodium (ophth) 1
TOBRADEX OINT 3 soln
Limit 10mls per
TOBRADEX ST SUSP 3 dorzolamide hcl soln 1 month;QL(0.34
ml daily)
TOBRADEX SUSP (Use QL(5 ml per fill
Tobramycin- GP retail,5 ml per Limit 10mls per
DORZOLAMIDE HCL
Dexamethasone) fill mail) 2 month;QL(0.34
SOLN ml daily)
QL(5 ml per fill
tobramycin- 1 retail,5 ml per ELESTAT SOLN (Use
dexamethasone susp GP
fill mail) Epinastine HCl (Ophth))
Limit 5mls per EMADINE SOLN 3
ZYLET SUSP 3 month;QL(0.17
ml daily) epinastine hcl (ophth) soln 1
Ophthalmic Surgical Aids FLURBIPROFEN SODIUM 2
GELFILM OP FILM 3 SOLN
flurbiprofen sodium soln 1
Ophthalmics - Misc.
ACULAR LS SOLN (Use ILEVRO SUSP 3
Ketorolac Tromethamine GP
(Ophth)) ketorolac tromethamine 1
(ophth) soln
page ii-iii.
94
LASTACAFT SOLN 3 ST Limit 2.5mls
XALATAN SOLN (Use GP per
NEVANAC SUSP 3 Latanoprost) month;QL(0.09
ml daily)
Limit 10mls per
olopatadine hcl soln 0.1 % 1 month;QL(0.34 XELPROS EMUL 3 PA
ml daily)
ZIOPTAN SOLN 3
Limit 2.5mls
per
olopatadine hcl soln 0.2 % 1
month;QL(0.09 OTIC AGENTS - Drugs to Treat the Ear
ml daily) Otic Agents - Miscellaneous
PAREMYD SOLN 3 acetic acid (otic) soln 1
Limit 2.5mls
PATADAY SOLN (Use Otic Anti-infectives
GP per CETRAXAL SOLN (Use
Olopatadine HCl) month;QL(0.09 GP
ml daily) Ciprofloxacin HCl (Otic))
Limit 10mls per ciprofloxacin hcl (otic) soln 1
PATANOL SOLN (Use GP month;QL(0.34
Olopatadine HCl) ml daily) FLOXIN OTIC SOLN (Use GP
Ofloxacin (Otic))
PROLENSA SOLN 3
ofloxacin (otic) soln 1
Limit 10mls per
TRUSOPT SOLN (Use GP month;QL(0.34
Dorzolamide HCl) Otic Combinations
ml daily)
CIPRO HC SUSP 3
Prostaglandins - Ophthalmic
Limit 2.5mls CIPRODEX SUSP 2
per
bimatoprost soln 1
month;QL(0.09 COLY-MYCIN S SUSP 3
ml daily)
Limit 2.5mls CORTANE-B AQUEOUS 3
per SOLN
latanoprost soln 1
month;QL(0.09 CORTANE-B-OTIC SOLN
ml daily) (Use Pramoxine-HC- GP
Limit 2.5mls Chloroxylenol)
per CORTISPORIN-TC SUSP 3
LATANOPROST SOLN 2
month;QL(0.09
ml daily) neomycin-polymyxin-hc 1
Limit 2.5mls (otic) soln
per neomycin-polymyxin-hc 1
LUMIGAN SOLN 2 (otic) susp
month;QL(0.09
ml daily) OTICIN HC NR SOLN (Use
Limit 2.5mls Pramoxine-HC- GP
per Chloroxylenol)
TRAVATAN Z SOLN 2
month;QL(0.09 Limit 14mls per
ml daily) OTOVEL SOLN 3 month;QL(0.5
ea daily)
page ii-iii.
95
PRAMOTIC LIQD 3 HIZENTRA SOLN SP PA
pramoxine-hc-chloroxylenol 1 OCTAGAM SOLN SP PA
soln
Otic Steroids PRIVIGEN SOLN SP PA
DERMOTIC OIL (Use
Fluocinolone Acetonide GP Monoclonal Antibodies
(Otic)) SYNAGIS SOLN SP PA
fluocinolone acetonide 1
(otic) oil Passive Immunizing Agents - Combinations
hydrocortisone w/acetic QL(10 ml per HYQVIA KIT SP PA
1 fill retail,30 ml
acid soln per fill mail)
PENICILLINS - Drugs to Treat Bacterial Infections
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding Aminopenicillins
Abortifacients/Agents for Cervical Ripening amoxicillin caps 1
PREPIDIL GEL 3 amoxicillin chew 1
PROSTIN E2 SUPP 3 amoxicillin susr 1
Oxytocics
amoxicillin tabs 1
methylergonovine maleate SP PA
soln ij 0.2 mg/ml AMPICILLIN CAPS 2
methylergonovine maleate 1
tabs or 0.2 mg ampicillin sodium solr ij 1 SP PA
gm, 250 mg, 500 mg
PASSIVE IMMUNIZING AND TREATMENT
AGENTS - Antibody Drugs to Treat Low Immune AMPICILLIN SODIUM SP PA
System SOLR IJ 125 MG
ampicillin sodium solr iv 10 SP PA
Immune Serums gm
BIVIGAM SOLN SP PA MOXATAG TB24 3 PA; QL(1 ea
daily)
CUVITRU SOLN SP PA Natural Penicillins
FLEBOGAMMA DIF SOLN SP PA BICILLIN L-A SUSP SP PA
GAMASTAN INJ SP PA PENICILLIN G PA

POTASSIUM IN ISO- SP
OSMOTIC DEXTROSE
GAMASTAN S/D INJ SP PA SOLN
GAMMAGARD LIQUID SP PA penicillin g potassium solr SP PA
SOLN
PENICILLIN G PROCAINE SP PA
GAMMAPLEX SOLN SP PA SUSP
GAMUNEX-C SOLN SP PA PENICILLIN G SODIUM SP PA
SOLR
page ii-iii.
96
PENICILLIN V ZOSYN SOLN PA
POTASSIUM SOLR 125 2 0.375GM/50ML-
MG/5ML, 250 MG/5ML 3GM/50ML-5%,
penicillin v potassium tabs 0.5GM/100ML- SP
1 4GM/100ML-5%,
250 mg, 500 mg
0.25GM/50ML-2GM/50ML-
PFIZERPEN SOLR (Use SP PA 5%
Penicillin G Potassium)
ZOSYN SOLR 0.375GM- PA
Penicillin Combinations 3GM, 0.25GM-2GM,
amoxicillin & pot 0.5GM-4GM (Use SP
1 Piperacillin Sodium-
clavulanate susr
amoxicillin & pot Tazobactam Sodium)
1
clavulanate tabs Penicillinase-Resistant Penicillins
amoxicillin & pot BACTOCILL IN
clavulanate tb12 1 SP PA
DEXTROSE SOLN
AMOXICILLIN/CLAVULAN 2
ATE POTASSIUM CHEW dicloxacillin sodium caps 1
AMOXICILLIN/CLAVULAN nafcillin sodium solr ij 1 gm SP PA
ATE POTASSIUM ER 2
TB12 NAFCILLIN SODIUM SP PA
ampicillin & sulbactam SOLR IJ 10 GM
SP PA
sodium solr NAFCILLIN SODIUM SP PA
AUGMENTIN ES-600 SOLR IV 2 GM
SUSR (Use Amoxicillin & GP NAFCILLIN SOLN SP PA
Pot Clavulanate)
AUGMENTIN SUSR 2 oxacillin sodium solr SP PA
125MG/5ML-31.25MG/5ML
AUGMENTIN SUSR PROGESTINS - Hormone Replacement/Modifying
250MG/5ML-62.5MG/5ML Drugs
GP
(Use Amoxicillin & Pot Progestins
Clavulanate)
AYGESTIN TABS (Use GP
AUGMENTIN TABS Norethindrone Acetate)
500MG-125MG, 875MG- GP
125MG (Use Amoxicillin & hydroxyprogesterone SP PA
Pot Clavulanate) caproate oil 250 mg/ml
AUGMENTIN XR TB12 MAKENA OIL (Use PA
(Use Amoxicillin & Pot GP Hydroxyprogesterone SP
Clavulanate) Caproate)
medroxyprogesterone
BICILLIN C-R SUSP SP PA acetate tabs 1
piperacillin sodium- MEGACE ES SUSP (Use
SP PA Megestrol Acetate GP
tazobactam sodium solr
UNASYN BULK PACK PA (Appetite))
SOLR (Use Ampicillin & SP megestrol acetate 1
Sulbactam Sodium) (appetite) susp
UNASYN SOLR (Use PA norethindrone acetate tabs 1
Ampicillin & Sulbactam SP
Sodium)
page ii-iii.
97
progesterone micronized 1 QL(2 ea daily) NAMENDA TITRATION
caps PAK TABS (Use GP
PROMETRIUM CAPS (Use GP QL(2 ea daily) Memantine HCl)
Progesterone Micronized) NAMENDA XR CP24 (Use GP PA
PROVERA TABS (Use Memantine HCl)
Medroxyprogesterone GP NAMENDA XR TITRATION 3 PA
Acetate) PACK CP24
PSYCHOTHERAPEUTIC AND NEUROLOGICAL RAZADYNE ER CP24 (Use QL(1 ea daily)
AGENTS - MISC. - Drugs to Treat Mental and Galantamine GP
Emotional Conditions Hydrobromide)
RAZADYNE TABS (Use
Agents for Chemical Dependency Galantamine GP
acamprosate calcium tbec 1 Hydrobromide)
ANTABUSE TABS (Use rivastigmine pt24 1
GP
Disulfiram)
rivastigmine tartrate caps 1
disulfiram tabs 1
Combination Psychotherapeutics
Anti-Cataplectic Agents chlordiazepoxide- 1
XYREM SOLN SP PA amitriptyline tabs
olanzapine-fluoxetine hcl 1
Antidementia Agents caps
ARICEPT TABS (Use GP QL(1 ea daily) perphenazine-amitriptyline
Donepezil Hydrochloride) 1
tabs
donepezil hydrochloride 1 QL(1 ea daily) SYMBYAX CAPS (Use
tabs Olanzapine-Fluoxetine HCl) GP
donepezil hydrochloride 1 QL(1 ea daily) Fibromyalgia Agents
tbdp
PA; QL(2 ea
EXELON PT24 (Use SAVELLA TABS 3
GP daily)
Rivastigmine)
SAVELLA TITRATION 3 PA; QL(2 ea
galantamine hydrobromide 1 QL(1 ea daily) PACK MISC daily)
cp24 8 mg, 16 mg, 24 mg
GALANTAMINE QL(1 ml daily) Movement Disorder Drug Therapy
HYDROBROMIDE SOLN 4 2 INGREZZA CAPS SP PA
MG/ML
galantamine hydrobromide 1 tetrabenazine tabs SP
tabs 4 mg, 8 mg, 12 mg
memantine hcl cp24 7 mg, PA XENAZINE TABS (Use SP
1 Tetrabenazine)
14 mg, 21 mg, 28 mg
memantine hcl soln 2 Multiple Sclerosis Agents
1
mg/ml AMPYRA TB12 (Use GP PA
memantine hcl tabs 5 mg, Dalfampridine)
1
10 mg, AUBAGIO TABS 3 PA
NAMENDA TABS (Use GP
Memantine HCl) AVONEX KIT SP PA
page ii-iii.
98
AVONEX PEN AJKT SP PA LYRICA CR TB24 165 MG, 3 PA; QL(1 ea
82.5 MG daily)
AVONEX PSKT SP PA LYRICA CR TB24 330 MG 3 PA; QL(2 ea
daily)
BETASERON KIT SP PA Premenstrual Dysphoric Disorder (PMDD) Agents
COPAXONE SOSY (Use SP PA FLUOXETINE CAPS 2
Glatiramer Acetate)
dalfampridine tb12 1 PA fluoxetine hcl (pmdd) tabs 1
SARAFEM TABS (Use
EXTAVIA KIT SP PA Fluoxetine HCl (PMDD)) GP
GILENYA CAPS 3 PA Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS 3 PA
glatiramer acetate sosy SP PA
Psychotherapeutic and Neurological Agents -
GLATOPA SOSY 2 PA
ERGOLOID MESYLATES 3
TABS
PLEGRIDY SOPN SP PA ORAP TABS (Use GP
Pimozide)
PLEGRIDY SOSY SP PA
PIMOZIDE TABS 2
PLEGRIDY STARTER SP PA
PACK SOPN Restless Leg Syndrome (RLS) Agents
PLEGRIDY STARTER SP PA
PACK SOSY HORIZANT TBCR 3 QL(1 ea daily)
REBIF REBIDOSE SOAJ SP PA Smoking Deterrents
REBIF REBIDOSE bupropion hcl (smoking PV PV
SP PA deterrent) tb12
TITRATIONPACK SOAJ
CHANTIX CONTINUING PV PV
REBIF SOSY SP PA MONTHPAK TABS
REBIF TITRATION PACK CHANTIX STARTING PV PV
SP PA MONTH PAK TABS
SOSY
TECFIDERA CPDR 3 PA CHANTIX TABS PV PV
TECFIDERA STARTER PA NICODERM CQ PT24 (Use GP PV
3 Nicotine)
PACK MISC
NICORETTE GUM (Use GP PV
TYSABRI CONC SP PA Nicotine Polacrilex)
ZINBRYTA SOSY SP PA NICORETTE LOZG (Use GP PV
Nicotine Polacrilex)
Postherpetic Neuralgia (PHN)/Neuropathic Pain NICORETTE MINI LOZG GP PV
(Use Nicotine Polacrilex)
GRALISE STARTER MISC 3 PA NICORETTE STARTER PV
PA KIT GUM (Use Nicotine GP
GRALISE TABS 3 Polacrilex)
page ii-iii.
99
nicotine polacrilex gum PV PV STERILE TALC POWDER AC
SUSR
nicotine polacrilex lozg PV PV Pulmonary Fibrosis Agents
nicotine pt24 PV PV ESBRIET CAPS SP PA
NICOTROL INHALER PV PV ESBRIET TABS SP PA

INHA
OFEV CAPS SP PA
NICOTROL NS SOLN PV PV
ZYBAN TB12 (Use PV SULFONAMIDES - Drugs to Treat Bacterial
Bupropion HCl (Smoking GP Infections
Deterrent)) Sulfonamides
Vasomotor Symptom Agents SULFADIAZINE TABS 3
BRISDELLE CAPS (Use
Paroxetine Mesylate GP TETRACYCLINES - Drugs to Treat Bacterial
(Vasomotor)) Infections
paroxetine mesylate 1 Glycylcyclines
(vasomotor) caps
TIGECYCLINE SOLR SP PA
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions tigecycline solr SP PA
Alpha-Proteinase Inhibitor (Human)
TYGACIL SOLR (Use SP PA
ARALAST NP SOLR SP PA Tigecycline)
Tetracyclines
GLASSIA SOLN SP PA
demeclocycline hcl tabs 1
PROLASTIN-C SOLR SP PA
DORYX MPC TBEC 3 PA
ZEMAIRA SOLR SP PA
DORYX TBEC 50 MG (Use GP ST
Cystic Fibrosis Agents Doxycycline Hyclate)
KALYDECO PACK 50 MG, doxycycline (monohydrate)
SP PA caps 50 mg, 75 mg, 100 1
75 MG
mg, 150 mg
KALYDECO TABS 150 MG SP PA doxycycline (monohydrate) 1
susr 25 mg/5ml
ORKAMBI PACK SP PA
doxycycline (monohydrate) 1
tabs 50 mg, 100 mg
ORKAMBI TABS SP PA
doxycycline (monohydrate) 1 ST
PA; Limited to tabs 75 mg, 150 mg
PULMOZYME SOLN SP 75mls per doxycycline hyclate caps 1
month;QL(2.5 50 mg, 100 mg
ml daily)
doxycycline hyclate tabs 20 1
Pleural Sclerosing Agents mg, 100 mg
SCLEROSOL AC DOXYCYCLINE HYCLATE PA
INTRAPLEURAL AERP 3
TABS 50 MG
page ii-iii.
100
doxycycline hyclate tbec 50 ST ARMOUR THYROID TABS
mg, 75 mg, 100 mg, 150 1 15 MG, 120 MG (Use GP
mg Thyroid)
MINOCIN CAPS (Use GP ARMOUR THYROID TABS 2
Minocycline HCl) 180 MG, 240 MG, 300 MG
minocycline hcl caps 50 1 ARMOUR THYROID TABS
mg, 75 mg, 100 mg 30 MG, 60 MG, 90 MG 3
minocycline hcl tabs 50 (Use Thyroid)
1
mg, 100 mg CYTOMEL TABS (Use 3
Liothyronine Sodium)
minocycline hcl tabs 75 mg 1 PA
levothyroxine sodium tabs 1
minocycline hcl tb24 45 1 ST
mg, 90 mg, 135 mg liothyronine sodium tabs 1
minocycline hcl tb24 55 PA
mg, 65 mg, 80 mg, 105 mg, 1 NATURE-THROID NT-2.5 3
115 mg TABS
MONODOX CAPS (Use NATURE-THROID TABS 3
Doxycycline GP 48.75 MG
(Monohydrate)) NATURE-THROID TABS
65 MG, 130 MG, 195 MG,
NUTRIDOX KIT 3 PA 260 MG, 325 MG, 32.5 2
SOLODYN TB24 (Use MG, 97.5 MG, 16.25 MG,
GP PA 81.25 MG, 113.75 MG,
Minocycline HCl)
146.25 MG
TARGADOX TABS 3 PA
SYNTHROID TABS (Use 3
Levothyroxine Sodium)
tetracycline hcl caps 1
thyroid tabs 1
VIBRAMYCIN CAPS 100
MG (Use Doxycycline GP THYROLAR-1 TABS 2
Hyclate)
VIBRAMYCIN SUSR 25 THYROLAR-1/2 TABS 2
MG/5ML (Use Doxycycline GP
(Monohydrate)) THYROLAR-1/4 TABS 2
VIBRAMYCIN SYRP 50 2
MG/5ML THYROLAR-2 TABS 2
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones THYROLAR-3 TABS 2
Antithyroid Agents TIROSINT CAPS 13 MCG,
25 MCG, 50 MCG, 75
methimazole tabs 1 MCG, 88 MCG, 100 MCG, 3
112 MCG, 125 MCG, 137
propylthiouracil tabs 1 MCG, 150 MCG
TAPAZOLE TABS (Use GP
Methimazole)
Thyroid Hormones
page ii-iii.
101
TIROSINT-SOL SOLN 13 glycopyrrolate tabs or 1 1
MCG/ML, 25 MCG/ML, 50 mg, 2 mg
MCG/ML, 75 MCG/ML, 88 GLYCOPYRROLATE PA
MCG/ML, 100 MCG/ML, 3
3 TABS OR 1.5 MG
112 MCG/ML, 125
MCG/ML, 137 MCG/ML, hyoscyamine sulfate subl 1
150 MCG/ML, 200
MCG/ML hyoscyamine sulfate tabs 1
WESTHROID TABS 2 hyoscyamine sulfate tb12 1
WP THYROID TABS 48.75 3
MG hyoscyamine sulfate tbdp 1
WP THYROID TABS 65 LEVBID TB12 (Use
MG, 130 MG, 32.5 MG, GP
2 Hyoscyamine Sulfate)
97.5 MG, 16.25 MG, 81.25
MG, 113.75 MG LEVSIN TABS (Use GP
Hyoscyamine Sulfate)
ULCER DRUGS - Drugs to Treat Bowel, Intestine LEVSIN/SL SUBL (Use
and Stomach Conditions GP
Antispasmodics LIBRAX CAPS (Use
ANASPAZ TBDP (Use Chlordiazepoxide HCl- GP
GP Clidinium Bromide)
ATROPINE SULFATE methscopolamine bromide 1
SOLN IJ 0.4 MG/ML, 1 SP tabs
MG/ML phenobarbital-
BELLADONNA/OPIUM hyoscyamine-atropine- 1
3 scopolamine elix
SUPP
BENTYL CAPS (Use phenobarbital-
GP hyoscyamine-atropine- 1
Dicyclomine HCl)
chlordiazepoxide hcl- scopolamine tabs
1
clidinium bromide caps propantheline bromide tabs 1
CUVPOSA SOLN 2 ROBINUL FORTE TABS GP
(Use Glycopyrrolate)
dicyclomine hcl caps 1 ROBINUL TABS (Use GP
Glycopyrrolate)
dicyclomine hcl soln 1
H-2 Antagonists
dicyclomine hcl tabs 1 CIMETIDINE HCL SOLN 2
DONNATAL ELIX (Use RX/OTC
Phenobarbital- cimetidine tabs 200 mg 1
GP
Hyoscyamine-Atropine- cimetidine tabs 300 mg,
Scopolamine) 1
400 mg, 800 mg
DONNATAL TABS (Use
Phenobarbital- famotidine susr 40 mg/5ml 1
GP
Hyoscyamine-Atropine-
Scopolamine) famotidine tabs 20 mg 1 RX/OTC
GLYCATE TABS 3 PA
page ii-iii.
102
famotidine tabs 40 mg 1 esomeprazole magnesium 1 PA; QL(1 ea
cpdr 20 mg daily); RX/OTC
nizatidine caps 150 mg, esomeprazole magnesium
300 mg 1 1 PA; QL(1 ea
cpdr 40 mg daily)
NIZATIDINE SOLN 15 2 ESOMEPRAZOLE PA; QL(1 ea
MG/ML STRONTIUM CPDR 49.3 3 daily)
PEPCID AC MAXIMUM RX/OTC MG, 24.65 MG
STRENGTH TABS (Use GP FIRST-LANSOPRAZOLE
Famotidine) 3
SUSP
PEPCID SUSR 40 MG/5ML GP FIRST-OMEPRAZOLE
(Use Famotidine) 3
SUSP
PEPCID TABS 20 MG (Use GP RX/OTC RX/OTC
Famotidine) lansoprazole cpdr 15 mg 1
PEPCID TABS 40 MG (Use GP lansoprazole cpdr 30 mg 1
Famotidine)
ranitidine hcl caps 150 mg, QL(1 ea daily);
1 lansoprazole tbdp 15 mg, 1 AL(Up to 12 yrs
300 mg 30 mg
ranitidine hcl syrp 15 old )
mg/ml, 75 mg/5ml, 150 1 NEXIUM 24HR CLEAR PA; QL(1 ea
mg/10ml MINIS CPDR (Use GP daily); RX/OTC
RX/OTC Esomeprazole Magnesium)
ranitidine hcl tabs 150 mg 1 NEXIUM 24HR CPDR (Use GP PA; QL(1 ea
Esomeprazole Magnesium) daily); RX/OTC
ranitidine hcl tabs 300 mg 1
NEXIUM CPDR 20 MG PA; QL(1 ea
TAGAMET HB TABS (Use (Use Esomeprazole GP daily); RX/OTC
GP RX/OTC Magnesium)
Cimetidine)
ZANTAC 150 MAXIMUM RX/OTC NEXIUM CPDR 40 MG PA; QL(1 ea
STRENGTH TABS (Use GP (Use Esomeprazole GP daily)
Ranitidine HCl) Magnesium)
ZANTAC TABS (Use NEXIUM PACK 5 MG, 10 PA
GP MG, 20 MG, 40 MG, 2.5 3
Ranitidine HCl)
MG
Misc. Anti-Ulcer
OMEPRAZOLE +
CARAFATE SUSP 1 2 SYRSPEND SFALKA 3
GM/10ML SUSP
CARAFATE TABS 1 GM GP omeprazole cpdr 10 mg, 40
(Use Sucralfate) 1
mg
sucralfate tabs 1 omeprazole cpdr 20 mg 1 RX/OTC
Proton Pump Inhibitors
pantoprazole sodium tbec 1
ACIPHEX SPRINKLE 3 PA
CPSP 5 MG, 10 MG PREVACID CPDR 15 MG GP RX/OTC
ACIPHEX TBEC (Use (Use Lansoprazole)
GP PA; QL(2 ea
Rabeprazole Sodium) daily) PREVACID CPDR 30 MG GP
(Use Lansoprazole)
DEXILANT CPDR 3 PA; QL(1 ea
daily)
page ii-iii.
103
PREVACID SOLUTAB
QL(1 ea daily); methenamine-hyosc-
TBDP (Use Lansoprazole)
GP AL(Up to 12 yrs methylene blue-benzoic 1
old ) acid-phenyl sal tabs
PRILOSEC PACK 3 PA methenamine-hyosc-
methylene blue-sod phos- 1
PROTONIX PACK 40 MG 3 phenyl sal caps
methenamine-hyosc-
PROTONIX TBEC 20 MG, methylene blue-sod phos- 1
40 MG (Use Pantoprazole GP phenyl sal tabs
Sodium)
RABEPRAZOLE SODIUM PA URIMAR-T TABS 3
3
DR SPRINKLE CPSP Urinary Anti-infectives
PA; QL(2 ea FURADANTIN SUSP (Use
rabeprazole sodium tbec 1
daily) GP
Nitrofurantoin)
Ulcer Drugs - Prostaglandins HIPREX TABS (Use GP
CYTOTEC TABS (Use Methenamine Hippurate)
GP
Misoprostol) MACROBID CAPS (Use
misoprostol tabs 1 Nitrofurantoin Monohyd GP
Macro)
Ulcer Therapy Combinations MACRODANTIN CAPS
amoxicillin-clarithromycin (Use Nitrofurantoin GP
1 Macrocrystal)
w/ lansoprazole misc
methenamine hippurate 1
OMECLAMOX-PAK MISC 3 tabs
omeprazole-sodium methenamine mandelate 1
1 tabs
bicarbonate caps
omeprazole-sodium 1 MONUROL PACK 3
bicarbonate pack
PREVPAC MISC (Use nitrofurantoin macrocrystal 1
Amoxicillin-Clarithromycin GP caps
w/ Lansoprazole) nitrofurantoin monohyd 1
macro caps
PYLERA CAPS 3
nitrofurantoin susp 1
ZEGERID CAPS (Use
Omeprazole-Sodium GP URINARY ANTISPASMODICS - Drugs to Treat
Bicarbonate) Miscellaneous Bladder Spasms
ZEGERID PACK (Use Urinary Antispasmodic - Antimuscarinics
Omeprazole-Sodium GP
Bicarbonate) darifenacin hydrobromide 1
tb24
URINARY ANTI-INFECTIVES - Drugs to Treat DETROL LA CP24 (Use
Bladder/Kidney Infections GP QL(1 ea daily)
Tolterodine Tartrate)
Urinary Anti-infective Combinations DETROL TABS (Use GP QL(2 ea daily)
Tolterodine Tartrate)
HYOPHEN TABS 2
DITROPAN XL TB24 (Use GP
Oxybutynin Chloride)
page ii-iii.
104
ENABLEX TB24 (Use GP QL(4 ea per fill
Darifenacin Hydrobromide) VIVOTIF BERNA CPDR 3 retail,4 ea per
fill mail)
GELNIQUE GEL 3
QL(4 ea per fill
GELNIQUE PUMP GEL 3 VIVOTIF CPDR 3 retail,4 ea per
fill mail)
oxybutynin chloride syrp 1 Viral Vaccines
oxybutynin chloride tabs 1 ROTATEQ SOLN 3
oxybutynin chloride tb24 1 ZOSTAVAX SUSR PV AL(At least 50

yrs old); PV
OXYTROL FOR WOMEN RX/OTC VAGINAL PRODUCTS - Drugs to Treat Vaginal
3 Infections and Low Hormones
PTTW
OXYTROL PTTW 3 RX/OTC Miscellaneous Vaginal Products
acetic acid-oxyquinoline 1
solifenacin succinate tabs 1 vaginal gel
tolterodine tartrate cp24 2 QL(1 ea daily) FEM PH GEL (Use Acetic
mg, 4 mg 1 Acid-Oxyquinoline Vaginal) GP
tolterodine tartrate tabs 1 QL(2 ea daily) Spermicides
1
mg, 2 mg ENCARE SUPP PV PV
TOVIAZ TB24 2 QL(1 ea daily)
nonoxynol-9 gel PV PV
trospium chloride cp24 1 OPTIONS CONCEPTROL PV
VAGINAL GP
trospium chloride tabs 1 CONTRACEPTIVE GEL
VESICARE TABS (Use (Use Nonoxynol-9)
GP OPTIONS GYNOL II PV
Solifenacin Succinate)
VAGINALCONTRACEPTIV PV
Urinary Antispasmodics - Beta-3 Adrenergic E GEL
MYRBETRIQ TB24 3 QL(1 ea daily) SHUR-SEAL GEL PV PV
Urinary Antispasmodics - Cholinergic Agonists
TODAY SPONGE MISC PV PV
bethanechol chloride tabs 1
VCF VAGINAL PV
URECHOLINE TABS (Use CONTRACEPTIVE FILM PV
GP FILM
Bethanechol Chloride)
Urinary Antispasmodics - Direct Muscle Relaxants VCF VAGINAL PV
CONTRACEPTIVE FOAM PV
flavoxate hcl tabs 1 FOAM
Vaginal Anti-infectives
VACCINES
AVC CREA 3
Bacterial Vaccines
CLEOCIN CREA VA 2 %
BCG VACCINE INJ AC (Use Clindamycin GP
Phosphate Vaginal)
page ii-iii.
105
CLEOCIN SUPP VA 100 2 VASOPRESSORS - Drugs to Treat Heart and
MG Circulation Conditions
clindamycin phosphate 1 Anaphylaxis Therapy Agents
vaginal crea
epinephrine (anaphylaxis) QL(0.14 ea
CLINDESSE CREA 3 soaj 0.15 mg/0.15ml, 0.3 SP daily,2 ea per
mg/0.3ml fill retail)
GYNAZOLE-1 CREA 3 Limit 4mls per
epinephrine (anaphylaxis)
METROGEL-VAGINAL soaj 0.15 mg/0.3ml, 0.3 SP month;QL(0.14
GEL (Use Metronidazole GP ea daily,2 ea
mg/0.3ml per fill retail)
Vaginal)
PA; Limit 4mls
metronidazole vaginal gel 1 per
EPIPEN 2-PAK SOAJ (Use SP month;QL(0.14
miconazole nitrate vaginal 1 Epinephrine (Anaphylaxis)) ea daily,2 ea
supp per fill retail)
TERAZOL 7 CREA (Use GP PA; Limit 4mls
Terconazole Vaginal) EPIPEN-JR 2-PAK SOAJ per
TERCONAZOLE CREA 2 (Use Epinephrine SP month;QL(0.14
(Anaphylaxis)) ea daily,2 ea
terconazole vaginal crea 1 per fill retail)
Neurogenic Orthostatic Hypotension (NOH) -
terconazole vaginal supp 1
NORTHERA CAPS SP PA
Vaginal Estrogens
ESTRACE CREA (Use Vasopressors
GP
Estradiol Vaginal) midodrine hcl tabs 1
estradiol vaginal crea 1
VITAMINS
estradiol vaginal tabs 1 Oil Soluble Vitamins
QL(1 ea per fill
ESTRING RING 3
retail) BABY DDROPS LIQD PV AL(At least 65
yrs old); PV
QL(1 ea per 90 cholecalciferol caps 400
days retail,1 ea PV AL(At least 65
FEMRING RING 3 unit yrs old); PV
per 90 days cholecalciferol chew 1000
mail) PV PV
unit
PREMARIN CREA VA cholecalciferol liqd 400
0.625 MG/GM
2 PV AL(At least 65
unit/ml, 400 unt/0.03ml yrs old); PV
VAGIFEM TABS (Use cholecalciferol tabs 400
Estradiol Vaginal) GP PV AL(At least 65
unit yrs old); PV
Vaginal Progestins D-VI-SOL LIQD (Use GP AL(At least 65
Cholecalciferol) yrs old); PV
CRINONE GEL 4 % 3
DRISDOL CAPS (Use GP
CRINONE GEL 8 % 3 PA Ergocalciferol)
PA ergocalciferol caps 1
ENDOMETRIN INST 3
page ii-iii.
106
Drug Requirements/
Drug Name Tier Limits
MEPHYTON TABS (Use GP
Phytonadione)
phytonadione tabs 1
VITAMIN D2 TABS PV AL(At least 65

yrs old); PV
VITAMIN D3 LIQD PV AL(At least 65
yrs old); PV
WELLESSE VITAMIN D3 PV AL(At least 65
LIQD yrs old); PV
page ii-iii.
107
Index
abacavir sulfate 43 ADAPALENE 55 alendronate sodium 68
abacavir sulfate-lamivudine 43 adapalene-benzoyl ALFERON N 39
abacavir sulfate-lamivudine- peroxide 55 alfuzosin hcl 74
zidovudine 43 ADCETRIS 35
ALIMTA 34
ABILIFY 43 ADCIRCA 49
ALINIA 11
abiraterone acetate 36 ADDERALL 1
aliskiren fumarate 32
ABRAXANE 39 ADDERALL XR 1
ALKERAN 34
ABSORICA 55 adefovir dipivoxil 45
allopurinol 75
ABSTRAL 6 ADEMPAS 50
almotriptan malate 82
acamprosate calcium 98 ADIPEX-P 1
ALOCRIL 94
ACANYA 55 ADMELOG 23
ALOGLIPTIN 23
acarbose 22 ADMELOG SOLOSTAR 23 ALOGLIPTIN/METFORMIN
ACCOLATE 14 ADRENALIN 91 HCL 22
ACCUPRIL 30 ADRIAMYCIN 37 ALOGLIPTIN/PIOGLITAZONE
ACCURETIC 31 ADVAIR DISKUS 15 22
ALOMIDE 94
acebutolol hcl 47 ADVAIR HFA 15
ALOQUIN 58
ACEON 30 ADVATE 75
ALORA 71
acetaminophen w/ codeine 8 ADZENYS XR-ODT 1
AEROCHAMBER MINI alosetron hcl 73
acetazolamide 67
AEROSOLCHAMBER 80 ALOXI 26
acetic acid (otic) 95
acetic acid-oxyquinoline AEROSPAN 14 ALPHAGAN P 92
vaginal 105 AEROVENT PLUS HOLDING ALPHANATE/VON
acetylcysteine 55 CHAMBER/COLLAPSIBLE WILLEBRANDFACTOR
80 COMPLEX/HUMAN 75
ACIPHEX 103 AFINITOR 37 ALPHANINE SD 75
ACIPHEX SPRINKLE 103 AFINITOR DISPERZ 37 alprazolam 12
acitretin 59 AFREZZA 23 ALPRAZOLAM INTENSOL 12
ACTEMRA 3 AGGRENOX 75 ALPROLIX 75
ACTHAR 68 AGRYLIN 75 ALREX 93
ACTIDOM DMX 54 AKTEN 93 ALTABAX 57
ACTIGALL 72 AKYNZEO 26 ALTACE 30
ACTIMMUNE 39 ALA SCALP 60 ALTOPREV 29
ACTIQ 6 ALA-QUIN 58 ALVESCO 14
ACTIVE OB 86 albendazole 10 amantadine hcl 40
ACTIVELLA 71 ALBENZA 10 AMARYL 25
ACTONEL 68 albuterol sulfate 15 AMBIEN 77
ACTOPLUS MET 22 ALBUTEROL SULFATE AMBIEN CR 77
ACTOPLUS MET XR 22 ER 15 ambrisentan 49
ACTOS 23 ALCAINE 93
AMCINONIDE 60
ACULAR 94 alclometasone
dipropionate 60 amcinonide 60
ACULAR LS 94 AMERGE 82
ALDACTAZIDE 67
ACUVAIL 94 AMICAR 77
ALDACTONE 67
acyclovir 46 amikacin sulfate 3
ALDARA 64
acyclovir topical 60 amiloride &
ALDURAZYME 69
ACZONE 55 hydrochlorothiazide 67
ALECENSA 37
ADAGEN 2 amiloride hcl 67
alendronate sodium 68
ADALAT CC 47,48 aminocaproic acid 77
ALENDRONATE SODIUM 68
adapalene 55 amiodarone hcl 13
Index 1
AMITIZA 72 ANTABUSE 98 ASTAGRAF XL 84
amitriptyline hcl 21 ANTARA 29 ASTEPRO 90
amlodipine besylate 48 ANUSOL-HC 10 ATABEX EC 86
amlodipine besylate-atorvastatin ANZEMET 26 ATACAND 30
calcium 49 APEXICON E 60 ATACAND HCT 31
amlodipine besylate-benazepril
hcl 31 APIDRA 23 atazanavir sulfate 43
amlodipine besylate-olmesartan APIDRA SOLOSTAR 23 ATELVIA 68
medoxomil 31 apraclonidine hcl 92 atenolol 47
amlodipine besylate-
valsartan 31 aprepitant 26 atenolol & chlorthalidone 31
amlodipine-valsartan- APRISO 72 ATGAM 84
hydrochlorothiazide 31 APTIOM 17 ATIVAN 12
AMOXAPINE 21 APTIVUS 43 atomoxetine hcl 1
amoxicillin 96 ARALAST NP 100 atorvastatin calcium 29
amoxicillin & pot clavulanate 97 ARANESP ALBUMIN atovaquone 11
amoxicillin-clarithromycin w/ FREE 76 atovaquone-proguanil hcl 33
lansoprazole 104 ARAVA 5
AMOXICILLIN/CLAVULANATE ATRALIN 55
ARCALYST 3
POTASSIUM 97 ATRIPLA 43
AMOXICILLIN/CLAVULANATE ARCAPTA NEOHALER 15
ATROPINE SULFATE 91,102
POTASSIUM ER 97 ARIAL CHAMBER 80
amphetamine- ATROVENT HFA 13
ARICEPT 98
dextroamphetamine 1 AUBAGIO 98
ARIKAYCE 3 AUGMENTED
AMPHOTERICIN B 27
ARIMIDEX 36 BETAMETHASONE
AMPICILLIN 96
ampicillin & sulbactam aripiprazole 43 DIPROPIONATE 60
sodium 97 ARIXTRA 16 AUGMENTIN 97
ampicillin sodium 96 armodafinil 2 AUGMENTIN ES-600 97
AMPICILLIN SODIUM 96 ARMOUR THYROID 101 AUGMENTIN XR 97
ampicillin sodium 96 ARNUITY ELLIPTA 14 AVALIDE 31
AMPYRA 98 AROMASIN 36 AVANDIA 23
AMRIX 89 arsenic trioxide 39 AVAPRO 30
ANADROL-50 9 ARTHROTEC 50 3 AVASTIN 35
ANAFRANIL 21 ARTHROTEC 75 4 AVC 105
anagrelide hcl 75 ARZERRA 35 AVELOX 72
ANALPRAM HC 10 ASACOL HD 72 AVODART 74
ANALPRAM HC SINGLES 10 ASCRIPTIN 5 AVONEX 98
ANALPRAM-HC 10 ASMANEX HFA 14 AVONEX PEN 99
ANAPROX DS 3 ASMANEX TWISTHALER 120 AXERT 82
ANASPAZ 102 METERED DOSES 14 AXIRON 9
ASMANEX TWISTHALER 14 AYGESTIN 97
anastrozole 36 METERED DOSES 14
ANCOBON 27 ASMANEX TWISTHALER 30 azacitidine 34
ANDRODERM 9 METERED DOSES 14 AZASAN 84
ASMANEX TWISTHALER 60 AZASITE 92
ANDROGEL 9 METERED DOSES 14
ANDROGEL PUMP 9 ASMANEX TWISTHALER 7 AZATHIOPRINE 84
ANDROID 9 METERED DOSES 14 azathioprine 84
ANDROXY 9 aspirin 5 azelaic acid 65
ANGELIQ 71 ASPIRIN-CAFFEINE- azelastine hcl 90
DIHYDROCODEINE 8 azelastine hcl (ophth) 94
ANORO ELLIPTA 15 aspirin-dipyridamole 75
AZELEX 55
Index 2
AZILECT 41 BENZAMYCIN 55 bosentan 49
azithromycin 78,79 benzonatate 54 BOSULIF 37
AZOPT 94 benzoyl peroxide 55 BOTOX 91
AZOR 31 benzoyl peroxide- BP CLEANSING WASH 56
AZULFIDINE 72 erythromycin 56 BP MULTINATAL PLUS 86
benztropine mesylate 40
AZULFIDINE EN-TABS 72 BRAFTOVI 37
BEPREVE 94 BREATHE EASE/LARGE
BABY DDROPS 106
BESIVANCE 92 MASK 80
bacitracin 10
BETAGAN 91 BREATHE EASE/MEDIUM
BACITRACIN 92 MASK 81
betamethasone dipropionate
bacitracin-poly-neomycin-hc 93 (topical) 60 BREATHE EASE/SMALL
bacitracin-polymyxin b betamethasone dipropionate MASK 81
(ophth) 92 augmented 60 BREO ELLIPTA 15
baclofen 89 betamethasone valerate 60 BREVICON-28 51
BACLOFEN 89 BETAPACE 47 BRILINTA 75
BACTOCILL IN DEXTROSE 97 BETAPACE AF 47 brimonidine tartrate 92
BACTRIM 11 BETASERON 99 BRISDELLE 100
BACTRIM DS 11 betaxolol hcl 47 BROMFENAC 94
BACTROBAN 57 betaxolol hcl (ophth) 91 bromfenac sodium (ophth) 94
BACTROBAN NASAL 90 bethanechol chloride 105 bromocriptine mesylate 41
BAL-CARE DHA 86 BETHKIS 3 BROMPHENIRAMINE
balsalazide disodium 73 BETIMOL 91 TANNATE 27
BANZEL 17 BROVANA 15
BETOPTIC-S 91
BARACLUDE 45 budesonide 53
BEVESPI AEROSPHERE 15
BASAGLAR KWIKPEN 23 budesonide (inhalation) 14
bexarotene 39
BAXDELA 72 budesonide (nasal) 90
BEYAZ 51
BCG VACCINE 105 bumetanide 67
bicalutamide 36
BD ECLIPSE NEEDLE 30G BUMEX 67
BICILLIN C-R 97
X1/2" 80 BUNAVAIL 8
BICILLIN L-A 96
BD NEEDLE/30G X 1/2" 80 BUPHENYL 69
BICNU 34
BECONASE AQ 90 buprenorphine 9
BIDIL 49
BELBUCA 8 BUPRENORPHINE 9
BILTRICIDE 10
BELEODAQ 37 buprenorphine 9
bimatoprost 95
BELLADONNA/OPIUM 102 BUPRENORPHINE 9
BINOSTO 68
BELSOMRA 78 buprenorphine hcl 8
BIO-STATIN 27
BELVIQ 1 buprenorphine hcl-naloxone hcl
bisacodyl-peg 3350-pot dihydrate 9
BELVIQ XR 1 chloride-sod bicarb-sod
benazepril & chloride 78 bupropion hcl 20
hydrochlorothiazide 31 bisoprolol & bupropion hcl (smoking
benazepril hcl 30 hydrochlorothiazide 31 deterrent) 99
bisoprolol fumarate 47 BUPROPION
BENEFIX 75 HYDROCHLORIDE ER (XL) 20
BENICAR 30 BIVIGAM 96 buspirone hcl 12
BENICAR HCT 31 bleomycin sulfate 37 busulfan 34
BENLYSTA 85 BLEPH-10 92 BUSULFEX 34
BENSAL HP 64 BLEPHAMIDE 93 butalbital-acetaminophen 5
BENTYL 102 BLEPHAMIDE S.O.P. 93 butalbital-acetaminophen-
BENZACLIN 55 BLINCYTO 35 caffeine 5
BENZACLIN WITH PUMP 55 BONIVA 68 butalbital-acetaminophen-
caffeine w/ codeine 8
Index 3
butalbital-aspirin-caffeine 5 carbamazepine 17 cefprozil 50
butalbital-aspirin-caffeine CARBATROL 17 ceftazidime 50
w/cod 8 carbidopa 40 CEFTIBUTEN 50
BUTALBITAL/ASPIRIN/CAFFEIN
E 5 carbidopa-levodopa 41 CEFTIN 50
butenafine hcl 58 carbidopa-levodopa- ceftriaxone sodium 50
entacapone 41 cefuroxime axetil 50
BUTISOL SODIUM 77
carbinoxamine maleate 27
butorphanol tartrate 9 cefuroxime sodium 50
carbonyl iron 76
BUTRANS 9 CELEBREX 4
carboplatin 34
BYDUREON 23 celecoxib 4
CARDIZEM 48
BYDUREON PEN 23 CELEXA 20
CARDIZEM CD 48
BYETTA 23 CELLCEPT 84
CARDIZEM LA 48
BYSTOLIC 47 CELLCEPT INTRAVENOUS 84
CARDURA 30
BYVALSON 31 CELONTIN 19
CARDURA XL 74
C-NATE DHA 86 CEM-UREA 63
carisoprodol 89
cabergoline 70 CENTANY 57
carisoprodol w/ aspirin 89
CABOMETYX 37 CENTANY AT 57
carisoprodol w/ aspirin &
CADUET 49 codeine 89 cephalexin 50
CAFERGOT 81 carmustine 34 CERDELGA 76
caffeine citrate 1 CARNITOR 69 CEREBYX 19
CALAN 48 CARNITOR SF 69 CEREZYME 76
CALAN SR 48 CARTEOLOL HCL 91 CESAMET 26
calcipotriene 59 carteolol hcl (ophth) 91 CETACAINE 65
calcipotriene-betamethasone carvedilol 47 cetirizine hcl 28
dipropionate 61 carvedilol phosphate 47 CETRAXAL 95
calcitonin (salmon) 68 cevimeline hcl 86
CASODEX 36
calcitriol 69 CHANTIX 99
CATAPRES 30
CALCITRIOL 69 CHANTIX CONTINUING
CAYA 79
calcitriol (topical) 59 MONTHPAK 99
CEDAX 50 CHANTIX STARTING MONTH
calcium acetate (phosphate
binder) 73 cefaclor 50 PAK 99
CALCIUM PNV 86 CEFACLOR 50 CHEK-STIX COMBO PAK
cefaclor 50 URINALYSIS CONTROL 66
CAMBIA 82
CHEK-STIX CONTROL 66
CAMPATH 35 CEFACLOR ER 50
CHEMET 25
CAMPTOSAR 40 cefadroxil 50
CHEMSTRIP-K 66
CANASA 73 cefazolin sodium 50
CHENODAL 72
candesartan cilexetil 30 CEFAZOLIN SODIUM 50
CHLORAMPHENICOL SODIUM
candesartan cilexetil- cefdinir 50 SUCCINATE 11
hydrochlorothiazide 31 cefditoren pivoxil 50 chlordiazepoxide hcl 12
CAPASTAT SULFATE 33 CEFEPIME 51 chlordiazepoxide hcl-clidinium
capecitabine 35 cefepime hcl 51 bromide 102
CAPEX 61 chlordiazepoxide-amitriptyline
CEFEPIME/DEXTROSE 51 98
CAPRELSA 37 cefixime 50 chlorhexidine gluconate (mouth-
captopril 30 CEFOTAN 50 throat) 86
captopril & CHLOROQUINE
hydrochlorothiazide 31 CEFOTETAN 50
PHOSPHATE 33
CARAC 59 cefotetan disodium 50 chloroquine phosphate 33
CARAFATE 103 cefoxitin sodium 50 CHLOROTHIAZIDE 67
CARBAGLU 69 cefpodoxime proxetil 50 chlorothiazide 67
Index 4
chlorpromazine hcl 43 clarithromycin 79 CLOCORTOLONE PIVALATE
chlorpropamide 25 CLEMASTINE PUMP 61
FUMARATE 27 CLODERM 61
chlorthalidone 68
CLEOCIN 105,106 CLODERM PUMP 61
CHLORZOXAZONE 89
CLEOCIN IN D5W 11 clofarabine 35
CHOLBAM 72
CLEOCIN PEDIATRIC CLOLAR 35
cholecalciferol 106 GRANULES 11 clomipramine hcl 21
cholestyramine 28 CLEOCIN PHOSPHATE 11
clonazepam 16
cholestyramine light 28 CLEOCIN-T 56
clonidine & chlorthalidone 31
choline & mag salicylate 6 CLEVER CHOICE ANTI-
STATICVALVED HOLDING clonidine hcl 31
choline fenofibrate 29
CHORIONIC CHAMBER/ADULT clonidine hcl (adhd) 1
GONADOTROPIN 69 LARGE 81 clopidogrel bisulfate 76
CLEVER CHOICE ANTI-
ciclopirox 58 STATICVALVED HOLDING clorazepate dipotassium 12
ciclopirox olamine 58 CHAMBER/MEDIUM 81 CLORPRES 31
cidofovir 45 CLEVER CHOICE ANTI- clotrimazole 86
cilostazol 76 STATICVALVED HOLDING clotrimazole (topical) 58
CHAMBER/SMALL 81 clotrimazole w/
CILOXAN 92
CLIMARA 71 betamethasone 58
cimetidine 102
CLIMARA PRO 71 clozapine 42
CIMETIDINE HCL 102
CLINDACIN ETZ 56 CLOZAPINE 42
CIMZIA 73 CLINDACIN ETZ clozapine 42
cinacalcet hcl 69 PLEDGETS 56
CLOZAPINE ODT 42
CINRYZE 75 CLINDACIN PAC 56
CLOZARIL 42
CIPRO 72 CLINDACIN-P 56
COARTEM 33
CIPRO HC 95 clindamycin hcl 11
clindamycin palmitate COCAINE HCL 65
CIPRODEX 95
hydrochloride 11 codeine sulfate 6
ciprofloxacin 72
clindamycin phosphate 11 CODEINE SULFATE 6
CIPROFLOXACIN ER 72 CLINDAMYCIN CODITUSSIN AC 54
CIPROFLOXACIN HCL 72 PHOSPHATE 56
clindamycin phosphate COGENTIN 40
ciprofloxacin hcl 72
(topical) 56 COLAZAL 73
ciprofloxacin hcl (ophth) 92
clindamycin phosphate in COLCHICINE 75
ciprofloxacin hcl (otic) 95 d5w 11 colchicine 75
CISPLATIN 34 clindamycin phosphate
vaginal 106 colchicine w/ probenecid 75
cisplatin 34
clindamycin phosphate-benzoyl COLCRYS 75
citalopram hydrobromide 20 peroxide 56 colesevelam hcl 28
CITRANATAL 90 DHA 86 clindamycin phosphate-benzoyl
peroxide (refrigerate) 56 COLESTID 28
CITRANATAL ASSURE 86
clindamycin phosphate- COLESTID FLAVORED 28
CITRANATAL B-CALM 86
tretinoin 56 colestipol hcl 28
CITRANATAL BLOOM DHA 86 CLINDESSE 106 COLY-MYCIN S 95
CITRANATAL DHA 86 clobazam 16 COLYTE-FLAVOR PACKS 78
CITRANATAL HARMONY 87 clobetasol propionate 61 COMBIGAN 91
CITRANATAL RX 87 clobetasol propionate emollient COMBIPATCH 71
cladribine 35 base 61
clobetasol propionate COMBIVENT RESPIMAT 15
CLARINEX 28
emulsion 61 COMBIVIR 43
CLARINEX-D 12 HOUR 54
CLOBEX 61 COMETRIQ 37
clarithromycin 79 CLOCORTOLONE COMPACT SPACE
CLARITHROMYCIN 79 PIVALATE 61 CHAMBER/ANTI-STATIC 81
Index 5
COMPACT SPACE CRESTOR 29 dalfampridine 99
CHAMBER/ANTI- CRINONE 106 DALIRESP 14
STATIC/LARGE MASK 81
COMPACT SPACE CRIXIVAN 43 danazol 9
CHAMBER/ANTI- cromolyn sodium 13 DANTRIUM 89
STATIC/MEDIUM MASK 81 cromolyn sodium dantrolene sodium 89
COMPACT SPACE (mastocytosis) 72
CHAMBER/ANTI-STATIC/SMALL dapsone 11
cromolyn sodium (ophth) 94
MASK 81 dapsone (topical) 56
crotamiton 66
COMPLERA 43 daptomycin 11
CUBICIN 11
Compounded Drug 85 DARAPRIM 33
CUBICIN RF 11
COMTAN 40 darifenacin hydrobromide 104
CUPRIMINE 84
CONCEPT DHA 87 DAURISMO 36
CUTIVATE 61
CONCEPT OB 87 DAYPRO 4
CUVITRU 96
CONCERTA 2 DAYTRANA 2
CUVPOSA 102
CONDYLOX 65 DDAVP 70
cyanocobalamin 76
CONTRAVE 1 decitabine 35
CYCLESSA 51
CONZIP 6 DECON-G 54
CYCLO/GABA10/300
COPAXONE 99 PACK 89 deferasirox 25
COPEGUS 45 cyclobenzaprine hcl 89 DELESTROGEN 71
COPIKTRA 37 CYCLOGYL 91 DELSTRIGO 44
CORDRAN 61 CYCLOMYDRIL 91 DELZICOL 73
COREG 47 cyclopentolate hcl 91 DEMADEX 67
COREG CR 47 cyclophosphamide 34 demeclocycline hcl 100
CORGARD 47 CYCLOPHOSPHAMIDE 34 DEMEROL 6
CORIFACT 75 cyclophosphamide 34 DEMSER 30
CORLANOR 50 cycloserine 33 DENAVIR 60
CORTANE-B 61 CYCLOSET 23 DEPAKENE 19
CORTANE-B AQUEOUS 95 cyclosporine 84,85 DEPAKOTE 19
CORTANE-B-OTIC 95 cyclosporine modified (for DEPAKOTE ER 19
CORTEF 53 microemulsion) 85 DEPAKOTE SPRINKLES 19
CYKLOKAPRON 77 DEPEN TITRATABS 84
CORTENEMA 10
CYMBALTA 21 DEPO-ESTRADIOL 71
CORTIFOAM 10
cyproheptadine hcl 28 DEPO-PROVERA 36
cortisone acetate 53
CYRAMZA 35 DEPO-PROVERA
CORTISPORIN 58
CYSTADANE 69 CONTRACEPTIVE 53
CORTISPORIN-TC 95 DEPO-SUBQ PROVERA
CYSTAGON 74
CORZIDE 31 104 53
CYSTARAN 94 DERMA-SMOOTHE/FS
COSENTYX 59
COSENTYX SENSOREADY cytarabine 35 BODY 61
PEN 59 CYTARABINEAQUEOUS 35 DERMA-SMOOTHE/FS
COSMEGEN 37 CYTOMEL 101 SCALP 61
DERMASORB TA 61
COSOPT 91 CYTOTEC 104
DERMATOP 61
COSOPT PF 91 D-VI-SOL 106
DERMOTIC 96
COTELLIC 37 DACARBAZINE 39
DESCOVY 44
COUMADIN 16 dacarbazine 39
desipramine hcl 21
COZAAR 30 DACOGEN 35
desloratadine 28
CREON 66 dactinomycin 37
DESLORATADINE ODT 28
CRESEMBA 27 DAKLINZA 45
desmopressin acetate 70
Index 6
desmopressin acetate spray 70 diclofenac w/ misoprostol 4 DORAL 77
desmopressin acetate spray dicloxacillin sodium 97 DORIBAX 11
refrigerated 70 dicyclomine hcl 102 DORIPENEM 11
DESOGEN 51
didanosine 44 DORYX 100
desogestrel & ethinyl
estradiol 51 DIFFERIN 56 DORYX MPC 100
desogestrel-ethinyl estradiol DIFICID 79 dorzolamide hcl 94
(biphasic) 51 diflorasone diacetate 61 DORZOLAMIDE HCL 94
desogestrel-ethinyl estradiol dorzolamide hcl-timolol
(triphasic) 51 DIFLUCAN 27
diflunisal 6 maleate 91
DESONATE 61 DORZOLAMIDE HCL/TIMOLOL
desonide 61 digoxin 48 MALEATE 91
DESOWEN 61 dihydroergotamine DOTHELLE DHA 87
mesylate 82
desoximetasone 61 DOVONEX 59
DILANTIN 19
DESOXYN 1 doxazosin mesylate 31
DILANTIN INFATABS 19
DESVENLAFAXINE ER 21 doxepin hcl 21
DILANTIN-125 19
desvenlafaxine succinate 21 DOXEPIN HCL 21
DILATRATE SR 12
DETROL 104 doxepin hcl 21
DILAUDID 6
DETROL LA 104 doxepin hcl (antipruritic) 59
DILT-XR 48
dexamethasone 53 doxercalciferol 70
diltiazem hcl 48
DEXAMETHASONE DOXIL 37
INTENSOL 53 diltiazem hcl coated beads 48
diltiazem hcl extended release doxorubicin hcl 37
DEXAMETHASONE SODIUM
PHOSPHATE 53 beads 48 doxorubicin hcl liposomal 37
dexamethasone sodium DIOVAN 30 DOXYCYCLINE 65
phosphate 53 DIOVAN HCT 31 doxycycline (monohydrate) 100
DEXAMETHASONE SODIUM DIPENTUM 73 doxycycline hyclate 100
PHOSPHATE 93
DEXCHLORPHENIRAMINE diphenhydramine hcl 28 DOXYCYCLINE HYCLATE 100
MALEATE 27 diphenhydramine hcl doxycycline hyclate 101
DEXEDRINE 1 (sleep) 77 doxylamine-pyridoxine 26
DEXILANT 103 diphenoxylate w/ atropine 25
DRISDOL 106
dexmethylphenidate hcl 2 DIPROLENE 62
dronabinol 26
dexrazoxane hcl 39 DIPROLENE AF 61 drospirenone-ethinyl
dextroamphetamine sulfate 1 dipyridamole 76 estradiol 51
disopyramide phosphate 13 drospirenone-ethinyl estradiol-
DIAMOX 67 levomefolate calcium 51
DIASTAT ACUDIAL 17 disulfiram 98
DROXIA 76
DIASTAT PEDIATRIC 17 DITROPAN XL 104
DRYSOL 65
diazepam 13 DIURIL 68
DUAC 56
diazepam (anticonvulsant) 17 divalproex sodium 19
DUAVEE 71
DIAZEPAM RECTAL GEL 17 DIVIGEL 71
DUET DHA 400 87
DIBENZYLINE 30 DOCETAXEL 39
DUET DHA BALANCED 87
DICLEGIS 26 docetaxel 39
DUETACT 22
DICLOFENAC EPOLAMINE 57 DOCETAXEL 39
DULERA 15
diclofenac potassium 4 docetaxel 39
duloxetine hcl 21
diclofenac sodium 4 dofetilide 13
DUOPA 41
diclofenac sodium (actinic DOLOPHINE 6
DURAGESIC 6
keratoses) 59 DOMETUSS-DMX 54
diclofenac sodium (ophth) 94 DURAXIN 5
donepezil hydrochloride 98
diclofenac sodium (topical) 57 DUREZOL 93
DONNATAL 102
dutasteride 74
Index 7
dutasteride-tamsulosin hcl 74 EMBEDA 6 ERIVEDGE 36
DUTOPROL 31 EMCYT 36 erlotinib hcl 37
DYANAVEL XR 1 EMEND 26,27 ERTACZO 58
DYAZIDE 67 EMEND TRIPACK 27 ertapenem sodium 11
DYMISTA 90 EMFLAZA 53 ERWINAZE 38
DYRENIUM 67 EMSAM 20 ERYGEL 56
E.E.S. GRANULES 79 EMTRIVA 44 ERYPED 200 79
EASY TOUCH FLIPLOCK ENABLEX 105 ERYPED 400 79
NEEDLES 30GX1/2" 80 enalapril maleate 30 erythromycin (acne aid) 56
EASY TOUCH HYPODERMIC
NEEDLES 30GX1/2" 80 enalapril maleate & erythromycin (ophth) 92
hydrochlorothiazide 31 erythromycin base 79
EC-NAPROSYN 4
ENBREL 5
EC-NAPROXEN 4 erythromycin ethylsuccinate 79
ENBREL SURECLICK 5
econazole nitrate 58 ESBRIET 100
ENCARE 105
ECOTRIN REGULAR escitalopram oxalate 20
STRENGTH 6 ENDOMETRIN 106
ESGIC 5
EDARBI 30 ENOVARX-IBUPROFEN 57
esomeprazole magnesium 103
EDARBYCLOR 31 enoxaparin sodium 16 ESOMEPRAZOLE
EDECRIN 67 ENSTILAR 62 STRONTIUM 103
EDLUAR 77 entacapone 40 estazolam 77
EDURANT 44 entecavir 45 esterified estrogens &
ENTEREG 73 methyltestosterone 71
efavirenz 44
ESTRACE 71
EFFERVESCENT ENTOCORT EC 53
POTASSIUM/CHLORIDE 84 estradiol 71
ENTRESTO 49
EFFEXOR XR 21 estradiol & norethindrone
ENVARSUS XR 85 acetate 71
EFFIENT 76 EPCLUSA 45 estradiol vaginal 106
EFUDEX 59 EPIDIOLEX 17 estradiol valerate 71
ELAPRASE 70 EPIDUO 56 ESTRING 106
ELAVIL 21 EPIFOAM 62 ESTROGEL 71
ELDEPRYL 41 epinastine hcl (ophth) 94 ESTROPIPATE 71
ELELYSO 76 epinephrine (anaphylaxis)106 estropipate 71
ELESTAT 94 EPIPEN 2-PAK 106 ESTROSTEP FE 51
ELESTRIN 71 EPIPEN-JR 2-PAK 106 eszopiclone 77
eletriptan hydrobromide 82 epirubicin hcl 37 ethacrynic acid 67
ELIDEL 64 EPIVIR 44 ethambutol hcl 33
ELIGARD 36 EPIVIR HBV 45 ethosuximide 19
ELIMITE 66 eplerenone 32 ETHYL CHLORIDE 65
ELIPHOS 73 EPOGEN 76 ETHYL CHLORIDE/FINE
ELIQUIS 16 epoprostenol sodium 49 PINPOINT 65
ELIQUIS STARTER PACK 16 EPROSARTAN ETHYL CHLORIDE/FINE
ELITEK 39 MESYLATE 30 STREAM 65
ETHYL CHLORIDE/MEDIUM
ELIXOPHYLLIN 16 EPZICOM 44 JET STREAM 65
ELLA 52 EQUETRO 42 ETHYL CHLORIDE/MEDIUM
ELLENCE 37 ERBITUX 35 STREAM 65
ELMIRON 74 ergocalciferol 106 ETHYL CHLORIDE/MIST 65
ERGOLOID MESYLATES 99 ethynodiol diacet & eth
ELOCON 62 estrad 51
ELOCTATE 75 ERGOMAR 82 etidronate disodium 68
EMADINE 94 ergotamine w/ caffeine 81 etodolac 4
Index 8
ETOPOPHOS 40 fenofibrate 29 FLONASE SENSIMIST 90
etoposide 40 fenofibrate micronized 29 FLORIVA PLUS 86
EUFLEXXA 90 fenofibric acid 29 FLOVENT DISKUS 14
EURAX 66 FENOGLIDE 29 FLOVENT HFA 14
EVAMIST 71 FENOPROFEN CALCIUM 4 FLOXIN OTIC 95
EVISTA 69 fenoprofen calcium 4 floxuridine 35
EVOCLIN 56 FENORTHO 4 fluconazole 27
EVOTAZ 44 fentanyl 6 fluconazole in dextrose 27
EVOXAC 86 fentanyl citrate 6 flucytosine 27
EVZIO 25 FENTANYL CITRATE 6 fludarabine phosphate 35
EXALGO 6 FENTORA 6 fludrocortisone acetate 54
EXELDERM 58 FER-IN-SOL 76 FLUMADINE 46
EXELON 98 FERRIPROX 25 FLUNISOLIDE 90
exemestane 36 ferrous sulfate 76,77 fluocinolone acetonide 62
EXFORGE 31 FERROUS SULFATE 77 fluocinolone acetonide (otic) 96
EXFORGE HCT 31 FETZIMA 21 fluocinonide 62
EXJADE 25 FETZIMA TITRATION fluocinonide emulsified base 62
EXODERM 58 PACK 21 FLUORABON 83
FEXMID 89
EXTAVIA 99 fluorometholone (ophth) 93
FIASP 23
EXTINA 58 FLUOROPLEX 59
FIASP FLEXTOUCH 23
ezetimibe 29 fluorouracil 35
FIBRICOR 29
ezetimibe-simvastatin 28 FLUOROURACIL 59
FINACEA 65
FABIOR 56 fluorouracil (topical) 59
finasteride 74
FABRAZYME 70 FLUOXETINE 99
FIORICET 5
famciclovir 46 FLUOXETINE DR 20
FIORICET/CODEINE 8
famotidine 102,103 fluoxetine hcl 20
FIORINAL 5
FANAPT 42 fluoxetine hcl (pmdd) 99
FIORINAL/CODEINE #3 8 FLUOXETINE
FANAPT TITRATION PACK 42
FIRAZYR 75 HYDROCHLORIDE 20
FARESTON 36
FIRDAPSE 33 fluphenazine hcl 43
FARXIGA 25
FIRMAGON 36 FLUPHENAZINE HCL 43
FARYDAK 37
FIRST-LANSOPRAZOLE 103 FLURA-DROPS 83
FASLODEX 36
FIRST-MOUTHWASH flurandrenolide 62
FAZACLO 42 BLM 85 flurazepam hcl 77
FC FEMALE CONDOM 79 FIRST-OMEPRAZOLE 103
flurbiprofen 4
FC2 FEMALE CONDOM 79 FLAGYL 10
FLURBIPROFEN SODIUM 94
febuxostat 75 FLAREX 93
flurbiprofen sodium 94
felbamate 19 flavoxate hcl 105
flutamide 36
FELBATOL 19 FLEBOGAMMA DIF 96
fluticasone propionate 62
FELDENE 4 flecainide acetate 13 fluticasone propionate
felodipine 48 FLECTOR 57 (nasal) 90
FEM PH 105 FLEXICHAMBER 81 fluticasone-salmeterol 15
FEMARA 36 FLOLAN 49 fluvastatin sodium 29
FEMCAP 79 FLOMAX 74 fluvoxamine maleate 20
FEMHRT LOW DOSE 71 FLONASE ALLERGY FML 93
FEMRING 106 RELIEF 90 FML FORTE 93
FLONASE ALLERGY RELIEF
FENOFIBRATE 29 CHILDRENS 90 FML LIQUIFILM 93
Index 9
FOCALGIN 90 DHA 87 FUZEON 44 GLEEVEC 37
FOCALGIN CA 87 FYCOMPA 16 GLEOSTINE 34
FOCALIN 2 gabapentin 17 GLIADEL WAFER 34
FOCALIN XR 2 GABITRIL 19 glimepiride 25
FOLCAL DHA 87 GABLOFEN 89 glipizide 25
FOLCAPS OMEGA 3 87 GALAFOLD 70 glipizide-metformin hcl 22
FOLET DHA 87 galantamine hydrobromide 98 GLUCAGEN DIAGNOSTIC 66
folic acid 76 GALANTAMINE GLUCAGEN HYPOKIT 22
folic acid-pyridoxine- HYDROBROMIDE 98 GLUCAGON 66
cyanocobalamin 66 galantamine hydrobromide 98 GLUCAGON EMERGENCY
FOLIVANE-F 76 GAMASTAN 96 KIT 23
FOLIVANE-OB 87 GAMASTAN S/D 96 GLUCAGON HCL
FOLOTYN 35 GAMMAGARD LIQUID 96 DIAGNOSTIC 66
GLUCOPHAGE 22
fondaparinux sodium 16 GAMMAPLEX 96
GLUCOPHAGE XR 22
FORFIVO XL 20 GAMUNEX-C 96
GLUCOTROL 25
FORMALDEHYDE 43 GASTROCROM 72
GLUCOTROL XL 25
formaldehyde 43 gatifloxacin (ophth) 92
GLUCOVANCE 22
FORTEO 68 GATTEX 74
GLUMETZA 22
FORTESTA 9 GAZYVA 35
glyburide 25
FOSAMAX 68 GELCLAIR 86
glyburide micronized 25
FOSAMAX PLUS D 68 GELFILM OP 94
glyburide-metformin 22
fosamprenavir calcium 44 GELNIQUE 105
GLYCATE 102
FOSCAVIR 45 GELNIQUE PUMP 105
glycopyrrolate 102
fosinopril sodium 30 GELX 86
fosinopril sodium & GLYCOPYRROLATE 102
GEMCITABINE 35
hydrochlorothiazide 31 GLYNASE 25
gemcitabine hcl 35
fosphenytoin sodium 19 GLYSET 22
gemfibrozil 29
FOSRENOL 73 GLYXAMBI 22
GEMZAR 35
FRAGMIN 16 GOLYTELY 78
GENERESS FE 51
FREESTYLE FREEDOM GORDONS UREA 63
LITE 80 GENOTROPIN 69
GENOTROPIN GRALISE 99
FREESTYLE INSULINX
BLOODGLUCOSE MINIQUICK 69 GRALISE STARTER 99
MONITORING SYSTEM 80 GENTAK 92 granisetron hcl 26
FREESTYLE LITE BLOOD gentamicin in saline 3 GRANIX 76
GLUCOSE MONITORING
SYSTEM 80 gentamicin sulfate 3 GRASTEK 2
FREESTYLE PRECISION NEO gentamicin sulfate (ophth) 92 GRIS-PEG 27
BLOOD GLUCOSE gentamicin sulfate (topical) 58 griseofulvin microsize 27
MONITORING SYSTEM 80 GENTAMICIN SULFATE/0.9% griseofulvin ultramicrosize 27
FROVA 82 SODIUM CHLORIDE 3 guaifenesin-codeine 54
frovatriptan succinate 82 GENVOYA 44
guanfacine hcl 31
FULVESTRANT 36 GEODON 42
guanfacine hcl (adhd) 1
fulvestrant 36 GIAZO 73
GUANIDINE HCL 33
FURADANTIN 104 GILENYA 99
GYNAZOLE-1 106
furosemide 67 GILOTRIF 37
HALAC 62
FUROSEMIDE 67 GLASSIA 100
HALAVEN 40
furosemide 67 glatiramer acetate 99
halcinonide 62
FUSILEV 39 GLATOPA 99
HALCION 77
Index 10
halobetasol propionate 62 HUMULIN 70/30 24 hydroxyurea 39
HALOG 62 HUMULIN 70/30 hydroxyzine hcl 12
haloperidol 42 KWIKPEN 24 hydroxyzine pamoate 12
HUMULIN N 24
haloperidol lactate 42 HYLIRA 64
HUMULIN N KWIKPEN 24
HALOTIN 58 HYOPHEN 104
HUMULIN R 24
HARVONI 46 hyoscyamine sulfate 102
HUMULIN R U-500
HECTOROL 70 (CONCENTRATED) 24 HYPER-SAL 55
HELIXATE FS 75 HUMULIN R U-500 HYPERSAL 55
HEMANGEOL 47 KWIKPEN 24 HYPODERMIC NEEDLE
HEMENATAL OB 87 HYALGAN 90 30GX1/2" 80
hyaluronate sodium HYQVIA 96
HEMENATAL OB + DHA 87 (emollient) 64 HYSINGLA ER 6
HEPARIN LOCK FLUSH 16 HYCAMTIN 40 HYZAAR 31
heparin sod (porcine) in d5w 16 HYCOFENIX 54 ibandronate sodium 68
HEPARIN SODIUM 16 hydralazine hcl 32 IBRANCE 37
heparin sodium (porcine) 16 HYDREA 39
heparin sodium (porcine) lock ibuprofen 4
HYDRO 35 64 ICAR PEDIATRIC 77
flush 16
HEPARIN SODIUM/D5W 16 HYDRO 40 FOAM 64 icatibant acetate 75
HEPARIN hydrochlorothiazide 68 ICLUSIG 37
SODIUM/DEXTROSE 16 HYDROCODONE
BITARTRATE/ACETAMINOPH IDAMYCIN PFS 37
HEPSERA 46
EN 8 idarubicin hcl 37
HERCEPTIN 35 HYDROCODONE IDELVION 75
HETLIOZ 78 BITARTRATE/CHLORPHENIR IFEX 34
HEXALEN 34 AMINE MALEATE/PSE 54
hydrocodone polistirex- ifosfamide 34
HIPREX 104
chlorpheniramine polistirex 54 IFOSFAMIDE 34
HIZENTRA 96 hydrocodone w/ ILARIS 3
homatropine hbr 91 homatropine 54
hydrocodone- ILEVRO 94
HORIZANT 99
acetaminophen 8 ILUMYA 59
HUMALOG 23
hydrocodone-ibuprofen 8 imatinib mesylate 37
HUMALOG JUNIOR
KWIKPEN 23 hydrocortisone 53 IMBRUVICA 37
HUMALOG KWIKPEN 23 hydrocortisone (intrarectal) 10 imipramine hcl 21
HUMALOG MIX 50/50 23 hydrocortisone (rectal) 10 imipramine pamoate 21
HUMALOG MIX 50/50 hydrocortisone (topical) 62 imiquimod 64
KWIKPEN 23 hydrocortisone acetate IMITREX 82
HUMALOG MIX 75/25 23 (rectal) 10 IMITREX STATDOSE
HUMALOG MIX 75/25 hydrocortisone acetate w/ REFILL 82
KWIKPEN 23 pramoxine 10 IMITREX STATDOSE
HUMAPEN LUXURA HD 80 hydrocortisone butyrate 62 SYSTEM 82
HUMATROPE 69 hydrocortisone butyrate IMODIUM A-D 25
HUMATROPE COMBO hydrophilic lipo base 62 IMPAVIDO 10
PACK 69 hydrocortisone valerate 62
IMURAN 85
HUMIRA 3 hydrocortisone w/acetic
acid 96 INCRELEX 69
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK 3 hydromorphone hcl 6 INCRUSE ELLIPTA 13
HUMIRA PEN 3 hydroxychloroquine sulfate 33 indapamide 68
HUMIRA PEN-CD/UC/HS HYDROXYPROGESTERONE INDERAL LA 47
STARTER 3 CAPROATE 36 INDERAL XL 47
HUMIRA PEN-PS/UV hydroxyprogesterone
caproate 97 INDOCIN 4
STARTER 3
Index 11
indomethacin 4 ISOMETHEPTENE/DICHLORA KEFLEX 50
INFANATE BALANCE 87 LPHENAZONE/ACETAMINOP KENALOG 62
HEN 82
INGREZZA 98 ISONIAZID 33 KEPIVANCE 39
INLYTA 37 isoniazid 33 KEPPRA 17
INNOPRAN XL 47 ISOPTO ATROPINE 91 KEPPRA XR 17
INSPIRACHAMBER/LARGE KERALAC 64
81 ISOPTO CARPINE 92
ISORDIL TITRADOSE 12 ketoconazole 27
INSPRA 32
ISOSORBIDE DINITRATE 12 ketoconazole (topical) 58
INSULIN SYRINGES AND PEN
NEEDLES 80 isosorbide dinitrate 12 KETONE 66
INTEGRA F 76 ISOSORBIDE DINITRATE KETONE TEST STRIPS 66
INTELENCE 44 ER 12 ketoprofen 4
INTERMEZZO 77 isosorbide mononitrate 12 KETOPROFEN 4
INTRON A 39 ISOTONIC GENTAMICIN 3 ketoprofen 4
INTRON A W/DILUENT 39 isotretinoin 56 ketorolac tromethamine 4
INTUNIV 1 isoxsuprine hcl 49 ketorolac tromethamine
isradipine 48 (ophth) 94
INVANZ 11
ISTALOL 91 KETOSTIX 66
INVEGA 42
ISTODAX (OVERFILL) 37 KEVEYIS 67
INVEGA SUSTENNA 42
itraconazole 27 KEYTRUDA 35
INVEGA TRINZA 42
ivermectin 10 KHEDEZLA 21
INVIRASE 44
IXEMPRA KIT 40 KINERET 3
INVOKAMET 22
IXINITY 75 KISQALI 38
INVOKAMET XR 22 KISQALI FEMARA 200
INVOKANA 25 JADENU 25 DOSE 37
iodoquinol-hc 58 JADENU SPRINKLE 25 KISQALI FEMARA 400
iodoquinol-hydrocortisone in aloe JAKAFI 38 DOSE 37
vehicle 58 JALYN 74 KISQALI FEMARA 600
IONSYS 6 DOSE 37
JANUMET 22 KITABIS PAK 3
IOPIDINE 92 JANUMET XR 22 KLARITY-A 92
ipratropium bromide 13 JANUVIA 23 KLARON 56
ipratropium bromide (nasal) 90 JARDIANCE 25 KLONOPIN 17
ipratropium-albuterol 15 JENTADUETO 22 KLOR-CON M15 84
irbesartan 30 JENTADUETO XR 22
irbesartan-hydrochlorothiazide KOGENATE FS 75
JEVTANA 40 KOGENATE FS BIO-SET 75
31
IRESSA 37 JUBLIA 58 KOMBIGLYZE XR 22
IRINOTECAN 40 JUXTAPID 29 KORLYM 23
irinotecan hcl 40 JYNARQUE 70,71 KOVALTRY 75
irrigation solutions, K-PHOS 83 KRINTAFEL 33
physiological 85 K-PHOS NEUTRAL 83 KRISTALOSE 78
ISENTRESS 44 K-PHOS NO 2 74 KUVAN 70
ISOLYTE-S 83 K-TAB 84 KYNAMRO 28
ISOMETHEPTENE KADCYLA 35
MUCATE/CAFFEINE/ACETAMIN KYPROLIS 38
OPHEN 82 KADIAN 6 labetalol hcl 47
isometheptene- KALETRA 44 LAC-HYDRIN 64
dichloralphenazone- KALYDECO 100
acetaminophen 82 LAC-HYDRIN TWELVE 64
KAPVAY 1 LACRISERT 91
KAZANO 22 lactated ringer's (irrigation) 85
Index 12
lactic acid (ammonium letrozole 36 LIDODERM 65
lactate) 64 leucovorin calcium 39 LILETTA 52
LACTULOSE 78
LEUCOVORIN CALCIUM 39 LINCOCIN 11
lactulose 78
leucovorin calcium 39 lincomycin hcl 11
lactulose (encephalopathy) 73
LEUKERAN 34 LINDANE 66
LAMICTAL 17
LEUKINE 76 linezolid 11
LAMICTAL CHEWABLE
DISPERSIBLE 17 leuprolide acetate 36 LINZESS 73
LAMICTAL ODT 17 levalbuterol hcl 15 LIORESAL INTRATHECAL 89
LAMICTAL STARTER/NOT levalbuterol tartrate 15 liothyronine sodium 101
TAKING CARBAMAZEPINE 17 LEVAMISOLE HCL 37 LIPITOR 29
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING LEVAQUIN 72 LIPOFEN 29
VALPROATE 17 LEVBID 102 lisinopril 30
LAMICTAL STARTER/TAKING LEVEMIR 24 lisinopril &
VALPROATE 17 LEVEMIR FLEXTOUCH 24 hydrochlorothiazide 31
LAMICTAL XR 17,18 LITHIUM 42
levetiracetam 18
LAMISIL 27 lithium carbonate 41
levobunolol hcl 91
lamivudine 44 levocarnitine (metabolic LITHOBID 42
lamivudine (hbv) 46 modifiers) 70 LITHOSTAT 75
lamivudine-zidovudine 44 levocetirizine LIVALO 29
lamotrigine 18 dihydrochloride 28 LO LOESTRIN FE 51
LANCETS AND LANCET levofloxacin 72
LOCOID 62
DEVICES 80 levofloxacin (ophth) 92
LOCOID LIPOCREAM 62
LANOXIN 48 levoleucovorin calcium 39
LODINE 4
lansoprazole 103 levonorgestrel & eth
estradiol 51 LODOSYN 40
lanthanum carbonate 73
levonorgestrel (emergency LOESTRIN 1.5/30-21 51
LANTUS 24 oc) 52 LOESTRIN 1/20-21 51
LANTUS SOLOSTAR 24 levonorgestrel-eth estradiol
(triphasic) 51 LOESTRIN FE 1.5/30 51
LASIX 67
levonorgestrel-ethinyl estradiol LOESTRIN FE 1/20 51
LASTACAFT 95 (91-day) 51 LOFIBRA 29
latanoprost 95 levonorgestrel-ethinyl estradiol LOKELMA 85
LATANOPROST 95 (continuous) 51
levorphanol tartrate 6 LOMOTIL 25
LATUDA 42
levothyroxine sodium 101 LONSURF 37
LAZANDA 6
LEVSIN 102 loperamide hcl 25
LEDIPASVIR/SOFOSBUVIR
46 LEVSIN/SL 102 LOPID 29
leflunomide 5 LEVULAN KERASTICK 59 lopinavir-ritonavir 44
LENVIMA 10 MG DAILY LEXAPRO 20 LOPRESSOR 47
DOSE 38 LOPRESSOR HCT 31
LENVIMA 14 MG DAILY LEXIVA 44
DOSE 38 LIALDA 73 LOPROX 58
LENVIMA 18 MG DAILY LIBRAX 102 LOPROX SHAMPOO 58
DOSE 38 lorazepam 13
LENVIMA 20 MG DAILY lidocaine 65
lidocaine hcl 65 LORBRENA 38
DOSE 38
LENVIMA 24 MG DAILY LIDOCAINE HCL 86 LORTAB 8
DOSE 38 lidocaine hcl (mouth- LORZONE 89
LENVIMA 8 MG DAILY throat) 85 losartan potassium 30
DOSE 38 lidocaine-hydrocortisone losartan potassium &
LESCOL XL 29 acetate (rectal) 10 hydrochlorothiazide 31
LETAIRIS 49 lidocaine-prilocaine 65 LOSEASONIQUE 51
Index 13
LOTEMAX 93 MARPLAN 20 mesalamine 73
LOTENSIN 30 MARQIBO 40 mesna 39
LOTENSIN HCT 31 MATULANE 39 MESNEX 39
loteprednol etabonate 93 MAVYRET 46 MESTINON 33
LOTREL 32 MAXALT 82 MESTINON TIMESPAN 33
LOTRIMIN ULTRA 58 MAXALT-MLT 82 metaproterenol sulfate 15
LOTRISONE 58 MAXIDEX 93 METASTRON 38
LOTRONEX 73 MAXIPIME 51 metaxalone 89
lovastatin 29 MAXITROL 93 metformin hcl 22
LOVAZA 28 MAXZIDE 67 METFORMIN
LOVENOX 16 MAXZIDE-25 67 HYDROCHLORIDE 22
methadone hcl 7
loxapine succinate 42 meclizine hcl 26
METHADOSE 7
LOZI-FLUR 83 meclofenamate sodium 4
METHADOSE SUGAR-FREE 7
LUCENTIS 92 MEDROL 53
methamphetamine hcl 1
LULICONAZOLE 58 MEDROL DOSEPAK 53
methazolamide 67
LUMIGAN 95 MEDROX-RX 65
medroxyprogesterone methenamine hippurate 104
LUMIZYME 70
acetate 97 methenamine mandelate 104
LUNESTA 77
medroxyprogesterone acetate methenamine-hyosc-methylene
LUPANETA PACK 69 (contraceptive) 53 blue-benzoic acid-phenyl
LUPRON DEPOT (1- mefenamic acid 4 sal 104
MONTH) 36 methenamine-hyosc-methylene
LUPRON DEPOT (3- mefloquine hcl 33
blue-sod phos-phenyl sal 104
MONTH) 36 MEFLOQUINE HCL 33 methimazole 101
LUPRON DEPOT (4- MEGACE ES 97
MONTH) 36 METHITEST 9
MEGESTROL ACETATE 36 methocarbamol 89
LUPRON DEPOT-PED (1-
MONTH) 69 megestrol acetate 36 METHOTREXATE 3
LUPRON DEPOT-PED (3- megestrol acetate
(appetite) 97 methotrexate sodium 35
MONTH) 69
LUXIQ 62 MEKINIST 38 METHOTREXATE SODIUM 35
LUZU 58 MEKTOVI 38 methotrexate sodium 35
LYNPARZA 38 meloxicam 4 methoxsalen rapid 59
LYRICA 18 melphalan 34 methscopolamine bromide 102
LYRICA CR 99 melphalan hcl 34 methyclothiazide 68
LYSODREN 36 memantine hcl 98 methyldopa 31
MENEST 71 methyldopa &
LYSTEDA 77 hydrochlorothiazide 32
MACROBID 104 MENOSTAR 71 METHYLDOPATE HCL 31
MACRODANTIN 104 MENTAX 58 methylergonovine maleate 96
mafenide acetate 60 meperidine hcl 6 METHYLIN 2
MAGNESIUM SULFATE 83 MEPERIDINE HCL 6 methylphenidate hcl 2
magnesium sulfate 83 meperidine hcl 6 METHYLPHENIDATE
MAGNESIUM SULFATE 83 MEPERIDINE HYDROCHLORIDE ER (LA) 2
HCL/PROMETHAZINE HCL 8 methylprednisolone 53
MAKENA 97
MEPHYTON 107 METHYLTESTOSTERONE 9
MALARONE 33
meprobamate 12 METIPRANOLOL 91
malathion 66
MEPRON 11 metoclopramide hcl 72
maprotiline hcl 20
mercaptopurine 35 METOCLOPRAMIDE ODT 72
MARINOL 26
meropenem 11 metolazone 68
MARNATAL-F 87
MERREM 11
Index 14
METOPIRONE 66 MIRVASO 66 mycophenolate mofetil 85
metoprolol & misoprostol 104 mycophenolate mofetil hcl 85
hydrochlorothiazide 32 MITIGARE 75 mycophenolate sodium 85
metoprolol succinate 47
mitomycin 37 MYDRIACYL 92
METOPROLOL SUCCINATE
ER/HYDROCHLOROTHIAZIDE mitoxantrone hcl 37 MYFORTIC 85
32 MOBIC 4 MYLERAN 34
metoprolol tartrate 47 modafinil 2 MYNATAL ADVANCE 87
METOPROLOL TARTRATE 47 MODERIBA 1200 DOSE MYNATAL ULTRACAPLET 87
METOPROLOL/HYDROCHLOR PACK 46 MYNATE 90 PLUS 87
OTHIAZIDE 32 MODERIBA 800 DOSE
PACK 46 MYRBETRIQ 105
METROCREAM 65
moexipril hcl 30 MYSOLINE 18
METROGEL 65
moexipril-hydrochlorothiazide MYTESI 25
METROGEL-VAGINAL 106 32 nabumetone 4
METROLOTION 65 MOLINDONE
HYDROCHLORIDE 43 nadolol 47
metronidazole 10
mometasone furoate 62 nadolol &
metronidazole (topical) 65,66 bendroflumethiazide 32
metronidazole in nacl 10 mometasone furoate NADOLOL/BENDROFLUMETHIA
(nasal) 90 ZIDE 32
metronidazole vaginal 106 MONISTAT SOOTHING CARE
MEXILETINE HCL 13 ITCH RELIEF 63 NAFCILLIN 97
MIACALCIN 68 MONODOX 101 nafcillin sodium 97
MICARDIS 30 montelukast sodium 14 NAFCILLIN SODIUM 97
MICARDIS HCT 32 MONUROL 104 naftifine hcl 58
miconazole nitrate vaginal 106 morphine sulfate 7 NAFTIN 59
MICONAZOLE NITRATE/ZINC MORPHINE SULFATE 7 NAGLAZYME 70
OXIDE/WHITE morphine sulfate 7 nalbuphine hcl 9
PETROLATUM 58 MORPHINE SULFATE ER 7 NALFON 4
MICROZIDE 68 NALOXONE HCL 25
MOTOFEN 25
midazolam hcl 77 naloxone hcl 26
MOVANTIK 73
midodrine hcl 106 NALOXONE HCL 26
MOVIPREP 78
MIGERGOT 82 naltrexone hcl 26
MOXATAG 96
miglitol 22 NAMENDA 98
MOXEZA 92
miglustat 76 NAMENDA TITRATION PAK98
moxifloxacin hcl 72
MIGRANAL 82 NAMENDA XR 98
moxifloxacin hcl (ophth) 92
MILLIPRED 53 NAMENDA XR TITRATION
MOZOBIL 77
MILLIPRED DP 53 PACK 98
MS CONTIN 7 NAPRELAN 4
MINASTRIN 24 FE 51
MUCINEX D 54 NAPROSYN 4
MINIPRESS 31
MULPLETA 76 naproxen 4
MINIVELLE 71
MULTAQ 13 naproxen sodium 4
MINOCIN 101 MULTIVITAMIN/FLUORIDE
minocycline hcl 101 86 naratriptan hcl 82
minoxidil 32 MUPIROCIN 58 NARCAN 26
MIRAPEX 41 mupirocin 58 NARDIL 20
MIRAPEX ER 41 mupirocin calcium (topical) 58 NASACORT ALLERGY
24HR 90
MIRCERA 76 MUSTARGEN 34 NASACORT ALLERGY 24HR
MIRCETTE 51 MYALEPT 70 CHILDRENS 90
MIRENA 53 MYAMBUTOL 33 NASONEX 90
mirtazapine 19 MYCOBUTIN 33 NATACHEW 87
Index 15
NATACYN 92 NEXIUM 24HR 103 norethindrone acet & eth
NATAZIA 51 NEXIUM 24HR CLEAR estra 52
MINIS 103 norethindrone acetate 97
nateglinide 25
NEXPLANON 53 norethindrone acetate-ethinyl
NATELLE ONE 87 estradiol 71
niacin (antihyperlipidemic) 30
NATPARA 68 norethindrone acetate-ethinyl
NIASPAN 30 estradiol-fe 52
NATROBA 66
nicardipine hcl 48 norethindrone-eth estradiol
NATURE-THROID 101 (triphasic) 52
NICODERM CQ 99
NATURE-THROID NT-2.5 101 norgestimate-ethinyl
NICORETTE 99 estradiol 52
NAVELBINE 40
NICORETTE MINI 99 norgestimate-ethinyl estradiol
NEBUPENT 10
NICORETTE STARTER (triphasic) 52
NEBUSAL 55 KIT 99 norgestrel & ethinyl estradiol 52
NECON 1/50-28 52 nicotine 100 NORITATE 66
NEEVO DHA 87 nicotine polacrilex 100 NORMOSOL -R 83
nefazodone hcl 21 NICOTROL INHALER 100 NORMOSOL-R 83
NEFAZODONE NICOTROL NS 100
HYDROCHLORIDE 21 NORPACE 13
nifedipine 48 NORPACE CR 13
NEO-SYNALAR 58
NILANDRON 36 NORPRAMIN 21
neomycin sulfate 3
neomycin-bacitracin zn- nilutamide 36 NORTHERA 106
polymyxin 92 nimodipine 48 nortriptyline hcl 21
neomycin-polymy-dexameth 93 NINLARO 38 NORVASC 48
neomycin-polymyxin-hc NIPENT 39 NORVIR 44
(ophth) 93 nisoldipine 48
neomycin-polymyxin-hc NOVAREL 69
(otic) 95 NITRO-BID 12 NOVOEIGHT 75
neomycin/polymyxin b gu 74 NITRO-DUR 12 NOVOLIN 70/30 24
NEOMYCIN/POLYMYXIN B NITRO-TIME 12 NOVOLIN 70/30 RELION 24
SULFATES 74 nitrofurantoin 104
NEOMYCIN/POLYMYXIN/GRAM NOVOLIN N 24
nitrofurantoin NOVOLIN N RELION 24
ICIDIN 92 macrocrystal 104
NEORAL 85 nitrofurantoin monohyd NOVOLIN R 24
NEOSPORIN 92 macro 104 NOVOLIN R RELION 24
NEOSPORIN GU IRRIGANT74 nitroglycerin 12 NOVOLOG 24
NEOTUSS PLUS 54 NITROLINGUAL NOVOLOG FLEXPEN 24
PUMPSPRAY 12
NEPTAZANE 67 NOVOLOG MIX 70/30 24
NITROMIST 12
NESINA 23 NOVOLOG MIX 70/30
NITROSTAT 12 PREFILLED FLEXPEN 24
NESTABS 87
NIVESTYM 76 NOVOLOG PENFILL 24
NESTABS ABC 87
nizatidine 103 NOXAFIL 27
NESTABS DHA 87
NIZATIDINE 103 NUCALA 13
NEULASTA 76
NIZORAL 59 NUCORT 63
NEULASTA ONPRO KIT 76
nonoxynol-9 105 NUCYNTA 7
NEUPOGEN 76
NORCO 8 NUCYNTA ER 7
NEUPRO 41
NORDITROPIN FLEXPRO 69 NUEDEXTA 99
NEURONTIN 18
norethin acet & estrad-fe 52 NULOJIX 85
NEVANAC 95 norethindrone & eth NULYTELY/FLAVOR
nevirapine 44 estradiol 52 PACKS 78
NEXA PLUS 87 norethindrone & ethinyl NUPLAZID 42
NEXAVAR 38 estradiol-fe 52
norethindrone NUTRIDOX 101
NEXIUM 103 (contraceptive) 53 NUTROPIN AQ NUSPIN 10 69
Index 16
NUTROPIN AQ NUSPIN 20 69 OMNIPRED 93 ORALAIR
NUTROPIN AQ NUSPIN 5 69 OMNITROPE 69 CHILDREN/ADOLESCENTS
STARTER PACK 2
NUVARING 52 ONCASPAR 38 ORAP 99
NUVIGIL 2 ondansetron 26 ORAPRED ODT 53
NYMALIZE 48 ondansetron hcl 26 ORAVIG 86
nystatin 27 ONETOUCH ULTRA 2 80 ORENCIA 5
nystatin (mouth-throat) 86 ONETOUCH ULTRA MINI 80 ORENCIA CLICKJECT 5
nystatin (topical) 59 ONETOUCH VERIO 80 ORENITRAM 49
nystatin-triamcinolone 59 ONETOUCH VERIO FLEX
BLOOD GLUCOSE ORFADIN 70
OB COMPLETE ONE 87 ORKAMBI 100
MONITORING SYSTEM 80
OB COMPLETE PETITE 87 ONETOUCH VERIO IQ orphenadrine citrate 89
OB COMPLETE PREMIER 87 BLOOD GLUCOSE ORTHO MICRONOR 53
OB COMPLETE/DHA 87 MONITORING SYSTEM 80
ONETOUCH VERIO SYNC ORTHO TRI-CYCLEN 52
OBIZUR 75 BLOODGLUCOSE ORTHO TRI-CYCLEN LO 52
OBSTETRIX DHA 87 MONITORING SYSTEM 80 ORTHO-CYCLEN 52
OBTREX DHA 87 ONFI 17 ORTHO-NOVUM 1/35 52
OCALIVA 72 ONGLYZA 23 ORTHO-NOVUM 7/7/7 52
OCTAGAM 96 ONMEL 27 ORTHOVISC 90
octreotide acetate 70 OPANA 7 oseltamivir phosphate 46
OCUFLOX 92 OPANA ER (CRUSH
RESISTANT) 7 OSENI 22
ODOMZO 36 OSPHENA 69
OFEV 100 OPDIVO 35
opium tincture 25 OTEZLA 5
OFLOXACIN 72 OTICIN HC NR 95
ofloxacin 72 OPSUMIT 49
OPTICHAMBER OTOVEL 95
ofloxacin (ophth) 92 DIAMOND 81 OTREXUP 3
ofloxacin (otic) 95 OPTICHAMBER OVIDE 66
olanzapine 42 DIAMOND/LARGEFACE
MASK 81 oxacillin sodium 97
olanzapine-fluoxetine hcl 98 OPTICHAMBER oxaliplatin 34
olmesartan medoxomil 30 DIAMOND/MEDIUM FACE OXANDRIN 9
olmesartan medoxomil- MASK 81
amlodipine-hydrochlorothiazide OPTICHAMBER oxandrolone 9
32 DIAMOND/SMALLFACE oxaprozin 5
olmesartan medoxomil- MASK 81 OXAYDO 7
hydrochlorothiazide 32 OPTIONS CONCEPTROL oxazepam 13
olopatadine hcl 95 VAGINAL
CONTRACEPTIVE 105 OXAZEPAM 13
olopatadine hcl (nasal) 90
OPTIONS GYNOL II oxcarbazepine 18
OLUX 63 VAGINALCONTRACEPTIVE OXERVATE 93
OLUX-E 63 105 oxiconazole nitrate 59
OLYSIO 46 ORACEA 66
OXISTAT 59
OMECLAMOX-PAK 104 ORACIT 74
OXSORALEN ULTRA 59
omega-3-acid ethyl esters 28 ORALAIR 2
OXTELLAR XR 18
omeprazole 103 ORALAIR ADULT SAMPLE
KIT 2 oxybutynin chloride 105
OMEPRAZOLE + SYRSPEND
SFALKA 103 ORALAIR ADULT STARTER oxycodone hcl 7
omeprazole-sodium PACK 2 OXYCODONE HCL ER 7
bicarbonate 104 ORALAIR OXYCODONE
OMNARIS 90 CHILDREN/ADOLESCENTS HYDROCHLORIDE ER 7
SAMPLE KIT 2
OMNIFLEX DIAPHRAGM 79 oxycodone w/ acetaminophen 8
Index 17
oxycodone-aspirin 8 peg 3350-kcl-sod bicarb-sod phenytoin 19
OXYCODONE/ACETAMINOPHE chloride-sod sulfate 78 phenytoin sodium 19
N 8 peg 3350-potassium chloride-
sod bicarbonate-sod phenytoin sodium extended 19
OXYCODONE/ASPIRIN 8
chloride 78 PHOSLYRA 73
OXYCODONE/IBUPROFEN 8 PEGANONE 19 PHOSPHOLINE IODIDE 92
OXYCONTIN 7 PEGASYS 46 PHOTOFRIN 39
oxymorphone hcl 7 PEGASYS PROCLICK 46 phytonadione 107
OXYTROL 105 PEGINTRON 46 PICATO 59
OXYTROL FOR WOMEN 105 penicillamine 84 PIFELTRO 44
PACLITAXEL 40 penicillin g potassium 96 pilocarpine hcl 92
paclitaxel 40 PENICILLIN G POTASSIUM IN pilocarpine hcl (oral) 86
paliperidone 42 ISO-OSMOTIC
DEXTROSE 96 pimecrolimus 64
palonosetron hcl 26
PENICILLIN G PROCAINE96 PIMOZIDE 99
PALONOSETRON
HYDROCHLORIDE 26 PENICILLIN G SODIUM 96 pindolol 47
PAMELOR 21 PENICILLIN V pioglitazone hcl 23
pamidronate disodium 68 POTASSIUM 97 pioglitazone hcl-glimepiride 22
PAMIDRONATE DISODIUM 68 penicillin v potassium 97 pioglitazone hcl-metformin
PENLAC NAIL LACQUER 59 hcl 22
PANCREAZE 66 piperacillin sodium-tazobactam
PANDEL 63 PENNSAID 57
sodium 97
PANRETIN 59 PENTASA 73 piroxicam 5
pantoprazole sodium 103 pentazocine w/ naloxone 9 PLAN B ONE-STEP 52
PARAFON FORTE DSC 89 pentoxifylline 75 PLAQUENIL 33
PARAGARD INTRAUTERINE PEPCID 103 PLASMA-LYTE A 83
COPPER CONTRACEPTIVE PEPCID AC MAXIMUM
STRENGTH 103 PLASMA-LYTE-148 83
T380A 52
paregoric 25 PERCOCET 8 PLAVIX 76
PAREMYD 95 PERFOROMIST 15 PLEGRIDY 99
PERIDEX 86 PLEGRIDY STARTER
paricalcitol 70 PACK 99
PARLODEL 41 perindopril erbumine 30 PLENVU 78
PARNATE 20 PERJETA 35 PNV OB+DHA 87
paromomycin sulfate 3 permethrin 66 PNV-DHA+DOCUSATE 87
paroxetine hcl 20 perphenazine 43 PNV-OMEGA 87
paroxetine mesylate perphenazine-amitriptyline 98 PNV-SELECT 87
(vasomotor) 100 PERSERIS 42
PASER 33 PNV-TOTAL 87
PERTZYE 66 PNV-VP-U 87
PATADAY 95 PEXEVA 20 PODOCON 25 IN BENZOIN
PATANASE 90 PFIZERPEN 97 TINCTURE 65
PATANOL 95 phenazopyridine hcl 74 podofilox 65
PAXIL 20 phendimetrazine tartrate 1 POLY HUB NEEDLE/30G X
PAXIL CR 20 1/2" 80
phenelzine sulfate 20 POLY-VI-FLOR 86
PCE 79 phenobarbital 77
ped multivitamins w/fl & iron 86 POLY-VI-FLOR FS 86
phenobarbital-hyoscyamine-
PEDIAPRED 54 atropine-scopolamine 102 POLY-VI-FLOR/IRON 86
pediatric multivitamins w/fl 86 phenoxybenzamine hcl 30 polymyxin b sulfate 12
pediatric vitamins acd fluoride & phentermine hcl 1 polymyxin b-trimethoprim 92
iron 86 phenylephrine hcl (ophth) 93 POLYTRIM 92
pediatric vitamins acd w/ POMALYST 37
fluoride 86 PHENYTEK 19
Index 18
PONSTEL 5 PREDNISOLONE ACETATE P- PREPIDIL 96
pot & sod citrates w/citric ac 74 F 94 PREPOPIK 78
PREDNISOLONE SODIUM
pot phosphate monobasic w/ sod PHOSPHATE 54 PREVACID 103
phosphate dibasic & prednisolone sodium PREVACID SOLUTAB 104
monobasic 83 phosphate 54
potassium bicarb & chloride 84 PREVPAC 104
PREDNISOLONE SODIUM
potassium bicarbonate 84 PHOSPHATE 94 PREVYMIS 45
potassium chloride 84 PREDNISOLONE SODIUM PREZCOBIX 44
PHOSPHATE/MOXIFLOXACIN PREZISTA 44
POTASSIUM CHLORIDE 84 94
potassium chloride 84 PRIFTIN 33
PREDNISOLONE/MOXIFLOXA
POTASSIUM CHLORIDE CIN 94 PRILOSEC 104
ER 84 PREDNISOLONE/MOXIFLOXA primaquine phosphate 33
potassium chloride in nacl 83 CIN/BROMFENAC 94 PRIMAQUINE PHOSPHATE 33
potassium chloride PREDNISOLONE/MOXIFLOXA
CIN/KETOROLAC 94 primidone 18
microencapsulated crystals
er 84 prednisone 54 PRIMLEV 8
potassium citrate PREDNISONE INTENSOL 54 PRIMSOL 10
(alkalinizer) 74 PREFEST 71 PRINIVIL 30
potassium citrate-citric acid 74 PRISTIQ 21
pregabalin 18
PR NATAL 400 87 PREGNYL W/DILUENT PRIVIGEN 96
PR NATAL 400 EC 87 BENZYLALCOHOL/NACL 69 PRO-RED AC 54
PR NATAL 430 87 PREMARIN 71,106 PROAIR HFA 15
PR NATAL 430 EC 87 PREMPHASE 71 PROAIR RESPICLICK 15
PRADAXA 16 PREMPRO 71 probenecid 75
PRALUENT 30 PRENA1 PEARL 87 PROCARDIA 48
pramipexole dihydrochloride 41 PRENAISSANCE PROCARDIA XL 48
PRAMOSONE 63 BALANCE 87
PRENAISSANCE HARMONY PROCENTRA 1
PRAMOSONE E 63 DHA 87 prochlorperazine 43
PRAMOTIC 96 PRENAISSANCE NEXT 87 prochlorperazine edisylate 43
pramoxine-hc 63 PRENAISSANCE NEXT-B 87 PROCHLORPERAZINE
pramoxine-hc-chloroxylenol 96 PRENAISSANCE PLUS 88 EDISYLATE 43
PRANDIN 25 PRENATA 88 prochlorperazine maleate 43
prasugrel hcl 76 PRENATAL 19 88 PROCORT 10
PRAVACHOL 29 prenatal vit w/ docusate-fe PROCRIT 76
pravastatin sodium 29 fumarate-folic acid 88 PROCTOCORT 10
prenatal vit w/ docusate-iron PROCTOFOAM HC 10
praziquantel 10 carbonyl-folic acid 88
prazosin hcl 31 prenatal vit w/ ferrous fumarate- PROCYSBI 74
PRECISION XTRA 80 l methylfolate-folic acid 88 PRODRIN 82
prenatal without a w/ fe progesterone micronized 98
PRECOSE 22 fumarate-l methylfolate-fa-
PRED FORTE 93 PROGLYCEM 23
dha 88
PRED MILD 93 PRENATAL-U 88 PROGRAF 85
PRED-G 94 PRENATE DHA 88 PROLASTIN-C 100
PRED-G S.O.P. 93 PRENATE ELITE 88 PROLENSA 95
PREDNICARBATE 63 PRENATE ENHANCE 88 PROLEUKIN 39
prednicarbate 63 PRENATE ESSENTIAL 88 PROLIA 68
prednisolone 54 PRENATE MINI 88 PROMACTA 76
PREDNISOLONE 54 promethazine &
PRENATE PIXIE 88 phenylephrine 54
PREDNISOLONE ACETATE94 PRENATE RESTORE 88 promethazine hcl 28
Index 19
promethazine w/codeine 54 QUDEXY XR 18 RELION KETONE TEST
promethazine-phenylephrine- QUESTRAN 29 STRIPS 66
codeine 54 RELISTOR 73
QUESTRAN LIGHT 28
PROMETHAZINE/DEXTROMET RELNATE DHA 88
HORPHAN 55 quetiapine fumarate 42
RELPAX 82
PROMETHAZINE/PHENYLEPHR QUFLORA PEDIATRIC 86
INE 55 REMERON 19
QUILLIVANT XR 2
PROMETHAZINE/PHENYLEPHR REMERON SOLTAB 19
INE/CODEINE 55 quinapril hcl 30
quinapril-hydrochlorothiazide REMICADE 73
PROMETRIUM 98 REMODULIN 49
32
propafenone hcl 13 quinidine gluconate 13 RENAGEL 73
propantheline bromide 102 QUINIDINE SULFATE 13 RENVELA 73
proparacaine hcl 93 quinine sulfate 33 repaglinide 25
propranolol & REPAGLINIDE/METFORMIN
hydrochlorothiazide 32 QUINJA 59
QVAR 15 HYDROCHLORIDE 22
propranolol hcl 47 REPATHA 30
propylthiouracil 101 QVAR REDIHALER 15
REPATHA PUSHTRONEX
PROSCAR 74 R-NATAL OB 88 SYSTEM 30
PROSTIN E2 96 rabeprazole sodium 104 REPATHA SURECLICK 30
PROTONIX 104 RABEPRAZOLE SODIUM DR REQUIP 41
SPRINKLE 104
PROTOPIC 64 REQUIP XL 41
RADIOGARDASE 25
protriptyline hcl 21 RESCRIPTOR 44
RAGWITEK 2
PROVENGE 36 RESTASIS 93
raloxifene hcl 69
PROVENTIL HFA 15 RESTASIS MULTIDOSE 93
ramelteon 78
PROVERA 98 RESTORIL 77
ramipril 30
PROVIGIL 2 RETIN-A 56
RANEXA 12
PROZAC 20 RETIN-A MICRO 57
ranitidine hcl 103
pseudoephed-cpm w/ RETIN-A MICRO PUMP 57
hydrocod 55 ranolazine 12
RETROVIR 44
pseudoephedrine w/ codeine- RAPAFLO 74
gg 55 REVATIO 49
RAPAMUNE 85
pseudoephedrine-guaifenesin REVLIMID 84
rasagiline mesylate 41
55 REXAPHENAC 57
PSORCON 63 RASUVO 3
REXULTI 43
PULMICORT 14 RAVICTI 70
REYATAZ 44
PULMICORT FLEXHALER 14 RAYOS 54
REZIRA 55
PULMOZYME 100 RAZADYNE 98
RIAX 57
PURIXAN 35 RAZADYNE ER 98
RIBASPHERE 46
PYLERA 104 REBETOL 46
RIBASPHERE RIBAPAK 46
pyrazinamide 33 REBIF 99
ribavirin 47
PYRIDIUM 75 REBIF REBIDOSE 99
REBIF REBIDOSE ribavirin (hepatitis c) 46
pyridostigmine bromide 33 TITRATIONPACK 99 RIDAURA 3
QNASL 91 REBIF TITRATION PACK 99 rifabutin 33
QNASL CHILDRENS 91 RECLAST 68 RIFADIN 34
QSYMIA 1 RECTIV 10 RIFAMATE 33
QUADRAMET 38 REGLAN 72 rifampin 34
QUALAQUIN 33 REGRANEX 66 RIFATER 33
QUARTETTE 52 RELENZA DISKHALER 46 RILUTEK 91
QUAZEPAM 77 RELION KETONE 66 riluzole 91
quazepam 77
Index 20
rimantadine hydrochloride 46 salsalate 6 SILENOR 77
ringer's irrigation 85 SAMSCA 71 silodosin 74
RIOMET 22 SANCUSO 26 SILVADENE 60
risedronate sodium 68 SANDIMMUNE 85 silver nitrate-potassium
RISPERDAL 42 SANDOSTATIN 70 nitrate 60
SANDOSTATIN LAR silver sulfadiazine 60
RISPERDAL CONSTA 42
DEPOT 70 SIMBRINZA 92
RISPERDAL M-TAB 42
SANTYL 64 SIMPONI 3
risperidone 42
SAPHRIS 43 SIMULECT 85
RISPERIDONE ODT 42
SARAFEM 99 simvastatin 29
RITALIN 2
SAVAYSA 16 SINEMET 41
RITALIN LA 2
SAVELLA 98 SINEMET CR 41
ritonavir 44
SAVELLA TITRATION SINGULAIR 14
RITUXAN 35 PACK 98 sirolimus 85
rivastigmine 98 SCLEROSOL
INTRAPLEURAL 100 SIRTURO 34
rivastigmine tartrate 98
scopolamine 26 SIVEXTRO 11
RIXUBIS 75
SE-NATAL 19 88 SKELAXIN 89
rizatriptan benzoate 82
SEASONIQUE 52 SKLICE 66
ROBAXIN 89
SECONAL SODIUM 77 SKYLA 53
ROBAXIN-750 89
SEEBRI NEOHALER 13 SODIUM CHLORIDE 84
ROBINUL 102
SEGLUROMET 22 sodium chloride 84
ROBINUL FORTE 102
SELECT-OB 88 SODIUM CHLORIDE 84
ROCALTROL 70
SELECT-OB+DHA 88 sodium chloride (gu irrigant) 74
ROMIDEPSIN 38
selegiline hcl 41 sodium chloride (inhalant) 55
ropinirole hydrochloride 41
SELEGILINE HCL 41 sodium citrate & citric acid 74
rosuvastatin calcium 29
selenium sulfide 60 sodium fluoride 83
ROTATEQ 105
SELENIUM SULFIDE 60 SODIUM FLUORIDE 83
ROXICODONE 7
SELZENTRY 44 SODIUM HYALURONATE 90
ROXYBOND 7
SEMPREX-D 55 sodium phenylbutyrate 70
ROZEREM 78
SENSIPAR 70 sodium polystyrene
RUBRACA 38 sulfonate 85
RUCONEST 75 SEREVENT DISKUS 15 SODIUM SULFACETAMIDE
RYCLORA 27 SERNIVO 63 WASH 60
SEROQUEL 43 SODIUM
RYTARY 41 SULFACETAMIDE/SULFUR
RYTHMOL SR 13 SEROQUEL XR 43
57
SABRIL 19 SEROSTIM 69 SODIUM
SAFYRAL 52 sertraline hcl 20 SULFACETAMIDE/SULFUR
sevelamer carbonate 73 CLEANSER IN UREA 57
SAIZEN 69 SOFOSBUVIR/VELPATASVIR
SAIZEN CLICK.EASY 69 sevelamer hcl 73 46
SAIZENPREP SEVELAMER solifenacin succinate 105
RECONSTITUTIONKIT 69 HYDROCHLORIDE 73
SFROWASA 73 SOLODYN 101
SALAGEN 86 SOLTAMOX 36
SALEX 65 SHUR-SEAL 105
SIGNIFOR 70 SOLU-CORTEF 54
SALEX LOTION 65 SOMA 89
salicylic acid 65 SIKLOS 76
sildenafil citrate 49 SOMATULINE DEPOT 70
SALICYLIC ACID 65 SOMAVERT 69
sildenafil citrate (pulmonary
SALICYLIC ACID LOTION 65 hypertension) 49 SONATA 77
Index 21
SOOLANTRA 66 SULAR 48 SYNRIBO 39
SORIATANE 59,60 sulfacetamide sod- SYNTHROID 101
SORILUX 60 prednisolone 94 SYNVISC 90
sulfacetamide sodium
sotalol hcl 47 (acne) 57 SYNVISC ONE 90
sotalol hcl (afib/afl) 47 sulfacetamide sodium SYPRINE 84
SOTYLIZE 47 (ophth) 92 TABLOID 35
sulfacetamide sodium w/
SOVALDI 46 sulfur 57 TACLONEX 63
spacer/aerosol-holding sulfacetamide sodium-sulfur in tacrolimus 85
chambers 81 urea vehicle 57 tacrolimus (topical) 64
SPECTRACEF 50 SULFACETAMIDE tadalafil (pulmonary
SPINOSAD 66 SODIUM/PREDNISOLONE hypertension) 49
SPIRIVA HANDIHALER 13 SODIUM PHOSPHATE 94 TAFINLAR 38
SULFADIAZINE 100
SPIRIVA RESPIMAT 13 TAGAMET HB 103
sulfamethoxazole-trimethoprim
spironolactone 67 11 TAGRISSO 38
spironolactone & SULFAMYLON 60 TALTZ 60
hydrochlorothiazide 67 TALWIN 9
sulfasalazine 73
SPORANOX 27
sulindac 5 TALZENNA 38
SPORANOX PULSEPAK 27
SUMADAN WASH 57 TAMIFLU 46,47
SPRITAM 18
sumatriptan 83 tamoxifen citrate 36
SPRIX 5
sumatriptan succinate 83 tamsulosin hcl 74
SPRYCEL 38
SUMATRIPTAN TANZEUM 23
SSS 10-5 57 SUCCINATE 83 TAPAZOLE 101
STALEVO 100 41 sumatriptan succinate 83 TAPERDEX 12-DAY 54
STALEVO 125 41 sumatriptan-naproxen
sodium 82 TARCEVA 38
STALEVO 150 41
SUMAVEL DOSEPRO 83 TARGADOX 101
STALEVO 200 41
SUMAXIN 57 TARGRETIN 39,59
STALEVO 50 41
SUMAXIN TS 57 TARKA 32
STALEVO 75 41
SUMAXIN WASH 57 TARON-BC 88
STARLIX 25
SUPRAX 50 TARON-C DHA 88
stavudine 45
SUPREP BOWEL PREP TARON-PREX 88
STEGLATRO 25 KIT 78 TASIGNA 38
STELARA 60 SURMONTIL 21 TASMAR 40
STERILE TALC POWDER 100 SUSTIVA 45 TAXOL 40
STIMATE 70 SUTENT 38 TAXOTERE 40
STIOLTO RESPIMAT 15 SYLATRON 39 TAYTULLA 52
STIVARGA 38 SYLVANT 85 tazarotene 60
STRATTERA 2 SYMBICORT 15 TAZORAC 60
STRENSIQ 70 SYMBYAX 98 TBC 64
STREPTOMYCIN SULFATE 3 SYMLINPEN 120 22 TECFIDERA 99
STRIANT 9 SYMLINPEN 60 22 TECFIDERA STARTER
STRIBILD 45 SYMTUZA 45 PACK 99
STRIVERDI RESPIMAT 15 SYNAGIS 96 TECHNIVIE 46
STROMECTOL 10 SYNALAR 63 TEFLARO 51
SUBOXONE 9 SYNALGOS-DC 8 TEGRETOL 18
SUBSYS 7 SYNAREL 69 TEGRETOL-XR 18
SUCRAID 67 SYNERA 65 TEKTURNA 32
sucralfate 103 SYNJARDY 22 TEKTURNA HCT 32
Index 22
telmisartan 30 TIAZAC 48 TOPAMAX SPRINKLE 18
telmisartan-amlodipine 32 TIBSOVO 38 TOPICORT 63
telmisartan-hydrochlorothiazide TICASPRAY 90 topiramate 18
32 TICE BCG 39 TOPIRAMATE ER 18
temazepam 77
TIGAN 26 TOPOTECAN HCL 40
TEMODAR 34
TIGECYCLINE 100 topotecan hcl 40
TEMOVATE 63
tigecycline 100 TOPROL XL 47
temozolomide 34
TIKOSYN 13 toremifene citrate 36
temsirolimus 38
timolol maleate 47 TORISEL 38
TENCON 5
timolol maleate (ophth) 91 torsemide 67
TENIPOSIDE 40 TIMOLOL MALEATE TOTECT 39
tenofovir disoproxil fumarate 45 OPHTHALMIC GEL TOUJEO MAX SOLOSTAR 24
TENORETIC 100 32 FORMING 91
TIMOPTIC 91 TOUJEO SOLOSTAR 24
TENORETIC 50 32
TIMOPTIC OCUDOSE 91 TOVIAZ 105
TENORMIN 47
TIMOPTIC-XE 91 TRACLEER 49
TEPADINA 34
TINDAMAX 10 TRADJENTA 23
TERAZOL 7 106
tinidazole 10 tramadol hcl 7
terazosin hcl 31
TIROSINT 101 TRAMADOL HCL ER 7
terbinafine hcl 27
TIROSINT-SOL 102 tramadol-acetaminophen 8
terbutaline sulfate 16
TIVICAY 45 trandolapril 30
TERCONAZOLE 106
TIVORBEX 5 trandolapril-verapamil hcl 32
terconazole vaginal 106 TRANDOLAPRIL/VERAPAMIL
TESSALON PERLES 54 tizanidine hcl 89 HCL ER 32
TESTIM 9 TL FOLATE 88 tranexamic acid 77
TESTONE CIK 9 TL-CARE DHA 88 TRANSDERM SCOP 26
testosterone 9 TOBI 3 TRANSDERM-SCOP 26
TESTRED 9 TOBI PODHALER 3 TRANXENE T 13
tetrabenazine 98 TOBRADEX 94 tranylcypromine sulfate 20
tetracaine hcl (ophth) 93 TOBRADEX ST 94 TRAVATAN Z 95
tetracycline hcl 101 TOBRAMYCIN 3 trazodone hcl 21
TEXACORT 63 tobramycin 3 TREANDA 34
THALOMID 84 tobramycin (ophth) 92 TRECATOR 34
THEO-24 16 TOBRAMYCIN SULFATE 3 TRELSTAR MIXJECT 36
theophylline 16 tobramycin sulfate 3 treprostinil 49
thioridazine hcl 43 tobramycin- TRESIBA FLEXTOUCH 24
dexamethasone 94
thiotepa 34 TOBREX 92 TRETIN-X 57
thiothixene 43 TODAY SPONGE 105 tretinoin 57
THRIVITE 19 88 TOFRANIL 22 tretinoin (chemotherapy) 39
THYMOGLOBULIN 85 TOLAZAMIDE 25 tretinoin microsphere 57
thyroid 101 tolazamide 25 TREXALL 35
THYROLAR-1 101 tolbutamide 25 TREXIMET 82
THYROLAR-1/2 101 tolcapone 40 TRI-NORINYL 28 52
THYROLAR-1/4 101 TOLMETIN SODIUM 5 TRI-TABS DHA 88
THYROLAR-2 101 tolmetin sodium 5 TRI-VI-FLOR 86
THYROLAR-3 101 tolterodine tartrate 105 TRI-VI-FLORO 86
tiagabine hcl 19 triamcinolone acetonide
TOPAMAX 18 (mouth) 86
Index 23
triamcinolone acetonide TYGACIL 100 VALCYTE 45
(nasal) 91 TYKERB 38 valganciclovir hcl 45
triamcinolone acetonide
(topical) 63 TYLENOL/CODEINE #3 8 VALIUM 13
triamterene 67 TYLENOL/CODEINE #4 8 valproate sodium 19
triamterene & TYSABRI 99 valproic acid 19
hydrochlorothiazide 67 TYVASO 49 valrubicin 37
TRIANEX 63 TYVASO REFILL 49 valsartan 30
triazolam 77 TYVASO STARTER 49 valsartan-hydrochlorothiazide
TRIBENZOR 32 UCERIS 10,54 32
TRICARE PRENATAL DHA VALSTAR 37
ONE 88 ULESFIA 66
VALTREX 46
TRICOR 29 ULORIC 75
VALVED HOLDING
TRIDESILON 63 ULTIMATECARE ONE 88 CHAMBER 81
trientine hcl 84 ULTIMATECARE ONE NF 88 VANATOL LQ 5
trifluoperazine hcl 43 ULTRACET 8 VANATOL S 5
TRIFLURIDINE 93 ULTRAM 7 VANOS 63
trifluridine 93 ULTRAVATE 63 VANTAS 36
TRIGLIDE 29 ULTRAVATE X 63 VARUBI 27
trihexyphenidyl hcl 40 UNASYN 97 VASCEPA 28
TRILEPTAL 18 UNASYN BULK PACK 97 VASERETIC 32
TRILIPIX 29 UNISOM SLEEPGELS 77 VASOTEC 30
trimethobenzamide hcl 26 UPTRAVI 49 VCF VAGINAL
URAMAXIN 64 CONTRACEPTIVE FILM 105
trimethoprim 10 VCF VAGINAL
trimipramine maleate 22 URAMAXIN GT 64 CONTRACEPTIVE FOAM 105
TRIMPEX 10 URE-K 64 VECAMYL 32
TRINATAL GT 88 urea 64 VECTIBIX 35
TRINTELLIX 21 UREA 64 VELCADE 38
TRISENOX 39 urea 64 VELETRI 49
TRIUMEQ 45 urea in lactic acid vehicle 64 VELPHORO 74
TRIVEEN-DUO DHA 88 UREA IN ZINC VELTASSA 85
UNDECYLENATE/LACTIC
TRIVEEN-PRX RNF 88 ACID VEHICLE 64 VELTIN 57
TRIZIVIR 45 UREA NAIL 64 VEMAVITE-PRX 2 88
TROKENDI XR 18 UREA TOPICAL 64 VENA-BAL DHA 88
tropicamide 92 URECHOLINE 105 VENCLEXTA 36
trospium chloride 105 URIMAR-T 104 VENCLEXTA STARTING
TRULANCE 72 PACK 36
UROCIT-K 10 74
venlafaxine hcl 21
TRULICITY 23 UROCIT-K 15 74
VENTAVIS 49
TRUSOPT 95 UROCIT-K 5 74
VENTOLIN HFA 16
TRUVADA 45 UROXATRAL 74
verapamil hcl 48
TUDORZA PRESSAIR 13 URSO 250 72
VERAPAMIL HCL ER 48
TUSNEL 55 URSO FORTE 72
VERAPAMIL HCL SR 48
TUSSICAPS 55 ursodiol 72
TUSSIONEX PENNKINETIC VERDESO 63
UTOPIC 64
EXTENDED RELEASE 55 VEREGEN 57
UVADEX 39
TUZISTRA XR 55 VERELAN 48
VAGIFEM 106
TWYNSTA 32 VERELAN PM 48
valacyclovir hcl 46
TYBOST 45 VERIPRED 20 54
VALCHLOR 59
Index 24
VERSACLOZ 43 VITAMIN D3 107 WIDE-SEAL SILICONE
VESICARE 105 VITAPEARL 89 DIAPHRAGM KIT 90 79
WIDE-SEAL SILICONE
VFEND 27 VITRAKVI 38 DIAPHRAGM KIT 95 80
VFEND IV 27 VITUZ 55 WILATE 75
VIAGRA 49 VIVA DHA 89 WP THYROID 102
VIBERZI 73 VIVELLE-DOT 71 XALATAN 95
VIBRAMYCIN 101 VIVITROL 26 XALKORI 38
VICTOZA 23 VIVLODEX 5 XANAX 13
VIDAZA 35 VIVOTIF 105 XANAX XR 13
VIDEX EC 45 VIVOTIF BERNA 105 XARELTO 16
VIDEXPEDIATRIC 45 VIZIMPRO 38 XARELTO STARTER PACK 16
VIEKIRA PAK 46 VOLTAREN 57 XELJANZ 3
VIEKIRA XR 46 VORAXAZE 39 XELJANZ XR 3
vigabatrin 19 voriconazole 27 XELODA 35
VIGAMOX 93 VOSPIRE ER 16 XELPROS 95
VIIBRYD 21 VOTRIENT 38 XENAZINE 98
VIIBRYD STARTER PACK 21 VP-CH PLUS 89 XENICAL 1
VIMOVO 5 VP-CH-PNV 89 XERAC AC 65
VIMPAT 18 VP-GGR-B6 PRENATAL 89 XGEVA 68
VINATE DHA RF 88 VP-HEME OB 89 XIAFLEX 84
VINBLASTINE SULFATE 40 VP-HEME OB + DHA 89 XIFAXAN 11
VINCRISTINE SULFATE 40 VP-PNV-DHA 89 XIGDUO XR 22
vincristine sulfate 40 VPRIV 76 XODOL 8
vinorelbine tartrate 40 VRAYLAR 42 XOFIGO 38
VIOKACE 67 VUSION 59 XOLAIR 13
VIRACEPT 45 VYTONE 59 XOLEGEL 59
VIRAMUNE 45 VYTORIN 28 XOPENEX 16
VIRAMUNE XR 45 VYVANSE 1 XOPENEX CONCENTRATE 16
VIRASAL 65 warfarin sodium 16 XOPENEX HFA 16
VIRAZOLE 47 water for irrigation, sterile 85 XOSPATA 38
VIREAD 45 WELCHOL 29 XTANDI 36
VIROPTIC 93 WELLBUTRIN SR 20 XULANE 52
VIRT-ADVANCE 88 WELLBUTRIN XL 20 XURIDEN 70
VIRT-C DHA 88 WELLESSE VITAMIN D3 107 XYREM 98
VIRT-NATE DHA 88 WESTCORT 63 XYZAL ALLERGY 24HR 28
VIRT-PN 88 WESTHROID 102 XYZAL ALLERGY 24HR
VIRT-PN DHA 88 WIDE-SEAL SILICONE CHILDRENS 28
VIRT-PN PLUS 88 DIAPHRAGM KIT 60 79 YASMIN 28 52
WIDE-SEAL SILICONE YAZ 52
VIRT-VITE GT 88 DIAPHRAGM KIT 65 79
VIRTPREX 88 WIDE-SEAL SILICONE YERVOY 35
VISTARIL 12 DIAPHRAGM KIT 70 79 zafirlukast 14
WIDE-SEAL SILICONE zaleplon 77
VISTOGARD 25 DIAPHRAGM KIT 75 79
VITAFOL ULTRA 88 ZALTRAP 35
WIDE-SEAL SILICONE
VITAFOL-NANO 89 DIAPHRAGM KIT 80 79 ZAMICET 8
VITAFOL-ONE 89 WIDE-SEAL SILICONE ZANAFLEX 89
DIAPHRAGM KIT 85 79 ZANOSAR 34
VITAMIN D2 107
Index 25
ZANTAC 103 ZOLINZA 38
ZANTAC 150 MAXIMUM zolmitriptan 83
STRENGTH 103 ZOLOFT 21
ZARONTIN 19
zolpidem tartrate 78
ZARXIO 76
ZOLPIMIST 78
ZATEAN-PN DHA 89
ZOMACTON 69
ZATEAN-PN PLUS 89
ZOMETA 68
ZAVESCA 76
ZOMIG 83
ZEGERID 104
ZOMIG ZMT 83
ZELAPAR 41
ZONALON 59
ZELBORAF 38
ZONEGRAN 18
ZEMAIRA 100
zonisamide 18
ZEMBRACE SYMTOUCH 83
ZONTIVITY 76
ZEMPLAR 70
ZORBTIVE 69
ZENPEP 67
ZORTRESS 85
ZEPATIER 46
ZORVOLEX 5
ZERIT 45
ZOSTAVAX 105
ZESTORETIC 32
ZOSYN 97
ZESTRIL 30
ZOVIRAX 46,60
ZETIA 29
ZUBSOLV 9
ZETONNA 91
ZUPLENZ 26
ZEVALIN Y-90 36
ZUTRIPRO 55
ZIAC 32
ZYBAN 100
ZIAGEN 45
ZYDELIG 38
ZIANA 57
ZYFLO 14
zidovudine 45
ZYFLO CR 14
zileuton 14
ZYKADIA 38
ZINBRYTA 99
ZYLET 94
ZINECARD 39
ZYLOPRIM 75
ZIOPTAN 95
ZYMAXID 93
ziprasidone hcl 42
ZYPREXA 43
ZIPSOR 5
ZYPREXA ZYDIS 43
ZIRGAN 93 ZYRTEC CHILDRENS
ZITHROMAX 79 ALLERGY 28
ZITHROMAX TRI-PAK 79 ZYTIGA 36
ZITHROMAX Z-PAK 79 ZYVOX 11
ZMAX 79
ZOCOR 29
ZODEX 12-DAY 54
ZOFRAN 26
ZOFRAN ODT 26
ZOHYDRO ER 7
ZOLADEX 36
zoledronic acid 68
ZOLEDRONIC ACID 68
zoledronic acid 68
Index 26

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Essential Rx Drug List

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KITABIS PAK NEBU SP OTREXUP SOAJ SP PA

neomycin sulfate tabs 1 RASUVO SOAJ SP PA

paromomycin sulfate caps 1 Gold Compounds

tobramycin nebu SP Interleukin-1beta Blockers

flurbiprofen tabs 1 NAPROSYN SUSP (Use GP

naproxen tbec 1 ORENCIA SOSY SP PA

oxaprozin tabs 1 Soluble Tumor Necrosis Factor Receptor Agents

Selective Costimulation Modulators aspirin chew PV PV

DEMEROL TABS (Use New starts HYSINGLA ER T24A 3 PA

ISORDIL TITRADOSE buspirone hcl tabs 1

ELIXOPHYLLIN ELIX 3 HEPARIN SODIUM SOSY SP PA

oxcarbazepine susp 1 VIMPAT SOLN 2

DILANTIN INFATABS divalproex sodium tbec 1

tranylcypromine sulfate paroxetine hcl tabs 1

GLYSET TABS (Use OSENI TABS 3 PA

SYMLINPEN 60 SOPN SP PA SEGLUROMET TABS 3

Antidiabetic Combinations SYNJARDY TABS 2

EMEND TRIPACK CAPS Limit 3 per itraconazole soln 1 PA

griseofulvin microsize susp 1 VFEND SUSR 40 MG/ML 2

doxazosin mesylate tabs 1 candesartan cilexetil- 1

decitabine solr AC PA AVASTIN SOLN AC

floxuridine solr AC PA CYRAMZA SOLN AC

fludarabine phosphate soln AC PA ZALTRAP SOLN AC

gemcitabine hcl soln AC PA CAMPATH SOLN AC PA

gemcitabine hcl solr AC PA ERBITUX SOLN AC PA

METHOTREXATE POWD AC KEYTRUDA SOLN AC PA

methotrexate sodium soln ij PA OPDIVO SOLN AC PA

DEPO-PROVERA SUSP AC PA SOLTAMOX SOLN AC

ELIGARD KIT AC PA tamoxifen citrate tabs PV PV

EMCYT CAPS AC toremifene citrate tabs AC

exemestane tabs AC TRELSTAR MIXJECT AC PA

ADRIAMYCIN SOLR AC ALECENSA CAPS AC PA

bleomycin sulfate solr AC BELEODAQ SOLR AC

INTRON A SOLN AC PA levoleucovorin calcium solr AC

INTRON A SOLR AC PA mesna soln AC

amantadine hcl tabs 1 SINEMET CR TBCR (Use GP

INVEGA TRINZA SUSY SP PA olanzapine tabs or 5 mg,

DESCOVY TABS 2 lamivudine tabs 1

didanosine cpdr 1 lamivudine-zidovudine tabs 1

EDURANT TABS 2 LEXIVA SUSP 50 MG/ML 2

efavirenz caps 1 LEXIVA TABS 700 MG

FUZEON SOLR SP PA PREZCOBIX TABS 2

SYMTUZA TABS 3 ST zidovudine tabs 1

TYVASO STARTER SOLN SP PA UPTRAVI TBPK SP PA

VELETRI SOLR SP PA Pulmonary Hypertension - Sol Guanylate Cyclase