2013 Formulary (List of covered drugs)

ODS AdvantageComprehensive Formulary

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

Benefi ciaries must use network pharmacies to access their prescription drug benefi t. Benefi ts, formulary, pharmacy network, premium and/or copayments/coinsurance may change onJanuary 1, 2014.

To receive this document in an alternate format or language, please contact Pharmacy Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacifi c time, seven days a week.

www.odscompanies.com/odsadvantage

2013 Formulary (List of covered drugs)

H3813-003H3813-006

Online documents give you easy access to all your Medicare information.

The Centers for Medicare and Medicaid Services (CMS) require that we send you important plan documents every year.

These documents contain information specific to your ODS Advantage plan:

�Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC)

�Comprehensive Formulary (if applicable)

�Provider and/or Pharmacy Directory (if applicable)

That’s a lot of paper to clutter your home. Luckily, all of these documents are available electronically through your myODS account.

To receive an email from ODS Advantage when new materials are available, simply log in to your myODS account by visiting www.odscompanies.com. The myODS log in is on the right side of your screen. You can also create an account on this page. Once logged in, select the “Account” tab. Next, click on “Change account settings.” From here, you can update your email and make your electronic delivery preference.

Once you request electronic delivery you will no longer receive these documents in the mail. For questions or help please contact Member Services at 877-299-9062.

Cut down on more paper — sign up for ODS eBill today!

902427 (8/12)

Next year, you can get these

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Now you can pay your premium online with ODS eBill. Using eBill you can view invoices online and set up your preferred payment methods (credit card, debit card, checking or savings) and set a recurring payment using our AutoPay feature. To access eBill, log in to myODS and click on the eBill tab.

I

ODS Advantage Comprehensive Formulary

2013 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE

COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014. ODS Advantage PPORX plan is a PPO plan with a Medicare contract. To receive document in an alternate format or language, please contact Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week.

Formulary ID 00013384, Version 5 H3813_1085PPORXS13A

File & Use (09/11/2012)

II

What is the ODS Advantage Formulary?

A formulary is a list of covered drugs selected by ODS Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. ODS Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a ODS Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 2012. To get updated information about the drugs covered by ODS Advantage, please visit our Web site at www.odscompanies.com/odsadvantage or call Customer Service at 1-888-786-7509, from 7 am to 8 pm, Pacific time, seven days a week. (TTY/TDD users should call 711.) How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

III

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1 (at the back of this booklet). The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? ODS Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

• Prior Authorization: ODS Advantage requires you or your physician to get prior authorization

for certain drugs. This means that you will need to get approval from ODS Advantage before you fill your prescriptions. If you don’t get approval, ODS Advantage may not cover the drug.

• Quantity Limits: For certain drugs, ODS Advantage limits the amount of the drug that ODS Advantage will cover. For example, ODS Advantage provides 9 tablets in 28 days per prescription for sumatriptan (Imitrex) tablets. This may be in addition to a standard one month or three month supply.

• Step Therapy: In some cases, ODS Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, ODS Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, ODS Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.odscompanies.com/odsadvantage. You can ask ODS Advantage to make an exception to these restrictions or limits. See the section, “How do I request an exception to the ODS Advantage formulary?” on page IV for information about how to request an exception.

IV

What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that ODS Advantage does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by ODS Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by ODS Advantage.

• You can ask ODS Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the ODS Advantage Formulary? You can ask ODS Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, ODS Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in one of our non-preferred/highest tiers subject to the tiering exceptions process tier (Tier 2 or Tier 4), you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier subject to the tiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated as the high-cost/unique drug tier (Specialty tier – Tier 5).

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

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s

V

supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

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

For more information For more detailed information about your ODS Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about ODS Advantage, please call Customer Service at 1-888-786-7509, 7 am to 8 pm, Pacific time, seven days a week. (TTY/TDD users should call 711.) Or visit www.odscompanies.com/odsadvantage.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

VI

ODS Advantage Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by ODS Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ASMANEX) and generic drugs are listed in lower-case italics (e.g., sumatriptan). The information in the Requirements/Limits column tells you if ODS Advantage has any special requirements for coverage of your drug.

o LA – This prescription may be available only at certain pharmacies. For more information call

Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

o PA for Ages 65 and Older; May be High Risk Medication – The Centers for Medicare and Medicaid Services (CMS) considers this medication to be of high risk for patients 65 years old or older. Please contact your provider for more information.

o PA – Prior authorization is required for these drugs. This means you or your provider will need to get approval from ODS Advantage before you can fill your prescription. If you don’t get approval, ODS Advantage may not cover the drug. See page IV for how to request an exception. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

o PA for Part B vs Part D Only - This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

o PA for ESRD only – These drugs are also prescribed for members who have End-Stage Renal

Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis facility. If you don’t have ESRD, see page IV for how to request an exception. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

o QL – These drugs have a quantity limit. This means you will receive a limited amount of these drugs unless you or your provider asks for an exception to the quantity limit. See page IV for how to request an exception. The maximum dosage allowed for the drug is noted first, then the days supply (e.g., sumatriptan tablets QL 9 in 28 days, this means a maximum of 9 tablets are allowed within 28 days). If you need help asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

VII

o Rx Product Only - This drug is now available as a generic over-the-counter (OTC) medication. OTC products are not covered under your Part D benefit. The prescription strength is only covered under your Part D benefit. If you have questions please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

o ST – These drugs require you to first try certain other drugs to treat your medical condition

before we will cover this drug. See page IV for how to request an exception. If you need help asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)

Below is your cost sharing by plan and tier.

ODS Advantage PPORX ODS Advantage PPORX Select

Deductible $120.00 $120.00 Drug Tier up to a 31-day

supply up to a 93-day



supply Tier 1 $5.00 $15.00 $5.00 $15.00 Tier 2 $33.00 $99.00 $33.00 $99.00 Tier 3 $41.00 $123.00 $41.00 $123.00 Tier 4 50% 50% 50% 50% Tier 5 30% drugs on this tier

are limited to a 31-day supply

30% drugs on this tier are limited to a 31-

day supply

1

Drug Name Drug

Tier Requirements/Limits

Adrenals Adrenals

ADVAIR DISKUS 3 QL: 62 in

31 days

ADVAIR HFA 3 QL: 12 in

28 days

AEROBID-M 4 QL: 14 in

25 days

A-HYDROCORT 4 PA (PA for Part B vs

Part D Only)

ALVESCO 4 QL: 12.2

in 25

days

ASMANEX 4 QL: 1 in

14 days

aer pow ba:

220mcg(60)

ASMANEX 4 QL: 1 in

25 days

aer pow ba:

110mcg(30),

220mcg120

ASMANEX 4 QL: 1 in

7 days

aer pow ba:

220mcg(30)

betamet acet/betamet na

ph

(Celestone) 1 PA (PA for Part B vs

Part D Only)

budesonide (Entocort EC) 2 capdr & er

cortisone acetate (Cortisone Acetate) 1 PA (PA for Part B vs

Part D Only)

dexamethasone acetate (Dexamethasone Acetate) 1 PA (PA for Part B vs

Part D Only)

dexamethasone sod

phosphate

(Dexamethasone Sod Phosphate) 1 PA vial: 10mg/ml, (PA

for Part B vs Part D

Only)

dexamethasone sod

phosphate

(Dexamethasone Sod Phosphate) 1 PA vial: 4mg/ml, (PA


Only)

dexamethasone (Dexamethasone) 1 PA elixir, tablet, (PA


Only)

dexamethasone (Dexamethasone) 1 PA tab ds pk, (PA for

Part B vs Part D

Only)

DULERA 3 QL: 13 in

28 days

2

Drug Name Drug


FLOVENT DISKUS 3 QL: 120

in 30

days

disk w/dev: 250mcg

FLOVENT DISKUS 3 QL: 60 in

30 days

disk w/dev: 50mcg,

100mcg

FLOVENT HFA 3 QL: 12 in

28 days

aer w/adap: 110mcg

FLOVENT HFA 3 QL: 21.2

in 28

days

aer w/adap: 44mcg

FLOVENT HFA 3 QL: 24 in

28 days

aer w/adap: 220mcg

fludrocortisone acetate (Fludrocortisone Acetate) 1

hydrocortisone sod

succinate

(Hydrocortisone Sod Succinate) 1 PA (PA for Part B vs

Part D Only)

hydrocortisone (Cortef) 1 PA (PA for Part B vs

Part D Only)

methylprednisolone

acetate

(Depo-medrol) 1 PA (PA for Part B vs

Part D Only)

methylprednisolone sod

succ

(Solu-medrol) 1 PA vial: 1000mg, (PA


Only)

methylprednisolone sod

succ

(Solu-medrol) 1 PA vial: 125mg/2ml,

(PA for Part B vs

Part D Only)

methylprednisolone (Medrol) 1 PA (PA for Part B vs

Part D Only)

prednisolone acetate (Prednisolone Acetate) 1 PA (PA for Part B vs

Part D Only)

prednisolone sod

phosphate

(Orapred) 1 PA (PA for Part B vs

Part D Only)

prednisolone (Prednisolone) 1 PA (PA for Part B vs

Part D Only)

PREDNISONE

INTENSOL

4 PA (PA for Part B vs

Part D Only)

prednisone (Prednisone) 1 PA solution, tablet,

(PA for Part B vs

Part D Only)

prednisone (Prednisone) 1 PA tab ds pk, (PA for

Part B vs Part D

Only)

3

Drug Name Drug


QVAR 3 QL: 17.4

in 25

days

SOLU-CORTEF (PF) 4 PA (PA for Part B vs

Part D Only)

SOLU-MEDROL (PF) 4 PA vial: 40mg/ml, (PA


Only)

SYMBICORT 4 ST, QL:

11 in 25

days

triamcinolone acetonide (Kenalog-40) 1 PA (PA for Part B vs

Part D Only)

VERIPRED 20 1 PA (PA for Part B vs

Part D Only)

Alpha-Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents

doxazosin mesylate (Cardura) 1

prazosin hcl (Minipress) 1

terazosin hcl (Hytrin) 1

Ammonia Detoxicants Ammonia Detoxicants

BUPHENYL 3

CARBAGLU 5

lactulose (Lactulose) 1 solution

lactulose (Lactulose) 1 syrup

LITHOSTAT 3

Analgesics and Antipyretics Analgesics And Antipyretics, Miscellaneous

acetaminophen/phenyltolx

cit

(Staflex) 1

ACUFLEX 4

FLEXTRA PLUS 4

mg sal/acetaminophn/p-

tlox/caf

(Durabac Forte) 1

OFIRMEV 4

RELAGESIC 4 liquid

sal-amide/acetamin/p-tlox/

caff

(Durabac) 1

sal-amide/acetaminophn/

p-tlox

(Asp) 1

4

Drug Name Drug


salicylamide/

acetaminophen

(Salicylamide/acetaminophen) 1

Nonsteroidal Anti-inflammatory Agents

CALDOLOR 4

CELEBREX 3 ST, QL:

62 in 31

days

choline sal/mag salicylate (Choline Sal/mag Salicylate) 1

diclofenac potassium (Cataflam) 1

diclofenac sodium (Voltaren) 1

diflunisal (Diflunisal) 1

etodolac (Etodolac) 1 capsule: 200mg;

tablet

etodolac (Etodolac) 1 capsule: 300mg

etodolac (Etodolac) 2 tab er 24h

fenoprofen calcium (Fenoprofen Calcium) 1

FLECTOR 4 ST

flurbiprofen (Ansaid) 1

ibuprofen (Motrin) 1

indomethacin sodium

trihydrate

(Indocin I.v.) 1 (May be High Risk

Med for Ages 65

and Older)

indomethacin (Indocin SR) 2 capsule er, (May be

High Risk Med for

Ages 65 and Older)

indomethacin (Indomethacin) 1 capsule, (May be

High Risk Med for

Ages 65 and Older)

ketoprofen (Ketoprofen) 1 capsule

ketoprofen (Ketoprofen) 2 cap24h pel

ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 20 in

31 days

vial: 60mg/2ml

ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 40 in

31 days

vial: 15mg/ml

ketorolac tromethamine (Toradol) 1 QL: 20 in

31 days

cartridge: 30mg/ml

ketorolac tromethamine (Toradol) 1 QL: 40 in

31 days

cartridge: 15mg/ml

LEVACET 4

magnesium salicylate (Magnesium Salicylate) 1

meclofenamate sodium (Meclofenamate Sodium) 2

mefenamic acid (Ponstel) 2

meloxicam (Mobic) 1

5

Drug Name Drug


nabumetone (Relafen) 1

naproxen sodium (Anaprox) 1

naproxen (Naprosyn) 1

oxaprozin (Oxaprozin) 1

piroxicam (Feldene) 1

salsalate (Salflex) 1

SOLARAZE 4

sulindac (Clinoril) 1

tolmetin sodium (Tolmetin Sodium) 2

VOLTAREN 3 ST gel (gram),

(Topical Gel)

Opiate Agonists

acetaminophen with

codeine

(Tylenol-codeine No.3) 1 QL: 180

in 30

days

tablet: 300mg-60mg

acetaminophen with

codeine


in 30

days

tablet: 650mg-

30mg, 650mg-60mg

acetaminophen with

codeine


in 30

days

tablet: 300mg-

15mg, 300mg-30mg

codeine phos/

acetaminophen

(Codeine Phos/acetaminophen) 1 QL: 2500

in 30

days

codeine phosphate (Codeine Phosphate) 1 (Injection)

codeine sulfate (Codeine Sulfate) 1 QL: 180

in 30

days

CODEINE SULFATE 1 QL: 1800

in 30

days

dhcodeine bt/

acetaminophn/caff

(Dhcodeine Bt/acetaminophn/

caff)

1 QL: 300

in 30

days

capsule

dhcodeine bt/

acetaminophn/caff

(Panlor SS) 1 QL: 150

in 30

days

tablet

fentanyl citrate (Actiq) 5 PA, QL:

120 in 30

days

fentanyl (Duragesic) 2 PA, QL:

10 in 30

days

patch td72: 12mcg/

hr, 25mcg/hr,

50mcg/hr, 75mcg/hr

6

Drug Name Drug


fentanyl (Duragesic) 2 PA, QL:

20 in 30

days

patch td72: 100mcg/

hr

hydrocodone bit/

acetaminophen

(Hycet) 1 QL: 2025

in 30

days

solution: 10-300/15

hydrocodone bit/

acetaminophen

(Hycet) 1 QL: 2700

in 30

days

solution: 5-163/7.5

hydrocodone bit/

acetaminophen

(Hycet) 1 QL: 2700

in 30

days

solution: 7.5-325/

15, 7.5-500/15

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 150

in 30

days

tablet: 7.5-750mg,

10-750mg

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 180

in 30

days

tablet: 7.5-650mg,

10-660mg, 10mg-

650mg

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 240

in 30

days

capsule, tablet: 2.5-

500mg, 5mg-

500mg, 7.5-500mg,

10mg-500mg

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 360

in 30

days

tablet: 2.5-325mg

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 360

in 30

days

tablet: 5mg-325mg,

7.5-325mg, 10mg-

325mg

hydrocodone bit/

acetaminophen

(Vicodin) 1 QL: 390

in 30

days

tablet: 5mg-300mg,

7.5-300mg, 10mg-

300mg

hydrocodone/ibuprofen (Vicoprofen) 1 QL: 150

in 30

days

hydromorphone hcl (Dilaudid) 1 QL: 180

in 30

days

tablet: 2mg, 4mg

hydromorphone hcl (Dilaudid) 1 QL: 240

in 30

days

tablet: 8mg

hydromorphone hcl (Dilaudid) 2 vial

7

Drug Name Drug


hydromorphone hcl (Dilaudid-5) 1 QL: 1200

in 30

days

liquid

hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 ampul, disp syrin

hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 vial

ibuprofen/oxycodone hcl (Combunox) 1 QL: 28 in

30 days

KADIAN 3 ST, QL:

60 in 30

days

cap er pel: 10mg

KADIAN 5 ST, QL:

120 in 30

days

cap er pel: 200mg

levorphanol tartrate (Levo-dromoran) 2 QL: 180

in 30

days

methadone hcl (Methadone HCl) 1 vial

methadone hcl (Methadone HCl) 1 QL: 1800

in 30

days

oral conc, solution

methadone hcl (Methadose) 1 QL: 360

in 30

days

tablet

methadone hcl (Methadose) 1 QL: 90 in

30 days

tablet sol

morphine sulfate in 0.9 %

nacl

(Morphine Sulfate In 0.9 %

NaCl)

1

morphine sulfate (Kadian) 2 ST, QL:

60 in 30

days

cap er pel: 20mg,

30mg, 50mg, 60mg,

80mg

morphine sulfate (Kadian) 5 ST, QL:

60 in 30

days

cap er pel: 100mg

morphine sulfate (Morphine Sulfate) 1 disp syrin, pen

injctr, supp.rect, vial

morphine sulfate (MS Contin) 1 QL: 120

in 30

days

tablet er: 30mg,

60mg, 100mg

morphine sulfate (MS Contin) 1 QL: 180

in 30

days

tablet, tablet er:

15mg, 200mg

8

Drug Name Drug


morphine sulfate (MSIR) 1 QL: 200

in 30

days

solution: 100mg/

5ml


in 30

days

solution: 20mg/5ml


in 30

days

solution: 10mg/5ml

morphine sulfate/d5w (Morphine Sulfate/D5W) 1

morphine sulfate/pf (Morphine Sulfate/PF) 1 pca vial, vial: 25mg/

ml

morphine sulfate/pf (Morphine Sulfate/PF) 1 vial: 0.5mg/ml,

1mg/ml

NUCYNTA ER 3 QL: 60 in

30 days

NUCYNTA 3 QL: 181

in 30

days

oxycodone hcl (Oxycodone HCl) 1 QL: 120

in 30

days

tab er 12h: 80mg

oxycodone hcl (Oxycodone HCl) 1 QL: 1300

in 30

days

solution

oxycodone hcl (Oxycodone HCl) 1 QL: 60 in

30 days

tab er 12h: 10mg,

20mg, 40mg

oxycodone hcl (Roxicodone) 1 QL: 180

in 30

days

capsule, oral conc,

tablet: 5mg, 15mg,

30mg

oxycodone hcl (Roxicodone) 1 QL: 180

in 30

days

tablet: 10mg, 20mg

oxycodone hcl/

acetaminophen

(Oxycodone HCl/

acetaminophen)

1 QL: 1800

in 30

days

solution

oxycodone hcl/

acetaminophen

(Percocet) 1 QL: 180

in 30

days

tablet: 10mg-650mg

oxycodone hcl/

acetaminophen


in 30

days

capsule, tablet:

5mg-500mg, 7.5-

500mg

9

Drug Name Drug


oxycodone hcl/

acetaminophen


in 30

days

tablet: 2.5-325mg,

5mg-325mg, 7.5-

325mg, 10mg-

325mg

oxycodone hcl/aspirin (Percodan) 1 QL: 360

in 30

days

oxycodone hcl/oxycodon

ter/asa

(Oxycodone HCl/oxycodon Ter/

asa)

1 QL: 360

in 30

days

OXYCONTIN 3 QL: 120

in 30

days

tab er 12h: 80mg

OXYCONTIN 3 QL: 60 in

30 days

tab er 12h: 10mg,

15mg, 20mg, 30mg,

40mg, 60mg

oxymorphone hcl (Opana ER) 2 QL: 60 in

30 days

tab er 12h

oxymorphone hcl (Opana) 2 QL: 180

in 30

days

tablet

tramadol hcl (Ultram ER) 1 QL: 30 in

30 days

tab er 24h: 200mg,

300mg

tramadol hcl (Ultram ER) 1 QL: 90 in

30 days

tab er 24h: 100mg

tramadol hcl (Ultram) 1 QL: 240

in 30

days

tablet

tramadol hcl/

acetaminophen

(Ultracet) 1 QL: 240

in 30

days

10

Drug Name Drug


Opiate Partial Agonists

buprenorphine hcl (Buprenorphine HCl) 2 disp syrin

buprenorphine hcl (Subutex) 2 PA, QL:

20 in 30

days

tab subl: 2mg

buprenorphine hcl (Subutex) 2 PA, QL:

5 in 30

days

tab subl: 8mg

butorphanol tartrate (Butorphanol Tartrate) 2 disp syrin

butorphanol tartrate (Butorphanol Tartrate) 2 QL: 5 in

28 days

spray

nalbuphine hcl (Nalbuphine HCl) 1

SUBOXONE 4 PA, QL:

90 in 30

days

Androgens Androgens

ANADROL-50 5

ANDRODERM 4 QL: 30 in

30 days

patch td24: 2mg/

24hr, 4mg/24hr

ANDROGEL 3 QL: 150

in 30

days

gel md pmp

ANDROGEL 3 QL: 300

in 30

days

gel packet

AXIRON 3 QL: 180

in 28

days

danazol (Danocrine) 2

fluoxymesterone (Fluoxymesterone) 2

oxandrolone (Oxandrin) 2

TESTIM 4 PA, QL:

300 in 30

days

testosterone cypionate (Depo-testosterone) 1 PA

testosterone enanthate (Delatestryl) 1 PA, QL:

5 in 28

days

11

Drug Name Drug


Anorexigenics, Respiratory, Cerebral Stimulants Amphetamines

amphet asp/amphet/d-

amphet

(Adderall XR) 2 PA, QL:

30 in 30

days

cap er 24h, (PA for

Ages 65 and Older;

May be High Risk

Med)

amphet asp/amphet/d-

amphet

(Adderall) 1 PA, QL:

60 in 30

days

tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

dextroamphetamine

sulfate

(Dexedrine) 2 PA, QL:

120 in 30

days

capsule er, (PA for

Ages 65 and Older;

May be High Risk

Med)

dextroamphetamine

sulfate

(Dextrostat) 1 PA, QL:

180 in 30

days

tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

methamphetamine hcl (Desoxyn) 1 QL: 150

in 30

days

(May be High Risk

Med for Ages 65

and Older)

VYVANSE 4 PA, QL:

30 in 30

days

(PA for Ages 65 and

Older; May be High

Risk Med)

Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous

caffeine citrated (Cafcit) 1

caffeine/sodium benzoate (Caffeine/sodium Benzoate) 1

dexmethylphenidate hcl (Focalin) 1 PA, QL:

60 in 30

days

(PA for Ages 65 and

Older; May be High

Risk Med)

FOCALIN XR 4 PA, QL:

30 in 30

days

(PA for Ages 65 and

Older; May be High

Risk Med)

METADATE CD 4 PA, QL:

30 in 30

days

(PA for Ages 65 and

Older; May be High

Risk Med)

METHYLIN 4 PA, QL:

180 in 30

days

tab chew: 10mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

12

Drug Name Drug


METHYLIN 4 PA, QL:

90 in 30

days

tab chew: 2.5mg,

5mg, (PA for Ages

65 and Older; May

be High Risk Med)

methylphenidate hcl (Concerta) 2 PA, QL:

31 in 31

days

tab er 24, (PA for

Ages 65 and Older;

May be High Risk

Med)

methylphenidate hcl (Methylin) 1 PA, QL:

900 in 30

days

solution, (PA for

Ages 65 and Older;

May be High Risk

Med)

methylphenidate hcl (Ritalin LA) 2 PA, QL:

30 in 30

days

cpmp 50-50: 20mg,

40mg, (PA for

Ages 65 and Older;

May be High Risk

Med)

methylphenidate hcl (Ritalin LA) 2 PA, QL:

60 in 30

days

cpmp 50-50: 30mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

methylphenidate hcl (Ritalin) 1 PA, QL:

90 in 30

days

tablet er: 10mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

methylphenidate hcl (Ritalin) 1 PA, QL:

90 in 30

days

tablet, tablet er:

20mg, (PA for

Ages 65 and Older;

May be High Risk

Med)

NUVIGIL 4 PA, QL:

30 in 30

days

tablet: 150mg,

250mg

NUVIGIL 4 PA, QL:

90 in 30

days

tablet: 50mg

RITALIN LA 4 PA, QL:

30 in 30

days

cpmp 50-50: 10mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

13

Drug Name Drug


Anthelmintics Anthelmintics

ALBENZA 3

BILTRICIDE 4

mebendazole (Mebendazole) 1

STROMECTOL 3

Antiallergic Agents Antiallergic Agents

ALOMIDE 4

ASTEPRO 3 QL: 30 in

25 days

azelastine hcl (Astelin) 1 QL: 30 in

25 days

spray/pump

azelastine hcl (Optivar) 2 drops

BEPREVE 4 ST

epinastine hcl (Elestat) 2

PATADAY 3 ST

PATANASE 4 QL: 30.5

in 30

days

PATANOL 3 ST

Antibacterials Aminoglycosides

amikacin sulfate (Amikacin Sulfate) 1

gentamicin in nacl, iso-

osm

(Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/

100ml, 100mg/50ml

gentamicin in nacl, iso-

osm

(Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/

50ml, 70mg/50ml,

80mg/100ml, 80mg/

50ml, 90mg/100ml,

100mg/0.1l

gentamicin sulfate (Garamycin) 1

gentamicin sulfate/pf (Gentamicin Sulfate/PF) 1

kanamycin sulfate (Kanamycin Sulfate) 1 vial: 1g/3ml

kanamycin sulfate (Kanamycin Sulfate) 1 vial: 500mg/2ml

NEBCIN IN DEXTROSE 4

NEBCIN 4 vial: 80mg

neomycin sulfate (Neomycin Sulfate) 1 solution

neomycin sulfate (Neomycin Sulfate) 1 tablet

streptomycin sulfate (Streptomycin Sulfate) 2

TOBI 5 PA (PA for Part B vs

Part D Only)

14

Drug Name Drug


tobramycin sulfate (Nebcin) 1 vial port

tobramycin sulfate (Nebcin) 2 vial

tobramycin/sodium

chloride

(Tobramycin/sodium Chloride) 1

Antibacterials, Miscellaneous

bacitracin (Bacitracin) 2

chloramphenicol na succ (Chloramphenicol Na Succ) 1

clindamycin hcl (Cleocin HCl) 1 capsule: 150mg,

300mg

clindamycin hcl (Cleocin HCl) 1 capsule: 75mg

clindamycin palmitate hcl (Cleocin Palmitate) 2

clindamycin phosphate (Cleocin Phosphate) 1

colistin (colistimethate na) (Coly-mycin M Parenteral) 2

CUBICIN 5 PA (PA for ESRD

Only)

polymyxin b sulfate (Polymyxin B Sulfate) 1

SYNERCID 5

vancomycin hcl (Vancocin HCl) 5 capsule

vancomycin hcl (Vancomycin HCl) 2 PA vial, (PA for ESRD

Only)

vancomycin hcl/d5w (Vancomycin HCl/D5W) 2

VANCOMYCIN HCL 4

XIFAXAN 3 PA, QL:

60 in 30

days

tablet: 550mg

XIFAXAN 3 PA, QL:

9 in 30

days

tablet: 200mg

ZYVOX 5

Cephalosporins

CEDAX 4 capsule

CEDAX 4 susp recon

cefaclor (Ceclor) 1 susp recon

cefaclor (Ceclor) 2 capsule, tab er 12h

cefadroxil hydrate (Cefadroxil Hydrate) 1

cefazolin sodium (Ancef) 2

cefazolin sodium/

dextrose,iso

(Cefazolin Sodium/dextrose, Iso) 2 froz.piggy

cefazolin sodium/

dextrose,iso

(Cefazolin Sodium/dextrose, Iso) 2 piggyback

cefdinir (Omnicef) 2

cefditoren pivoxil (Spectracef) 2

cefepime hcl (Maxipime) 2

15

Drug Name Drug


CEFEPIME 3

CEFEPIME-DEXTROSE 3

cefotaxime sodium (Claforan) 1 vial: 1g, 2g, 10g

cefotaxime sodium (Claforan) 1 vial: 500mg

cefpodoxime proxetil (Cefpodoxime Proxetil) 1 susp recon: 50mg/

5ml

cefpodoxime proxetil (Vantin) 2 susp recon: 100mg/

5ml; tablet

cefprozil (Cefzil) 2

ceftazidime pentahydrate (Fortaz) 2 vial: 1g; vial port

ceftazidime pentahydrate (Fortaz) 2 vial: 2g, 6g, 500mg

CEFTAZIDIME 2

ceftriaxone na/

dextrose,iso

(Ceftriaxone Na/dextrose, Iso) 2

ceftriaxone sodium (Rocephin) 2

cefuroxime axetil (Ceftin) 1 tablet

cefuroxime axetil (Cefuroxime Axetil) 1 susp recon

cefuroxime sodium (Zinacef) 1 vial: 7.5g

cefuroxime sodium (Zinacef) 2 vial: 1.5g, 750mg

cefuroxime sodium/

dextrose,iso

(Cefuroxime Sodium/dextrose,

Iso)

1

cephalexin (Keflex) 1

SUPRAX 4

TAZICEF IN

DEXTROSE

3

Macrolides

azithromycin hydrogen

citrate

(Azithromycin Hydrogen

Citrate)

1

azithromycin (Zithromax) 1 packet

azithromycin (Zithromax) 1 susp recon, tablet,

vial

clarithromycin (Biaxin XL) 2 susp recon, tab er

24h

clarithromycin (Biaxin) 1 tablet

DIFICID 5 QL: 20 in

10 days

ery e-succ/sulfisoxazole (Pediazole) 1

ERY-TAB 1

ERYTHROCIN

LACTOBIONATE

3 vial port: 1g

ERYTHROCIN

LACTOBIONATE

3 vial port: 500mg

erythromycin base (Eryc) 1 capsule dr

16

Drug Name Drug


erythromycin base (Erythromycin Base) 1 tablet, tablet dr

erythromycin

ethylsuccinate

(Erythromycin Ethylsuccinate) 1 oral susp: 200mg/

5ml

erythromycin

ethylsuccinate

(Erythromycin Ethylsuccinate) 1 tablet

erythromycin stearate (Erythromycin Stearate) 1 tablet: 250mg

erythromycin stearate (Erythromycin Stearate) 1 tablet: 500mg

KETEK 4 ST

Miscellaneous B-lactam Antibiotics

AZACTAM-ISO-

OSMOTIC DEXTROSE

4

aztreonam (Azactam) 2

CAYSTON 5 LA

cefotetan disod/

dextrose,iso

(Cefotetan Disod/dextrose, Iso) 2

cefotetan disodium (Cefotetan Disodium) 2

cefoxitin sodium (Mefoxin) 1 vial: 10g

cefoxitin sodium (Mefoxin) 2 vial: 1g, 2g

cefoxitin sodium/

dextrose,iso

(Cefoxitin Sodium/dextrose, Iso) 1

imipenem/cilastatin

sodium

(Primaxin) 2

INVANZ 4 vial

INVANZ 4 vial port

meropenem (Merrem) 2

Penicillins

amoxicillin (Amoxil) 1 capsule, susp recon,

tab chew: 125mg,

250mg; tablet

amoxicillin (Amoxil) 1 tab chew: 200mg,

400mg

amoxicillin/potassium clav (Augmentin) 1

ampicillin sodium (Totacillin-N) 1 vial: 125mg

ampicillin sodium (Totacillin-N) 2 vial port

ampicillin sodium (Totacillin-N) 2 vial: 2g, 10g

ampicillin sodium/

sulbactam na

(Unasyn) 1 vial: 15g

ampicillin sodium/

sulbactam na

(Unasyn) 2 vial port

ampicillin sodium/

sulbactam na

(Unasyn) 2 vial: 3g

ampicillin trihydrate (Ampicillin Trihydrate) 1

BACTOCILL 4

17

Drug Name Drug


BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium (Dicloxacillin Sodium) 1

nafcillin sodium (Unipen) 2 vial

nafcillin sodium (Unipen) 2 vial port

nafcillin sodium/d2.4w (Nafcillin Sodium/d2.4w) 2

oxacillin sodium (Oxacillin Sodium) 2

oxacillin sodium/

dextrose,iso

(Oxacillin Sodium/dextrose, Iso) 2

pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 froz.piggy: 1mm/

50ml

pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 froz.piggy: 2mm/

50ml, 3mm/50ml

penicillin g potassium (Penicillin G Potassium) 2

penicillin g potassium/d5w (Penicillin G Potassium/D5W) 2

penicillin g procaine (Penicillin G Procaine) 2 disp syrin: 1.2mm/

2ml

penicillin g procaine (Penicillin G Procaine) 2 disp syrin: 600000/

ml

penicillin v potassium (Veetids 500) 1

piperacillin sodium (Piperacillin Sodium) 2

piperacillin sodium/

tazobactam

(Zosyn) 2

PIPRACIL IN

DEXTROSE

4

TIMENTIN 4

ZOSYN 4 froz.piggy

18

Drug Name Drug


Quinolones

AVELOX ABC PACK 3

AVELOX IV 3

AVELOX 3

ciprofloxacin hcl (Cipro) 1

ciprofloxacin lactate (Cipro I.V.) 1

ciprofloxacin lactate/d5w (Cipro I.V.) 1

ciprofloxacin/ciprofloxa

hcl

(Cipro XR) 2

FACTIVE 4

levofloxacin (Levaquin) 1 vial

levofloxacin (Levaquin) 2 solution, tablet

levofloxacin/d5w (Levaquin) 1

nalidixic acid (Nalidixic Acid) 1

NOROXIN 4

ofloxacin (Floxin) 2

Sulfonamides (Systemic)

sulfadiazine (Sulfadiazine) 2

sulfamethoxazole/

trimethoprim

(Septra) 1

sulfasalazine (Azulfidine) 1

Tetracyclines

demeclocycline hcl (Declomycin) 2

doxycycline hyclate (Doryx) 2 tablet dr, vial

doxycycline hyclate (Vibramycin) 1 capsule

doxycycline hyclate (Vibramycin) 2 capsule dr

doxycycline hyclate (Vibra-tabs) 1 tablet

doxycycline monohydrate (Adoxa) 1 tablet: 50mg,

100mg

doxycycline monohydrate (Adoxa) 2 capsule: 75mg;

tablet: 75mg,

150mg

doxycycline monohydrate (Monodox) 2 capsule: 150mg

MINOCIN 5 vial

minocycline hcl (Dynacin) 1 capsule

minocycline hcl (Dynacin) 2 tab er 24h, tablet

tetracycline hcl (Ala-tet) 1 capsule

tetracycline hcl (Tetracycline HCl) 1 oral susp

TYGACIL 5

19

Drug Name Drug


Anticholinergic Agents Antimuscarinics/Antispasmodics

atropine sulfate (Atropine Sulfate) 1 ampul, vial

atropine sulfate (Atropine Sulfate) 1 disp syrin

ATROVENT HFA 3 QL: 25.8

in 28

days

dicyclomine hcl (Bentyl) 1 PA capsule, syrup,

tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

glycopyrrolate (Robinul) 1 vial

glycopyrrolate (Robinul) 2 tablet

isopropamide/

prochlorperazine

(Isopropamide/prochlorperazine) 1

methscopolamine bromide (Pamine) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

SPIRIVA 3 QL: 30 in

30 days

Anticonvulsants Anticonvulsants, Miscellaneous

BANZEL 4

carbamazepine (Carbatrol) 2 cpmp 12hr, oral

susp

carbamazepine (Tegretol XR) 2 tab er 12h

carbamazepine (Tegretol) 1 tab chew, tablet

divalproex sodium (Depakote ER) 2 cap sprink, tab er

24h

divalproex sodium (Depakote) 1 tablet dr

felbamate (Felbatol) 2

gabapentin (Neurontin) 1 capsule

gabapentin (Neurontin) 2 solution, tablet

GABITRIL 3

LAMICTAL (BLUE) 4

LAMICTAL (ORANGE) 4

LAMICTAL ODT

(BLUE)

4

LAMICTAL ODT

(GREEN)

4

LAMICTAL ODT

(ORANGE)

4

20

Drug Name Drug


LAMICTAL ODT 4

LAMICTAL XR (BLUE) 4

LAMICTAL XR

(GREEN)

4

LAMICTAL XR

(ORANGE)

4

LAMICTAL XR 4 tab er 24: 25mg,

50mg, 100mg,

200mg, 250mg

LAMICTAL XR 4 tab er 24: 300mg

lamotrigine (Lamictal (green)) 2 tab ds pk

lamotrigine (Lamictal) 1 tablet, tb chw dsp

levetiracetam (Keppra) 1 vial

levetiracetam (Keppra) 2 solution, tab er 24h,

tablet

LYRICA 3 QL: 93 in

31 days

magnesium chloride (Magnesium Chloride) 1

magnesium sulfate (Magnesium Sulfate) 1 disp syrin

magnesium sulfate (Magnesium Sulfate) 1 infus. btl,

piggyback, vial

magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1

oxcarbazepine (Trileptal) 1 tablet

oxcarbazepine (Trileptal) 2 oral susp

POTIGA 4 QL: 270

in 30

days

tablet: 50mg

POTIGA 4 QL: 90 in

30 days

tablet: 200mg,

300mg, 400mg

SABRIL 5

TEGRETOL XR 3 tab er 12h: 100mg

topiramate (Topamax) 1 tablet

topiramate (Topamax) 2 cap sprink

TRILEPTAL 4 oral susp

valproate sodium (Depakene) 1

valproic acid (Depakene) 1

VIMPAT 4 QL: 1200

in 30

days

solution

VIMPAT 4 QL: 200

in 5 days

vial

VIMPAT 4 QL: 60 in

30 days

tablet

21

Drug Name Drug


zonisamide (Zonegran) 1

Hydantoins

DILANTIN 3 capsule: 30mg

DILANTIN 3 tab chew

fosphenytoin sodium (Cerebyx) 1

PEGANONE 3

PHENYTEK 3

phenytoin sodium

extended

(Dilantin) 1

phenytoin sodium (Phenytoin Sodium) 1 ampul

phenytoin sodium (Phenytoin Sodium) 1 disp syrin

phenytoin (Dilantin-125) 1

Succinimides

CELONTIN 3

ethosuximide (Zarontin) 1 syrup

ethosuximide (Zarontin) 2 capsule

Antidiabetic Agents Antidiabetic Agents, Miscellaneous

acarbose (Precose) 2 QL: 90 in

30 days

BYDUREON 3 ST, QL:

4 in 28

days

BYETTA 3 ST, QL:

1.2 in 28

days

pen injctr: 5mcg/

0.02

BYETTA 3 ST, QL:

2.4 in 28

days

pen injctr: 10mcg/

0.04

GLYSET 4 QL: 90 in

30 days

JANUMET XR 3 QL: 30 in

30 days

tbmp 24hr: 50mg-

500mg, 100-

1000mg

JANUMET XR 3 QL: 60 in

30 days

tbmp 24hr: 50-

1000mg

JANUMET 3 QL: 60 in

30 days

JANUVIA 3 QL: 30 in

30 days

JENTADUETO 3 QL: 60 in

30 days

22

Drug Name Drug


JUVISYNC 3 QL: 30 in

30 days

KORLYM 5 PA, QL:

112 in 28

days

metformin hcl (Fortamet) 1 QL: 60 in

30 days

tab er 24

metformin hcl (Glucophage) 1 QL: 120

in 30

days

tab er 24h: 500mg;

tablet: 500mg

metformin hcl (Glucophage) 1 QL: 60 in

30 days

tablet: 1000mg

metformin hcl (Glucophage) 1 QL: 90 in

30 days

tab er 24h: 750mg;

tablet: 850mg

nateglinide (Starlix) 2 QL: 90 in

30 days

PRANDIMET 3 QL: 150

in 30

days

PRANDIN 3 QL: 240

in 30

days

SYMLIN 4 QL: 20 in

28 days

SYMLINPEN 120 4 QL: 16.2

in 28

days

SYMLINPEN 60 4 QL: 9 in

28 days

TRADJENTA 3 QL: 30 in

30 days

VICTOZA 3-PAK 4 PA, QL:

9 in 28

days

Insulins

HUMALOG MIX 50-50 3 QL: 30 in

28 days

insuln pen


28 days

vial


28 days

insuln pen


28 days

vial

23

Drug Name Drug


HUMALOG 3 QL: 30 in

28 days

insuln pen

HUMALOG 3 QL: 40 in

28 days

vial

HUMULIN 70-30 3 QL: 30 in

28 days

insuln pen

HUMULIN 70-30 3 QL: 40 in

28 days

vial

HUMULIN N 3 QL: 30 in

28 days

insuln pen

HUMULIN N 3 QL: 40 in

28 days

vial

HUMULIN R 3 QL: 40 in

28 days

LANTUS SOLOSTAR 3 QL: 30 in

28 days

LANTUS 3 QL: 40 in

28 days

LEVEMIR 3 ST, QL:

30 in 28

days

insuln pen

LEVEMIR 3 ST, QL:

40 in 28

days

vial

NOVOLIN 70-30

INNOLET

3 QL: 30 in

28 days

NOVOLIN 70-30 3 QL: 40 in

28 days

NOVOLIN N INNOLET 3 QL: 30 in

28 days

NOVOLIN N 3 QL: 40 in

28 days

NOVOLIN R 3 QL: 30 in

28 days

insuln pen

NOVOLIN R 3 QL: 40 in

28 days

vial

NOVOLOG MIX 70-30 3 QL: 30 in

28 days

insuln pen

NOVOLOG MIX 70-30 3 QL: 40 in

28 days

vial

NOVOLOG 3 QL: 30 in

28 days

insuln pen

24

Drug Name Drug


NOVOLOG 3 QL: 40 in

28 days

vial

Sulfonylureas

glimepiride (Amaryl) 1 QL: 30 in

30 days

tablet: 1mg, 2mg

glimepiride (Amaryl) 1 QL: 60 in

30 days

tablet: 4mg

glipizide (Glucotrol XL) 1 QL: 30 in

30 days

tab er 24: 2.5mg,

5mg

glipizide (Glucotrol) 1 QL: 120

in 30

days

tablet: 10mg

glipizide (Glucotrol) 1 QL: 60 in

30 days

tab er 24: 10mg;

tablet: 5mg

glipizide/metformin hcl (Metaglip) 2 QL: 120

in 30

days

tablet: 2.5-500mg,

5mg-500mg

glipizide/metformin hcl (Metaglip) 2 QL: 60 in

30 days

tablet: 2.5-250mg

glyburide (Micronase) 1 PA, QL:

120 in 30

days

tablet: 5mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

glyburide (Micronase) 1 PA, QL:

30 in 30

days

tablet: 1.25mg,

2.5mg, (PA for

Ages 65 and Older;

May be High Risk

Med)

glyburide,micronized (Glynase) 1 PA, QL:

30 in 30

days

tablet: 1.5mg, 3mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

glyburide,micronized (Glynase) 1 PA, QL:

60 in 30

days

tablet: 6mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

glyburide/metformin hcl (Glucovance) 1 PA, QL:

120 in 30

days

tablet: 2.5-500mg,

5mg-500mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

25

Drug Name Drug


glyburide/metformin hcl (Glucovance) 1 PA, QL:

60 in 30

days

tablet: 1.25-250mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

tolazamide (Tolazamide) 1 QL: 120

in 30

days

tablet: 250mg

tolazamide (Tolazamide) 1 QL: 60 in

30 days

tablet: 500mg

tolbutamide (Tolbutamide) 1 QL: 180

in 30

days

Thiazolidinediones

ACTOPLUS MET XR 3 QL: 60 in

30 days

ACTOPLUS MET 3 QL: 90 in

30 days

ACTOS 4 QL: 30 in

30 days

AVANDAMET 3 PA, QL:

60 in 30

days

AVANDARYL 3 PA, QL:

30 in 30

days

AVANDIA 3 PA, QL:

30 in 30

days

DUETACT 3 QL: 30 in

30 days

Antidiarrhea Agents Antidiarrhea Agents

diphenoxylate hcl/atropine (Lomotil) 1 (May be High Risk

Med for Ages 65

and Older)

loperamide hcl (Loperamide HCl) 1

paregoric (Paregoric) 2

Antiemetics 5-ht3 Receptor Antagonists

ALOXI 4

granisetron hcl (Kytril) 2 vial

26

Drug Name Drug


granisetron hcl (Kytril) 2 PA solution, tablet,

(PA for Part B vs

Part D Only)

granisetron hcl/pf (Kytril) 1

ondansetron hcl (Zofran) 1 vial

ondansetron hcl (Zofran) 1 PA tablet, (PA for Part

B vs Part D Only)

ondansetron hcl (Zofran) 2 PA solution, (PA for

Part B vs Part D

Only)

ondansetron (Zofran Odt) 1 PA (PA for Part B vs

Part D Only)

Antiemetics, Miscellaneous

CESAMET 4

dronabinol (Marinol) 2

EMEND 3 PA, QL:

1 per fill

capsule: 40mg,

125mg, (PA for

Part B vs Part D

Only)

EMEND 3 PA, QL:

2 per fill

capsule: 80mg, (PA


Only)

EMEND 3 PA, QL:

3 per fill

cap ds pk, (PA for

Part B vs Part D

Only)

EMEND 3 QL: 2 in

28 days

vial

Antihistamines (GI Drugs)

dimenhydrinate (Dimenhydrinate) 1

meclizine hcl (Antivert) 1

prochlorperazine edisylate (Compazine) 1

prochlorperazine maleate (Compazine) 1

Antifungal (Systemic) Antifungals, Miscellaneous

ABELCET 5 PA (PA for Part B vs

Part D Only)

amphotericin b (Amphotericin B) 2 PA (PA for Part B vs

Part D Only)

flucytosine (Ancobon) 5

griseofulvin,microsize (Grifulvin V) 1

GRIS-PEG 4

nystatin (Mycostatin) 1 powder(ea), tablet

nystatin (Nystatin) 1 powder

27

Drug Name Drug


terbinafine hcl (Lamisil) 1

triacetin (Triacetin) 1

Azoles

fluconazole in nacl,iso-

osm

(Fluconazole In Nacl,iso-osm) 1

fluconazole (Diflucan) 1

itraconazole (Sporanox) 2

ketoconazole (Nizoral) 1

NOXAFIL 5

SPORANOX 3 solution

VFEND IV 4

VFEND 5 susp recon

voriconazole (Vfend) 5 tablet

Echinocandins

CANCIDAS 5

ERAXIS (WATER

DILUENT)

5

Antiglaucoma Agents Antiglaucoma Agents

acetazolamide sodium (Acetazolamide Sodium) 1

acetazolamide (Acetazolamide) 1 tablet

acetazolamide (Diamox Sequels) 2 capsule er

ALPHAGAN P 3 drops: 0.1%

AZOPT 3

betaxolol hcl (Betaxolol HCl) 1

BETIMOL 4

BETOPTIC S 4

brimonidine tartrate (Alphagan P) 1

brimonidine tartrate (Alphagan P) 1 (Drops 0.15%)

COMBIGAN 3

dorzolamide hcl (Trusopt) 1

dorzolamide hcl/timolol

maleat

(Cosopt) 1

ISOPTO CARPINE 3 drops: 8%

ISTALOL 4

latanoprost (Xalatan) 1

levobunolol hcl (Betagan) 1 drops: 0.25%

levobunolol hcl (Betagan) 1 drops: 0.5%

LUMIGAN 3 QL: 2.5

in 25

days

methazolamide (Neptazane) 1

28

Drug Name Drug


metipranolol (Optipranolol) 1

PHOSPHOLINE IODIDE 4

pilocarpine hcl (Isopto Carpine) 1

PILOPINE HS 4

timolol maleate (Timoptic) 1

TRAVATAN Z 3 QL: 2.5

in 25

days

Antihistamines Antihistamines

carbinoxamine maleate (Palgic) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

clemastine fumarate (Clemastine Fumarate) 1 PA syrup, tablet:

2.68mg, (PA for

Ages 65 and Older;

May be High Risk

Med)

clemastine fumarate (Clemastine Fumarate) 1 PA tablet: 1.34mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

diphenhydramine hcl (Benadryl) 1 vial

diphenhydramine hcl (Diphenhydramine HCl) 1 disp syrin

levocetirizine

dihydrochloride

(Xyzal) 2

p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1

phenyleph/acetaminop/p-

tlox/cp

(Phenyleph/acetaminop/p-tlox/

cp)

1

phenylephrine/chlor-tan (Rynatan) 1

promethazine hcl (Promethazine HCl) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

tripelennamine hcl (Tripelennamine HCl) 1

Anti-infectives (EENT) Anti-infectives (EENT)

acetic acid (Vosol) 1

acetic acid/aluminum

acetate

(Domeboro) 1

acetic acid/hydrocortisone (Vosol HC) 2

AZASITE 4

bacitracin (Bacitracin) 1

29

Drug Name Drug


bacitracin/polymyxin b

sulfate

(Polycin-b) 1

BACTROBAN NASAL 4

BESIVANCE 4 ST

BLEPHAMIDE S.O.P. 3

BLEPHAMIDE 4

CETRAXAL 4

chlorhexidine gluconate (Peridex) 1

CILOXAN 4 oint. (g)

CIPRO HC 3

CIPRODEX 3

ciprofloxacin hcl (Ciloxan) 1

COLY-MYCIN S 4

CORTISPORIN-TC 4

cresyl ace/ben alc/

butanol/ipa

(Cresyl Ace/ben Alc/butanol/ipa) 1

doxycycline hyclate (Periostat) 1

erythromycin base (Romycin) 1

gentamicin sulfate (Garamycin) 1

levofloxacin (Quixin) 1

MOXEZA 3

NATACYN 3

neo/polymyx b sulf/

dexameth

(Maxitrol) 1

neomy sulf/bacitra/

polymyxin b

(Neomy Sulf/bacitra/polymyxin

B)

1 packet

neomy sulf/bacitra/

polymyxin b

(Neo-polycin) 1 oint. (g)

neomy sulf/bacitrac zn/

poly/hc

(Triple Antibiotic HC) 1

neomycin sulfate/dex na

ph

(Neomycin Sulfate/dex Na Ph) 1

neomycin/polymyxin b

sulf/hc

(Oticin HC) 1

neomycin/polymyxn b/

gramicidin

(Neosporin) 1

ofloxacin (Floxin) 1

polymyxin b sulfate/tmp (Polytrim) 1

sulfacetamide sodium (Sulfac) 1

sulfacetamide/

prednisolone sp

(Sulfacetamide/prednisolone Sp) 1

TOBRADEX 4 oint. (g)

30

Drug Name Drug


tobramycin sulf/

dexamethasone

(Tobradex) 1

tobramycin sulfate (Tobrex) 1

trifluridine (Viroptic) 2

VIGAMOX 3

ZIRGAN 4

ZYLET 3

ZYMAR 3

ZYMAXID 3

Anti-infectives (Skin and Mucous Membrane) Antibacterials (Skin and Mucous Membrane)

ALTABAX 4

clindamycin phos/benzoyl

perox

(Benzaclin) 2 gel (gram)


perox

(Duac) 2 gel er (g)

clindamycin phosphate (Cleocin T) 1

erythromycin base/ethanol (Emgel) 1

erythromycin/benzoyl

peroxide

(Benzamycin) 1

gentamicin sulfate (Gentamicin Sulfate) 1

metronidazole (Nydamax) 1 gel (gram), gel w/

appl

metronidazole (Vitazol) 2 cream (g), lotion

mupirocin (Centany) 1

neomy sulf/polymyxin b

sulfate

(Neosporin G.U. Irrigant) 1

Antifungals (Skin and Mucous Membrane)

ciclopirox olamine (Loprox) 1 suspension

ciclopirox olamine (Loprox) 2 cream (g)

ciclopirox (Penlac) 2

clotrimazole (Lotrimin) 1

clotrimazole/

betamethasone dip

(Lotrisone) 1

econazole nitrate (Spectazole) 1

EXELDERM 4

GYNAZOLE-1 3

ketoconazole (Extina) 2 foam

ketoconazole (Kuric) 1 cream (g), shampoo

LAMISIL 3

miconazole nitrate (Monistat 3) 1

31

Drug Name Drug


nystatin (Mycostatin) 1 cream (g), oint. (g),

powder

nystatin (Nystatin) 1 tablet

nystatin/triamcin (Mycogen II) 1

sod propionate/inosi/aa14/

urea

(Sod Propionate/inosi/aa14/urea) 1

sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 1

terconazole (Terazol 7) 1

XOLEGEL 4

Antivirals (Skin and Mucous Membrane)

DENAVIR 3

VEREGEN 4

ZOVIRAX 4

Local Anti-infectives, Miscellaneous

acetic ac/ricinoleic/

oxyquinol

(Acetic Ac/ricinoleic/oxyquinol) 1

alcohol antiseptic pads (Alcohol Antiseptic Pads) 1

AVC 3

selenium sulfide (Selenium Sulfide) 1 suspension

selenium sulfide (Selseb) 1 shampoo

silver nitrate (Silver Nitrate) 1

silver sulfadiazine (Silvadene) 1

sulfacetamide sodium (Klaron) 2

SULFAMYLON 4

Scabicides and Pediculicides

EURAX 3

lindane (Lindane) 2

malathion (Ovide) 1

permethrin (Elimite) 1

Anti-infectives (systemic), Miscellaneous Anti-infectives (systemic), Miscellaneous

FUROXONE 3

Anti-inflammatory Agents (EENT) Anti-inflammatory Agents (EENT)

ALREX 3

BECONASE AQ 4 QL: 50 in

28 days

BROMDAY 3

bromfenac sodium (Bromfenac Sodium) 2

dexamethasone sod

phosphate

(Ak-dex) 1

diclofenac sodium (Voltaren) 1

32

Drug Name Drug


DUREZOL 3

flunisolide (Nasarel) 1 QL: 50 in

25 days

fluocinolone acetonide oil (Dermotic) 1

fluorometholone (Fluorometholone) 1

flurbiprofen sodium (Ocufen) 1

fluticasone propionate (Flonase) 1 QL: 16 in

30 days

ketorolac tromethamine (Acular LS) 1 drops: 0.5%

ketorolac tromethamine (Acular LS) 2 drops: 0.4%

LOTEMAX 3

NASONEX 3 QL: 34 in

28 days

NEVANAC 3

OMNARIS 4 QL: 13 in

30 days

prednisolone acetate (Pred Forte) 1

prednisolone sod

phosphate

(Prednisol) 1

QNASL 4 QL: 8.7

in 28

days

RESTASIS 4 PA, QL:

64 in 31

days

RHINOCORT AQUA 4 QL: 17.2

in 30

days

triamcinolone acetonide (Nasacort Aq) 2 QL: 16.5

in 30

days

VERAMYST 4 QL: 10 in

30 days

ZETONNA 4 QL: 6.1

in 30

days

Anti-inflammatory Agents (GI Drugs) Anti-inflammatory Agents (GI Drugs)

APRISO 3

ASACOL HD 4

ASACOL 4

balsalazide disodium (Colazal) 2

DIPENTUM 3

33

Drug Name Drug


LIALDA 4

mesalamine w/cleansing

wipes

(Rowasa) 2

PENTASA 4

Anti-inflammatory Agents (Respiratory) Anti-inflammatory Agents (Respiratory)

ALOCRIL 4

cromolyn sodium (Cromolyn Sodium) 1 drops

cromolyn sodium (Gastrocrom) 2 solution

cromolyn sodium (Intal) 1 PA ampul-neb, (PA for

Part B vs Part D

Only)

SINGULAIR 4

zafirlukast (Accolate) 1

Anti-inflammatory Agents (Skin and Mucous) Anti-inflammatory Agents (Skin and Mucous)

alclometasone

dipropionate

(Aclovate) 1

amcinonide (Amcinonide) 1

APEXICON E 4

betamet diprop/prop gly (Diprolene AF) 1

betamethasone

dipropionate

(Betamethasone Dipropionate) 1 gel (gram)

betamethasone

dipropionate

(Del-beta) 1 cream (g), lotion,

oint. (g)

betamethasone valerate (Betamethasone Valerate) 1

clobetasol propionate (Olux) 2 foam, lotion,

shampoo

clobetasol propionate (Temovate) 1 cream (g), gel

(gram), oint. (g),

solution

CLODERM 4

CORDRAN SP 4

CORDRAN 4 lotion, med. tape

CORDRAN 4 oint. (g)

desonide (Desowen) 1 cream (g), lotion,

oint. (g): 0.05%

desoximetasone (Topicort) 2 cream (g), gel

(gram), oint. (g):

0.25%

desoximetasone (Topicort) 2 oint. (g): 0.05%

diflorasone diacetate (Psorcon) 1

34

Drug Name Drug


fluocinolone acetonide (Fluocinolone Acetonide) 1

fluocinolone/shower cap (Derma-smoothe-fs) 1

fluocinonide (Fluocinonide) 1

fluticasone propionate (Cutivate) 1 cream (g), oint. (g)

fluticasone propionate (Cutivate) 2 lotion

halobetasol propionate (Ultravate) 1

hydrocortisone acetate (Hydrocortisone Acetate) 1

hydrocortisone acetate/

aloe v

(Nuzon) 1

hydrocortisone acetate/

urea

(Carmol HC) 1

hydrocortisone butyrate (Locoid) 1

hydrocortisone valerate (Hydrocortisone Valerate) 1

hydrocortisone (Cortenema) 2 enema

hydrocortisone (Proctocort) 1 cream (g),

cream(gm), lotion,

oint. (g)

KENALOG 4 aerosol

LOCOID 4 cream (g)

mometasone furoate (Elocon) 1

prednicarbate (Dermatop) 1

triamcinolone acetonide (Triamcinolone Acetonide) 1 cream (g), lotion,

oint. (g): 0.025%,

0.1%, 0.5%; paste

(g)

triamcinolone acetonide (Triderm) 1 cream, oint. (g):

0.05%

Antilipemic Agents Antilipemic Agents, Miscellaneous

LOVAZA 3

niacin (Niacin) 1 tablet: 500mg

NIASPAN 3

ZETIA 4

Bile Acid Sequestrants

cholestyramine (with

sugar)

(Questran) 2

cholestyramine/aspartame (Questran Light) 2

colestipol hcl (Colestid) 2

WELCHOL 3

Fibric Acid Derivatives

fenofibrate (Lofibra) 1

fenofibrate,micronized (Lofibra) 1

35

Drug Name Drug


fenofibric acid (Fibricor) 1

gemfibrozil (Lopid) 1

TRICOR 4

TRILIPIX 3

HMG-CoA Reductase Inhibitors

ADVICOR 4 ST

ALTOPREV 4

amlodipine/atorvastatin (Caduet) 2

atorvastatin calcium (Lipitor) 2

CRESTOR 4 ST

fluvastatin sodium (Lescol) 2

lovastatin (Mevacor) 1

pravastatin sodium (Pravachol) 1

SIMCOR 4 tbmp 24hr: 1000-

20mg

SIMCOR 4 tbmp 24hr: 500mg-

20mg, 500mg-

40mg, 750mg-

20mg, 1000-40mg

simvastatin (Zocor) 1 QL: 30 in

30 days

Antimigraine Agents Selective Serotonin Agonists

AXERT 4 QL: 12 in

28 days

FROVA 4 QL: 18 in

28 days

naratriptan hcl (Amerge) 2 QL: 9 in

28 days

sumatriptan succinate (Imitrex) 1 QL: 9 in

28 days

tablet


28 days

cartridge, vial


28 days

pen injctr

sumatriptan (Imitrex) 2 QL: 12 in

28 days

spray: 20mg

sumatriptan (Imitrex) 2 QL: 18 in

28 days

spray: 5mg

ZOMIG ZMT 4 QL: 9 in

28 days

ZOMIG 4 QL: 6 in

28 days

spray

36

Drug Name Drug


ZOMIG 4 QL: 9 in

28 days

tablet

Antimycobacterials Antimycobacterials

CAPASTAT SULFATE 3

dapsone (Dapsone) 1

ethambutol hcl (Myambutol) 2

isoniazid (Isoniazid) 1

MYCOBUTIN 4

PASER 3

PRIFTIN 4

pyrazinamide (Pyrazinamide) 1

rifampin (Rifadin) 2

rifampin/isoniazid (Rifamate) 1

SEROMYCIN 4

TRECATOR 3

Antineoplastic Agents Antineoplastic Agents

ABRAXANE 5

ADCETRIS 5

AFINITOR 5 PA, QL:

28 in 28

days

ALIMTA 5

anastrozole (Arimidex) 1

ARRANON 5

ARZERRA 5 PA, QL:

80 in 30

days

AVASTIN 5

BEXXAR 5

bicalutamide (Casodex) 2

BICNU 4

bleomycin sulfate (Bleomycin Sulfate) 1 PA

BUSULFEX 5

CAMPATH 5

CAPRELSA 5 PA, QL:

30 in 30

days

tablet: 300mg

CAPRELSA 5 PA, QL:

60 in 30

days

tablet: 100mg

37

Drug Name Drug


carboplatin (Paraplatin) 2

CEENU 3

cisplatin (Cisplatin) 1

cladribine (Leustatin) 2 PA (PA for Part B vs

Part D Only)

CLOLAR 5

cyclophosphamide (Cyclophosphamide) 2 PA, ST tablet, (PA for Part

B vs Part D Only)

cyclophosphamide (Cytoxan) 2 PA vial, (PA for Part B

vs Part D Only)

cytarabine/pf (Cytarabine/PF) 1 PA (PA for Part B vs

Part D Only)

dacarbazine (Dtic-Dome IV) 1

DACOGEN 5

dactinomycin (Cosmegen) 1

daunorubicin hcl (Cerubidine) 2

DAUNOXOME 4

DOCEFREZ 5

docetaxel (Taxotere) 5 vial: 20mg/2ml,

20mg/ml(1)

docetaxel (Taxotere) 5 vial: fnl20mg/2

doxorubicin hcl liposomal (Doxil) 5 PA (PA for Part B vs

Part D Only)

doxorubicin hcl (Adriamycin RDF) 2 PA vial: 50mg

DROXIA 3

ELIGARD 4 QL: 1 in

112 days

disp syrin: 30mg

ELIGARD 4 QL: 1 in

28 days

disp syrin: 7.5mg

ELIGARD 4 QL: 1 in

84 days

disp syrin: 22.5mg

ELIGARD 5 QL: 1 in

168 days

disp syrin: 45mg

ELSPAR 3

EMCYT 3

epirubicin hcl (Ellence) 1

ERBITUX 4

ERIVEDGE 5 PA, QL:

30 in 30

days

ERWINAZE 5 PA, QL:

60 in 30

days

38

Drug Name Drug


ETOPOPHOS 4

etoposide (Etoposide) 2

exemestane (Aromasin) 2

FARESTON 5

FASLODEX 5 disp syrin: 125mg/

2.5

FASLODEX 5 disp syrin: 250mg/

5ml

FIRMAGON 4

floxuridine (FUDR) 1 PA (PA for Part B vs

Part D Only)

fludarabine phosphate (Fludara) 5

fluorouracil (Fluorouracil) 2 PA

flutamide (Flutamide) 2

FOLOTYN 5

gemcitabine hcl (Gemzar) 5 vial: 1g

gemcitabine hcl (Gemzar) 5 vial: 200mg

GLEEVEC 5 QL: 60 in

30 days

HALAVEN 5 PA, QL:

24 in 28

days

HERCEPTIN 5 PA (PA for Part B vs

Part D Only)

HEXALEN 5

hydroxyurea (Hydrea) 1

idarubicin hcl (Idamycin Pfs) 2

ifosfamide (Ifex) 2 PA (PA for Part B vs

Part D Only)

ifosfamide/mesna (Ifex-mesnex) 5 PA kit: 1g-1g, 3g-1g,

(PA for Part B vs

Part D Only)

INLYTA 5 PA, QL:

180 in 30

days

tablet: 1mg

INLYTA 5 PA, QL:

60 in 30

days

tablet: 5mg

IRESSA 5 PA, QL:

30 in 30

days

irinotecan hcl (Camptosar) 5

ISTODAX 5 PA

39

Drug Name Drug


IXEMPRA 5

JAKAFI 5 PA, QL:

60 in 30

days

JEVTANA 5

letrozole (Femara) 2

LEUKERAN 4

leuprolide acetate (Lupron) 2 QL: 2 in

28 days

LUPRON DEPOT 5 QL: 1 in

112 days

syringekit: 30mg


168 days

syringekit: 45mg


28 days

syringekit: 3.75mg


84 days

syringekit:

11.25mg, 22.5mg

LUPRON DEPOT-PED 5 QL: 1 in

28 days

LYSODREN 3

MATULANE 5

MEGACE ES 3 (May be High Risk

Med for Ages 65

and Older)

megestrol acetate (Megace) 1 (May be High Risk

Med for Ages 65

and Older)

melphalan hcl (Alkeran) 5

mercaptopurine (Purinethol) 2

methotrexate sodium (Methotrexate Sodium) 1 PA, ST tablet, (PA for Part

B vs Part D Only)

methotrexate sodium (Methotrexate Sodium) 1 PA vial, (PA for Part B

vs Part D Only)

methotrexate sodium/pf (Methotrexate Sodium/PF) 1 PA (PA for Part B vs

Part D Only)

mitomycin (Mitomycin) 1 PA

mitoxantrone hcl (Novantrone) 1

MUSTARGEN 3

NEXAVAR 5 PA, QL:

120 in 30

days

NILANDRON 3

ONCASPAR 5

40

Drug Name Drug


ONTAK 5

oxaliplatin (Oxaliplatin) 5

paclitaxel (Taxol) 2

pentostatin (Nipent) 5

PROLEUKIN 5

REVLIMID 5 LA, QL:

30 in 30

days

RITUXAN 5 PA

SPRYCEL 5

SUTENT 5 PA, QL:

30 in 30

days

TABLOID 3

tamoxifen citrate (Nolvadex) 1

TARCEVA 5 PA, QL:

30 in 30

days

TARGRETIN 5

TASIGNA 5

thiotepa (Thiotepa) 2

topotecan hcl (Hycamtin) 5

TORISEL 5 PA (PA for Part B vs

Part D Only)

TREANDA 5

TRELSTAR 5 QL: 1 in

168 days

disp syrin: 22.5mg/

2ml

TRELSTAR 5 QL: 1 in

28 days

disp syrin: 3.75mg/

2ml

TRELSTAR 5 QL: 1 in

84 days

disp syrin: 11.25/

2ml

tretinoin (Tretinoin) 5

TREXALL 3 PA, ST (PA for Part B vs

Part D Only)

TRISENOX 5

TYKERB 5

VALSTAR 5

VANDETANIB 5 PA, QL:

30 in 30

days

tablet: 300mg

VANDETANIB 5 PA, QL:

60 in 30

days

tablet: 100mg

41

Drug Name Drug


VECTIBIX 5

VELCADE 5

VIDAZA 5

vinblastine sulfate (Vinblastine Sulfate) 2 PA (PA for Part B vs

Part D Only)

vincristine sulfate (Vincristine Sulfate) 1 PA (PA for Part B vs

Part D Only)

vinorelbine tartrate (Navelbine) 1

VOTRIENT 5 PA, QL:

120 in 30

days

VUMON 4

XALKORI 5 PA, QL:

60 in 30

days

YERVOY 5 PA, QL:

30 in 21

days

ZANOSAR 5

ZELBORAF 5 PA, QL:

240 in 30

days

ZOLADEX 4 QL: 1 in

28 days

implant: 3.6mg

ZOLADEX 4 QL: 1 in

84 days

implant: 10.8mg

ZOLINZA 5

ZYTIGA 5 PA, QL:

120 in 30

days

Antiparkinsonian Agents Antiparkinsonian Agents

amantadine hcl (Amantadine HCl) 1

APOKYN 5

AZILECT 3

benztropine mesylate (Benztropine Mesylate) 1 PA tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

benztropine mesylate (Cogentin) 2 PA ampul, (PA for

Ages 65 and Older;

May be High Risk

Med)

42

Drug Name Drug


bromocriptine mesylate (Parlodel) 2

cabergoline (Cabergoline) 2

carbidopa/levodopa (Sinemet 25-100) 1

COMTAN 3

pramipexole di-hcl (Mirapex) 2

ropinirole hcl (Requip XL) 2 tab er 24h

ropinirole hcl (Requip) 1 tablet

selegiline hcl (Eldepryl) 1

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR 3

trihexyphenidyl hcl (Trihexyphenidyl HCl) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

43

Drug Name Drug


Antiprotozoal Agents Antiprotozoal Agents

ALINIA 4

atovaquone/proguanil hcl (Malarone) 2 tablet: 250-100mg

atovaquone/proguanil hcl (Malarone) 2 tablet: 62.5-25mg

chloroquine phosphate (Aralen Phosphate) 1

COARTEM 4

DARAPRIM 3

HALFAN 3

hydroxychloroquine

sulfate

(Plaquenil) 1

mefloquine hcl (Lariam) 1

MEPRON 5

metronidazole (Flagyl) 1

metronidazole/sodium

chloride

(Metro IV) 1

paromomycin sulfate (Paromomycin Sulfate) 1

pentamidine isethionate (Pentam 300) 1

PRIMAQUINE 3 QL: 93 in

31 days

QUALAQUIN 4 PA, QL:

42 in 30

days

tinidazole (Tindamax) 1

YODOXIN 3

Antipruritics and Local Anesthetics Antipruritics and Local Anesthetics

AMERICAINE 3

ANACAINE 3

lidocaine (Lidocaine) 1 PA (PA for ESRD

Only)

lidocaine/prilocaine (EMLA) 1 PA (PA for ESRD

Only)

LIDODERM 4

PRUDOXIN 4

ZONALON 4

Antiulcer Agents Antiulcer Agents

CARAFATE 3 oral susp

cimetidine hcl (Cimetidine HCl) 1 (Rx Product Only)

cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 1 (Rx Product Only)

cimetidine (Tagamet) 1 (Rx Product Only)

44

Drug Name Drug


famotidine in nacl,iso-

osm/pf

(Famotidine In Nacl,iso-osm/PF) 1

famotidine (Pepcid) 1 (Rx Product Only)

lansoprazole (Prevacid) 2 ST capsule dr, (Rx

Product Only)

lansoprazole (Prevacid) 2 ST tab rap dr, (Rx

Product Only)

misoprostol (Cytotec) 1 tablet: 100mcg

misoprostol (Cytotec) 1 tablet: 200mcg

nizatidine (Axid) 1 capsule

nizatidine (Axid) 2 solution

omeprazole (Prilosec) 1 capsule dr: 10mg,

20mg, 40mg, (Rx

Product Only)

omeprazole/sodium

bicarbonate

(Zegerid) 1 (Rx Product Only)

pantoprazole sodium (Protonix) 1

PROTONIX IV 4

ranitidine hcl (Zantac) 1 (Rx Product Only)

sucralfate (Carafate) 1 tablet

sucralfate (Sucralfate) 2 oral susp

Antivirals (Systemic) Antiretrovirals

APTIVUS 4 solution

APTIVUS 5 capsule

ATRIPLA 5

COMPLERA 5

CRIXIVAN 4 capsule: 100mg

CRIXIVAN 4 capsule: 200mg,

400mg

didanosine (Videx EC) 2

EDURANT 5

EMTRIVA 3

EPIVIR HBV 4

EPIVIR 4 solution

EPZICOM 5

FUZEON 5

INTELENCE 3 tablet: 25mg

INTELENCE 5 tablet: 100mg,

200mg

INVIRASE 5

ISENTRESS 5

45

Drug Name Drug


KALETRA 3 tablet: 100mg-25mg

KALETRA 5 solution, tablet:

200mg-50mg

lamivudine (Epivir) 2

lamivudine/zidovudine (Combivir) 5

LEXIVA 3 oral susp

LEXIVA 5 tablet

nevirapine (Viramune) 2 tablet

NORVIR 4

PREZISTA 3 tablet: 75mg

PREZISTA 5 tablet: 150mg,

400mg, 600mg

RESCRIPTOR 4

RETROVIR 3 vial

REYATAZ 3 capsule: 100mg

REYATAZ 5 capsule: 150mg,

200mg, 300mg

SELZENTRY 5

stavudine (Zerit) 2 capsule

stavudine (Zerit) 2 soln recon

SUSTIVA 4 capsule: 100mg

SUSTIVA 4 capsule: 50mg,

200mg; tablet

TRIZIVIR 5

TRUVADA 5

VIDEX 3

VIRACEPT 4 powder

VIRACEPT 4 tablet

VIRAMUNE XR 3

VIRAMUNE 3 oral susp

VIREAD 5

ZERIT 4 soln recon

ZIAGEN 4

zidovudine (Retrovir) 1 syrup

zidovudine (Retrovir) 2 capsule, tablet

46

Drug Name Drug


Antivirals, Miscellaneous

foscarnet sodium (Foscavir) 1 PA (PA for Part B vs

Part D Only)

RELENZA 4

rimantadine hcl (Flumadine) 1

SYNAGIS 4

TAMIFLU 3 capsule, susp recon:

6mg/ml

Hcv Protease Inhibitors

INCIVEK 5 PA, QL:

168 in 28

days

VICTRELIS 5 PA, QL:

336 in 28

days

Interferons

ALFERON N 5

INTRON A 3 PA pen ij kit: 3mm/

0.2ml; vial: 10mm/

ml

INTRON A 5 PA pen ij kit: 5mm/

0.2ml, 10mm/0.2ml;

vial: 6mmunit/ml

INTRON A 5 PA vial: 18mmunit,

50mmunit

PEGASYS PROCLICK 5 PA

PEGASYS 5 PA

PEGINTRON REDIPEN 5 PA

PEGINTRON 5 PA kit: 50mcg/0.5

PEGINTRON 5 PA kit: 80mcg/0.5,

120mcg/0.5,

150mcg/0.5

SYLATRON 5 PA, QL:

1 in 28

days

Nucleosides and Nucleotides

acyclovir sodium (Acyclovir Sodium) 1 PA (PA for Part B vs

Part D Only)

acyclovir (Zovirax) 1 capsule, tablet

acyclovir (Zovirax) 2 oral susp

BARACLUDE 4 solution

BARACLUDE 5 tablet

famciclovir (Famvir) 2

47

Drug Name Drug


ganciclovir sodium (Cytovene) 1 PA (PA for Part B vs

Part D Only)

ganciclovir (Cytovene) 2 capsule: 250mg

ganciclovir (Cytovene) 5 capsule: 500mg

HEPSERA 5

RIBATAB 5 tab ds pk: 600-

600mg

ribavirin (Copegus) 2 capsule, tablet

ribavirin (Ribatab) 5 tab ds pk: 200-

400mg

ribavirin (Ribatab) 5 tab ds pk: 400-

400mg, 600-400mg

TYZEKA 5

valacyclovir hcl (Valtrex) 2

VALCYTE 4 soln recon

VALCYTE 5 tablet

VISTIDE 5

Anxiolytics, Sedatives and Hypnotics Anxiolytics, Sedatives and Hypnotics, Miscellaneous

buspirone hcl (Buspar) 1

droperidol (Inapsine) 1

glutethimide (Glutethimide) 1

hydroxyzine hcl (Hydroxyzine HCl) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

hydroxyzine pamoate (Vistaril) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

ROZEREM 3

zaleplon (Sonata) 1 PA, QL:

90 in 365

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

zolpidem tartrate (Ambien CR) 2 PA, QL:

90 in 365

days

tab mphase, (PA/

QL for Ages 65 and

Older; May be High

Risk Med)

zolpidem tartrate (Ambien) 1 PA, QL:

90 in 365

days

tablet, (PA/QL for

Ages 65 and Older;

May be High Risk

Med)

Astringents Astringents

aluminum chloride (Drysol) 1

48

Drug Name Drug


XERAC AC 3

Benzodiazepines Benzodiazepines

alprazolam (Xanax XR) 1 QL: 30 in

30 days

tab er 24h: 0.5mg,

1mg

alprazolam (Xanax XR) 1 QL: 60 in

30 days

tab er 24h: 2mg,

3mg

alprazolam (Xanax) 1 QL: 90 in

30 days

tab rapdis, tablet

clonazepam (Klonopin) 1 QL: 300

in 30

days

tab rapdis: 2mg;

tablet: 2mg

clonazepam (Klonopin) 1 QL: 90 in

30 days

tab rapdis: 0.125mg,

0.25mg, 0.5mg,

1mg; tablet: 0.5mg,

1mg

clorazepate dipotassium (Tranxene T-tab) 1 PA, QL:

120 in 30

days

tablet: 15mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

clorazepate dipotassium (Tranxene T-tab) 1 PA, QL:

60 in 30

days

tablet: 3.75mg,

7.5mg, (PA for

Ages 65 and Older;

May be High Risk

Med)

DIASTAT ACUDIAL 4

diazepam (Diastat) 2 kit

diazepam (Diazepam) 1 PA, QL:

1200 in

30 days

oral conc, solution,

(PA for Ages 65 and

Older; May be High

Risk Med)

diazepam (Valium) 1 PA, QL:

120 in 30

days

tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

estazolam (Prosom) 1 QL: 30 in

30 days

lorazepam (Ativan) 1 QL: 2 in

30 days

disp syrin, vial

lorazepam (Ativan) 1 QL: 90 in

30 days

tablet

49

Drug Name Drug


ONFI 4 PA, QL:

60 in 30

days

oxazepam (Oxazepam) 1 QL: 120

in 30

days

temazepam (Restoril) 1 QL: 30 in

30 days

triazolam (Halcion) 1 QL: 30 in

30 days

Beta-Adrenergic Blocking Agents Beta-Adrenergic Blocking Agents

acebutolol hcl (Sectral) 1

atenolol (Tenormin) 1

atenolol/chlorthalidone (Tenoretic 100) 1

betaxolol hcl (Kerlone) 1

bisoprolol fumarate (Zebeta) 1

bisoprolol fumarate/hctz (Ziac) 1

BYSTOLIC 3

carvedilol (Coreg) 1

COREG CR 3

DUTOPROL 3

esmolol hcl (Brevibloc) 1 PA

INNOPRAN XL 4

labetalol hcl (Trandate) 1 disp syrin

labetalol hcl (Trandate) 1 tablet, vial

metoprolol succinate (Toprol XL) 1

metoprolol tartrate (Lopressor) 1

metoprolol/

hydrochlorothiazide

(Lopressor HCT) 1

nadolol (Corgard) 1

nadolol/

bendroflumethiazide

(Corzide) 1

pindolol (Pindolol) 1

propranolol hcl (Propranolol HCl) 1

propranolol/

hydrochlorothiazid

(Propranolol/hydrochlorothiazid) 1

sotalol hcl (Betapace) 1

SOTALOL HCL 4

timolol maleate (Timolol Maleate) 1

Blood Derivatives Blood Derivatives

50

Drug Name Drug


ALBUKED-25 3

ALBUKED-5 3

ALBUMIN (HUMAN) 3

ALBUMINAR-25 3

ALBUMINAR-5 3

ALBURX 3

ALBUTEIN 3

BUMINATE 3

FLEXBUMIN 3

KEDBUMIN 3

PLASBUMIN-25 3

PLASBUMIN-5 3

STERILE DILUENT 3

Calcium-Channel Blocking Agents Calcium-Channel Blocking Agents, Miscellaneous

diltiazem hcl (Cardizem CD) 1 various dosage and/

or strengths are

available

diltiazem hcl (Tiazac) 1 capsule er: 420mg

verapamil hcl (Calan) 1 cap24h pct, cap24h

pel: 120mg, 180mg,

240mg; tablet, tablet

er, vial

verapamil hcl (Verelan) 1 cap24h pel: 360mg;

disp syrin

Dihydropyridines

amlodipine besylate (Norvasc) 1

amlodipine besylate/

benazepril

(Lotrel) 2

AZOR 4 ST

CARDENE I.V. 4 piggyback

CARDENE SR 4

CLEVIPREX 4

DYNACIRC CR 4

EXFORGE HCT 3 ST

EXFORGE 3 ST

felodipine (Plendil) 1

isradipine (Dynacirc) 2

nicardipine hcl (Nicardipine HCl) 1

nifedipine (Procardia XL) 1 tab er 24, tablet er

nimodipine (Nimotop) 2

nisoldipine (Sular) 2

51

Drug Name Drug


Caloric Agents Caloric Agents

AMINO ACIDS 3 PA

AMINOSYN II 3.5% M-

DEXTROSE 5%


Part D Only)

AMINOSYN II 3.5%-

DEXTROSE 25%


Part D Only)

AMINOSYN II 3.5%-

DEXTROSE 5%


Part D Only)

AMINOSYN II 4.25% M-

DEXT 10%


Part D Only)

AMINOSYN II 4.25%-

DEXTROSE 25%


Part D Only)

AMINOSYN II 5% IN

25% DEXTROSE


Part D Only)

AMINOSYN II IN

DEXTROSE


Part D Only)

AMINOSYN II with

LYTES-CA-DW

3 PA iv soln: 3.5%, (PA


Only)

AMINOSYN II with

LYTES-CA-DW



Only)

AMINOSYN II 3 PA iv soln: 10%, (PA


Only)



Only)



Only)

AMINOSYN II 3 PA iv soln: 8.5%, (PA


Only)

AMINOSYN M 3 PA (PA for Part B vs

Part D Only)

AMINOSYN with

ELECTROLYTES


Part D Only)

AMINOSYN 3 PA iv soln: 10%, (PA


Only)

52

Drug Name Drug


AMINOSYN 3 PA iv soln: 3.5%, (PA


Only)



Only)



Only)



Only)



Only)

AMINOSYN-HBC 3 PA (PA for Part B vs

Part D Only)

AMINOSYN-HF 3 PA (PA for Part B vs

Part D Only)

AMINOSYN-PF 3 PA iv soln: 10%, (PA


Only)

AMINOSYN-PF 3 PA iv soln: 7%, (PA


Only)

AMINOSYN-RF 3 PA (PA for Part B vs

Part D Only)

BRANCHAMIN 3 PA (PA for Part B vs

Part D Only)

CLINIMIX E 3 PA iv soln: 2.75%, (PA


Only)

CLINIMIX E 3 PA iv soln: 4.25%, (PA


Only)

CLINIMIX E 3 PA iv soln: 5%, (PA


Only)

CLINIMIX 3 PA iv soln: 2.75%, (PA


Only)

53

Drug Name Drug


CLINIMIX 3 PA iv soln: 4.25%, (PA


Only)

CLINIMIX 3 PA iv soln: 5%, (PA


Only)

CLINISOL 3 PA (PA for Part B vs

Part D Only)

cysteine hcl (Cysteine HCl) 1 PA (PA for Part B vs

Part D Only)

dextrose 10 % and 0.225

% nacl

(Dextrose 10 % and 0.225 %

NaCl)

1

dextrose 10 % and 0.225

% nacl

(Dextrose 10 % and 0.225 %

NaCl)

1 iv soln

dextrose 10 % and 0.9 %

nacl

(Dextrose 10 % and 0.9 % NaCl) 1

dextrose 10%-0.5 normal

saline

(Dextrose 10%-0.5 Normal

Saline)

1

dextrose 10%-water (Dextrose 10%-water) 1 PA (PA for Part B vs

Part D Only)

dextrose 2.5 %-water (Dextrose 2.5 %-water) 1 PA (PA for Part B vs

Part D Only)

dextrose 2.5%-0.5normal

saline

(Dextrose 2.5%-0.5 Normal

Saline)

1

dextrose 20 % in water (Dextrose 20 % in Water) 1 PA (PA for Part B vs

Part D Only)


Part D Only)


Part D Only)


Part D Only)


nacl



nacl


dextrose 5 %-0.225 %

nacl

(Dextrose 5 %-0.225 % NaCl) 1

dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 1

dextrose 5 %-water (Dextrose 5 %-water) 1


Part D Only)

54

Drug Name Drug



Part D Only)


Part D Only)

ethyl alcohol/d5w (Ethyl Alcohol/D5W) 1

FREAMINE HBC 3 PA (PA for Part B vs

Part D Only)

FREAMINE III with

ELECTROLYTES


Part D Only)

FREAMINE III 3 PA iv soln: 10%, (PA


Only)

FREAMINE III 3 PA iv soln: 8.5%, (PA


Only)

fructose 10% (Fructose 10%) 1 PA (PA for Part B vs

Part D Only)

HEPATAMINE 3 PA (PA for Part B vs

Part D Only)

HEPATASOL 3 PA (PA for Part B vs

Part D Only)

INTRALIPID 3 PA emulsion: 10%,

(PA for Part B vs

Part D Only)

INTRALIPID 3 PA emulsion: 20%,

30%, (PA for Part

B vs Part D Only)

LIPOSYN II 3 PA (PA for Part B vs

Part D Only)

LIPOSYN III 3 PA emulsion: 10%,

20%, (PA for Part

B vs Part D Only)

LIPOSYN III 3 PA emulsion: 30%,

(PA for Part B vs

Part D Only)

NEPHRAMINE 3 PA (PA for Part B vs

Part D Only)

NOVAMINE 3 PA (PA for Part B vs

Part D Only)

PREMASOL 3 PA iv soln: 10%, (PA


Only)

55

Drug Name Drug


PREMASOL 3 PA iv soln: 6%, (PA


Only)

PROCALAMINE 3 PA (PA for Part B vs

Part D Only)

PROSOL 3 PA (PA for Part B vs

Part D Only)

QUICK MIX with LYTES 3 PA (PA for Part B vs

Part D Only)

RENAMIN 3 PA (PA for Part B vs

Part D Only)

TRAVAMULSION 3 PA (PA for Part B vs

Part D Only)

TRAVASOL W/

DEXTROSE


Part D Only)

TRAVASOL W/

ELECTROLYTES

3 PA iv soln.: 5.5%, (PA


Only)

TRAVASOL W/

ELECTROLYTES

3 PA iv soln.: 8.5%, (PA


Only)

TRAVASOL with

DEXTROSE



Only)

TRAVASOL with

ELECTROLYTES


Part D Only)

TRAVASOL 3 PA iv soln: 10%, (PA


Only)

TRAVASOL 3 PA iv soln: 5.5%, (PA


Only)

TRAVASOL 3 PA iv soln: 8.5%, (PA


Only)

TRAVERT IN NORMAL

SALINE


Part D Only)

TRAVERT 3 PA iv soln: 10%, (PA


Only)

TRAVERT 3 PA iv soln: 5%, (PA


Only)

56

Drug Name Drug


TROPHAMINE 3 PA iv soln: 10%, (PA


Only)

TROPHAMINE 3 PA iv soln: 6%, (PA


Only)

Cardiac Drugs Antiarrhythmic Agents

amiodarone hcl (Amiodarone HCl) 1 disp syrin

amiodarone hcl (Cordarone) 1 tablet, vial

disopyramide phosphate (Norpace) 1 PA capsule er, (PA for

Ages 65 and Older;

May be High Risk

Med)

disopyramide phosphate (Norpace) 1 PA capsule, (PA for

Ages 65 and Older;

May be High Risk

Med)

flecainide acetate (Tambocor) 1

lidocaine hcl (Lidocaine HCl) 1

lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 1 iv soln: 2mg/ml,

8mg/ml

lidocaine hcl/pf (Lidocaine HCl/PF) 1

mexiletine hcl (Mexitil) 1

MULTAQ 3

procainamide hcl (Procainamide HCl) 1 capsule, tablet sa

procainamide hcl (Procainamide HCl) 1 vial

PRONESTYL 3

propafenone hcl (Rythmol) 2

quinidine gluconate (Quinidine Gluconate) 1

quinidine sulfate (Quinidine Sulfate) 1

TIKOSYN 3

Cardiac Drugs, Miscellaneous

digoxin (Lanoxin) 1 PA, QL:

30 in 30

days

tablet, (PAfor Ages

65 and Older; May

be High Risk Med)

digoxin (Lanoxin) 1 PA ampul, (PA/QL for

Ages 65 and Older;

May be High Risk

Med)

DIGOXIN 3 PA, QL:

75 in 30

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

57

Drug Name Drug


inamrinone lactate (Inamrinone Lactate) 1 PA (PA for Part B vs

Part D Only)

milrinone lactate (Milrinone Lactate) 5 PA (PA for Part B vs

Part D Only)

milrinone lactate/d5w (Primacor in 5% Dextrose) 5 PA (PA for Part B vs

Part D Only)

RANEXA 3 QL: 120

in 30

days

tab er 12h: 500mg

RANEXA 3 QL: 60 in

30 days

tab er 12h: 1000mg

Cathartics and Laxatives Cathartics and Laxatives

AMITIZA 3 QL: 60 in

30 days

peg 3350/na sulf,bicarb,cl/

kcl

(Colyte with Flavor Packets) 1

polyethylene glycol 3350 (Polyethylene Glycol 3350) 1

sodium chloride/nahco3/

kcl/peg

(Nulytely) 1

Cell Stimulants and Proliferants Cell Stimulants and Proliferants

KEPIVANCE 5

RETIN-A MICRO 4 PA

tretinoin (Retin-A) 1 PA

Central Nervous System Agents, Miscellaneous Central Nervous System Agents, Miscellaneous

BUTISOL SODIUM 4 PA, QL:

120 in 30

days

tablet: 30mg, (May

be High Risk Med

for Ages 65 and

Older)


473 in 30

days

elixir: 30mg/5ml,

(May be High Risk

Med for Ages 65

and Older)


60 in 30

days

tablet: 50mg, (May

be High Risk Med

for Ages 65 and

Older)

CAMPRAL 3 tab ds pk

CAMPRAL 3 tablet dr

flumazenil (Romazicon) 1

58

Drug Name Drug


INTUNIV 4 QL: 30 in

30 days

lithium carbonate (Eskalith) 1

lithium citrate (Lithium Citrate) 1

LODOSYN 3

LUMINAL SODIUM 4 PA, QL:

2 in 30

days

disp syrin: 60mg/

ml, 130mg/ml

NAMENDA 3 QL: 360

in 30

days

solution

NAMENDA 3 QL: 49 in

28 days

tab ds pk

NAMENDA 3 QL: 62 in

31 days

tablet

NUEDEXTA 3 QL: 60 in

30 days

phenobarbital sodium (Phenobarbital Sodium) 1 PA, QL:

2 in 30

days

vial: 65mg/ml,

130mg/ml

phenobarbital (Phenobarbital) 1 PA, QL:

1500 in

30 days

elixir: 20mg/5ml,

(May be High Risk

Med for Ages 65

and Older)


200 in 30

days

tablet: 30mg, (May

be High Risk Med

for Ages 65 and

Older)


90 in 30

days

tablet: 15mg, 60mg,

100mg, (May be

High Risk Med for

Ages 65 and Older)


90 in 30

days

tablet: 16.2mg,

32.4mg, 64.8mg,

97.2mg, (May be

High Risk Med for

Ages 65 and Older)

primidone (Mysoline) 1

RILUTEK 5

SAVELLA 3 QL: 60 in

30 days

STRATTERA 3

59

Drug Name Drug


XENAZINE 5 PA, QL:

112 in 28

days

XYREM 5 LA

60

Drug Name Drug


Contraceptives Contraceptives

desogestrel-ethinyl

estradiol

(Desogen) 1

desog-et estra/ethin estra (Mircette) 1

ethinyl estradiol/

drospirenone

(Yaz) 2

ethynodiol d-ethinyl

estradiol

(Demulen 1-50-21) 1

levonorgestrel (Plan B) 1

levonorgestrel-eth

estradiol

(Lybrel) 1 tablet: 0.1-0.02,

0.15-0.03, 6-5-10

levonorgestrel-eth

estradiol

(Lybrel) 2 tablet: 90-20mcg

levonorgestrel-eth

estradiol

(Seasonale) 1 QL: 91 in

84 days

tbdspk 3mo

l-norgest-eth estr/ethin

estra

(Seasonique) 2 QL: 91 in

84 days

tbdspk 3mo: 100-

20(84)

l-norgest-eth estr/ethin

estra

(Seasonique) 2 QL: 91 in

84 days

tbdspk 3mo: 150-

30(84)

noreth a-et estra/fe

fumarate

(Loestrin Fe) 1

noreth-ethinyl estradiol/

iron

(Femcon Fe) 2

norethindrone a-e

estradiol

(Loestrin) 1

norethindrone (Nor-Q-D) 1

norethindrone-ethinyl

estrad

(Ovcon-35) 1

norethindrone-mestranol (Ortho-novum) 1

norgestimate-ethinyl

estradiol

(Ortho Tri-cyclen) 1

norgestrel-ethinyl

estradiol

(Lo-ovral-28) 1

NUVARING 3 QL: 1 in

28 days

ORTHO EVRA 4 QL: 3 in

28 days

61

Drug Name Drug


Devices Devices

needles, insulin disp.,

safety

(Needles, Insulin Disp., Safety) 1

needles, insulin disposable (Needles, Insulin Disposable) 1

syring w-

ndl,disp,insul,0.3ml

(Syring W-ndl,disp,insul,0.3ml) 1

syring w-

ndl,disp,insul,0.5ml

(Syring W-ndl,disp,insul,0.5ml) 1

syringe & needle,insulin,1

ml

(Syringe & Needle,insulin,1 Ml) 1

Diuretics Diuretics, Miscellaneous

chlorothiazide (Chlorothiazide) 1

chlorthalidone (Chlorthalidone) 1

hydrochlorothiazide (Hydrochlorothiazide) 1

indapamide (Lozol) 1

methyclothiazide (Methyclothiazide) 1

metolazone (Zaroxolyn) 1

SAMSCA 5 QL: 30 in

30 days

tablet: 15mg

SAMSCA 5 QL: 60 in

30 days

tablet: 30mg

Loop Diuretics

bumetanide (Bumex) 1

furosemide (Furosemide) 1 disp syrin

furosemide (Lasix) 1 solution, tablet, vial

torsemide (Demadex) 1

Potassium-sparing Diuretics

amiloride hcl (Midamor) 1

amiloride/

hydrochlorothiazide

(Amiloride/hydrochlorothiazide) 1

DYRENIUM 4

triamterene/

hydrochlorothiazid

(Maxzide-25mg) 1

EENT Drugs, Miscellaneous EENT Drugs, Miscellaneous

apraclonidine hcl (Iopidine) 1

atropine sulfate (Isopto Atropine) 1

carteolol hcl (Carteolol HCl) 1

CYCLOGYL 3 drops: 0.5%

cyclopentolate hcl (Cyclogyl) 1 drops: 1%

62

Drug Name Drug


homatropine hbr (Isopto Homatropine) 1

IOPIDINE 4 droperette

ipratropium bromide (Atrovent) 1 QL: 15 in

10 days

spray: 42mcg

ipratropium bromide (Atrovent) 1 QL: 30 in

28 days

spray: 21mcg

ISOPTO

HOMATROPINE

3 drops: 2%

LACRISERT 3

naphazoline hcl (Albalon) 1

naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1

phenylephrine hcl (Mydfrin) 1

PROPINE 3

tropicamide (Mydral) 1

TYZINE 3 drops

TYZINE 3 spray

Enzymes Enzymes

ADAGEN 5

ALDURAZYME 5

CEREDASE 5

CEREZYME 5

ELAPRASE 5

ELITEK 5

FABRAZYME 5

KRYSTEXXA 5

LUMIZYME 5

MYOZYME 5

NAGLAZYME 5

PULMOZYME 5 PA (PA for Part B vs

Part D Only)

VPRIV 5

XIAFLEX 5 PA, QL:

1 in 28

days

63

Drug Name Drug


Estrogens and Antiestrogens Estrogens and Antiestrogens

ALORA 4 PA, QL:

8 in 28

days

(PA for Ages 65 and

Older; May be High

Risk Med)

ANGELIQ 4 PA (PA for Ages 65 and

Older; May be High

Risk Med)

CENESTIN 4 PA (PA for Ages 65 and

Older; May be High

Risk Med)

COMBIPATCH 3 PA, QL:

8 in 28

days

(PA for Ages 65 and

Older; May be High

Risk Med)

DEPO-ESTRADIOL 4 PA

ESTRACE 3 PA cream/appl

estradiol valerate (Delestrogen) 1 PA

estradiol (Climara) 1 PA, QL:

4 in 28

days

patch tdwk, (PA for

Ages 65 and Older;

May be High Risk

Med)

estradiol (Estrace) 1 PA tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

estradiol/noreth ac (Activella) 1 PA tablet: 1-0.5mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

estradiol/noreth ac (Activella) 2 PA tablet: 0.5-0.1mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

ESTRASORB 4 PA, QL:

97.44 in

28 days

(PA for Ages 65 and

Older; May be High

Risk Med)

ESTRING 4 PA, QL:

1 in 84

days

estropipate (Ogen) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

EVISTA 3

64

Drug Name Drug


FEMHRT 4 tablet: 0.5mg-2.5

FEMRING 4 PA, QL:

1 in 84

days

MENEST 4 PA (PA for Ages 65 and

Older; May be High

Risk Med)

norethind ac/ethinyl

estradiol

(Femhrt) 2

PREFEST 4 PA (PA for Ages 65 and

Older; May be High

Risk Med)

PREMARIN 3 PA (PA for Ages 65 and

Older; May be High

Risk Med)

PREMPHASE 3 PA (PA for Ages 65 and

Older; May be High

Risk Med)

PREMPRO 3 PA (PA for Ages 65 and

Older; May be High

Risk Med)

VAGIFEM 3 PA, QL:

18 in 28

days

tablet: 10mcg

VAGIFEM 3 PA, QL:

8 in 28

days

tablet: 25mcg

VIVELLE-DOT 3 PA, QL:

8 in 28

days

(PA for Ages 65 and

Older; May be High

Risk Med)

Genitourinary Smooth Muscle Relaxants Genitourinary Smooth Muscle Relaxants

DETROL LA 3

flavoxate hcl (Urispas) 2

GELNIQUE 4 QL: 30 in

30 days

gel packet

GELNIQUE 4 QL: 92 in

30 days

gel md pmp

oxybutynin chloride (Ditropan) 1

OXYTROL 4 QL: 8 in

28 days

SANCTURA XR 4

tolterodine tartrate (Detrol) 2

65

Drug Name Drug


TOVIAZ 3

trospium chloride (Sanctura) 2

VESICARE 3

GI Drugs, Miscellaneous GI Drugs, Miscellaneous

CHENODAL 5 PA, QL:

120 in 30

days

CIMZIA 5 PA, QL:

3 in 28

days

CREON 3

lipase/protease/amylase (Zenpep) 2

LOTRONEX 5

metoclopramide hcl (Metoclopramide HCl) 1 PA disp syrin, (PA for

Ages 65 and Older;

May be High Risk

Med)

metoclopramide hcl (Reglan) 1 PA solution, tablet, vial,

(PA for Ages 65 and

Older; May be High

Risk Med)

NUTRESTORE 3

PANCREAZE 4

RELISTOR 4 PA, QL:

28 in 28

days

disp syrin

RELISTOR 4 PA, QL:

28 in 28

days

vial

ursodiol (Actigall) 2

ZENPEP 3

66

Drug Name Drug


Heavy Metal Antagonists Heavy Metal Antagonists

BAL IN OIL 3

CALCIUM DISODIUM

VERSENATE

3

deferoxamine mesylate (Desferal) 1 PA

edetate disodium (Edetate Disodium) 1

ENDRATE 3

EXJADE 3 tab disper: 125mg

EXJADE 5 tab disper: 250mg,

500mg

FERRIPROX 5

GALZIN 4

na nitrite/na thiosul/amyl

nit

(Na Nitrite/na Thiosul/amyl Nit) 1

sodium thiosulfate (Sodium Thiosulfate) 2

SYPRINE 5

Hematologic Agents Anticoagulants

CEPROTIN 5

citrate-phos-dex solution (Citrate-phos-dex Solution) 1

enoxaparin sodium (Lovenox) 2 QL: 13.6

in 30

days

disp syrin: 40mg/

0.4ml

enoxaparin sodium (Lovenox) 2 QL: 18 in

30 days

disp syrin: 30mg/

0.3ml


in 30

days

disp syrin: 60mg/

0.6ml


in 30

days

disp syrin: 80mg/

0.8ml


in 30

days

disp syrin: 120mg/

.8ml


30 days

disp syrin: 150mg/

ml


30 days

disp syrin: 100mg/

ml

fondaparinux sodium (Arixtra) 2 QL: 11.2

in 28

days

disp syrin: 10mg/

0.8ml

67

Drug Name Drug



in 28

days

disp syrin: 5mg/

0.4ml

fondaparinux sodium (Arixtra) 2 QL: 7 in

28 days

disp syrin: 2.5mg/

0.5


in 28

days

disp syrin: 7.5mg/

0.6

heparin sodium,porcine (Hep-lock) 1 PA (PA for ESRD

Only)

heparin sodium,porcine/

d5w

(Heparin Sodium, porcine/D5W) 1

heparin sodium,porcine/

ns/pf

(Heparin Sodium, porcine/ns/PF) 1

heparin sodium,porcine/pf (Hep-lock) 1 vial port

heparin sodium,porcine/pf (Hep-lock) 1 PA vial, (PA for ESRD

Only)

heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 PA disp syrin, (PA for

ESRD Only)

IPRIVASK 5 PA, QL:

24 in 28

days

LOVENOX 3 QL: 36 in

30 days

vial

PRADAXA 4 PA, QL:

60 in 30

days

warfarin sodium (Coumadin) 1

XARELTO 4 PA, QL:

30 in 30

days

Hematologic Agents, Miscellaneous

aminocaproic acid (Amicar) 2 solution, tablet

aminocaproic acid (Aminocaproic Acid) 1 vial

anagrelide hcl (Agrylin) 2

LYSTEDA 4 QL: 30 in

30 days

pentoxifylline (Trental) 1

protamine sulfate (Protamine Sulfate) 1 PA (PA for ESRD

Only)

tranexamic acid (Tranexamic Acid) 2

Platelet-aggregation Inhibitors

68

Drug Name Drug


BRILINTA 4 QL: 60 in

30 days

cilostazol (Pletal) 1

clopidogrel bisulfate (Plavix) 1

EFFIENT 3 QL: 30 in

30 days

Hematopoietic Agents Hematopoietic Agents

ARANESP 3 PA, QL:

1.2 in 28

days

disp syrin: 60mcg/

0.3

ARANESP 3 PA, QL:

1.6 in 28

days

disp syrin: 40mcg/

0.4

ARANESP 3 PA, QL:

1.68 in

28 days

disp syrin: 25mcg/

0.42

ARANESP 3 PA, QL:

4 in 28

days

vial: 25mcg/ml,

40mcg/ml, 60mcg/

ml

ARANESP 5 PA, QL:

1.2 in 28

days

disp syrin: 150mcg/

0.3

ARANESP 5 PA, QL:

1.6 in 28

days

disp syrin: 200mcg/

0.4

ARANESP 5 PA, QL:

2 in 28

days

disp syrin: 100mcg/

0.5

ARANESP 5 PA, QL:

2.4 in 28

days

disp syrin: 300mcg/

0.6

ARANESP 5 PA, QL:

4 in 28

days

disp syrin: 500mcg/

ml; vial: 100mcg/

ml, 200mcg/ml,

300mcg/ml

EPOGEN 3 PA, QL:

12 in 28

days

vial: 2000/ml, 3000/

ml, 4000/ml, 10000/

ml, 20000/ml

EPOGEN 5 PA, QL:

6 in 28

days

vial: 40000/ml

LEUKINE 5

69

Drug Name Drug


MOZOBIL 5 PA, QL:

9.6 per

fill

NEULASTA 5

NEUMEGA 5

NEUPOGEN 5

PROCRIT 3 PA, QL:

12 in 28

days

vial: 2000/ml, 3000/

ml, 4000/ml, 10000/

ml

PROCRIT 5 PA, QL:

12 in 28

days

vial: 20000/ml

PROCRIT 5 PA, QL:

6 in 28

days

vial: 40000/ml

PROMACTA 5 PA, QL:

30 in 30

days

Hypotensive Agents Hypotensive Agents, Miscellaneous

clonidine hcl (Catapres) 1

clonidine hcl/

chlorthalidone

(Clonidine HCl/chlorthalidone) 2

clonidine (Catapres-TTS 3) 2 QL: 4 in

28 days

patch tdwk: 0.1mg/

24hr, 0.2mg/24hr

clonidine (Catapres-TTS 3) 2 QL: 8 in

28 days

patch tdwk: 0.3mg/

24hr

fenoldopam mesylate (Corlopam) 1 PA (PA for Part B vs

Part D Only)

guanfacine hcl (Tenex) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

hydralazine hcl (Apresoline) 1

hydralazine/

hydrochlorothiazid

(Hydralazine/

hydrochlorothiazid)

1

hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1 PA, QL:

30 in 30

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

minoxidil (Minoxidil) 1

PROGLYCEM 3

reserpine (Reserpine) 1 PA, QL:

30 in 30

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

70

Drug Name Drug


reserpine/

hydrochlorothiazide

(Reserpine/hydrochlorothiazide) 1 PA, QL:

30 in 30

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

Ion-Removing Agents Ion-Removing Agents

calcium acetate (Phoslo) 2

calcium carbonate/mag

carb/fa

(Calcium Carbonate/mag Carb/

fa)

1

FOSRENOL 4

PHOSLYRA 4

RENAGEL 3

RENVELA 3 powd pack: 2.4g;

tablet

sodium polystyrene

sulfonate

(Sodium Polystyrene Sulfonate) 1

Irrigating Solutions Irrigating Solutions

acetic acid (Acetic Acid) 1

glycine (Aminoacetic Acid) 1

LACTATED RINGERS 3

mannitol/sorbitol solution (Mannitol/sorbitol Solution) 1

ringers solution (Tis-u-sol) 1

sod chloride 0.45% irrig.

soln

(Sod Chloride 0.45% Irrig. Soln) 1

sodium chloride irrig

solution

(Sodium Chloride Irrig Solution) 1

sorbitol solution (Sorbitol Solution) 1

UROLOGIC SOLUTION

G

3

water for irrigation,sterile (Water for Irrigation, Sterile) 1

Keratolytic Agents Keratolytic Agents

benzoyl peroxide

microspheres

(Neobenz Micro) 1

benzoyl peroxide (Acne Medication-5) 1 cleanser, gel (gram),

lotion, med. pad

benzoyl peroxide/aloe

vera

(Benziq) 1

benzoyl peroxide/

hydrocortison

(Benzoyl Peroxide/

hydrocortison)

1

benzoyl peroxide/urea (Zoderm) 1

potassium hydroxide (Potassium Hydroxide) 1

71

Drug Name Drug


salicylic acid (Salacyn) 1

salicylic acid/ammon lact/

aloe

(Salkera) 1

salicylic acid/ceramide

cmb #1

(Salex) 1

silver nitrate applicator (Silver Nitrate Applicator) 1

Keratoplastic Agents Keratoplastic Agents

DRITHO-SCALP 3

sulfacetamide sodium/urea (Rosula Ns) 1 med. pad

Local Anesthetics Local Anesthetics

aa/antipyrn/bcaine/

polico#1/al

(Auralgan) 2

aa/antpy/bcaine/polico/al

acet

(Aa/antpy/bcaine/polico/al Acet) 2

AKTEN 4

antipyrine/benzocaine/

glycerin

(Otra Nr) 1

benzocaine (Omedia Otic) 1

chloroprocaine hcl/pf (Nesacaine-MPF) 1

chloroxylenol/pramoxine

hcl

(Oticin) 1

cocaine hcl (Cocaine HCl) 2

lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app,

solution

lidocaine hcl (Xylocaine) 1 PA vial, (PA for ESRD

Only)

lidocaine hcl/pf (Xylocaine-MPF) 1 PA ampul, ampul luer,

(PA for ESRD

Only)

mepivacaine hcl/pf (Mepivacaine HCl/PF) 1

phenylephrine/antipy/b-

caine

(Otogesic) 1

proparacaine hcl (Ophthetic) 1

proparacaine/fluorescein

sod

(Proparacaine/fluorescein Sod) 1

tetracaine hcl/pf (Tetracaine HCl/PF) 1

XYLOCAINE 1 vial: 20mg/ml

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

72

Drug Name Drug


ACTEMRA 5 PA, QL:

40 in 30

days

ACTHAR H.P. 5 PA, QL:

35 in 28

days

ACTIMMUNE 5

ACTONEL with

CALCIUM

3 QL: 28 in

28 days

ACTONEL 3 QL: 1 in

28 days

tablet: 150mg

ACTONEL 3 QL: 31 in

31 days

tablet: 5mg, 30mg

ACTONEL 3 QL: 4 in

28 days

tablet: 35mg

alendronate sodium (Fosamax) 1 tablet: 5mg, 10mg,

40mg

alendronate sodium (Fosamax) 1 QL: 4 in

28 days

tablet: 35mg, 70mg

allopurinol sodium (Aloprim) 1

allopurinol (Zyloprim) 1

amifostine crystalline (Ethyol) 1

ammonium chloride (Ammonium Chloride) 1

AMPYRA 5 PA, QL:

60 in 30

days

ARCALYST 5

ATELVIA 4 QL: 4 in

28 days

AVODART 3

AVONEX

ADMINISTRATION

PACK

5 ST

AVONEX 5 ST

azathioprine sodium (Azathioprine Sodium) 1 PA (PA for Part B vs

Part D Only)

azathioprine (Imuran) 1 PA (PA for Part B vs

Part D Only)

BENLYSTA 5 PA, QL:

2 in 28

days

73

Drug Name Drug


BERINERT 5 PA, QL:

4 in 300

days

BETASERON 5 ST

BONIVA 3 PA, QL:

3 in 84

days

disp syrin, (PA for

ESRD Only)

BONIVA 3 QL: 31 in

31 days

tablet: 2.5mg

BOTOX 4 PA, QL:

1 in 90

days

vial: 200unit

BOTOX 4 PA, QL:

4 in 90

days

vial: 100unit

CELLCEPT 4 PA vial, (PA for Part B

vs Part D Only)

CELLCEPT 5 PA susp recon, (PA for

Part B vs Part D

Only)

CINRYZE 5 PA, QL:

20 in 28

days

citric acid/sodium citrate (Bicitra) 1

colchicine/probenecid (Colchicine/probenecid) 1

COLCRYS 3

COPAXONE 5

cyclosporine (Sandimmune) 2 PA capsule, vial, (PA


Only)

cyclosporine (Sandimmune) 2 PA solution, (PA for

Part B vs Part D

Only)

cyclosporine, modified (Neoral) 2 PA (PA for Part B vs

Part D Only)

CYSTADANE 4

dexrazoxane (Totect) 1

disulfiram (Antabuse) 2

DUODOTE 3

DYSPORT 4 PA, QL:

2 in 90

days

ELMIRON 3

74

Drug Name Drug


ENBREL 5 PA, QL:

7.84 in

28 days

pen injctr

ENBREL 5 PA, QL:

8 in 28

days

kit

ENBREL 5 PA, QL:

8.16 in

28 days

disp syrin

etidronate disodium (Didronel) 2

EXTAVIA 5 ST

finasteride (Proscar) 1

FIRAZYR 5

FLUORITAB 4

FLURA-DROPS 4

fomepizole (Antizol) 5

FUSILEV 5

gauze bandage (Gauze Bandage) 1

GILENYA 5 PA, QL:

28 in 28

days

GLUCAGEN 3

GLUCAGON

EMERGENCY KIT

3

gold sodium thiomalate (Myochrysine) 1

HUMIRA 5 PA, QL:

4 in 28

days

kit, pen ij kit: 40mg/

0.8ml

HUMIRA 5 PA, QL:

6 in 28

days

pen ij kit: 40mg/

0.8ml, (Starter Kit)

ibandronate sodium (Boniva) 2 QL: 1 in

28 days

ILARIS 5

KALBITOR 5

KINERET 5 PA, QL:

18.76 in

28 days

K-PHOS M.F. 3

K-PHOS NO.2 3

KUVAN 5

leflunomide (Arava) 2

leucovorin calcium (Leucovorin Calcium) 1

75

Drug Name Drug


levocarnitine (with sugar) (Carnitor) 2 PA (PA for ESRD

Only)

levocarnitine (Carnitor) 2 PA (PA for ESRD

Only)

mesna (Mesnex) 1

MESNEX 5 tablet

methylene blue (Methylene Blue) 1

methylergonovine maleate (Methergine) 1 tablet

methylergonovine maleate (Methylergonovine Maleate) 1 vial

mycophenolate mofetil (Cellcept) 2 PA (PA for Part B vs

Part D Only)

MYFORTIC 4 PA (PA for Part B vs

Part D Only)

MYOBLOC 4 PA, QL:

1 in 90

days

NPLATE 5 PA, QL:

8 in 28

days

NULOJIX 5 PA (PA for Part B vs

Part D Only)

octreotide acetate (Sandostatin) 2 vial: 50mcg/ml,

100mcg/ml,

200mcg/ml

octreotide acetate (Sandostatin) 5 vial: 500mcg/ml,

1000mcg/ml

ORENCIA 5 PA, QL:

4 in 28

days

disp syrin

ORENCIA 5 PA, QL:

4 in 28

days

vial

ORFADIN 3

pamidronate disodium (Aredia) 1 PA vial: 60mg/10ml,

90mg/10ml, (PA

for ESRD Only)

pamidronate disodium (Aredia) 2 PA vial: 30mg/10ml,

(PA for ESRD

Only)

phosphorus #1 (K-phos Neutral) 1

potassium citrate (Urocit-K) 1

potassium citrate/citric

acid

(Polycitra-k) 1

76

Drug Name Drug


PRALIDOXIME

CHLORIDE

3

probenecid (Probenecid) 1

PROGRAF 4 PA ampul, (PA for Part

B vs Part D Only)

PROLIA 4 PA, QL:

1 in 180

days

PROTOPAM CHLORIDE 4

RAPAMUNE 3 PA solution, tablet:

0.5mg, (PA for Part

B vs Part D Only)

RAPAMUNE 5 PA tablet: 1mg, 2mg,

(PA for Part B vs

Part D Only)

REBIF 5

RECLAST 4 QL: 100

in 300

days

REMICADE 5 PA

REVLIMID 5 LA, QL:

30 in 30

days

RIDAURA 4

SANDOSTATIN LAR 5

SENSIPAR 3 tablet: 30mg

SENSIPAR 5 tablet: 60mg, 90mg

SIMPONI 5 PA, QL:

0.5 in 28

days

SIMULECT 3 PA (PA for Part B vs

Part D Only)

SKELID 4

sod/pot/k cit/sod cit/cit

acid

(Polycitra-lc) 1

sodium bicarbonate (Sodium Bicarbonate) 1

sodium fluoride (Sodium Fluoride) 4 drops, tab chew

sodium lactate (Sodium Lactate) 1

SOLIRIS 5

SOMATULINE DEPOT 5 QL: 1 in

28 days

77

Drug Name Drug


STELARA 5 PA, QL:

10 in 360

days

vial

STELARA 5 PA, QL:

5 in 360

days

disp syrin

SUPPRELIN LA 5 QL: 1 in

360 days

SUPPRELIN 4

SYNAREL 5

tacrolimus (Prograf) 2 PA (PA for Part B vs

Part D Only)

THALOMID 5 QL: 60 in

30 days

TYSABRI 5 LA, PA,

QL: 15 in

28 days

ULORIC 3 ST, QL:

31 in 31

days

VANTAS 4 QL: 1 in

360 days

XEOMIN 4 PA, QL:

2 in 90

days

XGEVA 5 PA, QL:

1.7 in 28

days

ZAVESCA 5

ZOMETA 4 infus. btl

ZOMETA 4 vial

ZORTRESS 4 PA, QL:

60 in 30

days

tablet: 0.25mg, (PA


Only)

ZORTRESS 5 PA, QL:

60 in 30

days

tablet: 0.5mg,

0.75mg, (PA for

Part B vs Part D

Only)

Opiate Antagonists Opiate Antagonists

naloxone hcl (Naloxone HCl) 1 ampul, disp syrin:

0.4mg/ml; vial

naloxone hcl (Naloxone HCl) 1 disp syrin: 1mg/ml

78

Drug Name Drug


naltrexone hcl (Revia) 1

Parasympathomimetics (Cholinergic Agents) Parasympathomimetics (Cholinergic Agents)

ARICEPT 3 PA, QL:

31 in 31

days

tablet: 23mg

bethanechol chloride (Urecholine) 2

CHANTIX 3 PA, QL:

168 in 84

days

tablet

CHANTIX 3 PA, QL:

53 in 28

days

tab ds pk

donepezil hcl (Aricept Odt) 2 QL: 31 in

31 days

tab rapdis

donepezil hcl (Aricept) 1 QL: 31 in

31 days

tablet

EXELON 4 PA, QL:

30 in 30

days

patch td24

EXELON 4 QL: 240

in 31

days

solution

galantamine hbr (Razadyne ER) 2 QL: 30 in

30 days

cap24h pel

galantamine hbr (Razadyne) 2 QL: 200

in 30

days

solution

galantamine hbr (Razadyne) 2 QL: 60 in

30 days

tablet

MESTINON 4 syrup, tablet er

MYTELASE 3

neostigmine methylsulfate (Neostigmine Methylsulfate) 1

NICOTROL NS 4 QL: 240

in 180

days

NICOTROL 4 QL: 2016

in 365

days

physostigmine salicylate (Physostigmine Salicylate) 1

pilocarpine hcl (Salagen) 2

PROSTIGMIN 3

pyridostigmine bromide (Mestinon) 1

79

Drug Name Drug


REGONOL 4

rivastigmine tartrate (Exelon) 2 QL: 62 in

31 days

Parathyroid Parathyroid

calcitonin,salmon,syntheti

c

(Miacalcin) 2 QL: 3.7

in 28

days

FORTEO 4 QL: 3 in

28 days

FORTICAL 3 QL: 3.7

in 28

days

MIACALCIN 3 PA vial, (PA for ESRD

Only)

Pituitary Pituitary

DDAVP 3 ampul: 15mcg/ml

desmopressin acetate (DDAVP) 1 ampul

desmopressin acetate (DDAVP) 2 tablet

desmopressin acetate (Desmopressin Acetate) 2 QL: 15 in

30 days

solution

desmopressin acetate (Desmopressin Acetate) 2 QL: 15 in

30 days

spray/pump

GENOTROPIN 3 PA disp syrin: 0.2mg/

0.25

GENOTROPIN 5 PA various dosage and/

or strengths are

available

HUMATROPE 5 PA

NORDITROPIN

FLEXPRO

5 PA

NORDITROPIN

NORDIFLEX

5 PA

NORDITROPIN 5 PA

NUTROPIN AQ NUSPIN 5 PA cartridge: 10mg/2ml

NUTROPIN AQ NUSPIN 5 PA cartridge: 5mg/2ml

NUTROPIN AQ 5 PA

NUTROPIN 5 PA

OMNITROPE 3 PA cartridge: 10mg/

1.5ml

OMNITROPE 5 PA cartridge: 5mg/

1.5ml; vial

80

Drug Name Drug


SAIZEN 5 PA cartridge, vial: 5mg

SAIZEN 5 PA vial: 8.8mg

SEROSTIM 5 PA

STIMATE 4

TEV-TROPIN 3 PA

vasopressin (Pitressin) 1

ZORBTIVE 5 PA

Progestins Progestins

DEPO-PROVERA 3 QL: 10 in

28 days

vial: 400mg/ml

medroxyprogesterone

acetate

(Depo-provera) 1 QL: 1 in

84 days

disp syrin

medroxyprogesterone

acetate

(Depo-provera) 1 QL: 1 in

84 days

vial

medroxyprogesterone

acetate

(Provera) 1 tablet

norethindrone acetate (Aygestin) 1

progesterone (Progesterone In Oil) 1

progesterone,micronized (Prometrium) 1

Psychotherapeutic Agents Antidepressants

amitriptyline hcl (Amitriptyline HCl) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

amoxapine (Amoxapine) 1

bupropion hcl (Wellbutrin SR) 1

citalopram hydrobromide (Celexa) 1 solution

citalopram hydrobromide (Celexa) 1 QL: 30 in

30 days

tablet

clomipramine hcl (Anafranil) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

CYMBALTA 3 QL: 30 in

30 days

capsule dr: 30mg

CYMBALTA 3 QL: 60 in

30 days

capsule dr: 20mg,

60mg

desipramine hcl (Norpramin) 2

doxepin hcl (Doxepin HCl) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

EMSAM 4 QL: 30 in

30 days

81

Drug Name Drug


escitalopram oxalate (Lexapro) 2

fluoxetine hcl (Prozac) 1 capsule, solution,

tablet: 10mg, 20mg

fluoxetine hcl (Prozac) 2 capsule dr

fluoxetine hcl (Rapiflux) 2 tablet: 60mg

fluvoxamine maleate (Fluvoxamine Maleate) 1

imipramine hcl (Tofranil) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

imipramine pamoate (Tofranil-PM) 2 PA (PA for Ages 65 and

Older; May be High

Risk Med)

LEXAPRO 4 solution

LUVOX CR 4

maprotiline hcl (Maprotiline HCl) 1

MARPLAN 4

mirtazapine (Remeron) 1

nefazodone hcl (Nefazodone HCl) 1

nortriptyline hcl (Pamelor) 1

paroxetine hcl (Paroxetine HCl) 1 oral susp

paroxetine hcl (Paxil) 1 tab er 24h, tablet

PAXIL 4 oral susp

perphenazine/

amitriptyline hcl

(Perphenazine/amitriptyline

HCl)

1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

phenelzine sulfate (Nardil) 1

PRISTIQ ER 4 QL: 31 in

31 days

protriptyline hcl (Vivactil) 2

sertraline hcl (Zoloft) 1

SILENOR 3 QL: 30 in

30 days

SURMONTIL 4 PA (PA for Ages 65 and

Older; May be High

Risk Med)

SYMBYAX 4 QL: 30 in

30 days

tranylcypromine sulfate (Parnate) 2

trazodone hcl (Trazodone HCl) 1

trimipramine maleate (Surmontil) 2 PA (PA for Ages 65 and

Older; May be High

Risk Med)

82

Drug Name Drug


VENLAFAXINE HCL

ER

2

venlafaxine hcl (Effexor XR) 2 cap er 24h

venlafaxine hcl (Effexor) 1 tablet

VIIBRYD 4 QL: 30 in

30 days

Antipsychotic Agents

ABILIFY DISCMELT 3 ST, QL:

62 in 31

days

tab rapdis: 15mg

ABILIFY DISCMELT 3 ST, QL:

93 in 31

days

tab rapdis: 10mg

ABILIFY 3 ST, QL:

161.2 in

28 days

vial

ABILIFY 3 ST, QL:

31 in 31

days

tablet

ABILIFY 3 ST, QL:

930 in 31

days

solution

chlorpromazine hcl (Chlorpromazine HCl) 1 ampul, tablet

chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc.

clozapine (Clozaril) 1 QL: 140

in 31

days

tablet: 200mg

clozapine (Clozaril) 1 QL: 279

in 31

days

tablet: 100mg

clozapine (Clozaril) 1 QL: 93 in

31 days

tablet: 25mg, 50mg

FANAPT 4 ST, QL:

60 in 30

days

tablet

FANAPT 4 ST, QL:

8 in 28

days

tab ds pk

FAZACLO 4 ST, QL:

124 in 31

days

tab rapdis: 200mg

83

Drug Name Drug


FAZACLO 4 ST, QL:

186 in 31

days

tab rapdis: 150mg

FAZACLO 4 ST, QL:

93 in 31

days

tab rapdis: 12.5mg,

25mg, 100mg

fluphenazine decanoate (Fluphenazine Decanoate) 1

fluphenazine hcl (Fluphenazine HCl) 1

GEODON 4 QL: 6 in

28 days

vial

haloperidol decanoate (Haloperidol Decanoate) 1

haloperidol lactate (Haloperidol Lactate) 1

haloperidol (Haloperidol) 1

INVEGA SUSTENNA 3 QL: 0.25

in 28

days

disp syrin: 39mg/

0.25


in 28

days

disp syrin: 78mg/

0.5ml


in 28

days

disp syrin: 117mg/

0.75

INVEGA SUSTENNA 5 QL: 1 in

28 days

disp syrin: 156mg/

ml


in 28

days

disp syrin: 234mg/

1.5

INVEGA 4 ST, QL:

31 in 31

days

tab er 24: 1.5mg,

3mg, 9mg

INVEGA 4 ST, QL:

62 in 31

days

tab er 24: 6mg

LATUDA 4 ST, QL:

30 in 30

days

loxapine succinate (Loxitane) 1

MOBAN 4

NAVANE 4 capsule: 20mg

olanzapine (Zyprexa) 2 QL: 31 in

31 days

ORAP 4

perphenazine (Perphenazine) 1

84

Drug Name Drug


quetiapine fumarate (Seroquel) 2 QL: 93 in

31 days

RISPERDAL CONSTA 4 QL: 4 in

28 days

risperidone (Risperdal M-tab) 2 QL: 124

in 31

days

tab rapdis: 3mg,

4mg

risperidone (Risperdal M-tab) 2 QL: 62 in

31 days

tab rapdis: 0.25mg,

0.5mg, 1mg, 2mg

risperidone (Risperdal) 1 QL: 496

in 31

days

solution

risperidone (Risperdal) 1 QL: 62 in

31 days

tablet

SAPHRIS 4 ST, QL:

60 in 30

days

SEROQUEL XR 4 ST, QL:

31 in 31

days

tab er 24h: 200mg

SEROQUEL XR 4 ST, QL:

62 in 31

days

tab er 24h: 50mg,

150mg, 300mg,

400mg

thioridazine hcl (Thioridazine HCl) 1 PA oral conc., (PA for

Ages 65 and Older;

May be High Risk

Med)

thioridazine hcl (Thioridazine HCl) 1 PA tablet, (PA for

Ages 65 and Older;

May be High Risk

Med)

thiothixene (Navane) 1

trifluoperazine hcl (Trifluoperazine HCl) 1

ziprasidone hcl (Geodon) 2 QL: 62 in

31 days

ZYPREXA RELPREVV 5 QL: 2 in

28 days

ZYPREXA 4 QL: 31 in

31 days

vial

85

Drug Name Drug


Renin-Angiotensin-Aldosterone System Inhibitors Angiotensin II Receptor Antagonists

BENICAR HCT 3 ST

BENICAR 3 ST

DIOVAN HCT 4 ST

DIOVAN 4 ST

eprosartan mesylate (Teveten) 2

irbesartan (Avapro) 2

irbesartan/

hydrochlorothiazide

(Avalide) 2

losartan potassium (Cozaar) 1

losartan/

hydrochlorothiazide

(Hyzaar) 1

MICARDIS HCT 4 ST

MICARDIS 4 ST

TEVETEN HCT 4 ST

TEVETEN 4 ST tablet: 400mg

TRIBENZOR 4 ST

Angiotensin-Converting Enzyme Inhibitors

benazepril hcl (Lotensin) 1

benazepril/

hydrochlorothiazide

(Lotensin HCT) 1

captopril (Capoten) 1

captopril/

hydrochlorothiazide

(Capozide) 1

enalapril maleate (Vasotec) 1

enalapril/

hydrochlorothiazide

(Vaseretic) 1

enalaprilat dihydrate (Enalaprilat Dihydrate) 2

fosinopril sodium (Monopril) 1

fosinopril/

hydrochlorothiazide

(Monopril HCT) 1

lisinopril (Zestril) 1

lisinopril/

hydrochlorothiazide

(Prinzide) 1

moexipril hcl (Univasc) 1

moexipril/

hydrochlorothiazide

(Uniretic) 1

perindopril erbumine (Aceon) 1

quinapril hcl (Accupril) 1

quinapril/

hydrochlorothiazide

(Accuretic) 1

86

Drug Name Drug


ramipril (Altace) 1

trandolapril (Mavik) 1

trandolapril/verapamil hcl (Trandolapril/verapamil HCl) 1

Renin-Angiotensin-Aldosterone System Inhibitors

AMTURNIDE 4 ST

eplerenone (Inspra) 2

spironolact/

hydrochlorothiazid

(Aldactazide) 1

spironolactone (Aldactone) 1

TEKAMLO 4 ST

TEKTURNA HCT 4 ST

TEKTURNA 4 ST

VALTURNA 4 ST

Replacement Preparations Replacement Preparations

0.9 % sodium chloride (0.9 % Sodium Chloride) 1

calcium chloride (Calcium Chloride) 1

calcium gluconate (Calcium Gluconate) 1 PA

dex 2.5%-half str

lact.ringers

(Dex 2.5%-half Str Lact.ringers) 1

dextrose 2.5% in half

ringers

(Dextrose 2.5% In Half Ringers) 1

dextrose 5% in ringers (Dextrose 5% In Ringers) 1

dextrose 5%-lactated

ringers

(Dextrose 5%-Lactated Ringers) 1

DEXTROSE W/

ELECTROLYTE A

3

DEXTROSE W/

ELECTROLYTE B

3

EFFER-K 4

electrolyte-48 solution/

d10w

(Electrolyte-48 Solution/d10w) 1


d5w

(Electrolyte-48 Solution/D5W) 1

electrolyte-48/fructose

10%

(Electrolyte-48/fructose 10%) 1

electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 1


d5w

(Electrolyte-75 Solution/D5W) 1

electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 1

electrolyte-r solution/d5w (Normosol-r and Dextrose) 1

HYPERLYTE CR 3

HYPERLYTE R 3

87

Drug Name Drug


IONOSOL B with

DEXTROSE 5%

3

IONOSOL MB-

DEXTROSE 5%

3

IONOSOL T-DEXTROSE

5%

3

ISOLYTE E 3

ISOLYTE H W/

DEXTROSE

3

ISOLYTE M W/

DEXTROSE

3

ISOLYTE P with

DEXTROSE

3

ISOLYTE S with

DEXTROSE

3

ISOLYTE S 3

LACTATED RINGERS 4

NORMOSOL-M and

DEXTROSE

3

NORMOSOL-R PH 7.4 3

NUTRILYTE II 3

NUTRILYTE 3

PLASMA-LYTE 148 3

PLASMA-LYTE 56 IN

DEXTROSE

3

PLASMA-LYTE A PH

7.4

3

PLASMA-LYTE M IN

DEXTROSE

3

pot chloride/pot bicarb/cit

ac

(K-lyte-cl) 1

potassium acetate (Potassium Acetate) 1

potassium bicarbonate/cit

ac

(K-lyte) 1

potassium chlorid/d10-

0.2%nacl

(Potassium Chlorid/d10-

0.2%NaCl)

1


0.225nacl


0.225NaCl)

1 iv soln: 10meq/l,

30meq/l, 40meq/l


0.225nacl


0.225NaCl)

1 iv soln: 20meq/l

potassium chloride in

0.9%nacl

(Potassium Chloride In

0.9%NaCl)

1

88

Drug Name Drug


potassium chloride (Kaochlor) 1 liquid, packet, tablet

sa

potassium chloride (K-dur) 1 capsule er,

piggyback, tab er

prt, tablet er, vial

potassium chloride/d5-

0.25ns

(Potassium Chloride/D5-0.25

NS)

1


0.33nacl

(Potassium Chloride/d5-

0.33NaCl)

1


0.45nacl


0.45NaCl)

1


0.9%nacl


0.9%NaCl)

1

potassium chloride/d5lr (Potassium Chloride/D5 LR) 1

potassium chloride/d5w (Potassium Chloride/D5W) 1 iv soln: 10meq/l

potassium chloride/d5w (Potassium Chloride/D5W) 1 iv soln: 20meq/l,

30meq/l, 40meq/l

potassium chloride-0.45%

nacl

(Potassium Chloride-0.45%

NaCl)

1

potassium gluconate (Potassium Gluconate) 1

potassium phos,m-basic-d-

basic

(Potassium Phos,m-basic-d-

basic)

1

ringers solution (Ringers Solution) 1

sodium acetate (Sodium Acetate) 1

sodium chloride 0.45 % (Sodium Chloride 0.45 %) 1

sodium chloride 3% (Sodium Chloride 3%) 1

sodium chloride 5% (Sodium Chloride 5%) 1

sodium chloride (Sodium Chloride) 1 iv soln

sodium chloride (Sodium Chloride) 1 vial

sodium phos,m-basic-d-

basic

(Sodium Phos,m-basic-d-basic) 1

TPN ELECTROLYTES 3

TRAVERT-

ELECTROLYTE NO.1

3

TRAVERT-

ELECTROLYTE NO.2

3 iv soln: 10%

TRAVERT-

ELECTROLYTE NO.2

3 iv soln: 5%

TRAVERT-

ELECTROLYTE NO.3

3

TRAVERT-

ELECTROLYTE NO.4

3

Respiratory Tract Agents, Miscellaneous

89

Drug Name Drug


Respiratory Tract Agents, Miscellaneous

acetylcysteine (Acetylcysteine) 1 PA (PA for Part B vs

Part D Only)

aminophylline (Aminophylline) 1 liquid, tablet

aminophylline (Aminophylline) 1 vial

ARALAST 5

DALIRESP 3 ST, QL:

30 in 30

days

guaifen/theop anhyd/p-

ephed

(Guaifen/theop Anhyd/p-ephed) 1

KALYDECO 5 PA, QL:

60 in 30

days

PROLASTIN C 5

PROLASTIN 5

theophylline anhydrous (Theochron) 1 elixir, tab er 12h:

100mg, 200mg,

300mg, 450mg;

tablet er

theophylline anhydrous (Theochron) 1 solution, tab er 12h:

200mg

theophylline/d5w (Theophylline/D5W) 1

XOLAIR 5 PA, QL:

6 in 28

days

ZEMAIRA 5

90

Drug Name Drug


Sclerosing Agents Sclerosing Agents

ethanolamine oleate (Ethanolamine Oleate) 1

sodium morrhuate (Sodium Morrhuate) 1

sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 1

Serums Serums

ANASCORP 5

ANTIVENIN

LATRODECTUS

MACTANS

3

ANTIVENIN

MICRURUS FULVIUS

5

CARIMUNE NF

NANOFILTERED


Part D Only)

CROFAB 5

CYTOGAM 5

DIGIBIND 3

DIGIFAB 3

FLEBOGAMMA DIF 5 PA (PA for Part B vs

Part D Only)

FLEBOGAMMA 5 PA (PA for Part B vs

Part D Only)

GAMMAGARD LIQUID 5 PA (PA for Part B vs

Part D Only)

GAMMAPLEX 5 PA (PA for Part B vs

Part D Only)

GAMUNEX-C 5 PA (PA for Part B vs

Part D Only)

HIZENTRA 5 PA (PA for Part B vs

Part D Only)

HYPERRAB S-D 3

HYPERRHO S-D 3

IMOGAM RABIES-HT 3

MICRHOGAM PLUS 3

OCTAGAM 5 PA (PA for Part B vs

Part D Only)

PRIVIGEN 5 PA (PA for Part B vs

Part D Only)

RHOGAM PLUS 3

RHOPHYLAC 3

91

Drug Name Drug


VIVAGLOBIN 5 PA (PA for Part B vs

Part D Only)

WINRHO SDF 3

Skeletal Muscle Relaxants Skeletal Muscle Relaxants

baclofen (Baclofen) 1

carisoprodol (Soma) 1 PA, QL:

120 in 30

days

tablet: 250mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

carisoprodol (Soma) 1 PA, QL:

120 in 30

days

tablet: 350mg, (PA

for Ages 65 and

Older; May be High

Risk Med)

chlorzoxazone (Parafon Forte DSC) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

chlorzoxazone/

acetaminophen

(Chlorzoxazone/acetaminophen) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

cyclobenzaprine hcl (Flexeril) 1 PA tablet: 5mg, 10mg,

(PA for Ages 65 and

Older; May be High

Risk Med)

dantrolene sodium (Dantrium) 1 vial

dantrolene sodium (Dantrium) 2 capsule

metaxalone (Skelaxin) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

methocarbamol (Robaxin-750) 1 PA (PA for Ages 65 and

Older; May be High

Risk Med)

tizanidine hcl (Zanaflex) 1 tablet

tizanidine hcl (Zanaflex) 2 capsule

Skin and Mucous Membrane Agents, Miscellaneous Skin and Mucous Membrane Agents, Miscellaneous

8-MOP 3

adapalene (Differin) 2

AMEVIVE 5 PA, QL:

4 in 28

days

ammonium lactate (Lac-hydrin) 1

AZELEX 4

92

Drug Name Drug


calcipotriene (Calcipotriene) 1 oint. (g)

calcipotriene (Dovonex) 2 solution

calcitriol (Vectical) 2

CARAC 3

CONDYLOX 4 gel (gram)

DIFFERIN 4 gel (gram): 0.3%;

lotion

DOVONEX 3 cream

ELIDEL 3 PA

EPIDUO 4

FLUOROPLEX 3

fluorouracil (Efudex) 2 cream (g)

fluorouracil (Efudex) 2 solution

imiquimod (Aldara) 2 PA, QL:

24 in 30

days

isotretinoin (Accutane) 2

LEVULAN 3

METVIXIA 3

OXSORALEN 4

OXSORALEN-ULTRA 5

PANRETIN 5

PICATO 4 PA, QL:

2 in 56

days

gel (ea): 0.05%

PICATO 4 PA, QL:

3 in 56

days

gel (ea): 0.015%

podofilox (Condylox) 2

podophyllum resin (Pododerm) 2

PROTOPIC 4 PA

RECTIV 4 QL: 30 in

30 days

REGRANEX 4 PA, QL:

30 in 30

days

SANTYL 3

SORIATANE 5 capsule: 10mg,

17.5mg, 25mg

SORIATANE 5 capsule: 22.5mg

STELARA 5 PA, QL:

10 in 360

days

93

Drug Name Drug


TACLONEX SCALP 3

TACLONEX 2

TARGRETIN 5

TAZORAC 3

UVADEX 4

ZYCLARA 3 PA, QL:

28 in 28

days

Somatotropin Agonists and Antagonists Somatotropin Agonists and Antagonists

INCRELEX 5

SOMAVERT 5

Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents

alfuzosin hcl (Uroxatral) 2

dihydroergotamine

mesylate

(D.H.E. 45) 2

ergotamine tartrate/

caffeine

(Ergotamine Tartrate/caffeine) 1

phentolamine mesylate (Phentolamine Mesylate) 2 PA

PHENTOLAMINE

MESYLATE

2 PA

tamsulosin hcl (Flomax) 1

Sympathomimetic (Adrenergic) Agents Sympathomimetic (Adrenergic) Agents

albuterol sulfate (Accuneb) 1 PA solution, vial-neb:

0.63mg/3ml,

1.25mg/3ml, 2.5mg/

3ml, (PA for Part B

vs Part D Only)

albuterol sulfate (Proventil) 1 syrup, tablet

albuterol sulfate (Vospire ER) 2 tab er 12h

albuterol (Ventolin) 1

COMBIVENT

RESPIMAT

3 QL: 8 in

30 days

COMBIVENT 3 QL: 29.4

in 30

days

dobutamine hcl (Dobutamine HCl) 2 PA (PA for Part B vs

Part D Only)

dobutamine hcl/d5w (Dobutamine HCl/D5W) 1 PA (PA for Part B vs

Part D Only)

94

Drug Name Drug


dopamine hcl (Dopamine HCl) 1 PA (PA for Part B vs

Part D Only)

dopamine hcl/d5w (Dopamine HCl/D5W) 1 PA (PA for Part B vs

Part D Only)

ephedrine sulfate (Ephedrine Sulfate) 1

epinephrine (Adrenaclick) 2 QL: 2 in

30 days

disp syrin: 0.3mg/

0.3; pen injctr

epinephrine (Epinephrine) 1 disp syrin: 0.1mg/

ml

epinephrine/pf (Epinephrine/PF) 1

EPIPEN JR 4 QL: 2 in

30 days

EPIPEN 4 QL: 2 in

30 days

FORADIL 3 QL: 62 in

31 days

isoproterenol hcl (Isoproterenol HCl) 1

MAXAIR AUTOHALER 4 QL: 14 in

30 days

metaproterenol sulfate (Metaproterenol Sulfate) 1

midodrine hcl (Proamatine) 2

NEO-SYNEPHRINE 4

norepinephrine bit/0.9 %

nacl

(Norepinephrine Bit/0.9 %

NaCl)


Part D Only)

norepinephrine bitartrate (Norepinephrine Bitartrate) 1 PA (PA for Part B vs

Part D Only)

phenylephrine hcl (Phenylephrine HCl) 1

phenylephrine tannate (Phenylephrine Tannate) 1

PROAIR HFA 3 QL: 17 in

25 days

SEREVENT DISKUS 3 QL: 62 in

31 days

terbutaline sulfate (Brethine) 1

VENTOLIN HFA 4 QL: 36 in

25 days

Thyroid and Antithyroid Agents Thyroid and Antithyroid Agents

levothyroxine sodium (Levothyroxine Sodium) 2 vial

levothyroxine sodium (Synthroid) 1 tablet

liothyronine sodium (Cytomel) 1

methimazole (Tapazole) 1 tablet: 20mg

methimazole (Tapazole) 1 tablet: 5mg, 10mg

propylthiouracil (Propylthiouracil) 1

95

Drug Name Drug


Toxoids Toxoids

ADACEL 3 disp syrin

ADACEL 3 vial

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA-

TETANUS TOXOID

3

INFANRIX PF 3

INFANRIX 3

TE ANATOXAL BERNA 3 PA (PA for Part B vs

Part D Only)

TENIVAC 3

TETANUS DIPHTHERIA

TOXOIDS

3

TETANUS-DIPHTERIA-

DECAVAC

3

TRIHIBIT 3

TRIPEDIA 3

Urinary Anti-infectives Urinary Anti-infectives

methenamine mandelate (Mandelamine) 1 tablet: 500mg

methenamine mandelate (Mandelamine) 2 tablet: 1g

nitrofurantoin

macrocrystal

(Macrobid) 1 PA, QL:

90 in 365

days

(PA/QL for Ages 65

and Older; May be

High Risk Med)

trimethoprim (Trimethoprim) 1

Vaccines Vaccines

ACTHIB 3

ATTENUVAX

VACCINE with

DILUENT


Part D Only)

BCG VACCINE (TICE

STRAIN)


Part D Only)

BIOTHRAX 3

CERVARIX 4 disp syrin

CERVARIX 4 vial

COMVAX 3

ENGERIX-B 3 PA (PA for Part B vs

Part D Only)

GARDASIL 4 disp syrin

96

Drug Name Drug


GARDASIL 4 vial

HAVRIX 3 PA (PA for Part B vs

Part D Only)

IPOL 3

IXIARO 3

JE-VAX 3

KINRIX 3

MENACTRA 3 disp syrin

MENACTRA 3 vial

MENOMUNE-A-C-Y-W-

135

3

MENVEO A-C-Y-W-135-

DIP

3

MERUVAX II VACCINE

W-DILUENT

3

M-M-R II VACCINE 3

MUMPSVAX VACCINE

W-DILUENT

3

PEDIARIX 3

PEDVAXHIB 3

PENTACEL 3

PROQUAD 4

RABAVERT 3 PA (PA for Part B vs

Part D Only)

RECOMBIVAX HB 3 PA disp syrin

RECOMBIVAX HB 3 PA disp syrin, (PA for

Part B vs Part D

Only)

RECOMBIVAX HB 3 PA vial, (PA for Part B

vs Part D Only)

ROTARIX 3

ROTATEQ 3

THERACYS 3 PA (PA for Part B vs

Part D Only)

TWINRIX 3 disp syrin

TWINRIX 3 vial

TYPHIM VI 3

VAQTA 3 PA disp syrin, (PA for

Part B vs Part D

Only)

VAQTA 3 PA vial, (PA for Part B

vs Part D Only)

VARIVAX VACCINE 3

97

Drug Name Drug


YF-VAX 3

ZOSTAVAX 3

Vasodilating Agents Vasodilating Agents

ADCIRCA 5 PA, QL:

60 in 30

days

AGGRENOX 3 QL: 60 in

30 days

alprostadil (Alprostadil) 2 PA

amyl nitrite (Amyl Nitrite) 1

epoprostenol sodium

(glycine)

(Flolan) 2 PA vial: 0.5mg, (PA


Only)

epoprostenol sodium

(glycine)

(Flolan) 5 PA vial: 1.5mg, (PA


Only)

isosorbide dinitrate (Isordil) 1

isosorbide mononitrate (Imdur) 1 tab er 24h, tablet:

20mg

isosorbide mononitrate (Ismo) 1 tablet: 10mg

ISOVEX 3

LETAIRIS 5 PA, QL:

30 in 30

days

NITRO-BID 3

nitroglycerin (Nitro-dur) 1 QL: 30 in

30 days

patch td24: 0.1mg/

hr, 0.2mg/hr, 0.6mg/

hr

nitroglycerin (Nitro-dur) 1 QL: 60 in

30 days

patch td24: 0.4mg/

hr

nitroglycerin (Nitroglycerin) 1 vial

nitroglycerin (Nitrolingual) 2 spray

nitroglycerin/d5w (Nitroglycerin/D5W) 1

NITROSTAT 3

nylidrin hcl (Nylidrin HCl) 1 tablet: 12mg

papaverine hcl (Papaverine HCl) 1 PA

REMODULIN 5 PA (PA for Part B vs

Part D Only)

REVATIO 5 PA, QL:

37.5 in 1

day

vial

98

Drug Name Drug


REVATIO 5 PA, QL:

90 in 30

days

tablet

TRACLEER 5 LA, PA,

QL: 60 in

30 days

Vitamins and Minerals Vitamins and Minerals

calcitriol (Rocaltrol) 1 PA (PA for ESRD

Only)

FLUOR-A-DAY 4

fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 4

FLURA 4

HECTOROL 3 PA (PA for ESRD

Only)

LOZI-FLUR 4

multivitamins with

fluoride

(Multivitamins with Fluoride) 4

ped mv a,c,d3 #21 w-

fluoride

(Ped Mv A,c,d3 #21 W-fluoride) 4

pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 3 (All Pre-Natal

Vitamins are

Covered)

sodium fluoride (Luride) 4 drops

sodium fluoride (Luride) 4 tab chew

ZEMPLAR 4 PA (PA for ESRD

Only)

I-1

INDEX

0.9 % sodium chloride ....... 86

8-MOP................................ 91

aa/antipyrn/bcaine/polico#1/

al .................................... 71

aa/antpy/bcaine/polico/al

acet ................................. 71

ABELCET.......................... 26

ABILIFY ............................ 82

ABILIFY DISCMELT ....... 82

ABRAXANE ..................... 36

acarbose ............................. 21

acebutolol hcl ..................... 49

acetaminophen with codeine 5

acetaminophen/phenyltolx cit

.......................................... 3

acetazolamide .................... 27

acetazolamide sodium ........ 27

acetic ac/ricinoleic/oxyquinol

........................................ 31

acetic acid .................... 28, 70

acetic acid/aluminum acetate

........................................ 28

acetic acid/hydrocortisone . 28

acetylcysteine ..................... 89

ACTEMRA ........................ 72

ACTHAR H.P. ................... 72

ACTHIB ............................. 95

ACTIMMUNE ................... 72

ACTONEL ......................... 72

ACTONEL with CALCIUM

........................................ 72

ACTOPLUS MET ............. 25

ACTOPLUS MET XR ....... 25

ACTOS .............................. 25

ACUFLEX ........................... 3

acyclovir ............................. 46

acyclovir sodium ................ 46

ADACEL ........................... 95

ADAGEN ........................... 62

adapalene ........................... 91

ADCETRIS ........................ 36

ADCIRCA .......................... 97

ADVAIR DISKUS ............... 1

ADVAIR HFA ..................... 1

ADVICOR .......................... 35

AEROBID-M ....................... 1

AFINITOR ......................... 36

AGGRENOX ..................... 97

A-HYDROCORT ................. 1

AKTEN .............................. 71

ALBENZA ......................... 13

ALBUKED-25 ................... 50

ALBUKED-5 ..................... 50

ALBUMIN HUMAN ......... 50

ALBUMINAR-25 .............. 50

ALBUMINAR-5 ................ 50

ALBURX ........................... 50

ALBUTEIN ........................ 50

albuterol ............................. 93

albuterol sulfate.................. 93

alclometasone dipropionate

........................................ 33

alcohol antiseptic pads ....... 31

ALDURAZYME ................ 62

alendronate sodium ............ 72

ALFERON N...................... 46

alfuzosin hcl........................ 93

ALIMTA ............................ 36

ALINIA .............................. 43

allopurinol .......................... 72

allopurinol sodium ............. 72

ALOCRIL........................... 33

ALOMIDE ......................... 13

ALORA .............................. 63

ALOXI ............................... 25

ALPHAGAN P ................... 27

alprazolam .......................... 48

alprostadil .......................... 97

ALREX............................... 31

ALTABAX ......................... 30

ALTOPREV ....................... 35

aluminum chloride.............. 47

ALVESCO ........................... 1

amantadine hcl .................. 41

amcinonide......................... 33

AMERICAINE .................. 43

AMEVIVE ......................... 91

amifostine crystalline ......... 72

amikacin sulfate ................. 13

amiloride hcl ...................... 61

amiloride/

hydrochlorothiazide ....... 61

AMINO ACIDS ................. 51

aminocaproic acid ............. 67

aminophylline .................... 89

AMINOSYN ................ 51, 52

AMINOSYN II .................. 51

AMINOSYN II 3.5% M-

DEXTROSE 5% ............ 51

AMINOSYN II 3.5%-

DEXTROSE 25% .......... 51

AMINOSYN II 3.5%-

DEXTROSE 5% ............ 51

AMINOSYN II 4.25% M-

DEXT 10% .................... 51

AMINOSYN II 4.25%-

DEXTROSE 25% .......... 51

AMINOSYN II 5% IN 25%

DEXTROSE .................. 51

AMINOSYN II IN

DEXTROSE .................. 51

AMINOSYN II with LYTES-

CA-DW .......................... 51

AMINOSYN M ................. 51

AMINOSYN with

ELECTROLYTES ......... 51

AMINOSYN-HBC ............ 52

AMINOSYN-HF ............... 52

AMINOSYN-PF ................ 52

AMINOSYN-RF ............... 52

amiodarone hcl .................. 56

AMITIZA .......................... 57

amitriptyline hcl ................. 80

I-2

amlodipine besylate ........... 50

amlodipine besylate/

benazepril ....................... 50

amlodipine/atorvastatin ..... 35

ammonium chloride ........... 72

ammonium lactate .............. 91

amoxapine .......................... 80

amoxicillin.......................... 16

amoxicillin/potassium clav. 16

amphet asp/amphet/d-amphet

........................................ 11

amphotericin b ................... 26

ampicillin sodium ............... 16

ampicillin sodium/sulbactam

na.................................... 16

ampicillin trihydrate .......... 16

AMPYRA .......................... 72

AMTURNIDE.................... 86

amyl nitrite ......................... 97

ANACAINE ....................... 43

ANADROL-50 ................... 10

anagrelide hcl .................... 67

ANASCORP ...................... 90

anastrozole ......................... 36

ANDRODERM .................. 10

ANDROGEL...................... 10

ANGELIQ .......................... 63

antipyrine/benzocaine/

glycerin .......................... 71

ANTIVENIN

LATRODECTUS

MACTANS .................... 90

ANTIVENIN MICRURUS

FULVIUS ....................... 90

APEXICON E .................... 33

APOKYN ........................... 41

apraclonidine hcl ............... 61

APRISO ............................. 32

APTIVUS ........................... 44

ARALAST ......................... 89

ARANESP ......................... 68

ARCALYST ...................... 72

ARICEPT ........................... 78

ARRANON ........................ 36

ARZERRA ......................... 36

ASACOL ............................ 32

ASACOL HD ..................... 32

ASMANEX .......................... 1

ASTEPRO .......................... 13

ATELVIA........................... 72

atenolol ............................... 49

atenolol/chlorthalidone ...... 49

atorvastatin calcium ........... 35

atovaquone/proguanil hcl .. 43

ATRIPLA ........................... 44

atropine sulfate ............. 19, 61

ATROVENT HFA ............. 19

ATTENUVAX VACCINE

with DILUENT .............. 95

AVANDAMET .................. 25

AVANDARYL................... 25

AVANDIA ......................... 25

AVASTIN .......................... 36

AVC ................................... 31

AVELOX ........................... 18

AVELOX ABC PACK....... 18

AVELOX IV ...................... 18

AVODART ........................ 72

AVONEX ........................... 72

AVONEX

ADMINISTRATION

PACK ............................. 72

AXERT............................... 35

AXIRON ............................ 10

AZACTAM-ISO-OSMOTIC

DEXTROSE ................... 16

AZASITE ........................... 28

azathioprine ........................ 72

azathioprine sodium ........... 72

azelastine hcl ...................... 13

AZELEX ............................ 91

AZILECT ........................... 41

azithromycin ....................... 15

azithromycin hydrogen citrate

........................................ 15

AZOPT ............................... 27

AZOR ................................. 50

aztreonam ........................... 16

bacitracin ..................... 14, 28

bacitracin/polymyxin b sulfate

....................................... 29

baclofen ............................. 91

BACTOCILL ..................... 16

BACTROBAN NASAL .... 29

BAL IN OIL ...................... 66

balsalazide disodium ......... 32

BANZEL ........................... 19

BARACLUDE ................... 46

BCG VACCINE TICE

STRAIN ......................... 95

BECONASE AQ ............... 31

benazepril hcl .................... 85

benazepril/


BENICAR .......................... 85

BENICAR HCT ................. 85

BENLYSTA ...................... 72

benzocaine ......................... 71

benzoyl peroxide ................ 70

benzoyl peroxide

microspheres .................. 70

benzoyl peroxide/aloe vera 70

benzoyl peroxide/

hydrocortison ................. 70

benzoyl peroxide/urea ........ 70

benztropine mesylate ......... 41

BEPREVE ......................... 13

BERINERT ........................ 73

BESIVANCE ..................... 29

betamet acet/betamet na ph . 1

betamet diprop/prop gly .... 33

betamethasone dipropionate

....................................... 33

betamethasone valerate ..... 33

BETASERON .................... 73

betaxolol hcl ................ 27, 49

bethanechol chloride ......... 78

BETIMOL ......................... 27

BETOPTIC S ..................... 27

BEXXAR ........................... 36

bicalutamide ...................... 36

BICILLIN C-R .................. 17

I-3

BICILLIN L-A ................... 17

BICNU ............................... 36

BILTRICIDE ..................... 13

BIOTHRAX ....................... 95

bisoprolol fumarate ............ 49

bisoprolol fumarate/hctz .... 49

bleomycin sulfate ............... 36

BLEPHAMIDE .................. 29

BLEPHAMIDE S.O.P. ...... 29

BONIVA ............................ 73

BOOSTRIX........................ 95

BOTOX .............................. 73

BRANCHAMIN ................ 52

BRILINTA ......................... 68

brimonidine tartrate ........... 27

BROMDAY ....................... 31

bromfenac sodium .............. 31

bromocriptine mesylate ...... 42

budesonide ........................... 1

bumetanide ......................... 61

BUMINATE ...................... 50

BUPHENYL ........................ 3

buprenorphine hcl .............. 10

bupropion hcl ..................... 80

buspirone hcl ...................... 47

BUSULFEX ....................... 36

BUTISOL SODIUM .......... 57

butorphanol tartrate........... 10

BYDUREON ..................... 21

BYETTA ............................ 21

BYSTOLIC ........................ 49

cabergoline ........................ 42

caffeine citrated ................. 11

caffeine/sodium benzoate ... 11

calcipotriene ...................... 92

calcitonin,salmon,synthetic 79

calcitriol ....................... 92, 98

calcium acetate .................. 70

calcium carbonate/mag carb/

fa .................................... 70

calcium chloride................. 86

CALCIUM DISODIUM

VERSENATE ................ 66

calcium gluconate .............. 86

CALDOLOR ........................ 4

CAMPATH ........................ 36

CAMPRAL......................... 57

CANCIDAS ....................... 27

CAPASTAT SULFATE ..... 36

CAPRELSA ....................... 36

captopril ............................. 85

captopril/hydrochlorothiazide

........................................ 85

CARAC .............................. 92

CARAFATE ....................... 43

CARBAGLU ........................ 3

carbamazepine ................... 19

carbidopa/levodopa ............ 42

carbinoxamine maleate ...... 28

carboplatin ......................... 37

CARDENE I.V. .................. 50

CARDENE SR ................... 50

CARIMUNE NF

NANOFILTERED ......... 90

carisoprodol ....................... 91

carteolol hcl........................ 61

carvedilol ............................ 49

CAYSTON ......................... 16

CEDAX .............................. 14

CEENU............................... 37

cefaclor ............................... 14

cefadroxil hydrate .............. 14

cefazolin sodium ................. 14

cefazolin sodium/dextrose,iso

........................................ 14

cefdinir ............................... 14

cefditoren pivoxil ................ 14

CEFEPIME......................... 15

cefepime hcl ........................ 14

CEFEPIME-DEXTROSE .. 15

cefotaxime sodium .............. 15

cefotetan disod/dextrose,iso16

cefotetan disodium.............. 16

cefoxitin sodium.................. 16

cefoxitin sodium/dextrose,iso

........................................ 16

cefpodoxime proxetil .......... 15

cefprozil .............................. 15

CEFTAZIDIME................. 15

ceftazidime pentahydrate ... 15

ceftriaxone na/dextrose,iso 15

ceftriaxone sodium ............. 15

cefuroxime axetil ................ 15

cefuroxime sodium ............. 15

cefuroxime sodium/

dextrose,iso .................... 15

CELEBREX......................... 4

CELLCEPT ....................... 73

CELONTIN ....................... 21

CENESTIN ........................ 63

cephalexin .......................... 15

CEPROTIN ........................ 66

CEREDASE....................... 62

CEREZYME ...................... 62

CERVARIX ....................... 95

CESAMET......................... 26

CETRAXAL ...................... 29

CHANTIX ......................... 78

CHENODAL ..................... 65

chloramphenicol na succ ... 14

chlorhexidine gluconate .... 29

chloroprocaine hcl/pf ........ 71

chloroquine phosphate ...... 43

chlorothiazide .................... 61

chloroxylenol/pramoxine hcl

....................................... 71

chlorpromazine hcl ............ 82

chlorthalidone .................... 61

chlorzoxazone .................... 91

chlorzoxazone/acetaminophen

....................................... 91

cholestyramine (with sugar)

....................................... 34

cholestyramine/aspartame . 34

choline sal/mag salicylate ... 4

ciclopirox ........................... 30

ciclopirox olamine ............. 30

cilostazol ............................ 68

CILOXAN ......................... 29

cimetidine........................... 43

cimetidine hcl ..................... 43

cimetidine in 0.9 % nacl .... 43

I-4

CIMZIA ............................. 65

CINRYZE .......................... 73

CIPRO HC ......................... 29

CIPRODEX........................ 29

ciprofloxacin hcl .......... 18, 29

ciprofloxacin lactate .......... 18

ciprofloxacin lactate/d5w... 18

ciprofloxacin/ciprofloxa hcl

........................................ 18

cisplatin .............................. 37

citalopram hydrobromide .. 80

citrate-phos-dex solution ... 66

citric acid/sodium citrate ... 73

cladribine ........................... 37

clarithromycin .................... 15

clemastine fumarate ........... 28

CLEVIPREX...................... 50

clindamycin hcl .................. 14

clindamycin palmitate hcl .. 14


perox .............................. 30

clindamycin phosphate. 14, 30

CLINIMIX ................... 52, 53

CLINIMIX E ...................... 52

CLINISOL ......................... 53

clobetasol propionate......... 33

CLODERM ........................ 33

CLOLAR............................ 37

clomipramine hcl ............... 80

clonazepam ........................ 48

clonidine ............................. 69

clonidine hcl ....................... 69

clonidine hcl/chlorthalidone

........................................ 69

clopidogrel bisulfate .......... 68

clorazepate dipotassium..... 48

clotrimazole........................ 30

clotrimazole/betamethasone

dip .................................. 30

clozapine ............................ 82

COARTEM ........................ 43

cocaine hcl ......................... 71

codeine phos/acetaminophen5

codeine phosphate ................ 5

codeine sulfate ...................... 5

CODEINE SULFATE .......... 5

colchicine/probenecid ........ 73

COLCRYS ......................... 73

colestipol hcl ...................... 34

colistin (colistimethate na) . 14

COLY-MYCIN S ............... 29

COMBIGAN ...................... 27

COMBIPATCH .................. 63

COMBIVENT .................... 93

COMBIVENT RESPIMAT93

COMPLERA ...................... 44

COMTAN........................... 42

COMVAX .......................... 95

CONDYLOX ..................... 92

COPAXONE ...................... 73

CORDRAN ........................ 33

CORDRAN SP ................... 33

COREG CR ........................ 49

cortisone acetate .................. 1

CORTISPORIN-TC ........... 29

CREON .............................. 65

CRESTOR .......................... 35

cresyl ace/ben alc/butanol/ipa

........................................ 29

CRIXIVAN ........................ 44

CROFAB ............................ 90

cromolyn sodium ................ 33

CUBICIN ........................... 14

cyclobenzaprine hcl ............ 91

CYCLOGYL ...................... 61

cyclopentolate hcl ............... 61

cyclophosphamide .............. 37

cyclosporine ....................... 73

cyclosporine, modified ....... 73

CYMBALTA ..................... 80

CYSTADANE .................... 73

cysteine hcl ......................... 53

cytarabine/pf....................... 37

CYTOGAM ........................ 90

dacarbazine ........................ 37

DACOGEN ........................ 37

dactinomycin ...................... 37

DALIRESP ......................... 89

danazol............................... 10

dantrolene sodium ............. 91

dapsone .............................. 36

DAPTACEL ...................... 95

DARAPRIM ...................... 43

daunorubicin hcl ................ 37

DAUNOXOME ................. 37

DDAVP ............................. 79

deferoxamine mesylate ...... 66

demeclocycline hcl ............. 18

DENAVIR ......................... 31

DEPO-ESTRADIOL ......... 63

DEPO-PROVERA ............. 80

desipramine hcl.................. 80

desmopressin acetate ......... 79

desogestrel-ethinyl estradiol

....................................... 60

desog-et estra/ethin estra... 60

desonide ............................. 33

desoximetasone .................. 33

DETROL LA ..................... 64

dex 2.5%-half str lact.ringers

....................................... 86

dexamethasone..................... 1

dexamethasone acetate ........ 1

dexamethasone sod phosphate

................................... 1, 31

dexmethylphenidate hcl ..... 11

dexrazoxane ....................... 73

dextroamphetamine sulfate 11


nacl ................................ 53

dextrose 10 % and 0.9 % nacl

....................................... 53

dextrose 10%-0.5 normal

saline .............................. 53

dextrose 10%-water ........... 53

dextrose 2.5 %-water ......... 53

dextrose 2.5% in half ringers

....................................... 86

dextrose 2.5%-0.5normal

saline .............................. 53

dextrose 20 % in water ...... 53

dextrose 20%-water ........... 53

I-5

dextrose 25%-water ........... 53

dextrose 40%-water ........... 53


........................................ 53


........................................ 53

dextrose 5 %-0.225 % nacl 53

dextrose 5 %-0.45 % nacl .. 53

dextrose 5 %-water ............ 53

dextrose 5% in ringers ....... 86

dextrose 5%-lactated ringers

........................................ 86




DEXTROSE W/

ELECTROLYTE A ....... 86

DEXTROSE W/

ELECTROLYTE B ........ 86

dhcodeine bt/acetaminophn/

caff.................................... 5

DIASTAT ACUDIAL ....... 48

diazepam ............................ 48

diclofenac potassium ............ 4

diclofenac sodium .......... 4, 31

dicloxacillin sodium ........... 17

dicyclomine hcl .................. 19

didanosine .......................... 44

DIFFERIN.......................... 92

DIFICID ............................. 15

diflorasone diacetate .......... 33

diflunisal .............................. 4

DIGIBIND ......................... 90

DIGIFAB ........................... 90

digoxin................................ 56

DIGOXIN .......................... 56

dihydroergotamine mesylate

........................................ 93

DILANTIN ........................ 21

diltiazem hcl ....................... 50

dimenhydrinate .................. 26

DIOVAN ............................ 85

DIOVAN HCT ................... 85

DIPENTUM ....................... 32

diphenhydramine hcl .......... 28

diphenoxylate hcl/atropine . 25

DIPHTHERIA-TETANUS

TOXOID......................... 95

disopyramide phosphate ..... 56

disulfiram ........................... 73

divalproex sodium .............. 19

dobutamine hcl ................... 93

dobutamine hcl/d5w ........... 93

DOCEFREZ ....................... 37

docetaxel............................. 37

donepezil hcl ....................... 78

dopamine hcl ...................... 94

dopamine hcl/d5w .............. 94

dorzolamide hcl .................. 27

dorzolamide hcl/timolol

maleat ............................. 27

DOVONEX ........................ 92

doxazosin mesylate ............... 3

doxepin hcl ......................... 80

doxorubicin hcl ................... 37

doxorubicin hcl liposomal .. 37

doxycycline hyclate ...... 18, 29

doxycycline monohydrate ... 18

DRITHO-SCALP ............... 71

dronabinol .......................... 26

droperidol ........................... 47

DROXIA ............................ 37

DUETACT ......................... 25

DULERA .............................. 1

DUODOTE......................... 73

DUREZOL ......................... 32

DUTOPROL....................... 49

DYNACIRC CR ................. 50

DYRENIUM ...................... 61

DYSPORT .......................... 73

econazole nitrate ................ 30

edetate disodium ................. 66

EDURANT ......................... 44

EFFER-K ............................ 86

EFFIENT ............................ 68

ELAPRASE ........................ 62

electrolyte-48 solution/d10w

........................................ 86

electrolyte-48 solution/d5w 86

electrolyte-48/fructose 10%86

electrolyte-48/fructose 5% . 86

electrolyte-75 solution/d5w 86

electrolyte-75/fructose 5% . 86

electrolyte-r solution/d5w .. 86

ELIDEL ............................. 92

ELIGARD .......................... 37

ELITEK ............................. 62

ELMIRON ......................... 73

ELSPAR ............................ 37

EMCYT ............................. 37

EMEND ............................. 26

EMSAM............................. 80

EMTRIVA ......................... 44

enalapril maleate ............... 85

enalapril/hydrochlorothiazide

....................................... 85

enalaprilat dihydrate ......... 85

ENBREL ............................ 74

ENDRATE......................... 66

ENGERIX-B ...................... 95

enoxaparin sodium ............ 66

ephedrine sulfate................ 94

EPIDUO............................. 92

epinastine hcl ..................... 13

epinephrine ........................ 94

epinephrine/pf .................... 94

EPIPEN .............................. 94

EPIPEN JR ........................ 94

epirubicin hcl ..................... 37

EPIVIR .............................. 44

EPIVIR HBV ..................... 44

eplerenone ......................... 86

EPOGEN ........................... 68

epoprostenol sodium (glycine)

....................................... 97

eprosartan mesylate ........... 85

EPZICOM .......................... 44

ERAXIS WATER DILUENT

....................................... 27

ERBITUX .......................... 37

ergotamine tartrate/caffeine

....................................... 93

I-6

ERIVEDGE........................ 37

ERWINAZE ....................... 37

ery e-succ/sulfisoxazole ..... 15

ERY-TAB .......................... 15

ERYTHROCIN

LACTOBIONATE ......... 15

erythromycin base .. 15, 16, 29

erythromycin base/ethanol . 30

erythromycin ethylsuccinate

........................................ 16

erythromycin stearate ........ 16

erythromycin/benzoyl

peroxide.......................... 30

escitalopram oxalate .......... 81

esmolol hcl ......................... 49

estazolam............................ 48

ESTRACE .......................... 63

estradiol ............................. 63

estradiol valerate ............... 63

estradiol/noreth ac ............. 63

ESTRASORB .................... 63

ESTRING ........................... 63

estropipate.......................... 63

ethambutol hcl .................... 36

ethanolamine oleate ........... 90

ethinyl estradiol/drospirenone

........................................ 60

ethosuximide ...................... 21

ethyl alcohol/d5w ............... 54

ethynodiol d-ethinyl estradiol

........................................ 60

etidronate disodium ........... 74

etodolac ................................ 4

ETOPOPHOS .................... 38

etoposide ............................ 38

EURAX .............................. 31

EVISTA ............................. 63

EXELDERM ...................... 30

EXELON............................ 78

exemestane ......................... 38

EXFORGE ......................... 50

EXFORGE HCT ................ 50

EXJADE ............................ 66

EXTAVIA .......................... 74

FABRAZYME ................... 62

FACTIVE ........................... 18

famciclovir .......................... 46

famotidine ........................... 44

famotidine in nacl,iso-osm/pf

........................................ 44

FANAPT ............................ 82

FARESTON ....................... 38

FASLODEX ....................... 38

FAZACLO ................... 82, 83

felbamate ............................ 19

felodipine ............................ 50

FEMHRT ............................ 64

FEMRING .......................... 64

fenofibrate .......................... 34

fenofibrate,micronized........ 34

fenofibric acid .................... 35

fenoldopam mesylate .......... 69

fenoprofen calcium ............... 4

fentanyl ............................. 5, 6

fentanyl citrate...................... 5

FERRIPROX ...................... 66

finasteride ........................... 74

FIRAZYR ........................... 74

FIRMAGON....................... 38

flavoxate hcl ....................... 64

FLEBOGAMMA ............... 90

FLEBOGAMMA DIF ........ 90

flecainide acetate................ 56

FLECTOR ............................ 4

FLEXBUMIN..................... 50

FLEXTRA PLUS ................. 3

FLOVENT DISKUS ............ 2

FLOVENT HFA ................... 2

floxuridine .......................... 38

fluconazole ......................... 27

fluconazole in nacl,iso-osm 27

flucytosine........................... 26

fludarabine phosphate ........ 38

fludrocortisone acetate ......... 2

flumazenil ........................... 57

flunisolide ........................... 32

fluocinolone acetonide ....... 34

fluocinolone acetonide oil .. 32

fluocinolone/shower cap .... 34

fluocinonide ....................... 34

FLUOR-A-DAY ................ 98

fluoride/iron/vit a,c&d ....... 98

FLUORITAB ..................... 74

fluorometholone ................. 32

FLUOROPLEX ................. 92

fluorouracil .................. 38, 92

fluoxetine hcl ...................... 81

fluoxymesterone ................. 10

fluphenazine decanoate ..... 83

fluphenazine hcl ................. 83

FLURA .............................. 98

FLURA-DROPS ................ 74

flurbiprofen .......................... 4

flurbiprofen sodium ........... 32

flutamide ............................ 38

fluticasone propionate . 32, 34

fluvastatin sodium .............. 35

fluvoxamine maleate .......... 81

FOCALIN XR ................... 11

FOLOTYN......................... 38

fomepizole .......................... 74

fondaparinux sodium ... 66, 67

FORADIL .......................... 94

FORTEO ............................ 79

FORTICAL ........................ 79

foscarnet sodium ................ 46

fosinopril sodium ............... 85

fosinopril/


fosphenytoin sodium .......... 21

FOSRENOL....................... 70

FREAMINE HBC.............. 54

FREAMINE III .................. 54

FREAMINE III with


FROVA .............................. 35

fructose 10% ...................... 54

furosemide ......................... 61

FUROXONE ..................... 31

FUSILEV ........................... 74

FUZEON ........................... 44

gabapentin ......................... 19

I-7

GABITRIL ......................... 19

galantamine hbr ................. 78

GALZIN ............................. 66

GAMMAGARD LIQUID .. 90

GAMMAPLEX .................. 90

GAMUNEX-C ................... 90

ganciclovir ......................... 47

ganciclovir sodium ............. 47

GARDASIL ................. 95, 96

gauze bandage ................... 74

GELNIQUE ....................... 64

gemcitabine hcl .................. 38

gemfibrozil ......................... 35

GENOTROPIN .................. 79

gentamicin in nacl, iso-osm 13

gentamicin sulfate .. 13, 29, 30

gentamicin sulfate/pf .......... 13

GEODON ........................... 83

GILENYA .......................... 74

GLEEVEC ......................... 38

glimepiride ......................... 24

glipizide .............................. 24

glipizide/metformin hcl ...... 24

GLUCAGEN...................... 74

GLUCAGON EMERGENCY

KIT ................................. 74

glutethimide........................ 47

glyburide ............................ 24

glyburide,micronized ......... 24

glyburide/metformin hcl .... 24,

25

glycine ................................ 70

glycopyrrolate .................... 19

GLYSET ............................ 21

gold sodium thiomalate ...... 74

granisetron hcl ............. 25, 26

granisetron hcl/pf ............... 26

griseofulvin,microsize ........ 26

GRIS-PEG.......................... 26

guaifen/theop anhyd/p-ephed

........................................ 89

guanfacine hcl .................... 69

GYNAZOLE-1 .................. 30

HALAVEN ........................ 38

HALFAN ............................ 43

halobetasol propionate ....... 34

haloperidol ......................... 83

haloperidol decanoate ........ 83

haloperidol lactate ............. 83

HAVRIX ............................ 96

HECTOROL....................... 98

heparin sodium,porcine ...... 67

heparin sodium,porcine/d5w

........................................ 67

heparin sodium,porcine/ns/pf

........................................ 67

heparin sodium,porcine/pf . 67

HEPATAMINE .................. 54

HEPATASOL..................... 54

HEPSERA .......................... 47

HERCEPTIN ...................... 38

HEXALEN ......................... 38

HIZENTRA ........................ 90

homatropine hbr ................. 62

HUMALOG ....................... 23

HUMALOG MIX 50-50 .... 22

HUMALOG MIX 75-25 .... 22

HUMATROPE ................... 79

HUMIRA ............................ 74

HUMULIN 70-30 ............... 23

HUMULIN N ..................... 23

HUMULIN R ..................... 23

hydralazine hcl ................... 69

hydralazine/

hydrochlorothiazid ......... 69

hydralazine/reserpin/hctz ... 69

hydrochlorothiazide ........... 61

hydrocodone bit/

acetaminophen ................. 6

hydrocodone/ibuprofen ........ 6

hydrocortisone ................ 2, 34

hydrocortisone acetate ....... 34

hydrocortisone acetate/aloe v

........................................ 34

hydrocortisone acetate/urea

........................................ 34

hydrocortisone butyrate ..... 34

hydrocortisone sod succinate

......................................... 2

hydrocortisone valerate ..... 34

hydromorphone hcl .......... 6, 7

hydromorphone hcl/pf.......... 7

hydroxychloroquine sulfate 43

hydroxyurea ....................... 38

hydroxyzine hcl .................. 47

hydroxyzine pamoate ......... 47

HYPERLYTE CR.............. 86

HYPERLYTE R ................ 86

HYPERRAB S-D .............. 90

HYPERRHO S-D .............. 90

ibandronate sodium ........... 74

ibuprofen .............................. 4

ibuprofen/oxycodone hcl ...... 7

idarubicin hcl ..................... 38

ifosfamide........................... 38

ifosfamide/mesna ............... 38

ILARIS .............................. 74

imipenem/cilastatin sodium 16

imipramine hcl ................... 81

imipramine pamoate .......... 81

imiquimod .......................... 92

IMOGAM RABIES-HT .... 90

inamrinone lactate ............. 57

INCIVEK ........................... 46

INCRELEX ....................... 93

indapamide ........................ 61

indomethacin ....................... 4

indomethacin sodium

trihydrate ......................... 4

INFANRIX ........................ 95

INFANRIX PF ................... 95

INLYTA ............................ 38

INNOPRAN XL ................ 49

INTELENCE ..................... 44

INTRALIPID ..................... 54

INTRON A ........................ 46

INTUNIV........................... 58

INVANZ ............................ 16

INVEGA ............................ 83

INVEGA SUSTENNA ...... 83

INVIRASE......................... 44

I-8

IONOSOL B with

DEXTROSE 5% ............ 87

IONOSOL MB-DEXTROSE

5% .................................. 87

IONOSOL T-DEXTROSE

5% .................................. 87

IOPIDINE .......................... 62

IPOL ................................... 96

ipratropium bromide .......... 62

IPRIVASK ......................... 67

irbesartan ........................... 85

irbesartan/


IRESSA .............................. 38

irinotecan hcl ..................... 38

ISENTRESS ....................... 44

ISOLYTE E ....................... 87

ISOLYTE H W/DEXTROSE

........................................ 87

ISOLYTE M W/DEXTROSE

........................................ 87

ISOLYTE P with

DEXTROSE ................... 87

ISOLYTE S ........................ 87

ISOLYTE S with

DEXTROSE ................... 87

isoniazid ............................. 36

isopropamide/

prochlorperazine ............ 19

isoproterenol hcl ................ 94

ISOPTO CARPINE ........... 27

ISOPTO HOMATROPINE 62

isosorbide dinitrate ............ 97

isosorbide mononitrate ...... 97

isotretinoin ......................... 92

ISOVEX ............................. 97

isradipine ........................... 50

ISTALOL ........................... 27

ISTODAX .......................... 38

itraconazole........................ 27

IXEMPRA.......................... 39

IXIARO.............................. 96

JAKAFI .............................. 39

JANUMET ......................... 21

JANUMET XR ................... 21

JANUVIA........................... 21

JENTADUETO .................. 21

JE-VAX .............................. 96

JEVTANA .......................... 39

JUVISYNC......................... 22

KADIAN .............................. 7

KALBITOR ........................ 74

KALETRA ......................... 45

KALYDECO ...................... 89

kanamycin sulfate ............... 13

KEDBUMIN ...................... 50

KENALOG......................... 34

KEPIVANCE ..................... 57

KETEK ............................... 16

ketoconazole ................. 27, 30

ketoprofen ............................. 4

ketorolac tromethamine.. 4, 32

KINERET ........................... 74

KINRIX .............................. 96

KORLYM........................... 22

K-PHOS M.F. ..................... 74

K-PHOS NO.2 .................... 74

KRYSTEXXA .................... 62

KUVAN ............................. 74

labetalol hcl ........................ 49

LACRISERT ...................... 62

LACTATED RINGERS .... 70,

87

lactulose ............................... 3

LAMICTAL BLUE ............ 19

LAMICTAL ODT .............. 20

LAMICTAL ODT BLUE... 19

LAMICTAL ODT GREEN 19

LAMICTAL ODT ORANGE

........................................ 19

LAMICTAL ORANGE...... 19

LAMICTAL XR ................. 20

LAMICTAL XR BLUE ..... 20

LAMICTAL XR GREEN .. 20

LAMICTAL XR ORANGE

........................................ 20

LAMISIL ............................ 30

lamivudine .......................... 45

lamivudine/zidovudine ....... 45

lamotrigine......................... 20

lansoprazole....................... 44

LANTUS ........................... 23

LANTUS SOLOSTAR ...... 23

latanoprost ......................... 27

LATUDA ........................... 83

leflunomide ........................ 74

LETAIRIS ......................... 97

letrozole ............................. 39

leucovorin calcium ............ 74

LEUKERAN ...................... 39

LEUKINE .......................... 68

leuprolide acetate .............. 39

LEVACET ........................... 4

LEVEMIR ......................... 23

levetiracetam ..................... 20

levobunolol hcl .................. 27

levocarnitine ...................... 75

levocarnitine (with sugar) . 75

levocetirizine dihydrochloride

....................................... 28

levofloxacin .................. 18, 29

levofloxacin/d5w ................ 18

levonorgestrel .................... 60

levonorgestrel-eth estradiol60

levorphanol tartrate ............. 7

levothyroxine sodium ......... 94

LEVULAN ........................ 92

LEXAPRO ......................... 81

LEXIVA ............................ 45

LIALDA ............................ 33

lidocaine ............................ 43

lidocaine hcl ................ 56, 71

lidocaine hcl/d5w/pf .......... 56

lidocaine hcl/pf ............ 56, 71

lidocaine/prilocaine ........... 43

LIDODERM ...................... 43

lindane ............................... 31

liothyronine sodium ........... 94

lipase/protease/amylase..... 65

LIPOSYN II ....................... 54

LIPOSYN III ..................... 54

lisinopril............................. 85

I-9

lisinopril/hydrochlorothiazide

........................................ 85

lithium carbonate ............... 58

lithium citrate ..................... 58

LITHOSTAT........................ 3

l-norgest-eth estr/ethin estra

........................................ 60

LOCOID ............................ 34

LODOSYN ........................ 58

loperamide hcl ................... 25

lorazepam ........................... 48

losartan potassium ............. 85

losartan/hydrochlorothiazide

........................................ 85

LOTEMAX ........................ 32

LOTRONEX ...................... 65

lovastatin ............................ 35

LOVAZA ........................... 34

LOVENOX ........................ 67

loxapine succinate .............. 83

LOZI-FLUR ....................... 98

LUMIGAN ......................... 27

LUMINAL SODIUM ........ 58

LUMIZYME ...................... 62

LUPRON DEPOT .............. 39

LUPRON DEPOT-PED ..... 39

LUVOX CR ....................... 81

LYRICA ............................. 20

LYSODREN ...................... 39

LYSTEDA ......................... 67

magnesium chloride ........... 20

magnesium salicylate ........... 4

magnesium sulfate .............. 20

magnesium sulfate/d5w ...... 20

malathion ........................... 31

mannitol/sorbitol solution .. 70

maprotiline hcl ................... 81

MARPLAN ........................ 81

MATULANE ..................... 39

MAXAIR AUTOHALER .. 94

mebendazole ....................... 13

meclizine hcl....................... 26

meclofenamate sodium ......... 4

medroxyprogesterone acetate

........................................ 80

mefenamic acid ..................... 4

mefloquine hcl .................... 43

MEGACE ES ..................... 39

megestrol acetate................ 39

meloxicam............................. 4

melphalan hcl ..................... 39

MENACTRA ..................... 96

MENEST ............................ 64

MENOMUNE-A-C-Y-W-135

........................................ 96

MENVEO A-C-Y-W-135-

DIP ................................. 96

mepivacaine hcl/pf.............. 71

MEPRON ........................... 43

mercaptopurine .................. 39

meropenem ......................... 16

MERUVAX II VACCINE

W-DILUENT ................. 96

mesalamine w/cleansing

wipes ............................... 33

mesna .................................. 75

MESNEX ........................... 75

MESTINON ....................... 78

METADATE CD ............... 11

metaproterenol sulfate........ 94

metaxalone ......................... 91

metformin hcl...................... 22

methadone hcl ...................... 7

methamphetamine hcl ......... 11

methazolamide .................... 27

methenamine mandelate ..... 95

methimazole ........................ 94

methocarbamol ................... 91

methotrexate sodium .......... 39

methotrexate sodium/pf ...... 39

methscopolamine bromide.. 19

methyclothiazide ................. 61

methylene blue .................... 75

methylergonovine maleate.. 75

METHYLIN ................. 11, 12

methylphenidate hcl............ 12

methylprednisolone .............. 2

methylprednisolone acetate . 2

methylprednisolone sod succ 2

metipranolol....................... 28

metoclopramide hcl ........... 65

metolazone ......................... 61

metoprolol succinate.......... 49

metoprolol tartrate ............ 49

metoprolol/


metronidazole .............. 30, 43

metronidazole/sodium

chloride .......................... 43

METVIXIA ....................... 92

mexiletine hcl ..................... 56

mg sal/acetaminophn/p-tlox/

caf .................................... 3

MIACALCIN..................... 79

MICARDIS ........................ 85

MICARDIS HCT ............... 85

miconazole nitrate ............. 30

MICRHOGAM PLUS ....... 90

midodrine hcl ..................... 94

milrinone lactate ................ 57

milrinone lactate/d5w ........ 57

MINOCIN .......................... 18

minocycline hcl .................. 18

minoxidil ............................ 69

mirtazapine ........................ 81

misoprostol ........................ 44

mitomycin........................... 39

mitoxantrone hcl ................ 39

M-M-R II VACCINE ........ 96

MOBAN ............................ 83

moexipril hcl ...................... 85

moexipril/


mometasone furoate ........... 34

morphine sulfate .............. 7, 8

morphine sulfate in 0.9 %

nacl .................................. 7

morphine sulfate/d5w .......... 8

morphine sulfate/pf .............. 8

MOXEZA .......................... 29

MOZOBIL ......................... 69

I-10

MULTAQ .......................... 56

multivitamins with fluoride 98

MUMPSVAX VACCINE W-

DILUENT ...................... 96

mupirocin ........................... 30

MUSTARGEN ................... 39

MYCOBUTIN ................... 36

mycophenolate mofetil ....... 75

MYFORTIC ....................... 75

MYOBLOC........................ 75

MYOZYME ....................... 62

MYTELASE ...................... 78

na nitrite/na thiosul/amyl nit

........................................ 66

nabumetone .......................... 5

nadolol ............................... 49

nadolol/bendroflumethiazide

........................................ 49

nafcillin sodium .................. 17

nafcillin sodium/d2.4w ....... 17

NAGLAZYME .................. 62

nalbuphine hcl .................... 10

nalidixic acid ...................... 18

naloxone hcl ....................... 77

naltrexone hcl..................... 78

NAMENDA ....................... 58

naphazoline hcl .................. 62

naphazoline hcl/antazoline 62

naproxen .............................. 5

naproxen sodium .................. 5

naratriptan hcl ................... 35

NASONEX ........................ 32

NATACYN ........................ 29

nateglinide.......................... 22

NAVANE ........................... 83

NEBCIN ............................. 13

NEBCIN IN DEXTROSE.. 13

needles, insulin disp., safety

........................................ 61

needles, insulin disposable. 61

nefazodone hcl ................... 81

neo/polymyx b sulf/dexameth

........................................ 29

neomy sulf/bacitra/polymyxin

b ...................................... 29

neomy sulf/bacitrac zn/poly/

hc .................................... 29

neomy sulf/polymyxin b

sulfate ............................. 30

neomycin sulfate ................. 13

neomycin sulfate/dex na ph 29

neomycin/polymyxin b sulf/hc

........................................ 29

neomycin/polymyxn b/

gramicidin ...................... 29

neostigmine methylsulfate .. 78

NEO-SYNEPHRINE ......... 94

NEPHRAMINE .................. 54

NEULASTA ....................... 69

NEUMEGA ........................ 69

NEUPOGEN ...................... 69

NEVANAC ........................ 32

nevirapine ........................... 45

NEXAVAR ........................ 39

niacin .................................. 34

NIASPAN........................... 34

nicardipine hcl.................... 50

NICOTROL ........................ 78

NICOTROL NS.................. 78

nifedipine ............................ 50

NILANDRON .................... 39

nimodipine .......................... 50

nisoldipine .......................... 50

NITRO-BID ....................... 97

nitrofurantoin macrocrystal

........................................ 95

nitroglycerin ....................... 97

nitroglycerin/d5w ............... 97

NITROSTAT ...................... 97

nizatidine ............................ 44

NORDITROPIN ................. 79

NORDITROPIN FLEXPRO

........................................ 79

NORDITROPIN

NORDIFLEX ................. 79

norepinephrine bit/0.9 % nacl

........................................ 94

norepinephrine bitartrate .. 94

noreth a-et estra/fe fumarate

....................................... 60

noreth-ethinyl estradiol/iron

....................................... 60

norethind ac/ethinyl estradiol

....................................... 64

norethindrone .................... 60

norethindrone acetate ........ 80

norethindrone a-e estradiol 60

norethindrone-ethinyl estrad

....................................... 60

norethindrone-mestranol ... 60

norgestimate-ethinyl estradiol

....................................... 60

norgestrel-ethinyl estradiol 60

NORMOSOL-M and

DEXTROSE .................. 87

NORMOSOL-R PH 7.4 ..... 87

NOROXIN ......................... 18

nortriptyline hcl ................. 81

NORVIR ............................ 45

NOVAMINE ..................... 54

NOVOLIN 70-30 ............... 23

NOVOLIN 70-30 INNOLET

....................................... 23

NOVOLIN N ..................... 23

NOVOLIN N INNOLET ... 23

NOVOLIN R ..................... 23

NOVOLOG ................. 23, 24

NOVOLOG MIX 70-30 .... 23

NOXAFIL .......................... 27

NPLATE ............................ 75

NUCYNTA .......................... 8

NUCYNTA ER.................... 8

NUEDEXTA ..................... 58

NULOJIX .......................... 75

NUTRESTORE ................. 65

NUTRILYTE ..................... 87

NUTRILYTE II ................. 87

NUTROPIN ....................... 79

NUTROPIN AQ ................ 79

NUTROPIN AQ NUSPIN . 79

NUVARING ...................... 60

I-11

NUVIGIL ........................... 12

nylidrin hcl ......................... 97

nystatin ......................... 26, 31

nystatin/triamcin ................ 31

OCTAGAM ....................... 90

octreotide acetate ............... 75

OFIRMEV............................ 3

ofloxacin ....................... 18, 29

olanzapine .......................... 83

omeprazole ......................... 44

omeprazole/sodium

bicarbonate .................... 44

OMNARIS ......................... 32

OMNITROPE .................... 79

ONCASPAR ...................... 39

ondansetron........................ 26

ondansetron hcl .................. 26

ONFI .................................. 49

ONTAK.............................. 40

ORAP ................................. 83

ORENCIA .......................... 75

ORFADIN .......................... 75

ORTHO EVRA .................. 60

oxacillin sodium ................. 17

oxacillin sodium/dextrose,iso

........................................ 17

oxaliplatin .......................... 40

oxandrolone ....................... 10

oxaprozin.............................. 5

oxazepam............................ 49

oxcarbazepine .................... 20

OXSORALEN ................... 92

OXSORALEN-ULTRA ..... 92

oxybutynin chloride ............ 64

oxycodone hcl....................... 8

oxycodone hcl/acetaminophen

...................................... 8, 9

oxycodone hcl/aspirin .......... 9

oxycodone hcl/oxycodon ter/

asa .................................... 9

OXYCONTIN ...................... 9

oxymorphone hcl .................. 9

OXYTROL ........................ 64

paclitaxel ............................ 40

pamidronate disodium ........ 75

PANCREAZE .................... 65

PANRETIN ........................ 92

pantoprazole sodium .......... 44

papaverine hcl .................... 97

paregoric ............................ 25

paromomycin sulfate .......... 43

paroxetine hcl ..................... 81

PASER ............................... 36

PATADAY ......................... 13

PATANASE ....................... 13

PATANOL ......................... 13

PAXIL ................................ 81

ped mv a,c,d3 #21 w-fluoride

........................................ 98

PEDIARIX ......................... 96

PEDVAXHIB ..................... 96

peg 3350/na sulf,bicarb,cl/kcl

........................................ 57

PEGANONE ...................... 21

PEGASYS .......................... 46

PEGASYS PROCLICK ..... 46

PEGINTRON ..................... 46

PEGINTRON REDIPEN ... 46

pen g pot/dextrose-water .... 17

penicillin g potassium......... 17

penicillin g potassium/d5w . 17

penicillin g procaine........... 17

penicillin v potassium ......... 17

PENTACEL ....................... 96

pentamidine isethionate...... 43

PENTASA .......................... 33

pentostatin .......................... 40

pentoxifylline ...................... 67

p-epd tan/chlor-tan ............. 28

perindopril erbumine.......... 85

permethrin .......................... 31

perphenazine ...................... 83

perphenazine/amitriptyline

hcl ................................... 81

phenelzine sulfate ............... 81

phenobarbital ..................... 58

phenobarbital sodium ......... 58

phentolamine mesylate ....... 93

PHENTOLAMINE

MESYLATE .................. 93

phenyleph/acetaminop/p-tlox/

cp ................................... 28

phenylephrine hcl ........ 62, 94

phenylephrine tannate ....... 94

phenylephrine/antipy/b-caine

....................................... 71

phenylephrine/chlor-tan .... 28

PHENYTEK ...................... 21

phenytoin ........................... 21

phenytoin sodium ............... 21

phenytoin sodium extended 21

PHOSLYRA ...................... 70

PHOSPHOLINE IODIDE . 28

phosphorus #1.................... 75

physostigmine salicylate .... 78

PICATO ............................. 92

pilocarpine hcl ............. 28, 78

PILOPINE HS ................... 28

pindolol .............................. 49

piperacillin sodium ............ 17

piperacillin sodium/

tazobactam ..................... 17

PIPRACIL IN DEXTROSE

....................................... 17

piroxicam ............................. 5

PLASBUMIN-25 ............... 50

PLASBUMIN-5 ................. 50

PLASMA-LYTE 148 ........ 87

PLASMA-LYTE 56 IN

DEXTROSE .................. 87

PLASMA-LYTE A PH 7.4 87

PLASMA-LYTE M IN

DEXTROSE .................. 87

pnv with ca,no.72/iron/fa ... 98

podofilox ............................ 92

podophyllum resin ............. 92

polyethylene glycol 3350 ... 57

polymyxin b sulfate ............ 14

polymyxin b sulfate/tmp ..... 29

pot chloride/pot bicarb/cit ac

....................................... 87

potassium acetate .............. 87

I-12

potassium bicarbonate/cit ac

........................................ 87


0.2%nacl ........................ 87


0.225nacl ........................ 87

potassium chloride ............. 88

potassium chloride in

0.9%nacl ........................ 87

potassium chloride/d5-0.25ns

........................................ 88


0.33nacl .......................... 88


0.45nacl .......................... 88


0.9%nacl ........................ 88

potassium chloride/d5lr ..... 88

potassium chloride/d5w ..... 88

potassium chloride-0.45%

nacl ................................. 88

potassium citrate ................ 75

potassium citrate/citric acid

........................................ 75

potassium gluconate........... 88

potassium hydroxide .......... 70

potassium phos,m-basic-d-

basic ............................... 88

POTIGA ............................. 20

PRADAXA ........................ 67

PRALIDOXIME

CHLORIDE ................... 76

pramipexole di-hcl ............. 42

PRANDIMET .................... 22

PRANDIN .......................... 22

pravastatin sodium ............. 35

prazosin hcl .......................... 3

prednicarbate ..................... 34

prednisolone ......................... 2

prednisolone acetate ...... 2, 32

prednisolone sod phosphate 2,

32

prednisone ............................ 2

PREDNISONE INTENSOL 2

PREFEST ........................... 64

PREMARIN ....................... 64

PREMASOL................. 54, 55

PREMPHASE .................... 64

PREMPRO ......................... 64

PREZISTA ......................... 45

PRIFTIN ............................. 36

PRIMAQUINE ................... 43

primidone ........................... 58

PRISTIQ ER ....................... 81

PRIVIGEN ......................... 90

PROAIR HFA .................... 94

probenecid .......................... 76

procainamide hcl ................ 56

PROCALAMINE ............... 55

prochlorperazine edisylate . 26

prochlorperazine maleate .. 26

PROCRIT ........................... 69

progesterone ....................... 80

progesterone,micronized .... 80

PROGLYCEM ................... 69

PROGRAF ......................... 76

PROLASTIN ...................... 89

PROLASTIN C .................. 89

PROLEUKIN ..................... 40

PROLIA ............................. 76

PROMACTA ...................... 69

promethazine hcl ................ 28

PRONESTYL ..................... 56

propafenone hcl .................. 56

proparacaine hcl ................ 71

proparacaine/fluorescein sod

........................................ 71

PROPINE ........................... 62

propranolol hcl ................... 49

propranolol/

hydrochlorothiazid ......... 49

propylthiouracil .................. 94

PROQUAD......................... 96

PROSOL............................. 55

PROSTIGMIN ................... 78

protamine sulfate ................ 67

PROTONIX IV .................. 44

PROTOPAM CHLORIDE . 76

PROTOPIC ........................ 92

protriptyline hcl ................. 81

PRUDOXIN....................... 43

PULMOZYME .................. 62

pyrazinamide ..................... 36

pyridostigmine bromide ..... 78

QNASL .............................. 32

QUALAQUIN ................... 43

quetiapine fumarate ........... 84

QUICK MIX with LYTES 55

quinapril hcl ...................... 85

quinapril/hydrochlorothiazide

....................................... 85

quinidine gluconate ........... 56

quinidine sulfate ................ 56

QVAR .................................. 3

RABAVERT ...................... 96

ramipril .............................. 86

RANEXA........................... 57

ranitidine hcl...................... 44

RAPAMUNE ..................... 76

REBIF ................................ 76

RECLAST ......................... 76

RECOMBIVAX HB .......... 96

RECTIV ............................. 92

REGONOL ........................ 79

REGRANEX ..................... 92

RELAGESIC ....................... 3

RELENZA ......................... 46

RELISTOR ........................ 65

REMICADE ...................... 76

REMODULIN ................... 97

RENAGEL......................... 70

RENAMIN......................... 55

RENVELA......................... 70

RESCRIPTOR ................... 45

reserpine ............................ 69

reserpine/hydrochlorothiazide

....................................... 70

RESTASIS ......................... 32

RETIN-A MICRO ............. 57

RETROVIR ....................... 45

REVATIO .................... 97, 98

REVLIMID .................. 40, 76

I-13

REYATAZ ......................... 45

RHINOCORT AQUA ........ 32

RHOGAM PLUS ............... 90

RHOPHYLAC ................... 90

RIBATAB .......................... 47

ribavirin ............................. 47

RIDAURA ......................... 76

rifampin .............................. 36

rifampin/isoniazid .............. 36

RILUTEK .......................... 58

rimantadine hcl .................. 46

ringers solution ............ 70, 88

RISPERDAL CONSTA ..... 84

risperidone ......................... 84

RITALIN LA ..................... 12

RITUXAN.......................... 40

rivastigmine tartrate .......... 79

ropinirole hcl ..................... 42

ROTARIX .......................... 96

ROTATEQ ......................... 96

ROZEREM ........................ 47

SABRIL ............................. 20

SAIZEN ............................. 80

sal-amide/acetamin/p-tlox/

caff.................................... 3

sal-amide/acetaminophn/p-

tlox.................................... 3

salicylamide/acetaminophen 4

salicylic acid ...................... 71

salicylic acid/ammon lact/

aloe ................................. 71

salicylic acid/ceramide cmb

#1.................................... 71

salsalate ............................... 5

SAMSCA ........................... 61

SANCTURA XR ............... 64

SANDOSTATIN LAR....... 76

SANTYL ............................ 92

SAPHRIS ........................... 84

SAVELLA ......................... 58

selegiline hcl ...................... 42

selenium sulfide .................. 31

SELZENTRY ..................... 45

SENSIPAR ......................... 76

SEREVENT DISKUS ........ 94

SEROMYCIN .................... 36

SEROQUEL XR ................ 84

SEROSTIM ........................ 80

sertraline hcl ...................... 81

SILENOR ........................... 81

silver nitrate ....................... 31

silver nitrate applicator ...... 71

silver sulfadiazine ............... 31

SIMCOR............................. 35

SIMPONI ........................... 76

SIMULECT ........................ 76

simvastatin .......................... 35

SINGULAIR ...................... 33

SKELID .............................. 76

sod chloride 0.45% irrig. soln

........................................ 70

sod propionate/inosi/aa14/

urea................................. 31

sod/pot/k cit/sod cit/cit acid 76

sodium acetate .................... 88

sodium bicarbonate ............ 76

sodium chloride .................. 88

sodium chloride 0.45 % ...... 88

sodium chloride 3% ............ 88

sodium chloride 5% ............ 88

sodium chloride irrig solution

........................................ 70

sodium chloride/nahco3/kcl/

peg .................................. 57

sodium fluoride ............. 76, 98

sodium lactate .................... 76

sodium morrhuate .............. 90

sodium phos,m-basic-d-basic

........................................ 88

sodium polystyrene sulfonate

........................................ 70

sodium tetradecyl sulfate .... 90

sodium thiosulfate .............. 66

sodium thiosulfate/sal acid . 31

SOLARAZE ......................... 5

SOLIRIS ............................. 76

SOLU-CORTEF PF ............. 3

SOLU-MEDROL PF ............ 3

SOMATULINE DEPOT ... 76

SOMAVERT ..................... 93

sorbitol solution ................. 70

SORIATANE..................... 92

sotalol hcl .......................... 49

SOTALOL HCL ................ 49

SPIRIVA ............................ 19

spironolact/

hydrochlorothiazid......... 86

spironolactone ................... 86

SPORANOX ...................... 27

SPRYCEL .......................... 40

STALEVO 100 .................. 42

STALEVO 125 .................. 42

STALEVO 150 .................. 42

STALEVO 200 .................. 42

STALEVO 50 .................... 42

STALEVO 75 .................... 42

stavudine ............................ 45

STELARA ................... 77, 92

STERILE DILUENT ......... 50

STIMATE .......................... 80

STRATTERA .................... 58

streptomycin sulfate ........... 13

STROMECTOL................. 13

SUBOXONE ..................... 10

sucralfate ........................... 44

sulfacetamide sodium .. 29, 31

sulfacetamide sodium/urea 71

sulfacetamide/prednisolone

sp .................................... 29

sulfadiazine ........................ 18

sulfamethoxazole/

trimethoprim .................. 18

SULFAMYLON ................ 31

sulfasalazine ...................... 18

sulindac ................................ 5

sumatriptan ........................ 35

sumatriptan succinate ........ 35

SUPPRELIN ...................... 77

SUPPRELIN LA................ 77

SUPRAX ........................... 15

SURMONTIL .................... 81

SUSTIVA .......................... 45

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SUTENT ............................ 40

SYLATRON ...................... 46

SYMBICORT ...................... 3

SYMBYAX........................ 81

SYMLIN ............................ 22

SYMLINPEN 120 .............. 22

SYMLINPEN 60 ................ 22

SYNAGIS .......................... 46

SYNAREL ......................... 77

SYNERCID........................ 14

SYPRINE ........................... 66

syring w-ndl,disp,insul,0.3ml

........................................ 61

syring w-ndl,disp,insul,0.5ml

........................................ 61

syringe & needle,insulin,1 ml

........................................ 61

TABLOID .......................... 40

TACLONEX ...................... 93

TACLONEX SCALP......... 93

tacrolimus .......................... 77

TAMIFLU .......................... 46

tamoxifen citrate ................ 40

tamsulosin hcl .................... 93

TARCEVA ......................... 40

TARGRETIN ............... 40, 93

TASIGNA .......................... 40

TASMAR ........................... 42

TAZICEF IN DEXTROSE 15

TAZORAC ......................... 93

TE ANATOXAL BERNA . 95

TEGRETOL XR ................ 20

TEKAMLO ........................ 86

TEKTURNA ...................... 86

TEKTURNA HCT ............. 86

temazepam.......................... 49

TENIVAC .......................... 95

terazosin hcl ......................... 3

terbinafine hcl .................... 27

terbutaline sulfate .............. 94

terconazole ......................... 31

TESTIM ............................. 10

testosterone cypionate ........ 10

testosterone enanthate ....... 10

TETANUS DIPHTHERIA

TOXOIDS ...................... 95

TETANUS-DIPHTERIA-

DECAVAC..................... 95

tetracaine hcl/pf.................. 71

tetracycline hcl ................... 18

TEVETEN .......................... 85

TEVETEN HCT ................. 85

TEV-TROPIN .................... 80

THALOMID....................... 77

theophylline anhydrous ...... 89

theophylline/d5w ................ 89

THERACYS ....................... 96

thioridazine hcl ................... 84

thiotepa ............................... 40

thiothixene .......................... 84

TIKOSYN .......................... 56

TIMENTIN......................... 17

timolol maleate ............. 28, 49

tinidazole ............................ 43

tizanidine hcl ...................... 91

TOBI................................... 13

TOBRADEX ...................... 29

tobramycin sulf/

dexamethasone ............... 30

tobramycin sulfate ........ 14, 30

tobramycin/sodium chloride

........................................ 14

tolazamide .......................... 25

tolbutamide ......................... 25

tolmetin sodium .................... 5

tolterodine tartrate ............. 64

topiramate .......................... 20

topotecan hcl ...................... 40

TORISEL ........................... 40

torsemide ............................ 61

TOVIAZ ............................. 65

TPN ELECTROLYTES ..... 88

TRACLEER ....................... 98

TRADJENTA ..................... 22

tramadol hcl ......................... 9

tramadol hcl/acetaminophen 9

trandolapril ........................ 86

trandolapril/verapamil hcl . 86

tranexamic acid ................. 67

tranylcypromine sulfate ..... 81

TRAVAMULSION ........... 55

TRAVASOL ...................... 55

TRAVASOL W/DEXTROSE

....................................... 55

TRAVASOL W/


TRAVASOL with

DEXTROSE .................. 55

TRAVASOL with


TRAVATAN Z .................. 28

TRAVERT ......................... 55

TRAVERT IN NORMAL

SALINE ......................... 55

TRAVERT-ELECTROLYTE

NO.1 .............................. 88

TRAVERT-ELECTROLYTE

NO.2 .............................. 88

TRAVERT-ELECTROLYTE

NO.3 .............................. 88

TRAVERT-ELECTROLYTE

NO.4 .............................. 88

trazodone hcl ..................... 81

TREANDA ........................ 40

TRECATOR ...................... 36

TRELSTAR ....................... 40

tretinoin ....................... 40, 57

TREXALL ......................... 40

triacetin .............................. 27

triamcinolone acetonide 3, 32,

34

triamterene/

hydrochlorothiazid......... 61

triazolam ............................ 49

TRIBENZOR ..................... 85

TRICOR............................. 35

trifluoperazine hcl.............. 84

trifluridine .......................... 30

trihexyphenidyl hcl ............ 42

TRIHIBIT .......................... 95

TRILEPTAL ...................... 20

TRILIPIX........................... 35

I-15

trimethoprim ...................... 95

trimipramine maleate ......... 81

TRIPEDIA ......................... 95

tripelennamine hcl ............. 28

TRISENOX ........................ 40

TRIZIVIR .......................... 45

TROPHAMINE ................. 56

tropicamide ........................ 62

trospium chloride ............... 65

TRUVADA ........................ 45

TWINRIX .......................... 96

TYGACIL .......................... 18

TYKERB............................ 40

TYPHIM VI ....................... 96

TYSABRI .......................... 77

TYZEKA............................ 47

TYZINE ............................. 62

ULORIC ............................. 77

UROLOGIC SOLUTION G

........................................ 70

ursodiol .............................. 65

UVADEX ........................... 93

VAGIFEM ......................... 64

valacyclovir hcl .................. 47

VALCYTE ......................... 47

valproate sodium ................ 20

valproic acid ...................... 20

VALSTAR ......................... 40

VALTURNA...................... 86

vancomycin hcl................... 14

VANCOMYCIN HCL ....... 14

vancomycin hcl/d5w ........... 14

VANDETANIB ................. 40

VANTAS ........................... 77

VAQTA.............................. 96

VARIVAX VACCINE ...... 96

vasopressin ......................... 80

VECTIBIX ......................... 41

VELCADE ......................... 41

venlafaxine hcl ................... 82

VENLAFAXINE HCL ER 82

VENTOLIN HFA .............. 94

VERAMYST...................... 32

verapamil hcl ...................... 50

VEREGEN ......................... 31

VERIPRED 20 ..................... 3

VESICARE ........................ 65

VFEND............................... 27

VFEND IV ......................... 27

VICTOZA 3-PAK .............. 22

VICTRELIS ....................... 46

VIDAZA............................. 41

VIDEX ............................... 45

VIGAMOX......................... 30

VIIBRYD ........................... 82

VIMPAT............................. 20

vinblastine sulfate ............... 41

vincristine sulfate ............... 41

vinorelbine tartrate ............ 41

VIRACEPT ........................ 45

VIRAMUNE ...................... 45

VIRAMUNE XR ................ 45

VIREAD ............................. 45

VISTIDE ............................ 47

VIVAGLOBIN ................... 91

VIVELLE-DOT ................. 64

VOLTAREN ........................ 5

voriconazole ....................... 27

VOTRIENT ........................ 41

VPRIV ................................ 62

VUMON ............................. 41

VYVANSE ......................... 11

warfarin sodium ................. 67

water for irrigation,sterile.. 70

WELCHOL ........................ 34

WINRHO SDF ................... 91

XALKORI .......................... 41

XARELTO ......................... 67

XENAZINE ........................ 59

XEOMIN ............................ 77

XERAC AC ........................ 48

XGEVA .............................. 77

XIAFLEX ........................... 62

XIFAXAN .......................... 14

XOLAIR ............................. 89

XOLEGEL ......................... 31

XYLOCAINE .................... 71

XYREM ............................. 59

YERVOY........................... 41

YF-VAX ............................ 97

YODOXIN......................... 43

zafirlukast .......................... 33

zaleplon .............................. 47

ZANOSAR ........................ 41

ZAVESCA ......................... 77

ZELBORAF....................... 41

ZEMAIRA ......................... 89

ZEMPLAR......................... 98

ZENPEP............................. 65

ZERIT ................................ 45

ZETIA ................................ 34

ZETONNA ........................ 32

ZIAGEN ............................ 45

zidovudine .......................... 45

ziprasidone hcl ................... 84

ZIRGAN ............................ 30

ZOLADEX ........................ 41

ZOLINZA .......................... 41

zolpidem tartrate................ 47

ZOMETA........................... 77

ZOMIG ........................ 35, 36

ZOMIG ZMT ..................... 35

ZONALON ........................ 43

zonisamide ......................... 21

ZORBTIVE ....................... 80

ZORTRESS ....................... 77

ZOSTAVAX ...................... 97

ZOSYN .............................. 17

ZOVIRAX ......................... 31

ZYCLARA ........................ 93

ZYLET............................... 30

ZYMAR ............................. 30

ZYMAXID ........................ 30

ZYPREXA ......................... 84

ZYPREXA RELPREVV ... 84

ZYTIGA ............................ 41

ZYVOX ............................. 14

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2013 Formulary (List of covered drugs)

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