Bravo Health Rx Plan

Formulary2010

10_F

BravoRx_PDP

Bravo Health plans are offered by subsidiaries of Bravo Health, Inc., Medicare Advantage Organizations with Medicare contracts. Los planes de Bravo Health son ofrecidos por subsidiarias de Bravo Health, Inc., Organizaciones de Medicare Advantage con contratos de Medicare. S5998_10_1066 F&U

Last Updated 8/28/2009 Última actualización 8/28/2009 10_F_PDP

Bravo Health

2010 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.

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What is the Bravo Health Formulary? A formulary is a list of covered drugs selected by Bravo Health 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. Bravo Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Bravo Health 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 2010 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2010 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, or 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 8/28/2009. To get updated information about the drugs covered by Bravo Health, please visit our Web site at www.mybravohealth.com or call Member Services at 1-877-504-7252, 8 am to 8 pm, seven days a week. TTY/TDD users should call 1-800-964-2561. If the formulary is updated during the year, an errata sheet will be mailed and a copy placed online along with the original formulary at www.mybravohealth.com. 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, Cardiovascular, Hypertension & Lipids. If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 19. 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.

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What are generic drugs?

Bravo Health 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: Bravo Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Bravo Health before you fill your prescriptions. If you don’t get approval, Bravo Health may not cover the drug.

Quantity Limits: For certain drugs, Bravo Health limits the amount of the drug that Bravo Health will cover. For example,

Bravo Health provides 62 capsules per one month prescription for Celebrex. This may be in addition to a standard one month or three month supply.

Step Therapy: In some cases, Bravo Health 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, Bravo Health may not cover drug B unless you try Drug A first. If Drug A does not work for you, Bravo Health 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.mybravohealth.com. You can ask Bravo Health to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Bravo Health’s formulary?” on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Bravo Health does not cover your drug, you have two options:

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

You can ask Bravo Health 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 Bravo Health’s Formulary? You can ask Bravo Health 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, Bravo Health limit

the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

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Generally, Bravo Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary, 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 or utilization restriction exception. When you are requesting a formulary 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 prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your 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 cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If there is a change to your Part D coverage resulting from a change in health care delivery setting, we will cover a one time 31-day transition supply (or less, if you have a prescription written for fewer days). For more information For more detailed information about your Bravo Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Bravo Health, please call Member Services at 1-877-504-7252, 8 am to 8 pm, seven days a week. TTY/TDD users should call 1-800-964-2561.) Or visit www.mybravohealth.com. 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.

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Bravo Health’s Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Bravo Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 19. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BARACLUDE) and generic drugs are listed in lower-case italics (e.g., aspirin/codeine). The information in the Notes column tells you if Bravo Health has any special requirements for coverage of your drug. Key: QL= Quantity Limitations may apply PA= Prior Approval may be required ST= Step Therapy rules may apply RE= Restricted Access

B= Brand Name drug

G= Generic drug

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Bravo Health

Formulario de medicamentos 2010 (Lista de medicamentos cubiertos)

POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Nota para miembros existentes: este formulario de medicamentos ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía incluye los medicamentos que usted toma.

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¿Qué es el formulario de medicamentos de Bravo Health? Un formulario de medicamentos contiene los medicamentos cubiertos seleccionados por Bravo Health en consulta con un equipo de proveedores de atención médica, que representa los tratamientos por receta médica que se cree son parte necesaria de un programa de un tratamiento de calidad. Bravo Health generalmente cubrirá los medicamentos descritos en nuestro formulario de medicamentos siempre que el medicamento sea médicamente necesario, la receta médica sea surtida en una farmacia de la red de Bravo Health y se sigan otras reglas del plan. Para obtener más información acerca de cómo obtener sus medicamentos con prescripción, revise su Constancia de cobertura. ¿Puede cambiar el fomrulario de medicamentos? Generalmente, si usted está tomando un medicamento de nuestro formulario de medicamentos de 2010 que estaba cubierto al inicio del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2010, excepto cuando esté disponible un nuevo medicamento genérico, menos costoso o si se publica nueva información adversa sobre la seguridad o efectividad del medicamento. Otro tipo de cambios, tal como remover un medicamento de nuestro formulario de medicamentos, no afectará a los miembros que actualmente toman el medicamento. Permanecerá disponible al mismo costo compartido para los miembros que lo toman, por el resto del año de cobertura. Consideramos que es importante que usted tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario de medicamentos que estaban disponibles cuando usted eligió nuestro plan, excepto en los casos en que usted puede ahorrar dinero adicional o nosotros podamos garantizar su seguridad. Si retiramos medicamentos de nuestro formulario de medicamentos o agregamos autorización previa, límites de cantidad y/o restricciones de terapia de pasos o trasladamos un medicamento a un nivel con mayor costo compartido, debemos notificar a los miembros afectados sobre el cambio por lo menos 60 días antes de que el cambio cobre vigencia, o cuando el miembro solicite que le surtan nuevamente el medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la Food and Drug Administration (Administración de Alimentos y Medicamentos) considera que un medicamento de nuestro formulario de medicamentos no es seguro o el fabricante del medicamento lo retira del mercado, inmediatamente lo retiraremos de nuestro formulario de medicamentos y notificaremos a los miembros que toman dicho medicamento. El formulario de medicamentos adjunto se encuentra actualizado hasta 8/28/2009. Para obtener información actualizada sobre los medicamentos cubiertos por Bravo Health, visite nuestro sitio web en www.mybravohealth.com o llame a Servicios al Miembro al 1-877-504-7252, de 8 a.m. a 8 p.m., los siete días de la semana. El número TTY/TDD 1-800-964-2561 es para que llamen las personas con problemas auditivos. Si el formulario de medicamentos se actualiza durante el año, se enviará por correo una hoja de errata y se publicará en línea junto con el formulario de medicamentos original en www.mybravohealth.com. ¿Cómo uso el formulario de medicamentos? Hay dos maneras de encontrar su medicamento dentro del formulario de medicamentos: Afección médica

El formulario de medicamentos comienza en la página 1. Los medicamentos en este formulario de medicamentos están agrupados en categorías de acuerdo con el tipo de afecciones médicas en que se utilizan para su tratamiento. Por ejemplo, los medicamentos que se usan para tratar una afección cardiaca se muestran en la categoría Cardiovascular, hipertensión y lípidos. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página número 1. Luego busque su medicamento bajo el nombre de la categoría.

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Si no está seguro de la categoría en la que debe buscar, deberá buscar su medicamento en el Índice que comienza en la página 19. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en este documento. En este índice se describen los medicamentos de marca y los genéricos. Busque en el Índice y encuentre su medicamento. Al lado de su medicamento, verá el número de la página en donde puede encontrar la información de cobertura. Vaya a la página anotada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Bravo Health cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico está aprobado por la FDA como un fármaco que contiene el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos son más económicos que los medicamentos de marca.

¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Es posible que estos requisitos o límites incluyan:

Autorización previa: Bravo Health requiere que usted o su médico obtenga una autorización previa para algunos medicamentos. Esto significa que necesitará obtener aprobación de Bravo Health antes de surtir sus recetas médicas. Si no obtiene la aprobación, es probable que Bravo Health no cubra el medicamento.

Límites de cantidad: para ciertos medicamentos, Bravo Health limita la cantidad de medicamentos que cubrirá. Por

ejemplo, Bravo Health proporciona 62 cápsulas para un mes por una receta de Celebrex. Esto puede ser además del suministro estándar de uno o tres meses.

Terapia de pasos: en algunos casos, Bravo Health requiere que primero intente ciertos medicamentos para tratar su

condición médica antes de que nosotros cubramos otro medicamento para esa condición. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su condición médica, Bravo Health podría no cubrir el medicamento B a menos que primero intente usar el medicamento A. Si el medicamento A no es efectivo en su caso, Bravo Health cubrirá el medicamento B.

Puede saber si su medicamento tiene requisitos o límites adicionales al revisar el formulario de medicamentos que comienza en la página 1. Asimismo, puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos al visitar el sitio web www.mybravohealth.com. Puede solicitar a Bravo Health que haga una excepción a estas restricciones o límites. Consulte la sección “¿Cómo solicito una excepción al formulario de medicamentos de Bravo Health?” en la página número ix para obtener información acerca de cómo solicitar una excepción. ¿Qué pasa si mi medicamento no está en el formulario de medicamentos? Si su medicamento no se incluye en este formulario de medicamentos, primero debe comunicarse con Servicios al Miembro y confirmar si su medicamento está cubierto. Si su medicamento no tiene cobertura de Bravo Health, usted tiene dos opciones:

Puede solicitar en Servicios al Miembro una lista de medicamentos similares que están cubiertos por Bravo Health. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento similar que esté cubierto por Bravo Health.

Puede solicitar a Bravo Health que haga una excepción y cubra su medicamento. Consulte a continuación la información

acerca de cómo solicitar una excepción.

Lista alfabética

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¿Cómo solicito una excepción al formulario de medicamentos de Bravo Health? Puede solicitar a Bravo Health que haga una excepción en sus normas de cobertura. Hay diferentes clases de excepciones que puede solicitarnos.

Usted puede solicitarnos que cubramos su medicamento, aunque no esté en nuestro formulario de medicamentos. Usted puede solicitarnos exonerar las restricciones de cobertura o de límites de su medicamento. Por ejemplo, para

ciertos medicamentos Bravo Health limita la cantidad del medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una exoneración del límite y que cubramos más.

Generalmente, Bravo Health sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formualrio de medicamentos del plan o la restricción de utilización adicional no son tan efectivos en el tratamiento de su condición o podría ocasionar efectos médicos adversos. Debe contactarnos para solicitar una decisión inicial de excepción de cobertura por una restricción de formulario de medicamentos o utilización. Cuando solicita una excepción del folrmulario de medicamentos o restricción de uso debe presentar una declaración de su médico apoyando su solicitud. Generalmente, debemos tomar la decisión dentro de las 72 horas después de recibir la declaración de aval de su médico. Usted puede solicitar una excepción expedita (rápida) si usted o su médico consideran que su salud podría dañarse seriamente si espera hasta 72 horas por una decisión. Si su solicitud expedita de excepción es autorizada, debemos darle una decisión antes de 24 horas después de recibir la declaración de apoyo del médico que prescribe. ¿Qué debo hacer antes de hablarle a mi médico sobre un cambio en mis medicamentos o solicitar una excepción? Como miembro nuevo o continuo en nuestro plan usted puede estar tomando medicamentos que no están en nuestro formulario de medicamentos. O usted puede estar tomando un medicamento que está en nuestro formulario de medicamentos, pero su capacidad para obtenerlo es limitada. Por ejemplo, usted puede necesitar una autorización previa de nosotros antes de surtir su prescripción. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que nosotros cubrimos o solicitar una excepción al formulario de medicamentos para que cubramos el medicamento que usted toma. Mientras usted habla con su médico para determinar el curso de acción correcto para usted, nosotros podríamos cubrir su medicamento en algunos casos durante los primeros 90 días que usted es miembro del plan. Por cada uno de sus medicamentos que no está en nuestro formulario de medicamentos, o si su capacidad de obtener los medicamentos es limitada, cubriremos un suministro temporal de 31 días (a menos que usted tenga una prescripción por menos días) cuando usted se dirija a una farmacia de la red. Después de su primer suministro de 31 días, no pagaremos por estos medicamentos, aun si usted ha sido miembro del plan por menos de 90 días. Si usted es residente en un centro de atención a largo plazo, le cubriremos un suministro temporal de transición de 31 días (a menos que usted tenga una prescripción por menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si usted necesita un medicamento que no está en nuestro formulario de medicamentos o su capacidad de obtener sus medicamentos es limitada, pero usted tiene más de 90 días de ser miembro de nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una prescripción por menos días) mientras usted tramita una excepción al formulario de medicamentos. Si su cobertura de la Parte D se modifica debido a un cambio en el lugar de entrega de la atención médica, cubriremos un suministro de transición de 31 días (o menos si tiene una receta para menos días).

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Para obtener más información Para obtener mayor información sobre la cobertura de Bravo Health para medicamentos con receta médica, por favor revise su Constancia de Cobertura y otros materiales del plan.

Si tiene preguntas acerca de Bravo Health, llame a nuestro Servicios al Miembro al 1-877-504-7252, de 8 a.m. a 8 p.m., los siete días de la semana. (El número TTY/TDD 1-800-964-2561 es para que llamen las personas con problemas auditivos.) O visite www.mybravohealth.com. Si tiene preguntas generales acerca de la cobertura de medicamentos por prescripción de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O visitar www.medicare.gov. Formulario de medicamentos de Bravo Health El formulario de medicamentos que comienza en la siguiente página 1 contiene información sobre la cobertura de algunos medicamentos que cubre Bravo Health. Si tiene problemas para encontrar la lista, consulte el Índice que comienza en la página 19. La primera columna de la tabla muestra el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo: BARACLUDE) y los medicamentos genéricos están en minúsculas itálicas(por ejemplo: aspirina/codeina). La información de la columna Notas indica si Bravo Health tiene algún requisito especial para la cobertura de su medicamento. Clave: QL= Es posible que se apliquen límites de cantidad PA = Puede requerir autorización previa ST = Pueden ser aplicables las normas de terapia de pasos RE= Acceso restringido

B= Medicamento de marca

G= Medicamento genérico

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Drug Tier and Cost-Share Table The following table represents the plan name, plan service area, the drug tier number as it appears in the formulary, and the cost-share amount for that tier number. Tier number 1 is the tier for generic drugs. Tier number 2 is the tier for preferred brand drugs. Tier number 3 is the tier for specialty drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.

Tabla de niveles de medicamentos y costos compartidos

La siguiente tabla representa el nombre del plan, el área de servicio del plan, el número del nivel de medicamento como aparece en el formulario de medicamentos y el monto del costo compartido para ese número de nivel. El nivel número 1 es el nivel para medicamentos genéricos. El nivel número 2 es el nivel para medicamentos preferidos. El nivel número 3 es el nivel para medicamentos especializados. Consulte el siguiente cuadro. También puede consultar su documento de Constancia de cobertura para obtener más detalles.

Service Area Área de servicio

Drug Tier

Nivel del Medicamento Member Cost-Share

Costo compartido del miembro (See note below for more details

concerning the member cost-share)

(Vea la nota a continuación para obtener más detalles acerca del

costo compartido para el miembro)

Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, Wyoming

1 (Generic/Genéricos)

2 (Preferred Brand/ Marca preferida)

3 (Specialty/De especialidad)

25% coinsurance/coaseguro



Note: It is important to note that the table only indicates what the cost shares will be at your Initial Coverage Stage after you pay the applicable deductible. The cost shares will change when you reach the Coverage Gap and the Catastrophic Coverage Stage. Please refer to your Evidence of Coverage for more information. Nota: es importante señalar que la tabla sólo indica cuáles serán los costos compartidos en su Etapa de cobertura inicial, después de que pague el deducible correspondiente. Los costos compartidos cambiarán una vez que alcance la Brecha de cobertura y la Etapa de cobertura catastrófica. Consulte su Constancia de cobertura para obtener más información.

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Commonly Prescribed Therapeutic Drug Categories

ANTI - INFECTIVES...................................................................................................................................... 4

ANTIFUNGAL AGENTS ............................................................................................................................ 4

ANTIVIRALS.............................................................................................................................................. 4

CEPHALOSPORINS ................................................................................................................................. 4

ERYTHROMYCINS / OTHER MACROLIDES............................................................................................ 4

MISCELLANEOUS ANTIINFECTIVES ...................................................................................................... 5

PENICILLINS............................................................................................................................................. 5

QUINOLONES........................................................................................................................................... 5

SULFA'S / RELATED AGENTS ................................................................................................................. 5

TETRACYCLINES..................................................................................................................................... 5

URINARY TRACT AGENTS ...................................................................................................................... 5

VANCOMYCIN .......................................................................................................................................... 6

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS............................................................................. 6

ADJUNCTIVE AGENTS............................................................................................................................. 6

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS .......................................................................... 6

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH................................................................................ 7

ANTICONVULSANTS................................................................................................................................ 7

ANTIPARKINSONISM AGENTS................................................................................................................ 7

MIGRAINE / CLUSTER HEADACHE THERAPY ....................................................................................... 7

MISCELLANEOUS NEUROLOGICAL THERAPY ..................................................................................... 7

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY............................................................................ 8

NARCOTIC ANALGESICS ........................................................................................................................ 8

NON-NARCOTIC ANALGESICS ............................................................................................................... 8

PROPOXYPHENE..................................................................................................................................... 8

PSYCHOTHERAPEUTIC DRUGS............................................................................................................. 8

CARDIOVASCULAR, HYPERTENSION / LIPIDS........................................................................................ 9

ANTIARRHYTHMIC AGENTS ................................................................................................................... 9

ANTIHYPERTENSIVE THERAPY ............................................................................................................. 9

CARDIAC GLYCOSIDES ........................................................................................................................ 10

COAGULATION THERAPY..................................................................................................................... 10

LIPID/CHOLESTEROL LOWERING AGENTS ........................................................................................ 10

MISCELLANEOUS CARDIOVASCULAR AGENTS................................................................................. 11

NITRATES............................................................................................................................................... 11

DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................. 11

ANTIPSORIATIC / ANTISEBORRHEIC................................................................................................... 11

BURN THERAPY..................................................................................................................................... 11

MISCELLANEOUS DERMATOLOGICALS.............................................................................................. 11

THERAPY FOR ACNE............................................................................................................................. 11

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TOPICAL ANESTHETICS ....................................................................................................................... 11

TOPICAL ANTIBACTERIALS .................................................................................................................. 11

TOPICAL ANTIFUNGALS ....................................................................................................................... 11

TOPICAL ANTIVIRALS............................................................................................................................ 11

TOPICAL CORTICOSTEROIDS.............................................................................................................. 11

TOPICAL ENZYMES ............................................................................................................................... 12

TOPICAL SCABICIDES / PEDICULICIDES............................................................................................. 12

DIAGNOSTICS / MISCELLANEOUS AGENTS.......................................................................................... 12

MISCELLANEOUS AGENTS................................................................................................................... 12

SMOKING DETERRENTS....................................................................................................................... 12

EAR, NOSE / THROAT MEDICATIONS ..................................................................................................... 12

MISCELLANEOUS AGENTS................................................................................................................... 12

MISCELLANEOUS OTIC PREPARATIONS ............................................................................................ 12

OTIC STEROID / ANTIBIOTIC................................................................................................................. 12

ENDOCRINE/DIABETES............................................................................................................................ 13

ADRENAL HORMONES.......................................................................................................................... 13

ANTITHYROID AGENTS......................................................................................................................... 13

DIABETES THERAPY ............................................................................................................................. 13

MISCELLANEOUS HORMONES ............................................................................................................ 13

THYROID HORMONES........................................................................................................................... 13

GASTROENTEROLOGY ............................................................................................................................ 13

ANTIDIARRHEALS / ANTISPASMODICS ............................................................................................... 13

MISCELLANEOUS GASTROINTESTINAL AGENTS .............................................................................. 14

ULCER THERAPY................................................................................................................................... 14

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY..................................................................................... 14

BIOTECHNOLOGY DRUGS.................................................................................................................... 14

VACCINES / MISCELLANEOUS IMMUNOLOGICALS............................................................................ 14

MUSCULOSKELETAL / RHEUMATOLOGY.............................................................................................. 15

GOUT THERAPY..................................................................................................................................... 15

OSTEOPOROSIS THERAPY .................................................................................................................. 15

OTHER RHEUMATOLOGICALS............................................................................................................. 15

OBSTETRICS / GYNECOLOGY................................................................................................................. 15

ESTROGENS / PROGESTINS ................................................................................................................ 15

MISCELLANEOUS OB/GYN ................................................................................................................... 15

ORAL CONTRACEPTIVES / RELATED AGENTS................................................................................... 15

OXYTOCICS ........................................................................................................................................... 15

OPHTHALMOLOGY ................................................................................................................................... 16

3

ANTIBIOTICS .......................................................................................................................................... 16

ANTIVIRALS............................................................................................................................................ 16

BETA-BLOCKERS................................................................................................................................... 16

CHOLINESTERASE INHIBITOR MIOTICS ............................................................................................. 16

CYCLOPLEGIC MYDRIATICS ................................................................................................................ 16

DIRECT ACTING MIOTICS ..................................................................................................................... 16

MISCELLANEOUS OPHTHALMOLOGICS ............................................................................................. 16

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ............................................................................. 16

ORAL DRUGS FOR GLAUCOMA............................................................................................................ 16

OTHER GLAUCOMA DRUGS ................................................................................................................. 16

STEROID-ANTIBIOTIC COMBINATIONS ............................................................................................... 16

STEROIDS .............................................................................................................................................. 16

STEROID-SULFONAMIDE COMBINATIONS ......................................................................................... 16

SULFONAMIDES .................................................................................................................................... 16

SYMPATHOMIMETICS........................................................................................................................... 16

VASOCONSTRICTOR DECONGESTANTS............................................................................................ 16

RESPIRATORY, ALLERGY, COUGH / COLD ........................................................................................... 17

ANTIHISTAMINE / ANTIALLERGENIC AGENTS .................................................................................... 17

COUGH / COLD THERAPY ..................................................................................................................... 17

PULMONARY AGENTS .......................................................................................................................... 17

UROLOGICALS .......................................................................................................................................... 17

ANTICHOLINERGICS / ANTISPASMODICS........................................................................................... 17

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY......................................................................... 17

CHOLINERGIC STIMULANTS ................................................................................................................ 17

MISCELLANEOUS UROLOGICALS........................................................................................................ 17

VITAMINS, HEMATINICS / ELECTROLYTES............................................................................................ 17

ELECTROLYTES .................................................................................................................................... 17

MISCELLANEOUS NUTRITION PRODUCTS ......................................................................................... 17

VITAMINS / HEMATINICS ....................................................................................................................... 18

INDEX OF DRUGS...................................................................................................................................... 19

4 Key: QL = Quantity Limitations may apply PA = Prior Approval may be required ST = Step Therapy rules apply

Drug Name

Drug Tier

Reqs./ Limits

ANTI - INFECTIVES ANTIFUNGAL AGENTS

Generics

amphotericin b soln 1 PA

clotrimazole troc 1

fluconazole tabs 50mg; 100mg

1

fluconazole tabs 150mg; 200mg

1 QL

fluconazole (soln,susp)

1

griseofulvin microsize susp

1

itraconazole caps 1 QL

ketoconazole tabs 1

nystatin (susp,tabs) 1

terbinafine tabs 1 QL

Brands

ANCOBON 2

DIFLUCAN IN NACL 2

ERAXIS SOLN 2

NOXAFIL SUSP 2 QL

SPORANOX SOLN 2

VFEND SOLN 2

VFEND (SUSP,TAB) 2 QL

ANTIVIRALS

Generics

acyclovir (caps, soln, susp, tabs)

1

amantadine caps 1

amantadine tabs 1

didanosine caps 1

famciclovir tabs 1 QL

foscarnet soln 1 PA

ribasphere oral tabs 1 PA

ribavirin tabs 1 PA

rimantadine tabs 1

stavudine caps 1

zidovudine (cap, syrp,tab)

1

Brands

BARACLUDE SOLN 2 QL

CRIXIVAN CAPS 2

CYTOVENE SOLN 2 PA

EMTRIVA 2

EPIVIR 2

Drug Name

Drug Tier

Reqs./ Limits

EPIVIR HBV 2

KALETRA TABS 2

LEXIVA SUSP 2

NORVIR 2

PREZISTA TABS 2

REBETOL SOLN 2 PA

RELENZA DISKHALER

2 QL

RESCRIPTOR 2

RETROVIR IV SOLN 2

SUSTIVA 2

TAMIFLU CAPS 2 QL

TAMIFLU SUSP 2

VALTREX TABS 2 QL

VIDEX CAPS 2

VIDEX SOLN 2

VIRACEPT 2

VIRAMUNE 2

VIREAD TABS 2

ZERIT SOLN 2

ZIAGEN (SOLN,TABS)

2

APTIVUS CAPS 3

ATRIPLA TABS 3

BARACLUDE TABS 3 QL

COMBIVIR TABS 3

EPZICOM TABS 3

FUZEON KIT 3

HEPSERA TABS 3 QL

INTELENCE TABS 3

INVIRASE 3

ISENTRESS TABS 3

KALETRA TABS 3

KALETRA SOLN 3

LEXIVA TABS 3

PREZISTA TABS 3

REYATAZ 3

RIBAPAK TABS 3 PA

RIBASPHERE (CAPS, TABS)

3 PA

RIBAVIRIN CAPS 3 PA

SELZENTRY 3

TRIZIVIR TABS 3

TRUVADA TABS 3

TYZEKA TABS 3 PA

Drug Name

Drug Tier

Reqs./ Limits

VALCYTE TABS 3

CEPHALOSPORINS

Generics

cefaclor (caps,susp) 1

cefadroxil (caps,susp, tabs)

1

cefazolin soln 1

cefdinir (caps, susp) 1

cefotaxime soln 1

cefoxitin soln 1

cefpodoxime susp 1

cefpodoxime tabs 1

cefprozil (susp, tabs) 1

ceftriaxone soln 1

cefuroxime axetil (susp, tabs)

1

cephalexin 1

Brands

CEFAZOLIN SOLN 2

CEFTRIAXONE 2

CEFUROXIME 2

FORTAZ SOLN 2

FORTAZ 2

MAXIPIME SOLN 2

MEFOXIN SOLN 2

SUPRAX SUSP 2

SUPRAX TABS 2

TAZICEF SOLN 2

ZINACEF SOLN 2

ERYTHROMYCINS / OTHER MACROLIDES

Generics

azithromycin (soln, susp, tabs)

1

clarithromycin (susp, tab)

1

clarithromycin er 1

e.e.s. tabs 1

ery-tab oral tabs 1

erythrocin stearate 1

erythromycin /sulfisoxazole susp

1

Brands

ERY-TAB ORAL TABS

2

Key: QL = Quantity Limitations may apply PA = Prior Approval may be required ST = Step Therapy rules apply 5

Drug Name

Drug Tier

Reqs./ Limits

ERYTHROCIN LACTOBIONATE SOLN

2

ERYTHROMYCIN BASE TABS

2

ZMAX SUSP 2

MISCELLANEOUS ANTIINFECTIVES

Generics

amikacin soln 1

chloroquine tabs 1

clindamycin (caps,soln)

1

colistimethate sodium soln

1

ethambutol tabs 1

gentamicin soln 1

hydroxychloroquine 1

isonarif caps 1

isoniazid tabs 1

isotonic gentamicin 1

mebendazole chew 1

mefloquine tabs 1

metronidazole (caps, soln, tabs)

1

neomycin tabs 1

paromomycin caps 1

pyrazinamide tabs 1

rifampin caps 1

tobramycin soln 1

Brands

ALBENZA TABS 2

ALINIA (SUSP,TAB) 2

AZACTAM 2

BILTRICIDE TABS 2

CAPASTAT SULFATE SOLN

2

CLEOCIN SOLN 2

CLEOCIN PED GR 2

CUBICIN SOLN 2

DAPSONE 2

DARAPRIM TABS 2

FANSIDAR TABS 2

GENTAMICIN SOLN

2

ISONIAZID SYRP 2

Drug Name

Drug Tier

Reqs./ Limits

KETEK 2 QL

MALARONE TABS 2

MYCOBUTIN CAPS 2

NEBUPENT SOLN 2 PA

NEUTREXIN SOLN 2

PASER PACK 2

PRIFTIN TABS 2

PRIMAQUINE PHOSPHATE TABS

2

PRIMAXIN SOLN 2

QUALAQUIN CAPS 2

SEROMYCIN CAPS 2

STREPTOMYCIN 2

STROMECTOL 2

TOBRAMYCIN 2

TRECATOR TABS 2

TYGACIL SOLN 2

XIFAXAN TABS 2 PA QL

ZYVOX SOLN 2 PA

ZYVOX SUSP 2 PA QL

ZYVOX TABS 2 PA QL

MEPRON SUSP 3

TOBI NEBU 3 PA

PENICILLINS

Generics

amoxicillin (caps, chew, susp, tabs)

1

amox/clavulanate (chew, susp, tabs)

1

amoxil (caps, susp) 1

ampicillin ( soln, caps, susp)

1

ampicillin-sulbactam 1

dicloxacillin caps 1

nafcillin soln 1

penicillin g potassium soln

1

penicillin v (soln,tab) 1

pfizerpen-g soln 1

veetids soln 1

veetids tabs 1

Brands

AMPICILLIN SOLN 2

AUGMENTIN XR TABS

2

BICILLIN C-R SUSP 2

Drug Name

Drug Tier

Reqs./ Limits

BICILLIN L-A 2

NALLPEN/DEXTRO 2

PENICILLIN G POTASS IN DEXTR

2

PENICILLIN G PROCAINE SUSP

2

PENICILLIN G SODIUM SOLN

2

ZOSYN SOLN 2

QUINOLONES

Generics

ciprofloxacin soln 1

ciprofloxacin tabs 1

ofloxacin tabs 1

Brands

AVELOX SOLN 2

FACTIVE TABS 2

LEVAQUIN (ORAL SOLN, ORAL, TAB)

2

SULFA'S / RELATED AGENTS

Generics

sulfadiazine tabs 1

sulfamethoxazole /trimethoprim (soln, susp, tabs)

1

sulfatrim susp 1

Brands

GANTRISIN SUSP 2

TETRACYCLINES

Generics

demeclocycline hcl 1

doxycycline hyc (caps, soln, tabs)

1

doxycycline monohydrate tabs

1

minocycline (cap,tab) 1

myrac tabs 1

tetracycline caps 1

Brands

VIBRAMYCIN SYRP 2

URINARY TRACT AGENTS

Generics

methenamine hippurate tabs

1

nitrofurantoin macrocrystalline

1


Drug Name

Drug Tier

Reqs./ Limits

nitrofurantoin monohydrate caps

1

trimethoprim tabs 1

Brands

FURADANTIN SUSP 2

MACRODANTIN 2

PRIMSOL SOLN 2

VANCOMYCIN

Generics

vancomycin soln 1

Brands

VANCOCIN CAPS 2

VANCOMYCIN IN DEXTROSE SOLN

2

VANCOMYCIN SOLN

2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT

DRUGS ADJUNCTIVE AGENTS

Generics

leucovorin oral tabs 5mg, 25mg

1 PA

leucovorin soln 1 PA

mesna soln 1 PA

Brands

ELITEK SOLN 3 PA

LEUCOVORIN TABS 10MG, 15MG

2 PA

MESNEX TABS 2 PA

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

Generics

adriamycin soln 1 PA

azathioprine (soln,tabs)

1 PA

bleomycin soln 1 PA

carboplatin soln 1 PA

cisplatin soln 1 PA

cyclophosphamide 1 PA

cyclosporine (caps, soln)

1 PA

cyclosporine modified soln

1 PA

cytarabine soln 500mg

1 PA

Drug Name

Drug Tier

Reqs./ Limits

cytarabine soln 20mg/ml

1 PA

dacarbazine soln 1 PA

doxorubicin soln 1 PA

etoposide soln 1 PA

fluorouracil soln 1 PA

flutamide caps 1

gengraf (caps, soln) 1 PA

hydroxyurea caps 1

idarubicin soln 1 PA

irinotecan soln 1 PA

leuprolide kit 1 PA

megestrol (susp,tab) 1

mercaptopurine tabs 1

methotrexate soln 25mg/ml

1 PA

methotrexate tabs 1 PA

mitomycin soln 1 PA

mitoxantrone conc 1 PA

octreotide acetate 1 PA

onxol conc 1 PA

paclitaxel conc 1 PA

pentostatin soln 1 PA

tamoxifen tabs 1

thiotepa soln 1 PA

tretinoin caps 1

vinblastine soln 1 PA

vincasar pfs soln 1 PA

vincristine soln 1 PA

vinorelbine soln 1 PA

Brands

ABRAXANE SUSP 2 PA

ALIMTA SOLN 2 PA

ALKERAN SOLN 2 PA

ARIMIDEX TABS 2

AROMASIN TABS 2

ARRANON SOLN 2 PA

AVASTIN SOLN 2 PA

BICNU SOLN 2 PA

CAMPATH SOLN 2 PA

CASODEX TABS 2

CEENU 2

CELLCEPT (CAP, SOLN, SUSP, TAB)

2 PA

CLADRIBINE SOLN 2 PA

Drug Name

Drug Tier

Reqs./ Limits

CLOLAR SOLN 2 PA

COSMEGEN SOLN 2 PA

CYCLOSPORINE MODIFIED CAPS

2 PA

CYTARABINE SOLN 100MG/ML

2 PA

DAUNORUBICIN 2 PA

DAUNOXOME INJ 2 PA

DOXIL INJ 2 PA

DROXIA 2

ELLENCE SOLN 2 PA

ELOXATIN SOLN 2 PA

ELSPAR SOLN 2 PA

EMCYT CAPS 2

EPIRUBICIN SOLN 2 PA

ERBITUX SOLN 2 PA

ETOPOPHOS SOLN 2 PA

FARESTON TABS 2

FASLODEX 3 PA

FEMARA TABS 2

FLUDARABINE 2 PA

GEMZAR SOLN 2 PA

GLEEVEC 3

HERCEPTIN SOLN 2 PA

HEXALEN CAPS 3

HYCAMTIN SOLN 2 PA

IFEX SOLN 2 PA

IFOSFAMIDE SOLN 2 PA

IFOSFAMIDE/MESNA

3 PA

LEUKERAN TABS 2

LEUSTATIN SOLN 2 PA

LUPRON DEPOT 3 PA

LUPRON DEPOT 3.75MG

2 PA

LYSODREN TABS 2

MATULANE CAPS 3

MEGACE ES SUSP 2

METHOTREXATE SOLN 1GM

2 PA

MUSTARGEN SOLN 2 PA

MYFORTIC 2 PA

MYLOTARG SOLN 2 PA

NEORAL CAPS 2 PA

NEORAL SOLN 2 PA


Drug Name

Drug Tier

Reqs./ Limits

NEXAVAR TABS 3 PA QL

NILANDRON TABS 2

NIPENT SOLN 2 PA

ONCASPAR SOLN 2 PA

ONTAK SOLN 2 PA

PHOTOFRIN SOLN 2 PA

PROGRAF CAPS 2 PA

PROGRAF SOLN 2 PA

RAPAMUNE SOLN 2 PA

RAPAMUNE TABS 2 PA

REVLIMID CAPS 3

RHEUMATREX 2 PA

RITUXAN CONC 2 PA

SANDIMMUNE (CAPS, IV, SOLN)

2 PA

SANDOSTATIN LAR 2 PA

SOMATULINE 3 PA

SPRYCEL TABS 3 QL

SUTENT 3 PA QL

TABLOID TABS 2

TARCEVA 3 PA QL

TARGRETIN CAPS 2

TARGRETIN GEL 2 PA

TASIGNA CAPS 3

TAXOTERE CONC 3 PA

THALOMID CAPS 3 PA

TRELSTAR SUSP 2 PA

TRISENOX SOLN 2 PA

TYKERB TABS 3 QL

VELCADE SOLN 2 PA

VIDAZA SUSP 3 PA QL

ZANOSAR SOLN 2 PA

ZOLINZA CAPS 3

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Generics

carbamazepine (chew, susp, tabs)

1

divalproex caps 1

divalproex tabs 1

epitol tabs 1

ethosuximide (caps, soln)

1

fosphenytoin soln 1

Drug Name

Drug Tier

Reqs./ Limits

gabapentin (caps, tab)

1

lamotrigine tabs 1

levetiracetam (soln, tabs)

1

oxcarbazepine tabs 1

phenytoin susp 1

phenytoin sodium extended caps

1

primidone tabs 1

valproate soln 1

valproic acid caps 1

valproic acid syrp 1

zonisamide caps 1

Brands

BANZEL 2

CARBATROL CAPS 2

CELONTIN CAPS 2

DEPAKOTE ER TABS

2

DEPAKOTE SPRINKLES

2

DILANTIN (CAPS, CHEW)

2

FELBATOL (SUSP, TABS)

2

GABITRIL 2

KEPPRA (ORAL SOLN, SOLN)

2

LAMICTAL STARTER KIT

2

LYRICA CAPS 2 QL

NEURONTIN SOLN 2

PEGANONE TABS 2

PHENYTEK CAPS 2

PHENYTOIN SOLN 2

TEGRETOL-XR 2

TOPAMAX TABS 2

TOPAMAX SPRINKLE

2

TRILEPTAL SUSP 2

VIMPAT TABS 2

ANTIPARKINSONISM AGENTS

Generics

benztropine tabs 1

bromocriptine (caps, tabs)

1

Drug Name

Drug Tier

Reqs./ Limits

carbidopa/levo tabs 1

carbidopa/levo cr 1

carbidopa/levo odt 1

carbidopa/levo sr 1

ropinirole tabs 1

selegiline (cap, tab) 1

trihexyphenidyl (elix, tabs)

1

Brands

APOKYN SOLN 2 PA

COGENTIN SOLN 2

COMTAN TABS 2

LODOSYN TABS 2

MIRAPEX TABS 2

STALEVO 2

TASMAR 2

ZELAPAR TABS 2

MIGRAINE / CLUSTER HEADACHE THERAPY

Generics

dihydroergotamine mesylate soln

1

ergotamine /caffeine 1

migergot supp 1

sumatriptan (soln, tabs)

1 QL

Brands

MIGRANAL SOLN 2 QL

ZOMIG (NASAL, ORAL, ZMT)

2 QL

MISCELLANEOUS NEUROLOGICAL THERAPY

Generics

galantamine (caps, tabs)

1 QL

Brands

ARICEPT TABS 2 QL

ARICEPT ODT 2 QL

EXELON CAPS 2 QL

EXELON PATCH 2 QL

EXELON SOLN 2

MYTELASE TABS 2

NAMENDA SOLN 2

NAMENDA TABS 2 QL

NAMENDA TITRATION PAK

2


Drug Name

Drug Tier

Reqs./ Limits

RAZADYNE SOLN 2

COPAXONE KIT 3 PA QL

XENAZINE 3 PA QL

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

Generics

baclofen tabs 1

carisoprodol tabs 1

carisoprodol /aspirin 1

chlorzoxazone tabs 1

cyclobenzaprine tabs 1

dantrolene sodium 1

methocarbamol tabs 1

orphenadrine /asprin /caffeine tabs

1

orphenadrine soln 1

orphenadrine er tabs 1

orphenadrine cmp ds 1

pyridostigmine tabs 1

regonol soln 1

tizanidine tabs 1

Brands

MESTINON SYRP 2

MESTINON TIMESPAN TABS

2

NARCOTIC ANALGESICS

Generics

acetamin/cod (soln, tabs)

1

buprenorphine soln 1

duramorph soln 1

endocet tabs 1

fentanyl patch 1

fentanyl citrate lpop 1 PA QL

fentanyl citrate soln 1

hydrocod /apap (soln, tabs)

1

hydrocodone /ibuprof 1

hydromorphone (soln, tabs)

1

levorphanol tabs 1

margesic-h caps 1

meperidine (oral soln, soln, tabs)

1

methadone soln 10mg/ml

1

Drug Name

Drug Tier

Reqs./ Limits

methadone conc 1

methadone tabs 1

methadose tabs 1

morphine (oral soln, soln, tabs)

1

morphine er tabs 1

oxycodone tabs 1

oxycodone /apap (caps, tabs)

1

oxycodone /aspirin 1

roxicet tabs 1

stagesic caps 1

trezix caps 1

zerlor tabs 1

Brands

BUPRENEX SOLN 2

DILAUDID-5 LIQD 2

DILAUDID-HP SOLN 2

INFUMORPH SOLN 2

LEVO DROMORAN 2

MEPERIDINE SOLN 75MG/ML

2

METHADONE ORAL SOLN

2

ROXICET SOLN 2

SUBUTEX SUBL 2

NON-NARCOTIC ANALGESICS

Generics

butorphanol soln 1

butorphanol nasal 1 PA QL

depade tabs 1

diclofenac potassium 1

diclofenac sodium 1

diclofenac sodium ec 1

diclofenac sodium xr 1

diflunisal tabs 1

etodolac (cap, tab) 1

etodolac er tabs 1

fenoprofen calcium 1

flurbiprofen tabs 1

ibuprofen susp 1

ibuprofen tabs 1

indomethacin caps 1

indomethacin er caps

1

Drug Name

Drug Tier

Reqs./ Limits

ketoprofen caps 1

ketoprofen er caps 1

meclofenamate caps 1

meloxicam (susp,tab)

1

nabumetone tabs 1

naloxone soln 1

naltrexone tabs 1

naproxen (susp,tab) 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

tolmetin (caps, tabs) 1

tramadol tabs 1

tramadol /acetaminophen tabs

1

Brands

ARTHROTEC TABS 2

CELEBREX CAPS 2 QL

SUBOXONE 2

VOLTAREN GEL 2 PA QL

PROPOXYPHENE

Generics

propoxyphene caps 1

propoxyphene /acetaminophen tabs

1

PSYCHOTHERAPEUTIC DRUGS

Generics

amitriptyline tabs 1

amoxapine 1

amphetamine salt combo tabs

1 PA

budeprion sr tabs 1 QL

budeprion xl tabs 1 QL

bupropion tabs 1

bupropion sr tabs 1 QL

buspirone tabs 1

chlordiazepoxide /amitriptyline tabs

1

chlorpromazine (tabs, soln)

1 PA

citalopram soln 1

citalopram tabs 1 QL

clomipramine caps 1

clozapine oral tabs 1 PA

desipramine tabs 1


Drug Name

Drug Tier

Reqs./ Limits

dexmethylphenidate 1 PA

dextroamphetamine tabs

1 PA

dextroamphetamine er caps

1 PA

doxepin caps 1

doxepin conc 1

fluoxetine (caps, soln, tabs)

1

fluphenazine (conc, soln, tabs)

1

fluphenazine decanoate soln

1

fluvoxamine tabs 1 QL

haloperidol conc 1

haloperidol tabs 1

haloperidol decanoate soln

1

haloperidol lact soln 1

imipramine hcl tabs 1

lithium carbonate caps 300mg

1

lithium carb tabs 1

lithium carb er tabs 1

lithium citrate syrp 1

loxapine succinate 1

maprotiline 1

metadate er tabs 1 PA

methylin tabs 1 PA

methylin er tabs 1 PA

methylphenidate 1 PA

methylphenidate sr 1 PA

mirtazapine tabs 1 QL

mirtazapine odt tabs 1 QL

nefazodone 1 QL

nortriptyline (cap,sol) 1

paroxetine (susp,tab) 1

paroxetine er tabs 1

perphenazine tabs 1

perphenazine /amitriptyline tabs

1

protriptyline tabs 1

risperidone soln 1 PA QL

risperidone tabs 1 PA QL

selfemra (cap, conc) 1

sertraline tabs 1 QL

Drug Name

Drug Tier

Reqs./ Limits

thioridazine tabs 1

thiothixene caps 1

tranylcypromine tabs 1

trazodone tabs 1

trifluoperazine tabs 1

trimipramine maleate 1

venlafaxine tabs 1 QL

zaleplon caps 1 QL

zolpidem tabs 1 QL

Brands

ABILIFY SOLN 2 PA

ABILIFY ORAL SOLN

2 PA

ABILIFY TABS 2 PA QL

AMBIEN CR TABS 2 QL ST

CLOZAPINE TABS 2 PA

CYMBALTA 2 QL

EMSAM 2 QL

FAZACLO TABS 2 PA

GEODON CAPS 2 PA QL

GEODON SOLN 2 PA QL

HALDOL DECANOATE SOLN

2

INVEGA TABS 2 PA

LITHIUM CARBONATE CAPS 150MG; 600MG

2

MARPLAN TABS 2

METADATE CD 2 PA

METHYLIN CHEW 2 PA

METHYLIN SOLN 2 PA

MOBAN 2

NARDIL TABS 2

ORAP 2

PRISTIQ TABS 2 QL

PROVIGIL 2 PA QL

RISPERDAL CONSTA 12.5MG; 25MG

2 PA

RISPERDAL CONSTA 37.5MG; 50MG

3 PA

RISPERDAL M-TAB 2 PA QL

RITALIN LA CAPS 2 PA

SEROQUEL TABS 2 PA QL

SEROQUEL XR 2 PA QL

Drug Name

Drug Tier

Reqs./ Limits

STRATTERA 2

SURMONTIL CAPS 2

SYMBYAX CAPS 2 PA QL

VENLAFAXINE ER 2 QL

XYREM SOLN 3

ZYPREXA (SOLN, TAS, ZYDIS)

2 PA QL

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

Generics

amiodarone soln 1

amiodarone tabs 1

disopyramide caps 1

flecainide tabs 1

mexiletine 1

pacerone oral tabs 1

procainamide 1

propafenone tabs 1

quinidine gluc cr tabs 1

quinidine sulfate tabs 1

quinidine sulf er tabs 1

sorine tabs 1

sotalol tabs 1

Brands

NORPACE CR CP12 2

PACERONE ORAL 2

RYTHMOL SR CP12 2

TIKOSYN CAPS 2

ANTIHYPERTENSIVE THERAPY

Generics

acebutolol hcl caps 1

afeditab cr tabs 1

amiloride tabs 1

amiloride /hctz tabs 1

amlodipine tabs 1

amlodipine /benazepril caps

1

atenolol tabs 1

atenolol/chlorthalidon 1

benazepril tabs 1

benazepril /hctz tabs 1

betaxolol hcl tabs 1

bisoprolol tabs 1

bisoprolol /hctz tabs 1


Drug Name

Drug Tier

Reqs./ Limits

bumetanide soln 1

bumetanide tabs 1

captopril tabs 1

captopril /hctz tabs 1

cartia xt caps 1

carvedilol tabs 1

chlorothiazide tabs 1

chlorthalidone tabs 1

clonidine tabs 1

dilt-cd caps 1

diltiazem cd caps 1

diltiazem hcl caps 1

diltiazem hcl soln 25mg/5ml

1

diltiazem hcl tabs 1

diltiazem hcl er caps 1

diltiazem hcl er cp12 1

dilt-xr caps 1

doxazosin tabs 1 QL

enalapril tabs 1

enalapril /hctz tabs 1

felodipine er tabs 1

fosinopril tabs 1

fosinopril /hctz tabs 1

furosemide soln 10mg/ml

1

furosemide oral soln 1

furosemide tabs 1

guanfacine tabs 1

hctz (caps, tabs) 1

hydralazine (soln, tabs)

1

indapamide tabs 1

isradipine caps 1

labetalol (soln, tab) 1

lisinopril tabs 1

lisinopril /hctz tabs 1

methyclothiazide 1

metolazone tabs 1

metoprolol /hctz tabs 1

metoprolol succin er 1

metoprolol tartrate (soln, tabs)

1

minoxidil tabs 1

moexipril tabs 1

Drug Name

Drug Tier

Reqs./ Limits

moexipril /hctz tabs 1

nadolol tabs 1

nadolol /bendroflumethiazide

1

nicardipine caps 1

nifediac cc tabs 1

nifedical xl tabs 1

nifedipine caps 1

nifedipine er tabs 1

pindolol 1

prazosin caps 1 QL

propranolol (oral soln, soln, tabs)

1

propranolol /hctz 1

propranolol er caps 1

quinapril tabs 1

quinapril /hctz tabs 1

quinaretic tabs 1

ramipril caps 1

reserpine tabs 1

spironolactone tabs 1

spironolactone /hctz 1

taztia xt caps 1

terazosin caps 1 QL

timolol maleate 1

torsemide tabs 1

trandolapril tabs 1

triamterene /hctz 1

triamterene /hctz 1

verapamil (soln, tab) 1

verapamil er caps 1

verapamil er tabs 1

Brands

BIDIL TABS 2 QL

CARTROL 2

CATAPRES TTS 2

COZAAR TABS 2 QL ST

DEMSER CAPS 2

DIBENZYLINE 2

DILTIAZEM HCL SOLN 100MG

2

EDECRIN TABS 2

FUROSEMIDE ORAL 8MG/ML

2

HYZAAR TABS 2 QL ST

Drug Name

Drug Tier

Reqs./ Limits

MICARDIS 2 QL ST

MICARDIS HCT 2 QL ST

SODIUM EDECRIN 2

NIMODIPINE CAPS 3

CARDIAC GLYCOSIDES

Generics

digoxin (oral soln, soln, tabs)

1

COAGULATION THERAPY

Generics

cilostazol tabs 1 QL

dipyridamole tabs 1

heparin sodium soln 1

jantoven tabs 1

pentopak tabs 1

pentoxifylline er tabs 1

pentoxil tabs 1

ticlopidine tabs 1 QL

warfarin sodium tabs 1

Brands

AGGRENOX CP12 2 QL

ARIXTRA SOLN 2

CYKLOKAPRON SOLN

2

FRAGMIN INJ 2

HEPARIN SODIUM SOLN

2

LOVENOX SOLN 2

PLAVIX TABS 2 QL

ARIXTRA SOLN 3

FRAGMIN INJ 3

LOVENOX SOLN 3

LIPID/CHOLESTEROL LOWERING AGENTS Generics

cholestyramine (pack, powd)

1

cholestyramine light 1

colestipol (gran, tab) 1

fenofibrate tabs 1

fenofibrate micronized caps

1

gemfibrozil tabs 1

lovastatin tabs 1 QL

pravastatin tabs 1 QL

prevalite pack 1


Drug Name

Drug Tier

Reqs./ Limits

simvastatin tabs 1 QL

Brands

ANTARA CAPS 2

CRESTOR TABS 2 QL

LOVAZA CAPS 2 QL

NIASPAN 2

ZETIA TABS 2 QL

MISCELLANEOUS CARDIOVASCULAR AGENTS

Brands

RANEXA 2 QL ST

NITRATES

Generics

isosorbide dinitrate 1

isosorbide dinitrate er

1

isosorbide mononitrate tabs

1

isosorbide mononitrate er tabs

1

nitroglycerin patch 1

nitroglycerin soln 1 PA

Brands

NITROLINGUAL PUMPSPRAY

2

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

Generics

calcipotriene soln 1

selenium sulfide lotn 1

Brands

DOVONEX CR 2

SORIATANE CK 2

BURN THERAPY

Generics

silver sulfadiazine cr 1

ssd cr 1

thermazene cr 1

Brands

SULFAMYLON 2

MISCELLANEOUS DERMATOLOGICALS

Generics

Drug Name

Drug Tier

Reqs./ Limits

ammonium lactate cr 1

ammonium lactat lot 1

fluorouracil cr 1

fluorouracil soln 1

laclotion lotn 1

podofilox soln 1

Brands

8-MOP CAPS 2

ALDARA CR 2

CARAC CR 2

CARMOL-HC CR 2

CONDYLOX GEL 2

ELIDEL CR 2

FLUOROPLEX CR 2

PANRETIN GEL 2

PROTOPIC OINT 2

REGRANEX GEL 2 PA

SOLARAZE GEL 2

OXSORALEN ULTRA CAPS

3

THERAPY FOR ACNE

Generics

amnesteem caps 1

avita cr 1

claravis caps 1

clindamycin (soln, gel, lotn, swab)

1

ery pads 1

erythromycin (gel, soln)

1

erythromycin/benzoyl peroxide gel

1

metronidazole (cr, gel, lotn)

1

sotret caps 1

tretinoin (cr, gel) 1

Brands

AZELEX CR 2

EVOCLIN FOAM 2

FINACEA GEL 2

METROGEL GEL 2

TAZORAC (CR, GEL)

2

TOPICAL ANESTHETICS

Generics

lidocaine soln 1

Drug Name

Drug Tier

Reqs./ Limits

lidocaine (oint, gel) 1

lidocaine/prilocaine cr

1

Brands

LIDODERM PTCH 2 PA

TOPICAL ANTIBACTERIALS

Generics

gentamicin (cr, oint) 1

mupirocin oint 1

sodium sulfacetamide lotn

1

Brands

PHISOHEX LIQD 2

TOPICAL ANTIFUNGALS

Generics

ciclopirox (cr, gel, susp, soln)

1

clotrimazole (cr,soln) 1

clotrim/betameth (cr, lotn)

1

econazole cr 1

ketoconazole (cr, sh) 1

kuric cr 1

nystatin (cr, oint, powd)

1

nystatin/triamcin (cr, oint)

1

pedi-dri powd 1

Brands

ERTACZO CR 2

LOPROX SHAMP 2

NAFTIN (CR, GEL) 2

TOPICAL ANTIVIRALS

Brands

DENAVIR CR 2

ZOVIRAX (CR, OINT)

2

TOPICAL CORTICOSTEROIDS

Generics

alclometasone cr 1

alclometasone oint 1

amcinonide (cr, lotn, oint)

1

augmented betameth diprop lotn

1

betameth diprop (cr, gel, oint)

1


Drug Name

Drug Tier

Reqs./ Limits

betameth valerate cr 1

betameth val (lotn, oint)

1

clobetasol (cr, foam, gel, oint, soln)

1

cormax cr 1

del-beta lotn 1

desonide (cr, lotn, oint)

1

desoximetasone (cr, gel, oint)

1

diflorasone (cr, oint) 1

fluocinolone (cr, oint, soln)

1

fluocinonide (cr, gel, oint, soln)

1

fluticasone prop cr 1

fluticasone prop oint 1

halobetasol prop cr 1

halobetasol prop oint 1

hydrocortisone (cr, lotn, oint)

1

hydrocortisone butyrat (cr, oint, soln)

1

hydrocortisone val cr 1

hydrocort val oint 1

mometasone (cr, oint, soln)

1

prednicarbate cr 1

prednicarbate oint 1

triamcinolone (cr, lotn, oint)

1

triderm (cr, oint) 1

Brands

CAPEX SHAM 2

CLOBEX (LIQD, LOTN, SHAM)

2

CORDRAN TAPE 2

LUXIQ FOAM 2

OLUX-E FOAM 2

PANDEL CR 2

TOPICAL ENZYMES

Brands

SANTYL OINT 2

TOPICAL SCABICIDES / PEDICULICIDES

Generics

Drug Name

Drug Tier

Reqs./ Limits

acticin cr 1

permethrin cr 1

Brands

EURAX (CR, LOTN) 2

LINDANE (LOTN, SHAM)

2

OVIDE LOTN 2

DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS

Generics

alcohol /dextrose 1

alendronate oral tabs 1 PA QL

anagrelide caps 1

dextrose /nacl soln 1

dextrose 10% soln 1

dextrose 5% soln 1

etidronate tabs 1

kionex powd 1

levocarnitine soln 1

levocarnitine tabs 1

midodrine tabs 1

pilocarpine tabs 1

sodium chloride soln 1

sodium chloride irrigation soln

1

Brands

ACTONEL TABS 2 PA QL

ANTABUSE 2

BUPHENYL 2

CAMPRAL TABS 2 QL

CHEMET CAPS 2

CLINIMIX SOLN 2

DEXTROSE /NACL 2

EVOXAC CAPS 2

FOSRENOL CHEW 2

RENVELA TABS 2

SKELID TABS 2 PA QL

SYPRINE CAPS 2

THIOLA TABS 2

ADAGEN SOLN 3

EXJADE 3

INCRELEX SOLN 3 PA

ORFADIN 3

PROLASTIN SOLN 3 PA

Drug Name

Drug Tier

Reqs./ Limits

RILUTEK TABS 3

SMOKING DETERRENTS

Generics

bupropion sr tabs 1 PA QL

Brands

CHANTIX START 2 PA

CHANTIX TABS 2 PA

NICOTROL INH 2 PA QL

NICOTROL NS 2 PA

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

Generics

chlorhexidine soln 1

ipratropium nasal 1

periogard soln 1

triamcinolone paste 1

Brands

ASTELIN SOLN 2

BACTROBAN NASAL OINT

2

TYZINE SOLN 2

MISCELLANEOUS OTIC PREPARATIONS

Generics

acetasol hc soln 1

acetic acid soln 1

borofair soln 1

ofloxacin otic soln 1

Brands

DERMOTIC OIL 2

OTIC STEROID / ANTIBIOTIC

Generics

cortomycin soln 1

cortomycin susp 1

neo /poly /hc soln 1

neo /poly /hc susp 1

Brands

CIPRO HC SUSP 2

CIPRODEX SUSP 2

COLY-MYCIN S SUSP

2

CORTISPORIN-TC SUSP

2

PEDIOTIC SUSP 2


Drug Name

Drug Tier

Reqs./ Limits

ENDOCRINE/DIABETES ADRENAL HORMONES

Generics

cortisone acetate 1

dexamethasone (elix, oral)

1

dexameth sodium phos soln

1

fludrocortisone tabs 1

hydrocortisone (soln, tabs)

1

methylprednisolone (soln, tabs, susp)

1

methylpred sod succinate soln

1

prednisolone sodium phosphate oral soln

1

prednisone (soln, tabs)

1

solu-medrol soln 1

Brands

DEPO-MEDROL 2

DEXAMETHASONE (CONC, TABS)

2

METHYLPRED SOD SUCCINATE SOLN

2

PREDNISONE INTENSOL CONC

2

SOLU-CORTEF 2

SOLU-MEDROL 2

ANTITHYROID AGENTS

Generics

methimazole tabs 1

propylthiouracil tabs 1

DIABETES THERAPY

Generics

acarbose tabs 1 QL

glimepiride tabs 1 QL

glipizide tabs 1 QL

glipizide er tabs 1 QL

glipizide xl tabs 1 QL

glipizide/metformin 1 QL

glyburide tabs 1

glyburide micronized 1 QL

glyburide/metformin 1 QL

glycron oral tabs 1

metformin tabs 1 QL

Drug Name

Drug Tier

Reqs./ Limits

metformin er tabs 1 QL

tolazamide 1

tolbutamide tabs 1

Brands

ACTOPLUS MET 2 QL ST

ACTOS TABS 2 QL ST

ALCOHOL PREPS 2

BD INSULIN SYR 2

BYETTA SOLN 2 QL ST

CURITY GAUZE PADS 2"X2"

2

GLUCAGEN HYPOKIT

2

GLUCAGON EMERGENCY

2

GLYCRON ORAL 2

JANUMET TABS 2 QL ST

JANUVIA TABS 2 QL ST

LANTUS SOLN 2

LEVEMIR SOLN 2

NOVOLIN 70/30 2

NOVOLIN N SUSP 2

NOVOLIN R SOLN 2

NOVOLOG SOLN 2

NOVOLOG MIX 70/30 SUSP

2

PROGLYCEM SUSP 2

RELION 70/30 2

RELION N SUSP 2

RELION R SOLN 2

STARLIX 2 QL ST

SYMLIN SOLN 2 QL ST

MISCELLANEOUS HORMONES

Generics

androxy tabs 1 PA

cabergoline tabs 1 QL

calcitonin-salmon 1 QL

calcitriol (caps, oral soln, soln)

1

danazol caps 1

desmopressin (nasal, tabs, soln)

1

fortical soln 1 QL

oxandrolone tabs 1 PA

testosterone cyp 1 PA

testosterone enanth 1 PA

Drug Name

Drug Tier

Reqs./ Limits

Brands

ALDURAZYME 3 PA

ANADROL TABS 2 PA

ANDRODERM 2 PA QL

ANDROGEL GEL 2 PA

CEREZYME SOLN 3 PA

FABRAZYME SOLN 3 PA

HECTOROL CAPS 2

HECTOROL SOLN 2

MIACALCIN SOLN 2

NAGLAZYME SOLN 3

SENSIPAR 30MG 2 PA QL

SENSIPAR 60MG; 90MG

3 PA QL

SOMAVERT 2 PA QL

STIMATE SOLN 2

SYNAREL SOLN 2

TESTIM GEL 2 PA

ZAVESCA CAPS 2

ZEMPLAR CAPS 2

ZEMPLAR SOLN 2

THYROID HORMONES

Generics

levothyroxine tabs 1

levoxyl tabs 1

liothyronine soln 1

unithroid tabs 1

Brands

CYTOMEL TABS 2

SYNTHROID TABS 2

GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS

Generics

atropine soln 1

dicyclomine (caps, soln, tabs)

1

diphenoxy/atropine (liqd, tabs)

1

glycopyrrolate (soln, tabs)

1

lonox tabs 1

loperamide hcl caps 1

Brands

ATROPINE SOLN 2


Drug Name

Drug Tier

Reqs./ Limits

MISCELLANEOUS GASTROINTESTINAL AGENTS

Generics

balsalazide caps 1

compro 1

constulose soln 1

dronabinol caps 1 PA

enulose soln 1

generlac soln 1

hydrocortisone enem 1

lactulose soln 1

meclizine tabs 1

mesalamine enem 1

metoclopramide (soln, tabs)

1

ondansetron soln 1

ondansetron oral sol 1 PA

ondansetron tabs 1 PA QL

ondansetron odt tabs 1 PA QL

pancrelipase 1

pancrelipase tabs 1

pancron 1

peg 3350/electrolyte 1

prochlorperazine soln

1

prochlorperazine tabs

1 PA

prochlorperazine 1

procto-pak cr 1

proctosol hc cr 1

proctozone-hc cr 1

sulfasalazine tabs 1

sulfazine tabs 1

sulfazine ec tabs 1

ursodiol caps 1

Brands

AMITIZA 2 PA QL

ASACOL TABS 2

CANASA SUPP 2

CORTIFOAM FOAM 2

CYSTADANE 2

DIPENTUM CAPS 2

EMEND CAPS 2 PA QL

EMEND MISC 2 PA QL

ENTOCORT EC 2

Drug Name

Drug Tier

Reqs./ Limits

GASTROCROM 2

LOTRONEX 2 QL

MOVIPREP SOLN 2

NULYTELY/FLAVOR 2

PANCRSE MT 4 2

PANCRECARB 2

PENTASA CAPS 2

RELISTOR SOLN 2 PA QL

TRANSDERM-SCOP PATCH

2

ULTRASE 2

URSO TABS 2

URSO FORTE TABS 2

VIOKASE (POWD, TABS)

2

REMICADE SOLN 3 PA

SUCRAID SOLN 3

ULCER THERAPY

Generics

famotidine (soln, tab) 1

misoprostol tabs 1

nizatidine caps 1

omeprazole caps 1 QL

pantoprazole tabs 1 QL

ranitidine (caps, syrp, tabs)

1

sucralfate tabs 1

Brands

CARAFATE SUSP 2

NEXIUM CAPS 2 QL

NEXIUM PACKET 2 QL

NEXIUM I.V. 2

PEPCID SUSP 2

ZANTAC SOLN 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Brands

ACTIMMUNE SOLN 3 PA

ARANESP 3 PA QL

ARANESP 25MCG; 40MCG

2 PA QL

AVONEX 3 PA QL

BETASERON SOLN 3 PA QL

EPOGEN SOLN 2 PA QL

Drug Name

Drug Tier

Reqs./ Limits

EPOGEN SOLN 20000U; 40000U

3 PA QL

INTRON-A 2 PA

LEUKINE SOLN 3 PA

NEULASTA SOLN 2 PA QL

NEUMEGA SOLN 3 PA QL

NEUPOGEN SOLN 3 PA QL

NORDITROPIN NORDIFLEX PEN

3 PA

PEGASYS KIT 3 PA QL

PEG-INTRON KIT 3 PA QL

PROCRIT SOLN 2 PA QL

PROCRIT SOLN 20000U; 40000U

3 PA QL

PROLEUKIN SOLN 3

REBIF 3 PA QL

REBIF TITRATION PACK

3 PA QL

TEV-TROPIN SOLN 3 PA

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

Generics

tetanus toxoid soln 1

Brands

ACTHIB 2

ADACEL SUSP 2

ATTENUVAX INJ 2

BOOSTRIX SUSP 2

COMVAX SUSP 2 PA

DAPTACEL SUSP 2

DECAVAC INJ 2

DIP/TET TOX PEDIATRIC INJ

2

ENGERIX-B 2 PA

GARDASIL SUSP 2 PA

HAVRIX SUSP 2

HIBTITER SOLN 2

IMOVAX RABIES 2

INFANRIX SUSP 2

IPOL INACTIVATED 2

JE-VAX SOLN 2

MENACTRA INJ 2

MENOMUNE-A/C/Y/W INJ

2

MERUVAX II INJ 2

M-M-R II INJ 2


Drug Name

Drug Tier

Reqs./ Limits

PEDIARIX SUSP 2 PA

PEDVAX HIB 2

PROQUAD INJ 2

RABAVERT SUSP 2

RECOMBIVAX HB 2 PA

ROTATEQ SUSP 2

TETANUS/DIPHTHERIA TOXOIDS SUSP

2

THYMOGLOBULIN 2 PA

TRIHIBIT KIT 2

TRIPEDIA SUSP 2

TWINRIX SUSP 2 PA

TYPHIM VI SOLN 2

VAQTA SUSP 2

VARIVAX INJ 2

VIVOTIF BERNA 2

YF-VAX INJ 2

ZOSTAVAX SOLN 2 PA

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

Generics

allopurinol tabs 1

colchicine tabs 1

probenecid tabs 1

probenecid/colchicine

1

OSTEOPOROSIS THERAPY

Generics

alendronate oral tabs 1 QL

Brands

EVISTA TABS 2 QL

FORTEO SOLN 3 QL

OTHER RHEUMATOLOGICALS

Generics

leflunomide tabs 1 PA QL

Brands

CUPRIMINE 2

DEPEN TITRATABS 2

RIDAURA CAPS 2

ENBREL 3 PA QL

HUMIRA KIT 3 PA QL

OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS

Generics

Drug Name

Drug Tier

Reqs./ Limits

camila tabs 1

errin tabs 1

estradiol patch 1 QL

estradiol tabs 1

estropipate tabs 1

gynodiol oral tabs 1

jolivette tabs 1

medroxyprog susp 1

medroxyprogest tabs 1

nora-be tabs 1

norethindrone acetate tabs

1

ortho-est tabs 1

Brands

ACTIVELLA TABS 2

ALORA PATCH 2 QL

COMBIPATCH 2 QL

CRINONE GEL 2

DEPO-PROVERA 2

DEPO-SUBQ PROVERA

2

ENJUVIA 2 QL

ESTRASORB EMUL 2

ESTRING RING 2 QL

ESTROGEL GEL 2 QL

GYNODIOL TABS 2

MENEST 2 QL

MENOSTAR PTCH 2 QL

PREMARIN CR 2

PREMARIN TABS 2 QL

PREMPHASE TABS 2 QL

PREMPRO TABS 2 QL

PROMETRIUM 2

VAGIFEM TABS 2

MISCELLANEOUS OB/GYN

Generics

clindamycin cr 1

metronidazole gel 1

miconazole supp 1

terconazole (cr, sup) 1

vandazole gel 1

zazole (cr, supp) 1

Brands

CLEOCIN SUPP 2

GYNAZOLE CR 2

Drug Name

Drug Tier

Reqs./ Limits

NUVARING RING 2

ORTHO EVRA 2

ORAL CONTRACEPTIVES / RELATED AGENTS

Generics

apri tabs 1

aranelle tabs 1

aviane tabs 1

balziva tabs 1

cesia tabs 1

cryselle tabs 1

enpresse tabs 1

junel tabs 1

junel fe tabs 1

kariva tabs 1

kelnor tabs 1

leena tabs 1

lessina tabs 1

levora tabs 1

low-ogestrel tabs 1

lutera tabs 1

microgestin tabs 1

microgestin fe tabs 1

mononessa tabs 1

necon tabs 1

nortrel tabs 1

ogestrel tabs 1

portia tabs 1

previfem tabs 1

quasense tabs 1

reclipsen tabs 1

solia tabs 1

sprintec tabs 1

sronyx tabs 1

tri-legest fe tabs 1

trinessa tabs 1

tri-previfem tabs 1

tri-sprintec tabs 1

trivora tabs 1

velivet tabs 1

zovia tabs 1

Brands

PLAN B TABS 2

OXYTOCICS


Drug Name

Drug Tier

Reqs./ Limits

Brands

METHERGINE 2

OPHTHALMOLOGY ANTIBIOTICS

Generics

bacitracin oint 1

bacitrac /poly b oint 1

ciprofloxacin soln 1

erythromycin oint 1

gentak (oint, soln) 1

gentamicin (oint, soln)

1

gentasol soln 1

neomycin /bacitracin /polymyxin oint

1

neomycin /polymyxin /gramicidin soln

1

ofloxacin ophth soln 1

polymyxin b oint 1

tobramycin soln 1

tobrasol soln 1

trimethoprim /polymyxin b soln

1

Brands

CILOXAN OINT 2

NATACYN SUSP 2

TOBREX OINT 2

VIGAMOX SOLN 2

ZYMAR SOLN 2

ANTIVIRALS

Generics

trifluridine soln 1

BETA-BLOCKERS

Generics

betaxolol hcl soln 1

carteolol soln 1

levobunolol hcl soln 1

metipranolol soln 1

timolol maleate soln 1

Brands

BETOPTIC-S SUSP 2

ISTALOL SOLN 2

TIMOPTIC SOLN 2

CHOLINESTERASE INHIBITOR MIOTICS

Drug Name

Drug Tier

Reqs./ Limits

Brands

PHOSPHOLINE IODIDE SOLN

2

CYCLOPLEGIC MYDRIATICS

Generics

mydral soln 1

tropicacyl soln 1

tropicamide soln 1

DIRECT ACTING MIOTICS

Brands

PILOPINE HS GEL 2

MISCELLANEOUS OPHTHALMOLOGICS

Generics

cromolyn sodium 1

parcaine soln 1

proparacaine soln 1

Brands

ALAMAST SOLN 2

ALOCRIL SOLN 2

ELESTAT SOLN 2

LACRISERT INST 2

OPTIVAR SOLN 2

PATANOL SOLN 2

RESTASIS EMUL 2

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

Generics

diclofenac sod soln 1

flurbiprofen soln 1

Brands

ACULAR SOLN 2

ACULAR LS SOLN 2

ORAL DRUGS FOR GLAUCOMA

Generics

acetazolamide (cap, soln, tabs)

1

methazolamide tabs 1

OTHER GLAUCOMA DRUGS

Generics

dorzolamide soln 1

dorzolamide /timolol 1

Brands

AZOPT SUSP 2

LUMIGAN SOLN 2

Drug Name

Drug Tier

Reqs./ Limits

TRAVATAN Z SOLN 2

STEROID-ANTIBIOTIC COMBINATIONS

Generics

bac/poly/neo/hc oint 1

dexasporin susp 1

neo/poly/dex oint 1

neo/poly/dex susp 1

neo/poly/hc susp 1

poly-dex (oint, susp) 1

tobramycin/dexamet 1

Brands

TOBRADEX OINT 2

STEROIDS

Generics

dexamethasone sod phos ophth soln

1

fluorometholone 1

fluor-op susp 1

prednisolone acetate 1

prednisolone sod phos ophthalmic soln

1

Brands

FML OINT 2

FML FORTE SUSP 2

VEXOL SUSP 2

STEROID-SULFONAMIDE COMBINATIONS

Generics

sulfacetamide /prednisolone soln

1

SULFONAMIDES

Generics

ocusulf soln 1

sod sulfacetamide 1

SYMPATHOMIMETICS

Generics

brimonidine tartrate 1

dipivefrin soln 1

Brands

ALPHAGAN P SOLN 2

IOPIDINE SOLN 2

VASOCONSTRICTOR DECONGESTANTS

Generics


Drug Name

Drug Tier

Reqs./ Limits

naphazoline soln 1

RESPIRATORY, ALLERGY, COUGH / COLD ANTIHISTAMINE /

ANTIALLERGENIC AGENTS Generics

carbinoxamine liqd 1

carbinoxamine tabs 1

cetirizine syrp 1

clemastine (syrp, tab)

1

diphenhydramine (cap, elix, soln)

1

epinephrine soln 1

fexofenadine tabs 1 QL

hydroxyzine hcl soln 1

hydroxyzine hcl syrp 1 PA

hydroxyzine hcl tabs 1 PA

palgic liqd 1

phenadoz supp 1

promethazine soln 1

promethazine supp 1

promethazine syrp 1 PA

promethazine tabs 1 PA

promethegan supp 1

Brands

EPIPEN DEVI 2

PALGIC TABS 2

COUGH / COLD THERAPY

Brands

CLARINEX-D 2 QL

PULMONARY AGENTS

Generics

acetylcysteine soln 1 PA

albuterol nebu 1 PA

albuterol (syrp, tab) 1

albuterol er tabs 1

aminophylline soln 1

aminophylline tabs 1

cromolyn sod nebu 1 PA

flunisolide soln 1 QL

fluticasone prop susp 1 QL

ipratropium inh soln 1 PA

ipratropium /albuterol 1 PA

metaproterenol syrp 1

Drug Name

Drug Tier

Reqs./ Limits

metaproterenol tabs 1

terbutaline soln 1

terbutaline tabs 1

theochron tabs 1

theophylline cr tabs 1

theophylline er tabs 1

Brands

ACCOLATE 2 QL

ASMANEX AEPB 2 QL

ATROVENT HFA 2 QL

BRETHINE SOLN 2

COMBIVENT AERO 2 QL

ELIXOPHYLLIN 2

FORADIL CAPS 2 QL

INTAL INHALER 2 QL

PROAIR HFA AERS 2 QL

PULMICORT SUSP 2 PA

QVAR 2 QL

SINGULAIR (CHEW, PACK, TABS)

2 QL

SPIRIVA CAPS 2 QL

SYMBICORT AERO 2 QL

THEO-24 CAPS 2

LETAIRIS 3

PULMOZYME SOLN 3 PA

REVATIO TABS 3 QL

TRACLEER 3 PA QL

UROLOGICALS ANTICHOLINERGICS /

ANTISPASMODICS Generics

flavoxate tabs 1

oxybutynin (liq, tab) 1

oxybutynin er tabs 1 QL

Brands

OXYTROL 2 QL ST

SANCTURA 2 QL

SANCTURA XR 2 QL

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Generics

finasteride tabs 1 QL

Brands

FLOMAX CAPS 2

CHOLINERGIC STIMULANTS

Drug Name

Drug Tier

Reqs./ Limits

Generics

bethanechol tabs 1

MISCELLANEOUS UROLOGICALS

Generics

potassium citrate er 1

Brands

CYSTAGON CAPS 2

ELMIRON CAPS 2

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

Generics

calcium acetate caps 1

kcl/d5w/lr soln 1

kcl/d5w/lr iv lac ring 1

kcl/d5w/nacl soln 1

klor-con oral tabs 1

potassium chloride 1

potassium cl / nacl 1

potassium cl/ d5w 1

potass cl /d5w/nacl 1

potassium chloride cr 1

potassium chloride er

1

ringer's injection soln 1

sodium bicarbonate 1

sodium chloride soln 1

Brands

DEXTROSE /NACL 2

KAON-CL TABS 2

KCL/D5W/NACL 2

KLOR-CON TABS 2

K-TABS TABS 2

LACT RINGER'S 2

MAGNESIUM SULF 2

NORMOSOL-R 2

POTASS CL 2

POTASS CL / NACL 2

POTASS CL /D5W 2

POTASS CL /D5W/NACL

2

POTASS CL /NACL 2

MISCELLANEOUS NUTRITION PRODUCTS Generics


Drug Name

Drug Tier

Reqs./ Limits

aminosyn soln 1

intralipid emul 1

novamine soln 1

premasol soln 1

travasol soln 1

Brands

AMINOSYN SOLN 2

CLINIMIX SOLN 2

DEXTROSE /ELECTROLYTE

2

FREAMINE HBC 6.9% SOLN

2

FREAMINE III SOLN 2

HEPATAMINE 2

HEPATASOL SOLN 2

INTRALIPID EMUL 2

IONOSOL SOLN 2

ISOLYTE SOLN 2

KCL/D10W/NACL 2

NEPHRAMINE 2

NORMOSOL-R 2

PLASMA-LYTE 2

PREMASOL SOLN 2

RENAMIN SOLN 2

TRAVASOL SOLN 2

TROPHAMINE 2

VITAMINS / HEMATINICS

Generics

prenatabs obn tabs 1

sodium fluoride tabs 1

19

8

8-MOP .......................................11

A

ABILIFY .......................................9

ABRAXANE.................................6

acarbose....................................13

ACCOLATE ...............................17

acebutolol hcl...............................9

acetaminophen/codeine...............8

acetasol hc ................................12

acetazolamide ...........................16

acetic acid..................................12

acetylcysteine ............................17

ACTHIB .....................................14

acticin ........................................12

ACTIMMUNE.............................14

ACTIVELLA ...............................15

ACTONEL..................................12

ACTOPLUS MET.......................13

ACTOS ......................................13

ACULAR....................................16

ACULAR LS...............................16

acyclovir.......................................4

ADACEL ....................................14

ADAGEN ...................................12

adriamycin ...................................6

afeditab cr....................................9

AGGRENOX..............................10

ALAMAST..................................16

ALBENZA ....................................5

albuterol.....................................17

albuterol er.................................17

alclometasone ...........................11

alcohol /dextrose........................12

ALCOHOL PREPS ....................13

ALDARA ....................................11

ALDURAZYME ..........................13

alendronate..........................12, 15

ALIMTA........................................6

ALINIA .........................................5

ALKERAN....................................6

allopurinol ..................................15

ALOCRIL ...................................16

ALORA ......................................15

ALPHAGAN P ........................... 16

amantadine ................................. 4

AMBIEN CR ................................ 9

amcinonide................................ 11

amikacin ...................................... 5

amiloride ..................................... 9

amiloride /hctz ............................. 9

aminophylline ............................ 17

aminosyn................................... 17

AMINOSYN............................... 18

amiodarone ................................. 9

AMITIZA.................................... 14

amitriptyline ................................. 8

amlodipine................................... 9

amlodipine /benazepril ................ 9

ammonium lactate..................... 11

amnesteem ............................... 11

amoxapine .................................. 8

amoxicillin ................................... 5

amoxicillin/clavulanate ................ 5

amoxil.......................................... 5

amphetamine salt combo ............ 8

amphotericin b............................. 4

ampicillin ..................................... 5

AMPICILLIN ................................ 5

ampicillin-sulbactam.................... 5

ANADROL................................. 13

anagrelide ................................. 12

ANCOBON.................................. 4

ANDRODERM........................... 13

ANDROGEL.............................. 13

androxy ..................................... 13

ANTABUSE............................... 12

ANTARA ................................... 11

APOKYN..................................... 7

apri ............................................ 15

APTIVUS..................................... 4

aranelle ..................................... 15

ARANESP ALBUMIN FREE...... 14

ARICEPT .................................... 7

ARICEPT ODT............................ 7

ARIMIDEX................................... 6

ARIXTRA .................................. 10

AROMASIN................................. 6

ARRANON .................................. 6

ARTHROTEC.............................. 8

ASACOL....................................14

ASMANEX.................................17

ASTELIN ...................................12

atenolol ........................................9

atenolol/chlorthalidone.................9

ATRIPLA .....................................4

atropine .....................................13

ATROPINE ................................13

ATROVENT HFA.......................17

ATTENUVAX.............................14

augmented betamethasone

dipropionate...........................11

AUGMENTIN XR.........................5

AVASTIN .....................................6

AVELOX ......................................5

aviane........................................15

avita...........................................11

AVONEX ...................................14

AZACTAM ...................................5

azathioprine .................................6

AZELEX.....................................11

azithromycin ................................4

AZOPT ......................................16

B

bac /poly /neomy /hc..................16

bacitracin ...................................16

bacitracin/polymyxin b ...............16

baclofen .......................................8

BACTROBAN NASAL ...............12

balsalazide.................................14

balziva .......................................15

BANZEL ......................................7

BARACLUDE...............................4

BD INSULIN SYRINGE .............13

benazepril ....................................9

benazepril /hctz ...........................9

benztropine mesylate ..................7

betamethasone dipropionate .....11

betamethasone valerate ............11

BETASERON ............................14

betaxolol hcl...........................9, 16

bethanechol ...............................17

BETOPTIC-S.............................16

BICILLIN C-R...............................5

BICILLIN L-A ...............................5

Index of Drugs

Índice de medicamentos

20

BICNU .........................................6

BIDIL..........................................10

BILTRICIDE.................................5

bisoprolol .....................................9

bisoprolol /hctz.............................9

bleomycin sulfate .........................6

BOOSTRIX ................................14

borofair ......................................12

BRETHINE ................................17

brimonidine tartrate....................16

bromocriptine mesylate................7

budeprion sr.................................8

budeprion xl .................................8

bumetanide............................9, 10

BUPHENYL ...............................12

BUPRENEX.................................8

buprenorphine .............................8

bupropion...............................8, 12

bupropion sr...........................8, 12

buspirone.....................................8

butorphanol..................................8

BYETTA.....................................13

C

cabergoline ................................13

calcipotriene ..............................11

calcitonin-salmon .......................13

calcitriol......................................13

calcium acetate..........................17

camila ........................................15

CAMPATH ...................................6

CAMPRAL .................................12

CANASA....................................14

CAPASTAT SULFATE.................5

CAPEX ......................................12

captopril .....................................10

captopril /hctz ............................10

CARAC......................................11

CARAFATE ...............................14

carbamazepine ............................7

CARBATROL...............................7

carbidopa/levodopa .....................7

carbidopa/levodopa cr .................7

carbidopa/levodopa odt ...............7

carbidopa/levodopa sr .................7

carbinoxamine maleate..............17

carboplatin .................................. 6

carisoprodol ................................ 8

carisoprodol /aspirin .................... 8

CARMOL-HC ............................ 11

carteolol .................................... 16

cartia xt ..................................... 10

CARTROL................................. 10

carvedilol................................... 10

CASODEX .................................. 6

CATAPRES............................... 10

CEENU ....................................... 6

cefaclor ....................................... 4

cefadroxil..................................... 4

cefazolin...................................... 4

CEFAZOLIN................................ 4

cefdinir ........................................ 4

cefotaxime................................... 4

cefoxitin....................................... 4

cefpodoxime................................ 4

cefprozil....................................... 4

ceftriaxone .................................. 4

CEFTRIAXONE........................... 4

cefuroxime .................................. 4

CEFUROXIME ............................ 4

cefuroxime axetil ......................... 4

CELEBREX................................. 8

CELLCEPT ................................. 6

CELONTIN.................................. 7

cephalexin ................................... 4

CEREZYME .............................. 13

cesia.......................................... 15

cetirizine .................................... 17

CHANTIX .................................. 12

CHEMET................................... 12

chlordiazepoxide /amitriptyline .... 8

chlorhexidine gluconate ............ 12

chloroquine phosphate................ 5

chlorothiazide ............................ 10

chlorpromazine............................ 8

chlorthalidone............................ 10

chlorzoxazone ............................. 8

cholestyramine .......................... 10

cholestyramine light .................. 10

ciclopirox ................................... 11

cilostazol ................................... 10

CILOXAN .................................. 16

CIPRO HC.................................12

CIPRODEX................................12

ciprofloxacin...........................5, 16

cisplatin .......................................6

citalopram ....................................8

CLADRIBINE...............................6

claravis ......................................11

CLARINEX-D.............................17

clarithromycin ..............................4

clarithromycin er ..........................4

clemastine fumarate ..................17

CLEOCIN...............................5, 15

clindamycin phosphate ..............15

CLINIMIX.............................12, 18

clobetasol ..................................12

CLOBEX....................................12

CLOLAR ......................................6

clomipramine ...............................8

clonidine ....................................10

clotrimazole ...........................4, 11

clotrimazole/betamethasone......11

clozapine .....................................8

CLOZAPINE ................................9

COGENTIN..................................7

colchicine...................................15

colestipol ...................................10

colistimethate sodium ..................5

COLY-MYCIN S.........................12

COMBIPATCH...........................15

COMBIVENT .............................17

COMBIVIR...................................4

compro ......................................14

COMTAN.....................................7

COMVAX...................................14

CONDYLOX ..............................11

constulose .................................14

COPAXONE ................................8

CORDRAN TAPE......................12

cormax.......................................12

CORTIFOAM.............................14

cortisone acetate .......................13

CORTISPORIN-TC....................12

cortomycin .................................12

COSMEGEN................................6

COZAAR ...................................10

CRESTOR.................................11

21

CRINONE ..................................15

CRIXIVAN....................................4

cromolyn sodium..................16, 17

cryselle ......................................15

CUBICIN......................................5

CUPRIMINE ..............................15

CURITY GAUZE PADS 2 ..........13

cyclobenzaprine...........................8

cyclophosphamide .......................6

cyclosporine.................................6

CYCLOSPORINE ........................6

cyclosporine modified ..................6

CYCLOSPORINE MODIFIED......6

CYKLOKAPRON .......................10

CYMBALTA .................................9

CYSTADANE.............................14

CYSTAGON ..............................17

cytarabine ....................................6

CYTARABINE..............................6

CYTOMEL .................................13

CYTOVENE.................................4

D

dacarbazine .................................6

danazol ......................................13

dantrolene sodium .......................8

DAPSONE...................................5

DAPTACEL................................14

DARAPRIM..................................5

DAUNORUBICIN HCL.................6

DAUNOXOME .............................6

DECAVAC .................................14

del-beta......................................12

demeclocycline hcl.......................5

DEMSER ...................................10

DENAVIR...................................11

depade.........................................8

DEPAKOTE ER ...........................7

DEPAKOTE SPRINKLES............7

DEPEN TITRATABS..................15

DEPO-MEDROL........................13

DEPO-PROVERA......................15

DEPO-SUBQ PROVERA...........15

DERMOTIC ...............................12

desipramine .................................8

desmopressin ............................13

desonide ....................................12

desoximetasone ........................ 12

dexamethasone................... 13, 16

DEXAMETHASONE.................. 13

dexamethasone sodium phosphate13, 16

dexasporin ................................ 16

dexmethylphenidate .................... 8

dextroamphetamine .................... 9

dextroamphetamine er ................ 9

DEXTROSE /ELECTROLYTE... 18

dextrose /nacl............................ 12

DEXTROSE /NACL............. 12, 17

dextrose 10% ............................ 12

dextrose 5% .............................. 12

DIBENZYLINE........................... 10

diclofenac potassium................... 8

diclofenac sodium ....................... 8

diclofenac sodium ec................... 8

diclofenac sodium xr ................... 8

dicloxacillin sodium ..................... 5

dicyclomine ............................... 13

didanosine................................... 4

diflorasone ................................ 12

DIFLUCAN IN NACL ................... 4

diflunisal ...................................... 8

digoxin....................................... 10

dihydroergotamine mesylate ....... 7

DILANTIN.................................... 7

DILAUDID-5 ................................ 8

DILAUDID-HP ............................. 8

dilt-cd ........................................ 10

diltiazem cd ............................... 10

diltiazem hcl .............................. 10

DILTIAZEM HCL ....................... 10

diltiazem hcl er .......................... 10

dilt-xr ......................................... 10

DIPENTUM ............................... 14

diphenhydramine....................... 17

diphenoxylate/atropine .............. 13

dipivefrin.................................... 16

DIPTHERIA/TETANUS TOXOID

PEDIATRIC........................... 14

dipyridamole.............................. 10

disopyramide............................... 9

divalproex sodium ....................... 7

dorzolamide .............................. 16

dorzolamide /timolol .................. 16

DOVONEX ................................ 11

doxazosin ..................................10

doxepin ........................................9

DOXIL..........................................6

doxorubicin ..................................6

doxycycline hyclate......................5

doxycycline monohydrate ............5

dronabinol..................................14

DROXIA.......................................6

duramorph ...................................8

E

e.e.s.............................................4

econazole ..................................11

EDECRIN ..................................10

ELESTAT ..................................16

ELIDEL ......................................11

ELITEK ........................................6

ELIXOPHYLLIN.........................17

ELLENCE ....................................6

ELMIRON ..................................17

ELOXATIN...................................6

ELSPAR ......................................6

EMCYT........................................6

EMEND .....................................14

EMSAM .......................................9

EMTRIVA.....................................4

enalapril .....................................10

enalapril /hctz ............................10

ENBREL ....................................15

endocet........................................8

ENGERIX-B...............................14

ENJUVIA ...................................15

enpresse....................................15

ENTOCORT EC ........................14

enulose ......................................14

epinephrine................................17

EPIPEN .....................................17

EPIRUBICIN................................6

epitol............................................7

EPIVIR.........................................4

EPIVIR HBV ................................4

EPOGEN...................................14

EPZICOM ....................................4

ERAXIS .......................................4

ERBITUX.....................................6

ergotamine /caffeine ....................7

errin ...........................................15

22

ERTACZO .................................11

ery..........................................4, 11

ery-tab .........................................4

ERY-TAB .....................................4

ERYTHROCIN LACTOBIONATE 5

erythrocin stearate .......................4

erythromycin ....................4, 11, 16

erythromycin /sulfisoxazole..........4

ERYTHROMYCIN BASE.............5

erythromycin/benzoyl peroxide ..11

estradiol .....................................15

ESTRASORB ............................15

ESTRING...................................15

ESTROGEL ...............................15

estropipate.................................15

ethambutol...................................5

ethosuximide ...............................7

etidronate...................................12

etodolac .......................................8

etodolac er...................................8

ETOPOPHOS..............................6

etoposide .....................................6

EURAX ......................................12

EVISTA......................................15

EVOCLIN...................................11

EVOXAC....................................12

EXELON......................................7

EXJADE.....................................12

F

FABRAZYME.............................13

FACTIVE .....................................5

famciclovir....................................4

famotidine ..................................14

FANSIDAR ..................................5

FARESTON.................................6

FASLODEX .................................6

FAZACLO....................................9

FELBATOL ..................................7

felodipine er ...............................10

FEMARA......................................6

fenofibrate..................................10

fenofibrate micronized ...............10

fenoprofen calcium ......................8

fentanyl ........................................8

fentanyl citrate .............................8

fexofenadine ............................. 17

FINACEA .................................. 11

finasteride ................................. 17

flavoxate.................................... 17

flecainide..................................... 9

FLOMAX ................................... 17

fluconazole .................................. 4

FLUDARABINE........................... 6

fludrocortisone........................... 13

flunisolide .................................. 17

fluocinolone ............................... 12

fluocinonide ............................... 12

fluorometholone ........................ 16

fluor-op...................................... 16

FLUOROPLEX.......................... 11

fluorouracil ............................ 6, 11

fluoxetine..................................... 9

fluphenazine................................ 9

fluphenazine decanoate .............. 9

flurbiprofen ............................ 8, 16

flutamide ..................................... 6

fluticasone propionate ......... 12, 17

fluvoxamine maleate ................... 9

FML........................................... 16

FML FORTE.............................. 16

FORTAZ...................................... 4

FORTEO ................................... 15

fortical ....................................... 13

foscarnet ..................................... 4

fosinopril.................................... 10

fosinopril /hctz ........................... 10

fosphenytoin................................ 7

FOSRENOL .............................. 12

FRAGMIN ................................. 10

FREAMINE HBC 6.9%.............. 18

FREAMINE III............................ 18

FURADANTIN............................. 6

furosemide ................................ 10

FUROSEMIDE .......................... 10

FUZEON ..................................... 4

G

gabapentin .................................. 7

GABITRIL.................................... 7

galantamine ................................ 7

GANTRISIN PEDIATRIC ............ 5

GARDASIL ................................14

GASTROCROM ........................14

gemfibrozil .................................10

GEMZAR .....................................6

generlac.....................................14

gengraf ........................................6

gentak........................................16

gentamicin .......................5, 11, 16

GENTAMICIN..............................5

gentasol.....................................16

GEODON ....................................9

GLEEVEC....................................6

glimepiride .................................13

glipizide .....................................13

glipizide er .................................13

glipizide xl ..................................13

glipizide/metformin.....................13

GLUCAGEN HYPOKIT..............13

GLUCAGON EMERGENCY KIT13

glyburide ....................................13

glyburide micronized..................13

glyburide/metformin ...................13

glycopyrrolate ............................13

glycron .......................................13

GLYCRON.................................13

griseofulvin microsize ..................4

guanfacine .................................10

GYNAZOLE...............................15

gynodiol .....................................15

GYNODIOL................................15

H

HALDOL ......................................9

HALDOL DECANOATE...............9

halobetasol propionate ..............12

haloperidol ...................................9

haloperidol decanoate .................9

haloperidol lactate .......................9

HAVRIX .....................................14

hctz............................................10

HECTOROL...............................13

heparin sodium ..........................10

HEPARIN SODIUM ...................10

HEPATAMINE ...........................18

HEPATASOL.............................18

HEPSERA ...................................4

23

HERCEPTIN................................6

HEXALEN....................................6

HIBTITER ..................................14

HUMIRA ....................................15

HYCAMTIN..................................6

hydralazine hcl...........................10

hydrocodone /acetaminophen......8

hydrocodone /ibuprofen ...............8

hydrocortisone ...............12, 13, 14

hydrocortisone butyrate .............12

hydrocortisone valerate .............12

hydromorphone............................8

hydroxychloroquine......................5

hydroxyurea .................................6

hydroxyzine hcl ..........................17

HYZAAR....................................10

I

ibuprofen......................................8

idarubicin .....................................6

IFEX.............................................6

IFOSFAMIDE...............................6

IFOSFAMIDE/MESNA.................6

imipramine hcl .............................9

INCRELEX.................................12

indapamide ................................10

indomethacin ...............................8

indomethacin er ...........................8

INFANRIX..................................14

INFUMORPH...............................8

INTAL INHALER........................17

INTELENCE ................................4

intralipid .....................................17

INTRALIPID...............................18

INTRON-A .................................14

INVEGA.......................................9

INVIRASE....................................4

IONOSOL ..................................18

IOPIDINE...................................16

IPOL INACTIVATED IPV ...........14

ipratropium...........................12, 17

ipratropium /albuterol .................17

irinotecan .....................................6

ISENTRESS ................................4

ISOLYTE ...................................18

isonarif .........................................5

isoniazid.......................................5

ISONIAZID .................................. 5

isosorbide dinitrate .................... 11

isosorbide dinitrate er................ 11

isosorbide mononitrate.............. 11

isosorbide mononitrate er.......... 11

isotonic gentamicin...................... 5

isradipine................................... 10

ISTALOL ................................... 16

itraconazole................................. 4

J

jantoven .................................... 10

JANUMET ................................. 13

JANUVIA................................... 13

JE-VAX ..................................... 14

jolivette...................................... 15

junel .......................................... 15

junel fe ...................................... 15

K

KALETRA.................................... 4

KAON-CL .................................. 17

kariva ........................................ 15

KCL/D10W/NACL...................... 18

kcl/d5w/lr ................................... 17

kcl/d5w/lr iv lac ring ................... 17

kcl/d5w/nacl .............................. 17

KCL/D5W/NACL........................ 17

kelnor ........................................ 15

KEPPRA ..................................... 7

KETEK ........................................ 5

ketoconazole ......................... 4, 11

ketoprofen ................................... 8

ketoprofen er ............................... 8

kionex........................................ 12

klor-con ..................................... 17

KLOR-CON ............................... 17

K-TABS ..................................... 17

kuric .......................................... 11

L

labetalol..................................... 10

laclotion..................................... 11

LACRISERT.............................. 16

LACTATED RINGER'S VIAFLEX17

lactulose.................................... 14

LAMICTAL STARTER................. 7

lamotrigine ...................................7

LANTUS ....................................13

leena..........................................15

leflunomide ................................15

lessina .......................................15

LETAIRIS ..................................17

leucovorin calcium .......................6

LEUCOVORIN CALCIUM............6

LEUKERAN .................................6

LEUKINE ...................................14

leuprolide .....................................6

LEUSTATIN.................................6

LEVAQUIN ..................................5

LEVEMIR...................................13

levetiracetam ...............................7

LEVO DROMORAN.....................8

levobunolol hcl...........................16

levocarnitine ..............................12

levora.........................................15

levorphanol ..................................8

levothyroxine .............................13

levoxyl .......................................13

LEXIVA........................................4

lidocaine ....................................11

lidocaine/prilocaine ....................11

LIDODERM................................11

LINDANE...................................12

liothyronine ................................13

lisinopril .....................................10

lisinopril /hctz .............................10

lithium carbonate .........................9

LITHIUM CARBONATE...............9

lithium carbonate er .....................9

lithium citrate ...............................9

LODOSYN...................................7

lonox..........................................13

loperamide hcl ...........................13

LOPROX SHAMPOO ................11

LOTRONEX...............................14

lovastatin ...................................10

LOVAZA ....................................11

LOVENOX .................................10

low-ogestrel ...............................15

loxapine succinate .......................9

LUMIGAN ..................................16

LUPRON DEPOT ........................6

lutera .........................................15

24

LUXIQ........................................12

LYRICA........................................7

LYSODREN.................................6

M

MACRODANTIN..........................6

MAGNESIUM SULFATE ...........17

MALARONE ................................5

maprotiline ...................................9

margesic-h ...................................8

MARPLAN ...................................9

MATULANE .................................6

MAXIPIME ...................................4

mebendazole ...............................5

meclizine....................................14

meclofenamate ............................8

medroxyprogesterone................15

mefloquine ...................................5

MEFOXIN ....................................4

MEGACE ES ...............................6

megestrol acetate ........................6

meloxicam ...................................8

MENACTRA ..............................14

MENEST....................................15

MENOMUNE-A/C/Y/W ..............14

MENOSTAR ..............................15

meperidine...................................8

MEPERIDINE ..............................8

MEPRON.....................................5

mercaptopurine............................6

MERUVAX II..............................14

mesalamine ...............................14

mesna..........................................6

MESNEX .....................................6

MESTINON..................................8

MESTINON TIMESPAN ..............8

METADATE CD...........................9

metadate er .................................9

metaproterenol ..........................17

metformin...................................13

metformin er ..............................13

methadone...................................8

METHADONE..............................8

methadose...................................8

methazolamide ..........................16

methenamine hippurate ...............5

METHERGINE .......................... 15

methimazole.............................. 13

methocarbamol ........................... 8

methotrexate ............................... 6

methotrexate sodium................... 6

METHOTREXATE SODIUM ....... 6

methyclothiazide ....................... 10

methylin....................................... 9

METHYLIN.................................. 9

methylin er .................................. 9

methylphenidate.......................... 9

methylphenidate sr..................... 9

methylprednisolone ................... 13

methylprednisolone

sodiumsuccinate ................... 13

METHYLPREDNISOLONE

SODIUMSUCCINATE ........... 13

metipranolol .............................. 16

metoclopramide......................... 14

metolazone ............................... 10

metoprolol /hctz......................... 10

metoprolol succinate er ............. 10

metoprolol tartrate ..................... 10

METROGEL.............................. 11

metronidazole.................. 5, 11, 15

metronidazole vaginal ............... 15

mexiletine .................................... 9

MIACALCIN............................... 13

MICARDIS ................................ 10

MICARDIS HCT ........................ 10

miconazole ................................ 15

microgestin................................ 15

microgestin fe............................ 15

midodrine .................................. 12

migergot ...................................... 7

MIGRANAL ................................. 7

minocycline ................................. 5

minoxidil .................................... 10

MIRAPEX.................................... 7

mirtazapine ................................. 9

mirtazapine odt............................ 9

misoprostol................................ 14

mitomycin .................................... 6

mitoxantrone ............................... 6

M-M-R II .................................... 14

MOBAN....................................... 9

moexipril ....................................10

moexipril /hctz............................10

mometasone furoate..................12

mononessa ................................15

morphine sulfate ..........................8

morphine sulfate er......................8

MOVIPREP................................14

mupirocin ...................................11

MUSTARGEN..............................6

MYCOBUTIN...............................5

mydral........................................16

MYFORTIC..................................6

MYLOTARG ................................6

myrac...........................................5

MYTELASE .................................7

N

nabumetone.................................8

nadolol.......................................10

nadolol /bendroflumethiazide.....10

NAFTIN .....................................11

NAGLAZYME ............................13

NALLPEN/DEXTROSE ...............5

naloxone ......................................8

naltrexone....................................8

NAMENDA...................................7

NAMENDA TITRATION PAK.......7

naphazoline ...............................16

naproxen .....................................8

NARDIL .......................................9

NATACYN .................................16

NEBUPENT.................................5

necon.........................................15

nefazodone..................................9

neomycin /bacitracin /polymyxin 16

neomycin /polymyxin

/dexamethasone ....................16

neomycin /polymyxin /gramicidin16

neomycin /polymyxin /hc............12

neomycin /polymyxin

/hydrocortisone ................12, 16

neomycin sulfate..........................5

NEORAL......................................6

NEPHRAMINE...........................18

NEULASTA................................14

NEUMEGA ................................14

25

NEUPOGEN..............................14

NEURONTIN ...............................7

NEUTREXIN................................5

NEXAVAR ...................................6

NEXIUM.....................................14

NEXIUM I.V. ..............................14

NIASPAN...................................11

nicardipine .................................10

NICOTROL INHALER................12

NICOTROL NS ..........................12

nifediac cc..................................10

nifedical xl..................................10

nifedipine ...................................10

nifedipine er ...............................10

NILANDRON ...............................7

NIMODIPINE .............................10

NIPENT .......................................7

nitrofurantoin macrocrystalline .....5

nitrofurantoin monohydrate ..........6

nitroglycerin ...............................11

NITROLINGUAL PUMPSPRAY.11

nizatidine ...................................14

nora-be ......................................15

NORDITROPIN NORDIFLEX PEN

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

norethindrone acetate................15

NORMOSOL-R....................17, 18

NORPACE CR.............................9

nortrel ........................................15

nortriptyline hcl ............................9

NORVIR.......................................4

novamine ...................................17

NOVOLIN 70/30.........................13

NOVOLIN N...............................13

NOVOLIN R...............................13

NOVOLOG ................................13

NOVOLOG MIX 70/30 ...............13

NOXAFIL .....................................4

NUVARING................................15

nystatin ..................................4, 11

nystatin/triamcinolone ................11

O

octreotide acetate ........................6

ocusulf .......................................16

ofloxacin ..........................5, 12, 16

ogestrel......................................15

OLUX-E..................................... 12

omeprazole ............................... 14

ONCASPAR................................ 7

ondansetron .............................. 14

ondansetron odt ........................ 14

ONTAK........................................ 7

onxol ........................................... 6

OPTIVAR .................................. 16

ORAP.......................................... 9

ORFADIN.................................. 12

orphenadrine /asprin /caffeine..... 8

orphenadrine citrate .................... 8

orphenadrine citrate er ................ 8

orphenadrine compound ds ........ 8

ORTHO EVRA .......................... 15

ortho-est.................................... 15

OVIDE....................................... 12

oxandrolone .............................. 13

oxaprozin .................................... 8

oxcarbazepine............................. 7

OXSORALEN............................ 11

OXSORALEN ULTRA............... 11

oxybutynin ................................. 17

oxybutynin er............................. 17

oxycodone................................... 8

oxycodone /acetaminophen ........ 8

oxycodone /aspirin ...................... 8

OXYTROL................................. 17

P

pacerone ..................................... 9

PACERONE................................ 9

paclitaxel ..................................... 6

palgic......................................... 17

PALGIC..................................... 17

PANCREASE MT 4................... 14

PANCRECARB ......................... 14

pancrelipase.............................. 14

pancron ..................................... 14

PANDEL.................................... 12

PANRETIN................................ 11

pantoprazole ............................. 14

parcaine .................................... 16

paromomycin............................... 5

paroxetine ................................... 9

paroxetine er ............................... 9

PASER........................................ 5

PATANOL..................................16

PEDIARIX..................................14

pedi-dri ......................................11

PEDIOTIC..................................12

PEDVAX HIB.............................14

peg 3350/electrolytes ................14

PEGANONE ................................7

PEGASYS .................................14

PEG-INTRON............................14

PENICILLIN G PROCAINE..........5

PENICILLIN G SODIUM..............5

penicillin v potassium...................5

PENTASA..................................14

pentopak....................................10

pentostatin ...................................6

pentoxifylline er..........................10

pentoxil ......................................10

PEPCID .....................................14

periogard ...................................12

permethrin .................................12

perphenazine...............................9

perphenazine /amitriptyline..........9

pfizerpen-g...................................5

phenadoz...................................17

PHENYTEK .................................7

phenytoin .....................................7

PHENYTOIN................................7

phenytoin sodium extended.........7

PHISOHEX................................11

PHOSPHOLINE IODIDE ...........16

PHOTOFRIN ...............................7

pilocarpine .................................12

PILOPINE HS............................16

pindolol ......................................10

piroxicam .....................................8

PLAN B......................................15

PLASMA-LYTE..........................18

PLAVIX......................................10

podofilox ....................................11

poly-dex .....................................16

polymyxin b................................16

portia .........................................15

potassium chloride.....................17

POTASSIUM CHLORIDE..........17

potassium chloride / nacl ...........17

POTASSIUM CHLORIDE / NACL

..............................................17

26

potassium chloride /d5w ............17

POTASSIUM CHLORIDE /D5W 17

potassium chloride /d5w/nacl.....17

POTASSIUM CHLORIDE

/D5W/NACL ...........................17

POTASSIUM CHLORIDE /NACL17

potassium chloride cr.................17

potassium chloride er.................17

pravastatin .................................10

prazosin .....................................10

prednicarbate.............................12

prednisolone acetate .................16

prednisolone sodium phosphate13

PREDNISONE INTENSOL ........13

PREMARIN................................15

premasol....................................17

PREMASOL...............................18

PREMPHASE ............................15

PREMPRO ................................15

prenatabs obn............................18

prevalite .....................................10

previfem.....................................15

PREZISTA ...................................4

PRIFTIN.......................................5

PRIMAQUINE PHOSPHATE.......5

PRIMAXIN ...................................5

primidone.....................................7

PRIMSOL ....................................6

PRISTIQ ......................................9

PROAIR HFA.............................17

probenecid.................................15

probenecid/colchicine ................15

procainamide ...............................9

prochlorperazine ........................14

PROCRIT ..................................14

procto-pak..................................14

proctosol hc ...............................14

proctozone-hc ............................14

PROGLYCEM............................13

PROGRAF...................................7

PROLASTIN ..............................12

PROLEUKIN..............................14

promethazine .............................17

promethegan .............................17

PROMETRIUM ..........................15

propafenone ................................9

proparacaine ............................. 16

propoxyphene ............................. 8

propoxyphene /acetaminophen ... 8

propranolol ................................ 10

propranolol /hctz........................ 10

propranolol er ............................ 10

propylthiouracil .......................... 13

PROQUAD................................ 14

PROTOPIC ............................... 11

protriptyline ................................. 9

PROVIGIL ................................... 9

PULMICORT............................. 17

PULMOZYME ........................... 17

pyrazinamide............................... 5

pyridostigmine ............................. 8

Q

QUALAQUIN............................... 5

quasense .................................. 15

quinapril .................................... 10

quinapril /hctz ............................ 10

quinaretic .................................. 10

quinidine gluconate cr ................. 9

quinidine sulfate .......................... 9

quinidine sulfate er ...................... 9

QVAR........................................ 17

R

RABAVERT............................... 15

ramipril ...................................... 10

RANEXA ................................... 11

ranitidine ................................... 14

RAPAMUNE................................ 7

RAZADYNE................................. 7

REBETOL ................................... 4

REBIF ....................................... 14

REBIF TITRATION PACK......... 14

reclipsen.................................... 15

RECOMBIVAX HB .................... 15

regonol ........................................ 8

REGRANEX.............................. 11

RELENZA DISKHALER .............. 4

RELION 70/30........................... 13

RELION N ................................. 13

RELION R ................................. 13

RELISTOR................................ 14

REMICADE................................14

RENAMIN..................................18

RENVELA..................................12

RESCRIPTOR.............................4

reserpine ...................................10

RESTASIS.................................16

REVATIO...................................17

REVLIMID....................................7

REYATAZ....................................4

RHEUMATREX ...........................7

RIBAPAK.....................................4

ribasphere....................................4

RIBASPHERE .............................4

ribavirin ........................................4

RIBAVIRIN...................................4

RIDAURA ..................................15

rifampin........................................5

RILUTEK ...................................12

rimantadine..................................4

RISPERDAL CONSTA ................9

RISPERDAL M-TAB ....................9

risperidone...................................9

RITALIN LA .................................9

RITUXAN.....................................7

ropinirole......................................7

ROTATEQ .................................15

roxicet ..........................................8

ROXICET.....................................8

RYTHMOL SR.............................9

S

SANCTURA...............................17

SANCTURA XR.........................17

SANDIMMUNE............................7

SANTYL ....................................12

selegiline .....................................7

selenium sulfide.........................11

selfemra.......................................9

SELZENTRY ...............................4

SENSIPAR ................................13

SEROMYCIN...............................5

SEROQUEL.................................9

SEROQUEL XR...........................9

sertraline......................................9

silver sulfadiazine ......................11

simvastatin.................................10

27

SINGULAIR ...............................17

SKELID......................................12

sodium bicarbonate ...................17

sodium chloride....................12, 17

SODIUM EDECRIN ...................10

sodium fluoride ..........................18

sodium sulfacetamide ..........11, 16

SOLARAZE ...............................11

solia ...........................................15

SOLU-CORTEF.........................13

solu-medrol................................13

SOLU-MEDROL ........................13

SOMAVERT ..............................13

SORIATANE CK........................11

sorine...........................................9

sotalol ..........................................9

sotret..........................................11

spironolactone ...........................10

spironolactone /hctz...................10

SPORANOX ................................4

sprintec ......................................15

SPRYCEL....................................7

sronyx ........................................15

ssd .............................................11

stagesic .......................................8

STALEVO....................................7

STARLIX....................................13

stavudine .....................................4

STIMATE ...................................13

STRATTERA ...............................9

STREPTOMYCIN ........................5

STROMECTOL............................5

SUBOXONE ................................8

SUBUTEX....................................8

SUCRAID ..................................14

sucralfate ...................................14

sulfacetamide /prednisolone ......16

sulfadiazine..................................5

sulfamethoxazole /trimethoprim ...5

SULFAMYLON ..........................11

sulfasalazine ..............................14

sulfatrim .......................................5

sulfazine ....................................14

sulfazine ec................................14

sulindac .......................................8

sumatriptan succinate..................7

SUPRAX......................................4

SURMONTIL............................... 9

SUSTIVA..................................... 4

SUTENT...................................... 7

SYMBICORT............................. 17

SYMBYAX................................... 9

SYMLIN..................................... 13

SYNAREL ................................. 13

SYNTHROID............................. 13

SYPRINE .................................. 12

T

TABLOID..................................... 7

TAMIFLU..................................... 4

tamoxifen .................................... 6

TARCEVA ................................... 7

TARGRETIN ............................... 7

TASIGNA .................................... 7

TASMAR..................................... 7

TAXOTERE................................. 7

TAZICEF ..................................... 4

TAZORAC................................. 11

taztia xt...................................... 10

TEGRETOL-XR........................... 7

terazosin ................................... 10

terbinafine ................................... 4

terbutaline ................................. 17

terconazole ............................... 15

TESTIM..................................... 13

testosterone cypionate .............. 13

testosterone enanthate ............. 13

tetanus toxoid............................ 14

TETANUS/DIPHTHERIA TOXOIDS15

tetracycline .................................. 5

TEV-TROPIN ............................ 14

THALOMID ................................. 7

THEO-24................................... 17

theochron .................................. 17

theophylline cr ........................... 17

theophylline er........................... 17

thermazene ............................... 11

THIOLA ..................................... 12

thioridazine.................................. 9

thiotepa ....................................... 6

thiothixene................................... 9

THYMOGLOBULIN................... 15

ticlopidine .................................. 10

TIKOSYN .................................... 9

timolol maleate ....................10, 16

tizanidine .....................................8

TOBI ............................................5

TOBRADEX...............................16

tobramycin .............................5, 16

TOBRAMYCIN.............................5

tobramycin /dexamethasone......16

tobrasol......................................16

TOBREX....................................16

tolazamide .................................13

tolbutamide ................................13

tolmetin ........................................8

TOPAMAX...................................7

TOPAMAX SPRINKLE ................7

torsemide...................................10

TRACLEER ...............................17

tramadol ......................................8

tramadol /acetaminophen ............8

trandolapril.................................10

TRANSDERM-SCOP ................14

tranylcypromine ...........................9

travasol......................................18

TRAVASOL ...............................18

TRAVATAN Z ............................16

trazodone ....................................9

TRECATOR.................................5

TRELSTAR..................................7

tretinoin..................................6, 11

trezix ............................................8

triamcinolone acetonide.............12

triamterene /hctz........................10

triderm .......................................12

trifluoperazine ..............................9

trifluridine ...................................16

trihexyphenidyl.............................7

TRIHIBIT ...................................15

tri-legest fe.................................15

TRILEPTAL .................................7

trimethoprim...........................6, 16

trimethoprim /polymyxin b..........16

trimipramine maleate ...................9

trinessa ......................................15

TRIPEDIA..................................15

tri-previfem.................................15

TRISENOX ..................................7

tri-sprintec..................................15

trivora ........................................15

28

TRIZIVIR......................................4

TROPHAMINE...........................18

tropicacyl ...................................16

tropicamide ................................16

TRUVADA ...................................4

TWINRIX ...................................15

TYGACIL .....................................5

TYKERB ......................................7

TYPHIM VI.................................15

TYZEKA.......................................4

TYZINE......................................12

U

ULTRASE..................................14

unithroid.....................................13

URSO ........................................14

URSO FORTE ...........................14

ursodiol ......................................14

V

VAGIFEM ..................................15

VALCYTE ....................................4

valproate sodium .........................7

valproic acid.................................7

VALTREX ....................................4

VANCOCIN..................................6

vancomycin..................................6

VANCOMYCIN ............................6

vandazole ..................................15

VAQTA ......................................15

VARIVAX ...................................15

veetids......................................... 5

VELCADE ................................... 7

velivet........................................ 15

venlafaxine .................................. 9

VENLAFAXINE ER ..................... 9

verapamil .................................. 10

verapamil er .............................. 10

VEXOL...................................... 16

VFEND........................................ 4

VIBRAMYCIN.............................. 5

VIDAZA ....................................... 7

VIDEX ......................................... 4

VIGAMOX ................................. 16

VIMPAT....................................... 7

vinblastine ................................... 6

vincasar pfs ................................. 6

vincristine .................................... 6

vinorelbine................................... 6

VIOKASE .................................. 14

VIRACEPT .................................. 4

VIRAMUNE ................................. 4

VIREAD....................................... 4

VIVOTIF BERNA....................... 15

VOLTAREN................................. 8

W

warfarin sodium......................... 10

X

XENAZINE .................................. 8

XIFAXAN..................................... 5

XYREM........................................9

Y

YF-VAX .....................................15

Z

zaleplon .......................................9

ZANOSAR ...................................7

ZANTAC ....................................14

ZAVESCA..................................13

zazole ........................................15

ZELAPAR ....................................7

ZEMPLAR..................................13

ZERIT ..........................................4

zerlor ...........................................8

ZETIA ........................................11

ZIAGEN .......................................4

zidovudine ...................................4

ZINACEF .....................................4

ZMAX ..........................................5

ZOLINZA .....................................7

zolpidem ......................................9

ZOMIG.........................................7

zonisamide ..................................7

ZOSTAVAX ...............................15

ZOSYN ........................................5

zovia ..........................................15

ZOVIRAX...................................11

ZYMAR......................................16

ZYPREXA....................................9

ZYVOX ........................................5

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