[PDF] Express Scripts Medicare (PDP) 2013 Formulary (List of Covered Drugs)

1 Value plan Express Scripts Medicare (PDP) 2013 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFOR...

Value plan

Express Scripts Medicare™ (PDP)

2013 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this

document to make sure that it still contains the drugs you take.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, 2014. A Medicare-approved Part D sponsor This information is available for free in other languages. Please contact our Customer Service numbers at 1-800-758-4574; New York State residents: 1-800-758-4570 (TTY users only: 1-800-716-3231) for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Por favor comuníquese a los números de Servicio al cliente al 1-800-758-4574; residentes de New York: 1-800-758-4570 (sólo los usuarios de TTY: 1-800-716-3231) para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please call the Customer Service numbers listed above if you need plan information in another format.

Y0046_F00SNS3A CMS Accepted Formulary ID: 13012, V19

Last Updated: October 15, 2013

What is the Express Scripts Medicare formulary?

A formulary is a list of covered drugs selected by Express Scripts Medicare 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. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the formulary change?

Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year, except when a new, less expensive generic drug becomes available, or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, 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 November 1, 2013. To get updated information about the drugs covered by Express Scripts Medicare, please visit our website at http://www.Express-Scripts.com or call Customer Service at 1-800-758-4574; New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY users should call 1-800-716-3231. If there are additional changes made to the formulary that affect you and are not mentioned above, you will also be notified in writing of these changes within a reasonable period of time from when the changes are made.

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 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 41. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage

information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Express Scripts Medicare 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: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don’t get approval, Express Scripts Medicare may not cover the drug. • Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a one-month supply per prescription for PROAIR® HFA. This may be in addition to a standard one-month or three-month supply. • Step Therapy: In some cases, Express Scripts Medicare 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, Express Scripts Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicare 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 website at http://www.Express-Scripts.com. You can ask Express Scripts Medicare to make an exception to these restrictions or limits. See the section below “How do I request an exception to the Express Scripts Medicare formulary?” 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 Customer Service and confirm that your drug is not covered. If you learn that Express Scripts Medicare does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare. • You can ask Express Scripts Medicare 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 Express Scripts Medicare formulary?

You can ask Express Scripts Medicare 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, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Drug tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier. Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first

iii

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. Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include: • • • • • •

When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is

highly individualized

The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

For more information

For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Express Scripts Medicare, please call Customer Service at 1-800-758-4574;

New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. Customer Service is available

in English and other languages. TTY users should call 1-800-716-3231.

Or visit http://www.Express-Scripts.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 users should call 1-877-486-2048. Or visit www.medicare.gov.

Express Scripts Medicare’s formulary

The formulary that begins on page 1 provides coverage information about some of the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 41. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM®) and generic drugs are listed in lowercase italics (e.g., omeprazole). The information in the requirements/Limits column tells you if Express Scripts Medicare has any special requirements for coverage of your drug.

Your Costs

The amount you pay for a covered drug will depend on: • Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change. • The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier. The Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists the copayment and coinsurance amounts for each tier.

If you qualify for Extra Help

If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are. You can also contact Customer Service for more information.

Drug Tiers Tier

Tier 1: Preferred Generic Drugs Tier 2: Non-Preferred Generic Drugs Tier 3: Preferred Brand Drugs Tier 4: Non-Preferred Brand Drugs Tier 5: Specialty Tier Drugs

Includes

This tier includes many commonly prescribed low-cost drugs. This tier includes additional low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high-cost drugs.

Helpful Tips

This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use Tier 1 drugs for the lowest copayments. This tier includes generic drugs and may include other low-cost drugs. Use Tier 2 drugs to keep your copayments low. Drugs in this tier will generally have lower copayments than non-preferred drugs. Many non-preferred drugs have lower-cost alternatives in Tiers 1, 2, and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist at the numbers listed on the cover of this document.

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug.

List of Abbreviations QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service. GC: Gap Coverage. We provide coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at 1-800-758-4574; New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. (TTY users should call 1-800-716-3231.) FF: Free First Fill. This prescription drug may be provided at a reduced cost-sharing amount the first time you fill it. ED: Enhanced Drug. This prescription drug is not normally covered in a Medicare prescription drug plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for Catastrophic Coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for this drug. CB: Capped Benefit. This prescription drug has a capped benefit limit. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

Commonly Prescribed Therapeutic Drug Categories

Drug Name ATRIPLA

ANTI - INFECTIVES ANTIFUNGAL AGENTS Drug Name amphotericin b ANCOBON clotrimazole troc ERAXIS INJ 100MG fluconazole fluconazole in dextrose inj 56mg/ml; 400mg/200ml flucytosine GRIS-PEG griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole NOXAFIL nystatin susp nystatin tabs SPORANOX ORAL SOLN terbinafine hcl tabs VFEND IV VFEND SUSR voriconazole

Drug Tier 2 3 2 3 1 2

Requirements/ Limits PA MO MO MO MO MO

2 4 2 2 2 2 3 1 1 3 1 3 3 2

MO MO MO MO MO MO MO MO MO MO MO MO MO MO

abacavir

acyclovir caps acyclovir sodium inj 500mg acyclovir susp acyclovir tabs amantadine hcl APTIVUS CAPS

1 1 1 1 2 5

APTIVUS ORAL SOLN

QL(180 per 90 days) MO MO MO MO MO MO QL(360 per 90 days) MO QL(950 per 90 days)

ANTIVIRALS

Drug Tier 5

BARACLUDE ORAL SOLN

BARACLUDE TABS

CIDOFOVIR COMPLERA

5 5

CRIXIVAN didanosine

3 2

EDURANT

EMTRIVA CAPS

EMTRIVA ORAL SOLN

EPIVIR HBV EPIVIR ORAL SOLN

3 3

EPZICOM

famciclovir foscarnet sodium FUZEON

2 2 5

ganciclovir HEPSERA

2 5

INCIVEK

Requirements/ Limits QL(90 per 90 days) MO QL(1890 per 90 days) MO QL(90 per 90 days) MO MO QL(90 per 90 days) MO MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(2210 per 90 days) MO MO QL(2880 per 90 days) MO QL(90 per 90 days) MO MO PA MO QL(180 per 90 days) MO MO QL(90 per 90 days) MO PA QL(504 per 84 days) MO

Drug Name INTELENCE TABS 200MG INTELENCE TABS 100MG INTELENCE TABS 25MG INVIRASE CAPS INVIRASE TABS ISENTRESS CHEW 100MG ISENTRESS CHEW 25MG ISENTRESS TABS KALETRA ORAL SOLN KALETRA TABS 200MG; 50MG KALETRA TABS 100MG; 25MG lamivudine tabs 300mg lamivudine tabs 150mg lamivudine/zidovudine LEXIVA SUSP LEXIVA TABS

RequireDrug ments/ Tier Limits 5 QL(180 per 90 days) MO 5 QL(360 per 90 days) MO 3 QL(360 per 90 days) 4 QL(900 per 90 days) MO 5 QL(360 per 90 days) MO 5 QL(540 per 90 days) MO 3 QL(540 per 90 days) 5 QL(360 per 90 days) MO 5 QL(1280 per 90 days) MO 5 QL(360 per 90 days) MO 3 QL(900 per 90 days) MO 2 QL(90 per 90 days) MO 2 QL(180 per 90 days) MO 2 QL(180 per 90 days) MO 3 QL(5175 per 90 days) MO 5 QL(360 per 90 days) MO

Drug Name nevirapine tabs NORVIR CAPS NORVIR ORAL SOLN NORVIR TABS PREZISTA SUSP PREZISTA TABS 800MG PREZISTA TABS 400MG, 600MG PREZISTA TABS 150MG PREZISTA TABS 75MG REBETOL ORAL SOLN RELENZA DISKHALER RESCRIPTOR TABS 200MG RESCRIPTOR TABS 100MG RETROVIR IV INFUSION REYATAZ CAPS 300MG REYATAZ CAPS 150MG, 200MG REYATAZ CAPS 100MG ribapak tabs ribasphere caps

RequireDrug ments/ Tier Limits 2 QL(180 per 90 days) MO 3 QL(1080 per 90 days) MO 3 QL(1440 per 90 days) MO 3 QL(1080 per 90 days) MO 5 MO 5 MO 5 QL(180 per 90 days) MO 3 QL(540 per 90 days) MO 3 QL(900 per 90 days) MO 3 PA MO 3 QL(300 per 365 days) MO 4 QL(540 per 90 days) MO 4 QL(1080 per 90 days) MO 3 3 QL(90 per 90 days) MO 3 QL(180 per 90 days) MO 3 QL(360 per 90 days) MO 5 PA MO 2 PA MO

Drug Name ribasphere tabs 400mg ribasphere tabs 200mg ribasphere tabs 600mg ribavirin rimantadine hcl SELZENTRY TABS 150MG SELZENTRY TABS 300MG stavudine caps stavudine oral soln STRIBILD SUSTIVA CAPS 200MG SUSTIVA CAPS 50MG SUSTIVA TABS TAMIFLU CAPS 45MG, 75MG TAMIFLU CAPS 30MG TAMIFLU SUSR TIVICAY TRIZIVIR TRUVADA

RequireDrug ments/ Tier Limits 2 PA 2 PA MO 5 PA MO 2 PA MO 2 MO 5 QL(180 per 90 days) MO 5 QL(360 per 90 days) MO 2 QL(180 per 90 days) MO 2 QL(7200 per 90 days) MO 5 QL(90 per 90 days) MO 3 QL(360 per 90 days) MO 3 QL(630 per 90 days) MO 3 QL(90 per 90 days) MO 3 QL(60 per 365 days) MO 3 QL(120 per 365 days) MO 3 QL(720 per 365 days) MO 5 MO 5 QL(180 per 90 days) MO 5 QL(90 per 90 days) MO

Drug Name TYZEKA valacyclovir hcl tabs 1000mg valacyclovir hcl tabs 500mg VALCYTE VICTRELIS

VIDEX PEDIATRIC ORAL SOLN 2GM VIRACEPT TABS 625MG VIRACEPT TABS 250MG VIRAMUNE SUSP VIRAMUNE XR VIRAZOLE VIREAD POWD VIREAD TABS ZERIT ORAL SOLN ZIAGEN ORAL SOLN ZIAGEN TABS zidovudine caps

RequireDrug ments/ Tier Limits 5 MO 2 QL(100 per 90 days) MO 2 QL(200 per 90 days) MO 5 MO 5 PA QL(1008 per 84 days) MO 3 QL(3600 per 90 days) MO 5 QL(360 per 90 days) MO 5 QL(900 per 90 days) MO 3 QL(3600 per 90 days) MO 3 MO 5 MO 3 QL(720 per 90 days) MO 3 QL(90 per 90 days) MO 4 QL(7200 per 90 days) MO 3 QL(2880 per 90 days) MO 3 QL(180 per 90 days) MO 2 QL(540 per 90 days) MO

Drug Name zidovudine syrp zidovudine tabs

RequireDrug ments/ Tier Limits 2 QL(5520 per 90 days) MO 2 QL(180 per 90 days) MO

Drug Name ZINACEF IN ISO-OSMOTIC DILUENT

ERYTHROMYCINS / OTHER MACROLIDES

CEPHALOSPORINS cefaclor caps cefadroxil cefazolin sodium inj 10gm, 1gm; 5%, 500mg cefazolin sodium inj 1gm cefdinir cefepime inj 2gm cefepime inj 1gm cefotaxime sodium inj 1gm, 2gm cefotaxime sodium inj 10gm cefoxitin sodium inj 10gm, 2gm cefoxitin sodium inj 1gm cefpodoxime proxetil ceftazidime inj 1gm, 6gm ceftazidime inj 2gm ceftriaxone sodium inj 10gm ceftriaxone sodium inj 1gm, 250mg, 2gm, 500mg cefuroxime axetil tabs cefuroxime sodium inj 7.5gm cefuroxime sodium inj 1.5gm, 750mg cephalexin caps 250mg, 500mg cephalexin susr cephalexin tabs FORTAZ INJ 1GM/50ML; 5%, 2GM/50ML; 5%, 6GM SUPRAX CAPS SUPRAX SUSR 500MG/5ML SUPRAX SUSR 100MG/5ML, 200MG/5ML SUPRAX TABS TEFLARO ZINACEF IN ISO-OSMOTIC DEXTROSE

2 2 2

MO MO

2 2 2 2 2 2 2 2 2 2 2 2 2

MO MO

2 2 2

1 1 1 3

MO MO MO

4 4 4 4 3 3

Drug Tier 3

Requirements/ Limits

MO MO MO MO MO

azithromycin inj 500mg azithromycin susr azithromycin tabs clarithromycin clarithromycin er DIFICID

2 2 2 2 2 3

e.e.s. 400 E.E.S. GRANULES ERY-TAB TBEC 500MG ery-tab tbec 250mg, 333mg ERYTHROCIN LACTOBIONATE INJ 500MG erythrocin stearate erythromycin base erythromycin ethylsuccinate ZMAX

2 3 3 2 3 1 2 2 3

MO MO MO MO QL(60 per 90 days) MO MO MO MO MO MO MO MO MO

MISCELLANEOUS ANTIINFECTIVES

ALBENZA ALINIA amikacin sulfate inj 1gm/4ml, 50mg/ml atovaquone/proguanil hcl tabs 250mg; 100mg AZACTAM IN ISO-OSMOTIC DEXTROSE AZACTAM INJ 2GM aztreonam inj 1gm BILTRICIDE CAPASTAT SULFATE CAYSTON chloroquine phosphate CLEOCIN IN D5W CLEOCIN PEDIATRIC GRANULES clindamycin hcl clindamycin palmitate hcl

MO MO MO

3 3 2

MO MO MO

3 3 2 3 4 5 2 3 3 2 2

MO MO MO LA MO MO MO MO MO

Drug Drug Name Tier clindamycin phosphate 2 addvantage clindamycin phosphate in d5w inj 2 300mg/50ml; 5%, 600mg/50ml; 5% clindamycin phosphate in d5w inj 2 900mg/50ml; 5% COARTEM 3 colistimethate sodium 2 CUBICIN 3 DAPSONE 3 DARAPRIM 3 ethambutol hcl 2 gentamicin sulfate inj 2 gentamicin sulfate/0.9% sodium 2 chloride inj 0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% hydroxychloroquine sulfate 2 imipenem/cilastatin 2 isoniazid syrp 2 isoniazid tabs 1 isotonic gentamicin inj 0.8mg/ml; 2 0.9%, 1.2mg/ml; 0.9% KETEK 3 MALARONE mefloquine hcl MEPRON meropenem inj 500mg metronidazole metronidazole in nacl 0.79% MYCOBUTIN NEBUPENT neomycin sulfate tabs paromomycin sulfate PASER PRIMAQUINE PHOSPHATE pyrazinamide QUALAQUIN quinine sulfate

3 2 5 2 1 2 3 3 2 2 3 3 2 3 2

Requirements/ Limits MO

MO MO MO PA MO MO MO MO MO

MO MO MO MO QL(20 per 30 days) MO MO MO MO MO MO MO MO PA MO MO MO MO MO MO MO MO

Drug Name rifampin SEROMYCIN SIRTURO STREPTOMYCIN SULFATE STROMECTOL tinidazole

Drug Tier 2 3 5 3 3 2

TOBI tobramycin sulfate inj 10mg/ml, 80mg/2ml tobramycin sulfate/sodium chloride inj 0.9%; 1.2mg/ml tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml TRECATOR TYGACIL XIFAXAN TABS 200MG

5 1

XIFAXAN TABS 550MG

ZYVOX INJ ZYVOX SUSR

3 3

ZYVOX TABS

Requirements/ Limits MO MO LA MO MO MO QL(60 per 90 days) MO PA MO MO

2 2

3 3 3

MO MO QL(9 per 30 days) MO QL(180 per 90 days) MO MO QL(1800 per 30 days) MO QL(56 per 30 days) MO

PENICILLINS amoxicillin amoxicillin/clavulanate potassium chew amoxicillin/clavulanate potassium er amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tabs 250mg; 125mg amoxicillin/potassium clavulanate susr 200mg/5ml; 28.5mg/5ml amoxicillin/potassium clavulanate tabs

1 2

MO MO

Drug Drug Name Tier ampicillin 2 ampicillin sodium inj 1gm 2 ampicillin sodium inj 10gm, 2 125mg ampicillin-sulbactam inj 10gm; 2 5gm ampicillin-sulbactam inj 2gm; 2 1gm BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 2 nafcillin sodium inj 10gm, 1gm 2 nallpen/dextrose 2 PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE INJ 0; 40000UNIT/ML, 0; 60000UNIT/ML penicillin g potassium inj 5mu 2 penicillin g procaine 2 penicillin g sodium 2 penicillin v potassium 1 pfizerpen-g inj 20mu 2 piperacillin sodium/tazobactam 2 sodium inj 3gm; 0.375gm, 4gm; 0.5gm ZOSYN INJ 5%; 2GM/50ML; 3 0.25GM/50ML ZOSYN INJ 5%; 3GM/50ML; 3 0.375GM/50ML

Requirements/ Limits MO

Drug Name

SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim ds

2 1 1

MO MO MO

3 1 1 1 1 2

MO MO MO MO MO MO

2 2

MO MO

2 2 1 3 3

MO MO MO MO MO

3 2 2

MO MO MO

2 2 4 2

MO MO MO MO

2 2 2 3

MO PA PA MO

TETRACYCLINES demeclocycline hcl doxycycline hyclate caps doxycycline hyclate dr doxycycline hyclate inj doxycycline hyclate tabs doxycycline monohydrate caps 75mg doxycycline monohydrate susr doxycycline monohydrate tabs 150mg, 50mg, 75mg minocycline hcl minocycline hcl er tetracycline hcl VIBRAMYCIN SUSR VIBRAMYCIN SYRP

MO MO MO MO MO

MO MO MO MO MO MO

URINARY TRACT AGENTS MACRODANTIN CAPS 25MG methenamine hippurate nitrofurantoin macrocrystalline caps 50mg nitrofurantoin monohydrate nitrofurantoin susp PRIMSOL trimethoprim

QUINOLONES AVELOX AVELOX ABC PACK CIPRO I.V.-IN D5W INJ 200MG/100ML; 5% ciprofloxacin hcl ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% ciprofloxacin inj 400mg/40ml levofloxacin levofloxacin in d5w inj 5%; 500mg/100ml NOROXIN ofloxacin

Drug Tier

Requirements/ Limits

3 3 3

MO MO

1 2

MO MO

vancomycin hcl caps vancomycin hcl inj 500mg vancomycin hcl inj 1000mg, 10gm VIBATIV INJ 250MG

1 2 2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

4 2

MO MO

VANCOMYCIN

ADJUNCTIVE AGENTS amifostine dexrazoxane inj 500mg ELITEK INJ 1.5MG

5 2 5

MO MO

Drug Name FUSILEV leucovorin calcium inj 100mg, 350mg leucovorin calcium tabs mesna MESNEX TABS XGEVA ZINECARD INJ 250MG

Drug Tier 5 2 2 2 3 5 3

Requirements/ Limits MO MO

Drug Name CAPRELSA TABS 300MG CAPRELSA TABS 100MG

MO MO MO PA QL(8.5 per 90 days) MO MO

carboplatin inj 150mg/15ml CEENU CELLCEPT INTRAVENOUS CELLCEPT SUSR cisplatin inj 100mg/100ml cladribine CLOLAR COMETRIQ COSMEGEN cyclophosphamide tabs cyclosporine caps cyclosporine inj cyclosporine modified cytarabine aqueous cytarabine inj 500mg dacarbazine inj 200mg DACOGEN daunorubicin hcl inj 5mg/ml decitabine DOCEFREZ docetaxel inj 80mg/8ml docetaxel inj 80mg/4ml DOXIL doxorubicin hcl inj 2mg/ml DROXIA ELLENCE INJ 200MG/100ML ELOXATIN INJ 100MG/20ML ELSPAR EMCYT epirubicin hcl inj 50mg/25ml ERBITUX INJ 100MG/50ML ERIVEDGE ETOPOPHOS etoposide inj 500mg/25ml exemestane

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adriamycin inj 2mg/ml AFINITOR DISPERZ

4 2 5

AFINITOR TABS 10MG, 7.5MG

AFINITOR TABS 2.5MG, 5MG

ALIMTA INJ 500MG ALKERAN INJ anastrozole ARRANON ARZERRA INJ 100MG/5ML AVASTIN INJ 100MG/4ML azathioprine azathioprine sodium bicalutamide BICNU bleomycin sulfate inj 30unit BOSULIF TABS 500MG

4 4 2 4 3 4 2 2 2 4 2 5

BOSULIF TABS 100MG

BUSULFEX CAMPATH

3 4

MO MO PA QL(360 per 90 days) MO PA QL(180 per 90 days) MO PA QL(270 per 90 days) MO MO MO MO MO PA MO MO MO MO MO PA QL(90 per 90 days) MO PA QL(360 per 90 days) MO MO

RequireDrug ments/ Tier Limits 5 QL(90 per 90 days) MO 5 QL(180 per 90 days) MO 2 MO 3 MO 3 3 PA MO 2 MO 2 MO 4 MO 5 PA MO 4 MO 2 PA MO 2 PA MO 2 2 PA MO 2 MO 2 MO 2 MO 3 MO 2 5 MO 5 2 2 MO 3 MO 2 MO 3 MO 4 MO 4 MO 4 MO 3 MO 2 MO 4 MO 5 PA MO 4 MO 2 MO 2 MO

Drug Name FARESTON FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG fludarabine phosphate inj 50mg fluorouracil inj 2.5gm/50ml flutamide gemcitabine hcl inj 1gm gengraf GILOTRIF TABS 40MG GILOTRIF TABS 30MG GILOTRIF TABS 20MG GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea ICLUSIG idarubicin hcl inj 10mg/10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg/5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI JEVTANA KADCYLA INJ 100MG letrozole LEUKERAN leuprolide acetate

RequireDrug ments/ Tier Limits 4 MO 5 MO 5 QL(240 per 84 days) MO 3 QL(240 per 84 days) MO 2 MO 2 MO 2 MO 5 MO 2 PA MO 5 PA QL(31 per 31 days) MO 5 PA QL(42 per 31 days) MO 5 PA QL(62 per 31 days) MO 5 MO 5 MO 4 MO 5 MO 2 MO 5 PA MO 2 4 MO 2 MO 5 PA MO 5 MO 3 MO 5 MO 5 PA QL(180 per 90 days) MO 5 MO 5 MO 2 MO 3 MO 2 MO

Drug Name LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 22.5MG, 30MG, 45MG, 7.5MG LUPRON DEPOT-PED INJ 11.25MG, 15MG LYSODREN MATULANE MEGACE ES

Drug Tier 3 5

Requirements/ Limits MO MO

3 5 3

MO MO QL(150 per 30 days) MO MO PA QL(30 per 30 days) MO PA QL(120 per 30 days) MO

megestrol acetate MEKINIST TABS 2MG

1 5

MEKINIST TABS 0.5MG

melphalan hydrochloride mercaptopurine methotrexate methotrexate sodium inj 25mg/ml METHOTREXATE SODIUM INJ 1GM mitomycin inj 20mg mitoxantrone hcl MUSTARGEN mycophenolate mofetil MYFORTIC NEORAL NEXAVAR

2 2 2 2 4

NILANDRON

NIPENT NULOJIX octreotide acetate inj 1000mcg/ml, 500mcg/ml octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml ONTAK oxaliplatin inj 100mg/20ml

4 5 5

MO MO MO PA MO PA MO PA MO LA PA QL(360 per 90 days) MO QL(120 per 90 days) MO MO MO MO

4 5

2 2 4 2 3 3 5

MO PA MO MO

RequireDrug Drug ments/ Name Tier Limits pacl*taxel inj 300mg/50ml 2 MO pentostatin 2 MO PERJETA 5 PA MO POMALYST 5 MO PROGRAF INJ 3 MO RAPAMUNE 3 PA MO REVLIMID CAPS 2.5MG 5 LA MO REVLIMID CAPS 25MG 5 LA QL(21 per 28 days) MO REVLIMID CAPS 10MG, 5 LA QL(30 15MG, 5MG per 30 days) MO RHEUMATREX 4 MO RITUXAN 3 PA MO SANDIMMUNE CAPS 3 PA MO SANDIMMUNE INJ 3 MO SANDIMMUNE ORAL SOLN 3 PA MO SANDOSTATIN LAR DEPOT 4 MO SIGNIFOR 5 PA MO SIMULECT INJ 20MG 3 MO SOLTAMOX 3 MO SOMATULINE DEPOT 5 MO SPRYCEL TABS 140MG, 5 QL(90 per 50MG, 70MG, 80MG 90 days) MO SPRYCEL TABS 100MG, 20MG 5 QL(180 per 90 days) MO STIVARGA 5 PA QL(252 per 90 days) MO SUTENT CAPS 25MG, 50MG 5 PA QL(90 per 90 days) MO SUTENT CAPS 12.5MG 5 PA QL(270 per 90 days) MO SYNRIBO 5 PA MO TABLOID 3 MO tacrolimus 2 PA MO

RequireDrug Drug ments/ Name Tier Limits TAFINLAR CAPS 75MG 5 PA QL(124 per 31 days) MO TAFINLAR CAPS 50MG 5 PA QL(186 per 31 days) MO tamoxifen citrate 2 MO TARCEVA TABS 100MG, 5 PA QL(90 150MG per 90 days) MO TARCEVA TABS 25MG 5 PA QL(180 per 90 days) MO TARGRETIN 3 MO TASIGNA 5 QL(336 per 84 days) MO TAXOTERE INJ 80MG/4ML 5 MO THALOMID 5 PA MO thiotepa 2 MO toposar inj 1gm/50ml 2 MO topotecan hcl inj 4mg 2 MO TORISEL 5 PA MO TREANDA INJ 100MG 5 MO TRELSTAR DEPOT MIXJECT 4 MO TRELSTAR LA MIXJECT 4 MO TRELSTAR MIXJECT 4 MO tretinoin 2 MO TRISENOX 3 MO TYKERB 5 LA QL(540 per 90 days) MO VECTIBIX INJ 100MG/5ML 5 MO VELCADE 4 MO VIDAZA 5 QL(4200 per 90 days) MO vinblastine sulfate inj 10mg 2 MO vincasar pfs 2 MO vincristine sulfate 2 MO vinorelbine tartrate inj 50mg/5ml 2 MO

Drug Name VOTRIENT XALKORI XTANDI YERVOY INJ 50MG/10ML ZALTRAP INJ 100MG/4ML ZANOSAR ZELBORAF ZOLINZA ZORTRESS TABS 0.5MG, 0.75MG ZORTRESS TABS 0.25MG ZYTIGA

RequireDrug ments/ Tier Limits 5 QL(360 per 90 days) MO 5 PA QL(180 per 90 days) MO 5 PA QL(360 per 90 days) MO 5 PA MO 5 PA MO 4 MO 5 PA QL(720 per 90 days) MO 5 QL(360 per 90 days) MO 5 PA MO 3 5

PA MO PA QL(360 per 90 days) MO

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL carbamazepine carbamazepine er CARBATROL CELONTIN clonazepam clonazepam odt diazepam gel DILANTIN CAPS 30MG DILANTIN INFATABS divalproex sodium divalproex sodium dr divalproex sodium er epitol ethosuximide felbamate

3 1 1 3 3 2 2 2 3 3 2 2 2 1 2 2

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

Requirements/ Limits MO MO

Drug Drug Name Tier FELBATOL 3 fosphenytoin sodium inj 100mg 2 pe/2ml gabapentin 2 MO GABITRIL 3 MO LAMICTAL ODT TBDP 3 MO LAMICTAL STARTER/NOT 3 MO TAKING CARBAMAZEPINE LAMICTAL 3 MO STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL 3 MO STARTER/TAKING VALPROATE LAMICTAL XR 3 MO lamotrigine 2 MO lamotrigine er 2 MO levetiracetam er 2 MO levetiracetam inj 500mg/5ml 2 MO levetiracetam oral soln 2 MO levetiracetam tabs 2 MO LYRICA CAPS 225MG, 300MG 3 QL(180 per 90 days) MO LYRICA CAPS 100MG, 150MG, 3 QL(270 per 200MG, 25MG, 50MG, 75MG 90 days) MO LYRICA ORAL SOLN 3 QL(2880 per 90 days) MO ONFI 3 MO oxcarbazepine 2 MO PEGANONE 3 MO phenobarbital 2 PA MO phenytoin 2 MO phenytoin sodium 2 phenytoin sodium extended 2 MO POTIGA 4 MO primidone 2 MO SABRIL 3 MO TEGRETOL-XR TB12 100MG 3 MO tiagabine hydrochloride 2 MO

Drug Name topiramate TRILEPTAL SUSP valproate sodium valproic acid VIMPAT INJ VIMPAT ORAL SOLN VIMPAT TABS zonisamide

Requirements/ Limits MO MO MO MO

Drug Tier 2 4 2 2 3 3 3 2

MO MO MO

ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine mesylate inj benztropine mesylate tabs bromocriptine mesylate carbidopa/levodopa carbidopa/levodopa er carbidopa/levodopa odt COMTAN entacapone LODOSYN MIRAPEX ER pramipexole dihydrochloride ropinirole er ropinirole hcl selegiline hcl STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 trihexyphenidyl hcl ZELAPAR

3 3 1 1 2 2 2 2 3 2 3 3 2 2 2 2 3 3 3 3 3 3 1 3

LA MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine mesylate inj migergot MIGRANAL

2 2 4

MO MO QL(24 per 90 days) MO

TOPICAL CORTICOSTEROIDS ala cort alclometasone dipropionate amcinonide augmented betamethasone dipropionate crea augmented betamethasone dipropionate gel augmented betamethasone dipropionate lotn augmented betamethasone dipropionate oint betamethasone dipropionate betamethasone valerate CAPEX clobetasol propionate e clobetasol propionate external soln clobetasol propionate foam clobetasol propionate gel clobetasol propionate lotn clobetasol propionate oint clobetasol propionate sham CORDRAN TAPE DERMA-SMOOTHE/FS BODY OIL desonide desoximetasone diflorasone diacetate fluocinolone acetonide body fluocinolone acetonide crea

1 2 2 1

MO MO MO MO

2 1 3 2 2

MO MO MO MO MO

2 2 2 2 2 3 3

MO MO MO MO MO MO MO

2 2 2 1 1

MO MO MO MO MO

Requirements/ Limits MO

Drug Drug Name Tier fluocinolone acetonide external 1 soln fluocinolone acetonide oint 1 fluocinonide external soln 2 fluocinonide gel 2 fluocinonide oint 2 fluocinonide-e 2 fluticasone propionate 2 halobetasol propionate 2 hydrocortisone butyrate 2 hydrocortisone crea 1%, 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 1%, 2.5% 1 hydrocortisone valerate 2 LOCOID LOTN 3 LUXIQ 3 mometasone furoate crea 2 mometasone furoate external soln 2 mometasone furoate oint 2 PANDEL 3 prednicarbate 2 triamcinolone acetonide crea 1 triamcinolone acetonide lotn 1 triamcinolone acetonide oint 1 triderm 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

TOPICAL ENZYMES SANTYL

TOPICAL SCABICIDES / PEDICULICIDES EURAX lindane

3 2

malathion permethrin crea SKLICE spinosad

2 2 3 2

ULESFIA

MO QL(1800 per 365 days) MO MO MO MO QL(720 per 90 days) MO MO

DIAGNOSTICS / MISCELLANEOUS AGENTS

Drug Name

Drug Tier

Requirements/ Limits

MISCELLANEOUS AGENTS acamprosate calcium dr

ACTONEL TABS 30MG

ADAGEN alendronate sodium tabs 40mg

5 2

anagrelide hydrochloride ANTABUSE TABS 250MG ARALAST NP INJ 400MG BUPHENYL CAMPRAL

2 3 5 3 3

CARBAGLU cevimeline hcl CHEMET CLINIMIX 4.25%/DEXTROSE 5% dextrose 10%/nacl 0.45% dextrose 10% flex container dextrose 10%/nacl 0.2% dextrose 2.5%/sodium chloride 0.45% dextrose 5% dextrose 5%/lactated ringers dextrose 5%/nacl 0.2% dextrose 5%/nacl 0.225% dextrose 5%/nacl 0.33% dextrose 5%/nacl 0.45% dextrose 5%/nacl 0.9% disulfiram etidronate disodium EVOXAC EXJADE TBSO 125MG EXJADE TBSO 250MG, 500MG FOSRENOL INCRELEX

5 2 3 3

QL(540 per 90 days) MO PA QL(60 per 120 days) MO LA MO QL(180 per 365 days) MO MO MO LA MO MO QL(540 per 90 days) MO LA MO MO MO

2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 5 3 5

MO MO

MO MO MO MO MO LA MO LA MO MO LA PA MO

RequireDrug Drug ments/ Name Tier Limits kionex powd 2 MO levocarnitine oral soln 2 PA MO levocarnitine tabs 2 PA MO midodrine hcl 2 MO ORFADIN 5 LA MO pilocarpine hcl tabs 2 MO pilocarpine hydrochloride 2 MO PROLASTIN-C 5 LA MO RAVICTI 5 MO RECLAST 4 MO RENVELA 3 MO RILUTEK 5 MO riluzole 2 MO SKELID 4 PA QL(180 per 90 days) MO sodium chloride 0.9% 2 MO sodium chloride inj 0.9% 2 MO sodium phenylbutyrate 2 MO sodium polystyrene sulfonate susp 2 MO 15gm/60ml SYPRINE 3 MO zoledronic acid inj 5mg/100ml 2 MO

SMOKING DETERRENTS buproban

CHANTIX

CHANTIX STARTING MONTH PAK NICOTROL INHALER

NICOTROL NS

EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS

PA QL(180 per 90 days) MO PA QL(168 per 90 days) MO PA MO PA QL(1008 per 90 days) MO PA QL(120 per 90 days) MO

Drug Name ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

Drug Tier 3 2 3 1

Requirements/ Limits MO MO MO MO

1 1 1 3 3

MO MO MO MO MO

2 2 3 2 2 2

MO MO MO MO MO MO

MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic soln DERMOTIC fluocinolone acetonide oil hydrocortisone/acetic acid ofloxacin

OTIC STEROID / ANTIBIOTIC CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN-TC neomycin/polymyxin/hc 2 MO neomycin/polymyxin/hydrocortiso ne otic susp

4 3 3 3 2

MO MO MO MO MO

2 5 2 3 1 2 1

MO PA MO MO MO MO MO MO

1 2 1 1

MO MO MO PA MO

ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort ACTHAR HP cortisone acetate DEPO-MEDROL dexamethasone elix dexamethasone intensol dexamethasone sodium phosphate inj 4mg/ml dexamethasone tabs fludrocortisone acetate hydrocortisone tabs methylprednisolone

Drug Drug Name Tier methylprednisolone acetate 2 methylprednisolone dose pack 1 methylprednisolone 2 sodiumsuccinate inj 125mg, 1gm, 40mg prednisolone sodium phosphate 2 oral soln 25mg/5ml prednisolone sodium phosphate 2 oral soln 15mg/5ml, 5mg/5ml prednisone 1 prednisone intensol 1 SOLU-CORTEF INJ 100MG, 3 250MG SOLU-MEDROL INJ 2GM 3 SOLU-MEDROL INJ 125MG, 3 40MG, 500MG

Requirements/ Limits MO MO MO PA PA MO PA MO PA MO MO MO

Drug Name AVANDIA TABS 8MG AVANDIA TABS 2MG, 4MG BYDUREON BYETTA DUETACT GAUZE PADS 2"X2" glimepiride tabs 1mg, 2mg glimepiride tabs 4mg

ANTITHYROID AGENTS methimazole propylthiouracil

2 2

MO MO

acarbose

ACTOPLUS MET

ACTOS

alcohol preps pads APIDRA

2 4

QL(270 per 90 days) MO QL(270 per 90 days) MO QL(90 per 90 days) MO MO QL(180 per 90 days) MO QL(180 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO

glipizide er tb24 2.5mg, 5mg

DIABETES THERAPY

APIDRA SOLOSTAR

AVANDAMET

AVANDARYL TABS 2MG; 8MG, 4MG; 4MG, 4MG; 8MG

AVANDARYL TABS 1MG; 4MG, 2MG; 4MG

glipizide er tb24 10mg glipizide tabs 10mg glipizide tabs 5mg glipizide/metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glyburide micronized

RequireDrug ments/ Tier Limits 3 QL(90 per 90 days) MO 3 QL(180 per 90 days) MO 3 MO 3 MO 3 QL(90 per 90 days) MO 3 MO 1 QL(90 per 90 days) MO 1 QL(180 per 90 days) MO 1 QL(90 per 90 days) MO 1 QL(180 per 90 days) MO 1 QL(360 per 90 days) MO 1 QL(720 per 90 days) MO 2 QL(360 per 90 days) MO 3 MO 3 MO 1

glyburide tabs 1.25mg, 2.5mg

glyburide tabs 5mg

QL(180 per 90 days) MO QL(180 per 90 days) MO QL(360 per 90 days) MO

Drug Name glyburide/metformin hcl tabs 1.25mg; 250mg, 2.5mg; 500mg glyburide/metformin hcl tabs 5mg; 500mg HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN 3 QL(60 per 30 days) MO HUMULIN 70/30 HUMULIN 70/30 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R

RequireDrug ments/ Tier Limits 2 QL(180 per 90 days) MO 2 QL(360 per 90 days) MO 3 QL(60 per 30 days) MO 3 QL(60 per 30 days) MO 3 QL(60 per 30 days) MO 3 QL(60 per 30 days) MO 3 QL(60 per 30 days) MO 3 QL(60 per 30 days) MO

3 3 3 3

HUMULIN R U-500 (CONCENTRATED)

INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U100 0.3 ML

3 3

QL(60 per 30 days) MO QL(60 per 30 days) MO QL(60 per 30 days) MO QL(60 per 30 days) MO QL(60 per 30 days) MO MO MO

Drug Name INSULIN SYRINGE (DISP) U100 1 ML INSULIN SYRINGE (DISP) U100 1/2 ML INVOKANA TABS 300MG

Drug Tier 3 3

QL(90 per 90 days) MO QL(270 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO MO

INVOKANA TABS 100MG

JANUMET

JANUMET XR TB24 1000MG; 100MG

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG

JANUVIA

JENTADUETO

JUVISYNC TABS 10MG; 50MG, 20MG; 50MG, 40MG; 50MG JUVISYNC TABS 10MG; 100MG, 20MG; 100MG, 40MG; 100MG KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG; 5MG

KOMBIGLYZE XR TB24 1000MG; 2.5MG

LANTUS

LANTUS SOLOSTAR

LEVEMIR

Requirements/ Limits MO

3 3

QL(90 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO QL(30 per 30 days) MO QL(30 per 30 days) MO QL(90 per 90 days) MO

Drug Name LEVEMIR FLEXPEN metformin hcl er tb24 1000mg metformin hcl er tb24 750mg metformin hcl er tb24 500mg metformin hcl tabs 1000mg metformin hcl tabs 850mg metformin hcl tabs 500mg nateglinide NEEDLES, INSULIN DISP., SAFETY NOVOLOG NOVOLOG FLEXPEN

RequireDrug ments/ Tier Limits 3 QL(90 per 90 days) MO 1 QL(180 per 90 days) MO 1 QL(270 per 90 days) MO 1 QL(450 per 90 days) MO 1 QL(180 per 90 days) MO 1 QL(270 per 90 days) MO 1 QL(450 per 90 days) MO 2 QL(270 per 90 days) MO 3 MO 3 3

NOVOLOG MIX 70/30

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

ONGLYZA

pioglitazone hcl

QL(60 per 30 days) MO QL(60 per 30 days) MO QL(60 per 30 days) MO QL(60 per 30 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO

Drug Name pioglitazone hcl-glimepiride pioglitazone hcl/metformin hcl PRANDIN TABS 0.5MG, 1MG PRANDIN TABS 2MG PROGLYCEM repaglinide tabs 0.5mg, 1mg repaglinide tabs 2mg SYMLINPEN 120 SYMLINPEN 60 tolazamide tolbutamide TRADJENTA VICTOZA

RequireDrug ments/ Tier Limits 2 QL(90 per 90 days) MO 2 QL(270 per 90 days) MO 3 QL(360 per 90 days) MO 3 QL(720 per 90 days) MO 3 MO 2 QL(360 per 90 days) MO 2 QL(720 per 90 days) MO 4 QL(33 per 90 days) MO 4 QL(33 per 90 days) MO 2 MO 2 MO 3 QL(90 per 90 days) MO 3 MO

MISCELLANEOUS HORMONES ALDURAZYME ANDRODERM ANDROGEL GEL 50MG/5GM ANDROGEL PUMP GEL 1.62% ANDROID androxy cabergoline calcitonin-salmon

5 3 3 3 3 3 2 2

calcitriol caps calcitriol inj

2 2

LA MO PA MO PA MO PA MO PA MO PA MO MO QL(12 per 90 days) MO PA MO PA MO

RequireDrug Drug ments/ Name Tier Limits calcitriol oral soln 2 PA MO CEREZYME INJ 200UNIT 5 LA MO danazol 2 MO desmopressin acetate 2 MO FABRAZYME INJ 35MG 5 LA MO fortical 2 QL(12 per 90 days) MO KUVAN 5 LA MO NAGLAZYME 5 LA MO oxandrolone tabs 10mg 5 PA MO oxandrolone tabs 2.5mg 3 PA MO SAMSCA TABS 30MG 5 QL(730 per 365 days) MO SAMSCA TABS 15MG 5 QL(1460 per 365 days) MO SENSIPAR TABS 60MG, 90MG 5 MO SENSIPAR TABS 30MG 3 MO SOMAVERT 3 PA MO STIMATE 3 MO SYNAREL 4 MO testosterone cypionate 2 PA MO testosterone enanthate 2 PA MO ZAVESCA 3 LA MO ZEMPLAR 3 PA MO zoledronic acid inj 4mg/5ml 2 QL(30 per 90 days) MO ZOMETA INJ 4MG/5ML 5 QL(30 per 90 days) MO

Drug Name

Drug Tier

ANTIDIARRHEALS / ANTISPASMODICS atropine sulfate inj 0.05mg/ml, 0.1mg/ml dicyclomine hcl caps dicyclomine hcl oral soln glycopyrrolate inj 4mg/20ml glycopyrrolate tabs loperamide hcl caps propantheline bromide

2 2 2 2 2 2 2

1 1 2 1

MO MO MO MO

MO MO MO MO MO MO

MISCELLANEOUS GASTROINTESTINAL AGENTS AMITIZA APRISO ASACOL ASACOL HD balsalazide disodium budesonide cp24 CANASA CIMZIA

3 3 3 3 2 2 3 5

compro constulose CORTIFOAM CREON cromolyn sodium conc CYSTADANE DELZICOL DIPENTUM dronabinol EMEND CAPS 40MG

2 1 3 3 2 3 3 4 2 3

EMEND CAPS 125MG

EMEND CAPS

EMEND CAPS 80MG

THYROID HORMONES levothyroxine sodium tabs levoxyl liothyronine sodium tabs unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

Requirements/ Limits

GASTROENTEROLOGY

MO MO MO MO MO MO MO PA QL(6 per 28 days) MO MO MO MO MO MO MO MO MO PA MO PA QL(3 per 90 days) MO PA QL(6 per 90 days) MO PA QL(18 per 90 days) MO PA QL(24 per 90 days) MO

Drug Name ENTOCORT EC enulose GASTROCROM gavilyte-c gavilyte-g gavilyte-n/flavor pack generlac granisetron hcl inj 0.1mg/ml granisetron hcl inj 1mg/ml granisetron hcl tabs HALFLYTELY BOWEL PREP/FLAVOR PACKS hydrocortisone enem lactulose LIALDA LINZESS LOTRONEX meclizine hcl tabs metoclopramide hcl MOVIPREP ondansetron hcl inj 4mg/2ml ondansetron hcl oral soln ondansetron hcl tabs 24mg ondansetron hcl tabs 4mg, 8mg ondansetron odt

RequireDrug ments/ Tier Limits 3 MO 1 MO 3 MO 2 QL(4000 per 30 days) MO 2 QL(4000 per 30 days) MO 2 QL(4000 per 30 days) MO 1 MO 2 QL(42 per 90 days) 2 QL(42 per 90 days) MO 2 PA QL(180 per 90 days) MO 3 QL(6 per 90 days) MO 1 MO 1 MO 3 MO 3 MO 3 QL(180 per 90 days) MO 2 MO 1 MO 4 QL(6 per 90 days) MO 2 MO 2 PA MO 2 PA QL(21 per 90 days) 2 PA QL(135 per 90 days) MO 2 PA QL(135 per 90 days) MO

Drug Name PENTASA polyethylene glycol 3350 powd prochlorperazine prochlorperazine edisylate prochlorperazine maleate procto-pak proctozone-hc RECTIV RELISTOR INJ 12MG/0.6ML REMICADE SANCUSO SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP TRANSDERM-SCOP trilyte UCERIS ursodiol ZENPEP

RequireDrug ments/ Tier Limits 3 MO 2 MO 2 MO 2 MO 1 MO 1 MO 1 MO 3 MO 3 MO 5 PA MO 3 QL(6 per 90 days) MO 5 MO 2 MO 2 MO 3 MO 3 MO 2 QL(4000 per 30 days) MO 5 MO 2 MO 3 MO

ULCER THERAPY carafate susp DEXILANT

2 4

famotidine inj famotidine premixed famotidine susr famotidine tabs 20mg, 40mg lansoprazole

1 2 1 1 2

misoprostol NEXIUM

2 3

NEXIUM I.V. INJ 20MG NEXIUM I.V. INJ 40MG nizatidine

3 3 2

MO QL(90 per 90 days) ST MO MO MO MO QL(180 per 90 days) MO MO QL(90 per 90 days) MO MO MO

RequireDrug Drug ments/ Name Tier Limits omeprazole cpdr 40mg 2 QL(90 per 90 days) MO omeprazole cpdr 10mg, 20mg 2 QL(180 per 90 days) MO omeprazole/sodium bicarbonate 2 QL(90 per 90 days) MO pantoprazole sodium inj 2 pantoprazole sodium tbec 2 QL(180 per 90 days) MO PREVPAC 4 MO PYLERA 3 MO ranitidine hcl caps 1 MO ranitidine hcl syrp 1 MO ranitidine hcl tabs 150mg, 300mg 1 MO sucralfate tabs 2 MO ZANTAC INJ 50MG/50ML; 3 MO 0.45%

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP ALBUMIN FREE INJ 500MCG/ML

5 3

ARANESP ALBUMIN FREE INJ 150MCG/0.3ML

ARANESP ALBUMIN FREE INJ 200MCG/0.4ML

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML

ARANESP ALBUMIN FREE INJ 300MCG/0.6ML, 60MCG/0.3ML ARANESP ALBUMIN FREE INJ 40MCG/0.4ML

3 3

LA MO PA QL(3 per 90 days) MO PA QL(3.6 per 90 days) MO PA QL(4.8 per 90 days) MO PA QL(6 per 90 days) MO PA QL(7.2 per 90 days) MO PA QL(9.6 per 90 days) MO

RequireDrug Drug ments/ Name Tier Limits ARANESP ALBUMIN FREE 3 PA INJ 25MCG/0.42ML QL(10.08 per 90 days) MO ARANESP ALBUMIN FREE 3 PA QL(12 INJ 100MCG/ML, 200MCG/ML, per 90 days) 300MCG/ML MO ARANESP ALBUMIN FREE 3 PA QL(24 INJ 25MCG/ML, 40MCG/ML, per 90 days) 60MCG/ML MO ARCALYST 5 LA MO AVONEX 5 PA QL(12 per 90 days) MO BETASERON 5 PA QL(45 per 90 days) MO EPOGEN INJ 20000UNIT/ML, 4 PA QL(36 2000UNIT/ML, 3000UNIT/ML, per 90 days) 4000UNIT/ML MO EPOGEN INJ 10000UNIT/ML 4 PA QL(72 per 90 days) MO INTRON-A INJ 10MU/0.2ML 4 PA INTRON-A INJ 3MU/0.2ML 3 PA INTRON-A INJ 3 PA MO 6000000UNIT/ML INTRON-A INJ 5MU/0.2ML 5 PA INTRON-A W/DILUENT INJ 5 PA MO 10MU LEUKINE 5 PA MO MOZOBIL 5 QL(4.8 per 90 days) MO NEULASTA 4 PA QL(3.6 per 90 days) MO NEUMEGA 5 PA QL(63 per 90 days) MO NEUPOGEN INJ 5 PA QL(21 300MCG/0.5ML per 90 days) MO NEUPOGEN INJ 5 PA QL(33.6 480MCG/0.8ML per 90 days) MO

Drug Name NEUPOGEN INJ 480MCG/1.6ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN OMNITROPE INJ 5MG/1.5ML PEG-INTRON INJ 50MCG/0.5ML

RequireDrug ments/ Tier Limits 5 PA QL(67.2 per 90 days) MO 5 PA MO 5 PA MO 4 5

PEG-INTRON REDIPEN

PEGASYS INJ 180MCG/0.5ML

PEGASYS INJ 180MCG/ML

PEGASYS PROCLICK INJ 135MCG/0.5ML

PROCRIT INJ 40000UNIT/ML

PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML PROLEUKIN REBIF

REBIF TITRATION PACK SYLATRON INJ 888MCG

5 5

SYLATRON INJ 296MCG, 444MCG

5 5

PA MO PA QL(12 per 90 days) MO PA QL(12 per 90 days) MO PA QL(6 per 90 days) MO PA QL(12 per 90 days) MO PA QL(12 per 90 days) MO PA QL(18 per 90 days) MO PA QL(36 per 90 days) MO MO PA QL(18 per 90 days) MO PA MO PA QL(8 per 90 days) MO PA QL(12 per 90 days) MO

VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB ADACEL BOOSTRIX CERVARIX

3 3 3 3

MO MO MO PA MO

Drug Drug Name Tier COMVAX 3 DAPTACEL 3 DECAVAC 3 ENGERIX-B 3 GARDASIL 3 HAVRIX INJ 720ELU/0.5ML 3 HAVRIX INJ 1440ELU/ML 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II W/DILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-A/C/Y/W-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM/200ML 5 PROQUAD 3 RABAVERT 3 RECOMBIVAX HB INJ 3 10MCG/ML, 40MCG/ML ROTATEQ 3 tetanus toxoid adsorbed 2 TETANUS/DIPHTHERIA 3 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 3 TWINRIX 3 TYPHIM VI 3 VAQTA INJ 25UNIT/0.5ML 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3

Requirements/ Limits MO MO MO PA MO PA MO MO MO MO MO MO MO MO MO MO PA MO MO PA MO MO MO MO MO MO MO PA MO

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol COLCRYS

1 3

probenecid

MO QL(360 per 90 days) MO MO

Drug Name probenecid/colchicine ULORIC

Drug Tier 2 3

Requirements/ Limits MO MO

OSTEOPOROSIS THERAPY ACTONEL TABS 150MG

ACTONEL TABS 35MG

ACTONEL TABS 5MG

alendronate sodium oral soln alendronate sodium tabs 35mg, 70mg

2 2

alendronate sodium tabs 10mg, 5mg

ATELVIA

EVISTA

FORTEO

ibandronate sodium PROLIA

2 4

QL(3 per 90 days) MO QL(12 per 90 days) MO QL(90 per 90 days) MO MO QL(12 per 90 days) MO QL(90 per 90 days) MO QL(12 per 90 days) MO QL(90 per 90 days) MO QL(7.2 per 90 days) MO MO ST MO

OTHER RHEUMATOLOGICALS DEPEN TITRATABS ENBREL

3 5

HUMIRA INJ 20MG/0.4ML

HUMIRA INJ 40MG/0.8ML

HUMIRA PEN-CROHNS DISEASESTARTER leflunomide tabs 10mg

5 2

MO PA QL(600 per 90 days) MO PA QL(2.4 per 90 days) MO PA QL(4.8 per 90 days) MO PA MO QL(90 per 90 days) MO

Drug Name leflunomide tabs 20mg ORENCIA INJ 125MG/ML RIDAURA SAVELLA SAVELLA TITRATION PACK SIMPONI ARIA SIMPONI INJ 50MG/0.5ML XELJANZ

RequireDrug ments/ Tier Limits 2 QL(102 per 90 days) MO 5 PA QL(12 per 90 days) MO 4 MO 3 QL(180 per 90 days) MO 3 MO 5 PA MO 5 PA QL(1 per 30 days) MO 5 PA MO

OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS ALORA camila CLIMARA PRO COMBIPATCH CRINONE GEL 4% CRINONE GEL 8% DELESTROGEN INJ 10MG/ML DEPO-PROVERA 400MG/ML DEPO-SUBQ PROVERA 104 DIVIGEL GEL 1MG/GM errin ESTRACE CREA estradiol estradiol valerate estradiol/norethindrone acetate ESTRASORB ESTRING

3 2 3 3 3 3 4 3 4 3 2 3 1 2 2 4 4

estropipate jinteli jolivette lyza medroxyprogesterone acetate MENEST

1 2 2 2 1 4

MO MO MO MO MO PA MO MO MO MO MO MO MO MO MO MO MO QL(1 per 90 days) MO MO MO MO MO MO MO

Drug Name nora-be norethindrone norethindrone acetate PREFEST PREMARIN CREA PREMARIN TABS PREMPHASE PREMPRO progesterone caps VAGIFEM VIVELLE-DOT

Drug Tier 2 2 2 4 3 3 3 3 2 3 3

Requirements/ Limits MO MO MO MO MO MO MO MO MO MO MO

MISCELLANEOUS OB/GYN CLEOCIN SUPP clindamycin phosphate crea GYNAZOLE-1 LYSTEDA

3 2 3 4

metronidazole vagin*l miconazole 3 NUVARING ORTHO EVRA terconazole tranexamic acid tabs

1 2 4 4 2 2

vandazole zazole crea 0.4%

1 2

MO MO MO QL(120 per 90 days) MO MO MO MO MO MO QL(120 per 90 days) MO MO

ORAL CONTRACEPTIVES / RELATED AGENTS amethia amethyst apri aranelle aviane balziva briellyn cryselle-28 cyclafem 1/35 cyclafem 7/7/7 drospirenone/ethinyl estradiol

2 2 2 2 2 2 2 2 2 2 2

MO MO MO MO MO MO MO MO MO MO MO

Drug Name ELLA emoquette enpresse-28 gianvi gildagia introvale junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 kariva kelnor 1/35 leena lessina levonest levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg levora 0.15/30-28 loryna low-ogestrel lutera marlissa microgestin 1.5/30 microgestin 1/20 microgestin fe microgestin fe 1.5/30 mononessa necon 0.5/35-28 necon 1/35 necon 10/11-28 necon 7/7/7 nortrel 0.5/35 (28) nortrel 1/35 nortrel 7/7/7 ocella ogestrel orsythia pirmella 1/35 portia-28 previfem quasense

Drug Tier 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Requirements/ Limits MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

Drug Name reclipsen sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zenchent fe zeosa zovia 1/35e zovia 1/50e

Drug Tier 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Requirements/ Limits MO MO MO MO MO MO MO MO MO MO MO MO MO MO

OXYTOCICS METHERGINE methylergonovine maleate tabs

3 2

MO MO

Drug Name ZYMAXID

Drug Tier 3

Requirements/ Limits MO

ANTIVIRALS trifluridine ZIRGAN

2 4

MO MO

2 3 2 3 1

MO MO MO MO MO

2 1 1

MO MO MO

BETA-BLOCKERS betaxolol hcl BETOPTIC-S carteolol hcl ISTALOL levobunolol hcl ophthalmic soln 0.5% metipranolol timolol maleate timolol maleate ophthalmic gel forming TIMOPTIC OCUDOSE

DIRECT ACTING MIOTICS

OPHTHALMOLOGY

PILOPINE HS

ANTIBIOTICS

MISCELLANEOUS OPHTHALMOLOGICS

AZASITE bacitracin ophthalmic oint bacitracin/polymyxin b BESIVANCE CILOXAN OINT ciprofloxacin hcl erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin MOXEZA NATACYN neomycin/bacitracin/polymyxin neomycin/polymyxin/gramicidin ofloxacin tobramycin sulfate ophthalmic soln TOBREX OINT trimethoprim sulfate/polymyxin b sulfate VIGAMOX

3 1 2 3 3 1 1 1 1

MO MO MO MO MO MO MO MO MO

2 3 3 1 2 2 1

MO MO MO MO MO MO MO

3 1

MO MO

ALOCRIL azelastine hcl BEPREVE cromolyn sodium ophthalmic soln CYSTARAN epinastine hcl LACRISERT LASTACAFT PATADAY PATANOL RESTASIS

4 2 3 2 5 2 3 3 3 3 3

MO MO MO MO MO MO MO MO MO MO MO

NON-STEROIDAL ANTIINFLAMMATORY AGENTS ACUVAIL BROMDAY bromfenac diclofenac sodium flurbiprofen sodium ILEVRO ketorolac tromethamine ophthalmic soln NEVANAC

3 3 2 1 2 3 2

MO MO MO MO MO MO MO

Drug Name PROLENSA

Drug Tier 3

Requirements/ Limits MO

ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide er acetazolamide sodium methazolamide

2 2 2 2

MO MO

3 3 2 2 2 3 4 3 2

MO MO MO MO MO MO MO MO MO

OTHER GLAUCOMA DRUGS AZOPT COMBIGAN dorzolamide hcl dorzolamide hcl/timolol maleate latanoprost LUMIGAN SIMBRINZA TRAVATAN Z travoprost

STEROID-ANTIBIOTIC COMBINATIONS neomycin/polymyxin/bacitracin/h ydrocortisone neomycin/polymyxin/dexamethaso ne 1 MO neomycin/polymyxin/hydrocortiso ne ophthalmic susp TOBRADEX OINT TOBRADEX ST tobramycin/dexamethasone ZYLET

SULFONAMIDES BLEPH-10 sodium sulfacetamide ophthalmic soln sulfacetamide sodium oint

3 2

MO MO

3 2 2 4

MO MO MO MO

SYMPATHOMIMETICS ALPHAGAN P apraclonidine brimonidine tartrate IOPIDINE OPHTHALMIC SOLN 1%

VASOCONSTRICTOR DECONGESTANTS naphazoline hcl

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

3 3 2 3

MO MO MO MO

4 4 2

MO MO MO

STEROIDS ALREX dexamethasone sodium phosphate ophthalmic soln DUREZOL FML FML FORTE

Drug Tier 3 2 2

STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. sulfacetamide sodium/prednisolone sodium phosphate

Drug Name LOTEMAX prednisolone acetate prednisolone sodium phosphate ophthalmic soln

Requirements/ Limits MO MO MO

3 1

MO MO

3 3 3

MO MO MO

adrenalin inj carbinoxamine maleate cetirizine hcl syrp clemastine fumarate syrp clemastine fumarate tabs 2.68mg desloratadine

2 2 2 2 2 2

desloratadine odt epinephrine hcl inj 0.1mg/ml EPIPEN 2-PAK EPIPEN-JR 2-PAK hydroxyzine hcl levocetirizine dihydrochloride oral soln levocetirizine dihydrochloride tabs

2 2 3 3 2 2

palgic oral soln phenadoz promethazine hcl inj 25mg/ml promethazine hcl inj 50mg/ml

2 2 2 2

MO MO MO MO MO QL(90 per 90 days) MO MO MO MO MO MO MO QL(90 per 90 days) MO MO MO MO

Drug Name promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethegan supp 25mg, 50mg TWINJECT

Drug Tier 2 2 2 2 3

Requirements/ Limits MO MO MO MO MO

Drug Name COMBIVENT RESPIMAT cromolyn sodium nebu DALIRESP

PULMONARY AGENTS acetylcysteine inhalation soln ADVAIR DISKUS

2 3

ADVAIR HFA

albuterol sulfate er albuterol sulfate nebu albuterol sulfate syrp albuterol sulfate tabs ALVESCO

1 1 1 1 4

ARCAPTA NEOHALER

ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ATROVENT HFA

budesonide susp CINRYZE

2 5

COMBIVENT

3 3 3 3

PA MO QL(180 per 90 days) MO QL(36 per 90 days) MO MO PA MO MO MO QL(37 per 90 days) MO QL(90 per 90 days) MO QL(3 per 90 days) MO QL(3 per 90 days) MO QL(3 per 90 days) MO QL(3 per 90 days) MO QL(77.4 per 90 days) MO PA MO LA PA QL(60 per 90 days) MO QL(88.2 per 90 days) MO

DULERA ELIXOPHYLLIN FIRAZYR FLOVENT DISKUS FLOVENT HFA flunisolide fluticasone propionate FORADIL AEROLIZER ipratropium bromide inhalation soln ipratropium bromide/albuterol sulfate KALYDECO

RequireDrug ments/ Tier Limits 3 QL(20 per 90 days) MO 2 PA MO 3 QL(90 per 90 days) MO 4 QL(39 per 90 days) MO 4 MO 5 MO 3 QL(360 per 90 days) MO 3 QL(72 per 90 days) MO 2 MO 2 MO 3 QL(180 per 90 days) MO 1 PA MO 2

PA MO

PA QL(180 per 90 days) MO LA PA QL(90 per 90 days) MO PA MO PA MO

LETAIRIS

levalbuterol levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml metaproterenol sulfate montelukast sodium

2 2

NASONEX PERFOROMIST

3 3

2 2

MO QL(90 per 90 days) MO MO PA MO

Drug Name PROAIR HFA PULMICORT SUSP 1MG/2ML PULMOZYME QVAR REVATIO INJ REVATIO TABS SEREVENT DISKUS sildenafil citrate SINGULAIR SPIRIVA HANDIHALER SYMBICORT terbutaline sulfate theophylline cr theophylline er tb12 300mg, 450mg theophylline er tb24 TRACLEER

triamcinolone acetonide inha TYVASO XOLAIR

RequireDrug ments/ Tier Limits 3 QL(51 per 90 days) MO 3 PA MO 5 PA MO 3 QL(53 per 90 days) MO 5 QL(3375 per 90 days) MO 5 PA QL(270 per 90 days) MO 3 QL(180 per 90 days) MO 2 PA QL(270 per 90 days) MO 3 QL(90 per 90 days) MO 3 QL(90 per 90 days) MO 3 QL(30.6 per 90 days) MO 2 MO 2 MO 2 MO 2 5

2 5 5

MO LA PA QL(180 per 90 days) MO MO PA MO PA QL(7.2 per 30 days) MO

Drug Name XOPENEX HFA zafirlukast ZYFLO ZYFLO CR

RequireDrug ments/ Tier Limits 3 QL(90 per 90 days) MO 2 QL(180 per 90 days) MO 4 QL(360 per 90 days) MO 4 QL(360 per 90 days) MO

UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL LA

ENABLEX

flavoxate hcl GELNIQUE GEL 10%

2 3

GELNIQUE GEL 3%

MYRBETRIQ

oxybutynin chloride er tb24 5mg

oxybutynin chloride er tb24 10mg, 15mg

oxybutynin chloride syrp oxybutynin chloride tabs

1 1

OXYTROL

QL(90 per 90 days) MO QL(90 per 90 days) MO MO QL(90 per 90 days) MO QL(276 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO MO QL(360 per 90 days) MO QL(32 per 90 days) MO

Drug Name tolterodine tartrate TOVIAZ trospium chloride trospium chloride er VESICARE

RequireDrug ments/ Tier Limits 2 QL(180 per 90 days) MO 3 QL(90 per 90 days) MO 2 QL(180 per 90 days) MO 2 QL(90 per 90 days) MO 3 QL(90 per 90 days) MO

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er

AVODART

finasteride tabs 5mg

JALYN

RAPAFLO

tamsulosin hcl

UROXATRAL

QL(90 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO

CHOLINERGIC STIMULANTS bethanechol chloride

MISCELLANEOUS UROLOGICALS CIALIS TABS 2.5MG, 5MG CYSTAGON

3 3

PA QL(90 per 90 days) MO LA MO

Drug Name ELMIRON potassium citrate tbcr

Drug Tier 3 2

Requirements/ Limits MO MO

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate caps dextrose 5%/potassium chloride 0.15% eliphos K-TABS kcl 0.075%/d5w/nacl 0.45% kcl 0.15%/d5w/lr kcl 0.15%/d5w/nacl 0.2% kcl 0.15%/d5w/nacl 0.225% kcl 0.15%/d5w/nacl 0.9% kcl 0.3%/d5w/nacl 0.45% kcl 0.3%/d5w/nacl 0.9% klor-con 10 klor-con 8 KLOR-CON M15 klor-con m20 lactated ringers viaflex magnesium sulfate inj 50% NORMOSOL-R IN D5W PHOSLYRA potassium chloride 0.15% /nacl 0.45% viaflex potassium chloride 0.15% d5w/nacl 0.33% potassium chloride 0.15% d5w/nacl 0.45% viaflex potassium chloride 0.15% nacl 0.9% potassium chloride 0.22% d5w/nacl 0.45% potassium chloride 0.224%/dextrose 5% viaflex potassium chloride 0.3%/ nacl 0.9% potassium chloride 0.3%/d5w potassium chloride er cpcr

2 2

2 4 2 2 2 2 2 2 2 2 2 4 2 2 2 3 3 2

MO MO MO MO MO

2 2

2 2 2 2 2 2

Drug Drug Name Tier potassium chloride er tbcr 10meq, 2 20meq potassium chloride inj 0.4meq/ml, 2 10meq/100ml, 10meq/50ml, 30meq/100ml potassium chloride inj 2meq/ml 2 ringers injection 2 sodium chloride 0.45% viaflex 2 sodium chloride inj 5% 2 sodium chloride inj 2.5meq/ml, 2 3%

Requirements/ Limits MO

MO MO MO

MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN II AMINOSYN II 8.5%/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINISOL SF 15% FREAMINE III INJ 72MEQ/L; 600MG/100ML; 810MG/100ML; 3MEQ/L; 14MG/100ML; 1190MG/100ML; 240MG/100ML; 590MG/100ML; 770MG/100ML; 620MG/100ML; 450MG/100ML; 480MG/100ML; 10MMOLE/L; 115MG/100ML; 950MG/100ML; 500MG/100ML; 10MEQ/L; 340MG/100ML; 130MG/100ML; 560MG/100ML HEPATAMINE HEPATASOL

3 3 3 3 3 3 3 3 3 3 3 3 3 3

MO MO

Drug Drug Name Tier INTRALIPID INJ 1.7%; 30% 3 intralipid inj 2.25%; 20% 2 IONOSOL-B/DEXTROSE 5% 3 IONOSOL-MB/DEXTROSE 5% 3 ISOLYTE-H/DEXTROSE 5% 3 ISOLYTE-P/DEXTROSE 5% 3 ISOLYTE-S 3 ISOLYTE-S/DEXTROSE 5% 3 liposyn iii inj 1.2%; 2.5%; 10% 2 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE A 3 PLASMA-LYTE-148 3 PLASMA-LYTE-56/D5W 3 PREMASOL INJ 56MEQ/L; 3 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML premasol inj 52meq/l; 2 1760mg/100ml; 880mg/100ml; 34meq/l; 1760mg/100ml; 372mg/100ml; 406mg/100ml; 526mg/100ml; 492mg/100ml; 492mg/100ml; 526mg/100ml; 356mg/100ml; 356mg/100ml; 390mg/100ml; 34mg/100ml; 152mg/100ml travasol 3 TROPHAMINE 3

VITAMINS / HEMATINICS prenatabs obn sodium fluoride tabs 3 3

1 2

Requirements/ Limits MO

Index of Drugs 8 8-MOP ................................................................. 22 A abacavir ................................................................. 1 ABILIFY.............................................................. 14 ABILIFY DISCMELT......................................... 14 ABILIFY MAINTENA ....................................... 14 ABRAXANE ......................................................... 7 acamprosate calcium dr ...................................... 24 acarbose ............................................................... 26 acebutolol hcl....................................................... 18 acetaminophen/codeine ....................................... 12 acetaminophen/codeine #3 .................................. 12 acetasol hc ........................................................... 25 acetazolamide ...................................................... 36 acetazolamide er .................................................. 36 acetazolamide sodium .......................................... 36 acetic acid ............................................................ 25 acetylcysteine ....................................................... 37 acitretin ................................................................ 22 ACTHAR HP ....................................................... 25 ACTHIB .............................................................. 32 ACTIMMUNE ..................................................... 31 ACTONEL..................................................... 24, 33 ACTOPLUS MET ............................................... 26 ACTOS ................................................................ 26 ACUVAIL ........................................................... 35 acyclovir .......................................................... 1, 23 acyclovir sodium .................................................... 1 ADACEL ............................................................. 32 ADAGEN ............................................................ 24 adapalene ............................................................. 22 adrenalin .............................................................. 36 adriamycin ............................................................. 7 ADVAIR DISKUS .............................................. 37 ADVAIR HFA ..................................................... 37 afeditab cr ............................................................ 18 AFINITOR ............................................................. 7 AFINITOR DISPERZ ........................................... 7 AGGRENOX ....................................................... 21 a-hydrocort .......................................................... 25

ala cort ................................................................. 23 ALBENZA ............................................................. 4 albuterol sulfate ................................................... 37 albuterol sulfate er ............................................... 37 alclometasone dipropionate................................. 23 alcohol preps ....................................................... 26 ALDURAZYME ................................................. 28 alendronate sodium ....................................... 24, 33 alfuzosin hcl er ..................................................... 39 ALIMTA ................................................................ 7 ALINIA.................................................................. 4 ALKERAN ............................................................ 7 allopurinol ........................................................... 32 ALOCRIL ............................................................ 35 ALORA................................................................ 33 ALPHAGAN P .................................................... 36 ALREX ................................................................ 36 ALTABAX .......................................................... 23 ALVESCO ........................................................... 37 amantadine hcl....................................................... 1 amcinonide ........................................................... 23 amethia ................................................................ 34 amethyst ............................................................... 34 amifostine............................................................... 6 amikacin sulfate ..................................................... 4 amiloride hcl ........................................................ 18 amiloride/hydrochlorothiazide ............................ 18 AMINOSYN II .................................................... 40 AMINOSYN II 8.5%/ELECTROLYTES ........... 40 AMINOSYN-HBC .............................................. 40 AMINOSYN-PF .................................................. 40 AMINOSYN-PF 7% ............................................ 40 amiodarone hcl .................................................... 18 AMITIZA ............................................................ 29 amitriptyline hcl ................................................... 14 amlodipine besylate ............................................. 18 amlodipine besylate/benazepril hcl ..................... 18 amlodipine besylate/benazepril hydrochloride.... 18 ammonium lactate ................................................ 22 amnesteem............................................................ 22 amoxapine ............................................................ 15 amoxicillin ............................................................. 5

amoxicillin/clavulanate potassium ........................ 5 amoxicillin/clavulanate potassium er .................... 5 amoxicillin/potassium clavulanate ........................ 5 amphotericin b ....................................................... 1 ampicillin ............................................................... 6 ampicillin sodium................................................... 6 ampicillin-sulbactam ............................................. 6 AMTURNIDE ..................................................... 18 anagrelide hydrochloride .................................... 24 anastrozole............................................................. 7 ANCOBON............................................................ 1 ANDRODERM.................................................... 28 ANDROGEL ....................................................... 28 ANDROGEL PUMP ........................................... 28 ANDROID ........................................................... 28 androxy ................................................................ 28 ANTABUSE ........................................................ 24 APIDRA .............................................................. 26 APIDRA SOLOSTAR ......................................... 26 APOKYN ............................................................. 11 apraclonidine ....................................................... 36 apri ....................................................................... 34 APRISO ............................................................... 29 APTIVUS .............................................................. 1 ARALAST NP ..................................................... 24 aranelle ................................................................ 34 ARANESP ALBUMIN FREE ............................. 31 ARCALYST ........................................................ 31 ARCAPTA NEOHALER .................................... 37 ARICEPT ............................................................. 11 ARRANON............................................................ 7 ARTHROTEC 50 ................................................ 14 ARTHROTEC 75 ................................................ 14 ARZERRA ............................................................. 7 ASACOL ............................................................. 29 ASACOL HD....................................................... 29 ascomp/codeine.................................................... 12 ASMANEX 120 METERED DOSES ................. 37 ASMANEX 14 METERED DOSES ................... 37 ASMANEX 30 METERED DOSES ................... 37 ASMANEX 60 METERED DOSES ................... 37 ASTEPRO............................................................ 25 ATELVIA ............................................................ 33

atenolol ................................................................ 18 atenolol/chlorthalidone........................................ 18 atorvastatin calcium ............................................ 21 atovaquone/proguanil hcl ...................................... 4 ATRIPLA .............................................................. 1 atropine sulfate .................................................... 29 ATROVENT HFA ............................................... 37 augmented betamethasone dipropionate ............. 23 AVANDAMET.................................................... 26 AVANDARYL .................................................... 26 AVANDIA ........................................................... 26 AVASTIN .............................................................. 7 AVELOX ............................................................... 6 AVELOX ABC PACK .......................................... 6 aviane ................................................................... 34 avita ..................................................................... 22 AVODART .......................................................... 39 AVONEX ............................................................ 31 AZACTAM............................................................ 4 AZACTAM IN ISO-OSMOTIC DEXTROSE ...... 4 AZASITE ............................................................. 35 azathioprine ........................................................... 7 azathioprine sodium............................................... 7 azelastine hcl ................................................. 25, 35 AZELEX .............................................................. 22 AZILECT ............................................................. 11 azithromycin .......................................................... 4 AZOPT ................................................................ 36 AZOR .................................................................. 18 aztreonam .............................................................. 4 B bacitracin ............................................................. 35 bacitracin/polymyxin b ........................................ 35 baclofen................................................................ 12 BACTROBAN ..................................................... 23 BACTROBAN NASAL ...................................... 25 balsalazide disodium ........................................... 29 balziva .................................................................. 34 BANZEL.............................................................. 10 BARACLUDE ....................................................... 1 benazepril hcl....................................................... 18 benazepril hcl/hydrochlorothiazide ..................... 18

BENICAR ............................................................ 19 BENICAR HCT ................................................... 18 benztropine mesylate ........................................... 11 BEPREVE............................................................ 35 BESIVANCE ....................................................... 35 betamethasone dipropionate ................................ 23 betamethasone valerate ....................................... 23 BETASERON ...................................................... 31 betaxolol hcl................................................... 19, 35 bethanechol chloride ........................................... 39 BETOPTIC-S ....................................................... 35 bicalutamide .......................................................... 7 BICILLIN C-R....................................................... 6 BICILLIN L-A....................................................... 6 BICNU ................................................................... 7 BIDIL................................................................... 19 BILTRICIDE ......................................................... 4 bisoprolol fumarate ............................................. 19 bisoprolol fumarate/hydrochlorothiazide ............ 19 bleomycin sulfate ................................................... 7 BLEPH-10 ........................................................... 36 BLEPHAMIDE.................................................... 36 BLEPHAMIDE S.O.P ......................................... 36 BOOSTRIX ......................................................... 32 BOSULIF ............................................................... 7 briellyn ................................................................. 34 BRILINTA ........................................................... 21 brimonidine tartrate............................................. 36 BROMDAY ......................................................... 35 bromfenac ............................................................ 35 bromocriptine mesylate ....................................... 11 budeprion sr ......................................................... 15 budesonide ..................................................... 29, 37 bumetanide ........................................................... 19 BUPHENYL ........................................................ 24 BUPRENEX ........................................................ 12 buprenorphine hcl ................................................ 12 buprenorphine hcl/naloxone hcl .......................... 14 buproban .............................................................. 25 bupropion hcl ....................................................... 15 bupropion hcl sr ................................................... 15 bupropion hcl xl ................................................... 15 buspirone hcl ....................................................... 15

BUSULFEX ........................................................... 7 butorphanol tartrate ............................................ 14 BUTRANS ........................................................... 12 BYDUREON ....................................................... 26 BYETTA.............................................................. 26 BYSTOLIC .......................................................... 19 C cabergoline .......................................................... 28 calcipotriene ........................................................ 22 calcitonin-salmon ................................................ 28 calcitriol ......................................................... 28, 29 calcium acetate .................................................... 39 camila .................................................................. 33 CAMPATH ............................................................ 7 CAMPRAL .......................................................... 24 CANASA ............................................................. 29 candesartan cilexetil ............................................ 19 candesartan cilexetil/hydrochlorothiazide .......... 19 CAPASTAT SULFATE ........................................ 4 CAPEX ................................................................ 23 CAPRELSA ........................................................... 7 captopril ............................................................... 19 captopril/hydrochlorothiazide ............................. 19 CARAC................................................................ 22 carafate ................................................................ 30 CARBAGLU ....................................................... 24 carbamazepine ..................................................... 10 carbamazepine er................................................. 10 CARBATROL ..................................................... 10 carbidopa/levodopa ............................................. 11 carbidopa/levodopa er ......................................... 11 carbidopa/levodopa odt ....................................... 11 carbinoxamine maleate ........................................ 36 carboplatin............................................................. 7 CARMOL-HC ..................................................... 22 carteolol hcl ......................................................... 35 cartia xt ................................................................ 19 carvedilol ............................................................. 19 CAYSTON ............................................................ 4 CEENU .................................................................. 7 cefaclor .................................................................. 4 cefadroxil ............................................................... 4

cefazolin sodium .................................................... 4 cefdinir ................................................................... 4 cefepime ................................................................. 4 cefotaxime sodium ................................................. 4 cefoxitin sodium ..................................................... 4 cefpodoxime proxetil .............................................. 4 ceftazidime ............................................................. 4 ceftriaxone sodium ................................................. 4 cefuroxime axetil .................................................... 4 cefuroxime sodium ................................................. 4 CELEBREX ......................................................... 14 CELLCEPT............................................................ 7 CELLCEPT INTRAVENOUS .............................. 7 CELONTIN ......................................................... 10 cephalexin .............................................................. 4 CEREZYME ........................................................ 29 CERVARIX ......................................................... 32 cetirizine hcl......................................................... 36 cevimeline hcl ...................................................... 24 CHANTIX ........................................................... 25 CHANTIX STARTING MONTH PAK .............. 25 CHEMET ............................................................. 24 chlordiazepoxide/amitriptyline ............................ 15 chlorhexidine gluconate oral rinse ...................... 25 chloroquine phosphate........................................... 4 chlorothiazide ...................................................... 19 chlorothiazide sodium.......................................... 19 chlorpromazine hcl .............................................. 15 chlorthalidone ...................................................... 19 cholestyramine light............................................. 21 CIALIS ................................................................ 39 ciclopirox ............................................................. 23 ciclopirox nail lacquer ......................................... 23 ciclopirox olamine ............................................... 23 CIDOFOVIR.......................................................... 1 cilostazol .............................................................. 21 CILOXAN ........................................................... 35 CIMZIA ............................................................... 29 CINRYZE ............................................................ 37 CIPRO HC ........................................................... 25 CIPRO I.V.-IN D5W ............................................. 6 CIPRODEX ......................................................... 25 ciprofloxacin .......................................................... 6

ciprofloxacin hcl .............................................. 6, 35 ciprofloxacin i.v.-in d5w ........................................ 6 cisplatin.................................................................. 7 citalopram hydrobromide .................................... 15 cladribine ............................................................... 7 claravis ................................................................ 22 clarithromycin........................................................ 4 clarithromycin er ................................................... 4 clemastine fumarate ............................................. 36 CLEOCIN ............................................................ 34 CLEOCIN IN D5W ............................................... 4 CLEOCIN PEDIATRIC GRANULES .................. 4 CLIMARA PRO .................................................. 33 clindamycin hcl ...................................................... 4 clindamycin palmitate hcl ...................................... 4 clindamycin phosphate .................................. 22, 34 clindamycin phosphate add-vantage ..................... 5 clindamycin phosphate in d5w............................... 5 clindamycin/benzoyl peroxide ............................. 22 CLINIMIX 2.75%/DEXTROSE 5% ................... 40 CLINIMIX 4.25%/DEXTROSE 10% ................. 40 CLINIMIX 4.25%/DEXTROSE 20% ................. 40 CLINIMIX 4.25%/DEXTROSE 25% ................. 40 CLINIMIX 4.25%/DEXTROSE 5% ................... 24 CLINIMIX 5%/DEXTROSE 15% ...................... 40 CLINIMIX 5%/DEXTROSE 20% ...................... 40 CLINIMIX 5%/DEXTROSE 25% ...................... 40 CLINISOL SF 15% ............................................. 40 clobetasol propionate .......................................... 23 clobetasol propionate e........................................ 23 CLOLAR ............................................................... 7 clomipramine hcl ................................................. 15 clonazepam .......................................................... 10 clonazepam odt .................................................... 10 clonidine hcl......................................................... 19 clopidogrel ........................................................... 21 clorazepate dipotassium ...................................... 15 clotrimazole ..................................................... 1, 23 clotrimazole/betamethasone dipropionate........... 23 clozapine .............................................................. 15 COARTEM ............................................................ 5 codeine sulfate ..................................................... 12 COLCRYS ........................................................... 32

colestipol hcl ........................................................ 21 colistimethate sodium ............................................ 5 COLY-MYCIN S................................................. 25 COMBIGAN........................................................ 36 COMBIPATCH ................................................... 33 COMBIVENT...................................................... 37 COMBIVENT RESPIMAT ................................. 37 COMETRIQ .......................................................... 7 COMPLERA.......................................................... 1 compro ................................................................. 29 COMTAN ............................................................ 11 COMVAX............................................................ 32 CONDYLOX ....................................................... 22 constulose ............................................................ 29 COPAXONE........................................................ 11 CORDRAN TAPE ............................................... 23 COREG CR ......................................................... 19 CORTIFOAM ...................................................... 29 cortisone acetate .................................................. 25 CORTISPORIN-TC ............................................. 25 COSMEGEN ......................................................... 7 CREON ................................................................ 29 CRESTOR ........................................................... 21 CRINONE............................................................ 33 CRIXIVAN ............................................................ 1 cromolyn sodium ...................................... 29, 35, 37 cryselle-28............................................................ 34 CUBICIN ............................................................... 5 cyclafem 1/35 ....................................................... 34 cyclafem 7/7/7 ...................................................... 34 cyclobenzaprine hcl ............................................. 12 cyclophosphamide.................................................. 7 cyclosporine ........................................................... 7 cyclosporine modified ............................................ 7 CYKLOKAPRON ............................................... 21 CYMBALTA ....................................................... 15 CYSTADANE ..................................................... 29 CYSTAGON........................................................ 39 CYSTARAN ........................................................ 35 cytarabine .............................................................. 7 cytarabine aqueous ................................................ 7 D

dacarbazine............................................................ 7 DACOGEN ............................................................ 7 DALIRESP .......................................................... 37 danazol ................................................................. 29 dantrolene sodium ............................................... 12 DAPSONE ............................................................. 5 DAPTACEL ........................................................ 32 DARAPRIM .......................................................... 5 daunorubicin hcl .................................................... 7 DECAVAC .......................................................... 32 decitabine ............................................................... 7 DELESTROGEN ................................................. 33 DELZICOL .......................................................... 29 demeclocycline hcl ................................................. 6 DEMSER ............................................................. 19 DENAVIR ........................................................... 23 DEPEN TITRATABS ......................................... 33 DEPO-MEDROL................................................. 25 DEPO-PROVERA 400MG/ML .......................... 33 DEPO-SUBQ PROVERA 104 ............................ 33 DERMA-SMOOTHE/FS BODY OIL................. 23 DERMOTIC ........................................................ 25 desipramine hcl .................................................... 15 desloratadine ....................................................... 36 desloratadine odt ................................................. 36 desmopressin acetate ........................................... 29 desonide ............................................................... 23 desoximetasone .................................................... 23 DETROL LA ....................................................... 38 dexamethasone ..................................................... 25 dexamethasone intensol ....................................... 25 dexamethasone sodium phosphate ................. 25, 36 DEXILANT ......................................................... 30 dexrazoxane ........................................................... 6 dextroamphetamine sulfate .................................. 15 dextroamphetamine sulfate er.............................. 15 dextrose 10%/nacl 0.45% .................................... 24 dextrose 10% flex container ................................ 24 dextrose 10%/nacl 0.2% ...................................... 24 dextrose 2.5%/sodium chloride 0.45% ................ 24 dextrose 5% ......................................................... 24 dextrose 5%/lactated ringers ............................... 24

dextrose 5%/nacl 0.2% ........................................ 24 dextrose 5%/nacl 0.225% .................................... 24 dextrose 5%/nacl 0.33% ...................................... 24 dextrose 5%/nacl 0.45% ...................................... 24 dextrose 5%/nacl 0.9% ........................................ 24 dextrose 5%/potassium chloride 0.15% .............. 39 diazepam ........................................................ 10, 15 diazepam intensol ................................................ 15 DIBENZYLINE ................................................... 19 diclofenac potassium ........................................... 14 diclofenac sodium ................................................ 35 diclofenac sodium dr............................................ 14 diclofenac sodium er ............................................ 14 diclofenac sodium/misoprostol ............................ 14 dicloxacillin sodium ............................................... 6 dicyclomine hcl .................................................... 29 didanosine .............................................................. 1 DIFFERIN ........................................................... 22 DIFICID ................................................................. 4 diflorasone diacetate ........................................... 23 diflunisal .............................................................. 14 digoxin ................................................................. 21 dihydroergotamine mesylate ................................ 11 DILANTIN .......................................................... 10 DILANTIN INFATABS ...................................... 10 DILAUDID .......................................................... 12 DILAUDID-5 ...................................................... 12 DILAUDID-HP ................................................... 12 dilt-cd ................................................................... 19 diltiazem cd .......................................................... 19 diltiazem hcl ......................................................... 19 diltiazem hcl er .................................................... 19 dilt-xr ................................................................... 19 DIOVAN.............................................................. 19 DIPENTUM ......................................................... 29 disopyramide phosphate ...................................... 18 disulfiram ............................................................. 24 divalproex sodium ................................................ 10 divalproex sodium dr ........................................... 10 divalproex sodium er ........................................... 10 DIVIGEL ............................................................. 33 DOCEFREZ........................................................... 7 docetaxel ................................................................ 7

donepezil hcl ........................................................ 11 dorzolamide hcl ................................................... 36 dorzolamide hcl/timolol maleate ......................... 36 doxazosin mesylate .............................................. 19 doxepin hcl ........................................................... 15 DOXIL ................................................................... 7 doxorubicin hcl ...................................................... 7 doxycycline hyclate ................................................ 6 doxycycline hyclate dr ........................................... 6 doxycycline monohydrate ...................................... 6 dronabinol............................................................ 29 drospirenone/ethinyl estradiol ............................. 34 DROXIA ................................................................ 7 DUETACT ........................................................... 26 DULERA ............................................................. 37 duramorph ........................................................... 12 DUREZOL........................................................... 36 E e.e.s. 400 ................................................................ 4 E.E.S. GRANULES ............................................... 4 econazole nitrate .................................................. 23 EDECRIN ............................................................ 19 EDURANT ............................................................ 1 EFFIENT ............................................................. 21 ELIDEL ............................................................... 22 eliphos .................................................................. 39 ELIQUIS .............................................................. 21 ELITEK ................................................................. 6 ELIXOPHYLLIN ................................................ 37 ELLA ................................................................... 34 ELLENCE.............................................................. 7 ELMIRON ........................................................... 39 ELOXATIN ........................................................... 7 ELSPAR ................................................................ 7 EMCYT ................................................................. 7 EMEND ............................................................... 29 emoquette ............................................................. 34 EMSAM ............................................................... 15 EMTRIVA ............................................................. 1 ENABLEX ........................................................... 38 enalapril maleate ................................................. 19 enalapril maleate/hydrochlorothiazide ............... 19

ENBREL .............................................................. 33 endocet ................................................................. 12 ENGERIX-B ........................................................ 32 enoxaparin sodium............................................... 21 enpresse-28 .......................................................... 34 entacapone ........................................................... 11 ENTOCORT EC .................................................. 30 enulose ................................................................. 30 epinastine hcl ....................................................... 35 epinephrine hcl .................................................... 36 EPIPEN 2-PAK ................................................... 36 EPIPEN-JR 2-PAK .............................................. 36 epirubicin hcl ......................................................... 7 epitol .................................................................... 10 EPIVIR .................................................................. 1 EPIVIR HBV ......................................................... 1 eplerenone............................................................ 19 EPOGEN.............................................................. 31 eprosartan mesylate ............................................. 19 EPZICOM .............................................................. 1 ERAXIS ................................................................. 1 ERBITUX .............................................................. 7 ERIVEDGE ........................................................... 7 errin ..................................................................... 33 ery ........................................................................ 22 ERY-TAB .............................................................. 4 ERYTHROCIN LACTOBIONATE ...................... 4 erythrocin stearate ................................................. 4 erythromycin .................................................. 22, 35 erythromycin base .................................................. 4 erythromycin ethylsuccinate .................................. 4 erythromycin/benzoyl peroxide ............................ 22 escitalopram oxalate ............................................ 15 ESTRACE............................................................ 33 estradiol ............................................................... 33 estradiol valerate ................................................. 33 estradiol/norethindrone acetate........................... 33 ESTRASORB ...................................................... 33 ESTRING ............................................................ 33 estropipate ........................................................... 33 ethambutol hcl ....................................................... 5 ethosuximide ........................................................ 10 etidronate disodium ............................................. 24

etodolac................................................................ 14 etodolac er ........................................................... 14 ETOPOPHOS ........................................................ 7 etoposide ................................................................ 7 EURAX................................................................ 24 EVISTA ............................................................... 33 EVOXAC ............................................................. 24 EXALGO ............................................................. 12 EXELON ............................................................. 11 exemestane ............................................................. 7 EXFORGE ........................................................... 19 EXFORGE HCT .................................................. 19 EXJADE .............................................................. 24 F FABRAZYME ..................................................... 29 famciclovir ............................................................. 1 famotidine ............................................................ 30 famotidine premixed ............................................ 30 FANAPT .............................................................. 15 FANAPT TITRATION PACK ............................ 15 FARESTON ........................................................... 8 FASLODEX .......................................................... 8 FAZACLO ........................................................... 15 felbamate.............................................................. 10 FELBATOL ......................................................... 10 felodipine er ......................................................... 19 fenofibrate ............................................................ 21 fenofibrate micronized ......................................... 21 fenofibric acid dr ................................................. 21 fenoprofen calcium .............................................. 14 fentanyl citrate oral transmucosal ....................... 12 fentanyl patches ................................................... 12 FINACEA ............................................................ 23 finasteride ............................................................ 39 FIRAZYR ............................................................ 37 FIRMAGON .......................................................... 8 flavoxate hcl ......................................................... 38 flecainide acetate ................................................. 18 FLECTOR............................................................ 14 FLOVENT DISKUS ............................................ 37 FLOVENT HFA .................................................. 37 fluconazole ............................................................. 1

fluconazole in dextrose .......................................... 1 flucytosine .............................................................. 1 fludarabine phosphate ........................................... 8 fludrocortisone acetate ........................................ 25 flunisolide ............................................................ 37 fluocinolone acetonide ............................. 23, 24, 25 fluocinolone acetonide body ................................ 23 fluocinonide ......................................................... 24 fluocinonide-e ...................................................... 24 FLUOROPLEX ................................................... 22 fluorouracil ...................................................... 8, 22 fluoxetine dr ......................................................... 15 fluoxetine hcl ........................................................ 15 fluphenazine decanoate ....................................... 15 fluphenazine hcl ................................................... 15 flurbiprofen .......................................................... 14 flurbiprofen sodium ............................................. 35 flutamide ................................................................ 8 fluticasone propionate ................................... 24, 37 fluvastatin ............................................................ 21 fluvoxamine maleate ............................................ 16 fluvoxamine maleate er ........................................ 16 FML ..................................................................... 36 FML FORTE ....................................................... 36 FOCALIN XR ..................................................... 16 fondaparinux sodium ........................................... 21 FORADIL AEROLIZER ..................................... 37 FORFIVO XL ...................................................... 16 FORTAZ ................................................................ 4 FORTEO .............................................................. 33 fortical.................................................................. 29 foscarnet sodium .................................................... 1 fosinopril sodium ................................................. 19 fosinopril sodium/hydrochlorothiazide................ 19 fosphenytoin sodium ............................................ 10 FOSRENOL......................................................... 24 FRAGMIN ........................................................... 21 FREAMINE III .................................................... 40 furosemide............................................................ 19 FUSILEV ............................................................... 7 FUZEON................................................................ 1

gabapentin ........................................................... 10 GABITRIL........................................................... 10 galantamine hydrobromide ............................ 11, 12 ganciclovir ............................................................. 1 GARDASIL ......................................................... 32 GASTROCROM.................................................. 30 GAUZE PADS 2.................................................. 26 gavilyte-c.............................................................. 30 gavilyte-g ............................................................. 30 gavilyte-n/flavor pack .......................................... 30 GELNIQUE ......................................................... 38 gemcitabine hcl ...................................................... 8 gemfibrozil ........................................................... 21 generlac ............................................................... 30 gengraf ................................................................... 8 gentak ................................................................... 35 gentamicin sulfate ...................................... 5, 23, 35 gentamicin sulfate/0.9% sodium chloride.............. 5 GEODON ............................................................ 16 gianvi ................................................................... 34 gildagia ................................................................ 34 GILENYA............................................................ 12 GILOTRIF ............................................................. 8 GLEEVEC ............................................................. 8 glimepiride ........................................................... 26 glipizide................................................................ 26 glipizide er ........................................................... 26 glipizide/metformin hcl ........................................ 26 GLUCAGEN HYPOKIT ..................................... 26 GLUCAGON EMERGENCY KIT ..................... 26 glyburide .............................................................. 26 glyburide micronized ........................................... 26 glyburide/metformin hcl....................................... 27 glycopyrrolate ...................................................... 29 granisetron hcl ..................................................... 30 griseofulvin microsize ............................................ 1 griseofulvin ultramicrosize .................................... 1 GRIS-PEG ............................................................. 1 guanfacine hcl ...................................................... 19 GYNAZOLE-1 .................................................... 34

H HALAVEN ............................................................ 8 HALDOL ............................................................. 16 HALDOL DECANOATE 100 ............................ 16 HALDOL DECANOATE 50 .............................. 16 HALFLYTELY BOWEL PREP/FLAVOR PACKS ................................................................ 30 halobetasol propionate ........................................ 24 haloperidol ........................................................... 16 haloperidol decanoate ......................................... 16 haloperidol lactate ............................................... 16 HAVRIX .............................................................. 32 heparin sodium .................................................... 21 heparin sodium/d5w............................................. 21 heparin sodium/nacl 0.45% ................................. 21 heparin sodium/sodium chloride 0.9% premix .... 21 HEPATAMINE ................................................... 40 HEPATASOL ...................................................... 40 HEPSERA.............................................................. 1 HERCEPTIN ......................................................... 8 HEXALEN ............................................................ 8 HUMALOG ......................................................... 27 HUMALOG KWIKPEN ..................................... 27 HUMALOG MIX 50/50 ...................................... 27 HUMALOG MIX 50/50 KWIKPEN................... 27 HUMALOG MIX 75/25 ...................................... 27 HUMALOG MIX 75/25 KWIKPEN................... 27 HUMIRA ............................................................. 33 HUMIRA PEN-CROHNS DISEASESTARTER33 HUMULIN 70/30 ................................................ 27 HUMULIN 70/30 PEN ........................................ 27 HUMULIN N....................................................... 27 HUMULIN N U-100 PEN ................................... 27 HUMULIN R ....................................................... 27 HUMULIN R U-500 (CONCENTRATED) ........ 27 hydralazine hcl..................................................... 19 hydrochlorothiazide ............................................. 19 hydrocodone bitartrate/acetaminophen............... 12 hydrocodone/acetaminophen ............................... 13 hydrocodone/ibuprofen ........................................ 13 hydrocortisone ......................................... 24, 25, 30 hydrocortisone butyrate ....................................... 24

hydrocortisone valerate ....................................... 24 hydrocortisone/acetic acid................................... 25 hydromorphone hcl .............................................. 13 hydroxychloroquine sulfate ................................... 5 hydroxyurea ........................................................... 8 hydroxyzine hcl .................................................... 36 I ibandronate sodium ............................................. 33 ibuprofen .............................................................. 14 ICLUSIG................................................................ 8 idarubicin hcl ......................................................... 8 IFEX ...................................................................... 8 ifosfamide............................................................... 8 ILEVRO ............................................................... 35 imipenem/cilastatin ................................................ 5 imipramine hcl ..................................................... 16 imipramine pamoate ............................................ 16 imiquimod ............................................................ 22 IMOVAX RABIES (H.D.C.V.)........................... 32 INCIVEK ............................................................... 1 INCRELEX.......................................................... 24 indapamide .......................................................... 19 indomethacin........................................................ 14 indomethacin er ................................................... 14 INFANRIX .......................................................... 32 INLYTA ................................................................ 8 INSULIN PEN NEEDLE .................................... 27 INSULIN SYRINGE (DISP) U-100 0.3 ML ...... 27 INSULIN SYRINGE (DISP) U-100 1 ML ......... 27 INSULIN SYRINGE (DISP) U-100 1/2 ML ...... 27 INTELENCE ......................................................... 2 INTRALIPID ....................................................... 40 INTRON-A .......................................................... 31 INTRON-A W/DILUENT ................................... 31 introvale ............................................................... 34 INTUNIV ............................................................. 16 INVEGA .............................................................. 16 INVEGA SUSTENNA ........................................ 16 INVIRASE ............................................................. 2 INVOKANA ........................................................ 27 IONOSOL-B/DEXTROSE 5% ........................... 40 IONOSOL-MB/DEXTROSE 5% ........................ 40 IOPIDINE ............................................................ 36

IPOL INACTIVATED IPV ................................. 32 ipratropium bromide...................................... 25, 37 ipratropium bromide/albuterol sulfate ................ 37 irbesartan............................................................. 19 irbesartan/hydrochlorothiazide ........................... 19 irinotecan ............................................................... 8 ISENTRESS .......................................................... 2 ISOLYTE-H/DEXTROSE 5% ............................ 40 ISOLYTE-P/DEXTROSE 5% ............................. 40 ISOLYTE-S ......................................................... 40 ISOLYTE-S/DEXTROSE 5% ............................. 40 isoniazid ................................................................. 5 isosorbide dinitrate .............................................. 22 isosorbide dinitrate er.......................................... 22 isosorbide mononitrate ........................................ 22 isosorbide mononitrate er .................................... 22 isotonic gentamicin ................................................ 5 isradipine ............................................................. 19 ISTALOL............................................................. 35 ISTODAX .............................................................. 8 itraconazole ........................................................... 1 IXEMPRA KIT ...................................................... 8 IXIARO ............................................................... 32 J JAKAFI.................................................................. 8 JALYN ................................................................. 39 jantoven................................................................ 21 JANUMET........................................................... 27 JANUMET XR .................................................... 27 JANUVIA ............................................................ 27 JENTADUETO.................................................... 27 JEVTANA ............................................................. 8 jinteli .................................................................... 33 jolivette ................................................................ 33 junel 1.5/30 .......................................................... 34 junel 1/20 ............................................................. 34 junel fe 1.5/30 ...................................................... 34 junel fe 1/20 ......................................................... 34 JUVISYNC .......................................................... 27 JUXTAPID .......................................................... 21 K

KALETRA ............................................................. 2 KALYDECO ....................................................... 37 kariva ................................................................... 34 kcl 0.075%/d5w/nacl 0.45% ................................ 39 kcl 0.15%/d5w/lr .................................................. 39 kcl 0.15%/d5w/nacl 0.2% .................................... 39 kcl 0.15%/d5w/nacl 0.225% ................................ 39 kcl 0.15%/d5w/nacl 0.9% .................................... 39 kcl 0.3%/d5w/nacl 0.45% .................................... 39 kcl 0.3%/d5w/nacl 0.9% ...................................... 39 kelnor 1/35 ........................................................... 34 KETEK .................................................................. 5 ketoconazole .................................................... 1, 23 ketodan kit ............................................................ 23 ketoprofen ............................................................ 14 ketoprofen er ........................................................ 14 ketorolac tromethamine ....................................... 35 kionex ................................................................... 25 klor-con 10 ........................................................... 39 klor-con 8 ............................................................. 39 KLOR-CON M15 ................................................ 39 klor-con m20 ........................................................ 39 KOMBIGLYZE XR ............................................ 27 K-TABS ............................................................... 39 KUVAN ............................................................... 29 L labetalol hcl ......................................................... 19 laclotion ............................................................... 22 LACRISERT........................................................ 35 lactated ringers viaflex ........................................ 39 lactulose ............................................................... 30 LAMICTAL ODT ............................................... 10 LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE ........................................... 10 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE...................................................... 10 LAMICTAL STARTER/TAKING VALPROATE ............................................................................. 10 LAMICTAL XR .................................................. 10 lamivudine.............................................................. 2 lamivudine/zidovudine ........................................... 2

KADCYLA ............................................................ 8

lamotrigine........................................................... 10 lamotrigine er ...................................................... 10 LANOXIN ........................................................... 21 LANOXIN PEDIATRIC ..................................... 21 lansoprazole......................................................... 30 LANTUS.............................................................. 27 LANTUS SOLOSTAR ........................................ 27 LASTACAFT ...................................................... 35 latanoprost ........................................................... 36 LATUDA ............................................................. 16 LAZANDA .......................................................... 13 leena ..................................................................... 34 leflunomide .......................................................... 33 lessina .................................................................. 34 LETAIRIS............................................................ 37 letrozole ................................................................. 8 leucovorin calcium................................................. 7 LEUKERAN .......................................................... 8 LEUKINE ............................................................ 31 leuprolide acetate .................................................. 8 levalbuterol .......................................................... 37 levalbuterol hcl .................................................... 37 LEVEMIR............................................................ 27 LEVEMIR FLEXPEN ......................................... 28 levetiracetam........................................................ 10 levetiracetam er ................................................... 10 levobunolol hcl..................................................... 35 levocarnitine ........................................................ 25 levocetirizine dihydrochloride ............................. 36 levofloxacin ...................................................... 6, 35 levofloxacin in d5w ................................................ 6 levonest ................................................................ 34 levonorgestrel/ethinyl estradiol ........................... 34 levora 0.15/30-28 ................................................. 34 levorphanol tartrate ............................................. 13 levothyroxine sodium ........................................... 29 levoxyl .................................................................. 29 LEXIVA ................................................................ 2 LIALDA .............................................................. 30 lidocaine .............................................................. 23 lidocaine hcl......................................................... 23 lidocaine hcl jelly ................................................. 23 lidocaine viscous .................................................. 23

lidocaine/prilocaine ............................................. 23 LIDODERM ........................................................ 23 lindane ................................................................. 24 LINZESS ............................................................. 30 LIORESAL INTRATHECAL ............................. 12 liothyronine sodium ............................................. 29 LIPOFEN ............................................................. 21 liposyn iii ............................................................. 40 lisinopril............................................................... 20 lisinopril/hydrochlorothiazide ............................. 20 lithium carbonate ................................................. 16 lithium carbonate er ............................................ 16 lithium citrate....................................................... 16 LOCOID .............................................................. 24 LODOSYN .......................................................... 11 loperamide hcl ..................................................... 29 lorazepam ............................................................ 16 lorazepam intensol ............................................... 16 loryna ................................................................... 34 losartan potassium ............................................... 20 losartan potassium/hydrochlorothiazide ............. 20 LOTEMAX .......................................................... 36 LOTRONEX ........................................................ 30 lovastatin.............................................................. 21 LOVAZA ............................................................. 21 LOVENOX .......................................................... 21 low-ogestrel ......................................................... 34 loxapine succinate ............................................... 16 LUMIGAN .......................................................... 36 LUNESTA ........................................................... 16 LUPRON DEPOT ................................................. 8 LUPRON DEPOT-PED......................................... 8 lutera .................................................................... 34 LUXIQ ................................................................. 24 LYRICA .............................................................. 10 LYSODREN .......................................................... 8 LYSTEDA ........................................................... 34 lyza ....................................................................... 33 M MACRODANTIN ................................................. 6 mafenide acetate .................................................. 23 magnesium sulfate ............................................... 39

MALARONE ......................................................... 5 malathion ............................................................. 24 maprotiline hcl ..................................................... 16 marlissa................................................................ 34 MARPLAN .......................................................... 16 MATULANE ......................................................... 8 matzim la .............................................................. 20 meclizine hcl ........................................................ 30 meclofenamate sodium......................................... 14 medroxyprogesterone acetate .............................. 33 mefenamic acid .................................................... 14 mefloquine hcl ........................................................ 5 MEGACE ES ......................................................... 8 megestrol acetate ................................................... 8 MEKINIST ............................................................ 8 meloxicam ............................................................ 14 melphalan hydrochloride ....................................... 8 MENACTRA ....................................................... 32 MENEST ............................................................. 33 MENOMUNE-A/C/Y/W-135.............................. 32 MENVEO ............................................................ 32 MEPRON............................................................... 5 mercaptopurine ...................................................... 8 meropenem ............................................................. 5 mesna ..................................................................... 7 MESNEX ............................................................... 7 MESTINON ......................................................... 12 MESTINON TIMESPAN.................................... 12 METADATE CD ................................................. 16 metaproterenol sulfate ......................................... 37 metformin hcl ....................................................... 28 metformin hcl er ................................................... 28 methadone hcl ...................................................... 13 methadose ............................................................ 13 methazolamide ..................................................... 36 methenamine hippurate ......................................... 6 METHERGINE ................................................... 35 methimazole ......................................................... 26 methotrexate .......................................................... 8 methotrexate sodium .............................................. 8 methyclothiazide .................................................. 20 methylergonovine maleate ................................... 35 methylphenidate hcl ............................................. 16

methylphenidate hcl cd ........................................ 16 methylphenidate hcl er ......................................... 16 methylphenidate hydrochloride ........................... 16 methylprednisolone .............................................. 25 methylprednisolone acetate ................................. 26 methylprednisolone dose pack ............................. 26 methylprednisolone sodiumsuccinate .................. 26 metipranolol ......................................................... 35 metoclopramide hcl ............................................. 30 metolazone ........................................................... 20 metoprolol succinate er ....................................... 20 metoprolol tartrate............................................... 20 metoprolol/hydrochlorothiazide .......................... 20 METROGEL........................................................ 23 metronidazole .................................................. 5, 23 metronidazole in nacl 0.79% ................................. 5 metronidazole vagin*l ......................................... 34 mexiletine hcl ....................................................... 18 MICARDIS .......................................................... 20 MICARDIS HCT ................................................. 20 miconazole 3 ........................................................ 34 microgestin 1.5/30 ............................................... 34 microgestin 1/20 .................................................. 34 microgestin fe....................................................... 34 microgestin fe 1.5/30 ........................................... 34 midodrine hcl ....................................................... 25 migergot ............................................................... 11 MIGRANAL ........................................................ 11 minocycline hcl ...................................................... 6 minocycline hcl er .................................................. 6 minoxidil .............................................................. 20 MIRAPEX ER ..................................................... 11 mirtazapine .......................................................... 16 mirtazapine odt .................................................... 16 misoprostol .......................................................... 30 mitomycin ............................................................... 8 mitoxantrone hcl .................................................... 8 M-M-R II W/DILUENT 10 DOSE...................... 32 modafinil .............................................................. 16 moexipril hcl ........................................................ 20 moexipril/hydrochlorothiazide ............................ 20 mometasone furoate ............................................. 24 mononessa............................................................ 34

montelukast sodium ............................................. 37 morphine sulfate .................................................. 13 morphine sulfate er .............................................. 13 MOVIPREP ......................................................... 30 MOXEZA ............................................................ 35 MOZOBIL ........................................................... 31 MULTAQ ............................................................ 18 mupirocin ............................................................. 23 MUSTARGEN ...................................................... 8 MYCOBUTIN ....................................................... 5 mycophenolate mofetil ........................................... 8 MYFORTIC ........................................................... 8 myorisan .............................................................. 23 MYRBETRIQ ...................................................... 38 MYTELASE ........................................................ 12 N nabumetone .......................................................... 14 nadolol ................................................................. 20 nadolol/bendroflumethiazide ............................... 20 nafcillin sodium ..................................................... 6 NAFTIN ............................................................... 23 NAGLAZYME .................................................... 29 nallpen/dextrose ..................................................... 6 naloxone hcl ......................................................... 14 naltrexone hcl ...................................................... 14 NAMENDA ......................................................... 12 NAMENDA TITRATION PAK.......................... 12 NAMENDA XR .................................................. 12 NAMENDA XR TITRATION PACK ................ 12 naphazoline hcl .................................................... 36 naproxen .............................................................. 14 naproxen dr .......................................................... 14 naproxen sodium .................................................. 14 naratriptan hcl ..................................................... 11 NASONEX .......................................................... 37 NATACYN .......................................................... 35 nateglinide ........................................................... 28 NEBUPENT .......................................................... 5 necon 0.5/35-28 ................................................... 34 necon 1/35 ............................................................ 34 necon 10/11-28 .................................................... 34 necon 7/7/7........................................................... 34

NEEDLES, INSULIN DISP., SAFETY .............. 28 nefazodone hcl ..................................................... 16 neomycin sulfate .................................................... 5 neomycin/bacitracin/polymyxin ........................... 35 neomycin/polymyxin/bacitracin/hydrocortisone.. 36 neomycin/polymyxin/dexamethasone ................... 36 neomycin/polymyxin/gramicidin .......................... 35 neomycin/polymyxin/hc........................................ 25 neomycin/polymyxin/hydrocortisone ............. 25, 36 NEORAL ............................................................... 8 NEPHRAMINE ................................................... 40 NEULASTA ........................................................ 31 NEUMEGA ......................................................... 31 NEUPOGEN .................................................. 31, 32 NEVANAC .......................................................... 35 nevirapine .............................................................. 2 NEXAVAR ............................................................ 8 NEXIUM ............................................................. 30 NEXIUM I.V. ...................................................... 30 NIASPAN ............................................................ 21 nicardipine hcl ..................................................... 20 NICOTROL INHALER....................................... 25 NICOTROL NS ................................................... 25 nifediac cc ............................................................ 20 nifedical xl ........................................................... 20 nifedipine ............................................................. 20 nifedipine er ......................................................... 20 NILANDRON........................................................ 8 nimodipine ........................................................... 20 NIPENT ................................................................. 8 nisoldipine............................................................ 20 nisoldipine er ....................................................... 20 nitro-bid ............................................................... 22 NITRO-DUR ....................................................... 22 nitrofurantoin macrocrystalline............................. 6 nitrofurantoin monohydrate................................... 6 nitrofurantoin susp................................................. 6 nitroglycerin ........................................................ 22 nitroglycerin transdermal .................................... 22 NITROLINGUAL PUMPSPRAY....................... 22 NITROSTAT ....................................................... 22 nizatidine.............................................................. 30 nora-be ................................................................. 34

NORDITROPIN FLEXPRO ............................... 32 NORDITROPIN NORDIFLEX PEN .................. 32 norethindrone ...................................................... 34 norethindrone acetate .......................................... 34 NORMOSOL-R ................................................... 40 NORMOSOL-R IN D5W .................................... 39 NOROXIN ............................................................. 6 NORPACE CR .................................................... 18 nortrel 0.5/35 (28) ............................................... 34 nortrel 1/35 .......................................................... 34 nortrel 7/7/7 ......................................................... 34 nortriptyline hcl ................................................... 16 NORVIR ................................................................ 2 NOVOLOG.......................................................... 28 NOVOLOG FLEXPEN ....................................... 28 NOVOLOG MIX 70/30 ....................................... 28 NOVOLOG MIX 70/30 PREFILLED FLEXPEN ............................................................................. 28 NOXAFIL .............................................................. 1 NUCYNTA .......................................................... 14 NUCYNTA ER .................................................... 14 NUEDEXTA........................................................ 12 NULOJIX .............................................................. 8 NUVARING ........................................................ 34 nyamyc ................................................................. 23 nystatin ............................................................. 1, 23 nystatin/triamcinolone ......................................... 23 nystop ................................................................... 23 O ocella.................................................................... 34 octreotide acetate................................................... 8 ofloxacin .................................................... 6, 25, 35 ogestrel ................................................................ 34 olanzapine ...................................................... 16, 17 olanzapine odt ...................................................... 17 olanzapine/fluoxetine ........................................... 17 omeprazole ........................................................... 31 omeprazole/sodium bicarbonate .......................... 31 OMNITROPE ...................................................... 32 ondansetron hcl ................................................... 30 ondansetron odt ................................................... 30 ONFI .................................................................... 10

ONGLYZA .......................................................... 28 ONSOLIS ............................................................ 13 ONTAK ................................................................. 8 OPANA ER (CRUSH RESISTANT) .................. 13 ORAP ................................................................... 17 ORENCIA............................................................ 33 ORFADIN............................................................ 25 orsythia ................................................................ 34 ORTHO EVRA .................................................... 34 oxaliplatin .............................................................. 8 oxandrolone ......................................................... 29 oxaprozin ............................................................. 14 oxcarbazepine ...................................................... 10 OXSORALEN ULTRA ....................................... 22 oxybutynin chloride ............................................. 38 oxybutynin chloride er ......................................... 38 oxycodone hcl ...................................................... 13 oxycodone/acetaminophen ................................... 13 oxycodone/aspirin ................................................ 13 OXYCONTIN...................................................... 13 oxymorphone hydrochloride ................................ 13 oxymorphone hydrochloride er............................ 13 OXYTROL .......................................................... 38 P pacerone .............................................................. 18 pacl*taxel................................................................ 9 palgic ................................................................... 36 PANDEL.............................................................. 24 PANRETIN.......................................................... 22 pantoprazole sodium............................................ 31 paromomycin sulfate .............................................. 5 paroxetine hcl ...................................................... 17 paroxetine hcl er .................................................. 17 PASER ................................................................... 5 PATADAY .......................................................... 35 PATANOL........................................................... 35 PAXIL.................................................................. 17 pedi-dri ................................................................ 23 PEDVAX HIB ..................................................... 32 PEGANONE ........................................................ 10 PEGASYS............................................................ 32 PEGASYS PROCLICK ....................................... 32

PEG-INTRON ..................................................... 32 PEG-INTRON REDIPEN ................................... 32 penicillin g potassium ............................................ 6 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE .......................................................... 6 penicillin g procaine .............................................. 6 penicillin g sodium................................................. 6 penicillin v potassium ............................................ 6 PENNSAID.......................................................... 14 PENTASA ........................................................... 30 pentostatin.............................................................. 9 pentoxifylline er ................................................... 21 PERFOROMIST .................................................. 37 perindopril erbumine ........................................... 20 periogard ............................................................. 25 PERJETA............................................................... 9 permethrin............................................................ 24 perphenazine ........................................................ 17 pfizerpen-g ............................................................. 6 phenadoz .............................................................. 36 phenelzine sulfate................................................. 17 phenobarbital ....................................................... 10 phenytoin.............................................................. 10 phenytoin sodium ................................................. 10 phenytoin sodium extended .................................. 10 PHISOHEX.......................................................... 23 PHOSLYRA ........................................................ 39 pilocarpine hcl ..................................................... 25 pilocarpine hydrochloride ................................... 25 PILOPINE HS ..................................................... 35 pindolol ................................................................ 20 pioglitazone hcl .................................................... 28 pioglitazone hcl/metformin hcl ............................ 28 pioglitazone hcl-glimepiride ................................ 28 piperacillin sodium/tazobactam sodium ................ 6 pirmella 1/35........................................................ 34 piroxicam ............................................................. 14 PLASMA-LYTE A .............................................. 40 PLASMA-LYTE-148 .......................................... 40 PLASMA-LYTE-56/D5W .................................. 40 podofilox .............................................................. 22 polyethylene glycol 3350 ..................................... 30 POMALYST .......................................................... 9

portia-28 .............................................................. 34 potassium chloride ............................................... 40 potassium chloride 0.15% /nacl 0.45% viaflex ... 39 potassium chloride 0.15% d5w/nacl 0.33% ........ 39 potassium chloride 0.15% d5w/nacl 0.45% viaflex ............................................................................. 39 potassium chloride 0.15% nacl 0.9% .................. 39 potassium chloride 0.22% d5w/nacl 0.45% ........ 39 potassium chloride 0.224%/dextrose 5% viaflex . 39 potassium chloride 0.3%/ nacl 0.9% ................... 39 potassium chloride 0.3%/d5w .............................. 39 potassium chloride er .................................... 39, 40 potassium citrate.................................................. 39 POTIGA ............................................................... 10 PRADAXA .......................................................... 21 pramipexole dihydrochloride............................... 11 PRANDIN............................................................ 28 pravastatin sodium......................................... 21, 22 prazosin hcl .......................................................... 20 prednicarbate ....................................................... 24 prednisolone acetate ............................................ 36 prednisolone sodium phosphate .................... 26, 36 prednisone............................................................ 26 prednisone intensol .............................................. 26 PREFEST............................................................. 34 PREMARIN ......................................................... 34 PREMASOL ........................................................ 40 PREMPHASE ...................................................... 34 PREMPRO........................................................... 34 prenatabs obn ...................................................... 40 prevalite ............................................................... 22 previfem ............................................................... 34 PREVPAC ........................................................... 31 PREZISTA ............................................................. 2 PRIMAQUINE PHOSPHATE .............................. 5 primidone ............................................................. 10 PRIMSOL .............................................................. 6 PRISTIQ .............................................................. 17 PRIVIGEN ........................................................... 32 PROAIR HFA ...................................................... 38 probenecid ........................................................... 32 probenecid/colchicine .......................................... 33 procainamide hcl ................................................. 18

procentra.............................................................. 17 prochlorperazine.................................................. 30 prochlorperazine edisylate .................................. 30 prochlorperazine maleate .................................... 30 PROCRIT ............................................................ 32 procto-pak ............................................................ 30 proctozone-hc ...................................................... 30 progesterone ........................................................ 34 PROGLYCEM ..................................................... 28 PROGRAF ............................................................. 9 PROLASTIN-C ................................................... 25 PROLENSA ......................................................... 36 PROLEUKIN ....................................................... 32 PROLIA ............................................................... 33 PROMACTA ....................................................... 21 promethazine hcl ............................................ 36, 37 promethegan ........................................................ 37 propafenone hcl ................................................... 18 propafenone hcl er ............................................... 18 propantheline bromide......................................... 29 propranolol hcl .................................................... 20 propranolol hcl er ................................................ 20 propranolol/hydrochlorothiazide ........................ 20 propylthiouracil ................................................... 26 PROQUAD .......................................................... 32 PROTOPIC .......................................................... 22 protriptyline hcl ................................................... 17 PROVIGIL........................................................... 17 prudoxin ............................................................... 22 PULMICORT ...................................................... 38 PULMOZYME .................................................... 38 PYLERA .............................................................. 31 pyrazinamide.......................................................... 5 pyridostigmine bromide ....................................... 12 Q QUALAQUIN ....................................................... 5 quasense ............................................................... 34 quetiapine fumarate ............................................. 17 quinapril hcl......................................................... 20 quinapril/hydrochlorothiazide ............................. 20 quinidine gluconate cr ......................................... 18 quinidine sulfate................................................... 18

quinidine sulfate er .............................................. 18 quinine sulfate........................................................ 5 QVAR .................................................................. 38 R RABAVERT ........................................................ 32 ramipril ................................................................ 20 RANEXA ............................................................. 22 ranitidine hcl ........................................................ 31 RAPAFLO ........................................................... 39 RAPAMUNE ......................................................... 9 RAVICTI ............................................................. 25 REBETOL ............................................................. 2 REBIF .................................................................. 32 REBIF TITRATION PACK ................................ 32 RECLAST............................................................ 25 reclipsen ............................................................... 35 RECOMBIVAX HB ............................................ 32 RECTIV ............................................................... 30 regonol ................................................................. 12 REGRANEX........................................................ 22 RELENZA DISKHALER ..................................... 2 RELISTOR .......................................................... 30 RELPAX .............................................................. 11 REMICADE ........................................................ 30 REMODULIN ..................................................... 20 RENVELA ........................................................... 25 repaglinide ........................................................... 28 reprexain .............................................................. 13 RESCRIPTOR ....................................................... 2 reserpine .............................................................. 20 RESTASIS ........................................................... 35 RETROVIR IV INFUSION .................................. 2 REVATIO ............................................................ 38 REVLIMID ............................................................ 9 REYATAZ............................................................. 2 RHEUMATREX.................................................... 9 ribapak ................................................................... 2 ribasphere .......................................................... 2, 3 ribavirin ................................................................. 3 RIDAURA ........................................................... 33 rifampin.................................................................. 5 RILUTEK ............................................................ 25

riluzole ................................................................. 25 rimantadine hcl ...................................................... 3 ringers injection ................................................... 40 RISPERDAL CONSTA....................................... 17 risperidone ........................................................... 17 risperidone odt ..................................................... 17 RITALIN LA ....................................................... 17 RITUXAN ............................................................. 9 rivastigmine tartrate ............................................ 12 rizatriptan benzoate ............................................. 11 rizatriptan benzoate odt ....................................... 11 ropinirole er ......................................................... 11 ropinirole hcl ....................................................... 11 ROTATEQ ........................................................... 32 ROXICET ............................................................ 13 S SABRIL ............................................................... 10 SAMSCA ............................................................. 29 SANCUSO........................................................... 30 SANDIMMUNE .................................................... 9 SANDOSTATIN LAR DEPOT ............................ 9 SANTYL.............................................................. 24 SAPHRIS ............................................................. 17 SAVELLA ........................................................... 33 SAVELLA TITRATION PACK ......................... 33 selegiline hcl ........................................................ 11 selenium sulfide ................................................... 22 SELZENTRY ........................................................ 3 SENSIPAR .......................................................... 29 SEREVENT DISKUS ......................................... 38 SEROMYCIN ........................................................ 5 SEROQUEL XR .................................................. 17 sertraline hcl ........................................................ 17 SIGNIFOR ............................................................. 9 sildenafil citrate ................................................... 38 SILENOR ............................................................ 17 silver sulfadiazine ................................................ 22 SIMBRINZA ....................................................... 36 SIMPONI ............................................................. 33 SIMPONI ARIA .................................................. 33 SIMULECT ........................................................... 9 simvastatin ........................................................... 22

SINGULAIR ........................................................ 38 SIRTURO .............................................................. 5 SKELID ............................................................... 25 SKLICE ............................................................... 24 sodium chloride ............................................. 25, 40 sodium chloride 0.45% viaflex ............................ 40 sodium chloride 0.9% .......................................... 25 sodium fluoride .................................................... 40 sodium phenylbutyrate ......................................... 25 sodium polystyrene sulfonate ............................... 25 sodium sulfacetamide........................................... 36 SOLARAZE ........................................................ 22 SOLTAMOX ......................................................... 9 SOLU-CORTEF .................................................. 26 SOLU-MEDROL................................................. 26 SOMATULINE DEPOT ....................................... 9 SOMAVERT ....................................................... 29 SORIATANE ....................................................... 22 sorine ................................................................... 18 sotalol hcl............................................................. 18 sotalol hcl (af) ...................................................... 18 spinosad ............................................................... 24 SPIRIVA HANDIHALER................................... 38 spironolactone ..................................................... 20 spironolactone/hydrochlorothiazide .................... 20 SPORANOX .......................................................... 1 sprintec 28 ........................................................... 35 SPRYCEL .............................................................. 9 sronyx ................................................................... 35 ssd ........................................................................ 22 stagesic ................................................................ 13 STALEVO 100 .................................................... 11 STALEVO 125 .................................................... 11 STALEVO 150 .................................................... 11 STALEVO 200 .................................................... 11 STALEVO 50 ...................................................... 11 STALEVO 75 ...................................................... 11 stavudine ................................................................ 3 STIMATE ............................................................ 29 STIVARGA ........................................................... 9 STRATTERA ...................................................... 17 STREPTOMYCIN SULFATE .............................. 5 STRIBILD ............................................................. 3

STROMECTOL..................................................... 5 SUBOXONE........................................................ 14 SUCRAID ............................................................ 30 sucralfate ............................................................. 31 sulfacetamide sodium..................................... 23, 36 sulfacetamide sodium/prednisolone sodium phosphate ............................................................. 36 sulfadiazine ............................................................ 6 sulfamethoxazole/trimethoprim ............................. 6 sulfamethoxazole/trimethoprim ds ......................... 6 SULFAMYLON .................................................. 23 sulfasalazine ........................................................ 30 sulfazine ec........................................................... 30 sulindac ................................................................ 14 sumatriptan succinate .......................................... 11 SUPRAX................................................................ 4 SUPREP BOWEL PREP ..................................... 30 SUSTIVA .............................................................. 3 SUTENT ................................................................ 9 SYLATRON ........................................................ 32 SYMBICORT ...................................................... 38 SYMBYAX ......................................................... 17 SYMLINPEN 120 ............................................... 28 SYMLINPEN 60 ................................................. 28 SYNAREL ........................................................... 29 SYNRIBO .............................................................. 9 SYPRINE ............................................................. 25 T TABLOID .............................................................. 9 tacrolimus .............................................................. 9 TAFINLAR............................................................ 9 TAMIFLU.............................................................. 3 tamoxifen citrate .................................................... 9 tamsulosin hcl ...................................................... 39 TARCEVA ............................................................ 9 TARGRETIN ......................................................... 9 TASIGNA .............................................................. 9 TAXOTERE .......................................................... 9 TAZORAC .......................................................... 23 taztia xt................................................................. 20 TECFIDERA ....................................................... 12 TECFIDERA STARTER PACK ......................... 12

TEFLARO ............................................................. 4 TEGRETOL-XR .................................................. 10 TEKAMLO .......................................................... 20 TEKTURNA ........................................................ 20 TEKTURNA HCT ............................................... 20 temazepam ........................................................... 17 terazosin hcl ......................................................... 20 terbinafine hcl ........................................................ 1 terbutaline sulfate ................................................ 38 terconazole ........................................................... 34 testosterone cypionate ......................................... 29 testosterone enanthate ......................................... 29 tetanus toxoid adsorbed ....................................... 32 TETANUS/DIPHTHERIA TOXOIDSADSORBED ADULT ................................................................ 32 tetracycline hcl....................................................... 6 THALOMID .......................................................... 9 theophylline cr ..................................................... 38 theophylline er ..................................................... 38 thioridazine hcl .................................................... 17 thiotepa .................................................................. 9 thiothixene............................................................ 17 THYMOGLOBULIN .......................................... 32 tiagabine hydrochloride....................................... 10 ticlopidine hcl ...................................................... 21 TIKOSYN ............................................................ 18 timolol maleate .............................................. 20, 35 timolol maleate ophthalmic gel forming .............. 35 TIMOPTIC OCUDOSE....................................... 35 tinidazole................................................................ 5 TIVICAY ............................................................... 3 tizanidine hcl ........................................................ 12 TOBI ...................................................................... 5 TOBRADEX........................................................ 36 TOBRADEX ST .................................................. 36 tobramycin sulfate ........................................... 5, 35 tobramycin sulfate/sodium chloride ...................... 5 tobramycin/dexamethasone ................................. 36 TOBREX ............................................................. 35 tolazamide ............................................................ 28 tolbutamide .......................................................... 28 tolmetin sodium.................................................... 14 tolterodine tartrate............................................... 39

topiramate ............................................................ 11 toposar ................................................................... 9 topotecan hcl .......................................................... 9 TORISEL ............................................................... 9 torsemide.............................................................. 21 TOVIAZ .............................................................. 39 TRACLEER ......................................................... 38 TRADJENTA ...................................................... 28 tramadol hcl ......................................................... 14 tramadol hcl er .................................................... 14 trandolapril .......................................................... 21 tranexamic acid ................................................... 34 TRANSDERM-SCOP ......................................... 30 tranylcypromine sulfate ....................................... 17 travasol ................................................................ 40 TRAVATAN Z .................................................... 36 travoprost ............................................................. 36 trazodone hcl ....................................................... 17 TREANDA ............................................................ 9 TRECATOR .......................................................... 5 TRELSTAR DEPOT MIXJECT ........................... 9 TRELSTAR LA MIXJECT ................................... 9 TRELSTAR MIXJECT ......................................... 9 tretinoin............................................................ 9, 23 triamcinolone acetonide ................................ 24, 38 triamcinolone in orabase ..................................... 25 triamterene/hydrochlorothiazide ......................... 21 TRIBENZOR ....................................................... 21 triderm ................................................................. 24 trifluoperazine hcl ................................................ 17 trifluridine ............................................................ 35 trihexyphenidyl hcl............................................... 11 tri-legest fe ........................................................... 35 TRILEPTAL ........................................................ 11 TRILIPIX ............................................................. 22 trilyte .................................................................... 30 trimethoprim .......................................................... 6 trimethoprim sulfate/polymyxin b sulfate ............ 35 trimipramine maleate........................................... 17 trinessa................................................................. 35 tri-previfem .......................................................... 35 TRISENOX............................................................ 9 tri-sprintec ........................................................... 35

trivora-28 ............................................................. 35 TRIZIVIR .............................................................. 3 TROPHAMINE ................................................... 40 trospium chloride ................................................. 39 trospium chloride er ............................................ 39 TRUVADA ............................................................ 3 TWINJECT .......................................................... 37 TWINRIX ............................................................ 32 TWYNSTA .......................................................... 21 TYGACIL .............................................................. 5 TYKERB ............................................................... 9 TYPHIM VI ......................................................... 32 TYVASO ............................................................. 38 TYZEKA ............................................................... 3 TYZINE ............................................................... 25 TYZINE PEDIATRIC NASAL DROPS ............. 25 U UCERIS ............................................................... 30 ULESFIA ............................................................. 24 ULORIC .............................................................. 33 unithroid .............................................................. 29 UROXATRAL..................................................... 39 ursodiol ................................................................ 30 UVADEX ............................................................ 22 V VAGIFEM ........................................................... 34 valacyclovir hcl ...................................................... 3 VALCYTE ............................................................. 3 valproate sodium ................................................. 11 valproic acid ........................................................ 11 valsartan/hydrochlorothiazide............................. 21 vancomycin hcl ...................................................... 6 vandazole ............................................................. 34 VAQTA ............................................................... 32 VARIVAX ........................................................... 32 VASCEPA ........................................................... 22 VECTIBIX ............................................................. 9 VELCADE ............................................................. 9 velivet ................................................................... 35 venlafaxine hcl ............................................... 17, 18 venlafaxine hcl er ................................................. 17 verapamil hcl ....................................................... 21

verapamil hcl er ................................................... 21 verapamil hcl sr ................................................... 21 VEREGEN ........................................................... 22 VESICARE .......................................................... 39 vestura.................................................................. 35 VFEND .................................................................. 1 VFEND IV ............................................................. 1 VIBATIV ............................................................... 6 VIBRAMYCIN...................................................... 6 vicodin.................................................................. 13 vicodin es ............................................................. 14 vicodin hp............................................................. 14 VICTOZA ............................................................ 28 VICTRELIS ........................................................... 3 VIDAZA ................................................................ 9 VIDEX PEDIATRIC ............................................. 3 VIGAMOX .......................................................... 35 VIIBRYD ............................................................. 18 VIMOVO ............................................................. 14 VIMPAT .............................................................. 11 vinblastine sulfate .................................................. 9 vincasar pfs ............................................................ 9 vincristine sulfate ................................................... 9 vinorelbine tartrate ................................................ 9 VIRACEPT ............................................................ 3 VIRAMUNE .......................................................... 3 VIRAMUNE XR ................................................... 3 VIRAZOLE ........................................................... 3 VIREAD ................................................................ 3 VIVELLE-DOT ................................................... 34 VOLTAREN GEL ............................................... 14 voriconazole ........................................................... 1 VOTRIENT ......................................................... 10 W warfarin sodium ................................................... 21 WELCHOL .......................................................... 22 X XALKORI ........................................................... 10 XARELTO ........................................................... 21 XELJANZ ............................................................ 33 XENAZINE ......................................................... 12 XGEVA ................................................................. 7

XIFAXAN ............................................................. 5 XOLAIR .............................................................. 38 XOPENEX HFA .................................................. 38 XTANDI .............................................................. 10 XYREM ............................................................... 18 Y YERVOY ............................................................. 10 YF-VAX .............................................................. 32 Z zafirlukast ............................................................ 38 zaleplon ................................................................ 18 ZALTRAP ........................................................... 10 ZANOSAR .......................................................... 10 ZANTAC ............................................................. 31 ZAVESCA ........................................................... 29 zazole ................................................................... 34 ZELAPAR ........................................................... 11 ZELBORAF ......................................................... 10 ZEMPLAR ........................................................... 29 zenchent fe ........................................................... 35 ZENPEP ............................................................... 30 zenzedi.................................................................. 18 zeosa .................................................................... 35 ZERIT .................................................................... 3 ZETIA .................................................................. 22 ZIAGEN ................................................................ 3 zidovudine .......................................................... 3, 4 ZINACEF IN ISO-OSMOTIC DEXTROSE......... 4 ZINACEF IN ISO-OSMOTIC DILUENT ............ 4 ZINECARD ........................................................... 7 ziprasidone hcl ..................................................... 18 ZIRGAN .............................................................. 35 ZMAX.................................................................... 4 zoledronic acid............................................... 25, 29 ZOLINZA ............................................................ 10 zolpidem tartrate.................................................. 18 zolpidem tartrate er ............................................. 18 ZOMETA ............................................................. 29 zonisamide ........................................................... 11 ZORTRESS ......................................................... 10 ZOSTAVAX ........................................................ 32 ZOSYN .................................................................. 6

zovia 1/35e ........................................................... 35 zovia 1/50e ........................................................... 35 ZOVIRAX ........................................................... 23 ZYFLO ................................................................ 38 ZYFLO CR .......................................................... 38

ZYLET ................................................................. 36 ZYMAXID .......................................................... 35 ZYTIGA .............................................................. 10 ZYVOX ................................................................. 5

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