RDL Alpha List PDF

California
3-Tier Drug List

The 3-Tier Drug List includes a list of drugs covered by Health Net. This drug list is for California. The drug
list is updated often and may change. To get the most up-to-date information, you may view the latest drug
list on our website at www.healthnet.com or call us at the toll-free telephone number on your Health Net ID
card.
Welcome to Health Net
What is the 3-Tier Drug List?
The 3-Tier Drug List or formulary is a list of covered drugs used to treat common diseases or health
problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide
which drugs should be included. The committee reviews new drugs and new information about existing
drugs and chooses drugs based on:
 Safety;
 Effectiveness;
 Side effects; and
 Value (If two drugs are equally effective, the less costly drug will be preferred)
How much will I pay for my drugs?

To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier
column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not
know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan
documents.
Abbreviation Description
1 Preferred generic drugs
2 Preferred brand drugs
Non-preferred brand drugs, covered drugs not on the drug list and covered brand
3 drugs that are approved as medically necessary by Health Net.
Generic drugs are preferred. To get a brand drug that has a generic available, your
doctor must request prior authorization to show medical necessity. If we approve the
GP request, the drug may be covered at a higher copayment. Refer to your plan
documents for coverage details.
Non-formulary drugs are those not included in the list of drugs approved by our
Pharmacy and Therapeutics Committee. We may cover a non-formulary drug if your
NF doctor provides a medical reason. If approved, the drug will be covered under the non-
preferred tier.
Specialty and covered injectable drugs that may need to be filled by a Specialty
pharmacy. Prior authorization may be required. Some plans cover self-injectable drugs
SP
under the medical benefit. Not all plans cover specialty drugs under the pharmacy
benefit. Refer to your plan documents for coverage and copayment/coinsurance.
ii
Are there any limits on my drug coverage?
Some drugs have limits on coverage. The table below provides a description of abbreviations that may
appear in the Limits column on the drug list:
Abbreviation Definition Description

AC Anti-Cancer These oral cancer drugs are subject to a maximum $200
copayment per State law.
AL Age Limit These drugs may require prior authorization if your age does
not fall within manufacturer, FDA, or clinical recommendations.
PA Prior Authorization These drugs require prior authorization for coverage,

effectiveness, or safety reasons. This means that your doctor
must request approval from Health Net before the drug will be
covered.
PV Preventive Drugs Preventive benefit drugs covered at no cost to members under

the Affordable Care Act. A deductible does not apply. To get a
brand drug that has a generic available, your doctor must
request prior authorization to show medical necessity. You will
be responsible for the difference in cost between the brand and
the generic drug.
QL Quantity Limit These drugs have a limit on the amount that will be covered.
Your doctor must request approval for a higher quantity of the
drug from Health Net.
RX/OTC Prescription & Certain drugs are available both in a prescription form and in an
Over-the-Counter OTC form. Only prescription drugs are covered by your plan
(OTC) with the exception of some insulins, insulin supplies and some
covered preventive drugs.
ST Step Therapy You must first try and fail another specific drug(s) before these
drugs will be covered.
How can I get an exception to the rules for drug coverage?

Your doctor can ask for an exception to our rules for drug coverage.
 Your doctor can ask us to cover your drug even if it is not on the drug list. If we approve an exception for
a drug that’s not on the drug list, the non-preferred brand tier (Tier 3) applies.
 Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a
quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To request an exception, your doctor can fax a prior authorization form along with a written statement
supporting the request to us at 1-800-314-6223.
Can I go to any pharmacy?

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

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

You can save time and money with these simple steps:
 Ask your doctor about generic drugs that may work for you.
 Fill prescriptions at Health Net participating pharmacies.
 Be sure your doctor prescribes drugs on the drug list
 Fill your maintenance drugs through our mail order pharmacy program.
iv
Health Net Life Insurance Company (“Health Net”) complies with applicable federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Health Net does not exclude people or treat them differently because of race, color, national
origin, age, disability, or sex.
Health Net:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters and written information in other formats (large print,
accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as
qualified interpreters and information written in other languages.
If you need these services, contact Health Net's Customer Contact Center at:
On Exchange/Covered California 1-888-926-4988 (TTY: 711)
Off Exchange 1-800-522-0088 (TTY: 711)
If you believe that Health Net has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by
calling the number above and telling them you need help filing a grievance; Health Net's
Customer Contact Center is available to help you. You can also file a grievance by mail, fax or
online at:
Health Net Life Insurance Company
P.O. Box 10348
Van Nuys, CA 91410-0348
Fax: 1-877-831-6019
Online: healthnet.com
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.
Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH
Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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English
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you
in your language. For help, call us at the number listed on your ID card or call 1-800-522-0088 (TTY: 711).
If you bought coverage through the California marketplace call 1-888-926-4988 (TTY: 711). For more help:
If you are enrolled in a PPO or EPO insurance policy from Health Net Life Insurance Company, call the
CA Dept. of Insurance at 1-800-927-4357. If you are enrolled in an HMO or HSP plan from Health Net of
California, Inc., call the DMHC Helpline at 1-888-HMO-2219.
Arabic
‫ اتصل بنا على‬،‫ للحصول على المساعدة‬.‫ ويمكنك الحصول على وثائق مقروءة لك‬.‫ يمكنك الحصول على مترجم فوري‬.‫خدمات اللغة مجانية‬
‫ في حال قمت بشراء‬.)TTY: 711( 1-800-522-0088 ‫الرقم الموجود على بطاقة الهوية أو اتصل على مركز االتصال التجاري في‬
‫ في حال كنت مسجالً في‬:‫) وللحصول على المساعدة‬TTY: 711( 1-888-926-4988 ‫ اتصل على الرقم‬،‫التغطية من سوق كاليفورنيا‬
Health Net Life ‫ من شركة التأمين على الحياة‬EPO ‫ أو المنظمة المزودة الحصرية‬PPO ‫بوليصة تأمين المنظمة المزودة المفضلة‬
‫ في حال كنت مسجالً في منظمة‬.1-800-927-4357 ‫ اتصل على قسم التأمين في كاليفورنيا على الرقم‬، Insurance Company
‫ اتصل على خط المساعدة‬,.Health Net of California, Inc ‫ من شركة‬HSP ‫ أو خطة التوفير الصحية‬HMO ‫المحافظة على الصحة‬
.1-888-HMO-2219 ‫ على الرقم‬DMHC ‫في قسم الرعاية الصحية المدارة‬
Armenian
Անվճար լեզվական ծառայություններ: Դուք կարող եք բանավոր թարգմանիչ ստանալ:
Փաստաթղթերը կարող են կարդալ ձեզ համար: Օգնության համար զանգահարեք մեզ ձեր
ID քարտի վրա նշված հեռախոսահամարով կամ զանգահարեք 1-800-522-0088 (TTY: 711)
հեռախոսահամարով: Եթե ապահովագրում եք գնել Կալիֆորնիայի շուկայական հրապարակի
միջոցով, զանգահարեք 1-888-926-4988 (TTY: 711) հեռախոսահամարով: Լրացուցիչ
օգնության համար. եթե անդամագրված եք Health Net Life Insurance Company-ի PPO կամ EPO
ապահովագրությանը, զանգահարեք Կալիֆորնիայի Ապահովագրության բաժին՝
1-800-927-4357 հեռախոսահամարով: Եթե անդամագրված եք Health Net of California, Inc.-ի HMO
կամ HSP ծրագրին, զանգահարեք DMHC օգնության գիծ՝ 1-888-HMO-2219 հեռախոսահամարով:

Chinese
免費語言服務。您可使用口譯員。您可請人使用您的語言將文件內容唸給您聽，並請我們將有您
語言版本的部分文件寄給您。如需協助，請致電您會員卡上所列的電話號碼與我們聯絡，或致電
1-800-522-0088（TTY：711）。如果您是透過加州健康保險交易市場購買承保，請致電
1-888-926-4988（TTY：711）。如需進一步協助：如果您透過 Health Net Life Insurance Company 投保
PPO 或 EPO 保單，請致電 1-800-927-4357 與加州保險局聯絡。如果您透過 Health Net of California, Inc.
投保 HMO 或 HSP 計畫，請致電 DMHC 協助專線 1-888-HMO-2219。

!
Hindi
बिना लागत वाली भाषा सेवाए।ँ आप एक दभाबषया
ु प्ाप्त कर सकते ह।ैं आपको दसतावेज पढ़ कर सु
नाए
जा सकते हैं । मदद के ललए, आपके आईडी काड्ड पर ददए गए सूचीिद्ध नंिर पर हमें कॉल करें , या
1-800-522-0088 (TTY: 711) पर कॉल करें । यदद आपने कैललफोलन्डया मादक्ड ट पलैस के माधयम से कवरज े

खरीदा है तो 1-888-926-4988 (TTY: 711) पर कॉल करें । अलिक मदद के ललए: यदद आप Health Net
Life Insurance Company पीपीओ PPO या ईपीओ EPO िीमा पॉललसी में नामांदकत ह,ैं तो कैललफोलनया
्ड
िीमा बवभाग को 1-800-927-4357 पर कॉल करें । यदद आप Health Net of California, Inc. के एचएमओ
HMO या एचएसपी HSP पलैन में नामांदकत ह,ैं तो डीएमएचसी DMHC हलपलाइन े के
1-888-HMO-2219
पर कॉल करें ।

NOLAFED34_2017
Hmong
Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom
yog koj hom lus los tau. Kev pab, hu rau peb ntawm tus xov tooj teev nyob rau hauv koj daim ID card los yog
hu rau 1-800-522-0088 (TTY: 711). Yog tias koj yuav kev pov hwm ntawm California marketplace hu
1-888-926-4988 (TTY: 711). Xav tau kev pab ntxiv: Yog koj tau tsab ntawv tuav pov hwm PPO los yog EPO
los ntawm Health Net Life Insurance Company, hu mus rau CA Dept. of Insurance ntawm 1-800-927-4357.
Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau
DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219.
Japanese
無料の言語サービス。通訳をご利用いただけます。日本語で文書をお読みします。援助が必要な場
合は、IDカードに記載されている番号までお電話いただくか、1-800-522-0088、(TTY: 711) までお電
話ください。カリフォルニア州のマーケットプレイス (保険購入サイト) を通じて保険を購入され
た方は、1-888-926-4988 (TTY: 711) までお電話ください。さらに援助が必要な場合:Health Net Life
Insurance CompanyのPPOまたはEPO保険ポリシーに加入されている方は、カリフォルニア州保険局
1-800-927-4357 まで電話でお問い合わせください。Health Net of California, Inc.のHMOまたはHSPに
加入されている方は、DMHCヘルプライン 1-888-HMO-2219 まで電話でお問い合わせください。
Khmer
សេវាភាសាសោយឥតគតថ្លៃ
ិ ។ អ្នកអាចទទួលបានអ្នកបកប្បផ្ទា លមាត។
់ ់ អ្នកអាចសាបសគអានឯកសារឱ្យអ្ន
ដា ់ ក។
ំ យ េូ មទាក់ទងសយងខ្
េ្មាប់ជនួ ើ ញ ំតាមរយៈសលខទរេពទា
ូ បែលមានសៅសលកាតេមាលខនរបេអ្ន
ើ គា ់ ួ លៃ ់ ក ឬ ទាកទងសៅម
់
ជ្ឈមណ្ឌលទំនាកទំ
់ នងពាណជ្ជ
ិ កម្មថន្ករុមហន
៊ញ 1-800-522-0088 (TTY: 711)។ សបេនអ្ន
ើ ិ កបានទញការធានារបរ
ិ ៉ា ់
ងតាមរយៈ ទផ្សារថនរែ្ឋ
ី កាលី ហវ័្រញ៉ា េមទរេពទា
ូ ូ ់ ំ យបបនថែម ៖
សៅសលខ 1-888-926-4988 (TTY: 711)។ េ្មាបជនួ
សបេនអ្ន
ើ ិ កបានចះស្
ញ ្ម ះកញ្នងសោលការណធានារ
៍ ៉ា ប់រង PPO ឬ EPO ព្ករុ
ី មហញ៊នធានារបរងជវ
៉ា ់ ីត
ិ
Health Net Life Insurance Company េូ មទាកទងសៅនាយកោនធានារបរង
់ ្ឋ ៉ា ់ CA តាមរយៈទរេពទា
ូ សលខ
1-800-927-4357។ សបើេិនអ្នកបានចញះស្្មះកញ្នងបផ្នការ HMO ឬ HSP ពី្ករុមហ៊ញន Health Net of California, Inc.
ថនរែ្ឋកាលីហវ័្រញ៉ា េមទាកទងសលខទរេពទា
ូ ់ ូ ំ យ DMHC ៖ 1-888-HMO-2219។
ជនួ
Korean
무료 언어 서비스. 통역 서비스를 받을 수 있습니다. 문서 낭독 서비스를 받으실 수 있습니다. 도움이
필요하시면 보험 ID 카드에 수록된 번호로 전화하시거나1-800-522-0088 (TTY: 711)번으로 전화해
주십시오. 캘리포니아 주 마켓플레이스를 통해 보험을 구입하셨으면 1-888-926-4988 (TTY: 711)
번으로 전화해 주십시오. 추가 도움이 필요하시면, Health Net Life Insurance Company의 PPO 또는
EPO 보험에 가입되어 있으시면 캘리포니아 주 보험국에 1-800-927-4357번으로 전화해 주십시오.
Health Net of California, Inc.의 HMO 또는 HSP 플랜에 가입되어 있으시면 DMHC 도움라인에
1-888-HMO-2219번으로 전화해 주십시오.
Navajo
Saad Bee !k1 E’eyeed T’11 J77k’e. Ata’ halne’7g77 h0l=. T’11 h0 hazaad k’ehj7 naaltsoos hach’8’ w0ltah.
Sh7k1 a’doowo[ n7n7zingo naaltsoos bee n47ho’d0lzin7g77 bik1a’gi b44sh bee hane’7 bik11’ 1aj8’
hod77lnih 47 doodaii’ 1-800-522-0088 (TTY: 711). California marketplace hooly4h7j7 b4eso 1ch’33h
naanil7 ats’77s baa 1h1y3 biniiy4 nah7n7[nii’go 47 koj8’ h0lne’ 1-888-926-4988 (TTY: 711). Sh7k1
an11’doowo[ jin7zingo: PPO 47 doodaii’ EPO-j7 Health Net Life Insurance Company woly4h7j7 b4eso
1ch’33h naa’nil biniiy4 hwe’iina’ bik’4’4sti’go 47 CA Dept. of Insurance bich’8’ hojilnih 1-800-927-4357.
HMO 47 doodaii’ HSP-j7 Health Net of California, Inc.-j7 b4eso 1ch’33h naa’nil biniiy4 hats’77s
bik’4’4sti’go 47 koj8’ hojilnih DMHC Helpline 1-888-HMO-2219.
NOLAFED34_2017
Persian (Farsi)
.‫ می توانيد درخواست کنيد که اسناد برای شما قرائت شوند‬.‫ می توانيد يک مترجم شفاهی بگيريد‬.‫خدمات زبان به طور رايگان‬
‫ با ما به شماره ای که روی کارت شناسايی شما درج شده تماس بگيريد يا با مرکز تماس بازرگانی‬،‫برای دريافت راهنمايی‬
‫ اگر پوشش بيمه را از طريق بازارگاه کاليفرنيا خريداری کرديد با شماره‬.‫) تماس بگيريد‬TTY: 711( 1-800-522-0088
‫ از سوی‬EPO ‫ يا‬PPO ‫ اگر در بيمه نامه‬:‫ برای دريافت راهنمايی بيشتر‬.‫) تماس بگيريد‬TTY: 711( 1-888-926-4988
‫ تماس‬1-800-927-4357 ‫ به شماره‬CA Dept. of Insurance ‫ با‬،‫عضويت داريد‬Health Net Life Insurance Company
‫ با خط راهنمايی تلفنی‬،‫ عضويت داريد‬.Health Net of California, Inc ‫ از سوی‬HSP ‫ يا‬HMO ‫ اگر در برنامه‬.‫بگيريد‬
.‫ تماس بگيريد‬1-888-HMO-2219 ‫ به شماره‬DMHC
Panjabi (Punjabi)
ਬਿਨਾਂ ਬਿਸੇ ਲਾਗਤ ਤੋਂ ਭਾਸਾ ਸੇਵਾਵਾਂ। ਤੁਸੀਂ ਇੱਿ ਦੁਭਾਬਸਆ ਪ੍ਾਪਤ ਿਰ ਸਿਦੇ ਹੋ। ਤੁਹਾਨੰੂ ਦਸਤਾਵੇਜ਼ ਤੁਹਾਡੀ ਭਾਸਾ ਬਵੱਚ
ਪੜ੍ਹ ਿੇ ਸੁਣਾਏ ਜਾ ਸਿਦੇ ਹਨ। ਮਦਦ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਿਾਰਡ ਤੇ ਬਦੱਤੇ ਨੰਿਰ ਤੇ ਸਾਨੰੂ ਿਾਲ ਿਰੋ ਜਾਂ ਬਿਰਪਾ ਿਰਿੇ
1-800-522-0088 (TTY: 711) ’ਤੇ ਿਾਲ ਿਰੋ। ਜੇ ਤੁਸੀਂ ਿੈਲੀਫੋਰਨੀਆਂ ਮਾਰਬਿਟ ਪਲਸ ੇ ਦੇ ਰਾਹੀਂ ਿੀਮਾ ਿਵਰੇਜ਼ ਖਰੀਦੀ
ਹੈ ਤਾਂ 1-888-926-4988 (TTY: 711) ’ਤੇ ਿਾਲ ਿਰੋ। ਵਧੇਰੀ ਮਦਦ ਲਈ: ਜੇ ਤੁਸੀਂ Health Net Life Insurance
Company ਪੀਪੀਓ PPO ਜਾਂ ਈਓਪੋ EPO ਿੀਮਾ ਪਾਬਲਸੀ ਬਵੱਚ ਨਾਮਾਂਬਿਤ ਹੋ, ਤਾਂ ਿੈਲੀਫੋਰਨੀਆਂ ਿੀਮਾ ਬਵਭਾਗ ਨੰੂ
1-800-927-4357 ’ਤੇ ਿਾਲ ਿਰੋ। ਜੇ ਤੁਸੀਂ Healh Net of California, Inc. ਤੋਂ ਇੱਿ ਐਚਐਮਓ HMO ਜਾਂ ਐਚਐਸਪੀ
HSP ਪਲੈ ਨ ਬਵੱਚ ਨਾਮਾਂਬਿਤ ਹੋ ਤਾਂ ਡੀਐਮਐਚਸੀ DMHC ਹੈਲਪਲਾਈਨ ਨੰੂ 1-888-HMO-2219 ’ਤੇ ਿਾਲ ਿਰੋ।
Russian
Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика.
Вам могут прочитать документы. За помощью обращайтесь к нам по телефону, приведенному на
вашей идентификационной карточке участника плана. Кроме того, вы можете позвонить в
1-800-522-0088 (TTY: 711). Если свою страховку вы приобрели на едином сайте по продаже
медицинских страховок в штате Калифорния, звоните по телефону 1-888-926-4988 (TTY: 711).
Дополнительная помощь: Если вы включены в полис PPO или EPO от страховой компании Health Net
Life Insurance Company, звоните в Департамент страхования штата Калифорния (CA Dept. of Insurance),
телефон 1-800-927-4357. Если вы включены в план HMO или HSP от страховой компании Health Net of
California, Inc., звоните по контактной линии Департамента управляемого медицинского обслуживания
DMHC, телефон 1-888-HMO-2219.
Spanish
Servicios de idiomas sin costo. Puede solicitar un intérprete. Puede obtener el servicio de lectura de
documentos y recibir algunos en su idioma. Para obtener ayuda, llámenos al número que figura en su
tarjeta de identificación o comuníquese con el Centro de Comunicación Comercial de Health Net, al
1-800-522-0088 (TTY: 711). Si adquirió la cobertura a través del mercado de California, llame al
1-888-926-4988 (TTY: 711). Para obtener más ayuda, haga lo siguiente: Si está inscrito en una póliza de
seguro PPO o EPO de Health Net Life Insurance Company, llame al Departamento de Seguros de California,
al 1-800-927-4357. Si está inscrito en un plan HMO o HSP de Health Net of California, Inc., llame a la línea
de ayuda del Departamento de Atención Médica Administrada, al 1-888-HMO-2219.
NOLAFED34_2017
Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga
dokumento na babasahin sa inyo. Para sa tulong, tawagan kami sa nakalistang numero sa inyong ID card
o tawagan ang 1-800-522-0088 (TTY: 711). Kung bumili kayo ng pagsakop sa pamamagitan ng California
marketplace tawagan ang 1-888-926-4988 (TTY: 711). Para sa higit pang tulong: Kung nakatala kayo sa
insurance policy ng PPO o EPO mula sa Health Net Life Insurance Company, tawagan ang CA Dept. of
Insurance sa 1-800-927-4357. Kung nakatala kayo sa HMO o HSP na plan mula sa Health Net of California,
Inc., tawagan ang Helpline ng DMHC sa 1-888-HMO-2219.
Thai
ไม่มคี า่ บริการด้านภาษา คุณสามารถใช้ลา่ มได้ คุณสามารถให้อา่ นเอกสารให้ฟงั ได้ สาหรับความช่วยเหลือ โทรหาเราตาม
หมายเลขท่ใี ห้ไว้บนบัตรประจาตัวของคุณ หรือ โทรหาศูนย์ตดิ ต่อเชิงพาณิชย์ของ 1-800-522-0088 (TTY: 711) หากคุณ
ซ้อื ความค้มุ ครองผ่านทาง California marketplace โทร 1-888-926-4988 (TTY: 711) สาหรับความช่วยเหลือเพิม่ เติม หาก
คุณสมัครทากรมธรรม์ประกันภัย PPO หรือ EPO กับ Health Net Life Insurance Company โทรหากรมการประกันภัยรัฐ
แคลิฟอร์เนียได้ท่ี 1-800-927-4357 หากคุณสมัครแผน HMO หรือ HSP กับ Health Net of California, Inc. โทรหาสายด่วน
ความช่วยเหลือของ DMHC ได้ท่ี 1-888-HMO-2219.
Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc
cho nghe tài liệu. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID của quý vị hoặc
gọi 1-800-522-0088 (TTY: 711). Nếu quý vị mua khoản bao trả thông qua thị trường California
1-888-926-4988 (TTY: 711). Để nhận thêm trợ giúp: Nếu quý vị đăng ký hợp đồng bảo hiểm PPO hoặc
EPO từ Health Net Life Insurance Company, vui lòng gọi Sở Y Tế CA theo số 1-800-927-4357. Nếu quý
vị đăng ký vào chương trình HMO hoặc HSP từ Health Net of California, Inc., vui lòng gọi Đường Dây
Trợ Giúp DMHC theo số 1-888-HMO-2219.
CA Commercial On and Off-Exchange Member Notice of Language Assistance
FLY007785EH00 (06/16)
NOLAFED34_2017
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTI- PROCENTRA SOLN (Use
OBESITY/ANOREXIANTS - Drugs to Treat Dextroamphetamine GP
ADHD, Sleep and Eating Disorders Sulfate)
VYVANSE CAPS 10 MG, QL(1 ea daily)
Amphetamines 20 MG, 30 MG, 40 MG, 50 2
ADDERALL TABS (Use MG, 60 MG, 70 MG
Amphetamine- GP
Dextroamphetamine) VYVANSE CHEW 10 MG, Limited to 1 per
20 MG, 30 MG, 40 MG, 50 2 day;QL(1 ea
ADDERALL XR CP24 (Use QL(2 ea MG, 60 MG daily)
Amphetamine- GP daily,90 day(s)
Dextroamphetamine) limit) ZENZEDI TABS 3
amphetamine- QL(2 ea
dextroamphetamine cp24 daily,90 day(s) Analeptics
5mg-5mg-5mg-5mg, limit) caffeine citrate soln 1
2.5mg-2.5mg-2.5mg-
2.5mg, 7.5mg-7.5mg- 1 Anorexiants Non-Amphetamine
7.5mg-7.5mg, 1.25mg- ADIPEX-P CAPS (Use
1.25mg-1.25mg-1.25mg, SP PA
Phentermine HCl)
3.75mg-3.75mg-3.75mg-
3.75mg, 6.25mg-6.25mg- benzphetamine hcl tabs SP PA
6.25mg-6.25mg
LOMAIRA TABS 3 PA
amphetamine-
dextroamphetamine tabs
5mg-5mg-5mg-5mg, phentermine hcl caps SP PA
2.5mg-2.5mg-2.5mg-
2.5mg, 7.5mg-7.5mg- QSYMIA CP24 23MG- SP PA; QL(1 ea
7.5mg-7.5mg, 1.25mg- 3.75MG daily)
1.25mg-1.25mg-1.25mg, 1 QSYMIA CP24 92MG- PA
3.75mg-3.75mg-3.75mg- 15MG, 46MG-7.5MG, SP
3.75mg, 1.875mg- 69MG-11.25MG
1.875mg-1.875mg- REGIMEX TABS (Use
1.875mg, 3.125mg- SP PA
Benzphetamine HCl)
3.125mg-3.125mg-
3.125mg Anti-Obesity Agents
DESOXYN TABS (Use GP PA; BELVIQ TABS SP PA
Methamphetamine HCl)
DEXEDRINE CP24 (Use CONTRAVE TB12 SP PA
Dextroamphetamine GP
Sulfate) XENICAL CAPS SP PA
dextroamphetamine sulfate 1
cp24 5 mg, 10 mg, 15 mg Attention-Deficit/Hyperactivity Disorder (ADHD)
dextroamphetamine sulfate atomoxetine hcl caps 10 1 QL(2 ea daily)
3 mg, 18 mg, 25 mg, 40 mg
soln 5 mg/5ml
dextroamphetamine sulfate atomoxetine hcl caps 60 1 QL(1 ea daily)
1 mg, 80 mg, 100 mg
tabs 5 mg, 10 mg
methamphetamine hcl tabs 3 PA; guanfacine hcl (adhd) tb24 1 QL(1 ea daily)
INTUNIV TB24 (Use GP QL(1 ea daily)
Guanfacine HCl (ADHD))
You can find information on what the symbols and abbreviations on this table mean by going to
page ii-iii.
California 3-Tier Drug List Updated: December 1, 2018
1
STRATTERA CAPS 10 QL(2 ea daily) methylphenidate hcl cp24
MG, 18 MG, 25 MG, 40 MG GP 10 mg, 20 mg, 30 mg, 40 3
(Use Atomoxetine HCl) mg
STRATTERA CAPS 60 QL(1 ea daily) methylphenidate hcl cpcr
MG, 80 MG, 100 MG (Use GP 10 mg, 40 mg, 50 mg, 60 3
Atomoxetine HCl) mg
Stimulants - Misc. QL(2 ea
methylphenidate hcl cpcr 3 daily,90 day(s)
APTENSIO XR CP24 3 PA; QL(1 ea 20 mg, 30 mg limit)
daily)
PA methylphenidate hcl soln 3
armodafinil tabs 1 10 mg/5ml
CONCERTA TBCR 18 MG, QL(1 ea daily) methylphenidate hcl soln 5 1
27 MG, 36 MG (Use GP mg/5ml
Methylphenidate HCl) methylphenidate hcl tabs 1 QL(3 ea daily)
CONCERTA TBCR 54 MG 20 mg
GP QL(2 ea daily) methylphenidate hcl tabs 5
(Use Methylphenidate HCl) 1
mg, 10 mg
DAYTRANA PTCH 3
QL(1 ea
methylphenidate hcl tb24 1 daily,90 day(s)
dexmethylphenidate hcl 3 18 mg, 27 mg, 54 mg
cp24 35 mg limit)
dexmethylphenidate hcl QL(1 ea daily) QL(2 ea
methylphenidate hcl tb24 1 daily,90 day(s)
cp24 5 mg, 10 mg, 15 mg, 3 36 mg
20 mg, 25 mg, 30 mg, 40 limit)
mg QL(1 ea
methylphenidate hcl tb24 1 daily,90 ea per
dexmethylphenidate hcl 1 QL(2 ea daily) 54 mg
tabs 5 mg, 10 mg, 2.5 mg fill retail)
FOCALIN TABS (Use QL(1 ea
GP QL(2 ea daily) methylphenidate hcl tbcr 10 1 daily,90 ea per
Dexmethylphenidate HCl) mg
FOCALIN XR CP24 35 MG fill retail)
(Use Dexmethylphenidate GP methylphenidate hcl tbcr 18 1 QL(1 ea daily)
HCl) mg, 27 mg, 36 mg
FOCALIN XR CP24 5 MG, QL(1 ea daily) QL(1 ea
methylphenidate hcl tbcr 20 1 daily,90 day(s)
10 MG, 15 MG, 20 MG, 25 GP mg
MG, 30 MG, 40 MG (Use limit)
Dexmethylphenidate HCl) methylphenidate hcl tbcr 54 QL(2 ea daily)
1
METADATE CD CPCR 10 mg
MG, 40 MG, 50 MG, 60 MG GP methylphenidate hcl tbcr 72 QL(1 ea daily)
(Use Methylphenidate HCl) 3
mg
METADATE CD CPCR 20 QL(2 ea METHYLPHENIDATE QL(1 ea
MG, 30 MG (Use GP daily,90 day(s) HYDROCHLORIDE ER 3 daily,90 ea per
Methylphenidate HCl) limit) (LA) CP24 fill retail)
METHYLIN CHEW (Use
Methylphenidate HCl) GP modafinil tabs 3 ST; QL(1 ea
daily)
METHYLIN SOLN (Use NUVIGIL TABS (Use
Methylphenidate HCl) GP GP PA
Armodafinil)
methylphenidate hcl chew PROVIGIL TABS (Use
5 mg, 10 mg, 2.5 mg 3 GP ST; QL(1 ea
Modafinil) daily)
page ii-iii.
2
QUILLICHEW ER CHER 3 PA HUMIRA PEDIATRIC PA; Check plan
CROHNS DISEASE SP documents for
PA; QL(12 ml STARTER PACK PSKT 40 coverage
QUILLIVANT XR SUSR 3 MG/0.8ML
daily)
RITALIN LA CP24 (Use HUMIRA PEDIATRIC PA
GP CROHNS DISEASE
Methylphenidate HCl) SP
RITALIN TABS 20 MG STARTER PACK PSKT 80
GP QL(3 ea daily) MG/0.8ML
(Use Methylphenidate HCl)
RITALIN TABS 5 MG, 10 HUMIRA PEN PNKT 40 SP PA
MG (Use Methylphenidate GP MG/0.4ML
HCl) PA; Check plan
HUMIRA PEN PNKT 40 SP documents for
AMINOGLYCOSIDES - Drugs to Treat Bacterial MG/0.8ML coverage
Infections
PA; Check plan
Aminoglycosides HUMIRA PEN-CD/UC/HS SP documents for
STARTER PNKT coverage
BETHKIS NEBU 3 PA
PA; Check plan
PA; Must use HUMIRA PEN-PS/UV SP documents for
AcariaHlth Sp STARTER PNKT
KITABIS PAK NEBU 2 coverage
Rx 1-844-538- HUMIRA PSKT 10 PA
4661 MG/0.1ML, 20 MG/0.2ML, SP
neomycin sulfate tabs 1 40 MG/0.4ML
HUMIRA PSKT 10 PA; Check plan
paromomycin sulfate caps 1 MG/0.2ML, 20 MG/0.4ML, SP documents for
40 MG/0.8ML coverage
PA; Must use PA; Must use
TOBI NEBU (Use GP AcariaHlth Sp
Tobramycin) Rx 1-844-538- SIMPONI SOAJ SP AcariaHlth Sp
Rx 1-844-538-
4661 4661;SP
PA; Must use PA; Must use
TOBI PODHALER CAPS 3 AcariaHlth Sp SIMPONI SOSY SP AcariaHlth Sp
Rx 1-844-538- Rx 1-844-538-
4661 4661;SP
PA; Must use
Antirheumatic - Enzyme Inhibitors
tobramycin nebu 1 AcariaHlth Sp
Rx 1-844-538- XELJANZ TABS 10 MG SP PA
4661
PA; Must use XELJANZ TABS 5 MG SP PA; QL(2 ea
daily); SP
TOBRAMYCIN NEBU 2 AcariaHlth Sp
Rx 1-844-538-
4661 XELJANZ XR TB24 SP PA; QL(1 ea
daily); SP
ANALGESICS - ANTI-INFLAMMATORY - Drugs Gold Compounds
to Treat Pain, Swelling, Muscle and Joint
Conditions RIDAURA CAPS 2
Anti-TNF-alpha - Monoclonal Antibodies Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ANAPROX DS TABS (Use GP
Naproxen Sodium)
page ii-iii.
3
ARTHROTEC 50 TBEC etodolac tb24 400 mg, 500 1 QL(2 ea daily)
(Use Diclofenac w/ GP mg, 600 mg
Misoprostol) FELDENE CAPS 10 MG GP
ARTHROTEC 75 TBEC (Use Piroxicam)
(Use Diclofenac w/ GP FELDENE CAPS 20 MG
Misoprostol) GP QL(1 ea daily)
(Use Piroxicam)
ST; QL(1 ea
CELEBREX CAPS 100 MG daily); AL(At fenoprofen calcium tabs 1
GP
(Use Celecoxib) least 60 yrs
old) flurbiprofen tabs 100 mg 3
ST; QL(2 ea
CELEBREX CAPS 200 MG daily); AL(At flurbiprofen tabs 50 mg 1
GP
(Use Celecoxib) least 60 yrs
old) ibuprofen tabs 1
PA; QL(1 ea INDOCIN SUPP RE 50 MG 3
CELEBREX CAPS 400 MG GP daily); AL(At
(Use Celecoxib) least 60 yrs INDOCIN SUSP OR 25
old) 2
MG/5ML
CELEBREX CAPS 50 MG GP PA; AL(At least
(Use Celecoxib) 60 yrs old) indomethacin caps 1
ST; QL(1 ea indomethacin cpcr 1
daily); AL(At
celecoxib caps 100 mg 1
least 60 yrs KETOPROFEN CAPS 25 3
old) MG
ST; QL(2 ea ketoprofen caps 50 mg, 75
daily); AL(At 1
celecoxib caps 200 mg 1 mg
least 60 yrs KETOPROFEN CAPS 50
old) 2
MG, 75 MG
PA; QL(1 ea
daily); AL(At KETOPROFEN ER CP24 3
celecoxib caps 400 mg 1
least 60 yrs QL(20 ea per
old) ketorolac tromethamine fill retail,20 ea
PA; AL(At least 1
celecoxib caps 50 mg 1 tabs per 30 days
60 yrs old) retail)
DAYPRO TABS (Use GP LODINE TABS (Use
Oxaprozin) GP
Etodolac)
diclofenac potassium tabs 3 meclofenamate sodium 1
caps
diclofenac sodium tb24 100 3
mg mefenamic acid caps 3
diclofenac sodium tbec 25 1 QL(1 ea daily)
mg, 50 mg, 75 mg meloxicam tabs 15 mg 1
diclofenac w/ misoprostol meloxicam tabs 7.5 mg 1 QL(2 ea daily)
3
tbec
etodolac caps 200 mg, 300 MOBIC TABS 15 MG (Use GP QL(1 ea daily)
1 Meloxicam)
mg
etodolac tabs 400 mg, 500 MOBIC TABS 7.5 MG (Use GP QL(2 ea daily)
1 Meloxicam)
mg
page ii-iii.
4
nabumetone tabs 500 mg 1 QL(4 ea daily) ARAVA TABS 10 MG (Use GP QL(2 ea daily)
Leflunomide)
nabumetone tabs 750 mg 1 QL(3 ea daily) ARAVA TABS 20 MG (Use GP QL(1 ea daily)
Leflunomide)
NALFON TABS (Use
Fenoprofen Calcium) NF leflunomide tabs 10 mg 1 QL(2 ea daily)
NAPROSYN SUSP (Use GP QL(1 ea daily)
Naproxen) leflunomide tabs 20 mg 1
NAPROSYN TABS (Use GP Selective Costimulation Modulators
Naproxen) PA; Must use
naproxen sodium tabs 275 ORENCIA CLICKJECT
mg, 550 mg 1 SP AcariaHlth Sp
SOAJ Rx 1-844-538-
naproxen susp 125 mg/5ml 1 4661;SP
PA; Must use
naproxen tabs 250 mg, 375
mg, 500 mg 1 ORENCIA SOSY SP AcariaHlth Sp
Rx 1-844-538-
4661;SP
oxaprozin tabs 1
Soluble Tumor Necrosis Factor Receptor Agents
piroxicam caps 10 mg 1 PA; Check plan
ENBREL SOLR SP documents for
piroxicam caps 20 mg 1 QL(1 ea daily) coverage
PONSTEL CAPS (Use PA; Check plan
GP ENBREL SOSY SP documents for
Mefenamic Acid)
coverage
QL(1 ea daily,5
SPRIX SOLN 3 PA; Check plan
day(s) limit) ENBREL SURECLICK SP documents for
QL(2 ea daily) SOAJ
sulindac tabs 150 mg 1 coverage
ANALGESICS - NonNarcotic - Drugs to Treat
sulindac tabs 200 mg 1 Pain, Muscle and Joint Conditions
ST; QL(3 ea Analgesic Combinations
TIVORBEX CAPS 3
daily)
butalbital-acetaminophen 3
TOLMETIN SODIUM 2 tabs
CAPS 400 MG
butalbital-acetaminophen- 1
tolmetin sodium tabs 200 1 caffeine caps
mg, 600 mg
butalbital-acetaminophen- 1
Phosphodiesterase 4 (PDE4) Inhibitors caffeine tabs
PA; Must use butalbital-aspirin-caffeine 1
OTEZLA TABS SP AcariaHlth Sp caps
Rx 1-844-538- butalbital-aspirin-caffeine
4661;SP 1
tabs
PA; Must use BUTALBITAL/ACETAMINO 3
OTEZLA TBPK SP AcariaHlth Sp PHEN CAPS
Rx 1-844-538-
4661;SP ESGIC TABS (Use
Butalbital-Acetaminophen- GP
Pyrimidine Synthesis Inhibitors Caffeine)
page ii-iii.
5
FIORICET CAPS (Use EMBEDA CPCR 3 PA
Butalbital-Acetaminophen- GP
Caffeine) EXALGO T24A 32 MG GP QL(2 ea daily)
FIORINAL CAPS (Use (Use Hydromorphone HCl)
GP
Butalbital-Aspirin-Caffeine) EXALGO T24A 8 MG, 12 QL(4 ea daily)
MG, 16 MG (Use GP
TENCON TABS 3 Hydromorphone HCl)
Salicylates fentanyl citrate lpop bu 1 PA; QL(4 ea
AL(At least 50 1600 mcg daily)
aspirin tbec 1 yrs old - Up to fentanyl citrate lpop bu 200 PA
59 yrs old); PV mcg, 400 mcg, 600 mcg, 1
choline & mag salicylate 800 mcg, 1200 mcg
1 fentanyl pt72 12 mcg/hr, 25 Limit 15 per
liqd
mcg/hr, 50 mcg/hr, 75 1 month;QL(0.5
diflunisal tabs 3 mcg/hr, 100 mcg/hr ea daily)
DISALCID TABS (Use PA; Limit 15
GP fentanyl pt72 37.5 mcg/hr, patches per
Salsalate) 3
62.5 mcg/hr, 87.5 mcg/hr month;QL(0.5
salsalate tabs 1 ea daily)
hydromorphone hcl liqd 1 1
ANALGESICS - OPIOID - Drugs to Treat Pain, mg/ml
Muscle and Joint Conditions
hydromorphone hcl t24a 32 3 QL(2 ea daily)
Opioid Agonists mg
ABSTRAL SUBL 3 PA hydromorphone hcl t24a QL(4 ea daily)
1
8mg, 8 mg, 12 mg, 16 mg
ACTIQ LPOP 1600 MCG GP PA; QL(4 ea hydromorphone hcl tabs 2
(Use Fentanyl Citrate) daily) 1
mg, 4 mg, 8 mg
ACTIQ LPOP 200 MCG, PA PA
400 MCG, 600 MCG, 800 HYSINGLA ER T24A 3
GP
MCG, 1200 MCG (Use KADIAN CP24 10 MG (Use
Fentanyl Citrate) GP
Morphine Sulfate)
ARYMO ER TBEA 3 PA KADIAN CP24 20 MG, 30 QL(2 ea daily)
MG, 40 MG, 50 MG, 60 GP
codeine sulfate tabs 1 MG, 80 MG, 100 MG (Use
Morphine Sulfate)
CONZIP CP24 100 MG 3
KADIAN CP24 200 MG 3
DEMEROL TABS (Use
Meperidine HCl) GP LAZANDA SOLN 3 PA
DILAUDID LIQD (Use GP LEVORPHANOL PA
Hydromorphone HCl) 3
TARTRATE TABS
DILAUDID TABS (Use GP
Hydromorphone HCl) meperidine hcl soln 1
DOLOPHINE TABS (Use GP QL(12 ea daily)
Methadone HCl) meperidine hcl tabs 1
Limit 15 per methadone hcl conc 10 1
DURAGESIC PT72 (Use GP month;QL(0.5 mg/ml
Fentanyl) ea daily)
page ii-iii.
6
methadone hcl soln 5 1 OXAYDO TABA 7.5 MG 3 QL(4 ea daily)
mg/5ml, 10 mg/5ml
methadone hcl tabs 5 mg, 1 QL(12 ea daily) oxycodone hcl caps 5 mg 1
10 mg
oxycodone hcl conc 100 1
methadone hcl tbso 40 mg 1 mg/5ml
METHADOSE CONC (Use OXYCODONE HCL ER QL(3 ea daily)
GP T12A 10 MG, 15 MG, 20 3
Methadone HCl)
METHADOSE SUGAR- MG, 30 MG, 40 MG, 80 MG
FREE CONC (Use GP OXYCODONE HCL ER 3 QL(6 ea daily)
Methadone HCl) T12A 60 MG
METHADOSE TBSO (Use oxycodone hcl soln 5 1
GP mg/5ml
Methadone HCl)
morphine sulfate cp24 or oxycodone hcl tabs 30 mg 1 QL(4 ea daily)
1
10 mg
morphine sulfate cp24 or QL(2 ea daily) oxycodone hcl tabs 5 mg, 1
20 mg, 30 mg, 50 mg, 60 1 10 mg, 15 mg, 20 mg
mg, 80 mg, 100 mg OXYCONTIN T12A 10 MG, QL(3 ea daily)
morphine sulfate cp24 or QL(2 ea daily) 15 MG, 20 MG, 30 MG, 40 3
3 MG, 80 MG
40 mg
MORPHINE SULFATE ER QL(1 ea daily) OXYCONTIN T12A 60 MG 3 QL(6 ea daily)
2
CP24
oxymorphone hcl tabs 10 3 QL(8 ea daily)
morphine sulfate soln or 20 mg
mg/ml, 10 mg/5ml, 20 1
mg/5ml, 100 mg/5ml oxymorphone hcl tabs 5 mg 3
MORPHINE SULFATE 2
SUPP RE 30 MG OXYMORPHONE QL(2 ea daily)
HYDROCHLORIDE ER 2
morphine sulfate supp re 5 1 TB12
mg, 10 mg, 20 mg
ROXICODONE TABS 30 GP QL(4 ea daily)
morphine sulfate tabs or 15 1 MG (Use Oxycodone HCl)
mg, 30 mg
ROXICODONE TABS 5
morphine sulfate tbcr or 15 QL(3 ea daily) MG, 15 MG (Use GP
mg, 30 mg, 60 mg, 100 mg, 1 Oxycodone HCl)
200 mg
PA; QL(4 ea
MS CONTIN TBCR (Use SUBSYS LIQD 100 MCG 3
GP QL(3 ea daily) daily)
Morphine Sulfate)
SUBSYS LIQD 200 MCG, PA
NUCYNTA ER TB12 2 QL(2 ea daily) 400 MCG, 600 MCG, 800 3
MCG, 1200 MCG, 1600
NUCYNTA TABS 2 QL(6 ea daily) MCG
TRAMADOL HCL ER CP24 3
OPANA ER (CRUSH 2 QL(2 ea daily) 100 MG, 150 MG
RESISTANT) T12A
tramadol hcl tabs 50 mg 1 QL(8 ea daily)
OPANA TABS 10 MG (Use GP QL(8 ea daily)
Oxymorphone HCl) QL(3 ea daily)
OPANA TABS 5 MG (Use tramadol hcl tb24 100 mg 3
GP
Oxymorphone HCl) tramadol hcl tb24 100 mg, 3
200 mg, 300 mg
page ii-iii.
7
tramadol hcl tb24 200 mg 3 QL(1 ea daily) hydrocodone-ibuprofen
tabs 200mg-10mg, 200mg- 1
ULTRAM TABS (Use 7.5mg
GP QL(8 ea daily)
Tramadol HCl) hydrocodone-ibuprofen 3
Opioid Combinations tabs 200mg-5mg
acetaminophen w/ codeine 1 LORTAB ELIX 3
soln 120mg/5ml-12mg/5ml
MEPERIDINE
acetaminophen w/ codeine HCL/PROMETHAZINE 3
tabs 300mg-15mg, 300mg- 1
HCL CAPS
30mg
NORCO TABS (Use QL(240 ea per
acetaminophen w/ codeine 1 QL(6 ea daily)
Hydrocodone- GP fill retail)
tabs 300mg-60mg Acetaminophen)
butalbital-acetaminophen- 3 oxycodone w/ QL(4 ea daily)
caffeine w/ codeine caps acetaminophen tabs 10mg- 1
butalbital-aspirin-caffeine 3 325mg
w/cod caps oxycodone w/
CAPITAL/CODEINE SUSP 3 acetaminophen tabs 3
2.5mg-325mg
FIORICET/CODEINE oxycodone w/ QL(6 ea daily)
CAPS (Use Butalbital- GP acetaminophen tabs 5mg- 1
Acetaminophen-Caffeine 325mg
w/ Codeine)
oxycodone w/ QL(4 ea daily)
FIORINAL/CODEINE #3 acetaminophen tabs 3
CAPS (Use Butalbital- GP 7.5mg-325mg
Aspirin-Caffeine w/Cod)
oxycodone-ibuprofen tabs 3 QL(4 ea daily)
hydrocodone-
acetaminophen soln OXYCODONE/ACETAMIN
2.5mg/5ml-108mg/5ml, 1
OPHEN SOLN
2
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml PERCOCET TABS 10MG- QL(4 ea daily)
325MG, 7.5MG-325MG
hydrocodone- (Use Oxycodone w/
GP
acetaminophen tabs 3
Acetaminophen)
2.5mg-325mg
PERCOCET TABS 2.5MG-
hydrocodone- 325MG (Use Oxycodone w/ GP
acetaminophen tabs 5mg- 1
Acetaminophen)
300mg, 10mg-300mg
PERCOCET TABS 5MG- QL(6 ea daily)
hydrocodone- QL(240 ea per
325MG (Use Oxycodone w/ GP
acetaminophen tabs 5mg- 1 fill retail)
Acetaminophen)
325mg, 10mg-325mg,
7.5mg-325mg REPREXAIN TABS (Use GP
hydrocodone- QL(6 ea daily) Hydrocodone-Ibuprofen)
acetaminophen tabs 1 tramadol-acetaminophen 3 QL(8 ea daily)
7.5mg-300mg tabs
Not available TYLENOL/CODEINE #3
hydrocodone-ibuprofen 1 through mail TABS (Use Acetaminophen GP
tabs 200mg-10mg order w/ Codeine)
page ii-iii.
8
TYLENOL/CODEINE #4 QL(6 ea daily) ST; QL(60 ea
TABS (Use Acetaminophen GP ANDRODERM PT24 3 per fill
w/ Codeine) retail,120 ea
ULTRACET TABS (Use QL(8 ea daily) per fill mail)
Tramadol-Acetaminophen) GP ANDROGEL GEL 25 QL(10 gm
MG/2.5GM (Use GP daily)
VERDROCET TABS 3 Testosterone)
XODOL TABS 5MG- ANDROGEL GEL 40.5 Limited to 300
300MG, 10MG-300MG MG/2.5GM, 20.25 GP gms per
GP MG/1.25GM (Use month;QL(10
(Use Hydrocodone-
Acetaminophen) Testosterone) gm daily)
XODOL TABS 7.5MG- QL(6 ea daily) ANDROGEL GEL 50 QL(10 gm
300MG (Use Hydrocodone- GP MG/5GM (Use NF daily)
Acetaminophen) Testosterone)
Opioid Partial Agonists Limited to 300
ANDROGEL PUMP GEL GP gms per
buprenorphine hcl subl 2 1 QL(3 ea daily) (Use Testosterone) month;QL(10
mg gm daily)
buprenorphine hcl subl 8 QL(4 ea daily)
mg 1 ANDROXY TABS 2 AC
buprenorphine hcl- QL(3 ea daily) AXIRON SOLN (Use
naloxone hcl dihydrate subl 1 GP ST; QL(6 ml
Testosterone) daily)
8mg-2mg, 2mg-0.5mg
QL(4 ea per 28 danazol caps 1
BUPRENORPHINE PTWK 3
days retail)
METHITEST TABS 2
Limit 7.5mls
per Not available
butorphanol tartrate soln 3
month;QL(0.25 METHYLTESTOSTERONE 1 through mail
ml daily) CAPS order
QL(4 ea per 28
BUTRANS PTWK 3 methyltestosterone caps 1
days retail)
pentazocine w/ naloxone TESTIM GEL (Use GP PA; QL(10 gm
3 Testosterone) daily)
tabs
ANDROGENS-ANABOLIC - Drugs to Regulate testosterone gel 1 % 3 PA; QL(10 gm
Hormones daily)
Anabolic Steroids testosterone gel 1 % 3
ANADROL-50 TABS 3 PA; Limited to
300 gms per
OXANDRIN TABS 10 MG testosterone gel 1 % 3
GP QL(2 ea daily) month;QL(10
(Use Oxandrolone) gm daily)
OXANDRIN TABS 2.5 MG GP testosterone gel 1 %, 1.62 Limited to 300
(Use Oxandrolone) %, 50 mg/5gm, 25 gms per
1
oxandrolone tabs 10 mg 1 QL(2 ea daily) mg/2.5gm, 40.5 mg/2.5gm, month;QL(10
20.25 mg/1.25gm gm daily)
oxandrolone tabs 2.5 mg 1
Androgens
page ii-iii.
9
Limit 300gms ALBENZA TABS (Use GP
testosterone gel 1 %, 50 1 per Albendazole)
mg/5gm month;QL(10 AL(At least 2
gm daily) BENZNIDAZOLE TABS 2 yrs old - Up to
testosterone gel 50 1 QL(10 gm 12 yrs old)
mg/5gm, 25 mg/2.5gm daily) BILTRICIDE TABS (Use GP
testosterone soln 30 3 ST; QL(6 ml Praziquantel)
mg/act daily)
ivermectin tabs 3
TESTRED CAPS (Use GP
Methyltestosterone) praziquantel tabs 1
VOGELXO GEL (Use GP PA; QL(10 gm
Testosterone) daily) STROMECTOL TABS (Use GP
Ivermectin)
VOGELXO PUMP GEL 3 PA; QL(10 gm
daily) ANTI-INFECTIVE AGENTS - MISC. - Drugs to
ANORECTAL AGENTS - Rectal Drugs to Treat Treat Bacterial Infections
Pain, Swelling and Itching Anti-infective Agents - Misc.
Intrarectal Steroids FLAGYL CAPS (Use GP
CORTENEMA ENEM (Use QL(60 ml daily) Metronidazole)
Hydrocortisone GP FLAGYL TABS (Use GP
(Intrarectal)) Metronidazole)
CORTIFOAM FOAM 2 metronidazole caps 1
hydrocortisone (intrarectal) 1 QL(60 ml daily) metronidazole tabs 1
enem
UCERIS FOAM RE 2 3 PA NEBUPENT SOLR 2
MG/ACT
Rectal Combinations PRIMSOL SOLN 3
ANALPRAM-HC LOTN 3 TINDAMAX TABS (Use GP PA
Tinidazole)
PROCTOFOAM HC FOAM 2 tinidazole tabs 3 PA
Rectal Steroids trimethoprim tabs 1

ANUSOL-HC CREA (Use GP
Hydrocortisone (Rectal)) TRIMPEX SOLN 3
hydrocortisone (rectal) crea 1 PA; QL(9 ea
XIFAXAN TABS 200 MG 3
per fill retail)
Vasodilating Agents
PA; QL(2 ea
XIFAXAN TABS 550 MG 3
RECTIV OINT 3 daily)
ANTHELMINTICS - Drugs to Treat Worm Anti-infective Misc. - Combinations
Infections BACTRIM DS TABS (Use
Sulfamethoxazole- GP
Anthelmintics Trimethoprim)
albendazole tabs 3 BACTRIM TABS (Use
Sulfamethoxazole- GP
Trimethoprim)
page ii-iii.
10
sulfamethoxazole- 1 RANEXA TB12 1000 MG 3
trimethoprim susp
sulfamethoxazole- RANEXA TB12 500 MG 3 QL(4 ea daily)
1
trimethoprim tabs
Antiprotozoal Agents Nitrates
ALINIA SUSR 3 DILATRATE SR CPCR 3
GONITRO PACK 3 PA
ALINIA TABS 3
ISORDIL TITRADOSE 2
atovaquone susp 1 TABS 40 MG
MEPRON SUSP (Use ISORDIL TITRADOSE
GP TABS 5 MG (Use GP
Atovaquone)
Isosorbide Dinitrate)
Leprostatics
ISOSORBIDE DINITRATE 2
dapsone tabs 100 mg 1 QL(4 ea daily) ER TBCR
dapsone tabs 25 mg 1 isosorbide dinitrate tabs 1
Lincosamides isosorbide mononitrate tabs 1

CLEOCIN CAPS OR 75 isosorbide mononitrate
MG, 150 MG, 300 MG (Use GP 1
tb24
Clindamycin HCl)
NITRO-BID OINT 2
CLEOCIN PEDIATRIC
GRANULES SOLR (Use GP NITRO-DUR PT24 0.1 QL(1 ea daily)
Clindamycin Palmitate MG/HR, 0.2 MG/HR, 0.4
Hydrochloride) GP
MG/HR, 0.6 MG/HR (Use
Nitroglycerin)
clindamycin hcl caps 1
NITRO-DUR PT24 0.3 2 QL(1 ea daily)
clindamycin palmitate 3 MG/HR, 0.8 MG/HR
hydrochloride solr NITROGLYCERIN 3
Oxazolidinones LINGUAL AERS
QL(210 ml per nitroglycerin pt24 td 0.1 QL(1 ea daily)
linezolid susr 100 mg/5ml 1
90 days retail) mg/hr, 0.2 mg/hr, 0.4 1
mg/hr, 0.6 mg/hr
linezolid tabs 600 mg 1 QL(20 ea per nitroglycerin soln tl 0.4
90 days retail) 1
mg/spray
SIVEXTRO TABS 2 QL(6 ea per 90 nitroglycerin subl sl 0.3 mg,
days retail) 1
ZYVOX SUSR 100 0.4 mg, 0.6 mg
GP QL(210 ml per NITROLINGUAL
MG/5ML (Use Linezolid) 90 days retail)
ZYVOX TABS 600 MG QL(20 ea per PUMPSPRAY SOLN (Use GP
GP Nitroglycerin)
(Use Linezolid) 90 days retail)
ANTIANGINAL AGENTS - Drugs to Treat Chest NITROMIST AERS 3
Pain NITROSTAT SUBL (Use GP
Antianginals-Other Nitroglycerin)
page ii-iii.
11
VALIUM TABS 10 MG (Use GP QL(4 ea daily)
ANTIANXIETY AGENTS - Drugs to Treat Anxiety Diazepam)
Antianxiety Agents - Misc. VALIUM TABS 2 MG, 5 GP
MG (Use Diazepam)
buspirone hcl tabs 1
XANAX TABS (Use GP
Alprazolam)
hydroxyzine hcl syrp 1
ANTIARRHYTHMICS - Drugs to treat abnormal
hydroxyzine hcl tabs 1 heart rhythms
Antiarrhythmics Type I-A
hydroxyzine pamoate caps 1
disopyramide phosphate 1
VISTARIL CAPS (Use caps
GP
Hydroxyzine Pamoate) NORPACE CAPS (Use GP
Benzodiazepines Disopyramide Phosphate)
ALPRAZOLAM INTENSOL 3 NORPACE CR CP12 2
CONC
alprazolam tabs 0.25 mg, quinidine gluconate tbcr 1
1
0.5 mg, 1 mg, 2 mg
QUINIDINE SULFATE 2
alprazolam tbdp 0.25 mg, 3 TABS 200 MG
0.5 mg, 1 mg, 2 mg
quinidine sulfate tabs 300 1
ATIVAN TABS (Use NF mg
Lorazepam)
Antiarrhythmics Type I-B
chlordiazepoxide hcl caps 1
mexiletine hcl caps 1
clorazepate dipotassium 1
tabs Antiarrhythmics Type I-C
diazepam conc or 5 mg/ml 1 flecainide acetate tabs 1
diazepam soln or 5 mg/5ml 1 propafenone hcl cp12 225 1

mg, 325 mg, 425 mg
diazepam tabs or 10 mg 1 QL(4 ea daily) propafenone hcl tabs 150 QL(6 ea daily)
1
mg
diazepam tabs or 2 mg, 5 1 propafenone hcl tabs 225 QL(3 ea daily)
mg 1
mg, 300 mg
lorazepam conc 1 RYTHMOL SR CP12 (Use GP
Propafenone HCl)
lorazepam tabs 1 RYTHMOL TABS (Use GP QL(3 ea daily)
oxazepam caps 10 mg, 15 Propafenone HCl)
1
mg Antiarrhythmics Type III
oxazepam caps 30 mg 1 QL(2 ea daily) amiodarone hcl tabs 1
OXAZEPAM CAPS 30 MG 2 QL(2 ea daily) dofetilide caps 1

TRANXENE T TABS (Use GP MULTAQ TABS 2
Clorazepate Dipotassium)
page ii-iii.
12
TIKOSYN CAPS (Use GP ZYFLO CR TB12 (Use GP ST
Dofetilide) Zileuton)
ANTIASTHMATIC AND BRONCHODILATOR Steroid Inhalants
AGENTS - Drugs to Treat Lung Conditions Limit 2 inhalers
Anti-Inflammatory Agents per
AEROSPAN AERS 2
month;QL(0.6
cromolyn sodium nebu 1 gm daily)
Limit 2 inhalers
Bronchodilators - Anticholinergics per
Limit 2 inhalers ALVESCO AERS 3
month;QL(0.41
per gm daily)
ATROVENT HFA AERS 2
month;QL(0.86 ARMONAIR RESPICLICK QL(0.04 ea
gm daily) 3
113 AEPB daily)
INCRUSE ELLIPTA AEPB 2 QL(1 ea daily) ARMONAIR RESPICLICK QL(0.04 ea
3
232 AEPB daily)
ipratropium bromide soln 1 ARMONAIR RESPICLICK QL(0.04 ea
3
SEEBRI NEOHALER QL(2 ea daily) 55 AEPB daily)
3 QL(1 ea daily)
CAPS ARNUITY ELLIPTA AEPB 2
SPIRIVA HANDIHALER 2 QL(1 ea daily)
CAPS Limit 1 inhaler
per
Limit 1 Inhaler ASMANEX HFA AERO 2
month;QL(0.44
SPIRIVA RESPIMAT 2 per gm daily)
AERS 1.25 MCG/ACT month;QL(0.14
3 gm daily) Limit 1 inhaler
ASMANEX TWISTHALER per
Limit 1 inhaler 120 METERED DOSES 2
month;QL(0.04
SPIRIVA RESPIMAT per AEPB
2 ea daily)
AERS 2.5 MCG/ACT month;QL(0.14
gm daily) Limit 1 inhaler
ST; Limit 1 14 METERED DOSES 2
month;QL(0.04
TUDORZA PRESSAIR inhaler per AEPB
3 ea daily)
AEPB month;QL(0.04
ea daily) Limit 1 inhaler
Leukotriene Modulators 30 METERED DOSES 2
month;QL(0.04
AEPB
QL(1 ea daily) ea daily)
montelukast sodium chew 1
Limit 1 inhaler
QL(1 ea daily) ASMANEX TWISTHALER
montelukast sodium pack 1 per
60 METERED DOSES 2
month;QL(0.04
AEPB
montelukast sodium tabs 1 QL(1 ea daily) ea daily)
Limit 1 inhaler
SINGULAIR CHEW (Use ASMANEX TWISTHALER
GP QL(1 ea daily) 7 METERED DOSES 2 per
Montelukast Sodium) month;QL(0.04
AEPB
SINGULAIR PACK (Use ea daily)
GP QL(1 ea daily)
Montelukast Sodium) budesonide (inhalation) QL(8 ml daily)
1
SINGULAIR TABS (Use susp 0.25 mg/2ml
GP QL(1 ea daily)
Montelukast Sodium) budesonide (inhalation) QL(4 ml daily)
1
ST susp 0.5 mg/2ml
zileuton tb12 3
page ii-iii.
13
budesonide (inhalation) 1 QL(2 ml daily) Limit 1 inhaler
susp 1 mg/2ml ADVAIR HFA AERO 2 per
FLOVENT DISKUS AEPB QL(20 ea daily) month;QL(0.4
2 gm daily)
100 MCG/BLIST
FLOVENT DISKUS AEPB QL(8 ea daily) AIRDUO RESPICLICK 3 QL(0.04 ea
2 113/14 AEPB daily)
250 MCG/BLIST
FLOVENT DISKUS AEPB QL(40 ea daily) AIRDUO RESPICLICK 3 QL(0.04 ea
2 232/14 AEPB daily)
50 MCG/BLIST
Limit 2 inhalers AIRDUO RESPICLICK 3 QL(0.04 ea
FLOVENT HFA AERO 110 per 55/14 AEPB daily)
2
MCG/ACT, 220 MCG/ACT month;QL(0.8 ALBUTEROL SULFATE
gm daily) 2 QL(2 ea daily)
ER TB12
Limit 1 inhaler albuterol sulfate nebu in
FLOVENT HFA AERO 44 2 per 0.63 mg/3ml, 0.083 %, 0.5 1
MCG/ACT month;QL(0.36 %, 1.25 mg/3ml
gm daily) albuterol sulfate syrp or 2 1
Limit 2 inhalers mg/5ml
PULMICORT FLEXHALER 2 per albuterol sulfate tabs or 2
AEPB 180 MCG/ACT month;QL(0.07 1
mg, 4 mg
ea daily)
albuterol sulfate tb12 or 4 1 QL(2 ea daily)
Limit 2 inhalers mg, 8 mg
PULMICORT FLEXHALER 2 per
AEPB 90 MCG/ACT month;QL(0.27 ANORO ELLIPTA AEPB 2 QL(2 ea daily)
ea daily)
ARCAPTA NEOHALER 3 QL(1 ea daily)
PULMICORT SUSP 0.25 QL(8 ml daily) CAPS
MG/2ML (Use Budesonide GP
(Inhalation)) BEVESPI AEROSPHERE 3 QL(0.36 gm
AERO daily)
PULMICORT SUSP 0.5 QL(4 ml daily)
MG/2ML (Use Budesonide GP BREO ELLIPTA AEPB 2 QL(2 ea daily)
(Inhalation))
Limit 1 inhaler
PULMICORT SUSP 1 QL(2 ml daily) COMBIVENT RESPIMAT per
MG/2ML (Use Budesonide GP 3
AERS month;QL(0.2
(Inhalation)) gm daily)
Limit 3 Inhalers Limit 1 inhaler
per Month-7.3g per
pkg; 2 Inhalers DULERA AERO 2
QVAR AERS 40 MCG/ACT 2 month;QL(0.45
per Month-8.7g gm daily)
pkg;QL(0.58
gm daily) FLUTICASONE QL(0.04 ea
PROPIONATE/SALMETER 2 daily)
Limit 2 inhalers OL AEPB
per
QVAR AERS 80 MCG/ACT 2
month;QL(0.58 ipratropium-albuterol soln 1
gm daily)
QL(0.72 gm levalbuterol hcl nebu 1
QVAR REDIHALER AERB 2
daily)
QL(0.5 gm
Sympathomimetics levalbuterol tartrate aero 1
daily)
ADVAIR DISKUS AEPB 2 QL(2 ea daily)
page ii-iii.
14
metaproterenol sulfate syrp 1 XOPENEX NEBU (Use GP
Levalbuterol HCl)
metaproterenol sulfate tabs 1 Xanthines
Limit 2 inhalers ELIXOPHYLLIN ELIX 3
per
PROAIR HFA AERS 3
month;QL(0.57 THEO-24 CP24 2
gm daily)
Limit 2 inhalers
theophylline soln 80 3
PROAIR RESPICLICK per
mg/15ml
3 theophylline tb12 100 mg,
AEPB month;QL(0.07 1
ea daily) 200 mg
Limit 2 inhalers theophylline tb12 300 mg, 1 QL(1 ea daily)
per 450 mg
PROVENTIL HFA AERS 2
month;QL(0.47 theophylline tb24 400 mg, QL(1 ea daily)
gm daily) 1
600 mg
QL(0.47 gm
PROVENTIL HFA AERS 2 ANTICOAGULANTS - Blood Thinners
daily)
SEREVENT DISKUS 2 QL(2 ea daily) Coumarin Anticoagulants
AEPB COUMADIN TABS (Use
Limit 1 inhaler GP
Warfarin Sodium)
STIOLTO RESPIMAT 2 per
AERS month;QL(0.14 warfarin sodium tabs 1
gm daily)
Direct Factor Xa Inhibitors
Limit 1 inhaler
STRIVERDI RESPIMAT per QL(42 ea per
2 BEVYXXA CAPS 3
AERS month;QL(0.14 42 days retail)
gm daily) ELIQUIS STARTER PACK 2 QL(2 ea daily)
Limit 1 inhaler TABS
per ELIQUIS TABS 2 QL(2 ea daily)
SYMBICORT AERO 2
month;QL(0.34
gm daily) SAVAYSA TABS 3
terbutaline sulfate tabs 1 XARELTO STARTER 2
QL(2 ea daily) PACK TBPK
TRELEGY ELLIPTA AEPB 2
XARELTO TABS 10 MG, 2
UTIBRON NEOHALER QL(2 ea daily) 15 MG, 2.5 MG
3
CAPS QL(1 ea daily)
XARELTO TABS 20 MG 2
Limit 2 inhalers
VENTOLIN HFA AERS 3 per Thrombin Inhibitors
month;QL(1.2
gm daily) PRADAXA CAPS 3
VOSPIRE ER TB12 (Use GP QL(2 ea daily)
Albuterol Sulfate) ANTICONVULSANTS - Drugs to Treat Seizures
XOPENEX AMPA Glutamate Receptor Antagonists
CONCENTRATE NEBU GP
(Use Levalbuterol HCl) FYCOMPA SUSP 3
page ii-iii.
15
FYCOMPA TABS 3 BRIVIACT SOLN 10 3 PA
MG/ML
Anticonvulsants - Benzodiazepines BRIVIACT TABS 10 MG, 3 PA
25 MG, 50 MG, 75 MG
clobazam susp 2.5 mg/ml 3
PA; QL(2 ea
BRIVIACT TABS 100 MG 3
QL(1 ea daily) daily)
clobazam tabs 10 mg 3
carbamazepine chew 100 1
clobazam tabs 20 mg 3 QL(2 ea daily) mg
carbamazepine cp12 100 1
clonazepam tabs 1 mg, 200 mg, 300 mg
carbamazepine susp 100 1
clonazepam tbdp 1 mg/5ml
QL(4 ea per fill carbamazepine tabs 200 1
DIASTAT ACUDIAL GEL 3 retail,4 ea per mg
30 days retail) carbamazepine tb12 100 1
QL(4 ea per fill mg
DIASTAT PEDIATRIC GEL 3 retail,4 ea per carbamazepine tb12 200 1 QL(8 ea daily)
30 days retail) mg
QL(4 ea per fill carbamazepine tb12 400 1 QL(4 ea daily)
diazepam (anticonvulsant) 3 retail,4 ea per mg
gel 30 days retail) CARBATROL CP12 (Use GP
QL(4 ea per fill Carbamazepine)
DIAZEPAM GEL RE 20 3 retail,4 ea per
MG, 2.5 MG gabapentin caps 1
30 days retail)
QL(4 ea per fill gabapentin soln 1
DIAZEPAM RECTAL GEL 3 retail,4 ea per
GEL 30 days retail) gabapentin tabs 1
KLONOPIN TABS (Use GP
Clonazepam) KEPPRA SOLN 100
ONFI SUSP 2.5 MG/ML MG/ML (Use GP
GP Levetiracetam)
(Use Clobazam)
ONFI TABS 10 MG (Use KEPPRA TABS 250 MG, QL(6 ea daily)
GP QL(1 ea daily) 500 MG, 750 MG, 1000 GP
Clobazam)
MG (Use Levetiracetam)
ONFI TABS 20 MG (Use GP QL(2 ea daily)
Clobazam) KEPPRA XR TB24 (Use GP QL(4 ea daily)
Levetiracetam)
Anticonvulsants - Misc. LAMICTAL CHEWABLE
APTIOM TABS 200 MG, 3 QL(2 ea daily) DISPERSIBLE CHEW (Use GP
400 MG, 600 MG Lamotrigine)
APTIOM TABS 800 MG 3 QL(1 ea daily) PA
LAMICTAL ODT KIT 3
BANZEL SUSP 40 MG/ML 2 LAMICTAL ODT TBDP 25 PA
MG, 50 MG, 100 MG, 200 GP
BANZEL TABS 200 MG 2 MG (Use Lamotrigine)
BANZEL TABS 400 MG 2 QL(8 ea daily)
page ii-iii.
16
LAMICTAL STARTER/NOT LYRICA CAPS 225 MG, 3 PA; QL(2 ea
TAKING GP 300 MG daily)
CARBAMAZEPINE KIT LYRICA CAPS 25 MG, 50 PA; QL(3 ea
(Use Lamotrigine) MG, 75 MG, 100 MG, 150 3 daily)
LAMICTAL MG, 200 MG
STARTER/TAKING PA; QL(30 ml
CARBAMAZEPINE/NOT GP LYRICA SOLN 20 MG/ML 3
daily)
TAKING VALPROATE KIT
(Use Lamotrigine) MYSOLINE TABS (Use GP
Primidone)
LAMICTAL
STARTER/TAKING NEURONTIN CAPS (Use GP
GP Gabapentin)
VALPROATE KIT (Use
Lamotrigine) NEURONTIN SOLN (Use GP
LAMICTAL TABS (Use Gabapentin)
GP NEURONTIN TABS (Use
Lamotrigine) GP
PA Gabapentin)
LAMICTAL XR KIT 3 oxcarbazepine susp 60 QL(40 ml daily)
1
LAMICTAL XR TB24 25 PA; QL(1 ea mg/ml, 300 mg/5ml
MG, 50 MG, 100 MG, 200 GP daily) oxcarbazepine tabs 150 mg 1
MG (Use Lamotrigine)
LAMICTAL XR TB24 250 QL(8 ea daily)
GP PA oxcarbazepine tabs 300 mg 1
MG (Use Lamotrigine)
LAMICTAL XR TB24 300 QL(4 ea daily)
GP PA; QL(2 ea oxcarbazepine tabs 600 mg 1
MG (Use Lamotrigine) daily)
OXTELLAR XR TB24 150 3 PA
lamotrigine chew 5 mg, 25 1 MG, 300 MG
mg
OXTELLAR XR TB24 600 3 PA; QL(4 ea
lamotrigine kit 3 PA MG daily)
lamotrigine kit 25 mg, 1 POTIGA TABS 3
lamotrigine tabs 25 mg, 1 primidone tabs 1

100 mg, 150 mg, 200 mg
QUDEXY XR CS24 100 3 PA; QL(1 ea
lamotrigine tb24 25 mg, 50 3 PA; QL(1 ea MG, 150 MG, 200 MG daily)
mg, 100 mg, 200 mg daily)
QUDEXY XR CS24 25 MG, 3 PA; QL(2 ea
lamotrigine tb24 250 mg 3 PA 50 MG daily)
PA; QL(2 ea SPRITAM TB3D 3 PA
lamotrigine tb24 300 mg 3
daily)
TEGRETOL SUSP (Use GP
lamotrigine tbdp 25 mg, 50 3 PA Carbamazepine)
mg, 100 mg, 200 mg
TEGRETOL TABS (Use GP
levetiracetam soln or 100 1 Carbamazepine)
mg/ml, 500 mg/5ml
TEGRETOL-XR TB12 100 GP
levetiracetam tabs or 250 QL(6 ea daily) MG (Use Carbamazepine)
mg, 500 mg, 750 mg, 1000 1
mg TEGRETOL-XR TB12 200 GP QL(8 ea daily)
MG (Use Carbamazepine)
levetiracetam tb24 or 500 1 QL(4 ea daily)
mg, 750 mg TEGRETOL-XR TB12 400 GP QL(4 ea daily)
MG (Use Carbamazepine)
page ii-iii.
17
TOPAMAX SPRINKLE GP zonisamide caps 25 mg, 50 1
CPSP (Use Topiramate) mg
TOPAMAX TABS 100 MG GP QL(4 ea daily) Carbamates
(Use Topiramate)
TOPAMAX TABS 200 MG felbamate susp 1
GP QL(2 ea daily)
(Use Topiramate)
felbamate tabs 1
TOPAMAX TABS 25 MG GP
(Use Topiramate) FELBATOL SUSP (Use GP
TOPAMAX TABS 50 MG Felbamate)
GP QL(8 ea daily)
(Use Topiramate) FELBATOL TABS (Use GP
topiramate cpsp 15 mg, 25 Felbamate)
1
mg GABA Modulators
TOPIRAMATE ER CS24 3 PA; QL(1 ea GABITRIL TABS (Use
100 MG, 150 MG, 200 MG daily) GP
Tiagabine HCl)
TOPIRAMATE ER CS24 PA; QL(2 ea SABRIL PACK (Use
25 MG, 50 MG
3
daily) GP QL(6 ea daily)
Vigabatrin)
topiramate tabs 100 mg 1 QL(4 ea daily)
SABRIL TABS 2
tiagabine hcl tabs 3
topiramate tabs 25 mg 1 vigabatrin pack 1 QL(6 ea daily)

Hydantoins
TRILEPTAL SUSP 300 QL(40 ml daily) DILANTIN CAPS 100 MG
MG/5ML (Use GP (Use Phenytoin Sodium GP
Oxcarbazepine) Extended)
TRILEPTAL TABS 150 MG GP DILANTIN CAPS 30 MG 2
(Use Oxcarbazepine)
TRILEPTAL TABS 300 MG DILANTIN INFATABS
GP QL(8 ea daily) CHEW (Use Phenytoin)
GP
(Use Oxcarbazepine)
TRILEPTAL TABS 600 MG DILANTIN-125 SUSP (Use
GP QL(4 ea daily) Phenytoin) GP
(Use Oxcarbazepine)
TROKENDI XR CP24 200 PA; QL(2 ea PEGANONE TABS 3
3
MG daily)
PHENYTEK CAPS (Use
TROKENDI XR CP24 25 3 PA Phenytoin Sodium GP
MG, 50 MG, 100 MG Extended)
VIMPAT SOLN 10 MG/ML 2 QL(40 ml daily)
phenytoin chew 1
VIMPAT TABS 50 MG, 100 2 phenytoin sodium extended
MG, 150 MG, 200 MG 1
caps
ZONEGRAN CAPS 100 GP QL(6 ea daily)
MG (Use Zonisamide) phenytoin susp 1
ZONEGRAN CAPS 25 MG GP Succinimides
(Use Zonisamide)
QL(6 ea daily) CELONTIN CAPS 2
zonisamide caps 100 mg 1
page ii-iii.
18
ethosuximide caps 1 bupropion hcl tb12 100 mg, 1
150 mg, 200 mg
ethosuximide soln 1 bupropion hcl tb24 150 mg, 1 QL(1 ea daily)
300 mg
ZARONTIN CAPS (Use GP BUPROPION ST; QL(1 ea
Ethosuximide) HYDROCHLORIDE ER 3 daily)
ZARONTIN SOLN (Use GP TB24
Ethosuximide) ST; QL(1 ea
FORFIVO XL TB24 3
Valproic Acid daily)
DEPAKENE CAPS (Use GP maprotiline hcl tabs 1
Valproic Acid)
DEPAKENE SOLN (Use WELLBUTRIN SR TB12 GP
GP (Use Bupropion HCl)
Valproate Sodium)
DEPAKOTE ER TB24 (Use WELLBUTRIN XL TB24 GP QL(1 ea daily)
GP (Use Bupropion HCl)
Divalproex Sodium)
DEPAKOTE SPRINKLES Monoamine Oxidase Inhibitors (MAOIs)
CSDR (Use Divalproex GP
Sodium) EMSAM PT24 3 QL(1 ea daily)
DEPAKOTE TBEC (Use GP MARPLAN TABS 3
Divalproex Sodium)
NARDIL TABS (Use GP
divalproex sodium csdr 1 Phenelzine Sulfate)
divalproex sodium tb24 1 PARNATE TABS (Use GP
Tranylcypromine Sulfate)
divalproex sodium tbec 1 phenelzine sulfate tabs 1
valproate sodium soln 1 tranylcypromine sulfate 1
tabs
valproic acid caps 1 Selective Serotonin Reuptake Inhibitors (SSRIs)
ANTIDEPRESSANTS - Drugs to Treat CELEXA TABS (Use GP QL(1 ea daily)
Depression Citalopram Hydrobromide)
citalopram hydrobromide 3 QL(20 ml daily)
Alpha-2 Receptor Antagonists (Tetracyclics) soln 10 mg/5ml
mirtazapine tabs 1 citalopram hydrobromide 1 QL(1 ea daily)
tabs 10 mg, 20 mg, 40 mg
mirtazapine tbdp 1 escitalopram oxalate soln 5 1
mg/5ml
REMERON SOLTAB TBDP GP
(Use Mirtazapine) escitalopram oxalate tabs 1 QL(1 ea daily)
10 mg, 20 mg
REMERON TABS (Use GP
Mirtazapine) escitalopram oxalate tabs 5 1 QL(2 ea daily)
mg
Antidepressants - Misc.
PA; QL(1 ea FLUOXETINE DR CPDR 3
APLENZIN TB24 3
daily) fluoxetine hcl caps 10 mg, 1
bupropion hcl tabs 75 mg, 1 20 mg
100 mg
page ii-iii.
19
fluoxetine hcl caps 40 mg 1 QL(1 ea daily) PROZAC WEEKLY CPDR GP
(Use Fluoxetine HCl)
fluoxetine hcl soln 20 1 QL(15 ml daily) sertraline hcl conc 20
mg/5ml 1
mg/ml
fluoxetine hcl tabs 10 mg 1 sertraline hcl tabs 25 mg, 1 QL(2 ea daily)
50 mg, 100 mg
fluoxetine hcl tabs 20 mg 1 QL(1 ea daily) ZOLOFT CONC 20 MG/ML GP
(Use Sertraline HCl)
fluoxetine hcl tabs 60 mg 3 ST; QL(1 ea ZOLOFT TABS 25 MG, 50 QL(2 ea daily)
daily)
MG, 100 MG (Use GP
FLUOXETINE 3 ST; QL(1 ea Sertraline HCl)
HYDROCHLORIDE TABS daily)
FLUOXETINE ST; QL(1 ea Serotonin Modulators
HYDROCHLORIDE TABS GP daily) NEFAZODONE HCL TABS 3
(Use Fluoxetine HCl) 100 MG, 150 MG
fluvoxamine maleate cp24 nefazodone hcl tabs 50 mg,
1 QL(3 ea daily) 250 mg 3
100 mg
fluvoxamine maleate cp24 NEFAZODONE 3
1 HYDROCHLORIDE TABS
150 mg
fluvoxamine maleate tabs 1 QL(3 ea daily) trazodone hcl tabs 1
100 mg
fluvoxamine maleate tabs ST; QL(1 ea
1 TRINTELLIX TABS 3
25 mg, 50 mg daily)
LEXAPRO SOLN 5 VIIBRYD STARTER PACK 3 PA
MG/5ML (Use GP KIT
Escitalopram Oxalate) VIIBRYD TABS 10 MG, 40 3 ST
LEXAPRO TABS 10 MG, QL(1 ea daily) MG
20 MG (Use Escitalopram GP ST; QL(2 ea
VIIBRYD TABS 20 MG 3
Oxalate) daily)
LEXAPRO TABS 5 MG GP QL(2 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors
(Use Escitalopram Oxalate) CYMBALTA CPEP (Use GP QL(2 ea daily)
paroxetine hcl tabs 1 Duloxetine HCl)
DESVENLAFAXINE ER 3 ST; QL(1 ea
paroxetine hcl tb24 1 TB24 50 MG, 100 MG daily)
DESVENLAFAXINE ER 3 PA
PAXIL CR TB24 (Use GP TB24 50 MG, 100 MG
Paroxetine HCl)
desvenlafaxine succinate 1 QL(1 ea daily)
PAXIL SUSP 10 MG/5ML 2 tb24
PAXIL TABS 10 MG, 20 duloxetine hcl cpep 20 mg, 1 QL(2 ea daily)
MG, 30 MG, 40 MG (Use GP 30 mg, 60 mg
Paroxetine HCl) EFFEXOR XR CP24 150 GP QL(2 ea daily)
PROZAC CAPS 10 MG, 20 MG (Use Venlafaxine HCl)
GP EFFEXOR XR CP24 75 QL(1 ea daily)
MG (Use Fluoxetine HCl)
PROZAC CAPS 40 MG MG, 37.5 MG (Use GP
GP QL(1 ea daily) Venlafaxine HCl)
(Use Fluoxetine HCl)
page ii-iii.
20
FETZIMA CP24 20 MG 3 ST; QL(2 ea nortriptyline hcl caps 10 1
daily) mg, 25 mg, 50 mg, 75 mg
FETZIMA CP24 40 MG, 80 3 ST; QL(1 ea NORTRIPTYLINE HCL 2
MG, 120 MG daily) SOLN 10 MG/5ML
FETZIMA TITRATION 3 ST nortriptyline hcl soln 10 1
PACK C4PK mg/5ml
3 ST; QL(1 ea PAMELOR CAPS (Use
KHEDEZLA TB24 Nortriptyline HCl) GP
daily)
PRISTIQ TB24 (Use QL(1 ea daily) protriptyline hcl tabs 3
Desvenlafaxine Succinate) GP
venlafaxine hcl cp24 150 SURMONTIL CAPS (Use
1 QL(2 ea daily) Trimipramine Maleate) GP
mg
venlafaxine hcl cp24 75 TOFRANIL TABS 10 MG,
1 QL(1 ea daily) 25 MG (Use Imipramine GP
mg, 37.5 mg
venlafaxine hcl tabs 25 mg, HCl)
50 mg, 75 mg, 100 mg, 1 TOFRANIL TABS 50 MG GP QL(4 ea daily)
37.5 mg (Use Imipramine HCl)
venlafaxine hcl tb24 75 mg, 1 trimipramine maleate caps 3
150 mg, 225 mg, 37.5 mg
venlafaxine hcl tb24 75 mg, 1 QL(1 ea daily) ANTIDIABETICS - Drugs to Regulate Blood
150 mg, 37.5 mg Sugar
Tricyclic Agents Alpha-Glucosidase Inhibitors
amitriptyline hcl tabs 1 acarbose tabs 1
GLYSET TABS (Use GP
AMOXAPINE TABS 2 Miglitol)
ANAFRANIL CAPS (Use GP miglitol tabs 3
Clomipramine HCl)
PRECOSE TABS (Use GP
clomipramine hcl caps 1 Acarbose)
desipramine hcl tabs 1 Antidiabetic Combinations
ACTOPLUS MET TABS
doxepin hcl caps 1 (Use Pioglitazone HCl- GP
Metformin HCl)
doxepin hcl conc 1
ACTOPLUS MET XR TB24 3
ELAVIL TABS (Use GP
Amitriptyline HCl) ALOGLIPTIN/METFORMIN 3
HCL TABS
imipramine hcl tabs 10 mg, 1
25 mg DUETACT TABS (Use
Pioglitazone HCl- GP
imipramine hcl tabs 50 mg 1 QL(4 ea daily) Glimepiride)
imipramine pamoate caps 3 glipizide-metformin hcl tabs 1
NORPRAMIN TABS (Use GLUCOVANCE TABS (Use GP

GP Glyburide-Metformin)
Desipramine HCl)
page ii-iii.
21
glyburide-metformin tabs 1 metformin hcl tabs 1
GLYXAMBI TABS 2 metformin hcl tb24 1
INVOKAMET TABS 2 METFORMIN 3

HYDROCHLORIDE SOLN
INVOKAMET XR TB24 2 RIOMET SOLN 3
JANUMET TABS 50MG- 2 Diabetic Other
1000MG
JANUMET TABS 50MG- QL(2 ea daily) PROGLYCEM SUSP 3
2
500MG
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUMET XR TB24 2 QL(1 ea daily)
100MG-1000MG ALOGLIPTIN TABS 12.5 3
MG, 6.25 MG
JANUMET XR TB24 QL(2 ea daily)
50MG-500MG, 50MG- 2 ALOGLIPTIN TABS 25 MG 3 QL(1 ea daily)
1000MG
JENTADUETO TABS 2 JANUVIA TABS 25 MG 2
JENTADUETO XR TB24 JANUVIA TABS 50 MG, 2 QL(1 ea daily)

2 100 MG
2.5MG-1000MG
JENTADUETO XR TB24 QL(1 ea daily) NESINA TABS 12.5 MG, 3
2 6.25 MG
5MG-1000MG
NESINA TABS 25 MG 3 QL(1 ea daily)
KAZANO TABS 3
pioglitazone hcl-glimepiride TRADJENTA TABS 2 QL(1 ea daily)
1
tabs
pioglitazone hcl-metformin Insulin Sensitizing Agents
1 ACTOS TABS 15 MG (Use
hcl tabs GP
REPAGLINIDE/METFORM Pioglitazone HCl)
IN HYDROCHLORIDE 3 ACTOS TABS 30 MG, 45 GP QL(1 ea daily)
TABS MG (Use Pioglitazone HCl)
SYNJARDY TABS 2 AVANDIA TABS 2
SYNJARDY XR TB24 2 pioglitazone hcl tabs 15 mg 1

XIGDUO XR TB24 10MG- QL(1 ea daily) pioglitazone hcl tabs 30 1 QL(1 ea daily)
3 mg, 45 mg
500MG, 10MG-1000MG
XIGDUO XR TB24 5MG- QL(2 ea daily) Insulin
500MG, 5MG-1000MG, 3 Limit 45mls per
2.5MG-1000MG HUMALOG JUNIOR 2 month;QL(1.5
KWIKPEN SOPN
Biguanides ml daily)
GLUCOPHAGE TABS Limit 45mls per
GP HUMALOG KWIKPEN
(Use Metformin HCl) 2 month;QL(1.5
SOPN 100 UNIT/ML
GLUCOPHAGE XR TB24 ml daily)
GP
(Use Metformin HCl)
page ii-iii.
22
Limit 24mls per Limit 45mls per
HUMALOG KWIKPEN 2 month;QL(0.8 LANTUS SOLOSTAR 2 month;QL(1.5
SOPN 200 UNIT/ML SOPN
ml daily) ml daily)
PA; Limit 45mls LEVEMIR FLEXTOUCH 2 QL(135 ml per
HUMALOG MIX 50/50 2 per SOPN fill mail)
KWIKPEN SUPN month;QL(1.5 Limit 45mls per
ml daily) LEVEMIR SOLN 2 month;QL(1.5
Limit 45mls per ml daily)
HUMALOG MIX 50/50 2 month;QL(1.5
SUSP Limit 45mls per
ml daily) NOVOLIN 70/30 FLEXPEN 2 month;QL(1.5
Limit 45mls per RELION SUPN
HUMALOG MIX 75/25 ml daily)
2 month;QL(1.5 Limit 45mls per
KWIKPEN SUPN NOVOLIN 70/30 FLEXPEN
ml daily) 2 month;QL(1.5
Limit 40mls per SUPN
HUMALOG MIX 75/25 ml daily)
2 month;QL(1.34 Limit 3 pens
SUSP ml daily) TOUJEO MAX SOLOSTAR 2 per
Limit 45mls per SOPN month;QL(0.5
HUMALOG SOCT 2 month;QL(1.5 ml daily)
ml daily) Limit 3 pens
HUMALOG SOLN 2 QL(1.5 ml TOUJEO SOLOSTAR 2 per
daily) SOPN month;QL(0.5
HUMULIN 70/30 KWIKPEN 2 month;QL(1.5
SUPN Limit 45mls per
ml daily) TRESIBA FLEXTOUCH 2 month;QL(1.5
SOPN 100 UNIT/ML
HUMULIN 70/30 SUSP 2 month;QL(1.34 Limit 27mls per
ml daily) TRESIBA FLEXTOUCH 2 month;QL(0.9
SOPN 200 UNIT/ML
HUMULIN N KWIKPEN 2 month;QL(1.5
SUPN Meglitinide Analogues
ml daily)
nateglinide tabs 1
HUMULIN N SUSP 2 QL(1.34 ml
daily) PRANDIN TABS (Use
Limit 45mls per GP
Repaglinide)
HUMULIN R SOLN 2 month;QL(1.5
ml daily) repaglinide tabs 1
Limit 40mls per STARLIX TABS (Use
HUMULIN R SOLN 2 month;QL(1.34 GP
Nateglinide)
ml daily)
Sodium-Glucose Co-Transporter 2 (SGLT2)
HUMULIN R U-500 2 QL(1.34 ml
(CONCENTRATED) SOLN daily) FARXIGA TABS 3
QL(40 ml per
HUMULIN R U-500 INVOKANA TABS 100 MG 2
2 fill retail,40 ml
KWIKPEN SOPN per 30 days
retail) INVOKANA TABS 300 MG 2 QL(1 ea daily)
Limit 45 per
LANTUS SOLN 2 month;QL(1.5 JARDIANCE TABS 10 MG 2
ml daily)
page ii-iii.
23
JARDIANCE TABS 25 MG 2 QL(1 ea daily) ANTIDOTES AND SPECIFIC ANTAGONISTS
STEGLATRO TABS 3 Antidotes - Chelating Agents
Sulfonylureas CHEMET CAPS 3

AMARYL TABS (Use Not available
GP FERRIPROX SOLN 100
Glimepiride) MG/ML
3 through mail
order
chlorpropamide tabs 1
FERRIPROX TABS 500 3 SP
glimepiride tabs 1 MG
JADENU SPRINKLE PACK 3 PA; SP
glipizide tabs 1
JADENU TABS 2 PA
glipizide tb24 1
Antidotes and Specific Antagonists
GLUCOTROL TABS (Use GP
Glipizide) CETYLEV TBEF 3 PA
GLUCOTROL XL TB24 GP
(Use Glipizide) VISTOGARD PACK 3
glyburide micronized tabs 1 Opioid Antagonists
glyburide tabs 1 naltrexone hcl tabs 1
GLYNASE TABS (Use QL(4 ea per 30

GP NARCAN LIQD 3
Glyburide Micronized) days retail)
ANTIEMETICS - Drugs to Treat Nausea and
tolazamide tabs 1 Vomiting
tolbutamide tabs 1 5-HT3 Receptor Antagonists
PA; QL(2 ea
ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs ANZEMET TABS 3
per fill retail)
to Treat Diarrhea
PA; Limit 2
Antidiarrheal - Chloride Channel Antagonists tablets per
granisetron hcl tabs 3
day;QL(2 ea
MYTESI TBEC 3 PA; QL(2 ea daily)
daily)
Limit 50mls per
Antiperistaltic Agents prescription;QL
diphenoxylate w/ atropine ondansetron hcl soln 4 1 (1.67 ml
1 mg/5ml
liqd daily,50 ml per
diphenoxylate w/ atropine fill retail)
1
tabs ondansetron hcl tabs 4 mg, QL(20 ea per
1
LOMOTIL TABS (Use 8 mg fill retail)
GP
Diphenoxylate w/ Atropine) QL(20 ea per
ondansetron tbdp 1
fill retail)
MOTOFEN TABS 2
QL(2.4 ml
opium tincture tinc 3
daily)
PAREGORIC TINC 3
page ii-iii.
24
PA; QL(1 ea QL(1 ea per fill
per fill retail,1
aprepitant caps 80 mg, 125 3 retail,1 ea per
SANCUSO PTCH 3 ea per 21 days mg 30 days retail)
retail,3 ea per EMEND CAPS 40 MG (Use GP QL(2 ea per 30
90 days mail) Aprepitant) days retail)
ZOFRAN ODT TBDP (Use GP QL(20 ea per QL(1 ea per fill
Ondansetron) fill retail) EMEND CAPS 80 MG, 125 GP retail,1 ea per
Limit 50mls per MG (Use Aprepitant) 30 days retail)
prescription;QL
ZOFRAN SOLN 4 MG/5ML GP (1.67 ml EMEND SUSR 125 MG 3 QL(1 ea per 30
(Use Ondansetron HCl) days retail)
daily,50 ml per
fill retail) QL(3 ea per fill
EMEND TRIPACK CAPS GP retail,3 ea per
ZOFRAN TABS 4 MG, 8 QL(20 ea per (Use Aprepitant) 30 days retail)
MG (Use Ondansetron GP fill retail)
HCl) VARUBI TABS 3 QL(4 ea per fill
retail)
Antiemetics - Anticholinergic
ANTIFUNGALS - Drugs to Treat Fungal Infections
scopolamine pt72 3
Antifungals
TIGAN CAPS (Use GP
Trimethobenzamide HCl) ANCOBON CAPS (Use GP
Flucytosine)
TRANSDERM-SCOP PT72 3
BIO-STATIN CAPS 3
TRANSDERM-SCOP PT72 GP
(Use Scopolamine) flucytosine caps 3
trimethobenzamide hcl 1 GRIS-PEG TABS (Use
caps GP
Griseofulvin Ultramicrosize)
Antiemetics - Miscellaneous
griseofulvin microsize susp 1
QL(2 ea per 28
AKYNZEO CAPS 3
days retail) griseofulvin microsize tabs 1
PA; QL(2 ea
CESAMET CAPS 3 griseofulvin ultramicrosize
daily) 1
tabs
DICLEGIS TBEC 3 QL(4 ea daily)
QL(1 ea
LAMISIL TABS (Use GP daily,90 ea per
dronabinol caps 3 PA Terbinafine HCl) 365 days retail)
MARINOL CAPS (Use GP PA nystatin powd 3
Dronabinol)
SYNDROS SOLN 3 PA nystatin tabs 1
QL(1 ea
Substance P/Neurokinin 1 (NK1) Receptor terbinafine hcl tabs 1 daily,90 ea per
QL(3 ea per fill 365 days retail)
aprepitant caps 3 retail,3 ea per
30 days retail) Imidazole-Related Antifungals
Not available
aprepitant caps 40 mg 3 QL(2 ea per 30 CRESEMBA CAPS 3 through mail
days retail)
order
page ii-iii.
25
DIFLUCAN SUSR (Use GP Antihistamines - Phenothiazines
Fluconazole) promethazine hcl soln or
DIFLUCAN TABS (Use 1
GP 6.25 mg/5ml
Fluconazole) promethazine hcl supp re 1
fluconazole susr 1 25 mg, 12.5 mg
promethazine hcl supp re 1 QL(3 ea daily)
fluconazole tabs 1 50 mg
PA promethazine hcl syrp or 1
itraconazole caps 1 6.25 mg/5ml
PA promethazine hcl tabs or 1
itraconazole soln 1 12.5 mg
ketoconazole tabs 1 promethazine hcl tabs or 1 QL(6 ea daily)
25 mg
NOXAFIL SUSP 3 promethazine hcl tabs or 1 QL(3 ea daily)
50 mg
NOXAFIL TBEC 3 Antihistamines - Piperidines
ONMEL TABS 3 PA cyproheptadine hcl syrp 1
SPORANOX CAPS (Use GP PA cyproheptadine hcl tabs 1
Itraconazole)
SPORANOX PULSEPAK ANTIHYPERLIPIDEMICS - Drugs to Treat High
GP PA Cholesterol
CAPS (Use Itraconazole)
SPORANOX SOLN (Use GP PA Antihyperlipidemics - Combinations
Itraconazole) ezetimibe-simvastatin tabs
VFEND SUSR 40 MG/ML 1 ST; QL(1 ea
GP 10mg-10mg daily)
(Use Voriconazole) ezetimibe-simvastatin tabs
VFEND TABS 50 MG, 200 1 QL(1 ea daily)
GP QL(2 ea daily) 10mg-20mg, 40mg-10mg
MG (Use Voriconazole) ezetimibe-simvastatin tabs 1 PA; QL(1 ea
voriconazole susr 40 mg/ml 1 80mg-10mg daily)
VYTORIN TABS 10MG- ST; QL(1 ea
voriconazole tabs 50 mg, 1 QL(2 ea daily) 10MG (Use Ezetimibe- GP daily)
200 mg Simvastatin)
ANTIHISTAMINES - Drugs to Treat Allergies VYTORIN TABS 10MG- QL(1 ea daily)
20MG, 40MG-10MG (Use GP
Antihistamines - Alkylamines Ezetimibe-Simvastatin)
BROMPHENIRAMINE VYTORIN TABS 80MG- PA; QL(1 ea
3 10MG (Use Ezetimibe- GP daily)
TANNATE CHEW
Simvastatin)
Antihistamines - Ethanolamines
carbinoxamine maleate Antihyperlipidemics - Misc.
1 LOVAZA CAPS (Use QL(4 ea daily)
soln 4 mg/5ml
carbinoxamine maleate Omega-3-acid Ethyl Esters) GP
3 omega-3-acid ethyl esters
tabs 4 mg, 6 mg 1 QL(4 ea daily)
CLEMASTINE FUMARATE 2 caps
TABS VASCEPA CAPS 3 ST
page ii-iii.
26
Bile Acid Sequestrants fenofibrate tabs 48 mg 1
cholestyramine light powd 1
4 gm/dose fenofibrate tabs 54 mg 1 QL(2 ea daily)
cholestyramine powd or 4 1
gm/dose FENOFIBRIC ACID TABS 3
colesevelam hcl pack 3.75 3 QL(1 ea daily)
gm FIBRICOR TABS 3
colesevelam hcl tabs 625 3 QL(7 ea daily) gemfibrozil tabs 1
mg
COLESTID FLAVORED LIPOFEN CAPS 3
GRAN 5 GM (Use GP
Colestipol HCl) LOFIBRA CAPS (Use GP QL(1 ea daily)
COLESTID GRAN 5 GM Fenofibrate Micronized)
GP LOFIBRA TABS (Use
(Use Colestipol HCl) GP QL(1 ea daily)
COLESTID TABS 1 GM Fenofibrate)
GP LOPID TABS (Use
(Use Colestipol HCl) GP
Gemfibrozil)
colestipol hcl gran 5 gm 1
TRICOR TABS 145 MG GP QL(1 ea daily)
(Use Fenofibrate)
colestipol hcl tabs 1 gm 1
TRICOR TABS 48 MG GP
QUESTRAN LIGHT POWD GP (Use Fenofibrate)
(Use Cholestyramine Light) QL(1 ea daily)
TRIGLIDE TABS 2
QUESTRAN POWD 4
GM/DOSE (Use GP TRILIPIX CPDR 135 MG
Cholestyramine) GP QL(1 ea daily)
(Use Choline Fenofibrate)
WELCHOL PACK 3.75 GM GP QL(1 ea daily) TRILIPIX CPDR 45 MG
(Use Colesevelam HCl) GP
(Use Choline Fenofibrate)
WELCHOL TABS 625 MG GP QL(7 ea daily) HMG CoA Reductase Inhibitors
(Use Colesevelam HCl)
atorvastatin calcium tabs 1 QL(1 ea daily)
Fibric Acid Derivatives
ANTARA CAPS 3 CRESTOR TABS (Use GP QL(1 ea daily)
Rosuvastatin Calcium)
choline fenofibrate cpdr 1 QL(1 ea daily)
fluvastatin sodium caps 1 QL(1 ea daily)
135 mg
choline fenofibrate cpdr 45 fluvastatin sodium tb24 1 QL(1 ea daily)
1
mg
FENOFIBRATE CAPS 50 LESCOL XL TB24 (Use GP QL(1 ea daily)
3 Fluvastatin Sodium)
MG, 150 MG
fenofibrate micronized caps QL(1 ea daily) LIPITOR TABS (Use GP QL(1 ea daily)
1 Atorvastatin Calcium)
130 mg, 200 mg
fenofibrate micronized caps ST; QL(1 ea
1 LIVALO TABS 3
43 mg, 67 mg, 134 mg daily)
fenofibrate tabs 145 mg, 1 QL(1 ea daily)
160 mg
FENOFIBRATE TABS 160 2 QL(1 ea daily)
MG
page ii-iii.
27
$0 copay for JUXTAPID CAPS 5 MG, 10 3 PA; SP
Generic only, MG, 20 MG
age 40 to
lovastatin tabs 10 mg, 20 Nicotinic Acid Derivatives
1 75;QL(1 ea niacin (antihyperlipidemic)
mg daily); AL(At 1
least 40 yrs old tbcr
- Up to 75 yrs NIACOR TABS 3
old); PV
$0 copay for NIASPAN TBCR (Use GP
Generic only, Niacin (Antihyperlipidemic))
age 40 to ANTIHYPERTENSIVES - Drugs to Treat High
lovastatin tabs 40 mg 1 75;SL(2 ea Blood Pressure
daily); AL(At
least 40 yrs old ACE Inhibitors
- Up to 75 yrs ACCUPRIL TABS (Use
old); PV GP
Quinapril HCl)
$0 copay for ACEON TABS (Use
Generic only, GP
Perindopril Erbumine)
age 40 to ALTACE CAPS (Use
MEVACOR TABS (Use GP QL(2 ea daily)
GP 75;SL(2 ea Ramipril)
Lovastatin) daily); AL(At
least 40 yrs old benazepril hcl tabs 1
- Up to 75 yrs
old); PV captopril tabs 1
PRAVACHOL TABS 20 QL(1 ea daily)
MG, 80 MG (Use GP enalapril maleate tabs 1 QL(2 ea daily)
Pravastatin Sodium)
PRAVACHOL TABS 40 QL(2 ea daily) fosinopril sodium tabs 1
MG (Use Pravastatin GP QL(2 ea daily)
Sodium) lisinopril tabs 40 mg 1
pravastatin sodium tabs 10 1 QL(1 ea daily) lisinopril tabs 5 mg, 10 mg,
mg, 20 mg, 80 mg 1
20 mg, 30 mg, 2.5 mg
pravastatin sodium tabs 40 1 QL(2 ea daily) LOTENSIN TABS (Use
mg GP
Benazepril HCl)
rosuvastatin calcium tabs 1 QL(1 ea daily) MAVIK TABS (Use GP
Trandolapril)
simvastatin tabs 1 QL(1 ea daily)
moexipril hcl tabs 1
ZOCOR TABS (Use GP QL(1 ea daily)
Simvastatin) perindopril erbumine tabs 1
Intestinal Cholesterol Absorption Inhibitors PRINIVIL TABS (Use GP
Lisinopril)
ezetimibe tabs 1
QBRELIS SOLN 3 QL(5 ml daily)
ZETIA TABS (Use GP
Ezetimibe) quinapril hcl tabs 1
Microsomal Triglyceride Transfer Protein (MTP)
ramipril caps 1 QL(2 ea daily)
JUXTAPID CAPS 30 MG, 3 PA
40 MG, 60 MG
page ii-iii.
28
trandolapril tabs 1 EPROSARTAN 2
MESYLATE TABS
VASOTEC TABS (Use GP QL(2 ea daily)
Enalapril Maleate) irbesartan tabs 1
ZESTRIL TABS 40 MG GP QL(2 ea daily) losartan potassium tabs 1
(Use Lisinopril)
ZESTRIL TABS 5 MG, 10 MICARDIS TABS 20 MG, GP
MG, 20 MG, 30 MG, 2.5 GP 40 MG (Use Telmisartan)
MG (Use Lisinopril) MICARDIS TABS 80 MG GP QL(1 ea daily)
Agents for Pheochromocytoma (Use Telmisartan)
olmesartan medoxomil tabs 1 QL(1 ea daily)
DEMSER CAPS 3 40 mg
DIBENZYLINE CAPS (Use olmesartan medoxomil tabs
GP Not available 5 mg, 20 mg 1
Phenoxybenzamine HCl) through mail
phenoxybenzamine hcl telmisartan tabs 20 mg, 40
1 Not available mg 1
caps through mail
Angiotensin II Receptor Antagonists telmisartan tabs 80 mg 1 QL(1 ea daily)
ATACAND TABS 32 MG GP QL(1 ea daily) QL(2 ea daily)
(Use Candesartan Cilexetil) valsartan tabs 160 mg 1
ATACAND TABS 4 MG, 8 valsartan tabs 40 mg, 80
MG, 16 MG (Use GP 1
mg, 320 mg
Candesartan Cilexetil)
Antiadrenergic Antihypertensives
AVAPRO TABS (Use GP
Irbesartan) CARDURA TABS (Use GP
Doxazosin Mesylate)
BENICAR TABS 40 MG QL(1 ea daily)
(Use Olmesartan GP CATAPRES TABS (Use GP
Medoxomil) Clonidine HCl)
BENICAR TABS 5 MG, 20 clonidine hcl tabs 1
MG (Use Olmesartan GP
Medoxomil) doxazosin mesylate tabs 1
candesartan cilexetil tabs 1 QL(1 ea daily)
32 mg guanfacine hcl tabs 1
candesartan cilexetil tabs 4 1
mg, 8 mg, 16 mg methyldopa tabs 1
COZAAR TABS (Use GP MINIPRESS CAPS (Use
Losartan Potassium) GP
Prazosin HCl)
DIOVAN TABS 160 MG GP QL(2 ea daily)
(Use Valsartan) prazosin hcl caps 1
DIOVAN TABS 40 MG, 80 TENEX TABS (Use GP
MG, 320 MG (Use GP Guanfacine HCl)
Valsartan) terazosin hcl caps 1 mg, 2 1
EDARBI TABS 40 MG 3 mg, 5 mg
terazosin hcl caps 10 mg 1 QL(2 ea daily)
EDARBI TABS 80 MG 3 QL(1 ea daily)
Antihypertensive Combinations
page ii-iii.
29
ACCURETIC TABS 10MG- captopril & 1
12.5MG, 20MG-12.5MG GP hydrochlorothiazide tabs
(Use Quinapril-
Hydrochlorothiazide) CLORPRES TABS 3
ACCURETIC TABS 20MG- QL(1 ea daily) CORZIDE TABS 40MG-
25MG (Use Quinapril- GP 5MG (Use Nadolol & GP
Hydrochlorothiazide) Bendroflumethiazide)
amlodipine besylate- CORZIDE TABS 80MG-
benazepril hcl caps 2.5mg- 1 3
5MG
10mg DIOVAN HCT TABS QL(1 ea daily)
amlodipine besylate- QL(1 ea daily) 160MG-25MG (Use
benazepril hcl caps 5mg- GP
Valsartan-
10mg, 5mg-20mg, 5mg- 1 Hydrochlorothiazide)
40mg, 10mg-20mg, 10mg- DIOVAN HCT TABS
40mg 320MG-25MG, 80MG-
amlodipine besylate- QL(1 ea daily) 12.5MG, 160MG-12.5MG,
valsartan tabs 160mg- 1 GP
320MG-12.5MG (Use
10mg Valsartan-
amlodipine besylate- Hydrochlorothiazide)
valsartan tabs 160mg-5mg, 1 DUTOPROL TB24 3
320mg-5mg, 320mg-10mg
amlodipine-valsartan- EDARBYCLOR TABS 3 QL(1 ea daily)
1
hydrochlorothiazide tabs
ATACAND HCT TABS enalapril maleate & 1
(Use Candesartan Cilexetil- GP hydrochlorothiazide tabs
Hydrochlorothiazide) EXFORGE HCT TABS
atenolol & chlorthalidone (Use Amlodipine-Valsartan- GP
1 Hydrochlorothiazide)
tabs
AVALIDE TABS (Use EXFORGE TABS 160MG- QL(1 ea daily)
Irbesartan- GP 10MG (Use Amlodipine GP
Hydrochlorothiazide) Besylate-Valsartan)
benazepril & EXFORGE TABS 160MG-
1 5MG, 320MG-5MG,
320MG-10MG (Use GP
BENICAR HCT TABS Amlodipine Besylate-
20MG-12.5MG (Use GP Valsartan)
Olmesartan Medoxomil-
Hydrochlorothiazide) fosinopril sodium & 1
BENICAR HCT TABS QL(1 ea daily)
40MG-25MG, 40MG- HYZAAR TABS (Use
12.5MG (Use Olmesartan GP Losartan Potassium & GP
Medoxomil- Hydrochlorothiazide)
Hydrochlorothiazide) irbesartan- 1
bisoprolol & hydrochlorothiazide tabs
1 lisinopril &
QL(1 ea daily) hydrochlorothiazide tabs 1
BYVALSON TABS 3 10mg-12.5mg, 20mg-
candesartan cilexetil- 12.5mg
1
page ii-iii.
30
lisinopril & QL(2 ea daily) quinapril-
hydrochlorothiazide tabs 1 hydrochlorothiazide tabs 1
20mg-25mg 10mg-12.5mg, 20mg-
LOPRESSOR HCT TABS 12.5mg
(Use Metoprolol & GP quinapril- QL(1 ea daily)
Hydrochlorothiazide) hydrochlorothiazide tabs 1
losartan potassium & 20mg-25mg
1
hydrochlorothiazide tabs TARKA TBCR (Use
LOTENSIN HCT TABS Trandolapril-Verapamil GP
(Use Benazepril & GP HCl)
Hydrochlorothiazide) TEKTURNA HCT TABS 3 ST
LOTREL CAPS (Use QL(1 ea daily)
Amlodipine Besylate- GP telmisartan-amlodipine tabs 1
Benazepril HCl)
methyldopa & telmisartan- 1
1 hydrochlorothiazide tabs
metoprolol & TENORETIC 100 TABS
1 (Use Atenolol & GP
Chlorthalidone)
METOPROLOL
SUCCINATE TENORETIC 50 TABS
3 (Use Atenolol & GP
ER/HYDROCHLOROTHIA
ZIDE TB24 Chlorthalidone)
METOPROLOL/HYDROCH trandolapril-verapamil hcl 3
2 tbcr
LOROTHIAZIDE TABS
MICARDIS HCT TABS TRANDOLAPRIL/VERAPA 3
(Use Telmisartan- GP MIL HCL ER TBCR
Hydrochlorothiazide) TRIBENZOR TABS (Use ST
moexipril- Olmesartan Medoxomil- GP
1 Amlodipine-
Hydrochlorothiazide)
MOEXIPRIL/HYDROCHLO 2
ROTHIAZIDE TABS TWYNSTA TABS (Use GP
Telmisartan-Amlodipine)
nadolol & 3
bendroflumethiazide tabs valsartan- QL(1 ea daily)
hydrochlorothiazide tabs 1
olmesartan medoxomil- ST 160mg-25mg
amlodipine- 1
hydrochlorothiazide tabs valsartan-
olmesartan medoxomil- 320mg-25mg, 80mg- 1
hydrochlorothiazide tabs 1 12.5mg, 160mg-12.5mg,
20mg-12.5mg 320mg-12.5mg
olmesartan medoxomil- QL(1 ea daily) VASERETIC TABS (Use
hydrochlorothiazide tabs 1 Enalapril Maleate & GP
40mg-25mg, 40mg-12.5mg Hydrochlorothiazide)
PRESTALIA TABS 3 ST ZESTORETIC TABS
10MG-12.5MG, 20MG- GP
propranolol & 1 12.5MG (Use Lisinopril &
hydrochlorothiazide tabs Hydrochlorothiazide)
page ii-iii.
31
ZESTORETIC TABS QL(2 ea daily) QUALAQUIN CAPS (Use GP PA; QL(2 ea
20MG-25MG (Use GP Quinine Sulfate) daily)
Lisinopril &
Hydrochlorothiazide) quinine sulfate caps 3 PA; QL(2 ea
daily)
ZIAC TABS (Use Bisoprolol GP
& Hydrochlorothiazide) ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antihypertensives - Misc. Antimyasthenic/Cholinergic Agents
VECAMYL TABS 3 GUANIDINE HCL TABS 2
Direct Renin Inhibitors MESTINON SYRP 60 3 PA
ST MG/5ML
TEKTURNA TABS 3 MESTINON TABS 60 MG
Vasodilators (Use Pyridostigmine GP
Bromide)
hydralazine hcl tabs 1 MESTINON TIMESPAN
TBCR (Use Pyridostigmine GP
minoxidil tabs 1 Bromide)
pyridostigmine bromide 1
ANTIMALARIALS - Drugs to Treat Malaria tabs
(Parasitic Infections)
Antimalarial Combinations pyridostigmine bromide tbcr 1
atovaquone-proguanil hcl 3 ANTIMYCOBACTERIAL AGENTS - Drugs to
tabs Treat Tuberculosis (Bacterial Infections)
QL(0.8 ea Anti TB Combinations
COARTEM TABS 2
daily)
MALARONE TABS (Use RIFAMATE CAPS 2
GP
Atovaquone-Proguanil HCl)
RIFATER TABS 3
Antimalarials
CHLOROQUINE Antimycobacterial Agents
PHOSPHATE TABS 250 2
MG CYCLOSERINE CAPS 3
chloroquine phosphate 1
tabs 500 mg ethambutol hcl tabs 1
DARAPRIM TABS 3 PA isoniazid syrp 1

hydroxychloroquine sulfate 1 isoniazid tabs 1
tabs
QL(6 ea per fill MYAMBUTOL TABS (Use GP
MEFLOQUINE HCL TABS 2 Ethambutol HCl)
retail)
QL(6 ea per fill MYCOBUTIN CAPS (Use GP
mefloquine hcl tabs 1
retail) Rifabutin)
PLAQUENIL TABS (Use PASER PACK 3
Hydroxychloroquine GP
Sulfate) PRIFTIN TABS 3
PRIMAQUINE 2
PHOSPHATE TABS pyrazinamide tabs 1
page ii-iii.
32
rifabutin caps 1 methotrexate sodium tabs 1 AC
RIFADIN CAPS (Use GP PURIXAN SUSP 3 AL(Up to 13 yrs
Rifampin) old ); AC
rifampin caps 1 TABLOID TABS 2 AC
TRECATOR TABS 2 TREXALL TABS 3 AC
ANTINEOPLASTICS AND ADJUNCTIVE XATMEP SOLN 2 PA; AC

THERAPIES - Drugs to Treat Cancer
XELODA TABS (Use GP AC
Alkylating Agents Capecitabine)
ALKERAN TABS (Use GP AC
Melphalan) Antineoplastic - BCL-2 Inhibitors
cyclophosphamide caps 25 VENCLEXTA STARTING 2 PA; AC
1 PACK TBPK
mg
CYCLOPHOSPHAMIDE VENCLEXTA TABS 10 MG 2 PA; QL(2 ea
CAPS 25 MG (Use GP daily); AC
Cyclophosphamide) VENCLEXTA TABS 100 2 PA; QL(4 ea
cyclophosphamide caps 50 AC MG daily); AC
1
mg VENCLEXTA TABS 50 MG 2 PA; AC
CYCLOPHOSPHAMIDE AC
CAPS 50 MG (Use GP Antineoplastic - Hedgehog Pathway Inhibitors
Cyclophosphamide)
ERIVEDGE CAPS 2 AC
New
commercial ODOMZO CAPS 2 AC
members to be
GLEOSTINE CAPS 2
referred to Antineoplastic - Hormonal and Related Agents
AcariaHealth;S
P; AC PA; New
commercial
AC
HEXALEN CAPS 2 abiraterone acetate tabs 1 members to be
referred to
LEUKERAN TABS 2 AC AcariaHealth;S
P; AC
AC
melphalan tabs 1 anastrozole tabs 1 QL(1 ea daily);
AC
MYLERAN TABS 2 AC
ARIMIDEX TABS (Use GP QL(1 ea daily);
Anastrozole) AC
TEMODAR CAPS (Use GP AC
Temozolomide) AROMASIN TABS (Use GP AC
Exemestane)
temozolomide caps 1 AC
bicalutamide tabs 1 QL(1 ea daily);
AC
Antimetabolites
CASODEX TABS (Use GP QL(1 ea daily);
capecitabine tabs 1 AC Bicalutamide) AC
mercaptopurine tabs 1 AC EMCYT CAPS 2 AC
ERLEADA TABS 3 PA; AC
page ii-iii.
33
exemestane tabs 1 AC Antineoplastic Combinations
PA; Must use
FARESTON TABS 2 AC AcariaHlth SP
KISQALI FEMARA 200 3 pharmacy 1-
FEMARA TABS (Use DOSE TBPK
GP AC 844-538-4661
Letrozole) ;LA; AC
flutamide caps 1 AC PA; Must use
AcariaHlth SP
AC KISQALI FEMARA 400
letrozole tabs 1 3 pharmacy 1-
DOSE TBPK 844-538-4661
LYSODREN TABS 2 AC ;LA; AC
PA; Must use
MEGACE ORAL SUSP GP AC AcariaHlth SP
(Use Megestrol Acetate) KISQALI FEMARA 600 3 pharmacy 1-
AC DOSE TBPK
megestrol acetate susp 1 844-538-4661
;LA; AC
megestrol acetate tabs 1 AC PA; AC
LONSURF TABS 2
NILANDRON TABS (Use GP AC
Nilutamide) Antineoplastic Enzyme Inhibitors
AC AFINITOR DISPERZ TBSO 3 PA; AC
nilutamide tabs 1
PV; AC AFINITOR TABS 3 PA; AC
SOLTAMOX SOLN 3
PV; AC ALECENSA CAPS 2 PA; AC
tamoxifen citrate tabs 1
PA; New ALUNBRIG TABS 2 PA; AC
commercial
members to be ALUNBRIG TBPK 2 PA; AC
XTANDI CAPS 3
referred to
AcariaHealth;S BOSULIF TABS 100 MG, 3 PA; SP; AC
P; AC 500 MG
BOSULIF TABS 400 MG 3 PA; AC
YONSA TABS 3
PA; New BRAFTOVI CAPS 2 PA
commercial
ZYTIGA TABS 250 MG PA; AC
GP members to be CABOMETYX TABS 2
(Use Abiraterone Acetate) referred to
AcariaHealth;S CALQUENCE CAPS 3 PA; AC
P; AC
PA; New CAPRELSA TABS 2 AC
commercial
SP; AC
ZYTIGA TABS 500 MG 2 members to be COMETRIQ KIT 3
referred to
AcariaHealth;S COTELLIC TABS 2 PA; AC
P; AC
FARYDAK CAPS 2 PA; AC
Antineoplastic - Immunomodulators
POMALYST CAPS 3 SP; AC GILOTRIF TABS 2 PA; AC
page ii-iii.
34
GLEEVEC TABS (Use GP AC LYNPARZA TABS 100 MG, 2 PA; Refer to
Imatinib Mesylate) 150 MG Accredo SP
PA; Must use Rx;AC
AcariaHlth Sp MEKINIST TABS 2 PA; SP; AC
IBRANCE CAPS 2
Rx 1-844-538-
4661;LA; AC MEKTOVI TABS 2 PA
ICLUSIG TABS 3 PA; SP; AC
NERLYNX TABS 3 PA; SP; AC
PA; Specialty
drug-Health PA; Must use
Net will refer to AcariaHlth Sp
IDHIFA TABS 3 NEXAVAR TABS 2
SP Rx 1-844-538-
Pharmacy;LA; 4661;SP; AC
AC PA; Limit 3
AC capsules per
imatinib mesylate tabs 1 NINLARO CAPS 2
month;QL(0.1
IMBRUVICA CAPS 140 PA; SP; AC ea daily); AC
2
MG RUBRACA TABS 2 PA; SP; AC
IMBRUVICA CAPS 70 MG 2 PA; AC
RYDAPT CAPS 2 PA; AC
IMBRUVICA TABS 140 PA; QL(1 ea
MG, 280 MG, 420 MG, 560 2 daily); AC PA; Must use
MG AcariaHlth Sp
SPRYCEL TABS 2
PA; AC Rx 1-844-538-
INLYTA TABS 3 4661;SP; AC
AC STIVARGA TABS 3 PA; SP; AC
IRESSA TABS 2
AC PA; Must use
JAKAFI TABS 2 AcariaHlth Sp
SUTENT CAPS 2
Rx 1-844-538-
PA; Must use
AcariaHlth SP 4661;LA; AC
KISQALI TABS 3 pharmacy 1- TAFINLAR CAPS 2 PA; AC
844-538-4661
;LA; AC TAGRISSO TABS 2 PA; AC
LENVIMA 10 MG DAILY 2 PA; AC
DOSE CPPK PA; New
LENVIMA 14 MG DAILY PA; AC commercial
2 members to be
DOSE CPPK TARCEVA TABS 2
referred to
LENVIMA 18 MG DAILY 3 PA; LA; AC AcariaHealth;A
DOSE CPPK C
LENVIMA 20 MG DAILY 2 PA; AC PA; New
DOSE CPPK commercial
LENVIMA 24 MG DAILY 3 PA; AC TASIGNA CAPS 150 MG, members to be
DOSE CPPK 2
200 MG referred to
LENVIMA 8 MG DAILY PA; LA; AC AcariaHealth;S
3 P; AC
DOSE CPPK
PA; AC TASIGNA CAPS 50 MG 2 PA; AC
LYNPARZA CAPS 50 MG 2
page ii-iii.
35
PA; Must use Topoisomerase I Inhibitors
TYKERB TABS 2 AcariaHlth Sp HYCAMTIN CAPS 2 PA; AC
Rx 1-844-538-
4661;SP; AC
ANTIPARKINSON AND RELATED THERAPY
VERZENIO TABS 3 PA; AC AGENTS - Drugs to Treat Parkinson's Disease
PA; Must use Antiparkinson Adjuvants
AcariaHlth Sp
VOTRIENT TABS 2 carbidopa tabs 3
Rx 1-844-538-
4661;LA; AC LODOSYN TABS (Use
PA; AC GP
XALKORI CAPS 2 Carbidopa)
PA; Specialty Antiparkinson Anticholinergics
drug-Health benztropine mesylate tabs 1
Net will refer to
ZEJULA CAPS 2
SP trihexyphenidyl hcl elix 1
Pharmacy;LA;
AC trihexyphenidyl hcl tabs 1
ZELBORAF TABS 2 PA; AC
Antiparkinson COMT Inhibitors
ZOLINZA CAPS 2 PA; AC COMTAN TABS (Use GP
Entacapone)
ZYDELIG TABS 2 PA; AC
entacapone tabs 3
ZYKADIA CAPS 3 PA; AC TASMAR TABS (Use GP
Tolcapone)
Antineoplastics Misc.
tolcapone tabs 3
bexarotene caps 1 AC
Antiparkinson Dopaminergics
HYDREA CAPS (Use GP AC
Hydroxyurea) amantadine hcl caps 100 1
mg
hydroxyurea caps 1 AC
amantadine hcl syrp 50 1
mg/5ml
MATULANE CAPS 2 AC
amantadine hcl tabs 100 3
TARGRETIN CAPS OR 75 mg
GP AC bromocriptine mesylate
MG (Use Bexarotene) 1
tretinoin (chemotherapy) AC caps
1 bromocriptine mesylate
caps 1
tabs
Chemotherapy Rescue/Antidote Agents
carbidopa-levodopa tabs
leucovorin calcium tabs or AC 10mg-100mg, 25mg- 1
5 mg, 10 mg, 15 mg, 25 mg 1 100mg, 25mg-250mg
MESNEX TABS 3 AC carbidopa-levodopa tbcr 1 QL(8 ea daily)
25mg-100mg
Mitotic Inhibitors carbidopa-levodopa tbcr
AC 1
etoposide caps 1 50mg-200mg
page ii-iii.
36
carbidopa-levodopa tbdp REQUIP XL TB24 12 MG QL(2 ea daily)
10mg-100mg, 25mg- 3 (Use Ropinirole GP
100mg, 25mg-250mg Hydrochloride)
carbidopa-levodopa- 1 REQUIP XL TB24 2 MG, 4
entacapone tabs MG, 6 MG, 8 MG (Use GP
MIRAPEX ER TB24 0.375 Ropinirole Hydrochloride)
MG, 0.75 MG, 1.5 MG, 4.5 ropinirole hydrochloride
MG, 2.25 MG, 3.75 MG GP tabs 0.25 mg, 0.5 mg, 1 1
(Use Pramipexole mg, 2 mg, 3 mg, 4 mg, 5
Dihydrochloride) mg
MIRAPEX ER TB24 3 MG QL(1 ea daily) ropinirole hydrochloride 1 QL(2 ea daily)
(Use Pramipexole GP tb24 12 mg
Dihydrochloride) ropinirole hydrochloride
MIRAPEX TABS 0.125 tb24 2 mg, 4 mg, 6 mg, 8 1
MG, 0.25 MG, 0.75 MG, GP mg
0.5 MG (Use Pramipexole PA; QL(10 ea
Dihydrochloride) RYTARY CPCR 3
daily)
MIRAPEX TABS 1 MG QL(4 ea daily) SINEMET CR TBCR QL(8 ea daily)
(Use Pramipexole GP 25MG-100MG (Use GP
Dihydrochloride) Carbidopa-Levodopa)
MIRAPEX TABS 1.5 MG QL(3 ea daily) SINEMET CR TBCR
(Use Pramipexole GP 50MG-200MG (Use GP
Dihydrochloride) Carbidopa-Levodopa)
NEUPRO PT24 3 SINEMET TABS (Use GP
Carbidopa-Levodopa)
PARLODEL CAPS (Use GP STALEVO 100 TABS (Use
Bromocriptine Mesylate) Carbidopa-Levodopa- GP
PARLODEL TABS (Use GP Entacapone)
Bromocriptine Mesylate) STALEVO 125 TABS (Use
pramipexole Carbidopa-Levodopa- GP
dihydrochloride tabs 0.125 1 Entacapone)
mg, 0.25 mg, 0.75 mg, 0.5 STALEVO 150 TABS (Use
mg Carbidopa-Levodopa- GP
pramipexole 1 QL(4 ea daily) Entacapone)
dihydrochloride tabs 1 mg STALEVO 50 TABS (Use
pramipexole QL(3 ea daily) Carbidopa-Levodopa- GP
dihydrochloride tabs 1.5 1 Entacapone)
mg STALEVO 75 TABS (Use
pramipexole Carbidopa-Levodopa- GP
dihydrochloride tb24 0.375 3 Entacapone)
mg, 0.75 mg, 1.5 mg, 4.5
mg, 2.25 mg, 3.75 mg Antiparkinson Monoamine Oxidase Inhibitors
pramipexole QL(1 ea daily) AZILECT TABS (Use GP
3 Rasagiline Mesylate)
dihydrochloride tb24 3 mg
REQUIP TABS (Use ELDEPRYL CAPS (Use GP QL(2 ea daily)
GP Selegiline HCl)
Ropinirole Hydrochloride)
rasagiline mesylate tabs 1
page ii-iii.
37
selegiline hcl caps 1 QL(2 ea daily) paliperidone tb24 3
selegiline hcl tabs 1 QL(2 ea daily) RISPERDAL M-TAB TBDP GP

(Use Risperidone)
XADAGO TABS 3 PA RISPERDAL SOLN 1 GP
MG/ML (Use Risperidone)
ZELAPAR TBDP 3 RISPERDAL TABS 0.25
MG, 0.5 MG, 1 MG, 2 MG, GP
ANTIPSYCHOTICS/ANTIMANIC AGENTS - 4 MG (Use Risperidone)
Drugs to Treat Mood Disorders RISPERDAL TABS 3 MG GP QL(2 ea daily)
Antimanic Agents (Use Risperidone)
lithium carbonate caps 150 1 RISPERIDONE ODT TBDP 3
mg, 600 mg
lithium carbonate caps 300 1 QL(6 ea daily) risperidone soln 1 mg/ml 1
mg
risperidone tabs 0.25 mg, 1
lithium carbonate tabs 300 1 0.5 mg, 1 mg, 2 mg, 4 mg
mg
risperidone tabs 3 mg 1 QL(2 ea daily)
lithium carbonate tbcr 300 1
mg, 450 mg
risperidone tbdp 0.25 mg 3
LITHIUM SOLN 2
risperidone tbdp 0.5 mg, 1 1
LITHOBID TBCR (Use GP mg, 2 mg, 3 mg, 4 mg
Lithium Carbonate)
Butyrophenones
Antipsychotics - Misc.
GEODON CAPS 20 MG, haloperidol lactate conc 1
40 MG (Use Ziprasidone GP
HCl) haloperidol tabs 1
GEODON CAPS 60 MG, QL(2 ea daily) Dibenzapines
80 MG (Use Ziprasidone GP
HCl) CLOZAPINE ODT TBDP 3
NUPLAZID CAPS 3 PA clozapine tabs 25 mg, 50 1
mg, 100 mg, 200 mg
NUPLAZID TABS 3 PA
clozapine tbdp 25 mg, 100 3
PA; QL(1 ea mg, 12.5 mg
VRAYLAR CAPS 3 CLOZARIL TABS (Use
daily) GP
PA; QL(1 ea Clozapine)
VRAYLAR CPPK 3 FAZACLO TBDP 150 MG,
daily) 3
ziprasidone hcl caps 20 200 MG
1 FAZACLO TBDP 25 MG,
mg, 40 mg
ziprasidone hcl caps 60 QL(2 ea daily) 100 MG, 12.5 MG (Use GP
1 Clozapine)
mg, 80 mg
Benzisoxazoles loxapine succinate caps 1
INVEGA TB24 (Use GP olanzapine tabs 15 mg, 20 QL(1 ea daily)
Paliperidone) 1
mg
page ii-iii.
38
olanzapine tabs 5 mg, 10 1 prochlorperazine supp 1 QL(2 ea daily)
mg, 2.5 mg, 7.5 mg
olanzapine tbdp 5 mg, 10 thioridazine hcl tabs 10 mg, 1
3 25 mg, 100 mg
mg, 15 mg, 20 mg
quetiapine fumarate tabs QL(4 ea daily) thioridazine hcl tabs 50 mg 1 QL(4 ea daily)
1
200 mg
quetiapine fumarate tabs 1 trifluoperazine hcl tabs 1
25 mg, 50 mg, 100 mg
quetiapine fumarate tabs QL(2 ea daily) Quinolinone Derivatives
1 ABILIFY TABS 15 MG (Use GP QL(2 ea daily)
300 mg, 400 mg
quetiapine fumarate tb24 PA Aripiprazole)
50 mg, 150 mg, 200 mg, 3 ABILIFY TABS 2 MG, 5
300 mg, 400 mg MG, 10 MG, 30 MG (Use GP
PA Aripiprazole)
SAPHRIS SUBL 3
ABILIFY TABS 20 MG (Use GP QL(1 ea daily)
SEROQUEL TABS 200 MG Aripiprazole)
GP QL(4 ea daily)
(Use Quetiapine Fumarate)
aripiprazole soln 1 mg/ml 1
SEROQUEL TABS 25 MG,
50 MG, 100 MG (Use GP aripiprazole tabs 15 mg 1 QL(2 ea daily)
Quetiapine Fumarate)
SEROQUEL TABS 300 QL(2 ea daily) aripiprazole tabs 2 mg, 5 1
MG, 400 MG (Use GP mg, 10 mg, 30 mg
Quetiapine Fumarate) aripiprazole tabs 20 mg 1 QL(1 ea daily)
SEROQUEL XR TB24 (Use GP PA
Quetiapine Fumarate) REXULTI TABS 3 PA
VERSACLOZ SUSP 3 QL(18 ml daily)
Thioxanthenes
ZYPREXA TABS 15 MG, GP QL(1 ea daily) thiothixene caps 1
20 MG (Use Olanzapine)
ZYPREXA TABS 5 MG, 10 ANTIVIRALS - Drugs to Treat Viral Infections
MG, 2.5 MG, 7.5 MG (Use GP
Olanzapine) Antiretrovirals
ZYPREXA ZYDIS TBDP GP
(Use Olanzapine) abacavir sulfate soln 1
Phenothiazines abacavir sulfate tabs 1
chlorpromazine hcl tabs 1 abacavir sulfate-lamivudine 1
FLUPHENAZINE HCL
tabs
3 abacavir sulfate-
CONC 5 MG/ML 1
fluphenazine hcl elix 2.5 lamivudine-zidovudine tabs
1
mg/5ml APTIVUS CAPS 2
fluphenazine hcl tabs 1 mg, 1
5 mg, 10 mg, 2.5 mg APTIVUS SOLN 2
perphenazine tabs 1 atazanavir sulfate caps 1
prochlorperazine maleate 1
tabs
page ii-iii.
39
ATRIPLA TABS 2 QL(1 ea daily) ISENTRESS HD TABS 2
BIKTARVY TABS 2 ISENTRESS PACK 2
CIMDUO TABS 2 ISENTRESS TABS 2

COMBIVIR TABS (Use GP JULUCA TABS 2
Lamivudine-Zidovudine)
KALETRA SOLN
COMPLERA TABS 2 400MG/5ML-100MG/5ML GP
(Use Lopinavir-Ritonavir)
CRIXIVAN CAPS 2
KALETRA TABS 100MG- 2
DELSTRIGO TABS 2 25MG, 200MG-50MG
lamivudine soln 1
DESCOVY TABS 2
lamivudine tabs 1
didanosine cpdr 1
lamivudine-zidovudine tabs 1
EDURANT TABS 2
LEXIVA SUSP 50 MG/ML 2
efavirenz caps 1
LEXIVA TABS 700 MG
efavirenz tabs 1 (Use Fosamprenavir GP
Calcium)
EMTRIVA CAPS 2 lopinavir-ritonavir soln 1
EMTRIVA SOLN 2 nevirapine susp 1
EPIVIR SOLN (Use GP
Lamivudine) nevirapine tabs 1
EPIVIR TABS (Use
Lamivudine) GP nevirapine tb24 1
EPZICOM TABS (Use NORVIR CAPS 100 MG 2
Abacavir Sulfate- GP
Lamivudine) NORVIR PACK 100 MG 2
EVOTAZ TABS 2
NORVIR SOLN 80 MG/ML 2
fosamprenavir calcium tabs 1 NORVIR TABS 100 MG GP
(Use Ritonavir)
GENVOYA TABS 2
ODEFSEY TABS 2
INTELENCE TABS 2
PIFELTRO TABS 2
INVIRASE CAPS 2
PREZCOBIX TABS 2 QL(1 ea daily)
INVIRASE TABS 2
PREZISTA SUSP 100 3
ISENTRESS CHEW 2 MG/ML
page ii-iii.
40
PREZISTA TABS 75 MG, 2 VIDEXPEDIATRIC SOLR 2
150 MG, 600 MG, 800 MG
RESCRIPTOR TABS 2 VIRACEPT TABS 2
RETROVIR CAPS (Use VIRAMUNE SUSP (Use GP
GP Nevirapine)
Zidovudine)
RETROVIR SYRP (Use VIRAMUNE TABS (Use GP
GP Nevirapine)
Zidovudine)
REYATAZ CAPS 150 MG, VIRAMUNE XR TB24 (Use GP
200 MG, 300 MG (Use GP Nevirapine)
Atazanavir Sulfate) VIREAD POWD 40 MG/GM 2
REYATAZ PACK 50 MG 2 VIREAD TABS 150 MG, 2
200 MG, 250 MG
ritonavir tabs 1
VIREAD TABS 300 MG
SELZENTRY SOLN 2 (Use Tenofovir Disoproxil GP
Fumarate)
SELZENTRY TABS 2 VITEKTA TABS 2
stavudine caps 1 ZERIT CAPS 15 MG, 20
MG, 30 MG, 40 MG (Use GP
STRIBILD TABS 2 Stavudine)
SUSTIVA CAPS (Use ZERIT SOLR 1 MG/ML 2
GP
Efavirenz) ZIAGEN SOLN (Use
SUSTIVA TABS (Use GP
GP Abacavir Sulfate)
Efavirenz) ZIAGEN TABS (Use GP
SYMTUZA TABS 3 Abacavir Sulfate)
tenofovir disoproxil zidovudine caps 1
1
fumarate tabs
zidovudine syrp 1
TIVICAY TABS 2
zidovudine tabs 1
TRIUMEQ TABS 2
CMV Agents
TRIZIVIR TABS (Use
Abacavir Sulfate- GP VALCYTE SOLR 50 QL(21 ml daily)
Lamivudine-Zidovudine) MG/ML (Use Valganciclovir GP
HCl)
TRUVADA TABS 2 VALCYTE TABS 450 MG GP
(Use Valganciclovir HCl)
TYBOST TABS 2 valganciclovir hcl solr 50 QL(21 ml daily)
1
mg/ml
VIDEX EC CPDR 125 MG 2
valganciclovir hcl tabs 450 1
VIDEX EC CPDR 200 MG, mg
250 MG, 400 MG (Use GP Hepatitis Agents
Didanosine)
adefovir dipivoxil tabs 1
page ii-iii.
41
BARACLUDE SOLN 0.05 2 RIBASPHERE RIBAPAK 2 PA
MG/ML TBPK
BARACLUDE TABS 0.5 GP ribavirin (hepatitis c) caps 1 PA
MG, 1 MG (Use Entecavir)
COPEGUS TABS (Use PA
GP PA ribavirin (hepatitis c) tabs 1
Ribavirin (Hepatitis C))
DAKLINZA TABS 30 MG, PA SOFOSBUVIR/VELPATAS 3 PA; LA
3 VIR TABS
60 MG
PA; LA SOVALDI TABS 3 PA; SP
DAKLINZA TABS 90 MG 3
TECHNIVIE TABS 3 PA
entecavir tabs 1
PA; LA TYZEKA TABS 3 ST
EPCLUSA TABS 3
EPIVIR HBV SOLN 5 VEMLIDY TABS 3 ST; SP
3
MG/ML
VIEKIRA PAK TBPK 3 PA; SP
EPIVIR HBV TABS 100
MG (Use Lamivudine GP
(HBV)) VIEKIRA XR TB24 3 PA; SP
HARVONI TABS 3 PA; SP PA; Must use

AcariaHealth
HEPSERA TABS (Use GP VOSEVI TABS 3 Specialty Rx at
Adefovir Dipivoxil) 1-844-538-
lamivudine (hbv) tabs 3 4661 ;SP
ZEPATIER TABS 3 PA; SP
LEDIPASVIR/SOFOSBUVI 3 PA; SP
R TABS Herpes Agents
PA; Must use
AcariaHealth acyclovir caps 200 mg 1
MAVYRET TABS 3 Specialty Rx at
1-844-538- acyclovir susp 200 mg/5ml 1
4661;;LA
MODERIBA 1200 DOSE PA acyclovir tabs 400 mg 1
2
PACK TABS QL(5 ea daily)
MODERIBA 800 DOSE PA acyclovir tabs 800 mg 1
2
PACK TABS
famciclovir tabs 1
MODERIBA TBPK 2 PA
FAMVIR TABS (Use GP
PA; Must use Famciclovir)
AcariaHlth Sp PA
OLYSIO CAPS 3 SITAVIG TABS 3
Rx 1-844-538-
4661;SP valacyclovir hcl tabs 1 gm, QL(4 ea daily)
REBETOL CAPS 200 MG PA 1
1000 mg
(Use Ribavirin (Hepatitis GP valacyclovir hcl tabs 500 QL(8 ea daily)
C)) 1
mg
REBETOL SOLN 40 PA VALTREX TABS 1 GM
MG/ML
2 GP QL(4 ea daily)
(Use Valacyclovir HCl)
page ii-iii.
42
VALTREX TABS 500 MG GP QL(8 ea daily) carvedilol phosphate cp24 3
(Use Valacyclovir HCl)
ZOVIRAX CAPS OR 200 carvedilol tabs 25 mg, 12.5 1
GP mg, 6.25 mg
MG (Use Acyclovir)
ZOVIRAX SUSP OR 200 carvedilol tabs 3.125 mg 1 QL(2 ea daily)
GP
MG/5ML (Use Acyclovir)
ZOVIRAX TABS OR 400 COREG CR CP24 (Use GP
GP Carvedilol Phosphate)
MG (Use Acyclovir)
ZOVIRAX TABS OR 800 COREG TABS 25 MG,
GP QL(5 ea daily) 12.5 MG, 6.25 MG (Use GP
MG (Use Acyclovir)
Carvedilol)
Influenza Agents COREG TABS 3.125 MG
FLUMADINE TABS (Use GP QL(2 ea daily)
(Use Carvedilol)
Rimantadine GP
Hydrochloride) labetalol hcl tabs 1
QL(10 ea per Beta Blockers Cardio-Selective
oseltamivir phosphate caps 1 fill retail); AL(At
or 30 mg, 45 mg least 1 yrs old) acebutolol hcl caps 1
oseltamivir phosphate caps 1
or 75 mg atenolol tabs 1
QL(75 ml
oseltamivir phosphate susr daily,5 day(s) betaxolol hcl tabs 1
1
or 6 mg/ml limit); AL(At QL(1 ea daily)
least 1 yrs old) bisoprolol fumarate tabs 1
RELENZA DISKHALER 3 QL(20 ea per
AEPB fill retail) BYSTOLIC TABS 3
rimantadine hydrochloride 3 LOPRESSOR TABS (Use
tabs GP
Metoprolol Tartrate)
TAMIFLU CAPS 30 MG, 45 QL(10 ea per metoprolol succinate tb24 1
MG (Use Oseltamivir GP fill retail); AL(At
Phosphate) least 1 yrs old) metoprolol tartrate tabs 25 1
TAMIFLU CAPS 75 MG mg, 50 mg, 100 mg
(Use Oseltamivir GP METOPROLOL
Phosphate) TARTRATE TABS 75 MG, 2
QL(75 ml 37.5 MG
TAMIFLU SUSR 6 MG/ML
(Use Oseltamivir GP daily,5 day(s) SECTRAL CAPS (Use GP
limit); AL(At Acebutolol HCl)
Phosphate) least 1 yrs old) TENORMIN TABS (Use GP
Respiratory Syncytial Virus (RSV) Agents Atenolol)
TOPROL XL TB24 (Use
ribavirin solr 3 Metoprolol Succinate) GP
VIRAZOLE SOLR (Use ZEBETA TABS (Use
Ribavirin) GP GP QL(1 ea daily)
Bisoprolol Fumarate)
BETA BLOCKERS - Drugs to Treat High Blood Beta Blockers Non-Selective
Pressure BETAPACE AF TABS (Use GP
Alpha-Beta Blockers Sotalol HCl (AFIB/AFL))
page ii-iii.
43
BETAPACE TABS (Use GP CARDIZEM CD CP24 (Use QL(1 ea daily)
Sotalol HCl) Diltiazem HCl Coated GP
CORGARD TABS (Use Beads)
GP
Nadolol) CARDIZEM LA TB24 120 2
INDERAL LA CP24 (Use MG
GP
Propranolol HCl) CARDIZEM LA TB24 180
MG, 240 MG, 300 MG, 360
INDERAL XL CP24 3 MG, 420 MG (Use GP
Diltiazem HCl Coated
INNOPRAN XL CP24 3 Beads)
CARDIZEM TABS (Use GP
nadolol tabs 1 Diltiazem HCl)
pindolol tabs 1 diltiazem hcl coated beads QL(1 ea daily)
cp24 120 mg, 180 mg, 240 1
propranolol hcl cp24 1 mg, 300 mg, 360 mg
diltiazem hcl coated beads
propranolol hcl soln 1 tb24 180 mg, 240 mg, 300 1
mg, 360 mg, 420 mg
propranolol hcl tabs 1 diltiazem hcl cp12 1
sotalol hcl (afib/afl) tabs 1 diltiazem hcl cp24 1
sotalol hcl tabs 1 diltiazem hcl extended 1
release beads cp24
QL(6 ea
timolol maleate tabs 10 mg 1 daily,60 ea per diltiazem hcl tabs 1
fill retail)
felodipine tb24 10 mg 1 QL(1 ea daily)
timolol maleate tabs 5 mg, 1 QL(60 ea per
20 mg fill retail) felodipine tb24 5 mg, 2.5 1
CALCIUM CHANNEL BLOCKERS - Drugs to mg
Treat High Blood Pressure
isradipine caps 3
Calcium Channel Blockers
ADALAT CC TB24 30 MG, GP nicardipine hcl caps 3
60 MG (Use Nifedipine)
nifedipine caps 10 mg, 20 1
ADALAT CC TB24 90 MG GP QL(1 ea daily) mg
(Use Nifedipine)
nifedipine tb24 30 mg, 60 1
amlodipine besylate tabs 1 QL(2 ea daily) mg
2.5 mg
nifedipine tb24 30 mg, 60 1 QL(1 ea daily)
amlodipine besylate tabs 5 1 QL(1 ea daily) mg, 90 mg
mg, 10 mg
CALAN SR TBCR 120 MG GP nimodipine caps 1
(Use Verapamil HCl)
NISOLDIPINE ER TB24 2
CALAN SR TBCR 180 MG, QL(2 ea daily)
240 MG (Use Verapamil GP
HCl) nisoldipine tb24 1
CALAN TABS (Use NORVASC TABS 2.5 MG GP QL(2 ea daily)
GP (Use Amlodipine Besylate)
Verapamil HCl)
page ii-iii.
44
NORVASC TABS 5 MG, 10 QL(1 ea daily) CARDIOVASCULAR AGENTS - MISC. - Drugs to
MG (Use Amlodipine GP Treat Heart and Circulation Conditions
Besylate)
Cardiovascular Agents Misc. - Combinations
NYMALIZE SOLN 3 amlodipine besylate- 3 PA
PROCARDIA CAPS (Use atorvastatin calcium tabs
GP
Nifedipine) BIDIL TABS 3
PROCARDIA XL TB24 GP QL(1 ea daily)
(Use Nifedipine) CADUET TABS (Use PA
Amlodipine Besylate- GP
SULAR TB24 (Use GP Atorvastatin Calcium)
Nisoldipine)
ENTRESTO TABS 24MG- PA; QL(2 ea
TIAZAC CP24 (Use 26MG
3
daily)
Diltiazem HCl Extended GP
Release Beads) ENTRESTO TABS 49MG- 3 PA
51MG, 97MG-103MG
verapamil hcl cp24 100 mg,
120 mg, 200 mg, 240 mg, 1 Impotence Agents
300 mg PA; QL(0.27 ea
verapamil hcl cp24 180 mg 1 QL(2 ea daily) CIALIS TABS 10 MG, 20 SP daily); AL(At
MG (Use Tadalafil) least 21 yrs
VERAPAMIL HCL SR QL(1 ea daily) old)
2
CP24 CIALIS TABS 5 MG, 2.5 PA; QL(0.27 ea
SP
verapamil hcl tabs 40 mg, MG (Use Tadalafil) daily)
1
80 mg, 120 mg PA; Limit 6 per
month, Check
verapamil hcl tbcr 120 mg 1 your plan
verapamil hcl tbcr 180 mg, QL(2 ea daily) documents for
1 MUSE PLLT SP coverage,
240 mg
VERELAN CP24 120 MG, benefits and
240 MG (Use Verapamil GP copayment/coin
HCl) surance.;QL(0.
2 ea daily)
VERELAN CP24 180 MG GP QL(2 ea daily)
(Use Verapamil HCl) PA; Sildenafil is
preferred ED
VERELAN CP24 360 MG 2 QL(1 ea daily) drug;QL(8 ea
per fill retail,8
VERELAN PM CP24 (Use sildenafil citrate tabs SP
ea per 30 days
GP
Verapamil HCl) retail); AL(At
CARDIOTONICS - Drugs to Treat Heart Failure least 21 yrs
and Abnormal Heart Rhythm old)
ST; Limit 8 per
Cardiac Glycosides month;QL(0.27
STAXYN TBDP (Use
digoxin soln 1 SP ea daily); AL(At
Vardenafil HCl) least 21 yrs
digoxin tabs 1 old)
PA; QL(8 ea
LANOXIN TABS 125 MCG, GP per 30 days
250 MCG (Use Digoxin) STENDRA TABS SP retail); AL(At
LANOXIN TABS 62.5 2 least 21 yrs
MCG, 187.5 MCG old)
page ii-iii.
45
PA; QL(0.27 ea PA; New
tadalafil tabs 10 mg, 20 mg SP daily); AL(At
least 21 yrs ADCIRCA TABS (Use commercial
Tadalafil (Pulmonary GP members to be
old) referred to
Hypertension)) AcariaHealth;Q
tadalafil tabs 5 mg, 2.5 mg SP PA; QL(0.27 ea L(2 ea daily)
daily)
ST; Limit 8 per REVATIO SUSR 10 3 PA
month;QL(0.27 MG/ML
vardenafil hcl tbdp 10 mg SP ea daily); AL(At REVATIO TABS 20 MG PA; QL(3 ea
least 21 yrs (Use Sildenafil Citrate GP daily)
old) (Pulmonary Hypertension))
PA; Sildenafil is sildenafil citrate (pulmonary 3 PA; QL(3 ea
preferred ED hypertension) tabs daily)
drug;QL(8 ea PA; New
VIAGRA TABS (Use SP per fill retail,8 commercial
Sildenafil Citrate) ea per 30 days tadalafil (pulmonary members to be
retail); AL(At 1
hypertension) tabs referred to
least 21 yrs AcariaHealth;Q
old) L(2 ea daily)
Prostaglandin Vasodilators Pulmonary Hypertension - Prostacyclin Receptor
ORENITRAM TBCR 0.125 PA; SP
MG, 0.25 MG, 1 MG, 2.5 3 UPTRAVI TABS 3 PA
MG PA
UPTRAVI TBPK 3
ORENITRAM TBCR 5 MG 3 PA
Pulmonary Hypertension - Sol Guanylate Cyclase
TYVASO REFILL SOLN 3 PA; LA
ADEMPAS TABS 3 PA; SP
TYVASO SOLN 3 PA; LA
Sinus Node Inhibitors
TYVASO STARTER SOLN 3 PA; LA CORLANOR TABS 3 ST; QL(2 ea
daily)
VENTAVIS SOLN 3 PA; SP CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
Pulmonary Hypertension - Endothelin Receptor
Cephalosporins - 1st Generation
LETAIRIS TABS 2 SP
cefadroxil caps 1
OPSUMIT TABS 3 PA
cefadroxil susr 1
TRACLEER TABS 125 2
MG, 62.5 MG cefadroxil tabs 1
TRACLEER TBSO 32 MG 2 PA cephalexin caps 250 mg, 1
500 mg
Pulmonary Hypertension - Phosphodiesterase
cephalexin caps 750 mg 3
cephalexin susr 125 1
mg/5ml, 250 mg/5ml
page ii-iii.
46
CEPHALEXIN TABS 250 3 SUPRAX SUSR 100
MG, 500 MG MG/5ML, 200 MG/5ML GP
KEFLEX CAPS (Use (Use Cefixime)
GP
Cephalexin) SUPRAX SUSR 500 3
MG/5ML
Cephalosporins - 2nd Generation
cefaclor caps 250 mg, 500 1 CHEMICALS
mg
Bulk Chemicals - C's
CEFACLOR ER TB12 3
CALCITRIOL POWD XX 3
CEFACLOR SUSR 125
MG/5ML, 250 MG/5ML, 2 Bulk Chemicals - E's
375 MG/5ML ESTRADIOL 3
cefprozil susr 1 CONCENTRATE CREA
Bulk Chemicals - L's
cefprozil tabs 1 LEVETIRACETAM POWD 3
XX
CEFTIN SUSR 2
Bulk Chemicals - P's
cefuroxime axetil tabs 1 PROGESTERONE 3
CONCENTRATE CREA
Cephalosporins - 3rd Generation
CONTRACEPTIVES - Drugs to Prevent
CEDAX CAPS 3 Pregnancy
Combination Contraceptives - Oral
CEDAX SUSR 3
BEYAZ TABS (Use QL(1 ea daily)
Drospirenone-Ethinyl GP
cefdinir caps 1 Estradiol-Levomefolate
Calcium)
cefdinir susr 1
BREVICON-28 TABS (Use
CEFDITOREN PIVOXIL Norethindrone & Eth GP
3 Estradiol)
TABS 200 MG, 400 MG
cefixime susr 1 CYCLESSA TABS (Use
Desogestrel-Ethinyl GP
cefpodoxime proxetil susr 1
Estradiol (Triphasic))
DESOGEN TABS (Use PV
cefpodoxime proxetil tabs 1 Desogestrel & Ethinyl GP
Estradiol)
CEFTIBUTEN CAPS 3 desogestrel & ethinyl 1 PV
estradiol tabs
CEFTIBUTEN SUSR 3 desogestrel-ethinyl 1
estradiol (biphasic) tabs
SPECTRACEF TABS 3 desogestrel-ethinyl 1
estradiol (triphasic) tabs
SUPRAX CAPS 400 MG 3 drospirenone-ethinyl 1 QL(1 ea daily);
SUPRAX CHEW 100 MG, estradiol tabs 3mg-0.02mg PV
3
200 MG drospirenone-ethinyl 1 QL(1 ea daily)
estradiol tabs 3mg-0.03mg
page ii-iii.
47
drospirenone-ethinyl QL(1 ea daily) LOSEASONIQUE TABS QL(1 ea
estradiol-levomefolate 1 (Use Levonorgestrel- GP daily,91 day(s)
calcium tabs Ethinyl Estradiol (91-Day)) limit)
ESTROSTEP FE TABS PV MINASTRIN 24 FE CHEW QL(365 ea per
(Use Norethindrone GP (Use Norethin Acet & GP fill retail); PV
Acetate-Ethinyl Estradiol- Estrad-Fe)
Fe) MIRCETTE TABS (Use
ethynodiol diacet & eth 1 Desogestrel-Ethinyl GP
estrad tabs 1mg-35mcg Estradiol (Biphasic))
QL(365 ea per NATAZIA TABS 2 QL(1 ea daily)
ethynodiol diacet & eth 1 fill retail,365 ea
estrad tabs 1mg-50mcg per fill mail); PV NECON 10/11-28 TABS 2
FEMCON FE CHEW (Use
Norethindrone & Ethinyl GP norethin acet & estrad-fe 1 QL(365 ea per
Estradiol-Fe) chew 75mg-20mcg-1mg fill retail); PV
GENERESS FE CHEW QL(1 ea daily); norethin acet & estrad-fe 1 QL(1 ea daily);
(Use Norethindrone & GP PV tabs 75mg-20mcg-1mg PV
Ethinyl Estradiol-Fe) norethin acet & estrad-fe
levonorgestrel & eth tabs 75mg-20mcg-1mg, 1
1 75mg-30mcg-1.5mg
estradiol tabs
levonorgestrel-eth estradiol norethindrone & eth 1
1 estradiol tabs
(triphasic) tabs
QL(1 ea norethindrone & ethinyl
levonorgestrel-ethinyl 1 daily,91 day(s) estradiol-fe chew 0.4mg- 3
estradiol (91-day) tabs limit) 35mcg
QL(91 ea per norethindrone & ethinyl QL(1 ea daily);
levonorgestrel-ethinyl 3 fill retail,91 ea estradiol-fe chew 75mg- 1 PV
estradiol (91-day) tabs per fill mail) 0.8mg-25mcg
QL(1 ea norethindrone & mestranol 1
levonorgestrel-ethinyl 3 daily,91 day(s) tabs
estradiol (91-day) tabs limit); PV norethindrone acet & eth 1
levonorgestrel-ethinyl PV estra tabs
3
estradiol (continuous) tabs norethindrone acetate- PV
3
LO LOESTRIN FE TABS 3 QL(1 ea daily) ethinyl estradiol-fe tabs
norethindrone-eth estradiol 1
LOESTRIN 1.5/30-21 (triphasic) tabs
TABS (Use Norethindrone GP norethindrone-eth estradiol QL(1 ea daily);
Acet & Eth Estra) 1
(triphasic) tabs PV
LOESTRIN 1/20-21 TABS norgestimate-ethinyl QL(1 ea daily)
(Use Norethindrone Acet & GP 1
estradiol (triphasic) tabs
Eth Estra)
norgestimate-ethinyl 1 PV
LOESTRIN FE 1.5/30 estradiol (triphasic) tabs
TABS (Use Norethin Acet & GP
Estrad-Fe) norgestimate-ethinyl 1 QL(1 ea daily)
estradiol tabs
LOESTRIN FE 1/20 TABS
(Use Norethin Acet & GP norgestrel & ethinyl 1
Estrad-Fe) estradiol tabs
page ii-iii.
48
NORINYL 1+35 TABS (Use Limit 4 patches
Norethindrone & Eth GP
XULANE PTWK 2 per
Estradiol) month;QL(0.14
ORTHO TRI-CYCLEN LO PV 3 ea daily); PV
TABS (Use Norgestimate- GP Combination Contraceptives - Vaginal
Ethinyl Estradiol
(Triphasic)) NUVARING RING 2 PV
ORTHO TRI-CYCLEN QL(1 ea daily)
TABS (Use Norgestimate- Emergency Contraceptives
GP PV
Ethinyl Estradiol ELLA TABS 3
(Triphasic))
ORTHO-CYCLEN TABS QL(1 ea daily) levonorgestrel (emergency 1 PV
(Use Norgestimate-Ethinyl GP oc) tabs
Estradiol) PLAN B ONE-STEP TABS PV
ORTHO-NOVUM 1/35 (Use Levonorgestrel GP
TABS (Use Norethindrone GP (Emergency OC))
& Eth Estradiol) Progestin Contraceptives - Oral
ORTHO-NOVUM 7/7/7 QL(1 ea daily); NOR-QD TABS (Use QL(1 ea daily)
TABS (Use Norethindrone- GP PV Norethindrone GP
Eth Estradiol (Triphasic)) (Contraceptive))
OVCON-35 TABS (Use norethindrone
Norethindrone & Eth GP 1 QL(1 ea daily)
(contraceptive) tabs
Estradiol) ORTHO MICRONOR QL(1 ea daily)
QUARTETTE TABS (Use QL(1 ea TABS (Use Norethindrone GP
Levonorgestrel-Ethinyl GP daily,91 day(s) (Contraceptive))
Estradiol (91-Day)) limit); PV
CORTICOSTEROIDS - Steroid Hormone Drugs to
SAFYRAL TABS (Use QL(1 ea daily) Treat Systemic Swelling Conditions
Drospirenone-Ethinyl GP
Estradiol-Levomefolate Glucocorticosteroids
Calcium)
budesonide cpep 3 mg 1 QL(3 ea daily)
SEASONIQUE TABS (Use QL(1 ea
Levonorgestrel-Ethinyl GP daily,91 day(s) budesonide tb24 9 mg 3 PA
Estradiol (91-Day)) limit)
CORTEF TABS (Use
TAYTULLA CAPS 3 PA; PV Hydrocortisone) GP
TRI-NORINYL 28 TABS cortisone acetate tabs 1
(Use Norethindrone-Eth GP
Estradiol (Triphasic)) dexamethasone elix 0.5 1
YASMIN 28 TABS (Use QL(1 ea daily) mg/5ml
Drospirenone-Ethinyl GP DEXAMETHASONE
Estradiol) 2
INTENSOL CONC
YAZ TABS (Use QL(1 ea daily); dexamethasone soln 0.5
Drospirenone-Ethinyl GP PV 1
mg/5ml
Estradiol) dexamethasone tabs 0.75
Combination Contraceptives - Transdermal mg, 0.5 mg, 1 mg, 2 mg, 4 1
mg, 6 mg, 1.5 mg
EMFLAZA SUSP 3 PA; SP
page ii-iii.
49
EMFLAZA TABS 3 PA; SP prednisone soln 5 mg/5ml 1
ENTOCORT EC CPEP GP QL(3 ea daily) prednisone tabs 1 mg, 5
(Use Budesonide) mg, 10 mg, 20 mg, 50 mg, 1
2.5 mg
hydrocortisone tabs 1
PREDNISONE TBPK 10 2
MEDROL DOSEPAK TBPK GP MG
(Use Methylprednisolone)
PREDNISONE TBPK 5 MG 3
MEDROL TABS 2 MG 2
UCERIS TB24 OR 9 MG GP PA
MEDROL TABS 4 MG, 8 (Use Budesonide)
MG, 16 MG, 32 MG (Use GP VERIPRED 20 SOLN (Use
Methylprednisolone) Prednisolone Sodium GP
methylprednisolone tabs 1 Phosphate)
Mineralocorticoids
methylprednisolone tbpk 1
fludrocortisone acetate tabs 1
MILLIPRED SOLN 10
MG/5ML (Use COUGH/COLD/ALLERGY - Drugs to Treat
GP Cough, Cold and Allergy Symptoms
Prednisolone Sodium
Phosphate) Antitussives
MILLIPRED TABS 5 MG 2 benzonatate caps 100 mg, 1
200 mg
ORAPRED ODT TBDP
(Use Prednisolone Sodium GP benzonatate caps 150 mg 3
Phosphate)
hydrocodone w/ 1
prednisolone sodium homatropine syrp
phosphate soln or 10 3
mg/5ml, 20 mg/5ml hydrocodone w/ 1
homatropine tabs
PREDNISOLONE SODIUM
PHOSPHATE SOLN OR 3 TESSALON PERLES GP
25 MG/5ML CAPS (Use Benzonatate)
prednisolone sodium Cough/Cold/Allergy Combinations
phosphate soln or 5 1
mg/5ml, 15 mg/5ml, 6.7 CAPCOF SYRP 3
mg/5ml
CODITUSSIN AC LIQD 3
prednisolone sodium
phosphate tbdp or 10 mg, 3 FLOWTUSS SOLN 3
15 mg, 30 mg
guaifenesin-codeine liqd 1
prednisolone soln 1 100mg/5ml-10mg/5ml
PREDNISOLONE SOLN 2 guaifenesin-codeine liqd 3
225mg/5ml-7.5mg/5ml
prednisolone syrp 1 guaifenesin-codeine soln 1
100mg/5ml-10mg/5ml
PREDNISONE INTENSOL 2 guaifenesin-codeine soln
CONC 3
100mg/5ml-6.3mg/5ml
page ii-iii.
50
guaifenesin-codeine syrp 1 pseudoephedrine-
100mg/5ml-10mg/5ml guaifenesin tb12 60mg- 1
HYDROCODONE 600mg
BITARTRATE/GUAIFENES 3 RESPAIRE-30 CAPS 3
IN SOLN
Limit 10mls per TUSSIONEX Limit 10mls per
hydrocodone polistirex- day;QL(10 ml PENNKINETIC day;QL(10 ml
chlorpheniramine polistirex 1 EXTENDED RELEASE
suer daily); AL(At GP daily); AL(At
least 6 yrs old) SUER (Use Hydrocodone least 6 yrs old)
Polistirex-Chlorpheniramine
M-CLEAR WC SOLN 3 Polistirex)
MAR-COF CG Misc. Respiratory Inhalants
EXPECTORANT LIQD GP HYPER-SAL NEBU (Use
(Use Guaifenesin-Codeine) Sodium Chloride (Inhalant)) GP
MUCINEX D TB12 (Use
Pseudoephedrine- GP HYPERSAL NEBU 3.5 % 3
Guaifenesin) HYPERSAL NEBU 7 %
NINJACOF-XG LIQD 3 (Use Sodium Chloride GP
(Inhalant))
OBREDON SOLN 3 NEBUSAL NEBU 3
phenylephrine- sodium chloride (inhalant)
brompheniramine-dm liqd 3
3 nebu
4mg/5ml-20mg/5ml-
10mg/5ml Mucolytics
PHENYLHISTINE DH LIQD 2 acetylcysteine soln 1
PRO-RED AC SYRP 3 DERMATOLOGICALS - Drugs to Treat Skin

Conditions
promethazine & 1 QL(30 ml daily) Acne Products
phenylephrine soln
PA; QL(4 ea
promethazine w/codeine QL(30 ml daily) ABSORICA CAPS 10 MG 3
1 daily)
soln
ABSORICA CAPS 10 MG, PA
promethazine w/codeine 1 QL(30 ml daily) 20 MG, 25 MG, 30 MG, 35 3
syrp MG, 40 MG
promethazine-dm syrp 1 QL(30 ml daily) PA; Use
generic
promethazine- ABSORICA CAPS 20 MG 3 Isotretinoin
phenylephrine-codeine 1 Caps;QL(5 ea
syrp daily)
PROMETHAZINE/PHENYL 2 QL(30 ml daily) PA; Use
EPHRINE SYRP generic
PROMETHAZINE/PHENYL ABSORICA CAPS 30 MG 3
2 Isotretinoin
EPHRINE/CODEINE SYRP Caps
pseudoephedrine w/ 1
codeine-gg soln
page ii-iii.
51
PA; Use CLEOCIN-T LOTN (Use
generic Clindamycin Phosphate GP
ABSORICA CAPS 40 MG 3 Isotretinoin (Topical))
Caps;QL(2 ea CLEOCIN-T SOLN (Use
daily) Clindamycin Phosphate GP
ACZONE GEL 5 % (Use GP PA (Topical))
Dapsone (Topical)) CLEOCIN-T SWAB (Use
ACZONE GEL 7.5 % 3 PA; QL(2 gm Clindamycin Phosphate GP
daily) (Topical))
adapalene crea 0.1 % 1 QL(45 gm per CLINDAGEL GEL 2
fill retail)
QL(45 gm per clindamycin phosphate 3
adapalene gel 0.1 % 1 fill retail); (topical) foam
RX/OTC clindamycin phosphate 1
QL(45 gm per (topical) gel
adapalene gel 0.3 % 1 fill retail,135 gm clindamycin phosphate
per fill mail) 1
(topical) lotn
Limit 59mls per clindamycin phosphate
ADAPALENE LOTN 0.1 % 3 month;QL(1.97 1
(topical) soln
ml daily) clindamycin phosphate
Limit 45gms 3
(topical) swab
adapalene-benzoyl 3 per CLINDAMYCIN
peroxide gel month;QL(1.5 2
PHOSPHATE GEL
gm daily)
clindamycin phosphate-
Limit 45gms benzoyl peroxide 1
ATRALIN GEL (Use GP per (refrigerate) gel
Tretinoin) month;QL(1.5
gm daily) clindamycin phosphate- 3
benzoyl peroxide gel
AZELEX CREA 3 clindamycin phosphate- QL(1 gm daily)
3
BENZACLIN GEL (Use tretinoin gel
Clindamycin Phosphate- GP dapsone (topical) gel 3 PA
Benzoyl Peroxide)
BENZACLIN WITH PUMP DIFFERIN CREA 0.1 % GP QL(45 gm per
GEL (Use Clindamycin (Use Adapalene) fill retail)
GP QL(45 gm per
Phosphate-Benzoyl DIFFERIN GEL 0.1 % (Use
Peroxide) GP fill retail);
Adapalene) RX/OTC
BENZAMYCIN GEL (Use QL(2 gm daily)
Benzoyl Peroxide- GP QL(45 gm per
DIFFERIN GEL 0.3 % (Use GP fill retail,135 gm
Erythromycin) Adapalene)
benzoyl peroxide- QL(2 gm daily) per fill mail)
1 Limit 59mls per
erythromycin gel
BP CLEANSING WASH DIFFERIN LOTN 0.1 % 3 month;QL(1.97
2 ml daily)
EMUL
CLEOCIN-T GEL (Use DUAC GEL (Use
Clindamycin Phosphate GP Clindamycin Phosphate- GP
(Topical)) Benzoyl Peroxide
(Refrigerate))
page ii-iii.
52
PA; Limit RETIN-A CREA (Use GP
EPIDUO FORTE GEL 3 45gms per Tretinoin)
month;QL(1.5 RETIN-A GEL (Use
gm daily) GP
Tretinoin)
Limit 45gms Limit 50gms
EPIDUO GEL (Use RETIN-A MICRO GEL 0.04
Adapalene-Benzoyl GP per %, 0.1 % (Use Tretinoin GP per
month;QL(1.5 month;QL(1.7
Peroxide) gm daily) Microsphere) gm daily)
ERYGEL GEL (Use GP Limit 50gms
Erythromycin (Acne Aid)) RETIN-A MICRO PUMP
GEL 0.04 %, 0.1 % (Use GP per
erythromycin (acne aid) gel 1 month;QL(1.7
Tretinoin Microsphere) gm daily)
erythromycin (acne aid) 3 PA; Limit
pads RETIN-A MICRO PUMP 3 50gms per
erythromycin (acne aid) GEL 0.08 % month;QL(1.7
1 gm daily)
soln
EVOCLIN FOAM (Use ROSULA LIQD 4.5%-10% 3
Clindamycin Phosphate GP
(Topical)) SODIUM
Limit 50gms SULFACETAMIDE/SULFU 3
per R CLEANSER IN UREA
FABIOR FOAM 3 EMUL
month;QL(1.67
gm daily) SODIUM
QL(4 ea daily) SULFACETAMIDE/SULFU 3
isotretinoin caps 10 mg 1 R IN UREA GEL
isotretinoin caps 20 mg 1 QL(5 ea daily) SODIUM QL(30 gm per
SULFACETAMIDE/SULFU 2 fill retail)
R LOTN
isotretinoin caps 30 mg 1
SODIUM
Use generic SULFACETAMIDE/SULFU 3
Isotretinoin R SUSP
isotretinoin caps 30 mg 1
Caps;QL(2 ea sulfacetamide sodium 1
daily) (acne) lotn
isotretinoin caps 30 mg, 40 1 QL(2 ea daily) sulfacetamide sodium w/
mg 3
sulfur crea 4.8%-9.8%
KLARON LOTN (Use sulfacetamide sodium w/
Sulfacetamide Sodium GP 3
sulfur emul 1%-10%
(Acne))
sulfacetamide sodium w/ 3
PLEXION CLEANSER sulfur liqd 4.8%-9.8%
LIQD (Use Sulfacetamide GP
Sodium w/ Sulfur) sulfacetamide sodium w/ 3
sulfur lotn 4.8%-9.8%
PLEXION CREA (Use
Sulfacetamide Sodium w/ GP sulfacetamide sodium w/ 1
Sulfur) sulfur susp 4%-8%
PLEXION LOTN (Use SUMAXIN TS SUSP (Use
Sulfacetamide Sodium w/ GP Sulfacetamide Sodium w/ GP
Sulfur) Sulfur)
page ii-iii.
53
TRETIN-X CREA 3 CORTISPORIN OINT 3
tretinoin crea 0.025 %, 0.05 1 gentamicin sulfate (topical) 1
%, 0.1 % crea
tretinoin gel 0.025 %, 0.01 1 gentamicin sulfate (topical) 1
% oint
Limit 45gms mupirocin calcium (topical) 1
tretinoin gel 0.05 % 3 per crea
month;QL(1.5
gm daily) mupirocin oint 1
Limit 50gms Antifungals - Topical
per
tretinoin microsphere gel 1
month;QL(1.7 ciclopirox gel 0.77 % 1
gm daily)
QL(1 gm daily) ciclopirox olamine crea 1
VELTIN GEL 3
ZIANA GEL (Use QL(1 gm daily) ciclopirox olamine susp 1
Clindamycin Phosphate- GP
Tretinoin) ciclopirox sham 1 % 3
Agents for External Genital and Perianal Warts ciclopirox soln 8 % 3
VEREGEN OINT 3 QL(30 gm per RX/OTC
fill retail) clotrimazole (topical) soln 1
Anti-inflammatory Agents - Topical QL(45 gm per
diclofenac sodium (topical) 1 clotrimazole w/ fill retail,45 gm
gel 1 % 1
betamethasone crea per 30 days
diclofenac sodium (topical) retail)
1 QL(5 ml daily)
soln 1.5 % QL(60 ml per
FLECTOR PTCH 3 QL(2 ea daily) clotrimazole w/ 1 fill retail,60 ml
betamethasone lotn per 30 days
PA; QL(4 gm retail)
PENNSAID SOLN 3
daily)
econazole nitrate crea 1
REXAPHENAC CREA 3
Limit 70gms
VOLTAREN GEL (Use per
ECOZA FOAM 3
Diclofenac Sodium GP month;QL(2.5
(Topical)) gm daily)
Antibiotics - Topical ERTACZO CREA 3 PA
ALTABAX OINT 3 EXELDERM CREA 3

BACTROBAN CREA (Use
Mupirocin Calcium GP EXELDERM SOLN 2
(Topical))
EXODERM LOTN 3
CENTANY OINT 2
EXTINA FOAM (Use GP
CORTISPORIN CREA 3 Ketoconazole (Topical))
page ii-iii.
54
HALOTIN CREA 3 OXISTAT CREA (Use GP
Oxiconazole Nitrate)
iodoquinol-hydrocortisone 3
in aloe vehicle crea OXISTAT LOTN 3
ketoconazole (topical) crea 1 QL(2 gm daily) VYTONE CREA (Use

Iodoquinol-Hydrocortisone GP
ketoconazole (topical) foam 3 in Aloe Vehicle)
Antineoplastic or Premalignant Lesion Agents -
ketoconazole (topical) 1
sham CARAC CREA 2 QL(1 gm daily)
LAMISIL AT SPRAY SOLN 2 PA diclofenac sodium (actinic PA
3
keratoses) gel
LOPROX CREA (Use GP
Ciclopirox Olamine) EFUDEX CREA (Use GP
Fluorouracil (Topical))
LOPROX SHAMPOO GP
SHAM (Use Ciclopirox) FLUOROPLEX CREA 2
LOPROX SUSP (Use GP
Ciclopirox Olamine) fluorouracil (topical) crea 1
QL(45 gm per FLUOROURACIL CREA QL(1 gm daily)
LOTRISONE CREA (Use 2
Clotrimazole w/ GP fill retail,45 gm 0.5 %
per 30 days
Betamethasone) retail) FLUOROURACIL SOLN 2 2
%, 5 %
LULICONAZOLE CREA 3 PA
PANRETIN GEL 3
LUZU CREA 3
PICATO GEL 3
naftifine hcl crea 3 SOLARAZE GEL (Use PA
Diclofenac Sodium (Actinic GP
NAFTIN CREA 2 % (Use GP Keratoses))
Naftifine HCl)
TARGRETIN GEL EX 1 % 2
NAFTIN GEL 1 %, 2 % 3
VALCHLOR GEL 3 PA; SP
NIZORAL SHAM (Use GP
Ketoconazole (Topical))
Antipruritics - Topical
nystatin (topical) crea 1 doxepin hcl (antipruritic) 3
crea
nystatin (topical) oint 1
PRUDOXIN CREA 3
nystatin (topical) powd 1
ZONALON CREA 3
Limit 30gms
nystatin-triamcinolone crea 1 per month;QL(1 Antipsoriatics
gm daily) QL(1 ea daily)
Limit 30gms acitretin caps 10 mg 3
nystatin-triamcinolone oint 1 per month;QL(1
gm daily) acitretin caps 17.5 mg 3
oxiconazole nitrate crea 3 acitretin caps 25 mg 3 QL(2 ea daily)
page ii-iii.
55
calcipotriene crea 1 QL(5 gm daily) OVACE WASH LIQD (Use GP
Sulfacetamide Sodium)
calcipotriene oint 1 QL(5 gm daily)
selenium sulfide lotn 1
calcipotriene soln 1 SODIUM
SULFACETAMIDE WASH 3
DOVONEX CREA (Use GP QL(5 gm daily) LIQD
Calcipotriene)
sulfacetamide sodium liqd 1
methoxsalen rapid caps 1
sulfacetamide sodium 3
OXSORALEN ULTRA sham
CAPS (Use Methoxsalen GP
Rapid) Antivirals - Topical
SORIATANE CAPS 10 MG acyclovir topical oint QL(1 gm daily)
GP QL(1 ea daily) 1
(Use Acitretin)
PA; Limit 5gms
SORIATANE CAPS 17.5
MG (Use Acitretin)
GP XERESE CREA 3 per
month;QL(0.17
SORIATANE CAPS 25 MG GP QL(2 ea daily) gm daily)
(Use Acitretin) PA; Limit 5gms
QL(4 gm daily)
SORILUX FOAM 3 ZOVIRAX CREA EX 5 % 3 per
month;QL(0.17
tazarotene crea 1 QL(1 gm daily) gm daily)
ZOVIRAX OINT EX 5 % GP QL(1 gm daily)
TAZORAC CREA 0.05 % 2 QL(1 gm daily) (Use Acyclovir Topical)
TAZORAC CREA 0.1 % Burn Products
GP QL(1 gm daily)
(Use Tazarotene) mafenide acetate pack 3
TAZORAC GEL 0.05 %, 2 QL(1 gm daily)
0.1 % SILVADENE CREA (Use GP
Silver Sulfadiazine)
Limit 100gms
VECTICAL OINT (Use NF per silver sulfadiazine crea 1
Calcitriol (Topical)) month;QL(3.4
gm daily) SULFAMYLON CREA 85 3
MG/GM
ZITHRANOL-RR CREA 3 SULFAMYLON PACK 5 % GP
(Use Mafenide Acetate)
Antiseborrheic Products
OVACE PLUS FOAM 9.8 Corticosteroids - Topical
3
% ACLOVATE CREA (Use
Alclometasone GP
OVACE PLUS LOTN 9.8 % 3 Dipropionate)
OVACE PLUS SHAM 10 % ALA SCALP LOTN 3
(Use Sulfacetamide GP
Sodium) alclometasone dipropionate 1
OVACE PLUS WASH LIQD crea
(Use Sulfacetamide GP alclometasone dipropionate
Sodium) 1
oint
AMCINONIDE CREA 2
page ii-iii.
56
AMCINONIDE LOTN 3 clobetasol propionate foam 3
AMCINONIDE OINT 3 clobetasol propionate gel 1
APEXICON E CREA 2 clobetasol propionate liqd 3

AUGMENTED clobetasol propionate lotn 3
BETAMETHASONE 2
DIPROPIONATE GEL clobetasol propionate oint 1
betamethasone 1
dipropionate (topical) crea clobetasol propionate sham 1
betamethasone 1
dipropionate (topical) lotn clobetasol propionate soln 1
betamethasone
dipropionate (topical) oint 1 CLOBEX LIQD (Use GP
Clobetasol Propionate)
betamethasone
dipropionate augmented 1 CLOBEX LOTN (Use GP
crea Clobetasol Propionate)
betamethasone CLOBEX SHAM (Use GP
dipropionate augmented 1 Clobetasol Propionate)
gel CLOCORTOLONE 3
betamethasone PIVALATE CREA
dipropionate augmented 1 CLOCORTOLONE 3
lotn PIVALATE PUMP CREA
betamethasone CLODERM CREA 3
dipropionate augmented 1
oint CLODERM PUMP CREA 3
betamethasone valerate 1
crea 0.1 % CORDRAN CREA 0.05 % GP
(Use Flurandrenolide)
foam 0.12 % CORDRAN LOTN 0.05 % GP PA
lotn 0.1 % CORDRAN OINT 0.05 % GP PA
oint 0.1 % CORDRAN TAPE 4 3
MCG/SQCM
calcipotriene- ST; QL(2 gm
betamethasone 3 daily) CORTANE-B LOTN 3
dipropionate oint
CUTIVATE LOTN (Use GP
CAPEX SHAM 2 Fluticasone Propionate)
DERMA-SMOOTHE/FS
clobetasol propionate crea 1 BODY OIL (Use GP
clobetasol propionate Fluocinolone Acetonide)
1 DERMA-SMOOTHE/FS
emollient base crea
clobetasol propionate SCALP OIL (Use GP
3 Fluocinolone Acetonide)
emulsion foam
DERMATOP CREA (Use GP
Prednicarbate)
page ii-iii.
57
DERMATOP OINT (Use GP fluocinolone acetonide oint 1
Prednicarbate)
DESONATE GEL 3 fluocinolone acetonide soln 1
fluocinonide crea 0.05 %, 1
desonide crea 1 0.1 %
desonide lotn 1 fluocinonide crea 0.1 % 3
desonide oint 1 fluocinonide emulsified 1

base crea
DESOWEN CREA (Use GP
Desonide) fluocinonide gel 0.05 % 1
DESOWEN LOTN (Use GP fluocinonide oint 0.05 % 1
Desonide)
desoximetasone crea 0.05 1 fluocinonide soln 0.05 % 1
%, 0.25 %
desoximetasone gel 0.05 1 flurandrenolide crea 3
%
flurandrenolide lotn 3 PA
desoximetasone liqd 0.25 3 PA
%
flurandrenolide oint 3 PA
desoximetasone oint 0.05 3
% fluticasone propionate crea
desoximetasone oint 0.25 1
1 0.05 %
% fluticasone propionate lotn 3
diflorasone diacetate crea 1 0.05 %
fluticasone propionate oint 1
diflorasone diacetate oint 1 0.005 %
halobetasol propionate 1
DIPROLENE AF CREA crea
(Use Betamethasone GP
Dipropionate Augmented) halobetasol propionate oint 1
DIPROLENE LOTN (Use
Betamethasone GP hydrocortisone (topical) 1
Dipropionate Augmented) crea
DIPROLENE OINT (Use hydrocortisone (topical) lotn 1
Betamethasone GP
Dipropionate Augmented) hydrocortisone (topical) oint 1
ELOCON CREA (Use GP hydrocortisone butyrate
Mometasone Furoate) 1
crea
ELOCON OINT (Use GP hydrocortisone butyrate
Mometasone Furoate) 3
hydrophilic lipo base crea
EPIFOAM FOAM 3 hydrocortisone butyrate 3 PA
lotn
fluocinolone acetonide crea 1 hydrocortisone butyrate 1
oint
fluocinolone acetonide oil 1 hydrocortisone butyrate 3
soln
page ii-iii.
58
hydrocortisone valerate 3 SYNALAR OINT (Use GP
crea Fluocinolone Acetonide)
hydrocortisone valerate 3 SYNALAR SOLN (Use GP
oint Fluocinolone Acetonide)
KENALOG AERS (Use TACLONEX OINT (Use ST; QL(2 gm
Triamcinolone Acetonide GP Calcipotriene- GP daily)
(Topical)) Betamethasone
LOCOID CREA (Use Dipropionate)
GP
Hydrocortisone Butyrate) TACLONEX SUSP 3 ST; QL(2 gm
LOCOID LIPOCREAM daily)
CREA (Use Hydrocortisone GP TEMOVATE CREA (Use GP
Butyrate Hydrophilic Lipo Clobetasol Propionate)
Base) TEMOVATE E CREA (Use
LOCOID LOTN (Use GP PA Clobetasol Propionate GP
Hydrocortisone Butyrate) Emollient Base)
LOCOID OINT (Use GP TEMOVATE OINT (Use GP
Hydrocortisone Butyrate) Clobetasol Propionate)
LOCOID SOLN (Use GP TEXACORT SOLN 3
Hydrocortisone Butyrate)
LUXIQ FOAM (Use TOPICORT CREA 0.05 %,
GP 0.25 % (Use GP
Betamethasone Valerate)
Desoximetasone)
mometasone furoate crea 1 TOPICORT GEL 0.05 % GP
(Use Desoximetasone)
mometasone furoate oint 1
TOPICORT LIQD 0.25 % GP PA
mometasone furoate soln 1 (Use Desoximetasone)
TOPICORT OINT 0.05 %,
NUCORT LOTN 3 0.25 % (Use GP
Desoximetasone)
OLUX FOAM (Use GP triamcinolone acetonide
Clobetasol Propionate) 1
(topical) aers
OLUX-E FOAM (Use triamcinolone acetonide
Clobetasol Propionate GP 1
(topical) crea
Emulsion)
triamcinolone acetonide 1
PRAMOSONE E CREA 3 (topical) lotn
PRAMOSONE LOTN 3 (topical) oint
TRIDESILON CREA (Use GP
PRAMOSONE OINT 3 Desonide)
ULTRAVATE CREA (Use GP
PREDNICARBATE CREA 2 Halobetasol Propionate)
prednicarbate crea 1 ULTRAVATE LOTN 3 PA
PREDNICARBATE OINT 3 ULTRAVATE OINT (Use GP

Halobetasol Propionate)
SYNALAR CREA (Use GP VANOS CREA (Use
Fluocinolone Acetonide) NF
Fluocinonide)
page ii-iii.
59
WESTCORT OINT (Use GP Keratolytic/Antimitotic Agents
Hydrocortisone Valerate)
CONDYLOX GEL 2
Emollient/Keratolytic Agents
CONDYLOX SOLN (Use GP
GORDONS UREA OINT 3 Podofilox)
UMECTA EMUL 3 PODOCON 25 IN
BENZOIN TINCTURE 3
UMECTA NAIL FILM SUSP GP SOLN
(Use Urea)
podofilox soln 1
urea crea 40 % 3 RX/OTC
SALEX SHAM (Use GP
urea lotn 40 % 3 Salicylic Acid)
salicylic acid sham 6 % 1
urea susp 40 % 3
Local Anesthetics - Topical
UREA TOPICAL SUSP 3
ANASTIA LOTN 2
Immunomodulating Agents - Topical
ALDARA CREA (Use COCAINE HCL SOLN 3
GP
Imiquimod)
lidocaine hcl soln ex 1
imiquimod crea 1
lidocaine ptch 1 QL(3 ea daily)
PA; QL(1 gm
IMIQUIMOD PUMP CREA 3
daily) lidocaine-prilocaine crea 3
PA; QL(1 gm
ZYCLARA CREA 3 LIDODERM PTCH (Use
daily) GP QL(3 ea daily)
PA; Limit 1 per Lidocaine)
ZYCLARA PUMP CREA 3 month;QL(0.6 NUMBONEX LOTN 2
2.5 % gm daily)
ZYCLARA PUMP CREA PA; QL(1 gm Misc. Topical
3
3.75 % daily)
DRYSOL SOLN 2
Immunosuppressive Agents - Topical
XERAC AC SOLN 3
ELIDEL CREA 3 QL(60 gm per
fill retail)
Phosphodiesterase 4 (PDE4) Inhibitors - Topical
PROTOPIC OINT 0.03 % QL(2 gm daily);
GP AL(At least 2 PA; Limited to
(Use Tacrolimus (Topical))
yrs old) EUCRISA OINT 3 60 gm per
month;QL(2 gm
QL(2 gm daily); daily)
PROTOPIC OINT 0.1 % GP AL(At least 15
(Use Tacrolimus (Topical)) yrs old) Rosacea Agents
QL(2 gm daily); azelaic acid gel 1
tacrolimus (topical) oint 1 AL(At least 2
0.03 % yrs old) PA; QL(1 ea
DOXYCYCLINE CPDR 3
QL(2 gm daily); daily)
tacrolimus (topical) oint 0.1 1 AL(At least 15
% FINACEA FOAM 3
yrs old)
page ii-iii.
60
FINACEA GEL (Use GP
Azelaic Acid) DIAGNOSTIC PRODUCTS
METROCREAM CREA Diagnostic Drugs
(Use Metronidazole GP GLUCAGEN DIAGNOSTIC
(Topical)) 3
SOLR
METROGEL GEL (Use GP
Metronidazole (Topical)) METOPIRONE CAPS 3
METROLOTION LOTN QL(60 ml per Diagnostic Tests
(Use Metronidazole GP fill retail)
(Topical)) Limit 200 per
FREESTYLE INSULINX month without
metronidazole (topical) 1 BLOODGLUCOSE TEST 2 authorization;Q
crea 0.75 % STRIPS STRP L(6.7 ea daily);
metronidazole (topical) gel 1 QL(45 gm per RX/OTC
0.75 % fill retail) Limit 200 per
metronidazole (topical) gel 1 FREESTYLE INSULINX month without
1% BLOODGLUCOSE TEST 2 authorization;Q
metronidazole (topical) lotn QL(60 ml per STRP L(6.7 ea daily);
1 RX/OTC
0.75 % fill retail)
PA Limit 200 per
MIRVASO GEL 3 month without
FREESTYLE LITE TEST
PA 2 authorization;Q
NORITATE CREA 3 STRIPS STRP L(6.7 ea daily);
PA; QL(1 ea RX/OTC
ORACEA CPDR 3 Limit 200 per
daily)
PA month without
RHOFADE CREA 3 FREESTYLE TEST 2 authorization;Q
STRIPS STRP
PA; QL(1.5 gm L(6.7 ea daily);
SOOLANTRA CREA 3 RX/OTC
daily)
QL(50 ea per
Scabicides & Pediculicides KETOCARE STRP 2
fill retail)
ELIMITE CREA (Use
GP QL(60 gm per KETOSTIX STRP 2 QL(50 ea per
Permethrin) fill retail) fill retail)
malathion lotn 3 Limit 200 per
month without
AL(At least 4 ONETOUCH ULTRA BLUE
NATROBA SUSP 3 2 authorization;Q
yrs old) STRP L(6.7 ea daily);
OVIDE LOTN (Use RX/OTC
GP
Malathion) Limit 200 per
QL(60 gm per month without
permethrin crea 1 ONETOUCH VERIO TEST
fill retail) 2 authorization;Q
STRIPS STRP L(6.7 ea daily);
SKLICE LOTN 3 RX/OTC
AL(At least 4 Limit 200 per
SPINOSAD SUSP 3 PRECISION XTRA BLOOD month without
yrs old)
GLUCOSE TEST STRIPS 2 authorization;Q
Wound Care Products STRP L(6.7 ea daily);
QL(15 gm per RX/OTC
REGRANEX GEL 3
fill retail)
page ii-iii.
61
2 QL(50 ea per MAXZIDE TABS (Use QL(1 ea daily)
RELION KETONE STRP Triamterene &
fill retail) GP
DIGESTIVE AIDS - Drugs to Treat Low Digestive
Enzymes MAXZIDE-25 TABS (Use QL(2 ea daily)
Triamterene & GP
Digestive Enzymes Hydrochlorothiazide)
CREON CPEP 2 spironolactone & 1
PANCREAZE CPEP 3 triamterene &
hydrochlorothiazide caps 1
PERTZYE CPEP 3 50mg-25mg, 37.5mg-25mg
PA triamterene & QL(2 ea daily)
SUCRAID SOLN 3 hydrochlorothiazide tabs 1
37.5mg-25mg
VIOKACE TABS 3 triamterene & QL(1 ea daily)
hydrochlorothiazide tabs 1
ZENPEP CPEP 2 75mg-50mg
DIURETICS - Drugs to Treat Heart, Circulation Loop Diuretics
Conditions and Blood Pressure bumetanide tabs 0.5 mg, 1 1
Carbonic Anhydrase Inhibitors mg
acetazolamide cp12 500 QL(2 ea daily) bumetanide tabs 2 mg 1 QL(5 ea daily)
1
mg
BUMEX TABS 0.5 MG, 1 GP
acetazolamide tabs 125 mg 1 MG (Use Bumetanide)
QL(4 ea daily) BUMEX TABS 2 MG (Use GP QL(5 ea daily)
acetazolamide tabs 250 mg 1 Bumetanide)
DIAMOX CP12 (Use DEMADEX TABS (Use
GP QL(2 ea daily) Torsemide) GP
Acetazolamide)
PA EDECRIN TABS (Use GP ST
KEVEYIS TABS 3 Ethacrynic Acid)
methazolamide tabs 1 ethacrynic acid tabs 3 ST
NEPTAZANE TABS (Use GP furosemide soln 10 mg/ml 1

Methazolamide)
Diuretic Combinations FUROSEMIDE SOLN 8 3
MG/ML
ALDACTAZIDE TABS
25MG-25MG (Use furosemide tabs 20 mg, 40 1
GP mg, 80 mg
Spironolactone &
Hydrochlorothiazide) LASIX TABS (Use GP
ALDACTAZIDE TABS Furosemide)
2 QL(2 ea daily)
50MG-50MG torsemide tabs 100 mg 1
amiloride & 1
hydrochlorothiazide tabs torsemide tabs 5 mg, 10 1
mg, 20 mg
DYAZIDE CAPS (Use
Triamterene & GP Potassium Sparing Diuretics
page ii-iii.
62
ALDACTONE TABS (Use GP BONIVA TABS (Use GP QL(0.04 ea
Spironolactone) Ibandronate Sodium) daily)
amiloride hcl tabs 1 calcitonin (salmon) soln 1
DYRENIUM CAPS 3 ETIDRONATE DISODIUM 3

TABS
spironolactone tabs 1 PA; QL(0.15 ea
FOSAMAX PLUS D TABS 3
daily)
Thiazides and Thiazide-Like Diuretics FOSAMAX TABS (Use QL(0.15 ea
GP
chlorthalidone tabs 25 mg, Alendronate Sodium) daily)
1
50 mg
ibandronate sodium tabs 1 QL(0.04 ea
hydrochlorothiazide caps daily)
1
12.5 mg MIACALCIN SOLN (Use GP
hydrochlorothiazide tabs Calcitonin (Salmon))
3
12.5 mg risedronate sodium tabs QL(0.04 ea
3
hydrochlorothiazide tabs 25 1 150 mg daily)
mg, 50 mg risedronate sodium tabs 35 QL(0.15 ea
3
mg daily)
indapamide tabs 1
risedronate sodium tabs 5 3 QL(1 ea daily)
metolazone tabs 1 mg, 30 mg
MICROZIDE CAPS (Use Fertility Regulators
GP QL(15 ea per
fill retail,00 ea
ENDOCRINE AND METABOLIC AGENTS - clomiphene citrate tabs 1 per fill mail,15
MISC. - Drugs to Treat Bone Disease and ea per 30 days
Regulate Hormones retail)
Bone Density Regulators QL(15 ea per
ACTONEL TABS 150 MG fill retail,00 ea
GP QL(0.04 ea CLOMIPHENE CITRATE 2 per fill mail,15
(Use Risedronate Sodium) daily) TABS ea per 30 days
ACTONEL TABS 35 MG GP QL(0.15 ea retail)
(Use Risedronate Sodium) daily)
ACTONEL TABS 5 MG, 30 QL(1 ea daily) Hormone Receptor Modulators
MG (Use Risedronate GP EVISTA TABS (Use GP PV
Sodium) Raloxifene HCl)
ALENDRONATE SODIUM 3 OSPHENA TABS 3
SOLN 70 MG/75ML
alendronate sodium tabs PV
1 QL(0.15 ea raloxifene hcl tabs 1
35 mg, 70 mg daily)
ALENDRONATE SODIUM LHRH/GnRH Agonist Analog Pituitary
2
TABS 40 MG SYNAREL SOLN 2
alendronate sodium tabs 5 1 QL(1 ea daily)
mg, 10 mg Metabolic Modifiers
ST; Limit 4 per BUPHENYL POWD (Use
BINOSTO TBEF 3 month;QL(0.15 GP
Sodium Phenylbutyrate)
ea daily) BUPHENYL TABS (Use GP
Sodium Phenylbutyrate)
page ii-iii.
63
calcitriol caps or 0.25 mcg 1 ROCALTROL SOLN 1 GP
MCG/ML (Use Calcitriol)
calcitriol caps or 0.5 mcg 1 QL(4 ea daily) PA; Must use
AcariaHlth Sp
SENSIPAR TABS 3
calcitriol soln or 1 mcg/ml 1 Rx 1-844-538-
4661;SP
CARBAGLU TABS 2 sodium phenylbutyrate 3
powd
CARNITOR SF SOLN (Use
Levocarnitine (Metabolic GP sodium phenylbutyrate tabs 3
Modifiers))
ZEMPLAR CAPS (Use GP
CARNITOR SOLN 1 Paricalcitol)
GM/10ML (Use GP
Levocarnitine (Metabolic Posterior Pituitary Hormones
Modifiers)) DDAVP SOLN NA 0.01 % 2
CARNITOR TABS 330 MG RX/OTC
(Use Levocarnitine GP DDAVP SOLN NA 0.01 %
(Metabolic Modifiers)) (Use Desmopressin GP
Acetate Spray)
CYSTADANE POWD 3 DDAVP TABS OR 0.1 MG
(Use Desmopressin GP
doxercalciferol caps 3 Acetate)
HECTOROL CAPS (Use DDAVP TABS OR 0.2 MG QL(6 ea daily)
GP (Use Desmopressin
Doxercalciferol) GP
Specialty Drug Acetate)
refer to desmopressin acetate 1
KUVAN PACK 2
Caremark SP spray refrigerated soln
RX desmopressin acetate 1
Specialty Drug spray soln
refer to desmopressin acetate tabs
KUVAN TBSO 2 1
Caremark SP 0.1 mg
RX
desmopressin acetate tabs 1 QL(6 ea daily)
levocarnitine (metabolic 3 0.2 mg
modifiers) soln 1 gm/10ml
NOCTIVA EMUL 3 PA
levocarnitine (metabolic 3 RX/OTC
modifiers) tabs 330 mg
STIMATE SOLN 3
ORFADIN CAPS 3 PA
Prolactin Inhibitors
ORFADIN SUSP 3 PA
cabergoline tabs 1
paricalcitol caps 1 ESTROGENS - Hormone Replacement/Modifying
PA; SP Drugs
RAVICTI LIQD 3
Estrogen Combinations
ROCALTROL CAPS 0.25 GP ACTIVELLA TABS (Use
MCG (Use Calcitriol) Estradiol & Norethindrone GP
ROCALTROL CAPS 0.5 GP QL(4 ea daily) Acetate)
MCG (Use Calcitriol)
page ii-iii.
64
ANGELIQ TABS 3 ELESTRIN GEL 3
Limit 4 patches ESTRACE TABS (Use GP
CLIMARA PRO PTWK 2 per Estradiol)
month;QL(0.14 Limit 8 patches
3 ea daily) estradiol pttw td 0.025 per
1
COMBIPATCH PTTW 3 mg/24hr month;QL(0.29
ea daily)
DUAVEE TABS 3 estradiol pttw td 0.0375 1
mg/24hr
estradiol & norethindrone 1 Limit 8 patches
acetate tabs estradiol pttw td 0.05 per
FEMHRT LOW DOSE 1
mg/24hr month;QL(0.27
TABS (Use Norethindrone GP ea daily)
Acetate-Ethinyl Estradiol) Limit 8 per
norethindrone acetate- estradiol pttw td 0.075 1 month;QL(0.29
1 mg/24hr, 0.1 mg/24hr
ethinyl estradiol tabs ea daily)
PREFEST TABS 3 estradiol pttw td 0.075 1 QL(0.29 ea
mg/24hr, 0.1 mg/24hr daily)
PREMPHASE TABS 2 Limit 8 per 28
estradiol pttw td 0.075 1 days;QL(0.29
PREMPRO TABS 0.3MG- QL(1 ea daily) mg/24hr, 0.1 mg/24hr ea daily)
2
1.5MG estradiol ptwk td 0.025 QL(4 ea per fill
PREMPRO TABS mg/24hr, 0.075 mg/24hr, retail,4 ea per
0.625MG-2.5MG, 0.45MG- 2 0.05 mg/24hr, 0.06 1 30 days retail)
1.5MG, 0.625MG-5MG mg/24hr, 0.1 mg/24hr, 37.5
Estrogens mcg/24hr
Limit 8 patches estradiol tabs or 0.5 mg, 1 1
ALORA PTTW 0.025 mg, 2 mg
2 per Limit 50gms
MG/24HR month;QL(0.29
ea daily) per
ESTROGEL GEL 3
Limit 8 patches month;QL(1.67
ALORA PTTW 0.05 gm daily)
2 per ESTROPIPATE TABS 0.75
MG/24HR month;QL(0.27 2
ea daily) MG, 1.5 MG
Limit 8 patches estropipate tabs 3 mg 1
ALORA PTTW 0.075 3 per
MG/24HR month;QL(0.27 EVAMIST SOLN 3
ea daily)
Limit 8 per 28 MENEST TABS 2
ALORA PTTW 0.1 3 days;QL(0.29
MG/24HR QL(4 ea per 30
ea daily) MENOSTAR PTWK 3
QL(4 ea per fill days retail)
CLIMARA PTWK (Use GP retail,4 ea per Limit 8 patches
Estradiol) MINIVELLE PTTW 0.025
30 days retail) GP per
MG/24HR (Use Estradiol) month;QL(0.29
DIVIGEL GEL 3 ea daily)
page ii-iii.
65
MINIVELLE PTTW 0.0375 GP CIPRO XR TB24 500MG QL(3 ea per fill
MG/24HR (Use Estradiol) (Use Ciprofloxacin- GP retail)
Limit 8 patches Ciprofloxacin HCl)
MINIVELLE PTTW 0.05 GP per CIPROFLOXACIN ER 2 QL(14 ea per
MG/24HR (Use Estradiol) month;QL(0.27 TB24 1000MG fill retail)
ea daily) CIPROFLOXACIN ER QL(3 ea per fill
2
MINIVELLE PTTW 0.075 TB24 500MG retail)
MG/24HR, 0.1 MG/24HR NF CIPROFLOXACIN HCL
(Use Estradiol) 2
TABS 100 MG
MINIVELLE PTTW 0.075 Limit 8 per 28 ciprofloxacin hcl tabs 250
MG/24HR, 0.1 MG/24HR GP days;QL(0.29 1
mg, 500 mg, 750 mg
(Use Estradiol) ea daily)
PREMARIN TABS OR QL(1 ea daily) ciprofloxacin susr 1
0.625 MG, 0.45 MG, 0.3 2 QL(1 ea per 90
MG, 1.25 MG FACTIVE TABS 3
days retail)
PREMARIN TABS OR 0.9 LEVAQUIN TABS (Use
MG
2 GP QL(14 ea per
Levofloxacin) fill retail)
Limit 8 patches
VIVELLE-DOT PTTW levofloxacin soln 25 mg/ml 1
0.025 MG/24HR (Use GP per
month;QL(0.29 levofloxacin tabs 250 mg, QL(14 ea per
Estradiol) ea daily) 1
500 mg, 750 mg fill retail)
VIVELLE-DOT PTTW
0.0375 MG/24HR (Use GP moxifloxacin hcl tabs 1
Estradiol)
OFLOXACIN TABS 300 2
VIVELLE-DOT PTTW Limit 8 patches MG
0.075 MG/24HR, 0.05 GP per
MG/24HR, 0.1 MG/24HR month;QL(0.27 QL(28 ea per
ofloxacin tabs 400 mg 3
90 days retail)
(Use Estradiol) ea daily)
FLUOROQUINOLONES - Drugs to Treat Bacterial GASTROINTESTINAL AGENTS - MISC. -
Infections Miscellaneous Gastrointestinal Drugs
Fluoroquinolones Agents for Chronic Idiopathic Constipation (CIC)

AVELOX ABC PACK TABS TRULANCE TABS 3 PA
GP
(Use Moxifloxacin HCl)
AVELOX TABS (Use Farnesoid X Receptor (FXR) Agonists
GP
Moxifloxacin HCl) OCALIVA TABS 3 PA
CIPRO SUSR 5 2
GM/100ML Gallstone Solubilizing Agents
CIPRO SUSR 500 ACTIGALL CAPS (Use GP
MG/5ML (Use GP Ursodiol)
Ciprofloxacin) PA
CHENODAL TABS 3
CIPRO TABS 250 MG, 500
MG (Use Ciprofloxacin GP URSO 250 TABS (Use GP
HCl) Ursodiol)
CIPRO XR TB24 1000MG QL(14 ea per URSO FORTE TABS (Use GP
(Use Ciprofloxacin- GP fill retail) Ursodiol)
Ciprofloxacin HCl)
ursodiol caps 1
page ii-iii.
66
ursodiol tabs 1 mesalamine tbec or 1.2 gm 1 QL(4 ea daily)
Gastrointestinal Chloride Channel Activators mesalamine tbec or 800 1
mg
AMITIZA CAPS 2 PA
PENTASA CPCR 250 MG 3
Gastrointestinal Stimulants
PA; QL(8 ea
metoclopramide hcl soln 5 PENTASA CPCR 500 MG 3
3 daily)
mg/5ml, 10 mg/10ml
metoclopramide hcl tabs 5 SFROWASA ENEM 2
1
mg, 10 mg QL(8 ea daily)
METOCLOPRAMIDE ODT
sulfasalazine tabs 1
3
TBDP QL(8 ea daily)
sulfasalazine tbec 1
REGLAN TABS (Use GP
Metoclopramide HCl) Intestinal Acidifiers
Inflammatory Bowel Agents lactulose (encephalopathy) 1
PA; QL(4 ea soln
APRISO CP24 3
daily) Irritable Bowel Syndrome (IBS) Agents
ASACOL HD TBEC 2 alosetron hcl tabs 3
ASACOL HD TBEC (Use GP QL(1 ea daily)
Mesalamine) LINZESS CAPS 2
AZULFIDINE EN-TABS GP QL(8 ea daily) LOTRONEX TABS (Use
TBEC (Use Sulfasalazine) GP
Alosetron HCl)
AZULFIDINE TABS (Use GP QL(8 ea daily) VIBERZI TABS 3 PA
Sulfasalazine)
QL(9 ea Peripheral Opioid Receptor Antagonists
balsalazide disodium caps 1 daily,280 ea
per fill retail) ENTEREG CAPS 3
CANASA SUPP 2 QL(1 ea daily)
MOVANTIK TABS 12.5 MG 3
COLAZAL CAPS (Use QL(9 ea QL(1 ea daily)

GP daily,280 ea MOVANTIK TABS 25 MG 3
Balsalazide Disodium) per fill retail)
RELISTOR TABS 3 PA
DELZICOL CPDR 3 PA; QL(6 ea
daily) Phosphate Binder Agents
DIPENTUM CAPS 3 AURYXIA TABS 3 PA
PA; Use calcium acetate (phosphate 1
GIAZO TABS 3 generic binder) caps
BALSALAZIDE;
QL(6 ea daily) calcium acetate (phosphate 1 RX/OTC
binder) tabs
LIALDA TBEC (Use GP QL(4 ea daily)
Mesalamine) ELIPHOS TABS (Use RX/OTC
Calcium Acetate GP
mesalamine enem re 4 gm 1 QL(60 ml daily) (Phosphate Binder))
page ii-iii.
67
FOSRENOL CHEW 1000 QL(3 ea daily) K-PHOS NO 2 TABS 2
MG (Use Lanthanum GP
Carbonate) Alkalinizers
FOSRENOL CHEW 500
MG (Use Lanthanum GP ORACIT SOLN 3
Carbonate) pot & sod citrates w/citric
FOSRENOL CHEW 750 QL(4 ea daily) ac soln 550mg/5ml- 3
MG (Use Lanthanum GP 334mg/5ml-500mg/5ml
Carbonate) pot & sod citrates w/citric
FOSRENOL PACK 750 3 ac syrp 550mg/5ml-
MG, 1000 MG 550mg/5ml-334mg/5ml- 1
lanthanum carbonate chew QL(3 ea daily) 334mg/5ml-500mg/5ml-
1 500mg/5ml
1000 mg
lanthanum carbonate chew potassium citrate 1
1 (alkalinizer) tbcr
500 mg
lanthanum carbonate chew QL(4 ea daily) potassium citrate-citric acid 1
1 pack 3300mg-1002mg
750 mg
potassium citrate-citric acid RX/OTC
PHOSLYRA SOLN 3 soln 1100mg/5ml-
PA 334mg/5ml, 1100mg/5ml- 1
RENAGEL TABS 400 MG 3 1100mg/5ml-334mg/5ml-
PA; QL(16 ea 334mg/5ml
RENAGEL TABS 800 MG 3
daily) POTASSIUM
RENVELA PACK 0.8 GM CITRATE/SODIUMCITRAT 3
(Use Sevelamer GP E/CITRIC ACID SOLN
Carbonate) SHOHLS SOLUTION RX/OTC
RENVELA PACK 2.4 GM QL(5 ea daily) MODIFIED SOLN (Use GP
(Use Sevelamer GP Sodium Citrate & Citric
Carbonate) Acid)
RENVELA TABS 800 MG sodium citrate & citric acid 1 RX/OTC
(Use Sevelamer GP soln
Carbonate) TRICITRATES SOLN 3
sevelamer carbonate pack 1
0.8 gm UROCIT-K 10 TBCR (Use
sevelamer carbonate pack QL(5 ea daily)
Potassium Citrate GP
2.4 gm 1 (Alkalinizer))
UROCIT-K 15 TBCR (Use
sevelamer carbonate tabs 1 Potassium Citrate GP
800 mg (Alkalinizer))
Tryptophan Hydroxylase Inhibitors UROCIT-K 5 TBCR (Use
XERMELO TABS 3 PA; SP Potassium Citrate GP
(Alkalinizer))
GENITOURINARY AGENTS - MISCELLANEOUS Cystinosis Agents
- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System CYSTAGON CAPS 3
Acidifiers PROCYSBI CPDR 3 SP
page ii-iii.
68
Interstitial Cystitis Agents allopurinol tabs 100 mg 1 QL(3 ea daily)
ELMIRON CAPS 3 QL(3 ea daily)
allopurinol tabs 300 mg 1 QL(2 ea daily)
Prostatic Hypertrophy Agents
COLCHICINE CAPS 3
alfuzosin hcl tb24 1 QL(1 ea daily)
AVODART CAPS (Use

colchicine tabs 1
GP AL(At least 40
Dutasteride) yrs old)
COLCHICINE TABS 2
CARDURA XL TB24 3
COLCRYS TABS 2
AL(At least 40
dutasteride caps 1
yrs old) MITIGARE CAPS 3
dutasteride-tamsulosin hcl 1
caps ULORIC TABS 40 MG 2 QL(2 ea daily)
QL(1 ea daily);
finasteride tabs 1 AL(At least 40 ULORIC TABS 80 MG 2 QL(1 ea daily)
yrs old)
ZURAMPIC TABS 3 PA
FLOMAX CAPS (Use GP QL(2 ea daily)
Tamsulosin HCl) ZYLOPRIM TABS 100 MG
JALYN CAPS (Use GP QL(3 ea daily)
(Use Allopurinol)
Dutasteride-Tamsulosin GP ZYLOPRIM TABS 300 MG
HCl) GP QL(2 ea daily)
(Use Allopurinol)
QL(1 ea daily);
PROSCAR TABS (Use GP AL(At least 40 Uricosurics
Finasteride) yrs old) probenecid tabs 1
RAPAFLO CAPS 4 MG 3
HEMATOLOGICAL AGENTS - MISC. - Drugs to
RAPAFLO CAPS 8 MG 3 QL(1 ea daily) Treat Blood Disorders
Hematorheologic Agents
tamsulosin hcl caps 1 QL(2 ea daily)
pentoxifylline tbcr 1 QL(3 ea daily)
UROXATRAL TB24 (Use GP QL(1 ea daily)
Alfuzosin HCl) Platelet Aggregation Inhibitors
Urinary Stone Agents AGGRENOX CP12 (Use GP
Aspirin-Dipyridamole)
LITHOSTAT TABS 3 AGRYLIN CAPS (Use GP
Anagrelide HCl)
THIOLA TABS 3
anagrelide hcl caps 1
GOUT AGENTS - Drugs to Treat Gout
aspirin-dipyridamole cp12 3
Gout Agent Combinations
BRILINTA TABS 60 MG 2 QL(2 ea daily)
colchicine w/ probenecid 1
tabs
PA BRILINTA TABS 90 MG 2
DUZALLO TABS 3
cilostazol tabs 1 QL(2 ea daily)
Gout Agents
page ii-iii.
69
clopidogrel bisulfate tabs 1 QL(2 ea daily) Hemostatics - Systemic
AMICAR SOLN 0.25 3
dipyridamole tabs 1 GM/ML
EFFIENT TABS (Use GP AMICAR TABS 1000 MG 3
Prasugrel HCl)
LYSTEDA TABS (Use GP QL(6 ea daily,5
PLAVIX TABS (Use GP QL(2 ea daily) Tranexamic Acid) day(s) limit)
Clopidogrel Bisulfate)
prasugrel hcl tabs 1 tranexamic acid tabs 1 QL(6 ea daily,5
day(s) limit)
HEMATOPOIETIC AGENTS - Drugs to Treat HYPNOTICS/SEDATIVES/SLEEP DISORDER
Blood Disorders AGENTS
Agents for Gaucher Disease Barbiturate Hypnotics
CERDELGA CAPS 3 PA phenobarbital elix 1
miglustat caps 3 PA phenobarbital soln 1
ZAVESCA CAPS (Use GP PA phenobarbital tabs 1

Miglustat)
Non-Barbiturate Hypnotics
Agents for Sickle Cell Anemia
AMBIEN CR TBCR (Use GP QL(1 ea daily)
DROXIA CAPS 2 Zolpidem Tartrate)
PA AMBIEN TABS (Use GP QL(1 ea daily)
ENDARI PACK 3 Zolpidem Tartrate)
AL(Up to 19 yrs estazolam tabs 1
SIKLOS TABS 100 MG 2
old ); AC
eszopiclone tabs 3 QL(1 ea daily)
Folic Acid/Folates
folic acid tabs 1 mg 1 RX/OTC QL(2 ea daily)
flurazepam hcl caps 15 mg 1
folic acid tabs 400 mcg, 1 PV QL(1 ea daily)
800 mcg flurazepam hcl caps 30 mg 1
Hematopoietic Growth Factors HALCION TABS (Use GP QL(1 ea daily)
PA; New Triazolam)
commercial LUNESTA TABS (Use GP QL(1 ea daily)
members to be Eszopiclone)
PROMACTA TABS 3
referred to RESTORIL CAPS 15 MG
AcariaHealth;S GP QL(2 ea daily)
(Use Temazepam)
P RESTORIL CAPS 30 MG GP QL(1 ea daily)
Hematopoietic Mixtures (Use Temazepam)
RESTORIL CAPS 7.5 MG GP
FOLIVANE-F CAPS 2 (Use Temazepam)
INTEGRA F CAPS 2 SONATA CAPS (Use GP QL(1 ea daily)
Zaleplon)
HEMOSTATICS - Drugs to Stop Bleeding/Treat temazepam caps 15 mg 1 QL(2 ea daily)
Blood Disorders
page ii-iii.
70
temazepam caps 30 mg 1 QL(1 ea daily) peg 3350-kcl-sod bicarb- QL(4000 ml per
sod chloride-sod sulfate 1 fill retail); PV
temazepam caps 7.5 mg 1 solr
peg 3350-potassium PV
triazolam tabs 0.125 mg 1 chloride-sod bicarbonate- 1
sod chloride solr
triazolam tabs 0.25 mg 1 QL(1 ea daily) SUPREP BOWEL PREP PV
2
KIT SOLN
zaleplon caps 1 QL(1 ea daily)
Laxatives - Miscellaneous
zolpidem tartrate tabs or 5 1 QL(1 ea daily) lactulose soln 1
mg, 10 mg
zolpidem tartrate tbcr or QL(1 ea daily) Limit 528gms
3 per
12.5 mg, 6.25 mg MIRALAX POWD (Use GP month;QL(17.6
Orexin Receptor Antagonists Polyethylene Glycol 3350) gm daily);
ST; QL(1 ea RX/OTC
BELSOMRA TABS 2
daily) Limit 528gms
Selective Melatonin Receptor Agonists per
polyethylene glycol 3350 1 month;QL(17.6
HETLIOZ CAPS 3 PA powd gm daily);
RX/OTC
ST; QL(1 ea
ROZEREM TABS 3 Saline Laxatives
daily)
OSMOPREP TABS 3 PA
LAXATIVES - Bowel Treatment Drugs
Laxative Combinations Available for
members in
bisacodyl-peg 3350-pot QL(1 ea per fill non-
chloride-sod bicarb-sod 1 retail); PV grandfathered
chloride kit sodium phosphates soln 1 plans ages 50-
COLYTE-FLAVOR PACKS QL(4000 ml per 74;AL(At least
SOLR (Use PEG 3350- GP fill retail); PV 50 yrs old - Up
KCl-Sod Bicarb-Sod to 74 yrs old);
Chloride-Sod Sulfate) PV
GOLYTELY SOLR PA; QL(4000 Stimulant Laxatives
227.1GM-21.5GM-5.53GM- 2 ea per fill
2.82GM-6.36GM retail); PV Available for
members in
GOLYTELY SOLR 236GM- QL(4000 ml per non-
22.74GM-5.86GM-2.97GM- fill retail); PV grandfathered
6.74GM (Use PEG 3350- GP bisacodyl supp 1 plans ages 50-
KCl-Sod Bicarb-Sod 74;AL(At least
Chloride-Sod Sulfate) 50 yrs old - Up
MOVIPREP SOLR 2 PV to 74 yrs old);
PV
NULYTELY/FLAVOR PV
PACKS SOLR (Use PEG
3350-Potassium Chloride- GP
Sod Bicarbonate-Sod
Chloride)
page ii-iii.
71
Available for ZITHROMAX TABS 500 GP QL(3 ea daily)
members in MG (Use Azithromycin)
non- ZITHROMAX TABS 600
grandfathered GP QL(10 ea per
MG (Use Azithromycin) fill retail)
bisacodyl tbec 1 plans ages 50-
74;AL(At least ZITHROMAX TRI-PAK GP QL(3 ea daily)
50 yrs old - Up TABS (Use Azithromycin)
to 74 yrs old); ZITHROMAX Z-PAK TABS GP QL(6 ea per fill
PV (Use Azithromycin) retail)
Available for ZMAX SUSR 2 QL(2 ea daily)
members in
non- Clarithromycin
grandfathered BIAXIN SUSR (Use
DULCOLAX SUPP (Use GP plans ages 50- GP
Bisacodyl) Clarithromycin)
74;AL(At least
50 yrs old - Up BIAXIN TABS (Use GP
to 74 yrs old); Clarithromycin)
PV CLARITHROMYCIN SUSR 2
Available for 125 MG/5ML, 250 MG/5ML
members in clarithromycin susr 125 1
non- mg/5ml, 250 mg/5ml
grandfathered clarithromycin tabs 250 mg,
DULCOLAX TBEC (Use GP plans ages 50- 1
Bisacodyl) 500 mg
74;AL(At least QL(14 ea per
50 yrs old - Up clarithromycin tb24 500 mg 1
fill retail)
to 74 yrs old);
PV Erythromycins
MACROLIDES - Drugs to Treat Bacterial E.E.S. GRANULES SUSR
Infections (Use Erythromycin GP
Ethylsuccinate)
Azithromycin
AZITHROMYCIN PACK 1 ERY-TAB TBEC 2
2
GM ERYPED 200 SUSR (Use
azithromycin susr 100 1 Erythromycin GP
mg/5ml, 200 mg/5ml Ethylsuccinate)
QL(6 ea per fill ERYPED 400 SUSR 2
azithromycin tabs 250 mg 1
retail)
azithromycin tabs 500 mg 1 QL(3 ea daily) erythromycin base cpep 1
QL(10 ea per erythromycin base tabs 1
azithromycin tabs 600 mg 1
fill retail)
erythromycin 1
ZITHROMAX PACK 1 GM 2 ethylsuccinate susr
ZITHROMAX SUSR 100 erythromycin 1
MG/5ML, 200 MG/5ML GP ethylsuccinate tabs
(Use Azithromycin)
erythromycin stearate tabs 1
ZITHROMAX TABS 250 GP QL(6 ea per fill
MG (Use Azithromycin) retail) PCE TBEC 3
page ii-iii.
72
Fidaxomicin Limit 200 per
ADVOCATE INSULIN PEN 2 month;QL(6.67
DIFICID TABS 3 NEEDLES MISC ea daily)
Limited to 1
MEDICAL DEVICES AND SUPPLIES device per
AUTOPEN DEVI 2 year;QL(1 ea
Contraceptives per 365 days
QL(1 ea per retail); RX/OTC
CAYA DPRH 2 365 days BD ECLIPSE NEEDLE
retail); PV 2
30G X1/2" MISC
OMNIFLEX DIAPHRAGM 2 BD INSULIN SYRINGE Limit 200 per
DPRH ULTRAFINE/U-
WIDE-SEAL SILICONE PV 2 month;QL(6.67
100/1ML/31G X 15/64" ea daily)
DIAPHRAGM KIT 60 3 MISC
DPRH BD NEEDLE/30G X 1/2"
WIDE-SEAL SILICONE PV 2
MISC
DIAPHRAGM KIT 65 3 Limited to 1
DPRH device per
WIDE-SEAL SILICONE PV BD PEN MINI MISC 2 year;QL(1 ea
DIAPHRAGM KIT 70 3 per 365 days
DPRH retail); RX/OTC
WIDE-SEAL SILICONE PV Limited to 1
DIAPHRAGM KIT 75 3 device per
DPRH BD PEN MISC 2 year;QL(1 ea
WIDE-SEAL SILICONE PV per 365 days
DIAPHRAGM KIT 80 3 retail); RX/OTC
DPRH BD SAFETYGLIDE Limit 200 per
WIDE-SEAL SILICONE PV INSULIN 2 month;QL(6.67
DIAPHRAGM KIT 85 3 SYRINGE/1ML/31G X ea daily)
DPRH 15/64" MISC
WIDE-SEAL SILICONE PV BD VEO INSULIN Limit 200 per
DIAPHRAGM KIT 90 3 SYRINGE ULTRA- 2 month;QL(6.67
DPRH FINE/1ML/31G X 6MM ea daily)
WIDE-SEAL SILICONE PV MISC
DIAPHRAGM KIT 95 3 CLEVER CHOICE Limit 200 per
DPRH COMFORT EZINSULIN 2 month;QL(6.67
PEN NEEDLES 33GX4MM ea daily)
Diabetic Supplies MISC
GOODSENSE PREMIUM RX/OTC CLEVER CHOICE Limit 200 per
BLOODGLUCOSE COMFORT EZPEN
MONITORING SYSTEM
3 2 month;QL(6.67
NEEDLES 33GX4MM ea daily)
KIT MISC
GUARDIAN REAL-TIME QL(0.002 ea CLEVER CHOICE Limit 200 per
REPLACEMENT daily); B; NT COMFORT EZPEN
MONITOR PEDIATRIC
3 2 month;QL(6.67
NEEDLES 33GX5MM ea daily)
DEVI MISC
Parenteral Therapy Supplies
page ii-iii.
73
CLEVER CHOICE Limit 200 per Limited to 1
COMFORT EZPEN 2 month;QL(6.67 device per
NEEDLES 33GX6MM ea daily) INPEN 100/PINK/LILLY 2 year;QL(1 ea
MISC DEVI per 365 days
CLEVER CHOICE Limit 200 per retail); RX/OTC
COMFORT EZPEN 2 month;QL(6.67 Limited to 1
NEEDLES 33GX8MM ea daily) device per
MISC INPEN 100/PINK/NOVO 2 year;QL(1 ea
DEVI
DROPLET INSULIN Limit 200 per per 365 days
SYRINGE U-100/1ML/31G 2 month;QL(6.67 retail); RX/OTC
X 15/64" MISC ea daily) INSULIN SYRINGES AND 2 MO
EASY GLIDE PEN Limit 200 per PEN NEEDLES
NEEDLES 33G X 5/32" 2 month;QL(6.67 Limit 200 per
MISC ea daily) INSUPEN 33GX4MM MISC 2 month;QL(6.67
EASY TOUCH FLIPLOCK ea daily)
2
NEEDLES 30GX1/2" MISC Limited to 1
EASY TOUCH device per
HYPODERMIC NEEDLES 2 NOVOPEN ECHO DEVI 2 year;QL(1 ea
30GX1/2" MISC per 365 days
retail); RX/OTC
Limited to 1
device per POLY HUB NEEDLE/30G 2
HUMAPEN LUXURA HD X 1/2" MISC
2 year;QL(1 ea
DEVI per 365 days RELION INSULIN Limit 200 per
retail); RX/OTC SYRINGE 2 month;QL(6.67
HYPODERMIC NEEDLE 1ML/31GX15/64" MISC ea daily)
2
30GX1/2" MISC RELION INSULIN Limit 200 per
Limited to 1 SYRINGE/U-100/1ML/31G 2 month;QL(6.67
device per X 15/64" MISC ea daily)
INPEN 100/BLUE/LILLY 2 year;QL(1 ea TECHLITE INSULIN Limit 200 per
DEVI per 365 days SYRINGEU-100/1ML/31G 2 month;QL(6.67
retail); RX/OTC X 15/64" MISC ea daily)
Limited to 1 ULTRACARE PEN Limit 200 per
device per NEEDLES/33G X 5/32" 2 month;QL(6.67
INPEN 100/BLUE/NOVO 2 year;QL(1 ea MISC ea daily)
DEVI per 365 days Limit 200 per
retail); RX/OTC UNIFINE PENTIPS 2 month;QL(6.67
33GX4MM MISC
Limited to 1 ea daily)
device per Limit 200 per
INPEN 100/GRAY/LILLY UNIFINE PENTIPS PLUS
2 year;QL(1 ea 2 month;QL(6.67
DEVI 33GX4MM MISC
per 365 days ea daily)
retail); RX/OTC
Limited to 1 MIGRAINE PRODUCTS - Drugs to Treat Migraine
device per Headaches
INPEN 100/GREY/NOVO 2 year;QL(1 ea Migraine Combinations
DEVI per 365 days CAFERGOT TABS (Use
retail); RX/OTC GP
Ergotamine w/ Caffeine)
ergotamine w/ caffeine tabs 1
page ii-iii.
74
MIGERGOT SUPP 2 Limit 12 per
MAXALT-MLT TBDP (Use GP month;QL(0.4
Rizatriptan Benzoate) ea daily)
Migraine Products
Limit 8 inhalers QL(9 ea per fill
dihydroergotamine per naratriptan hcl tabs 1 retail,9 ea per
3 30 days retail)
mesylate soln month;QL(0.27
ml daily) ONZETRA XSAIL EXHP 3 PA
ERGOMAR SUBL 2 RELPAX TABS (Use GP QL(0.2 ea
Limit 8 inhalers Eletriptan Hydrobromide) daily)
per rizatriptan benzoate tabs 5 1 QL(0.6 ea
MIGRANAL SOLN 3 mg, 10 mg daily)
month;QL(0.27
ml daily) Limit 12 per
rizatriptan benzoate tbdp 5 1 month;QL(0.4
Serotonin Agonists mg, 10 mg ea daily)
QL(0.2 ea
almotriptan malate tabs 1
daily) Limit 6
QL(9 ea per fill sumatriptan soln 20 mg/act 1 sprayers per
AMERGE TABS (Use month;QL(2 ea
GP retail,9 ea per daily)
Naratriptan HCl) 30 days retail)
QL(6 ea per fill
AXERT TABS (Use GP QL(0.2 ea sumatriptan soln 5 mg/act 1 retail,6 ea per
Almotriptan Malate) daily) 30 days retail)
eletriptan hydrobromide QL(0.2 ea
tabs 3
daily) sumatriptan succinate tabs 1 QL(2 ea daily)
QL(9 ea per fill zolmitriptan tabs 5 mg, 2.5 QL(0.2 ea
retail,9 ea per 3
FROVA TABS (Use mg daily)
GP 30 days
Frovatriptan Succinate) retail,27 ea per Limit 6 per
zolmitriptan tbdp 5 mg, 2.5 3 month;QL(0.2
60 days mail) mg ea daily)
QL(9 ea per fill
retail,9 ea per QL(6 ea per 30
frovatriptan succinate tabs 3 30 days ZOMIG SOLN NA 5 MG, 3 days retail,18
retail,27 ea per 2.5 MG ea per 90 days
60 days mail) mail)
Limit 6 ZOMIG TABS OR 5 MG, GP QL(0.2 ea
IMITREX SOLN NA 20 2.5 MG (Use Zolmitriptan) daily)
sprayers per
MG/ACT (Use GP Limit 6 per
month;QL(2 ea ZOMIG ZMT TBDP (Use
Sumatriptan) daily) GP month;QL(0.2
Zolmitriptan) ea daily)
IMITREX SOLN NA 5 QL(6 ea per fill
MG/ACT (Use GP retail,6 ea per MINERALS & ELECTROLYTES
Sumatriptan) 30 days retail)
IMITREX TABS OR 25 MG, QL(2 ea daily) Calcium
50 MG, 100 MG (Use GP
Sumatriptan Succinate) CALCIFOL WAFR 3
MAXALT TABS (Use CALCIUM-FOLIC ACID
GP QL(0.6 ea PLUS D WAFR
3
Rizatriptan Benzoate) daily)
Fluoride
page ii-iii.
75
FLORIVA LIQD 3 potassium bicarb & chloride 1
tbef
AL(Up to 6 yrs
FLUORABON SOLN 2 potassium bicarbonate tbef 1
old ); PV
FLURA-DROPS SOLN 2 AL(Up to 6 yrs potassium chloride cpcr or 1
old ); PV 8 meq, 10 meq
LOZI-FLUR LOZG 2 POTASSIUM CHLORIDE 3
ER TBCR
LURIDE SOLN (Use GP AL(Up to 6 yrs potassium chloride
Sodium Fluoride) old ); PV microencapsulated crystals 1
er tbcr
sodium fluoride chew 1 AL(Up to 6 yrs
old ); PV potassium chloride pack or 1
20 meq
sodium fluoride soln 1 AL(Up to 6 yrs
old ); PV potassium chloride soln or 1
10 %, 20 %
sodium fluoride tabs 1 AL(Up to 6 yrs
old ); PV potassium chloride tbcr or 8 1
Iodine Products meq, 10 meq
IODINE STRONG SOLN 3 Zinc
GALZIN CAPS 3
Magnesium
MAGNEBIND 400 TABS 3 MISCELLANEOUS THERAPEUTIC CLASSES
Phosphate Chelating Agents

K-PHOS NEUTRAL TABS CUPRIMINE CAPS 2 PA
(Use Pot Phosphate
Monobasic w/ Sod GP DEPEN TITRATABS TABS 2
Phosphate Dibasic &
Monobasic) PA; Must use
SYPRINE CAPS (Use GP AcariaHlth Sp
K-PHOS TABS 2 Trientine HCl) Rx 1-844-538-
4661;SP
pot phosphate monobasic
w/ sod phosphate dibasic & 1 PA; Must use
monobasic tabs trientine hcl caps 3 AcariaHlth Sp
Rx 1-844-538-
Potassium 4661;SP
EFFER-K TBEF 3 Immunomodulators
REVLIMID CAPS 2 PA; AC
K-TAB TBCR 20 MEQ 3
K-TAB TBCR 8 MEQ, 10 THALOMID CAPS 3 SP; AC
MEQ (Use Potassium GP
Chloride) Immunosuppressive Agents
KLOR-CON M15 TBCR 2 ASTAGRAF XL CP24 3 PA
KLOR-CON/25 PACK 2 AZASAN TABS 3

MICRO-K CPCR (Use GP azathioprine tabs 1
Potassium Chloride)
page ii-iii.
76
CELLCEPT CAPS (Use GP SANDIMMUNE SOLN 100 2
Mycophenolate Mofetil) MG/ML
CELLCEPT SUSR (Use GP sirolimus tabs 3
Mycophenolate Mofetil)
CELLCEPT TABS (Use GP tacrolimus caps 1
Mycophenolate Mofetil)
cyclosporine caps 1 ZORTRESS TABS 2
cyclosporine modified (for Potassium Removing Agents

1
microemulsion) caps KAYEXALATE POWD (Use
cyclosporine modified (for Sodium Polystyrene GP
1 Sulfonate)
microemulsion) soln
CYCLOSPORINE sodium polystyrene 1
2 sulfonate powd or
MODIFIED CAPS
CYCLOSPORINE sodium polystyrene
MODIFIED CAPS (Use sulfonate susp or 15 1
GP gm/60ml
Cyclosporine Modified (For
Microemulsion)) sodium polystyrene
IMURAN TABS (Use sulfonate susp re 30 3
GP gm/120ml, 50 gm/200ml
Azathioprine)
mycophenolate mofetil ST; QL(1 ea
1 VELTASSA PACK 16.8 GM 3
caps daily)
VELTASSA PACK 8.4 GM, 3 ST
mycophenolate mofetil susr 1 25.2 GM
mycophenolate mofetil tabs 1 MOUTH/THROAT/DENTAL AGENTS
mycophenolate sodium 3 Anesthetics Topical Oral
tbec
lidocaine hcl (mouth-throat) 1
MYFORTIC TBEC (Use GP soln
Mycophenolate Sodium)
NEORAL CAPS (Use Anti-infectives - Throat
Cyclosporine Modified (For GP clotrimazole lozg 1
Microemulsion))
NEORAL SOLN (Use clotrimazole troc 1
Cyclosporine Modified (For GP
Microemulsion)) nystatin (mouth-throat) 1
susp
PROGRAF CAPS (Use GP
Tacrolimus) ORAVIG TABS 3
RAPAMUNE SOLN 1 3
MG/ML Dental Products
RAPAMUNE TABS 0.5 GEL-KAM ORAL CARE RX/OTC
MG, 1 MG, 2 MG (Use GP RINSE CONC (Use GP
Sirolimus) Stannous Fluoride)
SANDIMMUNE CAPS 25 NAFRINSE 3
MG, 100 MG (Use GP DAILY/NEUTRAL SOLR
Cyclosporine) NAFRINSE WEEKLY 3
SOLR
page ii-iii.
77
PREVIDENT RINSE SOLN Use generic
(Use Sodium Fluoride GP POLY-VI-FLOR CHEW polyvitamin
(Dental)) 200MCG-1MG-15UNIT- 3 with
sodium fluoride (dental) 400UNIT floride;AL(Up to
3 6 yrs old )
soln
RX/OTC POLY-VI-FLOR SUSP 3
stannous fluoride conc 3 200MCG/ML-0.25MG/ML
Steroids - Mouth/Throat QUFLORA GUMMIES 2 AL(Up to 6 yrs
CHEW old )
(mouth) pste QUFLORA PEDIATRIC 2 AL(Up to 6 yrs
CHEW old )
Throat Products - Misc. QUFLORA PEDIATRIC AL(Up to 6 yrs
QL(3 ea daily) 2
cevimeline hcl caps 3 SOLN old )
EVOXAC CAPS (Use TRI-VI-FLOR SUSP 3
GP QL(3 ea daily)
Cevimeline HCl)
TRI-VI-FLORO SUSP 3
MUCOTROL WAFR 3
Ped Multi Vitamins w/Fl & FE
pilocarpine hcl (oral) tabs 5 1 QL(6 ea daily)
mg ESCAVITE D CHEW 3
pilocarpine hcl (oral) tabs 1 QL(4 ea daily)
7.5 mg MYKIDZ IRON FL SUSP 3
SALAGEN TABS 5 MG QL(6 ea daily) ped multivitamins w/fl &
(Use Pilocarpine HCl GP 1
iron soln
(Oral))
pediatric vitamins acd 1 AL(Up to 6 yrs
SALAGEN TABS 7.5 MG QL(4 ea daily) fluoride & iron soln old )
(Use Pilocarpine HCl GP
(Oral)) QUFLORA FE PEDIATRIC 2 AL(Up to 6 yrs
LIQD old )
MULTIVITAMINS Pediatric Multiple Vitamins & Minerals w/ Fluoride
Ped MV w/ Fluoride FLORIVA CHEW 3
AL(Up to 6 yrs
FLORIVA PLUS SOLN 2 TEXAVITE LQ LIQD 3
old )
MULTIVITAMIN/FLUORID 2 AL(Up to 6 yrs
E CHEW old ) Prenatal Vitamins
pediatric multivitamins w/fl 1 AL(Up to 6 yrs ACTIVE OB CAPS 3
chew old )
pediatric multivitamins w/fl AL(Up to 6 yrs ATABEX EC TBEC 2
1
soln old )
pediatric vitamins acd w/ AL(Up to 6 yrs BAL-CARE DHA MISC 2
1
fluoride soln old )
C-NATE DHA CAPS 3
POLY-VI-FLOR CHEW AL(Up to 6 yrs
200MCG-0.5MG-15UNIT- 3 old )
400UNIT, 200MCG- CALCIUM PNV CAPS 3
0.25MG-15UNIT-400UNIT CITRANATAL 90 DHA 2
MISC
page ii-iii.
78
CITRANATAL ASSURE 2 HEMENATAL OB + DHA 2
MISC MISC
CITRANATAL B-CALM 3 HEMENATAL OB TABS 3
MISC
CITRANATAL BLOOM INFANATE BALANCE 3
2 CAPS
DHA MISC
CITRANATAL BLOOM MACNATAL CN DHA 3
3 CAPS
TABS
CITRANATAL DHA MISC 2 MARNATAL-F CAPS 2
CITRANATAL HARMONY MYNATAL ADVANCE 2
3 TABS
CAPS
CITRANATAL MEDLEY MYNATAL ULTRACAPLET 2
3 TABS
CAPS
CITRANATAL RX TABS 2 MYNATE 90 PLUS TBCR 2
COMPLETENATE CHEW 2 NATACHEW CHEW 3
CONCEPT DHA CAPS 2 NATELLE ONE CAPS 3
CONCEPT OB CAPS 2 NEEVO DHA CAPS 3

CVS WOMENS 3 NESTABS ABC MISC 3
PRENATAL+DHA MISC
DOTHELLE DHA CAPS 2 NESTABS DHA MISC 2
DUET DHA 400 MISC 3 NESTABS ONE CAPS 3
DUET DHA BALANCED 3 NESTABS TABS 3

MISC
NEWGEN TABS 3
ENBRACE HR CAPS 3
EXTRA-VIRT PLUS DHA NEXA PLUS CAPS 3
3
CAPS
OB COMPLETE 3
FOCALGIN 90 DHA MISC 2 ADVANCED CAPS
OB COMPLETE GOLD 3
FOCALGIN CA MISC 2 CAPS
OB COMPLETE ONE 3
FOLCAL DHA CAPS 3 CAPS
FOLCAPS OMEGA 3 OB COMPLETE PETITE 3
3 CAPS
CAPS
OB COMPLETE PREMIER 3
FOLET DHA THPK 3 TABS
FOLET ONE CAPS 3 OB COMPLETE/DHA 3
CAPS
FOLIVANE-OB CAPS 2 OBSTETRIX DHA MISC 2 RX/OTC
page ii-iii.
79
OBSTETRIX ONE CAPS 3 PRENAISSANCE NEXT-B 3
TABS
OBTREX DHA MISC 2 RX/OTC PRENAISSANCE PLUS 3
CAPS
PNV FERROUS
FUMARATE/DOCUSATE/F 3 PRENATA CHEW 2
OLIC ACID TABS
PRENATABS RX TABS 2
PNV OB+DHA MISC 2
PRENATAL + DHA THPK 3
PNV TABS 29-1 TABS 2
PRENATAL 19 CHEW
PNV-DHA CAPS 3 30UNIT-1000UNIT-20MG-
3MG-200MG-29MG-7MG-
PNV-DHA+DOCUSATE 3 15MG-3MG-12MCG-
CAPS 400UNIT-1MG-20MG- 2
100MG, 1000UNIT-
PNV-OMEGA CAPS 3 400UNIT-20MG-25MG-
3MG-200MG-29MG-7MG-
PNV-SELECT TABS 3 6MG-3MG-12MCG-1MG-
30UNIT-20MG-100MG
PNV-TOTAL CAPS 3
PRENATAL 19 TABS
1000UNIT-30UNIT-20MG-
PNV-VP-U CAPS 2 25MG-3MG-200MG-29MG-
15MG-3MG-7MG-12MCG-
PR NATAL 400 EC MISC 2 400UNIT-20MG-1MG-
100MG, 30UNIT- 3
PR NATAL 430 EC MISC 2 1000UNIT-20MG-25MG-
3MG-200MG-29MG-7MG-
PR NATAL 430 MISC 2 15MG-3MG-12MCG-
400UNIT-1MG-20MG-
PREFERA OB TABS 3 100MG
PRENATAL
PREFERAOB +DHA MISC 2 MULTIVITAMIN PLUS 3
DHA MISC
PREMESISRX TABS 3 PRENATAL PLUS IRON 2
TABS
PRENA 1 TRUE MISC 2
prenatal vit w/ docusate- 1
PRENA1 CHEW CHEW 3 iron carbonyl-folic acid tabs
prenatal without a vit w/ fe 1
PRENA1 PEARL CPCR 3 fumarate-folic acid tabs
PRENAISSANCE PRENATAL+DHA MISC 3
3
BALANCE CAPS
PRENATAL-U CAPS 2
PRENAISSANCE CAPS 3
PRENAISSANCE PRENATE AM TABS 3
3
HARMONY DHA MISC
PRENATE CHEW 3
PRENAISSANCE NEXT 3
TABS
page ii-iii.
80
PRENATE DHA CAPS PROVIDA OB CAPS 2
18MG-600MCG-40UNIT-
300MG-50MG-155MG- 3 R-NATAL OB CAPS 3
25MCG-400UNIT-
400MCG-26MG-90MG
RELNATE DHA CAPS 3
PRENATE DHA CAPS QL(1 ea daily)
600MCG-10UNIT-300MG- RULAVITE DHA CAPS 3
50MG-145MG-28MG- 2
13MCG-220UNIT- SE-NATAL 19 CHEW
400MCG-26MG-90MG 30UNIT-1000UNIT-100MG-
PRENATE ELITE TABS 20MG-3MG-200MG-29MG- 2
20MG-600MCG-40UNIT- 7MG-15MG-3MG-12MCG-
150MCG-2600UNIT- 400UNIT-1MG-20MG
1.5MG-15MG-25MG- 3 SE-NATAL 19 TABS
155MG-3MG-21MG- 30UNIT-1000UNIT-20MG-
3.5MG-13MCG-600UNIT- 25MG-200MG-29MG-7MG-
400MCG-330MCG-21MG- 3
15MG-3MG-12MCG-
75MG 400UNIT-3MG-20MG-
PRENATE ELITE TABS 1MG-100MG
600MCG-10UNIT- SELECT-OB CHEW
150MCG-2600UNIT- 0.6MG-29MG-30UNIT-
1.5MG-15MG-25MG-3MG- 15MG-25MG-1700UNIT-
100MG-26MG-6MG-21MG- 2
15MG-1.8MG-5MCG-
3.5MG-13MCG-450UNIT- 400UNIT-1.6MG-0.4MG-
400MCG-330MCG-21MG- 2.5MG-60MG
75MG, 600MCG-10UNIT- 2 SELECT-OB CHEW
150MCG-2600UNIT- 1700UNIT-29MG-30UNIT-
1.5MG-15MG-15MG- 15MG-25MG-1.6MG-
25MG-3MG-100MG-26MG- 3
15MG-1.8MG-5MCG-
6MG-21MG-3.5MG- 400UNIT-1MG-2.5MG-
13MCG-450UNIT- 60MG
400MCG-330MCG-21MG-
75MG SELECT-OB+DHA MISC 3
PRENATE ENHANCE 3
CAPS TARON-BC MISC 3
PRENATE ESSENTIAL 3
CAPS TARON-C DHA CAPS 2
PRENATE MINI CAPS 3 TARON-PREX CAPS 3
PRENATE PIXIE CAPS 3 THRIVITE 19 TABS 3

PRENATE RESTORE 3 THRIVITE RX TABS 2
CAPS
PRENATE STAR TABS 3 TL-CARE DHA CAPS 3
PREQUE 10 TABS 3 TL-SELECT CAPS 3
PROVIDA DHA CAPS 2 TRI-TABS DHA MISC 2
page ii-iii.
81
TRICARE PRENATAL VIRT-C DHA CAPS 2
CHEW 1MG-60MCG-1MG-
32.5MCG-4.5MG- VIRT-NATE DHA CAPS 3
37.5MCG-1MG-15UNIT- 3
7MG-1.25MG-5MG-10MG-
0.85MG-125MCG- VIRT-PN DHA CAPS 3
400UNIT-150MCG-2.5MG-
30MG VIRT-PN PLUS CAPS 3
TRICARE PRENATAL 3 VIRT-PN TABS 3
COMPLEAT MISC
TRICARE PRENATAL 3 VIRT-SELECT CAPS 3
DHA ONE CAPS
TRICARE PRENATAL 2 VIRT-VITE GT TABS 2
DHA ONE/FOLATE CAPS
TRICARE PRENATAL VIRTPREX CAPS 3
THPK 75MG-1MG-
37.5MG-60MCG-1MG- VITAFOL FE+ CPPK 3
32.5MCG-37.5MCG-
4.5MG-150MG-1MG- 2 VITAFOL GUMMIES 3
15UNIT-7MG-1.25MG- CHEW
5MG-10MG-0.85MG- VITAFOL-NANO TABS 3
125MCG-400UNIT-
150MCG-2.5MG-30MG VITAFOL-ONE CAPS 3
TRINATAL GT TABS 2 VITAMEDMD ONE 3
RX/QUATREFOLIC CAPS
TRINATAL RX 1 TABS 2
VITAMEDMD PLUS 3
TRISTART DHA CAPS 3 RX/QUATREFOLIC MISC
VITAMEDMD REDICHEW 3
TRISTART ONE CAPS 3 RX CHEW
VITAPEARL CPCR 3
TRIVEEN-PRX RNF CAPS 3
ULTIMATECARE ONE VITATRUE MISC 2
3
CAPS
ULTIMATECARE ONE NF VIVA DHA CAPS 3
3
CAPS
VOL-TAB RX TABS 2
VEMAVITE-PRX 2 CAPS 3
VP-CH PLUS CAPS 3
VENA-BAL DHA MISC 2
VP-CH-PNV CAPS 3
VIL-RX TABS 2
VP-GGR-B6 PRENATAL 3
VINATE DHA RF CAPS 3 TABS
VP-HEME OB + DHA MISC 2
VINATE ONE TABS 2
VP-HEME OB TABS 3
VIRT-ADVANCE TABS 2
page ii-iii.
82
VP-PNV-DHA CAPS 3 tizanidine hcl tabs 2 mg 1
WEGMANS COMPLETE 3 tizanidine hcl tabs 4 mg 1 QL(9 ea daily)
PRENATAL+DHA MISC
ZANAFLEX CAPS 2 MG, 4
ZATEAN-CH CAPS 3 MG, 6 MG (Use Tizanidine GP
HCl)
ZATEAN-PN DHA CAPS 3
ZANAFLEX TABS 4 MG GP QL(9 ea daily)
ZATEAN-PN PLUS CAPS 3 (Use Tizanidine HCl)
Direct Muscle Relaxants
MUSCULOSKELETAL THERAPY AGENTS - DANTRIUM CAPS (Use
Drugs to Treat Spasms GP
Dantrolene Sodium)
Central Muscle Relaxants
dantrolene sodium caps 1
baclofen tabs 10 mg 1 QL(6 ea daily)
Muscle Relaxant Combinations
baclofen tabs 20 mg 1 QL(4 ea daily) carisoprodol w/ aspirin & 3
codeine tabs
BACLOFEN TABS 5 MG 2
carisoprodol w/ aspirin tabs 1
carisoprodol tabs 250 mg 3 NASAL AGENTS - SYSTEMIC AND TOPICAL -
Drugs to treat the Nose or Sinus
carisoprodol tabs 350 mg 1
Nasal Agent Combinations
CHLORZOXAZONE TABS 3 Limit 1 bottle
per
cyclobenzaprine hcl tabs 5 DYMISTA SUSP 3
1 month;QL(0.77
mg, 10 mg gm daily)
LORZONE TABS 3 Nasal Anti-infectives
QL(4 ea daily) BACTROBAN NASAL 2
metaxalone tabs 3 OINT
methocarbamol tabs 1 Nasal Antiallergy
Limit 1 bottle
orphenadrine citrate tb12 1 ASTEPRO SOLN (Use GP per
Azelastine HCl) month;QL(1.2
PARAFON FORTE DSC ml daily)
TABS (Use GP
Chlorzoxazone) Limit 1 inhaler
azelastine hcl soln 0.1 %, 1 per
ROBAXIN TABS (Use GP 137 mcg/spray month;QL(1.2
Methocarbamol) ml daily)
ROBAXIN-750 TABS (Use GP Limit 1 bottle
Methocarbamol)
azelastine hcl soln 0.15 % 1 per
SKELAXIN TABS (Use month;QL(1.2
GP QL(4 ea daily) ml daily)
Metaxalone)
SOMA TABS (Use GP olopatadine hcl (nasal) soln 3
Carisoprodol)
tizanidine hcl caps 2 mg, 4 PATANASE SOLN (Use GP
3 Olopatadine HCl (Nasal))
mg, 6 mg
page ii-iii.
83
Nasal Anticholinergics RILUTEK TABS (Use GP
ipratropium bromide (nasal) Riluzole)
1
soln riluzole tabs 3
Nasal Steroids
FLONASE ALLERGY QL(32 ml per OPHTHALMIC AGENTS - Drugs to Treat the Eye
RELIEF CHILDRENS GP fill retail,32 ml Artificial Tears and Lubricants
SUSP (Use Fluticasone per 30 days
Propionate (Nasal)) retail); RX/OTC LACRISERT INST 3
FLONASE ALLERGY QL(32 ml per
RELIEF SUSP (Use fill retail,32 ml Beta-blockers - Ophthalmic
GP BETAGAN SOLN (Use
Fluticasone Propionate per 30 days GP
(Nasal)) retail); RX/OTC Levobunolol HCl)
QL(32 ml per betaxolol hcl (ophth) soln 1
fluticasone propionate 1 fill retail,32 ml
(nasal) susp per 30 days BETIMOL SOLN 2
retail); RX/OTC
Limit 2 inhalers BETOPTIC-S SUSP 2
mometasone furoate 1 per
(nasal) susp month;QL(1.22 carteolol hcl (ophth) soln 3
gm daily)
Limit 1 sprayer CARTEOLOL HCL SOLN 3
per
NASACORT ALLERGY 2 month;QL(1.2 COMBIGAN SOLN 3
24HR AERO ml daily);
RX/OTC COSOPT PF SOLN (Use
Limit 1 sprayer Dorzolamide HCl-Timolol GP
NASACORT ALLERGY per Maleate)
24HR AERO (Use GP month;QL(1.2 COSOPT SOLN (Use
Triamcinolone Acetonide ml daily); Dorzolamide HCl-Timolol GP
(Nasal)) RX/OTC Maleate)
Limit 1 sprayer dorzolamide hcl-timolol
NASACORT ALLERGY per maleate soln 2%-0.5%, 1
24HR CHILDRENS AERO GP month;QL(1.2 22.3mg/ml-6.8mg/ml
(Use Triamcinolone ml daily);
Acetonide (Nasal)) dorzolamide hcl-timolol
RX/OTC maleate soln 20mg/ml- 3
Limit 2 inhalers 5mg/ml
NASONEX SUSP (Use per
Mometasone Furoate GP DORZOLAMIDE
month;QL(1.22 HCL/TIMOLOL MALEATE 2
(Nasal)) gm daily) SOLN
Limit 1 sprayer
per ISTALOL SOLN 2
triamcinolone acetonide 1 month;QL(1.2
(nasal) aero ISTALOL SOLN (Use GP
ml daily); Timolol Maleate (Ophth))
RX/OTC
levobunolol hcl soln 1
NEUROMUSCULAR AGENTS - Drugs to
Relax/Paralyze Muscles
METIPRANOLOL SOLN 3
ALS Agents
page ii-iii.
84
timolol maleate (ophth) 1 ALPHAGAN P SOLN 0.15
solg % (Use Brimonidine GP
timolol maleate (ophth) Tartrate)
1
soln apraclonidine hcl soln 3
TIMOLOL MALEATE
OPHTHALMIC GEL 2 brimonidine tartrate soln 1
FORMING SOLG
TIMOPTIC OCUDOSE IOPIDINE SOLN 0.5 % GP
3 (Use Apraclonidine HCl)
SOLN
TIMOPTIC SOLN (Use GP IOPIDINE SOLN 1 % 3
Timolol Maleate (Ophth))
TIMOPTIC-XE SOLG 0.25 SIMBRINZA SUSP 3
% (Use Timolol Maleate GP
(Ophth)) Ophthalmic Anti-infectives
TIMOPTIC-XE SOLG 0.25 QL(6 ml per 30
2 days retail,0.0
%, 0.5 % AZASITE SOLN 3
ml per 90 days
Cycloplegic Mydriatics mail)
ATROPINE SULFATE 2
OINT OP 1 % bacitracin (ophthalmic) oint 1
ATROPINE SULFATE 2 bacitracin-polymyxin b
SOLN OP 1 % 1
(ophth) oint
CYCLOGYL SOLN (Use GP BESIVANCE SUSP 3
Cyclopentolate HCl)
BETADINE OPHTHALMIC 3
CYCLOMYDRIL SOLN 3 PREP SOLN
cyclopentolate hcl soln 1 BLEPH-10 SOLN (Use
Sulfacetamide Sodium GP
homatropine hbr soln 1 (Ophth))
CILOXAN OINT 2
ISOPTO ATROPINE SOLN 2
CILOXAN SOLN (Use GP
MYDRIACYL SOLN (Use GP Ciprofloxacin HCl (Ophth))
Tropicamide) ciprofloxacin hcl (ophth) 1
tropicamide soln 3 soln
Miotics erythromycin (ophth) oint 1

ISOPTO CARPINE SOLN GP QL(0.5 ml gatifloxacin (ophth) soln 1
(Use Pilocarpine HCl) daily)
PHOSPHOLINE IODIDE 2 GENTAK OINT 2
SOLR
QL(0.5 ml gentamicin sulfate (ophth) 1
pilocarpine hcl soln 1
daily) oint
gentamicin sulfate (ophth) 1
Ophthalmic Adrenergic Agents soln
ALPHAGAN P SOLN 0.1 % 2 levofloxacin (ophth) soln 3
page ii-iii.
85
MOXEZA SOLN 2 Ophthalmic Immunomodulators
QL(64 ml per
moxifloxacin hcl (ophth) QL(3 ml per fill RESTASIS EMUL 3
1 fill retail)
soln retail)
RESTASIS MULTIDOSE 3 QL(64 ml per
NATACYN SUSP 2 EMUL fill retail)
neomycin-bacitracin zn- Ophthalmic Integrin Antagonists
1
polymyxin oint PA
XIIDRA SOLN 3
neomycin-polymyxin- 1
gramicidin soln Ophthalmic Local Anesthetics
NEOSPORIN SOLN (Use
Neomycin-Polymyxin- GP AKTEN GEL 3
Gramicidin) ALCAINE SOLN (Use GP
OCUFLOX SOLN (Use Proparacaine HCl)
GP QL(5 ml per fill
Ofloxacin (Ophth)) retail)
proparacaine hcl soln 3
QL(5 ml per fill
ofloxacin (ophth) soln 1
retail) tetracaine hcl (ophth) soln 3
polymyxin b-trimethoprim 1
soln Ophthalmic Steroids
POLYTRIM SOLN (Use GP ALREX SUSP 3
Polymyxin B-Trimethoprim)
sulfacetamide sodium bacitracin-poly-neomycin- 1 QL(4 gm per fill
1 hc oint retail)
(ophth) oint
sulfacetamide sodium BLEPHAMIDE S.O.P. 2
1 OINT
(ophth) soln
tobramycin (ophth) soln 1 BLEPHAMIDE SUSP 2
TOBREX OINT 2 DUREZOL EMUL 3

TOBREX SOLN (Use GP FLAREX SUSP 2
Tobramycin (Ophth))
fluorometholone (ophth) 1
trifluridine soln 1 susp
VIGAMOX SOLN (Use GP QL(3 ml per fill FML FORTE SUSP 2
Moxifloxacin HCl (Ophth)) retail)
VIROPTIC SOLN (Use FML LIQUIFILM SUSP
GP (Use Fluorometholone GP
Trifluridine)
(Ophth))
ZIRGAN GEL 3
FML OINT 2
ZYMAXID SOLN (Use GP
Gatifloxacin (Ophth)) LOTEMAX GEL 3
Ophthalmic Decongestants
LOTEMAX OINT 3
phenylephrine hcl (ophth) 3
soln 10 % Limit 1 bottle
phenylephrine hcl (ophth) per
1 LOTEMAX SUSP 3
soln 2.5 % month;QL(0.2
ml daily)
page ii-iii.
86
MAXIDEX SUSP 2 ZYLET SUSP 3 QL(5 ml per fill
retail)
MAXITROL OINT (Use Ophthalmic Surgical Aids
Neomycin-Polymy- GP
Dexameth) GELFILM OP FILM 3
MAXITROL SUSP (Use
Neomycin-Polymy- GP Ophthalmics - Misc.
Dexameth) ACULAR LS SOLN (Use
neomycin-polymy- Ketorolac Tromethamine GP
1 (Ophth))
dexameth oint
neomycin-polymy- ACULAR SOLN (Use
1 Ketorolac Tromethamine GP
dexameth susp
(Ophth))
neomycin-polymyxin-hc 1
(ophth) susp ACUVAIL SOLN 3
OMNIPRED SUSP (Use
Prednisolone Acetate GP ALOCRIL SOLN 3
(Ophth))
PRED FORTE SUSP (Use ALOMIDE SOLN 2
Prednisolone Acetate GP
(Ophth)) azelastine hcl (ophth) soln 1
PRED MILD SUSP 2 Limit 10mls per
AZOPT SUSP 2 month;QL(0.4
PRED-G S.O.P. OINT 3 ml daily)
ST; Limit 10ml
PRED-G SUSP 3 per
BEPREVE SOLN 3
month;QL(0.34
prednisolone acetate 1 ml daily)
(ophth) susp
bromfenac sodium (ophth) 1
PREDNISOLONE 2 soln
ACETATE P-F SUSP
PREDNISOLONE SODIUM BROMFENAC SOLN 2
PHOSPHATE SOLN OP 1 2
% BROMSITE SOLN 3
PREDNISOLONE/MOXIFL 3 cromolyn sodium (ophth)
OXACIN SOLN 1
soln
sulfacetamide sod- 1 Limit 4 bottles
prednisolone soln per
CYSTARAN SOLN 3
month;QL(2.15
TOBRADEX OINT 3 ml daily)
TOBRADEX ST SUSP 3 diclofenac sodium (ophth) 1
soln
TOBRADEX SUSP (Use QL(5 ml per fill
Tobramycin- GP retail) dorzolamide hcl soln 1
Dexamethasone) DORZOLAMIDE HCL
tobramycin- QL(5 ml per fill 2
1 SOLN
dexamethasone susp retail) ELESTAT SOLN (Use GP
Epinastine HCl (Ophth))
page ii-iii.
87
EMADINE SOLN 3 Limit 2.5mls
bimatoprost soln 1 per
epinastine hcl (ophth) soln 1 month;QL(0.09
ml daily)
fluorescein sodium topical 3 Limit 2.5mls
strp
latanoprost soln op 1 per
month;QL(0.09
flurbiprofen sodium soln 1 ml daily)
FUL-GLO STRP 3 Limit 2.5mls
LATANOPROST SOLN OP 2 per
ILEVRO SUSP 3 month;QL(0.09
ml daily)
ketorolac tromethamine 1 Limit 2.5mls
(ophth) soln
LUMIGAN SOLN 2 per
ST month;QL(0.09
LASTACAFT SOLN 3 ml daily)
NEVANAC SUSP 3 Limit 1 bottle
RESCULA SOLN 3 per
OCUFEN SOLN (Use month;QL(0.17
GP ml daily)
Flurbiprofen Sodium)
Limit 10mls per Limit 2.5mls
olopatadine hcl soln 0.1 % 1 month;QL(0.34 TRAVATAN Z SOLN 2 per
ml daily) month;QL(0.09
Limit 2.5mls ml daily)
per Limit 2.5mls
olopatadine hcl soln 0.2 % 1 XALATAN SOLN (Use
month;QL(0.08 GP per
4 ml daily) Latanoprost) month;QL(0.09
ml daily)
PAREMYD SOLN 3
ZIOPTAN SOLN 3 QL(1 ea daily)
Limit 2.5mls
PATADAY SOLN (Use GP per OTIC AGENTS - Drugs to Treat the Ear
Olopatadine HCl) month;QL(0.08
4 ml daily) Otic Agents - Miscellaneous
Limit 10mls per
PATANOL SOLN (Use GP month;QL(0.34 acetic acid (otic) soln 1
Olopatadine HCl) ml daily) acetic acid-aluminum 1
ST; Limit acetate soln
PAZEO SOLN 3 2.5mls per Otic Anti-infectives
month;QL(0.08
4 ml daily) CETRAXAL SOLN (Use GP
Ciprofloxacin HCl (Otic))
PROLENSA SOLN 3
ciprofloxacin hcl (otic) soln 1
TRUSOPT SOLN (Use GP
Dorzolamide HCl) FLOXIN OTIC SOLN (Use GP
Ofloxacin (Otic))
Prostaglandins - Ophthalmic
ofloxacin (otic) soln 1
Otic Combinations
page ii-iii.
88
CIPRO HC SUSP 3 amoxicillin tabs 1
CIPRODEX SUSP 2 QL(8 ml per fill ampicillin caps 250 mg, 1

retail) 500 mg
COLY-MYCIN S SUSP 3 AMPICILLIN CAPS 500 2
MG
CORTANE-B-OTIC SOLN ampicillin susr 125 mg/5ml,
(Use Pramoxine-HC- GP 1
250 mg/5ml
Chloroxylenol) PA; QL(1 ea
neomycin-polymyxin-hc 1 MOXATAG TB24 3 daily,10 ea per
(otic) soln fill retail)
neomycin-polymyxin-hc 1 Natural Penicillins
(otic) susp
penicillin v potassium solr 1
OTICIN HC NR SOLN (Use 125 mg/5ml, 250 mg/5ml
Pramoxine-HC- GP
Chloroxylenol) PENICILLIN V
POTASSIUM SOLR 125 2
Limit 15mls per MG/5ML, 250 MG/5ML
OTOVEL SOLN 3 month;QL(0.5
ea daily) penicillin v potassium tabs 1
250 mg, 500 mg
PRAMOTIC LIQD 3
Penicillin Combinations
pramoxine-hc-chloroxylenol 1 amoxicillin & pot
soln 1
clavulanate chew
Otic Steroids amoxicillin & pot 1
DERMOTIC OIL (Use clavulanate susr
Fluocinolone Acetonide GP amoxicillin & pot 1
(Otic)) clavulanate tabs
fluocinolone acetonide amoxicillin & pot 1
3 clavulanate tb12
(otic) oil
QL(10 ml per AUGMENTIN ES-600
hydrocortisone w/acetic 3 fill retail,30 ml SUSR (Use Amoxicillin & GP
acid soln per fill mail) Pot Clavulanate)
OXYTOCICS - Drugs to Prevent/Control Uterine AUGMENTIN SUSR 2
Bleeding 125MG/5ML-31.25MG/5ML
AUGMENTIN SUSR
Oxytocics 250MG/5ML-62.5MG/5ML
methylergonovine maleate GP
1 (Use Amoxicillin & Pot
tabs Clavulanate)
PENICILLINS - Drugs to Treat Bacterial Infections AUGMENTIN TABS
500MG-125MG, 875MG- GP
Aminopenicillins 125MG (Use Amoxicillin &
Pot Clavulanate)
amoxicillin caps 1 AUGMENTIN XR TB12
(Use Amoxicillin & Pot GP
amoxicillin chew 1 Clavulanate)
amoxicillin susr 1 Penicillinase-Resistant Penicillins
page ii-iii.
89
dicloxacillin sodium caps 1 donepezil hydrochloride 1 QL(1 ea daily)
tabs
PROGESTINS - Hormone Replacement/Modifying donepezil hydrochloride 1 QL(1 ea daily)
Drugs tbdp
Progestins EXELON CAPS (Use GP
Rivastigmine Tartrate)
AYGESTIN TABS (Use GP
Norethindrone Acetate) EXELON PT24 (Use GP
Rivastigmine)
medroxyprogesterone 1 QL(1 ea daily)
acetate tabs 10 mg galantamine hydrobromide 1 QL(1 ea daily)
cp24 8 mg, 16 mg, 24 mg
medroxyprogesterone 1
acetate tabs 5 mg, 2.5 mg GALANTAMINE
HYDROBROMIDE SOLN 4 2
MEGACE ES SUSP (Use AC MG/ML
Megestrol Acetate GP
(Appetite)) galantamine hydrobromide 1
tabs 4 mg, 8 mg, 12 mg
megestrol acetate 3 AC
(appetite) susp memantine hcl cp24 7 mg, 3 PA
14 mg, 21 mg, 28 mg
norethindrone acetate tabs 1 memantine hcl soln 2 1
progesterone micronized mg/ml
3 QL(1 ea daily)
caps memantine hcl tabs 1
PROMETRIUM CAPS (Use GP QL(1 ea daily)
Progesterone Micronized) memantine hcl tabs 10 mg 1 QL(2 ea daily)
PROVERA TABS 10 MG QL(1 ea daily)
(Use Medroxyprogesterone GP memantine hcl tabs 5 mg 1 QL(4 ea daily)
Acetate)
NAMENDA SOLN 10
PROVERA TABS 5 MG, MG/5ML (Use Memantine GP
2.5 MG (Use GP HCl)
Medroxyprogesterone
Acetate) NAMENDA TABS 10 MG GP QL(2 ea daily)
(Use Memantine HCl)
PSYCHOTHERAPEUTIC AND NEUROLOGICAL NAMENDA TABS 5 MG
AGENTS - MISC. - Drugs to Treat Mental and GP QL(4 ea daily)
(Use Memantine HCl)
Emotional Conditions
NAMENDA TITRATION
Agents for Chemical Dependency PAK TABS (Use GP
Memantine HCl)
acamprosate calcium tbec 1
NAMENDA XR CP24 (Use GP PA
ANTABUSE TABS (Use GP Memantine HCl)
Disulfiram) NAMENDA XR TITRATION PA
3
disulfiram tabs 1 PACK CP24
NAMZARIC C4PK 3 PA
Anti-Cataplectic Agents
PA NAMZARIC CP24 3 PA
XYREM SOLN 3
Antidementia Agents RAZADYNE ER CP24 (Use QL(1 ea daily)
Galantamine GP
ARICEPT TABS (Use GP QL(1 ea daily) Hydrobromide)
Donepezil Hydrochloride)
page ii-iii.
90
RAZADYNE TABS (Use Postherpetic Neuralgia (PHN)/Neuropathic Pain
Galantamine GP
Hydrobromide) GRALISE STARTER MISC 3 PA
rivastigmine pt24 1 GRALISE TABS 300 MG 3 PA
rivastigmine tartrate caps 1 PA; QL(3 ea

GRALISE TABS 600 MG 3
daily)
Combination Psychotherapeutics Premenstrual Dysphoric Disorder (PMDD) Agents
olanzapine-fluoxetine hcl 3 FLUOXETINE CAPS 10
caps MG
2
SYMBYAX CAPS (Use FLUOXETINE CAPS 20 2 QL(1 ea daily)
Olanzapine-Fluoxetine GP
MG
HCl)
Fibromyalgia Agents Pseudobulbar Affect (PBA) Agents
PA; QL(2 ea NUEDEXTA CAPS 3 PA
SAVELLA TABS 3
daily)
SAVELLA TITRATION PA; QL(2 ea Psychotherapeutic and Neurological Agents -
3
PACK MISC daily) ergoloid mesylates tabs 3
Movement Disorder Drug Therapy
Restless Leg Syndrome (RLS) Agents
AUSTEDO TABS 3 PA
HORIZANT TBCR 300 MG 3 QL(1 ea daily)
INGREZZA CAPS 3 PA
HORIZANT TBCR 600 MG 3 QL(2 ea daily)
tetrabenazine tabs 3 Smoking Deterrents
XENAZINE TABS (Use GP bupropion hcl (smoking PV
Tetrabenazine) 1
deterrent) tb12
Multiple Sclerosis Agents CHANTIX CONTINUING 2 QL(2 ea daily);
AMPYRA TB12 (Use MONTHPAK TABS PV
GP PA CHANTIX STARTING PV
Dalfampridine) 2
PA; SP MONTH PAK TABS
AUBAGIO TABS 3 PV
CHANTIX TABS 0.5 MG 2
dalfampridine tb12 1 PA
QL(2 ea daily);
CHANTIX TABS 1 MG 2
PA; Must use PV
GILENYA CAPS 3 AcariaHlth Sp NICODERM CQ PT24 (Use GP PV
Rx 1-844-538- Nicotine)
4661;SP NICORETTE GUM (Use GP PV
PA; Must use Nicotine Polacrilex)
AcariaHlth Sp NICORETTE LOZG (Use
TECFIDERA CPDR 3
Rx 1-844-538- GP PV
Nicotine Polacrilex)
4661;LA
NICORETTE MINI LOZG GP PV
PA; Must use (Use Nicotine Polacrilex)
TECFIDERA STARTER 3 AcariaHlth Sp
PACK MISC Rx 1-844-538- NICORETTE STARTER PV
4661;LA KIT GUM (Use Nicotine GP
Polacrilex)
page ii-iii.
91
nicotine polacrilex gum 3 PV TETRACYCLINES - Drugs to Treat Bacterial
Infections
nicotine polacrilex lozg 3 PV
Tetracyclines
PV ACTICLATE TABS (Use GP PA
nicotine pt24 3 Doxycycline Hyclate)
NICOTINE PV ADOXA PAK 1/100 TABS
TRANSDERMAL SYSTEM 3 (Use Doxycycline GP
KIT (Monohydrate))
NICOTROL INHALER 3 PV ADOXA PAK 1/150 TABS ST
INHA (Use Doxycycline GP
PV (Monohydrate))
NICOTROL NS SOLN 3
ADOXA PAK 2/100 TABS
ZYBAN TB12 (Use PV (Use Doxycycline GP
Bupropion HCl (Smoking GP (Monohydrate))
Deterrent)) ADOXA TABS (Use
RESPIRATORY AGENTS - MISC. - Drugs to Doxycycline GP
Treat Lung Conditions (Monohydrate))
Cystic Fibrosis Agents demeclocycline hcl tabs 1
PA; Refer to doxycycline (monohydrate) ST
KALYDECO PACK 3 Accredo SP 3
caps 150 mg
Rx;LA
doxycycline (monohydrate) 1
PA; Refer to caps 50 mg, 100 mg
KALYDECO TABS 3 Accredo SP
Rx;LA doxycycline (monohydrate) 3
caps 75 mg
ORKAMBI PACK 100MG- 3 PA
125MG, 150MG-188MG doxycycline (monohydrate) 1
susr 25 mg/5ml
PA; Must use
ORKAMBI TABS 100MG- doxycycline (monohydrate) ST
3 Accredo SP 3
125MG, 200MG-125MG tabs 150 mg
pharmacy;LA
PA; QL(5 ml doxycycline (monohydrate) 3
PULMOZYME SOLN 2 tabs 50 mg, 75 mg, 100 mg
daily)
PA; SP doxycycline hyclate caps 1
SYMDEKO TBPK 3 50 mg, 100 mg
Pulmonary Fibrosis Agents doxycycline hyclate tabs 1
100 mg
ESBRIET CAPS 267 MG 3 PA
doxycycline hyclate tabs 20 3
mg
ESBRIET TABS 267 MG, 3 PA; SP
801 MG doxycycline hyclate tabs 75 3 PA
mg, 150 mg
PA; QL(1 ea
OFEV CAPS 3 MINOCIN CAPS (Use
daily) NF
Minocycline HCl)
SULFONAMIDES - Drugs to Treat Bacterial minocycline hcl caps 50
Infections 1
mg, 75 mg, 100 mg
Sulfonamides minocycline hcl tabs 50 mg, PA
3
SULFADIAZINE TABS 3 75 mg, 100 mg
page ii-iii.
92
MONODOX CAPS (Use SYNTHROID TABS 112 QL(1 ea daily)
Doxycycline GP MCG, 125 MCG, 175 MCG, GP
(Monohydrate)) 200 MCG (Use
Levothyroxine Sodium)
tetracycline hcl caps 1
SYNTHROID TABS 25
VIBRAMYCIN CAPS 100 MCG, 50 MCG, 75 MCG,
MG (Use Doxycycline GP 88 MCG, 100 MCG, 137 GP
Hyclate) MCG, 150 MCG, 300 MCG
VIBRAMYCIN SUSR 25 (Use Levothyroxine
MG/5ML (Use Doxycycline GP Sodium)
(Monohydrate)) thyroid tabs 1
VIBRAMYCIN SYRP 50 2
MG/5ML THYROLAR-1 TABS 3
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones THYROLAR-1/2 TABS 3
Antithyroid Agents THYROLAR-1/4 TABS 3
methimazole tabs 1
THYROLAR-2 TABS 3
propylthiouracil tabs 1 QL(3 ea daily)
THYROLAR-3 TABS 3
TAPAZOLE TABS (Use GP
Methimazole) WESTHROID TABS 2
Thyroid Hormones
WP THYROID TABS 2
ARMOUR THYROID TABS 2
ULCER DRUGS - Drugs to Treat Bowel, Intestine
CYTOMEL TABS 25 MCG, QL(2 ea daily) and Stomach Conditions
50 MCG (Use Liothyronine GP
Sodium) Antispasmodics
CYTOMEL TABS 5 MCG ANASPAZ TBDP (Use GP
GP Hyoscyamine Sulfate)
(Use Liothyronine Sodium)
levothyroxine sodium tabs QL(1 ea daily) BENTYL CAPS (Use GP
112 mcg, 125 mcg, 175 1 Dicyclomine HCl)
mcg, 200 mcg BENTYL TABS (Use GP
levothyroxine sodium tabs Dicyclomine HCl)
25 mcg, 50 mcg, 75 mcg, 1 chlordiazepoxide hcl-
88 mcg, 100 mcg, 137 1
clidinium bromide caps
mcg, 150 mcg, 300 mcg
CUVPOSA SOLN 2
liothyronine sodium tabs 25 1 QL(2 ea daily)
mcg, 50 mcg dicyclomine hcl caps 1
liothyronine sodium tabs 5 1
mcg dicyclomine hcl soln 1
NATURE-THROID NT-2.5 2
TABS dicyclomine hcl tabs 1
NATURE-THROID TABS 2 glycopyrrolate tabs or 1 1
mg, 2 mg
page ii-iii.
93
hyoscyamine sulfate tb12 1 ranitidine hcl syrp 15
mg/ml, 75 mg/5ml, 150 1
hyoscyamine sulfate tbdp 1 mg/10ml
QL(4 ea daily);
LEVBID TB12 (Use ranitidine hcl tabs 150 mg 1
RX/OTC
GP
Hyoscyamine Sulfate) QL(2 ea daily)
LIBRAX CAPS (Use ranitidine hcl tabs 300 mg 1
Chlordiazepoxide HCl- GP ZANTAC 150 MAXIMUM QL(4 ea daily);
Clidinium Bromide) STRENGTH TABS (Use GP RX/OTC
methscopolamine bromide Ranitidine HCl)
1
tabs ZANTAC TABS 150 MG GP QL(4 ea daily);
propantheline bromide tabs 1 (Use Ranitidine HCl) RX/OTC
ZANTAC TABS 300 MG GP QL(2 ea daily)
ROBINUL FORTE TABS GP (Use Ranitidine HCl)
(Use Glycopyrrolate)
Misc. Anti-Ulcer
ROBINUL TABS (Use GP
Glycopyrrolate) CARAFATE SUSP 1 2
GM/10ML
H-2 Antagonists CARAFATE TABS 1 GM GP QL(4 ea daily)
CIMETIDINE HCL SOLN 2 (Use Sucralfate)
sucralfate tabs 1 QL(4 ea daily)
cimetidine tabs 300 mg, 1
800 mg
Proton Pump Inhibitors
cimetidine tabs 400 mg 1 QL(4 ea daily)
ACIPHEX SPRINKLE 3 PA
CPSP
famotidine susr 40 mg/5ml 3 ACIPHEX TBEC (Use GP PA; QL(1 ea
QL(4 ea daily); Rabeprazole Sodium) daily)
famotidine tabs 20 mg 1 esomeprazole magnesium
RX/OTC 3 PA; QL(1 ea
QL(2 ea daily) cpdr 20 mg daily); RX/OTC
famotidine tabs 40 mg 1
esomeprazole magnesium 3 PA; QL(1 ea
nizatidine caps 150 mg, cpdr 40 mg daily)
1
300 mg FIRST-OMEPRAZOLE 3
NIZATIDINE SOLN 15 SUSP
2
MG/ML QL(1 ea daily);
lansoprazole cpdr 15 mg 1
RX/OTC
PEPCID AC MAXIMUM QL(4 ea daily);
STRENGTH TABS (Use GP RX/OTC QL(1 ea daily)
Famotidine) lansoprazole cpdr 30 mg 1
PEPCID SUSR 40 MG/5ML QL(2 ea daily);
GP lansoprazole tbdp 15 mg AL(Up to 12 yrs
(Use Famotidine) 3
PEPCID TABS 20 MG (Use old )
GP QL(4 ea daily); QL(1 ea daily);
Famotidine) RX/OTC
PEPCID TABS 40 MG (Use lansoprazole tbdp 30 mg 3 AL(Up to 12 yrs
GP QL(2 ea daily) old )
Famotidine)
ranitidine hcl caps 150 mg, NEXIUM 24HR CLEAR PA; QL(1 ea
3 MINIS CPDR (Use GP daily); RX/OTC
300 mg
Esomeprazole Magnesium)
page ii-iii.
94
NEXIUM 24HR CPDR (Use PA; QL(1 ea rabeprazole sodium tbec 3 PA; QL(1 ea
Esomeprazole Magnesium) GP daily); RX/OTC daily)
NEXIUM CPDR 20 MG PA; QL(1 ea Ulcer Drugs - Prostaglandins
(Use Esomeprazole GP daily); RX/OTC
CYTOTEC TABS (Use
Magnesium) Misoprostol) GP
NEXIUM CPDR 40 MG PA; QL(1 ea
(Use Esomeprazole GP daily) misoprostol tabs 1
Magnesium)
NEXIUM PACK 5 MG, 10 PA Ulcer Therapy Combinations
MG, 20 MG, 40 MG, 2.5 3 amoxicillin-clarithromycin 1
MG w/ lansoprazole misc
OMEPRAZOLE + OMECLAMOX-PAK MISC 3
SYRSPEND SFALKA 3
SUSP PREVPAC MISC (Use
Amoxicillin-Clarithromycin GP
omeprazole cpdr 10 mg 1 w/ Lansoprazole)
QL(1 ea daily); PYLERA CAPS 3
omeprazole cpdr 20 mg 1
RX/OTC
QL(1 ea daily) URINARY ANTI-INFECTIVES - Drugs to Treat
omeprazole cpdr 40 mg 1 Bladder/Kidney Infections
pantoprazole sodium tbec 1 QL(1 ea daily) Urinary Anti-infectives
FURADANTIN SUSP (Use GP
PREVACID 24HR CPDR GP QL(1 ea daily); Nitrofurantoin)
(Use Lansoprazole) RX/OTC
HIPREX TABS (Use GP
PREVACID CPDR 15 MG GP QL(1 ea daily); Methenamine Hippurate)
(Use Lansoprazole) RX/OTC
MACROBID CAPS (Use
PREVACID CPDR 30 MG GP QL(1 ea daily) Nitrofurantoin Monohyd GP
(Use Lansoprazole) Macro)
PREVACID SOLUTAB QL(2 ea daily); MACRODANTIN CAPS
TBDP 15 MG (Use GP AL(Up to 12 yrs (Use Nitrofurantoin GP
Lansoprazole) old ) Macrocrystal)
PREVACID SOLUTAB QL(1 ea daily); methenamine hippurate
TBDP 30 MG (Use GP AL(Up to 12 yrs tabs 3
Lansoprazole) old )
methenamine mandelate 1
PRILOSEC CPDR 10 MG GP tabs
(Use Omeprazole)
PRILOSEC CPDR 20 MG MONUROL PACK 3
GP QL(1 ea daily);
(Use Omeprazole) RX/OTC
nitrofurantoin macrocrystal 1
PRILOSEC CPDR 40 MG GP QL(1 ea daily) caps
(Use Omeprazole)
nitrofurantoin monohyd 1
PRILOSEC PACK 10 MG, 3 macro caps
2.5 MG
QL(1 ea daily) nitrofurantoin susp 1
PROTONIX PACK 40 MG 3
PROTONIX TBEC 20 MG, QL(1 ea daily) URINARY ANTISPASMODICS - Drugs to Treat
40 MG (Use Pantoprazole GP Miscellaneous Bladder Spasms
Sodium) Urinary Antispasmodic - Antimuscarinics
page ii-iii.
95
darifenacin hydrobromide 3 VIVOTIF CPDR 3 QL(4 ea per fill
tb24 retail)
DETROL LA CP24 (Use GP QL(1 ea daily) Viral Vaccines
Tolterodine Tartrate) FLUMIST
DETROL TABS (Use 3
GP QL(2 ea daily) QUADRIVALENT SUSP
Tolterodine Tartrate)
VAGINAL PRODUCTS - Drugs to Treat Vaginal
DITROPAN XL TB24 (Use GP Infections and Low Hormones
Oxybutynin Chloride)
ENABLEX TB24 (Use Miscellaneous Vaginal Products
GP FEM PH GEL (Use Acetic
Darifenacin Hydrobromide)
oxybutynin chloride syrp 5 QL(15 ml daily) Acid-Oxyquinoline Vaginal) GP
1 RELAGARD GEL (Use
mg/5ml
oxybutynin chloride tabs 5 QL(4 ea daily) Acetic Acid-Oxyquinoline GP
1 Vaginal)
mg
oxybutynin chloride tb24 5 Spermicides
1
mg, 10 mg, 15 mg
TODAY SPONGE MISC 2
tolterodine tartrate cp24 2 1 QL(1 ea daily)
mg, 4 mg Vaginal Anti-infectives
tolterodine tartrate tabs 1 1 QL(2 ea daily)
mg, 2 mg AVC CREA 3
TOVIAZ TB24 2 QL(1 ea daily) CLEOCIN CREA VA 2 %

(Use Clindamycin GP
trospium chloride cp24 60 Phosphate Vaginal)
1
mg CLEOCIN SUPP VA 100 3
trospium chloride tabs 20 QL(2 ea daily) MG
1
mg clindamycin phosphate 1
VESICARE TABS 10 MG 3 QL(1 ea daily) vaginal crea
CLINDESSE CREA 3
VESICARE TABS 5 MG 3
GYNAZOLE-1 CREA 3
Urinary Antispasmodics - Beta-3 Adrenergic
METROGEL-VAGINAL
MYRBETRIQ TB24 3 QL(1 ea daily) GEL (Use Metronidazole GP
Vaginal)
Urinary Antispasmodics - Cholinergic Agonists
metronidazole vaginal gel 1
bethanechol chloride tabs 1
URECHOLINE TABS (Use MICONAZOLE 3 SUPP 3
GP
Bethanechol Chloride)
NUVESSA GEL 3 PA
Urinary Antispasmodics - Direct Muscle Relaxants
TERAZOL 7 CREA (Use GP
flavoxate hcl tabs 1 Terconazole Vaginal)
VACCINES TERCONAZOLE CREA 2
Bacterial Vaccines terconazole vaginal crea 1
QL(4 ea per fill 0.4 %, 0.8 %
VIVOTIF BERNA CPDR 3
retail)
page ii-iii.
96
terconazole vaginal supp 3 POTABA CAPS 3
80 mg
Vaginal Estrogens
ESTRACE CREA (Use GP
Estradiol Vaginal)
estradiol vaginal crea 1
estradiol vaginal tabs 1
ESTRING RING 3
QL(1 ea per 90
FEMRING RING 3
days retail)
PREMARIN CREA VA 2 QL(2 gm daily)
0.625 MG/GM
VAGIFEM TABS (Use GP
Estradiol Vaginal)
Vaginal Progestins
CRINONE GEL 3 PA
ENDOMETRIN INST 3 PA
VASOPRESSORS - Drugs to Treat Heart and

Circulation Conditions
Neurogenic Orthostatic Hypotension (NOH) -
NORTHERA CAPS 3 PA
Vasopressors
midodrine hcl tabs 3
VITAMINS
Oil Soluble Vitamins
DRISDOL CAPS (Use GP
Ergocalciferol)
ergocalciferol caps 1
MEPHYTON TABS (Use GP
Phytonadione)
phytonadione tabs 1
Water Soluble Vitamins
AMINOBENZOATE 3
POTASSIUM PACK
page ii-iii.
97
Index
abacavir sulfate 39 ADEMPAS 46 ALOMIDE 87
abacavir sulfate-lamivudine 39 ADIPEX-P 1 ALORA 65
abacavir sulfate-lamivudine- ADOXA 92 alosetron hcl 67
zidovudine 39 ADOXA PAK 1/100 92 ALPHAGAN P 85
ABILIFY 39
ADOXA PAK 1/150 92 alprazolam 12
abiraterone acetate 33
ADOXA PAK 2/100 92 ALPRAZOLAM INTENSOL 12
ABSORICA 51,52
ADVAIR DISKUS 14 ALREX 86
ABSTRAL 6
ADVAIR HFA 14 ALTABAX 54
acamprosate calcium 90 ADVOCATE INSULIN PEN ALTACE 28
acarbose 21 NEEDLES 73 ALUNBRIG 34
ACCUPRIL 28 AEROSPAN 13
ALVESCO 13
ACCURETIC 30 AFINITOR 34
amantadine hcl 36
acebutolol hcl 43 AFINITOR DISPERZ 34
AMARYL 24
ACEON 28 AGGRENOX 69
AMBIEN 70
acetaminophen w/ codeine 8 AGRYLIN 69
AMBIEN CR 70
acetazolamide 62 AIRDUO RESPICLICK
113/14 14 AMCINONIDE 56
acetic acid (otic) 88
AIRDUO RESPICLICK AMERGE 75
acetic acid-aluminum 232/14 14
acetate 88 AMICAR 70
AIRDUO RESPICLICK amiloride &
acetylcysteine 51 55/14 14 hydrochlorothiazide 62
ACIPHEX 94 AKTEN 86 amiloride hcl 63
ACIPHEX SPRINKLE 94 AKYNZEO 25 AMINOBENZOATE
acitretin 55 ALA SCALP 56 POTASSIUM 97
ACLOVATE 56 albendazole 10 amiodarone hcl 12
ACTICLATE 92 ALBENZA 10 AMITIZA 67
ACTIGALL 66 albuterol sulfate 14 amitriptyline hcl 21
ACTIQ 6 ALBUTEROL SULFATE amlodipine besylate 44
ACTIVE OB 78 ER 14 amlodipine besylate-atorvastatin
ACTIVELLA 64 ALCAINE 86 calcium 45
alclometasone amlodipine besylate-benazepril
ACTONEL 63 dipropionate 56 hcl 30
ACTOPLUS MET 21 ALDACTAZIDE 62 amlodipine besylate-
ACTOPLUS MET XR 21 valsartan 30
ALDACTONE 63 amlodipine-valsartan-
ACTOS 22 ALDARA 60 hydrochlorothiazide 30
ACULAR 87 ALECENSA 34 AMOXAPINE 21
ACULAR LS 87 ALENDRONATE SODIUM 63 amoxicillin 89
ACUVAIL 87 alendronate sodium 63 amoxicillin & pot clavulanate 89
acyclovir 42 ALENDRONATE SODIUM 63 amoxicillin-clarithromycin w/
acyclovir topical 56 alendronate sodium 63 lansoprazole 95
ACZONE 52 amphetamine-
alfuzosin hcl 69 dextroamphetamine 1
ADALAT CC 44 ALINIA 11 ampicillin 89
adapalene 52 ALKERAN 33 AMPICILLIN 89
ADAPALENE 52 allopurinol 69 ampicillin 89
adapalene-benzoyl peroxide 52 almotriptan malate 75 AMPYRA 91
ADCIRCA 46 ALOCRIL 87 ANADROL-50 9
ADDERALL 1 ALOGLIPTIN 22 ANAFRANIL 21
ADDERALL XR 1 ALOGLIPTIN/METFORMIN anagrelide hcl 69
adefovir dipivoxil 41 HCL 21
ANALPRAM-HC 10
Index 1
ANAPROX DS 3 ASMANEX TWISTHALER 60 azelastine hcl (ophth) 87
ANASPAZ 93 METERED DOSES 13

AZELEX 52
ASMANEX TWISTHALER 7
ANASTIA 60 METERED DOSES 13 AZILECT 37
anastrozole 33 aspirin 6 AZITHROMYCIN 72
ANCOBON 25 aspirin-dipyridamole 69 azithromycin 72
ANDRODERM 9 ASTAGRAF XL 76 AZOPT 87
ANDROGEL 9 ASTEPRO 83 AZULFIDINE 67
ANDROGEL PUMP 9 ATABEX EC 78 AZULFIDINE EN-TABS 67
ANDROXY 9 ATACAND 29 bacitracin (ophthalmic) 85
ANGELIQ 65 ATACAND HCT 30 bacitracin-poly-neomycin-hc 86
ANORO ELLIPTA 14 atazanavir sulfate 39 bacitracin-polymyxin b
ANTABUSE 90 (ophth) 85
atenolol 43
baclofen 83
ANTARA 27 atenolol & chlorthalidone 30
BACLOFEN 83
ANUSOL-HC 10 ATIVAN 12
BACTRIM 10
ANZEMET 24 atomoxetine hcl 1
BACTRIM DS 10
APEXICON E 57 atorvastatin calcium 27
BACTROBAN 54
APLENZIN 19 atovaquone 11
BACTROBAN NASAL 83
apraclonidine hcl 85 atovaquone-proguanil hcl 32
BAL-CARE DHA 78
aprepitant 25 ATRALIN 52
balsalazide disodium 67
APRISO 67 ATRIPLA 40
BANZEL 16
APTENSIO XR 2 ATROPINE SULFATE 85
BARACLUDE 42
APTIOM 16 ATROVENT HFA 13 BD ECLIPSE NEEDLE 30G
APTIVUS 39 AUBAGIO 91 X1/2" 73
ARAVA 5 AUGMENTED BD INSULIN SYRINGE
ARCAPTA NEOHALER 14 BETAMETHASONE ULTRAFINE/U-100/1ML/31G X
DIPROPIONATE 57 15/64" 73
ARICEPT 90
AUGMENTIN 89 BD NEEDLE/30G X 1/2" 73
ARIMIDEX 33
AUGMENTIN ES-600 89 BD PEN 73
aripiprazole 39
AUGMENTIN XR 89 BD PEN MINI 73
armodafinil 2 BD SAFETYGLIDE INSULIN
AURYXIA 67
ARMONAIR RESPICLICK SYRINGE/1ML/31G X
113 13 AUSTEDO 91
15/64" 73
ARMONAIR RESPICLICK AUTOPEN 73 BD VEO INSULIN SYRINGE
232 13 AVALIDE 30 ULTRA-FINE/1ML/31G X
ARMONAIR RESPICLICK 6MM 73
55 13 AVANDIA 22
AVAPRO 29 BELSOMRA 71
ARMOUR THYROID 93
AVC 96 BELVIQ 1
ARNUITY ELLIPTA 13 benazepril &
AROMASIN 33 AVELOX 66 hydrochlorothiazide 30
ARTHROTEC 50 4 AVELOX ABC PACK 66 benazepril hcl 28
ARTHROTEC 75 4 AVODART 69 BENICAR 29
ARYMO ER 6 AXERT 75 BENICAR HCT 30
ASACOL HD 67 AXIRON 9 BENTYL 93
ASMANEX HFA 13 AYGESTIN 90 BENZACLIN 52
ASMANEX TWISTHALER 120 AZASAN 76 BENZACLIN WITH PUMP 52
METERED DOSES 13 AZASITE 85 BENZAMYCIN 52
ASMANEX TWISTHALER 14 azathioprine 76
METERED DOSES 13 BENZNIDAZOLE 10
ASMANEX TWISTHALER 30 azelaic acid 60 benzonatate 50
METERED DOSES 13 azelastine hcl 83
Index 2
benzoyl peroxide- BRILINTA 69 calcitonin (salmon) 63
erythromycin 52 brimonidine tartrate 85 CALCITRIOL 47
benzphetamine hcl 1
BRIVIACT 16 calcitriol 64
benztropine mesylate 36 calcium acetate (phosphate
BROMFENAC 87
BEPREVE 87 binder) 67
bromfenac sodium (ophth) 87
BESIVANCE 85 CALCIUM PNV 78
bromocriptine mesylate 36
BETADINE OPHTHALMIC CALCIUM-FOLIC ACID PLUS
PREP 85 BROMPHENIRAMINE D 75
TANNATE 26
BETAGAN 84 CALQUENCE 34
BROMSITE 87
betamethasone dipropionate CANASA 67
(topical) 57 budesonide 49
candesartan cilexetil 29
betamethasone dipropionate budesonide (inhalation) 13,14
augmented 57 candesartan cilexetil-
bumetanide 62 hydrochlorothiazide 30
betamethasone valerate 57 BUMEX 62 CAPCOF 50
BETAPACE 44 BUPHENYL 63 capecitabine 33
BETAPACE AF 43 BUPRENORPHINE 9 CAPEX 57
betaxolol hcl 43 buprenorphine hcl 9 CAPITAL/CODEINE 8
betaxolol hcl (ophth) 84 buprenorphine hcl-naloxone hcl CAPRELSA 34
bethanechol chloride 96 dihydrate 9
captopril 28
BETHKIS 3 bupropion hcl 19
captopril &
BETIMOL 84 bupropion hcl (smoking hydrochlorothiazide 30
deterrent) 91
BETOPTIC-S 84 BUPROPION CARAC 55
BEVESPI AEROSPHERE 14 HYDROCHLORIDE ER 19 CARAFATE 94
BEVYXXA 15 buspirone hcl 12 CARBAGLU 64
bexarotene 36 butalbital-acetaminophen 5 carbamazepine 16
BEYAZ 47 butalbital-acetaminophen- CARBATROL 16
BIAXIN 72 caffeine 5 carbidopa 36
butalbital-acetaminophen-
bicalutamide 33 caffeine w/ codeine 8 carbidopa-levodopa 36
BIDIL 45 butalbital-aspirin-caffeine 5 carbidopa-levodopa-entacapone
BIKTARVY 40 butalbital-aspirin-caffeine 37
w/cod 8 carbinoxamine maleate 26
BILTRICIDE 10
BUTALBITAL/ACETAMINOPH CARDIZEM 44
bimatoprost 88 EN 5 CARDIZEM CD 44
BINOSTO 63 butorphanol tartrate 9 CARDIZEM LA 44
BIO-STATIN 25 BUTRANS 9 CARDURA 29
bisacodyl 71 BYSTOLIC 43
bisacodyl-peg 3350-pot chloride- CARDURA XL 69
BYVALSON 30 carisoprodol 83
sod bicarb-sod chloride 71
bisoprolol & C-NATE DHA 78 carisoprodol w/ aspirin 83
hydrochlorothiazide 30 cabergoline 64 carisoprodol w/ aspirin &
bisoprolol fumarate 43 CABOMETYX 34 codeine 83
BLEPH-10 85 CADUET 45 CARNITOR 64
BLEPHAMIDE 86 CAFERGOT 74 CARNITOR SF 64
BLEPHAMIDE S.O.P. 86 caffeine citrate 1 CARTEOLOL HCL 84
BONIVA 63 CALAN 44 carteolol hcl (ophth) 84
BOSULIF 34 CALAN SR 44 carvedilol 43
BP CLEANSING WASH 52 CALCIFOL 75 carvedilol phosphate 43
BRAFTOVI 34 calcipotriene 56 CASODEX 33
BREO ELLIPTA 14 calcipotriene-betamethasone CATAPRES 29
BREVICON-28 47 dipropionate 57 CAYA 73
Index 3
CEDAX 47 ciclopirox 54 CLIMARA 65
cefaclor 47 ciclopirox olamine 54 CLIMARA PRO 65
CEFACLOR 47 cilostazol 69 CLINDAGEL 52
CEFACLOR ER 47 CILOXAN 85 clindamycin hcl 11
cefadroxil 46 CIMDUO 40 clindamycin palmitate
cefdinir 47 cimetidine 94 hydrochloride 11
CLINDAMYCIN
CEFDITOREN PIVOXIL 47 CIMETIDINE HCL 94 PHOSPHATE 52
cefixime 47 CIPRO 66 clindamycin phosphate
cefpodoxime proxetil 47 CIPRO HC 89 (topical) 52
clindamycin phosphate
cefprozil 47 CIPRO XR 66 vaginal 96
CEFTIBUTEN 47 CIPRODEX 89 clindamycin phosphate-benzoyl
CEFTIN 47 ciprofloxacin 66 peroxide 52
cefuroxime axetil 47 CIPROFLOXACIN ER 66 clindamycin phosphate-benzoyl
peroxide (refrigerate) 52
CELEBREX 4 CIPROFLOXACIN HCL 66 clindamycin phosphate-
celecoxib 4 ciprofloxacin hcl 66 tretinoin 52
CELEXA 19 ciprofloxacin hcl (ophth) 85 CLINDESSE 96
CELLCEPT 77 ciprofloxacin hcl (otic) 88 clobazam 16
CELONTIN 18 citalopram hydrobromide 19 clobetasol propionate 57
CENTANY 54 CITRANATAL 90 DHA 78 clobetasol propionate emollient
base 57
cephalexin 46 CITRANATAL ASSURE 79 clobetasol propionate
CEPHALEXIN 47 CITRANATAL B-CALM 79 emulsion 57
CERDELGA 70 CITRANATAL BLOOM 79 CLOBEX 57
CESAMET 25 CITRANATAL BLOOM CLOCORTOLONE
CETRAXAL 88 DHA 79 PIVALATE 57
CITRANATAL DHA 79 CLOCORTOLONE PIVALATE
CETYLEV 24 PUMP 57
CITRANATAL HARMONY 79
cevimeline hcl 78 CLODERM 57
CITRANATAL MEDLEY 79
CHANTIX 91 CLODERM PUMP 57
CHANTIX CONTINUING CITRANATAL RX 79
clomiphene citrate 63
MONTHPAK 91 CLARITHROMYCIN 72
CHANTIX STARTING MONTH CLOMIPHENE CITRATE 63
clarithromycin 72
PAK 91 CLEMASTINE clomipramine hcl 21
CHEMET 24 FUMARATE 26 clonazepam 16
CHENODAL 66 CLEOCIN 11,96 clonidine hcl 29
chlordiazepoxide hcl 12 CLEOCIN PEDIATRIC clopidogrel bisulfate 70
chlordiazepoxide hcl-clidinium GRANULES 11 clorazepate dipotassium 12
bromide 93 CLEOCIN-T 52
CLORPRES 30
CHLOROQUINE CLEVER CHOICE COMFORT
PHOSPHATE 32 EZINSULIN PEN NEEDLES clotrimazole 77
chloroquine phosphate 32 33GX4MM 73 clotrimazole (topical) 54
chlorpromazine hcl 39 CLEVER CHOICE COMFORT clotrimazole w/
EZPEN NEEDLES betamethasone 54
chlorpropamide 24 33GX4MM 73 clozapine 38
chlorthalidone 63 CLEVER CHOICE COMFORT CLOZAPINE ODT 38
CHLORZOXAZONE 83 EZPEN NEEDLES
33GX5MM 73 CLOZARIL 38
cholestyramine 27 CLEVER CHOICE COMFORT COARTEM 32
cholestyramine light 27 EZPEN NEEDLES COCAINE HCL 60
choline & mag salicylate 6 33GX6MM 74
CLEVER CHOICE COMFORT codeine sulfate 6
choline fenofibrate 27
EZPEN NEEDLES CODITUSSIN AC 50
CIALIS 45 33GX8MM 74
Index 4
COLAZAL 67 CRESTOR 27 demeclocycline hcl 92
COLCHICINE 69 CRINONE 97 DEMEROL 6
colchicine 69 CRIXIVAN 40 DEMSER 29
colchicine w/ probenecid 69 cromolyn sodium 13 DEPAKENE 19
COLCRYS 69 cromolyn sodium (ophth) 87 DEPAKOTE 19
colesevelam hcl 27 CUPRIMINE 76 DEPAKOTE ER 19
COLESTID 27 CUTIVATE 57 DEPAKOTE SPRINKLES 19
COLESTID FLAVORED 27 CUVPOSA 93 DEPEN TITRATABS 76
colestipol hcl 27 CVS WOMENS DERMA-SMOOTHE/FS
COLY-MYCIN S 89 PRENATAL+DHA 79 BODY 57
CYCLESSA 47 DERMA-SMOOTHE/FS
COLYTE-FLAVOR PACKS 71 SCALP 57
cyclobenzaprine hcl 83
COMBIGAN 84 DERMATOP 57
CYCLOGYL 85
COMBIPATCH 65 DERMOTIC 89
CYCLOMYDRIL 85
COMBIVENT RESPIMAT 14 DESCOVY 40
cyclopentolate hcl 85
COMBIVIR 40 desipramine hcl 21
cyclophosphamide 33
COMETRIQ 34 desmopressin acetate 64
CYCLOPHOSPHAMIDE 33
COMPLERA 40 desmopressin acetate spray 64
cyclophosphamide 33
COMPLETENATE 79 desmopressin acetate spray
CYCLOPHOSPHAMIDE 33 refrigerated 64
COMTAN 36
CYCLOSERINE 32 DESOGEN 47
CONCEPT DHA 79
cyclosporine 77 desogestrel & ethinyl
CONCEPT OB 79 estradiol 47
CYCLOSPORINE
CONCERTA 2 MODIFIED 77 desogestrel-ethinyl estradiol
CONDYLOX 60 cyclosporine modified (for (biphasic) 47
CONTRAVE 1 microemulsion) 77 desogestrel-ethinyl estradiol
CYMBALTA 20 (triphasic) 47
CONZIP 6 DESONATE 58
COPEGUS 42 cyproheptadine hcl 26
CYSTADANE 64 desonide 58
CORDRAN 57 DESOWEN 58
COREG 43 CYSTAGON 68
CYSTARAN 87 desoximetasone 58
COREG CR 43 DESOXYN 1
CORGARD 44 CYTOMEL 93
CYTOTEC 95 DESVENLAFAXINE ER 20
CORLANOR 46 desvenlafaxine succinate 20
CORTANE-B 57 DAKLINZA 42
dalfampridine 91 DETROL 96
CORTANE-B-OTIC 89 DETROL LA 96
CORTEF 49 danazol 9
DANTRIUM 83 dexamethasone 49
CORTENEMA 10 DEXAMETHASONE
CORTIFOAM 10 dantrolene sodium 83 INTENSOL 49
cortisone acetate 49 dapsone 11 DEXEDRINE 1
CORTISPORIN 54 dapsone (topical) 52 dexmethylphenidate hcl 2
CORZIDE 30 DARAPRIM 32 dextroamphetamine sulfate 1
COSOPT 84 darifenacin hydrobromide 96 DIAMOX 62
COSOPT PF 84 DAYPRO 4 DIASTAT ACUDIAL 16
COTELLIC 34 DAYTRANA 2 DIASTAT PEDIATRIC 16
COUMADIN 15 DDAVP 64 diazepam 12
COZAAR 29 DELSTRIGO 40 DIAZEPAM 16
CREON 62 DELZICOL 67 diazepam (anticonvulsant) 16
CRESEMBA 25 DEMADEX 62 DIAZEPAM RECTAL GEL 16
Index 5
DIBENZYLINE 29 dorzolamide hcl-timolol EDARBYCLOR 30
DICLEGIS 25 maleate 84 EDECRIN 62
DORZOLAMIDE
diclofenac potassium 4 HCL/TIMOLOL MALEATE 84 EDURANT 40
diclofenac sodium 4 DOTHELLE DHA 79 efavirenz 40
diclofenac sodium (actinic DOVONEX 56 EFFER-K 76
keratoses) 55 EFFEXOR XR 20
doxazosin mesylate 29
diclofenac sodium (ophth) 87
doxepin hcl 21 EFFIENT 70
diclofenac sodium (topical) 54
doxepin hcl (antipruritic) 55 EFUDEX 55
diclofenac w/ misoprostol 4
doxercalciferol 64 ELAVIL 21
dicloxacillin sodium 90
DOXYCYCLINE 60 ELDEPRYL 37
dicyclomine hcl 93
doxycycline (monohydrate) 92 ELESTAT 87
didanosine 40
doxycycline hyclate 92 ELESTRIN 65
DIFFERIN 52
DRISDOL 97 eletriptan hydrobromide 75
DIFICID 73
dronabinol 25 ELIDEL 60
diflorasone diacetate 58
DROPLET INSULIN SYRINGE ELIMITE 61
DIFLUCAN 26 U-100/1ML/31G X 15/64" 74 ELIPHOS 67
diflunisal 6 drospirenone-ethinyl
estradiol 47 ELIQUIS 15
digoxin 45
drospirenone-ethinyl estradiol- ELIQUIS STARTER PACK 15
dihydroergotamine mesylate 75 levomefolate calcium 48 ELIXOPHYLLIN 15
DILANTIN 18 DROXIA 70 ELLA 49
DILANTIN INFATABS 18 DRYSOL 60 ELMIRON 69
DILANTIN-125 18 DUAC 52 ELOCON 58
DILATRATE SR 11 DUAVEE 65 EMADINE 88
DILAUDID 6 DUET DHA 400 79 EMBEDA 6
diltiazem hcl 44 DUET DHA BALANCED 79 EMCYT 33
diltiazem hcl coated beads 44 DUETACT 21 EMEND 25
diltiazem hcl extended release DULCOLAX 72
beads 44 EMEND TRIPACK 25
DIOVAN 29 DULERA 14 EMFLAZA 49
DIOVAN HCT 30 duloxetine hcl 20 EMSAM 19
DIPENTUM 67 DURAGESIC 6 EMTRIVA 40
diphenoxylate w/ atropine 24 DUREZOL 86 ENABLEX 96
DIPROLENE 58 dutasteride 69 enalapril maleate 28
DIPROLENE AF 58 dutasteride-tamsulosin hcl 69 enalapril maleate &
DUTOPROL 30 hydrochlorothiazide 30
dipyridamole 70
DUZALLO 69 ENBRACE HR 79
DISALCID 6
DYAZIDE 62 ENBREL 5
disopyramide phosphate 12
DYMISTA 83 ENBREL SURECLICK 5
disulfiram 90
DYRENIUM 63 ENDARI 70
DITROPAN XL 96
E.E.S. GRANULES 72 ENDOMETRIN 97
divalproex sodium 19
EASY GLIDE PEN NEEDLES entacapone 36
DIVIGEL 65 33G X 5/32" 74 entecavir 42
dofetilide 12 EASY TOUCH FLIPLOCK ENTEREG 67
DOLOPHINE 6 NEEDLES 30GX1/2" 74
EASY TOUCH HYPODERMIC ENTOCORT EC 50
donepezil hydrochloride 90
NEEDLES 30GX1/2" 74 ENTRESTO 45
dorzolamide hcl 87 econazole nitrate 54 EPCLUSA 42
DORZOLAMIDE HCL 87 ECOZA 54 EPIDUO 53
EDARBI 29
Index 6
EPIDUO FORTE 53 ETIDRONATE DISODIUM 63 fentanyl citrate 6
EPIFOAM 58 etodolac 4 FERRIPROX 24
epinastine hcl (ophth) 88 etoposide 36 FETZIMA 21
EPIVIR 40 EUCRISA 60 FETZIMA TITRATION PACK21
EPIVIR HBV 42 EVAMIST 65 FIBRICOR 27
EPROSARTAN MESYLATE 29 EVISTA 63 FINACEA 60
EPZICOM 40 EVOCLIN 53 finasteride 69
ergocalciferol 97 EVOTAZ 40 FIORICET 6
ergoloid mesylates 91 EVOXAC 78 FIORICET/CODEINE 8
ERGOMAR 75 EXALGO 6 FIORINAL 6
ergotamine w/ caffeine 74 EXELDERM 54 FIORINAL/CODEINE #3 8
ERIVEDGE 33 EXELON 90 FIRST-OMEPRAZOLE 94
ERLEADA 33 exemestane 34 FLAGYL 10
ERTACZO 54 EXFORGE 30 FLAREX 86
ERY-TAB 72 EXFORGE HCT 30 flavoxate hcl 96
ERYGEL 53 EXODERM 54 flecainide acetate 12
ERYPED 200 72 EXTINA 54 FLECTOR 54
ERYPED 400 72 EXTRA-VIRT PLUS DHA 79 FLOMAX 69
erythromycin (acne aid) 53 ezetimibe 28 FLONASE ALLERGY
erythromycin (ophth) 85 ezetimibe-simvastatin 26 RELIEF 84
FLONASE ALLERGY RELIEF
erythromycin base 72 FABIOR 53 CHILDRENS 84
erythromycin ethylsuccinate 72 FACTIVE 66 FLORIVA 76
erythromycin stearate 72 famciclovir 42 FLORIVA PLUS 78
ESBRIET 92 famotidine 94 FLOVENT DISKUS 14
ESCAVITE D 78 FAMVIR 42 FLOVENT HFA 14
escitalopram oxalate 19 FARESTON 34 FLOWTUSS 50
ESGIC 5 FARXIGA 23 FLOXIN OTIC 88
esomeprazole magnesium 94 FARYDAK 34 fluconazole 26
estazolam 70 FAZACLO 38 flucytosine 25
ESTRACE 65 felbamate 18 fludrocortisone acetate 50
estradiol 65 FELBATOL 18 FLUMADINE 43
estradiol & norethindrone FELDENE 4 FLUMIST QUADRIVALENT 96
acetate 65 felodipine 44
ESTRADIOL fluocinolone acetonide 58
CONCENTRATE 47 FEM PH 96 fluocinolone acetonide (otic) 89
estradiol vaginal 97 FEMARA 34 fluocinonide 58
ESTRING 97 FEMCON FE 48 fluocinonide emulsified base 58
ESTROGEL 65 FEMHRT LOW DOSE 65 FLUORABON 76
ESTROPIPATE 65 FEMRING 97 fluorescein sodium topical 88
estropipate 65 FENOFIBRATE 27 fluorometholone (ophth) 86
ESTROSTEP FE 48 fenofibrate 27 FLUOROPLEX 55
eszopiclone 70 FENOFIBRATE 27 FLUOROURACIL 55
ethacrynic acid 62 fenofibrate 27 fluorouracil (topical) 55
ethambutol hcl 32 fenofibrate micronized 27 FLUOXETINE 91
ethosuximide 19 FENOFIBRIC ACID 27 FLUOXETINE DR 19
ethynodiol diacet & eth fenoprofen calcium 4 fluoxetine hcl 19,20
estrad 48 fentanyl 6
Index 7
FLUOXETINE FUL-GLO 88 GONITRO 11
HYDROCHLORIDE 20 FURADANTIN 95 GOODSENSE PREMIUM
FLUPHENAZINE HCL 39 BLOODGLUCOSE
furosemide 62
fluphenazine hcl 39 MONITORING SYSTEM 73
FUROSEMIDE 62 GORDONS UREA 60
FLURA-DROPS 76
furosemide 62 GRALISE 91
flurandrenolide 58
FYCOMPA 15 GRALISE STARTER 91
flurazepam hcl 70
gabapentin 16 granisetron hcl 24
flurbiprofen 4
GABITRIL 18 GRIS-PEG 25
flurbiprofen sodium 88
galantamine hydrobromide 90 griseofulvin microsize 25
flutamide 34 GALANTAMINE
fluticasone propionate 58 HYDROBROMIDE 90 griseofulvin ultramicrosize 25
fluticasone propionate galantamine hydrobromide 90 guaifenesin-codeine 50
(nasal) 84 GALZIN 76 guanfacine hcl 29
FLUTICASONE guanfacine hcl (adhd) 1
PROPIONATE/SALMETEROL gatifloxacin (ophth) 85
14 GEL-KAM ORAL CARE GUANIDINE HCL 32
fluvastatin sodium 27 RINSE 77 GUARDIAN REAL-TIME
GELFILM OP 87 REPLACEMENT MONITOR
fluvoxamine maleate 20 PEDIATRIC 73
FML 86 gemfibrozil 27
GYNAZOLE-1 96
FML FORTE 86 GENERESS FE 48
HALCION 70
FML LIQUIFILM 86 GENTAK 85
halobetasol propionate 58
FOCALGIN 90 DHA 79 gentamicin sulfate (ophth) 85
haloperidol 38
FOCALGIN CA 79 gentamicin sulfate (topical) 54
haloperidol lactate 38
FOCALIN 2 GENVOYA 40
HALOTIN 55
FOCALIN XR 2 GEODON 38
HARVONI 42
FOLCAL DHA 79 GIAZO 67
HECTOROL 64
FOLCAPS OMEGA 3 79 GILENYA 91
HEMENATAL OB 79
FOLET DHA 79 GILOTRIF 34
HEMENATAL OB + DHA 79
FOLET ONE 79 GLEEVEC 35
HEPSERA 42
folic acid 70 GLEOSTINE 33
HETLIOZ 71
FOLIVANE-F 70 glimepiride 24
HEXALEN 33
FOLIVANE-OB 79 glipizide 24
HIPREX 95
FORFIVO XL 19 glipizide-metformin hcl 21
GLUCAGEN homatropine hbr 85
FOSAMAX 63 DIAGNOSTIC 61 HORIZANT 91
FOSAMAX PLUS D 63 GLUCOPHAGE 22 HUMALOG 23
fosamprenavir calcium 40 GLUCOPHAGE XR 22 HUMALOG JUNIOR
fosinopril sodium 28 GLUCOTROL 24 KWIKPEN 22
fosinopril sodium & HUMALOG KWIKPEN 22,23
GLUCOTROL XL 24
hydrochlorothiazide 30 HUMALOG MIX 50/50 23
FOSRENOL 68 GLUCOVANCE 21
HUMALOG MIX 50/50
FREESTYLE INSULINX glyburide 24 KWIKPEN 23
BLOODGLUCOSE TEST 61 glyburide micronized 24 HUMALOG MIX 75/25 23
FREESTYLE INSULINX glyburide-metformin 22 HUMALOG MIX 75/25
BLOODGLUCOSE TEST KWIKPEN 23
STRIPS 61 glycopyrrolate 93
GLYNASE 24 HUMAPEN LUXURA HD 74
FREESTYLE LITE TEST
STRIPS 61 GLYSET 21 HUMIRA 3
FREESTYLE TEST STRIPS 61 HUMIRA PEDIATRIC CROHNS
GLYXAMBI 22 DISEASE STARTER PACK 3
FROVA 75 GOLYTELY 71 HUMIRA PEN 3
frovatriptan succinate 75
Index 8
HUMIRA PEN-CD/UC/HS ICLUSIG 35 irbesartan-hydrochlorothiazide
STARTER 3 IDHIFA 35
30
HUMIRA PEN-PS/UV IRESSA 35
STARTER 3 ILEVRO 88
ISENTRESS 40
HUMULIN 70/30 23 imatinib mesylate 35
ISENTRESS HD 40
HUMULIN 70/30 KWIKPEN 23 IMBRUVICA 35
isoniazid 32
HUMULIN N 23 imipramine hcl 21
ISOPTO ATROPINE 85
HUMULIN N KWIKPEN 23 imipramine pamoate 21
ISOPTO CARPINE 85
HUMULIN R 23 imiquimod 60
ISORDIL TITRADOSE 11
HUMULIN R U-500 IMIQUIMOD PUMP 60
(CONCENTRATED) 23 isosorbide dinitrate 11
IMITREX 75
HUMULIN R U-500 ISOSORBIDE DINITRATE
KWIKPEN 23 IMURAN 77 ER 11
HYCAMTIN 36 INCRUSE ELLIPTA 13 isosorbide mononitrate 11
hydralazine hcl 32 indapamide 63 isotretinoin 53

HYDREA 36 INDERAL LA 44 isradipine 44
hydrochlorothiazide 63 INDERAL XL 44 ISTALOL 84
HYDROCODONE INDOCIN 4 itraconazole 26
BITARTRATE/GUAIFENESIN indomethacin 4 ivermectin 10
51 INFANATE BALANCE 79
hydrocodone polistirex- JADENU 24
chlorpheniramine polistirex 51 INGREZZA 91 JADENU SPRINKLE 24
hydrocodone w/ INLYTA 35 JAKAFI 35
homatropine 50 INNOPRAN XL 44 JALYN 69
hydrocodone-acetaminophen 8 INPEN 100/BLUE/LILLY 74 JANUMET 22
hydrocodone-ibuprofen 8 INPEN 100/BLUE/NOVO 74 JANUMET XR 22
hydrocortisone 50 INPEN 100/GRAY/LILLY 74 JANUVIA 22
hydrocortisone (intrarectal) 10 INPEN 100/GREY/NOVO 74 JARDIANCE 23,24
hydrocortisone (rectal) 10 INPEN 100/PINK/LILLY 74 JENTADUETO 22
hydrocortisone (topical) 58 INPEN 100/PINK/NOVO 74 JENTADUETO XR 22
hydrocortisone butyrate 58 INSULIN SYRINGES AND PEN JULUCA 40
hydrocortisone butyrate NEEDLES 74
hydrophilic lipo base 58 JUXTAPID 28
INSUPEN 33GX4MM 74
hydrocortisone valerate 59 K-PHOS 76
INTEGRA F 70
hydrocortisone w/acetic acid 89 K-PHOS NEUTRAL 76
INTELENCE 40
hydromorphone hcl 6 K-PHOS NO 2 68
INTUNIV 1
hydroxychloroquine sulfate 32 K-TAB 76
INVEGA 38
hydroxyurea 36 KADIAN 6
INVIRASE 40
hydroxyzine hcl 12 KALETRA 40
INVOKAMET 22
hydroxyzine pamoate 12 KALYDECO 92
INVOKAMET XR 22
hyoscyamine sulfate 94 KAYEXALATE 77
INVOKANA 23
HYPER-SAL 51 KAZANO 22
IODINE STRONG 76
HYPERSAL 51 iodoquinol-hydrocortisone in KEFLEX 47
HYPODERMIC NEEDLE aloe vehicle 55 KENALOG 59
30GX1/2" 74 IOPIDINE 85 KEPPRA 16
HYSINGLA ER 6 ipratropium bromide 13 KEPPRA XR 16
HYZAAR 30 ipratropium bromide KETOCARE 61
ibandronate sodium 63 (nasal) 84 ketoconazole 26
IBRANCE 35 ipratropium-albuterol 14
ketoconazole (topical) 55
ibuprofen 4 irbesartan 29
KETOPROFEN 4
Index 9
ketoprofen 4 LASTACAFT 88 LIALDA 67
KETOPROFEN 4 latanoprost 88 LIBRAX 94
KETOPROFEN ER 4 LATANOPROST 88 lidocaine 60
ketorolac tromethamine 4 LAZANDA 6 lidocaine hcl 60
ketorolac tromethamine LEDIPASVIR/SOFOSBUVIR lidocaine hcl (mouth-throat) 77
(ophth) 88 42 lidocaine-prilocaine 60
KETOSTIX 61 leflunomide 5
LIDODERM 60
KEVEYIS 62 LENVIMA 10 MG DAILY
DOSE 35 linezolid 11
KHEDEZLA 21
LENVIMA 14 MG DAILY LINZESS 67
KISQALI 35 DOSE 35 liothyronine sodium 93
KISQALI FEMARA 200 LENVIMA 18 MG DAILY
DOSE 34 DOSE 35 LIPITOR 27
KISQALI FEMARA 400 LENVIMA 20 MG DAILY LIPOFEN 27
DOSE 34 DOSE 35 lisinopril 28
KISQALI FEMARA 600 LENVIMA 24 MG DAILY lisinopril &
DOSE 34 DOSE 35 hydrochlorothiazide 30,31
KITABIS PAK 3 LENVIMA 8 MG DAILY LITHIUM 38
KLARON 53 DOSE 35
LESCOL XL 27 lithium carbonate 38
KLONOPIN 16 LITHOBID 38
KLOR-CON M15 76 LETAIRIS 46
letrozole 34 LITHOSTAT 69
KLOR-CON/25 76 LIVALO 27
KUVAN 64 leucovorin calcium 36
LEUKERAN 33 LO LOESTRIN FE 48
labetalol hcl 43 LOCOID 59
LACRISERT 84 levalbuterol hcl 14
levalbuterol tartrate 14 LOCOID LIPOCREAM 59
lactulose 71 LODINE 4
lactulose (encephalopathy) 67 LEVAQUIN 66
LEVBID 94 LODOSYN 36
LAMICTAL 17 LOESTRIN 1.5/30-21 48
LAMICTAL CHEWABLE LEVEMIR 23
DISPERSIBLE 16 LEVEMIR FLEXTOUCH 23 LOESTRIN 1/20-21 48
LAMICTAL ODT 16 levetiracetam 17 LOESTRIN FE 1.5/30 48
LAMICTAL STARTER/NOT LEVETIRACETAM 47 LOESTRIN FE 1/20 48
TAKING CARBAMAZEPINE 17 LOFIBRA 27
LAMICTAL STARTER/TAKING levobunolol hcl 84
levocarnitine (metabolic LOMAIRA 1
CARBAMAZEPINE/NOT TAKING
VALPROATE 17 modifiers) 64 LOMOTIL 24
LAMICTAL STARTER/TAKING levofloxacin 66 LONSURF 34
VALPROATE 17 levofloxacin (ophth) 85 LOPID 27
LAMICTAL XR 17 levonorgestrel & eth lopinavir-ritonavir 40
LAMISIL 25 estradiol 48
levonorgestrel (emergency LOPRESSOR 43
LAMISIL AT SPRAY 55 LOPRESSOR HCT 31
oc) 49
lamivudine 40 levonorgestrel-eth estradiol LOPROX 55
lamivudine (hbv) 42 (triphasic) 48 LOPROX SHAMPOO 55
lamivudine-zidovudine 40 levonorgestrel-ethinyl estradiol
(91-day) 48 lorazepam 12
lamotrigine 17 levonorgestrel-ethinyl estradiol LORTAB 8
LANOXIN 45 (continuous) 48 LORZONE 83
lansoprazole 94 LEVORPHANOL
TARTRATE 6 losartan potassium 29
lanthanum carbonate 68 losartan potassium &
levothyroxine sodium 93
LANTUS 23 hydrochlorothiazide 31
LEXAPRO 20 LOSEASONIQUE 48
LANTUS SOLOSTAR 23
LEXIVA 40 LOTEMAX 86
LASIX 62
Index 10
LOTENSIN 28 mefenamic acid 4 methylergonovine maleate 89
LOTENSIN HCT 31 MEFLOQUINE HCL 32 METHYLIN 2
LOTREL 31 mefloquine hcl 32 methylphenidate hcl 2
LOTRISONE 55 MEGACE ES 90 METHYLPHENIDATE
LOTRONEX 67 MEGACE ORAL 34 HYDROCHLORIDE ER (LA) 2
methylprednisolone 50
lovastatin 28 megestrol acetate 34
megestrol acetate METHYLTESTOSTERONE 9
LOVAZA 26
(appetite) 90 methyltestosterone 9
loxapine succinate 38
MEKINIST 35 METIPRANOLOL 84
LOZI-FLUR 76
MEKTOVI 35 metoclopramide hcl 67
LULICONAZOLE 55
meloxicam 4 METOCLOPRAMIDE ODT 67
LUMIGAN 88
melphalan 33 metolazone 63
LUNESTA 70
memantine hcl 90 METOPIRONE 61
LURIDE 76
MENEST 65 metoprolol &
LUXIQ 59 hydrochlorothiazide 31
MENOSTAR 65
LUZU 55 metoprolol succinate 43
meperidine hcl 6
LYNPARZA 35 METOPROLOL SUCCINATE
MEPERIDINE ER/HYDROCHLOROTHIAZIDE
LYRICA 17 HCL/PROMETHAZINE HCL 8 31
LYSODREN 34 MEPHYTON 97 metoprolol tartrate 43
LYSTEDA 70 MEPRON 11 METOPROLOL TARTRATE 43
M-CLEAR WC 51 mercaptopurine 33 METOPROLOL/HYDROCHLOR
MACNATAL CN DHA 79 mesalamine 67 OTHIAZIDE 31
MACROBID 95 MESNEX 36 METROCREAM 61
MACRODANTIN 95 MESTINON 32 METROGEL 61
mafenide acetate 56 MESTINON TIMESPAN 32 METROGEL-VAGINAL 96
MAGNEBIND 400 76 METADATE CD 2 METROLOTION 61
MALARONE 32 metaproterenol sulfate 15 metronidazole 10
malathion 61 metaxalone 83 metronidazole (topical) 61
maprotiline hcl 19 metformin hcl 22 metronidazole vaginal 96
MAR-COF CG METFORMIN MEVACOR 28
EXPECTORANT 51 HYDROCHLORIDE 22 mexiletine hcl 12
MARINOL 25 methadone hcl 6,7 MIACALCIN 63
MARNATAL-F 79 METHADOSE 7 MICARDIS 29
MARPLAN 19 METHADOSE SUGAR-
FREE 7 MICARDIS HCT 31
MATULANE 36
methamphetamine hcl 1 MICONAZOLE 3 96
MAVIK 28
methazolamide 62 MICRO-K 76
MAVYRET 42
methenamine hippurate 95 MICROZIDE 63
MAXALT 75
methenamine mandelate 95 midodrine hcl 97
MAXALT-MLT 75
methimazole 93 MIGERGOT 75
MAXIDEX 87
METHITEST 9 miglitol 21
MAXITROL 87
methocarbamol 83 miglustat 70
MAXZIDE 62
methotrexate sodium 33 MIGRANAL 75
MAXZIDE-25 62
methoxsalen rapid 56 MILLIPRED 50
meclofenamate sodium 4
methscopolamine bromide 94 MINASTRIN 24 FE 48
MEDROL 50
methyldopa 29 MINIPRESS 29
MEDROL DOSEPAK 50
methyldopa & MINIVELLE 65,66
medroxyprogesterone
acetate 90 hydrochlorothiazide 31 MINOCIN 92
Index 11
minocycline hcl 92 mycophenolate mofetil 77 NATURE-THROID NT-2.5 93
minoxidil 32 mycophenolate sodium 77 NEBUPENT 10
MIRALAX 71 MYDRIACYL 85 NEBUSAL 51
MIRAPEX 37 MYFORTIC 77 NECON 10/11-28 48
MIRAPEX ER 37 MYKIDZ IRON FL 78 NEEVO DHA 79
MIRCETTE 48 MYLERAN 33 NEFAZODONE HCL 20
mirtazapine 19 MYNATAL ADVANCE 79 nefazodone hcl 20
MIRVASO 61 MYNATAL NEFAZODONE
misoprostol 95 ULTRACAPLET 79 HYDROCHLORIDE 20
MYNATE 90 PLUS 79 neomycin sulfate 3
MITIGARE 69
MYRBETRIQ 96 neomycin-bacitracin zn-
MOBIC 4 polymyxin 86
MYSOLINE 17
modafinil 2 neomycin-polymy-dexameth 87
MYTESI 24
MODERIBA 42 neomycin-polymyxin-gramicidin
MODERIBA 1200 DOSE nabumetone 5 86
PACK 42 nadolol 44 neomycin-polymyxin-hc
MODERIBA 800 DOSE nadolol & (ophth) 87
PACK 42 bendroflumethiazide 31 neomycin-polymyxin-hc
moexipril hcl 28 NAFRINSE (otic) 89
moexipril-hydrochlorothiazide DAILY/NEUTRAL 77 NEORAL 77
31 NAFRINSE WEEKLY 77 NEOSPORIN 86
MOEXIPRIL/HYDROCHLOROTH naftifine hcl 55 NEPTAZANE 62
IAZIDE 31 NAFTIN 55 NERLYNX 35
mometasone furoate 59
NALFON 5 NESINA 22
mometasone furoate (nasal) 84
naltrexone hcl 24 NESTABS 79
MONODOX 93
NAMENDA 90 NESTABS ABC 79
montelukast sodium 13 NAMENDA TITRATION NESTABS DHA 79
MONUROL 95 PAK 90
NESTABS ONE 79
morphine sulfate 7 NAMENDA XR 90
NAMENDA XR TITRATION NEUPRO 37
MORPHINE SULFATE 7
PACK 90 NEURONTIN 17
morphine sulfate 7
NAMZARIC 90 NEVANAC 88
MORPHINE SULFATE ER 7
NAPROSYN 5 nevirapine 40
MOTOFEN 24
naproxen 5 NEWGEN 79
MOVANTIK 67
naproxen sodium 5 NEXA PLUS 79
MOVIPREP 71
naratriptan hcl 75 NEXAVAR 35
MOXATAG 89
NARCAN 24 NEXIUM 95
MOXEZA 86
NARDIL 19 NEXIUM 24HR 95
moxifloxacin hcl 66
NASACORT ALLERGY NEXIUM 24HR CLEAR
moxifloxacin hcl (ophth) 86 24HR 84 MINIS 94
MS CONTIN 7 NASACORT ALLERGY 24HR niacin (antihyperlipidemic) 28
MUCINEX D 51 CHILDRENS 84 NIACOR 28
MUCOTROL 78 NASONEX 84
NIASPAN 28
MULTAQ 12 NATACHEW 79
nicardipine hcl 44
MULTIVITAMIN/FLUORIDE 78 NATACYN 86
NICODERM CQ 91
mupirocin 54 NATAZIA 48
NICORETTE 91
mupirocin calcium (topical) 54 nateglinide 23
NICORETTE MINI 91
MUSE 45 NATELLE ONE 79
NICORETTE STARTER KIT 91
MYAMBUTOL 32 NATROBA 61
nicotine 92
MYCOBUTIN 32 NATURE-THROID 93
nicotine polacrilex 92
Index 12
NICOTINE TRANSDERMAL NORINYL 1+35 49 ODOMZO 33
SYSTEM 92 NORITATE 61 OFEV 92
NICOTROL INHALER 92
NORPACE 12 OFLOXACIN 66
NICOTROL NS 92
NORPACE CR 12 ofloxacin 66
nifedipine 44
NORPRAMIN 21 ofloxacin (ophth) 86
NILANDRON 34
NORTHERA 97 ofloxacin (otic) 88
nilutamide 34
nortriptyline hcl 21 olanzapine 38,39
nimodipine 44
NORTRIPTYLINE HCL 21 olanzapine-fluoxetine hcl 91
NINJACOF-XG 51
nortriptyline hcl 21 olmesartan medoxomil 29
NINLARO 35 olmesartan medoxomil-
NORVASC 44,45
nisoldipine 44 amlodipine-hydrochlorothiazide
NORVIR 40
NISOLDIPINE ER 44 31
NOVOLIN 70/30 olmesartan medoxomil-
NITRO-BID 11 FLEXPEN 23 hydrochlorothiazide 31
NITRO-DUR 11 NOVOLIN 70/30 FLEXPEN
RELION 23 olopatadine hcl 88
nitrofurantoin 95 olopatadine hcl (nasal) 83
NOVOPEN ECHO 74
nitrofurantoin macrocrystal 95 OLUX 59
nitrofurantoin monohyd NOXAFIL 26
macro 95 NUCORT 59 OLUX-E 59
nitroglycerin 11 NUCYNTA 7 OLYSIO 42
NITROGLYCERIN LINGUAL 11 NUCYNTA ER 7 OMECLAMOX-PAK 95
NITROLINGUAL NUEDEXTA 91 omega-3-acid ethyl esters 26
PUMPSPRAY 11 NULYTELY/FLAVOR omeprazole 95
NITROMIST 11 PACKS 71 OMEPRAZOLE + SYRSPEND
NITROSTAT 11 NUMBONEX 60 SFALKA 95
nizatidine 94 NUPLAZID 38 OMNIFLEX DIAPHRAGM 73
NIZATIDINE 94 NUVARING 49 OMNIPRED 87
NIZORAL 55 NUVESSA 96 ondansetron 24
NOCTIVA 64 NUVIGIL 2 ondansetron hcl 24
NOR-QD 49 NYMALIZE 45 ONETOUCH ULTRA BLUE 61
NORCO 8 nystatin 25 ONETOUCH VERIO TEST
STRIPS 61
norethin acet & estrad-fe 48 nystatin (mouth-throat) 77 ONFI 16
norethindrone & eth estradiol48 nystatin (topical) 55 ONMEL 26
norethindrone & ethinyl estradiol- nystatin-triamcinolone 55
fe 48 ONZETRA XSAIL 75
OB COMPLETE
norethindrone & mestranol 48 ADVANCED 79 OPANA 7
norethindrone OB COMPLETE GOLD 79 OPANA ER (CRUSH
(contraceptive) 49 RESISTANT) 7
OB COMPLETE ONE 79 opium tincture 24
norethindrone acet & eth
estra 48 OB COMPLETE PETITE 79 OPSUMIT 46
norethindrone acetate 90 OB COMPLETE PREMIER79 ORACEA 61
norethindrone acetate-ethinyl OB COMPLETE/DHA 79 ORACIT 68
estradiol 65 OBREDON 51
norethindrone acetate-ethinyl ORAPRED ODT 50
estradiol-fe 48 OBSTETRIX DHA 79 ORAVIG 77
norethindrone-eth estradiol OBSTETRIX ONE 80 ORENCIA 5
(triphasic) 48 OBTREX DHA 80
norgestimate-ethinyl ORENCIA CLICKJECT 5
OCALIVA 66 ORENITRAM 46
estradiol 48
norgestimate-ethinyl estradiol OCUFEN 88 ORFADIN 64
(triphasic) 48 OCUFLOX 86 ORKAMBI 92
norgestrel & ethinyl estradiol 48 ODEFSEY 40
Index 13
orphenadrine citrate 83 PAREMYD 88 PHENYLHISTINE DH 51
ORTHO MICRONOR 49 paricalcitol 64 PHENYTEK 18
ORTHO TRI-CYCLEN 49 PARLODEL 37 phenytoin 18
ORTHO TRI-CYCLEN LO 49 PARNATE 19 phenytoin sodium extended 18
ORTHO-CYCLEN 49 paromomycin sulfate 3 PHOSLYRA 68
ORTHO-NOVUM 1/35 49 paroxetine hcl 20 PHOSPHOLINE IODIDE 85
ORTHO-NOVUM 7/7/7 49 PASER 32 phytonadione 97
oseltamivir phosphate 43 PATADAY 88 PICATO 55
OSMOPREP 71 PATANASE 83 PIFELTRO 40
OSPHENA 63 PATANOL 88 pilocarpine hcl 85
OTEZLA 5 PAXIL 20 pilocarpine hcl (oral) 78
OTICIN HC NR 89 PAXIL CR 20 pindolol 44
OTOVEL 89 PAZEO 88 pioglitazone hcl 22
OVACE PLUS 56 PCE 72 pioglitazone hcl-glimepiride 22
OVACE PLUS WASH 56 ped multivitamins w/fl & pioglitazone hcl-metformin
OVACE WASH 56 iron 78 hcl 22
pediatric multivitamins w/fl 78 piroxicam 5
OVCON-35 49
pediatric vitamins acd fluoride & PLAN B ONE-STEP 49
OVIDE 61 iron 78 PLAQUENIL 32
OXANDRIN 9 pediatric vitamins acd w/
fluoride 78 PLAVIX 70
oxandrolone 9
peg 3350-kcl-sod bicarb-sod PLEXION 53
oxaprozin 5 chloride-sod sulfate 71 PLEXION CLEANSER 53
OXAYDO 7 peg 3350-potassium chloride- PNV FERROUS
oxazepam 12 sod bicarbonate-sod FUMARATE/DOCUSATE/FOLIC
OXAZEPAM 12 chloride 71 ACID 80
PEGANONE 18 PNV OB+DHA 80
oxcarbazepine 17
penicillin v potassium 89 PNV TABS 29-1 80
oxiconazole nitrate 55
PENICILLIN V
OXISTAT 55 POTASSIUM 89 PNV-DHA 80
OXSORALEN ULTRA 56 penicillin v potassium 89 PNV-DHA+DOCUSATE 80
OXTELLAR XR 17 PENNSAID 54 PNV-OMEGA 80
oxybutynin chloride 96 PENTASA 67 PNV-SELECT 80
oxycodone hcl 7 pentazocine w/ naloxone 9 PNV-TOTAL 80
OXYCODONE HCL ER 7 pentoxifylline 69 PNV-VP-U 80
oxycodone w/ acetaminophen 8 PEPCID 94 PODOCON 25 IN BENZOIN
TINCTURE 60
oxycodone-ibuprofen 8 PEPCID AC MAXIMUM
STRENGTH 94 podofilox 60
OXYCODONE/ACETAMINOPHE
N 8 PERCOCET 8 POLY HUB NEEDLE/30G X
1/2" 74
OXYCONTIN 7 perindopril erbumine 28 POLY-VI-FLOR 78
oxymorphone hcl 7 permethrin 61 polyethylene glycol 3350 71
OXYMORPHONE perphenazine 39
HYDROCHLORIDE ER 7 polymyxin b-trimethoprim 86
PERTZYE 62 POLYTRIM 86
paliperidone 38
phenelzine sulfate 19 POMALYST 34
PAMELOR 21
phenobarbital 70 PONSTEL 5
PANCREAZE 62
phenoxybenzamine hcl 29 pot & sod citrates w/citric ac 68
PANRETIN 55
phentermine hcl 1 pot phosphate monobasic w/ sod
pantoprazole sodium 95
phenylephrine hcl (ophth) 86 phosphate dibasic &
PARAFON FORTE DSC 83 monobasic 76
phenylephrine-
PAREGORIC 24 brompheniramine-dm 51 POTABA 97
Index 14
potassium bicarb & chloride 76 PREDNISOLONE SODIUM PRESTALIA 31
potassium bicarbonate 76 PHOSPHATE 87 PREVACID 95
PREDNISOLONE/MOXIFLOXA
potassium chloride 76 CIN 87 PREVACID 24HR 95
POTASSIUM CHLORIDE prednisone 50 PREVACID SOLUTAB 95
ER 76 PREVIDENT RINSE 78
potassium chloride PREDNISONE 50
microencapsulated crystals PREDNISONE INTENSOL 50 PREVPAC 95
er 76 PREFERA OB 80 PREZCOBIX 40
potassium citrate PREFERAOB +DHA 80 PREZISTA 40,41
(alkalinizer) 68
PREFEST 65 PRIFTIN 32
potassium citrate-citric acid 68
POTASSIUM PREMARIN 66,97 PRILOSEC 95
CITRATE/SODIUMCITRATE/CIT PREMESISRX 80 PRIMAQUINE PHOSPHATE 32
RIC ACID 68 PREMPHASE 65 primidone 17
POTIGA 17 PREMPRO 65 PRIMSOL 10
PR NATAL 400 EC 80 PRENA 1 TRUE 80 PRINIVIL 28
PR NATAL 430 80 PRENA1 CHEW 80 PRISTIQ 21
PR NATAL 430 EC 80 PRENA1 PEARL 80 PRO-RED AC 51
PRADAXA 15 PRENAISSANCE 80 PROAIR HFA 15
pramipexole dihydrochloride 37 PRENAISSANCE PROAIR RESPICLICK 15
PRAMOSONE 59 BALANCE 80 probenecid 69
PRAMOSONE E 59 PRENAISSANCE HARMONY
DHA 80 PROCARDIA 45
PRAMOTIC 89 PROCARDIA XL 45
PRENAISSANCE NEXT 80
pramoxine-hc-chloroxylenol 89 PROCENTRA 1
PRENAISSANCE NEXT-B 80
PRANDIN 23 prochlorperazine 39
PRENAISSANCE PLUS 80
prasugrel hcl 70 prochlorperazine maleate 39
PRENATA 80
PRAVACHOL 28 PROCTOFOAM HC 10
PRENATABS RX 80
pravastatin sodium 28 PROCYSBI 68
PRENATAL + DHA 80
praziquantel 10 PROGESTERONE
PRENATAL 19 80
prazosin hcl 29 CONCENTRATE 47
PRENATAL MULTIVITAMIN
PRECISION XTRA BLOOD PLUS DHA 80 progesterone micronized 90
GLUCOSE TEST STRIPS 61 PRENATAL PLUS IRON 80 PROGLYCEM 22
PRECOSE 21 prenatal vit w/ docusate-iron PROGRAF 77
PRED FORTE 87 carbonyl-folic acid 80 PROLENSA 88
PRED MILD 87 prenatal without a vit w/ fe PROMACTA 70
PRED-G 87 fumarate-folic acid 80
promethazine &
PRENATAL+DHA 80 phenylephrine 51
PRED-G S.O.P. 87
PRENATAL-U 80 promethazine hcl 26
PREDNICARBATE 59
PRENATE 80 promethazine w/codeine 51
prednicarbate 59
PRENATE AM 80 promethazine-dm 51
prednisolone 50
PRENATE DHA 81 promethazine-phenylephrine-
PREDNISOLONE 50
PRENATE ELITE 81 codeine 51
prednisolone acetate (ophth) 87 PROMETHAZINE/PHENYLEPHR
PREDNISOLONE ACETATE P- PRENATE ENHANCE 81
INE 51
F 87 PRENATE ESSENTIAL 81 PROMETHAZINE/PHENYLEPHR
prednisolone sodium PRENATE MINI 81 INE/CODEINE 51
phosphate 50 PRENATE PIXIE 81 PROMETRIUM 90
PREDNISOLONE SODIUM
PHOSPHATE 50 PRENATE RESTORE 81 propafenone hcl 12
prednisolone sodium PRENATE STAR 81 propantheline bromide 94
phosphate 50 PREQUE 10 81 proparacaine hcl 86
Index 15
propranolol & QVAR REDIHALER 14 RETROVIR 41
hydrochlorothiazide 31 R-NATAL OB 81 REVATIO 46
propranolol hcl 44
rabeprazole sodium 95 REVLIMID 76
propylthiouracil 93
raloxifene hcl 63 REXAPHENAC 54
PROSCAR 69
ramipril 28 REXULTI 39
PROTONIX 95
RANEXA 11 REYATAZ 41
PROTOPIC 60
ranitidine hcl 94 RHOFADE 61
protriptyline hcl 21
RAPAFLO 69 RIBASPHERE RIBAPAK 42
PROVENTIL HFA 15
RAPAMUNE 77 ribavirin 43
PROVERA 90
rasagiline mesylate 37 ribavirin (hepatitis c) 42
PROVIDA DHA 81
RAVICTI 64 RIDAURA 3
PROVIDA OB 81
RAZADYNE 91 rifabutin 33
PROVIGIL 2
RAZADYNE ER 90 RIFADIN 33
PROZAC 20
REBETOL 42 RIFAMATE 32
PROZAC WEEKLY 20
RECTIV 10 rifampin 33
PRUDOXIN 55
REGIMEX 1 RIFATER 32
pseudoephedrine w/ codeine-
gg 51 REGLAN 67 RILUTEK 84
pseudoephedrine-guaifenesin REGRANEX 61 riluzole 84
51 RELAGARD 96 rimantadine hydrochloride 43
PULMICORT 14 RELENZA DISKHALER 43 RIOMET 22
PULMICORT FLEXHALER 14 RELION INSULIN SYRINGE risedronate sodium 63
PULMOZYME 92 1ML/31GX15/64" 74 RISPERDAL 38
PURIXAN 33 RELION INSULIN SYRINGE/U-
100/1ML/31G X 15/64" 74 RISPERDAL M-TAB 38
PYLERA 95 risperidone 38
RELION KETONE 62
pyrazinamide 32 RISPERIDONE ODT 38
RELISTOR 67
pyridostigmine bromide 32 RITALIN 3
RELNATE DHA 81
QBRELIS 28 RITALIN LA 3
RELPAX 75
QSYMIA 1 ritonavir 41
REMERON 19
QUALAQUIN 32 rivastigmine 91
REMERON SOLTAB 19
QUARTETTE 49 rivastigmine tartrate 91
RENAGEL 68
QUDEXY XR 17 rizatriptan benzoate 75
RENVELA 68
QUESTRAN 27 ROBAXIN 83
repaglinide 23
QUESTRAN LIGHT 27 REPAGLINIDE/METFORMIN ROBAXIN-750 83
quetiapine fumarate 39 HYDROCHLORIDE 22 ROBINUL 94
QUFLORA FE PEDIATRIC 78 REPREXAIN 8 ROBINUL FORTE 94
QUFLORA GUMMIES 78 REQUIP 37 ROCALTROL 64
QUFLORA PEDIATRIC 78 REQUIP XL 37 ropinirole hydrochloride 37
QUILLICHEW ER 3 RESCRIPTOR 41 ROSULA 53
QUILLIVANT XR 3 RESCULA 88 rosuvastatin calcium 28
quinapril hcl 28 RESPAIRE-30 51 ROXICODONE 7
quinapril-hydrochlorothiazide RESTASIS 86
31 ROZEREM 71
RESTASIS MULTIDOSE 86 RUBRACA 35
quinidine gluconate 12
RESTORIL 70 RULAVITE DHA 81
QUINIDINE SULFATE 12
RETIN-A 53 RYDAPT 35
quinidine sulfate 12
RETIN-A MICRO 53 RYTARY 37
quinine sulfate 32
RETIN-A MICRO PUMP 53 RYTHMOL 12
QVAR 14
Index 16
RYTHMOL SR 12 SIVEXTRO 11 STALEVO 75 37
SABRIL 18 SKELAXIN 83 stannous fluoride 78
SAFYRAL 49 SKLICE 61 STARLIX 23
SALAGEN 78 sodium chloride (inhalant) 51 stavudine 41
SALEX 60 sodium citrate & citric acid 68 STAXYN 45
salicylic acid 60 sodium fluoride 76 STEGLATRO 24
salsalate 6 sodium fluoride (dental) 78 STENDRA 45
SANCUSO 25 sodium phenylbutyrate 64 STIMATE 64
SANDIMMUNE 77 sodium phosphates 71 STIOLTO RESPIMAT 15
SAPHRIS 39 sodium polystyrene STIVARGA 35
SAVAYSA 15 sulfonate 77 STRATTERA 2
SODIUM SULFACETAMIDE
SAVELLA 91 WASH 56 STRIBILD 41
SAVELLA TITRATION SODIUM STRIVERDI RESPIMAT 15
PACK 91 SULFACETAMIDE/SULFUR STROMECTOL 10
scopolamine 25 53
SODIUM SUBSYS 7
SE-NATAL 19 81
SULFACETAMIDE/SULFUR SUCRAID 62
SEASONIQUE 49 CLEANSER IN UREA 53 sucralfate 94
SECTRAL 43 SODIUM SULAR 45
SEEBRI NEOHALER 13 SULFACETAMIDE/SULFUR IN sulfacetamide sod-
SELECT-OB 81 UREA 53 prednisolone 87
SOFOSBUVIR/VELPATASVIR
SELECT-OB+DHA 81 42 sulfacetamide sodium 56
selegiline hcl 38 SOLARAZE 55 sulfacetamide sodium (acne) 53
selenium sulfide 56 SOLTAMOX 34 sulfacetamide sodium
SELZENTRY 41 (ophth) 86
SOMA 83 sulfacetamide sodium w/
SENSIPAR 64 SONATA 70 sulfur 53
SEREVENT DISKUS 15 SOOLANTRA 61 SULFADIAZINE 92
SEROQUEL 39 SORIATANE 56 sulfamethoxazole-trimethoprim
SEROQUEL XR 39 SORILUX 56 11
sertraline hcl 20 SULFAMYLON 56
sotalol hcl 44
sevelamer carbonate 68 sulfasalazine 67
sotalol hcl (afib/afl) 44
SFROWASA 67 sulindac 5
SOVALDI 42
SHOHLS SOLUTION sumatriptan 75
SPECTRACEF 47
MODIFIED 68 sumatriptan succinate 75
SIKLOS 70 SPINOSAD 61
SUMAXIN TS 53
sildenafil citrate 45 SPIRIVA HANDIHALER 13
SUPRAX 47
sildenafil citrate (pulmonary SPIRIVA RESPIMAT 13
SUPREP BOWEL PREP KIT71
hypertension) 46 spironolactone 63
spironolactone & SURMONTIL 21
SILVADENE 56
hydrochlorothiazide 62 SUSTIVA 41
silver sulfadiazine 56
SPORANOX 26 SUTENT 35
SIMBRINZA 85
SPORANOX PULSEPAK 26 SYMBICORT 15
SIMPONI 3
SPRITAM 17 SYMBYAX 91
simvastatin 28
SPRIX 5 SYMDEKO 92
SINEMET 37
SPRYCEL 35 SYMTUZA 41
SINEMET CR 37
STALEVO 100 37 SYNALAR 59
SINGULAIR 13
STALEVO 125 37 SYNAREL 63
sirolimus 77
STALEVO 150 37 SYNDROS 25
SITAVIG 42
STALEVO 50 37 SYNJARDY 22
Index 17
SYNJARDY XR 22 tenofovir disoproxil tinidazole 10
SYNTHROID 93 fumarate 41 TIVICAY 41
TENORETIC 100 31
SYPRINE 76 TIVORBEX 5
TENORETIC 50 31
TABLOID 33 tizanidine hcl 83
TENORMIN 43
TACLONEX 59 TL-CARE DHA 81
TERAZOL 7 96
tacrolimus 77 TL-SELECT 81
terazosin hcl 29
tacrolimus (topical) 60 TOBI 3
terbinafine hcl 25
tadalafil 46 TOBI PODHALER 3
tadalafil (pulmonary terbutaline sulfate 15
TOBRADEX 87
hypertension) 46 TERCONAZOLE 96
TOBRADEX ST 87
TAFINLAR 35 terconazole vaginal 96,97
tobramycin 3
TAGRISSO 35 TESSALON PERLES 50
TOBRAMYCIN 3
TAMIFLU 43 TESTIM 9
tobramycin (ophth) 86
tamoxifen citrate 34 testosterone 9,10
tobramycin-dexamethasone 87
tamsulosin hcl 69 TESTRED 10
TOBREX 86
TAPAZOLE 93 tetrabenazine 91
TODAY SPONGE 96
TARCEVA 35 tetracaine hcl (ophth) 86
TOFRANIL 21
TARGRETIN 36,55 tetracycline hcl 93
tolazamide 24
TARKA 31 TEXACORT 59
tolbutamide 24
TARON-BC 81 TEXAVITE LQ 78
tolcapone 36
TARON-C DHA 81 THALOMID 76
TOLMETIN SODIUM 5
TARON-PREX 81 THEO-24 15
tolmetin sodium 5
TASIGNA 35 theophylline 15
tolterodine tartrate 96
TASMAR 36 THIOLA 69
TOPAMAX 18
TAYTULLA 49 thioridazine hcl 39
TOPAMAX SPRINKLE 18
tazarotene 56 thiothixene 39
TOPICORT 59
TAZORAC 56 THRIVITE 19 81
topiramate 18
TECFIDERA 91 THRIVITE RX 81
TOPIRAMATE ER 18
TECFIDERA STARTER thyroid 93
PACK 91 TOPROL XL 43
THYROLAR-1 93
TECHLITE INSULIN SYRINGEU- torsemide 62
100/1ML/31G X 15/64" 74 THYROLAR-1/2 93
TOUJEO MAX SOLOSTAR 23
TECHNIVIE 42 THYROLAR-1/4 93
TOUJEO SOLOSTAR 23
TEGRETOL 17 THYROLAR-2 93
TOVIAZ 96
TEGRETOL-XR 17 THYROLAR-3 93
TRACLEER 46
TEKTURNA 32 tiagabine hcl 18
TRADJENTA 22
TEKTURNA HCT 31 TIAZAC 45
tramadol hcl 7,8
telmisartan 29 TIGAN 25
TRAMADOL HCL ER 7
telmisartan-amlodipine 31 TIKOSYN 13
tramadol-acetaminophen 8
telmisartan-hydrochlorothiazide timolol maleate 44
31 trandolapril 29
timolol maleate (ophth) 85
temazepam 70,71 trandolapril-verapamil hcl 31
TIMOLOL MALEATE
TEMODAR 33 OPHTHALMIC GEL TRANDOLAPRIL/VERAPAMIL
FORMING 85 HCL ER 31
TEMOVATE 59 tranexamic acid 70
TEMOVATE E 59 TIMOPTIC 85
TIMOPTIC OCUDOSE 85 TRANSDERM-SCOP 25
temozolomide 33 TRANXENE T 12
TENCON 6 TIMOPTIC-XE 85
TINDAMAX 10 tranylcypromine sulfate 19
TENEX 29
Index 18
TRAVATAN Z 88 TRISTART ONE 82 UTIBRON NEOHALER 15
trazodone hcl 20 TRIUMEQ 41 VAGIFEM 97
TRECATOR 33 TRIVEEN-PRX RNF 82 valacyclovir hcl 42
TRELEGY ELLIPTA 15 TRIZIVIR 41 VALCHLOR 55
TRESIBA FLEXTOUCH 23 TROKENDI XR 18 VALCYTE 41
TRETIN-X 54 tropicamide 85 valganciclovir hcl 41
tretinoin 54 trospium chloride 96 VALIUM 12
tretinoin (chemotherapy) 36 TRULANCE 66 valproate sodium 19
tretinoin microsphere 54 TRUSOPT 88 valproic acid 19
TREXALL 33 TRUVADA 41 valsartan 29
TRI-NORINYL 28 49 TUDORZA PRESSAIR 13 valsartan-hydrochlorothiazide
TRI-TABS DHA 81 TUSSIONEX PENNKINETIC 31
EXTENDED RELEASE 51 VALTREX 42,43
TRI-VI-FLOR 78
TWYNSTA 31 VANOS 59
TRI-VI-FLORO 78
triamcinolone acetonide TYBOST 41 vardenafil hcl 46
(mouth) 78 TYKERB 36 VARUBI 25
triamcinolone acetonide TYLENOL/CODEINE #3 8 VASCEPA 26
(nasal) 84 TYLENOL/CODEINE #4 9 VASERETIC 31
triamcinolone acetonide
(topical) 59 TYVASO 46 VASOTEC 29
triamterene & TYVASO REFILL 46 VECAMYL 32
hydrochlorothiazide 62 TYVASO STARTER 46 VECTICAL 56
triazolam 71 TYZEKA 42 VELTASSA 77
TRIBENZOR 31 UCERIS 10,50 VELTIN 54
TRICARE PRENATAL 82 ULORIC 69 VEMAVITE-PRX 2 82
TRICARE PRENATAL
COMPLEAT 82 ULTIMATECARE ONE 82 VEMLIDY 42
TRICARE PRENATAL DHA ULTIMATECARE ONE NF 82 VENA-BAL DHA 82
ONE 82 ULTRACARE PEN VENCLEXTA 33
TRICARE PRENATAL DHA NEEDLES/33G X 5/32" 74 VENCLEXTA STARTING
ONE/FOLATE 82 ULTRACET 9 PACK 33
TRICITRATES 68 ULTRAM 8 venlafaxine hcl 21
TRICOR 27 ULTRAVATE 59 VENTAVIS 46
TRIDESILON 59 UMECTA 60 VENTOLIN HFA 15
trientine hcl 76 UMECTA NAIL FILM 60 verapamil hcl 45
trifluoperazine hcl 39 UNIFINE PENTIPS VERAPAMIL HCL SR 45
trifluridine 86 33GX4MM 74 VERDROCET 9
TRIGLIDE 27 UNIFINE PENTIPS PLUS
33GX4MM 74 VEREGEN 54
trihexyphenidyl hcl 36 UPTRAVI 46 VERELAN 45
TRILEPTAL 18 urea 60 VERELAN PM 45
TRILIPIX 27 UREA TOPICAL 60 VERIPRED 20 50
trimethobenzamide hcl 25 URECHOLINE 96 VERSACLOZ 39
trimethoprim 10 UROCIT-K 10 68 VERZENIO 36
trimipramine maleate 21 UROCIT-K 15 68 VESICARE 96
TRIMPEX 10 UROCIT-K 5 68 VFEND 26
TRINATAL GT 82 UROXATRAL 69 VIAGRA 46
TRINATAL RX 1 82 URSO 250 66 VIBERZI 67
TRINTELLIX 20 URSO FORTE 66 VIBRAMYCIN 93
TRISTART DHA 82 ursodiol 66 VIDEX EC 41
Index 19
VIDEXPEDIATRIC 41 VOGELXO PUMP 10 XELJANZ 3
VIEKIRA PAK 42 VOL-TAB RX 82 XELJANZ XR 3
VIEKIRA XR 42 VOLTAREN 54 XELODA 33
vigabatrin 18 voriconazole 26 XENAZINE 91
VIGAMOX 86 VOSEVI 42 XENICAL 1
VIIBRYD 20 VOSPIRE ER 15 XERAC AC 60
VIIBRYD STARTER PACK 20 VOTRIENT 36 XERESE 56
VIL-RX 82 VP-CH PLUS 82 XERMELO 68
VIMPAT 18 VP-CH-PNV 82 XIFAXAN 10
VINATE DHA RF 82 VP-GGR-B6 PRENATAL 82 XIGDUO XR 22
VINATE ONE 82 VP-HEME OB 82 XIIDRA 86
VIOKACE 62 VP-HEME OB + DHA 82 XODOL 9
VIRACEPT 41 VP-PNV-DHA 83 XOPENEX 15
VIRAMUNE 41 VRAYLAR 38 XOPENEX CONCENTRATE 15
VIRAMUNE XR 41 VYTONE 55 XTANDI 34
VIRAZOLE 43 VYTORIN 26 XULANE 49
VIREAD 41 VYVANSE 1 XYREM 90
VIROPTIC 86 warfarin sodium 15 YASMIN 28 49
VIRT-ADVANCE 82 WEGMANS COMPLETE YAZ 49
VIRT-C DHA 82 PRENATAL+DHA 83 YONSA 34
WELCHOL 27
VIRT-NATE DHA 82 zaleplon 71
WELLBUTRIN SR 19
VIRT-PN 82 ZANAFLEX 83
WELLBUTRIN XL 19
VIRT-PN DHA 82 ZANTAC 94
WESTCORT 60 ZANTAC 150 MAXIMUM
VIRT-PN PLUS 82
WESTHROID 93 STRENGTH 94
VIRT-SELECT 82
WIDE-SEAL SILICONE ZARONTIN 19
VIRT-VITE GT 82 DIAPHRAGM KIT 60 73 ZATEAN-CH 83
VIRTPREX 82 WIDE-SEAL SILICONE
DIAPHRAGM KIT 65 73 ZATEAN-PN DHA 83
VISTARIL 12
WIDE-SEAL SILICONE ZATEAN-PN PLUS 83
VISTOGARD 24 DIAPHRAGM KIT 70 73 ZAVESCA 70
VITAFOL FE+ 82 WIDE-SEAL SILICONE
DIAPHRAGM KIT 75 73 ZEBETA 43
VITAFOL GUMMIES 82
WIDE-SEAL SILICONE ZEJULA 36
VITAFOL-NANO 82
DIAPHRAGM KIT 80 73 ZELAPAR 38
VITAFOL-ONE 82 WIDE-SEAL SILICONE
VITAMEDMD ONE ZELBORAF 36
DIAPHRAGM KIT 85 73
RX/QUATREFOLIC 82 WIDE-SEAL SILICONE ZEMPLAR 64
VITAMEDMD PLUS DIAPHRAGM KIT 90 73 ZENPEP 62
RX/QUATREFOLIC 82 WIDE-SEAL SILICONE ZENZEDI 1
VITAMEDMD REDICHEW DIAPHRAGM KIT 95 73
RX 82 ZEPATIER 42
WP THYROID 93
VITAPEARL 82 ZERIT 41
XADAGO 38
VITATRUE 82 ZESTORETIC 31,32
XALATAN 88
VITEKTA 41 ZESTRIL 29
XALKORI 36
VIVA DHA 82 ZETIA 28
XANAX 12
VIVELLE-DOT 66 ZIAC 32
XARELTO 15
VIVOTIF 96 XARELTO STARTER ZIAGEN 41
VIVOTIF BERNA 96 PACK 15 ZIANA 54
VOGELXO 10 XATMEP 33 zidovudine 41
Index 20
zileuton 13
ZIOPTAN 88
ziprasidone hcl 38
ZIRGAN 86
ZITHRANOL-RR 56
ZITHROMAX 72
ZITHROMAX TRI-PAK 72
ZITHROMAX Z-PAK 72
ZMAX 72
ZOCOR 28
ZOFRAN 25
ZOFRAN ODT 25
ZOLINZA 36
zolmitriptan 75
ZOLOFT 20
zolpidem tartrate 71
ZOMIG 75
ZOMIG ZMT 75
ZONALON 55
ZONEGRAN 18
zonisamide 18
ZORTRESS 77
ZOVIRAX 43,56
ZURAMPIC 69
ZYBAN 92
ZYCLARA 60
ZYCLARA PUMP 60
ZYDELIG 36
ZYFLO CR 13
ZYKADIA 36
ZYLET 87
ZYLOPRIM 69
ZYMAXID 86
ZYPREXA 39
ZYPREXA ZYDIS 39
ZYTIGA 34
ZYVOX 11
Index 21

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California

3-Tier Drug List

drugs and chooses drugs based on:

 Side effects; and

How much will I pay for my drugs?

2 Preferred brand drugs

Abbreviation Definition Description

PA Prior Authorization These drugs require prior authorization for coverage,

PV Preventive Drugs Preventive benefit drugs covered at no cost to members under

How can I get an exception to the rules for drug coverage?

Can I go to any pharmacy?

Can I use a mail order pharmacy?

How can I save money on my prescription drugs?

 Fill prescriptions at Health Net participating pharmacies.

 Be sure your doctor prescribes drugs on the drug list

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

California, Inc., call the DMHC Helpline at 1-888-HMO-2219.

ID քարտի վրա նշված հեռախոսահամարով կամ զանգահարեք 1-800-522-0088 (TTY: 711)

հեռախոսահամարով: Եթե ապահովագրում եք գնել Կալիֆորնիայի շուկայական հրապարակի

միջոցով, զանգահարեք 1-888-926-4988 (TTY: 711) հեռախոսահամարով: Լրացուցիչ

ապահովագրությանը, զանգահարեք Կալիֆորնիայի Ապահովագրության բաժին՝

1-800-927-4357 հեռախոսահամարով: Եթե անդամագրված եք Health Net of California, Inc.-ի HMO

կամ HSP ծրագրին, զանգահարեք DMHC օգնության գիծ՝ 1-888-HMO-2219 հեռախոսահամարով:

1-888-926-4988（TTY：711）。如需進一步協助：如果您透過 Health Net Life Insurance Company 投保

PPO 或 EPO 保單，請致電 1-800-927-4357 與加州保險局聯絡。如果您透過 Health Net of California, Inc.

投保 HMO 或 HSP 計畫，請致電 DMHC 協助專線 1-888-HMO-2219。

CA Commercial On and Off-Exchange Member Notice of Language Assistance

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

Rectal Steroids trimethoprim tabs 1

California 3-Tier Drug List Updated: December 1, 2018

ALINIA SUSR 3 DILATRATE SR CPCR 3

dapsone tabs 25 mg 1 isosorbide dinitrate tabs 1

Lincosamides isosorbide mononitrate tabs 1

California 3-Tier Drug List Updated: December 1, 2018

diazepam soln or 5 mg/5ml 1 propafenone hcl cp12 225 1

OXAZEPAM CAPS 30 MG 2 QL(2 ea daily) dofetilide caps 1

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

BANZEL TABS 400 MG 2 QL(8 ea daily)

California 3-Tier Drug List Updated: December 1, 2018

lamotrigine kit 25 mg, 1 POTIGA TABS 3

lamotrigine tabs 25 mg, 1 primidone tabs 1

California 3-Tier Drug List Updated: December 1, 2018

topiramate tabs 50 mg 1 QL(8 ea daily)

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

California 3-Tier Drug List Updated: December 1, 2018

imipramine pamoate caps 3 glipizide-metformin hcl tabs 1

NORPRAMIN TABS (Use GLUCOVANCE TABS (Use GP

California 3-Tier Drug List Updated: December 1, 2018

GLYXAMBI TABS 2 metformin hcl tb24 1

INVOKAMET TABS 2 METFORMIN 3

JENTADUETO XR TB24 JANUVIA TABS 50 MG, 2 QL(1 ea daily)