Group Health Incorporated (GHI) Prescription Drug Plan 2007 High Performance Formulary (List of Covered Drugs

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

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This document includes GHI Medicare Prescription Drug Plan’s partial formulary as of January 1, 2007. For a complete, updated formulary, please visit our Web site at www.ghi.com or call 1-800-5855786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.

S5966 080625 10/3/2006 7660 Last Updated: September 2006

What is the GHI Medicare Prescription Drug Plan High Performance Formulary?
A formulary is a list of covered drugs selected by GHI Medicare Prescription Drug Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. GHI Medicare Prescription Drug Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a GHI Medicare Prescription Drug Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by GHI Medicare Prescription Drug Plan. For a complete listing of all prescription drugs covered by GHI Medicare Prescription Drug Plan’s formulary, please visit our Web site at www.ghi.com or call 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.

Can the Formulary change?
Generally, if you are taking a drug on our 2006 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2007 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2007. To get updated information about the drugs covered by GHI Medicare Prescription Drug Plan, please visit our Web site at www.ghi.com or call Customer Service at 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.

How do I use the Formulary?
There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications”. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. 2

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 35. The Index provides an alphabetical list of all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? GHI Medicare Prescription Drug Plan covers both brand-name drugs and generic drugs. A generic drug has the same active-ingredient as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).

Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: GHI Medicare Prescription Drug Plan requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from GHI Medicare Prescription Drug Plan before you fill your prescriptions. If you don’t get approval, GHI Medicare Prescription Drug Plan may not cover the drug. Quantity Limits: For certain drugs, GHI Medicare Prescription Drug Plan limits the amount of the drug that GHI Medicare Prescription Drug Plan will cover. For example, GHI Medicare Prescription Drug Plan provides 90 tablets per 90-day supply prescription for Crestor® 40 mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, GHI Medicare Prescription Drug Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, GHI Medicare Prescription Drug Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, GHI Medicare Prescription Drug Plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can ask GHI Medicare Prescription Drug Plan to make an exception to these restrictions or limits. See the section, “How do I request an exception to the GHI Medicare Prescription Drug Plan formulary?” on page 4 for information about how to request an exception.

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What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Service and ask if your drug is covered. This document includes only a partial list of covered drugs, so GHI Medicare Prescription Drug Plan may cover your drug. You can contact Customer Service at 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114. If you learn that GHI Medicare Prescription Drug Plan does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by GHI Medicare Prescription Drug Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by GHI Medicare Prescription Drug Plan. You can ask GHI Medicare Prescription Drug Plan to make an exception and cover your drug. See below for information about how to request an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject starting January 1, 2007. Call your Medicare Drug Plan for more information.

How do I request an exception to the GHI Medicare Prescription Drug Plan Formulary?
You can ask GHI Medicare Prescription Drug Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • • You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, GHI Medicare Prescription Drug Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, GHI Medicare Prescription Drug Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you are requesting a formulary, or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

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An example of this special circumstance would include when you are discharged from a hospital. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. even if you have been a member of the plan less than 90 days. we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. These circumstances usually involve level of care changes in which you are changing from one treatment setting to another. please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. For more information For more detailed information about your GHI Medicare Prescription Drug Plan’s prescription drug coverage. TTY/TDD users should call 1-800-899-2114.) Or visit www. While you talk to your doctor to determine the right course of action for you. we will not pay for these drugs. Or.What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. In addition to circumstances impacting new enrollees who may enter a plan with a medication list that contains non-formulary Part D drugs. If you have general questions about Medicare prescription drug coverage. If you are a resident of a long-term care facility. 24 hours a day. we may cover your drug in certain cases during the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited. TTY/TDD users should call 1-877-486-2048. level of care changes) to ensure that you have access to medications in these circumstances. we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy.e. The exception and appeals process takes into account these special circumstances (i. you may need a prior authorization from us before you can fill your prescription. we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). visit www. other circumstances exist in which unplanned transitions for current enrollees could arise and in which prescribed drug regimens may not be on GHI Medicare Prescription Drug Plan’s formulary. If you have questions about GHI Medicare Prescription Drug Plan. 5 .medicare. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited. For example. you may be taking a drug that is on our formulary but your ability to get it is limited. please call Customer Service at 1-800-5855786.com. but you are past the first 90 days of membership in our plan. Or. please review your Evidence of Coverage and other plan materials. 7 days a week.ghi. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan.gov. After your first 30-day supply.

please visit our Web site at www. 6 . TTY/TDD users should call 1-800-899-2114 for additional help. PREVACID®) and generic drugs are listed in lower-case italics (e. 7 days a week. If your prescription is not in this partial formulary. 24 hours a day. Remember: This is only a partial list of drugs covered by GHI Medicare Prescription Drug Plan..GHI Medicare Prescription Drug Plan’s Formulary The formulary than begins on page 7 provides coverage information about some of the drugs covered by GHI Medicare Prescription Drug Plan..g.com or call Customer Service at 1-800-585-5786. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.ghi. turn to the Index that begins on page 35. omeprazole). If you have trouble finding your drug in the list.

2007 MEDICARE HIGH PERFORMANCE (Closed) Abridged Formulary PAR indicates that prior authorization may apply. ST indicates that step therapy may apply. DRUG NAME GENERIC NAME Tier Restrictions ANESTHETICS LOCAL ANESTHETICS lidocaine 1 TOPICAL ANESTHETICS lidocaine lidocaine-viscous LIDODERM 1 1 2 lidocaine PAR ANTIINFECTIVES AMEBICIDES paromomycin YODOXIN iodoquinol 1 2 AMINOGLYCOSIDES gentamicin neomycin tobramycin 1 1 1 ANTHELMINTICS ALBENZA albendazole ivermectin mebendazole STROMECTOL 2 1 2 ANTIINFECTIVES SPECIALIZED INDICATIONS 7 . QLL indicates that quantities dispensed may be limited.

DRUG NAME DAPSONE GENERIC NAME dapsone metronidazole Tier 2 1 Restrictions ANTIRETROVIRALS & PROTEASE INH COMBIVIR lamivudine / zidovudine enfuvirtide lopinavir / ritonavir abacavir didanosine FUZEON KALETRA ZIAGEN zidovudine 2 1 3 2 2 1 PAR ANTITUBERCULOSIS DRUGS isoniazid rifampin 1 1 CEPHALOSPORINS cefadroxil cefpodoxime cefprozil cefuroxime cephalexin LORABID 1 1 1 1 1 2 loracarbef CHLORAMPHENICOLS chloramphenicol 1 CLINDAMYCINS CLEOCIN granules clindamycin clindamycin 2 1 ERYTHROMYCINS ERY-TAB erythromycin erythromycin erythromycin ethylsuccinate 2 1 1 8 .

ointment 1 1 3 1 2 3 2 oseltamivir ribavirin acyclovir QLL OTHER MACROLIDES azithromycin clarithromycin 1 1 QLL OTHER TOPICAL ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin 1 1 1 1 1 PARENTERAL ANTIFUNGALS 9 .DRUG NAME GENERIC NAME Tier Restrictions ORAL ANTIFUNGAL DRUGS clotrimazole fluconazole fluconazole 150mg tab itraconazole ketoconazole LAMISIL 1 1 1 1 1 2 1 3 PAR QLL PAR QLL PAR PAR terbinafine voriconazole nystatin VFEND OTHER ANTIINFECTIVE DRUGS bacitracin vancomycin 1 1 OTHER ANTIVIRAL DRUGS acyclovir amantadine ribavirin rimantadine TAMIFLU VIRAZOLE ZOVIRAX cream.

DRUG NAME GENERIC NAME amphotericin b fluconazole VFEND voriconazole Tier 1 1 3 Restrictions PENICILLINS amoxicillin amoxicillin / clavulanate penicillin v potassium 1 1 1 PLASMODICIDES hydroxychloroquine quinine sulfate 1 1 QUINOLONES AVELOX moxifloxacin ciprofloxacin ofloxacin 2 1 1 SULFONAMIDES GANTRISIN PEDIATRIC sulfisoxazole sulfamethoxazole / trimethoprim 2 1 TETRACYCLINES doxycycline minocycline tetracycline 1 1 1 TOPICAL ANTIBACTERIAL DRUGS CHLORHEXIDINE chlorhexidine gentamicin mupirocin silver sulfadiazine 2 1 1 1 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB. 10 .

DRUG NAME GENERIC NAME clotrimazole / betamethasone nystatin / triamcinolone Tier 1 1 Restrictions URINARY ANTIINFECTIVES methenamine nitrofurantoin trimethoprim 1 1 1 VAGINAL ANTIFUNGALS miconazole nystatin terconazole 1 1 1 QLL QLL ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS AMEVIVE ARIMIDEX alefacept anastrozole bicalutamide mycophenolate leuprolide etanercept letrozole imatinib adalimumab gefitinib azathioprine CASODEX CELLCEPT cyclophosphamide cyclosporine ELIGARD ENBREL FEMARA fluorouracil GLEEVEC HUMIRA hydroxyurea IRESSA leflunomide leucovorin megestrol methotrexate MYFORTIC NEXAVAR PROGRAF RAPAMUNE mycophenolate sorafenib tacrolimus sirolimus 11 3 2 1 2 2 1 1 2 3 2 1 3 3 1 3 1 1 1 1 2 3 2 2 PAR PAR PAR PAR PAR PAR PAR PAR QLL PAR PAR PAR PAR .

CONSTA SEROQUEL thioridazine ZYPREXA. ZYDIS 2 1 1 2 1 1 2 2 1 2 QLL QLL QLL QLL QLL 12 . ODT EXELON NAMENDA donepezil rivastigmine memantine 2 2 2 ANTIMANIA DRUGS lithium carbonate lithium citrate 1 1 ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine trihexyphenidyl 1 1 ANTIPSYCHOTIC DRUGS ABILIFY aripiprazole ziprasidone risperidone quetiapine olanzapine chlorpromazine fluphenazine GEODON haloperidol perphenazine RISPERDAL.DRUG NAME RAPTIVA REMICADE GENERIC NAME efalizumab infliximab erlotinib tamoxifen TARCEVA Tier 3 3 1 3 Restrictions PAR PAR AUTONOMIC AND CNS MEDICATIONS ANALGESICS butorphanol tramadol tramadol / acetaminophen 1 1 1 ANTIDEMENTIA DRUGS ARICEPT. M-TAB.

ODT ondansetron 2 2 1 1 1 2 PAR QLL PAR QLL ANXIOLYTICS buspirone meprobamate 1 1 CARBAMAZEPINES carbamazepine TEGRETOL XR TRILEPTAL carbamazepine oxcarbazepine 1 2 2 CLASS II NARCOTICS ACTIQ fentanyl fentanyl hydromorphone methadone morphine oxycodone oxycodone / acetaminophen 2 1 1 1 1 1 1 PAR QLL QLL CLASS III NARCOTICS acetaminophen / codeine hydrocodone / acetaminophen 1 1 CLASS IV NARCOTICS propoxyphene propoxyphene / acetaminophen propoxyphene / aspirin / caffeine 1 1 1 13 .DRUG NAME GENERIC NAME Tier Restrictions ANTIVERTIGO AND ANTIEMETIC DRUGS ALOXI EMEND palonosetron aprepitant meclizine prochlorperazine promethazine ZOFRAN.

DRUG NAME GENERIC NAME Tier Restrictions CNS STIMULANT DRUGS amphetamine / dextroamphetamine dextroamphetamine METADATE CD METADATE ER 10mg tablet 1 methylphenidate methylphenidate modafinil metadate er 20mg tablet methylphenidate. sr PROVIGIL 1 2 2 1 1 2 PAR DRUGS TO PREVENT AND TREAT HEADACHES acetaminophen / butalbital / caffeine / cod butorphanol IMITREX MAXALT. MLT 1 sumatriptan rizatriptan 1 2 2 QLL QLL QLL HYDANTOINS CEREBYX PEGANONE fosphenytoin ethotoin phenytoin 2 2 1 MAO INHIBITORS NARDIL phenelzine tranylcypromine 2 1 OTHER ANTICONVULSANTS gabapentin lamotrigine LYRICA 1 1 2 1 2 1 pregabalin topiramate ST PAR PAR primidone TOPAMAX zonisamide OTHER ANTIDEPRESSANTS 14 . er.

sr CYMBALTA duloxetine mirtazapine trazodone venlafaxine Tier 1 2 1 1 1 Restrictions QLL QLL ST OTHER ANTIPARKINSON DRUGS carbidopa / levodopa. er. cr COMTAN REQUIP entacapone ropinirole carbidopa / levodopa / entacapone tolcapone selegiline STALEVO TASMAR 1 2 2 1 2 2 OTHER CNS/AUTONOMIC DRUGS ANTABUSE disulfiram atomoxetine sodium oxybate atropine naltrexone STRATTERA XYREM 2 1 1 2 3 PAR SECONDARY AMINES desipramine nortriptyline 1 1 SEDATIVE/HYPNOTIC DRUGS AMBIEN zolpidem zaleplon chloral hydrate SONATA 2 1 2 QLL QLL SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram fluoxetine fluvoxamine paroxetine sertraline 1 1 1 1 2 QLL QLL QLL QLL QLL 15 .DRUG NAME GENERIC NAME bupropion.

DRUG NAME GENERIC NAME Tier Restrictions SMOKING CESSATION PRODUCTS bupropion sr nicotine patch 1 1 QLL SUCCINIMIDES CELONTIN methsuximide ethosuximide 2 1 TERTIARY AMINES amitriptyline doxepin imipramine 1 1 1 VALPROIC ACID AND DERIVATIVES DEPAKOTE. ER. SPRINKLES divalproex sodium valproic acid 2 1 CARDIOVASCULAR MEDICATIONS AMIODARONES amiodarone 1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril captopril enalapril fosinopril lisinopril quinapril 1 1 1 1 1 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND MICARDIS candesartan telmisartan 2 2 ST ST 16 .

er NORVASC SULAR 1 1 1 2 2 1 amlodipine nisoldipine ST ST verapamil. sr propafenone 2 1 1 1 1 BETA-ADRENERGIC ANTAGONIST DRUGS atenolol COREG INNOPRAN XL carvedilol propranolol labetalol metoprolol propranolol TOPROL XL metoprolol 1 2 2 1 1 1 2 CALCIUM ANTAGONISTS diltiazem.DRUG NAME GENERIC NAME Tier Restrictions ANTIDYSRHYTHMIC DRUGS ETHMOZINE moricizine flecainide mexiletine procainamide. sr CARDIAC GLYCOSIDES digitek digoxin 1 1 CENTRALLY ACTING ANTIHYPERTENSIVES clonidine methyldopa 1 1 DRUGS FOR PHEOCHROMOCYTOMA DEMSER DIBENZYLINE metyrosine phenoxybenzamine 2 2 17 . er. er. xr felodipine er nifedipine.

af TIKOSYN dofetilide 1 2 OTHER ANTIHYPERTENSIVES ATACAND HCT candesartan / hydrochlorothiazide 2 ST 18 . er. td 1 1 1 OTHER ANTIARRHYTHMICS sotalol.DRUG NAME GENERIC NAME Tier Restrictions ENDOTHELIN RECPTR ANTAGONIST TRACLEER bosentan 3 HMG-COA REDUCTASE INHIBITORS CRESTOR rosuvastatin lovastatin pravastatin simvastatin VYTORIN ezetimibe / simvastatin 2 1 1 1 2 QLL ST QLL QLL QLL QLL ST HYPOLIPOPROTEINEMICS cholestyramine gemfibrozil NIASPAN TRIGLIDE ZETIA 1 1 2 2 2 niacin fenofibrate ezetimibe ST LOOP DIURETICS bumetanide furosemide torsemide 1 1 1 NITRATES isosorbide dinitrate. er nitroglycerin. isosorbide mononitrate. er.

er REVATIO sildenafil 1 2 PARQLL POTASSIUM SPARING DIURETICS spironolactone triamterene / hydrochlorothiazide 1 1 THIAZIDE AND RELATED DRUGS chlorthalidone hydrochlorothiazide indapamide metolazone 1 1 1 1 VASODILATOR ANTIHYPERTENSIVES doxazosin hydralazine minoxidil prazosin terazosin 1 1 1 1 1 QLL QLL 19 .DRUG NAME GENERIC NAME benazepril / hydrochlorothiazide bisoprol / hydrochlorothizide enalapril / hydrochlorothiazide fosinopril / hydrochlorothiazide lisinopril / hydrochlorothiazide metoprolol / hydrochlorothiazide MICARDIS HCT telmisartan / hydrochlorothiazide propranolol / hydrochlothiazide quinapril / hydrochlorothiazide reserpine Tier 1 1 1 1 1 1 2 1 1 1 Restrictions ST OTHER CARDIOVASCULAR DRUGS midodrine pentoxifylline er 1 1 OTHER VASODILATING DRUGS papaverine.

DRUG NAME GENERIC NAME Tier Restrictions DERMATOLOGICAL MEDICATIONS ANTIACNE DRUGS clindamycin DIFFERIN 1 adapalene 1 1 1 1 erythromycin erythromycin / benzoyl peroxide metronidazole tretinoin PAR ANTIPRURITIC DRUGS hydroxyzine 1 ANTIPSORIASIS AND ANTIECZEMA DRUGS DOVONEX calcipotriene tazarotene selenium TAZORAC 2 1 2 PAR KERATOLYTIC DRUGS CONDYLOX gel KERALYT podofilox salicylic acid podofilox 2 2 1 ORAL DERMATOLOGICAL DRUGS isotretinoin OXSORALEN methoxsalen 1 2 SCABICIDES acticin permethrin 1 1 TOPICAL CORTICOSTEROID DRUGS betamethasone clobetasol desonide 1 1 1 20 .

DRUG NAME GENERIC NAME desoximetasone fluocinonide. e fluticasone hydrocortisone mometasone triamcinolone Tier 1 1 1 1 1 1 Restrictions TOPICAL DERMATOLOGICAL DRUGS ALDARA imiquimod pimecrolimus tacrolimus diclofenac ammonium lactate ELIDEL fluorouracil lactic acid PROTOPIC SOLARAZE urea 2 1 2 1 1 2 2 1 ST DIAGNOSTIC & MISCELLANEOUS MEDICATIONS DIAGNOSTIC PRODUCTS CHEMET EXJADE succimer deferasirox 2 2 MISCELLANEOUS DRUGS COPAXONE glatiramer acetate nitisinone thalidomide ergoloid mesylates ORFADIN THALOMID 3 1 3 3 PAR QLL EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR acetic acid antipyrine / benzocaine CIPRODEX 1 1 2 1 ciprofloxacin / dexamethasone hydrocortisone / neomycin / polymixin b DRUGS AFFECTING THE NOSE 21 .

DRUG NAME ASTELIN GENERIC NAME Tier 2 1 1 1 Restrictions QLL QLL QLL QLL azelastine flunisolide fluticasone ipratropium bromide DRUGS AFFECTING THE THROAT AND MOUTH chlorhexidine gluconate doxycycline hyclate pilocarpine triamcinolone 1 1 1 1 ENDOCRINE MEDICATIONS AMYLIN ANALOGUES SYMLIN pramlintide 2 PAR ANTITHYROID DRUGS methimazole propylthiouracil 1 1 GLUCOCORTICOID DRUGS dexamethasone hydrocortisone methylprednisolone prednisolone prednisone 1 1 1 1 1 GLUCOSE ELEVATING DRUGS GLUCAGEN PROGLYCEM glucagen diazoxide 2 2 INCRETIN MIMETICS BYETTA exenatide 2 PARQLL INSULIN 22 .

DRUG NAME LANTUS vial LEVEMIR vial NOVOLIN 70/30 NOVOLIN L NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG 70/30 GENERIC NAME Tier 2 2 2 2 2 2 2 2 Restrictions insulin glargine insulin detemir insulin nph / insulin regular insulin zinc insulin nph insulin regular insulin aspart insulin aspart / regular insulin MINERALOCORTICOID DRUGS fludrocortisone 1 ORAL HYPOGLYCEMICS & COMBOS AVANDAMET AVANDARYL AVANDIA rosiglitazone / metformin rosiglitazone / glimepiride rosiglitazone glimepiride glipizide / metformin glipizide. xl glyburide glyburide / metformin metformin. er PRANDIN PRECOSE repaglinide acarbose 2 2 2 1 1 1 1 1 1 2 2 QLL QLL QLL OTHER ENDOCRINE DRUGS desmopressin etidronate fortical nasal spray FOSAMAX FOSAMAX PLUS D SENSIPAR SOMAVERT 1 1 1 2 2 3 3 calcitonin alendronate alendronate / vitamin d3 cinacalcet pegvisomant QLL QLL PAR THYROID SUPPLEMENTS levothroid 1 23 . er.

er metoclopramide propantheline 1 1 1 1 ANTIULCER DRUGS cimetidine famotidine nizatidine ranitidine 1 1 1 1 IRRITABLE BOWEL DRUGS LOTRONEX ZELNORM alosetron tegaserod 2 2 LAXATIVES AND CATHARTICS polyethylene glycol VISICOL sodium phosphate salts 1 2 OTHER ANTIULCER DRUGS misoprostol sucralfate 1 1 OTHER GI DRUGS 24 .DRUG NAME GENERIC NAME levothyroxine levoxyl thyroid Tier 1 1 1 Restrictions GASTROINTESTINAL MEDICATIONS ANTIDIARRHEAL DRUGS diphenoxylate / atropine loperamide 1 1 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY dicyclomine hyoscyamine sulfate.

NF ENGERIX-B FLEBOGAMMA GAMMAGARD S/D GAMMAR-P GAMUNEX immune globulin (igg) hepatitis b vaccine immune globulin (igg) immune globulin (igg) immune globulin (igg) immune globulin (igg) immune globulin (igg) immune globulin (igg) immune globulin (igg) tetanus toxoid. adsorbed hep b vaccine / hep a vaccine immune globulin IVEEGAM EN PANGLOBULIN NF POLYGAM S/D TETANUS TOXOID ADSORBED TWINRIX 3 2 3 3 3 3 3 3 3 3 2 2 PAR PAR PAR PAR PAR PAR PAR PAR PAR 25 . MT URSO ursodiol Tier 2 2 2 1 1 2 2 2 1 Restrictions PROTON PUMP INHIBITORS omeprazole PROTONIX pantoprazole 1 2 QLL QLL ST IMMUNOLOGICALS AND VACCINES ERYTHROID STIMULANTS ARANESP PROCRIT darbepoetin epoetin 3 3 PAR PAR GROWTH HORMONES AND RELATED DRUGS NORDITROPIN SAIZEN somatropin somatropin 3 3 PAR PAR IMMUNOLOGICALS AND VACCINES CARIMUNE.DRUG NAME ASACOL CANASA CREON GENERIC NAME mesalamine mesalamine amylase / lipase / protease mesalamine amylase / lipase / protease ursodiol hydrocortisone peg / electrolytes PENTASA ULTRASE.

DRUG NAME GENERIC NAME Tier Restrictions INTERFERONS AVONEX BETASERON INFERGEN PEGASYS REBIF interferon beta-1a interferon beta-1b interferon alfacon peginterferon alfa-2a interferon beta-1a 3 3 3 3 3 PAR QLL PAR QLL PAR QLL PAR QLL INTERLEUKINS NEUMEGA PROLEUKIN ZENAPAX oprelvekin aldesleukin daclizumab 3 3 3 QLL MYELOID STIMULANTS LEUKINE NEULASTA NEUPOGEN sargramostim pegfilgrastim filgrastim 3 3 3 PAR PAR MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES ALCOHOL swab INSULIN needle INSULIN syringe alcohol antiseptic pad insulin needle insulin syringe 2 2 2 MUSCULOSKELETAL MEDICATIONS CNS MUSCLE RELAXANTS carisoprodal / aspirin / codeine carisoprodol cyclobenzaprine methocarbamol RILUTEK 1 1 1 1 2 riluzole DIRECT MUSCLE RELAXANTS baclofen dantrolene tizanidine 26 1 1 1 .

er naproxen.ELECTROLYTES ANTIPLATELET DRUGS AGGRENOX aspirin / dipyridamole clopidogrel cilostazol dipyridamole PLAVIX 2 1 1 2 BLOOD DETOXICANTS 27 .DRUG NAME GENERIC NAME Tier Restrictions DRUGS TO PREVENT AND TREAT GOUT allopurinol colchicine 1 1 NON-STEROIDAL ANTIINFLAMMATORY AGENTS CELEBREX celecoxib diclofenac potassium diclofenac sodium er. er ibuprofen indomethacin.BLOOD MODIFIERS. er nabumetone naproxen sodium. er piroxicam sulindac 2 1 1 1 1 1 1 1 1 1 1 ST OTHER DRUGS FOR ARTHRITIS gold myochrysine RIDAURA 1 1 2 auranofin SALICYLATES AND RELATED DRUGS diflunisal salsalate 1 1 NUTRITION. xr etodolac.

ETC. IRRIGATING SOLUTIONS.DRUG NAME GENERIC NAME lactulose RENAGEL sevelamer Tier 1 2 Restrictions ELECTROLYTES. bacteriostatic saline dextrose sodium chloride 1 1 1 FLUORIDE PRODUCTS sodium fluoride stannous fluoride 1 1 INJECTABLE ANTICOAGULANTS heparin LOVENOX enoxaparin 1 3 ORAL ANTICOAGULANTS. er 1 1 1 THERAPEUTIC VITAMINS & MINERALS calcitriol HECTOROL doxercalciferol calcium acetate levocarnitine PHOSLO 1 2 1 2 28 . cr. VITAMIN K jantoven warfarin warfarin 1 POTASSIUM REMOVING RESINS sodium polystyrene sulfonfonate SPS sodium polystyrene sulfonate 1 2 POTASSIUM SUPPLEMENTS citric acid / sodium citrate potassium acetate potassium chloride.

esterified estrogens. conjugated estradiol ESTROGEN/PROGESTIN COMBINATIONS ACTIVELLA norethindrone / estradiol 2 OB/GYN TOPICAL ANTIINFECTIVES 29 .DRUG NAME GENERIC NAME Tier Restrictions VITAMINS & MINERALS & RELATED PRODUCTS LIPOSYN fat emulsions multivitamin / fluoride multivitamin / fluoride / iron tri-vit / fluoride tri-vit / fluoride / iron 2 1 1 1 1 OBSTETRICAL & GYNECOLOGICAL MEDICATIONS ANDROGEN DRUGS OXANDRIN TESTIM oxandrolone testosterone testosterone testosterone cypionate testosterone enanthate testosterone propionate 2 2 1 1 1 1 PAR CONTRACEPTIVES apri levora necon sprintec zovia desogestrel / ethinyl estradiol levonorgestrel / ethinyl estradiol norethidrone / ethinyl estradiol norgestimate / ethinyl estradiol ethynodiol / ethinyl estradiol 1 1 1 1 1 ESTROGEN DRUGS estradiol estradiol patch estropipate MENEST PREMARIN vaginal cream VAGIFEM 1 1 1 2 2 2 QLL estrogens.

DRUG NAME GENERIC NAME amino acid cervical clindamycin Tier 1 1 Restrictions OXYTOCICS METHERGINE methylergonovine oxytocin 2 1 PRENATAL VITAMINS natalcare natatab prenatal advantage prenatal plus prenatal vitamin prenatal vitamin prenatal vitamin prenatal vitamin 1 1 1 1 PROGESTIN DRUGS camila jolivette medroxyprogesterone medroxyprogesterone injection norethindrone PROMETRIUM norethindrone norethindrone progesterone. micronized 1 1 1 1 1 2 QLL SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA raloxifene 2 SPECIALIZED OB/GYN DRUGS leuprolide LUPRON. DEPOT-PED SYNAREL leuprolide nafarelin 1 3 2 PAR OPHTHALMIC MEDICATIONS ANTIGLAUCOMA DRUGS acetazolamide ALPHAGAN P brimonidine bimatoprost brimonidine LUMIGAN 1 2 1 2 30 . DEPOT.

DRUG NAME GENERIC NAME pilocarpine piloptic timolol TRUSOPT XALATAN dorzolamide latanoprost Tier 1 1 1 2 2 Restrictions OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS neomycin / polymyxin b / dexamethasone sulf-pred ZYLET 1 sulfacetamide / prednisolone tobramycin / loteprednol 1 2 OPHTHALMIC CORTICOSTEROID DRUGS fluorometholone prednisolone 1 1 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS bacitracin ciprofloxacin erythromycin gentamicin ofloxacin tobramycin ZYMAR 1 1 1 1 1 1 2 gatifloxacin OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine 1 OTHER OPHTHALMIC DRUGS atropine RESTASIS VOLTAREN ZADITOR cyclosporine diclofenac ketotifen 1 2 2 2 QLL RESPIRATORY MEDICATIONS ANTIHISTAMINE/DECONGESTANT COMBINATIONS 31 .

DRUG NAME GENERIC NAME Tier 1 1 1 1 1 Restrictions bromfed durahist extendryl pseudoephedrine / chlorpheniramine rondec phenylephrine / brompheniramine phenyleph / chlorphen / scop phenyleph / chlorphen / scop phenylephrine / chlorpheniramine ANTIHISTAMINES cyproheptadine diphenhydramine fexofenadine promethazine 1 1 1 1 QLL ANTITUSSIVE AND EXPECTORANT DRUGS guaifenesin guaifenesin / phenylephrine guaifenesin / pseudoephedrine 1 1 1 BETA-2 ADRENERGIC DRUGS albuterol albuterol inhaler FORADIL PROAIR HFA PROVENTIL HFA 1 1 2 2 2 QLL QLL QLL QLL formoterol albuterol albuterol DECONGESTANTS phenylephrine phenylephrine / methscopolamine pseudoephedrine 1 1 1 LEUKOTRIENE MODIFIERS SINGULAIR ZYFLO montelukast zileuton 2 2 ST ST METHYL XANTHINE DRUGS 32 .

JR INTAL PULMICORT QVAR SPIRIVA TILADE TWINJECT XOLAIR albuterol / ipratropium epinephrine cromolyn budesonide beclomethasone tiotropium nedocromil epinephrine omalizumab 2 2 2 2 2 2 2 2 3 QLL QLL QLL QLL QLL QLL QLL QLL PAR OTHER RESPIRATORY DRUGS ARALAST BRONCHOLATE PROLASTIN alpha-1-proteinase inhibitor guaifenesin / ephedrine alpha-1-proteinase inhibitor 3 2 3 PAR PAR UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DITROPAN XL ENABLEX oxybutynin darifenacin flavoxate oxybutynin 2 2 1 1 QLL CHOLINERGIC STIMULANTS bethanechol 1 OTHER GENITOURINARY PRODUCTS finasteride potassium citrate / citric acid UROXATRAL 1 1 2 alfuzosin 33 . er UNIPHYL theophylline OTHER DRUGS FOR ASTHMA COMBIVENT EPIPEN.DRUG NAME GENERIC NAME Tier 1 1 2 Restrictions aminophylline theophylline.

DRUG NAME GENERIC NAME Tier Restrictions URINARY ANESTHETICS phenazopyridine 1 34 .

12 acarbose. 21 aldesleukin. 22 ANALGESICS. 26 ALCOHOL swab. 17 ANTIGLAUCOMA DRUGS. 7 AMIODARONES. 11 ANDROGEN DRUGS. 7 ANTIACNE DRUGS. 20 ACTIQ.INDEX ABILIFY. 10 amphetamine / dextroamphetamine. 33 allopurinol. 21 acticin. ANTIDEMENTIA DRUGS. 7 ALBENZA. 23 ANTABUSE. 33 amlodipine. 16 amitriptyline. 13 alpha-1-proteinase inhibitor. 32 ANTIINFECTIVES. 21 amoxicillin. 9 AMBIEN. 11 alendronate. 7 AMEVIVE. 7 33 alendronate / vitamin d3. 30 amantadine. 7 albuterol. 27 albendazole. 10 amoxicillin / clavulanate. 24 ALOXI. 9 adalimumab. 27 alosetron. 23 abacavir. 13 acetazolamide. 15 AMEBICIDES. 33 albuterol inhaler. 32 alcohol antiseptic pad. 29 ANESTHETICS. 14 acetaminophen / codeine. 33 amiodarone. 26 ALDARA. 20 ANTICHOLINERGIC ANTISPASMODICS. 30 aminophylline. 13 ACTIVELLA. 31 ANTIHISTAMINES. 11 ANTIPARKINSON ANTICHOLINERGIC DRUGS. 25 AMYLIN ANALOGUES. 30 ANTIHISTAMINE/DECONGESTANT COMBINATIONS. 12 anastrozole. 16 AMINOGLYCOSIDES. 20 35 . 30 acetic acid. 15 ANGIOTENSIN CONVERTING ENZYME INHIBITORS. 7 albuterol / ipratropium. 26 alefacept. 8 acetaminophen / butalbital / caffeine / cod. 16 ANTIINFECTIVES SPECIALIZED INDICATIONS. 16 ANTHELMINTICS. 20 AGGRENOX. 7 ANTIMANIA DRUGS. 33 ALPHAGAN P. 11 amino acid cervical. 12 ANTIPLATELET DRUGS. 12 ANTIDIARRHEAL DRUGS. 16 ANGIOTENSIN II RECEPTOR ANTAGONISTS. 11 adapalene. 12 ANTINEOPLASTIC/IMMUNOSUPPRESSA NT DRUGS. 27 ANTIPRURITIC DRUGS. 10 amylase / lipase / protease. 23 alfuzosin. 14 amphotericin b. 17 ammonium lactate. 32. 24 ANTIDYSRHYTHMIC DRUGS. 29 acyclovir.

33 bumetanide. 15 atropine. 12 ASACOL. 26 bacteriostatic saline. 17 camila. 24 ANTIVERTIGO AND ANTIEMETIC DRUGS. 13 butorphanol. 28 AUTONOMIC AND CNS MEDICATIONS. 21 ANTIRETROVIRALS & PROTEASE INH. 18 candesartan / hydrochlorothiazide. 32 ANTIULCER DRUGS. 12 AVANDAMET. 22 ATACAND. 26 azathioprine. 23 AVANDARYL. 27 BRONCHOLATE. 28 beclomethasone. 27 bosentan. 26 bethanechol. 31 auranofin. 17 36 . 12 ARIMIDEX. 13 CARBAMAZEPINES. 32 aspirin / dipyridamole. 12 BETA-2 ADRENERGIC DRUGS. 29 ARALAST. 13 carbidopa / levodopa / entacapone. 25 bacitracin. 11 bimatoprost. 31 baclofen. 27 ASTELIN. 33 benazepril. 18 captopril. sr. 15 buspirone.ANTIPSORIASIS AND ANTIECZEMA DRUGS. 18 brimonidine. 20 ANTIPSYCHOTIC DRUGS. 12 antipyrine / benzocaine. 10 AVONEX. 32 BETA-ADRENERGIC ANTAGONIST DRUGS. 18 ATACAND HCT. 16 bupropion. 18 atenolol. 19 benazepril / hydrochlorothiazide. 11 azelastine. 20 calcitonin. 13 ANXIOLYTICS. 9. 30 bromfed. 13 aprepitant. 17 atomoxetine. 22 ANTITUBERCULOSIS DRUGS. 16. 23 calcitriol. 22 calcipotriene. cr. 13 apri. 15 CARDIAC GLYCOSIDES. 30 CANASA. 15 carbidopa / levodopa. 11 aripiprazole. 16 carbamazepine. 9 CALCIUM ANTAGONISTS. 16. er. 30 bisoprol / hydrochlorothizide. 24 ANTITHYROID DRUGS. 25 candesartan. 8 ANTITUSSIVE AND EXPECTORANT DRUGS. 28 calcium acetate. 16. 23 AVELOX. 33 ARANESP. 33 bicalutamide. 20 BETASERON. 17 betamethasone. 18 bupropion sr. 22 azithromycin. ODT. 19 BLOOD DETOXICANTS. 23 AVANDIA. 12. 33 budesonide. 19 benztropine. 14 BYETTA. 15. 8 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY. 25 ARICEPT.

33 cyproheptadine. 13 CLEOCIN granules. 18 ciclopirox. 21 COREG. 33 DECONGESTANTS. 15 CHOLINERGIC STIMULANTS. 8 cefpodoxime. 26 carisoprodol. 26 CNS STIMULANT DRUGS. carisoprodal / aspirin / codeine. 21 ciprofloxacin. 8 CEREBYX. 21 DEMSER. 33 COMBIVIR. 8 chlorhexidine. desipramine. SPRINKLES. 9. 8 clobetasol. 8 cefprozil. 25 CRESTOR. 8 chloral hydrate. 16 CIPRODEX. 29 desonide. 11. 23 desogestrel / ethinyl estradiol. 24 cinacalcet. 8 DAPSONE. 14 CHEMET. 25 darifenacin. 28 clarithromycin. 11 CELONTIN. 11 CNS MUSCLE RELAXANTS. 16 CASODEX. 11 clotrimazole / betamethasone. 27 clotrimazole. 22 chlorhexidine gluconate. 17 CREON. ER. 25 CLASS IV NARCOTICS. 32 daclizumab. 13 . 8 CELEBREX. 11 16 CARIMUNE. 20 37 20 CLASS II NARCOTICS. 8. 20 COPAXONE. 19 cholestyramine. 8 darbepoetin.CARDIOVASCULAR MEDICATIONS. 15 citric acid / sodium citrate. 31 CYMBALTA. 27 cimetidine. 30 CLINDAMYCINS. 21 citalopram. 27 celecoxib. 9 DERMATOLOGICAL MEDICATIONS. 14 colchicine. 17 DEPAKOTE. 17 cefadroxil. 10 cyclobenzaprine. 8 clindamycin. 9 cilostazol. 26 dantrolene. 10. NF. 22 chlorpromazine. 13 CLASS III NARCOTICS. 33 CENTRALLY ACTING ANTIHYPERTENSIVES. 18 cromolyn. 23 CHLORHEXIDINE. 15 CONDYLOX gel. 15 chloramphenicol. 8 COMTAN. 15 desmopressin. 26 carvedilol. 12 chlorthalidone. 27 COMBIVENT. 8 CHLORAMPHENICOLS. 21 CONTRACEPTIVES. 17 clopidogrel. 8 cefuroxime. 10. 32 deferasirox. 17 cephalexin. 29 CEPHALOSPORINS. 26 dapsone. 11 cyclosporine. 26 cyclophosphamide. 27 CELLCEPT. 20 clonidine. 20. 21. 31 ciprofloxacin / dexamethasone.

8 ENGERIX-B. 13 ENABLEX. 22 erythromycin. 28 DRUGS TO PREVENT AND TREAT GOUT. 27. 8. er. 21 ELIGARD. 25 ERY-TAB. conjugated. 17 ERYTHROMYCINS. 12 ELECTROLYTES. 31 erythromycin / benzoyl peroxide. 24 dipyridamole. 28 entacapone. 22 DRUGS FOR PHEOCHROMOCYTOMA. 22 doxycycline hyclate. ETC. 8 ENDOTHELIN RECPTR ANTAGONIST. 33 enalapril. 17 digoxin. 27 digitek. 22 enfuvirtide. 15 DITROPAN XL. 9 efalizumab. JR. 29 38 . 8 DRUGS AFFECTING THE EAR. 16 dofetilide. 27 diclofenac sodium er. 18 DIRECT MUSCLE RELAXANTS. 27 disulfiram. 21 dexamethasone. 19 ENBREL. 11 EMEND. 32 21 27 DIABETIC SUPPLIES. 15 durahist. 21 DRUGS AFFECTING THE NOSE. 21 DIAGNOSTIC PRODUCTS. 10. 21 diazoxide. 33 epoetin. 17 EAR-NOSE-THROAT MEDICATIONS. 25 enoxaparin. 21 erlotinib. 29 ESTROGEN/PROGESTIN COMBINATIONS. 26 divalproex sodium. 18 donepezil. xr. 33 ENDOCRINE MEDICATIONS. 8 DIFFERIN. 29 ESTROGEN DRUGS. 20 diflunisal. DRUGS TO PREVENT AND TREAT HEADACHES. 14 dextrose. 14 duloxetine. 32 diphenoxylate / atropine. 29 estrogens. 27 dicyclomine. 28 doxycycline. 21. 20. 17 DIBENZYLINE. 20 doxazosin. 22 dextroamphetamine. 29 estradiol patch. 28 ELIDEL.. 19 doxepin. 20 erythromycin ethylsuccinate. 8 estradiol. 33 EPIPEN. 31 diclofenac potassium. 17 diphenhydramine. 24 didanosine.desoximetasone. 11 enalapril / hydrochlorothiazide. 16. xr. 12 ERYTHROID STIMULANTS. 19 diltiazem. 16 ergoloid mesylates. 26 DIAGNOSTIC & MISCELLANEOUS MEDICATIONS. 21 DRUGS AFFECTING THE THROAT AND MOUTH. econazole. 25 doxercalciferol. 22 diclofenac. 12 dorzolamide. 15 epinephrine. IRRIGATING SOLUTIONS. 31 DOVONEX.

24 gatifloxacin. 14 FOSAMAX PLUS D. 23 glyburide / metformin. 8 EVISTA. 26 finasteride. 28 hepatitis b vaccine. 25 guaifenesin. 10 glatiramer acetate. 16.estrogens. 32 haloperidol. er. 7. 10. 18 FUZEON. 32 formoterol. 21 fluoxetine. 10 GASTROINTESTINAL MEDICATIONS. 22 GLUCOCORTICOID DRUGS. 18 famotidine. 27 fluconazole 150mg tab. 25 GAMMAR-P. 15 fluphenazine. 33 guaifenesin / phenylephrine. 16 ethotoin. 23 HMG-COA REDUCTASE INHIBITORS. 22 fluocinonide. 11 39 fortical nasal spray. xl. 21 fluorometholone. 22 GLUCAGEN. 32 ezetimibe. 23 etodolac. 17 ethosuximide. 28 GROWTH HORMONES AND RELATED DRUGS. 23 fosinopril. 32 FOSAMAX. 31 gefitinib. 23 flunisolide. 12 exenatide. 29 etidronate. 25 flecainide. 23 FLUORIDE PRODUCTS. 33 flavoxate. 9 fludrocortisone. 21. 32 filgrastim. 22 fluvoxamine. 23 ezetimibe / simvastatin. 19 fosinopril / hydrochlorothiazide. 17 fluconazole. 21 extendryl. 32. 11 gemfibrozil. 11. 21 glipizide / metformin. 29 estropipate. 12 GLEEVEC. 24 fat emulsions. 31 fluorouracil. 11 glimepiride. 18 ethynodiol / ethinyl estradiol. 13 fexofenadine. 14 furosemide. 11 fenofibrate. 32 guaifenesin / pseudoephedrine. 25 HUMIRA. 23 gold. 25 heparin. 19 fosphenytoin. 17 FEMARA. 9. 22 GLUCOSE ELEVATING DRUGS. 14 GAMMAGARD S/D. 12 fluticasone. 12 HECTOROL. esterified. 30 EXELON. 22 EXJADE. 23 glipizide. 31 GEODON. 33 FLEBOGAMMA. 18 gentamicin. e. 27 gabapentin. 29 etanercept. 11 ETHMOZINE. er. 25 GAMUNEX. 22 glyburide. 33 guaifenesin / ephedrine. 29 felodipine er. 23 glucagen. 18 fentanyl. 18 . 15 FORADIL. 28 hep b vaccine / hep a vaccine. 25 GANTRISIN PEDIATRIC.

26 INTERLEUKINS. 33 interferon alfacon. 11 hydroxyzine. 25 IMMUNOLOGICALS AND VACCINES. 23 insulin glargine. 26 insulin nph / insulin regular. 28 jolivette. 18 isotretinoin. 18 ibuprofen. 25 immune globulin (igg). 23 lamivudine / zidovudine. 24 leflunomide. 24 40 . 26 KERATOLYTIC DRUGS. 27 imatinib. 29 levothroid. 18 isosorbide mononitrate. 26 INSULIN syringe. 22 IRRITABLE BOWEL DRUGS.. 10 hydroxyurea. 19 hydrocodone / acetaminophen. 23 insulin detemir. 28 levonorgestrel / ethinyl estradiol. 23 LAXATIVES AND CATHARTICS. 26 hydralazine. 9 INJECTABLE ANTICOAGULANTS. 19 indomethacin. 30 KALETRA. 27 infliximab. 26 interferon beta-1a. 7 jantoven. 24 isoniazid. 26 IRESSA. 23 insulin regular. 13 hydrocortisone. 23 INTAL. 17 lactic acid. 23 insulin syringe. 7 ipratropium bromide. 26 insulin nph. 25 INCRETIN MIMETICS. 26 LEUKOTRIENE MODIFIERS. 26 insulin aspart. er. 23 insulin needle. 20 ketoconazole. 17 INSULIN. 14 interferon beta-1b. 8 isosorbide dinitrate. 28 LAMISIL. 11 imipramine. 31 insulin aspart / regular insulin.HYDANTOINS. 24 levoxyl. 14 immune globulin. 11 iodoquinol. 12 INFERGEN. 20 hyoscyamine sulfate. er. 29 levora. er. 20 itraconazole. 21 lactulose. 8 KERALYT. 25 ivermectin. 26 insulin zinc. 11 LEUKINE. 23 levothyroxine. 13 hydroxychloroquine. er. 22. 9 IVEEGAM EN. 21 hydromorphone. 16 imiquimod. 22 indapamide. 22. 19 hydrochlorothiazide. 23 latanoprost. 26 INSULIN needle. 21. 28 INNOPRAN XL. 14 LANTUS vial. 30 LEVEMIR vial. 24 INTERFERONS. 11. 8 lamotrigine. 32 leuprolide. 21 IMITREX. 11 leucovorin. 9 ketotifen. 31 labetalol. 25 hydrocortisone / neomycin / polymixin b. 20 HYPOLIPOPROTEINEMICS. 11 letrozole. 23 levocarnitine.

26 medroxyprogesterone. 11 MYFORTIC. 11 MUSCULOSKELETAL MEDICATIONS. 10 minoxidil. 26 41 . 19 metoprolol / hydrochlorothiazide. 16 METHYL XANTHINE DRUGS. 11 myochrysine. 13 mesalamine. 19 metronidazole. 7 LOOP DIURETICS. 14 metadate er 20mg tablet. 14 mebendazole. 11 METHERGINE. 21 misoprostol. 17 mexiletine. 19 miconazole. 17 morphine.lidocaine. 19 lithium carbonate. 29 METADATE CD. 20 metyrosine. 24 modafinil. 19 methoxsalen. 29 mupirocin. 24 metolazone. 14 metformin. 8. 17. 32 moricizine. 21 montelukast. MLT. 7 LIPOSYN. 28 LUMIGAN. 11 midodrine. 23 methadone. 30 naltrexone. 17 methylergonovine. 13 methyldopa. 15 MEDICAL (MISCELLANEOUS) SUPPLIES. 18 loperamide. 18 LOVENOX. 29 lisinopril. 7 lidocaine-viscous. 30 LYRICA. 19 MINERALOCORTICOID DRUGS. MYELOID STIMULANTS. sr. 17 MICARDIS. 29 multivitamin / fluoride / iron. 30 LUPRON. 8 LOTRONEX. 25 MISCELLANEOUS DRUGS. 23 minocycline. 30 methimazole. er. 24 lopinavir / ritonavir. 27 nabumetone. 19 MICARDIS HCT. 20 methsuximide. 10 mycophenolate. 14 methylphenidate. 27 nafarelin. 19 metoprolol. 32 lisinopril / hydrochlorothiazide. 14 METADATE ER 10mg tablet. 30 methylphenidate. 26 methotrexate. 12 lithium citrate. 16. DEPOT-PED. 14 methylprednisolone. 14 MAXALT. 13 methenamine. 30 medroxyprogesterone injection. 8 LORABID. 12 meprobamate. 8 loracarbef. 24 lovastatin. 11 memantine. 13 moxifloxacin. 12 LOCAL ANESTHETICS. 22 metoclopramide. er. 14 MAO INHIBITORS. 15 26 MENEST. 19 mirtazapine. 30 megestrol. 7 LIDODERM. 16. DEPOT. 10 multivitamin / fluoride. 14 mometasone. 7 meclizine. 22 methocarbamol.

33 neomycin. 18 OTHER ANTIINFECTIVE DRUGS. 26 NEUPOGEN. 24 OTHER ANTIVIRAL DRUGS. 23 NOVOLIN N. 10. 9. 23 NORDITROPIN. 27 naproxen. 29 ofloxacin. 27 nystatin. 18 OTHER ANTICONVULSANTS. 23 NOVOLOG 70/30. 12 naproxen sodium. 27 norethidrone / ethinyl estradiol. 15 OTHER ANTIULCER DRUGS. 29 nedocromil. er. 33 omeprazole. 30 norethindrone / estradiol. 19 OTHER CNS/AUTONOMIC DRUGS. 11 niacin. 18 nitrofurantoin. 14 natalcare. 30 necon. 29 neomycin / polymyxin b / dexamethasone. 23 OTHER GENITOURINARY PRODUCTS. 29. 15 OTHER DRUGS FOR ARTHRITIS. 25 ondansetron. 15 NORVASC. er. 21 oseltamivir. 31 NEULASTA. 9 ORAL ANTICOAGULANTS. 9 ORAL DERMATOLOGICAL DRUGS. 20 ORAL HYPOGLYCEMICS & COMBOS. 14 OTHER ANTIHYPERTENSIVES. 18 NIASPAN. VITAMIN K. 26 NEXAVAR. 9 OTHER CARDIOVASCULAR DRUGS. 33 NUTRITION. 11 nystatin / triamcinolone. 24 NON-STEROIDAL ANTIINFLAMMATORY AGENTS. 9 OTHER ANTIPARKINSON DRUGS. 11 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS. er. er. 26 nitroglycerin. OPHTHALMIC CORTICOSTEROID DRUGS. 14 OTHER ANTIDEPRESSANTS. 18 nizatidine. 16 nifedipine. td. 23 NOVOLIN R. 31 OB/GYN TOPICAL ANTIINFECTIVES. 17 nisoldipine. 27 OTHER DRUGS FOR ASTHMA. 18 nicotine patch. 17 NOVOLIN 70/30. 26 NEUMEGA. 7. 23 NOVOLOG. 30 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS. 31 oprelvekin. 12 omalizumab. 31 olanzapine. 13 OBSTETRICAL & GYNECOLOGICAL MEDICATIONS. 28 ORAL ANTIFUNGAL DRUGS. 29 norethindrone. 29 nortriptyline.NAMENDA. 17 nitisinone. 21 NITRATES. 31 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS. 30 natatab. 23 NOVOLIN L. 31 31 OPHTHALMIC MEDICATIONS.ELECTROLYTES. 25 ORFADIN. 33 OTHER ENDOCRINE DRUGS. 23 OTHER ANTIARRHYTHMICS. 29 norgestimate / ethinyl estradiol. 11 42 .BLOOD MODIFIERS. 27 NARDIL.

26 peginterferon alfa-2a. 19 PARENTERAL ANTIFUNGALS. er. 30 prenatal plus. 23 penicillin v potassium. 18 prazosin. 26 pegfilgrastim. 22 pregabalin. 30 oxytocin. 29 prenatal advantage. 19 POTASSIUM SUPPLEMENTS. 32 phenylephrine / chlorpheniramine. 15 peg / electrolytes. 26 pegvisomant. 22. 14 phenoxybenzamine. 9 OTHER VASODILATING DRUGS. 11 PROLASTIN. micronized. 28 POTASSIUM SPARING DIURETICS. 10 polyethylene glycol. 20 perphenazine. 13. 25 progesterone. 22 PROGRAF. 32 PROMETRIUM. 13 PROCRIT. 30 PROGLYCEM. 28 . 22 PRANDIN.OTHER GI DRUGS. 31 piloptic. 32 pramlintide. 26 promethazine. 30 PROGESTIN DRUGS. sr. 13 phenytoin. 17 prochlorperazine. 25 pentoxifylline er. 17 phenyleph / chlorphen / scop. 24 OTHER MACROLIDES. 19 OXANDRIN. 29 oxandrolone. 13 potassium acetate. 25 papaverine. 10 PENICILLINS. 29 oxcarbazepine. 14 PHOSLO. 25 PEGANONE. 32 phenylephrine / brompheniramine. 30 PRENATAL VITAMINS. 19 PRECOSE. 27 PLAVIX. 9 OTHER OPHTHALMIC DRUGS. 30 43 POTASSIUM REMOVING RESINS. 14 PEGASYS. 30 prenatal vitamin. 13 OXYTOCICS. 32 procainamide. 30 primidone. 19 permethrin. 34 phenelzine. er. 28 potassium chloride. 33 PANGLOBULIN NF. 32 phenylephrine. 23 prednisolone. 12 phenazopyridine. 24 POLYGAM S/D. cr. 21 piroxicam. 22. 30 palonosetron. 28 pilocarpine. 33 PROLEUKIN. 7 paroxetine. er. 14 PROAIR HFA. 31 pimecrolimus. 28 potassium citrate / citric acid. 20 PLASMODICIDES. 27 podofilox. 25 pantoprazole. 14 PREMARIN vaginal cream. 23 pravastatin. 31 OTHER RESPIRATORY DRUGS. 9 paromomycin. 10 PENTASA. 33 OTHER TOPICAL ANTIFUNGALS. 32 phenylephrine / methscopolamine. 25 oxycodone / acetaminophen. 20 oxybutynin. 33 oxycodone. 13 OXSORALEN. 31 prednisone.

21 somatropin. 25 SALICYLATES AND RELATED DRUGS. 11 RAPTIVA. 28 SOLARAZE. 13 propoxyphene / aspirin / caffeine. 17. 24 QVAR. 23 SONATA. 23 SEROQUEL. 21 PROVENTIL HFA. 14 pseudoephedrine. 9 RISPERDAL. 28 repaglinide. 14 rondec. 30 SELECTIVE SEROTONIN REUPTAKE INHIBITORS. 15 44 . 12 RENAGEL. 8 RILUTEK. 12 sertraline. 26 pseudoephedrine / chlorpheniramine. 33 SCABICIDES. 19 quinapril / hydrochlorothiazide. 27 rifampin. 15 SEDATIVE/HYPNOTIC DRUGS. 10 simvastatin. 19 propranolol / hydrochlothiazide. 32 sirolimus. 32 PULMICORT. 19 quinine sulfate. 13 propoxyphene / acetaminophen. 27 salicylic acid. 19 ribavirin. 11 RESPIRATORY MEDICATIONS. 16 sodium chloride. 31 REVATIO. 15 reserpine. 23 REQUIP. 15 SENSIPAR. 12 risperidone. 19 propylthiouracil. 24 sodium polystyrene sulfonate. 26 REMICADE. 32 PROVIGIL. 23 rosuvastatin. 13 propranolol. 31 SMOKING CESSATION PRODUCTS. 23 rosiglitazone / metformin. 12 REBIF. 32 ropinirole. 10 QUINOLONES. 20 RAPAMUNE. 12 silver sulfadiazine. 20 salsalate. 19 selegiline. 25 PROTOPIC. 32 quetiapine. 25 SOMAVERT. 15 sevelamer. CONSTA. 17 propantheline. 18 SINGULAIR. 19 RESTASIS. 33 rivastigmine. 23 rosiglitazone / glimepiride. 15 selenium. 26 riluzole. 24 propoxyphene. 28 sildenafil. 26 rimantadine. 20 SECONDARY AMINES. 28 sodium fluoride. 28 sodium polystyrene sulfonfonate. 27 sargramostim. 18 SAIZEN. 10 raloxifene. M-TAB. 12 quinapril.propafenone. 15 SELECTIVE ESTROGEN RECEPTOR MODULATOR. 9 RIDAURA. 30 ranitidine. 25 PROTONIX. 15 rosiglitazone. 15 sodium phosphate salts. 28 sodium oxybate. 12 rizatriptan. 22 PROTON PUMP INHIBITORS. 16.

16 sucralfate. 33 28 THERAPEUTIC VITAMINS & MINERALS. adsorbed. 18 TILADE. 21 topiramate. 15 tretinoin. 26 tobramycin. 15 stannous fluoride.. 17 torsemide. 15 TOPICAL ANESTHETICS. 33 timolol. 7 succimer. 19 terbinafine. 12 TARCEVA. 10 thalidomide. 12 telmisartan / hydrochlorothiazide. 29 SPS. 19 sprintec. 31 sulfamethoxazole / trimethoprim. 33 testosterone propionate. 21. 15 STROMECTOL. 21 THALOMID. 14 trazodone. 10 TOPICAL CORTICOSTEROID DRUGS. 14 SYMLIN. 18 TRACLEER. 22 SYNAREL. 12 thyroid. 28 STALEVO. 19 trifluridine. 11. 33 tizanidine. 13 telmisartan. 31 tolcapone. 12 TASMAR. 19 tobramycin / loteprednol. af. 31 tiotropium. 21 TAMIFLU. 7. 25 tetanus toxoid. 23 TIKOSYN. 20 tegaserod. 27 sumatriptan. 29 testosterone cypionate. 18 tramadol.sorafenib. 24 SUCCINIMIDES. 10 TETRACYCLINES. THIAZIDE AND RELATED DRUGS. 25 tetracycline. 16 TESTIM. 18 SPIRIVA. 29 SPECIALIZED OB/GYN DRUGS. 29 tramadol / acetaminophen. 31 sulindac. 19 terazosin. 10 THYROID SUPPLEMENTS. 16. 17 sulfacetamide / prednisolone. 7 TOPICAL ANTIBACTERIAL DRUGS. 19 thioridazine. 20 TAZORAC. 14 SULFONAMIDES. 20 triamcinolone. 10 sulfisoxazole. 21 TETANUS TOXOID ADSORBED. 11 sotalol. 24 SULAR. 20 TOPICAL DERMATOLOGICAL DRUGS. 10 TOPICAL ANTIFUNGALCORTICOSTEROID COMB. 15 tazarotene. 22 triamterene / hydrochlorothiazide. 31 45 . 24 TEGRETOL XR. 31 TOPAMAX. 9 terconazole. 30 tacrolimus. 9 tamoxifen. 12 tranylcypromine. 30 spironolactone. 10 sulf-pred. 29 testosterone. 21 theophylline. 14 TOPROL XL. er. 11 TERTIARY AMINES. 28 STRATTERA. 29 testosterone enanthate. 33 theophylline.

19 venlafaxine. 18 trihexyphenidyl. 29 VOLTAREN. 29 UROLOGICAL MEDICATIONS. 34 URINARY ANTIINFECTIVES. 15 verapamil. 9 VISICOL. 31 ZYPREXA. 24 46 . 18 warfarin. 25 UNIPHYL. 32 ZYLET. 8 zileuton. ODT. 31 zaleplon. 32 ziprasidone. 10 VIRAZOLE. 7 ZADITOR. 25 ULTRASE. 17 VFEND. 31 TWINJECT. 15 ZELNORM. 12 TRILEPTAL. 9. 25 ursodiol. 12 tri-vit / fluoride / iron. 12 ZOFRAN. 13 trimethoprim. 26 ZETIA. 11 UROXATRAL. 33 URSO. 8 zidovudine. 31 voriconazole. 14 zovia. 18 ZIAGEN. 33 XYREM. MT. 9 VALPROIC ACID AND DERIVATIVES. 33 VAGINAL ANTIFUNGALS. 15 YODOXIN. 11 valproic acid. 13 zolpidem. 24 ZENAPAX. ointment. 31 ZYMAR. sr. 33 TWINRIX. 15 zonisamide. 33 urea. ZYDIS. 29 URINARY ANESTHETICS. 29 ZOVIRAX cream. 9 ZYFLO.TRIGLIDE. 11 tri-vit / fluoride. 29 TRUSOPT. 25 VAGIFEM. 21 VITAMINS & MINERALS & RELATED PRODUCTS. 16 vancomycin. 10 VYTORIN. 16 VASODILATOR ANTIHYPERTENSIVES. 28 XALATAN. 9. 31 XOLAIR.