2013 United HealthCare Formulary PDF

2013
Comprehensive
Formulary
(Complete list of covered drugs)
UnitedHealthcare Group Medicare Advantage Plan
Inside
Drug tiers and drug payment stages
Requirements and limits
Complete list of drugs by category

Index of covered drugs
Please read: This document contains information about thedrugs covered

bythis plan.
Note to existing members: This complete list of drugs has changed since last year.
Please review this document to make sure it still contains the drugs you take.
00013509G, 11
Y0066_120911_110211
About this complete drug list

This is a complete list of prescription drugs that are covered by the UnitedHealthcare Group
Medicare Advantage Plan, insured through UnitedHealthcare, for the 2013 plan year. It is called the
Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan.
For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your
prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your
drug iscovered:
1. See if your drug is included in this complete drug list.
2. Visit the plan website at www.UHCRetiree.com. You can use online tools to look up your drugs.
The information is updated on aregularbasis.
3. Call CustomerService at the number located on the back of your ID card. Customer Service can
look up your drugs and let you know if they are covered.
For more information

Please take the time to review your EvidenceofCoverage and any other 2013 plan materials you have
received. These materials give more detailed information about your drug coverage in the plan.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1800MEDICARE (1-800-633-4227), 24hoursaday, 7daysaweek. TTY/TDD users should call
18774862048. Or visitwww.medicare.gov.
Questions?
Online tools
If you have questions, were here to help.
Visit www.UHCRetiree.com to
allCustomerService at the number

C
located on the back of your ID card.
Or visit www.UHCRetiree.com
Look up your drugs and see what you

couldsave with lower-costdrugs
View your cost and benefits summary
Track your payment status and
claimshistory
2013 Complete drug list

The plan is designed to help you manage your prescription drug costs. An important part of this is giving
you choices so you and your doctor can choose the best course of treatment foryou.
A formulary is a list of the drugs covered by a Medicare Advantage 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. The plan will generally cover the drugs listed
in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network
pharmacy and other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
With your doctors help, you can use this drug list as a tool to choose the drugs that work best for you
and to findlower-cost drugs ifneeded.
Using the drug list

There are two ways to find your prescription drugs in this complete drug list:
1. Alphabetical list (index): Turn to the Index of covered drugs section, which begins on page62,
tosee the list of drug names in alphabetical order.
2. Medical condition: Turn to the Covered drugs by category section, which begins on page8,
to look for drug names based on your medical conditions. For example, if you want to find
drugs used to treat high cholesterol, goto the Cardiovascular Drugs category and look under
CholesterolControlDrugs.
Is it a generic or brand name drug?

The drug list shows brand name drugs in bold type(forexample, Crestor) andgeneric drugs in plain
type (for example, Simvastatin).
More information about your drug

Some drugs have requirements or limits. Please see the Requirements and limits section on page 4 for
more information on drugs you may use.
This document is a complete list of covered drugs. If your drug is not included in this drug list, the
plan may still cover it. Contact Customer Service to ask if its covered, or go to www.UHCRetiree.com
to look it up online. Ifyou learn that the plan does not cover your drug, you have two options:
1. Y
ou can ask Customer Service for a list of similar drugs that are covered by the 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 the plan.
2. Y
ou can ask the plan to make an exception and cover your drug. See the Coverage decisions
section on page 5 for information about how to request an exception.
Drug tiers and drug payment stages

The amount you pay for a covered drug will depend on:
Your drug payment stage. The plan has different stages ofdrug coverage. When you fill a
prescription, the amount you pay depends on the stage youre in.
The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a
different copay orcoinsurance amount. The chart below shows the differences between thetiers.
For more information about drug payment stages and copay or coinsurance amounts for each tier,
please refer to the plans Evidence of Coverage (EOC).
If you qualify for extra help

If you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower.
Members who qualify for extra help will receive the Evidence of Coverage Rider for People Who Get
Extra Help Paying for Prescription Drugs (LIS Rider). Please read it to find out what your costs are.
You can also contact CustomerService.
Drug Tier
Includes
Tier 1:
Preferredgeneric
Most genericdrugs.
Tier 2:
Preferred brand
Many common brand name drugs, called preferred brands, and

some higher-cost generic drugs.
Tier 3:
Non-preferred brand
Non-preferred generic and non-preferred brand name drugs.
Tier 4:
Specialty tier
Unique and/or very highcost drugs.
Generic drugs
The plan covers both brand name and generic drugs. TheFood and Drug Administration (FDA)
requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs,
whether preferred or non-preferred, may save you money on your copays or coinsurance and may help
you stay out of the coverage gap if you haveone.
Vaccines
The plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine
medication and the administration of the vaccine shot. Some vaccines, like those for the flu and
pneumonia, may be covered by Medicare Part B (doctor and outpatient health care).
For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state
allows it. The administration fee likely will be lower at a network pharmacy than at your doctors
office. If you get your vaccines at your doctors office, you will pay the entire cost of the vaccine and
administration fee to your doctor.
Please see your Evidence of Coverage for more information about vaccines and their costs.
To make sure a recommended vaccine is covered, call CustomerService at the number located on the
back of your ID card.
Requirements and limits

Some of the plans drugs have requirements or limits to help ensure safe, effective and affordable use.
Ifyour drug has any requirements or limits, there will be a code(s) in the Requirements & Limits
column of the drug list starting on page 8. The codes and what they mean are shown below.
You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug.
Seethe Coverage decisions section on the next page or your Evidence of Coverage to learn more.
If you do not get prior approval from the plan for a drug with a requirement or limit, you may be
responsible for paying the full cost of the drug.
B/D
Medicare Part B or Part D
LA
Limited access
PA
Prior authorization
ST
Step therapy
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor
and outpatient health care) or Medicare Part D (prescriptiondrugs). Your doctor may need
to provide the plan with more information about how this drug will be used to make sure
its correctly covered byMedicare.
Drugs are considered limited access if the FDA says the drug can be given out only by
certain facilities or doctors. These drugs may require extra handling, provider coordination or
patient education that cant be done at a network pharmacy.
The plan requires you or your doctor to get prior authorization for certain drugs. This
means the plan needs more information from your doctor to make sure the drug is being
used correctly for a medical condition covered by Medicare. If you dont get approval, the
plan may not cover the drug.
There are effective, lower-cost drugs that treat the same medical condition as this drug.
You may be required to try one or more of these other drugs before the plan will cover
your drug. If you have already tried other drugs or your doctor thinks they are not right for
you, you or your doctor can ask the plan to cover thisdrug.
For more information about requirements and limits, call CustomerService at the number located on
the back of your ID card.
Coverage decisions
At times you may need to ask for drug coverage thats not normally provided by the plan. When you do,
the plan will consider your request and respond with a coverage decision (coveragedetermination).
Examples of coverage decisions you may ask forinclude:
Asking the plan to pay you back for the cost of a drug you bought at an outofnetwork pharmacy.
Asking for an exception to the plans coveragerules.
How to request an exception

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions
that you can ask the plan to make.
process, you can ask the plan to cover it
at the costsharing amount that applies to
drugs in the preferred tier/lowest tier subject
to the tiering exception process tier instead.
This would lower the amount you must
pay for your drug. Please note, if we grant
your request to cover a drug that is not in
the plans formulary, you may not ask us to
provide a higher level of coverage for the
drug. Tiering exceptions are not available for
drugs in the specialty tier.
You can ask the plan to cover your

drug even if it is not on the formulary
(formularyexception).
You can ask the plan to waive coverage
restrictions or limits on your drug
(utilization exception).
You can ask the plan to provide a higher level
of coverage for your drug (tier exception).
If your drug is in the nonpreferred tier/the
highest tier subject to the tiering exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included
inthe plans formulary, the lower-tiered drug or additional utilization restrictions would not be
effectivein treating your condition and/or would cause you to have adverse medical effects.
Asking for a coverage decision

You (or your authorized representative) and your doctor can ask for an initial coverage decision by
calling CustomerService at the number located on the back of your ID card.
When you are requesting a formulary, tiering or utilization restriction exception, your prescriber
or physician should submit a statement supporting your request.
See your Evidence of Coverage for moreinformation.
Receiving a coverage decision

Generally, the plan will make a coverage decision within 72hours after receiving your prescribing
physicians statement. You can request an expedited, or fast, decision if you or your doctor believe your
health requires it. If the plan agrees to a fast decision, you will receive a decision within 24hours after the
plan receives your prescribers or prescribing physicians supportingstatement.
Drug list changes

The plan recognizes that drug list stability is very important to you. That is why the plan tries to make
as few changes to the drug list as possible during the plan year. From time to time, drug list changes
may be necessary for safety or otherreasons.
The drug list may change throughout the year when theplan:
Adds a new drug.
Removes a drug.
Changes the requirements or limits for a drug.
Moves a drug to a lower-cost tier.
Moves a drug to a higher-cost tier.
I f the FDA declares a drug to be unsafe or the drugs manufacturer removes the drug from the market,
the plan will immediately remove the drug from the drug list and inform affected members. If a drug
moves to a highercost tier or undergoes some other change, the plan will inform affected members at
least 60 days before the change 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.
Generally, if you are taking a drug on the 2013 druglist that was covered at the beginning of the year,
the plan will not remove the drug from the druglist or move a drug to a higher tier during the 2013
coverage year except when a new, less expensive generic equivalent drug becomes available (for example,
the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), orwhen
new information about the safety or effectiveness of a drug is released.
Other types of changes, such as removing a drug from the drug list, 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. It is important that you have continued access for the remainder
of the coverage year to the list of drugs that were available when you chose the plan, except for cases in
which you can save additional money or your safety is aconcern.
If there are changes to the druglist such as regular or necessary updates, members may see information
in the Explanation of Benefits statement, member newsletters or other member mailings. If there are
changes to the drug list outside of regular or necessary updates, members may receive a special mailing.
The plan website also has updatedinformation.
Transition supply process

New or continuing members
As a new or continuing member in the plan, you may be taking drugs that are not on the formulary.
Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example,
you may need prior authorization before you can fill your prescription. You should talk to your doctor to
decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception
so that the plan will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a
member of the plan.
For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the
plan will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when
you go to a network pharmacy. After your first 30-day supply, the plan will not pay for these drugs, even
if you have been a member of the plan less than 90 days.
Long-term care facility residents

If youre a resident of a long-term care facility, the plan will allow you to refill your prescription until
we have provided you with a 91-day transition supply of the drug consistent with dispensing increment
(unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90days
of your membership. If you need a drug thats not on the drug list or if you have limited ability to get your
drugs but you are past the first 90days of your plan membership, the plan will cover a 31-day emergency
supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.
Other transitions
You may have an unplanned transition, like a hospital discharge or a change in your level of care, after
the first 90days of your plan membership. If this happens and your doctor prescribes a drug thats
not on the drug list, orif its difficult for you to get your drugs, you are required to use the plans
exceptionprocess. You may ask for a one-time emergency supply of up to 31 days to give you time to talk
to your doctor about other treatment options or to try to get a formularyexception.
For more information

For more detailed information about the plans prescription drug coverage,
pleasereview your Evidence of Coverage and other plan materials.
If you have questions, please call CustomerService at the number located
onthe back of your ID card.
If you have general questions about Medicare prescription drug coverage, please call
Medicare at 1800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY/TDD users should call 18774862048. Or visit www.medicare.gov.
Covered drugs by category

This Comprehensive Formulary (drug list) below provides coverage information about the drugs covered
by the plan. It is current as of January 1, 2013.
The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for
example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information
in the Requirements & Limits column tells you if the plan has any special requirements for coverage of
your drug.
If you have trouble finding your drug in the list, turn to the Index of covered drugs section that begins on
page 62. If your prescription is not in this complete formulary, please visit www.UHCRetiree.com or call
Customer Service at the number located on the back of your ID card, for additionalhelp.
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Diflunisal
Duexis
EC-Naprosyn
Etodolac
(200mg Capsule, Tablet)
Etodolac ER
Feldene
Fenoprofen Calcium
Flector
Flurbiprofen
Ibuprofen (Suspension,
400mg Tablet, 600mg
Tablet, 800mg Tablet)
Indocin (Suspension)
Indomethacin (Capsule)
Indomethacin ER
Ketoprofen
Ketoprofen ER
Ketorolac Tromethamine
(Tablet)
Analgesics Drugs to Treat Pain,

Inflammation and Muscle and Joint
Conditions
Analgesics, Other Miscellaneous
Analgesics
Gralise
3
ST
Gralise Starter
3
ST
Nonsteroidal Anti-Inflammatory Drugs
Pain/Anti-Inflammatory Drugs
Anaprox
3
Anaprox DS
3
Arthrotec
3
Cambia
3
Cataflam
3
Celebrex
2
Clinoril
3
Daypro
3
Diclofenac Potassium
1
Diclofenac Sodium DR
1
Diclofenac Sodium ER
1
Drug Requirements
Tier
&Limits
1
3
3
ST
1
1
3
1
3
1
1
3
2
2
2
2
2
Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

PA = Prior authorization
ST = Step therapy
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Duragesic (100mcg/Hr
Patch 72 Hour, 75mcg/
Hr Patch 72 Hour)
Duramorph
Exalgo
Fentanyl (Patch)
Kadian (100mg Capsule
Extended Release
24 Hour, 10mg Capsule
Extended Release
Extended Release
Extended Release
Extended Release
Extended Release
Extended Release
24 Hour)
Kadian (200mg Capsule
Extended Release
24 Hour)
Levorphanol Tartrate
Methadone HCl
(Concentrate, Oral
Solution, Tablet)
Methadone HCl
(Injection)
Methadose (Tablet)
Morphine Sulfate
(Oral Solution, Tablet)
Morphine Sulfate ER
(15mg/ml Injection,
2
PA
30mg/ml Injection)
Meclofenamate Sodium
2
Mefenamic Acid
2
Meloxicam
1
Mobic
3
Nabumetone
2
Nalfon
3
Naprelan
(750mg Tablet Extended 3
Release 24 Hour)
Naprosyn
3
Naproxen
1
Naproxen DR
1
Naproxen Sodium (275mg
1
Oxaprozin
1
Oxycodone/Ibuprofen
2
Piroxicam
2
Ponstel
3
Sprix
3
PA
Sulindac
1
Tolmetin Sodium
2
Treximet
3
ST
Voltaren-XR
3
Zipsor
3
ST
Opioid Analgesics, Long-Acting Opioid
Pain Relievers
Astramorph
2
Avinza
2
Dolophine
3
Dolophine HCl
3
Duragesic (12mcg/Hr
Patch 72 Hour, 25mcg/
Hr Patch 72 Hour,
3
ST
50mcg/Hr Patch
72 Hour)
Drug Requirements
Tier
&Limits
4
2
2
2
4
2
2
3
2
2
2
ST
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
MS Contin
(100mg Tablet Extended
Release 12 Hour,
15mg Tablet Extended
Release 12 Hour,
3
Release 12 Hour,
Release 12 Hour)
MS Contin
(200mg Tablet Extended 4
Release 12 Hour)
Nucynta ER
2
Opana ER
2
(Crush Resistant)
Oxycontin
2
Oxymorphone HCl ER
2
Ryzolt
3
ST
Tramadol HCl ER
(Tablet Extended Release
3
24 Hour)
Ultram ER
3
Opioid Analgesics, Short-Acting
Opioid Pain Relievers
Abstral (100mcg Tablet
3
PA
Sublingual)
Abstral
(200mcg Tablet
Sublingual, 300mcg
Tablet Sublingual,
400mcg Tablet
4
PA
Sublingual, 600mcg
Tablet Sublingual,
800mcg Tablet
Sublingual)
Acetaminophen/Caffeine/
Dihydrocodeine Bitartrate
Acetaminophen/Codeine
Actiq
Butalbital/Aspirin/
Caffeine/Codeine
Butorphanol Tartrate
Capital/Codeine
Carisoprodol/Aspirin/
Codeine
Co-Gesic
Codeine Sulfate (Tablet)
Demerol
(50mg/ml Injection)
Demerol (Tablet)
Dilaudid
Dilaudid-5
Dilaudid-HP
(10mg/ml Injection)
Endocet
Endodan
Fentanyl Citrate Oral
Transmucosal
Fentora
Fiorinal/Codeine
Hycet
Drug Requirements
Tier
&Limits
2
1
4
PA
2
2
3
3
2
1
3
3
3
3
ST
3
2
1
4
PA
4
3
3
PA

ST = Step therapy
10
Drug Name
Hydrocodone/
Acetaminophen
(Oral Solution, 300mg;
10mg Tablet, 300mg;
5mg Tablet, 300mg;
7.5mg Tablet, 325mg;
10mg Tablet, 325mg;
5mg Tablet, 325mg;
10mg Tablet, 500mg;
5mg Tablet, 500mg;
10mg Tablet, 650mg;
10mg Tablet, 750mg;
10mg Tablet, 750mg;
7.5mg Tablet)
Hydrocodone/Ibuprofen
Hydromorphone HCl
(500mg/50ml Injection,
Tablet)
Lazanda
Lorcet
Lortab
Magnacet
Maxidone
Meperidine HCl
(100mg/ml Injection,
25mg/ml Injection,
50mg/ml Injection)
Meperidine HCl
Nalbuphine HCl
Norco
Nucynta
Onsolis
Opana (Tablet)
Oxecta
Drug Requirements
Tier
&Limits
Oxycodone HCl (Capsule,

Concentrate, 15mg Tablet,
30mg Tablet, 5mg Tablet)
Oxycodone/
Acetaminophen
Oxycodone/Aspirin
Oxymorphone HCl
Pentazocine/
Acetaminophen
Pentazocine/Naloxone HCl
Percocet
Percodan
Reprexain
Roxicet
(500mg; 5mg Tablet)
Roxicet (Oral Solution)
Roxicodone
Stagesic
Synalgos-DC
Talwin
Tramadol HCl
Tramadol HCl/
Acetaminophen
Tylenol/Codeine
Tylox
Ultracet
Ultram
Vicodin
Vicodin ES
Vicodin HP
Vicoprofen
Xodol
(300mg; 10mg Tablet,
300mg; 7.5mg Tablet)
Zamicet
Zydone
2
2
3
3
3
3
3
PA
ST
2
3
3
4
3
3
PA
PA
Drug Name
PA
11
Drug Requirements
Tier
&Limits
2
2
1
2
3
ST
3
3
3
3
ST
2
3
3
2
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Gentamicin Sulfate (Cream,

Injection, 0.1% Ointment,
1
Ophthalmic Solution)
Gentamicin Sulfate/NaCl
(1.2mg/ml; 0.9% Injection,
1
1.6mg/ml; 0.9% Injection,
1mg/ml; 0.9% Injection)
Gentamicin Sulfate/
NaCl (0.9mg/ml; 0.9%
2
Injection, 1.4mg/ml;
0.9% Injection)
Isotonic Gentamicin
1
(0.8mg/ml; 0.9% Injection)
Kanamycin Sulfate
2
Neomycin Sulfate
1
Neomycin/Polymyxin B
2
Sulfates
Paromomycin Sulfate
2
Streptomycin Sulfate
3
Tobi
4
B/D
Tobramycin Sulfate
1
(Ophthalmic Solution)
Tobramycin Sulfate
(10mg/ml Injection,
2
80mg/2ml Injection)
Tobramycin Sulfate/
2
Sodium Chloride
Tobrex (Ointment)
2
Tobrex
3
Antibacterials, Other Antibiotics
Altabax
3
Baciim
1
Anesthetics Drugs for Numbing

Local Anesthetics
Emla
Lidocaine (Ointment)
Lidocaine HCl
(External Solution)
Lidocaine HCl (0.5%
Injection, 1% Injection)
Lidocaine HCl (Gel)
Lidocaine Viscous
Lidocaine/Prilocaine
(Cream)
Lidoderm
Synera
Xylocaine (External
Solution)
Xylocaine (1% Injection)
3
2
B/D
B/D
2
2
B/D
2
2
2
B/D
2
3
B/D
3
3
Drug Requirements
Tier
&Limits
B/D
Anti-Inflammatory Agents
Nonsteroidal Anti-Inflammatory Drugs
Pain/Anti-Inflammatory Drugs
Naprelan
Release 24 Hour,
3
Release 24 Hour)
Antibacterials Drugs to Treat

Bacterial Infections
Aminoglycosides Antibiotics
Amikacin Sulfate
2
50mg/ml Injection)
Gentak (Ointment)
1

ST = Step therapy
12
Drug Name
Bacitracin (Injection,
Ophthalmic Ointment)
Bacitracin/Polymyxin B
Bactroban
Bactroban Nasal
Chloramphenicol
Sodium Succinate
Cleocin
Cleocin Galaxy
Cleocin in D5W
Cleocin Phosphate
(900mg/6ml Injection)
Clindamycin HCl (150mg
Capsule, 300mg Capsule)
Clindamycin Phosphate
(Cream)
Add-Vantage
Colistimethate Sodium
Coly-Mycin M
Cortisporin
(Cream, Ointment)
Cubicin
Flagyl
Flagyl ER
Furadantin
Hiprex
Lincocin
Macrobid
Macrodantin (100mg
Methenamine Hippurate
MetroCream
MetroGel
MetroGel-Vaginal
Metrolotion
Metronidazole
Drug Requirements
Tier
&Limits
Metronidazole in
NaCl 0.79%
Metronidazole Vaginal
Monurol
Mupirocin
Neomycin/Bacitracin/
Polymyxin
Neomycin/Polymyxin/
Gramicidin
Neosporin
Nitrofurantoin
Nitrofurantoin
Macrocrystalline
(50mg Capsule)
Nitrofurantoin Monohydrate
Phisohex
Polymyxin B Sulfate
Polytrim
Prevpac
Primsol
Silvadene
Silver Sulfadiazine
SSD
Sulfamylon
Synercid
Thermazene
Trimethoprim
Trimethoprim Sulfate/
Polymyxin B Sulfate
Tygacil
Vancocin HCl
Vancomycin HCl (1000mg
Injection, 10gm Injection,
500mg Injection)
Vancomycin HCl
(125mg Capsule)
1
1
3
3
2
3
3
3
3
1
1
2
3
3
ST
3
4
3
3
3
3
3
3
Drug Name
B/D
3
2
3
3
3
3
2
13
Drug Requirements
Tier
&Limits
2
1
3
1
1
1
3
2
2
2
3
2
3
3
3
3
1
1
3
4
1
1
1
3
4
PA
B/D
PA
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Vancomycin HCl
4
PA
(250mg Capsule)
Vandazole
1
Vibativ (250mg Injection) 3
Xifaxan (200mg Tablet)
3
Xifaxan (550mg Tablet)
4
Zyvox
4
PA
Beta-Lactam, Cephalosporins Antibiotics
Cedax (Capsule)
3
Cefaclor
1
Cefaclor ER
1
Cefadroxil
1
Cefazolin Sodium
(10gm Injection,
1gm Injection,
2
1gm; 5% Injection,
500mg Injection)
Cefdinir
2
Cefepime (1gm Injection,
2
2gm Injection)
Cefotaxime Sodium
(10gm Injection, 1gm
2
Injection, 2gm Injection)
Cefoxitin Sodium/
2
Dextrose
Cefoxitin Sodium
2
Cefpodoxime Proxetil
2
Cefprozil
2
Ceftazidime
(1gm Injection, 2gm
2
Ceftazidime/Dextrose
2
Ceftin
3
Drug Requirements
Tier
&Limits
Ceftriaxone Sodium
2
Cefuroxime Axetil (Tablet)
1
Cefuroxime Sodium
(1.5gm Injection,
1
7.5gm Injection,
750mg Injection)
Cephalexin
1
Claforan
3
Fortaz (1gm/50ml; 5%
Injection, 2gm Injection,
3
2gm/50ml; 5% Injection,
6gm Injection)
Keflex (250mg Capsule,
3
500mg Capsule)
Rocephin
3
(500mg Injection)
Spectracef
3
Suprax
2
Teflaro
3
Zinacef
3
Zinacef in Iso-Osmotic
3
Dextrose
3
Diluent
Beta-Lactam, Other Antibiotics
Azactam
2
(2gm Injection)
Azactam in Iso-Osmotic
3
Dextrose
Aztreonam (1gm Injection)
2
Cayston
4
Cefotetan
3
PA

ST = Step therapy
14
Drug Name
Drug Requirements
Tier
&Limits
Doribax
3
(500mg Injection)
Imipenem/Cilastatin
2
Invanz
3
Meropenem
2
(500mg Injection)
Merrem
3
(500mg Injection)
Primaxin
3
Beta-Lactam, Penicillins Antibiotics
Amoxicillin
1
Amoxicillin/Potassium
1
Clavulanate
1
Clavulanate ER
Ampicillin
2
Ampicillin Sodium
(10gm Injection, 125mg
2
Ampicillin-Sulbactam
(10gm; 5gm Injection, 2gm; 2
1gm Injection)
Bactocill in Dextrose
3
(1gm/50ml Injection)
Bactocill in Dextrose
4
Bicillin C-R
3
Bicillin L-A
3
Dicloxacillin Sodium
1
Moxatag
3
Nafcillin Sodium (10gm
2
Nallpen/Dextrose
3
Oxacillin Sodium (10gm
3
Penicillin G Potassium
3
(5mu Injection)
Drug Name
Penicillin G Potassium in
Iso-Osmotic Dextrose
Penicillin G Procaine
Penicillin G Sodium
Penicillin V Potassium
Pfizerpen-G
(20mu Injection)
Piperacillin Sodium/
Tazobactam Sodium
(3gm; 0.375gm Injection,
4gm; 0.5gm Injection)
Timentin
(0.1gm; 3gm Injection)
Unasyn
(2gm; 1gm Injection)
Unasyn Bulk Pack
Zosyn (3gm;
0.375gm Injection,
5%; 2gm/50ml;
0.25gm/50ml Injection,
5%; 3gm/50ml;
0.375gm/50ml Injection)
Macrolides Antibiotics
Akne-Mycin
Azasite
Azithromycin (500mg
Injection, Suspension
Reconstituted, Tablet)
Biaxin
Biaxin XL
Biaxin XL PAC
Clarithromycin
Clarithromycin ER
Dificid
E.E.S. 400
E.E.S. Granules
Ery
Ery-Tab
Eryped
15
Drug Requirements
Tier
&Limits
2
3
3
1
3
3
3
3
3
2
1
3
3
3
2
2
4
1
2
1
2
2
PA
Drug Name
Erythrocin Lactobionate
(500mg Injection)
Erythrocin Stearate
Erythromycin (External
Solution, Gel, Ointment)
Erythromycin Base
Erythromycin
Ethylsuccinate
Ketek
PCE
Zithromax
(Injection, Suspension
Zithromax Tri-Pak
Zithromax Z-Pak
Zmax
Quinolones Antibiotics
Avelox (Tablet)
Avelox (Injection)
Avelox ABC Pack
Besivance
Ciloxan
Cipro
Cipro HC
Cipro IV (200mg/100ml;
5% Injection)
Ciprodex
Ciprofloxacin
Ciprofloxacin ER
Ciprofloxacin HCl
Factive
Drug Requirements
Tier
&Limits
Drug Name
Levaquin (5%;
750mg/150ml Injection,
3
Oral Solution, Tablet)
Levofloxacin
2
Levofloxacin in D5W (5%;
2
500mg/100ml Injection)
Moxeza
2
Noroxin
3
Ocuflox
3
Ofloxacin
2
Vigamox
2
Zymaxid
2
Sulfonamides Antibiotics
Bactrim
3
Bactrim DS
3
Bleph-10
3
Septra DS
3
Sodium Sulfacetamide
1
Sulfacetamide Sodium
1
(Ointment)
Sulfadiazine
2
Sulfamethoxazole/
1
Trimethoprim
Sulfamethoxazole/
1
Trimethoprim DS
Tetracyclines Antibiotics
Demeclocycline HCl
2
Doryx
3
Doxycycline
2
(75mg Capsule)
3
3
1
1
1
3
3
Drug Requirements
Tier
&Limits
PA
3
3
3
3
2
3
2
2
3
3
3
3
2
1
2
1
3

ST = Step therapy
16
Drug Name
Doxycycline Hyclate
(Capsule, Injection, Tablet,
100mg Tablet Delayed
Release, 75mg Tablet
Delayed Release)
Doxycycline Hyclate
(150mg Tablet Delayed
Release)
Doxycycline Monohydrate
(150mg Tablet, 50mg
Dynacin
Minocin (Capsule)
Minocycline HCl (Capsule)
Minocycline HCl (Tablet)
Minocycline HCl ER
Monodox
Oracea
Solodyn
Tetracycline HCl
Vibramycin
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Calcium Channel Modifying Agents

Seizure Control Drugs
Celontin
3
Ethosuximide
2
Lyrica
2
Zarontin
3
Zonegran
3
Zonisamide
1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents Seizure Control
Drugs
Clonazepam
1
Clonazepam ODT
3
Clorazepate Dipotassium
1
Depacon
3
Depakene
3
Depakote
3
Depakote ER
3
Depakote Sprinkles
3
Diazepam (Gel)
3
Divalproex Sodium
1
Divalproex Sodium DR
1
Divalproex Sodium ER
1
Gabapentin
1
Gabitril
3
Horizant
3
ST
Klonopin
3
Mysoline
3
Neurontin
3
Onfi
3
PA
Primidone
1
Sabril
4
PA
Stavzor
3
Tranxene T
3
Valproate Sodium
2
(100mg/ml injection)
Valproic Acid
1
2
3
3
1
3
3
3
3
3
1
3
Anticonvulsants Drugs to Treat

Seizures
Anticonvulsants, Other Seizure Control
Drugs
Keppra
3
Keppra XR
3
Levetiracetam
1
Levetiracetam ER
2
Phenobarbital
(Elixir, 16.2mg Tablet,
30mg Tablet, 32.4mg
1
PA
Tablet, 64.8mg Tablet,
97.2mg Tablet)
Potiga
3
17
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Glutamate Reducing Agents Seizure

Control Drugs
Felbamate (Tablet)
3
Felbamate (Suspension)
4
Felbatol (Tablet)
3
Felbatol (Suspension)
4
Lamictal (Tablet)
3
Lamictal Chewable
3
Dispersible
Lamictal ODT (Tablet
3
Dispersible)
Lamictal Starter Kit
3
Lamictal XR (Kit,
Release 24 Hour,
Release 24 Hour,
3
Release 24 Hour,
Release 24 Hour,
Release 24 Hour)
Lamotrigine (Tablet)
1
Lamotrigine
2
(Tablet Chewable)
Topamax
3
Topamax Sprinkle
3
Topiramate
1
Sodium Channel Agents Seizure Control
Drugs
Banzel
3
Carbamazepine
2
Carbamazepine ER
(Capsule Extended
Release 12 Hour)
Carbatrol
Dilantin
Dilantin Infatabs
Epitol
Equetro
Fosphenytoin Sodium
(100mg pe/2ml Injection)
Oxcarbazepine
Peganone
Phenytek
Phenytoin
Phenytoin Sodium
Phenytoin Sodium
Extended
Tegretol
Tegretol-XR
Trileptal
Vimpat
Vimpat (Injection)
Drug Requirements
Tier
&Limits
2
3
2
2
2
3
2
2
3
1
1
1
1
2
2
3
3
3
PA
Antidementia Agents Drugs to Treat

Alzheimers Disease and Dementia
Antidementia Agents, Other
Ergoloid Mesylates
2
Cholinesterase Inhibitors Alzheimers
Disease and Dementia Drugs
Aricept (23mg Tablet)
2
Aricept (10mg Tablet,
3
5mg Tablet)

ST = Step therapy
18
Drug Name
Drug Requirements
Tier
&Limits
Aricept ODT
3
Donepezil HCl
1
Exelon
3
(Capsule, Oral Solution)
Exelon (Patch 24 Hour)
3
ST
Galantamine Hydrobromide 2
Razadyne
3
Razadyne ER
3
Rivastigmine Tartrate
2
N-methyl-D-aspartate (NMDA) Receptor
Antagonists Alzheimers Disease and
Dementia Drugs
Namenda
2
Namenda Titration Pak
2
Drug Name
Drug Requirements
Tier
&Limits
Monoamine Oxidase Inhibitors

Antidepressants
Emsam
3
ST
Marplan
3
Nardil
2
Parnate
3
Phenelzine Sulfate
1
Selegiline HCl
2
Tranylcypromine Sulfate
2
Zelapar
3
Serotonin/Norepinephrine Reuptake
Inhibitors Antidepressants
Celexa
3
Citalopram Hydrobromide
1
(Tablet)
Citalopram Hydrobromide
2
(Oral Solution)
Cymbalta
2
Effexor XR
3
Escitalopram Oxalate
1
Fluoxetine DR
3
Fluoxetine HCl (Capsule,
Oral Solution, 10mg Tablet, 1
20mg Tablet)
Fluvoxamine Maleate
1
Lexapro
3
Luvox CR
3
Paroxetine HCl
1
Paroxetine HCl ER
3
Paxil
3
Paxil CR
3
Pexeva
3
Pristiq
3
PA
Prozac
3
Prozac Weekly
3
Sarafem
3
ST
Sertraline HCl (Tablet)
1
Antidepressants Drugs to Treat

Depression
Antidepressants, Other Antidepressants
Aplenzin
3
Budeprion SR
1
Bupropion HCl
1
Bupropion HCl SR
1
Bupropion XL
1
Maprotiline HCl
1
Mirtazapine
1
Mirtazapine ODT
(30mg Tablet Dispersible,
1
45mg Tablet Dispersible)
Nefazodone HCl
1
Oleptro
3
Remeron
3
Remeron Soltab
3
Trazodone HCl
1
Wellbutrin
3
Wellbutrin SR
3
Wellbutrin XL
3
19
Drug Name
Drug Requirements
Tier
&Limits
Sertraline HCl
2
(Concentrate)
Venlafaxine HCl
2
Venlafaxine HCl ER
(Capsule Extended
1
Release 24 Hour)
Venlafaxine HCl ER
3
Release 24 Hour)
Venlafaxine HCl ER
Release 24 Hour,
37.5mg Tablet Extended
3
Release 24 Hour,
Release 24 Hour)
Viibryd
3
Zoloft
3
Tricyclics Antidepressants
Amitriptyline HCl
1
Amoxapine
1
Anafranil
3
Clomipramine HCl
1
Desipramine HCl
2
Doxepin HCl
1
Imipramine HCl
1
Imipramine Pamoate
2
Norpramin
3
Nortriptyline HCl
1
Pamelor
4
Perphenazine/Amitriptyline 1
Protriptyline HCl
2
Drug Name
Surmontil
Tofranil
Tofranil-PM
Trimipramine Maleate
Vivactil
Drug Requirements
Tier
&Limits
3
3
3
2
3
Antidotes, Deterrents, and Toxicologic

Agents Drugs for Overdose or
Deterrents
Alcohol Deterrents/Anti-Craving
Antidotes/Deterrents/Protectants
Antabuse
2
Campral
3
Disulfiram
2
Naltrexone HCl
2
Revia
3
Vivitrol
4
Opioid Antagonists Antidotes/
Deterrents/Protectants
Buprenex
3
Buprenorphine HCl
2
Butrans
3
PA
Naloxone HCl
2
(1mg/ml Injection)
Suboxone
3
Smoking Cessation Agents Deterrents
Buproban
1
Chantix
3
Chantix Pak
3
Nicotrol Inhaler
3
Nicotrol NS
2
Zyban
3
ST
ST

ST = Step therapy
20
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Zofran (Injection)
Zofran ODT
Zuplenz
Antiemetics Drugs to Treat Nausea

and Vomiting
Antiemetics, Other Nausea and Vomiting
Drugs
Antivert
3
Meclizine HCl
1
Tigan
3
PA
Trimethobenzamide HCl
3
PA
(Capsule)
Emetogenic Therapy Adjuncts Nausea
and Vomiting Drugs
Aloxi
3
Anzemet (Injection)
3
Anzemet (50mg Tablet)
3
B/D
Anzemet (100mg Tablet)
4
B/D
Cesamet
4
B/D, PA
Dronabinol (2.5mg
2
B/D, PA
Dronabinol (10mg Capsule) 4
B/D, PA
Emend (Capsule)
2
B/D, PA
Granisetron HCl
(0.1mg/ml Injection,
2
1mg/ml Injection)
Granisetron HCl (Tablet)
2
B/D
Granisol
2
B/D
Marinol (2.5mg Capsule)
3
B/D, PA
Marinol (10mg Capsule,
4
B/D, PA
5mg Capsule)
Ondansetron HCl (Tablet)
1
B/D
Ondansetron HCl
2
(4mg/2ml Injection)
Ondansetron HCl
2
B/D
(Oral Solution)
Ondansetron ODT
1
B/D
Sancuso
4
Zofran
4
B/D, PA
Drug Requirements
Tier
&Limits
4
4
3
ST
B/D, PA
B/D
Antifungals Drugs to Treat Fungal

Infections
Antifungals Fungal Infection Drugs
Abelcet
4
B/D
AmBisome
4
B/D
Amphotec
3
B/D
(50mg Injection)
Amphotericin B
2
B/D
Ancobon
4
Cancidas
4
Ciclopirox
2
Ciclopirox Nail Lacquer
2
Ciclopirox Olamine
2
Clotrimazole
(External Cream,
1
External Solution, Troche)
Clotrimazole/
Betamethasone
1
Dipropionate
Diflucan
3
Econazole Nitrate
1
Eraxis (100mg Injection)
4
Ertaczo
3
Exelderm
3
Extina
3
Fluconazole
1
Fluconazole in Dextrose
(56mg/ml;
1
Flucytosine
4
Gris-Peg
3
Griseofulvin Microsize
2
Itraconazole
2
PA
21
Drug Name
Ketoconazole
(Cream, Shampoo, Tablet)
Ketoconazole (Foam)
Lamisil (Packet, Tablet)
Loprox
Loprox Shampoo
Lotrisone
Mentax
Miconazole 3
Mycamine
Naftin (1% Cream, Gel)
Natacyn
Nizoral
Noxafil
Nyamyc
Nystatin (Cream, Ointment,
100000unit/gm Powder,
Suspension, Tablet)
Nystatin/Triamcinolone
Nystop
Oxistat
Pedi-Dri
Sporanox (Oral Solution)
Sporanox (Capsule)
Sporanox Pulsepak
Terazol
Terbinafine HCl (Tablet)
Terconazole (0.4% Cream,
Suppository)
Vfend (Suspension
Reconstituted)
Vfend (Tablet)
Drug Requirements
Tier
&Limits
Drug Name
Vfend IV
Voriconazole (Tablet)
Zazole (Cream)
1
3
3
3
3
3
3
1
4
3
2
3
4
1
Antigout Agents Gout Drugs

Allopurinol (Tablet)
1
Allopurinol Sodium
1
(Injection)
Aloprim
3
Colcrys
2
Probenecid
1
Probenecid/Colchicine
1
Uloric
2
Zyloprim
3
ST
Antimigraine Agents Drugs to Treat

Migraines
Ergot Alkaloids Migraine Drugs
Dihydroergotamine
2
Mesylate
Ergotamine Tartrate/
2
Caffeine
Migergot
2
Migranal
3
Serotonin (5-HT) 1b/1d Receptor
Agonists Migraine Drugs
Amerge
3
Axert
3
Frova
3
Imitrex
3
Imitrex Statdose Refill
3
Maxalt
2
PA
PA
PA
1
4
4
3
4
1
Antigout Agents Drugs to Treat Gout
1
1
1
3
1
3
4
3
3
1
Drug Requirements
Tier
&Limits
ST
ST
ST

ST = Step therapy
22
Drug Name
Maxalt-MLT
Naratriptan HCl
Relpax
Sumatriptan Succinate
(Tablet)
Sumatriptan Succinate
(6mg/0.5ml Injection)
Zomig
Zomig ZMT
Drug Requirements
Tier
&Limits
2
1
3
Drug Requirements
Tier
&Limits
Antineoplastics Drugs to Treat

Cancer
ST
Alkylating Agents Chemotherapy Agents

Alkeran (Injection)
3
BiCNU
3
Busulfex
4
CeeNU
3
Cyclophosphamide (Tablet) 2
B/D
Dacarbazine
2
(200mg Injection)
Hexalen
4
PA
Ifex (3gm Injection)
3
Ifosfamide (1gm Injection)
2
Leukeran
2
Matulane
4
Melphalan HCl
4
Mustargen
4
Thiotepa
3
Treanda
4
PA
(100mg Injection)
Zanosar
4
Antiangiogenic Agents Chemotherapy
Agents
Caprelsa
4
PA
Revlimid (10mg Capsule,
15mg Capsule, 25mg
4
PA, LA
Thalomid
4
PA
Antiestrogens/Modifiers Chemotherapy
Agents
Emcyt
3
PA
Fareston
3
Faslodex
4
Tamoxifen Citrate
1
1
2
3
3
Drug Name
ST
ST
Antimyasthenic Agents Drugs to Treat

Myasthenia Gravis
Parasympathomimetics Myasthenia
Gravis Drugs
Mestinon
3
Mestinon Timespan
3
Mytelase
3
Pyridostigmine Bromide
1
Regonol
1
Antimycobacterials Drugs to Treat

Infections
Antimycobacterials, Other Miscellaneous
Anti-Infectives
Dapsone
2
Mycobutin
3
Antituberculars Tuberculosis Drugs
Capastat Sulfate
3
Ethambutol HCl
2
Isoniazid
2
Paser
3
Priftin
3
Rifadin
3
Rifamate
3
Rifampin (Capsule)
2
Rifampin (Injection)
3
Rifater
3
Seromycin
3
Trecator
3
23
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Antimetabolites Chemotherapy Agents

Cladribine
2
B/D
Clolar
4
Cytarabine
2
B/D
(500mg Injection)
Cytarabine Aqueous
1
B/D
(20mg/ml Injection)
Cytarabine Aqueous
2
B/D
(100mg/ml Injection)
Droxia
3
Elitek (1.5mg Injection)
4
Fluorouracil
2
B/D
Folotyn
4
PA
Gemcitabine HCl
4
(1gm Injection)
Gemzar (1gm Injection)
4
Hydrea
3
Hydroxyurea
1
Mercaptopurine
2
Nipent
4
ST
Pentostatin
4
Purinethol
3
Tabloid
3
PA
Antineoplastics, Other Chemotherapy
Agents
Abraxane
4
PA
Adriamycin
2
B/D
(2mg/ml Injection)
Alimta (500mg Injection) 4
PA
Amifostine
4
Arranon
Bleomycin Sulfate
(30unit Injection)
Camptosar
Carboplatin
Cerubidine
Cisplatin
Cosmegen
Dacogen
Daunorubicin HCl
(5mg/ml Injection)
Dexrazoxane
(500mg Injection)
Docefrez
Docetaxel
80mg/8ml Injection)
Doxil
Doxorubicin HCl
(2mg/ml Injection)
Ellence
Eloxatin
Elspar
Epirubicin HCl
Erivedge
Ethyol
Drug Requirements
Tier
&Limits
4
2
B/D
ST
2
3
2
3
4
1
4
PA
4
4
4
B/D
B/D
ST
4
3
2
4
4
PA
ST

ST = Step therapy
24
Drug Name
Fludarabine Phosphate
(50mg Injection)
Fusilev
Halaven
Idamycin PFS
Idarubicin HCl
Irinotecan
Istodax
Ixempra Kit
(45mg Injection)
Jakafi
Jevtana
Leucovorin Calcium
(100mg Injection,
350mg Injection, Tablet)
Menest
Mesna
Mesnex
Mitomycin
(20mg Injection)
Mitoxantrone HCl
Ontak
Oxaliplatin
Paclitaxel
Picato
Proleukin
Sylatron
Taxotere
Trisenox
Velcade
Vidaza
Vinblastine Sulfate
(10mg Injection)
Drug Requirements
Tier
&Limits
Drug Name
Vincasar PFS
2
B/D
Vincristine Sulfate
2
B/D
Vinorelbine Tartrate
2
Zinecard
4
PA
(250mg Injection)
Zolinza
4
PA
Zytiga
4
PA
Aromatase Inhibitors, 3rd Generation
Chemotherapy Agents
Anastrozole
1
Arimidex
3
Aromasin
3
Exemestane
2
Femara
3
Letrozole
1
Enzyme Inhibitors Chemotherapy Agents
Etopophos
4
Etoposide (Injection)
2
Hycamtin (Injection)
4
Toposar
2
Topotecan HCl
4
(4mg Injection)
Molecular Target Inhibitors
Chemotherapy Agents
Afinitor
4
PA
Gleevec
4
PA
Inlyta
4
PA
Nexavar
4
PA
Sprycel
4
PA
Sutent
4
PA
Tarceva
4
PA
Tasigna
4
PA
Tykerb
4
PA
Votrient
4
PA
Xalkori
4
PA
Zelboraf
4
PA
4
4
4
PA
ST
4
2
4
PA
4
4
4
PA
PA
2
2
2
3
2
2
4
PA
PA
4
2
3
4
4
PA
PA
4
3
4
4
PA
PA
PA
B/D
Drug Requirements
Tier
&Limits
25
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Monoclonal Antibodies Chemotherapy

Agents
Arzerra
4
PA
Avastin
4
PA
Campath
4
PA
Erbitux
4
PA
Herceptin
4
PA
Rituxan
4
PA
Vectibix
4
PA
Yervoy
4
PA
Retinoids Chemotherapy Agents
Panretin
4
PA
Targretin
4
PA
Tretinoin (Capsule)
4
Hydroxychloroquine Sulfate 1
Malarone
3
Mefloquine HCl
1
Mepron
4
Nebupent
3
B/D
Pentam 300
3
Plaquenil
3
Primaquine Phosphate
3
Qualaquin
3
PA
Pediculicides/Scabicides Scabies and
Lice Drugs
Eurax
3
Lindane
2
Malathion
2
Ovide
3
Permethrin (Cream)
1
Ulesfia
3
Antiparasitics Drugs to Treat Parasitic

Infections
Antiparkinson Agents Drugs to Treat

Parkinsons Disease
Anthelmintics Worm Infection Drugs

Albenza
2
Biltricide
2
Stromectol
2
Antiprotozoals Protozoal Infection Drugs
Alinia
3
Atovaquone/Proguanil HCl
2
(250mg; 100mg Tablet)
Chloroquine Phosphate
2
Coartem
3
Daraprim
2
Anticholinergics Parkinsons Disease

Drugs
Benztropine Mesylate
1
Cogentin
3
Trihexyphenidyl HCl
1
Antiparkinson Agents Parkinsons
Disease Drugs
Comtan
2
Tasmar
4

ST = Step therapy
26
Drug Name
Drug Requirements
Tier
&Limits
Dopamine Agonists Parkinsons Disease

Drugs
Apokyn
4
Bromocriptine Mesylate
2
Mirapex
3
Mirapex ER
3
Parlodel
3
Pramipexole
2
Dihydrochloride
Requip
3
Requip XL
3
Ropinirole ER
3
Ropinirole HCl
1
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors Parkinsons
Disease Drugs
Carbidopa/Levodopa
1
Carbidopa/Levodopa ER
1
Carbidopa/
1
Levodopa ODT
Lodosyn
3
Parcopa
3
Sinemet
3
Sinemet CR
3
Stalevo
2
Monoamine Oxidase B (MAO-B)
Inhibitors Parkinsons Disease Drugs
Azilect
2
Eldepryl
3
Drug Name
Drug Requirements
Tier
&Limits
Haldol
3
Haldol Decanoate
3
Haloperidol
1
Haloperidol Decanoate
1
Haloperidol Lactate
1
Loxapine Succinate
1
Loxitane
3
Orap
2
Perphenazine
1
Prochlorperazine
1
Prochlorperazine Edisylate
2
Prochlorperazine Maleate
1
Thioridazine HCl
2
Thiothixene
1
Trifluoperazine HCl
1
2nd Generation/Atypical Mood Disorder
Drugs
Abilify
3
Abilify Discmelt
3
Fanapt
3
ST
Fanapt Titration Pack
3
ST
Geodon
3
Invega
3
ST
Invega Sustenna
(39mg/0.25ml Injection,
3
78mg/0.5ml Injection)
Invega Sustenna
4
156mg/ml Injection,
Latuda
3
Olanzapine
2
Olanzapine ODT
2
Quetiapine Fumarate
1
Risperdal
3
Antipsychotics Drugs to Treat Mood

Disorders
1st Generation/Typical Mood Disorder
Drugs
Chlorpromazine HCl
1
Compro
1
Fluphenazine Decanoate
2
Fluphenazine HCl
1
27
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Risperdal Consta
(12.5mg Injection,
3
25mg Injection)
Risperdal Consta
(37.5mg Injection,
4
50mg Injection)
Risperdal M-Tab
3
Risperidone (Tablet)
1
Risperidone (Oral Solution)
2
Risperidone ODT
2
Saphris
2
Seroquel
3
Seroquel XR
2
Ziprasidone HCl (Capsule)
3
Zyprexa
3
Zyprexa Zydis
3
Treatment-Resistant Mood Disorder
Drugs
Clozapine
2
Clozaril
3
Fazaclo
2
Gablofen
(10000mcg/20ml
Injection, 50mcg/ml
Injection)
Gablofen
(40000mcg/20ml
Injection)
Lioresal Intrathecal
Lioresal Intrathecal
Tizanidine HCl (Tablet)
Tizanidine HCl (Capsule)
Zanaflex
Drug Requirements
Tier
&Limits
B/D, PA
B/D, PA
B/D, PA
B/D, PA
1
3
3
Antivirals Drugs to Treat Viral

Infections
Anti-Cytomegalovirus (CMV) Agents
Miscellaneous Antiviral Drugs
Cytovene
3
B/D
Foscarnet Sodium
2
B/D
Ganciclovir (Capsule)
3
Ganciclovir (Injection)
3
B/D
Valcyte
4
Vistide
4
Zirgan
3
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors HIV Drugs
Atripla
4
Complera
4
Edurant
4
Intelence (100mg Tablet,
4
200mg Tablet)
Antispasticity Agents Drugs to Treat

Spasms
Antispasticity Agents Muscle Spasm
Drugs
Baclofen
1
Dantrium
3
Dantrolene Sodium
2
(Capsule)

ST = Step therapy
28
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Anti-HIV Agents, Protease Inhibitors

HIV Drugs
Aptivus
4
Crixivan
2
Invirase (Capsule)
3
Invirase (Tablet)
4
Kaletra
3
(100mg; 25mg Tablet)
Kaletra (Oral Solution,
4
200mg; 50mg Tablet)
Lexiva (Suspension)
3
Lexiva (Tablet)
4
Norvir
3
Prezista (150mg Tablet,
3
75mg Tablet)
Prezista (400mg Tablet,
4
600mg Tablet)
Reyataz
2
(100mg Capsule)
Reyataz
(150mg Capsule,
4
200mg Capsule,
300mg Capsule)
Viracept
4
Anti-Influenza Agents Flu Drugs
Amantadine HCl
1
Relenza Diskhaler
3
Rimantadine HCl
1
Tamiflu
2
Antihepatitis Agents Hepatitis Drugs
Baraclude
3
(Oral Solution)
Baraclude (Tablet)
4
Copegus
4
PA
Hepsera
4
Incivek
4
PA
Infergen
4
PA
(15mcg/0.5ml Injection)
Nevirapine (Tablet)
2
Rescriptor
3
Sustiva
3
Viramune (Tablet)
2
Viramune (Suspension)
3
Viramune XR
2
Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase
Inhibitors HIV Drugs
Combivir
4
Didanosine
2
Emtriva
3
Epivir (Oral Solution)
2
Epivir (Tablet)
3
Epivir HBV
2
Epzicom
4
Lamivudine
2
Lamivudine/Zidovudine
4
Retrovir
3
Retrovir IV Infusion
3
Stavudine (Capsule)
2
Trizivir
4
Truvada
4
Videx EC
3
Videx Pediatric
3
(2gm Oral Solution)
Viread
4
Zerit
3
Ziagen
3
Zidovudine
2
Anti-HIV Agents, Other HIV Drugs
Fuzeon
4
Isentress
4
Selzentry
4
29
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Intron-A (10mu/0.2ml
Injection, 3mu/0.2ml
3
PA
Injection, 6000000unit/
ml Injection)
Intron-A
4
PA
(5mu/0.2ml Injection)
Intron-A W/Diluent
4
PA
(10mu Injection)
Peg-Intron
4
PA
Peg-Intron Redipen
4
PA
Pegasys
4
PA
Pegasys Proclick
4
PA
Rebetol (Oral Solution)
3
PA
Rebetol (Capsule)
4
PA
Ribapak (Tablet)
4
PA
Ribasphere
2
PA
(Capsule, 200mg Tablet)
Ribasphere (400mg Tablet,
4
PA
600mg Tablet)
Ribavirin
2
PA
Tyzeka
4
Victrelis
4
PA
Antiherpetic Agents Herpes Drugs
Acyclovir
1
Acyclovir Sodium
1
B/D
(500mg Injection)
Denavir
3
Famciclovir
2
Famvir
3
Trifluridine
2
Valacyclovir HCl
2
Valtrex
Viroptic
Xerese
Zovirax
Drug Requirements
Tier
&Limits
2
3
3
3
Anxiolytics Drugs to Treat Anxiety

Anxiolytics, Other Anxiety Drugs
Alprazolam
1
Alprazolam ER
(0.5mg Tablet Extended
3
Release 24 Hour)
Alprazolam Intensol
3
Alprazolam ODT
3
Alprazolam XR
Release 24 Hour,
2mg Tablet Extended
3
Release 24 Hour,
3mg Tablet Extended
Release 24 Hour)
Ativan (Tablet)
3
Buspirone HCl
1
Chlordiazepoxide HCl
1
Chlordiazepoxide/
1
Amitriptyline
Diazepam
1
Diazepam Intensol
1
Estazolam
3
Lorazepam (Tablet)
1
Lorazepam Intensol
1
Meprobamate
3
PA
Niravam
3

ST = Step therapy
30
Drug Name
Oxazepam
Valium
Xanax
Xanax XR
Drug Requirements
Tier
&Limits
Drug Name
Glucophage
Glucophage XR
Glucotrol
Glucotrol XL
Glucovance
(2.5mg; 500mg Tablet,
5mg; 500mg Tablet)
Glumetza
Release 24 Hour)
Glyburide
Glyburide Micronized
Glyburide/Metformin HCl
Glynase
Glyset
Janumet
Janumet XR
Januvia
Jentadueto
Juvisync
Kombiglyze XR
Metformin HCl
Metformin HCl ER
Release 24 Hour,
Release 24 Hour)
Nateglinide
Onglyza
Prandimet
Prandin
Precose
Riomet
Starlix
Symlinpen 120
Symlinpen 60
Tolazamide
Tolbutamide
3
3
3
3
Bipolar Agents Drugs to Treat Mood

Disorders
Bipolar Agents Mood Disorder Drugs
Symbyax
3
Mood Stabilizers Mood Disorder Drugs
Lithium Carbonate
1
Lithium Carbonate ER
1
Lithium Citrate
1
Lithobid
2
Blood Glucose Regulators Drugs to

Regulate Blood Sugar
Antidiabetic Agents Diabetic Drugs
Acarbose
1
Actoplus Met
2
Actoplus Met XR
3
Actos
2
Amaryl
3
Avandamet
3
PA
Avandaryl
3
PA
Avandia
3
PA
Bydureon
3
Byetta
2
Chlorpropamide
3
ST
Cycloset
3
PA
Diabeta
3
Duetact
2
Fortamet
3
ST
Glimepiride
1
Glipizide
1
Glipizide ER
1
Glipizide/Metformin HCl
1
31
Drug Requirements
Tier
&Limits
3
3
3
3
3
3
1
1
1
3
3
2
3
2
3
3
2
1
ST
ST
ST
2
2
3
3
3
3
3
3
3
1
1
PA
PA
Drug Name
Drug Requirements
Tier
&Limits
Tradjenta
3
Victoza
2
Glycemic Agents Diabetic Drugs
Clinimix 4.25%/
3
Dextrose 20%
Clinimix 5%/
3
Dextrose 15%
Clinimix 5%/
3
Dextrose 20%
Clinimix E 2.75%/
3
Dextrose 10%
Clinimix E 2.75%/
3
Dextrose 5%
Clinimix E 4.25%/
3
Dextrose 25%
Clinimix E 4.25%/
3
Dextrose 5%
Clinimix E 5%/
3
Dextrose 15%
Clinimix E 5%/
3
Dextrose 25%
Dextrose 10%/
2
NaCl 0.45%
Dextrose 10%
2
Flex Container
Dextrose 10%/
2
NaCl 0.2%
Dextrose 2.5%/
2
Sodium Chloride 0.45%
Dextrose 5%
2
Dextrose 5%/NaCl 0.2%
2
Dextrose 5%/
2
NaCl 0.225%
Drug Name
ST
Dextrose 5%/
NaCl 0.33%
Dextrose 5%/
NaCl 0.45%
Dextrose 5%/NaCl 0.9%
Glucagen Hypokit
Glucagon Emergency
Kit
Ionosol-B/Dextrose 5%
Ionosol-MB/
Dextrose 5%
KCl 0.075%/D5W/
NaCl 0.45%
KCl 0.15%/D5W/LR
KCl 0.15%/D5W/
NaCl 0.2%
KCl 0.15%/D5W/
NaCl 0.225%
KCl 0.15%/D5W/
NaCl 0.9%
KCl 0.3%/D5W/
NaCl 0.45%
KCl 0.3%/D5W/
NaCl 0.9%
Normosol-R in D5W
Potassium Chloride
0.15%/D5W/NaCl 0.33%
Potassium Chloride
0.15%/D5W/
NaCl 0.45% Viaflex
Potassium Chloride
0.22%/D5W/
NaCl 0.45%
Proglycem
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Requirements
Tier
&Limits
2
2
2
3
2
3
3
2
2
2
2
2
2
2
2
2
2
2
3

ST = Step therapy
32
Drug Name
Insulins Diabetic Drugs
Humalog (Vial)
Humalog Kwikpen
Humulin (Vial)
Humulin Pen
Lantus
Lantus Solostar
Levemir
Levemir Flexpen
Novolin (Vial)
Novolog (Vial)
Novolog Flexpen
Drug Requirements
Tier
&Limits
Drug Name
Fondaparinux Sodium
(2.5mg/0.5ml Injection)
Fondaparinux Sodium
5mg/0.4ml Injection,
7.5mg/0.6ml Injection)
Fragmin
(25000unit/ml Injection,
2500unit/0.2ml
Injection,
5000unit/0.2ml
Injection)
Fragmin
12500unit/0.5ml
Injection,
15000unit/0.6ml
Injection,
18000unt/0.72ml
Injection,
7500unit/0.3ml
Injection)
Heparin Sodium
1000unit/ml Injection,
5000unit/ml Injection)
Heparin Sodium/D5W
(5%; 40unit/ml Injection)
Heparin Sodium/NaCl
(100unit/ml; 0.45%
Injection, 50unit/ml;
0.45% Injection)
Heparin Sodium/
NaCl 0.9% Premix
Jantoven
Lovenox
2
2
2
2
2
2
2
2
2
2
2
Blood Products/Modifiers/Volume
Expanders Drugs to Treat Blood
Disorders
Anticoagulants Blood Thinners
Argatroban
4
(100mg/ml Injection)
Argatroban (125mg/125ml;
4
0.9% Injection)
Arixtra
3
(2.5mg/0.5ml Injection)
Arixtra
4
7.5mg/0.6ml Injection)
Coumadin (Tablet)
2
Coumadin (Injection)
3
Enoxaparin Sodium
3
Enoxaparin Sodium
4
150mg/ml Injection)
33
Drug Requirements
Tier
&Limits
3
2
1
3
Drug Name
Drug Requirements
Tier
&Limits
Lovenox
4
150mg/ml Injection,
Pradaxa
2
Warfarin Sodium
1
Xarelto
2
Blood Formation Modifiers
Blood Formation Drugs
Agrylin
3
Anagrelide Hydrochloride
1
Aranesp Albumin Free
(100mcg/0.5ml Injection,
100mcg/ml Injection,
25mcg/0.42ml Injection,
25mcg/ml Injection,
3
40mcg/ml Injection,
60mcg/ml Injection)
Aranesp Albumin Free
(150mcg/0.3ml Injection,
4
500mcg/ml Injection)
Epogen
3
Leukine
4
Mozobil
4
Neulasta
4
Neumega
2
Drug Name
Drug Requirements
Tier
&Limits
Neupogen
(300mcg/0.5ml
Injection, 480mcg/0.8ml
4
PA
Injection, 480mcg/1.6ml
Injection)
Procrit
3
B/D, PA
Procrit
4
B/D, PA
Promacta
4
PA
Blood Products/Modifiers/Volume
Expanders
Cinryze
4
PA
Coagulants Blood Clotting Drugs
Cyklokapron
2
Tranexamic Acid
2
Platelet Modifying Agents
Platelet Modifying Drugs
Aggrenox
2
Brilinta
3
PA
Cilostazol
1
Clopidogrel
1
Dipyridamole (Tablet)
1
PA
Effient
3
PA
Persantine
3
PA
Plavix
3
Pletal
3
Ticlopidine HCl
2
PA
PA
B/D, PA
B/D, PA
B/D, PA
PA
PA
PA
PA

ST = Step therapy
34
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Eprosartan Mesylate
3
Hyzaar
3
Irbesartan
1
Irbesartan/
1
Hydrochlorothiazide
Losartan Potassium
1
Losartan Potassium/
1
Hydrochlorothiazide
Micardis
3
Micardis HCT
3
Teveten
3
Teveten HCT
3
ST
Angiotensin-Converting Enzyme (ACE)
Inhibitors Blood Pressure Drugs
Accupril
3
Accuretic
3
Aceon
3
Altace
3
Benazepril HCl
1
Benazepril HCl/
1
Hydrochlorothiazide
Captopril
1
Captopril/
1
Hydrochlorothiazide
Enalapril Maleate
1
Enalapril Maleate/
1
Hydrochlorothiazide
Fosinopril Sodium
1
Fosinopril Sodium/
1
Hydrochlorothiazide
Lisinopril
1
Lisinopril/
1
Hydrochlorothiazide
Lotensin
3
Lotensin HCT
3
Mavik
3
Moexipril HCl
2
Cardiovascular Agents Drugs to Treat

Heart and Circulation Conditions
Alpha-Adrenergic Agonists
Blood Pressure Drugs
Catapres
3
Catapres-TTS
3
Clonidine HCl (Tablet)
1
Clonidine HCl
2
(Patch Weekly)
Clorpres
3
Guanfacine HCl
1
Methyldopa
1
Methyldopa/
1
Hydrochlorothiazide
Methyldopate HCl
1
Midodrine HCl
2
Tenex
3
Alpha-Adrenergic Blocking Agents
Cardura XL
3
Dibenzyline
3
Minipress
3
Prazosin HCl
1
Reserpine
1
Angiotensin II Receptor Antagonists
Atacand
3
ST
Atacand HCT
3
ST
Avalide
3
Avapro
3
Benicar
2
Benicar HCT
2
Cozaar
3
Diovan
2
Diovan HCT
2
Edarbi
3
Edarbyclor
3
35
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Moexipril/
2
Hydrochlorothiazide
Perindopril Erbumine
1
Prinivil
3
Prinzide
3
Quinapril HCl
1
Quinapril/
1
Hydrochlorothiazide
Ramipril
1
Tarka
3
Trandolapril
1
Uniretic
3
Univasc
3
Vaseretic
3
Vasotec
3
Zestoretic
3
Zestril
3
Antiarrhythmics Heart Regulation Drugs
Amiodarone HCl (50mg/ml
1
Injection, Tablet)
Betapace (120mg Tablet,
3
160mg Tablet)
Betapace AF
3
(80mg Tablet)
Cordarone
3
Disopyramide Phosphate
1
Flecainide Acetate
1
Mexiletine HCl
1
Multaq
2
Norpace
3
Norpace CR
3
Drug Requirements
Tier
&Limits
Pacerone (200mg Tablet)

1
Pacerone (100mg Tablet,
3
400mg Tablet)
Procainamide HCl
2
Propafenone HCl
1
Propafenone HCl ER
2
Quinidine Gluconate
3
Quinidine Gluconate ER
1
Quinidine Sulfate
1
Quinidine Sulfate ER
1
Rythmol
3
Rythmol SR
3
Sorine
1
Sotalol HCl (Tablet)
1
Sotalol HCl (Injection)
2
Tikosyn
3
Beta-Adrenergic Blocking Agents
Acebutolol HCl
1
Atenolol
1
Atenolol/Chlorthalidone
1
Betaxolol HCl
1
(20mg Tablet)
Bisoprolol Fumarate
1
Bisoprolol Fumarate/
1
Hydrochlorothiazide
Bystolic
2
Carvedilol
1
Coreg
3
Coreg CR
3
ST
Corgard
3

ST = Step therapy
36
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Corzide
3
Inderal LA
3
Innopran XL
3
Labetalol HCl
1
Levatol
3
Lopressor
3
Lopressor HCT
3
Metoprolol Succinate ER
2
Metoprolol Tartrate (Tablet) 1
Metoprolol Tartrate
2
(Injection)
Metoprolol/
2
Hydrochlorothiazide
Nadolol
2
Nadolol/
2
Bendroflumethiazide
Pindolol
1
Propranolol HCl
1
Propranolol HCl ER
1
Propranolol/
1
Hydrochlorothiazide
Sectral
3
Tenoretic
3
Tenormin
3
Timolol Maleate (Tablet)
1
Toprol XL
3
Trandate (100mg Tablet,
3
200mg Tablet)
Zebeta
3
Ziac
3
Calcium Channel Blocking Agents
Adalat CC
3
Afeditab CR
1
Amlodipine Besylate
1
Amlodipine Besylate/
3
Benazepril HCl
Azor
Caduet
Calan
Calan SR
Cardizem
Cardizem CD
Cardizem LA
Cartia XT
Covera-HS
Dilacor XR
Dilt-CD
(120mg Capsule Extended
Release 24 Hour,
300mg Capsule Extended
Release 24 Hour)
Dilt-XR
Release 24 Hour,
Release 24 Hour)
Diltiazem CD
Release 24 Hour,
Release 24 Hour,
Release 24 Hour)
Diltiazem HCl (100mg
Injection, 50mg/10ml
Injection, Tablet)
Diltiazem HCl ER
(Capsule Extended
Release 12 Hour,
Release 24 Hour,
Release 24 Hour)
Dynacirc CR
Exforge
Exforge HCT
37
Drug Requirements
Tier
&Limits
2
3
3
3
3
3
3
1
3
3
3
2
2
ST
Drug Name
Felodipine ER
Isradipine
Lotrel
Matzim LA
Nicardipine HCl
Nifediac CC
Release 24 Hour)
Nifedical XL
Nifedipine (Capsule)
Nifedipine ER
Nimodipine
Nisoldipine
Nisoldipine ER
Norvasc
Procardia
Procardia XL
Sular
Taztia XT
Tiazac
Tribenzor
Twynsta
Verapamil HCl (Tablet)
Verapamil HCl (Injection)
Verapamil HCl ER (Tablet
Extended Release)
Verapamil HCl ER
(Capsule Extended
Release 24 Hour)
Verelan
Verelan PM
Drug Requirements
Tier
&Limits
Drug Name
Cardiovascular Agents, Other

Miscellaneous Cardiac Drugs
Amturnide
3
ST
Demser
4
Digoxin
1
Lanoxin (0.25mg/ml
2
Injection, Tablet)
Lanoxin
3
(0.1mg/ml Injection)
Pentoxifylline ER
1
Ranexa
2
ST
Tekamlo
3
ST
Tekturna
2
ST
Tekturna HCT
2
ST
Trental
3
Valturna
3
ST
Diuretics, Carbonic Anhydrase Inhibitors
Cardiac Drugs
Acetazolamide Sodium
2
Diuretics, Loop Cardiac Drugs
Bumetanide
1
Demadex (10mg Tablet,
20mg Tablet,
3
5mg Tablet)
Edecrin
3
Furosemide
1
Lasix
3
Torsemide (20mg/2ml
1
Injection, Tablet)
2
2
3
3
1
1
1
2
1
3
2
2
3
3
3
3
1
3
2
3
1
2
Drug Requirements
Tier
&Limits
ST
1
2
3
3

ST = Step therapy
38
Drug Name
Drug Requirements
Tier
&Limits
Diuretics, Potassium-Sparing Cardiac

Drugs
Aldactazide
3
Aldactone
3
Amiloride HCl
1
Amiloride/
1
Hydrochlorothiazide
Dyazide
3
Dyrenium
3
Eplerenone
2
Inspra
3
Maxzide
3
Spironolactone
1
Spironolactone/
1
Hydrochlorothiazide
Triamterene/
1
Hydrochlorothiazide
Diuretics, Thiazide Cardiac Drugs
Chlorothiazide
1
Chlorothiazide Sodium
1
Chlorthalidone (25mg
1
Diuril
3
Diuril IV
3
Hydrochlorothiazide
1
Indapamide
1
Methyclothiazide
1
Metolazone
1
Microzide
3
Thalitone
3
Dyslipidemics, Fibric Acid Derivatives
Cholesterol Control Drugs
Antara
2
Fenofibrate
1
Fenofibrate Micronized
1
Fenoglide
3
ST
Fibricor
3
ST
Drug Name
Drug Requirements
Tier
&Limits
Gemfibrozil
1
Lipofen
3
ST
Lofibra
3
Lopid
3
Tricor
2
Trilipix
2
Dyslipidemics, HMG CoA Reductase
Inhibitors Cholesterol Control Drugs
Advicor
3
ST
Altoprev
3
ST
Atorvastatin Calcium
1
Crestor
2
Fluvastatin
3
ST
Lescol
3
ST
Lescol XL
3
ST
Lipitor
3
Livalo
3
Lovastatin
1
Mevacor
3
Pravachol
3
Pravastatin Sodium
1
Simcor
(1000mg; 40mg Tablet
Extended Release
24 Hour, 500mg; 20mg
Tablet Extended Release
3
ST
24 Hour)
Simvastatin
1
Zocor
3
Dyslipidemics, Other Miscellaneous
Cholesterol Control Drugs
Cholestyramine Light
1
(Packet)
Colestid
3
(Granules, Tablet)
39
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Colestipol HCl (Tablet)

1
Colestipol HCl (Granules)
2
Lovaza
3
Niaspan
2
Prevalite (Powder)
1
Questran (Packet)
3
Vytorin
3
Welchol
2
Zetia
2
Vasodilators, Direct-Acting Arterial
Chest Pain Drugs
Hydralazine HCl
1
Minoxidil (Tablet)
1
Vasodilators, Direct-Acting Arterial/
Venous Chest Pain Drugs
Dilatrate SR
3
Isordil Titradose
3
Isosorbide Dinitrate
1
Isosorbide Dinitrate ER
1
Isosorbide Mononitrate
1
(20mg Tablet)
Isosorbide Mononitrate ER
1
Minitran
1
Monoket
3
Nitro-Bid
3
Nitroglycerin
1
(Injection, Patch)
Nitrolingual Pumpspray
3
Nitromist
3
Nitrostat
2
Rectiv
3
Drug Requirements
Tier
&Limits
Central Nervous System Agents

Drugs to Treat Nerve Conditions
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines ADHD Drugs
Adderall XR
3
Amphetamine/
Dextroamphetamine
2
(Tablet)
Desoxyn
3
Dexedrine
3
Dextroamphetamine
1
Sulfate (5mg Tablet)
Dextroamphetamine
2
Sulfate (10mg Tablet)
Dextroamphetamine
2
Sulfate ER
Methamphetamine HCl
2
Vyvanse
3
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines
ADHD Drugs
Concerta
3
Daytrana
3
Dexmethylphenidate HCl
2
Focalin
3
Focalin XR
3
Intuniv
3
Kapvay
3
Metadate CD
3
Metadate ER
1
Methylin
3
Methylphenidate HCl
2

ST = Step therapy
40
Drug Name
Drug Requirements
Tier
&Limits
Methylphenidate HCl ER
1
Release)
Methylphenidate HCl
ER (Capsule Extended
2
Release 24 Hour)
Ritalin
3
Ritalin LA
3
Ritalin SR
3
Strattera
3
ST
Central Nervous System, Other
Miscellaneous Central Nervous System
Drugs
Butalbital/Acetaminophen/
2
Caffeine/Codeine
Fioricet/Codeine
3
Nuedexta
2
PA
Rilutek
2
Xenazine
4
PA
Fibromyalgia Agents Fibromyalgia Drugs
Savella
2
Savella Titration Pack
2
Multiple Sclerosis Agents Multiple
Sclerosis Drugs
Ampyra
4
PA
Copaxone
4
PA
Gilenya
4
PA
Dermatological Agents Skin Agents

8-MOP
3
Acanya
3
ST
Aczone
3
Adapalene
2
Aldara
3
Amevive
4
PA
Ammonium Lactate
1
Amnesteem
2
Atralin
3
PA
Avita (Cream)
1
PA
Avita (Gel)
2
PA
Azelex
3
Benzamycin
3
Calcipotriene
2
Carac
3
Claravis
2
Cleocin-T
3
Clindacin PAC
3
Clindagel
3
(External Solution, Foam,
2
Gel, Lotion, Swab)
Clindamycin/Benzoyl
2
Peroxide (5%; 1% Gel)
Condylox (Gel)
3
Differin
3
Dovonex
3
Dovonex Scalp
3
Efudex
3
Elidel
3
ST
Epiduo
3
ST
Erythromycin/
1
Benzoyl Peroxide
Evoclin
3
1
3
4
1
2
3
1
Drug Requirements
Tier
&Limits
Dermatological Agents Drugs to Treat

Skin Conditions
Dental And Oral Agents Drugs to

Treat Mouth and Throat Conditions
Dental and Oral Agents
Chlorhexidine Gluconate
Oral Rinse
Evoxac
Kepivance
Periogard
Pilocarpine HCl (Tablet)
Salagen
Triamcinolone in Orabase
Drug Name
ST
41
Drug Name
Finacea
Fluoroplex
Fluorouracil (Cream)
Imiquimod
Klaron
LAC-Hydrin
Laclotion
Oxsoralen
Oxsoralen Ultra
Pennsaid
Podofilox
Protopic
Regranex
Retin-A
Retin-A Micro
Santyl
Selenium Sulfide (Lotion)
Solaraze
Soriatane
Sorilux
Stelara
Sulfacetamide Sodium
(Suspension)
Taclonex
Taclonex Scalp
Tazorac
Tretin-X (Kit)
Tretinoin (Cream, Gel)
Uvadex
Vectical
Veltin
Drug Requirements
Tier
&Limits
2
3
2
3
3
3
1
3
4
3
2
3
4
3
3
3
1
3
4
3
4
Drug Name
Veregen
Voltaren (Gel)
Ziana
Zonalon
Zyclara
3
2
3
3
2
PA
Enzyme Replacements/Modifiers
Drugs to Treat Enzyme Deficiency
PA
PA
Enzyme Replacements/Modifiers
Enzyme Replacement/Modifying Drugs
Adagen
4
Aldurazyme
4
Buphenyl
4
Carbaglu
4
Cerezyme
4
PA
(200unit Injection)
Creon
2
Cystadane
4
Cystagon
3
Elaprase
4
Fabrazyme
4
(35mg Injection)
Kuvan
4
Lumizyme
4
Myozyme
4
Naglazyme
4
Orfadin
4
Pancreaze
3
Sucraid
4
Vpriv
4
PA
Zavesca
4
Zenpep
2
ST
PA
PA
PA
PA
PA
2
3
3
3
3
2
3
3
3
Drug Requirements
Tier
&Limits
PA
PA
PA
PA

ST = Step therapy
42
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Pylera
3
Reglan
3
Relistor
3
PA
Urso
3
Ursodiol
2
Histamine2 (H2) Blocking Agents
Ulcer and Stomach Acid Drugs
Axid (Oral Solution)
3
Cimetidine
1
Cimetidine HCl
1
Famotidine
(Injection, Suspension
1
Reconstituted, 20mg
Famotidine Premixed
2
Nizatidine
1
Pepcid
3
Ranitidine HCl
(Capsule, 150mg/6ml
1
Injection, Syrup, Tablet)
Zantac
3
Irritable Bowel Syndrome Agents
Bowel Treatment Drugs
Amitiza
2
ST
Lotronex
4
PA
Laxatives Bowel Treatment Drugs
Colyte-Flavor Packs
(240gm; 2.98gm;
3
6.72gm; 5.84gm;
22.72gm Oral Solution)
Enulose
1
Gavilyte-C
1
Gavilyte-G
1
Gavilyte-N/Flavor Pack
1
Golytely
3
Lactulose
1
MoviPrep
3
Gastrointestinal Agents Drugs to

Treat Bowel, Intestine and Stomach
Conditions
Antispasmodics, Gastrointestinal
Bowel Treatment Drugs
Atropine Sulfate
1
PA
0.1mg/ml Injection)
Bentyl
3
PA
Cantil
3
Cuvposa
3
Dicyclomine HCl (Capsule,
1
PA
Glycopyrrolate
2
Helidac
3
Methscopolamine Bromide
2
Pamine
3
Pamine Forte
3
Propantheline Bromide
1
Robinul (Tablet)
3
Robinul Forte
3
Gastrointestinal Agents, Other
Miscellaneous Gastrointestinal Drugs
Actigall
3
Cromolyn Sodium
2
(Concentrate)
Diphenoxylate/Atropine
1
PA
Gastrocrom
3
Halflytely Bowel Prep/
2
Flavor Packs
Lomotil
3
Loperamide HCl (Capsule)
1
Metoclopramide HCl
1
Metozolv ODT
3
ST
Motofen
3
OsmoPrep
3
43
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Nulytely/Flavor Packs
2
Polyethylene Glycol 3350
1
(Powder)
Suprep Bowel Prep
3
Trilyte
1
Protectants Ulcer and Stomach Acid
Drugs
Carafate
3
Cytotec
3
Misoprostol
1
(200mcg Tablet)
Sucralfate
1
Proton Pump Inhibitors Ulcer and
Stomach Acid Drugs
Aciphex
3
ST
Dexilant
3
Lansoprazole
3
ST
Nexium
2
Nexium I.V.
3
Omeprazole (Capsule
1
Delayed Release)
Omeprazole/Sodium
2
Bicarbonate
Pantoprazole Sodium
1
Prevacid
3
ST
Prevacid Solutab
3
ST
Prilosec (Capsule
3
ST
Delayed Release)
Protonix (Injection)
3
Protonix (Packet,
3
ST
Tablet Delayed Release)
Vimovo
2
Zegerid
3
ST
Drug Requirements
Tier
&Limits
Genitourinary Agents Drugs to Treat

Bladder, Genital and Kidney Conditions
Antispasmodics, Urinary Bladder Control
Drugs
Detrol
3
ST
Detrol LA
3
ST
Ditropan XL
3
Enablex
3
ST
Flavoxate HCl
2
Gelnique (10% Gel)
2
Oxybutynin Chloride
1
Oxybutynin Chloride ER
2
Oxytrol
2
Sanctura
3
Sanctura XR
3
Toviaz
2
ST
Trospium Chloride
2
Vesicare
2
Benign Prostatic Hypertrophy Agents
Prostate Enlargement Drugs
Alfuzosin HCl ER
2
Avodart
2
Cardura
3
Doxazosin Mesylate
1
Finasteride (Tablet)
1
Flomax
3
Jalyn
3
ST
Proscar
3
Rapaflo
2
Tamsulosin HCl
1

ST = Step therapy
44
Drug Name
Drug Requirements
Tier
&Limits
Terazosin HCl
1
Uroxatral
3
Genitourinary Agents, Other
Miscellaneous Bladder, Genital, and Kidney
Conditions Drugs
Bethanechol Chloride
1
Cialis (2.5mg Tablet,
3
PA
5mg Tablet)
Elmiron
3
Urecholine
3
Phosphate Binders Phosphate-Removing
Agents
Fosrenol
4
Renagel
2
ST
Renvela
2
Drug Name
Clobetasol Propionate
(External Solution,
Gel, Lotion, Ointment,
Shampoo)
Clobetasol Propionate
(Foam)
Clobetasol Propionate E
Clobex
Cloderm Pump
Cordran
Cordran Tape
Cortef
Cortifoam
Cortisone Acetate
Cutivate
Depo-Medrol
Derma-Smoothe/FS
Dermatop
Desonate
Desonide
Desowen
(Cream, Lotion)
Desoximetasone (Cream,
Gel, 0.25% Ointment)
Dexamethasone
(Elixir, Tablet)
Dexamethasone Intensol
Dexamethasone Sodium
Phosphate
(4mg/ml Injection)
Dexpak 13 Day
Diflorasone Diacetate
Diprolene
Diprolene AF
Elocon
Flo-Pred
Fludrocortisone Acetate
Hormonal Agents, Stimulant/

Replacement/Modifying (Adrenal)
Drugs to Regulate Hormones
Glucocorticoids/Mineralocorticoids
Anti-Inflammatory Drugs
A-Hydrocort
2
Aclovate
3
Ala Scalp
3
Ala-Cort
2
Alclometasone
1
Dipropionate
Amcinonide
1
Anusol-HC (Cream)
3
Augmented
Betamethasone
1
Dipropionate (Cream,
Lotion, Ointment)
Betamethasone
1
Dipropionate
Betamethasone Valerate
1
Capex
3
Carmol-HC
3
Celestone
3
45
Drug Requirements
Tier
&Limits
2
1
3
3
3
3
3
3
1
3
3
3
3
3
1
3
2
1
1
1
3
1
3
3
3
3
1
Drug Name
Fluocinolone Acetonide
(Cream, External Solution,
Ointment)
Body Oil
Fluocinonide (External
Solution, Gel, Ointment)
Fluocinonide-E
Fluticasone Propionate
(Cream, Lotion, Ointment)
Halobetasol Propionate
Halog
Hydrocortisone
(1% Cream, 2.5% Cream,
2.5% Lotion, 1% Ointment,
2.5% Ointment, Tablet)
Hydrocortisone Valerate
Kenalog
Locoid
(External Solution,
Lotion, Ointment)
Locoid Lipocream
Lokara
Luxiq
Medrol (16mg Tablet,
32mg Tablet,
Medrol Dosepak
Methylprednisolone
(Tablet)
Methylprednisolone
Acetate (Injection)
Methylprednisolone Dose
Pack
Drug Requirements
Tier
&Limits
Drug Name
Methylprednisolone
Sodium Succinate
(Injection)
Millipred (Oral Solution)
Mometasone Furoate
Olux-E
Orapred
Orapred ODT (15mg
Tablet Dispersible,
30mg Tablet Dispersible)
Pandel
Prednicarbate
Prednisolone Sodium
Phosphate (Oral Solution)
Prednisone
Prednisone Intensol
Proctocream HC
Solu-Cortef
(100mg Injection,
250mg Injection)
Solu-Medrol
(125mg Injection,
2gm Injection,
40mg Injection,
500mg Injection)
Temovate
Topicort (Cream, Gel,
0.25% Ointment)
Triamcinolone Acetonide
(Cream, Lotion, Ointment)
Triderm
U-Cort
Ultravate
1
1
1
1
1
2
3
2
2
3
3
3
1
3
3
3
1
2
1
Drug Requirements
Tier
&Limits
2
3
1
3
3
3
3
1
1
1
1
2
3
3
3
1
1
1
3

ST = Step therapy
46
Drug Name
Vanos
Verdeso
Veripred 20
Westcort
Drug Requirements
Tier
&Limits
Drug Name
Omnitrope
(5.8mg Injection)
Pregnyl W/Diluent Benzyl
Alcohol/NaCl
Saizen
Serostim
Stimate
Tev-Tropin
Zorbtive
3
3
3
3

Replacement/Modifying (Pituitary)
Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/
Modifying (Pituitary) Hormone
Replacement/Modifying Drugs
Chorionic Gonadotropin
2
PA
DDAVP
3
(Nasal Solution, Tablet)
DDAVP (Injection)
4
ST
Desmopressin Acetate
2
Egrifta
4
PA
Genotropin
4
PA
Genotropin Miniquick
3
PA
(0.2mg Injection)
Genotropin Miniquick
(0.4mg Injection,
0.6mg Injection,
0.8mg Injection,
1.2mg Injection,
4
PA
1.4mg Injection,
1.6mg Injection,
1.8mg Injection,
1mg Injection,
2mg Injection)
Humatrope
4
PA
Increlex
4
PA
Norditropin Flexpro
4
PA
Norditropin Nordiflex
4
PA
Pen
Nutropin
4
PA
Nutropin AQ
4
PA
Omnitrope
3
PA
Drug Requirements
Tier
&Limits
4
PA
PA
4
4
3
3
4
PA
PA
PA
PA

Replacement/Modifying
(Sex Hormones/Modifiers) Drugs to
Regulate Hormones
Anabolic Steroids Hormone
Replacement/Modifying Drugs
Oxandrolone
2
PA
(2.5mg Tablet)
Oxandrolone (10mg Tablet) 4
PA
Androgens Hormone Replacement/
Modifying Drugs
Androgel
2
(50mg/5gm Gel)
Androgel Pump
2
(1.62% Gel)
Androxy
2
Axiron
3
PA
Danazol
2
Delatestryl
3
Depo-Testosterone
3
Fortesta
3
PA
Methitest
3
Striant
3
PA
Testim
3
PA
Testosterone Cypionate
2
Testosterone Enanthate
2
Testred
3
47
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Estrogens Hormone Replacement/

Modifying Drugs
Activella
3
Alora
3
Amethia
1
Amethyst
1
Angeliq
3
(0.5mg; 1mg Tablet)
Apri
1
Aranelle
1
Aviane
1
Balziva
1
Beyaz
3
Brevicon
3
Briellyn
1
Cenestin
3
Climara
3
Climara Pro
3
Combipatch
3
Cryselle
1
Cyclafem 1/35
1
Cyclafem 7/7/7
1
Cyclessa
3
Delestrogen
3
Depo-Estradiol
3
Desogen
3
Divigel (1mg/gm Gel)
3
Elestrin
3
Emoquette
1
Enjuvia
2
Enpresse
1
Estrace
Estradiol
Estradiol Valerate
Estradiol/Norethindrone
Acetate
(1mg; 0.5mg Tablet)
Estring
Estropipate
Estrostep Fe
Evamist
Femcon Fe
Femhrt 1/5
Femhrt Low Dose
Femring
Femtrace
Gianvi
Introvale
Jinteli
Junel
Junel Fe
Kariva
Kelnor
Leena
Lessina
Levora
Lo Loestrin Fe
Lo/Ovral
Loestrin Fe (20mcg;
75mg; 1mg Tablet)
LoSeasonique
Low-Ogestrel
Drug Requirements
Tier
&Limits
3
1
2
1
3
1
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
3
3
3
3
1

ST = Step therapy
48
Drug Name
Lutera
Lybrel
Marlissa
Menostar
Microgestin
Microgestin Fe
Modicon
Mononessa
Necon
Nordette
Norinyl (35mcg; 1mg
Tablet)
Nortrel
Nuvaring
Ocella
Ogestrel
Orsythia
Ortho Evra
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
Ortho-Cept
Ortho-Cyclen
Ortho-Novum 7/7/7
Ovcon-35
Ovcon-50 28
Portia
Prefest
Premarin
(Cream, Tablet)
Premarin (Injection)
Premphase
Prempro
Previfem
Quasense
Reclipsen
Safyral
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Seasonale
3
Seasonique
3
Sprintec
1
Sronyx
1
Tri-Legest Fe
1
Tri-Norinyl
3
Tri-Previfem
1
Tri-Sprintec
1
Trinessa
1
Trivora
1
Vagifem
3
Velivet
1
Vestura
1
Vivelle-Dot
2
Yasmin
3
Yaz
3
Zeosa
1
Zovia
1
Progesterone Hormone Replacement/
Modifying Drugs
Ella
3
Progestins Hormone Replacement/
Modifying Drugs
Aygestin
3
Camila
1
Crinone
3
Depo-Provera
3
Depo-SubQ Provera 104 3
Endometrin
3
Errin
1
Jolivette
1
Medroxyprogesterone
1
Acetate
Megace ES
3
Megace Oral
3
Megestrol Acetate
1
1
3
1
3
1
1
3
1
1
3
3
1
2
1
1
1
3
3
3
3
3
3
3
3
1
3
2
3
2
2
1
1
1
3
49
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Unithroid (100mcg
Tablet, 112mcg Tablet,
125mcg Tablet, 150mcg
200mcg Tablet, 25mcg
50mcg Tablet, 75mcg
Tablet, 88mcg Tablet)
Next Choice
1
Nor-QD
3
Nora-BE
1
Norethindrone Acetate
1
Ortho Micronor
3
Progesterone (Capsule)
1
Prometrium
3
Provera
3
Selective Estrogen Receptor Modifying
Agents Hormone Replacement/
Modifying Drugs
Evista
2
Drug Requirements
Tier
&Limits
Hormonal Agents, Suppressant

(Adrenal) Drugs to Regulate
Hormones
Hormonal Agents, Suppressant (Adrenal)
Hormone Suppressants
Lysodren
2

Replacement/Modifying (Thyroid)
Drugs to Replace Thyroid Hormones

(Parathyroid) Drugs to Regulate
Hormones
Hormonal Agents, Stimulant/Replacement/

Modifying (Thyroid) Thyroid Replacement
Drugs
Cytomel
3
Levothroid
2
Levothyroxine Sodium
1
(Tablet)
Levoxyl
2
Liothyronine Sodium
1
Synthroid
2
Tirosint
3

(Parathyroid) Hormone Suppressants
Sensipar (30mg Tablet)
2
Sensipar (60mg Tablet,
4
90mg Tablet)

(Pituitary) Drugs to Regulate
Hormones
(Pituitary) Hormone Suppressants
Cabergoline
2
Eligard
3
Firmagon
3
PA
(80mg Injection)
Firmagon
4
PA
(120mg Injection)

ST = Step therapy
50
Drug Name
Leuprolide Acetate
Lupron Depot
(3.75mg Injection)
Lupron Depot
(22.5mg Injection,
30mg Injection,
45mg Injection,
7.5mg Injection)
Lupron Depot-PED
(11.25mg Injection
3 Month)
Lupron Depot-PED
(11.25mg Injection
1 Month, 15mg Injection
1 Month)
Octreotide Acetate
(100mcg/ml Injection,
50mcg/ml Injection)
Octreotide Acetate
500mcg/ml Injection)
Sandostatin
Sandostatin LAR Depot
Somatuline Depot
Somavert
Synarel
Trelstar Depot
Trelstar LA
Trelstar Mixject
Drug Requirements
Tier
&Limits
2
Drug Name
Drug Requirements
Tier
&Limits

(Thyroid) Drugs to Suppress Thyroid
Hormones
Antithyroid Agents Thyroid Suppressing

Drugs
Methimazole
1
Propylthiouracil
1
Tapazole
3
Immunological Agents Drugs that

Stimulate or Suppress the Immune
System
PA
PA
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
Immune Suppressants Immune System

Drugs
Azasan
3
Azathioprine
1
Azathioprine Sodium
2
Benlysta
4
PA
(120mg Injection)
Cellcept (Capsule)
3
B/D, PA
Cellcept (Suspension
4
B/D, PA
Cellcept Intravenous
3
B/D, PA
Cimzia
4
PA
Cyclosporine
2
B/D
Cyclosporine Modified
1
B/D
(100mg Capsule)
Cyclosporine Modified
(50mg Capsule,
2
B/D
Oral Solution)
Enbrel
4
PA
Gengraf
2
B/D
Humira
4
PA
Humira Starter Kit
4
PA
Imuran
3
Kineret
4
PA
Methotrexate (Tablet)
1

(Sex Hormones/Modifiers) Drugs to
Regulate Hormones
Antiandrogens Hormone Suppressants
Bicalutamide
1
Casodex
3
Flutamide
2
Nilandron
3
51
Drug Name
Methotrexate Sodium
(25mg/ml Injection)
Methotrexate Sodium
(1gm Injection)
Mycophenolate Mofetil
Myfortic (180mg Tablet
Delayed Release)
Myfortic (360mg Tablet
Delayed Release)
Neoral
Nulojix
Orencia
Prograf (0.5mg Capsule,
1mg Capsule, Injection)
Prograf (5mg Capsule)
Rapamune
(0.5mg Tablet)
Rapamune
(Oral Solution,
Remicade
Rheumatrex
Sandimmune
Simponi
Tacrolimus (0.5mg
Tacrolimus (5mg Capsule)
Torisel
Trexall
Zortress (0.25mg Tablet)
Zortress (0.5mg Tablet,
0.75mg Tablet)
Drug Requirements
Tier
&Limits
Drug Name
Immunizing Agents, Passive Immune

System Drugs
Atgam
4
B/D
Carimune Nanofiltered
4
B/D, PA
(3gm Injection)
Gammagard Liquid
4
B/D, PA
Gammaplex
4
B/D, PA
Gamunex-C
4
B/D, PA
Hizentra
4
B/D, PA
(1gm/5ml Injection)
Privigen
4
B/D, PA
Thymoglobulin
4
B/D
Immunomodulators Immune System
Drugs
Actemra
4
PA
Actimmune
4
Arava
3
Arcalyst
4
PA
Avonex
4
PA
Betaseron
4
PA
Extavia
3
PA
Ilaris
4
PA
Leflunomide
1
Rebif
4
PA
Rebif Titration Pack
4
PA
Ridaura
3
Simulect
4
B/D
(20mg Injection)
1
2
2
B/D, PA
B/D
B/D
3
4
4
B/D
B/D, PA
PA
B/D, PA
B/D, PA
B/D
B/D
4
3
3
4
PA
B/D
PA
B/D, PA
4
4
3
3
B/D, PA
B/D, PA
B/D, PA
Drug Requirements
Tier
&Limits

ST = Step therapy
52
Drug Name
Synagis
Tysabri
Vaccines
ActHIB
Adacel
Boostrix
Cervarix
Comvax
Daptacel
Decavac
Engerix-B
Gardasil
Havrix
Infanrix
IPOL
Ixiaro
M-M-R II
Menactra
MenomuneA/C/Y/W-135
Menveo
Pedvax HIB
ProQuad
Rabavert
Recombivax HB
40mcg/ml Injection)
RotaTeq
Tetanus/Diphtheria
Toxoids-Adsorbed Adult
Twinrix
Typhim Vi
Vaqta
(25unit/0.5ml Injection)
Varivax
Drug Requirements
Tier
&Limits
YF-Vax
Zostavax
4
4
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
PA, LA
Drug Requirements
Tier
&Limits
2
3
Inflammatory Bowel Disease Agents

Drugs to Treat Inflammatory Bowel
Disease
Aminosalicylates Inflammatory Bowel
Disease Drugs
Apriso
2
Asacol
3
Asacol HD
3
PA
Balsalazide Disodium
2
Canasa
2
Colazal
3
Dipentum
3
Lialda
3
Mesalamine (Kit)
2
Pentasa
3
sfRowasa
4
Glucocorticoids Inflammatory Bowel
Disease Drugs
Budesonide
(Capsule Extended
2
Release 24 Hour)
Colocort
2
Entocort EC
3
Hydrocortisone (Enema)
2
Millipred (Tablet)
3
Sulfonamides Inflammatory Bowel
Disease Drugs
Azulfidine
3
Azulfidine EN-Tabs
3
Sulfasalazine (Tablet)
1
Sulfazine EC
1
B/D
2
2
2
2
2
2
Drug Name
B/D
2
2
2
2
2
2
53
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Rocaltrol
Skelid
Xgeva
Zemplar
Zometa
Metabolic Bone Disease Agents

Drugs to Treat Bone Conditions
Metabolic Bone Disease Agents
Osteoporosis (Bone Loss) Drugs
Actonel
3
Alendronate Sodium
1
Atelvia
3
Boniva (Tablet)
3
Boniva (Injection)
3
B/D
Calcijex
3
B/D
Calcitonin-Salmon
2
Calcitriol (Capsule,
1
B/D
Injection, Oral Solution)
Didronel
3
Etidronate Disodium
2
Forteo
3
B/D, PA
Fortical
2
Fosamax (70mg Tablet)
3
Fosamax Plus D
3
ST
Hectorol
2
B/D
Ibandronate Sodium
2
Miacalcin
3
(Nasal Solution)
Miacalcin (Injection)
3
B/D, PA
Pamidronate Disodium
2
B/D
Pamidronate Disodium
3
B/D
(6mg/ml Injection)
Prolia
3
PA
Reclast
3
PA
Drug Requirements
Tier
&Limits
3
3
4
2
4
B/D
PA
B/D
Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents
Alcohol Preps (Pad)
1
Botox (100unit Injection)
3
Carnitor
3
Ferriprox
4
Firazyr
4
Fomepizole
4
Gauze Pads
2
Insulin Syringes,
2
Needles
Intralipid
3
(1.7%; 30% Injection)
Intralipid
3
(2.25%; 20% Injection)
Lactated Ringers Irrigation
2
Levocarnitine
2
Liposyn III (1.2%; 2.5%;
10% Injection, 1.2%;
3
2.5%; 20% Injection)
Methergine
2
Methylergonovine Maleate
1
(Tablet)
Physiolyte
3
Physiosol Irrigation
3
Ringers Irrigation
2
PA
B/D
PA
PA
B/D
B/D
B/D
B/D

ST = Step therapy
54
Drug Name
(Irrigation Solution)
Sterile Water Irrigation
Xeomin
(50unit Injection)
Drug Requirements
Tier
&Limits
Blephamide
Blephamide S.O.P.
Bromday
Bromfenac
Phosphate
Diclofenac Sodium
Durezol
Flarex
Flurbiprofen Sodium
FML
FML Forte
FML Liquifilm
Lotemax
Maxidex
Maxitrol
Neomycin/Polymyxin/
Bacitracin/Hydrocortisone
Neomycin/Polymyxin/
Dexamethasone
Neomycin/Polymyxin/
Hydrocortisone
(Ophthalmic Suspension)
Nevanac
Ocufen
Omnipred
Pred Forte
Pred Mild
Pred-G
Pred-G S.O.P.
Prednisolone Acetate
1
2
3
Drug Name
PA
Ophthalmic Agents Drugs to Treat

Eye Conditions
Ophthalmic Agents, Other Miscellaneous
Eye Drugs
AK-Con
1
Alcaine
3
Mydriacyl
3
Proparacaine HCl
1
Restasis
2
Tropicamide
1
Ophthalmic Anti-Allergy Agents
Allergy, Infection and Inflammation Drugs
Alocril
3
Alomide
3
Azelastine HCl
2
Bepreve
3
Cromolyn Sodium
1
Elestat
3
Emadine
3
Epinastine HCl
2
Lastacaft
2
Optivar
3
ST
Pataday
3
Patanol
2
Ophthalmic Anti-Inflammatories
Allergy, Infection and Inflammation Drugs
Acular
2
Acular LS
2
Acuvail
3
PA
Alrex
2
55
Drug Requirements
Tier
&Limits
2
2
3
2
1
1
2
2
1
2
2
3
2
2
3
3
1
1
1
2
3
3
3
2
2
2
1
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Prednisolone Sodium
Phosphate
1
Sulfacetamide Sodium/
Prednisolone Sodium
1
Phosphate
Tobradex (Ointment)
2
Tobradex (Suspension)
3
Tobradex ST
3
Tobramycin/
2
Dexamethasone
Vexol
3
Voltaren (Ophthalmic
3
Solution)
Zylet
2
Ophthalmic Antiglaucoma Agents
Glaucoma Drugs
Acetazolamide
1
Acetazolamide ER
2
Alphagan P
2
Apraclonidine
2
Azopt
2
Betagan
3
Betaxolol HCl
1
Betimol
3
Betoptic-S
3
Brimonidine Tartrate
1
Carteolol HCl
1
Combigan
2
Cosopt
3
Diamox
3
Drug Requirements
Tier
&Limits
Dorzolamide HCl
1
Dorzolamide HCl/
1
Timolol Maleate
Iopidine
3
Isopto Carpine
3
Istalol
3
Levobunolol HCl (0.5%
1
Methazolamide
1
Metipranolol
1
Optipranolol
3
Phospholine Iodide
2
Pilopine HS
2
Timolol Maleate
(Gel Forming Solution,
1
Timoptic Ocudose
3
Timoptic-XE
3
Trusopt
3
Ophthalmic Prostaglandin and Prostamide
Analogs Glaucoma Drugs
Latanoprost
1
Lumigan
2
Travatan Z
2
Xalatan
3
ST
Zioptan
3
ST
Otic Agents Drugs to Treat Ear

Conditions
Otic Agents Ear Drugs
Acetasol HC
Acetic Acid
2
1

ST = Step therapy
56
Drug Name
Coly-Mycin S
Cortisporin (Solution,
Suspension)
Cortisporin-TC
Dermotic
(Otic Oil)
Hydrocortisone/
Acetic Acid
Neomycin/Polymyxin/
Hydrocortisone
(Solution, Suspension)
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
QVAR
2
Rhinocort Aqua
3
Symbicort
2
Triamcinolone Acetonide
2
(Inhaler)
Veramyst
3
Antihistamines Allergy Drugs
Astelin
3
Astepro
2
Azelastine HCl
2
(Nasal Spray)
Carbinoxamine Maleate
1
Cetirizine HCl (Syrup)
1
Clarinex
3
Clarinex Reditabs
3
Clarinex-D
3
Clemastine Fumarate
2
(Syrup, 2.68mg Tablet)
Cyproheptadine HCl
3
Diphenhydramine HCl
3
(50mg Capsule, Injection)
Hydroxyzine HCl
1
Hydroxyzine Pamoate
1
Levocetirizine
3
Dihydrochloride (Tablet)
Levocetirizine
Dihydrochloride
3
(Oral Solution)
Palgic
3
Patanase
2
Phenadoz
2
Phenergan
3
Promethazine HCl
2
Promethazine VC
2
Promethegan
(25mg Suppository,
2
50mg Suppository)
Semprex-D
3
3
3
3
2
1
2
1
Respiratory Tract Agents Drugs to

Treat Allergies, Cough, Cold and Lung
Conditions
Anti-Inflammatories, Inhaled
Corticosteroids Asthma/Lung Drugs
Advair Diskus
2
Advair HFA
2
Alvesco
3
ST
Asmanex
3
Beconase AQ
3
Budesonide (Suspension)
2
B/D
Dulera
3
Flonase
3
Flovent Diskus
2
Flovent HFA
2
Flunisolide
1
(0.025% Nasal Solution)
Fluticasone Propionate
1
(Nasal Suspension)
Nasacort AQ
3
Nasonex
2
Omnaris
3
Pulmicort
3
B/D
Pulmicort Flexhaler
2
Qnasl
3
57
ST
ST
ST
ST
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Vistaril
3
Xyzal (Tablet)
3
Xyzal (Oral Solution)
3
ST
Antileukotrienes Asthma/Lung Drugs
Accolate
3
Singulair
2
Zafirlukast
1
Zyflo
3
ST
Zyflo CR
3
ST
Bronchodilators, Anticholinergic
Asthma/Lung Drugs
Atrovent
3
Atrovent HFA
3
Combivent
2
Duoneb
3
B/D
Ipratropium Bromide
1
(Nasal Solution)
Ipratropium Bromide
1
B/D
(Inhalation Solution)
Ipratropium Bromide/
1
B/D
Albuterol Sulfate
Spiriva Handihaler
2
Bronchodilators, Phosphodiesterase
Inhibitors (Xanthines) Asthma/Lung
Drugs
Aminophylline
1
Elixophyllin
2
Lufyllin
3
Drug Requirements
Tier
&Limits
Theophylline ER (100mg
12 Hour, 200mg Tablet
Extended Release
1
Extended Release
Extended Release
12 Hour, Tablet Extended
Release 24 Hour)
Bronchodilators, Sympathomimetic
Asthma/Lung Drugs
Accuneb
3
B/D
Albuterol Sulfate
1
(Syrup, Tablet)
Albuterol Sulfate
1
B/D
(Nebulization Solution)
Albuterol Sulfate ER
1
Arcapta Neohaler
3
ST
Brovana
3
B/D
Epinephrine HCl
2
(0.1mg/ml Injection)
Epipen
2
Foradil Aerolizer
2
ST
Levalbuterol
3
B/D, ST
Maxair Autohaler
3
Metaproterenol Sulfate
1
Perforomist
3
B/D
Proair HFA
2
Proventil HFA
3
ST
Serevent Diskus
2
ST
Terbutaline Sulfate (Tablet)
1

ST = Step therapy
58
Drug Name
Drug Requirements
Tier
&Limits
Drug Name
Drug Requirements
Tier
&Limits
Edluar
3
ST
Flurazepam HCl
3
Halcion
3
Intermezzo
3
ST
Lunesta
2
Restoril
3
Sonata
3
ST
Temazepam (15mg
1
Temazepam (22.5mg
3
Capsule, 7.5mg Capsule)
Triazolam
3
Zaleplon
1
Zolpidem Tartrate
1
(5mg Tablet, 10mg Tablet)
Zolpidem Tartrate ER
3
ST
Zolpimist
3
ST
Sleep Disorders, Other Miscellaneous
Sedation and Sleep Drugs
Butisol Sodium
3
PA
Nuvigil
3
PA
Provigil
3
PA
Rozerem
3
Silenor
3
ST
Xyrem
2
PA, LA
Terbutaline Sulfate
3
(Injection)
Twinject
3
Ventolin HFA
3
ST
Xopenex
3
B/D, ST
Xopenex HFA
3
ST
Mast Cell Stabilizers Asthma/Lung
Drugs
Cromolyn Sodium
2
B/D
(Nebulization Solution)
Pulmonary Antihypertensives Asthma/
Lung Drugs
Adcirca
4
PA
Letairis
4
Remodulin
4
B/D, PA
Revatio
4
PA
Tracleer
4
LA
Ventavis (10mcg/ml
4
B/D, PA
Inhalation Solution)
Respiratory Tract Agents, Other
Asthma/Lung Drugs
Acetylcysteine
1
B/D
Aralast NP
4
PA
(400mg Injection)
Daliresp
3
PA
Glassia
4
PA
Kalydeco
4
PA
Prolastin-C
4
PA
Pulmozyme
4
B/D
Tyzine
2
Xolair
4
PA
Zemaira
4
PA
Skeletal Muscle Relaxants Drugs to

Treat Pain, Inflammation, and Muscle
and Joint Conditions
Skeletal Muscle Relaxants Pain/Swelling
Management Drugs
Amrix
3
ST
Carisoprodol
2
(350mg Tablet)
Carisoprodol/Aspirin
3
Chlorzoxazone
2
Cyclobenzaprine HCl
3
(10mg Tablet, 5mg Tablet)
Sedatives/Hypnotics Drugs for

Sedation and Sleep
GABA Receptor Modulators Sedation
and Sleep Drugs
Ambien
3
ST
Ambien CR
3
ST
59
Drug Name
Cyclobenzaprine HCl
(7.5mg Tablet)
Cyclobenzaprine HCl ER
Fexmid
Methocarbamol
Orphenadrine Citrate
Orphenadrine Citrate ER
Orphenadrine
Compound DS
Orphenadrine/Aspirin/
Caffeine
Parafon Forte DSC
Skelaxin
Soma
Drug Requirements
Tier
&Limits
3
ST
3
3
2
3
2
ST
ST
Drug Name
Drug Requirements
Tier
&Limits
Sodium Polystyrene
2
Sulfonate (Suspension)
Syprine
3
Electrolyte/Mineral Replacement
Vitamin, Mineral and Body Fluid Deficiency
Drugs
Aminosyn 8.5%/
2
B/D
Electrolytes
Aminosyn II
3
B/D
Aminosyn II 8.5%/
2
B/D
Electrolytes
Aminosyn M
3
B/D
Aminosyn-HBC
3
B/D
Aminosyn-PF
3
B/D
Calcium Acetate (Capsule)
2
Clinimix 2.75%/
3
B/D
Dextrose 5%
Clinimix 4.25%/
3
B/D
Dextrose 10%
Clinimix 4.25%/
3
B/D
Dextrose 25%
Clinimix 4.25%/
3
B/D
Dextrose 5%
Clinimix 5%/
3
B/D
Dextrose 25%
Clinimix E 5%/
3
B/D
Dextrose 20%
Clinisol SF 15%
2
B/D
Dextrose 5%/
2
Lactated Ringers
Dextrose 5%/Potassium
2
Chloride 0.15%
Eliphos
2
2
2
3
3
3
Therapeutic Nutrients/Minerals/
Electrolytes Drugs to Treat Vitamin,
Mineral and Body Fluid Deficiencies
Electrolyte/Mineral Modifiers Vitamin,
Mineral and Body Fluid Deficiency Drugs
Ammonium Chloride
3
Chemet
3
Depen Titratabs
3
Exjade
3
(125mg Tablet Soluble)
Exjade
(250mg Tablet Soluble,
4
500mg Tablet Soluble)
Kayexalate
3
Kionex (Powder)
2
Samsca
4
PA
Sodium Fluoride (Tablet)
1
Sodium Lactate
1

ST = Step therapy
60
Drug Name
Freamine III 3%
Freamine III
(8.5% Injection)
Hepatamine
Hepatasol
Isolyte-H/Dextrose 5%
Isolyte-M/Dextrose 5%
Isolyte-P/Dextrose 5%
Isolyte-S
Isolyte-S/Dextrose 5%
K-Tabs
Klor-Con 10
Klor-Con 8
Klor-Con M15
Klor-Con M20
Lactated Ringers
Magnesium Sulfate
(50% Injection)
Nephramine
Normosol-M in D5W
Normosol-R
Phoslo
Phoslyra
Plasma-Lyte
Plasma-Lyte/D5W
(16meq/L; 40meq/L;
5%; 3meq/L; 13meq/L;
40meq/L Injection)
Potassium Chloride
(0.4meq/ml Injection,
10meq/100ml Injection,
10meq/50ml Injection,
2meq/ml Injection,
30meq/100ml Injection)
Potassium Chloride
0.15%/NaCl 0.45% Viaflex
Drug Requirements
Tier
&Limits
3
B/D
B/D
2
3
3
2
3
3
3
3
1
1
2
1
2
B/D
B/D
Drug Requirements
Tier
&Limits
Potassium Chloride
2
0.15%/NaCl 0.9%
Potassium Chloride
0.224%/Dextrose 5%
2
Viaflex
Potassium Chloride
2
0.3%/NaCl 0.9%
Potassium Chloride 0.3%/
2
D5W/Viaflex
Potassium Chloride
ER (Capsule Extended
Release, 10meq Tablet
1
Extended Release, 20meq
Tablet Extended Release)
Premasol (6% Injection)
3
B/D
Premasol (10% Injection) 3
B/D
Procalamine
3
B/D
Prosol
3
B/D
Ringers Injection
2
Sodium Chloride
(0.9% Injection, 2.5meq/ml
1
Injection, 3% Injection,
5% Injection)
1
Viaflex (Injection)
TPN Electrolytes
2
Travasol
3
B/D
Trophamine
3
B/D
Vitamins Vitamin, Mineral and Body Fluid
Deficiency Drugs
Niacor
1
Prenatal Vitamins
1
2
3
2
3
2
3
3
Drug Name
B/D
ST
61
Index of covered drugs

8-MOP.................................... 41 Actoplus Met........................... 31
Alcohol Preps.......................... 54
Actoplus Met XR.................... 31
Aldactazide.............................. 39
Abelcet.................................... 21 Actos....................................... 31
Abilify..................................... 27 Acular...................................... 55
Aldactone................................ 39
Abilify Discmelt...................... 27 Acular LS................................ 55

Abraxane................................. 24 Acuvail.................................... 55
Aldurazyme............................. 42
Abstral..................................... 10 Acyclovir................................. 30
Acanya..................................... 41 Acyclovir Sodium.................... 30
Alfuzosin HCl ER.................. 44
Aldara...................................... 41
Alendronate Sodium............... 54
Alimta..................................... 24
Acarbose.................................. 31 Aczone..................................... 41 Alinia...................................... 26

Accolate................................... 58 Adacel...................................... 53 Alkeran.................................... 23
Accuneb................................... 58 Adagen.................................... 42
Accupril................................... 35 Adalat CC............................... 37
Allopurinol.............................. 22
Allopurinol Sodium................. 22
Accuretic................................. 35 Adapalene................................ 41 Alocril..................................... 55

Acebutolol HCl....................... 36 Adcirca.................................... 59 Alomide................................... 55
Aceon...................................... 35 Adderall XR............................ 40
Adriamycin.............................. 24
Acetaminophen/Caffeine/
Dihydrocodeine Bitartrate.... 10 Advair Diskus.......................... 57
Aloprim................................... 22
Alora........................................ 48
Aloxi........................................ 21
Acetaminophen/Codeine......... 10 Advair HFA............................ 57 Alphagan P.............................. 56

Acetasol HC............................ 56 Advicor.................................... 39 Alprazolam.............................. 30
Acetazolamide......................... 56 Afeditab CR............................ 37 Alprazolam ER....................... 30
Acetazolamide ER................... 56 Afinitor.................................... 25
Acetazolamide Sodium............ 38 Aggrenox................................. 34
Alprazolam Intensol................ 30
Acetic Acid.............................. 56 Agrylin.................................... 34

Acetylcysteine.......................... 59 A-Hydrocort............................ 45
Alprazolam XR....................... 30
Alprazolam ODT.................... 30
Alrex........................................ 55
Aciphex................................... 44 AK-Con.................................. 55
Aclovate................................... 45 Akne-Mycin............................ 15
Altabax.................................... 12
Actemra................................... 52 Ala-Cort.................................. 45
ActHIB................................... 53 Ala Scalp................................. 45
Altoprev................................... 39
Altace...................................... 35
Alvesco.................................... 57
Actigall.................................... 43 Albenza................................... 26 Amantadine HCl..................... 29

Actimmune............................. 52 Albuterol Sulfate..................... 58 Amaryl.................................... 31
Actiq........................................ 10 Albuterol Sulfate ER............... 58 Ambien.................................... 59
Activella.................................. 48 Alcaine.................................... 55
Actonel.................................... 54 Alclometasone Dipropionate....45
62
Ambien CR............................. 59
AmBisome............................... 21
Amcinonide............................. 45 Amphotericin B....................... 21
Aricept..................................... 18
Amerge.................................... 22 Ampicillin............................... 15
Aricept ODT.......................... 19
Amethia.................................. 48 Ampicillin-Sulbactam............. 15
Arimidex................................. 25
Amethyst................................. 48
Ampyra................................... 41
Arixtra..................................... 33
Amevive.................................. 41 Amrix...................................... 59
Aromasin................................. 25
Amifostine............................... 24
Amturnide............................... 38
Arranon................................... 24
Amikacin Sulfate..................... 12
Anafranil................................. 20
Arthrotec................................... 8
Amiloride HCl........................ 39 Anagrelide Hydrochloride....... 34
Arzerra.................................... 26
Amiloride/
Hydrochlorothiazide............. 39
Anaprox..................................... 8
Asacol...................................... 53
Anaprox DS.............................. 8
Asacol HD.............................. 53
Anastrozole............................. 25
Asmanex.................................. 57
Ancobon.................................. 21
Astelin..................................... 57
Aminophylline......................... 58
Aminosyn 8.5%/Electrolytes....60
Aminosyn-HBC...................... 60
Aminosyn II............................ 60
Aminosyn II 8.5%/
Electrolytes........................... 60
Aminosyn M........................... 60
Aminosyn-PF.......................... 60
Amiodarone HCl.................... 36
Amitiza................................... 43
Amitriptyline HCl.................. 20
Amlodipine Besylate............... 37
Androgel................................. 47 Astepro.................................... 57
Androgel Pump....................... 47 Astramorph............................... 9
Androxy................................... 47 Atacand................................... 35
Angeliq.................................... 48
Atacand HCT......................... 35
Antabuse.................................. 20
Atelvia..................................... 54
Antara..................................... 39 Atenolol................................... 36
Antivert................................... 21
Atenolol/Chlorthalidone......... 36
Anusol-HC.............................. 45
Atgam..................................... 52
Anzemet.................................. 21
Ativan...................................... 30
Amlodipine Besylate/
Benazepril HCl.................... 37
Aplenzin.................................. 19
Atorvastatin Calcium.............. 39
Apokyn.................................... 27
Atovaquone/Proguanil HCl.... 26
Ammonium Chloride.............. 60
Apraclonidine.......................... 56
Atralin..................................... 41
Ammonium Lactate................ 41
Apri......................................... 48
Atripla..................................... 28
Amnesteem............................. 41
Apriso...................................... 53
Atropine Sulfate...................... 43
Amoxapine.............................. 20
Aptivus.................................... 29
Atrovent.................................. 58
Amoxicillin.............................. 15
Aralast NP.............................. 59
Atrovent HFA......................... 58
Clavulanate........................... 15
Aranelle................................... 48
Augmented Betamethasone
Dipropionate......................... 45
Clavulanate ER.................... 15
Arava....................................... 52
Amphetamine/
Dextroamphetamine............. 40
Amphotec................................ 21
Aranesp Albumin Free............ 34

Arcalyst................................... 52
Avalide.................................... 35
Avandamet.............................. 31
Arcapta Neohaler.................... 58 Avandaryl................................ 31

Argatroban.............................. 33 Avandia................................... 31
Avapro..................................... 35
63
Avastin.................................... 26
Bactrim.................................... 16 Bicillin C-R............................. 15
Avelox...................................... 16
Bactrim DS............................. 16 Bicillin L-A............................. 15
Avelox ABC Pack.................... 16
Bactroban................................ 13 BiCNU.................................... 23
Aviane..................................... 48
Bactroban Nasal...................... 13 Biltricide.................................. 26
Avinza....................................... 9
Balsalazide Disodium.............. 53 Bisoprolol Fumarate................ 36
Avita........................................ 41
Balziva..................................... 48 Bisoprolol Fumarate/

Banzel...................................... 18
Avodart.................................... 44
Avonex..................................... 52
Axert....................................... 22
Axid......................................... 43
Axiron..................................... 47
Aygestin................................... 49
Azactam.................................. 14
Baraclude................................. 29 Bleomycin Sulfate.................... 24

Beconase AQ........................... 57 Bleph-10.................................. 16
Benazepril HCl....................... 35 Blephamide.............................. 55

Blephamide S.O.P................... 55
Benazepril HCl/
Hydrochlorothiazide............. 35 Boniva..................................... 54
Benicar.................................... 35 Boostrix................................... 53
Azactam in Iso-Osmotic
Dextrose............................... 14
Benicar HCT.......................... 35 Botox....................................... 54
Azasan..................................... 51
Bentyl...................................... 43 Briellyn.................................... 48
Azasite..................................... 15
Benzamycin............................. 41 Brilinta.................................... 34
Azathioprine............................ 51
Benztropine Mesylate.............. 26 Brimonidine Tartrate............... 56
Azathioprine Sodium.............. 51
Bepreve.................................... 55 Bromday.................................. 55
Azelastine HCl...................55, 57
Besivance................................. 16 Bromfenac............................... 55
Azelex...................................... 41
Betagan.................................... 56 Bromocriptine Mesylate.......... 27
Azilect..................................... 27
Betamethasone Dipropionate....45
Brovana................................... 58
Azithromycin.......................... 15
Betamethasone Valerate........... 45
Budeprion SR.......................... 19
Azopt....................................... 56
Betapace.................................. 36
Budesonide........................ 53, 57
Azor........................................ 37
Betapace AF............................ 36
Bumetanide............................. 38
Aztreonam............................... 14
Betaseron................................. 52
Buphenyl.................................. 42
Azulfidine............................... 53
Betaxolol HCl.................... 36, 56
Buprenex.................................. 20
Azulfidine EN-Tabs................ 53
Bethanechol Chloride.............. 45
Buprenorphine HCl................. 20
Betimol.................................... 56
Buproban................................. 20
Baciim..................................... 12
Betoptic-S................................ 56
Bupropion HCl........................ 19
Bacitracin................................ 13
Beyaz....................................... 48
Bupropion HCl SR.................. 19
Bacitracin/Polymyxin B.......... 13 Biaxin...................................... 15

Baclofen................................... 28 Biaxin XL................................ 15
Bupropion XL......................... 19
Bactocill in Dextrose............... 15 Biaxin XL PAC....................... 15

Bicalutamide............................ 51
Busulfex................................... 23
Benlysta................................... 51 Brevicon................................... 48
64
Buspirone HCl........................ 30
Butalbital/Acetaminophen/
Caffeine/Codeine................. 41
Butalbital/Aspirin/
Caffeine/Codeine................. 10
Butisol Sodium........................ 59
Butorphanol Tartrate............... 10
Butrans.................................... 20
Bydureon................................. 31
Byetta...................................... 31
Bystolic.................................... 36
C
Cabergoline............................. 50
Caduet..................................... 37
Calan....................................... 37
Calan SR................................. 37
Calcijex.................................... 54
Calcipotriene........................... 41
Calcitonin-Salmon.................. 54
Calcitriol.................................. 54
Calcium Acetate...................... 60
Cambia...................................... 8
Camila..................................... 49
Campath.................................. 26
Campral................................... 20
Camptosar............................... 24
Canasa..................................... 53
Cancidas.................................. 21
Cantil...................................... 43
Capastat Sulfate....................... 23
Capex...................................... 45
Capital/Codeine...................... 10
Caprelsa................................... 23
Captopril................................. 35
Captopril/
Carac....................................... 41
Cefadroxil................................ 14
Carafate................................... 44
Cefazolin Sodium.................... 14
Carbaglu.................................. 42
Cefdinir................................... 14
Carbamazepine........................ 18
Cefepime................................. 14
Carbamazepine ER................. 18
Cefotaxime Sodium................. 14
Carbatrol................................. 18
Cefotetan................................. 14
Carbidopa/Levodopa............... 27
Cefoxitin Sodium.................... 14
Carbidopa/Levodopa ER........ 27
Cefoxitin Sodium/Dextrose.... 14
Carbidopa/Levodopa ODT..... 27
Cefpodoxime Proxetil.............. 14
Carbinoxamine Maleate.......... 57
Cefprozil................................. 14
Carboplatin.............................. 24
Ceftazidime............................. 14
Cardizem................................. 37
Ceftazidime/Dextrose............. 14
Cardizem CD.......................... 37
Ceftin...................................... 14
Cardizem LA.......................... 37
Ceftriaxone Sodium................ 14
Cardura................................... 44
Cefuroxime Axetil................... 14
Cardura XL............................. 35
Cefuroxime Sodium................ 14
Carimune Nanofiltered............ 52 Celebrex..................................... 8

Carisoprodol............................ 59 Celestone................................. 45
Carisoprodol/Aspirin............... 59 Celexa...................................... 19
Carisoprodol/Aspirin/
Cellcept................................... 51
Codeine................................ 10
Cellcept Intravenous................ 51
Carmol-HC............................. 45
Celontin................................... 17
Carnitor................................... 54
Cenestin.................................. 48
Carteolol HCl.......................... 56
Cephalexin.............................. 14
Cartia XT................................ 37
Cerezyme................................ 42
Carvedilol................................ 36
Cerubidine............................... 24
Casodex................................... 51
Cervarix................................... 53
Cataflam.................................... 8
Cesamet................................... 21
Catapres................................... 35
Cetirizine HCl........................ 57
Catapres-TTS.......................... 35
Chantix.................................... 20
Cayston.................................... 14
Chantix Pak............................. 20
Cedax...................................... 14
Chemet.................................... 60
CeeNU.................................... 23
Chloramphenicol Sodium
Cefaclor................................... 14
Succinate.............................. 13
Cefaclor ER............................. 14
65
Chlordiazepoxide/
Claravis.................................... 41
Amitriptyline........................ 30
Clarinex................................... 57
Chlordiazepoxide HCl............ 30
Clarinex-D.............................. 57
Chlorhexidine Gluconate
Clarinex Reditabs.................... 57
Oral Rinse............................ 41
Clarithromycin........................ 15
Chloroquine Phosphate........... 26
Clarithromycin ER.................. 15
Chlorothiazide......................... 39
Clemastine Fumarate.............. 57
Chlorothiazide Sodium........... 39
Cleocin.................................... 13
Chlorpromazine HCl.............. 27
Cleocin Galaxy........................ 13
Chlorpropamide...................... 31
Cleocin in D5W...................... 13
Chlorthalidone........................ 39
Cleocin Phosphate................... 13
Chlorzoxazone......................... 59
Cleocin-T................................ 41
Cholestyramine Light............. 39
Climara................................... 48
Chorionic Gonadotropin......... 47
Climara Pro............................. 48
Cialis....................................... 45
Clindacin PAC........................ 41
Ciclopirox................................ 21
Clindagel................................. 41
Ciclopirox Nail Lacquer.......... 21
Clindamycin/
Ciclopirox Olamine................. 21
Benzoyl Peroxide.................. 41
Cilostazol................................. 34
Clindamycin HCl.................... 13
Ciloxan.................................... 16
Clindamycin Phosphate..... 13, 41
Cimetidine............................... 43
Cimetidine HCl...................... 43
Add-Vantage......................... 13
Clonidine HCl........................ 35
Cimzia..................................... 51
Clopidogrel.............................. 34
Cinryze.................................... 34
Cipro....................................... 16
Ciprodex.................................. 16
Ciprofloxacin........................... 16
Ciprofloxacin ER..................... 16
Ciprofloxacin HCl................... 16
Cipro HC................................ 16
Cipro IV.................................. 16
Cisplatin.................................. 24
Citalopram Hydrobromide...... 19
Cladribine................................ 24
Claforan................................... 14
Clinimix 2.75%/
Dextrose 5%......................... 60
Clinimix 4.25%/
Dextrose 5%......................... 60
Clinimix 4.25%/
Dextrose 10%....................... 60
Clinimix E 2.75%/
Dextrose 10%....................... 32
Clinimix E 4.25%/
Dextrose 5%......................... 32
Clinimix E 4.25%/
Dextrose 25%....................... 32
Clinimix E 5%/
Dextrose 15%....................... 32
Clinimix E 5%/
Dextrose 20%....................... 60
Clinimix E 5%/
Dextrose 25%....................... 32
Clinisol SF 15%....................... 60
Clinoril...................................... 8
Clobetasol Propionate.............. 45
Clobetasol Propionate E.......... 45
Clobex..................................... 45
Cloderm Pump........................ 45
Clolar....................................... 24
Clomipramine HCl................. 20
Clonazepam............................. 17
Clonazepam ODT.................. 17
Clorazepate Dipotassium......... 17
Clorpres................................... 35
Clotrimazole............................ 21
Clotrimazole/Betamethasone
Dipropionate......................... 21
Clinimix 4.25%/
Dextrose 20%....................... 32 Clozapine................................ 28
Clozaril.................................... 28
Clinimix 4.25%/
Dextrose 25%....................... 60
Coartem.................................. 26
Clinimix 5%/Dextrose 15%..... 32 Codeine Sulfate....................... 10

Clinimix 5%/Dextrose 20%.... 32 Cogentin.................................. 26
Clinimix 5%/Dextrose 25%.... 60
Co-Gesic................................. 10
Clinimix E 2.75%/
Colazal.................................... 53
Dextrose 5%......................... 32
Colcrys.................................... 22
66
Colestid................................... 39 Covera-HS.............................. 37 Danazol................................... 47

Colestipol HCl........................ 40
Cozaar..................................... 35 Dantrium................................. 28
Colistimethate Sodium............ 13 Creon....................................... 42 Dantrolene Sodium................. 28

Colocort................................... 53 Crestor..................................... 39 Dapsone................................... 23
Coly-Mycin M........................ 13 Crinone................................... 49 Daptacel.................................. 53
Coly-Mycin S.......................... 57 Crixivan................................... 29 Daraprim................................. 26
Colyte-Flavor Packs................ 43 Cromolyn Sodium........43, 55, 59 Daunorubicin HCl.................. 24
Combigan................................ 56 Cryselle.................................... 48 Daypro....................................... 8
Combipatch............................. 48 Cubicin.................................... 13 Daytrana.................................. 40
Combivent............................... 58 Cutivate................................... 45 DDAVP................................... 47
Combivir................................. 29 Cuvposa................................... 43 Decavac................................... 53
Complera................................. 28 Cyclafem 1/35......................... 48 Delatestryl............................... 47
Compro................................... 27 Cyclafem 7/7/7........................ 48 Delestrogen............................. 48
Comtan................................... 26 Cyclessa................................... 48 Demadex................................. 38
Comvax................................... 53 Cyclobenzaprine HCl........ 59, 60 Demeclocycline HCl............... 16
Concerta.................................. 40 Cyclobenzaprine HCl ER....... 60 Demerol................................... 10
Condylox................................. 41 Cyclophosphamide.................. 23 Demser.................................... 38
Copaxone................................ 41 Cycloset................................... 31 Denavir.................................... 30
Copegus................................... 29 Cyclosporine............................ 51 Depacon.................................. 17
Cordarone................................ 36 Cyclosporine Modified............ 51 Depakene................................. 17
Cordran................................... 45 Cyklokapron............................ 34 Depakote................................. 17
Cordran Tape.......................... 45 Cymbalta................................. 19 Depakote ER........................... 17
Coreg....................................... 36 Cyproheptadine HCl............... 57 Depakote Sprinkles................. 17
Coreg CR................................ 36
Cystadane................................ 42 Depen Titratabs...................... 60
Corgard................................... 36
Cystagon.................................. 42 Depo-Estradiol........................ 48
Cortef...................................... 45
Cytarabine............................... 24 Depo-Medrol.......................... 45
Cortifoam................................ 45
Cytarabine Aqueous................ 24 Depo-Provera.......................... 49
Cortisone Acetate.................... 45
Cytomel................................... 50 Depo-SubQ Provera 104......... 49
Cortisporin........................ 13, 57
Cytotec.................................... 44 Depo-Testosterone................... 47
Cortisporin-TC....................... 57
Cytovene.................................. 28 Derma-Smoothe/FS................ 45
Corzide.................................... 37
Dermatop................................ 45
Cosmegen................................ 24 Dacarbazine............................. 23 Dermotic................................. 57

Cosopt..................................... 56 Dacogen.................................. 24 Desipramine HCl.................... 20
Coumadin............................... 33 Daliresp................................... 59 Desmopressin Acetate............. 47
67
Desogen................................... 48
Diabeta.................................... 31 Dipentum................................ 53
Desonate.................................. 45
Diamox.................................... 56 Diphenhydramine HCl........... 57
Desonide................................. 45
Diazepam...........................17, 30
Diphenoxylate/Atropine.......... 43
Desowen.................................. 45
Diazepam Intensol.................. 30
Diprolene................................. 45
Desoximetasone....................... 45
Dibenzyline............................. 35
Diprolene AF.......................... 45
Desoxyn.................................. 40
Diclofenac Potassium................ 8
Dipyridamole........................... 34
Detrol...................................... 44
Diclofenac Sodium.................. 55 Disopyramide Phosphate......... 36
Detrol LA............................... 44
Diclofenac Sodium DR............. 8 Disulfiram............................... 20
Dexamethasone....................... 45
Diclofenac Sodium ER.............. 8 Ditropan XL........................... 44
Dexamethasone Intensol......... 45
Dicloxacillin Sodium............... 15 Diuril....................................... 39
Phosphate....................... 45, 55
Dicyclomine HCl.................... 43 Diuril IV................................. 39
Dexedrine................................ 40
Dexilant................................... 44
Dexmethylphenidate HCl....... 40
Dexpak 13 Day........................ 45
Dexrazoxane............................ 24
Dextroamphetamine Sulfate.... 40
Dextroamphetamine
Sulfate ER............................ 40
Didanosine.............................. 29 Divalproex Sodium.................. 17

Didronel.................................. 54 Divalproex Sodium DR........... 17
Differin.................................... 41 Divalproex Sodium ER........... 17
Dificid..................................... 15 Divigel..................................... 48
Diflorasone Diacetate.............. 45 Docefrez.................................. 24
Diflucan................................... 21 Docetaxel................................. 24
Diflunisal................................... 8 Dolophine.................................. 9
Digoxin................................... 38 Dolophine HCl......................... 9
Dihydroergotamine Mesylate....22
Dextrose 2.5%/
Sodium Chloride 0.45%....... 32 Dilacor XR.............................. 37
Dextrose 5%............................ 32 Dilantin................................... 18
Doryx...................................... 16
Dilantin Infatabs..................... 18
Dorzolamide HCl................... 56
Dextrose 5%/
Lactated Ringers.................. 60
Donepezil HCl........................ 19
Doribax................................... 15
Dilatrate SR............................ 40
Dorzolamide HCl/
Timolol Maleate................... 56
Dextrose 5%/NaCl 0.2%......... 32 Dilaudid.................................. 10
Dextrose 5%/NaCl 0.9%......... 32 Dilaudid-5............................... 10 Dovonex.................................. 41
Dextrose 5%/NaCl 0.33%....... 32 Dilaudid-HP........................... 10 Dovonex Scalp......................... 41
Dextrose 5%/NaCl 0.45%....... 32 Dilt-CD................................... 37
Dextrose 5%/NaCl 0.225%..... 32 Diltiazem CD......................... 37
Dextrose 5%/Potassium
Chloride 0.15%..................... 60
Diltiazem HCl........................ 37
Diltiazem HCl ER.................. 37
Dextrose 10%
Flex Container...................... 32 Dilt-XR................................... 37
Dextrose 10%/NaCl 0.2%....... 32 Diovan..................................... 35
Dextrose 10%/NaCl 0.45%.... 32 Diovan HCT........................... 35
68
Doxazosin Mesylate................ 44
Doxepin HCl........................... 20
Doxil....................................... 24
Doxorubicin HCl.................... 24
Doxycycline............................. 16
Doxycycline Hyclate................ 17
Doxycycline Monohydrate...... 17
Dronabinol.............................. 21
Droxia...................................... 24
Elixophyllin............................. 58 Epivir HBV............................. 29
Duetact.................................... 31
Ella.......................................... 49
Eplerenone............................... 39
Duexis....................................... 8
Ellence..................................... 24
Epogen.................................... 34
Dulera...................................... 57
Elmiron................................... 45
Eprosartan Mesylate................ 35
Duoneb.................................... 58 Elocon..................................... 45
Epzicom.................................. 29
Duragesic................................... 9
Eloxatin................................... 24
Equetro.................................... 18
Duramorph................................ 9
Elspar...................................... 24
Eraxis...................................... 21
Durezol................................... 55
Emadine.................................. 55
Erbitux.................................... 26
Dyazide................................... 39 Emcyt...................................... 23
Ergoloid Mesylates.................. 18
Dynacin................................... 17
Emend..................................... 21
Dynacirc CR........................... 37
Emla........................................ 12
Ergotamine Tartrate/
Caffeine................................ 22
Dyrenium................................ 39 Emoquette............................... 48
Erivedge.................................. 24
Emsam.................................... 19
Errin........................................ 49
EC-Naprosyn............................ 8 Emtriva.................................... 29
Econazole Nitrate.................... 21 Enablex.................................... 44
Ery........................................... 15
Edarbi...................................... 35 Enalapril Maleate.................... 35

Edarbyclor............................... 35 Enalapril Maleate/
Edecrin.................................... 38
Enbrel...................................... 51
Edluar...................................... 59
Endocet................................... 10
Edurant................................... 28
Endodan.................................. 10
E.E.S. 400............................... 15
Endometrin............................. 49
E.E.S. Granules...................... 15
Engerix-B................................ 53
Effexor XR.............................. 19
Enjuvia.................................... 48
Effient..................................... 34
Enoxaparin Sodium................. 33
Efudex..................................... 41
Enpresse.................................. 48
Egrifta..................................... 47
Entocort EC............................ 53
Elaprase................................... 42
Enulose.................................... 43
Eldepryl................................... 27
Epiduo..................................... 41
Elestat...................................... 55
Epinastine HCl....................... 55
Elestrin.................................... 48
Epinephrine HCl..................... 58
Elidel....................................... 41
Epipen..................................... 58
Eligard..................................... 50
Epirubicin HCl....................... 24
Eliphos.................................... 60
Epitol....................................... 18
Elitek....................................... 24
Epivir....................................... 29
69
Ertaczo.................................... 21
Eryped..................................... 15
Ery-Tab................................... 15
Erythrocin Lactobionate......... 16
Erythrocin Stearate................. 16
Erythromycin.......................... 16
Erythromycin Base.................. 16
Erythromycin/
Benzoyl Peroxide.................. 41
Erythromycin Ethylsuccinate....16
Escitalopram Oxalate.............. 19
Estazolam................................ 30
Estrace..................................... 48
Estradiol.................................. 48
Estradiol/Norethindrone
Acetate.................................. 48
Estradiol Valerate.................... 48
Estring..................................... 48
Estropipate.............................. 48
Estrostep Fe............................. 48
Ethambutol HCl..................... 23
Ethosuximide.......................... 17
Felbatol.................................... 18 Flovent Diskus......................... 57
Ethyol...................................... 24
Feldene...................................... 8 Flovent HFA........................... 57
Etidronate Disodium............... 54
Felodipine ER......................... 38 Fluconazole............................. 21
Etodolac.................................... 8
Femara..................................... 25 Fluconazole in Dextrose.......... 21
Etodolac ER.............................. 8
Femcon Fe............................... 48 Flucytosine.............................. 21
Etopophos............................... 25
Femhrt 1/5.............................. 48 Fludarabine Phosphate............ 25
Etoposide................................. 25
Femhrt Low Dose................... 48
Fludrocortisone Acetate.......... 45
Eurax....................................... 26
Femring................................... 48
Flunisolide............................... 57
Evamist.................................... 48
Femtrace.................................. 48
Fluocinolone Acetonide..... 46, 57
Evista....................................... 50 Fenofibrate............................... 39 Fluocinolone Acetonide

Body Oil............................... 46
Evoclin.................................... 41 Fenofibrate Micronized........... 39
Evoxac..................................... 41 Fenoglide................................. 39 Fluocinonide............................ 46

Exalgo....................................... 9 Fenoprofen Calcium.................. 8 Fluocinonide-E........................ 46
Exelderm................................. 21
Exelon..................................... 19
Exemestane............................. 25
Exforge.................................... 37
Exforge HCT.......................... 37
Exjade...................................... 60
Extavia.................................... 52
Extina...................................... 21
F
Fabrazyme............................... 42
Factive..................................... 16
Famciclovir.............................. 30
Famotidine.............................. 43
Famotidine Premixed.............. 43
Famvir..................................... 30
Fanapt...................................... 27
Fanapt Titration Pack.............. 27
Fareston................................... 23
Faslodex................................... 23
Fazaclo..................................... 28
Felbamate................................ 18
Fentanyl..................................... 9
Fluoroplex................................ 42
Fluorouracil....................... 24, 42
Fentanyl Citrate
Oral Transmucosal............... 10 Fluoxetine DR......................... 19
Fentora..................................... 10 Fluoxetine HCl........................ 19
Ferriprox.................................. 54
Fluphenazine Decanoate......... 27
Fexmid..................................... 60
Fluphenazine HCl................... 27
Fibricor.................................... 39 Flurazepam HCl..................... 59

Finacea.................................... 42
Flurbiprofen............................... 8
Finasteride............................... 44
Flurbiprofen Sodium............... 55
Fioricet/Codeine...................... 41
Flutamide................................ 51
Fiorinal/Codeine..................... 10
Fluticasone Propionate...... 46, 57
Firazyr..................................... 54
Fluvastatin............................... 39
Firmagon................................. 50
Fluvoxamine Maleate.............. 19
Flagyl....................................... 13
FML........................................ 55
Flagyl ER................................ 13
FML Forte.............................. 55
Flarex...................................... 55
FML Liquifilm....................... 55
Flavoxate HCl......................... 44
Focalin..................................... 40
Flecainide Acetate................... 36
Focalin XR.............................. 40
Flector....................................... 8
Folotyn.................................... 24
Flomax.................................... 44
Fomepizole.............................. 54
Flonase.................................... 57
Fondaparinux Sodium............. 33
Flo-Pred.................................. 45
Foradil Aerolizer..................... 58
70
Fortamet.................................. 31 Gavilyte-G.............................. 43 Glyset...................................... 31

Fortaz...................................... 14 Gavilyte-N/Flavor Pack.......... 43 Golytely................................... 43
Forteo...................................... 54 Gelnique.................................. 44 Gralise....................................... 8
Fortesta.................................... 47 Gemcitabine HCl.................... 24 Gralise Starter........................... 8
Fortical.................................... 54 Gemfibrozil............................. 39 Granisetron HCl..................... 21
Fosamax................................... 54 Gemzar.................................... 24
Granisol................................... 21
Fosamax Plus D....................... 54 Gengraf................................... 51
Griseofulvin Microsize............ 21
Foscarnet Sodium.................... 28 Genotropin.............................. 47 Gris-Peg.................................. 21

Fosinopril Sodium................... 35 Genotropin Miniquick............ 47 Guanfacine HCl...................... 35
Fosinopril Sodium/
Gentak..................................... 12
Gentamicin Sulfate.................. 12
Fosphenytoin Sodium.............. 18
Gentamicin Sulfate/NaCl....... 12
Fosrenol................................... 45
Geodon.................................... 27
Fragmin................................... 33
Gianvi...................................... 48
Freamine III............................ 61
Gilenya.................................... 41
Freamine III 3%...................... 61
Glassia..................................... 59
Frova........................................ 22
Gleevec.................................... 25
Furadantin............................... 13
Glimepiride............................. 31
Furosemide.............................. 38
Glipizide.................................. 31
Fusilev..................................... 25
Glipizide ER........................... 31
Fuzeon..................................... 29
Glipizide/Metformin HCl...... 31
H
Halaven................................... 25
Halcion.................................... 59
Haldol..................................... 27
Haldol Decanoate.................... 27
Halflytely Bowel Prep/
Flavor Packs......................... 43
Halobetasol Propionate............ 46
Halog....................................... 46
Haloperidol............................. 27
Haloperidol Decanoate............ 27
Haloperidol Lactate................. 27
Glucagen Hypokit................... 32
Havrix..................................... 53
Gabapentin.............................. 17 Glucagon Emergency Kit........ 32

Gabitril.................................... 17 Glucophage.............................. 31
Hectorol................................... 54
Gablofen.................................. 28 Glucophage XR....................... 31

Galantamine Hydrobromide....19 Glucotrol................................. 31
Heparin Sodium...................... 33
Gammagard Liquid................. 52 Glucotrol XL........................... 31

Gammaplex............................. 52 Glucovance.............................. 31
Heparin Sodium/NaCl........... 33
Gamunex-C............................. 52 Glumetza................................. 31
Ganciclovir.............................. 28 Glyburide................................ 31
Helidac.................................... 43
Heparin Sodium/D5W........... 33
Heparin Sodium/
NaCl 0.9% Premix................ 33
Hepatamine............................. 61
Hepatasol................................. 61
Gardasil................................... 53 Glyburide/Metformin HCl..... 31

Gastrocrom.............................. 43 Glyburide Micronized............. 31
Hepsera................................... 29
Gauze Pads.............................. 54 Glycopyrrolate......................... 43

Gavilyte-C.............................. 43 Glynase.................................... 31
Hexalen................................... 23
71
Herceptin................................. 26
Hiprex..................................... 13
Hizentra.................................. 52
Imipenem/Cilastatin............... 15
IPOL....................................... 53
Horizant.................................. 17
Imipramine HCl...................... 20
Ipratropium Bromide............... 58
Humalog................................. 33
Imipramine Pamoate............... 20 Ipratropium Bromide/

Albuterol Sulfate................... 58
Imiquimod............................... 42
Humalog Kwikpen.................. 33
Ibandronate Sodium................ 54
Imitrex..................................... 22 Irbesartan................................ 35
Imitrex Statdose Refill............. 22 Irbesartan/
Imuran..................................... 51
Irinotecan................................ 25
Incivek..................................... 29
Isentress................................... 29
Increlex.................................... 47
Isolyte-H/Dextrose 5%........... 61
Indapamide.............................. 39
Isolyte-M/Dextrose 5%........... 61
Inderal LA............................... 37
Isolyte-P/Dextrose 5%............. 61
Indocin...................................... 8
Isolyte-S.................................. 61
Indomethacin............................ 8
Isolyte-S/Dextrose 5%............. 61
Indomethacin ER...................... 8
Isoniazid.................................. 23
Infanrix................................... 53
Isopto Carpine......................... 56
Infergen................................... 29
Isordil Titradose...................... 40
Inlyta....................................... 25
Isosorbide Dinitrate................. 40
Innopran XL........................... 37
Isosorbide Dinitrate ER.......... 40
Inspra....................................... 39
Isosorbide Mononitrate............ 40
Insulin Syringes, Needles........ 54
Isosorbide Mononitrate ER..... 40
Intelence.................................. 28
Isotonic Gentamicin................ 12
Intermezzo.............................. 59
Isradipine................................. 38
Intralipid................................. 54
Istalol....................................... 56
Intron-A.................................. 30
Istodax..................................... 25
Intron-A W/Diluent................ 30
Itraconazole............................. 21
Introvale.................................. 48
Ixempra Kit............................. 25
Intuniv..................................... 40
Ixiaro....................................... 53
Invanz...................................... 15
Ibuprofen................................... 8
Invega...................................... 27
Idamycin PFS.......................... 25
Invega Sustenna....................... 27
Idarubicin HCl........................ 25
Invirase.................................... 29
Ifex.......................................... 23
Ionosol-B/Dextrose 5%........... 32
Ifosfamide................................ 23
Ionosol-MB/Dextrose 5%....... 32
Ilaris........................................ 52
Iopidine................................... 56
Humatrope.............................. 47
Humira.................................... 51
Humira Starter Kit.................. 51
Humulin.................................. 33
Humulin Pen........................... 33
Hycamtin................................. 25
Hycet....................................... 10
Hydralazine HCl..................... 40
Hydrea..................................... 24
Hydrochlorothiazide................ 39
Hydrocodone/
Acetaminophen.................... 11
Hydrocodone/Ibuprofen.......... 11
Hydrocortisone.................. 46, 53
Hydrocortisone/Acetic Acid.... 57
Hydrocortisone Valerate.......... 46
Hydromorphone HCl.............. 11
Hydroxychloroquine Sulfate.... 26
Hydroxyurea............................ 24
Hydroxyzine HCl.................... 57
Hydroxyzine Pamoate............. 57
Hyzaar..................................... 35
72
Jakafi........................................ 25
Jalyn......................................... 44
Jantoven................................... 33
Janumet................................... 31
Janumet XR............................. 31
Januvia..................................... 31
Jentadueto................................ 31
Kineret..................................... 51
Latanoprost............................. 56
Jevtana..................................... 25
Kionex..................................... 60
Latuda..................................... 27
Jinteli....................................... 48
Klaron..................................... 42
Lazanda................................... 11
Jolivette.................................... 49
Klonopin.................................. 17
Leena....................................... 48
Junel......................................... 48
Klor-Con 8.............................. 61
Leflunomide............................ 52
Junel Fe.................................... 48
Klor-Con 10............................ 61
Lescol...................................... 39
Juvisync.................................... 31
Klor-Con M15........................ 61
Lescol XL................................ 39
Klor-Con M20........................ 61
Lessina..................................... 48
Kadian....................................... 9
Kombiglyze XR....................... 31
Letairis.................................... 59
Kaletra..................................... 29
K-Tabs..................................... 61
Letrozole................................. 25
Kalydeco.................................. 59
Kuvan...................................... 42
Leucovorin Calcium................ 25
Kanamycin Sulfate.................. 12
Leukeran................................. 23
Kapvay..................................... 40
Labetalol HCl......................... 37
Leukine................................... 34
Kariva...................................... 48
LAC-Hydrin........................... 42
Leuprolide Acetate.................. 51
Kayexalate............................... 60
Laclotion................................. 42
Levalbuterol............................. 58
KCl 0.3%/D5W/NaCl 0.9%.... 32 Lactated Ringers..................... 61
Levaquin.................................. 16
KCl 0.3%/D5W/NaCl 0.45%....32 Lactated Ringers Irrigation..... 54
Levatol..................................... 37
KCl 0.15%/D5W/LR.............. 32 Lactulose................................. 43
Levemir................................... 33
KCl 0.15%/D5W/NaCl 0.2%....32 Lamictal.................................. 18
Levemir Flexpen..................... 33
KCl 0.15%/D5W/NaCl 0.9%.... 32 Lamictal Chewable

Dispersible............................ 18
KCl 0.15%/D5W/
Levetiracetam.......................... 17
Levetiracetam ER.................... 17
NaCl 0.225%........................ 32 Lamictal ODT........................ 18
Levobunolol HCl..................... 56
KCl 0.075%/D5W/
Lamictal Starter Kit................ 18
NaCl 0.45%.......................... 32
Lamictal XR............................ 18
Keflex...................................... 14
Lamisil.................................... 22
Kelnor...................................... 48
Lamivudine............................. 29
Kenalog................................... 46
Lamivudine/Zidovudine......... 29
Kepivance................................ 41
Lamotrigine............................. 18
Keppra..................................... 17
Lanoxin................................... 38
Keppra XR.............................. 17
Lansoprazole........................... 44
Ketek....................................... 16
Lantus..................................... 33
Ketoconazole........................... 22
Lantus Solostar........................ 33
Ketoprofen................................. 8
Lasix........................................ 38
Ketoprofen ER.......................... 8
Lastacaft.................................. 55
Ketorolac Tromethamine....8, 9, 55
Levocarnitine.......................... 54
73
Levocetirizine
Dihydrochloride................... 57
Levofloxacin............................ 16
Levofloxacin in D5W.............. 16
Levora...................................... 48
Levorphanol Tartrate................. 9
Levothroid............................... 50
Levothyroxine Sodium............ 50
Levoxyl.................................... 50
Lexapro................................... 19
Lexiva...................................... 29
Lialda...................................... 53
Lidocaine................................. 12
Loprox Shampoo..................... 22
Lidocaine HCl......................... 12
Lorazepam.............................. 30
Macrobid................................. 13
Lidocaine/Prilocaine............... 12
Lorazepam Intensol................. 30
Macrodantin............................ 13
Lidocaine Viscous.................... 12
Lorcet...................................... 11
Magnacet................................. 11
Lidoderm................................. 12
Lortab...................................... 11
Magnesium Sulfate.................. 61
Lincocin.................................. 13
Losartan Potassium................. 35
Malarone................................. 26
Lindane................................... 26
Losartan Potassium/
Malathion................................ 26
Hydrochlorothiazide.
.
...........
35
Lioresal Intrathecal.................. 28
Maprotiline HCl..................... 19
LoSeasonique..........................
48
Liothyronine Sodium.............. 50
Marinol................................... 21
Lotemax..................................
55
Lipitor...................................... 39
Marlissa................................... 49
Lotensin..................................
35
Lipofen.................................... 39
Marplan................................... 19
Lotensin
HCT........................
35
Liposyn III.............................. 54
Matulane................................. 23
Lotrel.
.
.....................................
38
Lisinopril................................. 35
Matzim LA............................. 38
Lotrisone.................................
22
Lisinopril/
Mavik...................................... 35
Hydrochlorothiazide............. 35 Lotronex.................................. 43
Maxair Autohaler.................... 58
Lithium Carbonate.................. 31 Lovastatin................................ 39
Maxalt..................................... 22
Lithium Carbonate ER........... 31 Lovaza..................................... 40
Maxalt-MLT........................... 23
Lithium Citrate....................... 31 Lovenox............................. 33, 34
Maxidex.................................. 55
Lithobid................................... 31 Low-Ogestrel.......................... 48
Maxidone................................ 11
Livalo...................................... 39 Loxapine Succinate.................. 27
Maxitrol.................................. 55
Locoid..................................... 46 Loxitane.................................. 27
Maxzide................................... 39
Locoid Lipocream................... 46 Lufyllin................................... 58
Meclizine HCl........................ 21
Lodosyn................................... 27 Lumigan.................................. 56
Meclofenamate Sodium............. 9
Loestrin Fe.............................. 48 Lumizyme............................... 42
Medrol..................................... 46
Lofibra..................................... 39 Lunesta.................................... 59
Medrol Dosepak...................... 46
Lokara..................................... 46 Lupron Depot.......................... 51
Medroxyprogesterone
Lo Loestrin Fe........................ 48 Lupron Depot-PED................ 51
Acetate.................................. 49
Lomotil................................... 43 Lutera...................................... 49 Mefenamic Acid........................ 9
Lo/Ovral................................. 48
Loperamide HCl..................... 43
Luvox CR................................ 19 Mefloquine HCl...................... 26

Luxiq....................................... 46 Megace ES.............................. 49
Lopid....................................... 39 Lybrel...................................... 49 Megace Oral............................ 49

Lopressor................................. 37 Lyrica...................................... 17 Megestrol Acetate.................... 49
Lopressor HCT....................... 37
Lysodren.................................. 50 Meloxicam................................. 9
Loprox..................................... 22
Melphalan HCl....................... 23
74
Menactra................................. 53
Methyclothiazide..................... 39
Miconazole 3........................... 22
Menest..................................... 25
Methyldopa............................. 35
Microgestin............................. 49
Menomune-A/C/Y/W-135..... 53
Methyldopa/
Microgestin Fe........................ 49
Menostar................................. 49
Mentax.................................... 22
Menveo.................................... 53
Meperidine HCl...................... 11
Meprobamate.......................... 30
Mepron.................................... 26
Mercaptopurine....................... 24
Meropenem............................. 15
Methyldopate HCl.................. 35
Methylergonovine Maleate...... 54
Methylin.................................. 40
Methylphenidate HCl............. 40
Methylphenidate HCl ER....... 41
Methylprednisolone................. 46
Methylprednisolone Acetate.... 46
Microzide................................ 39
Midodrine HCl....................... 35
Migergot.................................. 22
Migranal.................................. 22
Millipred........................... 46, 53
Minipress................................. 35
Minitran.................................. 40
Minocin................................... 17
Methylprednisolone
Dose Pack............................. 46
Minocycline HCl.................... 17
Mesna...................................... 25
Methylprednisolone Sodium
Succinate.............................. 46
Minoxidil................................ 40
Mesnex.................................... 25
Metipranolol............................ 56
Mirapex................................... 27
Mestinon................................. 23
Metoclopramide HCl.............. 43
Mirapex ER............................. 27
Mestinon Timespan................ 23
Metolazone.............................. 39 Mirtazapine............................. 19
Metadate CD.......................... 40
Mirtazapine ODT................... 19
Metadate ER........................... 40
Metoprolol/
Metaproterenol Sulfate............ 58
Metoprolol Succinate ER........ 37
Mitomycin............................... 25
Metformin HCl....................... 31
Metoprolol Tartrate................. 37
Mitoxantrone HCl................... 25
Metformin HCl ER................ 31
Metozolv ODT....................... 43
M-M-R II............................... 53
Methadone HCl........................ 9
MetroCream............................ 13
Mobic........................................ 9
Methadose................................. 9
MetroGel................................. 13
Modicon.................................. 49
Methamphetamine HCl.......... 40
MetroGel-Vaginal................... 13
Moexipril HCl......................... 35
Methazolamide........................ 56
Metrolotion............................. 13
Methenamine Hippurate......... 13
Metronidazole......................... 13
Moexipril/
Methergine.............................. 54
Metronidazole in
NaCl 0.79%.......................... 13
Mometasone Furoate............... 46
Metronidazole Vaginal............ 13
Monoket.................................. 40
Merrem................................... 15
Mesalamine............................. 53
Methimazole........................... 51
Methitest................................. 47
Methocarbamol....................... 60
Methotrexate........................... 51
Methotrexate Sodium.............. 52
Methscopolamine Bromide..... 43
Minocycline HCl ER.............. 17
Misoprostol.............................. 44
Monodox................................. 17
Mevacor................................... 39 Mononessa............................... 49
Mexiletine HCl....................... 36 Monurol................................... 13
Miacalcin................................. 54
Morphine Sulfate...................... 9
Micardis.................................. 35
Morphine Sulfate ER................ 9
Micardis HCT........................ 35
Motofen................................... 43
75
MoviPrep................................. 43 Naproxen DR............................ 9
Next Choice............................ 50
Moxatag................................... 15 Naproxen Sodium...................... 9
Niacor...................................... 61
Moxeza.................................... 16 Naratriptan HCl...................... 23
Niaspan................................... 40
Mozobil................................... 34 Nardil...................................... 19
Nicardipine HCl...................... 38
MS Contin.............................. 10 Nasacort AQ............................ 57
Nicotrol Inhaler....................... 20
Multaq..................................... 36 Nasonex................................... 57
Nicotrol NS............................. 20
Mupirocin................................ 13 Natacyn................................... 22
Nifediac CC............................ 38
Mustargen............................... 23 Nateglinide.............................. 31
Nifedical XL........................... 38
Mycamine................................ 22 Nebupent................................. 26
Nifedipine................................ 38
Mycobutin............................... 23 Necon...................................... 49
Nifedipine ER......................... 38
Mycophenolate Mofetil........... 52 Nefazodone HCl..................... 19
Nilandron................................ 51
Mydriacyl................................ 55 Neomycin/Bacitracin/
Polymyxin............................. 13
Myfortic.................................. 52
Nimodipine............................. 38
Nipent..................................... 24
Neomycin/Polymyxin/
Myozyme................................. 42
Niravam................................... 30
Bacitracin/Hydrocortisone....55
Mysoline.................................. 17
Nisoldipine.............................. 38
Neomycin/Polymyxin B
Mytelase.................................. 23
Sulfates................................. 12 Nisoldipine ER........................ 38
N
Nabumetone.............................. 9
Nadolol.................................... 37
Nadolol/
Bendroflumethiazide............ 37
Nafcillin Sodium..................... 15
Naftin...................................... 22
Naglazyme............................... 42
Nalbuphine HCl...................... 11
Nalfon....................................... 9
Nallpen/Dextrose.................... 15
Naloxone HCl......................... 20
Naltrexone HCl....................... 20
Namenda................................. 19
Namenda Titration Pak........... 19
Naprelan.............................. 9, 12
Naprosyn................................... 9
Naproxen................................... 9
Nitro-Bid................................. 40
Neomycin/Polymyxin/
Dexamethasone.................... 55 Nitrofurantoin......................... 13
Neomycin/Polymyxin/
Nitrofurantoin
Gramicidin........................... 13
Macrocrystalline................... 13
Neomycin/Polymyxin/
Nitrofurantoin Monohydrate....13
Hydrocortisone................55, 57
Nitroglycerin........................... 40
Neomycin Sulfate.................... 12
Nitrolingual Pumpspray.......... 40
Neoral...................................... 52
Nitromist................................. 40
Neosporin................................ 13
Nitrostat.................................. 40
Nephramine............................. 61
Nizatidine................................ 43
Neulasta................................... 34
Nizoral..................................... 22
Neumega................................. 34
Nora-BE.................................. 50
Neupogen................................ 34
Norco....................................... 11
Neurontin................................ 17
Nordette.................................. 49
Nevanac................................... 55
Norditropin Flexpro................ 47
Nevirapine............................... 29
Norditropin Nordiflex Pen...... 47
Nexavar................................... 25
Norethindrone Acetate............ 50
Nexium.................................... 44
Norinyl.................................... 49
Nexium I.V.............................. 44
Normosol-M in D5W............. 61
76
Normosol-R............................. 61
Ogestrel................................... 49 Ortho-Cyclen.......................... 49
Normosol-R in D5W.............. 32 Olanzapine.............................. 27 Ortho Evra.............................. 49

Noroxin................................... 16
Olanzapine ODT.................... 27 Ortho Micronor...................... 50
Norpace................................... 36
Oleptro.................................... 19 Ortho-Novum 7/7/7................ 49
Norpace CR............................. 36
Olux-E..................................... 46 Ortho Tri-Cyclen.................... 49
Norpramin............................... 20
Omeprazole............................. 44 Ortho Tri-Cyclen Lo.............. 49
Nor-QD.................................. 50 Omeprazole/Sodium
OsmoPrep................................ 43
Bicarbonate.
.
.........................
44
Nortrel..................................... 49
Ovcon-35................................. 49
Omnaris..................................
57
Nortriptyline HCl................... 20
Ovcon-50 28............................ 49
Omnipred................................
55
Norvasc.................................... 38
Ovide....................................... 26
Omnitrope.
.
.............................
47
Norvir...................................... 29
Oxacillin Sodium.................... 15
Ondansetron
HCl...................
21
Novolin.................................... 33
Oxaliplatin.............................. 25
Ondansetron
ODT.
.
................
21
Novolog................................... 33
Oxandrolone............................ 47
Onfi.........................................
17
Novolog Flexpen..................... 33
Oxaprozin.................................. 9
Onglyza...................................
31
Noxafil..................................... 22
Oxazepam............................... 31
Onsolis....................................
11
Nucynta................................... 11
Oxcarbazepine......................... 18
Ontak......................................
25
Nucynta ER............................. 10
Oxecta..................................... 11
Opana.
.
....................................
11
Nuedexta................................. 41
Oxistat..................................... 22
Opana
ER...............................
10
Nulojix..................................... 52
Oxsoralen................................ 42
Optipranolol............................
56
Nulytely/Flavor Packs............. 44
Oxsoralen Ultra....................... 42
Optivar....................................
55
Nutropin.................................. 47
Oxybutynin Chloride.............. 44
Oracea.....................................
17
Nutropin AQ........................... 47
Oxybutynin Chloride ER........ 44
Orap........................................
27
Nuvaring................................. 49
Oxycodone/Acetaminophen.... 11
Orapred...................................
46
Nuvigil.................................... 59
Oxycodone/Aspirin................. 11
Orapred
ODT.........................
46
Nyamyc.................................... 22
Oxycodone HCl...................... 11
Orencia.
.
..................................
52
Nystatin................................... 22
Oxycodone/Ibuprofen............... 9
Orfadin.
.
..................................
42
Nystatin/Triamcinolone.......... 22
Oxycontin................................ 10
Orphenadrine/Aspirin/
Nystop..................................... 22
Oxymorphone HCl................. 11
Caffeine................................ 60
Oxymorphone HCl ER........... 10
O
Orphenadrine Citrate.............. 60
Ocella...................................... 49 Orphenadrine Citrate ER........ 60 Oxytrol.................................... 44
Octreotide Acetate.................. 51 Orphenadrine
Compound DS..................... 60
Ocufen..................................... 55
Ocuflox.................................... 16 Orsythia.................................. 49
Paclitaxel................................. 25
Ofloxacin................................. 16 Ortho-Cept............................. 49
Palgic....................................... 57
77
Pacerone.................................. 36
Pamelor................................... 20
Pennsaid.................................. 42 Pilocarpine HCl...................... 41
Pamidronate Disodium........... 54
Pentam 300............................. 26 Pilopine HS............................. 56
Pamine.................................... 43
Pentasa..................................... 53 Pindolol................................... 37
Pamine Forte........................... 43
Pancreaze................................. 42
Pentazocine/Acetaminophen....11 Piperacillin Sodium/

Tazobactam Sodium............. 15
Pentazocine/Naloxone HCl..... 11
Pandel...................................... 46
Pentostatin............................... 24
Panretin................................... 26
Pentoxifylline ER.................... 38
Pantoprazole Sodium............... 44
Pepcid...................................... 43
Parafon Forte DSC.................. 60
Percocet................................... 11
Parcopa.................................... 27
Percodan.................................. 11
Plavix....................................... 34
Permethrin.............................. 26
Polymyxin B Sulfate................ 13
Piroxicam.................................. 9
Plaquenil.................................. 26
Plasma-Lyte............................. 61
Plasma-Lyte/D5W.................. 61
Perforomist.............................. 58 Pletal....................................... 34
Parnate.................................... 19 Perindopril Erbumine.............. 36 Podofilox................................. 42
Paromomycin Sulfate............... 12 Periogard................................. 41 Polyethylene Glycol 3350......... 44
Parlodel.................................... 27
Paroxetine HCl........................ 19
Paroxetine HCl ER................. 19 Perphenazine........................... 27

Paser........................................ 23 Perphenazine/Amitriptyline.... 20
Pataday.................................... 55
Persantine................................ 34
Patanase................................... 57
Pexeva...................................... 19
Patanol..................................... 55
Pfizerpen-G............................ 15
Paxil........................................ 19
Phenadoz................................. 57
Paxil CR.................................. 19
Phenelzine Sulfate................... 19
PCE......................................... 16
Phenergan................................ 57
Pedi-Dri.................................. 22
Phenobarbital.......................... 17
Pedvax HIB............................. 53
Phenytek.................................. 18
Peganone................................. 18
Phenytoin................................ 18
Pegasys.................................... 30
Phenytoin Sodium................... 18
Pegasys Proclick...................... 30
Phenytoin Sodium Extended....18
Peg-Intron............................... 30
Phisohex.................................. 13
Peg-Intron Redipen................. 30
Phoslo...................................... 61
Penicillin G Potassium............ 15 Phoslyra................................... 61

Phospholine Iodide.................. 56
Penicillin G Potassium in
Iso-Osmotic Dextrose.......... 15 Physiolyte................................ 54
Penicillin G Procaine.............. 15 Physiosol Irrigation................. 54
Penicillin G Sodium................ 15 Picato....................................... 25
Penicillin V Potassium............. 15
78
Polytrim................................... 13
Ponstel....................................... 9
Portia....................................... 49
Potassium Chloride................. 61
D5W/Viaflex........................ 61
NaCl 0.9%............................ 61
D5W/NaCl 0.33%............... 32
D5W/NaCl 0.45% Viaflex... 32
NaCl 0.9%............................ 61
NaCl 0.45% Viaflex.............. 61
D5W/NaCl 0.45%................ 32
Dextrose 5% Viaflex............. 61
Potassium Chloride ER........... 61
Potiga...................................... 17
Pradaxa.................................... 34
Pramipexole Dihydrochloride....27
Primidone................................ 17
Propranolol HCl ER............... 37
Prandimet................................ 31
Primsol.................................... 13
Prandin.................................... 31
Prinivil..................................... 36
Propranolol/
Pravachol................................. 39 Prinzide................................... 36
Pravastatin Sodium................. 39 Pristiq...................................... 19
Propylthiouracil....................... 51
ProQuad.................................. 53
Privigen................................... 52
Proscar..................................... 44
Pred Forte................................ 55
Proair HFA............................. 58 Prosol....................................... 61

Probenecid............................... 22 Protonix................................... 44
Pred-G.................................... 55
Probenecid/Colchicine............ 22
Protopic................................... 42
Pred-G S.O.P.......................... 55
Procainamide HCl.................. 36
Pred Mild................................ 55
Procalamine............................. 61
Prednicarbate........................... 46
Procardia................................. 38
Prazosin HCl........................... 35
Precose..................................... 31
Prednisolone Acetate............... 55 Procardia XL........................... 38

Prednisolone Sodium
Prochlorperazine..................... 27
Phosphate....................... 46, 56
Prochlorperazine Edisylate...... 27
Prednisone............................... 46
Prochlorperazine Maleate........ 27
Prednisone Intensol................. 46
Procrit...................................... 34
Prefest...................................... 49
Proctocream HC..................... 46
Pregnyl W/Diluent Benzyl
Progesterone............................ 50
Alcohol/NaCl....................... 47
Proglycem................................ 32
Premarin.................................. 49
Prograf..................................... 52
Premasol.................................. 61
Prolastin-C.............................. 59
Premphase............................... 49
Proleukin................................. 25
Prempro................................... 49
Prolia....................................... 54
Prenatal Vitamins.................... 61
Promacta.................................. 34
Prevacid................................... 44
Promethazine HCl.................. 57
Prevacid Solutab...................... 44
Promethazine VC.................... 57
Prevalite................................... 40
Promethegan........................... 57
Previfem.................................. 49
Prometrium............................. 50
Prevpac.................................... 13
Propafenone HCl.................... 36
Prezista.................................... 29
Propafenone HCl ER.............. 36
Priftin...................................... 23
Propantheline Bromide............ 43
Prilosec.................................... 44
Proparacaine HCl.................... 55
Primaquine Phosphate............. 26
Propranolol HCl...................... 37
Primaxin.................................. 15
79
Protriptyline HCl.................... 20
Proventil HFA......................... 58
Provera..................................... 50
Provigil.................................... 59
Prozac...................................... 19
Prozac Weekly......................... 19
Pulmicort................................. 57
Pulmicort Flexhaler................. 57
Pulmozyme............................. 59
Purinethol................................ 24
Pylera....................................... 43
Pyridostigmine Bromide......... 23
Q
Qnasl....................................... 57
Qualaquin................................ 26
Quasense................................. 49
Questran.................................. 40
Quetiapine Fumarate............... 27
Quinapril HCl......................... 36
Quinapril/
Quinidine Gluconate............... 36
Quinidine Gluconate ER........ 36
Quinidine Sulfate.................... 36
Quinidine Sulfate ER.............. 36
QVAR..................................... 57
Restoril.................................... 59
Robinul.................................... 43
Rabavert.................................. 53
Retin-A................................... 42
Robinul Forte.......................... 43
Ramipril.................................. 36
Retin-A Micro......................... 42
Rocaltrol.................................. 54
Ranexa..................................... 38
Retrovir................................... 29
Rocephin................................. 14
Ranitidine HCl....................... 43
Retrovir IV Infusion................ 29
Ropinirole ER......................... 27
Rapaflo.................................... 44
Revatio.................................... 59
Ropinirole HCl........................ 27
Rapamune............................... 52
Revia....................................... 20
RotaTeq................................... 53
Razadyne................................. 19
Revlimid.................................. 23
Roxicet..................................... 11
Razadyne ER........................... 19
Reyataz.................................... 29
Roxicodone.............................. 11
Rebetol.................................... 30
Rheumatrex............................. 52
Rozerem.................................. 59
Rebif........................................ 52
Rhinocort Aqua....................... 57
Rythmol.................................. 36
Rebif Titration Pack................ 52
Ribapak................................... 30
Rythmol SR............................. 36
Reclast..................................... 54
Ribasphere............................... 30
Ryzolt...................................... 10
Reclipsen................................. 49
Ribavirin.................................. 30
Recombivax HB...................... 53
Ridaura.................................... 52 Sabril....................................... 17
Rifadin.................................... 23 Safyral..................................... 49
Rectiv...................................... 40
Reglan..................................... 43
Regonol................................... 23
Regranex.................................. 42
Relenza Diskhaler................... 29
Relistor.................................... 43
Relpax...................................... 23
Remeron.................................. 19
Remeron Soltab....................... 19
Remicade................................. 52
Remodulin............................... 59
Renagel.................................... 45
Renvela.................................... 45
Reprexain................................ 11
Requip..................................... 27
Requip XL............................... 27
Rescriptor................................ 29
Reserpine................................. 35
Restasis.................................... 55
Rifamate.................................. 23 Saizen...................................... 47
Rifampin................................. 23 Salagen.................................... 41
Rifater..................................... 23 Samsca..................................... 60
Rilutek..................................... 41 Sanctura.................................. 44
Rimantadine HCl.................... 29 Sanctura XR............................ 44
Ringers Injection..................... 61 Sancuso.................................... 21
Ringers Irrigation.................... 54 Sandimmune........................... 52
Riomet..................................... 31 Sandostatin.............................. 51
Risperdal................................. 27 Sandostatin LAR Depot......... 51
Risperdal Consta..................... 28 Santyl...................................... 42
Risperdal M-Tab..................... 28 Saphris..................................... 28
Risperidone............................. 28 Sarafem................................... 19
Risperidone ODT................... 28 Savella..................................... 41
Ritalin..................................... 41 Savella Titration Pack.............. 41
Ritalin LA............................... 41 Seasonale................................. 49
Ritalin SR................................ 41 Seasonique............................... 49
Rituxan.................................... 26 Sectral...................................... 37
Rivastigmine Tartrate.............. 19 Selegiline HCl......................... 19
80
Selenium Sulfide...................... 42
Solu-Medrol............................ 46
Sucralfate................................. 44
Selzentry.................................. 29
Soma........................................ 60
Sular........................................ 38
Semprex-D.............................. 57
Somatuline Depot................... 51
Sulfacetamide Sodium....... 16, 42
Sensipar................................... 50
Somavert.................................. 51
Septra DS................................ 16
Sonata...................................... 59
Serevent Diskus....................... 58
Soriatane.................................. 42
Sulfacetamide Sodium/
Prednisolone Sodium
Phosphate............................. 56
Seromycin................................ 23
Sorilux..................................... 42
Seroquel................................... 28
Sorine...................................... 36
Seroquel XR............................ 28
Sotalol HCl............................. 36
Serostim.................................. 47
Spectracef................................ 14
Sertraline HCl................... 19, 20
Spiriva Handihaler.................. 58 Sulfamylon.............................. 13

Spironolactone......................... 39 Sulfasalazine............................ 53
sfRowasa................................. 53
Silenor..................................... 59
Silvadene................................. 13
Silver Sulfadiazine................... 13
Sulfadiazine............................. 16
Sulfamethoxazole/
Trimethoprim....................... 16
Sulfamethoxazole/
Trimethoprim DS................. 16
Sulfazine EC........................... 53
Spironolactone/
Hydrochlorothiazide............. 39 Sulindac..................................... 9
Sporanox.................................. 22 Sumatriptan Succinate............. 23
Simcor..................................... 39 Sporanox Pulsepak.................. 22

Simponi................................... 52 Sprintec................................... 49
Suprax...................................... 14
Simulect................................... 52
Sprix.......................................... 9
Surmontil................................ 20
Simvastatin.............................. 39 Sprycel..................................... 25
Sinemet.................................... 27 Sronyx..................................... 49
Sustiva..................................... 29
Sinemet CR............................. 27
SSD......................................... 13
Sylatron................................... 25
Singulair.................................. 58 Stagesic.................................... 11
Skelaxin................................... 60 Stalevo..................................... 27
Symbicort................................ 57
Symbyax.................................. 31
Skelid....................................... 54
Starlix...................................... 31
Symlinpen 60.......................... 31
Stavudine................................. 29
Symlinpen 120........................ 31
Sodium Chloride 0.9%............ 55 Stavzor..................................... 17

Stelara...................................... 42
Synagis.................................... 53
Sodium Chloride..................... 61
Viaflex.................................. 61 Sterile Water Irrigation........... 55
Sodium Fluoride...................... 60
Suprep Bowel Prep.................. 44
Sutent...................................... 25
Synalgos-DC........................... 11
Synarel..................................... 51
Sodium Lactate....................... 60
Stimate.................................... 47 Synera...................................... 12
Strattera................................... 41 Synercid................................... 13
Sodium Polystyrene Sulfonate.60
Streptomycin Sulfate............... 12
Sodium Sulfacetamide............. 16
Solaraze................................... 42
Striant...................................... 47 Syprine.................................... 60
Stromectol............................... 26
Solodyn.................................... 17
Suboxone................................. 20
Solu-Cortef.............................. 46
Sucraid..................................... 42
81
Synthroid................................. 50
Testim...................................... 47 Tobrex...................................... 12
Tabloid..................................... 24
Testosterone Cypionate............ 47 Tofranil.................................... 20
Taclonex.................................. 42
Testosterone Enanthate........... 47 Tofranil-PM............................ 20
Taclonex Scalp......................... 42
Testred..................................... 47 Tolazamide.............................. 31
Tacrolimus............................... 52
Tolbutamide............................ 31
Tetanus/Diphtheria
Toxoids-Adsorbed Adult...... 53 Tolmetin Sodium...................... 9
Tetracycline HCl..................... 17 Topamax.................................. 18
Talwin..................................... 11
Tamiflu.................................... 29
Tamoxifen Citrate................... 23
Tamsulosin HCl...................... 44
Tapazole.................................. 51
Tarceva.................................... 25
Targretin.................................. 26
Tarka....................................... 36
Tasigna.................................... 25
Tasmar..................................... 26
Taxotere................................... 25
Tazorac.................................... 42
Taztia XT................................ 38
Teflaro..................................... 14
Tegretol................................... 18
Tegretol-XR............................. 18
Tekamlo................................... 38
Tekturna.................................. 38
Tekturna HCT........................ 38
Temazepam............................. 59
Temovate................................. 46
Tenex....................................... 35
Tenoretic.................................. 37
Tenormin................................. 37
Terazol..................................... 22
Terazosin HCl......................... 45
Terbinafine HCl...................... 22
Terbutaline Sulfate............ 58, 59
Terconazole.............................. 22
Teveten.................................... 35 Topamax Sprinkle................... 18

Teveten HCT.......................... 35 Topicort................................... 46
Tev-Tropin............................... 47 Topiramate.............................. 18
Thalitone................................. 39 Toposar.................................... 25
Thalomid................................. 23 Topotecan HCl........................ 25

Theophylline ER..................... 58 Toprol XL................................ 37
Thermazene............................. 13 Torisel...................................... 52
Thioridazine HCl.................... 27 Torsemide................................ 38
Thiotepa.................................. 23 Toviaz...................................... 44
Thiothixene............................. 27 TPN Electrolytes.................... 61
Thymoglobulin........................ 52 Tracleer.................................... 59
Tiazac...................................... 38 Tradjenta................................. 32
Ticlopidine HCl...................... 34 Tramadol HCl......................... 11
Tigan....................................... 21 Tramadol HCl/
Tikosyn................................... 36
Acetaminophen.................... 11
Timentin................................. 15 Tramadol HCl ER................... 10

Timolol Maleate.................37, 56 Trandate.................................. 37
Timoptic Ocudose................... 56 Trandolapril............................. 36
Timoptic-XE........................... 56 Tranexamic Acid..................... 34
Tirosint.................................... 50 Tranxene T.............................. 17
Tizanidine HCl....................... 28 Tranylcypromine Sulfate......... 19
Tobi......................................... 12 Travasol................................... 61
Tobradex.................................. 56 Travatan Z............................... 56
Tobradex ST............................ 56 Trazodone HCl....................... 19
Tobramycin/Dexamethasone....56 Treanda................................... 23
Tobramycin Sulfate.................. 12 Trecator................................... 23
Tobramycin Sulfate/
Trelstar Depot......................... 51
Sodium Chloride.................. 12
Trelstar LA.............................. 51
82
Trelstar Mixject....................... 51
Trospium Chloride.................. 44
Trental..................................... 38
Trusopt.................................... 56 Vagifem................................... 49
Truvada................................... 29 Valacyclovir HCl..................... 30
Tretinoin............................ 26, 42
Tretin-X................................... 42
Trexall..................................... 52
Treximet.................................... 9
Triamcinolone Acetonide....46, 57
Triamcinolone in Orabase....... 41
Triamterene/
Triazolam................................ 59
Tribenzor................................. 38
Tricor....................................... 39
Triderm................................... 46
Trifluoperazine HCl................ 27
Trifluridine.............................. 30
Trihexyphenidyl HCl.............. 26
Tri-Legest Fe........................... 49
Trileptal................................... 18
Trilipix..................................... 39
Trilyte...................................... 44
Trimethobenzamide HCl........ 21
Twinject................................... 59 Valcyte..................................... 28
Twinrix.................................... 53 Valium..................................... 31
Twynsta................................... 38 Valproate Sodium ................... 17
Tygacil..................................... 13 Valproic Acid........................... 17
Tykerb...................................... 25 Valtrex..................................... 30
Tylenol/Codeine...................... 11 Valturna................................... 38
Tylox........................................ 11 Vancocin HCl.......................... 13
Typhim Vi............................... 53 Vancomycin HCl............... 13, 14
Tysabri..................................... 53 Vandazole................................ 14
Tyzeka..................................... 30 Vanos....................................... 47
Tyzine...................................... 59 Vaqta....................................... 53
Varivax..................................... 53
U-Cort.................................... 46
Vaseretic.................................. 36
Ulesfia...................................... 26
Vasotec..................................... 36
Uloric....................................... 22
Vectibix.................................... 26
Ultracet.................................... 11
Vectical.................................... 42
Ultram..................................... 11
Velcade.................................... 25
Ultram ER............................... 10 Velivet...................................... 49

Ultravate.................................. 46
Veltin....................................... 42
Unasyn..................................... 15
Trimethoprim Sulfate/
Polymyxin B Sulfate............. 13 Unasyn Bulk Pack................... 15
Trimipramine Maleate............ 20 Uniretic.................................... 36
Venlafaxine HCl...................... 20
Trinessa................................... 49 Unithroid................................. 50
Tri-Norinyl.............................. 49 Univasc.................................... 36
Ventolin HFA.......................... 59
Tri-Previfem............................ 49 Urecholine............................... 45
Trisenox................................... 25 Uroxatral.................................. 45
Verapamil HCl........................ 38
Tri-Sprintec............................. 49 Urso......................................... 43
Trivora..................................... 49 Ursodiol................................... 43
Verdeso.................................... 47
Veregen.................................... 42
Trizivir..................................... 29 Uvadex..................................... 42
Verelan..................................... 38
Trophamine............................. 61
Verelan PM............................. 38
Tropicamide............................. 55
Veripred 20.............................. 47
Trimethoprim.......................... 13
83
Venlafaxine HCl ER............... 20

Ventavis................................... 59
Veramyst.................................. 57
Verapamil HCl ER.................. 38
Vesicare.................................... 44
Voltaren............................. 42, 56
Vestura..................................... 49
Voltaren-XR.............................. 9
Yasmin..................................... 49
Vexol........................................ 56
Voriconazole............................ 22
Yaz........................................... 49
Vfend....................................... 22
Votrient.................................... 25
Yervoy...................................... 26
Vfend IV.................................. 22
Vpriv........................................ 42
YF-Vax.................................... 53
Vibativ..................................... 14
Vytorin.................................... 40
Vibramycin.............................. 17
Vyvanse................................... 40
Vicodin.................................... 11
Vicodin ES.............................. 11
Warfarin Sodium.................... 34
Vicodin HP............................. 11
Zamicet................................... 11
Welchol................................... 40
Vicoprofen............................... 11
Zanaflex................................... 28
Wellbutrin............................... 19
Zanosar.................................... 23
Zaleplon.................................. 59
Victoza.................................... 32 Wellbutrin SR......................... 19

Victrelis................................... 30 Wellbutrin XL......................... 19
Vidaza..................................... 25
Videx EC................................. 29
Videx Pediatric........................ 29
Vigamox.................................. 16
Viibryd.................................... 20
Vimovo.................................... 44
Vimpat..................................... 18
Vinblastine Sulfate.................. 25
Vincasar PFS........................... 25
Vincristine Sulfate................... 25
Vinorelbine Tartrate................ 25
Viracept................................... 29
Viramune................................. 29
Viramune XR.......................... 29
Viread...................................... 29
Viroptic................................... 30
Vistaril..................................... 58
Vistide..................................... 28
Vivactil.................................... 20
Vivelle-Dot.............................. 49
Zafirlukast............................... 58
Zantac..................................... 43
Zarontin.................................. 17
Westcort.................................. 47 Zavesca.................................... 42
Zazole...................................... 22
Xalatan.................................... 56
Zebeta..................................... 37
Xalkori.................................... 25
Zegerid.................................... 44
Xanax...................................... 31
Zelapar.................................... 19
Xanax XR................................ 31
Zelboraf................................... 25
Xarelto..................................... 34
Zemaira................................... 59
Xenazine.................................. 41 Zemplar................................... 54
Xeomin.................................... 55
Zenpep.................................... 42
Xerese...................................... 30
Zeosa....................................... 49
Xgeva....................................... 54
Zerit........................................ 29
Xifaxan.................................... 14
Zestoretic................................. 36
Xodol....................................... 11
Zestril...................................... 36
Xolair....................................... 59
Zetia........................................ 40
Xopenex................................... 59
Ziac......................................... 37
Xopenex HFA......................... 59
Ziagen..................................... 29
Xylocaine................................. 12
Ziana....................................... 42
Xyrem...................................... 59
Zidovudine.............................. 29
Xyzal........................................ 58 Zinacef.................................... 14
Dextrose............................... 14
Vivitrol.................................... 20
84
Zyflo........................................ 58
Diluent................................. 14
Zyflo CR................................. 58
Zinecard.................................. 25
Zylet........................................ 56
Zioptan.................................... 56
Zyloprim.................................. 22
Ziprasidone HCl...................... 28
Zymaxid.................................. 16
Zipsor........................................ 9
Zyprexa.................................... 28
Zirgan...................................... 28
Zyprexa Zydis.......................... 28
Zithromax............................... 16
Zytiga...................................... 25
Zithromax Tri-Pak.................. 16
Zyvox....................................... 14
Zithromax Z-Pak.................... 16
Zmax....................................... 16
Zocor....................................... 39
Zofran..................................... 21
Zofran ODT........................... 21
Zolinza.................................... 25
Zoloft...................................... 20
Zolpidem Tartrate................... 59
Zolpidem Tartrate ER............. 59
Zolpimist................................. 59
Zometa.................................... 54
Zomig...................................... 23
Zomig ZMT........................... 23
Zonalon................................... 42
Zonegran................................. 17
Zonisamide.............................. 17
Zorbtive................................... 47
Zortress................................... 52
Zostavax.................................. 53
Zosyn...................................... 15
Zovia....................................... 49
Zovirax.................................... 30
Zuplenz................................... 21
Zyban...................................... 20
Zyclara..................................... 42
Zydone.................................... 11
85
This complete formulary (drug list) is effective January 1, 2013.

It was updated August2012. Changes may have beenmade to this list after it wasprinted.
Call Customer Service for complete,

updatedinformation.
lease contact our Customer Service at the number located
P
on the back of your ID card.
This information is available for free in other languages. Please contact our Customer Service at the
number located on the back of your ID card.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January1, 2014.
Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare
Advantage organization with a Medicarecontract.
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UnitedHealthcare Group Medicare Advantage Plan

Complete list of drugs by category

Please read: This document contains information about thedrugs covered

About this complete drug list

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If you have questions, were here to help.

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2013 Complete drug list

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Drug tiers and drug payment stages

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Many common brand name drugs, called preferred brands, and

Non-preferred generic and non-preferred brand name drugs.

Unique and/or very highcost drugs.

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Covered drugs by category

Analgesics Drugs to Treat Pain,

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Oxycodone HCl (Capsule,

Gentamicin Sulfate (Cream,

Anesthetics Drugs for Numbing

Antibacterials Drugs to Treat

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Calcium Channel Modifying Agents

Anticonvulsants Drugs to Treat

Glutamate Reducing Agents Seizure

Antidementia Agents Drugs to Treat

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Monoamine Oxidase Inhibitors

Antidepressants Drugs to Treat

Antidotes, Deterrents, and Toxicologic

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Antiemetics Drugs to Treat Nausea

Antifungals Drugs to Treat Fungal

Antigout Agents Gout Drugs

Antimigraine Agents Drugs to Treat

Antigout Agents Drugs to Treat Gout

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Antineoplastics Drugs to Treat

Alkylating Agents Chemotherapy Agents

Antimyasthenic Agents Drugs to Treat

Antimycobacterials Drugs to Treat

Antimetabolites Chemotherapy Agents

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug

Monoclonal Antibodies Chemotherapy

Antiparasitics Drugs to Treat Parasitic

Antiparkinson Agents Drugs to Treat

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