EXCHANGES MOLINA TX - CaremarkPA - Prior Authorization QL - Special Quantity Limit may apply ST - Step Therapy 5 Age - Special Age Limit may apply Tier 0 = Preventative Services at

1PA - Prior Authorization QL - Special Quantity Limit may apply ST - Step TherapyAge - Special Age Limit may apply

Tier 0 = Preventative Services at $0 copayDME = Coinsurance may apply

EXCHANGES_MOLINA_TX

Drug Name Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAmphetamines

amphetamine cap 5mg er Tier 1 AGEamphetamine cap 10mg er Tier 1 AGEamphetamine cap 15mg er Tier 1 AGEamphetamine cap 20mg er Tier 1 AGEamphetamine cap 25mg er Tier 1 AGEamphetamine cap 30mg er Tier 1 AGEamphetamine tab 5mg Tier 1 AGEamphetamine tab 7.5mg Tier 1 AGEamphetamine tab 10mg Tier 1 AGEamphetamine tab 12.5mg Tier 1 AGEamphetamine tab 15mg Tier 1 AGEamphetamine tab 20mg Tier 1 AGEamphetamine tab 30mg Tier 1 AGEdextroamphet cap 5mg er Tier 1 AGEdextroamphet cap 10mg er Tier 1 AGEdextroamphet cap 15mg er Tier 1 AGEdextroamphet tab 5mg Tier 1 AGEdextroamphet tab 10mg Tier 1 AGEmethamphetam tab 5mg Tier 1 AGEVYVANSE CAP 20MG Tier 3 PA; AGEVYVANSE CAP 30MG Tier 3 PA; AGEVYVANSE CAP 40MG Tier 3 PA; AGEVYVANSE CAP 50MG Tier 3 PA; AGEVYVANSE CAP 60MG Tier 3 PA; AGEVYVANSE CAP 70MG Tier 3 PA; AGEzenzedi tab 5mg Tier 1 AGEzenzedi tab 10mg Tier 1 AGE

Attention-Deficit/Hyperactivity Disorder (ADHD) AgentsINTUNIV TAB 1MG Tier 3 PAINTUNIV TAB 2MG Tier 3 PAINTUNIV TAB 3MG Tier 3 PAINTUNIV TAB 4MG Tier 3 PASTRATTERA CAP 10MG Tier 2 AGESTRATTERA CAP 18MG Tier 2 AGESTRATTERA CAP 25MG Tier 2 AGESTRATTERA CAP 40MG Tier 2 AGESTRATTERA CAP 60MG Tier 2 AGESTRATTERA CAP 80MG Tier 2 AGE



Drug Name Drug Tier Requirements/LimitsSTRATTERA CAP 100MG Tier 2 AGE

Stimulants - Misc.DAYTRANA DIS 15MG/9HR Tier 3 PA; AGEdexmethylph tab 2.5mg Tier 1 AGEdexmethylph tab 5mg Tier 1 AGEdexmethylph tab 10mg Tier 1 AGEFOCALIN XR CAP 5MG Tier 3 PA; AGEFOCALIN XR CAP 10MG Tier 3 PA; AGEFOCALIN XR CAP 15MG Tier 3 PA; AGEFOCALIN XR CAP 20MG Tier 3 PA; AGEFOCALIN XR CAP 25MG Tier 3 PA; AGEFOCALIN XR CAP 30MG Tier 3 PA; AGEFOCALIN XR CAP 35MG Tier 3 PA; AGEFOCALIN XR CAP 40MG Tier 3 PA; AGEmetadate tab 20mg er Tier 1 AGEmethylin tab 5mg Tier 1 AGEmethylin tab 10mg Tier 1 AGEmethylin tab 10mg er Tier 1 AGEmethylin tab 20mg Tier 1 AGEmethylin tab 20mg er Tier 1 AGEmethylphenid cap 10mg Tier 1 AGEmethylphenid cap 20mg Tier 1 AGEmethylphenid cap 20mg er Tier 1 AGEmethylphenid cap 30mg Tier 1 AGEmethylphenid cap 30mg er Tier 1 AGEmethylphenid cap 40mg Tier 1 AGEmethylphenid cap 40mg er Tier 1 AGEmethylphenid cap 50mg Tier 1 AGEmethylphenid cap 60mg Tier 1 AGEmethylphenid tab 5mg Tier 1 AGEmethylphenid tab 10mg Tier 1 AGEmethylphenid tab 10mg er Tier 1 AGEmethylphenid tab 18mg er Tier 1 AGEmethylphenid tab 20mg Tier 1 AGEmethylphenid tab 20mg er Tier 1 AGEmethylphenid tab 20mg sr Tier 1 AGEmethylphenid tab 27mg er Tier 1 AGEmethylphenid tab 36mg er Tier 1 AGEmethylphenid tab 54mg er Tier 1 AGEmodafinil tab 100mg Tier 1 PAmodafinil tab 200mg Tier 1 PANUVIGIL TAB 50MG Tier 3 PANUVIGIL TAB 150MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsNUVIGIL TAB 250MG Tier 3 PARITALIN LA CAP 10MG Tier 3 PA; AGE

AMINOGLYCOSIDESAminoglycosides

neomycin tab 500mg Tier 1paromomycin cap 250mg Tier 1 PATOBI NEB 300/5ML Tier 4 PA

ANALGESICS - ANTI-INFLAMMATORYAnti-TNF-alpha - Monoclonoal Antibodies

HUMIRA KIT 20MG/0.4 Tier 4 PAHUMIRA KIT 40MG/0.8 Tier 4 PAHUMIRA PEN KIT 40MG/0.8 Tier 4 PAHUMIRA PEN KIT CROHNS Tier 4 PAHUMIRA PEN KIT PSORIASI Tier 4 PA

Antirheumatic AntimetabolitesRHEUMATREX TAB 2.5MG Tier 2

Gold CompoundsRIDAURA CAP 3MG Tier 3

Interleukin-1 BlockersARCALYST INJ 220MG Tier 4 PA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET INJ Tier 4 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)CELEBREX CAP 100MG Tier 2 PACELEBREX CAP 200MG Tier 2 PACELEBREX CAP 400MG Tier 2 PAdiclofenac tab 25mg dr Tier 1diclofenac tab 50mg dr Tier 1diclofenac tab 75mg dr Tier 1etodolac cap 200mg Tier 1etodolac cap 300mg Tier 1etodolac er tab 400mg Tier 1etodolac er tab 500mg Tier 1etodolac er tab 600mg Tier 1etodolac tab 400mg Tier 1etodolac tab 500mg Tier 1fenoprofen tab 600mg Tier 1flurbiprofen tab 50mg Tier 1flurbiprofen tab 100mg Tier 1ibuprofen tab 400mg Tier 1ibuprofen tab 600mg Tier 1ibuprofen tab 800mg Tier 1



Drug Name Drug Tier Requirements/Limitsindomethacin cap 25mg Tier 1indomethacin cap 50mg Tier 1indomethacin cap 75mg er Tier 1ketoprofen cap 200mg er Tier 1ketorolac tab 10mg Tier 1meclofen sod cap 50mg Tier 1meclofen sod cap 100mg Tier 1mefenam acid cap 250mg Tier 1meloxicam tab 7.5mg Tier 1meloxicam tab 15mg Tier 1nabumetone tab 500mg Tier 1nabumetone tab 750mg Tier 1naproxen sod tab 550mg Tier 1naproxen tab 375mg Tier 1naproxen tab 500mg Tier 1oxaprozin tab 600mg Tier 1piroxicam cap 10mg Tier 1piroxicam cap 20mg Tier 1sulindac tab 150mg Tier 1sulindac tab 200mg Tier 1tolmetin sod cap 400mg Tier 1tolmetin sod tab 200mg Tier 1tolmetin sod tab 600mg Tier 1

Pyrimidine Synthesis Inhibitorsleflunomide tab 10mg Tier 1leflunomide tab 20mg Tier 1

Selective Costimulation ModulatorsORENCIA INJ 250MG Tier 4 PA

Soluble Tumor Necrosis Factor Receptor AgentsENBREL INJ 25/0.5ML Tier 4 PAENBREL INJ 25MG Tier 4 PAENBREL INJ 50MG/ML Tier 4 PAENBREL SRCLK INJ 50MG/ML Tier 4 PA

ANALGESICS - NonNarcoticAnalgesic Combinations

alagesic cap Tier 1anolor 300 cap Tier 1bupap tab 50-650mg Tier 1but/apap/caf cap Tier 1but/apap/caf tab Tier 1but/asa/caff cap Tier 1but/asa/caff tab Tier 1



Drug Name Drug Tier Requirements/Limitsbutal/apap tab 50-325mg Tier 1butalbital tab cpd Tier 1capacet cap Tier 1cephadyn tab 50-650mg Tier 1margesic cap Tier 1marten-tab tab 50-325mg Tier 1PHRENILIN CAP FORTE Tier 2promacet tab 50-650mg Tier 1repan tab Tier 1

Salicylatesanacin tab 81mg ec Tier 0aspir-81 tab 81mg ec Tier 0aspir-low tab 81mg ec Tier 0aspirin adlt tab 81mg Tier 0aspirin chil chw 81mg Tier 0aspirin chld chw 81mg Tier 0aspirin chw 81mg Tier 0aspirin low chw 81mg Tier 0aspirin low tab 81mg ec Tier 0aspirin tab 5gr ec Tier 0aspirin tab 81mg Tier 0aspirin tab 81mg ec Tier 0aspirin tab 325mg Tier 0aspirin tab 325mg ec Tier 0aspirtab tab 324mg ec Tier 0bayer adv tab 325mg Tier 0bayer asa tab 325mg Tier 0bayer low chw 81mg Tier 0bayer low tab 81mg ec Tier 0child asa chw 81mg Tier 0child asa ls chw 81mg Tier 0cho mag tris liq 500/5ml Tier 1cho mag tris tab 500mg Tier 1cho mag tris tab 750mg Tier 1cho mag tris tab 1000mg Tier 1cvs aspirin tab 81mg ec Tier 0cvs aspirin tab 325mg Tier 0cvs aspirin tab 325mg ec Tier 0cvs chld asa chw 81mg Tier 0diflunisal tab 500mg Tier 1ecotrin low tab 81mg ec Tier 0ecpirin tab 325mg ec Tier 0eq aspirin tab 325mg Tier 0



Drug Name Drug Tier Requirements/Limitseq aspirin tab 325mg ec Tier 0eq child asa chw 81mg Tier 0eql aspirin tab 81mg ec Tier 0eql aspirin tab 325mg Tier 0eql aspirin tab 325mg ec Tier 0eql chld asa chw 81mg Tier 0gnp aspirin chw 81mg Tier 0gnp aspirin tab 81mg ec Tier 0gnp aspirin tab 325mg Tier 0gnp aspirin tab 325mg ec Tier 0halfprin tab 81mg ec Tier 0hm aspirin chw 81mg Tier 0hm aspirin tab 325mg Tier 0kls aspirin tab 81mg ec Tier 0kls aspirin tab 325mg ec Tier 0kp aspirin tab 81mg ec Tier 0miniprin low tab 81mg ec Tier 0mm aspirin tab 325mg Tier 0norwich asa tab 325mg Tier 0px aspirin chw 81mg Tier 0px aspirin tab 81mg ec Tier 0px aspirin tab 325mg Tier 0px aspirin tab 325mg ec Tier 0qc aspirin tab 325mg Tier 0qc aspirin tab 325mg ec Tier 0qc child asa chw 81mg Tier 0ra aspirin chw 81mg Tier 0ra aspirin tab 81mg ec Tier 0ra aspirin tab 325mg Tier 0ra aspirin tab 325mg ec Tier 0ra child asa chw 81mg Tier 0salsalate tab 500mg Tier 1salsalate tab 750mg Tier 1sb aspirin tab 325mg Tier 0sb aspirin tab 325mg ec Tier 0sb child asa chw 81mg Tier 0sm aspirin chw 81mg Tier 0sm aspirin tab 81mg ec Tier 0sm aspirin tab 325mg Tier 0sm aspirin tab 325mg ec Tier 0sm child asa chw 81mg Tier 0st joseph as chw 81mg Tier 0tgt aspirin chw 81mg Tier 0



Drug Name Drug Tier Requirements/Limitstgt aspirin chw child Tier 0tgt aspirin tab 81mg ec Tier 0tgt aspirin tab 325mg Tier 0th aspirin tab 81mg ec Tier 0th aspirin tab 325mg Tier 0th aspirin tab 325mg ec Tier 0

ANALGESICS - OPIOIDOpioid Agonists

codeine sulf tab 30mg Tier 1codeine sulf tab 60mg Tier 1fentanyl dis 12mcg/hr Tier 1 STfentanyl dis 25mcg/hr Tier 1 STfentanyl dis 50mcg/hr Tier 1 STfentanyl dis 75mcg/hr Tier 1 STfentanyl dis 100mcg/h Tier 1 SThydromorphon liq 1mg/ml Tier 1hydromorphon tab 2mg Tier 1hydromorphon tab 4mg Tier 1hydromorphon tab 8mg Tier 1levorphanol tab 2mg Tier 1meperidine sol 50mg/5ml Tier 1 PAmeperidine tab 50mg Tier 1meperidine tab 100mg Tier 1meperitab tab 50mg Tier 1meperitab tab 100mg Tier 1methadone tab 5mg Tier 1methadone tab 10mg Tier 1methadone tab 40mg Tier 1methadose tab 5mg Tier 1methadose tab 10mg Tier 1methadose tab 40mg Tier 1morphine sul cap 20mg er Tier 1morphine sul cap 30mg er Tier 1morphine sul cap 50mg er Tier 1morphine sul cap 60mg er Tier 1morphine sul cap 80mg er Tier 1morphine sul cap 100mg er Tier 1morphine sul tab 15mg Tier 1morphine sul tab 15mg er Tier 1morphine sul tab 30mg Tier 1morphine sul tab 30mg er Tier 1morphine sul tab 100mg er Tier 1



Drug Name Drug Tier Requirements/Limitsmorphine sul tab 200mg er Tier 1NUCYNTA ER TAB 50MG Tier 3 PANUCYNTA ER TAB 100MG Tier 3 PANUCYNTA ER TAB 150MG Tier 3 PANUCYNTA ER TAB 200MG Tier 3 PANUCYNTA ER TAB 250MG Tier 3 PANUCYNTA TAB 50MG Tier 3 PANUCYNTA TAB 75MG Tier 3 PANUCYNTA TAB 100MG Tier 3 PAoxycodone cap 5mg Tier 1oxycodone tab 5mg Tier 1oxycodone tab 10mg Tier 1oxycodone tab 15mg Tier 1oxycodone tab 20mg Tier 1oxycodone tab 30mg Tier 1OXYCONTIN TAB 10MG CR Tier 3 PAOXYCONTIN TAB 15MG CR Tier 3 PAOXYCONTIN TAB 20MG CR Tier 3 PAOXYCONTIN TAB 30MG CR Tier 3 PAOXYCONTIN TAB 40MG CR Tier 3 PAOXYCONTIN TAB 60MG CR Tier 3 PAOXYCONTIN TAB 80MG CR Tier 3 PAoxymorphone tab 5mg er Tier 1 PAoxymorphone tab 7.5mg er Tier 1 PAoxymorphone tab 10mg er Tier 1 PAoxymorphone tab 15mg er Tier 1 PAoxymorphone tab 20mg er Tier 1 PAoxymorphone tab 30mg er Tier 1 PAoxymorphone tab 40mg er Tier 1 PAoxymorphone tab hcl 5mg Tier 1oxymorphone tab hcl 10mg Tier 1tramadol hcl tab 50mg Tier 1tramadol hcl tab 100mg er Tier 1 PAtramadol hcl tab 200mg er Tier 1 PAtramadol hcl tab 300mg er Tier 1 PA

Opioid Combinationsapap/codeine sol 120-12/5 Tier 1apap/codeine tab 300-15mg Tier 1apap/codeine tab 300-30mg Tier 1apap/codeine tab 300-60mg Tier 1ascomp/cod cap 30mg Tier 1but/apap/caf cap codeine Tier 1but/asa/caf/ cap cod 30mg Tier 1



Drug Name Drug Tier Requirements/Limitsco-gesic tab 5-500mg Tier 1endocet tab 5-325mg Tier 1endocet tab 7.5-325 Tier 1endocet tab 7.5-500m Tier 1endocet tab 10-325mg Tier 1endocet tab 10-650mg Tier 1endodan tab Tier 1hydroco/apap sol 7.5-500 Tier 1hydroco/apap tab 2.5-500 Tier 1hydroco/apap tab 5-325mg Tier 1hydroco/apap tab 5-500mg Tier 1hydroco/apap tab 7.5-325 Tier 1hydroco/apap tab 7.5-500 Tier 1hydroco/apap tab 7.5-650 Tier 1hydroco/apap tab 7.5-750 Tier 1hydroco/apap tab 10-500mg Tier 1hydroco/apap tab 10-650mg Tier 1hydrocod/ibu tab 2.5-200 Tier 1hydrocod/ibu tab 5-200mg Tier 1hydrocod/ibu tab 7.5-200 Tier 1hydrocod/ibu tab 10-200mg Tier 1hydrocodone-acetaminophen SOLN Tier 1 AGEhydrocodone-acetaminophen TABS Tier 1ibudone tab 5-200mg Tier 1ibudone tab 10-200mg Tier 1oxycod/apap cap 5-500mg Tier 1oxycod/apap tab 5-325mg Tier 1oxycod/apap tab 7.5-325 Tier 1oxycod/apap tab 7.5-500 Tier 1oxycod/apap tab 10-325mg Tier 1oxycod/apap tab 10-650mg Tier 1oxycod/asa tab Tier 1oxycod/ibu tab 5-400mg Tier 1reprexain tab 10-200mg Tier 1ROXICET SOL 5-325/5 Tier 2roxicet tab 5-325mg Tier 1ROXICET TAB 5-500MG Tier 2

Opioid Partial Agonistsbupren/nalox sub 2-0.5mg Tier 1 PAbupren/nalox sub 8-2mg Tier 1 PAbuprenorphin sub 2mg Tier 1 PAbuprenorphin sub 8mg Tier 1 PAbutorphanol sol 10mg/ml Tier 1 PA



Drug Name Drug Tier Requirements/LimitsBUTRANS DIS 5MCG/HR Tier 3 PABUTRANS DIS 10MCG/HR Tier 3 PABUTRANS DIS 20MCG/HR Tier 3 PA

ANDROGENS-ANABOLICAnabolic Steroids

ANADROL-50 TAB 50MG Tier 3 PAoxandrolone tab 2.5mg Tier 1 PAoxandrolone tab 10mg Tier 1 PA

AndrogensANDRODERM DIS 2.5MG/24 Tier 2 PAANDRODERM DIS 2MG/24HR Tier 2 PAANDRODERM DIS 4MG/24HR Tier 2 PAANDRODERM DIS 5MG/24HR Tier 2 PAandroid cap 10mg Tier 1ANDROXY TAB 10MG Tier 2danazol cap 50mg Tier 1danazol cap 100mg Tier 1danazol cap 200mg Tier 1METHITEST TAB 10MG Tier 2testost cyp inj 100mg/ml Tier 1testost cyp inj 200mg/ml Tier 1testost enan inj 200mg/ml Tier 1

ANORECTAL AGENTSIntrarectal Steroids

colocort ene 100mg Tier 1hydrocort ene 100mg Tier 1

Rectal Combinationshc pramoxine cre 1-1% Tier 1hc pramoxine cre 2.5-1% Tier 1lidazone cre Tier 1lidocaine/hc cre 3%-0.5% Tier 1PROCORT CRE Tier 2PROCTOFOAM AER HC 1% Tier 2

Rectal Steroidsanucort-hc sup 25mg Tier 1hemril-30 sup 30mg Tier 1hydrocort ac sup 25mg Tier 1hydrocort ac sup 30mg Tier 1procto-pak cre 1% Tier 1proctocream cre hc 2.5% Tier 1proctosol hc cre 2.5% Tier 1proctozone cre -hc 2.5% Tier 1



Drug Name Drug Tier Requirements/Limitsrectacort-hc sup 25mg Tier 1

Vasodilating AgentsRECTIV OIN 0.4% Tier 2

ANTHELMINTICSAnthelmintics

ALBENZA TAB 200MG Tier 3mebendazole chw 100mg Tier 1STROMECTOL TAB 3MG Tier 3

ANTI-INFECTIVE AGENTS - MISC.Anti-infective Agents - Misc.

metronidazol cap 375mg Tier 1metronidazol tab 250mg Tier 1metronidazol tab 500mg Tier 1NEBUPENT INH 300MG Tier 3 PAPRIMSOL SOL 50MG/5ML Tier 3 PAtrimethoprim tab 100mg Tier 1vancomycin cap 125mg Tier 1 PAvancomycin cap 250mg Tier 1 PAXIFAXAN TAB 200MG Tier 3 PAXIFAXAN TAB 550MG Tier 3 PA

Anti-infective Misc. - Combinationse.s.p. sus 200-600 Tier 1ees/sulfisox sus 200-600 Tier 1smz-tmp sus Tier 1smz-tmp sus 200-40/5 Tier 1smz-tmp tab 400-80mg Tier 1smz/tmp ds tab 800-160 Tier 1

Antiprotozoal AgentsALINIA SUS 100MG/5M Tier 3ALINIA TAB 500MG Tier 3MEPRON SUS Tier 3

KetolidesKETEK TAB 300MG Tier 3 PAKETEK TAB 400MG Tier 3 PA

Leprostaticsdapsone tab 25mg Tier 1dapsone tab 100mg Tier 1

Lincosamidesclindamycin cap 75mg Tier 1 PAclindamycin cap 150mg Tier 1clindamycin cap 300mg Tier 1 PAclindamycin sol 75mg/5ml Tier 1



Drug Name Drug Tier Requirements/LimitsOxazolidinones

ZYVOX SUS 100MG/5M Tier 4 PAZYVOX TAB 600MG Tier 4 PA

ANTIANGINAL AGENTSAntianginals-Other

RANEXA TAB 500MG Tier 3 PARANEXA TAB 1000MG Tier 3 PA

NitratesDILATRATE SR CAP 40MG Tier 2isochron tab 40mg cr Tier 1isoditrate tab 40mg er Tier 1ISORDIL TAB 40MG Tier 2isosorb din sub 2.5mg Tier 1isosorb din sub 5mg Tier 1isosorb din tab 5mg Tier 1isosorb din tab 10mg Tier 1isosorb din tab 20mg Tier 1isosorb din tab 30mg Tier 1isosorb din tab 40mg er Tier 1isosorb mono tab 10mg Tier 1isosorb mono tab 20mg Tier 1isosorb mono tab 30mg er Tier 1isosorb mono tab 60mg er Tier 1isosorb mono tab 120mg er Tier 1minitran dis 0.1mg/hr Tier 1minitran dis 0.2mg/hr Tier 1minitran dis 0.4mg/hr Tier 1minitran dis 0.6mg/hr Tier 1NITRO-DUR DIS 0.3MG/HR Tier 2NITRO-DUR DIS 0.8MG/HR Tier 2nitro-time cap 2.5mg cr Tier 1nitro-time cap 6.5mg cr Tier 1nitro-time cap 9mg cr Tier 1nitroglycer aer 400mcg Tier 1nitroglycer cap 2.5mg er Tier 1nitroglycer cap 2.5mg sr Tier 1nitroglycer cap 6.5mg cr Tier 1nitroglycer cap 6.5mg er Tier 1nitroglycer cap 9mg cr Tier 1nitroglycer cap 9mg er Tier 1nitroglycer dis 0.1mg/hr Tier 1nitroglycer dis 0.2mg/hr Tier 1



Drug Name Drug Tier Requirements/Limitsnitroglycer dis 0.4mg/hr Tier 1nitroglycer dis 0.6mg/hr Tier 1nitroglyceri dis 0.6mg/hr Tier 1nitroglycrn spr lingual Tier 1NITROSTAT SUB 0.3MG Tier 2NITROSTAT SUB 0.4MG Tier 2NITROSTAT SUB 0.6MG Tier 2

ANTIANXIETY AGENTSAntianxiety Agents - Misc.

buspirone tab 5mg Tier 1buspirone tab 7.5mg Tier 1buspirone tab 10mg Tier 1buspirone tab 15mg Tier 1buspirone tab 30mg Tier 1hydroxyz hcl sol 10mg/5ml Tier 1hydroxyz hcl syp 10mg/5ml Tier 1hydroxyz hcl tab 10mg Tier 1hydroxyz hcl tab 25mg Tier 1hydroxyz hcl tab 50mg Tier 1hydroxyz pam cap 25mg Tier 1hydroxyz pam cap 50mg Tier 1hydroxyz pam cap 100mg Tier 1meprobamate tab 200mg Tier 1meprobamate tab 400mg Tier 1

Benzodiazepinesalprazolam tab 0.5mg Tier 1alprazolam tab 0.25mg Tier 1alprazolam tab 1mg Tier 1alprazolam tab 2mg Tier 1chlordiazep cap 5mg Tier 1chlordiazep cap 10mg Tier 1chlordiazep cap 25mg Tier 1cloraz dipot tab 3.75mg Tier 1cloraz dipot tab 7.5mg Tier 1cloraz dipot tab 15mg Tier 1diazepam sol 1mg/ml Tier 1diazepam tab 2mg Tier 1diazepam tab 5mg Tier 1diazepam tab 10mg Tier 1lorazepam tab 0.5mg Tier 1lorazepam tab 1mg Tier 1lorazepam tab 2mg Tier 1



Drug Name Drug Tier Requirements/Limitsoxazepam cap 10mg Tier 1oxazepam cap 15mg Tier 1oxazepam cap 30mg Tier 1

ANTIARRHYTHMICSAntiarrhythmics Type I-A

disopyramide cap 100mg Tier 1disopyramide cap 150mg Tier 1quinidine gl tab 324mg cr Tier 1quinidine gl tab 324mg er Tier 1quinidine su tab 200mg Tier 1quinidine su tab 300mg Tier 1quinidine su tab 300mg er Tier 1

Antiarrhythmics Type I-Bmexiletine cap 150mg Tier 1mexiletine cap 200mg Tier 1mexiletine cap 250mg Tier 1

Antiarrhythmics Type I-Cflecainide tab 50mg Tier 1flecainide tab 100mg Tier 1flecainide tab 150mg Tier 1propafenone cap 225mg er Tier 1propafenone cap 325mg er Tier 1propafenone cap 425mg sr Tier 1propafenone tab 150mg Tier 1propafenone tab 225mg Tier 1propafenone tab 300mg Tier 1

Antiarrhythmics Type IIIamiodarone tab 200mg Tier 1amiodarone tab 400mg Tier 1MULTAQ TAB 400MG Tier 3 PAPACERONE TAB 100MG Tier 2pacerone tab 200mg Tier 1TIKOSYN CAP 125MCG Tier 3 PATIKOSYN CAP 250MCG Tier 3 PATIKOSYN CAP 500MCG Tier 3 PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTSAnti-Inflammatory Agents

cromolyn sod neb 20mg/2ml Tier 1Antiasthmatic - Monoclonal Antibodies

XOLAIR SOL 150MG Tier 4 PABronchodilators - Anticholinergics

ATROVENT HFA AER 17MCG Tier 2



Drug Name Drug Tier Requirements/Limitsipratropium sol 0.02%inh Tier 1SPIRIVA CAP HANDIHLR Tier 2TUDORZA PRES AER 400/ACT Tier 2

Leukotriene Modulatorsmontelukast chw 4mg Tier 1montelukast chw 5mg Tier 1montelukast gra 4mg Tier 1montelukast tab 10mg Tier 1zafirlukast tab 10mg Tier 1zafirlukast tab 20mg Tier 1ZYFLO CR TAB 600MG Tier 3 PA

Selective Phosphodiesterase 4 (PDE4) InhibitorsDALIRESP TAB 500MCG Tier 3 PA

Steroid InhalantsALVESCO AER 80MCG Tier 3 PAALVESCO AER 160MCG Tier 3 PAASMANEX 7 AER 110MCG Tier 2ASMANEX 14 AER 220MCG Tier 2ASMANEX 30 AER 110MCG Tier 2ASMANEX 30 AER 220MCG Tier 2ASMANEX 60 AER 220MCG Tier 2ASMANEX 120 AER 220MCG Tier 2budesonide sus 0.5mg/2 Tier 1budesonide sus 0.25mg/2 Tier 1FLOVENT DISK AER 50MCG Tier 2FLOVENT DISK AER 100MCG Tier 2FLOVENT DISK AER 250MCG Tier 2FLOVENT HFA AER 44MCG Tier 2FLOVENT HFA AER 110MCG Tier 2FLOVENT HFA AER 220MCG Tier 2PULMICORT INH 90MCG Tier 3 PAPULMICORT INH 180MCG Tier 3 PAPULMICORT SUS 1MG/2ML Tier 2QVAR AER 40MCG Tier 2QVAR AER 80MCG Tier 2

SympathomimeticsADVAIR DISKU AER 100/50 Tier 2 STADVAIR DISKU AER 250/50 Tier 2 STADVAIR DISKU AER 500/50 Tier 2 STADVAIR HFA AER 45/21 Tier 2 STADVAIR HFA AER 115/21 Tier 2 STADVAIR HFA AER 230/21 Tier 2 STalbuterol neb 0.5% Tier 1



Drug Name Drug Tier Requirements/Limitsalbuterol neb 0.63mg/3 Tier 1albuterol neb 0.083% Tier 1albuterol neb 1.25mg/3 Tier 1albuterol syp 2mg/5ml Tier 1albuterol tab 2mg Tier 1albuterol tab 4mg Tier 1albuterol tab 4mg er Tier 1albuterol tab 8mg er Tier 1ARCAPTA CAP 75MCG Tier 3 PABROVANA NEB 15MCG Tier 3 PACOMBIVENT AER Tier 2COMBIVENT AER RESPIMAT Tier 2DULERA AER 100-5MCG Tier 2 STDULERA AER 200-5MCG Tier 2 STFORADIL CAP AEROLIZE Tier 2 STMAXAIR AUTOH AER 200MCG Tier 2metaproteren syp 10mg/5ml Tier 1metaproteren tab 10mg Tier 1metaproteren tab 20mg Tier 1PROAIR HFA AER Tier 2SEREVENT DIS AER 50MCG Tier 2 STSYMBICORT AER 80-4.5 Tier 2 STSYMBICORT AER 160-4.5 Tier 2 STterbutaline tab 2.5mg Tier 1terbutaline tab 5mg Tier 1VENTOLIN HFA AER Tier 2XOPENEX HFA AER Tier 2 PA

Xanthinesaminophyllin tab 100mg Tier 1aminophyllin tab 200mg Tier 1ELIXOPHYLLIN ELX 80/15ML Tier 2THEO-24 CAP 100MG CR Tier 2THEO-24 CAP 200MG CR Tier 2THEO-24 CAP 300MG CR Tier 2THEO-24 CAP 400MG ER Tier 2theochron tab 100mg cr Tier 1theochron tab 200mg cr Tier 1theochron tab 300mg cr Tier 1theophylline sol 80/15ml Tier 1theophylline tab 100mg cr Tier 1theophylline tab 100mg er Tier 1theophylline tab 200mg cr Tier 1theophylline tab 200mg er Tier 1



Drug Name Drug Tier Requirements/Limitstheophylline tab 300mg er Tier 1theophylline tab 400mg er Tier 1theophylline tab 450mg er Tier 1theophylline tab 600mg er Tier 1

ANTICOAGULANTSCoumarin Anticoagulants

jantoven tab 1mg Tier 1jantoven tab 2.5mg Tier 1jantoven tab 2mg Tier 1jantoven tab 3mg Tier 1jantoven tab 4mg Tier 1jantoven tab 5mg Tier 1jantoven tab 6mg Tier 1jantoven tab 7.5mg Tier 1jantoven tab 10mg Tier 1warfarin tab 1mg Tier 1warfarin tab 2.5mg Tier 1warfarin tab 2mg Tier 1warfarin tab 3mg Tier 1warfarin tab 4mg Tier 1warfarin tab 5mg Tier 1warfarin tab 6mg Tier 1warfarin tab 7.5mg Tier 1warfarin tab 10mg Tier 1

Direct Factor Xa InhibitorsXARELTO TAB 10MG Tier 3 PAXARELTO TAB 15MG Tier 3 PAXARELTO TAB 20MG Tier 3 PA

Heparins And Heparinoid-Like Agentsenoxaparin inj 30/0.3ml Tier 4 QLenoxaparin inj 40/0.4ml Tier 4 QLenoxaparin inj 60/0.6ml Tier 4 QLenoxaparin inj 80/0.8ml Tier 4 QLenoxaparin inj 100mg/ml Tier 4 QLenoxaparin inj 120/0.8 Tier 4 QLenoxaparin inj 150mg/ml Tier 4 QLenoxaparin inj 300/3ml Tier 4 QLfondaparinux sol 2.5/0.5 Tier 4 PAfondaparinux sol 5.0/0.4 Tier 4 PAfondaparinux sol 7.5/0.6 Tier 4 PAfondaparinux sol 10/0.8 Tier 4 PAFRAGMIN INJ 2500/0.2 Tier 4 PA



Drug Name Drug Tier Requirements/LimitsFRAGMIN INJ 5000/0.2 Tier 4 PAFRAGMIN INJ 7500/0.3 Tier 4 PAFRAGMIN INJ 10000/ML Tier 4 PAFRAGMIN INJ 12500UNT Tier 4 PAFRAGMIN INJ 15000UNT Tier 4 PAFRAGMIN INJ 18000UNT Tier 4 PAFRAGMIN INJ 25000/ML Tier 4 PA

Thrombin InhibitorsPRADAXA CAP 75MG Tier 3 PAPRADAXA CAP 150MG Tier 3 PA

ANTICONVULSANTSAnticonvulsants - Benzodiazepines

clonazepam tab 0.5mg Tier 1clonazepam tab 1mg Tier 1clonazepam tab 2mg Tier 1diazepam gel 2.5mg Tier 1diazepam gel 10mg Tier 1diazepam gel 20mg Tier 1

Anticonvulsants - Misc.BANZEL SUS 40MG/ML Tier 3 PABANZEL TAB 200MG Tier 3 PABANZEL TAB 400MG Tier 3 PAcarbamazepin cap 100mg er Tier 1carbamazepin cap 200mg er Tier 1carbamazepin cap 300mg er Tier 1carbamazepin chw 100mg Tier 1carbamazepin sus 100/5ml Tier 1carbamazepin tab 200mg Tier 1carbamazepin tab 200mg er Tier 1carbamazepin tab 400mg er Tier 1epitol tab 200mg Tier 1gabapentin cap 100mg Tier 1gabapentin cap 300mg Tier 1gabapentin cap 400mg Tier 1gabapentin tab 600mg Tier 1gabapentin tab 800mg Tier 1LAMICTAL CHW 2MG Tier 2LAMICTAL ODT TAB 25MG Tier 3 PALAMICTAL ODT TAB 50MG Tier 3 PALAMICTAL ODT TAB 100MG Tier 3 PALAMICTAL ODT TAB 200MG Tier 3 PALAMICTAL XR KIT Tier 3 PA



Drug Name Drug Tier Requirements/Limitslamotrigine chw 5mg Tier 1lamotrigine chw 25mg Tier 1lamotrigine tab 25mg Tier 1lamotrigine tab 25mg er Tier 1 PAlamotrigine tab 50mg er Tier 1 PAlamotrigine tab 100mg Tier 1lamotrigine tab 100mg er Tier 1 PAlamotrigine tab 150mg Tier 1lamotrigine tab 200mg Tier 1lamotrigine tab 200mg er Tier 1 PAlamotrigine tab 250mg er Tier 1 PAlamotrigine tab 300mg er Tier 1 PAlevetiraceta sol 100mg/ml Tier 1levetiraceta sol 500/5ml Tier 1levetiraceta tab 250mg Tier 1levetiraceta tab 500mg Tier 1levetiraceta tab 750mg Tier 1levetiraceta tab 1000mg Tier 1LYRICA CAP 25MG Tier 3 PALYRICA CAP 50MG Tier 3 PALYRICA CAP 75MG Tier 3 PALYRICA CAP 100MG Tier 3 PALYRICA CAP 150MG Tier 3 PALYRICA CAP 200MG Tier 3 PALYRICA CAP 225MG Tier 3 PALYRICA CAP 300MG Tier 3 PAoxcarbazepin sus 300mg/5m Tier 1oxcarbazepin tab 150mg Tier 1oxcarbazepin tab 300mg Tier 1oxcarbazepin tab 600mg Tier 1POTIGA TAB 50MG Tier 3 PAPOTIGA TAB 200MG Tier 3 PAPOTIGA TAB 300MG Tier 3 PAPOTIGA TAB 400MG Tier 3 PAprimidone tab 50mg Tier 1primidone tab 250mg Tier 1TEGRETOL-XR TAB 100MG Tier 2topiragen tab 25mg Tier 1topiragen tab 50mg Tier 1topiragen tab 100mg Tier 1topiragen tab 200mg Tier 1topiramate cap 15mg Tier 1topiramate cap 25mg Tier 1



Drug Name Drug Tier Requirements/Limitstopiramate tab 25mg Tier 1topiramate tab 50mg Tier 1topiramate tab 100mg Tier 1topiramate tab 200mg Tier 1VIMPAT SOL 10MG/ML Tier 3 PAVIMPAT TAB 50MG Tier 3 PAVIMPAT TAB 100MG Tier 3 PAVIMPAT TAB 150MG Tier 3 PAVIMPAT TAB 200MG Tier 3 PAzonisamide cap 25mg Tier 1zonisamide cap 50mg Tier 1zonisamide cap 100mg Tier 1

Carbamatesfelbamate sus 600/5ml Tier 1felbamate tab 400mg Tier 1felbamate tab 600mg Tier 1

GABA ModulatorsGABITRIL TAB 12MG Tier 2GABITRIL TAB 16MG Tier 2SABRIL POW 500MG Tier 4 PASABRIL TAB 500MG Tier 4 PAtiagabine tab 2mg Tier 1tiagabine tab 4mg Tier 1

HydantoinsDILANTIN CAP 30MG Tier 2PEGANONE TAB 250MG Tier 2phenytoin chw 50mg Tier 1phenytoin ex cap 100mg Tier 1phenytoin ex cap 200mg Tier 1phenytoin ex cap 300mg Tier 1phenytoin sus 125/5ml Tier 1

SuccinimidesCELONTIN CAP 300MG Tier 2ethosuximide cap 250mg Tier 1ethosuximide sol 250/5ml Tier 1

Valproic Aciddivalproex cap 125mg Tier 1divalproex tab 125mg dr Tier 1divalproex tab 250mg dr Tier 1divalproex tab 250mg er Tier 1divalproex tab 500mg dr Tier 1divalproex tab 500mg er Tier 1STAVZOR CAP 125MG Tier 3



Drug Name Drug Tier Requirements/LimitsSTAVZOR CAP 250MG Tier 3STAVZOR CAP 500MG Tier 3valproic acd cap 250mg Tier 1valproic acd sol 250/5ml Tier 1valproic acd syp 250/5ml Tier 1

ANTIDEPRESSANTSAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tab 7.5mg Tier 1mirtazapine tab 15mg Tier 1mirtazapine tab 15mg odt Tier 1mirtazapine tab 30mg Tier 1mirtazapine tab 30mg odt Tier 1mirtazapine tab 45mg Tier 1mirtazapine tab 45mg odt Tier 1

Antidepressants - Misc.budeprion tab 100mg sr Tier 1budeprion tab 150mg sr Tier 1budeprion xl tab 150mg Tier 1 PAbudeprion xl tab 300mg Tier 1 PAbupropion tab 75mg Tier 1bupropion tab 100mg Tier 1bupropion tab 100mg er Tier 1bupropion tab 100mg sr Tier 1bupropion tab 150mg er Tier 1bupropion tab 150mg sr Tier 1bupropion tab 200mg er Tier 1bupropion tab 200mg sr Tier 1bupropn hcl tab 150mg xl Tier 1 PAbupropn hcl tab 300mg xl Tier 1 PAmaprotiline tab 25mg Tier 1maprotiline tab 50mg Tier 1maprotiline tab 75mg Tier 1

Modified Cyclicsnefazodone tab 50mg Tier 1nefazodone tab 100mg Tier 1nefazodone tab 150mg Tier 1nefazodone tab 200mg Tier 1nefazodone tab 250mg Tier 1OLEPTRO TAB 24HR150 Tier 3OLEPTRO TAB 24HR300 Tier 3trazodone tab 50mg Tier 1trazodone tab 100mg Tier 1



Drug Name Drug Tier Requirements/Limitstrazodone tab 150mg Tier 1trazodone tab 300mg Tier 1VIIBRYD KIT Tier 3 PAVIIBRYD TAB 10MG Tier 3 PAVIIBRYD TAB 20MG Tier 3 PAVIIBRYD TAB 40MG Tier 3 PA

Monoamine Oxidase Inhibitors (MAOIs)EMSAM DIS 6MG/24HR Tier 3 PAEMSAM DIS 9MG/24HR Tier 3 PAEMSAM DIS 12MG/24H Tier 3 PAMARPLAN TAB 10MG Tier 2phenelzine tab 15mg Tier 1tranylcyprom tab 10mg Tier 1

Selective Serotonin Reuptake Inhibitors (SSRIs)citalopram tab 10mg Tier 1citalopram tab 20mg Tier 1citalopram tab 40mg Tier 1escitalopram tab 10mg Tier 1escitalopram tab 20mg Tier 1fluoxetine cap 10mg 10mg Tier 1fluoxetine cap 20mg 20mg Tier 1fluoxetine cap 40mg Tier 1 PAfluoxetine sol 20mg/5ml Tier 1 PAfluoxetine tab 10mg Tier 1fluoxetine tab 20mg Tier 1FLUOXETINE TAB 60MG Tier 3fluvoxamine cap 100mg er Tier 1fluvoxamine cap 150mg er Tier 1fluvoxamine tab 25mg Tier 1fluvoxamine tab 50mg Tier 1fluvoxamine tab 100mg Tier 1paroxetine sus 10mg/5ml Tier 1paroxetine tab 10mg Tier 1paroxetine tab 20mg Tier 1paroxetine tab 30mg Tier 1paroxetine tab 40mg Tier 1sertraline tab 25mg Tier 1sertraline tab 50mg Tier 1sertraline tab 100mg Tier 1

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)CYMBALTA CAP 20MG Tier 2 PACYMBALTA CAP 30MG Tier 2 PACYMBALTA CAP 60MG Tier 2 PA



Drug Name Drug Tier Requirements/LimitsPRISTIQ TAB 50MG Tier 3 PAPRISTIQ TAB 100MG Tier 3 PAvenlafaxine cap 37.5mg Tier 1venlafaxine cap 75mg er Tier 1venlafaxine cap 150mg er Tier 1venlafaxine tab 25mg Tier 1venlafaxine tab 37.5mg Tier 1venlafaxine tab 50mg Tier 1venlafaxine tab 75mg Tier 1venlafaxine tab 100mg Tier 1

Tricyclic Agentsamitriptylin tab 10mg Tier 1amitriptylin tab 25mg Tier 1amitriptylin tab 50mg Tier 1amitriptylin tab 75mg Tier 1amitriptylin tab 100mg Tier 1amitriptylin tab 150mg Tier 1amoxapine tab 25mg Tier 1amoxapine tab 50mg Tier 1amoxapine tab 100mg Tier 1amoxapine tab 150mg Tier 1clomipramine cap 25mg Tier 1clomipramine cap 50mg Tier 1clomipramine cap 75mg Tier 1desipramine tab 10mg Tier 1desipramine tab 25mg Tier 1desipramine tab 50mg Tier 1desipramine tab 75mg Tier 1desipramine tab 100mg Tier 1desipramine tab 150mg Tier 1doxepin hcl cap 10mg Tier 1doxepin hcl cap 25mg Tier 1doxepin hcl cap 50mg Tier 1doxepin hcl cap 75mg Tier 1doxepin hcl cap 100mg Tier 1doxepin hcl cap 150mg Tier 1doxepin hcl con 10mg/ml Tier 1imipram hcl tab 10mg Tier 1imipram hcl tab 25mg Tier 1imipram hcl tab 50mg Tier 1nortriptylin cap 10mg Tier 1nortriptylin cap 25mg Tier 1nortriptylin cap 50mg Tier 1



Drug Name Drug Tier Requirements/Limitsnortriptylin cap 75mg Tier 1nortriptylin sol 10mg/5ml Tier 1protriptylin tab 5mg Tier 1protriptylin tab 10mg Tier 1trimipramine cap 25mg Tier 1trimipramine cap 50mg Tier 1trimipramine cap 100mg Tier 1

ANTIDIABETICSAlpha-Glucosidase Inhibitors

acarbose tab 25mg Tier 1acarbose tab 50mg Tier 1acarbose tab 100mg Tier 1GLYSET TAB 25MG Tier 2GLYSET TAB 50MG Tier 2GLYSET TAB 100MG Tier 2

Antidiabetic - Amylin AnalogsSYMLINPEN 60 INJ 1000MCG Tier 3 PASYMLNPEN 120 INJ 1000MCG Tier 3 PA

Antidiabetic CombinationsAVANDAMET TAB 2-500MG Tier 2 PAAVANDAMET TAB 2-1000MG Tier 2 PAAVANDAMET TAB 4-500MG Tier 2 PAAVANDAMET TAB 4-1000MG Tier 2 PAAVANDARYL TAB 4-1MG Tier 2 PAAVANDARYL TAB 4-2MG Tier 2 PAAVANDARYL TAB 4-4MG Tier 2 PAAVANDARYL TAB 8-2MG Tier 2 PAAVANDARYL TAB 8-4MG Tier 2 PAglip/metform tab 2.5-250m Tier 1glip/metform tab 5-500mg Tier 1glyb/metform tab 1.25-250 Tier 1glyb/metform tab 2.5-500 Tier 1glyb/metform tab 5-500mg Tier 1JENTADUETO TAB 2.5-500 Tier 2 STJENTADUETO TAB 2.5-850 Tier 2 STJENTADUETO TAB 2.5-1000 Tier 2 STpioglita/met tab 15-500mg Tier 1pioglita/met tab 15-850mg Tier 1

BiguanidesGLUMETZA TAB 500MG Tier 2GLUMETZA TAB 1000MG Tier 2metformin er tab 1000mg Tier 1



Drug Name Drug Tier Requirements/Limitsmetformin tab 500mg Tier 1metformin tab 500mg er Tier 1metformin tab 750mg er Tier 1metformin tab 850mg Tier 1metformin tab 1000mg Tier 1

Diabetic OtherGLUCAGON KIT 1MG Tier 2

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA TAB 25MG Tier 2 STJANUVIA TAB 50MG Tier 2 STJANUVIA TAB 100MG Tier 2 STONGLYZA TAB 2.5MG Tier 3 PAONGLYZA TAB 5MG Tier 3 PATRADJENTA TAB 5MG Tier 2 ST

Dopamine Receptor Agonists - AntidiabeticCYCLOSET TAB 0.8MG Tier 2

Incretin Mimetic Agents (GLP-1 Receptor Agonists)BYETTA INJ 5MCG Tier 3 PABYETTA INJ 10MCG Tier 3 PAVICTOZA INJ 18MG/3ML Tier 3 PA

InsulinAPIDRA INJ SOLOSTAR Tier 2APIDRA INJ U-100 Tier 2HUMALOG INJ 100/ML Tier 2HUMALOG KWIK INJ 100/ML Tier 2HUMALOG MIX INJ 50/50 Tier 2HUMALOG MIX INJ 50/50KWP Tier 2HUMALOG MIX INJ 75/25KWP Tier 2HUMALOG MIX SUS 75/25 Tier 2HUMULIN INJ 70/30 Tier 2HUMULIN N INJ U-100 Tier 2HUMULIN N PN INJ U-100 Tier 2HUMULIN PEN INJ 70/30 Tier 2HUMULIN R INJ U-100 Tier 2LANTUS INJ 100/ML Tier 2LANTUS INJ SOLOSTAR Tier 2LEVEMIR INJ Tier 2LEVEMIR INJ FLEXPEN Tier 2NOVOLIN INJ 70/30 Tier 2NOVOLIN N INJ U-100 Tier 2NOVOLIN R INJ U-100 Tier 2NOVOLOG INJ 100/ML Tier 2NOVOLOG INJ FLEXPEN Tier 2



Drug Name Drug Tier Requirements/LimitsNOVOLOG INJ PENFILL Tier 2NOVOLOG MIX INJ 70/30 Tier 2NOVOLOG MIX INJ FLEXPEN Tier 2

Insulin Sensitizing AgentsAVANDIA TAB 2MG Tier 2 PAAVANDIA TAB 4MG Tier 2 PAAVANDIA TAB 8MG Tier 2 PApioglitazone tab 15mg Tier 1pioglitazone tab 30mg Tier 1pioglitazone tab 45mg Tier 1

Meglitinide Analoguesnateglinide tab 60mg Tier 1nateglinide tab 120mg Tier 1PRANDIN TAB 0.5MG Tier 2repaglinide Tier 1

Sulfonylureaschlorpropam tab 100mg Tier 1chlorpropam tab 250mg Tier 1glimepiride tab 1mg Tier 1glimepiride tab 2mg Tier 1glimepiride tab 4mg Tier 1glipizide er tab 2.5mg Tier 1glipizide er tab 5mg Tier 1glipizide er tab 10mg Tier 1glipizide tab 5mg Tier 1glipizide tab 10mg Tier 1glipizide xl tab 2.5mg Tier 1glipizide xl tab 5mg Tier 1glipizide xl tab 10mg Tier 1glyburid mcr tab 1.5mg Tier 1glyburid mcr tab 3mg Tier 1glyburid mcr tab 6mg Tier 1glyburide tab 1.25mg Tier 1glyburide tab 2.5mg Tier 1glyburide tab 5mg Tier 1tolazamide tab 250mg Tier 1tolazamide tab 500mg Tier 1tolbutamide tab 500mg Tier 1

ANTIDIARRHEALSAntiperistaltic Agents

anti-diarrhe cap 2mg Tier 1anti-diarrhe tab 2mg Tier 1



Drug Name Drug Tier Requirements/Limitsdiamode tab 2mg Tier 1diphen/atrop liq 2.5/5 Tier 1diphen/atrop tab 2.5mg Tier 1imperim tab 2mg Tier 1kls anti-dia tab 2mg Tier 1lofene tab 2.5mg Tier 1lonox tab 2.5mg Tier 1loperamide cap 2mg Tier 1loperamide tab 2mg Tier 1MOTOFEN TAB Tier 3sm anti-diar tab 2mg Tier 1

ANTIDOTESAntidotes - Chelating Agents

CHEMET CAP 100MG Tier 3EXJADE TAB 125MG Tier 4 PAEXJADE TAB 250MG Tier 4 PAEXJADE TAB 500MG Tier 4 PAFERRIPROX TAB 500MG Tier 4 PA

Opioid AntagonistsVIVITROL INJ 380MG Tier 4 PA

ANTIEMETICS5-HT3 Receptor Antagonists

ANZEMET TAB 50MG Tier 3 PAANZEMET TAB 100MG Tier 3 PAgranisetron tab 1mg Tier 1 PAGRANISOL SOL 2MG/10ML Tier 2 PAondansetron tab 4mg Tier 1ondansetron tab 4mg odt Tier 1ondansetron tab 8mg Tier 1ondansetron tab 8mg odt Tier 1ondansetron tab 24mg Tier 1ZUPLENZ MIS 4MG Tier 2 PAZUPLENZ MIS 8MG Tier 2 PA

Antiemetics - AnticholinergicANTIVERT TAB 50MG Tier 2dramamine tab 25mg Tier 1meclizine tab 12.5mg Tier 1meclizine tab 25mg Tier 1medi-meclizi tab 25mg Tier 1motion relf tab 25mg Tier 1motion sick tab 25mg Tier 1TRANSDERM-SC DIS 1.5MG Tier 3



Drug Name Drug Tier Requirements/Limitstrimethobenz cap 300mg Tier 1wal-dram ii tab 25mg Tier 1

Antiemetics - MiscellaneousCESAMET CAP 1MG Tier 3 PAdronabinol cap 2.5mg Tier 1dronabinol cap 5mg Tier 1dronabinol cap 10mg Tier 1

Substance P/Neurokinin 1 (NK1) Receptor AntagonistsEMEND CAP 40MG Tier 3 PAEMEND CAP 80MG Tier 3 PAEMEND CAP 125MG Tier 3 PAEMEND PAK 80 & 125 Tier 3 PA

ANTIFUNGALSAntifungals

bio-statin pow Tier 1griseofulvin sus 125/5ml Tier 1griseofulvin tab micr 500 Tier 1griseofulvin tab ultr 125 Tier 1griseofulvin tab ultr 250 Tier 1nystatin pow Tier 1nystatin tab 500000 Tier 1terbinafine tab 250mg Tier 1

Imidazole-Related Antifungalsfluconazole sus 10mg/ml Tier 1fluconazole sus 40mg/ml Tier 1fluconazole tab 50mg Tier 1fluconazole tab 100mg Tier 1fluconazole tab 150mg Tier 1fluconazole tab 200mg Tier 1itraconazole cap 100mg Tier 1 PAketoconazole tab 200mg Tier 1NOXAFIL SUS 40MG/ML Tier 2 PAvoriconazole tab 50mg Tier 1 PAvoriconazole tab 200mg Tier 1 PA

ANTIHISTAMINESAntihistamines - Alkylamines

dexchlorphen syp 2mg/5ml Tier 1Antihistamines - Ethanolamines

af-diphedryl elx 12.5/5ml Tier 1aler-cap cap 25mg Tier 1allergy cap 25mg Tier 1allergy med cap 25mg Tier 1



Drug Name Drug Tier Requirements/Limitsallergy rel elx 12.5/5ml Tier 1allergy relf cap 25mg Tier 1altaryl elx 12.5/5ml Tier 1altaryl syp 12.5/5ml Tier 1anti-hist cap 25mg Tier 1antihistamin cap 25mg Tier 1arbinoxa liq 4mg/5ml Tier 1arbinoxa tab 4mg Tier 1banophen cap 25mg Tier 1banophen cap 50mg Tier 1carbinoxamin liq 4mg/5ml Tier 1carbinoxamin tab 4mg Tier 1clemastine syp 0.5/5ml Tier 1clemastine tab 2.68mg Tier 1comp allergy cap 25mg Tier 1cvs allergy cap 25mg Tier 1diphenhist cap 25mg Tier 1diphenhydram cap 25mg Tier 1diphenhydram cap 50mg Tier 1diphenhydram elx 12.5/5ml Tier 1dormin cap 25mg Tier 1dytuss syp 12.5/5ml Tier 1eq allergy cap 25mg Tier 1eql allergy cap 25mg Tier 1genahist cap 25mg Tier 1geri-dryl cap 25mg Tier 1gnp allergy cap 25mg Tier 1medi-phedryl cap 25mg Tier 1medi-phedryl elx 12.5/5ml Tier 1mp aller med cap 25mg Tier 1pharbedryl cap 25mg Tier 1pharbedryl cap 50mg Tier 1px allergy cap 25mg Tier 1q-dryl cap 25mg Tier 1quenalin syp 12.5/5ml Tier 1silphen coug syp 12.5/5ml Tier 1wal-dryl cap 25mg Tier 1

Antihistamines - Non-Sedatingall day allg sol 1mg/ml Tier 1all day allg sol 5mg/5ml Tier 1all day allg syp 1mg/ml Tier 1all day allg syp 5mg/5ml Tier 1aller-ease tab 180mg Tier 1



Drug Name Drug Tier Requirements/Limitsaller-fex tab 180mg Tier 1aller-tec sol 1mg/ml Tier 1allergy chld sol 1mg/ml Tier 1allergy comp sol 1mg/ml Tier 1allergy rel sol 1mg/ml Tier 1allergy relf sol 5mg/5ml Tier 1allergy relf tab 180mg Tier 1cetirizine sol 1mg/ml Tier 1cetirizine sol 5mg/5ml Tier 1cetirizine syp 1mg/ml Tier 1cetirizine syp 5mg/5ml Tier 1cvs allergy tab 180mg Tier 1desloratadin tab 2.5 odt Tier 1 PAdesloratadin tab 5mg Tier 1 PAdesloratadin tab 5mg odt Tier 1 PAfexofenadine tab 180mg Tier 1gnp allergy tab 180mg Tier 1wal-fex allr tab 180mg Tier 1wal-zyr sol 1mg/ml Tier 1wal-zyr sol 5mg/5ml Tier 1

Antihistamines - Phenothiazinesphenadoz sup 12.5mg Tier 1phenadoz sup 25mg Tier 1promethazine sol 6.25/5ml Tier 1promethazine sup 12.5mg Tier 1promethazine sup 25mg Tier 1promethazine syp 6.25/5ml Tier 1promethazine tab 12.5mg Tier 1promethazine tab 25mg Tier 1promethazine tab 50mg Tier 1promethegan sup 12.5mg Tier 1promethegan sup 25mg Tier 1promethegan sup 50mg Tier 1

Antihistamines - Piperidinescyproheptad syp 2mg/5ml Tier 1cyproheptad tab 4mg Tier 1

ANTIHYPERLIPIDEMICSAntihyperlipidemics - Combinations

VYTORIN TAB 10-10MG Tier 3 PAVYTORIN TAB 10-20MG Tier 3 PAVYTORIN TAB 10-40MG Tier 3 PAVYTORIN TAB 10-80MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsAntihyperlipidemics - Misc.

LOVAZA CAP 1GM Tier 3 PABile Acid Sequestrants

cholestyram pow 4gm POWD Tier 1cholestyram pow 4gm lite POWD Tier 1colestipol gra 5gm Tier 1colestipol tab 1gm Tier 1prevalite pow 4gm Tier 1WELCHOL TAB 625MG Tier 2 PA

Fibric Acid Derivativesfenofibrate tab 48mg Tier 1fenofibrate tab 54mg Tier 1fenofibrate tab 160mg Tier 1FENOGLIDE TAB 40MG Tier 3FENOGLIDE TAB 120MG Tier 3gemfibrozil tab 600mg Tier 1TRIGLIDE TAB 50MG Tier 3

HMG CoA Reductase InhibitorsADVICOR TAB 500-20MG Tier 3 PAADVICOR TAB 750-20MG Tier 3 PAADVICOR TAB 1000-20 Tier 3 PAADVICOR TAB 1000-40 Tier 3 PAALTOPREV TAB 20MG ER Tier 3 PAALTOPREV TAB 40MG ER Tier 3 PAALTOPREV TAB 60MG ER Tier 3 PAatorvastatin tab 10mg Tier 1 STatorvastatin tab 20mg Tier 1 STatorvastatin tab 40mg Tier 1 STatorvastatin tab 80mg Tier 1 STCRESTOR TAB 5MG Tier 3 PACRESTOR TAB 10MG Tier 3 PACRESTOR TAB 20MG Tier 3 PACRESTOR TAB 40MG Tier 3 PAfluvastatin cap 20mg Tier 1fluvastatin cap 40mg Tier 1LIVALO TAB 1MG Tier 3 PALIVALO TAB 2MG Tier 3 PALIVALO TAB 4MG Tier 3 PAlovastatin tab 10mg Tier 1lovastatin tab 20mg Tier 1lovastatin tab 40mg Tier 1pravastatin tab 10mg Tier 1pravastatin tab 20mg Tier 1



Drug Name Drug Tier Requirements/Limitspravastatin tab 40mg Tier 1pravastatin tab 80mg Tier 1SIMCOR TAB 500-20MG Tier 3 PASIMCOR TAB 500-40MG Tier 3 PASIMCOR TAB 750-20MG Tier 3 PASIMCOR TAB 1000-20 Tier 3 PASIMCOR TAB 1000-40 Tier 3 PAsimvastatin tab 5mg Tier 1simvastatin tab 10mg Tier 1simvastatin tab 20mg Tier 1simvastatin tab 40mg Tier 1simvastatin tab 80mg Tier 1

Intestinal Cholesterol Absorption InhibitorsZETIA TAB 10MG Tier 2 PA

Nicotinic Acid Derivativesniacor tab 500mg Tier 1NIASPAN TAB 500MG ER Tier 2NIASPAN TAB 750MG ER Tier 2NIASPAN TAB 1000 ER Tier 2

ANTIHYPERTENSIVESACE Inhibitors

benazepril tab 5mg Tier 1benazepril tab 10mg Tier 1benazepril tab 20mg Tier 1benazepril tab 40mg Tier 1captopril tab 12.5mg Tier 1captopril tab 25mg Tier 1captopril tab 50mg Tier 1captopril tab 100mg Tier 1enalapril tab 2.5mg Tier 1enalapril tab 5mg Tier 1enalapril tab 10mg Tier 1enalapril tab 20mg Tier 1fosinopril tab 10mg Tier 1fosinopril tab 20mg Tier 1fosinopril tab 40mg Tier 1lisinopril tab 2.5mg Tier 1lisinopril tab 5mg Tier 1lisinopril tab 10mg Tier 1lisinopril tab 20mg Tier 1lisinopril tab 30mg Tier 1lisinopril tab 40mg Tier 1



Drug Name Drug Tier Requirements/Limitsmoexipril tab 7.5mg Tier 1moexipril tab 15mg Tier 1perindopril tab 2mg Tier 1perindopril tab 4mg Tier 1perindopril tab 8mg Tier 1quinapril tab 5mg Tier 1quinapril tab 10mg Tier 1quinapril tab 20mg Tier 1quinapril tab 40mg Tier 1ramipril cap 1.25mg Tier 1ramipril cap 2.5mg Tier 1ramipril cap 5mg Tier 1ramipril cap 10mg Tier 1trandolapril tab 1mg Tier 1trandolapril tab 2mg Tier 1trandolapril tab 4mg Tier 1

Agents for PheochromocytomaDIBENZYLINE CAP 10MG Tier 3

Angiotensin II Receptor AntagonistsBENICAR TAB 5MG Tier 2 STBENICAR TAB 20MG Tier 2 STBENICAR TAB 40MG Tier 2 STcandesartan tab 4mg Tier 1 STcandesartan tab 8mg Tier 1 STcandesartan tab 16mg Tier 1 STcandesartan tab 32mg Tier 1 STDIOVAN TAB 40MG Tier 2 STDIOVAN TAB 80MG Tier 2 STDIOVAN TAB 160MG Tier 2 STDIOVAN TAB 320MG Tier 2 STEDARBI TAB 40MG Tier 3 PAEDARBI TAB 80MG Tier 3 PAeprosart mes tab 600mg Tier 1 PAirbesartan tab 75mg Tier 1 PAlosartan pot tab 25mg Tier 1losartan pot tab 50mg Tier 1losartan pot tab 100mg Tier 1MICARDIS TAB 20MG Tier 3 PAMICARDIS TAB 40MG Tier 3 PAMICARDIS TAB 80MG Tier 3 PA

Antiadrenergic Antihypertensivesclonidine dis 0.1/24hr Tier 1clonidine dis 0.2/24hr Tier 1



Drug Name Drug Tier Requirements/Limitsclonidine dis 0.3/24hr Tier 1clonidine tab 0.1mg Tier 1clonidine tab 0.2mg Tier 1clonidine tab 0.3mg Tier 1doxazosin tab 1mg Tier 1doxazosin tab 2mg Tier 1doxazosin tab 4mg Tier 1doxazosin tab 8mg Tier 1guanfacine tab 1mg Tier 1guanfacine tab 2mg Tier 1methyldopa tab 250mg Tier 1methyldopa tab 500mg Tier 1prazosin hcl cap 1mg Tier 1prazosin hcl cap 2mg Tier 1prazosin hcl cap 5mg Tier 1terazosin cap 1mg Tier 1terazosin cap 2mg Tier 1terazosin cap 5mg Tier 1terazosin cap 10mg Tier 1

Antihypertensive Combinationsamlod/benazp cap 2.5-10mg Tier 1 PAamlod/benazp cap 5-10mg Tier 1 PAamlod/benazp cap 5-20mg Tier 1 PAamlod/benazp cap 5-40mg Tier 1 PAamlod/benazp cap 10-20mg Tier 1 PAamlod/benazp cap 10-40mg Tier 1 PAatenol/chlor tab 50-25mg Tier 1atenol/chlor tab 100-25mg Tier 1AZOR TAB 5-20MG Tier 3 PAAZOR TAB 5-40MG Tier 3 PAAZOR TAB 10-20MG Tier 3 PAAZOR TAB 10-40MG Tier 3 PAbisoprl/hctz tab 2.5/6.25 Tier 1bisoprl/hctz tab 5-6.25mg Tier 1bisoprl/hctz tab 10/6.25 Tier 1captopr/hctz tab 25-15mg Tier 1captopr/hctz tab 25-25mg Tier 1captopr/hctz tab 50-15mg Tier 1captopr/hctz tab 50-25mg Tier 1lisinop/hctz tab 10-12.5 Tier 1lisinop/hctz tab 20-12.5 Tier 1lisinop/hctz tab 20-25mg Tier 1losartan/hct tab 50-12.5 Tier 1



Drug Name Drug Tier Requirements/Limitslosartan/hct tab 100-12.5 Tier 1losartan/hct tab 100-25 Tier 1MICARDIS HCT Tier 3 PATWYNSTA TAB 40-5MG Tier 3 PATWYNSTA TAB 40-10MG Tier 3 PATWYNSTA TAB 80-5MG Tier 3 PATWYNSTA TAB 80-10MG Tier 3 PA

Direct Renin InhibitorsTEKTURNA TAB 150MG Tier 3 PATEKTURNA TAB 300MG Tier 3 PA

Selective Aldosterone Receptor Antagonists (SARAs)eplerenone tab 25mg Tier 1 PAeplerenone tab 50mg Tier 1 PA

Vasodilatorshydralazine tab 10mg Tier 1hydralazine tab 25mg Tier 1hydralazine tab 50mg Tier 1hydralazine tab 100mg Tier 1minoxidil tab 2.5mg Tier 1minoxidil tab 10mg Tier 1

ANTIMALARIALSAntimalarial Combinations

atovaq/progu tab 62.5-25 Tier 1atovaq/progu tab 250-100 Tier 1COARTEM TAB 20-120MG Tier 3

Antimalarialschloroquine tab 250mg Tier 1chloroquine tab 500mg Tier 1DARAPRIM TAB 25MG Tier 2hydroxychlor tab 200mg Tier 1mefloquine tab 250mg Tier 1PRIMAQUINE TAB 26.3MG Tier 2quinine sulf cap 324mg Tier 1

ANTIMYASTHENIC AGENTSAntimyasthenic Agents

MESTINON SYP 60MG/5ML Tier 2MESTINON TAB TIMESPAN Tier 2MYTELASE TAB 10MG Tier 2pyridostigm tab 60mg Tier 1

ANTIMYCOBACTERIAL AGENTSAnti TB Combinations



Drug Name Drug Tier Requirements/Limitsisonarif cap Tier 1RIFATER TAB Tier 2

Antimycobacterial Agentscycloserine cap 250mg Tier 1 PAethambutol tab 100mg Tier 1ethambutol tab 400mg Tier 1isoniazid syp 50mg/5ml Tier 1isoniazid tab 100mg Tier 1isoniazid tab 300mg Tier 1MYCOBUTIN CAP 150MG Tier 2PASER GRA 4GM Tier 2 PAPRIFTIN TAB 150MG Tier 3pyrazinamide tab 500mg Tier 1rifampin cap 150mg Tier 1rifampin cap 300mg Tier 1TRECATOR TAB 250MG Tier 2

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAlkylating Agents

ALKERAN TAB 2MG Tier 3cyclophosph tab 25mg Tier 1cyclophosph tab 50mg Tier 1HEXALEN CAP 50MG Tier 3 PALEUKERAN TAB 2MG Tier 3lomustine cap 10mg Tier 3lomustine cap 40mg Tier 3lomustine cap 100mg Tier 3MYLERAN TAB 2MG Tier 3TEMODAR CAP 5MG Tier 4 PATEMODAR CAP 20MG Tier 4 PATEMODAR CAP 100MG Tier 4 PATEMODAR CAP 140MG Tier 4 PATEMODAR CAP 180MG Tier 4 PATEMODAR CAP 250MG Tier 4 PA

Antimetabolitesmercaptopur tab 50mg Tier 1methotrexate tab 2.5mg Tier 1OFORTA TAB 10MG Tier 4 PATABLOID TAB 40MG Tier 3 PAXELODA TAB 150MG Tier 4 PAXELODA TAB 500MG Tier 4 PA

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE CAP 150MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsAntineoplastic - Hormonal and Related Agents

anastrozole tab 1mg Tier 1bicalutamide tab 50mg Tier 1ELIGARD INJ 7.5MG Tier 4 PAELIGARD INJ 22.5MG Tier 4 PAELIGARD INJ 30MG Tier 4 PAELIGARD INJ 45MG Tier 4 PAEMCYT CAP 140MG Tier 3exemestane tab 25mg Tier 1FARESTON TAB 60MG Tier 3flutamide cap 125mg Tier 1letrozole tab 2.5mg Tier 1leuprolide inj 1mg/0.2 Tier 4 PALUPRON DEPOT INJ 3.75MG Tier 4 PALUPRON DEPOT INJ 7.5MG Tier 4 PALUPRON DEPOT INJ 11.25MG Tier 4 PALUPRON DEPOT INJ 22.5MG Tier 4 PALUPRON DEPOT INJ 30MG Tier 4 PALYSODREN TAB 500MG Tier 3megestrol ac sus 40mg/ml Tier 1megestrol ac sus 400mg/10 Tier 1megestrol ac tab 20mg Tier 1megestrol ac tab 40mg Tier 1NILANDRON TAB 150MG Tier 3 PAtamoxifen tab 10mg Tier 1tamoxifen tab 20mg Tier 1TRELSTAR DEP INJ 3.75MG Tier 4 PATRELSTAR LA INJ 11.25MG Tier 4 PAVANTAS KIT 50MG Tier 4 PAZYTIGA TAB 250MG Tier 4 PA

Antineoplastic Enzyme InhibitorsAFINITOR TAB 2.5MG Tier 4 PAAFINITOR TAB 5MG Tier 4 PAAFINITOR TAB 7.5MG Tier 4 PAAFINITOR TAB 10MG Tier 4 PACAPRELSA TAB 100MG Tier 4 PACAPRELSA TAB 300MG Tier 4 PAGLEEVEC TAB 100MG Tier 4 PAGLEEVEC TAB 400MG Tier 4 PAJAKAFI TAB 5MG Tier 4 PAJAKAFI TAB 10MG Tier 4 PAJAKAFI TAB 15MG Tier 4 PAJAKAFI TAB 20MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsJAKAFI TAB 25MG Tier 4 PANEXAVAR TAB 200MG Tier 4 PASPRYCEL TAB 20MG Tier 4 PASPRYCEL TAB 50MG Tier 4 PASPRYCEL TAB 70MG Tier 4 PASPRYCEL TAB 80MG Tier 4 PASPRYCEL TAB 100MG Tier 4 PASPRYCEL TAB 140MG Tier 4 PASUTENT CAP 12.5MG Tier 4 PASUTENT CAP 25MG Tier 4 PASUTENT CAP 50MG Tier 4 PATARCEVA TAB 25MG Tier 4 PATARCEVA TAB 100MG Tier 4 PATARCEVA TAB 150MG Tier 4 PATASIGNA CAP 150MG Tier 4 PATASIGNA CAP 200MG Tier 4 PATYKERB TAB 250MG Tier 4 PAVANDETANIB TAB 100MG Tier 4 PAVANDETANIB TAB 300MG Tier 4 PAVOTRIENT TAB 200MG Tier 4 PAXALKORI CAP 200MG Tier 4 PAXALKORI CAP 250MG Tier 4 PAZELBORAF TAB 240MG Tier 4 PAZOLINZA CAP 100MG Tier 4 PA

Antineoplastics Misc.ACTIMMUNE INJ 2MU/0.5 Tier 4 PAALFERON N INJ 5MU/ML Tier 4 PAhydroxyurea cap 500mg Tier 1INTRON-A INJ 3MU PEN Tier 4 PAINTRON-A INJ 5MU PEN Tier 4 PAINTRON-A INJ 10MU Tier 4 PAINTRON-A INJ 10MU PEN Tier 4 PAINTRON-A INJ 18MU Tier 4 PAINTRON-A INJ 25MU Tier 4 PAINTRON-A INJ 50MU Tier 4 PAMATULANE CAP 50MG Tier 3 PAPROLEUKIN INJ 22MU Tier 4 PATARGRETIN CAP 75MG Tier 4 PAtretinoin cap 10mg Tier 1 PA

Chemotherapy Rescue/Antidote Agentsleucovor ca tab 5mg Tier 1leucovor ca tab 10mg Tier 1leucovor ca tab 15mg Tier 1



Drug Name Drug Tier Requirements/Limitsleucovor ca tab 25mg Tier 1

Mitotic Inhibitorsetoposide cap 50mg Tier 1 PA

ANTIPARKINSON AGENTSAntiparkinson Adjuvants

LODOSYN TAB 25MG Tier 2Antiparkinson Anticholinergics

benztropine inj 1mg/ml Tier 1benztropine tab 0.5mg Tier 1benztropine tab 1mg Tier 1benztropine tab 2mg Tier 1trihexyphen elx 0.4mg/ml Tier 1trihexyphen tab 2mg Tier 1trihexyphen tab 5mg Tier 1

Antiparkinson COMT Inhibitorsentacapone tab 200mg Tier 1TASMAR TAB 100MG Tier 3

Antiparkinson Dopaminergicsamantadine cap 100mg Tier 1amantadine syp 50mg/5ml Tier 1amantadine tab 100mg Tier 1APOKYN INJ Tier 4 PAAPOKYN INJ 10MG/ML Tier 4 PAbromocriptin cap 5mg Tier 1bromocriptin tab 2.5mg Tier 1carb/levo er tab 25-100mg Tier 1carb/levo er tab 50-200mg Tier 1carb/levo sr tab 25-100mg Tier 1carb/levo sr tab 50-200mg Tier 1carb/levo tab 10-100mg Tier 1carb/levo tab 25-100mg Tier 1carb/levo tab 25-250mg Tier 1pramipexole tab 0.5mg Tier 1pramipexole tab 0.25mg Tier 1pramipexole tab 0.75mg Tier 1pramipexole tab 0.125mg Tier 1pramipexole tab 1.5mg Tier 1pramipexole tab 1mg Tier 1ropinirole tab 0.5mg Tier 1ropinirole tab 0.25mg Tier 1ropinirole tab 1mg Tier 1ropinirole tab 2mg Tier 1



Drug Name Drug Tier Requirements/Limitsropinirole tab 2mg er Tier 1 PAropinirole tab 3mg Tier 1ropinirole tab 4mg Tier 1ropinirole tab 4mg er Tier 1 PAropinirole tab 5mg Tier 1ropinirole tab 6mg er Tier 1 PAropinirole tab 8mg er Tier 1 PAropinirole tab 12mg er Tier 1 PA

Antiparkinson Monoamine Oxidase InhibitorsAZILECT TAB 0.5MG Tier 3 PAAZILECT TAB 1MG Tier 3 PAselegiline cap 5mg Tier 1selegiline tab 5mg Tier 1ZELAPAR TAB 1.25MG Tier 3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTSAntimanic Agents

lithium carb cap 150mg Tier 1lithium carb cap 300mg Tier 1lithium carb cap 600mg Tier 1lithium carb tab 300mg Tier 1lithium carb tab 300mg er Tier 1lithium carb tab 450mg er Tier 1LITHIUM CITR SOL 8MEQ/5ML Tier 2

Antipsychotics - Misc.LATUDA TAB 20MG Tier 2 STLATUDA TAB 40MG Tier 2 STLATUDA TAB 80MG Tier 2 STLATUDA TAB 120MG Tier 2 STziprasidone cap 20mg Tier 1 STziprasidone cap 40mg Tier 1 STziprasidone cap 60mg Tier 1 STziprasidone cap 80mg Tier 1 ST

BenzisoxazolesFANAPT PAK Tier 3 PAFANAPT TAB 1MG Tier 3 PAFANAPT TAB 2MG Tier 3 PAFANAPT TAB 4MG Tier 3 PAFANAPT TAB 6MG Tier 3 PAFANAPT TAB 8MG Tier 3 PAFANAPT TAB 10MG Tier 3 PAFANAPT TAB 12MG Tier 3 PAINVEGA TAB 1.5MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsINVEGA TAB 3MG Tier 3 PAINVEGA TAB 6MG Tier 3 PAINVEGA TAB 9MG Tier 3 PArisperidone sol 1mg/ml Tier 1risperidone tab 0.5mg Tier 1risperidone tab 0.5mg od Tier 1risperidone tab 0.25 odt Tier 1risperidone tab 0.25mg Tier 1risperidone tab 1mg Tier 1risperidone tab 1mg odt Tier 1risperidone tab 2mg Tier 1risperidone tab 2mg odt Tier 1risperidone tab 3mg Tier 1risperidone tab 3mg odt Tier 1risperidone tab 4mg Tier 1risperidone tab 4mg odt Tier 1

Butyrophenoneshaloperidol con 2mg/ml Tier 1haloperidol tab 0.5mg Tier 1haloperidol tab 1mg Tier 1haloperidol tab 2mg Tier 1haloperidol tab 5mg Tier 1haloperidol tab 10mg Tier 1haloperidol tab 20mg Tier 1

Dibenzapinesclozapine tab 12.5/odt Tier 1clozapine tab 25mg Tier 1clozapine tab 25mg odt Tier 1clozapine tab 50mg Tier 1clozapine tab 100/odt Tier 1clozapine tab 100mg Tier 1clozapine tab 200mg Tier 1loxapine cap 5mg Tier 1loxapine cap 10mg Tier 1loxapine cap 25mg Tier 1loxapine cap 50mg Tier 1olanzapine tab 2.5mg Tier 1 STolanzapine tab 5mg Tier 1 STolanzapine tab 7.5mg Tier 1 STolanzapine tab 10mg Tier 1 STolanzapine tab 15mg Tier 1 STolanzapine tab 20mg Tier 1 STquetiapine tab 25mg Tier 1 ST



Drug Name Drug Tier Requirements/Limitsquetiapine tab 50mg Tier 1 STquetiapine tab 100mg Tier 1 STquetiapine tab 200mg Tier 1 STquetiapine tab 300mg Tier 1 STquetiapine tab 400mg Tier 1 STSAPHRIS SUB 5MG Tier 3 PASAPHRIS SUB 10MG Tier 3 PASEROQUEL XR TAB 50MG Tier 3 PASEROQUEL XR TAB 150MG Tier 3 PASEROQUEL XR TAB 200MG Tier 3 PASEROQUEL XR TAB 300MG Tier 3 PASEROQUEL XR TAB 400MG Tier 3 PA

Phenothiazineschlorpromaz tab 10mg Tier 1chlorpromaz tab 25mg Tier 1chlorpromaz tab 50mg Tier 1chlorpromaz tab 100mg Tier 1chlorpromaz tab 200mg Tier 1compro sup 25mg Tier 1fluphenazine con 5mg/ml Tier 1fluphenazine elx 2.5/5ml Tier 1fluphenazine tab 1mg Tier 1fluphenazine tab 2.5mg Tier 1fluphenazine tab 5mg Tier 1fluphenazine tab 10mg Tier 1perphenazine tab 2mg Tier 1perphenazine tab 4mg Tier 1perphenazine tab 8mg Tier 1perphenazine tab 16mg Tier 1prochlorper sup 25mg Tier 1prochlorper tab 5mg Tier 1prochlorper tab 10mg Tier 1thioridazine tab 10mg Tier 1thioridazine tab 25mg Tier 1thioridazine tab 50mg Tier 1thioridazine tab 100mg Tier 1trifluoperaz tab 1mg Tier 1trifluoperaz tab 2mg Tier 1trifluoperaz tab 5mg Tier 1trifluoperaz tab 10mg Tier 1

Quinolinone DerivativesABILIFY DISC TAB 10MG Tier 3 STABILIFY DISC TAB 15MG Tier 3 ST



Drug Name Drug Tier Requirements/LimitsABILIFY SOL 1MG/ML Tier 3 STABILIFY TAB 2MG Tier 3 STABILIFY TAB 5MG Tier 3 STABILIFY TAB 10MG Tier 3 STABILIFY TAB 15MG Tier 3 STABILIFY TAB 20MG Tier 3 STABILIFY TAB 30MG Tier 3 ST

Thioxanthenesthiothixene cap 1mg Tier 1thiothixene cap 2mg Tier 1thiothixene cap 5mg Tier 1thiothixene cap 10mg Tier 1

ANTISEPTICS DISINFECTANTSChlorine Antiseptics

PHISOHEX LIQ 3% Tier 2

ANTIVIRALSAntiretrovirals

abacavir tab 300mg Tier 1APTIVUS CAP 250MG Tier 2APTIVUS SOL Tier 2ATRIPLA TAB Tier 2COMPLERA TAB Tier 2CRIXIVAN CAP 100MG Tier 2CRIXIVAN CAP 200MG Tier 2CRIXIVAN CAP 400MG Tier 2didanosine cap 125mg Tier 1didanosine cap 200mg Tier 1didanosine cap 250mg Tier 1didanosine cap 400mg Tier 1EDURANT TAB 25MG Tier 2EMTRIVA CAP 200MG Tier 2EMTRIVA SOL 10MG/ML Tier 2EPIVIR HBV SOL 5MG/ML Tier 2EPIVIR HBV TAB 100MG Tier 2EPZICOM TAB 600-300 Tier 2FUZEON INJ 90MG Tier 4 PAFUZEON KIT Tier 4 PAINTELENCE TAB 25MG Tier 4 PAINTELENCE TAB 100MG Tier 4 PAINTELENCE TAB 200MG Tier 4 PAINVIRASE CAP 200MG Tier 2INVIRASE TAB 500MG Tier 2



Drug Name Drug Tier Requirements/LimitsISENTRESS CHW 25MG Tier 2ISENTRESS CHW 100MG Tier 2ISENTRESS TAB 400MG Tier 2KALETRA SOL Tier 2KALETRA TAB 100-25MG Tier 2KALETRA TAB 200-50MG Tier 2lamivud/zido tab 150-300 Tier 1lamivudine tab 150mg Tier 1lamivudine tab 300mg Tier 1LEXIVA SUS 50MG/ML Tier 2LEXIVA TAB 700MG Tier 2nevirapine sus 50mg/5ml Tier 1nevirapine tab 200mg Tier 1NORVIR CAP 100MG Tier 2NORVIR SOL 80MG/ML Tier 2NORVIR TAB 100MG Tier 2PREZISTA TAB 75MG Tier 2PREZISTA TAB 150MG Tier 2PREZISTA TAB 400MG Tier 2PREZISTA TAB 600MG Tier 2RESCRIPTOR TAB 100 MG Tier 2RESCRIPTOR TAB 200MG Tier 2REYATAZ CAP 100MG Tier 2REYATAZ CAP 150MG Tier 2REYATAZ CAP 200MG Tier 2REYATAZ CAP 300MG Tier 2SELZENTRY TAB 150MG Tier 2SELZENTRY TAB 300MG Tier 2stavudine cap 15mg Tier 1stavudine cap 20mg Tier 1stavudine cap 30mg Tier 1stavudine cap 40mg Tier 1stavudine sol 1mg/ml Tier 1STRIBILD TAB Tier 2 PASUSTIVA CAP 50MG Tier 2SUSTIVA CAP 200MG Tier 2SUSTIVA TAB 600MG Tier 2TRIZIVIR TAB Tier 2TRUVADA TAB 200-300 Tier 2VIRACEPT POW 50MG/GM Tier 2VIRACEPT TAB 250MG Tier 2VIRACEPT TAB 625MG Tier 2VIRAMUNE XR TAB 400MG Tier 2



Drug Name Drug Tier Requirements/LimitsVIREAD TAB 150MG Tier 2VIREAD TAB 200MG Tier 2VIREAD TAB 250MG Tier 2VIREAD TAB 300MG Tier 2ZIAGEN SOL 20MG/ML Tier 2zidovudine cap 100mg Tier 1zidovudine syp 50mg/5ml Tier 1zidovudine tab 300mg Tier 1

CMV AgentsVALCYTE SOL 50MG/ML Tier 3 PAVALCYTE TAB 450MG Tier 3 PA

Hepatitis AgentsBARACLUDE SOL .05MG/ML Tier 2BARACLUDE TAB 0.5MG Tier 2BARACLUDE TAB 1MG Tier 2HEPSERA TAB 10MG Tier 2INCIVEK TAB 375MG Tier 4 PAINFERGEN INJ 9MCG Tier 4 PAINFERGEN INJ 15MCG Tier 4 PAPEG-INTRON KIT 50MCG Tier 4 PAPEG-INTRON KIT 50MCG RP Tier 4 PAPEG-INTRON KIT 80MCG Tier 4 PAPEG-INTRON KIT 80MCG RP Tier 4 PAPEG-INTRON KIT 120 RP Tier 4 PAPEG-INTRON KIT 120MCG Tier 4 PAPEG-INTRON KIT 150 RP Tier 4 PAPEG-INTRON KIT 150MCG Tier 4 PAPEGASYS INJ Tier 4 PAPEGASYS INJ 180MCG/M Tier 4 PAPEGASYS INJ PROCLICK Tier 4 PAPEGASYS KIT Tier 4 PAREBETOL SOL 40MG/ML Tier 4 PARIBAPAK PAK 800/DAY Tier 4 PARIBAPAK PAK 1000/DAY Tier 4 PARIBAPAK PAK 1200/DAY Tier 4 PAribasphere cap 200mg Tier 4 PAribasphere tab 200mg Tier 4 PAribasphere tab 400mg Tier 4 PAribasphere tab 600mg Tier 4 PARIBATAB PAK 1000/DAY Tier 4 PARIBATAB TAB 800/DAY Tier 4 PARIBATAB TAB 1200/DAY Tier 4 PAribavirin cap 200mg Tier 4 PA



Drug Name Drug Tier Requirements/Limitsribavirin tab 200mg Tier 4 PATYZEKA TAB 600MG Tier 2VICTRELIS CAP 200MG Tier 4 PA

Herpes Agentsacyclovir cap 200mg Tier 1acyclovir sus 200/5ml Tier 1 PAacyclovir tab 400mg Tier 1acyclovir tab 800mg Tier 1famciclovir tab 125mg Tier 1famciclovir tab 250mg Tier 1famciclovir tab 500mg Tier 1valacyclovir tab 1gm Tier 1 PAvalacyclovir tab 500mg Tier 1 PA

Influenza AgentsRELENZA MIS DISKHALE Tier 2rimantadine tab 100mg Tier 1TAMIFLU CAP 30MG Tier 2TAMIFLU CAP 45MG Tier 2TAMIFLU CAP 75MG Tier 2TAMIFLU SUS 6MG/ML Tier 2TAMIFLU SUS 12MG/ML Tier 2

ASSORTED CLASSESChelating Agents

CUPRIMINE CAP 250MG Tier 2SYPRINE CAP 250MG Tier 3

ImmunomodulatorsREVLIMID CAP 5MG Tier 4 PAREVLIMID CAP 10MG Tier 4 PAREVLIMID CAP 15MG Tier 4 PAREVLIMID CAP 25MG Tier 4 PATHALOMID CAP 50MG Tier 4 PATHALOMID CAP 100MG Tier 4 PATHALOMID CAP 150MG Tier 4 PATHALOMID CAP 200MG Tier 4 PA

Immunosuppressive AgentsAZASAN TAB 75 MG Tier 2AZASAN TAB 100MG Tier 2azathioprine tab 50mg Tier 1CELLCEPT SUS 200MG/ML Tier 3cyclosporine cap 25mg Tier 1cyclosporine cap 25mg mod Tier 1cyclosporine cap 50mg mod Tier 1



Drug Name Drug Tier Requirements/Limitscyclosporine cap 100mg Tier 1cyclosporine cap 100mg md Tier 1cyclosporine sol modified Tier 1gengraf cap 25mg Tier 1gengraf cap 100mg Tier 1gengraf sol 100mg/ml Tier 1hecoria cap 0.5mg Tier 1hecoria cap 1mg Tier 1hecoria cap 5mg Tier 1mycophenolat cap 250mg Tier 1mycophenolat tab 500mg Tier 1MYFORTIC TAB 180MG Tier 3MYFORTIC TAB 360MG Tier 3RAPAMUNE SOL 1MG/ML Tier 3RAPAMUNE TAB 0.5MG Tier 3RAPAMUNE TAB 1MG Tier 3RAPAMUNE TAB 2MG Tier 3SANDIMMUNE SOL 100MG/ML Tier 1tacrolimus cap 0.5mg Tier 1tacrolimus cap 1mg Tier 1tacrolimus cap 5mg Tier 1ZORTRESS TAB 0.5MG Tier 3ZORTRESS TAB 0.25MG Tier 3ZORTRESS TAB 0.75MG Tier 3

Potassium Removing Resinskalexate pow Tier 1kionex pow usp Tier 1sod poly sul pow Tier 1

BETA BLOCKERSAlpha-Beta Blockers

carvedilol tab 3.125mg Tier 1carvedilol tab 6.25mg Tier 1carvedilol tab 12.5mg Tier 1carvedilol tab 25mg Tier 1COREG CR CAP 10MG Tier 3 PACOREG CR CAP 20MG Tier 3 PACOREG CR CAP 40MG Tier 3 PACOREG CR CAP 80MG Tier 3 PAlabetalol tab 100mg Tier 1labetalol tab 200mg Tier 1labetalol tab 300mg Tier 1

Beta Blockers Cardio-Selective



Drug Name Drug Tier Requirements/Limitsacebutolol cap 200mg Tier 1acebutolol cap 400mg Tier 1atenolol tab 25mg Tier 1atenolol tab 50mg Tier 1atenolol tab 100mg Tier 1betaxolol tab 10mg Tier 1betaxolol tab 20mg Tier 1bisoprol fum tab 5mg Tier 1bisoprol fum tab 10mg Tier 1BYSTOLIC TAB 2.5MG Tier 3BYSTOLIC TAB 5MG Tier 3BYSTOLIC TAB 10MG Tier 3BYSTOLIC TAB 20MG Tier 3metoprol tar tab 25mg Tier 1metoprol tar tab 50mg Tier 1metoprol tar tab 100mg Tier 1metoprolol tab 25mg er Tier 1metoprolol tab 50mg er Tier 1metoprolol tab 100mg er Tier 1metoprolol tab 200mg er Tier 1

Beta Blockers Non-SelectiveLEVATOL TAB 20MG Tier 2nadolol tab 20mg Tier 1nadolol tab 40mg Tier 1nadolol tab 80mg Tier 1pindolol tab 5mg Tier 1pindolol tab 10mg Tier 1propranolol cap 60mg er Tier 1propranolol cap 80mg er Tier 1propranolol cap 120mg er Tier 1propranolol cap 160mg er Tier 1propranolol tab 10mg Tier 1propranolol tab 20mg Tier 1propranolol tab 40mg Tier 1propranolol tab 60mg Tier 1propranolol tab 80mg Tier 1sorine tab 80mg Tier 1sorine tab 120mg Tier 1sorine tab 160mg Tier 1sorine tab 240mg Tier 1sotalol af tab 80mg Tier 1sotalol af tab 120mg Tier 1sotalol af tab 160mg Tier 1



Drug Name Drug Tier Requirements/Limitssotalol hcl tab 80mg Tier 1sotalol hcl tab 120mg Tier 1sotalol hcl tab 160mg Tier 1sotalol hcl tab 240mg Tier 1timolol mal tab 5mg Tier 1timolol mal tab 10mg Tier 1timolol mal tab 20mg Tier 1

CALCIUM CHANNEL BLOCKERSCalcium Channel Blockers

afeditab tab 30mg cr Tier 1afeditab tab 60mg cr Tier 1amlodipine tab 2.5mg Tier 1amlodipine tab 5mg Tier 1amlodipine tab 10mg Tier 1cartia xt cap 120/24hr Tier 1cartia xt cap 180/24hr Tier 1cartia xt cap 240/24hr Tier 1cartia xt cap 300/24hr Tier 1COVERA-HS TAB 180MG Tier 2 PACOVERA-HS TAB 240MG Tier 2 PAdilt-cd cap 120mg Tier 1dilt-cd cap 180mg Tier 1dilt-cd cap 240mg Tier 1dilt-cd cap 300mg Tier 1dilt-xr cap 120mg Tier 1dilt-xr cap 180mg Tier 1dilt-xr cap 240mg Tier 1diltiazem cap 60mg er Tier 1diltiazem cap 90mg er Tier 1diltiazem cap 120mg cd Tier 1diltiazem cap 120mg er Tier 1diltiazem cap 120mg/24 Tier 1diltiazem cap 180mg cd Tier 1diltiazem cap 180mg er Tier 1diltiazem cap 180mg/24 Tier 1diltiazem cap 240mg cd Tier 1diltiazem cap 240mg er Tier 1diltiazem cap 240mg/24 Tier 1diltiazem cap 300mg cd Tier 1diltiazem cap 300mg er Tier 1diltiazem cap 300mg/24 Tier 1diltiazem cap 360mg cd Tier 1



Drug Name Drug Tier Requirements/Limitsdiltiazem cap 360mg er Tier 1diltiazem cap 360mg/24 Tier 1diltiazem cap 420mg/24 Tier 1diltiazem tab 30mg Tier 1diltiazem tab 60mg Tier 1diltiazem tab 90mg Tier 1diltiazem tab 120mg Tier 1diltzac cap 120mg/24 Tier 1diltzac cap 180mg/24 Tier 1diltzac cap 240mg/24 Tier 1diltzac cap 300mg/24 Tier 1diltzac cap 360mg/24 Tier 1DYNACIRC CR TAB 5MG Tier 2DYNACIRC CR TAB 10MG Tier 2felodipine tab 2.5mg er Tier 1felodipine tab 5mg er Tier 1felodipine tab 10mg er Tier 1isradipine cap 2.5mg Tier 1isradipine cap 5mg Tier 1nicardipine cap 20mg Tier 1 PAnicardipine cap 30mg Tier 1 PAnifediac cc tab 30mg er Tier 1nifediac cc tab 60mg er Tier 1nifediac cc tab 90mg er Tier 1nifedical xl tab 30mg Tier 1nifedical xl tab 60mg Tier 1nifedipine cap 10mg Tier 1nifedipine cap 20mg Tier 1nifedipine tab 30mg er Tier 1nifedipine tab 60mg er Tier 1nifedipine tab 90mg er Tier 1nimodipine cap 30mg Tier 1 PAnisoldipine tab 8.5mg er Tier 1 PAnisoldipine tab 17mg er Tier 1 PAnisoldipine tab 20mg Tier 1 PAnisoldipine tab 25.5mg Tier 1 PAnisoldipine tab 30mg Tier 1 PAnisoldipine tab 34mg er Tier 1 PAnisoldipine tab 40mg Tier 1 PAtaztia xt cap 120mg/24 Tier 1taztia xt cap 180mg/24 Tier 1taztia xt cap 240mg/24 Tier 1taztia xt cap 300mg/24 Tier 1



Drug Name Drug Tier Requirements/Limitstaztia xt cap 360mg/24 Tier 1verapamil cap 120mg er Tier 1verapamil cap 120mg sr Tier 1verapamil cap 180mg er Tier 1verapamil cap 180mg sr Tier 1verapamil cap 240mg er Tier 1verapamil cap 240mg sr Tier 1verapamil cap 360mg sr Tier 1verapamil tab 40mg Tier 1verapamil tab 80mg Tier 1verapamil tab 120mg Tier 1verapamil tab 120mg er Tier 1verapamil tab 120mg sr Tier 1verapamil tab 180mg er Tier 1verapamil tab 180mg sr Tier 1verapamil tab 240mg er Tier 1verapamil tab 240mg sr Tier 1

CARDIOTONICSCardiac Glycosides

digoxin tab 0.25mg Tier 1digoxin tab 0.125mg Tier 1

CARDIOVASCULAR AGENTS - MISC.Impotence Agents

CIALIS TAB 2.5MG Tier 3 PA; QLCIALIS TAB 5MG Tier 3 PA; QLCIALIS TAB 10MG Tier 3 PA; QLCIALIS TAB 20MG Tier 3 PA; QLLEVITRA TAB 2.5MG Tier 3 PA; QLLEVITRA TAB 5MG Tier 3 PA; QLLEVITRA TAB 10MG Tier 3 PA; QLLEVITRA TAB 20MG Tier 3 PA; QLSTAXYN TAB 10MG Tier 3 PA; QLVIAGRA TAB 25MG Tier 3 PA; QLVIAGRA TAB 50MG Tier 3 PA; QLVIAGRA TAB 100MG Tier 3 PA; QLyohimbine tab 5.4mg Tier 1 PA

Prostaglandin VasodilatorsREMODULIN INJ 1MG/ML Tier 4 PAREMODULIN INJ 2.5MG/ML Tier 4 PAREMODULIN INJ 5MG/ML Tier 4 PAREMODULIN INJ 10MG/ML Tier 4 PAVENTAVIS SOL 10MCG/ML Tier 4 PA



Drug Name Drug Tier Requirements/LimitsPulmonary Hypertension - Endothelin Receptor Antagonists

LETAIRIS TAB 5MG Tier 4 PALETAIRIS TAB 10MG Tier 4 PATRACLEER TAB 62.5MG Tier 4 PATRACLEER TAB 125MG Tier 4 PA

Pulmonary Hypertension - Phosphodiesterase Inhibitorssildenafil tab 20mg Tier 4 PA

CEPHALOSPORINSCephalosporins - 1st Generation

cefadroxil cap 500mg Tier 1cefadroxil sus 250/5ml Tier 1cefadroxil sus 500/5ml Tier 1cefadroxil tab 1gm Tier 1cephalexin cap 250mg Tier 1cephalexin cap 500mg Tier 1cephalexin cap 750mg Tier 2 PAcephalexin sus 125/5ml Tier 1cephalexin sus 250/5ml Tier 1cephalexin tab 250mg Tier 1cephalexin tab 500mg Tier 1KEFLEX CAP 750MG Tier 2 PA

Cephalosporins - 2nd Generationcefaclor cap 250mg Tier 1cefaclor cap 500mg Tier 1cefaclor sus 125/5ml Tier 1cefaclor sus 250/5ml Tier 1cefaclor sus 375/5ml Tier 1cefprozil sus 125/5ml Tier 1cefprozil sus 250/5ml Tier 1cefprozil tab 250mg Tier 1cefprozil tab 500mg Tier 1CEFTIN SUS 250/5ML Tier 2cefuroxime sus 125/5ml Tier 1cefuroxime tab 250mg Tier 1cefuroxime tab 500mg Tier 1

Cephalosporins - 3rd GenerationCEDAX CAP 400MG Tier 3 PAcefdinir cap 300mg Tier 1cefdinir sus 125/5ml Tier 1cefdinir sus 250/5ml Tier 1cefditoren tab 200mg Tier 1cefditoren tab 400mg Tier 1



Drug Name Drug Tier Requirements/Limitscefpodo prox sus 50mg/5ml Tier 1cefpodo prox sus 100/5ml Tier 1cefpodoxime tab 100mg Tier 1cefpodoxime tab 200mg Tier 1SUPRAX SUS 100/5ML Tier 2SUPRAX SUS 200/5ML Tier 2SUPRAX TAB 400MG Tier 2

CONTRACEPTIVESCombination Contraceptives - Oral

altavera tab Tier 0alyacen tab 1/35 Tier 0alyacen tab 7/7/7 Tier 0amethyst tab 90-20mcg Tier 0apri tab Tier 0aranelle tab Tier 0aviane tab Tier 0azurette tab 28 day Tier 0balziva tab Tier 0briellyn tab Tier 0caziant pak Tier 0cesia pak Tier 0chateal tab 0.15/30 Tier 0cryselle-28 tab 28 tabs Tier 0cyclafem tab 1/35 Tier 0cyclafem tab 7/7/7 Tier 0dasetta tab 1/35 Tier 0dasetta tab 7/7/7 Tier 0drospir/ethi tab 3-0.03mg Tier 0elinest tab Tier 0emoquette tab Tier 0enpresse-28 tab Tier 0enskyce tab Tier 0estarylla tab 0.25-35 Tier 0falmina tab Tier 0gianvi tab 3-0.02mg Tier 0gildagia tab 0.4-35 Tier 0gildess fe tab 1.5/30 Tier 0gildess fe tab 1/20 Tier 0gildess tab 1.5/30 Tier 0gildess tab 1/20 Tier 0junel 1.5/30 tab Tier 0junel 1/20 tab Tier 0



Drug Name Drug Tier Requirements/Limitsjunel fe tab 1.5/30 Tier 0junel fe tab 1/20 Tier 0kariva tab 28 day Tier 0kelnor tab 1/35 Tier 0kurvelo tab 0.15/30 Tier 0leena tab Tier 0lessina tab Tier 0levonest tab Tier 0levonor/ethi tab 0.1-0.02 Tier 0levonor/ethi tab estradio Tier 0levora-28 tab 0.15/30 Tier 0loryna tab 3-0.02mg Tier 0low-ogestrel tab Tier 0lutera tab Tier 0marlissa tab 0.15/30 Tier 0microgestin tab 1.5/30 Tier 0microgestin tab 1/20 Tier 0microgestin tab fe1.5/30 Tier 0microgestin tab fe 1/20 Tier 0mono-linyah tab 0.25-35 Tier 0mononessa tab Tier 0myzilra tab Tier 0necon tab 0.5/35 Tier 0necon tab 1/35 Tier 0necon tab 1/50-28 Tier 0necon tab 7/7/7 Tier 0norgest/eth tab estrad Tier 0norgest/ethi tab 0.25/35 Tier 0norgest/ethi tab estradio Tier 0nortrel tab 0.5/35 Tier 0nortrel tab 1/35 Tier 0nortrel tab 7/7/7 Tier 0ocella tab 3-0.03mg Tier 0ogestrel tab Tier 0orsythia tab Tier 0philith tab 0.4-35 Tier 0pirmella tab 1/35 Tier 0pirmella tab 7/7/7 Tier 0portia-28 tab Tier 0previfem tab Tier 0reclipsen tab Tier 0solia tab Tier 0sprintec 28 tab 28 day Tier 0



Drug Name Drug Tier Requirements/Limitssronyx tab Tier 0syeda tab 3-0.03mg Tier 0tilia fe tab Tier 0tri-estaryll tab Tier 0tri-legest tab fe Tier 0tri-linyah tab Tier 0tri-previfem tab Tier 0tri-sprintec tab Tier 0trinessa tab Tier 0trivora-28 tab Tier 0velivet pak Tier 0vestura tab 3-0.02mg Tier 0viorele tab Tier 0wera tab 0.5/35 Tier 0wymzya fe chw 0.4mg-35 Tier 0zarah tab 3-0.03mg Tier 0zenchent fe chw Tier 0zenchent fe chw 0.4mg-35 Tier 0zenchent tab Tier 0zeosa chw Tier 0zovia 1/35e tab Tier 0zovia 1/50e tab Tier 0

Combination Contraceptives - TransdermalORTHO EVRA DIS WEEK Tier 0

Combination Contraceptives - VaginalNUVARING MIS Tier 0

Emergency ContraceptivesELLA TAB 30MG Tier 0levonorgestr tab 0.75mg Tier 0my way tab 1.5mg Tier 0next choice tab 0.75mg Tier 0next choice tab 1.5mg Tier 0PLAN B TAB 1.5MG Tier 0

Progestin Contraceptives - IUDMIRENA IUD SYSTEM Tier 0 PA

Progestin Contraceptives - InjectableDEPO-SQ PROV INJ 104 Tier 2medroxypr ac inj 150mg/ml Tier 0

Progestin Contraceptives - Oralcamila tab 0.35mg Tier 0errin tab 0.35mg Tier 0heather tab 0.35mg Tier 0jencycla tab 0.35mg Tier 0



Drug Name Drug Tier Requirements/Limitsjolivette tab 0.35mg Tier 0nora-be tab 0.35mg Tier 0norethindron tab 0.35mg Tier 0

CORTICOSTEROIDSGlucocorticosteroids

asmalpred sol 15mg/5ml Tier 1asmalpred sol plus Tier 1baycadron elx 0.5/5ml Tier 1budesonide cap 3mg/24hr Tier 1 PAcortisone ac tab 25mg Tier 1dexamethason elx 0.5/5ml Tier 1dexamethason sol 0.5/5ml Tier 1dexamethason tab 0.5mg Tier 1dexamethason tab 0.75mg Tier 1dexamethason tab 1.5mg Tier 1dexamethason tab 1mg Tier 1dexamethason tab 2mg Tier 1dexamethason tab 4mg Tier 1dexamethason tab 6mg Tier 1hydrocort tab 20mg Tier 1methylpred pak 4mg Tier 1methylpred tab 4mg Tier 1methylpred tab 8mg Tier 1methylpred tab 16mg Tier 1methylpred tab 32mg Tier 1MILLIPRED SOL 10MG/5ML Tier 2MILLIPRED TAB 5MG Tier 2ORAPRED ODT TAB 10MG Tier 2 PAORAPRED ODT TAB 15MG Tier 2 PAORAPRED ODT TAB 30MG Tier 2 PApred sod pho sol 5mg/5ml Tier 1pred sod pho sol 6.7/5ml Tier 1prednisolone sol 15mg/5ml Tier 1prednisolone sol 25mg/5ml Tier 1prednisolone syp 15mg/5ml Tier 1prednisone pak 5mg Tier 1prednisone pak 10mg Tier 1prednisone sol 5mg/5ml Tier 1prednisone tab 1mg Tier 1prednisone tab 2.5mg Tier 1prednisone tab 5mg Tier 1prednisone tab 10mg Tier 1



Drug Name Drug Tier Requirements/Limitsprednisone tab 20mg Tier 1prednisone tab 50mg Tier 1VERIPRED 20 SOL 20MG/5ML Tier 2

Mineralocorticoidsfludrocort tab 0.1mg Tier 1

COUGH/COLD/ALLERGYAntitussives

benzonatate cap 100mg Tier 1benzonatate cap 200mg Tier 1hydrocod/hom syp 5-1.5/5 Tier 1hydromet syp 5-1.5/5 Tier 1

Cough/Cold/Allergy Combinationsallergy-d tab 12 hour Tier 1allergy-d tab 60-120mg Tier 1alrgy relf d tab 180-240 Tier 1biocotron liq 100-10/5 Tier 1brom/pse/dm syp Tier 1bromfed dm syp Tier 1broncotron liq 10-100/5 Tier 1c-phen dm syp Tier 1ceron-dm syp Tier 1cheratussin sol dac Tier 1cheratussin syp ac Tier 1diabetic tus liq children Tier 1diabetic tus liq dm Tier 1dimetane dx syp Tier 1dm/gg sol Tier 1dm/gg sol 10-100/5 Tier 1fexofen/pse tab 180-240 Tier 1g-tron liq 10-100/5 Tier 1gani-tuss dm liq 100-10/5 Tier 1gani-tuss nr liq 100-10/5 Tier 1gg/codeine sol 100-10/5 Tier 1gnp tussin liq dm Tier 1gnp tussin liq dm cough Tier 1guaiasorb dm liq 100-10/5 Tier 1guaiatussin syp ac Tier 1guaifenesin sol dac Tier 1guaifenesin syp ac Tier 1hm tussin liq adlt dm Tier 1hyd polst-ch liq lor pols Tier 1iophen c-nr liq 100-10/5 Tier 1



Drug Name Drug Tier Requirements/Limitsiophen dm-nr liq 100-10/5 Tier 1medi-tuss dm liq diabetic Tier 1myci-gc sol 100-10/5 Tier 1mytussin ac syp 100-10/5 Tier 1mytussin dac sol Tier 1novagest/cod sol expect Tier 1ped formula liq 100-10/5 Tier 1prometh vc syp 6.25-5/5 Tier 1prometh vc syp plain Tier 1prometh vc/ syp codeine Tier 1prometh/cod syp 6.25-10 Tier 1promethazine syp dm Tier 1px tussin dm liq 100-10/5 Tier 1ra tussin dm liq 100-10/5 Tier 1robafen ac syp 100-10/5 Tier 1robitussin liq cgh/cong Tier 1robitussin liq to go dm Tier 1romilar ac sol 100-10/5 Tier 1safe tussin liq 10-100/5 Tier 1sb cgh contr liq dm Tier 1sildec pe-dm syp Tier 1siltussin dm liq das Tier 1siltussin-dm liq diabetic Tier 1tgt cough liq form dm Tier 1tolu-sed dm liq 100-10/5 Tier 1tusnel diabt liq 10-100/5 Tier 1tussin adult liq cgh/cong Tier 1tussin cough liq 10-100/5 Tier 1tussin cough liq congesti Tier 1tussin dm liq Tier 1tussin dm liq 100-10/5 Tier 1tussin dm liq clear Tier 1wal-fex d tab 12 hour Tier 1wal-fex d tab 24 hour Tier 1wal-tussin liq dm Tier 1

Misc. Respiratory Inhalantssod chloride neb 0.9% Tier 1sodium chlor neb 3% Tier 1

Mucolyticsacetylcyst sol 10% Tier 1acetylcyst sol 20% Tier 1

DERMATOLOGICALS



Drug Name Drug Tier Requirements/LimitsAcne Products

adapalene cre 0.1% Tier 1adapalene gel 0.1% Tier 1amnesteem cap 10mg Tier 1 PAamnesteem cap 20mg Tier 1 PAamnesteem cap 40mg Tier 1 PAATRALIN GEL 0.05% Tier 2 AGEavita cre 0.025% Tier 1 AGEavita gel 0.025% Tier 1 AGEAZELEX CRE 20% Tier 2claravis cap 10mg Tier 1 PAclaravis cap 20mg Tier 1 PAclaravis cap 30mg Tier 1 PAclaravis cap 40mg Tier 1 PAclindacin-p pad 1% Tier 1clindamax gel 1% Tier 1clindamax lot 10mg/ml Tier 1clindamy/ben gel 1-5% Tier 1clindamy/ben gel 1.2-5% Tier 1clindamycin aer 1% Tier 1clindamycin gel 1% Tier 1clindamycin lot 1% Tier 1clindamycin lot 10mg/ml Tier 1clindamycin pad 1% Tier 1clindamycin sol 1% Tier 1erythromycin gel 2% Tier 1erythromycin gel /benzoyl Tier 1erythromycin sol 2% Tier 1myorisan cap 10mg Tier 1 PAmyorisan cap 20mg Tier 1 PAmyorisan cap 40mg Tier 1 PAsotret cap 10mg Tier 1 PAsotret cap 20mg Tier 1 PAsotret cap 30mg Tier 1 PATRETIN-X CRE 0.0375% Tier 2 AGEtretinoin cre 0.1% Tier 1 AGEtretinoin cre 0.05% Tier 1 AGEtretinoin cre 0.025% Tier 1 AGEtretinoin gel 0.01% Tier 1 AGEtretinoin gel 0.025% Tier 1 AGEzenatane cap 10mg Tier 1 PAzenatane cap 20mg Tier 1 PAzenatane cap 40mg Tier 1 PA



Drug Name Drug Tier Requirements/LimitsAnti-inflammatory Agents - Topical

FLECTOR DIS 1.3% Tier 2Antibiotics - Topical

ALTABAX OIN 1% Tier 3CENTANY AT KIT 2% Tier 2centany oin 2% Tier 1CORTISPORIN OIN 1% Tier 2gentamicin cre 0.1% Tier 1gentamicin oin 0.1% Tier 1mupirocin ca cre 2% Tier 1mupirocin cre 2% Tier 1mupirocin oin 2% Tier 1

Antifungals - Topicalantifungal cre 1% Tier 1antifungal cre 2% Tier 1athlete foot cre 1% Tier 1baza antifun cre 2% Tier 1ciclodan cre 0.77% Tier 1ciclopirox cre 0.77% Tier 1ciclopirox sus 0.77% Tier 1clotrim/beta cre 1-0.05% Tier 1clotrim/beta cre diprop Tier 1clotrim/beta lot diprop Tier 1clotrimazole cre 1% Tier 1clotrimazole sol 1% Tier 1desenex cre 1% Tier 1econazole cre 1% Tier 1ERTACZO CRE 2% Tier 3EXELDERM CRE 1% Tier 2EXELDERM SOL 1% Tier 2fungicure spr intens Tier 1jock itch cre 1% Tier 1ketoconazole cre 2% Tier 1ketoconazole sha 2% Tier 1LOTRIMIN ULT CRE 1% Tier 2MENTAX CRE 1% Tier 2micaderm cre 2% Tier 1miconazole cre 2% Tier 1MICONAZOLE POW NITRATE Tier 1micro guard cre 2% Tier 1mp clotrimaz cre 1% Tier 1NAFTIN CRE 1% Tier 2NAFTIN CRE 2% Tier 2



Drug Name Drug Tier Requirements/LimitsNAFTIN GEL 1% Tier 2neosporin af cre 2% jock Tier 1NIZORAL A-D SHA 1% Tier 2nuzole cre 2% Tier 1nyamyc pow 100000 Tier 1nystat/triam cre Tier 1nystat/triam oin Tier 1nystatin cre 100000 Tier 1nystatin oin 100000 Tier 1NYSTATIN POW Tier 1nystatin pow 100000 Tier 1nystop pow 100000 Tier 1OXISTAT CRE 1% Tier 3OXISTAT LOT 1% Tier 3pedi-dri pow 100000 Tier 1podactin cre 2% Tier 1remedy cre antifung Tier 1ringworm cre 1% Tier 1sm antifungl cre 2% Tier 1soothe&cool cre inzo 2% Tier 1

Antineoplastic or Premalignant Lesion Agents - Topicalfluorouracil cre 5% Tier 1fluorouracil dro 2% Tier 1fluorouracil dro 5% Tier 1fluorouracil sol 2% Tier 1fluorouracil sol 5% Tier 1PANRETIN GEL 0.1% Tier 3 PAPICATO GEL 0.05% Tier 3 PAPICATO GEL 0.015% Tier 3 PA

Antipruritics - Topicalprudoxin cre 5% Tier 1

AntipsoriaticsAMEVIVE INJ 15MG Tier 4 PAcalcipotrien cre 0.005% Tier 1calcipotrien oin 0.005% Tier 1calcipotrien sol 0.005% Tier 1calcitrene oin 0.005% Tier 1calcitriol oin 3mcg/gm Tier 1DRITHO-CREME CRE HP 1% Tier 2DRITHO-SCALP CRE 0.5% Tier 28-MOP CAP 10MG Tier 3 PAOXSORALEN-UL CAP 10MG Tier 3 PASORIATANE CAP 10MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsSORIATANE CAP 17.5MG Tier 3 PASORIATANE CAP 25MG Tier 3 PASTELARA INJ 45MG/0.5 Tier 4 PASTELARA INJ 90MG/ML Tier 4 PATAZORAC GEL 0.1% Tier 2TAZORAC GEL 0.05% Tier 2

Antiseborrheic Productsselenium sul lot 2.5% Tier 1selenium sul sha 2.5% Tier 1selenium sul sha 2.25% Tier 1

Antivirals - TopicalDENAVIR CRE 1% Tier 2

Burn Productssilver sulfa cre 1% Tier 1ssd af cre 1% Tier 1ssd cre 1% Tier 1SULFAMYLON CRE 85MG/GM Tier 3thermazene cre 1% Tier 1

Corticosteroids - Topicalala cort cre 1% Tier 1ala-cort lot 1% Tier 1alclometason cre 0.05% Tier 1alclometason oin 0.05% Tier 1alphatrex gel 0.05% Tier 1amcinonide cre 0.1% Tier 1amcinonide lot 0.1% Tier 1anti-itch cre 1% Tier 1anti-itch cre 1%pls 10 Tier 1anti-itch cre /aloe/e Tier 1anti-itch cre /oatmeal Tier 1anti-itch lot 1% Tier 1apexicon oin 0.05% Tier 1aquanil hc lot 1% Tier 1aug betamet cre 0.05% Tier 1aug betamet gel 0.05% Tier 1aug betamet lot 0.05% Tier 1aug betamet oin 0.05% Tier 1aveeno cre 1% Tier 1beta hc lot 1% Tier 1betameth dip cre 0.05% Tier 1betameth dip lot 0.05% Tier 1betameth dip oin 0.05% Tier 1betameth val cre 0.1% Tier 1



Drug Name Drug Tier Requirements/Limitsbetameth val lot 0.1% Tier 1betameth val oin 0.1% Tier 1caldecort cre 1% Tier 1clobetasol cre 0.05% Tier 1clobetasol oin 0.05% Tier 1clobetasol sol 0.05% Tier 1CLODERM CRE 0.1% Tier 3CLODERM CRE 0.1% PMP Tier 3CORDRAN 24X3 TAP 4MCG/CM Tier 3CORDRAN 80X3 TAP 4MCG/CM Tier 3CORDRAN LOT 0.05% Tier 3CORDRAN SP CRE 0.05% Tier 3cormax oin 0.05% Tier 1cormax scalp sol 0.05% Tier 1cormax sol 0.05% Tier 1cort intense cre heal 1% Tier 1cortaid adv cre 1% 12 hr Tier 1cortaid cre 1% Tier 1cortisone + cre 1% Tier 1cortisone cre 1% Tier 1cortisone lot 1% Tier 1cortizone-10 lot eczema Tier 1cortizone-10 lot hydraten Tier 1cvs cort int cre heal 1% Tier 1desonide cre 0.05% Tier 1desonide lot 0.05% Tier 1desonide oin 0.05% Tier 1desoximetas cre 0.05% Tier 1desoximetas cre 0.25% Tier 1desoximetas gel 0.05% Tier 1desoximetas oin 0.05% Tier 1desoximetas oin 0.25% Tier 1diflorasone cre 0.05% Tier 1diflorasone oin 0.05% Tier 1eq hydrocort cre 1% Tier 1fluocin acet cre 0.01% Tier 1fluocin acet cre 0.025% Tier 1fluocin acet oil body Tier 1fluocin acet oil scalp Tier 1fluocin acet oin 0.025% Tier 1fluocin acet sol 0.01% Tier 1fluocinonide cre 0.05% Tier 1fluocinonide gel 0.05% Tier 1



Drug Name Drug Tier Requirements/Limitsfluocinonide oin 0.05% Tier 1fluocinonide sol 0.05% Tier 1fluticasone cre 0.05% Tier 1fluticasone lot 0.05% Tier 1fluticasone oin 0.005% Tier 1gnp hydrocor cre 1% plus Tier 1halobetasol cre 0.05% Tier 1halobetasol oin 0.05% Tier 1HALOG CRE 0.1% Tier 2HALOG OIN 0.1% Tier 2hc pramoxine cre 1-2.5% Tier 1hc valerate cre 0.2% Tier 1hc valerate oin 0.2% Tier 1hydro-lotion lot 1% Tier 1hydrocort cre 1% Tier 1hydrocort cre 1% plus Tier 1hydrocort cre 1%pls 10 Tier 1hydrocort cre 1%pls 12 Tier 1hydrocort cre 2.5% Tier 1hydrocort lot 1% Tier 1hydrocort lot 2.5% Tier 1hydrocort oin 2.5% Tier 1hydrocream cre 1% Tier 1hydroskin cre 1% Tier 1itch-x lot 1% Tier 1KENALOG AER SPRAY Tier 2kericort 10 cre 1% Tier 1lokara lot 0.05% Tier 1med-derm hc cre 1% Tier 1mometasone cre 0.1% Tier 1mometasone oin 0.1% Tier 1mometasone sol 0.1% Tier 1mp hydrocort cre 1% Tier 1neosporin cre eczema Tier 1noble formul cre hc 1% Tier 1pramcort cre 1-1% Tier 1prednicarbat cre 0.1% Tier 1prednicarbat oin 0.1% Tier 1prep h hc cre 1% Tier 1qc hydrocort cre 1% Tier 1ra anti-itch cre 1% Tier 1ra hydrocort cre 1% Tier 1ra hydrocort cre 1%pls 12 Tier 1



Drug Name Drug Tier Requirements/Limitsrecort plus cre 1% Tier 1rederm lot 1% Tier 1sarnol-hc lot 1% Tier 1sb hydrocort cre 1% Tier 1scalacort lot 2% Tier 1sm hydrocort cre 1% Tier 1TACLONEX OIN Tier 3 PATACLONEX SUS Tier 3 PAth hydrocort cre 1% Tier 1theracort lot 1% Tier 1triamcinolon cre 0.1% Tier 1triamcinolon cre 0.5% Tier 1triamcinolon cre 0.025% Tier 1triamcinolon lot 0.1% Tier 1triamcinolon lot 0.025% Tier 1triamcinolon oin 0.1% Tier 1triamcinolon oin 0.5% Tier 1triamcinolon oin 0.05% Tier 1triamcinolon oin 0.025% Tier 1triderm cre 0.1% Tier 1VANOS CRE 0.1% Tier 2

Emollientsal12 lot 12% Tier 1amlactin cre 12% Tier 1amlactin lot 12% Tier 1ammonium lac cre 12% Tier 1ammonium lac lot 12% Tier 1geri-hydrola cre 12% Tier 1geri-hydrola lot 12% Tier 1laclotion lot 12% Tier 1moist skin cre 12% Tier 1moist skin lot 12% Tier 1skin trtment lot 12% Tier 1

Enzymes - TopicalSANTYL OIN 250/GM Tier 3

Immunomodulating Agents - Topicalimiquimod cre 5% Tier 1

Immunosuppressive Agents - TopicalELIDEL CRE 1% Tier 2 PAPROTOPIC OIN 0.1% Tier 2 PAPROTOPIC OIN 0.03% Tier 2 PA

Keratolytic/Antimitotic Agentspodofilox sol 0.5% Tier 1



Drug Name Drug Tier Requirements/LimitsLocal Anesthetics - Topical

lido/prilocn cre 2.5-2.5% Tier 1lidocaine gel 2% Tier 1lidocaine gel 2% jelly Tier 1lidocaine oin 5% Tier 1lidocaine sol 4% 4% Tier 1LIDODERM DIS 5% Tier 2 PAregenecare gel ha 2% Tier 1SYNERA DIS 70-70MG Tier 3 PA

Misc. Topicalhypercare sol 20% Tier 1

Rosacea AgentsFINACEA GEL 15% Tier 2metronidazol cre 0.75% Tier 1metronidazol gel 0.75% Tier 1metronidazol gel 1% Tier 2metronidazol lot 0.75% Tier 1rosadan cre 0.75% Tier 1rosadan gel 0.75% Tier 1vitazol cre 0.75% Tier 1

Scabicides Pediculicidesacticin cre 5% Tier 1EURAX CRE 10% Tier 2EURAX LOT 10% Tier 2lindane sha 1% Tier 1malathion lot 0.5% Tier 1 STNIX LICE SPR CONTROL Tier 2permethrin cre 5% Tier 1PRONTO AER 0.4% Tier 2PYRE/PIPERON LIQ Tier 2SKLICE LOT 0.5% Tier 3 PAspinosad sus 0.9% Tier 1ULESFIA LOT 5% Tier 3 ST

Wound Care ProductsREGRANEX GEL 0.01% Tier 3 PA

DIAGNOSTIC PRODUCTSDiagnostic Drugs

THYROGEN INJ 1.1MG Tier 4 PADiagnostic Tests

CHEMSTRIP 2 TES GP Tier 2CHEMSTRIP 5 TES OB Tier 2CHEMSTRIP 7 TES Tier 2



Drug Name Drug Tier Requirements/LimitsCHEMSTRIP 9 TES STRIPS Tier 2CHEMSTRIP 10 TES MD Tier 2CHEMSTRIP TES -10 SG Tier 2CHEMSTRIP TES UGK Tier 2COMBISTIX TES Tier 2CVS KETONE TES CARE Tier 2HEMA-COMBIST TES Tier 2KETO-DIASTIX TES Tier 2LABSTIX TES Tier 2MULTISTIX 5 TES Tier 2MULTISTIX 7 TES Tier 2MULTISTIX 8 TES SG Tier 2MULTISTIX 9 TES Tier 2MULTISTIX 9 TES SG Tier 2MULTISTIX 10 TES SG Tier 2MULTISTIX TES Tier 2TRUETEST TES Tier 2URINARY TRAC TES INFECTIO Tier 2URISTIX 4 TES Tier 2URISTIX TES Tier 2

DIGESTIVE AIDSDigestive Enzymes

CREON CAP 3000UNIT Tier 3CREON CAP 6000UNIT Tier 3CREON CAP 12000UNT Tier 3CREON CAP 24000UNT Tier 3PANCREAZE CAP 4200UNIT Tier 3PANCREAZE CAP 10500UNT Tier 3PANCREAZE CAP 16800UNT Tier 3PANCREAZE CAP 21000UNT Tier 3pancrelipase cap 5000unit Tier 1PERTZYE CAP Tier 3ULTRESA CAP 13800UNT Tier 3ULTRESA CAP 20700UNT Tier 3ULTRESA CAP 23000UNT Tier 3ZENPEP CAP 3000UNIT Tier 3ZENPEP CAP 10000UNT Tier 3ZENPEP CAP 15000UNT Tier 3ZENPEP CAP 20000UNT Tier 3ZENPEP CAP 25000UNT Tier 3

DIURETICSCarbonic Anhydrase Inhibitors



Drug Name Drug Tier Requirements/Limitsacetazolamid cap 500mg er Tier 1acetazolamid tab 125mg Tier 1acetazolamid tab 250mg Tier 1methazolamid tab 25mg Tier 1methazolamid tab 50mg Tier 1

Diuretic Combinationsspirono/hctz tab 25/25 Tier 1triamt/hctz cap 37.5-25 Tier 1triamt/hctz tab 37.5-25 Tier 1triamt/hctz tab 75-50mg Tier 1

Loop Diureticsbumetanide tab 0.5mg Tier 1bumetanide tab 1mg Tier 1bumetanide tab 2mg Tier 1EDECRIN TAB 25MG Tier 2furosemide sol 10mg/ml Tier 1furosemide tab 20mg Tier 1furosemide tab 40mg Tier 1furosemide tab 80mg Tier 1torsemide tab 5mg Tier 1torsemide tab 10mg Tier 1torsemide tab 20mg Tier 1torsemide tab 100mg Tier 1

Potassium Sparing Diureticsamiloride tab 5mg Tier 1DYRENIUM CAP 50MG Tier 2DYRENIUM CAP 100MG Tier 2spironolact tab 25mg Tier 1spironolact tab 50mg Tier 1spironolact tab 100mg Tier 1

Thiazides and Thiazide-Like Diureticschlorothiaz tab 250mg Tier 1chlorothiaz tab 500mg Tier 1chlorthalid tab 25mg Tier 1chlorthalid tab 50mg Tier 1hydrochlorot cap 12.5mg Tier 1hydrochlorot tab 12.5mg Tier 1hydrochlorot tab 25mg Tier 1hydrochlorot tab 50mg Tier 1indapamide tab 1.25mg Tier 1indapamide tab 2.5mg Tier 1methyclothia tab 5mg Tier 1metolazone tab 2.5mg Tier 1



Drug Name Drug Tier Requirements/Limitsmetolazone tab 5mg Tier 1metolazone tab 10mg Tier 1

ENDOCRINE AND METABOLIC AGENTS - MISC.Bone Density Regulators

ACTONEL TAB 5MG Tier 2 PAACTONEL TAB 30MG Tier 2 PAACTONEL TAB 35MG Tier 2 PAACTONEL TAB 150MG Tier 2 PAalendronate sol 70/75ml Tier 2 PAalendronate tab 5mg Tier 1alendronate tab 10mg Tier 1alendronate tab 35mg Tier 1alendronate tab 40mg Tier 1alendronate tab 70mg Tier 1calcitonin spr 200/act Tier 1etidron disd tab 200mg Tier 3etidron disd tab 400mg Tier 3FORTEO SOL 600/2.4 Tier 4 PAibandronate tab 150mg Tier 1 PAPROLIA SOL 60MG/ML Tier 4 PASKELID TAB 200MG Tier 3XGEVA INJ Tier 4 PA

Growth Hormone Receptor AntagonistsSOMAVERT INJ 10MG Tier 4 PASOMAVERT INJ 15MG Tier 4 PASOMAVERT INJ 20MG Tier 4 PA

Growth HormonesTEV-TROPIN INJ 5MG Tier 4 PA

Hormone Receptor ModulatorsEVISTA TAB 60MG Tier 2

Insulin-Like Growth Factors (Somatomedins)INCRELEX INJ 40MG/4ML Tier 4 PA

LHRH/GnRH Agonist Analog Pituitary SuppressantsSUPPRELIN LA KIT 50MG Tier 4 PASYNAREL SOL 2MG/ML Tier 4 PA

Metabolic ModifiersALDURAZYME INJ 2.9MG/5M Tier 4 PAcalcitriol cap 0.5mcg Tier 1calcitriol cap 0.25mcg Tier 1calcitriol inj 1mcg/ml Tier 1ELAPRASE INJ 6MG/3ML Tier 4 PAFABRAZYME INJ 5MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsFABRAZYME INJ 35MG Tier 4 PAHECTOROL CAP 0.5MCG Tier 3HECTOROL CAP 1MCG Tier 3HECTOROL CAP 2.5MCG Tier 3HECTOROL INJ 2MCG/ML Tier 3HECTOROL INJ 4MCG/2ML Tier 3KUVAN TAB 100MG Tier 4 PAlevocarnitin sol 1gm/10ml Tier 1levocarnitin tab 330mg Tier 1LUMIZYME INJ 50MG Tier 4 PAMYOZYME INJ 50MG Tier 4 PANAGLAZYME INJ 1MG/ML Tier 4 PASENSIPAR TAB 30MG Tier 4 PASENSIPAR TAB 60MG Tier 4 PASENSIPAR TAB 90MG Tier 4 PAZEMPLAR CAP 1MCG Tier 3 PAZEMPLAR CAP 2MCG Tier 3 PAZEMPLAR CAP 4MCG Tier 3 PA

Posterior Pituitary Hormonesdesmopressin inj 4mcg/ml Tier 4 PAdesmopressin sol 0.01% Tier 4 PAdesmopressin spr 0.01% Tier 1 PAdesmopressin tab 0.1mg Tier 1desmopressin tab 0.2mg Tier 1minirin spr nasal Tier 1 PASTIMATE SOL 1.5MG/ML Tier 4 PA

Somatostatic Agentsoctreotide inj 50mcg/ml Tier 4 PAoctreotide inj 100mcg Tier 4 PAoctreotide inj 200mcg Tier 4 PAoctreotide inj 500mcg Tier 4 PAoctreotide inj 1000mcg Tier 4 PASANDOSTATIN KIT LAR 10MG Tier 4 PASANDOSTATIN KIT LAR 20MG Tier 4 PASANDOSTATIN KIT LAR 30MG Tier 4 PASOMATULINE INJ 60/0.2ML Tier 4 PASOMATULINE INJ 90/0.3ML Tier 4 PASOMATULINE INJ 120/.5ML Tier 4 PA

Vasopressin Receptor AntagonistsSAMSCA TAB 15MG Tier 4 PASAMSCA TAB 30MG Tier 4 PA

ESTROGENS



Drug Name Drug Tier Requirements/LimitsEstrogen Combinations

COMBIPATCH DIS .05/.14 Tier 2COMBIPATCH DIS .05/.25 Tier 2covaryx hs tab Tier 1covaryx tab Tier 1eemt hs tab Tier 1eemt tab Tier 1essian h.s. tab Tier 1essian tab Tier 1est estrogen tab mtest Tier 1est estrogen tab mtest ds Tier 1est estrogen tab mtest hs Tier 1FEMHRT TAB 0.5-2.5 Tier 2jevantique tab 1mg-5mcg Tier 1jinteli tab 1mg-5mcg Tier 1mtest hs/est tab estrogen Tier 1mtest/est tab estrogen Tier 1PREMPHASE TAB Tier 2PREMPRO TAB 0.3-1.5 Tier 2PREMPRO TAB 0.45-1.5 Tier 2PREMPRO TAB 0.625-5 Tier 2PREMPRO TAB .625-2.5 Tier 2

EstrogensALORA DIS 0.1MG Tier 2ALORA DIS 0.05MG Tier 2ALORA DIS 0.025MG Tier 2ALORA DIS 0.075MG Tier 2CENESTIN TAB 0.3MG Tier 3CENESTIN TAB 0.9MG Tier 3CENESTIN TAB 0.45MG Tier 3CENESTIN TAB 0.625MG Tier 3CENESTIN TAB 1.25MG Tier 3ENJUVIA TAB 0.3MG Tier 2ENJUVIA TAB 0.9MG Tier 2ENJUVIA TAB 0.45MG Tier 2ENJUVIA TAB 0.625MG Tier 2ENJUVIA TAB 1.25MG Tier 2ESTRADERM DIS 0.1MG Tier 2ESTRADERM DIS 0.05MG Tier 2estradiol dis 0.1mg Tier 1estradiol dis 0.05mg Tier 1estradiol dis 0.06mg Tier 1estradiol dis 0.025mg Tier 1



Drug Name Drug Tier Requirements/Limitsestradiol dis 0.075mg Tier 1estradiol dis 0.0375mg Tier 1estradiol tab 0.5mg Tier 1estradiol tab 1mg Tier 1estradiol tab 2mg Tier 1MENEST TAB 0.3MG Tier 2MENEST TAB 0.625MG Tier 2MENEST TAB 1.25MG Tier 2MENEST TAB 2.5MG Tier 2MINIVELLE DIS 0.1MG Tier 2MINIVELLE DIS 0.05MG Tier 2MINIVELLE DIS 0.075MG Tier 2MINIVELLE DIS 0.0375MG Tier 2PREMARIN TAB 0.3MG Tier 2PREMARIN TAB 0.9MG Tier 2PREMARIN TAB 0.45MG Tier 2PREMARIN TAB 0.625MG Tier 2PREMARIN TAB 1.25MG Tier 2VIVELLE-DOT DIS 0.1MG Tier 2VIVELLE-DOT DIS 0.05MG Tier 2VIVELLE-DOT DIS 0.025MG Tier 2VIVELLE-DOT DIS 0.075MG Tier 2VIVELLE-DOT DIS 0.0375MG Tier 2

FLUOROQUINOLONESFluoroquinolones

CIPRO (5%) SUS 250MG/5 Tier 2 PACIPRO (10%) SUS 500MG/5 Tier 2 PAciprofloxacn tab 100mg Tier 1 PAciprofloxacn tab 250mg Tier 1ciprofloxacn tab 500mg Tier 1ciprofloxacn tab 750mg Tier 1FACTIVE TAB 320MG Tier 3 PAlevofloxacin tab 250mg Tier 1 PAlevofloxacin tab 500mg Tier 1 PAlevofloxacin tab 750mg Tier 1 PANOROXIN TAB 400MG Tier 2 PAofloxacin tab 200mg Tier 1ofloxacin tab 300mg Tier 1ofloxacin tab 400mg Tier 1

GASTROINTESTINAL AGENTS - MISC.Gallstone Solubilizing Agents

ursodiol cap 300mg Tier 1



Drug Name Drug Tier Requirements/Limitsursodiol tab 250mg Tier 1ursodiol tab 500mg Tier 1

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAP 8MCG Tier 3 PAAMITIZA CAP 24MCG Tier 3 PA

Gastrointestinal Stimulantsmetoclopram sol 5mg/5ml Tier 1metoclopram sol 10/10ml Tier 1metoclopram tab 5mg Tier 1metoclopram tab 10mg Tier 1

Inflammatory Bowel AgentsASACOL TAB 400MG DR Tier 2balsalazide cap 750mg Tier 1CIMZIA KIT Tier 4 PADIPENTUM CAP 250MG Tier 2LIALDA TAB 1.2GM Tier 2PENTASA CAP 250MG CR Tier 2PENTASA CAP 500MG CR Tier 2REMICADE INJ 100MG Tier 4 PAsulfasalazin tab 500mg Tier 1sulfasalazin tab 500mg dr Tier 1sulfazine ec tab 500mg Tier 1sulfazine tab 500mg Tier 1

Intestinal Acidifiersenulose sol 10gm/15 Tier 1generlac sol 10gm/15 Tier 1lactulose sol 10gm/15 10gm/15ml Tier 1

Irritable Bowel Syndrome (IBS) AgentsLINZESS CAP 145MCG Tier 3 PALINZESS CAP 290MCG Tier 3 PA

Peripheral Opioid Receptor AntagonistsRELISTOR KIT 12/0.6ML Tier 4 PA

Phosphate Binder Agentscalc acetate cap 667mg Tier 1calc acetate tab 667mg Tier 1FOSRENOL CHW 500MG Tier 3 PAFOSRENOL CHW 750MG Tier 3 PAFOSRENOL CHW 1000MG Tier 3 PARENAGEL TAB 400MG Tier 2 STRENAGEL TAB 800MG Tier 2 STRENVELA TAB 800MG Tier 2 ST

GENITOURINARY AGENTS - MISCELLANEOUS



Drug Name Drug Tier Requirements/LimitsAlkalinizers

pot citrate tab 540mg Tier 1pot citrate tab 1080mg Tier 1

Genitourinary Irrigantsargyl saline sol 0.9% Tier 1curity salin sol 0.9% irr Tier 1sod chloride sol 0.45%irr Tier 1sodium chlor sol 0.9% irr Tier 1

Interstitial Cystitis AgentsELMIRON CAP 100MG Tier 2

Prostatic Hypertrophy Agentsalfuzosin tab 10mg Tier 1AVODART CAP 0.5MG Tier 3 PAfinasteride tab 5mg Tier 1RAPAFLO CAP 4MG Tier 3RAPAFLO CAP 8MG Tier 3tamsulosin cap 0.4mg Tier 1

Urinary Analgesicsphenazo tab 200mg Tier 1phenazopyrid tab 100mg Tier 1phenazopyrid tab 200mg Tier 1

GOUT AGENTSGout Agent Combinations

proben/colch tab 500-0.5 Tier 1Gout Agents

allopurinol tab 100mg Tier 1allopurinol tab 300mg Tier 1COLCRYS TAB 0.6MG Tier 3ULORIC TAB 40MG Tier 3 PAULORIC TAB 80MG Tier 3 PA

Uricosuricsprobenecid tab 500mg Tier 1

HEMATOLOGICAL AGENTS - MISC.Antihemophilic Products

ADVATE INJ 250UNIT Tier 4 PAADVATE INJ 500UNIT Tier 4 PAADVATE INJ 1000UNIT Tier 4 PAADVATE INJ 1500UNIT Tier 4 PAADVATE INJ 2000UNIT Tier 4 PAADVATE INJ 3000UNIT Tier 4 PAALPHANATE INJ VWF/HUM Tier 4 PA



Drug Name Drug Tier Requirements/LimitsALPHANINE SD INJ 500UNIT Tier 4 PAALPHANINE SD INJ 1000UNIT Tier 4 PABEBULIN INJ 200-1200 Tier 4 PABEBULIN VH INJ 200-1200 Tier 4 PABENEFIX INJ 250UNIT Tier 4 PABENEFIX INJ 500UNIT Tier 4 PABENEFIX INJ 1000UNIT Tier 4 PABENEFIX INJ 2000UNIT Tier 4 PAFEIBA NF INJ Tier 4 PAFEIBA VH INJ IMMUNO Tier 4 PAHELIXATE FS INJ 250UNIT Tier 4 PAHELIXATE FS INJ 500UNIT Tier 4 PAHELIXATE FS INJ 1000UNIT Tier 4 PAHELIXATE FS INJ 2000UNIT Tier 4 PAHELIXATE FS SOL 250UNIT Tier 4 PAHELIXATE FS SOL 500UNIT Tier 4 PAHELIXATE FS SOL 1000UNIT Tier 4 PAHEMOFIL M INJ 220-400 Tier 4 PAHEMOFIL M INJ 401-800 Tier 4 PAHUMATE-P INJ 500UNIT Tier 4 PAHUMATE-P INJ 600UNIT Tier 4 PAHUMATE-P INJ 1000UNIT Tier 4 PAHUMATE-P INJ 2000UNIT Tier 4 PAHUMATE-P SOL 600UNIT Tier 4 PAHUMATE-P SOL 1200UNIT Tier 4 PAHUMATE-P SOL 2400UNIT Tier 4 PAKOATE-DVI INJ 250UNIT Tier 4 PAKOATE-DVI INJ 500UNIT Tier 4 PAKOATE-DVI INJ 1000UNIT Tier 4 PAKOGENATE FS INJ 250/BS Tier 4 PAKOGENATE FS INJ 250UNIT Tier 4 PAKOGENATE FS INJ 500/BS Tier 4 PAKOGENATE FS INJ 500UNIT Tier 4 PAKOGENATE FS INJ 1000/BS Tier 4 PAKOGENATE FS INJ 1000UNIT Tier 4 PAKOGENATE FS INJ 2000/BS Tier 4 PAKOGENATE FS INJ 2000UNIT Tier 4 PAMONOCLATE-P INJ 250UNIT Tier 4 PAMONOCLATE-P INJ 500UNIT Tier 4 PAMONOCLATE-P INJ 1000UNIT Tier 4 PAMONOCLATE-P INJ 1500UNIT Tier 4 PAMONONINE INJ 250UNIT Tier 4 PAMONONINE INJ 500UNIT Tier 4 PA



Drug Name Drug Tier Requirements/LimitsMONONINE INJ 1000UNIT Tier 4 PANOVOSEVEN INJ 1200MCG Tier 4 PANOVOSEVEN INJ 2400MCG Tier 4 PANOVOSEVEN INJ 4800MCG Tier 4 PAPROFILNINE INJ 500UNIT Tier 4 PARECOMBINATE INJ 220-400 Tier 4 PARECOMBINATE INJ 401-800 Tier 4 PARECOMBINATE INJ 801-1240 Tier 4 PAREFACTO INJ 500UNIT Tier 4 PA

Complement InhibitorsCINRYZE SOL 500 UNIT Tier 4 PA

Hematorheologic Agentspentoxifylli tab 400mg er Tier 1

Platelet Aggregation InhibitorsAGGRENOX CAP 25-200MG Tier 3anagrelide cap 0.5mg Tier 1anagrelide cap 1mg Tier 1BRILINTA TAB 90MG Tier 3 PAcilostazol tab 50mg Tier 1cilostazol tab 100mg Tier 1clopidogrel tab 75mg Tier 1clopidogrel tab 300mg Tier 1 PAdipyridamole tab 25mg Tier 1dipyridamole tab 50mg Tier 1dipyridamole tab 75mg Tier 1EFFIENT TAB 5MG Tier 3EFFIENT TAB 10MG Tier 3ticlopidine tab 250mg Tier 1

HEMATOPOIETIC AGENTSAgents for Gaucher Disease

CEREZYME INJ 200UNIT Tier 4 PACEREZYME INJ 400UNIT Tier 4 PA

Folic Acid/Folatesfa-8 tab 0.8mg Tier 0folic acid tab 1mg Tier 1folic acid tab 400mcg Tier 0folic acid tab 800mcg Tier 0folic acid tab 1000mcg Tier 1sm folic acd tab 400mcg Tier 0yl folic aci tab 400mcg Tier 0

Hematopoietic Growth FactorsARANESP INJ 25MCG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsARANESP INJ 40MCG Tier 4 PAARANESP INJ 60MCG Tier 4 PAARANESP INJ 100MCG Tier 4 PAARANESP INJ 150MCG Tier 4 PAARANESP INJ 200MCG Tier 4 PAARANESP INJ 300MCG Tier 4 PAARANESP INJ 500MCG Tier 4 PAEPOGEN INJ 2000/ML Tier 4 PAEPOGEN INJ 3000/ML Tier 4 PAEPOGEN INJ 4000/ML Tier 4 PAEPOGEN INJ 10000/ML Tier 4 PAEPOGEN INJ 20000/ML Tier 4 PALEUKINE INJ 250MCG Tier 4 PALEUKINE INJ 500 MCG Tier 4 PANEULASTA INJ 6MG/0.6M Tier 4 PANEUMEGA INJ 5MG Tier 4 PANEUPOGEN INJ 300/0.5 Tier 4 PANEUPOGEN INJ 300MCG Tier 4 PANEUPOGEN INJ 480/0.8 Tier 4 PANEUPOGEN INJ 480MCG Tier 4 PANPLATE INJ 250MCG Tier 4 PANPLATE INJ 500MCG Tier 4 PAPROCRIT INJ 2000/ML Tier 4 PAPROCRIT INJ 3000/ML Tier 4 PAPROCRIT INJ 4000/ML Tier 4 PAPROCRIT INJ 10000/ML Tier 4 PAPROCRIT INJ 20000/ML Tier 4 PAPROCRIT INJ 40000/ML Tier 4 PAPROMACTA TAB 12.5MG Tier 4 PAPROMACTA TAB 25MG Tier 4 PAPROMACTA TAB 50MG Tier 4 PAPROMACTA TAB 75MG Tier 4 PA

Hematopoietic Mixturesferocon cap Tier 1ferotrin cap Tier 1ferotrinsic cap Tier 1ferrex 150 cap forte Tier 1foltrin cap Tier 1iferex 150 cap forte Tier 1martinic cap Tier 1myferon 150 cap forte Tier 1poly-iron cap 150 fort Tier 1polysacchari cap iron Tier 1



Drug Name Drug Tier Requirements/Limitstl icon cap Tier 1tricon cap Tier 1

Ironfer-iron dro 15mg/ml Tier 0ferosul elx 220/5ml Tier 0ferrous dro 15mg/ml Tier 0ferrous sulf dro 15mg/ml Tier 0ferrous sulf elx 220/5ml Tier 0iron supplmt dro 15mg/ml Tier 0wee care sus 15/1.25 Tier 0

Stem Cell MobilizersMOZOBIL INJ Tier 4 PA

HYPNOTICSBarbiturate Hypnotics

phenobarb elx 20mg/5ml Tier 1phenobarb sol 20mg/5ml Tier 1phenobarb tab 15mg Tier 1phenobarb tab 16.2mg Tier 1phenobarb tab 30mg Tier 1phenobarb tab 32.4mg Tier 1phenobarb tab 60mg Tier 1phenobarb tab 64.8mg Tier 1phenobarb tab 97.2mg Tier 1phenobarb tab 100mg Tier 1

Non-Barbiturate Hypnoticschloral hydr syp 500/5ml Tier 1estazolam tab 1mg Tier 1estazolam tab 2mg Tier 1flurazepam cap 15mg Tier 1flurazepam cap 30mg Tier 1LUNESTA TAB 1MG Tier 3 PALUNESTA TAB 2MG Tier 3 PALUNESTA TAB 3MG Tier 3 PASOMNOTE CAP 500MG Tier 2temazepam cap 7.5mg Tier 1temazepam cap 15mg Tier 1temazepam cap 30mg Tier 1triazolam tab 0.25mg Tier 1triazolam tab 0.125mg Tier 1zaleplon cap 5mg Tier 1zaleplon cap 10mg Tier 1zolpidem tab 5mg Tier 1



Drug Name Drug Tier Requirements/Limitszolpidem tab 10mg Tier 1

Selective Melatonin Receptor AgonistsROZEREM TAB 8MG Tier 3 PA

LAXATIVESLaxative Combinations

COLYTE/FLAVR SOL PACKS Tier 2gavilyte-c sol Tier 1gavilyte-g sol Tier 1MOVIPREP SOL Tier 2peg 3350 sol electrol Tier 1peg-3350 sol electrol Tier 1PREPOPIK PAK Tier 2SUPREP BOWEL SOL PREP Tier 2

Laxatives - Miscellaneousclearlax pow POWD Tier 1constulose sol 10gm/15 Tier 1cvs purelax pow POWD Tier 1dulcolax pow balance Tier 1eql clearlax pow Tier 1gavilax pow Tier 1gentlelax pow POWD Tier 1glycolax pow 3350 nf Tier 1gnp clearlax pow Tier 1hm clearlax pow Tier 1lactulose sol 10gm/15 10gm/15ml Tier 1lactulose sol 20gm/30 Tier 1laxaclear pow Tier 1natura-lax pow 3350 nf Tier 1peg 3350 pow POWD Tier 1polyeth glyc pow 3350 nf POWD Tier 1polyeth glyc pow 3350-grx Tier 1ra laxative pow POWD Tier 1sm clearlax pow Tier 1smooth lax pow Tier 1sw clearlax pow Tier 1

Saline LaxativesOSMOPREP TAB 1.5GM Tier 2VISICOL TAB 1.5GM Tier 2

MACROLIDESAzithromycin

azithromycin pow 1gm pak Tier 1azithromycin sus 100/5ml Tier 1



Drug Name Drug Tier Requirements/Limitsazithromycin sus 200/5ml Tier 1azithromycin tab 250mg Tier 1azithromycin tab 500mg Tier 1azithromycin tab 600mg Tier 1ZMAX SUS 2GM Tier 2 PA

Clarithromycinclarithromyc sus 125/5ml Tier 1clarithromyc sus 250/5ml Tier 1clarithromyc tab 250mg Tier 1clarithromyc tab 500mg Tier 1

Erythromycinse.e.s. 400 tab 400mg Tier 1E.E.S. GRAN SUS 200/5ML Tier 1ERY-TAB TAB 333MG EC Tier 1ERY-TAB TAB 500MG EC Tier 1ERYPED SUS 200/5ML Tier 1ERYPED SUS 400/5ML Tier 2erythrocin tab 250mg Tier 1erythrom eth tab 400mg Tier 1erythromycin cap 250mg ec Tier 1erythromycin tab 250mg bs Tier 1erythromycin tab 500mg bs Tier 1

FidaxomicinDIFICID TAB 200MG Tier 4 PA

MEDICAL DEVICESContraceptives

FC2 FEMALE MIS CONDOM Tier 0FC FEMALE MIS CONDOM Tier 0FEMCAP MIS 22MM Tier 0FEMCAP MIS 26MM Tier 0FEMCAP MIS 30MM Tier 0OMNIFLEX DPR Tier 0ORTHO COIL DPR KIT 50 Tier 0ORTHO COIL DPR KIT 100 Tier 0ORTHO COIL DPR KIT 105 Tier 0ORTHO FLAT DPR KIT 55 Tier 0ORTHO FLAT DPR KIT 60 Tier 0ORTHO FLAT DPR KIT 65 Tier 0ORTHO FLAT DPR KIT 70 Tier 0ORTHO FLAT DPR KIT 75 Tier 0ORTHO FLAT DPR KIT 80 Tier 0ORTHO FLAT DPR KIT 85 Tier 0



Drug Name Drug Tier Requirements/LimitsORTHO FLAT DPR KIT 90 Tier 0ORTHO FLAT DPR KIT 95 Tier 0ORTHO FLEX DPR 65MM Tier 0ORTHO FLEX DPR 70MM Tier 0ORTHO FLEX DPR 75MM Tier 0ORTHO FLEX DPR 80MM Tier 0PARAGARD IUD T380A Tier 0PRENTIF MIS 22MM Tier 0PRENTIF MIS 25MM Tier 0PRENTIF MIS 28MM Tier 0PRENTIF MIS 31MM Tier 0PRENTIF MIS FITTING Tier 0TODAY SPONGE MIS Tier 0WIDE-SEAL DPR KIT 60 Tier 0WIDE-SEAL DPR KIT 65 Tier 0WIDE-SEAL DPR KIT 70 Tier 0WIDE-SEAL DPR KIT 75 Tier 0WIDE-SEAL DPR KIT 80 Tier 0WIDE-SEAL DPR KIT 85 Tier 0WIDE-SEAL DPR KIT 90 Tier 0WIDE-SEAL DPR KIT 95 Tier 0

Diabetic SuppliesLANCETS Tier 5TRUERESULT KIT Tier 5 QL

Parenteral Therapy SuppliesINSULIN PEN NEEDLES Tier 5INSULIN SYRINGES Tier 5

Respiratory Therapy SuppliesINSPIREASE MIS MOUTHPCE Tier 2 QLINSPIREASE MIS REP MOUT Tier 2 QLSPACERS Tier 2 QL

MIGRAINE PRODUCTSMigraine Combinations

CAFERGOT TAB 1-100MG Tier 2epidrin cap Tier 1isometh/apap cap dichlor Tier 1MIGERGOT SUP 2/100 Tier 2migragesic cap ida Tier 1nodolor cap Tier 1

Migraine Productsdihydroergot inj 1mg/ml Tier 1dihydroergot spr 4mg/ml Tier 1



Drug Name Drug Tier Requirements/LimitsERGOMAR SUB 2MG Tier 2

Serotonin AgonistsAXERT TAB 6.25MG Tier 3 PA; QLAXERT TAB 12.5MG Tier 3 PAFROVA TAB 2.5MG Tier 3 PA; QLnaratriptan tab 1mg Tier 1 ST; QLnaratriptan tab 2.5mg Tier 1 ST; QLRELPAX TAB 20MG Tier 2 ST; QLRELPAX TAB 40MG Tier 2 ST; QLrizatriptan tab 5mg Tier 1 ST; QLrizatriptan tab 10mg Tier 1 ST; QLsumatriptan inj 4mg/0.5 Tier 1 PA; QLsumatriptan inj 6mg/0.5 Tier 1 PA; QLsumatriptan spr 5mg/act Tier 1 QLsumatriptan spr 20mg/act Tier 1 QLsumatriptan tab 25mg Tier 1 QLsumatriptan tab 50mg Tier 1 QLsumatriptan tab 100mg Tier 1 QLzolmitriptan tab 2.5 mg Tier 2 ST; QLzolmitriptan tab 2.5mg Tier 2 ST; QLzolmitriptan tab 5mg Tier 2 ST; QL

MINERALS ELECTROLYTESFluoride

epiflur chw 0.5mg f Tier 0epiflur chw 0.25mg f Tier 0epiflur chw 1mg f Tier 1fluor-a-day dro 0.125mg Tier 0FLUORABON DRO Tier 2fluoride chw 0.5mg f Tier 0fluoride chw 0.25mg f Tier 0fluoride chw 1mg f Tier 1fluoritab chw 0.5mg f Tier 0fluoritab chw 0.25mg f Tier 0fluoritab chw 1mg f Tier 1fluoritab chw 2.2mg Tier 1fluoritab dro 0.125mg Tier 0flura-drops dro 0.25mg f Tier 0flura-drops dro 0.125mg Tier 0karidium dro 0.125mg Tier 0ludent chw 0.5mg f Tier 0ludent chw 0.25mg f Tier 0ludent chw 1mg f Tier 1



Drug Name Drug Tier Requirements/Limitsnafrinse chw 1mg f Tier 1nafrinse dro 0.125mg Tier 0sod fluoride chw 0.5mg f Tier 0sod fluoride chw 0.25mg f Tier 0sod fluoride chw 1.1mg Tier 0sod fluoride chw 1mg f Tier 1sod fluoride chw 2.2mg Tier 1sod fluoride dro 0.5mg/ml Tier 0sod fluoride tab 0.5mg f Tier 0

Potassiumklor-con 8 tab 8meq er Tier 1klor-con 10 tab 10meq er Tier 1klor-con m10 tab 10meq er Tier 1KLOR-CON M15 TAB Tier 2klor-con m20 tab 20meq er Tier 1pot chloride cap 8meq er Tier 1pot chloride cap 10meq er Tier 1pot chloride liq 10% Tier 1pot chloride liq 20% Tier 1pot chloride liq 20% sf Tier 1pot chloride sol 10% sf Tier 1pot chloride tab 8meq er Tier 1pot chloride tab 8meq sr Tier 1pot chloride tab 10meq cr Tier 1pot chloride tab 10meq er Tier 1pot cl micro tab 10meq cr Tier 1pot cl micro tab 10meq er Tier 1pot cl micro tab 20meq er Tier 1

MOUTH/THROAT/DENTAL AGENTSAnesthetics Topical Oral

lidocaine sol 2% visc Tier 1lidocaine sol 4% 4% Tier 1

Anti-infectives - Throatclotrimazole loz 10mg Tier 1clotrimazole tro 10mg Tier 1nystatin sus 100000 Tier 1ORAVIG TAB 50MG Tier 3

Antiseptics - Mouth/Throatchlorhex glu sol 0.12% Tier 1periogard sol 0.12% Tier 1

Steroids - Mouth/Throatoralone pst 0.1% Tier 1



Drug Name Drug Tier Requirements/Limitstriamcin/ora pst 0.1% Tier 1triamcinolon pst 0.1% Tier 1

Throat Products - Misc.cevimeline cap 30mg Tier 1pilocarpine tab 5mg Tier 1pilocarpine tab 7.5mg Tier 1

MULTIVITAMINSB-Complex w/ Folic Acid

mynephrocaps cap Tier 1renal cap softgel Tier 1renalpren cap Tier 1renaphro cap Tier 1reno cap Tier 1triphrocaps cap Tier 1

Ped MV w/ Fluorideacd/fluoride dro 0.25mg Tier 1mult-vit/fl chw 0.5mg Tier 1multi-vit/fl chw 0.5mg Tier 1multi-vit/fl chw 0.25mg Tier 1multi-vit/fl chw 1mg Tier 1multi-vit/fl dro 0.5mg/ml Tier 1multi-vit/fl dro 0.25mg Tier 1multivit/fl chw 0.5mg Tier 1multivit/fl chw 0.25mg Tier 1multivit/fl chw 1mg Tier 1mvc-fluoride chw 0.5mg Tier 1mvc-fluoride chw 0.25mg Tier 1mvc-fluoride chw 1mg Tier 1poly-vi-flor chw 0.5mg Tier 1poly-vi-flor chw 0.25mg Tier 1poly-vi-flor chw 1mg Tier 1poly-vit/fl dro 0.25mg Tier 1polyvit/fl dro 0.5mg/ml Tier 1tri-vit/fl dro 0.5mg Tier 1tri-vit/fl dro 0.25mg Tier 1tri-vit/fluo dro 0.5mg Tier 1tri-vit/fluo dro 0.25mg Tier 1tri-vita/fl dro 0.25mg Tier 1

Ped Multi Vitamins w/Fl FEmulti-vit/fe dro /fl 0.25 Tier 1multi-vit/fl dro /fe 0.25 Tier 1POLY-VI-FLOR CHW W/IRON Tier 2



Drug Name Drug Tier Requirements/Limitspoly-vit/fe dro /fl 0.5 Tier 1poly-vit/fe dro /fl 0.25 Tier 1tri-vit/fe dro /fl 0.25 Tier 1

Prenatal VitaminsCL PRENATAL TAB 28-0.8MG Tier 2CONCEPT DHA CAP Tier 2CONCEPT OB CAP Tier 2CVS PRENATAL TAB Tier 2CVS PRENATAL TAB 28-0.8MG Tier 2EQL PRENATAL TAB FORMULA Tier 2EZFE FORTE CAP Tier 2FOLIVANE-OB CAP Tier 2GNP DAILY MIS PRENATAL Tier 2GNP PRENATAL TAB 28-0.8MG Tier 2HM PRENATAL TAB Tier 2KP PRENATAL TAB MULTIVIT Tier 2ONE-A-DAY PAK PRENATAL Tier 2prenaplus tab Tier 1prenatabs rx tab Tier 1prenatal 19 chw tab Tier 1prenatal 19 tab Tier 1PRENATAL TAB Tier 2PRENATAL TAB 28-0.8MG Tier 2PRENATAL TAB COMPLETE Tier 2PRENATAL TAB FORMULA Tier 2prenatal tab plus Tier 1prenatal tab plus fe Tier 1PRENATAL+DHA MIS Tier 2PRENATAL+DHA MIS WOMENS Tier 2PRENATAL-U CAP Tier 2PROFE FORTE CAP 155-1MG Tier 2PX PRENATAL TAB MULTIVIT Tier 2QC PRENATAL TAB 28-0.8MG Tier 2RA ONE DAILY MIS Tier 2RA PRENATAL TAB 28-0.8MG Tier 2RA PRENATAL TAB FORMULA Tier 2SM PRENATAL TAB VITAMINS Tier 2STUART PREN TAB Tier 2TARON-C DHA CAP Tier 2TH PRENATAL TAB VITAMINS Tier 2TRIVEEN-U CAP Tier 2VINATE AZ EX TAB Tier 2VINATE II TAB Tier 2



Drug Name Drug Tier Requirements/Limits

MUSCULOSKELETAL THERAPY AGENTSCentral Muscle Relaxants

baclofen tab 10mg Tier 1baclofen tab 20mg Tier 1carisoprodol tab 250mg Tier 1carisoprodol tab 350mg Tier 1chlorzoxazon tab 500mg Tier 1cyclobenzapr tab 10mg Tier 1ed baclofen tab 10mg Tier 1LORZONE TAB 375MG Tier 3LORZONE TAB 750MG Tier 3metaxalone tab 800mg Tier 1methocarbam tab 500mg Tier 1methocarbam tab 750mg Tier 1orphenadrine tab 100mg er Tier 1tizanidine cap 2mg Tier 1tizanidine cap 4mg Tier 1tizanidine cap 6mg Tier 1tizanidine tab 2mg Tier 1tizanidine tab 4mg Tier 1

Direct Muscle Relaxantsdantrolene cap 25mg Tier 1dantrolene cap 50mg Tier 1dantrolene cap 100mg Tier 1

Muscle Relaxant Combinationscarisopr/asa tab 200-325 Tier 1orph/asa/caf tab Tier 1orphen cpd tab ds Tier 1

ViscosupplementsEUFLEXXA INJ 10MG/ML Tier 4 PAHYALGAN INJ 20MG/2ML Tier 4 PAORTHOVISC INJ 15MG/ML Tier 4 PASUPARTZ INJ 25/2.5ML Tier 4 PASYNVISC INJ 8MG/ML Tier 4 PASYNVISC ONE INJ 8MG/ML Tier 4 PA

NASAL AGENTS - SYSTEMIC AND TOPICALNasal Anti-infectives

BACTROBAN OIN NASAL 2% Tier 2Nasal Antiallergy

azelastine spr 0.1% Tier 1PATANASE SPR 0.6% Tier 3 PA

Nasal Anticholinergics



Drug Name Drug Tier Requirements/Limitsipratropium spr 0.03% Tier 1ipratropium spr 0.06% Tier 1

Nasal SteroidsBECONASE AQ SUS 0.042% Tier 2 STflunisolide spr 0.025% Tier 1flunisolide spr 29mcg Tier 1fluticasone spr 50mcg Tier 1NASONEX SPR 50MCG/AC Tier 2 STOMNARIS SPR Tier 2 STQNASL AER 80MCG Tier 3 STRHINOCORT SUS AQUA Tier 2 STtriamcinolon spr 55mcg/ac Tier 1VERAMYST SPR 27.5MCG Tier 2 ST

Sympathomimetic Decongestantscongest aid tab 30mg Tier 1congestion tab 30mg Tier 1decongestant tab 30mg Tier 1decongestant tab 60mg Tier 1eq suphedrin tab 30mg Tier 1genaphed tab 30mg Tier 1medi-phedrin tab 30mg Tier 1nasal decon syp 30mg/5ml Tier 1nasal decong tab 30mg Tier 1pseudoephedr syp 30mg/5ml Tier 1pseudoephedr tab 30mg Tier 1pseudoephedr tab 60mg Tier 1psudatabs tab 30mg Tier 1ra suphedrin tab 30mg Tier 1sb pseudophe tab 30mg Tier 1simply stuff tab 30mg Tier 1sm nasal dec tab 30mg Tier 1sudanyl tab 30mg Tier 1sudogest tab 30mg Tier 1sudogest tab 60mg Tier 1sudophed tab 30mg Tier 1suphedrine tab 30mg Tier 1sw nasal dec tab 30mg Tier 1TYZINE PED DRO 0.05% Tier 2TYZINE SOL 0.1% Tier 2wal-phed tab 30mg Tier 1

NEUROMUSCULAR AGENTSALS Agents



Drug Name Drug Tier Requirements/Limitsriluzole tab 50mg Tier 3 PA

Neuromuscular Blocking Agent - NeurotoxinsBOTOX INJ 100UNIT Tier 4 PAMYOBLOC INJ 2500/0.5 Tier 4 PAMYOBLOC INJ 5000/ML Tier 4 PAMYOBLOC INJ 10000/2 Tier 4 PA

OPHTHALMIC AGENTSArtificial Tears and Lubricants

LACRISERT MIS 5MG OP Tier 3 PABeta-blockers - Ophthalmic

betaxolol sol 0.5% op Tier 1BETOPTIC-S SUS 0.25% OP Tier 2carteolol sol 1% op Tier 1COMBIGAN SOL 0.2/0.5% Tier 2dorzol/timol sol 2-0.5%op Tier 1levobunolol sol 0.5% op Tier 1levobunolol sol 0.25% op Tier 1metipranolol sol 0.3% Tier 1metipranolol sol 0.3% oph Tier 1timolol gel sol 0.5% op Tier 1timolol gel sol 0.25% op Tier 1timolol mal sol 0.5% op Tier 1timolol mal sol 0.25% op Tier 1TIMOPTIC OCU SOL 0.5% OP Tier 2TIMOPTIC OCU SOL 0.25% OP Tier 2

Cycloplegic Mydriaticsak-pentolate sol 1% op Tier 1atropin-care sol 1% op Tier 1ATROPINE SUL OIN 1% OP Tier 2atropine sul sol 1% op Tier 1CYCLOGYL SOL 0.5% OP Tier 2cyclopentol sol 1% op Tier 1cyclopentol sol 2% op Tier 1cylate sol 1% op Tier 1homatropaire sol 5% op Tier 1homatropine sol 5% op Tier 1ISO HOMATROP SOL 2% OP Tier 2mydral sol 0.5% op Tier 1mydral sol 1% op Tier 1tropicamide sol 0.5% op Tier 1tropicamide sol 1% op Tier 1

Miotics



Drug Name Drug Tier Requirements/LimitsPHOSPHOLINE SOL 0.125%OP Tier 2pilocarpine sol 1% op Tier 1pilocarpine sol 2% op Tier 1pilocarpine sol 4% op Tier 1

Ophthalmic Adrenergic AgentsALPHAGAN P SOL 0.1% Tier 2apraclonidin sol 0.5% op Tier 1brimonidine sol 0.2% op Tier 1brimonidine sol 0.15% Tier 1IOPIDINE SOL 1% OP Tier 3

Ophthalmic Anti-infectivesbacitracin oin op Tier 1BESIVANCE SUS 0.6% Tier 3 PACILOXAN OIN 0.3% OP Tier 2ciprofloxacn sol 0.3% op Tier 1erythromycin oin 5mg/gm Tier 1erythromycin oin op Tier 1garamycin oin 0.3% op Tier 1gentak oin 0.3% op Tier 1gentak sol 0.3% op Tier 1gentamicin oin 0.3% op Tier 1gentamicin sol 0.3% op Tier 1gentasol sol 0.3% op Tier 1ilotycin oin op Tier 1MOXEZA SOL 0.5% Tier 2 PANATACYN SUS 5% OP Tier 2neo-polycin oin op Tier 1neo/bac/poly oin op Tier 1neo/poly/gra sol op Tier 1ofloxacin dro 0.3% op Tier 1polymyxin b/ sol trimethp Tier 1romycin oin op Tier 1sod sulfacet sol 10% op Tier 1sulfacet sod oin 10% op Tier 1sulfacet sod sol 10% op Tier 1tobramycin sol 0.3% op Tier 1tobrasol sol 0.3% op Tier 1TOBREX OIN 0.3% OP Tier 2trifluridine sol 1% op Tier 1trimethoprim sol polymyxn Tier 1VIGAMOX DRO 0.5% Tier 2 PAZIRGAN GEL 0.15% Tier 2 PAZYMAXID SOL 0.5% Tier 2 PA



Drug Name Drug Tier Requirements/LimitsOphthalmic Decongestants

naphazoline sol 0.1% op Tier 1Ophthalmic Immunomodulators

RESTASIS EMU 0.05% Tier 3 PAOphthalmic Local Anesthetics

parcaine sol 0.5% op Tier 1proparacaine sol 0.5% op Tier 1

Ophthalmic SteroidsALREX SUS 0.2% Tier 2BLEPHAMIDE OIN S.O.P. Tier 2BLEPHAMIDE SUS OP Tier 2dexameth pho sol 0.1% op Tier 1DUREZOL EMU 0.05% Tier 3FLAREX SUS 0.1% OP Tier 2fluor-op sus 0.1% op Tier 1fluoromethol sus 0.1% op Tier 1FML FORTE SUS 0.25% OP Tier 2FML OIN 0.1% OP Tier 2LOTEMAX GEL 0.5% Tier 2LOTEMAX OIN 0.5% Tier 2LOTEMAX SUS 0.5% Tier 2neo-polycin oin hc 1%op Tier 1neo/poly/bac oin /hc 1%op Tier 1neo/poly/dex oin 0.1% op Tier 1neo/poly/dex sus 0.1% op Tier 1neo/poly/hc sus op Tier 1poly-dex oin 0.1% op Tier 1PRED MILD SUS 0.12% OP Tier 2PRED SOD PHO SOL 1% OP Tier 1PRED-G S.O.P OIN OP Tier 2PRED-G SUS OP Tier 2prednisolone sus 1% op Tier 1sulf/pred na sol op Tier 1tobra/dexame sus 0.3-0.1% Tier 1TOBRADEX OIN 0.3-0.1% Tier 2VEXOL SUS 1% OP Tier 2

Ophthalmics - Misc.ACUVAIL SOL 0.45% Tier 2ALAMAST DRO 0.1% Tier 3alaway child dro 0.025%op Tier 1alaway dro 0.025%op Tier 1allergy eye dro 0.025%op Tier 1ALOCRIL SOL 2% Tier 3 PA



Drug Name Drug Tier Requirements/LimitsALOMIDE SOL 0.1% OP Tier 2antihistamin dro 0.025%op Tier 1AZOPT SUS 1% OP Tier 2BEPREVE DRO 1.5% Tier 2 PAbromfenac sol 0.09% Tier 1claritin eye dro 0.025%op Tier 1cromolyn sod sol 4% op Tier 1cvs allergy dro 0.025%op Tier 1diclofenac sol 0.1% op Tier 1dorzolamide sol 2% op Tier 1EMADINE SOL 0.05% OP Tier 3epinastine dro 0.05% Tier 1eq itchy eye dro 0.025%op Tier 1eye itch rel dro 0.025%op Tier 1flurbiprofen sol 0.03% op Tier 1itchy eye dro 0.025%op Tier 1ketorolac sol 0.4% Tier 1ketorolac sol 0.5% Tier 1ketotif fum dro 0.025%op Tier 1LASTACAFT SOL 0.25% Tier 3NEVANAC SUS 0.1% Tier 3PATANOL SOL 0.1% OP Tier 2 STwal-zyr dro 0.025%op Tier 1zyrtec itchy dro 0.025%op Tier 1

Prostaglandins - Ophthalmiclatanoprost sol 0.005% Tier 1LUMIGAN SOL 0.01% Tier 2LUMIGAN SOL 0.03% Tier 2TRAVATAN Z DRO 0.004% Tier 2travoprost dro 0.004% Tier 2ZIOPTAN DRO 0.0015% Tier 2

OTIC AGENTSOtic Agents - Miscellaneous

ace acd/alum sol 2% otic Tier 1acetic acid sol 2% otic Tier 1

Otic Anti-infectivesofloxacin dro 0.3%otic Tier 1

Otic Combinationsantipy/benzo sol otic Tier 1aurax sol 5.5-1.4% Tier 1aurodex sol otic Tier 1CIPRO HC SUS OTIC Tier 2



Drug Name Drug Tier Requirements/LimitsCIPRODEX SUS 0.3-0.1% Tier 2COLY-MYCIN S SUS OTIC Tier 2CORTISPORIN SUS -TC OTIC Tier 2neo/poly/hc sol 1% otic Tier 1neo/poly/hc sus 1% otic Tier 1

Otic Steroidsacetasol hc sol otic Tier 1fluocin acet oil 0.01% Tier 1hc/acet acid sol otic Tier 1

OXYTOCICSOxytocics

methylergon tab 0.2mg Tier 1

PASSIVE IMMUNIZING AGENTSImmune Serums

BIVIGAM INJ 10% 10gm/100ml Tier 4 PACARIMUNE NF INJ 3GM Tier 4 PACARIMUNE NF INJ 6GM Tier 4 PACARIMUNE NF INJ 12GM Tier 4 PAFLEBOGAMMA INJ 5% Tier 4 PAFLEBOGAMMA INJ 10% Tier 4 PAFLEBOGAMMA INJ DIF 5% .5gm/10ml, 5%Tier 4 PAGAMASTAN S/D INJ Tier 4 PAGAMMAGARD SD INJ 2.5GM HU Tier 4 PAGAMMAGARD SD INJ 5GM HU Tier 4 PAGAMMAGARD SD INJ 10GM HU Tier 4 PAGAMMAPLEX INJ 5GM Tier 4 PAGAMUNEX INJ 10% Tier 4 PAHIZENTRA INJ 2GM/10ML Tier 4 PAHYPERRHO S/D INJ 300MCG Tier 4 PAOCTAGAM INJ 1GM Tier 4 PAOCTAGAM INJ 5GM Tier 4 PAOCTAGAM INJ 25GM Tier 4 PAPRIVIGEN INJ 10GRAMS Tier 4 PAPRIVIGEN INJ 20GRAMS Tier 4 PARHOGAM PLUS INJ 300MCG Tier 4 PAVIVAGLOBIN SOL 160MG/ML Tier 4 PAWINRHO SDF INJ 1500UNIT Tier 4 PAWINRHO SDF INJ 2500UNIT Tier 4 PAWINRHO SDF INJ 5000UNIT Tier 4 PAWINRHO SDF INJ 15000UNT Tier 4 PA

Monoclonal AntibodiesSYNAGIS INJ 50MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsSYNAGIS INJ 100MG/ML Tier 4 PA

PENICILLINSAminopenicillins

amoxicillin cap 250mg Tier 1amoxicillin cap 500mg Tier 1amoxicillin chw 125mg Tier 1amoxicillin chw 250mg Tier 1amoxicillin sus 125/5ml Tier 1amoxicillin sus 200/5ml Tier 1amoxicillin sus 250/5ml Tier 1amoxicillin sus 400/5ml Tier 1amoxicillin tab 500mg Tier 1amoxicillin tab 875mg Tier 1ampicillin cap 250mg Tier 1ampicillin cap 500mg Tier 1ampicillin sus 125/5ml Tier 1ampicillin sus 250/5ml Tier 1MOXATAG TAB 775MG Tier 3 PA

Natural Penicillinspenicilln vk sol 125/5ml Tier 1penicilln vk sol 250/5ml Tier 1penicilln vk tab 250mg Tier 1penicilln vk tab 500mg Tier 1

Penicillin Combinationsamox-pot cla tab er Tier 1amox/k clav chw 200mg Tier 1amox/k clav chw 400mg Tier 1amox/k clav sus 200/5ml Tier 1amox/k clav sus 250/5ml Tier 1amox/k clav sus 400/5ml Tier 1amox/k clav sus 600/5ml Tier 1amox/k clav tab 250mg Tier 1amox/k clav tab 500mg Tier 1amox/k clav tab 875mg Tier 1AUGMENTIN SUS 125/5ML Tier 2

Penicillinase-Resistant Penicillinsdicloxacill cap 250mg Tier 1dicloxacill cap 500mg Tier 1

PROGESTINSProgestins

medroxypr ac tab 2.5mg Tier 1medroxypr ac tab 5mg Tier 1



Drug Name Drug Tier Requirements/Limitsmedroxypr ac tab 10mg Tier 1norethin ace tab 5mg Tier 1progesterone cap 100mg Tier 1progesterone cap 200mg Tier 1

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.Agents for Chemical Dependency

CAMPRAL TAB 333MG Tier 3 PAdisulfiram tab 250mg Tier 1disulfiram tab 500mg Tier 1

Anti-Cataplectic AgentsXYREM SOL 500MG/ML Tier 4 PA

Antidementia Agentsdonepezil tab 5mg Tier 1donepezil tab 5mg odt Tier 1donepezil tab 10mg Tier 1donepezil tab 10mg odt Tier 1galantamine cap 8mg er Tier 1galantamine cap 16mg er Tier 1galantamine cap 24mg er Tier 1galantamine tab 4mg Tier 1galantamine tab 8mg Tier 1galantamine tab 12mg Tier 1NAMENDA SOL 10MG/5ML Tier 2 PANAMENDA TAB 5MG Tier 2 PANAMENDA TAB 10MG Tier 2 PArivastigmine cap 3mg Tier 1

Combination Psychotherapeuticsperphen/amit tab 2-10mg Tier 1perphen/amit tab 2-25mg Tier 1perphen/amit tab 4-10mg Tier 1perphen/amit tab 4-25mg Tier 1perphen/amit tab 4-50mg Tier 1

Fibromyalgia AgentsSAVELLA MIS TITR PAK Tier 3 PASAVELLA TAB 12.5MG Tier 3 PASAVELLA TAB 25MG Tier 3 PASAVELLA TAB 50MG Tier 3 PASAVELLA TAB 100MG Tier 3 PA

Movement Disorder Drug TherapyXENAZINE TAB 12.5MG Tier 4 PAXENAZINE TAB 25MG Tier 4 PA

Multiple Sclerosis Agents



Drug Name Drug Tier Requirements/LimitsAVONEX KIT 30MCG Tier 4 PAAVONEX PEN KIT 30MCG Tier 4 PAAVONEX PREFL KIT 30MCG Tier 4 PABETASERON INJ 0.3MG Tier 4 PACOPAXONE KIT 20MG/ML Tier 4 PAEXTAVIA INJ 0.3MG Tier 4 PAGILENYA CAP 0.5MG Tier 4 PAREBIF INJ 22/0.5 Tier 4 PAREBIF INJ 44/0.5 Tier 4 PAREBIF REBIDO INJ 22/0.5 Tier 4 PAREBIF REBIDO INJ 44/0.5 Tier 4 PAREBIF REBIDO SOL TITRATN Tier 4 PAREBIF TITRTN SOL PACK Tier 4 PATYSABRI INJ Tier 4 PA

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine cap 10mg 10mg Tier 1fluoxetine cap 20mg 20mg Tier 1

Pseudobulbar Affect (PBA) AgentsNUEDEXTA CAP 20-10MG Tier 3 PA

Psychotherapeutic and Neurological Agents - Misc.ergoloid mes tab 1mg oral Tier 1ORAP TAB 1MG Tier 2 PAORAP TAB 2MG Tier 2 PA

Restless Leg Syndrome (RLS) AgentsHORIZANT TAB 600MG Tier 3 PA

Smoking Deterrentsbuproban tab 150mg Tier 0 QLbupropion tab 150mg Tier 0 QLCHANTIX PAK 0.5& 1MG Tier 0 QLCHANTIX PAK 1MG Tier 0 QLCHANTIX TAB 0.5MG Tier 0 QLCHANTIX TAB 1MG Tier 0 QLcvs nicotine dis 7mg/24hr Tier 0 QLcvs nicotine dis 14mg/24h Tier 0 QLcvs nicotine dis 21mg/24h Tier 0 QLcvs nicotine gum 2mg cinn Tier 0 QLcvs nicotine gum 2mg mint Tier 0 QLcvs nicotine gum 2mg orig Tier 0 QLcvs nicotine gum 2mgfruit Tier 0 QLcvs nicotine gum 4mg cinn Tier 0 QLcvs nicotine gum 4mg mint Tier 0 QLcvs nicotine gum 4mg orig Tier 0 QLcvs nicotine gum 4mgfruit Tier 0 QL



Drug Name Drug Tier Requirements/Limitscvs nicotine loz 2mg mint Tier 0 QLcvs nicotine loz 4mg mint Tier 0 QLcvs nts dis step 1 Tier 0 QLeq nicotine dis 7mg/24hr Tier 0 QLeq nicotine dis 14mg/24h Tier 0 QLeq nicotine dis 21mg/24h Tier 0 QLeq nicotine gum 2mg cinn Tier 0 QLeq nicotine gum 2mg mint Tier 0 QLeq nicotine gum 2mg orig Tier 0 QLeq nicotine gum 2mgfruit Tier 0 QLeq nicotine gum 4mg cinn Tier 0 QLeq nicotine gum 4mg mint Tier 0 QLeq nicotine gum 4mg orig Tier 0 QLeq nicotine gum 4mg ref Tier 0 QLeq nicotine gum 4mg strt Tier 0 QLeq nicotine gum 4mgfruit Tier 0 QLeq nicotine loz 2mg cher Tier 0 QLeq nicotine loz 2mg mint Tier 0 QLeq nicotine loz 4mg chry Tier 0 QLeq nicotine loz 4mg mint Tier 0 QLeql nicotine dis 7mg/24hr Tier 0 QLeql nicotine dis 14mg/24h Tier 0 QLeql nicotine dis 21mg/24h Tier 0 QLeql nicotine gum 2mg Tier 0 QLeql nicotine gum 2mg ref Tier 0 QLeql nicotine gum 2mg strt Tier 0 QLeql nicotine gum 4mg Tier 0 QLeql nicotine gum 4mg ref Tier 0 QLeql nicotine gum 4mg strt Tier 0 QLeql nicotine loz 2mg mint Tier 0 QLeql nicotine loz 4mg mint Tier 0 QLgnp nicotine gum 2mg mint Tier 0 QLgnp nicotine gum 2mg orig Tier 0 QLgnp nicotine gum 4mg mint Tier 0 QLgnp nicotine gum 4mg orig Tier 0 QLgnp nicotine loz 2mg mint Tier 0 QLgnp nicotine loz 4mg mint Tier 0 QLhm nicotine dis 14mg/24h Tier 0 QLhm nicotine dis 21mg/24h Tier 0 QLhm nicotine gum 2mg mint Tier 0 QLhm nicotine gum 4mg mint Tier 0 QLhm nicotine loz 2mg mint Tier 0 QLhm nicotine loz 4mg mint Tier 0 QL



Drug Name Drug Tier Requirements/Limitskls quit2 gum 2mg Tier 0 QLkls quit4 gum 4mg Tier 0 QLnicorelief gum 2mg mint Tier 0 QLnicorelief gum 2mg orig Tier 0 QLnicorelief gum 4mg mint Tier 0 QLnicorelief gum 4mg orig Tier 0 QLnicorelief loz 2mg mint Tier 0 QLnicorelief loz 4mg mint Tier 0 QLnicotine dis 7mg/24hr Tier 0 QLnicotine dis 14mg/24h Tier 0 QLnicotine dis 21mg/24h Tier 0 QLnicotine dis step 1 Tier 0 QLnicotine dis step 2 Tier 0 QLnicotine dis step 3 Tier 0 QLnicotine gum 2mg Tier 0 QLnicotine gum 2mgfruit Tier 0 QLnicotine gum 4mg Tier 0 QLnicotine loz 2mg chry Tier 0 QLnicotine loz 2mg mint Tier 0 QLnicotine loz 4mg chry Tier 0 QLnicotine loz 4mg cinn Tier 0 QLnicotine loz 4mg mint Tier 0 QLnicotine pol gum 2mg Tier 0 QLnicotine pol gum 2mg cinn Tier 0 QLnicotine pol gum 2mg mint Tier 0 QLnicotine pol gum 2mg orig Tier 0 QLnicotine pol gum 2mg ref Tier 0 QLnicotine pol gum 2mg strt Tier 0 QLnicotine pol gum 2mgfruit Tier 0 QLnicotine pol gum 4mg Tier 0 QLnicotine pol gum 4mg mint Tier 0 QLnicotine pol gum 4mg orig Tier 0 QLnicotine pol gum 4mg ref Tier 0 QLnicotine pol gum 4mg strt Tier 0 QLnicotine pol gum 4mgfruit Tier 0 QLnicotine pol loz 2mg cinn Tier 0 QLnicotine pol loz 2mg mint Tier 0 QLnicotine pol loz 4mg chry Tier 0 QLnicotine pol loz 4mg mint Tier 0 QLnicotine td dis 7mg/24hr Tier 0 QLnicotine td dis 14mg/24h Tier 0 QLnicotine td dis 21mg/24h Tier 0 QLNICOTROL INH Tier 0 PA; QL



Drug Name Drug Tier Requirements/LimitsNICOTROL NS SPR 10MG/ML Tier 0 PA; QLra nicotine dis 7mg/24hr Tier 0 QLra nicotine dis 14mg/24h Tier 0 QLra nicotine dis 21mg/24h Tier 0 QLra nicotine gum 2mg Tier 0 QLra nicotine gum 2mg cinn Tier 0 QLra nicotine gum 2mg mint Tier 0 QLra nicotine gum 2mgfruit Tier 0 QLra nicotine gum 4mg Tier 0 QLra nicotine gum 4mg frut Tier 0 QLra nicotine gum 4mg mint Tier 0 QLra nicotine loz 2mg mint Tier 0 QLra nicotine loz 4mg mint Tier 0 QLsm nicotine dis 7mg/24hr Tier 0 QLsm nicotine dis 14mg/24h Tier 0 QLsm nicotine dis 21mg Tier 0 QLsm nicotine gum 2mg Tier 0 QLsm nicotine gum 2mg mint Tier 0 QLsm nicotine gum 4mg Tier 0 QLsm nicotine gum 4mg mint Tier 0 QLsm nicotine loz 2mg mint Tier 0 QLsm nicotine loz 4mg mint Tier 0 QLstop smoking gum 2mg mint Tier 0 QLstop smoking gum 2mg orig Tier 0 QLstop smoking gum 4mg Tier 0 QLstop smoking loz 2mg mint Tier 0 QLstop smoking loz 4mg mint Tier 0 QLsw nicotine gum 2mg mint Tier 0 QLsw nicotine gum 4mg Tier 0 QLsw nicotine loz 2mg mint Tier 0 QLsw nicotine loz 4mg mint Tier 0 QLtgt nicotine dis 7mg/24hr Tier 0 QLtgt nicotine dis 14mg/24h Tier 0 QLtgt nicotine dis 21mg/24h Tier 0 QLtgt nicotine gum 2mg mint Tier 0 QLtgt nicotine gum 2mg orig Tier 0 QLtgt nicotine gum 2mgfruit Tier 0 QLtgt nicotine gum 4mg Tier 0 QLtgt nicotine gum 4mg mint Tier 0 QLtgt nicotine gum 4mg orig Tier 0 QLtgt nicotine loz 2mg chry Tier 0 QLtgt nicotine loz 2mg mint Tier 0 QLtgt nicotine loz 4mg chry Tier 0 QL



Drug Name Drug Tier Requirements/Limitstgt nicotine loz 4mg mint Tier 0 QLthrive gum 2mg mint Tier 0 QLthrive gum 4mg mint Tier 0 QL

RESPIRATORY AGENTS - MISC.Alpha-Proteinase Inhibitor (Human)

ARALAST NP INJ 400MG Tier 4 PAARALAST NP INJ 1000MG Tier 4 PAGLASSIA INJ Tier 4 PAPROLASTIN INJ 1000MG Tier 4 PAPROLASTIN-C INJ 1000MG Tier 4 PAZEMAIRA INJ 1000MG Tier 4 PA

Cystic Fibrosis AgentsKALYDECO TAB 150MG Tier 4 PAPULMOZYME SOL 1MG/ML Tier 4 PA

SULFONAMIDESSulfonamides

SULFADIAZINE TAB 500MG Tier 2

TETRACYCLINESTetracyclines

demeclocycl tab 150mg Tier 1demeclocycl tab 300mg Tier 1doxycycl hyc cap 50mg Tier 1doxycycl hyc cap 100mg CAPS Tier 1doxycycl hyc tab 75mg dr Tier 1doxycycl hyc tab 100mg Tier 1doxycycl hyc tab 100mg dr Tier 1doxycycl hyc tab 150mg dr Tier 1doxycycline sus 25mg/5ml Tier 1doxycycline tab 20mg Tier 1 PAminocycline cap 50mg Tier 1minocycline cap 100mg Tier 1morgidox cap 1x100mg Tier 1morgidox cap 2x100mg Tier 1tetracycline cap 250mg Tier 1tetracycline cap 500mg Tier 1VIBRAMYCIN SYP 50MG/5ML Tier 2 PA

THYROID AGENTSAntithyroid Agents

methimazole tab 5mg Tier 1methimazole tab 10mg Tier 1propylthiour tab 50mg Tier 1



Drug Name Drug Tier Requirements/LimitsThyroid Hormones

ARMOUR THYRO TAB 15MG Tier 1ARMOUR THYRO TAB 120MG Tier 1ARMOUR THYRO TAB 180MG Tier 1ARMOUR THYRO TAB 240MG Tier 1ARMOUR THYRO TAB 300MG Tier 1levothroid tab 25mcg Tier 1levothroid tab 50mcg Tier 1levothroid tab 75mcg Tier 1levothroid tab 88mcg Tier 1levothroid tab 100mcg Tier 1levothroid tab 112mcg Tier 1levothroid tab 125mcg Tier 1levothroid tab 137mcg Tier 1levothroid tab 150mcg Tier 1levothroid tab 175mcg Tier 1levothroid tab 200mcg Tier 1levothroid tab 300mcg Tier 1levothyroxin tab 25mcg Tier 1levothyroxin tab 50mcg Tier 1levothyroxin tab 75mcg Tier 1levothyroxin tab 88mcg Tier 1levothyroxin tab 100mcg Tier 1levothyroxin tab 112mcg Tier 1levothyroxin tab 125mcg Tier 1levothyroxin tab 137mcg Tier 1levothyroxin tab 150mcg Tier 1levothyroxin tab 175mcg Tier 1levothyroxin tab 200mcg Tier 1levothyroxin tab 300mcg Tier 1levoxyl tab 25mcg Tier 1levoxyl tab 50mcg Tier 1levoxyl tab 75mcg Tier 1levoxyl tab 88mcg Tier 1levoxyl tab 100mcg Tier 1levoxyl tab 112mcg Tier 1levoxyl tab 125mcg Tier 1levoxyl tab 137mcg Tier 1levoxyl tab 150mcg Tier 1levoxyl tab 175mcg Tier 1levoxyl tab 200mcg Tier 1liothyronine tab 5mcg Tier 1liothyronine tab 25mcg Tier 1



Drug Name Drug Tier Requirements/Limitsliothyronine tab 50mcg Tier 1np thyroid tab 30mg Tier 1np thyroid tab 60mg Tier 1np thyroid tab 90mg Tier 1THYROLAR-1 TAB 60MG Tier 2THYROLAR-1/2 TAB 30MG Tier 2THYROLAR-1/4 TAB 15MG Tier 2THYROLAR-2 TAB 120MG Tier 2THYROLAR-3 TAB 180MG Tier 2unith direct tab 25mcg Tier 1unith direct tab 50mcg Tier 1unith direct tab 75mcg Tier 1unith direct tab 88mcg Tier 1unith direct tab 100mcg Tier 1unith direct tab 112mcg Tier 1unith direct tab 125mcg Tier 1unith direct tab 150mcg Tier 1unith direct tab 175mcg Tier 1unith direct tab 200mcg Tier 1unith direct tab 300mcg Tier 1unithroid tab 25mcg Tier 1unithroid tab 50mcg Tier 1unithroid tab 75mcg Tier 1unithroid tab 88mcg Tier 1unithroid tab 100mcg Tier 1unithroid tab 112mcg Tier 1unithroid tab 125mcg Tier 1unithroid tab 137mcg Tier 1unithroid tab 150mcg Tier 1unithroid tab 175mcg Tier 1unithroid tab 200mcg Tier 1unithroid tab 300mcg Tier 1

ULCER DRUGSAntispasmodics

bella alk/pb tab 16.2mg Tier 1CANTIL TAB 25MG Tier 2chlord/clidi cap 5-2.5mg Tier 1colidrops dro 0.125/ml Tier 1dicyclomine cap 10mg Tier 1dicyclomine sol 10mg/5ml Tier 1dicyclomine tab 20mg Tier 1glycopyrrol inj 0.2mg/ml .2mg/ml Tier 1



Drug Name Drug Tier Requirements/Limitsglycopyrrol tab 1mg Tier 1glycopyrrol tab 2mg Tier 1hyomax tab 0.125mg Tier 1hyomax-sl sub 0.125mg Tier 1hyoscyamine dro 0.125/ml Tier 1hyoscyamine elx 0.125/5 Tier 1hyoscyamine sub 0.125mg Tier 1hyoscyamine tab 0.125mg TABS Tier 1hyosyne dro 0.125/ml Tier 1hyosyne elx 0.125/5 Tier 1methscopolam tab 2.5mg Tier 1oscimin sub 0.125mg Tier 1oscimin tab 0.125mg TABS Tier 1propanthelin tab 15mg Tier 1quadrapax elx Tier 1se-donna elx pb hyos Tier 1symax-sl sub 0.125mg Tier 1

H-2 Antagonistsacid control tab 20mg Tier 1acid control tab 150mg Tier 1acid reducer tab 20mg Tier 1acid reducer tab 150mg Tier 1acid reducer tab 200mg Tier 1acid relief tab 200mg Tier 1cimetidine sol 300/5ml Tier 1cimetidine tab 200mg Tier 1cimetidine tab 300mg Tier 1cimetidine tab 400mg Tier 1cimetidine tab 800mg Tier 1eq heartburn tab relief Tier 1famotidine sus 40mg/5ml Tier 1 PAfamotidine tab 20mg Tier 1heartbrn rel tab 200mg Tier 1heartburn tab 20mg Tier 1heartburn tab 150mg Tier 1heartburn tab 200mg Tier 1heartburn tab relief 200mg Tier 1nizatidine cap 150mg Tier 1nizatidine cap 300mg Tier 1qc heartburn tab 200mg Tier 1ranitidine syp 15mg/ml Tier 1ranitidine syp 75mg/5ml Tier 1ranitidine syp 150/10ml Tier 1



Drug Name Drug Tier Requirements/Limitsranitidine tab 150mg Tier 1ranitidine tab 300mg Tier 1sm acid redu tab 200mg Tier 1wal-zan tab 150mg Tier 1

Misc. Anti-Ulcersucralfate tab 1gm Tier 1

Proton Pump InhibitorsACIPHEX TAB 20MG Tier 3 PADEXILANT CAP 30MG DR Tier 3 PADEXILANT CAP 60MG DR Tier 3 PAhrtbrn rel cap 15mg dr Tier 1lansoprazole cap 15mg dr Tier 1lansoprazole cap 30mg dr Tier 1NEXIUM CAP 20MG Tier 3 PANEXIUM CAP 40MG Tier 3 PAomeprazole cap 10mg Tier 1omeprazole cap 20mg Tier 1omeprazole cap 40mg Tier 1 PApantoprazole tab 20mg Tier 1pantoprazole tab 40mg Tier 1

Ulcer Drugs - Prostaglandinsmisoprostol tab 100mcg Tier 1misoprostol tab 200mcg Tier 1

URINARY ANTI-INFECTIVESUrinary Anti-infectives

MACRODANTIN CAP 25MG Tier 2methenam hip tab 1gm Tier 1MONUROL PAK GRANULES Tier 3 PAnitrofur mac cap 50mg Tier 1nitrofur mac cap 100mg Tier 1nitrofurantn cap 100mg Tier 1nitrofurantn sus 25mg/5ml Tier 1

URINARY ANTISPASMODICSUrinary Antispasmodics

bethanechol tab 5mg Tier 1bethanechol tab 10mg Tier 1bethanechol tab 25mg Tier 1bethanechol tab 50mg Tier 1DETROL LA CAP 2MG Tier 2 STDETROL LA CAP 4MG Tier 2 STENABLEX TAB 7.5MG Tier 2 STENABLEX TAB 15MG Tier 2 ST



Drug Name Drug Tier Requirements/Limitsflavoxate tab 100mg Tier 1GELNIQUE GEL 10% Tier 2 PAoxybutynin syp 5mg/5ml Tier 1oxybutynin tab 5mg Tier 1tolterodine tab 1mg Tier 1 STtolterodine tab 2mg Tier 1 STTOVIAZ TAB 4MG Tier 2 STTOVIAZ TAB 8MG Tier 2 STtrospium chl cap 60mg er Tier 1 STVESICARE TAB 5MG Tier 3 PAVESICARE TAB 10MG Tier 3 PA

VACCINESViral Vaccines

AFLURIA INJ 2011-12 Tier 0AFLURIA INJ 2012-13 Tier 0AFLURIA INJ PF 10-11 Tier 0AFLURIA INJ PF 11-12 Tier 0AFLURIA INJ PF 12-13 Tier 0AGRIFLU INJ PF 10-11 Tier 0EZ USE FLU KIT 2012-13 Tier 0FLUARIX INJ PF 10-11 Tier 0FLUARIX INJ PF 11-12 Tier 0FLUARIX INJ PF 12-13 Tier 0FLUARIX PF INJ 2013-14 Tier 0FLUARIX QUAD INJ 2013-14 Tier 0FLULAVAL INJ 2010-11 Tier 0FLULAVAL INJ 2011-12 Tier 0FLULAVAL INJ 2012-13 Tier 0FLULAVAL INJ 2013-14 Tier 0FLUVIRIN INJ 2011-12 Tier 0FLUVIRIN INJ 2012-13 Tier 0FLUVIRIN INJ PF 11-12 Tier 0FLUVIRIN INJ PF 12-13 Tier 0FLUZONE INJ INTRADRM Tier 0FLUZONE INJ PF 11-12 Tier 0FLUZONE INJ PF 12-13 Tier 0FLUZONE INJ PF 13-14 Tier 0FLUZONE PED/ INJ PF 11-12 Tier 0FLUZONE PED/ INJ PF 12-13 Tier 0FLUZONE PED/ INJ PF 13-14 Tier 0FLUZONE QUAD INJ 13-14 Tier 0FLUZONE SPLT INJ 2011-12 Tier 0



Drug Name Drug Tier Requirements/LimitsFLUZONE SPLT INJ 2012-13 Tier 0FLUZONE SPLT INJ 2013-14 Tier 0INFLUENZA A INJ PF09H1N1 Tier 0

VAGINAL PRODUCTSMiscellaneous Vaginal Products

ACID JELLY GEL VAG/APPL Tier 2Spermicides

encare gel 4% Tier 0Vaginal Anti-infectives

clindamycin cre 2% vag Tier 1GYNAZOLE-1 CRE 2% Tier 2metronidazol gel 0.75%vag Tier 1NYSTATIN VAG TAB 100000 Tier 1terconazole cre 0.4% Tier 1terconazole cre 0.8% Tier 1terconazole sup 80mg Tier 1vandazole gel 0.75% Tier 1zazole cre 0.4% Tier 1zazole cre 0.8% Tier 1zazole sup 80mg Tier 1

Vaginal EstrogensPREMARIN VAG CRE 0.625MG Tier 2VAGIFEM TAB 10MCG Tier 2

VASOPRESSORSAnaphylaxis Therapy Agents

ADRENACLICK INJ 0.3MG Tier 2AUVI-Q INJ 0.3MG Tier 2epinephrine inj 0.3mg Tier 1EPIPEN 2-PAK INJ 0.3MG Tier 2EPIPEN INJ 0.3MG Tier 2EPIPEN-JR INJ 0.15MG Tier 2EPIPEN-JR INJ 2-PAK Tier 2TWINJECT INJ 0.3MG Tier 2

VITAMINSOil Soluble Vitamins

A-25 CAP 25000UNT Tier 1bio-d-mulsio liq 400unit Tier 0child vit d chw 400unit Tier 0d3 kids chw 400unit Tier 0d-3 gummy chw 400unit Tier 0d-400 tab 400unit Tier 0



Drug Name Drug Tier Requirements/Limitsd-vita liq 400unit Tier 0delta d3 tab 400unit Tier 0ergocalcifer cap 50000unt Tier 1gnp vit d tab 400unit Tier 0just d liq 400unit Tier 0MEPHYTON TAB 5MG Tier 2sm vitamin d tab 400unit Tier 0vit d gummie chw 400unit Tier 0VITAMIN A CAP 25000UNT Tier 1vitamin d3 chw 400unit Tier 0vitamin d3 dro 400unit Tier 0vitamin d3 tab 400unit Tier 0vitamin d cap 50000unt Tier 1vitamin d chw 400unit Tier 0vitamin d dro 400unit Tier 0vitamin d tab 400unit Tier 0

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Index

88-MOP CAP 10MG 61

AA-25 CAP 25000UNT 105abacavir tab 300mg 43ABILIFY DISC TAB 10MG 42ABILIFY DISC TAB 15MG 42ABILIFY SOL 1MG/ML 43ABILIFY TAB 10MG 43ABILIFY TAB 15MG 43ABILIFY TAB 20MG 43ABILIFY TAB 2MG 43ABILIFY TAB 30MG 43ABILIFY TAB 5MG 43acarbose tab 100mg 24acarbose tab 25mg 24acarbose tab 50mg 24acd/fluoride dro 0.25mg 84ace acd/alum sol 2% otic 91acebutolol cap 200mg 48acebutolol cap 400mg 48acetasol hc sol otic 92acetazolamid cap 500mg er 68acetazolamid tab 125mg 68acetazolamid tab 250mg 68acetic acid sol 2% otic 91acetylcyst sol 10% 58acetylcyst sol 20% 58acid control tab 150mg 102acid control tab 20mg 102ACID JELLY GEL VAG/APPL 105acid reducer tab 150mg 102acid reducer tab 200mg 102acid reducer tab 20mg 102acid relief tab 200mg 102ACIPHEX TAB 20MG 103acticin cre 5% 66ACTIMMUNE INJ 2MU/0.5 38ACTONEL TAB 150MG 69ACTONEL TAB 30MG 69ACTONEL TAB 35MG 69ACTONEL TAB 5MG 69ACUVAIL SOL 0.45% 90acyclovir cap 200mg 46acyclovir sus 200/5ml 46acyclovir tab 400mg 46acyclovir tab 800mg 46adapalene cre 0.1% 59adapalene gel 0.1% 59ADRENACLICK INJ 0.3MG 105ADVAIR DISKU AER 100/50 15ADVAIR DISKU AER 250/50 15ADVAIR DISKU AER 500/50 15ADVAIR HFA AER 115/21 15ADVAIR HFA AER 230/21 15

ADVAIR HFA AER 45/21 15ADVATE INJ 1000UNIT 74ADVATE INJ 1500UNIT 74ADVATE INJ 2000UNIT 74ADVATE INJ 250UNIT 74ADVATE INJ 3000UNIT 74ADVATE INJ 500UNIT 74ADVICOR TAB 1000-20 31ADVICOR TAB 1000-40 31ADVICOR TAB 500-20MG 31ADVICOR TAB 750-20MG 31af-diphedryl elx 12.5/5ml 28afeditab tab 30mg cr 49afeditab tab 60mg cr 49AFINITOR TAB 10MG 37AFINITOR TAB 2.5MG 37AFINITOR TAB 5MG 37AFINITOR TAB 7.5MG 37AFLURIA INJ 2011-12 104AFLURIA INJ 2012-13 104AFLURIA INJ PF 10-11 104AFLURIA INJ PF 11-12 104AFLURIA INJ PF 12-13 104AGGRENOX CAP 25-200MG 76AGRIFLU INJ PF 10-11 104ak-pentolate sol 1% op 88al12 lot 12% 65ala cort cre 1% 62ala-cort lot 1% 62alagesic cap 4ALAMAST DRO 0.1% 90alaway child dro 0.025%op 90alaway dro 0.025%op 90ALBENZA TAB 200MG 11albuterol neb 0.083% 16albuterol neb 0.5% 15albuterol neb 0.63mg/3 16albuterol neb 1.25mg/3 16albuterol syp 2mg/5ml 16albuterol tab 2mg 16albuterol tab 4mg 16albuterol tab 4mg er 16albuterol tab 8mg er 16alclometason cre 0.05% 62alclometason oin 0.05% 62ALDURAZYME INJ 2.9MG/5M 69alendronate sol 70/75ml 69alendronate tab 10mg 69alendronate tab 35mg 69alendronate tab 40mg 69alendronate tab 5mg 69alendronate tab 70mg 69aler-cap cap 25mg 28ALFERON N INJ 5MU/ML 38alfuzosin tab 10mg 74ALINIA SUS 100MG/5M 11ALINIA TAB 500MG 11ALKERAN TAB 2MG 36all day allg sol 1mg/ml 29all day allg sol 5mg/5ml 29

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all day allg syp 1mg/ml 29all day allg syp 5mg/5ml 29aller-ease tab 180mg 29aller-fex tab 180mg 30aller-tec sol 1mg/ml 30allergy cap 25mg 28allergy chld sol 1mg/ml 30allergy comp sol 1mg/ml 30allergy eye dro 0.025%op 90allergy med cap 25mg 28allergy rel elx 12.5/5ml 29allergy rel sol 1mg/ml 30allergy relf cap 25mg 29allergy relf sol 5mg/5ml 30allergy relf tab 180mg 30allergy-d tab 12 hour 57allergy-d tab 60-120mg 57allopurinol tab 100mg 74allopurinol tab 300mg 74ALOCRIL SOL 2% 90ALOMIDE SOL 0.1% OP 91ALORA DIS 0.025MG 71ALORA DIS 0.05MG 71ALORA DIS 0.075MG 71ALORA DIS 0.1MG 71ALPHAGAN P SOL 0.1% 89ALPHANATE INJ VWF/HUM 74ALPHANINE SD INJ 1000UNIT 75ALPHANINE SD INJ 500UNIT 75alphatrex gel 0.05% 62alprazolam tab 0.25mg 13alprazolam tab 0.5mg 13alprazolam tab 1mg 13alprazolam tab 2mg 13ALREX SUS 0.2% 90alrgy relf d tab 180-240 57ALTABAX OIN 1% 60altaryl elx 12.5/5ml 29altaryl syp 12.5/5ml 29altavera tab 53ALTOPREV TAB 20MG ER 31ALTOPREV TAB 40MG ER 31ALTOPREV TAB 60MG ER 31ALVESCO AER 160MCG 15ALVESCO AER 80MCG 15alyacen tab 1/35 53alyacen tab 7/7/7 53amantadine cap 100mg 39amantadine syp 50mg/5ml 39amantadine tab 100mg 39amcinonide cre 0.1% 62amcinonide lot 0.1% 62amethyst tab 90-20mcg 53AMEVIVE INJ 15MG 61amiloride tab 5mg 68aminophyllin tab 100mg 16aminophyllin tab 200mg 16amiodarone tab 200mg 14amiodarone tab 400mg 14AMITIZA CAP 24MCG 73

AMITIZA CAP 8MCG 73amitriptylin tab 100mg 23amitriptylin tab 10mg 23amitriptylin tab 150mg 23amitriptylin tab 25mg 23amitriptylin tab 50mg 23amitriptylin tab 75mg 23amlactin cre 12% 65amlactin lot 12% 65amlod/benazp cap 10-20mg 34amlod/benazp cap 10-40mg 34amlod/benazp cap 2.5-10mg 34amlod/benazp cap 5-10mg 34amlod/benazp cap 5-20mg 34amlod/benazp cap 5-40mg 34amlodipine tab 10mg 49amlodipine tab 2.5mg 49amlodipine tab 5mg 49ammonium lac cre 12% 65ammonium lac lot 12% 65amnesteem cap 10mg 59amnesteem cap 20mg 59amnesteem cap 40mg 59amox-pot cla tab er 93amox/k clav chw 200mg 93amox/k clav chw 400mg 93amox/k clav sus 200/5ml 93amox/k clav sus 250/5ml 93amox/k clav sus 400/5ml 93amox/k clav sus 600/5ml 93amox/k clav tab 250mg 93amox/k clav tab 500mg 93amox/k clav tab 875mg 93amoxapine tab 100mg 23amoxapine tab 150mg 23amoxapine tab 25mg 23amoxapine tab 50mg 23amoxicillin cap 250mg 93amoxicillin cap 500mg 93amoxicillin chw 125mg 93amoxicillin chw 250mg 93amoxicillin sus 125/5ml 93amoxicillin sus 200/5ml 93amoxicillin sus 250/5ml 93amoxicillin sus 400/5ml 93amoxicillin tab 500mg 93amoxicillin tab 875mg 93amphetamine cap 10mg er 1amphetamine cap 15mg er 1amphetamine cap 20mg er 1amphetamine cap 25mg er 1amphetamine cap 30mg er 1amphetamine cap 5mg er 1amphetamine tab 10mg 1amphetamine tab 12.5mg 1amphetamine tab 15mg 1amphetamine tab 20mg 1amphetamine tab 30mg 1amphetamine tab 5mg 1amphetamine tab 7.5mg 1

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ampicillin cap 250mg 93ampicillin cap 500mg 93ampicillin sus 125/5ml 93ampicillin sus 250/5ml 93anacin tab 81mg ec 5ANADROL-50 TAB 50MG 10anagrelide cap 0.5mg 76anagrelide cap 1mg 76anastrozole tab 1mg 37ANDRODERM DIS 2.5MG/24 10ANDRODERM DIS 2MG/24HR 10ANDRODERM DIS 4MG/24HR 10ANDRODERM DIS 5MG/24HR 10android cap 10mg 10ANDROXY TAB 10MG 10anolor 300 cap 4anti-diarrhe cap 2mg 26anti-diarrhe tab 2mg 26anti-hist cap 25mg 29anti-itch cre /aloe/e 62anti-itch cre /oatmeal 62anti-itch cre 1% 62anti-itch cre 1%pls 10 62anti-itch lot 1% 62antifungal cre 1% 60antifungal cre 2% 60antihistamin cap 25mg 29antihistamin dro 0.025%op 91antipy/benzo sol otic 91ANTIVERT TAB 50MG 27anucort-hc sup 25mg 10ANZEMET TAB 100MG 27ANZEMET TAB 50MG 27apap/codeine sol 120-12/5 8apap/codeine tab 300-15mg 8apap/codeine tab 300-30mg 8apap/codeine tab 300-60mg 8apexicon oin 0.05% 62APIDRA INJ SOLOSTAR 25APIDRA INJ U-100 25APOKYN INJ 39APOKYN INJ 10MG/ML 39apraclonidin sol 0.5% op 89apri tab 53APTIVUS CAP 250MG 43APTIVUS SOL 43aquanil hc lot 1% 62ARALAST NP INJ 1000MG 99ARALAST NP INJ 400MG 99aranelle tab 53ARANESP INJ 100MCG 77ARANESP INJ 150MCG 77ARANESP INJ 200MCG 77ARANESP INJ 25MCG 76ARANESP INJ 300MCG 77ARANESP INJ 40MCG 77ARANESP INJ 500MCG 77ARANESP INJ 60MCG 77arbinoxa liq 4mg/5ml 29arbinoxa tab 4mg 29

ARCALYST INJ 220MG 3ARCAPTA CAP 75MCG 16argyl saline sol 0.9% 74ARMOUR THYRO TAB 120MG 100ARMOUR THYRO TAB 15MG 100ARMOUR THYRO TAB 180MG 100ARMOUR THYRO TAB 240MG 100ARMOUR THYRO TAB 300MG 100ASACOL TAB 400MG DR 73ascomp/cod cap 30mg 8asmalpred sol 15mg/5ml 56asmalpred sol plus 56ASMANEX 120 AER 220MCG 15ASMANEX 14 AER 220MCG 15ASMANEX 30 AER 110MCG 15ASMANEX 30 AER 220MCG 15ASMANEX 60 AER 220MCG 15ASMANEX 7 AER 110MCG 15aspir-81 tab 81mg ec 5aspir-low tab 81mg ec 5aspirin adlt tab 81mg 5aspirin chil chw 81mg 5aspirin chld chw 81mg 5aspirin chw 81mg 5aspirin low chw 81mg 5aspirin low tab 81mg ec 5aspirin tab 325mg 5aspirin tab 325mg ec 5aspirin tab 5gr ec 5aspirin tab 81mg 5aspirin tab 81mg ec 5aspirtab tab 324mg ec 5atenol/chlor tab 100-25mg 34atenol/chlor tab 50-25mg 34atenolol tab 100mg 48atenolol tab 25mg 48atenolol tab 50mg 48athlete foot cre 1% 60atorvastatin tab 10mg 31atorvastatin tab 20mg 31atorvastatin tab 40mg 31atorvastatin tab 80mg 31atovaq/progu tab 250-100 35atovaq/progu tab 62.5-25 35ATRALIN GEL 0.05% 59ATRIPLA TAB 43atropin-care sol 1% op 88ATROPINE SUL OIN 1% OP 88atropine sul sol 1% op 88ATROVENT HFA AER 17MCG 14aug betamet cre 0.05% 62aug betamet gel 0.05% 62aug betamet lot 0.05% 62aug betamet oin 0.05% 62AUGMENTIN SUS 125/5ML 93aurax sol 5.5-1.4% 91aurodex sol otic 91AUVI-Q INJ 0.3MG 105AVANDAMET TAB 2-1000MG 24AVANDAMET TAB 2-500MG 24

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AVANDAMET TAB 4-1000MG 24AVANDAMET TAB 4-500MG 24AVANDARYL TAB 4-1MG 24AVANDARYL TAB 4-2MG 24AVANDARYL TAB 4-4MG 24AVANDARYL TAB 8-2MG 24AVANDARYL TAB 8-4MG 24AVANDIA TAB 2MG 26AVANDIA TAB 4MG 26AVANDIA TAB 8MG 26aveeno cre 1% 62aviane tab 53avita cre 0.025% 59avita gel 0.025% 59AVODART CAP 0.5MG 74AVONEX KIT 30MCG 95AVONEX PEN KIT 30MCG 95AVONEX PREFL KIT 30MCG 95AXERT TAB 12.5MG 82AXERT TAB 6.25MG 82AZASAN TAB 100MG 46AZASAN TAB 75 MG 46azathioprine tab 50mg 46azelastine spr 0.1% 86AZELEX CRE 20% 59AZILECT TAB 0.5MG 40AZILECT TAB 1MG 40azithromycin pow 1gm pak 79azithromycin sus 100/5ml 79azithromycin sus 200/5ml 80azithromycin tab 250mg 80azithromycin tab 500mg 80azithromycin tab 600mg 80AZOPT SUS 1% OP 91AZOR TAB 10-20MG 34AZOR TAB 10-40MG 34AZOR TAB 5-20MG 34AZOR TAB 5-40MG 34azurette tab 28 day 53

Bbacitracin oin op 89baclofen tab 10mg 86baclofen tab 20mg 86BACTROBAN OIN NASAL 2% 86balsalazide cap 750mg 73balziva tab 53banophen cap 25mg 29banophen cap 50mg 29BANZEL SUS 40MG/ML 18BANZEL TAB 200MG 18BANZEL TAB 400MG 18BARACLUDE SOL .05MG/ML 45BARACLUDE TAB 0.5MG 45BARACLUDE TAB 1MG 45baycadron elx 0.5/5ml 56bayer adv tab 325mg 5bayer asa tab 325mg 5bayer low chw 81mg 5

bayer low tab 81mg ec 5baza antifun cre 2% 60BEBULIN INJ 200-1200 75BEBULIN VH INJ 200-1200 75BECONASE AQ SUS 0.042% 87bella alk/pb tab 16.2mg 101benazepril tab 10mg 32benazepril tab 20mg 32benazepril tab 40mg 32benazepril tab 5mg 32BENEFIX INJ 1000UNIT 75BENEFIX INJ 2000UNIT 75BENEFIX INJ 250UNIT 75BENEFIX INJ 500UNIT 75BENICAR TAB 20MG 33BENICAR TAB 40MG 33BENICAR TAB 5MG 33benzonatate cap 100mg 57benzonatate cap 200mg 57benztropine inj 1mg/ml 39benztropine tab 0.5mg 39benztropine tab 1mg 39benztropine tab 2mg 39BEPREVE DRO 1.5% 91BESIVANCE SUS 0.6% 89beta hc lot 1% 62betameth dip cre 0.05% 62betameth dip lot 0.05% 62betameth dip oin 0.05% 62betameth val cre 0.1% 62betameth val lot 0.1% 63betameth val oin 0.1% 63BETASERON INJ 0.3MG 95betaxolol sol 0.5% op 88betaxolol tab 10mg 48betaxolol tab 20mg 48bethanechol tab 10mg 103bethanechol tab 25mg 103bethanechol tab 50mg 103bethanechol tab 5mg 103BETOPTIC-S SUS 0.25% OP 88bicalutamide tab 50mg 37bio-d-mulsio liq 400unit 105bio-statin pow 28biocotron liq 100-10/5 57bisoprl/hctz tab 10/6.25 34bisoprl/hctz tab 2.5/6.25 34bisoprl/hctz tab 5-6.25mg 34bisoprol fum tab 10mg 48bisoprol fum tab 5mg 48BIVIGAM INJ 10% 92BLEPHAMIDE OIN S.O.P. 90BLEPHAMIDE SUS OP 90BOTOX INJ 100UNIT 88briellyn tab 53BRILINTA TAB 90MG 76brimonidine sol 0.15% 89brimonidine sol 0.2% op 89brom/pse/dm syp 57bromfed dm syp 57

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bromfenac sol 0.09% 91bromocriptin cap 5mg 39bromocriptin tab 2.5mg 39broncotron liq 10-100/5 57BROVANA NEB 15MCG 16budeprion tab 100mg sr 21budeprion tab 150mg sr 21budeprion xl tab 150mg 21budeprion xl tab 300mg 21budesonide cap 3mg/24hr 56budesonide sus 0.25mg/2 15budesonide sus 0.5mg/2 15bumetanide tab 0.5mg 68bumetanide tab 1mg 68bumetanide tab 2mg 68bupap tab 50-650mg 4bupren/nalox sub 2-0.5mg 9bupren/nalox sub 8-2mg 9buprenorphin sub 2mg 9buprenorphin sub 8mg 9buproban tab 150mg 95bupropion tab 100mg 21bupropion tab 100mg er 21bupropion tab 100mg sr 21bupropion tab 150mg 95bupropion tab 150mg er 21bupropion tab 150mg sr 21bupropion tab 200mg er 21bupropion tab 200mg sr 21bupropion tab 75mg 21bupropn hcl tab 150mg xl 21bupropn hcl tab 300mg xl 21buspirone tab 10mg 13buspirone tab 15mg 13buspirone tab 30mg 13buspirone tab 5mg 13buspirone tab 7.5mg 13but/apap/caf cap 4but/apap/caf cap codeine 8but/apap/caf tab 4but/asa/caf/ cap cod 30mg 8but/asa/caff cap 4but/asa/caff tab 4butal/apap tab 50-325mg 5butalbital tab cpd 5butorphanol sol 10mg/ml 9BUTRANS DIS 10MCG/HR 10BUTRANS DIS 20MCG/HR 10BUTRANS DIS 5MCG/HR 10BYETTA INJ 10MCG 25BYETTA INJ 5MCG 25BYSTOLIC TAB 10MG 48BYSTOLIC TAB 2.5MG 48BYSTOLIC TAB 20MG 48BYSTOLIC TAB 5MG 48

Cc-phen dm syp 57CAFERGOT TAB 1-100MG 81

calc acetate cap 667mg 73calc acetate tab 667mg 73calcipotrien cre 0.005% 61calcipotrien oin 0.005% 61calcipotrien sol 0.005% 61calcitonin spr 200/act 69calcitrene oin 0.005% 61calcitriol cap 0.25mcg 69calcitriol cap 0.5mcg 69calcitriol inj 1mcg/ml 69calcitriol oin 3mcg/gm 61caldecort cre 1% 63camila tab 0.35mg 55CAMPRAL TAB 333MG 94candesartan tab 16mg 33candesartan tab 32mg 33candesartan tab 4mg 33candesartan tab 8mg 33CANTIL TAB 25MG 101capacet cap 5CAPRELSA TAB 100MG 37CAPRELSA TAB 300MG 37captopr/hctz tab 25-15mg 34captopr/hctz tab 25-25mg 34captopr/hctz tab 50-15mg 34captopr/hctz tab 50-25mg 34captopril tab 100mg 32captopril tab 12.5mg 32captopril tab 25mg 32captopril tab 50mg 32carb/levo er tab 25-100mg 39carb/levo er tab 50-200mg 39carb/levo sr tab 25-100mg 39carb/levo sr tab 50-200mg 39carb/levo tab 10-100mg 39carb/levo tab 25-100mg 39carb/levo tab 25-250mg 39carbamazepin cap 100mg er 18carbamazepin cap 200mg er 18carbamazepin cap 300mg er 18carbamazepin chw 100mg 18carbamazepin sus 100/5ml 18carbamazepin tab 200mg 18carbamazepin tab 200mg er 18carbamazepin tab 400mg er 18carbinoxamin liq 4mg/5ml 29carbinoxamin tab 4mg 29CARIMUNE NF INJ 12GM 92CARIMUNE NF INJ 3GM 92CARIMUNE NF INJ 6GM 92carisopr/asa tab 200-325 86carisoprodol tab 250mg 86carisoprodol tab 350mg 86carteolol sol 1% op 88cartia xt cap 120/24hr 49cartia xt cap 180/24hr 49cartia xt cap 240/24hr 49cartia xt cap 300/24hr 49carvedilol tab 12.5mg 47carvedilol tab 25mg 47

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carvedilol tab 3.125mg 47carvedilol tab 6.25mg 47caziant pak 53CEDAX CAP 400MG 52cefaclor cap 250mg 52cefaclor cap 500mg 52cefaclor sus 125/5ml 52cefaclor sus 250/5ml 52cefaclor sus 375/5ml 52cefadroxil cap 500mg 52cefadroxil sus 250/5ml 52cefadroxil sus 500/5ml 52cefadroxil tab 1gm 52cefdinir cap 300mg 52cefdinir sus 125/5ml 52cefdinir sus 250/5ml 52cefditoren tab 200mg 52cefditoren tab 400mg 52cefpodo prox sus 100/5ml 53cefpodo prox sus 50mg/5ml 53cefpodoxime tab 100mg 53cefpodoxime tab 200mg 53cefprozil sus 125/5ml 52cefprozil sus 250/5ml 52cefprozil tab 250mg 52cefprozil tab 500mg 52CEFTIN SUS 250/5ML 52cefuroxime sus 125/5ml 52cefuroxime tab 250mg 52cefuroxime tab 500mg 52CELEBREX CAP 100MG 3CELEBREX CAP 200MG 3CELEBREX CAP 400MG 3CELLCEPT SUS 200MG/ML 46CELONTIN CAP 300MG 20CENESTIN TAB 0.3MG 71CENESTIN TAB 0.45MG 71CENESTIN TAB 0.625MG 71CENESTIN TAB 0.9MG 71CENESTIN TAB 1.25MG 71CENTANY AT KIT 2% 60centany oin 2% 60cephadyn tab 50-650mg 5cephalexin cap 250mg 52cephalexin cap 500mg 52cephalexin cap 750mg 52cephalexin sus 125/5ml 52cephalexin sus 250/5ml 52cephalexin tab 250mg 52cephalexin tab 500mg 52CEREZYME INJ 200UNIT 76CEREZYME INJ 400UNIT 76ceron-dm syp 57CESAMET CAP 1MG 28cesia pak 53cetirizine sol 1mg/ml 30cetirizine sol 5mg/5ml 30cetirizine syp 1mg/ml 30cetirizine syp 5mg/5ml 30cevimeline cap 30mg 84

CHANTIX PAK 0.5& 1MG 95CHANTIX PAK 1MG 95CHANTIX TAB 0.5MG 95CHANTIX TAB 1MG 95chateal tab 0.15/30 53CHEMET CAP 100MG 27CHEMSTRIP 10 TES MD 67CHEMSTRIP 2 TES GP 66CHEMSTRIP 5 TES OB 66CHEMSTRIP 7 TES 66CHEMSTRIP 9 TES STRIPS 67CHEMSTRIP TES -10 SG 67CHEMSTRIP TES UGK 67cheratussin sol dac 57cheratussin syp ac 57child asa chw 81mg 5child asa ls chw 81mg 5child vit d chw 400unit 105chloral hydr syp 500/5ml 78chlord/clidi cap 5-2.5mg 101chlordiazep cap 10mg 13chlordiazep cap 25mg 13chlordiazep cap 5mg 13chlorhex glu sol 0.12% 83chloroquine tab 250mg 35chloroquine tab 500mg 35chlorothiaz tab 250mg 68chlorothiaz tab 500mg 68chlorpromaz tab 100mg 42chlorpromaz tab 10mg 42chlorpromaz tab 200mg 42chlorpromaz tab 25mg 42chlorpromaz tab 50mg 42chlorpropam tab 100mg 26chlorpropam tab 250mg 26chlorthalid tab 25mg 68chlorthalid tab 50mg 68chlorzoxazon tab 500mg 86cho mag tris liq 500/5ml 5cho mag tris tab 1000mg 5cho mag tris tab 500mg 5cho mag tris tab 750mg 5cholestyram pow 4gm 31cholestyram pow 4gm lite 31CIALIS TAB 10MG 51CIALIS TAB 2.5MG 51CIALIS TAB 20MG 51CIALIS TAB 5MG 51ciclodan cre 0.77% 60ciclopirox cre 0.77% 60ciclopirox sus 0.77% 60cilostazol tab 100mg 76cilostazol tab 50mg 76CILOXAN OIN 0.3% OP 89cimetidine sol 300/5ml 102cimetidine tab 200mg 102cimetidine tab 300mg 102cimetidine tab 400mg 102cimetidine tab 800mg 102CIMZIA KIT 73

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CINRYZE SOL 500 UNIT 76CIPRO (10%) SUS 500MG/5 72CIPRO (5%) SUS 250MG/5 72CIPRO HC SUS OTIC 91CIPRODEX SUS 0.3-0.1% 92ciprofloxacn sol 0.3% op 89ciprofloxacn tab 100mg 72ciprofloxacn tab 250mg 72ciprofloxacn tab 500mg 72ciprofloxacn tab 750mg 72citalopram tab 10mg 22citalopram tab 20mg 22citalopram tab 40mg 22CL PRENATAL TAB 28-0.8MG 85claravis cap 10mg 59claravis cap 20mg 59claravis cap 30mg 59claravis cap 40mg 59clarithromyc sus 125/5ml 80clarithromyc sus 250/5ml 80clarithromyc tab 250mg 80clarithromyc tab 500mg 80claritin eye dro 0.025%op 91clearlax pow 79clemastine syp 0.5/5ml 29clemastine tab 2.68mg 29clindacin-p pad 1% 59clindamax gel 1% 59clindamax lot 10mg/ml 59clindamy/ben gel 1-5% 59clindamy/ben gel 1.2-5% 59clindamycin aer 1% 59clindamycin cap 150mg 11clindamycin cap 300mg 11clindamycin cap 75mg 11clindamycin cre 2% vag 105clindamycin gel 1% 59clindamycin lot 1% 59clindamycin lot 10mg/ml 59clindamycin pad 1% 59clindamycin sol 1% 59clindamycin sol 75mg/5ml 11clobetasol cre 0.05% 63clobetasol oin 0.05% 63clobetasol sol 0.05% 63CLODERM CRE 0.1% 63CLODERM CRE 0.1% PMP 63clomipramine cap 25mg 23clomipramine cap 50mg 23clomipramine cap 75mg 23clonazepam tab 0.5mg 18clonazepam tab 1mg 18clonazepam tab 2mg 18clonidine dis 0.1/24hr 33clonidine dis 0.2/24hr 33clonidine dis 0.3/24hr 34clonidine tab 0.1mg 34clonidine tab 0.2mg 34clonidine tab 0.3mg 34clopidogrel tab 300mg 76

clopidogrel tab 75mg 76cloraz dipot tab 15mg 13cloraz dipot tab 3.75mg 13cloraz dipot tab 7.5mg 13clotrim/beta cre 1-0.05% 60clotrim/beta cre diprop 60clotrim/beta lot diprop 60clotrimazole cre 1% 60clotrimazole loz 10mg 83clotrimazole sol 1% 60clotrimazole tro 10mg 83clozapine tab 100/odt 41clozapine tab 100mg 41clozapine tab 12.5/odt 41clozapine tab 200mg 41clozapine tab 25mg 41clozapine tab 25mg odt 41clozapine tab 50mg 41co-gesic tab 5-500mg 9COARTEM TAB 20-120MG 35codeine sulf tab 30mg 7codeine sulf tab 60mg 7COLCRYS TAB 0.6MG 74colestipol gra 5gm 31colestipol tab 1gm 31colidrops dro 0.125/ml 101colocort ene 100mg 10COLY-MYCIN S SUS OTIC 92COLYTE/FLAVR SOL PACKS 79COMBIGAN SOL 0.2/0.5% 88COMBIPATCH DIS .05/.14 71COMBIPATCH DIS .05/.25 71COMBISTIX TES 67COMBIVENT AER 16COMBIVENT AER RESPIMAT 16comp allergy cap 25mg 29COMPLERA TAB 43compro sup 25mg 42CONCEPT DHA CAP 85CONCEPT OB CAP 85congest aid tab 30mg 87congestion tab 30mg 87constulose sol 10gm/15 79COPAXONE KIT 20MG/ML 95CORDRAN 24X3 TAP 4MCG/CM 63CORDRAN 80X3 TAP 4MCG/CM 63CORDRAN LOT 0.05% 63CORDRAN SP CRE 0.05% 63COREG CR CAP 10MG 47COREG CR CAP 20MG 47COREG CR CAP 40MG 47COREG CR CAP 80MG 47cormax oin 0.05% 63cormax scalp sol 0.05% 63cormax sol 0.05% 63cort intense cre heal 1% 63cortaid adv cre 1% 12 hr 63cortaid cre 1% 63cortisone + cre 1% 63cortisone ac tab 25mg 56

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cortisone cre 1% 63cortisone lot 1% 63CORTISPORIN OIN 1% 60CORTISPORIN SUS -TC OTIC 92cortizone-10 lot eczema 63cortizone-10 lot hydraten 63covaryx hs tab 71covaryx tab 71COVERA-HS TAB 180MG 49COVERA-HS TAB 240MG 49CREON CAP 12000UNT 67CREON CAP 24000UNT 67CREON CAP 3000UNIT 67CREON CAP 6000UNIT 67CRESTOR TAB 10MG 31CRESTOR TAB 20MG 31CRESTOR TAB 40MG 31CRESTOR TAB 5MG 31CRIXIVAN CAP 100MG 43CRIXIVAN CAP 200MG 43CRIXIVAN CAP 400MG 43cromolyn sod neb 20mg/2ml 14cromolyn sod sol 4% op 91cryselle-28 tab 28 tabs 53CUPRIMINE CAP 250MG 46curity salin sol 0.9% irr 74cvs allergy cap 25mg 29cvs allergy dro 0.025%op 91cvs allergy tab 180mg 30cvs aspirin tab 325mg 5cvs aspirin tab 325mg ec 5cvs aspirin tab 81mg ec 5cvs chld asa chw 81mg 5cvs cort int cre heal 1% 63CVS KETONE TES CARE 67cvs nicotine dis 14mg/24h 95cvs nicotine dis 21mg/24h 95cvs nicotine dis 7mg/24hr 95cvs nicotine gum 2mg cinn 95cvs nicotine gum 2mg mint 95cvs nicotine gum 2mg orig 95cvs nicotine gum 2mgfruit 95cvs nicotine gum 4mg cinn 95cvs nicotine gum 4mg mint 95cvs nicotine gum 4mg orig 95cvs nicotine gum 4mgfruit 95cvs nicotine loz 2mg mint 96cvs nicotine loz 4mg mint 96cvs nts dis step 1 96CVS PRENATAL TAB 85CVS PRENATAL TAB 28-0.8MG 85cvs purelax pow 79cyclafem tab 1/35 53cyclafem tab 7/7/7 53cyclobenzapr tab 10mg 86CYCLOGYL SOL 0.5% OP 88cyclopentol sol 1% op 88cyclopentol sol 2% op 88cyclophosph tab 25mg 36cyclophosph tab 50mg 36

cycloserine cap 250mg 36CYCLOSET TAB 0.8MG 25cyclosporine cap 100mg 47cyclosporine cap 100mg md 47cyclosporine cap 25mg 46cyclosporine cap 25mg mod 46cyclosporine cap 50mg mod 46cyclosporine sol modified 47cylate sol 1% op 88CYMBALTA CAP 20MG 22CYMBALTA CAP 30MG 22CYMBALTA CAP 60MG 22cyproheptad syp 2mg/5ml 30cyproheptad tab 4mg 30

Dd-3 gummy chw 400unit 105d-400 tab 400unit 105d-vita liq 400unit 106d3 kids chw 400unit 105DALIRESP TAB 500MCG 15danazol cap 100mg 10danazol cap 200mg 10danazol cap 50mg 10dantrolene cap 100mg 86dantrolene cap 25mg 86dantrolene cap 50mg 86dapsone tab 100mg 11dapsone tab 25mg 11DARAPRIM TAB 25MG 35dasetta tab 1/35 53dasetta tab 7/7/7 53DAYTRANA DIS 15MG/9HR 2decongestant tab 30mg 87decongestant tab 60mg 87delta d3 tab 400unit 106demeclocycl tab 150mg 99demeclocycl tab 300mg 99DENAVIR CRE 1% 62DEPO-SQ PROV INJ 104 55desenex cre 1% 60desipramine tab 100mg 23desipramine tab 10mg 23desipramine tab 150mg 23desipramine tab 25mg 23desipramine tab 50mg 23desipramine tab 75mg 23desloratadin tab 2.5 odt 30desloratadin tab 5mg 30desloratadin tab 5mg odt 30desmopressin inj 4mcg/ml 70desmopressin sol 0.01% 70desmopressin spr 0.01% 70desmopressin tab 0.1mg 70desmopressin tab 0.2mg 70desonide cre 0.05% 63desonide lot 0.05% 63desonide oin 0.05% 63desoximetas cre 0.05% 63

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desoximetas cre 0.25% 63desoximetas gel 0.05% 63desoximetas oin 0.05% 63desoximetas oin 0.25% 63DETROL LA CAP 2MG 103DETROL LA CAP 4MG 103dexameth pho sol 0.1% op 90dexamethason elx 0.5/5ml 56dexamethason sol 0.5/5ml 56dexamethason tab 0.5mg 56dexamethason tab 0.75mg 56dexamethason tab 1.5mg 56dexamethason tab 1mg 56dexamethason tab 2mg 56dexamethason tab 4mg 56dexamethason tab 6mg 56dexchlorphen syp 2mg/5ml 28DEXILANT CAP 30MG DR 103DEXILANT CAP 60MG DR 103dexmethylph tab 10mg 2dexmethylph tab 2.5mg 2dexmethylph tab 5mg 2dextroamphet cap 10mg er 1dextroamphet cap 15mg er 1dextroamphet cap 5mg er 1dextroamphet tab 10mg 1dextroamphet tab 5mg 1diabetic tus liq children 57diabetic tus liq dm 57diamode tab 2mg 27diazepam gel 10mg 18diazepam gel 2.5mg 18diazepam gel 20mg 18diazepam sol 1mg/ml 13diazepam tab 10mg 13diazepam tab 2mg 13diazepam tab 5mg 13DIBENZYLINE CAP 10MG 33diclofenac sol 0.1% op 91diclofenac tab 25mg dr 3diclofenac tab 50mg dr 3diclofenac tab 75mg dr 3dicloxacill cap 250mg 93dicloxacill cap 500mg 93dicyclomine cap 10mg 101dicyclomine sol 10mg/5ml 101dicyclomine tab 20mg 101didanosine cap 125mg 43didanosine cap 200mg 43didanosine cap 250mg 43didanosine cap 400mg 43DIFICID TAB 200MG 80diflorasone cre 0.05% 63diflorasone oin 0.05% 63diflunisal tab 500mg 5digoxin tab 0.125mg 51digoxin tab 0.25mg 51dihydroergot inj 1mg/ml 81dihydroergot spr 4mg/ml 81DILANTIN CAP 30MG 20

DILATRATE SR CAP 40MG 12dilt-cd cap 120mg 49dilt-cd cap 180mg 49dilt-cd cap 240mg 49dilt-cd cap 300mg 49dilt-xr cap 120mg 49dilt-xr cap 180mg 49dilt-xr cap 240mg 49diltiazem cap 120mg cd 49diltiazem cap 120mg er 49diltiazem cap 120mg/24 49diltiazem cap 180mg cd 49diltiazem cap 180mg er 49diltiazem cap 180mg/24 49diltiazem cap 240mg cd 49diltiazem cap 240mg er 49diltiazem cap 240mg/24 49diltiazem cap 300mg cd 49diltiazem cap 300mg er 49diltiazem cap 300mg/24 49diltiazem cap 360mg cd 49diltiazem cap 360mg er 50diltiazem cap 360mg/24 50diltiazem cap 420mg/24 50diltiazem cap 60mg er 49diltiazem cap 90mg er 49diltiazem tab 120mg 50diltiazem tab 30mg 50diltiazem tab 60mg 50diltiazem tab 90mg 50diltzac cap 120mg/24 50diltzac cap 180mg/24 50diltzac cap 240mg/24 50diltzac cap 300mg/24 50diltzac cap 360mg/24 50dimetane dx syp 57DIOVAN TAB 160MG 33DIOVAN TAB 320MG 33DIOVAN TAB 40MG 33DIOVAN TAB 80MG 33DIPENTUM CAP 250MG 73diphen/atrop liq 2.5/5 27diphen/atrop tab 2.5mg 27diphenhist cap 25mg 29diphenhydram cap 25mg 29diphenhydram cap 50mg 29diphenhydram elx 12.5/5ml 29dipyridamole tab 25mg 76dipyridamole tab 50mg 76dipyridamole tab 75mg 76disopyramide cap 100mg 14disopyramide cap 150mg 14disulfiram tab 250mg 94disulfiram tab 500mg 94divalproex cap 125mg 20divalproex tab 125mg dr 20divalproex tab 250mg dr 20divalproex tab 250mg er 20divalproex tab 500mg dr 20divalproex tab 500mg er 20

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dm/gg sol 57dm/gg sol 10-100/5 57donepezil tab 10mg 94donepezil tab 10mg odt 94donepezil tab 5mg 94donepezil tab 5mg odt 94dormin cap 25mg 29dorzol/timol sol 2-0.5%op 88dorzolamide sol 2% op 91doxazosin tab 1mg 34doxazosin tab 2mg 34doxazosin tab 4mg 34doxazosin tab 8mg 34doxepin hcl cap 100mg 23doxepin hcl cap 10mg 23doxepin hcl cap 150mg 23doxepin hcl cap 25mg 23doxepin hcl cap 50mg 23doxepin hcl cap 75mg 23doxepin hcl con 10mg/ml 23doxycycl hyc cap 100mg 99doxycycl hyc cap 50mg 99doxycycl hyc tab 100mg 99doxycycl hyc tab 100mg dr 99doxycycl hyc tab 150mg dr 99doxycycl hyc tab 75mg dr 99doxycycline sus 25mg/5ml 99doxycycline tab 20mg 99dramamine tab 25mg 27DRITHO-CREME CRE HP 1% 61DRITHO-SCALP CRE 0.5% 61dronabinol cap 10mg 28dronabinol cap 2.5mg 28dronabinol cap 5mg 28drospir/ethi tab 3-0.03mg 53dulcolax pow balance 79DULERA AER 100-5MCG 16DULERA AER 200-5MCG 16DUREZOL EMU 0.05% 90DYNACIRC CR TAB 10MG 50DYNACIRC CR TAB 5MG 50DYRENIUM CAP 100MG 68DYRENIUM CAP 50MG 68dytuss syp 12.5/5ml 29

Ee.e.s. 400 tab 400mg 80E.E.S. GRAN SUS 200/5ML 80e.s.p. sus 200-600 11econazole cre 1% 60ecotrin low tab 81mg ec 5ecpirin tab 325mg ec 5ed baclofen tab 10mg 86EDARBI TAB 40MG 33EDARBI TAB 80MG 33EDECRIN TAB 25MG 68EDURANT TAB 25MG 43eemt hs tab 71eemt tab 71

ees/sulfisox sus 200-600 11EFFIENT TAB 10MG 76EFFIENT TAB 5MG 76ELAPRASE INJ 6MG/3ML 69ELIDEL CRE 1% 65ELIGARD INJ 22.5MG 37ELIGARD INJ 30MG 37ELIGARD INJ 45MG 37ELIGARD INJ 7.5MG 37elinest tab 53ELIXOPHYLLIN ELX 80/15ML 16ELLA TAB 30MG 55ELMIRON CAP 100MG 74EMADINE SOL 0.05% OP 91EMCYT CAP 140MG 37EMEND CAP 125MG 28EMEND CAP 40MG 28EMEND CAP 80MG 28EMEND PAK 80 & 125 28emoquette tab 53EMSAM DIS 12MG/24H 22EMSAM DIS 6MG/24HR 22EMSAM DIS 9MG/24HR 22EMTRIVA CAP 200MG 43EMTRIVA SOL 10MG/ML 43ENABLEX TAB 15MG 103ENABLEX TAB 7.5MG 103enalapril tab 10mg 32enalapril tab 2.5mg 32enalapril tab 20mg 32enalapril tab 5mg 32ENBREL INJ 25/0.5ML 4ENBREL INJ 25MG 4ENBREL INJ 50MG/ML 4ENBREL SRCLK INJ 50MG/ML 4encare gel 4% 105endocet tab 10-325mg 9endocet tab 10-650mg 9endocet tab 5-325mg 9endocet tab 7.5-325 9endocet tab 7.5-500m 9endodan tab 9ENJUVIA TAB 0.3MG 71ENJUVIA TAB 0.45MG 71ENJUVIA TAB 0.625MG 71ENJUVIA TAB 0.9MG 71ENJUVIA TAB 1.25MG 71enoxaparin inj 100mg/ml 17enoxaparin inj 120/0.8 17enoxaparin inj 150mg/ml 17enoxaparin inj 30/0.3ml 17enoxaparin inj 300/3ml 17enoxaparin inj 40/0.4ml 17enoxaparin inj 60/0.6ml 17enoxaparin inj 80/0.8ml 17enpresse-28 tab 53enskyce tab 53entacapone tab 200mg 39enulose sol 10gm/15 73epidrin cap 81

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epiflur chw 0.25mg f 82epiflur chw 0.5mg f 82epiflur chw 1mg f 82epinastine dro 0.05% 91epinephrine inj 0.3mg 105EPIPEN 2-PAK INJ 0.3MG 105EPIPEN INJ 0.3MG 105EPIPEN-JR INJ 0.15MG 105EPIPEN-JR INJ 2-PAK 105epitol tab 200mg 18EPIVIR HBV SOL 5MG/ML 43EPIVIR HBV TAB 100MG 43eplerenone tab 25mg 35eplerenone tab 50mg 35EPOGEN INJ 10000/ML 77EPOGEN INJ 2000/ML 77EPOGEN INJ 20000/ML 77EPOGEN INJ 3000/ML 77EPOGEN INJ 4000/ML 77eprosart mes tab 600mg 33EPZICOM TAB 600-300 43eq allergy cap 25mg 29eq aspirin tab 325mg 5eq aspirin tab 325mg ec 6eq child asa chw 81mg 6eq heartburn tab relief 102eq hydrocort cre 1% 63eq itchy eye dro 0.025%op 91eq nicotine dis 14mg/24h 96eq nicotine dis 21mg/24h 96eq nicotine dis 7mg/24hr 96eq nicotine gum 2mg cinn 96eq nicotine gum 2mg mint 96eq nicotine gum 2mg orig 96eq nicotine gum 2mgfruit 96eq nicotine gum 4mg cinn 96eq nicotine gum 4mg mint 96eq nicotine gum 4mg orig 96eq nicotine gum 4mg ref 96eq nicotine gum 4mg strt 96eq nicotine gum 4mgfruit 96eq nicotine loz 2mg cher 96eq nicotine loz 2mg mint 96eq nicotine loz 4mg chry 96eq nicotine loz 4mg mint 96eq suphedrin tab 30mg 87eql allergy cap 25mg 29eql aspirin tab 325mg 6eql aspirin tab 325mg ec 6eql aspirin tab 81mg ec 6eql chld asa chw 81mg 6eql clearlax pow 79eql nicotine dis 14mg/24h 96eql nicotine dis 21mg/24h 96eql nicotine dis 7mg/24hr 96eql nicotine gum 2mg 96eql nicotine gum 2mg ref 96eql nicotine gum 2mg strt 96eql nicotine gum 4mg 96eql nicotine gum 4mg ref 96

eql nicotine gum 4mg strt 96eql nicotine loz 2mg mint 96eql nicotine loz 4mg mint 96EQL PRENATAL TAB FORMULA 85ergocalcifer cap 50000unt 106ergoloid mes tab 1mg oral 95ERGOMAR SUB 2MG 82ERIVEDGE CAP 150MG 36errin tab 0.35mg 55ERTACZO CRE 2% 60ERY-TAB TAB 333MG EC 80ERY-TAB TAB 500MG EC 80ERYPED SUS 200/5ML 80ERYPED SUS 400/5ML 80erythrocin tab 250mg 80erythrom eth tab 400mg 80erythromycin cap 250mg ec 80erythromycin gel /benzoyl 59erythromycin gel 2% 59erythromycin oin 5mg/gm 89erythromycin oin op 89erythromycin sol 2% 59erythromycin tab 250mg bs 80erythromycin tab 500mg bs 80escitalopram tab 10mg 22escitalopram tab 20mg 22essian h.s. tab 71essian tab 71est estrogen tab mtest 71est estrogen tab mtest ds 71est estrogen tab mtest hs 71estarylla tab 0.25-35 53estazolam tab 1mg 78estazolam tab 2mg 78ESTRADERM DIS 0.05MG 71ESTRADERM DIS 0.1MG 71estradiol dis 0.025mg 71estradiol dis 0.0375mg 72estradiol dis 0.05mg 71estradiol dis 0.06mg 71estradiol dis 0.075mg 72estradiol dis 0.1mg 71estradiol tab 0.5mg 72estradiol tab 1mg 72estradiol tab 2mg 72ethambutol tab 100mg 36ethambutol tab 400mg 36ethosuximide cap 250mg 20ethosuximide sol 250/5ml 20etidron disd tab 200mg 69etidron disd tab 400mg 69etodolac cap 200mg 3etodolac cap 300mg 3etodolac er tab 400mg 3etodolac er tab 500mg 3etodolac er tab 600mg 3etodolac tab 400mg 3etodolac tab 500mg 3etoposide cap 50mg 39EUFLEXXA INJ 10MG/ML 86

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EURAX CRE 10% 66EURAX LOT 10% 66EVISTA TAB 60MG 69EXELDERM CRE 1% 60EXELDERM SOL 1% 60exemestane tab 25mg 37EXJADE TAB 125MG 27EXJADE TAB 250MG 27EXJADE TAB 500MG 27EXTAVIA INJ 0.3MG 95eye itch rel dro 0.025%op 91EZ USE FLU KIT 2012-13 104EZFE FORTE CAP 85

Ffa-8 tab 0.8mg 76FABRAZYME INJ 35MG 70FABRAZYME INJ 5MG 69FACTIVE TAB 320MG 72falmina tab 53famciclovir tab 125mg 46famciclovir tab 250mg 46famciclovir tab 500mg 46famotidine sus 40mg/5ml 102famotidine tab 20mg 102FANAPT PAK 40FANAPT TAB 10MG 40FANAPT TAB 12MG 40FANAPT TAB 1MG 40FANAPT TAB 2MG 40FANAPT TAB 4MG 40FANAPT TAB 6MG 40FANAPT TAB 8MG 40FARESTON TAB 60MG 37FC FEMALE MIS CONDOM 80FC2 FEMALE MIS CONDOM 80FEIBA NF INJ 75FEIBA VH INJ IMMUNO 75felbamate sus 600/5ml 20felbamate tab 400mg 20felbamate tab 600mg 20felodipine tab 10mg er 50felodipine tab 2.5mg er 50felodipine tab 5mg er 50FEMCAP MIS 22MM 80FEMCAP MIS 26MM 80FEMCAP MIS 30MM 80FEMHRT TAB 0.5-2.5 71fenofibrate tab 160mg 31fenofibrate tab 48mg 31fenofibrate tab 54mg 31FENOGLIDE TAB 120MG 31FENOGLIDE TAB 40MG 31fenoprofen tab 600mg 3fentanyl dis 100mcg/h 7fentanyl dis 12mcg/hr 7fentanyl dis 25mcg/hr 7fentanyl dis 50mcg/hr 7fentanyl dis 75mcg/hr 7

fer-iron dro 15mg/ml 78ferocon cap 77ferosul elx 220/5ml 78ferotrin cap 77ferotrinsic cap 77ferrex 150 cap forte 77FERRIPROX TAB 500MG 27ferrous dro 15mg/ml 78ferrous sulf dro 15mg/ml 78ferrous sulf elx 220/5ml 78fexofen/pse tab 180-240 57fexofenadine tab 180mg 30FINACEA GEL 15% 66finasteride tab 5mg 74FLAREX SUS 0.1% OP 90flavoxate tab 100mg 104FLEBOGAMMA INJ 10% 92FLEBOGAMMA INJ 5% 92FLEBOGAMMA INJ DIF 5% 92flecainide tab 100mg 14flecainide tab 150mg 14flecainide tab 50mg 14FLECTOR DIS 1.3% 60FLOVENT DISK AER 100MCG 15FLOVENT DISK AER 250MCG 15FLOVENT DISK AER 50MCG 15FLOVENT HFA AER 110MCG 15FLOVENT HFA AER 220MCG 15FLOVENT HFA AER 44MCG 15FLUARIX INJ PF 10-11 104FLUARIX INJ PF 11-12 104FLUARIX INJ PF 12-13 104FLUARIX PF INJ 2013-14 104FLUARIX QUAD INJ 2013-14 104fluconazole sus 10mg/ml 28fluconazole sus 40mg/ml 28fluconazole tab 100mg 28fluconazole tab 150mg 28fluconazole tab 200mg 28fluconazole tab 50mg 28fludrocort tab 0.1mg 57FLULAVAL INJ 2010-11 104FLULAVAL INJ 2011-12 104FLULAVAL INJ 2012-13 104FLULAVAL INJ 2013-14 104flunisolide spr 0.025% 87flunisolide spr 29mcg 87fluocin acet cre 0.01% 63fluocin acet cre 0.025% 63fluocin acet oil 0.01% 92fluocin acet oil body 63fluocin acet oil scalp 63fluocin acet oin 0.025% 63fluocin acet sol 0.01% 63fluocinonide cre 0.05% 63fluocinonide gel 0.05% 63fluocinonide oin 0.05% 64fluocinonide sol 0.05% 64fluor-a-day dro 0.125mg 82fluor-op sus 0.1% op 90

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FLUORABON DRO 82fluoride chw 0.25mg f 82fluoride chw 0.5mg f 82fluoride chw 1mg f 82fluoritab chw 0.25mg f 82fluoritab chw 0.5mg f 82fluoritab chw 1mg f 82fluoritab chw 2.2mg 82fluoritab dro 0.125mg 82fluoromethol sus 0.1% op 90fluorouracil cre 5% 61fluorouracil dro 2% 61fluorouracil dro 5% 61fluorouracil sol 2% 61fluorouracil sol 5% 61fluoxetine cap 10mg 22, 95fluoxetine cap 20mg 22, 95fluoxetine cap 40mg 22fluoxetine sol 20mg/5ml 22fluoxetine tab 10mg 22fluoxetine tab 20mg 22FLUOXETINE TAB 60MG 22fluphenazine con 5mg/ml 42fluphenazine elx 2.5/5ml 42fluphenazine tab 10mg 42fluphenazine tab 1mg 42fluphenazine tab 2.5mg 42fluphenazine tab 5mg 42flura-drops dro 0.125mg 82flura-drops dro 0.25mg f 82flurazepam cap 15mg 78flurazepam cap 30mg 78flurbiprofen sol 0.03% op 91flurbiprofen tab 100mg 3flurbiprofen tab 50mg 3flutamide cap 125mg 37fluticasone cre 0.05% 64fluticasone lot 0.05% 64fluticasone oin 0.005% 64fluticasone spr 50mcg 87fluvastatin cap 20mg 31fluvastatin cap 40mg 31FLUVIRIN INJ 2011-12 104FLUVIRIN INJ 2012-13 104FLUVIRIN INJ PF 11-12 104FLUVIRIN INJ PF 12-13 104fluvoxamine cap 100mg er 22fluvoxamine cap 150mg er 22fluvoxamine tab 100mg 22fluvoxamine tab 25mg 22fluvoxamine tab 50mg 22FLUZONE INJ INTRADRM 104FLUZONE INJ PF 11-12 104FLUZONE INJ PF 12-13 104FLUZONE INJ PF 13-14 104FLUZONE PED/ INJ PF 11-12 104FLUZONE PED/ INJ PF 12-13 104FLUZONE PED/ INJ PF 13-14 104FLUZONE QUAD INJ 13-14 104FLUZONE SPLT INJ 2011-12 104

FLUZONE SPLT INJ 2012-13 105FLUZONE SPLT INJ 2013-14 105FML FORTE SUS 0.25% OP 90FML OIN 0.1% OP 90FOCALIN XR CAP 10MG 2FOCALIN XR CAP 15MG 2FOCALIN XR CAP 20MG 2FOCALIN XR CAP 25MG 2FOCALIN XR CAP 30MG 2FOCALIN XR CAP 35MG 2FOCALIN XR CAP 40MG 2FOCALIN XR CAP 5MG 2folic acid tab 1000mcg 76folic acid tab 1mg 76folic acid tab 400mcg 76folic acid tab 800mcg 76FOLIVANE-OB CAP 85foltrin cap 77fondaparinux sol 10/0.8 17fondaparinux sol 2.5/0.5 17fondaparinux sol 5.0/0.4 17fondaparinux sol 7.5/0.6 17FORADIL CAP AEROLIZE 16FORTEO SOL 600/2.4 69fosinopril tab 10mg 32fosinopril tab 20mg 32fosinopril tab 40mg 32FOSRENOL CHW 1000MG 73FOSRENOL CHW 500MG 73FOSRENOL CHW 750MG 73FRAGMIN INJ 10000/ML 18FRAGMIN INJ 12500UNT 18FRAGMIN INJ 15000UNT 18FRAGMIN INJ 18000UNT 18FRAGMIN INJ 2500/0.2 17FRAGMIN INJ 25000/ML 18FRAGMIN INJ 5000/0.2 18FRAGMIN INJ 7500/0.3 18FROVA TAB 2.5MG 82fungicure spr intens 60furosemide sol 10mg/ml 68furosemide tab 20mg 68furosemide tab 40mg 68furosemide tab 80mg 68FUZEON INJ 90MG 43FUZEON KIT 43

Gg-tron liq 10-100/5 57gabapentin cap 100mg 18gabapentin cap 300mg 18gabapentin cap 400mg 18gabapentin tab 600mg 18gabapentin tab 800mg 18GABITRIL TAB 12MG 20GABITRIL TAB 16MG 20galantamine cap 16mg er 94galantamine cap 24mg er 94galantamine cap 8mg er 94

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galantamine tab 12mg 94galantamine tab 4mg 94galantamine tab 8mg 94GAMASTAN S/D INJ 92GAMMAGARD SD INJ 10GM HU 92GAMMAGARD SD INJ 2.5GM HU 92GAMMAGARD SD INJ 5GM HU 92GAMMAPLEX INJ 5GM 92GAMUNEX INJ 10% 92gani-tuss dm liq 100-10/5 57gani-tuss nr liq 100-10/5 57garamycin oin 0.3% op 89gavilax pow 79gavilyte-c sol 79gavilyte-g sol 79GELNIQUE GEL 10% 104gemfibrozil tab 600mg 31genahist cap 25mg 29genaphed tab 30mg 87generlac sol 10gm/15 73gengraf cap 100mg 47gengraf cap 25mg 47gengraf sol 100mg/ml 47gentak oin 0.3% op 89gentak sol 0.3% op 89gentamicin cre 0.1% 60gentamicin oin 0.1% 60gentamicin oin 0.3% op 89gentamicin sol 0.3% op 89gentasol sol 0.3% op 89gentlelax pow 79geri-dryl cap 25mg 29geri-hydrola cre 12% 65geri-hydrola lot 12% 65gg/codeine sol 100-10/5 57gianvi tab 3-0.02mg 53gildagia tab 0.4-35 53gildess fe tab 1.5/30 53gildess fe tab 1/20 53gildess tab 1.5/30 53gildess tab 1/20 53GILENYA CAP 0.5MG 95GLASSIA INJ 99GLEEVEC TAB 100MG 37GLEEVEC TAB 400MG 37glimepiride tab 1mg 26glimepiride tab 2mg 26glimepiride tab 4mg 26glip/metform tab 2.5-250m 24glip/metform tab 5-500mg 24glipizide er tab 10mg 26glipizide er tab 2.5mg 26glipizide er tab 5mg 26glipizide tab 10mg 26glipizide tab 5mg 26glipizide xl tab 10mg 26glipizide xl tab 2.5mg 26glipizide xl tab 5mg 26GLUCAGON KIT 1MG 25GLUMETZA TAB 1000MG 24

GLUMETZA TAB 500MG 24glyb/metform tab 1.25-250 24glyb/metform tab 2.5-500 24glyb/metform tab 5-500mg 24glyburid mcr tab 1.5mg 26glyburid mcr tab 3mg 26glyburid mcr tab 6mg 26glyburide tab 1.25mg 26glyburide tab 2.5mg 26glyburide tab 5mg 26glycolax pow 3350 nf 79glycopyrrol inj 0.2mg/ml 101glycopyrrol tab 1mg 102glycopyrrol tab 2mg 102GLYSET TAB 100MG 24GLYSET TAB 25MG 24GLYSET TAB 50MG 24gnp allergy cap 25mg 29gnp allergy tab 180mg 30gnp aspirin chw 81mg 6gnp aspirin tab 325mg 6gnp aspirin tab 325mg ec 6gnp aspirin tab 81mg ec 6gnp clearlax pow 79GNP DAILY MIS PRENATAL 85gnp hydrocor cre 1% plus 64gnp nicotine gum 2mg mint 96gnp nicotine gum 2mg orig 96gnp nicotine gum 4mg mint 96gnp nicotine gum 4mg orig 96gnp nicotine loz 2mg mint 96gnp nicotine loz 4mg mint 96GNP PRENATAL TAB 28-0.8MG 85gnp tussin liq dm 57gnp tussin liq dm cough 57gnp vit d tab 400unit 106granisetron tab 1mg 27GRANISOL SOL 2MG/10ML 27griseofulvin sus 125/5ml 28griseofulvin tab micr 500 28griseofulvin tab ultr 125 28griseofulvin tab ultr 250 28guaiasorb dm liq 100-10/5 57guaiatussin syp ac 57guaifenesin sol dac 57guaifenesin syp ac 57guanfacine tab 1mg 34guanfacine tab 2mg 34GYNAZOLE-1 CRE 2% 105

Hhalfprin tab 81mg ec 6halobetasol cre 0.05% 64halobetasol oin 0.05% 64HALOG CRE 0.1% 64HALOG OIN 0.1% 64haloperidol con 2mg/ml 41haloperidol tab 0.5mg 41haloperidol tab 10mg 41

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haloperidol tab 1mg 41haloperidol tab 20mg 41haloperidol tab 2mg 41haloperidol tab 5mg 41hc pramoxine cre 1-1% 10hc pramoxine cre 1-2.5% 64hc pramoxine cre 2.5-1% 10hc valerate cre 0.2% 64hc valerate oin 0.2% 64hc/acet acid sol otic 92heartbrn rel tab 200mg 102heartburn tab 150mg 102heartburn tab 200mg 102heartburn tab 20mg 102heartburn tab relief 102heather tab 0.35mg 55hecoria cap 0.5mg 47hecoria cap 1mg 47hecoria cap 5mg 47HECTOROL CAP 0.5MCG 70HECTOROL CAP 1MCG 70HECTOROL CAP 2.5MCG 70HECTOROL INJ 2MCG/ML 70HECTOROL INJ 4MCG/2ML 70HELIXATE FS INJ 1000UNIT 75HELIXATE FS INJ 2000UNIT 75HELIXATE FS INJ 250UNIT 75HELIXATE FS INJ 500UNIT 75HELIXATE FS SOL 1000UNIT 75HELIXATE FS SOL 250UNIT 75HELIXATE FS SOL 500UNIT 75HEMA-COMBIST TES 67HEMOFIL M INJ 220-400 75HEMOFIL M INJ 401-800 75hemril-30 sup 30mg 10HEPSERA TAB 10MG 45HEXALEN CAP 50MG 36HIZENTRA INJ 2GM/10ML 92hm aspirin chw 81mg 6hm aspirin tab 325mg 6hm clearlax pow 79hm nicotine dis 14mg/24h 96hm nicotine dis 21mg/24h 96hm nicotine gum 2mg mint 96hm nicotine gum 4mg mint 96hm nicotine loz 2mg mint 96hm nicotine loz 4mg mint 96HM PRENATAL TAB 85hm tussin liq adlt dm 57homatropaire sol 5% op 88homatropine sol 5% op 88HORIZANT TAB 600MG 95hrtbrn rel cap 15mg dr 103HUMALOG INJ 100/ML 25HUMALOG KWIK INJ 100/ML 25HUMALOG MIX INJ 50/50 25HUMALOG MIX INJ 50/50KWP 25HUMALOG MIX INJ 75/25KWP 25HUMALOG MIX SUS 75/25 25HUMATE-P INJ 1000UNIT 75

HUMATE-P INJ 2000UNIT 75HUMATE-P INJ 500UNIT 75HUMATE-P INJ 600UNIT 75HUMATE-P SOL 1200UNIT 75HUMATE-P SOL 2400UNIT 75HUMATE-P SOL 600UNIT 75HUMIRA KIT 20MG/0.4 3HUMIRA KIT 40MG/0.8 3HUMIRA PEN KIT 40MG/0.8 3HUMIRA PEN KIT CROHNS 3HUMIRA PEN KIT PSORIASI 3HUMULIN INJ 70/30 25HUMULIN N INJ U-100 25HUMULIN N PN INJ U-100 25HUMULIN PEN INJ 70/30 25HUMULIN R INJ U-100 25HYALGAN INJ 20MG/2ML 86hyd polst-ch liq lor pols 57hydralazine tab 100mg 35hydralazine tab 10mg 35hydralazine tab 25mg 35hydralazine tab 50mg 35hydro-lotion lot 1% 64hydrochlorot cap 12.5mg 68hydrochlorot tab 12.5mg 68hydrochlorot tab 25mg 68hydrochlorot tab 50mg 68hydroco/apap sol 7.5-500 9hydroco/apap tab 10-500mg 9hydroco/apap tab 10-650mg 9hydroco/apap tab 2.5-500 9hydroco/apap tab 5-325mg 9hydroco/apap tab 5-500mg 9hydroco/apap tab 7.5-325 9hydroco/apap tab 7.5-500 9hydroco/apap tab 7.5-650 9hydroco/apap tab 7.5-750 9hydrocod/hom syp 5-1.5/5 57hydrocod/ibu tab 10-200mg 9hydrocod/ibu tab 2.5-200 9hydrocod/ibu tab 5-200mg 9hydrocod/ibu tab 7.5-200 9hydrocodone-acetaminophen 9hydrocort ac sup 25mg 10hydrocort ac sup 30mg 10hydrocort cre 1% 64hydrocort cre 1% plus 64hydrocort cre 1%pls 10 64hydrocort cre 1%pls 12 64hydrocort cre 2.5% 64hydrocort ene 100mg 10hydrocort lot 1% 64hydrocort lot 2.5% 64hydrocort oin 2.5% 64hydrocort tab 20mg 56hydrocream cre 1% 64hydromet syp 5-1.5/5 57hydromorphon liq 1mg/ml 7hydromorphon tab 2mg 7hydromorphon tab 4mg 7

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hydromorphon tab 8mg 7hydroskin cre 1% 64hydroxychlor tab 200mg 35hydroxyurea cap 500mg 38hydroxyz hcl sol 10mg/5ml 13hydroxyz hcl syp 10mg/5ml 13hydroxyz hcl tab 10mg 13hydroxyz hcl tab 25mg 13hydroxyz hcl tab 50mg 13hydroxyz pam cap 100mg 13hydroxyz pam cap 25mg 13hydroxyz pam cap 50mg 13hyomax tab 0.125mg 102hyomax-sl sub 0.125mg 102hyoscyamine dro 0.125/ml 102hyoscyamine elx 0.125/5 102hyoscyamine sub 0.125mg 102hyoscyamine tab 0.125mg 102hyosyne dro 0.125/ml 102hyosyne elx 0.125/5 102hypercare sol 20% 66HYPERRHO S/D INJ 300MCG 92

Iibandronate tab 150mg 69ibudone tab 10-200mg 9ibudone tab 5-200mg 9ibuprofen tab 400mg 3ibuprofen tab 600mg 3ibuprofen tab 800mg 3iferex 150 cap forte 77ilotycin oin op 89imipram hcl tab 10mg 23imipram hcl tab 25mg 23imipram hcl tab 50mg 23imiquimod cre 5% 65imperim tab 2mg 27INCIVEK TAB 375MG 45INCRELEX INJ 40MG/4ML 69indapamide tab 1.25mg 68indapamide tab 2.5mg 68indomethacin cap 25mg 4indomethacin cap 50mg 4indomethacin cap 75mg er 4INFERGEN INJ 15MCG 45INFERGEN INJ 9MCG 45INFLUENZA A INJ PF09H1N1 105INSPIREASE MIS MOUTHPCE 81INSPIREASE MIS REP MOUT 81INSULIN PEN NEEDLES 81INSULIN SYRINGES 81INTELENCE TAB 100MG 43INTELENCE TAB 200MG 43INTELENCE TAB 25MG 43INTRON-A INJ 10MU 38INTRON-A INJ 10MU PEN 38INTRON-A INJ 18MU 38INTRON-A INJ 25MU 38INTRON-A INJ 3MU PEN 38

INTRON-A INJ 50MU 38INTRON-A INJ 5MU PEN 38INTUNIV TAB 1MG 1INTUNIV TAB 2MG 1INTUNIV TAB 3MG 1INTUNIV TAB 4MG 1INVEGA TAB 1.5MG 40INVEGA TAB 3MG 41INVEGA TAB 6MG 41INVEGA TAB 9MG 41INVIRASE CAP 200MG 43INVIRASE TAB 500MG 43iophen c-nr liq 100-10/5 57iophen dm-nr liq 100-10/5 58IOPIDINE SOL 1% OP 89ipratropium sol 0.02%inh 15ipratropium spr 0.03% 87ipratropium spr 0.06% 87irbesartan tab 75mg 33iron supplmt dro 15mg/ml 78ISENTRESS CHW 100MG 44ISENTRESS CHW 25MG 44ISENTRESS TAB 400MG 44ISO HOMATROP SOL 2% OP 88isochron tab 40mg cr 12isoditrate tab 40mg er 12isometh/apap cap dichlor 81isonarif cap 36isoniazid syp 50mg/5ml 36isoniazid tab 100mg 36isoniazid tab 300mg 36ISORDIL TAB 40MG 12isosorb din sub 2.5mg 12isosorb din sub 5mg 12isosorb din tab 10mg 12isosorb din tab 20mg 12isosorb din tab 30mg 12isosorb din tab 40mg er 12isosorb din tab 5mg 12isosorb mono tab 10mg 12isosorb mono tab 120mg er 12isosorb mono tab 20mg 12isosorb mono tab 30mg er 12isosorb mono tab 60mg er 12isradipine cap 2.5mg 50isradipine cap 5mg 50itch-x lot 1% 64itchy eye dro 0.025%op 91itraconazole cap 100mg 28

JJAKAFI TAB 10MG 37JAKAFI TAB 15MG 37JAKAFI TAB 20MG 37JAKAFI TAB 25MG 38JAKAFI TAB 5MG 37jantoven tab 10mg 17jantoven tab 1mg 17jantoven tab 2.5mg 17

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jantoven tab 2mg 17jantoven tab 3mg 17jantoven tab 4mg 17jantoven tab 5mg 17jantoven tab 6mg 17jantoven tab 7.5mg 17JANUVIA TAB 100MG 25JANUVIA TAB 25MG 25JANUVIA TAB 50MG 25jencycla tab 0.35mg 55JENTADUETO TAB 2.5-1000 24JENTADUETO TAB 2.5-500 24JENTADUETO TAB 2.5-850 24jevantique tab 1mg-5mcg 71jinteli tab 1mg-5mcg 71jock itch cre 1% 60jolivette tab 0.35mg 56junel 1.5/30 tab 53junel 1/20 tab 53junel fe tab 1.5/30 54junel fe tab 1/20 54just d liq 400unit 106

KKALETRA SOL 44KALETRA TAB 100-25MG 44KALETRA TAB 200-50MG 44kalexate pow 47KALYDECO TAB 150MG 99karidium dro 0.125mg 82kariva tab 28 day 54KEFLEX CAP 750MG 52kelnor tab 1/35 54KENALOG AER SPRAY 64kericort 10 cre 1% 64KETEK TAB 300MG 11KETEK TAB 400MG 11KETO-DIASTIX TES 67ketoconazole cre 2% 60ketoconazole sha 2% 60ketoconazole tab 200mg 28ketoprofen cap 200mg er 4ketorolac sol 0.4% 91ketorolac sol 0.5% 91ketorolac tab 10mg 4ketotif fum dro 0.025%op 91KINERET INJ 3kionex pow usp 47klor-con 10 tab 10meq er 83klor-con 8 tab 8meq er 83klor-con m10 tab 10meq er 83KLOR-CON M15 TAB 83klor-con m20 tab 20meq er 83kls anti-dia tab 2mg 27kls aspirin tab 325mg ec 6kls aspirin tab 81mg ec 6kls quit2 gum 2mg 97kls quit4 gum 4mg 97KOATE-DVI INJ 1000UNIT 75

KOATE-DVI INJ 250UNIT 75KOATE-DVI INJ 500UNIT 75KOGENATE FS INJ 1000/BS 75KOGENATE FS INJ 1000UNIT 75KOGENATE FS INJ 2000/BS 75KOGENATE FS INJ 2000UNIT 75KOGENATE FS INJ 250/BS 75KOGENATE FS INJ 250UNIT 75KOGENATE FS INJ 500/BS 75KOGENATE FS INJ 500UNIT 75kp aspirin tab 81mg ec 6KP PRENATAL TAB MULTIVIT 85kurvelo tab 0.15/30 54KUVAN TAB 100MG 70

Llabetalol tab 100mg 47labetalol tab 200mg 47labetalol tab 300mg 47LABSTIX TES 67laclotion lot 12% 65LACRISERT MIS 5MG OP 88lactulose sol 10gm/15 73, 79lactulose sol 20gm/30 79LAMICTAL CHW 2MG 18LAMICTAL ODT TAB 100MG 18LAMICTAL ODT TAB 200MG 18LAMICTAL ODT TAB 25MG 18LAMICTAL ODT TAB 50MG 18LAMICTAL XR KIT 18lamivud/zido tab 150-300 44lamivudine tab 150mg 44lamivudine tab 300mg 44lamotrigine chw 25mg 19lamotrigine chw 5mg 19lamotrigine tab 100mg 19lamotrigine tab 100mg er 19lamotrigine tab 150mg 19lamotrigine tab 200mg 19lamotrigine tab 200mg er 19lamotrigine tab 250mg er 19lamotrigine tab 25mg 19lamotrigine tab 25mg er 19lamotrigine tab 300mg er 19lamotrigine tab 50mg er 19LANCETS 81lansoprazole cap 15mg dr 103lansoprazole cap 30mg dr 103LANTUS INJ 100/ML 25LANTUS INJ SOLOSTAR 25LASTACAFT SOL 0.25% 91latanoprost sol 0.005% 91LATUDA TAB 120MG 40LATUDA TAB 20MG 40LATUDA TAB 40MG 40LATUDA TAB 80MG 40laxaclear pow 79leena tab 54leflunomide tab 10mg 4

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leflunomide tab 20mg 4lessina tab 54LETAIRIS TAB 10MG 52LETAIRIS TAB 5MG 52letrozole tab 2.5mg 37leucovor ca tab 10mg 38leucovor ca tab 15mg 38leucovor ca tab 25mg 39leucovor ca tab 5mg 38LEUKERAN TAB 2MG 36LEUKINE INJ 250MCG 77LEUKINE INJ 500 MCG 77leuprolide inj 1mg/0.2 37LEVATOL TAB 20MG 48LEVEMIR INJ 25LEVEMIR INJ FLEXPEN 25levetiraceta sol 100mg/ml 19levetiraceta sol 500/5ml 19levetiraceta tab 1000mg 19levetiraceta tab 250mg 19levetiraceta tab 500mg 19levetiraceta tab 750mg 19LEVITRA TAB 10MG 51LEVITRA TAB 2.5MG 51LEVITRA TAB 20MG 51LEVITRA TAB 5MG 51levobunolol sol 0.25% op 88levobunolol sol 0.5% op 88levocarnitin sol 1gm/10ml 70levocarnitin tab 330mg 70levofloxacin tab 250mg 72levofloxacin tab 500mg 72levofloxacin tab 750mg 72levonest tab 54levonor/ethi tab 0.1-0.02 54levonor/ethi tab estradio 54levonorgestr tab 0.75mg 55levora-28 tab 0.15/30 54levorphanol tab 2mg 7levothroid tab 100mcg 100levothroid tab 112mcg 100levothroid tab 125mcg 100levothroid tab 137mcg 100levothroid tab 150mcg 100levothroid tab 175mcg 100levothroid tab 200mcg 100levothroid tab 25mcg 100levothroid tab 300mcg 100levothroid tab 50mcg 100levothroid tab 75mcg 100levothroid tab 88mcg 100levothyroxin tab 100mcg 100levothyroxin tab 112mcg 100levothyroxin tab 125mcg 100levothyroxin tab 137mcg 100levothyroxin tab 150mcg 100levothyroxin tab 175mcg 100levothyroxin tab 200mcg 100levothyroxin tab 25mcg 100levothyroxin tab 300mcg 100

levothyroxin tab 50mcg 100levothyroxin tab 75mcg 100levothyroxin tab 88mcg 100levoxyl tab 100mcg 100levoxyl tab 112mcg 100levoxyl tab 125mcg 100levoxyl tab 137mcg 100levoxyl tab 150mcg 100levoxyl tab 175mcg 100levoxyl tab 200mcg 100levoxyl tab 25mcg 100levoxyl tab 50mcg 100levoxyl tab 75mcg 100levoxyl tab 88mcg 100LEXIVA SUS 50MG/ML 44LEXIVA TAB 700MG 44LIALDA TAB 1.2GM 73lidazone cre 10lido/prilocn cre 2.5-2.5% 66lidocaine gel 2% 66lidocaine gel 2% jelly 66lidocaine oin 5% 66lidocaine sol 2% visc 83lidocaine sol 4% 66, 83lidocaine/hc cre 3%-0.5% 10LIDODERM DIS 5% 66lindane sha 1% 66LINZESS CAP 145MCG 73LINZESS CAP 290MCG 73liothyronine tab 25mcg 100liothyronine tab 50mcg 101liothyronine tab 5mcg 100lisinop/hctz tab 10-12.5 34lisinop/hctz tab 20-12.5 34lisinop/hctz tab 20-25mg 34lisinopril tab 10mg 32lisinopril tab 2.5mg 32lisinopril tab 20mg 32lisinopril tab 30mg 32lisinopril tab 40mg 32lisinopril tab 5mg 32lithium carb cap 150mg 40lithium carb cap 300mg 40lithium carb cap 600mg 40lithium carb tab 300mg 40lithium carb tab 300mg er 40lithium carb tab 450mg er 40LITHIUM CITR SOL 8MEQ/5ML 40LIVALO TAB 1MG 31LIVALO TAB 2MG 31LIVALO TAB 4MG 31LODOSYN TAB 25MG 39lofene tab 2.5mg 27lokara lot 0.05% 64lomustine cap 100mg 36lomustine cap 10mg 36lomustine cap 40mg 36lonox tab 2.5mg 27loperamide cap 2mg 27loperamide tab 2mg 27

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lorazepam tab 0.5mg 13lorazepam tab 1mg 13lorazepam tab 2mg 13loryna tab 3-0.02mg 54LORZONE TAB 375MG 86LORZONE TAB 750MG 86losartan pot tab 100mg 33losartan pot tab 25mg 33losartan pot tab 50mg 33losartan/hct tab 100-12.5 35losartan/hct tab 100-25 35losartan/hct tab 50-12.5 34LOTEMAX GEL 0.5% 90LOTEMAX OIN 0.5% 90LOTEMAX SUS 0.5% 90LOTRIMIN ULT CRE 1% 60lovastatin tab 10mg 31lovastatin tab 20mg 31lovastatin tab 40mg 31LOVAZA CAP 1GM 31low-ogestrel tab 54loxapine cap 10mg 41loxapine cap 25mg 41loxapine cap 50mg 41loxapine cap 5mg 41ludent chw 0.25mg f 82ludent chw 0.5mg f 82ludent chw 1mg f 82LUMIGAN SOL 0.01% 91LUMIGAN SOL 0.03% 91LUMIZYME INJ 50MG 70LUNESTA TAB 1MG 78LUNESTA TAB 2MG 78LUNESTA TAB 3MG 78LUPRON DEPOT INJ 11.25MG 37LUPRON DEPOT INJ 22.5MG 37LUPRON DEPOT INJ 3.75MG 37LUPRON DEPOT INJ 30MG 37LUPRON DEPOT INJ 7.5MG 37lutera tab 54LYRICA CAP 100MG 19LYRICA CAP 150MG 19LYRICA CAP 200MG 19LYRICA CAP 225MG 19LYRICA CAP 25MG 19LYRICA CAP 300MG 19LYRICA CAP 50MG 19LYRICA CAP 75MG 19LYSODREN TAB 500MG 37

MMACRODANTIN CAP 25MG 103malathion lot 0.5% 66maprotiline tab 25mg 21maprotiline tab 50mg 21maprotiline tab 75mg 21margesic cap 5marlissa tab 0.15/30 54MARPLAN TAB 10MG 22

marten-tab tab 50-325mg 5martinic cap 77MATULANE CAP 50MG 38MAXAIR AUTOH AER 200MCG 16mebendazole chw 100mg 11meclizine tab 12.5mg 27meclizine tab 25mg 27meclofen sod cap 100mg 4meclofen sod cap 50mg 4med-derm hc cre 1% 64medi-meclizi tab 25mg 27medi-phedrin tab 30mg 87medi-phedryl cap 25mg 29medi-phedryl elx 12.5/5ml 29medi-tuss dm liq diabetic 58medroxypr ac inj 150mg/ml 55medroxypr ac tab 10mg 94medroxypr ac tab 2.5mg 93medroxypr ac tab 5mg 93mefenam acid cap 250mg 4mefloquine tab 250mg 35megestrol ac sus 400mg/10 37megestrol ac sus 40mg/ml 37megestrol ac tab 20mg 37megestrol ac tab 40mg 37meloxicam tab 15mg 4meloxicam tab 7.5mg 4MENEST TAB 0.3MG 72MENEST TAB 0.625MG 72MENEST TAB 1.25MG 72MENEST TAB 2.5MG 72MENTAX CRE 1% 60meperidine sol 50mg/5ml 7meperidine tab 100mg 7meperidine tab 50mg 7meperitab tab 100mg 7meperitab tab 50mg 7MEPHYTON TAB 5MG 106meprobamate tab 200mg 13meprobamate tab 400mg 13MEPRON SUS 11mercaptopur tab 50mg 36MESTINON SYP 60MG/5ML 35MESTINON TAB TIMESPAN 35metadate tab 20mg er 2metaproteren syp 10mg/5ml 16metaproteren tab 10mg 16metaproteren tab 20mg 16metaxalone tab 800mg 86metformin er tab 1000mg 24metformin tab 1000mg 25metformin tab 500mg 25metformin tab 500mg er 25metformin tab 750mg er 25metformin tab 850mg 25methadone tab 10mg 7methadone tab 40mg 7methadone tab 5mg 7methadose tab 10mg 7methadose tab 40mg 7

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methadose tab 5mg 7methamphetam tab 5mg 1methazolamid tab 25mg 68methazolamid tab 50mg 68methenam hip tab 1gm 103methimazole tab 10mg 99methimazole tab 5mg 99METHITEST TAB 10MG 10methocarbam tab 500mg 86methocarbam tab 750mg 86methotrexate tab 2.5mg 36methscopolam tab 2.5mg 102methyclothia tab 5mg 68methyldopa tab 250mg 34methyldopa tab 500mg 34methylergon tab 0.2mg 92methylin tab 10mg 2methylin tab 10mg er 2methylin tab 20mg 2methylin tab 20mg er 2methylin tab 5mg 2methylphenid cap 10mg 2methylphenid cap 20mg 2methylphenid cap 20mg er 2methylphenid cap 30mg 2methylphenid cap 30mg er 2methylphenid cap 40mg 2methylphenid cap 40mg er 2methylphenid cap 50mg 2methylphenid cap 60mg 2methylphenid tab 10mg 2methylphenid tab 10mg er 2methylphenid tab 18mg er 2methylphenid tab 20mg 2methylphenid tab 20mg er 2methylphenid tab 20mg sr 2methylphenid tab 27mg er 2methylphenid tab 36mg er 2methylphenid tab 54mg er 2methylphenid tab 5mg 2methylpred pak 4mg 56methylpred tab 16mg 56methylpred tab 32mg 56methylpred tab 4mg 56methylpred tab 8mg 56metipranolol sol 0.3% 88metipranolol sol 0.3% oph 88metoclopram sol 10/10ml 73metoclopram sol 5mg/5ml 73metoclopram tab 10mg 73metoclopram tab 5mg 73metolazone tab 10mg 69metolazone tab 2.5mg 68metolazone tab 5mg 69metoprol tar tab 100mg 48metoprol tar tab 25mg 48metoprol tar tab 50mg 48metoprolol tab 100mg er 48metoprolol tab 200mg er 48metoprolol tab 25mg er 48

metoprolol tab 50mg er 48metronidazol cap 375mg 11metronidazol cre 0.75% 66metronidazol gel 0.75% 66metronidazol gel 0.75%vag 105metronidazol gel 1% 66metronidazol lot 0.75% 66metronidazol tab 250mg 11metronidazol tab 500mg 11mexiletine cap 150mg 14mexiletine cap 200mg 14mexiletine cap 250mg 14micaderm cre 2% 60MICARDIS HCT 35MICARDIS TAB 20MG 33MICARDIS TAB 40MG 33MICARDIS TAB 80MG 33miconazole cre 2% 60MICONAZOLE POW NITRATE 60micro guard cre 2% 60microgestin tab 1.5/30 54microgestin tab 1/20 54microgestin tab fe 1/20 54microgestin tab fe1.5/30 54MIGERGOT SUP 2/100 81migragesic cap ida 81MILLIPRED SOL 10MG/5ML 56MILLIPRED TAB 5MG 56miniprin low tab 81mg ec 6minirin spr nasal 70minitran dis 0.1mg/hr 12minitran dis 0.2mg/hr 12minitran dis 0.4mg/hr 12minitran dis 0.6mg/hr 12MINIVELLE DIS 0.0375MG 72MINIVELLE DIS 0.05MG 72MINIVELLE DIS 0.075MG 72MINIVELLE DIS 0.1MG 72minocycline cap 100mg 99minocycline cap 50mg 99minoxidil tab 10mg 35minoxidil tab 2.5mg 35MIRENA IUD SYSTEM 55mirtazapine tab 15mg 21mirtazapine tab 15mg odt 21mirtazapine tab 30mg 21mirtazapine tab 30mg odt 21mirtazapine tab 45mg 21mirtazapine tab 45mg odt 21mirtazapine tab 7.5mg 21misoprostol tab 100mcg 103misoprostol tab 200mcg 103mm aspirin tab 325mg 6modafinil tab 100mg 2modafinil tab 200mg 2moexipril tab 15mg 33moexipril tab 7.5mg 33moist skin cre 12% 65moist skin lot 12% 65mometasone cre 0.1% 64

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mometasone oin 0.1% 64mometasone sol 0.1% 64mono-linyah tab 0.25-35 54MONOCLATE-P INJ 1000UNIT 75MONOCLATE-P INJ 1500UNIT 75MONOCLATE-P INJ 250UNIT 75MONOCLATE-P INJ 500UNIT 75mononessa tab 54MONONINE INJ 1000UNIT 76MONONINE INJ 250UNIT 75MONONINE INJ 500UNIT 75montelukast chw 4mg 15montelukast chw 5mg 15montelukast gra 4mg 15montelukast tab 10mg 15MONUROL PAK GRANULES 103morgidox cap 1x100mg 99morgidox cap 2x100mg 99morphine sul cap 100mg er 7morphine sul cap 20mg er 7morphine sul cap 30mg er 7morphine sul cap 50mg er 7morphine sul cap 60mg er 7morphine sul cap 80mg er 7morphine sul tab 100mg er 7morphine sul tab 15mg 7morphine sul tab 15mg er 7morphine sul tab 200mg er 8morphine sul tab 30mg 7morphine sul tab 30mg er 7motion relf tab 25mg 27motion sick tab 25mg 27MOTOFEN TAB 27MOVIPREP SOL 79MOXATAG TAB 775MG 93MOXEZA SOL 0.5% 89MOZOBIL INJ 78mp aller med cap 25mg 29mp clotrimaz cre 1% 60mp hydrocort cre 1% 64mtest hs/est tab estrogen 71mtest/est tab estrogen 71mult-vit/fl chw 0.5mg 84MULTAQ TAB 400MG 14multi-vit/fe dro /fl 0.25 84multi-vit/fl chw 0.25mg 84multi-vit/fl chw 0.5mg 84multi-vit/fl chw 1mg 84multi-vit/fl dro /fe 0.25 84multi-vit/fl dro 0.25mg 84multi-vit/fl dro 0.5mg/ml 84MULTISTIX 10 TES SG 67MULTISTIX 5 TES 67MULTISTIX 7 TES 67MULTISTIX 8 TES SG 67MULTISTIX 9 TES 67MULTISTIX 9 TES SG 67MULTISTIX TES 67multivit/fl chw 0.25mg 84multivit/fl chw 0.5mg 84

multivit/fl chw 1mg 84mupirocin ca cre 2% 60mupirocin cre 2% 60mupirocin oin 2% 60mvc-fluoride chw 0.25mg 84mvc-fluoride chw 0.5mg 84mvc-fluoride chw 1mg 84my way tab 1.5mg 55myci-gc sol 100-10/5 58MYCOBUTIN CAP 150MG 36mycophenolat cap 250mg 47mycophenolat tab 500mg 47mydral sol 0.5% op 88mydral sol 1% op 88myferon 150 cap forte 77MYFORTIC TAB 180MG 47MYFORTIC TAB 360MG 47MYLERAN TAB 2MG 36mynephrocaps cap 84MYOBLOC INJ 10000/2 88MYOBLOC INJ 2500/0.5 88MYOBLOC INJ 5000/ML 88myorisan cap 10mg 59myorisan cap 20mg 59myorisan cap 40mg 59MYOZYME INJ 50MG 70MYTELASE TAB 10MG 35mytussin ac syp 100-10/5 58mytussin dac sol 58myzilra tab 54

Nnabumetone tab 500mg 4nabumetone tab 750mg 4nadolol tab 20mg 48nadolol tab 40mg 48nadolol tab 80mg 48nafrinse chw 1mg f 83nafrinse dro 0.125mg 83NAFTIN CRE 1% 60NAFTIN CRE 2% 60NAFTIN GEL 1% 61NAGLAZYME INJ 1MG/ML 70NAMENDA SOL 10MG/5ML 94NAMENDA TAB 10MG 94NAMENDA TAB 5MG 94naphazoline sol 0.1% op 90naproxen sod tab 550mg 4naproxen tab 375mg 4naproxen tab 500mg 4naratriptan tab 1mg 82naratriptan tab 2.5mg 82nasal decon syp 30mg/5ml 87nasal decong tab 30mg 87NASONEX SPR 50MCG/AC 87NATACYN SUS 5% OP 89nateglinide tab 120mg 26nateglinide tab 60mg 26natura-lax pow 3350 nf 79

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NEBUPENT INH 300MG 11necon tab 0.5/35 54necon tab 1/35 54necon tab 1/50-28 54necon tab 7/7/7 54nefazodone tab 100mg 21nefazodone tab 150mg 21nefazodone tab 200mg 21nefazodone tab 250mg 21nefazodone tab 50mg 21neo-polycin oin hc 1%op 90neo-polycin oin op 89neo/bac/poly oin op 89neo/poly/bac oin /hc 1%op 90neo/poly/dex oin 0.1% op 90neo/poly/dex sus 0.1% op 90neo/poly/gra sol op 89neo/poly/hc sol 1% otic 92neo/poly/hc sus 1% otic 92neo/poly/hc sus op 90neomycin tab 500mg 3neosporin af cre 2% jock 61neosporin cre eczema 64NEULASTA INJ 6MG/0.6M 77NEUMEGA INJ 5MG 77NEUPOGEN INJ 300/0.5 77NEUPOGEN INJ 300MCG 77NEUPOGEN INJ 480/0.8 77NEUPOGEN INJ 480MCG 77NEVANAC SUS 0.1% 91nevirapine sus 50mg/5ml 44nevirapine tab 200mg 44NEXAVAR TAB 200MG 38NEXIUM CAP 20MG 103NEXIUM CAP 40MG 103next choice tab 0.75mg 55next choice tab 1.5mg 55niacor tab 500mg 32NIASPAN TAB 1000 ER 32NIASPAN TAB 500MG ER 32NIASPAN TAB 750MG ER 32nicardipine cap 20mg 50nicardipine cap 30mg 50nicorelief gum 2mg mint 97nicorelief gum 2mg orig 97nicorelief gum 4mg mint 97nicorelief gum 4mg orig 97nicorelief loz 2mg mint 97nicorelief loz 4mg mint 97nicotine dis 14mg/24h 97nicotine dis 21mg/24h 97nicotine dis 7mg/24hr 97nicotine dis step 1 97nicotine dis step 2 97nicotine dis step 3 97nicotine gum 2mg 97nicotine gum 2mgfruit 97nicotine gum 4mg 97nicotine loz 2mg chry 97nicotine loz 2mg mint 97

nicotine loz 4mg chry 97nicotine loz 4mg cinn 97nicotine loz 4mg mint 97nicotine pol gum 2mg 97nicotine pol gum 2mg cinn 97nicotine pol gum 2mg mint 97nicotine pol gum 2mg orig 97nicotine pol gum 2mg ref 97nicotine pol gum 2mg strt 97nicotine pol gum 2mgfruit 97nicotine pol gum 4mg 97nicotine pol gum 4mg mint 97nicotine pol gum 4mg orig 97nicotine pol gum 4mg ref 97nicotine pol gum 4mg strt 97nicotine pol gum 4mgfruit 97nicotine pol loz 2mg cinn 97nicotine pol loz 2mg mint 97nicotine pol loz 4mg chry 97nicotine pol loz 4mg mint 97nicotine td dis 14mg/24h 97nicotine td dis 21mg/24h 97nicotine td dis 7mg/24hr 97NICOTROL INH 97NICOTROL NS SPR 10MG/ML 98nifediac cc tab 30mg er 50nifediac cc tab 60mg er 50nifediac cc tab 90mg er 50nifedical xl tab 30mg 50nifedical xl tab 60mg 50nifedipine cap 10mg 50nifedipine cap 20mg 50nifedipine tab 30mg er 50nifedipine tab 60mg er 50nifedipine tab 90mg er 50NILANDRON TAB 150MG 37nimodipine cap 30mg 50nisoldipine tab 17mg er 50nisoldipine tab 20mg 50nisoldipine tab 25.5mg 50nisoldipine tab 30mg 50nisoldipine tab 34mg er 50nisoldipine tab 40mg 50nisoldipine tab 8.5mg er 50NITRO-DUR DIS 0.3MG/HR 12NITRO-DUR DIS 0.8MG/HR 12nitro-time cap 2.5mg cr 12nitro-time cap 6.5mg cr 12nitro-time cap 9mg cr 12nitrofur mac cap 100mg 103nitrofur mac cap 50mg 103nitrofurantn cap 100mg 103nitrofurantn sus 25mg/5ml 103nitroglycer aer 400mcg 12nitroglycer cap 2.5mg er 12nitroglycer cap 2.5mg sr 12nitroglycer cap 6.5mg cr 12nitroglycer cap 6.5mg er 12nitroglycer cap 9mg cr 12nitroglycer cap 9mg er 12

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nitroglycer dis 0.1mg/hr 12nitroglycer dis 0.2mg/hr 12nitroglycer dis 0.4mg/hr 13nitroglycer dis 0.6mg/hr 13nitroglyceri dis 0.6mg/hr 13nitroglycrn spr lingual 13NITROSTAT SUB 0.3MG 13NITROSTAT SUB 0.4MG 13NITROSTAT SUB 0.6MG 13NIX LICE SPR CONTROL 66nizatidine cap 150mg 102nizatidine cap 300mg 102NIZORAL A-D SHA 1% 61noble formul cre hc 1% 64nodolor cap 81nora-be tab 0.35mg 56norethin ace tab 5mg 94norethindron tab 0.35mg 56norgest/eth tab estrad 54norgest/ethi tab 0.25/35 54norgest/ethi tab estradio 54NOROXIN TAB 400MG 72nortrel tab 0.5/35 54nortrel tab 1/35 54nortrel tab 7/7/7 54nortriptylin cap 10mg 23nortriptylin cap 25mg 23nortriptylin cap 50mg 23nortriptylin cap 75mg 24nortriptylin sol 10mg/5ml 24NORVIR CAP 100MG 44NORVIR SOL 80MG/ML 44NORVIR TAB 100MG 44norwich asa tab 325mg 6novagest/cod sol expect 58NOVOLIN INJ 70/30 25NOVOLIN N INJ U-100 25NOVOLIN R INJ U-100 25NOVOLOG INJ 100/ML 25NOVOLOG INJ FLEXPEN 25NOVOLOG INJ PENFILL 26NOVOLOG MIX INJ 70/30 26NOVOLOG MIX INJ FLEXPEN 26NOVOSEVEN INJ 1200MCG 76NOVOSEVEN INJ 2400MCG 76NOVOSEVEN INJ 4800MCG 76NOXAFIL SUS 40MG/ML 28np thyroid tab 30mg 101np thyroid tab 60mg 101np thyroid tab 90mg 101NPLATE INJ 250MCG 77NPLATE INJ 500MCG 77NUCYNTA ER TAB 100MG 8NUCYNTA ER TAB 150MG 8NUCYNTA ER TAB 200MG 8NUCYNTA ER TAB 250MG 8NUCYNTA ER TAB 50MG 8NUCYNTA TAB 100MG 8NUCYNTA TAB 50MG 8NUCYNTA TAB 75MG 8

NUEDEXTA CAP 20-10MG 95NUVARING MIS 55NUVIGIL TAB 150MG 2NUVIGIL TAB 250MG 3NUVIGIL TAB 50MG 2nuzole cre 2% 61nyamyc pow 100000 61nystat/triam cre 61nystat/triam oin 61nystatin cre 100000 61nystatin oin 100000 61NYSTATIN POW 61nystatin pow 28nystatin pow 100000 61nystatin sus 100000 83nystatin tab 500000 28NYSTATIN VAG TAB 100000 105nystop pow 100000 61

Oocella tab 3-0.03mg 54OCTAGAM INJ 1GM 92OCTAGAM INJ 25GM 92OCTAGAM INJ 5GM 92octreotide inj 1000mcg 70octreotide inj 100mcg 70octreotide inj 200mcg 70octreotide inj 500mcg 70octreotide inj 50mcg/ml 70ofloxacin dro 0.3% op 89ofloxacin dro 0.3%otic 91ofloxacin tab 200mg 72ofloxacin tab 300mg 72ofloxacin tab 400mg 72OFORTA TAB 10MG 36ogestrel tab 54olanzapine tab 10mg 41olanzapine tab 15mg 41olanzapine tab 2.5mg 41olanzapine tab 20mg 41olanzapine tab 5mg 41olanzapine tab 7.5mg 41OLEPTRO TAB 24HR150 21OLEPTRO TAB 24HR300 21omeprazole cap 10mg 103omeprazole cap 20mg 103omeprazole cap 40mg 103OMNARIS SPR 87OMNIFLEX DPR 80ondansetron tab 24mg 27ondansetron tab 4mg 27ondansetron tab 4mg odt 27ondansetron tab 8mg 27ondansetron tab 8mg odt 27ONE-A-DAY PAK PRENATAL 85ONGLYZA TAB 2.5MG 25ONGLYZA TAB 5MG 25oralone pst 0.1% 83ORAP TAB 1MG 95

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ORAP TAB 2MG 95ORAPRED ODT TAB 10MG 56ORAPRED ODT TAB 15MG 56ORAPRED ODT TAB 30MG 56ORAVIG TAB 50MG 83ORENCIA INJ 250MG 4orph/asa/caf tab 86orphen cpd tab ds 86orphenadrine tab 100mg er 86orsythia tab 54ORTHO COIL DPR KIT 100 80ORTHO COIL DPR KIT 105 80ORTHO COIL DPR KIT 50 80ORTHO EVRA DIS WEEK 55ORTHO FLAT DPR KIT 55 80ORTHO FLAT DPR KIT 60 80ORTHO FLAT DPR KIT 65 80ORTHO FLAT DPR KIT 70 80ORTHO FLAT DPR KIT 75 80ORTHO FLAT DPR KIT 80 80ORTHO FLAT DPR KIT 85 80ORTHO FLAT DPR KIT 90 81ORTHO FLAT DPR KIT 95 81ORTHO FLEX DPR 65MM 81ORTHO FLEX DPR 70MM 81ORTHO FLEX DPR 75MM 81ORTHO FLEX DPR 80MM 81ORTHOVISC INJ 15MG/ML 86oscimin sub 0.125mg 102oscimin tab 0.125mg 102OSMOPREP TAB 1.5GM 79oxandrolone tab 10mg 10oxandrolone tab 2.5mg 10oxaprozin tab 600mg 4oxazepam cap 10mg 14oxazepam cap 15mg 14oxazepam cap 30mg 14oxcarbazepin sus 300mg/5m 19oxcarbazepin tab 150mg 19oxcarbazepin tab 300mg 19oxcarbazepin tab 600mg 19OXISTAT CRE 1% 61OXISTAT LOT 1% 61OXSORALEN-UL CAP 10MG 61oxybutynin syp 5mg/5ml 104oxybutynin tab 5mg 104oxycod/apap cap 5-500mg 9oxycod/apap tab 10-325mg 9oxycod/apap tab 10-650mg 9oxycod/apap tab 5-325mg 9oxycod/apap tab 7.5-325 9oxycod/apap tab 7.5-500 9oxycod/asa tab 9oxycod/ibu tab 5-400mg 9oxycodone cap 5mg 8oxycodone tab 10mg 8oxycodone tab 15mg 8oxycodone tab 20mg 8oxycodone tab 30mg 8oxycodone tab 5mg 8

OXYCONTIN TAB 10MG CR 8OXYCONTIN TAB 15MG CR 8OXYCONTIN TAB 20MG CR 8OXYCONTIN TAB 30MG CR 8OXYCONTIN TAB 40MG CR 8OXYCONTIN TAB 60MG CR 8OXYCONTIN TAB 80MG CR 8oxymorphone tab 10mg er 8oxymorphone tab 15mg er 8oxymorphone tab 20mg er 8oxymorphone tab 30mg er 8oxymorphone tab 40mg er 8oxymorphone tab 5mg er 8oxymorphone tab 7.5mg er 8oxymorphone tab hcl 10mg 8oxymorphone tab hcl 5mg 8

PPACERONE TAB 100MG 14pacerone tab 200mg 14PANCREAZE CAP 10500UNT 67PANCREAZE CAP 16800UNT 67PANCREAZE CAP 21000UNT 67PANCREAZE CAP 4200UNIT 67pancrelipase cap 5000unit 67PANRETIN GEL 0.1% 61pantoprazole tab 20mg 103pantoprazole tab 40mg 103PARAGARD IUD T380A 81parcaine sol 0.5% op 90paromomycin cap 250mg 3paroxetine sus 10mg/5ml 22paroxetine tab 10mg 22paroxetine tab 20mg 22paroxetine tab 30mg 22paroxetine tab 40mg 22PASER GRA 4GM 36PATANASE SPR 0.6% 86PATANOL SOL 0.1% OP 91ped formula liq 100-10/5 58pedi-dri pow 100000 61peg 3350 pow 79peg 3350 sol electrol 79peg-3350 sol electrol 79PEG-INTRON KIT 120 RP 45PEG-INTRON KIT 120MCG 45PEG-INTRON KIT 150 RP 45PEG-INTRON KIT 150MCG 45PEG-INTRON KIT 50MCG 45PEG-INTRON KIT 50MCG RP 45PEG-INTRON KIT 80MCG 45PEG-INTRON KIT 80MCG RP 45PEGANONE TAB 250MG 20PEGASYS INJ 45PEGASYS INJ 180MCG/M 45PEGASYS INJ PROCLICK 45PEGASYS KIT 45penicilln vk sol 125/5ml 93penicilln vk sol 250/5ml 93

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penicilln vk tab 250mg 93penicilln vk tab 500mg 93PENTASA CAP 250MG CR 73PENTASA CAP 500MG CR 73pentoxifylli tab 400mg er 76perindopril tab 2mg 33perindopril tab 4mg 33perindopril tab 8mg 33periogard sol 0.12% 83permethrin cre 5% 66perphen/amit tab 2-10mg 94perphen/amit tab 2-25mg 94perphen/amit tab 4-10mg 94perphen/amit tab 4-25mg 94perphen/amit tab 4-50mg 94perphenazine tab 16mg 42perphenazine tab 2mg 42perphenazine tab 4mg 42perphenazine tab 8mg 42PERTZYE CAP 67pharbedryl cap 25mg 29pharbedryl cap 50mg 29phenadoz sup 12.5mg 30phenadoz sup 25mg 30phenazo tab 200mg 74phenazopyrid tab 100mg 74phenazopyrid tab 200mg 74phenelzine tab 15mg 22phenobarb elx 20mg/5ml 78phenobarb sol 20mg/5ml 78phenobarb tab 100mg 78phenobarb tab 15mg 78phenobarb tab 16.2mg 78phenobarb tab 30mg 78phenobarb tab 32.4mg 78phenobarb tab 60mg 78phenobarb tab 64.8mg 78phenobarb tab 97.2mg 78phenytoin chw 50mg 20phenytoin ex cap 100mg 20phenytoin ex cap 200mg 20phenytoin ex cap 300mg 20phenytoin sus 125/5ml 20philith tab 0.4-35 54PHISOHEX LIQ 3% 43PHOSPHOLINE SOL 0.125%OP 89PHRENILIN CAP FORTE 5PICATO GEL 0.015% 61PICATO GEL 0.05% 61pilocarpine sol 1% op 89pilocarpine sol 2% op 89pilocarpine sol 4% op 89pilocarpine tab 5mg 84pilocarpine tab 7.5mg 84pindolol tab 10mg 48pindolol tab 5mg 48pioglita/met tab 15-500mg 24pioglita/met tab 15-850mg 24pioglitazone tab 15mg 26pioglitazone tab 30mg 26

pioglitazone tab 45mg 26pirmella tab 1/35 54pirmella tab 7/7/7 54piroxicam cap 10mg 4piroxicam cap 20mg 4PLAN B TAB 1.5MG 55podactin cre 2% 61podofilox sol 0.5% 65poly-dex oin 0.1% op 90poly-iron cap 150 fort 77poly-vi-flor chw 0.25mg 84poly-vi-flor chw 0.5mg 84poly-vi-flor chw 1mg 84POLY-VI-FLOR CHW W/IRON 84poly-vit/fe dro /fl 0.25 85poly-vit/fe dro /fl 0.5 85poly-vit/fl dro 0.25mg 84polyeth glyc pow 3350 nf 79polyeth glyc pow 3350-grx 79polymyxin b/ sol trimethp 89polysacchari cap iron 77polyvit/fl dro 0.5mg/ml 84portia-28 tab 54pot chloride cap 10meq er 83pot chloride cap 8meq er 83pot chloride liq 10% 83pot chloride liq 20% 83pot chloride liq 20% sf 83pot chloride sol 10% sf 83pot chloride tab 10meq cr 83pot chloride tab 10meq er 83pot chloride tab 8meq er 83pot chloride tab 8meq sr 83pot citrate tab 1080mg 74pot citrate tab 540mg 74pot cl micro tab 10meq cr 83pot cl micro tab 10meq er 83pot cl micro tab 20meq er 83POTIGA TAB 200MG 19POTIGA TAB 300MG 19POTIGA TAB 400MG 19POTIGA TAB 50MG 19PRADAXA CAP 150MG 18PRADAXA CAP 75MG 18pramcort cre 1-1% 64pramipexole tab 0.125mg 39pramipexole tab 0.25mg 39pramipexole tab 0.5mg 39pramipexole tab 0.75mg 39pramipexole tab 1.5mg 39pramipexole tab 1mg 39PRANDIN TAB 0.5MG 26pravastatin tab 10mg 31pravastatin tab 20mg 31pravastatin tab 40mg 32pravastatin tab 80mg 32prazosin hcl cap 1mg 34prazosin hcl cap 2mg 34prazosin hcl cap 5mg 34PRED MILD SUS 0.12% OP 90

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PRED SOD PHO SOL 1% OP 90pred sod pho sol 5mg/5ml 56pred sod pho sol 6.7/5ml 56PRED-G S.O.P OIN OP 90PRED-G SUS OP 90prednicarbat cre 0.1% 64prednicarbat oin 0.1% 64prednisolone sol 15mg/5ml 56prednisolone sol 25mg/5ml 56prednisolone sus 1% op 90prednisolone syp 15mg/5ml 56prednisone pak 10mg 56prednisone pak 5mg 56prednisone sol 5mg/5ml 56prednisone tab 10mg 56prednisone tab 1mg 56prednisone tab 2.5mg 56prednisone tab 20mg 57prednisone tab 50mg 57prednisone tab 5mg 56PREMARIN TAB 0.3MG 72PREMARIN TAB 0.45MG 72PREMARIN TAB 0.625MG 72PREMARIN TAB 0.9MG 72PREMARIN TAB 1.25MG 72PREMARIN VAG CRE 0.625MG 105PREMPHASE TAB 71PREMPRO TAB .625-2.5 71PREMPRO TAB 0.3-1.5 71PREMPRO TAB 0.45-1.5 71PREMPRO TAB 0.625-5 71prenaplus tab 85prenatabs rx tab 85prenatal 19 chw tab 85prenatal 19 tab 85PRENATAL TAB 85PRENATAL TAB 28-0.8MG 85PRENATAL TAB COMPLETE 85PRENATAL TAB FORMULA 85prenatal tab plus 85prenatal tab plus fe 85PRENATAL+DHA MIS 85PRENATAL+DHA MIS WOMENS 85PRENATAL-U CAP 85PRENTIF MIS 22MM 81PRENTIF MIS 25MM 81PRENTIF MIS 28MM 81PRENTIF MIS 31MM 81PRENTIF MIS FITTING 81prep h hc cre 1% 64PREPOPIK PAK 79prevalite pow 4gm 31previfem tab 54PREZISTA TAB 150MG 44PREZISTA TAB 400MG 44PREZISTA TAB 600MG 44PREZISTA TAB 75MG 44PRIFTIN TAB 150MG 36PRIMAQUINE TAB 26.3MG 35primidone tab 250mg 19

primidone tab 50mg 19PRIMSOL SOL 50MG/5ML 11PRISTIQ TAB 100MG 23PRISTIQ TAB 50MG 23PRIVIGEN INJ 10GRAMS 92PRIVIGEN INJ 20GRAMS 92PROAIR HFA AER 16proben/colch tab 500-0.5 74probenecid tab 500mg 74prochlorper sup 25mg 42prochlorper tab 10mg 42prochlorper tab 5mg 42PROCORT CRE 10PROCRIT INJ 10000/ML 77PROCRIT INJ 2000/ML 77PROCRIT INJ 20000/ML 77PROCRIT INJ 3000/ML 77PROCRIT INJ 4000/ML 77PROCRIT INJ 40000/ML 77procto-pak cre 1% 10proctocream cre hc 2.5% 10PROCTOFOAM AER HC 1% 10proctosol hc cre 2.5% 10proctozone cre -hc 2.5% 10PROFE FORTE CAP 155-1MG 85PROFILNINE INJ 500UNIT 76progesterone cap 100mg 94progesterone cap 200mg 94PROLASTIN INJ 1000MG 99PROLASTIN-C INJ 1000MG 99PROLEUKIN INJ 22MU 38PROLIA SOL 60MG/ML 69promacet tab 50-650mg 5PROMACTA TAB 12.5MG 77PROMACTA TAB 25MG 77PROMACTA TAB 50MG 77PROMACTA TAB 75MG 77prometh vc syp 6.25-5/5 58prometh vc syp plain 58prometh vc/ syp codeine 58prometh/cod syp 6.25-10 58promethazine sol 6.25/5ml 30promethazine sup 12.5mg 30promethazine sup 25mg 30promethazine syp 6.25/5ml 30promethazine syp dm 58promethazine tab 12.5mg 30promethazine tab 25mg 30promethazine tab 50mg 30promethegan sup 12.5mg 30promethegan sup 25mg 30promethegan sup 50mg 30PRONTO AER 0.4% 66propafenone cap 225mg er 14propafenone cap 325mg er 14propafenone cap 425mg sr 14propafenone tab 150mg 14propafenone tab 225mg 14propafenone tab 300mg 14propanthelin tab 15mg 102

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proparacaine sol 0.5% op 90propranolol cap 120mg er 48propranolol cap 160mg er 48propranolol cap 60mg er 48propranolol cap 80mg er 48propranolol tab 10mg 48propranolol tab 20mg 48propranolol tab 40mg 48propranolol tab 60mg 48propranolol tab 80mg 48propylthiour tab 50mg 99PROTOPIC OIN 0.03% 65PROTOPIC OIN 0.1% 65protriptylin tab 10mg 24protriptylin tab 5mg 24prudoxin cre 5% 61pseudoephedr syp 30mg/5ml 87pseudoephedr tab 30mg 87pseudoephedr tab 60mg 87psudatabs tab 30mg 87PULMICORT INH 180MCG 15PULMICORT INH 90MCG 15PULMICORT SUS 1MG/2ML 15PULMOZYME SOL 1MG/ML 99px allergy cap 25mg 29px aspirin chw 81mg 6px aspirin tab 325mg 6px aspirin tab 325mg ec 6px aspirin tab 81mg ec 6PX PRENATAL TAB MULTIVIT 85px tussin dm liq 100-10/5 58pyrazinamide tab 500mg 36PYRE/PIPERON LIQ 66pyridostigm tab 60mg 35

Qq-dryl cap 25mg 29qc aspirin tab 325mg 6qc aspirin tab 325mg ec 6qc child asa chw 81mg 6qc heartburn tab 200mg 102qc hydrocort cre 1% 64QC PRENATAL TAB 28-0.8MG 85QNASL AER 80MCG 87quadrapax elx 102quenalin syp 12.5/5ml 29quetiapine tab 100mg 42quetiapine tab 200mg 42quetiapine tab 25mg 41quetiapine tab 300mg 42quetiapine tab 400mg 42quetiapine tab 50mg 42quinapril tab 10mg 33quinapril tab 20mg 33quinapril tab 40mg 33quinapril tab 5mg 33quinidine gl tab 324mg cr 14quinidine gl tab 324mg er 14quinidine su tab 200mg 14

quinidine su tab 300mg 14quinidine su tab 300mg er 14quinine sulf cap 324mg 35QVAR AER 40MCG 15QVAR AER 80MCG 15

Rra anti-itch cre 1% 64ra aspirin chw 81mg 6ra aspirin tab 325mg 6ra aspirin tab 325mg ec 6ra aspirin tab 81mg ec 6ra child asa chw 81mg 6ra hydrocort cre 1% 64ra hydrocort cre 1%pls 12 64ra laxative pow 79ra nicotine dis 14mg/24h 98ra nicotine dis 21mg/24h 98ra nicotine dis 7mg/24hr 98ra nicotine gum 2mg 98ra nicotine gum 2mg cinn 98ra nicotine gum 2mg mint 98ra nicotine gum 2mgfruit 98ra nicotine gum 4mg 98ra nicotine gum 4mg frut 98ra nicotine gum 4mg mint 98ra nicotine loz 2mg mint 98ra nicotine loz 4mg mint 98RA ONE DAILY MIS 85RA PRENATAL TAB 28-0.8MG 85RA PRENATAL TAB FORMULA 85ra suphedrin tab 30mg 87ra tussin dm liq 100-10/5 58ramipril cap 1.25mg 33ramipril cap 10mg 33ramipril cap 2.5mg 33ramipril cap 5mg 33RANEXA TAB 1000MG 12RANEXA TAB 500MG 12ranitidine syp 150/10ml 102ranitidine syp 15mg/ml 102ranitidine syp 75mg/5ml 102ranitidine tab 150mg 103ranitidine tab 300mg 103RAPAFLO CAP 4MG 74RAPAFLO CAP 8MG 74RAPAMUNE SOL 1MG/ML 47RAPAMUNE TAB 0.5MG 47RAPAMUNE TAB 1MG 47RAPAMUNE TAB 2MG 47REBETOL SOL 40MG/ML 45REBIF INJ 22/0.5 95REBIF INJ 44/0.5 95REBIF REBIDO INJ 22/0.5 95REBIF REBIDO INJ 44/0.5 95REBIF REBIDO SOL TITRATN 95REBIF TITRTN SOL PACK 95reclipsen tab 54RECOMBINATE INJ 220-400 76

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RECOMBINATE INJ 401-800 76RECOMBINATE INJ 801-1240 76recort plus cre 1% 65rectacort-hc sup 25mg 11RECTIV OIN 0.4% 11rederm lot 1% 65REFACTO INJ 500UNIT 76regenecare gel ha 2% 66REGRANEX GEL 0.01% 66RELENZA MIS DISKHALE 46RELISTOR KIT 12/0.6ML 73RELPAX TAB 20MG 82RELPAX TAB 40MG 82remedy cre antifung 61REMICADE INJ 100MG 73REMODULIN INJ 10MG/ML 51REMODULIN INJ 1MG/ML 51REMODULIN INJ 2.5MG/ML 51REMODULIN INJ 5MG/ML 51RENAGEL TAB 400MG 73RENAGEL TAB 800MG 73renal cap softgel 84renalpren cap 84renaphro cap 84reno cap 84RENVELA TAB 800MG 73repaglinide 26repan tab 5reprexain tab 10-200mg 9RESCRIPTOR TAB 100 MG 44RESCRIPTOR TAB 200MG 44RESTASIS EMU 0.05% 90REVLIMID CAP 10MG 46REVLIMID CAP 15MG 46REVLIMID CAP 25MG 46REVLIMID CAP 5MG 46REYATAZ CAP 100MG 44REYATAZ CAP 150MG 44REYATAZ CAP 200MG 44REYATAZ CAP 300MG 44RHEUMATREX TAB 2.5MG 3RHINOCORT SUS AQUA 87RHOGAM PLUS INJ 300MCG 92RIBAPAK PAK 1000/DAY 45RIBAPAK PAK 1200/DAY 45RIBAPAK PAK 800/DAY 45ribasphere cap 200mg 45ribasphere tab 200mg 45ribasphere tab 400mg 45ribasphere tab 600mg 45RIBATAB PAK 1000/DAY 45RIBATAB TAB 1200/DAY 45RIBATAB TAB 800/DAY 45ribavirin cap 200mg 45ribavirin tab 200mg 46RIDAURA CAP 3MG 3rifampin cap 150mg 36rifampin cap 300mg 36RIFATER TAB 36riluzole tab 50mg 88

rimantadine tab 100mg 46ringworm cre 1% 61risperidone sol 1mg/ml 41risperidone tab 0.25 odt 41risperidone tab 0.25mg 41risperidone tab 0.5mg 41risperidone tab 0.5mg od 41risperidone tab 1mg 41risperidone tab 1mg odt 41risperidone tab 2mg 41risperidone tab 2mg odt 41risperidone tab 3mg 41risperidone tab 3mg odt 41risperidone tab 4mg 41risperidone tab 4mg odt 41RITALIN LA CAP 10MG 3rivastigmine cap 3mg 94rizatriptan tab 10mg 82rizatriptan tab 5mg 82robafen ac syp 100-10/5 58robitussin liq cgh/cong 58robitussin liq to go dm 58romilar ac sol 100-10/5 58romycin oin op 89ropinirole tab 0.25mg 39ropinirole tab 0.5mg 39ropinirole tab 12mg er 40ropinirole tab 1mg 39ropinirole tab 2mg 39ropinirole tab 2mg er 40ropinirole tab 3mg 40ropinirole tab 4mg 40ropinirole tab 4mg er 40ropinirole tab 5mg 40ropinirole tab 6mg er 40ropinirole tab 8mg er 40rosadan cre 0.75% 66rosadan gel 0.75% 66ROXICET SOL 5-325/5 9roxicet tab 5-325mg 9ROXICET TAB 5-500MG 9ROZEREM TAB 8MG 79

SSABRIL POW 500MG 20SABRIL TAB 500MG 20safe tussin liq 10-100/5 58salsalate tab 500mg 6salsalate tab 750mg 6SAMSCA TAB 15MG 70SAMSCA TAB 30MG 70SANDIMMUNE SOL 100MG/ML 47SANDOSTATIN KIT LAR 10MG 70SANDOSTATIN KIT LAR 20MG 70SANDOSTATIN KIT LAR 30MG 70SANTYL OIN 250/GM 65SAPHRIS SUB 10MG 42SAPHRIS SUB 5MG 42sarnol-hc lot 1% 65

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SAVELLA MIS TITR PAK 94SAVELLA TAB 100MG 94SAVELLA TAB 12.5MG 94SAVELLA TAB 25MG 94SAVELLA TAB 50MG 94sb aspirin tab 325mg 6sb aspirin tab 325mg ec 6sb cgh contr liq dm 58sb child asa chw 81mg 6sb hydrocort cre 1% 65sb pseudophe tab 30mg 87scalacort lot 2% 65se-donna elx pb hyos 102selegiline cap 5mg 40selegiline tab 5mg 40selenium sul lot 2.5% 62selenium sul sha 2.25% 62selenium sul sha 2.5% 62SELZENTRY TAB 150MG 44SELZENTRY TAB 300MG 44SENSIPAR TAB 30MG 70SENSIPAR TAB 60MG 70SENSIPAR TAB 90MG 70SEREVENT DIS AER 50MCG 16SEROQUEL XR TAB 150MG 42SEROQUEL XR TAB 200MG 42SEROQUEL XR TAB 300MG 42SEROQUEL XR TAB 400MG 42SEROQUEL XR TAB 50MG 42sertraline tab 100mg 22sertraline tab 25mg 22sertraline tab 50mg 22sildec pe-dm syp 58sildenafil tab 20mg 52silphen coug syp 12.5/5ml 29siltussin dm liq das 58siltussin-dm liq diabetic 58silver sulfa cre 1% 62SIMCOR TAB 1000-20 32SIMCOR TAB 1000-40 32SIMCOR TAB 500-20MG 32SIMCOR TAB 500-40MG 32SIMCOR TAB 750-20MG 32simply stuff tab 30mg 87simvastatin tab 10mg 32simvastatin tab 20mg 32simvastatin tab 40mg 32simvastatin tab 5mg 32simvastatin tab 80mg 32SKELID TAB 200MG 69skin trtment lot 12% 65SKLICE LOT 0.5% 66sm acid redu tab 200mg 103sm anti-diar tab 2mg 27sm antifungl cre 2% 61sm aspirin chw 81mg 6sm aspirin tab 325mg 6sm aspirin tab 325mg ec 6sm aspirin tab 81mg ec 6sm child asa chw 81mg 6

sm clearlax pow 79sm folic acd tab 400mcg 76sm hydrocort cre 1% 65sm nasal dec tab 30mg 87sm nicotine dis 14mg/24h 98sm nicotine dis 21mg 98sm nicotine dis 7mg/24hr 98sm nicotine gum 2mg 98sm nicotine gum 2mg mint 98sm nicotine gum 4mg 98sm nicotine gum 4mg mint 98sm nicotine loz 2mg mint 98sm nicotine loz 4mg mint 98SM PRENATAL TAB VITAMINS 85sm vitamin d tab 400unit 106smooth lax pow 79smz-tmp sus 11smz-tmp sus 200-40/5 11smz-tmp tab 400-80mg 11smz/tmp ds tab 800-160 11sod chloride neb 0.9% 58sod chloride sol 0.45%irr 74sod fluoride chw 0.25mg f 83sod fluoride chw 0.5mg f 83sod fluoride chw 1.1mg 83sod fluoride chw 1mg f 83sod fluoride chw 2.2mg 83sod fluoride dro 0.5mg/ml 83sod fluoride tab 0.5mg f 83sod poly sul pow 47sod sulfacet sol 10% op 89sodium chlor neb 3% 58sodium chlor sol 0.9% irr 74solia tab 54SOMATULINE INJ 120/.5ML 70SOMATULINE INJ 60/0.2ML 70SOMATULINE INJ 90/0.3ML 70SOMAVERT INJ 10MG 69SOMAVERT INJ 15MG 69SOMAVERT INJ 20MG 69SOMNOTE CAP 500MG 78soothe&cool cre inzo 2% 61SORIATANE CAP 10MG 61SORIATANE CAP 17.5MG 62SORIATANE CAP 25MG 62sorine tab 120mg 48sorine tab 160mg 48sorine tab 240mg 48sorine tab 80mg 48sotalol af tab 120mg 48sotalol af tab 160mg 48sotalol af tab 80mg 48sotalol hcl tab 120mg 49sotalol hcl tab 160mg 49sotalol hcl tab 240mg 49sotalol hcl tab 80mg 49sotret cap 10mg 59sotret cap 20mg 59sotret cap 30mg 59SPACERS 81

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spinosad sus 0.9% 66SPIRIVA CAP HANDIHLR 15spirono/hctz tab 25/25 68spironolact tab 100mg 68spironolact tab 25mg 68spironolact tab 50mg 68sprintec 28 tab 28 day 54SPRYCEL TAB 100MG 38SPRYCEL TAB 140MG 38SPRYCEL TAB 20MG 38SPRYCEL TAB 50MG 38SPRYCEL TAB 70MG 38SPRYCEL TAB 80MG 38sronyx tab 55ssd af cre 1% 62ssd cre 1% 62st joseph as chw 81mg 6stavudine cap 15mg 44stavudine cap 20mg 44stavudine cap 30mg 44stavudine cap 40mg 44stavudine sol 1mg/ml 44STAVZOR CAP 125MG 20STAVZOR CAP 250MG 21STAVZOR CAP 500MG 21STAXYN TAB 10MG 51STELARA INJ 45MG/0.5 62STELARA INJ 90MG/ML 62STIMATE SOL 1.5MG/ML 70stop smoking gum 2mg mint 98stop smoking gum 2mg orig 98stop smoking gum 4mg 98stop smoking loz 2mg mint 98stop smoking loz 4mg mint 98STRATTERA CAP 100MG 2STRATTERA CAP 10MG 1STRATTERA CAP 18MG 1STRATTERA CAP 25MG 1STRATTERA CAP 40MG 1STRATTERA CAP 60MG 1STRATTERA CAP 80MG 1STRIBILD TAB 44STROMECTOL TAB 3MG 11STUART PREN TAB 85sucralfate tab 1gm 103sudanyl tab 30mg 87sudogest tab 30mg 87sudogest tab 60mg 87sudophed tab 30mg 87sulf/pred na sol op 90sulfacet sod oin 10% op 89sulfacet sod sol 10% op 89SULFADIAZINE TAB 500MG 99SULFAMYLON CRE 85MG/GM 62sulfasalazin tab 500mg 73sulfasalazin tab 500mg dr 73sulfazine ec tab 500mg 73sulfazine tab 500mg 73sulindac tab 150mg 4sulindac tab 200mg 4

sumatriptan inj 4mg/0.5 82sumatriptan inj 6mg/0.5 82sumatriptan spr 20mg/act 82sumatriptan spr 5mg/act 82sumatriptan tab 100mg 82sumatriptan tab 25mg 82sumatriptan tab 50mg 82SUPARTZ INJ 25/2.5ML 86suphedrine tab 30mg 87SUPPRELIN LA KIT 50MG 69SUPRAX SUS 100/5ML 53SUPRAX SUS 200/5ML 53SUPRAX TAB 400MG 53SUPREP BOWEL SOL PREP 79SUSTIVA CAP 200MG 44SUSTIVA CAP 50MG 44SUSTIVA TAB 600MG 44SUTENT CAP 12.5MG 38SUTENT CAP 25MG 38SUTENT CAP 50MG 38sw clearlax pow 79sw nasal dec tab 30mg 87sw nicotine gum 2mg mint 98sw nicotine gum 4mg 98sw nicotine loz 2mg mint 98sw nicotine loz 4mg mint 98syeda tab 3-0.03mg 55symax-sl sub 0.125mg 102SYMBICORT AER 160-4.5 16SYMBICORT AER 80-4.5 16SYMLINPEN 60 INJ 1000MCG 24SYMLNPEN 120 INJ 1000MCG 24SYNAGIS INJ 100MG/ML 93SYNAGIS INJ 50MG 92SYNAREL SOL 2MG/ML 69SYNERA DIS 70-70MG 66SYNVISC INJ 8MG/ML 86SYNVISC ONE INJ 8MG/ML 86SYPRINE CAP 250MG 46

TTABLOID TAB 40MG 36TACLONEX OIN 65TACLONEX SUS 65tacrolimus cap 0.5mg 47tacrolimus cap 1mg 47tacrolimus cap 5mg 47TAMIFLU CAP 30MG 46TAMIFLU CAP 45MG 46TAMIFLU CAP 75MG 46TAMIFLU SUS 12MG/ML 46TAMIFLU SUS 6MG/ML 46tamoxifen tab 10mg 37tamoxifen tab 20mg 37tamsulosin cap 0.4mg 74TARCEVA TAB 100MG 38TARCEVA TAB 150MG 38TARCEVA TAB 25MG 38TARGRETIN CAP 75MG 38

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TARON-C DHA CAP 85TASIGNA CAP 150MG 38TASIGNA CAP 200MG 38TASMAR TAB 100MG 39TAZORAC GEL 0.05% 62TAZORAC GEL 0.1% 62taztia xt cap 120mg/24 50taztia xt cap 180mg/24 50taztia xt cap 240mg/24 50taztia xt cap 300mg/24 50taztia xt cap 360mg/24 51TEGRETOL-XR TAB 100MG 19TEKTURNA TAB 150MG 35TEKTURNA TAB 300MG 35temazepam cap 15mg 78temazepam cap 30mg 78temazepam cap 7.5mg 78TEMODAR CAP 100MG 36TEMODAR CAP 140MG 36TEMODAR CAP 180MG 36TEMODAR CAP 20MG 36TEMODAR CAP 250MG 36TEMODAR CAP 5MG 36terazosin cap 10mg 34terazosin cap 1mg 34terazosin cap 2mg 34terazosin cap 5mg 34terbinafine tab 250mg 28terbutaline tab 2.5mg 16terbutaline tab 5mg 16terconazole cre 0.4% 105terconazole cre 0.8% 105terconazole sup 80mg 105testost cyp inj 100mg/ml 10testost cyp inj 200mg/ml 10testost enan inj 200mg/ml 10tetracycline cap 250mg 99tetracycline cap 500mg 99TEV-TROPIN INJ 5MG 69tgt aspirin chw 81mg 6tgt aspirin chw child 7tgt aspirin tab 325mg 7tgt aspirin tab 81mg ec 7tgt cough liq form dm 58tgt nicotine dis 14mg/24h 98tgt nicotine dis 21mg/24h 98tgt nicotine dis 7mg/24hr 98tgt nicotine gum 2mg mint 98tgt nicotine gum 2mg orig 98tgt nicotine gum 2mgfruit 98tgt nicotine gum 4mg 98tgt nicotine gum 4mg mint 98tgt nicotine gum 4mg orig 98tgt nicotine loz 2mg chry 98tgt nicotine loz 2mg mint 98tgt nicotine loz 4mg chry 98tgt nicotine loz 4mg mint 99th aspirin tab 325mg 7th aspirin tab 325mg ec 7th aspirin tab 81mg ec 7

th hydrocort cre 1% 65TH PRENATAL TAB VITAMINS 85THALOMID CAP 100MG 46THALOMID CAP 150MG 46THALOMID CAP 200MG 46THALOMID CAP 50MG 46THEO-24 CAP 100MG CR 16THEO-24 CAP 200MG CR 16THEO-24 CAP 300MG CR 16THEO-24 CAP 400MG ER 16theochron tab 100mg cr 16theochron tab 200mg cr 16theochron tab 300mg cr 16theophylline sol 80/15ml 16theophylline tab 100mg cr 16theophylline tab 100mg er 16theophylline tab 200mg cr 16theophylline tab 200mg er 16theophylline tab 300mg er 17theophylline tab 400mg er 17theophylline tab 450mg er 17theophylline tab 600mg er 17theracort lot 1% 65thermazene cre 1% 62thioridazine tab 100mg 42thioridazine tab 10mg 42thioridazine tab 25mg 42thioridazine tab 50mg 42thiothixene cap 10mg 43thiothixene cap 1mg 43thiothixene cap 2mg 43thiothixene cap 5mg 43thrive gum 2mg mint 99thrive gum 4mg mint 99THYROGEN INJ 1.1MG 66THYROLAR-1 TAB 60MG 101THYROLAR-1/2 TAB 30MG 101THYROLAR-1/4 TAB 15MG 101THYROLAR-2 TAB 120MG 101THYROLAR-3 TAB 180MG 101tiagabine tab 2mg 20tiagabine tab 4mg 20ticlopidine tab 250mg 76TIKOSYN CAP 125MCG 14TIKOSYN CAP 250MCG 14TIKOSYN CAP 500MCG 14tilia fe tab 55timolol gel sol 0.25% op 88timolol gel sol 0.5% op 88timolol mal sol 0.25% op 88timolol mal sol 0.5% op 88timolol mal tab 10mg 49timolol mal tab 20mg 49timolol mal tab 5mg 49TIMOPTIC OCU SOL 0.25% OP 88TIMOPTIC OCU SOL 0.5% OP 88tizanidine cap 2mg 86tizanidine cap 4mg 86tizanidine cap 6mg 86tizanidine tab 2mg 86

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tizanidine tab 4mg 86tl icon cap 78TOBI NEB 300/5ML 3tobra/dexame sus 0.3-0.1% 90TOBRADEX OIN 0.3-0.1% 90tobramycin sol 0.3% op 89tobrasol sol 0.3% op 89TOBREX OIN 0.3% OP 89TODAY SPONGE MIS 81tolazamide tab 250mg 26tolazamide tab 500mg 26tolbutamide tab 500mg 26tolmetin sod cap 400mg 4tolmetin sod tab 200mg 4tolmetin sod tab 600mg 4tolterodine tab 1mg 104tolterodine tab 2mg 104tolu-sed dm liq 100-10/5 58topiragen tab 100mg 19topiragen tab 200mg 19topiragen tab 25mg 19topiragen tab 50mg 19topiramate cap 15mg 19topiramate cap 25mg 19topiramate tab 100mg 20topiramate tab 200mg 20topiramate tab 25mg 20topiramate tab 50mg 20torsemide tab 100mg 68torsemide tab 10mg 68torsemide tab 20mg 68torsemide tab 5mg 68TOVIAZ TAB 4MG 104TOVIAZ TAB 8MG 104TRACLEER TAB 125MG 52TRACLEER TAB 62.5MG 52TRADJENTA TAB 5MG 25tramadol hcl tab 100mg er 8tramadol hcl tab 200mg er 8tramadol hcl tab 300mg er 8tramadol hcl tab 50mg 8trandolapril tab 1mg 33trandolapril tab 2mg 33trandolapril tab 4mg 33TRANSDERM-SC DIS 1.5MG 27tranylcyprom tab 10mg 22TRAVATAN Z DRO 0.004% 91travoprost dro 0.004% 91trazodone tab 100mg 21trazodone tab 150mg 22trazodone tab 300mg 22trazodone tab 50mg 21TRECATOR TAB 250MG 36TRELSTAR DEP INJ 3.75MG 37TRELSTAR LA INJ 11.25MG 37TRETIN-X CRE 0.0375% 59tretinoin cap 10mg 38tretinoin cre 0.025% 59tretinoin cre 0.05% 59tretinoin cre 0.1% 59

tretinoin gel 0.01% 59tretinoin gel 0.025% 59tri-estaryll tab 55tri-legest tab fe 55tri-linyah tab 55tri-previfem tab 55tri-sprintec tab 55tri-vit/fe dro /fl 0.25 85tri-vit/fl dro 0.25mg 84tri-vit/fl dro 0.5mg 84tri-vit/fluo dro 0.25mg 84tri-vit/fluo dro 0.5mg 84tri-vita/fl dro 0.25mg 84triamcin/ora pst 0.1% 84triamcinolon cre 0.025% 65triamcinolon cre 0.1% 65triamcinolon cre 0.5% 65triamcinolon lot 0.025% 65triamcinolon lot 0.1% 65triamcinolon oin 0.025% 65triamcinolon oin 0.05% 65triamcinolon oin 0.1% 65triamcinolon oin 0.5% 65triamcinolon pst 0.1% 84triamcinolon spr 55mcg/ac 87triamt/hctz cap 37.5-25 68triamt/hctz tab 37.5-25 68triamt/hctz tab 75-50mg 68triazolam tab 0.125mg 78triazolam tab 0.25mg 78tricon cap 78triderm cre 0.1% 65trifluoperaz tab 10mg 42trifluoperaz tab 1mg 42trifluoperaz tab 2mg 42trifluoperaz tab 5mg 42trifluridine sol 1% op 89TRIGLIDE TAB 50MG 31trihexyphen elx 0.4mg/ml 39trihexyphen tab 2mg 39trihexyphen tab 5mg 39trimethobenz cap 300mg 28trimethoprim sol polymyxn 89trimethoprim tab 100mg 11trimipramine cap 100mg 24trimipramine cap 25mg 24trimipramine cap 50mg 24trinessa tab 55triphrocaps cap 84TRIVEEN-U CAP 85trivora-28 tab 55TRIZIVIR TAB 44tropicamide sol 0.5% op 88tropicamide sol 1% op 88trospium chl cap 60mg er 104TRUERESULT KIT 81TRUETEST TES 67TRUVADA TAB 200-300 44TUDORZA PRES AER 400/ACT 15tusnel diabt liq 10-100/5 58

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tussin adult liq cgh/cong 58tussin cough liq 10-100/5 58tussin cough liq congesti 58tussin dm liq 58tussin dm liq 100-10/5 58tussin dm liq clear 58TWINJECT INJ 0.3MG 105TWYNSTA TAB 40-10MG 35TWYNSTA TAB 40-5MG 35TWYNSTA TAB 80-10MG 35TWYNSTA TAB 80-5MG 35TYKERB TAB 250MG 38TYSABRI INJ 95TYZEKA TAB 600MG 46TYZINE PED DRO 0.05% 87TYZINE SOL 0.1% 87

UULESFIA LOT 5% 66ULORIC TAB 40MG 74ULORIC TAB 80MG 74ULTRESA CAP 13800UNT 67ULTRESA CAP 20700UNT 67ULTRESA CAP 23000UNT 67unith direct tab 100mcg 101unith direct tab 112mcg 101unith direct tab 125mcg 101unith direct tab 150mcg 101unith direct tab 175mcg 101unith direct tab 200mcg 101unith direct tab 25mcg 101unith direct tab 300mcg 101unith direct tab 50mcg 101unith direct tab 75mcg 101unith direct tab 88mcg 101unithroid tab 100mcg 101unithroid tab 112mcg 101unithroid tab 125mcg 101unithroid tab 137mcg 101unithroid tab 150mcg 101unithroid tab 175mcg 101unithroid tab 200mcg 101unithroid tab 25mcg 101unithroid tab 300mcg 101unithroid tab 50mcg 101unithroid tab 75mcg 101unithroid tab 88mcg 101URINARY TRAC TES INFECTIO 67URISTIX 4 TES 67URISTIX TES 67ursodiol cap 300mg 72ursodiol tab 250mg 73ursodiol tab 500mg 73

VVAGIFEM TAB 10MCG 105valacyclovir tab 1gm 46valacyclovir tab 500mg 46VALCYTE SOL 50MG/ML 45

VALCYTE TAB 450MG 45valproic acd cap 250mg 21valproic acd sol 250/5ml 21valproic acd syp 250/5ml 21vancomycin cap 125mg 11vancomycin cap 250mg 11vandazole gel 0.75% 105VANDETANIB TAB 100MG 38VANDETANIB TAB 300MG 38VANOS CRE 0.1% 65VANTAS KIT 50MG 37velivet pak 55venlafaxine cap 150mg er 23venlafaxine cap 37.5mg 23venlafaxine cap 75mg er 23venlafaxine tab 100mg 23venlafaxine tab 25mg 23venlafaxine tab 37.5mg 23venlafaxine tab 50mg 23venlafaxine tab 75mg 23VENTAVIS SOL 10MCG/ML 51VENTOLIN HFA AER 16VERAMYST SPR 27.5MCG 87verapamil cap 120mg er 51verapamil cap 120mg sr 51verapamil cap 180mg er 51verapamil cap 180mg sr 51verapamil cap 240mg er 51verapamil cap 240mg sr 51verapamil cap 360mg sr 51verapamil tab 120mg 51verapamil tab 120mg er 51verapamil tab 120mg sr 51verapamil tab 180mg er 51verapamil tab 180mg sr 51verapamil tab 240mg er 51verapamil tab 240mg sr 51verapamil tab 40mg 51verapamil tab 80mg 51VERIPRED 20 SOL 20MG/5ML 57VESICARE TAB 10MG 104VESICARE TAB 5MG 104vestura tab 3-0.02mg 55VEXOL SUS 1% OP 90VIAGRA TAB 100MG 51VIAGRA TAB 25MG 51VIAGRA TAB 50MG 51VIBRAMYCIN SYP 50MG/5ML 99VICTOZA INJ 18MG/3ML 25VICTRELIS CAP 200MG 46VIGAMOX DRO 0.5% 89VIIBRYD KIT 22VIIBRYD TAB 10MG 22VIIBRYD TAB 20MG 22VIIBRYD TAB 40MG 22VIMPAT SOL 10MG/ML 20VIMPAT TAB 100MG 20VIMPAT TAB 150MG 20VIMPAT TAB 200MG 20VIMPAT TAB 50MG 20

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VINATE AZ EX TAB 85VINATE II TAB 85viorele tab 55VIRACEPT POW 50MG/GM 44VIRACEPT TAB 250MG 44VIRACEPT TAB 625MG 44VIRAMUNE XR TAB 400MG 44VIREAD TAB 150MG 45VIREAD TAB 200MG 45VIREAD TAB 250MG 45VIREAD TAB 300MG 45VISICOL TAB 1.5GM 79vit d gummie chw 400unit 106VITAMIN A CAP 25000UNT 106vitamin d cap 50000unt 106vitamin d chw 400unit 106vitamin d dro 400unit 106vitamin d tab 400unit 106vitamin d3 chw 400unit 106vitamin d3 dro 400unit 106vitamin d3 tab 400unit 106vitazol cre 0.75% 66VIVAGLOBIN SOL 160MG/ML 92VIVELLE-DOT DIS 0.025MG 72VIVELLE-DOT DIS 0.0375MG 72VIVELLE-DOT DIS 0.05MG 72VIVELLE-DOT DIS 0.075MG 72VIVELLE-DOT DIS 0.1MG 72VIVITROL INJ 380MG 27voriconazole tab 200mg 28voriconazole tab 50mg 28VOTRIENT TAB 200MG 38VYTORIN TAB 10-10MG 30VYTORIN TAB 10-20MG 30VYTORIN TAB 10-40MG 30VYTORIN TAB 10-80MG 30VYVANSE CAP 20MG 1VYVANSE CAP 30MG 1VYVANSE CAP 40MG 1VYVANSE CAP 50MG 1VYVANSE CAP 60MG 1VYVANSE CAP 70MG 1

Wwal-dram ii tab 25mg 28wal-dryl cap 25mg 29wal-fex allr tab 180mg 30wal-fex d tab 12 hour 58wal-fex d tab 24 hour 58wal-phed tab 30mg 87wal-tussin liq dm 58wal-zan tab 150mg 103wal-zyr dro 0.025%op 91wal-zyr sol 1mg/ml 30wal-zyr sol 5mg/5ml 30warfarin tab 10mg 17warfarin tab 1mg 17warfarin tab 2.5mg 17warfarin tab 2mg 17

warfarin tab 3mg 17warfarin tab 4mg 17warfarin tab 5mg 17warfarin tab 6mg 17warfarin tab 7.5mg 17wee care sus 15/1.25 78WELCHOL TAB 625MG 31wera tab 0.5/35 55WIDE-SEAL DPR KIT 60 81WIDE-SEAL DPR KIT 65 81WIDE-SEAL DPR KIT 70 81WIDE-SEAL DPR KIT 75 81WIDE-SEAL DPR KIT 80 81WIDE-SEAL DPR KIT 85 81WIDE-SEAL DPR KIT 90 81WIDE-SEAL DPR KIT 95 81WINRHO SDF INJ 15000UNT 92WINRHO SDF INJ 1500UNIT 92WINRHO SDF INJ 2500UNIT 92WINRHO SDF INJ 5000UNIT 92wymzya fe chw 0.4mg-35 55

XXALKORI CAP 200MG 38XALKORI CAP 250MG 38XARELTO TAB 10MG 17XARELTO TAB 15MG 17XARELTO TAB 20MG 17XELODA TAB 150MG 36XELODA TAB 500MG 36XENAZINE TAB 12.5MG 94XENAZINE TAB 25MG 94XGEVA INJ 69XIFAXAN TAB 200MG 11XIFAXAN TAB 550MG 11XOLAIR SOL 150MG 14XOPENEX HFA AER 16XYREM SOL 500MG/ML 94

Yyl folic aci tab 400mcg 76yohimbine tab 5.4mg 51

Zzafirlukast tab 10mg 15zafirlukast tab 20mg 15zaleplon cap 10mg 78zaleplon cap 5mg 78zarah tab 3-0.03mg 55zazole cre 0.4% 105zazole cre 0.8% 105zazole sup 80mg 105ZELAPAR TAB 1.25MG 40ZELBORAF TAB 240MG 38ZEMAIRA INJ 1000MG 99ZEMPLAR CAP 1MCG 70ZEMPLAR CAP 2MCG 70ZEMPLAR CAP 4MCG 70zenatane cap 10mg 59

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zenatane cap 20mg 59zenatane cap 40mg 59zenchent fe chw 55zenchent fe chw 0.4mg-35 55zenchent tab 55ZENPEP CAP 10000UNT 67ZENPEP CAP 15000UNT 67ZENPEP CAP 20000UNT 67ZENPEP CAP 25000UNT 67ZENPEP CAP 3000UNIT 67zenzedi tab 10mg 1zenzedi tab 5mg 1zeosa chw 55ZETIA TAB 10MG 32ZIAGEN SOL 20MG/ML 45zidovudine cap 100mg 45zidovudine syp 50mg/5ml 45zidovudine tab 300mg 45ZIOPTAN DRO 0.0015% 91ziprasidone cap 20mg 40ziprasidone cap 40mg 40ziprasidone cap 60mg 40ziprasidone cap 80mg 40ZIRGAN GEL 0.15% 89ZMAX SUS 2GM 80ZOLINZA CAP 100MG 38zolmitriptan tab 2.5 mg 82zolmitriptan tab 2.5mg 82zolmitriptan tab 5mg 82zolpidem tab 10mg 79zolpidem tab 5mg 78zonisamide cap 100mg 20zonisamide cap 25mg 20zonisamide cap 50mg 20ZORTRESS TAB 0.25MG 47ZORTRESS TAB 0.5MG 47ZORTRESS TAB 0.75MG 47zovia 1/35e tab 55zovia 1/50e tab 55ZUPLENZ MIS 4MG 27ZUPLENZ MIS 8MG 27ZYFLO CR TAB 600MG 15ZYMAXID SOL 0.5% 89zyrtec itchy dro 0.025%op 91ZYTIGA TAB 250MG 37ZYVOX SUS 100MG/5M 12ZYVOX TAB 600MG 12

EXCHANGES MOLINA TX - CaremarkPA - Prior Authorization QL - Special Quantity Limit may apply ST - Step Therapy 5 Age - Special Age Limit may apply Tier 0 = Preventative Services at

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