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2017 Aetna Pharmacy Drug Guide
Three Tier Open Aetna Premier Plus Plan
www.aetna.com
©2017 Aetna Inc.
05.05.338.1 X (1/17)
Do you have questions?
Call the toll-free number on your member ID card. Or visit
www.aetna.com/formulary for the most up-to-date information.
Dear Member:
What pharmacy benefits plan do I have?
We are pleased to provide you with a copy of our 2017 Aetna
Pharmacy drug guide that includes information about your
pharmacy benefits plan. Take this guide with you when you
see your doctor if you want to talk about what medicines are
covered under your plan and what they may cost.
You are enrolled in the Aetna Three Tier Open Premier
Plus formulary plan.
Many commonly prescribed drugs are listed in this guide.
Note: this is not a complete list of drugs covered under
your plan. We list only the most commonly prescribed
medicines as thousands of drugs are covered by your plan.
Want to learn more your plan’s drug coverage? Just visit
www.aetna.com and log in to Aetna Navigator®, your
secure member website. Then take these simple steps:
Here’s what that means to you:
Think of tier as a level. Three Tier means you could pay three
different amounts, depending on the drug you take.
A formulary is a list of generic and brand-name drugs that
your plan covers. An open formulary means your plan covers
most prescription drugs. But it may not cover some others.
What can I expect to pay?
1. Select “Aetna Pharmacy” at the top of the page.
2. I n the “Coverage & Benefits” section, select “Pharmacy”.
Then, “View your pharmacy plan details.”
With this health benefits and health insurance plan, the amount
you pay depends on the drug your doctor prescribes. It’s either
a flat fee or a percent of the prescription’s price. Each drug your
plan covers falls under a different level or tier. The lower the
tier, the lower the price. The higher the tier, the higher the price.
What you pay falls into one of these tiers or levels:
Tier One: You pay the lowest cost for drugs in this level.
Your plan may include an additional benefit where some
Tier 1 drugs would be provided at an even lower cost to you.
These are considered Value Drugs/Tier 1a and include generics
and some over-the-counter brand and generic products.
These would be available at the lowest cost share indicated
in your plan materials.
Tier Two: You pay a slightly higher cost for drugs in this level.
Tier Three: You pay the highest cost for drugs in this level.
To find your exact costs
Check your Plan Design and Benefits summary in your
enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug to help reduce what you pay. This means that if you fill
a brand-name drug when a generic is available, that in addition
to your standard copay or coinsurance, you must also pay the
difference in cost between the brand-name and generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.aetna.com and log in to Aetna
Navigator. Or call the toll-free number on your member ID card.
www.aetna.com/formulary
Where can I find more formulary information?
Why is the formulary subject to change?
You and your doctor can search for a drug, find out if it’s covered
and see what tier it’s in. You can also see if there are alternatives
that cost less. Tell your doctor that you pay more for tier three
drugs so he or she can consider this when writing a prescription.
We may add or remove drugs for certain reasons. We might
also move a drug from one coverage tier to another.
Visit www.aetna.com/formulary. You arrive at a page that
says “Find a Medication.” This is where you can learn more
about the types of drug coverage reviews required for your
medicine(s); things like precertification, step therapy or quantity
limits. You will arrive at a menu page where you can view various
drug lists, including your Aetna Pharmacy drug guide and more.
How is the formulary developed?
Aetna’s Pharmacy and Therapeutics (P&T) Committee meets
regularly to review new drugs and new information about
drugs that are already on the market. It reviews available
information concerning safety, effectiveness and current use
in therapy. The P&T Committee reviews scientific evidence,
including relevant findings of federal government agencies,
pharmaceutical manufacturers, medical professional
associations, national commissions and peer-reviewed journals.
Our P&T Committee includes licensed pharmacists and doctors,
including those who are currently in practice and others who are
Aetna employees. All committee members must tell us if they
are in a situation that can create a conflict of interest or if they
have a financial stake that might affect their decisions.
Once the P&T Committee completes its clinical review, we also
consider overall value (including cost and manufacturer rebate
arrangements) and other factors before adding or removing
a drug from the formulary. The Aetna Pharmacy drug guide
shows you recent changes to the guide. For example, it could
show what drugs started requiring coverage reviews like
precertification, step therapy or quantity limits. Or which drugs
no longer do. The P&T Committee can make recommendations
to change the tier level of a drug or to place it on our Formulary
Exclusions List, designating it as a drug that is no longer covered.
Here are some reasons why:
•As brand-name drugs lose their patents and generic versions
become available, the brand-name may be covered at a higher
out-of-pocket cost while the generic may be covered at a lower
out-of-pocket cost.
•The U.S. Food and Drug Administration (FDA) approves many
new drugs throughout the year.
•Drugs can be withdrawn from the market or may become
available without a prescription. Over-the-counter (OTC)
drugs are not generally covered under a prescription plan,
unless required by law.
Our website, www.aetna.com/formulary, reflects the most
up-to-date formulary information – so please visit it often.
Why do some drugs require prior authorization
or precertification?
This drug coverage review encourages appropriate and costeffective use of prescription drugs by allowing coverage only
when certain conditions are met.
Reasons for precertification include:
•Compliance with dosing guidelines
•Avoiding duplicate therapies
•Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based on current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
If your plan requires precertification, you will find a list of drugs
that are subject to precertification with this guide. Please keep
in mind that:
•Your doctor must contact Aetna to request approval of
coverage for these drugs.
•If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
www.aetna.com/formulary
Why do some drugs have quantity limits?
Saving on prescriptions
This drug coverage review limits coverage of quantities for
certain drugs. These limits help your doctor and pharmacist
check that your prescribed drug is used correctly and safely.
Here are some other tips to pay less out of pocket for your
prescription drugs:
We use medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The quantity limit
program includes:
•Dose Efficiency Edits – Limit coverage of prescriptions to one
dose per day for drugs that are approved for once-daily dosing.
•Maximum Daily Dose – A message is sent to the pharmacy
if a prescription is less than the minimum or higher than the
maximum allowed dose.
•Quantity Limits Over Time – Limit coverage of prescriptions
to a specific number of units in a defined amount of time.
What is step therapy?
This drug coverage review promotes the appropriate use of
equally effective but lower-cost drugs first. These lower-cost
drugs are FDA-approved and treat the same condition as the
corresponding step therapy drugs.
What is therapeutic duplication?
Therapeutic duplication means that two or more drugs of
the same type are prescribed at the same time. This can occur
when two doctors prescribe similar drugs or when your doctor
switches from one drug to another drug in the same class
without cancelling the first prescription.
It is rare that you should ever need two drugs from the same
class to treat a medical condition. Since serious side effects
may occur, we help bring such duplications to your pharmacist’s
and doctor’s attention.
Learn more about drug coverage reviews
If you have a medical need for a drug that requires precertification,
quantity limits or step therapy, your doctor can ask for a medical
exception. The list of drugs requiring precertification, quantity
limits or step therapy is subject to change. Find the most
up-to-date information at www.aetna.com/formulary.
You may be able to save with generic drugs
Generic drugs are approved by FDA and proven to be just as
safe and effective as brand-name drugs. They contain the same
active ingredients in the same amounts as the brand-name
drugs. The difference is that generics may be a different color,
shape or size.
When appropriate, your doctor may decide to prescribe, or allow
substitution with, a generic drug. Please talk to your doctor to
find out if a generic is right for you.
•Ask your doctor to consider prescribing drugs that are
on the Pharmacy Drug (formulary) Guide.
•Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
•Check to see if your plan includes our mail-order pharmacy
service. Depending upon your plan, mail order may save you
money. See Aetna Rx Home Delivery in this guide for details.
•Remind your doctor to check your plan to make sure you
get maximum coverage.
What is Aetna Rx Home Delivery?
Check your plan documents to see if your plan includes our Aetna
Rx Home Delivery mail order pharmacy. It fills prescriptions
for maintenance medicine. This type of medicine is used
regularly, to treat conditions like arthritis, asthma, diabetes
or high cholesterol. If you need this type of drug, you can get
up to a 90-day supply, or the maximum supply allowed by your
plan, and free delivery right to your mailbox.
You also get:
•Quick, confidential service
•Free standard shipping
•Pharmacists who check all prescriptions for accuracy
and can answer questions any time
It’s easy and fast to order – choose one of these ways:
1. CourtesyStart sm – Fill your new mail order prescription
online at www.aetna.com. Click “Order Medications Online”
and “Request a New Prescription”. Or, call us toll-free at
1-888-RX AETNA (1-888-792-3862) or TDD: 1-800-823-6373.
We will contact your doctor to try and get a new prescription
for you. You may need to schedule a visit with your doctor
before he or she will write a new prescription.
2. M
ail – Get a new 90-day prescription from your doctor.
Mail it to us with a completed order form. Access the
order form online. Log in to www.aetna.com, then click
“Aetna Pharmacy.”
3. Fax – Ask your doctor to fax your new prescription, with
your completed order form to 1-877-270-3317. Make sure
your doctor includes your member ID number, your date of
birth and your mailing address on the fax cover sheet. Only
a doctor may fax a prescription.
If your prescription is for a controlled medicine, a written
prescription from your doctor may be needed.
Generally, if your order is complete, you will receive your
medicine within 10-14 days from when Aetna Rx Home Delivery
receives your order. You can request expedited delivery for an
additional charge.
www.aetna.com/formulary
What is Aetna Specialty Pharmacy?
Aetna Specialty Pharmacy is Aetna’s in-house specialty
pharmacy. It can fill your prescription specialty medicine.
These types of drugs may be injected, infused or taken by
mouth. Specialty medicine often needs special storage and
handling. It must be delivered quickly. And a nurse or pharmacist
should monitor you during your treatment. Use Aetna Specialty
Pharmacy to get this medicine sent right to your mailbox.
You also get:
•Free delivery that is reliable, secure and sent anywhere
you choose
•Extra help when you need it – like injection training and
side effect monitoring
•Refill reminders
•Proactive outreach to confirm your refills
•Free standard supplies
•Nurses and pharmacists to help 24 hours a day, every day
It’s easy and fast to order – choose one of these ways:
•Fax – Your doctor can fax your prescription to
1-866-FAX-ASRX (1-866-329-2779).
•Mail – You or your doctor can mail your prescription order to:
Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL
32809. If you mail in your own prescription, please send it
along with a completed Patient Profile Form. Find the form
at www.AetnaSpecialtyRx.com by clicking on “Specialty
pharmacy: How to enroll.”
•Phone – Your doctor can also call and speak to one
of our registered pharmacists at 1-866-782-ASRX
(1-866-782-2779) during normal business hours of
8 a.m. until 7 p.m. ET.
To transfer an existing prescription order and have it filled by
Aetna Specialty Pharmacy, call toll-free at 1-866-353-1892.
www.aetna.com/formulary
Nondiscrimination Notice
Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.
Aetna:
•
•
Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,
other formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact our Civil Rights Coordinator.
If you believe that Aetna has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights
Coordinator at:
Address: P.O. Box 14462, Lexington, KY 40512
Telephone: 1-800-648-7817 (TTY: 711), Fax: 1-859-425-3379
Email: [email protected]
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Civil
Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and
Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201,
1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna
Life Insurance Company, and its affiliates.
www.aetna.com/formulary
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www.aetna.com/formulary
Need more information?
Visit www.aetna.com/formulary or call the
appropriate toll-free number on your member ID card.
Please note that if your prescription drug benefits plan changes, the information herein may no longer apply.
A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law
to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That
means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.
Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York,
Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In
Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy
Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary
of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features
and availability may vary by location and are subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Pharmacy Drug (formulary) Guide. Rebates do not
reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to
www.aetna.com.
The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The
quantity limits and step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fullyinsured members in Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans.
In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during
the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known
as “pre-service utilization review.” It is not “verification” as defined by Texas law.
In accordance with state law, fully-insured Commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered, for as long as the treating
physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical
condition. In accordance with state law, fully-insured Commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are
receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered for as long as the
treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall
preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this
section be construed to prohibit generic drug substitutions.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are
subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide
care or guarantee access to health services. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2017 Aetna Inc.
05.05.338.1 X (1/17)
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ......................................................................................................................................................... 6
*ALTERNATIVE MEDICINES* .................................................................................................................................................................................................................................................................. 7
*AMEBICIDES* .................................................................................................................................................................................................................................................................................................................. 7
*AMINOGLYCOSIDES* ......................................................................................................................................................................................................................................................................................... 7
*ANALGESICS - ANTI-INFLAMMATORY* ........................................................................................................................................................................................................................... 8
*ANALGESICS - NONNARCOTIC* .................................................................................................................................................................................................................................................. 10
*ANALGESICS - OPIOID* ............................................................................................................................................................................................................................................................................... 11
*ANDROGENS-ANABOLIC* ...................................................................................................................................................................................................................................................................... 14
*ANORECTAL AGENTS* ................................................................................................................................................................................................................................................................................ 15
*ANTHELMINTICS* ................................................................................................................................................................................................................................................................................................ 16
*ANTIANGINAL AGENTS* .......................................................................................................................................................................................................................................................................... 16
*ANTIANXIETY AGENTS* .......................................................................................................................................................................................................................................................................... 16
*ANTIARRHYTHMICS* .................................................................................................................................................................................................................................................................................... 17
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* ......................................................................................................................................................................... 18
*ANTICOAGULANTS* ........................................................................................................................................................................................................................................................................................ 19
*ANTICONVULSANTS* .................................................................................................................................................................................................................................................................................... 20
*ANTIDEMENTIA AGENT COMBINATIONS*** ....................................................................................................................................................................................................... 22
*ANTIDEPRESSANTS* ....................................................................................................................................................................................................................................................................................... 22
*ANTIDIABETICS* .................................................................................................................................................................................................................................................................................................... 25
*ANTIDIARRHEALS* ........................................................................................................................................................................................................................................................................................... 29
*ANTIDOTES AND SPECIFIC ANTAGONISTS* .......................................................................................................................................................................................................... 29
*ANTIDOTES* .................................................................................................................................................................................................................................................................................................................. 29
*ANTIEMETICS* .......................................................................................................................................................................................................................................................................................................... 30
*ANTIFUNGALS* ........................................................................................................................................................................................................................................................................................................ 30
*ANTIHISTAMINES* ............................................................................................................................................................................................................................................................................................. 31
*ANTIHYPERLIPIDEMICS* ......................................................................................................................................................................................................................................................................... 32
*ANTIHYPERTENSIVES* ............................................................................................................................................................................................................................................................................... 33
*ANTI-INFECTIVE AGENTS - MISC.* ......................................................................................................................................................................................................................................... 36
*ANTIMALARIALS* ............................................................................................................................................................................................................................................................................................... 37
*ANTIMYASTHENIC AGENTS* ........................................................................................................................................................................................................................................................... 38
*ANTIMYASTHENIC/CHOLINERGIC AGENTS* ....................................................................................................................................................................................................... 38
*ANTIMYCOBACTERIAL AGENTS* ............................................................................................................................................................................................................................................ 38
*ANTINEOPLASTIC - BCL-2 INHIBITORS*** ................................................................................................................................................................................................................ 39
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* .............................................................................................................................................................................. 39
*ANTIPARKINSON AGENTS* ................................................................................................................................................................................................................................................................. 42
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* .................................................................................................................................................................................................................. 43
*ANTIRETROVIRALS ADJUVANTS*** ................................................................................................................................................................................................................................... 44
*ANTISEPTICS & DISINFECTANTS* ........................................................................................................................................................................................................................................... 44
*ANTIVIRALS* ............................................................................................................................................................................................................................................................................................................... 44
*ASSORTED CLASSES* .................................................................................................................................................................................................................................................................................... 47
*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB*** ........................................................................................................... 49
*BETA BLOCKERS* ................................................................................................................................................................................................................................................................................................ 49
*BILE ACID SYNTHESIS DISORDER AGENTS*** ................................................................................................................................................................................................. 50
*BIOLOGICALS MISC* ....................................................................................................................................................................................................................................................................................... 50
*CALCIUM CHANNEL BLOCKERS* ............................................................................................................................................................................................................................................. 50
*CARDIOTONICS* ..................................................................................................................................................................................................................................................................................................... 51
*CARDIOVASCULAR AGENTS - MISC.* ............................................................................................................................................................................................................................... 51
*CEPHALOSPORINS* ........................................................................................................................................................................................................................................................................................... 52
*CHEMICALS* ................................................................................................................................................................................................................................................................................................................. 52
*CONTRACEPTIVES* ........................................................................................................................................................................................................................................................................................... 52
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*CORTICOSTEROIDS* ........................................................................................................................................................................................................................................................................................ 57
*COUGH/COLD/ALLERGY* ....................................................................................................................................................................................................................................................................... 58
*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** ......................................................................................................................................................................... 60
*CYSTIC FIBROSIS AGENT - COMBINATIONS*** ............................................................................................................................................................................................... 60
*DERMATOLOGICALS* ................................................................................................................................................................................................................................................................................... 60
*DIAGNOSTIC PRODUCTS* ...................................................................................................................................................................................................................................................................... 70
*DIGESTIVE AIDS* .................................................................................................................................................................................................................................................................................................. 77
*DIRECT-ACTING P2Y12 INHIBITORS*** .......................................................................................................................................................................................................................... 77
*DIURETICS* ..................................................................................................................................................................................................................................................................................................................... 77
*ENDOCRINE AND METABOLIC AGENTS - MISC.* .......................................................................................................................................................................................... 78
*ESTROGENS* ................................................................................................................................................................................................................................................................................................................. 82
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB*** ............................................................................................................. 82
*FARNESOID X RECEPTOR (FXR) AGONISTS*** ................................................................................................................................................................................................. 83
*FLUOROQUINOLONES* ............................................................................................................................................................................................................................................................................... 83
*GASTROINTESTINAL AGENTS - MISC.* ........................................................................................................................................................................................................................... 83
*GENERAL ANESTHETICS* ...................................................................................................................................................................................................................................................................... 85
*GENITOURINARY AGENTS - MISCELLANEOUS* ............................................................................................................................................................................................. 85
*GOUT AGENTS* ........................................................................................................................................................................................................................................................................................................ 86
*HEMATOLOGICAL AGENTS - MISC.* ................................................................................................................................................................................................................................... 86
*HEMATOPOIETIC AGENTS* ................................................................................................................................................................................................................................................................. 88
*HEMOSTATICS* ........................................................................................................................................................................................................................................................................................................ 91
*HEPATITIS C AGENT - COMBINATIONS*** ............................................................................................................................................................................................................... 91
*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** ..................................................................................................................................................... 91
*HYPNOTICS* .................................................................................................................................................................................................................................................................................................................. 92
*HYPOPHOSPHATASIA (HPP) AGENTS*** ...................................................................................................................................................................................................................... 92
*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** ................................................................................................................................................................................... 92
*INTEGRIN RECEPTOR ANTAGONISTS*** ..................................................................................................................................................................................................................... 92
*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** ....................................................................................................................................................................................... 92
*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** ....................................................................................................................................................................................... 93
*LAXATIVES* .................................................................................................................................................................................................................................................................................................................. 93
*LEPTIN ANALOGUES*** ............................................................................................................................................................................................................................................................................ 93
*LHRH/GNRH AGONIST ANALOG COMBINATIONS*** ............................................................................................................................................................................ 93
*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** ............................................................................................................ 94
*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** ................................................................................................................................................... 94
*MACROLIDES* ............................................................................................................................................................................................................................................................................................................ 94
*MEDICAL DEVICES* ......................................................................................................................................................................................................................................................................................... 94
*MIGRAINE PRODUCTS* ........................................................................................................................................................................................................................................................................... 119
*MINERALS & ELECTROLYTES* ................................................................................................................................................................................................................................................. 120
*MOUTH/THROAT/DENTAL AGENTS* ............................................................................................................................................................................................................................... 121
*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** ................................................................................................................................................................. 122
*MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** ....................................................................................................... 122
*MULTIVITAMINS* ............................................................................................................................................................................................................................................................................................. 122
*MUSCULOSKELETAL THERAPY AGENTS* ............................................................................................................................................................................................................ 129
*NASAL AGENTS - SYSTEMIC AND TOPICAL* .................................................................................................................................................................................................... 130
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** ............................................................................................................ 130
*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** ............................................................................................................................. 130
*NEUROMUSCULAR AGENTS* ....................................................................................................................................................................................................................................................... 130
*OPHTHALMIC AGENTS* ......................................................................................................................................................................................................................................................................... 130
*OREXIN RECEPTOR ANTAGONISTS*** ........................................................................................................................................................................................................................ 135
*OTIC AGENTS* ........................................................................................................................................................................................................................................................................................................ 136
*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** ..................................................................................................................................................................... 136
*OXYTOCICS* .............................................................................................................................................................................................................................................................................................................. 136
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** ...................................................................................................................................................................... 136
*PASSIVE IMMUNIZING AGENTS* ........................................................................................................................................................................................................................................... 136
*PCSK9 INHIBITORS*** ............................................................................................................................................................................................................................................................................... 137
*PENICILLINS* ........................................................................................................................................................................................................................................................................................................... 138
*PHARMACEUTICAL ADJUVANTS* ....................................................................................................................................................................................................................................... 138
*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** ................................................................................................................................................... 138
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** .......................................................................................................................................................................................... 138
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** ...................................................................................................................................................... 139
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*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** .................................................................................................................................................... 139
*POTASSIUM REMOVING AGENTS*** ............................................................................................................................................................................................................................... 139
*PRENATAL MV & MINERALS W/FA WITHOUT IRON*** .................................................................................................................................................................. 139
*PROGESTINS* ........................................................................................................................................................................................................................................................................................................... 139
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* ................................................................................................................................... 139
*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** ..................................................................................................................................................... 141
*PULMONARY FIBROSIS AGENTS*** ................................................................................................................................................................................................................................. 141
*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** .................................................................................................. 141
*RESPIRATORY AGENTS - MISC.* ............................................................................................................................................................................................................................................. 142
*SEROTONIN MODULATORS*** .................................................................................................................................................................................................................................................. 142
*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** ........................................................................................................................................................ 142
*SINUS NODE INHIBITORS** ............................................................................................................................................................................................................................................................. 142
*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** ............................................................................................. 142
*TETRACYCLINES* ............................................................................................................................................................................................................................................................................................ 142
*THYROID AGENTS* ........................................................................................................................................................................................................................................................................................ 143
*ULCER DRUGS* ..................................................................................................................................................................................................................................................................................................... 144
*URINARY ANTI-INFECTIVES* ....................................................................................................................................................................................................................................................... 146
*URINARY ANTISPASMODICS* ..................................................................................................................................................................................................................................................... 146
*VAGINAL PRODUCTS* .............................................................................................................................................................................................................................................................................. 146
*VASOPRESSORS* ................................................................................................................................................................................................................................................................................................ 147
*VITAMINS* .................................................................................................................................................................................................................................................................................................................... 147
3
4
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Drug Status
CE = Copay Exception:
Available to some
members at no cost with a
prescription from your
provider when obtained at
an in-network pharmacy.
Certain limitations may
apply.
Tier 1 = Generic
Tier 2 = Preferred Brand
Tier 3 = Non-Preferred
Brand
Drug Details
# = Brand-name drug expected to
become available generically in the
near future. After the generic drug
becomes available, the brand-name
drug may be covered at a higher
non-preferred copay and/or added to
the Formulary Exclusion List. The
brand-name drug may also be subject
to precertification and/or step-therapy.
AL = Age Limit
LGC = Lowest Generic Copay
Applies
MA = Prior Authorization does not
apply to members residing in
Massachusetts.
N1 = Refer to member plan
documents for Erectile Dysfunction
use/coverage.
PA = Prior Authorization Applies
QL = Quantity Limit
Select OTC = Select OTC Program if
your pharmacy plan includes this
program you may have coverage for
products noted with a doctors
prescription. Please see your plan
benefit information for specific
coverage details.
SP = You may pay higher out of
pocket costs and may be required to
get these products at an Aetna
Specialty Pharmacy network provider,
like Aetna Specialty Pharmacy.
Specialty products are limited to a 30
day supply.
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
5
Drug Name
Drug Status
Drug Details
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS*
ADDERALL
Tier 3
QL
ADDERALL XR
Tier 3
QL
ADZENYS XR-ODT
Tier 3
QL
amphetamine salt combo
Tier 1
QL
amphetamine-dextroamphet er
Tier 1
QL
amphetamine-dextroamphetamine
Tier 1
QL
APTENSIO XR
Tier 3
QL
armodafinil
Tier 1
CAFCIT ORAL SOLUTION 60 MG/3ML
Tier 3
caffeine citrate oral
Tier 1
clonidine hcl er
Tier 1
QL
CONCERTA ORAL TABLET
EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG, 54
MG
Tier 3
QL
DAYTRANA
Tier 3
#; QL
DESOXYN
Tier 3
QL
DEXEDRINE ORAL CAPSULE EXTENDED
RELEASE 24 HOUR
Tier 3
QL
DEXEDRINE ORAL TABLET
Tier 1
QL
dexmethylphenidate hcl
Tier 1
QL
dexmethylphenidate hcl er
Tier 1
QL
dextroamphetamine sulfate er
Tier 1
QL
dextroamphetamine sulfate oral solution
Tier 1
QL
dextroamphetamine sulfate oral tablet
Tier 1
QL
DYANAVEL XR
Tier 3
QL
EVEKEO
Tier 3
PA; QL
FOCALIN
Tier 3
QL
FOCALIN XR
Tier 3
QL
guanfacine hcl er oral tablet extended release 24 hr*
1 mg
Tier 1
PA; QL
INTUNIV
Tier 3
PA; QL; AL
KAPVAY ORAL TABLET EXTENDED RELEASE
12 HR*
Tier 3
PA; QL; AL
METADATE CD
Tier 3
QL
METADATE ER ORAL TABLET
EXTENDEDRELEASE* 20 MG
Tier 1
QL
methamphetamine hcl
Tier 1
QL
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
6
Drug Name
Drug Status
Drug Details
METHYLIN ORAL SOLUTION 10 MG/5ML, 5
MG/5ML
Tier 3
QL
METHYLIN ORAL TABLET CHEWABLE
Tier 3
QL
methylphenidate hcl er (cd)
Tier 1
QL
methylphenidate hcl er (la) oral capsule extended
release 24 hour 20 mg, 30 mg, 40 mg
Tier 1
QL
methylphenidate hcl er oral tablet extended release 24
hr* 18 mg, 27 mg, 36 mg, 54 mg
Tier 1
QL
methylphenidate hcl er oral tablet extendedrelease*
18 mg, 20 mg, 27 mg, 36 mg, 54 mg
Tier 1
QL
methylphenidate hcl oral solution 10 mg/5ml, 5
mg/5ml
Tier 1
QL
methylphenidate hcl oral tablet
Tier 1
QL
methylphenidate hcl oral tablet chewable
Tier 1
QL
modafinil
Tier 1
NUVIGIL
Tier 3
#
PROCENTRA
Tier 3
QL
PROVIGIL
Tier 3
QUILLICHEW ER ORAL 20 MG, 30 MG, 40 MG
Tier 3
QL
QUILLIVANT XR
Tier 3
QL
RITALIN
Tier 3
QL
RITALIN LA ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40
MG, 60 MG
Tier 3
QL
RITALIN SR
Tier 3
QL
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18
MG, 25 MG, 40 MG, 60 MG, 80 MG
Tier 2
#; QL
VYVANSE
Tier 2
QL
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
QL
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG,
30 MG, 7.5 MG
Tier 3
QL
*ALTERNATIVE MEDICINES*
QUINZYME
Tier 3
*AMEBICIDES*
YODOXIN
Tier 2
*AMINOGLYCOSIDES*
BETHKIS
Tier 3
neo-fradin
Tier 3
neomycin sulfate oral
Tier 1
paromomycin sulfate oral
Tier 1
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
7
Drug Name
Drug Status
TOBI
Tier 3
TOBI PODHALER
Tier 2
tobramycin inhalation
Tier 1
Drug Details
*ANALGESICS - ANTI-INFLAMMATORY*
ACTEMRA
Tier 3
ANAPROX
Tier 3
ANAPROX DS
Tier 3
ARCALYST
Tier 3
ARTHROTEC ORAL TABLET DELAYED
RELEASE
Tier 3
CATAFLAM
Tier 3
CELEBREX
Tier 3
celecoxib oral
Tier 1
DAYPRO
Tier 3
diclofenac potassium
Tier 1
diclofenac sodium er
Tier 1
diclofenac sodium oral tablet delayed release 25 mg,
50 mg
Tier 1
diclofenac sodium oral tablet delayed release 75 mg
Tier 1
diclofenac-misoprostol oral tablet delayed release
Tier 1
DUEXIS
Tier 3
EC-NAPROSYN
Tier 3
ENBREL SUBCUTANEOUS*
Tier 2
PA; QL
ENBREL SUBCUTANEOUS* KIT
Tier 2
PA; QL
ENBREL SURECLICK SUBCUTANEOUS*
Tier 2
PA; QL
etodolac er
Tier 1
etodolac oral
Tier 1
FELDENE
Tier 3
fenoprofen calcium oral capsule
Tier 1
flurbiprofen oral
Tier 1
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS* 40 MG/0.8ML
Tier 2
PA
HUMIRA PEN SUBCUTANEOUS*
Tier 2
PA
HUMIRA PEN-CROHNS STARTER
SUBCUTANEOUS*
Tier 2
PA
HUMIRA PEN-PSORIASIS STARTER
SUBCUTANEOUS*
Tier 2
PA
HUMIRA SUBCUTANEOUS*
Tier 2
PA
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
LGC
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
8
PA
PA
LGC
Drug Name
Drug Status
Drug Details
ILARIS
Tier 2
PA
INDOCIN
Tier 3
INDOCIN ORAL
Tier 2
indomethacin er
Tier 1
indomethacin oral
Tier 1
ketoprofen er
Tier 1
ketoprofen oral
Tier 1
ketorolac tromethamine oral
Tier 1
KINERET SUBCUTANEOUS*
Tier 3
leflunomide oral
Tier 1
meclofenamate sodium oral
Tier 1
mefenamic acid oral
Tier 1
MELOXICAM COMFORT PAC
Tier 3
meloxicam oral tablet
Tier 1
MOBIC
Tier 3
nabumetone oral
Tier 1
NALFON ORAL CAPSULE 400 MG
Tier 3
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HR* 375 MG, 500 MG, 750 MG
Tier 3
NAPROSYN
Tier 3
naproxen dr
Tier 1
naproxen oral suspension
Tier 1
naproxen oral tablet
Tier 1
naproxen sodium er
Tier 1
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1
ORENCIA CLICKJECT
Tier 3
PA
ORENCIA INTRAVENOUS*
Tier 3
PA
ORENCIA SUBCUTANEOUS*
Tier 3
PA; QL
OTREXUP
Tier 2
oxaprozin
Tier 1
piroxicam oral
Tier 1
PONSTEL
Tier 3
RASUVO
Tier 2
RHEUMATREX ORAL TABLET 2.5 MG
Tier 3
RIDAURA
Tier 3
SIMPONI ARIA
Tier 2
PA
SIMPONI SUBCUTANEOUS*
Tier 3
PA; QL
SPRIX
Tier 3
PA
LGC
LGC
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
9
Drug Name
Drug Status
sulindac oral
Tier 1
TIVORBEX
Tier 3
tolmetin sodium oral capsule
Tier 1
tolmetin sodium oral tablet 200 mg
Tier 1
VIMOVO
Tier 3
VIVLODEX
Tier 3
VOLTAREN-XR
Tier 3
XELJANZ
Tier 3
PA; QL
XELJANZ XR
Tier 3
PA
ZIPSOR
Tier 3
ZORVOLEX
Tier 3
*ANALGESICS - NONNARCOTIC*
ALAGESIC LQ
Tier 3
ALLZITAL
Tier 3
aspirin oral tablet 325 mg
CE
aspirin oral tablet chewable
CE
aspirin oral tablet delayed release 325 mg, 81 mg
CE
BUPAP ORAL TABLET 50-300 MG
Tier 3
butalbital-acetaminophen
Tier 1
butalbital-apap-caffeine oral capsule
Tier 1
butalbital-apap-caffeine oral tablet 50-325-40 mg
Tier 1
butalbital-asa-caffeine
Tier 1
CAPACET
Tier 1
choline & mag trisalicylate oral tablet 1000 mg
Tier 1
choline-mag trisalicylate
Tier 1
diflunisal oral
Tier 1
duraxin
Tier 1
ED-FLEX
Tier 1
EQUAGESIC
Tier 3
ESGIC ORAL TABLET
Tier 3
FIORICET ORAL CAPSULE
Tier 3
FIORINAL
Tier 3
margesic
Tier 1
marten-tab
Tier 1
MINIPRIN LOW DOSE
CE
MST 600
Tier 3
PRIALT
Tier 3
salsalate oral
Tier 1
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
10
Drug Details
Drug Name
ST JOSEPH ASPIRIN ORAL TABLET DELAYED
RELEASE
Drug Status
Drug Details
CE
TENCON ORAL TABLET 50-325 MG
Tier 1
ZEBUTAL ORAL CAPSULE 50-325-40 MG
Tier 1
*ANALGESICS - OPIOID*
ABSTRAL
Tier 3
PA; QL
acetaminophen-codeine
Tier 1
acetaminophen-codeine #2
Tier 1
acetaminophen-codeine #3
Tier 1
acetaminophen-codeine #4
Tier 1
ACTIQ
Tier 3
apap-caff-dihydrocodeine oral capsule
Tier 1
ASCOMP-CODEINE
Tier 1
AVINZA
Tier 3
QL
BELBUCA
Tier 3
PA; QL
BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7
MG, 6.3-1 MG
Tier 1
PA; MA; QL
buprenorphine hcl sublingual tablet sublingual 2 mg,
8 mg
Tier 1
PA; MA; QL
buprenorphine hcl-naloxone hcl
Tier 1
PA; MA; QL
butalbital compound/codeine
Tier 1
butalbital-apap-caff-cod
Tier 1
butalbital-asa-caff-codeine
Tier 1
butorphanol tartrate nasal
Tier 1
QL
BUTRANS TRANSDERMAL PATCH WEEKLY 10
MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR,
7.5 MCG/HR
Tier 2
QL
CAPITAL/CODEINE
Tier 2
DEMEROL ORAL
Tier 3
DILAUDID ORAL
Tier 3
DOLOPHINE ORAL TABLET 5 MG
Tier 3
QL
DURAGESIC-100
Tier 3
QL
DURAGESIC-12
Tier 3
QL
DURAGESIC-25
Tier 3
QL
DURAGESIC-50
Tier 3
QL
DURAGESIC-75
Tier 3
QL
EMBEDA
Tier 3
QL
ENDOCET ORAL TABLET 10-325 MG, 5-325 MG,
7.5-325 MG
Tier 1
PA; QL
ENDODAN
Tier 1
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
11
Drug Name
Drug Status
Drug Details
EXALGO ORAL 12 MG, 16 MG, 8 MG
Tier 3
EXALGO ORAL 32 MG
Tier 3
fentanyl
Tier 1
QL
fentanyl citrate buccal
Tier 1
PA; QL
FENTORA BUCCAL TABLET 100 MCG, 200
MCG, 400 MCG, 600 MCG, 800 MCG
Tier 3
PA; QL
FIORICET/CODEINE ORAL CAPSULE
50-300-40-30 MG
Tier 3
FIORINAL/CODEINE #3
Tier 3
HYCET
Tier 3
hydrocodone-acetaminophen oral solution 10-325
mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325
mg/15ml
Tier 1
hydrocodone-acetaminophen oral tablet 10-300 mg,
10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325
mg
Tier 1
hydrocodone-ibuprofen
Tier 1
hydromorphone hcl oral
Tier 1
HYSINGLA ER
Tier 2
IBUDONE ORAL TABLET 10-200 MG
Tier 3
IBUDONE ORAL TABLET 5-200 MG
Tier 1
KADIAN ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG,
40 MG, 50 MG, 60 MG, 80 MG
Tier 3
QL
LAZANDA
Tier 3
PA; QL
levorphanol tartrate oral
Tier 1
LORCET
Tier 1
LORCET HD
Tier 1
LORTAB ORAL ELIXIR
Tier 3
LORTAB ORAL TABLET 10-325 MG, 5-325 MG,
7.5-325 MG
Tier 1
LORTAB ORAL TABLET 10-500 MG, 5-500 MG,
7.5-500 MG
Tier 3
meperidine hcl oral tablet
Tier 1
meperitab
Tier 1
METHADONE HCL INTENSOL
Tier 1
QL
methadone hcl oral concentrate
Tier 1
QL
methadone hcl oral solution 10 mg/5ml, 5 mg/5ml
Tier 1
QL
methadone hcl oral tablet
Tier 1
QL
methadone hcl oral tablet soluble
Tier 1
METHADOSE ORAL CONCENTRATE
Tier 3
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
12
QL
QL
Drug Name
Drug Status
Drug Details
METHADOSE ORAL TABLET 10 MG
Tier 1
METHADOSE ORAL TABLET SOLUBLE
Tier 3
METHADOSE SUGAR-FREE
Tier 3
morphine sulfate er beads
Tier 1
QL
morphine sulfate er oral capsule extended release 24
hour
Tier 1
QL
morphine sulfate er oral tablet extendedrelease*
Tier 1
QL
MS CONTIN ORAL TABLET
EXTENDEDRELEASE*
Tier 3
QL
NORCO
Tier 3
NUCYNTA
Tier 2
QL
NUCYNTA ER
Tier 2
QL
OPANA ER ORAL
Tier 3
QL
OPANA ORAL
Tier 3
OXAYDO
Tier 2
oxycodone hcl er oral 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
oxycodone hcl oral capsule
Tier 1
oxycodone hcl oral concentrate 100 mg/5ml
Tier 1
oxycodone hcl oral solution
Tier 1
oxycodone hcl oral tablet
Tier 1
oxycodone-acetaminophen oral solution
Tier 1
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1
oxycodone-aspirin oral tablet 4.8355-325 mg
Tier 1
oxycodone-ibuprofen
Tier 1
QL
OXYCONTIN ORAL
Tier 2
QL
oxymorphone hcl
Tier 1
oxymorphone hcl er
Tier 1
PERCOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 5-325 MG, 7.5-325 MG
Tier 3
PERCODAN
Tier 3
PRIMLEV
Tier 3
REPREXAIN ORAL TABLET 10-200 MG
Tier 1
REPREXAIN ORAL TABLET 2.5-200 MG, 5-200
MG
Tier 3
ROXICET ORAL SOLUTION
Tier 2
ROXICET ORAL TABLET 5-325 MG
Tier 1
ROXICODONE ORAL TABLET
Tier 3
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5
Tier 1
MG
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
QL
QL
PA; MA; #; QL
13
Drug Name
Drug Status
Drug Details
SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG
Tier 3
PA; MA; #; QL
SUBOXONE SUBLINGUAL TABLET
SUBLINGUAL
Tier 3
PA; MA; QL
SUBSYS SUBLINGUAL LIQUID† 100 MCG, 1200
(600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG,
400 MCG, 600 MCG, 800 MCG
Tier 3
PA; QL
SYNALGOS-DC
Tier 3
tramadol hcl er (biphasic)
Tier 1
tramadol hcl er oral capsule extended release 24 hour
100 mg, 200 mg, 300 mg
Tier 1
tramadol hcl er oral tablet extended release 24 hr*
Tier 1
tramadol hcl oral
Tier 1
tramadol-acetaminophen
Tier 1
TREZIX ORAL CAPSULE 320.5-30-16 MG
Tier 3
TYLENOL WITH CODEINE #3
Tier 3
TYLENOL WITH CODEINE #4
Tier 3
ULTRACET
Tier 3
ULTRAM
Tier 3
ULTRAM ER
Tier 3
VICODIN ES ORAL TABLET 7.5-300 MG
Tier 1
VICODIN HP ORAL TABLET 10-300 MG
Tier 1
VICODIN ORAL TABLET 5-300 MG
Tier 1
VICOPROFEN
Tier 3
XARTEMIS XR
Tier 3
XODOL
Tier 3
XTAMPZA ER
Tier 3
ZOHYDRO ER
Tier 3
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL
1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4
MG, 8.6-2.1 MG
Tier 3
*ANDROGENS-ANABOLIC*
ANADROL-50
Tier 3
ANDRODERM TRANSDERMAL PATCH 24 HR 2
MG/24HR, 4 MG/24HR
Tier 3
ANDROGEL PUMP TRANSDERMAL GEL 12.5
MG/ACT (1%)
Tier 3
ANDROGEL PUMP TRANSDERMAL GEL 20.25
MG/ACT (1.62%)
Tier 2
ANDROGEL TRANSDERMAL GEL 20.25
MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
Tier 2
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
14
QL
PA; MA; QL
Drug Name
Drug Status
ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM
(1%), 50 MG/5GM (1%)
Tier 3
ANDROID
Tier 3
ANDROXY
Tier 1
AXIRON
Tier 3
danazol oral
Tier 1
FORTESTA
Tier 3
methitest
Tier 3
methyltestosterone oral
Tier 1
NATESTO
Tier 3
OXANDRIN
Tier 3
oxandrolone oral
Tier 1
STRIANT
Tier 3
TESTIM
Tier 3
testosterone cypionate intramuscular* solution
Tier 1
testosterone enanthate intramuscular* solution
Tier 1
testosterone transdermal gel 10 mg/act (2%), 12.5
mg/act (1%), 50 mg/5gm (1%)
Tier 1
testosterone transdermal gel 25 mg/2.5gm (1%)
Tier 3
VOGELXO PUMP
Tier 3
VOGELXO TRANSDERMAL GEL 50 MG/5GM
(1%)
Tier 3
Drug Details
*ANORECTAL AGENTS*
ANALPRAM-HC LOTION 1-2.5 %
Tier 3
ANUSOL-HC CREAM
Tier 3
COLOCORT
Tier 1
CORTENEMA
Tier 3
CORTIFOAM
Tier 3
hydrocortisone ace-pramoxine cream 1-1 %
Tier 1
hydrocortisone enema
Tier 1
LIDAZONE HC CREAM
Tier 1
lidocaine-hydrocortisone ace cream
Tier 1
lidocaine-hydrocortisone ace kit 3-0.5 %, 3-1 %, 3-2.5
%
Tier 1
pramcort
Tier 1
PROCORT
Tier 3
PROCTOCARE-HC
Tier 1
PROCTOFOAM HC
Tier 3
PROCTO-PAK
Tier 1
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
15
Drug Name
Drug Status
PROCTOSOL HC
Tier 1
PROCTOZONE-HC
Tier 1
RECTIV
Tier 3
Drug Details
*ANTHELMINTICS*
ALBENZA
Tier 3
BILTRICIDE
Tier 2
EMVERM
Tier 1
ivermectin oral
Tier 1
STROMECTOL
Tier 3
*ANTIANGINAL AGENTS*
DILATRATE-SR
Tier 3
IMDUR
Tier 3
isoditrate er
Tier 1
ISORDIL TITRADOSE
Tier 3
isosorbide dinitrate er
Tier 1
isosorbide dinitrate oral
Tier 1
isosorbide dinitrate sublingual tablet sublingual 5 mg
Tier 1
isosorbide mononitrate
Tier 1
isosorbide mononitrate er
Tier 1
MINITRAN
Tier 1
NITRO-BID
Tier 3
NITRO-DUR
Tier 3
nitroglycerin er oral capsule extended release* 9 mg
Tier 1
nitroglycerin sublingual
Tier 1
nitroglycerin transdermal patch 24 hr
Tier 1
nitroglycerin translingual
Tier 1
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
NITROSTAT
Tier 2
NITRO-TIME ORAL CAPSULE EXTENDED
RELEASE* 9 MG
Tier 1
RANEXA
Tier 2
*ANTIANXIETY AGENTS*
alprazolam er
Tier 1
ALPRAZOLAM INTENSOL
Tier 3
alprazolam oral
Tier 1
alprazolam xr
Tier 1
ATIVAN ORAL
Tier 3
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
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16
#
Drug Name
Drug Status
buspirone hcl oral tablet 10 mg, 5 mg
Tier 1
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg
Tier 1
chlordiazepoxide hcl
Tier 1
clorazepate dipotassium
Tier 1
DIAZEPAM INTENSOL
Tier 3
diazepam oral solution
Tier 1
diazepam oral tablet
Tier 1
hydroxyzine hcl oral
Tier 1
hydroxyzine pamoate
Tier 1
hydroxyzine pamoate oral capsule 25 mg, 50 mg
Tier 1
LORAZEPAM INTENSOL
Tier 3
lorazepam oral tablet
Tier 1
meprobamate
Tier 1
NIRAVAM ORAL TABLET DISPERSIBLE 0.25
MG
Tier 3
oxazepam
Tier 1
TRANXENE-T
Tier 3
VALIUM
Tier 3
VISTARIL
Tier 3
XANAX
Tier 3
XANAX XR
Tier 3
Drug Details
LGC
*ANTIARRHYTHMICS*
amiodarone hcl oral
Tier 1
CORDARONE
Tier 3
disopyramide phosphate oral
Tier 1
dofetilide
Tier 1
flecainide acetate
Tier 1
mexiletine hcl oral
Tier 1
MULTAQ
Tier 2
NORPACE
Tier 3
NORPACE CR
Tier 3
PACERONE ORAL TABLET 100 MG, 200 MG, 400
MG
Tier 1
propafenone hcl
Tier 1
propafenone hcl er
Tier 1
quinidine gluconate er
Tier 1
quinidine sulfate oral
Tier 1
RYTHMOL ORAL TABLET 150 MG, 225 MG
Tier 3
RYTHMOL SR
Tier 3
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Drug Name
Drug Status
TIKOSYN
Tier 3
Drug Details
#
*ANTIASTHMATIC AND BRONCHODILATOR
AGENTS*
ACCOLATE
Tier 3
ADVAIR DISKUS
Tier 2
ADVAIR HFA
Tier 2
AEROSPAN
Tier 3
albuterol sulfate er
Tier 1
albuterol sulfate inhalation
Tier 1
albuterol sulfate oral
Tier 1
ALVESCO
Tier 3
ANORO ELLIPTA
Tier 2
ARCAPTA NEOHALER
Tier 3
ARNUITY ELLIPTA
Tier 3
ASMANEX 120 METERED DOSES
Tier 2
ASMANEX 14 METERED DOSES
Tier 2
ASMANEX 30 METERED DOSES
Tier 2
ASMANEX 60 METERED DOSES
Tier 2
ASMANEX 7 METERED DOSES
Tier 2
ASMANEX HFA
Tier 2
ATROVENT HFA
Tier 3
BEVESPI AEROSPHERE
Tier 3
BREO ELLIPTA
Tier 2
BROVANA
Tier 3
budesonide inhalation
Tier 1
COMBIVENT RESPIMAT
Tier 2
cromolyn sodium inhalation
Tier 1
DALIRESP
Tier 3
DIFIL-G FORTE
Tier 1
DULERA
Tier 2
ELIXOPHYLLIN
Tier 3
FLOVENT DISKUS
Tier 2
FLOVENT HFA
Tier 2
FORADIL AEROLIZER
Tier 2
INCRUSE ELLIPTA
Tier 2
ipratropium bromide inhalation
Tier 1
ipratropium-albuterol
Tier 1
levalbuterol hcl inhalation
Tier 1
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#
#
Drug Name
Drug Status
LUFYLLIN
Tier 3
metaproterenol sulfate oral
Tier 1
montelukast sodium oral
Tier 1
PERFOROMIST
Tier 3
PROAIR HFA
Tier 2
PROAIR RESPICLICK
Tier 2
PROVENTIL HFA
Tier 3
PULMICORT
Tier 3
PULMICORT FLEXHALER
Tier 3
QVAR INHALATION AEROSOL, SOLUTION 40
MCG/ACT, 80 MCG/ACT
Tier 2
SEEBRI NEOHALER
Tier 3
SEREVENT DISKUS
Tier 2
SINGULAIR
Tier 3
SPIRIVA HANDIHALER
Tier 2
SPIRIVA RESPIMAT
Tier 2
STIOLTO RESPIMAT
Tier 2
STRIVERDI RESPIMAT
Tier 3
SYMBICORT
Tier 2
terbutaline sulfate oral
Tier 1
THEO-24
Tier 2
THEOCHRON ORAL TABLET EXTENDED
RELEASE 12 HR* 100 MG, 200 MG, 300 MG
Tier 1
theophylline er
Tier 1
theophylline oral solution
Tier 1
TUDORZA PRESSAIR INHALATION AEROSOL
POWDER, BREATH ACTIVATED 400 MCG/ACT
Tier 3
UTIBRON NEOHALER
Tier 3
VENTOLIN HFA
Tier 2
VOSPIRE ER
Tier 3
XOLAIR
Tier 2
XOPENEX
Tier 3
XOPENEX CONCENTRATE
Tier 3
XOPENEX HFA
Tier 3
zafirlukast
Tier 1
ZYFLO
Tier 3
ZYFLO CR
Tier 3
Drug Details
#
QL
PA
*ANTICOAGULANTS*
acd formula a
Tier 3
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Drug Name
Drug Status
acd formula b
Tier 3
acd-a
Tier 3
ACD-A NOCLOT-50
Tier 3
anticoagulant cit dext soln a
Tier 3
ANTICOAGULANT COMPOUND
Tier 3
ARIXTRA
Tier 3
COUMADIN ORAL
Tier 3
ELIQUIS
Tier 2
enoxaparin sodium
Tier 1
fondaparinux sodium
Tier 1
FRAGMIN SUBCUTANEOUS* SOLUTION 10000
UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML,
18000 UNT/0.72ML, 2500 UNIT/0.2ML, 25000
UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML,
95000 UNIT/3.8ML
Tier 3
heparin sodium (porcine) injection
Tier 1
heparin sodium (porcine) pf
Tier 1
IPRIVASK
Tier 3
JANTOVEN
Tier 1
LOVENOX
Tier 3
PRADAXA
Tier 2
SAVAYSA
Tier 3
warfarin sodium oral
Tier 1
XARELTO
Tier 2
XARELTO STARTER PACK
Tier 2
*ANTICONVULSANTS*
APTIOM
Tier 3
BANZEL
Tier 3
BRIVIACT ORAL TABLET
Tier 3
carbamazepine er
Tier 1
carbamazepine oral
Tier 1
CARBATROL
Tier 2
CELONTIN
Tier 2
clonazepam oral
Tier 1
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
DEPAKOTE ER
Tier 3
DEPAKOTE SPRINKLES ORAL CAPSULE
SPRINKLE
Tier 3
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Drug Details
LGC
Drug Name
Drug Status
DIASTAT ACUDIAL
Tier 2
DIASTAT PEDIATRIC
Tier 2
DILANTIN
Tier 2
DILANTIN INFATABS
Tier 2
divalproex sodium er oral tablet extended release 24
hr*
Tier 1
divalproex sodium oral capsule sprinkle
Tier 1
divalproex sodium oral tablet delayed release
Tier 1
EPITOL
Tier 1
ethosuximide oral
Tier 1
felbamate
Tier 1
FELBATOL
Tier 3
FYCOMPA
Tier 3
gabapentin oral capsule
Tier 1
gabapentin oral solution 250 mg/5ml
Tier 1
gabapentin oral tablet
Tier 1
GABITRIL
Tier 3
KEPPRA
Tier 3
KEPPRA XR
Tier 3
KLONOPIN
Tier 3
LAMICTAL
Tier 3
LAMICTAL ODT
Tier 3
LAMICTAL STARTER
Tier 3
LAMICTAL XR
Tier 3
lamotrigine er
Tier 1
lamotrigine oral tablet
Tier 1
lamotrigine oral tablet chewable
Tier 1
lamotrigine oral tablet dispersible
Tier 1
levetiracetam er
Tier 1
levetiracetam oral
Tier 1
LYRICA
Tier 2
MYSOLINE
Tier 3
NEURONTIN
Tier 3
ONFI
Tier 3
oxcarbazepine
Tier 1
OXTELLAR XR
Tier 3
PEGANONE
Tier 3
PHENYTEK
Tier 2
Drug Details
LGC
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Drug Name
Drug Status
PHENYTOIN INFATABS
Tier 1
phenytoin oral
Tier 1
phenytoin sodium extended
Tier 1
POTIGA
Tier 3
primidone oral
Tier 1
QUDEXY XR
Tier 3
SABRIL
Tier 3
SPRITAM
Tier 3
STAVZOR
Tier 3
TEGRETOL
Tier 2
TEGRETOL-XR
Tier 3
tiagabine hcl
Tier 1
TOPAMAX
Tier 3
TOPAMAX SPRINKLE
Tier 3
TOPIRAGEN
Tier 1
topiramate oral
Tier 1
TRILEPTAL
Tier 3
TROKENDI XR
Tier 3
valproic acid oral
Tier 1
VIMPAT ORAL
Tier 3
ZARONTIN
Tier 3
ZONEGRAN
Tier 3
zonisamide oral
Tier 1
Drug Details
PA
#
*ANTIDEMENTIA AGENT
COMBINATIONS***
NAMZARIC
Tier 2
*ANTIDEPRESSANTS*
amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50
mg, 75 mg
Tier 1
amitriptyline hcl oral tablet 150 mg
Tier 1
amoxapine
Tier 1
ANAFRANIL
Tier 3
APLENZIN
Tier 3
BRINTELLIX
Tier 3
BUDEPRION SR ORAL TABLET EXTENDED
RELEASE 12 HR* 150 MG
Tier 1
BUDEPRION XL
Tier 1
bupropion hcl er (sr)
Tier 1
bupropion hcl er (xl)
Tier 1
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LGC
Drug Name
Drug Status
bupropion hcl oral
Tier 1
CELEXA ORAL TABLET
Tier 3
citalopram hydrobromide oral solution
Tier 1
citalopram hydrobromide oral tablet
Tier 1
clomipramine hcl oral
Tier 1
CYMBALTA
Tier 3
desipramine hcl oral
Tier 1
desvenlafaxine er
Tier 3
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg
Tier 1
doxepin hcl oral concentrate
Tier 1
duloxetine hcl oral
Tier 1
EFFEXOR XR
Tier 3
EMSAM
Tier 3
escitalopram oxalate
Tier 1
FETZIMA
Tier 3
FETZIMA TITRATION
Tier 3
fluoxetine hcl oral capsule
Tier 1
fluoxetine hcl oral capsule delayed release
Tier 1
fluoxetine hcl oral solution
Tier 1
fluoxetine hcl oral tablet 10 mg, 20 mg
Tier 1
fluoxetine hcl oral tablet 60 mg
Tier 3
fluvoxamine maleate
Tier 1
fluvoxamine maleate er
Tier 1
FORFIVO XL
Tier 3
imipramine hcl oral
Tier 1
imipramine pamoate
Tier 1
IRENKA
Tier 3
KHEDEZLA
Tier 3
LEXAPRO
Tier 3
LUVOX CR
Tier 3
maprotiline hcl
Tier 1
MARPLAN
Tier 3
mirtazapine oral tablet 15 mg, 30 mg, 45 mg
Tier 1
mirtazapine oral tablet dispersible
Tier 1
NARDIL
Tier 3
nefazodone hcl oral tablet 250 mg
Tier 3
nefazodone hcl oral tablet 50 mg
Tier 1
Drug Details
LGC
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Drug Name
Drug Status
NORPRAMIN
Tier 3
nortriptyline hcl oral capsule 10 mg, 25 mg
Tier 1
nortriptyline hcl oral capsule 50 mg, 75 mg
Tier 1
OLEPTRO
Tier 3
PAMELOR ORAL CAPSULE
Tier 3
PARNATE
Tier 3
paroxetine hcl er
Tier 1
paroxetine hcl oral tablet
Tier 1
PAXIL
Tier 3
PAXIL CR
Tier 3
PEXEVA
Tier 3
phenelzine sulfate oral
Tier 1
PRISTIQ
Tier 3
protriptyline hcl
Tier 1
PROZAC ORAL CAPSULE
Tier 3
PROZAC WEEKLY
Tier 3
REMERON
Tier 3
REMERON SOLTAB
Tier 3
SENTRAVIL PM-25
Tier 3
sertraline hcl oral concentrate
Tier 1
sertraline hcl oral tablet
Tier 1
SURMONTIL
Tier 3
TOFRANIL
Tier 3
TOFRANIL-PM
Tier 3
tranylcypromine sulfate
Tier 1
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg
Tier 1
trazodone hcl oral tablet 300 mg
Tier 1
venlafaxine hcl
Tier 1
venlafaxine hcl er oral capsule extended release 24
hour
Tier 1
venlafaxine hcl er oral tablet extended release 24 hr*
Tier 3
VIIBRYD
Tier 3
VIIBRYD STARTER PACK
Tier 3
VIVACTIL
Tier 3
WELLBUTRIN
Tier 3
WELLBUTRIN SR
Tier 3
WELLBUTRIN XL
Tier 3
ZOLOFT
Tier 3
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Drug Details
LGC
LGC
#
LGC
LGC
Drug Name
Drug Status
Drug Details
*ANTIDIABETICS*
acarbose
Tier 1
ACTOPLUS MET
Tier 3
ACTOPLUS MET XR
Tier 3
ACTOS
Tier 3
AFREZZA INHALATION POWDER 4 (30) & 8 (60)
UNIT, 4 (60) & 8 (30) UNIT, 4 (90) & 8 (90) UNIT, 4
UNIT, 8 (60)& 12 (30) UNIT
Tier 3
alogliptin benzoate
Tier 1
alogliptin-metformin hcl
Tier 1
alogliptin-pioglitazone
Tier 1
AMARYL
Tier 3
APIDRA
Tier 3
APIDRA SOLOSTAR SUBCUTANEOUS*
Tier 3
AVANDAMET ORAL TABLET 2-1000 MG, 2-500
MG, 4-500 MG
Tier 3
AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG,
4-4 MG, 8-4 MG
Tier 3
AVANDIA
Tier 3
BD GLUCOSE
Tier 3
BYDUREON SUBCUTANEOUS* 2 MG
Tier 3
BYDUREON SUBCUTANEOUS* SUSPENSION
RECONSTITUTED
Tier 3
BYETTA 10 MCG PEN SUBCUTANEOUS*
Tier 3
BYETTA 5 MCG PEN SUBCUTANEOUS*
Tier 3
chlorpropamide oral tablet 100 mg
Tier 1
cvs glucose bits
Tier 3
cvs glucose oral gel
Tier 1
cvs glucose oral tablet chewable
Tier 3
cvs glucose shot oral liquid† 15 gm/59ml
Tier 1
CYCLOSET
Tier 3
DEX4
Tier 3
DEX4 GLUCOSE ORAL GEL 15 GM/38GM
Tier 1
DEX4 GLUCOSE ORAL LIQUID†
Tier 3
DEX4 NATURALS
Tier 3
DEX4 POUCH PACK
Tier 3
DEX4 QUICK DISSOLVE GLUCOSE
Tier 3
DIABETA
Tier 3
drug mart glucose
Tier 3
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Drug Name
Drug Status
DUETACT
Tier 3
FARXIGA
Tier 3
glimepiride
Tier 1
LGC
glipizide er oral tablet extended release 24 hr* 10 mg,
5 mg
Tier 1
LGC
glipizide er oral tablet extended release 24 hr* 2.5 mg
Tier 1
glipizide oral
Tier 1
glipizide xl
Tier 1
glipizide-metformin hcl
Tier 1
GLUCAGEN HYPOKIT
Tier 3
GLUCAGON EMERGENCY
Tier 2
GLUCO BURST ORAL GEL
Tier 1
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
glucose oral gel
Tier 1
glucose oral tablet chewable
Tier 3
GLUCOTROL
Tier 3
GLUCOTROL XL
Tier 3
GLUCOVANCE
Tier 3
GLUMETZA
Tier 3
GLUTOSE 15
Tier 1
GLUTOSE 45
Tier 1
glyburide micronized oral tablet 1.5 mg
Tier 1
glyburide micronized oral tablet 3 mg, 6 mg
Tier 1
glyburide oral tablet 1.25 mg
Tier 1
glyburide oral tablet 2.5 mg, 5 mg
Tier 1
glyburide-metformin
Tier 1
GLYNASE
Tier 3
GLYSET
Tier 3
gnp glucose oral tablet chewable
Tier 3
gnp quick dissolve glucose
Tier 3
hm glucose
Tier 3
HUMALOG KWIKPEN SUBCUTANEOUS* 100
UNIT/ML, 200 UNIT/ML
Tier 2
HUMALOG MIX 50/50
Tier 2
HUMALOG MIX 50/50 KWIKPEN
SUBCUTANEOUS*
Tier 2
HUMALOG MIX 75/25
Tier 2
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Drug Details
LGC
#
LGC
LGC
Drug Name
Drug Status
HUMALOG MIX 75/25 KWIKPEN
SUBCUTANEOUS*
Tier 2
HUMULIN 70/30
Tier 2
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS*
Tier 2
HUMULIN N
Tier 2
HUMULIN N KWIKPEN SUBCUTANEOUS*
Tier 2
HUMULIN R
Tier 2
HUMULIN R U-500 (CONCENTRATED)
Tier 2
hy-vee glucose
Tier 3
INVOKANA
Tier 2
JANUMET
Tier 2
JANUMET XR
Tier 2
JANUVIA
Tier 2
JARDIANCE
Tier 2
JENTADUETO
Tier 2
JENTADUETO XR
Tier 2
KAZANO
Tier 3
KOMBIGLYZE XR ORAL TABLET EXTENDED
RELEASE 24 HR* 2.5-1000 MG
Tier 2
KOMBIGLYZE XR ORAL TABLET EXTENDED
RELEASE 24 HR* 5-1000 MG, 5-500 MG
Tier 2
KORLYM
Tier 3
kroger glucose oral tablet chewable
Tier 3
LANTUS
Tier 2
LANTUS SOLOSTAR SUBCUTANEOUS*
Tier 2
leader glucose
Tier 3
leader quick dissolve glucose
Tier 3
LEVEMIR
Tier 2
LEVEMIR FLEXPEN SUBCUTANEOUS*
Tier 2
longs glucose oral tablet chewable 4-6 gm-mg
Tier 3
meijer glucose oral tablet chewable 4-6 gm-mg
Tier 3
metformin hcl er (mod)
Tier 1
metformin hcl er (osm)
Tier 1
metformin hcl er oral tablet extended release 24 hr*
500 mg
Tier 1
metformin hcl er oral tablet extended release 24 hr*
750 mg
Tier 1
metformin hcl oral
Tier 1
miglitol
Tier 1
Drug Details
QL
QL
PA; QL
LGC
LGC
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Drug Name
Drug Status
ms quick dissolve glucose
Tier 3
nateglinide
Tier 1
NESINA
Tier 3
NOVOLIN 70/30
Tier 3
NOVOLIN 70/30 RELION
Tier 3
NOVOLIN N
Tier 3
NOVOLIN N RELION
Tier 3
NOVOLIN R
Tier 3
NOVOLIN R RELION
Tier 3
NOVOLOG
Tier 3
NOVOLOG FLEXPEN SUBCUTANEOUS*
Tier 3
NOVOLOG MIX 70/30
Tier 3
NOVOLOG MIX 70/30 FLEXPEN
SUBCUTANEOUS*
Tier 3
NOVOLOG PENFILL SUBCUTANEOUS*
Tier 3
ONGLYZA
Tier 2
OSENI
Tier 3
pioglitazone hcl
Tier 1
pioglitazone hcl-glimepiride
Tier 1
pioglitazone hcl-metformin hcl
Tier 1
PRANDIMET
Tier 3
PRANDIN
Tier 3
PRECOSE
Tier 3
preferred plus glucose
Tier 3
PROGLYCEM
Tier 3
px glucose
Tier 3
ra glucose oral gel
Tier 1
ra glucose oral tablet chewable
Tier 3
RELION GLUCOSE DRINK
Tier 1
RELION GLUCOSE ORAL GEL
Tier 1
RELION GLUCOSE ORAL TABLET CHEWABLE
Tier 3
repaglinide
Tier 1
repaglinide-metformin hcl
Tier 1
RIOMET
Tier 3
sm glucose
Tier 3
SMART SENSE GLUCOSE
Tier 3
STARLIX
Tier 3
SYMLINPEN 120 SUBCUTANEOUS*
Tier 2
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Drug Details
#
Drug Name
Drug Status
SYMLINPEN 60 SUBCUTANEOUS*
Tier 2
TANZEUM
Tier 3
tgt glucose oral tablet chewable 4-6 gm-mg
Tier 3
tolazamide oral tablet 250 mg
Tier 1
TOUJEO SOLOSTAR
Tier 2
TRADJENTA
Tier 2
TRESIBA FLEXTOUCH
Tier 2
TRULICITY
Tier 2
up & up glucose
Tier 3
value plus glucose oral gel
Tier 1
value plus glucose oral tablet chewable
Tier 3
VICTOZA SUBCUTANEOUS*
Tier 2
walgreens glucose
Tier 3
Drug Details
*ANTIDIARRHEALS*
diphenatol
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
lofene
Tier 1
LOMOTIL ORAL TABLET
Tier 3
LONOX
Tier 1
MOTOFEN
Tier 3
MYTESI
Tier 3
opium
Tier 1
*ANTIDOTES AND SPECIFIC ANTAGONISTS*
deferoxamine mesylate
Tier 1
DESFERAL
Tier 3
RADIOGARDASE
Tier 2
VISTOGARD
Tier 2
*ANTIDOTES*
CHEMET
Tier 2
deferoxamine mesylate
Tier 1
DESFERAL
Tier 3
EVZIO
Tier 3
EXJADE
Tier 3
PA
FERRIPROX
Tier 3
PA
JADENU
Tier 3
PA
naltrexone hcl oral
Tier 1
NARCAN
Tier 2
RADIOGARDASE
Tier 2
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Drug Name
Drug Status
REVIA
Tier 3
VISTOGARD
Tier 2
VIVITROL
Tier 3
Drug Details
*ANTIEMETICS*
AKYNZEO
Tier 3
ANTIVERT ORAL TABLET 50 MG
Tier 3
ANZEMET ORAL
Tier 3
CESAMET
Tier 3
DICLEGIS
Tier 3
dronabinol
Tier 1
EMEND ORAL CAPSULE
Tier 3
EMEND ORAL SUSPENSION RECONSTITUTED
Tier 2
granisetron hcl oral
Tier 1
GRANISOL
Tier 3
MARINOL
Tier 3
ondansetron
Tier 1
ondansetron hcl oral
Tier 1
SANCUSO
Tier 3
TIGAN ORAL
Tier 3
TRANSDERM-SCOP (1.5 MG)
Tier 3
trimethobenzamide hcl oral
Tier 1
VARUBI
Tier 3
ZOFRAN ODT
Tier 3
ZOFRAN ORAL
Tier 3
ZUPLENZ
Tier 3
*ANTIFUNGALS*
bio-statin oral capsule
Tier 3
bio-statin oral powder
Tier 1
CRESEMBA ORAL
Tier 3
DIFLUCAN
Tier 3
fluconazole oral
Tier 1
flucytosine oral
Tier 1
GRIFULVIN V ORAL TABLET
Tier 3
griseofulvin microsize oral
Tier 1
griseofulvin ultramicrosize
Tier 1
GRIS-PEG
Tier 3
itraconazole oral
Tier 1
ketoconazole oral
Tier 1
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#
Drug Name
Drug Status
LAMISIL ORAL
Tier 3
NOXAFIL
Tier 3
nystatin oral
Tier 1
ONMEL
Tier 3
SPORANOX
Tier 3
SPORANOX PULSEPAK
Tier 3
terbinafine hcl oral
Tier 1
VFEND
Tier 3
voriconazole oral
Tier 1
Drug Details
*ANTIHISTAMINES*
ALAVERT ORAL TABLET DISPERSIBLE
Tier 1
Select OTC
ALLEGRA ALLERGY
Tier 1
Select OTC
ALLEGRA ALLERGY CHILDRENS
Tier 1
Select OTC
allergy oral tablet dispersible
Tier 1
allergy relief oral syrup
Tier 1
allergy relief oral tablet dispersible
Tier 1
ARBINOXA ORAL SOLUTION
Tier 1
ARBINOXA ORAL TABLET
Tier 1
carbinoxamine maleate oral solution
Tier 1
carbinoxamine maleate oral tablet
Tier 1
cetirizine hcl oral tablet 10 mg
Tier 1
Select OTC
cetirizine hcl oral tablet chewable
Tier 1
Select OTC
childrens loratadine
Tier 1
Select OTC
CLARINEX
Tier 3
CLARINEX REDITABS
Tier 3
CLARITIN ORAL TABLET
Tier 1
Select OTC
CLARITIN ORAL TABLET CHEWABLE
Tier 1
Select OTC
clemastine fumarate oral tablet 2.68 mg
Tier 1
cyproheptadine hcl oral
Tier 1
desloratadine
Tier 1
DOXYTEX
Tier 3
ED-CHLOR-TAN
Tier 3
fexofenadine hcl childrens
Tier 1
Select OTC
fexofenadine hcl oral tablet 180 mg, 60 mg
Tier 1
Select OTC
KARBINAL ER ORAL LIQUID
EXTENDEDRELEASE*
Tier 3
kp cetirizine hcl oral tablet 5 mg
Tier 1
levocetirizine dihydrochloride oral
Tier 1
LGC
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Drug Name
Drug Status
Drug Details
loratadine allergy relief oral tablet dispersible
Tier 1
Select OTC
loratadine childrens
Tier 1
Select OTC
loratadine oral solution
Tier 1
loratadine oral syrup
Tier 1
loratadine oral tablet
Tier 1
LGC; Select OTC
PHENADOZ
Tier 1
AL
promethazine hcl oral
Tier 1
AL
promethazine hcl suppository 12.5 mg, 25 mg
Tier 1
AL
PROMETHEGAN SUPPOSITORY 12.5 MG, 25 MG
Tier 1
AL
PROMETHEGAN SUPPOSITORY 50 MG
Tier 3
AL
RESPA-BR
Tier 3
WAL-ITIN CHILDRENS
Tier 1
WAL-ITIN ORAL SYRUP
Tier 1
WAL-ITIN ORAL TABLET DISPERSIBLE
Tier 1
WAL-VERT
Tier 1
XYZAL
Tier 3
ZYRTEC ALLERGY ORAL TABLET
Tier 1
Select OTC
*ANTIHYPERLIPIDEMICS*
ADVICOR
Tier 3
ALTOPREV
Tier 3
ANTARA ORAL CAPSULE 30 MG, 90 MG
Tier 3
atorvastatin calcium oral
Tier 1
cholestyramine light
Tier 1
cholestyramine oral
Tier 1
COLESTID FLAVORED ORAL PACKET
Tier 3
COLESTID ORAL PACKET
Tier 3
COLESTID ORAL TABLET
Tier 3
colestipol hcl
Tier 1
CRESTOR
Tier 3
fenofibrate micronized
Tier 1
fenofibrate oral tablet
Tier 1
fenofibric acid oral capsule delayed release
Tier 1
FENOGLIDE
Tier 3
FIBRICOR
Tier 3
fluvastatin sodium
Tier 1
fluvastatin sodium er
Tier 1
gemfibrozil oral
Tier 1
LGC
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
Tier 3
PA; QL
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Drug Name
Drug Status
Drug Details
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60
MG
Tier 3
PA
KYNAMRO SUBCUTANEOUS*
Tier 3
PA
LESCOL
Tier 3
LESCOL XL
Tier 3
LIPITOR
Tier 3
LIPOFEN
Tier 3
LIPTRUZET
Tier 2
LIVALO
Tier 3
LOFIBRA
Tier 3
LOPID
Tier 3
lovastatin
Tier 1
LOVAZA
Tier 3
MEVACOR ORAL TABLET 20 MG, 40 MG
Tier 3
micronized colestipol hcl
Tier 1
niacin er (antihyperlipidemic)
Tier 1
NIACOR
Tier 3
NIASPAN
Tier 3
omega-3-acid ethyl esters
Tier 1
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80
MG
Tier 3
pravastatin sodium
Tier 1
PREVALITE
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT ORAL POWDER
Tier 3
rosuvastatin calcium
Tier 1
SIMCOR
Tier 3
simvastatin oral
Tier 1
TRICOR
Tier 3
TRIGLIDE ORAL TABLET 160 MG
Tier 3
TRILIPIX
Tier 3
VASCEPA ORAL CAPSULE 1 GM
Tier 2
VYTORIN
Tier 3
#
WELCHOL
Tier 3
#
ZETIA
Tier 2
#
ZOCOR
Tier 3
LGC
LGC
QL
LGC
*ANTIHYPERTENSIVES*
ACCUPRIL
Tier 3
ACCURETIC
Tier 3
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Drug Name
Drug Status
Drug Details
ACEON ORAL TABLET 4 MG, 8 MG
Tier 3
ALTACE ORAL CAPSULE
Tier 3
amlodipine besy-benazepril hcl
Tier 1
amlodipine besylate-valsartan
Tier 1
amlodipine-valsartan-hctz
Tier 1
AMTURNIDE
Tier 3
ATACAND
Tier 3
ATACAND HCT
Tier 3
atenolol-chlorthalidone
Tier 1
AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5
MG
Tier 3
AVAPRO
Tier 3
AZOR
Tier 3
#
benazepril hcl oral
Tier 1
LGC
benazepril-hydrochlorothiazide
Tier 1
LGC
BENICAR
Tier 3
#
BENICAR HCT
Tier 3
#
bisoprolol-hydrochlorothiazide
Tier 1
LGC
candesartan cilexetil
Tier 1
candesartan cilexetil-hctz
Tier 1
captopril oral
Tier 1
CARDURA
Tier 3
CATAPRES
Tier 3
CATAPRES-TTS-1
Tier 3
CATAPRES-TTS-2
Tier 3
CATAPRES-TTS-3
Tier 3
clonidine hcl oral
Tier 1
clonidine hcl transdermal
Tier 1
CLORPRES
Tier 3
CORZIDE
Tier 3
COZAAR ORAL TABLET 25 MG, 50 MG
Tier 3
DEMSER
Tier 3
DIBENZYLINE
Tier 3
DIOVAN
Tier 3
DIOVAN HCT
Tier 3
doxazosin mesylate
Tier 1
DUTOPROL
Tier 3
EDARBI
Tier 3
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LGC
LGC
LGC
PA
LGC
Drug Name
Drug Status
Drug Details
EDARBYCLOR
Tier 3
enalapril maleate oral
Tier 1
LGC
enalapril-hydrochlorothiazide
Tier 1
LGC
EPANED
Tier 3
AL
eplerenone
Tier 1
eprosartan mesylate
Tier 1
EXFORGE
Tier 3
EXFORGE HCT
Tier 3
fosinopril sodium
Tier 1
fosinopril sodium-hctz
Tier 1
guanfacine hcl oral
Tier 1
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg
Tier 1
hydralazine hcl oral tablet 25 mg
Tier 1
HYZAAR
Tier 3
INSPRA
Tier 3
irbesartan
Tier 1
irbesartan-hydrochlorothiazide
Tier 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
lisinopril oral tablet 30 mg, 40 mg
Tier 1
lisinopril-hydrochlorothiazide
Tier 1
LOPRESSOR HCT ORAL TABLET 100-25 MG,
50-25 MG
Tier 3
losartan potassium
Tier 1
LGC
losartan potassium-hctz
Tier 1
LGC
LOTENSIN HCT ORAL TABLET 10-12.5 MG,
20-12.5 MG, 20-25 MG
Tier 3
LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG
Tier 3
LOTREL
Tier 3
MAVIK
Tier 3
methyldopa oral
Tier 1
metoprolol-hydrochlorothiazide
Tier 1
MICARDIS
Tier 3
MICARDIS HCT
Tier 3
MINIPRESS
Tier 3
minoxidil oral
Tier 1
moexipril hcl
Tier 1
moexipril-hydrochlorothiazide
Tier 1
nadolol-bendroflumethiazide
Tier 1
LGC
LGC
LGC
perindopril erbumine
Tier 1
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Drug Name
Drug Status
phenoxybenzamine hcl oral
Tier 1
prazosin hcl oral
Tier 1
PRESTALIA
Tier 3
PRINIVIL
Tier 3
QBRELIS
Tier 3
quinapril hcl
Tier 1
quinapril-hydrochlorothiazide
Tier 1
ramipril
Tier 1
TARKA
Tier 3
TEKAMLO
Tier 3
TEKTURNA
Tier 3
TEKTURNA HCT
Tier 3
telmisartan
Tier 1
telmisartan-hctz
Tier 1
TENEX
Tier 3
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
terazosin hcl oral
Tier 1
TEVETEN HCT
Tier 3
TEVETEN ORAL TABLET 600 MG
Tier 3
trandolapril
Tier 1
trandolapril-verapamil hcl er
Tier 1
TRIBENZOR
Tier 3
UNIRETIC ORAL TABLET 15-12.5 MG
Tier 3
UNIVASC
Tier 3
valsartan
Tier 1
valsartan-hydrochlorothiazide
Tier 1
VASERETIC
Tier 3
VASOTEC
Tier 3
VECAMYL
Tier 3
ZESTORETIC
Tier 3
ZESTRIL
Tier 3
ZIAC
Tier 3
Drug Details
PA
LGC
#
PA; QL
*ANTI-INFECTIVE AGENTS - MISC.*
ALINIA
Tier 3
BACTRIM
Tier 3
BACTRIM DS
Tier 3
CAYSTON
Tier 3
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#
Drug Name
Drug Status
CLEOCIN ORAL CAPSULE 150 MG, 300 MG
Tier 3
CLEOCIN ORAL SOLUTION RECONSTITUTED
Tier 3
clindamycin hcl oral
Tier 1
clindamycin palmitate hcl
Tier 1
colistimethate sodium injection
Tier 1
COLY-MYCIN M
Tier 3
dapsone oral
Tier 1
FIRST-VANCOMYCIN 25
Tier 3
FIRST-VANCOMYCIN 50
Tier 3
FLAGYL ER
Tier 3
FLAGYL ORAL TABLET
Tier 3
IMPAVIDO
Tier 3
KETEK
Tier 3
linezolid oral
Tier 1
MEPRON
Tier 3
metronidazole oral tablet
Tier 1
NEBUPENT
Tier 2
PRIMSOL
Tier 3
SIVEXTRO ORAL
Tier 3
smz-tmp ds
Tier 1
sulfamethoxazole-trimethoprim oral suspension
200-40 mg/5ml
Tier 1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg
Tier 1
SULFATRIM PEDIATRIC
Tier 1
TINDAMAX
Tier 3
tinidazole oral
Tier 1
trimethoprim oral
Tier 1
VANCOCIN HCL
Tier 3
vancomycin hcl oral
Tier 1
XIFAXAN ORAL TABLET 200 MG
Tier 3
XIFAXAN ORAL TABLET 550 MG
Tier 2
ZYVOX ORAL SUSPENSION RECONSTITUTED
Tier 2
ZYVOX ORAL TABLET
Tier 3
Drug Details
LGC
#
*ANTIMALARIALS*
ARALEN
Tier 3
atovaquone-proguanil hcl oral tablet 250-100 mg
Tier 1
chloroquine phosphate oral
Tier 1
COARTEM
Tier 3
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Drug Name
Drug Status
DARAPRIM
Tier 2
hydroxychloroquine sulfate oral
Tier 1
MALARONE
Tier 3
mefloquine hcl
Tier 1
PLAQUENIL
Tier 3
primaquine phosphate oral
Tier 1
QUALAQUIN
Tier 3
quinine sulfate oral
Tier 1
*ANTIMYASTHENIC AGENTS*
guanidine hcl oral
Tier 1
MESTINON ORAL SYRUP
Tier 2
MESTINON ORAL TABLET
Tier 3
MESTINON ORAL TABLET
EXTENDEDRELEASE*
Tier 2
MYTELASE
Tier 3
pyridostigmine bromide er
Tier 1
pyridostigmine bromide oral
Tier 1
*ANTIMYASTHENIC/CHOLINERGIC
AGENTS*
guanidine hcl oral
Tier 1
MESTINON ORAL SYRUP
Tier 2
MESTINON ORAL TABLET
Tier 3
MESTINON ORAL TABLET
EXTENDEDRELEASE*
Tier 2
MYTELASE
Tier 3
pyridostigmine bromide er
Tier 1
pyridostigmine bromide oral
Tier 1
*ANTIMYCOBACTERIAL AGENTS*
cycloserine oral
Tier 1
ethambutol hcl oral
Tier 1
isoniazid oral tablet
Tier 1
MYAMBUTOL
Tier 3
PASER
Tier 3
PRIFTIN
Tier 3
pyrazinamide oral
Tier 1
rifabutin
Tier 1
RIFADIN ORAL
Tier 3
RIFAMATE
Tier 3
rifampin oral
Tier 1
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Drug Details
Drug Name
Drug Status
RIFATER
Tier 3
SIRTURO
Tier 3
TRECATOR
Tier 3
Drug Details
PA; QL
*ANTINEOPLASTIC - BCL-2 INHIBITORS***
VENCLEXTA
Tier 3
PA
VENCLEXTA STARTING PACK
Tier 3
PA; QL
ACTIMMUNE
Tier 3
PA
AFINITOR
Tier 3
PA; QL
AFINITOR DISPERZ
Tier 3
PA; QL
ALECENSA
Tier 3
PA
ALFERON N
Tier 3
ALKERAN ORAL
Tier 2
anastrozole oral
Tier 1
ARIMIDEX
Tier 3
AROMASIN
Tier 3
bexarotene
Tier 1
bicalutamide
Tier 1
BOSULIF
Tier 3
PA; QL
CABOMETYX
Tier 3
PA
capecitabine
Tier 1
PA
CAPRELSA
Tier 3
PA; QL
CASODEX
Tier 3
COMETRIQ (100 MG DAILY DOSE)
Tier 3
PA; QL
COMETRIQ (140 MG DAILY DOSE)
Tier 3
PA; QL
COMETRIQ (60 MG DAILY DOSE)
Tier 3
PA; QL
COTELLIC
Tier 3
PA
cyclophosphamide oral capsule
Tier 1
ELIGARD
Tier 3
EMCYT
Tier 2
ERIVEDGE
Tier 3
etoposide oral
Tier 1
exemestane
Tier 1
FARESTON
Tier 3
FARYDAK
Tier 3
PA; QL
FASLODEX INTRAMUSCULAR* SOLUTION 250
MG/5ML
Tier 3
PA
*ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES*
PA
PA; QL
FEMARA
Tier 3
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Drug Name
Drug Status
FIRMAGON
Tier 3
flutamide
Tier 1
GILOTRIF
Tier 3
PA; QL
GLEEVEC
Tier 3
PA; #
GLEOSTINE
Tier 3
HEXALEN
Tier 2
HYCAMTIN ORAL
Tier 3
hydroxyurea oral
Tier 1
ICLUSIG
Tier 3
PA; QL
imatinib mesylate
Tier 1
PA
IMBRUVICA
Tier 3
PA; QL
INLYTA
Tier 3
PA; QL
INTRON A
Tier 2
PA
IRESSA
Tier 3
PA
JAKAFI
Tier 3
PA; QL
LENVIMA 10 MG DAILY DOSE
Tier 3
PA; QL
LENVIMA 14 MG DAILY DOSE
Tier 3
PA; QL
LENVIMA 18 MG DAILY DOSE
Tier 3
PA
LENVIMA 20 MG DAILY DOSE
Tier 3
PA; QL
LENVIMA 24 MG DAILY DOSE
Tier 3
PA; QL
LENVIMA 8 MG DAILY DOSE
Tier 3
PA
letrozole oral
Tier 1
leucovorin calcium oral tablet 25 mg, 5 mg
Tier 1
LEUKERAN
Tier 2
leuprolide acetate injection
Tier 1
lomustine
Tier 1
LONSURF
Tier 3
PA
LUPRON DEPOT
Tier 2
PA; #
LYSODREN
Tier 3
MATULANE
Tier 2
MEGACE ORAL
Tier 3
megestrol acetate oral suspension 40 mg/ml, 400
mg/10ml, 800 mg/20ml
Tier 1
megestrol acetate oral tablet
Tier 1
MEKINIST
Tier 3
mercaptopurine oral
Tier 1
MESNEX ORAL
Tier 3
methotrexate oral
Tier 1
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Drug Details
PA
PA; QL
PA
PA; QL
Drug Name
Drug Status
MYLERAN
Tier 2
NEXAVAR
Tier 3
NILANDRON
Tier 2
nilutamide
Tier 1
NINLARO
Tier 3
PA
ODOMZO
Tier 3
PA
POMALYST
Tier 3
PA; QL
PURINETHOL
Tier 3
PURIXAN
Tier 3
SOLTAMOX
Tier 3
SPRYCEL
Tier 3
PA; QL
STIVARGA
Tier 3
PA; QL
SUTENT
Tier 2
PA; QL
SYLATRON SUBCUTANEOUS* KIT 200 MCG,
300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG
Tier 3
PA
TABLOID
Tier 2
TAFINLAR
Tier 3
PA; QL
TAGRISSO
Tier 3
PA
tamoxifen citrate oral
Drug Details
PA; QL
PA
CE
TARCEVA
Tier 2
PA; QL
TARGRETIN ORAL
Tier 3
TASIGNA
Tier 3
PA; QL
TEMODAR ORAL
Tier 3
PA; QL
temozolomide
Tier 1
PA
TRELSTAR
Tier 3
PA; #
TRELSTAR MIXJECT
Tier 3
PA; #
tretinoin oral
Tier 1
TREXALL
Tier 3
TYKERB
Tier 3
PA; QL
VANTAS
Tier 3
PA
VOTRIENT
Tier 3
PA; QL
XALKORI
Tier 3
PA; QL
XELODA
Tier 3
PA; QL
XTANDI
Tier 3
PA; QL
ZELBORAF
Tier 3
PA; QL
ZOLADEX
Tier 3
PA
ZOLINZA
Tier 3
PA; QL
ZYKADIA
Tier 3
PA
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Drug Name
ZYTIGA
Drug Status
Tier 2
Drug Details
PA; QL
*ANTIPARKINSON AGENTS*
amantadine hcl oral capsule
Tier 1
amantadine hcl oral syrup
Tier 1
AZILECT
Tier 2
#
benztropine mesylate oral
Tier 1
LGC
bromocriptine mesylate oral
Tier 1
carbidopa oral
Tier 1
carbidopa-levodopa
Tier 1
carbidopa-levodopa er oral tablet extendedrelease*
25-100 mg, 50-200 mg
Tier 1
carbidopa-levodopa-entacapone
Tier 1
COMTAN
Tier 3
ELDEPRYL
Tier 3
entacapone
Tier 1
LODOSYN
Tier 3
MIRAPEX
Tier 3
MIRAPEX ER ORAL TABLET EXTENDED
RELEASE 24 HR* 0.375 MG, 0.75 MG, 1.5 MG, 3
MG, 4.5 MG
Tier 3
MIRAPEX ER ORAL TABLET EXTENDED
RELEASE 24 HR* 2.25 MG, 3.75 MG
Tier 3
NEUPRO
Tier 3
PARLODEL ORAL CAPSULE
Tier 3
pramipexole dihydrochloride
Tier 1
pramipexole dihydrochloride er
Tier 1
REQUIP
Tier 3
REQUIP XL
Tier 3
ropinirole hcl
Tier 1
ropinirole hcl er
Tier 1
RYTARY
Tier 3
selegiline hcl oral
Tier 1
SINEMET
Tier 3
SINEMET CR
Tier 3
STALEVO 100
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
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#
Drug Name
Drug Status
STALEVO 75
Tier 3
TASMAR ORAL TABLET 100 MG
Tier 3
tolcapone
Tier 1
trihexyphenidyl hcl oral elixir
Tier 1
trihexyphenidyl hcl oral tablet 2 mg
Tier 1
trihexyphenidyl hcl oral tablet 5 mg
Tier 1
ZELAPAR
Tier 3
Drug Details
LGC
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
ABILIFY DISCMELT
Tier 3
ABILIFY MAINTENA INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 300 MG, 400 MG
Tier 3
ABILIFY ORAL
Tier 3
aripiprazole
Tier 1
chlorpromazine hcl oral
Tier 1
clozapine oral tablet
Tier 1
clozapine oral tablet dispersible 150 mg, 200 mg
Tier 1
CLOZARIL
Tier 3
COMPAZINE
Tier 1
COMPRO
Tier 1
EQUETRO
Tier 3
FANAPT
Tier 3
FANAPT TITRATION PACK
Tier 3
FAZACLO
Tier 3
fluphenazine hcl oral tablet
Tier 1
GEODON ORAL
Tier 3
haloperidol lactate oral
Tier 1
haloperidol oral
Tier 1
INVEGA
Tier 3
LATUDA
Tier 2
lithium
Tier 1
lithium carbonate er
Tier 1
lithium carbonate oral
Tier 1
LITHOBID
Tier 3
loxapine succinate oral
Tier 1
molindone hcl
Tier 1
NUPLAZID
Tier 3
olanzapine oral
Tier 1
paliperidone er
Tier 1
#
PA
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Drug Name
Drug Status
perphenazine oral
Tier 1
prochlorperazine
Tier 1
prochlorperazine maleate oral
Tier 1
quetiapine fumarate
Tier 1
REXULTI
Tier 3
RISPERDAL
Tier 3
RISPERDAL M-TAB
Tier 3
risperidone
Tier 1
RISPERIDONE M-TAB
Tier 1
SAPHRIS
Tier 3
SEROQUEL
Tier 3
SEROQUEL XR
Tier 2
thioridazine hcl oral
Tier 1
thiothixene oral
Tier 1
trifluoperazine hcl oral
Tier 1
VERSACLOZ
Tier 3
VRAYLAR
Tier 3
ziprasidone hcl
Tier 1
ZYPREXA ORAL
Tier 3
ZYPREXA ZYDIS
Tier 3
Drug Details
#
*ANTIRETROVIRALS ADJUVANTS***
TYBOST
Tier 3
*ANTISEPTICS & DISINFECTANTS*
BUCALSEP EXTERNAL SOLUTION
Tier 3
FORMADON
Tier 1
formaldehyde external solution 10 %
Tier 1
FORMA-RAY
Tier 3
KERR TRIPLE DYE SWABS
Tier 3
*ANTIVIRALS*
abacavir sulfate
Tier 1
abacavir-lamivudine-zidovudine
Tier 1
acyclovir oral capsule
Tier 1
acyclovir oral suspension
Tier 1
acyclovir oral tablet 400 mg
Tier 1
acyclovir oral tablet 800 mg
Tier 1
adefovir dipivoxil
Tier 1
APTIVUS
Tier 2
ATRIPLA
Tier 2
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LGC
LGC
Drug Name
Drug Status
Drug Details
BARACLUDE
Tier 3
cidofovir intravenous*
Tier 1
COMBIVIR
Tier 3
COMPLERA
Tier 2
COPEGUS
Tier 3
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 3
CYTOVENE
Tier 3
DAKLINZA
Tier 3
PA
DESCOVY
Tier 3
LGC
didanosine
Tier 1
EDURANT
Tier 3
EMTRIVA
Tier 2
entecavir
Tier 1
EPIVIR
Tier 3
EPIVIR HBV
Tier 2
EPZICOM
Tier 3
EVOTAZ
Tier 3
famciclovir oral
Tier 1
FAMVIR
Tier 3
FLUMADINE
Tier 3
FOSCAVIR INTRAVENOUS* SOLUTION 24
MG/ML
Tier 3
FUZEON SUBCUTANEOUS* KIT
Tier 3
PA
FUZEON SUBCUTANEOUS* SOLUTION
RECONSTITUTED
Tier 3
PA; #
ganciclovir sodium
Tier 1
GENVOYA
Tier 3
HEPSERA
Tier 3
INFERGEN
Tier 3
INTELENCE
Tier 3
INVIRASE
Tier 3
ISENTRESS
Tier 2
KALETRA ORAL SOLUTION
Tier 2
#
KALETRA ORAL TABLET
Tier 2
#
lamivudine
Tier 1
lamivudine-zidovudine
Tier 1
LEXIVA
Tier 2
MODERIBA 1200 DOSE PACK
Tier 3
QL
#
PA
#
MODERIBA 800 DOSE PACK
Tier 3
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Drug Name
Drug Status
Drug Details
MODERIBA ORAL
Tier 3
moderiba oral tablet
Tier 1
nevirapine
Tier 1
nevirapine er
Tier 1
NORVIR ORAL CAPSULE
Tier 2
NORVIR ORAL SOLUTION
Tier 2
NORVIR ORAL TABLET
Tier 2
ODEFSEY
Tier 3
OLYSIO
Tier 3
PA; QL
PEGASYS PROCLICK
Tier 2
PA
PEGASYS SUBCUTANEOUS* KIT
Tier 3
PA
PEGASYS SUBCUTANEOUS* SOLUTION
Tier 2
PA
PEGINTRON
Tier 3
PA
PEG-INTRON
Tier 3
PA
PEG-INTRON REDIPEN
Tier 3
PA
PEG-INTRON REDIPEN PAK 4
Tier 3
PA
PREZCOBIX
Tier 2
PREZISTA ORAL SUSPENSION
Tier 2
PREZISTA ORAL TABLET 150 MG, 400 MG, 600
MG, 75 MG, 800 MG
Tier 2
REBETOL
Tier 3
RELENZA DISKHALER
Tier 3
RESCRIPTOR
Tier 3
RETROVIR ORAL
Tier 3
REYATAZ ORAL CAPSULE
Tier 2
REYATAZ ORAL PACKET
Tier 2
ribasphere
Tier 1
RIBASPHERE RIBAPAK ORAL TABLET 200 &
400 MG
Tier 3
ribasphere ribapak oral tablet 400 & 600 mg, 400 mg,
600 mg
Tier 1
ribatab
Tier 1
ribavirin oral capsule
Tier 1
ribavirin oral tablet 200 mg
Tier 1
rimantadine hcl
Tier 1
SELZENTRY
Tier 3
SOVALDI
Tier 2
stavudine
Tier 1
STRIBILD
Tier 3
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#
#
PA; QL
Drug Name
Drug Status
Drug Details
SUSTIVA
Tier 2
#
TAMIFLU ORAL CAPSULE
Tier 3
#
TAMIFLU ORAL SUSPENSION
RECONSTITUTED 6 MG/ML
Tier 3
#
TIVICAY
Tier 2
TRIUMEQ
Tier 2
TRIZIVIR
Tier 3
TRUVADA ORAL TABLET 100-150 MG, 133-200
MG, 167-250 MG
Tier 2
TRUVADA ORAL TABLET 200-300 MG
Tier 2
TYZEKA
Tier 3
valacyclovir hcl oral
Tier 1
VALCYTE
Tier 3
PA
valganciclovir hcl oral solution reconstituted
Tier 2
PA
valganciclovir hcl oral tablet
Tier 1
PA; QL
VALTREX
Tier 3
VICTRELIS
Tier 3
VIDEX
Tier 2
VIDEX EC
Tier 3
VIRACEPT ORAL TABLET
Tier 3
VIRAMUNE
Tier 3
VIRAMUNE XR
Tier 3
VIRAZOLE
Tier 3
VIREAD
Tier 2
VISTIDE
Tier 3
VITEKTA
Tier 2
ZERIT
Tier 3
ZIAGEN ORAL SOLUTION
Tier 2
ZIAGEN ORAL TABLET
Tier 3
zidovudine
Tier 1
ZOVIRAX ORAL CAPSULE
Tier 3
ZOVIRAX ORAL SUSPENSION
Tier 3
ZOVIRAX ORAL TABLET 800 MG
Tier 3
PA
PA; QL
#
*ASSORTED CLASSES*
ARGYLE STERILE WATER
Tier 1
ASTAGRAF XL
Tier 3
ATGAM
Tier 3
AZASAN
Tier 3
azathioprine oral
Tier 1
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Drug Name
Drug Status
BENLYSTA
Tier 3
CELLCEPT
Tier 3
CUPRIMINE ORAL CAPSULE 250 MG
Tier 3
cyclosporine intravenous*
Tier 1
cyclosporine modified
Tier 1
cyclosporine oral capsule
Tier 1
DEPEN TITRATABS
Tier 2
ENVARSUS XR
Tier 3
gengraf oral capsule 100 mg, 25 mg
Tier 1
GENGRAF ORAL CAPSULE 50 MG
Tier 1
gengraf oral solution
Tier 1
HECORIA
Tier 2
IMURAN
Tier 3
kalexate
Tier 1
KAYEXALATE
Tier 3
KIONEX
Tier 1
lactated ringers irrigation
Tier 1
mycophenolate mofetil
Tier 1
mycophenolic acid
Tier 1
MYFORTIC
Tier 3
NEORAL
Tier 3
NULOJIX
Tier 3
PHYSIOLYTE
Tier 1
PHYSIOSOL IRRIGATION
Tier 1
PROGRAF
Tier 3
RAPAMUNE
Tier 3
REVLIMID
Tier 3
ringers irrigation
Tier 1
SANDIMMUNE
Tier 3
SIMULECT
Tier 3
sirolimus oral
Tier 1
sodium polystyrene sulfonate oral
Tier 1
sodium polystyrene sulfonate suspension
Tier 1
SPS
Tier 3
sterile water for irrigation
Tier 1
SYPRINE
Tier 3
tacrolimus oral
Tier 1
THALOMID
Tier 3
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Drug Details
PA
PA
PA
PA
PA
PA
Drug Name
Drug Status
THYMOGLOBULIN
Tier 3
TIS-U-SOL
Tier 1
VELTASSA
Tier 3
XIAFLEX
Tier 2
ZORTRESS
Tier 3
Drug Details
PA
*BETA BLOCKER & ANGIOTENSIN II
RECEPTOR ANTAGONIST COMB***
BYVALSON
Tier 2
*BETA BLOCKERS*
acebutolol hcl oral
Tier 1
atenolol oral
Tier 1
BETAPACE AF
Tier 3
BETAPACE ORAL TABLET 120 MG, 160 MG, 80
MG
Tier 3
betaxolol hcl oral
Tier 1
bisoprolol fumarate
Tier 1
BYSTOLIC
Tier 2
carvedilol
Tier 1
COREG
Tier 3
COREG CR
Tier 3
CORGARD
Tier 3
HEMANGEOL
Tier 3
INDERAL LA
Tier 3
INDERAL XL
Tier 3
KERLONE
Tier 3
labetalol hcl oral
Tier 1
LEVATOL
Tier 3
LOPRESSOR ORAL
Tier 3
metoprolol succinate er
Tier 1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Tier 1
metoprolol tartrate oral tablet 37.5 mg, 75 mg
Tier 1
nadolol oral tablet 20 mg, 40 mg, 80 mg
Tier 1
pindolol
Tier 1
propranolol hcl er
Tier 1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80
mg
Tier 1
propranolol hcl oral tablet 60 mg
Tier 1
SECTRAL
Tier 3
SORINE
Tier 1
LGC
LGC
LGC
#
LGC
LGC
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Drug Name
Drug Status
sotalol hcl (af) oral tablet 120 mg
Tier 1
sotalol hcl (af) oral tablet 160 mg, 80 mg
Tier 1
sotalol hcl oral tablet 120 mg, 80 mg
Tier 1
sotalol hcl oral tablet 160 mg, 240 mg
Tier 1
SOTYLIZE
Tier 3
TENORMIN
Tier 3
timolol maleate oral
Tier 1
TOPROL XL
Tier 3
TRANDATE ORAL
Tier 3
ZEBETA
Tier 3
Drug Details
LGC
LGC
*BILE ACID SYNTHESIS DISORDER
AGENTS***
CHOLBAM
Tier 3
PA
*BIOLOGICALS MISC*
ADAGEN
Tier 3
*CALCIUM CHANNEL BLOCKERS*
ADALAT CC
Tier 3
AFEDITAB CR
Tier 1
amlodipine besylate oral
Tier 1
CALAN ORAL TABLET 120 MG, 80 MG
Tier 3
CALAN SR
Tier 3
CARDIZEM CD
Tier 3
CARDIZEM LA
Tier 3
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60
MG
Tier 3
CARTIA XT
Tier 1
diltiazem hcl cd
Tier 1
diltiazem hcl er beads
Tier 1
diltiazem hcl er coated beads
Tier 1
diltiazem hcl er oral capsule extended release 12 hour
Tier 1
diltiazem hcl er oral capsule extended release 24 hour
120 mg, 180 mg, 240 mg
Tier 1
diltiazem hcl oral
Tier 1
dilt-xr
Tier 1
felodipine er
Tier 1
ISOPTIN SR
Tier 3
isradipine
Tier 1
MATZIM LA
Tier 1
nicardipine hcl oral
Tier 1
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LGC
LGC
Drug Name
Drug Status
NIFEDIAC CC
Tier 1
NIFEDICAL XL
Tier 1
nifedipine er
Tier 1
nifedipine er osmotic release
Tier 1
nifedipine oral
Tier 1
nimodipine oral
Tier 1
nisoldipine er oral tablet extended release 24 hr* 17
mg, 34 mg, 8.5 mg
Tier 1
NORVASC
Tier 3
NYMALIZE
Tier 3
PROCARDIA
Tier 3
PROCARDIA XL
Tier 3
SULAR ORAL TABLET EXTENDED RELEASE 24
HR* 17 MG, 34 MG, 8.5 MG
Tier 3
TAZTIA XT
Tier 1
TIAZAC
Tier 3
verapamil hcl er oral capsule extended release 24
hour
Tier 1
verapamil hcl er oral tablet extendedrelease* 120 mg
Tier 1
verapamil hcl er oral tablet extendedrelease* 180 mg,
240 mg
Tier 1
verapamil hcl oral
Tier 1
VERELAN
Tier 3
VERELAN PM
Tier 3
Drug Details
LGC
LGC
*CARDIOTONICS*
DIGOX
Tier 1
digoxin oral tablet
Tier 1
LANOXIN ORAL
Tier 3
LGC
*CARDIOVASCULAR AGENTS - MISC.*
ADCIRCA
Tier 3
PA; QL
ADEMPAS
Tier 3
PA; QL
BIDIL
Tier 3
CIALIS ORAL TABLET 2.5 MG, 5 MG
Tier 2
N1
epoprostenol sodium
Tier 1
PA
FLOLAN
Tier 3
PA
LETAIRIS
Tier 2
PA
OPSUMIT
Tier 2
PA; QL
ORENITRAM
Tier 3
PA
REMODULIN
Tier 3
PA
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Drug Name
Drug Status
Drug Details
REVATIO INTRAVENOUS*
Tier 3
PA
REVATIO ORAL SUSPENSION
RECONSTITUTED
Tier 3
PA; #; QL
REVATIO ORAL TABLET
Tier 3
PA; QL
sildenafil citrate oral
Tier 1
PA
TRACLEER
Tier 2
PA; #
TYVASO
Tier 3
PA
TYVASO REFILL
Tier 3
PA
TYVASO STARTER
Tier 3
PA
VELETRI
Tier 3
PA
VENTAVIS
Tier 3
PA
*CEPHALOSPORINS*
CEDAX
Tier 3
cefaclor oral capsule
Tier 1
cefadroxil
Tier 1
cefdinir
Tier 1
cefixime
Tier 1
cefpodoxime proxetil
Tier 1
cefprozil
Tier 1
CEFTIN ORAL SUSPENSION RECONSTITUTED
250 MG/5ML
Tier 3
CEFTIN ORAL TABLET
Tier 3
cefuroxime axetil oral suspension reconstituted 125
mg/5ml
Tier 1
cefuroxime axetil oral tablet
Tier 1
cephalexin oral capsule 250 mg, 500 mg
Tier 1
cephalexin oral capsule 750 mg
Tier 1
cephalexin oral suspension reconstituted
Tier 1
KEFLEX
Tier 3
SPECTRACEF
Tier 3
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION RECONSTITUTED
Tier 3
SUPRAX ORAL TABLET CHEWABLE
Tier 3
LGC
#
#
*CHEMICALS*
ethosuximide
Tier 1
hydroxyzine hcl
Tier 1
*CONTRACEPTIVES*
ALTAVERA
CE
QL
alyacen 1/35
CE
QL
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Drug Name
Drug Status
alyacen 7/7/7
Tier 1
AMETHIA
Tier 1
AMETHIA LO
Tier 1
AMETHYST
Tier 1
Drug Details
APRI
CE
QL
ARANELLE
CE
QL
AUBRA
Tier 1
AVIANE
CE
QL
AZURETTE
CE
QL
BALZIVA
CE
QL
BEYAZ
Tier 3
BREVICON (28)
Tier 3
briellyn
CE
CAMILA
Tier 1
CAMRESE
Tier 1
CAMRESE LO
Tier 1
QL
CAZIANT
CE
CESIA
CE
CHATEAL
CE
QL
CRYSELLE-28
CE
QL
CYCLAFEM 1/35
CE
QL
CYCLAFEM 7/7/7
Tier 1
CYCLESSA
Tier 3
DASETTA 1/35
CE
DASETTA 7/7/7
Tier 1
DAYSEE
Tier 1
DEPO-PROVERA INTRAMUSCULAR*
SUSPENSION 150 MG/ML
Tier 3
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS*
SUSPENSION
Tier 3
DESOGEN
Tier 3
desogestrel-ethinyl estradiol
Tier 1
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
Tier 1
QL
QL
ELINEST
CE
QL
ELLA
CE
QL
EMOQUETTE
CE
QL
ENPRESSE-28
CE
QL
ENSKYCE
Tier 1
ERRIN
Tier 1
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Drug Name
Drug Status
ESTARYLLA
Tier 1
ESTROSTEP FE
Tier 3
FALMINA
CE
FEMCON FE
Tier 3
GENERESS FE
Tier 3
GIANVI
Tier 1
Drug Details
QL
GILDAGIA
CE
GILDESS 1.5/30
CE
GILDESS 1/20
CE
GILDESS 24 FE
CE
GILDESS FE 1.5/30
CE
QL
GILDESS FE 1/20
CE
QL
HEATHER
QL
Tier 1
IMPLANON
CE
INTROVALE
Tier 1
JENCYCLA
Tier 1
JOLESSA
Tier 1
JOLIVETTE
Tier 1
JUNEL 1.5/30
CE
QL
JUNEL 1/20
CE
QL
JUNEL FE 1.5/30
CE
QL
JUNEL FE 1/20
CE
QL
KARIVA
CE
QL
KELNOR 1/35
CE
QL
KURVELO
CE
QL
LARIN 1/20
Tier 1
LARIN FE 1.5/30
Tier 1
LARIN FE 1/20
Tier 1
LEENA
CE
QL
LESSINA
CE
QL
LEVONEST
CE
QL
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 &
0.01 mg, 0.15-0.03 mg
levonorgestrel oral tablet 0.75 mg
Tier 1
CE
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg
Tier 1
levonorgestrel-ethinyl estrad oral tablet 0.15-30
mg-mcg
CE
QL
LEVORA 0.15/30 (28)
CE
QL
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Drug Name
Drug Status
Drug Details
LILETTA (52 MG)
CE
LO LOESTRIN FE
Tier 3
LOESTRIN 1.5/30 (21)
Tier 3
LOESTRIN 1/20 (21)
Tier 3
LOESTRIN FE 1.5/30
Tier 3
LOESTRIN FE 1/20
Tier 3
LORYNA
Tier 1
LOSEASONIQUE
Tier 3
LOW-OGESTREL
CE
QL
LUTERA
CE
QL
LYZA
Tier 1
marlissa
CE
medroxyprogesterone acetate intramuscular*
suspension
CE
MICROGESTIN 1.5/30
CE
QL
MICROGESTIN 1/20
CE
QL
MICROGESTIN FE 1.5/30
CE
QL
MICROGESTIN FE 1/20
CE
QL
MINASTRIN 24 FE
Tier 3
MIRCETTE
Tier 3
MIRENA (52 MG)
CE
MODICON (28)
Tier 3
MONO-LINYAH
Tier 1
MONONESSA
Tier 1
MYZILRA
CE
NATAZIA
Tier 3
QL
#
#
NECON 0.5/35 (28)
CE
QL
NECON 1/35 (28)
CE
QL
NECON 1/50 (28)
Tier 3
NECON 10/11 (28)
CE
NECON 7/7/7
Tier 1
NEXPLANON
CE
NEXT CHOICE
CE
NEXT CHOICE ONE DOSE
CE
NORA-BE
Tier 1
norethin ace-eth estrad-fe oral tablet 1-20
mg-mcg(24)
Tier 1
norethindrone oral
Tier 1
QL
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
Tier 1
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Drug Name
norgestim-eth estrad triphasic oral tablet
0.18/0.215/0.25 mg-35 mcg
norgestrel-ethinyl estradiol
Drug Status
Drug Details
Tier 1
CE
NORINYL 1+35 (28)
Tier 3
NORINYL 1+50 (28)
Tier 3
NOR-QD
Tier 3
QL
NORTREL 0.5/35 (28)
CE
QL
NORTREL 1/35 (21)
CE
QL
NORTREL 1/35 (28)
CE
QL
NORTREL 7/7/7
Tier 1
NUVARING
Tier 2
OCELLA
Tier 1
ORSYTHIA
CE
ORTHO EVRA
Tier 3
ORTHO MICRONOR
Tier 3
ORTHO TRI-CYCLEN (28)
Tier 3
ORTHO TRI-CYCLEN LO
Tier 3
ORTHO-CEPT (28)
Tier 3
ORTHO-CYCLEN (28)
Tier 3
ORTHO-NOVUM 1/35 (28)
Tier 3
ORTHO-NOVUM 7/7/7 (28)
Tier 3
OVCON-35 (28)
Tier 3
PARAGARD INTRAUTERINE COPPER
CE
PHILITH
CE
PIMTREA
Tier 1
PIRMELLA 1/35
Tier 1
PIRMELLA 7/7/7
Tier 1
PORTIA-28
CE
PREVIFEM
Tier 1
QUARTETTE
Tier 3
QUASENSE
Tier 1
RECLIPSEN
CE
SAFYRAL
Tier 3
SEASONIQUE
Tier 3
SKYLA
Tier 3
SOLIA
Tier 1
SPRINTEC 28
Tier 1
SRONYX
CE
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#
QL
#
QL
QL
#
QL
QL
Drug Name
Drug Status
SYEDA
Tier 1
TAYTULLA
Tier 3
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
CE
Drug Details
QL
Tier 1
CE
QL
TRI-LINYAH
Tier 1
TRINESSA (28)
Tier 1
TRI-NORINYL (28)
Tier 3
TRI-PREVIFEM
Tier 1
TRI-SPRINTEC
Tier 1
TRIVORA (28)
CE
QL
VELIVET
CE
QL
VESTURA
Tier 1
viorele
VYFEMLA
CE
Tier 1
WERA
CE
WYMZYA FE
CE
XULANE
CE
YASMIN 28
Tier 3
YAZ
Tier 3
ZARAH
Tier 1
QL
ZENCHENT
CE
QL
ZENCHENT FE
CE
ZEOSA
CE
ZOVIA 1/35E (28)
CE
QL
ZOVIA 1/50E (28)
CE
QL
*CORTICOSTEROIDS*
BAYCADRON
Tier 1
budesonide er
Tier 1
CORTEF
Tier 3
DEXAMETHASONE INTENSOL
Tier 3
dexamethasone oral elixir
Tier 1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4
mg, 6 mg
Tier 1
DEXPAK 10 DAY ORAL TABLET
Tier 3
DEXPAK 13 DAY ORAL TABLET
Tier 3
DEXPAK 6 DAY ORAL TABLET
Tier 3
ENTOCORT EC ORAL CAPSULE EXTENDED
Tier 3
RELEASE 24 HOUR
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Drug Name
Drug Status
FLO-PRED
Tier 3
fludrocortisone acetate oral
Tier 1
hydrocortisone oral
Tier 1
MEDROL (PAK)
Tier 3
MEDROL ORAL TABLET 16 MG, 2 MG, 32 MG, 4
MG
Tier 3
methylprednisolone (pak) oral tablet
Tier 1
methylprednisolone oral tablet
Tier 1
MILLIPRED
Tier 3
MILLIPRED DP 12-DAY ORAL TABLET
Tier 3
MILLIPRED DP ORAL TABLET
Tier 3
ORAPRED ODT
Tier 3
PEDIAPRED
Tier 3
prednisolone oral solution
Tier 1
prednisolone oral syrup 15 mg/5ml
Tier 1
prednisolone sodium phosphate oral solution 15
mg/5ml, 6.7 (5 base) mg/5ml
Tier 1
prednisolone sodium phosphate oral tablet dispersible
Tier 1
prednisone (pak)
Tier 1
PREDNISONE INTENSOL
Tier 3
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5
mg
Tier 1
PRELONE
Tier 3
RAYOS
Tier 3
UCERIS ORAL
Tier 3
VERIPRED 20
Tier 3
Drug Details
LGC
*COUGH/COLD/ALLERGY*
acetylcysteine inhalation
Tier 1
ALAVERT ALLERGY/SINUS
Tier 1
benzonatate
Tier 1
BROMFED DM
Tier 1
CARBAPHEN 12 ORAL LIQUID†
Tier 3
CARBAPHEN 12 PED ORAL SUSPENSION
2.5-1.25-7.5 MG/ML
Tier 3
cetirizine-pseudoephedrine er
Tier 1
CLARINEX-D 12 HOUR
Tier 3
CLARITIN-D 12 HOUR
Tier 1
Select OTC
CLARITIN-D 24 HOUR
Tier 1
Select OTC
CPB WC
Tier 3
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Select OTC
Select OTC
Drug Name
Drug Status
Drug Details
DECON-A ORAL ELIXIR
Tier 3
EXACTUSS
Tier 3
fexofenadine-pseudoephed er oral tablet extended
release 24 hr*
Tier 1
GILPHEX TR
Tier 3
GILTUSS ORAL LIQUID† 10-28-388 MG/5ML
Tier 3
GILTUSS PED-C
Tier 3
GILTUSS TR
Tier 3
HISTEX-AC
Tier 3
HYCOFENIX
Tier 3
hydrocod polst-cpm polst er oral liquid
extendedrelease*
Tier 1
hydrocodone-homatropine
Tier 1
hydromet
Tier 1
HYPERSAL INHALATION NEBULIZATION
SOLUTION 3.5 %
Tier 3
loratadine-d 12hr
Tier 1
Select OTC
loratadine-d 24hr
Tier 1
Select OTC
NEBUSAL INHALATION NEBULIZATION
SOLUTION 3 %
Tier 1
NEBUSAL INHALATION NEBULIZATION
SOLUTION 6 %
Tier 3
NEOTUSS PLUS
Tier 3
nortuss-ex
Tier 3
OBREDON
Tier 3
PEDIATEX TDM
Tier 3
promethazine-codeine
Tier 1
AL
promethazine-dm
Tier 1
AL
pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml
Tier 1
PULMOSAL
Tier 1
RELHIST
Tier 3
RESCON-JR
Tier 3
RESCON-MX ORAL TABLET EXTENDED
RELEASE 12 HR* 6-40 MG
Tier 3
REZIRA
Tier 3
SEMPREX-D
Tier 3
sodium chloride inhalation nebulization solution 10
%, 3 %, 7 %
Tier 1
TESSALON PERLES
Tier 3
tgq 30pse/150gfn/15dm
Tier 3
Select OTC
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Drug Name
Drug Status
Drug Details
tgq 30pse/3brm/15dm
Tier 3
TRICODE AR
Tier 3
TUSSICAPS
Tier 3
TUSSIGON
Tier 1
TUSSIONEX PENNKINETIC ER ORAL LIQUID
EXTENDEDRELEASE*
Tier 3
TUZISTRA XR ORAL
Tier 3
VITUZ
Tier 3
ZONATUSS
Tier 3
ZYRTEC-D ALLERGY & CONGESTION
Tier 1
Select OTC
Tier 3
PA; QL
Tier 3
PA
*CYCLIN-DEPENDENT KINASES (CDK)
INHIBITORS***
IBRANCE
*CYSTIC FIBROSIS AGENT COMBINATIONS***
ORKAMBI ORAL TABLET 200-125 MG
*DERMATOLOGICALS*
8-MOP
Tier 3
ABREVA
Tier 1
Select OTC
ABSORICA
Tier 3
PA
ACANYA
Tier 3
acitretin
Tier 1
ACLOVATE EXTERNAL CREAM
Tier 3
ACTICIN
Tier 1
acyclovir external
Tier 1
ACZONE EXTERNAL GEL 5 %
Tier 3
ACZONE EXTERNAL GEL 7.5 %
Tier 3
adapalene external cream
Tier 1
AL
adapalene external gel 0.1 %
Tier 1
AL
adapalene external gel 0.3 %
Tier 1
adapalene external lotion
Tier 1
aif #2 drug preparation kit
Tier 3
AKNE-MYCIN
Tier 3
alclometasone dipropionate
Tier 1
ALDARA
Tier 3
alphatrex
Tier 1
ALTABAX
Tier 3
amcinonide external cream
Tier 1
AMNESTEEM
Tier 1
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#
PA
Drug Name
Drug Status
ANACAINE
Tier 3
antifungal external cream 2 %
Tier 1
APEXICON
Tier 1
APEXICON E
Tier 3
ATRALIN
Tier 3
AVAR CLEANSER
Tier 1
AVAR LS CLEANSER
Tier 3
AVAR-E EMOLLIENT
Tier 1
AVAR-E GREEN
Tier 1
AVAR-E LS
Tier 3
AVITA
Tier 1
AZELEX
Tier 3
BACTROBAN
Tier 3
baza antifungal
Tier 1
bensal hp
Tier 3
BENZAMYCIN
Tier 3
BENZAMYCINPAK
Tier 3
BENZEPRO
Tier 1
BENZEPRO SHORT CONTACT
Tier 1
BENZIQ
Tier 3
BENZIQ LS
Tier 3
benzoyl peroxide external foam
Tier 1
benzoyl peroxide short contact
Tier 1
benzoyl peroxide-erythromycin
Tier 1
betamethasone dipropionate aug
Tier 1
betamethasone dipropionate external
Tier 1
betamethasone valerate external
Tier 1
bp 10-1
Tier 1
bp cleansing wash
Tier 1
bp foam
Tier 1
bpo
Tier 3
bpo foaming cloths
Tier 3
calcipotriene external
Tier 1
CALCITRENE
Tier 1
CAPEX
Tier 3
CARAC
Tier 3
CARRINGTON ANTIFUNGAL
Tier 1
CEM-UREA
Tier 3
Drug Details
#; AL
AL
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Drug Name
Drug Status
CENTANY
Tier 3
CERISA WASH
Tier 1
CICLODAN
Tier 1
ciclopirox
Tier 1
ciclopirox olamine external
Tier 1
CLARAVIS
Tier 1
CLARIS CLARIFYING WASH
Tier 1
CLEOCIN-T
Tier 3
CLINDACIN ETZ EXTERNAL SWAB
Tier 1
CLINDACIN-P
Tier 1
CLINDAGEL
Tier 3
CLINDAMAX EXTERNAL
Tier 1
clindamycin phos-benzoyl perox
Tier 1
clindamycin phosphate external
Tier 1
clindamycin-tretinoin
Tier 1
clobetasol propionate e
Tier 1
clobetasol propionate emulsion
Tier 1
clobetasol propionate external cream
Tier 1
clobetasol propionate external foam
Tier 1
clobetasol propionate external gel
Tier 1
clobetasol propionate external lotion
Tier 1
clobetasol propionate external ointment
Tier 1
clobetasol propionate external shampoo
Tier 1
clobetasol propionate external solution
Tier 1
CLOBEX
Tier 3
CLOBEX SPRAY
Tier 2
clotrimazole-betamethasone
Tier 1
CNL8 NAIL
Tier 3
CONDYLOX
Tier 3
CORDRAN EXTERNAL LOTION
Tier 3
CORDRAN EXTERNAL TAPE
Tier 3
CORMAX SCALP APPLICATION
Tier 1
CORTANE-B EXTERNAL
Tier 3
CORTISPORIN EXTERNAL
Tier 2
COSENTYX
Tier 3
PA
COSENTYX SENSOREADY PEN
SUBCUTANEOUS* 150 MG/ML
Tier 3
PA
CUTIVATE
Tier 3
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Drug Details
PA
Drug Name
Drug Status
Drug Details
DENAVIR
Tier 3
DERMA-SMOOTHE/FS BODY
Tier 3
DERMA-SMOOTHE/FS SCALP
Tier 3
DERMASORB XM
Tier 3
DERMATOP EXTERNAL CREAM
Tier 3
DERMAZENE
Tier 1
DESONATE
Tier 3
desonide external
Tier 1
DESOWEN
Tier 3
desoximetasone external cream 0.25 %
Tier 1
desoximetasone external gel
Tier 1
desoximetasone external ointment 0.25 %
Tier 1
diclofenac sodium transdermal gel
Tier 1
DIFFERIN EXTERNAL CREAM
Tier 3
AL
DIFFERIN EXTERNAL GEL 0.1 %
Tier 3
AL
DIFFERIN EXTERNAL GEL 0.3 %
Tier 2
DIFFERIN EXTERNAL LOTION
Tier 3
diflorasone diacetate external ointment
Tier 1
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
DOVONEX EXTERNAL CREAM
Tier 3
doxepin hcl external
Tier 1
doxycycline
Tier 1
DRITHO-CREME HP
Tier 3
DUAC
Tier 3
econazole nitrate external
Tier 1
ECOZA
Tier 3
EFUDEX EXTERNAL CREAM
Tier 3
ELIDEL
Tier 2
ELIMITE
Tier 3
ELOCON
Tier 3
EMLA
Tier 3
ENSTILAR
Tier 3
EPIDUO
Tier 2
#; AL
EPIDUO FORTE
Tier 2
#
EPIFOAM
Tier 3
ERTACZO
Tier 3
ery
Tier 1
AL
PA
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Drug Name
Drug Status
Drug Details
ERYGEL
Tier 3
erythromycin external pad
Tier 1
erythromycin external solution
Tier 1
EURAX
Tier 3
EVOCLIN
Tier 3
EXELDERM
Tier 3
EXODERM EXTERNAL LOTION
Tier 1
EXTINA
Tier 3
FABIOR
Tier 3
AL
FINACEA
Tier 3
#
FLECTOR
Tier 2
fluocinolone acetonide body
Tier 1
fluocinolone acetonide external
Tier 1
fluocinolone acetonide scalp
Tier 1
fluocinonide external cream 0.05 %
Tier 1
fluocinonide external gel
Tier 1
fluocinonide external ointment
Tier 1
fluocinonide external solution
Tier 1
fluocinonide-e
Tier 1
FLUOROPLEX
Tier 3
fluorouracil external
Tier 1
flurandrenolide
Tier 1
fluticasone propionate external
Tier 1
GEBAUERS PAIN EASE
Tier 3
GEBAUERS SPRAY AND STRETCH
Tier 3
gentamicin sulfate external
Tier 1
GORDOFILM
Tier 3
halobetasol propionate
Tier 1
HALOG
Tier 3
HALOTIN
Tier 3
hydrocortisone acetate-aloe external gel
Tier 1
hydrocortisone butyr lipo base
Tier 1
hydrocortisone butyrate external
Tier 1
hydrocortisone external cream 2.5 %
Tier 1
hydrocortisone external lotion 2.5 %
Tier 1
hydrocortisone external ointment 2.5 %
Tier 1
hydrocortisone valerate
Tier 1
hydrocortisone-iodoquinol external cream 1-1 %
Tier 1
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Drug Name
Drug Status
imiquimod external
Tier 1
JUBLIA
Tier 3
KENALOG EXTERNAL
Tier 3
KERAFOAM
Tier 3
KERAFOAM 42
Tier 3
ketoconazole external cream
Tier 1
ketoconazole external shampoo
Tier 1
KETODAN EXTERNAL FOAM
Tier 1
KLARON
Tier 3
kp miconazole nitrate
Tier 1
lactic acid external lotion
Tier 1
lavare wound wash
Tier 3
LEVULAN KERASTICK
Tier 3
lidocaine external ointment
Tier 1
lidocaine external patch 5 %
Tier 1
lidocaine hcl external solution
Tier 1
lidocaine-prilocaine external cream
Tier 1
LIDODERM
Tier 3
lindane external
Tier 1
LOCOID
Tier 3
LOCOID LIPOCREAM
Tier 3
LOKARA
Tier 1
LOPROX EXTERNAL SHAMPOO
Tier 3
LOTRISONE EXTERNAL CREAM
Tier 3
LUXIQ
Tier 3
LUZU
Tier 3
mafenide acetate external
Tier 1
malathion external
Tier 1
METROCREAM
Tier 3
METROGEL EXTERNAL GEL
Tier 3
METROLOTION
Tier 3
metronidazole external
Tier 1
micaderm
Tier 1
MICATIN EXTERNAL CREAM
Tier 3
miconazole nitrate external cream
Tier 1
MICRO GUARD EXTERNAL CREAM
Tier 1
MIRVASO
Tier 3
mometasone furoate external
Tier 1
Drug Details
PA; QL
PA; QL
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Drug Name
Drug Status
mupirocin calcium
Tier 1
mupirocin external
Tier 1
MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40
MG
Tier 1
naftifine hcl
Tier 1
NAFTIN
Tier 3
NATROBA
Tier 3
NEOSPORIN AF
Tier 1
NEO-SYNALAR EXTERNAL CREAM
Tier 3
NEUAC EXTERNAL GEL
Tier 1
NIZORAL
Tier 3
NORITATE
Tier 3
NUCORT
Tier 3
NUOX
Tier 3
NYAMYC
Tier 1
nystatin external cream
Tier 1
nystatin external ointment
Tier 1
nystatin external powder 100000 unit/gm
Tier 1
nystatin-triamcinolone
Tier 1
NYSTOP
Tier 1
OLUX
Tier 3
OLUX-E
Tier 3
ONEXTON
Tier 3
ORACEA
Tier 2
OVACE PLUS EXTERNAL CREAM
Tier 3
OVACE PLUS EXTERNAL SHAMPOO
Tier 3
OVACE PLUS WASH
Tier 3
OVACE WASH
Tier 3
OVIDE
Tier 3
oxiconazole nitrate
Tier 1
OXISTAT
Tier 3
OXSORALEN
Tier 2
OXSORALEN ULTRA
Tier 3
PANDEL
Tier 3
PANRETIN
Tier 2
PENLAC
Tier 3
PENNSAID
Tier 3
permethrin external cream
Tier 1
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Drug Details
PA
AL
Drug Name
Drug Status
Drug Details
PICATO
Tier 2
PLEXION
Tier 3
PLEXION CLEANSER EXTERNAL LIQUID†
Tier 3
PLEXION CLEANSING CLOTH EXTERNAL PAD
Tier 3
PLIAGLIS
Tier 3
podactin external cream
Tier 1
podocon
Tier 3
podofilox external
Tier 1
PRAMOSONE EXTERNAL CREAM 1-1 %
Tier 3
PRAMOSONE EXTERNAL LOTION
Tier 3
PRASCION
Tier 1
PRASCION FC
Tier 1
PRASCION RA
Tier 1
prednicarbate
Tier 1
PROTOPIC
Tier 2
PRUDOXIN
Tier 1
QUTENZA
Tier 3
QUTENZA (2 PATCH)
Tier 3
ra antifungal external cream
Tier 1
RE 10 WASH
Tier 1
REGENECARE
Tier 3
REGRANEX
Tier 3
REMEDY ANTIFUNGAL EXTERNAL CREAM
Tier 1
RETIN-A
Tier 3
AL
RETIN-A MICRO
Tier 3
#; AL
RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %,
0.1 %
Tier 3
#; AL
RIAX
Tier 3
ROSADAN EXTERNAL CREAM
Tier 1
ROSADAN EXTERNAL GEL
Tier 1
ROSANIL CLEANSER
Tier 1
SALACYN
Tier 1
salicylic acid external cream
Tier 1
salicylic acid external liquid† 27.5 %
Tier 1
salicylic acid external lotion
Tier 1
salicylic acid external shampoo
Tier 1
salicylic acid external solution 28.5 %
Tier 1
salicylic acid wart remover
Tier 1
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Drug Name
Drug Status
SALKERA
Tier 3
SANTYL
Tier 3
scalacort
Tier 1
SEB-PREV WASH
Tier 1
SECURA ANTIFUNGAL
Tier 1
SECURA ANTIFUNGAL EXTRA THICK
Tier 1
selenium sulfide external lotion
Tier 1
SELRX
Tier 3
SERNIVO
Tier 3
SILVADENE
Tier 3
silver sulfadiazine external
Tier 1
SKLICE
Tier 3
sm antifungal miconazole
Tier 1
sodium sulfacetamide external shampoo
Tier 1
sodium sulfacetamide wash
Tier 3
SOLARAZE
Tier 3
SOOLANTRA
Tier 3
SOOTHE & COOL INZO ANTIFUNGAL
Tier 1
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG,
25 MG
Tier 3
SORILUX
Tier 3
SSD
Tier 1
sss 10-5
Tier 1
STELARA SUBCUTANEOUS*
Tier 2
sulfacetamide sodium (acne)
Tier 1
sulfacetamide sodium external gel
Tier 1
sulfacetamide sodium external liquid†
Tier 1
sulfacetamide sodium external suspension
Tier 1
sulfacetamide sodium-sulfur external cream
Tier 1
sulfacetamide sodium-sulfur external emulsion
Tier 1
sulfacetamide sodium-sulfur external foam
Tier 1
sulfacetamide sodium-sulfur external liquid† 10-2 %,
9-4 %, 9.8-4.8 %
Tier 1
sulfacetamide sodium-sulfur external lotion
Tier 1
sulfacetamide sodium-sulfur external pad
Tier 1
sulfacetamide sodium-sulfur external suspension 8-4
%
Tier 1
SULFACLEANSE 8/4
Tier 1
SULFAMYLON
Tier 3
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Drug Details
PA
Drug Name
Drug Status
Drug Details
SYNALAR
Tier 3
SYNERA
Tier 3
TACLONEX
Tier 3
tacrolimus external
Tier 1
QL
TALTZ
Tier 3
PA
TARGRETIN EXTERNAL
Tier 2
TAZORAC
Tier 2
#; AL
TEMOVATE
Tier 3
#
TEMOVATE E
Tier 3
#
TERSI
Tier 3
TEXACORT
Tier 3
THERMAZENE
Tier 1
TOLAK
Tier 3
TOPICORT EXTERNAL CREAM
Tier 3
TOPICORT EXTERNAL GEL
Tier 3
TOPICORT EXTERNAL OINTMENT
Tier 3
TOPICORT SPRAY
Tier 3
tretinoin external cream
Tier 1
AL
tretinoin external gel 0.01 %, 0.025 %
Tier 1
AL
tretinoin external gel 0.05 %
Tier 1
tretinoin microsphere
Tier 1
AL
tretinoin microsphere pump
Tier 1
AL
TRETIN-X EXTERNAL CREAM
Tier 3
AL
triamcinolone acetonide external aerosol, solution
Tier 1
triamcinolone acetonide external cream
Tier 1
triamcinolone acetonide external lotion
Tier 1
triamcinolone acetonide external ointment
Tier 1
TRIDERM EXTERNAL CREAM
Tier 1
ULESFIA
Tier 3
ULTRAVATE
Tier 3
URAMAXIN EXTERNAL FOAM
Tier 3
urea nail external kit
Tier 3
urea nail external stick
Tier 3
UTOPIC
Tier 3
VALCHLOR
Tier 3
VANOXIDE-HC
Tier 3
VASOLEX
Tier 1
VECTICAL
Tier 3
LGC
LGC
PA
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Drug Name
Drug Status
VERDESO
Tier 3
VEREGEN
Tier 3
VERSICLEAR
Tier 1
virti-sulf
Tier 1
VOLTAREN TRANSDERMAL
Tier 2
VUSION
Tier 3
VYTONE
Tier 3
WESTCORT
Tier 3
XERAC AC
Tier 3
XERESE
Tier 3
XOLEGEL
Tier 3
XYLOCAINE EXTERNAL
Tier 3
zaclir cleansing external lotion 8 %
Tier 3
ZENATANE
Tier 1
ZENCIA
Tier 1
ZIANA
Tier 2
ZITHRANOL-RR
Tier 3
ZONALON
Tier 3
ZOVIRAX EXTERNAL
Tier 3
ZYCLARA
Tier 3
ZYCLARA PUMP
Tier 3
*DIAGNOSTIC PRODUCTS*
ACCU-CHEK ACTIVE
Tier 3
ACCU-CHEK ADVANTAGE TEST
Tier 3
ACCU-CHEK AVIVA IN VITRO STRIP
Tier 3
ACCU-CHEK AVIVA PLUS IN VITRO
Tier 3
ACCU-CHEK COMFORT CURVE IN VITRO
STRIP
Tier 3
ACCU-CHEK COMPACT
Tier 3
ACCU-CHEK COMPACT PLUS
Tier 3
ACCU-CHEK COMPACT TEST DRUM
Tier 3
ACCU-CHEK SMARTVIEW
Tier 3
ACCUTREND GLUCOSE
Tier 3
ACETEST
Tier 3
active-medicated spec collect
Tier 3
ACURA BLOOD GLUCOSE TEST
Tier 3
ADVANCE INTUITION TEST
Tier 3
ADVANCE MICRO-DRAW TEST
Tier 3
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#
Drug Name
Drug Status
Drug Details
ADVOCATE REDI-CODE IN VITRO
Tier 3
ADVOCATE REDI-CODE+ TEST
Tier 3
ADVOCATE TEST
Tier 3
AGAMATRIX AMP TEST
Tier 3
AGAMATRIX JAZZ TEST
Tier 3
AGAMATRIX KEYNOTE TEST
Tier 3
AGAMATRIX PRESTO TEST
Tier 3
ALBUSTIX
Tier 3
ARIDOL
Tier 3
ASCENSIA AUTODISC TEST
Tier 3
ASSURE 3 TEST
Tier 3
ASSURE 4 TEST
Tier 3
ASSURE II
Tier 3
ASSURE II CHECK
Tier 3
ASSURE PLATINUM
Tier 3
ASSURE PRISM MULTI TEST
Tier 3
ASSURE PRO TEST
Tier 3
AT LAST TEST
Tier 3
BAR-TEST
Tier 3
BAYER BREEZE 2 TEST
Tier 3
BAYER CONTOUR NEXT TEST
Tier 3
QL
BAYER CONTOUR TEST
Tier 3
QL
BD TEST
Tier 3
BG STAR TEST
Tier 3
BIOSCANNER GLUCOSE TEST
Tier 3
bl test strip pack
Tier 3
blood glucose test
Tier 3
CAREONE BLOOD GLUCOSE TEST
Tier 3
CARESENS N GLUCOSE TEST
Tier 3
CHEK-STIX CONTROL
Tier 3
CHEMSTRIP 10 MD
Tier 3
CHEMSTRIP 10/SG
Tier 3
CHEMSTRIP 2 GP
Tier 3
CHEMSTRIP 5 OB
Tier 3
CHEMSTRIP 7
Tier 3
CHEMSTRIP 9
Tier 3
CHEMSTRIP K
Tier 3
CHEMSTRIP MICRAL
Tier 3
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Drug Name
Drug Status
CHEMSTRIP UGK
Tier 3
CHOICE DM FORA G20 TEST STRIPS
Tier 3
CLEVER CHEK AUTO-CODE TEST
Tier 3
CLEVER CHEK AUTO-CODE VOICE IN VITRO
Tier 3
CLEVER CHEK TEST
Tier 3
CLEVER CHOICE AUTO-CODE TEST
Tier 3
CLEVER CHOICE MICRO TEST
Tier 3
CLINISTIX
Tier 3
CLINITEST
Tier 3
COMBISTIX
Tier 3
CONTROL AST
Tier 3
CONTROL TEST
Tier 3
COOL BLOOD GLUCOSE TEST STRIPS
Tier 3
CVS ADVANCED GLUCOSE TEST
Tier 3
cvs blood glucose test
Tier 3
CVS KETONE CARE
Tier 3
CYSTO-CONRAY II
Tier 3
CYSTOGRAFIN-DILUTE
Tier 3
DIASTIX
Tier 3
diatrue plus test
Tier 3
DIGIBAR 190
Tier 3
DUO-CARE TEST
Tier 3
easy plus blood glucose test
Tier 3
easy plus ii glucose test
Tier 3
EASY STEP TEST
Tier 3
easy talk blood glucose test
Tier 3
EASY TOUCH TEST
Tier 3
easy trak blood glucose test
Tier 3
EASYGLUCO IN VITRO
Tier 3
EASYGLUCO PLUS IN VITRO
Tier 3
EASYMAX 15 TEST
Tier 3
EASYMAX TEST
Tier 3
easyplus blood glucose test
Tier 3
EASYPRO BLOOD GLUCOSE TEST
Tier 3
EASYPRO PLUS IN VITRO
Tier 3
ECLIPSE TEST
Tier 3
element compact test
Tier 3
ELEMENT PLUS TEST
Tier 3
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Drug Details
Drug Name
Drug Status
ELEMENT TEST
Tier 3
EMBRACE BLOOD GLUCOSE TEST
Tier 3
EMBRACE EVO BLOOD GLUCOSE TEST
Tier 3
EMBRACE PRO GLUCOSE TEST
Tier 3
ENTERO VU
Tier 3
ENVISION AUTOCODE TEST
Tier 3
EQL TRUETEST TEST
Tier 3
EQL TRUETRACK TEST
Tier 3
EVENCARE + BLOOD GLUCOSE TEST
Tier 3
EVENCARE BLOOD GLUCOSE TEST
Tier 3
EVENCARE G2 TEST
Tier 3
EVENCARE G3 TEST
Tier 3
EVENCARE MINI GLUCOSE TEST
Tier 3
EVOLUTION AUTOCODE IN VITRO
Tier 3
EZ SMART BLOOD GLUCOSE TEST
Tier 3
EZ SMART PLUS GLUCOSE TEST
Tier 3
E-Z-CAT DRY
Tier 3
E-Z-DISK
Tier 3
E-Z-DOSE
Tier 3
E-Z-HD
Tier 3
E-Z-PAQUE
Tier 3
E-Z-PASTE
Tier 3
FIFTY50 GLUCOSE TEST 2.0
Tier 3
FORA D10 BLOOD GLUCOSE TEST
Tier 3
FORA D15C BLOOD GLUCOSE TEST
Tier 3
FORA D15G BLOOD GLUCOSE TEST
Tier 3
FORA D15Z BLOOD GLUCOSE TEST
Tier 3
FORA D20 BLOOD GLUCOSE TEST
Tier 3
FORA D40/G31 BLOOD GLUCOSE
Tier 3
FORA G20 BLOOD GLUCOSE TEST
Tier 3
FORA G30A BLOOD GLUCOSE TEST
Tier 3
FORA G71A BLOOD GLUCOSE TEST
Tier 3
FORA G90 BLOOD GLUCOSE TEST
Tier 3
FORA GD20 TEST
Tier 3
FORA GD50 BLOOD GLUCOSE TEST
Tier 3
FORA TEST N' GO GLUCOSE TEST
Tier 3
FORA TN'G/TN'G VOICE
Tier 3
FORA V10 BLOOD GLUCOSE TEST
Tier 3
Drug Details
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Drug Name
Drug Status
FORA V12 BLOOD GLUCOSE TEST
Tier 3
FORA V20 BLOOD GLUCOSE TEST
Tier 3
FORA V22 BLOOD GLUCOSE TEST
Tier 3
FORA V30A BLOOD GLUCOSE TEST
Tier 3
FORACARE GD40 TEST
Tier 3
FORACARE PREMIUM V10 TEST
Tier 3
FORACARE TEST N GO TEST
Tier 3
FORTISCARE TEST
Tier 3
FREESTYLE INSULINX TEST
Tier 2
FREESTYLE LITE TEST
Tier 2
FREESTYLE TEST
Tier 2
GASTROGRAFIN
Tier 3
GASTROMARK
Tier 3
ge100 blood glucose test
Tier 3
GENSTRIP 50
Tier 3
ght test
Tier 3
GLUCO PERFECT 3 TEST
Tier 3
GLUCOCARD 01 SENSOR PLUS
Tier 3
GLUCOCARD 01 TEST
Tier 3
GLUCOCARD EXPRESSION TEST
Tier 3
GLUCOCARD SHINE TEST
Tier 3
GLUCOCARD VITAL TEST
Tier 3
GLUCOCARD X-SENSOR
Tier 3
GLUCOCOM TEST
Tier 3
GLUCOLAB TEST
Tier 3
GLUCONAVII BLOOD GLUCOSE TEST
Tier 3
GMATE BLOOD GLUCOSE TEST
Tier 3
HEMA-COMBISTIX
Tier 3
HYSKON
Tier 3
IN TOUCH BLOOD GLUCOSE TEST
Tier 3
INFINITY BLOOD GLUCOSE TEST
Tier 3
KETOCARE
Tier 3
KETO-DIASTIX
Tier 3
KETOSTIX
Tier 3
kroger blood glucose test
Tier 3
kroger premium glucose test
Tier 3
kroger test
Tier 3
LABSTIX
Tier 3
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QL
Drug Name
Drug Status
LIBERTY NEXT GENERATION TEST
Tier 3
liberty test
Tier 3
LIQUID E-Z-PAQUE
Tier 3
LIQUID POLIBAR
Tier 3
LIQUID POLIBAR PLUS
Tier 3
MAXIBAR
Tier 3
MAXIMA BLOOD GLUCOSE TEST
Tier 3
MD-GASTROVIEW
Tier 1
meijer blood glucose test
Tier 3
meijer premium glucose test
Tier 3
MEIJER TRUETEST TEST
Tier 3
MEIJER TRUETRACK TEST
Tier 3
METOPIRONE
Tier 3
MICRO-BUMINTEST
Tier 3
MICRODOT TEST
Tier 3
MULTISTIX
Tier 3
MULTISTIX 10 SG
Tier 3
MULTISTIX 5
Tier 3
MULTISTIX 7
Tier 3
MULTISTIX 8
Tier 3
MULTISTIX 9
Tier 3
MULTISTIX 9 SG
Tier 3
MYGLUCOHEALTH TEST
Tier 3
NEUTEK 2TEK TEST
Tier 3
NEXGEN TEST
Tier 3
NOVA MAX GLUCOSE TEST
Tier 3
ON CALL EXPRESS BLOOD GLUCOSE
Tier 3
ON CALL PLUS BLOOD GLUCOSE
Tier 3
ON CALL VIVID BLOOD GLUCOSE
Tier 3
ONETOUCH ULTRA BLUE
Tier 2
ONETOUCH VERIO IN VITRO STRIP
Tier 2
OPTUMRX BLOOD GLUCOSE TEST
Tier 3
PHARMACIST CHOICE AUTOCODE
Tier 3
POCKETCHEM EZ TEST
Tier 3
POLIBAR ACB
Tier 3
PRECISION PCX
Tier 2
PRECISION PCX PLUS TEST
Tier 2
PRECISION POINT OF CARE TEST
Tier 2
Drug Details
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Drug Name
Drug Status
PRECISION QID TEST
Tier 2
PRECISION SOF-TACT TEST
Tier 2
PRECISION XTRA BLOOD GLUCOSE
Tier 2
premium blood glucose test
Tier 1
prestige smart system test
Tier 3
PRESTIGE TEST
Tier 3
PRODIGY AUTOCODE BLOOD GLUCOSE IN
VITRO
Tier 3
PRODIGY NO CODING BLOOD GLUC
Tier 3
PROVOCHOLINE
Tier 3
PTS PANELS GLUCOSE TEST
Tier 3
QUICKTEK TEST
Tier 3
QUINTET AC BLOOD GLUCOSE TEST
Tier 3
QUINTET BLOOD GLUCOSE TEST
Tier 3
RA TRUETEST TEST
Tier 3
READI-CAT
Tier 3
READI-CAT 2
Tier 3
REFUAH PLUS BLOOD GLUCOSE TEST
Tier 3
RELION KETONE
Tier 3
REVEAL BLOOD GLUCOSE TEST
Tier 3
REXALL BLOOD GLUCOSE TEST
Tier 3
RIGHTEST GS100 BLOOD GLUCOSE
Tier 3
RIGHTEST GS300 BLOOD GLUCOSE
Tier 3
RIGHTEST GS550 BLOOD GLUCOSE
Tier 3
SITZMARKS
Tier 3
SMART DIABETES XPRES TEST
Tier 3
SMART SENSE PREMIUM TEST
Tier 3
SMART SENSE VALUE TEST
Tier 3
SMARTEST BLOOD GLUCOSE TEST
Tier 3
SOLUS V2 TEST
Tier 3
SUPREME TEST
Tier 3
SURE EDGE TEST
Tier 3
SURECHEK BLOOD GLUCOSE TEST
Tier 3
SURESTEP PRO TEST
Tier 3
SURE-TEST EASYPLUS MINI TEST
Tier 3
T.R.U.E. TEST
Tier 3
TAGITOL V
Tier 3
TELCARE BLOOD GLUCOSE TEST
Tier 3
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Drug Details
Drug Name
Drug Status
tgt blood glucose test
Tier 3
THYROGEN
Tier 2
TRUE METRIX BLOOD GLUCOSE TEST
Tier 3
TRUETEST TEST
Tier 3
TRUETRACK TEST
Tier 3
ULTIMA TEST
Tier 3
ULTRATRAK PRO TEST
Tier 3
ULTRATRAK ULTIMATE TEST
Tier 3
UNISTRIP1 GENERIC
Tier 3
URISTIX
Tier 3
URISTIX 4
Tier 3
VARIBAR HONEY
Tier 3
VARIBAR NECTAR
Tier 3
VARIBAR PUDDING
Tier 3
VARIBAR THIN HONEY
Tier 3
VARIBAR THIN LIQUID
Tier 3
VICTORY AGM-4000 TEST
Tier 3
VOCAL POINT BLOOD GLUCOSE TEST
Tier 3
VOLUMEN
Tier 3
WAVESENSE PRESTO
Tier 3
Drug Details
*DIGESTIVE AIDS*
CREON
Tier 2
PANCREAZE
Tier 3
PERTZYE
Tier 3
SUCRAID
Tier 3
ULTRESA
Tier 3
VIOKACE
Tier 3
ZENPEP
Tier 2
*DIRECT-ACTING P2Y12 INHIBITORS***
BRILINTA
Tier 2
*DIURETICS*
acetazolamide er
Tier 1
acetazolamide oral tablet 250 mg
Tier 1
ALDACTAZIDE
Tier 3
ALDACTONE
Tier 3
amiloride hcl oral
Tier 1
amiloride-hydrochlorothiazide
Tier 1
LGC
bumetanide oral tablet 0.5 mg, 1 mg
Tier 1
LGC
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Drug Name
Drug Status
Drug Details
bumetanide oral tablet 2 mg
Tier 1
chlorothiazide oral tablet 500 mg
Tier 1
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
DEMADEX
Tier 3
DIAMOX SEQUELS
Tier 3
DIURIL
Tier 3
DYAZIDE
Tier 3
DYRENIUM
Tier 3
EDECRIN
Tier 3
ethacrynic acid oral
Tier 1
furosemide oral solution 10 mg/ml, 40 mg/4ml
Tier 1
furosemide oral tablet
Tier 1
LGC
hydrochlorothiazide oral capsule
Tier 1
LGC
hydrochlorothiazide oral tablet 12.5 mg
Tier 1
hydrochlorothiazide oral tablet 25 mg, 50 mg
Tier 1
indapamide oral
Tier 1
INTROL
Tier 3
KEVEYIS
Tier 3
LASIX
Tier 3
MAXZIDE
Tier 3
MAXZIDE-25
Tier 3
methazolamide oral
Tier 1
methyclothiazide oral
Tier 1
metolazone
Tier 1
MICROZIDE
Tier 3
NEPTAZANE
Tier 3
spironolactone oral tablet 100 mg, 50 mg
Tier 1
spironolactone oral tablet 25 mg
Tier 1
spironolactone-hctz
Tier 1
torsemide oral
Tier 1
triamterene-hctz oral capsule 37.5-25 mg
Tier 1
LGC
triamterene-hctz oral tablet
Tier 1
LGC
ZAROXOLYN ORAL TABLET 2.5 MG, 5 MG
Tier 3
LGC
PA
LGC
*ENDOCRINE AND METABOLIC AGENTS MISC.*
ACTONEL ORAL TABLET 150 MG, 30 MG, 35
MG, 5 MG
Tier 3
ALDURAZYME
Tier 2
alendronate sodium oral solution
Tier 1
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PA
Drug Name
Drug Status
Drug Details
alendronate sodium oral tablet 10 mg, 35 mg, 5 mg
Tier 1
alendronate sodium oral tablet 70 mg
Tier 1
AMMONUL
Tier 3
ATELVIA
Tier 2
BINOSTO
Tier 3
BONIVA INTRAVENOUS*
Tier 3
BONIVA ORAL TABLET 150 MG
Tier 3
BRAVELLE
Tier 2
PA
BUPHENYL ORAL POWDER 3 GM/TSP
Tier 3
PA
BUPHENYL ORAL TABLET
Tier 2
PA
cabergoline
Tier 1
calcitonin (salmon)
Tier 1
calcitriol oral
Tier 1
CARBAGLU
Tier 3
CARNITOR ORAL
Tier 3
CARNITOR SF
Tier 3
CETROTIDE
Tier 3
PA
chorionic gonadotropin intramuscular*
Tier 1
PA
clomiphene citrate oral
Tier 1
CYSTADANE
Tier 2
PA
DDAVP NASAL
Tier 3
AL
DDAVP ORAL
Tier 3
desmopressin ace rhinal tube
Tier 1
AL
desmopressin ace spray refrig
Tier 1
AL
desmopressin acetate oral
Tier 1
desmopressin acetate spray
Tier 1
doxercalciferol oral
Tier 1
ELAPRASE
Tier 2
EVISTA
Tier 3
FABRAZYME
Tier 2
PA
FOLLISTIM AQ
Tier 3
PA
FORTEO SUBCUTANEOUS* SOLUTION 600
MCG/2.4ML
Tier 3
PA
FOSAMAX ORAL TABLET 70 MG
Tier 3
FOSAMAX PLUS D
Tier 3
ganirelix acetate
Tier 1
PA
GENOTROPIN
Tier 3
PA
GENOTROPIN MINIQUICK
Tier 3
PA
LGC
PA
AL
PA
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Drug Name
Drug Status
GONAL-F
Tier 2
PA
GONAL-F RFF
Tier 2
PA
GONAL-F RFF PEN
Tier 2
PA
GONAL-F RFF REDIJECT
Tier 2
PA
HECTOROL
Tier 3
HP ACTHAR
Tier 3
PA
HUMATROPE
Tier 3
PA
ibandronate sodium intravenous* solution 3 mg/3ml
Tier 1
ibandronate sodium oral
Tier 1
INCRELEX
Tier 2
PA
KUVAN
Tier 2
PA
levocarnitine oral solution
Tier 1
levocarnitine oral tablet
Tier 1
LUMIZYME
Tier 3
PA
LUPRON DEPOT-PED
Tier 2
PA; #
MENOPUR
Tier 2
PA
MIACALCIN
Tier 3
MYOZYME
Tier 2
PA
NAGLAZYME
Tier 2
PA
NATPARA
Tier 3
PA
NORDITROPIN FLEXPRO SUBCUTANEOUS*
SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5
MG/1.5ML
Tier 3
PA
NORDITROPIN NORDIFLEX PEN
SUBCUTANEOUS* SOLUTION 30 MG/3ML
Tier 3
PA
novarel
Tier 1
PA
NUTROPIN AQ
Tier 3
PA
NUTROPIN AQ NUSPIN 10
Tier 3
PA
NUTROPIN AQ NUSPIN 20
Tier 3
PA
NUTROPIN AQ NUSPIN 5
Tier 3
PA
NUTROPIN AQ PEN
Tier 3
PA
NUTROPIN SUBCUTANEOUS* SOLUTION
RECONSTITUTED 10 MG
Tier 3
PA
octreotide acetate
Tier 1
PA
OMNITROPE
Tier 2
PA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
Tier 2
PA
ORFADIN ORAL CAPSULE 20 MG
Tier 2
ORFADIN ORAL SUSPENSION
Tier 2
OSPHENA
Tier 3
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PA
Drug Name
Drug Status
OVIDREL
Tier 3
pamidronate disodium
Tier 1
paricalcitol
Tier 1
pregnyl
Tier 1
PA
PROLIA
Tier 3
PA
raloxifene hcl
Drug Details
PA
CE
RAVICTI
Tier 3
PA
RECLAST
Tier 3
REPRONEX
Tier 3
risedronate sodium oral tablet 150 mg, 30 mg, 35 mg,
5 mg
Tier 1
risedronate sodium oral tablet delayed release
Tier 1
ROCALTROL
Tier 3
SAIZEN
Tier 3
PA
SAIZEN CLICK.EASY
Tier 3
PA
SAMSCA
Tier 2
PA
SANDOSTATIN
Tier 3
PA
SANDOSTATIN LAR DEPOT
Tier 3
PA
SENSIPAR
Tier 3
PA
SEROPHENE
Tier 1
SEROSTIM SUBCUTANEOUS* SOLUTION
RECONSTITUTED 4 MG, 5 MG, 6 MG
Tier 3
PA
SIGNIFOR
Tier 3
PA; QL
SIGNIFOR LAR
Tier 3
PA; QL
sod benz-sod phenylacet
Tier 1
sodium phenylbutyrate oral powder 3 gm/tsp
Tier 1
PA
SOMATULINE DEPOT
Tier 3
PA
SOMAVERT
Tier 3
PA
STIMATE
Tier 3
PA; AL
SUPPRELIN LA
Tier 2
PA
SYNAREL
Tier 3
PA
TEV-TROPIN
Tier 3
PA
XGEVA
Tier 3
PA
ZEMPLAR INTRAVENOUS*
Tier 3
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG
Tier 3
ZEMPLAR ORAL CAPSULE 4 MCG
Tier 2
zoledronic acid
Tier 1
ZOMACTON
Tier 3
PA
PA
ZOMETA
Tier 3
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Drug Name
Drug Status
ZORBTIVE
Tier 3
Drug Details
PA
*ESTROGENS*
ACTIVELLA
Tier 3
ALORA
Tier 3
ANGELIQ
Tier 3
CENESTIN ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG
Tier 3
#
CLIMARA
Tier 3
#
CLIMARA PRO
Tier 3
#
COMBIPATCH
Tier 3
DIVIGEL
Tier 3
ELESTRIN
Tier 3
ENJUVIA
Tier 3
ESTRACE ORAL
Tier 3
estradiol oral
Tier 1
estradiol transdermal patch weekly
Tier 1
estradiol-norethindrone acet
Tier 1
ESTRASORB
Tier 3
ESTROGEL
Tier 3
estropipate oral tablet 0.75 mg, 1.5 mg
Tier 1
EVAMIST
Tier 3
FEMHRT LOW DOSE
Tier 3
MENEST
Tier 3
MENOSTAR
Tier 3
MIMVEY
Tier 1
MINIVELLE
Tier 3
norethindrone-eth estradiol
Tier 1
ORTHO-EST 0.625
Tier 1
ORTHO-EST 1.25
Tier 1
PREFEST
Tier 3
PREMARIN ORAL
Tier 2
PREMPHASE
Tier 2
PREMPRO
Tier 2
VIVELLE-DOT
Tier 2
*ESTROGEN-SELECTIVE ESTROGEN
RECEPTOR MODULATOR COMB***
DUAVEE
Tier 2
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LGC
Drug Name
Drug Status
Drug Details
*FARNESOID X RECEPTOR (FXR)
AGONISTS***
OCALIVA ORAL TABLET 5 MG
Tier 3
PA
CIPRO ORAL SUSPENSION RECONSTITUTED
Tier 3
AL
CIPRO ORAL TABLET 250 MG, 500 MG
Tier 3
AL
CIPRO XR
Tier 3
AL
ciprofloxacin hcl oral tablet 100 mg, 750 mg
Tier 1
AL
ciprofloxacin hcl oral tablet 250 mg, 500 mg
Tier 1
LGC; AL
ciprofloxacin-ciproflox hcl er
Tier 1
AL
FACTIVE
Tier 3
#; AL
LEVAQUIN ORAL
Tier 3
AL
levofloxacin oral
Tier 1
AL
NOROXIN
Tier 3
AL
ofloxacin oral tablet 400 mg
Tier 1
AL
*FLUOROQUINOLONES*
*GASTROINTESTINAL AGENTS - MISC.*
ACTIGALL
Tier 3
alosetron hcl
Tier 1
AMITIZA
Tier 2
APRISO
Tier 2
ASACOL HD
Tier 3
AURYXIA
Tier 3
AZULFIDINE
Tier 3
AZULFIDINE EN-TABS
Tier 3
balsalazide disodium
Tier 1
calcium acetate (phos binder) oral tablet
Tier 1
CANASA
Tier 2
CHENODAL
Tier 3
CIMZIA PREFILLED
Tier 3
PA; QL
CIMZIA STARTER KIT
Tier 3
PA; QL
CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG
Tier 3
PA; QL
COLAZAL
Tier 3
cromolyn sodium oral
Tier 1
DELZICOL
Tier 2
DIPENTUM
Tier 3
ELIPHOS
Tier 3
enulose
Tier 1
FOSRENOL ORAL PACKET
Tier 2
#
LGC
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Drug Name
Drug Status
Drug Details
FOSRENOL ORAL TABLET CHEWABLE 1000
MG, 500 MG, 750 MG
Tier 2
GASTROCROM
Tier 3
GATTEX
Tier 3
generlac
Tier 1
GIAZO
Tier 3
lactulose encephalopathy
Tier 1
LIALDA
Tier 2
LINZESS
Tier 2
LOTRONEX
Tier 3
mesalamine enema
Tier 1
mesalamine oral
Tier 1
metoclopramide hcl oral solution 10 mg/10ml
Tier 1
metoclopramide hcl oral solution 5 mg/5ml
Tier 1
LGC
metoclopramide hcl oral tablet 10 mg
Tier 1
LGC
metoclopramide hcl oral tablet 5 mg
Tier 1
metoclopramide hcl oral tablet dispersible
Tier 1
METOZOLV ODT ORAL TABLET DISPERSIBLE
5 MG
Tier 3
MOVANTIK
Tier 2
PENTASA
Tier 2
PHOSLO
Tier 3
PHOSLYRA
Tier 2
REGLAN ORAL
Tier 3
RELISTOR ORAL
Tier 3
RELISTOR SUBCUTANEOUS* KIT
Tier 2
RELISTOR SUBCUTANEOUS* SOLUTION 12
MG/0.6ML, 8 MG/0.4ML
Tier 2
REMICADE
Tier 2
PA
RENAGEL
Tier 3
#
RENVELA
Tier 2
SFROWASA
Tier 3
sulfasalazine oral
Tier 1
SULFAZINE
Tier 1
SULFAZINE EC
Tier 1
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral
Tier 1
VELPHORO
Tier 3
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PA
#
#
Drug Name
Drug Status
Drug Details
*GENERAL ANESTHETICS*
FORANE
Tier 3
isoflurane
Tier 1
sevoflurane
Tier 1
SOJOURN
Tier 1
SUPRANE
Tier 3
TERRELL
Tier 1
ULTANE
Tier 3
*GENITOURINARY AGENTS MISCELLANEOUS*
acetic acid irrigation
Tier 1
alfuzosin hcl er
Tier 1
aminoacetic acid
Tier 1
ARGYLE STERILE SALINE
Tier 1
AVODART
Tier 3
CARDURA XL
Tier 3
citric acid-sodium citrate
Tier 1
CURITY STERILE SALINE
Tier 1
CYSTAGON
Tier 3
cytra k crystals
Tier 1
cytra-2
Tier 1
CYTRA-3
Tier 3
cytra-k
Tier 3
dutasteride
Tier 1
dutasteride-tamsulosin hcl
Tier 1
ELMIRON
Tier 2
finasteride oral tablet 5 mg
Tier 1
FLOMAX
Tier 3
glycine irrigation
Tier 1
glycine urologic
Tier 1
JALYN
Tier 3
K-PHOS NO 2
Tier 3
LITHOSTAT
Tier 3
neomycin-polymyxin b gu
Tier 1
NEOSPORIN GU IRRIGANT
Tier 3
ORACIT
Tier 3
PHENAZO ORAL TABLET 200 MG
Tier 1
phenazopyridine hcl oral tablet 100 mg, 200 mg
Tier 1
#
#
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Drug Name
Drug Status
potassium citrate-citric acid oral packet
Tier 1
potassium citrate-citric acid oral solution
Tier 3
PROCYSBI ORAL CAPSULE DELAYED
RELEASE 25 MG, 75 MG
Tier 3
PROSCAR
Tier 3
RAPAFLO
Tier 2
RENACIDIN
Tier 3
RESECTISOL
Tier 3
sodium chloride irrigation solution 0.9 %
Tier 1
tamsulosin hcl
Tier 1
TARON-CRYSTALS
Tier 1
THIOLA
Tier 3
UROCIT-K 10
Tier 3
UROCIT-K 5
Tier 3
UROXATRAL
Tier 3
Drug Details
PA; QL
LGC
PA
*GOUT AGENTS*
allopurinol oral
Tier 1
colchicine oral tablet
Tier 1
colchicine-probenecid
Tier 1
COLCRYS
Tier 3
KRYSTEXXA
Tier 3
MITIGARE
Tier 2
probenecid oral
Tier 1
ULORIC
Tier 3
ZURAMPIC
Tier 3
ZYLOPRIM
Tier 3
LGC
PA
*HEMATOLOGICAL AGENTS - MISC.*
ADVATE
Tier 2
PA
adynovate
Tier 3
PA
AFSTYLA
Tier 3
PA
AGGRENOX
Tier 3
AGRYLIN
Tier 3
ALPHANATE/VWF COMPLEX/HUMAN
Tier 3
PA
ALPHANINE SD
Tier 3
PA
ALPROLIX
Tier 3
PA
anagrelide hcl
Tier 1
aspirin-dipyridamole er
Tier 1
BEBULIN
Tier 3
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PA
Drug Name
Drug Status
Drug Details
BEBULIN VH
Tier 3
PA
BENEFIX INTRAVENOUS* SOLUTION
RECONSTITUTED
Tier 2
PA
BERINERT
Tier 3
PA
BRILINTA
Tier 2
cilostazol
Tier 1
CINRYZE
Tier 2
clopidogrel bisulfate
Tier 1
COAGADEX
Tier 3
PA
CORIFACT
Tier 3
PA
dipyridamole oral
Tier 1
DURLAZA
Tier 3
EFFIENT
Tier 2
ELOCTATE
Tier 3
PA
FEIBA
Tier 2
PA
FEIBA NF
Tier 2
PA
FEIBA VH IMMUNO
Tier 2
PA
FIRAZYR
Tier 2
PA
HELIXATE FS
Tier 3
PA
HEMOFIL M INTRAVENOUS* SOLUTION
RECONSTITUTED 1000 UNIT, 1501-2000 UNIT,
1700 UNIT, 220-400 UNIT, 250 UNIT, 401-800
UNIT, 500 UNIT, 801-1500 UNIT
Tier 3
PA
HUMATE-P INTRAVENOUS* SOLUTION
RECONSTITUTED 1000-2400 UNIT, 250-600
UNIT, 500-1200 UNIT
Tier 3
PA
IDELVION
Tier 3
PA
IXINITY INTRAVENOUS* SOLUTION
RECONSTITUTED 1500 UNIT
Tier 3
PA
KALBITOR
Tier 3
PA
KCENTRA INTRAVENOUS* KIT 500 UNIT
Tier 3
KOATE-DVI
Tier 3
PA
KOGENATE FS
Tier 3
PA
KOGENATE FS BIO-SET
Tier 3
PA
KOVALTRY
Tier 3
PA
MONOCLATE-P
Tier 2
PA
MONONINE
Tier 2
PA
NOVOEIGHT
Tier 3
PA
NOVOSEVEN RT
Tier 2
PA
NUWIQ
Tier 3
PA
PA
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Drug Name
Drug Status
Drug Details
pentoxifylline er
Tier 1
PERSANTINE
Tier 3
PLAVIX
Tier 3
PLETAL
Tier 3
PROFILNINE SD
Tier 3
PA
RECOMBINATE
Tier 3
PA
RIASTAP
Tier 2
PA
RIXUBIS
Tier 3
PA
RUCONEST
Tier 3
PA
SOLIRIS
Tier 2
PA
ticlopidine hcl
Tier 1
TRETTEN
Tier 3
PA
VONVENDI
Tier 3
PA
WILATE INTRAVENOUS* KIT
Tier 3
PA
WILATE INTRAVENOUS* SOLUTION
RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT
Tier 3
PA
XYNTHA INTRAVENOUS* KIT 1000 UNIT, 2000
UNIT, 250 UNIT, 500 UNIT
Tier 3
PA
XYNTHA SOLOFUSE
Tier 3
PA
YOSPRALA
Tier 3
*HEMATOPOIETIC AGENTS*
active fe
Tier 3
AIRAVITE
Tier 1
ALBAFORT INTRAMUSCULAR* SOLUTION
Tier 3
ANIMI-3
Tier 3
ANIMI-3/VITAMIN D
Tier 3
ARANESP (ALBUMIN FREE) INJECTION
Tier 2
PA
ARANESP (ALBUMIN FREE) INJECTION
SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150
MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300
MCG/ML, 40 MCG/ML, 60 MCG/ML
Tier 2
PA
BIFERARX
Tier 3
bp vit 3
Tier 3
CENFOL
Tier 3
CENTRATEX
Tier 3
CERDELGA
Tier 2
CEREZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 200 UNIT
Tier 2
CEREZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 400 UNIT
Tier 2
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PA; QL
PA
Drug Name
Drug Status
Drug Details
CORVITA 150
Tier 1
DIVISTA
Tier 3
DROXIA
Tier 3
ED CYTE F
Tier 3
ELELYSO
Tier 3
PA
EPOGEN INJECTION SOLUTION 10000 UNIT/ML,
2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML,
4000 UNIT/ML
Tier 3
PA
fabb
Tier 1
fa-cyanocobalamin-pyridoxine
Tier 1
fa-vitamin b-6-vitamin b-12
Tier 1
fe 90 plus
Tier 3
FER-IN-SOL
CE
fer-iron
CE
FERIVA
Tier 3
ferocon
Tier 1
ferotrinsic
Tier 1
FERRALET 90
Tier 3
ferraplus 90
Tier 3
ferrex 150 forte
Tier 1
FERREX 150 FORTE PLUS
Tier 3
FERREX 28
Tier 3
FERRLECIT
Tier 3
FERROCITE PLUS ORAL TABLET
Tier 1
FERROGELS FORTE
Tier 1
FERRO-PLEX HEMATINIC
Tier 3
FERROTRIN
Tier 3
ferrous sulfate oral solution 75 (15 fe) mg/ml
folbee
CE
Tier 1
folic acid oral tablet 1 mg
CE
folic acid oral tablet 400 mcg, 800 mcg
CE
FOLIVANE-F
Tier 3
FOLIVANE-PLUS
Tier 3
folplex 2.2
Tier 1
foltrin
Tier 1
FUSION PLUS
Tier 3
GRANIX
Tier 3
hematinic plus complex
Tier 1
LGC
PA
hematinic plus vit/minerals
Tier 1
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Drug Name
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Drug Details
hematinic/folic acid
Tier 1
HEMATOGEN FA
Tier 3
HEMATOGEN FORTE
Tier 1
hemetab
Tier 3
HEMOCYTE PLUS
Tier 3
HEMOCYTE-F ORAL TABLET
Tier 1
hemocyte-plus oral tablet 106-1 mg
Tier 1
IFEREX 150 FORTE
Tier 1
INTEGRA F
Tier 3
INTEGRA PLUS
Tier 3
IROSPAN 24/6
Tier 3
LEUKINE
Tier 3
MAXARON FORTE ORAL TABLET
Tier 3
MIRCERA INJECTION
Tier 3
MULTIGEN
Tier 3
MULTIGEN FOLIC
Tier 3
MULTIGEN PLUS
Tier 3
myferon 150 forte
Tier 1
na ferric gluc cplx in sucrose
Tier 1
NASCOBAL
Tier 3
NATALVIRT FLT
Tier 3
NEPHRON FA
Tier 3
NEULASTA DELIVERY KIT SUBCUTANEOUS*
Tier 2
PA
NEULASTA SUBCUTANEOUS*
Tier 2
PA
NEUMEGA
Tier 3
PA
NEUPOGEN INJECTION
Tier 3
PA
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6ML
Tier 3
PA
neurin-sl
Tier 3
NOVAFERRUM
Tier 3
NPLATE
Tier 3
NUFOL
Tier 1
poly-iron 150 forte
Tier 1
polysaccharide iron forte
Tier 1
PRE-FOLIC
Tier 3
PROCRIT
Tier 2
PROFERRIN-FORTE
Tier 3
PROMACTA
Tier 3
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PA
PA
PA
PA
PA
Drug Name
Drug Status
Drug Details
PROTECTIRON
Tier 3
purefe plus
Tier 3
purevit dualfe plus
Tier 1
revesta
Tier 3
se-tan plus
Tier 1
TANDEM F
Tier 3
taron forte
Tier 3
tl gard rx
Tier 1
tl icon
Tier 1
TRICON
Tier 1
trigels-f forte
Tier 1
VENOFER
Tier 3
virt-vite
Tier 1
VPRIV
Tier 2
PA
ZARXIO
Tier 3
PA
zavara
Tier 3
ZAVESCA
Tier 3
PA
*HEMOSTATICS*
AMICAR
Tier 3
aminocaproic acid oral syrup
Tier 1
aminocaproic acid oral tablet 500 mg
Tier 1
ARTISS EXTERNAL SOLUTION
Tier 3
EVICEL
Tier 3
LYSTEDA
Tier 3
monsels ferric subsulfate external
Tier 3
TISSEEL VH
Tier 3
TISSEEL VHSD
Tier 3
tranexamic acid oral
Tier 1
*HEPATITIS C AGENT - COMBINATIONS***
EPCLUSA
Tier 2
PA
HARVONI
Tier 2
PA; QL
TECHNIVIE
Tier 3
PA
VIEKIRA PAK
Tier 3
PA
VIEKIRA XR
Tier 3
PA
ZEPATIER
Tier 2
PA
Tier 2
PA
*HEREDITARY OROTIC ACIDURIA
TREATMENT - AGENTS**
XURIDEN
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Drug Name
Drug Status
Drug Details
*HYPNOTICS*
AMBIEN
Tier 3
AMBIEN CR
Tier 3
BUTISOL SODIUM
Tier 3
DORAL
Tier 3
EDLUAR
Tier 3
estazolam
Tier 1
eszopiclone
Tier 1
flurazepam hcl
Tier 1
HALCION
Tier 3
HETLIOZ
Tier 3
PA
INTERMEZZO
Tier 3
#
LUNESTA
Tier 3
midazolam hcl oral
Tier 1
phenobarbital oral elixir
Tier 1
phenobarbital oral solution
Tier 1
phenobarbital oral tablet 16.2 mg, 32.4 mg
Tier 1
RESTORIL
Tier 3
ROZEREM
Tier 3
SECONAL
Tier 3
SILENOR
Tier 3
SONATA
Tier 3
temazepam
Tier 1
triazolam
Tier 1
zaleplon
Tier 1
zolpidem tartrate
Tier 1
zolpidem tartrate er
Tier 1
ZOLPIMIST
Tier 3
*HYPOPHOSPHATASIA (HPP) AGENTS***
STRENSIQ
Tier 3
PA
*IBS AGENT - MU-OPIOID RECEPTOR
AGONISTS***
VIBERZI
Tier 2
*INTEGRIN RECEPTOR ANTAGONISTS***
ENTYVIO
Tier 3
PA
Tier 3
PA
*INTERLEUKIN-5 ANTAGONISTS (IGG1
KAPPA)***
NUCALA
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Drug Name
Drug Status
Drug Details
*INTERLEUKIN-5 ANTAGONISTS (IGG4
KAPPA)***
CINQAIR
Tier 3
PA
CLEARLAX ORAL POWDER
Tier 1
LGC
COLYTE WITH FLAVOR PACKS ORAL
SOLUTION RECONSTITUTED 227.1 GM
Tier 3
constulose
Tier 1
*LAXATIVES*
gavilax oral packet
CE
GAVILYTE-C
Tier 1
GAVILYTE-G
Tier 1
GAVILYTE-H
CE
GAVILYTE-N WITH FLAVOR PACK
Tier 1
GOLYTELY
Tier 3
KRISTALOSE
Tier 3
lactulose oral solution 10 gm/15ml
Tier 1
lactulose oral solution 20 gm/30ml
Tier 1
magnesium citrate oral solution
MIRALAX ORAL POWDER
MOVIPREP
NULYTELY WITH FLAVOR PACKS
CE
Tier 1
Select OTC
CE
Tier 3
OSMOPREP
CE
peg 3350 oral packet
CE
peg 3350/electrolytes
CE
peg 3350-kcl-na bicarb-nacl
Tier 1
peg-3350/electrolytes
Tier 1
PEG-PREP
CE
phosphate enema
CE
polyethylene glycol 3350 oral powder
LGC
Tier 1
PREPOPIK
CE
SUCLEAR
Tier 3
SUPREP BOWEL PREP
CE
TRILYTE
CE
Select OTC
*LEPTIN ANALOGUES***
MYALEPT
Tier 2
PA
Tier 3
PA
*LHRH/GNRH AGONIST ANALOG
COMBINATIONS***
LUPANETA PACK
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Drug Name
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Drug Details
*LYMPHOCYTE FUNCTION-ASSOCIATED
ANTIGEN-1 (LFA-1) ANTAG***
XIIDRA
Tier 2
*LYSOSOMAL ACID LIPASE (LAL)
DEFICIENCY - AGENTS***
KANUMA
Tier 2
*MACROLIDES*
azithromycin oral suspension reconstituted
Tier 1
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1
BIAXIN ORAL SUSPENSION RECONSTITUTED
250 MG/5ML
Tier 3
BIAXIN ORAL TABLET
Tier 3
BIAXIN XL
Tier 3
BIAXIN XL PAC
Tier 3
clarithromycin er
Tier 1
clarithromycin oral
Tier 1
DIFICID
Tier 3
E.E.S. 400 ORAL TABLET
Tier 3
E.E.S. GRANULES
Tier 3
ERYPED 200
Tier 3
ERYPED 400
Tier 3
ERY-TAB
Tier 3
ERYTHROCIN STEARATE ORAL TABLET 250
MG
Tier 3
erythromycin base oral capsule delayed release
particles
Tier 1
PCE
Tier 3
ZITHROMAX ORAL
Tier 3
ZITHROMAX TRI-PAK
Tier 3
ZITHROMAX Z-PAK
Tier 3
ZMAX
Tier 3
*MEDICAL DEVICES*
1st choice lancets super thin
Tier 1
1st choice lancets thin
Tier 1
1st choice lancets ultra thin
Tier 1
1st tier unifine pentips
Tier 3
1st tier unifine pentips plus
Tier 3
1st tier unilet comfortouch
Tier 3
ACCU-CHEK ACTIVE GLUCOSE CONT
Tier 3
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PA
Drug Name
Drug Status
ACCU-CHEK AVIVA IN VITRO SOLUTION
Tier 3
ACCU-CHEK COMFORT CURVE IN VITRO
SOLUTION
Tier 3
ACCU-CHEK COMFORT CURVE LINEAR
Tier 3
ACCU-CHEK COMPACT BLUE CONTROL
Tier 3
ACCU-CHEK COMPACT PLUS CONTROL
Tier 3
ACCU-CHEK FASTCLIX LANCET
Tier 3
ACCU-CHEK FASTCLIX LANCETS
Tier 3
ACCU-CHEK INSTANT CONTROL
Tier 3
ACCU-CHEK MULTICLIX LANCET DEV
Tier 3
ACCU-CHEK MULTICLIX LANCETS
Tier 3
ACCU-CHEK SAFE-T PRO LANCETS
Tier 3
ACCU-CHEK SMARTVIEW CONTROL
Tier 3
ACCU-CHEK SOFT TOUCH LANCETS
Tier 3
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 3
ACCU-CHEK SOFTCLIX LANCETS
Tier 3
ACCUTREND GLUCOSE CONTROL
Tier 3
ACE AEROSOL CLOUD ENHANCER
Tier 3
acti-lance 28g
Tier 3
acti-lance lite lancets 28g
Tier 1
acti-lance special lancets 17g
Tier 1
acti-lance universal 23g
Tier 3
ACTIVITY POUCH
Tier 3
ACURA CONTROL
Tier 3
ADAPTER PED DISPOSABLE
Tier 3
adjustable lancing device
Tier 3
adult aerosol mask
Tier 3
adult mask
Tier 3
adult mask large
Tier 3
ADVANCE INTUITION CONTROL
Tier 3
ADVANCE MICRO-DRAW CONTROL
Tier 3
ADVANCE MICRO-DRAW NORMAL
Tier 3
ADVOCATE CONTROL SOLUTION
Tier 3
ADVOCATE INSULIN PEN NEEDLES 31G X 5
MM , 31G X 8 MM
Tier 3
ADVOCATE INSULIN SYRINGE
Tier 3
ADVOCATE LANCETS
Tier 3
ADVOCATE LANCING DEVICE
Tier 3
Drug Details
ADVOCATE RAPID-SAFE LANCING
Tier 3
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ADVOCATE REDI-CODE+ CONTROL
Tier 3
ADVOCATE SAFETY LANCETS
Tier 3
AEROCHAMBER MINI CHAMBER
Tier 3
AEROCHAMBER MV
Tier 3
AEROCHAMBER PLUS
Tier 3
AEROCHAMBER PLUS FLO-VU
Tier 3
AEROCHAMBER PLUS FLO-VU LARGE
Tier 3
AEROCHAMBER PLUS FLO-VU MEDIUM
Tier 3
AEROCHAMBER PLUS FLO-VU SMALL
Tier 3
AEROCHAMBER PLUS FLO-VU W/MASK
Tier 3
AEROCHAMBER PLUS FLOW VU
Tier 3
AEROCHAMBER PLUS W/MASK
Tier 3
AEROCHAMBER PLUS W/MASK SMALL
Tier 3
AEROCHAMBER W/FLOWSIGNAL
Tier 3
AEROCHAMBER Z-STAT PLUS
Tier 3
AEROCHAMBER Z-STAT PLUS CHAMBR
Tier 3
AEROCHAMBER Z-STAT PLUS/LARGE
Tier 3
AEROCHAMBER Z-STAT PLUS/MEDIUM
Tier 3
AEROCHAMBER Z-STAT PLUS/SMALL
Tier 3
AEROTRACH PLUS
Tier 3
af lancets super thin
Tier 1
AGAMATRIX CONTROL
Tier 3
AGAMATRIX ULTRA-THIN LANCETS
Tier 3
AIRS PEDIATRIC AEROSOL MASK
Tier 3
AIRZONE PEAK FLOW METER
Tier 3
ALCOH-GLOVE CONTOURED WIPE
Tier 3
alcohol pads
Tier 3
alcohol prep pad 70 %
Tier 3
alcohol swabs
Tier 3
alcohol wipes
Tier 3
ALL FLOW 1000 PFT FILTER
Tier 3
alternate site lancing device
Tier 3
aqua lance adjustable lancing
Tier 3
ARIAL CHAMBER
Tier 3
ASCENSIA AUTODISC CONTROL
Tier 3
ASCENSIA AUTODISC CONTROLS
Tier 3
ASSESS FULL RANGE PEAK METER
Tier 3
ASSESS LOW RANGE PEAK METER
Tier 3
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Drug Details
Drug Name
Drug Status
ASSESS PEAK FLOW METER
Tier 3
ASSURE 3 CONTROL
Tier 3
ASSURE 4 CONTROL LEVEL 1 & 2
Tier 3
assure comfort lancets 28g
Tier 1
assure comfort lancets 30g
Tier 1
ASSURE DOSE CONTROL
Tier 3
ASSURE DOSE NORM/HIGH CONTROL
Tier 3
ASSURE HAEMOLANCE PLUS HIGH
Tier 3
ASSURE HAEMOLANCE PLUS LOW
Tier 3
ASSURE HAEMOLANCE PLUS MICRO
Tier 3
ASSURE HAEMOLANCE PLUS NORMAL
Tier 3
ASSURE HAEMOLANCE PLUS PED
Tier 3
ASSURE ID INSULIN SAFETY SYR
Tier 3
ASSURE II CONTROL
Tier 3
ASSURE II CONTROL LEVEL 1 & 2
Tier 3
ASSURE LANCE LANCETS
Tier 3
ASSURE LANCETS
Tier 3
ASSURE PRO CONTROL LEVEL 1 & 2
Tier 3
ASTHMA CHECK METER-ZONE SYSTEM
Tier 3
ASTHMAMENTOR
Tier 3
AT LAST CONTROL
Tier 3
AT LAST LANCETS
Tier 3
aurora lancet super thin 30g
Tier 3
aurora lancet thin 23g
Tier 3
aurora pen needles
Tier 3
aurora unifine pentips
Tier 3
AUTOJECT 2
Tier 3
AUTO-LANCET
Tier 3
AUTO-LANCET MINI
Tier 3
AUTOLET II CLINISAFE
Tier 3
AUTOLET IMPRESSION
Tier 3
AUTOLET LANCING DEVICE
Tier 3
AUTOLET LITE CLINISAFE
Tier 3
AUTOLET LITE STARTER PACK
Tier 3
AUTOLET MINI
Tier 3
AUTOLET PLATFORMS
Tier 3
BAYER BREEZE 2 CONTROL
Tier 3
BAYER CONTOUR
Tier 3
Drug Details
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Drug Name
Drug Status
BAYER CONTOUR NEXT CONTROL
Tier 3
BAYER MICROLET 2 LANCING DEVIC
Tier 3
BAYER MICROLET LANCETS
Tier 3
BD AUTOSHIELD 29G X 12MM
Tier 3
BD AUTOSHIELD 29G X 5MM , 29G X 8MM
Tier 2
BD AUTOSHIELD DUO
Tier 2
BD GENIE
Tier 2
BD GENIE LANCETS
Tier 2
BD INSULIN SYR ULTRAFINE II
Tier 2
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8"
1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X
1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML,
29G X 1/2" 2 ML, 30G X 1/2" 0.5 ML, 31G X 5/16"
0.3 ML
Tier 2
BD INSULIN SYRINGE 29G X 1/2" 1 ML, U-100 1
ML
Tier 3
BD INSULIN SYRINGE HALF-UNIT
Tier 2
BD INSULIN SYRINGE MICROFINE
Tier 2
BD INSULIN SYRINGE U-40
Tier 2
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2"
0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G
X 1/2" 0.3 ML, 30G X 1/2" 1 ML, 31G X 15/64" 0.3
ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G
X 5/16" 0.5 ML
Tier 2
BD INSULIN SYRINGE ULTRAFINE 31G X 5/16"
0.3 ML, 31G X 5/16" 1 ML
Tier 3
BD INTEGRA INSULIN SYRINGE
Tier 2
BD INTEGRA SYRINGE 25G X 1" 1 ML
Tier 2
BD LANCET DEVICE
Tier 3
BD LANCET ULTRAFINE 30G
Tier 2
BD LANCET ULTRAFINE 33G
Tier 2
BD MICROTAINER LANCETS
Tier 2
BD PEN
Tier 2
BD PEN MINI
Tier 2
BD PEN NEEDLE MINI U/F
Tier 2
BD PEN NEEDLE NANO U/F
Tier 2
BD PEN NEEDLE SHORT U/F
Tier 2
BD PEN NEEDLE ULTRAFINE
Tier 2
BD SAFETYGLIDE INSULIN SYRINGE 30G X
5/16" 0.5 ML
Tier 2
BD SAFETY-LOK INSULIN SYRINGE
Tier 2
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Drug Details
Drug Name
Drug Status
BD SWAB SINGLE USE REGULAR
Tier 3
BD SWABS SINGLE USE BUTTERFLY
Tier 3
BD ULTRA-FINE LANCETS
Tier 2
BREATHERITE
Tier 3
BREATHERITE COLL SPACER ADULT
Tier 3
BREATHERITE COLL SPACER CHILD
Tier 3
BREATHERITE COLL SPACER INFANT
Tier 3
BREATHERITE RIGID SPACER/MASK
Tier 3
BREATHERITE SPACER NEONATE
Tier 3
BREATHERITE SPACER SMALL CHILD
Tier 3
BREATHERITE/LARGE MASK
Tier 3
BREATHERITE/MEDIUM MASK
Tier 3
BREATHERITE/SMALL MASK
Tier 3
BUBBLES THE FISH II PEDI MASK
Tier 3
bullseye mini safety lancets
Tier 1
BULLSEYE SAFETY LANCETS
Tier 3
CARDIOCOM LANCING DEVICE
Tier 3
careone advanced lancing dev
Tier 3
careone lancet thin 23g
Tier 3
careone lancet ultra thin 28g
Tier 3
careone unifine pentips
Tier 3
careone unifine pentips plus
Tier 3
CARESENS CONTROL A
Tier 3
CLEANLET LANCETS 28G
Tier 3
CLEVER CHEK LANCETS
Tier 3
CLEVER CHOICE GLUCOSE CONTROL
Tier 3
clickfine pen needles
Tier 3
CLOSERCARE
Tier 3
co monitor replacement pieces
Tier 3
COAGUCHEK LANCETS
Tier 3
comfort assured lancets 28g
Tier 1
comfort assured lancets 33g
Tier 1
COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X
5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1
ML
Tier 3
Drug Details
COMFORT EZ INSULIN SYRINGE 30G X 1/2" 0.3
Tier 2
ML, 30G X 1/2" 1 ML
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Drug Name
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COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G
X 6 MM , 31G X 8 MM , 32G X 4 MM
Tier 3
comfort lancets
Tier 1
cone mask
Tier 3
control
Tier 3
CORNWALL METAL PIPETTING
Tier 3
CURITY ALCOHOL PREPS
Tier 3
CURITY ALCOHOL SWABS
Tier 3
cvs alcohol prep swabs
Tier 3
cvs alcohol swabs
Tier 3
cvs insulin syringe 30g x 1/2" 0.3 ml
Tier 2
cvs lancets 21g
Tier 1
cvs lancets micro thin 33g
Tier 1
cvs lancets original
Tier 1
cvs lancets thin
Tier 1
cvs lancets thin 26g
Tier 1
cvs lancets ultra thin 30g
Tier 1
cvs lancing device
Tier 3
cvs ultra thin lancets
Tier 1
DIASTAR EASY TEST II LANCETS
Tier 3
DIASTAR EASY TEST LANCETS
Tier 3
diatrue control level 1
Tier 3
diatrue control level 2
Tier 3
diatrue control level 3
Tier 3
DROPLET LANCETS ULTRA THIN 30G
Tier 3
DROPLET LANCING DEVICE
Tier 3
drug mart lancets thin 26g
Tier 1
drug mart lancets ultra thin
Tier 1
DRUG MART LANCING DEVICE
Tier 3
DRUG MART ON-THE-GO LANCET 30G
Tier 3
drug mart unifine pentips
Tier 3
DRUG MART UNILET LANCETS 28G
Tier 3
DRUG MART UNILET LANCETS 30G
Tier 3
duane reade lancet altern site
Tier 3
duane reade lancet super thin
Tier 3
duane reade lancet ultra thin
Tier 3
duane reade unifine pentips
Tier 3
DUO-CARE CONTROL SOLUTION
Tier 3
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Drug Details
Drug Name
Drug Status
earloop mask
Tier 3
EASIVENT
Tier 3
EASIVENT MASK LARGE
Tier 3
EASIVENT MASK MEDIUM
Tier 3
EASIVENT MASK SMALL
Tier 3
easy comfort insulin syringe 30g x 1/2" 1 ml
Tier 2
easy comfort lancets
Tier 1
easy comfort pen needles 31g x 5 mm , 31g x 8 mm
Tier 3
easy mini lancing device
Tier 3
easy plus ii control
Tier 3
EASY STEP CONTROL
Tier 3
easy talk control
Tier 3
EASY TOUCH ALCOHOL PREP MEDIUM
Tier 3
EASY TOUCH CONTROL HIGH & LOW
Tier 3
EASY TOUCH INSULIN SAFETY SYR 29G X 1/2"
0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML
Tier 3
EASY TOUCH INSULIN SAFETY SYR 30G X 1/2"
1 ML
Tier 2
EASY TOUCH INSULIN SYRINGE 27G X 1/2" 1
ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML
Tier 2
EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X
1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5
ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X
5/16" 0.5 ML, 31G X 5/16" 1 ML
Tier 3
EASY TOUCH LANCETS 21G
Tier 3
EASY TOUCH LANCETS 23G
Tier 3
EASY TOUCH LANCETS 26G
Tier 3
EASY TOUCH LANCETS 28G
Tier 3
EASY TOUCH LANCETS 28G/TWIST
Tier 3
EASY TOUCH LANCETS 30G
Tier 3
EASY TOUCH LANCETS 30G/TWIST
Tier 3
EASY TOUCH LANCETS 32G
Tier 3
EASY TOUCH LANCETS 32G/TWIST
Tier 3
EASY TOUCH LANCETS 33G/TWIST
Tier 3
EASY TOUCH LANCING DEVICE
Tier 3
EASY TOUCH PEN NEEDLES 29G X 12MM , 31G
X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 5
MM , 32G X 6 MM
Tier 3
EASY TOUCH SAFETY LANCETS 21G
Tier 3
Drug Details
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Drug Name
Drug Status
EASY TOUCH SAFETY LANCETS 23G
Tier 3
EASY TOUCH SAFETY LANCETS 26G
Tier 3
EASY TOUCH SAFETY LANCETS 28G
Tier 3
easy trak control
Tier 3
EASY TWIST & CAP LANCETS
Tier 3
EASYGLUCO CONTROL
Tier 3
EASYMAX 15 LEVEL 1 CONTROL
Tier 3
EASYMAX 15 LEVEL 2 CONTROL
Tier 3
EASYMAX CONTROL
Tier 3
EASYTEST II LANCETS
Tier 3
EASYTEST LANCETS
Tier 3
EFLOW SCF AEROSOL HEAD
Tier 3
element compact control 2
Tier 3
element compact control 3
Tier 3
ELEMENT CONTROL
Tier 3
ELITE DC AUTO ADAPTER
Tier 3
elite-thin insulin syringe 28g x 5/16" 0.5 ml, 28g x
5/16" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml
Tier 3
EMBRACE CONTROL
Tier 3
eql color lancets 21g
Tier 1
eql color lancets micro 33g
Tier 1
eql short pen needle
Tier 3
eql super thin lancets 30g
Tier 1
eql thin lancets 26g
Tier 1
eql ultra short pen needle
Tier 3
EVENCARE CONTROL LOW/HIGH
Tier 3
EVENCARE G2 LOW/HIGH CONTROL
Tier 3
EVENCARE G3 LOW/HIGH CONTROL
Tier 3
EVOLUTION CONTROL
Tier 3
E-Z JECT LANCET MICRO-THIN 33G
Tier 3
E-Z JECT LANCET SUPER THIN 30G
Tier 3
E-Z JECT LANCETS
Tier 3
E-Z JECT LANCETS 21G
Tier 3
E-Z JECT LANCETS THIN 26G
Tier 3
EZ SMART BLOOD GLUCOSE LANCETS
Tier 3
E-Z SPACER
Tier 3
E-Z SPACER THE BODY GUARDS PK
Tier 3
EZ-LETS LANCETS 21G
Tier 3
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Drug Status
EZ-LETS LANCETS 23G
Tier 3
EZ-LETS LANCETS 26G
Tier 3
EZ-LETS LANCETS 28G
Tier 3
EZ-LETS LANCETS 30G
Tier 3
FC FEMALE CONDOM
CE
FC2 FEMALE CONDOM
Tier 3
FEMCAP
Drug Details
CE
FIFTY50 ALCOHOL PREP
Tier 3
FIFTY50 CONTROL 2.0
Tier 3
FIFTY50 LANCING DEVICE
Tier 3
FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8
MM
Tier 3
FIFTY50 SAFETY SEAL LANCETS
Tier 3
FIFTY50 SUPERIOR COMFORT SYR
Tier 3
filter air pp
Tier 3
FINE 30
Tier 3
FINGERSTIX LANCETS
Tier 3
FORA CONTROL
Tier 3
FORA LANCETS
Tier 3
FORA LANCING DEVICE
Tier 3
FORACARE GDH CONTROL
Tier 3
freds pharmacy autolet lancing
Tier 3
freds pharmacy unifine pentip+
Tier 3
freds pharmacy unifine pentips
Tier 3
freds pharmacy unilet lanc 28g
Tier 3
freds pharmacy unilet lanc 30g
Tier 3
FREESTYLE CONTROL SOLUTION
Tier 3
FREESTYLE LANCETS
Tier 3
FREESTYLE PRECISION INS SYR
Tier 3
FREESTYLE UNISTICK II LANCETS
Tier 3
full kit nebulizer set
Tier 3
ge100 control
Tier 3
GENTLE-LET GP LANCETS
Tier 3
GENTLE-LET LANCETS
Tier 3
GENTLE-LET PLATFORMS
Tier 3
global alcohol prep ease
Tier 3
global ease inject pen needles
Tier 3
global inject ease insulin syr 30g x 1/2" 0.3 ml, 30g x
Tier 2
1/2" 1 ml
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Drug Name
Drug Status
global inject ease lancets 28g
Tier 1
global inject ease lancets 30g
Tier 1
global lancing device
Tier 3
GLUCOCARD 01 CONTROL
Tier 3
GLUCOCARD EXPRESSION CONTROL
Tier 3
GLUCOCARD SHINE
Tier 3
GLUCOCARD SHINE CONTROL
Tier 3
GLUCOCARD X-SENSOR CONTROL
Tier 3
GLUCOCOM CONTROL
Tier 3
GLUCOCOM LANCETS 28G
Tier 3
GLUCOCOM LANCETS 30G
Tier 3
GLUCOCOM LANCETS 33G
Tier 3
GLUCOLET 2 AUTOMATIC LANCING
Tier 3
GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3
ML, 30G X 1/2" 1 ML
Tier 2
GLUCOPRO INSULIN SYRINGE 30G X 5/16" 0.3
ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X
5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1
ML
Tier 3
glucose control
Tier 3
GLUCOSOURCE LANCET DEVICE
Tier 3
GLUCOSOURCE LANCETS
Tier 3
GMATE CONTROL LEVEL 2
Tier 3
gnp alcohol swabs
Tier 3
gnp clickfine pen needles
Tier 3
gnp lancets
Tier 1
gnp lancets 21g
Tier 1
gnp lancets micro thin 33g
Tier 1
gnp lancets super thin 30g
Tier 1
gnp lancets thin
Tier 1
gnp lancets thin 26g
Tier 1
gnp micro thin lancets 33g
Tier 1
gnp super thin lancets 30g
Tier 1
H&H THINLET LANCETS 26G
Tier 3
H&H THINLET LANCETS 30G
Tier 3
HAEMOLANCE
Tier 3
HAEMOLANCE LOW FLOW LANCETS
Tier 3
HAEMOLANCE PLUS
Tier 3
HAEMOLANCE PLUS HIGH FLOW
Tier 3
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Drug Name
Drug Status
HAEMOLANCE PLUS LOW FLOW
Tier 3
HAEMOLANCE PLUS MAX FLOW
Tier 3
HAEMOLANCE PLUS PEDIATRIC FLOW
Tier 3
HEALTH CARE LANCING DEVICE
Tier 3
healthwise alcohol prep
Tier 3
healthwise lancets 30g
Tier 1
healthwise lancing pen
Tier 3
healthwise mini pen needles
Tier 3
healthwise pen needles
Tier 3
healthwise short pen needles
Tier 3
healthwise unifine pentips
Tier 3
healthy accents lancing device
Tier 3
healthy accents unifine pentip
Tier 3
healthy accents unilet lancets
Tier 1
HEALTHY LIVING FILTERS
Tier 3
HEALTHY LIVING MASKS
Tier 3
HEALTHY LIVING REPLACEMENT KIT
Tier 3
h-e-b incontrol adv lancing
Tier 3
h-e-b incontrol lancets 28g
Tier 1
h-e-b incontrol lancets 30g
Tier 1
h-e-b incontrol pen needles
Tier 3
hm lancets micro thin 33g
Tier 1
hm lancets ultra thin 30g
Tier 1
HUMATROPEN FOR 12MG
Tier 3
HUMATROPEN FOR 24MG
Tier 3
HUMATROPEN FOR 6MG
Tier 3
HYPOLANCE AST LANCING
Tier 3
HY-VEE LANCETS
Tier 3
hy-vee thin lancets
Tier 1
INFINITY CONTROL
Tier 3
inject-ease
Tier 3
INJECT-EASE AUTOMATIC INJECTOR
Tier 3
INNOSPIRE REPLACEMENT FILTER
Tier 3
INSPIREASE
Tier 3
INSPIREASE BAGS
Tier 3
INSPIREASE MOUTHPIECE
Tier 3
INSPIREASE RESERVOIR BAGS
Tier 3
insupen pen needles 32g x 4 mm
Tier 3
Drug Details
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Drug Name
Drug Status
INSUPEN SENSITIVE
Tier 3
INSUPEN ULTRAFIN
Tier 3
J-TIP KIT W/VIAL ADAPTERS
Tier 3
kinney lancets
Tier 1
kinney thin lancets
Tier 1
kmart valu insulin syringe 29g
Tier 3
kmart valu insulin syringe 30g
Tier 3
KOKO PEAK PRO MOUTHPIECE
Tier 3
kroger lancets
Tier 1
kroger lancets 21g
Tier 1
kroger lancets micro thin 33g
Tier 1
kroger lancets super thin
Tier 1
kroger lancets thin
Tier 1
kroger lancets thin 26g
Tier 1
kroger lancets ultrathin 30g
Tier 1
kroger lancing device
Tier 3
kroger pen needles
Tier 3
lady lite lancets
Tier 1
lancet device
Tier 3
lancets
Tier 1
lancets 28g
Tier 1
lancets 30g
Tier 1
lancets micro thin 33g
Tier 1
lancets super thin 28g
Tier 1
lancets thin
Tier 1
LANCETS ULTRA FINE
Tier 3
LANCETS ULTRA THIN
Tier 3
lancets ultra thin 30g
Tier 1
lancing device
Tier 3
leader advanced lancing device
Tier 3
LEADER UNIFINE PENTIPS
Tier 3
LEADER UNIFINE PENTIPS PLUS
Tier 3
LIBERTY GLUCOSE CONTROL
Tier 3
LIBERTY GLUCOSE CONTROL MID
Tier 3
LIBERTY MINI LANCING DEVICE
Tier 3
LIFESCAN UNISTIK 2
Tier 3
LIFESCAN UNISTIK II LANCETS
Tier 3
lite touch lancets
Tier 1
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Drug Name
Drug Status
LITE TOUCH LANCING DEVICE
Tier 3
LITE TOUCH LANCING PEN
Tier 3
LITE TOUCH PEN NEEDLES
Tier 3
LITEAIRE
Tier 3
LITETOUCH INSULIN SYRINGE
Tier 3
LITETOUCH LANCETS
Tier 3
LITETOUCH MASK LARGE
Tier 3
LITETOUCH MASK MEDIUM
Tier 3
LITETOUCH MASK SMALL
Tier 3
LITETOUCH PEN NEEDLES
Tier 3
live better adv lancing device
Tier 3
live better lancet super thin
Tier 3
live better lancet ultra thin
Tier 3
live better pen needles
Tier 3
longs lancets standard
Tier 1
longs lancets thin
Tier 1
longs lancets ultra thin
Tier 1
MAGELLAN INSULIN SAFETY SYR
Tier 3
major comfort lancets
Tier 1
MASK VORTEX
Tier 3
MAXI-COMFORT INSULIN SYRINGE
Tier 3
MAXIMA CONTROL
Tier 3
medichoice safety lancet
Tier 3
medichoice safety lancet extra
Tier 3
medichoice safety lancet norm
Tier 3
medicine shoppe lancets
Tier 1
medicine shoppe lancets thin
Tier 1
medicine shoppe pen needles
Tier 3
medi-lance lancets
Tier 1
MEDISENSE GLUCOSE KETONE CONTR
Tier 3
MEDISENSE HI/MID/LOW CONTROL
Tier 3
MEDISENSE HIGH/LOW CONTROL
Tier 3
MEDISENSE MID CONTROL
Tier 3
MEDISENSE THIN LANCETS
Tier 3
MEDLANCE EXTRA 21G
Tier 3
MEDLANCE LITE 25G
Tier 3
MEDLANCE PLUS EXTRA 21G
Tier 3
MEDLANCE PLUS LANCETS
Tier 3
Drug Details
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Drug Name
Drug Status
MEDLANCE PLUS LITE 25G
Tier 3
MEDLANCE PLUS SPECIAL 0.8MM
Tier 3
MEDLANCE PLUS SUPERLITE 30G
Tier 3
MEDLANCE PLUS UNIVERSAL 21G
Tier 3
MEDLANCE UNIVERSAL 21G
Tier 3
meijer alcohol swabs
Tier 3
MEIJER LANCETS
Tier 3
MEIJER LANCETS THIN
Tier 3
MEIJER LANCETS UNIVERSAL 21G
Tier 3
MEIJER LANCETS UNIVERSAL 30G
Tier 3
MEIJER LANCETS UNIVERSAL 33G
Tier 3
meijer pen needles
Tier 3
MEIJER SUPER THIN LANCETS
Tier 3
MICROCHAMBER
Tier 3
MICRODOT CONTROL HIGH/LOW
Tier 3
MICROELITE BATTERY
Tier 3
MICROELITE FILTER REPLACEMENTS
Tier 3
MICROLET LANCETS
Tier 3
MICROLIFE DIGITAL PEAK FLOW
Tier 3
MICROSPACER
Tier 3
MICROTAINER SAFETY FLOW LANCET
Tier 3
mini lancing device
Tier 3
MINI WRIGHT PEAK FLOW METER
Tier 3
MINIELITE FILTER REPLACEMENTS
Tier 3
MINIELITE RECHARGEABLE BATTERY
Tier 3
MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML,
27G X 1/2" 1 ML
Tier 2
MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X
5/16" 1 ML, U-100 1 ML
Tier 3
MONOJECT ULTRA COMFORT SYRINGE
Tier 3
MONOJECTOR END CAPS
Tier 3
MONOJECTOR OPD END CAPS
Tier 3
MONOLET LANCETS
Tier 3
MONOLET OPD LANCETS
Tier 3
MONOLETTOR SAFETY LANCETS
Tier 3
MOORE MONO INSULIN SYRINGE
Tier 3
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Drug Name
Drug Status
multi-lancet device
Tier 3
MYGLUCOHEALTH CONTROL
Tier 3
MYGLUCOHEALTH LANCETS 30G
Tier 3
nebulizer air tube/plugs
Tier 3
nebulizer mask pediatric
Tier 3
NESSI SPACER WITH MASK LARGE
Tier 3
NESSI SPACER WITH MASK SM/MED
Tier 3
NESSI SPACER WITH MOUTHPIECE
Tier 3
NETGROUP LANCETS
Tier 3
NEUTEK 2TEK CONTROL
Tier 3
NEXGEN CONTROL
Tier 3
NORDIPEN 5 INJECTION DEVICE
Tier 3
NORDIPEN DELIVERY SYSTEM
Tier 3
nose clip
Tier 3
NOVA MAX PLUS GLU/KET CONTROL
Tier 3
NOVA SAFETY LANCETS 23G
Tier 3
NOVA SAFETY LANCETS 28G
Tier 3
NOVA SUREFLEX LANCETS
Tier 3
NOVA SUREFLEX LANCING DEVICE
Tier 3
NOVOFINE
Tier 3
NOVOFINE AUTOCOVER
Tier 3
NOVOTWIST
Tier 3
OMNIFLEX DIAPHRAGM
Tier 3
ON CALL EXPRESS GLUCOSE CONTR
Tier 3
ON CALL LANCETS
Tier 3
ON CALL LANCING DEVICE
Tier 3
ON CALL PLUS GLUCOSE CONTROL
Tier 3
ON CALL PLUS LANCETS
Tier 3
ON CALL PLUS LANCING DEVICE
Tier 3
ON CALL VIVID GLUCOSE CONTROL
Tier 3
ONE FLOW TESTER
Tier 3
ONETOUCH CLUB LANCETS FINE PT
Tier 3
ONETOUCH COMBO PACK
Tier 3
ONETOUCH DELICA LANCETS 33G
Tier 3
ONETOUCH DELICA LANCETS FINE
Tier 3
ONETOUCH DELICA LANCING DEV
Tier 3
ONETOUCH FINEPOINT LANCETS
Tier 3
ONETOUCH LANCETS
Tier 3
Drug Details
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Drug Name
Drug Status
ONETOUCH SURESOFT LANCING DEV
Tier 3
ONETOUCH ULTRA CONTROL
Tier 3
ONETOUCH ULTRASOFT LANCETS
Tier 3
ONETOUCH VERIO IN VITRO SOLUTION
Tier 3
OPTICHAMBER ADVANTAGE
Tier 3
OPTICHAMBER ADVANTAGE-LG MASK
Tier 3
OPTICHAMBER ADVANTAGE-MED MASK
Tier 3
OPTICHAMBER ADVANTAGE-SM MASK
Tier 3
OPTICHAMBER DIAMOND
Tier 3
OPTICHAMBER DIAMOND-LG MASK
Tier 3
OPTICHAMBER DIAMOND-MD MASK
Tier 3
OPTICHAMBER DIAMOND-SM MASK
Tier 3
OPTICHAMBER FACE MASK-LARGE
Tier 3
OPTICHAMBER FACE MASK-MEDIUM
Tier 3
OPTICHAMBER FACE MASK-SMALL
Tier 3
OPTIHALER
Tier 3
OPTUMRX GLUCOSE CONTROL
Tier 3
ORTHO DIAPHRAGM COIL
Tier 3
ORTHO DIAPHRAGM FLAT
Tier 3
PANDA MASK LARGE
Tier 3
PANDA MASK MEDIUM
Tier 3
PANDA MASK SMALL
Tier 3
PARI ALTERA NEBULIZER HANDSET
Tier 3
PARI BABY CONVERSION KIT
Tier 3
PARI ERAPID NEBULIZER HANDSET
Tier 3
PARI EXPIRATORY FILTER SET
Tier 3
PARI MASK SET
Tier 3
PARI SOFT PLASTIC ADULT MASK
Tier 3
PARI SOFT PLASTIC PED MASK
Tier 3
pc lancets super thin 30g
Tier 1
pc unifine pentips
Tier 3
pca injector
Tier 3
PEAK AIR PEAK FLOW METER
Tier 3
pediatric aerosol mask
Tier 3
pediatric mouthpiece
Tier 3
PEDIATRIC PANDA MASK
Tier 3
pen needles 1/2"
Tier 3
pen needles 29g x 12mm , 31g x 6 mm
Tier 3
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Drug Details
Drug Name
Drug Status
pen needles 3/16"
Tier 3
pen needles 5/16"
Tier 3
PENLET II BLOOD SAMPLER
Tier 3
PENLET II REPLACEMENT CAP
Tier 3
PERFECT LANCETS 28G
Tier 3
PERFECT LANCETS 30G
Tier 3
PERSONAL BEST FULL RANGE
Tier 3
PERSONAL BEST LOW RANGE
Tier 3
PFLEX
Tier 3
PHARMACIST CHOICE ALCOHOL
Tier 3
PHARMACIST CHOICE LANCETS
Tier 1
PHARMACY COUNTER LANCETS
Tier 3
PIKO 1
Tier 3
pillow mask/adult
Tier 3
pillow mask/child
Tier 3
pillow mask/pediatric
Tier 3
plastic adapter
Tier 3
POCKET CHAMBER
Tier 3
POCKET PEAK FLOW METER
Tier 3
POCKET SPACER
Tier 3
POCKETCHEM EZ CONTROL
Tier 3
POCKETPEAK PEAK FLOW METER
Tier 3
PRECISION GLUCOSE CONTROL
Tier 3
PRECISION GLUCOSE CONTROL SOLN
Tier 3
PRECISION GLUCOSE KETONE CONTR
Tier 3
PRECISION GLUCOSE/KETONE CONTR
Tier 3
PRECISION SUREDOSE PLUS SYR
Tier 3
PRECISION SURE-DOSE SYRINGE
Tier 3
PRECISION THIN LANCETS
Tier 3
PRECISION THINS GP LANCETS
Tier 3
PRECISION ULTRA LANCET
Tier 3
preferred plus lancets colored
Tier 1
preferred plus lancets thin
Tier 1
preferred plus unifine pentips
Tier 3
PRENTIF CAVITY-RIM CERV CAP
Tier 3
PRENTIF FITTING SET
Tier 3
PRODIGY CONTROL SOLUTION
Tier 3
PRODIGY INSULIN PEN NEEDLES
Tier 3
Drug Details
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Drug Name
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PRODIGY INSULIN SYRINGE
Tier 3
PRODIGY LANCETS 28G
Tier 3
PRODIGY LANCING DEVICE
Tier 3
PRODIGY MINI PEN NEEDLES
Tier 3
PRODIGY SHORT PEN NEEDLES
Tier 3
PRODIGY TWIST TOP LANCETS 28G
Tier 3
PSS SELECT GP LANCETS
Tier 3
PSS SELECT PLATFORMS
Tier 3
PSS SELECT SAFETY LANCETS
Tier 3
px advanced lancing device
Tier 3
px extra short pen needles
Tier 3
px insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 1 ml
Tier 2
px lancet auto injector
Tier 3
px lancets
Tier 1
px lancets ultra thin
Tier 1
px pen needle
Tier 3
px shortlength pen needles
Tier 3
qc advanced lancing device
Tier 3
qc alcohol swabs
Tier 3
qc insulin syringe 29g 0.3 ml, 29g 0.5 ml, 29g 1 ml,
30g 0.5 ml, 30g 1 ml
Tier 3
qc lancets super thin 30g
Tier 1
qc lancets ultra thin
Tier 1
qc pen needles
Tier 3
qc unifine pentips
Tier 3
QUICKTEK CONTROL SOLUTION
Tier 3
QUINTET CONTROL HIGH/NORMAL
Tier 3
ra alcohol swabs
Tier 3
RA E-ZJECT COLOR LANCETS 33G
Tier 3
RA E-ZJECT LANCETS 28G
Tier 3
RA E-ZJECT LANCETS THIN 26G
Tier 3
RA E-ZJECT LANCETS THIN 28G
Tier 3
RA E-ZJECT LANCETS ULTRA THIN
Tier 3
ra lancing device
Tier 3
ra pen needles
Tier 3
reality lancets
Tier 1
reality swabs
Tier 3
reality trigger lancets
Tier 1
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Drug Details
Drug Name
Drug Status
REFUAH PLUS GLUCOSE CONTROL
Tier 3
RELION ALCOHOL SWABS
Tier 3
RELION INSULIN SYRINGE
Tier 3
RELI-ON INSULIN SYRINGE
Tier 3
RELION LANCETS MICRO-THIN 33G
Tier 3
RELION LANCETS STANDARD 21G
Tier 3
RELION LANCETS THIN 26G
Tier 3
RELION LANCETS ULTRA-THIN 30G
Tier 3
RELION LANCING DEVICE
Tier 3
RELION MINI PEN NEEDLES
Tier 3
RELION PEN NEEDLES 29G X 12MM , 31G X 8
MM , 32G X 4 MM
Tier 3
RELION SHORT PEN NEEDLES
Tier 3
RELION ULTRA THIN LANCETS 30G
Tier 3
RELION ULTRA THIN PLUS LANCETS
Tier 3
RENEW ADV CARTRIDGE REFILLS
Tier 3
RENEW ADVANCED LANCING DEVICE
Tier 3
replacement air filter
Tier 3
replacement filters
Tier 3
REXALL LANCETS ULTRA THIN 30G
Tier 3
RIGHTEST ALTERNATE SITE ADAPT
Tier 3
RIGHTEST GC300 CONTROL
Tier 3
RIGHTEST GD500 LANCING DEVICE
Tier 3
RIGHTEST GL300 LANCETS
Tier 3
RITEFLO
Tier 3
SAFESNAP INSULIN SYRINGE
Tier 3
SAFE-T-LANCE
Tier 3
SAFE-T-LANCE PLUS
Tier 3
safety lancet 21g/pressure act
Tier 3
safety lancet 28g/pressure act
Tier 3
SAFETY LANCETS
Tier 3
SAFETY LANCETS 21G
Tier 3
safety lancets 28g
Tier 1
SAFETY LET LANCETS
Tier 3
SAFETY SEAL LANCETS
Tier 3
SAFETY-GLIDE SYRINGE
Tier 3
SAMI THE SEAL FILTERS
Tier 3
sb alcohol prep
Tier 3
Drug Details
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Drug Name
Drug Status
sb lancets thin
Tier 1
sb lancets ultra thin
Tier 1
select-lite device/lancets
Tier 1
select-lite lancing device
Tier 3
SHOPKO ALCOHOL SWABS
Tier 3
SHOPKO AUTOLET LANCING DEVICE
Tier 3
SHOPKO ON-THE-GO LANCETS 30G
Tier 3
SHOPKO UNIFINE PENTIPS
Tier 3
SHOPKO UNILET LANCETS 28G
Tier 3
SHOPKO UNILET LANCETS 30G
Tier 3
SIDESTREAM ADULT FACE MASK
Tier 3
SIDESTREAM PEDIATRIC FACE MASK
Tier 3
SIDESTREAM PLS ADULT FACE MASK
Tier 3
silicone mask/adult
Tier 3
silicone mask/infant
Tier 3
silicone mask/pediatric
Tier 3
SIMPLE DIAGNOSTICS LANCING DEV
Tier 3
SINGLE-LET
Tier 3
sm alcohol prep
Tier 3
sm lancets 21g
Tier 1
sm lancets 33g
Tier 1
sm super thin lancets 30g
Tier 1
sm thin lancets 26g
Tier 1
SMART DIABETES VANTAGE LANCETS
Tier 3
SMART DIABETES VANTAGE LANCING
Tier 3
SMART SENSE COLOR LANCETS 33G
Tier 3
SMART SENSE STANDARD LANCETS
Tier 3
SMART SENSE SUPER THIN LANCETS
Tier 3
SMART SENSE THIN LANCETS 26G
Tier 3
SMARTEST CONTROL MEDIUM
Tier 3
SMARTEST LANCETS 28G
Tier 3
SOLARTEK GLUCOSE CONTROL
Tier 3
SOLUS V2 CONTROL
Tier 3
SOLUS V2 LANCETS 28G
Tier 3
SOLUS V2 LANCING DEVICE
Tier 3
SOLUS V2 TWIST LANCETS 30G
Tier 3
STERILANCE PA
Tier 3
STERILANCE TL
Tier 3
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Drug Details
Drug Name
Drug Status
super thin lancets
Tier 1
supreme ii high/low control
Tier 3
sure comfort alcohol prep
Tier 3
sure comfort insulin syringe 30g x 1/2" 0.3 ml, 30g x
1/2" 1 ml
Tier 2
sure comfort lancets 28g
Tier 1
sure comfort lancets 30g
Tier 1
sure comfort lancing pen
Tier 3
sure comfort pen needles 29g x 12.7mm , 30g x 8 mm ,
31g x 5 mm , 31g x 8 mm , 32g x 4 mm
Tier 3
SURE-FINE PEN NEEDLES
Tier 3
SURE-JECT INSULIN SYRINGE
Tier 3
SURE-LANCE FLAT LANCETS
Tier 3
SURE-LANCE LANCETS 26G
Tier 3
SURE-LANCE THIN LANCETS 28G
Tier 3
SURE-LANCE ULTRA THIN LANCETS
Tier 3
SURELITE LANCETS
Tier 3
SURE-PEN
Tier 3
SURE-PREP ALCOHOL PREP
Tier 3
SURESTEP GLUCOSE CONTROL
Tier 3
SURESTEP PRO HIGH GLUCOSE
Tier 3
SURESTEP PRO LOW GLUCOSE
Tier 3
SURESTEP PRO NORMAL GLUCOSE
Tier 3
SURE-TOUCH LANCETS UNIVERSAL
Tier 3
TAI DOC CONTROL
Tier 3
TECHLITE AST LANCETS
Tier 3
TECHLITE LANCETS
Tier 3
TECHLITE LANCETS 30G
Tier 3
TELCARE GLUCOSE CONTROL
Tier 3
TERUMO INSULIN SYRINGE 27G X 1/2" 1 ML
Tier 2
TERUMO INSULIN SYRINGE 28G X 1/2" 0.5 ML,
28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2"
0.5 ML, 29G X 1/2" 1 ML, 30G X 3/8" 0.3 ML, 30G
X 3/8" 0.5 ML, 30G X 3/8" 1 ML
Tier 3
TERUMO SURGUARD INSULIN SYR
Tier 3
tgt advanced lancing device
Tier 3
tgt alcohol swabs
Tier 3
tgt lancet alternate site
Tier 3
tgt lancet micro thin 33g
Tier 3
Drug Details
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Drug Name
Drug Status
tgt lancet super thin 30g
Tier 3
tgt lancet thin 23g
Tier 3
tgt lancet thin 26g
Tier 3
tgt lancet ultra thin 28g
Tier 3
tgt lancet ultra thin 30g
Tier 3
tgt lancing device
Tier 3
THINLETS GP LANCETS
Tier 3
THINLETS LANCET
Tier 3
THINPRO INSULIN SYRINGE
Tier 3
THRESHOLD IMT
Tier 3
todays health lancing device
Tier 3
todays health mini pen needles
Tier 3
todays health pen needles
Tier 3
todays health short pen needle
Tier 3
todays health thin lancets 28g
Tier 1
todays health thin lancets 30g
Tier 1
topcare clickfine pen needles
Tier 3
TRUECONTROL GLUCOSE CONT LEV 0
Tier 3
TRUECONTROL GLUCOSE CONT LEV 1
Tier 3
TRUEDRAW LANCING DEVICE
Tier 3
TRUEPLUS INSULIN SYRINGE
Tier 3
TRUEPLUS LANCETS 26G
Tier 3
TRUEPLUS LANCETS 28G
Tier 3
TRUEPLUS LANCETS 30G
Tier 3
TRUEPLUS LANCETS 33G
Tier 3
TRUEPLUS SAFETY LANCETS 28G
Tier 3
TRUETEST CONTROL LEVEL 1
Tier 3
TRUETEST CONTROL LEVEL 2
Tier 3
TRUETEST CONTROL LEVEL 3
Tier 3
TRUZONE PEAK FLOW METER
Tier 3
tubing/wing tip
Tier 3
ULTICARE INSULIN SAFETY SYR
Tier 3
ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X
5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1
ML
Tier 3
ULTICARE INSULIN SYRINGE 30G X 1/2" 0.3
Tier 2
ML, 30G X 1/2" 1 ML
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Drug Details
Drug Name
Drug Status
ULTICARE MICRO PEN NEEDLES 32G X 4 MM
Tier 3
ULTICARE MINI PEN NEEDLES
Tier 3
ULTICARE PEN NEEDLES
Tier 3
ULTICARE SHORT PEN NEEDLES
Tier 3
ULTICARE THIN LANCETS 30G
Tier 3
ULTI-LANCE AUTOMATIC
Tier 3
ULTILET CLASSIC LANCETS
Tier 3
ULTILET INSULIN SYRINGE SHORT 30G X 5/16"
0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML
Tier 3
ULTILET LANCETS
Tier 3
ULTILET SAFETY LANCETS 23G
Tier 3
ultra thin lancets 28g
Tier 1
ultra thin lancets 30g
Tier 1
ULTRALANCE
Tier 3
ULTRA-THIN II AUTO LANCET
Tier 3
ULTRA-THIN II INS SYR SHORT
Tier 3
ULTRA-THIN II INSULIN SYRINGE
Tier 3
ULTRA-THIN II LANCETS
Tier 3
ULTRA-THIN II MINI PEN NEEDLE
Tier 3
ULTRA-THIN II PEN NEEDLE SHORT
Tier 3
ULTRA-THIN II PEN NEEDLES
Tier 3
ULTRATRAK PRO CONTROL
Tier 3
ULTRATRAK ULTIMATE CONTROL
Tier 3
UNIFINE PENTIPS
Tier 3
unifine pentips plus 32g x 4 mm
Tier 3
UNILET COMFORTOUCH LANCET
Tier 3
UNILET EXCELITE
Tier 3
UNILET EXCELITE II
Tier 3
UNILET G.P. LANCET
Tier 3
UNILET G.P. SUPERLITE LANCET
Tier 3
UNILET GP 28 ULTRA THIN
Tier 3
UNILET LANCET
Tier 3
UNILET SUPERLITE LANCET
Tier 3
UNISTIK 1
Tier 3
UNISTIK 2
Tier 3
UNISTIK 2 COMFORT
Tier 3
UNISTIK 2 EXTRA
Tier 3
UNISTIK 2 NEONATAL
Tier 3
Drug Details
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Drug Name
Drug Status
UNISTIK 2 NORMAL
Tier 3
UNISTIK 2 SUPER
Tier 3
UNISTIK 3
Tier 3
UNISTIK 3 COMFORT
Tier 3
UNISTIK 3 EXTRA
Tier 3
UNISTIK 3 GENTLE
Tier 3
UNISTIK 3 NEONATAL
Tier 3
UNISTIK 3 NORMAL
Tier 3
UNISTIK CZT COMFORT
Tier 3
UNISTIK CZT NORMAL
Tier 3
UNISTRIP CONTROL
Tier 3
UNIVERSAL 1 LANCETS THIN 26G
Tier 3
UNIVERSAL 1 LANCETS ULTRA THIN
Tier 3
value plus lancet standard 21g
Tier 3
value plus lancets super thin
Tier 1
value plus lancets thin 26g
Tier 1
value plus lancing device
Tier 3
valumark lancet super thin 30g
Tier 3
valumark lancet ultra thin 28g
Tier 3
valumark pen needles
Tier 3
valved holding chamber
Tier 3
VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1
ML
Tier 3
VICTORY CONTROL LEVEL 1/2
Tier 3
VIDA MIA AUTOLET LANCING DEV
Tier 3
VIDA MIA UNIFINE PENTIPS
Tier 3
VIDA MIA UNILET LANCETS 28G
Tier 3
VIDA MIA UNILET LANCETS 30G
Tier 3
VITALET PRO LANCETS
Tier 3
VITALET PRO PLUS LANCETS
Tier 3
VORTEX VALVED HOLDING CHAMBER
Tier 3
V-R MONO INSULIN SYRINGE
Tier 3
W&F LANCETS 26G
Tier 3
W&F LANCETS COLORED 21G
Tier 3
walgreens adv travel lancets
Tier 1
WALGREENS LANCETS
Tier 3
walgreens lancets micro thin
Tier 1
walgreens lancets super thin
Tier 1
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Drug Details
Drug Name
Drug Status
WALGREENS THIN LANCETS
Tier 3
WALGREENS ULTRA THIN LANCETS
Tier 3
WATCHHALER
Tier 3
WEBCOL ALCOHOL PREP LARGE
Tier 3
WEBCOL ALCOHOL PREP MEDIUM
Tier 3
wegmans unifine pentips plus
Tier 3
WIDE-SEAL DIAPHRAGM 60
CE
WIDE-SEAL DIAPHRAGM 65
CE
WIDE-SEAL DIAPHRAGM 70
CE
WIDE-SEAL DIAPHRAGM 75
CE
WIDE-SEAL DIAPHRAGM 80
CE
WIDE-SEAL DIAPHRAGM 85
CE
WIDE-SEAL DIAPHRAGM 90
CE
WIDE-SEAL DIAPHRAGM 95
CE
WINDMILL TRAINER
Tier 3
XPRES CONTROL
Tier 3
Drug Details
*MIGRAINE PRODUCTS*
almotriptan malate
Tier 1
ALSUMA SUBCUTANEOUS*
Tier 3
AMERGE
Tier 3
AXERT
Tier 3
CAFERGOT
Tier 3
CAMBIA
Tier 3
D.H.E. 45
Tier 3
dihydroergotamine mesylate injection
Tier 1
ERGOMAR
Tier 3
FROVA
Tier 3
frovatriptan succinate
Tier 1
IMITREX
Tier 3
IMITREX STATDOSE SYSTEM
SUBCUTANEOUS*
Tier 3
MAXALT
Tier 3
MAXALT-MLT
Tier 3
MIGERGOT
Tier 3
MIGRAL
Tier 3
MIGRALAM
Tier 3
MIGRANAL
Tier 3
naratriptan hcl
Tier 1
#
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Drug Name
Drug Status
ONZETRA XSAIL
Tier 3
RELPAX
Tier 3
rizatriptan benzoate
Tier 1
sumatriptan succinate oral
Tier 1
SUMAVEL DOSEPRO SUBCUTANEOUS*
Tier 3
TREXIMET
Tier 3
ZECUITY
Tier 3
ZEMBRACE SYMTOUCH
Tier 3
zolmitriptan oral
Tier 1
ZOMIG
Tier 3
ZOMIG ZMT
Tier 3
*MINERALS & ELECTROLYTES*
CALCIFOL
Tier 3
calcium-folic acid plus d
Tier 3
EFFER-K ORAL TABLET EFFERVESCENT 10
MEQ, 20 MEQ
Tier 3
EFFER-K ORAL TABLET EFFERVESCENT 25
MEQ
Tier 1
effervescent pot chloride
Tier 1
FLUORABON
CE
FLUOR-A-DAY ORAL SOLUTION
Tier 1
FLUOR-A-DAY ORAL TABLET CHEWABLE
Tier 3
fluoritab oral solution
Tier 1
fluoritab oral tablet chewable 0.55 (0.25 f) mg
Tier 1
fluoritab oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f)
mg
CE
FLURA-DROPS ORAL SOLUTION 0.275 (0.125 F)
MG/DROP
Tier 1
FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F)
MG/DROP
CE
GALZIN
Tier 3
KAON-CL-10
Tier 1
KARIDIUM
Tier 1
k-effervescent
Tier 1
KLOR-CON 10
Tier 1
KLOR-CON M10
Tier 1
KLOR-CON M15
Tier 3
KLOR-CON M20
Tier 1
KLOR-CON ORAL PACKET 20 MEQ
Tier 1
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#
Drug Name
Drug Status
KLOR-CON ORAL PACKET 25 MEQ
Tier 3
KLOR-CON ORAL TABLET
EXTENDEDRELEASE*
Tier 1
KLOR-CON/EF
Tier 1
KLOTRIX
Tier 1
K-PHOS
Tier 3
K-PRIME
Tier 1
K-SOL ORAL SOLUTION 20 MEQ/15ML (10%)
Tier 1
k-vescent
Tier 1
LOZI-FLUR
Tier 3
LUDENT
CE
MICRO-K
Tier 3
NAFRINSE
Tier 1
NAFRINSE DROPS
Tier 1
PHOSPHA 250 NEUTRAL
Tier 1
pot bicarb-pot chloride
Tier 1
potassium bicarbonate oral
Tier 1
potassium chloride crys er oral tablet
extendedrelease* 10 meq
Tier 1
potassium chloride crys er oral tablet
extendedrelease* 20 meq
Tier 1
potassium chloride er oral capsule extended release*
10 meq
Tier 1
potassium chloride er oral capsule extended release*
8 meq
Tier 1
potassium chloride er oral tablet extendedrelease* 10
meq, 8 meq
Tier 1
potassium chloride oral liquid† 20 meq/15ml (10%)
Tier 1
potassium chloride oral packet
Tier 1
potassium chloride oral solution 10 %
Tier 1
potassium chloride oral solution 20 meq/15ml (10%)
Tier 1
sodium fluoride oral solution
CE
sodium fluoride oral tablet 2.2 (1 f) mg
CE
sodium fluoride oral tablet chewable 0.55 (0.25 f) mg
CE
sodium fluoride oral tablet chewable 1.1 (0.5 f) mg,
2.2 (1 f) mg
CE
SSKI
Drug Details
LGC
LGC
LGC
LGC
LGC
Tier 3
*MOUTH/THROAT/DENTAL AGENTS*
cevimeline hcl
Tier 1
chlorhexidine gluconate mouth/throat
Tier 1
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Drug Name
Drug Status
clotrimazole mouth/throat
Tier 1
CONTROLRX DENTAL CREAM
Tier 1
DEBACTEROL
Tier 3
DENTA 5000 PLUS
Tier 1
dentall 1100 plus
Tier 1
EVOXAC
Tier 3
FLUORIDEX SENSITIVITY RELIEF DENTAL
GEL
Tier 3
lidocaine viscous
Tier 1
NAFRINSE DAILY ACIDULATED
Tier 3
NAFRINSE DAILY/NEUTRAL
Tier 3
NAFRINSE WEEKLY
Tier 3
nystatin mouth/throat
Tier 1
ORALONE
Tier 1
ORAMAGICRX
Tier 3
ORAVIG
Tier 3
PERIDEX
Tier 3
PERIOGARD
Tier 1
PERIOMED
Tier 1
pilocarpine hcl oral
Tier 1
SALAGEN
Tier 3
SALICEPT MOUTH/THROAT SUSPENSION
RECONSTITUTED
Tier 3
sf 5000 plus
Tier 1
stannous fluoride mouth/throat
Tier 1
triamcinolone acetonide mouth/throat
Tier 1
Drug Details
*MUCOPOLYSACCHARIDOSIS IV (MPS IV) AGENTS***
VIMIZIM
Tier 2
*MULTIPLE VITAMINS W/ MINERALS &
FLUORIDE-IRON-FOLIC ACID***
QUFLORA FE
Tier 3
*MULTIVITAMINS*
active ob
Tier 3
advanced am/pm
Tier 3
ATABEX EC
Tier 3
ATABEX ORAL TABLET
Tier 3
BAL-CARE DHA
Tier 3
CITRANATAL 90 DHA ORAL 90-1 & 300 MG
Tier 3
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PA
Drug Name
Drug Status
CITRANATAL B-CALM
Tier 3
CITRANATAL DHA
Tier 3
CITRANATAL HARMONY ORAL CAPSULE
27-1-260 MG
Tier 3
CITRANATAL RX
Tier 3
c-nate dha
Tier 3
completenate
Tier 3
CO-NATAL FA
Tier 3
CONCEPT DHA
Tier 3
CONCEPT OB
Tier 3
CORVITA
Tier 1
CRNATAL
Tier 3
DIALYVITE
Tier 1
DIALYVITE 3000
Tier 3
DIALYVITE 5000
Tier 3
DIALYVITE SUPREME D
Tier 3
DIALYVITE/ZINC
Tier 3
DUET DHA 400
Tier 3
DUET DHA 400EC
Tier 3
DUET DHA 430
Tier 3
DUET DHA 430EC
Tier 3
DUET DHA BALANCED ORAL 25-1 & 267 MG
Tier 3
ELITE-OB
Tier 3
ESCAVITE
Tier 3
extra-virt plus dha
Tier 3
focalgin-b
Tier 3
folbee plus
Tier 1
FOLBEE PLUS CZ
Tier 1
folcal dha oral capsule 27-1.25-300 mg
Tier 3
FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG
Tier 3
FOLGARD OS
Tier 3
FOLIVANE-OB
Tier 3
FOLIVANE-PRX DHA NF
Tier 3
GESTICARE DHA ORAL 27-1 & 250 MG
Tier 3
hemenatal ob
Tier 3
hemenatal ob + dha
Tier 3
INATAL ADVANCE
Tier 3
INATAL GT
Tier 3
Drug Details
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Drug Name
Drug Status
INATAL ULTRA
Tier 3
infanate balance
Tier 3
levomefolate dha
Tier 3
MACNATAL CN DHA
Tier 3
MARNATAL-F
Tier 3
multi vit/fl
Tier 1
multi vita-bets/fluoride oral tablet chewable 0.25 mg
Tier 1
multi vitamin/fluoride
Tier 1
multiple vitamins/fluoride
Tier 1
multi-vit/fluoride oral solution
Tier 1
multi-vit/fluoride/iron
Tier 3
multi-vitamin/fluoride oral solution
Tier 1
multivitamin/fluoride oral tablet chewable 0.25 mg,
0.5 mg, 1 mg
Tier 1
multi-vitamin/fluoride oral tablet chewable 0.5 mg
Tier 1
multi-vitamin/fluoride/iron
Tier 3
multivitamins/fluoride
Tier 1
multi-vitamins/fluoride oral solution 0.5 mg/ml
Tier 1
multi-vits/fluoride
Tier 1
mult-vitamin/fluoride
Tier 1
MVC-FLUORIDE
Tier 1
MYKIDZ IRON FL
Tier 3
MYNATAL ADVANCE
Tier 1
MYNATAL ORAL CAPSULE
Tier 3
MYNATAL ORAL TABLET
Tier 1
mynatal plus
Tier 1
mynatal-z
Tier 1
mynephrocaps
Tier 1
NATACHEW ORAL TABLET CHEWABLE 28-1
MG
Tier 3
NATALVIRT 90 DHA
Tier 3
NATALVIRT CA
Tier 3
NATALVIT
Tier 3
NATELLE ONE ORAL CAPSULE 28-1-250 MG
Tier 3
NEEVO DHA ORAL CAPSULE 27-1.13 MG
Tier 3
NEPHPLEX RX
Tier 3
NEPHROCAPS
Tier 3
NEPHROCAPS QT
Tier 3
NEPHRONEX ORAL TABLET
Tier 1
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Drug Name
Drug Status
NESTABS
Tier 3
NESTABS ABC
Tier 3
NESTABS DHA
Tier 3
NEXA PLUS
Tier 3
NICOMIDE
Tier 3
NUTRIVIT
Tier 3
OB COMPLETE 400 ORAL CAPSULE 40-10-1-400
MG
Tier 3
OB COMPLETE GOLD
Tier 3
OB COMPLETE ONE
Tier 3
OB COMPLETE ORAL TABLET
Tier 3
OB COMPLETE ORAL TABLET CHEWABLE
15-5-1-100 MG
Tier 3
OB COMPLETE PETITE
Tier 3
OB COMPLETE PREMIER
Tier 3
OB COMPLETE/DHA
Tier 3
O-CAL PRENATAL
Tier 3
OCUVEL ORAL CAPSULE 0.5 MG
Tier 3
PAIRE OB
Tier 3
pnv fe fum/docusate/folic acid
Tier 3
pnv ob+dha
Tier 3
pnv-dha
Tier 3
pnv-dha+docusate
Tier 3
pnv-omega
Tier 3
pnv-select
Tier 3
pnv-total
Tier 3
POLY-VI-FLOR
Tier 3
POLY-VI-FLOR/IRON
Tier 3
polyvitamin/fluoride
Tier 1
poly-vitamin/fluoride oral solution 0.5 mg/ml
Tier 1
PR NATAL 400
Tier 3
PREFERA OB + DHA ORAL 28-6-1 & 203 MG
Tier 3
PREFERA OB ORAL TABLET 28-6-1 MG
Tier 3
PREFERAOB ONE
Tier 3
PREFOL-DHA
Tier 3
prena1 pearl
Tier 3
prena1 plus/quatrefolic
Tier 3
prena1/quatrefolic oral capsule
Tier 3
Drug Details
prenaissance
Tier 3
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Drug Name
Drug Status
prenaissance 90 dha
Tier 3
prenaissance balance
Tier 3
prenaissance dha
Tier 3
prenaissance harmony dha
Tier 3
prenaissance next
Tier 3
prenaissance next-b
Tier 3
prenaissance plus
Tier 3
prenaissance promise
Tier 3
PRENATA
Tier 3
prenatabs fa
Tier 3
PRENATABS RX
Tier 3
prenatal 19
Tier 3
PRENATAL AD
Tier 3
PRENATAL MULTIVITAMIN-ULTRA
Tier 3
prenatal plus iron
Tier 3
PRENATAL-U
Tier 3
PRENATE
Tier 3
PRENATE AM
Tier 3
PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300
MG
Tier 3
PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG
Tier 3
PRENATE ENHANCE
Tier 3
PRENATE MINI
Tier 3
PRENATE RESTORE
Tier 3
PREQUE 10 ORAL TABLET 15-25-0.5-50 MG
Tier 3
PROVIDA OB
Tier 3
purefe ob plus
Tier 3
QUFLORA PEDIATRIC ORAL SOLUTION
Tier 3
QUFLORA PEDIATRIC ORAL TABLET
CHEWABLE
Tier 1
relnate dha
Tier 3
RENAL ORAL CAPSULE
Tier 1
RENATABS
Tier 3
RENATABS WITH IRON
Tier 3
rena-vite rx
Tier 1
reno caps
Tier 1
R-NATAL OB
Tier 3
SELECT-OB ORAL TABLET CHEWABLE 29-1
MG
Tier 3
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Drug Name
Drug Status
SELECT-OB+DHA
Tier 3
se-natal 19
Tier 3
STROVITE FORTE ORAL SYRUP
Tier 2
SUPERVITE EC
Tier 3
SYNAGEX
Tier 3
SYNATEK
Tier 3
TARON-BC
Tier 3
TARON-C DHA
Tier 3
TARON-PREX
Tier 3
TL G-FOL OS
Tier 3
tl-care dha
Tier 3
tl-fluorivite
Tier 3
tl-select
Tier 3
triadvance
Tier 3
TRICARE PRENATAL 1
Tier 3
TRICARE PRENATAL COMPLEAT
Tier 3
TRICARE PRENATAL DHA ONE
Tier 3
trinatal gt
Tier 3
TRINATE
Tier 3
triphrocaps
Tier 1
triple-vitamin/fluoride
Tier 1
tri-tabs dha
Tier 3
TRIVEEN-DUO DHA
Tier 3
TRIVEEN-PRX RNF
Tier 3
TRI-VI-FLOR
Tier 3
tri-vi-floro
Tier 3
tri-vit/fluoride
Tier 1
tri-vit/fluoride/iron
Tier 3
tri-vitamin/fluoride
Tier 1
UDAMIN SP
Tier 3
ultra tabs
Tier 3
VEMAVITE-PRX 2
Tier 3
vena-bal dha
Tier 3
venatal-fa
Tier 3
VINACAL B
Tier 3
VINATE AZ EXTRA
Tier 3
VINATE CALCIUM
Tier 3
VINATE DHA RF
Tier 3
Drug Details
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Drug Name
Drug Status
VINATE IC
Tier 3
VINATE II
Tier 3
VINATE M
Tier 3
virt-caps
Tier 1
virt-pn
Tier 3
virt-pn dha
Tier 3
virt-pn plus
Tier 3
virt-select
Tier 3
virt-vite plus
Tier 1
VITAFOL FE+
Tier 3
VITAFOL GUMMIES
Tier 3
VITAFOL ULTRA
Tier 3
VITAFOL-NANO
Tier 3
VITAFOL-OB
Tier 3
VITAFOL-OB+DHA
Tier 3
VITAFOL-ONE
Tier 3
VITAL-D RX
Tier 3
VITAMEDMD ONE RX/QUATREFOLIC
Tier 3
VITAMEDMD PLUS RX/QUATREFOLIC
Tier 3
vitamins acd-fluoride
Tier 1
VITAPEARL
Tier 3
VITA-PREN
Tier 3
VIVA DHA
Tier 3
vol-care rx
Tier 1
vol-nate
Tier 3
vol-tab rx
Tier 3
vp-ch plus
Tier 3
vp-ch-pnv
Tier 3
vp-ggr-b6 prenatal
Tier 3
vp-heme ob
Tier 3
vp-heme ob + dha
Tier 3
vp-heme one
Tier 3
vp-pnv-dha
Tier 3
ZATEAN-CH
Tier 3
ZATEAN-PN
Tier 3
ZATEAN-PN DHA
Tier 3
ZATEAN-PN PLUS
Tier 3
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Drug Name
Drug Status
Drug Details
*MUSCULOSKELETAL THERAPY AGENTS*
AMRIX
Tier 3
baclofen oral tablet 10 mg
Tier 1
baclofen oral tablet 20 mg
Tier 1
carisoprodol oral tablet 350 mg
Tier 1
carisoprodol-aspirin
Tier 1
carisoprodol-aspirin-codeine
Tier 1
chlorzoxazone oral tablet 500 mg
Tier 1
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
Tier 1
cyclobenzaprine hcl oral tablet 7.5 mg
Tier 1
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
Tier 3
dantrolene sodium oral
Tier 1
EUFLEXXA INTRA-ARTICULAR*
Tier 2
FEXMID
Tier 3
GEL-ONE INTRA-ARTICULAR*
Tier 3
PA
GELSYN-3
Tier 3
PA
HYALGAN
Tier 3
PA
HYMOVIS
Tier 3
PA
LORZONE
Tier 3
metaxalone
Tier 1
methocarbamol oral
Tier 1
MONOVISC
Tier 2
orphenadrine citrate er
Tier 1
orphenadrine-aspirin-caffeine oral tablet 25-385-30
mg
Tier 1
ORTHOVISC INTRA-ARTICULAR*
Tier 2
PARAFON FORTE DSC
Tier 3
ROBAXIN ORAL
Tier 3
ROBAXIN-750
Tier 3
SKELAXIN
Tier 3
SOMA
Tier 3
SUPARTZ INTRA-ARTICULAR*
Tier 3
PA
SYNVISC INTRA-ARTICULAR*
Tier 3
PA
SYNVISC ONE INTRA-ARTICULAR*
Tier 3
PA
THERABENZAPRINE-90-5
Tier 3
tizanidine hcl oral
Tier 1
ZANAFLEX
Tier 3
LGC
LGC
PA
PA
PA
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Drug Details
*NASAL AGENTS - SYSTEMIC AND
TOPICAL*
ADRENALIN NASAL
Tier 3
ASTEPRO NASAL SOLUTION 0.15 %
Tier 3
ATROVENT
Tier 3
azelastine hcl nasal
Tier 1
BACTROBAN NASAL
Tier 3
BECONASE AQ
Tier 3
DYMISTA
Tier 3
FLONASE ALLERGY RELIEF
Tier 1
flunisolide nasal solution 25 mcg/act (0.025%)
Tier 1
fluticasone propionate nasal
Tier 1
ipratropium bromide nasal
Tier 1
mometasone furoate nasal
Tier 1
NASACORT ALLERGY 24HR
Tier 1
Select OTC
NASONEX
Tier 3
#
olopatadine hcl nasal
Tier 1
OMNARIS
Tier 3
PATANASE
Tier 3
QNASL
Tier 3
QNASL CHILDRENS
Tier 3
TYZINE
Tier 3
VERAMYST
Tier 3
ZETONNA
Tier 3
Select OTC
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II
RECEPT ANTAG COMB***
ENTRESTO
Tier 2
*NEUROGENIC ORTHOSTATIC
HYPOTENSION (NOH) - AGENTS***
NORTHERA ORAL CAPSULE 100 MG, 200 MG,
300 MG
Tier 3
PA; QL
BOTOX
Tier 2
PA
DYSPORT
Tier 3
PA
RILUTEK
Tier 3
riluzole
Tier 1
XEOMIN
Tier 3
*NEUROMUSCULAR AGENTS*
*OPHTHALMIC AGENTS*
ACULAR
Tier 3
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PA
Drug Name
Drug Status
Drug Details
ACULAR LS
Tier 3
ACUVAIL
Tier 3
ak-poly-bac
Tier 1
AKTEN
Tier 3
ALAWAY
Tier 1
Select OTC
ALAWAY CHILDRENS ALLERGY
Tier 1
Select OTC
ALCAINE
Tier 3
allergy eye drops
Tier 1
ALOCRIL
Tier 3
ALOMIDE
Tier 3
ALPHAGAN P
Tier 2
ALREX
Tier 2
ALTACAINE
Tier 1
ALTAFLUOR
Tier 1
ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5
%
Tier 1
apraclonidine hcl
Tier 1
atropine sulfate ophthalmic solution
Tier 1
atropine-care
Tier 1
AZASITE
Tier 2
azelastine hcl ophthalmic
Tier 1
AZOPT
Tier 2
bacitracin ophthalmic
Tier 1
bacitracin-polymyxin b ophthalmic ointment
500-10000 unit/gm
Tier 1
bacitra-neomycin-polymyxin-hc
Tier 1
BEPREVE
Tier 3
BESIVANCE
Tier 3
BETADINE OPHTHALMIC PREP
Tier 3
BETAGAN
Tier 3
betaxolol hcl ophthalmic
Tier 1
BETIMOL
Tier 2
BETOPTIC-S
Tier 2
bimatoprost ophthalmic
Tier 1
BIO GLO
Tier 1
BLEPHAMIDE
Tier 3
BLEPHAMIDE S.O.P.
Tier 3
brimonidine tartrate ophthalmic
Tier 1
bromfenac sodium ophthalmic
Tier 1
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Drug Status
carteolol hcl
Tier 1
CILOXAN
Tier 3
ciprofloxacin hcl ophthalmic
Tier 1
CLARITIN EYE
Tier 1
COMBIGAN
Tier 2
COSOPT
Tier 3
COSOPT PF
Tier 3
cromolyn sodium ophthalmic
Tier 1
cvs allergy eye drops
Tier 1
CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2
%
Tier 3
CYCLOMYDRIL
Tier 3
cyclopentolate hcl ophthalmic
Tier 1
CYSTARAN
Tier 3
dexamethasone sodium phosphate ophthalmic
Tier 1
diclofenac sodium ophthalmic
Tier 1
dorzolamide hcl
Tier 1
dorzolamide hcl-timolol mal
Tier 1
DUREZOL
Tier 2
ELESTAT
Tier 3
EMADINE
Tier 3
epinastine hcl
Tier 1
eq itchy eye drops
Tier 1
erythromycin ophthalmic
Tier 1
eye itch relief
Tier 1
EYLEA
Tier 3
FLAREX
Tier 3
fluorescein-benoxinate
Tier 1
FLUOR-I-STRIPS A.T.
Tier 1
fluorometholone ophthalmic
Tier 1
FLURA-SAFE
Tier 3
flurbiprofen sodium
Tier 1
FLUROX
Tier 1
FML
Tier 3
FML FORTE
Tier 3
FML LIQUIFILM
Tier 3
FUL-GLO OPHTHALMIC STRIP 0.6 MG
Tier 3
FUL-GLO OPHTHALMIC STRIP 1 MG
Tier 1
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Drug Details
#
PA
PA
Drug Name
Drug Status
GARAMYCIN OPHTHALMIC SOLUTION
Tier 3
gatifloxacin ophthalmic
Tier 1
GELFILM OPHTHALMIC
Tier 3
GENTAK OPHTHALMIC OINTMENT
Tier 1
gentamicin sulfate ophthalmic
Tier 1
HOMATROPAIRE
Tier 1
homatropine hbr ophthalmic
Tier 1
ILEVRO
Tier 3
ILOTYCIN
Tier 1
IOPIDINE
Tier 3
ISOPTO CARBACHOL
Tier 2
ISOPTO HOMATROPINE OPHTHALMIC
SOLUTION 2 %
Tier 3
ISOPTO HYOSCINE
Tier 3
ISTALOL
Tier 3
itchy eye drops
Tier 1
JETREA
Tier 3
ketorolac tromethamine ophthalmic
Tier 1
ketotifen fumarate ophthalmic
Tier 1
LACRISERT
Tier 3
LASTACAFT
Tier 3
latanoprost ophthalmic
Tier 1
levobunolol hcl ophthalmic solution 0.5 %
Tier 1
levofloxacin ophthalmic
Tier 1
LOTEMAX OPHTHALMIC GEL
Tier 2
LOTEMAX OPHTHALMIC OINTMENT
Tier 3
LOTEMAX OPHTHALMIC SUSPENSION
Tier 2
LUCENTIS
Tier 3
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
Tier 2
MACUGEN
Tier 3
MAXIDEX
Tier 3
MAXITROL
Tier 3
metipranolol
Tier 1
MOXEZA
Tier 3
mydral
Tier 1
MYDRIACYL
Tier 3
NATACYN
Tier 3
NEOFRIN
Tier 1
Drug Details
PA
#
PA
PA
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Drug Details
neomycin-bacitracin zn-polymyx
Tier 1
neomycin-polymyxin-dexameth ophthalmic ointment
Tier 1
neomycin-polymyxin-dexameth ophthalmic suspension
3.5-10000-0.1
Tier 1
neomycin-polymyxin-gramicidin ophthalmic solution
1.75-10000-.025
Tier 1
NEO-POLYCIN
Tier 1
NEO-POLYCIN HC
Tier 1
NEOSPORIN
Tier 3
NEVANAC
Tier 3
OCUFEN
Tier 3
OCUFLOX
Tier 3
ofloxacin ophthalmic
Tier 1
olopatadine hcl ophthalmic
Tier 1
OMNIPRED
Tier 3
OPTIVAR
Tier 3
OZURDEX
Tier 2
parcaine
Tier 1
PAREMYD
Tier 3
PATADAY
Tier 2
#
PATANOL
Tier 3
#
PAZEO
Tier 2
phenylephrine hcl ophthalmic solution 10 %, 2.5 %
Tier 1
PHOSPHOLINE IODIDE
Tier 2
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
Tier 1
POLYCIN
Tier 1
polycin b
Tier 1
poly-dex ophthalmic ointment
Tier 1
polymyxin b-trimethoprim
Tier 1
POLYTRIM
Tier 3
PRED FORTE
Tier 3
PRED MILD
Tier 3
PRED-G
Tier 3
PRED-G S.O.P.
Tier 3
prednisolone acetate ophthalmic
Tier 1
prednisolone sodium phosphate ophthalmic
Tier 1
PROLENSA
Tier 3
proparacaine hcl ophthalmic
Tier 1
RESCULA
Tier 3
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Drug Name
Drug Status
RESTASIS
Tier 2
romycin
Tier 1
SIMBRINZA
Tier 3
sulfacetamide sodium ophthalmic solution
Tier 1
sulfacetamide-prednisolone ophthalmic solution
Tier 1
TETCAINE
Tier 1
tetracaine hcl ophthalmic
Tier 1
TETRAVISC
Tier 1
TETRAVISC FORTE
Tier 1
timolol maleate ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC OCUDOSE
Tier 3
TIMOPTIC-XE
Tier 3
TOBRADEX
Tier 3
TOBRADEX ST
Tier 3
tobramycin ophthalmic
Tier 1
tobramycin-dexamethasone
Tier 1
TOBREX
Tier 3
TRAVATAN Z
Tier 2
travoprost
Tier 1
trifluridine ophthalmic
Tier 1
triple antibiotic ophthalmic ointment 5-400-10000
Tier 1
tropicamide ophthalmic
Tier 1
TRUSOPT
Tier 3
VEXOL
Tier 3
VIGAMOX
Tier 3
VIROPTIC
Tier 3
VISUDYNE
Tier 3
WAL-ZYR OPHTHALMIC
Tier 1
XALATAN
Tier 3
ZADITOR
Tier 1
ZIOPTAN
Tier 3
ZIRGAN
Tier 3
ZYLET
Tier 3
ZYMAXID
Tier 3
ZYRTEC ITCHY EYE
Tier 1
Drug Details
PA; #
Select OTC
#
*OREXIN RECEPTOR ANTAGONISTS***
BELSOMRA
Tier 3
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Drug Details
*OTIC AGENTS*
ACETASOL HC
Tier 1
acetic acid otic
Tier 1
antibiotic ear
Tier 1
antipyrine-benzocaine
Tier 1
AURODEX
Tier 1
CETRAXAL
Tier 3
CIPRO HC
Tier 3
CIPRODEX
Tier 2
COLY-MYCIN S
Tier 3
CORTISPORIN OTIC SOLUTION
Tier 3
CORTISPORIN-TC
Tier 3
CRESYLATE
Tier 3
DERMOTIC
Tier 3
FLOXIN OTIC
Tier 3
fluocinolone acetonide otic
Tier 1
hydrocortisone-acetic acid
Tier 1
MYOXIN
Tier 3
neomycin-polymyxin-hc otic
Tier 1
ofloxacin otic
Tier 1
otic care
Tier 1
oticin
Tier 1
OTOVEL
Tier 3
OTOZIN
Tier 3
pinnacaine otic
Tier 3
VOSOL HC
Tier 3
#
*OXABOROLE-RELATED ANTIFUNGALS TOPICAL***
KERYDIN
Tier 3
*OXYTOCICS*
CERVIDIL
Tier 3
methylergonovine maleate oral
Tier 1
PREPIDIL
Tier 3
PROSTIN E2
Tier 3
*PASSIVE IMMUNIZING AGENTS COMBINATIONS***
HYQVIA
Tier 3
PA
*PASSIVE IMMUNIZING AGENTS*
BIVIGAM
Tier 3
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Drug Name
Drug Status
Drug Details
CARIMUNE NF INTRAVENOUS* SOLUTION
RECONSTITUTED 12 GM, 6 GM
Tier 3
CYTOGAM
Tier 2
FLEBOGAMMA DIF
Tier 3
PA
FLEBOGAMMA INTRAVENOUS* SOLUTION 0.5
GM/10ML
Tier 3
PA
GAMASTAN S/D
Tier 3
GAMMAGARD
Tier 3
PA
GAMMAGARD S/D INTRAVENOUS* SOLUTION
RECONSTITUTED 10 GM, 5 GM
Tier 3
PA
GAMMAGARD S/D INTRAVENOUS* SOLUTION
RECONSTITUTED 2.5 GM
Tier 3
GAMMAGARD S/D LESS IGA
Tier 3
GAMMAKED
Tier 3
PA
GAMMAPLEX
Tier 3
PA
GAMUNEX-C
Tier 3
PA
HEPAGAM B
Tier 2
HIZENTRA SUBCUTANEOUS* SOLUTION 1
GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML
Tier 3
HYPERHEP B S/D
Tier 3
HYPERRAB S/D INTRAMUSCULAR*
INJECTABLE 150 UNIT/ML
Tier 3
HYPERRHO S/D INTRAMUSCULAR*
Tier 3
HYPERTET S/D
Tier 2
IMOGAM RABIES-HT
Tier 2
MICRHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR*
Tier 3
NABI-HB
Tier 3
OCTAGAM
Tier 3
PA
PRIVIGEN
Tier 3
PA
RHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR*
Tier 3
RHOPHYLAC INJECTION
Tier 2
SYNAGIS
Tier 2
WINRHO SDF
Tier 3
PA
PA
PA
*PCSK9 INHIBITORS***
PRALUENT
Tier 2
PA
REPATHA
Tier 2
PA
REPATHA PUSHTRONEX SYSTEM
Tier 2
PA
REPATHA SURECLICK
Tier 2
PA
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Drug Details
*PENICILLINS*
amoxicillin oral capsule
Tier 1
LGC
amoxicillin oral suspension reconstituted
Tier 1
LGC
amoxicillin oral tablet
Tier 1
amoxicillin-pot clavulanate er
Tier 1
amoxicillin-pot clavulanate oral
Tier 1
AMOXIL ORAL CAPSULE
Tier 1
LGC
AMOXIL ORAL SUSPENSION RECONSTITUTED
250 MG/5ML
Tier 1
LGC
ampicillin oral capsule
Tier 1
AUGMENTIN ES-600
Tier 3
AUGMENTIN ORAL SUSPENSION
RECONSTITUTED 125-31.25 MG/5ML
Tier 2
AUGMENTIN ORAL SUSPENSION
RECONSTITUTED 250-62.5 MG/5ML
Tier 3
AUGMENTIN ORAL TABLET 500-125 MG,
875-125 MG
Tier 3
AUGMENTIN XR
Tier 3
dicloxacillin sodium
Tier 1
MOXATAG
Tier 3
penicillin v potassium oral solution reconstituted 125
mg/5ml
Tier 1
penicillin v potassium oral solution reconstituted 250
mg/5ml
Tier 1
penicillin v potassium oral tablet 250 mg
Tier 1
penicillin v potassium oral tablet 500 mg
Tier 1
TRIMOX
Tier 1
LGC
VEETIDS ORAL TABLET 250 MG
Tier 1
LGC
LGC
LGC
*PHARMACEUTICAL ADJUVANTS*
PCCA ACACIA SYRUP BASE
Tier 3
polyethylene glycol 3350 powder
Tier 1
LGC
Tier 3
PA
OTEZLA ORAL 10 & 20 & 30 MG
Tier 3
PA
OTEZLA ORAL TABLET
Tier 2
PA
*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K)
INHIBITORS***
ZYDELIG
*PHOSPHODIESTERASE 4 (PDE4)
INHIBITORS***
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Drug Details
*POLY (ADP-RIBOSE) POLYMERASE (PARP)
INHIBITORS**
LYNPARZA
Tier 3
PA; QL
Tier 3
PA; QL
*POLY (ADP-RIBOSE) POLYMERASE (PARP)
INHIBITORS***
LYNPARZA
*POTASSIUM REMOVING AGENTS***
kalexate
Tier 1
KAYEXALATE
Tier 3
KIONEX
Tier 1
sodium polystyrene sulfonate oral
Tier 1
sodium polystyrene sulfonate suspension
Tier 1
SPS
Tier 3
VELTASSA
Tier 3
PA
*PRENATAL MV & MINERALS W/FA
WITHOUT IRON***
PRENATE
Tier 3
*PROGESTINS*
AYGESTIN
Tier 3
MAKENA
Tier 3
PA
medroxyprogesterone acetate oral
Tier 1
LGC
MEGACE ES
Tier 3
megestrol acetate oral suspension 625 mg/5ml
Tier 1
norethindrone acetate oral
Tier 1
progesterone intramuscular*
Tier 1
progesterone micronized oral
Tier 1
PROMETRIUM
Tier 3
PROVERA
Tier 3
*PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.*
acamprosate calcium
Tier 1
AMPYRA
Tier 3
ANTABUSE
Tier 3
ARICEPT
Tier 3
ARICEPT ODT ORAL TABLET DISPERSIBLE 10
MG
Tier 3
AUBAGIO
Tier 3
PA; QL
AVONEX
Tier 3
PA
AVONEX PEN INTRAMUSCULAR*
Tier 3
PA; QL
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Drug Name
Drug Status
AVONEX PREFILLED INTRAMUSCULAR*
Tier 3
BETASERON SUBCUTANEOUS* KIT
Tier 3
BRISDELLE
Tier 3
BUPROBAN
CE
bupropion hcl er (smoking det)
CE
CAMPRAL
Tier 3
CHANTIX
CE
CHANTIX CONTINUING MONTH PAK
CE
CHANTIX STARTING MONTH PAK
CE
Drug Details
PA; QL
COPAXONE SUBCUTANEOUS* 20 MG/ML
Tier 3
PA
COPAXONE SUBCUTANEOUS* 40 MG/ML
Tier 2
PA
disulfiram oral
Tier 1
donepezil hcl
Tier 1
ergoloid mesylates oral
Tier 1
EXELON ORAL CAPSULE
Tier 3
#
EXELON TRANSDERMAL
Tier 3
#
EXTAVIA SUBCUTANEOUS* KIT
Tier 3
PA; QL
fluoxetine hcl (pmdd)
Tier 1
galantamine hydrobromide
Tier 1
galantamine hydrobromide er
Tier 1
GILENYA
Tier 2
PA; QL
GLATOPA
Tier 1
PA
GRALISE
Tier 3
GRALISE STARTER
Tier 3
HORIZANT ORAL TABLET
EXTENDEDRELEASE*
Tier 3
LEMTRADA
Tier 3
memantine hcl oral tablet
Tier 1
NAMENDA ORAL SOLUTION
Tier 3
NAMENDA ORAL TABLET
Tier 3
NAMENDA TITRATION PAK
Tier 3
NAMENDA XR
Tier 2
#
NAMENDA XR TITRATION PACK
Tier 2
#
NICODERM CQ
CE
NICORETTE
Tier 3
NICORETTE MINI
Tier 3
NICORETTE STARTER KIT
Tier 3
nicotine
CE
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PA; QL
#
Drug Name
Drug Status
nicotine polacrilex mouth/throat
CE
NICOTROL
CE
NICOTROL NS
CE
Drug Details
NUEDEXTA
Tier 2
olanzapine-fluoxetine hcl
Tier 1
ORAP
Tier 3
pimozide
Tier 1
PLEGRIDY
Tier 3
PA; QL
PLEGRIDY STARTER PACK
Tier 3
PA; QL
RAZADYNE
Tier 3
RAZADYNE ER
Tier 3
REBIF REBIDOSE SUBCUTANEOUS*
Tier 2
REBIF REBIDOSE TITRATION PACK
SUBCUTANEOUS*
Tier 2
REBIF SUBCUTANEOUS*
Tier 2
REBIF TITRATION PACK SUBCUTANEOUS*
Tier 2
rivastigmine
Tier 1
rivastigmine tartrate
Tier 1
SARAFEM ORAL TABLET 10 MG, 20 MG
Tier 1
SAVELLA
Tier 2
SAVELLA TITRATION PACK
Tier 2
SYMBYAX
Tier 3
TECFIDERA ORAL
Tier 3
PA; QL
TECFIDERA ORAL CAPSULE DELAYED
RELEASE 120 MG, 240 MG
Tier 3
PA; QL
tetrabenazine
Tier 1
PA
TYSABRI
Tier 3
PA
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 3
PA; QL
XYREM
Tier 3
PA
ZINBRYTA
Tier 3
PA
ZYBAN
Tier 3
#
*PULMONARY FIBROSIS AGENTS - KINASE
INHIBITORS***
OFEV
Tier 3
PA; QL
Tier 3
PA; QL
Tier 3
PA
*PULMONARY FIBROSIS AGENTS***
ESBRIET
*PULMONARY HYPERTENSION PROSTACYCLIN RECEPTOR AGONIST***
UPTRAVI
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Drug Name
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Drug Details
*RESPIRATORY AGENTS - MISC.*
ARALAST NP
Tier 3
PA
CUROSURF
Tier 3
GLASSIA
Tier 3
INFASURF
Tier 3
KALYDECO ORAL PACKET
Tier 3
PA
KALYDECO ORAL TABLET
Tier 3
PA; QL
PROLASTIN-C INTRAVENOUS* SOLUTION
RECONSTITUTED 1000 MG
Tier 3
PA
PULMOZYME
Tier 2
PA
SCLEROSOL INTRAPLEURAL
Tier 3
STERILE TALC POWDER
Tier 3
ZEMAIRA
Tier 3
PA
PA
*SEROTONIN MODULATORS***
BRINTELLIX
Tier 3
nefazodone hcl oral tablet 250 mg
Tier 3
nefazodone hcl oral tablet 50 mg
Tier 1
OLEPTRO
Tier 3
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg
Tier 1
trazodone hcl oral tablet 300 mg
Tier 1
VIIBRYD
Tier 3
VIIBRYD STARTER PACK
Tier 3
LGC
*SGLT2 INHIBITOR - DPP-4 INHIBITOR
COMBINATIONS***
GLYXAMBI
Tier 2
*SINUS NODE INHIBITORS**
CORLANOR
Tier 3
*SODIUM-GLUCOSE CO-TRANSPORTER 2
INHIBITOR-BIGUANIDE COMB***
INVOKAMET
Tier 2
INVOKAMET XR
Tier 2
SYNJARDY
Tier 2
XIGDUO XR
Tier 3
*TETRACYCLINES*
ACTICLATE
Tier 3
ADOXA
Tier 3
AL
ADOXA PAK 1/100
Tier 3
AL
ADOXA PAK 1/150
Tier 3
AL
ADOXA PAK 2/100
Tier 3
AL
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Drug Name
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Drug Details
avidoxy
Tier 1
AL
demeclocycline hcl oral
Tier 1
AL
DORYX MPC
Tier 3
DORYX ORAL TABLET DELAYED RELEASE 150
MG, 200 MG
Tier 3
DORYX ORAL TABLET DELAYED RELEASE 50
MG
Tier 3
doxycycline hyclate oral capsule
Tier 1
AL
doxycycline hyclate oral tablet 100 mg, 20 mg
Tier 1
AL
doxycycline hyclate oral tablet delayed release 100
mg, 150 mg, 75 mg
Tier 1
AL
doxycycline hyclate oral tablet delayed release 200
mg, 50 mg
Tier 1
doxycycline monohydrate oral
Tier 1
AL
MINOCIN ORAL CAPSULE 100 MG, 50 MG
Tier 3
AL
minocycline hcl er
Tier 1
AL
minocycline hcl oral
Tier 1
AL
MONODOX ORAL CAPSULE 100 MG, 75 MG
Tier 3
AL
MORGIDOX ORAL CAPSULE 100 MG
Tier 1
AL
NICAZELDOXY 30
Tier 3
NICAZELDOXY 60
Tier 3
SOLODYN ORAL TABLET EXTENDED
RELEASE 24 HR* 105 MG, 115 MG, 55 MG, 65
MG, 80 MG
Tier 3
TARGADOX
Tier 3
tetracycline hcl oral
Tier 1
VIBRAMYCIN
Tier 3
AL
AL
AL
*THYROID AGENTS*
ARMOUR THYROID ORAL TABLET 120 MG, 15
MG, 180 MG, 240 MG, 300 MG
Tier 3
CYTOMEL
Tier 3
levothyroxine sodium oral tablet 100 mcg, 112 mcg,
125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
levothyroxine sodium oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
liothyronine sodium oral
Tier 1
methimazole oral
Tier 1
NATURE-THROID
Tier 3
np thyroid
Tier 1
LGC
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Drug Name
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propylthiouracil oral
Tier 1
SYNTHROID
Tier 3
TAPAZOLE
Tier 3
THYROLAR-1
Tier 3
THYROLAR-1/2
Tier 3
THYROLAR-1/4
Tier 3
THYROLAR-2
Tier 3
THYROLAR-3
Tier 3
TIROSINT
Tier 3
UNITHROID
Tier 1
UNITHROID DIRECT
Tier 1
WESTHROID
Tier 3
WP THYROID ORAL TABLET 113.75 MG, 130
MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 97.5
MG
Tier 3
Drug Details
*ULCER DRUGS*
acid reducer maximum strength oral tablet 20 mg
Tier 1
ACIPHEX
Tier 3
ACIPHEX SPRINKLE
Tier 3
amoxicill-clarithro-lansopraz
Tier 1
AXID ORAL CAPSULE 300 MG
Tier 3
AXID ORAL SOLUTION
Tier 3
BENTYL ORAL CAPSULE
Tier 3
BENTYL ORAL TABLET
Tier 3
CANTIL
Tier 3
CARAFATE
Tier 3
chlordiazepoxide-clidinium
Tier 1
cimetidine hcl oral
Tier 1
cimetidine oral tablet 300 mg, 400 mg, 800 mg
Tier 1
CUVPOSA
Tier 3
CYTOTEC
Tier 3
DEXILANT
Tier 2
dicyclomine hcl oral capsule
Tier 1
LGC
dicyclomine hcl oral tablet
Tier 1
LGC
esomeprazole magnesium oral capsule delayed
release 40 mg
Tier 1
esomeprazole strontium oral capsule delayed release
49.3 mg
Tier 3
famotidine oral suspension reconstituted
Tier 1
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LGC
#
Drug Name
Drug Status
famotidine oral tablet 40 mg
Tier 1
GLYCATE
Tier 3
glycopyrrolate oral
Tier 1
kp omeprazole magnesium
Tier 1
lansoprazole oral capsule delayed release 15 mg
Tier 1
lansoprazole oral capsule delayed release 30 mg
Tier 1
LIBRAX
Tier 3
methscopolamine bromide oral
Tier 1
misoprostol oral
Tier 1
NEXIUM 24HR
Tier 1
NEXIUM ORAL CAPSULE DELAYED RELEASE
40 MG
Tier 3
NEXIUM ORAL PACKET
Tier 3
nizatidine
Tier 1
OMECLAMOX-PAK
Tier 2
omeprazole magnesium
Tier 1
omeprazole oral capsule delayed release 10 mg, 40
mg
Tier 1
omeprazole oral tablet delayed release
Tier 1
omeprazole-sodium bicarbonate oral capsule 40-1100
mg
Tier 1
omeprazole-sodium bicarbonate oral packet
Tier 1
PAMINE
Tier 3
PAMINE FORTE
Tier 3
pantoprazole sodium oral
Tier 1
PEPCID ORAL SUSPENSION RECONSTITUTED
Tier 3
PEPCID ORAL TABLET 40 MG
Tier 3
PREVACID 24HR
Tier 1
PREVACID ORAL CAPSULE DELAYED
RELEASE 30 MG
Tier 3
PREVACID SOLUTAB
Tier 3
PREVPAC
Tier 3
PRILOSEC
Tier 3
PRILOSEC OTC
Tier 1
PROTONIX ORAL
Tier 3
PYLERA
Tier 2
rabeprazole sodium
Tier 1
ranitidine hcl oral capsule 300 mg
Tier 1
ranitidine hcl oral syrup
Tier 1
Drug Details
LGC
Select OTC
Select OTC
#
Select OTC
Select OTC
Select OTC
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Drug Name
Drug Status
Drug Details
ranitidine hcl oral tablet 300 mg
Tier 1
LGC
ROBINUL ORAL
Tier 3
ROBINUL-FORTE
Tier 3
sucralfate oral tablet
Tier 1
ZEGERID ORAL CAPSULE 40-1100 MG
Tier 3
ZEGERID ORAL PACKET
Tier 3
#
ZEGERID OTC
Tier 1
#; Select OTC
*URINARY ANTI-INFECTIVES*
FURADANTIN
Tier 3
HIPREX
Tier 3
MACROBID
Tier 3
MACRODANTIN
Tier 3
methenamine hippurate
Tier 1
methenamine mandelate oral tablet 1 gm
Tier 1
MONUROL
Tier 3
nitrofurantoin macrocrystal oral capsule 100 mg, 50
mg
Tier 1
nitrofurantoin monohyd macro
Tier 1
nitrofurantoin oral suspension
Tier 1
UREX
Tier 3
#
*URINARY ANTISPASMODICS*
bethanechol chloride oral tablet 25 mg
Tier 1
darifenacin hydrobromide er
Tier 1
DETROL
Tier 3
DETROL LA
Tier 3
DITROPAN XL
Tier 3
ENABLEX
Tier 3
flavoxate hcl
Tier 1
GELNIQUE TRANSDERMAL GEL 3 (28) %
(MG/ACT)
Tier 3
MYRBETRIQ
Tier 2
oxybutynin chloride oral tablet
Tier 1
LGC
OXYTROL FOR WOMEN
Tier 1
#; Select OTC
TOVIAZ
Tier 3
trospium chloride er
Tier 1
VESICARE
Tier 2
*VAGINAL PRODUCTS*
AVC VAGINAL
Tier 3
CLEOCIN VAGINAL
Tier 3
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#
Drug Name
Drug Status
clindamycin phosphate vaginal
Tier 1
CLINDESSE
Tier 3
CRINONE
Tier 2
ENCARE VAGINAL SUPPOSITORY
Tier 3
ENDOMETRIN
Tier 2
ESTRACE VAGINAL
Tier 3
ESTRING
Tier 3
FEM PH
Tier 3
FEMRING
Tier 3
GYNAZOLE-1
Tier 3
METROGEL-VAGINAL
Tier 3
metronidazole vaginal
Tier 1
NUVESSA
Tier 3
OPTIONS CONCEPTROL
Tier 3
OPTIONS GYNOL II CONTRACEPTIVE
Tier 3
PREMARIN VAGINAL
Tier 2
RELAGARD
Tier 3
SHUR-SEAL CONTRACEPTIVE
Tier 3
TERAZOL 3 VAGINAL CREAM
Tier 3
TERAZOL 7
Tier 3
terconazole
Tier 1
TODAY SPONGE
Drug Details
#
CE
VAGIFEM VAGINAL TABLET 10 MCG
Tier 3
VANDAZOLE
Tier 1
VCF VAGINAL CONTRACEPTIVE VAGINAL
FILM
CE
VCF VAGINAL CONTRACEPTIVE VAGINAL
FOAM
Tier 3
ZAZOLE
Tier 1
#
*VASOPRESSORS*
ADRENACLICK INJECTION
Tier 3
AUVI-Q INJECTION
Tier 2
epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml
Tier 1
EPIPEN 2-PAK INJECTION
Tier 2
#
EPIPEN JR 2-PAK INJECTION
Tier 2
#
midodrine hcl
Tier 1
*VITAMINS*
delta d3
CE
DRISDOL ORAL CAPSULE
Tier 3
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D-VI-SOL
CE
D-VITA
CE
ENDUR-ACIN
Tier 1
eql niacin
Tier 1
ergocalciferol oral capsule
Tier 1
gnp niacin
Tier 1
gnp niacin tr
Tier 1
hm niacin
Tier 1
MEPHYTON
Tier 2
niacin er
Tier 1
niacin oral tablet
Tier 1
niacin-50
Tier 1
px niacin
Tier 1
ra niacin
Tier 1
ra no flush niacin
Tier 1
SLO-NIACIN ORAL TABLET
EXTENDEDRELEASE* 250 MG
Tier 1
SLO-NIACIN ORAL TABLET
EXTENDEDRELEASE* 500 MG, 750 MG
Tier 3
sm niacin cr
Tier 1
vitamin d (ergocalciferol)
Tier 1
vitamin d2 oral tablet 400 unit
CE
vitamin d3 oral capsule 1000 unit, 400 unit
CE
vitamin d3 oral liquid† 400 unit/ml
CE
vitamin d3 oral tablet 1000 unit, 400 unit
CE
vitamin d3 oral tablet chewable 400 unit
CE
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Drug Details
1st choice lancets super thin .................... 94
1st choice lancets thin ...................................... 94
1st choice lancets ultra thin ...................... 94
1st tier unifine pentips ..................................... 94
1st tier unifine pentips plus ....................... 94
1st tier unilet comfortouch ......................... 94
8-MOP ................................................................................. 60
abacavir sulfate ........................................................ 44
abacavir-lamivudine-zidovudine ........ 44
ABILIFY .......................................................................... 43
ABILIFY DISCMELT .................................... 43
ABILIFY MAINTENA ................................. 43
ABREVA ......................................................................... 60
ABSORICA .................................................................. 60
ABSTRAL ...................................................................... 11
acamprosate calcium ..................................... 139
ACANYA ........................................................................ 60
acarbose ............................................................................ 25
ACCOLATE ................................................................ 18
ACCU-CHEK ACTIVE ................................ 70
ACCU-CHEK ACTIVE GLUCOSE
CONT ................................................................................... 94
ACCU-CHEK ADVANTAGE TEST
........................................................................................................ 70
ACCU-CHEK AVIVA ........................ 70, 95
ACCU-CHEK AVIVA PLUS ............... 70
ACCU-CHEK COMFORT CURVE
............................................................................................. 70, 95
ACCU-CHEK COMFORT CURVE
LINEAR ............................................................................ 95
ACCU-CHEK COMPACT ....................... 70
ACCU-CHEK COMPACT BLUE
CONTROL .................................................................... 95
ACCU-CHEK COMPACT PLUS ... 70
ACCU-CHEK COMPACT PLUS
CONTROL .................................................................... 95
ACCU-CHEK COMPACT TEST
DRUM ................................................................................. 70
ACCU-CHEK FASTCLIX LANCET
........................................................................................................ 95
ACCU-CHEK FASTCLIX
LANCETS ...................................................................... 95
ACCU-CHEK INSTANT CONTROL
........................................................................................................ 95
ACCU-CHEK MULTICLIX
LANCET DEV ......................................................... 95
ACCU-CHEK MULTICLIX
LANCETS ...................................................................... 95
ACCU-CHEK SAFE-T PRO
LANCETS ...................................................................... 95
ACCU-CHEK SMARTVIEW .............. 70
ACCU-CHEK SMARTVIEW
CONTROL .................................................................... 95
ACCU-CHEK SOFT TOUCH
LANCETS ...................................................................... 95
ACCU-CHEK SOFTCLIX LANCET
DEV ........................................................................................ 95
ACCU-CHEK SOFTCLIX
LANCETS ...................................................................... 95
ACCUPRIL ................................................................... 33
ACCURETIC .............................................................. 33
ACCUTREND GLUCOSE ....................... 70
ACCUTREND GLUCOSE
CONTROL .................................................................... 95
acd formula a .............................................................. 19
acd formula b .............................................................. 20
acd-a ...................................................................................... 20
ACD-A NOCLOT-50 ....................................... 20
ACE AEROSOL CLOUD
ENHANCER ............................................................... 95
acebutolol hcl ............................................................. 49
ACEON .............................................................................. 34
acetaminophen-codeine ................................. 11
acetaminophen-codeine #2 ........................ 11
acetaminophen-codeine #3 ........................ 11
acetaminophen-codeine #4 ........................ 11
ACETASOL HC ................................................. 136
acetazolamide ............................................................. 77
acetazolamide er ..................................................... 77
ACETEST ....................................................................... 70
acetic acid ........................................................ 85, 136
acetylcysteine .............................................................. 58
acid reducer maximum strength ...... 144
ACIPHEX .................................................................... 144
ACIPHEX SPRINKLE ............................... 144
acitretin .............................................................................. 60
ACLOVATE ................................................................ 60
ACTEMRA ....................................................................... 8
ACTICIN ......................................................................... 60
ACTICLATE ........................................................... 142
ACTIGALL .................................................................. 83
acti-lance 28g ............................................................. 95
acti-lance lite lancets 28g ........................... 95
acti-lance special lancets 17g ................ 95
acti-lance universal 23g ................................ 95
ACTIMMUNE .......................................................... 39
ACTIQ ................................................................................. 11
active fe .............................................................................. 88
active ob ......................................................................... 122
ACTIVELLA .............................................................. 82
active-medicated spec collect ................. 70
ACTIVITY POUCH .......................................... 95
ACTONEL ..................................................................... 78
ACTOPLUS MET ................................................ 25
ACTOPLUS MET XR .................................... 25
ACTOS ............................................................................... 25
ACULAR ..................................................................... 130
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Index
Index
Index
Index
ACULAR LS ........................................................... 131
ACURA BLOOD GLUCOSE TEST
........................................................................................................ 70
ACURA CONTROL ......................................... 95
ACUVAIL .................................................................. 131
acyclovir ................................................................. 44, 60
ACZONE ......................................................................... 60
ADAGEN ........................................................................ 50
ADALAT CC ............................................................. 50
adapalene ......................................................................... 60
ADAPTER PED DISPOSABLE ....... 95
ADCIRCA ...................................................................... 51
ADDERALL ................................................................... 6
ADDERALL XR ....................................................... 6
adefovir dipivoxil ................................................... 44
ADEMPAS .................................................................... 51
adjustable lancing device ............................ 95
ADOXA ......................................................................... 142
ADOXA PAK 1/100 ...................................... 142
ADOXA PAK 1/150 ...................................... 142
ADOXA PAK 2/100 ...................................... 142
ADRENACLICK ............................................... 147
ADRENALIN ......................................................... 130
adult aerosol mask ............................................... 95
adult mask ....................................................................... 95
adult mask large ...................................................... 95
ADVAIR DISKUS .............................................. 18
ADVAIR HFA .......................................................... 18
ADVANCE INTUITION CONTROL
........................................................................................................ 95
ADVANCE INTUITION TEST ......... 70
ADVANCE MICRO-DRAW
CONTROL .................................................................... 95
ADVANCE MICRO-DRAW
NORMAL ....................................................................... 95
ADVANCE MICRO-DRAW TEST
........................................................................................................ 70
advanced am/pm .................................................. 122
ADVATE ......................................................................... 86
ADVICOR ...................................................................... 32
ADVOCATE CONTROL
SOLUTION .................................................................. 95
ADVOCATE INSULIN PEN
NEEDLES ....................................................................... 95
ADVOCATE INSULIN SYRINGE
........................................................................................................ 95
ADVOCATE LANCETS ............................ 95
ADVOCATE LANCING DEVICE
........................................................................................................ 95
ADVOCATE RAPID-SAFE
LANCING ...................................................................... 95
ADVOCATE REDI-CODE ..................... 71
ADVOCATE REDI-CODE+
CONTROL .................................................................... 96
149
71
ADVOCATE SAFETY LANCETS
96
ADVOCATE TEST ........................................... 71
adynovate ......................................................................... 86
ADZENYS XR-ODT ........................................... 6
AEROCHAMBER MINI CHAMBER
........................................................................................................ 96
AEROCHAMBER MV ................................. 96
AEROCHAMBER PLUS ........................... 96
AEROCHAMBER PLUS FLO-VU
........................................................................................................ 96
AEROCHAMBER PLUS FLO-VU
LARGE ............................................................................... 96
AEROCHAMBER PLUS FLO-VU
MEDIUM ......................................................................... 96
AEROCHAMBER PLUS FLO-VU
SMALL .............................................................................. 96
AEROCHAMBER PLUS FLO-VU
W/MASK ......................................................................... 96
AEROCHAMBER PLUS FLOW VU
........................................................................................................ 96
AEROCHAMBER PLUS W/MASK
........................................................................................................ 96
AEROCHAMBER PLUS W/MASK
SMALL .............................................................................. 96
AEROCHAMBER
W/FLOWSIGNAL .............................................. 96
AEROCHAMBER Z-STAT PLUS
........................................................................................................ 96
AEROCHAMBER Z-STAT PLUS
CHAMBR ....................................................................... 96
AEROCHAMBER Z-STAT
PLUS/LARGE ........................................................... 96
AEROCHAMBER Z-STAT
PLUS/MEDIUM ..................................................... 96
AEROCHAMBER Z-STAT
PLUS/SMALL .......................................................... 96
AEROSPAN ................................................................ 18
AEROTRACH PLUS ....................................... 96
af lancets super thin ........................................... 96
AFEDITAB CR ....................................................... 50
AFINITOR ..................................................................... 39
AFINITOR DISPERZ ..................................... 39
AFREZZA ...................................................................... 25
AFSTYLA ...................................................................... 86
AGAMATRIX AMP TEST ..................... 71
AGAMATRIX CONTROL ...................... 96
AGAMATRIX JAZZ TEST .................... 71
AGAMATRIX KEYNOTE TEST
........................................................................................................ 71
AGAMATRIX PRESTO TEST .......... 71
AGAMATRIX ULTRA-THIN
LANCETS ...................................................................... 96
AGGRENOX .............................................................. 86
........................................................................................................
Index
........................................................................................................
Index
Index
ADVOCATE REDI-CODE+ TEST
AGRYLIN ...................................................................... 86
aif #2 drug preparation kit ........................ 60
AIRAVITE .................................................................... 88
AIRS PEDIATRIC AEROSOL
MASK .................................................................................. 96
AIRZONE PEAK FLOW METER
........................................................................................................ 96
AKNE-MYCIN ........................................................ 60
ak-poly-bac ................................................................ 131
AKTEN ........................................................................... 131
AKYNZEO .................................................................... 30
ALAGESIC LQ ....................................................... 10
ALAVERT ..................................................................... 31
ALAVERT ALLERGY/SINUS .......... 58
ALAWAY ................................................................... 131
ALAWAY CHILDRENS ALLERGY
.................................................................................................... 131
ALBAFORT ................................................................ 88
ALBENZA ..................................................................... 16
ALBUSTIX ................................................................... 71
albuterol sulfate ....................................................... 18
albuterol sulfate er ............................................... 18
ALCAINE ................................................................... 131
alclometasone dipropionate ..................... 60
ALCOH-GLOVE CONTOURED
WIPE ..................................................................................... 96
alcohol pads ................................................................. 96
alcohol prep .................................................................. 96
alcohol swabs ............................................................. 96
alcohol wipes ............................................................... 96
ALDACTAZIDE ................................................... 77
ALDACTONE .......................................................... 77
ALDARA ......................................................................... 60
ALDURAZYME .................................................... 78
ALECENSA ................................................................. 39
alendronate sodium .................................. 78, 79
ALFERON N .............................................................. 39
alfuzosin hcl er .......................................................... 85
ALINIA .............................................................................. 36
ALKERAN .................................................................... 39
ALL FLOW 1000 PFT FILTER ......... 96
ALLEGRA ALLERGY ................................. 31
ALLEGRA ALLERGY CHILDRENS
........................................................................................................ 31
allergy .................................................................................. 31
allergy eye drops ................................................. 131
allergy relief ................................................................. 31
allopurinol ...................................................................... 86
ALLZITAL .................................................................... 10
almotriptan malate ........................................... 119
ALOCRIL .................................................................... 131
alogliptin benzoate ............................................... 25
alogliptin-metformin hcl ............................... 25
alogliptin-pioglitazone .................................... 25
ALOMIDE .................................................................. 131
ALORA .............................................................................. 82
alosetron hcl ................................................................. 83
ALPHAGAN P ..................................................... 131
ALPHANATE/VWF
COMPLEX/HUMAN ...................................... 86
ALPHANINE SD .................................................. 86
alphatrex ........................................................................... 60
alprazolam ...................................................................... 16
alprazolam er .............................................................. 16
ALPRAZOLAM INTENSOL ............... 16
alprazolam xr .............................................................. 16
ALPROLIX ................................................................... 86
ALREX ........................................................................... 131
ALSUMA .................................................................... 119
ALTABAX .................................................................... 60
ALTACAINE ......................................................... 131
ALTACE .......................................................................... 34
ALTAFLUOR ........................................................ 131
ALTAFRIN ............................................................... 131
ALTAVERA ................................................................ 52
alternate site lancing device .................... 96
ALTOPREV ................................................................. 32
ALVESCO ..................................................................... 18
alyacen 1/35 ................................................................. 52
alyacen 7/7/7 ............................................................... 53
amantadine hcl .......................................................... 42
AMARYL ....................................................................... 25
AMBIEN .......................................................................... 92
AMBIEN CR ............................................................... 92
amcinonide ..................................................................... 60
AMERGE .................................................................... 119
AMETHIA ..................................................................... 53
AMETHIA LO .......................................................... 53
AMETHYST ............................................................... 53
AMICAR .......................................................................... 91
amiloride hcl ................................................................ 77
amiloride-hydrochlorothiazide ............. 77
aminoacetic acid ..................................................... 85
aminocaproic acid ................................................ 91
amiodarone hcl ......................................................... 17
AMITIZA ........................................................................ 83
amitriptyline hcl ...................................................... 22
amlodipine besy-benazepril hcl ........... 34
amlodipine besylate ............................................ 50
amlodipine besylate-valsartan .............. 34
amlodipine-valsartan-hctz .......................... 34
AMMONUL ................................................................ 79
AMNESTEEM ......................................................... 60
amoxapine ....................................................................... 22
amoxicill-clarithro-lansopraz ............ 144
amoxicillin .................................................................. 138
amoxicillin-pot clavulanate ................... 138
amoxicillin-pot clavulanate er ........... 138
AMOXIL ...................................................................... 138
amphetamine salt combo ................................. 6
amphetamine-dextroamphet er ................. 6
amphetamine-dextroamphetamine ....... 6
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Index
ampicillin ...................................................................... 138
AMPYRA .................................................................... 139
AMRIX ........................................................................... 129
AMTURNIDE ........................................................... 34
ANACAINE ................................................................. 61
ANADROL-50 ......................................................... 14
ANAFRANIL ............................................................. 22
anagrelide hcl ............................................................. 86
ANALPRAM-HC ................................................. 15
ANAPROX ....................................................................... 8
ANAPROX DS ............................................................ 8
anastrozole ..................................................................... 39
ANDRODERM ........................................................ 14
ANDROGEL .................................................... 14, 15
ANDROGEL PUMP ......................................... 14
ANDROID ..................................................................... 15
ANDROXY .................................................................. 15
ANGELIQ ....................................................................... 82
ANIMI-3 ........................................................................... 88
ANIMI-3/VITAMIN D .................................. 88
ANORO ELLIPTA ............................................. 18
ANTABUSE ............................................................ 139
ANTARA ......................................................................... 32
antibiotic ear ............................................................ 136
anticoagulant cit dext soln a .................... 20
ANTICOAGULANT COMPOUND
........................................................................................................ 20
antifungal ......................................................................... 61
antipyrine-benzocaine .................................. 136
ANTIVERT .................................................................. 30
ANUSOL-HC ............................................................. 15
ANZEMET .................................................................... 30
apap-caff-dihydrocodeine ........................... 11
APEXICON .................................................................. 61
APEXICON E ............................................................ 61
APIDRA ............................................................................ 25
APIDRA SOLOSTAR .................................... 25
APLENZIN ................................................................... 22
apraclonidine hcl ................................................ 131
APRI ...................................................................................... 53
APRISO ............................................................................. 83
APTENSIO XR ........................................................... 6
APTIOM ........................................................................... 20
APTIVUS ........................................................................ 44
aqua lance adjustable lancing ............... 96
ARALAST NP ...................................................... 142
ARALEN ......................................................................... 37
ARANELLE ................................................................ 53
ARANESP (ALBUMIN FREE) ......... 88
ARBINOXA ................................................................ 31
ARCALYST .................................................................... 8
ARCAPTA NEOHALER ............................ 18
ARGYLE STERILE SALINE .............. 85
ARGYLE STERILE WATER .............. 47
ARIAL CHAMBER ........................................... 96
ARICEPT ..................................................................... 139
ARICEPT ODT .................................................... 139
ARIDOL ........................................................................... 71
ARIMIDEX .................................................................. 39
aripiprazole ................................................................... 43
ARIXTRA ....................................................................... 20
armodafinil ........................................................................ 6
ARMOUR THYROID ................................ 143
ARNUITY ELLIPTA ....................................... 18
AROMASIN ................................................................ 39
ARTHROTEC ............................................................... 8
ARTISS .............................................................................. 91
ASACOL HD ............................................................. 83
ASCENSIA AUTODISC CONTROL
........................................................................................................ 96
ASCENSIA AUTODISC
CONTROLS ................................................................ 96
ASCENSIA AUTODISC TEST ......... 71
ASCOMP-CODEINE ...................................... 11
ASMANEX 120 METERED DOSES
........................................................................................................ 18
ASMANEX 14 METERED DOSES
........................................................................................................ 18
ASMANEX 30 METERED DOSES
........................................................................................................ 18
ASMANEX 60 METERED DOSES
........................................................................................................ 18
ASMANEX 7 METERED DOSES
........................................................................................................ 18
ASMANEX HFA .................................................. 18
aspirin .................................................................................. 10
aspirin-dipyridamole er ................................. 86
ASSESS FULL RANGE PEAK
METER .............................................................................. 96
ASSESS LOW RANGE PEAK
METER .............................................................................. 96
ASSESS PEAK FLOW METER ....... 97
ASSURE 3 CONTROL ................................. 97
ASSURE 3 TEST .................................................. 71
ASSURE 4 CONTROL LEVEL 1 & 2
........................................................................................................ 97
ASSURE 4 TEST .................................................. 71
assure comfort lancets 28g ........................ 97
assure comfort lancets 30g ........................ 97
ASSURE DOSE CONTROL .................. 97
ASSURE DOSE NORM/HIGH
CONTROL .................................................................... 97
ASSURE HAEMOLANCE PLUS
HIGH ..................................................................................... 97
ASSURE HAEMOLANCE PLUS
LOW ...................................................................................... 97
ASSURE HAEMOLANCE PLUS
MICRO ............................................................................... 97
ASSURE HAEMOLANCE PLUS
NORMAL ....................................................................... 97
ASSURE HAEMOLANCE PLUS
PED ......................................................................................... 97
ASSURE ID INSULIN SAFETY
SYR ......................................................................................... 97
ASSURE II .................................................................... 71
ASSURE II CHECK .......................................... 71
ASSURE II CONTROL ................................ 97
ASSURE II CONTROL LEVEL 1 &
2 ................................................................................................... 97
ASSURE LANCE LANCETS .............. 97
ASSURE LANCETS ........................................ 97
ASSURE PLATINUM ................................... 71
ASSURE PRISM MULTI TEST ....... 71
ASSURE PRO CONTROL LEVEL 1
& 2 ............................................................................................ 97
ASSURE PRO TEST ........................................ 71
ASTAGRAF XL ..................................................... 47
ASTEPRO ................................................................... 130
ASTHMA CHECK METER-ZONE
SYSTEM .......................................................................... 97
ASTHMAMENTOR ......................................... 97
AT LAST CONTROL ..................................... 97
AT LAST LANCETS ...................................... 97
AT LAST TEST ...................................................... 71
ATABEX ...................................................................... 122
ATABEX EC ........................................................... 122
ATACAND ................................................................... 34
ATACAND HCT ................................................... 34
ATELVIA ....................................................................... 79
atenolol ............................................................................... 49
atenolol-chlorthalidone ................................. 34
ATGAM ............................................................................ 47
ATIVAN ........................................................................... 16
atorvastatin calcium ........................................... 32
atovaquone-proguanil hcl ........................... 37
ATRALIN ....................................................................... 61
ATRIPLA ........................................................................ 44
atropine sulfate ..................................................... 131
atropine-care ........................................................... 131
ATROVENT ............................................................ 130
ATROVENT HFA ............................................... 18
AUBAGIO .................................................................. 139
AUBRA ............................................................................. 53
AUGMENTIN ....................................................... 138
AUGMENTIN ES-600 ............................... 138
AUGMENTIN XR ........................................... 138
AURODEX ................................................................ 136
aurora lancet super thin 30g ................... 97
aurora lancet thin 23g ..................................... 97
aurora pen needles .............................................. 97
aurora unifine pentips ...................................... 97
AURYXIA ..................................................................... 83
AUTOJECT 2 ............................................................. 97
AUTO-LANCET ................................................... 97
AUTO-LANCET MINI ................................. 97
AUTOLET II CLINISAFE ....................... 97
AUTOLET IMPRESSION ........................ 97
AUTOLET LANCING DEVICE ...... 97
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Index
AUTOLET LITE CLINISAFE ............ 97
AUTOLET LITE STARTER PACK
........................................................................................................ 97
AUTOLET MINI ................................................... 97
AUTOLET PLATFORMS ........................ 97
AUVI-Q ......................................................................... 147
AVALIDE ....................................................................... 34
AVANDAMET ........................................................ 25
AVANDARYL ......................................................... 25
AVANDIA ..................................................................... 25
AVAPRO ......................................................................... 34
AVAR CLEANSER ........................................... 61
AVAR LS CLEANSER ................................ 61
AVAR-E EMOLLIENT ................................ 61
AVAR-E GREEN ................................................. 61
AVAR-E LS ................................................................. 61
AVC VAGINAL ................................................. 146
AVIANE ........................................................................... 53
avidoxy ............................................................................. 143
AVINZA ........................................................................... 11
AVITA ................................................................................ 61
AVODART ................................................................... 85
AVONEX .................................................................... 139
AVONEX PEN ..................................................... 139
AVONEX PREFILLED ............................ 140
AXERT ........................................................................... 119
AXID ................................................................................. 144
AXIRON ........................................................................... 15
AYGESTIN ............................................................... 139
AZASAN ......................................................................... 47
AZASITE ..................................................................... 131
azathioprine .................................................................. 47
azelastine hcl ............................................. 130, 131
AZELEX ........................................................................... 61
AZILECT ......................................................................... 42
azithromycin ................................................................. 94
AZOPT ............................................................................ 131
AZOR ................................................................................... 34
AZULFIDINE ............................................................ 83
AZULFIDINE EN-TABS ........................... 83
AZURETTE ................................................................. 53
bacitracin ..................................................................... 131
bacitracin-polymyxin b ............................... 131
bacitra-neomycin-polymyxin-hc ...... 131
baclofen .......................................................................... 129
BACTRIM ...................................................................... 36
BACTRIM DS .......................................................... 36
BACTROBAN .......................................................... 61
BACTROBAN NASAL ............................ 130
BAL-CARE DHA ............................................. 122
balsalazide disodium ......................................... 83
BALZIVA ....................................................................... 53
BANZEL .......................................................................... 20
BARACLUDE .......................................................... 45
BAR-TEST .................................................................... 71
BAYCADRON ......................................................... 57
BAYER BREEZE 2 CONTROL ....... 97
BAYER BREEZE 2 TEST ........................ 71
BAYER CONTOUR ......................................... 97
BAYER CONTOUR NEXT
CONTROL .................................................................... 98
BAYER CONTOUR NEXT TEST
........................................................................................................ 71
BAYER CONTOUR TEST ...................... 71
BAYER MICROLET 2 LANCING
DEVIC ................................................................................. 98
BAYER MICROLET LANCETS .... 98
baza antifungal ......................................................... 61
BD AUTOSHIELD ............................................. 98
BD AUTOSHIELD DUO ........................... 98
BD GENIE ..................................................................... 98
BD GENIE LANCETS .................................. 98
BD GLUCOSE ......................................................... 25
BD INSULIN SYR ULTRAFINE II
........................................................................................................ 98
BD INSULIN SYRINGE ............................ 98
BD INSULIN SYRINGE
HALF-UNIT ................................................................ 98
BD INSULIN SYRINGE
MICROFINE ............................................................... 98
BD INSULIN SYRINGE U-40 ........... 98
BD INSULIN SYRINGE
ULTRAFINE .............................................................. 98
BD INTEGRA INSULIN SYRINGE
........................................................................................................ 98
BD INTEGRA SYRINGE ......................... 98
BD LANCET DEVICE ................................. 98
BD LANCET ULTRAFINE 30G ..... 98
BD LANCET ULTRAFINE 33G ..... 98
BD MICROTAINER LANCETS ..... 98
BD PEN ............................................................................. 98
BD PEN MINI ........................................................... 98
BD PEN NEEDLE MINI U/F ............... 98
BD PEN NEEDLE NANO U/F ........... 98
BD PEN NEEDLE SHORT U/F ........ 98
BD PEN NEEDLE ULTRAFINE .... 98
BD SAFETYGLIDE INSULIN
SYRINGE ....................................................................... 98
BD SAFETY-LOK INSULIN
SYRINGE ....................................................................... 98
BD SWAB SINGLE USE REGULAR
........................................................................................................ 99
BD SWABS SINGLE USE
BUTTERFLY ............................................................. 99
BD TEST .......................................................................... 71
BD ULTRA-FINE LANCETS ............. 99
BEBULIN ....................................................................... 86
BEBULIN VH ........................................................... 87
BECONASE AQ ................................................ 130
BELBUCA ..................................................................... 11
BELSOMRA ............................................................ 135
benazepril hcl ............................................................. 34
benazepril-hydrochlorothiazide .......... 34
BENEFIX ........................................................................ 87
BENICAR ....................................................................... 34
BENICAR HCT ...................................................... 34
BENLYSTA ................................................................. 48
bensal hp ........................................................................... 61
BENTYL ....................................................................... 144
BENZAMYCIN ...................................................... 61
BENZAMYCINPAK ........................................ 61
BENZEPRO ................................................................. 61
BENZEPRO SHORT CONTACT ... 61
BENZIQ ............................................................................ 61
BENZIQ LS .................................................................. 61
benzonatate .................................................................... 58
benzoyl peroxide ..................................................... 61
benzoyl peroxide short contact ............. 61
benzoyl peroxide-erythromycin ............ 61
benztropine mesylate ......................................... 42
BEPREVE ................................................................... 131
BERINERT ................................................................... 87
BESIVANCE .......................................................... 131
BETADINE OPHTHALMIC PREP
.................................................................................................... 131
BETAGAN ................................................................ 131
betamethasone dipropionate ................... 61
betamethasone dipropionate aug ....... 61
betamethasone valerate ................................. 61
BETAPACE ................................................................. 49
BETAPACE AF ...................................................... 49
BETASERON ........................................................ 140
betaxolol hcl .................................................. 49, 131
bethanechol chloride ..................................... 146
BETHKIS ............................................................................ 7
BETIMOL ................................................................... 131
BETOPTIC-S .......................................................... 131
BEVESPI AEROSPHERE ........................ 18
bexarotene ....................................................................... 39
BEYAZ ............................................................................... 53
BG STAR TEST ..................................................... 71
BIAXIN ............................................................................. 94
BIAXIN XL .................................................................. 94
BIAXIN XL PAC .................................................. 94
bicalutamide ................................................................. 39
BIDIL .................................................................................... 51
BIFERARX ................................................................... 88
BILTRICIDE .............................................................. 16
bimatoprost ................................................................ 131
BINOSTO ....................................................................... 79
BIO GLO ...................................................................... 131
BIOSCANNER GLUCOSE TEST
........................................................................................................ 71
bio-statin ........................................................................... 30
bisoprolol fumarate ............................................. 49
bisoprolol-hydrochlorothiazide ........... 34
BIVIGAM ................................................................... 136
bl test strip pack ...................................................... 71
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Index
BLEPHAMIDE .................................................... 131
BLEPHAMIDE S.O.P. ............................... 131
blood glucose test .................................................. 71
BONIVA ........................................................................... 79
BOSULIF ......................................................................... 39
BOTOX .......................................................................... 130
bp 10-1 ................................................................................. 61
bp cleansing wash ................................................. 61
bp foam ............................................................................... 61
bp vit 3 ................................................................................. 88
bpo ............................................................................................ 61
bpo foaming cloths ............................................... 61
BRAVELLE ................................................................. 79
BREATHERITE ..................................................... 99
BREATHERITE COLL SPACER
ADULT .............................................................................. 99
BREATHERITE COLL SPACER
CHILD ................................................................................. 99
BREATHERITE COLL SPACER
INFANT ............................................................................ 99
BREATHERITE RIGID
SPACER/MASK .................................................... 99
BREATHERITE SPACER
NEONATE .................................................................... 99
BREATHERITE SPACER SMALL
CHILD ................................................................................. 99
BREATHERITE/LARGE MASK .... 99
BREATHERITE/MEDIUM MASK
........................................................................................................ 99
BREATHERITE/SMALL MASK ... 99
BREO ELLIPTA .................................................... 18
BREVICON (28) .................................................... 53
briellyn ................................................................................ 53
BRILINTA .......................................................... 77, 87
brimonidine tartrate ....................................... 131
BRINTELLIX ............................................. 22, 142
BRISDELLE ............................................................ 140
BRIVIACT .................................................................... 20
BROMFED DM ...................................................... 58
bromfenac sodium ............................................. 131
bromocriptine mesylate .................................. 42
BROVANA ................................................................... 18
BUBBLES THE FISH II PEDI
MASK .................................................................................. 99
BUCALSEP .................................................................. 44
BUDEPRION SR .................................................. 22
BUDEPRION XL .................................................. 22
budesonide ...................................................................... 18
budesonide er .............................................................. 57
bullseye mini safety lancets ....................... 99
BULLSEYE SAFETY LANCETS
........................................................................................................ 99
bumetanide .......................................................... 77, 78
BUNAVAIL ................................................................. 11
BUPAP ............................................................................... 10
BUPHENYL ................................................................ 79
buprenorphine hcl ................................................. 11
buprenorphine hcl-naloxone hcl ......... 11
BUPROBAN ............................................................ 140
bupropion hcl .............................................................. 23
bupropion hcl er (smoking det) ........ 140
bupropion hcl er (sr) ......................................... 22
bupropion hcl er (xl) .......................................... 22
buspirone hcl ............................................................... 17
butalbital compound/codeine ................. 11
butalbital-acetaminophen ........................... 10
butalbital-apap-caff-cod ............................... 11
butalbital-apap-caffeine ................................ 10
butalbital-asa-caff-codeine ....................... 11
butalbital-asa-caffeine .................................... 10
BUTISOL SODIUM ......................................... 92
butorphanol tartrate ........................................... 11
BUTRANS ..................................................................... 11
BYDUREON .............................................................. 25
BYETTA 10 MCG PEN ............................... 25
BYETTA 5 MCG PEN .................................. 25
BYSTOLIC ................................................................... 49
BYVALSON ............................................................... 49
cabergoline .................................................................... 79
CABOMETYX ......................................................... 39
CAFCIT ................................................................................. 6
CAFERGOT ............................................................. 119
caffeine citrate ............................................................... 6
CALAN .............................................................................. 50
CALAN SR ................................................................... 50
CALCIFOL ................................................................ 120
calcipotriene ................................................................ 61
calcitonin (salmon) .............................................. 79
CALCITRENE ......................................................... 61
calcitriol ............................................................................ 79
calcium acetate (phos binder) ............... 83
calcium-folic acid plus d ........................... 120
CAMBIA ...................................................................... 119
CAMILA .......................................................................... 53
CAMPRAL ................................................................ 140
CAMRESE .................................................................... 53
CAMRESE LO ......................................................... 53
CANASA ......................................................................... 83
candesartan cilexetil .......................................... 34
candesartan cilexetil-hctz ............................ 34
CANTIL ......................................................................... 144
CAPACET ...................................................................... 10
capecitabine .................................................................. 39
CAPEX ............................................................................... 61
CAPITAL/CODEINE ...................................... 11
CAPRELSA .................................................................. 39
captopril ............................................................................ 34
CARAC .............................................................................. 61
CARAFATE ............................................................. 144
CARBAGLU ............................................................... 79
carbamazepine .......................................................... 20
carbamazepine er .................................................. 20
CARBAPHEN 12 .................................................. 58
CARBAPHEN 12 PED .................................. 58
CARBATROL ........................................................... 20
carbidopa ......................................................................... 42
carbidopa-levodopa ............................................ 42
carbidopa-levodopa er .................................... 42
carbidopa-levodopa-entacapone ....... 42
carbinoxamine maleate .................................. 31
CARDIOCOM LANCING DEVICE
........................................................................................................ 99
CARDIZEM ................................................................. 50
CARDIZEM CD ..................................................... 50
CARDIZEM LA ..................................................... 50
CARDURA ................................................................... 34
CARDURA XL ........................................................ 85
careone advanced lancing dev .............. 99
CAREONE BLOOD GLUCOSE
TEST ...................................................................................... 71
careone lancet thin 23g .................................. 99
careone lancet ultra thin 28g .................. 99
careone unifine pentips .................................. 99
careone unifine pentips plus .................... 99
CARESENS CONTROL A ...................... 99
CARESENS N GLUCOSE TEST ... 71
CARIMUNE NF ................................................. 137
carisoprodol .............................................................. 129
carisoprodol-aspirin ...................................... 129
carisoprodol-aspirin-codeine ............. 129
CARNITOR .................................................................. 79
CARNITOR SF ........................................................ 79
CARRINGTON ANTIFUNGAL ...... 61
carteolol hcl .............................................................. 132
CARTIA XT ................................................................ 50
carvedilol ......................................................................... 49
CASODEX .................................................................... 39
CATAFLAM .................................................................. 8
CATAPRES .................................................................. 34
CATAPRES-TTS-1 ............................................ 34
CATAPRES-TTS-2 ............................................ 34
CATAPRES-TTS-3 ............................................ 34
CAYSTON .................................................................... 36
CAZIANT ....................................................................... 53
CEDAX .............................................................................. 52
cefaclor ............................................................................... 52
cefadroxil ......................................................................... 52
cefdinir ................................................................................ 52
cefixime ............................................................................... 52
cefpodoxime proxetil ......................................... 52
cefprozil ............................................................................. 52
CEFTIN ............................................................................. 52
cefuroxime axetil .................................................... 52
CELEBREX ..................................................................... 8
celecoxib ............................................................................... 8
CELEXA .......................................................................... 23
CELLCEPT ................................................................... 48
CELONTIN .................................................................. 20
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Index
CEM-UREA ................................................................. 61
CENESTIN .................................................................... 82
CENFOL ........................................................................... 88
CENTANY .................................................................... 62
CENTRATEX ............................................................ 88
cephalexin ....................................................................... 52
CERDELGA ................................................................ 88
CEREZYME ................................................................ 88
CERISA WASH ...................................................... 62
CERVIDIL ................................................................. 136
CESAMET ..................................................................... 30
CESIA .................................................................................. 53
cetirizine hcl ................................................................. 31
cetirizine-pseudoephedrine er ............... 58
CETRAXAL ............................................................ 136
CETROTIDE .............................................................. 79
cevimeline hcl ......................................................... 121
CHANTIX .................................................................. 140
CHANTIX CONTINUING MONTH
PAK ..................................................................................... 140
CHANTIX STARTING MONTH
PAK ..................................................................................... 140
CHATEAL ..................................................................... 53
CHEK-STIX CONTROL ............................ 71
CHEMET ......................................................................... 29
CHEMSTRIP 10 MD ....................................... 71
CHEMSTRIP 10/SG ......................................... 71
CHEMSTRIP 2 GP ............................................. 71
CHEMSTRIP 5 OB ............................................ 71
CHEMSTRIP 7 ........................................................ 71
CHEMSTRIP 9 ........................................................ 71
CHEMSTRIP K ....................................................... 71
CHEMSTRIP MICRAL ................................ 71
CHEMSTRIP UGK ............................................ 72
CHENODAL ............................................................... 83
childrens loratadine ........................................... 31
chlordiazepoxide hcl .......................................... 17
chlordiazepoxide-clidinium ................... 144
chlorhexidine gluconate ............................ 121
chloroquine phosphate .................................... 37
chlorothiazide ............................................................. 78
chlorpromazine hcl .............................................. 43
chlorpropamide ........................................................ 25
chlorthalidone ............................................................ 78
chlorzoxazone ......................................................... 129
CHOICE DM FORA G20 TEST
STRIPS ............................................................................... 72
CHOLBAM .................................................................. 50
cholestyramine .......................................................... 32
cholestyramine light ........................................... 32
choline & mag trisalicylate ....................... 10
choline-mag trisalicylate .............................. 10
chorionic gonadotropin ................................. 79
CIALIS ............................................................................... 51
CICLODAN ................................................................. 62
ciclopirox ......................................................................... 62
ciclopirox olamine ................................................ 62
cidofovir ............................................................................. 45
cilostazol ........................................................................... 87
CILOXAN .................................................................. 132
cimetidine ..................................................................... 144
cimetidine hcl .......................................................... 144
CIMZIA ............................................................................. 83
CIMZIA PREFILLED ..................................... 83
CIMZIA STARTER KIT ............................. 83
CINQAIR ......................................................................... 93
CINRYZE ....................................................................... 87
CIPRO .................................................................................. 83
CIPRO HC .................................................................. 136
CIPRO XR ..................................................................... 83
CIPRODEX ............................................................... 136
ciprofloxacin hcl ....................................... 83, 132
ciprofloxacin-ciproflox hcl er ................ 83
citalopram hydrobromide ............................ 23
CITRANATAL 90 DHA .......................... 122
CITRANATAL B-CALM ...................... 123
CITRANATAL DHA ................................... 123
CITRANATAL HARMONY ............. 123
CITRANATAL RX ......................................... 123
citric acid-sodium citrate ............................. 85
CLARAVIS .................................................................. 62
CLARINEX .................................................................. 31
CLARINEX REDITABS ............................ 31
CLARINEX-D 12 HOUR ........................... 58
CLARIS CLARIFYING WASH ....... 62
clarithromycin ............................................................ 94
clarithromycin er .................................................... 94
CLARITIN ..................................................................... 31
CLARITIN EYE ................................................. 132
CLARITIN-D 12 HOUR ............................. 58
CLARITIN-D 24 HOUR ............................. 58
CLEANLET LANCETS 28G ................ 99
CLEARLAX ................................................................ 93
clemastine fumarate ........................................... 31
CLEOCIN ......................................................... 37, 146
CLEOCIN-T ................................................................ 62
CLEVER CHEK AUTO-CODE
TEST ...................................................................................... 72
CLEVER CHEK AUTO-CODE
VOICE ................................................................................. 72
CLEVER CHEK LANCETS .................. 99
CLEVER CHEK TEST ................................. 72
CLEVER CHOICE AUTO-CODE
TEST ...................................................................................... 72
CLEVER CHOICE GLUCOSE
CONTROL .................................................................... 99
CLEVER CHOICE MICRO TEST
........................................................................................................ 72
clickfine pen needles .......................................... 99
CLIMARA ..................................................................... 82
CLIMARA PRO ..................................................... 82
CLINDACIN ETZ ................................................ 62
CLINDACIN-P ........................................................ 62
CLINDAGEL ............................................................. 62
CLINDAMAX .......................................................... 62
clindamycin hcl ........................................................ 37
clindamycin palmitate hcl ........................... 37
clindamycin phos-benzoyl perox ........ 62
clindamycin phosphate ..................... 62, 147
clindamycin-tretinoin ........................................ 62
CLINDESSE ............................................................ 147
CLINISTIX ................................................................... 72
CLINITEST .................................................................. 72
clobetasol propionate ....................................... 62
clobetasol propionate e .................................. 62
clobetasol propionate emulsion ........... 62
CLOBEX .......................................................................... 62
CLOBEX SPRAY ................................................ 62
clomiphene citrate ................................................ 79
clomipramine hcl .................................................... 23
clonazepam .................................................................... 20
clonidine hcl ................................................................. 34
clonidine hcl er ............................................................. 6
clopidogrel bisulfate .......................................... 87
clorazepate dipotassium ................................ 17
CLORPRES .................................................................. 34
CLOSERCARE ....................................................... 99
clotrimazole ............................................................... 122
clotrimazole-betamethasone .................... 62
clozapine ........................................................................... 43
CLOZARIL ................................................................... 43
c-nate dha .................................................................... 123
CNL8 NAIL ................................................................. 62
co monitor replacement pieces ............. 99
COAGADEX .............................................................. 87
COAGUCHEK LANCETS ...................... 99
COARTEM ................................................................... 37
COLAZAL ..................................................................... 83
colchicine ......................................................................... 86
colchicine-probenecid ...................................... 86
COLCRYS ..................................................................... 86
COLESTID .................................................................... 32
COLESTID FLAVORED ........................... 32
colestipol hcl ................................................................ 32
colistimethate sodium ....................................... 37
COLOCORT ................................................................ 15
COLY-MYCIN M ................................................ 37
COLY-MYCIN S ............................................... 136
COLYTE WITH FLAVOR PACKS
........................................................................................................ 93
COMBIGAN ............................................................ 132
COMBIPATCH ....................................................... 82
COMBISTIX ............................................................... 72
COMBIVENT RESPIMAT ..................... 18
COMBIVIR .................................................................. 45
COMETRIQ (100 MG DAILY
DOSE) .................................................................................. 39
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Index
COMETRIQ (140 MG DAILY
DOSE) .................................................................................. 39
COMETRIQ (60 MG DAILY DOSE)
........................................................................................................ 39
comfort assured lancets 28g .................... 99
comfort assured lancets 33g .................... 99
COMFORT EZ INSULIN SYRINGE
........................................................................................................ 99
COMFORT EZ PEN NEEDLES ... 100
comfort lancets ...................................................... 100
COMPAZINE ............................................................ 43
COMPLERA ............................................................... 45
completenate ............................................................ 123
COMPRO ........................................................................ 43
COMTAN ....................................................................... 42
CO-NATAL FA ................................................... 123
CONCEPT DHA ................................................ 123
CONCEPT OB ...................................................... 123
CONCERTA ................................................................... 6
CONDYLOX .............................................................. 62
cone mask ..................................................................... 100
constulose ........................................................................ 93
control .............................................................................. 100
CONTROL AST ..................................................... 72
CONTROL TEST ................................................. 72
CONTROLRX ....................................................... 122
COOL BLOOD GLUCOSE TEST
STRIPS ............................................................................... 72
COPAXONE ............................................................ 140
COPEGUS ...................................................................... 45
CORDARONE ......................................................... 17
CORDRAN ................................................................... 62
COREG .............................................................................. 49
COREG CR ................................................................... 49
CORGARD ................................................................... 49
CORIFACT ................................................................... 87
CORLANOR ........................................................... 142
CORMAX SCALP APPLICATION
........................................................................................................ 62
CORNWALL METAL PIPETTING
.................................................................................................... 100
CORTANE-B ............................................................. 62
CORTEF ........................................................................... 57
CORTENEMA ......................................................... 15
CORTIFOAM ............................................................ 15
CORTISPORIN ........................................ 62, 136
CORTISPORIN-TC ........................................ 136
CORVITA ................................................................... 123
CORVITA 150 .......................................................... 89
CORZIDE ....................................................................... 34
COSENTYX ................................................................ 62
COSENTYX SENSOREADY PEN
........................................................................................................ 62
COSOPT ....................................................................... 132
COSOPT PF ............................................................. 132
COTELLIC .................................................................... 39
COUMADIN ............................................................... 20
COZAAR ......................................................................... 34
CPB WC ............................................................................ 58
CREON .............................................................................. 77
CRESEMBA ................................................................ 30
CRESTOR ...................................................................... 32
CRESYLATE ......................................................... 136
CRINONE ................................................................... 147
CRIXIVAN ................................................................... 45
CRNATAL ................................................................. 123
cromolyn sodium ........................... 18, 83, 132
CRYSELLE-28 ........................................................ 53
CUPRIMINE ............................................................... 48
CURITY ALCOHOL PREPS ............ 100
CURITY ALCOHOL SWABS ........ 100
CURITY STERILE SALINE ................. 85
CUROSURF ............................................................. 142
CUTIVATE .................................................................. 62
CUVPOSA ................................................................. 144
CVS ADVANCED GLUCOSE TEST
........................................................................................................ 72
cvs alcohol prep swabs ............................... 100
cvs alcohol swabs .............................................. 100
cvs allergy eye drops ..................................... 132
cvs blood glucose test ....................................... 72
cvs glucose ...................................................................... 25
cvs glucose bits ......................................................... 25
cvs glucose shot ....................................................... 25
cvs insulin syringe ............................................. 100
CVS KETONE CARE .................................... 72
cvs lancets 21g ....................................................... 100
cvs lancets micro thin 33g ...................... 100
cvs lancets original .......................................... 100
cvs lancets thin ...................................................... 100
cvs lancets thin 26g ......................................... 100
cvs lancets ultra thin 30g ......................... 100
cvs lancing device .............................................. 100
cvs ultra thin lancets ...................................... 100
CYCLAFEM 1/35 ................................................ 53
CYCLAFEM 7/7/7 .............................................. 53
CYCLESSA .................................................................. 53
cyclobenzaprine hcl ......................................... 129
CYCLOGYL ............................................................ 132
CYCLOMYDRIL .............................................. 132
cyclopentolate hcl .............................................. 132
cyclophosphamide ................................................. 39
cycloserine ...................................................................... 38
CYCLOSET ................................................................. 25
cyclosporine .................................................................. 48
cyclosporine modified ...................................... 48
CYMBALTA .............................................................. 23
cyproheptadine hcl ............................................... 31
CYSTADANE ........................................................... 79
CYSTAGON ............................................................... 85
CYSTARAN ............................................................ 132
CYSTO-CONRAY II ....................................... 72
CYSTOGRAFIN-DILUTE ....................... 72
CYTOGAM .............................................................. 137
CYTOMEL ................................................................ 143
CYTOTEC .................................................................. 144
CYTOVENE ................................................................ 45
cytra k crystals .......................................................... 85
cytra-2 .................................................................................. 85
CYTRA-3 ........................................................................ 85
cytra-k .................................................................................. 85
D.H.E. 45 ...................................................................... 119
DAKLINZA ................................................................. 45
DALIRESP .................................................................... 18
danazol ................................................................................ 15
DANTRIUM ............................................................ 129
dantrolene sodium ............................................. 129
dapsone ............................................................................... 37
DARAPRIM ................................................................ 38
darifenacin hydrobromide er .............. 146
DASETTA 1/35 ....................................................... 53
DASETTA 7/7/7 ..................................................... 53
DAYPRO ............................................................................. 8
DAYSEE .......................................................................... 53
DAYTRANA .................................................................. 6
DDAVP .............................................................................. 79
DEBACTEROL ................................................... 122
DECON-A ...................................................................... 59
deferoxamine mesylate .................................... 29
delta d3 ............................................................................ 147
DELZICOL ................................................................... 83
DEMADEX .................................................................. 78
demeclocycline hcl ........................................... 143
DEMEROL .................................................................... 11
DEMSER ......................................................................... 34
DENAVIR ...................................................................... 63
DENTA 5000 PLUS ...................................... 122
dentall 1100 plus ................................................. 122
DEPAKENE ................................................................ 20
DEPAKOTE ................................................................ 20
DEPAKOTE ER ..................................................... 20
DEPAKOTE SPRINKLES ....................... 20
DEPEN TITRATABS ..................................... 48
DEPO-PROVERA ............................................... 53
DEPO-SUBQ PROVERA 104 ............. 53
DERMA-SMOOTHE/FS BODY ...... 63
DERMA-SMOOTHE/FS SCALP .... 63
DERMASORB XM ............................................ 63
DERMATOP ............................................................... 63
DERMAZENE .......................................................... 63
DERMOTIC ............................................................. 136
DESCOVY .................................................................... 45
DESFERAL .................................................................. 29
desipramine hcl ........................................................ 23
desloratadine ............................................................... 31
desmopressin ace rhinal tube ................. 79
desmopressin ace spray refrig ............... 79
desmopressin acetate ........................................ 79
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Index
Index
desmopressin acetate spray ...................... 79
DESOGEN ..................................................................... 53
desogestrel-ethinyl estradiol ................... 53
DESONATE ................................................................ 63
desonide ............................................................................. 63
DESOWEN ................................................................... 63
desoximetasone ......................................................... 63
DESOXYN ........................................................................ 6
desvenlafaxine er .................................................... 23
DETROL ....................................................................... 146
DETROL LA ........................................................... 146
DEX4 .................................................................................... 25
DEX4 GLUCOSE ................................................. 25
DEX4 NATURALS ........................................... 25
DEX4 POUCH PACK .................................... 25
DEX4 QUICK DISSOLVE
GLUCOSE ..................................................................... 25
dexamethasone .......................................................... 57
DEXAMETHASONE INTENSOL
........................................................................................................ 57
dexamethasone sodium phosphate
.................................................................................................... 132
DEXEDRINE ................................................................. 6
DEXILANT .............................................................. 144
dexmethylphenidate hcl ..................................... 6
dexmethylphenidate hcl er ............................. 6
DEXPAK 10 DAY .............................................. 57
DEXPAK 13 DAY .............................................. 57
DEXPAK 6 DAY .................................................. 57
dextroamphetamine sulfate ........................... 6
dextroamphetamine sulfate er ................... 6
DIABETA ....................................................................... 25
DIALYVITE ............................................................ 123
DIALYVITE 3000 ........................................... 123
DIALYVITE 5000 ........................................... 123
DIALYVITE SUPREME D ................. 123
DIALYVITE/ZINC ......................................... 123
DIAMOX SEQUELS ....................................... 78
DIASTAR EASY TEST II LANCETS
.................................................................................................... 100
DIASTAR EASY TEST LANCETS
.................................................................................................... 100
DIASTAT ACUDIAL ..................................... 21
DIASTAT PEDIATRIC ................................ 21
DIASTIX .......................................................................... 72
diatrue control level 1 .................................. 100
diatrue control level 2 .................................. 100
diatrue control level 3 .................................. 100
diatrue plus test ........................................................ 72
diazepam ........................................................................... 17
DIAZEPAM INTENSOL ............................ 17
DIBENZYLINE ...................................................... 34
DICLEGIS ...................................................................... 30
diclofenac potassium ............................................. 8
diclofenac sodium ............................ 8, 63, 132
diclofenac sodium er ............................................. 8
diclofenac-misoprostol ....................................... 8
dicloxacillin sodium ........................................ 138
dicyclomine hcl ..................................................... 144
didanosine ....................................................................... 45
DIFFERIN ...................................................................... 63
DIFICID ............................................................................ 94
DIFIL-G FORTE .................................................... 18
diflorasone diacetate ......................................... 63
DIFLUCAN .................................................................. 30
diflunisal ........................................................................... 10
DIGIBAR 190 ............................................................ 72
DIGOX ............................................................................... 51
digoxin ................................................................................. 51
dihydroergotamine mesylate ................ 119
DILANTIN .................................................................... 21
DILANTIN INFATABS .............................. 21
DILATRATE-SR ................................................... 16
DILAUDID ................................................................... 11
diltiazem hcl ................................................................. 50
diltiazem hcl cd ......................................................... 50
diltiazem hcl er ......................................................... 50
diltiazem hcl er beads ....................................... 50
diltiazem hcl er coated beads ................. 50
dilt-xr ..................................................................................... 50
DIOVAN .......................................................................... 34
DIOVAN HCT .......................................................... 34
DIPENTUM ................................................................. 83
diphenatol ........................................................................ 29
diphenoxylate-atropine ................................... 29
DIPROLENE .............................................................. 63
DIPROLENE AF ................................................... 63
dipyridamole ................................................................ 87
disopyramide phosphate ............................... 17
disulfiram ..................................................................... 140
DITROPAN XL ................................................... 146
DIURIL .............................................................................. 78
divalproex sodium ................................................. 21
divalproex sodium er ......................................... 21
DIVIGEL ......................................................................... 82
DIVISTA .......................................................................... 89
dofetilide ........................................................................... 17
DOLOPHINE ............................................................. 11
donepezil hcl ............................................................. 140
DORAL .............................................................................. 92
DORYX ......................................................................... 143
DORYX MPC ........................................................ 143
dorzolamide hcl .................................................... 132
dorzolamide hcl-timolol mal ................ 132
DOVONEX ................................................................... 63
doxazosin mesylate .............................................. 34
doxepin hcl .......................................................... 23, 63
doxercalciferol .......................................................... 79
doxycycline .................................................................... 63
doxycycline hyclate .......................................... 143
doxycycline monohydrate ........................ 143
DOXYTEX .................................................................... 31
DRISDOL .................................................................... 147
DRITHO-CREME HP ..................................... 63
dronabinol ....................................................................... 30
DROPLET LANCETS ULTRA THIN
30G ....................................................................................... 100
DROPLET LANCING DEVICE ... 100
drospirenone-ethinyl estradiol .............. 53
DROXIA ........................................................................... 89
drug mart glucose ................................................. 25
drug mart lancets thin 26g ..................... 100
drug mart lancets ultra thin .................. 100
DRUG MART LANCING DEVICE
.................................................................................................... 100
DRUG MART ON-THE-GO
LANCET 30G ........................................................ 100
drug mart unifine pentips ......................... 100
DRUG MART UNILET LANCETS
28G ....................................................................................... 100
DRUG MART UNILET LANCETS
30G ....................................................................................... 100
DUAC .................................................................................. 63
duane reade lancet altern site ............ 100
duane reade lancet super thin ............ 100
duane reade lancet ultra thin .............. 100
duane reade unifine pentips .................. 100
DUAVEE ......................................................................... 82
DUET DHA 400 ................................................. 123
DUET DHA 400EC ........................................ 123
DUET DHA 430 ................................................. 123
DUET DHA 430EC ........................................ 123
DUET DHA BALANCED .................... 123
DUETACT ..................................................................... 26
DUEXIS ................................................................................ 8
DULERA ......................................................................... 18
duloxetine hcl .............................................................. 23
DUO-CARE CONTROL SOLUTION
.................................................................................................... 100
DUO-CARE TEST .............................................. 72
DURAGESIC-100 ................................................ 11
DURAGESIC-12 ................................................... 11
DURAGESIC-25 ................................................... 11
DURAGESIC-50 ................................................... 11
DURAGESIC-75 ................................................... 11
duraxin ................................................................................ 10
DUREZOL ................................................................. 132
DURLAZA .................................................................... 87
dutasteride ...................................................................... 85
dutasteride-tamsulosin hcl ......................... 85
DUTOPROL ................................................................ 34
D-VI-SOL .................................................................... 148
D-VITA .......................................................................... 148
DYANAVEL XR ...................................................... 6
DYAZIDE ....................................................................... 78
DYMISTA .................................................................. 130
DYRENIUM ................................................................ 78
DYSPORT .................................................................. 130
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Index
Index
E.E.S. 400 ........................................................................ 94
E.E.S. GRANULES ............................................ 94
earloop mask ............................................................ 101
EASIVENT ................................................................ 101
EASIVENT MASK LARGE .............. 101
EASIVENT MASK MEDIUM ........ 101
EASIVENT MASK SMALL .............. 101
easy comfort insulin syringe ................. 101
easy comfort lancets ....................................... 101
easy comfort pen needles .......................... 101
easy mini lancing device ........................... 101
easy plus blood glucose test ..................... 72
easy plus ii control ........................................... 101
easy plus ii glucose test .................................. 72
EASY STEP CONTROL ......................... 101
EASY STEP TEST .............................................. 72
easy talk blood glucose test ...................... 72
easy talk control ................................................... 101
EASY TOUCH ALCOHOL PREP
MEDIUM ..................................................................... 101
EASY TOUCH CONTROL HIGH &
LOW ................................................................................... 101
EASY TOUCH INSULIN SAFETY
SYR ..................................................................................... 101
EASY TOUCH INSULIN SYRINGE
.................................................................................................... 101
EASY TOUCH LANCETS 21G .... 101
EASY TOUCH LANCETS 23G .... 101
EASY TOUCH LANCETS 26G .... 101
EASY TOUCH LANCETS 28G .... 101
EASY TOUCH LANCETS
28G/TWIST .............................................................. 101
EASY TOUCH LANCETS 30G .... 101
EASY TOUCH LANCETS
30G/TWIST .............................................................. 101
EASY TOUCH LANCETS 32G .... 101
EASY TOUCH LANCETS
32G/TWIST .............................................................. 101
EASY TOUCH LANCETS
33G/TWIST .............................................................. 101
EASY TOUCH LANCING DEVICE
.................................................................................................... 101
EASY TOUCH PEN NEEDLES ... 101
EASY TOUCH SAFETY LANCETS
21G ....................................................................................... 101
EASY TOUCH SAFETY LANCETS
23G ....................................................................................... 102
EASY TOUCH SAFETY LANCETS
26G ....................................................................................... 102
EASY TOUCH SAFETY LANCETS
28G ....................................................................................... 102
EASY TOUCH TEST ...................................... 72
easy trak blood glucose test ...................... 72
easy trak control .................................................. 102
EASY TWIST & CAP LANCETS
.................................................................................................... 102
EASYGLUCO ........................................................... 72
EASYGLUCO CONTROL ................... 102
EASYGLUCO PLUS ....................................... 72
EASYMAX 15 LEVEL 1 CONTROL
.................................................................................................... 102
EASYMAX 15 LEVEL 2 CONTROL
.................................................................................................... 102
EASYMAX 15 TEST ...................................... 72
EASYMAX CONTROL ........................... 102
EASYMAX TEST ................................................ 72
easyplus blood glucose test ....................... 72
EASYPRO BLOOD GLUCOSE
TEST ...................................................................................... 72
EASYPRO PLUS .................................................. 72
EASYTEST II LANCETS ..................... 102
EASYTEST LANCETS ............................ 102
ECLIPSE TEST ....................................................... 72
EC-NAPROSYN ....................................................... 8
econazole nitrate .................................................... 63
ECOZA ............................................................................... 63
ED CYTE F .................................................................. 89
EDARBI ............................................................................ 34
EDARBYCLOR ..................................................... 35
ED-CHLOR-TAN ................................................. 31
EDECRIN ....................................................................... 78
ED-FLEX ......................................................................... 10
EDLUAR ......................................................................... 92
EDURANT .................................................................... 45
EFFER-K ...................................................................... 120
effervescent pot chloride ........................... 120
EFFEXOR XR .......................................................... 23
EFFIENT .......................................................................... 87
EFLOW SCF AEROSOL HEAD
.................................................................................................... 102
EFUDEX .......................................................................... 63
ELAPRASE .................................................................. 79
ELDEPRYL .................................................................. 42
ELELYSO ....................................................................... 89
element compact control 2 ..................... 102
element compact control 3 ..................... 102
element compact test .......................................... 72
ELEMENT CONTROL ............................. 102
ELEMENT PLUS TEST .............................. 72
ELEMENT TEST .................................................. 73
ELESTAT .................................................................... 132
ELESTRIN .................................................................... 82
ELIDEL ............................................................................. 63
ELIGARD ....................................................................... 39
ELIMITE .......................................................................... 63
ELINEST ......................................................................... 53
ELIPHOS ......................................................................... 83
ELIQUIS ........................................................................... 20
ELITE DC AUTO ADAPTER ......... 102
ELITE-OB .................................................................. 123
elite-thin insulin syringe ............................ 102
ELIXOPHYLLIN .................................................. 18
ELLA .................................................................................... 53
ELMIRON ...................................................................... 85
ELOCON ......................................................................... 63
ELOCTATE ................................................................. 87
EMADINE .................................................................. 132
EMBEDA ........................................................................ 11
EMBRACE BLOOD GLUCOSE
TEST ...................................................................................... 73
EMBRACE CONTROL ............................ 102
EMBRACE EVO BLOOD
GLUCOSE TEST .................................................. 73
EMBRACE PRO GLUCOSE TEST
........................................................................................................ 73
EMCYT ............................................................................. 39
EMEND ............................................................................. 30
EMLA .................................................................................. 63
EMOQUETTE .......................................................... 53
EMSAM ............................................................................ 23
EMTRIVA ...................................................................... 45
EMVERM ....................................................................... 16
ENABLEX ................................................................. 146
enalapril maleate ................................................... 35
enalapril-hydrochlorothiazide .............. 35
ENBREL .............................................................................. 8
ENBREL SURECLICK .................................... 8
ENCARE ...................................................................... 147
ENDOCET ..................................................................... 11
ENDODAN ................................................................... 11
ENDOMETRIN ................................................... 147
ENDUR-ACIN ...................................................... 148
ENJUVIA ........................................................................ 82
enoxaparin sodium ............................................... 20
ENPRESSE-28 ......................................................... 53
ENSKYCE ..................................................................... 53
ENSTILAR .................................................................... 63
entacapone ..................................................................... 42
entecavir ............................................................................ 45
ENTERO VU .............................................................. 73
ENTOCORT EC ..................................................... 57
ENTRESTO .............................................................. 130
ENTYVIO ....................................................................... 92
enulose ................................................................................. 83
ENVARSUS XR .................................................... 48
ENVISION AUTOCODE TEST ....... 73
EPANED .......................................................................... 35
EPCLUSA ....................................................................... 91
EPIDUO ............................................................................ 63
EPIDUO FORTE ................................................... 63
EPIFOAM ....................................................................... 63
epinastine hcl ........................................................... 132
epinephrine ................................................................ 147
EPIPEN 2-PAK .................................................... 147
EPIPEN JR 2-PAK .......................................... 147
EPITOL .............................................................................. 21
EPIVIR ............................................................................... 45
EPIVIR HBV .............................................................. 45
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Index
Index
eplerenone ....................................................................... 35
EPOGEN .......................................................................... 89
epoprostenol sodium .......................................... 51
eprosartan mesylate ........................................... 35
EPZICOM ....................................................................... 45
eq itchy eye drops .............................................. 132
eql color lancets 21g ...................................... 102
eql color lancets micro 33g ................... 102
eql niacin ...................................................................... 148
eql short pen needle ........................................ 102
eql super thin lancets 30g ........................ 102
eql thin lancets 26g .......................................... 102
EQL TRUETEST TEST ............................... 73
EQL TRUETRACK TEST ........................ 73
eql ultra short pen needle ........................ 102
EQUAGESIC .............................................................. 10
EQUETRO ..................................................................... 43
ergocalciferol .......................................................... 148
ergoloid mesylates ............................................ 140
ERGOMAR ............................................................... 119
ERIVEDGE .................................................................. 39
ERRIN ................................................................................. 53
ERTACZO ..................................................................... 63
ery .............................................................................................. 63
ERYGEL .......................................................................... 64
ERYPED 200 .............................................................. 94
ERYPED 400 .............................................................. 94
ERY-TAB ....................................................................... 94
ERYTHROCIN STEARATE ................. 94
erythromycin ................................................. 64, 132
erythromycin base ................................................. 94
ESBRIET ...................................................................... 141
ESCAVITE ................................................................ 123
escitalopram oxalate ......................................... 23
ESGIC .................................................................................. 10
esomeprazole magnesium ........................ 144
esomeprazole strontium ............................. 144
ESTARYLLA ............................................................ 54
estazolam .......................................................................... 92
ESTRACE ........................................................ 82, 147
estradiol ............................................................................. 82
estradiol-norethindrone acet ................... 82
ESTRASORB ............................................................. 82
ESTRING .................................................................... 147
ESTROGEL .................................................................. 82
estropipate ...................................................................... 82
ESTROSTEP FE .................................................... 54
eszopiclone ..................................................................... 92
ethacrynic acid .......................................................... 78
ethambutol hcl ........................................................... 38
ethosuximide ..................................................... 21, 52
etodolac .................................................................................. 8
etodolac er .......................................................................... 8
etoposide ........................................................................... 39
EUFLEXXA ............................................................. 129
EURAX .............................................................................. 64
EVAMIST ....................................................................... 82
EVEKEO ............................................................................. 6
EVENCARE + BLOOD GLUCOSE
TEST ...................................................................................... 73
EVENCARE BLOOD GLUCOSE
TEST ...................................................................................... 73
EVENCARE CONTROL
LOW/HIGH .............................................................. 102
EVENCARE G2 LOW/HIGH
CONTROL ................................................................. 102
EVENCARE G2 TEST .................................. 73
EVENCARE G3 LOW/HIGH
CONTROL ................................................................. 102
EVENCARE G3 TEST .................................. 73
EVENCARE MINI GLUCOSE TEST
........................................................................................................ 73
EVICEL ............................................................................. 91
EVISTA ............................................................................. 79
EVOCLIN ....................................................................... 64
EVOLUTION AUTOCODE ................... 73
EVOLUTION CONTROL ..................... 102
EVOTAZ .......................................................................... 45
EVOXAC ..................................................................... 122
EVZIO ................................................................................. 29
EXACTUSS ................................................................. 59
EXALGO ......................................................................... 12
EXELDERM ............................................................... 64
EXELON ...................................................................... 140
exemestane ..................................................................... 39
EXFORGE ..................................................................... 35
EXFORGE HCT ..................................................... 35
EXJADE ........................................................................... 29
EXODERM ................................................................... 64
EXTAVIA ................................................................... 140
EXTINA ............................................................................ 64
extra-virt plus dha ............................................. 123
eye itch relief ............................................................ 132
EYLEA ........................................................................... 132
E-Z JECT LANCET MICRO-THIN
33G ....................................................................................... 102
E-Z JECT LANCET SUPER THIN
30G ....................................................................................... 102
E-Z JECT LANCETS ................................... 102
E-Z JECT LANCETS 21G .................... 102
E-Z JECT LANCETS THIN 26G
.................................................................................................... 102
EZ SMART BLOOD GLUCOSE
LANCETS .................................................................. 102
EZ SMART BLOOD GLUCOSE
TEST ...................................................................................... 73
EZ SMART PLUS GLUCOSE TEST
........................................................................................................ 73
E-Z SPACER .......................................................... 102
E-Z SPACER THE BODY GUARDS
PK .......................................................................................... 102
E-Z-CAT DRY ......................................................... 73
E-Z-DISK ........................................................................ 73
E-Z-DOSE ...................................................................... 73
E-Z-HD ............................................................................... 73
EZ-LETS LANCETS 21G ..................... 102
EZ-LETS LANCETS 23G ..................... 103
EZ-LETS LANCETS 26G ..................... 103
EZ-LETS LANCETS 28G ..................... 103
EZ-LETS LANCETS 30G ..................... 103
E-Z-PAQUE ................................................................. 73
E-Z-PASTE ................................................................... 73
fabb .......................................................................................... 89
FABIOR ............................................................................ 64
FABRAZYME .......................................................... 79
FACTIVE ........................................................................ 83
fa-cyanocobalamin-pyridoxine ............. 89
FALMINA ...................................................................... 54
famciclovir ...................................................................... 45
famotidine ..................................................... 144, 145
FAMVIR ........................................................................... 45
FANAPT ........................................................................... 43
FANAPT TITRATION PACK ............ 43
FARESTON ................................................................. 39
FARXIGA ....................................................................... 26
FARYDAK .................................................................... 39
FASLODEX ................................................................. 39
fa-vitamin b-6-vitamin b-12 ...................... 89
FAZACLO ..................................................................... 43
FC FEMALE CONDOM ......................... 103
FC2 FEMALE CONDOM ..................... 103
fe 90 plus ........................................................................... 89
FEIBA .................................................................................. 87
FEIBA NF ....................................................................... 87
FEIBA VH IMMUNO .................................... 87
felbamate .......................................................................... 21
FELBATOL .................................................................. 21
FELDENE .......................................................................... 8
felodipine er .................................................................. 50
FEM PH ......................................................................... 147
FEMARA ......................................................................... 39
FEMCAP ...................................................................... 103
FEMCON FE .............................................................. 54
FEMHRT LOW DOSE .................................. 82
FEMRING .................................................................. 147
fenofibrate ....................................................................... 32
fenofibrate micronized ..................................... 32
fenofibric acid ............................................................ 32
FENOGLIDE .............................................................. 32
fenoprofen calcium .................................................. 8
fentanyl ............................................................................... 12
fentanyl citrate ........................................................... 12
FENTORA ..................................................................... 12
FER-IN-SOL ............................................................... 89
fer-iron ................................................................................ 89
FERIVA ............................................................................. 89
ferocon ................................................................................. 89
ferotrinsic ......................................................................... 89
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Index
Index
Index
FERRALET 90 ......................................................... 89
ferraplus 90 ................................................................... 89
ferrex 150 forte ......................................................... 89
FERREX 150 FORTE PLUS ................. 89
FERREX 28 .................................................................. 89
FERRIPROX ............................................................... 29
FERRLECIT ................................................................ 89
FERROCITE PLUS ........................................... 89
FERROGELS FORTE .................................... 89
FERRO-PLEX HEMATINIC ................ 89
FERROTRIN .............................................................. 89
ferrous sulfate ............................................................. 89
FETZIMA ....................................................................... 23
FETZIMA TITRATION .............................. 23
FEXMID ....................................................................... 129
fexofenadine hcl ....................................................... 31
fexofenadine hcl childrens .......................... 31
fexofenadine-pseudoephed er ................. 59
FIBRICOR ..................................................................... 32
FIFTY50 ALCOHOL PREP ................ 103
FIFTY50 CONTROL 2.0 ........................ 103
FIFTY50 GLUCOSE TEST 2.0 ......... 73
FIFTY50 LANCING DEVICE ........ 103
FIFTY50 PEN NEEDLES ...................... 103
FIFTY50 SAFETY SEAL LANCETS
.................................................................................................... 103
FIFTY50 SUPERIOR COMFORT
SYR ..................................................................................... 103
filter air pp .................................................................. 103
FINACEA ....................................................................... 64
finasteride ........................................................................ 85
FINE 30 .......................................................................... 103
FINGERSTIX LANCETS ...................... 103
FIORICET ...................................................................... 10
FIORICET/CODEINE .................................... 12
FIORINAL ..................................................................... 10
FIORINAL/CODEINE #3 .......................... 12
FIRAZYR ........................................................................ 87
FIRMAGON ................................................................ 40
FIRST-VANCOMYCIN 25 ..................... 37
FIRST-VANCOMYCIN 50 ..................... 37
FLAGYL .......................................................................... 37
FLAGYL ER ............................................................... 37
FLAREX ....................................................................... 132
flavoxate hcl .............................................................. 146
FLEBOGAMMA ............................................... 137
FLEBOGAMMA DIF .................................. 137
flecainide acetate ................................................... 17
FLECTOR ....................................................................... 64
FLOLAN .......................................................................... 51
FLOMAX ........................................................................ 85
FLONASE ALLERGY RELIEF .... 130
FLO-PRED .................................................................... 58
FLOVENT DISKUS ......................................... 18
FLOVENT HFA ..................................................... 18
FLOXIN OTIC ...................................................... 136
fluconazole ..................................................................... 30
flucytosine ....................................................................... 30
fludrocortisone acetate ................................... 58
FLUMADINE ............................................................ 45
flunisolide .................................................................... 130
fluocinolone acetonide ..................... 64, 136
fluocinolone acetonide body .................... 64
fluocinolone acetonide scalp ................... 64
fluocinonide .................................................................. 64
fluocinonide-e ............................................................. 64
FLUORABON ....................................................... 120
FLUOR-A-DAY ................................................. 120
fluorescein-benoxinate ................................ 132
FLUORIDEX SENSITIVITY
RELIEF ........................................................................... 122
FLUOR-I-STRIPS A.T. ............................. 132
fluoritab .......................................................................... 120
fluorometholone ................................................... 132
FLUOROPLEX ....................................................... 64
fluorouracil .................................................................... 64
fluoxetine hcl ............................................................... 23
fluoxetine hcl (pmdd) ..................................... 140
fluphenazine hcl ....................................................... 43
FLURA-DROPS ................................................. 120
flurandrenolide ......................................................... 64
FLURA-SAFE ....................................................... 132
flurazepam hcl ........................................................... 92
flurbiprofen ....................................................................... 8
flurbiprofen sodium ......................................... 132
FLUROX ...................................................................... 132
flutamide ........................................................................... 40
fluticasone propionate ...................... 64, 130
fluvastatin sodium ................................................. 32
fluvastatin sodium er ......................................... 32
fluvoxamine maleate .......................................... 23
fluvoxamine maleate er .................................. 23
FML .................................................................................... 132
FML FORTE ........................................................... 132
FML LIQUIFILM ............................................. 132
focalgin-b ..................................................................... 123
FOCALIN ........................................................................... 6
FOCALIN XR ............................................................... 6
folbee ..................................................................................... 89
folbee plus ................................................................... 123
FOLBEE PLUS CZ ......................................... 123
folcal dha ...................................................................... 123
FOLCAPS OMEGA 3 ................................. 123
FOLGARD OS ...................................................... 123
folic acid ............................................................................ 89
FOLIVANE-F ............................................................ 89
FOLIVANE-OB .................................................. 123
FOLIVANE-PLUS .............................................. 89
FOLIVANE-PRX DHA NF ................. 123
FOLLISTIM AQ .................................................... 79
folplex 2.2 ........................................................................ 89
foltrin ..................................................................................... 89
fondaparinux sodium ......................................... 20
FORA CONTROL ........................................... 103
FORA D10 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA D15C BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA D15G BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA D15Z BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA D20 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA D40/G31 BLOOD GLUCOSE
........................................................................................................ 73
FORA G20 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA G30A BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA G71A BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA G90 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA GD20 TEST ............................................ 73
FORA GD50 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA LANCETS ............................................. 103
FORA LANCING DEVICE ................ 103
FORA TEST N' GO GLUCOSE
TEST ...................................................................................... 73
FORA TN'G/TN'G VOICE ....................... 73
FORA V10 BLOOD GLUCOSE
TEST ...................................................................................... 73
FORA V12 BLOOD GLUCOSE
TEST ...................................................................................... 74
FORA V20 BLOOD GLUCOSE
TEST ...................................................................................... 74
FORA V22 BLOOD GLUCOSE
TEST ...................................................................................... 74
FORA V30A BLOOD GLUCOSE
TEST ...................................................................................... 74
FORACARE GD40 TEST ......................... 74
FORACARE GDH CONTROL ...... 103
FORACARE PREMIUM V10 TEST
........................................................................................................ 74
FORACARE TEST N GO TEST ...... 74
FORADIL AEROLIZER ............................. 18
FORANE .......................................................................... 85
FORFIVO XL ............................................................ 23
FORMADON ............................................................. 44
formaldehyde ............................................................... 44
FORMA-RAY ........................................................... 44
FORTEO ........................................................................... 79
FORTESTA .................................................................. 15
FORTISCARE TEST ....................................... 74
FOSAMAX ................................................................... 79
FOSAMAX PLUS D ........................................ 79
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Next update 12/2016
159
Index
Index
Index
FOSCAVIR ................................................................... 45
fosinopril sodium .................................................... 35
fosinopril sodium-hctz ..................................... 35
FOSRENOL ...................................................... 83, 84
FRAGMIN ..................................................................... 20
freds pharmacy autolet lancing ........ 103
freds pharmacy unifine pentip+ ...... 103
freds pharmacy unifine pentips ........ 103
freds pharmacy unilet lanc 28g ........ 103
freds pharmacy unilet lanc 30g ........ 103
FREESTYLE CONTROL
SOLUTION ............................................................... 103
FREESTYLE INSULINX TEST ....... 74
FREESTYLE LANCETS ........................ 103
FREESTYLE LITE TEST ......................... 74
FREESTYLE PRECISION INS SYR
.................................................................................................... 103
FREESTYLE TEST ........................................... 74
FREESTYLE UNISTICK II
LANCETS .................................................................. 103
FROVA ........................................................................... 119
frovatriptan succinate .................................. 119
FUL-GLO .................................................................... 132
full kit nebulizer set ......................................... 103
FURADANTIN .................................................... 146
furosemide ....................................................................... 78
FUSION PLUS ......................................................... 89
FUZEON .......................................................................... 45
FYCOMPA .................................................................... 21
gabapentin ...................................................................... 21
GABITRIL ..................................................................... 21
galantamine hydrobromide ................... 140
galantamine hydrobromide er ........... 140
GALZIN ........................................................................ 120
GAMASTAN S/D ............................................. 137
GAMMAGARD .................................................. 137
GAMMAGARD S/D ..................................... 137
GAMMAGARD S/D LESS IGA ... 137
GAMMAKED ....................................................... 137
GAMMAPLEX .................................................... 137
GAMUNEX-C ....................................................... 137
ganciclovir sodium ............................................... 45
ganirelix acetate ...................................................... 79
GARAMYCIN ...................................................... 133
GASTROCROM .................................................... 84
GASTROGRAFIN .............................................. 74
GASTROMARK .................................................... 74
gatifloxacin ................................................................ 133
GATTEX .......................................................................... 84
gavilax .................................................................................. 93
GAVILYTE-C ........................................................... 93
GAVILYTE-G .......................................................... 93
GAVILYTE-H .......................................................... 93
GAVILYTE-N WITH FLAVOR
PACK .................................................................................... 93
ge100 blood glucose test .............................. 74
ge100 control ........................................................... 103
GEBAUERS PAIN EASE ......................... 64
GEBAUERS SPRAY AND
STRETCH ....................................................................... 64
GELFILM .................................................................... 133
GELNIQUE .............................................................. 146
GEL-ONE .................................................................... 129
GELSYN-3 ................................................................ 129
gemfibrozil ...................................................................... 32
GENERESS FE ........................................................ 54
generlac ............................................................................. 84
gengraf ................................................................................ 48
GENGRAF .................................................................... 48
GENOTROPIN ........................................................ 79
GENOTROPIN MINIQUICK ............... 79
GENSTRIP 50 ........................................................... 74
GENTAK ..................................................................... 133
gentamicin sulfate .................................. 64, 133
GENTLE-LET GP LANCETS ......... 103
GENTLE-LET LANCETS .................... 103
GENTLE-LET PLATFORMS .......... 103
GENVOYA ................................................................... 45
GEODON ........................................................................ 43
GESTICARE DHA ......................................... 123
ght test .................................................................................. 74
GIANVI ............................................................................. 54
GIAZO ................................................................................ 84
GILDAGIA ................................................................... 54
GILDESS 1.5/30 ..................................................... 54
GILDESS 1/20 .......................................................... 54
GILDESS 24 FE ..................................................... 54
GILDESS FE 1.5/30 .......................................... 54
GILDESS FE 1/20 ................................................ 54
GILENYA ................................................................... 140
GILOTRIF ...................................................................... 40
GILPHEX TR ............................................................. 59
GILTUSS ......................................................................... 59
GILTUSS PED-C .................................................. 59
GILTUSS TR .............................................................. 59
GLASSIA .................................................................... 142
GLATOPA ................................................................. 140
GLEEVEC ...................................................................... 40
GLEOSTINE ............................................................... 40
glimepiride ..................................................................... 26
glipizide .............................................................................. 26
glipizide er ...................................................................... 26
glipizide xl ....................................................................... 26
glipizide-metformin hcl .................................. 26
global alcohol prep ease ........................... 103
global ease inject pen needles ........... 103
global inject ease insulin syr ............... 103
global inject ease lancets 28g ............ 104
global inject ease lancets 30g ............ 104
global lancing device .................................... 104
GLUCAGEN HYPOKIT ............................. 26
GLUCAGON EMERGENCY ............... 26
GLUCO BURST .................................................... 26
GLUCO PERFECT 3 TEST .................... 74
GLUCOCARD 01 CONTROL ........ 104
GLUCOCARD 01 SENSOR PLUS
........................................................................................................ 74
GLUCOCARD 01 TEST ............................. 74
GLUCOCARD EXPRESSION
CONTROL ................................................................. 104
GLUCOCARD EXPRESSION TEST
........................................................................................................ 74
GLUCOCARD SHINE .............................. 104
GLUCOCARD SHINE CONTROL
.................................................................................................... 104
GLUCOCARD SHINE TEST ............... 74
GLUCOCARD VITAL TEST .............. 74
GLUCOCARD X-SENSOR .................... 74
GLUCOCARD X-SENSOR
CONTROL ................................................................. 104
GLUCOCOM CONTROL ..................... 104
GLUCOCOM LANCETS 28G ........ 104
GLUCOCOM LANCETS 30G ........ 104
GLUCOCOM LANCETS 33G ........ 104
GLUCOCOM TEST .......................................... 74
GLUCOLAB TEST ............................................ 74
GLUCOLET 2 AUTOMATIC
LANCING .................................................................. 104
GLUCONAVII BLOOD GLUCOSE
TEST ...................................................................................... 74
GLUCOPHAGE ..................................................... 26
GLUCOPHAGE XR ......................................... 26
GLUCOPRO INSULIN SYRINGE
.................................................................................................... 104
glucose ................................................................................. 26
glucose control ...................................................... 104
GLUCOSOURCE LANCET DEVICE
.................................................................................................... 104
GLUCOSOURCE LANCETS .......... 104
GLUCOTROL ........................................................... 26
GLUCOTROL XL ............................................... 26
GLUCOVANCE ..................................................... 26
GLUMETZA ............................................................... 26
GLUTOSE 15 ............................................................. 26
GLUTOSE 45 ............................................................. 26
glyburide ........................................................................... 26
glyburide micronized ......................................... 26
glyburide-metformin .......................................... 26
GLYCATE ................................................................. 145
glycine .................................................................................. 85
glycine urologic ....................................................... 85
glycopyrrolate ........................................................ 145
GLYNASE ..................................................................... 26
GLYSET ........................................................................... 26
GLYXAMBI ............................................................ 142
GMATE BLOOD GLUCOSE TEST
........................................................................................................ 74
GMATE CONTROL LEVEL 2 ...... 104
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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160
Index
Index
Index
gnp alcohol swabs ............................................. 104
gnp clickfine pen needles .......................... 104
gnp glucose .................................................................... 26
gnp lancets .................................................................. 104
gnp lancets 21g ..................................................... 104
gnp lancets micro thin 33g ..................... 104
gnp lancets super thin 30g ...................... 104
gnp lancets thin ..................................................... 104
gnp lancets thin 26g ........................................ 104
gnp micro thin lancets 33g ..................... 104
gnp niacin .................................................................... 148
gnp niacin tr .............................................................. 148
gnp quick dissolve glucose ......................... 26
gnp super thin lancets 30g ...................... 104
GOLYTELY ................................................................ 93
GONAL-F ....................................................................... 80
GONAL-F RFF ........................................................ 80
GONAL-F RFF PEN ........................................ 80
GONAL-F RFF REDIJECT .................... 80
GORDOFILM ............................................................ 64
GRALISE .................................................................... 140
GRALISE STARTER .................................. 140
granisetron hcl .......................................................... 30
GRANISOL .................................................................. 30
GRANIX ........................................................................... 89
GRIFULVIN V ........................................................ 30
griseofulvin microsize ...................................... 30
griseofulvin ultramicrosize ........................ 30
GRIS-PEG ...................................................................... 30
guanfacine hcl ............................................................ 35
guanfacine hcl er ....................................................... 6
guanidine hcl ............................................................... 38
GYNAZOLE-1 ..................................................... 147
H&H THINLET LANCETS 26G
.................................................................................................... 104
H&H THINLET LANCETS 30G
.................................................................................................... 104
HAEMOLANCE ................................................ 104
HAEMOLANCE LOW FLOW
LANCETS .................................................................. 104
HAEMOLANCE PLUS ............................ 104
HAEMOLANCE PLUS HIGH
FLOW ............................................................................... 104
HAEMOLANCE PLUS LOW FLOW
.................................................................................................... 105
HAEMOLANCE PLUS MAX FLOW
.................................................................................................... 105
HAEMOLANCE PLUS PEDIATRIC
FLOW ............................................................................... 105
HALCION ...................................................................... 92
halobetasol propionate ................................... 64
HALOG ............................................................................. 64
haloperidol ..................................................................... 43
haloperidol lactate ............................................... 43
HALOTIN ....................................................................... 64
HARVONI ..................................................................... 91
HEALTH CARE LANCING
DEVICE ......................................................................... 105
healthwise alcohol prep ............................. 105
healthwise lancets 30g ................................. 105
healthwise lancing pen ................................ 105
healthwise mini pen needles ................. 105
healthwise pen needles ................................ 105
healthwise short pen needles ............... 105
healthwise unifine pentips ....................... 105
healthy accents lancing device .......... 105
healthy accents unifine pentip ............ 105
healthy accents unilet lancets ............. 105
HEALTHY LIVING FILTERS ....... 105
HEALTHY LIVING MASKS ........... 105
HEALTHY LIVING
REPLACEMENT KIT ................................ 105
HEATHER ..................................................................... 54
h-e-b incontrol adv lancing ................... 105
h-e-b incontrol lancets 28g .................... 105
h-e-b incontrol lancets 30g .................... 105
h-e-b incontrol pen needles ................... 105
HECORIA ....................................................................... 48
HECTOROL ................................................................ 80
HELIXATE FS ......................................................... 87
HEMA-COMBISTIX ....................................... 74
HEMANGEOL ......................................................... 49
hematinic plus complex .................................. 89
hematinic plus vit/minerals ....................... 89
hematinic/folic acid ............................................. 90
HEMATOGEN FA ............................................. 90
HEMATOGEN FORTE ................................ 90
hemenatal ob ............................................................ 123
hemenatal ob + dha ........................................ 123
hemetab .............................................................................. 90
HEMOCYTE PLUS ........................................... 90
HEMOCYTE-F ........................................................ 90
hemocyte-plus ............................................................. 90
HEMOFIL M .............................................................. 87
HEPAGAM B ........................................................ 137
heparin sodium (porcine) ............................ 20
heparin sodium (porcine) pf ..................... 20
HEPSERA ....................................................................... 45
HETLIOZ ........................................................................ 92
HEXALEN .................................................................... 40
HIPREX ......................................................................... 146
HISTEX-AC ................................................................ 59
HIZENTRA ............................................................... 137
hm glucose ...................................................................... 26
hm lancets micro thin 33g ....................... 105
hm lancets ultra thin 30g .......................... 105
hm niacin ...................................................................... 148
HOMATROPAIRE ......................................... 133
homatropine hbr .................................................. 133
HORIZANT .............................................................. 140
HP ACTHAR .............................................................. 80
HUMALOG KWIKPEN .............................. 26
HUMALOG MIX 50/50 ............................... 26
HUMALOG MIX 50/50 KWIKPEN
........................................................................................................ 26
HUMALOG MIX 75/25 ............................... 26
HUMALOG MIX 75/25 KWIKPEN
........................................................................................................ 27
HUMATE-P ................................................................. 87
HUMATROPE ......................................................... 80
HUMATROPEN FOR 12MG ........... 105
HUMATROPEN FOR 24MG ........... 105
HUMATROPEN FOR 6MG ............... 105
HUMIRA ............................................................................. 8
HUMIRA PEDIATRIC CROHNS
START .................................................................................... 8
HUMIRA PEN ............................................................. 8
HUMIRA PEN-CROHNS STARTER
............................................................................................................ 8
HUMIRA PEN-PSORIASIS
STARTER .......................................................................... 8
HUMULIN 70/30 .................................................. 27
HUMULIN 70/30 KWIKPEN .............. 27
HUMULIN N ............................................................. 27
HUMULIN N KWIKPEN .......................... 27
HUMULIN R .............................................................. 27
HUMULIN R U-500
(CONCENTRATED) ....................................... 27
HYALGAN ............................................................... 129
HYCAMTIN ................................................................ 40
HYCET ............................................................................... 12
HYCOFENIX ............................................................. 59
hydralazine hcl .......................................................... 35
hydrochlorothiazide ............................................ 78
hydrocod polst-cpm polst er ..................... 59
hydrocodone-acetaminophen .................. 12
hydrocodone-homatropine ......................... 59
hydrocodone-ibuprofen .................................. 12
hydrocortisone ..................................... 15, 58, 64
hydrocortisone ace-pramoxine ............. 15
hydrocortisone acetate-aloe ..................... 64
hydrocortisone butyr lipo base ............. 64
hydrocortisone butyrate ................................ 64
hydrocortisone valerate ................................. 64
hydrocortisone-acetic acid ..................... 136
hydrocortisone-iodoquinol ........................ 64
hydromet ........................................................................... 59
hydromorphone hcl ............................................. 12
hydroxychloroquine sulfate ....................... 38
hydroxyurea .................................................................. 40
hydroxyzine hcl .............................................. 17, 52
hydroxyzine pamoate ......................................... 17
HYMOVIS ................................................................. 129
HYPERHEP B S/D .......................................... 137
HYPERRAB S/D ............................................... 137
HYPERRHO S/D ............................................... 137
HYPERSAL ................................................................. 59
HYPERTET S/D ................................................. 137
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Next update 12/2016
161
Index
Index
Index
HYPOLANCE AST LANCING ..... 105
HYQVIA ....................................................................... 136
HYSINGLA ER ...................................................... 12
HYSKON ......................................................................... 74
hy-vee glucose ............................................................ 27
HY-VEE LANCETS ..................................... 105
hy-vee thin lancets ............................................ 105
HYZAAR ......................................................................... 35
ibandronate sodium ............................................ 80
IBRANCE ....................................................................... 60
IBUDONE ...................................................................... 12
ibuprofen .............................................................................. 8
ICLUSIG .......................................................................... 40
IDELVION .................................................................... 87
IFEREX 150 FORTE ........................................ 90
ILARIS ................................................................................... 9
ILEVRO ......................................................................... 133
ILOTYCIN ................................................................. 133
imatinib mesylate ................................................... 40
IMBRUVICA ............................................................. 40
IMDUR ............................................................................... 16
imipramine hcl ........................................................... 23
imipramine pamoate .......................................... 23
imiquimod ........................................................................ 65
IMITREX ..................................................................... 119
IMITREX STATDOSE SYSTEM
.................................................................................................... 119
IMOGAM RABIES-HT ............................ 137
IMPAVIDO .................................................................. 37
IMPLANON ................................................................ 54
IMURAN ......................................................................... 48
IN TOUCH BLOOD GLUCOSE
TEST ...................................................................................... 74
INATAL ADVANCE .................................. 123
INATAL GT ............................................................. 123
INATAL ULTRA .............................................. 124
INCRELEX ................................................................... 80
INCRUSE ELLIPTA ........................................ 18
indapamide .................................................................... 78
INDERAL LA ........................................................... 49
INDERAL XL ........................................................... 49
INDOCIN ............................................................................ 9
indomethacin ................................................................... 9
indomethacin er ........................................................... 9
infanate balance .................................................. 124
INFASURF ................................................................ 142
INFERGEN ................................................................... 45
INFINITY BLOOD GLUCOSE
TEST ...................................................................................... 74
INFINITY CONTROL ............................... 105
inject-ease .................................................................... 105
INJECT-EASE AUTOMATIC
INJECTOR ................................................................. 105
INLYTA ............................................................................ 40
INNOSPIRE REPLACEMENT
FILTER ........................................................................... 105
INSPIREASE .......................................................... 105
INSPIREASE BAGS .................................... 105
INSPIREASE MOUTHPIECE ......... 105
INSPIREASE RESERVOIR BAGS
.................................................................................................... 105
INSPRA ............................................................................. 35
insupen pen needles ........................................ 105
INSUPEN SENSITIVE .............................. 106
INSUPEN ULTRAFIN .............................. 106
INTEGRA F ................................................................. 90
INTEGRA PLUS ................................................... 90
INTELENCE ............................................................... 45
INTERMEZZO ........................................................ 92
INTROL ............................................................................ 78
INTRON A .................................................................... 40
INTROVALE ............................................................. 54
INTUNIV ............................................................................ 6
INVEGA ........................................................................... 43
INVIRASE ..................................................................... 45
INVOKAMET ....................................................... 142
INVOKAMET XR ........................................... 142
INVOKANA ................................................................ 27
IOPIDINE .................................................................... 133
ipratropium bromide ........................... 18, 130
ipratropium-albuterol ...................................... 18
IPRIVASK ..................................................................... 20
irbesartan ......................................................................... 35
irbesartan-hydrochlorothiazide ........... 35
IRENKA ........................................................................... 23
IRESSA .............................................................................. 40
IROSPAN 24/6 ......................................................... 90
ISENTRESS ................................................................. 45
isoditrate er ................................................................... 16
isoflurane ......................................................................... 85
isoniazid ............................................................................. 38
ISOPTIN SR ................................................................ 50
ISOPTO CARBACHOL ........................... 133
ISOPTO HOMATROPINE ................... 133
ISOPTO HYOSCINE ................................... 133
ISORDIL TITRADOSE ................................ 16
isosorbide dinitrate ............................................. 16
isosorbide dinitrate er ...................................... 16
isosorbide mononitrate ................................... 16
isosorbide mononitrate er ........................... 16
isradipine ......................................................................... 50
ISTALOL ..................................................................... 133
itchy eye drops ....................................................... 133
itraconazole .................................................................. 30
ivermectin ........................................................................ 16
IXINITY ........................................................................... 87
JADENU ........................................................................... 29
JAKAFI .............................................................................. 40
JALYN ................................................................................ 85
JANTOVEN ................................................................. 20
JANUMET ..................................................................... 27
JANUMET XR ......................................................... 27
JANUVIA ....................................................................... 27
JARDIANCE .............................................................. 27
JENCYCLA .................................................................. 54
JENTADUETO ........................................................ 27
JENTADUETO XR ............................................ 27
JETREA ......................................................................... 133
JOLESSA ......................................................................... 54
JOLIVETTE ................................................................. 54
J-TIP KIT W/VIAL ADAPTERS
.................................................................................................... 106
JUBLIA .............................................................................. 65
JUNEL 1.5/30 ............................................................ 54
JUNEL 1/20 .................................................................. 54
JUNEL FE 1.5/30 .................................................. 54
JUNEL FE 1/20 ....................................................... 54
JUXTAPID ......................................................... 32, 33
KADIAN .......................................................................... 12
KALBITOR .................................................................. 87
KALETRA ..................................................................... 45
kalexate ................................................................ 48, 139
KALYDECO ........................................................... 142
KANUMA ...................................................................... 94
KAON-CL-10 ......................................................... 120
KAPVAY ............................................................................ 6
KARBINAL ER ...................................................... 31
KARIDIUM .............................................................. 120
KARIVA ........................................................................... 54
KAYEXALATE ....................................... 48, 139
KAZANO ........................................................................ 27
KCENTRA .................................................................... 87
k-effervescent ........................................................... 120
KEFLEX ........................................................................... 52
KELNOR 1/35 ........................................................... 54
KENALOG .................................................................... 65
KEPPRA ........................................................................... 21
KEPPRA XR ............................................................... 21
KERAFOAM .............................................................. 65
KERAFOAM 42 ..................................................... 65
KERLONE ..................................................................... 49
KERR TRIPLE DYE SWABS ............. 44
KERYDIN .................................................................. 136
KETEK ............................................................................... 37
KETOCARE ................................................................ 74
ketoconazole ...................................................... 30, 65
KETODAN .................................................................... 65
KETO-DIASTIX .................................................... 74
ketoprofen ........................................................................... 9
ketoprofen er ................................................................... 9
ketorolac tromethamine ...................... 9, 133
KETOSTIX ................................................................... 74
ketotifen fumarate .............................................. 133
KEVEYIS ........................................................................ 78
KHEDEZLA ................................................................ 23
KINERET ........................................................................... 9
kinney lancets .......................................................... 106
kinney thin lancets ............................................ 106
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Index
KIONEX ............................................................ 48, 139
KLARON ......................................................................... 65
KLONOPIN .................................................................. 21
KLOR-CON ............................................... 120, 121
KLOR-CON 10 .................................................... 120
KLOR-CON M10 .............................................. 120
KLOR-CON M15 .............................................. 120
KLOR-CON M20 .............................................. 120
KLOR-CON/EF ................................................... 121
KLOTRIX ................................................................... 121
kmart valu insulin syringe 29g .......... 106
kmart valu insulin syringe 30g .......... 106
KOATE-DVI ............................................................... 87
KOGENATE FS ..................................................... 87
KOGENATE FS BIO-SET ....................... 87
KOKO PEAK PRO MOUTHPIECE
.................................................................................................... 106
KOMBIGLYZE XR ........................................... 27
KORLYM ....................................................................... 27
KOVALTRY ............................................................... 87
kp cetirizine hcl ........................................................ 31
kp miconazole nitrate ........................................ 65
kp omeprazole magnesium ..................... 145
K-PHOS ......................................................................... 121
K-PHOS NO 2 ........................................................... 85
K-PRIME ..................................................................... 121
KRISTALOSE .......................................................... 93
kroger blood glucose test ............................. 74
kroger glucose ........................................................... 27
kroger lancets ......................................................... 106
kroger lancets 21g ............................................ 106
kroger lancets micro thin 33g ............ 106
kroger lancets super thin .......................... 106
kroger lancets thin ............................................ 106
kroger lancets thin 26g ............................... 106
kroger lancets ultrathin 30g ................. 106
kroger lancing device ................................... 106
kroger pen needles ............................................ 106
kroger premium glucose test ................... 74
kroger test ........................................................................ 74
KRYSTEXXA ........................................................... 86
K-SOL .............................................................................. 121
KURVELO .................................................................... 54
KUVAN ............................................................................. 80
k-vescent ........................................................................ 121
KYNAMRO ................................................................. 33
labetalol hcl .................................................................. 49
LABSTIX ........................................................................ 74
LACRISERT ............................................................ 133
lactated ringers ........................................................ 48
lactic acid ........................................................................ 65
lactulose ............................................................................. 93
lactulose encephalopathy ............................ 84
lady lite lancets ..................................................... 106
LAMICTAL ................................................................. 21
LAMICTAL ODT ................................................ 21
LAMICTAL STARTER ............................... 21
LAMICTAL XR ..................................................... 21
LAMISIL ......................................................................... 31
lamivudine ....................................................................... 45
lamivudine-zidovudine .................................... 45
lamotrigine ..................................................................... 21
lamotrigine er ............................................................. 21
lancet device ............................................................. 106
lancets ............................................................................... 106
lancets 28g .................................................................. 106
lancets 30g .................................................................. 106
lancets micro thin 33g .................................. 106
lancets super thin 28g .................................. 106
lancets thin ................................................................. 106
LANCETS ULTRA FINE ...................... 106
LANCETS ULTRA THIN ..................... 106
lancets ultra thin 30g .................................... 106
lancing device ......................................................... 106
LANOXIN ...................................................................... 51
lansoprazole .............................................................. 145
LANTUS .......................................................................... 27
LANTUS SOLOSTAR .................................. 27
LARIN 1/20 .................................................................. 54
LARIN FE 1.5/30 .................................................. 54
LARIN FE 1/20 ....................................................... 54
LASIX .................................................................................. 78
LASTACAFT ......................................................... 133
latanoprost .................................................................. 133
LATUDA ......................................................................... 43
lavare wound wash .............................................. 65
LAZANDA .................................................................... 12
leader advanced lancing device ...... 106
leader glucose ............................................................ 27
leader quick dissolve glucose ................. 27
LEADER UNIFINE PENTIPS ......... 106
LEADER UNIFINE PENTIPS PLUS
.................................................................................................... 106
LEENA ............................................................................... 54
leflunomide ........................................................................ 9
LEMTRADA ........................................................... 140
LENVIMA 10 MG DAILY DOSE
........................................................................................................ 40
LENVIMA 14 MG DAILY DOSE
........................................................................................................ 40
LENVIMA 18 MG DAILY DOSE
........................................................................................................ 40
LENVIMA 20 MG DAILY DOSE
........................................................................................................ 40
LENVIMA 24 MG DAILY DOSE
........................................................................................................ 40
LENVIMA 8 MG DAILY DOSE ..... 40
LESCOL ........................................................................... 33
LESCOL XL ................................................................ 33
LESSINA ......................................................................... 54
LETAIRIS ....................................................................... 51
letrozole ............................................................................. 40
leucovorin calcium ............................................... 40
LEUKERAN ................................................................ 40
LEUKINE ....................................................................... 90
leuprolide acetate .................................................. 40
levalbuterol hcl ......................................................... 18
LEVAQUIN ................................................................. 83
LEVATOL ..................................................................... 49
LEVEMIR ....................................................................... 27
LEVEMIR FLEXPEN ..................................... 27
levetiracetam ............................................................... 21
levetiracetam er ....................................................... 21
levobunolol hcl ...................................................... 133
levocarnitine ................................................................ 80
levocetirizine dihydrochloride ............... 31
levofloxacin ..................................................... 83, 133
levomefolate dha ................................................. 124
LEVONEST ................................................................. 54
levonorgest-eth estrad 91-day ............... 54
levonorgestrel ............................................................. 54
levonorgestrel-ethinyl estrad .................. 54
LEVORA 0.15/30 (28) ................................... 54
levorphanol tartrate ........................................... 12
levothyroxine sodium ..................................... 143
LEVOXYL ................................................................. 143
LEVULAN KERASTICK .......................... 65
LEXAPRO ..................................................................... 23
LEXIVA ............................................................................ 45
LIALDA ............................................................................ 84
LIBERTY GLUCOSE CONTROL
.................................................................................................... 106
LIBERTY GLUCOSE CONTROL
MID ..................................................................................... 106
LIBERTY MINI LANCING DEVICE
.................................................................................................... 106
LIBERTY NEXT GENERATION
TEST ...................................................................................... 75
liberty test ........................................................................ 75
LIBRAX ........................................................................ 145
LIDAZONE HC ...................................................... 15
lidocaine ............................................................................ 65
lidocaine hcl ................................................................. 65
lidocaine viscous ................................................. 122
lidocaine-hydrocortisone ace ................. 15
lidocaine-prilocaine ........................................... 65
LIDODERM ................................................................ 65
LIFESCAN UNISTIK 2 ............................ 106
LIFESCAN UNISTIK II LANCETS
.................................................................................................... 106
LILETTA (52 MG) ............................................. 55
lindane ................................................................................. 65
linezolid .............................................................................. 37
LINZESS .......................................................................... 84
liothyronine sodium ......................................... 143
LIPITOR ........................................................................... 33
LIPOFEN ......................................................................... 33
LIPTRUZET ................................................................ 33
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Index
Index
LIQUID E-Z-PAQUE ...................................... 75
LIQUID POLIBAR ............................................. 75
LIQUID POLIBAR PLUS ......................... 75
lisinopril ............................................................................ 35
lisinopril-hydrochlorothiazide .............. 35
lite touch lancets ................................................. 106
LITE TOUCH LANCING DEVICE
.................................................................................................... 107
LITE TOUCH LANCING PEN ...... 107
LITE TOUCH PEN NEEDLES ...... 107
LITEAIRE .................................................................. 107
LITETOUCH INSULIN SYRINGE
.................................................................................................... 107
LITETOUCH LANCETS ....................... 107
LITETOUCH MASK LARGE ......... 107
LITETOUCH MASK MEDIUM ... 107
LITETOUCH MASK SMALL ......... 107
LITETOUCH PEN NEEDLES ........ 107
lithium .................................................................................. 43
lithium carbonate ................................................... 43
lithium carbonate er ........................................... 43
LITHOBID .................................................................... 43
LITHOSTAT ............................................................... 85
LIVALO ............................................................................ 33
live better adv lancing device ............. 107
live better lancet super thin ................... 107
live better lancet ultra thin ..................... 107
live better pen needles .................................. 107
LO LOESTRIN FE .............................................. 55
LOCOID ........................................................................... 65
LOCOID LIPOCREAM ............................... 65
LODOSYN .................................................................... 42
LOESTRIN 1.5/30 (21) ................................. 55
LOESTRIN 1/20 (21) ....................................... 55
LOESTRIN FE 1.5/30 ..................................... 55
LOESTRIN FE 1/20 .......................................... 55
lofene ..................................................................................... 29
LOFIBRA ........................................................................ 33
LOKARA ......................................................................... 65
LOMOTIL ...................................................................... 29
lomustine ........................................................................... 40
longs glucose ............................................................... 27
longs lancets standard ................................. 107
longs lancets thin ................................................ 107
longs lancets ultra thin ................................ 107
LONOX ............................................................................. 29
LONSURF ...................................................................... 40
LOPID .................................................................................. 33
LOPRESSOR .............................................................. 49
LOPRESSOR HCT ............................................. 35
LOPROX .......................................................................... 65
loratadine ......................................................................... 32
loratadine allergy relief ................................. 32
loratadine childrens ........................................... 32
loratadine-d 12hr ................................................... 59
loratadine-d 24hr ................................................... 59
lorazepam ........................................................................ 17
LORAZEPAM INTENSOL ..................... 17
LORCET ........................................................................... 12
LORCET HD .............................................................. 12
LORTAB .......................................................................... 12
LORYNA ......................................................................... 55
LORZONE ................................................................. 129
losartan potassium ............................................... 35
losartan potassium-hctz ................................. 35
LOSEASONIQUE ............................................... 55
LOTEMAX ................................................................ 133
LOTENSIN ................................................................... 35
LOTENSIN HCT ................................................... 35
LOTREL ........................................................................... 35
LOTRISONE .............................................................. 65
LOTRONEX ................................................................ 84
lovastatin .......................................................................... 33
LOVAZA ......................................................................... 33
LOVENOX .................................................................... 20
LOW-OGESTREL .............................................. 55
loxapine succinate ................................................ 43
LOZI-FLUR .............................................................. 121
LUCENTIS ................................................................ 133
LUDENT ...................................................................... 121
LUFYLLIN ................................................................... 19
LUMIGAN ................................................................. 133
LUMIZYME ................................................................ 80
LUNESTA ...................................................................... 92
LUPANETA PACK ........................................... 93
LUPRON DEPOT ................................................ 40
LUPRON DEPOT-PED ................................ 80
LUTERA .......................................................................... 55
LUVOX CR .................................................................. 23
LUXIQ ................................................................................ 65
LUZU .................................................................................... 65
LYNPARZA ............................................................ 139
LYRICA ............................................................................ 21
LYSODREN ................................................................ 40
LYSTEDA ...................................................................... 91
LYZA .................................................................................... 55
MACNATAL CN DHA ............................ 124
MACROBID ............................................................ 146
MACRODANTIN ............................................ 146
MACUGEN .............................................................. 133
mafenide acetate ..................................................... 65
MAGELLAN INSULIN SAFETY
SYR ..................................................................................... 107
magnesium citrate ................................................. 93
major comfort lancets ................................... 107
MAKENA ................................................................... 139
MALARONE .............................................................. 38
malathion ......................................................................... 65
maprotiline hcl .......................................................... 23
margesic ............................................................................ 10
MARINOL ..................................................................... 30
marlissa .............................................................................. 55
MARNATAL-F ................................................... 124
MARPLAN ................................................................... 23
marten-tab ....................................................................... 10
MASK VORTEX ............................................... 107
MATULANE .............................................................. 40
MATZIM LA .............................................................. 50
MAVIK .............................................................................. 35
MAXALT .................................................................... 119
MAXALT-MLT .................................................. 119
MAXARON FORTE ........................................ 90
MAXIBAR .................................................................... 75
MAXI-COMFORT INSULIN
SYRINGE .................................................................... 107
MAXIDEX ................................................................. 133
MAXIMA BLOOD GLUCOSE TEST
........................................................................................................ 75
MAXIMA CONTROL ................................ 107
MAXITROL ............................................................. 133
MAXZIDE ..................................................................... 78
MAXZIDE-25 ............................................................ 78
MD-GASTROVIEW ........................................ 75
meclofenamate sodium ....................................... 9
medichoice safety lancet ........................... 107
medichoice safety lancet extra .......... 107
medichoice safety lancet norm .......... 107
medicine shoppe lancets ............................ 107
medicine shoppe lancets thin ............... 107
medicine shoppe pen needles .............. 107
medi-lance lancets ............................................ 107
MEDISENSE GLUCOSE KETONE
CONTR ........................................................................... 107
MEDISENSE HI/MID/LOW
CONTROL ................................................................. 107
MEDISENSE HIGH/LOW
CONTROL ................................................................. 107
MEDISENSE MID CONTROL ...... 107
MEDISENSE THIN LANCETS .... 107
MEDLANCE EXTRA 21G .................. 107
MEDLANCE LITE 25G ........................... 107
MEDLANCE PLUS EXTRA 21G
.................................................................................................... 107
MEDLANCE PLUS LANCETS .... 107
MEDLANCE PLUS LITE 25G ....... 108
MEDLANCE PLUS SPECIAL
0.8MM ............................................................................. 108
MEDLANCE PLUS SUPERLITE
30G ....................................................................................... 108
MEDLANCE PLUS UNIVERSAL
21G ....................................................................................... 108
MEDLANCE UNIVERSAL 21G
.................................................................................................... 108
MEDROL ........................................................................ 58
MEDROL (PAK) ................................................... 58
medroxyprogesterone acetate
......................................................................................... 55, 139
mefenamic acid ............................................................. 9
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Index
Index
mefloquine hcl ............................................................ 38
MEGACE ES .......................................................... 139
MEGACE ORAL .................................................. 40
megestrol acetate ..................................... 40, 139
meijer alcohol swabs ..................................... 108
meijer blood glucose test .............................. 75
meijer glucose ............................................................ 27
MEIJER LANCETS ....................................... 108
MEIJER LANCETS THIN .................... 108
MEIJER LANCETS UNIVERSAL
21G ....................................................................................... 108
MEIJER LANCETS UNIVERSAL
30G ....................................................................................... 108
MEIJER LANCETS UNIVERSAL
33G ....................................................................................... 108
meijer pen needles ............................................ 108
meijer premium glucose test .................... 75
MEIJER SUPER THIN LANCETS
.................................................................................................... 108
MEIJER TRUETEST TEST .................... 75
MEIJER TRUETRACK TEST ............ 75
MEKINIST .................................................................... 40
meloxicam ........................................................................... 9
MELOXICAM COMFORT PAC ........ 9
memantine hcl ........................................................ 140
MENEST .......................................................................... 82
MENOPUR ................................................................... 80
MENOSTAR ............................................................... 82
meperidine hcl ........................................................... 12
meperitab ......................................................................... 12
MEPHYTON ........................................................... 148
meprobamate ............................................................... 17
MEPRON ......................................................................... 37
mercaptopurine ........................................................ 40
mesalamine .................................................................... 84
MESNEX ......................................................................... 40
MESTINON ................................................................. 38
METADATE CD ...................................................... 6
METADATE ER ....................................................... 6
metaproterenol sulfate ..................................... 19
metaxalone .................................................................. 129
metformin hcl .............................................................. 27
metformin hcl er ...................................................... 27
metformin hcl er (mod) ................................... 27
metformin hcl er (osm) .................................... 27
methadone hcl ............................................................ 12
METHADONE HCL INTENSOL
........................................................................................................ 12
METHADOSE ............................................... 12, 13
METHADOSE SUGAR-FREE ........... 13
methamphetamine hcl .......................................... 6
methazolamide ........................................................... 78
methenamine hippurate .............................. 146
methenamine mandelate ............................ 146
methimazole .............................................................. 143
methitest ............................................................................. 15
methocarbamol ..................................................... 129
methotrexate ................................................................. 40
methscopolamine bromide ...................... 145
methyclothiazide ..................................................... 78
methyldopa ..................................................................... 35
methylergonovine maleate ...................... 136
METHYLIN .................................................................... 7
methylphenidate hcl ................................................ 7
methylphenidate hcl er ........................................ 7
methylphenidate hcl er (cd) .......................... 7
methylphenidate hcl er (la) ........................... 7
methylprednisolone ............................................. 58
methylprednisolone (pak) ............................ 58
methyltestosterone ................................................ 15
metipranolol .............................................................. 133
metoclopramide hcl ............................................. 84
metolazone ...................................................................... 78
METOPIRONE ........................................................ 75
metoprolol succinate er ................................. 49
metoprolol tartrate ............................................... 49
metoprolol-hydrochlorothiazide ......... 35
METOZOLV ODT .............................................. 84
METROCREAM ................................................... 65
METROGEL ............................................................... 65
METROGEL-VAGINAL ........................ 147
METROLOTION .................................................. 65
metronidazole ................................... 37, 65, 147
MEVACOR .................................................................. 33
mexiletine hcl .............................................................. 17
MIACALCIN .............................................................. 80
micaderm .......................................................................... 65
MICARDIS ................................................................... 35
MICARDIS HCT ................................................... 35
MICATIN ........................................................................ 65
miconazole nitrate ................................................ 65
MICRHOGAM ULTRA-FILTERED
PLUS .................................................................................. 137
MICRO GUARD ................................................... 65
MICRO-BUMINTEST ................................... 75
MICROCHAMBER ....................................... 108
MICRODOT CONTROL
HIGH/LOW .............................................................. 108
MICRODOT TEST ............................................. 75
MICROELITE BATTERY ................... 108
MICROELITE FILTER
REPLACEMENTS .......................................... 108
MICROGESTIN 1.5/30 ................................. 55
MICROGESTIN 1/20 ...................................... 55
MICROGESTIN FE 1.5/30 ...................... 55
MICROGESTIN FE 1/20 ............................ 55
MICRO-K .................................................................... 121
MICROLET LANCETS ........................... 108
MICROLIFE DIGITAL PEAK
FLOW ............................................................................... 108
micronized colestipol hcl ............................. 33
MICROSPACER ................................................ 108
MICROTAINER SAFETY FLOW
LANCET ....................................................................... 108
MICROZIDE .............................................................. 78
midazolam hcl ............................................................ 92
midodrine hcl ........................................................... 147
MIGERGOT ............................................................. 119
miglitol ................................................................................ 27
MIGRAL ....................................................................... 119
MIGRALAM ........................................................... 119
MIGRANAL ............................................................ 119
MILLIPRED ................................................................ 58
MILLIPRED DP ..................................................... 58
MILLIPRED DP 12-DAY ......................... 58
MIMVEY ......................................................................... 82
MINASTRIN 24 FE ........................................... 55
mini lancing device .......................................... 108
MINI WRIGHT PEAK FLOW
METER ........................................................................... 108
MINIELITE FILTER
REPLACEMENTS .......................................... 108
MINIELITE RECHARGEABLE
BATTERY .................................................................. 108
MINIPRESS ................................................................. 35
MINIPRIN LOW DOSE .............................. 10
MINITRAN .................................................................. 16
MINIVELLE ............................................................... 82
MINOCIN ................................................................... 143
minocycline hcl ..................................................... 143
minocycline hcl er ............................................. 143
minoxidil ........................................................................... 35
MIRALAX ..................................................................... 93
MIRAPEX ...................................................................... 42
MIRAPEX ER ........................................................... 42
MIRCERA ...................................................................... 90
MIRCETTE .................................................................. 55
MIRENA (52 MG) .............................................. 55
mirtazapine .................................................................... 23
MIRVASO ..................................................................... 65
misoprostol ................................................................. 145
MITIGARE ................................................................... 86
MOBIC ................................................................................... 9
modafinil ............................................................................... 7
MODERIBA ................................................................ 46
moderiba ........................................................................... 46
MODERIBA 1200 DOSE PACK ..... 45
MODERIBA 800 DOSE PACK ......... 45
MODICON (28) ...................................................... 55
moexipril hcl ................................................................ 35
moexipril-hydrochlorothiazide ............. 35
molindone hcl ............................................................. 43
mometasone furoate ............................. 65, 130
MONOCLATE-P ................................................... 87
MONODOX ............................................................. 143
MONOJECT INSULIN SYRINGE
.................................................................................................... 108
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Index
Index
MONOJECT ULTRA COMFORT
SYRINGE .................................................................... 108
MONOJECTOR END CAPS ............. 108
MONOJECTOR OPD END CAPS
.................................................................................................... 108
MONOLET LANCETS ............................. 108
MONOLET OPD LANCETS ............ 108
MONOLETTOR SAFETY
LANCETS .................................................................. 108
MONO-LINYAH .................................................. 55
MONONESSA ......................................................... 55
MONONINE ............................................................... 87
MONOVISC ............................................................ 129
monsels ferric subsulfate .............................. 91
montelukast sodium ............................................. 19
MONUROL .............................................................. 146
MOORE MONO INSULIN
SYRINGE .................................................................... 108
MORGIDOX ........................................................... 143
morphine sulfate er .............................................. 13
morphine sulfate er beads ........................... 13
MOTOFEN .................................................................... 29
MOVANTIK ............................................................... 84
MOVIPREP .................................................................. 93
MOXATAG .............................................................. 138
MOXEZA .................................................................... 133
MS CONTIN ............................................................... 13
ms quick dissolve glucose ............................ 28
MST 600 ........................................................................... 10
MULTAQ ........................................................................ 17
multi vit/fl ..................................................................... 124
multi vita-bets/fluoride ................................ 124
multi vitamin/fluoride ................................... 124
MULTIGEN ................................................................. 90
MULTIGEN FOLIC .......................................... 90
MULTIGEN PLUS ............................................. 90
multi-lancet device ........................................... 109
multiple vitamins/fluoride ....................... 124
MULTISTIX ................................................................ 75
MULTISTIX 10 SG ........................................... 75
MULTISTIX 5 .......................................................... 75
MULTISTIX 7 .......................................................... 75
MULTISTIX 8 .......................................................... 75
MULTISTIX 9 .......................................................... 75
MULTISTIX 9 SG ............................................... 75
multi-vit/fluoride ................................................. 124
multi-vit/fluoride/iron ................................... 124
multivitamin/fluoride ..................................... 124
multi-vitamin/fluoride ................................... 124
multi-vitamin/fluoride/iron .................... 124
multivitamins/fluoride .................................. 124
multi-vitamins/fluoride ................................ 124
multi-vits/fluoride .............................................. 124
mult-vitamin/fluoride ..................................... 124
mupirocin ......................................................................... 66
mupirocin calcium ................................................ 66
MVC-FLUORIDE ............................................ 124
MYALEPT .................................................................... 93
MYAMBUTOL ....................................................... 38
mycophenolate mofetil ..................................... 48
mycophenolic acid ................................................ 48
mydral ............................................................................... 133
MYDRIACYL ....................................................... 133
myferon 150 forte ................................................... 90
MYFORTIC ................................................................. 48
MYGLUCOHEALTH CONTROL
.................................................................................................... 109
MYGLUCOHEALTH LANCETS
30G ....................................................................................... 109
MYGLUCOHEALTH TEST ................. 75
MYKIDZ IRON FL ........................................ 124
MYLERAN ................................................................... 41
MYNATAL ............................................................... 124
MYNATAL ADVANCE ......................... 124
mynatal plus .............................................................. 124
mynatal-z ....................................................................... 124
mynephrocaps ......................................................... 124
MYORISAN ................................................................ 66
MYOXIN ..................................................................... 136
MYOZYME ................................................................. 80
MYRBETRIQ ........................................................ 146
MYSOLINE ................................................................. 21
MYTELASE ................................................................ 38
MYTESI ............................................................................ 29
MYZILRA ...................................................................... 55
na ferric gluc cplx in sucrose ................. 90
NABI-HB ..................................................................... 137
nabumetone ....................................................................... 9
nadolol ................................................................................. 49
nadolol-bendroflumethiazide .................. 35
NAFRINSE ................................................................ 121
NAFRINSE DAILY ACIDULATED
.................................................................................................... 122
NAFRINSE DAILY/NEUTRAL ... 122
NAFRINSE DROPS ...................................... 121
NAFRINSE WEEKLY ............................... 122
naftifine hcl .................................................................... 66
NAFTIN ............................................................................ 66
NAGLAZYME ......................................................... 80
NALFON ............................................................................. 9
naltrexone hcl ............................................................. 29
NAMENDA .............................................................. 140
NAMENDA TITRATION PAK ..... 140
NAMENDA XR .................................................. 140
NAMENDA XR TITRATION PACK
.................................................................................................... 140
NAMZARIC ................................................................ 22
NAPRELAN .................................................................... 9
NAPROSYN ................................................................... 9
naproxen ............................................................................... 9
naproxen dr ....................................................................... 9
naproxen sodium ........................................................ 9
naproxen sodium er ................................................ 9
naratriptan hcl ....................................................... 119
NARCAN ........................................................................ 29
NARDIL ........................................................................... 23
NASACORT ALLERGY 24HR ..... 130
NASCOBAL ................................................................ 90
NASONEX ................................................................ 130
NATACHEW ......................................................... 124
NATACYN ................................................................ 133
NATALVIRT 90 DHA ............................... 124
NATALVIRT CA ............................................. 124
NATALVIRT FLT .............................................. 90
NATALVIT .............................................................. 124
NATAZIA ....................................................................... 55
nateglinide ...................................................................... 28
NATELLE ONE .................................................. 124
NATESTO ...................................................................... 15
NATPARA .................................................................... 80
NATROBA .................................................................... 66
NATURE-THROID ........................................ 143
nebulizer air tube/plugs ............................. 109
nebulizer mask pediatric ........................... 109
NEBUPENT ................................................................. 37
NEBUSAL ..................................................................... 59
NECON 0.5/35 (28) ........................................... 55
NECON 1/35 (28) ................................................. 55
NECON 1/50 (28) ................................................. 55
NECON 10/11 (28) ............................................. 55
NECON 7/7/7 ............................................................. 55
NEEVO DHA ......................................................... 124
nefazodone hcl ............................................ 23, 142
neo-fradin ............................................................................ 7
NEOFRIN .................................................................... 133
neomycin sulfate ......................................................... 7
neomycin-bacitracin zn-polymyx .... 134
neomycin-polymyxin b gu ............................ 85
neomycin-polymyxin-dexameth ........ 134
neomycin-polymyxin-gramicidin .... 134
neomycin-polymyxin-hc ............................. 136
NEO-POLYCIN .................................................. 134
NEO-POLYCIN HC ...................................... 134
NEORAL ......................................................................... 48
NEOSPORIN .......................................................... 134
NEOSPORIN AF ................................................... 66
NEOSPORIN GU IRRIGANT ............. 85
NEO-SYNALAR ................................................... 66
NEOTUSS PLUS .................................................. 59
NEPHPLEX RX .................................................. 124
NEPHROCAPS .................................................... 124
NEPHROCAPS QT ........................................ 124
NEPHRON FA ......................................................... 90
NEPHRONEX ....................................................... 124
NEPTAZANE ............................................................ 78
NESINA ............................................................................ 28
NESSI SPACER WITH MASK
LARGE ........................................................................... 109
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Index
Index
Index
NESSI SPACER WITH MASK
SM/MED ....................................................................... 109
NESSI SPACER WITH
MOUTHPIECE .................................................... 109
NESTABS ................................................................... 125
NESTABS ABC .................................................. 125
NESTABS DHA ................................................. 125
NETGROUP LANCETS .......................... 109
NEUAC .............................................................................. 66
NEULASTA ................................................................ 90
NEULASTA DELIVERY KIT ............ 90
NEUMEGA .................................................................. 90
NEUPOGEN ................................................................ 90
NEUPRO .......................................................................... 42
neurin-sl ............................................................................. 90
NEURONTIN ............................................................ 21
NEUTEK 2TEK CONTROL .............. 109
NEUTEK 2TEK TEST ................................... 75
NEVANAC ................................................................ 134
nevirapine ........................................................................ 46
nevirapine er ................................................................ 46
NEXA PLUS ........................................................... 125
NEXAVAR ................................................................... 41
NEXGEN CONTROL ................................. 109
NEXGEN TEST ...................................................... 75
NEXIUM ...................................................................... 145
NEXIUM 24HR ................................................... 145
NEXPLANON .......................................................... 55
NEXT CHOICE ...................................................... 55
NEXT CHOICE ONE DOSE ................. 55
niacin ................................................................................. 148
niacin er ......................................................................... 148
niacin er (antihyperlipidemic) ............... 33
niacin-50 ....................................................................... 148
NIACOR ........................................................................... 33
NIASPAN ....................................................................... 33
nicardipine hcl ........................................................... 50
NICAZELDOXY 30 ...................................... 143
NICAZELDOXY 60 ...................................... 143
NICODERM CQ ................................................ 140
NICOMIDE ............................................................... 125
NICORETTE ........................................................... 140
NICORETTE MINI ........................................ 140
NICORETTE STARTER KIT .......... 140
nicotine ............................................................................ 140
nicotine polacrilex ............................................ 141
NICOTROL .............................................................. 141
NICOTROL NS ................................................... 141
NIFEDIAC CC ......................................................... 51
NIFEDICAL XL ..................................................... 51
nifedipine .......................................................................... 51
nifedipine er .................................................................. 51
nifedipine er osmotic release .................. 51
NILANDRON ............................................................ 41
nilutamide ........................................................................ 41
nimodipine ...................................................................... 51
NINLARO ...................................................................... 41
NIRAVAM .................................................................... 17
nisoldipine er ............................................................... 51
NITRO-BID .................................................................. 16
NITRO-DUR ............................................................... 16
nitrofurantoin .......................................................... 146
nitrofurantoin macrocrystal ................. 146
nitrofurantoin monohyd macro ......... 146
nitroglycerin ................................................................. 16
nitroglycerin er ......................................................... 16
NITROLINGUAL ................................................ 16
NITROMIST ............................................................... 16
NITROSTAT .............................................................. 16
NITRO-TIME ............................................................ 16
nizatidine ....................................................................... 145
NIZORAL ....................................................................... 66
NORA-BE ....................................................................... 55
NORCO ............................................................................. 13
NORDIPEN 5 INJECTION DEVICE
.................................................................................................... 109
NORDIPEN DELIVERY SYSTEM
.................................................................................................... 109
NORDITROPIN FLEXPRO ................... 80
NORDITROPIN NORDIFLEX PEN
........................................................................................................ 80
norethin ace-eth estrad-fe ........................... 55
norethindrone ............................................................. 55
norethindrone acetate .................................. 139
norethindrone-eth estradiol ...................... 82
norgestimate-eth estradiol .......................... 55
norgestim-eth estrad triphasic .............. 56
norgestrel-ethinyl estradiol ....................... 56
NORINYL 1+35 (28) ....................................... 56
NORINYL 1+50 (28) ....................................... 56
NORITATE .................................................................. 66
NOROXIN ..................................................................... 83
NORPACE ..................................................................... 17
NORPACE CR ......................................................... 17
NORPRAMIN ........................................................... 24
NOR-QD ........................................................................... 56
NORTHERA ............................................................ 130
NORTREL 0.5/35 (28) ................................... 56
NORTREL 1/35 (21) ........................................ 56
NORTREL 1/35 (28) ........................................ 56
NORTREL 7/7/7 .................................................... 56
nortriptyline hcl ....................................................... 24
nortuss-ex ......................................................................... 59
NORVASC .................................................................... 51
NORVIR ........................................................................... 46
nose clip ......................................................................... 109
NOVA MAX GLUCOSE TEST ........ 75
NOVA MAX PLUS GLU/KET
CONTROL ................................................................. 109
NOVA SAFETY LANCETS 23G
.................................................................................................... 109
NOVA SAFETY LANCETS 28G
109
NOVA SUREFLEX LANCETS ..... 109
NOVA SUREFLEX LANCING
DEVICE ......................................................................... 109
NOVAFERRUM .................................................... 90
novarel ................................................................................. 80
NOVOEIGHT ............................................................ 87
NOVOFINE .............................................................. 109
NOVOFINE AUTOCOVER ............... 109
NOVOLIN 70/30 ................................................... 28
NOVOLIN 70/30 RELION ...................... 28
NOVOLIN N ............................................................... 28
NOVOLIN N RELION .................................. 28
NOVOLIN R ............................................................... 28
NOVOLIN R RELION .................................. 28
NOVOLOG ................................................................... 28
NOVOLOG FLEXPEN ................................. 28
NOVOLOG MIX 70/30 ................................ 28
NOVOLOG MIX 70/30 FLEXPEN
........................................................................................................ 28
NOVOLOG PENFILL .................................... 28
NOVOSEVEN RT ............................................... 87
NOVOTWIST ........................................................ 109
NOXAFIL ....................................................................... 31
np thyroid ..................................................................... 143
NPLATE ........................................................................... 90
NUCALA ......................................................................... 92
NUCORT ......................................................................... 66
NUCYNTA ................................................................... 13
NUCYNTA ER ........................................................ 13
NUEDEXTA ............................................................ 141
NUFOL ............................................................................... 90
NULOJIX ........................................................................ 48
NULYTELY WITH FLAVOR
PACKS ............................................................................... 93
NUOX .................................................................................. 66
NUPLAZID .................................................................. 43
NUTRIVIT ................................................................. 125
NUTROPIN .................................................................. 80
NUTROPIN AQ ...................................................... 80
NUTROPIN AQ NUSPIN 10 ................ 80
NUTROPIN AQ NUSPIN 20 ................ 80
NUTROPIN AQ NUSPIN 5 .................... 80
NUTROPIN AQ PEN ...................................... 80
NUVARING ................................................................ 56
NUVESSA .................................................................. 147
NUVIGIL ............................................................................ 7
NUWIQ .............................................................................. 87
NYAMYC ....................................................................... 66
NYMALIZE ................................................................. 51
nystatin ...................................................... 31, 66, 122
nystatin-triamcinolone .................................... 66
NYSTOP ........................................................................... 66
OB COMPLETE ................................................. 125
OB COMPLETE 400 .................................... 125
....................................................................................................
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Index
Index
Index
OB COMPLETE GOLD ........................... 125
OB COMPLETE ONE ................................ 125
OB COMPLETE PETITE ...................... 125
OB COMPLETE PREMIER ............... 125
OB COMPLETE/DHA ............................... 125
OBREDON .................................................................... 59
O-CAL PRENATAL ..................................... 125
OCALIVA ...................................................................... 83
OCELLA .......................................................................... 56
OCTAGAM .............................................................. 137
octreotide acetate .................................................. 80
OCUFEN ...................................................................... 134
OCUFLOX ................................................................. 134
OCUVEL ...................................................................... 125
ODEFSEY ...................................................................... 46
ODOMZO ....................................................................... 41
OFEV ................................................................................ 141
ofloxacin .............................................. 83, 134, 136
olanzapine ....................................................................... 43
olanzapine-fluoxetine hcl ......................... 141
OLEPTRO ....................................................... 24, 142
olopatadine hcl ....................................... 130, 134
OLUX ................................................................................... 66
OLUX-E ............................................................................ 66
OLYSIO ............................................................................ 46
OMECLAMOX-PAK .................................. 145
omega-3-acid ethyl esters ........................... 33
omeprazole ................................................................. 145
omeprazole magnesium .............................. 145
omeprazole-sodium bicarbonate .... 145
OMNARIS .................................................................. 130
OMNIFLEX DIAPHRAGM ............... 109
OMNIPRED ............................................................. 134
OMNITROPE ............................................................ 80
ON CALL EXPRESS BLOOD
GLUCOSE ..................................................................... 75
ON CALL EXPRESS GLUCOSE
CONTR ........................................................................... 109
ON CALL LANCETS ................................. 109
ON CALL LANCING DEVICE .... 109
ON CALL PLUS BLOOD
GLUCOSE ..................................................................... 75
ON CALL PLUS GLUCOSE
CONTROL ................................................................. 109
ON CALL PLUS LANCETS ............. 109
ON CALL PLUS LANCING
DEVICE ......................................................................... 109
ON CALL VIVID BLOOD
GLUCOSE ..................................................................... 75
ON CALL VIVID GLUCOSE
CONTROL ................................................................. 109
ondansetron .................................................................. 30
ondansetron hcl ........................................................ 30
ONE FLOW TESTER ................................. 109
ONETOUCH CLUB LANCETS
FINE PT ......................................................................... 109
ONETOUCH COMBO PACK ......... 109
ONETOUCH DELICA LANCETS
33G ....................................................................................... 109
ONETOUCH DELICA LANCETS
FINE ................................................................................... 109
ONETOUCH DELICA LANCING
DEV .................................................................................... 109
ONETOUCH FINEPOINT
LANCETS .................................................................. 109
ONETOUCH LANCETS ........................ 109
ONETOUCH SURESOFT LANCING
DEV .................................................................................... 110
ONETOUCH ULTRA BLUE ................ 75
ONETOUCH ULTRA CONTROL
.................................................................................................... 110
ONETOUCH ULTRASOFT
LANCETS .................................................................. 110
ONETOUCH VERIO ........................ 75, 110
ONEXTON .................................................................... 66
ONFI ...................................................................................... 21
ONGLYZA .................................................................... 28
ONMEL ............................................................................. 31
ONZETRA XSAIL .......................................... 120
OPANA .............................................................................. 13
OPANA ER ................................................................... 13
opium ..................................................................................... 29
OPSUMIT ....................................................................... 51
OPTICHAMBER ADVANTAGE
.................................................................................................... 110
OPTICHAMBER ADVANTAGE-LG
MASK .............................................................................. 110
OPTICHAMBER
ADVANTAGE-MED MASK ............ 110
OPTICHAMBER ADVANTAGE-SM
MASK .............................................................................. 110
OPTICHAMBER DIAMOND .......... 110
OPTICHAMBER DIAMOND-LG
MASK .............................................................................. 110
OPTICHAMBER DIAMOND-MD
MASK .............................................................................. 110
OPTICHAMBER DIAMOND-SM
MASK .............................................................................. 110
OPTICHAMBER FACE
MASK-LARGE ................................................... 110
OPTICHAMBER FACE
MASK-MEDIUM ............................................. 110
OPTICHAMBER FACE
MASK-SMALL ................................................... 110
OPTIHALER ........................................................... 110
OPTIONS CONCEPTROL ................... 147
OPTIONS GYNOL II
CONTRACEPTIVE ....................................... 147
OPTIVAR .................................................................... 134
OPTUMRX BLOOD GLUCOSE
TEST ...................................................................................... 75
OPTUMRX GLUCOSE CONTROL
.................................................................................................... 110
ORACEA ......................................................................... 66
ORACIT ............................................................................ 85
ORALONE ................................................................ 122
ORAMAGICRX ................................................. 122
ORAP ................................................................................ 141
ORAPRED ODT .................................................... 58
ORAVIG ....................................................................... 122
ORENCIA .......................................................................... 9
ORENCIA CLICKJECT .................................. 9
ORENITRAM ............................................................ 51
ORFADIN ....................................................................... 80
ORKAMBI .................................................................... 60
orphenadrine citrate er ............................... 129
orphenadrine-aspirin-caffeine ........... 129
ORSYTHIA .................................................................. 56
ORTHO DIAPHRAGM COIL ......... 110
ORTHO DIAPHRAGM FLAT ........ 110
ORTHO EVRA ........................................................ 56
ORTHO MICRONOR ..................................... 56
ORTHO TRI-CYCLEN (28) .................. 56
ORTHO TRI-CYCLEN LO ..................... 56
ORTHO-CEPT (28) ........................................... 56
ORTHO-CYCLEN (28) ................................ 56
ORTHO-EST 0.625 ............................................ 82
ORTHO-EST 1.25 ................................................ 82
ORTHO-NOVUM 1/35 (28) ................... 56
ORTHO-NOVUM 7/7/7 (28) ................. 56
ORTHOVISC ......................................................... 129
OSENI .................................................................................. 28
OSMOPREP ................................................................ 93
OSPHENA ..................................................................... 80
OTEZLA ....................................................................... 138
otic care .......................................................................... 136
oticin ................................................................................... 136
OTOVEL ...................................................................... 136
OTOZIN ........................................................................ 136
OTREXUP ......................................................................... 9
OVACE PLUS .......................................................... 66
OVACE PLUS WASH ................................... 66
OVACE WASH ...................................................... 66
OVCON-35 (28) ..................................................... 56
OVIDE ................................................................................ 66
OVIDREL ....................................................................... 81
OXANDRIN ................................................................ 15
oxandrolone .................................................................. 15
oxaprozin ............................................................................. 9
OXAYDO ....................................................................... 13
oxazepam .......................................................................... 17
oxcarbazepine ............................................................ 21
oxiconazole nitrate ............................................... 66
OXISTAT ........................................................................ 66
OXSORALEN ........................................................... 66
OXSORALEN ULTRA ................................ 66
OXTELLAR XR .................................................... 21
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Index
Index
oxybutynin chloride ......................................... 146
oxycodone hcl ............................................................. 13
oxycodone hcl er ..................................................... 13
oxycodone-acetaminophen ......................... 13
oxycodone-aspirin ................................................. 13
oxycodone-ibuprofen ......................................... 13
OXYCONTIN ............................................................ 13
oxymorphone hcl .................................................... 13
oxymorphone hcl er ............................................ 13
OXYTROL FOR WOMEN .................. 146
OZURDEX ................................................................ 134
PACERONE ................................................................ 17
PAIRE OB .................................................................. 125
paliperidone er .......................................................... 43
PAMELOR .................................................................... 24
pamidronate disodium ..................................... 81
PAMINE ....................................................................... 145
PAMINE FORTE .............................................. 145
PANCREAZE ............................................................ 77
PANDA MASK LARGE ......................... 110
PANDA MASK MEDIUM ................... 110
PANDA MASK SMALL ........................ 110
PANDEL .......................................................................... 66
PANRETIN ................................................................... 66
pantoprazole sodium ...................................... 145
PARAFON FORTE DSC ........................ 129
PARAGARD INTRAUTERINE
COPPER ........................................................................... 56
parcaine ......................................................................... 134
PAREMYD ................................................................ 134
PARI ALTERA NEBULIZER
HANDSET ................................................................. 110
PARI BABY CONVERSION KIT
.................................................................................................... 110
PARI ERAPID NEBULIZER
HANDSET ................................................................. 110
PARI EXPIRATORY FILTER SET
.................................................................................................... 110
PARI MASK SET ............................................. 110
PARI SOFT PLASTIC ADULT
MASK .............................................................................. 110
PARI SOFT PLASTIC PED MASK
.................................................................................................... 110
paricalcitol ..................................................................... 81
PARLODEL ................................................................. 42
PARNATE ..................................................................... 24
paromomycin sulfate ............................................. 7
paroxetine hcl ............................................................. 24
paroxetine hcl er ..................................................... 24
PASER ................................................................................ 38
PATADAY ................................................................ 134
PATANASE ............................................................. 130
PATANOL ................................................................. 134
PAXIL .................................................................................. 24
PAXIL CR ...................................................................... 24
PAZEO ............................................................................ 134
pc lancets super thin 30g .......................... 110
pc unifine pentips ............................................... 110
pca injector ................................................................ 110
PCCA ACACIA SYRUP BASE .... 138
PCE .......................................................................................... 94
PEAK AIR PEAK FLOW METER
.................................................................................................... 110
PEDIAPRED ............................................................... 58
PEDIATEX TDM ................................................. 59
pediatric aerosol mask ................................ 110
pediatric mouthpiece ..................................... 110
PEDIATRIC PANDA MASK ........... 110
peg 3350 ............................................................................ 93
peg 3350/electrolytes ........................................ 93
peg 3350-kcl-na bicarb-nacl ................... 93
peg-3350/electrolytes ........................................ 93
PEGANONE ................................................................ 21
PEGASYS ....................................................................... 46
PEGASYS PROCLICK ................................ 46
PEGINTRON .............................................................. 46
PEG-INTRON ........................................................... 46
PEG-INTRON REDIPEN .......................... 46
PEG-INTRON REDIPEN PAK 4 .... 46
PEG-PREP ..................................................................... 93
pen needles ................................................................. 110
pen needles 1/2" ................................................... 110
pen needles 3/16" ............................................... 111
pen needles 5/16" ............................................... 111
penicillin v potassium ................................... 138
PENLAC ........................................................................... 66
PENLET II BLOOD SAMPLER ... 111
PENLET II REPLACEMENT CAP
.................................................................................................... 111
PENNSAID ................................................................... 66
PENTASA ...................................................................... 84
pentoxifylline er ....................................................... 88
PEPCID .......................................................................... 145
PERCOCET .................................................................. 13
PERCODAN ................................................................ 13
PERFECT LANCETS 28G ................... 111
PERFECT LANCETS 30G ................... 111
PERFOROMIST ..................................................... 19
PERIDEX .................................................................... 122
perindopril erbumine ........................................ 35
PERIOGARD ......................................................... 122
PERIOMED .............................................................. 122
permethrin ....................................................................... 66
perphenazine ................................................................ 44
PERSANTINE .......................................................... 88
PERSONAL BEST FULL RANGE
.................................................................................................... 111
PERSONAL BEST LOW RANGE
.................................................................................................... 111
PERTZYE ....................................................................... 77
PEXEVA .......................................................................... 24
PFLEX ............................................................................. 111
PHARMACIST CHOICE ALCOHOL
.................................................................................................... 111
PHARMACIST CHOICE
AUTOCODE ............................................................... 75
PHARMACIST CHOICE LANCETS
.................................................................................................... 111
PHARMACY COUNTER LANCETS
.................................................................................................... 111
PHENADOZ ................................................................ 32
PHENAZO ..................................................................... 85
phenazopyridine hcl ........................................... 85
phenelzine sulfate .................................................. 24
phenobarbital .............................................................. 92
phenoxybenzamine hcl ..................................... 36
phenylephrine hcl ............................................... 134
PHENYTEK ................................................................ 21
phenytoin .......................................................................... 22
PHENYTOIN INFATABS ....................... 22
phenytoin sodium extended ....................... 22
PHILITH ........................................................................... 56
PHOSLO ........................................................................... 84
PHOSLYRA ................................................................ 84
PHOSPHA 250 NEUTRAL ................. 121
phosphate enema .................................................... 93
PHOSPHOLINE IODIDE ...................... 134
PHYSIOLYTE .......................................................... 48
PHYSIOSOL IRRIGATION .................. 48
PICATO ............................................................................. 67
PIKO 1 ............................................................................. 111
pillow mask/adult ............................................... 111
pillow mask/child ............................................... 111
pillow mask/pediatric .................................... 111
pilocarpine hcl ........................................ 122, 134
pimozide ......................................................................... 141
PIMTREA ....................................................................... 56
pindolol ............................................................................... 49
pinnacaine otic ...................................................... 136
pioglitazone hcl ........................................................ 28
pioglitazone hcl-glimepiride .................... 28
pioglitazone hcl-metformin hcl ............. 28
PIRMELLA 1/35 .................................................... 56
PIRMELLA 7/7/7 .................................................. 56
piroxicam ............................................................................. 9
PLAQUENIL .............................................................. 38
plastic adapter ....................................................... 111
PLAVIX ............................................................................ 88
PLEGRIDY ............................................................... 141
PLEGRIDY STARTER PACK ....... 141
PLETAL ............................................................................ 88
PLEXION ........................................................................ 67
PLEXION CLEANSER ................................ 67
PLEXION CLEANSING CLOTH
........................................................................................................ 67
PLIAGLIS ....................................................................... 67
pnv fe fum/docusate/folic acid ........... 125
pnv ob+dha ................................................................ 125
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
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Index
pnv-dha ........................................................................... 125
pnv-dha+docusate ............................................ 125
pnv-omega ................................................................... 125
pnv-select ...................................................................... 125
pnv-total ......................................................................... 125
POCKET CHAMBER ................................. 111
POCKET PEAK FLOW METER
.................................................................................................... 111
POCKET SPACER ......................................... 111
POCKETCHEM EZ CONTROL
.................................................................................................... 111
POCKETCHEM EZ TEST ....................... 75
POCKETPEAK PEAK FLOW
METER ........................................................................... 111
podactin ............................................................................. 67
podocon .............................................................................. 67
podofilox ........................................................................... 67
POLIBAR ACB ....................................................... 75
POLYCIN .................................................................... 134
polycin b ........................................................................ 134
poly-dex .......................................................................... 134
polyethylene glycol 3350 ............... 93, 138
poly-iron 150 forte ............................................... 90
polymyxin b-trimethoprim ....................... 134
polysaccharide iron forte ............................. 90
POLYTRIM .............................................................. 134
POLY-VI-FLOR ................................................. 125
POLY-VI-FLOR/IRON ............................. 125
polyvitamin/fluoride ........................................ 125
poly-vitamin/fluoride ..................................... 125
POMALYST ................................................................ 41
PONSTEL ........................................................................... 9
PORTIA-28 ................................................................... 56
pot bicarb-pot chloride ............................... 121
potassium bicarbonate ................................ 121
potassium chloride ........................................... 121
potassium chloride crys er ..................... 121
potassium chloride er ................................... 121
potassium citrate-citric acid .................... 86
POTIGA ............................................................................ 22
PR NATAL 400 ................................................... 125
PRADAXA .................................................................... 20
PRALUENT ............................................................. 137
pramcort ............................................................................ 15
pramipexole dihydrochloride ................. 42
pramipexole dihydrochloride er ......... 42
PRAMOSONE .......................................................... 67
PRANDIMET ............................................................ 28
PRANDIN ....................................................................... 28
PRASCION ................................................................... 67
PRASCION FC ........................................................ 67
PRASCION RA ....................................................... 67
PRAVACHOL .......................................................... 33
pravastatin sodium ............................................... 33
prazosin hcl ................................................................... 36
PRECISION GLUCOSE CONTROL
.................................................................................................... 111
PRECISION GLUCOSE CONTROL
SOLN ................................................................................ 111
PRECISION GLUCOSE KETONE
CONTR ........................................................................... 111
PRECISION GLUCOSE/KETONE
CONTR ........................................................................... 111
PRECISION PCX ................................................. 75
PRECISION PCX PLUS TEST .......... 75
PRECISION POINT OF CARE TEST
........................................................................................................ 75
PRECISION QID TEST ............................... 76
PRECISION SOF-TACT TEST ......... 76
PRECISION SUREDOSE PLUS SYR
.................................................................................................... 111
PRECISION SURE-DOSE SYRINGE
.................................................................................................... 111
PRECISION THIN LANCETS ....... 111
PRECISION THINS GP LANCETS
.................................................................................................... 111
PRECISION ULTRA LANCET ..... 111
PRECISION XTRA BLOOD
GLUCOSE ..................................................................... 76
PRECOSE ....................................................................... 28
PRED FORTE ........................................................ 134
PRED MILD ............................................................ 134
PRED-G ......................................................................... 134
PRED-G S.O.P. .................................................... 134
prednicarbate .............................................................. 67
prednisolone ................................................................. 58
prednisolone acetate ...................................... 134
prednisolone sodium phosphate
......................................................................................... 58, 134
prednisone ....................................................................... 58
prednisone (pak) ..................................................... 58
PREDNISONE INTENSOL .................... 58
PREFERA OB ....................................................... 125
PREFERA OB + DHA ................................ 125
PREFERAOB ONE ........................................ 125
preferred plus glucose ..................................... 28
preferred plus lancets colored ........... 111
preferred plus lancets thin ...................... 111
preferred plus unifine pentips ............ 111
PREFEST ......................................................................... 82
PREFOL-DHA ...................................................... 125
PRE-FOLIC .................................................................. 90
pregnyl ................................................................................. 81
PRELONE ...................................................................... 58
PREMARIN ................................................... 82, 147
premium blood glucose test ...................... 76
PREMPHASE ............................................................ 82
PREMPRO ..................................................................... 82
prena1 pearl ............................................................. 125
prena1 plus/quatrefolic .............................. 125
prena1/quatrefolic ............................................ 125
prenaissance ............................................................. 125
prenaissance 90 dha ....................................... 126
prenaissance balance .................................... 126
prenaissance dha ................................................ 126
prenaissance harmony dha .................... 126
prenaissance next ............................................... 126
prenaissance next-b ......................................... 126
prenaissance plus ............................................... 126
prenaissance promise ................................... 126
PRENATA .................................................................. 126
prenatabs fa ............................................................... 126
PRENATABS RX ............................................. 126
prenatal 19 ................................................................. 126
PRENATAL AD ................................................. 126
PRENATAL
MULTIVITAMIN-ULTRA .................. 126
prenatal plus iron .............................................. 126
PRENATAL-U ..................................................... 126
PRENATE .................................................... 126, 139
PRENATE AM ..................................................... 126
PRENATE DHA ................................................. 126
PRENATE ELITE ............................................ 126
PRENATE ENHANCE .............................. 126
PRENATE MINI ................................................ 126
PRENATE RESTORE ................................ 126
PRENTIF CAVITY-RIM CERV CAP
.................................................................................................... 111
PRENTIF FITTING SET ........................ 111
PREPIDIL ................................................................... 136
PREPOPIK .................................................................... 93
PREQUE 10 .............................................................. 126
PRESTALIA ................................................................ 36
prestige smart system test ............................ 76
PRESTIGE TEST .................................................. 76
PREVACID ............................................................... 145
PREVACID 24HR ........................................... 145
PREVACID SOLUTAB ........................... 145
PREVALITE ............................................................... 33
PREVIFEM ................................................................... 56
PREVPAC .................................................................. 145
PREZCOBIX .............................................................. 46
PREZISTA ..................................................................... 46
PRIALT ............................................................................. 10
PRIFTIN ........................................................................... 38
PRILOSEC ................................................................. 145
PRILOSEC OTC ................................................ 145
primaquine phosphate ..................................... 38
primidone ......................................................................... 22
PRIMLEV ....................................................................... 13
PRIMSOL ....................................................................... 37
PRINIVIL ........................................................................ 36
PRISTIQ ........................................................................... 24
PRIVIGEN ................................................................. 137
PROAIR HFA ............................................................ 19
PROAIR RESPICLICK ................................ 19
probenecid ...................................................................... 86
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Index
PROCARDIA ............................................................. 51
PROCARDIA XL ................................................. 51
PROCENTRA ............................................................... 7
prochlorperazine .................................................... 44
prochlorperazine maleate ........................... 44
PROCORT ..................................................................... 15
PROCRIT ........................................................................ 90
PROCTOCARE-HC .......................................... 15
PROCTOFOAM HC ......................................... 15
PROCTO-PAK ......................................................... 15
PROCTOSOL HC ................................................ 16
PROCTOZONE-HC .......................................... 16
PROCYSBI ................................................................... 86
PRODIGY AUTOCODE BLOOD
GLUCOSE ..................................................................... 76
PRODIGY CONTROL SOLUTION
.................................................................................................... 111
PRODIGY INSULIN PEN
NEEDLES ................................................................... 111
PRODIGY INSULIN SYRINGE
.................................................................................................... 112
PRODIGY LANCETS 28G .................. 112
PRODIGY LANCING DEVICE ... 112
PRODIGY MINI PEN NEEDLES
.................................................................................................... 112
PRODIGY NO CODING BLOOD
GLUC ................................................................................... 76
PRODIGY SHORT PEN NEEDLES
.................................................................................................... 112
PRODIGY TWIST TOP LANCETS
28G ....................................................................................... 112
PROFERRIN-FORTE ..................................... 90
PROFILNINE SD ................................................. 88
progesterone ............................................................. 139
progesterone micronized .......................... 139
PROGLYCEM .......................................................... 28
PROGRAF ..................................................................... 48
PROLASTIN-C .................................................... 142
PROLENSA .............................................................. 134
PROLIA ............................................................................. 81
PROMACTA .............................................................. 90
promethazine hcl .................................................... 32
promethazine-codeine ...................................... 59
promethazine-dm .................................................... 59
PROMETHEGAN ................................................ 32
PROMETRIUM ................................................... 139
propafenone hcl ....................................................... 17
propafenone hcl er ............................................... 17
proparacaine hcl ................................................. 134
propranolol hcl ......................................................... 49
propranolol hcl er ................................................. 49
propylthiouracil ................................................... 144
PROSCAR ...................................................................... 86
PROSTIN E2 ........................................................... 136
PROTECTIRON ..................................................... 91
PROTONIX .............................................................. 145
PROTOPIC .................................................................... 67
protriptyline hcl ....................................................... 24
PROVENTIL HFA .............................................. 19
PROVERA ................................................................. 139
PROVIDA OB ....................................................... 126
PROVIGIL ......................................................................... 7
PROVOCHOLINE .............................................. 76
PROZAC .......................................................................... 24
PROZAC WEEKLY ......................................... 24
PRUDOXIN ................................................................. 67
pseudoeph-bromphen-dm ............................ 59
PSS SELECT GP LANCETS ............ 112
PSS SELECT PLATFORMS ............. 112
PSS SELECT SAFETY LANCETS
.................................................................................................... 112
PTS PANELS GLUCOSE TEST ...... 76
PULMICORT ............................................................. 19
PULMICORT FLEXHALER ................ 19
PULMOSAL ................................................................ 59
PULMOZYME ..................................................... 142
purefe ob plus ......................................................... 126
purefe plus ...................................................................... 91
purevit dualfe plus ................................................ 91
PURINETHOL ......................................................... 41
PURIXAN ....................................................................... 41
px advanced lancing device .................. 112
px extra short pen needles ...................... 112
px glucose ........................................................................ 28
px insulin syringe ............................................... 112
px lancet auto injector ................................. 112
px lancets ...................................................................... 112
px lancets ultra thin ......................................... 112
px niacin ........................................................................ 148
px pen needle ........................................................... 112
px shortlength pen needles ..................... 112
PYLERA ....................................................................... 145
pyrazinamide ............................................................... 38
pyridostigmine bromide ................................. 38
pyridostigmine bromide er ......................... 38
QBRELIS ......................................................................... 36
qc advanced lancing device .................. 112
qc alcohol swabs ................................................. 112
qc insulin syringe ............................................... 112
qc lancets super thin 30g .......................... 112
qc lancets ultra thin ......................................... 112
qc pen needles ........................................................ 112
qc unifine pentips ............................................... 112
QNASL ........................................................................... 130
QNASL CHILDRENS ................................ 130
QUALAQUIN ........................................................... 38
QUARTETTE ............................................................ 56
QUASENSE ................................................................. 56
QUDEXY XR ............................................................ 22
QUESTRAN ................................................................ 33
QUESTRAN LIGHT ........................................ 33
quetiapine fumarate ............................................ 44
QUFLORA FE ...................................................... 122
QUFLORA PEDIATRIC ......................... 126
QUICKTEK CONTROL SOLUTION
.................................................................................................... 112
QUICKTEK TEST .............................................. 76
QUILLICHEW ER .................................................. 7
QUILLIVANT XR .................................................. 7
quinapril hcl ................................................................. 36
quinapril-hydrochlorothiazide .............. 36
quinidine gluconate er ..................................... 17
quinidine sulfate ...................................................... 17
quinine sulfate ............................................................ 38
QUINTET AC BLOOD GLUCOSE
TEST ...................................................................................... 76
QUINTET BLOOD GLUCOSE
TEST ...................................................................................... 76
QUINTET CONTROL
HIGH/NORMAL ............................................... 112
QUINZYME .................................................................... 7
QUTENZA .................................................................... 67
QUTENZA (2 PATCH) ................................ 67
QVAR .................................................................................. 19
ra alcohol swabs ................................................. 112
ra antifungal ................................................................. 67
RA E-ZJECT COLOR LANCETS
33G ....................................................................................... 112
RA E-ZJECT LANCETS 28G .......... 112
RA E-ZJECT LANCETS THIN 26G
.................................................................................................... 112
RA E-ZJECT LANCETS THIN 28G
.................................................................................................... 112
RA E-ZJECT LANCETS ULTRA
THIN .................................................................................. 112
ra glucose ........................................................................ 28
ra lancing device ................................................. 112
ra niacin ......................................................................... 148
ra no flush niacin ............................................... 148
ra pen needles ......................................................... 112
RA TRUETEST TEST ................................... 76
rabeprazole sodium ......................................... 145
RADIOGARDASE ............................................. 29
raloxifene hcl ............................................................... 81
ramipril ............................................................................... 36
RANEXA ......................................................................... 16
ranitidine hcl ............................................. 145, 146
RAPAFLO ...................................................................... 86
RAPAMUNE .............................................................. 48
RASUVO ............................................................................. 9
RAVICTI ......................................................................... 81
RAYOS .............................................................................. 58
RAZADYNE ........................................................... 141
RAZADYNE ER ................................................ 141
RE 10 WASH ............................................................. 67
READI-CAT ................................................................ 76
READI-CAT 2 .......................................................... 76
reality lancets .......................................................... 112
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Index
reality swabs ............................................................. 112
reality trigger lancets ................................... 112
REBETOL ...................................................................... 46
REBIF ............................................................................... 141
REBIF REBIDOSE ......................................... 141
REBIF REBIDOSE TITRATION
PACK ................................................................................ 141
REBIF TITRATION PACK ................ 141
RECLAST ....................................................................... 81
RECLIPSEN ................................................................ 56
RECOMBINATE .................................................. 88
RECTIV ............................................................................. 16
REFUAH PLUS BLOOD GLUCOSE
TEST ...................................................................................... 76
REFUAH PLUS GLUCOSE
CONTROL ................................................................. 113
REGENECARE ....................................................... 67
REGLAN ......................................................................... 84
REGRANEX ............................................................... 67
RELAGARD ............................................................ 147
RELENZA DISKHALER .......................... 46
RELHIST ......................................................................... 59
RELION ALCOHOL SWABS ......... 113
RELION GLUCOSE ......................................... 28
RELION GLUCOSE DRINK ................ 28
RELION INSULIN SYRINGE ........ 113
RELI-ON INSULIN SYRINGE ..... 113
RELION KETONE ............................................. 76
RELION LANCETS MICRO-THIN
33G ....................................................................................... 113
RELION LANCETS STANDARD
21G ....................................................................................... 113
RELION LANCETS THIN 26G .... 113
RELION LANCETS ULTRA-THIN
30G ....................................................................................... 113
RELION LANCING DEVICE ......... 113
RELION MINI PEN NEEDLES .... 113
RELION PEN NEEDLES ...................... 113
RELION SHORT PEN NEEDLES
.................................................................................................... 113
RELION ULTRA THIN LANCETS
30G ....................................................................................... 113
RELION ULTRA THIN PLUS
LANCETS .................................................................. 113
RELISTOR .................................................................... 84
relnate dha .................................................................. 126
RELPAX ....................................................................... 120
REMEDY ANTIFUNGAL ....................... 67
REMERON ................................................................... 24
REMERON SOLTAB ..................................... 24
REMICADE ................................................................. 84
REMODULIN ........................................................... 51
RENACIDIN ............................................................... 86
RENAGEL ..................................................................... 84
RENAL ........................................................................... 126
RENATABS ............................................................. 126
RENATABS WITH IRON .................... 126
rena-vite rx ................................................................. 126
RENEW ADV CARTRIDGE
REFILLS ....................................................................... 113
RENEW ADVANCED LANCING
DEVICE ......................................................................... 113
reno caps ....................................................................... 126
RENVELA ..................................................................... 84
repaglinide ..................................................................... 28
repaglinide-metformin hcl .......................... 28
REPATHA .................................................................. 137
REPATHA PUSHTRONEX
SYSTEM ....................................................................... 137
REPATHA SURECLICK ....................... 137
replacement air filter ..................................... 113
replacement filters ............................................ 113
REPREXAIN .............................................................. 13
REPRONEX ................................................................ 81
REQUIP ............................................................................. 42
REQUIP XL ................................................................. 42
RESCON-JR ................................................................ 59
RESCON-MX ............................................................ 59
RESCRIPTOR ........................................................... 46
RESCULA .................................................................. 134
RESECTISOL ............................................................ 86
RESPA-BR .................................................................... 32
RESTASIS .................................................................. 135
RESTORIL .................................................................... 92
RETIN-A .......................................................................... 67
RETIN-A MICRO ................................................ 67
RETIN-A MICRO PUMP .......................... 67
RETROVIR .................................................................. 46
REVATIO ....................................................................... 52
REVEAL BLOOD GLUCOSE TEST
........................................................................................................ 76
revesta .................................................................................. 91
REVIA ................................................................................. 30
REVLIMID ................................................................... 48
REXALL BLOOD GLUCOSE TEST
........................................................................................................ 76
REXALL LANCETS ULTRA THIN
30G ....................................................................................... 113
REXULTI ........................................................................ 44
REYATAZ ..................................................................... 46
REZIRA ............................................................................. 59
RHEUMATREX ........................................................ 9
RHOGAM ULTRA-FILTERED
PLUS .................................................................................. 137
RHOPHYLAC ....................................................... 137
RIASTAP ......................................................................... 88
RIAX ..................................................................................... 67
ribasphere ....................................................................... 46
RIBASPHERE RIBAPAK ........................ 46
ribasphere ribapak ............................................... 46
ribatab .................................................................................. 46
ribavirin ............................................................................. 46
RIDAURA ......................................................................... 9
rifabutin ............................................................................. 38
RIFADIN ......................................................................... 38
RIFAMATE .................................................................. 38
rifampin .............................................................................. 38
RIFATER ......................................................................... 39
RIGHTEST ALTERNATE SITE
ADAPT ........................................................................... 113
RIGHTEST GC300 CONTROL ..... 113
RIGHTEST GD500 LANCING
DEVICE ......................................................................... 113
RIGHTEST GL300 LANCETS ....... 113
RIGHTEST GS100 BLOOD
GLUCOSE ..................................................................... 76
RIGHTEST GS300 BLOOD
GLUCOSE ..................................................................... 76
RIGHTEST GS550 BLOOD
GLUCOSE ..................................................................... 76
RILUTEK .................................................................... 130
riluzole ............................................................................. 130
rimantadine hcl ........................................................ 46
ringers irrigation .................................................... 48
RIOMET ........................................................................... 28
risedronate sodium .............................................. 81
RISPERDAL ............................................................... 44
RISPERDAL M-TAB ...................................... 44
risperidone ..................................................................... 44
RISPERIDONE M-TAB .............................. 44
RITALIN ............................................................................. 7
RITALIN LA .................................................................. 7
RITALIN SR ................................................................... 7
RITEFLO ..................................................................... 113
rivastigmine ............................................................... 141
rivastigmine tartrate ....................................... 141
RIXUBIS .......................................................................... 88
rizatriptan benzoate ........................................ 120
R-NATAL OB ....................................................... 126
ROBAXIN .................................................................. 129
ROBAXIN-750 ..................................................... 129
ROBINUL ................................................................... 146
ROBINUL-FORTE ......................................... 146
ROCALTROL ........................................................... 81
romycin ........................................................................... 135
ropinirole hcl ............................................................... 42
ropinirole hcl er ....................................................... 42
ROSADAN .................................................................... 67
ROSANIL CLEANSER ................................ 67
rosuvastatin calcium .......................................... 33
ROXICET ....................................................................... 13
ROXICODONE ....................................................... 13
ROZEREM .................................................................... 92
RUCONEST ................................................................ 88
RYTARY ......................................................................... 42
RYTHMOL ................................................................... 17
RYTHMOL SR ........................................................ 17
SABRIL ............................................................................. 22
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Index
SAFESNAP INSULIN SYRINGE
SEMPREX-D .............................................................. 59
se-natal 19 ................................................................... 127
SENSIPAR .................................................................... 81
SENTRAVIL PM-25 ........................................ 24
SEREVENT DISKUS ..................................... 19
SERNIVO ....................................................................... 68
SEROPHENE ............................................................. 81
SEROQUEL ................................................................. 44
SEROQUEL XR ..................................................... 44
SEROSTIM ................................................................... 81
sertraline hcl ................................................................ 24
se-tan plus ....................................................................... 91
sevoflurane ..................................................................... 85
sf 5000 plus ................................................................ 122
SFROWASA ............................................................... 84
SHOPKO ALCOHOL SWABS ...... 114
SHOPKO AUTOLET LANCING
DEVICE ......................................................................... 114
SHOPKO ON-THE-GO LANCETS
30G ....................................................................................... 114
SHOPKO UNIFINE PENTIPS ........ 114
SHOPKO UNILET LANCETS 28G
.................................................................................................... 114
SHOPKO UNILET LANCETS 30G
.................................................................................................... 114
SHUR-SEAL CONTRACEPTIVE
.................................................................................................... 147
SIDESTREAM ADULT FACE
MASK .............................................................................. 114
SIDESTREAM PEDIATRIC FACE
MASK .............................................................................. 114
SIDESTREAM PLS ADULT FACE
MASK .............................................................................. 114
SIGNIFOR ..................................................................... 81
SIGNIFOR LAR ..................................................... 81
sildenafil citrate ....................................................... 52
SILENOR ........................................................................ 92
silicone mask/adult ........................................... 114
silicone mask/infant ......................................... 114
silicone mask/pediatric ............................... 114
SILVADENE .............................................................. 68
silver sulfadiazine .................................................. 68
SIMBRINZA ........................................................... 135
SIMCOR ........................................................................... 33
SIMPLE DIAGNOSTICS LANCING
DEV .................................................................................... 114
SIMPONI ............................................................................. 9
SIMPONI ARIA ......................................................... 9
SIMULECT .................................................................. 48
simvastatin ...................................................................... 33
SINEMET ....................................................................... 42
SINEMET CR ............................................................ 42
SINGLE-LET ......................................................... 114
SINGULAIR ................................................................ 19
sirolimus ............................................................................ 48
SIRTURO ........................................................................ 39
SITZMARKS .............................................................. 76
SIVEXTRO ................................................................... 37
SKELAXIN ............................................................... 129
SKLICE ............................................................................. 68
SKYLA ............................................................................... 56
SLO-NIACIN ......................................................... 148
sm alcohol prep .................................................... 114
sm antifungal miconazole ............................ 68
sm glucose ....................................................................... 28
sm lancets 21g ........................................................ 114
sm lancets 33g ........................................................ 114
sm niacin cr ............................................................... 148
sm super thin lancets 30g ........................ 114
sm thin lancets 26g ........................................... 114
SMART DIABETES VANTAGE
LANCETS .................................................................. 114
SMART DIABETES VANTAGE
LANCING .................................................................. 114
SMART DIABETES XPRES TEST
........................................................................................................ 76
SMART SENSE COLOR LANCETS
33G ....................................................................................... 114
SMART SENSE GLUCOSE .................. 28
SMART SENSE PREMIUM TEST
........................................................................................................ 76
SMART SENSE STANDARD
LANCETS .................................................................. 114
SMART SENSE SUPER THIN
LANCETS .................................................................. 114
SMART SENSE THIN LANCETS
26G ....................................................................................... 114
SMART SENSE VALUE TEST ........ 76
SMARTEST BLOOD GLUCOSE
TEST ...................................................................................... 76
SMARTEST CONTROL MEDIUM
.................................................................................................... 114
SMARTEST LANCETS 28G ............ 114
smz-tmp ds ...................................................................... 37
sod benz-sod phenylacet ............................... 81
sodium chloride ............................................. 59, 86
sodium fluoride ..................................................... 121
sodium phenylbutyrate .................................... 81
sodium polystyrene sulfonate ... 48, 139
sodium sulfacetamide ....................................... 68
sodium sulfacetamide wash ...................... 68
SOJOURN ...................................................................... 85
SOLARAZE ................................................................. 68
SOLARTEK GLUCOSE CONTROL
.................................................................................................... 114
SOLIA .................................................................................. 56
SOLIRIS ........................................................................... 88
SOLODYN ................................................................ 143
SOLTAMOX .............................................................. 41
SOLUS V2 CONTROL ............................. 114
SOLUS V2 LANCETS 28G ................ 114
113
SAFE-T-LANCE ................................................ 113
SAFE-T-LANCE PLUS ............................ 113
safety lancet 21g/pressure act ............ 113
safety lancet 28g/pressure act ............ 113
SAFETY LANCETS ..................................... 113
SAFETY LANCETS 21G ...................... 113
safety lancets 28g ............................................... 113
SAFETY LET LANCETS ...................... 113
SAFETY SEAL LANCETS ................. 113
SAFETY-GLIDE SYRINGE .............. 113
SAFYRAL ...................................................................... 56
SAIZEN ............................................................................. 81
SAIZEN CLICK.EASY ................................ 81
SALACYN .................................................................... 67
SALAGEN ................................................................. 122
SALICEPT ................................................................. 122
salicylic acid ................................................................ 67
salicylic acid wart remover ....................... 67
SALKERA ..................................................................... 68
salsalate ............................................................................. 10
SAMI THE SEAL FILTERS .............. 113
SAMSCA ......................................................................... 81
SANCUSO ..................................................................... 30
SANDIMMUNE ..................................................... 48
SANDOSTATIN .................................................... 81
SANDOSTATIN LAR DEPOT .......... 81
SANTYL .......................................................................... 68
SAPHRIS ......................................................................... 44
SARAFEM ................................................................. 141
SAVAYSA .................................................................... 20
SAVELLA .................................................................. 141
SAVELLA TITRATION PACK .... 141
sb alcohol prep ...................................................... 113
sb lancets thin ......................................................... 114
sb lancets ultra thin ......................................... 114
scalacort ............................................................................ 68
SCLEROSOL INTRAPLEURAL
.................................................................................................... 142
SEASONIQUE ......................................................... 56
SEB-PREV WASH ............................................. 68
SECONAL ..................................................................... 92
SECTRAL ....................................................................... 49
SECURA ANTIFUNGAL ......................... 68
SECURA ANTIFUNGAL EXTRA
THICK ................................................................................. 68
SEEBRI NEOHALER ..................................... 19
select-lite device/lancets ............................ 114
select-lite lancing device ........................... 114
SELECT-OB ............................................................ 126
SELECT-OB+DHA ........................................ 127
selegiline hcl ................................................................ 42
selenium sulfide ........................................................ 68
SELRX ................................................................................ 68
SELZENTRY ............................................................. 46
....................................................................................................
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Index
Index
SOLUS V2 LANCING DEVICE
STRIANT ........................................................................ 15
STRIBILD ...................................................................... 46
STRIVERDI RESPIMAT ........................... 19
STROMECTOL ...................................................... 16
STROVITE FORTE ....................................... 127
SUBOXONE .................................................... 13, 14
SUBSYS ........................................................................... 14
SUCLEAR ...................................................................... 93
SUCRAID ....................................................................... 77
sucralfate ...................................................................... 146
SULAR ............................................................................... 51
sulfacetamide sodium ......................... 68, 135
sulfacetamide sodium (acne) ................... 68
sulfacetamide sodium-sulfur .................... 68
sulfacetamide-prednisolone .................. 135
SULFACLEANSE 8/4 .................................... 68
sulfamethoxazole-trimethoprim ........... 37
SULFAMYLON ..................................................... 68
sulfasalazine ................................................................. 84
SULFATRIM PEDIATRIC ..................... 37
SULFAZINE ............................................................... 84
SULFAZINE EC .................................................... 84
sulindac .............................................................................. 10
sumatriptan succinate .................................. 120
SUMAVEL DOSEPRO ............................. 120
SUPARTZ ................................................................... 129
super thin lancets ............................................... 115
SUPERVITE EC ................................................. 127
SUPPRELIN LA .................................................... 81
SUPRANE ...................................................................... 85
SUPRAX .......................................................................... 52
supreme ii high/low control .................. 115
SUPREME TEST .................................................. 76
SUPREP BOWEL PREP ............................. 93
sure comfort alcohol prep ....................... 115
sure comfort insulin syringe ................. 115
sure comfort lancets 28g ........................... 115
sure comfort lancets 30g ........................... 115
sure comfort lancing pen .......................... 115
sure comfort pen needles .......................... 115
SURE EDGE TEST ............................................ 76
SURECHEK BLOOD GLUCOSE
TEST ...................................................................................... 76
SURE-FINE PEN NEEDLES ............ 115
SURE-JECT INSULIN SYRINGE
.................................................................................................... 115
SURE-LANCE FLAT LANCETS
.................................................................................................... 115
SURE-LANCE LANCETS 26G ..... 115
SURE-LANCE THIN LANCETS
28G ....................................................................................... 115
SURE-LANCE ULTRA THIN
LANCETS .................................................................. 115
SURELITE LANCETS .............................. 115
SURE-PEN ................................................................ 115
SURE-PREP ALCOHOL PREP ..... 115
SURESTEP GLUCOSE CONTROL
.................................................................................................... 115
SURESTEP PRO HIGH GLUCOSE
.................................................................................................... 115
SURESTEP PRO LOW GLUCOSE
.................................................................................................... 115
SURESTEP PRO NORMAL
GLUCOSE .................................................................. 115
SURESTEP PRO TEST ................................ 76
SURE-TEST EASYPLUS MINI
TEST ...................................................................................... 76
SURE-TOUCH LANCETS
UNIVERSAL .......................................................... 115
SURMONTIL ............................................................ 24
SUSTIVA ........................................................................ 47
SUTENT ........................................................................... 41
SYEDA ............................................................................... 57
SYLATRON ................................................................ 41
SYMBICORT ............................................................ 19
SYMBYAX ............................................................... 141
SYMLINPEN 120 ................................................ 28
SYMLINPEN 60 .................................................... 29
SYNAGEX ................................................................ 127
SYNAGIS .................................................................... 137
SYNALAR .................................................................... 69
SYNALGOS-DC ................................................... 14
SYNAREL ..................................................................... 81
SYNATEK ................................................................. 127
SYNERA .......................................................................... 69
SYNJARDY ............................................................. 142
SYNTHROID ......................................................... 144
SYNVISC .................................................................... 129
SYNVISC ONE ................................................... 129
SYPRINE ......................................................................... 48
T.R.U.E. TEST ......................................................... 76
TABLOID ....................................................................... 41
TACLONEX ................................................................ 69
tacrolimus ............................................................. 48, 69
TAFINLAR ................................................................... 41
TAGITOL V ................................................................ 76
TAGRISSO ................................................................... 41
TAI DOC CONTROL ................................. 115
TALTZ ................................................................................ 69
TAMIFLU ....................................................................... 47
tamoxifen citrate ..................................................... 41
tamsulosin hcl ............................................................. 86
TANDEM F .................................................................. 91
TANZEUM ................................................................... 29
TAPAZOLE .............................................................. 144
TARCEVA .................................................................... 41
TARGADOX .......................................................... 143
TARGRETIN ................................................... 41, 69
TARKA .............................................................................. 36
taron forte ........................................................................ 91
TARON-BC .............................................................. 127
TARON-C DHA ................................................. 127
114
SOLUS V2 TEST .................................................. 76
SOLUS V2 TWIST LANCETS 30G
.................................................................................................... 114
SOMA .............................................................................. 129
SOMATULINE DEPOT .............................. 81
SOMAVERT ............................................................... 81
SONATA ......................................................................... 92
SOOLANTRA ........................................................... 68
SOOTHE & COOL INZO
ANTIFUNGAL ........................................................ 68
SORIATANE .............................................................. 68
SORILUX ....................................................................... 68
SORINE ............................................................................. 49
sotalol hcl ........................................................................ 50
sotalol hcl (af) ............................................................ 50
SOTYLIZE .................................................................... 50
SOVALDI ....................................................................... 46
SPECTRACEF ......................................................... 52
SPIRIVA HANDIHALER ......................... 19
SPIRIVA RESPIMAT .................................... 19
spironolactone ........................................................... 78
spironolactone-hctz ............................................. 78
SPORANOX ................................................................ 31
SPORANOX PULSEPAK ......................... 31
SPRINTEC 28 ........................................................... 56
SPRITAM ....................................................................... 22
SPRIX ...................................................................................... 9
SPRYCEL ....................................................................... 41
SPS ............................................................................ 48, 139
SRONYX ......................................................................... 56
SSD .......................................................................................... 68
SSKI .................................................................................... 121
sss 10-5 ............................................................................... 68
ST JOSEPH ASPIRIN .................................... 11
STALEVO 100 ......................................................... 42
STALEVO 125 ......................................................... 42
STALEVO 150 ......................................................... 42
STALEVO 200 ......................................................... 42
STALEVO 50 ............................................................. 42
STALEVO 75 ............................................................. 43
stannous fluoride ................................................ 122
STARLIX ........................................................................ 28
stavudine ........................................................................... 46
STAVZOR ..................................................................... 22
STELARA ...................................................................... 68
STERILANCE PA ........................................... 114
STERILANCE TL ............................................ 114
STERILE TALC POWDER ................ 142
sterile water for irrigation ......................... 48
STIMATE ....................................................................... 81
STIOLTO RESPIMAT .................................. 19
STIVARGA .................................................................. 41
STRATTERA ................................................................ 7
STRENSIQ .................................................................... 92
....................................................................................................
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Index
Index
TARON-CRYSTALS ...................................... 86
TARON-PREX ..................................................... 127
TASIGNA ....................................................................... 41
TASMAR ......................................................................... 43
TAYTULLA ................................................................ 57
TAZORAC .................................................................... 69
TAZTIA XT ................................................................. 51
TECFIDERA ........................................................... 141
TECHLITE AST LANCETS .............. 115
TECHLITE LANCETS .............................. 115
TECHLITE LANCETS 30G ............... 115
TECHNIVIE ................................................................ 91
TEGRETOL ................................................................. 22
TEGRETOL-XR ..................................................... 22
TEKAMLO ................................................................... 36
TEKTURNA ................................................................ 36
TEKTURNA HCT ............................................... 36
TELCARE BLOOD GLUCOSE
TEST ...................................................................................... 76
TELCARE GLUCOSE CONTROL
.................................................................................................... 115
telmisartan ...................................................................... 36
telmisartan-hctz ....................................................... 36
temazepam ...................................................................... 92
TEMODAR ................................................................... 41
TEMOVATE ............................................................... 69
TEMOVATE E ........................................................ 69
temozolomide .............................................................. 41
TENCON ......................................................................... 11
TENEX ............................................................................... 36
TENORETIC 100 .................................................. 36
TENORETIC 50 ..................................................... 36
TENORMIN ................................................................ 50
TERAZOL 3 ............................................................. 147
TERAZOL 7 ............................................................. 147
terazosin hcl ................................................................. 36
terbinafine hcl ............................................................ 31
terbutaline sulfate .................................................. 19
terconazole ................................................................. 147
TERRELL ....................................................................... 85
TERSI ................................................................................... 69
TERUMO INSULIN SYRINGE .... 115
TERUMO SURGUARD INSULIN
SYR ..................................................................................... 115
TESSALON PERLES ..................................... 59
TESTIM ............................................................................. 15
testosterone .................................................................... 15
testosterone cypionate ..................................... 15
testosterone enanthate ..................................... 15
TETCAINE ................................................................ 135
tetrabenazine ............................................................ 141
tetracaine hcl ........................................................... 135
tetracycline hcl ...................................................... 143
TETRAVISC ........................................................... 135
TETRAVISC FORTE .................................. 135
TEVETEN ...................................................................... 36
TEVETEN HCT ...................................................... 36
TEV-TROPIN ............................................................ 81
TEXACORT ................................................................ 69
tgq 30pse/150gfn/15dm .................................. 59
tgq 30pse/3brm/15dm ....................................... 60
tgt advanced lancing device ................. 115
tgt alcohol swabs ................................................ 115
tgt blood glucose test ......................................... 77
tgt glucose ....................................................................... 29
tgt lancet alternate site ................................ 115
tgt lancet micro thin 33g ........................... 115
tgt lancet super thin 30g ............................ 116
tgt lancet thin 23g .............................................. 116
tgt lancet thin 26g .............................................. 116
tgt lancet ultra thin 28g .............................. 116
tgt lancet ultra thin 30g .............................. 116
tgt lancing device ............................................... 116
THALOMID ................................................................ 48
THEO-24 .......................................................................... 19
THEOCHRON .......................................................... 19
theophylline ................................................................... 19
theophylline er ........................................................... 19
THERABENZAPRINE-90-5 ............. 129
THERMAZENE ..................................................... 69
THINLETS GP LANCETS .................. 116
THINLETS LANCET .................................. 116
THINPRO INSULIN SYRINGE ... 116
THIOLA ............................................................................ 86
thioridazine hcl ......................................................... 44
thiothixene ....................................................................... 44
THRESHOLD IMT ......................................... 116
THYMOGLOBULIN ....................................... 49
THYROGEN ............................................................... 77
THYROLAR-1 ..................................................... 144
THYROLAR-1/2 ................................................ 144
THYROLAR-1/4 ................................................ 144
THYROLAR-2 ..................................................... 144
THYROLAR-3 ..................................................... 144
tiagabine hcl ................................................................. 22
TIAZAC ............................................................................ 51
ticlopidine hcl ............................................................. 88
TIGAN ................................................................................ 30
TIKOSYN ....................................................................... 18
TILIA FE .......................................................................... 57
timolol maleate ........................................... 50, 135
TIMOPTIC ................................................................. 135
TIMOPTIC OCUDOSE ............................ 135
TIMOPTIC-XE ..................................................... 135
TINDAMAX ............................................................... 37
tinidazole .......................................................................... 37
TIROSINT .................................................................. 144
TISSEEL VH .............................................................. 91
TISSEEL VHSD ..................................................... 91
TIS-U-SOL .................................................................... 49
TIVICAY ......................................................................... 47
TIVORBEX .................................................................. 10
tizanidine hcl ............................................................ 129
tl gard rx ........................................................................... 91
TL G-FOL OS ........................................................ 127
tl icon ..................................................................................... 91
tl-care dha ................................................................... 127
tl-fluorivite .................................................................. 127
tl-select ............................................................................ 127
TOBI .......................................................................................... 8
TOBI PODHALER ................................................. 8
TOBRADEX ............................................................ 135
TOBRADEX ST ................................................. 135
tobramycin ........................................................... 8, 135
tobramycin-dexamethasone .................. 135
TOBREX ...................................................................... 135
TODAY SPONGE ........................................... 147
todays health lancing device ................ 116
todays health mini pen needles ......... 116
todays health pen needles ........................ 116
todays health short pen needle .......... 116
todays health thin lancets 28g ........... 116
todays health thin lancets 30g ........... 116
TOFRANIL ................................................................... 24
TOFRANIL-PM ...................................................... 24
TOLAK .............................................................................. 69
tolazamide ....................................................................... 29
tolcapone .......................................................................... 43
tolmetin sodium ........................................................ 10
TOPAMAX ................................................................... 22
TOPAMAX SPRINKLE .............................. 22
topcare clickfine pen needles .............. 116
TOPICORT ................................................................... 69
TOPICORT SPRAY .......................................... 69
TOPIRAGEN .............................................................. 22
topiramate ....................................................................... 22
TOPROL XL ............................................................... 50
torsemide .......................................................................... 78
TOUJEO SOLOSTAR .................................... 29
TOVIAZ ........................................................................ 146
TRACLEER ................................................................. 52
TRADJENTA ............................................................. 29
tramadol hcl ................................................................. 14
tramadol hcl er ......................................................... 14
tramadol hcl er (biphasic) .......................... 14
tramadol-acetaminophen ............................. 14
TRANDATE ................................................................ 50
trandolapril ................................................................... 36
trandolapril-verapamil hcl er ................ 36
tranexamic acid ........................................................ 91
TRANSDERM-SCOP (1.5 MG) ........ 30
TRANXENE-T ......................................................... 17
tranylcypromine sulfate ................................. 24
TRAVATAN Z ..................................................... 135
travoprost ..................................................................... 135
trazodone hcl ................................................ 24, 142
TRECATOR ................................................................ 39
TRELSTAR .................................................................. 41
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Index
Index
TRELSTAR MIXJECT ................................. 41
TRESIBA FLEXTOUCH ........................... 29
tretinoin ................................................................... 41, 69
tretinoin microsphere ....................................... 69
tretinoin microsphere pump ..................... 69
TRETIN-X ..................................................................... 69
TRETTEN ....................................................................... 88
TREXALL ...................................................................... 41
TREXIMET .............................................................. 120
TREZIX ............................................................................. 14
triadvance .................................................................... 127
triamcinolone acetonide ................. 69, 122
triamterene-hctz ....................................................... 78
triazolam ........................................................................... 92
TRIBENZOR .............................................................. 36
TRICARE PRENATAL 1 ...................... 127
TRICARE PRENATAL COMPLEAT
.................................................................................................... 127
TRICARE PRENATAL DHA ONE
.................................................................................................... 127
TRICODE AR ........................................................... 60
TRICON ............................................................................ 91
TRICOR ............................................................................ 33
TRIDERM ...................................................................... 69
TRI-ESTARYLLA .............................................. 57
trifluoperazine hcl ................................................. 44
trifluridine ................................................................... 135
trigels-f forte ................................................................ 91
TRIGLIDE ..................................................................... 33
trihexyphenidyl hcl ............................................... 43
TRI-LEGEST FE ................................................... 57
TRILEPTAL ................................................................ 22
TRI-LINYAH ............................................................. 57
TRILIPIX ......................................................................... 33
TRILYTE ......................................................................... 93
trimethobenzamide hcl .................................... 30
trimethoprim ................................................................ 37
TRIMOX ....................................................................... 138
trinatal gt ...................................................................... 127
TRINATE .................................................................... 127
TRINESSA (28) ...................................................... 57
TRI-NORINYL (28) .......................................... 57
triphrocaps ................................................................. 127
triple antibiotic ...................................................... 135
triple-vitamin/fluoride .................................. 127
TRI-PREVIFEM ..................................................... 57
TRI-SPRINTEC ...................................................... 57
tri-tabs dha ................................................................. 127
TRIUMEQ ...................................................................... 47
TRIVEEN-DUO DHA ................................ 127
TRIVEEN-PRX RNF ................................... 127
TRI-VI-FLOR ........................................................ 127
tri-vi-floro .................................................................... 127
tri-vit/fluoride ......................................................... 127
tri-vit/fluoride/iron ........................................... 127
tri-vitamin/fluoride ........................................... 127
TRIVORA (28) ........................................................ 57
TRIZIVIR ........................................................................ 47
TROKENDI XR ...................................................... 22
tropicamide ................................................................ 135
trospium chloride er ....................................... 146
TRUE METRIX BLOOD GLUCOSE
TEST ...................................................................................... 77
TRUECONTROL GLUCOSE CONT
LEV 0 ................................................................................ 116
TRUECONTROL GLUCOSE CONT
LEV 1 ................................................................................ 116
TRUEDRAW LANCING DEVICE
.................................................................................................... 116
TRUEPLUS INSULIN SYRINGE
.................................................................................................... 116
TRUEPLUS LANCETS 26G ............. 116
TRUEPLUS LANCETS 28G ............. 116
TRUEPLUS LANCETS 30G ............. 116
TRUEPLUS LANCETS 33G ............. 116
TRUEPLUS SAFETY LANCETS
28G ....................................................................................... 116
TRUETEST CONTROL LEVEL 1
.................................................................................................... 116
TRUETEST CONTROL LEVEL 2
.................................................................................................... 116
TRUETEST CONTROL LEVEL 3
.................................................................................................... 116
TRUETEST TEST ............................................... 77
TRUETRACK TEST ........................................ 77
TRULICITY ................................................................ 29
TRUSOPT ................................................................... 135
TRUVADA ................................................................... 47
TRUZONE PEAK FLOW METER
.................................................................................................... 116
tubing/wing tip ....................................................... 116
TUDORZA PRESSAIR ................................ 19
TUSSICAPS ................................................................ 60
TUSSIGON ................................................................... 60
TUSSIONEX PENNKINETIC ER
........................................................................................................ 60
TUZISTRA XR ........................................................ 60
TYBOST ........................................................................... 44
TYKERB .......................................................................... 41
TYLENOL WITH CODEINE #3 ..... 14
TYLENOL WITH CODEINE #4 ..... 14
TYSABRI .................................................................... 141
TYVASO ......................................................................... 52
TYVASO REFILL ............................................... 52
TYVASO STARTER ....................................... 52
TYZEKA .......................................................................... 47
TYZINE ......................................................................... 130
UCERIS ............................................................................. 58
UDAMIN SP ........................................................... 127
ULESFIA ......................................................................... 69
ULORIC ............................................................................ 86
ULTANE .......................................................................... 85
ULTICARE INSULIN SAFETY SYR
.................................................................................................... 116
ULTICARE INSULIN SYRINGE
.................................................................................................... 116
ULTICARE MICRO PEN NEEDLES
.................................................................................................... 117
ULTICARE MINI PEN NEEDLES
.................................................................................................... 117
ULTICARE PEN NEEDLES ............. 117
ULTICARE SHORT PEN NEEDLES
.................................................................................................... 117
ULTICARE THIN LANCETS 30G
.................................................................................................... 117
ULTI-LANCE AUTOMATIC .......... 117
ULTILET CLASSIC LANCETS
.................................................................................................... 117
ULTILET INSULIN SYRINGE
SHORT ........................................................................... 117
ULTILET LANCETS .................................. 117
ULTILET SAFETY LANCETS 23G
.................................................................................................... 117
ULTIMA TEST ....................................................... 77
ultra tabs ....................................................................... 127
ultra thin lancets 28g .................................... 117
ultra thin lancets 30g .................................... 117
ULTRACET ................................................................. 14
ULTRALANCE ................................................... 117
ULTRAM ........................................................................ 14
ULTRAM ER ............................................................. 14
ULTRA-THIN II AUTO LANCET
.................................................................................................... 117
ULTRA-THIN II INS SYR SHORT
.................................................................................................... 117
ULTRA-THIN II INSULIN
SYRINGE .................................................................... 117
ULTRA-THIN II LANCETS ............. 117
ULTRA-THIN II MINI PEN
NEEDLE ....................................................................... 117
ULTRA-THIN II PEN NEEDLE
SHORT ........................................................................... 117
ULTRA-THIN II PEN NEEDLES
.................................................................................................... 117
ULTRATRAK PRO CONTROL
.................................................................................................... 117
ULTRATRAK PRO TEST ....................... 77
ULTRATRAK ULTIMATE
CONTROL ................................................................. 117
ULTRATRAK ULTIMATE TEST
........................................................................................................ 77
ULTRAVATE ........................................................... 69
ULTRESA ...................................................................... 77
UNIFINE PENTIPS ....................................... 117
unifine pentips plus .......................................... 117
UNILET COMFORTOUCH
LANCET ....................................................................... 117
UNILET EXCELITE .................................... 117
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Index
UNILET EXCELITE II ............................. 117
UNILET G.P. LANCET ........................... 117
UNILET G.P. SUPERLITE LANCET
.................................................................................................... 117
UNILET GP 28 ULTRA THIN ....... 117
UNILET LANCET .......................................... 117
UNILET SUPERLITE LANCET
.................................................................................................... 117
UNIRETIC ..................................................................... 36
UNISTIK 1 ................................................................. 117
UNISTIK 2 ................................................................. 117
UNISTIK 2 COMFORT ........................... 117
UNISTIK 2 EXTRA ...................................... 117
UNISTIK 2 NEONATAL ....................... 117
UNISTIK 2 NORMAL ............................... 118
UNISTIK 2 SUPER ........................................ 118
UNISTIK 3 ................................................................. 118
UNISTIK 3 COMFORT ........................... 118
UNISTIK 3 EXTRA ...................................... 118
UNISTIK 3 GENTLE .................................. 118
UNISTIK 3 NEONATAL ....................... 118
UNISTIK 3 NORMAL ............................... 118
UNISTIK CZT COMFORT ................. 118
UNISTIK CZT NORMAL ..................... 118
UNISTRIP CONTROL .............................. 118
UNISTRIP1 GENERIC ................................. 77
UNITHROID ........................................................... 144
UNITHROID DIRECT .............................. 144
UNIVASC ....................................................................... 36
UNIVERSAL 1 LANCETS THIN
26G ....................................................................................... 118
UNIVERSAL 1 LANCETS ULTRA
THIN .................................................................................. 118
up & up glucose ....................................................... 29
UPTRAVI .................................................................... 141
URAMAXIN ............................................................... 69
urea nail ............................................................................ 69
UREX ............................................................................... 146
URISTIX .......................................................................... 77
URISTIX 4 ..................................................................... 77
UROCIT-K 10 ........................................................... 86
UROCIT-K 5 ............................................................... 86
UROXATRAL .......................................................... 86
URSO 250 ....................................................................... 84
URSO FORTE .......................................................... 84
ursodiol ............................................................................... 84
UTIBRON NEOHALER ............................. 19
UTOPIC ............................................................................. 69
VAGIFEM .................................................................. 147
valacyclovir hcl ........................................................ 47
VALCHLOR ............................................................... 69
VALCYTE ..................................................................... 47
valganciclovir hcl .................................................. 47
VALIUM .......................................................................... 17
valproic acid ................................................................ 22
valsartan ........................................................................... 36
valsartan-hydrochlorothiazide ............. 36
VALTREX ..................................................................... 47
value plus glucose ................................................. 29
value plus lancet standard 21g ......... 118
value plus lancets super thin ................ 118
value plus lancets thin 26g ..................... 118
value plus lancing device ......................... 118
valumark lancet super thin 30g ........ 118
valumark lancet ultra thin 28g .......... 118
valumark pen needles ................................... 118
valved holding chamber ............................. 118
VANCOCIN HCL ................................................ 37
vancomycin hcl ......................................................... 37
VANDAZOLE ...................................................... 147
VANISHPOINT INSULIN
SYRINGE .................................................................... 118
VANOXIDE-HC .................................................... 69
VANTAS ......................................................................... 41
VARIBAR HONEY ........................................... 77
VARIBAR NECTAR ....................................... 77
VARIBAR PUDDING ................................... 77
VARIBAR THIN HONEY ....................... 77
VARIBAR THIN LIQUID ........................ 77
VARUBI ........................................................................... 30
VASCEPA ...................................................................... 33
VASERETIC ............................................................... 36
VASOLEX ..................................................................... 69
VASOTEC ..................................................................... 36
VCF VAGINAL CONTRACEPTIVE
.................................................................................................... 147
VECAMYL ................................................................... 36
VECTICAL ................................................................... 69
VEETIDS ..................................................................... 138
VELETRI ......................................................................... 52
VELIVET ........................................................................ 57
VELPHORO ................................................................ 84
VELTASSA ................................................... 49, 139
VEMAVITE-PRX 2 ....................................... 127
vena-bal dha ............................................................. 127
venatal-fa ...................................................................... 127
VENCLEXTA ........................................................... 39
VENCLEXTA STARTING PACK
........................................................................................................ 39
venlafaxine hcl ........................................................... 24
venlafaxine hcl er ................................................... 24
VENOFER ..................................................................... 91
VENTAVIS .................................................................. 52
VENTOLIN HFA .................................................. 19
VERAMYST ........................................................... 130
verapamil hcl ............................................................... 51
verapamil hcl er ....................................................... 51
VERDESO ..................................................................... 70
VEREGEN ..................................................................... 70
VERELAN ..................................................................... 51
VERELAN PM ........................................................ 51
VERIPRED 20 .......................................................... 58
VERSACLOZ ............................................................ 44
VERSICLEAR .......................................................... 70
VESICARE ................................................................ 146
VESTURA ..................................................................... 57
VEXOL ........................................................................... 135
VFEND ............................................................................... 31
VIBERZI .......................................................................... 92
VIBRAMYCIN .................................................... 143
VICODIN ........................................................................ 14
VICODIN ES .............................................................. 14
VICODIN HP ............................................................. 14
VICOPROFEN ......................................................... 14
VICTORY AGM-4000 TEST ............... 77
VICTORY CONTROL LEVEL 1/2
.................................................................................................... 118
VICTOZA ....................................................................... 29
VICTRELIS .................................................................. 47
VIDA MIA AUTOLET LANCING
DEV .................................................................................... 118
VIDA MIA UNIFINE PENTIPS ... 118
VIDA MIA UNILET LANCETS 28G
.................................................................................................... 118
VIDA MIA UNILET LANCETS 30G
.................................................................................................... 118
VIDEX ................................................................................ 47
VIDEX EC ..................................................................... 47
VIEKIRA PAK ........................................................ 91
VIEKIRA XR ............................................................. 91
VIGAMOX ................................................................ 135
VIIBRYD .......................................................... 24, 142
VIIBRYD STARTER PACK
......................................................................................... 24, 142
VIMIZIM ..................................................................... 122
VIMOVO ......................................................................... 10
VIMPAT ........................................................................... 22
VINACAL B ............................................................ 127
VINATE AZ EXTRA .................................. 127
VINATE CALCIUM ..................................... 127
VINATE DHA RF ............................................ 127
VINATE IC ............................................................... 128
VINATE II ................................................................. 128
VINATE M ................................................................ 128
VIOKACE ...................................................................... 77
viorele ................................................................................... 57
VIRACEPT ................................................................... 47
VIRAMUNE ................................................................ 47
VIRAMUNE XR .................................................... 47
VIRAZOLE .................................................................. 47
VIREAD ........................................................................... 47
VIROPTIC .................................................................. 135
virt-caps ......................................................................... 128
virti-sulf .............................................................................. 70
virt-pn ............................................................................... 128
virt-pn dha ................................................................... 128
virt-pn plus ................................................................. 128
virt-select ...................................................................... 128
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virt-vite ................................................................................ 91
virt-vite plus .............................................................. 128
VISTARIL ...................................................................... 17
VISTIDE ........................................................................... 47
VISTOGARD .................................................. 29, 30
VISUDYNE .............................................................. 135
VITAFOL FE+ ...................................................... 128
VITAFOL GUMMIES ................................ 128
VITAFOL ULTRA .......................................... 128
VITAFOL-NANO ............................................ 128
VITAFOL-OB ....................................................... 128
VITAFOL-OB+DHA ................................... 128
VITAFOL-ONE ................................................... 128
VITAL-D RX .......................................................... 128
VITALET PRO LANCETS .................. 118
VITALET PRO PLUS LANCETS
.................................................................................................... 118
VITAMEDMD ONE
RX/QUATREFOLIC .................................... 128
VITAMEDMD PLUS
RX/QUATREFOLIC .................................... 128
vitamin d (ergocalciferol) ........................ 148
vitamin d2 .................................................................... 148
vitamin d3 .................................................................... 148
vitamins acd-fluoride ..................................... 128
VITAPEARL ........................................................... 128
VITA-PREN ............................................................. 128
VITEKTA ....................................................................... 47
VITUZ ................................................................................. 60
VIVA DHA ............................................................... 128
VIVACTIL .................................................................... 24
VIVELLE-DOT ....................................................... 82
VIVITROL .................................................................... 30
VIVLODEX ................................................................. 10
VOCAL POINT BLOOD GLUCOSE
TEST ...................................................................................... 77
VOGELXO .................................................................... 15
VOGELXO PUMP .............................................. 15
vol-care rx ................................................................... 128
vol-nate ........................................................................... 128
vol-tab rx ....................................................................... 128
VOLTAREN ................................................................ 70
VOLTAREN-XR ................................................... 10
VOLUMEN .................................................................. 77
VONVENDI ................................................................ 88
voriconazole ................................................................. 31
VORTEX VALVED HOLDING
CHAMBER ............................................................... 118
VOSOL HC ............................................................... 136
VOSPIRE ER ............................................................. 19
VOTRIENT .................................................................. 41
vp-ch plus ..................................................................... 128
vp-ch-pnv ...................................................................... 128
vp-ggr-b6 prenatal ........................................... 128
vp-heme ob ................................................................. 128
vp-heme ob + dha .............................................. 128
vp-heme one .............................................................. 128
vp-pnv-dha .................................................................. 128
VPRIV ................................................................................. 91
V-R MONO INSULIN SYRINGE
.................................................................................................... 118
VRAYLAR .................................................................... 44
VUSION ........................................................................... 70
VYFEMLA .................................................................... 57
VYTONE ......................................................................... 70
VYTORIN ...................................................................... 33
VYVANSE ........................................................................ 7
W&F LANCETS 26G ................................. 118
W&F LANCETS COLORED 21G
.................................................................................................... 118
walgreens adv travel lancets ............... 118
walgreens glucose ................................................. 29
WALGREENS LANCETS ................... 118
walgreens lancets micro thin ............... 118
walgreens lancets super thin ............... 118
WALGREENS THIN LANCETS
.................................................................................................... 119
WALGREENS ULTRA THIN
LANCETS .................................................................. 119
WAL-ITIN ..................................................................... 32
WAL-ITIN CHILDRENS .......................... 32
WAL-VERT ................................................................. 32
WAL-ZYR .................................................................. 135
warfarin sodium ...................................................... 20
WATCHHALER ................................................ 119
WAVESENSE PRESTO .............................. 77
WEBCOL ALCOHOL PREP LARGE
.................................................................................................... 119
WEBCOL ALCOHOL PREP
MEDIUM ..................................................................... 119
wegmans unifine pentips plus ............. 119
WELCHOL ................................................................... 33
WELLBUTRIN ....................................................... 24
WELLBUTRIN SR ............................................. 24
WELLBUTRIN XL ............................................ 24
WERA .................................................................................. 57
WESTCORT ................................................................ 70
WESTHROID ........................................................ 144
WIDE-SEAL DIAPHRAGM 60 .... 119
WIDE-SEAL DIAPHRAGM 65 .... 119
WIDE-SEAL DIAPHRAGM 70 .... 119
WIDE-SEAL DIAPHRAGM 75 .... 119
WIDE-SEAL DIAPHRAGM 80 .... 119
WIDE-SEAL DIAPHRAGM 85 .... 119
WIDE-SEAL DIAPHRAGM 90 .... 119
WIDE-SEAL DIAPHRAGM 95 .... 119
WILATE ........................................................................... 88
WINDMILL TRAINER ............................ 119
WINRHO SDF ...................................................... 137
WP THYROID ...................................................... 144
WYMZYA FE ........................................................... 57
XALATAN ................................................................ 135
XALKORI ...................................................................... 41
XANAX ............................................................................. 17
XANAX XR ................................................................. 17
XARELTO ..................................................................... 20
XARELTO STARTER PACK ............. 20
XARTEMIS XR ...................................................... 14
XELJANZ ....................................................................... 10
XELJANZ XR ........................................................... 10
XELODA ......................................................................... 41
XENAZINE .............................................................. 141
XEOMIN ...................................................................... 130
XERAC AC .................................................................. 70
XERESE ........................................................................... 70
XGEVA ............................................................................. 81
XIAFLEX ........................................................................ 49
XIFAXAN ...................................................................... 37
XIGDUO XR ........................................................... 142
XIIDRA ............................................................................. 94
XODOL ............................................................................. 14
XOLAIR ........................................................................... 19
XOLEGEL ..................................................................... 70
XOPENEX ..................................................................... 19
XOPENEX CONCENTRATE ............. 19
XOPENEX HFA .................................................... 19
XPRES CONTROL ........................................ 119
XTAMPZA ER ........................................................ 14
XTANDI ........................................................................... 41
XULANE ......................................................................... 57
XURIDEN ...................................................................... 91
XYLOCAINE ............................................................ 70
XYNTHA ........................................................................ 88
XYNTHA SOLOFUSE ................................. 88
XYREM ......................................................................... 141
XYZAL .............................................................................. 32
YASMIN 28 ................................................................. 57
YAZ ........................................................................................ 57
YODOXIN ......................................................................... 7
YOSPRALA ................................................................ 88
zaclir cleansing ........................................................ 70
ZADITOR ................................................................... 135
zafirlukast ........................................................................ 19
zaleplon .............................................................................. 92
ZANAFLEX ............................................................. 129
ZARAH .............................................................................. 57
ZARONTIN .................................................................. 22
ZAROXOLYN ......................................................... 78
ZARXIO ........................................................................... 91
ZATEAN-CH ......................................................... 128
ZATEAN-PN .......................................................... 128
ZATEAN-PN DHA ......................................... 128
ZATEAN-PN PLUS ....................................... 128
zavara ................................................................................... 91
ZAVESCA ..................................................................... 91
ZAZOLE ....................................................................... 147
ZEBETA ........................................................................... 50
ZEBUTAL ...................................................................... 11
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
178
Index
Index
ZECUITY .................................................................... 120
ZEGERID .................................................................... 146
ZEGERID OTC .................................................... 146
ZELAPAR ...................................................................... 43
ZELBORAF ................................................................. 41
ZEMAIRA .................................................................. 142
ZEMBRACE SYMTOUCH ................. 120
ZEMPLAR ..................................................................... 81
ZENATANE ................................................................ 70
ZENCHENT ................................................................ 57
ZENCHENT FE ...................................................... 57
ZENCIA ............................................................................ 70
ZENPEP ............................................................................ 77
ZENZEDI ............................................................................ 7
ZEOSA ............................................................................... 57
ZEPATIER .................................................................... 91
ZERIT .................................................................................. 47
ZESTORETIC ........................................................... 36
ZESTRIL .......................................................................... 36
ZETIA .................................................................................. 33
ZETONNA ................................................................. 130
ZIAC ...................................................................................... 36
ZIAGEN ............................................................................ 47
ZIANA ................................................................................ 70
zidovudine ....................................................................... 47
ZINBRYTA .............................................................. 141
ZIOPTAN .................................................................... 135
ziprasidone hcl .......................................................... 44
ZIPSOR .............................................................................. 10
ZIRGAN ........................................................................ 135
ZITHRANOL-RR ................................................. 70
ZITHROMAX ........................................................... 94
ZITHROMAX TRI-PAK ............................ 94
ZITHROMAX Z-PAK .................................... 94
ZMAX .................................................................................. 94
ZOCOR .............................................................................. 33
ZOFRAN .......................................................................... 30
ZOFRAN ODT ......................................................... 30
ZOHYDRO ER ........................................................ 14
ZOLADEX .................................................................... 41
zoledronic acid .......................................................... 81
ZOLINZA ....................................................................... 41
zolmitriptan ................................................................ 120
ZOLOFT ........................................................................... 24
zolpidem tartrate .................................................... 92
zolpidem tartrate er ............................................ 92
ZOLPIMIST ................................................................. 92
ZOMACTON .............................................................. 81
ZOMETA ......................................................................... 81
ZOMIG ........................................................................... 120
ZOMIG ZMT .......................................................... 120
ZONALON .................................................................... 70
ZONATUSS ................................................................. 60
ZONEGRAN ............................................................... 22
zonisamide ...................................................................... 22
ZORBTIVE ................................................................... 82
ZORTRESS .................................................................. 49
ZORVOLEX ................................................................ 10
ZOVIA 1/35E (28) ............................................... 57
ZOVIA 1/50E (28) ............................................... 57
ZOVIRAX ........................................................... 47, 70
ZUBSOLV ..................................................................... 14
ZUPLENZ ....................................................................... 30
ZURAMPIC ................................................................. 86
ZYBAN .......................................................................... 141
ZYCLARA .................................................................... 70
ZYCLARA PUMP ............................................... 70
ZYDELIG .................................................................... 138
ZYFLO ............................................................................... 19
ZYFLO CR .................................................................... 19
ZYKADIA ...................................................................... 41
ZYLET ............................................................................ 135
ZYLOPRIM .................................................................. 86
ZYMAXID ................................................................. 135
ZYPREXA ..................................................................... 44
ZYPREXA ZYDIS .............................................. 44
ZYRTEC ALLERGY ....................................... 32
ZYRTEC ITCHY EYE ............................... 135
ZYRTEC-D ALLERGY &
CONGESTION ........................................................ 60
ZYTIGA ............................................................................ 42
ZYVOX ............................................................................. 37
2017 Aetna Pharmacy Drug Guide - Three Tier Open Premier Plus Formulary
Last update 11/2016
Next update 12/2016
179