Antihistamine Drugs Ethanolamine Derivatives

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Colleen Simpson
6 years ago
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2 lowercase italics= Generic drugs UPPERCASE= Brand name drugs Tier Alt= Alt Benefit Exclusion= Benefit Exclusion Non-formulary= Non-formulary Not covered= Not covered = Formulary = Non-Preferred Brand, Generic Available = Non-Formulary T4= Specialty Notes AL= Age limit applies PA= PA Applies QL= Quantity Limit ST= ST applies Drug Tier Notes Antihistamine Drugs Ethanolamine Derivatives CHILDREN'S BENADRYL ALLERGY clemastine DIPHENHIST diphenhydramine hcl injection QL (20 ML per 25 days) diphenhydramine hcl oral SLEEP AID (DOXYLAMINE) First Gen. Antihist. Derivatives, Misc. cyproheptadine First Generation Antihistamines ALLER-CHLOR CHILDREN'S BENADRYL ALLERGY chlorpheniramine maleate clemastine cyproheptadine DIPHENHIST diphenhydramine hcl injection QL (20 ML per 25 days) diphenhydramine hcl oral 1

3 SLEEP AID (DOXYLAMINE) Phenothiazine Derivatives PHENERGAN promethazine injection solution QL (20 ML per 25 days) promethazine injection syringe promethazine oral promethazine rectal PROMETHAZINE VC PROMETHAZINE VC-CODEINE Piperazine Derivatives ANTIVERT hydroxyzine hcl hydroxyzine pamoate meclizine VISTARIL Propylamine Derivatives ALLER-CHLOR chlorpheniramine maleate M-END DMX Second Generation Antihistamines ALAVERT ALAVERT D-12 ALLERGY-SINUS ALLEGRA ALLERGY ST cetirizine cetirizine-pseudoephedrine CHILDREN'S CLARITIN CLARINEX PA CLARITIN CLARITIN REDITABS CLARITIN-D 12 HOUR 2

4 CLARITIN-D 24 HOUR desloratadine PA fexofenadine oral suspension ST; QL (10 ML per 1 day) fexofenadine oral tablet ST levocetirizine oral solution PA levocetirizine oral tablet ST loratadine loratadine-pseudoephedrine XYZAL ORAL SOLUTION PA XYZAL ORAL TABLET ST ZYRTEC ZYRTEC-D Anti-Infective Agents Adamantanes amantadine hcl Allylamines LAMISIL QL (90 DS per 365 DYs) terbinafine hcl QL (90 DS per 365 DYs) Amebicides FLAGYL metronidazole paromomycin PA; QL (10 DS per 30 DYs) YODOXIN Aminoglycosides BETHKIS T4 PA paromomycin PA; QL (10 DS per 30 DYs) TOBI T4 PA TOBI PODHALER T4 PA Aminopenicillins amoxicillin 3

5 amoxicillin-pot clavulanate ampicillin AUGMENTIN Anthelmintics ALBENZA BILTRICIDE ivermectin STROMECTOL Antifungals, Miscellaneous griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 125 MG GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 250 MG SSKI Antimalarials ARALEN chloroquine phosphate DARAPRIM T4 PA hydroxychloroquine mefloquine PLAQUENIL primaquine quinidine sulfate Antimycobacterials, Miscellaneous dapsone Antiprotozoals, Miscellaneous dapsone FLAGYL 4

6 MEPRON PA metronidazole NEBUPENT T4 PA Antituberculosis Agents AVELOX QL (10 QY per 30 DYs) AVELOX ABC PACK QL (1 FL per 30 DYs) BIAXIN QL (1 FL per 30 DYs) BIAXIN XL QL (1 FL per 30 DYs) CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET QL (68 QY per 34 DYs) ciprofloxacin ciprofloxacin hcl oral tablet 250 mg QL (68 EA per 34 DYs) ciprofloxacin hcl oral tablet 500 mg QL (68 QY per 34 DYs) ciprofloxacin hcl oral tablet 750 mg QL (28 QY per 30 DYs) clarithromycin QL (1 FL per 30 DYs) ethambutol isoniazid LEVAQUIN ORAL SOLUTION QL (1 FL per 30 DYs) LEVAQUIN ORAL TABLET QL (14 QY per 30 DYs) levofloxacin oral solution QL (1 FL per 30 DYs) levofloxacin oral tablet QL (14 QY per 30 DYs) moxifloxacin QL (10 QY per 30 DYs) pyrazinamide rifabutin RIFADIN INTRAVENOUS T4 PA RIFADIN ORAL rifampin Azoles DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 5

7 DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG DIFLUCAN ORAL TABLET 150 MG QL (2 QY per 30 DYs) fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL (2 QY per 30 DYs) ketoconazole Carbapenems INVANZ T4 PA Chloramphenicol chloramphenicol sod succinate Cyclic Lipopeptides CUBICIN T4 PA Erythromycins ERYPED 400 ERY-TAB ERYTHROCIN (AS STEARATE) erythromycin erythromycin ethylsuccinate erythromycin-sulfisoxazole Fifth Generation Cephalosporins TEFLARO T4 PA First Generation Cephalosporins cefadroxil cephalexin KEFLEX Glycopeptides DALVANCE T4 PA vancomycin PA Glycylcyclines 6

8 TYGACIL T4 PA Hcv Polymerase Inhibitors EPCLUSA T4 PA HARVONI T4 PA SOVALDI T4 PA VIEKIRA PAK T4 PA VIEKIRA XR T4 PA VOSEVI T4 PA Hcv Protease Inhibitors MAVYRET T4 PA OLYSIO T4 PA VIEKIRA PAK T4 PA VIEKIRA XR T4 PA ZEPATIER T4 PA Hcv Replication Complex Inhibitors EPCLUSA T4 PA HARVONI T4 PA MAVYRET T4 PA VIEKIRA PAK T4 PA VIEKIRA XR T4 PA VOSEVI T4 PA ZEPATIER T4 PA Hiv Entry And Fusion Inhibitors FUZEON T4 PA SELZENTRY ORAL TABLET 150 MG QL (2 EA per 1 day) SELZENTRY ORAL TABLET 25 MG, 300 MG, 75 MG Hiv Integrase Inhibitors GENVOYA ISENTRESS 7

9 ISENTRESS HD STRIBILD TIVICAY TRIUMEQ Hiv Nonnucleoside Rev.Transcrip. Inhib. EDURANT efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg QL (3 EA per 1 day) INTELENCE ORAL TABLET 100 MG QL (2 EA per 1 day) INTELENCE ORAL TABLET 200 MG nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg ODEFSEY RESCRIPTOR SUSTIVA Hiv Nucleoside, Nucleotide Rt Inhibitors abacavir abacavir-lamivudine-zidovudine COMBIVIR DESCOVY didanosine EMTRIVA EPIVIR EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPZICOM GENVOYA 8 QL (4 EA per 1 day)

10 lamivudine lamivudine-zidovudine ODEFSEY RETROVIR stavudine oral capsule 15 mg, 20 mg QL (2 EA per 1 day) stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD tenofovir disoproxil fumarate TRIZIVIR TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX EC ZERIT zidovudine Hiv Protease Inhibitors APTIVUS atazanavir CRIXIVAN fosamprenavir INVIRASE KALETRA LEXIVA NORVIR PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG QL (6 EA per 1 day) PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG QL (4 EA per 1 day) REYATAZ 9

11 VIEKIRA PAK T4 PA VIEKIRA XR T4 PA VIRACEPT Interferons ALFERON N T4 PA INTRON A T4 PA PEGASYS T4 PA PEGASYS PROCLICK T4 PA PEGINTRON T4 PA PEGINTRON REDIPEN T4 PA SYLATRON T4 PA Lincomycins CLEOCIN HCL CLEOCIN PEDIATRIC clindamycin hcl clindamycin palmitate hcl Macrolides ERYPED 400 ERY-TAB ERYTHROCIN (AS STEARATE) erythromycin erythromycin ethylsuccinate Monobactams CAYSTON T4 PA Monoclonal Antibodies SYNAGIS T4 PA Natural Penicillins penicillin v potassium Neuraminidase Inhibitors oseltamivir QL (1 Fill per 180 days) 10

12 RELENZA DISKHALER QL (1 FL per 180 DYs) Nucleosides And Nucleotides acyclovir adefovir T4 PA BARACLUDE T4 PA cidofovir T4 PA COPEGUS T4 PA CYTOVENE T4 PA entecavir HEPSERA PA MODERIBA DOSE PACK T4 PA REBETOL T4 PA RIBASPHERE T4 PA RIBASPHERE RIBAPAK T4 PA valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg QL (3 EA per 1 day) VALCYTE T4 PA valganciclovir T4 PA VALTREX VIRAZOLE T4 PA ZOVIRAX Other Macrolides azithromycin oral packet QL (1 FL per 30 DYs) azithromycin oral suspension for reconstitution QL (1 FL per 30 DYs) azithromycin oral tablet 250 mg QL (6 QY per 30 DYs) azithromycin oral tablet 500 mg QL (1 FL per 30 DYs) azithromycin oral tablet 600 mg QL (8 QY per 24 DYs) BIAXIN QL (1 FL per 30 DYs) BIAXIN XL QL (1 FL per 30 DYs) clarithromycin QL (1 FL per 30 DYs) 11

13 ZITHROMAX QL (1 FL per 30 DYs) ZITHROMAX TRI-PAK QL (1 FL per 30 DYs) ZMAX QL (1 QY per 30 DYs) Oxazolidinones linezolid PA SIVEXTRO T4 PA ZYVOX PA Penicillinase-Resistant Penicillins dicloxacillin Polyenes nystatin Polymyxins colistin (colistimethate na) T4 PA Quinolones AVELOX QL (10 QY per 30 DYs) CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET QL (68 QY per 34 DYs) ciprofloxacin ciprofloxacin hcl oral tablet 250 mg QL (68 EA per 34 DYs) ciprofloxacin hcl oral tablet 500 mg QL (68 QY per 34 DYs) ciprofloxacin hcl oral tablet 750 mg QL (28 QY per 30 DYs) LEVAQUIN QL (14 QY per 30 DYs) levofloxacin oral solution QL (1 FL per 30 DYs) levofloxacin oral tablet QL (14 QY per 30 DYs) moxifloxacin QL (10 QY per 30 DYs) Rifamycins rifabutin RIFADIN INTRAVENOUS T4 PA RIFADIN ORAL 12

14 rifampin Second Generation Cephalosporins cefaclor cefprozil CEFTIN ORAL SUSPENSION FOR RECONSTITUTION CEFTIN ORAL TABLET cefuroxime axetil oral suspension for reconstitution QL (100 QY per 1 day) QL (100 QY per 1 day) cefuroxime axetil oral tablet 250 mg QL (2 EA per 1 day) cefuroxime axetil oral tablet 500 mg Sulfonamides (Systemic) AZULFIDINE AZULFIDINE EN-TABS BACTRIM BACTRIM DS erythromycin-sulfisoxazole sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine Tetracyclines doxycycline monohydrate minocycline tetracycline Third Generation Cephalosporins cefdinir cefpodoxime ceftriaxone Urinary Anti-Infectives MACROBID 13

15 MACRODANTIN nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim Antineoplastic Agents Antineoplastic Agents ABRAXANE T4 PA ADCETRIS T4 PA ADRUCIL T4 PA AFINITOR T4 PA AFINITOR DISPERZ T4 PA ALFERON N T4 PA ALIMTA T4 PA ALKERAN T4 PA anastrozole ARIMIDEX AROMASIN T4 PA ARZERRA T4 PA AVASTIN T4 PA azacitidine T4 PA BELEODAQ T4 PA bicalutamide BICNU T4 PA bleomycin T4 PA BOSULIF T4 PA BUSULFEX T4 PA CAMPTOSAR T4 PA CAPRELSA T4 PA carboplatin T4 PA 14

16 CASODEX CEENU cisplatin T4 PA COMETRIQ T4 PA COSMEGEN T4 PA cyclophosphamide intravenous T4 PA cyclophosphamide oral CYRAMZA T4 PA cytarabine T4 PA cytarabine (pf) T4 PA dacarbazine T4 PA daunorubicin T4 PA decitabine T4 PA DOCEFREZ T4 PA docetaxel T4 PA doxorubicin T4 PA doxorubicin, peg-liposomal T4 PA DROXIA ELIGARD T4 PA ELIGARD (3 MONTH) T4 PA ELIGARD (4 MONTH) T4 PA ELIGARD (6 MONTH) T4 PA ELLENCE T4 PA ELOXATIN T4 PA EMCYT epirubicin T4 PA ERBITUX T4 PA ERIVEDGE T4 PA ERWINAZE T4 PA ETOPOPHOS T4 PA 15

17 etoposide T4 PA FARESTON ST FASLODEX T4 PA FEMARA QL (1 QY per 1 DY) FIRMAGON T4 PA floxuridine T4 PA fludarabine T4 PA fluorouracil T4 PA flutamide FOLOTYN T4 PA GAZYVA T4 PA gemcitabine T4 PA GEMZAR T4 PA GILOTRIF T4 PA GLEEVEC T4 PA GLEOSTINE T4 PA HALAVEN T4 PA HERCEPTIN T4 PA HEXALEN T4 PA HYCAMTIN T4 PA HYDREA hydroxyurea ICLUSIG T4 PA IDAMYCIN PFS T4 PA IFEX T4 PA ifosfamide T4 PA ifosfamide-mesna T4 PA imatinib T4 PA IMBRUVICA T4 PA INLYTA T4 PA 16

18 INTRON A T4 PA irinotecan T4 PA ISTODAX T4 PA IXEMPRA T4 PA JAKAFI T4 PA JEVTANA T4 PA KADCYLA T4 PA KEYTRUDA T4 PA KYPROLIS T4 PA letrozole QL (1 QY per 1 DY) LEUKERAN T4 PA leuprolide T4 PA lomustine T4 PA LUPANETA PACK (1 MONTH) T4 PA LUPANETA PACK (3 MONTH) T4 PA LUPRON DEPOT T4 PA LUPRON DEPOT (3 MONTH) T4 PA LUPRON DEPOT (4 MONTH) T4 PA LUPRON DEPOT (6 MONTH) T4 PA LUPRON DEPOT-PED T4 PA LUPRON DEPOT-PED (3 MONTH) T4 PA LYSODREN T4 PA MARQIBO T4 PA MATULANE MEGACE MEGACE ES QL (150 QY per 30 DYs) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml QL (150 ML per 30 DYs) megestrol oral tablet MEKINIST T4 PA 17 T4

19 mercaptopurine methotrexate sodium (pf) T4 PA methotrexate sodium injection T4 PA methotrexate sodium oral mitomycin T4 PA mitoxantrone T4 PA MUSTARGEN T4 PA MYLERAN NEXAVAR T4 PA nilutamide T4 PA NIPENT T4 PA ONCASPAR T4 PA OTREXUP (PF) T4 PA oxaliplatin T4 PA PERJETA T4 PA PHOTOFRIN T4 PA POMALYST T4 PA PROLEUKIN T4 PA REVLIMID T4 PA RHEUMATREX RITUXAN T4 PA RITUXAN HYCELA T4 PA SPRYCEL T4 PA STIVARGA T4 PA SUTENT T4 PA SYLATRON T4 PA SYLVANT T4 PA SYNRIBO T4 PA TABLOID T4 PA TAFINLAR T4 PA 18

20 tamoxifen TARCEVA T4 PA TARGRETIN T4 PA TASIGNA T4 PA TAXOTERE T4 PA TEMODAR T4 PA teniposide T4 PA THERACYS T4 PA TICE BCG T4 PA TOPOSAR T4 PA topotecan T4 PA TREANDA T4 PA TRELSTAR T4 PA TRELSTAR DEPOT T4 PA TRELSTAR LA T4 PA tretinoin (chemotherapy) T4 PA TREXALL ORAL TABLET 10 MG, 5 MG T4 PA TREXALL ORAL TABLET 7.5 MG TRISENOX T4 PA TYKERB T4 PA VALSTAR T4 PA VANTAS T4 PA VECTIBIX T4 PA VELCADE T4 PA vinblastine T4 PA VINCASAR PFS T4 PA vinorelbine T4 PA VOTRIENT T4 PA XALKORI T4 PA XELODA T4 PA 19

21 XTANDI T4 PA YERVOY T4 PA ZALTRAP T4 PA ZELBORAF T4 PA ZEVALIN (Y-90) T4 PA ZOLADEX T4 PA ZOLINZA T4 PA ZYDELIG T4 PA ZYKADIA T4 PA ZYTIGA T4 PA Antitoxins,Immune Glob,Toxoids,Vaccines Antitoxins And Immune Globulins CARIMUNE NF NANOFILTERED T4 PA CYTOGAM T4 PA FLEBOGAMMA DIF T4 PA GAMASTAN S/D T4 PA GAMMAGARD LIQUID T4 PA GAMMAGARD S/D T4 PA GAMUNEX-C T4 PA HEPAGAM B T4 PA HIZENTRA T4 PA HYPERHEP B S/D T4 PA HYPERHEP B S-D NEONATAL T4 PA HYPERRAB S/D (PF) T4 PA HYPERRHO S/D T4 PA HYPERTET S/D (PF) T4 PA HYQVIA T4 PA MICRHOGAM ULTRA-FILTERED PLUS T4 PA NABI-HB T4 PA OCTAGAM T4 PA 20

22 RHOGAM ULTRA-FILTERED PLUS T4 PA RHOPHYLAC T4 PA VARIZIG T4 PA WINRHO SDF T4 PA Toxoids ADACEL(TDAP ADOLESN/ADULT)(PF) AL BOOSTRIX TDAP AL Vaccines AFLURIA QL (0.5 ML per 180 days); AL AFLURIA (PF) QL (0.5 ML per 180 days); AL AFLURIA QUAD QL (0.5 ML per 180 days); AL AFLURIA QUAD (PF) QL (0.5 ML per 180 days); AL ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) FLUARIX QUAD (PF) QL (0.5 ML per 180 days); AL FLUCELVAX QUAD QL (0.5 ML per 180 days); AL FLUCELVAX QUAD (PF) QL (0.5 ML per 180 days); AL FLULAVAL QUAD QL (0.5 ML per 180 days); AL FLULAVAL QUAD (PF) QL (0.5 ML per 180 days); AL FLUVIRIN QL (0.5 ML per 180 days); AL FLUVIRIN (PF) QL (0.5 ML per 180 days); AL FLUZONE HIGH-DOSE (PF) QL (0.5 ML per 180 days); AL FLUZONE INTRADERM QUAD QL (0.1 ML per 180 days); AL FLUZONE QUAD QL (0.5 ML per 180 days); AL FLUZONE QUAD (PF) INTRAMUSCULAR SUSPENSION FLUZONE QUAD (PF) INTRAMUSCULAR SYRINGE HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML QL (0.5 ML per 180 days); AL QL (0.5 ML per 180 days) AL 21

23 HAVRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML PNEUMOVAX 23 INJECTION SOLUTION AL PNEUMOVAX 23 INJECTION SYRINGE PREVNAR 13 (PF) AL RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML THERACYS T4 PA TICE BCG T4 PA TWINRIX (PF) INTRAMUSCULAR SUSPENSION TWINRIX (PF) INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML VAQTA (PF) INTRAMUSCULAR SYRINGE 50 UNIT/ML ZOSTAVAX (PF) QL (1 QY per 365 DYs) Autonomic Drugs Alpha- And Beta-Adrenergic Agonists ALAVERT D-12 ALLERGY-SINUS 22 AL AL AL AL AL AL

24 BROMFED DM cetirizine-pseudoephedrine CHERATUSSIN DAC CLARITIN-D 12 HOUR CLARITIN-D 24 HOUR epinephrine QL (2 EA per 30 DYs) loratadine-pseudoephedrine M-END DMX MUCINEX D pseudoephedrine hcl ZYRTEC-D Alpha-Adrenergic Agonists CATAPRES CATAPRES-TTS-1 CATAPRES-TTS-2 CATAPRES-TTS-3 clonidine clonidine hcl CLORPRES ED BRON GP methyldopa methyldopa-hydrochlorothiazide phenylephrine-chlophedianol-gg PROMETHAZINE VC PROMETHAZINE VC-CODEINE ROBAFEN CF (PHENYLEPHRINE) Antimuscarinics/Antispasmodics ANORO ELLIPTA ATROVENT HFA BENTYL 23

25 COMBIVENT RESPIMAT dicyclomine diphenoxylate-atropine glycopyrrolate hydrocodone-homatropine hyoscyamine sulfate ipratropium bromide LEVBID LOMOTIL propantheline ROBINUL ROBINUL FORTE SPIRIVA RESPIMAT AL TUSSIGON Antiparkinsonian Agents benztropine trihexyphenidyl Autonomic Drugs, Miscellaneous CHANTIX QL (360 QY per 365 DYs); AL CHANTIX CONTINUING MONTH BOX QL (360 EA per 365 DYs) CHANTIX CONTINUING MONTH PAK QL (360 EA per 365 DYs) CHANTIX STARTING MONTH BOX QL (360 QY per 365 DYs); AL NICODERM CQ NICORETTE nicotine nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal lozenge QL (20 EA per 1 day) nicotine (polacrilex) buccal mini lozenge QL (20 EA per 1 day) Centrally Acting Skeletal Muscle Relaxnt carisoprodol 24

26 chlorzoxazone cyclobenzaprine methocarbamol ROBAXIN ROBAXIN-750 SOMA tizanidine ZANAFLEX Gaba-Derivative Skeletal Muscle Relaxant baclofen GABLOFEN T4 PA LIORESAL T4 PA Non-Sel. Beta-Adrenergic Blocking Agents BETAPACE BETAPACE AF carvedilol COREG CORGARD CORZIDE INDERAL LA labetalol nadolol nadolol-bendroflumethiazide pindolol propranolol propranolol-hydrochlorothiazid sotalol SOTALOL AF timolol maleate TRANDATE 25

27 Non-Sel.Alpha-1-Adrenergic Blocking Agts CARDURA doxazosin MINIPRESS prazosin terazosin Non-Sel.Alpha-Adrenergic Blocking Agents CAFERGOT D.H.E.45 DIBENZYLINE dihydroergotamine injection QL (12 ML per 30 days) dihydroergotamine nasal QL (1 QY per 30 DYs) ERGOMAR QL (20 EA per 30 days) MIGRANAL QL (1 QY per 30 DYs) phenoxybenzamine PA Parasympathomimetic (Cholinergic Agents) ARICEPT AL ARICEPT ODT AL bethanechol chloride donepezil oral tablet 10 mg AL donepezil oral tablet 5 mg QL (1 EA per 1 DY); AL donepezil oral tablet,disintegrating AL EXELON ORAL AL EXELON TRANSDERMAL PATCH 24 HOUR 4.6 MG/24 HR EXELON TRANSDERMAL PATCH 24 HOUR 9.5 MG/24 HR MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN PROSTIGMIN AL 26 QL (1 EA per 1 day); AL AL

28 pyridostigmine bromide AL rivastigmine AL rivastigmine tartrate oral capsule 1.5 mg, 3 mg QL (2 EA per 1 day); AL rivastigmine tartrate oral capsule 4.5 mg, 6 mg AL URECHOLINE Selective Alpha-1-Adrenergic Block.Agent alfuzosin carvedilol COREG labetalol tamsulosin TRANDATE Selective Beta-2-Adrenergic Agonists albuterol sulfate ANORO ELLIPTA BREO ELLIPTA COMBIVENT RESPIMAT DULERA QL (13 QY per 30 DYs); AL SEREVENT DISKUS terbutaline VENTOLIN HFA QL (1 QY per 30 DYs) XOPENEX HFA ST Selective Beta-Adrenergic Blocking Agent atenolol bisoprolol fumarate bisoprolol-hydrochlorothiazide LOPRESSOR LOPRESSOR HCT metoprolol succinate metoprolol ta-hydrochlorothiaz 27

29 metoprolol tartrate TENORMIN TOPROL XL ZEBETA ZIAC Skeletal Muscle Relaxants, Miscellaneous BOTOX T4 PA BOTOX COSMETIC T4 PA DYSPORT T4 PA MYOBLOC T4 PA XEOMIN T4 PA Blood Formation, Coagulation, Thrombosis Coumarin Derivatives COUMADIN warfarin Direct Factor Xa Inhibitors ARIXTRA T4 PA ELIQUIS XARELTO Direct Thrombin Inhibitors PRADAXA ORAL CAPSULE 110 MG, 150 MG PRADAXA ORAL CAPSULE 75 MG QL (2 EA per 1 day) Hematopoietic Agents ARANESP (IN ALBUMIN) T4 PA ARANESP (IN POLYSORBATE) T4 PA EPOGEN T4 PA GRANIX T4 PA LEUKINE T4 PA MOZOBIL T4 PA NEULASTA T4 PA 28

30 NEUMEGA T4 PA NEUPOGEN T4 PA NPLATE T4 PA PROCRIT T4 PA PROMACTA T4 PA ZARXIO T4 PA Hemorrheologic Agents pentoxifylline Hemostatics ADVATE T4 PA ALPHANATE T4 PA ALPHANINE SD T4 PA ALPROLIX T4 PA AMICAR BEBULIN T4 PA BENEFIX T4 PA CORIFACT T4 PA DDAVP NASAL PA DDAVP ORAL PA; AL desmopressin nasal PA desmopressin oral PA; AL ELOCTATE T4 PA FEIBA NF T4 PA HEMOFIL M HIGH T4 PA HEMOFIL M LOW T4 PA HEMOFIL M MID T4 PA HEMOFIL M SUPER HIGH T4 PA HUMATE-P T4 PA KOATE-DVI T4 PA KOGENATE FS T4 PA 29

31 MONOCLATE-P T4 PA NOVOSEVEN RT T4 PA PROFILNINE T4 PA RECOMBINATE T4 PA RIASTAP T4 PA RIXUBIS T4 PA STIMATE PA WILATE T4 PA XYNTHA T4 PA XYNTHA SOLOFUSE T4 PA Heparins enoxaparin T4 PA FRAGMIN T4 PA heparin (porcine) LOVENOX T4 PA Iron Preparations CADEAU DHA CENTRUM COMPLETE AL CERTAVITE-ANTIOXID (IRON GLUC) CHILDREN'S CHEWABLE COMPLETE COMPLETE PREMIUM VITAMIN DAILY PRENATAL DAILY VITES/IRON AL FERAHEME T4 PA FERRETTS FERRLECIT T4 PA ferrous fumarate ferrous gluconate ferrous sulfate HIGH POTENCY IRON 30

32 INFED T4 PA INJECTAFER T4 PA iron oral tablet IRON ORAL TABLET EXTENDED RELEASE MULTIGEN MULTIGEN FOLIC MULTIGEN PLUS MULTI-VIT WITH FLUORIDE-IRON AL MULTIVITAMIN WITH MINERALS OBSTETRIX DHA OBTREX DHA ONE DAILY PRENATAL ONE-A-DAY WOMENS FORMULA ONE-A-DAY WOMEN'S PRENATAL 1 POLY-IRON 150 FORTE polysaccharide iron complex POLY-VITAMIN WITH IRON AL PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PRENATA PRENATAL + DHA PRENATAL 19 PRENATAL MULTI-DHA PRENATAL MULTI-DHA (ALGAL OIL) PRENATAL PLUS PRENATAL VITAMIN PRENATAL VITAMIN PLUS LOW IRON prenatal vit-iron fum-folic ac PRORENAL QD 31

33 THERAPEUTIC-M TRINATAL GT TRIVEEN-DUO DHA TRI-VI-SOL WITH IRON AL TRI-VIT WITH FLUORIDE AND IRON AL VENOFER T4 PA WOMEN'S DAILY FORMULA WOMEN'S PRENATAL + DHA Platelet-Aggregation Inhibitors aspirin aspirin-caffeine-dihydrocodein aspirin-dipyridamole butalbital-aspirin-caffeine cilostazol clopidogrel dipyridamole PERSANTINE PLAVIX PLETAL prasugrel oral tablet 10 mg prasugrel oral tablet 5 mg QL (1 EA per 1 day) SYNALGOS-DC ticlopidine Thrombolytic Agents ACTIVASE T4 PA aspirin aspirin-caffeine-dihydrocodein butalbital-aspirin-caffeine CATHFLO ACTIVASE T4 PA SYNALGOS-DC 32

34 Cardiovascular Drugs Alpha-Adrenergic Blocking Agents CARDURA carvedilol COREG doxazosin labetalol MINIPRESS prazosin terazosin TRANDATE Alpha-Adrenergic Blocking Agt.(Hypoten) CARDURA doxazosin labetalol MINIPRESS prazosin terazosin TRANDATE Angiotensin Ii Receptor Antagon.(Hypotn) AVALIDE ST AVAPRO ST COZAAR HYZAAR irbesartan ST irbesartan-hydrochlorothiazide ST losartan losartan-hydrochlorothiazide valsartan ST valsartan-hydrochlorothiazide ST 33

35 Angiotensin Ii Receptor Antagonists AVALIDE ST AVAPRO ST COZAAR HYZAAR irbesartan ST irbesartan-hydrochlorothiazide ST losartan losartan-hydrochlorothiazide valsartan ST valsartan-hydrochlorothiazide ST Angiotensin-Convert.Enzyme Inhib(Hypotn) ACCUPRIL ACCURETIC ACEON benazepril oral tablet 10 mg, 20 mg, 5 mg QL (2 EA per 1 day) benazepril oral tablet 40 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg benazepril-hydrochlorothiazide oral tablet mg captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril lisinopril lisinopril-hydrochlorothiazide LOTENSIN LOTENSIN HCT MAVIK 34 QL (2 EA per 1 day)

36 moexipril moexipril-hydrochlorothiazide perindopril erbumine PRINIVIL quinapril quinapril-hydrochlorothiazide trandolapril UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL Angiotensin-Converting Enzyme Inhibitors ACCUPRIL ACCURETIC ACEON benazepril oral tablet 10 mg, 20 mg, 5 mg QL (2 EA per 1 day) benazepril oral tablet 40 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg benazepril-hydrochlorothiazide oral tablet mg captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril lisinopril lisinopril-hydrochlorothiazide LOTENSIN 35 QL (2 EA per 1 day)

37 LOTENSIN HCT MAVIK moexipril moexipril-hydrochlorothiazide perindopril erbumine PRINIVIL quinapril quinapril-hydrochlorothiazide trandolapril UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL Antiarrhythmics, Miscellaneous digoxin LANOXIN Antilipemic Agents, Miscellaneous JUXTAPID T4 PA KYNAMRO T4 PA niacin oral capsule, extended release niacin oral tablet niacin oral tablet extended release 1,000 mg, 500 mg, 750 mg niacin oral tablet extended release 24 hr ST niacin oral tablet extended release 250 mg NIACOR Beta-Adrenergic Blocking Agents atenolol 36 ST

38 BETAPACE BETAPACE AF bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol COREG CORGARD CORZIDE INDERAL LA labetalol LOPRESSOR LOPRESSOR HCT metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate nadolol nadolol-bendroflumethiazide pindolol propranolol propranolol-hydrochlorothiazid sotalol SOTALOL AF TENORMIN timolol maleate TOPROL XL TRANDATE ZEBETA ZIAC Beta-Adrenergic Blocking Agt.(Hypoten) atenolol 37

39 BETAPACE BETAPACE AF bisoprolol fumarate bisoprolol-hydrochlorothiazide CORGARD CORZIDE INDERAL LA labetalol LOPRESSOR LOPRESSOR HCT metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate nadolol nadolol-bendroflumethiazide pindolol propranolol propranolol-hydrochlorothiazid sotalol SOTALOL AF TENORMIN timolol maleate TOPROL XL TRANDATE ZEBETA ZIAC Bile Acid Sequestrants cholestyramine (with sugar) CHOLESTYRAMINE LIGHT COLESTID 38

40 colestipol PREVALITE QUESTRAN QUESTRAN LIGHT WELCHOL Calcium-Channel Block.Agt,Misc(Hypoten) CALAN CALAN SR CARDIZEM CARDIZEM CD diltiazem hcl DILT-XR ISOPTIN SR TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 300 MG, 360 MG TIAZAC verapamil VERELAN Calcium-Channel Blocking Agents ADALAT CC amlodipine oral tablet 10 mg amlodipine oral tablet 2.5 mg, 5 mg QL (1 EA per 1 DY) CALAN CALAN SR CARDIZEM CARDIZEM CD diltiazem hcl DILT-XR ISOPTIN SR 39

41 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg QL (1 EA per 1 day) nifedipine oral tablet extended release 90 mg nisoldipine oral tablet extended release 24 hr 17 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg, 34 mg, 40 mg NORVASC PROCARDIA PROCARDIA XL SULAR TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 300 MG, 360 MG TEKAMLO ST TIAZAC verapamil VERELAN Calcium-Channel Blocking Agents, Misc. CALAN CALAN SR CARDIZEM CARDIZEM CD diltiazem hcl DILT-XR ISOPTIN SR 40 QL (1 EA per 1 day)

42 TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 300 MG, 360 MG TIAZAC verapamil VERELAN Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide DIAMOX SEQUELS PA Cardiotonic Agents digoxin LANOXIN milrinone T4 PA Central Alpha-Agonists CATAPRES CATAPRES-TTS-1 CATAPRES-TTS-2 CATAPRES-TTS-3 clonidine clonidine hcl CLORPRES guanfacine oral tablet guanfacine oral tablet extended release 24 hr AL methyldopa methyldopa-hydrochlorothiazide TENEX Cholesterol Absorption Inhibitors ezetimibe ezetimibe-simvastatin 41

43 Class Ia Antiarrhythmics disopyramide phosphate NORPACE NORPACE CR quinidine gluconate quinidine sulfate Class Ib Antiarrhythmics DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN-125 mexiletine phenytoin phenytoin sodium extended Class Ic Antiarrhythmics flecainide propafenone RYTHMOL Class Ii Antiarrhythmics atenolol BETAPACE BETAPACE AF bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol COREG CORGARD CORZIDE INDERAL LA labetalol 42

44 LOPRESSOR LOPRESSOR HCT metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate nadolol nadolol-bendroflumethiazide pindolol propranolol propranolol-hydrochlorothiazid sotalol SOTALOL AF TENORMIN timolol maleate TOPROL XL TRANDATE ZEBETA ZIAC Class Iii Antiarrhythmics amiodarone BETAPACE BETAPACE AF CORDARONE MULTAQ PA sotalol SOTALOL AF Class Iv Antiarrhythmics CALAN CALAN SR CARDIZEM 43

45 CARDIZEM CD diltiazem hcl DILT-XR ISOPTIN SR TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 300 MG, 360 MG TIAZAC verapamil VERELAN Dihydropyridines ADALAT CC amlodipine oral tablet 10 mg amlodipine oral tablet 2.5 mg, 5 mg QL (1 EA per 1 DY) NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg QL (1 EA per 1 day) nifedipine oral tablet extended release 90 mg nisoldipine oral tablet extended release 24 hr 17 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg, 34 mg, 40 mg NORVASC PROCARDIA PROCARDIA XL SULAR TEKAMLO ST 44 QL (1 EA per 1 day)

46 Dihydropyridines (Hypotensive Agents) ADALAT CC amlodipine oral tablet 10 mg amlodipine oral tablet 2.5 mg, 5 mg QL (1 EA per 1 DY) NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg QL (1 EA per 1 day) nifedipine oral tablet extended release 90 mg nisoldipine oral tablet extended release 24 hr 17 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg, 34 mg, 40 mg NORVASC PROCARDIA PROCARDIA XL SULAR TEKAMLO ST Direct Vasodilators hydralazine minoxidil Diuretics, Miscellaneous (Hypotensive) THEO-24 theophylline Fibric Acid Derivatives fenofibrate fenofibrate micronized fenofibrate nanocrystallized 45 QL (1 EA per 1 day)

47 gemfibrozil LOFIBRA LOPID TRICOR Hmg-Coa Reductase Inhibitors atorvastatin oral tablet 10 mg QL (1 EA per 1 DY) atorvastatin oral tablet 20 mg, 40 mg, 80 mg ezetimibe-simvastatin fluvastatin ST LESCOL ST LESCOL XL ST LIPITOR lovastatin oral tablet 10 mg, 20 mg QL (3 EA per 1 day) lovastatin oral tablet 40 mg MEVACOR PRAVACHOL ST pravastatin oral tablet 10 mg, 20 mg ST; QL (1 EA per 1 day) pravastatin oral tablet 40 mg ST; QL (2 EA per 1 day) pravastatin oral tablet 80 mg ST rosuvastatin simvastatin ZOCOR Hypotensive Agents, Miscellaneous BETAPACE BETAPACE AF CARDURA carvedilol COREG DIBENZYLINE doxazosin 46

48 INDERAL LA phenoxybenzamine PA pindolol propranolol sotalol SOTALOL AF terazosin timolol maleate Loop Diuretics (Hypotensive Agents) bumetanide DEMADEX furosemide LASIX torsemide Mineralocorticoid (Aldosterone) Antagnts ALDACTAZIDE ALDACTONE spironolactone spironolacton-hydrochlorothiaz Mineralocorticoid(Aldoster.)Antag(Hypot) ALDACTAZIDE ALDACTONE spironolactone spironolacton-hydrochlorothiaz Nitrates And Nitrites ISORDIL isosorbide dinitrate isosorbide mononitrate NITRO-BID 47

49 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin NITROSTAT NITRO-TIME Peripheral Adrenergic Inhibitors reserpine Phosphodiesterase Type 5 Inhibitors ADCIRCA T4 PA cilostazol PLETAL REVATIO T4 PA sildenafil (antihypertensive) PA Potassium-Sparing Diuretics (Hypoten) ALDACTAZIDE ALDACTONE amiloride amiloride-hydrochlorothiazide DYAZIDE MAXZIDE MAXZIDE-25MG spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid Renin Inhibitors TEKAMLO ST Thiazide Diuretics(Hypotensive Agents) ACCURETIC 48

50 ALDACTAZIDE amiloride-hydrochlorothiazide AVALIDE ST benazepril-hydrochlorothiazide oral tablet mg, mg, mg benazepril-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide CORZIDE DIURIL DYAZIDE enalapril-hydrochlorothiazide hydrochlorothiazide HYZAAR irbesartan-hydrochlorothiazide ST lisinopril-hydrochlorothiazide LOPRESSOR HCT losartan-hydrochlorothiazide LOTENSIN HCT MAXZIDE MAXZIDE-25MG methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz moexipril-hydrochlorothiazide nadolol-bendroflumethiazide propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid 49 QL (2 EA per 1 day)

51 UNIRETIC valsartan-hydrochlorothiazide ST VASERETIC ZESTORETIC ZIAC Thiazide-Like Diuretics(Hypotensive Agt) chlorthalidone CLORPRES indapamide metolazone ZAROXOLYN Vasodilating Agents, Miscellaneous ADALAT CC amlodipine oral tablet 10 mg amlodipine oral tablet 2.5 mg, 5 mg QL (1 EA per 1 DY) aspirin-dipyridamole CALAN CALAN SR CARDIZEM CARDIZEM CD diltiazem hcl DILT-XR dipyridamole epoprostenol (glycine) T4 PA FLOLAN T4 PA ISOPTIN SR LETAIRIS T4 PA NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG 50

52 nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg QL (1 EA per 1 day) nifedipine oral tablet extended release 90 mg NORVASC OPSUMIT T4 PA ORENITRAM T4 PA PERSANTINE PROCARDIA PROCARDIA XL REMODULIN T4 PA TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 300 MG, 360 MG TEKAMLO ST TIAZAC TRACLEER T4 PA TYVASO T4 PA TYVASO REFILL KIT T4 PA TYVASO STARTER KIT T4 PA UPTRAVI T4 PA VELETRI T4 PA VENTAVIS T4 PA verapamil VERELAN Cellular And Gene Therapy Cellular And Gene Therapy PROVENGE T4 PA Cellular Therapy PROVENGE T4 PA 51

53 Central Nervous System Agents Adamantanes (Cns) amantadine hcl Amphetamines ADDERALL ADDERALL XR DEXEDRINE SPANSULE dextroamphetamine PA; AL dextroamphetamine-amphetamine PA; AL VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Analgesics And Antipyretics, Misc. ACEPHEN acetaminophen acetaminophen-caff-dihydrocod acetaminophen-codeine butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen butalbital-acetaminophen-caff CAPITAL WITH CODEINE ED-APAP ENDOCET ORAL TABLET MG, MG, MG ENDOCET ORAL TABLET MG ESGIC FEVERALL AL AL 52

54 FIORICET WITH CODEINE gabapentin oral capsule 100 mg, 400 mg gabapentin oral capsule 300 mg QL (9 EA per 1 day) gabapentin oral tablet HORIZANT T4 PA HYCET hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg LORTAB LORTAB ELIXIR ORAL SOLUTION MG/15 ML LORTAB ELIXIR ORAL SOLUTION MG/15 ML MAPAP (ACETAMINOPHEN) MARTEN-TAB NEURONTIN NON-ASPIRIN JR STRENGTH oxycodone-acetaminophen oral capsule oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-acetaminophen oral tablet mg PAIN RELIEF PERCOCET ORAL TABLET MG, MG, MG PERCOCET ORAL TABLET MG PRIALT T4 PA 53

55 PRIMLEV Q-PAP tramadol-acetaminophen TREZIX TYLENOL-CODEINE #4 ULTRACET VERDROCET VICODIN VICODIN ES VICODIN HP XODOL 10/300 XODOL 5/300 XODOL 7.5/300 ZAMICET Anticholinergic Agents (Cns) benztropine trihexyphenidyl Anticonvulsants, Miscellaneous BANZEL PA carbamazepine DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr 250 mg divalproex oral tablet extended release 24 hr 500 mg divalproex oral tablet,delayed release (dr/ec) gabapentin oral capsule 100 mg, 400 mg 54 QL (3 EA per 1 day)

56 gabapentin oral capsule 300 mg QL (9 EA per 1 day) gabapentin oral tablet HORIZANT T4 PA KEPPRA LAMICTAL lamotrigine oral tablet 100 mg QL (5 EA per 1 day) lamotrigine oral tablet 150 mg, 200 mg lamotrigine oral tablet 25 mg QL (3 EA per 1 day) lamotrigine oral tablet, chewable dispersible 25 mg 55 QL (3 EA per 1 day) lamotrigine oral tablet, chewable dispersible 5 mg QL (2 EA per 1 day) lamotrigine oral tablets,dose pack levetiracetam NEURONTIN oxcarbazepine SABRIL T4 PA TEGRETOL TEGRETOL XR TOPAMAX topiramate oral capsule, sprinkle topiramate oral tablet 100 mg, 200 mg, 25 mg topiramate oral tablet 50 mg QL (6 EA per 1 day) TRILEPTAL valproic acid valproic acid (as sodium salt) vigabatrin Antidepressants, Miscellaneous bupropion hcl mirtazapine oral tablet QL (1 EA per 1 day) mirtazapine oral tablet,disintegrating REMERON T4

57 REMERON SOLTAB WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL ZYBAN Antimanic Agents DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr 250 mg divalproex oral tablet extended release 24 hr 500 mg divalproex oral tablet,delayed release (dr/ec) lithium carbonate lithium citrate LITHOBID valproic acid valproic acid (as sodium salt) Antimigraine Agents, Miscellaneous ASCOMP WITH CODEINE aspirin aspirin-caffeine-dihydrocodein BUTALBITAL COMPOUND W/CODEINE BUTALBITAL COMPOUND-CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg QL (3 EA per 1 day) 56

58 butalbital-acetaminophen-caff butalbital-aspirin-caffeine CAFERGOT codeine-butalbital-asa-caff D.H.E.45 DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES dihydroergotamine injection QL (12 ML per 30 days) dihydroergotamine nasal QL (1 QY per 30 DYs) divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr 250 mg divalproex oral tablet extended release 24 hr 500 mg divalproex oral tablet,delayed release (dr/ec) 57 QL (3 EA per 1 day) ERGOMAR QL (20 EA per 30 days) ESGIC FIORICET WITH CODEINE FIORINAL-CODEINE #3 INDERAL LA MIGRANAL QL (1 QY per 30 DYs) propranolol SYNALGOS-DC timolol maleate tramadol-acetaminophen ULTRACET valproic acid valproic acid (as sodium salt) Antipsychotics, Miscellaneous

59 loxapine succinate AL pimozide AL Anxiolytics,Sedatives,And Hypnotics,Misc AMBIEN AMBIEN CR PA buspirone droperidol EDLUAR PA eszopiclone ST HETLIOZ T4 PA hydroxyzine hcl hydroxyzine pamoate LUNESTA PA meprobamate PHENERGAN promethazine injection solution QL (20 ML per 25 days) promethazine injection syringe promethazine oral promethazine rectal SLEEP AID (DOXYLAMINE) SONATA VISTARIL zaleplon oral capsule 10 mg QL (14 EA per 25 days) zaleplon oral capsule 5 mg QL (1 EA per 1 day) zolpidem Atypical Antipsychotics ABILIFY AL ABILIFY MAINTENA T4 PA aripiprazole oral solution AL aripiprazole oral tablet 10 mg, 15 mg QL (1 EA per 1 DY); AL 58

60 aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg AL aripiprazole oral tablet,disintegrating 10 mg QL (2 EA per 1 day); AL aripiprazole oral tablet,disintegrating 15 mg AL ARISTADA T4 PA clozapine oral tablet 100 mg, 200 mg, 50 mg AL clozapine oral tablet 25 mg QL (3 EA per 1 day); AL CLOZARIL AL GEODON AL INVEGA SUSTENNA T4 PA INVEGA TRINZA T4 PA LATUDA AL olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg olanzapine oral tablet 20 mg AL quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg quetiapine oral tablet 300 mg, 400 mg AL quetiapine oral tablet extended release 24 hr 150 mg quetiapine oral tablet extended release 24 hr 300 mg RISPERDAL AL RISPERDAL CONSTA T4 PA risperidone oral solution AL risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet 3 mg, 4 mg AL SAPHRIS AL 59 QL (1 EA per 1 day); AL QL (3 EA per 1 day); AL QL (1 EA per 1 day); AL AL QL (2 EA per 1 day); AL SAPHRIS (BLACK CHERRY) QL (2 EA per 1 day); AL SEROQUEL AL ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg QL (2 EA per 1 day); AL ziprasidone hcl oral capsule 80 mg AL

61 ZYPREXA INTRAMUSCULAR T4 PA ZYPREXA ORAL AL ZYPREXA RELPREVV T4 PA Barbiturates (Anticonvulsants) MYSOLINE phenobarbital primidone Barbiturates (Anxiolytic, Sedative/Hyp) ASCOMP WITH CODEINE BUTALBITAL COMPOUND W/CODEINE BUTALBITAL COMPOUND-CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen butalbital-acetaminophen-caff butalbital-aspirin-caffeine codeine-butalbital-asa-caff ESGIC FIORICET WITH CODEINE FIORINAL-CODEINE #3 MARTEN-TAB phenobarbital Benzodiazepines (Anticonvulsants) ATIVAN clonazepam clorazepate dipotassium diazepam oral diazepam rectal QL (2 EA per 30 DYs) KLONOPIN 60

62 lorazepam TRANXENE T-TAB Benzodiazepines (Anxiolytic,Sedativ/Hyp) alprazolam QL (4 EA per 1 day) amitriptyline-chlordiazepoxide ATIVAN chlordiazepoxide hcl clonazepam clorazepate dipotassium diazepam oral diazepam rectal QL (2 EA per 30 DYs) estazolam HALCION KLONOPIN lorazepam oxazepam RESTORIL temazepam TRANXENE T-TAB triazolam XANAX Butyrophenones haloperidol AL haloperidol decanoate haloperidol lactate injection haloperidol lactate oral AL Central Nervous System Agents, Misc. atomoxetine AL guanfacine oral tablet guanfacine oral tablet extended release 24 hr AL 61

63 memantine AL NAMENDA AL NAMENDA TITRATION PAK AL riluzole T4 PA TENEX XENAZINE T4 PA XYREM T4 PA Cyclooxygenase-2 (Cox-2) Inhibitors celecoxib oral capsule 100 mg, 200 mg, 50 mg QL (2 EA per 1 day) celecoxib oral capsule 400 mg Dopamine Precursors carbidopa-levodopa SINEMET SINEMET CR Ergot-Deriv. Dopamine Receptor Agonists bromocriptine cabergoline PA PARLODEL Fibromyalgia Agents CYMBALTA duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg, 60 mg SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK Hydantoins DILANTIN DILANTIN EXTENDED 62 QL (3 EA per 1 day) QL (2 EA per 1 day) QL (2 EA per 1 day)

64 DILANTIN INFATABS DILANTIN-125 phenytoin phenytoin sodium extended Monoamine Oxidase B Inhibitors ELDEPRYL selegiline hcl Monoamine Oxidase Inhibitors ELDEPRYL NARDIL PARNATE phenelzine selegiline hcl tranylcypromine Nonergot-Deriv.Dopamine Receptor Agonist APOKYN T4 PA MIRAPEX pramipexole REQUIP ropinirole Opiate Agonists ABSTRAL acetaminophen-caff-dihydrocod acetaminophen-codeine ACTIQ ASCOMP WITH CODEINE aspirin-caffeine-dihydrocodein belladonna alkaloids-opium BELLADONNA-OPIUM BUTALBITAL COMPOUND W/CODEINE 63

65 BUTALBITAL COMPOUND-CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg CAPITAL WITH CODEINE codeine sulfate codeine-butalbital-asa-caff DEMEROL DILAUDID DOLOPHINE DURAGESIC QL (10 QY per 30 DYs) ENDOCET ORAL TABLET MG, MG, MG ENDOCET ORAL TABLET MG ENDODAN fentanyl QL (10 QY per 30 DYs) fentanyl citrate FENTORA FIORICET WITH CODEINE FIORINAL-CODEINE #3 HYCET hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen hydromorphone IBUDONE 64

66 ibuprofen-oxycodone KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG LAZANDA levorphanol tartrate LORTAB LORTAB ELIXIR ORAL SOLUTION MG/15 ML LORTAB ELIXIR ORAL SOLUTION MG/15 ML meperidine methadone morphine concentrate morphine intramuscular morphine oral capsule, er multiphase 24 hr PA morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.release pellets 80 mg morphine oral solution morphine oral tablet morphine oral tablet extended release morphine rectal MS CONTIN NUCYNTA OPANA OXAYDO 65 QL (2 EA per 1 day) oxycodone oral capsule QL (12 EA per 1 day) oxycodone oral concentrate oxycodone oral solution

67 oxycodone oral tablet 10 mg QL (9 EA per 1 day) oxycodone oral tablet 15 mg QL (7 EA per 1 day) oxycodone oral tablet 20 mg, 30 mg oxycodone oral tablet 5 mg QL (12 EA per 1 day) oxycodone-acetaminophen oral capsule oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oxymorphone PERCOCET ORAL TABLET MG, MG, MG PERCOCET ORAL TABLET MG PRIMLEV PROMETHAZINE VC-CODEINE REPREXAIN ROXICODONE ORAL TABLET 15 MG, 30 MG ROXICODONE ORAL TABLET 5 MG SUBSYS SYNALGOS-DC tramadol tramadol-acetaminophen TREZIX TYLENOL-CODEINE #4 ULTRACET ULTRAM VERDROCET VICODIN VICODIN ES VICODIN HP 66

68 VICOPROFEN XODOL 10/300 XODOL 5/300 XODOL 7.5/300 XYLON 10 ZAMICET Opiate Antagonists naloxone naltrexone NARCAN REVIA VIVITROL QL (1 EA per 30 days) Opiate Partial Agonists buprenorphine hcl PA buprenorphine-naloxone PA butorphanol tartrate PA nalbuphine ZUBSOLV PA Other Nonsteroidal Anti-Inflam. Agents ANAPROX ANAPROX DS CATAFLAM CHILDREN'S IBUPROFEN DAYPRO diclofenac potassium diclofenac sodium oral diclofenac sodium topical ST EC-NAPROSYN FELDENE fenoprofen 67

69 flurbiprofen hydrocodone-ibuprofen IBUDONE ibuprofen ibuprofen-oxycodone INDOCIN indomethacin INFANT'S IBUPROFEN ketoprofen meclofenamate meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg QL (1 EA per 1 DY) MOBIC NAPROSYN naproxen naproxen sodium oxaprozin piroxicam REPREXAIN sulindac VICOPROFEN XYLON 10 Phenothiazines chlorpromazine AL fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral AL perphenazine AL perphenazine-amitriptyline AL prochlorperazine 68

70 prochlorperazine edisylate QL (20 ML per 30 days) prochlorperazine maleate AL thioridazine AL trifluoperazine AL Respiratory And Cns Stimulants acetaminophen-caff-dihydrocod ASCOMP WITH CODEINE aspirin-caffeine-dihydrocodein BUTALBITAL COMPOUND W/CODEINE BUTALBITAL COMPOUND-CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen-caff butalbital-aspirin-caffeine CAFCIT caffeine citrate codeine-butalbital-asa-caff CONCERTA PA; AL dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 5 mg dexmethylphenidate oral capsule,er biphasic mg dexmethylphenidate oral capsule,er biphasic mg, 40 mg PA; QL (1 EA per 1 day); AL PA; QL (2 EA per 1 day); AL PA; AL dexmethylphenidate oral tablet 10 mg PA; AL dexmethylphenidate oral tablet 2.5 mg, 5 mg QL (4 EA per 1 day); AL ESGIC FIORICET WITH CODEINE FIORINAL-CODEINE #3 69

71 FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 35 MG methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral solution AL 70 PA; AL PA; AL methylphenidate hcl oral tablet PA; AL methylphenidate hcl oral tablet extended release PA; AL methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate hcl oral tablet extended release 24hr 36 mg methylphenidate hcl oral tablet,chewable AL RITALIN PA; AL RITALIN SR PA; AL SYNALGOS-DC TREZIX Salicylates ASCOMP WITH CODEINE aspirin aspirin-caffeine-dihydrocodein aspirin-dipyridamole BUTALBITAL COMPOUND W/CODEINE BUTALBITAL COMPOUND-CODEINE butalbital-aspirin-caffeine choline,magnesium salicylate codeine-butalbital-asa-caff ENDODAN FIORINAL-CODEINE #3 oxycodone-aspirin AL PA; QL (1 EA per 1 day); AL PA; QL (2 EA per 1 day); AL

72 salsalate SYNALGOS-DC Sel.Serotonin,Norepi Reuptake Inhibitor CYMBALTA duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg, 60 mg EFFEXOR XR SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr Selective Serotonin Agonists 71 QL (3 EA per 1 day) QL (2 EA per 1 day) QL (2 EA per 1 day) QL (1 EA per 1 day) QL (3 EA per 1 day) AMERGE PA; QL (12 QY per 30 DYs) eletriptan hbr PA; QL (12 EA per 30 days) FROVA PA; QL (12 QY per 30 DYs) IMITREX ORAL QL (12 QY per 30 DYs) IMITREX STATDOSE KIT REFILL QL (2 QY per 30 DYs) IMITREX STATDOSE PEN QL (2 QY per 30 DYs) IMITREX SUBCUTANEOUS QL (4 QY per 30 DYs) MAXALT QL (12 QY per 30 DYs) MAXALT-MLT QL (12 QY per 30 DYs) rizatriptan QL (12 QY per 30 DYs)

73 sumatriptan QL (6 QY per 30 DYs) sumatriptan succinate oral QL (12 QY per 30 DYs) sumatriptan succinate subcutaneous cartridge QL (2 QY per 30 DYs) sumatriptan succinate subcutaneous pen injector QL (2 QY per 30 DYs) sumatriptan succinate subcutaneous solution QL (4 QY per 30 DYs) ZOMIG PA; QL (1 QY per 30 DYs) Selective-Serotonin Reuptake Inhibitors CELEXA citalopram escitalopram oxalate fluoxetine fluvoxamine LEXAPRO paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg paroxetine hcl oral tablet 20 mg QL (1 EA per 1 day) PAXIL PROZAC sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg, 50 mg QL (45 EA per 30 days) ZOLOFT Serotonin Modulators nefazodone trazodone Succinimides ethosuximide ZARONTIN Thioxanthenes thiothixene AL Tricyclics, Other Norepi-Ru Inhibitors 72

74 amitriptyline amitriptyline-chlordiazepoxide amoxapine ANAFRANIL clomipramine desipramine doxepin imipramine hcl maprotiline NORPRAMIN nortriptyline PAMELOR perphenazine-amitriptyline TOFRANIL Devices Devices 1ST TIER UNIFINE PENTIPS QL (100 EA per 20 days) 1ST TIER UNIFINE PENTIPS PLUS QL (100 EA per 20 days) ACCU-CHEK AVIVA CONTROL SOLN ACCU-CHEK FASTCLIX ACCU-CHEK GUIDE GLUCOSE METER ACCU-CHEK GUIDE L1-L2 CTRL SOL ACCU-CHEK MULTICLIX LANCET ACCU-CHEK SMARTVIEW CONTRL SOL ACCU-CHEK SOFT DEV LANCETS ACCU-CHEK SOFTCLIX LANCET DEV ACCU-CHEK SOFTCLIX LANCETS EUFLEXXA T4 PA GEL-ONE T4 PA HYALGAN T4 PA 73

75 MEDI-JECTOR NEEDLE-FREE SYR A QL (1 EA per 365 days) MEDI-JECTOR NEEDLE-FREE SYR B QL (1 EA per 365 days) MEDI-JECTOR NEEDLE-FREE SYR C QL (1 EA per 365 days) MONOVISC T4 PA NEEDLE FREE SYRINGE KIT A QL (100 EA per 20 days) NEEDLE FREE SYRINGE KIT B QL (100 EA per 20 days) NEUROPEN QL (1 EA per 365 days) NEUROTIPS QL (1 EA per 365 days) ORTHOVISC T4 PA PEN NEEDLE QL (100 EA per 20 days) pen needle, diabetic QL (100 EA per 20 days) PENTIPS QL (100 EA per 20 days) SOFT TOUCH LANCETS SOLESTA T4 PA SYNVISC T4 PA SYNVISC-ONE T4 PA UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16" UNIFINE PENTIPS NEEDLE 29 GAUGE X 5/16" 74 QL (100 EA per 20 days) QL (1 EA per 365 days) UNIFINE PENTIPS PLUS QL (100 EA per 20 days) Diagnostic Agents Adrenocortical Insufficiency ACTHREL T4 PA Diabetes Mellitus ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK GUIDE ACCU-CHEK SMARTVIEW TEST STRIP Ketones KETOSTIX

76 Pituitary Function ACTHREL T4 PA Protein ALBUSTIX REAGENT Thyroid Function THYROGEN T4 PA Urine And Feces Contents KETO-DIASTIX Electrolytic, Caloric, And Water Balance Alkalinizing Agents potassium citrate sodium citrate-citric acid UROCIT-K 10 UROCIT-K 5 Ammonia Detoxicants CARBAGLU T4 PA lactulose Caloric Agents glucose Carbonic Anhydrase Inhibitors acetazolamide DIAMOX SEQUELS PA Diuretics, Miscellaneous THEO-24 theophylline Irrigating Solutions water for irrigation, sterile Loop Diuretics bumetanide 75

77 DEMADEX furosemide LASIX torsemide Phosphate-Removing Agents calcium acetate lanthanum PHOSLO sevelamer carbonate Potassium-Removing Agents SPS (WITH SORBITOL) Potassium-Sparing Diuretics ALDACTAZIDE ALDACTONE amiloride amiloride-hydrochlorothiazide DYAZIDE MAXZIDE MAXZIDE-25MG spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid Replacement Preparations CALCITRATE CALCIUM 600 CALCIUM D(3) CALCIUM ANTACID calcium carbonate calcium carbonate-vitamin d2 calcium carbonate-vitamin d3 76

78 calcium citrate calcium citrate-vitamin d3 CITRACAL + D3 (CALCIUM PHOS) CITRUS CALCIUM DAILY PRENATAL KLOR-CON KLOR-CON M10 KLOR-CON M20 LIQUID CALCIUM WITH VITAMIN D ONE DAILY PRENATAL ONE-A-DAY WOMENS FORMULA ONE-A-DAY WOMEN'S PRENATAL 1 OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D2 OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET MG-UNIT OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 500 MG(1,250MG) -400 UNIT PEDIATRIC ELECTROLYTE potassium chloride PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PRENATAL PLUS PRENATAL VITAMIN PRENATAL VITAMIN PLUS LOW IRON prenatal vit-iron fum-folic ac THERAPEUTIC-M TRIVEEN-DUO DHA TUMS TUMS ULTRA 77

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE