2014 CA Marketplace Formulary

2015 California
Marketplace Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
WHEN YOU PARTICIPATE IN A QUALIFIED HEALTH PLAN OFFERED BY KAISER PERMANENTE,
AND INCLUDES THE HEALTH INSURANCE MARKETPLACE (IN CALIFORNIA, MARKETPLACE IS
KNOWN AS COVERED CALIFORNIA).
For the most recent drug formulary information or other questions, please call our Member Services 24
hours a day, seven days a week (closed holidays). 1-800-464-4000 English 1-800-788-0616 Spanish 1800-757-7585 Chinese dialects 1-800-777-1370 TTY for the hearing/speech impaired.
What is the Kaiser Permanente California Marketplace Formulary?
The California Marketplace Formulary is a list of covered drugs chosen by a group of Kaiser Permanente
physicians and pharmacists known as the Pharmacy and Therapeutics Committee. The Committee
meets regularly to evaluate and select drugs that are safe and effective for our members. This Formulary
meets the requirements outlined under the Federal regulations for Qualified Health Plans being offered
inside a health insurance marketplace (in California, marketplace is known as Covered California).
What drugs are covered?
Kaiser Permanente will generally cover brand and generic drugs listed on the California Marketplace
Formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente,
or an affiliated pharmacy, and other coverage rules are followed.
If you are prescribed a drug on the California Marketplace Formulary, that drug will be covered under
the terms of your drug benefit.
What drugs are not covered?
Drugs not listed on the California Marketplace Formulary (referred to as “non-formulary” drugs) are not
covered unless your Kaiser Permanente physician determines through an exception process that one is
medically necessary. If a non-formulary drug is medically necessary, that drug will be covered under the
terms of your drug benefit. Prescriptions for non-formulary drugs may be filled at
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Kaiser Permanente pharmacies. However, the full price of the drug will generally apply unless a
medically necessary exception has been provided by your Kaiser Permanente physician.
Are there any restrictions on the drugs covered on the Formulary?
Some covered drugs may have additional requirements or limits on coverage, such as Quantity Limits.
For certain drugs, Kaiser Permanente may limit the amount of the drug dispensed to a certain days’
supply. Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug
dispensed.
What is a brand-name drug?
Brand-name drugs are usually manufactured and sold by the drug company that originally researched and
developed the drug. When the patent on a brand-name drug expires, other drug companies may
manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at
lower prices.
What is a generic drug?
A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug.
Generally, generic drugs cost less than brand-name drugs.
What drugs are eligible to be mailed from the mail order pharmacy?
Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are
extremely high cost or require special handling) may not be eligible for mailing. Drugs cannot be mailed
outside the United States.
You can order refills through our mail-order service online at kp.org/refill or by phone or mobile app.
There is no extra charge for mail order. The appropriate cost share (according to your prescription drug
benefit) will apply.
Your prescription drug benefit may have a lower cost share if you use the mail order pharmacy.
Please refer to your Evidence of Coverage or Certificate of Insurance for complete details of your
prescription drug benefit.
Kaiser Permanente California Marketplace Formulary
Kaiser Permanente may add or remove drugs from the California Marketplace Formulary during the year.
These changes to the Formulary are based on new information or new drugs that become available.
The most current California Marketplace Formulary list begins on page 4; it provides coverage
information about some of the drugs covered by Kaiser Permanente. You may also look for the drugs
alphabetically by using the index that starts on page 20.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.
ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin).
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All dosage forms and strengths for a particular drug listed may not be on the Formulary. Some drugs
have multiple dosage forms. In such cases, some dosages may be on the Formulary and others not. Note:
Some of these drugs may be available only in a clinic setting.
The second column, “Drug Tier,” will indicate what tier number the drug is in. Drugs on the
California Marketplace Formulary are categorized in one of the three tiers.
Tier 1 – Generic Tier
Tier 2 – Brand Tier
Tier 3 – Specialty Tier
Note: The tier in which a generic or brand drug is classified under may change at any time during the year.
Additionally, certain brand drugs may be covered at the cost share that applies for Tier 1 and certain
generic drugs may be covered at the Tier 2 cost share. Tier 3 is for specialty drugs that are covered at a
higher cost share.
The third column of the chart will indicate any requirements or limits for that drug:
QL = Quantity Limits -For certain drugs, we may limit the amount of drug that you can receive.
Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug
dispensed.
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Name of drug
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA
BILTRICIDE
MEBENDAZOLE
ANTIBACTERIALS
amikacin sulfate
amoxicillin
amoxicillin & pot
clavulanate
ampicillin
ampicillin & sulbactam
sodium
ampicillin sodium
AVELOX
AZACTAM IN ISOOSMOTIC DEXTROSE
azithromycin
aztreonam
bacitracin
BACTOCILL IN
DEXTROSE
BICILLIN L-A
CAYSTON
cefaclor
cefadroxil
cefazolin sodium
CEFAZOLIN
SODIUM/DEXTROSE
cefdinir
cefepime hcl
cefotaxime sodium
CEFOTETAN
CEFOTETAN/DEXTROSE
cefoxitin sodium
cefpodoxime proxetil
ceftazidime
CEFTRIAXONE IN ISOOSMOTI C DEXTROSE
ceftriaxone sodium
CEFTRIAXONE/DEXTROS
E
cefuroxime axetil
cefuroxime sodium
CEFUROXIME/DEXTROS
E
cephalexin
CHLORAMPHENICOL
SODIUM SU CCINATE
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin in d5w
Drug
Tier
2
2
2
1
1, 2
1, 2
1, 2
1, 2
1, 2
2
2
1, 2
1, 2
1
2
2
3
1
1
1, 2
2
1
1
1
2
2
1, 2
1
1, 2
2
1
2
1
1, 2
2
1, 2
2
1, 2
1
1
Requirements
/ Limits
Name of drug
clarithromycin
CLEOCIN IN D5W
clindamycin hcl
clindamycin palmitate
hydrochloride
clindamycin phosphate
CUBICIN
demeclocycline hcl
dicloxacillin sodium
doxycycline (monohydrate)
doxycycline hyclate
ERY-TAB
ERYTHROCIN
LACTOBIONATE
ERYTHROCIN STEARATE
erythromycin ethylsuccinate
erythromycin-sulfisoxazole
FLUCONAZOLE IN NACL
FORTAZ
gentamicin in saline
gentamicin sulfate
INVANZ
levofloxacin
levofloxacin in d5w
meropenem
minocycline hcl
moxifloxacin hcl
nafcillin sodium
NALLPEN ISO-OSMOTIC
IN DE XTROSE
neomycin sulfate
oxacillin sodium
penicillin g potassium
PENICILLIN G
POTASSIUM IN ISOOSMOTIC DEXTROSE
PENICILLIN G PROCAINE
PENICILLIN G SODIUM
penicillin v potassium
piperacillin sodiumtazobactam sodium
PRIMAXIN IV
PRIMSOL
STREPTOMYCIN
SULFATE
SULFADIAZINE
sulfamethoxazoletrimethoprim
sulfasalazine
SUPRAX
SYNERCID
tetracycline hcl
tobramycin
tobramycin sulfate
Drug
Tier
1
2
1
Requirements
/ Limits
1, 2
1, 2
3
1
1
1, 2
1
2
2
2
1, 2
1
2
2
1, 2
1
3
1
1
1
1, 2
1, 2
1, 2
2
1
1
1
2
2
2
1
1
2
2
2
2
1, 2
1
2
3
1
1, 3
1
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Name of drug
vancomycin hcl
VANCOMYCIN HCL IN
DEXTROS E
XIFAXAN
ZINACEF IN ISOOSMOTIC DEXTROSE
ZINACEF IN ISOOSMOTIC DILUENT
ZOSYN
ZYVOX
ANTIFUNGALS
ABELCET
AMBISOME
AMPHOTERICIN B
CANCIDAS
fluconazole
fluconazole in dextrose
fluconazole in nacl
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole
nystatin
nystatin (mouth-throat)
terbinafine hcl
voriconazole
ANTIMYCOBACTERIALS
CAPASTAT SULFATE
DAPSONE
ethambutol hcl
isoniazid
PRIFTIN
pyrazinamide
rifabutin
RIFAMATE
rifampin
SEROMYCIN
TRECATOR
ANTIPROTOZOALS
ALINIA
atovaquone
atovaquone-proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
metronidazole
metronidazole in nacl
NEBUPENT
paromomycin sulfate
PRIMAQUINE
Drug
Tier
1
2
2
2
2
2
3
2
3
2
3
1
1
1
1
1, 2
1
1, 2
1
1
1
1
1, 2
2
2
1
1, 2
2
1
1
2
1
2
2
2
1
1
1
2
2
1
1
1
1, 2
2
1
2
Requirements
/ Limits
Name of drug
PHOSPHATE
YODOXIN
ANTIVIRALS
abacavir sulfate
abacavir sulfatelamivudine-zidovudine
acyclovir
acyclovir sodium
adefovir dipivoxil
APTIVUS
ATRIPLA
BARACLUDE
COMPLERA
CRIXIVAN
CYTOVENE
didanosine
EDURANT
EMTRIVA
EPZICOM
famciclovir
FOSCARNET SODIUM
FUZEON
INCIVEK
INFERGEN
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine
NORVIR
PEG-INTRON
PEGASYS
PREZISTA
RELENZA DISKHALER
RESCRIPTOR
REYATAZ
ribavirin (hepatitis c)
rimantadine hydrochloride
SELZENTRY
SOVALDI
stavudine
STRIBILD
SUSTIVA
SYNAGIS
TAMIFLU
TIVICAY
TRUVADA
valacyclovir hcl
valganciclovir hcl
Drug
Tier
Requirements
/ Limits
2
1, 2
1
1
1, 2
1, 3
3
3
3
3
2
2
1, 2
3
2
3
1
2
3
3
3
3
3
3
3
1, 2
1
3
1, 2
2
3
3
3
2
2
3
1
1
3
3
1
3
2
3
2, 3
3
3
1
1, 3
QL
QL
QL
QL
QL
QL
QL
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Name of drug
Drug
Tier
3
3
3
3
3
1
1, 2
Requirements
/ Limits
QL
VICTRELIS
VIRACEPT
VIRAZOLE
VIREAD
VISTIDE
voriconazole
zidovudine
URINARY ANTI-INFECTIVES
methenamine hippurate
1
nitrofurantoin
1, 2
nitrofurantoin macrocrystal
1, 2
nitrofurantoin monohyd
1
macro
TRAC
2
trimethoprim
1
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
chlorpheniramine &
1
phenylephrine
cyproheptadine hcl
1
diphenhydramine hcl
1
promethazine hcl
1
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
ABRAXANE
3
ADCETRIS
2
AFINITOR
3
QL
ALIMTA
3
ALKERAN
2
anastrozole
1
ARRANON
3
AVASTIN
3
bicalutamide
1
BICNU
2
bleomycin sulfate
1
CAMPATH
3
capecitabine
1, 2
QL
carboplatin
1
CEENU
2
cisplatin
1
cladribine
1
COMETRIQ
3
QL
cyclophosphamide
1, 2
CYRAMZA
3
cytarabine
1, 2
dacarbazine
1, 2
DACOGEN
3
dactinomycin
1
daunorubicin hcl
1, 2
DAUNOXOME
2
DEPOCYT
2
doxorubicin hcl
1
Name of drug
doxorubicin hcl liposomal
ELSPAR
EMCYT
ERBITUX
ERIVEDGE
ERWINAZE
etoposide
exemestane
FASLODEX
fludarabine phosphate
fluorouracil
flutamide
GAZYVA
GEMZAR
GLEEVEC
HALAVEN
HERCEPTIN
HEXALEN
hydroxyurea
idarubicin hcl
ifosfamide
IFOSFAMIDE/MESNA
IMBRUVICA
INTRON-A
irinotecan hcl
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
KEYTRUDA
KYPROLIS
letrozole
LEUKERAN
leuprolide acetate
LUPRON DEPOT
LUPRON DEPOT-PED
LYSODREN
MATULANE
megestrol acetate
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
MYLERAN
NEXAVAR
ONCASPAR
oxaliplatin
paclitaxel
Drug
Tier
1
3
3
3
3
2
1, 2
1
3
1
1
1
3
2, 3
3
3
3
3
1
1, 2
1
2
3
3
1
3
2, 3
3
3
3
3
3
1
2
1, 2
2
2
2
3
1
3
1
1
1
1
1
2
2
3
3
1
1
Requirements
/ Limits
QL
QL
QL
QL
QL
QL
QL
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Name of drug
Drug
Tier
1
3
3
3
3
3
3
3
3
2
3
1
3
3
3
3
1
2
1, 2
3
3
1
3
3
3
3
2
2
1
1
3
3
3
3
3
3
3
3
3
pentostatin
PERJETA
POMALYST
PROLEUKIN
REVLIMID
RITUXAN
SPRYCEL
STIVARGA
SUTENT
TABLOID
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN
TASIGNA
TAXOTERE
temozolomide
THIOTEPA
topotecan hcl
TORISEL
TREANDA
tretinoin (chemotherapy)
TRISENOX
TYKERB
VANDETANIB
VELCADE
VIDAZA
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VOTRIENT
VUMON
XALKORI
XTANDI
YERVOY
ZANOSAR
ZELBORAF
ZYKADIA
ZYTIGA
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
atropine sulfate
1
ATROVENT HFA
2
BELLADONNA & OPIUM
2
chlordiazepoxide hcl1
clidinium bromide
dicyclomine hcl
1, 2
glycopyrrolate
1, 2
hyoscyamine sulfate
1, 2
ipratropium bromide
1
ipratropium bromide (nasal) 1
phenobarbital1, 2
Requirements
/ Limits
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Name of drug
Drug
Tier
Requirements
/ Limits
hyoscyamine-atropinescopolamine
PROPANTHELINE
2
BROMIDE
SCOPOLAMINE
2
HYDROBROMIDE
SPIRIVA HANDIHALER
2
AUTONOMIC DRUGS, MISCELLANEOUS
nicotine
1
nicotine polacrilex
1, 2
PARASYMPATHOMIMETIC (CHOLINERGIC)
AGENTS
bethanechol chloride
1
donepezil hydrochloride
1
ENLON
2
galantamine hydrobromide
1
GUANIDINE HCL
2
MYTELASE
2
neostigmine methylsulfate
1
PHYSOSTIGMINE
2
SALICYLATE
pilocarpine hcl (oral)
1
PROSTIGMIN
2
pyridostigmine bromide
1, 2
SKELETAL MUSCLE RELAXANTS
atracurium besylate
1
baclofen
1, 2
cisatracurium besylate
1
cyclobenzaprine hcl
1
dantrolene sodium
1
methocarbamol
1
pancuronium bromide
1
QUELICIN
2
rocuronium bromide
1, 2
tizanidine hcl
1
vecuronium bromide
1
SYMPATHOLYTIC (ADRENERGIC BLOCKING)
AGENTS
DIBENZYLINE
2
dihydroergotamine
1, 2
mesylate
ERGOMAR
2
guanfacine hcl
1
PHENTOLAMINE
2
MESYLATE
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR DISKUS
2
albuterol sulfate
1, 2
COMBIVENT
2
dobutamine hcl
1
dobutamine in d5w
1
dopamine hcl
1, 2
dopamine in d5w
1
ephedrine sulfate
1
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Name of drug
Drug
Tier
Requirements
/ Limits
(pressors)
EPINEPHRINE
2
epinephrine hcl
1
isoproterenol hcl
1, 2
metaproterenol sulfate
1, 2
midodrine hcl
1
norepinephrine bitartrate
1
phenylephrine hcl
1
(pressors)
SEREVENT DISKUS
2
terbutaline sulfate
1
BLOOD DERIVATIVES
BLOOD DERIVATIVES
albumin, human
1
PLASMANATE
2
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS
ANTIANEMIA DRUGS
iron dextran
1
polysaccharide iron
1
complex
PROFERRIN ES
2
PROFERRIN-FORTE
2
VENOFER
2
ANTIHEMORRHAGIC AGENTS
ADVATE
2
QL
ALPHANATE/VON
WILLEBRAND FACTOR
2
QL
COMPLEX/HUMAN
ALPHANINE SD
2
QL
aminocaproic acid
1, 2
BENEFIX
2
CYKLOKAPRON
3
GELFILM OP
2
GELFOAM SPONGE
2
HEMOFIL M
2
QL
KCENTRA
2
KOGENATE FS
2
QL
NOVOSEVEN RT
2
PROFILNINE SD
3
QL
PROTAMINE SULFATE
2
RECOTHROM
2
THROMBIN-JMI DILUENT
2
XYNTHA
2
QL
ANTITHROMBOTIC AGENTS
ACD-A NOCLOT-50
2
ACTIVASE
2
AGGRENOX
2
anagrelide hcl
1
ANGIOMAX
2
argatroban
1, 2
ATRYN
2
BRILINTA
2
Name of drug
Drug
Tier
1
2
Requirements
/ Limits
clopidogrel bisulfate
EFFIENT
heparin (porcine) in sodium
1, 2
chloride
heparin sod (porcine) in
1
d5w
heparin sodium (porcine)
1
heparin sodium (porcine)
1
lock flush
INTEGRILIN
3
LOVENOX
2
QL
PROFILNINE SD
3
REFLUDAN
2
REOPRO
2
THROMBATE III W/10 ML
2
STE RILE WATER
TNKASE
2
warfarin sodium
1, 2
HEMATOPOIETIC AGENTS
LEUKINE
3
NEUMEGA
3
NEUPOGEN
3
QL
PROCRIT
2
QL
PROMACTA
3
QL
HEMORRHEOLOGIC AGENTS
pentoxifylline
1
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate
1
prazosin hcl
1
tamsulosin hcl
1
terazosin hcl
1
ANTILIPEMIC AGENTS
atorvastatin calcium
1
cholestyramine
1
cholestyramine light
1
colestipol hcl
1
fenofibrate
1
gemfibrozil
1
lovastatin
1
pravastatin sodium
1
simvastatin
1
BETA-ADRENERGIC BLOCKING AGENTS
atenolol
1
atenolol & chlorthalidone
1
bisoprolol &
1
hydrochlorothiazide
bisoprolol fumarate
1
BREVIBLOC
2
carvedilol
1
esmolol hcl
1
labetalol hcl
1
metoprolol &
1
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Name of drug
Drug
Tier
Requirements
/ Limits
Name of drug
Drug
Tier
Requirements
/ Limits
hydrochlorothiazide
hydrochlorothiazide
metoprolol tartrate
SCLEROSING AGENTS
1
nadolol
1
ETHAMOLIN
2
propranolol hcl
1
SOTRADECOL
2
sotalol hcl
VASODILATING AGENTS
1
sotalol hcl (afib/afl)
alprostadil
1
1
CALCIUM-CHANNEL BLOCKING AGENTS
CAVERJECT
2
amlodipine besylate
dipyridamole
1
1
diltiazem hcl
dipyridamole (diagnostic)
1
1
diltiazem hcl coated beads
isosorbide dinitrate
1
1, 2
nicardipine hcl
isosorbide mononitrate
1
1
nifedipine
1
LETAIRIS
3
nimodipine
1
LEVITRA
2
QL
verapamil hcl
nitroglycerin
1, 2
1, 2
CARDIAC DRUGS
nitroglycerin in d5w
1, 2
adenosine
papaverine hcl
1, 2
1
amiodarone hcl
1
REMODULIN
3
sildenafil citrate (pulmonary
digoxin
1, 2
1
hypertension)
disopyramide phosphate
1, 2
TRACLEER
3
flecainide acetate
1
TYVASO
2
ibutilide fumarate
1
VENTAVIS
3
lidocaine hcl (cardiac)
1, 2
CENTRAL NERVOUS SYSTEM AGENTS
lidocaine in d5w
1
ANALGESICS AND ANTIPYRETICS
mexiletine hcl
1
acetaminophen w/ codeine
1
milrinone in dextrose
1
alfentanil
1, 2
milrinone lactate
1
buprenorphine
hcl
1, 2
PROCAINAMIDE HCL
2
buprenorphine
hcl-naloxone
propafenone hcl
1
1
hcl dihydrate
quinidine gluconate
1, 2
butorphanol tartrate
1
quinidine sulfate
1, 2
choline & mag salicylate
1
TIKOSYN
2
codeine sulfate
1, 2
QL
HYPOTENSIVE AGENTS
etodolac
1
clonidine hcl
1
fentanyl
1
QL
hydralazine hcl
1
fentanyl citrate
1
QL
methyldopa
1
hydrocodone1, 2
QL
METHYLDOPATE HCL
2
acetaminophen
minoxidil
1
hydromorphone hcl
1, 2
QL
NITROPRESS
2
ibuprofen
1
PROGLYCEM
3
indomethacin
1, 2
RESERPINE
2
indomethacin sodium
1
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
INFUMORPH 200
2
QL
INHIBITORS
ketorolac tromethamine
1, 2
benazepril hcl
1
MECLOFENAMATE
2
captopril
1
SODIUM
enalaprilat
1
mefenamic acid
1
lisinopril
1
meloxicam
1
lisinopril &
meperidine hcl
1
QL
1
hydrochlorothiazide
methadone hcl
1, 2
QL
losartan potassium
1
morphine sulfate
1, 2
QL
losartan potassium &
1
MORPHINE
SULFATE
IN
hydrochlorothiazide
2
QL
DEXTR OSE 5%
spironolactone
1
nabumetone
1
spironolactone &
1
Kaiser Permanente 2015 California Marketplace Formulary • Page 9 of
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Name of drug
Drug
Tier
1
1
1
2
2
2
1
Requirements
/ Limits
nalbuphine hcl
naproxen
naproxen sodium
NEOPROFEN
OFIRMEV
OPANA
QL
oxycodone hcl
QL
oxycodone w/
1
QL
acetaminophen
pentazocine w/ naloxone
1
salsalate
1
sufentanil citrate
1
sulindac
1
tramadol hcl
1
tramadol-acetaminophen
1
ULTIVA
2
ANOREXIGENIC AGENTS AND RESPIRATORY
AND CEREBRAL STIMULANTS
amphetamine1, 2
dextroamphetamine
caffeine citrate
1
dextroamphetamine sulfate 1
methylphenidate hcl
1, 2
VYVANSE
2
ANTICONVULSANTS
BANZEL
3
carbamazepine
1, 2
CELONTIN
2
clonazepam
1
divalproex sodium
1
EQUETRO
2
ethosuximide
1
felbamate
1
fosphenytoin sodium
1
gabapentin
1
lamotrigine
1, 2
levetiracetam
1, 2
magnesium sulfate
1, 2
oxcarbazepine
1, 2
phenytoin
1
phenytoin sodium
1
phenytoin sodium extended 1, 2
primidone
1
SABRIL
3
QL
topiramate
1
valproate sodium
1
valproic acid
1
ANTIMANIC AGENTS
LITHIUM
2
lithium carbonate
1, 2
ANTIMIGRAINE AGENTS
acetaminophen1
isometheptene-
Name of drug
Drug
Tier
Requirements
/ Limits
dichloralphenazone
ergoloid mesylates
1
ergotamine w/ caffeine
1, 2
naratriptan hcl
1
rizatriptan benzoate
1
SUMATRIPTAN
2
sumatriptan succinate
1
ANTIPARKINSONIAN AGENTS
amantadine hcl
1
APOKYN
3
AZILECT
2
benztropine mesylate
1
bromocriptine mesylate
1
cabergoline
1
carbidopa-levodopa
1
CARBIDOPA/LEVODOPA/
2
ENTACA PONE
entacapone
1, 2
LODOSYN
2
pramipexole
1
dihydrochloride
ropinirole hydrochloride
1
selegiline hcl
1
trihexyphenidyl hcl
1
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam
1
buspirone hcl
1
BUTISOL SODIUM
2
CHLORAL HYDRATE
2
chlordiazepoxide hcl
1
clorazepate dipotassium
1
DIASTAT ACUDIAL
2
diazepam
1, 2
droperidol
1
hydroxyzine hcl
1, 2
hydroxyzine pamoate
1, 2
lorazepam
1, 2
midazolam hcl
1
NEMBUTAL
2
oxazepam
1
phenobarbital
1, 2
PHENOBARBITAL
1, 2
SODIUM
PRECEDEX
2
temazepam
1
zolpidem tartrate
1
CENTRAL NERVOUS SYSTEM AGENTS,
MISCELLANEOUS
acamprosate calcium
1
flumazenil
1
NAMENDA
2
riluzole
1
selegiline hcl
1
Kaiser Permanente 2015 California Marketplace Formulary • Page 10 of
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Name of drug
Drug
Tier
GENERAL ANESTHETICS
BREVITAL SODIUM
2
ETHRANE
2
etomidate
1
FORANE
2
ketamine hcl
1
propofol
1
SUPRANE
2
OPIATE ANTAGONISTS
naloxone hcl
1, 2
naltrexone hcl
1, 2
PSYCHOTHERAPEUTIC AGENTS
ABILIFY
2
amitriptyline hcl
1
AMOXAPINE
2
bupropion hcl
1
chlorpromazine hcl
1, 2
citalopram hydrobromide
1
clomipramine hcl
1
clozapine
1
desipramine hcl
1
doxepin hcl
1, 2
duloxetine hcl
1
escitalopram oxalate
1
fluoxetine hcl
1
fluphenazine decanoate
1
fluphenazine hcl
1, 2
fluvoxamine maleate
1
haloperidol
1
haloperidol decanoate
1
haloperidol lactate
1
imipramine hcl
1
loxapine succinate
1
MAPROTILINE HCL
2
mirtazapine
1
nefazodone hcl
1, 2
nortriptyline hcl
1, 2
olanzapine
1, 2
ORAP
2
paroxetine hcl
1
perphenazine
1
PERPHENAZINE/AMITRIP
2
TYLIN E
phenelzine sulfate
1
prochlorperazine
1
prochlorperazine edisylate
1
prochlorperazine maleate
1
protriptyline hcl
1
quetiapine fumarate
1
risperidone
1
sertraline hcl
1
SURMONTIL
2
Requirements
/ Limits
Drug Requirements
Tier
/ Limits
thioridazine hcl
1
thiothixene
1
tranylcypromine sulfate
1
trazodone hcl
1
trifluoperazine hcl
1
venlafaxine hcl
1
ziprasidone hcl
1
CONTRACEPTIVES (FOAMS, DEVICES)
CONTRACEPTIVES (FOAMS, DEVICES)
levonorgestrel & eth
1
estradiol
ORTHO DIAPHRAGM ALL2
FLEX/ 65MM
WIDE-SEAL SILICONE
2
DIAPHR AGM KIT 60
DEVICES
DEVICES
AEROCHAMBER Z-STAT
2
PLUS/F LOWSIGNAL
AEROTRACH PLUS
2
ASTHMAPACK I
2
BAYER BREEZE 2
2
NORMAL CON TROL
BD INSULIN SYRINGE
MICROF INE IV/U2
100/0.5ML/28G X 1/2"
BD LANCET DEVICE
2
BD LANCET ULTRAFINE
2
33G
BD PEN
NEEDLE/MINI/ULTRAF
2
INE/31G X 3/16"
BD SAFETYGLIDE 27G X
2
5/8"
DISPOSABLE POWER
2
INSPIREASE
REPLACEMENT MO
2
UTHPIECE
INSPIREASE RESERVOIR
2
BAGS
NORDIPEN 5 INJECTION
2
DEVI CE
ONETOUCH ULTRA MINI
2
PEDIATRIC SMALL MASK
2
PENLET II AUTOMATIC
2
BLOOD SAMPLER
TRUZONE PEAK FLOW
2
METER
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
ACETEST
2
ADENOSCAN
2
ALBUSTIX
2
CANDIN
2
CHEMSTRIP 9 STRIPS
2
CHIRHOSTIM
2
Kaiser Permanente 2015 California Marketplace Formulary • Page 11 of
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Name of drug
Drug Requirements
Tier
/ Limits
CLINITEST
2
CONRAY
2
CORTROSYN
2
CREON
2
CYSTOGRAFIN
2
D-XYLOSE
2
DEFINITY
2
DIASTIX
2
E-Z-CAT DRY
2
EOVIST
2
fluorescein sodium injection 1
fluorescein sodium topical
1
fluorescein w/ benoxinate
1
GADAVIST
2
GASTROGRAFIN
2
HYPAQUE SODIUM
2
indigotindisulfonate sodium 1
KETO-DIASTIX
2
LEXISCAN
2
MAGNEVIST
2
METOPIRONE
2
MULTIHANCE
2
OMNIPAQUE
2
ONETOUCH ULTRA BLUE 2
THYROGEN
2
TUBERSOL
2
ELECTROLYTIC, CALORIC, AND WATER
BALANCE
ACIDIFYING AGENTS
AMMONIUM CHLORIDE
2
K-PHOS MF
2
ALKALINIZING AGENTS
pot & sod citrates w/citric ac 1
potassium citrate
1
(alkalinizer)
potassium citrate-citric acid 1
sodium acetate
1
sodium bicarbonate
1, 2
sodium citrate & citric acid
1
THAM
2
AMMONIA DETOXICANTS
BUPHENYL
3
lactulose
1
lactulose (encephalopathy)
1
LITHOSTAT
2
CALORIC AGENTS
amino acid electrolyte
1, 2
infusion
amino acid infusion
1, 2
CLINIMIX
2
2.75%/DEXTROSE 5 %
CLINIMIX
2
4.25%/DEXTROSE 1 0%
Name of drug
Name of drug
Drug
Tier
Requirements
/ Limits
CLINIMIX
2
4.25%/DEXTROSE 2 0%
CLINIMIX
2
4.25%/DEXTROSE 2 5%
CLINIMIX 5%/DEXTROSE
2
15%
CLINIMIX E
2
2.75%/DEXTROSE 10%
CLINIMIX E
2
2.75%/DEXTROSE 5%
CLINIMIX E
2
4.25%/DEXTROSE 25%
CLINIMIX E
2
5%/DEXTROSE 15 %
CLINIMIX E
2
5%/DEXTROSE 20 %
dextrose
1, 2
fat emulsion
1, 2
PHENEX-1
2
DIURETICS
amiloride &
1
hydrochlorothiazide
bumetanide
1
CHLORTHALIDONE
2
DYRENIUM
2
EDECRIN
2
furosemide
1, 2
hydrochlorothiazide
1
indapamide
1
mannitol
1
metolazone
1
SODIUM EDECRIN
2
torsemide
1
triamterene &
1
hydrochlorothiazide
ION-REMOVING AGENTS
RENVELA
2
sodium polystyrene
1, 2
sulfonate
IRRIGATING SOLUTIONS
acetic acid
1
DIANEAL LOW
CALCIUM/1.5%
2
DEXTROSE
lactated ringer's (irrigation)
1
ringer's irrigation
1
sodium chloride (gu irrigant) 1
water for irrigation, sterile
1
REPLACEMENT PREPARATIONS
calcium acetate (phosphate
1, 2
binder)
calcium chloride (dihydrate) 1
calcium gluconate
1
chromium chloride
1, 2
COPPER SULFATE
2
Kaiser Permanente 2015 California Marketplace Formulary • Page 12 of
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Name of drug
COPPER TRACE METAL
DEXTROSE 5%
/ELECTROLYTE #48
VIAFLEX
dextrose in lactated ringers
dextrose in ringers
dextrose w/ sodium chloride
hetastarch in sodium
chloride
HEXTEND
HYPERLYTE-CR
K-PHOS
KCL 0.15%/D5W/LR
lactated ringer's
LMD 10% DEXTROSE 5%
LMD 10% SODIUM
CHLORIDE 0 .9%
M.T.E.-5 CONCENTRATE
MAGNESIUM SULFATE IN
D5W
MANGANESE TRACE
METAL
PLASMA-LYTE A
potassium acetate
potassium bicarbonate
potassium chloride
potassium chloride in
dextrose
potassium chloride in
dextrose & sodium chloride
potassium chloride in nacl
potassium chloride
microencapsulated crystals
cr
potassium phosphate
dibasic
ringer's
saline, bacteriostatic
SELENIUM
sodium chloride
sodium chloride flush
sodium phosphate
trace minerals (cr-cu-mnzn)
zinc sulfate
ZINC TRACE METAL
URICOSURIC AGENTS
colchicine w/ probenecid
probenecid
ENZYMES
ENZYMES
ALDURAZYME
CEREDASE
CEREZYME
ELAPRASE
Drug
Tier
2
2
1
1
1, 2
1
2
1
2
2
1
2
2
2
2
2
2
1
1
1, 2
1
1, 2
1, 2
1
1
1
1
2
1
1
1
1, 2
1, 2
2
1
1
3
2
3
3
Requirements
/ Limits
Drug Requirements
Tier
/ Limits
ELITEK
3
FABRAZYME
3
HYLENEX
2
MYOZYME
3
NAGLAZYME
3
PROLASTIN
3
PULMOZYME
3
VORAXAZE
3
VPRIV
3
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
ANTI-INFECTIVES
BACITRACIN
2
bacitracin-polymyxin b
1
(ophth)
chlorhexidine gluconate
1
(mouth-throat)
ciprofloxacin hcl (ophth)
1
erythromycin (ophth)
1
gentamicin sulfate (ophth)
1
neomycin-bacitracin zn1
polymyxin
neomycin-polymyxin1
gramicidin
ofloxacin (ophth)
1
ofloxacin (otic)
1
polymyxin b-trimethoprim
1
sulfacetamide sodium
1
(ophth)
tobramycin (ophth)
1, 2
trifluridine
1
VITRASERT
2
ZYMAXID
2
ANTI-INFLAMMATORY AGENTS
CIPRODEX
2
COLY-MYCIN S
2
dexamethasone sodium
1
phosphate (ophth)
diclofenac sodium (ophth)
1
flunisolide (nasal)
1, 2
fluorometholone (ophth)
1, 2
flurbiprofen sodium
1
fluticasone propionate
1
(nasal)
ketorolac tromethamine
1
(ophth)
neomycin-polymy1
dexameth
neomycin-polymyxin-hc
1
(otic)
prednisolone acetate
1, 2
(ophth)
PREDNISOLONE SODIUM
2
PHOSP HATE
RESTASIS
2
Name of drug
Kaiser Permanente 2015 California Marketplace Formulary • Page 13 of
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Name of drug
Drug
Tier
2
RETISERT
sulfacetamide sod1, 2
prednisolone
TOBRADEX
2
VEXOL
2
ANTIALLERGIC AGENTS
ALOCRIL
2
azelastine hcl
1
cromolyn sodium (ophth)
1
ANTIGLAUCOMA AGENTS
acetazolamide
1, 2
acetazolamide sodium
1
betaxolol hcl (ophth)
1
brimonidine tartrate
1
dorzolamide hcl
1
dorzolamide hcl-timolol
1
maleate
ISOPTO CARBACHOL
2
latanoprost
1
levobunolol hcl
1, 2
LUMIGAN
2
methazolamide
1
MIOCHOL-E
2
PHOSPHOLINE IODIDE
2
pilocarpine hcl
1
timolol maleate (ophth)
1
EENT DRUGS, MISCELLANEOUS
acetic acid (otic)
1
ACETIC ACID/ALUMINUM
2
ACET ATE
apraclonidine hcl
1, 2
EYLEA
2
HEALON5
2
JETREA
2
LACRISERT
2
LUCENTIS
2
MACUGEN
2
ophthalmic irrigation
1
solution - intraocular
VISUDYNE
2
LOCAL ANESTHETICS
AKTEN
2
antipyrine-benzocaine
1
COCAINE HCL
2
lidocaine hcl (mouth-throat) 1
proparacaine hcl
1, 2
tetracaine hcl (ophth)
1
MYDRIATICS
atropine sulfate
1, 2
(ophthalmic)
CYCLOMYDRIL
2
cyclopentolate hcl
1, 2
ISOPTO HOMATROPINE
2
Requirements
/ Limits
Name of drug
Drug
Tier
1
Requirements
/ Limits
tropicamide
VASOCONSTRICTORS
NAPHAZOLINE HCL
2
phenylephrine hcl (ophth)
1
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS
balsalazide disodium
1
mesalamine
1, 2
ANTIDIARRHEA AGENTS
diphenoxylate w/ atropine
1, 2
OPIUM TINCTURE
2
(PAREGORIC )
ANTIEMETICS
dronabinol
1
EMEND
2
meclizine hcl
1
ondansetron
1
ondansetron hcl
1
TRANSDERM-SCOP
2
ANTIULCER AGENTS AND ACID SUPPRESSANTS
cimetidine hcl
1
famotidine
1
FAMOTIDINE PREMIXED
2
misoprostol
1
omeprazole
1
pantoprazole sodium
1, 2
ranitidine hcl
1, 2
sucralfate
1, 2
ZANTAC
2
CATHARTICS AND LAXATIVES
AMITIZA
2
CASCARA SAGRADA
2
peg 3350-kcl-sod bicarb1
sod chloride-sod sulfate
SORBITOL
2
CHOLELITHOLYTIC AGENTS
ursodiol
1
DIGESTANTS
CREON
2
PROKINETIC AGENTS
metoclopramide hcl
1
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA
2
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
BAL IN OIL
2
CHEMET
3
CUPRIMINE
2
deferoxamine mesylate
1
EXJADE
3
QL
PENTETATE CALCIUM
2
TRISODI UM
Kaiser Permanente 2015 California Marketplace Formulary • Page 14 of
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Name of drug
Drug
Tier
Requirements
/ Limits
PENTETATE ZINC
2
TRISODIUM
sodium thiosulfate
1, 2
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-HYDROCORT
1, 2
ARISTOSPAN INTRA2
ARTICULA R
ASMANEX TWISTHALER
2
120 ME TERED DOSES
betamethasone sod
1
phosphate & acetate
budesonide
1, 3
budesonide (inhalation)
1, 2
CELESTONE
2
CORTISONE ACETATE
2
dexamethasone
1, 2
dexamethasone sodium
1
phosphate
FLOVENT HFA
2
fludrocortisone acetate
1
hydrocortisone
1
KENALOG-10
2
methylprednisolone
1, 2
methylprednisolone acetate 1
methylprednisolone sod
1, 2
succ
prednisolone
1, 2
prednisolone sodium
1
phosphate
prednisone
1, 2
QVAR
2
ANDROGENS
ANDRODERM
2
ANDROID
2
ANDROXY
2
danazol
1
oxandrolone
1
testosterone cypionate
1, 2
testosterone enanthate
1
ANTIDIABETIC AGENTS
acarbose
1
glimepiride
1
glipizide
1
glipizide-metformin hcl
1
glyburide
1, 2
HUMALOG
2
HUMALOG MIX 50/50
2
HUMULIN 70/30
2
HUMULIN N
2
HUMULIN R
2
LANTUS
2
metformin hcl
1
pioglitazone hcl
1
Drug Requirements
Tier
/ Limits
TOLBUTAMIDE
2
ANTIHYPOGLYCEMIC AGENTS
GLUCAGEN
2
GLUCAGON
2
EMERGENCY KIT
CONTRACEPTIVES
desogestrel & ethinyl
1
estradiol
drospirenone-ethinyl
1
estradiol
ELLA
2
ethynodiol diacet & eth
1, 2
estrad
levonorgestrel & eth
1
estradiol
levonorgestrel-eth estradiol
1
(triphasic)
MIRENA
2
NECON 1/50-28
2
NECON 10/11-28
2
NEXPLANON
2
norethin acet & estrad-fe
1
norethindrone & eth
1
estradiol
norethindrone
1
(contraceptive)
norethindrone acet & eth
1
estra
norethindrone-eth estradiol
1
(triphasic)
norgestimate-ethinyl
1
estradiol
norgestimate-ethinyl
1
estradiol (triphasic)
norgestrel & ethinyl
1, 2
estradiol
NUVARING
2
PLAN B ONE-STEP
2
ESTROGENS AND ESTROGEN AGONISTSANTAGONISTS
clomiphene citrate
1
DEPO-ESTRADIOL
2
esterified estrogens &
1
methyltestosterone
ESTRACE
2
estradiol
1, 2
estradiol valerate
1
PREMARIN
2
raloxifene hcl
1
GONADOTROPINS
BRAVELLE
2
chorionic gonadotropin
1
MENOPUR
2
SYNAREL
3
PARATHYROID
Name of drug
Kaiser Permanente 2015 California Marketplace Formulary • Page 15 of
33
Name of drug
Drug
Tier
3
2
Requirements
/ Limits
QL
FORTEO
FORTICAL
PITUITARY
ACTHAR HP
3
desmopressin acetate
1, 3
desmopressin acetate
1
refrigerated
desmopressin acetate
1
spray
desmopressin acetate
1
spray refrigerated
vasopressin
1
PROGESTINS
DEPO-PROVERA
2
ENDOMETRIN
2
medroxyprogesterone
1
acetate
medroxyprogesterone
1
acetate (contraceptive)
norethindrone acetate
1
progesterone
1
progesterone micronized
1
SOMATROPIN AGONISTS-ANTAGONISTS
MAKENA
2
QL
NORDITROPIN FLEXPRO
2, 3
QL
SEROSTIM
3
QL
THYROID AND ANTITHYROID AGENTS
ARMOUR THYROID
2
levothyroxine sodium
1, 2
liothyronine sodium
1
methimazole
1
propylthiouracil
1
SSKI
2
LOCAL ANESTHETICS
LOCAL ANESTHETICS
bupivacaine hcl
1
bupivacaine in dextrose
1
bupivacaine w/ epinephrine 1, 2
chloroprocaine hcl
1, 2
lidocaine hcl (cardiac)
1
lidocaine hcl (local anesth.) 1
lidocaine w/ epinephrine
1, 2
mepivacaine hcl
1, 2
NAROPIN
2
TETRACAINE HCL
1
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
ACETADOTE
2
acetylcysteine
1
ACTIMMUNE
3
alendronate sodium
1, 2
allopurinol
1
amifostine crystalline
1
Name of drug
ATGAM
AVONEX
azathioprine
AZATHIOPRINE SODIUM
BOTOX
BOTOX COSMETIC
CINRYZE
COLCRYS
COPAXONE
cyclosporine modified (for
microemulsion)
CYSTADANE
CYSTAGON
dexrazoxane
disulfiram
ELMIRON
ENBREL
ETIDRONATE DISODIUM
EXTAVIA
finasteride
FIRAZYR
FLUOR-A-DAY
FUSILEV
GRASTEK
HUMIRA
KALYDECO
KINERET
leflunomide
leucovorin calcium
levocarnitine (metabolic
modifiers)
mesna
methylene blue (antidote)
mycophenolate mofetil
MYOBLOC
octreotide acetate
ORENCIA
pamidronate disodium
REMICADE
RIMSO-50
SANDIMMUNE
SENSIPAR
sirolimus
sodium fluoride
sodium fluoride (dental)
SOLIRIS
SORIATANE
SUPARTZ
tacrolimus
THALOMID
THIOLA
TRI-CHLOR
Drug
Tier
2
3
1
2
2
2
2
2
3
Requirements
/ Limits
QL
QL
QL
1, 2
3
2
1
1, 2
2
3
2
3
1
3
2
2
2
3
3
3
1
1
QL
QL
QL
QL
QL
QL
1
1, 2
1
1, 2
2
1, 3
3
1, 2
3
2
2
3
1, 2
1, 2
1, 2
2
3
2
1, 2
3
2
2
QL
QL
QL
Kaiser Permanente 2015 California Marketplace Formulary • Page 16 of
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Name of drug
TYSABRI
water for injection, sterile
zoledronic acid
OXYTOCICS
OXYTOCICS
CERVIDIL
HEMABATE
methylergonovine maleate
MIFEPREX
oxytocin
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
ALOE VERA
ALPROSTADIL
ATROPINE SULFATE
MONOHYDR ATE
BACLOFEN
BACTERIOSTATIC
WATER FOR
INJECTION/BENZYL
ALCOHOL
BIOTIN
BORIC ACID
CANTHARIDIN
CARBAMAZEPINE
CHLOROFORM
CHLORPROMAZINE HCL
CHOLESTEROL ACETATE
CLINDAMYCIN HCL
CLOBETASOL
PROPIONATE
CLONIDINE HCL
CLOTRIMAZOLE
COAL TAR
COLLODION FLEXIBLE
CYSTEAMINE HCL
DEXAMETHASONE
DILTIAZEM HCL
DIPHENYLCYCLOPROPE
NONE
ESTRADIOL
GABAPENTIN
GLYCERIN
GLYCOPYRROLATE
HALOPERIDOL
HYDROCORTISONE
hydrophilic ointment
HYDROXOCOBALAMIN
HYDROXYPROGESTERO
NE CAPRO ATE
INDOMETHACIN
ISOSORBIDE
KETAMINE HCL
Drug
Tier
3
1
1
2
2
1, 2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
Requirements
/ Limits
Name of drug
Drug
Tier
2
2
2
2
2
2
2
2
Requirements
/ Limits
KETOPROFEN
L-ARGININE
L-CITRULLINE
L-ISOLEUCINE
L-PROLINE
L-VALINE
LACTIC ACID
LACTOSE
LACTOSE
2
MONOHYDRATE
LIDOCAINE HCL
2
MONOHYDRATE
METHADONE HCL
2
METHYLCELLULOSE
2
METOCLOPRAMIDE HCL
2
MONOHY DRATE
METRONIDAZOLE
2
MORPHINE SULFATE
2
NEOMYCIN SULFATE
2
PAPAVERINE HCL
2
PHENOBARBITAL
2
PHENTOLAMINE
2
MESYLATE
PLURONIC F127
2
PODOPHYLLIN RESIN
2
POLYETHYLENE GLYCOL
2
400
POLYETHYLENE GLYCOL
2
8000
PROGESTERONE
2
MICRONIZED
PROGESTERONE
2
WETTABLE
PROPYLENE GLYCOL
2
QUINACRINE HCL
2
SALICYLIC ACID
2
SODIUM BENZOATE
2
SORBITOL
2
SQUARIC ACID
2
DIBUTYLESTER
SULFUR PRECIPITATED
2
TESTOSTERONE
2
THYMOL
2
TRANEXAMIC ACID
2
TRIAMCINOLONE
2
ACETONIDE
UREA
2
VERAPAMIL HCL
2
water for injection, sterile
1
ZINC SULFATE
2
HEPTAHYDRATE
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
COMBIVENT RESPIMAT
2
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Name of drug
Drug
Tier
1
Requirements
/ Limits
CROMOLYN SODIUM
cromolyn sodium
1
(mastocytosis)
DULERA
2
montelukast sodium
1
ANTITUSSIVES
benzonatate
1
guaifenesin-codeine
1
hydrocodone w/
1
homatropine
phenyleph-promethazine w/
1
cod
phenylephrine-chlorphen1
dm
PHENYLHISTINE DH
2
promethazine w/codeine
1
promethazine-dm
1
pseudoephedrine w/
1
codeine-gg
MUCOLYTIC AGENTS
sodium chloride (inhalant)
1
PULMONARY SURFACTANTS
CUROSURF
2
SURVANTA
2
INTRATRACHEAL
RESPIRATORY AGENTS, MISCELLANEOUS
XOLAIR
3
VASODILATING
OPSUMIT
2
SERUMS, TOXOIDS, AND VACCINES
SERUMS
ANTIVENIN
LATRODECTUS MAC
2
TANS
CARIMUNE
2
NANOFILTERED
CROFAB
2
CYTOGAM
2
DIGIFAB
2
GAMASTAN S/D
2
GAMMAGARD LIQUID
2
HYPERRAB S/D
2
HYPERRHO S/D
2
HYPERTET S/D
2
NABI-HB
2
VARIZIG
2
WILATE
2
TOXOIDS
ADACEL
2
DECAVAC
2
DIPHTHERIA/TETANUS
2
TOXOID PEDIATRIC
INFANRIX
2
VACCINES
Name of drug
Drug
Tier
2
2
2
Requirements
/ Limits
ACTHIB
AFLURIA PF 2013-2014
ENGERIX-B
FLUARIX QUADRIVALENT
2
2013 -2014
FLUBLOK 2013-2014
2
FLUCELVAX 2013-2014
2
FLULAVAL 2013-2014
2
FLUMIST QUADRIVALENT 2
FLUVIRIN 2013-2014
2
FLUVIRIN PF 2013-2014
2
FLUZONE HIGH-DOSE PF
2
2013 -2014
GARDASIL
2
HAVRIX
2
IMOVAX RABIES
2
(H.D.C.V.)
IPOL INACTIVATED IPV
2
IXIARO
2
KINRIX
2
M-M-R II W/DILUENT 10
2
DOS E
MENACTRA
2
MENOMUNE-A/C/Y/W-135 2
PEDIARIX
2
PNEUMOVAX 23/5 DOSE
2
PREVNAR 13
2
PROQUAD
2
RABAVERT
2
ROTARIX
2
ROTATEQ
2
THERACYS
2
TWINRIX
2
TYPHIM VI
2
VARIVAX
2
VIVOTIF BERNA
2
YF-VAX
2
ZOSTAVAX
2
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES
benzoyl peroxide1, 2
erythromycin
clindamycin phosphate
1
(topical)
clindamycin phosphate
1
vaginal
clindamycin phosphate1
benzoyl peroxide
clindamycin phosphatebenzoyl peroxide
1
(refrigerate)
clotrimazole
1
dakin's solution
1, 2
erythromycin (acne aid)
1, 2
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Drug Requirements
Tier
/ Limits
gentamicin sulfate (topical)
1
iodoquinol-hc
1
ketoconazole (topical)
1
malathion
1
metronidazole (topical)
1
metronidazole vaginal
1
mupirocin
1
neomycin/polymyxin b gu
1
nystatin (topical)
1
permethrin
1, 2
PHISOHEX
2
selenium sulfide
1
silver sulfadiazine
1
SULFAMYLON
2
ANTI-INFLAMMATORY AGENTS
alclometasone dipropionate 1
AMCINONIDE
2
betamethasone
1
dipropionate augmented
betamethasone valerate
1
clobetasol propionate
1
clobetasol propionate
1
emollient base
CORDRAN TAPE
2
CORTISPORIN
2
desonide
1
fluocinolone acetonide
1
fluocinonide
1
fluocinonide emulsified
1
base
fluticasone propionate
1
halobetasol propionate
1
hydrocortisone (intrarectal)
1
hydrocortisone (rectal)
1
hydrocortisone (topical)
1
hydrocortisone acetate
1
(rectal)
hydrocortisone butyrate
1
hydrocortisone valerate
1
mometasone furoate
1
nystatin-triamcinolone
1
PRAMOSONE
2
PROCTOFOAM HC
2
triamcinolone acetonide
1
(mouth)
triamcinolone acetonide
1, 2
(topical)
ANTIPRURITICS AND LOCAL ANESTHETICS
butamben-tetracaine1
benzocaine
hydrocortisone acetate w/
1, 2
pramoxine
lidocaine
1
lidocaine hcl
1
Name of drug
Name of drug
Drug
Tier
1, 2
2
2
Requirements
/ Limits
lidocaine-prilocaine
PHENOL
PONTOCAINE
ASTRINGENTS
aluminum chloride
1
XERAC AC
2
CELL STIMULANTS AND PROLIFERANTS
KEPIVANCE
3
RETIN-A MICRO
2
tretinoin
1, 2
DEPIGMENTING AND PIGMENTING AGENTS
8-MOP
2
OXSORALEN
2
OXSORALEN ULTRA
2
KERATOLYTIC AGENTS
KERALYT
2
sulfacetamide sodium w/
1, 2
sulfur
sulfacetamide sodium1
sulfur w/ sunscreens
KERATOPLASTIC AGENTS
ELTA TAR
2
SKIN AND MUCOUS MEMBRANE AGENTS,
MISCELLANEOUS
acitretin
1
AQUAPHOR
2
BENZOIN COMPOUND
2
TINCTURE
calcipotriene
1
DIFFERIN
2
DRITHO-CREME HP
2
ELIDEL
2
EPIDUO
2
fluorouracil (topical)
1, 2
imiquimod
1
isotretinoin
1, 2
LEVULAN KERASTICK
2
PODOCON 25 IN
2
BENZOIN TIN CTURE
podofilox
1, 2
SANTYL
2
sodium chloride
1
tacrolimus (topical)
1, 2
TARGRETIN
3
TAZORAC
2
VECTICAL
2
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
oxybutynin chloride
1
OXYTROL
2
trospium chloride
1
RESPIRATORY SMOOTH MUSCLE RELAXANTS
aminophylline
1, 2
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Name of drug
Drug
Tier
1
1, 2
Requirements
/ Limits
theophylline
theophylline in dextrose
VITAMINS
MULTIVITAMIN PREPARATIONS
b-complex w/ c & folic acid
1
multiple vitamin
1
ped multivitamins w/fl & iron 1, 2
pediatric multiple vitamin w/
1
c
pediatric multiple vitamins
1
w/ iron
pediatric multivitamins w/fl
1
pediatric vitamins acd
1
fluoride & iron
pediatric vitamins acd w/
1
fluoride
VITAMIN A
AQUASOL A
2
PARENTERAL
VITAMIN B COMPLEX
cyanocobalamin
1
FOLIC ACID
2
niacin
1, 2
POTABA
2
PYRIDOXINE HCL
2
thiamine hcl
1
VITAMIN C
ascorbic acid
1
VITAMIN D
calcitriol
1, 2
ergocalciferol
1
VITAMIN K ACTIVITY
phytonadione
1, 2
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INDEX
8
8-MOP ........................................................................... 19
A
abacavir sulfate ............................................................... 5
abacavir sulfate-lamivudine-zidovudine .......................... 5
ABELCET ........................................................................ 5
ABILIFY ......................................................................... 10
ABRAXANE ..................................................................... 6
acamprosate calcium .................................................... 10
acarbose........................................................................ 15
ACD-A NOCLOT-50 ........................................................ 8
ACETADOTE ................................................................ 16
acetaminophen w/ codeine ............................................. 9
acetaminophen-isometheptene-dichloralphenazone .... 10
acetazolamide ............................................................... 13
acetazolamide sodium .................................................. 13
ACETEST ...................................................................... 11
acetic acid ..................................................................... 12
acetic acid (otic) ............................................................ 14
ACETIC ACID/ALUMINUM ACET ATE ........................ 14
acetylcysteine ................................................................ 16
acitretin .......................................................................... 19
ACTHAR HP.................................................................. 15
ACTHIB ......................................................................... 18
ACTIMMUNE................................................................. 16
ACTIVASE....................................................................... 8
acyclovir .......................................................................... 5
acyclovir sodium .............................................................. 5
ADACEL ........................................................................ 18
ADCETRIS ...................................................................... 6
adefovir dipivoxil .............................................................. 5
ADENOSCAN................................................................ 11
adenosine ........................................................................ 9
ADVAIR DISKUS ............................................................ 7
ADVATE .......................................................................... 8
AEROCHAMBER Z-STAT PLUS/F LOWSIGNAL ........ 11
AEROTRACH PLUS ..................................................... 11
AFINITOR........................................................................ 6
AFLURIA PF 2013-2014 ............................................... 18
AGGRENOX.................................................................... 8
A-HYDROCORT............................................................ 14
AKTEN .......................................................................... 14
ALBENZA ........................................................................ 4
albumin, human ............................................................... 8
ALBUSTIX ..................................................................... 11
albuterol sulfate ............................................................... 7
alclometasone dipropionate .......................................... 18
ALDURAZYME .............................................................. 13
alendronate sodium ....................................................... 16
alfentanil .......................................................................... 9
ALIMTA ........................................................................... 6
ALINIA ............................................................................. 5
ALKERAN........................................................................ 6
allopurinol ...................................................................... 16
ALOCRIL ....................................................................... 13
ALOE VERA .................................................................. 16
ALPHANATE/VON WILLEBRAND FACTOR
COMPLEX/HUMAN..................................................... 8
ALPHANINE SD.............................................................. 8
alprazolam .................................................................... 10
alprostadil ........................................................................ 9
ALPROSTADIL ............................................................. 16
aluminum chloride ......................................................... 19
amantadine hcl.............................................................. 10
AMBISOME ..................................................................... 5
AMCINONIDE ............................................................... 18
amifostine crystalline..................................................... 16
amikacin sulfate .............................................................. 4
amiloride & hydrochlorothiazide.................................... 12
amino acid electrolyte infusion ...................................... 12
amino acid infusion ....................................................... 12
aminocaproic acid ........................................................... 8
aminophylline ................................................................ 19
amiodarone hcl ............................................................... 9
AMITIZA ........................................................................ 14
amitriptyline hcl ............................................................. 10
amlodipine besylate ........................................................ 8
AMMONIUM CHLORIDE .............................................. 12
AMOXAPINE................................................................. 10
amoxicillin ....................................................................... 4
amoxicillin & pot clavulanate........................................... 4
amphetamine-dextroamphetamine ............................... 10
AMPHOTERICIN B ......................................................... 5
ampicillin ......................................................................... 4
ampicillin & sulbactam sodium ........................................ 4
ampicillin sodium............................................................. 4
anagrelide hcl.................................................................. 8
anastrozole ..................................................................... 6
ANDRODERM .............................................................. 15
ANDROID ..................................................................... 15
ANDROXY .................................................................... 15
ANGIOMAX ..................................................................... 8
antipyrine-benzocaine ................................................... 14
ANTIVENIN LATRODECTUS MAC TANS ................... 18
APOKYN ....................................................................... 10
apraclonidine hcl ........................................................... 14
APTIVUS ......................................................................... 5
AQUAPHOR ................................................................. 19
AQUASOL A PARENTERAL ........................................ 19
argatroban ....................................................................... 8
ARISTOSPAN INTRA-ARTICULA R ............................ 14
ARMOUR THYROID ..................................................... 16
ARRANON ...................................................................... 6
ascorbic acid ................................................................. 19
ASMANEX TWISTHALER 120 ME TERED DOSES.... 14
ASTHMAPACK I ........................................................... 11
atenolol ........................................................................... 8
atenolol & chlorthalidone ................................................ 8
ATGAM ......................................................................... 16
atorvastatin calcium ........................................................ 8
atovaquone ..................................................................... 5
atovaquone-proguanil hcl ............................................... 5
atracurium besylate......................................................... 7
ATRIPLA ......................................................................... 5
atropine sulfate ............................................................. 14
atropine sulfate (ophthalmic) ........................................ 14
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ATROPINE SULFATE MONOHYDR ATE .................... 16
ATROVENT HFA ............................................................ 7
ATRYN ............................................................................ 8
AVASTIN ......................................................................... 6
AVELOX .......................................................................... 4
AVONEX ....................................................................... 16
AZACTAM IN ISO-OSMOTIC DEXTROSE .................... 4
azathioprine ................................................................... 16
AZATHIOPRINE SODIUM ............................................ 16
azelastine hcl................................................................. 13
AZILECT........................................................................ 10
azithromycin .................................................................... 4
aztreonam ....................................................................... 4
B
brimonidine tartrate ....................................................... 13
bromocriptine mesylate ................................................. 10
budesonide ................................................................... 14
budesonide (inhalation) ................................................ 14
bumetanide ................................................................... 12
BUPHENYL ................................................................... 12
bupivacaine hcl ............................................................. 16
bupivacaine in dextrose ................................................ 16
bupivacaine w/ epinephrine .......................................... 16
buprenorphine hcl ........................................................... 9
buprenorphine hcl-naloxone hcl dihydrate ...................... 9
bupropion hcl ................................................................ 11
buspirone hcl................................................................. 10
butamben-tetracaine-benzocaine ................................. 19
BUTISOL SODIUM ....................................................... 10
butorphanol tartrate......................................................... 9
bacitracin ....................................................................... 13
BACITRACIN................................................................. 13
C
bacitracin-polymyxin b (ophth) ...................................... 13
baclofen ........................................................................... 7
cabergoline ................................................................... 10
BACLOFEN ................................................................... 16
caffeine citrate............................................................... 10
BACTERIOSTATIC WATER FOR INJECTION/BENZYL
calcipotriene .................................................................. 19
ALCOHOL.................................................................. 16
calcitriol ......................................................................... 19
BACTOCILL IN DEXTROSE ........................................... 4
calcium acetate (phosphate binder).............................. 12
BAL IN OIL .................................................................... 14
calcium chloride (dihydrate) .......................................... 12
balsalazide disodium ..................................................... 14
calcium gluconate ......................................................... 12
BANZEL ........................................................................ 10
CAMPATH ...................................................................... 6
BARACLUDE .................................................................. 5
CANCIDAS ..................................................................... 5
CANDIN ........................................................................ 11
BAYER BREEZE 2 NORMAL CON TROL ................... 11
CANTHARIDIN ............................................................. 16
b-complex w/ c & folic acid ............................................ 19
CAPASTAT SULFATE .................................................... 5
BD INSULIN SYRINGE MICROF INE IV/Ucapecitabine .................................................................... 6
100/0.5ML/28G X 1/2 ................................................ 11
captopril .......................................................................... 9
BD LANCET DEVICE .................................................... 11
carbamazepine ............................................................. 10
BD LANCET ULTRAFINE 33G ..................................... 11
CARBAMAZEPINE ....................................................... 16
BD PEN NEEDLE/MINI/ULTRAF INE/31G X 3/16 ....... 11
CARBIDOPA/LEVODOPA/ENTACA PONE ................. 10
BD SAFETYGLIDE 27G X 5/8 ...................................... 11
carbidopa-levodopa ...................................................... 10
BELLADONNA & OPIUM ................................................ 7
carboplatin ...................................................................... 6
benazepril hcl .................................................................. 9
CARIMUNE NANOFILTERED ...................................... 18
BENEFIX ......................................................................... 8
carvedilol ......................................................................... 8
BENZOIN COMPOUND TINCTURE............................. 19
CASCARA SAGRADA .................................................. 14
benzonatate................................................................... 17
CAVERJECT................................................................... 9
benzoyl peroxide-erythromycin ..................................... 18
CAYSTON....................................................................... 4
benztropine mesylate .................................................... 10
CEENU ........................................................................... 6
betamethasone dipropionate augmented ..................... 18
cefaclor ........................................................................... 4
betamethasone sod phosphate & acetate .................... 14
cefadroxil ......................................................................... 4
betamethasone valerate ................................................ 18
cefazolin sodium ............................................................. 4
betaxolol hcl (ophth) ...................................................... 13
bethanechol chloride ....................................................... 7
CEFAZOLIN SODIUM/DEXTROSE ............................... 4
bicalutamide .................................................................... 6
cefdinir ............................................................................ 4
BICILLIN L-A ................................................................... 4
cefepime hcl .................................................................... 4
BICNU ............................................................................. 6
cefotaxime sodium .......................................................... 4
BILTRICIDE..................................................................... 4
CEFOTETAN .................................................................. 4
BIOTIN .......................................................................... 16
CEFOTETAN/DEXTROSE ............................................. 4
bisoprolol & hydrochlorothiazide ..................................... 8
cefoxitin sodium .............................................................. 4
bisoprolol fumarate .......................................................... 8
cefpodoxime proxetil ....................................................... 4
bleomycin sulfate ............................................................ 6
ceftazidime ...................................................................... 4
BORIC ACID ................................................................. 16
CEFTRIAXONE IN ISO-OSMOTI C DEXTROSE .......... 4
BOTOX .......................................................................... 16
ceftriaxone sodium .......................................................... 4
BOTOX COSMETIC ...................................................... 16
CEFTRIAXONE/DEXTROSE ......................................... 4
BRAVELLE .................................................................... 15
cefuroxime axetil ............................................................. 4
BREVIBLOC .................................................................... 8
cefuroxime sodium .......................................................... 4
BREVITAL SODIUM ..................................................... 10
CEFUROXIME/DEXTROSE ........................................... 4
BRILINTA ........................................................................ 8
CELESTONE ................................................................ 14
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CELONTIN .................................................................... 10
cephalexin ....................................................................... 4
CEREDASE................................................................... 13
CEREZYME .................................................................. 13
CERVIDIL ...................................................................... 16
CHEMET ....................................................................... 14
CHEMSTRIP 9 STRIPS ................................................ 11
CHIRHOSTIM................................................................ 11
CHLORAL HYDRATE ................................................... 10
CHLORAMPHENICOL SODIUM SU CCINATE ............. 4
chlordiazepoxide hcl ...................................................... 10
chlordiazepoxide hcl-clidinium bromide .......................... 7
chlorhexidine gluconate (mouth-throat) ........................ 13
CHLOROFORM ............................................................ 16
chloroprocaine hcl ......................................................... 16
chloroquine phosphate .................................................... 5
chlorpheniramine & phenylephrine ................................. 6
chlorpromazine hcl ........................................................ 11
CHLORPROMAZINE HCL ............................................ 16
CHLORTHALIDONE ..................................................... 12
CHOLESTEROL ACETATE .......................................... 17
cholestyramine ................................................................ 8
cholestyramine light ........................................................ 8
choline & mag salicylate .................................................. 9
chorionic gonadotropin .................................................. 15
chromium chloride ......................................................... 12
cimetidine hcl................................................................. 14
CINRYZE....................................................................... 16
CIPRODEX.................................................................... 13
ciprofloxacin .................................................................... 4
ciprofloxacin hcl ............................................................... 4
ciprofloxacin hcl (ophth) ................................................ 13
ciprofloxacin in d5w ......................................................... 4
cisatracurium besylate .................................................... 7
cisplatin ........................................................................... 6
citalopram hydrobromide............................................... 11
cladribine ......................................................................... 6
clarithromycin .................................................................. 4
CLEOCIN IN D5W ........................................................... 4
clindamycin hcl ................................................................ 4
CLINDAMYCIN HCL ..................................................... 17
clindamycin palmitate hydrochloride ............................... 4
clindamycin phosphate .................................................... 4
clindamycin phosphate (topical) .................................... 18
clindamycin phosphate vaginal ..................................... 18
clindamycin phosphate-benzoyl peroxide ..................... 18
clindamycin phosphate-benzoyl peroxide (refrigerate) . 18
CLINIMIX 2.75%/DEXTROSE 5 % ............................... 12
CLINIMIX 4.25%/DEXTROSE 1 0% ............................. 12
CLINIMIX 4.25%/DEXTROSE 2 0% ............................. 12
CLINIMIX 4.25%/DEXTROSE 2 5% ............................. 12
CLINIMIX 5%/DEXTROSE 15% ................................... 12
CLINIMIX E 2.75%/DEXTROSE 10% ........................... 12
CLINIMIX E 2.75%/DEXTROSE 5% ............................. 12
CLINIMIX E 4.25%/DEXTROSE 25% ........................... 12
CLINIMIX E 5%/DEXTROSE 15 % ............................... 12
CLINIMIX E 5%/DEXTROSE 20 % ............................... 12
CLINITEST .................................................................... 11
clobetasol propionate .................................................... 18
CLOBETASOL PROPIONATE...................................... 17
clobetasol propionate emollient base ............................ 18
clomiphene citrate ......................................................... 15
clomipramine hcl ........................................................... 11
clonazepam ................................................................... 10
clonidine hcl .................................................................... 9
CLONIDINE HCL .......................................................... 17
clopidogrel bisulfate ........................................................ 8
clorazepate dipotassium ............................................... 10
clotrimazole ................................................................... 18
CLOTRIMAZOLE .......................................................... 17
clozapine ....................................................................... 11
COAL TAR .................................................................... 17
COARTEM ...................................................................... 5
COCAINE HCL ............................................................. 14
codeine sulfate ................................................................ 9
colchicine w/ probenecid ............................................... 13
COLCRYS ..................................................................... 16
colestipol hcl ................................................................... 8
COLLODION FLEXIBLE ............................................... 17
COLY-MYCIN S ............................................................ 13
COMBIVENT................................................................... 7
COMBIVENT RESPIMAT ............................................. 17
COMETRIQ..................................................................... 6
COMPLERA .................................................................... 5
CONRAY ....................................................................... 11
COPAXONE .................................................................. 16
COPPER SULFATE...................................................... 12
COPPER TRACE METAL ............................................ 12
CORDRAN TAPE ......................................................... 18
CORTISONE ACETATE ............................................... 14
CORTISPORIN ............................................................. 18
CORTROSYN ............................................................... 11
CREON ......................................................................... 11
CRIXIVAN ....................................................................... 5
CROFAB ....................................................................... 18
CROMOLYN SODIUM .................................................. 17
cromolyn sodium (mastocytosis) .................................. 17
cromolyn sodium (ophth) .............................................. 13
CUBICIN ......................................................................... 4
CUPRIMINE .................................................................. 14
CUROSURF .................................................................. 17
cyanocobalamin ............................................................ 19
cyclobenzaprine hcl ........................................................ 7
CYCLOMYDRIL ............................................................ 14
cyclopentolate hcl ......................................................... 14
cyclophosphamide .......................................................... 6
cyclosporine modified (for microemulsion) ................... 16
CYKLOKAPRON............................................................. 8
cyproheptadine hcl .......................................................... 6
CYRAMZA ...................................................................... 6
CYSTADANE ................................................................ 16
CYSTAGON .................................................................. 16
CYSTEAMINE HCL ...................................................... 17
CYSTOGRAFIN ............................................................ 11
cytarabine ....................................................................... 6
CYTOGAM .................................................................... 18
CYTOVENE .................................................................... 5
D
dacarbazine .................................................................... 6
DACOGEN ...................................................................... 6
dactinomycin ................................................................... 6
danazol ......................................................................... 15
dantrolene sodium .......................................................... 7
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DAPSONE ....................................................................... 5
DARAPRIM ..................................................................... 5
daunorubicin hcl .............................................................. 6
DAUNOXOME ................................................................. 6
DECAVAC ..................................................................... 18
deferoxamine mesylate ................................................. 14
DEFINITY ...................................................................... 11
demeclocycline hcl .......................................................... 4
DEPOCYT ....................................................................... 6
DEPO-ESTRADIOL ...................................................... 15
DEPO-PROVERA ......................................................... 15
desipramine hcl ............................................................. 11
desmopressin acetate ................................................... 15
desmopressin acetate refrigerated ............................... 15
desmopressin acetate spray ......................................... 15
desmopressin acetate spray refrigerated ...................... 15
desogestrel & ethinyl estradiol ...................................... 15
desonide ........................................................................ 18
dexamethasone ............................................................. 13
DEXAMETHASONE ...................................................... 17
dexamethasone sodium phosphate .............................. 13
dexamethasone sodium phosphate (ophth) .................. 13
dexrazoxane .................................................................. 16
dextroamphetamine sulfate ........................................... 10
dextrose......................................................................... 12
DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX ........ 12
dextrose in lactated ringers ........................................... 12
dextrose in ringers ......................................................... 12
dextrose w/ sodium chloride.......................................... 12
DIANEAL LOW CALCIUM/1.5% DEXTROSE .............. 12
DIASTAT ACUDIAL ...................................................... 10
DIASTIX ........................................................................ 11
diazepam ....................................................................... 10
DIBENZYLINE ................................................................. 7
diclofenac sodium (ophth) ............................................. 13
dicloxacillin sodium ......................................................... 4
dicyclomine hcl ................................................................ 7
didanosine ....................................................................... 5
DIFFERIN ...................................................................... 19
DIGIFAB ........................................................................ 18
digoxin ............................................................................. 9
dihydroergotamine mesylate ........................................... 7
diltiazem hcl..................................................................... 8
DILTIAZEM HCL ........................................................... 17
diltiazem hcl coated beads .............................................. 8
diphenhydramine hcl ....................................................... 6
diphenoxylate w/ atropine ............................................. 14
DIPHENYLCYCLOPROPENONE ................................. 17
DIPHTHERIA/TETANUS TOXOID PEDIATRIC ........... 18
dipyridamole .................................................................... 9
dipyridamole (diagnostic) ................................................ 9
disopyramide phosphate ................................................. 9
DISPOSABLE POWER ................................................. 11
disulfiram ....................................................................... 16
divalproex sodium ......................................................... 10
dobutamine hcl ................................................................ 7
dobutamine in d5w .......................................................... 7
donepezil hydrochloride .................................................. 7
dopamine hcl ................................................................... 7
dopamine in d5w ............................................................. 7
dorzolamide hcl ............................................................. 13
dorzolamide hcl-timolol maleate.................................... 13
doxazosin mesylate ........................................................ 8
doxepin hcl .................................................................... 11
doxorubicin hcl ................................................................ 6
doxorubicin hcl liposomal ................................................ 6
doxycycline (monohydrate) ............................................. 4
doxycycline hyclate ......................................................... 4
DRITHO-CREME HP .................................................... 19
dronabinol ..................................................................... 14
droperidol ...................................................................... 10
drospirenone-ethinyl estradiol ....................................... 15
DULERA ....................................................................... 17
duloxetine hcl ................................................................ 11
D-XYLOSE .................................................................... 11
DYRENIUM ................................................................... 12
E
EDECRIN ...................................................................... 12
EDURANT ....................................................................... 5
EFFIENT ......................................................................... 8
ELAPRASE ................................................................... 13
ELIDEL .......................................................................... 19
ELITEK .......................................................................... 13
ELLA ............................................................................. 15
ELMIRON ...................................................................... 16
ELSPAR .......................................................................... 6
ELTA TAR ..................................................................... 19
EMCYT ........................................................................... 6
EMEND ......................................................................... 14
EMTRIVA ........................................................................ 5
enalaprilat ....................................................................... 9
ENBREL ........................................................................ 16
ENDOMETRIN .............................................................. 15
ENGERIX-B .................................................................. 18
ENLON ............................................................................ 7
entacapone ................................................................... 10
EOVIST ......................................................................... 11
ephedrine sulfate (pressors) ........................................... 7
EPIDUO ........................................................................ 19
EPINEPHRINE................................................................ 7
epinephrine hcl................................................................ 7
EPZICOM ........................................................................ 5
EQUETRO .................................................................... 10
ERBITUX ........................................................................ 6
ergocalciferol................................................................. 19
ergoloid mesylates ........................................................ 10
ERGOMAR ..................................................................... 7
ergotamine w/ caffeine .................................................. 10
ERIVEDGE ..................................................................... 6
ERWINAZE ..................................................................... 6
ERY-TAB ........................................................................ 4
ERYTHROCIN LACTOBIONATE ................................... 4
ERYTHROCIN STEARATE ............................................ 4
erythromycin (acne aid) ................................................ 18
erythromycin (ophth) ..................................................... 13
erythromycin ethylsuccinate ........................................... 4
erythromycin-sulfisoxazole ............................................. 4
escitalopram oxalate ..................................................... 11
esmolol hcl ...................................................................... 8
esterified estrogens & methyltestosterone ................... 15
ESTRACE ..................................................................... 15
estradiol ........................................................................ 15
ESTRADIOL .................................................................. 17
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estradiol valerate ........................................................... 15
ethambutol hcl ................................................................. 5
ETHAMOLIN ................................................................... 9
ethosuximide ................................................................. 10
ETHRANE ..................................................................... 10
ethynodiol diacet & eth estrad ....................................... 15
ETIDRONATE DISODIUM ............................................ 16
etodolac ........................................................................... 9
etomidate....................................................................... 10
etoposide ......................................................................... 6
exemestane ..................................................................... 6
EXJADE ........................................................................ 14
EXTAVIA ....................................................................... 16
EYLEA ........................................................................... 14
E-Z-CAT DRY................................................................ 11
FLUVIRIN 2013-2014 ................................................... 18
FLUVIRIN PF 2013-2014 .............................................. 18
fluvoxamine maleate ..................................................... 11
FLUZONE HIGH-DOSE PF 2013 -2014 ....................... 18
FOLIC ACID .................................................................. 19
FORANE ....................................................................... 10
FORTAZ.......................................................................... 4
FORTEO ....................................................................... 15
FORTICAL .................................................................... 15
FOSCARNET SODIUM .................................................. 5
fosphenytoin sodium ..................................................... 10
furosemide .................................................................... 12
FUSILEV ....................................................................... 16
FUZEON ......................................................................... 5
G
F
gabapentin .................................................................... 10
FABRAZYME ................................................................ 13
GABAPENTIN ............................................................... 17
famciclovir ....................................................................... 5
GADAVIST .................................................................... 11
famotidine ...................................................................... 14
galantamine hydrobromide ............................................. 7
FAMOTIDINE PREMIXED ............................................ 14
GAMASTAN S/D ........................................................... 18
FASLODEX ..................................................................... 6
GAMMAGARD LIQUID ................................................. 18
fat emulsion ................................................................... 12
GARDASIL .................................................................... 18
felbamate....................................................................... 10
GASTROGRAFIN ......................................................... 11
GAZYVA ......................................................................... 6
fenofibrate ....................................................................... 8
GELFILM OP .................................................................. 8
fentanyl ............................................................................ 9
GELFOAM SPONGE ...................................................... 8
fentanyl citrate ................................................................. 9
gemfibrozil ....................................................................... 8
finasteride ...................................................................... 16
GEMZAR ......................................................................... 6
FIRAZYR ....................................................................... 16
gentamicin in saline ........................................................ 4
flecainide acetate ............................................................ 9
gentamicin sulfate ........................................................... 4
FLOVENT HFA.............................................................. 14
gentamicin sulfate (ophth) ............................................ 13
FLUARIX QUADRIVALENT 2013 -2014 ....................... 18
gentamicin sulfate (topical) ........................................... 18
FLUBLOK 2013-2014 .................................................... 18
GLEEVEC ....................................................................... 6
FLUCELVAX 2013-2014 ............................................... 18
glimepiride ..................................................................... 15
fluconazole ...................................................................... 5
glipizide ......................................................................... 15
fluconazole in dextrose ................................................... 5
glipizide-metformin hcl .................................................. 15
fluconazole in nacl ........................................................... 5
GLUCAGEN .................................................................. 15
FLUCONAZOLE IN NACL .............................................. 4
GLUCAGON EMERGENCY KIT .................................. 15
flucytosine ....................................................................... 5
glyburide ....................................................................... 15
fludarabine phosphate ..................................................... 6
GLYCERIN .................................................................... 17
fludrocortisone acetate .................................................. 14
glycopyrrolate.................................................................. 7
FLULAVAL 2013-2014 .................................................. 18
GLYCOPYRROLATE ................................................... 17
flumazenil ...................................................................... 10
FLUMIST QUADRIVALENT .......................................... 18
GRASTEK ..................................................................... 16
flunisolide (nasal) .......................................................... 13
griseofulvin microsize ..................................................... 5
fluocinolone acetonide .................................................. 18
griseofulvin ultramicrosize .............................................. 5
fluocinonide ................................................................... 18
guaifenesin-codeine ...................................................... 17
fluocinonide emulsified base ......................................... 18
guanfacine hcl ................................................................. 7
FLUOR-A-DAY .............................................................. 16
GUANIDINE HCL ............................................................ 7
fluorescein sodium injection .......................................... 11
fluorescein sodium topical ............................................. 11
H
fluorescein w/ benoxinate .............................................. 11
HALAVEN ....................................................................... 6
fluorometholone (ophth) ................................................ 13
halobetasol propionate ................................................. 18
fluorouracil ....................................................................... 6
haloperidol .................................................................... 11
fluorouracil (topical) ....................................................... 19
HALOPERIDOL ............................................................ 17
fluoxetine hcl ................................................................. 11
haloperidol decanoate .................................................. 11
fluphenazine decanoate ................................................ 11
haloperidol lactate ......................................................... 11
fluphenazine hcl ............................................................ 11
HAVRIX ......................................................................... 18
flurbiprofen sodium ........................................................ 13
HEALON5 ..................................................................... 14
flutamide .......................................................................... 6
HEMABATE .................................................................. 16
fluticasone propionate ................................................... 18
HEMOFIL M .................................................................... 8
fluticasone propionate (nasal) ....................................... 13
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heparin (porcine) in sodium chloride ............................... 8
heparin sod (porcine) in d5w ........................................... 8
heparin sodium (porcine) ................................................ 8
heparin sodium (porcine) lock flush ................................ 8
HERCEPTIN.................................................................... 6
hetastarch in sodium chloride ....................................... 12
HEXALEN........................................................................ 6
HEXTEND ..................................................................... 12
HUMALOG .................................................................... 15
HUMALOG MIX 50/50 ................................................... 15
HUMIRA ........................................................................ 16
HUMULIN 70/30 ............................................................ 15
HUMULIN N .................................................................. 15
HUMULIN R .................................................................. 15
hydralazine hcl ................................................................ 9
hydrochlorothiazide ....................................................... 12
hydrocodone w/ homatropine ........................................ 17
hydrocodone-acetaminophen.......................................... 9
hydrocortisone ............................................................... 14
HYDROCORTISONE .................................................... 17
hydrocortisone (intrarectal) ........................................... 19
hydrocortisone (rectal) .................................................. 19
hydrocortisone (topical) ................................................. 19
hydrocortisone acetate (rectal)...................................... 19
hydrocortisone acetate w/ pramoxine ........................... 19
hydrocortisone butyrate ................................................. 19
hydrocortisone valerate ................................................. 19
hydromorphone hcl ......................................................... 9
hydrophilic ointment ...................................................... 17
HYDROXOCOBALAMIN ............................................... 17
hydroxychloroquine sulfate ............................................. 5
HYDROXYPROGESTERONE CAPRO ATE ................ 17
hydroxyurea..................................................................... 6
hydroxyzine hcl.............................................................. 10
hydroxyzine pamoate .................................................... 10
HYLENEX ...................................................................... 13
hyoscyamine sulfate ........................................................ 7
HYPAQUE SODIUM ..................................................... 11
HYPERLYTE-CR .......................................................... 12
HYPERRAB S/D ........................................................... 18
HYPERRHO S/D ........................................................... 18
HYPERTET S/D ............................................................ 18
I
INSPIREASE REPLACEMENT MO UTHPIECE .......... 11
INSPIREASE RESERVOIR BAGS ............................... 11
INTEGRILIN .................................................................... 8
INTELENCE .................................................................... 5
INTRON-A....................................................................... 6
INVANZ ........................................................................... 4
INVIRASE ....................................................................... 5
iodoquinol-hc ................................................................. 18
IPOL INACTIVATED IPV .............................................. 18
ipratropium bromide ........................................................ 7
ipratropium bromide (nasal) ............................................ 7
irinotecan hcl ................................................................... 6
iron dextran ..................................................................... 8
ISENTRESS .................................................................... 5
isoniazid .......................................................................... 5
isoproterenol hcl.............................................................. 7
ISOPTO CARBACHOL ................................................. 13
ISOPTO HOMATROPINE ............................................ 14
ISOSORBIDE................................................................ 17
isosorbide dinitrate .......................................................... 9
isosorbide mononitrate ................................................... 9
isotretinoin ..................................................................... 19
ISTODAX ........................................................................ 6
itraconazole ..................................................................... 5
IXEMPRA KIT ................................................................. 6
IXIARO .......................................................................... 18
J
JAKAFI ............................................................................ 6
JETREA ........................................................................ 14
JEVTANA ........................................................................ 6
K
KADCYLA ....................................................................... 6
KALETRA ........................................................................ 5
KALYDECO .................................................................. 16
KCENTRA ....................................................................... 8
KCL 0.15%/D5W/LR ..................................................... 12
KENALOG-10 ............................................................... 14
KEPIVANCE ................................................................. 19
KERALYT ...................................................................... 19
ketamine hcl .................................................................. 10
KETAMINE HCL ........................................................... 17
ketoconazole ................................................................... 5
ketoconazole (topical) ................................................... 18
KETO-DIASTIX ............................................................. 12
KETOPROFEN ............................................................. 17
ketorolac tromethamine .................................................. 9
ketorolac tromethamine (ophth) .................................... 13
KEYTRUDA .................................................................... 6
KINERET ...................................................................... 16
KINRIX .......................................................................... 18
KOGENATE FS .............................................................. 8
K-PHOS ........................................................................ 12
K-PHOS MF .................................................................. 12
KYPROLIS ...................................................................... 6
ibuprofen ......................................................................... 9
ibutilide fumarate ............................................................. 9
idarubicin hcl ................................................................... 6
ifosfamide ........................................................................ 6
IFOSFAMIDE/MESNA .................................................... 6
IMBRUVICA .................................................................... 6
imipramine hcl ............................................................... 11
imiquimod ...................................................................... 19
IMOVAX RABIES (H.D.C.V.) ........................................ 18
INCIVEK .......................................................................... 5
indapamide .................................................................... 12
indigotindisulfonate sodium ........................................... 11
indomethacin ................................................................... 9
INDOMETHACIN .......................................................... 17
L
indomethacin sodium ...................................................... 9
INFANRIX ...................................................................... 18
labetalol hcl ..................................................................... 8
INFERGEN ...................................................................... 5
LACRISERT .................................................................. 14
INFUMORPH 200 ........................................................... 9
lactated ringer's ............................................................. 12
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lactated ringer's (irrigation) ............................................ 12
LACTIC ACID ................................................................ 17
LACTOSE...................................................................... 17
LACTOSE MONOHYDRATE ........................................ 17
lactulose ........................................................................ 12
lactulose (encephalopathy) ........................................... 12
lamivudine ....................................................................... 5
lamivudine-zidovudine ..................................................... 5
lamotrigine ..................................................................... 10
LANTUS ........................................................................ 15
L-ARGININE .................................................................. 17
latanoprost..................................................................... 13
L-CITRULLINE .............................................................. 17
leflunomide .................................................................... 16
LETAIRIS ........................................................................ 9
letrozole ........................................................................... 6
leucovorin calcium ......................................................... 16
LEUKERAN ..................................................................... 6
LEUKINE ......................................................................... 8
leuprolide acetate ............................................................ 6
levetiracetam ................................................................. 10
LEVITRA ......................................................................... 9
levobunolol hcl............................................................... 13
levocarnitine (metabolic modifiers)................................ 16
levofloxacin...................................................................... 4
levofloxacin in d5w .......................................................... 4
levonorgestrel & eth estradiol........................................ 11
levonorgestrel-eth estradiol (triphasic) .......................... 15
levothyroxine sodium .................................................... 16
LEVULAN KERASTICK ................................................ 19
LEXISCAN..................................................................... 12
LEXIVA ............................................................................ 5
lidocaine ........................................................................ 19
lidocaine hcl................................................................... 19
lidocaine hcl (cardiac) ..................................................... 9
lidocaine hcl (local anesth.) ........................................... 16
lidocaine hcl (mouth-throat)........................................... 14
LIDOCAINE HCL MONOHYDRATE ............................. 17
lidocaine in d5w ............................................................... 9
lidocaine w/ epinephrine ................................................ 16
lidocaine-prilocaine ....................................................... 19
liothyronine sodium ....................................................... 16
lisinopril ........................................................................... 9
lisinopril & hydrochlorothiazide........................................ 9
L-ISOLEUCINE ............................................................. 17
LITHIUM ........................................................................ 10
lithium carbonate ........................................................... 10
LITHOSTAT................................................................... 12
LMD 10% DEXTROSE 5% ........................................... 12
LMD 10% SODIUM CHLORIDE 0 .9% ......................... 12
LODOSYN ..................................................................... 10
lorazepam...................................................................... 10
losartan potassium .......................................................... 9
losartan potassium & hydrochlorothiazide ...................... 9
lovastatin ......................................................................... 8
LOVENOX ....................................................................... 8
loxapine succinate ......................................................... 11
L-PROLINE ................................................................... 17
LUCENTIS..................................................................... 14
LUMIGAN ...................................................................... 13
LUPRON DEPOT ............................................................ 6
LUPRON DEPOT-PED ................................................... 6
L-VALINE ...................................................................... 17
LYSODREN .................................................................... 6
M
M.T.E.-5 CONCENTRATE ............................................ 12
MACUGEN .................................................................... 14
magnesium sulfate ........................................................ 10
MAGNESIUM SULFATE IN D5W ................................. 12
MAGNEVIST ................................................................. 12
MAKENA ....................................................................... 15
malathion ...................................................................... 18
MANGANESE TRACE METAL..................................... 13
mannitol ........................................................................ 12
MAPROTILINE HCL ..................................................... 11
MATULANE .................................................................... 6
MEBENDAZOLE ............................................................. 4
meclizine hcl ................................................................. 14
MECLOFENAMATE SODIUM ........................................ 9
medroxyprogesterone acetate ...................................... 15
medroxyprogesterone acetate (contraceptive) ............. 15
mefenamic acid ............................................................... 9
mefloquine hcl ................................................................. 5
megestrol acetate ........................................................... 6
MEKINIST ....................................................................... 6
meloxicam ....................................................................... 9
melphalan hcl .................................................................. 6
MENACTRA .................................................................. 18
MENOMUNE-A/C/Y/W-135 .......................................... 18
MENOPUR .................................................................... 15
meperidine hcl................................................................. 9
mepivacaine hcl ............................................................ 16
mercaptopurine ............................................................... 6
meropenem ..................................................................... 4
mesalamine................................................................... 14
mesna ........................................................................... 16
metaproterenol sulfate .................................................... 7
metformin hcl ................................................................ 15
methadone hcl ................................................................ 9
METHADONE HCL ....................................................... 17
methazolamide.............................................................. 14
methenamine hippurate .................................................. 6
methimazole .................................................................. 16
methocarbamol ............................................................... 7
methotrexate sodium ...................................................... 6
METHYLCELLULOSE .................................................. 17
methyldopa ..................................................................... 9
METHYLDOPATE HCL .................................................. 9
methylene blue (antidote) ............................................. 16
methylergonovine maleate ............................................ 16
methylphenidate hcl ...................................................... 10
methylprednisolone ....................................................... 15
methylprednisolone acetate .......................................... 15
methylprednisolone sod succ ....................................... 15
metoclopramide hcl ....................................................... 14
METOCLOPRAMIDE HCL MONOHY DRATE ............. 17
metolazone ................................................................... 12
METOPIRONE .............................................................. 12
metoprolol & hydrochlorothiazide ................................... 8
metoprolol tartrate ........................................................... 8
metronidazole ................................................................. 5
METRONIDAZOLE ....................................................... 17
metronidazole (topical) ................................................. 18
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metronidazole in nacl ...................................................... 5
metronidazole vaginal ................................................... 18
mexiletine hcl................................................................... 9
midazolam hcl ............................................................... 10
midodrine hcl ................................................................... 7
MIFEPREX .................................................................... 16
milrinone in dextrose ....................................................... 9
milrinone lactate .............................................................. 9
minocycline hcl ................................................................ 4
minoxidil .......................................................................... 9
MIOCHOL-E .................................................................. 14
MIRENA ........................................................................ 15
mirtazapine .................................................................... 11
misoprostol .................................................................... 14
mitomycin ........................................................................ 6
mitoxantrone hcl .............................................................. 6
M-M-R II W/DILUENT 10 DOS E .................................. 18
mometasone furoate ..................................................... 19
montelukast sodium ...................................................... 17
morphine sulfate .............................................................. 9
MORPHINE SULFATE .................................................. 17
MORPHINE SULFATE IN DEXTR OSE 5% ................... 9
moxifloxacin hcl ............................................................... 4
MULTIHANCE ............................................................... 12
multiple vitamin.............................................................. 19
mupirocin ....................................................................... 18
MUSTARGEN ................................................................. 6
mycophenolate mofetil .................................................. 16
MYLERAN ....................................................................... 6
MYOBLOC .................................................................... 16
MYOZYME .................................................................... 13
MYTELASE ..................................................................... 7
N
neostigmine methylsulfate .............................................. 7
NEUMEGA ...................................................................... 8
NEUPOGEN ................................................................... 8
nevirapine ....................................................................... 5
NEXAVAR ....................................................................... 6
NEXPLANON ................................................................ 15
niacin ............................................................................. 19
nicardipine hcl ................................................................. 8
nicotine ............................................................................ 7
nicotine polacrilex ........................................................... 7
nifedipine ......................................................................... 9
nimodipine ....................................................................... 9
nitrofurantoin ................................................................... 6
nitrofurantoin macrocrystal ............................................. 6
nitrofurantoin monohyd macro ........................................ 6
nitroglycerin ..................................................................... 9
nitroglycerin in d5w ......................................................... 9
NITROPRESS................................................................. 9
NORDIPEN 5 INJECTION DEVI CE ............................ 11
NORDITROPIN FLEXPRO ........................................... 15
norepinephrine bitartrate ................................................. 7
norethin acet & estrad-fe .............................................. 15
norethindrone & eth estradiol ........................................ 15
norethindrone (contraceptive) ....................................... 15
norethindrone acet & eth estra ..................................... 15
norethindrone acetate ................................................... 15
norethindrone-eth estradiol (triphasic) .......................... 15
norgestimate-ethinyl estradiol ....................................... 15
norgestimate-ethinyl estradiol (triphasic) ...................... 15
norgestrel & ethinyl estradiol ........................................ 15
nortriptyline hcl .............................................................. 11
NORVIR .......................................................................... 5
NOVOSEVEN RT ........................................................... 8
NUVARING ................................................................... 15
nystatin ............................................................................ 5
nystatin (mouth-throat) .................................................... 5
nystatin (topical) ............................................................ 18
nystatin-triamcinolone ................................................... 19
NABI-HB ........................................................................ 18
nabumetone .................................................................... 9
nadolol ............................................................................. 8
nafcillin sodium ................................................................ 4
NAGLAZYME ................................................................ 13
O
nalbuphine hcl ................................................................. 9
octreotide acetate ......................................................... 16
NALLPEN ISO-OSMOTIC IN DE XTROSE .................... 4
OFIRMEV ........................................................................ 9
naloxone hcl .................................................................. 10
ofloxacin (ophth) ........................................................... 13
naltrexone hcl ................................................................ 10
NAMENDA .................................................................... 10
ofloxacin (otic) ............................................................... 13
NAPHAZOLINE HCL ..................................................... 14
olanzapine ..................................................................... 11
naproxen ......................................................................... 9
omeprazole ................................................................... 14
naproxen sodium ............................................................. 9
OMNIPAQUE ................................................................ 12
naratriptan hcl................................................................ 10
ONCASPAR .................................................................... 6
NAROPIN ...................................................................... 16
ondansetron .................................................................. 14
NEBUPENT ..................................................................... 5
ondansetron hcl ............................................................ 14
NECON 1/50-28 ............................................................ 15
ONETOUCH ULTRA BLUE .......................................... 12
NECON 10/11-28 .......................................................... 15
ONETOUCH ULTRA MINI ............................................ 11
nefazodone hcl .............................................................. 11
OPANA ........................................................................... 9
NEMBUTAL ................................................................... 10
ophthalmic irrigation solution - intraocular .................... 14
neomycin sulfate ............................................................. 4
OPIUM TINCTURE (PAREGORIC ) ............................. 14
NEOMYCIN SULFATE .................................................. 17
OPSUMIT ...................................................................... 17
neomycin/polymyxin b gu .............................................. 18
ORAP ............................................................................ 11
neomycin-bacitracin zn-polymyxin ................................ 13
ORENCIA ...................................................................... 16
neomycin-polymy-dexameth ......................................... 13
ORTHO DIAPHRAGM ALL-FLEX/ 65MM .................... 11
neomycin-polymyxin-gramicidin .................................... 13
oxacillin sodium............................................................... 4
neomycin-polymyxin-hc (otic)........................................ 13
oxaliplatin ........................................................................ 6
NEOPROFEN.................................................................. 9
oxandrolone .................................................................. 15
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oxazepam ...................................................................... 10
oxcarbazepine ............................................................... 10
OXSORALEN ................................................................ 19
OXSORALEN ULTRA ................................................... 19
oxybutynin chloride ....................................................... 19
oxycodone hcl ................................................................. 9
oxycodone w/ acetaminophen......................................... 9
oxytocin ......................................................................... 16
OXYTROL ..................................................................... 19
P
PHISOHEX ................................................................... 18
PHOSPHOLINE IODIDE .............................................. 14
PHYSOSTIGMINE SALICYLATE ................................... 7
phytonadione ................................................................ 19
pilocarpine hcl ............................................................... 14
pilocarpine hcl (oral)........................................................ 7
pioglitazone hcl ............................................................. 15
piperacillin sodium-tazobactam sodium .......................... 4
PLAN B ONE-STEP ...................................................... 15
PLASMA-LYTE A .......................................................... 13
PLASMANATE ................................................................ 8
PLURONIC F127 .......................................................... 17
PNEUMOVAX 23/5 DOSE ............................................ 18
PODOCON 25 IN BENZOIN TIN CTURE .................... 19
podofilox ........................................................................ 19
PODOPHYLLIN RESIN ................................................ 17
POLYETHYLENE GLYCOL 400................................... 17
POLYETHYLENE GLYCOL 8000................................. 17
polymyxin b-trimethoprim .............................................. 13
polysaccharide iron complex .......................................... 8
POMALYST .................................................................... 6
PONTOCAINE .............................................................. 19
pot & sod citrates w/citric ac ......................................... 12
POTABA ....................................................................... 19
potassium acetate ......................................................... 13
potassium bicarbonate .................................................. 13
potassium chloride ........................................................ 13
potassium chloride in dextrose ..................................... 13
potassium chloride in dextrose & sodium chloride ....... 13
potassium chloride in nacl ............................................ 13
potassium chloride microencapsulated crystals cr ....... 13
potassium citrate (alkalinizer) ....................................... 12
potassium citrate-citric acid .......................................... 12
potassium phosphate dibasic ....................................... 13
pramipexole dihydrochloride ......................................... 10
PRAMOSONE............................................................... 19
pravastatin sodium .......................................................... 8
prazosin hcl ..................................................................... 8
PRECEDEX .................................................................. 10
prednisolone ................................................................. 15
prednisolone acetate (ophth) ........................................ 13
PREDNISOLONE SODIUM PHOSP HATE ................. 13
prednisolone sodium phosphate ................................... 15
prednisone .................................................................... 15
PREMARIN ................................................................... 15
PREVNAR 13................................................................ 18
PREZISTA ...................................................................... 5
PRIFTIN .......................................................................... 5
PRIMAQUINE PHOSPHATE .......................................... 5
PRIMAXIN IV .................................................................. 4
primidone ...................................................................... 10
PRIMSOL ........................................................................ 4
probenecid .................................................................... 13
PROCAINAMIDE HCL .................................................... 9
prochlorperazine ........................................................... 11
prochlorperazine edisylate ............................................ 11
prochlorperazine maleate ............................................. 11
PROCRIT ........................................................................ 8
PROCTOFOAM HC ...................................................... 19
PROFERRIN ES ............................................................. 8
PROFERRIN-FORTE ..................................................... 8
PROFILNINE SD ............................................................ 8
paclitaxel ......................................................................... 6
pamidronate disodium ................................................... 16
pancuronium bromide ..................................................... 7
pantoprazole sodium ..................................................... 14
papaverine hcl ................................................................. 9
PAPAVERINE HCL ....................................................... 17
paromomycin sulfate ....................................................... 5
paroxetine hcl ................................................................ 11
ped multivitamins w/fl & iron.......................................... 19
PEDIARIX ...................................................................... 18
pediatric multiple vitamin w/ c ....................................... 19
pediatric multiple vitamins w/ iron ................................. 19
pediatric multivitamins w/fl ............................................ 19
PEDIATRIC SMALL MASK ........................................... 11
pediatric vitamins acd fluoride & iron ............................ 19
pediatric vitamins acd w/ fluoride .................................. 19
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........ 14
PEGASYS ....................................................................... 5
PEG-INTRON .................................................................. 5
penicillin g potassium ...................................................... 4
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE ................................................................. 4
PENICILLIN G PROCAINE ............................................. 4
PENICILLIN G SODIUM ................................................. 4
penicillin v potassium ...................................................... 4
PENLET II AUTOMATIC BLOOD SAMPLER ............... 11
pentazocine w/ naloxone ................................................. 9
PENTETATE CALCIUM TRISODI UM ......................... 14
PENTETATE ZINC TRISODIUM .................................. 14
pentostatin ....................................................................... 6
pentoxifylline.................................................................... 8
PERJETA ........................................................................ 6
permethrin ..................................................................... 18
perphenazine................................................................. 11
PERPHENAZINE/AMITRIPTYLIN E ............................. 11
phenelzine sulfate ......................................................... 11
PHENEX-1 .................................................................... 12
phenobarbital................................................................. 10
PHENOBARBITAL ........................................................ 17
PHENOBARBITAL SODIUM......................................... 10
phenobarbital-hyoscyamine-atropine-scopolamine ........ 7
PHENOL........................................................................ 19
PHENTOLAMINE MESYLATE........................................ 7
phenyleph-promethazine w/ cod ................................... 17
phenylephrine hcl (ophth) .............................................. 14
phenylephrine hcl (pressors) ........................................... 7
phenylephrine-chlorphen-dm ........................................ 17
PHENYLHISTINE DH ................................................... 17
phenytoin ....................................................................... 10
phenytoin sodium .......................................................... 10
phenytoin sodium extended .......................................... 10
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progesterone ................................................................. 15
progesterone micronized ............................................... 15
PROGESTERONE MICRONIZED ................................ 17
PROGESTERONE WETTABLE ................................... 17
PROGLYCEM ................................................................. 9
PROLASTIN .................................................................. 13
PROLEUKIN.................................................................... 6
PROMACTA .................................................................... 8
promethazine hcl ............................................................. 6
promethazine w/codeine ............................................... 17
promethazine-dm .......................................................... 17
propafenone hcl .............................................................. 9
PROPANTHELINE BROMIDE ........................................ 7
proparacaine hcl ............................................................ 14
propofol ......................................................................... 10
propranolol hcl ................................................................. 8
PROPYLENE GLYCOL ................................................. 17
propylthiouracil .............................................................. 16
PROQUAD .................................................................... 18
PROSTIGMIN.................................................................. 7
PROTAMINE SULFATE .................................................. 8
protriptyline hcl .............................................................. 11
pseudoephedrine w/ codeine-gg ................................... 17
PULMOZYME................................................................ 13
pyrazinamide ................................................................... 5
pyridostigmine bromide ................................................... 7
PYRIDOXINE HCL ........................................................ 19
RIMSO-50 ..................................................................... 16
risperidone .................................................................... 11
RITUXAN ........................................................................ 6
rizatriptan benzoate ...................................................... 10
rocuronium bromide ........................................................ 7
ropinirole hydrochloride ................................................ 10
ROTARIX ...................................................................... 18
ROTATEQ..................................................................... 18
S
SABRIL ......................................................................... 10
SALICYLIC ACID .......................................................... 17
saline, bacteriostatic ..................................................... 13
salsalate .......................................................................... 9
SANDIMMUNE ............................................................. 16
SANTYL ........................................................................ 19
SCOPOLAMINE HYDROBROMIDE............................... 7
selegiline hcl ................................................................. 10
SELENIUM .................................................................... 13
selenium sulfide ............................................................ 18
SELZENTRY ................................................................... 5
SENSIPAR .................................................................... 16
SEREVENT DISKUS ...................................................... 8
SEROMYCIN .................................................................. 5
SEROSTIM ................................................................... 16
sertraline hcl .................................................................. 11
sildenafil citrate (pulmonary hypertension) ..................... 9
silver sulfadiazine.......................................................... 18
Q
simvastatin ...................................................................... 8
sirolimus ........................................................................ 16
QUELICIN ....................................................................... 7
sodium acetate.............................................................. 12
quetiapine fumarate ...................................................... 11
SODIUM BENZOATE ................................................... 17
QUINACRINE HCL ....................................................... 17
sodium bicarbonate....................................................... 12
quinidine gluconate ......................................................... 9
sodium chloride ............................................................. 19
quinidine sulfate .............................................................. 9
sodium chloride (gu irrigant) ......................................... 12
QVAR ............................................................................ 15
sodium chloride (inhalant) ............................................. 17
sodium chloride flush .................................................... 13
R
sodium citrate & citric acid ............................................ 12
RABAVERT ................................................................... 18
SODIUM EDECRIN ...................................................... 12
raloxifene hcl ................................................................. 15
sodium fluoride.............................................................. 16
ranitidine hcl .................................................................. 14
sodium fluoride (dental) ................................................ 16
RECOTHROM ................................................................. 8
sodium phosphate......................................................... 13
REFLUDAN ..................................................................... 8
sodium polystyrene sulfonate ....................................... 12
RELENZA DISKHALER .................................................. 5
sodium thiosulfate ......................................................... 14
REMICADE ................................................................... 16
SOLIRIS ........................................................................ 16
REMODULIN ................................................................... 9
SORBITOL .................................................................... 14
RENVELA...................................................................... 12
SORIATANE ................................................................. 16
REOPRO ......................................................................... 8
sotalol hcl ........................................................................ 8
RESCRIPTOR ................................................................. 5
sotalol hcl (afib/afl) .......................................................... 8
RESERPINE.................................................................... 9
SOTRADECOL ............................................................... 9
RESTASIS..................................................................... 13
SOVALDI ........................................................................ 5
RETIN-A MICRO ........................................................... 19
SPIRIVA HANDIHALER ................................................. 7
RETISERT..................................................................... 13
spironolactone................................................................. 9
REVLIMID ....................................................................... 6
spironolactone & hydrochlorothiazide ............................. 9
REYATAZ ........................................................................ 5
SPRYCEL ....................................................................... 6
ribavirin (hepatitis c) ........................................................ 5
SQUARIC ACID DIBUTYLESTER................................ 17
RIDAURA ...................................................................... 14
SSKI .............................................................................. 16
rifabutin ............................................................................ 5
stavudine ......................................................................... 5
RIFAMATE ...................................................................... 5
STIVARGA ...................................................................... 7
rifampin............................................................................ 5
STREPTOMYCIN SULFATE .......................................... 4
riluzole ........................................................................... 10
STRIBILD ........................................................................ 5
rimantadine hydrochloride ............................................... 5
sucralfate ...................................................................... 14
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sufentanil citrate .............................................................. 9
sulfacetamide sodium (ophth) ....................................... 13
sulfacetamide sodium w/ sulfur ..................................... 19
sulfacetamide sodium-sulfur w/ sunscreens ................. 19
sulfacetamide sod-prednisolone ................................... 13
SULFADIAZINE............................................................... 4
sulfamethoxazole-trimethoprim ....................................... 4
SULFAMYLON .............................................................. 18
sulfasalazine.................................................................... 4
SULFUR PRECIPITATED............................................. 17
sulindac ........................................................................... 9
SUMATRIPTAN............................................................. 10
sumatriptan succinate ................................................... 10
SUPARTZ...................................................................... 16
SUPRANE ..................................................................... 10
SUPRAX .......................................................................... 4
SURMONTIL ................................................................. 11
SURVANTA INTRATRACHEAL.................................... 17
SUSTIVA ......................................................................... 5
SUTENT .......................................................................... 7
SYNAGIS ........................................................................ 5
SYNAREL...................................................................... 15
SYNERCID ...................................................................... 4
T
TIKOSYN ........................................................................ 9
timolol maleate (ophth) ................................................. 14
TIVICAY .......................................................................... 5
tizanidine hcl ................................................................... 7
TNKASE .......................................................................... 8
TOBRADEX .................................................................. 13
tobramycin ...................................................................... 4
tobramycin (ophth) ........................................................ 13
tobramycin sulfate ........................................................... 4
TOLBUTAMIDE ............................................................ 15
topiramate ..................................................................... 10
topotecan hcl................................................................... 7
TORISEL ......................................................................... 7
torsemide ...................................................................... 12
TRAC .............................................................................. 6
trace minerals (cr-cu-mn-zn)......................................... 13
TRACLEER ..................................................................... 9
tramadol hcl .................................................................. 10
tramadol-acetaminophen .............................................. 10
TRANEXAMIC ACID ..................................................... 17
TRANSDERM-SCOP .................................................... 14
tranylcypromine sulfate ................................................. 11
trazodone hcl ................................................................ 11
TREANDA ....................................................................... 7
TRECATOR .................................................................... 5
tretinoin ......................................................................... 19
tretinoin (chemotherapy) ................................................. 7
TRIAMCINOLONE ACETONIDE .................................. 17
triamcinolone acetonide (mouth) .................................. 19
triamcinolone acetonide (topical) .................................. 19
triamterene & hydrochlorothiazide ................................ 12
TRI-CHLOR .................................................................. 16
trifluoperazine hcl .......................................................... 11
trifluridine ...................................................................... 13
trihexyphenidyl hcl ........................................................ 10
trimethoprim .................................................................... 6
TRISENOX ...................................................................... 7
tropicamide ................................................................... 14
trospium chloride........................................................... 19
TRUVADA ....................................................................... 5
TRUZONE PEAK FLOW METER ................................. 11
TUBERSOL ................................................................... 12
TWINRIX ....................................................................... 18
TYKERB .......................................................................... 7
TYPHIM VI .................................................................... 18
TYSABRI ....................................................................... 16
TYVASO ......................................................................... 9
TABLOID ......................................................................... 7
tacrolimus ...................................................................... 16
tacrolimus (topical) ........................................................ 19
TAFINLAR ....................................................................... 7
TAMIFLU ......................................................................... 5
tamoxifen citrate .............................................................. 7
tamsulosin hcl.................................................................. 8
TARCEVA ....................................................................... 7
TARGRETIN.................................................................... 7
TASIGNA......................................................................... 7
TAXOTERE ..................................................................... 7
TAZORAC ..................................................................... 19
temazepam.................................................................... 10
temozolomide .................................................................. 7
terazosin hcl .................................................................... 8
terbinafine hcl .................................................................. 5
terbutaline sulfate ............................................................ 8
TESTOSTERONE ......................................................... 17
testosterone cypionate .................................................. 15
testosterone enanthate ................................................. 15
TETRACAINE HCL ....................................................... 16
tetracaine hcl (ophth) .................................................... 14
tetracycline hcl................................................................. 4
U
THALOMID .................................................................... 16
THAM ............................................................................ 12
ULTIVA ......................................................................... 10
theophylline ................................................................... 19
UREA ............................................................................ 17
theophylline in dextrose ................................................ 19
ursodiol ......................................................................... 14
THERACYS ................................................................... 18
thiamine hcl ................................................................... 19
V
THIOLA ......................................................................... 16
valacyclovir hcl ................................................................ 5
thioridazine hcl .............................................................. 11
valganciclovir hcl ............................................................. 5
THIOTEPA ...................................................................... 7
valproate
sodium........................................................... 10
thiothixene ..................................................................... 11
valproic acid .................................................................. 10
THROMBATE III W/10 ML STE RILE WATER ............... 8
vancomycin hcl ............................................................... 4
THROMBIN-JMI DILUENT .............................................. 8
VANCOMYCIN HCL IN DEXTROS E ............................. 4
THYMOL ....................................................................... 17
VANDETANIB ................................................................. 7
THYROGEN .................................................................. 12
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VARIVAX ....................................................................... 18
VARIZIG ........................................................................ 18
vasopressin ................................................................... 15
VECTICAL ..................................................................... 19
vecuronium bromide ........................................................ 7
VELCADE........................................................................ 7
venlafaxine hcl............................................................... 11
VENOFER ....................................................................... 8
VENTAVIS....................................................................... 9
verapamil hcl ................................................................... 9
VERAPAMIL HCL ......................................................... 17
VEXOL .......................................................................... 13
VICTRELIS ...................................................................... 5
VIDAZA ........................................................................... 7
VINBLASTINE SULFATE................................................ 7
vincristine sulfate ............................................................. 7
vinorelbine tartrate .......................................................... 7
VIRACEPT ...................................................................... 5
VIRAZOLE....................................................................... 5
VIREAD ........................................................................... 5
VISTIDE .......................................................................... 5
VISUDYNE .................................................................... 14
VITRASERT .................................................................. 13
VIVOTIF BERNA ........................................................... 18
VORAXAZE ................................................................... 13
voriconazole .................................................................... 5
VOTRIENT ...................................................................... 7
VPRIV ............................................................................ 13
VUMON ........................................................................... 7
VYVANSE ..................................................................... 10
W
warfarin sodium ............................................................... 8
water for injection, sterile .............................................. 16
water for irrigation, sterile .............................................. 12
WIDE-SEAL SILICONE DIAPHR AGM KIT 60 ............. 11
WILATE......................................................................... 18
X
XALKORI ........................................................................ 7
XERAC AC .................................................................... 19
XIFAXAN ......................................................................... 5
XOLAIR ......................................................................... 17
XTANDI ........................................................................... 7
XYNTHA ......................................................................... 8
Y
YERVOY ......................................................................... 7
YF-VAX ......................................................................... 18
YODOXIN ....................................................................... 5
Z
ZANOSAR ....................................................................... 7
ZANTAC ........................................................................ 14
ZELBORAF ..................................................................... 7
zidovudine ....................................................................... 6
ZINACEF IN ISO-OSMOTIC DEXTROSE ...................... 5
ZINACEF IN ISO-OSMOTIC DILUENT .......................... 5
zinc sulfate .................................................................... 13
ZINC SULFATE HEPTAHYDRATE .............................. 17
ZINC TRACE METAL ................................................... 13
ziprasidone hcl .............................................................. 11
zoledronic acid .............................................................. 16
zolpidem tartrate ........................................................... 10
ZOSTAVAX ................................................................... 18
ZOSYN ............................................................................ 5
ZYKADIA ......................................................................... 7
ZYMAXID ...................................................................... 13
ZYTIGA ........................................................................... 7
ZYVOX ............................................................................ 5
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California Member Services
24 hours a day, seven days a week (closed holidays)
1-800-464-4000 English
1- 800-788-0616 Spanish
1-800-757-7585 Chinese dialects
1-800-777-1370 TTY for the hearing/speech impaired
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