IEHP Medi-Cal Formulary Maintenance Drug List
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- Anna Wilcox
- 6 years ago
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1 IEHP Medi-Cal Formulary Maintenance Drug List The following formulary medications may be approvable up to a three-month supply. FDA-approved generic products must be used if available. Brand name products may be covered through the prior authorization process. BRAND GENERIC STRENGTH DOSAGE ACARBOSE ACARBOSE 25 MG TABLET ACARBOSE ACARBOSE 50 MG TABLET ACARBOSE ACARBOSE 100 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 500 MG CAPSULE ER ACID REDUCER RANITIDINE HCL 75 MG TABLET ACYCLOVIR ACYCLOVIR 800 MG TABLET ACYCLOVIR ACYCLOVIR 200 MG CAPSULE ACYCLOVIR ACYCLOVIR 400 MG TABLET ACYCLOVIR ACYCLOVIR 200 MG/5ML ORAL SUSP AGGRENOX ASPIRIN/DIPYRIDAMOLE 25MG- 200MG CPMP 12HR ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 4 MG TAB ER 12H ALBUTEROL SULFATE ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG/5 ML SYRUP ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 255_FormularyMaintenance_March2015 Page 1 of 47
2 ALBUTEROL SULFATE ALBUTEROL SULFATE 8 MG TAB ER 12H ALDACTAZIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 50 MG-50MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 40 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 35 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 70 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG TABLET ALL DAY ALLERGY CETIRIZINE HCL 5 MG TAB CHEW ALL DAY ALLERGY CETIRIZINE HCL 10 MG TAB CHEW ALLOPURINOL ALLOPURINOL 100 MG TABLET ALLOPURINOL ALLOPURINOL 300 MG TABLET ALORA ESTRADIOL 0.1MG/24HR PATCH TDSW ALORA ESTRADIOL 0.05MG/24H PATCH TDSW ALORA ESTRADIOL 0.05MG/24H PATCH TDSW ALORA ESTRADIOL.075MG/24H PATCH TDSW ALORA ESTRADIOL 0.1MG/24HR PATCH TDSW ALORA ESTRADIOL.075MG/24H PATCH TDSW ALORA ESTRADIOL.025MG/24H PATCH TDSW ALORA ESTRADIOL.025MG/24H PATCH TDSW ALORA ESTRADIOL 0.1MG/24HR PATCH TDSW ALORA ESTRADIOL 0.05MG/24H PATCH TDSW AMIODARONE HCL AMIODARONE HCL 200 MG TABLET 255_FormularyMaintenance_March2015 Page 2 of 47
3 AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG TABLET AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-20MG CAPSULE AMLODIPINE BESYLATE/BENAZEPRIL HCL 2.5MG-10MG CAPSULE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-10 MG CAPSULE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-20 MG CAPSULE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-40 MG CAPSULE AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-40MG CAPSULE AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE 15 MG TABLET AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE 5 MG TABLET 255_FormularyMaintenance_March2015 Page 3 of 47
4 SULF-ASPARTATE AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE 20 MG TABLET 30 MG TABLET 7.5 MG TABLET 12.5 MG TABLET 10 MG TABLET ANTABUSE DISULFIRAM 500 MG TABLET ANTABUSE DISULFIRAM 250 MG TABLET ANTABUSE DISULFIRAM 500 MG TABLET ANTI-DIARRHEAL LOPERAMIDE HCL 1 MG/5 ML LIQUID APIDRA INSULIN GLULISINE 100/ML VIAL APIDRA SOLOSTAR INSULIN GLULISINE 100/ML INSULN PEN ARIMIDEX ANASTROZOLE 1 MG TABLET ARMOUR THYROID THYROID,PORK 30 MG TABLET ARMOUR THYROID THYROID,PORK 120 MG TABLET ARMOUR THYROID THYROID,PORK 180 MG TABLET ARMOUR THYROID THYROID,PORK 15 MG TABLET ARMOUR THYROID THYROID,PORK 240 MG TABLET 255_FormularyMaintenance_March2015 Page 4 of 47
5 ARMOUR THYROID THYROID,PORK 90 MG TABLET ARMOUR THYROID THYROID,PORK 60 MG TABLET ARMOUR THYROID THYROID,PORK 300 MG TABLET ASMANEX MOMETASONE FUROATE 110MCG(30) AER POW BA ASMANEX MOMETASONE FUROATE 220MCG 120 AER POW BA ASMANEX MOMETASONE FUROATE 220MCG 120 AER POW BA ASMANEX MOMETASONE FUROATE 220MCG 120 AER POW BA ATENOLOL ATENOLOL 50 MG TABLET ATENOLOL ATENOLOL 100 MG TABLET ATENOLOL ATENOLOL 25 MG TABLET ATENOLOL-CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 100MG- 25MG TABLET ATENOLOL-CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG TABLET ATROPINE SULFATE ATROPINE SULFATE 1 % OINT. (G) ATROPINE SULFATE ATROPINE SULFATE/PF 1 % DROPS ATROVENT HFA IPRATROPIUM BROMIDE 17MCG HFA AER AD AZATHIOPRINE AZATHIOPRINE 50 MG TABLET 255_FormularyMaintenance_March2015 Page 5 of 47
6 AZELASTINE HCL AZELASTINE HCL 137 MCG SPRAY/PUMP AZOPT BRINZOLAMIDE 1 % DROPS SUSP AZURETTE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL 21-5 TABLET BACLOFEN BACLOFEN 20 MG TABLET BACLOFEN BACLOFEN 10 MG TABLET BALZIVA NORETHINDRONE-ETHINYL ESTRADIOL TABLET BENAZEPRIL HCL BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20-25MG TABLET BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BETAXOLOL HCL BETAXOLOL HCL 0.5 % DROPS BETIMOL TIMOLOL 0.5 % DROPS BETIMOL TIMOLOL 0.25 % DROPS BETOPTIC S BETAXOLOL HCL 0.25 % DROPS SUSP 255_FormularyMaintenance_March2015 Page 6 of 47
7 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.15 % DROPS BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.2 % DROPS BUDESONIDE BUDESONIDE 0.5 MG/2ML AMPUL-NEB BUDESONIDE BUDESONIDE 0.25MG/2ML AMPUL-NEB BUMETANIDE BUMETANIDE 1 MG TABLET BUMETANIDE BUMETANIDE 0.5 MG TABLET BUMETANIDE BUMETANIDE 2 MG TABLET BUPROPION HCL BUPROPION HCL 75 MG TABLET BUPROPION HCL BUPROPION HCL 100 MG TABLET BUPROPION HCL SR BUPROPION HCL 200 MG TABLET ER BUPROPION HCL SR BUPROPION HCL 150 MG TABLET ER BUPROPION HCL SR BUPROPION HCL 100 MG TABLET ER BUPROPION XL BUPROPION HCL 150 MG TAB ER 24H BUPROPION XL BUPROPION HCL 300 MG TAB ER 24H BUSPIRONE HCL BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 7.5 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 10 MG TABLET CALCITONIN-SALMON CALCITONIN,SALMON,SYNTHETIC 200/SPRAY SPRAY/PUMP CALCITRIOL CALCITRIOL 0.25 MCG CAPSULE 255_FormularyMaintenance_March2015 Page 7 of 47
8 CALCITRIOL CALCITRIOL 0.5 MCG CAPSULE CALCIUM ACETATE CALCIUM ACETATE 667 MG TABLET CALCIUM ACETATE CALCIUM ACETATE 667 MG CAPSULE CAMRESE LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL (84) TBDSPK 3MO CAPTOPRIL CAPTOPRIL 12.5 MG TABLET CAPTOPRIL CAPTOPRIL 100 MG TABLET CAPTOPRIL CAPTOPRIL 50 MG TABLET CAPTOPRIL CAPTOPRIL 25 MG TABLET CARAFATE SUCRALFATE 1 G/10 ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE CARBAMAZEPINE 200 MG CPMP 12HR CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 300 MG CPMP 12HR CARBAMAZEPINE CARBAMAZEPINE 100 MG CPMP 12HR CARBAMAZEPINE XR CARBAMAZEPINE 400 MG TAB ER 12H CARBAMAZEPINE XR CARBAMAZEPINE 200 MG TAB ER 12H CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 10MG- 100MG CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG- 100MG TABLET TABLET 255_FormularyMaintenance_March2015 Page 8 of 47
9 CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG- 250MG CARBIDOPA-LEVODOPA ER CARBIDOPA/LEVODOPA 50MG- 200MG TABLET TABLET ER CARNITOR SF LEVOCARNITINE 100 MG/ML SOLUTION CARVEDILOL CARVEDILOL MG TABLET CARVEDILOL CARVEDILOL 12.5 MG TABLET CARVEDILOL CARVEDILOL 25 MG TABLET CARVEDILOL CARVEDILOL 6.25 MG TABLET CESIA DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET CETIRIZINE HCL CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL CETIRIZINE HCL 5 MG TABLET CETIRIZINE-PSEUDOEPHEDRINE CETIRIZINE HCL/PSEUDOEPHEDRINE HCL 5 MG-120MG TAB ER 12H CHEMSTRIP K URINE ACETONE TEST,STRIPS STRIP CHILDREN'S ALL DAY ALLERGY CETIRIZINE HCL 1 MG/ML SOLUTION CHILDREN'S ALL DAY ALLERGY CETIRIZINE HCL 1 MG/ML SOLUTION CHILDREN'S WAL-ZYR CETIRIZINE HCL 1 MG/ML SOLUTION CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 250 MG TABLET CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 500 MG TABLET CHLOROTHIAZIDE CHLOROTHIAZIDE 500 MG TABLET CHLOROTHIAZIDE CHLOROTHIAZIDE 250 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 100 MG TABLET 255_FormularyMaintenance_March2015 Page 9 of 47
10 CHLORTHALIDONE CHLORTHALIDONE 25 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 50 MG TABLET CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWDER CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK CILOSTAZOL CILOSTAZOL 50 MG TABLET CILOSTAZOL CILOSTAZOL 100 MG TABLET CIMETIDINE CIMETIDINE 300 MG TABLET CIMETIDINE CIMETIDINE HCL 300 MG/5ML SOLUTION CIMETIDINE CIMETIDINE 200 MG TABLET CIMETIDINE CIMETIDINE 800 MG TABLET CIMETIDINE CIMETIDINE 400 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 20 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 10 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 40 MG TABLET CLARITIN LORATADINE 10 MG TABLET CLARITIN LORATADINE 10 MG TAB RAPDIS CLONAZEPAM CLONAZEPAM 1 MG TABLET CLONAZEPAM CLONAZEPAM 0.5 MG TABLET CLONAZEPAM CLONAZEPAM 2 MG TABLET 255_FormularyMaintenance_March2015 Page 10 of 47
11 CLONIDINE CLONIDINE 0.3MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.1MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.2MG/24HR PATCH TDWK CLONIDINE HCL CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.3 MG TABLET CLONIDINE HCL ER CLONIDINE HCL 0.1 MG TAB ER 12H COLCRYS COLCHICINE 0.6 MG TABLET COMBIVENT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE MCG AER W/ADAP COMBIVENT RESPIMAT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE MCG MIST INHAL CONCERTA METHYLPHENIDATE HCL 54 MG TAB ER 24 CONCERTA METHYLPHENIDATE HCL 36 MG TAB ER 24 CONCERTA METHYLPHENIDATE HCL 27 MG TAB ER 24 CONCERTA METHYLPHENIDATE HCL 18 MG TAB ER 24 CREON LIPASE/PROTEASE/AMYLASE 12K-38K-60 CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 6K-19K-30K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE K CAPSULE DR CROMOLYN SODIUM CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB CYANOCOBALAMIN INJECTION CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL 255_FormularyMaintenance_March2015 Page 11 of 47
12 CYCLOGYL CYCLOPENTOLATE HCL 0.5 % DROPS CYCLOGYL CYCLOPENTOLATE HCL 2 % DROPS CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 1 % DROPS CYPROHEPTADINE HCL CYPROHEPTADINE HCL 4 MG/10 ML SYRUP CYPROHEPTADINE HCL CYPROHEPTADINE HCL 4 MG TABLET DAPSONE DAPSONE 100 MG TABLET DAPSONE DAPSONE 25 MG TABLET DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 400 MG/ML VIAL DESIPRAMINE HCL DESIPRAMINE HCL 50 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 25 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 150 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 10 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 100 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 75 MG TABLET DETROL LA TOLTERODINE TARTRATE 2 MG CAP ER 24H DETROL LA TOLTERODINE TARTRATE 4 MG CAP ER 24H DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 5 MG TABLET DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 10 MG TABLET DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 2.5 MG TABLET DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE 5 MG TABLET 255_FormularyMaintenance_March2015 Page 12 of 47
13 DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE 10 MG TABLET DEXTROAMPHETAMINE SULFATE 5 MG CAPSULE ER DEXTROAMPHETAMINE SULFATE 10 MG CAPSULE ER DEXTROAMPHETAMINE SULFATE 15 MG CAPSULE ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE 5 MG CAP ER 24H 20 MG CAP ER 24H 15 MG CAP ER 24H 25 MG CAP ER 24H 10 MG CAP ER 24H 30 MG CAP ER 24H DICLOFENAC SODIUM DICLOFENAC SODIUM 75 MG TABLET DR DICLOFENAC SODIUM DICLOFENAC SODIUM 50 MG TABLET DR DICLOFENAC SODIUM DICLOFENAC SODIUM 25 MG TABLET DR DICLOFENAC SODIUM ER DICLOFENAC SODIUM 100 MG TAB ER 24H DIGOXIN DIGOXIN 125 MCG TABLET 255_FormularyMaintenance_March2015 Page 13 of 47
14 DIGOXIN DIGOXIN 50 MCG/ML SOLUTION DIGOXIN DIGOXIN 250 MCG TABLET DILANTIN PHENYTOIN 50 MG TAB CHEW DILANTIN PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE DILATRATE-SR ISOSORBIDE DINITRATE 40 MG CAPSULE ER DILTIAZEM 12HR ER DILTIAZEM HCL 120 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 90 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 60 MG CAP ER 12H DILTIAZEM 24HR ER DILTIAZEM HCL 300 MG CAP ER 24H DILTIAZEM 24HR ER DILTIAZEM HCL 120 MG CAP ER 24H DILTIAZEM 24HR ER DILTIAZEM HCL 180 MG CAP ER 24H DILTIAZEM 24HR ER DILTIAZEM HCL 360 MG CAP ER 24H DILTIAZEM 24HR ER DILTIAZEM HCL 240 MG CAP ER 24H DILTIAZEM ER DILTIAZEM HCL 360 MG CAPSULE ER DILTIAZEM ER DILTIAZEM HCL 360 MG CAPSULE ER DILTIAZEM ER DILTIAZEM HCL 420MG CAPSULE ER DILTIAZEM HCL DILTIAZEM HCL 30 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 60 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 90 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 120 MG TABLET DILT-XR DILTIAZEM HCL 240 MG CAP ER DEG 255_FormularyMaintenance_March2015 Page 14 of 47
15 DILT-XR DILTIAZEM HCL 180 MG CAP ER DEG DILT-XR DILTIAZEM HCL 120 MG CAP ER DEG DIURIL CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP DIVALPROEX SODIUM DIVALPROEX SODIUM 250 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG CAP SPRINK DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 500 MG TABLET DR DIVALPROEX SODIUM ER DIVALPROEX SODIUM 500 MG TAB ER 24H DIVALPROEX SODIUM ER DIVALPROEX SODIUM 250 MG TAB ER 24H DONEPEZIL HCL DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL ODT DONEPEZIL HCL 5 MG TAB RAPDIS DONEPEZIL HCL ODT DONEPEZIL HCL 10 MG TAB RAPDIS DORZOLAMIDE HCL DORZOLAMIDE HCL 2 % DROPS DORZOLAMIDE-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEATE /1 DROPS DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 1 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 4 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 2 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 8 MG TABLET DOXEPIN HCL DOXEPIN HCL 75 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 10 MG CAPSULE 255_FormularyMaintenance_March2015 Page 15 of 47
16 DOXEPIN HCL DOXEPIN HCL 25 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 100 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 150 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 50 MG CAPSULE DULOXETINE HCL DULOXETINE HCL 60 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 30 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 20 MG CAPSULE DR DYRENIUM TRIAMTERENE 50 MG CAPSULE EDECRIN ETHACRYNIC ACID 25 MG TABLET EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 25 MEQ TABLET EFF EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 20 MEQ TABLET EFF EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 10 MEQ TABLET EFF ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 5 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 10 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 20 MG TABLET ENULOSE LACTULOSE 10 G/15 ML SOLUTION ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG TABLET ESTRADIOL ESTRADIOL.075MG/24H PATCH TDWK 255_FormularyMaintenance_March2015 Page 16 of 47
17 ESTRADIOL ESTRADIOL 0.06MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 0.1MG/24HR PATCH TDWK ESTRADIOL ESTRADIOL 0.05MG/24H PATCH TDWK ESTRADIOL ESTRADIOL.025MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 2 MG TABLET ESTRADIOL ESTRADIOL 1 MG TABLET ESTRADIOL ESTRADIOL 0.5 MG TABLET ESTRADIOL ESTRADIOL.0375MG/24 PATCH TDWK ESTROGEN & METHYLTESTOSTERONE ESTROGEN- METHYLTESTOSTERONE ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE TABLET ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE MG TABLET ETHAMBUTOL HCL ETHAMBUTOL HCL 100 MG TABLET ETHAMBUTOL HCL ETHAMBUTOL HCL 400 MG TABLET ETHOSUXIMIDE ETHOSUXIMIDE 250 MG/5ML SOLUTION ETHOSUXIMIDE ETHOSUXIMIDE 250 MG CAPSULE ETODOLAC ETODOLAC 400 MG TABLET ETODOLAC ETODOLAC 500 MG TABLET ETODOLAC ETODOLAC 200 MG CAPSULE ETODOLAC ETODOLAC 300 MG CAPSULE FAMOTIDINE FAMOTIDINE 40 MG TABLET FAMOTIDINE FAMOTIDINE 20 MG TABLET 255_FormularyMaintenance_March2015 Page 17 of 47
18 FELODIPINE ER FELODIPINE 5 MG TAB ER 24H FELODIPINE ER FELODIPINE 10 MG TAB ER 24H FELODIPINE ER FELODIPINE 2.5 MG TAB ER 24H FEMCON FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE (21) TAB CHEW FEMHRT NORETHINDRONE ACETATE-ETHINYL ESTRADIOL 1MG-5MCG TABLET FENOFIBRATE FENOFIBRATE,MICRONIZED 67 MG CAPSULE FENOFIBRATE FENOFIBRATE,MICRONIZED 200 MG CAPSULE FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET FENOFIBRATE FENOFIBRATE 160 MG TABLET FENOFIBRATE FENOFIBRATE 54 MG TABLET FENOFIBRATE FENOFIBRATE,MICRONIZED 134MG CAPSULE FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR FINASTERIDE FINASTERIDE 5 MG TABLET FIRST-LANSOPRAZOLE LANSOPRAZOLE 3 MG/ML SUSP RECON FIRST-OMEPRAZOLE OMEPRAZOLE 2 MG/ML SUSP RECON FLOVENT DISKUS FLUTICASONE PROPIONATE 250 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 100 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 50 MCG BLST W/DEV 255_FormularyMaintenance_March2015 Page 18 of 47
19 FLOVENT HFA FLUTICASONE PROPIONATE 220 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 44 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 110 MCG AER W/ADAP FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE 0.1 MG TABLET FLUNISOLIDE FLUNISOLIDE 25 MCG SPRAY FLUNISOLIDE FLUNISOLIDE 29MCG SPRAY FLUOR-A-DAY SODIUM FLUORIDE 2.5 MG/ML DROPS FLUOR-A-DAY SODIUM FLUORIDE 2.5 MG/ML DROPS FLUORITAB SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW FLUORITAB SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW FLUOXETINE HCL FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 20 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 10 MG TABLET FLUOXETINE HCL FLUOXETINE HCL 20 MG TABLET FLUOXETINE HCL FLUOXETINE HCL 20 MG/5 ML SOLUTION FLUOXETINE HCL FLUOXETINE HCL 40 MG CAPSULE FLUTAMIDE FLUTAMIDE 125 MG CAPSULE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP FOCALIN XR DEXMETHYLPHENIDATE HCL 5 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 10 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 20 MG CPBP _FormularyMaintenance_March2015 Page 19 of 47
20 FOCALIN XR DEXMETHYLPHENIDATE HCL 30 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 40 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 15 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 25 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 35 MG CPBP FOLIC ACID FOLIC ACID 1 MG TABLET FOLIC ACID FOLIC ACID 0.4 MG TABLET FORA TEST STRIP BLOOD SUGAR DIAGNOSTIC STRIP FUROSEMIDE FUROSEMIDE 10 MG/ML SOLUTION FUROSEMIDE FUROSEMIDE 40MG/5ML SOLUTION FUROSEMIDE FUROSEMIDE 80 MG TABLET FUROSEMIDE FUROSEMIDE 40 MG TABLET FUROSEMIDE FUROSEMIDE 20 MG TABLET GABAPENTIN GABAPENTIN 300 MG CAPSULE GABAPENTIN GABAPENTIN 100 MG CAPSULE GABAPENTIN GABAPENTIN 400 MG CAPSULE GABAPENTIN GABAPENTIN 800 MG TABLET GABAPENTIN GABAPENTIN 600 MG TABLET GEMFIBROZIL GEMFIBROZIL 600 MG TABLET GIANVI ETHINYL ESTRADIOL/DROSPIRENONE (24) TABLET GLIMEPIRIDE GLIMEPIRIDE 2 MG TABLET 255_FormularyMaintenance_March2015 Page 20 of 47
21 GLIMEPIRIDE GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE GLIMEPIRIDE 4 MG TABLET GLIPIZIDE GLIPIZIDE 10 MG TABLET GLIPIZIDE GLIPIZIDE 5 MG TABLET GLIPIZIDE ER GLIPIZIDE 2.5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 2.5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 10 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 10 MG TAB ER 24 GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL MG TABLET GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL MG TABLET GLYBURIDE GLYBURIDE 5 MG TABLET GLYBURIDE GLYBURIDE 2.5 MG TABLET GLYBURIDE GLYBURIDE 1.25 MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET GUANFACINE HCL GUANFACINE HCL 2 MG TABLET GUANFACINE HCL GUANFACINE HCL 1 MG TABLET 255_FormularyMaintenance_March2015 Page 21 of 47
22 HEARTBURN RELIEF FAMOTIDINE 10 MG TABLET HOMATROPAIRE HOMATROPINE HBR 5 % DROPS HUMALOG INSULIN LISPRO 100/ML INSULN PEN HUMALOG INSULIN LISPRO 100/ML CARTRIDGE HUMALOG INSULIN LISPRO 100/ML VIAL HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 50-50/ML INSULN PEN HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 50-50/ML VIAL HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML INSULN PEN HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML VIAL HUMULIN 70/30 KWIKPEN NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML INSULN PEN HUMULIN NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML VIAL HUMULIN N NPH, HUMAN INSULIN ISOPHANE 100/ML VIAL HUMULIN N NPH, HUMAN INSULIN ISOPHANE 100/ML (3) INSULN PEN HUMULIN R INSULIN REGULAR, HUMAN 500/ML VIAL HUMULIN R INSULIN REGULAR, HUMAN 100/ML VIAL HYDRALAZINE HCL HYDRALAZINE HCL 100 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 50 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 10 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 25 MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG TABLET 255_FormularyMaintenance_March2015 Page 22 of 47
23 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25 MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50 MG TABLET HYDROCORTISONE HYDROCORTISONE 20 MG TABLET HYDROCORTISONE HYDROCORTISONE 10 MG TABLET HYDROCORTISONE HYDROCORTISONE 5 MG TABLET HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200 MG TABLET HYDROXYUREA HYDROXYUREA 500 MG CAPSULE IBUPROFEN IBUPROFEN 100 MG/5ML ORAL SUSP IBUPROFEN IBUPROFEN 200 MG TABLET IBUPROFEN IBUPROFEN 800 MG TABLET IBUPROFEN IBUPROFEN 600 MG TABLET IBUPROFEN IBUPROFEN 200 MG CAPSULE IBUPROFEN IBUPROFEN 400 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 25 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 50 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 10 MG TABLET IMPERIM LOPERAMIDE HCL 2 MG TABLET INDAPAMIDE INDAPAMIDE 1.25 MG TABLET INDAPAMIDE INDAPAMIDE 2.5 MG TABLET 255_FormularyMaintenance_March2015 Page 23 of 47
24 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION ISONIAZID ISONIAZID 300 MG TABLET ISONIAZID ISONIAZID 100 MG TABLET ISONIAZID ISONIAZID 50 MG/5 ML SOLUTION ISOPTO CARBACHOL CARBACHOL 3 % DROPS ISOPTO CARBACHOL CARBACHOL 1.5 % DROPS ISOPTO HOMATROPINE HOMATROPINE HBR 2 % DROPS ISORDIL ISOSORBIDE DINITRATE 40 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 20 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 40 MG TABLET ER ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 2.5 MG TAB SUBL ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 10 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 30 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5 MG TABLET ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 10 MG TABLET ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 20 MG TABLET ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 60 MG TAB ER 24H ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 30 MG TAB ER 24H ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 120 MG TAB ER 24H JOLIVETTE NORETHINDRONE 0.35 MG TABLET JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS (21) TABLET 255_FormularyMaintenance_March2015 Page 24 of 47
25 FUMARATE JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1MG-20(21) TABLET JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE (21) TABLET JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1MG-20(21) TABLET KETO-DIASTIX REAGENT URINE GLUC-ACET COMB.TST,STRIP STRIP KLOR-CON 10 POTASSIUM CHLORIDE 10 MEQ TABLET ER KLOR-CON 8 POTASSIUM CHLORIDE 8 MEQ TABLET ER LABETALOL HCL LABETALOL HCL 100 MG TABLET LABETALOL HCL LABETALOL HCL 200 MG TABLET LABETALOL HCL LABETALOL HCL 300 MG TABLET LACTULOSE LACTULOSE 10 G/15 ML SOLUTION LAMOTRIGINE LAMOTRIGINE 150 MG TABLET LAMOTRIGINE LAMOTRIGINE 25 MG TB CHW DSP LAMOTRIGINE LAMOTRIGINE 100 MG TABLET LAMOTRIGINE LAMOTRIGINE 5 MG TB CHW DSP LAMOTRIGINE LAMOTRIGINE 25 MG TABLET LAMOTRIGINE LAMOTRIGINE 200 MG TABLET LANCETS ULTRA THIN LANCETS 26 GAUGE EACH LANSOPRAZOLE LANSOPRAZOLE 15 MG CAPSULE DR 255_FormularyMaintenance_March2015 Page 25 of 47
26 LANSOPRAZOLE LANSOPRAZOLE 15 MG CAPSULE DR LANTUS INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG 100/ML VIAL LANTUS SOLOSTAR INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG 100/ML (3) INSULN PEN LEENA NORETHINDRONE-ETHINYL ESTRADIOL TABLET LEFLUNOMIDE LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE LEFLUNOMIDE 20 MG TABLET LEVALBUTEROL CONCENTRATE LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB LEVETIRACETAM LEVETIRACETAM 100 MG/ML SOLUTION LEVETIRACETAM LEVETIRACETAM 750 MG TABLET LEVETIRACETAM LEVETIRACETAM 500 MG TABLET LEVETIRACETAM LEVETIRACETAM 250 MG TABLET LEVETIRACETAM LEVETIRACETAM 1000 MG TABLET LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.5 % DROPS LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.25 % DROPS LEVOCARNITINE LEVOCARNITINE 330 MG TABLET LEVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 112 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 125 MCG TABLET 255_FormularyMaintenance_March2015 Page 26 of 47
27 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 150 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 100 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 75 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 50 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 25 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 137 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 175MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 88 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 200 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 5 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 50 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 25 MCG TABLET LISINOPRIL LISINOPRIL 2.5 MG TABLET LISINOPRIL LISINOPRIL 5 MG TABLET LISINOPRIL LISINOPRIL 10 MG TABLET LISINOPRIL LISINOPRIL 20 MG TABLET LISINOPRIL LISINOPRIL 40 MG TABLET LISINOPRIL LISINOPRIL 30 MG TABLET LISINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET 255_FormularyMaintenance_March2015 Page 27 of 47
28 LISINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET LOPERAMIDE LOPERAMIDE HCL 2 MG CAPSULE LORATADINE LORATADINE 5 MG/5 ML SOLUTION LORATADINE LORATADINE 5 MG/5 ML SOLUTION LOSARTAN POTASSIUM LOSARTAN POTASSIUM 25 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 100 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 50 MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 100MG- 25MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE MG TABLET LOSEASONIQUE LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL (84) TBDSPK 3MO LOVASTATIN LOVASTATIN 20 MG TABLET LOVASTATIN LOVASTATIN 10 MG TABLET LOVASTATIN LOVASTATIN 40 MG TABLET LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL MG TABLET MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 5 MG TABLET 255_FormularyMaintenance_March2015 Page 28 of 47
29 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET MEDROXYPROGESTERONE ACETATE 10 MG TABLET MEDROXYPROGESTERONE ACETATE 150 MG/ML VIAL MEGESTROL ACETATE MEGESTROL ACETATE 400MG/10ML ORAL SUSP MEGESTROL ACETATE MEGESTROL ACETATE 400MG/10ML ORAL SUSP MELOXICAM MELOXICAM 15 MG TABLET MELOXICAM MELOXICAM 7.5 MG TABLET MENEST ESTROGENS,ESTERIFIED 2.5 MG TABLET MENEST ESTROGENS,ESTERIFIED 1.25 MG TABLET MENEST ESTROGENS,ESTERIFIED 0.3 MG TABLET MENEST ESTROGENS,ESTERIFIED MG TABLET MESTINON PYRIDOSTIGMINE BROMIDE 60 MG/5 ML SYRUP MESTINON PYRIDOSTIGMINE BROMIDE 180 MG TABLET ER METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10 MG/5 ML SYRUP METAPROTERENOL SULFATE METAPROTERENOL SULFATE 20 MG TABLET METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10 MG TABLET METFORMIN HCL METFORMIN HCL 1000 MG TABLET METFORMIN HCL METFORMIN HCL 850 MG TABLET METFORMIN HCL METFORMIN HCL 500 MG TABLET 255_FormularyMaintenance_March2015 Page 29 of 47
30 METFORMIN HCL ER METFORMIN HCL 500 MG TAB ER 24H METFORMIN HCL ER METFORMIN HCL 750 MG TAB ER 24H METHIMAZOLE METHIMAZOLE 10 MG TABLET METHIMAZOLE METHIMAZOLE 5 MG TABLET METHOTREXATE METHOTREXATE SODIUM 2.5 MG TABLET METHYLDOPA METHYLDOPA 250 MG TABLET METHYLDOPA METHYLDOPA 500 MG TABLET METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG- 25MG TABLET METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG- 15MG TABLET METHYLPHENIDATE ER METHYLPHENIDATE HCL 20 MG TABLET ER METHYLPHENIDATE ER METHYLPHENIDATE HCL 10 MG TABLET ER METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG TABLET METIPRANOLOL METIPRANOLOL 0.3 % DROPS METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG TAB ER 24H METOPROLOL TARTRATE METOPROLOL TARTRATE 100 MG TABLET 255_FormularyMaintenance_March2015 Page 30 of 47
31 METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG TABLET METOPROLOL TARTRATE METOPROLOL TARTRATE 50 MG TABLET MEXILETINE HCL MEXILETINE HCL 250 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 200 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 150 MG CAPSULE MICROGESTIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL 1MG-20MCG TABLET MICROGESTIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL MG TABLET MINOXIDIL MINOXIDIL 2.5 MG TABLET MINOXIDIL MINOXIDIL 10 MG TABLET MIRTAZAPINE MIRTAZAPINE 30 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 15 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 45 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 30 MG TABLET MIRTAZAPINE MIRTAZAPINE 15 MG TABLET MIRTAZAPINE MIRTAZAPINE 7.5 MG TABLET MIRTAZAPINE MIRTAZAPINE 45 MG TABLET MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL TABLET MONTELUKAST SODIUM MONTELUKAST SODIUM 4 MG TAB CHEW MONTELUKAST SODIUM MONTELUKAST SODIUM 5 MG TAB CHEW MONTELUKAST SODIUM MONTELUKAST SODIUM 10 MG TABLET NABUMETONE NABUMETONE 750 MG TABLET 255_FormularyMaintenance_March2015 Page 31 of 47
32 NABUMETONE NABUMETONE 500 MG TABLET NAPROXEN NAPROXEN 125 MG/5ML ORAL SUSP NAPROXEN NAPROXEN 500 MG TABLET NAPROXEN NAPROXEN 375 MG TABLET NAPROXEN NAPROXEN 250 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 220 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 275 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 550 MG TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL TABLET NECON NORETHINDRONE-MESTRANOL 1 MG-50MCG TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-35MCG TABLET NEFAZODONE HCL NEFAZODONE HCL 150 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 250 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 200 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 50 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 100 MG TABLET NEXIUM ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE DR NIACIN NIACIN 250 MG CAPSULE ER NIACIN NIACIN 500 MG CAPSULE ER 255_FormularyMaintenance_March2015 Page 32 of 47
33 NIACOR NIACIN 500 MG TABLET NIASPAN NIACIN 500 MG TAB ER 24H NIASPAN NIACIN 750 MG TAB ER 24H NIASPAN NIACIN 1000 MG TAB ER 24H NIFEDIPINE NIFEDIPINE 20 MG CAPSULE NIFEDIPINE NIFEDIPINE 10 MG CAPSULE NIFEDIPINE ER NIFEDIPINE 60 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 90 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 90 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 60 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 30 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 30 MG TAB ER 24 NITRO-BID NITROGLYCERIN 2 % OINT. (G) NITROSTAT NITROGLYCERIN 0.4 MG TAB SUBL NITROSTAT NITROGLYCERIN 0.3 MG TAB SUBL NITROSTAT NITROGLYCERIN 0.6 MG TAB SUBL NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION 255_FormularyMaintenance_March2015 Page 33 of 47
34 NOVOLOG INSULIN ASPART 100/ML VIAL NOVOLOG INSULIN ASPART 100/ML CARTRIDGE NOVOLOG FLEXPEN INSULIN ASPART 100/ML INSULN PEN NOVOLOG MIX INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML VIAL NOVOLOG MIX FLEXPEN INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML INSULN PEN NUVARING ETONOGESTREL/ETHINYL ESTRADIOL MG VAG RING OCELLA ETHINYL ESTRADIOL/DROSPIRENONE MG TABLET OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.5 MG-50 TABLET OMEPRAZOLE OMEPRAZOLE 20 MG TABLET DR OMEPRAZOLE OMEPRAZOLE 40 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 20 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 10 MG CAPSULE DR OVCON-50 NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-50MCG TABLET OXCARBAZEPINE OXCARBAZEPINE 150 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML ORAL SUSP OXCARBAZEPINE OXCARBAZEPINE 300 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 600 MG TABLET OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG TABLET OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 15 MG TAB ER _FormularyMaintenance_March2015 Page 34 of 47
35 PANCRELIPASE 5,000 LIPASE/PROTEASE/AMYLASE 5K-17K-27K CAPSULE DR PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG TABLET DR PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG TABLET DR PAROXETINE HCL PAROXETINE HCL 40 MG TABLET PAROXETINE HCL PAROXETINE HCL 10 MG TABLET PAROXETINE HCL PAROXETINE HCL 30 MG TABLET PAROXETINE HCL PAROXETINE HCL 20 MG TABLET PENTOXIFYLLINE PENTOXIFYLLINE 400 MG TABLET ER PEPCID FAMOTIDINE 40MG/5ML ORAL SUSP PHENOBARBITAL PHENOBARBITAL 60 MG TABLET PHENOBARBITAL PHENOBARBITAL 15 MG TABLET PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML ELIXIR PHENOBARBITAL PHENOBARBITAL 30 MG TABLET PHENOBARBITAL PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET PHENOBARBITAL PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL PHENOBARBITAL 100 MG TABLET PHENYTOIN PHENYTOIN 125 MG/5ML ORAL SUSP PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 255_FormularyMaintenance_March2015 Page 35 of 47
36 PHOSPHOLINE IODIDE ECHOTHIOPHATE IODIDE % DROPS PILOCARPINE HCL PILOCARPINE HCL 4 % DROPS PILOCARPINE HCL PILOCARPINE HCL 1 % DROPS PILOCARPINE HCL PILOCARPINE HCL 2 % DROPS PIOGLITAZONE HCL PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 30 MG TABLET PIROXICAM PIROXICAM 10 MG CAPSULE PIROXICAM PIROXICAM 20 MG CAPSULE PLAVIX CLOPIDOGREL BISULFATE 75 MG TABLET POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ CAPSULE ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ CAPSULE ER PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL MG TABLET PRAMIPEXOLE DI-HCL 0.25 MG TABLET PRAMIPEXOLE DI-HCL 0.5 MG TABLET 255_FormularyMaintenance_March2015 Page 36 of 47
37 PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 1 MG TABLET PRAMIPEXOLE DI-HCL 1.5 MG TABLET PRAMIPEXOLE DI-HCL 0.75 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 10 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 80 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 40 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 20 MG TABLET PRAZOSIN HCL PRAZOSIN HCL 1 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 5 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 2 MG CAPSULE PREMARIN ESTROGENS, CONJUGATED MG/G CREAM/APPL PREMARIN ESTROGENS, CONJUGATED 0.9 MG TABLET PREMARIN ESTROGENS, CONJUGATED MG TABLET PREMARIN ESTROGENS, CONJUGATED 1.25 MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.45MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.3 MG TABLET PREMPHASE ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE (14) TABLET PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE MG TABLET 255_FormularyMaintenance_March2015 Page 37 of 47
38 PREMPRO PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE TABLET MG TABLET PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE MG TABLET PREVIDENT 5000 PLUS SODIUM FLUORIDE 1.1 % CREAM (G) PRILOSEC OTC OMEPRAZOLE MAGNESIUM 20 MG TABLET DR PRIMAQUINE PRIMAQUINE PHOSPHATE 26.3 MG TABLET PRIMIDONE PRIMIDONE 50 MG TABLET PRIMIDONE PRIMIDONE 250 MG TABLET PROBENECID PROBENECID 500 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 300 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 225 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL ER PROPAFENONE HCL 425 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 325 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 225 MG CAP ER 12H PROPRANOLOL HCL PROPRANOLOL HCL 20 MG/5 ML SOLUTION PROPRANOLOL HCL PROPRANOLOL HCL 20 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 40 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 40MG/5ML SOLUTION 255_FormularyMaintenance_March2015 Page 38 of 47
39 PROPRANOLOL HCL PROPRANOLOL HCL 60 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 10 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 80 MG TABLET PROPRANOLOL HCL ER PROPRANOLOL HCL 160 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 60 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 80 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 120 MG CAP SA 24H PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG TABLET PULMICORT BUDESONIDE 1 MG/2 ML AMPUL-NEB PULMICORT FLEXHALER BUDESONIDE 90 MCG AER POW BA PULMICORT FLEXHALER BUDESONIDE 180 MCG AER POW BA PYRAZINAMIDE PYRAZINAMIDE 500 MG TABLET PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE 60 MG TABLET QUASENSE LEVONORGESTREL-ETHINYL ESTRADIOL TBDSPK 3MO QUINIDINE GLUCONATE QUINIDINE GLUCONATE 324 MG TABLET ER QVAR BECLOMETHASONE DIPROPIONATE 40 MCG AER W/ADAP QVAR BECLOMETHASONE DIPROPIONATE 80 MCG AER W/ADAP RABEPRAZOLE SODIUM RABEPRAZOLE SODIUM 20 MG TABLET DR RANITIDINE HCL RANITIDINE HCL 150 MG TABLET RANITIDINE HCL RANITIDINE HCL 300 MG TABLET RANITIDINE HCL RANITIDINE HCL 15 MG/ML SYRUP 255_FormularyMaintenance_March2015 Page 39 of 47
40 RENAGEL SEVELAMER HCL 400 MG TABLET RENAGEL SEVELAMER HCL 800 MG TABLET RENVELA SEVELAMER CARBONATE 800 MG TABLET RHEUMATREX METHOTREXATE SODIUM 2.5 MG TAB DS PK RIDAURA AURANOFIN 3 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 1.5 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 3 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 6 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 4.5 MG CAPSULE ROPINIROLE HCL ROPINIROLE HCL 5 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 0.25 MG TABLET SEREVENT DISKUS SALMETEROL XINAFOATE 50 MCG BLST W/DEV SERTRALINE HCL SERTRALINE HCL 25 MG TABLET SERTRALINE HCL SERTRALINE HCL 100 MG TABLET SERTRALINE HCL SERTRALINE HCL 50 MG TABLET SERTRALINE HCL SERTRALINE HCL 20 MG/ML ORAL CONC 255_FormularyMaintenance_March2015 Page 40 of 47
41 SIMVASTATIN SIMVASTATIN 5 MG TABLET SIMVASTATIN SIMVASTATIN 10 MG TABLET SIMVASTATIN SIMVASTATIN 40 MG TABLET SIMVASTATIN SIMVASTATIN 20 MG TABLET SIMVASTATIN SIMVASTATIN 80 MG TABLET SODIUM CHLORIDE SODIUM CHLORIDE 5 % DROPS SODIUM CHLORIDE SODIUM CHLORIDE 5 % OINT. (G) SODIUM FLUORIDE SODIUM FLUORIDE 0.5 MG/ML DROPS SODIUM FLUORIDE SODIUM FLUORIDE 0.25(0.55) TAB CHEW SOLIA DESOGESTREL-ETHINYL ESTRADIOL TABLET SOTALOL SOTALOL HCL 80 MG TABLET SOTALOL SOTALOL HCL 120 MG TABLET SOTALOL SOTALOL HCL 240 MG TABLET SOTALOL SOTALOL HCL 160 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 50 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE-HCTZ SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET SRONYX LEVONORGESTREL-ETHINYL ESTRADIOL TABLET SSKI POTASSIUM IODIDE 1 G/ML SOLUTION STRATTERA ATOMOXETINE HCL 18 MG CAPSULE 255_FormularyMaintenance_March2015 Page 41 of 47
42 STRATTERA ATOMOXETINE HCL 40 MG CAPSULE STRATTERA ATOMOXETINE HCL 25 MG CAPSULE STRATTERA ATOMOXETINE HCL 100 MG CAPSULE STRATTERA ATOMOXETINE HCL 60 MG CAPSULE STRATTERA ATOMOXETINE HCL 80 MG CAPSULE STRATTERA ATOMOXETINE HCL 10 MG CAPSULE SUCRALFATE SUCRALFATE 1 G TABLET SULFASALAZINE SULFASALAZINE 500 MG TABLET SULFASALAZINE DR SULFASALAZINE 500 MG TABLET DR SULINDAC SULINDAC 150 MG TABLET SULINDAC SULINDAC 200 MG TABLET TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG TABLET TAMOXIFEN CITRATE TAMOXIFEN CITRATE 20 MG TABLET TAMSULOSIN HCL TAMSULOSIN HCL 0.4 MG CAP ER 24H TAZTIA XT DILTIAZEM HCL 240 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 120 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 300 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 180 MG CAPSULE ER TEGRETOL XR CARBAMAZEPINE 100 MG TAB ER 12H TERAZOSIN HCL TERAZOSIN HCL 10 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 5 MG CAPSULE 255_FormularyMaintenance_March2015 Page 42 of 47
43 TERAZOSIN HCL TERAZOSIN HCL 2 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 1 MG CAPSULE TERBUTALINE SULFATE TERBUTALINE SULFATE 2.5 MG TABLET TERBUTALINE SULFATE TERBUTALINE SULFATE 5 MG TABLET THALITONE CHLORTHALIDONE 15 MG TABLET THEO-24 THEOPHYLLINE ANHYDROUS 100 MG CAP ER 24H THEO-24 THEOPHYLLINE ANHYDROUS 400 MG CAP ER 24H THEO-24 THEOPHYLLINE ANHYDROUS 300 MG CAP ER 24H THEO-24 THEOPHYLLINE ANHYDROUS 200 MG CAP ER 24H THEOPHYLLINE THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION THEOPHYLLINE THEOPHYLLINE ANHYDROUS 400 MG TABLET ER THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H TILIA FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE TABLET TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.5 % SOL-GEL TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % SOL-GEL TIMOLOL MALEATE TIMOLOL MALEATE 0.5 % DROPS 255_FormularyMaintenance_March2015 Page 43 of 47
44 TIZANIDINE HCL TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL TIZANIDINE HCL 4 MG TABLET TOLTERODINE TARTRATE TOLTERODINE TARTRATE 2 MG TABLET TOLTERODINE TARTRATE TOLTERODINE TARTRATE 1 MG TABLET TOPIRAMATE TOPIRAMATE 25 MG TABLET TOPIRAMATE TOPIRAMATE 100 MG TABLET TOPIRAMATE TOPIRAMATE 200 MG TABLET TOPIRAMATE TOPIRAMATE 50 MG TABLET TOPIRAMATE TOPIRAMATE 25 MG CAP SPRINK TOPIRAMATE TOPIRAMATE 15 MG CAP SPRINK TRAVATAN Z TRAVOPROST % DROPS TRAZODONE HCL TRAZODONE HCL 300 MG TABLET TRAZODONE HCL TRAZODONE HCL 150 MG TABLET TRAZODONE HCL TRAZODONE HCL 100 MG TABLET TRAZODONE HCL TRAZODONE HCL 50 MG TABLET TRIAMTERENE- HYDROCHLOROTHIAZID TRIAMTERENE- HYDROCHLOROTHIAZID TRIAMTERENE- HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 MG-50MG TABLET TRIAMTERENE/HYDROCHLOROTHIAZIDE MG CAPSULE TRIAMTERENE/HYDROCHLOROTHIAZIDE MG TABLET TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 255_FormularyMaintenance_March2015 Page 44 of 47
45 TRIVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL TABLET TROPICAMIDE TROPICAMIDE 0.5 % DROPS TROPICAMIDE TROPICAMIDE 1 % DROPS TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400 MCG AER POW BA URSODIOL URSODIOL 250 MG TABLET URSODIOL URSODIOL 300 MG CAPSULE VALACYCLOVIR VALACYCLOVIR HCL 500 MG TABLET VALACYCLOVIR VALACYCLOVIR HCL 1000 MG TABLET VALPROIC ACID VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) 250 MG/5ML SOLUTION VALPROIC ACID VALPROIC ACID 250 MG CAPSULE VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE 320MG- 25MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 25 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 100 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 37.5 MG TABLET 255_FormularyMaintenance_March2015 Page 45 of 47
46 VENLAFAXINE HCL VENLAFAXINE HCL 75 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 50 MG TABLET VENLAFAXINE HCL ER VENLAFAXINE HCL 150 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 75 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 150 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 75 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 225 MG TAB ER 24 VENTOLIN HFA ALBUTEROL SULFATE 90 MCG HFA AER AD VERAPAMIL ER VERAPAMIL HCL 180 MG CAP24H PEL VERAPAMIL ER VERAPAMIL HCL 120 MG TABLET ER VERAPAMIL ER VERAPAMIL HCL 120 MG CAP24H PEL VERAPAMIL ER VERAPAMIL HCL 240 MG TABLET ER VERAPAMIL ER VERAPAMIL HCL 180 MG TABLET ER VERAPAMIL ER VERAPAMIL HCL 240 MG CAP24H PEL VERAPAMIL ER PM VERAPAMIL HCL 100 MG CAP24H PCT VERAPAMIL ER PM VERAPAMIL HCL 200 MG CAP24H PCT VERAPAMIL ER PM VERAPAMIL HCL 300 MG CAP24H PCT VERAPAMIL HCL VERAPAMIL HCL 80 MG TABLET VERAPAMIL HCL VERAPAMIL HCL 120 MG TABLET 255_FormularyMaintenance_March2015 Page 46 of 47
47 VERAPAMIL HCL VERAPAMIL HCL 40 MG TABLET VITAMIN D2 ERGOCALCIFEROL (VITAMIN D2) UNIT CAPSULE VITAMIN D2 ERGOCALCIFEROL (VITAMIN D2) UNIT CAPSULE VIVELLE-DOT ESTRADIOL.0375MG/24 PATCH TDSW VOLTAREN DICLOFENAC SODIUM 1 % GEL (GRAM) WARFARIN SODIUM WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 4 MG TABLET XALATAN LATANOPROST % DROPS ZONISAMIDE ZONISAMIDE 100 MG CAPSULE ZONISAMIDE ZONISAMIDE 50 MG CAPSULE ZONISAMIDE ZONISAMIDE 25 MG CAPSULE ZOVIA 1-35E ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 1 MG-35MCG TABLET ZOVIA 1-50E ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 1 MG-50MCG TABLET 255_FormularyMaintenance_March2015 Page 47 of 47
Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Riesbeck's Pharmacy Reward Club Generic Medication List September 2017
Drug Category Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Riesbeck's Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine
Riesbeck's Pharmacy Reward Club Generic Medication List October 2017
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Professionalism & Service with Great Prices
Acyclovir Capsules 200mg Viruses 30 90 Albuterol Syrup 2mg/5ml Asthma 120 360 Albuterol Sulfate Solution 0.05% * Asthma ----- ----- 20 60 Albuterol Sulfate Solution 0.083% Asthma ----- ----- 75 225 Alendronate
TennCare Program TN MAC Price Change List As of: 03/30/2017
1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014
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1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
Cash Wise Pharmacy $4 GENERIC MEDICATION FORMULARY. Cash Wise Pharmacy s $4 generic medication formulary is sorted by medical condition.
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90-Day Generic Drug Discount List Treatment Medication Strength Dose Quantity Price Allergy/Cold&Flu Benzonatate 100mg Tablet 42 $15.
90-Day Generic Drug Discount List Treatment Medication Strength Dose Quantity Price Allergy/Cold&Flu Benzonatate 100mg Tablet 42 $15.00 Allergy/Cold&Flu C-Phen Drops n/a Drops 90 $15.00 Allergy/Cold&Flu
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$4 Prescription Program May 5, 2008
Allergies & Cold and Flu Benzonatate 100mg 14 42 Ceron DM syrup 120ml 360ml Ceron drops* 30ml 90ml Dec-Chlorphen drops* 30ml 90ml Dec-Chlorphen DM syrup* 118ml 354ml Loratadine 10mg 30 90 Promethazine
$4 Prescription Program October 23, 2007
Allergies & Cold and Flu Benzonatate 100mg 14 Ceron DM syrup Ceron drops Dec-Chlorphen drops Dec-Chlorphen DM syrup 118ml* Loratadine 10mg Promethazine DM syrup Trivent DPC syrup * Antibiotic Treatments
AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS 30 90
Antibiotics Qty* DRUG NAME $0.00 Copay $ 4.00 $ 10.00 AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) 150 AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) 80 AMOXICILLIN 200 MG/5
Fruth Pharmacy Prescription Savings Club Prescription Club October 2010 Generics item list 30 Day Qty
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RETAIL PRESCRIPTION PROGRAM DRUG LIST -- WALMART Revised 8/24/11
Allergies & Cold and Flu $4, 30-day $10, 90-day Benzonatate 100mg cap 14 42 Loratadine 10mg tab 30 90 Promethazine DM syrup 120ml 360ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) 1
Oakwood Healthcare Low Cost Drug List for OHSCare & BCN
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QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8
2019 LiveWELL Health Plan PREVENTIVE DRUG LIST - GENERIC Names ( Copay) - ALPHABETICAL by DRUG CATEGORY You should always check with your prescriber and/or pharmacist to determine if these alternatives
Nebraska Medicaid Program NE Weekly MAC Price Change List For Period: 12/14/ /20/2017
1 Medicaid Run : 12/21/17 NE Weekly List Old AMIODARONE HCL 200 MG TABLET ORAL 12/20/2017 0.15321 0.14370 6.6 HYDRALAZINE HCL 10 MG TABLET ORAL 12/20/2017 0.05226 0.05213 0.2 LISINOPRIL 10 MG TABLET ORAL
Hundreds of Choices. More Savings Every Day. 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses
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Allergy, Cough and Cold. Analgesic. Anti-Anxiety. Antibiotic
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Antibiotics Antifungal Antiviral Arthritis/ Pain 30 Day Qty* Free AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 200
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DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
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DT Description Price Category Price change
Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant
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School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
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Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
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Generic Medications 2,500 + available Call or MEDSerivces for medications not listed.
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ABACAVIR SULFATE 300 MG TAB 0000 4.94966 02/05/2016 ACAMPROSATE CALCIUM 333 MG TAB DR 0000 1.07161 11/05/2015 ACARBOSE 100 MG TAB 0000 0.47754 11/05/2015 ACARBOSE 25 MG TAB 0000 0.41100 08/05/2015 ACARBOSE
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ABACAVIR SULFATE 300 mg TAB TABLET $5.4480 ACARBOSE 100 mg TAB TABLET $0.4337 ACARBOSE 25 mg TAB TABLET $0.5040 ACARBOSE 50 mg TAB TABLET $0.3904 ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668 ACEBUTOLOL HCL
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