AvMed Medicare Choice
2011 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2012.
To get this material in other formats or ask for language translation services, call AvMed Member services at 1-800-782-8633. TTY users call 1-877-442-8633.
HPMS Approved Formulary File 11206, Version 22
A formulary is a list of covered drugs selected by AvMed Medicare Choice in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. AvMed Medicare Choice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a AvMed Medicare Choice network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2011 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.
Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 1, 2011. To get updated information about the drugs covered by AvMed Medicare Choice, please visit our Web site at www.avmed.org or call Member Services at 1-800-782-8633, 24 hours a day/7 days a week. TTY/TDD users should call 1-877-442-8633. The AvMed Medicare Choice monthly formulary updates include all changes approved by CMS and is posted monthly at www.avmed.org. You may request a printed formulary by calling 1-800-782-8633, 24 hours a day/7 days a week. TTY/TDD users should call 1-877-442-8633.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used
what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 113. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
AvMed Medicare Choice covers both brand name drugs and generic drugs. 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.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: AvMed Medicare Choice requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from AvMed Medicare Choice before you fill your prescriptions. If you don’t get approval, AvMed Medicare Choice may not cover the drug.
Quantity Limits: For certain drugs, AvMed Medicare Choice limits the amount of the drug that AvMed Medicare Choice will cover. For example, AvMed Medicare Choice provides 30 tablets per prescription for Zetia. This may be in addition to a standard one month or three month supply.
Step Therapy: In some cases, AvMed Medicare Choice requires you to first try certain drugs to treat your medical condition before we will cover another drug for that
condition. For example, if Drug A and Drug B both treat your medical condition, AvMed Medicare Choice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AvMed Medicare Choice will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.avmed.org.
the section, “How do I request an exception to the AvMed Medicare Choice’s formulary?” on page 4 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that AvMed Medicare Choice does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by AvMed Medicare Choice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AvMed Medicare Choice.
You can ask AvMed Medicare Choice to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the AvMed Medicare Choice’s Formulary?
You can ask AvMed Medicare Choice to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AvMed Medicare Choice limit the amount of the drug that we will cover.
If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand Name Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Name Drug tier instead.
This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier.
Generally, AvMed Medicare Choice will only approve your request for an exception if the alternative drugs included on the plan’s formulary, Preferred Brand Name Drug tier or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or
prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.
While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
You will be allowed to refill any appropriate and necessary drugs upon admission to or discharge from a long-term care facility.
For more information
For more detailed information about your AvMed Medicare Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about AvMed Medicare Choice, please call Member Services at 1-800- 782-8633, 24 hours a day/7 days a week. TTY/TDD users should call 1-877-442-8633. Or visit www.avmed.org.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
The formulary that begins on the next page provides coverage information about some of the drugs covered by AvMed Medicare Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 113.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin).
The second column specifies the cost sharing tiers for your prescribed drugs. There are 4 tiers of cost sharing described as follows:
Cost Sharing Tier 1 - Generic drugs
Cost Sharing Tier 2 - Preferred brand drugs Cost Sharing Tier 3 – Non-preferred brand drugs Cost Sharing Tier 4 – Specialty drugs
Please refer to your Evidence of Coverage for more information regarding how much you will pay for your prescription drugs.
The information in the Notes column tells you if AvMed Medicare Choice has any special requirements for coverage of your drug.
“QL” indicates that there is a quantity limit for the medication.
“PA” indicates that a prior authorization is required before the medication will be covered.
“B/D” indicates this drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
“ST” indicates that the medication has a step therapy and a preferred medication must first be tried.
“LA” indicates limited availability. This prescription may be available only at certain pharmacies.
“E” indicates this prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
“MO” indicates this is a medication that can be obtained through mail order.
“GAP” indicates we provide additional coverage of this prescription drug in the coverage gap.
Please refer to our Evidence of Coverage for more information about this coverage.
Analgesics
Opioid Analgesics, Long-Acting
AVINZA 24 HR CAP 120 mg, 30 mg, 60 mg, 90 mg
2
AVINZA 24 HR CAP 45 mg, 75 mg 2 QL (30 EA per 30 day(s))
DURAGESIC TRANSDERM PATCH 3 QL (10 EA per 30 day(s))
EMBEDA CAP 3 QL (60 EA per 30 day(s))
EXALGO ER 24 HR TAB 12 mg, 16 mg 3 QL (120 EA per 30 day(s))
EXALGO ER 24 HR TAB 8 mg 3 QL (30 EA per 30 day(s))
fentanyl transderm patch 1 GAP; QL (10 EA per 30 day(s))
KADIAN CAP 2
morphine er tab 1 GAP
MS CONTIN TAB 3
OPANA ER 12 HR TAB 3
OXYCONTIN 12 HR TAB 80 mg 2 QL (120 EA per 30 day(s))
OXYCONTIN 12 HR TAB 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg
2 QL (60 EA per 30 day(s))
tramadol er 24 hr tab 200 mg 1 GAP; QL (60 EA per 30 day(s))
tramadol er 24 hr tab 100 mg 1 GAP; QL (90 EA per 30 day(s))
ULTRAM ER 24 HR TAB 200 mg 3 QL (60 EA per 30 day(s))
ULTRAM ER 24 HR TAB 100 mg 3 QL (90 EA per 30 day(s))
Opioid Analgesics, Short-Acting
ABSTRAL SUBLINGUAL TAB 3 QL (240 EA per 30 day(s))
acetaminophen-codeine elixir 1 GAP
acetaminophen-codeine tab 1 GAP; QL (360 EA per 30 day(s))
ACTIQ LOZENGE ON A HANDLE 3 QL (120 EA per 30 day(s))
ASCOMP W/CODEINE CAP 1 GAP; QL (240 EA per 30 day(s))
buprenorphine sublingual tab 1 GAP
codeine-butalbital-acetaminophen-caffeine cap 1 GAP; QL (240 EA per 30 day(s))
codeine tab 1 GAP
CO-GESIC TAB 1 GAP; QL (240 EA per 30 day(s))
COMBUNOX TAB 3 QL (150 EA per 30 day(s))
DEMEROL TAB 3
DILAUDID TAB 3
DILAUDID-5 ORAL LIQUID 3
DILAUDID-HP INJECTION 3 B/D
DOLOPHINE TAB 3
DURAMORPH INJECTION 1 B/D; GAP
ENDOCET TAB 10-650 mg 1 GAP; QL (180 EA per 30 day(s))
ENDOCET TAB 7.5-500 mg 1 GAP; QL (240 EA per 30 day(s))
ENDOCET TAB 10-325 mg, 5-325 mg, 7.5-325 mg
1 GAP; QL (360 EA per 30 day(s))
ENDODAN TAB 1 GAP; QL (360 EA per 30 day(s))
fentanyl lozenge on a handle 3 QL (120 EA per 30 day(s))
FENTORA BUCCAL TAB, EFFERVESCENT 3 QL (120 EA per 30 day(s))
FIORICET-CODEINE CAP 3 QL (240 EA per 30 day(s))
FIORINAL-CODEINE #3 CAP 3 QL (240 EA per 30 day(s))
hydrocodone-acetaminophen oral soln 7.5-500 mg/15 mL
1 GAP
hydrocodone-acetaminophen tab 10-750 mg, 7.5- 750 mg
1 GAP; QL (150 EA per 30 day(s))
hydrocodone-acetaminophen tab 10-650 mg, 10- 660 mg, 7.5-650 mg
1 GAP; QL (180 EA per 30 day(s))
hydrocodone-acetaminophen tab 10-500 mg, 2.5- 500 mg, 5-500 mg, 7.5-500 mg
1 GAP; QL (240 EA per 30 day(s))
hydrocodone-acetaminophen tab 10-325 mg, 5- 325 mg, 7.5-325 mg
1 GAP; QL (360 EA per 30 day(s))
hydrocodone-ibuprofen tab 1 GAP; QL (240 EA per 30 day(s))
hydromorphone tab 1 GAP
hydromorphone (pf) injection 1 B/D; GAP
ibuprofen-oxycodone tab 1 GAP; QL (150 EA per 30 day(s))
LORCET 10/650 TAB 3 QL (180 EA per 30 day(s))
LORCET PLUS TAB 3 QL (180 EA per 30 day(s))
LORTAB TAB 3 QL (240 EA per 30 day(s))
LORTAB ELIXIR ORAL SOLN 3
MARGESIC-H CAP 1 GAP; QL (240 EA per 30 day(s))
MAXIDONE TAB 3 QL (150 EA per 30 day(s))
meperidine oral soln 1 GAP
meperidine tab 1 GAP
meperidine (pf) pca syringe 1 B/D; GAP
methadone injection 1 B/D; GAP
methadone oral concentrate 1 GAP
methadone oral soln 1 GAP
methadone tab 1 GAP
METHADOSE TAB 1 GAP
morphine injection 1 B/D; GAP
morphine tab 1 GAP
morphine (pf) injection 1 B/D; GAP
morphine concentrate oral 1 GAP
NORCO TAB 3 QL (360 EA per 30 day(s))
ONSOLIS BUCCAL FILM 3 QL (120 EA per 30 day(s))
OPANA TAB 3
oxycodone cap 1
oxycodone oral concentrate 1
oxycodone tab 1 GAP
oxycodone hcl-oxycodone ter-aspirin tab 1 GAP; QL (360 EA per 30 day(s))
oxycodone-acetaminophen cap 1 GAP; QL (240 EA per 30 day(s))
oxycodone-acetaminophen tab 10-650 mg 1 GAP; QL (180 EA per 30 day(s)) oxycodone-acetaminophen tab 7.5-500 mg 1 GAP; QL (240 EA per 30 day(s)) oxycodone-acetaminophen tab 10-325 mg, 2.5-
325 mg, 5-325 mg, 7.5-325 mg
1 GAP; QL (360 EA per 30 day(s))
oxycodone-aspirin tab 1
oxymorphone tab 1 GAP
pentazocine-acetaminophen tab 1 GAP; QL (180 EA per 30 day(s))
pentazocine-naloxone tab 1 GAP; QL (360 EA per 30 day(s))
PERCOCET TAB 7.5-500 mg 3 QL (240 EA per 30 day(s))
PERCOCET TAB 10-325 mg, 5-325 mg, 7.5-325 mg
3 QL (360 EA per 30 day(s))
PERCODAN TAB 3 QL (360 EA per 30 day(s))
ROXICET ORAL SOLN 3 QL (960 ML per 30 day(s))
ROXICET TAB 5-325 mg 1 GAP; QL (360 EA per 30 day(s))
ROXICET TAB 5-500 mg 3 QL (240 EA per 30 day(s))
ROXICODONE TAB 3
SUBOXONE SUBLINGUAL FILM 3
SUBOXONE SUBLINGUAL TAB 3
SUBUTEX SUBLINGUAL TAB 3
TALACEN TAB 3 QL (180 EA per 30 day(s))
TALWIN NX TAB 3 QL (360 EA per 30 day(s))
tramadol tab 1 GAP; QL (240 EA per 30 day(s))
tramadol-acetaminophen tab 1 GAP; QL (240 EA per 30 day(s))
TYLENOL-CODEINE #3 TAB 3 QL (360 EA per 30 day(s))
TYLENOL-CODEINE #4 TAB 3 QL (360 EA per 30 day(s))
TYLOX CAP 3 QL (240 EA per 30 day(s))
ULTRACET TAB 3 QL (240 EA per 30 day(s))
ULTRAM TAB 3 QL (240 EA per 30 day(s))
VICODIN TAB 3 QL (240 EA per 30 day(s))
VICODIN ES TAB 3 QL (150 EA per 30 day(s))
VICOPROFEN TAB 3 QL (240 EA per 30 day(s))
Anesthetics Local Anesthetics
EMLA TOPICAL CREAM 3
lidocaine mucosal gel 1 GAP
lidocaine mucosal soln 1 GAP
lidocaine mucous membrane jelly in applicator 1 GAP
lidocaine ointment 1 GAP
lidocaine-prilocaine topical cream 1 GAP
LIDODERM ADHESIVE PATCH 3 QL (90 EA per 30 day(s))
SYNERA PATCH 2
XYLOCAINE JELLY MUCOSAL GEL 3
Antibacterials
Amino Derivative Penicillins
amoxicillin cap 1 GAP
amoxicillin chewable tab 1 GAP
amoxicillin oral susp 1 GAP
amoxicillin tab 1 GAP
amoxicillin-potassium clavulanate chewable tab 1 GAP amoxicillin-potassium clavulanate er 12 hr tab 1 GAP amoxicillin-potassium clavulanate oral susp 1 GAP
amoxicillin-potassium clavulanate tab 1 GAP
ampicillin cap 1 GAP
ampicillin oral susp 1 GAP
ampicillin solution for injection 1 B/D; GAP
ampicillin-sulbactam solution for injection 1 B/D; GAP
AUGMENTIN ES-600 ORAL SUSP 3
UNASYN SOLUTION FOR INJECTION 3 B/D
Aminoglycosides
amikacin injection 1 GAP
gentamicin eye drops 1 GAP
gentamicin injection 1 B/D; GAP
gentamicin ointment 1 GAP
gentamicin topical cream 1 GAP
gentamicin in sodium chloride(iso-osmotic) iv piggy back 70 mg/50 mL
1 B/D
gentamicin in sodium chloride(iso-osmotic) iv piggy back 100 mg/100 mL, 60 mg/100 mL, 60 mg/50 mL, 80 mg/100 mL
1 B/D; GAP
gentamicin in sodium chloride(iso-osmotic) iv piggy back 80 mg/50 mL
1 GAP
gentamicin in sodium chloride(iso-osmotic) iv piggy back 90 mg/100 mL
3
gentamicin sulfate (pf) iv 3
kanamycin injection 1 B/D; GAP
neomycin tab 1 GAP
paromomycin cap 1 GAP
streptomycin im 3 B/D
tobramycin in ns iv piggy back 3 B/D
tobramycin eye drops 1 GAP
tobramycin injection 1 B/D; GAP
Antifolate Antibacterials
PRIMSOL ORAL SOLN 2
trimethoprim tab 1 GAP
Beta-Lactam, Other
AZACTAM SOLUTION FOR INJECTION 3
AZACTAM IN ISO-OSMOTIC DEXTROSE IV PIGGY BACK
3
aztreonam solution for injection 1 GAP
INVANZ SOLUTION FOR INJECTION 3
PRIMAXIN IM SUSP 3
PRIMAXIN IV IV SOLUTION 3
Cephalosporin Antibacterials, 1St Generation
cefadroxil cap 1 GAP
cefadroxil oral susp 1 GAP
cefadroxil tab 1 GAP
cefazolin solution for injection 1 B/D; GAP
cefazolin in dextrose (iso-osmotic) iv piggy back 1 B/D; GAP
cephalexin cap 1 GAP
cephalexin oral susp 1 GAP
cephalexin tab 1 GAP
KEFLEX CAP 250 mg, 500 mg 3
Cephalosporin Antibacterials, 2Nd Generation
cefaclor cap 1 GAP
cefaclor er 12 hr tab 1 GAP
cefaclor oral susp 1 GAP
cefoxitin iv solution 1 B/D; GAP
cefoxitin in dextrose, iso-osmotic iv piggy back 1 gram/50 mL
1 B/D; GAP
cefoxitin in dextrose, iso-osmotic iv piggy back 2 gram/50 mL
1 GAP
cefprozil oral susp 1 GAP
cefprozil tab 1 GAP
CEFTIN ORAL SUSP 125 mg/5 mL 3
CEFTIN TAB 3
cefuroxime axetil oral susp 1 GAP
cefuroxime axetil tab 1 GAP
cefuroxime sodium iv solution 1 B/D; GAP
cefuroxime sodium solution for injection 1 B/D; GAP cefuroxime-dextrose (iso-osmotic) iv piggy back 1 GAP Cephalosporin Antibacterials, 3Rd Generation
CEDAX CAP 3
cefdinir cap 1 GAP
cefdinir oral susp 1 GAP
cefepime solution for injection 1 B/D; GAP
cefotaxime solution for injection 500 mg 1 B/D; GAP cefotaxime solution for injection 1 gram, 10 gram,
2 gram
1 GAP
cefpodoxime oral susp 1 GAP
cefpodoxime tab 1 GAP ceftazidime solution for injection 6 gram 1 B/D; GAP ceftazidime solution for injection 1 gram, 2 gram 1 GAP
ceftriaxone iv solution 1 B/D; GAP
CLAFORAN SOLUTION FOR INJECTION 10 gram, 2 gram
3
CLAFORAN SOLUTION FOR INJECTION 500 mg
3 B/D
FORTAZ SOLUTION FOR INJECTION 3
FORTAZ IN D5W IV PIGGY BACK 3
OMNICEF CAP 3
OMNICEF ORAL SUSP 3
SPECTRACEF TAB 3
SUPRAX ORAL SUSP 3
SUPRAX TAB 3
TAZICEF IV SOLUTION 1 GAP
TAZICEF SOLUTION FOR INJECTION 1 GAP
VANTIN TAB 3
Cephalosporin Antibacterials, 4Th Generation
MAXIPIME SOLUTION FOR INJECTION 3 B/D
Extended Spectrum Penicillins
piperacillin iv solution 1 B/D; GAP
piperacillin solution for injection 1 B/D; GAP
piperacillin-tazobactam iv solution 4.5 gram 1 B/D piperacillin-tazobactam iv solution 3.375 gram 1 B/D; GAP
TIMENTIN IV SOLUTION 3 B/D
ZOSYN IV SOLUTION 3 B/D
ZOSYN IN DEXTROSE (ISO-OSMOTIC) IV PIGGY BACK
3 B/D
Glycopeptide Antibacterials
VANCOCIN CAP 2
vancomycin iv solution 10 gram 1 B/D; GAP
vancomycin iv solution 1,000 mg, 500 mg 3 B/D
VIBATIV IV SOLUTION 3 B/D
Lincomycin Antibacterials
CLEOCIN CAP 150 mg, 300 mg 3
CLEOCIN ORAL SOLUTION 3
CLEOCIN VAGINAL CREAM 3
CLEOCIN VAGINAL SUPPOSITORY 2
CLEOCIN IN D5W IV PIGGY BACK 3 B/D
clindamycin cap 1 GAP
clindamycin iv 1 B/D; GAP
clindamycin vaginal cream 1 GAP
CLINDESSE VAGINAL CREAM 3
LINCOCIN INJECTION 3 B/D
Macrolides
azithromycin iv solution 1 GAP
azithromycin oral susp 1 GAP
azithromycin tab 250 mg, 500 mg 1 GAP; QL (12 EA per 30 day(s))
azithromycin tab 600 mg 1 GAP; QL (30 EA per 30 day(s))
BIAXIN ORAL SUSP 3
BIAXIN TAB 3
BIAXIN XL 24 HR TAB 3
clarithromycin er 24 hr tab 1 GAP
clarithromycin oral susp 1 GAP
clarithromycin tab 1 GAP
DIFICID TAB 3 PA; QL (20 EA per 30 day(s))
ERY-TAB TAB 2
ERYTHROCIN IV SOLUTION 3 B/D
ERYTHROCIN STEARATE TAB 1 GAP
erythromycin eye ointment 1 GAP
erythromycin tab 2
erythromycin ethylsuccinate tab 1
erythromycin-sulfisoxazole oral susp 1 GAP
KETEK TAB 3
ZITHROMAX IV SOLUTION 3
ZITHROMAX ORAL SUSP 3
ZITHROMAX TAB 250 mg, 500 mg 3 QL (12 EA per 30 day(s))
ZITHROMAX TAB 600 mg 3 QL (30 EA per 30 day(s))
ZITHROMAX TRI-PAK TAB 3 QL (12 EA per 30 day(s))
ZITHROMAX Z-PAK TAB 3 QL (12 EA per 30 day(s))
ZMAX ADULT-PEDIATRIC ORAL SUSP 2
Miscellaneous Antibacterials
alcohol swabs 2 MO
ALTABAX OINTMENT 3 QL (15 GM per 30 day(s))
BACI-IM IM 1 B/D; GAP
bacitracin im 1 B/D; GAP
BACTROBAN OINTMENT 3
BACTROBAN TOPICAL CREAM 2
BACTROBAN NASAL OINTMENT 3
colistimethate sodium solution for injection 1 B/D; GAP COLY-MYCIN M PARENTERAL SOLUTION
FOR INJECTION
3 B/D
CUBICIN IV SOLUTION 3 B/D
FLAGYL CAP 3
FLAGYL TAB 3
HIPREX TAB 3
meropenem iv solution 1 GAP
MERREM IV SOLUTION 3
methenamine hippurate tab 1 GAP
METROCREAM TOPICAL 3
METROGEL VAGINAL 3
METROLOTION 3
metronidazole cap 1 GAP
metronidazole lotion 1 GAP
metronidazole tab 1 GAP
metronidazole topical cream 1 GAP
metronidazole topical gel 1 GAP
metronidazole vaginal gel 1 GAP
metronidazole in sodium chloride (iso-osm) iv piggy back
1 GAP
MONUROL ORAL PACKET 2
mupirocin ointment 1 GAP
NEO-FRADIN ORAL SOLN 3
neomycin-polymyxin-hc ear drops, susp 1 GAP
neomycin-polymyxin-hc ear soln 1 GAP
polymyxin b sulfate solution for injection 1 GAP
PREVPAC ORAL PACK 3
SILVADENE TOPICAL CREAM 3
silver sulfadiazine topical cream 1 GAP
SSD TOPICAL CREAM 1 GAP
SULFATRIM ORAL SUSP 1 GAP
TEFLARO IV SOLUTION 4 B/D
THERMAZENE TOPICAL CREAM 1 GAP
TYGACIL IV SOLUTION 3 B/D
VANDAZOLE VAGINAL GEL 1 GAP
XIFAXAN TAB 550 mg 3 QL (60 EA per 30 day(s))
XIFAXAN TAB 200 mg 3 QL (9 EA per 30 day(s))
Natural Penicillins
BICILLIN C-R IM SYRINGE 3
penicillin g pot in dextrose iv piggy back 1 B/D; GAP
penicillin g potassium solution for injection 1 B/D; GAP
penicillin g procaine im syringe 1 B/D; GAP
penicillin g sodium solution for injection 1 B/D; GAP
penicillin v potassium oral susp 1 GAP
penicillin v potassium tab 1 GAP
PFIZERPEN-G SOLUTION FOR INJECTION 3 B/D
Nitrofuran Antibacterials
FURADANTIN ORAL SUSP 3
MACROBID CAP 3
MACRODANTIN CAP 100 mg, 50 mg 3
nitrofurantoin oral susp 1
nitrofurantoin macrocrystal cap 1 GAP
nitrofurantoin monohydrate/macrocrystals cap 1 GAP Oxazolidinone Antibacterials
ZYVOX IV 2 B/D
ZYVOX ORAL SUSP 2 QL (180 ML per 3 day(s))
ZYVOX TAB 2 QL (6 EA per 3 day(s))
Penicillinase-Resistant Penicillins
dicloxacillin cap 1 GAP
nafcillin solution for injection 1 B/D; GAP
oxacillin solution for injection 1 GAP
oxacillin in dextrose, iso-osmotic iv piggy back 3 B/D Quinolones
AVELOX TAB 2
AVELOX ABC PACK TAB 2
AVELOX IN SODIUM CHLORIDE (ISO- OSMOTIC) IV PIGGY BACK
2 B/D
CIPRO ORAL SUSP 2
CIPRO TAB 3
CIPRO HC EAR DROPS, SUSP 3
CIPRODEX EAR DROPS, SUSP 3 QL (7.5 ML per 30 day(s))
ciprofloxacin eye drops 1 GAP
ciprofloxacin iv 1 B/D; GAP
ciprofloxacin tab 1 GAP
ciprofloxacin er multiphase 24 hr tab 1 GAP
FACTIVE TAB 2
LEVAQUIN IV 3 B/D
LEVAQUIN ORAL SOLN 3
LEVAQUIN TAB 3
LEVAQUIN IN D5W IV PIGGY BACK 3 B/D
levofloxacin oral soln 1
levofloxacin tab 1
levofloxacin in d5w iv piggy back 1 B/D
OCUFLOX EYE DROPS 3
ofloxacin ear drops 1 GAP
ofloxacin eye drops 1 GAP
ofloxacin tab 1 GAP
Sulfonamides
BACTRIM TAB 3
BACTRIM DS TAB 3
sulfacetamide-prednisolone eye drops 1 GAP
sulfadiazine tab 2
sulfamethoxazole-trimethoprim iv 1 B/D; GAP
sulfamethoxazole-trimethoprim oral susp 1 GAP
sulfamethoxazole-trimethoprim tab 1 GAP
Tetracyclines
ADOXA TAB 50 mg 3
ADOXA PAK TAB 75 mg 3
demeclocycline tab 1 GAP
doxycycline hyclate cap 1 GAP
doxycycline hyclate cap, delayed release 1 GAP
doxycycline hyclate iv solution 100 mg 1 B/D; GAP
doxycycline hyclate tab 1 GAP
doxycycline hyclate tab, delayed release 1
doxycycline cap 1
doxycycline tab 1 GAP
DYNACIN TAB 3
MINOCIN CAP 3
minocycline cap 1 GAP
minocycline tab 1 GAP
PERIOSTAT TAB 3
tetracycline cap 1 GAP
VIBRAMYCIN CAP 3
VIBRA-TABS TAB 3
Anticonvulsants
Anticonvulsants, Other
BANZEL ORAL SUSP 3 QL (2400 ML per 30 day(s))
BANZEL TAB 400 mg 3 MO; QL (240 EA per 30 day(s))
BANZEL TAB 200 mg 3 MO; QL (480 EA per 30 day(s))
clonazepam tab 2 mg 1 E; QL (120 EA per 30 day(s))
clonazepam tab 0.5 mg, 1 mg 1 E; QL (90 EA per 30 day(s))
DIASTAT ACUDIAL RECTAL KIT 3 E; QL (5 EA per 30 day(s))
KEPPRA IV 3
KEPPRA ORAL SOLN 3 MO
KEPPRA TAB 250 mg, 750 mg 3 MO; QL (120 EA per 30 day(s))
KEPPRA TAB 500 mg 3 MO; QL (180 EA per 30 day(s))
KEPPRA TAB 1,000 mg 3 MO; QL (90 EA per 30 day(s))
KEPPRA XR 24 HR TAB 750 mg 2 MO; QL (120 EA per 30 day(s))
KEPPRA XR 24 HR TAB 500 mg 2 MO; QL (180 EA per 30 day(s))
levetiracetam iv 1 GAP
levetiracetam oral soln 1 MO; GAP
levetiracetam tab 250 mg, 750 mg 1 MO; GAP; QL (120 EA per 30
day(s))
levetiracetam tab 500 mg 1 MO; GAP; QL (180 EA per 30
day(s))
levetiracetam tab 1,000 mg 1 MO; GAP; QL (90 EA per 30
day(s)) Calcium Channel Modifying Agents
CELONTIN CAP 2 MO
ethosuximide cap 1 MO; GAP
ethosuximide syrup 1 MO; GAP
LYRICA CAP 150 mg 3 MO; QL (120 EA per 30 day(s))
LYRICA CAP 100 mg, 25 mg, 50 mg, 75 mg 3 MO; QL (150 EA per 30 day(s))
LYRICA CAP 225 mg, 300 mg 3 MO; QL (60 EA per 30 day(s))
LYRICA CAP 200 mg 3 MO; QL (90 EA per 30 day(s))
ZARONTIN CAP 3 MO
ZARONTIN SYRUP 3 MO
ZONEGRAN CAP 3 MO
zonisamide cap 1 MO; GAP
Gamma-Aminobutyric Acid (Gaba) Augmenting Agents
DEPACON IV 3
DEPAKENE CAP 3 MO
DEPAKENE SYRUP 3 MO
DEPAKOTE TAB 3 MO
DEPAKOTE ER 24 HR TAB 3 MO
DEPAKOTE SPRINKLES SPRINKLE CAP 3 MO
divalproex er 24 hr tab 1 MO; GAP
divalproex sprinkle cap 1 MO; GAP
divalproex tab, delayed release 1 MO; GAP
gabapentin cap 1 MO; GAP
gabapentin oral soln 1 QL (2160 ML per 30 day(s))
gabapentin tab 1 MO; GAP
GABITRIL TAB 2 MO
MYSOLINE TAB 50 mg 3
MYSOLINE TAB 250 mg 3 MO
NEURONTIN CAP 3 MO
NEURONTIN ORAL SOLN 3 MO; QL (2160 ML per 30 day(s))
NEURONTIN TAB 3 MO
primidone tab 1 MO; GAP
SABRIL ORAL POWDER IN PACKET 4 LA; QL (180 EA per 30 day(s))
SABRIL TAB 4 LA; QL (180 EA per 30 day(s))
valproate sodium iv 1 GAP
valproic acid cap 1 MO; GAP
valproic acid (as sodium salt) syrup 1 MO; GAP
Glutamate Reducing Agents
FELBATOL ORAL SUSP 2 MO
FELBATOL TAB 2 MO
LAMICTAL TAB 3 MO
lamotrigine dispersible tab 1 MO; GAP
lamotrigine tab 1 MO; GAP
TOPAMAX SPRINKLE CAP 3 MO
TOPAMAX TAB 3 MO
topiramate sprinkle cap 1 MO; GAP
topiramate tab 1 MO; GAP
Sodium Channel Inhibitors
carbamazepine chewable tab 1 MO; GAP
carbamazepine er 12 hr tab 1 MO; GAP
carbamazepine er multiphase 12 hr cap 1
carbamazepine oral susp 1 MO; GAP
carbamazepine tab 1 MO; GAP
CEREBYX INJECTION 3 B/D
DILANTIN CAP 2 MO
DILANTIN EXTENDED CAP 3 MO
DILANTIN INFATABS CHEWABLE 2 MO
DILANTIN-125 ORAL SUSP 3 MO
EPITOL TAB 1 MO; GAP
fosphenytoin injection 1 B/D; GAP
oxcarbazepine oral susp 1 MO; GAP
oxcarbazepine tab 1 MO; GAP
PEGANONE TAB 2 MO
PHENYTEK CAP 3 MO
phenytoin oral susp 1 MO; GAP
phenytoin sodium iv 1 B/D; GAP
phenytoin sodium extended cap 200 mg, 300 mg 1 GAP
phenytoin sodium extended cap 100 mg 1 MO; GAP
TEGRETOL CHEWABLE TAB 3 MO
TEGRETOL ORAL SUSP 3 MO
TEGRETOL TAB 3 MO
TEGRETOL XR 12 HR TAB 100 mg 2 MO
TEGRETOL XR 12 HR TAB 200 mg, 400 mg 3 MO
TRILEPTAL ORAL SUSP 3 MO
TRILEPTAL TAB 3 MO
VIMPAT IV 3
VIMPAT ORAL SOLN 3 MO; QL (1800 ML per 30 day(s))
VIMPAT TAB 3 MO; QL (60 EA per 30 day(s))
Antidementia Agents
Antidementia Agents, Other
ergoloid tab 1 GAP
Cholinesterase Inhibitors
ARICEPT TAB 23 mg 2 MO; QL (30 EA per 30 day(s))
ARICEPT TAB 10 mg, 5 mg 3 MO; QL (30 EA per 30 day(s))
ARICEPT ODT TAB, RAPID DISSOLVE 3 MO; QL (30 EA per 30 day(s))
COGNEX CAP 3
donepezil tab 1 MO; GAP; QL (30 EA per 30
day(s))
donepezil tab, rapid dissolve 1 MO; GAP; QL (30 EA per 30
day(s))
EXELON CAP 3 MO; QL (60 EA per 30 day(s))
EXELON ORAL SOLN 2 MO; QL (600 ML per 30 day(s))
EXELON TRANSDERM 24 HR PATCH 2 MO; QL (30 EA per 30 day(s))
galantamine er 24 hr cap 1 MO; GAP; QL (30 EA per 30
day(s))
galantamine oral soln 1 MO; GAP; QL (600 ML per 30
day(s))
galantamine tab 1 MO; GAP; QL (60 EA per 30
day(s))
RAZADYNE ORAL SOLN 3 MO; QL (600 ML per 30 day(s))
RAZADYNE TAB 3 MO; QL (60 EA per 30 day(s))
RAZADYNE ER 24 HR CAP 3 MO; QL (30 EA per 30 day(s))
rivastigmine cap 1 MO; GAP; QL (60 EA per 30
day(s)) Glutamate Pathway Modifiers
NAMENDA ORAL SOLN 2 MO; QL (300 ML per 30 day(s))
NAMENDA TAB 2 MO; QL (60 EA per 30 day(s))
NAMENDA TITRATION PAK TABS IN A DOSE PACK
2 MO
Antidepressants
Antidepressants, Other
BUDEPRION SR TAB 1 MO; GAP; QL (60 EA per 30
day(s))
BUDEPRION XL 24 HR TAB 300 mg 1 MO; GAP; QL (30 EA per 30
day(s))
BUDEPRION XL 24 HR TAB 150 mg 1 MO; GAP; QL (90 EA per 30
day(s))
bupropion hcl sr tab 150 mg 1 GAP; QL (60 EA per 30 day(s))
bupropion hcl sr tab 100 mg, 200 mg 1 MO; GAP; QL (60 EA per 30
day(s))
bupropion hcl tab 1 MO; GAP
maprotiline tab 1 MO; GAP
mirtazapine tab 1 MO; GAP
mirtazapine tab, rapid dissolve 1 MO; GAP
nefazodone tab 100 mg, 150 mg, 250 mg, 50 mg 1 MO; GAP; QL (60 EA per 30 day(s))
nefazodone tab 200 mg 1 MO; GAP; QL (90 EA per 30
day(s))
OLEPTRO ER 24 HR TAB 300 mg 3 QL (30 EA per 30 day(s))
OLEPTRO ER 24 HR TAB 150 mg 3 QL (75 EA per 30 day(s))
REMERON TAB 3 MO
REMERON SOLTAB 3 MO
trazodone tab 1 MO; GAP
VIIBRYD TAB 3 QL (30 EA per 30 day(s))
WELLBUTRIN TAB 3 MO
WELLBUTRIN SR TAB 3 MO; QL (60 EA per 30 day(s))
WELLBUTRIN XL 24 HR TAB 300 mg 3 MO; QL (30 EA per 30 day(s))
WELLBUTRIN XL 24 HR TAB 150 mg 3 MO; QL (90 EA per 30 day(s))
Monoamine Oxidase Inhibitors
EMSAM TRANSDERM 24 HR PATCH 3 MO; QL (30 EA per 30 day(s))
MARPLAN TAB 3 MO
PARNATE TAB 3 MO
tranylcypromine tab 1 MO; GAP
Serotonin/ Norepinephrine Reuptake Inhibitors
CYMBALTA CAP 60 mg 2 MO; QL (30 EA per 30 day(s))
CYMBALTA CAP 20 mg, 30 mg 2 MO; QL (60 EA per 30 day(s))
EFFEXOR TAB 3 MO; QL (90 EA per 30 day(s))
EFFEXOR XR 24 HR CAP 150 mg, 37.5 mg 3 MO; QL (30 EA per 30 day(s))
EFFEXOR XR 24 HR CAP 75 mg 3 MO; QL (90 EA per 30 day(s))
PRISTIQ 24 HR TAB 3 MO; QL (30 EA per 30 day(s))
SAVELLA TAB 2 QL (60 EA per 30 day(s))
SAVELLA TABS IN A DOSE PACK 2 QL (55 EA per 28 day(s))
venlafaxine er 24 hr cap 150 mg, 37.5 mg 1 MO; GAP; QL (30 EA per 30 day(s))
venlafaxine er 24 hr cap 75 mg 1 MO; GAP; QL (90 EA per 30
day(s))
venlafaxine er 24 hr tab 150 mg, 225 mg 2 MO; QL (30 EA per 30 day(s)) venlafaxine er 24 hr tab 37.5 mg, 75 mg 2 MO; QL (90 EA per 30 day(s))
venlafaxine tab 75 mg 1 MO; GAP; QL (150 EA per 30
day(s))
venlafaxine tab 100 mg, 25 mg, 37.5 mg, 50 mg 1 MO; GAP; QL (90 EA per 30 day(s))
Tricyclics
amitriptyline tab 1 MO; GAP
amoxapine tab 1 MO; GAP
ANAFRANIL CAP 3 MO
clomipramine cap 1 MO; GAP
desipramine tab 1 MO; GAP
doxepin cap 1 MO; GAP
doxepin oral concentrate 1 MO; GAP
imipramine tab 1 MO; GAP
imipramine pamoate cap 1 MO; GAP
NORPRAMIN TAB 3 MO
nortriptyline cap 1 MO; GAP
nortriptyline oral soln 1 MO; GAP
PAMELOR CAP 3 MO
perphenazine-amitriptyline tab 1 MO; GAP
protriptyline tab 1 MO; GAP
SURMONTIL CAP 3
TOFRANIL TAB 3 MO
VIVACTIL TAB 3 MO
Antidotes, Deterrents, And Toxicologic Agents Alcohol Deterrents
ANTABUSE TAB 2
CAMPRAL TAB 2
disulfiram tab 1
Antidotes
acetylcysteine soln 1 GAP
amifostine crystalline iv solution 1 GAP
ANTIZOL IV 3 B/D
ETHYOL IV SOLUTION 3
EXJADE TAB 2 LA
fomepizole iv 1 B/D; GAP
leucovorin calcium solution for injection 1 B/D; GAP
leucovorin calcium tab 1 MO; GAP
mesna iv 1 B/D; GAP
MESNEX TAB 2 MO
sodium polystyrene sulfonate oral powder 1 GAP
SYPRINE CAP 2
Opioid Antagonists
DEPADE TAB 1 GAP
naloxone syringe 1 B/D; GAP
naltrexone tab 1 GAP
REVIA TAB 3
Smoking Cessation Agents
CHANTIX TAB 3
CHANTIX STARTING MONTH PAK TABS IN A DOSE PACK
3
NICOTROL INHALATION CARTRIDGE 2
NICOTROL NS NASAL SPRAY 2 Antiemetics
5-Hydroxytryptamine 3 (5-Ht3) Antagonists
ANZEMET TAB 100 mg 3 B/D; QL (4 EA per 30 day(s))
ANZEMET TAB 50 mg 3 B/D; QL (8 EA per 30 day(s))
granisetron tab 1 B/D; GAP; QL (30 EA per 30
day(s))
GRANISOL ORAL SOLN 1 B/D; GAP
KYTRIL TAB 3 B/D; QL (30 EA per 30 day(s))
ondansetron tab, rapid dissolve 1 B/D; GAP; QL (45 EA per 30
day(s))
ondansetron hcl oral soln 1 B/D; GAP; QL (450 ML per 30
day(s))
ondansetron hcl tab 24 mg 1 B/D; GAP; QL (15 EA per 30
day(s))
ondansetron hcl tab 4 mg, 8 mg 1 B/D; GAP; QL (45 EA per 30
day(s))
ondansetron hcl (pf) injection 1 GAP
ZOFRAN IV 3
ZOFRAN ORAL SOLN 3 B/D; QL (450 ML per 30 day(s))
ZOFRAN TAB 3 B/D; QL (45 EA per 30 day(s))
ZOFRAN ODT TAB, RAPID DISSOLVE 3 B/D; QL (45 EA per 30 day(s))
Antiemetics, Other
CESAMET CAP 3 QL (60 EA per 30 day(s))
COMPRO RECTAL SUPPOSITORY 1 MO; GAP
dronabinol cap 1 GAP; QL (120 EA per 30 day(s))
MARINOL CAP 3 QL (120 EA per 30 day(s))
metoclopramide oral soln 1 GAP
metoclopramide tab 1 GAP
PHENADOZ RECTAL SUPPOSITORY 1 GAP
PHENERGAN INJECTION 3 B/D
prochlorperazine rectal suppository 1 MO; GAP
prochlorperazine edisylate injection 1 GAP
prochlorperazine maleate tab 1 MO; GAP
promethazine injection 1 B/D; GAP
promethazine rectal suppository 1 GAP
promethazine syringe 1 B/D; GAP
promethazine syrup 1 GAP
promethazine tab 1 GAP
PROMETHAZINE VC SYRUP 1 GAP
PROMETHEGAN RECTAL SUPPOSITORY 1 GAP
REGLAN TAB 3
SANCUSO TRANSDERM PATCH 3 QL (4 EA per 28 day(s))
TIGAN CAP 3
TIGAN IM 3 B/D
TRANSDERM-SCOP 72 HR TRANSDERM PATCH
3
trimethobenzamide cap 1 GAP
trimethobenzamide im syringe 1 B/D; GAP
Neurokinin 1 (Nk1) Receptor Antagonists
EMEND CAP 2 QL (6 EA per 30 day(s))
EMEND CAPS IN DOSE PACK 2 QL (6 EA per 30 day(s))
Antifungals
Allylamine Antifungals
LAMISIL TAB 3 QL (30 EA per 30 day(s))
NAFTIN TOPICAL CREAM 2
NAFTIN TOPICAL GEL 2
terbinafine tab 1 GAP; QL (30 EA per 30 day(s))
Antifungals (Other)
ANCOBON CAP 3
ciclopirox shampoo 1 GAP
ciclopirox topical cream 1 GAP
ciclopirox topical gel 1 GAP
ciclopirox topical soln 1 GAP
ciclopirox topical susp 1 GAP
GRIFULVIN V TAB 3
griseofulvin microsize oral susp 1 GAP
LOPROX SHAMPOO 3
LOPROX TOPICAL GEL 3
PENLAC TOPICAL SOLN 3
Azole Antifungals
clotrimazole topical cream 1 GAP
clotrimazole troche 1 GAP
clotrimazole-betamethasone lotion 1 GAP
clotrimazole-betamethasone topical cream 1 GAP
DIFLUCAN ORAL SUSP 3
DIFLUCAN TAB 100 mg, 200 mg, 50 mg 3
DIFLUCAN TAB 150 mg 3 QL (4 EA per 30 day(s))
econazole topical cream 1 GAP
EXELDERM TOPICAL CREAM 3
EXELDERM TOPICAL SOLN 3
fluconazole oral susp 1 GAP
fluconazole tab 100 mg, 200 mg, 50 mg 1 GAP
fluconazole tab 150 mg 1 GAP; QL (4 EA per 30 day(s))
fluconazole in dextrose (iso-osmotic) iv piggy back
1 B/D; GAP
itraconazole cap 1 PA; GAP
ketoconazole shampoo 1 GAP
ketoconazole tab 1 GAP
ketoconazole topical cream 1 GAP
KURIC TOPICAL CREAM 1 GAP
LOTRISONE LOTION 3
LOTRISONE TOPICAL CREAM 3
MICONAZOLE-3 VAGINAL SUPPOSITORY 1 GAP
NIZORAL SHAMPOO 3
NOXAFIL ORAL SUSP 2 PA
OXISTAT LOTION 3
OXISTAT TOPICAL CREAM 3
SPORANOX CAP 3 PA
TERAZOL 3 VAGINAL CREAM 3 QL (40 GM per 30 day(s))
TERAZOL 3 VAGINAL SUPPOSITORY 3 QL (12 EA per 30 day(s))
TERAZOL 7 VAGINAL CREAM 3 QL (90 GM per 30 day(s))
terconazole vaginal cream 0.8 % 1 GAP; QL (40 GM per 30 day(s))
terconazole vaginal cream 0.4 % 1 GAP; QL (90 GM per 30 day(s))
terconazole vaginal suppository 1 GAP; QL (12 EA per 30 day(s))
VFEND ORAL SUSP 3 QL (300 ML per 30 day(s))
VFEND TAB 50 mg 3 QL (120 EA per 30 day(s))
VFEND TAB 200 mg 3 QL (60 EA per 30 day(s))
VFEND IV SOLN 4 B/D
voriconazole tab 50 mg 1 QL (120 EA per 30 day(s))
voriconazole tab 200 mg 1 QL (60 EA per 30 day(s))
ZAZOLE VAGINAL CREAM 0.8 % 1 GAP; QL (40 GM per 30 day(s))
ZAZOLE VAGINAL CREAM 0.4 % 1 GAP; QL (90 GM per 30 day(s))
ZAZOLE VAGINAL SUPPOSITORY 1 GAP
Echinocandin Antifungals
CANCIDAS IV SOLUTION 3 B/D
ERAXIS(WATER DILUENT) IV SOLUTION 3 B/D
Polyene Antifungals
NATACYN EYE DROPS 3
nystatin ointment 1 GAP
nystatin oral susp 1 GAP
nystatin tab 1 GAP
nystatin topical cream 1 GAP
nystatin topical powder 1 GAP
nystatin-triamcinolone ointment 1 GAP
nystatin-triamcinolone topical cream 1 GAP
NYSTOP TOPICAL POWDER 1 GAP
PEDI-DRI TOPICAL POWDER 1 GAP
Antigout Agents
Antigout Agents (Non-Renal Tubular Blocking Agents And Non-Xanthine Inhibitors)
COLCRYS TAB 3 MO; QL (120 EA per 30 day(s))
Renal Tubular Blocking Agents
colchicine-probenecid tab 1 MO; GAP
probenecid tab 1 MO; GAP
Xanthine Oxidase Inhibitors
allopurinol tab 1 MO; GAP
allopurinol iv solution 1 B/D; GAP
ALOPRIM IV SOLUTION 3 B/D; MO
ULORIC TAB 2 MO; QL (30 EA per 30 day(s))
ZYLOPRIM TAB 3 MO
Anti-Inflammatory Agents
Nonsteroidal Anti-Inflammatory Drugs
ANAPROX TAB 3
ANAPROX DS TAB 3
ARTHROTEC 50 TAB 3
ARTHROTEC 75 TAB 3
CATAFLAM TAB 3
CELEBREX CAP 3 QL (60 EA per 30 day(s))
CLINORIL TAB 3
DAYPRO TAB 3
diclofenac potassium tab 1 GAP
diclofenac sodium er 24 hr tab 1 GAP
diclofenac sodium tab, delayed release 1 GAP
diflunisal tab 1 GAP
EC-NAPROSYN TAB 3
etodolac cap 1 GAP
etodolac er 24 hr tab 1 GAP
etodolac tab 1 GAP
FELDENE CAP 3
fenoprofen tab 1 GAP
FLECTOR ADHESIVE PATCH 3 QL (60 EA per 30 day(s))
flurbiprofen tab 1 GAP
ibuprofen tab 1 GAP
indomethacin cap 1 GAP
indomethacin er cap 1 GAP
ketoprofen cap 1 GAP
ketoprofen er 24 hr cap 1 GAP
ketorolac injection 1 B/D; GAP
ketorolac tab 1 GAP; QL (20 EA per 30 day(s))
meclofenamate cap 3
meloxicam oral susp 1 GAP; QL (300 ML per 30 day(s))
meloxicam tab 1 GAP; QL (30 EA per 30 day(s))
MOBIC TAB 3 QL (30 EA per 30 day(s))
nabumetone tab 1 GAP
NALFON CAP 400 mg 3
NAPROSYN ORAL SUSP 3
NAPROSYN TAB 3
naproxen oral susp 1 GAP
naproxen tab 500 mg 1
naproxen tab 250 mg, 375 mg 1 GAP
naproxen tab, delayed release 1 GAP
naproxen sodium tab 1 GAP
oxaprozin tab 1 GAP
piroxicam cap 1 GAP
sulindac tab 1 GAP
tolmetin cap 1 GAP
tolmetin tab 1 GAP
VOLTAREN TAB 3
VOLTAREN TOPICAL GEL 3
VOLTAREN-XR 24 HR TAB 3
Antimigraine Agents Ergot Alkaloids
CAFERGOT TAB 3 QL (40 EA per 30 day(s))
D.H.E.45 INJECTION 3 B/D
dihydroergotamine injection 1 B/D; GAP
ergotamine-caffeine tab 1 GAP; QL (40 EA per 30 day(s))
MIGERGOT RECTAL SUPPOSITORY 1 GAP; QL (20 EA per 28 day(s))
MIGRANAL NASAL SPRAY 3 QL (16 ML per 30 day(s))
Triptans
AMERGE TAB 3 QL (9 EA per 30 day(s))
FROVA TAB 3 QL (12 EA per 30 day(s))
IMITREX SUB-Q 3 QL (6 ML per 30 day(s))
IMITREX TAB 3 QL (9 EA per 30 day(s))
MAXALT TAB 2 QL (12 EA per 30 day(s))
MAXALT-MLT TAB, RAPID DISSOLVE 2 QL (12 EA per 30 day(s))
naratriptan tab 1 GAP; QL (9 EA per 30 day(s))
RELPAX TAB 2 QL (9 EA per 30 day(s))
sumatriptan sub-q 6 mg/0.5 mL 1 GAP; QL (6 ML per 30 day(s))
sumatriptan sub-q pen injector 1 QL (6 ML per 30 day(s))
sumatriptan tab 1 GAP; QL (9 EA per 30 day(s))
ZOMIG NASAL SPRAY 3 QL (6 EA per 30 day(s))
ZOMIG TAB 3 QL (9 EA per 30 day(s))
ZOMIG ZMT TAB, RAPID DISSOLVE 3 QL (9 EA per 30 day(s)) Antimyasthenic Agents
Parasympathomimetics
guanidine tab 1 GAP
MESTINON SYRUP 3
MESTINON TAB 3
MYTELASE TAB 3
pyridostigmine bromide tab 1 GAP
Antimycobacterials
Antimycobacterials, Other
ACZONE TOPICAL GEL 3
dapsone tab 2
MYCOBUTIN CAP 2
Antituberculars
CAPASTAT SOLUTION FOR INJECTION 3 B/D
ethambutol tab 1 GAP
ISONARIF CAP 1 GAP
isoniazid injection 1 GAP
isoniazid syrup 1 GAP
isoniazid tab 1 GAP
MYAMBUTOL TAB 3
PASER ORAL PACKET 2
PRIFTIN TAB 2
pyrazinamide tab 1 GAP
RIFADIN CAP 3
RIFADIN IV SOLUTION 3 B/D
RIFAMATE CAP 3
rifampin cap 1 GAP
rifampin iv solution 1 B/D; GAP
RIFATER TAB 2
SEROMYCIN CAP 2
TRECATOR TAB 2
Antineoplastics
Alkylating Agents, Other
BUSULFEX IV 3 B/D
carboplatin iv 1 B/D; GAP
cisplatin iv 1 B/D; GAP
cyclophosphamide tab 1 MO; GAP
dacarbazine iv solution 1 B/D; GAP
ifosfamide iv solution 1 B/D; GAP
ifosfamide-mesna iv kit 4 B/D
MATULANE CAP 4
oxaliplatin soln 1 B/D; GAP
thiotepa solution for injection 3 B/D
TREANDA IV SOLUTION 4 B/D
vinblastine iv powder for solution 2 B/D
vincristine iv 1 B/D; GAP
Antiangiogenic Agents
REVLIMID CAP 4 LA; QL (30 EA per 30 day(s))
THALOMID CAP 4
Anti-Cd20 Antibodies
ARZERRA IV 4 B/D
AVASTIN IV 3 B/D
CAMPATH IV 2 B/D; LA
ERBITUX IV 2 B/D
RITUXAN CONCENTRATE, IV 4 B/D; LA
SIMULECT IV SOLUTION 4 B/D
VECTIBIX IV 3 B/D
Antimetabolites, Other
ALIMTA IV SOLUTION 4 B/D
DROXIA CAP 2
fluorouracil iv 1 B/D; GAP
HYDREA CAP 3 MO
hydroxyurea cap 1 MO; GAP
idarubicin iv 1 B/D; GAP
Antineoplastics, Other
ABRAXANE IV SOLUTION 2 B/D
ADRIAMYCIN PFS IV 1 B/D; GAP
bleomycin solution for injection 2 B/D
COSMEGEN IV SOLUTION 2 B/D
daunorubicin iv solution 2 B/D
DAUNOXOME IV 2 B/D
DOCEFREZ IV SOLUTION 4 B/D
docetaxel iv 4 B/D
DOXIL IV 3 B/D
doxorubicin iv 1 B/D; GAP
ELSPAR SOLUTION FOR INJECTION 2 B/D
epirubicin iv 1 B/D; GAP
ETOPOPHOS IV SOLUTION 2 B/D
etoposide iv 1 B/D; GAP
HALAVEN IV 3 B/D
HYCAMTIN IV SOLUTION 4 B/D
irinotecan iv 1 B/D; GAP
ISTODAX IV SOLUTION 4 B/D
IXEMPRA IV SOLUTION 4 B/D
JEVTANA IV 4 PA
LYSODREN TAB 2 MO
mitomycin iv solution 1 B/D; GAP
mitoxantrone concentrate, iv 1 B/D; GAP
NOVANTRONE CONCENTRATE, IV 3 B/D
ONCASPAR INJECTION 2 B/D
ONTAK IV 2 B/D
paclitaxel concentrate, iv 1 B/D; GAP
PANRETIN TOPICAL GEL 2
PHOTOFRIN IV SOLUTION 4 B/D
SYLATRON SUB-Q KIT 4 PA
TAXOTERE IV 4 B/D
topotecan iv solution 4 B/D
TORISEL IV SOLUTION 4 B/D
TRISENOX IV 2 B/D
VELCADE IV SOLUTION 2 B/D
vinorelbine iv 1 B/D; GAP
ZANOSAR IV SOLUTION 2 B/D
ZOLINZA CAP 4 QL (120 EA per 30 day(s))
ZYTIGA TAB 4 PA
Aromatase Inhibitors, 3Rd Generation
anastrozole tab 1 MO; GAP
ARIMIDEX TAB 3 MO
AROMASIN TAB 3 MO
exemestane tab 1
FEMARA TAB 3 MO
letrozole tab 1
Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors
IRESSA TAB 4 LA; QL (30 EA per 30 day(s))
TARCEVA TAB 4
vandetanib tab 4 PA; LA
Estrogen-Nitrosoureas
EMCYT CAP 3 MO
FASLODEX IM SYRINGE 4 B/D
Ethylenimines/ Methylmelamines
HEXALEN CAP 4
Multitargeted Kinase Inhibitors, Bcr-Abl/C-Kit Receptor Tyrosine Kinase Inhibitors
GLEEVEC TAB 4
SPRYCEL TAB 100 mg 4 MO; QL (30 EA per 30 day(s))
SPRYCEL TAB 50 mg 4 QL (120 EA per 30 day(s))
SPRYCEL TAB 140 mg, 80 mg 4 QL (30 EA per 30 day(s))
SPRYCEL TAB 20 mg, 70 mg 4 QL (60 EA per 30 day(s))
TASIGNA CAP 4 QL (112 EA per 28 day(s))
Multitargeted Kinase Inhibitors, Her2 Receptor Tyrosine Kinase Inhibitors
HERCEPTIN IV SOLUTION 4 B/D
TYKERB TAB 4 QL (150 EA per 30 day(s))
Multitargeted Kinase Inhibitors, Vascular Endothelial Growth Factor Receptor Tyrosine Kinase Inhib.
AFINITOR TAB 4 QL (30 EA per 30 day(s))
NEXAVAR TAB 4 LA; QL (120 EA per 30 day(s))
SUTENT CAP 4
VOTRIENT TAB 4 MO; QL (120 EA per 30 day(s))
ZORTRESS TAB 2 B/D; QL (60 EA per 30 day(s))
Nitrogen Mustards
LEUKERAN TAB 2 MO
melphalan iv solution 1 B/D; GAP
MUSTARGEN SOLUTION FOR INJECTION 2 B/D
Nitrosoureas
BICNU IV SOLUTION 3 B/D
CEENU CAP 3 MO
Purine Analogs And Related Inhibitors
ARRANON IV 3 B/D
cladribine iv 1 B/D; GAP
CLOLAR IV 2 B/D
cytarabine (pf) solution for injection 1 B/D; GAP
DACOGEN IV SOLUTION 4 B/D
fludarabine iv powder for solution 1 B/D; GAP
gemcitabine iv solution 1 B/D
GEMZAR IV SOLUTION 3 B/D
mercaptopurine tab 1 MO; GAP
pentostatin iv solution 1 B/D; GAP
PURINETHOL TAB 3 MO
TABLOID TAB 3 MO
VIDAZA SUB-Q SOLN 2 B/D
Retinoids
TARGRETIN CAP 4
TARGRETIN TOPICAL GEL 2
tretinoin (chemotherapy) cap 1 MO; GAP
Selective Estrogen Receptor Modulators, 1St Generation
FARESTON TAB 3 MO
tamoxifen tab 1 MO; GAP
Antiparasitics Anthelmintics
ALBENZA TAB 3
BILTRICIDE TAB 3
mebendazole chewable tab 1 GAP
Antimalarials
ARALEN TAB 3
chloroquine tab 1 GAP
COARTEM TAB 2 QL (24 EA per 31 day(s))
DARAPRIM TAB 2
hydroxychloroquine tab 1 MO; GAP
PLAQUENIL TAB 3 MO
QUALAQUIN CAP 2 PA
Antiprotozoals (Non-Antimalarials)
ALINIA ORAL SUSP 3 QL (60 ML per 7 day(s))
ALINIA TAB 3 QL (60 EA per 30 day(s))
MEPRON ORAL SUSP 2
NEBUPENT SOLUTION FOR INHALATION 3
PENTAM SOLUTION FOR INJECTION 3 B/D
Pediculicides/ Scabicides
EURAX LOTION 3
EURAX TOPICAL CREAM 3
OVIDE LOTION 3
permethrin topical cream 1 GAP
Antiparkinson Agents Anticholinergics
benztropine tab 1 MO; GAP
trihexyphenidyl elixir 1 MO; GAP
trihexyphenidyl tab 1 MO; GAP
Antiparkinson Agents, Other
amantadine cap 1 MO; GAP
amantadine syrup 1 MO; GAP
amantadine tab 1 MO; GAP
APOKYN SUBQ CARTRIDGE 4 LA; QL (60 ML per 30 day(s))
Catechol O-Methyltransferase (Comt) Inhibitors
COMTAN TAB 2 MO
TASMAR TAB 2 MO
Dopamine Agonists, Ergot
bromocriptine cap 1 MO; GAP
bromocriptine tab 1 MO; GAP
cabergoline tab 1 GAP
PARLODEL CAP 3 MO
PARLODEL TAB 3 MO
Dopamine Agonists, Nonergot
MIRAPEX TAB 3 MO
MIRAPEX ER 24 HR TAB 0.375 mg, 0.75 mg, 1.5 mg, 3 mg
3 MO
MIRAPEX ER 24 HR TAB 4.5 mg 3 MO; QL (30 EA per 30 day(s))
pramipexole tab 1 MO; GAP
REQUIP TAB 3 MO
REQUIP XL 24 HR TAB 12 mg, 6 mg, 8 mg 2 MO; QL (60 EA per 30 day(s))
REQUIP XL 24 HR TAB 2 mg, 4 mg 2 MO; QL (90 EA per 30 day(s))
ropinirole tab 1 MO; GAP
Dopamine Precursors
carbidopa-levodopa er tab 1 MO; GAP
carbidopa-levodopa tab 1 MO; GAP
PARCOPA TAB, RAPID DISSOLVE 25-100 mg, 25-250 mg
3 MO
SINEMET TAB 3 MO
SINEMET CR TAB 3 MO
STALEVO 100 TAB 2 MO
STALEVO 125 TAB 2 MO
STALEVO 150 TAB 2 MO
STALEVO 200 TAB 2 MO
STALEVO 50 TAB 2 MO
STALEVO 75 TAB 2 MO
Monoamine Oxidase B (Mao-B) Inhibitors
AZILECT TAB 2 MO; QL (30 EA per 30 day(s))
ELDEPRYL CAP 3 MO
selegiline cap 1 MO; GAP
selegiline tab 1 MO; GAP
Antipsychotics Atypicals
ABILIFY IM 2
ABILIFY ORAL SOLN 2 MO
ABILIFY TAB 2 MO
ABILIFY DISCMELT 2 MO
clozapine tab 1 MO; GAP
CLOZARIL TAB 3 MO
FANAPT TAB 3 MO
FANAPT TABS IN A DOSE PACK 3 MO
FAZACLO TAB, RAPID DISSOLVE 2 MO
GEODON CAP 2 MO; QL (60 EA per 30 day(s))
GEODON IM 2
INVEGA 24 HR TAB 3 mg, 9 mg 3 MO; QL (30 EA per 30 day(s))
INVEGA 24 HR TAB 1.5 mg, 6 mg 3 MO; QL (60 EA per 30 day(s))
INVEGA SUSTENNA IM SYRINGE 39 mg/0.25 mL
3 MO; QL (0.5 ML per 30 day(s))
INVEGA SUSTENNA IM SYRINGE 156 mg/mL (1 mL), 78 mg/0.5 mL
3 MO; QL (1 ML per 30 day(s))
INVEGA SUSTENNA IM SYRINGE 117 mg/0.75 mL, 234 mg/1.5 mL
3 MO; QL (1.5 ML per 30 day(s))
LATUDA TAB 3 MO; QL (30 EA per 30 day(s))
RISPERDAL ORAL SOLN 3 MO
RISPERDAL TAB 3 MO
RISPERDAL CONSTA IM SYRINGE 2
RISPERDAL M-TAB 3 MO
risperidone oral soln 1 MO; GAP
risperidone tab 1 MO; GAP
risperidone tab, rapid dissolve 1 MO; GAP
SAPHRIS SUBLINGUAL TAB 3 MO; QL (60 EA per 30 day(s))
SEROQUEL TAB 50 mg 2 MO
SEROQUEL TAB 100 mg, 200 mg, 25 mg, 300 mg, 400 mg
2 MO; QL (60 EA per 30 day(s))
SEROQUEL XR 24 HR TAB 300 mg, 400 mg 2 MO; QL (60 EA per 30 day(s)) SEROQUEL XR 24 HR TAB 150 mg, 200 mg, 50
mg
2 MO; QL (90 EA per 30 day(s))
ZYPREXA IM 2
ZYPREXA TAB 2 MO; QL (30 EA per 30 day(s))
ZYPREXA ZYDIS TAB, RAPID DISSOLVE 2 MO; QL (30 EA per 30 day(s))
Conventional
chlorpromazine injection 1 GAP
chlorpromazine tab 1 MO; GAP
fluphenazine decanoate injection 1 GAP
fluphenazine elixir 1 MO; GAP
fluphenazine injection 1 GAP
fluphenazine oral concentrate 1 MO; GAP
fluphenazine tab 1 MO; GAP
HALDOL INJECTION 3
HALDOL DECANOATE IM 3
haloperidol tab 1 MO; GAP
haloperidol decanoate im 1 GAP
haloperidol injection 1 GAP
haloperidol oral concentrate 1 MO; GAP
loxapine cap 1 MO; GAP
LOXITANE CAP 3 MO
NAVANE CAP 10 mg, 2 mg, 5 mg 3 MO
ORAP TAB 2
perphenazine tab 1 MO; GAP
thioridazine tab 1 MO; GAP
thiothixene cap 1 MO; GAP
trifluoperazine tab 1 MO; GAP
Antispasticity Agents Antispasticity Agents
baclofen tab 1 GAP
DANTRIUM CAP 3
dantrolene cap 1 GAP
tizanidine tab 1 GAP
ZANAFLEX TAB 3 Antivirals
Anti-Cytomegalovirus (Cmv) Agents
foscarnet iv 1 B/D; GAP
ganciclovir cap 1 MO; GAP
VISTIDE IV 3 B/D
Antihepatitis Agents
BARACLUDE ORAL SOLN 2 QL (600 ML per 30 day(s))
BARACLUDE TAB 2 QL (30 EA per 30 day(s))
COPEGUS TAB 3 PA
HEPSERA TAB 2 QL (30 EA per 30 day(s))
INCIVEK TAB 4 PA
REBETOL CAP 3 PA
REBETOL ORAL SOLN 2 PA
RIBASPHERE CAP 1 PA; GAP
RIBASPHERE TAB 1 PA; GAP
ribavirin cap 1 PA; GAP
ribavirin tab 1 PA; GAP
TYZEKA TAB 2 QL (30 EA per 30 day(s))
VICTRELIS CAP 4 PA
Antiherpetic Agents
acyclovir cap 1 GAP
acyclovir oral susp 1 GAP
acyclovir tab 1 GAP
acyclovir sodium iv powder for solution 1 B/D; GAP
CYTOVENE IV SOLUTION 3 B/D
DENAVIR TOPICAL CREAM 3
famciclovir tab 500 mg 1 GAP; QL (60 EA per 30 day(s))
famciclovir tab 125 mg, 250 mg 1 GAP; QL (90 EA per 30 day(s))
FAMVIR TAB 500 mg 3 QL (60 EA per 30 day(s))
FAMVIR TAB 125 mg, 250 mg 3 QL (90 EA per 30 day(s))
ganciclovir iv solution 1 B/D; GAP
valacyclovir tab 1 GAP; QL (60 EA per 30 day(s))
VALCYTE ORAL SOLUTION 3
VALCYTE TAB 3 MO
VALTREX TAB 3 QL (60 EA per 30 day(s))
ZOVIRAX CAP 3
ZOVIRAX OINTMENT 2 QL (30 GM per 30 day(s))
ZOVIRAX ORAL SUSP 3
ZOVIRAX TAB 3
ZOVIRAX TOPICAL CREAM 2 QL (15 GM per 30 day(s))
Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors
ATRIPLA TAB 4 QL (30 EA per 30 day(s))
EDURANT TAB 3 QL (30 EA per 30 day(s))
INTELENCE TAB 100 mg 4 QL (120 EA per 30 day(s))
INTELENCE TAB 200 mg 4 QL (60 EA per 30 day(s))
RESCRIPTOR DISPERSIBLE TAB 3 MO
RESCRIPTOR TAB 3 MO
SUSTIVA CAP 2 MO
SUSTIVA TAB 2 MO
VIRAMUNE ORAL SUSP 2 MO
VIRAMUNE TAB 2 MO
VIRAMUNE XR 24 HR TAB 2
Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors
COMBIVIR TAB 2 MO
didanosine cap, delayed release 1 MO; GAP
EMTRIVA CAP 3 MO
EMTRIVA ORAL SOLN 3 MO
EPIVIR ORAL SOLN 2 MO
EPIVIR TAB 2 MO
EPIVIR HBV ORAL SOLN 2 MO
EPIVIR HBV TAB 2 MO
EPZICOM TAB 2 MO
RETROVIR CAP 3 MO
RETROVIR IV 3
RETROVIR SYRUP 3 MO
RETROVIR TAB 3 MO
stavudine cap 1 MO; GAP
stavudine oral solution 1 MO; GAP
TRIZIVIR TAB 4
TRUVADA TAB 4
VIDEX 2 GRAM PEDIATRIC ORAL SOLUTION
3 MO
VIDEX EC CAP 3 MO
VIREAD TAB 3 MO
ZERIT CAP 3 MO
ZERIT ORAL SOLUTION 3 MO
ZIAGEN ORAL SOLN 2 MO
ZIAGEN TAB 2 MO
zidovudine cap 1 MO; GAP
zidovudine syrup 1 MO; GAP
zidovudine tab 1 MO; GAP
Anti-Hiv Agents, Other
FUZEON SUB-Q KIT 4 QL (1 EA per 30 day(s))
ISENTRESS TAB 4 QL (60 EA per 30 day(s))
SELZENTRY TAB 300 mg 4 QL (120 EA per 30 day(s))
SELZENTRY TAB 150 mg 4 QL (60 EA per 30 day(s))
Anti-Hiv Agents, Protease Inhibitors
APTIVUS CAP 3 MO
APTIVUS ORAL SOLN 3 MO; QL (300 ML per 30 day(s))
CRIXIVAN CAP 3 MO
INVIRASE CAP 3 MO
INVIRASE TAB 3 MO
KALETRA ORAL SOLN 4
KALETRA TAB 100-25 mg 3 MO
KALETRA TAB 200-50 mg 4
LEXIVA ORAL SUSP 3 MO
LEXIVA TAB 3 MO
NORVIR CAP 3 MO
NORVIR ORAL SOLN 3 MO
NORVIR TAB 3 MO
PREZISTA TAB 3 MO
REYATAZ CAP 2 MO
VIRACEPT ORAL POWDER 3 MO
VIRACEPT TAB 3 MO
Anti-Influenza Agents
FLUMADINE TAB 3
RELENZA DISKHALER FOR INHALATION 3 QL (56 EA per 180 day(s))
rimantadine tab 1 GAP
TAMIFLU CAP 75 mg 2 QL (28 EA per 180 day(s))
TAMIFLU CAP 45 mg 2 QL (42 EA per 180 day(s))
TAMIFLU CAP 30 mg 2 QL (84 EA per 180 day(s))
TAMIFLU ORAL SUSP 12 mg/mL 2 QL (275 ML per 180 day(s))
TAMIFLU ORAL SUSP 6 mg/mL 2 QL (550 ML per 180 day(s))
Anxiolytics Antidepressants
CELEXA TAB 3 MO
citalopram oral soln 1 MO; GAP
citalopram tab 1 MO; GAP
fluoxetine cap 1 MO; GAP
fluoxetine cap, delayed release 1 MO; GAP; QL (4 EA per 28 day(s))
fluoxetine oral soln 1 MO; GAP
fluoxetine tab 1 MO; GAP
fluvoxamine tab 1 MO; GAP
LEXAPRO ORAL SOLN 2 MO; QL (600 ML per 30 day(s))
LEXAPRO TAB 20 mg, 5 mg 2 MO; QL (30 EA per 30 day(s))
LEXAPRO TAB 10 mg 2 MO; QL (45 EA per 30 day(s))
NARDIL TAB 3 MO
paroxetine er 24 hr tab 12.5 mg 1 MO; GAP; QL (60 EA per 30
day(s))
paroxetine er 24 hr tab 25 mg 1 MO; GAP; QL (90 EA per 30
day(s))
paroxetine er 24 hr tab 37.5 mg 1 QL (60 EA per 30 day(s))
paroxetine oral susp 1 MO; GAP
paroxetine tab 1 MO; GAP
PAXIL ORAL SUSP 3 MO
PAXIL TAB 3 MO
PAXIL CR 24 HR TAB 12.5 mg 3 MO; QL (60 EA per 30 day(s))
PAXIL CR 24 HR TAB 25 mg 3 MO; QL (90 EA per 30 day(s))
phenelzine tab 1
PROZAC CAP 3 MO
PROZAC WEEKLY CAP 3 MO; QL (4 EA per 28 day(s))
sertraline oral concentrate 1 MO; GAP; QL (300 ML per 30
day(s))
sertraline tab 1 MO; GAP
ZOLOFT ORAL CONCENTRATE 3 MO; QL (300 ML per 30 day(s))
ZOLOFT TAB 3 MO
Anxiolytics, Other
alprazolam tab 1 E; QL (90 EA per 30 day(s))
amitriptyline-chlordiazepoxide tab 1 MO; GAP
BUSPAR TAB 3 MO
buspirone tab 1 MO; GAP
chlordiazepoxide cap 1 E; QL (120 EA per 30 day(s))
clorazepate dipotassium tab 15 mg 1 E; QL (120 EA per 30 day(s)) clorazepate dipotassium tab 3.75 mg, 7.5 mg 1 E; QL (90 EA per 30 day(s))
diazepam tab 1 E; QL (120 EA per 30 day(s))
lorazepam tab 1 E; QL (90 EA per 30 day(s))
meprobamate tab 1 GAP
oxazepam cap 1 E; QL (120 EA per 30 day(s))
Bipolar Agents Bipolar Agents
lithium carbonate cap 1 MO; GAP
lithium carbonate er tab 1 MO; GAP
lithium carbonate tab 1 MO; GAP
lithium citrate oral soln 1 MO; GAP
LITHOBID TAB 3 MO
SYMBYAX CAP 2 MO; QL (30 EA per 30 day(s))
Blood Glucose Regulators Alpha Glucosidase Inhibitors
acarbose tab 1 MO; GAP; QL (90 EA per 30
day(s))
GLYSET TAB 2 MO; QL (90 EA per 30 day(s))
PRECOSE TAB 3 MO; QL (90 EA per 30 day(s))
Amylinomimetics
SYMLIN SUB-Q 2 MO; QL (20 ML per 30 day(s))
SYMLINPEN 120 SUB-Q PEN INJECTOR 2 MO; QL (5.4 ML per 30 day(s))
SYMLINPEN 60 SUB-Q PEN INJECTOR 2 MO; QL (6 ML per 30 day(s))
Biguanides
GLUCOPHAGE TAB 500 mg 3 MO; QL (120 EA per 30 day(s))
GLUCOPHAGE TAB 1,000 mg 3 MO; QL (60 EA per 30 day(s))
