INDEPENDENT HEALTH’S Child Health Plus® 2013 Drug Formulary Updated January 2013 This drug formulary lists covered generic and brand name drugs under our MediSource (Medicaid) Prescription Drug Plan             Covered generic drugs appear in lower case, covered brand name drugs start with a capital letter Covered over-the-counter drugs must have a prescription When a generic drug becomes available for a formulary brand name drug, the generic will be covered and the brand will become non-formulary and will require prior authorization to be covered Independent Health makes every attempt to provide you with as accurate a listing of drugs as possible However, the list of drugs and availability of generics can change frequently Please discuss any questions you may have about the formulary with your physician In order to ensure the safest and most appropriate care, Independent Health’s drug coverage criteria is limited to medically-accepted indications based on FDA approved labeling and guidelines, that is not otherwise excluded from New York State Medicaid Independent Health also relies on support by one or more official compendia citations to provide guidelines when a drug or indication is not FDA approved Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component The dispensing pharmacy is required to submit for prior approval and when covered, will take the applicable copayment Coverage is provided in accordance with our Compounding Drug Products Policy Bulk products and powders are excluded from coverage because they are not prescription drug products that are approved under sections 505, 505 (j) or 507 of the Federal Food Drug and Cosmetic Act Replacement of lost, stolen or damaged medications is the responsibility of the member ER Scripts are limited to a 10 day supply Prior authorization cannot be used to obtain early refills for lost, stolen or damaged medication; or for extended supplies or vacation supplies This formulary is subject to change Drugs may be added or removed as necessary Additional restrictions or coverage limits may apply: There are two ways to find your drug within the formulary: Medical Condition 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 to treat a heart condition are listed under the category, “Cardiovascular Agents” Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the index The index provides an alphabetical list of all of the drugs included in this document Both covered brand name drugs and covered generic drugs are listed in the index Next to your drug, you will see the page number where you can find your drug in the formulary Prior Authorization This formulary requires prior authorization for certain drugs (listed in the formulary with the symbol “PA”) In addition, drugs not listed in the formulary are considered “non-covered” and require prior authorization To obtain coverage for a drug requiring prior authorization or for non-covered drugs, a prior authorization request for medical exception from the prescribing doctor must be submitted to and approved by Independent Health’s Medical Director Step Therapy Some drugs are only covered after you have tried certain other drugs to treat your medical condition (listed in the formulary with the symbol “ST”) For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first Quantity Limits Certain drugs have a limit on the amount of drug that is covered based on Food and Drug Administration (FDA) guidelines (listed in the formulary with the symbol “QL”) Specialty Pharmacy Some drugs are restricted to participating specialty pharmacies in order to be covered Formulary Symbols ‡ - Drug is available through Reliance RX and/or Walgreens Specialty Pharmacy only, unless otherwise noted + - Maintenance drug, a 90-day supply may be prescribed and dispensed QL – Quantity Limit applies PAR – Prior Authorization must be obtained in order for the drug to be covered ST – Pharmacy Step Therapy Program Benefit Exclusions:  Amphetamine and amphetamine-like drugs which are used for the treatment of obesity  Drugs whose sole clinical use is the reduction of weight;  Drugs used for cosmetic purposes  Any item marked “sample” or “not for sale”  Any contrast agents, used for radiological testing (these are included in the radiologist’s fee)  Any drug which does not have a National Drug Code  Drugs packaged in unit doses for which bulk product exists  Any drug regularly supplied to the general public free of charge must also be provided free of charge to Medicaid beneficiaries  Any controlled substance stamped or preprinted on a prescription blank  Drugs used for the treatment of erectile dysfunction  Drugs used to promote fertility  Drugs or supplies drugs used for gender reassignment  Vacation supplies are not covered under this benefit Enteral and Parenteral Nutritional Formula Benefit: Enteral nutritional Formula benefit coverage is based on medical necessity and is limited to: Prior authorization is required and is valid for a defined approved period of service • Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube • Beneficiaries with inborn metabolic disorders • Children up to 21 years of age, who require liquid oral enteral nutritional formula when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized Enteral feeding Supplies – Supplies that are necessary to administer the specific type of feeding, and maintain the feeding site This includes, but is not limited to: syringes, measuring containers, tip adapters, anchoring device, gauze pads, protective-dressing wipes, tape, and tube cleaning brushes Parenteral Nutritional Formula benefit coverage is based on medical necessity Pharmacy Administered Immunizations: Influenza and Pneumococcal vaccinations administered by licensed pharmacists who obtain additional certification to administer influenza and pneumococcal to adults 18 years of age and older TABLE OF CONTENTS CHAPTER - ALLERGY/COUGH & COLD CHAPTER – ASTHMA/RESPIRATORY CHAPTER – BLADDER/KIDNEY CHAPTER – BLOOD CHAPTER – CANCER CHAPTER – CARDIOVASCULAR – HYPERTENSION CHAPTER – CARDIOVASCULAR – LIPID LOWERING 10 CHAPTER – CARDIOVASCULAR/HEART 10 CHAPTER – DERMATOLOGICAL MEDICATIONS 11 CHAPTER 10 – DIABETES 13 CHAPTER 11 – EAR/THROAT MEDICATIONS 14 CHAPTER 12 – EYE 14 CHAPTER 13 – HORMONES/STEROIDS 16 CHAPTER 14 – INFECTION 17 CHAPTER 15 – MEN’S HEALTH 19 CHAPTER 16 – MENTAL HEALTH 20 CHAPTER 17 – NERVOUS SYSTEM 21 CHAPTER 18 – PAIN 23 CHAPTER 19 – SMOKING CESSATION 24 CHAPTER 20 – STOMACH/INTESTINAL 25 CHAPTER 21 – VITAMINS/MINERALS 26 CHAPTER 22 – WOMEN’S HEALTH 26 CHAPTER 23 – DENTAL FORMULARY 28 INDEX 38  CHAPTER - ALLERGY/COUGH & COLD 1.A Sedating Antihistamines TIER TIER clemastine fumarate syrup cyproheptadine + diphenhydramine 50mg + generic Poly-Histine® hydroxyzine HCl + (Max age of 64) hydroxyzine pamoate + (Max age of 64) promethazine +, PAR age < 1.B Non-Sedating Antihistamines TIER TIER desloratadine PAR levocetirizine dihydrochloride PAR 1.C Sedating Antihistamine/Decongestant Combinations TIER TIER chlorpheniramine/pseudoephedrine 1mg/15mg per ml OTC, QL chlorpheniramine/pseudoephedrine tabs 4mg/60mg OTC, QL chlorpheniramine/pseudoephedrine SR tabs 8mg/120mg OTC, QL chlorpheniramine tan-phenylephrine tannate susp QL promethazine VC triprolidine/pseudoephedrine liquid 1.25mg/30mg per ml OTC, QL triprolidine/pseudoephedrine tabs 2.5mg/60mg OTC, QL 1.D Nasal Steroids/Other Nasal Products TIER TIER azelastine nasal spray flunisolide nasal fluticasone propionate nasal ipratropium triamcinolone acetonide 1.E Nasonex® Narcotic-containing Cough Products TIER TIER generic Hycodan® (syrup only) generic Novahistine® expt phenylephrine chlorpheniramine w/hydrocodone syrup promethazine with codeine promethazine/phenylephrine/codiene syrup generic Robitussin® DAC codeine-guaifenesin 1.F Non-Narcotic-containing Cough Products TIER TIER generic benzonatate promethazine/dextromethorphan PAR age < pseudoephedrine/guaifenesin SSKI 1.G Other Allergy TIER TIER Epipen® Twinject® CHAPTER – ASTHMA/RESPIRATORY 2.A Sympathomimetics TIER TIER albuterol sulfate tabs + albuterol nebs albuterol tabs; syrup metaproterenol tabs +; syrup terbutaline tabs + 2.B Arcapta® Neohaler + Min patient age of 45 years old Foradil® + , ST Maxair® Autohaler Proair® HFA Proventil HFA® Serevent® Diskus + , ST Ventolin HFA® Xanthine Derivatives TIER TIER aminophylline + theophylline SR + theophylline ER + 2.C Inhaled Corticosteroids and Combinations TIER TIER Advair® + Advair® HFA + Azmacort® + Dulera® Ages > 12 years Symbicort® + Alvesco® Asmanex® + budesonide respules 0.25mg, 0.5mg (Ages ≤ 8) + Flovent® Diskus 50mcg, 100mcg, 250mg Flovent® HFA + Pulmicort® Flexhaler Pulmicort® Respules 1mg (Ages ≤ 8) + QVar® + 2.D Mast Cell Stabilizers TIER TIER cromolyn sodium 10mg/ml nebs + 2.E Leukotriene Modifiers TIER TIER montelukast sodium chews (ages 1-5 only) + , ST montelukast sodium tabs + , ST 2.F Other Respiratory Drugs TIER TIER acetylcysteine ipratropium 200mcg/ml nebs + sodium chloride for inhalation Atrovent® HFA + Combivent® Kalydeco® PAR ‡ Pulmozyme® Spiriva® + (ages ≥ 45 years only) TudorzaTM Pressair (ages ≥ 45 years only) CHAPTER – BLADDER/KIDNEY 3.A Antispasmodics TIER TIER flavoxate hcl + hyoscyamine + (Max pt age of 64) oxybutynin + oxybutynin chloride SR + Enablex® + , ST except ages >65 3.B Cholinergic Stimulants TIER TIER bethanechol chloride + 3.C Urinary Anesthetics TIER TIER phenazopyridine 3.D Other Urinary Products TIER TIER generic Bicitra® potassium citrate potassium citrate/citric acid + Elmiron® PAR except Urology, QL Renacidin® CHAPTER – BLOOD 4.A Anticoagulants TIER TIER enoxaparin sodium PAR required for duration of greater than 14 days except when written by an oncologist fondaparinox PAR except for duration of therapy < 14 days heparin sodium jantoven + warfarin sodium + 4.B Fragmin® PAR except for duration of therapy < 14 days Mephyton® + PradaxaTM Xarelto® Antiplatelets TIER TIER aspirin/dipyridamole + clopidigrel bisulfate + dipyridamole + sulfinpyrazone + 4.C Aggrenox® PAR except Neurology Brilinta® + Effient® + (Max age of 75) Hematopoietic Agents TIER TIER Aranesp® PAR ‡ Epogen® PAR ‡ Neulasta® PAR ‡ Neupogen® PAR ‡ Procrit® PAR ‡ Promacta® PAR ‡ 4.D Other Blood Modifiers TIER TIER aminocaproic acid anagrelide + PAR except Oncology and Hematology cilostazol + pentoxifylline + Arcalyst® PAR ‡ Must be obtained through Accredo or Caremark Pharmacy Exjade® PAR ‡ Revlimid® PAR ‡ CHAPTER – CANCER 5.A Cancer Drugs TIER TIER anastrozole + ‡ PAR except Oncology, Oncology Surgery and Breast Surgeons Restricted to female patients only bicalutamide ‡ (Restricted to males) cyclophosphamide etoposide (caps only) ‡ exemestane ‡ + PAR except Oncology, Oncology Surgery and Breast Surgeons Restricted to female patients only flutamide ‡ Restricted to male patients only hydroxyurea 500mg ‡ letrozole ‡ + PAR except Oncology, breast and oncologic surgery or fertility specialists; QL = 10 tablets per fill for cycles for fertility specialists Restricted to female patients Maximum age limit for fertility is 44 years old leucovorin calcium tabs megestrol acetate ‡ mercaptopurine methotrexate tabs + octreotide PAR tamoxifen + tretinoin ‡ Actimmune® PAR ‡ Afinitor® PAR ‡ Alkeran® ‡ Caprelsa® PAR Must be obtained through Biologics, Inc only CeeNu® Emcyt® ‡ ErivedgeTM PAR ‡ Fareston® + ‡ (Restricted to females only) Gleevec® PAR ‡ Hexalen® ‡ Hycamtin® cap PAR ‡ Jakafi® PAR ‡ Leukeran® Lysodren® ‡ Matulane® ‡ Mesnex® ‡ PAR except Oncology Myleran® ‡ Nilandron® PAR except Oncology and Urology Oforta® PAR ‡ Proleukin® PAR Sprycel® ST ‡ Sutent® PAR ‡ Tabloid® Tarceva® ‡ PAR except Oncology Tasigna® PAR ‡ Temodar® ‡ Teslac® Thalomid® ‡ Tykerb® PAR ‡ Votrient® PAR ‡ Xeloda® PAR except Oncology Zolinza® PAR ‡ Zortress® PAR except Nephrology and transplant surgeons Zytiga® PAR ‡ 5.B Immunosuppressant Drugs TIER TIER azathioprine + cyclosporine capsules cyclosporine modified + cyclosporine oral solution mycophenolate + prednisolone prednisone tacrolimus Azasan® + Myfortic® + PAR except Nephrology and Renal Transplant Surgeons Rapamune® PAR except Nephrology and Renal Transplant Surgeons CHAPTER – Cardiovascular – Hypertension 6.A ACE Inhibitors TIER TIER benazepril + captopril + enalapril + , HT fosinopril + , HT lisinopril + , HT moexipril+ , HT quinapril + , HT perindopril +, HT ramipril + trandolapril + , HT 6.B Angiotensin II Receptor Blockers TIER TIER irbesartan +, ST, HT losartan +, ST 6.C Diovan® +, ST, HT Beta Blockers TIER TIER acebutolol HCl + atenolol + bisoprolol fumerate +, HT carvedilol + Dutoprol® + labetalol + metoprolol + metoprolol succinate SR + nadolol + pindolol+ propranolol + propranolol ER + timolol + 6.D Calcium Channel Blockers TIER TIER amlodipine + amlodipine besylate-benazepril hcl + generic Cardizem® CD + Cartia XT + generic Dilacor® XR + diltiazem ER bead caps + diltiazem HCl + diltiazem SR + felodipine er + Nifediac CC Nifedical XL nifedipine ER + nimodipine PAR nisoldipine verapamil + verapamil ER caps + verapamil SR tablets+ 6.E Diuretics 6.E.i Loop Diuretic TIER TIER bumetanide + furosemide + torsemide + 6.E.ii Thiazide and Related Drugs TIER TIER chlorothiazide tabs + chlorthalidone + 25mg, 50mg, 100mg tabs hydrochlorothiazide + indapamide + methyclothiazide + metolazone + Diuril® susp 6.E.iii Potassium Sparing Diuretics TIER TIER amiloride hcl + generic Dyazide® generic Maxzide® + spironolactone + 6.F Aldactazide® 50/50 + Vasodilators TIER TIER doxazosin+ hydralazine HCl + minoxidil tabs + prazosin HCl + terazosin (capsules only) + 6.G Centrally Acting Hypertensives TIER TIER clonidine HCl + clonidine HCl TD patch guanfacine HCl + methyldopa + 6.H Hypertensive Combinations TIER TIER amlodipine besylate-benazepril hcl + atenolol/chlorthalidone + benazepril/hctz + captopril/hctz + enalapril/hctz +, HT irbesartan/hctz +, ST, HT lisinopril/hctz +, HT losartan/hctz ST metoprolol/hctz + moexipril/hctz +, HT propranolol/hctz + quinapril/hctz +, HT valsartan/hctz +, ST, HT generic Ziac®+ CHAPTER – Cardiovascular – Lipid Lowering 7.A Bile Acid Sequestrants TIER TIER cholestyramine/cholestyramine light (bulk) + colestipol granules(bulk) + colestipol tab 1gm + 7.B Welchol® + HMG-CoA Reductase Inhibitors TIER TIER atorvastatin calcium +, HT lovastatin +, HT pravastatin +, HT simvastatin +, HT 7.C Crestor® +, HT Fibric Acid Derivatives TIER TIER fenofibrate + gemfibrozil + Lofibra + 7.D Other Antihyperlipidemic TIER TIER Lovaza® + Niaspan® + Zetia® + 7.E Antihyperlipidemic Combination Products TIER TIER Simcor® + CHAPTER – Cardiovascular/Heart 8.A Antiarrhythmics TIER amiodarone + digoxin + disopyramide + disopyramide CR 150mg + flecainide acetate + mexiletine HCl + phenytoin sodium ext + procainamide caps + TIER Norpace CR® 100mg + Tikosyn® + procainamide sr + propafenone hcl + propafenone hcl sr + quinidine gluconate SR + quinidine sulfate + quinidine sulfate SR + sotalol + 10 18.C Migraine Drugs TIER TIER butorphanol tartrate NS PAR divalproex sodium sr ergotamine w/caffeine generic Esgic® generic Esgic® Plus generic Fioricet® generic Forinal®w/codeine No.3 generic Fiorinal® generic Midrin® generic Phrenilin® sumatriptan inj QL sumatriptan nasal spray QL sumatriptan tabs QL Cafergot® Ergomar® Phrenilin® Forte Migranal® PAR except Neurology, QL Relpax® tablets QL Zomig®/Zomig® ZMT QL Zomig® Nasal Spray QL 18.D Antirheumatics TIER TIER hydroxychloroquine sulfate + leflunomide +, PAR except Rheumatology methotrexate tabs + methotrexate inj PAR except Rheumatology and Dermatology Arthrotec® QL Cuprimine® + Depen® Titratabs Enbrel® ‡, PAR Humira® ‡, PAR Ridaura® Trexall® 18.E Gout TIER TIER allopurinol + colchicine w/probenicid + probenicid + sulfinpyrazone + Colcrys® + Uloric® ST 18.F Muscle Relaxants TIER TIER baclofen + carisoprodol chlorzoxazone (max age of 64) cyclobenzaprine 5mg, 10mg tabs (max age of 64) dantrolene caps diazepam (max age of 64) methocarbamol tizanidine tablets + Rilutek® + CHAPTER 19 – Smoking Cessation Smoking cessation products are not covered under all pharmacy programs 19.A Smoking Cessation TIER TIER bupropion SR QL Chantix® QL 24 CHAPTER 20 – Stomach/Intestinal 20.A Antiulcer/Reflux Drugs TIER TIER cimetidine + famotidine 10mg, 20mg, 40mg +, QL misoprostol 100mcg, 200mcg + omeprazole 10mg, 20mg caps omeprazole 40mg caps PAR except gastroenterology and otolaryngology pantoprazole ranitidine tabs + ranitidine syrup sucralfate + 20.B Drugs affecting GI Motility TIER TIER bethanechol chloride+ chlordiazepoxide/clidinium dicyclomine generic Donnatal® hyoscyamine sulfate + (Max pt age of 64) generic Lomotil® metoclopramide propantheline 20.C Antiemetics TIER TIER meclizine 12.5mg, 25mg + ondansetron 24mg QL ondansetron 4mg, 8mg QL ondansetron odt QL ondansetron susp QL promethazine hcl supp PAR age < prochlorperazine tab +, supp trimethobenzamide PAR for age >65 Emend® (Therapy pack only) ST, QL Emend® 40mg capsules Emend® 80mg, 125mg capsules ST except hematology and oncology, QL 20.D Other GI Drugs TIER TIER balsalazide (Minimum age of 5) budesonide PAR except Gastroenterology and colon/rectal specialists Colocort® cromolyn sodium oral generic Colyte® generic Golytely® QL glycopyrrolate hydrocortisone enema hydrocortisone cream, supp lactulose syrup mesalamine enema Procto-Pak® 1% Proctocream-HC® 2.5% Proctosol-HC® 2.5% Proctosone® 2.5% sulfasalazine + sulfasalazine DR + ursodiol AprisoTM Asacol® + Asacol® HD + Canasa® suppositories Creon® + Cystadane® ‡, PAR Kuvan® ‡, PAR, QL Pancreaze® + Pentasa® + Pertzye® + Relistor® Sucraid® PAR Available through CuraScript Pharmacy only Ultresa® Viokace® Zenpep® + 25 20.E Hepatitis TIER TIER ribavirin ‡ , PAR Epivir-HBV® PAR except Gastroenterology or Infectious Disease Hepsera® PAR except Gastroenterology or Infectious Disease Incivek® ‡, PAR Infergen® ‡, PAR Intron A® ‡, PAR Pegasys® ‡, PAR Peg-Intron® ‡, PAR Victrelis® PAR, ‡ CHAPTER 21 – Vitamins/Minerals 21.A Vitamins/Minerals (Multivitamins are NOT included in the Formulary as various OTC products are available.) TIER TIER calcitriol + calcium acetate caps + Cavan-Heme® ergocalciferol + fe-fumarate vit C/vit B12/folic acid + folic acid + iron polysaccharide complex/folic acid/vitamin B12 + Klor-Con-25® poly-vitamin w/fluoride + potassium bicarbonate/chloride+ potassium chloride tab, cap, liquid + potassium chloride extended release tabs 20mEq + brand and generic prenatalvitamins + (restricted to female patients, ages 13-45 only) Rena-Vite Rx®+ PAR except Nephrology sodium fluoride + sodium polystyrene sulfonate tri-vitamin w/fluoride + vitamin B12 inj DHT® + Fosrenol® + Galzin® +, QL PhoslyraTM Renagel® + Renvela® Zemplar® +, ST CHAPTER 22 – Women’s Health 22.A Estrogen Related Products TIER TIER danazol estradiol + estradiol weekly patch + estropipate + Alora® + Estrace® cream Estraderm® + Estring® Evista® + Premarin® + Premarin® cream Vagifem® Vivelle-Dot® + 26 22.B Estrogen Combinations TIER TIER estradiol/norethindrone acetate + norethindrone acetate-ethinyl estradiol + Restricted to females Combipatch® + Estratest® HS + Estratest® + Femhrt Low Dose® + Premphase® + Prempro® + progesterone suppositories 22.C Progestins TIER TIER medroxyprogesterone + norethindrone acetate + progesterone micronized caps + 22.D Contraceptives (For members with contraceptive coverage) TIER Apri® + Altavera® + Amethia® Amethyst® Aranelle® + Aviane® + Balziva® + Camila® + Camrese® Cesia® + Cryselle® + drospirenone/estradiol Emoquette® Enpresse® + Errin® + estradiol/norethindrone + Gianvi® + Jolessa® + Jolivette® + Junel®/Junel FE® + Kariva® + Kelnor® + Leena® + Lessina® + levonorgestrel QL Levora® + Loryna® + TIER Low-Ogestrel® + Lutera® + medroxyprogesterone PAR Microgestin®+ Microgestin FE® + Mononessa® + Necon® + Nora-Be® + Nortrel® + Ocella® + Ogestrel® + Portia® + Previfem® + Quasense® + Reclipsen® + Solia® + Sprintec® + Sronyx® + Tilia FE® + Tri-Legest FE®+ Trinessa® + Tri-Previfem® + Tri-Sprintec® + Trivora® + Velivet® + Zenchent® + Zovia® + Cervical caps Depo-Provera® PAR Diaphragms EllaTM QL NuvaRing® +, QL OrthoEvra® + Ortho Tri-Cyclen® Lo + 22.E Fertility (Other coverage restrictions may apply) TIER TIER chorionic gonadotropin ST clomiphene citrate (Restricted to female patients only) QL = 10 tabs/cycle up to cycles except for infertility specialists Bravelle® PAR Menopur® PAR Repronex® PAR 22.F Vaginal Antiinfectives TIER TIER clindamycin phosphate vaginal cream clotrimazole vaginal cream OTC metronidazole vaginal gel miconazole vaginal cream OTC AVC® Cream Cleocin® vaginal suppositories 27 22.G Other Women’s Health Drugs TIER TIER nifedipine PAR except OB/GYN terbutaline Alferon N® PAR Lupron® Methergine® Synarel® PAR CHAPTER 23 – Dental Formulary Note: Drugs in this category are reserved for dental providers only Unless otherwise specified, all products are limited to a 10 day supply with refill Drugs not on the list below will not be covered 23.A Antiinfectives TIER TIER amoxicillin amoxicillin susp azithromycin cephalexin clarithromycin 500mg QL clindamycin 150mg, 300mg doxycycline hyclate doxycycline hyclate 20mg QL erythromycin erythromycin susp nystatin oral suspension penicillin VK tetracycline capsules Cleocin® 75mg 23.B Analgesics TIER TIER acetaminophen w/codeine acetaminophen w/codeine susp acetaminophen w/hydrocodone apap/codeine tabs hydrocodone w/acetaminophen hydrocodone-ibuprofen tab 7.5-200mg PAR except pain medicine, ER physicians, dentists and oral surgeons ibuprofen (Rx strengths only) ibuprofen suspension (Rx strengths only) naproxen naproxen sodium 23.C Fluoride Products TIER TIER poly-vitamin w/fluoride sodium fluoride QL tri-vitamin w/fluoride 23.D Glucocorticoid Drugs TIER TIER dexamethasone triamcinolone in orabase methylprednisolone prednisone 23.E Other Drugs Affecting the Throat and Mouth TIER TIER chlorhexidine QL lidocaine viscous 28 INDEX amitriptyline/ perphenazine 20 amlodipine besylate- amlodipine besylate-benazepril hcl 10 ammonium lactate cr 12 ammonium lactate lotion 12 amoxicillin 28 amoxicillin caps, susp 17 amoxicillin clavulanate 17 amoxicillin susp 28 amphetamine mixture 21 amphetamine-dextroamphetamine sr 21 ampicillin caps, susp 17 AmpyraTM ER 22 anagrelide anastrozole Androderm® 19 Androgel® 19 Android® 19 Androxy® 19 antyipyrine/benzocaine otic soln 14 apap/codeine tabs 28 Apokyn® 22 apraclonidine 15 Apri® 27 AprisoTM 25 Aptivus® 18 Aranelle® 27 Aranesp® Arcalyst® Arcapta® Neohaler Armour Thyroid® 16 Arthrotec ® 24 Asacol® 25 Asacol® HD 25 Asmanex® aspirin CR 800mg 23 aspirin w/codeine 23 aspirin/dipyridamole AtelviaTM 16 atenolol atenolol/chlorthalidone 10 atorvastatin calcium 10 Atripla® 18 atropine 15 Atrovent® HFA augmented betamethasone 11 AVC® Cream 27 Avelox® 17 Aviane® 27 Avodart® 19 Avonex® 22 Azasan® azathioprine azelastine 15 azelastine nasal spray Azelex® 11 Azilect® 22 azithromycin 17, 28 azithromycin® susp 17 A  abacavir sulfate 18 Abilify® 21 Abilify® oral solution 21 acarbose 13 Accu-Chek® 13, 14 Accu-Chek® Active 14 Accu-Chek® Aviva 13, 14 acebutolol HCl acetaminophen w/codeine 23, 28 acetaminophen w/codeine susp 28 acetaminophen w/hydrocodone 28 acetazolamide tab 15 acetic acid otic soln 14 acetylcysteine Actimmune® Actonel® 16 Actonel® with Calcium 16 Actoplus Met® XR 13 Actos® 13 Acuvail® 15 acyclovir 18 adapalene 11 Adcirca® 11 Advair® Advair® HFA Afinitor® Aggrenox® Alaway® 15 albuterol nebs albuterol sulfate tabs albuterol tabs; syrup alclometasone 11 Aldactazide® 50/50 alendronate tabs 16 Alferon N® 18, 28 alfuzosin 19 Alinia® tabs, soln 19 Alkeran® allopurinol 24 Alomide® 15 Alora® 26 Alphagan P® 0.1% 15 alprazolam 20 Alrex® 15 Altavera® 27 aluminum chloride 20% 12 Alvesco® amantadine 18 amantadine hcl 22 Amethia® 27 Amethyst® 27 amiloride hcl aminocaproic acid aminophylline amiodarone 10 amitriptyline 20 29 Azmacort® Azopt® 15 Carac® 12 CarbagluTM 16 carbamazepine 21 carbamazepine er 21 carbidopa/levodopa 22 carbidopa/levodopa CR 22 carbidopa/levodopa/entacapone tabs 22 carisoprodol 24 carteolol 15 Cartia XT carvedilol Cavan-Heme® 26 Caverject® 19 Cayston® 19 CeeNu® cefaclor caps, susp 17 cefadroxil 17 cefprozil 17 Ceftin® 125mg tabs, susp 17 cefuroxime 17 Celebrex® 23 Celontin® 21 cephalexin 28 cephalexin caps, susp 17 cephradine capsules 17 Cervical caps 27 Cesia® 27 cevimeline 14 Chantix® 24 Chemet® 16 Chemstrip® K 14 Chemstrip® UGK 14 chloramphenicol 14 chlordiazepoxide 20 chlordiazepoxide/clidinium 25 chlorhexidine 28 chlorhexidine oral rinse 14 Chloromycetin® Otic 14 chloroquine phosphate 19 chlorothiazide tabs chlorpheniramine tan-phenylephrine tannate susp chlorpheniramine/pseudoephedrine 1mg/15mg per ml chlorpheniramine/pseudoephedrine SR tabs 8mg/120mg chlorpheniramine/pseudoephedrine tabs 4mg/60mg chlorpromazine 21 chlorthalidone chlorzoxazone 24 cholestyramine/cholestyramine light (bulk) 10 chorionic gonadotropin 27 ciclopirox gel 0.77% 12 cilostazol cimetidine 25 Ciprodex® 14 ciprofloxacin ophth soln 14 ciprofloxacin tabs 17 citalopram 20 clarithromycin 17 clarithromycin 500mg 28 clarithromycin SR 17 clemastine Cleocin® 75mg 28 Cleocin® pediatric granules 17 Cleocin® vaginal suppositories 27 B  bacitracin ophthalmic 14 baclofen 24 Bactroban® cream 12 balsalazide 25 Balziva® 27 Banzel® 21 Baraclude® 18 belladonna/opium supp 23 benazepril benazepril/hctz 10 benzoyl peroxide cr,gel,lot 11 benztropine 22 betamethasone 11 bethamethasone valerate 11 bethanechol chloride 6, 25 Betimol® 15 Betoptic® S 15 bicalutamide bisoprolol fumerate Blephamide® Liquifilm 15 brand and generic prenatal 26 Bravelle® 27 Brilinta® brimonidine solution 15 brimonidine tartrate 0.2% 15 BromdayTM 15 bromfenac 15 bromocriptine mesylate 22 budesonide 25 budesonide respules 0.25mg, 0.5mg bumetanide buprenorphine hcl 22 bupropion 20 bupropion hcl SR 12 hr 20 bupropion hcl SR 24hr 20 bupropion SR 24 buspirone 20 butorphanol tartrate NS 24 Bydureon® 13 Byetta® 13 C  cabergoline 16 Cafergot® 24 calciprotiene soln, oint, cream 12 calcitonin 16 calcitonin-salmon 16 calcitriol 26 calcitriol ointment 12 calcium acetate caps 26 Camila® 27 Campral® 22 Camrese® 27 Canasa® suppositories 25 Capex® 11 captopril captopril/hctz 10 30 clindamax 11 clindamycin 17, 28 clindamycin phosphate gel 1% 11 clindamycin phosphate vaginal cream 27 clindamycin phosphate-benzoyl peroxide gel 11 clindamycintopical 11 clobetasol proprionate 11 clomiphene citrate 27 clomipramine 20 clonazepam tabs 21 clonidine HCl clonidine HCl TD patch clopidigrel bisulfate clorazepate 20 clotrimazole cream, lotion, soln 12 clotrimazole troche 17 clotrimazole vaginal cream 27 clotrimazole with betamethasone cream 1-0.05% 12 clozapine 21 Coartem® 19 codeine sulfate 23 codeine-guaifenesin colchicine w/probenicid 24 Colcrys® 24 colestipol granules(bulk) 10 colestipol tab 1gm 10 Colocort® 25 Combigan® 15 Combipatch® 27 Combivent® CompleraTM 18 Comtan® 22 Concerta® 21 Copaxone® 22 Cordran® Tape only 11 cortisone acetate 16 Creon® 25 Crestor® 10 Crixivan® 18 cromolyn sodium 15 cromolyn sodium 10mg/ml nebs cromolyn sodium oral 25 Cryselle® 27 Cuprimine® 24 cyclobenzaprine 5mg, 10mg tabs 24 cyclophosphamide cyclosporine capsules cyclosporine modified cyclosporine oral solution Cymbalta® 20 cyproheptadine Cystadane® 25 Cystagon® 16 desipramine 20 desmopressin 16 desonide0.05% 11 desoximetasone 11 dexamethasone 16, 28 dexamethasone ophthalmic 15 dexamethasone/tobramycin 15 dextroamphetamine tabs & SR 21 DHT® 26 Diaphragms 27 Diastat® 21 diazepam 20, 24 Dibenzyline® 11 diclofenac sodium enteric coated tablets 23 diclofenac sodium ophth soln 15 diclofenac sodium SR 24-hr 100 mg 23 dicloxacillin caps 17 dicyclomine 25 didanosine DR 18 Didronel® 16 Differin® 0.3% 11 diflorasone diacetate 11 diflunisal 23 digoxin 10 Dilantin® Infatab 21 diltiazem ER bead diltiazem HCl diltiazem SR Diovan® diphenhydramine 20 diphenhydramine 50mg 4, 22 dipivefrin 15 dipyridamole disopyramide 10 disopyramide CR 150mg 10 Diuril® susp divalproex sodium sprinkles 21 divalproex sodium sr 21, 24 divalproex sodium tabs 21 donepezil 22 dorzolamide hcl soln 15 dorzolamide/timolol ophth soln 15 doxazosin 19 doxepin 20 doxycycline hyclate caps, tabs 17 doxycycline hyclate 28 doxycycline hyclate 20mg 28 drospirenone/estradiol 27 Duetact® 13 Dulera® Dutoprol® D  econazole nitrate cream 1% 12 Edex® 19 Effient® Elidel® 12 EllaTM 27 Elmiron® Embeda® 23 Emcyt® Emend® 25 E  danazol 26 dantrolene caps 24 Dapsone 19 Daraprim® 19 Depen® Titratabs 24 Depo-Provera® 27 Derma-Smoothe/FS® 11 31 Emoquette® 27 Emtriva® 18 Enablex® enalapril Enbrel® 24 enoxaparin sodium Enpresse® 27 epinastine 15 Epipen® Epivir-HBV® 18, 26 eplerenone 11 Epogen® Epzicom® 18 ergocalciferol 26 Ergomar® 24 ergotamine w/caffeine 24 ErivedgeTM Errin® 27 Ery-Tab® 17 erythromycin 28 erythromycin base enteric pellets 17 erythromycin estolate caps, susp 17 erythromycin ethylsuccinate tabs, susp 17 erythromycin gel 11 erythromycin ophthalmic 14 erythromycin pads 11 erythromycin stearate 17 erythromycin susp 28 erythromycin/benzoyl peroxide gel 11 erythromycin/sulfisoxazole susp 17 escitalopram oxalate 20 Estrace® cream 26 Estraderm® 26 estradiol 26 estradiol weekly patch 26 estradiol/norethindrone 27 Estratest® 27 Estratest® HS 27 Estring® 26 estropipate 26 ethambutol 18 ethosuximide 250mg/5ml syrup 21 ethosuximide capsules 21 etodolac 23 etoposide (caps only) Eurax® 12 evetiracetam 21 Evista® 26 Exalgo® 23 exemestane Exjade® fentanyl TD patch 23 Finacea® 11 Finacea® Plus Kit 11 finasteride 19 Flarex® 15 flavoxate hcl flecainide acetate 10 Flovent® Diskus 50mcg, 100mcg, 250mg Flovent® HFA fluconazole 150mg tab 17 fluconazole tabs/oral suspension 17 fludrocortisone acetate 16 flunisolide nasal fluocinolone acetonide 11 fluocinonide 11 fluorouracil 12 fluoxetine hcl 20 fluoxetine liquid 20 fluphenazine 21 flurazepam 20 flurbiprofen tabs 23 flutamide fluticasone cr; oint 11 fluticasone propionate lotion 0.05% 11 fluticasone propionate nasal fluvoxamine 20 FML-Forte® ophthalmic 15 folic acid 26 fondaparinox Foradil® Forteo® 16 Fortical® 16 Fosamax® plus D 16 fosinopril Fosrenol® 26 Fragmin® furosemide G  gabapentin 21 galantamine 22 galantamine oral solution 22 galantamine SR 22 Galzin® 26 ganciclovir 18 Gantrisin® Ped susp 17 gemfibrozil 10 generic Avita® 11 generic benzonatate generic Bicitra® generic Cardizem® CD generic Colyte® 25 generic Cortisporin® ophthalmic 15 generic Cortisporin® Otic sol, susp 14 generic Dilacor® XR generic Domeboro® Otic 14 generic Donnatal® 25 generic Dyazide® generic Econopred® Plus 15 generic Esgic® 24 generic Esgic® Plus 24 generic Fioricet® 24 F  famciclovir 18 famotidine 25 Fareston® Fasttake® 14 fe-fumarate vitamin C/vitamin B12/folic acid 26 felbamate 21 felodipine er Femhrt Low Dose® 27 fenofibrate 10 32 generic Fiorinal® 24 generic Fiorinal® w/codeine No.3 24 generic FML® Liquifilm 15 generic Golytely® 25 generic Hycodan® generic Inflamase® Forte 15 generic Lomotil® 25 generic Maxitrol® ophthalmic 15 generic Maxzide® generic Metimyd® 15 generic Midrin® 24 generic NeoDecadron® 15 generic Neosporin® 14 generic Novahistine® expt generic Percodan® 23 generic Phrenilin® 24 generic Poly-Histine® generic Polysporin® 14 generic Polytrim® 14 generic Pred Forte® 15 generic Retin-A® 11 generic Robitussin® DAC generic Sulfacet-R® 11 generic Timoptic-XE® 15 generic Tylox® 23 generic Vasocidin® 15 generic Ziac® 10 gentamicin 12 gentamicin ophthalmic 14 Gianvi® 27 Gleevec® glimepiride 13 glipizide 13 glipizide CR tablets 13 glipizide-metformin 13 glucagon 13 glyburide 13 glyburide micronized 13 glyburide-metformin 13 glycopyrrolate 25 griseofulvin suspension 17 Gris-Peg® 250 mg 17 guanfacine HCl hydrocortisone 2.5% 11 hydrocortisone 25mg rectal 11 hydrocortisone cream, supp 25 hydrocortisone enema 25 hydrocortisone rectal 11 hydrocortisone tab 16 hydrocortisone valerate 11 hydrocortisone w/acetic acid otic soln 14, 15 hydromorphone hcl 23 hydroxychloroquine sulfate 19, 24 hydroxyurea 500mg hydroxyzine HCl 4, 20 hydroxyzine pamoate 4, 20 hyoscyamine hyoscyamine sulfate 25 I  ibuprofen 23, 28 ibuprofen suspension 28 imipramine HCl 20 imiquimod cream 12 Incivek® 26 indapamide indomethacin 23 indomethacin SR 23 Infergen® 26 Intelence® 18 Intron A® 26 Invirase® 18 ipratropium ipratropium 200mcg/ml nebs irbesartan irbesartan/hctz 10 iron polysaccharide complex/folic acid/vitamin B12 26 Isentress® 18 isoniazid 18 Isopto Carbachol® 15 isosorbide dinitrate 11 isosorbide mononitrate 11 isotretinoin 11 itraconazole caps 17 J  H  Jakafi® jantoven Janumet® 13 Janumet® XR 13 Januvia® 13 Jolessa® 27 Junel FE® 27 Junel® 27 halobetasol propionate 11 Halog® 11 haloperidol 21 heparin sodium Hepsera® 18, 26 Hexalen® homatropine 15 Humalog® 13 Humira® 24 Humulin® Insulins 13 Hycamtin® cap hydralazine HCl hydrochlorothiazide hydrocodone w/acetaminophen 23, 28 hydrocodone w/ibuprofen 23 hydrocodone/APAP soln 23 hydrocodone-ibuprofen tab 7.5-200mg 28 K  Kaletra® 18 Kalydeco® Kariva® 27 Kelnor® 27 ketoconazole 2% shampoo 12 ketoconazole cream 12 ketoconazole tabs 17 33 ketoprofen 23 ketorolac 23 ketorolac tromethamine ophth soln 0.4% and 0.5% 15 Klor-Con-25® 26 Kombiglyze® XR 13 Korlym® 16 Kuvan® 25 Lutera® 27 Lyrica® 21 Lysodren® M  maprotiline 20 Matulane® Maxair® Autohaler mebendazole 19 meclizine 25 meclofenamate 23 medroxyprogesterone 27 mefloquine hcl 19 megestrol acetate meloxicam 23 Menopur® 27 Menostar® 16 Mephyton® Mepron® 19 mercaptopurine mesalamine enema 25 Mesnex® Mestinon® 22 metaproterenol tabs metformin hcl 13 metformin SR 13 metformin tb24 13 methadone hcl 23 methamphetamine 21 methazolamide 15 Methergine® 28 methimazole 16 Methitest® 19 methocarbamol 24 methotrexate inj 24 methotrexate tabs 7, 12, 24 methyclothiazide methyldopa methylphenidate 21 methylphenidate SR tabs 21 methylprednisolone 28 methylprednisolone generic 16 metipranolol 15 metoclopramide 25 metoprolol metoprolol succinate SR metoprolol/hctz 10 Metrogel® 1% 11 metronidazole 19 metronidazole cream, lotion 11 metronidazole vaginal gel 27 mexiletine HCl 10 Miacalcin® inj 16 miconazole cream, lotion, aerosol, soln 12 miconazole vaginal cream 27 Microgestin FE® 27 midodrine hcl 11 Migranal® 24 Minitran® 11 minocycline caps (50mg & 100mg only) 17 minoxidil tabs mirtazapine ODT 20 L  labetalol Lacrisert® 15 lactulose syrup 25 Lamisil AT® cream 12 Lamisil® oral granules 17 lamivudine 18 lamivudine/zidovudine 18 lamotrigine chewable tablets 21 lamotrigine tablets 21 Lantus® 13 latanoprost ophth soln 15 Leena® 27 leflunomide 24 Lessina® 27 Letairis® 11 letrozole leucovorin calcium tabs Leukeran® Levemir® 13 levobunolol HCl 15 levofloxacin 17 levofloxacin opth soln 14 levonorgestrel 27 Levora® 27 levothroid 16 levothyroxine 16 levoxyl 16 Lexapro® Oral Solution 20 Lexiva® 18 lidocaine cr 12 lidocaine HC cr 12 lidocaine viscous 14, 28 lidocaine viscous soln 12 lidocaine-prilocaine cream 12 lindane 12 liothyronine 16 lisinopril lisinopril/hctz 10 lithium carbonate 20 lithium carbonate CR tab 20 Lofibra 10 lorazepam 20 Loryna® 27 losartan losartan/hctz 10 Lotemax® 15 Lotemax® ointment 15 lovastatin 10 Lovaza® 10 Low-Ogestrel® 27 loxapine 21 Lumigan® 15 Lupron® 28 34 misoprostol 25 moexipril/hctz 10 mometasone furoate 11 Mononessa® 27 montelukast sodium chews montelukast sodium tabs morphine sulfate cap sr 24hr 100mg, 200mg 23 morphine sulfate cap sr 24hr 10mg, 20mg, 23 morphine sulfate ER 23 morphine sulfate ir 23 morphine sulfate supp 23 morphine sulfate tablets, oral solution 23 mupirocin oint 12 Muse® 19 Mycobutin® 18 mycophenolate Myfortic® Myleran® NovoFine® Needles 13 Novolin® insulins 13 Novolog® insulins 13 Noxafil® 17 Nucynta® 23 Nucynta® ER 23 NuedextaTM XR 22 Nutropin® 16 Nutropin® AQ 16 NuvaRing® 27 Nuvigil® 21 nystatin 100,000u/1g cream; oint 12 nystatin oral suspension 17, 28 nystatin pwd 12 nystatin tabs 17 nystatin-triamcinolone 12 Nystop® 12 O  N  Ocella 27 octreotide ofloxacin ophth soln 14 ofloxacin otic 14 Oforta® Ogestrel® 27 olanzapine 21 omeprazole 25 ondansetron 25 ondansetron odt 25 ondansetron susp 25 One Touch® 14 One Touch® Ultra 14 OneTouch® 13 OneTouch® Verio IQ 13, 14 OnfiTM 22 Onglyza® 13 Opana ER® 23 Orap® 21 Orfadin® 16 Ortho Tri-Cyclen® Lo 27 OrthoEvra® 27 oxaprozin 23 oxazepam 20 oxcarbazine 21 Oxsoralen-Ultra® 12 oxybutynin oxybutynin chloride SR oxycodone 5mg tablets/soln 23 oxycodone w/acetaminophen 5/325mg 23 Oxycontin® 23 ® nabumetone 23 nadolol naltrexone 22 Namenda® soln 22 naphazoline 15 naproxen 23, 28 naproxen sodium 23, 28 Nardil® 20 Nasonex® Natacyn® 14 nateglinide 13 Nebupent® 19 Necon® 27 nefazodone hcl 20 neomycin sulfate 19 Neulasta® Neupogen® Nevanac® 15 nevirapine 18 Niaspan® 10 Nifediac CC Nifedical XL nifedipine 28 nifedipine ER Nilandron® nimodipine nislodipine Nitro-Dur® 11 nitrofurantoin macrocrystals 17 nitroglycerin ointment 11 nitroglycerin patch 11 nitroglycerin sublingual 11 Nitrostat® 11 Nizoral A-D® shampoo 12 Nora-Be® 27 norethindrone acetate 27 norethindrone acetate-ethinyl estradiol 27 Noritate® 11 Norpace CR® 100mg 10 Nortrel® 27 nortriptyline 20 Norvir® 18 P  Pancreaze® 25 pantoprazole 25 paromomycin 19 paroxetine hcl sr 20 paroxetine tabs 20 Peganone® 21 Pegasys® 26 Peg-Intron® 26 penicillin VK 28 35 Proctosone® 2.5% 25 progesterone suppositories 27 Proglycem® 13 Proleukin® Promacta® promethazine promethazine hcl supp 25 promethazine VC promethazine/ promethazine/dextromethorphan propafenone hcl 10 propafenone hcl sr 10 propantheline 25 propranolol propranolol ER propranolol/hctz 10 propylthiouracil 16 Prostigmin® 22 Protopic® 12 protriptyline 20 Proventil HFA® pseudoephedrine/guaifenesin Pulmicort® Flexhaler Pulmicort® Respules 1mg Pulmozyme® pyrazinamide 18 pyridostigmine bromide 60mg tab 22 penicillin VK tabs, soln 17 Pentasa® 25 pentoxifylline perindopril permethrin cream 12 perphenazine 21 Pertzye® 25 phenazopyridine phenobarbital 21 phentolamine inj 11 phenylephrine phenylephrine ophthalmic 2.5% 15 Phenytek® 21 phenytoin 21 phenytoin sodium 21 phenytoin sodium ext 10 phenytoin sodium susp 21 PhoslyraTM 26 Phospholine® iodide 15 Phrenilin® Forte 24 pilocarpine soln 15 pilocarpine tab 14 Pilopine® H.S 15 pioglitazone hcl/metformin hcl 13 piroxicam 23 podofilox solution 12 Poly-Pred® 15 poly-vitamin w/fluoride 26, 28 Portia® 27 potassium bicarbonate/chloride 26 potassium chloride extended release tabs 26 potassium chloride tab, cap, liquid 26 potassium citrate potassium citrate/citric acid PradaxaTM pramipexole dihydrochloride 22 Prandimet® 13 Prandin® 13 pravastatin 10 prazosin HCl Precision Xtra® 13, 14 Pred Mild® 15 prednicarbate cr,oint 11 prednisolone prednisolone oral syrup 16 prednisone 8, 16, 28 Premarin® 26 Premarin® cream 26 Premphase® 27 Prempro® 27 Previfem® 27 Prezista® 18 primaquine phosphate 19 primidone 21 Proair® HFA probenicid 24 procainamide caps 10 procainamide sr 10 prochlorperazine tab, supp 25 Procrit® Proctocream-HC®2.5% 25 Procto-Pak® 1% 25 Proctosol-HC® 2.5% 25 Q  Quasense 27 quetiapine fumarate 21 quinapril quinapril/hctz 10 quinidine gluconate SR 10 quinidine sulfate 10 quinidine sulfate SR 10 quinine sulfate 19 QVar® ® R  ramipril ranitidine syrup 25 ranitidine tabs 25 Rapamune® Rebif® 22 Reclipsen® 27 Relenza® 18 Relistor® 25 Relpax® tablets 24 Renacidin® Renagel® 26 Renvela® 26 Repronex® 27 Rescriptor® 18 Restasis® 15 Retin-A® Micro 11 Revlimid® Reyataz® 18 ribavirin 18, 26 Ridaura® 24 rifampin 18 36 Rifater® 18 Rilutek® 24 Riomet® 13 risperidone 21 risperidone m-tab 21 risperidone odt 21 ropinirole hydrochloride 22 rosadan 11 Rozerem® 20 Suprax® tabs, susp 17 SureStep® 14 Sustiva® 18 Sutent® Symbicort® Symlin® 13 Synarel® 28 Synthroid® 16 Syprine® 16 S  T  Sabril 21 salsalate 23 Savella® 20 selegiline 22 selenium sulfide 12 Selzentry® 18 Sensipar® 16 Serevent® Diskus sertraline 20 sildenafil 11 silver sulfadiazine 12 Simcor® 10 simvastatin 10 sodium chloride for inhalation sodium fluoride 26, 28 sodium polystyrene sulfonate 26 Sof-Tact® 13, 14 Solaraze® 12 Solia® 27 Somavert® 16 Soriatane® 12 sotalol 10 Spiriva® spironolactone Sprintec® 27 Sprycel® Sronyx® 27 SSKI stavudine 18 StibildTM 18 Stimate® 16 Strattera® 21 Striant® 19 Stromectol® 19 Suboxone® 22 Suboxone® SL Filmtab 22 Sucraid® 25 sucralfate 25 sulfacetamide sodium 10% 14 sulfacetamide sodium lotion 11, 12 sulfacetamide sodium w/sulfur emulsion/cleanser 11 sulfamethoxazole/ 17 sulfamethoxazole/trimethoprim 17 sulfasalazine 25 sulfasalazine DR 25 sulfinpyrazone 6, 24 sulfisoxazole tabs 17 sulindac 23 sumatriptan inj 24 sumatriptan nasal spray 24 sumatriptan tabs 24 Tabloid® tacrolimus Tamiflu® 18 tamoxifen tamsulosin hcl sr 19 Tarceva® Tasigna® Tazorac® 12 temazepam 20 Temodar® terazosin 19 terazosin (capsules only) terbinafine hcl 17 terbutaline 28 terbutaline tabs Teslac® Testim® 19 testosterone cypionate 19 Testred® 19 tetracycline caps, susp 17 tetracycline capsules 28 Thalomid® theophylline ER theophylline SR thioguanine thioridazine 21 thiothixene 21 thyroid 16 tiagabine 21 Tikosyn® 10 Tilia FE® 27 timolol timolol maleate 15 tinidazole tabs 19 tizanidine tablets 24 Tobradex® ST 15 tobramycin 14 tolmetin sodium 23 topiramate 21 topiramate sprinkle 21 torsemide Tracer® BG 14 Tracleer® 11 tramadol 23 tramadol er 23 trandolapril tranylcypromine 20 Travatan® 15 Travatan® Z 15 trazodone 20 tretinoin ® 37 Videx® 18 Vimpat® 21 Viokace® 25 Viracept® 18 Viramune® XR 18 Viread® 18 vitamin B12 inj 26 Vivelle-Dot® 26 voriconazole 17 Votrient® Trexall® 24 triamcinolone in orabase 14 triamcinolone acetonide 4, 11 triamcinolone in orabase 28 triazolam 20 trifluoperazine 21 trifluridine 14 trihexyphenidyl 22 Tri-Legest FE® 27 trimethobenzamide 25 trimethoprim tabs 17 trimipramine 20 Trinessa® 27 Tri-Previfem® 27 triprolidine/pseudoephedrine liquid 1.25mg/30mg per ml triprolidine/pseudoephedrine tabs 2.5mg/60mg Tri-Sprintec® 27 tri-vitamin w/fluoride 26, 28 Trivora® 27 Trizivir® 18 tropicamide 15 Truvada® 18 TudorzaTM Pressair Twinject® Tykerb® Tyzeka® 18 W  warfarin sodium Welchol® 10, 13 X  Xarelto® Xeloda® Xenazine® 22 Xyrem® 22 Y  Yodoxin 19 yohimbine 19 ® U  Z  Uloric® 24 Ultresa® 25 unithroid 16 ursodiol 25 Zaditor 15 zaleplon 20 Zavesca® 16 Zelapar® 22 Zemplar® 26 Zenchent® 27 Zenpep® 25 Zetia® 10 Ziagen® 18 Ziana® 11 zidovudine 18 ziprasidone 21 Zirgan® 14 Zolinza® zolpidem tartrate 20 Zomig® 24 Zomig® Nasal Spray 24 Zomig® ZMT 24 zonisamide 21 Zortress® Zovia® 27 Zovirax® ointment 12 Zytiga® ® V  Vagifem 26 valacyclovir 18 Valcyte® 18 valproic acid 21 valsartan/hctz 10 vancomycin caps 19 Velivet® 27 venlafaxine 20 venlafaxine er caps 20 Ventolin HFA® verapamil verapamil ER caps Veregen® 12 Vexol® 15 Viagra® 19 Vibramycin® susp 17 Victoza® 13 Victrelis® 26 ® 38 ... stamped or preprinted on a prescription blank  Drugs used for the treatment of erectile dysfunction  Drugs used to promote fertility  Drugs or supplies drugs used for gender reassignment  Vacation... 27 22.G Other Women’s Health Drugs TIER TIER nifedipine PAR except OB/GYN terbutaline Alferon N® PAR Lupron® Methergine® Synarel® PAR CHAPTER 23 – Dental Formulary Note: Drugs in this category... radiologist’s fee)  Any drug which does not have a National Drug Code  Drugs packaged in unit doses for which bulk product exists  Any drug regularly supplied to the general public free of charge