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Generic Name Brand Name Annotation
I. ANTI-INFECTIVE AGENTS
PENICILLINS
Penicillins
$ Amoxicillin* AMOXIL
$ Ampicillin* TOTACILLIN
$ Penicillin V Potassium* PEN VEE K
Penicillinase-resistant
$ Dicloxacillin Sodium* DYCILL
Penicillin Combinations
$$$ Amoxicillin & K Clavanate AUGMENTIN all forms, all generics
CEPHALOSPORINS
Cephalosporins - 1st Generation
$ Cephalexin* KEFLEX

no tablets

 

 

 
$ Cephradine* VELOSEF
Cephalosporins - 2nd Generation
$$$ Cefaclor* CECLOR
$$$ Cefuroxime Axetil CEFTIN SUSP
$$$ Loracarbef LORABID SUSP only
Cephalosporins - 3rd Generation
$$$ Cefdinir OMNICEF SUSP  
$$$ Cefixime SUPRAX SUSP only  
MACROLIDE ANTIBIOTICS  
Erythromycins
$ Erythromycin Base* ERY-TAB
$ Erythromycin Stearate* ERYTHROCIN
$ Erythromycin Estolate* ILOSONE no 500mg tabs
$ Erythromycin Ethylsuccinate* E.E.S. no chewables
Misc. Antiinfective Combinations
$ Erythromycin & Sulfisoxazole* PEDIAZOLE
Lincomycins
$$ Clindamycin* CLEOCIN
Misc. Macrolide Antibiotics
$$$ Clarithromycin BIAXIN,XL
$$$ Azithromycin ZITHROMAX no PA on 1 gm powder
    Prior Authorization Required  
TETRACYCLINES
$ Doxycycline* VIBRAMYCIN
$ Tetracycline* SUMYCIN no tablets
FLUOROQUINOLONES
$$$ Ciprofloxacin CIPRO
$$$ Lomefloxacin MAXAQUIN  
    Prior Authorization Required  
ANTIMALARIAL
$ Chloroquine* ARALEN no 500mg tabs
$ Hydroxychloroquine PLAQUENIL
$ Pyrimethamine DARAPRIM
$ Quinine QUININE
ANTHELMINTIC
$$$$$ Mebendazole VERMOX
$$$$$ Pyrantel Pamoate ANTIMINTH
AMINOGLYCOSIDES
$ Neomycin Sulfate* NEOMYCIN tablets only
$ Sulfasalazine AZULFIDINE
SULFONAMIDES
$ Sulfadiazine SULFADIAZINE
$ Sulfamethoxazole GANTANOL
$ Sulfasalazine AZULFIDINE
$ TMP/Sulfamethoxazole* BACTRIM / DS
$$ Sulfisoxazole* GANTRISIN
ANTIMYCOBACTERIAL AGENTS  
 
$ Isoniazid* INH
$$$$$ Cycloserine SEROMYCIN
$$$$$ Ethambutol MYAMBUTOL
$$$$$ Ethionamide TRECATOR
$$$$$ Pyrazinamide PYRAZINAMIDE
$$$$$ Rifabutin MYCOBUTIN
$$$$$ Rifampin RIFADIN
MISC. ANTIINFECTIVES
$ Metronidazole* FLAGYL
$ Trimethoprim* PROLOPRIM
Urinary Antiinfectives
$ Methenamine Mandelate* MANDELAMINE
$ Trimethoprim TRIMPEX
$$ Nitrofurantoin* FURADANTIN
$$ Nitrofurantoin Macrocrystals* MACRODANTIN
Chloramphenicols
$$ Chloramphenicol* CHLOROMYCETIN
Leprostatics
$ Clofazimine LAMPRENE
$ Dapsone DAPSONE
Antiprotozoal
$$$$ Atovaquone MEPRON
ANTIFUNGALS
$ Griseofulvin Microsize GRIFULVIN V
$ Griseofulvin Ultramicrosize GRISEOFULVIN
$$ Nystatin* MYCOSTATIN
Imidazole-Related Antifungals
$ Miconazole MONISTAT OTC product
$$$ Ketoconazole NIZORAL tablets only
$$$$ Itraconazole SPORANOX  
    Prior Authorization Required  
Triazoles
$$$$ Fluconazole DIFLUCAN PA after 1x150mg disp
    Prior Authorization Required  
ANTIVIRAL
Antiretrovirals - Protease Inhibitors
$$$$$ Amprenavir AGENERASE
$$$$$ Indinavir Sulfate CRIXIVAN
$$$$$ Nelfinavir Mesylate VIRACEPT
$$$$$ Ritonavir NORVIR
$$$$$ Saquinavir FORTOVASE
$$$$$ Saquinavir Mesylate INVIRASE
$$$$$ Tenofovir VIREAD
Antiretrovirals - RTI-Nucleoside Analogues
$$$$ Didanosine VIDEX,VIDEX EC
$$$$$ Lamivudine EPIVIR
$$$$$ Stavudine ZERIT
$$$$$ Zalcitabine HIVID
$$$$$ Zidovudine RETROVIR
Antiretrovirals - RTI-Non Nucleoside Analogues
$$$$$ Abacavir Sulfate ZIAGEN
$$$$$ Delavirdine Mesylate RESCRIPTOR
$$$$$ Efavirenz SUSTIVA
$$$$$ Nevirapine VIRAMUNE
Antiretroviral Combinations
$$$$$ Abacavir/Lamivudine/Zidovudine TRIZIVIR
$$$$$ Lopinavir-Ritonavir KALETRA
$$$$$ Zidovudine/lamivudine COMBIVIR
Hepatits Agents
$$$$$ Peginterferon PEG-INTRON  
    Prior Authorization Required  
Herpes Agents
$$$ Acyclovir*   ZOVIRAX PA < 12 yrs of age
  Prior Authorization Required  
AMEBICIDES
$$$ Iodoquinol YODOXIN
II. ANTINEOPLASTICS
ANTINEOPLASTICS
Alkylating Agents
$$$$$ Busulfan MYLERAN
$$$$$ Pipobroman VERCYTE
Nitrogen Mustards
$$$$$ Chlorambucil LEUKERAN
$$$$$ Cyclophosphamide* CYTOXAN
$$$$$ Melphalan ALKERAN
$$$$$ Uracil Mustard URACIL MUSTARD
Nitrosoureas
$$$$$ Lomustine CCNU
Antimetabolites
$$$$ Methotrexate* RHEUMATREX
$$$$$ Diethylstibestrol D.E.S.
$$$$$ Fluouracil EFUDEX
$$$$$ Mercaptopurine PURINETHOL
$$$$$ Thioguanine THIOGUANINE
Androgens-Antineoplastic
$$$$$ Testolactone TESLAC
Progestins-Antineoplastic
$$$$ Megestrol* MEGACE no suspension
Antiandrogens
$$$$$ Bicalutamide CASODEX
$$$$$ Flutamide EULEXIN
$$$$$ Nilutamide NILANDRON
Aromatase Inhibitors
$$$$$ Anastrozole ARIMIDEX
$$$$$ Letrozole FEMARA
Antineoplastic Hormones Misc.
$$$$$ Tamoxifen NOLVADEX
$$$$$ Leuprolide LUPRON  
    Prior Authorization Required  
Mitotic Inhibitors
$$$$ Etoposide VEPESID
Antineoplastics Misc.
$ Procarbazine MATULANE
$$$$ Hydroxyurea HYDREA
$$$$$ Mitotane LYSODREN
$$$$$ Interferon Alfa-2A ROFERON-A  
$$$$$ Interferon Alfa-2B INTRON-A  
$$$$$ Interferon Alfa-n3 ALFERON N  
$$$$$ Interferon Beta-1a AVONEX  
$$$$$ Interferon Beta-1b* BETASERON  
    Prior Authorization Required  
III. ENDOCRINE & METABOLIC DRUGS
CORTICOSTEROIDS
Glucocorticosteroids
$ Cortisone CORTONE
$ Dexamethasone* DECADRON no dosepak, no inh.
$ Hydrocortisone* CORTEF
$ Methylprednisolone* MEDROL
$ Prednisolone* PRELONE
$ Prednisone* DELTASONE
$$$ Prednisolone Na Phosphate PEDIAPRED
Mineralocorticoids
$$ Fludrocortisone FLORINEF
ANDROGEN-ANABOLIC
Androgens
$$ Fluoxymesterone HALOTESTIN
$$$ Methyltestosterone ANDROID
$$$$$ Danazol DANOCRINE
ESTROGENS
$ Estradiol* ESTRACE
$ Estropipate* OGEN
$$ Estrogens, Conjugated PREMARIN
$$ Esterified Estrogens ESTRATAB
$$ Dienestrol ORTHO-DIENESTROL
$$$$ Estradiol Patch ALORA
PROGESTINS
$ Medroxyprogesterone* PROVERA tablets only
$ Norethindrone AYGESTIN
ESTROGEN COMBINATIONS
$$ Conjugated Estrogens &
Medroxyprogesterone PREMPRO,PREMPHASE
$$ Ethinyl Estradiol-Norethindrone FEMHRT
CONTRACEPTIVES
Progestin OC's
$ Norethindrone NOR-Q-D
$$$ Medroxyprogesterone Depot DEPO-PROVERA 150mg inj only
Combinations OC's
$$ Desogest-Eth Estrad & Eth Estrad KARIVA
$$ Drospirenone-Eth.Estradiol YASMIN
$$ Ethynodiol Diacet & Eth. Estrd. DEMULEN,ZOVIA
$$ Levonorgestrel & Eth. Estradiol ALESSE
$$ Levonorgestrel & Eth. Estradiol LEVLEN,LEVORA
$$ Levonorgestrel & Eth. Estradiol LEVLITE
$$ Levonorgestrel & Eth. Estradiol NORDETTE
$$ Norethindrone & Eth. Estradiol BREVICON,NECON
$$ Norethindrone & Mestranol NORINYL
$$ Norgestimate & Ethinyl Estradiol SPRINTEC
$$ Norgestrel & Ethinyl Estradiol CRYSELLE,OVRAL,OGESTREL
Triphasic OC's
$$ Levonorgestrel-Eth. Estradiol TRI-LEVLEN
$$ Norethindrone-Ethinyl Estrad TRI-NORINYL
ANTIDIABETIC
Human Insulin
$ Insulin Isophane HUMULIN N
$ Insulin Reg & Isophane HUMULIN 50/50
$ Insulin Reg & NPH HUMULIN 70/30
$ Insulin Regular HUMULIN R
$ Insulin Zinc HUMULIN L
$ Insulin Zinc Extended HUMULIN U
$ Insulin Glargine LANTUS
Sulfonylureas
$ Chlorpropamide* DIABINESE
$ Tolazamide* TOLINASE
$ Tolbutamide* ORINASE
$$ Glipizide* GLUCOTROL no XL
$$ Glyburide* DIABETA
$$ Glyburide* GLYNASE
Insulin Sensitizing Agents
$$$ Pioglitazone ACTOS  
$$$ Rosiglitazone AVANDIA  
    Prior Authorization Required  
Biguanides
$$ Metformin GLUCOPHAGE no XR
Diabetic Other
$$$ Glucagon GLUCAGON
THYROID
Thyroid Hormones
$ Levothyroxine LEVOXYL,SYNTHROID
$ Liothyronine CYTOMEL
$ Thyroid* THYROID
Antithyroid Agents
$ Methimazole TAPAZOLE
$ Propylthiouracil* PROPYLTHIOURACIL
OXYTOCICS
$ Ergonovine ERGOTRATE
$ Methylergonovine METHERGINE
MISC. ENDOCRINE
Calcium Regulators
$$ Etidronate DIDRONEL
$$$$ Calcitonin (Salmon) MIACALCIN INJ  
$$$$$ Calcitonin (Salmon) MIACALCIN NASAL  
    Prior Authorization Required  
Hormone Receptor Modulators
$$$ Raloxifene EVISTA
Gonadotropin Releasing Hormones
$$$$$ Nafarelin   SYNAREL  
    Prior Authorization Required  
Growth Hormone
$$$$$ Somatropin HUMATROPE  
    Prior Authorization Required  
Posterior Pituitary
$$$ Alendronate FOSAMAX
$$$ Risedronate ACTONEL 35 mg only
IV. CARDIOVASCULAR AGENTS
CARDIOTONICS
Digitalis
$ Digoxin LANOXIN no capsules
ANTIANGINAL AGENTS
Nitrates
$ Isosorbide Dinitrate* ISORDIL, ISORDIL TEMBIDS
$ Nitroglycerin (oral)* NITROSTAT
$ Nitroglycerin (topical)* NITROL, NITROPASTE
$$ Isosorbide Mononitrate* IMDUR SR covered
$$$ Nitroglycerin (patch)* NITRO-DUR
BETA BLOCKERS
Beta Blockers Non-Selective
$ Propranolol* INDERAL / LA
$ Timolol BLOCADREN
$$ Nadolol* CORGARD
$$$$ Sotalol BETAPACE
$$$$ Carvedilol   COREG  
    Prior Authorization Required  
Beta Blockers Cardio-Selective
$ Atenolol* TENORMIN
$ Metoprolol Tartrate* LOPRESSOR
$ Bisoprolol ZEBETA
$$$ Metoprolol Succinate TOPROL XL
Alpha-Beta Blockers
$$$ Labetalol NORMODYNE
Beta Blocker Combinations
$ Atenolol & Chlorthalidone* TENORETIC
$ Bisoprolol & HCTZ* ZIAC
$ Propranolol & HCTZ* INDERIDE no LA
CALCIUM BLOCKERS
$$ Felodipine PLENDIL
$$ Verapamil* CALAN, SR
$$$ Amlodipine NORVASC
$$$ Diltiazem* CARDIZEM CD
$$$ Nifedipine* ADALAT CC,PROCARDIA XL
$$$$$ Bepridil VASCOR
ANTIARRHYTHMIC
$ Disopyramide* NORPACE, CR
$ Procainamide* PRONESTYL, PROCANBID
$ Quinidine Sulfate* QUINORA
$$ Quinidine Gluconate* QUINAGLUTE DURATABS
$$$ Flecainide TAMBOCOR
$$$ Tocainide TONOCARD
$$$$ Amiodarone CORDARONE
$$$$ Mexiletine MEXITIL
$$$$ Moricizine ETHMOZINE
$$$$ Propafenone RYTHMOL
$$$$ Sotalol BETAPACE
ANTIHYPERTENSIVE
ACE Inhibitors
$ Captopril* CAPOTEN
$$ Benazepril LOTENSIN
$$ Enalapril* VASOTEC
$$ Fosinopril MONOPRIL
$$ Lisinopril ZESTRIL
$$ Quinapril ACCUPRIL
$$$ Ramipril ALTACE
ACE Inhibitors & Thiazide/Thiazide-Like
$$ Benazapril & HCTZ LOTENSIN HCT
Adrenolytics - Central
$ Methyldopa* ALDOMET
Adrenolytics - Peripheral
$ Reserpine* RESERPINE
Adrenolytics-Central & Thiazides
$ Methyldopa & HCTZ* ALDORIL
Reserpine Combinations
$ Reserpine & HCTZ HYDROPRES
$ Hydralazine-Reserpine-HCTZ* SER-AP-ES
Alpha Blockers
$ Doxazosin* CARDURA
$ Prazosin* MINIPRESS
$$$ Phenoxybenzamine DIBENZYLINE
$$$ Terazosin* HYTRIN
Vasodilators
$ Hydralazine* APRESOLINE
$ Minoxidil* LONITEN
Angiotensin II Receptor Antagonists
$$ Losartan COZAAR
$$ Valsartan DIOVAN
Angiotensin II Receptor Antagonists &Thiazides
$$ Losartan-HCTZ HYZAAR
$$ Valsartan-HCTZ DIOVAN HCT
Vasodilators & Thiazides
$ Hydralazine & HCTZ* APRESAZIDE
DIURETICS
Carbonic Anhydrase Inhibitors
$ Acetazolamide* DIAMOX no sequels
$$$ Methazolamide NEPTAZANE
Loop Diuretics
$ Furosemide* LASIX
$$ Bumetanide* BUMEX
$$ Torsemide DEMADEX
Potassium Sparing Diuretics
$ Spironolactone* ALDACTONE
Thiazides
$ Chlorothiazide* DIURIL
$ Chlorthalidone* HYGROTON
$ Hydrochlorothiazide* HYDRODIURIL
$ Metolazone ZAROXOLYN
$$ Indapamide* LOZOL
Combination Diuretics
$ Amiloride & HCTZ* MODURETIC
$ Spironolactone & HCTZ* ALDACTAZIDE
$ Triamterene & HCTZ* MAXZIDE
PRESSORS
Emergency Kits
$$ Epinephrine EPI-PEN, EPI-PEN JR
$$ Epinephrine & Chlorpheniramine ANA-KIT
ANTIHYPERLIPIDEMIC
Bile Sequestrants
$$$ Cholestyramine* QUESTRAN, LIGHT cans only
$$$ Colestipol COLESTID cans only
Miscellaneous
$ Niacin CR* NIASPAN
$ Nicotinic Acid NIACIN OTC product (slow release)
Fibrates
$$$ Gemfibrozil* LOPID
HMG CoA Reductase Inhibitors
$$$ Fluvastatin LESCOL,LESCOL XL
$$$ Simvastatin ZOCOR
V.RESPIRATORY AGENTS
ANTIHISTAMINES
Antihistamines - Alkylamines
$ Dexchlorpheniramine* POLARAMINE no syrup
Antihistamines - Ethanolamines
$ Chlorpheniramine Maleate* CHLOR-TRIMETON OTC product
Antihistamines - Non-Sedating
$$ Loratidine CLARITIN,CLARITIN-D OTC only
$$ Cetirizine ZYRTEC  
$$ Desloratadine CLARINEX  
    Prior Authorization Required  
Antihistamines - Phenothiazines
$$$$$ Promethazine* PHENERGAN
Antihistamines - Piperidines
$ Cyproheptadine* PERIACTIN
TOPICAL NASAL PRODUCTS
Nasal Steroids
$$ Beclomethasone Dipropionate BECONASE/VANCENASE
$$ Flunisolide NASALIDE
$$ Fluticasone FLONASE
$$ Mometasone NASONEX
$$ Triamcinolone NASACORT,NASACORT AQ
Misc. Nasal Products
$$$ Cromolyn (nasal) NASALCROM
ANTIASTHMATIC
Sympathomimetic Agents
$ Albuterol* PROVENTIL no HFA,SR, Rotocaps
$$ Formotrol Fumarate FORADIL
$$ Metaproterenol* ALUPENT
Beta Adrenergics
$$ Pirbuterol MAXAIR AUTOHALER
$$ Terbutaline BRETHINE
$$$ Salmeterol SEREVENT
Leukotreine Modulators
$$$ Zafirlukast ACCOLATE
$$$ Montelukast SINGULAIR
Steroid Inhalants
$$ Beclomethasone VANCERIL DS
$$$ Triamcinolone AZMACORT
$$$$ Budesonide PULMICORT
$$$$ Fluticasone FLOVENT
Anti-Inflammatory Agents
$$$ Cromolyn (inhalation) INTAL
$$$ Nedocromil TILADE
Anticholinergics
$$ Ipratropium ATROVENT
Adrenergic Combinations
$$ Albuterol-Ipratropium COMBIVENT
$$ Salmeterol-Fluticasone ADVAIR  
Xanthines
$ Dyphylline-Guaifenesin PANFIL-G
$ Theophylline* T-PHYL, UNIPHYL
Mucolytics
$$ Acetylcysteine* MUCOMYST
$$ Sodium Chloride* BRONCHO SALINE NEB.0.9%
Mixed Adrenergics
$$ Epinephrine EPI-PEN, EPI-PEN JR
$$ Epinephrine & Chlorpheniramine ANA-KIT
COUGH/COLD/ALLERGY
$ Guaifenesin* GUAIFENESIN OTC product
$ Guaifenesin-DM* GUAIFENESIN DM OTC product
$ Pseudoephedrine HCL* PSEUDOEPHEDRINE OTC product
VI. GASTROINTESTINAL AGENTS
LAXATIVES
Surfactant Laxatives
$ Docusate Sodium* COLACE capsules only, OTC product
Miscellaneous Laxatives
$ Glycerin* GLYCERIN OTC product
$ Glycerin Supp. GLYCERIN Adult, Infant, Child, OTC product
$ Lactulose* CHRONULAC
$ PEG-Electrolyte GOLYTELY, NULYTELY
ANTIDIARRHEALS
Antiperistaltic Agents
$ Diphenoxylate w/ Atropine LOMOTIL
$ Loperamide* IMODIUM OTC product
$ Paregoric* PAREGORIC
Misc Antidiarrheal Agents
$ Bismuth Subsalicylate PEPTO-BISMOL OTC product
$$$$$ Octreotide Acetate SANDOSTATIN  
    Prior Authorization Required  
ANTACIDS
Antacids - Aluminum Salts
$ Aluminum Hydroxide Gel* AMPHOGEL OTC product
Antacids - Calcium Salts
$ Calcium Carbonate* OS-CAL OTC product
Antacids - Magnesium Salts
$ Magnesium Oxide MAG-OX
Antacid Combinations
$ Aluminum & Mag Hydroxide* MYLANTA no tabs, OTC product
$ Al Hydrox-Mag Carb* MAALOX no tabs, OTC product
ULCER DRUGS
Antispasmodics/Anticholinergics
$ Dicyclomine* BENTYL
$ Hyoscyamine Sulfate LEVSIN/LEVSINEX
$ Propantheline Bromide* PRO-BANTHINE
H-2 Antagonists
$ Cimetidine* TAGAMET
$ Famotidine PEPCID
$ Nizatidine AXID
$ Ranitidine* ZANTAC no gelcaps
Proton Pump Inhibitors
$$$$ Pantoprazole PROTONIX
$$$$ Rabeprazole ACIPHEX
$$$$ Lansoprazole PREVACID  
    Prior Authorization Required  
Misc. Anti-Ulcer
$$$$ Sucralfate* CARAFATE  
ANTIEMETICS
Antivertigo
$ Meclizine* ANTIVERT
Antiemetics
$$ Prochlorperazine COMPAZINE no SR
5-HT3 Receptor Antagonists
$$ Ondansetron HCL ZOFRAN
    Prior Authorization Required
DIGESTIVE AIDS
Digestive Aids - Mixtures
$$$ Amylase-Lipase-Protease Reg.Rls VIOKASE
$$$$ Amylase-Lipase-Protease CREON  
    Prior Authorization Required  
MISC. GI
GI Stimulants
$ Metoclopramide* REGLAN
Gallstone Solubilizing Agents
$$$$$ Ursodiol ACTIGALL
Inflammatory Bowel Agents
$ Sulfasalazine* AZULFIDINE
$$$$ Mesalamine ASACOL
VII. GENITOURINARY
URINARY ANTIINFECTIVES
$ Methenamine Mandelate* MANDELAMINE
$ Trimethoprim TRIMPEX
$$ Nitrofurantoin* FURADANTIN
$$ Nitrofurantoin Macrocrystals* MACRODANTIN
URINARY ANTISPASMODICS
$ Bethanechol* URECHOLINE
$ Hyoscyamine LEVSIN, LEVSINEX
$$ Oxybutynin DITROPAN no XL
MISCELLANEOUS GENITOURINARY PRODUCTS
Citrates
$ Sodium Citrate & Citric Acid BICITRA
Urinary Analgesics
$ Phenazopyridine* PYRIDIUM
INTRA-VAGINAL PRODUCTS
Vaginal Antiinfectives
$ Nystatin* NYSTATIN
$$ Metronidazole METROGEL vaginal only
$$ Sulfanilamide AVC
$$ Clindamycin CLEOCIN  
    Prior Authorization Required  
Imidazole-Related Antifungals
$ Butoconazole Nitrate FEMSTAT
$ Clotrimazole* MYCELEX OTC product
$ Miconazole MONISTAT OTC product
Vaginal Antiinfective Combinations
$ Triple Sulfas Vaginal* SULTRIN
Vaginal Estrogens
$$ Dienestrol ORTHO-DIENESTROL
IX. ANALGESICS & ANESTHETICS
ANALGESICS - NonNarcotic
Salicylates
$ Aspirin Enteric Coated* ECOTRIN OTC product
$ Aspirin zero order* ZORPRIN
$$ Salsalate* DISALCID
Salicylate Combinations
$ Aspirin with Buffers* ASPIRIN BUFFERED OTC product
$$$$ Choline & Mag Salicylate* TRILISATE
Analgesics Other
$ Acetaminophen* TYLENOL OTC product
ANALGESICS - Narcotic
Narcotic Agonists
$ Codeine Phosphate CODEINE PHOSPHATE
$ Codeine Sulfate* CODEINE SULFATE
$ Meperidine* DEMEROL
$ Oxycodone* ROXICODONE
$$ Propoxyphene DARVON
$$ Tramadol ULTRAM
$$$ Hydromorphone* DILAUDID
$$$ Morphine Sulfate* MSIR
$$$$ Morphine Sulfate CR KADIAN
$$$$ Morphine Sulfate SR MS CONTIN
$$$$ Morphine Sulfate SR ORAMORPH SR
Narcotic Combinations
$ Oxycodone w/ Acetaminophen* PERCOCET 5/325,7.5/500,10/650
$ Oxycodone w/Aspirin* PERCODAN
$ Propoxyphene w/Acetaminophen* DARVOCET N-50,N-100
Codeine Combinations
$ Acetaminophen w/ Codeine* TYLENOL / COD
Hydrocodone Combinations
$$$ Acetaminophen w/ Hydrocodone* LORTAB,LORCET,
LORTAB 5/500,7.5/500,7.5/650,7.5/750
VICODIN,VICODIN ES elixir covered
$$$ Aspirin w/Hydrocodne LORTAB
ANTI-RHEUMATIC
NSAID's
$ Ibuprofen* MOTRIN
$$ Diclofenac sodium* VOLTAREN no XR
$$ Diclofenac Potassium* CATAFLAM
$$ Diflunisal DOLOBID
$$ Fenoprofen* NALFON
$$ Flurbiprofen ANSAID
$$ Indomethacin* INDOCIN
$$ Ketoprofen ORUDIS
$$ Nabumetone RELAFEN
$$ Naproxen Sodium* ANAPROX
$$ Naproxen* NAPROSYN
$$ Oxaprozin DAYPRO
$$ Piroxicam FELDENE
$$ Sulindac* CLINORIL
$$ Tolmentin Sodium TOLECTIN
$$$ Etodolac* LODINE
$$$ Ketorolac TORADOL
Cox-2 Inhibitors
$$ Rofecoxib   VIOXX  
$$$ Celecoxib   CELEBREX  
    Prior Authorization Required  
Disease Modifying Antirheumatic Agents (DMARS)
$ Hydroxychloroquine PLAQUENIL
$ Sulfasalazine AZULFIDINE
$$$ Penicillamine CUPRIMINE
$$$$ Azathioprine IMURAN
$$$$ Methotrexate* RHEUMATREX tablets only
$$$$$ Cyclophosphamide* CYTOXAN
GOUT
$ Allopurinol* ZYLOPRIM
$ Colchicine* COLCHICINE
Uricosurics
$ Probenecid* PROBENECID
LOCAL ANESTHETICS
$ Lidocaine* LIDOCAINE no patch
MIGRAINE PRODUCTS
Ergotamines
$$ Ergoloid mesylates HYDERGINE
$$ Ergotamine w/Caffeine ERCAF
5HT 1 Receptor Agonists
$$$ Almotriptan AXERT
$$$ Zolmitriptan ZOMIG
$$$$ Sumatriptan IMITREX
Migraine Combinations
$ APAP/Caffeine/Butalbital* FIORICET
$ ASA/Caffeine/Butalbital* FIORINAL
$$ Ergotamine w/ Caffeine CAFERGOT
X. NEUROMUSCULAR AGENTS
ANTICONVULSANT
Hydantoins
$$ Phenytoin DILANTIN
$$ Phenytoin PHENYTOIN
$$$ Ethotoin PEGANONE
ANTIPARKINSONIAN
Antiparkinsonian Dopaminergic
$$$$ Bromocriptine PARLODEL no postpartum use
D2 Class Dopamine Receptor Agonists
$$$$$ Pramipexole dihydrochloride MIRAPEX
Levodopa Combinations
$$$ Carbidopa-Levodopa* SINEMET, CR cr 25/100 mg only
Antiparkinsonian Monoamine Oxidase Inhibitor
$$$$ Selegiline ELDEPRYL
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
$ Chlorzoxazone* CHLORZOXAZONE
$ Cyclobenzaprine* FLEXERIL
$ Methocarbamol* ROBAXIN
$$ Baclofen* LIORESAL
$$ Tizanidine ZANAFLEX
Direct Muscle Relaxants
$$$$ Dantrolene DANTRIUM  
    Prior Authorization Required  
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
$$$$ Pyridostigmine MESTINON
Benzothiazoles
$$$$$ Riluzole   RILUTEK  
    Prior Authorization Required  
XI. NUTRITIONAL PRODUCTS
VITAMINS
Water Soluble Vitamins
$ Niacin* NIACIN
$ Vitamin B-3* VITAMIN B-3
Oil Soluble Vitamins
$ Vitamin A* AQUASOL A
Vitamin D
$$ Calcitriol ROCALTROL
$$ Ergocalciferol DRISDOL
MULTIVITAMINS
$ Folic Acid & Vitamin B Complex* NEPHROCAPS
$ Multiple Vitamin* ONE-A-DAY OTC product
$ Pediatric Vitamins* CHILDS COMPLETE OTC product
$ Prenatal MV & Min w/FE-FA* PRENATAL-1
$ Prenatal Vitamins* MATERNA
CITRATES
$ Sodium Citrate & Citric Acid BICITRA
MINERALS & ELECTROLYTES
Calcium
$ Calcium Acetate PHOSLO
$ Calcium Carbonate* OS-CAL OTC product
$ Calcium Chloride CALCIUM CHLORIDE
$ Calcium Gluconate* CALCIUM GLUCONATE
Fluoride
$ Sodium Fluoride LURIDE
Iron
$ Ferrous Gluconate* FERGON OTC product
$ Ferrous Sulfate* FEOSOL OTC product
Potassium
$ Potassium Chloride Capsule* MICRO-K
$ Potassium Chloride Liquid* KAYCIEL
$ Potassium Chloride Tablet* KLOR-CON,K-DUR
Electrolyte Mixtures
$ Oral Electrolytes PEDIALYTE OTC product
DIETARY PRODUCTS
$$ Infant Foods LOFENALAC OTC product
$$ Phenyl-Free PHENYL-FREE OTC product
XII. HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Cobalamines
$ Folic Acid* FOLVITE
$$$$$ Leucovorin Calcium* LEUCOVORIN  
$ Cyanocobalamin* VITAMIN B-12  
$ Hydroxocobalamin* HYDROBEXAN  
    Prior Authorization Required  
Iron
$ Ferrous Gluconate* FERGON OTC product
$ Ferrous Sulfate* FEOSOL OTC product
Erythropoietins
$$$$$ Epoetin Alfa PROCRIT  
    Prior Authorization Required  
Leukocytes
$$$$$ Filgrastim   NEUPOGEN  
    Prior Authorization Required  
ANTICOAGULANTS
Coumarin Anticoagulants
$$ Warfarin Sodium COUMADIN
Heparins
$ Heparin Sodium HEPARIN
$$$ Enoxaparin LOVENOX (PA required > 14 days)
    Prior Authorization Required  
HEMOSTATICS
Hemostatics - Topical
$$$$ Thrombin   THROMBIN  
    Prior Authorization Required  
MISC. HEMATOLOGICAL
Antihemophilic Products
$$$$$ Antihemophilic Factor (Human) ALPHANATE  
$$$$$ Antihemophilic Factor (Porcine) HYATE:C  
$$$$$ Antihemophilic Factor (Recombinant) BIOCLATE  
$$$$$ Antiinhibitor Coagulant Complex AUTOPLEX T  
$$$$$ Antithrombin III (Human) THROMBAT III  
    Prior Authorization Required  
Antiplatlet Agent
$ Dipyridamole* PERSANTINE
Platelet Aggregation Inhibitors
$$ Dipyridamole/Aspirin AGGRENOX
$$$ Clopidogrel bisulfate PLAVIX
$$$ Ticlopidine* TICLID  
    Prior Authorization Required  
Hematorheological
$$$ Pentoxifylline TRENTAL  
XIII. TOPICAL AGENTS
OPHTHALMIC
Antibiotics
$ Bacitracin* AK-TRACIN
$ Chloramphenicol CHLOROPTIC
$ Erythromycin* ILOTYCIN
$ Gentamicin Sulfate* GARAMYCIN
Sulfonamides
$ Sodium Sulfacetamide* SULAMYD
Antivirals
$ Vidarabine VIRA-A
$$$ Idoxuridine HERPLEX
$$$ Trifluridine VIROPTIC
Antiinfective Combinations
$ Bacitracin-Polymyxin B* POLYSPORIN
$ Neomycin-Bac Zn-Polymyxin* NEOSPORIN
$ Neomycin-Polymy-Gramicidin* AK-SPORE
$ Polymixin B/Trimethoprim POLYTRIM
Artificial Tears and Lubricants
$ Artificial Tear Solution* OCUCOAT
Beta-Blockers
$$ Metipranolol OPTIPRANOLOL
$$ Timolol* TIMOPTIC
$$$ Betaxolol BETOPTIC,BETOPTIC S
Steroids
$ Dexamethasone* DECADRON
$$ Fluorometholone* FML,FML,FORTE
$$ Prednisolone Acetate* PRED FORTE, MILD
Steroid Combinations
$ Bacitracin-Polymyxin-Neomycin-HC AK-SPORE HC
$ Neomycin-Dexamethasone* NEO-DECADRON
$ Neomycin-Polymyxin-Dexamethasone* MAXITROL
$ Neomycin-Polymyxin-HC CORTISPORIN
$ Sulfacetamide Sod-Prednisolone VASOCIDIN
$ Tobramycin Sulfate TOBREX
Cycloplegics
$ Atropine Sulfate* ISOPTO ATROPINE
$ Cyclopentolate HCL* CYCLOGYL
$ Homatropine ISOPTO HOMATROPINE
$ Scopolamine ISO HYOSCINE
Decongestants
$ Naphazoline* VASOCON
$ Phenylephrine* MYDFRIN
Miotics - Direct Acting
$ Pilocarpine* ISOPTO-CARPINE No Ocusert
Miotics - Cholinesterase Inhibitors
$ Demecarium Bromide HUMORSOL
$ Physostigmine Sulfate ESERINE
$$ Echothiophate Iodide PHOSPHOLINE
Adrenergic Agents
$$ Dipivefrin* PROPINE
Antiallergic
$$ Cromolyn Sodium OPTICROM
Misc. EENT Drugs
$$$ Latanoprost XALATAN  
    Prior Authorization Required  
Carbonic Anhydrase Inhibitors
$$ Dorzolamide TRUSOPT  
    Prior Authorization Required  
OTIC
Steroids
$ Hydrocortisone w/Acetic Acid* VOSOL-HC
Miscellaneous
$ Acetic Acid in Propylene Glycol* VOSOL
Antibiotics & Steroid-Antibiotic Combinations
$ Neomycin-Polymyxin-HC* CORTISPORIN
$$ Chloramphenicol CHLOROMYCETIN
$$ Polymyxin B-HC OTOBIOTIC
Analgesic Combinations
$ Benzocaine & Antipyrine* AURALGAN
MOUTH & THROAT (Local)
Antiinfectives - Throat
$ Nystatin* NYSTATIN
ANORECTAL
Rectal Steroids
$ Hydrocortisone ANUSOL-HC 2.5% cream only
$$ Hydrocortisone PROCTOCREAM 2.5% cream only
DERMATOLOGICAL
Antibiotics - Topical
$ Bacitracin* BACITRACIN OTC product
$ Gentamicin Sulfate* GARAMYCIN
$ Neomycin Sulfate* NEOMYCIN
Antibiotic Mixtures Topical
$ Neomycin-Bacitracin-Polymyxin* NEOSPORIN OTC product
Antibiotic Steroid Combinations
$ Neomycin-Dexamethasone NEO-DECADRON
$ Neomycin-Polymyxin-HC CORTISPORIN
Imidazole-Related Antifungals (Topical)
$ Miconazole* MONISTAT OTC product
$$ Clotrimazole* LOTRIMIN no vaginal, OTC product
$$ Econazole SPECTAZOLE
Antifungals
$$ Ketoconazole NIZORAL
$$ Nystatin* NYSTATIN
Antifungals - Topical Combinations
$ Betamethasone-Clotrimazole LOTRISONE
$ Nystatin-Triamcinolone* MYCOLOG II
Antipsoriatics
$$$ Calcipotriene DOVONEX
Burn Products
$ Silver Sulfadiazine* SILVADENE
Anti-Seborrheal
$ Selenium Sulfide Shampoo SELENIUM SULFIDE
Tar Products
$ Coal Tar COAL TAR SHAMPOO 1% only
Keratolytics/Antimitotics
$$$ Podofilox CONDYLOX
Local Anesthetics - Topical
$ Lidocaine viscous* XYLOCAINE VISCOUS
Scabicides & Pediculocides
$ Lindane* KWELL
$$ Permethrin* ELIMITE
Misc. Topical
$$$ Fluorouracil* EFUDEX
Antiviral Topical
$$ Acyclovir   ZOVIRAX  
    Prior Authorization Required  
Corticosteroids - Topical
$ Betamethasone Dipropionate* DIPROSONE
$ Betamethasone Valerate* VALISONE
$ Desonide* DESOWEN
$ Fluocinolone* SYNALAR
$ Hydrocortisone Valerate WESTCORT
$ Hydrocortisone* HYTONE OTC product
$ Triamcinolone Acetonide in Orabase* KENALOG / ORABASE
$ Triamcinolone Acetonide* KENALOG
$$ Augmented Betamethasone DIPROLENE
$$ Clobetasol Propionate TEMOVATE
$$ Desoximetasone* TOPICORT
$$ Dexamethasone DECADRON
$$ Diflorasone diacetate PSORCON
$$ Fluocinonide* LIDEX
XIV. MISCELLANEOUS PRODUCTS
ANTIDOTES
$ Ipecac* IPECAC OTC product
Chelating Agents
$$$ Penicillamine CUPRIMINE
$$$$ Sodium Polystyrene Sulfonate KAYEXALATE
DIAGNOSTIC PRODUCTS
Diagnostic Reagents
$ Acetone Test* KETOSTIX
$ Acetone Tablets ACETEST
$ Glucose Urine Test* CLINITEST
$ Pregnancy Test EPT
$ Pregnancy Test FACT PLUS
$$ Glucose Blood Strip* ONE TOUCH
Radiographic Contrast Media Iodinated
$ Iopanoic Acid TELEPAQUE
PHARMACEUTICAL ADJUVANTS
MEDICAL DEVICES
Parenteral Therapy Supplies
$ Disposable Needles & Syringes* B-D INSULIN SYRINGE
Diabetic Supplies
$ Calibration Solution CALIBRATION SOLUTION
$ Lancet Device HYPOLET
$ Lancets LANCETS
$$ Blood Glucose Monitoring Tests* GLUCOMETER/ACCU-CHECK
Misc. Devices
$ Alcohol Swabs* ALCOHOL PADS
ASSORTED CLASSES
Immunosuppressive Agents
$$$$$ Cyclosporine SANDIMMUNE
$$$$$ Cyclosporine Microsize NEORAL
Inosine Monophosphate Dehydrogenase Inhibitors
$$$$$ Mycophenolate Mofetil CELLCEPT
Purine Analogs
$$$$ Azathioprine IMURAN