Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
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- Marybeth Hancock
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1 Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 HPMS Approved Formulary File Submission ID: Version Number: 21 H3237_2016_0006_ CHI CMS Approved
2 Health Net Cal MediConnect Health Net Cal MediConnect Plan Medicare-Medicaid Plan Medicare Medi-Cal / / calmediconnect Health Net Cal MediConnect Los Angeles County San Diego County Los Angeles County San Diego County Health Net Cal MediConnect Health Net Cal MediConnect You can get this information for free in or languages. Call for Los Angeles County or for San Diego County, TTY: 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al para el condado de Los Angeles o para el condado de San Diego, TTY: 711. La llamada es gratuita.? Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 i
3 (FAQ) FAQ 1. Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect 5 com/calmediconnect Los Angeles County San Diego County ii
4 2. Health Net Cal MediConnect Health Net Cal MediConnect iv calmediconnect Health Net Cal MediConnect Los Angeles County San Diego County Food and Drug Administration (FDA)? Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 iii
5 5. Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect / / iv
6 8. Index Los Angeles County San Diego County Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect Health Net Cal MediConnect 98 90? Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 v
7 Health Net Cal MediConnect Health Net Cal MediConnect Food and Drug Administration (FDA) Health Net Cal MediConnect vi
8 15. (OTC) OTC over--counter Health Net Cal MediConnect OTC Health Net Cal MediConnect OTC 16. Health Net Cal MediConnect OTC Health Net Cal MediConnect OTC Health Net Cal MediConnect OTC 17. Health Net Cal MediConnect Health Net Cal MediConnect Medi-Cal Medi-Cal Medi-Cal OTC? Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 vii
9 1 Health Net Cal MediConnect Index 1 Health Net Cal MediConnect LIPITOR atorvastatin calcium AL FDA B/D Medicare B D Medicare B D Medicare GL LA FDA Health Net Cal MediConnect viii
10 D D PA Health Net Cal MediConnect QL Health Net Cal MediConnect RX/OTC OTC (OTC) SL FDA Health Net FDA simvastatin simvastatin ST? Health Net Cal MediConnect Los Angeles County San Diego County :00 8:00 8:00 8:00 ix
11 D Medicare Medi-Cal Los Angeles County San Diego County x
12 Name of ADHD/AI-NARCOLEPSY/AI- OBESITY/ANOREXIAS - Drugs to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL XR (Amphetamine- Dextroamphetamine) DESOXYN (Methamphetamine HCl) DEXEDRINE 10 MG,15 MG,5 MG (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10, 15, 5 dextroamphetamine sulfate tabs 10, 5 methamphetamine hcl amphetaminedextroamphetamine Anorexiants Non-Amphetamine ADIPEX-P (Phentermine HCl) benzphetamine hcl 25 diethylpropion hcl tabs 25 DIETHYLPROPION HCL TABS 25 MG (Diethylpropion HCl) PA; ; PA; ; PA; ; PA; ; Name of diethylpropion hcl tb24 75 phentermine hcl QSYMIA REGIMEX SUPRENZA 15 MG, 30 MG Anti-Obesity Agents ALLI BELVIQ CORAVE SAXENDA XENICAL PA; ; PA; ; PA; PA; ; PA; ; PA; PA; ; PA; ; PA; ; PA; ; Attention-Deficit/Hyperactivity Disorder (ADHD) clonidine hcl (adhd) AL; guanfacine hcl (adhd) IUNIV (Guanfacine HCl (ADHD)) AL; You can find information on what symbols and abbreviations in this table mean by going to 1
13 Name of KAPVAY (Clonidine HCl (ADHD)) STRATTERA 10 MG STRATTERA 100 MG STRATTERA 18 MG STRATTERA 25 MG STRATTERA 40 MG STRATTERA 60 MG STRATTERA 80 MG Stimulants - Misc. CONCERTA 27 MG, 36 MG (Methylphenidate HCl) dexmethylphenidate hcl cp24 15 dexmethylphenidate hcl tabs 10, 2.5, 5 SL(10 ea daily); SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); Name of FOCALIN (Dexmethylphenidate HCl) FOCALIN XR 15 MG (Dexmethylphenidate HCl) METADATE CD (Methylphenidate HCl) methylphenidate hcl cp24 or 20, 30, 40 methylphenidate hcl cpcr or 10, 20, 30, 40, 50, 60 methylphenidate hcl tabs or 10, 20, 5 methylphenidate hcl tb24 or 27, 36 methylphenidate hcl tbcr or 20, 27, 36 modafinil PROVIGIL (Modafinil) RITALIN (Methylphenidate HCl) RITALIN LA 20 MG, 30 MG, 40 MG (Methylphenidate HCl) RITALIN LA 60 MG PA; PA; You can find information on what symbols and abbreviations in this table mean by going to 2
14 Name of RITALIN SR (Methylphenidate HCl) ALTERNATIVE MEDICINES Alternative Medicine - A's ALPHA LIPOIC ACID CAPS OR 50 MG ALPHA-LIPOIC ACID alpha-lipoic acid (thioctic acid) caps 100 Alternative Medicine - C's CHEW Q 100 MG coenzyme q10 (ubidecarenone) caps 10, 150, 60 coenzyme q10 (ubidecarenone) caps 30 COENZYME Q10 CHEW OR 60 MG COENZYME Q10 TABS OR 25 MG Alternative Medicine - G's glucosamine sulfate caps or 500 glucosamine sulfate tabs or 500 Alternative Medicine - L's lutein caps or 6 ; ; ; ; Name of Alternative Medicine Combinations glucosamine-chondroitin caps glucosamine-chondroitin tabs LIQ-10 50MG/5ML- 15UNIT/5ML VITALINE COQ10/VITAMIN E 100MG-300UNIT AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij 1 gm/4ml, 500 /2ml BETHKIS gentamicin in saline 0.9%- 1/ml gentamicin sulfate soln ij 40 /ml KITABIS PAK neomycin sulfate tabs or You can find information on what symbols and abbreviations in this table mean by going to B/D B/D 3
15 Name of paromomycin sulfate TOBI (Tobramycin) B/D TOBI PODHALER tobramycin nebu in tobramycin sulfate soln ij 1.2 gm/30ml, 40 /ml, 80 /2ml tobramycin sulfate solr ij 1.2 gm B/D ANALGESICS - AI-ILAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies PA HUMIRA HUMIRA PEDIATRIC PA CROHNS DISEASE STARTER PACK PA HUMIRA PEN HUMIRA PEN-CROHNS DISEASESTARTER PA Name of HUMIRA PEN-PSORIASIS STARTER SIMPONI SIMPONI ARIA PA PA PA Antirheumatic - Enzyme Inhibitors PA XELJANZ Antirheumatic Antimetabolites PA OTREXUP PA RASUVO Gold Compounds RIDAURA Interleukin-1 Blockers ARCALYST LA Interleukin-1 Receptor Antagonist (IL-1Ra) PA KINERET You can find information on what symbols and abbreviations in this table mean by going to 4
16 Name of Interleukin-1beta Blockers ILARIS LA Interleukin-6 Receptor Inhibitors PA ACTEMRA Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL (Ibuprofen) ; ADVIL MIGRAINE ; (Ibuprofen) ALEVE CAPS (Naproxen Sodium) ANAPROX DS (Naproxen Sodium) ARTHROTEC 50 (Diclofenac w/ Misoprostol) ARTHROTEC 75 (Diclofenac w/ Misoprostol) CATAFLAM (Diclofenac Potassium) CELEBREX (Celecoxib) celecoxib CHILDRENS TRIN CHEW 50 MG CHILDRENS TRIN JUNIOR STRENGTH (Ibuprofen) CHILDRENS TRIN SUSP 40 MG/ML (Ibuprofen) ; Name of DAYPRO (Oxaprozin) diclofenac potassium diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 50, 75 diclofenac w/ misoprostol EC-NAPROSYN (Naproxen) etodolac FELDENE (Piroxicam) flurbiprofen tabs or 100, 50 ibuprofen caps or 200 ibuprofen chew or 100 ibuprofen susp or 100 /5ml ibuprofen susp or 40 /ml, 50 /1.25ml ; ; RX/OTC; You can find information on what symbols and abbreviations in this table mean by going to 5
17 Name of ibuprofen tabs or 100 ibuprofen tabs or 200 ibuprofen tabs or 400 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or 25, 50 indomethacin cpcr or 75 IAS ADVIL (Ibuprofen) ketoprofen caps or 50, 75 ketorolac tromethamine soln ij 15 /ml, 30 /ml ketorolac tromethamine soln im 30 /ml, 60 /2ml ; SL(8 ea daily); SL(5.33 ea daily); SL(4 ea daily); AL; AL; AL; AL; Name of mefenamic acid caps or meloxicam tabs or 15, 7.5 BIC TABS 15 MG, 7.5 MG (Meloxicam) TRIN IAS (Ibuprofen) TRIN IAS DROPS (Ibuprofen) TRIN JUNIOR STRENGTH CHEW (Ibuprofen) TRIN JUNIOR STRENGTH TABS (Ibuprofen) nabumetone NAPROSYN TABS 250 MG, 375 MG, 500 MG (Naproxen) naproxen sodium caps or 220 naproxen sodium tabs or 275, 550 naproxen tabs or 250, 375, 500 naproxen tbec or 375, 500 ; You can find information on what symbols and abbreviations in this table mean by going to 6
18 Name of oxaprozin piroxicam caps or 10, 20 PONSTEL (Mefenamic Acid) sulindac tabs or 150, 200 tolmetin sodium caps 400 tolmetin sodium tabs 200 VOLTAREN-XR (Diclofenac Sodium) Phosphodiesterase 4 (PDE4) Inhibitors PA OTEZLA Pyrimidine Synsis Inhibitors ARAVA (Leflunomide) leflunomide tabs or 10, 20 Selective Costimulation Modulators PA ORENCIA Name of Soluble Tumor Necrosis Factor Receptor Agents PA ENBREL PA ENBREL SURECLICK ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions Analgesic Combinations acetaminophen-caffeinepyrilamine BIPHENOX MIDOL COMPLETE 500MG-15MG-60MG (Acetaminophen-Caffeine- Pyrilamine) MIDOL MAXIMUM STRENGTH MENSTRUAL (Acetaminophen-Caffeine- Pyrilamine) MIDOL MAXIMUM STRENGTH MENSTRUAL FORMULA (Acetaminophen-Caffeine- Pyrilamine) Analgesics Or acetaminophen chew or 160 acetaminophen chew or 80 acetaminophen elix or 160 /5ml, 80 /2.5ml ; You can find information on what symbols and abbreviations in this table mean by going to 7
19 Name of acetaminophen liqd or 160 /5ml acetaminophen soln or 100 /ml, 160 /5ml, 80 /0.8ml acetaminophen supp re 120 acetaminophen susp or 160 /5ml, 80 /2.5ml acetaminophen susp or 80 /0.8ml acetaminophen tbdp or 160 acetaminophen tbdp or 80 ELIXSURE FEVER/PAIN FEVERALL IAS TYLENOL CHILDRENS (Acetaminophen) TYLENOL IAS (Acetaminophen) TYLENOL IAS PAIN+FEVER (Acetaminophen) Salicylates ASCRIPTIN aspirin buffered (cal carbmag carb-mag oxide) ; ; ; ; ; ; ; ; ; Name of ASPIRIN LOW DOSE ASPIRIN SUPP RE 120 MG, 200 MG aspirin supp re 300, 600 aspirin tabs or 325 aspirin tbec or 324, 325, 500, 81 BUFFERIN (Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)) diflunisal ECOTRIN MAXIMUM STRENGTH (Aspirin) ECOTRIN REGULAR STRENGTH (Aspirin) ST JOSEPH ADULT ST JOSEPH ADULT ANALGESICLOW DOSE BITE SIZE ; ; ; ; ; ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ 1200 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG (Fentanyl Citrate) ACTIQ 200 MCG (Fentanyl Citrate) PA; QL(4 ea daily); PA; QL(6 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 8
20 Name of DEMEROL SOLN IJ 100 MG/ML, 50 MG/ML (Meperidine HCl) DEMEROL SOLN IJ 25 MG/ML (Meperidine HCl) DILAUDID LIQD OR 1 MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ 2 MG/ML DILAUDID TABS OR 2 MG (Hydromorphone HCl) DILAUDID TABS OR 4 MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN 10 MG/ML (Hydromorphone HCl) DOLOPHINE 10 MG (Methadone HCl) DOLOPHINE 5 MG (Methadone HCl) DURAGESIC 100 MCG/HR (Fentanyl) DURAGESIC 12 MCG/HR (Fentanyl) DURAGESIC 25 MCG/HR (Fentanyl) DURAGESIC 50 MCG/HR (Fentanyl) AL; AL QL(32 ml daily); QL(29 ea daily); QL(14 ea daily); QL(7 ea daily); QL(19 ea daily); QL(38 ea daily); QL(1 ea daily); Limit 43 patches per month;ql(1.44 ea daily); Limit 21 patches per month;ql(0.7 ea daily); Limit 22 patches per month;ql(0.74 ea daily); Name of DURAGESIC 75 MCG/HR (Fentanyl) fentanyl 100 mcg/hr fentanyl 12 mcg/hr fentanyl 25 mcg/hr fentanyl 50 mcg/hr fentanyl 75 mcg/hr fentanyl citrate lpop bu 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate lpop bu 200 mcg hydromorphone hcl liqd or 1 /ml hydromorphone hcl soln ij 10 /ml, 2 /ml, 50 /5ml, 500 /50ml Limit 18 patches per month;ql(0.61 ea daily); QL(1 ea daily); Limit 43 patches per month;ql(1.44 ea daily); Limit 21 patches per month;ql(0.7 ea daily); Limit 22 patches per month;ql(0.74 ea daily); Limit 18 patches per month;ql(0.61 ea daily); PA; QL(4 ea daily); PA; QL(6 ea daily); QL(32 ml daily); You can find information on what symbols and abbreviations in this table mean by going to 9
21 Name of hydromorphone hcl tabs or 2 hydromorphone hcl tabs or 4 hydromorphone hcl tabs or 8 KADIAN 100 MG (Morphine Sulfate) KADIAN 20 MG, 30 MG, 50 MG, 60 MG, 80 MG (Morphine Sulfate) LAZANDA 100 MCG/ACT LAZANDA 300 MCG/ACT LAZANDA 400 MCG/ACT meperidine hcl soln ij 100 /ml, 50 /ml meperidine hcl soln ij 25 /ml methadone hcl conc or 10 /ml QL(29 ea daily); QL(14 ea daily); QL(7 ea daily); QL(6 ea daily); QL(5 ea daily); PA; QL(6 ea daily); PA; QL(5 ea daily) PA; QL(4 ea daily) AL; AL QL(4 ml daily); Name of methadone hcl soln or 10 /5ml methadone hcl soln or 5 /5ml methadone hcl tabs or 10 methadone hcl tabs or 5 METHADOSE 10 MG/ML (Methadone HCl) METHADOSE SUGAR- FREE (Methadone HCl) morphine sulfate cp24 or 100 morphine sulfate cp24 or 20, 30, 50, 60, 80 morphine sulfate soln ij 0.5 /ml morphine sulfate soln ij 1 /ml morphine sulfate soln or 10 /5ml QL(20 ml daily); QL(40 ml daily); QL(19 ea daily); QL(38 ea daily); QL(4 ml daily); QL(4 ml daily); QL(6 ea daily); QL(5 ea daily); QL(60 ml daily); You can find information on what symbols and abbreviations in this table mean by going to 10
22 Name of morphine sulfate soln or 100 /5ml, 20 /ml morphine sulfate soln or 20 /5ml RPHINE SULFATE TABS OR 15 MG RPHINE SULFATE TABS OR 30 MG morphine sulfate tbcr or 100 morphine sulfate tbcr or 15 morphine sulfate tbcr or 200 morphine sulfate tbcr or 30, 60 MS COIN 100 MG (Morphine Sulfate) MS COIN 15 MG (Morphine Sulfate) MS COIN 200 MG (Morphine Sulfate) MS COIN 30 MG, 60 MG (Morphine Sulfate) OPANA TABS OR 10 MG (Oxymorphone HCl) QL(6 ml daily); QL(30 ml daily); QL(8 ea daily); QL(14 ea daily); QL(6 ea daily); QL(8 ea daily); QL(3 ea daily); QL(5 ea daily); QL(6 ea daily); QL(8 ea daily); QL(3 ea daily); QL(5 ea daily); QL(4 ea daily); Name of OPANA TABS OR 5 MG (Oxymorphone HCl) oxycodone hcl caps or 5 oxycodone hcl conc or 100 /5ml oxycodone hcl tabs or 15 oxycodone hcl tabs or 30 oxycodone hcl tabs or 5 oxymorphone hcl tabs 10 oxymorphone hcl tabs 5 oxymorphone hcl tb12 15 oxymorphone hcl tb ROXICODONE 15 MG (Oxycodone HCl) ROXICODONE 30 MG (Oxycodone HCl) QL(8 ea daily); QL(17 ea daily); QL(4 ml daily); QL(11 ea daily); QL(15 ea daily); QL(17 ea daily); QL(4 ea daily); QL(8 ea daily); QL(2.67 ea daily); QL(5 ea daily); QL(11 ea daily); QL(15 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 11
23 Name of ROXICODONE 5 MG (Oxycodone HCl) SUBSYS 100 MCG, 200 MCG SUBSYS 1200 MCG SUBSYS 1600 MCG, 400 MCG, 600 MCG, 800 MCG tramadol hcl tabs or 50 tramadol hcl tb24 or 100 tramadol hcl tb24 or 200 tramadol hcl tb24 or 300 ULTRAM (Tramadol HCl) ULTRAM ER 100 MG (Tramadol HCl) ULTRAM ER 200 MG (Tramadol HCl) ULTRAM ER 300 MG (Tramadol HCl) ZOHYDRO ER C12A 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG QL(17 ea daily); PA; QL(6 ea daily); PA; QL(4 ea daily) PA; QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); PA; QL(2 ea daily); Name of ZOHYDRO ER CP12 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs , butalbital-aspirin-caffeine w/cod FIORINAL/CODEINE #3 (Butalbital-Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs , 5-300, hydrocodoneacetaminophen tabs , 5-325, hydrocodone-ibuprofen PA; QL(2 ea daily) SL(166 ml daily); SL(13.3 ea daily); SL(13 ea daily); AL; AL; Limit 5535mls per month;sl( ml daily); SL(13.3 ea daily); SL(12.3 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 12
24 Name of oxycodone w/ acetaminophen soln 5/5ml-325/5ml oxycodone w/ acetaminophen tabs , , 5-325, oxycodone-aspirin PERCODAN (Oxycodone- Aspirin) tramadol-acetaminophen Opioid Partial Agonists BUPRENEX (Buprenorphine HCl) buprenorphine hcl soln ij 0.3 /ml buprenorphine hcl subl sl 2 buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate ULTRACET (Tramadol- Acetaminophen) VICOPROFEN (Hydrocodone-Ibuprofen) Limit 1845mls per month;sl(61.5 ml daily) SL(12.3 ea daily); SL(8 ea daily); SL(8 ea daily); PA; QL(16 ea daily); PA; QL(4 ea daily); PA; QL(16 ea daily); Name of buprenorphine hclnaloxone hcl dihydrate 8-2 butorphanol tartrate soln ij 2 /ml butorphanol tartrate soln na 10 /ml nalbuphine hcl soln ij 10 /ml, 20 /ml PA; QL(4 ea daily); Limit 126mls per month;ql(4.2 ml daily); ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Anabolic Steroids ANADROL-50 OXANDRIN (Oxandrolone) oxandrolone tabs or 10, 2.5 Androgens ANDRODERM ANDROGEL MG/1.25GM, 40.5 MG/2.5GM ANDROGEL 25 MG/2.5GM, 50 MG/5GM (Testosterone) GL; GL; GL; You can find information on what symbols and abbreviations in this table mean by going to 13
25 Name of ANDROGEL PUMP 1.62 % AVEED danazol caps or 100, 200, 50 fluoxymesterone tabs or testosterone cypionate testosterone enanthate soln im TESTOSTERONE GEL TD 1 %, 25 MG/2.5GM, 50 MG/5GM testosterone gel td 1 %, 25 /2.5gm, 50 /5gm TESTOSTERONE PUMP VOGELXO GL; LA GL; GL; GL; GL; Name of VOGELXO PUMP GL; ANORECTAL AGES - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) UCERIS FOAM RE 2 MG/ACT Rectal Combinations phenylephrine-shark liver oil-glycerin-petrolatum Rectal Products - Misc. starch (topical) Rectal Steroids hydrocortisone (rectal) PROCTOCORT CREA 1 % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV AACIDS - Ulcer and Stomach Acid Drugs You can find information on what symbols and abbreviations in this table mean by going to 14
26 Name of Antacid Combinations alum & mag hydroxsimethicone chew alum & mag hydroxsimethicone liqd 200/5ml-20/5ml- 200/5ml, 400/5ml- 40/5ml-400/5ml alum & mag hydroxsimethicone susp 200/5ml-200/5ml- 20/5ml-20/5ml- 200/5ml-200/5ml, 200/5ml-20/5ml- 200/5ml, 400/5ml- 400/5ml-40/5ml- 40/5ml-400/5ml- 400/5ml, 400/5ml- 40/5ml-400/5ml aluminum hydroxide-mag trisil GELUSIL 200MG-25MG- 200MG (Alum & Mag Hydrox-Simethicone) HYVEE ADVANCED AACID MAXIMUM STRENGTH (Alum & Mag Hydrox-Simethicone) MYLAA DOUBLE- STRENGTH (Alum & Mag Hydrox-Simethicone) MYLAA SUSP 200MG/5ML-20MG/5ML- 200MG/5ML (Alum & Mag Hydrox-Simethicone) Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Calcium Salts ; ; ; ; ; Name of calcium carbonate (antacid) chew 500, 750 calcium carbonate (antacid) chew 600 calcium carbonate (antacid) tabs 648 MAALOX TUMS (Calcium Carbonate (Antacid)) TUMS E-X 750 (Calcium Carbonate (Antacid)) TUMS KIDS (Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS (Calcium Carbonate (Antacid)) TUMS SOTHIES 750 MG (Calcium Carbonate (Antacid)) ; ; ; ; ; ; ; AHELMIICS - Drugs to Treat Worm Infections Anlmintics ALBENZA ivermectin tabs or STROMECTOL (Ivermectin) AI-IECTIVE AGES - MISC. - Drugs to Treat Bacterial Infections You can find information on what symbols and abbreviations in this table mean by going to 15
27 Name of Anti-infective Agents - Misc. AZACTAM (Aztreonam) aztreonam LA CAYSTON colistimethate sodium solr ij COLY-MYCIN M (Colistimethate Sodium) FLAGYL CAPS 375 MG SL(10.6 ea (Metronidazole) daily); FLAGYL TABS 250 MG SL(16 ea daily); (Metronidazole) FLAGYL TABS 500 MG SL(8 ea daily); (Metronidazole) SL(10.6 ea metronidazole caps or 375 daily); metronidazole in nacl metronidazole tabs or 250 metronidazole tabs or 500 SL(16 ea daily); SL(8 ea daily); Name of NEBUPE ORBACTIV PEAM 300 TINDAMAX (Tinidazole) tinidazole tabs or 250, 500 trimethoprim tabs or VANCOCIN HCL (Vancomycin HCl) vancomycin hcl caps or 125, 250 VANCOMYCIN HCL IN DEXTROSE vancomycin hcl solr iv 10 gm, 1000, 5000 vancomycin hcl solr iv 500 ; B/D PA; PA; You can find information on what symbols and abbreviations in this table mean by going to 16
28 Name of XIFAXAN Anti-infective Misc. - Combinations BACTRIM (Sulfamethoxazole- Trimethoprim) BACTRIM DS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim Antiprotozoal Agents ALINIA TABS 500 MG atovaquone MEPRON (Atovaquone) Carbapenems imipenem-cilastatin INVANZ IJ meropenem MERREM (Meropenem) Name of PRIMAXIN IV (Imipenem- Cilastatin) Chloramphenicols chloramphenicol sodium succinate Cyclic Lipopeptides CUBICIN CUBICIN RF Glycylcyclines TYGACIL Leprostatics dapsone tabs or 100, 25 Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG, 75 MG (Clindamycin HCl) CLEOCIN IN D5W (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE IJ 600 MG/4ML, 900 MG/6ML (Clindamycin Phosphate) You can find information on what symbols and abbreviations in this table mean by going to 17
29 Name of CLEOCIN PHOSPHATE IV 300MG/50ML-5%, 600MG/50ML-5%, 900MG/50ML-5% (Clindamycin Phosphate in D5W) clindamycin hcl caps or 150, 300, 75 clindamycin palmitate hydrochloride clindamycin phosphate in d5w clindamycin phosphate soln ij 150 /ml, 9000 /60ml clindamycin phosphate soln ij 600 /4ml, 900 /6ml clindamycin phosphate soln iv 150 /ml, 600 /4ml LINCOCIN (Lincomycin HCl) lincomycin hcl soln ij Oxazolidinones linezolid in sodium chloride Name of linezolid soln iv 600 /300ml linezolid susr or 100 /5ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 200 MG/100ML ZYVOX SOLN IV 600 MG/300ML (Linezolid) ZYVOX SUSR OR 100 MG/5ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij Streptogramins You can find information on what symbols and abbreviations in this table mean by going to 18
30 Name of SYNERCID AIANGINAL AGES - Drugs to Treat Chest Pain Antianginals-Or RANEXA Nitrates ISORDIL TITRADOSE 5 MG (Isosorbide Dinitrate) isosorbide dinitrate isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 120, 30, 60 NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin soln tl 0.4 /spray PA; Name of NITROLINGUAL PUMPSPRAY (Nitroglycerin) NITROMIST NITROSTAT AIANXIETY AGES - Drugs to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 10, 15, 30, 5, 7.5 hydroxyzine hcl soln im 50 /ml hydroxyzine hcl soln or 10 /5ml hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 hydroxyzine pamoate caps or 25, 50 VISTARIL (Hydroxyzine Pamoate) Benzodiazepines AL; AL; AL; AL; AL; AL; You can find information on what symbols and abbreviations in this table mean by going to 19
31 Name of alprazolam tabs or 0.25, 0.5, 1, 2 alprazolam tb24 or 0.5, 1, 2, 3 alprazolam tbdp or 0.25, 0.5, 1, 2 ATIVAN SOLN IJ 2 MG/ML (Lorazepam) ATIVAN SOLN IJ 4 MG/ML (Lorazepam) ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Lorazepam) clorazepate dipotassium diazepam conc or 5 /ml diazepam soln or 1 /ml diazepam tabs or 10, 2, 5 lorazepam conc or 2 /ml lorazepam soln ij 2 /ml, 20 /10ml Name of lorazepam soln ij 4 /ml lorazepam tabs or 0.5, 1, 2 NIRAVAM (Alprazolam) oxazepam TRANXENE T (Clorazepate Dipotassium) VALIUM (Diazepam) XANAX (Alprazolam) XANAX XR (Alprazolam) AIARRHYTHMICS - Drugs to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate NORPACE (Disopyramide Phosphate) quinidine gluconate tbcr or 324 quinidine sulfate Antiarrhythmics Type I-B AL; AL; You can find information on what symbols and abbreviations in this table mean by going to 20
32 Name of mexiletine hcl Antiarrhythmics Type I-C flecainide acetate 100 flecainide acetate 150 flecainide acetate 50 propafenone hcl RYTHL (Propafenone HCl) RYTHL SR (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 100, 200, 400 CORDARONE (Amiodarone HCl) dofetilide MULTAQ SL(4 ea daily); SL(2.66 ea daily); SL(8 ea daily); Name of TIKOSYN (Dofetilide) AIASTHMATIC AND BRONCHODILATOR AGES - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in ; B/D Antiasthmatic - Monoclonal Antibodies PA; LA NUCALA PA; LA XOLAIR Asthma and Bronchodilator Agent Combinations dyphylline-guaifenesin Bronchodilators - Anticholinergics ATROVE HFA ipratropium bromide soln in SPIRIVA HANDIHALER Limit 2 inhalers per month;ql(0.86 gm daily); ; B/D QL(1 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 21
33 Name of SPIRIVA RESPIMAT 1.25 MCG/ACT, 2.5 MCG/ACT SPIRIVA RESPIMAT 2.5 MCG/ACT TUDORZA PRESSAIR Leukotriene Modulators ACCOLATE (Zafirlukast) montelukast sodium chew 4, 5 montelukast sodium tabs 10 SINGULAIR CHEW 4 MG, 5 MG (Montelukast Sodium) SINGULAIR TABS 10 MG (Montelukast Sodium) zafirlukast Limit 1 inhaler per month (60 actuations);sl( 0.14 gm daily); Limit 2 inhalers per month (Institutional Pack) ;SL(0.29 gm daily); Limit 1 inhaler per month;ql(0.04 ea daily); Selective Phosphodiesterase 4 (PDE4) Inhibitors QL(1 ea daily); DALIRESP Steroid Inhalants Name of AEROSPAN AEROSPAN budesonide (inhalation) 0.25 /2ml, 0.5 /2ml FLOVE DISKUS 100 MCG/BLIST FLOVE DISKUS 250 MCG/BLIST FLOVE DISKUS 50 MCG/BLIST FLOVE HFA 110 MCG/ACT, 220 MCG/ACT FLOVE HFA 44 MCG/ACT PULMICORT 0.25 MG/2ML, 0.5 MG/2ML (Budesonide (Inhalation)) QVAR Sympathomimetics Limit 2 inhalers per month (120 actuations);sl( 0.6 gm daily); Limit 3 inhalers per month (Institutional pack);sl(0.6 gm daily); ; B/D SL(20 ea daily); SL(8 ea daily); SL(40 ea daily); Limit 2 inhalers per month;ql(0.8 gm daily); Limit 1 inhaler per month;ql(0.36 gm daily); ; B/D Limit 3 inhalers per month;ql(0.87 gm daily); You can find information on what symbols and abbreviations in this table mean by going to 22
34 Name of ADVAIR DISKUS ADVAIR HFA albuterol sulfate nebu in %, 0.5 %, 0.63 /3ml, 1.25 /3ml albuterol sulfate syrp or 2 /5ml albuterol sulfate tabs or 2, 4 albuterol sulfate tb12 or 4, 8 ANORO ELLIPTA BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH COMBIVE RESPIMAT QL(4 gm daily); ; B/D QL(2 ea daily); Limit 1 inhaler per month;sl(2 ea daily); Limit 2 inhalers per month (Institutional Pack);SL(2 ea daily); Limit 1 inhaler per month;sl(0.2 gm daily); Name of DULERA EPHEDRINE HCL TABS OR EPHEDRINE SULFATE CAPS OR 25 MG epinephrine hcl sosy ij 0.1 /ml FORADIL AEROLIZER ipratropium-albuterol levalbuterol hcl nebu in 0.31 /3ml, 0.63 /3ml, 1.25 /0.5ml, 1.25 /3ml PROAIR HFA PROAIR RESPICLICK PROVEIL HFA SEREVE DISKUS QL(4 gm daily); QL(2 ea daily) ; B/D ; B/D QL(2 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 23
35 Name of STIOLTO RESPIMAT STRIVERDI RESPIMAT STRIVERDI RESPIMAT terbutaline sulfate tabs or 2.5, 5 XOPENEX (Levalbuterol HCl) XOPENEX CONCERATE (Levalbuterol HCl) Xanthines aminophylline ophylline tb12 100, 200, 300, 450 ophylline tb24 400, 600 Limit 1 inhaler per month;ql(0.14 gm daily); Limit 1 inhaler per month (60 actuations);sl( 0.14 gm daily); Limit 2 inhalers per month (Institutional Pack) ;SL(0.29 gm daily); AICOAGULAS - Blood Thinners Coumarin Anticoagulants COUMADIN (Warfarin Sodium) ; B/D ; B/D Name of warfarin sodium Direct Factor Xa Inhibitors ELIQUIS XARELTO XARELTO STARTER PACK Heparins And Heparinoid-Like Agents ARIXTRA (Fondaparinux Sodium) enoxaparin sodium fondaparinux sodium FRAGMIN UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, U/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML FRAGMIN UNIT/ML You can find information on what symbols and abbreviations in this table mean by going to 24
36 Name of heparin sodium (porcine) LOVENOX (Enoxaparin Sodium) Thrombin Inhibitors argatroban 250 /2.5ml IPRIVASK PRADAXA AICONVULSAS - Drugs to Treat Seizures AMPA Glutamate Receptor Antagonists FYCOMPA SUSP 0.5 MG/ML FYCOMPA TABS 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG Anticonvulsants - Benzodiazepines clonazepam tabs or 0.5 clonazepam tabs or 1 SL(40 ea daily); SL(20 ea daily); Name of clonazepam tabs or 2 clonazepam tbdp or 0.125, 0.25, 0.5, 1, 2 DIASTAT ACUDIAL DIASTAT PEDIATRIC DIAZEPAM GEL RE 10 MG, 2.5 MG, 20 MG KLONOPIN 0.5 MG (Clonazepam) KLONOPIN 1 MG (Clonazepam) KLONOPIN 2 MG (Clonazepam) OI Anticonvulsants - Misc. APTIOM BANZEL SL(10 ea daily); SL(40 ea daily); SL(20 ea daily); SL(10 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 25
37 Name of BRIVIACT SOLN IV 50 MG/5ML BRIVIACT SOLN OR 10 MG/ML BRIVIACT TABS OR 10 MG BRIVIACT TABS OR 100 MG BRIVIACT TABS OR 25 MG BRIVIACT TABS OR 50 MG BRIVIACT TABS OR 75 MG carbamazepine chew or 100 carbamazepine cp12 or 100, 200, 300 carbamazepine susp or 100 /5ml SL(20 ml daily) PA; SL(20 ml daily) PA; SL(20 ea daily) PA; SL(2 ea daily); PA; SL(8 ea daily); PA; SL(4 ea daily); PA; SL(2.67 ea daily) Name of carbamazepine tabs or 200 carbamazepine tb12 or 100, 200, 400 CARBATROL (Carbamazepine) gabapentin caps or 100, 300, 400 gabapentin soln or 250 /5ml, 300 /6ml gabapentin tabs or 600, 800 KEPPRA (Levetiracetam) KEPPRA XR (Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE (Lamotrigine) LAMICTAL TABS 100 MG, 150 MG, 200 MG, 25 MG (Lamotrigine) LAMICTAL XR KIT LAMICTAL XR TB MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG (Lamotrigine) You can find information on what symbols and abbreviations in this table mean by going to 26
38 Name of lamotrigine chew 25, 5 lamotrigine tabs 100, 150, 200, 25 lamotrigine tb24 100, 200, 25, 250, 300, 50 LEVETIRACETAM SOLN IV 1000MG/100ML- 750MG/100ML, 1500MG/100ML- 540MG/100ML, 500MG/100ML- 820MG/100ML levetiracetam soln iv 500 /5ml levetiracetam soln or 100 /ml, 500 /5ml levetiracetam tabs or 1000, 250, 500, 750 levetiracetam tb24 or 500, 750 LYRICA CAPS 100 MG LYRICA CAPS 150 MG SL(6 ea daily); SL(4 ea daily); Name of LYRICA CAPS 200 MG LYRICA CAPS 225 MG LYRICA CAPS 25 MG LYRICA CAPS 300 MG LYRICA CAPS 50 MG LYRICA CAPS 75 MG LYRICA SOLN 20 MG/ML MYSOLINE (Primidone) NEUROIN (Gabapentin) oxcarbazepine POTIGA 200 MG SL(3 ea daily); SL(2.66 ea daily); SL(24 ea daily); SL(2 ea daily); SL(12 ea daily); SL(8 ea daily); SL(30 ml daily); SL(6 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 27
39 Name of POTIGA 300 MG POTIGA 400 MG POTIGA 50 MG primidone tabs or 250, 50 SPRITAM 1000 MG SPRITAM 250 MG SPRITAM 500 MG SPRITAM 750 MG TEGRETOL (Carbamazepine) TEGRETOL-XR 100 MG (Carbamazepine) SL(4 ea daily); SL(3 ea daily); SL(24 ea daily); PA; SL(3 ea daily); PA; SL(12 ea daily) PA; SL(6 ea daily) PA; SL(4 ea daily) TEGRETOL-XR 200 MG, 400 MG (Carbamazepine) TOPAMAX (Topiramate) Name of TOPAMAX SPRINKLE (Topiramate) topiramate cpsp or 15, 25 topiramate tabs or 100, 200, 25, 50 TRILEPTAL (Oxcarbazepine) VIMPAT SOLN IV 200 MG/20ML VIMPAT SOLN OR 10 MG/ML VIMPAT TABS OR 100 MG, 150 MG, 200 MG, 50 MG ZONEGRAN (Zonisamide) zonisamide Carbamates felbamate FELBATOL (Felbamate) GABA Modulators GABITRIL 12 MG, 16 MG You can find information on what symbols and abbreviations in this table mean by going to 28
40 Name of GABITRIL 2 MG, 4 MG (Tiagabine HCl) SABRIL tiagabine hcl LA Hydantoins CEREBYX 100 MG PE/2ML (Fosphenytoin Sodium) CEREBYX 500 MG PE/10ML (Fosphenytoin Sodium) DILAIN-125 (Phenytoin) fosphenytoin sodium 100 pe/2ml fosphenytoin sodium 500 pe/10ml PEGANONE phenytoin chew or 50 phenytoin sodium extended phenytoin sodium soln ij Name of phenytoin susp or 125 /5ml Succinimides CELOIN ethosuximide caps or 250 ethosuximide soln or 250 /5ml ZAROIN 250 MG (Ethosuximide) Valproic Acid DEPACON (Valproate Sodium) DEPAKENE (Valproate Sodium) DEPAKENE (Valproic Acid) DEPAKOTE (Divalproex Sodium) DEPAKOTE ER (Divalproex Sodium) DEPAKOTE SPRINKLES (Divalproex Sodium) divalproex sodium valproate sodium soln iv 100 /ml, 500 /5ml You can find information on what symbols and abbreviations in this table mean by going to 29
41 Name of valproate sodium soln or 250 /5ml valproate sodium syrp or 250 /5ml valproic acid caps or AIDEPRESSAS - Drugs to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine REMERON (Mirtazapine) REMERON SOLTAB (Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 100 bupropion hcl tabs or 75 bupropion hcl tb12 or 100 bupropion hcl tb12 or 150 SL(4.5 ea daily); SL(6 ea daily); SL(4 ea daily); SL(2.66 ea daily); Name of bupropion hcl tb12 or 200 bupropion hcl tb24 or 150 bupropion hcl tb24 or 300 FORFIVO XL maprotiline hcl WELLBUTRIN 100 MG (Bupropion HCl) WELLBUTRIN 75 MG (Bupropion HCl) WELLBUTRIN SR 100 MG (Bupropion HCl) WELLBUTRIN SR 150 MG (Bupropion HCl) WELLBUTRIN SR 200 MG (Bupropion HCl) WELLBUTRIN XL 150 MG (Bupropion HCl) WELLBUTRIN XL 300 MG (Bupropion HCl) SL(2 ea daily); SL(3 ea daily); SL(1.5 ea daily); ST; SL(4.5 ea daily); SL(6 ea daily); SL(4 ea daily); SL(2.66 ea daily); SL(2 ea daily); SL(3 ea daily); SL(1.5 ea daily); Monoamine Oxidase Inhibitors (MAOIs) EMSAM You can find information on what symbols and abbreviations in this table mean by going to 30
42 Name of MARPLAN NARDIL (Phenelzine Sulfate) PARNATE (Tranylcypromine Sulfate) phenelzine sulfate tabs or tranylcypromine sulfate Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA 10 MG SL(4 ea daily); (Citalopram Hydrobromide) CELEXA 20 MG SL(2 ea daily); (Citalopram Hydrobromide) CELEXA 40 MG SL(1 ea daily); (Citalopram Hydrobromide) SL(20 ml daily); citalopram hydrobromide soln 10 /5ml citalopram hydrobromide tabs 10 citalopram hydrobromide tabs 20 citalopram hydrobromide tabs 40 SL(4 ea daily); SL(2 ea daily); SL(1 ea daily); Name of escitalopram oxalate fluoxetine hcl caps or 10, 20, 40 fluoxetine hcl cpdr or 90 fluoxetine hcl soln or 20 /5ml fluoxetine hcl tabs or 10, 20 fluvoxamine maleate LEXAPRO (Escitalopram Oxalate) LUVOX CR (Fluvoxamine Maleate) paroxetine hcl PAXIL CR (Paroxetine HCl) PAXIL SUSP 10 MG/5ML PAXIL TABS 10 MG, 20 MG, 30 MG, 40 MG (Paroxetine HCl) PROZAC (Fluoxetine HCl) You can find information on what symbols and abbreviations in this table mean by going to 31
43 Name of PROZAC WEEKLY (Fluoxetine HCl) sertraline hcl conc or 20 /ml sertraline hcl tabs or 100, 25, 50 ZOLOFT (Sertraline HCl) Serotonin Modulators BRIELLIX 10 MG BRIELLIX 20 MG BRIELLIX 5 MG nefazodone hcl trazodone hcl tabs or 100, 150, 300, 50 TRIELLIX 10 MG TRIELLIX 20 MG ST; QL(2 ea daily); ST; QL(1 ea daily); ST; QL(4 ea daily); ST; QL(2 ea daily); ST; QL(1 ea daily); Name of TRIELLIX 5 MG VIIBRYD KIT VIIBRYD STARTER PACK VIIBRYD TABS 10 MG, 20 MG, 40 MG ST; QL(4 ea daily); ST ST; ST; Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA (Duloxetine HCl) DESVENLAFAXINE ER 100 MG, 50 MG DESVENLAFAXINE ER 100 MG, 50 MG duloxetine hcl 20, 30, 60 EFFEXOR XR 150 MG (Venlafaxine HCl) EFFEXOR XR 37.5 MG (Venlafaxine HCl) EFFEXOR XR 75 MG (Venlafaxine HCl) FETZIMA 120 MG, 40 MG, 80 MG ST; Fumarate ST; SL(1.5 ea daily); SL(6 ea daily); SL(3 ea daily); ST; QL(1 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 32
44 Name of FETZIMA 20 MG FETZIMA TITRATION PACK KHEDEZLA PRISTIQ venlafaxine hcl cp venlafaxine hcl cp venlafaxine hcl cp24 75 VENLAFAXINE HCL ER venlafaxine hcl tabs 100 venlafaxine hcl tabs 25 ST; QL(2 ea daily); ST; ST; ST; SL(1.5 ea daily); SL(6 ea daily); SL(3 ea daily); ST; SL(1 ea daily); SL(3.75 ea daily); SL(15 ea daily); Name of venlafaxine hcl tabs 37.5 venlafaxine hcl tabs 50 venlafaxine hcl tabs 75 venlafaxine hcl tb venlafaxine hcl tb venlafaxine hcl tb24 75 Tricyclic Agents amitriptyline hcl amoxapine ANAFRANIL (Clomipramine HCl) clomipramine hcl caps or 25, 50, 75 desipramine hcl tabs or 10, 100, 150, 25, 50, 75 SL(10 ea daily); SL(7.5 ea daily); SL(5 ea daily); SL(1.5 ea daily); SL(6 ea daily); SL(3 ea daily); AL; AL; AL; You can find information on what symbols and abbreviations in this table mean by going to 33
45 Name of doxepin hcl caps or 10, 100, 150, 25, 50, 75 doxepin hcl conc or 10 /ml ELAVIL (Amitriptyline HCl) imipramine hcl tabs or 10, 25, 50 imipramine pamoate NORPRAMIN (Desipramine HCl) nortriptyline hcl caps or 10, 25, 50, 75 nortriptyline hcl soln or 10 /5ml PAMELOR (Nortriptyline HCl) protriptyline hcl SURIL TOFRANIL-PM (Imipramine Pamoate) AL; AL; AL; AL; AL; AL; AL; Name of trimipramine maleate caps or 100, 25, 50 AL; AIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose GLYSET (Miglitol) miglitol PRECOSE (Acarbose) Antidiabetic - Amylin Analogs SYMLINPEN 120 SYMLINPEN 60 Antidiabetic Combinations ACTOPLUS MET (Pioglitazone HCl- Metformin HCl) ALOGLIPTIN/METFORMIN HCL ALOGLIPTIN/PIOGLITAZO NE 12.5MG-15MG QL(3 ea daily); QL(3 ea daily); QL(3 ea daily); QL(3 ea daily); Limit 12mls per month;ql(0.4 ml daily); Limit 12mls per month;ql(0.4 ml daily); SL(3 ea daily); PA; SL(2 ea daily); PA; SL(2 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 34
46 Name of ALOGLIPTIN/PIOGLITAZO NE 12.5MG-30MG ALOGLIPTIN/PIOGLITAZO NE 12.5MG-45MG, 25MG- 15MG, 25MG-30MG, 25MG-45MG DUETACT (Pioglitazone HCl-Glimepiride) glipizide-metformin hcl glipizide-metformin hcl , GLUCOVANCE 1.25MG- 250MG (Glyburide- Metformin) GLUCOVANCE 2.5MG- 500MG, 5MG-500MG (Glyburide-Metformin) glyburide-metformin glyburide-metformin , INVOKAMET 150MG- 1000MG, 150MG-500MG, 50MG-1000MG INVOKAMET 50MG- 500MG PA; SL(1.5 ea daily); PA; SL(1 ea daily); SL(1.5 ea daily); SL(8 ea daily); SL(4 ea daily); AL; SL(8 ea daily); AL; SL(4 ea daily); AL; SL(8 ea daily); AL; SL(4 ea daily); SL(2 ea daily); SL(4 ea daily); Name of JANUMET JANUMET XR 100MG- 1000MG JANUMET XR 50MG- 1000MG, 50MG-500MG JEADUETO KAZANO KOMBIGLYZE XR 2.5MG- 1000MG KOMBIGLYZE XR 5MG- 1000MG, 5MG-500MG OSENI 12.5MG-15MG OSENI 12.5MG-30MG OSENI 12.5MG-45MG, 25MG-15MG, 25MG- 30MG, 25MG-45MG SL(2 ea daily); SL(1 ea daily); SL(2 ea daily); SL(2 ea daily); PA; SL(2 ea daily); PA; SL(2 ea daily); PA; SL(1 ea daily); PA; SL(2 ea daily); PA; SL(1.5 ea daily); PA; SL(1 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 35
47 Name of pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl PRANDIMET (Repaglinide- Metformin HCl) repaglinide-metformin hcl SYNJARDY 12.5MG- 1000MG, 5MG-1000MG SYNJARDY 12.5MG- 500MG, 5MG-500MG Biguanides FORTAMET 1000 MG (Metformin HCl) FORTAMET 500 MG (Metformin HCl) GLUCOPHAGE 1000 MG (Metformin HCl) GLUCOPHAGE 500 MG (Metformin HCl) GLUCOPHAGE 850 MG (Metformin HCl) GLUCOPHAGE XR 500 MG (Metformin HCl) GLUCOPHAGE XR 750 MG (Metformin HCl) SL(1.5 ea daily); SL(3 ea daily); SL(5 ea daily); SL(5 ea daily); SL(2 ea daily); SL(4 ea daily); Osmotic;SL(2.5 ea daily); Osmotic;SL(5 ea daily); SL(2.55 ea daily); SL(5.1 ea daily); SL(3 ea daily); SL(4 ea daily); SL(2.66 ea daily); Name of metformin hcl tabs or 1000 metformin hcl tabs or 500 metformin hcl tabs or 850 metformin hcl tb24 or 1000 metformin hcl tb24 or 1000 metformin hcl tb24 or 500 metformin hcl tb24 or 500 metformin hcl tb24 or 500 metformin hcl tb24 or 750 Diabetic Or BD GLUCOSE CVS GLUCOSE 4 GM SL(2.55 ea daily); SL(5.1 ea daily); SL(3 ea daily); (GLUMETZA); SL(2 ea daily); Osmotic;SL(2.5 ea daily); (GLUMETZA); SL(4 ea daily); Osmotic;SL(5 ea daily); SL(4 ea daily); SL(2.66 ea daily); ; You can find information on what symbols and abbreviations in this table mean by going to 36
48 Name of DEX4 QUICK DISSOLVE GLUCOSE dextrose (diabetic use) gel 15 gm/38gm, 40 % GLUCAGEN HYPOKIT glucagon (rdna) GLUCOSE CHEW 4 GM GNP GLUCOSE 4 GM GNP QUICK DISSOLVE GLUCOSE KORLYM LEADER QUICK DISSOLVE GLUCOSE MS QUICK DISSOLVE GLUCOSE PROGLYCEM SM GLUCOSE 4 GM WALGREENS GLUCOSE 4 GM ; ; ; ; ; SL(4 ea daily); LA ; ; ; ; Name of Dipeptidyl Peptidase-4 (DPP-4) Inhibitors PA; ALOGLIPTIN JANUVIA PA; NESINA PA; ONGLYZA TRADJEA Dopamine Receptor Agonists - Antidiabetic QL(6 ea daily); CYCLOSET Incretin Mimetic Agents (GLP-1 Receptor ST; BYDUREON ST; BYETTA ST; Limit 9mls VICTOZA per month;ql(0.3 ml daily); Insulin Sensitizing Agents You can find information on what symbols and abbreviations in this table mean by going to 37
49 Name of ACTOS 15 MG (Pioglitazone HCl) ACTOS 30 MG (Pioglitazone HCl) ACTOS 45 MG (Pioglitazone HCl) AVANDIA 2 MG AVANDIA 4 MG AVANDIA 8 MG pioglitazone hcl 15 pioglitazone hcl 30 pioglitazone hcl 45 Insulin HUMALOG HUMALOG KWIKPEN SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(4 ea daily); SL(2 ea daily); SL(1 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Name of HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCERATED) Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); You can find information on what symbols and abbreviations in this table mean by going to 38
50 Name of HUMULIN R U-500 KWIKPEN LAUS LAUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH TOUJEO SOLOSTAR TRESIBA FLEXTOUCH 100 UNIT/ML TRESIBA FLEXTOUCH 200 UNIT/ML Meglitinide Analogues nateglinide PRANDIN 0.5 MG (Repaglinide) Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 45mls per month;ql(1.5 ml daily); Limit 15mls per month;ql(0.5 ml daily); QL(1.5 ml daily); QL(0.9 ml daily); QL(3 ea daily); SL(32 ea daily); Name of PRANDIN 1 MG (Repaglinide) PRANDIN 2 MG (Repaglinide) repaglinide 0.5 repaglinide 1 repaglinide 2 STARLIX (Nateglinide) SL(16 ea daily); SL(8 ea daily); SL(32 ea daily); SL(16 ea daily); SL(8 ea daily); QL(3 ea daily); Sodium-Glucose Co-Transporter 2 (SGLT INVOKANA JARDIANCE Sulfonylureas AMARYL 1 MG (Glimepiride) AMARYL 2 MG (Glimepiride) AMARYL 4 MG (Glimepiride) DIABETA 1.25 MG (Glyburide) DIABETA 2.5 MG (Glyburide) You can find information on what symbols and abbreviations in this table mean by going to SL(8 ea daily); SL(4 ea daily); SL(2 ea daily); AL; SL(16 ea daily); AL; SL(8 ea daily); 39
51 Name of DIABETA 5 MG (Glyburide) glimepiride 1 glimepiride 2 glimepiride 4 glipizide tabs or 10 glipizide tabs or 5 glipizide tb24 or 10 glipizide tb24 or 2.5 glipizide tb24 or 5 GLUCOTROL 10 MG (Glipizide) GLUCOTROL 5 MG (Glipizide) GLUCOTROL XL 10 MG (Glipizide) AL; SL(4 ea daily); SL(8 ea daily); SL(4 ea daily); SL(2 ea daily); SL(4 ea daily); SL(8 ea daily); SL(2 ea daily); SL(8 ea daily); SL(4 ea daily); SL(4 ea daily); SL(8 ea daily); SL(2 ea daily); Name of GLUCOTROL XL 2.5 MG (Glipizide) GLUCOTROL XL 5 MG (Glipizide) glyburide micronized 1.5 glyburide micronized 3 glyburide micronized 6 glyburide tabs or 1.25 glyburide tabs or 2.5 glyburide tabs or 5 GLYNASE 1.5 MG (Glyburide Micronized) GLYNASE 3 MG (Glyburide Micronized) GLYNASE 6 MG (Glyburide Micronized) tolazamide 250 tolazamide 500 SL(8 ea daily); SL(4 ea daily); AL; SL(8 ea daily); AL; SL(4 ea daily); AL; SL(2 ea daily); AL; SL(16 ea daily); AL; SL(8 ea daily); AL; SL(4 ea daily); AL; SL(8 ea daily); AL; SL(4 ea daily); AL; SL(2 ea daily); SL(4 ea daily); SL(2 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 40
52 Name of tolbutamide SL(6 ea daily); AIDIARRHEALS - Drugs to Treat Diarrhea Antidiarrheal Agents - Misc. bismuth subsalicylate chew or 262 bismuth subsalicylate susp or 262 /15ml, 525 /30ml, 527 /30ml bismuth subsalicylate susp or 525 /15ml bismuth subsalicylate tabs or 262 PEPTO BISL (Bismuth Subsalicylate) PEPTO-BISL CHEW 262 MG (Bismuth Subsalicylate) PEPTO-BISL INSTACOOL (Bismuth Subsalicylate) PEPTO-BISL MAX STRENGTH (Bismuth Subsalicylate) PEPTO-BISL SUSP 262 MG/15ML (Bismuth Subsalicylate) PEPTO-BISL TO-GO (Bismuth Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine ; ; ; ; ; ; Name of LOTIL (Diphenoxylate w/ Atropine) loperamide hcl caps or 2 RX/OTC; AIDOTES AND SPECIFIC AAGONISTS Antidotes - Chelating Agents LA EXJADE PA; LA FERRIPROX TABS 500 MG JADENU Antidotes and Specific Antagonists SM IPECAC SYRUP Opioid Antagonists naloxone hcl soln ij 1 /ml naltrexone hcl tabs or REVIA (Naltrexone HCl) AIEMETICS - Drugs to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists You can find information on what symbols and abbreviations in this table mean by going to 41
53 Name of granisetron hcl tabs or 1 ondansetron ondansetron hcl soln ij 4 /2ml, 40 /20ml ondansetron hcl soln or 4 /5ml ondansetron hcl tabs or 24, 4, 8 ZOFRAN ODT (Ondansetron) ZOFRAN SOLN IJ 40 MG/20ML (Ondansetron HCl) ZOFRAN SOLN OR 4 MG/5ML (Ondansetron HCl) ZOFRAN TABS OR 4 MG, 8 MG (Ondansetron HCl) ; B/D ; B/D ; B/D ; B/D ; B/D ; B/D ; B/D Antiemetics - Anticholinergic ; meclizine hcl chew 25 RX/OTC; meclizine hcl tabs 12.5, 25 TIGAN SOLN IM 100 MG/ML AL; Name of TRANSDERM-SCOP Antiemetics - Miscellaneous CESAMET ; B/D dronabinol ; B/D MARINOL (Dronabinol) ; B/D Substance P/Neurokinin 1 (NK Receptor ; B/D EMEND CAPS OR 125 MG, 80 MG PA; EMEND CAPS OR 40 MG B/D VARUBI AIFUNGALS - Drugs to Treat Fungal Infections Antifungal - Glucan Synsis Inhibitors CANCIDAS 50 MG CANCIDAS 70 MG You can find information on what symbols and abbreviations in this table mean by going to 42
54 Name of ERAXIS 100 MG MYCAMINE flucytosine 500 GRIS-PEG (Griseofulvin Ultramicrosize) griseofulvin microsize griseofulvin ultramicrosize LAMISIL TABS 250 MG (Terbinafine HCl) Antifungals ABELCET AMBISOME amphotericin b solr ij 50 ANCOBON 500 MG (Flucytosine) Name of nystatin tabs or terbinafine hcl tabs or Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG CRESEMBA SOLR IV 372 MG DIFLUCAN (Fluconazole) fluconazole in dextrose fluconazole in nacl 200/100ml-0.9%, 400/200ml-0.9% fluconazole susr or 10 /ml, 40 /ml fluconazole tabs or 100, 150, 200, 50 itraconazole caps or ketoconazole tabs or You can find information on what symbols and abbreviations in this table mean by going to 43
55 Name of NOXAFIL SOLN IV 300 MG/16.7ML NOXAFIL SUSP OR 40 MG/ML NOXAFIL TBEC OR 100 MG SPORANOX CAPS 100 MG (Itraconazole) SPORANOX PULSEPAK (Itraconazole) VFEND (Voriconazole) VFEND IV (Voriconazole) voriconazole solr iv 200 voriconazole susr or 40 /ml voriconazole tabs or 200, 50 AIHISTAMINES - Drugs to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYRP 2 MG/5ML (Chlorpheniramine Maleate) CHLOR-TRIMETON TABS 4 MG (Chlorpheniramine Maleate) AL; AL; ; Name of chlorpheniramine maleate syrp or 2 /5ml chlorpheniramine maleate tabs or 4 ED CHLORPED AL; AL; ; AL; Antihistamines - Ethanolamines AL; ALER-DRYL BENADRYL AL; ; (Diphenhydramine HCl) BENADRYL ALLERGY AL; ; (Diphenhydramine HCl) BENADRYL ALLERGY AL; CHILDRENS CHEW 12.5 MG (Diphenhydramine HCl) BENADRYL ALLERGY AL; ; CHILDRENS LIQD 12.5 MG/5ML (Diphenhydramine HCl) BENADRYL DYE-FREE AL; ; ALLERGYLIQUID-GELS (Diphenhydramine HCl) AL; carbinoxamine maleate clemastine fumarate tabs or 2.68 diphenhydramine hcl caps or 25 diphenhydramine hcl chew or 12.5 AL; AL; ; AL; You can find information on what symbols and abbreviations in this table mean by going to 44
56 Name of diphenhydramine hcl elix or 12.5 /5ml diphenhydramine hcl liqd or 12.5 /5ml, 25 /10ml, 50 /20ml diphenhydramine hcl soln ij 50 /ml diphenhydramine hcl syrp or 12.5 /5ml diphenhydramine hcl tabs or 25 TRIAMINIC COUGH & RUNNY NOSE AL; RX/OTC AL; ; AL; AL; AL; ; AL; Antihistamines - Non-Sedating RX/OTC; cetirizine hcl soln 1 /ml RX/OTC; cetirizine hcl syrp 1 /ml CLARINEX TABS 5 MG (Desloratadine) CLARITIN TABS 10 MG QL(1 ea daily); (Loratadine) ; desloratadine levocetirizine dihydrochloride Name of loratadine tabs or 10 XYZAL (Levocetirizine Dihydrochloride) Antihistamines - Phenothiazines promethazine hcl soln ij 25 /ml, 50 /ml promethazine hcl soln or 6.25 /5ml promethazine hcl supp re 12.5, 25 promethazine hcl syrp or 6.25 /5ml promethazine hcl tabs or 12.5, 25, 50 Antihistamines - Piperidines cyproheptadine hcl syrp or 2 /5ml cyproheptadine hcl tabs or 4 QL(1 ea daily); ; AL; AL; AL; AL; AL; AL; AL; AIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol Antihyperlipidemics - Misc. You can find information on what symbols and abbreviations in this table mean by going to 45
57 Name of KYNAMRO LOVAZA (Omega-3-acid Ethyl Esters) omega-3-acid ethyl esters VASCEPA Bile Acid Sequestrants cholestyramine light cholestyramine pack or 4 gm cholestyramine powd or 4 gm/dose COLESTID (Colestipol HCl) COLESTID FLAVORED GRAN 5 GM (Colestipol HCl) colestipol hcl WELCHOL Fibric Acid Derivatives PA; LA ST; Name of AARA 30 MG AARA 90 MG choline fenofibrate fenofibrate micronized 130 fenofibrate micronized 134, 200, 67 fenofibrate micronized 43 fenofibrate tabs 145, 160, 48, 54 gemfibrozil tabs or SL(4.33 ea daily); SL(1.44 ea daily); SL(1 ea daily); SL(3.02 ea daily); LOPID (Gemfibrozil) TRICOR (Fenofibrate) TRIGLIDE TRILIPIX (Choline Fenofibrate) HMG CoA Reductase Inhibitors You can find information on what symbols and abbreviations in this table mean by going to 46
58 Name of atorvastatin calcium CRESTOR (Rosuvastatin Calcium) fluvastatin sodium caps 20, 40 LESCOL (Fluvastatin Sodium) LIPITOR (Atorvastatin Calcium) lovastatin ST; MEVACOR (Lovastatin) PRAVACHOL (Pravastatin Sodium) pravastatin sodium rosuvastatin calcium simvastatin tabs or 10 simvastatin tabs or 20 ST; SL(8 ea daily); SL(4 ea daily); Name of simvastatin tabs or 40 simvastatin tabs or 5 simvastatin tabs or 80 ZOCOR 10 MG (Simvastatin) ZOCOR 20 MG (Simvastatin) ZOCOR 40 MG (Simvastatin) ZOCOR 5 MG (Simvastatin) ZOCOR 80 MG (Simvastatin) SL(2 ea daily); SL(16 ea daily); SL(1 ea daily); SL(8 ea daily); SL(4 ea daily); SL(2 ea daily); SL(16 ea daily); SL(1 ea daily); Intestinal Cholesterol Absorption Inhibitors ZETIA Microsomal Triglyceride Transfer Protein (MTP) PA; SL(6 ea JUXTAPID 10 MG daily); LA JUXTAPID 20 MG JUXTAPID 30 MG PA; SL(3 ea daily); LA PA; SL(2 ea daily); LA You can find information on what symbols and abbreviations in this table mean by going to 47
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