Drug Formulary

GlobalHealth Medicare (HMO)
PO Box 2328
H0435_2014_Formulary_Abridged_Rev13 oma Cdit 11
GlobalHealth Medicare
2014 Abridged Formulary
List of Covered Drugs

HPMS Approved Formulary File Submission ID 14443, Version 13

This abridged formulary was updated on 11/01/2014 and is not a complete list of drugs covered by our plan.
For a complete listing or other questions, please contact GlobalHealth Medicare Member Services at
(866) 844-0151 or, for TTY users, (800) 899-2114, 24 hours a day, 7 days a week, 365 days a year, or visit

Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.

When this drug list (formulary) refers to "we," "us", or "our," it means GlobalHealth Medicare. When it
refers to "plan" or "our plan," it means GlobalHealth Medicare.
This document includes a partial list of the drugs (formulary) for our plan which is current as of 11/01/2014.
For a complete updated formulary, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.

What is the GlobalHealth Medicare Abridged Formulary?
A formulary is a list of covered drugs selected by GlobalHealth Medicare in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. GlobalHealth Medicare will generally cover the drugs listed in our formulary as long as
the drug is medically necessary, the prescription is filled at a GlobalHealth Medicare network pharmacy, and
other plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
This document is a partial formulary and includes only some of the drugs covered by GlobalHealth Medicare.
For a complete listing of all prescription drugs covered by GlobalHealth Medicare, please visit our website or
call us. Our contact information, along with the date we last updated the formulary, appears on the front and
back cover pages.
Updated 11/01/2014
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from
the market, we will immediately remove the drug from our formulary and provide notice to members who
take the drug. The enclosed formulary is current as of 11/01/2014. To get updated information about the
drugs covered by GlobalHealth Medicare, please contact us. Our contact information appears on the front and
back cover pages.
GlobalHealth Medicare will provide at least 60 days' notice to SPAPs, authorized prescribers, and network
pharmacies before removing a Part D drug from the Part D plan's formulary, adding prior authorization,
quantity limits, step therapy or other restrictions on a drug and moving a drug to a higher cost-sharing tier. All
negative formulary changes will be communicated to affected members by providing direct written notice to
affected enrollees at least 60 days prior to the effective date of the negative formulary change.
GlobalHealth Medicare may elect to immediately remove from the formulary covered Part D drugs deemed
unsafe by the Food and Drug Administration or removed from the market by their manufacturer without
meeting these requirements. GlobalHealth Medicare will provide retrospective notice of any such formulary
changes to affected enrollees, CMS, State Pharmaceutical Assistance Programs, entities providing other
prescription drug coverage, authorized prescribers as defined by State law, network pharmacies, and
The written notice must contain the following information:
1. The name of the affected covered Part D drug; 2. Information on whether the covered Part D drug is being removed from the formulary or changing its preferred or tiered cost-sharing status or subject to other UM changes (prior authorization, quantity limits, step therapy); 3. The reason why the covered Part D drug is being removed from the formulary or changing its preferred or cost-sharing status; 4. Alternative drugs in the same therapeutic category, class or cost-sharing tier, and the expected cost-sharing for those drugs; and 5. The means by which enrollees may obtain an updated coverage determination or an exception to a coverage determination. Notice of the change must also be posted on the Part D plan's Web site.
Updated 11/01/2014
How do I use the Formulary?
There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, "Cardiovascular, Hypertension / Lipids". If you know what your drug is used for, look for the category name in the list that begins on page number 9. Then look under the category name for your drug. Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 41. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
GlobalHealth Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
Prior Authorization: GlobalHealth Medicare requires you [or your physician] to get prior
authorization for certain drugs. This means that you will need to get approval from GlobalHealth Medicare before you fill your prescriptions. If you don't get approval, GlobalHealth Medicare may not cover the drug.  Quantity Limits: For certain drugs, GlobalHealth Medicare limits the amount of the drug that
GlobalHealth Medicare will cover. For example, GlobalHealth Medicare provides thirteen pills for a 90-day supply prescription for alendronate sodium 35 mg. This may be in addition to a standard one-month or three-month supply.  Step Therapy: In some cases, GlobalHealth Medicare requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, GlobalHealth Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, GlobalHealth Medicare will then cover Drug B. Updated 11/01/2014 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask GlobalHealth Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, "How do I request an exception to the GlobalHealth Medicare's formulary?" on this page for information about how to request an exception. What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan.
GlobalHealth Medicare pays for certain OTC drugs.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so
GlobalHealth Medicare may cover your drug. For more information, please contact us. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you learn that GlobalHealth Medicare does not cover your drug, you have two options:
 You can ask Member Services for a list of similar drugs that are covered by GlobalHealth Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by GlobalHealth Medicare.  You can ask GlobalHealth Medicare to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the GlobalHealth Medicare's Formulary?
You can ask GlobalHealth Medicare to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.  You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
Updated 11/01/2014  You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, GlobalHealth Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, GlobalHealth Medicare will only approve your request for an exception if the alternative drugs
included on the plan's formulary, the lower cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request.
Generally, we
must make our decision within 72 hours of getting your prescriber's supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may
cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
1. All transition medication procedures are managed under the direct oversight of the Quality, Operations and Compliance Committee (QOC) and are reviewed and updated annually; 2. Level of care setting change medication transition eligible enrollees will receive a temporary 30 day supply (unless the enrollee presents with a prescription written for less than 30 days) from a network pharmacy; 3. Current enrollees transitioning to a network LTC facility with a new prescription for a drug not on the Plan formulary or a drug that is subject to prior authorization, step therapy requirements or quantity limit requirements will receive an temporary 31 day supply (unless the enrollee presents with a Updated 11/01/2014 prescription written for less than 30 days) from the network pharmacy (see policy number RX 1.003 Part D LTC resident medication transition); 4. Medication transition supplies that are subject to point of sale quantity limit edits allowing for less than the prescribed quantity can be refilled up to the prescribed amount for a 30 day supply or 31 day supply (LTC residents) within the first 90 days while an exception is requested and processed. 5. Enrollees receiving transition supplies for a non-formulary drugs are subject to the same cost sharing charged for a third tier non preferred brand drug. LIS Enrollees pay LIS copays for transition supplies for non-formulary drugs; 6. Enrollees receiving transition supplies at the point of sale for edits that are associated with prior authorizations, quantity limits or step therapy are subject to the same cost sharing charged for the drug on the Plan formulary. LIS Enrollees pay LIS copays; 7. Enrollees who do not reside in a LTC and who have not completed the exception request or appeal process by the end of the minimum transition period (90 days) will be treated on a case-by-case basis until the transition is actually made either through a switch to an appropriate formulary drug, or a decision is made. 8. Enrollees who enroll after the Plan distributes the Annual Notice of Change (ANOC) (Oct. 31st) and have a level of care change prior to the new contract year will be provided a transition supply consistent with the transition process used for other enrollees with level of care changes. The enrollee is given a full 90 day transition period that extends across contract years; 9. CMS approved medication transition notices are sent by the PBM via US First Class Mail, to affected enrollees within 3 business days of receipt of a temporary supply; 10. Plan transition process is updated annually or on an as needed basis and is available via Plan web site and enrollment materials in the Evidence of Coverage, Abridged and Comprehensive formularies. For more information

For more detailed information about your GlobalHealth Medicare prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about GlobalHealth Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit Updated 11/01/2014 GlobalHealth Medicare's Formulary

The abridged formulary that begins on the next page provides coverage information about some of the drugs
covered by GlobalHealth Medicare. If you have trouble finding your drug in the list, turn to the Index that
begins on page 40.
Remember: This is only a partial list of drugs covered by GlobalHealth Medicare. If your prescription is not
in this partial formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lower-case italics (e.g., pravastatin sodium).
The information in the Requirements/Limits column tells you if GlobalHealth Medicare has any special
requirements for coverage of your drug.
The symbol [B/D] next to a drug name indicates that the drug may be covered under Medicare Part B or D
depending upon the circumstances. Information may need to be submitted describing the use and setting of
the drug to make the determination.
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form.
The symbol [G] next to a drug name indicates that the drug may be available in a generic form.
The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted to certain
pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated
pharmacies able to appropriately handle the drugs.
The symbol [PA] in the Requirements/Limits column indicates that prior authorization may apply.
The symbol [QL] in the Requirements/Limits column indicates that quantities dispensed may be limited.
The symbol [ST] in the Requirements/Limits column indicates that step therapy may apply.

o GlobalHealth Medicare Advantage Option 3 provides additional coverage of generic prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Updated 11/01/2014 Require-
Commonly Prescribed Therapeutic
Drug Categories
cidofovir Require-
didanosine amphotericin b EPIVIR ORAL SOLN clotrimazole troc fluconazole famciclovir fluconazole in dextrose inj 56mg/ml; 400mg/200ml foscarnet sodium flucytosine griseofulvin microsize ganciclovir griseofulvin ultramicrosize itraconazole INTELENCE TABS 100MG, ketoconazole INTELENCE TABS 25MG MYCAMINE INJ 50MG MYCAMINE INJ 100MG ISENTRESS CHEW 100MG ISENTRESS CHEW 25MG nystatin susp nystatin tabs SPORANOX ORAL SOLN KALETRA ORAL SOLN terbinafine hcl tabs KALETRA TABS 200MG; 50MG KALETRA TABS 100MG; voriconazole inj voriconazole susr lamivudine voriconazole tabs 200mg lamivudine/zidovudine voriconazole tabs 50mg ANTIVIRALS
abacavir moderiba 1200 dose pack moderiba 800 dose pack sulfate/lamivudine/zidovudine moderiba tabs acyclovir nevirapine acyclovir sodium inj 50mg/ml nevirapine er adefovir dipivoxil amantadine hcl Updated 11/01/2014 Require-
ZIAGEN ORAL SOLN PREZISTA TABS 600MG, zidovudine PREZISTA TABS 150MG, cefaclor cefaclor er RELENZA DISKHALER cefadroxil cefazolin sodium inj 10gm, 1gm, RETROVIR IV INFUSION 1gm; 5%, 500mg cefdinir REYATAZ CAPS 100MG cefditoren pivoxil tabs 200mg REYATAZ CAPS 150MG, cefepime inj 1gm, 2gm ribasphere caps cefotaxime sodium ribasphere ribapak cefotetan ribasphere tabs 600mg cefoxitin sodium ribasphere tabs 200mg, 400mg cefpodoxime proxetil ribavirin cefprozil rimantadine hcl ceftazidime inj 1gm, 2gm, 6gm ceftriaxone sodium cefuroxime axetil tabs stavudine cefuroxime sodium inj 1.5gm, 7.5gm, 750mg cephalexin caps 250mg, 500mg cephalexin susr SYNAGIS INJ 50MG/0.5ML cephalexin tabs TAMIFLU CAPS 45MG, 75MG TAMIFLU CAPS 30MG ERYTHROMYCINS / OTHER
azithromycin inj 500mg azithromycin pack azithromycin susr azithromycin tabs clarithromycin clarithromycin er valacyclovir hcl e.e.s. 400 ERY-TAB TBEC 500MG VIDEX PEDIATRIC ORAL ery-tab tbec 250mg, 333mg LACTOBIONATE INJ 500MG erythrocin stearate erythromycin base Updated 11/01/2014 Require-
erythromycin ethylsuccinate meropenem inj 500mg MISCELLANEOUS ANTIINFECTIVES
metronidazole metronidazole in nacl 0.79% amikacin sulfate inj 500mg/2ml atovaquone atovaquone/proguanil hcl neomycin sulfate aztreonam inj 1gm paromomycin sulfate bacitracin inj polymyxin b sulfate CAPASTAT SULFATE PRIMAQUINE PHOSPHATE pyrazinamide quinine sulfate chloramphenicol sodium rifabutin succinate rifampin chloroquine phosphate clindamycin hcl clindamycin palmitate hcl STREPTOMYCIN SULFATE clindamycin phosphate add- clindamycin phosphate in d5w tinidazole colistimethate sodium tobramycin DORIBAX INJ 500MG ethambutol hcl tobramycin sulfate inj 10mg/ml, gentamicin sulfate inj 80mg/2ml tobramycin sulfate/sodium gentamicin sulfate/0.9% sodium chloride chloride inj 0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% hydroxychloroquine sulfate XIFAXAN TABS 200MG imipenem/cilastatin XIFAXAN TABS 550MG isoniazid isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9% PENICILLINS
mefloquine hcl amoxicillin amoxicillin/clavulanate potassium 2 Updated 11/01/2014 Require-
amoxicillin/clavulanate potassium 2 demeclocycline hcl doxycycline hyclate ampicillin doxycycline hyclate dr ampicillin sodium inj 10gm, doxycycline monohydrate caps 125mg, 1gm ampicillin-sulbactam inj 10gm; doxycycline monohydrate susr 5gm, 2gm; 1gm doxycycline monohydrate tabs bactocill in dextrose inj 0; 150mg, 50mg, 75mg minocycline hcl bactocill in dextrose inj 0; minocycline hcl er 2gm/50ml dicloxacillin sodium URINARY TRACT AGENTS
nafcillin sodium inj 1gm MACRODANTIN CAPS 25MG nafcillin sodium inj 10gm methenamine hippurate nallpen/dextrose nitrofurantoin macrocrystals caps 2 oxacillin sodium inj 10gm 50mg nitrofurantoin monohydrate oxacillin sodium inj 1gm nitrofurantoin susp penicillin g potassium inj 5mu penicillin g procaine trimethoprim penicillin g sodium penicillin v potassium VANCOMYCIN
pfizerpen-g inj 20mu vancomycin hcl caps piperacillin sodium/tazobactam vancomycin hcl inj 1000mg, sodium inj 3gm; 0.375gm, 4gm; 10gm, 500mg ANTINEOPLASTIC /
amifostine ciprofloxacin er dexrazoxane inj 250mg ciprofloxacin hcl ELITEK INJ 1.5MG ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% ciprofloxacin inj 400mg/40ml leucovorin calcium inj 100mg, ciprofloxacin susr levofloxacin leucovorin calcium tabs levofloxacin in d5w inj 5%; 500mg/100ml moxifloxacin hcl ofloxacin ANTINEOPLASTIC /
sulfadiazine sulfamethoxazole/trimethoprim AFINITOR DISPERZ sulfamethoxazole/trimethoprim ds 2 AFINITOR TABS 2.5MG, 5MG, Updated 11/01/2014 Require-
AFINITOR TABS 10MG ALIMTA INJ 500MG anastrozole epirubicin hcl inj 50mg/25ml ERBITUX INJ 100MG/50ML ARZERRA INJ 100MG/5ML AVASTIN INJ 100MG/4ML azacitidine azathioprine etoposide inj 500mg/25ml exemestane bicalutamide bleomycin sulfate inj 30unit FIRMAGON INJ 120MG BOSULIF TABS 100MG FIRMAGON INJ 80MG BOSULIF TABS 500MG fludarabine phosphate inj 50mg fluorouracil inj 2.5gm/50ml flutamide CAPRELSA TABS 100MG FOLOTYN INJ 40MG/2ML CAPRELSA TABS 300MG gemcitabine hcl inj 1gm carboplatin inj 150mg/15ml GILOTRIF TABS 40MG CELLCEPT INTRAVENOUS GILOTRIF TABS 30MG cisplatin inj 100mg/100ml GILOTRIF TABS 20MG cladribine GLEEVEC TABS 100MG GLEEVEC TABS 400MG CYCLOPHOSPHAMIDE CAPS cyclophosphamide tabs cyclosporine cyclosporine modified hydroxyurea cytarabine aqueous idarubicin hcl inj 10mg/10ml dacarbazine inj 200mg ifosfamide inj 1gm daunorubicin hcl decitabine docetaxel inj 80mg/4ml, irinotecan inj 100mg/5ml doxorubicin hcl inj 2mg/ml IXEMPRA KIT INJ 45MG Updated 11/01/2014 Require-
JAKAFI TABS 10MG, 15MG, RAPAMUNE ORAL SOLN JAKAFI TABS 25MG RAPAMUNE TABS 0.5MG, RAPAMUNE TABS 2MG KADCYLA INJ 100MG letrozole SANDIMMUNE ORAL SOLN leuprolide acetate SANDOSTATIN LAR DEPOT LUPRON DEPOT INJ 22.5MG, SIMULECT INJ 20MG 3.75MG, 30MG, 45MG sirolimus LUPRON DEPOT-PED INJ 11.25MG, 15MG, 7.5MG LYSODREN SPRYCEL TABS 100MG, 20MG, 50MG, 80MG SPRYCEL TABS 140MG megestrol acetate SPRYCEL TABS 70MG MEKINIST TABS 2MG MEKINIST TABS 0.5MG SUTENT CAPS 12.5MG, melphalan hydrochloride mercaptopurine SUTENT CAPS 50MG methotrexate methotrexate sodium inj 1gm, SUTENT CAPS 25MG mitomycin inj 20mg SYLVANT INJ 100MG mitoxantrone hcl mycophenolate mofetil tacrolimus caps 0.5mg, 1mg mycophenolic acid dr tacrolimus caps 5mg TAFINLAR CAPS 75MG TAFINLAR CAPS 50MG tamoxifen citrate octreotide acetate inj TARCEVA TABS 100MG, 1000mcg/ml, 500mcg/ml octreotide acetate inj 100mcg/ml, TARCEVA TABS 150MG 200mcg/ml, 50mcg/ml oxaliplatin inj 100mg/20ml TASIGNA CAPS 150MG paclitaxel inj 300mg/50ml TASIGNA CAPS 200MG Updated 11/01/2014 Require-
toposar inj 1gm/50ml APTIOM TABS 200MG, topotecan hcl inj 4mg APTIOM TABS 600MG TREANDA INJ 100MG BANZEL TABS 200MG TRELSTAR DEPOT MIXJECT BANZEL TABS 400MG carbamazepine chew TRELSTAR LA MIXJECT carbamazepine er TRELSTAR MIXJECT carbamazepine susp tretinoin caps carbamazepine tabs clonazepam clonazepam odt diazepam gel VECTIBIX INJ 100MG/5ML DILANTIN CAPS 30MG divalproex sodium divalproex sodium dr vinblastine sulfate inj 1mg/ml divalproex sodium er vincasar pfs vincristine sulfate ethosuximide vinorelbine tartrate inj 50mg/5ml felbamate fosphenytoin sodium inj 100mg XALKORI CAPS 200MG XALKORI CAPS 250MG gabapentin caps gabapentin oral soln gabapentin tabs GABITRIL TABS 12MG, 16MG YERVOY INJ 50MG/10ML lamotrigine ZALTRAP INJ 100MG/4ML lamotrigine er levetiracetam er levetiracetam inj 500mg/5ml levetiracetam oral soln ZORTRESS TABS 0.5MG, levetiracetam tabs ZORTRESS TABS 0.25MG oxcarbazepine phenobarbital AUTONOMIC / CNS DRUGS,
phenytoin sodium phenytoin sodium extended Updated 11/01/2014 Require-
sumatriptan succinate inj primidone 6mg/0.5ml sumatriptan succinate tabs TEGRETOL-XR TB12 100MG zolmitriptan tiagabine hydrochloride topiramate zolmitriptan odt valproate sodium valproic acid MISCELLANEOUS NEUROLOGICAL
COPAXONE INJ 20MG/ML donepezil hcl benztropine mesylate galantamine hydrobromide bromocriptine mesylate carbidopa carbidopa/levodopa NAMENDA TITRATION PAK carbidopa/levodopa er carbidopa/levodopa odt NAMENDA XR TITRATION carbidopa/levodopa/entacapone entacapone rivastigmine tartrate pramipexole dihydrochloride ropinirole er TECFIDERA STARTER PACK 4 ropinirole hcl selegiline hcl MUSCLE RELAXANTS /
trihexyphenidyl hcl ANTISPASMODIC THERAPY
baclofen chlorzoxazone dihydroergotamine mesylate inj dantrolene sodium migergot naratriptan hcl 40000MCG/20ML, 50MCG/ML LIORESAL INTRATHECAL INJ 3 rizatriptan benzoate 0.05MG/ML, 10MG/20ML, rizatriptan benzoate odt MESTINON TIMESPAN sumatriptan nasal soln 20mg/act metaxalone methocarbamol sumatriptan nasal soln 5mg/act orphenadrine citrate orphenadrine citrate er Updated 11/01/2014 Require-
pyridostigmine bromide tizanidine hcl NARCOTIC ANALGESICS
levorphanol tartrate acetaminophen/codeine #3 acetaminophen/codeine oral soln lorcet hd acetaminophen/codeine tabs 300mg; 60mg lorcet plus acetaminophen/codeine tabs 300mg; 15mg buprenorphine hcl codeine sulfate tabs meperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml duramorph methadone hcl inj endocet tabs 325mg; 10mg, methadone hcl oral soln 325mg; 5mg, 325mg; 7.5mg methadone hcl tabs fentanyl citrate oral transmucosal 4 morphine sulfate er cp24 lpop 1600mcg (multiphase) 120mg fentanyl citrate oral transmucosal 4 morphine sulfate er cp24 lpop 1200mcg (multiphase) 30mg, 45mg, 60mg, fentanyl citrate oral transmucosal 4 75mg, 90mg lpop 800mcg morphine sulfate er cp24 100mg fentanyl citrate oral transmucosal 4 lpop 600mcg morphine sulfate er cp24 80mg fentanyl citrate oral transmucosal 4 lpop 200mcg, 400mcg morphine sulfate er cp24 10mg, fentanyl patches 20mg, 30mg, 50mg, 60mg morphine sulfate er tbcr 200mg hydrocodone bitartrate/acetaminophen oral morphine sulfate er tbcr 100mg hydrocodone morphine sulfate er tbcr 60mg bitartrate/acetaminophen tabs hydrocodone/acetaminophen tabs 2 morphine sulfate er tbcr 15mg, hydrocodone/ibuprofen tabs morphine sulfate inj 2mg/ml, 7.5mg; 200mg hydromorphone hcl er t24a 12mg, 2 morphine sulfate oral soln 16mg, 8mg hydromorphone hcl inj morphine sulfate oral soln 500mg/50ml 10mg/5ml, 20mg/5ml hydromorphone hcl liqd morphine sulfate tabs hydromorphone hcl tabs oxycodone hcl caps Updated 11/01/2014 Require-
oxycodone hcl conc flurbiprofen ibuprofen susp oxycodone hcl oral soln ibuprofen tabs 400mg, 600mg, oxycodone hcl tabs 30mg indomethacin caps indomethacin er oxycodone hcl tabs 10mg, 15mg, ketoprofen oxycodone hcl tabs 5mg ketoprofen er ketorolac tromethamine inj oxycodone/acetaminophen 15mg/ml, 30mg/ml ketorolac tromethamine tabs oxycodone/aspirin meclofenamate sodium mefenamic acid oxycodone/ibuprofen meloxicam susp meloxicam tabs 15mg oxymorphone hydrochloride er meloxicam tabs 7.5mg oxymorphone hydrochloride tabs nabumetone oxymorphone hydrochloride tabs nalbuphine hcl naloxone hcl inj 1mg/ml reprexain naltrexone hcl naproxen dr naproxen sodium tabs 275mg, vicodin es naproxen susp naproxen tabs vicodin hp oxaprozin piroxicam NON-NARCOTIC ANALGESICS
buprenorphine hcl/naloxone hcl sulindac tolmetin sodium butorphanol tartrate tramadol hcl diclofenac potassium tramadol hcl er tb24 diclofenac sodium dr diclofenac sodium er hydrochloride/acetaminophen diclofenac sodium transdermal PSYCHOTHERAPEUTIC DRUGS
diclofenac sodium/misoprostol ABILIFY DISCMELT TBDP diflunisal etodolac ABILIFY DISCMELT TBDP etodolac er fenoprofen calcium tabs Updated 11/01/2014 Require-
ABILIFY MAINTENA INJ clonidine hcl er clorazepate dipotassium ABILIFY ORAL SOLN clozapine ABILIFY TABS 15MG CYMBALTA CPEP 60MG ABILIFY TABS 10MG CYMBALTA CPEP 30MG ABILIFY TABS 5MG CYMBALTA CPEP 20MG ABILIFY TABS 2MG desipramine hcl dexedrine tabs ABILIFY TABS 30MG dexmethylphenidate hcl ABILIFY TABS 20MG dexmethylphenidate hcl er dextroamphetamine sulfate er amitriptyline hcl dextroamphetamine sulfate tabs amoxapine diazepam intensol amphetamine/dextroamphetamine 2 diazepam oral soln BRINTELLIX TABS 20MG diazepam tabs doxepin hcl BRINTELLIX TABS 10MG duloxetine hcl cpep 60mg BRINTELLIX TABS 5MG duloxetine hcl cpep 30mg budeprion sr duloxetine hcl cpep 20mg bupropion hcl bupropion hcl sr tb12 200mg ergoloid mesylates escitalopram oxalate oral soln bupropion hcl sr tb12 150mg escitalopram oxalate tabs 20mg bupropion hcl sr tb12 100mg escitalopram oxalate tabs 10mg bupropion hcl xl tb24 300mg escitalopram oxalate tabs 5mg bupropion hcl xl tb24 150mg eszopiclone buspirone hcl FANAPT TABS 12MG chlorpromazine hcl FANAPT TABS 10MG, 8MG citalopram hydrobromide oral citalopram hydrobromide tabs citalopram hydrobromide tabs citalopram hydrobromide tabs clomipramine hcl Updated 11/01/2014 Require-
INVEGA SUSTENNA INJ FANAPT TITRATION PACK 39MG/0.25ML, 78MG/0.5ML INVEGA SUSTENNA INJ FAZACLO TBDP 150MG, 117MG/0.75ML, 156MG/ML, FETZIMA CP24 120MG FETZIMA CP24 80MG FETZIMA CP24 40MG FETZIMA CP24 20MG INVEGA TB24 1.5MG FETZIMA TITRATION PACK LATUDA TABS 60MG, 80MG fluoxetine dr LATUDA TABS 40MG fluoxetine hcl caps 20mg LATUDA TABS 20MG fluoxetine hcl caps 40mg LATUDA TABS 120MG fluoxetine hcl caps 10mg fluoxetine hcl oral soln lithium carbonate fluoxetine hcl tabs 20mg lithium carbonate er fluoxetine hcl tabs 10mg lorazepam intensol lorazepam tabs fluphenazine decanoate loxapine succinate fluphenazine hcl maprotiline hcl fluvoxamine maleate er cp24 metadate er fluvoxamine maleate er cp24 methamphetamine hcl fluvoxamine maleate tabs 100mg methylphenidate hcl methylphenidate hcl cd cpcr fluvoxamine maleate tabs 50mg 10mg, 50mg, 60mg methylphenidate hcl er cp24 fluvoxamine maleate tabs 25mg methylphenidate hcl er tbcr 18mg, 2 20mg, 27mg, 36mg, 54mg methylphenidate hydrochloride guanidine hcl mirtazapine haloperidol conc mirtazapine odt tbdp 30mg, 45mg haloperidol decanoate modafinil haloperidol lactate nefazodone hcl haloperidol tabs nortriptyline hcl imipramine hcl olanzapine inj imipramine pamoate Updated 11/01/2014 Require-
olanzapine odt tbdp 20mg quetiapine fumarate tabs 400mg olanzapine odt tbdp 15mg quetiapine fumarate tabs 300mg olanzapine odt tbdp 10mg quetiapine fumarate tabs 200mg olanzapine odt tbdp 5mg quetiapine fumarate tabs 100mg olanzapine tabs 20mg quetiapine fumarate tabs 50mg olanzapine tabs 15mg quetiapine fumarate tabs 25mg olanzapine tabs 10mg RISPERDAL CONSTA INJ olanzapine tabs 7.5mg RISPERDAL CONSTA INJ olanzapine tabs 5mg risperidone odt tbdp 4mg olanzapine tabs 2.5mg risperidone odt tbdp 3mg olanzapine/fluoxetine risperidone odt tbdp 2mg oxazepam risperidone odt tbdp 1mg paroxetine hcl er tb24 37.5mg risperidone odt tbdp 0.5mg paroxetine hcl er tb24 25mg risperidone odt tbdp 0.25mg paroxetine hcl er tb24 12.5mg risperidone oral soln paroxetine hcl tabs 40mg risperidone tabs 4mg paroxetine hcl tabs 30mg risperidone tabs 3mg paroxetine hcl tabs 20mg risperidone tabs 2mg paroxetine hcl tabs 10mg risperidone tabs 1mg risperidone tabs 0.5mg perphenazine perphenazine/amitriptyline risperidone tabs 0.25mg phenelzine sulfate PRISTIQ TB24 100MG PRISTIQ TB24 50MG SAPHRIS SUBL 10MG procentra SAPHRIS SUBL 5MG protriptyline hcl Updated 11/01/2014 Require-
SEROQUEL XR TB24 400MG VIIBRYD TABS 10MG SEROQUEL XR TB24 300MG zaleplon caps 5mg SEROQUEL XR TB24 200MG zaleplon caps 10mg SEROQUEL XR TB24 150MG zenzedi tabs 10mg, 5mg SEROQUEL XR TB24 50MG ziprasidone hcl caps 80mg sertraline hcl conc ziprasidone hcl caps 60mg sertraline hcl tabs 100mg ziprasidone hcl caps 40mg sertraline hcl tabs 50mg ziprasidone hcl caps 20mg sertraline hcl tabs 25mg zolpidem tartrate temazepam zolpidem tartrate er thioridazine hcl thiothixene tranylcypromine sulfate HYPERTENSION / LIPIDS
trifluoperazine hcl amiodarone hcl inj 50mg/ml trimipramine maleate amiodarone hcl tabs 200mg, venlafaxine hcl er cp24 150mg flecainide acetate venlafaxine hcl er cp24 75mg mexiletine hcl pacerone venlafaxine hcl er cp24 37.5mg procainamide hcl propafenone hcl venlafaxine hcl tabs 100mg, 75mg 2 propafenone hcl er venlafaxine hcl tabs 50mg quinidine gluconate quinidine gluconate cr venlafaxine hcl tabs 37.5mg quinidine sulfate quinidine sulfate er venlafaxine hcl tabs 25mg sotalol hcl (af) tabs 120mg sotalol hcl tabs 160mg, 240mg, VIIBRYD TABS 40MG ANTIHYPERTENSIVE THERAPY
VIIBRYD TABS 20MG acebutolol hcl afeditab cr amiloride hcl Updated 11/01/2014 Require-
amiloride/hydrochlorothiazide doxazosin mesylate tabs 1mg, amlodipine besylate amlodipine besylate/benazepril doxazosin mesylate tabs 8mg amlodipine besylate/benazepril hydrochloride enalapril maleate atenolol enalapril atenolol/chlorthalidone maleate/hydrochlorothiazide benazepril hcl eplerenone benazepril eprosartan mesylate hcl/hydrochlorothiazide betaxolol hcl bisoprolol fumarate felodipine er bisoprolol fosinopril sodium fumarate/hydrochlorothiazide fosinopril bumetanide sodium/hydrochlorothiazide candesartan cilexetil furosemide inj candesartan furosemide oral soln cilexetil/hydrochlorothiazide furosemide tabs captopril guanfacine hcl captopril/hydrochlorothiazide hydralazine hcl cartia xt hydrochlorothiazide carvedilol indapamide chlorothiazide irbesartan chlorothiazide sodium irbesartan/hydrochlorothiazide chlorthalidone tabs 25mg, 50mg isradipine clonidine hcl ptwk labetalol hcl lisinopril clonidine hcl tabs lisinopril/hydrochlorothiazide clorpres tabs 15mg; 0.1mg, losartan potassium 15mg; 0.2mg CLORPRES TABS 15MG; potassium/hydrochlorothiazide matzim la methyclothiazide methyldopa methyldopa/hydrochlorothiazide diltiazem cd cp24 120mg, 240mg, methyldopate hcl metolazone diltiazem hcl er cp12 metoprolol succinate er diltiazem hcl er cp24 180mg, metoprolol tartrate inj 360mg, 420mg metoprolol tartrate tabs diltiazem hcl inj 100mg, metoprolol/hydrochlorothiazide 50mg/10ml minoxidil tabs diltiazem hcl tabs moexipril hcl Updated 11/01/2014 Require-
moexipril/hydrochlorothiazide verapamil hcl tabs CARDIAC GLYCOSIDES
nadolol/bendroflumethiazide nicardipine hcl LANOXIN TABS 187.5MCG, nifedical xl nifedipine er COAGULATION THERAPY
nimodipine nisoldipine nisoldipine er cilostazol perindopril erbumine clopidogrel pindolol dipyridamole tabs prazosin hcl propranolol hcl er propranolol hcl inj enoxaparin sodium inj propranolol hcl oral soln 120mg/0.8ml, 150mg/ml propranolol hcl tabs enoxaparin sodium inj 100mg/ml, 300mg/3ml, 30mg/0.3ml, propranolol/hydrochlorothiazide 1 40mg/0.4ml, 60mg/0.6ml, quinapril hcl 80mg/0.8ml quinapril/hydrochlorothiazide fondaparinux sodium inj ramipril 2.5mg/0.5ml fondaparinux sodium inj reserpine 10mg/0.8ml, 5mg/0.4ml, spironolactone 7.5mg/0.6ml heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml taztia xt heparin sodium/d5w inj 5%; telmisartan 40unit/ml telmisartan/amlodipine heparin sodium/nacl 0.45% telmisartan/hydrochlorothiazide heparin sodium/sodium chloride terazosin hcl caps 1mg, 2mg, 5mg 1 0.9% premix jantoven terazosin hcl caps 10mg pentoxifylline er timolol maleate torsemide inj 20mg/2ml tranexamic acid torsemide tabs warfarin sodium trandolapril XARELTO TABS 10MG triamterene/hydrochlorothiazide XARELTO TABS 15MG, 20MG valsartan LIPID/CHOLESTEROL LOWERING
valsartan/hydrochlorothiazide verapamil hcl er ADVICOR TB24 20MG; 500MG verapamil hcl inj verapamil hcl sr cp24 360mg Updated 11/01/2014 Require-
ADVICOR TB24 20MG; isosorbide dinitrate 1000MG, 20MG; 750MG, 40MG; isosorbide dinitrate er isosorbide mononitrate amlodipine besylate/atorvastatin isosorbide mononitrate er nitro-bid atorvastatin calcium nitroglycerin inj cholestyramine light pack nitroglycerin lingual translingual colestipol hcl soln nitroglycerin pt24 nitroglycerin transdermal pt24 fenofibrate caps 130mg, 43mg 0.1mg/hr NITROSTAT fenofibrate micronized fenofibrate tabs fenofibric acid dr fluvastatin caps 20mg ANTIPSORIATIC / ANTISEBORRHEIC
acitretin caps 10mg fluvastatin caps 40mg acitretin caps 17.5mg, 25mg calcipotriene gemfibrozil dipropionate lovastatin tabs 10mg calcitriol selenium sulfide lotn lovastatin tabs 20mg, 40mg BURN THERAPY
niacin er tbcr silver sulfadiazine omega-3-acid ethyl esters MISCELLANEOUS DERMATOLOGICALS
pravastatin sodium ammonium lactate prevalite powd SIMCOR TB24 1000MG; 40MG, diclofenac sodium gel 500MG; 20MG, 500MG; 40MG fluorouracil crea 5% SIMCOR TB24 1000MG; 20MG, fluorouracil external soln simvastatin imiquimod methoxsalen MISCELLANEOUS CARDIOVASCULAR
podofilox prudoxin NITRATES
Updated 11/01/2014 Require-
mupirocin sulfacetamide sodium susp TOPICAL ANTIFUNGALS
ciclopirox adapalene ciclopirox nail lacquer amnesteem ciclopirox olamine avita crea clotrimazole external crea claravis caps 10mg, 20mg, 40mg clotrimazole external soln claravis caps 30mg clindamycin phosphate external dipropionate econazole nitrate clindamycin phosphate foam ketoconazole clindamycin phosphate gel ketodan kit clindamycin phosphate lotn clindamycin phosphate swab nystatin crea clindamycin/benzoyl peroxide gel nystatin oint nystatin powd 100000unit/gm nystatin/triamcinolone erythromycin external soln erythromycin gel pedi-dri erythromycin/benzoyl peroxide TOPICAL ANTIVIRALS
metronidazole acyclovir myorisan caps 10mg, 20mg myorisan caps 40mg TOPICAL CORTICOSTEROIDS
tretinoin crea ala cort tretinoin gel alclometasone dipropionate TOPICAL ANESTHETICS
amcinonide lidocaine hcl external soln apexicon e lidocaine hcl inj 0.5%, 1%, 2% augmented betamethasone lidocaine hcl jelly dipropionate lidocaine oint betamethasone dipropionate lidocaine ptch betamethasone valerate lidocaine viscous clobetasol propionate e lidocaine/prilocaine crea clobetasol propionate external TOPICAL ANTIBACTERIALS
clobetasol propionate foam gentamicin sulfate crea clobetasol propionate gel gentamicin sulfate oint 0.1% clobetasol propionate lotn mafenide acetate clobetasol propionate oint clobetasol propionate sham Updated 11/01/2014 Require-
acamprosate calcium dr desonide desoximetasone alendronate sodium tabs 40mg diflorasone diacetate fluocinolone acetonide anagrelide hydrochloride fluocinolone acetonide body ARALAST NP INJ 400MG fluocinonide crea 0.1% fluocinonide external soln fluocinonide gel cevimeline hcl fluocinonide oint fluocinonide-e CLINIMIX 4.25%/DEXTROSE fluticasone propionate crea fluticasone propionate lotn 2.75%/DEXTROSE 10% fluticasone propionate oint halobetasol propionate 2.75%/DEXTROSE 5% hydrocortisone butyrate dextrose 10%/nacl 0.45% hydrocortisone butyrate dextrose 10% flex container (lipophilic) dextrose 10%/nacl 0.2% hydrocortisone crea 1%, 2.5% dextrose 2.5%/sodium chloride hydrocortisone lotn 2.5% hydrocortisone oint 1%, 2.5% dextrose 5% hydrocortisone valerate dextrose 5%/lactated ringers mometasone furoate dextrose 5%/nacl 0.2% prednicarbate dextrose 5%/nacl 0.225% triamcinolone acetonide crea dextrose 5%/nacl 0.33% triamcinolone acetonide lotn dextrose 5%/nacl 0.45% triamcinolone acetonide oint dextrose 5%/nacl 0.9% disulfiram TOPICAL ENZYMES
EXJADE TBSO 250MG, 500MG malathion permethrin crea kionex powd spinosad levocarnitine midodrine hcl DIAGNOSTICS / MISCELLANEOUS
pilocarpine hcl tabs IRRIGATING SOLUTIONS
pilocarpine hydrochloride lactated ringers irrigation neomycin/polymyxin b sulfates ringers irrigation MISCELLANEOUS AGENTS
Updated 11/01/2014 Require-
riluzole sodium chloride 0.9% ADRENAL HORMONES
sodium chloride inj 0.9% a-hydrocort sodium phenylbutyrate cortisone acetate sodium polystyrene sulfonate susp 2 dexamethasone elix 15gm/60ml dexamethasone intensol sterile water irrigation dexamethasone sodium phosphate 2 inj 10mg/ml, 120mg/30ml zoledronic acid inj 5mg/100ml dexamethasone tabs SMOKING DETERRENTS
fludrocortisone acetate buproban hydrocortisone tabs CHANTIX STARTING MONTH methylprednisolone methylprednisolone acetate NICOTROL INHALER methylprednisolone dose pack EAR, NOSE / THROAT
sodiumsuccinate inj 125mg, 40mg MEDICATIONS
prednisolone sodium phosphate azelastine hcl nasal soln 0.15% prednisone intensol azelastine hcl nasal soln prednisone oral soln 137mcg/spray prednisone tabs chlorhexidine gluconate oral triamcinolone acetonide inj veripred 20 ipratropium bromide nasal soln ANTITHYROID AGENTS
ipratropium bromide nasal soln methimazole propylthiouracil periogard DIABETES THERAPY
triamcinolone in orabase acarbose tabs 100mg TYZINE PEDIATRIC NASAL acarbose tabs 50mg MISCELLANEOUS OTIC
acarbose tabs 25mg acetasol hc ACCU-CHEK ACTIVE acetic acid fluocinolone acetonide hydrocortisone/acetic acid ACCU-CHEK ACTIVE STRIPS 3 ofloxacin ACCU-CHEK AVIVA IN OTIC STEROID / ANTIBIOTIC
ACCU-CHEK AVIVA PLUS neomycin/polymyxin/hc ACCU-CHEK COMFORT CURVE CONTROL SOLUTION ne otic susp Updated 11/01/2014 Require-
ACCU-CHEK COMFORT glyburide micronized tabs 6mg glyburide micronized tabs 3mg ACCU-CHEK COMFORT CURVE TEST STRIPS glyburide micronized tabs 1.5mg ACCU-CHEK COMPACT BLUE 3 CONTROL SOLUTION (2 glyburide tabs 5mg ACCU-CHEK COMPACT PLUS 3 glyburide tabs 2.5mg ACCU-CHEK COMPACT PLUS glyburide tabs 1.25mg ACCU-CHEK SMARTVIEW glyburide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg ALCOHOL PREPS PADS glyburide/metformin hcl tabs 1.25mg; 250mg BYETTA INJ 5MCG/0.02ML HUMALOG MIX 50/50 BYETTA INJ 10MCG/0.04ML HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMALOG MIX 75/25 GAUZE PADS 2"X2" glimepiride tabs 4mg HUMULIN 70/30 KWIKPEN glimepiride tabs 2mg HUMULIN 70/30 PEN glimepiride tabs 1mg HUMULIN N KWIKPEN glipizide er tb24 10mg HUMULIN N U-100 PEN glipizide er tb24 5mg glipizide er tb24 2.5mg INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U- glipizide tabs 10mg INSULIN SYRINGE (DISP) U- glipizide tabs 5mg INSULIN SYRINGE (DISP) U- glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg INVOKANA TABS 300MG glipizide/metformin hcl tabs 2.5mg; 250mg INVOKANA TABS 100MG GLUCAGEN HYPOKIT GLUCAGON EMERGENCY Updated 11/01/2014 Require-
JANUMET XR TB24 1000MG; ONETOUCH VERIO IQ 100MG, 500MG; 50MG JANUMET XR TB24 1000MG; MONITORING SYSTEM ONETOUCH VERIO TEST pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl/metformin hcl PRODIGY INSULIN MINI PEN NEEDLES/31G X 3/16" metformin hcl er tb24 1000mg, PRODIGY INSULIN PEN NEEDLES/29G X 1/2" metformin hcl er tb24 500mg PRODIGY INSULIN SHORT PENNEEDLES/31G X 5/16" metformin hcl tabs 1000mg SYRING/U-100/0.3ML/31G X metformin hcl tabs 850mg metformin hcl tabs 500mg SYRINGE/1/2ML/31G X 5/16" nateglinide tabs 120mg SYRINGE/1ML/28G X 1/2" nateglinide tabs 60mg repaglinide tabs 2mg NEEDLES, INSULIN DISP., repaglinide tabs 1mg NOVOFINE 30GX8MM repaglinide tabs 0.5mg NOVOFINE 32GX6MM NOVOFINE AUTOCOVER tolazamide tabs 500mg NOVOLOG MIX 70/30 tolazamide tabs 250mg NOVOLOG MIX 70/30 PREFILLED FLEXPEN tolbutamide ONETOUCH ULTRA 2 ONETOUCH ULTRA BLUE ONETOUCH ULTRA MINI ONETOUCH ULTRA SYSTEM Updated 11/01/2014 Require-
zoledronic acid inj 4mg/5ml THYROID HORMONES
levothyroxine sodium tabs 25MG/2.5GM, 50MG/5GM liothyronine sodium cabergoline calcitonin-salmon calcitriol CEREZYME INJ 200UNIT unithroid tabs 100mcg, 112mcg, chorionic gonadotropin 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, desmopressin acetate 75mcg, 88mcg doxercalciferol ANTIDIARRHEALS / ANTISPASMODICS
atropine sulfate inj 0.05mg/ml, FABRAZYME INJ 35MG fortical diphenoxylate/atropine glycopyrrolate inj 4mg/20ml glycopyrrolate tabs loperamide hcl caps MISCELLANEOUS GASTROINTESTINAL
oxandrolone tabs 2.5mg balsalazide disodium oxandrolone tabs 10mg budesonide cp24 pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml paricalcitol colocort SENSIPAR TABS 60MG, 90MG constulose SENSIPAR TABS 30MG SOMAVERT INJ 10MG, 15MG, cromolyn sodium conc testosterone cypionate testosterone enanthate dronabinol caps 10mg dronabinol caps 2.5mg, 5mg Updated 11/01/2014 Require-
ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT, gavilyte-c 136000UNIT; 25000UNIT; 85000UNIT, 16000UNIT; gavilyte-g 3000UNIT; 10000UNIT, gavilyte-n/flavor pack 55000UNIT; 10000UNIT; generlac 34000UNIT, 82000UNIT; granisetron hcl inj 0.1mg/ml, 15000UNIT; 51000UNIT ULCER THERAPY
granisetron hcl tabs carafate susp hydrocortisone enem cimetidine lactulose cimetidine hcl esomeprazole sodium famotidine inj 20mg/2ml famotidine premixed meclizine hcl tabs famotidine susr mesalamine kit famotidine tabs 20mg, 40mg metoclopramide hcl inj lansoprazole cpdr 30mg metoclopramide hcl oral soln lansoprazole cpdr 15mg metoclopramide hcl tabs ondansetron hcl inj 4mg/2ml ondansetron hcl oral soln ondansetron hcl tabs misoprostol ondansetron odt NEXIUM CPDR 40MG NEXIUM CPDR 20MG polyethylene glycol 3350 powd prochlorperazine NEXIUM PACK 40MG prochlorperazine edisylate NEXIUM PACK 10MG, 2.5MG, prochlorperazine maleate procto-pak nizatidine proctosol hc omeprazole cpdr 40mg proctozone-hc omeprazole cpdr 10mg, 20mg omeprazole/sodium bicarbonate pantoprazole sodium inj pantoprazole sodium tbec 40mg sulfasalazine tabs pantoprazole sodium tbec 20mg sulfazine ec rabeprazole sodium trimethobenzamide hcl ranitidine hcl caps ranitidine hcl inj 150mg/6ml ursodiol ranitidine hcl syrp ranitidine hcl tabs sucralfate Updated 11/01/2014 Require-
allopurinol SAVELLA TABS 12.5MG probenecid SAVELLA TITRATION PACK probenecid/colchicine OBSTETRICS / GYNECOLOGY
alendronate sodium oral soln DEPO-PROVERA 400MG/ML alendronate sodium tabs 35mg, alendronate sodium tabs 10mg, estradiol ptwk estradiol tabs estradiol valerate estradiol/norethindrone acetate ibandronate sodium inj estropipate ibandronate sodium tabs jolivette raloxifene hydrochloride risedronate sodium medroxyprogesterone acetate OTHER RHEUMATOLOGICALS
mimvey lo ACTEMRA INJ 162MG/0.9ML, BENLYSTA INJ 120MG norethindrone norethindrone acetate norlyroc ENBREL SURECLICK Updated 11/01/2014 Require-
larin 1/20 progesterone caps larin fe 1.5/30 sharobel larin fe 1/20 MISCELLANEOUS OB/GYN
clindamycin phosphate crea levonest metronidazole vaginal levonorgestrel/ethinyl estradiol miconazole 3 tabs 0.03mg; 0.15mg levora 0.15/30-28 terconazole lomedia 24 fe tranexamic acid vandazole low-ogestrel zazole crea 0.4% marlissa ORAL CONTRACEPTIVES / RELATED
mononessa necon 0.5/35-28 necon 1/35 amethyst necon 10/11-28 necon 7/7/7 aranelle nortrel 0.5/35 (28) nortrel 1/35 nortrel 7/7/7 briellyn cryselle-28 ogestrel cyclafem 1/35 orsythia cyclafem 7/7/7 pirmella 1/35 drospirenone/ethinyl estradiol portia-28 emoquette previfem enpresse-28 quasense reclipsen sprintec 28 gildagia gildess 1.5/30 tri-legest fe introvale tri-previfem junel 1.5/30 tri-sprintec junel 1/20 trinessa junel fe 1.5/30 trivora-28 junel fe 1/20 kelnor 1/35 larin 1.5/30 zenchent Updated 11/01/2014 Require-
zovia 1/35e pilocarpine hcl ophthalmic soln zovia 1/50e MISCELLANEOUS OPHTHALMOLOGICS
azelastine hcl ophthalmic soln methylergonovine maleate tabs cromolyn sodium ophthalmic soln 2 ANTIBIOTICS
epinastine hcl proparacaine hcl bacitracin ophthalmic oint bacitracin/polymyxin b NON-STEROIDAL ANTI-

ciprofloxacin hcl bromfenac erythromycin oint diclofenac sodium ophthalmic garamycin gatifloxacin flurbiprofen sodium ketorolac tromethamine gentamicin sulfate oint 0.3% ophthalmic soln gentamicin sulfate ophthalmic ORAL DRUGS FOR GLAUCOMA
acetazolamide levofloxacin acetazolamide er acetazolamide sodium neomycin/bacitracin/polymyxin methazolamide neomycin/polymyxin/gramicidin OTHER GLAUCOMA DRUGS
ofloxacin polymyxin b sulfate/trimethoprim dorzolamide hcl tobramycin sulfate ophthalmic dorzolamide hcl/timolol maleate latanoprost ANTIVIRALS
ydrocortisone betaxolol hcl carteolol hcl levobunolol hcl ophthalmic soln ne ophthalmic susp tobramycin/dexamethasone metipranolol timolol maleate timolol maleate ophthalmic gel CHOLINESTERASE INHIBITOR

BLEPHAMIDE S.O.P. PHOSPHOLINE IODIDE Updated 11/01/2014 Require-
sulfacetamide hydroxyzine pamoate sodium/prednisolone sodium levocetirizine dihydrochloride phosphate oral soln STEROIDS
levocetirizine dihydrochloride dexamethasone sodium phosphate 2 ophthalmic soln fluorometholone phenadoz promethazine hcl inj promethazine hcl supp prednisolone acetate promethazine hcl syrp prednisolone sodium phosphate promethazine hcl tabs promethegan supp 25mg, 50mg sodium sulfacetamide ophthalmic PULMONARY AGENTS
acetylcysteine inhalation soln sulfacetamide sodium oint ALPHAGAN P OPHTHALMIC apraclonidine brimonidine tartrate albuterol sulfate er VASOCONSTRICTOR DECONGESTANTS
albuterol sulfate nebu naphazoline hcl albuterol sulfate syrp albuterol sulfate tabs RESPIRATORY AND ALLERGY
ASMANEX TWISTHALER 120 adrenalin inj 1mg/ml ASMANEX TWISTHALER 30 arbinoxa carbinoxamine maleate ASMANEX TWISTHALER 60 cetirizine hcl syrp 1mg/ml clemastine fumarate syrp clemastine fumarate tabs 2.68mg budesonide susp 32mcg/act cyproheptadine hcl budesonide susp 0.25mg/2ml, desloratadine 0.5mg/2ml desloratadine odt COMBIVENT RESPIMAT diphenhydramine hcl inj cromolyn sodium nebu hydroxyzine hcl inj hydroxyzine hcl oral soln flunisolide hydroxyzine hcl tabs Updated 11/01/2014 Require-
fluticasone propionate susp TUDORZA PRESSAIR FORADIL AEROLIZER ipratropium bromide inhalation ipratropium bromide/albuterol zafirlukast UROLOGICALS

levalbuterol flavoxate hcl levalbuterol hcl nebu 0.31mg/3ml, 2 0.63mg/3ml oxybutynin chloride metaproterenol sulfate oxybutynin chloride er montelukast sodium tolterodine tartrate tolterodine tartrate er trospium chloride trospium chloride er BENIGN PROSTATIC
alfuzosin hcl er QVAR AERS 40MCG/ACT finasteride tabs 5mg tamsulosin hcl QVAR AERS 80MCG/ACT CHOLINERGIC STIMULANTS
80MCG/ACT; 4.5MCG/ACT 160MCG/ACT; 4.5MCG/ACT calcium acetate caps terbutaline sulfate dextrose 5%/potassium chloride theophylline theophylline cr theophylline er tb12 300mg, kcl 0.075%/d5w/nacl 0.45% kcl 0.15%/d5w/lr theophylline er tb24 kcl 0.15%/d5w/nacl 0.2% kcl 0.15%/d5w/nacl 0.225% triamcinolone acetonide aero kcl 0.15%/d5w/nacl 0.9% kcl 0.3%/d5w/nacl 0.45% Updated 11/01/2014 Require-
kcl 0.3%/d5w/nacl 0.9% klor-con 8 CLINIMIX 2.75%/DEXTROSE klor-con m10 klor-con m15 CLINIMIX 4.25%/DEXTROSE klor-con m20 CLINIMIX 4.25%/DEXTROSE lactated ringers viaflex magnesium sulfate inj 50% CLINIMIX 4.25%/DEXTROSE NORMOSOL-R IN D5W potassium chloride 0.15% /nacl CLINIMIX 5%/DEXTROSE 15% 3 0.45% viaflex CLINIMIX 5%/DEXTROSE 20% 3 potassium chloride 0.15% CLINIMIX 5%/DEXTROSE 25% 3 d5w/nacl 0.33% potassium chloride 0.15% 4.25%/DEXTROSE 25% d5w/nacl 0.45% viaflex potassium chloride 0.15% nacl 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE potassium chloride 0.22% d5w/nacl 0.45% CLINIMIX E 5%/DEXTROSE potassium chloride 0.3%/ nacl CLINIMIX E 5%/DEXTROSE potassium chloride 0.3%/d5w potassium chloride er cpcr potassium chloride er tbcr 10meq, 1 intralipid inj 2.25%; 20% potassium chloride inj IONOSOL-B/DEXTROSE 5% 10meq/100ml, 20meq/100ml, 2meq/ml, 30meq/100ml, IONOSOL-MB/DEXTROSE 5% 3 40meq/100ml ISOLYTE-P/DEXTROSE 5% ringers injection sodium chloride 0.45% viaflex liposyn iii inj 2.5%; 10%, 2.5%; sodium chloride inj 2.5meq/ml, sodium lactate NORMOSOL-M IN D5W MISCELLANEOUS NUTRITION
PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML premasol inj 52meq/l; 1760mg/100ml; 880mg/100ml; 34meq/l; 1760mg/100ml; 372mg/100ml; 406mg/100ml; 526mg/100ml; 492mg/100ml; 492mg/100ml; 526mg/100ml; 356mg/100ml; 356mg/100ml; 390mg/100ml; 34mg/100ml; 152mg/100ml PROCALAMINE travasol VITAMINS / HEMATINICS
prenatal vitamins (generic)
sodium fluoride tabs Updated 11/01/2014 Index of Drugs
acyclovir 9, 26 A
acyclovir sodium 9 ADACEL 33 abacavir 9 abacavir sulfate/lamivudine/zidovudine 9 adapalene 26 adefovir dipivoxil 9 ABILIFY DISCMELT 18 adrenalin 37 ABILIFY MAINTENA 19 ADVAIR DISKUS 37 acamprosate calcium dr 27 acarbose 28 afeditab cr 22 ACCU-CHEK ACTIVE GLUCOSE CONTROL AFINITOR DISPERZ 12 ACCU-CHEK ACTIVE STRIPS 28 ACCU-CHEK AVIVA 28 a-hydrocort 28 ACCU-CHEK AVIVA PLUS 28 ala cort 26 ACCU-CHEK COMFORT CURVE CONTROL SOLUTION (2 LEVELS) 28 albuterol sulfate 37 ACCU-CHEK COMFORT CURVE LINEARITY albuterol sulfate er 37 alclometasone dipropionate 26 ACCU-CHEK COMFORT CURVE TEST ALCOHOL PREPS 29 ACCU-CHEK COMPACT BLUE CONTROL alendronate sodium 27, 34 SOLUTION (2 LEVELS) 29 alfuzosin hcl er 38 ACCU-CHEK COMPACT PLUS 29 ACCU-CHEK COMPACT PLUS CARE KIT 29 ACCU-CHEK NANO SMARTVIEW 29 allopurinol 34 ACCU-CHEK SMARTVIEW STRIPS 29 aloprim 34 acebutolol hcl 22 acetaminophen/codeine 17 acetaminophen/codeine #3 17 amantadine hcl 9 acetasol hc 28 acetazolamide 36 amcinonide 26 acetazolamide er 36 amethia 35 acetazolamide sodium 36 amethyst 35 acetic acid 28 amifostine 12 acetylcysteine 37 amikacin sulfate 11 acitretin 25 amiloride hcl 22 amiloride/hydrochlorothiazide 23 aminophylline 37 aranelle 35 AMINOSYN 7%/ELECTROLYTES 39 arbinoxa 37 AMINOSYN 8.5%/ELECTROLYTES 39 AMINOSYN II 8.5%/ELECTROLYTES 39 ASMANEX TWISTHALER 120 METERED ASMANEX TWISTHALER 30 METERED AMINOSYN-PF 7% 39 ASMANEX TWISTHALER 60 METERED amiodarone hcl 22 atenolol 23 amitriptyline hcl 19 atenolol/chlorthalidone 23 amlodipine besylate 23 amlodipine besylate/atorvastatin calcium 25 atorvastatin calcium 25 amlodipine besylate/benazepril hcl 23 atovaquone 11 amlodipine besylate/benazepril hydrochloride 23 atovaquone/proguanil hcl 11 AMMONIUM CHLORIDE 38 ammonium lactate 25 atropine sulfate 31 amnesteem 26 amoxapine 19 amoxicillin 11 augmented betamethasone dipropionate 26 amoxicillin/clavulanate potassium 11 amoxicillin/clavulanate potassium er 12 amphetamine/dextroamphetamine 19 aviane 35 amphotericin b 9 ampicillin 12 ampicillin sodium 12 ampicillin-sulbactam 12 azacitidine 13 anagrelide hydrochloride 27 anastrozole 13 azathioprine 13 azelastine hcl 28, 36 ANDROGEL PUMP 31 androxy 31 azithromycin 10 apexicon e 26 aztreonam 11 B
apraclonidine 37 apri 35 baciim 11 bacitracin 11, 36 bacitracin/polymyxin b 36 baclofen 16 bupropion hcl 19 bactocill in dextrose 12 bupropion hcl sr 19 balsalazide disodium 31 bupropion hcl xl 19 balziva 35 buspirone hcl 19 butorphanol tartrate 18 benazepril hcl 23 C
benazepril hcl/hydrochlorothiazide 23 BENLYSTA 34 cabergoline 31 benztropine mesylate 16 calcipotriene 25 calcipotriene/betamethasone dipropionate 25 betamethasone dipropionate 26 calcitonin-salmon 31 betamethasone valerate 26 calcitriol 25, 31 calcium acetate 38 betaxolol hcl 23, 36 camila 34 bethanechol chloride 38 bicalutamide 13 candesartan cilexetil 23 candesartan cilexetil/hydrochlorothiazide 23 bisoprolol fumarate 23 CAPASTAT SULFATE 11 bisoprolol fumarate/hydrochlorothiazide 23 bleomycin sulfate 13 captopril 23 captopril/hydrochlorothiazide 23 BLEPHAMIDE S.O.P. 36 carafate 32 carbamazepine 15 briellyn 35 carbamazepine er 15 carbidopa 16 brimonidine tartrate 37 carbidopa/levodopa 16 carbidopa/levodopa er 16 bromfenac 36 carbidopa/levodopa odt 16 bromocriptine mesylate 16 carbidopa/levodopa/entacapone 16 budeprion sr 19 carbinoxamine maleate 37 budesonide 31, 37 carboplatin 13 bumetanide 23 CARIMUNE NANOFILTERED 33 carteolol hcl 36 buprenorphine hcl 17 cartia xt 23 buprenorphine hcl/naloxone hcl 18 carvedilol 23 buproban 28 ciclopirox nail lacquer 26 cefaclor 10 ciclopirox olamine 26 cefaclor er 10 cidofovir 9 cefadroxil 10 cilostazol 24 cefazolin sodium 10 cimetidine 32 cefdinir 10 cimetidine hcl 32 cefditoren pivoxil 10 cefepime 10 cefotaxime sodium 10 cefotetan 10 ciprofloxacin 12 cefoxitin sodium 10 ciprofloxacin er 12 cefpodoxime proxetil 10 ciprofloxacin hcl 12, 36 cefprozil 10 ciprofloxacin i.v.-in d5w 12 ceftazidime 10 cisplatin 13 ceftriaxone sodium 10 citalopram hydrobromide 19 cefuroxime axetil 10 cladribine 13 cefuroxime sodium 10 claravis 26 clarithromycin 10 clarithromycin er 10 CELLCEPT INTRAVENOUS 13 clemastine fumarate 37 clindamycin hcl 11 cephalexin 10 clindamycin palmitate hcl 11 clindamycin phosphate 26, 35 clindamycin phosphate add-vantage 11 clindamycin phosphate in d5w 11 cetirizine hcl 37 clindamycin/benzoyl peroxide 26 cevimeline hcl 27 CLINIMIX 2.75%/DEXTROSE 5% 39 CLINIMIX 4.25%/DEXTROSE 10% 39 CHANTIX STARTING MONTH PAK 28 CLINIMIX 4.25%/DEXTROSE 20% 39 CLINIMIX 4.25%/DEXTROSE 25% 39 CLINIMIX 4.25%/DEXTROSE 5% 27 chloramphenicol sodium succinate 11 CLINIMIX 5%/DEXTROSE 15% 39 chlorhexidine gluconate oral rinse 28 CLINIMIX 5%/DEXTROSE 20% 39 chloroquine phosphate 11 CLINIMIX 5%/DEXTROSE 25% 39 chlorothiazide 23 CLINIMIX E 2.75%/DEXTROSE 10% 27 chlorothiazide sodium 23 CLINIMIX E 2.75%/DEXTROSE 5% 27 chlorpromazine hcl 19 CLINIMIX E 4.25%/DEXTROSE 25% 39 chlorthalidone 23 CLINIMIX E 4.25%/DEXTROSE 5% 39 chlorzoxazone 16 CLINIMIX E 5%/DEXTROSE 15% 39 cholestyramine light 25 CLINIMIX E 5%/DEXTROSE 20% 39 chorionic gonadotropin 31 CLINIMIX E 5%/DEXTROSE 25% 39 ciclopirox 26 CLINISOL SF 15% 39 clobetasol propionate 26 cyclosporine modified 13 clobetasol propionate e 26 clodan 27 cyproheptadine hcl 37 clomipramine hcl 19 clonazepam 15 clonazepam odt 15 cytarabine aqueous 13 clonidine hcl 23 D
clonidine hcl er 19 clopidogrel 24 dacarbazine 13 clorazepate dipotassium 19 clorpres 23 clotrimazole 9, 26 danazol 31 clotrimazole/betamethasone dipropionate 26 dantrolene sodium 16 clozapine 19 codeine sulfate 17 daunorubicin hcl 13 colestipol hcl 25 decitabine 13 colistimethate sodium 11 delyla 35 colocort 31 demeclocycline hcl 12 COMBIVENT RESPIMAT 37 DEPO-PROVERA 400MG/ML 34 desipramine hcl 19 compro 31 desloratadine 37 desloratadine odt 37 constulose 31 desmopressin acetate 31 desonide 27 desoximetasone 27 cortisone acetate 28 dexamethasone 28 dexamethasone intensol 28 dexamethasone sodium phosphate 28, 37 dexedrine 19 cromolyn sodium 31, 36, 37 dexmethylphenidate hcl 19 cryselle-28 35 dexmethylphenidate hcl er 19 dexrazoxane 12 cyclafem 1/35 35 dextroamphetamine sulfate 19 cyclafem 7/7/7 35 dextroamphetamine sulfate er 19 CYCLOPHOSPHAMIDE 13 dextrose 10%/nacl 0.45% 27 dextrose 10% flex container 27 cyclosporine 13 dextrose 10%/nacl 0.2% 27 dextrose 2.5%/sodium chloride 0.45% 27 dextrose 5% 27 dorzolamide hcl 36 dextrose 5%/lactated ringers 27 dorzolamide hcl/timolol maleate 36 dextrose 5%/nacl 0.2% 27 doxazosin mesylate 23 dextrose 5%/nacl 0.225% 27 doxepin hcl 19 dextrose 5%/nacl 0.33% 27 doxercalciferol 31 dextrose 5%/nacl 0.45% 27 dextrose 5%/nacl 0.9% 27 doxorubicin hcl 13 dextrose 5%/potassium chloride 0.15% 38 doxycycline hyclate 12 diazepam 15, 19 doxycycline hyclate dr 12 diazepam intensol 19 doxycycline monohydrate 12 dronabinol 31 diclofenac potassium 18 drospirenone/ethinyl estradiol 35 diclofenac sodium 18, 25, 36 diclofenac sodium dr 18 diclofenac sodium er 18 duloxetine hcl 19 diclofenac sodium/misoprostol 18 duramorph 17 dicloxacillin sodium 12 didanosine 9 E
diflorasone diacetate 27 diflunisal 18 e.e.s. 400 10 digoxin 24 E.E.S. GRANULES 10 dihydroergotamine mesylate 16 econazole nitrate 26 dilt-cd 23 diltiazem cd 23 diltiazem hcl 23 diltiazem hcl er 23 dilt-xr 23 eliphos 38 diphenhydramine hcl 37 diphenoxylate/atropine 31 DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC 33 dipyridamole 24 disulfiram 27 emoquette 35 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 enalapril maleate 23 enalapril maleate/hydrochlorothiazide 23 docetaxel 13 donepezil hcl 16 ENBREL SURECLICK 34 endocet 17 ethosuximide 15 endodan 17 etidronate disodium 27 etodolac 18 enoxaparin sodium 24 etodolac er 18 enpresse-28 35 entacapone 16 etoposide 13 enulose 32 epinastine hcl 36 exemestane 13 EPIPEN-JR 2-PAK 37 epirubicin hcl 13 epitol 15 F
EPIVIR HBV 9 eplerenone 23 eprosartan mesylate 23 falmina 35 famciclovir 9 famotidine 32 ergoloid mesylates 19 famotidine premixed 32 FANAPT TITRATION PACK 20 felbamate 15 felodipine er 23 fenofibrate 25 ERYTHROCIN LACTOBIONATE 10 fenofibrate micronized 25 erythrocin stearate 10 fenofibric acid dr 25 erythromycin 26, 36 fenoprofen calcium 18 erythromycin base 10 fentanyl citrate oral transmucosal 17 erythromycin ethylsuccinate 11 fentanyl patches 17 erythromycin/benzoyl peroxide 26 escitalopram oxalate 19 esomeprazole sodium 32 FETZIMA TITRATION PACK 20 finasteride 38 estradiol 34 estradiol valerate 34 estradiol/norethindrone acetate 34 flavoxate hcl 38 estropipate 34 flecainide acetate 22 eszopiclone 19 fluconazole 9 ethambutol hcl 11 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 13 fludrocortisone acetate 28 ganciclovir 9 flunisolide 37 garamycin 36 fluocinolone acetonide 27, 28 fluocinolone acetonide body 27 gatifloxacin 36 fluocinonide 27 fluocinonide-e 27 gavilyte-c 32 fluorometholone 37 gavilyte-g 32 fluorouracil 13, 25 gavilyte-n/flavor pack 32 fluoxetine dr 20 gemcitabine hcl 13 fluoxetine hcl 20 gemfibrozil 25 fluphenazine decanoate 20 generlac 32 fluphenazine hcl 20 gengraf 13 flurbiprofen 18 gentak 36 flurbiprofen sodium 36 gentamicin sulfate 11, 26, 36 flutamide 13 gentamicin sulfate/0.9% sodium chloride 11 fluticasone propionate 27, 38 fluvastatin 25 gianvi 35 fluvoxamine maleate 20 gildagia 35 fluvoxamine maleate er 20 gildess 1.5/30 35 fomepizole 33 fondaparinux sodium 24 glimepiride 29 FORADIL AEROLIZER 38 glipizide 29 glipizide er 29 fortical 31 glipizide/metformin hcl 29 foscarnet sodium 9 GLUCAGEN HYPOKIT 29 fosinopril sodium 23 GLUCAGON EMERGENCY KIT 29 fosinopril sodium/hydrochlorothiazide 23 glyburide 29 fosphenytoin sodium 15 glyburide micronized 29 furosemide 23 glyburide/metformin hcl 29 glycopyrrolate 31 granisetron hcl 32 GRASTEK 33 griseofulvin microsize 9 G
griseofulvin ultramicrosize 9 gabapentin 15 guanfacine hcl 23 guanidine hcl 20 GABLOFEN 16 galantamine hydrobromide 16 H
hydrocortisone/acetic acid 28 hydromorphone hcl 17 hydromorphone hcl er 17 hydroxychloroquine sulfate 11 halobetasol propionate 27 hydroxyurea 13 haloperidol 20 hydroxyzine hcl 37 haloperidol decanoate 20 hydroxyzine pamoate 37 haloperidol lactate 20 HAVRIX 33 I
heparin sodium 24 ibandronate sodium 34 heparin sodium/d5w 24 ibuprofen 18 heparin sodium/nacl 0.45% 24 idarubicin hcl 13 heparin sodium/sodium chloride 0.9% premix 24 ifosfamide 13 imipenem/cilastatin 11 imipramine hcl 20 imipramine pamoate 20 HUMALOG KWIKPEN 29 imiquimod 25 HUMALOG MIX 50/50 29 IMOVAX RABIES (H.D.C.V.) 33 HUMALOG MIX 50/50 KWIKPEN 29 HUMALOG MIX 75/25 29 HUMALOG MIX 75/25 KWIKPEN 29 indapamide 23 indomethacin 18 HUMIRA PEN-CROHNS DISEASESTARTER indomethacin er 18 HUMULIN 70/30 29 HUMULIN 70/30 KWIKPEN 29 INSULIN PEN NEEDLE 29 HUMULIN 70/30 PEN 29 INSULIN SYRINGE (DISP) U-100 0.3 ML 29 INSULIN SYRINGE (DISP) U-100 1 ML 29 HUMULIN N KWIKPEN 29 INSULIN SYRINGE (DISP) U-100 1/2 ML 29 HUMULIN N U-100 PEN 29 intralipid 39 HUMULIN R U-500 (CONCENTRATED) 29 hydralazine hcl 23 INTRON-A W/DILUENT 33 hydrochlorothiazide 23 introvale 35 hydrocodone bitartrate/acetaminophen 17 hydrocodone/acetaminophen 17 hydrocodone/ibuprofen 17 hydrocortisone 27, 28, 32 INVEGA SUSTENNA 20 hydrocortisone butyrate 27 hydrocortisone butyrate (lipophilic) 27 hydrocortisone valerate 27 IONOSOL-B/DEXTROSE 5% 39 kariva 35 IONOSOL-MB/DEXTROSE 5% 39 kcl 0.075%/d5w/nacl 0.45% 38 IPOL INACTIVATED IPV 33 kcl 0.15%/d5w/lr 38 ipratropium bromide 28, 38 kcl 0.15%/d5w/nacl 0.2% 38 ipratropium bromide/albuterol sulfate 38 kcl 0.15%/d5w/nacl 0.225% 38 irbesartan 23 kcl 0.15%/d5w/nacl 0.9% 38 irbesartan/hydrochlorothiazide 23 kcl 0.3%/d5w/nacl 0.45% 38 irinotecan 13 kcl 0.3%/d5w/nacl 0.9% 39 kelnor 1/35 35 ISOLYTE-P/DEXTROSE 5% 39 ketoconazole 9, 26 isoniazid 11 ketodan kit 26 isosorbide dinitrate 25 ketoprofen 18 isosorbide dinitrate er 25 ketoprofen er 18 isosorbide mononitrate 25 ketorolac tromethamine 18, 36 isosorbide mononitrate er 25 kionex 27 isotonic gentamicin 11 klor-con 8 39 isradipine 23 klor-con m10 39 klor-con m15 39 itraconazole 9 klor-con m20 39 L
labetalol hcl 23 lactated ringers irrigation 27 jantoven 24 lactated ringers viaflex 39 lactulose 32 lamivudine 9 lamivudine/zidovudine 9 lamotrigine 15 jinteli 34 lamotrigine er 15 jolivette 34 junel 1.5/30 35 lansoprazole 32 junel 1/20 35 junel fe 1.5/30 35 junel fe 1/20 35 LANTUS SOLOSTAR 30 larin 1.5/30 35 larin 1/20 35 K
larin fe 1.5/30 35 larin fe 1/20 35 latanoprost 36 lisinopril/hydrochlorothiazide 23 lithium 20 lithium carbonate 20 leflunomide 34 lithium carbonate er 20 lessina 35 lomedia 24 fe 35 letrozole 14 leucovorin calcium 12 loperamide hcl 31 lorazepam 20 lorazepam intensol 20 leuprolide acetate 14 lorcet 17 levalbuterol 38 lorcet hd 17 levalbuterol hcl 38 lorcet plus 17 lortab 17 LEVEMIR FLEXPEN 30 loryna 35 levetiracetam 15 losartan potassium 23 levetiracetam er 15 losartan potassium/hydrochlorothiazide 23 levobunolol hcl 36 levocarnitine 27 lovastatin 25 levocetirizine dihydrochloride 37 levofloxacin 12, 36 low-ogestrel 35 levofloxacin in d5w 12 loxapine succinate 20 levonest 35 levonorgestrel/ethinyl estradiol 35 levora 0.15/30-28 35 LUPRON DEPOT-PED 14 levorphanol tartrate 17 lutera 35 levothyroxine sodium 31 levoxyl 31 M
lidocaine 26 lidocaine hcl 26 lidocaine hcl jelly 26 mafenide acetate 26 lidocaine viscous 26 magnesium sulfate 39 lidocaine/prilocaine 26 malathion 27 maprotiline hcl 20 lindane 27 marlissa 35 LIORESAL INTRATHECAL 16 liothyronine sodium 31 matzim la 23 liposyn iii 39 meclizine hcl 32 lisinopril 23 meclofenamate sodium 18 medroxyprogesterone acetate 34 methylphenidate hcl cd 20 mefenamic acid 18 methylphenidate hcl er 20 mefloquine hcl 11 methylphenidate hydrochloride 20 methylprednisolone 28 megestrol acetate 14 methylprednisolone acetate 28 methylprednisolone dose pack 28 meloxicam 18 methylprednisolone sodiumsuccinate 28 melphalan hydrochloride 14 metipranolol 36 metoclopramide hcl 32 metolazone 23 MENOMUNE-A/C/Y/W-135 33 metoprolol succinate er 23 metoprolol tartrate 23 meperidine hcl 17 metoprolol/hydrochlorothiazide 23 metronidazole 11, 26 mercaptopurine 14 metronidazole in nacl 0.79% 11 meropenem 11 metronidazole vaginal 35 mesalamine 32 mexiletine hcl 22 miconazole 3 35 midodrine hcl 27 MESTINON TIMESPAN 16 migergot 16 metadate er 20 millipred 28 metaproterenol sulfate 38 mimvey lo 34 metaxalone 16 minocycline hcl 12 metformin hcl 30 minocycline hcl er 12 metformin hcl er 30 minoxidil 23 methadone hcl 17 mirtazapine 20 methamphetamine hcl 20 mirtazapine odt 20 methazolamide 36 misoprostol 32 methenamine hippurate 12 mitomycin 14 methimazole 28 mitoxantrone hcl 14 M-M-R II W/DILUENT 10 DOSE 33 methocarbamol 16 modafinil 20 methotrexate 14 moderiba 9 methotrexate sodium 14 moderiba 1200 dose pack 9 methoxsalen 25 moderiba 800 dose pack 9 methyclothiazide 23 moexipril hcl 23 methyldopa 23 moexipril/hydrochlorothiazide 24 methyldopa/hydrochlorothiazide 23 mometasone furoate 27 methyldopate hcl 23 mononessa 35 methylergonovine maleate 36 montelukast sodium 38 methylphenidate hcl 20 morphine sulfate 17 morphine sulfate er 17 neomycin sulfate 11 moxifloxacin hcl 12 neomycin/bacitracin/polymyxin 36 neomycin/polymyxin b sulfates 27 mupirocin 26 neomycin/polymyxin/dexamethasone 36 neomycin/polymyxin/gramicidin 36 neomycin/polymyxin/hc 28 neomycin/polymyxin/hydrocortisone 28, 36 mycophenolate mofetil 14 mycophenolic acid dr 14 myorisan 26 NEUPOGEN 33 nevirapine 9 N
nevirapine er 9 nabumetone 18 nadolol 24 nadolol/bendroflumethiazide 24 nafcillin sodium 12 niacin er 25 nalbuphine hcl 18 nicardipine hcl 24 nallpen/dextrose 12 NICOTROL INHALER 28 naloxone hcl 18 naltrexone hcl 18 nifedical xl 24 nifedipine er 24 NAMENDA TITRATION PAK 16 NAMENDA XR TITRATION PACK 16 nimodipine 24 naphazoline hcl 37 nisoldipine 24 naproxen 18 nisoldipine er 24 naproxen dr 18 nitro-bid 25 naproxen sodium 18 nitrofurantoin macrocrystals 12 naratriptan hcl 16 nitrofurantoin monohydrate 12 nitrofurantoin susp 12 nateglinide 30 nitroglycerin 25 nitroglycerin lingual 25 necon 0.5/35-28 35 nitroglycerin transdermal 25 necon 1/35 35 necon 10/11-28 35 nizatidine 32 necon 7/7/7 35 nora-be 34 NEEDLES, INSULIN DISP., SAFETY 30 norethindrone 34 nefazodone hcl 20 norethindrone acetate 34 norlyroc 34 NORMOSOL-M IN D5W 39 ondansetron hcl 32 NORMOSOL-R IN D5W 39 ondansetron odt 32 nortrel 0.5/35 (28) 35 ONETOUCH ULTRA 2 30 nortrel 1/35 35 ONETOUCH ULTRA BLUE 30 nortrel 7/7/7 35 ONETOUCH ULTRA MINI 30 nortriptyline hcl 20 ONETOUCH ULTRA SYSTEM KIT 30 ONETOUCH VERIO IQ BLOOD GLUCOSE novarel 31 MONITORING SYSTEM 30 NOVOFINE 30GX8MM 30 ONETOUCH VERIO TEST STRIPS 30 NOVOFINE 32GX6MM 30 NOVOFINE AUTOCOVER 30GX8MM 30 NOVOLIN 70/30 30 orphenadrine citrate 16 NOVOLOG FLEXPEN 30 orphenadrine citrate er 16 NOVOLOG MIX 70/30 30 orsythia 35 NOVOLOG MIX 70/30 PREFILLED FLEXPEN oxacillin sodium 12 NOVOLOG PENFILL 30 oxaliplatin 14 oxandrolone 31 oxaprozin 18 oxazepam 21 nyamyc 26 oxcarbazepine 15 nystatin 9, 26 nystatin/triamcinolone 26 OXSORALEN ULTRA 25 nystop 26 oxybutynin chloride 38 oxybutynin chloride er 38 O
oxycodone hcl 17, 18 ocella 35 oxycodone/acetaminophen 18 octreotide acetate 14 oxycodone/aspirin 18 ofloxacin 12, 28, 36 oxycodone/ibuprofen 18 ogestrel 35 oxymorphone hydrochloride 18 olanzapine 20, 21 oxymorphone hydrochloride er 18 olanzapine odt 21 P
olanzapine/fluoxetine 21 OLYSIO 9 pacerone 22 omega-3-acid ethyl esters 25 paclitaxel 14 omeprazole 32 palgic 37 omeprazole/sodium bicarbonate 32 pamidronate disodium 31 pioglitazone hcl/metformin hcl 30 pantoprazole sodium 32 pioglitazone hcl-glimepiride 30 paricalcitol 31 piperacillin sodium/tazobactam sodium 12 paromomycin sulfate 11 pirmella 1/35 35 paroxetine hcl 21 piroxicam 18 paroxetine hcl er 21 PLASMA-LYTE A 39 PLASMA-LYTE-148 39 PLASMA-LYTE-56/D5W 39 pedi-dri 26 podofilox 25 polyethylene glycol 3350 32 polymyxin b sulfate 11 polymyxin b sulfate/trimethoprim sulfate 36 PEGASYS PROCLICK 33 portia-28 35 PEG-INTRON REDIPEN 33 potassium chloride 39 penicillin g potassium 12 potassium chloride 0.15% /nacl 0.45% viaflex 39 penicillin g procaine 12 potassium chloride 0.15% d5w/nacl 0.33% 39 penicillin g sodium 12 potassium chloride 0.15% d5w/nacl 0.45% viaflex penicillin v potassium 12 potassium chloride 0.15% nacl 0.9% 39 potassium chloride 0.22% d5w/nacl 0.45% 39 pentoxifylline er 24 potassium chloride 0.3%/ nacl 0.9% 39 potassium chloride 0.3%/d5w 39 perindopril erbumine 24 potassium chloride er 39 periogard 28 potassium citrate er 38 permethrin 27 perphenazine 21 pramipexole dihydrochloride 16 perphenazine/amitriptyline 21 pravastatin sodium 25 pfizerpen-g 12 prazosin hcl 24 phenadoz 37 phenelzine sulfate 21 prednicarbate 27 phenobarbital 15 prednisolone acetate 37 phenytoin 15 prednisolone sodium phosphate 28, 37 phenytoin sodium 15 prednisone 28 phenytoin sodium extended 15 prednisone intensol 28 PHOSPHOLINE IODIDE 36 pilocarpine hcl 27, 36 pilocarpine hydrochloride 27 pimtrea 35 pindolol 24 prevalite 25 pioglitazone hcl 30 previfem 35 propafenone hcl er 22 proparacaine hcl 36 PRIMAQUINE PHOSPHATE 11 propranolol hcl 24 primidone 16 propranolol hcl er 24 propranolol/hydrochlorothiazide 24 propylthiouracil 28 probenecid 34 protriptyline hcl 21 probenecid/colchicine 34 prudoxin 25 procainamide hcl 22 procentra 21 pyrazinamide 11 prochlorperazine 32 pyridostigmine bromide 17 prochlorperazine edisylate 32 Q
prochlorperazine maleate 32 PROCRIT 33 quasense 35 procto-pak 32 quetiapine fumarate 21 proctosol hc 32 quinapril hcl 24 proctozone-hc 32 quinapril/hydrochlorothiazide 24 PRODIGY INSULIN MINI PEN NEEDLES/31G quinidine gluconate 22 quinidine gluconate cr 22 PRODIGY INSULIN PEN NEEDLES/29G X 1/2 quinidine sulfate 22 quinidine sulfate er 22 PRODIGY INSULIN SHORT quinine sulfate 11 PENNEEDLES/31G X 5/16 30 PRODIGY INSULIN SYRING/U-100/0.3ML/31G R
PRODIGY INSULIN SYRINGE/1/2ML/31G X rabeprazole sodium 32 PRODIGY INSULIN SYRINGE/1ML/28G X 1/2 raloxifene hydrochloride 34 ramipril 24 progesterone 35 ranitidine hcl 32 REBIF REBIDOSE 33 REBIF REBIDOSE TITRATION PACK 33 promethazine hcl 37 REBIF TITRATION PACK 33 promethegan 37 reclipsen 35 propafenone hcl 22 RECOMBIVAX HB 34 S
RELENZA DISKHALER 10 SAIZEN CLICK.EASY 33 SANDOSTATIN LAR DEPOT 14 repaglinide 30 reprexain 18 reserpine 24 SAVELLA TITRATION PACK 34 selegiline hcl 16 RETROVIR IV INFUSION 10 selenium sulfide 25 SEREVENT DISKUS 38 ribasphere 10 ribasphere ribapak 10 ribavirin 10 sertraline hcl 22 sharobel 35 rifabutin 11 rifampin 11 sildenafil 38 silver sulfadiazine 25 riluzole 28 rimantadine hcl 10 ringers injection 39 simvastatin 25 ringers irrigation 27 sirolimus 14 risedronate sodium 34 sodium chloride 28, 39 RISPERDAL CONSTA 21 sodium chloride 0.45% viaflex 39 risperidone 21 sodium chloride 0.9% 28 risperidone odt 21 sodium fluoride 40 sodium lactate 39 rivastigmine tartrate 16 sodium phenylbutyrate 28 rizatriptan benzoate 16 sodium polystyrene sulfonate 28 rizatriptan benzoate odt 16 sodium sulfacetamide 37 ropinirole er 16 ropinirole hcl 16 SORIATANE 25 sorine 22 sotalol hcl 22 sotalol hcl (af) 22 spinosad 27 SPIRIVA HANDIHALER 38 spironolactone 24 T
spironolactone/hydrochlorothiazide 24 SPORANOX 9 sprintec 28 35 tacrolimus 14 sronyx 35 tamoxifen citrate 14 stavudine 10 tamsulosin hcl 38 sterile water irrigation 28 STREPTOMYCIN SULFATE 11 taztia xt 24 TECFIDERA STARTER PACK 16 sucralfate 32 sulfacetamide sodium 26, 37 telmisartan 24 sulfacetamide sodium/prednisolone sodium telmisartan/amlodipine 24 phosphate 37 telmisartan/hydrochlorothiazide 24 sulfadiazine 12 temazepam 22 sulfamethoxazole/trimethoprim 12 terazosin hcl 24 sulfamethoxazole/trimethoprim ds 12 terbinafine hcl 9 terbutaline sulfate 38 sulfasalazine 32 terconazole 35 sulfazine ec 32 testosterone cypionate 31 sulindac 18 testosterone enanthate 31 sumatriptan 16 tetanus toxoid adsorbed 34 sumatriptan succinate 16 ADSORBED ADULT 34 theophylline 38 theophylline cr 38 theophylline er 38 thioridazine hcl 22 SYMLINPEN 120 30 thiothixene 22 TRELSTAR MIXJECT 15 tretinoin 15, 26 triamcinolone acetonide 27, 28, 38 tiagabine hydrochloride 16 triamcinolone in orabase 28 triamterene/hydrochlorothiazide 24 timolol maleate 24, 36 triderm 27 timolol maleate ophthalmic gel forming 36 trifluoperazine hcl 22 tinidazole 11 trifluridine 36 trihexyphenidyl hcl 16 tizanidine hcl 17 tri-legest fe 35 trilyte 32 tobramycin 11 trimethobenzamide hcl 32 tobramycin sulfate 11, 36 trimethoprim 12 tobramycin sulfate/sodium chloride 11 trimipramine maleate 22 tobramycin/dexamethasone 36 trinessa 35 tolazamide 30 tri-previfem 35 tolbutamide 30 tolmetin sodium 18 tri-sprintec 35 tolterodine tartrate 38 trivora-28 35 tolterodine tartrate er 38 topiramate 16 toposar 15 trospium chloride 38 topotecan hcl 15 trospium chloride er 38 torsemide 24 TUDORZA PRESSAIR 38 tramadol hcl 18 tramadol hcl er 18 tramadol hydrochloride/acetaminophen 18 trandolapril 24 tranexamic acid 24, 35 tranylcypromine sulfate 22 TYZINE PEDIATRIC NASAL DROPS 28 travasol 40 U
travoprost 36 trazodone hcl 22 unithroid 31 TRELSTAR DEPOT 15 ursodiol 32 TRELSTAR DEPOT MIXJECT 15 V
TRELSTAR LA MIXJECT 15 valacyclovir hcl 10 valproate sodium 16 valproic acid 16 voriconazole 9 valsartan 24 valsartan/hydrochlorothiazide 24 vancomycin hcl 12 vyfemla 35 vandazole 35 W
VAQTA 34 VARIVAX 34 warfarin sodium 24 X
velivet 35 venlafaxine hcl 22 venlafaxine hcl er 22 verapamil hcl 24 verapamil hcl er 24 verapamil hcl sr 24 veripred 20 28 xulane 35 vestura 35 VFEND 9 V-GO 20 30 Y
vicodin 18 Z
vicodin es 18 vicodin hp 18 zafirlukast 38 zaleplon 22 VIDEX PEDIATRIC 10 zamicet 18 vinblastine sulfate 15 zazole 35 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 zenchent 35 zenchent fe 36 zenzedi 22 zidovudine 10 zovia 1/35e 36 ziprasidone hcl 22 zovia 1/50e 36 zoledronic acid 28, 31 zolmitriptan 16 zolmitriptan odt 16 zolpidem tartrate 22 zolpidem tartrate er 22 zonisamide 16 This abridged formulary was updated on 11/01/2014 and is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact GlobalHealth Medicare Member Services, at (866) 844-0151 or, for TTY users, (800) 899-2114, 24 hours a day, 7 days a week, 365 days a year, or visit

GlobalHealth is an HMO with a Medicare contract. Enrollment in GlobalHealth Medicare (HMO) depends on contract renewal. Mailing address:
GlobalHealth Medicare Oklahoma City, OK 73101-2328 Customer care:
866 844 0151 (tty/tdd 800 899 2114) Date last updated: 11/01/2014 Effective date: 1/1/2014


Ramadan health guide

FASTING is complete abstinence from food and drink between dawn and dusk. All those who are ill or frail, pregnant or menstruating women, breastfeeding mothers and travellers are exempted. They are required to make up the number of days missed at a later date or give a fixed sum to charity. Page 4 Acknowledgements and useful contacts Page 5 Introduction


Cosmetic Special Topic Textured-Surface Saline-Filled Silicone BreastImplants for Augmentation Mammaplasty Scott L. Spear, M.D., Mohamed Elmaraghy, M.D., and Christopher Hess, M.D. Washington, D.C. The earliest silicone breast implants were smooth-sur- sues include but are not necessarily limited to face, silicone rubber devices filled with either silicone gel