Acne Agents, Oral (Tetracyclines) Acne Agents, Topical Adoxa CK Adoxa TT Doryx Nutridox Oracea Solodyn Vibramycin Suspension Acanya Aczone Akne-mycin Atralin Avar, Avar-E Azelex Benzac Benzaclin Benzagel Benzamycin Benzashave Benziq Brevoxyl Breze Benzefoam Clarifoam EF Clinac BPO Clindagel Clindareach Differin Duac Epiduo Evoclin Inova Demeclocycline Doxycycline Hyclate Doxycycline Hyclate DR Doxycycline Monohydrate Minocycline Minocycline ER Minocycline Tablets Tetracycline Benzoyl Peroxide OTC Benzoyl Peroxide Rx Clindamycin Clindamycin-Benzoyl Peroxide Erythromycin Erythromycin/Benzoyl Peroxide Sodium Sulfa/Sulfur/ Meratan Sulfacetamide Sulfacetamide/Sulfur Tretinoin 1 Effective August 8, 2011
Analgesics, Narcotic - Long Acting Analgesics, Narcotic - Short Acting Klaron Lavoclen Neobenz Micro Nuox Ovace, Ovace Plus Plexion Prascion Retin-A Retin-A-Micro Rosac Rosaderm Rosanil Rosula, Rosula CLK Soluclenz Sulfacet-R Sulfatol, Sulfatol-M Sulfoxyl Suphera Tazorac Topisulf Triaz Zaclir Z-Clinz Zetacet Ziana Zoderm Avinza Butrans (transdermal) Dolophine Duragesic Embeda Exalgo Kadian Methadose MS Contin Opana ER Ryzolt Oxycontin Ultram ER Fentanyl (transdermal) Methadone Morphine ER Oxycodone ER Tramadol ER ASA/Codeine APAP/Codeine Butalbital Compound w/codeine Butorphanol Tartrate (nasal) Codeine 2 Effective August 8, 2011
Actiq Abstral Combunox Darvocet Darvon Dazidox Demerol Dilaudid Liquid Ibudone Nucynta Onsolis Fentora Opana IR Fioricet/Codeine Fiorinal/Codeine Levo-Dromoran Oxyir Panlor DC/SS Percocet Percodan Phrenilin/Caffeine/ Codeine Reprexain Rybix ODT Roxanol Synalgos-DC Talacen Talwin Nx Tylenol with Codeine Ultracet Ultram Dihydrocodeine/APAP/ Caffeine Fentanyl (buccal) Hydrocodone/APAP Hydrocodone/Ibuprofen Hydromorphone Levorphanol Meperidine Morphine IR Oxycodone IR Oxycodone/APAP Oxycodone/ASA Oxycodone/Ibuprofen Pentazocine/APAP Pentazocine/Naloxone Propoxyphene Propoxyphene/APAP Propoxyphene Compound Tramadol Tramadol/APAP Trezix 3 Effective August 8, 2011
Androgenic Agents Angiotensin Modulators Vicodin Vicoprofen Zamicet Zolvit Androderm Androgel Fortesta Testim Accupril, Accuretic Aceon Altace Atacand, Atacand HCT Avapro, Avalide Benicar, Benicar HCT Capoten, Capozide Cozaar, Hyzaar Diovan, Diovan HCT Lotensin, Lotensin HCT Benazepril, Benazepril HCTZ Captopril, Captopril HCTZ Enalapril, Enalapril HCTZ Fosinopril, Fosinopril HCTZ Lisinopril, Lisinopril HCTZ Losartan, Losartan HCTZ Moexipril, Moexepril HCTZ Quinapril, Quinapril HCTZ Ramipril Trandolapril Mavik Micardis, Micardis HCT Prinivil, Prinzide Tekturna, Tekturna HCT Angiotensin Modulators / CCB Combinations Antibiotics, GI Teveten, Teveten HCT Univasc, Uniretic Vasotec, Vaseretic Zestril, Zestoretic Azor Exforge, Exforge HCT Lotrel Tarka Twynsta Valturna Alinia Amlodipine/Benazepril Metronidazole Neomycin Tinidazole 4 Effective August 8, 2011
Antibiotics, Inhaled Antibiotics, Topical Antibiotics, Vaginal Anticoagulants Antiemetics/ Antivertigo Agents Flagyl Flagyl ER Mycifradin Tindamax Vancocin ifaxan Cayston Tobi Altabax Bactroban Cream Bactroban Ointment Centany Cleocin Cream Cleocin Ovules Clindesse Metrogel-Vaginal Vandazole Arixtra Fragmin Innohep Lovenox Pradaxa Aloxi (Intravenous) Anzemet Anzemet (Intravenous) Bacitracin Bacitracin/Polymyxin Gentamicin Sulfate Mupirocin Clindamycin Metronidazole Warfarin Dimenhydrinate (Injection) Dronabinol Granisetron Granisetron (Intravenous) Meclizine Metoclopramide Metoclopramide (Injection) Motion Sickness OTC Ondansetron / ODT Ondansetron (Intravenous) Prochlorperazine Prochlorperazine (Injection) Prochlorperazine (Rectal) Promethazine Promethazine (Injection) Promethazine (Rectal) Trimethobenzamide Trimethobenzamide (Intramuscular) 5 Effective August 8, 2011
Antifungals, Oral Antifungals, Topical Cesamet Emend Emend (Intravenous) Marinol Metozolv ODT Sancuso (Transdermal) Scopace Transderm-Scop (Transdermal) Ancobon Grifulvin V Gris-Peg Lamisil Granules Noxafil Oravig Terbinex Vfend Clotrimazole Mucous Mem Fluconazole Griseofulvin Suspension Itraconazole Ketoconazole Nystatin Terbinafine Ciclopirox CR / Susp / Gel Ciclopirox Shampoo Ciclopirox Solution Clotrimazole OTC Clotrimazole R Clotrimazole-Betamethasone Antimigraine Agents, Bensal HP CNL 8 Ertaczo Exelderm Extina Lamisil Solution Mentax Naftin Oxistat Vusion olegel Econazole Ketoconazole Ketoconazole Shampoo Miconazole OTC Nystatin Nystatin-Triamcinolone Terbinafine OTC Tolnaftate OTC Sumatriptan 6 Effective August 8, 2011
Triptans Antiparasitics, Topical Antivirals, Oral Antivirals, Topical Beta-Blockers Amerge Axert Frova Imitrex Maxalt, Maxalt MLT Relpax Treximet Zomig, Zomig ZMT Eurax Lindane Ovide Ulesfia Relenza Tamiflu Valtrex Abreva Denavir Zovirax Cream Zovirax Ointment Betapace Bystolic Coreg Coreg CR Corgard Inderal, Inderal LA Innopran L Kerlone Levatol Lopressor Sectral Tenormin Malathion Permethrin Permethrin OTC Acyclovir Amantadine Famciclovir Rimantadine Valacyclovir Acebutolol Atenolol Betaxolol Bisoprolol Carvedilol Labetalol Metoprolol Nadolol Pindolol Propranolol Sotalol Timolol 7 Effective August 8, 2011
Bladder Relaxant Preparations Bone Resorption Suppression and Related Agents BPH Treatment Calcium Channel Blockers Toprol L Trandate Zebeta Detrol Detrol LA Ditropan Ditropan L Enablex Gelnique Oxytrol Sanctura, Sanctura R Toviaz Vesicare Actonel Actionel w/ Calcium Boniva Boniva (Intravenous) Didronel Evista Forteo (Subcutaneous) Fortical (Nasal) Fosamax Plus D Fosamax Solution Miacalcin (Injection) Miacalcin (Nasal) Reclast (Intravenous) geva (Sub-Q) Zometa (Intravenous) Avodart Cardura, Cardura L Flomax Hytrin Jalyn Proscar Rapaflo Uroxatral Oxybutynin Oxybutynin ER Alendronate Tablets Calcitonin Salmon (Nasal) Etidronate Disodium Pamidronate Disodium (Intravenous) Doxazosin Finasteride Terazosin Amlodipine Diltiazem, Diltiazem SR Felodipine ER Isradipine Nicardipine 8 Effective August 8, 2011
Cephalosporins and Related Antibiotics Colony Stimulating Factors Contraceptives, Oral Adalat, Adalat CC Calan, Calan SR Cardene, Cardene SR Cardizem, Cardizem CD, Cardizem SR Cardizem LA Covera-HS Dynacirc Dynacirc CR Isoptin, Isoptin SR Norvasc Plendil Procardia, Procardia L Sular Tiazac Vascor Verelan Verelan PM Augmentin 125 Suspension Augmentin 250 Suspension Augmentin R Cedax Ceftin Suspension Suprax Leukine Neulasta Neupogen Nifedipine, Nifedipine ER Nimodipine Nisoldipine Verapamil, Verapamil SR Verapamil ER PM Amoxicillin / Clav Suspension Amoxicillin / Clav Tablet Amoxicillin / Clav R Cefaclor Cefadroxil Cefdinir capsules Cefdinir suspension Cefditoren Cefpodoxime Cefprozil Cefuroxime Cephalexin Apri Aranelle Aviane 9 Effective August 8, 2011
Beyaz Brevicon 28 Cesia Cyclessa Desogen Enpresse-28 Estrostep FE-28 Femcon FE Heather Jolessa Jolivette Leena Azurette Balziva Camila Caziant Cryselle Cyclafem Errin Gianvi Gildess FE Introvale Junel Junel FE Kariva Kelnor 1-35 Lessina Levora-28 Low-Ogestrel Lutera Microgestin Microgestin FE Norethindrone Norgestrel-Ethinyl Estra Nortrel Ovcon-35 Portia Previfem Quasense Reclipsen Sprintec Sronyx Tilia FE Tri-Legest FE Trinessa Tri-Previfem Tri-Sprintec Velivet Zarah Zenchent Zovia 1-35E Zovia 1-50E 10 Effective August 8, 2011
Diabetic Meters Diabetic Strips Levlen 28 Lo Loestrin FE Loestrin Loestrin 24 FE Loestrin FE Lo-Ovral-28 Loseasonique Lybel Micronor Mircette Modicon Mononessa Natazia Necon Nora-Be Nordette-28 Norinyl 1+35 Norinyl 1+50 Nor-Q-D Ocella Ogestrel Ortho Cyclen Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ortho-Cept Ortho-Novum Ovcon-50 Safyral Seasonale Seasonique Solia Tri-Norinyl Trivora-28 Yasmin 28 Abbott Agamatrix Arkray Bayer Becton Dickinson CCS Envision HMD Home Diagnostics Lifescan Roche Therasense Truetrack US Diagnostics Vertex Abbott Agamatrix Arkray 11 Effective August 8, 2011
Erythropoiesis Stimulating Proteins Fluoroquinolones, Oral Growth Hormones Hepatitis C Agents HIV/AIDS Bayer Becton Dickinson CCS Medical Diabetic Supply Dispense Express Home Diagnostics Lifescan Medisense Roche Solartek US Diagnostics Therasense Aranesp Epogen Procrit Avelox Cipro Suspension Factive Levaquin Noroxin Proquin R Genotropin Humatrope Norditropin Nutropin Nutropin AQ Omnitrope Saizen Serostim Tev-tropin Zorbtive Copegus Infergen Pegasys Peg-Intron Rebetol Aptivus Atripla Combivir Crixivan Emtriva Epivir Epzicom Fuzeon (Injection) Ciprofloxacin ER Ciprofloxacin Tablets Ofloxacin Ribavirin Didanosine Stavudine Zidovudine 12 Effective August 8, 2011
Hypoglycemics, Incretin Mimetics/ Enhancers Intelence Invirase Isentress Kaletra Lexiva Norvir Prezista Rescriptor Retrovir Reyataz Selzentry Sustiva Trizivir Truvada Videx Videx EC Viracept Viramune Viramune R Viread Zerit Ziagan Byetta Pens (Subcutaneous) Janumet Januvia Kombiglyze R Onglyza Symlin (Subcutaneous) Symlin Pens (Subcutaneous) Victoza (Subcutaneous) Hypoglycemics, Insulin Apidra Apidra Pens Humalog Humalog Mix Humalog Mix Pens Humalog Pens Humulin Humulin Pens Lantus Lantus Pens Levemir Levemir Pens Novolin Novolin Pens Novolog Novolog Mix 70/30 Novolog Mix 70/30 Pens 13 Effective August 8, 2011
Hypoglycemics, Meglitinides Hypoglycemics, TZDs Immunosuppressive, Oral Lipotropics, Other Lipotropics, Statins Novolog Pens Nateglinide Prandimet Prandin Starlix Actoplus Met Actoplus Met R Actos Avandamet Avandia Avandryl Duetact Azasan Cellcept Gengraf Myfortic Neoral Prograf Rapamune Sandimmune Antara Colestid Fenoglide Fibricor Lofibra Lipofen Lopid Lovaza Niacor Niaspan Questran Tricor Triglide Trilipix Welchol Zetia Advicor Altoprev Azathrioprine Cyclosporine Cyclosporine, Modified Mycophenolate Mofetil Tacrolimus Cholestyramine Colestipol Fenofibrate Gemfibrozil Niacin Lovastatin Pravastatin Simvastatin 14 Effective August 8, 2011
Macrolides/ Ketolides Multiple Sclerosis Agents Opiate Dependence Treatments PAH Agents, Oral Pancreatic Enzymes Phosphate Binders Platelet Aggregation Inhibitors Prenatal Vitamins Caduet Crestor Lescol, Lescol L Lipitor Mevacor Pravachol Simcor Vytorin Zocor Ketek Zmax Avonex Ampyra Betaseron Copaxone Gilenya Extavia Rebif Suboxone Film Suboxone Tablets Subutex Vivitrol Adcirca Letairis Revatio Tracleer Tyvaso Ventavis Creon Pancreaze Zenpep Eliphos Fosrenol PhosLo Renagel Renvela Aggrenox Effient Plavix Ticlid Azithromycin Clarithromycin Clarithromycin ER Buprenorphine HCL Pancrelipase Calcium acetate Dipyridamole Ticlopidine Advanced Care Plus Cavan One Omega Cavan-Alpha Kit 15 Effective August 8, 2011
Cavan-EC Sod DHA Cavan-Heme Omega Combi R Co-Natal FA Daily Prenatal Combo Docosavit Dualvit OB Edge OB Elite-OB 400 FE C Folbecal Folinatal Plus B Folivane-EC Calcium DHA NF Folivane-OB Folivane-PR DHA NF Foltabs Foltabs Prenatal Plus DHA Icar-C Plus Inatal Advance Inatal Ultra Maternity Multinatal Plus Neevo Neevo DHA Nutrispire OB + DHA OB-Natal One PNV-DHA PNV-DHA + Docusate PNV-Select PNV-Total PR Natal 430 PR Natal 430 EC PR Natal 440 EC Prenaplus Prenatabs R Prenatal Prenatal 19 Prenatal AD Prenatal Low Iron Prenatal MR 90 FE Prenatal Multivitamin w/ Iron Prenatal Plus Prenatal Plus Iron Prenatal S OTC Prenatal Vitamins OTC Prenate Plus Prenexa Previte R Pruet DHA Pruet DHA EC 16 Effective August 8, 2011
Citranatal 90 DHA Citranatal Assure Citranatal B-Calm Citranatal DHA Citranatal Harmony Citranatal R Complete Natal DHA Completenate Complete-RF Prenatal RE-Nata 29 RE-Nata 29 OB SE-Care SE-Care Conceive SE-Care Gesture Select-OB SE-Natal 19 SE-Natal 90 SE-Natal One SE-Plete DHA SE-Tan DHA Setonet Setonet-EC Taron-C DHA Taron-EC Cal Tri R Triadvance Tricare Trimesis R Triveen-PR RNF Ultimatecare One Ultimatecare One NF Vemavite-PR 2 Venatal-FA Vinacal Vinate C Vinate Care Vinate IC Vinate One Vinate PN Care Vinate Ultra Vinate-M Vitanatal OB + DHA Vitaphil Vitaphil + DHA Vitaspire Vol-Nate Vol-Plus Vol-Tab Rx Zatean-CH Zatean-PN Zatean-PN DHA Zatean-PN Plus 17 Effective August 8, 2011
Concept DHA Concept OB Corenate-DHA Duet DHA Duet DHA Balanced Duet DHA Complete Duet DHA EC Duet DHA with Ferrazone Duet Stuartnatal ED Cyte F Elite OB DHA Elite-OB Femecal OB Folcal DHA Folcaps Care One Folcaps Omega-3 Gesticare Gesticare DHA Icar-C Plus SR Inatal GT Infanate DHA Lactocal-F Marnatal-F Maxinate Mission Prenatal FA OTC Mission Prenatal HP OTC Mission Prenatal OTC Multi-Nate 30 DHA Multi-Nate DHA Extra M-Vit Natachew Natafort Natalvit Natelle One Natelle-EZ Navatab + DHA Nexa Select OB 90 + DHA OB Complete OB Complete 400 OB Complete Chewable OB Complete DHA OB Complete One OB Complete Premier O-Cal FA O-Cal Prenatal Paire OB Plus DHA PNV-DHA Plus PNV-Iron 18 Effective August 8, 2011
Proton Pump Inhibitors PNV-Omega Poly Iron PN Poly Iron PN Forte PR Natal 400 PR Natal 400 EC Prefera OB Prefera-OB One Prefera-OB Plus DHA Prenafirst Prenatabs FA Prenatal-U Prenate DHA Prenate Elite Prenate Essential Prenavite OTC Prenexa Premier Preque 10 Renate DHA Rovin-NV Rovin-NV DHA Select-OB + DHA Tandem OB Taron EC Calcium Taron-BC Taron-Duo EC Taron-Prex Prenatal Tricare DHA Trinatal R 1 Trinate Triveen-Duo DHA Triveen-One Triveen-Ten Triveen-U Trust Natal DHA Ultimatecare Advantage Ultimatecare Combo Vinate AZ Vinate AZ Extra Vinate Calcium Vinate GT Vinate II Vitafol-OB Vitafol-OB+DHA Vitafol-PN Viva DHA Aciphex Nexium Kapidex Lansoprazole Omeprazole OTC Omeprazole Rx Pantoprazole 19 Effective August 8, 2011
Skeletal Muscle Relaxants Ulcerative Colitis Agents Nexium Suspension Prevacid Capsules Prevacid Solutab Prilosec Prilosec OTC Prilosec Suspension Protonix Protonix Suspension Amrix Dantrium Fexmid Flexeril Norgesic Norgesic Forte Parafon Forte Robaxin, Robaxisal Skelaxin Soma, Soma Compound Zanaflex Apriso Asacol Asacol HD Azulfidine Canasa Colazal Dipentum Lialda Pentasa sfrowasa Baclofen Carisoprodol,Carisoprodol Compound Chlorzoxazone Cyclobenzaprine Dantrolene Sodium Methocarbamol Orphenadrine, Orphenadrine Compound Tizanidine Balsalazide Mesalamine (rectal) Sulfasalazine 20 Effective August 8, 2011