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Florida Medicaid Preferred Drug List (Updated 10/27/04) Excluding Injectibles The Florida Medicaid Preferred Drug List is subject to revision following consideration and recommendations by the Pharmacy and Therapeutics Committee and the Agency for Health Care Administration. The list is in order by the therapeutic classification. To locate a specific drug or therapeutic class, use the search or find feature available in Adobe Acrobat Reader. (Keyboard shortcut: CTRL+F) This is the updated list from the September 29, 2004, P&T Committee meeting. Additions to list are indicated in red. Deletions to the list are indicated with strickthrough. (* Cleanup of category) (** Change in Category) Therapeutic Classification A1A A1A A1B A1B A1B A1B A1B A1B A1B A1B A1B A1B A1B A1B A1B A1B A1D A1D A1D A1D A1D Drug Name A1A - DIGITALIS GLYCOSIDES DIGOXIN LANOXICAPS A1B - XANTHINES AEROLATE 111 AEROLATE JR AMINOPHYLLINE CAFCIT LUFYLLIN LUFYLLIN-400 QUIBRON-T QUIBRON-T/SR THEO-24 THEOBID THEOPHYLLINE THEOPHYLLINE ANHYDROUS UNI-DUR UNIPHYL A1D - GENERAL BRONCHODILATOR AGENTS ATROVENT BRONDELATE IPRATROPIUM BROMIDE QUIBRON QUIBRON-300 -1- Date Effective Therapeutic Classification A2A A2A A2A A2A A2A A2A A2A A2A A2A A2A A2A A4A A4A A4A A4A A4A A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4B A4D A4D A4D A4D A4D A4D Drug Name A2A - ANTIARRHYTHMICS AMIODARONE HCL DISOPYRAMIDE PHOSPHATE ETHMOZINE MEXILETINE HCL PROCAINAMIDE HCL PROPAFENONE HCL QUINIDINE GLUCONATE QUINIDINE SULFATE TAMBOCOR TIKOSYN TONOCARD A4A - HYPOTENSIVES, VASODILATORS HCTZ/RESERPINE/HYDRALAZINE HYDRALAZINE HCL HYDRALAZINE W/HCTZ MINODIXIL MINOXIDIL A4B - HYPOTENSIVES, SYMPATHOLYTIC CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 CLONIDINE HCL CLONIDINE HCL W/CHLORTHALIDONE ENDURONYL ENDURONYL FORTE GUANABENZ ACETATE GUANFACINE HCL ISMELIN METHYLDOPA METHYLDOPA/HYDROCHLOROTHIAZIDE RAUWOLFIA/BENDROFLUMETHIAZIDE RESERPINE RESERPINE/HYDROCLOROTHIAZIDE SALUTENSIN SALUTENSIN-DEMI TENEX WYTENSIN A4D - HYPOTENSIVES, ACE BLOCKING TYPE ACCUPRIL ACCURETIC ACEON ALTACE BENAZEPRIL HCL BENAZEPRIL HCL-HCTZ -2- Date Effective 10/12/04* 10/12/04* 10/12/04* Therapeutic Classification A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D A4D Date Effective Drug Name CAPTOPRIL CAPTOPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL MALEATE ENALAPRIL MALEATE/HCTZ FOSINOPRIL SODIUM 10/12/04 LISINOPRIL 10/12/04* LISINOPRIL-HCTZ 10/12/04* 10/12/04* LOTENSIN LOTENSIN HCT 10/12/04* 10/12/04** LOTREL MAVIK MOEXIPRIL HCL MONOPRIL HCT 10/12/04 PRINIVIL 10/12/04* QUINARETIC 10/12/04* PRINZIDE 10/12/04* TARKA 10/12/04** UNIRETIC VASERETIC 10/12/04* VASOTEC 10/12/04* ZESTRIL 10/12/04* ZESTORETIC 10/12/04* A4F - HYPOTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST AVALIDE A4F AVAPRO A4F BENICAR A4F BENICAR HCT A4F COZAAR A4F DIOVAN A4F DIOVAN HCT A4F HYZAAR A4F MICARDIS A4F MICARDIS HCT A4F TEVETEN A4F TEVETEN HCT A4F A4K - ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION LEXXEL A4K LOTREL 10/12/04** A4K TARKA 10/12/04** A4K A4Y - HYPOTENSIVES, MISCELLANEOUS ATENOLOL W/CHLORTHALIDONE A4Y BISOPROLOL FUMARATE/HCTZ A4Y CORZIDE A4Y LOPRESSOR HCT A4Y -3- Therapeutic Classification A4Y A4Y A7B A7B A7B A7B A7B A7B A7B A7B A7C A7C A7C A7C A7C A9A A9A A9A A9A A9A A9A A9A A9A A9A A9A A9A A9A A9A A9A B0A B3A B3A B3J B3J B3J B3J B3J B3J Drug Name PROPRANOLOL HCL W/HCTZ ZIAC A7B - VASODILATORS, CORONARY AMYL NITRITE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE NITROGLYCERIN NITROGLYCERIN TRANSDERMAL NITROL NITROLINGUAL NITROSTAT A7C - VASODILATORS, PERIPHERAL ERGOLOID MESYLATES ETHAVERINE HCL HYDERGINE LC ISOXSUPRINE HCL PAPAVERINE HCL A9A - CALCIUM CHANNEL BLOCKING AGENTS CARDIZEM LA COVERA-HS DILTIAZEM HCL DILTIAZEM XR DYNACIRC DYNACIRC CR NICARDIPINE HCL NIFEDIPINE NIFEDIPINE ER NORVASC PLENDIL SULAR VERELAN PM VERAPAMIL HCL B0A - GENERAL INHALATION AGENTS SODIUM CHLORIDE B3A - MUCOLYTICS ACETYLCYSTEINE PULMOZYME B3J - EXPECTORANTS DESPEC GUAIFENESIN GUAIFENESIN ER GUAIFENESIN LA GUAIFENESIN NR GUAIFENESIN SR C0B - WATER -4- Date Effective 10/12/04 10/12/04 10/12/04 Therapeutic Classification C0B C0B C0D C0D C1A C1A C1D C1D C1D C1D C1D C1D C1D C1D C1D C1D C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3B C3H C3H C4G C4G C4G C4G C4G Drug Name WATER WATER FOR INHALATION C0D - ANTI-ALCOHOLIC PREPARATIONS ANTABUSE DISULFIRAM C1A - ELECTROLYTE DEPLETERS PHOSLO SODIUM POLYSTYRENE SULFONATE C1D - POTASSIUM REPLACEMENT K-DUR K-LYTE KAON KAON-CL KLORVESS POTASSIUM POTASSIUM BICARBONATE POTASSIUM CHLORIDE POTASSIUM GLUCONATE SLOW-K C3B - IRON REPLACEMENT B-COMPLEX LIVER/IRON B-COMPLEX W/IRON CALCIUM CARBONATE/VIT D & IRON CALCIUM W/VITAMIN D & IRON CARBONYL IRON FERRONATE FERROUS FUMARATE W/DOCUSATE FERROUS GLUCONATE FERROUS SULFATE HM IRON IRON IRON W/VITAMIN C & B COMPLEX POLYSACCHARIDE IRON POLYSACCHARIDE-IRON RA FERROUS GLUCONATE V-R FERROUS SULFATE C3H - IODINE CONTAINING AGENTS POTASSIUM IODIDE SSKI C4G - INSULINS LANTUS NOVOLIN 70/30 NOVOLOG MIX 70/30 NOVOLIN L NOVOLIN N -5- Date Effective 12/19/03 Therapeutic Date Drug Name Classification Effective NOVOLIN R C4G NOVOLOG C4G RELION 70/30 C4G RELION N C4G RELION R C4G C4K - HYPOGLYCEMICS, INSULIN-RELEASE STIMULANT TYPE ACETOHEXAMIDE C4K AMARYL C4K CHLORPROPAMIDE C4K GLIPIZIDE C4K GLUCOTROL XL C4K GLUCOVANCE 10/12/04* C4K GLYBURIDE C4K GLYBURIDE-METFORMIN HCL 10/12/04* C4K GLYBURIDE MICRONIZED C4K METAGLIP C4K PRANDIN 10/12/04 C4K STARLIX C4K TOLAZAMIDE C4K TOLBUTAMIDE C4K C4L - HYPOGLYCEMICS, BIGUANIDE TYPE (NON-SULFONYLUREAS) GLUCOPHAGE 10/12/04* C4L GLUCOPHAGE XR 10/12/04* C4L METFORMIN HCL 10/12/04* C4L METFORMIN HCL ER 10/12/04* C4L RIOMET 10/12/04 C4L C4M - HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIB TYPE (N-S) GLYSET C4M C4N - HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S) ACTOS C4N AVANDIA C4N C6D - VITAMIN D PREPARATIONS CALDEROL C6D DHT C6D HECTOROL C6D HYTAKEROL C6D ROCALTROL C6D C6F - PRENATAL VITAMIN PREPARATIONS PRENATAL 1 C6F PRENATAL 1/1 C6F PRENATAL 1MG AND IRON C6F PRENATAL 1MG PLUS IRON C6F PRENATAL W/FOLIC ACID C6F C6H - PEDIATRIC VITAMIN PREPARATIONS -6- Therapeutic Classification C6H C6H C6H C6H C6H C6H C6H C6H C6H C6H C6M C7A C7B C8A C8A C8A D1A D1D D1D D2A D2A D2A D2A D2A D2A D2A D2A D2A D2A D2A D2A D2A D2A D4E D4E Drug Name MULTI VIT W/FLUORIDE MULTI-VIT/IRON & FLOURIDE MULTI-VIT/IRON & FLUORIDE MULTI-VITA BETS W/FLUORIDE MULTIVITAMIN W/FLUORIDE MULTIVITAMIN W/FLUORIDE & IRON MULTIVITAMINS W/FLUORIDE MULTIVITAMINS/FLUORIDE/IRON POLYVITAMINS W/FLUORIDE TRI-VIT W/FLUORIDE & IRON C6M - FOLIC ACID PREPARATIONS FOLIC ACID C7A - PURINE INHIBITORS ALLOPURINOL C7B - DECARBOXYLASE INHIBITORS LODOSYN C8A - METALLIC POISON, AGENTS TO TREAT CHEMET CUPRIMINE DEPEN D1A - PERIODONTAL COLLAGENASE INHIBITORS PERIOSTAT D1D - DENTAL AIDS AND PREPARATIONS CHLORHEXIDINE GLUCONATE TRIAMCINOLONE ACETONIDE D2A - FLUORIDE PREPARATIONS FLO-GEL FLUOR-A-DAY FLURA FLURA-DROPS GEL-KAM JUST FOR KIDS LURIDE LURIDE-SF PEDIAFLOR PHOS-FLUR PREVIDENT PREVIDENT 5000 PLUS SODIUM FLUORIDE STANNOUS FLUORIDE D4E - ANTI-ULCER PREPARATIONS CYTOTEC SUCRALFATE D4F - ANTI-ULCER-H.PYLORI AGENTS -7- Date Effective Therapeutic Classification D4F D4F Drug Name Date Effective HELIDAC TRITEC D4G - GASTRIC ENZYMES KUTRASE ORAL MUCOSITIS/STOMATITIS AGENTS ORAMAGICRX 10/12/04 D4H D4K - GASTRIC ACID SECRETION REDUCERS CIMETIDINE D4K CIMETIDINE HCL D4K FAMOTIDINE D4K PREVACID D4K PRILOSEC OTC D4K PROTONIX (Effective January 1, 2004) D4K RANITIDINE HCL D4K D5A - WEIGHT LOSS XENICAL D5A D6D - ANTIDIARRHEALS DIPHENOXYLATE W/ATROPINE D6D LOPERAMIDE HCL D6D PAREGORIC D6D D6F - DRUG TX-CHRONIC INFLAM. COLON DX, 5-AMINOSALICYLAT ASACOL D6F COLAZAL D6F 7/13/04 DIPENTUM D6F PENTASA D6F 7/13/04 D6S - LAXATIVES AND CATHARTICS LACTULOSE D6S MIRALAX D6S PEG 3350/ELECTROLYTE D6S D7A - BILE SALTS URSODIOL D7A D7L - BILE SALT SEQUESTRANTS COLESTID D7L CHOLESTYRAMINE D7L CHOLESTYRAMINE LIGHT D7L D8A - PANCREATIC ENZYMES CREON 10 D8A CREON 20 D8A CREON 5 D8A ENZYMAX D8A KUTRASE D8A PANCREASE D8A PANCREASE MT 10 D8A PANCREASE MT 16 D8A PANCREASE MT 20 D8A D4G -8- Therapeutic Classification D8A D8A D8A D8A D8A D8A D8A D8A D8A D8A D8A F1A F1A F1A F1A F1A F1A F1A F1A F1A F1A F1A F1A F2A F2A F2A F2A F2A G1A G1A G1A G1A G1A G1A G1A G1A G1A G1A G1A G1A G1A G1A Drug Name PANCREASE MT 4 PANCRELIPASE PANCRELIPASE MT-16 PANCRECARB ULTRASE ULTRASE MT 12 ULTRASE MT 18 ULTRASE MT 20 ULTRASE MT 6 VIOKASE ZYMASE F1A - ANDROGENIC AGENTS ANDRODERM ANDROID ANDROGEL FIRST-TESTOSTERONE FLUOXYMESTERONE HALOTESTIN METHYLTESTOSTERONE OXANDRIN TESTIM TESTODERM TESTRED WINSTROL F2A - DRUGS TO TREAT IMPOTENCY CAVERJECT EDEX LEVITRA MUSE VIAGRA G1A - ESTROGENIC AGENTS ACTIVELLA CENESTIN CLIMARA COMBIPATCH ESCLIM ESTINYL ESTRADERM ESTRADIOL ESTRADIOL TRANSDERMAL PATCH ESTROPIPATE FEMHRT MENEST ORTHO-PREFEST PREMARIN -9- Date Effective 12/19/03 12/19/03 Therapeutic Classification G1A G1A G1A G2A G2A G2A G2A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A Drug Name PREMPHASE PREMPRO VIVELLE G2A - PROGESTATIONAL AGENTS AYGESTIN MEDROXYPROGESTERONE ACETATE NORETHINDRONE ACETATE PROMETRIUM G8A - CONTRACEPTIVES, ORAL ALESSE-21 ALESSE-28 APRI ARANELLE AVIANE BREVICON CAMILA CESIA CRYSELLE CYCLESSA DEMULEN 1/35-21 DEMULEN 1/35-28 DEMULEN 1/50-21 DEMULEN 1/50-28 DESOGEN DESOGESTREL/ETHINYL ESTRADIOL ENPRESSE ERRIN ESTROSTEP FE GENORA GENORA 1/50 JENEST-28 JOLIVETTE JUNEL JUNEL FE KARIVA LESSINA LEVLEN 21 LEVLEN 28 LEVLITE-21 LEVLITE-28 LEVORA-21 LEVORA-28 LO/OVRAL-21 LO/OVRAL-28 LOESTRIN -10- Date Effective Therapeutic Classification G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A G8A Drug Name LOESTRIN FE LOW-OGESTREL MICROGESTIN MICROGESTIN FE MICRONOR MIRCETTE MODICON MONONESSA NECON NELOVA NELOVA 1/50 NORA-BE NORDETTE-21 NORDETTE-28 NORINYL 1+35 NORINYL 1+50 NOR-Q-D NORTREL OGESTREL ORTHO MICRONOR ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CEPT ORTHO-CYCLEN ORTHO-NOVUM OVCON-35 OVCON-50 OVRAL-28 OVRETTE PORTIA PREVEN PREVIFEM SEASONALE SOLIA SPRINTEC TRI-LEVLEN TRI-LEVLEN 21 TRI-LEVLEN 28 TRINESSA TRI-NORINYL TRIPHASIL-21 TRIPHASIL-28 TRI-PREVIFEM TRI-SPRINTEC TRIVORA-28 -11- Date Effective Therapeutic Classification G8A G8A G8A G8A Drug Name Date Effective VELIVET YASMIN 28 ZOVIA 1/35E ZOVIA 1/50E G8C - CONTRACEPTIVES G8C G8C G8F G9B H0A H0A H0A H1A H2A H2A H2D H2D H2E H2E H2E H2E H2E H2E H2E H2E H2E H2F H2F H2F H2F H2F H2F H2F H2F H2F H2F H2F LUNELLE NUVARING G8F - CONTRACEPTIVES, TRANSDERMAL ORTHO EVRA G9B - CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC NUVARING VAGINAL RING H0A - LOCAL ANESTHETICS LIDOCAINE HCL LIDOCAINE HCL VISCOUS XYLOCAINE VISCOUS H1A - ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS NAMENDA H2A - CENTRAL NERVOUS SYSTEM STIMULANTS PEMADD PEMOLINE H2D - BARBITURATES BUTISOL SODIUM PHENOBARBITAL H2E - SEDATIVE-HYPNOTICS, NON-BARBITURATE AMBIEN CHLORAL HYDRATE ESTAZOLAM GLUTETHIMIDE LORAZEPAM PLACIDYL RESTORIL 7.5 MG TEMAZEPAM TRIAZOLAM H2F - ANTI-ANXIETY DRUGS ALPRAZOLAM BUSPAR BUSPIRONE HCL CHLORDIAZEPOXIDE HCL CLORAZEPATE DIPOTASSIUM DIAZEPAM LORAZEPAM MEPROBAMATE OXAZEPAM PAXIPAM TRANXENE SD -12- 12/19/03 ** ** 10/12/04 2/1/04 12/19/03 12/19/03 Therapeutic Classification H2F H2G H2G H2G H2G H2G H2G H2G H2G H2G H2G H2G H2M H2M H2M H2M H2M H2S H2S H2S H2S H2S H2S H2S H2S H2S H2S H2S H2S H2S H2U H2U H2U H2U H2U H2U H2U H2U H2U H2U Drug Name TRANXENE T-TAB H2G - ANTI-PSYCHOTICS, PHENOTHIAZINES CHLORPROMAZINE HCL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL MELLARIL-S PERPHENAZINE SERENTIL STELAZINE THIORIDAZINE HCL THORAZINE TRIFLUOPERAZINE HCL TRILAFON H2M - ANTI-MANIA DRUGS ESKALITH CR LITHIUM CARBONATE LITHIUM CITRATE LITHOBID LITHOTABS H2S - SEROTONIN SPECIFIC REUPTAKE INHIBITOR (SSRIS) CELEXA FLUOXETINE FLUOXETINE HCL FLUVOXAMINE MALEATE LEXAPRO PAROXETINE HCL PAXIL CR PAXIL PROZAC PROZAC WEEKLY SARAFEM SYNTHON ZOLOFT H2U - TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMITRIPTYLINE HCL AMOXAPINE CLOMIPRAMINE HCL DESIPRAMINE DESIPRAMINE HCL DOXEPIN HCL IMIPRAMINE HCL MAPROTILINE HCL NORTRIPTYLINE HCL PROTRIPTYLINE HCL -13- Date Effective * * * * Therapeutic Date Drug Name Classification Effective SINEQUAN H2U SURMONTIL H2U TOFRANIL H2U TOFRANIL-PM H2U VANATRIP H2U VIVACTIL H2U H2V - TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY CONCERTA H2V FOCALIN H2V METADATE CD H2V 12/19/03 METHYLPHENIDATE H2V METHYLPHENIDATE ER H2V METHYLPHENIDATE HCL H2V RITALIN LA H2V 12/19/03 H2W - TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS AMITRIPTYLINE W/PERPHENAZINE H2W TRIAVIL 10-2 H2W TRIAVIL 25-2 H2W TRIAVIL 25-4 H2W H2X - TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS AMITRIPTYLINE/CHLORDIAZEPOXIDE H2X H3A - ANALGESICS, NARCOTICS ACETAMINOPHEN W/CODEINE H3A ACETAMINOPHEN WITH CODEINE H3A ASPIRIN W/CODEINE H3A AVINZA H3A BELLADONNA & OPIUM H3A BUTALBITAL COMPOUND W/CODEINE H3A BUTALBITAL/CAFF/APAP/CODEINE H3A BUTORPHANOL TARTRATE H3A CAPITAL W/CODEINE H3A CO-GESIC H3A CODEINE SULFATE H3A DURAGESIC H3A 10/10/04 FIORICET W/CODEINE H3A HYDROCODONE W/ACETAMINOPHEN H3A HYDROCODONE W/ACETAMINOPHEN HS H3A HYDROCODONE/ACETAMINOPHEN H3A HYDROMORPHONE HCL H3A KADIAN H3A LEVO-DROMORAN H3A LEVORPHANOL TARTRATE H3A MEPERIDINE HCL H3A MEPERIDINE W/PROMETHAZINE H3A MEPERITAB H3A -14- Therapeutic Classification H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3A H3D H3D H3D H3D H3D H3D Drug Name METHADONE METHADONE HCL METHADONE INTENSOL MORPHINE SULFATE MORPHINE SULFATE IR MS/L OXYCODONE HCL OXYCODONE W/ACETAMINOPHEN OXYCODONE W/ASPIRIN OXYCODONE W/APAP PANLOR DC PANLOR SS PENTAZOCINE AND NALOXONE HCL PENTAZOCINE/ACETAMINOPHEN PERCODAN DEMI PERCOLONE PHENAPHEN W/CODEINE PROPOXYPHENE HCL PROPOXYPHENE HCL COMPOUND PROPOXYPHENE HCL W/APAP PROPOXYPHENE HCL/APAP PROPOXYPHENE NAPSYLATE W/APAP ROXICET ROXICODONE ROXICODONE INTENSOL SOMA COMPOUND W/CODEINE SYNALGOS-DC TALACEN TALWIN COMPOUND TALWIN NX TYLOX ULTRAM ULTRACET VICODIN VICODIN ES VICODIN HP VICOPROFEN WYGESIC H3D - ANALGESIC/ANTIPYRETICS, SALICYLATES BUTALBITAL COMPOUND CHOLINE MAG TRISALICYLATE DIFLUNISAL DISALCID SALSALATE TRILISATE -15- Date Effective 3/22/04 Therapeutic Classification H3E H3E H3E H3E H3E H3F H3F H3F H3F H3F H3F H3F H3H H3T H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B H4B Drug Name H3E - ANALGESIC/ANTIPYRETICS, NON-SALICYLATE ACETAMINOPHEN W/BUTALBITAL BUTALBITAL/APAP/CAFFEINE ESGIC PLUS RELAGESIC TENCON H3F - ANTIMIGRAINE PREPARATIONS AXERT IMITREX NASAL IMITREX ORAL MAXALT MAXALT MLT MIGRANAL RELPAX H3H - ANALGESICS NARCOTIC, ANESTHETIC ADJUNCT AGENTS FENTANYL ORALET H3T - NARCOTIC ANTAGONISTS NALTREXONE HYDROCHLORIDE H4B - ANTICONVULSANTS CARBAMAZEPINE CARBATROL CELONTIN CLONAZEPAM DEPAKOTE DEPAKOTE SPRINKLE DIASTAT DILANTIN DILANTIN-125 ETHOSUXIMIDE FELBATOL GABITRIL KEPPRA LAMICTAL MEBARAL MEPHOBARBITAL MESANTOIN NEURONTIN PARADIONE PEGANONE PHENYTOIN PHENYTOIN SODIUM PHENYTOIN SODIUM, EXTENDED PHENYTOIN SODIUM, EXTENDED PHENYTOIN SODIUM, EXTENDED -16- Date Effective 12/19/03 Therapeutic Classification H4B H4B H4B H4B H4B H4B H4B H6A H6A H6A H6A H6A H6A H6A H6A H6A H6A H6A H6A H6A H6A H6B H6B H6B H6C H6H H6H H6H H6H H6H H6H H6I H6J H6J H6J H6J H6J H6J Drug Name PRIMIDONE TEGRETOL XR TOPAMAX TRILEPTAL VALPROIC ACID ZARONTIN ZONEGRAN H6A - ANTIPARKINSONISM DRUGS, OTHER AMANTADINE HCL CARBIDOPA/LEVODOPA COMTAN LARODOPA MIRAPEX REQUIP SELEGILINE HCL SINEMET CR SINEMET-10/100 SINEMET-25/100 SINEMET-25/250 STALEVO 50 STALEVO 100 STALEVO 150 H6B - ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC AKINETON BENZTROPINE MESYLATE TRIHEXYPHENIDYL HCL H6C - ANTITUSSIVES, NON-NARCOTIC BENZONATATE H6H - SKELETAL MUSCLE RELAXANTS BACLOFEN CHLORZOXAZONE CYCLOBENZAPRINE HCL METHOCARBAMOL METHOCARBAMOL W/ASPIRIN SKELAXIN H6I - AMYOTROPHIC LATERAL SCLEROSIS AGENTS RILUTEK H6J - ANTIEMETIC/ANTIVERTIGO AGENTS DIMENHYDRINATE MARINOL MECLIZINE HCL PROCHLORPERAZINE PROCHLORPERAZINE MALEATE PROMETHAZINE HCL -17- Date Effective 3/22/04 5/28/04 3/22/04 3/22/04 3/22/04 Therapeutic Date Drug Name Classification Effective SCOPACE H6J TORECAN H6J TRANSDERM-SCOP H6J TRIMETHOBENZAMIDE HCL H6J TRIMETHOBENZAMIDE W/BENZOCAINE H6J ZOFRAN H6J H7B - ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE * H7B MIRTAZAPINE SOLTAB * H7B * REMERON H7B * REMERON SOLTAB H7B H7C - SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA * H7C EFFEXOR H7C EFFEXOR XR H7C H7D - NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL H7D BUPROPION SR * H7D * WELLBUTRIN H7D WELLBUTRIN SR * H7D WELLBUTRIN XL H7D 12/19/03 H7E - SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL * H7E SERZONE * H7E TRAZODONE H7E TRAZODONE HCL H7E H7J - MAOIS - NON-SELECTIVE & IRREVERSIBLE MARPLAN H7J NARDIL H7J PARNATE H7J H7N - SMOKING DETERRENTS, OTHER ZYBAN H7N H7O - ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, BUTYROPHENONES HALOPERIDOL H7O HALOPERIDOL LACTATE H7O H7P - ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, THIOXANTHENES THIOTHIXENE H7P THIOTHIXENE HCL H7P H7R - ANTIPSYCH, DOPAMINE ANTAG, DIPHENYLBUTYLPIPERIDINES ORAP H7R H7S - ANTIPSYCHOTICS, DOPAMINE ANTAGONST, DIHYDROINDOLONES MOBAN H7S -18- Therapeutic Date Drug Name Classification Effective H7T - ANTIPSYCHOTICS, ATYPICAL, DOPAMINE, & SEROTONIN ANTAG CLOZAPINE H7T FAZACLO * H7T GEODON H7T RISPERDAL H7T RISPERDAL CONSTA * H7T RISPERDAL ORAL SOLUTION H7T SEROQUEL H7T ZYPREXA H7T ZYPREXA ZYDIS H7T H7U - ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS LOXAPINE H7U LOXAPINE SUCCINATE H7U LOXITANE C H7U H7X - ANTIPSYCHOTICS, ATYPICAL, DOPAMINE PARTIAL AGONIST ABILIFY H7X H7Z - SSRI &ANTIPSYCH, ATYP, DOPAMINE & SEROTONIN ANTAG COMB SYMBYAX * H7Z J1A - PARASYMPATHETIC AGENTS BETHANECHOL CHLORIDE J1A EVOXAC J1A SALAGEN J1A J1B - CHOLINESTERASE INHIBITORS ARICEPT J1B EXELON J1B PROSTIGMIN J1B REMINYL J1B REMINYL LIQUID J1B J2A - BELLADONNA ALKALOIDS BELLADONNA W/PHENOBARBITAL J2A HYOSCYAMINE J2A HYOSCYAMINE SULFATE J2A J2B - ANTICHOLINERGICS, QUATERNARY AMMONIUM CANTIL J2B PROPANTHELINE BROMIDE J2B ROBINUL J2B ROBINUL FORTE J2B J2D - ANTICHOLINERGICS/ANTISPASMODICS DICYCLOMINE HCL J2D J3A - SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS) NICOTINE J3A NICOTINE TRANSDERMAL J3A NICOTROL J3A ZYBAN J3A -19- Therapeutic Classification Date Effective Drug Name J5B - ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL J5B ADDERALL XR J5B DEXTROAMPHETAMINE SULFATE J5B J5D - BETA-ADRENERGIC AGENTS ACCUNEB J5D ADVAIR (This drug has been moved to a new category.) 7/13/04 J5D ALBUTEROL J5D ALBUTEROL SULFATE J5D ALBUTEROLSULFATE J5D BRETHINE J5D COMBIVENT J5D FORADIL 3/22/04 J5D MAXAIR J5D 3/22/04 MAXAIR AUTOHALER J5D 3/22/04 METAPROTERENOL SULFATE J5D PROVENTIL HFA J5D SEREVENT DISKUS J5D TERBUTALINE SULFATE J5D VENTOLIN ROTACAPS J5D 3/22/04 VOLMAX J5D 3/22/04 XOPENEX J5D J5G - BETA-ADRENERGICS AND GLUCOCORTICOIDS COMBINATION ADVAIR DISKUS (This is not a new addition; just moving J5G 7/13/04 Advair from its old category to new category.) J5H - ADRENERGIC VASOPRESSOR AGENTS PROAMATINE J5H J7A - ALPHA/BETA-ADRENERGIC BLOCKING AGENTS COREG J7A LABETALOL HCL J7A J7B - ALPHA-ADRENERGIC BLOCKING AGENTS DIBENZYLINE J7B DOXAZOSIN MESYLATE J7B PRAZOSIN HCL J7B TERAZOSIN J7B TERAZOSIN HCL J7B J7C - BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL J7C ATENOLOL J7C BETAXOLOL HCL J7C BISOPROLOL FUMARATE J7C INDERAL LA J7C 7/13/04 INNOPRAN XL J7C 12/19/03 METOPROLOL TARTRATE J7C NADOLOL J7C -20- Therapeutic Classification J7C J7C J7C J7C J7C J7C J7C J7C J7E J7E J7E J9A L0B L0B L0B L0B L0B L1A L1A L1B L1D L2A L3A L5A L5E L5F L5F L5G L5G L5G L5G Drug Name PINDOLOL PROPRANOLOL HCL SOTALOL SOTALOL HCL TIMOLOL MALEATE TOPROL XL VISKEN ZEBETA J7E - ALPHA-ADRENERGIC BLOCKING AGENT/THIAZIDE COMB MINIZIDE 1 MINIZIDE 2 MINIZIDE 5 J9A - INTESTINAL MOTILITY STIMULANTS METOCLOPRAMIDE HCL L0B - TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES ACCUZYME PANAFIL PAPAIN-UREA-CHLOROPHYLLIN SANTYL XENADERM L1A - ANTIPSORIATIC AGENTS, SYSTEMIC OXSORALEN-ULTRA SORIATANE L1B - ACNE AGENTS, SYSTEMIC ACCUTANE L1D - HYPERPIGMENTATION AGENTS, SYSTEMIC TRISORALEN L2A - EMOLLIENTS LAC-HYDRIN L3A - PROTECTIVES RADIAPLEXRX L5A - KERATOLYTICS BENZOYL PEROXIDE L5E - ANTISEBORRHEIC AGENTS SELENIUM SULFIDE L5F - ANTIPSORIATICS AGENTS DOVONEX TAZORAC L5G - ROSACEA AGENTS, TOPICAL METROCREAM METROLOTION METROGEL NORITATE -21- Date Effective 7/13/04 7/13/04 10/12/04 10/12/04* 10/12/04* 10/12/04* 10/12/04* Therapeutic Classification L5H L5H L5H L5H L5H L5H L7A L9B L9B L9B L9B L9B L9D M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A Drug Name L5H - ACNE AGENTS, TOPICAL AZELEX DUAC METROCREAM METROGEL METROLOTION NORITATE L7A - SHAMPOOS/LOTION CAPITROL L9B - VITAMIN A DERIVATIVES AVITA DIFFERIN RETIN-A RETIN-A MICRO TRETINOIN L9D - TOPICAL HYPERPIGMENTATION AGENTS OXSORALEN M4A - BLOOD SUGAR DIAGNOSTICS ALBERTSONS TEST STRIP ASCENSIA AUTODISC ASCENSIA ELITE ASCENSIA MICROFILL B-D TEST STRIPS BLOOD GLUCOSE BLOOD GLUCOSE TEST BRITE LIFE TEST STRIP CVS TEST STRIP DISCOUNT DRUG MART DRUG EMP TEST STRIP DUANE READE TEST STRIPS ECKERD TEST STRIP FAST TAKE FREESTYLE FREESTYLE TEST STRIPS GLUCOMETER DEX GLUCOMETER ELITE GOOD NEIGH TEST STRIP HCA TEST STRIP HEALTH ALLIANCE STRIP KERR TEST STRIPS KINRAY TEST STRIPS LEADER TEST STRIP LONG TEST STRIP MEIJER TEST STRIP NAVARRO TEST STRIPS -22- Date Effective 10/12/04* 10/12/04 10/12/04* 10/12/04* 10/12/04* 10/12/04* 12/19/03 12/19/03 12/19/03 3/22/04 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 Therapeutic Classification M4A M4A M4A M4A M4A M4A M4A M4A M4A M4A Date Effective 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 12/19/03 Drug Name ONE TOUCH TEST STRIPS ONE TOUCH ULTRA TEST STRIPS PRECISION XTRA PRESTIGE PRESTIGE SMART SYSTEM SHOPRITE TEST STRIPS SURESTEP TRUETRACK WALGREENS TEST STRIP W-D TEST STRIP M4E - LIPOTROPICS M4E ADVICOR M4E ALTOCOR (Name Change) 10/12/04 ALTOPREV (Name Change) 10/12/04 M4E CRESTOR M4E CLOFIBRATE M4E GEMFIBROZIL M4E ILOPAN-CHOLINE M4E LESCOL M4E LESCOL XL M4E LIPITOR M4E LOFIBRA M4E 3/22/04 LOVASTATIN 10/12/04* M4E MEVACOR 10/12/04* M4E NIACOR M4E NIASPAN M4E PRAVACHOL M4E TRICOR M4E VYTORIN 10/12/04 M4E ZETIA M4E ZOCOR M4E M4G - HYPERGLYCEMICS PROGLYCEM M4G M4I - ANTIHYPERLIP (HMGCOA) & CALCIUM CHANNEL BLOCKER CMB CADUET 10/12/04 M4I M9D - ANTIFIBRINOLYTIC AGENTS AMINOCAPROIC ACID M9D M9L - ORAL ANTICOAGULANTS, COUMARIN TYPE DICUMAROL M9L WARFARIN SODIUM M9L M9P – PLATELET AGGREGATION INHIBITORS AGGRENOX M9P DIPYRIDAMOLE M9P PLAVIX M9P PLETAL M9P -23- Therapeutic Classification Date Effective Drug Name M9S - HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE M9S N1D - PLATELET REDUCING AGENTS AGRYLIN N1D P1F - PITUITARY SUPPRESSIVE AGENTS BROMOCRIPTINE MESYLATE P1F DANAZOL P1F DOSTINEX P1F P1G - ADRENAL STEROID INHIBITORS CYTADREN P1G P2B - ANTIDIURETIC AND VASOPRESSOR HORMONES DESMOPRESSIN ACETATE P2B P3A - THYROID HORMONES ARMOUR THYROID P3A CYTOMEL P3A L-THYROXINE P3A LEVOTHYROXINE SODIUM P3A THYROID P3A THYROID STRONG P3A UNITHROID P3A P3L - ANTITHYROID PREPARATIONS METHIMAZOLE P3L PROPYLTHIOURACIL P3L TAPAZOLE P3L P4L - BONE RESORPTION INHIBITORS (Change in Catogory 10/12/04) ACTONEL P4L FOSAMAX P4L MIACALCIN P4L P4L - BONE RESORPTION SUPPRESSION AGENTS (Change in Category 10/12/04) ACTONEL P4L FOSAMAX P4L MIACALCIN P4L P5A - GLUCOCORTICOIDS AEROBID P5A AEROBID-M P5A ARISTO-PAK P5A AZMACORT P5A CELESTONE P5A CORTISONE ACETATE P5A DEXAMETHASONE P5A FLOVENT P5A FLOVENT ROTADISK P5A HEXADROL P5A HYDROCORTISONE P5A METHYLPREDNISOLONE P5A -24- Therapeutic Classification P5A P5A P5A P5A P5A P5A P5A P5A Date Effective Drug Name PEDIAPRED PREDNISOLONE PREDNISONE PULMICORT RESPULES PULMICORT TURBUHALER QVAR TRIAMCINOLONE VANCERIL 7/13/04 P5S - MINERALOCORTICOIDS FLORINEF ACETATE P5S Q3A - RECTAL PREPARATIONS HEMORRHOIDAL HC Q3A HYDROCORTISONE ACETATE Q3A PROCTOCORT Q3A Q3B - RECTAL/LOWER BOWEL PREP., GLUCOCORT. (NON-HEMORR) CORTIFOAM Q3B HYDROCORTISONE Q3B Q4B - VAGINAL ANTISEPTICS ACI-JEL Q4B Q3D - HEMORRHOIDAL PREPARATIONS ANALPRAM-HC Q3D 10/12/04 Q3E - CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT, RECTAL CANASA Q3E 7/13/04 Q4F - VAGINAL ANTIFUNGALS GYNAZOLE-1 Q4F MICONAZOLE 3 Q4F MONISTAT 3 Q4F MONISTAT DUAL-PAK Q4F MYCELEX TWIN PACK Q4F MYCELEX-G Q4F NYSTATIN Q4F TERAZOL 3 Q4F TERAZOL 7 Q4F Q4K - VAGINAL ESTROGEN PREPARATIONS ESTRING Q4K ORTHO-DIENESTROL Q4K PREMARIN Q4K VAGIFEM Q4K Q4W - VAGINAL ANTIBIOTICS CLEOCIN Q4W METROGEL-VAGINAL Q4W -25- Therapeutic Classification Date Effective Drug Name Q5B - TOPICAL PREPARATIONS, ANTIBACTERIALS AZELEX 10/12/04* Q5B NITROFURAZONE Q5B SILVER NITRATE Q5B SILVER NITRATE APPLICATOR Q5B Q5F - TOPICAL ANTIFUNGALS CLOTRIMAZOLE Q5F EXELDERM Q5F KETOCONAZOLE Q5F 2/1/04 LOPROX Q5F MENTAX Q5F 12/19/03 NAFTIN Q5F 12/19/03 NIZORAL SHAMPOO Q5F 12/19/03 NYSTATIN Q5F NYSTATIN W/TRIAMCINOLONE Q5F SPECTAZOLE Q5F 12/19/03 Q5H - TOPICAL LOCAL ANESTHETICS EMLA Q5H ETHYL CHLORIDE Q5H LIDOCAINE HCL Q5H LIDODERM 10/12/04 Q5H PRAMOSONE Q5H Q5K - TOPICAL IMMUNOSUPPRESSIVE AGENTS ELIDEL Q5K PROTOPIC Q5K Q5N - TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS EFUDEX Q5N FLUOROPLEX Q5N Q5P - TOPICAL ANTI-INFLAMMATORY STEROIDAL ACLOVATE Q5P BETAMETHASONE DIPROPIONATE Q5P BETAMETHASONE DP AUGMENTED Q5P BETAMETHASONE VALERATE Q5P CAPEX SHAMPOO Q5P CLOBETASOL E Q5P CLOBETASOL PROPIONATE Q5P CYCLOCORT Q5P DESONIDE Q5P DESOXIMETASONE Q5P DIFLORASONE DIACETATE Q5P DIPROLENE Q5P DIPROLENE AF Q5P FLORONE E Q5P FLUOCINOLONE ACETONIDE Q5P FLUOCINONIDE Q5P -26- Therapeutic Classification Q5P Q5P Q5P Q5P Q5P Q5P Q5P Q5P Q5P Q5P Q5P Q5R Q5R Q5R Q5R Q5S Q5S Q5S Q5S Q5S Q5V Q5W Q5W Q5W Q5W Q5W Q5W Q5W Q5W Q5W Q6A Q6C Q6C Q6C Q6G Q6G Q6G Q6G Drug Name FLUOCINONIDE-E HALOG HALOG-E HYDROCORTISONE HYDROCORTISONE VALERATE TEMOVATE TOPICORT TOPICORT LP TRIAMCINOLONE ACETONIDE ULTRAVATE WESTCORT Q5R - TOPICAL ANTIPARASITICS EURAX LINDANE OVIDE PERMETHRIN Q5S - TOPICAL SULFONAMIDES NOVACET SILVER SULFADIAZINE SOD.SULFACETAMIDE/SULFUR TF SODIUM SULFACETAMIDE/SULFUR SSD AF Q5V - TOPICAL ANTIVIRALS DENAVIR Q5W - TOPICAL ANTIBIOTICS AKNE-MYCIN BACTROBAN BENZAMYCIN CENTANY CLINDAMYCIN CLINDAMYCIN PHOSPHATE ERYTHROMYCIN ERYTHROMYCIN BASE GENTAMICIN SULFATE Q6A - OPHTHALMIC PREPARATIONS, MISCELLANEOUS FML-S Q6C - EYE VASOCONSTRICTORS (RX ONLY) NAPHAZOLINE HCL PHENYLEPHRINE HCL VASOCON Q6G - MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS ALPHAGAN P AZOPT BETAXOLOL HCL BETIMOL -27- Date Effective 10/12/04 Therapeutic Classification Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6G Q6I Q6I Q6I Q6I Q6I Q6I Q6I Q6I Q6J Q6J Q6J Q6J Q6J Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Q6P Drug Name BETOPTIC S CARTEOLOL HCL COSOPT LEVOBUNOLOL HCL LUMIGAN METIPRANOLOL OPTIPRANOLOL PILOCARPINE HCL PILOPINE HS TIMOLOL MALEATE TIMOPTIC TIMOPTIC-XE TRAVATAN TRUSOPT XALATAN Q6I - EYE ANTIBIOTIC-CORTICOID COMBINATIONS CORTISPORIN NEO/POLYMYXIN/DEXAMETHASONE NEOMYCIN W/DEXAMETHASONE NEOMYCIN/BACITRACIN/POLY/HC NEOMYCIN/POLYMYXIN/DEXAMETH NEOMYCIN/POLYMYXIN/HC POLY-PRED TOBRADEX Q6J - MYDRIATICS ATROPINE SULFATE CYCLOPENTOLATE HCL DIPIVEFRIN HCL HOMATROPINE HYDROBROMIDE TROPICAMIDE Q6P - EYE ANTIINFLAMMATORY AGENTS ACULAR ALREX DEXAMETHASONE SODIUM PHOSPHATE DICLOFENAC SODIUM FLUOROMETHOLONE FLURBIPROFEN SODIUM FML FORTE FML S.O.P. HMS LOTEMAX MAXIDEX PRED FORTE PRED MILD PREDNISOLONE ACETATE -28- Date Effective Therapeutic Classification Q6P Q6P Q6R Q6R Q6S Q6S Q6S Q6S Q6S Q6S Q6S Q6U Q6U Q6U Q6U Q6U Q6U Q6V Q6V Q6V Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q6W Q7A Drug Name PREDNISOLONE SODIUM PHOSPHATE VOLTAREN Q6R - EYE ANTIHISTAMINES ELESTAT LIVOSTIN Q6S - EYE SULFONAMIDES BLEPHAMIDE BLEPHAMIDE S.O.P. SODIUM SULAMYD SULF-10 SULFACETAMIDE SODIUM SULFACETAMIDE W/PREDNISOLONE VASOCIDIN Q6U - OPHTHALMIC MAST CELL STABILIZERS ALAMAST CROLOM CROMOLYN SODIUM OPTICROM OPTIVAR PATANOL Q6V - EYE ANTIVIRALS TRIFLURIDINE VIRA-A VIROPTIC Q6W - OPHTHALMIC ANTIBIOTICS BACITRACIN BACITRACIN/POLYMYXIN BACITRACIN/POLYMYXIN B CHLORAMPHENICOL CILOXAN ERYTHROMYCIN GENTAMICIN SULFATE NATACYN NEOMYCIN/BACITRACIN/POLYMYXIN NEOMYCIN/POLYMYXIN/GRAMICIDIN OCUFLOX POLYMYXIN B SUL/TRIMETHOPRIM QUIXIN TOBRAMYCIN SULFATE TOBREX VIGAMOX ZYMAR Q7A - NOSE PREPARATIONS, MISCELLANEOUS (RX) IPRATROPIUM BROMIDE -29- Date Effective 7/13/04 7/13/04 Therapeutic Classification Drug Name Q7E - NASAL ANTIHISTAMINE Date Effective ASTELIN Q7P - NASAL ANTI-INFLAMMATORY STEROIDS FLONASE Q7P FLUNISOLIDE Q7P 12/19/03 NASAREL Q7P NASONEX Q7P 12/19/03 RHINOCORT AQUA Q7P Q7W - NOSE PREPARATIONS ANTIBIOTICS BACTROBAN NASAL Q7W Q8B - EAR PREPARATIONS, MISC. ANTI-INFECTIVES ACETIC ACID Q8B ACETIC ACID/ALUMINUM Q8B ACETIC ACID/HYDROCORTISONE Q8B CORTANE-B Q8B VOSOL Q8B VOSOL HC Q8B Q8F - OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS CIPROHC Q8F 7/13/04 CIPRODEX Q8F 12/19/03 Q8H - EAR PREPARATIONS, LOCAL ANESTHETICS ANTIPYRINE W/BENZOCAINE Q8H AURALGAN Q8H Q8R - EAR PREPARATIONS, EAR WAX REMOVERS CERUMENEX Q8R Q8W - EAR PREPARATIONS, ANTIBIOTICS FLOXIN Q8W NEOMYCIN/POLYMYXIN/HC Q8W OTOBIOTIC Q8W PEDIOTIC Q8W Q9B - BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS AVODART Q9B FLOMAX Q9B PROSCAR Q9B UROXATRAL Q9B 3/22/04 R1A - URINARY TRACT ANTISPASMODIC/ ANTIINCONTINENCE AGENT DETROL R1A DETROL LA R1A 3/22/04 DITROPAN XL R1A FLAVOXATE HCL R1A 3/22/04 OXYTROL R1A OXYBUTYNIN CHLORIDE R1A URISPAS R1A 3/22/04 R1E - CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE R1E Q7E -30- Therapeutic Classification R1E Date Effective Drug Name METHAZOLAMIDE R1F - THIAZIDE AND RELATED DIURETICS CHLOROTHIAZIDE R1F CHLORTHALIDONE R1F HYDROCHLOROTHIAZIDE R1F INDAPAMIDE R1F METHYCLOTHIAZIDE R1F MYKROX R1F SALURON R1F TRICHLORMETHIAZIDE R1F ZAROXOLYN R1F R1H - POTASSIUM SPARING DIURETICS AMILORIDE HCL R1H DYRENIUM R1H SPIRONOLACTONE R1H R1L - POTASSIUM SPARING DIURETICS IN COMBINATION AMILORIDE HCL W/HCTZ R1L SPIRONOLACTONE W/HCTZ R1L TRIAMTERENE W/HCTZ R1L R1M - LOOP DIURETICS BUMETANIDE R1M DEMADEX R1M EDECRIN R1M FUROSEMIDE R1M R1R - URICOSURIC AGENTS PROBENECID R1R SULFINPYRAZONE R1R R1S - URINARY PH MODIFIERS BICITRA R1S POLYCITRA R1S POLYCITRA-K R1S POLYCITRA-LC R1S SODIUM CITRATE & CITRIC ACID R1S UROCIT-K R1S R5A - URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) PHENAZOPYRIDINE HCL R5A PYRIDIUM R5A S2A - COLCHICINE COLCHICINE S2A PROBENECID W/COLCHICINE S2A S2B - NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE BEXTRA S2B CELEBREX S2B DAYPRO S2B DICLOFENAC POTASSIUM S2B -31- Therapeutic Classification S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B S2B Date Effective Drug Name DICLOFENAC SODIUM ETODOLAC FENOPROFEN CALCIUM FLURBIPROFEN IBUPROFEN INDOMETHACIN KETOPROFEN KETOROLAC TROMETHAMINE MECLOFENAMATE SODIUM MOBIC NABUMETONE NALFON NAPROXEN NAPROXEN SODIUM OXAPROZIN PIROXICAM PONSTEL RELAFEN SULINDAC TOLECTIN 200 TOLECTIN 600 TOLECTIN DS TOLMETIN SODIUM VIOXX 10/12/04** VOLTAREN VOLTAREN-XR S2C - GOLD SALTS RIDAURA S2C S2I - ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR ARAVA S2I S2N - ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS METHOTREXATE S2N RHEUMATREX S2N S2P - NSAID, COX INHIBITOR-TYPE & PROTON PUMP INHIB COMB PREVACID NAPRAPAC S2P 7/13/04 V1A - ALKYLATING AGENTS ALKERAN V1A CEENU V1A CYCLOPHOSPHAMIDE V1A DROXIA V1A HEXALEN V1A HYDROXYUREA V1A LEUKERAN V1A MYLERAN V1A TEMODAR V1A -32- Therapeutic Classification V1A V1B V1B V1B V1B V1E V1E V1E V1F V1F V1F V1F V1F V1F V1F V1I V1J V1J V1J W1A W1A W1A W1A W1A W1A W1A W1A W1A W1A W1A W1B W1B W1B W1B W1B W1B W1B W1B Drug Name URACIL MUSTARD V1B - ANTIMETABOLITES METHOTREXATE PURINETHOL THIOGUANINE XELODA V1E - STEROID ANTINEOPLASTICS EMCYT MEGESTROL ACETATE TESLAC V1F - ANTINEOPLASTICS, MISCELLANEOUS ARIMIDEX AROMASIN FARESTON FEMARA LYSODREN VEPESID VESANOID V1I - CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM V1J - ANTIANDROGENIC AGENTS CASODEX EULEXIN NILANDRON W1A - PENICILLINS AMOXICILLIN AMPICILLIN AMPICILLIN TRIHYDRATE AUGMENTIN AUGMENTIN ES AUGMENTIN XR DICLOXACILLIN SODIUM OXACILLIN SODIUM PENICILLIN V POTASSIUM SPECTROBID TRIMOX W1B - CEPHALOSPORINS CEFACLOR CEFADROXIL CEFADROXIL MONOHYDRATE CEFTIN CEFZIL CEPHADROXIL CEPHALEXIN CEPHRADINE -33- Date Effective 10/12/04 12/19/03 Therapeutic Classification W1B W1B W1B W1C W1C W1C W1C W1C W1C W1C W1C W1C W1D W1D W1D W1D W1D W1D W1D W1D W1D W1D W1D W1D W1D W1F W1F W1F W1F W1G W1G W1G W1G W1J W1J W1K W1K W1Q Drug Name Date Effective OMNICEF SUPRAX SPECTRACEF W1C - TETRACYCLINES DECLOMYCIN DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE MINOCYCLINE HCL SUMYCIN SUMYCIN 250 SUMYCIN 500 TETRACYCLINE HCL UROBIOTIC-250 W1D - MACROLIDES BIAXIN BIAXIN XL DYNABAC E.E.S. 400 ERYTHROCIN STEARATE ERYTHROMYCIN ERYTHROMYCIN BASE ERYTHROMYCIN ESTOLATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN STEARATE ERYTHROMYCIN W/SULFISOXAZOLE TAO ZITHROMAX W1F - AMINOGLYCOSIDES KANTREX NEO-FRADIN NEOMYCIN SULFATE TOBI W1G - ANTITUBERCULAR ANTIBIOTICS RIFAMATE RIFAMPIN RIFATER SEROMYCIN W1J - VANCOMYCIN AND DERIVATIVES VANCOCIN HCL VANCOMYCIN HCL W1K - LINCOSAMIDES CLEOCIN PALMITATE CLINDAMYCIN HCL W1Q - QUINOLONES AVELOX -34- 12/19/03 Therapeutic Classification W1Q W1Q W1Q W1Q W1Q W1Q W1Q W1Q W1Q W1Y W2A W2A W2A W2A W2A W2A W2A W2E W2E W2E W2E W2E W2F W2F W2F W2F W2F W2F W2G W2G W2G W3A W3A W3A W3A W3A W3B W3B Drug Name CIPRO CIPRO XR FLOXIN LEVAQUIN MAXAQUIN NEGGRAM NOROXIN OFLOXACIN TEQUIN W1Y - CEPHALOSPORINS - 3RD GENERATION VANTIN W2A - ABSORBABLE SULFONAMIDES GANTANOL GANTRISIN SULFADIAZINE SULFAMETHOXAZOLE/TRIMETHOPRIM SULFASALAZINE SULFATRIM SULFISOXAZOLE W2E - ANTI-MYCOBACTERIUM AGENTS ISONAIZID ISONIAZID MYAMBUTOL MYCOBUTIN PYRAZINAMIDE W2F - NITROFURAN DERIVATIVES FURADANTIN FUROXONE MACROBID NITROFURANTOIN NITROFURANTOIN MONOHYD MACRO NITROFURANTOIN MACROCRYSTAL W2G - CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. METHENAMINE MANDELATE TRIMETHOPRIM TRIMPEX W3A - ANTIFUNGAL ANTIBIOTICS FUNGIZONE GRIFULVIN V GRISEOFULVIN MICROSIZE GRISEOFULVIN ULTRAMICROSIZE NYSTATIN W3B - ANTIFUNGAL AGENTS DIFLUCAN KETOCONAZOLE -35- Date Effective 3/22/04 3/22/04 3/22/04 12/19/03 10/12/04 10/12/04 10/12/04 Therapeutic Classification W3B W3B W3B W4A W4A W4A W4A W4A W4A W4C W4C W4C W4E W4E W4E W4E W4K W4L W4L W4L W4L W4L W4L W4P W4P W5A W5A W5A W5A W5A W5A W5B W5B W5B W5B W5B W5B Drug Name Date Effective LAMISIL MYCELEX VFEND W4A - ANTIMALARIAL DRUGS CHLOROQUINE PHOSPHATE DARAPRIM HYDROXYCHLOROQUINE SULFATE LARIAM PRIMAQUINE QUININE SULFATE W4C - AMEBACIDES PAROMOMYCIN SULFATE TINDAMAX 10/12/04 YODOXIN W4E - ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL 375 FLAGYL ER METRONIDAZOLE METRONIDAZOLE HCL W4K - ANTIPROTOZOAL DRUGS, MISCELLANEOUS MEPRON W4L - ANTHELMINTICS ALBENZA BILTRICIDE MEBENDAZOLE MINTEZOL STROMECTOL VERMOX W4P - ANTILEPROTICS DAPSONE LAMPRENE W5A - ANTIVIRALS, GENERAL ACYCLOVIR FLUMADINE GANCICLOVIR 12/19/03 TAMIFLU 10/12/04 VALCYTE VALTREX W5B - ANTIVIRALS, HIV-SPECIFIC COMBIVIR EPIVIR HIVID RESCRIPTOR RETROVIR SUSTIVA -36- Therapeutic Drug Name Classification TRIZIVIR W5B VIDEX W5B VIDEX EC W5B VIRAMUNE W5B VIREAD W5B ZERIT W5B ZIAGEN W5B W5C - ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS AGENERASE W5C CRIXIVAN W5C FORTOVASE W5C INVIRASE W5C KALETRA W5C NORVIR W5C VIRACEPT W5C W5F - HEPATITIS B TREATMENT AGENTS EPIVIR HBV W5F W5G - HEPATITIS C TREATMENT AGENTS COPEGUS W5G REBETOL W5G Y7A - RESPIRATORY AIDS, DEVICES, EQUIPMENT AEROCHAMBER PLUS Y7A AEROGEAR ASTHMA ACTION KIT Y7A AIRZONE Y7A ASSESS Y7A EASIVENT Y7A ELLIPSE COMPACT SPACER Y7A E-Z SPACER Y7A E-Z SPACER & MASK Y7A E-Z SPACER MASK Y7A MICROCHAMBER Y7A MICROSPACER Y7A OPTICHAMBER Y7A OPTIHALER Y7A PEAK-AIR Y7A PERSONAL BEST PEAK FLOW METER Y7A POCKET CHAMBER Y7A POCKET SPACER Y7A TRUZONE Y7A TRUZONE PEAK FLOW METER Y7A VORTEX Y7A Y9A - DIABETIC SUPPLIES ASCENSIA BREEZE MONITOR Y9A ASCENSIA CONTOUR SYSTEM Y9A ASCENSIA DEX2 CARE SYSTEM Y9A -37- Date Effective 7/13/04 7/13/04 7/13/04 7/13/04 7/13/04 7/13/04 7/13/04 7/13/04 1/1/04 1/1/04 1/1/04 Therapeutic Classification Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Y9A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Z2A Drug Name ASCENSIA ELITE XL KIT BD LATITUDE DIABET SYSTEM BD LOGIC GLUCOSE MONITOR FREESTYLE SYSTEM KIT GLUCOMETER ELITE SYSTEM ONE TOUCH ULTRA SYSTEM KIT PRECISION XTRA MONITOR PRESTIGE SMART SYS IQ KIT PRESTIGE SMART SYS IQ METER PRESTIGE SMART SYS VALUE PK PRESTIGE SMART SYSTEM METER PRESTIGE STARTER KIT TRUETRACK SMART SYSTEM Z2A - ANTIHISTAMINES ALLEGRA ALLEGRA-D BROMPHENIRAMINE W/PSEUDOEPHED CARBINOXAMINE PD CARBINOXAMINE W/PSEUDOEPHED CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE TR CLARINEX CLEMASTINE FUMARATE CYPROHEPTADINE HCL DEXCHLORPHENIRAMINE DEXCHLORPHENIRAMINE MALEATE DIPHENHYDRAMINE DIPHENHYDRAMINE HCL HISTEX SR HYDROXYZINE HCL HYDROXYZINE PAMOATE LORATADINE LORATADINE-D NALEX-A NASAL DECONGESTANT PD OPTIMINE PALGIC D PBZ PBZ-SR PEDIATEX PEDIATEX-D PROMETHAZINE HCL RONDEC RYNATAN SEMPREX-D -38- Date Effective 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 1/1/04 3/22/04 3/22/04 10/12/04 10/12/04 Therapeutic Classification Z2A Z2A Z2A Z2E Z2E Z2E Z2E Z2E Z2E Z2F Z2F Z2F Z2G Z4B Z4B Drug Name Date Effective TRINALIN ZYRTEC ZYRTEC-D Z2E - IMMUNOSUPPRESSIVES AZATHIOPRINE CELLCEPT CYCLOSPORINE PROGRAF RAPAMUNE SANDIMMUNE Z2F - MAST CELL STABILIZERS CROMOLYN SODIUM GASTROCROM TILADE Z2G - IMMUNOMODULATORS ALDARA Z4B - LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE SINGULAIR -39- 12/19/03
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