REACTINE PFI W no APO-CETIRIZINE APX W no

PMS-DIPHENHYDRAMINE PMS W no

PMS-DIPHENHYDRAMINE PMS W no

PMS-DIPHENHYDRAMINE PMS W no

CLARITIN SCH W no

VERMOX JAN FW no

ENTACYL RBP W no

ENTACYL RBP W no

GARAMYCIN SCH FSW no GENTAMICIN SULFATE NOP FSW no

NEBCIN LIL FSW no SCHEINPHARM TOBRAMYCIN SCN FSW no TOBRAMYCIN SAB FSW no

FULVICIN U/F SCH FSW no

FULVICIN U/F SCH FSW no

SEE APPENDIX A FOR EDS CRITERIA

NIZORAL JAN FSW yes NU-KETOCON NXP FSW yes NOVO-KETOCONAZOLE NOP FSW yes APO-KETOCONAZOLE APX FSW yes

MYCOSTATIN BMS FSW no NYADERM TAR FSW no NYSTATIN PMS FSW no NILSTAT TCH FSW no

NILSTAT TCH FSW no

SEE APPENDIX A FOR EDS CRITERIA

CEFTIN GLA FSW yes

CEFTIN GLA FSW yes

CEFTIN GLA FSW yes

CEFTIN GLA FSW yes

KEFLEX LIL FSW no NOVO-LEXIN NOP FSW no PMS-CEPHALEXIN PMS FSW no

KEFLEX LIL FSW no NOVO-LEXIN NOP FSW no PMS-CEPHALEXIN PMS FSW no

NOVO-LEXIN NOP FSW no

NOVO-LEXIN NOP FSW no

KEFLEX LIL FSW no NOVO-LEXIN NOP FSW no APO-CEPHALEX APX FSW no NU-CEPHALEX NXP FSW no PMS-CEPHALEXIN PMS FSW no

KEFLEX LIL FSW no NOVO-LEXIN NOP FSW no APO-CEPHALEX APX FSW no NU-CEPHALEX NXP FSW no PMS-CEPHALEXIN PMS FSW no

SEE APPENDIX A FOR EDS CRITERIA

BIAXIN ABB FSW yes

BIAXIN ABB FSW yes

BIAXIN ABB FSW yes

ERYC PDA FSW no APO-ERYTHRO E-C APX FSW no NOVO-RYTHRO ENCAP NOP FSW no

ERYC PDA FSW no APO-ERYTHRO E-C APX FSW no

ERYTHROMID ABB FSW no APO-ERYTHRO APX FSW no

NOVO-RYTHRO ESTOLATE NOP FSW no

NOVO-RYTHRO ESTOLATE NOP FSW no

EES-200 ABB FSW no NOVO-RYTHRO-EES NOP FSW no

EES-400 ABB FSW no NOVO-RYTHRO-EES NOP FSW no

EES-600 ABB FSW no AP0-ERYTHRO-ES APX FSW no

NOVAMOXIN NOP FSW no APO-AMOXI APX FSW no NU-AMOXI NXP FSW no NOVAMOXIN SUGAR REDUCED NOP FSW no AMOXIL WAY FSW no LIN-AMOX LIN FSW no

NOVAMOXIN NOP FSW no APO-AMOXI APX FSW no NU-AMOXI NXP FSW no NOVAMOXIN SUGAR REDUCED NOP FSW no AMOXIL WAY FSW no LIN-AMOX LIN FSW no

NOVAMOXIN NOP FSW no APO-AMOXI APX FSW no NU-AMOXI NXP FSW no AMOXIL WAY FSW no LIN-AMOX LIN FSW no GEN-AMOXICILLIN GPM FSW no

NOVAMOXIN NOP FSW no APO-AMOXI APX FSW no NU-AMOXI NXP FSW no AMOXIL WAY FSW no LIN-AMOX LIN FSW no GEN-AMOXICILLIN GPM FSW no

CLAVULIN SKB FSW no

CLAVULIN SKB FSW no

CLAVULIN SKB FSW no

CLAVULIN SKB FSW no

NOVO-AMPICILLIN NOP FSW no APO-AMPI APX FSW no NU-AMPI NXP FSW no

NOVO-AMPICILLIN NOP FSW no APO-AMPI APX FSW no NU-AMPI NXP FSW no

NOVO-AMPICILLIN NOP FSW no APO-AMPI APX FSW no NU-AMPI NXP FSW no

NOVO-AMPICILLIN NOP FSW no APO-AMPI APX FSW no NU-AMPI NXP FSW no

NOVO-CLOXIN NOP FSW no APO-CLOXI APX FSW no NU-CLOXI NXP FSW no

NOVO-CLOXIN NOP FSW no APO-CLOXI APX FSW no NU-CLOXI NXP FSW no

NOVO-CLOXIN NOP FSW no APO-CLOXI APX FSW no NU-CLOXI NXP FSW no

PEN-VEE LIH FW no

PEN-VEE LIH FSW no

NOVO-PEN-VK NOP FSW no APO-PEN VK APX FSW no NU-PEN VK NXP FSW no

VIBRAMYCIN PFI FSW no NOVO-DOXYLIN NOP FSW no APO-DOXY APX FSW no DOXYCIN GPM FSW no NU-DOXYCYCLINE NXP FSW no DOXYTEC TCH FSW no ALTI-DOXYCYCLINE ALT FSW no

VIBRA-TABS PFI FSW no DOXYCIN GPM FSW no APO-DOXY APX FSW no NU-DOXYCYCLINE NXP FSW no DOXYTEC TCH FSW no ALTI-DOXYCYCLINE ALT FSW no NOVO-DOXYLIN NOP FSW no

SEE APPENDIX A FOR EDS CRITERIA

ALTI-MINOCYCLINE ALT FW yes APO-MINOCYCLINE APX FW yes NOVO-MINOCYCLINE NOP FW yes MINOCIN WAY FW yes GEN-MINOCYCLINE GPM FW yes

ALTI-MINOCYCLINE ALT FW yes APO-MINOCYCLINE APX FW yes NOVO-MINOCYCLINE NOP FW yes MINOCIN WAY FW yes GEN-MINOCYCLINE GPM FW yes SCHEINPHARM MINOCYCLINE SCN FW yes

NOVO-TETRA NOP FSW no

NOVO-TETRA NOP FSW no APO-TETRA APX FSW no NU-TETRA NXP FSW no

DALACIN C PHU FSW no

DALACIN C PHU FSW no

DALACIN C PHU FSW no

SEE APPENDIX A FOR EDS CRITERIA

VANCOCIN LIL FSW yes

VANCOCIN LIL FSW yes

ZOVIRAX GLA FSW no AVIRAX TCH FSW no NU-ACYCLOVIR NXP FSW no APO-ACYCLOVIR APX FSW no ALTI-ACYCLOVIR ALT FSW no

ZOVIRAX GLA FSW no AVIRAX TCH FSW no NU-ACYCLOVIR NXP FSW no APO-ACYCLOVIR APX FSW no ALTI-ACYCLOVIR ALT FSW no

ZOVIRAX GLA FSW no AVIRAX TCH FSW no NU-ACYCLOVIR NXP FSW no APO-ACYCLOVIR APX FSW no ALTI-ACYCLOVIR ALT FSW no

FAMVIR SKB FSW no

VALTREX GLA FSW no

NOVO-CHLOROQUINE NOP FSW no ARALEN SAW FSW no

PLAQUENIL SAW FSW no

NOVO-QUININE NOP FSW no QUININE ODN FSW no

NOVO-QUININE NOP FSW no QUININE ODN FSW no

SEE APPENDIX A FOR EDS CRITERIA

CIPRO BAY FSW yes

CIPRO BAY FSW yes

CIPRO BAY FSW yes

CIPRO BAY FSW yes

SEE APPENDIX A FOR EDS CRITERIA

LEVAQUIN JAN FSW yes

LEVAQUIN JAN FSW yes

SEE APPENDIX A FOR EDS CRITERIA

NOROXIN MSD FSW yes APO-NORFLOX APX FSW yes NOVO-NORFLOXACIN NOP FSW yes

SEE APPENDIX A FOR EDS CRITERIA

FLOXIN JAN FSW yes APO-OFLOX APX FSW yes

FLOXIN JAN FSW yes APO-OFLOX APX FSW yes

FLOXIN JAN FSW yes APO-OFLOX APX FSW yes

AVLOSULFON WAY FSW no

NOVO-FURAN NOP FSW no

MACRODANTIN ALZ FSW no NOVO-FURANTOIN NOP FSW no

NOVO-FURAN NOP FSW no APO-NITROFURANTOIN APX FSW no

NOVO-FURAN NOP FSW no APO-NITROFURANTOIN APX FSW no

PROLOPRIM GLA FSW no

PROLOPRIM GLA FSW no

PEDIAZOLE ABB FW no

NOVO-NIDAZOL NOP FSW no APO-METRONIDAZOLE APX FSW no

SEPTRA GLA FSW no BACTRIM HLR FSW no NOVO-TRIMEL NOP FSW no APO-SULFATRIM APX FSW no NU-COTRIMOX NXP FSW no

SEPTRA GLA FSW no APO-SULFATRIM APX FSW no NOVO-TRIMEL NOP FSW no NU-COTRIMOX NXP FSW no

SEPTRA DS GLA FSW no BACTRIM DS HLR FSW no APO-SULFATRIM DS APX FSW no NOVO-TRIMEL DS NOP FSW no NU-COTRIMOX DS NXP FSW no

SEE APPENDIX A FOR EDS CRITERIA

ARIMIDEX AZE FSW yes

MYLERAN GLA FSW no

LEUKERAN GLA FSW no

PROCYTOX HOR FSW no CYTOXAN BMS FSW no

PROCYTOX HOR FSW no CYTOXAN BMS FSW no

ANDROCUR BEX FSW no ALTI-CPA ALT FSW no GEN-CYPROTERONE GPM FSW no NOVO-CYPROTERONE NOP FSW no

EUFLEX SCH FSW no PMS-FLUTAMIDE PMS FSW no NOVO-FLUTAMIDE NOP FSW no APO-FLUTAMIDE APX FSW no

ZOLADEX AZE FSW no

ZOLADEX LA AZE FSW no

HYDREA BMS FSW no

LUPRON DEPOT ABB FSW no

LUPRON DEPOT ABB FSW no

PROVERA PHU FSW no

SEE APENDIX A FOR EDS CRITERIA

MEGACE BMS FSW yes LIN-MEGESTROL LIN FSW yes NU-MEGESTROL NXP FSW yes APO-MEGESTROL APX FSW yes

MEGACE BMS FSW yes LIN-MEGESTROL LIN FSW yes NU-MEGESTROL NXP FSW yes APO-MEGESTROL APX FSW yes

ALKERAN GLA FSW no

PURINETHOL GLA FSW no

METHOTREXATE WAY FSW no METHOTREXATE FAU FSW no

APO-TAMOX APX FSW no NOVO-TAMOXIFEN NOP FSW no TAMOFEN RPR FSW no NOLVADEX AZE FSW no GEN-TAMOXIFEN GPM FSW no

APO-TAMOX APX FSW no NOVO-TAMOXIFEN NOP FSW no TAMOFEN RPR FSW no NOLVADEX D AZE FSW no GEN-TAMOXIFEN GPM FSW no

DUVOID RBP FSW no

URECHOLINE FRS FSW no DUVOID RBP FSW no

PROSTIGMIN ICN FSW no

MESTINON ICN FSW no

MESTINON ICN FSW no

COGENTIN MSD FSW no APO-BENZTROPINE APX FSW no PMS-BENZTROPINE PMS FSW no

KEMADRIN GLA FSW no PMS-PROCYCLIDINE PMS FSW no

KEMADRIN GLA FSW no PMS-PROCYCLIDINE PMS FSW no

NOVO-HEXIDYL NOP FSW no APO-TRIHEX APX FSW no

NOVO-HEXIDYL NOP FSW no APO-TRIHEX APX FSW no

BENTYLOL HMR FSW no

BENTYLOL HMR FSW no

BENTYLOL HMR FSW no

BUSCOPAN BOE FSW no

ATROVENT BOE FSW no

ATROVENT BOE FSW no ALTI-IPRATROPIUM ALT FSW no APO-IPRAVENT APX FSW no NOVO-IPRAMIDE NOP FSW no PMS-IPRATROPIUM PMS FSW no GEN-IPRATROPIUM GPM FSW no

PRO-BANTHINE RBP FSW no

PROPANTHEL ICN FSW no PRO-BANTHINE RBP FSW no

ANA-KIT BAY W no Note: Coverage is limited to one Ana-Kit at a time.

BEROTEC BOE FSW no

BEROTEC BOE FSW no

SEE APPENDIX A FOR EDS CRITERIA

FORADIL NVR FSW yes

OXEZE TURBUHALER AZE FSW yes

SEE APPENDIX A FOR EDS CRITERIA

AMATINE RBP FSW yes

AMATINE RBP FSW yes

ALUPENT BOE FSW no

ALUPENT BOE FSW no ALTI-ORCIPRENALINE ALT FSW no ORCIPREN TCH FSW no APO-ORCIPRENALINE APX FSW no

APO-SALVENT APX FSW no ALTI-SALBUTAMOL ALT FSW no NOVO-SALMOL NOP FSW no VENTOLIN GLA FSW no AIROMIR (CFC-FREE) HMR FSW no

VENTODISK GLA FSW no

VENTODISK GLA FSW no

VENOTOLIN ROTACAPS GLA FSW no

VENTOLIN ROTACAPS GLA FSW no

SALBUTAMOL ALT FSW no APO-SALVENT APX FSW no ASMAVENT TCH FSW no PMS-SALBUTAMOL PMS FSW no RHO-SALBUTAMOL RHP FSW no VENTOLIN GLA FSW no GEN-SALBUTAMOL GPM FSW no

VENTOLIN GLA FSW no

NOVO-SALMOL NOP FSW no APO-SALVENT APX FSW no NU-SALBUTAMOL NXP FSW no

NOVO-SALMOL NOP FSW no APO-SALVENT APX FSW no NU-SALBUTAMOL NXP FSW no

SEE APPENDIX A FOR EDS CRITERIA

SEREVENT GLA FSW yes

SEREVENT DISKHALER GLA FSW yes

SEREVENT DISKUS GLA FSW yes

BRICANYL TURBUHALER AZE FSW no

BRICANYL AZE FSW no

BRICANYL AZE FSW no

SEE APPENDIX A FOR EDS CRITERIA

MIGRANAL NVR FW yes Note: Coverage is limited to 6 bottles per 30 day period.

ERGOMAR RPR FSW no

CAFERGOT-PB NVR FSW no

SIBELIUM PMS FSW no

SEE APPENDIX A FOR EDS CRITERIA

SANSERT NVR FSW yes

SEE APPENDIX A FOR EDS CRITERIA

AMERGE GLA FW yes

AMERGE GLA FW yes Note: Coverage is limited to 6 tablets per 30 day period.

SEE APPENDIX A FOR EDS CRITERIA

IMITREX GLA FW yes

IMITREX GLA FW yes

IMITREX GLA FW yes

IMITREX GLA FW yes SEE APPENDIX A FOR EDS CRITERIA

IMITREX GLA FW yes Note: Coverage is limited to 6 tablets or 6 sprays or 6 syringes per 30 day period.

SANDOMIGRAN NVR FSW no

SANDOMIGRAN DS NVR FSW no

SEE APPENDIX A FOR EDS CRITERIA

ZOMIG AZE FW yes Note: Coverage is limited to 6 tablets per 30 day period.

LIORESAL NVR FSW no PMS-BACLOFEN PMS FSW no GEN-BACLOFEN GPM FSW no NU-BACLO NXP FSW no APO-BACLOFEN APX FSW no NOVO-BACLOFEN NOP FSW no LIOTEC TCH FSW no

LIORESAL DS NVR FSW no PMS-BACLOFEN PMS FSW no GEN-BACLOFEN GPM FSW no NU-BACLO NXP FSW no APO-BACLOFEN APX FSW no NOVO-BACLOFEN NOP FSW no LIOTEC TCH FSW no

SEE APPENDIX A FOR EDS CRITERIA

FLEXERIL MSD FSW yes NOVO-CYCLOPRINE NOP FSW yes NU-CYLCOBENZAPRINE NXP FSW yes ALTI-CYCLOBENZAPRINE ALT FSW yes APO-CYCLOBENZAPRINE APX FSW yes PMS-CYCLOBENZAPRINE PMS FSW yes GEN-CYCLOPRINE GPM FSW yes FLEXITEC TCH FSW yes

DANTRIUM PGA FSW no

DANTRIUM PGA FSW no

ROBAXIN WRI W no

ROBAXACET WRI W no

ROBAXACET WRI W no

ROBAXISAL WRI W no

ROBAXISAL C-1/4 WRI FW no

ROBAXISAL C-1/2 WRI FW no

NOVO-FERROGLUC NOP W no FERROUS GLUCONATE WAM W no APO-FERROUS GLUCONATE APX W no

PMS-FERROUS SULFATE PMS W no

FERROUS SULFATE WAM W no PMS-FERROUS SULFATE PMS W no APO-FERROUS SULFATE APX W no

SLOW-FE NVR W no

PMS-FERROUS SULFATE PMS W no

JECTOFER AZE W no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

COUMADIN DUP FSW no

SEE APPENDIX A FOR EDS CRITERIA

PLAVIX SAW FSW yes

PENTOXIFYLLINE ALT FSW no TRENTAL HMR FSW no APO-PENTOXIFYLLINE SR APX FSW no NU-PENTOXIFYLLINE SR NXP FSW no

SEE APPENDIX A FOR EDS CRITERIA

TICLID HLR FSW yes SYN-TICLOPIDINE ALT FSW yes NU-TICLOPIDINE NXP FSW yes APO-TICLOPIDINE APX FSW yes GEN-TICLOPIDINE GPM FSW yes

RHOTRAL RHP FSW no SECTRAL RPR FSW no MONITAN WAY FSW no APO-ACEBUTOLOL APX FSW no NU-ACEBUTOLOL NXP FSW no NOVO-ACEBUTOLOL NOP FSW no GEN-ACEBUTOLOL GPM FSW no GEN-ACEBUTOLOL (TYPE S) GPM FSW no

RHOTRAL RHP FSW no SECTRAL RPR FSW no MONITAN WAY FSW no APO-ACEBUTOLOL APX FSW no NU-ACEBUTOLOL NXP FSW no NOVO-ACEBUTOLOL NOP FSW no GEN-ACEBUTOLOL GPM FSW no GEN-ACEBUTOLOL (TYPE S) GPM FSW no

RHOTRAL RHP FSW no SECTRAL RPR FSW no MONITAN WAY FSW no APO-ACEBUTOLOL APX FSW no NU-ACEBUTOLOL NXP FSW no NOVO-ACEBUTOLOL NOP FSW no GEN-ACEBUTOLOL GPM FSW no GEN-ACEBUTOLOL (TYPE S) GPM FSW no

SEE APPENDIX A FOR EDS CRITERIA

CORDARONE WAY FSW yes ALTI-AMIODARONE ALT FSW yes

NORVASC PFI FSW no

NORVASC PFI FSW no

APO-ATENOL APX FSW no NU-ATENOL NXP FSW no NOVO-ATENOL NOP FSW no TENORMIN AZE FSW no GEN-ATENOLOL GPM FSW no TENOLIN TCH FSW no SCHEIN-ATENOLOL SCN FSW no RHO-ATENOLOL RHP FSW no PMS-ATENOLOL PMS FSW no

APO-ATENOL APX FSW no NU-ATENOL NXP FSW no NOVO-ATENOL NOP FSW no TENORMIN AZE FSW no GEN-ATENOLOL GPM FSW no TENOLIN TCH FSW no SCHEIN-ATENOLOL SCN FSW no RHO-ATENOLOL RHP FSW no PMS-ATENOLOL PMS FSW no

SEE APPENDIX A FOR EDS CRITERIA

COREG HLR FSW yes

COREG HLR FSW yes

COREG HLR FSW yes

COREG HLR FSW yes

LANOXIN GLA FSW no

LANOXIN GLA FSW no

LANOXIN GLA FSW no

LANOXIN GLA FSW no

CARDIZEM-SR HMR FSW no APO-DILTIAZ SR APX FSW no NOVO-DILTAZEM SR NOP FSW no GEN-DILTIAZEM SR GPM FSW no

CARDIZEM-SR HMR FSW no APO-DILTIAZ SR APX FSW no NOVO-DILTAZEM SR NOP FSW no GEN-DILTIAZEM SR GPM FSW no

CARDIZEM-SR HMR FSW no APO-DILTIAZ SR APX FSW no NOVO-DILTAZEM SR NOP FSW no GEN-DILTIAZEM SR GPM FSW no

CARDIZEM CD HMR FSW no ALTI-DILTIAZEM CD ALT FSW no APO-DILTIAZEM CD APX FSW no NU-DILTIAZ CD NXP FSW no

CARDIZEM CD HMR FSW no ALTI-DILTIAZEM CD ALT FSW no APO-DILTIAZEM CD APX FSW no NU-DILTIAZ CD NXP FSW no

CARDIZEM CD HMR FSW no ALTI-DILTIAZEM CD ALT FSW no APO-DILTIAZEM CD APX FSW no NU-DILTIAZ CD NXP FSW no

CARDIZEM CD HMR FSW no APO-DILTIAZEM CD APX FSW no ALTI-DILTIAZEM CD ALT FSW no

APO-DILTIAZ APX FSW no NOVO-DILTAZEM NOP FSW no NU-DILTIAZ NXP FSW no ALTI-DILTIAZEM ALT FSW no CARDIZEM HMR FSW no GEN-DILTIAZEM GPM FSW no

APO-DILTIAZ APX FSW no NOVO-DILTAZEM NOP FSW no NU-DILTIAZ NXP FSW no ALTI-DILTIAZEM ALT FSW no CARDIZEM HMR FSW no GEN-DILTIAZEM GPM FSW no

RYTHMODAN HMR FSW no

RYTHMODAN HMR FSW no

LOPRESOR SR NVR FSW no

BETALOC DURULES AZE FSW no LOPRESOR SR NVR FSW no

LOPRESOR NVR FSW no BETALOC AZE FSW no APO-METOPROLOL APX FSW no NOVO-METOPROL NOP FSW no APO-METOPROLOL (TYPE L) APX FSW no NOVO-METOPROL (UNCOATED) NOP FSW no NU-METOP NXP FSW no PMS-METOPROLOL-B PMS FSW no GEN-METOPROLOL (TYPE L) GPM FSW no GEN-METOPROLOL GPM FSW no PMS-METOPROLOL-L PMS FSW no

LOPRESOR NVR FSW no BETALOC AZE FSW no APO-METOPROLOL APX FSW no NOVO-METOPROL NOP FSW no APO-METOPROLOL (TYPE L) APX FSW no NOVO-METOPROL (UNCOATED) NOP FSW no NU-METOP NXP FSW no PMS-METOPROLOL-B PMS FSW no GEN-METOPROLOL (TYPE L) GPM FSW no GEN-METOPROLOL GPM FSW no PMS-METOPROLOL-L PMS FSW no

MEXITIL BOE FSW no NOVO-MEXILETINE NOP FSW no ALTI-MEXILETINE ALT FSW no

MEXITIL BOE FSW no NOVO-MEXILETINE NOP FSW no ALTI-MEXILETINE ALT FSW no

CORGARD BMS FSW no APO-NADOL APX FSW no ALTI-NADOLOL ALT FSW no NOVO-NADOLOL NOP FSW no

CORGARD BMS FSW no APO-NADOL APX FSW no ALTI-NADOLOL ALT FSW no NOVO-NADOLOL NOP FSW no

CORGARD BMS FSW no APO-NADOL APX FSW no ALTI-NADOLOL ALT FSW no

SEE APPENDIX A FOR EDS CRITERIA

CARDENE HLR FSW yes

CARDENE HLR FSW yes

APO-NIFED APX FSW no NOVO-NIFEDIN NOP FSW no PMS-NIFEDIPINE PMS FSW no

APO-NIFED APX FSW no NOVO-NIFEDIN NOP FSW no NU-NIFED NXP FSW no GEN-NIFEDIPINE GPM FSW no PMS-NIFEDIPINE PMS FSW no

NIFEDIPINE PA SCN FSW no ADALAT PA BAY FSW no APO-NIFED PA APX FSW no NU-NIFEDIPINE PA NXP FSW no

NIFEDIPINE PA SCN FSW no ADALAT PA BAY FSW no APO-NIFED PA APX FSW no NU-NIFEDIPINE PA NXP FSW no

ADALAT XL BAY FSW no

ADALAT XL BAY FSW no

ADALAT XL BAY FSW no

PRONESTYL BMS FSW no APO-PROCAINAMIDE APX FSW no

PRONESTYL BMS FSW no APO-PROCAINAMIDE APX FSW no

PRONESTYL BMS FSW no APO-PROCAINAMIDE APX FSW no

PROCAN SR PDA FSW no

PROCAN SR PDA FSW no PRONESTYL SR BMS FSW no

PROCAN SR PDA FSW no

RYTHMOL KNL FSW no

RYTHMOL KNL FSW no

APO-PROPRANOLOL APX FSW no NOVO-PRANOL NOP FSW no PMS-PROPRANOLOL PMS FSW no INDERAL WAY FSW no

APO-PROPRANOLOL APX FSW no NOVO-PRANOL NOP FSW no INDERAL WAY FSW no NU-PROPRANOLOL NXP FSW no

APO-PROPRANOLOL APX FSW no NOVO-PRANOL NOP FSW no PMS-PROPRANOLOL PMS FSW no INDERAL WAY FSW no NU-PROPRANOLOL NXP FSW no

APO-PROPRANOLOL APX FSW no NOVO-PRANOL NOP FSW no PMS-PROPRANOLOL PMS FSW no INDERAL WAY FSW no

APO-PROPRANOLOL APX FSW no NOVO-PRANOL NOP FSW no INDERAL WAY FSW no

INDERAL L.A. WAY FSW no

INDERAL L.A. WAY FSW no

INDERAL L.A. WAY FSW no

INDERAL L.A. WAY FSW no

BIQUIN DURULES AZE FSW no

NOVO-QUINIDIN NOP FSW no APO-QUINIDINE APX FSW no

SOTACOR BMS FSW no ALTI-SOTALOL ALT FSW no LIN-SOTALOL LIN FSW no NU-SOTALOL NXP FSW no APO-SOTALOL APX FSW no GEN-SOTALOL GPM FSW no NOVO-SOTALOL NOP FSW no RHO-SOTALOL RHP FSW no PMS-SOTALOL PMS FSW no SOTAMOL TCH FSW no

SOTACOR BMS FSW no ALTI-SOTALOL ALT FSW no NU-SOTALOL NXP FSW no APO-SOTALOL APX FSW no LIN-SOTALOL LIN FSW no GEN-SOTALOL GPM FSW no NOVO-SOTALOL NOP FSW no RHO-SOTALOL RHP FSW no PMS-SOTALOL PMS FSW no SOTAMOL TCH FSW no

APO-TIMOL APX FSW no NOVO-TIMOL NOP FSW no NU-TIMOLOL NXP FSW no

APO-TIMOL APX FSW no NOVO-TIMOL NOP FSW no NU-TIMOLOL NXP FSW no

APO-TIMOL APX FSW no NOVO-TIMOL NOP FSW no

ISOPTIN KNL FSW no APO-VERAP APX FSW no NOVO-VERAMIL NOP FSW no ALTI-VERAPAMIL ALT FSW no NU-VERAP NXP FSW no GEN-VERAPAMIL GPM FSW no

ISOPTIN KNL FSW no APO-VERAP APX FSW no NOVO-VERAMIL NOP FSW no ALTI-VERAPAMIL ALT FSW no NU-VERAP NXP FSW no GEN-VERAPAMIL GPM FSW no

ISOPTIN SR KNL FSW no GEN-VERAPAMIL SR GPM FSW no

ISOPTIN SR KNL FSW no GEN-VERAPAMIL SR GPM FSW no

ISOPTIN SR KNL FSW no GEN-VERAPAMIL SR GPM FSW no NOVO-VERAMIL SR NOP FSW no PMS-VERAPAMIL SR PMS FSW no

CHRONOVERA SEA FSW no

CHRONOVERA SEA FSW no

LIPITOR PDA FSW no

LIPITOR PDA FSW no

LIPITOR PDA FSW no

BAYCOL BAY FSW no

BAYCOL BAY FSW no

BAYCOL BAY FSW no

QUESTRAN (42 DOSES) BMS FSW no PMS-CHOLESTYRAMINE (42 DOSES) PMS FSW no

QUESTRAN BMS FSW no NOVO-CHOLAMINE NOP FSW no PMS-CHOLESTYRAMINE PMS FSW no

PMS-CHOLESTYRAMINE (80 DOSES) PMS FSW no PMS-CHOLESTYRAMINE (42 DOSES) PMS FSW no

PMS-CHOLESTYRAMINE LIGHT PMS FSW no QUESTRAN LIGHT BMS FSW no NOVO-CHOLAMINE LIGHT NOP FSW no

NU-FENOFIBRATE NXP FSW no APO-FENOFIBRATE APX FSW no

LIPIDIL MICRO FRS FSW no PMS-FENOFIBRATE MICRO PMS FSW no APO-FENO-MICRO APX FSW no GEN-FENOFIBRATE MICRO GPM FSW no

LESCOL NVR FSW no

LESCOL NVR FSW no

LOPID PDA FSW no GEMFIBROZIL ALT FSW no APO-GEMFIBROZIL APX FSW no NU-GEMFIBROZIL NXP FSW no GEN-GEMFIBROZIL GPM FSW no PMS-GEMFIBROZIL PMS FSW no

LOPID PDA FSW no GEMFIBROZIL ALT FSW no APO-GEMFIBROZIL APX FSW no NU-GEMFIBROZIL NXP FSW no NOVO-GEMFIBROZIL NOP FSW no PMS-GEMFIBROZIL PMS FSW no GEN-GEMFIBROZIL GPM FSW no

MEVACOR MSD FSW no APO-LOVASTATIN APX FSW no

MEVACOR MSD FSW no APO-LOVASTATIN APX FSW no

PRAVACHOL BMS FSW no

PRAVACHOL BMS FSW no

PRAVACHOL BMS FSW no

ZOCOR MSD FSW no

ZOCOR MSD FSW no

ZOCOR MSD FSW no

ZOCOR MSD FSW no

ZOCOR MSD FSW no

LOTENSIN NVR FSW no

LOTENSIN NVR FSW no

LOTENSIN NVR FSW no

ATACAND AZE FSW no

ATACAND AZE FSW no

CAPOTEN BMS FSW no ALTI-CAPTOPRIL ALT FSW no APO-CAPTO APX FSW no NU-CAPTO NXP FSW no NOVO-CAPTORIL NOP FSW no GEN-CAPTOPRIL GPM FSW no PMS-CAPTOPRIL PMS FSW no CAPTRIL TCH FSW no

CAPOTEN BMS FSW no ALTI-CAPTOPRIL ALT FSW no APO-CAPTO APX FSW no NU-CAPTO NXP FSW no NOVO-CAPTORIL NOP FSW no GEN-CAPTOPRIL GPM FSW no PMS-CAPTOPRIL PMS FSW no CAPTRIL TCH FSW no

CAPOTEN BMS FSW no ALTI-CAPTOPRIL ALT FSW no APO-CAPTO APX FSW no NU-CAPTO NXP FSW no NOVO-CAPTORIL NOP FSW no GEN-CAPTOPRIL GPM FSW no PMS-CAPTOPRIL PMS FSW no CAPTRIL TCH FSW no

CAPOTEN BMS FSW no ALTI-CAPTOPRIL ALT FSW no APO-CAPTO APX FSW no NU-CAPTO NXP FSW no NOVO-CAPTORIL NOP FSW no GEN-CAPTOPRIL GPM FSW no PMS-CAPTOPRIL PMS FSW no CAPTRIL TCH FSW no

INHIBACE HLR FSW no

INHIBACE HLR FSW no

INHIBACE HLR FSW no

CATAPRES BOE FSW no APO-CLONIDINE APX FSW no NU-CLONIDINE NXP FSW no NOVO-CLONIDINE NOP FSW no

CATAPRES BOE FSW no APO-CLONIDINE APX FSW no NU-CLONIDINE NXP FSW no NOVO-CLONIDINE NOP FSW no

VASOTEC FRS FSW no

VASOTEC FRS FSW no

VASOTEC FRS FSW no

VASOTEC FRS FSW no

PLENDIL AZE FSW no RENEDIL HMR FSW no

PLENDIL AZE FSW no RENEDIL HMR FSW no

PLENDIL AZE FSW no RENEDIL HMR FSW no

MONOPRIL BMS FSW no

MONOPRIL BMS FSW no

APRESOLINE NVR FSW no APO-HYDRALAZINE APX FSW no NOVO-HYLAZIN NOP FSW no NU-HYDRAL NXP FSW no

APRESOLINE NVR FSW no APO-HYDRALAZINE APX FSW no NOVO-HYLAZIN NOP FSW no NU-HYDRAL NXP FSW no

APRESOLINE NVR FSW no APO-HYDRALAZINE APX FSW no NOVO-HYLAZIN NOP FSW no NU-HYDRAL NXP FSW no

AVAPRO BMS FSW no

AVAPRO BMS FSW no

AVAPRO BMS FSW no

TRANDATE RBP FSW no

TRANDATE RBP FSW no

PRINIVIL MSD FSW no ZESTRIL AZE FSW no APO-LISINOPRIL APX FSW no

PRINIVIL MSD FSW no ZESTRIL AZE FSW no

PRINIVIL MSD FSW no ZESTRIL AZE FSW no

COZAAR MSD FSW no

COZAAR MSD FSW no

COZAAR MSD FSW no

NOVO-MEDOPA NOP FSW no APO-METHYLDOPA APX FSW no NU-MEDOPA NXP FSW no

ALDOMET MSD FSW no NOVO-MEDOPA NOP FSW no APO-METHYLDOPA APX FSW no NU-MEDOPA NXP FSW no

NOVO-MEDOPA NOP FSW no APO-METHYLDOPA APX FSW no NU-MEDOPA NXP FSW no

NOVO-DOPARIL-15 NOP FSW no APO-METHAZIDE-15 APX FSW no

NOVO-DOPARIL-25 NOP FSW no APO-METHAZIDE-25 APX FSW no

TRASICOR NVR FSW no

TRASICOR NVR FSW no

VISKEN NVR FSW no APO-PINDOL APX FSW no NOVO-PINDOL NOP FSW no NU-PINDOL NXP FSW no GEN-PINDOLOL GPM FSW no PMS-PINDOLOL PMS FSW no

VISKEN NVR FSW no APO-PINDOL APX FSW no NOVO-PINDOL NOP FSW no NU-PINDOL NXP FSW no GEN-PINDOLOL GPM FSW no PMS-PINDOLOL PMS FSW no

VISKEN NVR FSW no APO-PINDOL APX FSW no NOVO-PINDOL NOP FSW no NU-PINDOL NXP FSW no GEN-PINDOLOL GPM FSW no PMS-PINDOLOL PMS FSW no

MINIPRESS PFI FSW no APO-PRAZO APX FSW no NU-PRAZO NXP FSW no NOVO-PRAZIN NOP FSW no ALTI-PRAZOSIN ALT FSW no

MINIPRESS PFI FSW no APO-PRAZO APX FSW no NU-PRAZO NXP FSW no NOVO-PRAZIN NOP FSW no ALTI-PRAZOSIN ALT FSW no

MINIPRESS PFI FSW no APO-PRAZO APX FSW no NU-PRAZO NXP FSW no NOVO-PRAZIN NOP FSW no ALTI-PRAZOSIN ALT FSW no

ACCUPRIL PDA FSW no

ACCUPRIL PDA FSW no

ACCUPRIL PDA FSW no

ACCUPRIL PDA FSW no

ALTACE HMR FSW no

ALTACE HMR FSW no

ALTACE HMR FSW no

ALTACE HMR FSW no

MICARDIS BOE FSW no

MICARDIS BOE FSW no

HYTRIN ABB FSW no ALTI-TERAZOSIN ALT FSW no NOVO-TERAZOSIN NOP FSW no NU-TERAZOSIN NXP FSW no APO-TERAZOSIN APX FSW no

HYTRIN ABB FSW no ALTI-TERAZOSIN ALT FSW no NOVO-TERAZOSIN NOP FSW no NU-TERAZOSIN NXP FSW no APO-TERAZOSIN APX FSW no

HYTRIN ABB FSW no ALTI-TERAZOSIN ALT FSW no NOVO-TERAZOSIN NOP FSW no NU-TERAZOSIN NXP FSW no APO-TERAZOSIN APX FSW no

HYTRIN ABB FSW no ALTI-TERAZOSIN ALT FSW no NOVO-TERAZOSIN NOP FSW no NU-TERAZOSIN NXP FSW no APO-TERAZOSIN APX FSW no

DIOVAN NVR FSW no

DIOVAN NVR FSW no

SEE APPENDIX A FOR EDS CRITERIA

SERC SLV FSW yes

PERSANTINE BOE FSW no APO-DIPYRIDAMOLE-SC APX FSW no NOVO-DIPIRADOL NOP FSW no APO-DIPYRIDAMOLE-FC APX FSW no

PERSANTINE BOE FSW no APO-DIPYRIDAMOLE-SC APX FSW no NOVO-DIPIRADOL NOP FSW no APO-DIPYRIDAMOLE-FC APX FSW no

PERSANTINE BOE FSW no APO-DIPYRIDAMOLE-SC APX FSW no NOVO-DIPIRADOL NOP FSW no APO-DIPYRIDAMOLE-FC APX FSW no

APO-ISDN APX FSW no ISORDIL WAY FSW no

APO-ISDN APX FSW no NOVO-SORBIDE NOP FSW no ISORDIL WAY FSW no

APO-ISDN APX FSW no NOVO-SORBIDE NOP FSW no ISORDIL WAY FSW no

NOTES: 1. To prevent development of tolerance, patches should be removed after 12-14 hours to provide daily NITRATE-FREE periods of 10-12 hours. The NITRATE-FREE period should be timed to coincide with the period in which angina is least likely to occur (USUALLY AT NIGHT). 2. Patients should not be using both the nitroglycerin transdermal patch and sustained release tablet concurrently.

TRANSDERM - NITRO 0.2 NVR FSW no NITRO-DUR 0.2 KEY FSW no MINITRAN 0.2 MDA FSW no

NITRO-DUR 0.3 KEY FSW no

TRANSDERM - NITRO 0.4 NVR FSW no NITRO-DUR 0.4 KEY FSW no MINITRAN 0.4 MDA FSW no

NITRO-DUR 0.6 KEY FSW no TRANSDERM - NITRO 0.6 NVR FSW no MINITRAN 0.6 MDA FSW no

NITRO-DUR 0.8 KEY FSW no

NITROSTAT PDA W no

NITROSTAT PDA W no

NITROLINGUAL PUMPSPRAY RPR W no

NITRONG S.R. RPR FSW no

NITROL PMS FSW no

ENTROPHEN-5 JJM W no NOVASEN NOP W no

NOVASEN NOP W no MSD ENTERIC-COATED ASA JJM W no

VOLTAREN NVR FSW no NOVO-DIFENAC NOP FSW no APO-DICLO APX FSW no NU-DICLO NXP FSW no PMS-DICLOFENAC PMS FSW no

VOLTAREN NVR FSW no NOVO-DIFENAC NOP FSW no APO-DICLO APX FSW no NU-DICLO NXP FSW no PMS-DICLOFENAC PMS FSW no

APO-DIFLUNISAL APX FSW no NOVO-DIFLUNISAL NOP FSW no NU-DIFLUNISAL NXP FSW no

APO-DIFLUNISAL APX FSW no NOVO-DIFLUNISAL NOP FSW no NU-DIFLUNISAL NXP FSW no

ANSAID PHU FSW no ALTI-FLURBIPROFEN ALT FSW no APO-FLURBIPROFEN APX FSW no NU-FLURBIPROFEN NXP FSW no NOVO-FLURPROFEN NOP FSW no

ANSAID PHU FSW no ALTI-FLURBIPROFEN ALT FSW no APO-FLURBIPROFEN APX FSW no NU-FLURBIPROFEN NXP FSW no NOVO-FLURPROFEN NOP FSW no

MOTRIN PHU FSW no APO-IBUPROFEN APX FSW no NOVO-PROFEN NOP FSW no NU-IBUPROFEN NXP FSW no

MOTRIN PHU FSW no APO-IBUPROFEN APX FSW no NOVO-PROFEN NOP FSW no NU-IBUPROFEN NXP FSW no

MOTRIN PHU FSW no APO-IBUPROFEN APX FSW no NOVO-PROFEN NOP FSW no NU-IBUPROFEN NXP FSW no

NOVO-METHACIN NOP FSW no APO-INDOMETHACIN APX FSW no NU-INDO NXP FSW no INDOTEC TCH FSW no RHODACINE RHP FSW no

NOVO-METHACIN NOP FSW no APO-INDOMETHACIN APX FSW no NU-INDO NXP FSW no INDOTEC TCH FSW no RHODACINE RHP FSW no

INDOCID MSD FSW no INDOTEC TCH FSW no RHODACINE RHP FSW no NOVO-METHACIN NOP FSW no SAB-INDOMETHACIN SAB FSW no

INDOCID MSD FSW no INDOTEC TCH FSW no RHODACINE RHP FSW no NOVO-METHACIN NOP FSW no SAB-INDOMETHACIN SAB FSW no

RHODIS RHP FSW no APO-KETO APX FSW no ORUDIS RPR FSW no PMS-KETOPROFEN PMS FSW no

RHODIS-EC RHP FSW no APO-KETO-E APX FSW no ORUDIS E-50 RPR FSW no NOVO-KETO-EC NOP FSW no PMS-KETOPROFEN-EC PMS FSW no

RHODIS-EC RHP FSW no APO-KETO-E APX FSW no ORUDIS E-100 RPR FSW no NOVO-KETO-EC NOP FSW no PMS-KETOPROFEN-EC PMS FSW no

ORUDIS RPR FSW no PMS-KETOPROFEN PMS FSW no

RHODIS RHP FSW no ORUDIS RPR FSW no PMS-KETOPROFEN PMS FSW no NOVO-KETO NOP FSW no ORAFEN TCH FSW no

PONSTAN PDA FW no APO-MEFENAMIC APX FW no NU-MEFENAMIC NXP FW no PMS-MEFENAMIC ACID PMS FW no

NAXEN ALT FSW no PMS-NAPROXEN PMS FSW no NAPROSYN HLR FSW no RHODIAPROX RHP FSW no SAB-NAPROXEN SAB FSW no

APO-NAPROXEN APX FSW no NOVO-NAPROX NOP FSW no NU-NAPROX NXP FSW no

APO-NAPROXEN APX FSW no NOVO-NAPROX NOP FSW no NAXEN ALT FSW no NU-NAPROX NXP FSW no NAPROSYN HLR FSW no

APO-NAPROXEN APX FSW no NAXEN ALT FSW no NOVO-NAPROX NOP FSW no NU-NAPROX NXP FSW no NAPROSYN HLR FSW no

NOVO-NAPROX NOP FSW no APO-NAPROXEN APX FSW no NAXEN ALT FSW no NU-NAPROX NXP FSW no NAPROSYN HLR FSW no

FELDENE PFI FSW no APO-PIROXICAM APX FSW no NOVO-PIROCAM NOP FSW no PMS-PIROXICAM PMS FSW no NU-PIROX NXP FSW no ALTI-PIROXICAM ALT FSW no GEN-PIROXICAM GPM FSW no

FELDENE PFI FSW no APO-PIROXICAM APX FSW no NOVO-PIROCAM NOP FSW no PMS-PIROXICAM PMS FSW no NU-PIROX NXP FSW no ALTI-PIROXICAM ALT FSW no GEN-PIROXICAM GPM FSW no

NOVO-SUNDAC NOP FSW no APO-SULIN APX FSW no NU-SULINDAC NXP FSW no

NOVO-SUNDAC NOP FSW no APO-SULIN APX FSW no NU-SULINDAC NXP FSW no

ALB-TIAFEN ALT FSW no APO-TIAPROFENIC APX FSW no NOVO-TIAPROFENIC NOP FSW no PMS-TIAPROFENIC PMS FSW no

ALB-TIAFEN ALT FSW no APO-TIAPROFENIC APX FSW no NU-TIAPROFENIC NXP FSW no NOVO-TIAPROFENIC NOP FSW no SURGAM HMR FSW no PMS-TIAPROFENIC PMS FSW no

NOVO-TOLMETIN NOP FSW no

TOLECTIN JAN FSW no

TOLECTIN JAN FSW no

LENOLTEC NO.4 TCH FSW no EMPRACET-60 GLA FSW no TYLENOL NO.4 JAN FSW no

ATASOL-15 HOR FSW no EXDOL-15 LIH FSW no LENOLTEC NO.2 TCH FSW no NOVO-GESIC C-15 NOP FSW no TYLENOL NO.2 JAN FSW no

ATASOL-30 HOR FSW no EXDOL-30 LIH FSW no LENOLTEC NO.3 TCH FSW no NOVO-GESIC C-30 NOP FSW no TYLENOL NO.3 JAN FSW no

292 LIH FSW no

CODEINE PHOSPHATE TCH FSW no

CODEINE PHOSPHATE TCH FSW no

CODEINE PHOSPHATE TCH FSW no

DILAUDID KNL FSW no PMS-HYDROMORPHONE PMS FSW no

DILAUDID KNL FSW no

DILAUDID KNL FSW no

DILAUDID KNL FSW no PMS-HYDROMORPHONE PMS FSW no

DILAUDID KNL FSW no PMS-HYDROMORPHONE PMS FSW no

DILAUDID KNL FSW no

SEE APPENDIX A FOR EDS CRITERIA HYDROMORPH CONTIN PFR FSW yes

SEE APPENDIX A FOR EDS CRITERIA HYDROMORPH CONTIN PFR FSW yes

SEE APPENDIX A FOR EDS CRITERIA HYDROMORPH CONTIN PFR FSW yes

SEE APPENDIX A FOR EDS CRITERIA HYDROMORPH CONTIN PFR FSW yes

SEE APPENDIX A FOR EDS CRITERIA HYDROMORPH CONTIN PFR FSW yes

DEMEROL SAW FSW no

M.O.S. ICN FSW no STATEX PMS FSW no MORPHITEC-1 TCH FSW no

M.O.S. ICN FSW no STATEX PMS FSW no MORPHITEC-5 TCH FSW no

M.O.S. ICN FSW no STATEX PMS FSW no MORPHITEC-10 TCH FSW no

STATEX PMS FSW no M.O.S. ICN FSW no MORPHITEC-20 TCH FSW no

STATEX PMS FSW no M.O.S.-SULFATE ICN FSW no MSIR PFR FSW no

STATEX PMS FSW no M.O.S. ICN FSW no M.O.S.-SULFATE ICN FSW no MSIR PFR FSW no

M.O.S. ICN FSW no MSIR PFR FSW no

STATEX PMS FSW no M.O.S.-SULFATE ICN FSW no

MSIR PFR FSW no

M.O.S. ICN FSW no

STATEX PMS FSW no M.O.S.-SULFATE ICN FSW no

M.O.S. ICN FSW no

M-ESLON RPR FSW no

M-ESLON RPR FSW no

M-ESLON RPR FSW no

M-ESLON RPR FSW no

M-ESLON RPR FSW no

M-ESLON RPR FSW no

MS CONTIN PFR FSW no

M.O.S.-SR ICN FSW no ORAMORPH SR BOE FSW no MS CONTIN PFR FSW no

M.O.S.-SR ICN FSW no ORAMORPH SR BOE FSW no MS CONTIN PFR FSW no

ORAMORPH SR BOE FSW no MS CONTIN PFR FSW no

MS CONTIN PFR FSW no

OXYCOCET TCH FSW no PERCOCET DUP FSW no ENDOCET END FSW no

OXYCODAN TCH FSW no ENDODAN END FSW no PERCODAN DUP FSW no

642 LIH FSW no NOTE: PROPOXYPHENE NAPSYLATE 100MG IS EQUIVALENT IN ANALGESIC ACTIVITY TO PROPOXYPHENE HCL 65MG

NOVO-PROPOXYN NOP FSW no DARVON-N LIL FSW no NOTE: PROPOXYPHENE NAPSYLATE 100MG IS EQUIVALENT IN ANALGESIC ACTIVITY TO PROPOXYPHENE HCL 65MG

TALWIN SAW FSW no

PMS-ACETAMINOPHEN PMS W no

PMS-ACETAMINOPHEN PMS W no

NOVO-GESIC NOP W no APO-ACETAMINOPHEN APX W no PMS-ACETAMINOPHEN PMS W no

NOVO-GESIC FORTE NOP W no APO-ACETAMINOPHEN APX W no

ABENOL SKB W no ACET-120 PMS W no

ABENOL SKB W no ACET-325 PMS W no

IDARAC SAW FSW no

IDARAC SAW FSW no

PHENOBARBITAL SDR FSW no

PHENOBARBITAL PDA FSW no PHENOBARBITAL SDR FSW no

PHENOBARBITAL PDA FSW no PHENOBARBITAL SDR FSW no

PHENOBARBITAL PDA FSW no PHENOBARBITAL SDR FSW no

PHENOBARBITAL SDR FSW no

APO-PRIMIDONE APX FW no MYSOLINE WAY FW no

APO-PRIMIDONE APX FSW no MYSOLINE WAY FSW no

RIVOTRIL HLR FSW no ALTI-CLONAZEPAM ALT FSW no NU-CLONAZEPAM NXP FSW no APO-CLONAZEPAM APX FSW no PMS-CLONAZEPAM-R PMS FSW no CLONAPAM ICN FSW no GEN-CLONAZEPAM GPM FSW no RHO-CLONAZEPAM RHP FSW no NOVO-CLONAZEPAM NOP FSW no

RIVOTRIL HLR FSW no PMS-CLONAZEPAM PMS FSW no ALTI-CLONAZEPAM ALT FSW no NU-CLONAZEPAM NXP FSW no APO-CLONAZEPAM APX FSW no CLONAPAM ICN FSW no GEN-CLONAZEPAM GPM FSW no RHO-CLONAZEPAM RHP FSW no NOVO-CLONAZEPAM NOP FSW no

DILANTIN PDA FSW no

DILANTIN PDA FSW no

DILANTIN PDA FSW no

DILANTIN PDA FSW no

ZARONTIN PDA FSW no

ZARONTIN PDA FSW no

CELONTIN PDA FSW no

TEGRETOL CHEWTAB NVR FW no

TEGRETOL CHEWTAB NVR FW no

TEGRETOL NVR FSW no APO-CARBAMAZEPINE APX FSW no NOVO-CARBAMAZ NOP FSW no NU-CARBAMAZEPINE NXP FSW no TARO-CARBAMAZEPINE TAR FSW no

TEGRETOL CR NVR FSW no PMS-CARBAMAZEPINE CR PMS FSW no TARO-CARBAMAZEPINE CR TAR FSW no

TEGRETOL CR NVR FSW no PMS-CARBAMAZEPINE CR PMS FSW no TARO-CARBAMAZEPINE CR TAR FSW no

FRISIUM HMR FSW no NOVO-CLOBAZAM NOP FSW no ALTI-CLOBAZAM ALT FSW no

EPIVAL ABB FSW no NU-DIVALPROEX NXP FSW no APO-DIVALPROEX APX FSW no NOVO-DIVALPROEX NOP FSW no

EPIVAL ABB FSW no NU-DIVALPROEX NXP FSW no APO-DIVALPROEX APX FSW no NOVO-DIVALPROEX NOP FSW no

EPIVAL ABB FSW no NU-DIVALPROEX NXP FSW no APO-DIVALPROEX APX FSW no NOVO-DIVALPROEX NOP FSW no

SEE APPENDIX A FOR EDS CRITERIA

NEURONTIN PDA FSW yes

NEURONTIN PDA FSW yes

NEURONTIN PDA FSW yes

LAMICTAL GLA FSW no

LAMICTAL GLA FSW no

LAMICTAL GLA FSW no Note: Limited to a maximum 30-day supply of medication.

TOPAMAX JAN FW no

TOPAMAX JAN FSW no

TOPAMAX JAN FSW no

TOPAMAX JAN FSW no Note: Limited to a maximum 30-day supply of medication.

DEPAKENE ABB FSW no ALTI-VALPROIC ALT FSW no PMS-VALPROIC PMS FSW no DEPROIC TCH FSW no APO-VALPROIC APX FSW no

DEPAKENE ABB FSW no NOVO-VALPROIC NOP FSW no ALTI-VALPROIC ALT FSW no GEN-VALPROIC GPM FSW no DEPROIC TCH FSW no PMS-VALPROIC PMS FSW no NU-VALPROIC NXP FSW no APO-VALPROIC APX FSW no

DEPAKENE ABB FSW no ALTI-VALPROIC ALT FSW no NOVO-VALPROIC NOP FSW no PMS-VALPROIC PMS FSW no DEPROIC TCH FSW no

SABRIL HMR FSW no Note: Limited to a maximum 30-day supply of medication.

ELAVIL MSD FSW no NOVO-TRIPTYN NOP FSW no APO-AMITRIPTYLINE APX FSW no

ELAVIL MSD FSW no APO-AMITRIPTYLINE APX FSW no

ELAVIL MSD FSW no NOVO-TRIPTYN NOP FSW no APO-AMITRIPTYLINE APX FSW no

ASENDIN WAY FSW no

ASENDIN WAY FSW no

SEE APPENDIX A FOR EDS CRITERIA

WELLBUTRIN SR GLA FSW yes

WELLBUTRIN SR GLA FSW yes

CELEXA LUD FSW no

CELEXA LUD FSW no

ANAFRANIL NVR FSW no APO-CLOMIPRAMINE APX FSW no GEN-CLOMIPRAMINE GPM FSW no NOVO-CLOPAMINE NOP FSW no

ANAFRANIL NVR FSW no APO-CLOMIPRAMINE APX FSW no NOVO-CLOPAMINE NOP FSW no GEN-CLOMIPRAMINE GPM FSW no

ANAFRANIL NVR FSW no APO-CLOMIPRAMINE APX FSW no NOVO-CLOPAMINE NOP FSW no GEN-CLOMIPRAMINE GPM FSW no

PMS-DESIPRAMINE PMS FSW no ALTI-DESIPRAMINE ALT FSW no NORPRAMIN HMR FSW no NU-DESIPRAMINE NXP FSW no APO-DESIPRAMINE APX FSW no NOVO-DESIPRAMINE NOP FSW no

PMS-DESIPRAMINE PMS FSW no ALTI-DESIPRAMINE ALT FSW no NORPRAMIN HMR FSW no NU-DESIPRAMINE NXP FSW no APO-DESIPRAMINE APX FSW no NOVO-DESIPRAMINE NOP FSW no

PMS-DESIPRAMINE PMS FSW no ALTI-DESIPRAMINE ALT FSW no NORPRAMIN HMR FSW no NU-DESIPRAMINE NXP FSW no APO-DESIPRAMINE APX FSW no NOVO-DESIPRAMINE NOP FSW no

PMS-DESIPRAMINE PMS FSW no ALTI-DESIPRAMINE ALT FSW no NU-DESIPRAMINE NXP FSW no APO-DESIPRAMINE APX FSW no NOVO-DESIPRAMINE NOP FSW no

NORPRAMINE HMR FSW no PMS-DESIPRAMINE PMS FSW no NU-DESIPRAMINE NXP FSW no APO-DESIPRAMINE APX FSW no

SINEQUAN PFI FSW no APO-DOXEPIN APX FSW no ALTI-DOXEPIN ALT FSW no

SINEQUAN PFI FSW no NOVO-DOXEPIN NOP FSW no APO-DOXEPIN APX FSW no ALTI-DOXEPIN ALT FSW no

SINEQUAN PFI FSW no NOVO-DOXEPIN NOP FSW no APO-DOXEPIN APX FSW no ALTI-DOXEPIN ALT FSW no

SINEQUAN PFI FSW no NOVO-DOXEPIN NOP FSW no APO-DOXEPIN APX FSW no ALTI-DOXEPIN ALT FSW no

SINEQUAN PFI FSW no NOVO-DOXEPIN NOP FSW no APO-DOXEPIN APX FSW no

NOVO-DOXEPIN NOP FSW no APO-DOXEPIN APX FSW no

PROZAC LIL FSW no PMS-FLUOXETINE PMS FSW no NU-FLUOXETINE NXP FSW no APO-FLUOXETINE APX FSW no NOVO-FLUOXETINE NOP FSW no GEN-FLUOXETINE GPM FSW no ALTI-FLUOXETINE ALT FSW no

PROZAC LIL FSW no PMS-FLUOXETINE PMS FSW no NU-FLUOXETINE NXP FSW no APO-FLUOXETINE APX FSW no NOVO-FLUOXETINE NOP FSW no GEN-FLUOXETINE GPM FSW no ALTI-FLUOXETINE ALT FSW no

LUVOX SLV FSW no ALTI-FLUVOXAMINE ALT FSW no APO-FLUVOXAMINE APX FSW no NOVO-FLUVOXAMINE NOP FSW no GEN-FLUVOXAMINE GPM FSW no PMS-FLUVOXAMINE PMS FSW no

LUVOX SLV FSW no ALTI-FLUVOXAMINE ALT FSW no APO-FLUVOXAMINE APX FSW no NOVO-FLUVOXAMINE NOP FSW no GEN-FLUVOXAMINE GPM FSW no PMS-FLUVOXAMINE PMS FSW no

NOVO-PRAMINE NOP FSW no APO-IMIPRAMINE APX FSW no

TOFRANIL NVR FSW no NOVO-PRAMINE NOP FSW no APO-IMIPRAMINE APX FSW no

TOFRANIL NVR FSW no NOVO-PRAMINE NOP FSW no APO-IMIPRAMINE APX FSW no

TOFRANIL NVR FSW no

LUDIOMIL NVR FSW no NOVO-MAPROTILINE NOP FSW no

LUDIOMIL NVR FSW no NOVO-MAPROTILINE NOP FSW no

LUDIOMIL NVR FSW no NOVO-MAPROTILINE NOP FSW no

LUDIOMIL NVR FSW no NOVO-MAPROTILINE NOP FSW no

APO-MOCLOBEMIDE APX FSW no NU-MOCLOBEMIDE NXP FSW no NOVO-MOCLOBEMIDE NOP FSW no

MANERIX HLR FSW no ALTI-MOCLOBEMIDE ALT FSW no APO-MOCLOBEMIDE APX FSW no NU-MOCLOBEMIDE NXP FSW no NOVO-MOCLOBEMIDE NOP FSW no

MANERIX HLR FSW no ALTI-MOCLOBEMIDE ALT FSW no NOVO-MOCLOBEMIDE NOP FSW no APO-MOCLOBEMIDE APX FSW no

SERZONE BMS FSW no

SERZONE BMS FSW no

SERZONE BMS FSW no

AVENTYL LIL FSW no PMS-NORTRIPTYLINE PMS FSW no NU-NORTRIPTYLINE NXP FSW no APO-NORTRIPTYLINE APX FSW no NORVENTYL ICN FSW no GEN-NORTRIPTYLINE GPM FSW no NOVO-NORTRIPTYLINE NOP FSW no ALTI-NORTRIPTYLINE ALT FSW no

AVENTYL LIL FSW no PMS-NORTRIPTYLINE PMS FSW no NU-NORTRIPTYLINE NXP FSW no APO-NORTRIPTYLINE APX FSW no NORVENTYL ICN FSW no GEN-NORTRIPTYLINE GPM FSW no NOVO-NORTRIPTYLINE NOP FSW no ALTI-NORTRIPTYLINE ALT FSW no

PAXIL SKB FSW no

PAXIL SKB FSW no

NARDIL PDA FSW no

TRIPTIL MSD FSW no

ZOLOFT PFI FSW no APO-SERTRALINE APX FSW no NOVO-SERTRALINE NOP FSW no

ZOLOFT PFI FSW no APO-SERTRALINE APX FSW no NOVO-SERTRALINE NOP FSW no

ZOLOFT PFI FSW no APO-SERTRALINE APX FSW no NOVO-SERTRALINE NOP FSW no

PARNATE SKB FSW no

DESYREL BMS FSW no PMS-TRAZODONE PMS FSW no ALTI-TRAZODONE ALT FSW no NOVO-TRAZODONE NOP FSW no APO-TRAZODONE APX FSW no NU-TRAZODONE NXP FSW no TRAZOREL ICN FSW no GEN-TRAZODONE GPM FSW no

DESYREL BMS FSW no PMS-TRAZODONE PMS FSW no ALTI-TRAZODONE ALT FSW no NOVO-TRAZODONE NOP FSW no APO-TRAZODONE APX FSW no NU-TRAZODONE NXP FSW no TRAZOREL ICN FSW no GEN-TRAZODONE GPM FSW no

DESYREL BMS FSW no NOVO-TRAZADONE NOP FSW no APO-TRAZADONE APX FSW no NU-TRAZADONE NXP FSW no

RHOTRIMINE RHP FSW no SURMONTIL RPR FSW no APO-TRIMIP APX FSW no

APO-TRIMIP APX FSW no RHOTRIMINE RHP FSW no SURMONTIL RPR FSW no NU-TRIMIPRAMINE NXP FSW no

APO-TRIMIP APX FSW no RHOTRIMINE RHP FSW no SURMONTIL RPR FSW no NOVO-TRIPRAMINE NOP FSW no NU-TRIMIPRAMINE NXP FSW no

APO-TRIMIP APX FSW no RHOTRIMINE RHP FSW no SURMONTIL RPR FSW no NOVO-TRIPRAMINE NOP FSW no NU-TRIMIPRAMINE NXP FSW no

APO-TRIMIP APX FSW no RHOTRIMINE RHP FSW no SURMONTIL RPR FSW no NOVO-TRIPRAMINE NOP FSW no NU-TRIMIPRAMINE NXP FSW no

EFFEXOR WAY FSW no

EFFEXOR WAY FSW no

EFFEXOR XR WAY FSW no

EFFEXOR XR WAY FSW no

EFFEXOR XR WAY FSW no

LARGACTIL RPR FSW no

CHLORPROMANYL 20 TCH FSW no LARGACTIL RPR FSW no

NOVO-CHLORPROMAZINE NOP FSW no

NOVO-CHLORPROMAZINE NOP FSW no

NOVO-CHLORPROMAZINE NOP FSW no

NOVO-CHLORPROMAZINE NOP FSW no

SEE APPENDIX A FOR EDS CRITERIA

CLOZARIL NVR FSW yes

CLOZARIL NVR FSW yes Note: Clozapine is only to be dispensed to patients upon receipt of weekly or bi-weekly hematological test results by the pharmacy.

FLUANXOL LUD FSW no

FLUANXOL LUD FSW no

APO-FLUPHENAZINE APX FSW no

APO-FLUPHENAZINE APX FSW no

APO-FLUPHENAZINE APX FSW no

MODITEN BMS FSW no

PERIDOL TCH FSW no APO-HALOPERIDOL APX FSW no PMS-HALOPERIDOL PMS FSW no

NOVO-PERIDOL NOP FSW no APO-HALOPERIDOL APX FSW no PERIDOL TCH FSW no

NOVO-PERIDOL NOP FSW no APO-HALOPERIDOL APX FSW no PERIDOL TCH FSW no

NOVO-PERIDOL NOP FSW no APO-HALOPERIDOL APX FSW no

NOVO-PERIDOL NOP FSW no APO-HALOPERIDOL APX FSW no PERIDOL TCH FSW no

APO-HALOPERIDOL APX FSW no NOVO-PERIDOL NOP FSW no

NOVO-PERIDOL NOP FSW no

LOXAPAC WAY FSW no PMS-LOXAPINE PMS FSW no NU-LOXAPINE NXP FSW no APO-LOXAPINE APX FSW no

LOXAPAC WAY FSW no PMS-LOXAPINE PMS FSW no NU-LOXAPINE NXP FSW no APO-LOXAPINE APX FSW no

LOXAPAC WAY FSW no PMS-LOXAPINE PMS FSW no NU-LOXAPINE NXP FSW no APO-LOXAPINE APX FSW no

LOXAPAC WAY FSW no PMS-LOXAPINE PMS FSW no NU-LOXAPINE NXP FSW no APO-LOXAPINE APX FSW no

TRYPTAN ICN FSW no PMS-TRYPTOPHAN PMS FSW no

TRYPTAN ICN FSW no PMS-TRYPTOPHAN PMS FSW no ALTI-TRYPTOPHAN ALT FSW no

SEE APPENDIX A FOR EDS CRITERIA

ZYPREXA LIL FSW yes

ZYPREXA LIL FSW yes

ZYPREXA LIL FSW yes

ZYPREXA LIL FSW yes

NEULEPTIL RPR FSW no

NEULEPTIL RPR FSW no

NEULEPTIL RPR FSW no

APO-PERPHENAZINE APX FSW no

APO-PERPHENAZINE APX FSW no

APO-PERPHENAZINE APX FSW no

APO-PERPHENAZINE APX FSW no

ORAP PMS FSW no

ORAP PMS FSW no

STEMETIL RHP FSW no

STEMETIL RHP FSW no

STEMETIL RHP FSW no NU-PROCHLOR NXP FSW no

STEMETIL RHP FSW no NU-PROCHLOR NXP FSW no

SEE APPENDIX A FOR EDS CRITERIA

SEROQUEL AZE FSW yes

SEROQUEL AZE FSW yes

SEROQUEL AZE FSW yes

SEE APPENDIX A FOR EDS CRITERIA

RISPERDAL JAN FSW yes

RISPERDAL JAN FSW yes

RISPERDAL JAN FSW yes

RISPERDAL JAN FSW yes

MELLARIL NVR FSW no

NOVO-RIDAZINE NOP FSW no APO-THIORIDAZINE APX FSW no PMS-THIORIDAZINE PMS FSW no

NOVO-RIDAZINE NOP FSW no APO-THIORIDAZINE APX FSW no PMS-THIORIDAZINE PMS FSW no

NOVO-RIDAZINE NOP FSW no APO-THIORIDAZINE APX FSW no PMS-THIORIDAZINE PMS FSW no

NOVO-RIDAZINE NOP FSW no APO-THIORIDAZINE APX FSW no PMS-THIORIDAZINE PMS FSW no

NAVANE PFI FSW no

NAVANE PFI FSW no

NAVANE PFI FSW no

PMS-TRIFLUOPERAZINE PMS FSW no

APO-TRIFLUOPERAZINE APX FSW no STELAZINE SKB FSW no

NOVO-TRIFLUZINE NOP FSW no APO-TRIFLUOPERAZINE APX FSW no STELAZINE SKB FSW no

NOVO-TRIFLUZINE NOP FSW no APO-TRIFLUOPERAZINE APX FSW no STELAZINE SKB FSW no

NOVO-TRIFLUZINE NOP FSW no APO-TRIFLUOPERAZINE APX FSW no STELAZINE SKB FSW no

DEXEDRINE SKB FW no

DEXEDRINE SKB FW no

DEXEDRINE SKB FW no

RITALIN NVR FW no PMS-METHYLPHENIDATE PMS FW no RIPHENIDATE TCH FW no

RITALIN NVR FW no PMS-METHYLPHENIDATE PMS FW no RIPHENIDATE TCH FW no

RITALIN SR NVR FW no

XANAX PHU FSW no ALTI-ALPRAZOLAM ALT FSW no APO-ALPRAZ APX FSW no NU-ALPRAZ NXP FSW no NOVO-ALPRAZOL NOP FSW no GEN-ALPRAZOLAM GPM FSW no

XANAX PHU FSW no ALTI-ALPRAZOLAM ALT FSW no APO-ALPRAZ APX FSW no NU-ALPRAZ NXP FSW no NOVO-ALPRAZOL NOP FSW no GEN-ALPRAZOLAM GPM FSW no

LECTOPAM HLR FSW no ALTI-BROMAZEPAM ALT FSW no NU-BROMAZEPAM NXP FSW no APO-BROMAZEPAM APX FSW no GEN-BROMAZEPAM GPM FSW no

LECTOPAM HLR FSW no ALTI-BROMAZEPAM ALT FSW no NU-BROMAZEPAM NXP FSW no APO-BROMAZEPAM APX FSW no GEN-BROMAZEPAM GPM FSW no NOVO-BROMAZEPAM NOP FSW no

LECTOPAM HLR FSW no ALTI-BROMAZEPAM ALT FSW no NU-BROMAZEPAM NXP FSW no APO-BROMAZEPAM APX FSW no GEN-BROMAZEPAM GPM FSW no NOVO-BROMAZEPAM NOP FSW no

NOVO-POXIDE NOP FSW no APO-CHLORDIAZEPOXIDE APX FSW no

NOVO-POXIDE NOP FSW no APO-CHLORDIAZEPOXIDE APX FSW no

NOVO-POXIDE NOP FSW no APO-CHLORDIAZEPOXIDE APX FSW no

TRANXENE ABB FSW no NOVO-CLOPATE NOP FSW no APO-CLORAZEPATE APX FSW no

TRANXENE ABB FSW no NOVO-CLOPATE NOP FSW no APO-CLORAZEPATE APX FSW no

TRANXENE ABB FSW no NOVO-CLOPATE NOP FSW no APO-CLORAZEPATE APX FSW no

VIVOL HOR FSW no NOVO-DIPAM NOP FSW no APO-DIAZEPAM APX FSW no

VALIUM HLR FSW no VIVOL HOR FSW no NOVO-DIPAM NOP FSW no APO-DIAZEPAM APX FSW no

VALIUM HLR FSW no VIVOL HOR FSW no NOVO-DIPAM NOP FSW no APO-DIAZEPAM APX FSW no

DALMANE ICN FSW no NOVO-FLUPAM NOP FSW no APO-FLURAZEPAM APX FSW no PMS-FLURAZEPAM PMS FSW no

DALMANE ICN FSW no NOVO-FLUPAM NOP FSW no APO-FLURAZEPAM APX FSW no PMS-FLURAZEPAM PMS FSW no

APO-LORAZEPAM APX FSW no NOVO-LORAZEM NOP FSW no NU-LORAZ NXP FSW no ATIVAN WAY FSW no

NOVO-LORAZEM NOP FSW no APO-LORAZEPAM APX FSW no NU-LORAZ NXP FSW no ATIVAN WAY FSW no

NOVO-LORAZEM NOP FSW no APO-LORAZEPAM APX FSW no NU-LORAZ NXP FSW no ATIVAN WAY FSW no

MOGADON ICN FSW no NITRAZADON ICN FSW no RHO-NITRAZEPAM RHP FSW no

MOGADON ICN FSW no NITRAZADON ICN FSW no RHO-NITRAZEPAM RHP FSW no

APO-OXAZEPAM APX FSW no NOVOXAPAM NOP FSW no SERAX WAY FSW no

APO-OXAZEPAM APX FSW no NOVOXAPAM NOP FSW no SERAX WAY FSW no

APO-OXAZEPAM APX FSW no NOVOXAPAM NOP FSW no SERAX WAY FSW no

RESTORIL NVR FSW no NU-TEMAZEPAM NXP FSW no APO-TEMAZEPAM APX FSW no PMS-TEMAZEPAM PMS FSW no NOVO-TEMAZEPAM NOP FSW no GEN-TEMAZEPAM GPM FSW no

RESTORIL NVR FSW no NU-TEMAZEPAM NXP FSW no APO-TEMAZEPAM APX FSW no PMS-TEMAZEPAM PMS FSW no NOVO-TEMAZEPAM NOP FSW no GEN-TEMAZEPAM GPM FSW no

Note: Treatment with Triazolam should not exceed 7 consecutive days. As a result, quantities dispensed should not exceed a 7 day supply. Use for more than 2 to 3 consecutive weeks requires a complete re-evaluation of the patient.

ALTI-TRIAZOLAM ALT FSW no APO-TRIAZO APX FSW no NOVO-TRIOLAM NOP FSW no GEN-TRIAZOLAM GPM FSW no

HALCION PHU FSW no ALTI-TRIAZOLAM ALT FSW no APO-TRIAZO APX FSW no NOVO-TRIOLAM NOP FSW no GEN-TRIAZOLAM GPM FSW no

BUSPAR BMS FSW no LIN-BUSPIRONE LIN FSW no NU-BUSPIRONE NXP FSW no APO-BUSPIRONE APX FSW no GEN-BUSPIRONE GPM FSW no PMS-BUSPIRONE PMS FSW no NOVO-BUSPIRONE NOP FSW no BUSPIREX TCH FSW no

PMS-CHLORAL HYDRATE PMS FSW no

ATARAX PFI FSW no PMS-HYDROXYZINE PMS FSW no

APO-HYDROXYZINE APX FSW no NOVO-HYDROXYZIN NOP FSW no

ATARAX PFI FSW no APO-HYDROXYZINE APX FSW no NOVO-HYDROXYZIN NOP FSW no

APO-HYDROXYZINE APX FSW no NOVO-HYDROXYZIN NOP FSW no

NOZINAN RPR FSW no

NOZINAN RPR FSW no

NOZINAN RPR FSW no APO-METHOPRAZINE APX FSW no

NOZINAN RPR FSW no NOVO-MEPRAZINE NOP FSW no PMS-METHOTRIMEPRAZINE PMS FSW no APO-METHOPRAZINE APX FSW no

NOZINAN RPR FSW no NOVO-MEPRAZINE NOP FSW no PMS-METHOTRIMEPRAZINE PMS FSW no APO-METHOPRAZINE APX FSW no

NOZINAN RPR FSW no NOVO-MEPRAZINE NOP FSW no PMS-METHOTRIMEPRAZINE PMS FSW no APO-METHOPRAZINE APX FSW no

CARBOLITH ICN FSW no PMS-LITHIUM CARBONATE PMS FSW no

LITHANE PFI FSW no

CARBOLITH ICN FSW no PMS-LITHIUM CARBONATE PMS FSW no

LITHANE PFI FSW no

CARBOLITH ICN FSW no PMS-LITHIUM CARBONATE PMS FSW no

DURALITH JAN FSW no

Note: The identification numbers listed in this section have been generated by the Drug Cost Assistance Programs for billing purposes only.

DIASTIX BAY D no

KETOSTIX BAY D no

CALCIUM-250 NOP W no APO-CAL 250 APX W no

CALCIUM-500 NOP W no APO-CAL 500 APX W no

MICRO-K EXTENCAPS WYA W no

SLOW-K NVR W no APO-K APX W no

K-10 SKB W no PMS-POTASSIUM CHLORIDE PMS W no

K-LYTE RBP W no

PMS-SOD POLYSTYRENE SULF PMS FSW no KAYEXALATE SAW FSW no

NOVO-THALIDONE NOP FSW no APO-CHLORTHALIDONE APX FSW no

NOVO-THALIDONE NOP FSW no APO-CHLORTHALIDONE APX FSW no

LASIX HMR FSW no

NOVO-SEMIDE NOP FSW no APO-FUROSEMIDE APX FSW no LASIX HMR FSW no

NOVO-SEMIDE NOP FSW no APO-FUROSEMIDE APX FSW no LASIX HMR FSW no

APO-FUROSEMIDE APX FSW no NOVO-SEMIDE NOP FSW no LASIX HMR FSW no

HYDRODIURIL MSD FSW no NOVO-HYDRAZIDE NOP FSW no APO-HYDRO 25 APX FSW no

NOVO-HYDRAZIDE NOP FSW no APO-HYDRO 50 APX FSW no

ZAROXOLYN RPR FSW no

ZAROXOLYN RPR FSW no

MODURET MSD FSW no APO-AMILZIDE APX FSW no NU-AMILZIDE NXP FSW no NOVAMILOR NOP FSW no ALTI-AMILORIDE ALT FSW no

ALDACTONE SEA FSW no NOVO-SPIROTON NOP FSW no

ALDACTONE SEA FSW no NOVO-SPIROTON NOP FSW no

ALDACTAZIDE-25 SEA FSW no NOVO-SPIROZINE-25 NOP FSW no

ALDACTAZIDE-50 SEA FSW no NOVO-SPIROZINE-50 NOP FSW no

DYRENIUM SKB FSW no

DYRENIUM SKB FSW no

APO-TRIAZIDE APX FSW no NOVO-TRIAMZIDE NOP FSW no NU-TRIAZIDE NXP FSW no DYAZIDE SKB FSW no

BENURYL ICN FSW no

APO-SULFINPYRAZONE APX FSW no NOVO-PYRAZONE NOP FSW no NU-SULFINPYRAZONE NXP FSW no

ANTURAN NVR FSW no APO-SULFINPYRAZONE APX FSW no NOVO-PYRAZONE NOP FSW no NU-SULFINPYRAZONE NXP FSW no

CALMYLIN #1 TCH W no

CALDOMINE DH FORTE TCH W no

CALDOMINE DH PEDIATRIC TCH W no

CALMYLIN EXPECTORANT TCH W no

PENTAMYCETIN SAB FSW no

PENTAMYCETIN SAB FSW no

PMS-ERYTHROMYCIN PMS FSW no

GARAMYCIN SCH FSW no SAB-GENTAMICIN SAB FSW no

ALCOMICIN ALC FSW no GARAMYCIN SCH FSW no PMS-GENTAMICIN PMS FSW no GARATEC TCH FSW no GENTACIDIN CIV FSW no SCHEIN-GENTAMICIN SCN FSW no SAB-GENTAMICIN SAB FSW no

GARAMYCIN SCH FSW no SAB-GENTAMICIN SAB FSW no PMS-GENTAMICIN PMS FSW no

POLYSPORIN WLA W no

POLYSPORIN WLA W no

NEOSPORIN GLA FSW no

NEOSPORIN GLA FSW no OPTIMYXIN PLUS SAB FSW no

TOBREX ALC FSW no

TOBREX ALC FSW no TOMYCINE CIV FSW no PMS-TOBRAMYCIN PMS FSW no

VIROPTIC GLA FSW no

SODIUM SULAMYD SCH FSW no CETAMIDE ALC FSW no

BLEPH-10 ALL FSW no SODIUM SULAMYD SCH FSW no

SEE APPENDIX A FOR CRITERIA

CILOXAN ALC FSW yes

CILOXAN ALC FSW yes

SEE APPENDIX A FOR CRITERIA

NOROXIN MSD FSW yes

VANCENASE SCH FSW no

ALTI-BECLOMETHASONE AQ. ALT FSW no GEN-BECLO AQ. GPM FSW no NU-BECLOMETHASONE NXP FSW no APO-BECLOMETHASONE APX FSW no

MAXIDEX ALC FSW no

MAXIDEX ALC FSW no

DEXAMETHASONE SOD. PHOS SAB FSW no PMS-DEXAMETHASONE PMS FSW no

ALTI-FLUNISOLIDE ALT FSW no RHINALAR HLR FSW no

FML ALL FSW no

FLAREX ALC FSW no

SEE APPENDIX A FOR EDS CRITERIA

OCUFEN ALL FSW yes

FLONASE GLA FSW no

SEE APPENDIX A FOR EDS CRITERIA

ACULAR ALL FSW yes

PRED MILD ALL FSW no SAB-PREDNISOLONE SAB FSW no

PRED FORTE ALL FSW no OPHTHO-TATE ALT FSW no SAB-PREDNISOLONE SAB FSW no

PENTAMYCETIN HC SAB FSW no

LOCACORTEN-VIOFORM NVR FSW no

SOFRACORT HMR FSW no

GARASONE SCH FSW no

GARASONE SCH FSW no

CORTISPORIN GLA FSW no

CORTISPORIN GLA FSW no CORTIMYXIN SAB FSW no

CORTISPORIN GLA FSW no

TOBRADEX ALC FSW no

TOBRADEX ALC FSW no

NOVO-ZOLAMIDE NOP FSW no APO-ACETAZOLAMIDE APX FSW no DIAMOX WAY FSW no

TRUSOPT MSD FSW no

NEPTAZANE WAY FSW no

NEPTAZANE WAY FSW no

SEE APPENDIX A FOR EDS CRITERIA

TANTUM ORAL RINSE MDA FSW yes SUN-BENZ SUN FSW yes PMS-BENZYDAMINE PMS FSW yes NOVO-BENZYDAMINE NOP FSW yes ALTI-BENZYDAMINE ALT FSW yes APO-BENZYDAMINE APX FSW yes

ISOPTO CARBACHOL ALC FSW no

ISOPTO CARBACHOL ALC FSW no

PILOPINE HS ALC FSW no

ISOPTO CARPINE ALC FSW no

ISOPTO CARPINE ALC FSW no MIOCARPINE CIV FSW no PILOCARPINE TCH FSW no SCHEIN-PILOCARPINE SCN FSW no

ISOPTO CARPINE ALC FSW no MIOCARPINE CIV FSW no PILOCARPINE TCH FSW no SCHEIN-PILOCARPINE SCN FSW no

ISOPTO CARPINE ALC FSW no MIOCARPINE CIV FSW no PILOCARPINE TCH FSW no SCHEIN-PILOCARPINE SCN FSW no

ISOPTO CARPINE ALC FSW no MIOCARPINE CIV FSW no

ATROPINE SULFATE ALC FSW no

ISOPTO ATROPINE ALC FSW no ATROPINE CIV FSW no ATROPISOL CIV FSW no

PROPINE ALL FSW no OPHTHO-DIPIVEFRIN ALT FSW no DPE ALC FSW no PMS-DIPIVEFRIN PMS FSW no

ISOPTO HOMATROPINE ALC FSW no

ISOPTO HOMATROPINE ALC FSW no

MYDFRIN ALC FSW no

IOPIDINE ALC FSW no

ISOPTO-TEARS ALC W no EYELUBE SAB W no

ISOPTO-TEARS ALC W no EYELUBE SAB W no

BETOPTIC S ALC FSW no

ALPHAGAN ALL FSW no

SEE APPENDIX A FOR EDS CRITERIA

VOLTAREN OPHTHA CIV FSW yes

XALATAN PHU FSW no Note: The provincial drug programs will only pay for one 2.5 mL bottle of Xalatan per client every 30 days. Clients are responsible for the entire prescription cost of any Xalatan required beyond this.

BETAGAN ALL FSW no OPHTHO-BUNOLOL ALT FSW no NOVO-LEVOBUNOLOL NOP FSW no

BETAGAN ALL FSW no OPHTHO-BUNOLOL ALT FSW no NOVO-LEVOBUNOLOL NOP FSW no PMS-LEVOBUNOLOL PMS FSW no

DURATEARS NATURALE ALC W no

CROMOLYN PMS FSW no APO-CROMOLYN APX FSW no

CROMOLYN PMS SW no OPTICROM ALL SW no SOLU-CROM SAB SW no

TIMOPTIC MSD FSW no APO-TIMOP APX FSW no GEN-TIMOLOL GPM FSW no NOVO-TIMOL NOP FSW no PMS-TIMOLOL PMS FSW no TIMOLOL MALEATE SAB FSW no

TIMOPTIC MSD FSW no APO-TIMOP APX FSW no GEN-TIMOLOL GPM FSW no NOVO-TIMOL NOP FSW no PMS-TIMOLOL PMS FSW no TIMOLOL MALEATE SAB FSW no

GAVISCON SKB W no

GAVISCON SKB W no

DIOVOL HOR W no

DIOVOL PLUS HOR W no

IMODIUM MCL FSW no NOVO-LOPERAMIDE NOP FSW no APO-LOPERAMIDE APX FSW no LOPERACAP ICN FSW no PMS-LOPERAMIDE PMS FSW no DIARR-EZE PMS FSW no RHO-LOPERAMIDE RHP FSW no

PMS-LOPERAMIDE HCL PMS FSW no DIARR-EZE PMS FSW no

OVOL HOR W no

Note: Cathartics and laxatives should only be used after failure of simpler measures. A high fibre diet, adequate hydration, and a review of potentially constipating medications is often effective in relieving constipation.

DULCOLAX BOE W no APO-BISACODYL APX W no PMS-BISACODYL PMS W no

DULCOLAX BOE W no

DULCOLAX BOE W no BISACOLAX ICN W no BISACODYL TCH W no PMS-BISACODYL PMS W no

PMS-DOCUSATE SODIUM PMS W no DOCUSATE SODIUM TCH W no COLACE RBP W no

COLACE RBP W no DOCUSATE SODIUM TAR W no PMS-DOCUSATE SODIUM PMS W no DOCUSATE SODIUM TCH W no

NOVO-FIBRE NOP W no

PMS-LACTULOSE PMS W no ACILAC TCH W no

CITRO-MAG ROG W no

ROYVAC BOWEL EVACUANT KIT WAY W no

NOVO-MUCILAX NOP W no NOVO-MUCILAX SUGAR FREE NOP W no METAMUCIL SUGAR FREE PGA W no METAMUCIL PGA W no

PRODIEM PLAIN NVR W no

PRODIEM PLUS NVR W no

FLEET JJM W no

COTAZYM ORG FSW no

COTAZYM ECS 8 ORG FSW no

COTAZYM ECS 20 ORG FSW no

VIOKASE AXC S no

GRAVOL HOR W no NOVO-DIMENATE NOP W no APO-DIMENHYDRINATE APX W no PMS-DIMENHYDRINATE PMS W no

GRAVOL HOR W no

GRAVOL HOR W no

DICLECTIN DUI FW no

BONAMINE PFI FSW no

SEE APPENDIX A FOR EDS CRITERIA

ZOFRAN GLA FSW yes

ZOFRAN GLA FSW yes

PENTASA HMR FSW no

PENTASA HMR FSW no

SALOFALK AXC FSW no

SALOFALK AXC FSW no

SALOFALK AXC FSW no

ASACOL PGA FSW no

SALOFALK AXC FSW no MESASAL SKB FSW no

BETNESOL RBP FSW no

TAGAMET SKB FSW no

PEPTOL TCH FSW no NOVO-CIMETINE NOP FSW no APO-CIMETIDINE APX FSW no NU-CIMET NXP FSW no GEN-CIMETIDINE GPM FSW no PMS-CIMETIDINE PMS FSW no

APO-CIMETIDINE APX FSW no PEPTOL TCH FSW no NOVO-CIMETINE NOP FSW no NU-CIMET NXP FSW no TAGAMET SKB FSW no GEN-CIMETIDINE GPM FSW no PMS-CIMETIDINE PMS FSW no

PEPTOL TCH FSW no APO-CIMETIDINE APX FSW no NOVO-CIMETINE NOP FSW no NU-CIMET NXP FSW no TAGAMET SKB FSW no GEN-CIMETIDINE GPM FSW no PMS-CIMETIDINE PMS FSW no

PEPTOL TCH FSW no APO-CIMETIDINE APX FSW no NOVO-CIMETINE NOP FSW no NU-CIMET NXP FSW no TAGAMET SKB FSW no GEN-CIMETIDINE GPM FSW no PMS-CIMETIDINE PMS FSW no

PEPTOL TCH FSW no NOVO-CIMETINE NOP FSW no APO-CIMETIDINE APX FSW no PMS-CIMETIDINE PMS FSW no

NOTE: Coverage of all Cisapride products will be discontinued as of August 7, 2000.

PREPULSID JAN FW no

PREPULSID JAN FSW no NOTE: Coverage of all Cisapride products will be discontinued as of August 7, 2000.

PREPULSID JAN FSW no

PREPULSID JAN FSW no

MOTILIUM JAN FSW no ALTI-DOMPERIDONE ALT FSW no APO-DOMPERIDONE APX FSW no NOVO-DOMPERIDONE NOP FSW no MOTILIDONE TCH FSW no PMS-DOMPERIDONE PMS FSW no NU-DOMPERIDONE NXP FSW no

PEPCID MSD FSW no APO-FAMOTIDINE APX FSW no NOVO-FAMOTIDINE NOP FSW no NU-FAMOTIDINE NXP FSW no GEN-FAMOTIDINE GPM FSW no ULCIDINE ICN FSW no

PEPCID MSD FSW no APO-FAMOTIDINE APX FSW no NOVO-FAMOTIDINE NOP FSW no NU-FAMOTIDINE NXP FSW no GEN-FAMOTIDINE GPM FSW no ULCIDINE ICN FSW no

HYCORT ICN FSW no CORTENEMA AXC FSW no

SEE APPENDIX A FOR EDS CRITERIA

PREVACID ABB FSW yes

PREVACID ABB FSW yes

SEE APPENDIX A FOR EDS CRITERIA

HP-PAC ABB FSW yes

REGLAN WAY FSW no PMS-METOCLOPRAMIDE PMS FSW no

APO-METOCLOP APX FSW no NU-METOCLOPRAMIDE NXP FSW no PMS-METOCLOPRAMIDE PMS FSW no

APO-METOCLOP APX FSW no NU-METOCLOPRAMIDE NXP FSW no PMS-METOCLOPRAMIDE PMS FSW no

CYTOTEC SEA FSW no

CYTOTEC SEA FSW no

AXID LIL FSW no PMS-NIZATIDINE PMS FSW no APO-NIZATIDINE APX FSW no NOVO-NIZATIDINE NOP FSW no

AXID LIL FSW no PMS-NIZATIDINE PMS FSW no APO-NIZATIDINE APX FSW no NOVO-NIZATIDINE NOP FSW no

DIPENTUM PHU FSW no

SEE APPENDIX A FOR EDS CRITERIA

LOSEC AZE FSW yes

SEE APPENDIX A FOR EDS CRITERIA

PANTOLOC SLV FSW yes

ZANTAC GLA FW no

APO-RANITIDINE APX FSW no NOVO-RANIDINE NOP FSW no ALTI-RANITIDINE ALT FSW no NU-RANIT NXP FSW no GEN-RANITIDINE GPM FSW no ZANTAC GLA FSW no

ZANTAC GLA FSW no APO-RANITIDINE APX FSW no NOVO-RANIDINE NOP FSW no ALTI-RANITIDINE ALT FSW no NU-RANIT NXP FSW no GEN-RANITIDINE GPM FSW no

SULCRATE PLUS HMR FSW no

NOVO-SUCRALATE NOP FSW no SULCRATE HMR FSW no APO-SUCRALFATE APX FSW no NU-SUCRALFATE NXP FSW no PMS-SUCRALFATE PMS FSW no

S.A.S. ENTERIC 500 ICN FSW no PMS-SULFASALAZINE-E.C. PMS FSW no ALTI-SULFASALAZINE-E.C. ALT FSW no SALAZOPYRIN PHU FSW no

PMS-SULFASALAZINE PMS FSW no ALTI-SULFASALAZINE ALT FSW no SALAZOPYRIN PHU FSW no

MODULON AXC FSW no

MODULON AXC FSW no

MYOCHRYSINE RPR FSW no

MYOCHRYSINE RPR FSW no

MYOCHRYSINE RPR FSW no

CUPRIMINE MSD FSW no

CUPRIMINE MSD FSW no

DEPEN HOR FSW no

VANCERIL SCH FSW no ALTI-BECLOMETHASONE ALT FSW no

BETNESOL RBP FSW no

PULMICORT TURBUHALER AZE FW no

PULMICORT TURBUHALER AZE FSW no

PULMICORT TURBUHALER AZE FSW no

(USE RESTRICTED TO CHILDREN UNDER 6 YEARS OF AGE) PULMICORT NEBUAMP AZE FW no

(USE RESTRICTED TO CHILDREN UNDER 6 YEARS OF AGE) PULMICORT NEBUAMP AZE FW no

(USE RESTRICTED TO CHILDREN UNDER 6 YEARS OF AGE) PULMICORT NEBUAMP AZE FW no

CORTONE MSD FSW no

CORTONE MSD FSW no CORTISONE ICN FSW no

DECADRON MSD FSW no DEXASONE ICN FSW no PMS-DEXAMETHASONE PMS FSW no

DEXASONE ICN FSW no PMS-DEXAMETHASONE PMS FSW no

DECADRON MSD FSW no DEXASONE ICN FSW no PMS-DEXAMETHASONE PMS FSW no

DECADRON MSD FSW no DEXAMETHASONE SAB FSW no PMS-DEXAMETHASONE PMS FSW no DEXAMETHASONE CYT FSW no

FLORINEF RBP FSW no

FLOVENT DISKUS GLA FW no

FLOVENT DISKUS GLA FSW no

FLOVENT DISKUS GLA FSW no

FLOVENT DISKUS GLA FSW no

FLOVENT GLA FW no

FLOVENT GLA FSW no

FLOVENT GLA FSW no

FLOVENT GLA FSW no

CORTEF PHU FSW no

CORTEF PHU FSW no

MEDROL PHU FSW no

MEDROL PHU FSW no

DEPO-MEDROL PHU FSW no

DEPO-MEDROL PHU FSW no

PEDIAPRED RPR FW no

WINPRED ICN FSW no APO-PREDNISONE APX FSW no

NOVO-PREDNISONE NOP FSW no APO-PREDNISONE APX FSW no

NOVO-PREDNISONE NOP FSW no APO-PREDNISONE APX FSW no

ARISTOCORT STI FSW no

ARISTOCORT STI FSW no

AZMACORT RPR FSW no

CYCLOMEN SAW FW no

CYCLOMEN SAW FW no

CYCLOMEN SAW FW no

DELATESTRYL BMS FW no TESTOSTERONE ENANTHATE TAR FW no PMS-TESTOSTERONE ENANTHATE PMS FW no

CLIMACTERON SAB FW no

OVRAL WAY FW no

OVRAL WAY FW no

MARVELON ORG FW no ORTHO-CEPT JAN FW no

MARVELON ORG FW no ORTHO-CEPT JAN FW no

DEMULEN 30 SEA FW no

DEMULEN 30 SEA FW no

DEMULEN 50 SEA FW no

DEMULEN 50 SEA FW no

ALESSE WAY FW no

ALESSE WAY FW no

TRIQUILAR BEX FW no TRIPHASIL WAY FW no

TRIQUILAR BEX FW no TRIPHASIL WAY FW no

MIN-OVRAL WAY FW no

MIN-OVRAL WAY FW no

ORTHO 0.5/35 JAN FW no BREVICON SEA FW no

ORTHO 0.5/35 JAN FW no BREVICON SEA FW no

ORTHO 7/7/7 JAN FW no

ORTHO 7/7/7 JAN FW no

SYNPHASIC SEA FW no

SYNPHASIC SEA FW no

ORTHO 1/35 JAN FW no BREVICON 1/35 SEA FW no SELECT 1/35 SEA FW no

ORTHO 1/35 JAN FW no BREVICON 1/35 SEA FW no SELECT 1/35 SEA FW no

MINESTRIN 1/20 PDA FW no

MINESTRIN 1/20 PDA FW no

LOESTRIN 1.5/30 PDA FW no

LOESTRIN 1.5/30 PDA FW no

TRI-CYCLEN JAN FW no

TRI-CYCLEN JAN FW no

CYCLEN JAN FW no

CYCLEN JAN FW no

ORTHO-NOVUM 1/50 JAN FW no

ORTHO-NOVUM 1/50 JAN FW no

MICRONOR JAN FW no

PREMARIN WAY FSW no C.E.S. ICN FSW no

C.E.S. ICN FSW no PREMARIN WAY FSW no

PREMARIN WAY FSW no C.E.S. ICN FSW no

C.E.S. ICN FSW no PREMARIN WAY FSW no

PREMARIN WAY FSW no

PREMARIN WAY FSW no

DIENESTROL JAN FSW no

SEE APPENDIX A FOR EDS CRITERIA

ESTRADERM NVR FSW yes

ESTRADERM NVR FSW yes

ESTRADERM NVR FSW yes

OGEN PHU FSW no

OGEN PHU FSW no

OGEN PHU FSW no

STILBESTROL RBP FSW no

STILBESTROL RBP FSW no

STILBESTROL RBP FSW no

HUMULIN-N LIL D no NOVOLIN GE NPH NNO D no

HUMULIN-N CARTRIDGE LIL D no NOVOLIN GE NPH PENFILL NNO D no

HUMULIN-L LIL D no NOVOLIN GE LENTE NNO D no

HUMULIN-R LIL D no NOVOLIN GE TORONTO NNO D no

HUMULIN-R CARTRIDGE LIL D no NOVOLIN GE TORONTO PENFILL NNO D no

HUMULIN 10/90 LIL D no

HUMULIN 10/90 CARTRIDGE LIL D no NOVOLIN GE 10/90 PENFILL NNO D no

HUMULIN 20/80 LIL D no

HUMULIN 20/80 CARTRIDGE LIL D no NOVOLIN GE 20/80 PENFILL NNO D no

HUMULIN 30/70 LIL D no NOVOLIN GE 30/70 NNO D no

HUMULIN 30/70 CARTRIDGE LIL D no NOVOLIN GE 30/70 PENFILL NNO D no

HUMULIN 40/60 LIL D no

HUMULIN 40/60 CARTRIDGE LIL D no NOVOLIN GE 40/60 PENFILL NNO D no

HUMULIN 50/50 LIL D no

HUMULIN 50/50 CARTRIDGE LIL D no NOVOLIN GE 50/50 PENFILL NNO D no

HUMULIN-U LIL D no NOVOLIN GE ULTRALENTE NNO D no

HUMALOG LIL D no

HUMALOG CARTRIDGE LIL D no

HUMALOG MIX 25 LIL D no

DIABINESE PFI D no APO-CHLORPROPAMIDE APX D no

NOVO-PROPAMIDE NOP D no DIABINESE PFI D no APO-CHLORPROPAMIDE APX D no

EUGLUCON PMS D no GEN-GLYBE GPM D no ALBERT-GLYBURIDE ALT D no APO-GLYBURIDE APX D no NOVO-GLYBURIDE NOP D no NU-GLYBURIDE NXP D no DIABETA HMR D no PMS-GLYBURIDE PMS D no

EUGLUCON PMS D no GEN-GLYBE GPM D no ALBERT-GLYBURIDE ALT D no APO-GLYBURIDE APX D no NOVO-GLYBURIDE NOP D no NU-GLYBURIDE NXP D no DIABETA HMR D no PMS-GLYBURIDE PMS D no

NOVO-METFORMIN NOP D no GLUCOPHAGE HMR D no GEN-METFORMIN GPM D no NU-METFORMIN NXP D no APO-METFORMIN APX D no GLYCON ICN D no PMS-METFORMIN PMS D no RHO-METFORMIN RHP D no

NOVO-BUTAMIDE NOP D no APO-TOLBUTAMIDE APX D no

SEE APPENDIX A FOR EDS CRITERIA

D.D.A.V.P. FEI FW yes

D.D.A.V.P. FEI FW yes

PROVERA PHU FSW no ALTI-MPA ALT FSW no NOVO-MEDRONE NOP FSW no GEN-MEDROXY GPM FSW no

PROVERA PHU FSW no ALTI-MPA ALT FSW no NOVO-MEDRONE NOP FSW no GEN-MEDROXY GPM FSW no

PROVERA PHU FSW no ALTI-MPA ALT FSW no NOVO-MEDRONE NOP FSW no GEN-MEDROXY GPM FSW no

DEPO-PROVERA PHU FW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no ELTROXIN GLA FSW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no ELTROXIN GLA FSW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no ELTROXIN GLA FSW no

SYNTHROID KNL FSW no

SYNTHROID KNL FSW no ELTROXIN GLA FSW no

SYNTHROID KNL FSW no ELTROXIN GLA FSW no

TAPAZOLE LIL FSW no

PROPYL-THYRACIL FRS FSW no

PROPYL-THYRACIL FRS FSW no

STATICIN WSD FW no

SOFRA-TULLE HMR FSW no

FUCIDIN LEO FSW no

GARAMYCIN SCH FSW no

GARAMYCIN SCH FSW no

BACTROBAN SKB W no

BACTROBAN SKB W no

NEOTOPIC TCH FSW no NEOSPORIN GLA FSW no

NEOSPORIN GLA FSW no

FUCIDIN LEO FSW no

ZOVIRAX GLA FSW no

ZOVIRAX GLA FSW no

HERPLEX-D ALL FSW no SAB-IDOXURIDINE SAB FSW no

LOPROX HMR FSW no

LOPROX HMR FSW no

CLOTRIMADERM TAR SW no CANESTEN BAY SW no SCHEIN-CLOTRAMAZOLE SCN SW no

CANESTEN BAY SW no

CANESTEN 6 BAY SW no CLOTRIMADERM TAR SW no

CANESTEN 3 BAY SW no CLOTRIMADERM TAR SW no

CANESTEN-3-COMBI PAK BAY SW no

CANESTEN-1-COMBI PAK BAY SW no

NIZORAL JAN FSW no

MICATIN MCL SW no MONISTAT DERM MCL SW no

MONISTAT-7 MCL SW no MONAZOLE-7 TCH SW no

MONISTAT-7 MCL SW no

MONISTAT-3 MCL SW no

MONISTAT-3 COMBINATION MCL SW no

MYCOSTATIN BMS SW no NYADERM TAR SW no NILSTAT TCH SW no

MYCOSTATIN BMS SW no NYADERM TAR SW no NILSTAT TCH SW no

MYCOSTATIN BMS SW no NYADERM TAR SW no

NILSTAT TCH SW no

NILSTAT TCH SW no

TINACTIN SCH W no

PMS-LINDANE PMS W no

PMS-LINDANE PMS W no

NIX CREME RINSE WLA W no KWELLADA-P CREME RINSE RCA W no

NIX DERMAL CREAM WLA W no

KWELLADA-P LOTION RCA W no

PHISOHEX SAW FW no

FLAGYL RPR FSW no

FLAGYL RPR FSW no

FLAGYSTATIN RPR FSW no

SULTRIN JAN FSW no

FLAMAZINE SNE FSW no

AVC HMR FSW no

TERSASEPTIC TCD W no

CYCLOCORT STI FSW no

CYCLOCORT STI FSW no

CYCLOCORT STI FSW no

PROPADERM RBP FSW no

PROPADERM RBP FSW no

DIPROSONE SCH FSW no TARO-SONE TAR FSW no

DIPROSONE SCH FSW no TOPISONE TCH FSW no TARO-SONE TAR FSW no

DIPROSONE SCH FSW no TOPISONE TCH FSW no TARO-SONE TAR FSW no

DIPROLENE SCH FSW no TOPILENE GLYCOL TCH FSW no

DIPROLENE SCH FSW no TOPILENE GLYCOL TCH FSW no

DIPROLENE SCH FSW no TOPILENE GLYCOL TCH FSW no

DIPROSALIC SCH FSW no

DIPROSALIC SCH FSW no

CELESTODERM-V/2 SCH FSW no ECTOSONE MILD TCH FSW no BETADERM TAR FSW no

CELESTODERM-V/2 SCH FSW no BETADERM TAR FSW no

CELESTODERM-V SCH FSW no ECTOSONE REGULAR TCH FSW no BETADERM TAR FSW no

CELESTODERM-V SCH FSW no BETADERM TAR FSW no

ECTOSONE REGULAR TCH FSW no BETNOVATE RBP FSW no

VALISONE SCH FSW no ECTOSONE TCH FSW no BETADERM TAR FSW no

DERMOVATE GLA FSW no ALTI-CLOBETASOL ALT FSW no DERMASONE TCH FSW no GEN-CLOBETASOL GPM FSW no NOVO-CLOBETASOL NOP FSW no PMS-CLOBETASOL PMS FSW no

DERMOVATE GLA FSW no ALTI-CLOBETASOL ALT FSW no DERMASONE TCH FSW no GEN-CLOBETASOL GPM FSW no NOVO-CLOBETASOL NOP FSW no PMS-CLOBETASOL PMS FSW no

ALTI-CLOBETASOL ALT FSW no DERMASONE TCH FSW no DERMOVATE GLA FSW no GEN-CLOBETASOL GPM FSW no PMS-CLOBETASOL PMS FSW no

EUMOVATE GLA FSW no

EUMOVATE GLA FSW no

DESOCORT GAC FSW no SCHEIN-DESONIDE SCN FSW no

DESOCORT GAC FSW no SCHEIN-DESONIDE SCN FSW no

TOPICORT MILD HMR FSW no TARO-DESOXIMETASONE TAR FSW no

TOPICORT HMR FSW no TARO-DESOXIMETASONE TAR FSW no

TOPICORT HMR FSW no

TOPICORT HMR FSW no

NERISONE OILY STI FSW no

FLUODERM TAR FSW no

FLUODERM TAR FSW no

FLUODERM TAR FSW no

LYDERM TAR FSW no LIDEX MDC FSW no

TOPSYN MDC FSW no LYDERM TAR FSW no

LIDEX MDC FSW no LYDERM TAR FSW no

HYDROCORTISONE SDR W no CORTATE SCH W no HYDERM TAR W no

HYDROCORTISONE SDR FSW no CORTATE SCH FSW no HYDERM TAR FSW no

CORTATE SCH W no CORTODERM TAR W no

CORTATE SCH FSW no CORTODERM TAR FSW no

CORTATE SCH W no

UREMOL-HC STI FSW no

UREMOL-HC STI FSW no

HEMCORT-HC TCH FSW no

HEMCORT-HC TCH FSW no

ELOCOM SCH FSW no

ELOCOM SCH FSW no

TRIADERM TAR FSW no

TRIADERM TAR FSW no ARISTOCORT R STI FSW no

TRIADERM TAR FSW no ARISTOCORT R STI FSW no

ORACORT TAR FSW no KENALOG-ORABASE WSD FSW no

VIOFORM HYDROCORTISONE NVR FSW no

PROCTOSEDYL HMR FSW no PROCTOSONE TCH FSW no

PROCTOSEDYL HMR FSW no PROCTOSONE TCH FSW no

VALISONE G SCH FSW no

VALISONE G SCH FSW no

KENACOMB MILD WSD FSW no

KENACOMB MILD WSD FSW no

VIADERM K-C TAR FSW no KENACOMB WSD FSW no

VIADERM K-C TAR FSW no KENACOMB WSD FSW no

XYLOCAINE AZE FSW no

XYLOCAINE VISCOUS AZE FSW no

PHENAZO ICN FSW no PYRIDIUM PDA FSW no

PHENAZO ICN FSW no PYRIDIUM PDA FSW no

STIEVA-A STI FW no RETIN A JAN FW no VITAMIN A ACID RPR FW no

STIEVA-A STI FW no RETIN A JAN FW no VITAMIN A ACID RPR FW no VITINOIN PMS FW no

RETIN A JAN FW no STIEVA-A STI FW no VITAMIN A ACID RPR FW no VITINOIN PMS FW no

STIEVA-A FORTE STI FW no RETIN A JAN FW no VITAMIN A ACID RPR FW no VITINOIN PMS FW no

STIEVA-A STI FW no RETIN A JAN FW no VITAMIN A ACID RPR FW no

RETIN A JAN FW no STIEVA-A STI FW no VITAMIN A ACID RPR FW no VITINOIN PMS FW no

STIEVA-A STI FW no VITAMIN A ACID RPR FW no

BARRIERE RBP W no

LAC-HYDRIN WSD W no

BENOXYL STI FW no OXYDERM ICN FW no

BENOXYL STI FW no OXYDERM ICN FW no

PODOFILM PMS FW no

DUOFILM STI W no

DUOPLANT STI W no

UREMOL 10 TCD W no

UREMOL 20 TCD W no

UREMOL 10 TCD W no

ZETAR RPR W no

MULTI-TAR PLUS ICN W no

SEE APPENDIX A FOR EDS CRITERIA

SORIATANE HLR FSW yes

SORIATANE HLR FSW yes

SORIATANE HLR FSW yes

DOVONEX LEO FSW no

DOVONEX LEO FSW no

EFUDEX HLR FSW no

ACCUTANE HLR FW no

ACCUTANE HLR FW no

PRESUN ULTRA 30 WSD W no Note: Only for patients on concurrent phenothiazine therapy.

DITROPAN ALZ FSW no PMS-OXYBUTYNIN PMS FSW no APO-OXYBUTYNIN APX FSW no

DITROPAN ALZ FSW no NU-OXYBUTYNIN NXP FSW no APO-OXYBUTYNIN APX FSW no OXYBUTYN ICN FSW no ALB-OXYBUTYNIN ALT FSW no NOVO-OXYBUTYNIN NOP FSW no GEN-OXYBUTYNIN GPM FSW no PMS-OXYBUTYNIN PMS FSW no

SEE APPENDIX A FOR EDS CRITERIA

DETROL PHU FSW yes

DETROL PHU FSW yes

PHYLLOCONTIN PFR FSW no

PHYLLOCONTIN-350 PFR FSW no

CHOLEDYL PDA FSW no PMS-OXTRIPHYLLINE PMS FSW no

APO-OXTRIPHYLLINE APX FSW no

APO-OXTRIPHYLLINE APX FSW no

APO-OXTRIPHYLLINE APX FSW no

CHOLEDYL SA PDA FSW no

CHOLEDYL SA PDA FSW no

ROUPHYLLINE ROG FSW no

THEOPHYLLINE TCH FSW no PMS-THEOPHYLLINE PMS FSW no

THEOLAIR MDA FSW no

SLO-BID RPR FSW no

SLO-BID RPR FSW no

SLO-BID RPR FSW no

SLO-BID RPR FSW no

THEO-DUR AZE FSW no APO-THEO-LA APX FSW no NOVO-THEOPHYL SR NOP FSW no

THEO-DUR AZE FSW no APO-THEO-LA APX FSW no NOVO-THEOPHYL SR NOP FSW no

THEOLAIR-SR MDA FSW no

THEO-DUR AZE FSW no QUIBRON-T/SR BMS FSW no APO-THEO-LA APX FSW no THEOLAIR-SR MDA FSW no NOVO-THEOPHYL SR NOP FSW no

UNIPHYL PFR FSW no

THEO-DUR AZE FSW no

UNIPHYL PFR FSW no

VITAMIN B12 SAB W no CYANOCOBALAMIN CYT W no CYANOCOBALAMIN TAR W no SCHEINPHARM B12 SCN W no

NOVO-FOLACID NOP FW no FOLIC ACID SDR FW no APO-FOLIC APX FW no

NIACIN ICN W no

NIACIN ICN W no

NOVO-C NOP W no APO-C APX W no

SEE APPENDIX A FOR EDS CRITERIA

ROCALTROL HLR FSW yes

ROCALTROL HLR FSW yes

DRISDOL SAW FSW no

OSTOFORTE FRS FSW no

HEXAVITAMINS NOP W no

CHILDREN'S CHEWABLE MULTIVIT MSC W no Note: The identification number for Children's Chewable Multivitamins has been generated by the Drug Cost Assistance Programs for billing purposes only.

POLY-VI-SOL MJO W no

MATERNA WAY W no

NOVO-VITES PLUS IRON NOP W no

ZYLOPRIM GLA FSW no NOVO-PUROL NOP FSW no APO-ALLOPURINOL APX FSW no

APO-ALLOPURINOL APX FSW no ZYLOPRIM GLA FSW no NOVO-PUROL NOP FSW no

ZYLOPRIM GLA FSW no NOVO-PUROL NOP FSW no APO-ALLOPURINOL APX FSW no

SYMMETREL DUP FSW no PMS-AMANTADINE PMS FSW no

SYMMETREL DUP FSW no PMS-AMANTADINE PMS FSW no ENDANTADINE END FSW no GEN-AMANTADINE GPM FSW no

IMURAN GLA FSW no GEN-AZATHIOPRINE GPM FSW no ALTI-AZATHIOPRINE ALT FSW no NOVO-AZATHIOPRINE NOP FSW no

PARLODEL NVR FSW no APO-BROMOCRIPTINE APX FSW no PMS-BROMOCRIPTINE PMS FSW no

PARLODEL NVR FSW no APO-BROMOCRIPTINE APX FSW no PMS-BROMOCRIPTINE PMS FSW no

SEE APPENDIX A FOR EDS CRITERIA

ZYBAN GLA FW yes

DIXARIT BOE FSW no

COLCHICINE ROG FSW no COLCHICINE ODN FSW no

ANTABUSE WAY FSW no

ANTABUSE WAY FSW no

SEE APPENDIX A FOR EDS CRITERIA

DIDRONEL PGA FSW yes

SEE APPENDIX A FOR EDS CRITERIA

DIDROCAL PGA FSW yes

COPAXONE TVM M no

Note: Interferon Beta-1a products are only approved for the treatment of relapsing-remitting multiple sclerosis.

AVONEX BGN M no

REBIF SRO M no

REBIF SRO M no

REBIF SRO M no

Note: Interferon Beta-1b (Betaseron) is approved only for the treatment of relapsing-remitting and secondary-progressive multiple sclerosis.

BETASERON BEX M no

ZADITEN NVR FW no NOVO-KETOTIFEN NOP FW no NU-KETOTIFEN NXP FW no APO-KETOTIFEN APX FW no PMS-KETOTIFEN PMS FW no

ZADITEN NVR FW no NOVO-KETOTIFEN NOP FW no PMS-KETOTIFEN PMS FW no

SEE APPENDIX A FOR EDS CRITERIA

ERGAMISOL JAN FSW yes

SINEMET DUP FSW no LEVODOPA/CARBIDOPA ALT FSW no NU-LEVOCARB NXP FSW no APO-LEVOCARB APX FSW no

SINEMET DUP FSW no LEVODOPA/CARBIDOPA ALT FSW no NU-LEVOCARB NXP FSW no APO-LEVOCARB APX FSW no

SINEMET DUP FSW no LEVODOPA/CARBIDOPA ALT FSW no NU-LEVOCARB NXP FSW no APO-LEVOCARB APX FSW no

SEE APPENDIX A FOR EDS CRITERIA SINEMET CR DUP FSW yes

SEE APPENDIX A FOR EDS CRITERIA SINEMET CR DUP FSW yes

SEE APPENDIX A FOR EDS CRITERIA

SINGULAIR MSD FSW yes

SINGULAIR MSD FSW yes

TILADE RPR FSW no

SEE APPENDIX A FOR EDS CRITERIA

ELMIRON ALZ FSW yes

SEE APPENDIX A FOR EDS CRITERIA

MIRAPEX BOE FSW yes

MIRAPEX BOE FSW yes

MIRAPEX BOE FSW yes

NOVO-SELEGILINE NOP FSW no ELDEPRYL DPY FSW no APO-SELEGILINE APX FSW no NU-SELEGILINE NXP FSW no GEN-SELEGILINE GPM FSW no

SEE APPENDIX A FOR EDS CRITERIA NALCROM RPR FSW yes

INTAL RPR FSW no

INTAL RPR FSW no PMS-SODIUM CROMOGLYCATE PMS FSW no GEN-CROMOGLYCATE GPM FSW no APO-CROMOLYN APX FSW no NU-CROMOLYN NXP FSW no

PANECTYL RPR FW no

PANECTYL RPR FW no

SEE APPENDIX A FOR EDS CRITERIA

URSO AXC FSW yes