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2010 Three-Tier Prescription Drug Reference Guide Amoxicillin Trihydrate Capsule, Chewable Tablet, Drops, Suspension, Tablet Amoxicillin Trihydrate/ Potassium Clavulanate Chloromycetin Erythromycin Base Capsule, Delayed Release Erythromycin Base Tablet, Enteric-Coated 250, 333 Erythromycin Ethylsuccinate/ Sulfisoxazole Acetyl 2010 Three-Tier Prescription Drug Reference Guide Cardiovascular/Heart Disease Coagulation Therapy 2010 Three-Tier Prescription Drug Reference Guide Cardiovascular/Heart Disease High Blood Pressure Bisoprolol Fumarate/ Hydrochlorothiazide Dibenzyline 2010 Three-Tier Prescription Drug Reference Guide Cardiovascular/Heart Disease High Blood Pressure (continued from previous page) Nifedipine Tablet, Osmotic Laser-Drilled Cardiovascular/Heart Disease High Cholesterol 2010 Three-Tier Prescription Drug Reference Guide Central Nervous System Attention Deficit Disorder Sulfate/Dextroamphetamine Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Capsule, Sustained-Release 24 Hour D-Amphetamine Sulfate Tablet, Capsule, Sustained-Action Methamphetamine HCI Tablet 2010 Three-Tier Prescription Drug Reference Guide Bupropion HCI Tablet, Sustained-Release 24 Hour Paroxetine HCI Sustained-Release, 24 Hour Acetaminophen/Caffeine/Butalbital Ergomar Alkaloids/Phenobarbital Ergotamine Tartrate/Caffeine Suppository, Rectal Ergotamine Tartrate/Caffeine/Belladonna Alkaloids/Pentobarbital Mucate/Acetaminophen/Dichloralphenazone Isometheptene/Acetaminophen/Caffeine 2010 Three-Tier Prescription Drug Reference Guide Central Nervous System Sedatives/Hypnotics Central Nervous System Seizure Disorders 2010 Three-Tier Prescription Drug Reference Guide 2010 Three-Tier Prescription Drug Reference Guide Alclometasone Dipropionate Cream, Ointment Betamethasone Dipropionate Cream, Lotion, Ointment Betamethasone Dipropionate/Propylene Glycol Gel, Lotion, Ointment Betamethasone DP Augmented Cream 0.05% Locoid Betamethasone Valerate Cream, Lotion, Ointment Clobetasol Propionate Cream, Gel, Ointment Sulfoxyl Clobetasol Propionate Solution, Non-Oral Trisoralen Clotrimazole/Betamethasone Dipropionate Zovirax Erythromycin Base/Ethyl Alcohol Swab, Medicated Fluocinolone Acetonide Solution Non-Oral Hydrocortisone Butyrate Ointment, Solution, Non- Oral Hydrocortisone Cream, Lotion, Ointment Mometasone Furoate Cream, Ointment, Solution 2010 Three-Tier Prescription Drug Reference Guide Dermatology (Continued from previous page) Sulfacetamide Sodium Suspension. Topical Triamcinolone Acetonide Cream, Lotion, Ointment Endocrine/Diabetes Blood Glucose Monitoring 2010 Three-Tier Prescription Drug Reference Guide Fortamet Tablet, Sr Osmotic Push 24 Hour 2010 Three-Tier Prescription Drug Reference Guide Methylprednisolone Tablet, Does Pack 4 mg Prednisolone Sodium Phosphate Solution, Oral 2010 Three-Tier Prescription Drug Reference Guide Neomycin Sulfate/Bacitracin Zinc Polymyxin B/ Hydrocortisone Ointment Neomycin Sulfate/Bacitracin/Polymyxin B Ointment Neomycin Sulfate/Dexamethasone Sodium Phosphate Neomycin Sulfate/Gramicidin D/Polymyxin B Sulfate/Hydrocortisone Suspension, Drops Neomycin/Polymyxin B Sulfate/Dexamethasone Sulfacetamide Sodium/Prednisolone Acetate Sulfacetamide Sodium/Prednisolone Sodium Acetazolamide Capsule, Sustained-Action Azopt 2010 Three-Tier Prescription Drug Reference Guide Prevacid Capsule, Delayed-Release Enteric-Coated Prevacid Suspension, Delayed Release, Reconst. Prochlorperazine Maleate 25 mg Suppository, 2010 Three-Tier Prescription Drug Reference Guide Promethazine/Codeine Neoral Tamoxifen Prograf 2010 Three-Tier Prescription Drug Reference Guide Acetaminophen/Phenyltoloxamine Citrate OxyContin Aspirin/Caffeine/Butalbital RMS-Suppository 10, 20, 30 mg Acetaminophen/Caffeine/Butalbital Codeine Phosphate/Aspirin/Caffeine/Butalbital Dihydrocodeine Bit/ Acetaminophen/Caffeine Hydrocodone Bit/Acetaminophen Elixir, Tablet 2010 Three-Tier Prescription Drug Reference Guide Musculoskeletal Pain Relief (continued from previous page) Morphine Sulfate Suppository, Rectal 5 mg Morphine Sulfate Tablet, Sustained-Action HCI/AcetaminophencetaminophenMusculoskelet Oxycodone HCI/Ibuprofen 2010 Three-Tier Prescription Drug Reference Guide Albuterol Sulfate/Ipratropium Solution, Non-Oral Cromolyn Sodium Ampul for Nebuization Pulmicort Isoetharine HCI Solution, Non-Oral T-Phyl 2010 Three-Tier Prescription Drug Reference Guide Maleate/Scopolamine Syrup Phenylephrine HCI/Phenylpropanolamine HCI/Phenyltoloxamine/Chlorpheniramine Phenylephrine HCI/Promethazine HCI Pseudoephedrine HCI/Brompheniramine Maleate Pseudoephedrine HCI/Chlorpheniramine Maleate Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Tablet, Dosepak, 3 month Medroxyprogesterone Acet 150 mg/ml Norethindrone A-E Estradiol/Ferrous Fumarate 2010 Three-Tier Prescription Drug Reference Guide Estradiol 1 mg/Norethindrone Acetate 0.5 mg Methyltestosterone/Estrogens, Esterified Tablet Prenatal Vitamins/Fe Asp Gly/Docusate/Folic Acid Prenatal Vitamins/Iron, Carbonyl/Docusate/Folic Acid Prenatal Vitamins/Vitamin A/Iron Fumarate/Folic 2010 Three-Tier Prescription Drug Reference Guide Additional Tier 3 Drugs with generic equivalent in Tier 1 Adderall (Amphetamine with Dextroamphetamine Salt Combination) Aldactone (Spironolactone) Augmentin ES (Amoxicillin with Potassium Clavulanate) Biaxin Tablet (Clarithromycin Tablet) Ritalin SR (Methylphenidate Extended-Release) Lamisil Tablet (Terbinafine Tablet) Sonata Lofibra (Fenofibrate Micronized) Tenoretic (Diltiazem Sustained-Release 24 Hour Capsule) Cleocin T (Clindamycin Gel, Lotion, Solution, Darvocet-N (Propoxyphene with Acetaminophen) Depakote (Divalproex Sodium Tablet, Enteric- Depo-Provera (Medroxyprogesterone Acetate 150 Ditropan XL (Oxybutynin Chloride Tablet, Diazide (Triamterene with Hydrochlorothiazide) Eskalith CR (Lithium Carbonate Controlled- Fioricet (Butalbital with Acetaminophen and Zovirax Capsule, Tablet, Suspension (Acyclovir)

Source: http://benefits.maverickeis.com/benefits/benefits_2002_pdfs/rxtiergroups.pdf

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