| 01919628 | CEFAZOLIN SODIUM | Ancef (Off-Formulary Interchangeable) 10g/Vial Inj Pd-Vial Pk (Preservative-Free) | SMJ | N/A | N/A | YES | NO | NO |
| 01916777 | CIMETIDINE | Tagamet (Not a Benefit) 600mg Tab | SMJ | N/A | N/A | YES | NO | YES |
| 01916785 | CIMETIDINE | Tagamet (Not a Benefit) 400mg Tab | SMJ | N/A | N/A | YES | NO | YES |
| 01916815 | CIMETIDINE | Tagamet (Not a Benefit) 300mg Tab | SMJ | N/A | N/A | YES | NO | YES |
| 01916769 | CIMETIDINE | Tagamet (Not a Benefit) 800mg Tab | SMJ | N/A | N/A | YES | NO | YES |
| 01916793 | CIMETIDINE | Tagamet (Not a Benefit) 200mg Tab | SMJ | N/A | N/A | YES | NO | YES |
| 01919547 | HYDROCHLOROTHIAZIDE & TRIAMTERENE | Dyazide (Not a Benefit) 25mg & 50mg Tab | SMJ | N/A | N/A | YES | NO | NO |
| 02027887 | PAROXETINE HCL | Paxil (Off-Formulary Interchangeable) 10mg Tab | SMJ | N/A | N/A | YES | NO | NO |
| 01918222 | TRIFLUOPERAZINE | Stelazine (Not a Benefit) 5mg Tab | SMJ | N/A | N/A | YES | NO | NO |
| 01918214 | TRIFLUOPERAZINE | Stelazine (Not a Benefit) 2mg Tab | SMJ | N/A | N/A | YES | NO | NO |
| 01918206 | TRIFLUOPERAZINE | Stelazine (Not a Benefit) 1mg Tab | SMJ | N/A | N/A | YES | NO | NO |
| 01918230 | TRIFLUOPERAZINE | Stelazine (Not a Benefit) 10mg Tab | SMJ | N/A | N/A | YES | NO | NO |