2016 drug formulary for qualified health plans (hap personal

USE THIS DOCUMENT TO LEARN ABOUT THE PRESCRIPTION DRUGS WE COVER IN ALL

QUALIFIED HEALTH PLANS.

Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health

benefits and follow established limits on cost-sharing. This includes HAP Personal Alliance and small

group QHPs purchased through the Health Insurance Marketplace or directly from HAP.

For more information

If you have questions about your health plan, please call a Customer Service specialist at one of the

phone numbers listed below or log in at hap.org and send us a message.

Personal Alliance QHPs

HMO Plans: (800) 759-3436

PPO Plans: (800) 944-9399

Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 8 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 8 p.m.; Saturday 8 a.m. to noon

Small Group QHPs

HMO Plans: (800) 422-4641

Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 7 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 7 p.m.; Saturday 8 a.m. to noon

PPO Plans: (888) 999-4347

Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 5 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 5 p.m.; Saturday 8 a.m.

to noon

If you are deaf, hard of hearing or unable to speak, please call 711 for our TTY service.

A drug's formulary status may change prior to being updated in this document. The listing of

a drug does not imply coverage for all benefits. Some dosage forms or strengths of an

existing formulary drug may not be covered. Please contact us for more details.

2016 Drug Formulary for Qualified Health Plans (HAP Personal Alliance

® and

Small Group)

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What is the drug formulary?

A formulary is a list of covered prescription drugs. Prescription drugs are self-administered medications

that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered

prescription drugs is selected with a team of health care providers. This represents the prescription

therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed

in our formulary as long as it is medically necessary, the prescription is filled at an in-network pharmacy

and other rules of the health plan are followed.

Formulary list can change over time. We may add new drugs as they are approved by the FDA and

likewise we may remove drugs as new information about safety and effectiveness is available. We may

also change the tier which reflects your cost-share for the drug. We may update our rules for coverage

meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage

(see page XX for recent formulary changes).

This list only includes “medical drugs” that are required to be obtained from HAP contracted Specialty

Pharmacy. Medical drugs are those that are administered in the doctor’s office or other health care

facility. These are generally supplied by your doctor or other health care provider. Drugs provided for

home infusion therapy are also considered medical. Please refer to your Medical Cost Share Rider for

information about your cost-sharing for Medical drugs.

The Qualified Health Plan Formulary is available at hap.org/formulary.

How do I use the drug formulary?

The formulary has a list of covered generic and brand name drugs and is organized by categories. Each

category depends on the type of medical conditions that the drugs are used to treat. For example, drugs

used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what a

drug is used for, look for the category name in the list. Then look under the category name for the drug.

If you are not sure what category to look under, you should look for your drug in the Index that is at the

end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document.

To search for a specific drug within the formulary, select Ctrl-F and enter the name of the drug in the

search box.

What is a generic substitution?

When an FDA approved generic drug is available, your prescription will be filled with the generic form of

the medication. Generic drugs contain the same active ingredients and are equivalent in strength and

dosage to the original brand name product. Generic drugs cost you and your health plan less money

than a brand name drug.

.

What are specialty drugs?

Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy.

For this reason we contract with Pharmacy Advantage, a specialty pharmacy, from whom you can obtain

specialty drugs. Specialty drugs require prior authorization and Pharmacy Advantage can help you and

your doctor submit a request. You or your doctor can contact Pharmacy Advantage at (800) 456-2112.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. The coverage

requirements are listed on the drug formulary. These requirements and limits may include:

Prior Authorization – Some medications on our formulary have criteria you must meet beforewe cover them. This means that you will need to get approval from us before you fill yourprescriptions for these drugs.

Step Therapy – In some cases, we require you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.

Quantity Limits – Certain drugs have quantity limits. A quantity limit is the maximum quantitythat can be dispensed on each fill of medication or the maximum number of fills allowed fortreatment of certain conditions. Specialty/injectable drugs (except insulin) and select oral drugs(e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugsrequire a 15-day supply for the first fill.

Benefit limitations

Our drug formulary applies to drugs used in an outpatient setting. It does not include medication

administered in the doctor’s office or while in the hospital. These are known as medical drugs. Note that

some medical drugs are listed on this formulary because they are part of our Specialty Program. Please

refer to “what are specialty drug?” section for information about these medications

The following are general drug coverage exclusions that apply to all members:

• Over-the-counter (OTC) medications and their equivalents are not covered unless specified inthe formulary or on the rider

• Drug products used for cosmetic purposes are not covered• Experimental drugs and/or any drug products used in an experimental manner are not covered• Replacement of lost or stolen medication is not covered

Since the selected drug packages and coverage vary for each Qualified Health Plan, check your

Summary of Benefits and Coverage (SBC) for your cost-sharing and exclusions.

What if my drug is not on the drug formulary?

When your drug is not listed on the formulary it is considered non-formulary. You or your doctor can ask

us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the

medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist

if one of the formulary alternatives will work for you.

Exception approvals for standard non-formulary medications will process at the highest non specialty

(Tier three) copayment. Exception approvals for non-formulary specialty drugs will process at the

highest Specialty (Tier four) copayment. Non-formulary specialty drugs when approved for use by the

health plan can be required to be dispensed by Pharmacy Advantage.

How do I request prior authorization or drug formulary exception?

You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us

to cover a drug not included on our formulary or ask us to exempt you from a formulary requirement

through the exception process. Your doctor must submit a request to us indicating why formulary

requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us

information when requesting either prior authorization or exception to the formulary.

What is included in the drug formulary?

The name of the covered drug is listed in the first column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case (e.g., gabapentin). When a generic drug is listed on the formulary, only the generic is covered.

The second column represents the drug’s cost-sharing level, or Tier. Every drug on the formulary is in

one of four cost-sharing Tiers.

The following table will translate how the four Tiers shown on the formulary are applicable to your health

plan’s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-

sharing information.

Description of Tier Copay

Preventive (HCR) – generic prescription preventive drugs that

are mandated by the Affordable Care Act. These are covered

at zero copay when Health Care Reform rules are met.

Tier 0

Generic – non-brand name drugs that have the lowest copay Tier 1

Preferred Brand – brand name formulary drugs that have

the lowest brand copay

Tier 2

Non-Preferred Brand – brand name formulary drugs that

are not in the Preferred Brand Tier

Tier 3

Specialty Drugs – biologics or drugs that require close

monitoring for safety and efficacy and as designated by us to

be a specialty drug

Tier 4

Medical Drugs - These are drugs that are infused or

administered in doctor’s office or facility and are covered

under the medical benefit of your plan.

Medical Coinsurance

The third column lists the Requirements/Limits that must be met for coverage of your drug. Please

refer to the abbreviations used in this column and their explanation.

The fourth column is the Comment section and may include specific information about strengths or

dosage forms that are covered.

The fifth column is the list of covered lower cost alternatives that you may be able to use.

Abbreviations for Requirements/Limits are as follows:

PA (Prior Authorization) – You or your doctor is required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug.

QL (Quantity Limit) – We limit the amount of these drugs that are covered for each prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

ST (Step Therapy) – Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.

SP (Specialty Pharmacy) –This specialty drug can only be obtained from Pharmacy Advantage by calling them at (800) 456 2112.

TABLE OF CONTENTS

ANTIHISTAMINE DRUGS 1

FIRST GENERATION ANTIHISTAMINES 1

ETHANOLAMINE DERIVATIVES 1

FIRST GEN. ANTIHIST. DERIVATIVES, MISC. 1

PHENOTHIAZINE DERIVATIVES 1

PROPYLAMINE DERIVATIVES 1

SECOND GENERATION ANTIHISTAMINES 1

ANTI-INFECTIVE AGENTS 1

ANTHELMINTICS 1

ANTIBACTERIALS 2

AMINOGLYCOSIDES 2

ANTIBACTERIALS, MISCELLANEOUS 2

CEPHALOSPORINS 2

MACROLIDES 3

MISCELLANEOUS B-LACTAM ANTIBIOTICS 4

PENICILLINS 4

QUINOLONES 5

SULFONAMIDES (SYSTEMIC) 6

TETRACYCLINES 6

ANTIFUNGAL (SYSTEMIC) 7

ALLYLAMINES 7

ANTIFUNGALS, MISCELLANEOUS 7

AZOLES 7

POLYENES 7

PYRIMIDINES 8

ANTIMYCOBACTERIALS 8

ANTIMYCOBACTERIALS, MISCELLANEOUS 8

ANTITUBERCULOSIS AGENTS 8

ANTIPROTOZOALS 8

AMEBICIDES 8

ANTIMALARIALS 8

ANTIPROTOZOALS, MISCELLANEOUS 9

ANTIVIRALS (SYSTEMIC) 9

ADAMANTANES 9

ANTIRETROVIRALS 9

HCV ANTIVIRALS 12

INTERFERONS 12

MONOCLONAL ANTIBODIES 13

NEURAMINIDASE INHIBITORS 13

NUCLEOSIDES AND NUCLEOTIDES 13

URINARY ANTI-INFECTIVES 14

ANTINEOPLASTIC AGENTS 14

AUTONOMIC DRUGS 18

ANTICHOLINERGIC AGENTS 18

ANTIMUSCARINICS/ANTISPASMODICS 18

TABLE OF CONTENTS

AUTONOMIC DRUGS 18

ANTICHOLINERGIC AGENTS 18

ANTIPARKINSONIAN AGENTS 19

AUTONOMIC DRUGS, MISCELLANEOUS 19

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 20

SKELETAL MUSCLE RELAXANTS 21

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 21

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS 21

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT 21

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 22

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS 22

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) 22

SYMPATHOMIMETIC (ADRENERGIC) AGENTS 22

ALPHA- AND BETA-ADRENERGIC AGONISTS 22

ALPHA-ADRENERGIC AGONISTS 22

BETA-ADRENERGIC AGONISTS 22

BLOOD FORMATION,COAGULATION & THROMBOSIS 24

ANTIANEMIA DRUGS 24

IRON PREPARATIONS 24

ANTIHEMORRHAGIC AGENTS 25

HEMOSTATICS 25

ANTITHROMBOTIC AGENTS 27

ANTICOAGULANTS 27

PLATELET-AGGREGATION INHIBITORS 29

PLATELET-REDUCING AGENTS 29

HEMATOPOIETIC AGENTS 29

HEMORRHEOLOGIC AGENTS 31

CARDIOVASCULAR DRUGS 31

ALPHA-ADRENERGIC BLOCKING AGENTS 31

ANTILIPEMIC AGENTS 31

ANTILIPEMIC AGENTS, MISCELLANEOUS 31

BILE ACID SEQUESTRANTS 31

CHOLESTEROL ABSORPTION INHIBITORS 32

FIBRIC ACID DERIVATIVES 32

HMG-COA REDUCTASE INHIBITORS 32

BETA-ADRENERGIC BLOCKING AGENTS 33

CALCIUM-CHANNEL BLOCKING AGENTS 36

CALCIUM-CHANNEL BLOCKING AGENTS, MISC. 36

DIHYDROPYRIDINES 38

CARDIAC DRUGS 39

ANTIARRHYTHMIC AGENTS 39

CARDIAC DRUGS, MISCELLANEOUS 40

CARDIOTONIC AGENTS 40

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM 41

HYPOTENSIVE AGENTS 41

TABLE OF CONTENTS

CARDIOVASCULAR DRUGS 31

HYPOTENSIVE AGENTS 41

CENTRAL ALPHA-AGONISTS 41

DIRECT VASODILATORS 41

DIURETICS (HYPOTENSIVE AGENTS) 41

PERIPHERAL ADRENERGIC INHIBITORS 41

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB 41

ANGIOTENSIN II RECEPTOR ANTAGONISTS 41

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 43

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS 44

RENIN INHIBITORS 45

VASODILATING AGENTS 45

NITRATES AND NITRITES 45

PHOSPHODIESTERASE TYPE 5 INHIBITORS 46

VASODILATING AGENTS, MISCELLANEOUS 46

CENTRAL NERVOUS SYSTEM AGENTS 46

ANALGESICS AND ANTIPYRETICS 46

ANALGESICS AND ANTIPYRETICS, MISC. 46

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS 46

OPIATE AGONISTS 49

OPIATE PARTIAL AGONISTS 54

ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS 54

AMPHETAMINES 54

ANOREXIGENIC AGENTS 55

RESPIRATORY AND CNS STIMULANTS 56

WAKEFULNESS-PROMOTING AGENTS 57

ANTICONVULSANTS 57

ANTICONVULSANTS, MISCELLANEOUS 57

BARBITURATES (ANTICONVULSANTS) 62

BENZODIAZEPINES (ANTICONVULSANTS) 62

HYDANTOINS 63

SUCCINIMIDES 63

ANTIMANIC AGENTS 63

ANTIMIGRAINE AGENTS 64

SELECTIVE SEROTONIN AGONISTS 64

ANTIPARKINSONIAN AGENTS (CNS) 64

ADAMANTANES (CNS) 64

ANTICHOLINERGIC AGENTS (CNS) 65

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. 65

DOPAMINE PRECURSORS 65

DOPAMINE RECEPTOR AGONISTS 65

MONOAMINE OXIDASE B INHIBITORS 66

ANXIOLYTICS, SEDATIVES AND HYPNOTICS 67

ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. 67

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 67

TABLE OF CONTENTS

CENTRAL NERVOUS SYSTEM AGENTS 46

ANXIOLYTICS, SEDATIVES AND HYPNOTICS 67

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 68

CENTRAL NERVOUS SYSTEM AGENTS, MISC. 69

FIBROMYALGIA AGENTS 70

OPIATE ANTAGONISTS 70

PSYCHOTHERAPEUTIC AGENTS 70

ANTIDEPRESSANTS 70

ANTIPSYCHOTIC AGENTS 75

CONTRACEPTIVES (E.G. FOAMS, DEVICES) 80

ELECTROLYTIC, CALORIC, AND WATER BALANCE 80

ALKALINIZING AGENTS 80

AMMONIA DETOXICANTS 80

DIURETICS 80

LOOP DIURETICS 80

POTASSIUM-SPARING DIURETICS 81

THIAZIDE DIURETICS 81

THIAZIDE-LIKE DIURETICS 81

VASOPRESSIN ANTAGONISTS 82

ION-REMOVING AGENTS 82

PHOSPHATE-REMOVING AGENTS 82

POTASSIUM-REMOVING AGENTS 82

REPLACEMENT PREPARATIONS 82

URICOSURIC AGENTS 84

EYE, EAR, NOSE AND THROAT (EENT) PREPS. 84

ANTIALLERGIC AGENTS 84

ANTIGLAUCOMA AGENTS 84

ALPHA-ADRENERGIC AGONISTS (EENT) 84

BETA-ADRENERGIC BLOCKING AGENTS (EENT) 85

CARBONIC ANHYDRASE INHIBITORS (EENT) 85

MIOTICS 85

PROSTAGLANDIN ANALOGS 85

ANTI-INFECTIVES (EENT) 86

ANTIBACTERIALS (EENT) 86

ANTIVIRALS (EENT) 87

EENT ANTI-INFECTIVES, MISCELLANEOUS 87

ANTI-INFLAMMATORY AGENTS (EENT) 87

CORTICOSTEROIDS (EENT) 87

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS 88

EENT DRUGS, MISCELLANEOUS 88

LOCAL ANESTHETICS (EENT) 89

MYDRIATICS 89

VASOCONSTRICTORS 89

GASTROINTESTINAL DRUGS 90

ANTIDIARRHEA AGENTS 90

TABLE OF CONTENTS

GASTROINTESTINAL DRUGS 90

ANTIEMETICS 90

5-HT3 RECEPTOR ANTAGONISTS 90

ANTIEMETICS, MISCELLANEOUS 90

ANTIHISTAMINES (GI DRUGS) 91

ANTI-INFLAMMATORY AGENTS (GI DRUGS) 91

ANTIULCER AGENTS AND ACID SUPPRESSANTS 91

HISTAMINE H2-ANTAGONISTS 91

PROSTAGLANDINS 92

PROTECTANTS 92

PROTON-PUMP INHIBITORS 92

CATHARTICS AND LAXATIVES 92

CHOLELITHOLYTIC AGENTS 93

DIGESTANTS 93

GI DRUGS, MISCELLANEOUS 93

PROKINETIC AGENTS 94

GOLD COMPOUNDS 94

HEAVY METAL ANTAGONISTS 94

HORMONES AND SYNTHETIC SUBSTITUTES 94

ADRENALS 94

ANDROGENS 96

ANTIDIABETIC AGENTS 97

ALPHA-GLUCOSIDASE INHIBITORS 97

AMYLINOMIMETICS 97

ANTIDIABETIC AGENTS, MISCELLANEOUS 97

BIGUANIDES 97

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS 97

INCRETIN MIMETICS 98

INSULINS 98

MEGLITINIDES 99

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS 99

SULFONYLUREAS 99

THIAZOLIDINEDIONES 100

ANTIHYPOGLYCEMIC AGENTS 101

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS 101

GLYCOGENOLYTIC AGENTS 101

CONTRACEPTIVES 101

ESTROGENS AND ANTIESTROGENS 106

ESTROGEN AGONIST-ANTAGONISTS 106

ESTROGENS 106

GONADOTROPINS 108

PARATHYROID 108

PITUITARY 108

PROGESTINS 109

SOMATOSTATIN AGONISTS AND ANTAGONISTS 109

TABLE OF CONTENTS

HORMONES AND SYNTHETIC SUBSTITUTES 94

SOMATOSTATIN AGONISTS AND ANTAGONISTS 109

SOMATOSTATIN AGONISTS 109

SOMATOTROPIN AGONISTS AND ANTAGONISTS 109

SOMATOTROPIN AGONISTS 109

SOMATOTROPIN ANTAGONISTS 109

THYROID AND ANTITHYROID AGENTS 110

ANTITHYROID AGENTS 110

THYROID AGENTS 110

LOCAL ANESTHETICS (PARENTERAL) 113

MISCELLANEOUS THERAPEUTIC AGENTS 113

5-ALPHA-REDUCTASE INHIBITORS 113

ALCOHOL DETERRENTS 114

ANTIDOTES 114

ANTIGOUT AGENTS 114

BIOLOGIC RESPONSE MODIFIERS 114

BONE RESORPTION INHIBITORS 115

CARIOSTATIC AGENTS 115

COMPLEMENT INHIBITORS 115

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS 116

GONADOTROPIN-RELEASING HORMONE ANTAGNTS 117

IMMUNOSUPPRESSIVE AGENTS 117

OTHER MISCELLANEOUS THERAPEUTIC AGENTS 118

RESPIRATORY TRACT AGENTS 118

ANTIFIBROTIC AGENTS 118

ANTI-INFLAMMATORY AGENTS (RESPIRATORY) 118

LEUKOTRIENE MODIFIERS 118

MAST-CELL STABILIZERS 118

ANTITUSSIVES 118

CYSTIC FIBROSIS (CFTR) MODULATORS 119

CYSTIC FIBROSIS (CFTR) POTENTIATORS 119

MUCOLYTIC AGENTS 119

PHOSPHODIESTERASE TYPE 4 INHIBITORS 119

RESPIRATORY TRACT AGENTS, MISCELLANEOUS 119

VASODILATING AGENTS (RESPIRATORY TRACT) 119

SERUMS, TOXOIDS, AND VACCINES 120

SERUMS 120

TOXOIDS 121

VACCINES 121

SKIN AND MUCOUS MEMBRANE AGENTS 122

ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE) 122

ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) 122

ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) 123

ANTIVIRALS (SKIN & MUCOUS MEMBRANE) 124

LOCAL ANTI-INFECTIVES, MISCELLANEOUS 125

TABLE OF CONTENTS

SKIN AND MUCOUS MEMBRANE AGENTS 122

ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE) 122

SCABICIDES AND PEDICULICIDES 126

ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) 126

ANTIPRURITICS AND LOCAL ANESTHETICS 129

ASTRINGENTS 131

CELL STIMULANTS AND PROLIFERANTS 131

DEPIGMENTING AND PIGMENTING AGENTS 131

PIGMENTING AGENTS 131

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS 131

BASIC LOTIONS AND LINIMENTS 131

KERATOLYTIC AGENTS 131

SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 132

SMOOTH MUSCLE RELAXANTS 133

GENITOURINARY SMOOTH MUSCLE RELAXANTS 133

ANTIMUSCARINICS 133

BETA-3-ADRENERGIC AGONISTS 134

RESPIRATORY SMOOTH MUSCLE RELAXANTS 134

VITAMINS 134

MULTIVITAMIN PREPARATIONS 134

VITAMIN B COMPLEX 135

VITAMIN D 135

Drug Name Tier Requirements/Limits

AlternativesComments

ANTIHISTAMINE DRUGSFIRST GENERATION ANTIHISTAMINES

ETHANOLAMINE DERIVATIVES

T1clemastine syp 0.5/5ml

T1clemastine tab 2.68mg

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

T1cyproheptad syp 2mg/5ml

T1cyproheptad tab 4mg

PHENOTHIAZINE DERIVATIVES

T1phenadoz sup 25mg (promethazine)

T1phenergan sup 25mg (promethazine)

T1phenergan sup 50mg (promethazine)

T1 QLprometh vc syp 6.25-5/5 (promethazine)

T1 QLprometh vc syp plain (promethazine)

T1 QLprometh/pe syp 6.25-5/5

T1promethazine sol 6.25/5ml

T1promethazine sup 25mg

T1promethazine sup 50mg

T1promethazine syp 6.25/5ml

T1promethazine tab 12.5mg

T1promethazine tab 25mg

T1promethazine tab 50mg

T1promethegan sup 25mg (promethazine)

T1promethegan sup 50mg (promethazine)

PROPYLAMINE DERIVATIVES

T1dexchlorphen syp 2mg/5ml

SECOND GENERATION ANTIHISTAMINES

T1desloratadin tab 5mg

T1levocetirizi sol 2.5/5ml

T1levocetirizi tab 5mg

ANTI-INFECTIVE AGENTSANTHELMINTICS

T3ALBENZA TAB 200MG (albendazole)

1Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform



ANTI-INFECTIVE AGENTSANTIBACTERIALS

AMINOGLYCOSIDES

T1neomycin tab 500mg

T4 PA, QL (2 nebulizers/day)tobramycin neb 300/5ml

ANTIBACTERIALS, MISCELLANEOUS

T1baciim inj 50000unt (bacitracin)

T1bacitracin inj 50000unt

T1clindamycin cap 150mg

T1clindamycin cap 300mg

T1

T1

T1

T1

T1

QL (28 tabs/14 days)

QL (112 caps/14 days)


T2

T2

T3

T3

T3

PA

PA

QL (840ml/14 days)

clindamycin cap 75mg

clindamycin sol 75mg/5ml

linezolid tab 600mg

vancomycin cap 125mg

vancomycin cap 250mg

VANCOMYCN 25 SOL 25MG/ML (vancomycin)

VANCOMYCN 50 SOL 50MG/ML (vancomycin)

XIFAXAN TAB 200MG (rifaximin)

XIFAXAN TAB 550MG (rifaximin)

ZYVOX SUS 100MG/5M (linezolid)

CEPHALOSPORINS

T2CEDAX CAP 400MG (ceftibuten)

T1cefaclor cap 250mg

T1cefaclor cap 500mg

T1cefaclor er tab 500mg

T1cefadroxil cap 500mg

T1cefadroxil sus 250/5ml

T1cefadroxil sus 500/5ml

T1cefadroxil tab 1gm

T1cefdinir cap 300mg

T1cefdinir sus 125/5ml

T1cefdinir sus 250/5ml

T1cefditoren tab 200mg

T1cefditoren tab 400mg





CEPHALOSPORINS

T1cefixime sus 100/5ml

T1cefixime sus 200/5ml

T1cefpodo prox sus 100/5ml

T1cefpodo prox sus 50mg/5ml

T1cefpodoxime tab 100mg

T1cefpodoxime tab 200mg

T1cefprozil sus 125/5ml

T1cefprozil sus 250/5ml

T1cefprozil tab 250mg

T1cefprozil tab 500mg

T1cefuroxime tab 250mg

T1cefuroxime tab 500mg

T1cephalexin cap 250mg



T1cephalexin sus 125/5ml

T1cephalexin sus 250/5ml

T3

T3

SUPRAX SUS 500/5ML (cefixime)

SUPRAX TAB 400MG (cefixime)

MACROLIDES

T1 QLazithromycin pow 1gm pak

T1 QL (120 ml/fill)azithromycin sus 100/5ml

T1 QL (120 ml/fill)azithromycin sus 200/5ml

T1 QL (8/5 days)azithromycin tab 250mg



T1clarithromyc sus 125/5ml

T1clarithromyc sus 250/5ml

T1clarithromyc tab 250mg





MACROLIDES

T1clarithromyc tab 500mg

T1clarithromyc tab 500mg er

T3 QL (20/10 days)DIFICID TAB 200MG (fidaxomicin)

T1e.e.s. 400 tab 400mg (erythromycin)

T2E.E.S. GRAN SUS 200/5ML (erythromycin)

T2ERYPED SUS 200/5ML (erythromycin)

T2ERYPED SUS 400/5ML (erythromycin)

T1erythrom eth tab 400mg

T1erythromycin tab 250mg bs

T1erythromycin tab 500mg bs

T3 QL (20 tabs/10 days)KETEK TAB 300MG (telithromycin)

T3 QL (20 tabs/10 days)KETEK TAB 400MG (telithromycin)

T2PCE TAB 333MG EC (erythromycin)

T2PCE TAB 500MG EC (erythromycin)

MISCELLANEOUS B-LACTAM ANTIBIOTICS

T4 PA, QL (1 kit/28 days)CAYSTON INH 75MG (aztreonam)

PENICILLINS

T1amox/k clav chw 200mg

T1amox/k clav chw 400mg

T1amox/k clav sus 200/5ml




T1amox/k clav tab 250mg



T1amoxicillin cap 250mg

T1amoxicillin cap 500mg

T1amoxicillin chw 125mg

T1amoxicillin chw 250mg

T1amoxicillin sus 125/5ml






PENICILLINS


T1amoxicillin sus 250mg/5m


T1amoxicillin tab 500mg

T1amoxicillin tab 875mg

T1amox-pot cla tab er

T1ampicillin cap 250mg

T1ampicillin cap 500mg

T1ampicillin sus 125/5ml

T1ampicillin sus 250/5ml

T1dicloxacill cap 250mg

T1dicloxacill cap 500mg

T1penicilln vk sol 125/5ml

T1penicilln vk sol 250/5ml

T1penicilln vk tab 250mg

T1penicilln vk tab 500mg

QUINOLONES

T1ciprofloxacn sus 250mg/5

T1ciprofloxacn sus 500mg/5

T1 QL (14 tabs/Rx)ciprofloxacn tab 1000mg

T1ciprofloxacn tab 100mg



T1 QL (14 tabs/Rx)ciprofloxacn tab 500mg er


T3 QL (7 tabs/7 days)FACTIVE TAB 320MG (gemifloxacin)

T1levofloxacin inj 25mg/ml

T1levofloxacin sol 25mg/ml

T1levofloxacin tab 250mg







QUINOLONES

T1 QL (14 tabs/Rx)moxifloxacin tab 400mg

T3 QL (56 tabs/28 days)NOROXIN TAB 400MG (norfloxacin)

T1ofloxacin tab 200mg



SULFONAMIDES (SYSTEMIC)

T1smz/tmp ds tab 800-160

T1smz-tmp sus 200-40/5

T1smz-tmp tab 400-80mg

T1smz-tmp ds tab 800-160 (sulfamethoxazole-trimethoprim)

T1sulfadiazine tab 500mg

T1sulfasalazin tab 500mg

T1sulfasalazin tab 500mg dr

T1sulfatrim pd sus 200-40/5 (sulfamethoxazole-trimethoprim)

T1sulfazine tab 500mg (sulfasalazine)

T1sulfazine ec tab 500mg (sulfasalazine)

TETRACYCLINES

T1demeclocycl tab 150mg

T1demeclocycl tab 300mg

T1doxycyc mono cap 100mg

T1doxycycl hyc cap 100mg

T1 QL (90 caps/30 days)doxycycl hyc cap 50mg

T1 QL (90 caps/30 days)doxycycl hyc tab 100mg

T1minocycline cap 100mg



T1minocycline tab 100mg



T1tetracycline cap 250mg





TETRACYCLINES

T1tetracycline cap 500mg

ANTIFUNGAL (SYSTEMIC)ALLYLAMINES

T1terbinafine tab 250mg

ANTIFUNGALS, MISCELLANEOUS

T1griseofulvin sus 125/5ml

T1griseofulvin tab micr 500

T1griseofulvin tab ultr 125

T1griseofulvin tab ultr 250

AZOLES

T1fluconazole sus 10mg/ml

T1fluconazole sus 40mg/ml

T1fluconazole tab 100mg




T1itraconazole cap 100mg

T1ketoconazole tab 200mg

T3 QL (2 bottles/fill)NOXAFIL SUS 40MG/ML (posaconazole)

T3SPORANOX SOL 10MG/ML (itraconazole)

T1 PAvoriconazole tab 200mg

T1 PAvoriconazole tab 50mg

POLYENES

T1nystatin pow

T1nystatin pow 10bu

T1nystatin pow 150mu

T1nystatin pow 1bu

T1nystatin pow 2bu

T1nystatin pow 500mu

T1nystatin pow 50mu

T1nystatin pow 5bu

T1nystatin sus 100000




ANTI-INFECTIVE AGENTSANTIFUNGAL (SYSTEMIC)

POLYENES

T1nystatin tab 500000

PYRIMIDINES

T1flucytosine cap 250mg

T1flucytosine cap 500mg

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS

T1dapsone tab 100mg

T1dapsone tab 25mg

ANTITUBERCULOSIS AGENTS

T1cycloserine cap 250mg

T1ethambutol tab 100mg

T1ethambutol tab 400mg

T1isoniazid syp 50mg/5ml

T1isoniazid tab 100mg

T1isoniazid tab 300mg

T1pyrazinamide tab 500mg

T1rifabutin cap 150mg

T2RIFAMATE CAP (isoniazid)

T1rifampin cap 150mg

T1rifampin cap 300mg

T1rifampin inj 600 mg

T4 PASIRTURO TAB 100MG (bedaquiline)

ANTIPROTOZOALSAMEBICIDES

T1paromomycin cap 250mg

ANTIMALARIALS

T1 QLatovaq/progu tab 250-100

T1 QLatovaq/progu tab 62.5-25

T1chloroquine tab 250mg

T1chloroquine tab 500mg

T3 QL (24 tabs/fill)COARTEM TAB 20-120MG (artemether-lumefantrine)


Only covered for treatment




ANTI-INFECTIVE AGENTSANTIPROTOZOALS

ANTIMALARIALS

T3 QL (90 tabs/30 days)DARAPRIM TAB 25MG (pyrimethamine)

T1hydroxychlor tab 200mg

T1 QL (5 tabs/30 days)mefloquine tab 250mg

T2primaquine tab 26.3mg

ANTIPROTOZOALS, MISCELLANEOUS

T3 QL (150ml/3 days)ALINIA SUS 100/5ML (nitazoxanide)

T3 QL (6 tabs/3 days)ALINIA TAB 500MG (nitazoxanide)

T1atovaquone sus 750/5ml

T1metronidazol cap 375mg

T1metronidazol tab 250mg

T1metronidazol tab 500mg

T3 PANEBUPENT INH 300MG (pentamidine)

T1tinidazole tab 250mg

T1tinidazole tab 500mg

ANTIVIRALS (SYSTEMIC)ADAMANTANES

T1rimantadine tab 100mg

ANTIRETROVIRALS

T4abacav/lamiv tab /zidovud

T4 QL (60 tabs/30 days)abacavir tab 300mg

T4APTIVUS CAP 250MG (tipranavir)

T4APTIVUS SOL (tipranavir)

T4 QL (30 tabs/30 days)ATRIPLA TAB (efavirenz-emtricitabine-tenofovir)

T4 QL (30 tabs/30 days)COMPLERA TAB (emtricitabine-rilpivirine-tenofovir)

T4 QL (180 caps/30 days)CRIXIVAN CAP 200MG (indinavir)

T4 QL (180 caps/30 days)CRIXIVAN CAP 400MG (indinavir)

T4CRIXIVAN 100 MG CAPSULE (INDINAVIR)

T4 QL (60 caps/30 day)didanosine cap 125mg









ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)

ANTIRETROVIRALS

T4EDURANT TAB 25MG (rilpivirine)

T4EMTRIVA CAP 200MG (emtricitabine)

T4EMTRIVA SOL 10MG/ML (emtricitabine)

T4EPIVIR HBV SOL 5MG/ML (lamivudine)

T4EPZICOM TAB (abacavir)

T4



QL (680ml/23 days)

PA, SP


QL (30 tabs/30 days)EPZICOM TAB 600-300 (abacavir)

T4 PAFUZEON INJ 90MG (enfuvirtide)

T4 PAFUZEON CONVENIENCE KIT (ENFUVIRTIDE)

T4 QL (60 tabs/30 days)INTELENCE TAB 100MG (etravirine)

T4 QL (60 tabs/30 days)INTELENCE TAB 200MG (etravirine)

T4 QLINTELENCE TAB 25MG (etravirine)

T4 QL (60 tabs/30 days)ISENTRESS TAB 400MG (raltegravir)

T4 QL (640ml/23 days)KALETRA SOL (lopinavir-ritonavir)

T4 QL (60 tabs/30 days)KALETRA TAB 100-25MG (lopinavir-ritonavir)

T4 QL (60 tabs/30 days)KALETRA TAB 200-50MG (lopinavir-ritonavir)

T4 QL (60 tab/30 day)lamivud/zido tab 150-300

T4lamivudine sol 10mg/ml

T4 PA, SPlamivudine tab 100mg

T4lamivudine tab 150mg

T4lamivudine tab 300mg

T4 QL (1800ml/30 days)LEXIVA SUS 50MG/ML (fosamprenavir)

T4 QL (120 tabs/30 days)LEXIVA TAB 700MG (fosamprenavir)

T4nevirapine sus 50mg/5ml

T4 QL (60 tab/30 day)nevirapine tab 200mg

T4 QL (30 TABS/30 DAYS)nevirapine tab 400mg er

T4 QL (60 caps/30 days)NORVIR CAP 100MG (ritonavir)

T4 QL (240 ml/30 day)NORVIR SOL 80MG/ML (ritonavir)

T4 QL (60 tabs/30 days)NORVIR TAB 100MG (ritonavir)

T4 QL (60 tabs/30 days)PREZISTA TAB 150MG (darunavir)







ANTIRETROVIRALS



T4 QL (180 tabs/30 days)RESCRIPTOR TAB 100 MG (delavirdine)

T4 QL (180 tabs/30 days)RESCRIPTOR TAB 200MG (delavirdine)

T4 QL (30 caps/30 days)REYATAZ CAP 100MG (atazanavir)




T4 QL (60 tabs/30 days)SELZENTRY TAB 150MG (maraviroc)

T4 QL (60 tabs/30 days)SELZENTRY TAB 300MG (maraviroc)

T4 QL (60 caps/30 day)stavudine cap 15mg




T4 QL (60 caps/30 day)

T4 QL (30 tabs/30 days)

T4 QL (30 caps/30 days)



T4

T4

T4

T4

T4

T4

T4

T4

QL (60 TABS/30 DAYS)

PA, QL (30 tabs/30 days)

QL (800ml/30 days)

QL (800ml/30 days)



QL (480 ml /30 day)


T4



stavudine sol 1mg/ml

STRIBILD TAB (elvitegravir-cobicistat-

emtricitabine-tenofovir)

SUSTIVA CAP 200MG (efavirenz)

SUSTIVA CAP 50MG (efavirenz)

SUSTIVA TAB 600MG (efavirenz)

TIVICAY TAB 50MG (dolutegravir)

TRUVADA TAB 200-300 (emtricitabine-tenofovir)

VIDEX SOL 2GM (didanosine)

VIDEX SOL 4GM (didanosine)

VIRACEPT TAB 250MG (nelfinavir)

VIRACEPT TAB 625MG (nelfinavir)

VIRAMUNE SUS 50MG/5ML (nevirapine)

VIRAMUNE XR TAB 100MG (nevirapine) VIREAD

POW 40MG/GM (tenofovir)

VIREAD TAB 150MG (tenofovir)

VIREAD TAB 200MG (tenofovir)


PA reqyured fior HIV prophylaxis




ANTIRETROVIRALS

T4 QL (30 tabs/30 days)VIREAD TAB 250MG (tenofovir)

T4 QL (30 tabs/30 days)VIREAD TAB 300MG (tenofovir)

T4 QL (480ml/30 days)ZIAGEN SOL 20MG/ML (abacavir)

T4 QL (60 caps/30 day)zidovudine cap 100mg

T4 QL (480ml/30 day)zidovudine syp 50mg/5ml

T4 QL (60 tab/30 day)zidovudine tab 300mg

T4 PA, SP

T4 PA, SP

T4 PA, SP

HCV ANTIVIRALS

HARVONI TAB 90-400MG (ledipasvir-sofosbuvir)

SOVALDI TAB 400MG (sofosbuvir)

ZEPATIER 50MG-100MG TAB (Eelbasvir-grazoprevir)

INTERFERONS

T4 PAINFERGEN INJ 15MCG (interferon)

T4 PAINFERGEN INJ 9MCG (interferon)

T4 PA, SPPEGASYS 180 MCG/0.5 ML CONV.PK (PEGINTERFERON)

T4 PA, SPPEGINTRON KIT 120MCG (peginterferon)




T4 PA, SPPEG-INTRON KIT 120 RP (peginterferon)

T4 PA, SPPEG-INTRON KIT 120MCG (peginterferon)

T4 PA, SPPEG-INTRON KIT 150 RP (peginterferon)



T4 PA, SPPEG-INTRON KIT 50MCG RP (peginterferon)


T4 PA, SPPEG-INTRON KIT 80MCG RP (peginterferon)


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MONOCLONAL ANTIBODIES

MED PA, SP Medical coinsuranceSYNAGIS INJ 50MG (palivizumab)

NEURAMINIDASE INHIBITORS

T3 QL (20 inhalations/fill; 2 fills/365 days)

RELENZA AER DISKHALE (zanamivir)

T3 QL (20 inhalations/fill; 2 fills/365 days)

RELENZA MIS DISKHALE (zanamivir)

T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 30MG (oseltamivir)



T3 QL (120ml/fill; 2 fills/365 days)TAMIFLU SUS 6MG/ML (oseltamivir)

NUCLEOSIDES AND NUCLEOTIDES

T1acyclovir cap 200mg

T1acyclovir sus 200/5ml

T1acyclovir tab 400mg

T1acyclovir tab 800mg

T4 PA, SPadefov dipiv tab 10mg

T4 PA, SPBARACLUDE SOL .05MG/ML (entecavir)

T4 PA, SPentecavir tab 0.5mg

T4 PA, SPentecavir tab 1mg

T1famciclovir tab 125mg



T1ganciclovir cap 250 mg

T1 PA, SPmoderiba tab 200mg (ribavirin)

T1 PA, SP ribapak pak 1200/day (ribavirin)

T1 PA, SPribapak pak 800/day (ribavirin)

T1 PA, SPribasphere cap 200mg (ribavirin)

T1 PA, SPribasphere tab 200mg (ribavirin)



T1 PA, SPribatab pak 1000/day (ribavirin)

T1 PA, SPribatab tab 1200/day (ribavirin)





T1 PA, SP

T1 PA, SP

T1 PA, SP

T4 PA, SP

T1

T1

T1



PA

NUCLEOSIDES AND NUCLEOTIDES

ribatab tab 800/day (ribavirin)

ribavirin cap 200mg

ribavirin tab 200mg

TYZEKA TAB 600MG (telbivudine)

valacyclovir tab 1gm

valacyclovir tab 500mg

valganciclov tab 450mg

URINARY ANTI-INFECTIVES

T1 QLhyophen tab (methenamine-hyosc-methylene)

T1methenam hip tab 1gm

T3 PA, QL (3 packs/fill)MONUROL PAK GRANULES (fosfomycin)

T1nitrofur mac cap 100mg

T1nitrofur mac cap 50mg

T1nitrofurantn cap 100mg

T1nitrofurantn sus 25mg/5ml

T1nitrofuranto cap 100mg

T1trimethoprim tab 100mg

ANTINEOPLASTIC AGENTS

T4 PA, SPAFINITOR TAB 10MG (everolimus)

T4 PA, SPAFINITOR TAB 2.5MG (everolimus)

T4 PA, SPAFINITOR TAB 5MG (everolimus)

T4 PA, SPAFINITOR TAB 7.5MG (everolimus)

T4ALKERAN TAB 2MG (melphalan)

T1anastrozole tab 1mg

T4 PA, SPbexarotene cap 75mg

T1bicalutamide tab 50mg

T4 PA, SPBOSULIF TAB 100MG (bosutinib)

T4 PA, SPBOSULIF TAB 500MG (bosutinib)

T4 PA, SPcapecitabine tab 150mg

T4 PA, SPcapecitabine tab 500mg





T4 PACAPRELSA TAB 100MG (vandetanib)

T4 PACAPRELSA TAB 300MG (vandetanib)

T4 PACOMETRIQ KIT 100MG (cabozantinib)



T1cyclophosph cap 25mg

T1cyclophosph tab 25mg

T1cyclophosph tab 50mg

T2DROXIA CAP 200MG (hydroxyurea)



T2EMCYT CAP 140MG (estramustine)

T4 PA, SP

T1

T1

T2

T1

T1

T4 PA, SP

T4 PA, SP

T4 PA, SP

T1 PA, SP

T1 PA, SP

T2

ERIVEDGE CAP 150MG (vismodegib)

etoposide cap 50mg

exemestane tab 25mg

FARESTON TAB 60MG (toremifene)

floxuridine inj 0.5gm

flutamide cap 125mg

GILOTRIF TAB 20MG (afatinib)



imatinib tab 100mg

imatinib tab 400mg

GLEOSTINE CAP 100MG (lomustine)

T2GLEOSTINE CAP 10MG (lomustine)

T2GLEOSTINE CAP 40MG (lomustine)

T2HEXALEN CAP 50MG (altretamine)

T1hydroxyurea cap 500mg

T4 PAIBRANCE CAP 100MG (palbociclib)



T4 PAICLUSIG TAB 15MG (ponatinib)

T4 PAICLUSIG TAB 45MG (ponatinib)


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T4 PA, SPIMBRUVICA CAP 140MG (ibrutinib)

T4 PA, SPINLYTA TAB 1MG (axitinib)

T4 PA, SPINLYTA TAB 5MG (axitinib)

T4 PAINTRON A INJ 10MU (interferon)

T4INTRON A INJ 18MU (interferon)



T4INTRON A INJ 50MU (interferon)

T4 PA, SPIRESSA TAB 250MG (gefitinib)

T4 PA, SPJAKAFI TAB 10MG (ruxolitinib)




T4 PA, SP

T1

T2

T2

T2

T1

T1

T1

T1

T1

T4 PA, SP

T4 PA, SP

T1

T1

T4 PA

T4 PA, SP

T4 PA

T4 PA, SP

T4 PA, SP

T4 PA, SP

JAKAFI TAB 5MG (ruxolitinib)

letrozole tab 2.5mg

LEUKERAN TAB 2MG (chlorambucil)

LYSODREN TAB 500MG (mitotane)

MATULANE CAP 50MG (procarbazine)

megestrol ac sus 400mg/10

megestrol ac sus 40mg/ml

megestrol ac sus 800mg/20

megestrol ac tab 20mg

megestrol ac tab 40mg

MEKINIST TAB 0.5MG (trametinib)

MEKINIST TAB 2MG (trametinib)

mercaptopur tab 50mg

methotrexate tab 2.5mg

MYLERAN TAB 2MG (busulfan)

NEXAVAR TAB 200MG (sorafenib)

NILANDRON TAB 150MG (nilutamide)

NINLARO

ODOMZA

POMALYST CAP 3MG (pomalidomide)





T4 PA, SPPOMALYST CAP 4MG (pomalidomide)

T4 PA, SPREVLIMID CAP 10MG (lenalidomide)


T4 PA, SPREVLIMID CAP 2.5MG (lenalidomide)




MED PA, SP Medical coinsuranceRITUXAN INJ 500MG (rituximab)

T4 PA, SPSPRYCEL TAB 100MG (dasatinib)






T4 PA, SPSTIVARGA TAB 40MG (regorafenib)

T4 PA, SPSUTENT CAP 12.5MG (sunitinib)

T4 PA, SPSUTENT CAP 25MG (sunitinib)

T4 PA, SPSUTENT CAP 37.5MG (sunitinib)

T4 PA, SPSUTENT CAP 50MG (sunitinib)

T4 PA, SPSYLATRON KIT 200MCG (peginterferon)



T4 PA, SPSYLATRON 296 MCG 4-PACK (PEGINTERFERON)



T2TABLOID TAB 40MG (thioguanine)

T4 PA, SPTAFINLAR CAP 50MG (dabrafenib)

T4 PA, SPTAFINLAR CAP 75MG (dabrafenib)

T0 HCR Rules for Coveragetamoxifen citrate tab 10 mg

T0 HCR Rules for Coveragetamoxifen citrate tab 20 mg

T4 PA, SPTARCEVA TAB 100MG (erlotinib)







T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T1

T4 PA

T4 PA

T4 PA

T4 PA

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

TASIGNA CAP 150MG (nilotinib)

TASIGNA CAP 200MG (nilotinib)

temozolomide cap 100mg






tretinoin cap 10mg

TREXALL TAB 10MG (methotrexate)



TREXALL TAB 7.5MG (methotrexate)

TYKERB TAB 250MG (lapatinib)

VOTRIENT TAB 200MG (pazopanib)

XALKORI CAP 200MG (crizotinib)

XALKORI CAP 250MG (crizotinib)

XTANDI CAP 40MG (enzalutamide)

ZELBORAF TAB 240MG (vemurafenib)

ZOLINZA CAP 100MG (vorinostat)

ZYDELIG TAB 100MG (idelalisib)

ZYDELIG TAB 150MG (idelalisib)

ZYTIGA TAB 250MG (abiraterone)

AUTONOMIC DRUGSANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

T3 PA, QLANORO ELLIPT AER 62.5-25 (umeclidinium-vilanterol)

T1atropine sul inj 0.05mg/1

T1atropine sul inj 0.1mg/ml

T1atropine sul inj 0.4/0.5

T2 QL (2 inhalers/30 days)ATROVENT HFA AER 17MCG (ipratropium)




AUTONOMIC DRUGSANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

T1 QLchlord/clidi cap 5-2.5mg

T1 QLclidi/chlord cap 2.5-5mg

T1dicyclomine cap 10mg

T1dicyclomine sol 10mg/5ml

T1dicyclomine tab 20mg

T1glycopyrrol tab 1mg

T1glycopyrrol tab 2mg

T1 QLhyoscyamine sub 0.125mg

T1 QLhyoscyamine tab 0.125mg

T1ipratropium sol 0.02%inh

T1ipratropium spr 0.03%

T1ipratropium spr 0.06%

T1methscopolam tab 2.5mg

T1methscopolam tab 5mg

T1 QLnulev tab 0.125mg (hyoscyamine)

T1 QLoscimin sub 0.125mg (hyoscyamine)

T1 QLoscimin tab 0.125mg (hyoscyamine)

T2 QL (1 inhaler/30 days)SPIRIVA CAP HANDIHLR (tiotropium)

T2 QLSPIRIVA SPR RESPIMAT (tiotropium)

T2 QLSTIOLTO

T1 QLsymax-sl sub 0.125mg (hyoscyamine)

T2 QL (1 inhaler/30 days)TUDORZA PRES AER 400/ACT (aclidinium)

ANTIPARKINSONIAN AGENTS

T1benztropine tab 1mg

T1benztropine tab 2mg

AUTONOMIC DRUGS, MISCELLANEOUS

T0 QL HCR Rules for CoverageCHANTIX PAK 0.5& 1MG (varenicline)

T0 QL (1 fill/30 days; 6 fills/365 days)

HCR Rules for CoverageCHANTIX PAK 1MG (varenicline)


HCR Rules for CoverageCHANTIX TAB 0.5MG (varenicline)


HCR Rules for CoverageCHANTIX TAB 1MG (varenicline)


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AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS

T0 HCR Rules for Coveragenicotine kit

T0 QL (14 Patches/14 days, 12 fills/365 days)

HCR Rules for Coveragenicotine patch 14 mg/24hr

T0 QL HCR Rules for Coveragenicotine patch 14 mg/24hr







T0 QL (360 units/30 days, 6 fills/365 days)

HCR Rules for Coveragenicotine polacrilex gum 2 mg

T0 QL HCR Rules for Coveragenicotine polacrilex gum 2 mg

T0 QL HCR Rules for Coveragenicotine polacrilex lozg 2 mg


HCR Rules for Coveragenicotine polacrilex lozg 2 mg


HCR Rules for Coveragenicotine polacrilex lozg 4 mg

T0 QL HCR Rules for Coveragenicotine polacrilex lozg 4 mg

T0 QL NICOTROL INH (nicotine)

NICOTROL NS SPR 10MG/ML (nicotine) T0

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

T1cevimeline cap 30mg

T1donepezil tab 10mg

T1donepezil tab 10mg odt

T1donepezil tab 5mg

T1donepezil tab 5mg odt

T1galantamine cap 16mg er



T1galantamine sol 4mg/ml

T1galantamine tab 12mg




QL



AUTONOMIC DRUGSPARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

T1guanidine tab 125mg

T2MESTINON SYP 60MG/5ML (pyridostigmine)

T1pilocarpine tab 5mg

T1pilocarpine tab 7.5mg

T1pyridostigm tab 60mg

T1pyridostigmi tab 180mg

T1 QL (60 caps/30 days)rivastigmine cap 1.5mg

T1 QL (60 caps/30 days)rivastigmine cap 3mg

T1 QL (60 caps/30 days)rivastigmine cap 4.5mg

T1 QL (60 caps/30 days)rivastigmine cap 6mg

SKELETAL MUSCLE RELAXANTS

T1methocarbam tab 500mg

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

T1 QL (120 tabs/30 days)carisopr/asa tab 200-325

T1 QL (120 tabs/30 days)carisoprodol tab 250mg

T1 QL (120 tabs/30 days)carisoprodol tab 350mg

T1 QL (120 tabs/30 days)carisoprodol tab asa/cod

T1chlorzoxazon tab 500mg

T1 QL (90 tabs/30 days)cyclobenzapr tab 10mg

T1 QL (90 tabs/30 days)cyclobenzapr tab 5mg

T3LORZONE TAB 750MG (chlorzoxazone)

T1metaxalone tab 400mg

T1metaxalone tab 800mg

T1methocarbam tab 750mg

T1tizanidine tab 2mg

T1tizanidine tab 4mg

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

T1dantrolene cap 100mg



GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

T1baclofen tab 10mg




AUTONOMIC DRUGSSKELETAL MUSCLE RELAXANTS

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

T1baclofen tab 20mg

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

T1orphenadrine inj 30mg/ml

T1orphenadrine tab 100mg cr (orphenadrine)

T1orphenadrine tab 100mg er

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTSALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

T1alfuzosin tab 10mg

T1ergoloid mes tab 1mg oral

T2 QL (6 units/30 days)MIGRANAL SPR 4MG/ML (dihydroergotamine)

T3 PA, QL (30 caps/30 days) alfuzosin, finasteride, tamsulosin

RAPAFLO CAP 8MG (silodosin)

T1 QL (30 caps/30 days)tamsulosin cap 0.4mg

SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS

T1epinephrine inj 0.1mg/ml

T1epinephrine inj 1mg/ml

T2EPIPEN 2-PAK INJ 0.3MG (epinephrine)

T2EPIPEN-JR INJ 2-PAK (epinephrine)

ALPHA-ADRENERGIC AGONISTS

T1midodrine tab 10mg

T1midodrine tab 2.5mg

T1midodrine tab 5mg

BETA-ADRENERGIC AGONISTS

T2 QL (1 inhaler/30 days)ADVAIR DISKU AER 100/50 (fluticasone-salmeterol)



T2 QL (1 inhaler/30 days)ADVAIR HFA AER 115/21 (fluticasone-salmeterol)



T1albuterol neb 0.083%




AUTONOMIC DRUGSSYMPATHOMIMETIC (ADRENERGIC) AGENTS

BETA-ADRENERGIC AGONISTS

T1albuterol neb 0.5%

T1albuterol neb 0.63mg/3

T1albuterol neb 1.25mg/3

T1albuterol syp 2mg/5ml

T1albuterol tab 2mg

T1albuterol tab 4mg

T1albuterol tab 4mg er

T3 QL (30 caps/30 days)ARCAPTA CAP 75MCG (indacaterol)

T3 PABROVANA NEB 15MCG (arformoterol)

T2 QLCOMBIVENT AER RESPIMAT (ipratropium-albuterol)

T3FORADIL CAP AEROLIZE (formoterol)

T1levalbuterol neb 0.31mg


T1levalbuterol neb 1.25/0.5


T3 QL (1 canister/month) PROAIR HFA, VENTOLIN HFA

MAXAIR AUTOH AER 200MCG (pirbuterol)

T1metaproteren syp 10mg/5ml

T1metaproteren tab 10mg

T1metaproteren tab 20mg

T3PERFOROMIST NEB 20MCG (formoterol)

T2PROAIR HFA AER (albuterol)

T2PROAIR RESPI AER (albuterol)

T3

QL

QL (2canister/30days)


QL (2canister/30days) PROAIR HFA, VENTOLIN HFA

PROVENTIL AER HFA (albuterol)

T2 QL (1 diskus/30 days)SEREVENT DIS AER 50MCG (salmeterol)

T1terbutaline tab 2.5mg

T1terbutaline tab 5mg

T2VENTOLIN HFA AER (albuterol)

T3


PA PROAIR HFA, VENTOLIN HFA

XOPENEX HFA AER (levalbuterol)




BLOOD FORMATION,COAGULATION & THROMBOSISANTIANEMIA DRUGS

IRON PREPARATIONS

T0 HCR Rules for Coveragecarbonyl iron chew 15 mg

T0 HCR Rules for Coveragecarbonyl iron suspension 15 mg/1.25ml

T1fe c plus tab (iron-vitamin)

T0 HCR Rules for Coverageferrous aspartate tab 112 mg

T0 HCR Rules for Coverageferrous fumarate cap 86 mg

T0 HCR Rules for Coverageferrous fumarate tab 18 mg





T0 HCR Rules for Coverageferrous gluconate tab 225 mg





T0 HCR Rules for Coverageferrous sulfate elixir 220 mg/5ml

T0 HCR Rules for Coverageferrous sulfate soln 15 mg/ml

T0 HCR Rules for Coverageferrous sulfate syrup 300 mg/5ml

T0 HCR Rules for Coverageferrous sulfate tab 134 mg











T0 HCR Rules for Coverageferrous sulfate tab 47.5 mg





BLOOD FORMATION,COAGULATION & THROMBOSISANTIANEMIA DRUGS

IRON PREPARATIONS



T0 HCR Rules for Coveragepolysaccharide iron complex cap 150 mg

T0 HCR Rules for Coveragepolysaccharide iron complex cap 200 mg

ANTIHEMORRHAGIC AGENTSHEMOSTATICS

MED PA, SP Medical coinsuranceADVATE INJ 1000UNIT (antihemophilic)






MED PA, SP Medical coinsuranceALPHANATE INJ VWF/HUM (antihemophilic)

MED PA, SP Medical coinsuranceALPHANATE 1,000-400 UNIT VIAL (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceALPHANATE 1,500-600 UNIT VIAL (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceALPHANATE 500-200 UNIT VIAL (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceALPHANINE SD INJ 1000UNIT (coagulation)

MED PA, SP Medical coinsuranceALPHANINE SD INJ 1500UNIT (coagulation)

MED PA, SP Medical coinsuranceBEBULIN INJ 200-1200 (factor)

MED PA, SP Medical coinsuranceBEBULIN VH IMMU 200-1,200 UNIT (FACTOR)

MED PA, SP Medical coinsuranceBENEFIX INJ 1000UNIT (coagulation)




MED PA, SP Medical coinsuranceCORIFACT KIT (factor)

MED PA, SP Medical coinsuranceELOCTATE INJ 1000UNIT (antihemophilic)








BLOOD FORMATION,COAGULATION & THROMBOSISANTIHEMORRHAGIC AGENTS

HEMOSTATICS



MED PA, SP Medical coinsuranceFEIBA VH IMMU 1,750-3,250 UNIT (ANTIINHIBITOR)

MED PA, SP Medical coinsuranceHELIXATE FS INJ 1000UNIT (antihemophilic)




MED PA, SP Medical coinsuranceHEMOFIL M INJ 1700UNIT (antihemophilic)

MED PA, SP Medical coinsuranceHEMOFIL M INJ 220-400 (antihemophilic)

MED PA, SP Medical coinsuranceHEMOFIL M INJ 401-800 (antihemophilic)

MED PA, SP Medical coinsuranceHEMOFIL M SOL 501-2000 (antihemophilic)

MED PA, SP Medical coinsuranceHEMOFIL M SOL 801-1500 (antihemophilic)

MED PA, SP Medical coinsuranceHUMATE-P SOL 2400UNIT (antihemophilic)

MED PA, SP Medical coinsuranceHUMATE-P SOL 250-600 (antihemophilic)

MED PA, SP Medical coinsuranceHUMATE-P SOL 500-1200 (antihemophilic)

MED PA, SP Medical coinsuranceKCENTRA KIT 1000UNIT (prothrombin)

MED PA, SP Medical coinsuranceKCENTRA KIT 500UNIT (prothrombin)

MED PA, SP Medical coinsurancekoate-dvi inj 1000unit (antihemophilic)

MED PA, SP Medical coinsurancekoate-dvi inj 250unit (antihemophilic)

MED PA, SP Medical coinsuranceKOATE-DVI INJ 500UNIT (antihemophilic)

MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000/BS (antihemophilic)

MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000UNIT (antihemophilic)









MED PA, SP Medical coinsuranceMONOCLATE-P INJ 250UNIT (antihemophilic)




BLOOD FORMATION,COAGULATION & THROMBOSISANTIHEMORRHAGIC AGENTS

HEMOSTATICS

MED PA, SP Medical coinsuranceMONOCLATE-P INJ 500UNIT (antihemophilic)

MED PA, SP Medical coinsuranceMONONINE INJ 500UNIT (coagulation)

MED PA, SP Medical coinsuranceNOVOSEVEN INJ 2400MCG (coagulation)

MED PA, SP Medical coinsuranceNOVOSEVEN 1,200 MCG VIAL (COAGULATION)

MED PA, SP Medical coinsuranceNOVOSEVEN 4,800 MCG VIAL (COAGULATION)

MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 1MG (coagulation)




MED PA, SP Medical coinsurancePROFILNINE SD 500 UNITS VIAL (FACTOR)

MED PA, SP Medical coinsuranceRECOMBINATE INJ 220-400 (antihemophilic)



MED PA, SP Medical coinsuranceRIASTAP SOL 1GM (fibrinogen)

MED PA, SP Medical coinsuranceRIXUBIS INJ 1000UNIT (coagulation)


MED PA, SP Medical coinsuranceRIXUBIS INJ 250 UNIT (coagulation)



T1tranex acid tab 650mg

MED PA, SP Medical coinsuranceWILATE INJ (antihemophilic)

MED PA, SP Medical coinsuranceWILATE 1,000-1,000 UNIT KIT (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceWILATE 450-450 UNIT KIT (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceWILATE 900-900 UNIT KIT (ANTIHEMOPHILIC)

MED PA, SP Medical coinsuranceXYNTHA INJ 1000UNIT (antihemophilic)




ANTITHROMBOTIC AGENTS

T2

ANTICOAGULANTS

COUMADIN tab 10mg (warfarin)




BLOOD FORMATION,COAGULATION & THROMBOSISANTITHROMBOTIC AGENTS

ANTICOAGULANTS

T2COUMADIN tab 1mg (warfarin)

T2

T2

COUMADIN tab 2.5mg (warfarin)


T2

T2

T2

T2





T2



T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

COUMADIN tab 7.5mg (warfarin)

ELIQUIS TAB 2.5MG (apixaban)

ELIQUIS TAB 5MG (apixaban)

enoxaparin inj 100mg/ml

enoxaparin inj 120/0.8

enoxaparin inj 150mg/ml

enoxaparin inj 30/0.3ml

enoxaparin inj 300/3ml

T1 QLenoxaparin inj 40/0.4ml



T1 QLfondaparinux inj 10/0.8ml

T1 QLfondaparinux inj 2.5/0.5

T1 QLfondaparinux inj 5/0.4ml

T1 QLfondaparinux inj 7.5/0.6

T3 PAFRAGMIN INJ 10000/ML (dalteparin)

T3FRAGMIN INJ 12500UNT (dalteparin)



T3FRAGMIN INJ 2500/0.2 (dalteparin)




T2

PA

QL (60 caps/30 days)PRADAXA CAP 150MG (dabigatran)


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BLOOD FORMATION,COAGULATION & THROMBOSISANTITHROMBOTIC AGENTS

ANTICOAGULANTS

T2PRADAXA CAP 75MG (dabigatran) QL (74 caps/30 days)

T1warfarin tab 10mg

T1warfarin tab 1mg

T1warfarin tab 2.5mg

T1warfarin tab 2mg

T1warfarin tab 3mg

T1warfarin tab 4mg

T1warfarin tab 5mg

T1warfarin tab 6mg

T1warfarin tab 7.5mg

T1warfarin sod tab 10mg

T2 QL (30 tabs/30 days)XARELTO TAB 10MG (rivaroxaban)



T2 QL (30 tabs/30 days)XARELTO STAR TAB 15/20MG (rivaroxaban)

PLATELET-AGGREGATION INHIBITORS

T2AGGRENOX CAP 25-200MG (aspirin-dipyridamole)

T3 clopidogrelBRILINTA TAB 60MG (ticagrelor)

T3



PA, QL (60 tabs/30 days) clopidogrelBRILINTA TAB 90MG (ticagrelor)

T1cilostazol tab 100mg

T1cilostazol tab 50mg

T1clopidogrel tab 300mg

T1 QL (30 tabs/30 days)clopidogrel tab 75mg

T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 10MG (prasugrel)

T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 5MG (prasugrel)

T1ticlopidine tab 250mg

PLATELET-REDUCING AGENTS

T1anagrelide cap 0.5mg

T1anagrelide cap 1mg

HEMATOPOIETIC AGENTS

T4ARANESP INJ 100MCG (darbepoetin)


PRADAXA CAP 110MG (dabigatran



BLOOD FORMATION,COAGULATION & THROMBOSISHEMATOPOIETIC AGENTS









T4 QL (4 vials/30 days)EPOGEN INJ 10000/ML (epoetin)

T4EPOGEN INJ 2000/ML (epoetin)

T4 QL (4 vials/30 days)EPOGEN INJ 20000/ML (epoetin)



T4LEUKINE INJ 250MCG (sargramostim)

T4LEUKINE INJ 500 MCG (sargramostim)

T4 PANEULASTA INJ 6MG/0.6M (pegfilgrastim)

T4 PANEULASTA KIT 6MG/0.6M (pegfilgrastim)

T4 QLNEUPOGEN INJ 300/0.5 (filgrastim)

T4 QLNEUPOGEN INJ 300MCG (filgrastim)

T4 QLNEUPOGEN INJ 480/0.8 (filgrastim)

T4 QLNEUPOGEN INJ 480MCG (filgrastim)

T4 QL (4 vials/30 days)PROCRIT INJ 10000/ML (epoetin)

T4PROCRIT INJ 2000/ML (epoetin)

T4 QL (4 vials/30 days)PROCRIT INJ 20000/ML (epoetin)




T4 PA, SPPROMACTA TAB 12.5MG (eltrombopag)

T4 PA, SPPROMACTA TAB 25MG (eltrombopag)






BLOOD FORMATION,COAGULATION & THROMBOSISHEMORRHEOLOGIC AGENTS

T1pentoxifylli tab 400mg cr

T1pentoxifylli tab 400mg er

CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS

T3 QL (30 tabs/30 days)CARDURA XL TAB 4MG (doxazosin)

T1doxazosin tab 1mg

T1doxazosin tab 2mg

T1doxazosin tab 4mg

T1doxazosin tab 8mg

T1prazosin hcl cap 1mg



T1terazosin cap 10mg

T1terazosin cap 1mg

T1terazosin cap 2mg

T1terazosin cap 5mg

ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS

T1 QLniacin tab 500mg er

T1 QLniacin er tab 1000mg



T1 PA, QL (120 caps/30 days)omega-3-acid cap 1gm

BILE ACID SEQUESTRANTS

T1cholestyram pow 4gm

T1cholestyram pow 4gm lite

T1colestipol gra 5gm

T1colestipol tab 1gm (colestipol)

T1prevalite pow 4gm (cholestyramine)

T1prevalite pow 4gm pk (cholestyramine)

T3 PA, QL (30 packets/30 days) cholestyramineWELCHOL PAK 3.75GM (colesevelam)

T3 PA, QL (210 tabs/30 days) cholestyramineWELCHOL TAB 625MG (colesevelam)




CARDIOVASCULAR DRUGSANTILIPEMIC AGENTS

CHOLESTEROL ABSORPTION INHIBITORS

T2 QL (30 tabs/30 days)ZETIA TAB 10MG (ezetimibe)

FIBRIC ACID DERIVATIVES

T1fenofibrate cap 130mg





T1fenofibrate tab 120mg






T1fenofibric tab 105mg

T1fenofibric tab 35mg

T1gemfibrozil tab 600mg

HMG-COA REDUCTASE INHIBITORS

T3 QL (60 tabs/30 days)ADVICOR TAB 1000-20 (niacin-lovastatin)

T3 QL (60 tabs/30 days)ADVICOR TAB 1000-40 (niacin-lovastatin)

T3 QL (60 tabs/30 days)ADVICOR TAB 500-20MG (niacin-lovastatin)

T3 QL (60 tabs/30 days)ADVICOR TAB 750-20MG (niacin-lovastatin)

T1atorvastatin tab 10mg




T3 QL (30 tabs/30 days), (atorvastatin 80MG)

atorvastatin, simvastatin

rosuvastatin tab 20mg













CARDIOVASCULAR DRUGSANTILIPEMIC AGENTS

HMG-COA REDUCTASE INHIBITORS

T1fluvastatin cap 20mg

T1fluvastatin cap 40mg

T1 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin

Fluvastatin TAB 80MG


LIVALO TAB 1MG (pitavastatin)





T1lovastatin tab 10mg



T1pravastatin tab 10mg




T1simvastatin tab 10mg





T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)


VYTORIN TAB 10-10MG (ezetimibe-simvastatin)










BETA-ADRENERGIC BLOCKING AGENTS

T1 atenololacebutolol cap 200mg




CARDIOVASCULAR DRUGSBETA-ADRENERGIC BLOCKING AGENTS

T1 atenololacebutolol cap 400mg

T1 QL (60 tabs/30 days)atenol/chlor tab 100-25mg

T1 QL (60 tabs/30 days)atenol/chlor tab 50-25mg

T1atenolol tab 100mg

T1atenolol tab 25mg

T1atenolol tab 50mg

T1betaxolol tab 10mg

T1betaxolol tab 20mg

T1 QL (60 tabs/30 days)bisoprl/hctz tab 10/6.25

T1 QL (60 tabs/30 days)bisoprl/hctz tab 2.5/6.25

T1 QL (60 tabs/30 days)bisoprl/hctz tab 5-6.25mg

T1bisoprol fum tab 10mg

T1bisoprol fum tab 5mg

T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 10MG (nebivolol)

T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 2.5MG (nebivolol)



T1carvedilol tab 12.5mg

T1carvedilol tab 25mg



T1labetalol tab 100mg



T2 PA, QL (60 tabs/30 days) atenolol, carvedilolLEVATOL TAB 20MG (penbutolol)

T1 QLmetoprl/hctz tab 100-25mg



T1metoprol tar tab 100mg



T1metoprolol tab 100mg er




CARDIOVASCULAR DRUGSBETA-ADRENERGIC BLOCKING AGENTS




T1nadolol tab 20mg

T1nadolol tab 40mg

T1nadolol tab 80mg

T1 atenololpindolol tab 10mg

T1 atenololpindolol tab 5mg

T1propranolol cap 120mg er




T1propranolol sol 20mg/5ml

T1propranolol sol 40mg/5ml

T1propranolol tab 10mg





T1sorine tab 120mg (sotalol)




T1sotalol hcl tab 120mg




T1timolol mal tab 10mg






CARDIOVASCULAR DRUGSCALCIUM-CHANNEL BLOCKING AGENTS

CALCIUM-CHANNEL BLOCKING AGENTS, MISC.

T3CORLANOR

T1cartia xt cap 180/24hr (diltiazem)



T1dilt-cd cap 120mg (diltiazem)




T1diltiazem cap 120mg cd (diltiazem)

T1diltiazem cap 120mg er

T1 QLdiltiazem cap 120mg er




T1diltiazem cap 180mg/24

T1diltiazem cap 240mg cd




T1diltiazem cap 300mg cd









T1diltiazem tab 120mg




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T1 QLdiltiazem er tab 180mg





T1 QLdilt-xr cap 120mg (diltiazem)



T1diltzac cap 180mg/24 (diltiazem)




T1 QLmatzim la tab 180mg/24 (diltiazem)





T1taztia xt cap 180mg/24 (diltiazem)




T1verapamil cap 100mg er


T1verapamil cap 120mg sr













T1verapamil tab 120mg

T1verapamil tab 120mg er

T1verapamil tab 120mg sr


T1verapamil tab 180mg sa


T1verapamil tab 240mg cr


T1verapamil tab 240mg sa




DIHYDROPYRIDINES

T1afeditab tab 30mg cr (nifedipine)

T1afeditab tab 60mg cr (nifedipine)

T1 QL (60 caps/30 days)amlod/benazp cap 10-20mg


T1 QL (60 caps/30 days)amlod/benazp cap 2.5-10mg




T1 QL (60 caps/30 days)amlod/valsar tab /hctz

T1amlodipine tab 10mg

T1amlodipine tab 2.5mg

T1amlodipine tab 5mg

T1felodipine tab 10mg er

T1felodipine tab 2.5mg er

T1felodipine tab 5mg er

T1isradipine cap 2.5mg

T1isradipine cap 5mg





DIHYDROPYRIDINES

T1nicardipine cap 20mg

T1nicardipine cap 30mg

T1nifediac cc tab 30mg er (nifedipine)

T1nifediac cc tab 60mg er (nifedipine)

T1nifedical xl tab 30mg (nifedipine)

T1nifedical xl tab 60mg (nifedipine)

T1nifedipine cap 10mg

T1nifedipine cap 20mg

T1nifedipine tab 30mg er



T1nimodipine cap 30mg

T1nisoldipine tab 17mg er

T1nisoldipine tab 20mg

T1nisoldipine tab 25.5mg


T1nisoldipine tab 34mg er


T1nisoldipine tab 8.5mg er

CARDIAC DRUGSANTIARRHYTHMIC AGENTS

T1amiodarone tab 200mg

T1 QLamiodarone tab 400mg

T1disopyramide cap 100mg

T1disopyramide cap 150mg

T1flecainide tab 100mg



T1 QL (90 caps/30 days)mexiletine cap 150mg






CARDIOVASCULAR DRUGSCARDIAC DRUGS

ANTIARRHYTHMIC AGENTS

T2 PA, QL (60 tabs/30 days)MULTAQ TAB 400MG (dronedarone)

T3NORPACE CAP 100MG CR (disopyramide)

T1pacerone tab 200mg (amiodarone)

T1 QLpacerone tab 400mg (amiodarone)

T1propafenone cap 225mg er

T1propafenone cap 325mg er

T1propafenone cap 425mg sr

T1propafenone tab 150mg



T1quinidine gl tab 324mg cr

T1quinidine gl tab 324mg er

T1quinidine su tab 300mg

T1quinidine su tab 300mg er

T2 QL (120 caps/30 days)TIKOSYN CAP 125MCG (dofetilide)



CARDIAC DRUGS, MISCELLANEOUS

T3 QL (60 tabs/30 days)RANEXA TAB 1000MG (ranolazine)

T3 QL (60 tabs/30 days)RANEXA TAB 500MG (ranolazine)

CARDIOTONIC AGENTS

T1digitek tab 0.125mg (digoxin)

T1digitek tab 0.25mg (digoxin)

T1digox tab 0.125mg (digoxin)

T1digox tab 0.25mg (digoxin)

T1digoxin inj 0.25mg/1

T1digoxin sol 50mcg/ml

T1digoxin tab 0.125mg

T1digoxin tab 0.25mg

T1lanoxin tab 0.125mg (digoxin)

T1lanoxin tab 0.25mg (digoxin)




CARDIOVASCULAR DRUGSCARDIAC DRUGS

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS, MISC

T3ENTRESTO TAB 24-26MG (sacubitril-valsartan)



HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS

T1clonidine dis 0.1/24hr



T1clonidine tab 0.1mg



T1guanfacine tab 1mg

T1guanfacine tab 2mg

T1methyldopa tab 250mg

T1methyldopa tab 500mg

DIRECT VASODILATORS

T1hydralazine inj 20mg/ml

T1hydralazine tab 100mg




T1minoxidil tab 10mg

T1minoxidil tab 2.5mg

DIURETICS (HYPOTENSIVE AGENTS)

T1acetazolamid tab 250mg

PERIPHERAL ADRENERGIC INHIBITORS

T1reserpine tab 0.1mg

T1reserpine tab 0.25mg

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS

T1candesa/hctz tab 16-12.5

T1candesa/hctz tab 32-12.5


PA

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iMMEDIATE RELEASE

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EXTENDED RELEASE

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CARDIOVASCULAR DRUGSRENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

T1candesa/hctz tab 32-25mg

T1 PAcandesartan tab 16mg




T3 PAEDARBI TAB 40MG (azilsartan)

T3 PAEDARBI TAB 80MG (azilsartan)

T1eprosart mes tab 600mg

T1irbesar/hctz tab 150-12.5

T1irbesar/hctz tab 300-12.5

T1irbesartan tab 150mg



T1losartan pot tab 100mg



T1losartan/hct tab 100-12.5

T1losartan/hct tab 100-25

T1losartan/hct tab 50-12.5

T1 PAtelmisartan tab 20mg



T1valsart/hctz tab 160-12.5

T1valsart/hctz tab 160-25mg


T1valsart/hctz tab 320-25mg


T1 QLvalsartan tab 160mg








ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

T1benazep/hctz tab 10-12.5


T1benazep/hctz tab 20-25mg


T1benazepril tab 10mg




T1captopr/hctz tab 25-15mg




T1captopril tab 100mg

T1captopril tab 12.5mg



T1enalapr/hctz tab 10-25mg

T1enalapr/hctz tab 5-12.5mg

T1enalapril tab 10mg

T1enalapril tab 2.5mg

T1enalapril tab 20mg

T1enalapril tab 5mg

T1fosinop/hctz tab 10/12.5

T1fosinop/hctz tab 20/12.5

T1fosinopril tab 10mg



T1lisinop/hctz tab 10-12.5

T1lisinop/hctz tab 20-12.5

T1lisinop/hctz tab 20-25mg

T1lisinopril tab 10mg





ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

T1lisinopril tab 2.5mg





T1moexipr/hctz tab 15-12.5

T1moexipr/hctz tab 15-25mg

T1moexipr/hctz tab 7.5-12.5

T1moexipril tab 15mg

T1moexipril tab 7.5mg

T1 QL (60 tabs/30 days)perindopril tab 2mg



T1qnapril/hctz tab 10-12.5

T1qnapril/hctz tab 20-12.5

T1qnapril/hctz tab 20-25mg

T1quinapril tab 10mg



T1quinapril tab 5mg

T1ramipril cap 1.25mg

T1ramipril cap 10mg

T1ramipril cap 2.5mg

T1ramipril cap 5mg

T1trandolapril tab 1mg



MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

T1eplerenone tab 25mg

T1eplerenone tab 50mg

T1spirono/hctz tab 25/25





MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

T1spironolact tab 100mg



RENIN INHIBITORS

T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan

TEKTURNA TAB 150MG (aliskiren)

T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan

TEKTURNA TAB 300MG (aliskiren)

VASODILATING AGENTSNITRATES AND NITRITES

T1isoditrate tab 40mg er (isosorbide)

T3ISORDIL TAB 40MG (isosorbide)

T1isosorb din tab 10mg



T1isosorb din tab 40mg er

T1isosorb din tab 40mg sa


T1isosorb mono tab 10mg

T1isosorb mono tab 120mg er

T1isosorb mono tab 20mg



T3NITRO-BID OIN 2% (nitroglycerin)

T3NITRO-DUR DIS 0.3MG/HR (nitroglycerin)

T1nitroglycer aer 400mcg

T1nitroglycer cap 2.5mg er

T1nitroglycer cap 2.5mg sr

T1nitroglycer cap 6.5mg er

T1nitroglycer cap 6.5mg sr

T1nitroglycer cap 9mg er

T3NITRONAL SOL 1MG/ML (nitroglycerin)




CARDIOVASCULAR DRUGSVASODILATING AGENTS

NITRATES AND NITRITES

T3NITROSTAT SUB 0.3MG (nitroglycerin)



T1nitro-time cap 2.5mg cr (nitroglycerin)

T1nitro-time cap 6.5mg cr (nitroglycerin)

T1nitro-time cap 9mg cr (nitroglycerin)

PHOSPHODIESTERASE TYPE 5 INHIBITORS

T4 PAADCIRCA TAB 20MG (tadalafil)

T3 PA, QL (30 tabs/30 days) for BPH alfuzosin, finasteride, tamsulosin

CIALIS TAB 5MG (tadalafil)

T1 QLsildenafil tab 20mg

VASODILATING AGENTS, MISCELLANEOUS

T1dipyridamole inj 5mg/ml

T1dipyridamole tab 25mg



CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

T1 QLbut/apap/caf cap

T1 QL (120 tabs/30 days)but/apap/caf tab

T1zebutal cap (butalbital-acetaminophen-caffeine)

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

T0 QL HCR Rules for Coverageaspirin chew 81 mg

T0 QL HCR Rules for Coverageaspirin chew 81 mg

T0 HCR Rules for Coverageaspirin tab 324 mg



T0 QL HCR Rules for Coverageaspirin tab 81 mg

T0 QL HCR Rules for Coverageaspirin tab 81 mg

T1 QLBAYER CHILD CHW ASA 81MG (aspirin)






T1but/asa/caff cap

T1but/asa/caff tab

T1 QL, STcelecoxib cap 100mg




T1cho mag tris liq 500/5ml

T1cho mag tris tab 1000mg

T1diclo/misopr tab 50-0.2mg

T1diclo/misopr tab 75-0.2mg

T1diclofen pot tab 50mg

T1diclofenac tab 100mg er

T1diclofenac tab 100mg xr

T1diclofenac tab 25mg dr



T1diflunisal tab 500mg

T1etodolac cap 200mg

T1etodolac cap 300mg

T1etodolac tab 400mg

T1etodolac tab 500mg

T1etodolac er tab 400mg

T1etodolac er tab 500mg (etodolac)

T1etodolac er tab 600mg

T1fenoprofen tab 600mg

T1flurbiprofen tab 100mg

T1flurbiprofen tab 50mg

T1ibuprofen sus 100/5ml (ibuprofen)

T1ibuprofen tab 400mg








T1indomethacin cap 25mg

T1indomethacin cap 50mg

T1indomethacin cap 75mg cr

T1indomethacin cap 75mg er

T1indomethacin cap 75mg sa

T1indomethacin cap 75mg sr

T1ketoprofen cap 200mg er

T1ketoprofen cap 50mg

T1ketoprofen cap 75mg

T1ketorolac tab 10mg

T1meclofen sod cap 100mg

T1meclofen sod cap 50mg

T3MEDI-SELTZER TAB (aspirin)

T1mefenam acid cap 250mg

T1meloxicam sus 7.5/5ml

T1meloxicam tab 15mg

T1meloxicam tab 7.5mg

T1nabumetone tab 500mg

T1nabumetone tab 750mg

T1naproxen sus 125/5ml

T1naproxen tab 250mg

T1naproxen tab 375mg

T1naproxen tab 500mg (naproxen)

T1naproxen dr tab 375mg (naproxen)

T1naproxen dr tab 500mg (naproxen)

T1naproxen ec tab 375mg (naproxen)

T1naproxen ec tab 500mg (naproxen)

T1naproxen sod tab 220mg (naproxen)

T1naproxen sod tab 275mg

T1naproxen sod tab 550mg

T1orph/asa/caf tab






T1oxaprozin tab 600mg

T1piroxicam cap 10mg

T1piroxicam cap 20mg

T1salsalate tab 500mg

T1salsalate tab 750mg

T1sulindac tab 150mg

T1sulindac tab 200mg

T1tolmetin sod cap 400mg

T1tolmetin sod tab 200mg

T1tolmetin sod tab 600mg

OPIATE AGONISTS

T1 QL (240 caps/30 days)apap/caff/di tab hydrocod

T1 QL (4500ml/30 days)apap/codeine sol 120-12/5

T1 QL (300 tabs/30 days)apap/codeine tab 300-15mg

T1 QLapap/codeine tab 300-30mg

T1 QLapap/codeine tab 300-60mg

T1asa/caff/but cap cod 30mg

T1ascomp/cod cap 30mg (acetaminophen)

T1 QL (240 caps/30 days)but/apap/caf cap codeine

T1but/asa/caf/ cap cod 30mg

T1butal cpd/ cap codeine (acetaminophen)

T1codeine sulf tab 15mg



T1 QLcodeine/apap tab 15-300mg



T1duramorph inj 0.5mg/ml (morphine)

T1duramorph inj 1mg/ml (morphine)

T1 QLendocet tab 10-325mg (oxycodone)

T1 QL (300 tabs/30 days)endocet tab 10-650mg (oxycodone)





OPIATE AGONISTS

T1 QLendocet tab 5-325mg (oxycodone)

T1 QLendocet tab 7.5-325 (oxycodone)

T1 QL (300 tabs/30 days)endocet tab 7.5-500m (oxycodone)

T1 QL (10 patches/30 days)fentanyl dis 100mcg/h

T1 QL (10 patches/30 days)fentanyl dis 12mcg/hr


T1 QLfentanyl dis 37.5mcg





T1 PAfentanyl ot loz 1200mcg






T1hydroco/apap sol 5-217/10

T1hydroco/apap sol 7.5-325

T1hydroco/apap tab 10-325mg

T1hydroco/apap tab 5-325mg

T1hydroco/apap tab 7.5-325

T1hydrocod/ibu tab 2.5-200

T1

QL (3600ml/30 days)

QL (3600ml/30 days)

QL

QL

QL

QL

QL hydrocod/ibu tab 7.5-200

T1hydromorphon liq 1mg/ml

T1hydromorphon sup 3mg

T1hydromorphon tab 2mg



T3 PAIBUDONE TAB 10-200MG (hydrocodone-ibuprofen)

T1levorphanol tab 2mg





OPIATE AGONISTS

T1 QL (28 tabs/28 days)lorcet tab 5-325mg (hydrocodone-acetaminophen)

T1 QL (150 tabs/30 days)lorcet hd tab 10-325mg (hydrocodone-acetaminophen)

T1 QL (150 tabs/30 days)lorcet plus tab 7.5-325 (hydrocodone-acetaminophen)

T1 QL (4 patches/28 days)lortab tab 10-325mg (hydrocodone-acetaminophen)

T1 QL (28 tabs/28 days)lortab tab 5-325mg (hydrocodone-acetaminophen)

T1 QL (28 tabs/28 days)lortab tab 7.5-325 (hydrocodone-acetaminophen)

T1meperidine inj 100mg/ml




T1meperidine sol 50mg/5ml

T1meperidine tab 100mg

T1meperidine tab 50mg

T1meperitab tab 100mg (meperidine)

T1meperitab tab 50mg (meperidine)

T1methadone sol 10mg/5ml

T1methadone sol 5mg/5ml

T1methadone tab 10mg

T1methadone tab 5mg

T1 QL (60 caps/30 days)morphine sul cap 100mg er

T1 PA, QL (30 caps/30 days)morphine sul cap 120mg er












OPIATE AGONISTS




T1morphine sul inj 0.5mg/ml

T1morphine sul inj 10mg/ml

T1morphine sul inj 150/30ml








T1morphine sul sol 10/0.5ml

T1morphine sul sol 100/5ml

T1morphine sul sol 10mg/5ml

T1morphine sul sol 20mg/5ml

T1morphine sul sol 20mg/ml

T1morphine sul sup 20mg

T1morphine sul sup 5mg

T1 QLmorphine sul tab 100mg cr

T1 QL (90 tabs/30 days)morphine sul tab 100mg er

T1 QL (120 tabs/30 days)morphine sul tab 15mg




T1 QL (120 tabs/30 days)morphine sul tab 30mg









OPIATE AGONISTS

T3 PA, QL (180 tabs/30 days) morphine, oxycodone

NUCYNTA TAB 100MG (tapentadol)


NUCYNTA TAB 75MG (tapentadol)


NUCYNTA ER TAB 100MG (tapentadol)


NUCYNTA ER TAB 200MG (tapentadol)

T1 QL (180 abs/30 days)






T1

T1

T1

T1

T1

T1

T1

T1

T1

T1

T1

oxycod/apap tab 10-325mg

oxycod/apap tab 2.5-325




oxycod/ibu tab 5-400mg

oxycodone cap 5mg

oxycodone sol 5mg/5ml

oxycodone tab 10mg

oxycodone tab 10mg er

oxycodone tab 15mg

oxycodone tab 20mg


oxycodone tab 30mg


oxycodone tab 5mg

oxycodone tab 80mg er e)

T1


QL (500ml/30 days)

QL (120 tabs/30 days

PA, QL



PA, QL

QL

PA,QL

QL

PA, QL

PA, QL (60 tabs/30 days)oxymorphone tab 10mg er

T1 PA, QL (60 tabs/30 days)oxymorphone tab 15mg er









OPIATE AGONISTS

T1 PA, QL (60 tabs/30 days)oxymorphone tab 7.5mg er

T1 PA, QL (60 tabs/30 days)oxymorphone tab hcl 10mg

T1 PA, QL (60 tabs/30 days)oxymorphone tab hcl 5mg

T1 QLroxicet tab 5-325mg (oxycodone)

T1 QL (240 tabs/30 days)tramadl/apap tab 37.5-325

T1tramadol hcl tab 100mg er



T1tramadol hcl tab 50mg

T1 PA, QL

T1 PA, QL

T3

T1

T1

OPIATE PARTIAL AGONISTS

bupren/nalox sub 2-0.5mg

bupren/nalox sub 8-2mg

NARCAN SPRAY

buprenorphin sub 2mg

buprenorphin sub 8mg

T1 QLbutorphanol inj 1mg/ml

T1 QL (2.5ml/14 days)butorphanol sol 10mg/ml

T3 PA, QL (4 patches/28 days)BUTRANS DIS 10MCG/HR (buprenorphine)




T3 PA, QL (4 patches/28 days)BUTRANS DIS 7.5/HR (buprenorphine)

T1penta/apap tab 25-650mg

T1pentaz/nalox tab 50-0.5mg

ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTSAMPHETAMINES

T1 QL (60 caps/30 days)amphetamine cap 10mg er







bpatel

Typewritten Text

PA



CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS

AMPHETAMINES

T1 QL (60 caps/30 days)amphetamine tab 10mg

T1 QL (60 caps/30 days)amphetamine tab 12.5mg

T1 QL (60 tabs/30 days)amphetamine tab 15mg




T1 QLamphetamine tab 7.5mg

T1benzphetamin tab 50mg

T1 QL (120 tabs/30 days)dexedrine tab 10mg (dextroamphetamine)

T1 QL (180 tabs/30 days)dexedrine tab 5mg (dextroamphetamine)

T1 QL (120 tabs/30 days)dextroamphet cap 10mg er



T1 QL (120 tabs/30 days)dextroamphet tab 10mg

T1 QL (28 tabs/28 days)dextroamphet tab 5mg

T1methamphetam tab 5mg

T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine

VYVANSE CAP 10MG (lisdexamfetamine)













ANOREXIGENIC AGENTS

T3 PABELVIQ TAB 10MG (lorcaserin)

T1diethylprop tab 75mg er

T1phentermine tab 37.5mg





RESPIRATORY AND CNS STIMULANTS

T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 10MG/9HR (methylphenidate)




T1 PAdexmethylph cap 15mg er






T1 PA, QL

T1 PA, QL

T1 PA, QL

T1 PA, QL

dexmethylph tab 10mg

dexmethylph tab 2.5mg

dexmethylph tab 5mg

dexmethylphe cap 10mg er



dexmethylphenidate cap 30mg er

T1 PA, QL dexmethylphenidate cap 40mg er

T1 QL (60 tabs/30 days)metadate tab 20mg er (methylphenidate)

T1 QL (28 tabs/28 days)methylphenid cap 10mg


T1 QL (60 tabs/30 days)methylphenid cap 20mg er



T1 QL (60 caps/30 days)methylphenid cap 40mg




T1methylphenid sol 10mg/5ml

T1methylphenid sol 5mg/5ml





RESPIRATORY AND CNS STIMULANTS

T1 QL (28 tabs/28 days)methylphenid tab 10mg

T1 QL (60 tabs/30 days)methylphenid tab 10mg er

T1 QLmethylphenid tab 18mg er




T1 QL (60 tabs/30 days)methylphenid tab 20mg sr








WAKEFULNESS-PROMOTING AGENTS

T1 PA, QL (60 tabs/30 days)modafinil tab 100mg

T1 PA, QL (60 tabs/30 days)modafinil tab 200mg

T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 150MG (armodafinil)



ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS

T3 QL (240 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide

BANZEL TAB 200MG (rufinamide)


BANZEL TAB 400MG (rufinamide)

T1carbamazepin cap 100mg er




CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS



T1carbamazepin chw 100mg

T1carbamazepin sus 100/5ml

T1carbamazepin tab 200mg

T1carbamazepin tab 200mg er

T1carbamazepin tab 400mg er

T1divalproex cap 125mg

T1divalproex tab 125mg dr


T1divalproex tab 250mg er


T1divalproex tab 500mg er

T1epitol tab 200mg (carbamazepine)

T1felbamate sus 600/5ml

T1felbamate tab 400mg

T1felbamate tab 600mg

T1gabapentin cap 100mg



T1gabapentin sol 250/5ml

T1gabapentin tab 600mg

T1gabapentin tab 800mg

T3 PAHORIZANT TAB 300MG (gabapentin)

T3 PAHORIZANT TAB 600MG (gabapentin)

T1 PALAMICTAL CHW 25MG (lamotrigine)

T1 PALAMICTAL CHW 5MG (lamotrigine)

T3 PA, QL (1 kit/fill, 1 fill per 365 days)

LAMICTAL KIT START 49 (lamotrigine)

T1 PAlamotrigine chw 25mg

T1 PAlamotrigine chw 5mg

T1lamotrigine tab 100mg






T1 QL (30 tabs/30 days)lamotrigine tab 100mg er









T1levetiraceta sol 100mg/ml

T1levetiraceta sol 500/5ml

T1levetiraceta tab 1000mg



T1 QLlevetiraceta tab 500mg er


T1 QLlevetiraceta tab 750mg er

T1levetiracetm inj 500/5ml

T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 100MG (pregabalin)








T1oxcarbazepin sus 300mg/5m

T1oxcarbazepin tab 150mg









POTIGA TAB 200MG (ezogabine)







T3 QL (210 packets/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide

SABRIL POW 500MG (vigabatrin)


SABRIL TAB 500MG (vigabatrin)

T3 PA divalproex, valproate, valproic

STAVZOR CAP 125MG (valproic)





T1tiagabine tab 2mg






T1tiagabine tab 4mg

T1topiragen tab 100mg (topiramate)




T1topiramate cap 15mg

T1topiramate cap 25mg

T1topiramate tab 100mg




T1valproate inj 100mg/ml

T1valproate inj 500/5ml

T1valproic acd cap 250mg

T1valproic acd sol 250/5ml

T1valproic acd syp 250/5ml

T3 carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide

VIMPAT INJ 200MG/20 (lacosamide)

T3 QL (1200 ml/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide

VIMPAT SOL 10MG/ML (lacosamide)


VIMPAT TAB 100MG (lacosamide)












T1zonisamide cap 100mg



BARBITURATES (ANTICONVULSANTS)

T1primidone tab 250mg

T1primidone tab 50mg

BENZODIAZEPINES (ANTICONVULSANTS)

T1clonazep odt tab 0.125mg



T1clonazep odt tab 1mg

T1clonazep odt tab 2mg

T1clonazepam tab 0.5mg

T1clonazepam tab 1mg

T1clonazepam tab 2mg

T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate

ONFI TAB 10MG (clobazam)





BENZODIAZEPINES (ANTICONVULSANTS)





HYDANTOINS

T2DILANTIN CAP 30MG (phenytoin)

T2DILANTIN CHW 50MG (phenytoin)

T2DILANTIN-125 SUS 125/5ML (phenytoin)

T2PEGANONE TAB 250MG (ethotoin)

T2PHENYTEK CAP 200MG (phenytoin)

T2PHENYTEK CAP 300MG (phenytoin)

T1phenytoin chw 50mg (phenytoin)

T1phenytoin inj 50mg/ml

T1phenytoin sus 125/5ml

T1phenytoin ex cap 100mg



SUCCINIMIDES

T2 QL (120 caps/30 days)CELONTIN CAP 300MG (methsuximide)

T1 QL (210 caps/30 days)ethosuximide cap 250mg

T1ethosuximide sol 250/5ml

ANTIMANIC AGENTS

T1lithium sol 8meq/5ml

T1lithium carb cap 150mg



T1lithium carb tab 300mg

T1lithium carb tab 300mg er

T1lithium carb tab 450mg er




CENTRAL NERVOUS SYSTEM AGENTSANTIMIGRAINE AGENTS

SELECTIVE SEROTONIN AGONISTS

T1 PAalmotrip mal tab 12.5mg

T1 PAalmotrip mal tab 6.25mg

T1 PAalmotriptan tab 12.5mg

T1 PAalmotriptan tab 6.25mg

T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan

FROVA TAB 2.5MG (frovatriptan)

T1

T1

T3



PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan

I

naratriptan tab 1mg

naratriptan tab 2.5mg

RELPAX TAB 20MG (eletriptan)

T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan

RELPAX TAB 40MG (eletriptan)

T1 QL (12 tabs/30 days)rizatriptan tab 10mg

T1 QL (12 tabs/30 days)rizatriptan tab 10mg odt

T1 QL (12 tabs/30 days)rizatriptan tab 5mg

T1 QL (12 tabs/30 days)rizatriptan tab 5mg odt

T1 QL (12 units/30 days)sumatriptan inj 4mg/0.5

T1 QLsumatriptan inj 4mg/0.5

T1 QL (12 units/30 days)sumatriptan inj 6mg/0.5

T1 QLsumatriptan spr 5mg/act

T1 QL (18 tabs/30 days)sumatriptan tab 100mg



T1 PA, QL (12 tabs/30 days)zolmitriptan tab 2.5mg

T1 PA, QL (12 tabs/30 days)zolmitriptan tab 5mg

ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)

T1amantadine cap 100mg

T1amantadine syp 50mg/5ml

T1amantadine tab 100mg




CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)

ANTICHOLINERGIC AGENTS (CNS)

T1benztropine tab 0.5mg

T1trihexyphen elx 0.4mg/ml

T1trihexyphen tab 2mg

T1trihexyphen tab 5mg

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

T1entacapone tab 200mg

T1tolcapone tab 100mg

DOPAMINE PRECURSORS

T1carb/levo tab 10-100mg

T1carb/levo tab 25-250mg

T1carb/levo 50 tab /entacap

T1carb/levo 75 tab /entacap

T1carb/levo er tab 25-100mg

T1carb/levo er tab 50-200mg

T1carb/levo sr tab 50-200mg

T1carb/levo100 tab /entacap




T1carbidopa tab 25mg

DOPAMINE RECEPTOR AGONISTS

T1bromocriptin cap 5mg

T1bromocriptin tab 2.5mg

T1cabergoline tab 0.5mg

T3 QL (30 tabs/30 days)MIRAPEX ER TAB 2.25MG (pramipexole)

T3NEUPRO DIS 1MG/24HR (rotigotine)



T3 PA, QL (30 patches/30 days)NEUPRO DIS 4MG/24HR (rotigotine)



T1pramipexole tab 0.125mg




CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)

DOPAMINE RECEPTOR AGONISTS


T1 QLpramipexole tab 0.375mg




T1pramipexole tab 1mg

T1requip tab 1mg (ropinirole)

T1ropinirole tab 0.25mg

T1ropinirole tab 0.5mg

T1ropinirole tab 12mg er

T1ropinirole tab 1mg









MONOAMINE OXIDASE B INHIBITORS

T3 QL (30 tabs/30 days)AZILECT TAB 0.5MG (rasagiline)

T3 QL (30 tabs/30 days)AZILECT TAB 1MG (rasagiline)

T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine

EMSAM DIS 12MG/24H (selegiline)


EMSAM DIS 6MG/24HR (selegiline)


EMSAM DIS 9MG/24HR (selegiline)

T1selegiline cap 5mg




CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.

T1buspirone tab 10mg



T1buspirone tab 5mg

T1buspirone tab 7.5mg

T1 QL (30 tabs/30 days) zolpidemeszopiclone tab 1mg



T1hydroxyz hcl sol 10mg/5ml

T1hydroxyz hcl syp 10mg/5ml

T1hydroxyz hcl tab 10mg



T1hydroxyz pam cap 100mg



T1meprobamate tab 200mg

T1meprobamate tab 400mg

T3 PA, QL (30 tabs/30 days) zolpidemROZEREM TAB 8MG (ramelteon)

T1zaleplon cap 10mg

T1zaleplon cap 5mg

T1 QL (30 tabs/30 days)zolpidem tab 10mg

T1 QL (30 tabs/30 days)zolpidem tab 5mg

T1zolpidem er tab 12.5mg

T1 QL (30 tabs/30 days)zolpidem er tab 6.25mg

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

T1phenobarb elx 20mg/5ml

T1phenobarb sol 20mg/5ml

T1phenobarb tab 100mg


T1phenobarb tab 16.2mg





BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)






BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

T1alprazolam tab 0.25 odt

T1alprazolam tab 0.25mg

T1alprazolam tab 0.5mg

T1alprazolam tab 0.5mg er

T1alprazolam tab 0.5mg od

T1alprazolam tab 0.5mg xr (alprazolam)

T1alprazolam tab 1mg

T1alprazolam tab 1mg er

T1alprazolam tab 1mg odt

T1alprazolam tab 1mg xr (alprazolam)

T1alprazolam tab 2mg


T1alprazolam tab 2mg odt




T1chlordiazep cap 10mg



T1cloraz dipot tab 15mg

T1cloraz dipot tab 3.75mg

T1cloraz dipot tab 7.5mg

T1diazepam gel 10mg

T1diazepam gel 2.5mg

T1diazepam gel 20mg





BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

T1diazepam inj 5mg/ml

T1diazepam sol 1mg/ml

T1diazepam sol 5mg/5ml

T1diazepam tab 10mg

T1diazepam tab 2mg

T1diazepam tab 5mg

T1estazolam tab 1mg

T1estazolam tab 2mg

T1flurazepam cap 15mg

T1flurazepam cap 30mg

T1lorazepam tab 0.5mg

T1lorazepam tab 1mg

T1lorazepam tab 2mg

T1midazolam syp 2mg/ml

T1oxazepam cap 10mg

T1oxazepam cap 15mg

T1oxazepam cap 30mg

T1temazepam cap 15mg

T1temazepam cap 22.5mg

T1temazepam cap 30mg

T1temazepam cap 7.5mg

T1triazolam tab 0.125mg

T1triazolam tab 0.25mg

CENTRAL NERVOUS SYSTEM AGENTS, MISC.

T1acampro cal tab 333mg

T1 PAguanfacine tab 1mg er




T1memantine tab hcl 5mg

T1memantine hc tab 10mg




CENTRAL NERVOUS SYSTEM AGENTSCENTRAL NERVOUS SYSTEM AGENTS, MISC.

T1 ST (donepezil)

T1 ST (donepezil)

T1 ST (donepezil)

T3 PA, QL (60 caps/30 days)

T1



memantine sol 10mg/5ml

memantine tab 10mg

memantibe tab 5mg

NUEDEXTA CAP 20-10MG (dextromethorphan)

riluzole tab 50mg

STRATTERA CAP 100MG (atomoxetine)

STRATTERA CAP 10MG (atomoxetine)T3 PA, QL (60 caps/30 days)STRATTERA CAP 18MG (atomoxetine)

T3 PA, QL (60 caps/30 days)STRATTERA CAP 25MG (atomoxetine)




T4 PAtetrabenazin tab 12.5mg

T4 PAtetrabenazin tab 25mg

T4 PA, QL (540 ml/30 days)XYREM SOL 500MG/ML (sodium)

FIBROMYALGIA AGENTS

T3 PA, QL (60 tabs/30 days)SAVELLA MIS TITR PAK (milnacipran)

T3 PA, QL (60 tabs/30 days)SAVELLA TAB 100MG (milnacipran)



OPIATE ANTAGONISTS

T1naloxone inj 1mg/ml

T1naltrexone tab 50mg

MED PA, SP Medical coinsuranceVIVITROL INJ 380MG (naltrexone)

PSYCHOTHERAPEUTIC AGENTSANTIDEPRESSANTS

T1amitriptylin tab 100mg









CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS

ANTIDEPRESSANTS

T1amoxapine tab 100mg




T1budeprion tab 100mg sr (bupropion)

T1budeprion tab 150mg sr (bupropion)

T1bupropion tab 100mg

T1bupropion tab 100mg er

T1bupropion tab 100mg sr





T1bupropion tab 75mg

T0 QL (30 tabs/30 days) HCR Rules for Coveragebupropion hcl (smoking deterrent) tab 150 mg

T1bupropn hcl tab 150mg xl

T1bupropn hcl tab 300mg xl

T1citalopram sol 10mg/5ml

T1citalopram tab 10mg



T1clomipramine cap 25mg



T1desipramine tab 100mg






T1 PAdesvenlafax tab 100mg er





ANTIDEPRESSANTS

T1 PAdesvenlafax tab 50mg er

T1doxepin hcl cap 100mg






T1doxepin hcl con 10mg/ml

T1 QL (60 caps/30 days)duloxetine cap 20mg



T1escitalopram sol 5mg/5ml

T1escitalopram tab 10mg



T1fluoxetine cap 10mg



T1 PAfluoxetine cap 90mg dr

T1fluoxetine sol 20mg/5ml

T1fluoxetine tab 10mg

T1fluoxetine tab 20mg

T1fluvoxamine tab 100mg



T1imipram hcl tab 10mg



T1imipram pam cap 100mg







ANTIDEPRESSANTS


T1 PAmaprotiline tab 25mg



T3 QL (180 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine

MARPLAN TAB 10MG (isocarboxazid)

T1mirtazapine tab 15mg

T1mirtazapine tab 15mg odt





T1mirtazapine tab 7.5mg

T1nefazodone tab 100mg





T1nortriptylin cap 10mg




T1nortriptylin sol 10mg/5ml

T1 QL (30 caps/30 days)olanza/fluox cap 12-25mg




T1 QL (30 tabs/30 days)paroxetine tab 10mg








ANTIDEPRESSANTS

T1phenelzine tab 15mg

T1 venlafaxine

T1 venlafaxine

desvenlafaxine tab 100mg er

desvenlafaxine tab 50mg er



T1protriptylin tab 10mg

T1protriptylin tab 5mg

T1sertraline con 20mg/ml

T1sertraline tab 100mg



T1tranylcyprom tab 10mg

T1trazodone tab 100mg




T1 QL (60 caps/30 days)venlafaxine cap 150mg er

T1 QL (60 caps/30 days)venlafaxine cap 37.5 er

T1 QL (60 caps/30 days)venlafaxine cap 37.5mg

T1 QL (60 caps/30 days)venlafaxine cap 75mg er

T1 QLvenlafaxine tab 100mg

T1 QLvenlafaxine tab 150mg er



T1 QLvenlafaxine tab 37.5 er

T1 QLvenlafaxine tab 37.5mg








ANTIDEPRESSANTS

T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine

VIIBRYD TAB 10MG (vilazodone)





ANTIPSYCHOTIC AGENTS

T1 PA olanzapine, quetiapine, risperidone

aripiprazole tab 10mg
















T1chlorpromaz inj 25mg/ml

T1chlorpromaz inj 50mg/2ml

T1chlorpromaz tab 100mg





T1 QL (150 tabs/30 days)clozapine tab 100mg




T1compazine sup 25mg (prochlorperazine)

T1compro sup 25mg (prochlorperazine)

T3FANAPT TAB 10MG (iloperidone)












T1fluphenazine tab 10mg

T1

T1

T1

T1

T1

T1

T1

T1

T1

T1

T3

fluphenazine tab 1mg

fluphenazine tab 2.5mg

fluphenazine tab 5mg

haloperidol con 2mg/ml

haloperidol tab 0.5mg

haloperidol tab 10mg

haloperidol tab 1mg

haloperidol tab 20mg

haloperidol tab 2mg

haloperidol tab 5mg

T3LATUDA TAB 120MG (lurasidone)


T3


PA, QL (30 tabs/30 days)LATUDA TAB 40MG (lurasidone)


T3 PA, QL (30 tabs/30 days)LATUDA TAB 80MG (lurasidone)

T1loxapine cap 10mg

T1loxapine cap 25mg

T1loxapine cap 50mg

T1loxapine cap 5mg

T1 QL (30 tabs/30 days)olanzapine tab 10mg

T1 QL (30 tabs/30 days)olanzapine tab 10mg odt



T1 QL (30 tabs/30 days)olanzapine tab 2.5mg


PA, QL (30tabs/30days)

PA, QL (30tabs/30days)

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T1 QL (30 tabs/30 days)olanzapine tab 7.5mg

T2ORAP TAB 1MG (PIMOZIDE)

T2ORAP TAB 2MG (PIMOZIDE)

T4 PApaliperidone tab er 1.5mg

T4paliperidone tab er 3mg



T1perphenazine tab 16mg




T1prochlorper sup 25mg

T1prochlorper tab 10mg

T1prochlorper tab 5mg

T1 QL (60 tabs/30 days)quetiapine tab 100mg






T1risperidone sol 1mg/ml

T1risperidone tab 0.25 odt

T1 QL (280 tabs/30 days)risperidone tab 0.25mg

T1 QL (280 tabs/30 days)risperidone tab 0.5mg

T1risperidone tab 0.5mg od (risperidone)

T1 QL (280 tabs/30 days)risperidone tab 1 mg

T1 QL (280 tabs/30 days)risperidone tab 1mg


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T1 QL (280 tabs/30 days)risperidone tab 1mg odt







T3 PA, QL (60 tabs/30 days)SAPHRIS SUB 10MG (asenapine)

T3 PASAPHRIS SUB 2.5MG (asenapine)

T3 PASAPHRIS SUB 5MG (asenapine)

T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 150MG (quetiapine)





T1thioridazine tab 100mg




T1thiothixene cap 10mg




T1trifluoperaz tab 10mg




T1 QL (60 caps/30 days)ziprasidone cap 20mg







CONTRACEPTIVES (E.G. FOAMS, DEVICES)

T0 HCR Rules for Coverage



encare sup 100mg (nonoxynol-9)

vcf vaginal aer contracp (nonoxynol-9)

vcf vaginal gel contrace (nonoxynol-9)

ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS

T1cytra-k sol (potassium)

T1k citrate sol citr acd

T1pot citrate tab 1080mg

T1pot citrate tab 1620mg

T1pot citrate tab 540mg er

T1virtrate-k sol (potassium)

T1virtrate-k sol 1100-334 (potassium)

AMMONIA DETOXICANTS

T4 PA, SPBUPHENYL TAB 500MG (sodium)

T1constulose sol 10gm/15 (lactulose)

T1enulose sol 10gm/15 (lactulose)

T1generlac sol 10gm/15 (lactulose)

T2KRISTALOSE PAK 10GM (lactulose)

T2KRISTALOSE PAK 20GM (lactulose)

T1lactulose sol 10gm/15

T1lactulose sol 20gm/30

DIURETICSLOOP DIURETICS

T1bumetanide inj 0.25/ml

T1bumetanide tab 0.5mg

T1bumetanide tab 1mg

T1bumetanide tab 2mg

T3 QL (480 tabs/30 days)EDECRIN TAB 25MG (ethacrynic)

T1furosemide inj 100/10ml

T1furosemide inj 10mg/ml

T1furosemide inj 20mg/2ml

T1furosemide inj 40mg/4ml




ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS

LOOP DIURETICS

T1furosemide sol 10mg/ml

T1furosemide sol 40mg/4ml

T1furosemide sol 8mg/ml

T1furosemide tab 20mg



T1torsemide tab 100mg



T1torsemide tab 5mg

POTASSIUM-SPARING DIURETICS

T1amilor/hctz tab 5-50

T1amiloride tab 5mg

T3 PA, QL (120 caps/30 days)DYRENIUM CAP 100MG (triamterene)

T3 PA, QL (120 caps/30 days)DYRENIUM CAP 50MG (triamterene)

T1triamt/hctz cap 37.5-25

T1triamt/hctz cap 50-25mg

T1triamt/hctz tab 37.5-25

T1triamt/hctz tab 75-50mg

THIAZIDE DIURETICS

T1chlorothiaz tab 250mg

T1chlorothiaz tab 500mg

T1hydrochlorot cap 12.5mg

T1hydrochlorot tab 12.5mg

T1hydrochlorot tab 25mg

T1hydrochlorot tab 50mg

T1methyclothia tab 5mg

THIAZIDE-LIKE DIURETICS

T1chlorthalid tab 100mg



T1indapamide tab 1.25mg




ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS

THIAZIDE-LIKE DIURETICS

T1indapamide tab 2.5mg

T1metolazone tab 10mg

T1metolazone tab 2.5mg

T1metolazone tab 5mg

VASOPRESSIN ANTAGONISTS

T4 PASAMSCA TAB 15MG (tolvaptan)

T4 PASAMSCA TAB 30MG (tolvaptan)

ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS

T3 QL (150 tabs/30 days)FOSRENOL CHW 1000MG (lanthanum)



T3 QL (120 tabs/30 days)RENAGEL TAB 400MG (sevelamer)

T3 QL (120 tabs/30 days)RENAGEL TAB 800MG (sevelamer)

T3

T3

T3

QL (300 packs/30 days)

PA

RENVELA PAK 0.8GM (sevelamer)

RENVELA PAK 2.4GM (sevelamer)

VELTASSA

POTASSIUM-REMOVING AGENTS

T1kionex sus 15gm/60 (sodium)

T1sod poly sul sus 15gm/60

T1sod poly sul sus 30/120ml

T1sod poly sul sus 50/200ml

T1sps sus 15gm/60 (sodium)

REPLACEMENT PREPARATIONS

T1calc acetate cap 667mg

T1chloromag inj 20% (magnesium)

T2EFFER-K TAB 10MEQ (potassium)

T2EFFER-K TAB 20MEQ (potassium)

T1effer-k tab 25meq ef (potassium)

T1k-effervesce tab 25meq ef (potassium)

T1klor-con 10 tab 10meq er (potassium)


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QL (300 packs /30 days)

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ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS

T1klor-con 8 tab 8meq er (potassium)

T1klor-con m10 tab 10meq er (potassium)

T3KLOR-CON M15 TAB (potassium)

T3KLOR-CON M15 TAB 15MEQ ER (potassium)

T1klor-con m20 tab 20meq er (potassium)

T1klor-con spr cap 10meq (potassium)

T1klor-con spr cap 8meq (potassium)

T1klor-con/ef tab 25meq ef (potassium)

T1klor-con/ef tab 25meq fr (potassium)

T1k-prime tab 25meq ef (potassium)

T1k-sol sol 10% (potassium)

T1k-sol sol 20% (potassium)

T1k-vescent tab 25meq ef (potassium)

T1magnesium cl inj 20%

T3PHOSLYRA SOL (calcium)

T1 QLphospha 250 tab neutral (potassium)

T1pot bicarbon tab 25meq ef

T1pot chloride cap 10meq er

T1pot chloride cap 8meq er

T1pot chloride inj 10meq


T1pot chloride inj 2meq/ml


T1pot chloride sol 10%

T1pot chloride sol 10% sf

T1pot chloride sol 20%

T1pot chloride sol 20% sf

T1pot chloride tab 10meq cr

T1pot chloride tab 10meq er


T1pot chloride tab 25meq ef (potassium)

T1pot chloride tab 8meq cr




ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS


T1pot chloride tab 8meq sa

T1pot chloride tab 8meq sr

T1pot cl micro tab 10meq cr

T1pot cl micro tab 10meq er

T1pot cl micro tab 20meq cr

T1pot cl micro tab 20meq er

T1pot/chloride tab 25meq ef

T1potassium tab 25meq ef

T1 QLvirt-phos tab 250 neut (potassium)

T1zinc sulfate cap 220mg

URICOSURIC AGENTS

T1proben/colch tab 500-0.5

T1probenecid tab 500mg

EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS

T3 QL (5 ml/fill)ALOCRIL SOL 2% (nedocromil)

T2ALOMIDE SOL 0.1% OP (lodoxamide)

T1azelastine dro 0.05%

T1azelastine spr 0.1%

T1azelastine spr 0.15%

T3 PABEPREVE DRO 1.5% (bepotastine)

T1cromolyn sod sol 4% op

T3 QL (5 ml/fill)EMADINE SOL 0.05% OP (emedastine)

T1epinastine dro 0.05%

T1ketotif fum dro 0.025%op

T3 QL (3 ml/fill)LASTACAFT SOL 0.25% (alcaftadine)

T3 QL (2.5 ml/fill)PATADAY SOL 0.2% (olopatadine)

T1 QL (5 ml/fill)Olopatadine SOL 0.1% OP

ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)

T1brimonidine sol 0.15%




EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

T1brimonidine sol 0.2% op

T3 QL (10 ml/fill)COMBIGAN SOL 0.2/0.5% (brimonidine)

T3 PASIMBRINZA SUS 1-0.2% (brinzolamide-brimonidine)

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

T1betaxolol sol 0.5% op

T3 QL (10 ml/fill) betaxololBETOPTIC-S SUS 0.25% OP (betaxolol)

T1carteolol sol 1% op

T1levobunolol sol 0.25% op

T1levobunolol sol 0.5% op

T1metipranolol sol 0.3% oph

T1timolol gel sol 0.25% op

T1timolol gel sol 0.5% op

T1timolol mal sol 0.25% op

T1timolol mal sol 0.5% op

CARBONIC ANHYDRASE INHIBITORS (EENT)

T1acetazolamid cap 500mg er

T1acetazolamid tab 125mg

T2 QL (10 ml/fill)AZOPT SUS 1% OP (brinzolamide)

T1dorzol/timol sol 22.3-6.8

T1dorzolamide sol 2% op

T1methazolamid tab 25mg

T1methazolamid tab 50mg

MIOTICS

T3PHOSPHOLINE SOL 0.125%OP (echothiophate)

T1pilocarpine sol 1% op



PROSTAGLANDIN ANALOGS

T1latanoprost sol 0.005%

T2 QL (5 ml/fill), ST (latanoprost)LUMIGAN SOL 0.01% (bimatoprost)

T2 QL (5 ml/fill), ST (latanoprost)TRAVATAN Z DRO 0.004% (travoprost)

T1 QL, ST (latanoprost)travoprost dro 0.004%




EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS

PROSTAGLANDIN ANALOGS

T3 PA, QL (3 pouches/fill)ZIOPTAN DRO 0.0015% (tafluprost)

ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)

T2 QL (2.5 ml/30 days)AZASITE SOL 1% (azithromycin)

T1bacitracin oin op

T3 QL (5 ml/30 days)BESIVANCE SUS 0.6% (besifloxacin)

T2CILOXAN OIN 0.3% OP (ciprofloxacin)

T1ciprofloxacn sol 0.2%

T1ciprofloxacn sol 0.3% op

T1erythromycin oin 5mg/gm

T1erythromycin oin op

T1garamycin oin 0.3% op (gentamicin)

T1 QLgatifloxacin sol 0.5%

T1gentak oin 0.3% op (gentamicin)

T1gentamicin oin 0.3% op

T1gentamicin sol 0.3% op

T1ilotycin oin op (erythromycin)

T1 QL (5 ml/30 days)levofloxacin sol 0.5%

T3 QL (3 ml (1 bottle)/fill)MOXEZA SOL 0.5% (moxifloxacin)

T1ofloxacin dro 0.3% op

T1ofloxacin dro 0.3%otic

T1polymyxin b/ sol trimethp

T1polytrim sol op (polymyxin)

T1romycin oin op (erythromycin)

T1sod sulfacet sol 10% op

T1sulfacet sod sol 10% op

T1tobramycin sol 0.3% op

T3 QL (1 tube/fill)TOBREX OIN 0.3% OP (tobramycin)

T1tobrex sol 0.3% op (tobramycin)

T1trimethoprim sol polymyxn

T2 QL (3 ml (1 bottle)/fill)VIGAMOX DRO 0.5% (moxifloxacin)




EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFECTIVES (EENT)

ANTIVIRALS (EENT)

T1trifluridine sol 1% op

T3 QL (5 gram/ fill)ZIRGAN GEL 0.15% (ganciclovir)

EENT ANTI-INFECTIVES, MISCELLANEOUS

T1chlorhex glu sol 0.12%

T1paroex sol 0.12% (chlorhexidine)

T1periogard sol 0.12% (chlorhexidine)

ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)

T1acetasol hc sol otic (hydrocortisone)

T2ALREX SUS 0.2% (loteprednol)

T1antibiot ear sol 1% otic (neomycin-polymyxin-hc)

T3 ST (fluticasone nasal spray, triamcinolone nasal spray)

fluticasone, triamcinolone

BECONASE AQ SUS 0.042% (beclomethasone)

T2 QLBLEPHAMIDE SUS LIQUIFLM (sulfacetamide)

T2 QLBLEPHAMIDE SUS OP (sulfacetamide)

T1budesonide sus 32mcg

T3 QL (1 bottle/fill)CIPRO HC SUS OTIC (ciprofloxacin-hydrocortisone)

T2 QL (7.5ml/ fill)CIPRODEX SUS 0.3-0.1% (ciprofloxacin-dexamethasone)

T2COLY-MYCIN S SUS OTIC (neomycin-colistin-hc-thonzonium)

T2CORTISPORIN SUS -TC OTIC (neomycin-colistin-hc-thonzonium)

T1dexameth pho sol 0.1% op

T2DUREZOL EMU 0.05% (difluprednate)

T2FLAREX SUS 0.1% OP (fluorometholone)

T1flunisolide spr 0.025%

T1fluocin acet oil 0.01%

T1fluocin acet oil ear0.01%

T1fluoromethol sus 0.1% op

T1fluticasone spr 50mcg

T1 hc = hydrocortisonehc/acet acid sol otic

T3LOTEMAX SUS 0.5% (loteprednol)


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ST (fluticasone nasal spray, triamcinolone nasal spray)

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EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

T2MAXIDEX SUS 0.1% OP (dexamethasone)



NASONEX SPR 50MCG/AC (mometasone)

T1 QLneo/poly/dex sus 0.1% op

T1neo/poly/hc sol 1% otic

T1neo/poly/hc sus 1% otic

T3PRED MILD SUS 0.12% OP (prednisolone)

T1pred sod pho sol 1% op

T1prednisolone sus 1% op

T1sulf/pred na sol op

T1 QLtobra/dexame sus 0.3-0.1%

T2TOBRADEX OIN 0.3-0.1% (tobramycin-dexamethasone)

T1triamcinolon aer 55mcg/ac

T3 PA fluticasone, triamcinolone

VERAMYST SPR 27.5MCG (fluticasone)

T3 PAVEXOL SUS 1% OP (rimexolone)



ZETONNA AER 37MCG (ciclesonide)

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

T3ACUVAIL SOL 0.45% (ketorolac)

T1bromfenac sol 0.09%

T1bromfenac sol 0.09% op

T1diclofenac sol 0.1% op

T1flurbiprofen sol 0.03% op

T2 QL (1.7 ml/fill)ILEVRO DRO 0.3% OP (nepafenac)

T1ketorolac sol 0.4%

T1ketorolac sol 0.5%

T2NEVANAC SUS 0.1% (nepafenac)

EENT DRUGS, MISCELLANEOUS

T1acetic acid sol 2% otic

T1apraclonidin sol 0.5% op

T2IOPIDINE SOL 1% OP (apraclonidine)




EYE, EAR, NOSE AND THROAT (EENT) PREPS.LOCAL ANESTHETICS (EENT)

T1a/b sol otic (antipyrine-benzocaine)

T1altacaine sol 0.5% op (tetracaine)

T1antipy/benzo sol otic

T1aurodex sol otic (antipyrine-benzocaine)

T1auroguard sol otic (antipyrine-benzocaine)

T1lidocaine sol 2% visc

T1parcaine sol 0.5% op (proparacaine)

T1proparacaine sol 0.5% op

T1tetcaine sol 0.5% op (tetracaine)

T1tetracaine sol 0.5% op

T1tetravisc sol 0.5% op (tetracaine)

T1tetravisc sol forte (tetracaine)

MYDRIATICS

T1atropin-care sol 1% op (atropine)

T1atropine sul oin 1% op

T1atropine sul sol 1% op

T1cyclopentol sol 1% op

T1cyclopentol sol 2% op

T1homatropaire sol 5% op (homatropine)

T1homatropine sol 5% op

T1mydral sol 0.5% op (tropicamide)

T1mydral sol 1% op (tropicamide)

T1tropicamide sol 0.5% op

T1tropicamide sol 1% op

VASOCONSTRICTORS

T1altafrin sol 10% op (phenylephrine)

T1altafrin sol 2.5% op (phenylephrine)

T1naphazoline sol 0.1% op

T1neofrin sol 10% op (phenylephrine)

T1neofrin sol 2.5% op (phenylephrine)

T1phenylephrin sol 10% op

T1phenylephrin sol 2.5% op




EYE, EAR, NOSE AND THROAT (EENT) PREPS.VASOCONSTRICTORS

T3TYZINE PED DRO 0.05% (tetrahydrozoline)

GASTROINTESTINAL DRUGSANTIDIARRHEA AGENTS

T1diphen/atrop liq 2.5/5

T1diphen/atrop tab 2.5mg

T1diphenatol tab 2.5mg (diphenoxylate)

T1kaopectate tab (bismuth)

T1lofene tab 2.5mg (diphenoxylate)

T1lonox tab 2.5mg (diphenoxylate)

T1 QLloperamide cap 2mg (loperamide)

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)

ondansetronANZEMET TAB 100MG (dolasetron)

T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)

ondansetronANZEMET TAB 50MG (dolasetron)

T1granisetron tab 1mg

T1ondansetron inj 4mg/2ml

T1ondansetron sol 4mg/5ml

T1ondansetron tab 24mg


T1ondansetron tab 4mg odt


T1ondansetron tab 8mg odt

ANTIEMETICS, MISCELLANEOUS

T3 PACESAMET CAP 1MG (nabilone)

T4 PA, SP, QL (120 tabs/ 30 days)DICLEGIS TAB 10-10MG (doxylamine-pyridoxine)

T1 QLdronabinol cap 10mg

T1 QLdronabinol cap 2.5mg

T1 QLdronabinol cap 5mg

T3 QLEMEND CAP 125MG (aprepitant)

T3 QL (1 capsule/fill)EMEND CAP 40MG (aprepitant)

T3 QL (1 capsule/fill)EMEND CAP 80MG (aprepitant)




GASTROINTESTINAL DRUGSANTIEMETICS

ANTIEMETICS, MISCELLANEOUS

T3 QL (1 capsule/fill)EMEND PAK 80 & 125 (aprepitant)

T3 QL (3 patches/fill)TRANSDERM-SC DIS 1.5MG (scopolamine)

T3 QL (3 patches/fill)TRANSDERM-SC DIS 1MG (scopolamine)

ANTIHISTAMINES (GI DRUGS)

T1meclizine tab 12.5mg

T1meclizine tab 25mg

T1trimethobenz cap 300mg

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

T1balsalazide cap 750mg

T3 QL (30 supp/30 days)CANASA SUP 1000MG (mesalamine)

T2 QL (180 caps/30 days)DELZICOL CAP 400MG (mesalamine)

T2DIPENTUM CAP 250MG (olsalazine)

T3 QL (180 tabs/30 days)LIALDA TAB 1.2GM (mesalamine)

T1mesalamine ene 4gm

T1 QL (1 kit/fill)



mesalamine kit 4gm

ASACOL HD (mesalamine)

PENTASA CAP CR (mesalamine)

ANTIULCER AGENTS AND ACID SUPPRESSANTSHISTAMINE H2-ANTAGONISTS

T1cimetidine tab 200mg (cimetidine)

T1cimetidine tab 300mg



T1famotidine tab 20mg (famotidine)

T1famotidine tab 40mg

T1nizatidine cap 150mg

T1nizatidine cap 300mg

T1nizatidine sol 15mg/ml

T1ranitidine syp 150/10ml

T1ranitidine syp 15mg/ml

T1ranitidine syp 75mg/5ml




GASTROINTESTINAL DRUGSANTIULCER AGENTS AND ACID SUPPRESSANTS

HISTAMINE H2-ANTAGONISTS

T1ranitidine tab 150mg

T1ranitidine tab 300mg

PROSTAGLANDINS

T1misoprostol tab 100mcg

T1misoprostol tab 200mcg

PROTECTANTS

T2CARAFATE SUS 1GM/10ML (sucralfate)

T1sucralfate tab 1gm

PROTON-PUMP INHIBITORS

T1 QL (30 tabs/30 days)lansoprazole cap 15mg dr

T1 QL (30 tabs/30 days)lansoprazole cap 30mg dr

T3 QLLANSOPRAZOLE SUS 3MG/ML (lansoprazole)

T1 QL (60 caps/30 days)omeprazole cap 10mg

T1omeprazole cap 20mg

T1 QL (60 caps/30 days)omeprazole cap 40mg

T1pantoprazole tab 20mg

T1pantoprazole tab 40mg

T1 QL (30 tabs/30 days) lansoprazole, omeprazole, pantoprazole

rabeprazole tab 20mg

CATHARTICS AND LAXATIVES

T1gavilyte-c sol (peg)

T1gavilyte-g sol (peg)

T1 QLgavilyte-n sol flav pk (peg)

T3OSMOPREP TAB 1.5GM (sodium)

T1peg 3350 sol electrol

T1peg-3350 sol electrol

T1 QLpeg-3350/kcl sol /sodium

T1pegylax pow (polyethylene)

T1polyeth glyc pow 3350 nf (polyethylene)

T3 PAPREPOPIK PAK (sodium)

T3SUPREP BOWEL SOL PREP (sodium)




GASTROINTESTINAL DRUGSCATHARTICS AND LAXATIVES

T1 QLtrilyte sol (peg)

CHOLELITHOLYTIC AGENTS

T1ursodiol cap 300mg

T1ursodiol tab 250mg

T1ursodiol tab 500mg

DIGESTANTS

T3CREON CAP 12000UNT (pancrelipase)


T3CREON CAP 3000UNIT (pancrelipase)


T3CREON CAP 6000UNIT (pancrelipase)

T3PANCREAZE CAP 10500UNT (pancrelipase)



T3PANCREAZE CAP 4200UNIT (pancrelipase)

T1pancrelipase cap 5000unit

T3PERTZYE CAP (pancrelipase)

T3ZENPEP CAP 10000UNT (pancrelipase)




T3ZENPEP CAP 3000UNIT (pancrelipase)


T3ZENPEP CAP 5000UNIT (pancrelipase)

GI DRUGS, MISCELLANEOUS

T3

T3

T4

T3

T3

T3

PA, QL (60 caps/30 days)


PA, SP



PA

AMITIZA CAP 24MCG (lubiprostone)

AMITIZA CAP 8MCG (lubiprostone)

GATTEX KIT 5MG (teduglutide)

LINZESS CAP 145MCG (linaclotide)

LINZESS CAP 290MCG (linaclotide)

XENICAL CAP 120MG (orlistat)




GASTROINTESTINAL DRUGSPROKINETIC AGENTS

T1metoclopram inj 10mg/2ml

T1metoclopram inj 5mg/ml

T1metoclopram sol 10/10ml

T1metoclopram sol 5mg/5ml

T1metoclopram tab 10mg

T1metoclopram tab 5mg

GOLD COMPOUNDS

T2RIDAURA CAP 3MG (auranofin)

HEAVY METAL ANTAGONISTS

T2CHEMET CAP 100MG (succimer)

T3CUPRIMINE CAP 250MG (penicillamine)

T2DEPEN TITRA TAB 250MG (penicillamine)

T4 PA, SPEXJADE TAB 125MG (deferasirox)



T3SYPRINE CAP 250MG (trientine)

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS

T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR

ALVESCO AER 160MCG (ciclesonide)


ALVESCO AER 80MCG (ciclesonide)


ASMANEX 120 AER 220MCG (mometasone)

T3 QLASMANEX 30 AER 110MCG (mometasone)

T3ASMANEX 30 AER 220MCG (mometasone)


ASMANEX 60 AER 220MCG (mometasone)

T3 QLASMANEX 7 AER 110MCG (mometasone)

T3ASMANEX HFA AER 100 MCG (mometasone)





T3ASMANEX HFA AER 200 MCG (mometasone)

T1 QLbaycadron elx 0.5/5ml (dexamethasone)

T1 PAbudesonide cap 3mg/24hr

T1budesonide sus 0.25mg/2

T1budesonide sus 0.5mg/2

T1budesonide sus 1mg/2ml

T1cortisone ac tab 25mg

T1deltasone tab 20mg (prednisone)

T2 QL (30 ml/ fill)DEXAMETHASON CON 1MG/ML (dexamethasone)

T1 QLdexamethason elx 0.5/5ml

T1dexamethason sol 0.5/5ml

T1dexamethason tab 0.5mg



T1dexamethason tab 1mg





DULERA AER 100-5MCG (mometasone)


DULERA AER 200-5MCG (mometasone)

T2FLOVENT DISK AER 100MCG (fluticasone)



T2FLOVENT HFA AER 110MCG (fluticasone)



T1fludrocort tab 0.1mg

T1hydrocort tab 10mg

T1hydrocort tab 20mg

T1hydrocort tab 5mg





T1methylpred pak 4mg

T1methylpred tab 16mg




T1pred sod pho sol 5mg/5ml

T1prednisolone sol 15mg/5ml

T1 QLprednisolone sol 15mg/5ml

T1prednisolone sol 25mg/5ml

T1 QLprednisolone syp 15mg/5ml

T2PREDNISONE CON 5MG/ML (prednisone)

T1prednisone pak 10mg

T1prednisone pak 5mg

T1prednisone sol 5mg/5ml

T1prednisone tab 10mg


T1prednisone tab 2.5mg




T2 QL (1 inhaler/30 days)PULMICORT INH 180MCG (budesonide)

T2 QL (1 inhaler/30 days)PULMICORT INH 90MCG (budesonide)

T2QVAR AER 40MCG (beclomethasone)

T2QVAR AER 80MCG (beclomethasone)


SYMBICORT AER 160-4.5 (budesonide-formoterol)


SYMBICORT AER 80-4.5 (budesonide-formoterol)

T2 QL (480ml/30 days)VERIPRED 20 SOL 20MG/5ML (prednisolone)

ANDROGENS

)




HORMONES AND SYNTHETIC SUBSTITUTESANDROGENS

T3 PA

T1 PA

T1 PA

T1 PA

ANDROGEL GEL 1.62% (testosterone)

danazol cap 100mg

danazol cap 200mg

danazol cap 50mg

T3NATESTO GEL 5.5MG (testosterone)

T1oxandrolone tab 10mg

T1oxandrolone tab 2.5mg

T1 PA, QLtestosterone gel 1%(25mg)

T1 PA, QLtestosterone gel 1%(50mg)

T1 PA, QLtestosterone gel pump 1%

ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS

T1acarbose tab 100mg

T1acarbose tab 25mg

T1acarbose tab 50mg

T3 acarboseGLYSET TAB 100MG (miglitol)



AMYLINOMIMETICS

T3 PASYMLINPEN 60 INJ 1000MCG (pramlintide)

ANTIDIABETIC AGENTS, MISCELLANEOUS

T3 PA, QL (180 tabs/30 days)CYCLOSET TAB 0.8MG (bromocriptine)

BIGUANIDES

T1metformin tab 1000mg


T1metformin tab 500mg er

T1metformin tab 750mg er


DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

T2 QL (30 tabs/30 days)JANUVIA TAB 100MG (sitagliptin)



Generic for Glutmetza & Fortamet not coveredGeneric for Glutmetza & Fortamet not covered

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PA

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HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS


T3 PA, QL (30 tabs/30 days) JANUVIAONGLYZA TAB 2.5MG (saxagliptin)

T3 PA, QL (30 tabs/30 days) JANUVIAONGLYZA TAB 5MG (saxagliptin)

T3 PA, QL (30 tabs/30 days) JANUVIATRADJENTA TAB 5MG (linagliptin)

INCRETIN MIMETICS

T3 PABYDUREON INJ (exenatide)

T3 PABYDUREON INJ (exenatide)

T3 PA, QL (1 cartridge/month)BYETTA INJ 5MCG (exenatide)

T3 PA, QL (2 pens/30 days)VICTOZA INJ 18MG/3ML (liraglutide)

INSULINS

T2 QL (60 ml/30 days)APIDRA INJ SOLOSTAR (insulin)

T2 QL (60 ml/30 days)APIDRA INJ U-100 (insulin)

T3 QL (60ml/30 days) NOVOLOGHUMALOG INJ 100/ML (insulin)

T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30

HUMALOG KWIK INJ 100/ML (insulin)


HUMALOG MIX INJ 50/50 (insulin)


HUMALOG MIX INJ 50/50KWP (insulin)


HUMALOG MIX INJ 75/25KWP (insulin)


HUMALOG MIX SUS 75/25 (insulin)

T3 QL (60 ml/30 days)HUMULIN INJ 70/30 (insulin)

T3 QL (60 ml/30 days)HUMULIN INJ 70/30KWP (insulin)

T3 QL (60 ml/30 days)HUMULIN N INJ U-100 (insulin)

T3 QL (60 ml/30 days)HUMULIN N INJ U-100KWP (insulin)

T3 QL (60 ml/30 days)HUMULIN N PN INJ U-100 (insulin)

T3 QL (60 ml/30 days)HUMULIN PEN INJ 70/30 (insulin)


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Novolin

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Novolin

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Novolin

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Novolin

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Novolin

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Novolin




INSULINS

T3 QL (60 ml/30 days) NOVOLOG, NOVOLOG MIX 70/30, quetiapine

HUMULIN R INJ U-100 (insulin)

T3 ST, QL

T1

T1

T3

T2

T2

T2

T2

T2

T2

T2

T2

T2

QL (60 ml/30 days)

QL (60 ml/30 days)

ST, QL(60ml/30days

ST, QL(60ml/30days

QL (60 ml/30 days)

QL (60 ml/30 days)

QL (60 ml/30 days)

QL (60ml/30 days)

QL (60ml/30 days)

QL (60ml/30 days)

QL (60ml/30 days)

QL (60ml/30 days)

QL (9ml/30 days)

HUMULIN R INJ U-500 (insulin)

LANTUS INJ 100/ML (insulin)

LANTUS INJ SOLOSTAR (insulin)

LEVEMIR INJ (insulin)

LEVEMIR INJ FLEXTOUC (insulin)

NOVOLIN INJ 70/30 (insulin)

NOVOLIN N INJ U-100 (insulin)

NOVOLIN R INJ U-100 (insulin)

NOVOLOG INJ 100/ML (insulin)

NOVOLOG INJ FLEXPEN (insulin)

NOVOLOG INJ PENFILL (insulin)

NOVOLOG MIX INJ 70/30 (insulin)

NOVOLOG MIX INJ FLEXPEN (insulin)

TOUJEO SOLO INJ 300IU/ML (insulin)

MEGLITINIDES

T1nateglinide tab 120mg

T1nateglinide tab 60mg

T1 QL (240 tabs/30 days)repaglinide tab 0.5mg

T1 QL (240 tabs/30 days)repaglinide tab 1mg

T1 QL (240 tabs/30 days)repaglinide tab 2mg

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS

T3 PAFARXIGA TAB 10MG (dapagliflozin)

T3 PAFARXIGA TAB 5MG (dapagliflozin)

SULFONYLUREAS

T1chlorpropam tab 100mg

T1chlorpropam tab 250mg

T1glimepiride tab 1mg



LANTUS

T3 LANTUS

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Lantus, Toujeo




SULFONYLUREAS


T1glip/metform tab 2.5-250m

T1glip/metform tab 2.5-500m

T1glip/metform tab 5-500mg

T1glipizide tab 10mg

T1glipizide tab 5mg

T1glipizide er tab 10mg

T1glipizide er tab 2.5mg

T1glipizide er tab 5mg

T1glipizide xl tab 10mg (glipizide)

T1glipizide xl tab 2.5mg (glipizide)

T1glipizide xl tab 5mg (glipizide)

T1glyb/metform tab 1.25-250

T1glyb/metform tab 2.5-500

T1glyb/metform tab 5-500mg

T1glyburid mcr tab 1.5mg

T1glyburid mcr tab 3mg

T1glyburid mcr tab 6mg

T1glyburide tab 1.25mg

T1glyburide tab 2.5mg

T1glyburide tab 5mg

T1tolazamide tab 250mg

T1tolazamide tab 500mg

T1tolbutamide tab 500mg

THIAZOLIDINEDIONES

T2 QL (60 tabs/30 days)AVANDIA TAB 2MG (rosiglitazone)



T1 QL (120 tabs/30 days)pioglita/met tab 15-500mg

T1 QL (120 tabs/30 days)pioglita/met tab 15-850mg

T1pioglitazone tab 15mg





THIAZOLIDINEDIONES



ANTIHYPOGLYCEMIC AGENTSANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS

T2PROGLYCEM SUS 50MG/ML (diazoxide)

GLYCOGENOLYTIC AGENTS

T3GLUCAGEN INJ HYPOKIT (glucagon)

T3GLUCAGON KIT 1MG (glucagon)

CONTRACEPTIVES

T0 QL HCR Rules for Coverageaftera tab 1.5mg (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragealtavera tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragealyacen tab 1/35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragealyacen tab 7/7/7 (norethindrone-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coverageamethia tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coverageamethia lo tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coverageamethyst tab 90-20mcg (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coverageapri tab (desogestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragearanelle tab (norethindrone-eth)

T0 QL HCR Rules for Coverageashlyna tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coverageaubra tab 0.1-0.02 (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageaviane tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageazurette tab 28 day (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragebalziva tab (norethindrone)

T0 QL (2.5ml/14 days) HCR Rules for Coveragebriellyn tab (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecamila tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecamrese tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecamrese lo tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecaziant pak (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecesia pak (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragechateal tab 0.15/30 (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecryselle-28 tab 28 tabs (norgestrel)




HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES

T0 QL (28 tabs/28 days) HCR Rules for Coveragecyclafem tab 1/35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragecyclafem tab 7/7/7 (norethindrone-eth)

T0 QL HCR Rules for Coveragecyred tab (desogestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedasetta tab 1/35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedasetta tab 7/7/7 (norethindrone-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedaysee tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedeblitane tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedelyla tab 0.1-0.02 (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragedeso/ethinyl tab estradio

T0 QL (28 tabs/28 days) HCR Rules for Coveragedrospir/ethi tab 3-0.03mg

T0 QL HCR Rules for Coveragedrospirenone tab ethy est

T0 QL HCR Rules for Coverageecontra ez tab 1.5mg (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageelinest tab (norgestrel)

T0 QL (1 pack /fill, 3 fills/365 days)ELLA TAB 30MG (ulipristal)

T0 QL (28 tabs/28 days) HCR Rules for Coverageemoquette tab (desogestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageenpresse-28 tab (levonorgestrel-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coverageenskyce tab (desogestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageerrin tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coverageestarylla tab 0.25-35 (norgestimate-ethinyl)

T0 QL HCR Rules for Coveragefallback tab 1.5mg (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragefalmina tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegianvi tab 3-0.02mg (drospirenone-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegildagia tab 0.4-35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess tab 1.5/30 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess tab 1/20 (norethindrone)

T0 QL HCR Rules for Coveragegildess 24 tab fe 1/20 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess fe tab 1.5/30 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess fe tab 1/20 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coverageheather tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coverageintrovale tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejencycla tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejolessa tab (levonorgestrel-ethinyl)





T0 QL (28 tabs/28 days) HCR Rules for Coveragejolivette tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel 1.5/30 tab (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel 1/20 tab (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel fe tab 1.5/30 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel fe tab 1/20 (norethin)

T0 QL HCR Rules for Coveragejunel fe 24 tab 1/20 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragekariva tab 28 day (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragekelnor tab 1/35 (ethynodiol)

T0 QL HCR Rules for Coveragekimidess tab (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragekurvelo tab 0.15/30 (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin tab 1.5/30 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin tab 1/20 (norethindrone)

T0 QL HCR Rules for Coveragelarin 24 tab fe 1/20 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin fe tab 1.5/30 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin fe tab 1/20 (norethin)

T0 QL HCR Rules for Coveragelayolis fe chw (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coverageleena tab (norethindrone-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelessina tab (levonorgestrel)

T0 QL HCR Rules for Coveragelevo-eth est tab 90-20mcg

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonest tab (levonorgestrel-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonor/ethi tab 0.1-0.02

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonor/ethi tab estradio

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonorgestr tab 0.75mg

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonorgestr tab 1.5mg

T0 QL (28 tabs/28 days) HCR Rules for Coveragelevora-28 tab 0.15/30 (levonorgestrel)

T0 QL HCR Rules for Coveragelomedia 24 tab fe (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coverageloryna tab 3-0.02mg (drospirenone-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelow-ogestrel tab (norgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelutera tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragelyza tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragemarlissa tab 0.15/30 (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragemicrogestin tab 1.5/30 (norethindrone)





T0 HCR Rules for Coveragemicrogestin tab 1/20 (norethindrone)

T0 HCR Rules for Coveragemicrogestin tab fe 1/20 (norethin)

T0 HCR Rules for Coveragemicrogestin tab fe1.5/30 (norethin)

T0 HCR Rules for Coveragemono-linyah tab 0.25-35 (norgestimate-ethinyl)

T0 HCR Rules for Coveragemononessa tab (norgestimate-ethinyl)

T0 HCR Rules for Coveragemy way tab 1.5mg (levonorgestrel)

T0 HCR Rules for Coveragemyzilra tab (levonorgestrel-eth)

T0 HCR Rules for Coveragenecon tab 0.5/35 (norethindrone)

T0 HCR Rules for Coveragenecon tab 1/35 (norethindrone)

T0 HCR Rules for Coveragenecon tab 1/50-28 (norethindrone)

T0 HCR Rules for Coveragenecon tab 10/11-28 (norethindrone-eth)

T0





QL(28tabs/28days)

QL(1tabs/fill,3fillsper365days)






QL (28 tabs/28 days) HCR Rules for Coveragenecon tab 7/7/7 (norethindrone-eth)

T0 QL (1 tab/fill, 3 fill per 365 days) HCR Rules for Coveragenext choice tab 1.5mg (levonorgestrel)

T0 HCR Rules for Coveragenikki tab 3-0.02mg (drospirenone-ethinyl)

T0 HCR Rules for Coveragenora-be tab 0.35mg (norethindrone)

T0 HCR Rules for Coveragenoreth/ethin chw fe

T0 HCR Rules for Coveragenoreth/ethin tab 1/20

T0 HCR Rules for Coveragenoreth/ethin tab fe 1/20

T0 HCR Rules for Coveragenorethindron tab 0.35mg

T0 HCR Rules for Coveragenorgest/ethi tab 0.25/35

T0 HCR Rules for Coveragenorgest/ethi tab estradio

T0 HCR Rules for Coveragenorlyroc tab 0.35mg (norethindrone)

T0 HCR Rules for Coveragenortrel tab 0.5/35 (norethindrone)

T0 HCR Rules for Coveragenortrel tab 1/35 (norethindrone)

T0 HCR Rules for Coveragenortrel tab 7/7/7 (norethindrone-eth)

T0 HCR Rules for CoverageNUVARING MIS (etonogestrel-ethinyl)

T0 HCR Rules for Coverageocella tab 3-0.03mg (drospirenone-ethinyl)

T0 HCR Rules for Coverageogestrel tab (norgestrel)

T0 HCR Rules for Coverageopcicon tab 1.5mg (levonorgestrel)

T0 HCR Rules for Coverageorsythia tab (levonorgestrel)

T0 HCR Rules for Coveragephilith tab 0.4-35 (norethindrone)

T0













QL (1 per 28 days)



QL



QL (28 tabs/28 days) HCR Rules for Coveragepimtrea tab (desogestrel-ethinyl)





T0 QL (28 tabs/28 days) HCR Rules for Coveragepirmella tab 1/35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragepirmella tab 7/7/7 (norethindrone-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coverageportia-28 tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coverageprevifem tab (norgestimate-ethinyl)

T0 QL (14 patch/14 days, 12 fills/365 days)

HCR Rules for Coveragequasense tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragereclipsen tab (desogestrel)

T0 QL HCR Rules for Coveragesetlakin tab (levonorgestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragesharobel tab 0.35mg (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragesolia tab (desogestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragesprintec 28 tab 28 day (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragesronyx tab (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragesyeda tab 3-0.03mg (drospirenone-ethinyl)

T0 QL HCR Rules for Coveragetake action tab 1.5mg (levonorgestrel)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetarina fe tab 1/20 (norethin)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetilia fe tab (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-estaryll tab (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-legest tab fe (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-linyah tab (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetrinessa tab (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-previfem tab (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-sprintec tab (norgestimate-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragetrivora-28 tab (levonorgestrel-eth)

T0 QL (28 tabs/28 days) HCR Rules for Coveragevelivet pak (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragevestura tab 3-0.02mg (drospirenone-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coverageviorele tab (desogestrel-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragevyfemla tab 0.4-35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragewera tab 0.5/35 (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragewymzya fe chw 0.4mg-35 (norethindrone)

T0 QL (3 patches/28 days) HCR Rules for Coveragexulane dis 150-35 (norelgestromin-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragezarah tab 3-0.03mg (drospirenone-ethinyl)

T0 QL (28 tabs/28 days) HCR Rules for Coveragezenchent tab (norethindrone)

T0 QL (28 tabs/28 days) HCR Rules for Coveragezenchent fe chw 0.4mg-35 (norethindrone)





T0 QL (28 tabs/28 days) HCR Rules for Coveragezovia 1/35e tab (ethynodiol)

T0 QL (28 tabs/28 days) HCR Rules for Coveragezovia 1/50e tab (ethynodiol)

ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS

T1 QLclomiphene tab 50mg


T1 QL

raloxifene hcl tab 60 mg

serophene tab 50mg (clomiphene)

ESTROGENS

T3 QL (30 tabs/30 days)CENESTIN TAB 0.3MG (estrogens,)





T3 QL (4/30 days)CLIMARA PRO DIS WEEKLY (estradiol-levonorgestrel)

T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.14 (estradiol)

T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.25 (estradiol)

T3 QL (1 bottle/30 days)DIVIGEL GEL 0.25MG (estradiol)

T3 QL (1 bottle/30 days)DIVIGEL GEL 0.5MG (estradiol)

T3 QL (1 bottle/30 days)DIVIGEL GEL 1MG/GM (estradiol)

T3 QL (1 bottle/30 days)ELESTRIN GEL 0.06% (estradiol)

T3 QL (30 tabs/30 days)ENJUVIA TAB 0.3MG (estrogens,)





T1estra/noreth tab 0.5-0.1

T1estra/noreth tab 1-0.5mg

T3 QL (1 tube = 42.5gm/fill)ESTRACE VAG CRE 0.1MG/GM (estradiol)

T1 QLestradiol dis 0.025mg






HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS

ESTROGENS




T1estradiol tab 0.5mg

T1estradiol tab 1mg

T1estradiol tab 2mg

T3ESTRASORB EMU (estradiol)

T3 QL (1 ring/90 days)ESTRING MIS 2MG (estradiol)

T3 QL (1 bottle/30 days)ESTROGEL GEL (estradiol)

T1estropipate tab 0.75mg

T1estropipate tab 1.5mg

T1estropipate tab 3mg

T3 QL (1 bottle/30 days)EVAMIST SPR 1.53MG (estradiol)

T3 PA, QL (1 ring/90 days)FEMRING MIS 0.05/24H (estradiol)

T3 PA, QL (1 ring/90 days)FEMRING MIS 0.1MG/24 (estradiol)

T1jinteli tab 1mg-5mcg (norethindrone)

T1lopreeza tab 0.5-0.1 (estradiol)

T1lopreeza tab 1-0.5mg (estradiol)

T2MENEST TAB 0.3MG (esterified)




T3 QL (4 patches/28 days)MENOSTAR DIS 14MCG (estradiol)

T1mimvey tab 1-0.5mg (estradiol)

T1mimvey lo tab 0.5-0.1 (estradiol)

T1noreth/ethin tab 0.5-2.5

T1noreth/ethin tab 1mg-5mcg

T1ortho-est tab 0.625 (estropipate)

T1ortho-est tab 1.25 (estropipate)

T3PREFEST TAB (estradiol-norgestimate)

T2PREMARIN TAB 0.3MG (estrogens,)




HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS

ESTROGENS





T2PREMARIN VAG CRE 0.625MG (estrogens,)

T2 QL (30 tabs/30 days)PREMPHASE TAB (conjugated)

T2 QL (30 tabs/30 days)PREMPRO TAB .625-2.5 (conjugated)

T2 QL (30 tabs/30 days)PREMPRO TAB 0.3-1.5 (conjugated)

T2 QL (30 tabs/30 days)PREMPRO TAB 0.45-1.5 (conjugated)

T2 QL (30 tabs/30 days)PREMPRO TAB 0.625-5 (conjugated)

T2VAGIFEM TAB 10MCG (estradiol)

GONADOTROPINS

T4 PA

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA

T3

chor gonadot inj 10000unt

GONAL-F RFF INJ 300 (follitropin)

GONAL-F RFF INJ 300/0.5 (follitropin)





MENOPUR INJ 75UNIT (menotropins)

pregnyl inj 10000unt (chorionic)

SYNAREL SOL 2MG/ML (nafarelin)

PARATHYROID

T4 ST, SP, QL (1 pen/28 days), alendronate, ibandronate, Prolia (medical benefit))

alendronate, ibandronate, PROLIA

FORTEO SOL 600/2.4 (teriparatide)

PITUITARY

T1desmopressin sol 0.01%

T1desmopressin tab 0.1mg

T1desmopressin tab 0.2mg




HORMONES AND SYNTHETIC SUBSTITUTESPROGESTINS

T2CRINONE GEL 4% VAG (progesterone)

T2CRINONE GEL 8% VAG (progesterone)

T3DEPO-PROVERA INJ 400/ML (medroxyprogesterone)

T3ENDOMETRIN SUP 100MG (progesterone)

T0 QL HCR Rules for Coveragemedroxypr ac inj 150mg/ml

T1medroxypr ac tab 10mg

T1medroxypr ac tab 2.5mg

T1medroxypr ac tab 5mg

T3 QL (175ml/30 days)MEGACE ES SUS (megestrol)

T1megestrol sus 625mg/5m

T1norethin ace tab 5mg

T1progesterone cap 100mg

T1progesterone cap 200mg

T1progesterone inj 50mg/ml

SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS

T4 PA, SPSIGNIFOR INJ 0.3MG/ML (pasireotide)



T3 PA, QLSOMATULINE INJ 90/0.3ML (lanreotide)

SOMATOTROPIN AGONISTS AND ANTAGONISTSSOMATOTROPIN AGONISTS

T4 PAINCRELEX INJ 40MG/4ML (mecasermin)

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

NUTROPIN INJ 10MG (somatropin)

NUTROPIN AQ INJ 10MG/2ML (somatropin)

NUTROPIN AQ INJ 20MG/2ML (somatropin)

NUTROPIN AQ INJ NUSPIN 5 (somatropin)

SOMATOTROPIN ANTAGONISTS

T3 PASOMAVERT INJ 10MG (pegvisomant)




QL

QL



HORMONES AND SYNTHETIC SUBSTITUTESSOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN ANTAGONISTS



THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS

T1methimazole tab 10mg

T1methimazole tab 5mg

T1propylthiour tab 50mg

THYROID AGENTS

T1 QL (30 tab / 30 days)armour thyro tab 120mg (thyroid)

T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 120MG (thyroid)



T1 QL (30 tab / 30 days)armour thyro tab 180mg (thyroid)



T2ARMOUR THYRO TAB 30MG (thyroid)

T1armour thyro tab 30mg (thyroid)


T1armour thyro tab 60mg (thyroid)


T1levothyroxin tab 100mcg








T1

QL

QL

QL

QL

QL

QL

QL

QL

QL

QL

QL

QL

QL

QLlevothyroxin tab 300mcg




HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS

THYROID AGENTS

T1 QLlevothyroxin tab 50mcg



T1 QL

T2 QL (30 tabs/30 days) levothyroxine








levothyroxine tab 0.075mg

LEVOXYL (levothyroxine) tab 100mcg












LEVOXYL(levothyroxine)tab 75mcg


(levothyroxine) T1liothyronine tab 25mcg

T1liothyronine tab 50mcg

T1liothyronine tab 5mcg

T1 QLnature-throi tab 130mg (thyroid)

T1 QLnature-throi tab 16.25mg (thyroid)


T1 QLnature-throi tab 32.5mg (thyroid)


T1 QLnp thyroid tab 30mg (thyroid)



T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 100MCG (levothyroxine)









THYROID AGENTS








T2THYROLAR-1 TAB 60MG (liotrix)

T2THYROLAR-1/2 TAB 30MG (liotrix)

T2THYROLAR-1/4 TAB 15MG (liotrix)



T2 QLTIROSINT CAP 100MCG (levothyroxine)










T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

unith direct tab 100mcg (levothyroxine)












THYROID AGENTS

T1 QLunith direct tab 75mcg (levothyroxine)

T1 QLunith direct tab 88mcg (levothyroxine)

T2 QL

T2 QL

T2 QL

T2 QL

T2 QL

T2 QL

T2 QL

UNITHROID tab 100mcg (levothyroxine)







T2 QLunithroid tab 25mcg (levothyroxine)





T1 QL

T1 QL

westhroid tab 32.5mg (thyroid)

westhroid tab 65mg (thyroid) )

LOCAL ANESTHETICS (PARENTERAL)

T1chloroproc inj 2%

T1chloroproc inj 3%

T1tetracaine inj 1%

MISCELLANEOUS THERAPEUTIC AGENTS

T1colchicine tab 0.6mg

T1leucovor ca tab 15mg



5-ALPHA-REDUCTASE INHIBITORS

T1 QL (30 caps/30 days), ST (finasteride)

Dutasteride 0.5MG

T1finasteride tab 5mg




MISCELLANEOUS THERAPEUTIC AGENTSALCOHOL DETERRENTS

T1disulfiram tab 250mg

T1disulfiram tab 500mg

ANTIDOTES


ANTIGOUT AGENTS

T1allopurinol tab 100mg

T1allopurinol tab 300mg

T1colchicine cap 0.6mg

BIOLOGIC RESPONSE MODIFIERS

T4 PA, QL (3 vials / 30 days)

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4

T1

PA, SP

PA, SP

T4

T4

T4

PA, SP

PA, SP

PA, SP

T4

T4

T4

T4

T4

PA, SP

PA, SP

PA, SP

PA,SP

PA,SP

ACTIMMUNE INJ 2MU/0.5 (interferon)

AUBAGIO TAB 14MG (teriflunomide)

AUBAGIO TAB 7MG (teriflunomide)

AVONEX KIT 30MCG (interferon)

AVONEX PEN KIT 30MCG (interferon)

AVONEX PREFL KIT 30MCG (interferon)

T4 PA, SP

T4 PA, SP

T4 PA, SP

T4 PA, SP

MED PA, SP, QL (15 ml (1 vial) every 23 days)

Medical coinsurance

glatiramer inj 20MG/ML

EXTAVIA INJ 0.3MG (interferon)

GILENYA CAP 0.5MG (fingolimod)

REBIF INJ 22/0.5 (interferon)

REBIF INJ 44/0.5 (interferon)

REBIF REBIDO INJ 22/0.5 (interferon)

REBIF REBIDO INJ 44/0.5 (interferon)

REBIF REBIDO INJ TITRATN (interferon)

REBIF TITRTN INJ PACK (interferon)

THALOMID CAP 100MG (thalidomide)




TYSABRI INJ 300/15ML (natalizumab)


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Copaxone/Glatopa Equivalent

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MISCELLANEOUS THERAPEUTIC AGENTSBONE RESORPTION INHIBITORS

T1 QL (4 tabs/28 days), ST (alendronate, ibandronate)

alendronaterisedronate tab 35mg

T1alendronate tab 10mg





T1etidron disd tab 200mg

T1etidron disd tab 400mg


FOSAMAX + D TAB 70-2800 (alendronate)


FOSAMAX + D TAB 70-5600 (alendronate)

T1 QL (1 tab/28 days)ibandronate tab 150mg

MED PA, SP Medical coinsurancePROLIA SOL 60MG/ML (denosumab)

T1 QL (1 tab/28 days)risedronate tab 150mg

MED PA, SP Medical coinsuranceXGEVA INJ (denosumab)

CARIOSTATIC AGENTS

T0 HCR Rules for Coveragesodium fluoride chew 0.25 mg


T0 HCR Rules for Coveragesodium fluoride chew 1 mg



T0 HCR Rules for Coveragesodium fluoride lozg 1 mg

T0 HCR Rules for Coveragesodium fluoride soln 0.125 mg/drop

T0 HCR Rules for Coveragesodium fluoride soln 0.25 mg/drop

T0 HCR Rules for Coveragesodium fluoride soln 0.5 mg/ml

T0 HCR Rules for Coveragesodium fluoride tab 0.5 mg

T0 HCR Rules for Coveragesodium fluoride tab 1 mg

COMPLEMENT INHIBITORS

MED PA, SP Medical coinsuranceBERINERT INJ 500UNIT (c1)

MED PA, SP Medical coinsuranceCINRYZE SOL 500 UNIT (c1)




MISCELLANEOUS THERAPEUTIC AGENTSDISEASE-MODIFYING ANTIRHEUMATIC AGENTS

MED PA, SPACTEMRA INJ 162/0.9 (tocilizumab)

MED PA, SP Medical coinsuranceACTEMRA INJ 200/10ML (tocilizumab)

MED PA, SP Medical coinsuranceACTEMRA INJ 400/20ML (tocilizumab)

MED PA, SP Medical coinsuranceACTEMRA INJ 80MG/4ML (tocilizumab)

T4 PA, SP ENBREL, HUMIRA, CIMZIA KIT (certolizumab)

T4 PA, SP ENBREL, HUMIRA, CIMZIA KIT STARTER (certolizumab)

T4 PA, SP ENBREL, HUMIRA, CIMZIA PREFL KIT 200MG/ML (certolizumab)

T4 PA, SPENBREL INJ 25/0.5ML (etanercept)

T4 PA, SPENBREL INJ 25MG (etanercept)

T4 PA, SPENBREL INJ 50MG/ML (etanercept)

T4 PA, SPENBREL SRCLK INJ 50MG/ML (etanercept)

T4 PA, SPHUMIRA INJ 10MG/0.2 (adalimumab)

T4 PA, SPHUMIRA INJ 40MG/0.8 (adalimumab)

T4 PA, SPHUMIRA KIT 20MG/0.4 (adalimumab)

T4 PA,SPHUMIRA PEDIA INJ CROHNS (adalimumab)

T4 PA,SPHUMIRA PEN INJ 40MG/0.8 (adalimumab)

T4 PA,SPHUMIRA PEN INJ CROHNS (adalimumab)

T4 PA, SPHUMIRA PEN INJ PSORIASI (adalimumab)

T1leflunomide tab 10mg

T1leflunomide tab 20mg

T4ORENCIA INJ 125MG/ML (abatacept)

T4OTEZLA TAB 10/20/30 (apremilast)

T4OTEZLA TAB 30MG (apremilast)

MED Medical coinsuranceREMICADE INJ 100MG (infliximab)

T4SIMPONI INJ 100MG/ML (golimumab)

T4

PA, SP

PA, SP, QL (1 kit/ 365 days)

PA, SP, QL (60 tab / 30 days)

PA, SP

PA, SP

PA, SPSIMPONI INJ 50/0.5ML (golimumab)

T4SIMPONI ARIA SOL 50MG/4ML (golimumab)

T4 PA, SP ENBREL, leflunomide,

XELJANZ TAB 5MG (tofacitinib)


PA, SP



MISCELLANEOUS THERAPEUTIC AGENTSGONADOTROPIN-RELEASING HORMONE ANTAGNTS

T4 PA, SPCETROTIDE KIT 0.25MG (cetrorelix)

T4 PA, SP ganirelix ac inj

IMMUNOSUPPRESSIVE AGENTS

T1azathioprine tab 50mg

MED PA, SP Medical coinsuranceBENLYSTA INJ 120MG (belimumab)

MED PA, SP Medical coinsuranceBENLYSTA INJ 400MG (belimumab)

T1cyclosporine cap 100mg

T1cyclosporine cap 100mg md

T1cyclosporine cap 25mg

T1cyclosporine cap 25mg mod

T1cyclosporine cap 50mg mod

T1gengraf cap 100mg (cyclosporine)

T1gengraf cap 25mg (cyclosporine)

T1hecoria cap 0.5mg (tacrolimus)

T1hecoria cap 1mg (tacrolimus)

T1hecoria cap 5mg (tacrolimus)

T1mycophenolat cap 250mg

T1mycophenolat sus 200mg/ml

T1mycophenolat tab 500mg

T1mycophenolic tab 180mg dr

T1mycophenolic tab 360mg dr

T2RAPAMUNE SOL 1MG/ML (sirolimus)

T3SANDIMMUNE SOL 100MG/ML (cyclosporine)

T1sirolimus tab 0.5mg

T1sirolimus tab 1mg

T1sirolimus tab 2mg

T1tacrolimus cap 0.5mg

T1tacrolimus cap 1mg

T1tacrolimus cap 5mg

T3 PAZORTRESS TAB 0.25MG (everolimus)






MISCELLANEOUS THERAPEUTIC AGENTSOTHER MISCELLANEOUS THERAPEUTIC AGENTS

T4 PA, SPAMPYRA TAB 10MG (dalfampridine)

T3 PAARCALYST INJ 220MG (rilonacept)

T2CYSTAGON CAP 150MG (cysteamine)

T2CYSTAGON CAP 50MG (cysteamine)

T2ELMIRON CAP 100MG (pentosan)

T2ORFADIN CAP 10MG (nitisinone)



T3 QL (360 tabs/30 days)SENSIPAR TAB 30MG (cinacalcet)



RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS

T4 PAESBRIET CAP 267MG (pirfenidone)

T4 PAOFEV CAP 100MG (nintedanib)

T4 PAOFEV CAP 150MG (nintedanib)

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)LEUKOTRIENE MODIFIERS

T1montelukast chw 4mg

T1montelukast chw 5mg

T1montelukast gra 4mg

T1montelukast tab 10mg

T1zafirlukast tab 10mg

T1zafirlukast tab 20mg

T3 QL (120 tabs/30 days) montelukastZYFLO CR TAB 600MG (zileuton)

MAST-CELL STABILIZERS

T1cromolyn sod con 100/5ml

ANTITUSSIVES

T1benzonatate cap 100mg

T1benzonatate cap 150mg

T1 QLbenzonatate cap 200mg

T1chlor/phen dro dm


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RESPIRATORY TRACT AGENTSANTITUSSIVES

T1dm/cpm/pe dro

T1 QLhyd pol/cpm liq 10-8/5ml

T1nohist-dm liq (phenylephrine-chlorphen-dm)

T1prometh/cod syp 6.25-10

T1promethazine syp dm

CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) POTENTIATORS

T4 PA, SPKALYDECO TAB 150MG (ivacaftor)

MUCOLYTIC AGENTS

T1pulmosal neb 7% (sodium)

T3 PAPULMOZYME SOL 1MG/ML (dornase)

T1sodium chlor neb 7%

PHOSPHODIESTERASE TYPE 4 INHIBITORS

T3 PA, QL (30 tabs/30 days)DALIRESP TAB 500MCG (roflumilast)

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

MED PA, SP Medical coinsuranceXOLAIR SOL 150MG (omalizumab)

VASODILATING AGENTS (RESPIRATORY TRACT)

T4

T4

T4

T4

T4

T4

T4

T4

T4

T4









SP, PA


T4 PA, QL (28 units / 30 days)



T4

T4

PA

PA, QL (270 ampules/ 30 days)

ADEMPAS TAB 0.5MG (riociguat)


ADEMPAS TAB 1MG (riociguat)


ADEMPAS TAB 2MG (riociguat)

LETAIRIS TAB 10MG (ambrisentan)

LETAIRIS TAB 5MG (ambrisentan)

OPSUMIT TAB 10MG (macitentan)

ORKAMBI TAB

TRACLEER TAB 62.5MG (bosentan)

TYVASO SOL 0.6MG/ML (treprostinil)

TYVASO REFIL SOL 0.6MG/ML (treprostinil)

TYVASO START SOL 0.6MG/ML (treprostinil)

UPTRAVI TAB

VENTAVIS SOL 20MCG/ML (iloprost)




SERUMS, TOXOIDS, AND VACCINESSERUMS

MED PA, SP Medical coinsuranceBIVIGAM INJ 10% (immune)

MED PA, SP Medical coinsurancecarimune nf inj 12gm (immune)



MED PA, SP Medical coinsuranceFLEBOGAMMA INJ 20/400ML (immune)

MED PA, SP Medical coinsuranceflebogamma 5% vial

MED PA, SP Medical coinsurancegamastan s/d inj (immune)

MED PA, SP Medical coinsurancegammagard inj 1gm/10ml (immune)

MED PA, SP Medical coinsurancegammagard inj 2.5gm/25 (immune)

MED PA, SP Medical coinsurancegammagard inj 20gm/200 (immune)

MED PA, SP Medical coinsurancegammagard inj 5gm/50ml (immune)

MED PA, SP Medical coinsuranceGAMMAGARD S-D 10 G (IGA<1) SOL

MED PA, SP Medical coinsurancegammagard s-d 2.5 gm vl w/st

MED PA, SP Medical coinsuranceGAMMAGARD S-D 5 G (IGA<1) SOLN

MED PA, SP Medical coinsuranceGAMMAKED INJ 10GM/100 (immune)

MED PA, SP Medical coinsuranceGAMMAKED INJ 1GM/10ML (immune)

MED PA, SP Medical coinsuranceGAMMAKED INJ 2.5GM/25 (immune)

MED PA, SP Medical coinsuranceGAMMAKED INJ 20GM/200 (immune)

MED PA, SP Medical coinsuranceGAMMAKED INJ 5GM/50ML (immune)

MED PA, SP Medical coinsuranceGAMMAPLEX INJ 10GM (immune)

MED PA, SP Medical coinsuranceGAMMAPLEX INJ 2.5GM (immune)

MED PA, SP Medical coinsuranceGAMMAPLEX INJ 5GM (immune)

MED PA, SP Medical coinsuranceGAMUNEX 10% VIAL (IMMUNE)

MED PA, SP Medical coinsuranceHIZENTRA INJ 1GM/5ML (immune)



MED PA, SP Medical coinsuranceOCTAGAM INJ 10GM (immune)


MED PA, SP Medical coinsuranceOCTAGAM INJ 2.5GM (immune)



MED PA, SP Medical coinsurancePRIVIGEN INJ 10GRAMS (immune)




SERUMS, TOXOIDS, AND VACCINESSERUMS

MED PA, SP Medical coinsurancePRIVIGEN INJ 20GRAMS (immune)

MED PA, SP Medical coinsurancePRIVIGEN INJ 5 GRAMS (immune)

MED PA, SP Medical coinsuranceVIVAGLOBIN SOL 160MG/ML (immune)

TOXOIDS

VACCINES

T0 HCR Rules for CoverageAFLURIA INJ 2015-16 (influenza)

T0 HCR Rules for CoverageAFLURIA INJ PF 12-13 (influenza)

















EZ FLU SHOT INJ 2015-16 (influenza)

FLUARIX PF INJ 2013-14 (influenza)

FLUARIX PF INJ 2014-15 (influenza)

FLUARIX QUAD INJ 2013-14 (influenza)



FLUBLOK SOL 2013-14 (influenza)



FLUCELVAX INJ 2013-14 (influenza)



FLULAVAL INJ 2013-14 (influenza)

T0 HCR Rules for CoverageFLULAVAL QUA INJ 2013-14 (influenza)



T0 HCR Rules for CoverageFLUMIST QUAD SUS 2013-14 (influenza)



T0 HCR Rules for CoverageFLUVIRIN INJ 2013-14 (influenza)




SERUMS, TOXOIDS, AND VACCINESVACCINES

T0 HCR Rules for CoverageFLUVIRIN INJ 2015-16 (influenza)

T0 HCR Rules for CoverageFLUVIRIN INJ PF 13-14 (influenza)

T0 HCR Rules for CoverageFLUVIRIN PF INJ 2014-15 (influenza)

T0 HCR Rules for CoverageFLUZONE INJ INTRADRM (influenza)

T0 HCR Rules for CoverageFLUZONE INJ PF 13-14 (influenza)

T0 HCR Rules for CoverageFLUZONE INJ PF 14-15 (influenza)

T0 HCR Rules for CoverageFLUZONE HD INJ PF 13-14 (influenza)



T0 HCR Rules for CoverageFLUZONE PED/ INJ PF 13-14 (influenza)

T0 HCR Rules for CoverageFLUZONE QUAD INJ 13-14 (influenza)







FLUZONE QUAD INJ 2015-16 (influenza)

FLUZONE QUAD INJ 9MCG (influenza)

FLUZONE SPLT INJ 2015-16 (influenza)

INFLUENZA FIRUS VACCINE (INFLUENZA)

SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)

T3 QL (1 tube/fill) clindamycin, erythromycin

ALTABAX OIN 1% (retapamulin)

T2BACTROBAN OIN NASAL 2% (mupirocin)

T1clindacin mis etz 1% (clindamycin)

T1clindacin-p pad 1% (clindamycin)

T1clindamax gel 1% (clindamycin)

T1clindamax lot 10mg/ml (clindamycin)

T1 QLclindamy/ben gel 1.2-5%

T1clindamy/ben gel 1-5%

T1clindamycin cre 2% vag





ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)

T1clindamycin gel 1%

T1clindamycin lot 1%

T1clindamycin lot 10mg/ml

T1clindamycin pad 1%

T1clindamycin sol 1%

T1ery pad 2% (erythromycin)

T1erythromycin gel /benzoyl

T1erythromycin gel 2%

T1erythromycin pad 2%

T1erythromycin sol 2%

T1gentamicin cre 0.1%

T1gentamicin oin 0.1%

T1metronidazol cre 0.75%

T1metronidazol gel 0.75%vag

T1metronidazol lot 0.75%

T1 QLmupirocin cre 2%

T1mupirocin oin 2%

T1 QLmupirocin ca cre 2%

T1 QLneuac gel 1.2-5% (clindamycin)

T1rosadan cre 0.75% (metronidazole)

T1sulfacetamid lot 10%

T1sulfacetamid sus 10%

T1vandazole gel 0.75% (metronidazole)

ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)

T1ciclodan cre 0.77% (ciclopirox)

T1ciclodan sol 8% (ciclopirox)

T1ciclopirox cre 0.77%

T1ciclopirox gel 0.77%

T1ciclopirox sha 1%

T1ciclopirox sol 8%

T1ciclopirox sus 0.77%





ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)

T1 QL (60 gram tube/fill)clotrim/beta cre 1-0.05%

T1 QL (60 gram tube/fill)clotrim/beta cre diprop

T1clotrim/beta lot diprop

T1 QLclotrimazole cre 1% (clotrimazole)

T1clotrimazole loz 10mg

T1clotrimazole tro 10mg

T1econazole cre 1%

T3 QL (60 gm/fill) ciclopirox, econazole, ketoconazole, nystatin

ERTACZO CRE 2% (sertaconazole)

T3 QL (30 gram tube/fill)EXELDERM SOL 1% (sulconazole)

T1ketoconazole aer 2%

T1ketoconazole cre 2%

T1ketoconazole sha 2%

T1ketodan aer 2% (ketoconazole)

T3 QL (30 gram tube/fill) ciclopirox, nystatinMENTAX CRE 1% (butenafine)

T1nyamyc pow 100000 (nystatin)

T1nystatin cre 100000

T1nystatin oin 100000

T1nystatin pow 100000

T1nystop pow 100000 (nystatin)

T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT CRE 1% (oxiconazole)

T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT LOT 1% (oxiconazole)

T1pedi-dri pow 100000 (nystatin)

T1 QLterconazole cre 0.4%

T1 QLterconazole cre 0.8%

T1terconazole sup 80mg

T1 QLzazole cre 0.4% (terconazole)

T1 QLzazole cre 0.8% (terconazole)

T1zazole sup 80mg (terconazole)

ANTIVIRALS (SKIN & MUCOUS MEMBRANE)

T1 QL (60gm/30 days)acyclovir oin 5%





ANTIVIRALS (SKIN & MUCOUS MEMBRANE)

T3 QL (5gram / fill) acyclovirDENAVIR CRE 1% (penciclovir)

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

T1 QLacne medicat gel 10% (benzoyl)

T1 QLacne medicat gel 5% (benzoyl)

T1 QLacne pimple gel 10% (benzoyl)

T1 QLacne treatmn gel 10% (benzoyl)

T1 QLacne-clear gel 10% (benzoyl)

T1benzepro aer 5.3% (benzoyl)

T1benzepro liq creamy (benzoyl)

T1benzepro sc aer 9.8% (benzoyl)

T1benziq wash liq 5.25% (benzoyl)

T1benzoyl per aer 5.3%

T1benzoyl per aer 9.8%

T1 QLbenzoyl per gel 10% (benzoyl)

T1 QLbenzoyl per gel 5% (benzoyl)

T1benzoyl per liq 10% wash (benzoyl)

T1benzoyl pero aer 9.8%

T1benzoyl pero kit acne pck (benzoyl)

T1bp foam aer 5.3% (benzoyl)

T1bp foam aer 9.8% (benzoyl)

T1bp foaming liq wash 10% (benzoyl)

T1 QLbp gel gel 10% (benzoyl)

T1 QLbp gel gel 5% (benzoyl)

T1bp wash liq 2.5% (benzoyl)

T1bp wash liq 7% (benzoyl)

T1bpo gel 4% (benzoyl)

T1bpo gel 8% (benzoyl)

T1bpo creamy kit 4% wash (benzoyl)

T1bpo creamy kit 8% wash (benzoyl)

T1 QLclearplex v gel 5% (benzoyl)

T1 QLclearplex x gel 10% (benzoyl)





LOCAL ANTI-INFECTIVES, MISCELLANEOUS

T1 QLpersa-gel gel 10% (benzoyl)

T1 QLpersa-gel xs gel 5% (benzoyl)

T1pr benzoyl liq 7% wash (benzoyl)

T1 QLra renewal gel 10% (benzoyl)

T1se bpo wash liq 7% (benzoyl)

T1selenium sul lot 2.5%

T1selenium sul sha 2.25%

T1selenium sul sha 2.5%

T1silver sulfa cre 1%

T1ssd cre 1% (silver)

T1thermazene cre 1% (silver)

SCABICIDES AND PEDICULICIDES

T1acticin cre 5% (permethrin)

T2EURAX CRE 10% (crotamiton)

T2 QL (454 ml/30 days)EURAX LOT 10% (crotamiton)

T1lindane lot 1%

T1lindane sha 1%

T1malathion lot 0.5%

T1permethrin cre 5%

T3SKLICE LOT 0.5% (ivermectin)

T3 QL (227 ml/30 days)ULESFIA LOT 5% (benzyl)

ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)

T1ala cort cre 1% (hydrocortisone)

T1alclometason cre 0.05%

T1alclometason oin 0.05%

T1 QL (60 gram tube/fill)alphatrex gel 0.05% (betamethasone)

T1amcinonide cre 0.1%

T1amcinonide lot 0.1%

T1amcinonide oin 0.1%

T1 QLanucort-hc sup 25mg (hydrocortisone)

T2 QL (30 gm/fill)APEXICON E CRE 0.05% (diflorasone)




SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)

T1 QL (60 gram tube/fill)aug betamet cre 0.05%

T1 QL (60 gram tube/fill)aug betamet gel 0.05%

T1 QL (60 gram tube/fill)aug betamet lot 0.05%

T1 QL (60 gram tube/fill)aug betamet oin 0.05%

T1beta diprop gel 0.05%

T1 QL (60 gram tube/fill)betameth dip cre 0.05%

T1 QL (60 gram tube/fill)betameth dip lot 0.05%

T1 QL (60 gram tube/fill)betameth dip oin 0.05%

T1 QL (60 gram tube/fill)betameth val cre 0.1%

T1 PA, QL (60 gram tube/fill)betameth val lot 0.1%

T1 PA, QL (60 gram tube/fill)betameth val oin 0.1%

T3 JANUVIACAPEX SHA 0.01% (fluocinolone)

T1clobetasol aer 0.05%

T1clobetasol cre 0.05%

T1clobetasol gel 0.05%

T1clobetasol lot 0.05%

T1clobetasol oin 0.05%

T1clobetasol sha 0.05%

T1clobetasol sol 0.05%

T1

T1

T3 betamethasone

T3 betamethasone

T1 betamethasone

T1

T3

T2

QL (60gram/30 days)

QL (60gram/30 days)

QL (60gram/30 days)

QL (60gram/30 days)

QL (60gram/30 days)

QL (60gram/30 days)

QL (60gram/30 days)

QL

QL (60gram/30 days)

QL (45gm/fill)

QL

QL (60 grams/fill)

QL (60gram/30 days)

PA

QL (60gm/fill) desonide

T1

T1

T1

T1 QL (30 gram tube /fill)

T1 QL (30 gram tube /fill)

clobetasol e cre 0.05% (clobetasol)

clodan sha 0.05% (clobetasol)

CLODERM CRE 0.1% (clocortolone)

CLODERM CRE 0.1% PMP (clocortolone)

flurandrenolide cre 0.05%

cormax scalp sol 0.05% (clobetasol)

CORTISPORIN CRE 0.5% (neomycin-polymyxin-hc)

DESONATE GEL 0.05% (desonide)

desonide cre 0.05%

desonide lot 0.05%

desonide oin 0.05%

diflorasone cre 0.05%

diflorasone oin 0.05%





T1fluocin acet cre 0.01%

T1fluocin acet oil 0.01% sc (fluocinolone)

T1fluocin acet oil body (fluocinolone)

T1fluocin acet oil scalp (fluocinolone)

T1fluocin acet sol 0.01%

T1fluocinonide cre 0.05%

T1 PAfluocinonide cre 0.1%

T1fluocinonide gel 0.05%

T1fluocinonide oin 0.05%

T1fluocinonide sol 0.05%

T1fluticasone cre 0.05%

T1fluticasone lot 0.05%

T1fluticasone oin 0.005%

T1 QLgrx hicort sup 25mg (hydrocortisone)

T1halobetasol cre 0.05%

T1halobetasol oin 0.05%

T3 QL (30 grams/fill) betamethasone, clobetasol

HALOG CRE 0.1% (halcinonide)

T1 hc = hydrocortisonehc butyrate cre 0.1%

T1 hc = hydrocortisonehc butyrate oin 0.1%

T1 hc = hydrocortisonehc butyrate sol 0.1%

T1 QL hc = hydrocortisonehc pramoxine cre 1-2.5%

T1 QL hc = hydrocortisonehc pramoxine cre 2.5-1%

T1 hc = hydrocortisonehc valerate cre 0.2%

T1 hc = hydrocortisonehc valerate oin 0.2%

T1 QLhemorrhoidal sup -hc 25mg (hydrocortisone)

T1hydrocort cre 1% (hydrocortisone)

T1hydrocort cre 2.5%

T1hydrocort lot 2.5%

T1hydrocort oin 1%

T1hydrocort oin 2.5%

T1 QLhydrocort ac sup 25mg

T1hydrocort/ab oin 1%





T1 QLhydrocortiso cre 2.5%

T3KENALOG AER SPRAY (triamcinolone)

T1locoid cre 0.1% (hydrocortisone)

T1lokara lot 0.05% (desonide)

T1mometasone cre 0.1%

T1mometasone oin 0.1%

T1mometasone sol 0.1%

T1nystat/triam cre

T1nystat/triam oin

T1oralone pst 0.1% (triamcinolone)

T1prednicarbat cre 0.1%

T1 QLproctocare cre -hc 2.5% (hydrocortisone)

T1 QLprocto-pak cre 1% (hydrocortisone)

T1 QLproctosol hc cre 2.5% (hydrocortisone)

T1 QLproctozone cre -hc 2.5% (hydrocortisone)

T1proctozone cre -hc 2.5% (hydrocortisone)

T1 QLrectacort-hc sup 25mg (hydrocortisone)

T1scalacort lot 2% (hydrocortisone)

T1triamcin/ora pst 0.1%

T1triamcinolon aer spray

T1triamcinolon cre 0.025%

T1 QLtriamcinolon cre 0.1%

T1triamcinolon cre 0.5%

T1triamcinolon lot 0.025%

T1triamcinolon lot 0.1%

T1triamcinolon oin 0.025%



T1triamcinolon pst 0.1%

T1 QLtriderm cre 0.1% (triamcinolone)

ANTIPRURITICS AND LOCAL ANESTHETICS

T1 QLanecream cre 4% (lidocaine)




SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1

T1 QL

T1

T1 QL

T1

T1

T1 QL

T1 QL

T1

T1

T1 QL

T1

T1 QL

T1 QL

T1

T1

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1 QL

T1

T1 QL

T1 QL

T1 QL

aspercreme cre lidocain (lidocaine)

azo dine tab 95mg (phenazopyridine)

azo dine tab max st (phenazopyridine)

azo pain rel tab 95mg (phenazopyridine)

azo tabs tab 95mg (phenazopyridine)

azo urinary tab 97.5mg (phenazopyridine)

azo urinary tab 97.5mg (phenazopyridine)

azo-standard tab 95mg (phenazopyridine)

glydo gel 2% (lidocaine)

lc-4 lidocne cre 4% (lidocaine)

lido/prilocn cre 2.5-2.5%

lido/prilocn kit 2.5-2.5%

lidocaine cre 3%

lidocaine cre 4%

lidocaine gel 2%

lidocaine gel 2% jelly

lidocaine oin 5%

lidocaine sol 4%

lidocream cre 4% (lidocaine)

lidopin cre 3% (lidocaine)

livixil pak kit 2.5-2.5% (lidocaine-prilocaine)

lp lite pak kit 2.5-2.5% (lidocaine-prilocaine)

phenazo tab 200mg (phenazopyridine)

phenazo tab 95mg (phenazopyridine)

phenazopyrid tab 100mg



phenazoyrid tab 95mg

lidocaine pad 5% (lidocaine)

qc azo tab 95mg (phenazopyridine)

ra urinary tab 95mg (phenazopyridine)

ra urinary tab pain max (phenazopyridine)


bpatel

Typewritten Text

bpatel

Typewritten Text

PA

bpatel

Typewritten Text

bpatel

Typewritten Text

Generic for Lidoderm patch

bpatel

Typewritten Text



SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

T1relador pak kit 2.5-2.5% (lidocaine-prilocaine)

T1relador pak kit plus (lidocaine-prilocaine)

T1 QLsb urinary tab pain max (phenazopyridine)

T1 QLsm urinary tab pain max (phenazopyridine)

T1 QLurinary pain tab 95mg (phenazopyridine)

T1 QLurinary pain tab 97.5mg (phenazopyridine)

T1 QLuti relief tab 97.2mg (phenazopyridine)

ASTRINGENTS

T1hypercare sol 20% (aluminum)

CELL STIMULANTS AND PROLIFERANTS

T1 QL (45 gm/30 days)avita cre 0.025% (tretinoin)

T1 QL (45 gm/30 days)avita gel 0.025% (tretinoin)

T1 QL (45 gm/30 days)tretinoin cre 0.025%



T1 QL (45 gm/30 days)tretinoin gel 0.01%

T1 QL (45 gm/30 days)tretinoin gel 0.025%

T1tretinoin gel 0.05%

DEPIGMENTING AND PIGMENTING AGENTSPIGMENTING AGENTS

T2OXSORALEN LOT 1% (methoxsalen)

EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS

T1ammonium lac cre 12%

T1ammonium lac lot 12%

T1laclotion lot 12% (lactic)

T1lactic acid lot 10%

KERATOLYTIC AGENTS

T1 QLavar cleanse emu 10-5% (sulfacetamide)

T1 QLbp 10-1 emu (sulfacetamide)

T1 QLcerisa wash emu 10-1% (sulfacetamide)

T1 QLprascion emu (sulfacetamide)




SKIN AND MUCOUS MEMBRANE AGENTSKERATOLYTIC AGENTS

T1 QLrosanil emu cleanser (sulfacetamide)

T1 QLsod sul/sulf emu 10-5%

T1urea cre 47%

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

T3 PA, QL (30gram /30 days) clindamycin, erythromycin

ACZONE GEL 5% (dapsone)

T1 QL (45 gram/ 30 days)adapalene cre 0.1%

T1 QL (45 gram/ 30 days)adapalene gel 0.1%

T1 QLadapalene gel 0.3%

MED PA, SP Medical coinsurance

T1 QL (60gm tube/ 30 days)

T1 QL (60gm/30 days)

T1

T1 QL (60gm/30 days)

T1

T1 PA

AMEVIVE 15 MG VIAL (ALEFACEPT)

calcipotrien cre 0.005%

calcipotrien oin 0.005%

calcipotrien sol 0.005%

calcitrene oin 0.005% (calcipotriene)

calcitriol oin 3mcg/gm

amnesteem cap (isotretinoin)

T1 PA

T1 PA

T1 PA

zenatane cap (isotretinoin)

claravis cap 30mg (isotretinoin)

claravis cap 40mg (isotretinoin)

T3 QL (30gm/30 days)ELIDEL CRE 1% (pimecrolimus)

T3EPIDUO FORTE GEL 0.3-2.5% (adapalene-benzoyl)

T1fluorouracil cre 0.5%

T1fluorouracil cre 5%

T1fluorouracil dro 2%

T1fluorouracil dro 5%

T1fluorouracil sol 2%

T1fluorouracil sol 5%

T1imiquimod cre 5%

T1minocycline tab 135mg er



T3 PAMIRVASO GEL 0.33% (brimonidine)


All strengths

QL (30gm/30 days)

All strengths

All strengths

bpatel

Typewritten Text

bpatel

Typewritten Text



SKIN AND MUCOUS MEMBRANE AGENTSSKIN AND MUCOUS MEMBRANE AGENTS, MISC.

T3 fluorouracilPICATO GEL 0.015% (ingenol)

T3 fluorouracilPICATO GEL 0.05% (ingenol)

T1podofilox sol 0.5%

T3RECTIV OIN 0.4% (nitroglycerin)

T3 PA, QLREGRANEX GEL 0.01% (becaplermin)

T2SANTYL OIN 250/GM (collagenase)

MED PA, SP Medical coinsuranceSTELARA INJ 45MG/0.5 (ustekinumab)

T1 PAtacrolimus oin 0.03%

T1 PAtacrolimus oin 0.1%

T3 PA calcipotrieneTAZORAC CRE 0.05% (tazarotene)

T3 PA calcipotrieneTAZORAC CRE 0.1% (tazarotene)

T3 PA calcipotrieneTAZORAC GEL 0.05% (tazarotene)

T3 PA calcipotrieneTAZORAC GEL 0.1% (tazarotene)

T3 PA, QL (15gm/fill)VEREGEN OIN 15% (sinecatechins)

T3 QL (400gm/28 days)VOLTAREN GEL 1% (diclofenac)

SMOOTH MUSCLE RELAXANTSGENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

T3 PAENABLEX TAB 15MG (darifenacin)

T3 PAENABLEX TAB 7.5MG (darifenacin)

T1flavoxate tab 100mg

T1oxybutynin syp 5mg/5ml

T1 QL(30 caps/30 days)oxybutynin tab 10mg er

T1oxybutynin tab 15mg er

T1oxybutynin tab 5mg

T1oxybutynin tab 5mg er

T1tolterodine cap 2mg er

T1

QL(30 caps/30 days)


QL(30 caps/30 days)


QL (30 caps/30 days)tolterodine cap 4mg er

T1tolterodine tab 1mg

T1tolterodine tab 2mg

T3 PATOVIAZ TAB 4MG (fesoterodine)

T3 PATOVIAZ TAB 8MG (fesoterodine)




SMOOTH MUSCLE RELAXANTSGENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

T3 QL (( 30 tabs/ 30 days)), STVESICARE TAB 10MG (solifenacin)

T3 QL (( 30 tabs/ 30 days)), STVESICARE TAB 5MG (solifenacin)

BETA-3-ADRENERGIC AGONISTS

T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)

oxybutynin, tolterodine

MYRBETRIQ TAB 25MG (mirabegron)

T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)

oxybutynin, tolterodine

MYRBETRIQ TAB 50MG (mirabegron)

RESPIRATORY SMOOTH MUSCLE RELAXANTS

T1aminophyllin inj 25mg/ml

T3THEO-24 CAP 100MG CR (theophylline)



T3THEO-24 CAP 400MG ER (theophylline)

T1theochron tab 100mg cr (theophylline)



T1theophylline elx 80/15ml

T1theophylline tab 100mg cr (theophylline)

T1theophylline tab 100mg er

T1theophylline tab 200mg cr


T1theophylline tab 200mg sr

T1theophylline tab 300mg cr


T1theophylline tab 300mg sr


T1theophylline tab 450mg er (theophylline)


VITAMINSMULTIVITAMIN PREPARATIONS

T0 HCR Rules for Coverageprenatal multivit-min w/fe-fa tab

T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid cap




VITAMINSMULTIVITAMIN PREPARATIONS

T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid tab

T0 HCR Rules for Coverageprenatal vit w/ ferrous gluconate-folic acid tab

VITAMIN B COMPLEX

T1 QL (30 tabs/ 30 days)folic acid tab 1mg

T0 HCR Rules for Coveragefolic acid tab 400 mcg

T0 HCR Rules for Coveragefolic acid tab 800 mcg

VITAMIN D

T1calcitriol cap 0.25mcg

T1calcitriol cap 0.5mcg

T0 HCR Rules for Coveragecholecalciferol cap 1000 unit






T0 HCR Rules for Coveragecholecalciferol chew 1000 unit




T0 HCR Rules for Coveragecholecalciferol liqd 1000 unit/spray

T0 HCR Rules for Coveragecholecalciferol liqd 1200 unit/15ml

T0 HCR Rules for Coveragecholecalciferol liqd 2000 unt/0.03ml

T0 HCR Rules for Coveragecholecalciferol liqd 400 unit/ml

T0 HCR Rules for Coveragecholecalciferol liqd 400 unt/0.03ml

T0 HCR Rules for Coveragecholecalciferol liqd 5000 unit/ml

T0 HCR Rules for Coveragecholecalciferol tab 1000 unit




T1doxercalcif cap 0.5mcg

T1doxercalcif cap 1mcg

T1doxercalcif cap 2.5mcg




VITAMINSVITAMIN D

T1 QL (30 caps/ 30 days)ergocalcifer cap 50000unt

T1 QL (60 caps/30 days)paricalcitol cap 1 mcg

T1paricalcitol cap 2 mcg

T1paricalcitol cap 4 mcg

T1 QL (28 tabs/28 days)vitamin d cap 50000unt


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PCSK9

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INHIBITOR

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PRALUENT

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T4

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SP, PA

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REPATHA

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T4

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Index

Drug Name Page # Drug Name Page #

89

9

9

69

97

97

97

33

34

87

85

85

41

88

125

125

125

125

125

116

116

116

116

126

114

115

88

13

124

13

13

13

132

a/b sol otic

abacav/lamiv tab /zidovud

abacavir tab 300mg

acampro cal tab 333mg

acarbose tab 100mg

acarbose tab 25mg

acarbose tab 50mg

acebutolol cap 200mg

acebutolol cap 400mg

acetasol hc sol otic

acetazolamid cap 500mg er

acetazolamid tab 125mg

acetazolamid tab 250mg

acetic acid sol 2% otic

acne medicat gel 10%

acne medicat gel 5%

acne pimple gel 10%

acne treatmn gel 10%

acne-clear gel 10%

ACTEMRA INJ 162/0.9

ACTEMRA INJ 200/10ML

ACTEMRA INJ 400/20ML

ACTEMRA INJ 80MG/4ML

acticin cre 5%

ACTIMMUNE INJ 2MU/0.5

risedronate tab 35 mgACUVAIL SOL 0.45%

acyclovir cap 200mg

acyclovir oin 5%

acyclovir sus 200/5ml

acyclovir tab 400mg

acyclovir tab 800mg

ACZONE GEL 5%

132adapalene cre 0.1%

132adapalene gel 0.1%

132adapalene gel 0.3%

46ADCIRCA TAB 20MG

13adefov dipiv tab 10mg

119ADEMPAS TAB 0.5MG


119ADEMPAS TAB 1MG


119ADEMPAS TAB 2MG

22ADVAIR DISKU AER 100/50



22ADVAIR HFA AER 115/21



25ADVATE INJ 1000UNIT






32ADVICOR TAB 1000-20

32ADVICOR TAB 1000-40

32ADVICOR TAB 500-20MG

32ADVICOR TAB 750-20MG

38afeditab tab 30mg cr

38afeditab tab 60mg cr

14AFINITOR TAB 10MG

14AFINITOR TAB 2.5MG

14AFINITOR TAB 5MG

14AFINITOR TAB 7.5MG

121AFLURIA INJ 2015-16

121AFLURIA INJ PF 12-13




101aftera tab 1.5mg

29AGGRENOX CAP 25-200MG

126ala cort cre 1%

1ALBENZA TAB 200MG

22albuterol neb 0.083%

23albuterol neb 0.5%

23albuterol neb 0.63mg/3

23albuterol neb 1.25mg/3

23albuterol syp 2mg/5ml

23albuterol tab 2mg


23albuterol tab 4mg

23albuterol tab 4mg er

126alclometason cre 0.05%

126alclometason oin 0.05%

115alendronate tab 10mg





22alfuzosin tab 10mg

9ALINIA SUS 100/5ML

9ALINIA TAB 500MG

14ALKERAN TAB 2MG

114allopurinol tab 100mg

114allopurinol tab 300mg

64almotrip mal tab 12.5mg

64almotrip mal tab 6.25mg

64almotriptan tab 12.5mg

64almotriptan tab 6.25mg

84ALOCRIL SOL 2%

84ALOMIDE SOL 0.1% OP

25ALPHANATE 1,000-400 UNIT VIAL

25ALPHANATE 1,500-600 UNIT VIAL

25ALPHANATE 500-200 UNIT VIAL

25ALPHANATE INJ VWF/HUM

25ALPHANINE SD INJ 1000UNIT

25ALPHANINE SD INJ 1500UNIT

126alphatrex gel 0.05%

68alprazolam tab 0.25 odt

68alprazolam tab 0.25mg

68alprazolam tab 0.5mg

68alprazolam tab 0.5mg er

68alprazolam tab 0.5mg od

68alprazolam tab 0.5mg xr

68alprazolam tab 1mg

68alprazolam tab 1mg er

68alprazolam tab 1mg odt

68alprazolam tab 1mg xr

68alprazolam tab 2mg


68alprazolam tab 2mg odt




87ALREX SUS 0.2%

122ALTABAX OIN 1%

89altacaine sol 0.5% op

89altafrin sol 10% op

89altafrin sol 2.5% op

101altavera tab

94ALVESCO AER 160MCG

94ALVESCO AER 80MCG

101alyacen tab 1/35

101alyacen tab 7/7/7

64amantadine cap 100mg

64amantadine syp 50mg/5ml

64amantadine tab 100mg

126amcinonide cre 0.1%

126amcinonide lot 0.1%

126amcinonide oin 0.1%

101amethia lo tab

101amethia tab

101amethyst tab 90-20mcg

132AMEVIVE 15 MG VIAL

81amilor/hctz tab 5-50

81amiloride tab 5mg

134aminophyllin inj 25mg/ml

39amiodarone tab 200mg

39amiodarone tab 400mg

93AMITIZA CAP 24MCG

93AMITIZA CAP 8MCG

70amitriptylin tab 100mg






38amlod/benazp cap 10-20mg


38amlod/benazp cap 2.5-10mg




38amlod/valsar tab /hctz

38amlodipine tab 10mg

38amlodipine tab 2.5mg

38amlodipine tab 5mg

131ammonium lac cre 12%

131ammonium lac lot 12%

4amox/k clav chw 200mg

4amox/k clav chw 400mg

4amox/k clav sus 200/5ml





4amox/k clav tab 250mg



71amoxapine tab 100mg




4amoxicillin cap 250mg

4amoxicillin cap 500mg

4amoxicillin chw 125mg

4amoxicillin chw 250mg

4amoxicillin sus 125/5ml



5amoxicillin sus 250mg/5m


5amoxicillin tab 500mg

5amoxicillin tab 875mg

5amox-pot cla tab er

54amphetamine cap 10mg er






55amphetamine tab 10mg

55amphetamine tab 12.5mg





55amphetamine tab 7.5mg

5ampicillin cap 250mg

5ampicillin cap 500mg

5ampicillin sus 125/5ml

5ampicillin sus 250/5ml

118AMPYRA TAB 10MG

29anagrelide cap 0.5mg

29anagrelide cap 1mg

14anastrozole tab 1mg

96ANDROGEL GEL 1%(25MG)

97ANDROGEL GEL 1.62%

97ANDROGEL GEL PUMP 1%

129anecream cre 4%

18ANORO ELLIPT AER 62.5-25

87antibiot ear sol 1% otic

89antipy/benzo sol otic

126anucort-hc sup 25mg

90ANZEMET TAB 100MG

90ANZEMET TAB 50MG

49apap/caff/di tab hydrocod

49apap/codeine sol 120-12/5

49apap/codeine tab 300-15mg



126APEXICON E CRE 0.05%

98APIDRA INJ SOLOSTAR

98APIDRA INJ U-100

88apraclonidin sol 0.5% op

101apri tab

9APTIVUS CAP 250MG

9APTIVUS SOL

101aranelle tab

29ARANESP INJ 100MCG

30ARANESP INJ 10MCG



30ARANESP INJ 25MCG


30ARANESP INJ 40MCG


30ARANESP INJ 60MCG

118ARCALYST INJ 220MG

23ARCAPTA CAP 75MCG

75aripiprazole tab 10mg






110ARMOUR THYRO TAB 120MG

110armour thyro tab 120mg











49asa/caff/but cap cod 30mg


49ascomp/cod cap 30mg

101ashlyna tab

94ASMANEX 120 AER 220MCG





94ASMANEX HFA AER 100 MCG

95ASMANEX HFA AER 200 MCG

130aspercreme cre lidocain

46aspirin chew 81 mg

46aspirin chew 81 mg

46aspirin tab 324 mg



46aspirin tab 81 mg

46aspirin tab 81 mg

34atenol/chlor tab 100-25mg

34atenol/chlor tab 50-25mg

34atenolol tab 100mg

34atenolol tab 25mg

34atenolol tab 50mg

32atorvastatin tab 10mg




8atovaq/progu tab 250-100

8atovaq/progu tab 62.5-25

9atovaquone sus 750/5ml

9ATRIPLA TAB

89atropin-care sol 1% op

18atropine sul inj 0.05mg/1

18atropine sul inj 0.1mg/ml

18atropine sul inj 0.4/0.5

89atropine sul oin 1% op

89atropine sul sol 1% op

18ATROVENT HFA AER 17MCG

114AUBAGIO TAB 14MG

114AUBAGIO TAB 7MG

101aubra tab 0.1-0.02

127aug betamet cre 0.05%

127aug betamet gel 0.05%

127aug betamet lot 0.05%

127aug betamet oin 0.05%

89aurodex sol otic

89auroguard sol otic

100AVANDIA TAB 2MG

100AVANDIA TAB 4MG

100AVANDIA TAB 8MG

131avar cleanse emu 10-5%

101aviane tab

131avita cre 0.025%

131avita gel 0.025%

114AVONEX KIT 30MCG

114AVONEX PEN KIT 30MCG

114AVONEX PREFL KIT 30MCG

86AZASITE SOL 1%

117azathioprine tab 50mg

84azelastine dro 0.05%

84azelastine spr 0.1%

84azelastine spr 0.15%

66AZILECT TAB 0.5MG

66AZILECT TAB 1MG

3azithromycin pow 1gm pak

3azithromycin sus 100/5ml

3azithromycin sus 200/5ml

3azithromycin tab 250mg



130azo dine tab 95mg

130azo dine tab max st

130azo pain rel tab 95mg

130azo tabs tab 95mg

130azo urinary tab 97.5mg

130azo urinary tab 97.5mg

85AZOPT SUS 1% OP

130azo-standard tab 95mg

101azurette tab 28 day

2baciim inj 50000unt

2bacitracin inj 50000unt

86bacitracin oin op

21baclofen tab 10mg

22baclofen tab 20mg

122BACTROBAN OIN NASAL 2%

91balsalazide cap 750mg

101balziva tab

57BANZEL TAB 200MG

57BANZEL TAB 400MG

13BARACLUDE SOL .05MG/ML

95baycadron elx 0.5/5ml

46BAYER CHILD CHW ASA 81MG

25BEBULIN INJ 200-1200

25BEBULIN VH IMMU 200-1,200 UNIT

87BECONASE AQ SUS 0.042%


55BELVIQ TAB 10MG

43benazep/hctz tab 10-12.5


43benazep/hctz tab 20-25mg


43benazepril tab 10mg




25BENEFIX INJ 1000UNIT




117BENLYSTA INJ 120MG

117BENLYSTA INJ 400MG

125benzepro aer 5.3%

125benzepro liq creamy

125benzepro sc aer 9.8%

125benziq wash liq 5.25%

118benzonatate cap 100mg



125benzoyl per aer 5.3%

125benzoyl per aer 9.8%

125benzoyl per gel 10%

125benzoyl per gel 5%

125benzoyl per liq 10% wash

125benzoyl pero aer 9.8%

125benzoyl pero kit acne pck

55benzphetamin tab 50mg

65benztropine tab 0.5mg

19benztropine tab 1mg

19benztropine tab 2mg

84BEPREVE DRO 1.5%

115BERINERT INJ 500UNIT

86BESIVANCE SUS 0.6%

127beta diprop gel 0.05%

127betameth dip cre 0.05%

127betameth dip lot 0.05%

127betameth dip oin 0.05%

127betameth val cre 0.1%

127betameth val lot 0.1%

127betameth val oin 0.1%

85

34

34

betaxolol sol 0.5% op

betaxolol tab 10mg

betaxolol tab 20mg

85

14

14

34

34

34

34

34

120

87

BETOPTIC-S SUS 0.25% OP

bexarotene cap 75mg

bicalutamide tab 50mg

bisoprl/hctz tab 10/6.25

bisoprl/hctz tab 2.5/6.25

bisoprl/hctz tab 5-6.25mg

bisoprol fum tab 10mg

bisoprol fum tab 5mg

BIVIGAM INJ 10%

BLEPHAMIDE SUS LIQUIFLM

87BLEPHAMIDE SUS OP

14BOSULIF TAB 100MG

14BOSULIF TAB 500MG

131bp 10-1 emu

125bp foam aer 5.3%

125bp foam aer 9.8%

125bp foaming liq wash 10%

125bp gel gel 10%

125bp gel gel 5%

125bp wash liq 2.5%

125bp wash liq 7%

125bpo gel 4%

125bpo gel 8%

125bpo creamy kit 4% wash

125bpo creamy kit 8% wash

101briellyn tab

29BRILINTA TAB 60MG

29BRILINTA TAB 90MG

84brimonidine sol 0.15%

85brimonidine sol 0.2% op

88bromfenac sol 0.09%

88bromfenac sol 0.09% op

65bromocriptin cap 5mg

65bromocriptin tab 2.5mg

23BROVANA NEB 15MCG

71budeprion tab 100mg sr

71budeprion tab 150mg sr

95budesonide cap 3mg/24hr

95budesonide sus 0.25mg/2

95budesonide sus 0.5mg/2

95budesonide sus 1mg/2ml

87budesonide sus 32mcg

80bumetanide inj 0.25/ml

80bumetanide tab 0.5mg

80bumetanide tab 1mg

80bumetanide tab 2mg


80BUPHENYL TAB 500MG

54bupren/nalox sub 2-0.5mg

54bupren/nalox sub 8-2mg

54buprenorphin inj 0.3mg/ml

54buprenorphin sub 2mg

54buprenorphin sub 8mg

71bupropion hcl (smoking deterrent) tab 150 mg

71bupropion tab 100mg

71bupropion tab 100mg er

71bupropion tab 100mg sr





71bupropion tab 75mg

71bupropn hcl tab 150mg xl

71bupropn hcl tab 300mg xl

67buspirone tab 10mg



67buspirone tab 5mg

67buspirone tab 7.5mg

46but/apap/caf cap

49but/apap/caf cap codeine

46but/apap/caf tab

49but/asa/caf/ cap cod 30mg

47but/asa/caff cap

47but/asa/caff tab

49butal cpd/ cap codeine

54butorphanol inj 1mg/ml

54butorphanol sol 10mg/ml

54BUTRANS DIS 10MCG/HR




54BUTRANS DIS 7.5/HR

98BYDUREON INJ

98BYDUREON INJ

98BYETTA INJ 5MCG

34BYSTOLIC TAB 10MG

34BYSTOLIC TAB 2.5MG

34BYSTOLIC TAB 20MG

34BYSTOLIC TAB 5MG

65cabergoline tab 0.5mg

82calc acetate cap 667mg

132calcipotrien cre 0.005%

132calcipotrien oin 0.005%

132calcipotrien sol 0.005%

132calcitrene oin 0.005%

135calcitriol cap 0.25mcg

135calcitriol cap 0.5mcg

132calcitriol oin 3mcg/gm

101camila tab 0.35mg

101camrese lo tab

101camrese tab

91CANASA SUP 1000MG

41candesa/hctz tab 16-12.5

41candesa/hctz tab 32-12.5

42candesa/hctz tab 32-25mg

42candesartan tab 16mg




14capecitabine tab 150mg

14capecitabine tab 500mg

127CAPEX SHA 0.01%

15CAPRELSA TAB 100MG

15CAPRELSA TAB 300MG

43captopr/hctz tab 25-15mg




43captopril tab 100mg

43captopril tab 12.5mg



92CARAFATE SUS 1GM/10ML

65carb/levo 50 tab /entacap

65carb/levo 75 tab /entacap

65carb/levo er tab 25-100mg

65carb/levo er tab 50-200mg

65carb/levo sr tab 50-200mg

65carb/levo tab 10-100mg

65carb/levo tab 25-250mg

65carb/levo100 tab /entacap




57carbamazepin cap 100mg er



58carbamazepin chw 100mg

58carbamazepin sus 100/5ml


58carbamazepin tab 200mg

58carbamazepin tab 200mg er

58carbamazepin tab 400mg er

65carbidopa tab 25mg

24carbonyl iron chew 15 mg

24carbonyl iron suspension 15 mg/1.25ml

31CARDURA XL TAB 4MG

120carimune nf inj 12gm



21carisopr/asa tab 200-325

21carisoprodol tab 250mg

21carisoprodol tab 350mg

21carisoprodol tab asa/cod

85carteolol sol 1% op

36cartia xt cap 120/24hr




34carvedilol tab 12.5mg

34carvedilol tab 25mg



4CAYSTON INH 75MG

101caziant pak

2CEDAX CAP 400MG

2cefaclor cap 250mg

2cefaclor cap 500mg

2cefaclor er tab 500mg

2cefadroxil cap 500mg

2cefadroxil sus 250/5ml

2cefadroxil sus 500/5ml

2cefadroxil tab 1gm

2cefdinir cap 300mg

2cefdinir sus 125/5ml

2cefdinir sus 250/5ml

2cefditoren tab 200mg

2cefditoren tab 400mg

3cefixime sus 100/5ml

3cefixime sus 200/5ml

3cefpodo prox sus 100/5ml

3cefpodo prox sus 50mg/5ml

3cefpodoxime tab 100mg

3cefpodoxime tab 200mg

3cefprozil sus 125/5ml

3cefprozil sus 250/5ml

3cefprozil tab 250mg

3cefprozil tab 500mg

3cefuroxime tab 250mg

3cefuroxime tab 500mg

47celecoxib cap 100mg




63CELONTIN CAP 300MG

106CENESTIN TAB 0.3MG





3cephalexin cap 250mg



3cephalexin sus 125/5ml

3cephalexin sus 250/5ml

131cerisa wash emu 10-1%

90CESAMET CAP 1MG

101cesia pak

117CETROTIDE KIT 0.25MG

20cevimeline cap 30mg

19CHANTIX PAK 0.5& 1MG

19CHANTIX PAK 1MG

19CHANTIX TAB 0.5MG

19CHANTIX TAB 1MG

101chateal tab 0.15/30

94CHEMET CAP 100MG

118chlor/phen dro dm

19chlord/clidi cap 5-2.5mg

68chlordiazep cap 10mg



87chlorhex glu sol 0.12%

82chloromag inj 20%

113chloroproc inj 2%

113chloroproc inj 3%

8chloroquine tab 250mg

8chloroquine tab 500mg

81chlorothiaz tab 250mg

81chlorothiaz tab 500mg

76chlorpromaz inj 25mg/ml

76chlorpromaz inj 50mg/2ml

76chlorpromaz tab 100mg






99chlorpropam tab 100mg

99chlorpropam tab 250mg

81chlorthalid tab 100mg



21chlorzoxazon tab 500mg

47cho mag tris liq 500/5ml

47cho mag tris tab 1000mg

135cholecalciferol cap 1000 unit






135cholecalciferol chew 1000 unit




135cholecalciferol liqd 1000 unit/spray

135cholecalciferol liqd 1200 unit/15ml

135cholecalciferol liqd 2000 unt/0.03ml

135cholecalciferol liqd 400 unit/ml

135cholecalciferol liqd 400 unt/0.03ml

135cholecalciferol liqd 5000 unit/ml

135cholecalciferol tab 1000 unit




31cholestyram pow 4gm

31cholestyram pow 4gm lite

108chor gonadot inj 10000unt

46CIALIS TAB 5MG

123ciclodan cre 0.77%

123ciclodan sol 8%

123ciclopirox cre 0.77%

123ciclopirox gel 0.77%

123ciclopirox sha 1%

123ciclopirox sol 8%

123ciclopirox sus 0.77%

29cilostazol tab 100mg

29cilostazol tab 50mg

86CILOXAN OIN 0.3% OP

91cimetidine tab 200mg




116CIMZIA KIT

116CIMZIA KIT STARTER

116CIMZIA PREFL KIT 200MG/ML

115CINRYZE SOL 500 UNIT

87CIPRO HC SUS OTIC

87CIPRODEX SUS 0.3-0.1%

86ciprofloxacn sol 0.2%

86ciprofloxacn sol 0.3% op

5ciprofloxacn sus 250mg/5

5ciprofloxacn sus 500mg/5

5ciprofloxacn tab 1000mg




5ciprofloxacn tab 500mg er


71citalopram sol 10mg/5ml

71citalopram tab 10mg



132claravis cap 10mg




3clarithromyc sus 125/5ml

3clarithromyc sus 250/5ml

3clarithromyc tab 250mg

4clarithromyc tab 500mg

4clarithromyc tab 500mg er

125clearplex v gel 5%

125clearplex x gel 10%

1clemastine syp 0.5/5ml

1clemastine tab 2.68mg

19clidi/chlord cap 2.5-5mg

106CLIMARA PRO DIS WEEKLY

122clindacin mis etz 1%

122clindacin-p pad 1%

122clindamax gel 1%

122clindamax lot 10mg/ml

122clindamy/ben gel 1.2-5%

122clindamy/ben gel 1-5%

2clindamycin cap 150mg



122clindamycin cre 2% vag

123clindamycin gel 1%


123clindamycin lot 1%

123clindamycin lot 10mg/ml

123clindamycin pad 1%

123clindamycin sol 1%

2clindamycin sol 75mg/5ml

127clobetasol aer 0.05%

127clobetasol cre 0.05%

127clobetasol e cre 0.05%

127clobetasol gel 0.05%

127clobetasol lot 0.05%

127clobetasol oin 0.05%

127clobetasol sha 0.05%

127clobetasol sol 0.05%

127clodan sha 0.05%

127CLODERM CRE 0.1%

127CLODERM CRE 0.1% PMP

106clomiphene tab 50mg

71clomipramine cap 25mg



62clonazep odt tab 0.125mg



62clonazep odt tab 1mg

62clonazep odt tab 2mg

62clonazepam tab 0.5mg

62clonazepam tab 1mg

62clonazepam tab 2mg

41clonidine dis 0.1/24hr



41clonidine tab 0.1mg



29clopidogrel tab 300mg

29clopidogrel tab 75mg

68cloraz dipot tab 15mg

68cloraz dipot tab 3.75mg

68cloraz dipot tab 7.5mg

124clotrim/beta cre 1-0.05%

124clotrim/beta cre diprop

124clotrim/beta lot diprop

124clotrimazole cre 1%

124clotrimazole loz 10mg

124clotrimazole tro 10mg

76clozapine tab 100mg




8COARTEM TAB 20-120MG

49codeine sulf tab 15mg



49codeine/apap tab 15-300mg



114colchicine cap 0.6mg

113colchicine tab 0.6mg

31colestipol gra 5gm

31colestipol tab 1gm

87COLY-MYCIN S SUS OTIC

85COMBIGAN SOL 0.2/0.5%

106COMBIPATCH DIS .05/.14

106COMBIPATCH DIS .05/.25

23COMBIVENT AER RESPIMAT

15COMETRIQ KIT 100MG

15COMETRIQ KIT 140MG

15COMETRIQ KIT 60MG

76compazine sup 25mg

9COMPLERA TAB

76compro sup 25mg

80constulose sol 10gm/15

114COPAXONE INJ 20MG/ML

127CORDRAN CRE 0.05%

25CORIFACT KIT

127cormax scalp sol 0.05%

95cortisone ac tab 25mg

127CORTISPORIN CRE 0.5%

87CORTISPORIN SUS -TC OTIC

27coumadin tab 10mg

28coumadin tab 1mg

28coumadin tab 2.5mg

28coumadin tab 2mg

28coumadin tab 3mg

28coumadin tab 4mg

28coumadin tab 5mg

28coumadin tab 6mg

28

93

93

93

93

93

32

coumadin tab 7.5mg CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT rosuvastatin tab 10mg


32

32

32

109

109

9

9

9

118

84

101

94

102

102

21

rosuvastatin tab 20mg rosuvastatin tab 40mg rosuvastatin tab 5mg CRINONE GEL 4% VAG CRINONE GEL 8% VAG CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG CRIXIVAN 100 MG CAPSULE cromolyn sod con 100/5ml cromolyn sod sol 4% op cryselle-28 tab 28 tabs CUPRIMINE CAP 250MG cyclafem tab 1/35 cyclafem

tab 7/7/7 cyclobenzapr tab

10mg

21cyclobenzapr tab 5mg

89cyclopentol sol 1% op

89cyclopentol sol 2% op

15cyclophosph cap 25mg

15cyclophosph tab 25mg

15cyclophosph tab 50mg

8cycloserine cap 250mg

97CYCLOSET TAB 0.8MG

117cyclosporine cap 100mg

117cyclosporine cap 100mg md

117cyclosporine cap 25mg

117cyclosporine cap 25mg mod

117cyclosporine cap 50mg mod

1cyproheptad syp 2mg/5ml

1cyproheptad tab 4mg

102cyred tab

118CYSTAGON CAP 150MG

118CYSTAGON CAP 50MG

80cytra-k sol

119DALIRESP TAB 500MCG

97danazol cap 100mg

97danazol cap 200mg

97danazol cap 50mg

21dantrolene cap 100mg



8dapsone tab 100mg

8dapsone tab 25mg

9DARAPRIM TAB 25MG

102dasetta tab 1/35

102dasetta tab 7/7/7

102daysee tab

56DAYTRANA DIS 10MG/9HR




102deblitane tab 0.35mg

95deltasone tab 20mg

102delyla tab 0.1-0.02

91DELZICOL CAP 400MG

6demeclocycl tab 150mg

6demeclocycl tab 300mg

125DENAVIR CRE 1%

94DEPEN TITRA TAB 250MG

109DEPO-PROVERA INJ 400/ML

71desipramine tab 100mg






1desloratadin tab 5mg

108desmopressin sol 0.01%

108desmopressin tab 0.1mg

108desmopressin tab 0.2mg

102deso/ethinyl tab estradio

127DESONATE GEL 0.05%

127desonide cre 0.05%

127desonide lot 0.05%

127desonide oin 0.05%

71desvenlafax tab 100mg er

72desvenlafax tab 50mg er

87dexameth pho sol 0.1% op

95DEXAMETHASON CON 1MG/ML

95dexamethason elx 0.5/5ml

95dexamethason sol 0.5/5ml

95dexamethason tab 0.5mg



95dexamethason tab 1mg




1dexchlorphen syp 2mg/5ml

55dexedrine tab 10mg

55dexedrine tab 5mg

56dexmethylph cap 15mg er




56dexmethylph tab 10mg

56dexmethylph tab 2.5mg

56dexmethylph tab 5mg

56dexmethylphe cap 10mg er



55dextroamphet cap 10mg er



55dextroamphet tab 10mg

55dextroamphet tab 5mg

68diazepam gel 10mg

68diazepam gel 2.5mg

68diazepam gel 20mg

69diazepam inj 5mg/ml

69diazepam sol 1mg/ml

69diazepam sol 5mg/5ml

69diazepam tab 10mg

69diazepam tab 2mg

69diazepam tab 5mg

90DICLEGIS TAB 10-10MG

47diclo/misopr tab 50-0.2mg

47diclo/misopr tab 75-0.2mg

47diclofen pot tab 50mg

88diclofenac sol 0.1% op

47diclofenac tab 100mg er

47diclofenac tab 100mg xr

47diclofenac tab 25mg dr



5dicloxacill cap 250mg

5dicloxacill cap 500mg

19dicyclomine cap 10mg

19dicyclomine sol 10mg/5ml

19dicyclomine tab 20mg

9didanosine cap 125mg




55diethylprop tab 75mg er

4DIFICID TAB 200MG

127diflorasone cre 0.05%

127diflorasone oin 0.05%

47diflunisal tab 500mg

40digitek tab 0.125mg

40digitek tab 0.25mg

40digox tab 0.125mg

40digox tab 0.25mg

40digoxin inj 0.25mg/1

40digoxin sol 50mcg/ml

40digoxin tab 0.125mg

40digoxin tab 0.25mg

63DILANTIN CAP 30MG

63DILANTIN CHW 50MG

63DILANTIN-125 SUS 125/5ML

36dilt-cd cap 120mg

36dilt-cd cap 180mg

36dilt-cd cap 240mg

36dilt-cd cap 300mg

36diltiazem cap 120mg cd

36diltiazem cap 120mg er





36diltiazem cap 180mg/24














37diltiazem er tab 180mg





36diltiazem tab 120mg




37dilt-xr cap 120mg

37dilt-xr cap 180mg

37dilt-xr cap 240mg

37diltzac cap 180mg/24





91DIPENTUM CAP 250MG

90diphen/atrop liq 2.5/5

90diphen/atrop tab 2.5mg

90diphenatol tab 2.5mg

46dipyridamole inj 5mg/ml

46dipyridamole tab 25mg



39disopyramide cap 100mg

39disopyramide cap 150mg

114disulfiram tab 250mg

114disulfiram tab 500mg

58divalproex cap 125mg

58divalproex tab 125mg dr


58divalproex tab 250mg er


58divalproex tab 500mg er

106DIVIGEL GEL 0.25MG

106DIVIGEL GEL 0.5MG

106DIVIGEL GEL 1MG/GM

119dm/cpm/pe dro

20donepezil tab 10mg

20donepezil tab 10mg odt

20donepezil tab 5mg

20donepezil tab 5mg odt

85dorzol/timol sol 22.3-6.8

85dorzolamide sol 2% op

31doxazosin tab 1mg

31doxazosin tab 2mg

31doxazosin tab 4mg

31doxazosin tab 8mg

72doxepin hcl cap 100mg






72doxepin hcl con 10mg/ml

135doxercalcif cap 0.5mcg

135doxercalcif cap 1mcg

135doxercalcif cap 2.5mcg

6doxycyc mono cap 100mg

6doxycycl hyc cap 100mg

6doxycycl hyc cap 50mg

6doxycycl hyc tab 100mg

90dronabinol cap 10mg

90dronabinol cap 2.5mg

90dronabinol cap 5mg

102drospir/ethi tab 3-0.03mg

102drospirenone tab ethy est

15DROXIA CAP 200MG

15DROXIA CAP 300MG

15DROXIA CAP 400MG

95DULERA AER 100-5MCG

95DULERA AER 200-5MCG

72duloxetine cap 20mg



49duramorph inj 0.5mg/ml

49duramorph inj 1mg/ml

87DUREZOL EMU 0.05%

113Dutasteride 0.5MG

81DYRENIUM CAP 100MG

81DYRENIUM CAP 50MG

4e.e.s. 400 tab 400mg

4E.E.S. GRAN SUS 200/5ML

124econazole cre 1%

102econtra ez tab 1.5mg

42EDARBI TAB 40MG

42EDARBI TAB 80MG

80EDECRIN TAB 25MG

10EDURANT TAB 25MG

82EFFER-K TAB 10MEQ

82EFFER-K TAB 20MEQ

82effer-k tab 25meq ef

29EFFIENT TAB 10MG

29EFFIENT TAB 5MG

106ELESTRIN GEL 0.06%

132ELIDEL CRE 1%

102elinest tab

28ELIQUIS TAB 2.5MG

28ELIQUIS TAB 5MG

102ELLA TAB 30MG

118ELMIRON CAP 100MG

25ELOCTATE INJ 1000UNIT







84EMADINE SOL 0.05% OP


15EMCYT CAP 140MG

90EMEND CAP 125MG

90EMEND CAP 40MG

90EMEND CAP 80MG

91EMEND PAK 80 & 125

102emoquette tab

66EMSAM DIS 12MG/24H

66EMSAM DIS 6MG/24HR

66EMSAM DIS 9MG/24HR

10EMTRIVA CAP 200MG

10EMTRIVA SOL 10MG/ML

133ENABLEX TAB 15MG

133ENABLEX TAB 7.5MG

43enalapr/hctz tab 10-25mg

43enalapr/hctz tab 5-12.5mg

43enalapril tab 10mg

43enalapril tab 2.5mg

43enalapril tab 20mg

43enalapril tab 5mg

116ENBREL INJ 25/0.5ML

116ENBREL INJ 25MG

116ENBREL INJ 50MG/ML

116ENBREL SRCLK INJ 50MG/ML

80encare sup 100mg

49endocet tab 10-325mg



50endocet tab 7.5-325

50endocet tab 7.5-500m

109ENDOMETRIN SUP 100MG

106ENJUVIA TAB 0.3MG





28enoxaparin inj 100mg/ml

28enoxaparin inj 120/0.8

28enoxaparin inj 150mg/ml

28enoxaparin inj 30/0.3ml

28enoxaparin inj 300/3ml




102enpresse-28 tab

102enskyce tab

65entacapone tab 200mg

13entecavir tab 0.5mg

13entecavir tab 1mg

41ENTRESTO TAB 24-26MG



93ENTYVIO INJ 300MG

80enulose sol 10gm/15

132EPIDUO FORTE GEL 0.3-2.5%

84epinastine dro 0.05%

22epinephrine inj 0.1mg/ml

22epinephrine inj 1mg/ml

22EPIPEN 2-PAK INJ 0.3MG

22EPIPEN-JR INJ 2-PAK

58epitol tab 200mg

10EPIVIR HBV SOL 5MG/ML

44eplerenone tab 25mg

44eplerenone tab 50mg

30EPOGEN INJ 10000/ML





42eprosart mes tab 600mg

10EPZICOM TAB

10EPZICOM TAB 600-300

136ergocalcifer cap 50000unt

22ergoloid mes tab 1mg oral

15ERIVEDGE CAP 150MG

102errin tab 0.35mg

124ERTACZO CRE 2%

123ery pad 2%

4ERYPED SUS 200/5ML

4ERYPED SUS 400/5ML

4erythrom eth tab 400mg

123erythromycin gel /benzoyl

123erythromycin gel 2%

86erythromycin oin 5mg/gm

86erythromycin oin op

123erythromycin pad 2%

123erythromycin sol 2%

4erythromycin tab 250mg bs

4erythromycin tab 500mg bs

118ESBRIET CAP 267MG

72escitalopram sol 5mg/5ml

72escitalopram tab 10mg



102estarylla tab 0.25-35


69estazolam tab 1mg

69estazolam tab 2mg

106estra/noreth tab 0.5-0.1

106estra/noreth tab 1-0.5mg

106ESTRACE VAG CRE 0.1MG/GM

106estradiol dis 0.025mg






107estradiol tab 0.5mg

107estradiol tab 1mg

107estradiol tab 2mg

107ESTRASORB EMU

107ESTRING MIS 2MG

107ESTROGEL GEL

107estropipate tab 0.75mg

107estropipate tab 1.5mg

107estropipate tab 3mg

67eszopiclone tab 1mg



8ethambutol tab 100mg

8ethambutol tab 400mg

63ethosuximide cap 250mg

63ethosuximide sol 250/5ml

115etidron disd tab 200mg

115etidron disd tab 400mg

47etodolac cap 200mg

47etodolac cap 300mg

47etodolac tab 400mg

47etodolac tab 500mg

47

47

47

15

126

126

107

124

15

etodolac er tab 400mg



etoposide cap 50mg

EURAX CRE 10%

EURAX LOT 10%

EVAMIST SPR 1.53MG

EVAMIST SPR 1.53MGEXELDERM SOL 1%

exemestane tab 25mg

94EXJADE TAB 125MG

94EXJADE TAB 250MG

94EXJADE TAB 500MG

114EXTAVIA INJ 0.3MG

121EZ FLU SHOT INJ 2015-16

5FACTIVE TAB 320MG

102fallback tab 1.5mg

102falmina tab

13famciclovir tab 125mg



91famotidine tab 20mg

91famotidine tab 40mg

76FANAPT TAB 10MG

76FANAPT TAB 12MG

76FANAPT TAB 1MG

76FANAPT TAB 2MG

76FANAPT TAB 4MG

76FANAPT TAB 6MG

76FANAPT TAB 8MG

15FARESTON TAB 60MG

99FARXIGA TAB 10MG

99FARXIGA TAB 5MG

24fe c plus tab

26FEIBA VH IMMU 1,750-3,250 UNIT

58felbamate sus 600/5ml

58felbamate tab 400mg

58felbamate tab 600mg

38felodipine tab 10mg er

38felodipine tab 2.5mg er

38felodipine tab 5mg er

107FEMRING MIS 0.05/24H

107FEMRING MIS 0.1MG/24

32fenofibrate cap 130mg





32fenofibrate tab 120mg






32fenofibric tab 105mg

32fenofibric tab 35mg

47fenoprofen tab 600mg

50fentanyl dis 100mcg/h

50fentanyl dis 12mcg/hr


50fentanyl dis 37.5mcg






50fentanyl ot loz 1200mcg






24ferrous aspartate tab 112 mg

24ferrous fumarate cap 86 mg

24ferrous fumarate tab 18 mg





24ferrous gluconate tab 225 mg





24ferrous sulfate elixir 220 mg/5ml

24ferrous sulfate soln 15 mg/ml

24ferrous sulfate syrup 300 mg/5ml

24ferrous sulfate tab 134 mg











24ferrous sulfate tab 47.5 mg




113finasteride tab 5mg

87FLAREX SUS 0.1% OP

133flavoxate tab 100mg

120flebogamma 5% vial

120FLEBOGAMMA INJ 20/400ML

39flecainide tab 100mg



95FLOVENT DISK AER 100MCG



95FLOVENT HFA AER 110MCG



15floxuridine inj 0.5gm

121FLUARIX PF INJ 2013-14

121FLUARIX PF INJ 2014-15

121FLUARIX QUAD INJ 2013-14



121FLUBLOK SOL 2013-14



121FLUCELVAX INJ 2013-14



7fluconazole sus 10mg/ml

7fluconazole sus 40mg/ml

7fluconazole tab 100mg




8flucytosine cap 250mg

8flucytosine cap 500mg

95fludrocort tab 0.1mg

121FLULAVAL INJ 2013-14

121FLULAVAL QUA INJ 2013-14



121FLUMIST QUAD SUS 2013-14



87flunisolide spr 0.025%

128fluocin acet cre 0.01%

87fluocin acet oil 0.01%

128fluocin acet oil 0.01% sc

128fluocin acet oil body

87fluocin acet oil ear0.01%

128fluocin acet oil scalp

128fluocin acet sol 0.01%

128fluocinonide cre 0.05%

128fluocinonide cre 0.1%

128fluocinonide gel 0.05%

128fluocinonide oin 0.05%


128fluocinonide sol 0.05%

87fluoromethol sus 0.1% op

132fluorouracil cre 0.5%

132fluorouracil cre 5%

132fluorouracil dro 2%

132fluorouracil dro 5%

132fluorouracil sol 2%

132fluorouracil sol 5%

72fluoxetine cap 10mg



72fluoxetine cap 90mg dr

72fluoxetine sol 20mg/5ml

72fluoxetine tab 10mg

72fluoxetine tab 20mg

77fluphenazine tab 10mg


77fluphenazine tab 2.5mg


69flurazepam cap 15mg

69flurazepam cap 30mg

88flurbiprofen sol 0.03% op

47flurbiprofen tab 100mg

47flurbiprofen tab 50mg

15flutamide cap 125mg

128fluticasone cre 0.05%

128fluticasone lot 0.05%

128fluticasone oin 0.005%

87fluticasone spr 50mcg

33Fluvastatin TAB 80MG

33fluvastatin cap 20mg

33fluvastatin cap 40mg

121FLUVIRIN INJ 2013-14

122FLUVIRIN INJ 2015-16

122FLUVIRIN INJ PF 13-14

122FLUVIRIN PF INJ 2014-15

72fluvoxamine tab 100mg



122FLUZONE HD INJ PF 13-14



122FLUZONE INJ INTRADRM

122FLUZONE INJ PF 13-14

122FLUZONE INJ PF 14-15

122FLUZONE PED/ INJ PF 13-14

122FLUZONE QUAD INJ 13-14

122

122

122

122

122

FLUZONE QUAD INJ 14-15



FLUZONE QUAD INJ 9MCG

FLUZONE SPLT INJ 2015-16

135folic acid tab 1mg

135folic acid tab 400 mcg

135folic acid tab 800 mcg

28fondaparinux inj 10/0.8ml

28fondaparinux inj 2.5/0.5

28fondaparinux inj 5/0.4ml

28fondaparinux inj 7.5/0.6

23FORADIL CAP AEROLIZE

108FORTEO SOL 600/2.4

115FOSAMAX + D TAB 70-2800

115FOSAMAX + D TAB 70-5600

43fosinop/hctz tab 10/12.5

43fosinop/hctz tab 20/12.5

43fosinopril tab 10mg



82FOSRENOL CHW 1000MG



28FRAGMIN INJ 10000/ML

28FRAGMIN INJ 12500UNT



28FRAGMIN INJ 2500/0.2




64FROVA TAB 2.5MG

80furosemide inj 100/10ml

80furosemide inj 10mg/ml

80furosemide inj 20mg/2ml

80furosemide inj 40mg/4ml

81furosemide sol 10mg/ml

81furosemide sol 40mg/4ml

81furosemide sol 8mg/ml

81furosemide tab 20mg




10FUZEON INJ 90MG

10FUZEON CONVENIENCE KIT

58gabapentin cap 100mg



58

58

58

20

20

20

20

20

20

20

120

120

120

120

120

120

120

120

120

120

120

120

120

120

120

120

120

13

117

86

86

93

92

92

92

32

80

117

117

86

123

gabapentin sol 250/5ml

gabapentin tab 600mg

gabapentin tab 800mg

galantamine cap 16mg er



galantamine sol 4mg/ml

galantamine tab 12mg

galantamine tab 4mg

galantamine tab 8mg

gamastan s/d inj

gammagard inj 1gm/10ml

gammagard inj 2.5gm/25

gammagard inj 20gm/200

gammagard inj 5gm/50ml

GAMMAGARD S-D 10 G (IGA<1) SOL

gammagard s-d 2.5 gm vl w/st

GAMMAGARD S-D 5 G (IGA<1) SOLN

GAMMAKED INJ 10GM/100

GAMMAKED INJ 1GM/10ML

GAMMAKED INJ 2.5GM/25

GAMMAKED INJ 20GM/200

GAMMAKED INJ 5GM/50ML

GAMMAPLEX INJ 10GM

GAMMAPLEX INJ 2.5GM

GAMMAPLEX INJ 5GM

GAMUNEX 10% VIAL

ganciclovir cap 250 mg

ganirelix ac inj

garamycin oin 0.3% op

gatifloxacin sol 0.5%

GATTEX KIT 5MG

gavilyte-c sol

gavilyte-g sol

gavilyte-n sol flav pk

gemfibrozil tab 600mg

generlac sol 10gm/15

gengraf cap 100mg

gengraf cap 25mg

gentak oin 0.3% op

gentamicin cre 0.1%

123gentamicin oin 0.1%

86gentamicin oin 0.3% op

86gentamicin sol 0.3% op

102gianvi tab 3-0.02mg

102gildagia tab 0.4-35

102gildess 24 tab fe 1/20

102gildess fe tab 1.5/30

102gildess fe tab 1/20

102gildess tab 1.5/30

102gildess tab 1/20

114GILENYA CAP 0.5MG

15GILOTRIF TAB 20MG

15GILOTRIF TAB 30MG

15GILOTRIF TAB 40MG

114

15

15

15

15

15

99

99

100

100

100

100

100

100

100

100

100

100

100

100

101

101

100

100

100

100

glatiramer inj 20mg/ml imatinab tab 100MG imatinab tab 400MG GLEOSTINE CAP 100MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG glimepiride tab 1mg glimepiride tab 2mg glimepiride tab 4mg

glip/metform tab 2.5-250m glip/metform tab 2.5-500m glip/metform tab 5-500mg glipizide er tab 10mg glipizide er tab 2.5mg glipizide er tab 5mg glipizide tab 10mg glipizide

tab 5mg

glipizide xl tab 10mg glipizide xl tab 2.5mg glipizide xl tab 5mg GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG glyb/

metform tab 1.25-250 glyb/

metform tab 2.5-500 glyb/

metform tab 5-500mg glyburid mcr tab 1.5mg

100glyburid mcr tab 3mg

100glyburid mcr tab 6mg

100glyburide tab 1.25mg

100glyburide tab 2.5mg

100glyburide tab 5mg

19glycopyrrol tab 1mg

19glycopyrrol tab 2mg


130glydo gel 2%

97GLYSET TAB 100MG

97GLYSET TAB 25MG

97GLYSET TAB 50MG

108GONAL-F RFF INJ 300

108GONAL-F RFF INJ 300/0.5





90granisetron tab 1mg

7griseofulvin sus 125/5ml

7griseofulvin tab micr 500

7griseofulvin tab ultr 125

7griseofulvin tab ultr 250

128grx hicort sup 25mg

41guanfacine tab 1mg

69guanfacine tab 1mg er

41guanfacine tab 2mg




21guanidine tab 125mg

128halobetasol cre 0.05%

128halobetasol oin 0.05%

128HALOG CRE 0.1%

77haloperidol con 2mg/ml

77haloperidol tab 0.5mg

77haloperidol tab 10mg





12HARVONI TAB 90-400MG

128hc butyrate cre 0.1%

128hc butyrate oin 0.1%

128hc butyrate sol 0.1%

128hc pramoxine cre 1-2.5%

128hc pramoxine cre 2.5-1%

128hc valerate cre 0.2%

128hc valerate oin 0.2%

87hc/acet acid sol otic

102heather tab 0.35mg

117hecoria cap 0.5mg

117hecoria cap 1mg

117hecoria cap 5mg

26HELIXATE FS INJ 1000UNIT




26HEMOFIL M INJ 1700UNIT

26HEMOFIL M INJ 220-400

26HEMOFIL M INJ 401-800

26HEMOFIL M SOL 501-2000

26HEMOFIL M SOL 801-1500

128hemorrhoidal sup -hc 25mg

15HEXALEN CAP 50MG

120HIZENTRA INJ 1GM/5ML



89homatropaire sol 5% op

89homatropine sol 5% op

58HORIZANT TAB 300MG

58HORIZANT TAB 600MG

98HUMALOG INJ 100/ML

98HUMALOG KWIK INJ 100/ML

98HUMALOG MIX INJ 50/50

98HUMALOG MIX INJ 50/50KWP

98HUMALOG MIX INJ 75/25KWP

98HUMALOG MIX SUS 75/25

26HUMATE-P SOL 2400UNIT

26HUMATE-P SOL 250-600

26HUMATE-P SOL 500-1200

116HUMIRA INJ 10MG/0.2

116HUMIRA INJ 40MG/0.8

116HUMIRA KIT 20MG/0.4

116HUMIRA PEDIA INJ CROHNS

116HUMIRA PEN INJ 40MG/0.8

116HUMIRA PEN INJ CROHNS

116HUMIRA PEN INJ PSORIASI

98HUMULIN INJ 70/30

98HUMULIN INJ 70/30KWP

98HUMULIN N INJ U-100

98HUMULIN N INJ U-100KWP

98HUMULIN N PN INJ U-100

98HUMULIN PEN INJ 70/30

99HUMULIN R INJ U-100

99HUMULIN R INJ U-500

119hyd pol/cpm liq 10-8/5ml

41hydralazine inj 20mg/ml

41hydralazine tab 100mg





81hydrochlorot cap 12.5mg

81hydrochlorot tab 12.5mg

81hydrochlorot tab 25mg

81hydrochlorot tab 50mg

50hydroco/apap sol 5-217/10

50hydroco/apap sol 7.5-325

50hydroco/apap tab 10-325mg

50hydroco/apap tab 5-325mg

50hydroco/apap tab 7.5-325

50hydrocod/ibu tab 2.5-200

50hydrocod/ibu tab 7.5-200

128hydrocort ac sup 25mg

128hydrocort cre 1%

128hydrocort cre 2.5%

128hydrocort lot 2.5%

128hydrocort oin 1%

128hydrocort oin 2.5%

95hydrocort tab 10mg

95hydrocort tab 20mg

95hydrocort tab 5mg

128hydrocort/ab oin 1%

129hydrocortiso cre 2.5%

50hydromorphon liq 1mg/ml

50hydromorphon sup 3mg

50hydromorphon tab 2mg



9hydroxychlor tab 200mg

15hydroxyurea cap 500mg

67hydroxyz hcl sol 10mg/5ml

67hydroxyz hcl syp 10mg/5ml

67hydroxyz hcl tab 10mg



67hydroxyz pam cap 100mg



14hyophen tab

19hyoscyamine sub 0.125mg

19hyoscyamine tab 0.125mg

131hypercare sol 20%

115ibandronate tab 150mg

15IBRANCE CAP 100MG

15IBRANCE CAP 125MG

15IBRANCE CAP 75MG

50IBUDONE TAB 10-200MG

47ibuprofen sus 100/5ml

47ibuprofen tab 400mg



15ICLUSIG TAB 15MG

15ICLUSIG TAB 45MG

88ILEVRO DRO 0.3% OP

86ilotycin oin op

16IMBRUVICA CAP 140MG

72imipram hcl tab 10mg



72

72

72

73

132

109

81

82

48

48

48

48

48

48

12

12

122

16

16

10

10

10

imipram pam cap 100mg




imiquimod cre 5%

NCRELEX INJ 40MG/4ML

indapamide tab 1.25mg

indapamide tab 2.5mg

indomethacin cap 25mg

indomethacin cap 50mg

indomethacin cap 75mg cr

indomethacin cap 75mg er

indomethacin cap 75mg sa

indomethacin cap 75mg sr

INFERGEN INJ 15MCG

INFERGEN INJ 9MCG

INFLUENZA FIRUS VACCINE

INLYTA TAB 1MG

INLYTA TAB 5MG

INTELENCE TAB 100MG

INTELENCE TAB 200MG

INTELENCE TAB 25MG

16INTRON A INJ 10MU

16INTRON A INJ 18MU

16INTRON A INJ 18MU

16INTRON A INJ 25MU

16INTRON A INJ 50MU

102introvale tab

88IOPIDINE SOL 1% OP

19ipratropium sol 0.02%inh


19ipratropium spr 0.03%

19ipratropium spr 0.06%

42irbesar/hctz tab 150-12.5

42irbesar/hctz tab 300-12.5

42irbesartan tab 150mg



16IRESSA TAB 250MG

10ISENTRESS TAB 400MG

45isoditrate tab 40mg er

8isoniazid syp 50mg/5ml

8isoniazid tab 100mg

8isoniazid tab 300mg

45ISORDIL TAB 40MG

45isosorb din tab 10mg



45isosorb din tab 40mg er

45isosorb din tab 40mg sa


45isosorb mono tab 10mg

45isosorb mono tab 120mg er

45isosorb mono tab 20mg



38isradipine cap 2.5mg

38isradipine cap 5mg

7itraconazole cap 100mg

16JAKAFI TAB 10MG

16JAKAFI TAB 15MG

16JAKAFI TAB 20MG

16JAKAFI TAB 25MG

16JAKAFI TAB 5MG

97JANUVIA TAB 100MG

97JANUVIA TAB 25MG

98JANUVIA TAB 50MG

102jencycla tab 0.35mg

107jinteli tab 1mg-5mcg

102jolessa tab

103jolivette tab 0.35mg

103junel 1.5/30 tab

103junel 1/20 tab

103junel fe tab 1.5/30

103junel fe tab 1/20

103junel fe 24 tab 1/20

80k citrate sol citr acd

10KALETRA SOL

10KALETRA TAB 100-25MG

10KALETRA TAB 200-50MG

119KALYDECO TAB 150MG

90kaopectate tab

103kariva tab 28 day

26KCENTRA KIT 1000UNIT

26KCENTRA KIT 500UNIT

82k-effervesce tab 25meq ef

103kelnor tab 1/35

129KENALOG AER SPRAY

4KETEK TAB 300MG

4KETEK TAB 400MG

124ketoconazole aer 2%

124ketoconazole cre 2%

124ketoconazole sha 2%

7ketoconazole tab 200mg

124ketodan aer 2%

48ketoprofen cap 200mg er

48ketoprofen cap 50mg

48ketoprofen cap 75mg

88ketorolac sol 0.4%

88ketorolac sol 0.5%

48ketorolac tab 10mg

84ketotif fum dro 0.025%op

103kimidess tab

82kionex sus 15gm/60

82klor-con 10 tab 10meq er

83klor-con 8 tab 8meq er

83klor-con m10 tab 10meq er

83KLOR-CON M15 TAB

83KLOR-CON M15 TAB 15MEQ ER

83klor-con m20 tab 20meq er

83klor-con spr cap 10meq

83klor-con spr cap 8meq

83klor-con/ef tab 25meq ef

83klor-con/ef tab 25meq fr

26koate-dvi inj 1000unit

26koate-dvi inj 250unit

26KOATE-DVI INJ 500UNIT

26KOGENATE FS INJ 1000/BS

26KOGENATE FS INJ 1000UNIT










83k-prime tab 25meq ef

80KRISTALOSE PAK 10GM

80KRISTALOSE PAK 20GM

83k-sol sol 10%

83k-sol sol 20%

103kurvelo tab 0.15/30

83k-vescent tab 25meq ef

34labetalol tab 100mg



131laclotion lot 12%

131lactic acid lot 10%

80lactulose sol 10gm/15

80lactulose sol 20gm/30

58LAMICTAL CHW 25MG

58LAMICTAL CHW 5MG

58LAMICTAL KIT START 49

10lamivud/zido tab 150-300

10lamivudine sol 10mg/ml

10lamivudine tab 100mg



58lamotrigine chw 25mg

58lamotrigine chw 5mg

58lamotrigine tab 100mg

59lamotrigine tab 100mg er









40lanoxin tab 0.125mg

40lanoxin tab 0.25mg

92lansoprazole cap 15mg dr

92lansoprazole cap 30mg dr

92LANSOPRAZOLE SUS 3MG/ML

99LANTUS INJ 100/ML

99LANTUS INJ SOLOSTAR

103larin tab 1.5/30

103larin tab 1/20

103larin 24 tab fe 1/20

103larin fe tab 1.5/30

103larin fe tab 1/20

84LASTACAFT SOL 0.25%

85latanoprost sol 0.005%

77LATUDA TAB 120MG

77LATUDA TAB 20MG

77LATUDA TAB 40MG

77LATUDA TAB 60MG

77LATUDA TAB 80MG

103layolis fe chw

130lc-4 lidocne cre 4%

103leena tab

116leflunomide tab 10mg

116leflunomide tab 20mg

103lessina tab

119LETAIRIS TAB 10MG

119LETAIRIS TAB 5MG

16letrozole tab 2.5mg

114leucovor ca tab 10mg




16LEUKERAN TAB 2MG

30LEUKINE INJ 250MCG

30LEUKINE INJ 500 MCG

23levalbuterol neb 0.31mg


23levalbuterol neb 1.25/0.5


34LEVATOL TAB 20MG

99LEVEMIR INJ

99LEVEMIR INJ FLEXPEN

99LEVEMIR INJ FLEXTOUC

59levetiraceta sol 100mg/ml

59levetiraceta sol 500/5ml

59levetiraceta tab 1000mg



59levetiraceta tab 500mg er


59levetiraceta tab 750mg er

59levetiracetm inj 500/5ml

85levobunolol sol 0.25% op

85levobunolol sol 0.5% op

1levocetirizi sol 2.5/5ml

1levocetirizi tab 5mg

103levo-eth est tab 90-20mcg

5levofloxacin inj 25mg/ml


86levofloxacin sol 0.5%

5levofloxacin sol 25mg/ml

5levofloxacin tab 250mg



103levonest tab

103levonor/ethi tab 0.1-0.02

103levonor/ethi tab estradio

103levonorgestr tab 0.75mg

103levonorgestr tab 1.5mg

103levora-28 tab 0.15/30

50levorphanol tab 2mg

110levothyroxin inj 100mcg



110levothyroxin tab 100mcg












111levothyroxine tab 0.075mg

111levoxyl tab 100mcg











10LEXIVA SUS 50MG/ML

10LEXIVA TAB 700MG

91LIALDA TAB 1.2GM

130lido/prilocn cre 2.5-2.5%

130lido/prilocn kit 2.5-2.5%

130lidocaine cre 3%

130lidocaine cre 4%

130lidocaine gel 2%

130lidocaine gel 2% jelly

130lidocaine oin 5%

89lidocaine sol 2% visc

130lidocaine sol 4%

130lidocream cre 4%

130lidopin cre 3%

126lindane lot 1%

126lindane sha 1%

2linezolid tab 600mg

93LINZESS CAP 145MCG

93LINZESS CAP 290MCG

111liothyronine tab 25mcg



43lisinop/hctz tab 10-12.5

43lisinop/hctz tab 20-12.5

43lisinop/hctz tab 20-25mg

43lisinopril tab 10mg

44lisinopril tab 2.5mg





63lithium carb cap 150mg



63lithium carb tab 300mg

63lithium carb tab 300mg er

63lithium carb tab 450mg er

63lithium sol 8meq/5ml

33LIVALO TAB 1MG

33LIVALO TAB 2MG

33LIVALO TAB 4MG

130livixil pak kit 2.5-2.5%

129locoid cre 0.1%

90lofene tab 2.5mg

129lokara lot 0.05%

103lomedia 24 tab fe

90lonox tab 2.5mg

90loperamide cap 2mg

107lopreeza tab 0.5-0.1

107lopreeza tab 1-0.5mg

69lorazepam tab 0.5mg

69lorazepam tab 1mg

69lorazepam tab 2mg

51lorcet tab 5-325mg

51lorcet hd tab 10-325mg


51lorcet plus tab 7.5-325

51lortab tab 10-325mg

51lortab tab 5-325mg

51lortab tab 7.5-325

103loryna tab 3-0.02mg

21LORZONE TAB 750MG

42losartan pot tab 100mg



42losartan/hct tab 100-12.5

42losartan/hct tab 100-25

42losartan/hct tab 50-12.5

87LOTEMAX SUS 0.5%

33lovastatin tab 10mg



103low-ogestrel tab

77loxapine cap 10mg

77loxapine cap 25mg

77loxapine cap 50mg

77loxapine cap 5mg

130lp lite pak kit 2.5-2.5%

85LUMIGAN SOL 0.01%

103lutera tab

59LYRICA CAP 100MG

59LYRICA CAP 150MG

59LYRICA CAP 200MG

59LYRICA CAP 225MG

59LYRICA CAP 25MG

59LYRICA CAP 300MG

59LYRICA CAP 50MG

59LYRICA CAP 75MG

16LYSODREN TAB 500MG

103lyza tab 0.35mg

83magnesium cl inj 20%

126malathion lot 0.5%

73maprotiline tab 25mg



103marlissa tab 0.15/30

73MARPLAN TAB 10MG

16MATULANE CAP 50MG

37matzim la tab 180mg/24





23

88

91

91

48

48

48

109

109

109

109

48

9

109

16

16

16

16

16

109

16

16

48

48

48

69

69

107

107

107

107

108

107

124

51

MAXAIR AUTOH AER 200MCG MAXIDEX SUS 0.1% OP meclizine tab 12.5mg meclizine tab 25mg meclofen sod cap 100mg meclofen sod cap 50mg MEDI-SELTZER TAB medroxypr ac inj 150mg/ml medroxypr ac tab 10mg medroxypr ac tab 2.5mg medroxypr ac tab 5mg mefenam acid cap 250mg mefloquine tab 250mg MEGACE ES SUS

megestrol ac sus 400mg/10 megestrol ac sus 40mg/ml megestrol ac sus 800mg/20 megestrol ac tab 20mg megestrol ac tab 40mg megestrol sus 625mg/5m MEKINIST TAB 0.5MG MEKINIST TAB 2MG meloxicam sus 7.5/5ml meloxicam tab 15mg meloxicam tab 7.5mg memantine hc tab 10mg memantine tab hcl 5mg MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG

MENOPUR INJ 75UNIT MENOSTAR DIS 14MCG MENTAX CRE 1%meperidine

inj 100mg/ml

51meperidine inj 10mg/ml



51meperidine sol 50mg/5ml

51meperidine tab 100mg

51meperidine tab 50mg

51meperitab tab 100mg

51meperitab tab 50mg

67meprobamate tab 200mg

67meprobamate tab 400mg

16mercaptopur tab 50mg


91mesalamine ene 4gm

91mesalamine kit 4gm

21MESTINON SYP 60MG/5ML

56metadate tab 20mg er

23metaproteren syp 10mg/5ml

23metaproteren tab 10mg

23metaproteren tab 20mg

21metaxalone tab 400mg

21metaxalone tab 800mg

97metformin tab 1000mg


97metformin tab 500mg er

97metformin tab 750mg er


51methadone sol 10mg/5ml

51methadone sol 5mg/5ml

51methadone tab 10mg

51methadone tab 5mg

55methamphetam tab 5mg

85methazolamid tab 25mg

85methazolamid tab 50mg

14methenam hip tab 1gm

110methimazole tab 10mg

110methimazole tab 5mg

21methocarbam tab 500mg

21methocarbam tab 750mg

16methotrexate tab 2.5mg

19methscopolam tab 2.5mg

19methscopolam tab 5mg

81methyclothia tab 5mg

41methyldopa tab 250mg

41methyldopa tab 500mg

56methylphenid cap 10mg


56methylphenid cap 20mg er







56methylphenid sol 10mg/5ml

56methylphenid sol 5mg/5ml

57methylphenid tab 10mg

57methylphenid tab 10mg er





57methylphenid tab 20mg sr








96methylpred pak 4mg

96methylpred tab 16mg




85metipranolol sol 0.3% oph

94metoclopram inj 10mg/2ml

94metoclopram inj 5mg/ml

94metoclopram sol 10/10ml

94metoclopram sol 5mg/5ml

94metoclopram tab 10mg

94metoclopram tab 5mg

82metolazone tab 10mg

82metolazone tab 2.5mg

82metolazone tab 5mg

34metoprl/hctz tab 100-25mg



34metoprol tar tab 100mg



34metoprolol tab 100mg er




9metronidazol cap 375mg

123metronidazol cre 0.75%

123metronidazol gel 0.75%vag

123metronidazol lot 0.75%

9metronidazol tab 250mg

9metronidazol tab 500mg

39mexiletine cap 150mg



103microgestin tab 1.5/30

104microgestin tab 1/20

104microgestin tab fe 1/20


104microgestin tab fe1.5/30

69midazolam syp 2mg/ml

22midodrine tab 10mg

22midodrine tab 2.5mg

22midodrine tab 5mg

22MIGRANAL SPR 4MG/ML

107mimvey tab 1-0.5mg

107mimvey lo tab 0.5-0.1

6minocycline cap 100mg



6minocycline tab 100mg

132minocycline tab 135mg er





41minoxidil tab 10mg

41minoxidil tab 2.5mg

65MIRAPEX ER TAB 2.25MG

73mirtazapine tab 15mg

73mirtazapine tab 15mg odt





73mirtazapine tab 7.5mg

132MIRVASO GEL 0.33%

92misoprostol tab 100mcg

92misoprostol tab 200mcg

57modafinil tab 100mg

57modafinil tab 200mg

13moderiba tab 200mg

44moexipr/hctz tab 15-12.5

44moexipr/hctz tab 15-25mg

44moexipr/hctz tab 7.5-12.5

44moexipril tab 15mg

44moexipril tab 7.5mg

129mometasone cre 0.1%

129mometasone oin 0.1%

129mometasone sol 0.1%

26MONOCLATE-P INJ 250UNIT

27MONOCLATE-P INJ 500UNIT

104mono-linyah tab 0.25-35

104mononessa tab

27MONONINE INJ 500UNIT

118montelukast chw 4mg

118montelukast chw 5mg

118montelukast gra 4mg

118montelukast tab 10mg

14MONUROL PAK GRANULES

51morphine sul cap 100mg er












52morphine sul inj 0.5mg/ml

52morphine sul inj 10mg/ml

52morphine sul inj 150/30ml








52morphine sul sol 10/0.5ml

52morphine sul sol 100/5ml

52morphine sul sol 10mg/5ml

52morphine sul sol 20mg/5ml

52morphine sul sol 20mg/ml

52morphine sul sup 20mg

52morphine sul sup 5mg

52morphine sul tab 100mg cr

52morphine sul tab 100mg er

52morphine sul tab 15mg




52morphine sul tab 30mg





86MOXEZA SOL 0.5%

6moxifloxacin tab 400mg

40MULTAQ TAB 400MG


123

123

123

104

117

117

117

117

117

89

89

16

134

134

104

48

48

35

35

35

70

70

8948

mupirocin ca cre 2%

mupirocin cre 2%

mupirocin oin 2%

my way tab 1.5mg

mycophenolat cap 250mg

mycophenolat sus 200mg/ml

mycophenolat tab 500mg

mycophenolic tab 180mg dr

mycophenolic tab 360mg dr

mydral sol 0.5% op

mydral sol 1% op

MYLERAN TAB 2MG

MYRBETRIQ TAB 25MG

MYRBETRIQ TAB 50MG

myzilra tab

nabumetone tab 500mg

nabumetone tab 750mg

nadolol tab 20mg

nadolol tab 40mg

nadolol tab 80mg

naloxone inj 1mg/ml

naltrexone tab 50mg

naphazoline sol 0.1% op

naproxen sus 125/5ml

48naproxen tab 250mg



48naproxen dr tab 375mg

48naproxen dr tab 500mg

48naproxen ec tab 375mg

48naproxen ec tab 500mg

48naproxen sod tab 220mg



64naratriptan tab 1mg

64naratriptan tab 2.5mg

88NASONEX SPR 50MCG/AC

99nateglinide tab 120mg

99nateglinide tab 60mg

97NATESTO GEL 5.5MG

111nature-throi tab 130mg

111nature-throi tab 16.25mg


111nature-throi tab 32.5mg


9NEBUPENT INH 300MG

104necon tab 0.5/35

104necon tab 1/35

104necon tab 1/50-28

104necon tab 10/11-28

104necon tab 7/7/7

73nefazodone tab 100mg





88neo/poly/dex sus 0.1% op

88neo/poly/hc sol 1% otic

88neo/poly/hc sus 1% otic

89neofrin sol 10% op

89neofrin sol 2.5% op

2neomycin tab 500mg

123neuac gel 1.2-5%

30NEULASTA INJ 6MG/0.6M

30NEULASTA KIT 6MG/0.6M

30NEUPOGEN INJ 300/0.5

30NEUPOGEN INJ 300MCG

30NEUPOGEN INJ 480/0.8

30NEUPOGEN INJ 480MCG

65NEUPRO DIS 1MG/24HR






88NEVANAC SUS 0.1%

10nevirapine sus 50mg/5ml

10nevirapine tab 200mg

10nevirapine tab 400mg er

16NEXAVAR TAB 200MG

104next choice tab 1.5mg

31niacin tab 500mg er

31niacin er tab 1000mg



39nicardipine cap 20mg

39nicardipine cap 30mg

20nicotine kit

20nicotine patch 14 mg/24hr







20nicotine polacrilex gum 2 mg

20nicotine polacrilex gum 2 mg

20nicotine polacrilex lozg 2 mg




20NICOTROL INH

20NICOTROL NS SPR 10MG/ML

39nifediac cc tab 30mg er

39nifediac cc tab 60mg er

39nifedical xl tab 30mg

39nifedical xl tab 60mg

39nifedipine cap 10mg

39nifedipine cap 20mg

39nifedipine tab 30mg er



104nikki tab 3-0.02mg

16NILANDRON TAB 150MG

39nimodipine cap 30mg

39nisoldipine tab 17mg er

39nisoldipine tab 20mg

39nisoldipine tab 25.5mg


39nisoldipine tab 34mg er


39nisoldipine tab 8.5mg er

45NITRO-BID OIN 2%

45NITRO-DUR DIS 0.3MG/HR

14nitrofur mac cap 100mg

14nitrofur mac cap 50mg

14nitrofurantn cap 100mg

14nitrofurantn sus 25mg/5ml

14nitrofuranto cap 100mg

45nitroglycer aer 400mcg

45nitroglycer cap 2.5mg er

45nitroglycer cap 2.5mg sr

45nitroglycer cap 6.5mg er

45nitroglycer cap 6.5mg sr

45nitroglycer cap 9mg er

45NITRONAL SOL 1MG/ML

46NITROSTAT SUB 0.3MG



46nitro-time cap 2.5mg cr

46nitro-time cap 6.5mg cr

46nitro-time cap 9mg cr

91nizatidine cap 150mg

91nizatidine cap 300mg

91nizatidine sol 15mg/ml

119nohist-dm liq

104nora-be tab 0.35mg

104noreth/ethin chw fe

107noreth/ethin tab 0.5-2.5

104noreth/ethin tab 1/20

107noreth/ethin tab 1mg-5mcg

104noreth/ethin tab fe 1/20

109norethin ace tab 5mg

104norethindron tab 0.35mg

104norgest/ethi tab 0.25/35

104norgest/ethi tab estradio

104norlyroc tab 0.35mg

6NOROXIN TAB 400MG

40NORPACE CAP 100MG CR

104nortrel tab 0.5/35

104nortrel tab 1/35

104nortrel tab 7/7/7

73nortriptylin cap 10mg




73

10

10

10

99

99

99

99

99

99

99

99

27

27

27

27

nortriptylin sol 10mg/5ml

NORVIR CAP 100MG

NORVIR SOL 80MG/ML

NORVIR TAB 100MG

NOVOLIN INJ 70/30

NOVOLIN N INJ U-100

NOVOLIN R INJ U-100

NOVOLOG INJ 100/ML

NOVOLOG INJ FLEXPEN

NOVOLOG INJ PENFILL

NOVOLOG MIX INJ 70/30

NOVOLOG MIX INJ FLEXPEN

NOVOSEVEN 1,200 MCG VIAL

NOVOSEVEN 4,800 MCG VIAL

NOVOSEVEN INJ 2400MCG

NOVOSEVEN RT INJ 1MG

27NOVOSEVEN RT INJ 2MG




7NOXAFIL SUS 40MG/ML

111np thyroid tab 30mg



53NUCYNTA ER TAB 100MG

53NUCYNTA ER TAB 200MG

53NUCYNTA TAB 100MG

53NUCYNTA TAB 75MG

70NUEDEXTA CAP 20-10MG

19nulev tab 0.125mg

109NUTROPIN INJ 10MG

109NUTROPIN AQ INJ 10MG/2ML

109NUTROPIN AQ INJ 20MG/2ML

109NUTROPIN AQ INJ NUSPIN 5

104NUVARING MIS

57NUVIGIL TAB 150MG

57NUVIGIL TAB 200MG

57NUVIGIL TAB 250MG

124nyamyc pow 100000

129nystat/triam cre

129nystat/triam oin

124nystatin cre 100000

124nystatin oin 100000

7nystatin pow

124nystatin pow 100000

7nystatin pow 10bu

7nystatin pow 150mu

7nystatin pow 1bu

7nystatin pow 2bu

7nystatin pow 500mu

7nystatin pow 50mu

7nystatin pow 5bu

7nystatin sus 100000

8nystatin tab 500000

124nystop pow 100000

104ocella tab 3-0.03mg

120OCTAGAM INJ 10GM

120OCTAGAM INJ 1GM

120OCTAGAM INJ 2.5GM

120OCTAGAM INJ 25GM

120OCTAGAM INJ 5GM

118OFEV CAP 100MG

118OFEV CAP 150MG

86ofloxacin dro 0.3% op

86ofloxacin dro 0.3%otic

6ofloxacin tab 200mg



104ogestrel tab

73olanza/fluox cap 12-25mg




77olanzapine tab 10mg

77olanzapine tab 10mg odt



77olanzapine tab 2.5mg





78olanzapine tab 7.5mg

84Olopatadine SOL 0.1% OP

31omega-3-acid cap 1gm

92omeprazole cap 10mg



90ondansetron inj 4mg/2ml

90ondansetron sol 4mg/5ml

90ondansetron tab 24mg


90ondansetron tab 4mg odt


90ondansetron tab 8mg odt

62ONFI TAB 10MG

63ONFI TAB 20MG

63ONFI TAB 5MG

98ONGLYZA TAB 2.5MG

98ONGLYZA TAB 5MG

104opcicon tab 1.5mg

119OPSUMIT TAB 10MG

129oralone pst 0.1%

78ORAP TAB 1MG

78ORAP TAB 2MG

116ORENCIA INJ 125MG/ML

118ORFADIN CAP 10MG

118ORFADIN CAP 2MG

118ORFADIN CAP 5MG

48orph/asa/caf tab

22orphenadrine inj 30mg/ml

22orphenadrine tab 100mg cr

22orphenadrine tab 100mg er

104orsythia tab


107

107

19

19

92

116

116

97

97

49

ortho-est tab 0.625 ortho-est tab 1.25 oscimin sub 0.125mg oscimin tab 0.125mg OSMOPREP TAB 1.5GM OTEZLA TAB 10/20/30 OTEZLA TAB 30MG

oxandrolone tab 10mg oxandrolone tab 2.5mg oxaprozin tab 600mg

69oxazepam cap 10mg

69oxazepam cap 15mg

69oxazepam cap 30mg

59oxcarbazepin sus 300mg/5m

59oxcarbazepin tab 150mg



124

124

131

133

133

133

133

133

53

53

53

53

53

53

53

53

53

53

53

53

53

53

53

53

53

53

53

OXISTAT CRE 1%

OXISTAT LOT 1%

OXSORALEN LOT 1%

oxybutynin syp 5mg/5ml

oxybutynin tab 10mg er


oxybutynin tab 5mg







oxycod/ibu tab 5-400mg

oxycodone cap 5mg

oxycodone sol 5mg/5ml

oxycodone tab 10mg


oxycodone tab 15mg

oxycodone tab 20mg


oxycodone tab 30mg


oxycodone tab 5mg


oxymorphone tab 10mg er

oxymorphone tab 15mg er

53oxymorphone tab 20mg er




54oxymorphone tab 7.5mg er

54oxymorphone tab hcl 10mg

54oxymorphone tab hcl 5mg

40pacerone tab 200mg

40pacerone tab 400mg

78paliperidone tab er 1.5mg

78paliperidone tab er 3mg



93PANCREAZE CAP 10500UNT



93PANCREAZE CAP 4200UNIT

93pancrelipase cap 5000unit

92pantoprazole tab 20mg

92pantoprazole tab 40mg

89parcaine sol 0.5% op

136paricalcitol cap 1 mcg



87paroex sol 0.12%

8paromomycin cap 250mg

73paroxetine tab 10mg




84PATADAY SOL 0.2%

4PCE TAB 333MG EC

4PCE TAB 500MG EC

124pedi-dri pow 100000

92peg 3350 sol electrol

92peg-3350 sol electrol

92peg-3350/kcl sol /sodium

63PEGANONE TAB 250MG

12PEGASYS 180 MCG/0.5 ML CONV.PK

12PEG-INTRON KIT 120 RP

12PEGINTRON KIT 120MCG

12PEG-INTRON KIT 120MCG

12PEG-INTRON KIT 150 RP






12PEG-INTRON KIT 50MCG RP



12PEG-INTRON KIT 80MCG RP

92pegylax pow

5penicilln vk sol 125/5ml

5penicilln vk sol 250/5ml

5penicilln vk tab 250mg

5penicilln vk tab 500mg

54penta/apap tab 25-650mg

91PENTASA CAP 250MG CR

91PENTASA CAP 500MG CR

54pentaz/nalox tab 50-0.5mg

31pentoxifylli tab 400mg cr

31pentoxifylli tab 400mg er

23PERFOROMIST NEB 20MCG

44perindopril tab 2mg



87periogard sol 0.12%

126permethrin cre 5%

78perphenazine tab 16mg




126persa-gel gel 10%

126persa-gel xs gel 5%

93PERTZYE CAP

1phenadoz sup 25mg

130phenazo tab 200mg

130phenazo tab 95mg

130phenazopyrid tab 100mg



130phenazoyrid tab 95mg

74phenelzine tab 15mg

1phenergan sup 25mg

1phenergan sup 50mg

67phenobarb elx 20mg/5ml

67phenobarb sol 20mg/5ml

67phenobarb tab 100mg


67phenobarb tab 16.2mg






55phentermine tab 37.5mg

89phenylephrin sol 10% op

89phenylephrin sol 2.5% op

63PHENYTEK CAP 200MG

63PHENYTEK CAP 300MG

63phenytoin chw 50mg

63phenytoin ex cap 100mg



63phenytoin inj 50mg/ml

63phenytoin sus 125/5ml

104philith tab 0.4-35

83PHOSLYRA SOL

83phospha 250 tab neutral

85PHOSPHOLINE SOL 0.125%OP

133PICATO GEL 0.015%

133PICATO GEL 0.05%

85pilocarpine sol 1% op



21pilocarpine tab 5mg

21pilocarpine tab 7.5mg

104pimtrea tab

35pindolol tab 10mg

35pindolol tab 5mg

100pioglita/met tab 15-500mg

100pioglita/met tab 15-850mg

100pioglitazone tab 15mg



105pirmella tab 1/35

105pirmella tab 7/7/7

49piroxicam cap 10mg

49piroxicam cap 20mg

133podofilox sol 0.5%

92polyeth glyc pow 3350 nf

86polymyxin b/ sol trimethp

25polysaccharide iron complex cap 150 mg

25polysaccharide iron complex cap 200 mg

86polytrim sol op

16POMALYST CAP 1MG

16POMALYST CAP 2MG

16POMALYST CAP 3MG

17POMALYST CAP 4MG

105portia-28 tab

83pot bicarbon tab 25meq ef


83pot chloride cap 10meq er

83pot chloride cap 8meq er

83pot chloride inj 10meq


83pot chloride inj 2meq/ml


83pot chloride sol 10%

83pot chloride sol 10% sf

83pot chloride sol 20%

83pot chloride sol 20% sf

83pot chloride tab 10meq cr

83pot chloride tab 10meq er


83pot chloride tab 25meq ef

83pot chloride tab 8meq cr


84pot chloride tab 8meq sa

84pot chloride tab 8meq sr

80pot citrate tab 1080mg

80pot citrate tab 1620mg

80pot citrate tab 540mg er

84pot cl micro tab 10meq cr

84pot cl micro tab 10meq er

84pot cl micro tab 20meq cr

84pot cl micro tab 20meq er

84pot/chloride tab 25meq ef

84potassium tab 25meq ef

60POTIGA TAB 200MG

60POTIGA TAB 300MG

60POTIGA TAB 400MG

60POTIGA TAB 50MG

126pr benzoyl liq 7% wash

28PRADAXA CAP 150MG

29PRADAXA CAP 75MG

65pramipexole tab 0.125mg






66pramipexole tab 1mg

131prascion emu

33pravastatin tab 10mg




31prazosin hcl cap 1mg



88PRED MILD SUS 0.12% OP

88pred sod pho sol 1% op

96pred sod pho sol 5mg/5ml

129prednicarbat cre 0.1%

96prednisolone sol 15mg/5ml



88prednisolone sus 1% op

96prednisolone syp 15mg/5ml

96PREDNISONE CON 5MG/ML

96prednisone pak 10mg

96prednisone pak 5mg

96prednisone sol 5mg/5ml

96prednisone tab 10mg


96prednisone tab 2.5mg




107PREFEST TAB

108pregnyl inj 10000unt

107PREMARIN TAB 0.3MG





108PREMARIN VAG CRE 0.625MG

108PREMPHASE TAB

108PREMPRO TAB .625-2.5

108PREMPRO TAB 0.3-1.5

108PREMPRO TAB 0.45-1.5

108PREMPRO TAB 0.625-5

134prenatal multivit-min w/fe-fa tab

134prenatal vit w/ ferrous fumarate-folic acid cap

135prenatal vit w/ ferrous fumarate-folic acid tab

135prenatal vit w/ ferrous gluconate-folic acid tab

92PREPOPIK PAK

31prevalite pow 4gm

31prevalite pow 4gm pk

105previfem tab

10PREZISTA TAB 150MG

10PREZISTA TAB 400MG


10

11

11

9

62

62

74

120

121

121

23

23

84

84

78

78

78

30

30

30

30

30

30

129

129

129

129

129

27

109

109

109

101

115

30

30

30

30

1

1

119

1

1

PREZISTA TAB 600MG

PREZISTA TAB 75MG

PREZISTA TAB 800MG

primaquine tab 26.3mg

primidone tab 250mg

primidone tab 50mg

desvenlafaxin 100mg erPRIVIGEN INJ 10GRAMS

PRIVIGEN INJ 20GRAMS

PRIVIGEN INJ 5 GRAMS

PROAIR HFA AER

PROAIR RESPI AER

proben/colch tab 500-0.5

probenecid tab 500mg

prochlorper sup 25mg

prochlorper tab 10mg

prochlorper tab 5mg

PROCRIT INJ 10000/ML

PROCRIT INJ 2000/ML


PROCRIT INJ 3000/ML

PROCRIT INJ 4000/ML


proctocare cre -hc 2.5%

procto-pak cre 1%

proctosol hc cre 2.5%

proctozone cre -hc 2.5%

proctozone cre -hc 2.5%

PROFILNINE SD 500 UNITS VIAL

progesterone cap 100mg

progesterone cap 200mg

progesterone inj 50mg/ml

PROGLYCEM SUS 50MG/ML

PROLIA SOL 60MG/ML

PROMACTA TAB 12.5MG

PROMACTA TAB 25MG

PROMACTA TAB 50MG

PROMACTA TAB 75MG

prometh vc syp 6.25-5/5

prometh vc syp plain

prometh/cod syp 6.25-10

prometh/pe syp 6.25-5/5

promethazine sol 6.25/5ml

1promethazine sup 25mg

1promethazine sup 50mg

1promethazine syp 6.25/5ml

119promethazine syp dm

1promethazine tab 12.5mg

1promethazine tab 25mg

1promethazine tab 50mg

1promethegan sup 25mg

1promethegan sup 50mg

40propafenone cap 225mg er

40propafenone cap 325mg er

40propafenone cap 425mg sr

40propafenone tab 150mg



89proparacaine sol 0.5% op

35propranolol cap 120mg er




35propranolol sol 20mg/5ml

35propranolol sol 40mg/5ml

35propranolol tab 10mg





110propylthiour tab 50mg

74protriptylin tab 10mg

74protriptylin tab 5mg

23PROVENTIL AER HFA

130PROZENA PAD 4%

96PULMICORT INH 180MCG

96PULMICORT INH 90MCG

119pulmosal neb 7%

119PULMOZYME SOL 1MG/ML

8pyrazinamide tab 500mg

21pyridostigm tab 60mg

21pyridostigmi tab 180mg

130qc azo tab 95mg

44qnapril/hctz tab 10-12.5

44qnapril/hctz tab 20-12.5

44qnapril/hctz tab 20-25mg

105quasense tab

78quetiapine tab 100mg







44quinapril tab 10mg



44quinapril tab 5mg

40quinidine gl tab 324mg cr

40quinidine gl tab 324mg er

40quinidine su tab 300mg

40quinidine su tab 300mg er

96QVAR AER 40MCG

96QVAR AER 80MCG

126ra renewal gel 10%

130ra urinary tab 95mg

130ra urinary tab pain max

92rabeprazole tab 20mg

106raloxifene hcl tab 60 mg

44ramipril cap 1.25mg

44ramipril cap 10mg

44ramipril cap 2.5mg

44ramipril cap 5mg

40RANEXA TAB 1000MG

40RANEXA TAB 500MG

91ranitidine syp 150/10ml

91ranitidine syp 15mg/ml

91ranitidine syp 75mg/5ml

92ranitidine tab 150mg

92ranitidine tab 300mg

22RAPAFLO CAP 8MG

117RAPAMUNE SOL 1MG/ML

114REBIF INJ 22/0.5

114REBIF INJ 44/0.5

114REBIF REBIDO INJ 22/0.5

114REBIF REBIDO INJ 44/0.5

114REBIF REBIDO INJ TITRATN

114REBIF TITRTN INJ PACK

105reclipsen tab

27RECOMBINATE INJ 220-400



129rectacort-hc sup 25mg

133RECTIV OIN 0.4%

133REGRANEX GEL 0.01%

131relador pak kit 2.5-2.5%

131relador pak kit plus

13RELENZA AER DISKHALE

13RELENZA MIS DISKHALE

64RELPAX TAB 20MG

64RELPAX TAB 40MG

116REMICADE INJ 100MG

82RENAGEL TAB 400MG

82RENAGEL TAB 800MG

82RENVELA PAK 0.8GM

82RENVELA PAK 2.4GM

99repaglinide tab 0.5mg

99repaglinide tab 1mg

99repaglinide tab 2mg

66requip tab 1mg

11RESCRIPTOR TAB 100 MG

11RESCRIPTOR TAB 200MG

41reserpine tab 0.1mg

41reserpine tab 0.25mg

17REVLIMID CAP 10MG

17REVLIMID CAP 15MG

17REVLIMID CAP 2.5MG

17REVLIMID CAP 20MG

17REVLIMID CAP 25MG

17REVLIMID CAP 5MG

11REYATAZ CAP 100MG

11REYATAZ CAP 150MG

11REYATAZ CAP 200MG

11REYATAZ CAP 300MG

27RIASTAP SOL 1GM

13ribapak pak 1200/day

13ribapak pak 800/day

13ribasphere cap 200mg

13ribasphere tab 200mg



13ribatab pak 1000/day

13ribatab tab 1200/day

14ribatab tab 800/day

14ribavirin cap 200mg

14ribavirin tab 200mg

94RIDAURA CAP 3MG

8rifabutin cap 150mg

8RIFAMATE CAP

8rifampin cap 150mg

8rifampin cap 300mg

8rifampin inj 600 mg

70riluzole tab 50mg

9rimantadine tab 100mg

115risedronate tab 150mg


78risperidone sol 1mg/ml

78risperidone tab 0.25 odt

78risperidone tab 0.25mg

78risperidone tab 0.5mg

78risperidone tab 0.5mg od

78risperidone tab 1 mg

78risperidone tab 1mg

79risperidone tab 1mg odt







17RITUXAN INJ 500MG

21rivastigmine cap 1.5mg

21rivastigmine cap 3mg

21rivastigmine cap 4.5mg

21rivastigmine cap 6mg

27RIXUBIS INJ 1000UNIT


27RIXUBIS INJ 250 UNIT



64rizatriptan tab 10mg

64rizatriptan tab 10mg odt

64rizatriptan tab 5mg

64rizatriptan tab 5mg odt

86romycin oin op

66ropinirole tab 0.25mg

66ropinirole tab 0.5mg

66ropinirole tab 12mg er

66ropinirole tab 1mg









123rosadan cre 0.75%

132rosanil emu cleanser

54roxicet tab 5-325mg

67ROZEREM TAB 8MG

60SABRIL POW 500MG

60SABRIL TAB 500MG

49salsalate tab 500mg

49salsalate tab 750mg

82SAMSCA TAB 15MG

82SAMSCA TAB 30MG

117SANDIMMUNE SOL 100MG/ML

133SANTYL OIN 250/GM

79SAPHRIS SUB 10MG

79SAPHRIS SUB 2.5MG

79SAPHRIS SUB 5MG

70SAVELLA MIS TITR PAK

70SAVELLA TAB 100MG

70SAVELLA TAB 25MG

70SAVELLA TAB 50MG

131sb urinary tab pain max

129scalacort lot 2%

126se bpo wash liq 7%

66selegiline cap 5mg

126selenium sul lot 2.5%

126selenium sul sha 2.25%

126selenium sul sha 2.5%

11SELZENTRY TAB 150MG

11SELZENTRY TAB 300MG

118SENSIPAR TAB 30MG



23SEREVENT DIS AER 50MCG

106serophene tab 50mg

79SEROQUEL XR TAB 150MG





74sertraline con 20mg/ml

74sertraline tab 100mg



105setlakin tab

82sevelamer tab 800mg

105sharobel tab 0.35mg

80SHUR-SEAL GEL 2%

109SIGNIFOR INJ 0.3MG/ML



46sildenafil tab 20mg

126silver sulfa cre 1%

85SIMBRINZA SUS 1-0.2%

116SIMPONI ARIA SOL 50MG/4ML


116SIMPONI INJ 100MG/ML

116SIMPONI INJ 50/0.5ML

33simvastatin tab 10mg





117sirolimus tab 0.5mg

117sirolimus tab 1mg

117sirolimus tab 2mg

8SIRTURO TAB 100MG

126SKLICE LOT 0.5%

131sm urinary tab pain max

6smz/tmp ds tab 800-160

6smz-tmp ds tab 800-160

6smz-tmp sus 200-40/5

6smz-tmp tab 400-80mg

82sod poly sul sus 15gm/60

82sod poly sul sus 30/120ml

82sod poly sul sus 50/200ml

132sod sul/sulf emu 10-5%

86sod sulfacet sol 10% op

119sodium chlor neb 7%

115sodium fluoride chew 0.25 mg


115sodium fluoride chew 1 mg



115sodium fluoride lozg 1 mg

115sodium fluoride soln 0.125 mg/drop

115sodium fluoride soln 0.25 mg/drop

115sodium fluoride soln 0.5 mg/ml

115sodium fluoride tab 0.5 mg

115sodium fluoride tab 1 mg

105solia tab

109SOMATULINE INJ 90/0.3ML

109SOMAVERT INJ 10MG





35sorine tab 120mg

35sorine tab 160mg

35sorine tab 240mg

35sorine tab 80mg

35sotalol hcl tab 120mg




12SOVALDI TAB 400MG

19SPIRIVA CAP HANDIHLR

19SPIRIVA SPR RESPIMAT

44spirono/hctz tab 25/25

45spironolact tab 100mg



7SPORANOX SOL 10MG/ML

105sprintec 28 tab 28 day

17SPRYCEL TAB 100MG

17SPRYCEL TAB 140MG

17SPRYCEL TAB 20MG

17SPRYCEL TAB 50MG

17SPRYCEL TAB 70MG

17SPRYCEL TAB 80MG

82sps sus 15gm/60

105sronyx tab

126ssd cre 1%

11stavudine cap 15mg




11stavudine sol 1mg/ml

60STAVZOR CAP 125MG

60STAVZOR CAP 250MG

60STAVZOR CAP 500MG

133STELARA INJ 45MG/0.5

17STIVARGA TAB 40MG

70STRATTERA CAP 100MG







11STRIBILD TAB

92sucralfate tab 1gm

88sulf/pred na sol op

86sulfacet sod sol 10% op

123sulfacetamid lot 10%

123sulfacetamid sus 10%

6sulfadiazine tab 500mg

6sulfasalazin tab 500mg

6sulfasalazin tab 500mg dr

6sulfatrim pd sus 200-40/5


6sulfazine ec tab 500mg

6sulfazine tab 500mg

49sulindac tab 150mg

49sulindac tab 200mg

64sumatriptan inj 4mg/0.5



64sumatriptan spr 5mg/act

64sumatriptan tab 100mg

64sumatriptan tab 25mg

64

3

sumatriptan tab 50mg

SUPRAX SUS 500/5ML

3SUPRAX TAB 400MG

92SUPREP BOWEL SOL PREP

11SUSTIVA CAP 200MG

11SUSTIVA CAP 50MG

11SUSTIVA TAB 600MG

17SUTENT CAP 12.5MG

17SUTENT CAP 25MG

17SUTENT CAP 37.5MG

17SUTENT CAP 50MG

105syeda tab 3-0.03mg

17SYLATRON KIT 200MCG



17SYLATRON 296 MCG 4-PACK



19symax fastab tab 0.125mg

19symax-sl sub 0.125mg

96SYMBICORT AER 160-4.5

96SYMBICORT AER 80-4.5

97SYMLINPEN 60 INJ 1000MCG

13SYNAGIS INJ 50MG

108SYNAREL SOL 2MG/ML

111SYNTHROID TAB 100MCG












94SYPRINE CAP 250MG

17TABLOID TAB 40MG

117tacrolimus cap 0.5mg

117tacrolimus cap 1mg

117tacrolimus cap 5mg

133tacrolimus oin 0.03%

133tacrolimus oin 0.1%

17TAFINLAR CAP 50MG

17TAFINLAR CAP 75MG

105take action tab 1.5mg

13TAMIFLU CAP 30MG

13TAMIFLU CAP 45MG

13TAMIFLU CAP 75MG

13TAMIFLU SUS 6MG/ML

17tamoxifen citrate tab 10 mg

17tamoxifen citrate tab 20 mg

22tamsulosin cap 0.4mg

17TARCEVA TAB 100MG

17TARCEVA TAB 150MG

17

105

18

18

133

133

133

133

37

TARCEVA TAB 25MG

tarina fe tab 1/20

TASIGNA CAP 150MG

TASIGNA CAP 200MG

TAZORAC CRE 0.05%

TAZORAC CRE 0.1%

TAZORAC GEL 0.05%

TAZORAC GEL 0.1%

taztia xt cap 180mg/24

37taztia xt cap 240mg/24



12TECHNIVIE TAB

45TEKTURNA TAB 150MG

45TEKTURNA TAB 300MG

42telmisartan tab 20mg



69temazepam cap 15mg

69temazepam cap 22.5mg

69temazepam cap 30mg

69temazepam cap 7.5mg

18temozolomide cap 100mg







31terazosin cap 10mg

31terazosin cap 1mg

31terazosin cap 2mg

31terazosin cap 5mg

7

23

23

124

124

124

97

97

97

89

70

70

113

89

6

7

89

89

114

114

114

114

terbinafine tab 250mg

terbutaline tab 2.5mg

terbutaline tab 5mg

terconazole cre 0.4%

terconazole cre 0.8%

terconazole sup 80mg

testosterone gel 1%(25mg)

testosterone gel 1%(50mg)

testosterone gel pump 1%

tetcaine sol 0.5% op

tetrabenazin tab 12.5mg

tetrabenazin tab 25mg

tetracaine inj 1%

tetracaine sol 0.5% op

tetracycline cap 250mg

tetracycline cap 500mg

tetravisc sol 0.5% op

tetravisc sol forte

THALOMID CAP 100MG

THALOMID CAP 150MG

THALOMID CAP 200MG

THALOMID CAP 50MG

134THEO-24 CAP 100MG CR



134THEO-24 CAP 400MG ER

134theochron tab 100mg cr



134theophylline elx 80/15ml

134theophylline tab 100mg cr

134theophylline tab 100mg er



134theophylline tab 200mg sr



134theophylline tab 300mg sr




126thermazene cre 1%

79thioridazine tab 100mg




79thiothixene cap 10mg




112THYROLAR-1 TAB 60MG

112THYROLAR-1/2 TAB 30MG

112THYROLAR-1/4 TAB 15MG



60tiagabine tab 2mg

61tiagabine tab 4mg

29ticlopidine tab 250mg

40TIKOSYN CAP 125MCG



105tilia fe tab

85timolol gel sol 0.25% op

85timolol gel sol 0.5% op

85timolol mal sol 0.25% op

85timolol mal sol 0.5% op

35timolol mal tab 10mg



9tinidazole tab 250mg

9tinidazole tab 500mg

112TIROSINT CAP 100MCG










11TIVICAY TAB 50MG

21tizanidine tab 2mg

21tizanidine tab 4mg

88tobra/dexame sus 0.3-0.1%

88TOBRADEX OIN 0.3-0.1%


2tobramycin neb 300/5ml

86tobramycin sol 0.3% op

86TOBREX OIN 0.3% OP

86tobrex sol 0.3% op

100tolazamide tab 250mg

100tolazamide tab 500mg

100tolbutamide tab 500mg

65tolcapone tab 100mg

49tolmetin sod cap 400mg

49tolmetin sod tab 200mg

49tolmetin sod tab 600mg

133tolterodine cap 2mg er

133tolterodine cap 4mg er

133tolterodine tab 1mg

133tolterodine tab 2mg

61topiragen tab 100mg




61topiramate cap 15mg

61topiramate cap 25mg

61topiramate tab 100mg




81torsemide tab 100mg



81torsemide tab 5mg

99TOUJEO SOLO INJ 300IU/ML

133TOVIAZ TAB 4MG

133TOVIAZ TAB 8MG

119TRACLEER TAB 125MG

119TRACLEER TAB 62.5MG

98TRADJENTA TAB 5MG

54tramadl/apap tab 37.5-325

54tramadol hcl tab 100mg er



54tramadol hcl tab 50mg

44trandolapril tab 1mg



27tranex acid tab 650mg

91TRANSDERM-SC DIS 1.5MG

91TRANSDERM-SC DIS 1MG

74tranylcyprom tab 10mg

85TRAVATAN Z DRO 0.004%

85travoprost dro 0.004%

74trazodone tab 100mg




18tretinoin cap 10mg

131tretinoin cre 0.025%



131tretinoin gel 0.01%



18TREXALL TAB 10MG

18TREXALL TAB 15MG

18TREXALL TAB 5MG

18TREXALL TAB 7.5MG

129triamcin/ora pst 0.1%

88triamcinolon aer 55mcg/ac

129triamcinolon aer spray

129triamcinolon cre 0.025%



129triamcinolon lot 0.025%

129triamcinolon lot 0.1%

129triamcinolon oin 0.025%



129triamcinolon pst 0.1%

81triamt/hctz cap 37.5-25

81triamt/hctz cap 50-25mg

81triamt/hctz tab 37.5-25

81triamt/hctz tab 75-50mg

69triazolam tab 0.125mg

69triazolam tab 0.25mg

129triderm cre 0.1%

105tri-estaryll tab

79trifluoperaz tab 10mg




87trifluridine sol 1% op

65trihexyphen elx 0.4mg/ml

65trihexyphen tab 2mg

65trihexyphen tab 5mg

105tri-legest tab fe

105tri-linyah tab


93

91

86

14

105

105

105

105

89

89

11

11

19

18

114

119

119

119

14

90

126

112

trilyte sol

trimethobenz cap 300mg trimethoprim sol polymyxn trimethoprim tab 100mg trinessa tab

tri-previfem tab

tri-sprintec tab

trivora-28 tab

tropicamide sol 0.5% op tropicamide sol 1% op

TRUVADA TAB

TRUVADA TAB 200-300 TUDORZA PRES AER 400/ACT TYKERB TAB 250MG TYSABRI

INJ 300/15ML TYVASO SOL

0.6MG/ML TYVASO REFIL SOL

0.6MG/ML TYVASO START SOL

0.6MG/ML TYZEKA TAB

600MG

TYZINE PED DRO 0.05%

ULESFIA LOT 5%

unith direct tab 100mcg

112unith direct tab 112mcg










113unithroid tab 100mcg












132urea cre 47%

131urinary pain tab 95mg

131urinary pain tab 97.5mg

93ursodiol cap 300mg

93ursodiol tab 250mg

93ursodiol tab 500mg

131uti relief tab 97.2mg

108

14

14

14

61

61

61

61

61

42

42

42

42

42

42

42

42

42

2

2

2

2

123

80

80

105

74

74

74

74

74

74

74

74

74

74

74

74

74

119

119

VAGIFEM TAB 10MCG

valacyclovir tab 1gm

valacyclovir tab 500mg

valganciclov tab 450mg

valproate inj 100mg/ml

valproate inj 500/5ml

valproic acd cap 250mg valproic

acd sol 250/5ml valproic acd

syp 250/5ml valsart/hctz tab

160-12.5 valsart/hctz tab

160-25mg valsart/hctz tab

320-12.5 valsart/hctz tab

320-25mg valsart/hctz tab

80-12.5 valsartan tab 160mg

valsartan tab 320mg

valsartan tab 40mg

valsartan tab 80mg vancomycin

cap 125mg vancomycin cap

250mg VANCOMYCN 25 SOL

25MG/ML VANCOMYCN 50 SOL

50MG/ML vandazole gel 0.75%

vcf vaginal aer contracp

vcf vaginal gel contrace velivet

pak

venlafaxine cap 150mg er

venlafaxine cap 37.5 er

venlafaxine cap 37.5mg

venlafaxine cap 75mg er

venlafaxine tab 100mg

venlafaxine tab 150mg er



venlafaxine tab 37.5 er

venlafaxine tab 37.5mg




VENTAVIS SOL 10MCG/ML

VENTAVIS SOL 20MCG/ML


23VENTOLIN HFA AER

88VERAMYST SPR 27.5MCG

37verapamil cap 100mg er


37verapamil cap 120mg sr








38verapamil tab 120mg

38verapamil tab 120mg er

38verapamil tab 120mg sr


38verapamil tab 180mg sa


38verapamil tab 240mg cr


38verapamil tab 240mg sa




133VEREGEN OIN 15%

96VERIPRED 20 SOL 20MG/5ML

134VESICARE TAB 10MG

134VESICARE TAB 5MG

105vestura tab 3-0.02mg

88VEXOL SUS 1% OP

98VICTOZA INJ 18MG/3ML

12VICTRELIS CAP 200MG

11VIDEX SOL 2GM

11VIDEX SOL 4GM

12VIEKIRA PAK TAB

86VIGAMOX DRO 0.5%

75VIIBRYD TAB 10MG

75VIIBRYD TAB 20MG

75VIIBRYD TAB 40MG

61VIMPAT INJ 200MG/20

61VIMPAT SOL 10MG/ML

61VIMPAT TAB 100MG

62VIMPAT TAB 150MG

62VIMPAT TAB 200MG

62VIMPAT TAB 50MG

105viorele tab

11VIRACEPT TAB 250MG

11VIRACEPT TAB 625MG

11VIRAMUNE SUS 50MG/5ML

11VIRAMUNE XR TAB 100MG

11VIREAD POW 40MG/GM

11VIREAD TAB 150MG

11VIREAD TAB 200MG

12VIREAD TAB 250MG

12VIREAD TAB 300MG

84virt-phos tab 250 neut

80virtrate-k sol

80virtrate-k sol 1100-334

136vitamin d cap 50000unt

121VIVAGLOBIN SOL 160MG/ML

70VIVITROL INJ 380MG

133VOLTAREN GEL 1%

7voriconazole tab 200mg

7voriconazole tab 50mg

18VOTRIENT TAB 200MG

105vyfemla tab 0.4-35

33VYTORIN TAB 10-10MG




55VYVANSE CAP 10MG

55VYVANSE CAP 20MG

55VYVANSE CAP 30MG

55VYVANSE CAP 40MG

55VYVANSE CAP 50MG

55VYVANSE CAP 60MG

55VYVANSE CAP 70MG

29warfarin tab 10mg

29warfarin tab 1mg

29warfarin tab 2.5mg

29warfarin tab 2mg

29warfarin tab 3mg

29warfarin tab 4mg

29warfarin tab 5mg

29warfarin tab 6mg

29warfarin tab 7.5mg

29warfarin sod tab 10mg

31WELCHOL PAK 3.75GM

31WELCHOL TAB 625MG

105wera tab 0.5/35

113westhroid tab 130mg

113westhroid tab 32.5mg

113westhroid tab 65mg

27WILATE INJ


27WILATE 1,000-1,000 UNIT KIT

27WILATE 450-450 UNIT KIT

27WILATE 900-900 UNIT KIT

113WP THYROID TAB 130MG

105wymzya fe chw 0.4mg-35

18XALKORI CAP 200MG

18XALKORI CAP 250MG

29XARELTO STAR TAB 15/20MG

29XARELTO TAB 10MG

29XARELTO TAB 15MG

29XARELTO TAB 20MG

116XELJANZ TAB 5MG

93XENICAL CAP 120MG

115XGEVA INJ

2XIFAXAN TAB 200MG

2XIFAXAN TAB 550MG

119XOLAIR SOL 150MG

23XOPENEX HFA AER

18XTANDI CAP 40MG

105xulane dis 150-35

27XYNTHA INJ 1000UNIT




70XYREM SOL 500MG/ML

118zafirlukast tab 10mg

118zafirlukast tab 20mg

67zaleplon cap 10mg

67zaleplon cap 5mg

105zarah tab 3-0.03mg

124zazole cre 0.4%

124zazole cre 0.8%

124zazole sup 80mg

46zebutal cap

18ZELBORAF TAB 240MG

105zenchent tab

105zenchent fe chw 0.4mg-35

93ZENPEP CAP 10000UNT




93ZENPEP CAP 3000UNIT


93ZENPEP CAP 5000UNIT

32ZETIA TAB 10MG

88ZETONNA AER 37MCG

12ZIAGEN SOL 20MG/ML

12zidovudine cap 100mg

12zidovudine syp 50mg/5ml

12zidovudine tab 300mg

84zinc sulfate cap 220mg

86ZIOPTAN DRO 0.0015%

79ziprasidone cap 20mg




87ZIRGAN GEL 0.15%

18ZOLINZA CAP 100MG

64zolmitriptan tab 2.5mg

64zolmitriptan tab 5mg

67zolpidem tab 10mg

67zolpidem tab 5mg

67zolpidem er tab 12.5mg

67zolpidem er tab 6.25mg

109ZOMACTON INJ 10MG

62zonisamide cap 100mg



117ZORTRESS TAB 0.25MG



106zovia 1/35e tab

106zovia 1/50e tab

18ZYDELIG TAB 100MG

18ZYDELIG TAB 150MG

118ZYFLO CR TAB 600MG

18ZYTIGA TAB 250MG

2ZYVOX SUS 100MG/5M

2ZYVOX TAB 600MG

2016 drug formulary for qualified health plans (hap personal

Documents