2018 commercial formulary fdb - health first · 2018-11-15 · 2018 commercial/tpa 5 tier formulary...

2018 Commercial/TPA 5 Tier Formulary Version 5

Effective: November 1, 2018 Large Group Health Plans

Small Group Health Plans

2018 Commercial 5-Tier Formulary (List of Covered Drugs)

What is the Drug List? Also called a “formulary” by doctors and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription drugs used to treat the most common medical conditions.

The Health First Pharmacy and Therapeutics Committee (P&T), a panel of physicians and pharmacists, developed our Drug List and updates it regularly. The list includes quality drugs available to you at a reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The P&T Committee reviews and evaluates all available literature about a drug when updating the list.

About Tiers

Most covered prescription drugs will be categorized into one of five cost-sharing tiers. Drug costs vary widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Florida Hospital Care Advantage (FHCA) offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in the FHCA Summary of Benefits.

Prescriptions that exceed a 30-day supply will default to a 90-day supply copay (this does not apply to coinsurances). For coinsurances, you will always pay a percentage of the total cost after the applicable deductible is met.

Tier 1 (T1) - Includes low-cost preferred generic drugs.

Tier 2 (T2) - Includes higher-cost generic drugs.

Tier 3 (T3) - Includes preferred brand-name drugs and some higher-cost generic drugs.

Tier 4 (T4) - Includes higher-cost non-preferred brand-name drugs and generic drugs (some plans may be limited to a 30-day supply).

Tier 5 (T5 SP) - Includes higher-cost biologics or prescription drugs that require close monitoring for safety and efficacy. These medications must be obtained from Health First Family Pharmacy when possible and are limited to a 30-day supply.

Preventive Care (NCS) - Includes some select preventive products, prescription medications and specific over-the-counter (OTC) medications available to you at no cost-sharing ($0) when applicable conditions are met.

Generic drugs are prescription drugs that have the same active ingredients as brand drugs and are prescribed for the same reasons. When the patent expires on a brand name drug, the FDA permits new manufacturers to produce an equivalent of the brand name drug and make it available to the public. Generally, more than one manufacturer will produce generic versions, although often the same pharmaceutical firm that produces the brand name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug that is as safe and effective as the brand name drug.


What will my expenses be?

Every plan is different, and your financial obligation will vary based on your specific plan. You are responsible for any cost sharing your plan requires.

What is a deductible?

A deductible is a set dollar amount that you must pay each calendar year before your health plan starts paying. If your plan includes an integrated pharmacy deductible, it will accumulate with your in-network medical deductible. Refer to your plan documents to see when your deductible starts over for your plan.

What is the difference between a copayment and coinsurance?

Copayments and coinsurance are types of member cost sharing, and they represent the portion of covered prescription expenses members must pay. A copayment is a flat dollar amount while coinsurance is a percentage of the total allowable charges.

What does out-of-pocket maximum mean? The out-of-pocket maximum protects you from catastrophic medical and prescription drug expenses by limiting how much you have to pay during the benefit year. Your cost sharing for covered prescription drugs (deductible, coinsurance and copayment) all accumulate with your in-network medical out-of-pocket maximum. Refer to your plan documents to see when your out-of-pocket maximum starts over for your plan and to verify the specific cost sharing you have for specific tiers.

The Drug List is subject to change In order to continue to offer a safe and cost effective selection of prescription drugs, FHCA periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. Updated formularies are posted to the website as changes are made. The following list represents some of the most common scenarios in which changes to drug coverage will occur:

Throughout the year, new medications are approved by the FDA. It is the policy of FHCA that new drugs will be excluded for 6 months from the date of FDA approval, during which time the Health First P&T Committee can review the drug for safety and efficacy.

When a medication is withdrawn from the market due to safety reasons or if it becomes available over-the-counter (OTC). At the time that a medication on the HFP Drug List becomes available OTC, it may be excluded from coverage from that point forward.

When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to Tier 4 or removed from the formulary.

This formulary is current as of November 01, 2018. To get updated information about covered drugs, please visit our Web site at myFHCA.org or call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: The Plan requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. In order for the plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to FHCA documenting the medical necessity. These drugs are identified in the Drug List.

Step Therapy: In some cases, The Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 6.

http://www.myhfhp.org/


Quantity Limits: For some covered drugs, there is a maximum amount that will be covered by FHCA over a certain period of time. For example, FHCA covers 30 tablets every 30 days or 90 tablets every 90 days for TRADJENTA.

How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. FHCA helps you pay for your medications by sharing the cost with you and providing substantial discounts for covered medications. To help you manage your drug costs, here are some money-saving tips to consider:

Use generic medications whenever possible. Generic drugs are the chemical equivalent of brand name drugs and are just as effective in most cases. If you take generic drugs you will generally pay less. Talk to your doctor to see if switching to a generic equivalent of any brand-name drug you are taking is appropriate. Please see the list of drugs below to determine which generic drugs are included in lower cost-sharing tiers.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that FHCA does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by FHCA. When you receive the list, show it to your doctor and ask if switching to a covered medication is appropriate.

You can ask your physician to send FHCA information requesting we make an exception and cover your drug.

If FHCA approves the request for an exception to the formulary, the approved drug will be covered at the Tier 4 cost share unless the cost of the medication is greater than $500 per month, then it will be covered at the Tier 5 cost share.

Excluded drugs FHCA does not provide coverage for all drugs. In addition to the drugs marked “excluded” in this drug list, newly FDA approved drugs are not covered unless the Health First P&T Committee in its sole discretion approves these drugs for coverage. FHCA will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter.

The following are NOT covered by FHCA:

Compounded drugs Cosmetics or any drugs used for cosmetic purposes Diabetic supplies, blood glucose monitors and test strips other than those manufactured by Abbott under

the product name Freestyle, Precision, and test strips® Erectile dysfunction drugs (such as Viagra) Infertility drugs (such as Clomid) Some injectables (except insulin, Imitrex, and those requiring prior authorization) Most multivitamins and nutritional supplements (except prescription pre-natal vitamins and products

covered under the Preventive Care benefit) Nonprescription supplies or substances Over-the-counter (OTC) medications (except products covered under the Preventive Care benefit), or any

drug for which a similar over-the-counter version is available All new drugs approved by the FDA will be excluded from the preferred drug list/formulary unless the

Health First P&T Committee, in its sole discretion, decides to waive this exclusion for a particular drug. Support garments Syringes, needles, or other disposable supplies (except those used with insulin).


Preventive Care Medications: $0 Cost-share Medications and Products

The Affordable Care Act (ACA), commonly known as health care reform, was signed into federal law in 2010. The ACA requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network provider.

The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate.

The following products, prescription medications and specific over-the-counter (OTC) medications (notated in Tier NCS throughout this formulary) are available to our members at no ($0) cost-sharing when:

Prescribed by a health care professional (all prescription and OTC medications will require a prescription)

Age and/or gender appropriate

This list will be reviewed periodically and is subject to change.

Medicine/Product Category and Who is Covered Examples of the Medicine/Product Covered

Aspirin Individuals < 60 years

Aspirin products < 325 MG

Fluoride Children age 6 months through 5 years

Fluoride Chewable Tablet 0.25 MG and 0.5 MG; Fluoride Drops 0.125 MG, 0.25 MG and 0.5 MG; Multivitamin W/ Fluoride Chewable 0.25 MG

and 0.5 MG; Multivitamin W/ Fluoride Drops 0.25 MG and 0.5

MG; Multivitamin W/ Fluoride Suspension 0.25 MG

and 0.5 MG

Folic Acid Women only through age 50 years

Folic Acid Tablet 0.4 MG and 0.8 MG; Prenatal Multivitamins W/ Folic Acid (0.4 MG

and 0.8 MG)

Vitamin D Supplements Adults > 65 years of age

Vitamin D 1,000 Units Or Less Per Dose Unit; Calcium With Vitamin D (1,000 Units Or Less

Per Dose Unit)

Immunizations The age of coverage varies based on the

vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention

Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and that meet the US Food and Drug Administration approved indications for age and/or gender limitations. Coverage also includes non-routine immunizations used to prevent other illnesses such as typhoid, yellow fever, and Japanese encephalitis.

Contraceptive Methods Women only, through age 50 years

Covered products include one or more Food and Drug Administration (FDA) approved 16 contraceptive methods available through the prescription drug benefit, including: Generic OTC spermicide and legend

diaphragms; Today® contraceptive sponge; Female condom;


Medicine/Product Category and Who is Covered Examples of the Medicine/Product Covered

Femcap®; Generic oral, transdermal and intramuscular

hormonal methods; Nuvaring®; Generic, OTC emergency contraceptives and

Ella®; The intrauterine systems Mirena® and

Paragard®; The intradermal agent, Nexplanon®

Primary Prevention of Breast Cancer For women > 35 years of age who meet

criteria Raloxifene is covered for only those who are

postmenopausal If you are 35 years of age or older and have

not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to prescribe one of these risk-reducing medications.

You or your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met.

Tamoxifen Raloxifene Soltamox (Liquid Tamoxifen)

Tobacco Cessation Adults 18 and older Must receive counseling and have prescription

from a health care provider Up to two, 3-month treatment courses are

covered at no cost each year (any additional treatment may be subject to a cost-share)

Zyban (Generic); Chantix; Nicotine Replacement Products

Medications used to prepare for Colonoscopy Adults > 50 and < 75 years of age Limit of 2 prescriptions per year

Generic products such as: Bisacodyl; Magnesium Citrate; Milk Of Magnesia; PEG 3350-Electrolyte

If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m.


Step Therapy Reference Table

Drug Name Drug that must be tried first

ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RELPAX,

ZOLMITRIPTAN, ZOLMITRIPTAN ODT, ZOMIG NASAL

Sumatriptan, rizatriptan in the last 180 days

FOSRENAL, RENAGEL, RENVELA calcium acetate 667 mg in the last 180 days

OXICONAXOLE ketoconazole AND clotrimazole topical products in

the last 180 days

ULORIC Allopurinol in the last 180 days

VIIBRYD

Trial of any two (2) of the following drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone,

venlafaxine in the last year

WELCHOL cholestyramine or colestipol in the last 180 days

SYMBICORT Advair in the last 180 days


Florida Hospital Care Advantage Formulary

The formulary provides coverage information about some of the drugs covered by FHCA. If you have trouble finding your drug in the list, turn to the Index that begins on page 102. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril).

The information in the Notes column tells you if FHCA has any special requirements for coverage of your drug.

Specialty Pharmacy (SP): Must be obtained from Health First Family Pharmacy and are limited to a 30-day supply. For members who reside outside the state of Florida, an exception will be considered to allow the medication to be filled at another pharmacy. Please contact Customer Service Department to initiate this process.

Prior Authorization (PA): FHCA requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FHCA before you fill your prescriptions. If you don't get approval, the drug will not be covered.

Quantity Limit (QL): Quantity Limits may also be listed. For example, “30 EA per 30 days” would mean your coverage of this drug is limited to 30 pills every 30 days. Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount unless an exception is requested by your physician and approved by FHCA.

Step Therapy (ST): In some cases, FHCA requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 6.

Maintenance Drug (MD): You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term conditions. **Some exceptions may apply (i.e. certain medications used for ADHD, asthma/COPD rescue, acute pain, and acute infections).

No Cost-Share (NCS): Select preventive products, prescription medications and specific over-the-counter (OTC) medications available to our members at no cost-sharing ($0) when applicable conditions are met.


You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name Tier Notes

ANALGESICS

acetaminophen-codeine oral solution 120 mg-12

mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg

/10 ml (10 ml), 300 mg-30 mg /12.5 ml

T3 QL (2700 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg T3 QL (240 EA per 30 days)

acetaminophen-codeine oral tablet 300-60 mg T3 QL (180 EA per 30 days)

almotriptan malate oral tablet 12.5 mg, 6.25 mg T4 ST; QL (18 EA per 30 days)

ASCOMP WITH CODEINE ORAL CAPSULE

30-50-325-40 MG T3

aspirin oral tablet 325 mg NCS MD

aspirin oral tablet,delayed release (dr/ec) 325 mg NCS MD

BAYER ASPIRIN ORAL TABLET 325 MG NCS

BUTALBITAL COMPOUND W/CODEINE

ORAL CAPSULE 30-50-325-40 MG T4 QL (180 EA per 30 days)

BUTALBITAL COMPOUND-CODEINE ORAL

CAPSULE 30-50-325-40 MG T4 QL (180 EA per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50-

300-40-30 mg, 50-325-40-30 mg T4 QL (180 EA per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg T4 QL (180 EA per 30 days)

butalbital-acetaminophen-caff oral capsule 50-

300-40 mg, 50-325-40 mg T4 QL (180 EA per 30 days)

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg T4 QL (180 EA per 30 days)

butalbital-aspirin-caffeine oral capsule 50-325-


butorphanol tartrate injection solution 1 mg/ml, 2

mg/ml T3

BUTRANS TRANSDERMAL PATCH

WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20

MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR

T3 QL (4 EA per 28 days)

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg T3 QL (180 EA per 30 days)

codeine-butalbital-asa-caff oral capsule 30-50-

325-40 mg T4 QL (180 EA per 30 days)

diclofenac potassium oral tablet 50 mg T2

dihydroergotamine injection solution 1 mg/ml T3




dihydroergotamine nasal spray,non-aerosol 0.5

mg/pump act. (4 mg/ml) T4

ELMIRON ORAL CAPSULE 100 MG T4

ENDOCET ORAL TABLET 10-325 MG T3 QL (180 EA per 30 days)

ENDOCET ORAL TABLET 2.5-325 MG, 5-325

MG, 7.5-325 MG T3 QL (240 EA per 30 days)

ERGOMAR SUBLINGUAL TABLET 2 MG T4

fentanyl citrate buccal lozenge on a handle 1,200

mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800

mcg

T5 (SP) PA; QL (120 EA per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr T3 QL (15 EA per 30 days)

frovatriptan oral tablet 2.5 mg T4 ST; QL (18 EA per 30 days)

hydrocodone-acetaminophen oral solution 7.5-

325 mg/15 ml T4 QL (2700 ML per 30 days)

hydrocodone-acetaminophen oral tablet 10-300

mg, 10-325 mg T3 QL (180 EA per 30 days)

hydrocodone-acetaminophen oral tablet 2.5-325

mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg T3 QL (240 EA per 30 days)

hydrocodone-acetaminophen oral tablet 7.5-325

mg T3 QL (84 EA per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg, 7.5-200 mg T3 QL (50 EA per 30 days)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg T3 QL (180 EA per 30 days)

ibuprofen-oxycodone oral tablet 400-5 mg T3 QL (28 EA per 30 days)

ketorolac oral tablet 10 mg T2

levorphanol tartrate oral tablet 2 mg T4 QL (180 EA per 30 days)

LITE COAT ASPIRIN ORAL TABLET 325 MG NCS

mefenamic acid oral capsule 250 mg T4

meperidine oral tablet 100 mg, 50 mg T3 QL (180 EA per 30 days)

methadone oral tablet 10 mg, 5 mg T3 QL (240 EA per 30 days)

MIGERGOT RECTAL SUPPOSITORY 2-100

MG T4 QL (20 EA per 28 days)

morphine concentrate oral solution 100 mg/5 ml

(20 mg/ml) T3 QL (600 ML per 30 days)

morphine concentrate oral syringe 20 mg/ml T3 QL (600 EA per 30 days)

morphine oral solution 10 mg/5 ml T3 QL (2700 ML per 30 days)

morphine oral solution 20 mg/5 ml (4 mg/ml) T3 QL (1350 ML per 30 days)

morphine oral tablet 15 mg, 30 mg T3 QL (180 EA per 30 days)




morphine oral tablet extended release 100 mg, 15

mg, 30 mg, 60 mg T3 QL (90 EA per 30 days)

morphine oral tablet extended release 200 mg T3 QL (60 EA per 30 days)

naratriptan oral tablet 1 mg, 2.5 mg T3 ST; QL (18 EA per 30 days)

NUCYNTA ER ORAL TABLET EXTENDED

RELEASE 12 HR 100 MG, 150 MG, 200 MG,

250 MG, 50 MG

T4 PA; QL (60 EA per 30 days)

NUCYNTA ORAL TABLET 100 MG, 50 MG,

75 MG T4 PA; QL (180 EA per 30 days)

OPANA ER ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG,

30 MG, 40 MG, 5 MG, 7.5 MG


oxycodone oral solution 5 mg/5 ml T4 QL (5400 ML per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg T3 QL (180 EA per 30 days)

oxycodone oral tablet 30 mg T3 QL (120 EA per 30 days)

oxycodone oral tablet 5 mg T3 QL (240 EA per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg T3 QL (180 EA per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325

mg, 5-325 mg, 7.5-325 mg T3 QL (240 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg T3 QL (360 EA per 30 days)

oxymorphone oral tablet 10 mg, 5 mg T4 QL (120 EA per 30 days)

oxymorphone oral tablet extended release 12 hr

10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg T4 QL (60 EA per 30 days)

pentazocine-naloxone oral tablet 50-0.5 mg T3

RELPAX ORAL TABLET 20 MG, 40 MG T4 ST; QL (18 EA per 30 days)

rizatriptan oral tablet 10 mg, 5 mg T2 QL (18 EA per 30 days)

rizatriptan oral tablet,disintegrating 10 mg, 5 mg T2 QL (18 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg,


sumatriptan succinate subcutaneous pen injector

6 mg/0.5 ml T4 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous solution 6

mg/0.5 ml T4 QL (8 ML per 30 days)

tramadol oral tablet 50 mg T3 QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr 100


tramadol oral tablet, er multiphase 24 hr 100 mg,

200 mg, 300 mg T4 QL (30 EA per 30 days)




tramadol-acetaminophen oral tablet 37.5-325 mg T3 QL (240 EA per 30 days)

XTAMPZA ER ORAL

CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5

MG, 18 MG, 27 MG, 36 MG, 9 MG


ZOHYDRO ER ORAL CAPSULE, ORAL

ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30

MG, 40 MG, 50 MG


zolmitriptan oral tablet 2.5 mg, 5 mg T4 ST; QL (18 EA per 30 days)

zolmitriptan oral tablet,disintegrating 2.5 mg, 5

mg T4 ST; QL (18 EA per 30 days)

ZOMIG NASAL SPRAY,NON-AEROSOL 2.5

MG, 5 MG T4 ST; QL (12 EA per 30 days)

ANESTHETICS

lidocaine hcl laryngotracheal solution 4 % T2

lidocaine hcl mucous membrane jelly 2 % T2

lidocaine hcl mucous membrane solution 2 %, 4

% (40 mg/ml) T2

lidocaine hcl topical cream 3 % T2

lidocaine hcl topical lotion 3 % T2

lidocaine topical adhesive patch,medicated 5 % T4 PA; QL (90 EA per 30 days)

lidocaine topical ointment 5 % T4 PA; QL (150 GM per 30 days)

LIDOCAINE VISCOUS MUCOUS

MEMBRANE SOLUTION 2 % T2

lidocaine-prilocaine topical cream 2.5-2.5 % T2

lidocaine-prilocaine topical kit 2.5-2.5 % T2

phenazopyridine oral tablet 100 mg, 200 mg T2

SYNERA TOPICAL PATCH, MEDICATED

SELF-HEATING 70-70 MG T4 PA

ANTIALLERGY

cromolyn oral concentrate 100 mg/5 ml T2

ANTIARTHRITICS

allopurinol oral tablet 100 mg, 300 mg T2 MD

celecoxib oral capsule 100 mg, 200 mg, 400 mg,

50 mg T3 MD; QL (60 EA per 30 days)

colchicine oral capsule 0.6 mg T3 MD

colchicine oral tablet 0.6 mg T3 MD

DEPEN TITRATABS ORAL TABLET 250 MG T5 (SP) MD

diclofenac sodium oral tablet extended release 24

hr 100 mg T2




diclofenac sodium oral tablet,delayed release

(dr/ec) 25 mg, 50 mg, 75 mg T2

etodolac oral capsule 200 mg, 300 mg T3 MD

etodolac oral tablet 400 mg, 500 mg T3 MD

etodolac oral tablet extended release 24 hr 400

mg, 500 mg, 600 mg T4 MD

fenoprofen oral tablet 600 mg T4

flurbiprofen oral tablet 100 mg T2

flurbiprofen oral tablet 50 mg T2 MD

ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 MD

indomethacin oral capsule 25 mg, 50 mg T2

ketoprofen oral capsule 50 mg, 75 mg T2

leflunomide oral tablet 10 mg, 20 mg T3 MD; QL (30 EA per 30 days)

meclofenamate oral capsule 100 mg T4

meclofenamate oral capsule 50 mg T4 MD

meloxicam oral suspension 7.5 mg/5 ml T2 MD

meloxicam oral tablet 15 mg, 7.5 mg T2 MD

nabumetone oral tablet 500 mg, 750 mg T2

naproxen oral tablet 250 mg, 375 mg, 500 mg T1 MD

naproxen oral tablet,delayed release (dr/ec) 375

mg, 500 mg T2 MD

OTEZLA ORAL TABLET 30 MG T5 (SP) PA; MD

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47), 10

MG (4)-20 MG (4)-30 MG(19)

T5 (SP) PA

oxaprozin oral tablet 600 mg T3

piroxicam oral capsule 10 mg, 20 mg T3

probenecid oral tablet 500 mg T2 MD

probenecid-colchicine oral tablet 500-0.5 mg T2 MD

RIDAURA ORAL CAPSULE 3 MG T5 (SP) MD

sulindac oral tablet 150 mg, 200 mg T2

tolmetin oral capsule 400 mg T3

tolmetin oral tablet 200 mg, 600 mg T3 MD

ULORIC ORAL TABLET 40 MG, 80 MG T4 ST; MD

XELJANZ ORAL TABLET 10 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

XELJANZ ORAL TABLET 5 MG T5 (SP) PA; MD




XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HR 11 MG T5 (SP) PA; MD

ANTIASTHMATICS

acetylcysteine solution 100 mg/ml (10 %), 200

mg/ml (20 %) T2

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE

T3 MD; QL (60 EA per 30 days)

ADVAIR HFA INHALATION HFA AEROSOL

INHALER 115-21 MCG/ACTUATION, 230-21

MCG/ACTUATION, 45-21 MCG/ACTUATION

T3 MD; QL (12 GM per 30 days)

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg

/3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

T2 MD

albuterol sulfate oral syrup 2 mg/5 ml T2 MD

albuterol sulfate oral tablet 2 mg, 4 mg T4 MD

aminophylline intravenous solution 250 mg/10 ml T2

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE 62.5-25 MCG/ACTUATION T3 MD

ARCAPTA NEOHALER INHALATION

CAPSULE, W/INHALATION DEVICE 75 MCG T4 MD

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION

T3 MD

ASMANEX HFA INHALATION HFA

AEROSOL INHALER 100 MCG/ACTUATION,

200 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED

110 MCG (30 DOSES), 220 MCG (120 DOSES),

220 MCG (30 DOSES), 220 MCG (60 DOSES)


ATROVENT HFA INHALATION HFA

AEROSOL INHALER 17 MCG/ACTUATION T4 MD; QL (26 GM per 30 days)

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE 100-25 MCG/DOSE, 200-25

MCG/DOSE

T3 MD

BROVANA INHALATION SOLUTION FOR

NEBULIZATION 15 MCG/2 ML T4 PA; MD

budesonide inhalation suspension for nebulization

0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml T4 MD

COMBIVENT RESPIMAT INHALATION

MIST 20-100 MCG/ACTUATION T3 MD; QL (8 GM per 30 days)




cromolyn inhalation solution for nebulization 20

mg/2 ml T2 MD

DULERA INHALATION HFA AEROSOL

INHALER 100-5 MCG/ACTUATION, 200-5

MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 50

MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 250 MCG/ACTUATION T3 MD; QL (240 EA per 30 days)

FLOVENT HFA INHALATION HFA





AEROSOL INHALER 44 MCG/ACTUATION T3 MD; QL (10.6 GM per 30 days)

ipratropium bromide inhalation solution 0.02 % T2 MD

ipratropium-albuterol inhalation solution for

nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml T2 MD

levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25

mg/0.5 ml, 1.25 mg/3 ml

T4 MD

metaproterenol oral syrup 10 mg/5 ml T2 MD

metaproterenol oral tablet 10 mg, 20 mg T3 MD

montelukast oral granules in packet 4 mg T2 MD

montelukast oral tablet 10 mg T2 MD; QL (30 EA per 30 days)

montelukast oral tablet,chewable 4 mg, 5 mg T2 MD; QL (30 EA per 30 days)

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE 50 MCG/DOSE T3 MD; QL (60 EA per 30 days)

SPIRIVA RESPIMAT INHALATION MIST

1.25 MCG/ACTUATION, 2.5

MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION

CAPSULE, W/INHALATION DEVICE 18 MCG T3 MD; QL (30 EA per 30 days)

STIOLTO RESPIMAT INHALATION MIST

2.5-2.5 MCG/ACTUATION T3 MD; QL (4 GM per 30 days)

STRIVERDI RESPIMAT INHALATION MIST

2.5 MCG/ACTUATION T3 MD




SYMBICORT INHALATION HFA AEROSOL

INHALER 160-4.5 MCG/ACTUATION, 80-4.5

MCG/ACTUATION

T3 ST; MD; QL (10.2 GM per 30

days)

terbutaline oral tablet 2.5 mg, 5 mg T2 MD

theophylline oral tablet extended release 12 hr

100 mg, 200 mg, 300 mg, 450 mg T2 MD

theophylline oral tablet extended release 400 mg,

600 mg T3

TRELEGY ELLIPTA INHALATION BLISTER

WITH DEVICE 100-62.5-25 MCG T4 PA; MD

VENTOLIN HFA INHALATION HFA


XOLAIR SUBCUTANEOUS RECON SOLN

150 MG T5 (SP) PA; MD

zafirlukast oral tablet 10 mg, 20 mg T3 MD; QL (60 EA per 30 days)

ZYFLO CR ORAL TABLET, ER

MULTIPHASE 12 HR 600 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

ZYFLO ORAL TABLET 600 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

ANTIBIOTICS

AK-POLY-BAC OPHTHALMIC (EYE)

OINTMENT 500-10,000 UNIT/GRAM T2

amoxicillin oral capsule 250 mg, 500 mg T1

amoxicillin oral suspension for reconstitution 125

mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml T1

amoxicillin oral tablet 500 mg, 875 mg T1

amoxicillin oral tablet,chewable 125 mg T2

amoxicillin oral tablet,chewable 250 mg T1

amoxicillin-pot clavulanate oral suspension for

reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,

600-42.9 mg/5 ml

T2

amoxicillin-pot clavulanate oral suspension for

reconstitution 250-62.5 mg/5 ml T3

amoxicillin-pot clavulanate oral tablet 250-125

mg T3

amoxicillin-pot clavulanate oral tablet 500-125

mg, 875-125 mg T2

amoxicillin-pot clavulanate oral tablet extended

release 12 hr 1,000-62.5 mg T3

amoxicillin-pot clavulanate oral tablet,chewable

200-28.5 mg, 400-57 mg T2

ampicillin oral capsule 250 mg, 500 mg T2




ampicillin oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml T3

AVAR TOPICAL CLEANSER 10-5 % (W/W) T4

AVAR-E GREEN TOPICAL CREAM 10-5 %

(W/W) T4

AVAR-E TOPICAL CREAM 10-5 % (W/W) T4

AZASITE OPHTHALMIC (EYE) DROPS 1 % T4

azithromycin oral packet 1 gram T2

azithromycin oral suspension for reconstitution

100 mg/5 ml, 200 mg/5 ml T2

azithromycin oral tablet 250 mg, 500 mg, 600 mg T1

bacitracin ophthalmic (eye) ointment 500

unit/gram T3

bacitracin-polymyxin b ophthalmic (eye) ointment

500-10,000 unit/gram T2

BACTROBAN NASAL NASAL OINTMENT 2

% T4

BENZAMYCINPAK TOPICAL GEL 3-5 % T4

BESIVANCE OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.6 % T4

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)

OINTMENT 10-0.2 % T3

CAYSTON INHALATION SOLUTION FOR

NEBULIZATION 75 MG/ML T5 (SP) PA

cefaclor oral capsule 250 mg, 500 mg T3

cefadroxil oral capsule 500 mg T2

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml T3

cefadroxil oral tablet 1 gram T3

cefazolin injection recon soln 1 gram, 300 g, 500

mg T2

cefdinir oral capsule 300 mg T2

cefdinir oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml T3

cefixime oral suspension for reconstitution 100

mg/5 ml, 200 mg/5 ml T4

cefpodoxime oral suspension for reconstitution

100 mg/5 ml, 50 mg/5 ml T3




cefpodoxime oral tablet 100 mg, 200 mg T3

cefprozil oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml T3

cefprozil oral tablet 250 mg, 500 mg T2

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION 125 MG/5 ML, 250 MG/5

ML

T4

ceftriaxone injection recon soln 1 gram, 10 gram,

2 gram, 250 mg, 500 mg T2

cefuroxime axetil oral tablet 250 mg, 500 mg T3

cefuroxime sodium injection recon soln 1.5 gram,

750 mg T2

cephalexin oral capsule 250 mg, 500 mg T1

cephalexin oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml T2

CILOXAN OPHTHALMIC (EYE) OINTMENT

0.3 % T3

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

0.2-1 % T4

CIPRODEX OTIC (EAR)

DROPS,SUSPENSION 0.3-0.1 % T3

ciprofloxacin (mixture) oral tablet, er multiphase

24 hr 1,000 mg, 500 mg T3

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % T1

ciprofloxacin hcl oral tablet 100 mg T4

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750

mg T1

ciprofloxacin hcl otic (ear) dropperette 0.2 % T2 QL (60 EA per 30 days)

ciprofloxacin oral suspension,microcapsule recon

250 mg/5 ml, 500 mg/5 ml T3

clarithromycin oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml T3

clarithromycin oral tablet 250 mg, 500 mg T3

clarithromycin oral tablet extended release 24 hr

500 mg T3

CLEOCIN VAGINAL SUPPOSITORY 100 MG T4

CLINDACIN ETZ TOPICAL SWAB 1 % T2

CLINDACIN P TOPICAL SWAB 1 % T2

clindamycin hcl oral capsule 150 mg, 300 mg T1




clindamycin palmitate hcl oral recon soln 75

mg/5 ml T3

clindamycin phosphate topical gel 1 % T3

clindamycin phosphate topical lotion 1 % T3

clindamycin phosphate topical solution 1 % T3

clindamycin phosphate topical swab 1 % T2

clindamycin phosphate vaginal cream 2 % T3

COLY-MYCIN S OTIC (EAR)

DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML T3

CORTISPORIN TOPICAL CREAM 3.5-10,000-

0.5 MG/G-UNIT/G-% T4

CORTISPORIN TOPICAL OINTMENT 1 % T4

CORTISPORIN-TC OTIC (EAR)

DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML T3

cycloserine oral capsule 250 mg T4

dapsone oral tablet 100 mg, 25 mg T3 MD

demeclocycline oral tablet 150 mg, 300 mg T3

dicloxacillin oral capsule 250 mg, 500 mg T2

DIFICID ORAL TABLET 200 MG T5 (SP) PA

doxycycline hyclate oral capsule 100 mg, 50 mg T3

doxycycline hyclate oral tablet 100 mg T3

doxycycline monohydrate oral capsule 100 mg,

50 mg T2

doxycycline monohydrate oral tablet 100 mg, 50

mg, 75 mg T3

E.E.S. 200 ORAL SUSPENSION FOR

RECONSTITUTION 200 MG/5 ML T4

E.E.S. 400 ORAL TABLET 400 MG T2

E.E.S. GRANULES ORAL SUSPENSION FOR

RECONSTITUTION 200 MG/5 ML T4

ERY PADS TOPICAL SWAB 2 % T3

ERY-TAB ORAL TABLET,DELAYED

RELEASE (DR/EC) 250 MG, 333 MG, 500 MG T3

ERYTHROCIN (AS STEARATE) ORAL

TABLET 250 MG T4

erythromycin ethylsuccinate oral tablet 400 mg T4

erythromycin ophthalmic (eye) ointment 5

mg/gram (0.5 %) T2




erythromycin oral capsule,delayed release(dr/ec)

250 mg T4

erythromycin oral tablet 250 mg, 500 mg T4

erythromycin with ethanol topical gel 2 % T2

erythromycin with ethanol topical solution 2 % T2

erythromycin with ethanol topical swab 2 % T2

erythromycin-benzoyl peroxide topical gel 3-5 % T4

ethambutol oral tablet 100 mg, 400 mg T3 MD

FIRVANQ ORAL RECON SOLN 25 MG/ML,

50 MG/ML T3

gatifloxacin ophthalmic (eye) drops 0.5 % T3

GENTAK OPHTHALMIC (EYE) OINTMENT

0.3 % (3 MG/GRAM) T2

gentamicin ophthalmic (eye) drops 0.3 % T2

gentamicin ophthalmic (eye) ointment 0.3 % (3

mg/gram) T2

gentamicin topical cream 0.1 % T2

gentamicin topical ointment 0.1 % T2

isoniazid oral solution 50 mg/5 ml T2 MD

isoniazid oral tablet 100 mg, 300 mg T2

levofloxacin ophthalmic (eye) drops 0.5 % T2

levofloxacin oral solution 250 mg/10 ml T4

levofloxacin oral tablet 250 mg, 500 mg, 750 mg T2

linezolid oral suspension for reconstitution 100

mg/5 ml T5 (SP) PA

linezolid oral tablet 600 mg T5 (SP) PA

methenamine hippurate oral tablet 1 gram T2

metronidazole oral tablet 250 mg, 500 mg T2

metronidazole vaginal gel 0.75 % T2

minocycline oral capsule 100 mg, 50 mg, 75 mg T2

MONUROL ORAL PACKET 3 GRAM T4

MOXEZA OPHTHALMIC (EYE) DROPS,

VISCOUS 0.5 % T3

mupirocin topical ointment 2 % T2

neomycin oral tablet 500 mg T2

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit/g-1% T2




neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit-unit/g T2

neomycin-polymyxin b-dexameth ophthalmic

(eye) drops,suspension 3.5mg/ml-10,000 unit/ml-

0.1 %

T2

neomycin-polymyxin b-dexameth ophthalmic

(eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % T2

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops 1.75 mg-10,000 unit-0.025mg/ml T2

neomycin-polymyxin-hc otic (ear)

drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% T2

neomycin-polymyxin-hc otic (ear) solution 3.5-

10,000-1 mg/ml-unit/ml-% T2

nitrofurantoin macrocrystal oral capsule 100 mg,

50 mg T2

nitrofurantoin monohyd/m-cryst oral capsule 100

mg T2

nitrofurantoin oral suspension 25 mg/5 ml T2

ofloxacin ophthalmic (eye) drops 0.3 % T2

ofloxacin oral tablet 400 mg T2

ofloxacin otic (ear) drops 0.3 % T4

penicillin v potassium oral recon soln 125 mg/5

ml, 250 mg/5 ml T2

penicillin v potassium oral tablet 250 mg, 500 mg T2

polymyxin b sulfate injection recon soln 500,000

unit T2

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops 10,000 unit- 1 mg/ml T2

PRIFTIN ORAL TABLET 150 MG T4

pyrazinamide oral tablet 500 mg T2

rifabutin oral capsule 150 mg T4

rifampin oral capsule 150 mg, 300 mg T2

ROSANIL TOPICAL CLEANSER 10-5 %

(W/W) T4

ROSULA CLEANSING CLOTHS TOPICAL

PADS, MEDICATED 10-5 % T4

silver sulfadiazine topical cream 1 % T2

SSD TOPICAL CREAM 1 % T2




SSS 10-5 TOPICAL CREAM 10-5 % (W/W) T4

SSS 10-5 TOPICAL FOAM 10-5 % T4

streptomycin intramuscular recon soln 1 gram T3

sulfacetamide sodium ophthalmic (eye) drops 10

% T2

sulfacetamide sodium ophthalmic (eye) ointment

10 % T2

sulfacetamide sodium-sulfur topical cleanser 10-2

%, 10-5 % (w/w), 9-4.5 %, 9.8-4.8 % T4

sulfacetamide sodium-sulfur topical cream 10-2

%, 10-5 % (w/w), 9.8-4.8 % T4

sulfacetamide sodium-sulfur topical foam 10-5 % T4

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v) T4

sulfacetamide sodium-sulfur topical pads,

medicated 10-4 % T4

sulfacetamide sodium-sulfur topical suspension

10-5 % T4

sulfacetamide sod-sulfur-urea topical cleanser

10-5-10 % T4

sulfadiazine oral tablet 500 mg T3

sulfamethoxazole-trimethoprim intravenous

solution 400-80 mg/5 ml T3

sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5 ml T2

sulfamethoxazole-trimethoprim oral tablet 400-80

mg, 800-160 mg T1

SULFAMYLON TOPICAL CREAM 85 MG/G T4

tetracycline oral capsule 250 mg, 500 mg T4

THALOMID ORAL CAPSULE 100 MG, 150

MG, 200 MG, 50 MG T5 (SP) PA; MD

THERMAZENE TOPICAL CREAM 1 % T2

TOBRADEX OPHTHALMIC (EYE)

OINTMENT 0.3-0.1 % T3

TOBRADEX ST OPHTHALMIC (EYE)


tobramycin in 0.225 % nacl inhalation solution

for nebulization 300 mg/5 ml T5 (SP) PA; MD

tobramycin ophthalmic (eye) drops 0.3 % T2




tobramycin-dexamethasone ophthalmic (eye)

drops,suspension 0.3-0.1 % T3

TRECATOR ORAL TABLET 250 MG T4

trimethoprim oral tablet 100 mg T2

vancomycin intravenous recon soln 1,000 mg, 500

mg T2

vancomycin oral capsule 125 mg, 250 mg T5 (SP) PA

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5

% T3

XIFAXAN ORAL TABLET 200 MG T5 (SP) PA; QL (9 EA per 30 days)

XIFAXAN ORAL TABLET 550 MG T5 (SP) PA; MD; QL (90 EA per 30 days)

ZYLET OPHTHALMIC (EYE)


ANTICOAGULANTS

ELIQUIS ORAL TABLET 2.5 MG, 5 MG T3 MD

ELIQUIS ORAL TABLETS,DOSE PACK 5 MG

(74 TABS) T3

enoxaparin subcutaneous solution 300 mg/3 ml T4 QL (24 ML per 30 days)

enoxaparin subcutaneous syringe 100 mg/ml, 150

mg/ml T4 QL (28 ML per 30 days)

enoxaparin subcutaneous syringe 120 mg/0.8 ml,

80 mg/0.8 ml T4 QL (22.4 ML per 30 days)

enoxaparin subcutaneous syringe 30 mg/0.3 ml T4 QL (8.4 ML per 30 days)



fondaparinux subcutaneous syringe 10 mg/0.8 ml T5 (SP) PA; QL (24 ML per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml T5 (SP) PA; QL (15 ML per 30 days)

fondaparinux subcutaneous syringe 5 mg/0.4 ml T5 (SP) PA; QL (12 ML per 30 days)

fondaparinux subcutaneous syringe 7.5 mg/0.6 ml T5 (SP) PA; QL (18 ML per 30 days)

heparin (porcine) injection solution 10,000

unit/ml, 20,000 unit/ml, 5,000 unit/ml T2

heparin, porcine (pf) injection solution 1,000

unit/ml T2

heparin, porcine (pf) injection syringe 5,000

unit/0.5 ml T2

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2

MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5

MG

T1 MD




PRADAXA ORAL CAPSULE 110 MG, 150

MG, 75 MG T3 MD

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg, 7.5 mg T1 MD

XARELTO ORAL TABLET 10 MG T3

XARELTO ORAL TABLET 15 MG, 20 MG T3 MD

XARELTO ORAL TABLETS,DOSE PACK 15

MG (42)- 20 MG (9) T3

ANTIDOTES

MOVANTIK ORAL TABLET 12.5 MG, 25 MG T4 PA

naloxone injection syringe 1 mg/ml T2

naltrexone oral tablet 50 mg T2

ANTIFUNGALS

caspofungin intravenous recon soln 50 mg, 70 mg T5 (SP) PA

CICLODAN TOPICAL SOLUTION 8 % T2

ciclopirox topical cream 0.77 % T3

ciclopirox topical gel 0.77 % T3

ciclopirox topical shampoo 1 % T3

ciclopirox topical solution 8 % T2

ciclopirox topical suspension 0.77 % T3

clotrimazole mucous membrane troche 10 mg T2

clotrimazole topical cream 1 % T2

clotrimazole topical solution 1 % T2

clotrimazole-betamethasone topical cream 1-0.05

% T2

clotrimazole-betamethasone topical lotion 1-0.05

% T3

econazole topical cream 1 % T4

ERTACZO TOPICAL CREAM 2 % T5 (SP) PA

fluconazole oral tablet 100 mg, 150 mg, 200 mg,

50 mg T2

flucytosine oral capsule 250 mg, 500 mg T5 (SP)

griseofulvin microsize oral suspension 125 mg/5

ml T2

GYNAZOLE-1 VAGINAL CREAM 2 % T4

itraconazole oral capsule 100 mg T4 PA; QL (120 EA per 30 days)

ketoconazole oral tablet 200 mg T2

ketoconazole topical cream 2 % T2




ketoconazole topical shampoo 2 % T2

MENTAX TOPICAL CREAM 1 % T3

naftifine topical cream 1 %, 2 % T4

NAFTIN TOPICAL GEL 1 % T4

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION 5 % T3

NOXAFIL INTRAVENOUS SOLUTION 300

MG/16.7 ML T5 (SP) PA

NOXAFIL ORAL SUSPENSION 200 MG/5 ML

(40 MG/ML) T5 (SP) PA

NOXAFIL ORAL TABLET,DELAYED

RELEASE (DR/EC) 100 MG T5 (SP) PA

nystatin oral suspension 100,000 unit/ml T2

nystatin oral tablet 500,000 unit T2

nystatin topical cream 100,000 unit/gram T2

nystatin topical ointment 100,000 unit/gram T2

nystatin topical powder 100,000 unit/gram T2

nystatin-triamcinolone topical cream 100,000-0.1

unit/g-% T4

nystatin-triamcinolone topical ointment 100,000-

0.1 unit/gram-% T4

NYSTOP TOPICAL POWDER 100,000

UNIT/GRAM T2

oxiconazole topical cream 1 % T4 ST

terbinafine hcl oral tablet 250 mg T2 QL (30 EA per 30 days)

terconazole vaginal cream 0.4 %, 0.8 % T4

terconazole vaginal suppository 80 mg T4

voriconazole oral suspension for reconstitution

200 mg/5 ml (40 mg/ml) T5 (SP) PA

voriconazole oral tablet 200 mg, 50 mg T5 (SP) PA

VUSION TOPICAL OINTMENT 0.25-15-81.35

% T4

ANTIHISTAMINE AND

DECONGESTANT COMBINATION

PROMETHAZINE VC ORAL SYRUP 6.25-5

MG/5 ML T3

promethazine-phenylephrine oral syrup 6.25-5

mg/5 ml T3




ANTIHISTAMINES

azelastine ophthalmic (eye) drops 0.05 % T2

BEPREVE OPHTHALMIC (EYE) DROPS 1.5

% T4

carbinoxamine maleate oral tablet 4 mg T3

clemastine oral tablet 2.68 mg T3

cyproheptadine oral tablet 4 mg T2

desloratadine oral tablet 5 mg T2 MD; QL (30 EA per 30 days)

diphenhydramine hcl injection solution 50 mg/ml T2

diphenhydramine hcl injection syringe 50 mg/ml T2

EMADINE OPHTHALMIC (EYE) DROPS 0.05

% T4

epinastine ophthalmic (eye) drops 0.05 % T3

hydroxyzine hcl intramuscular solution 25 mg/ml,

50 mg/ml T2

hydroxyzine hcl oral solution 10 mg/5 ml T2

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T2

hydroxyzine pamoate oral capsule 100 mg, 25

mg, 50 mg T2

LASTACAFT OPHTHALMIC (EYE) DROPS

0.25 % T4 QL (6 ML per 30 days)

levocetirizine oral solution 2.5 mg/5 ml T4 MD

levocetirizine oral tablet 5 mg T2 MD; QL (30 EA per 30 days)

olopatadine ophthalmic (eye) drops 0.1 % T3 QL (10 ML per 30 days)

PATADAY OPHTHALMIC (EYE) DROPS 0.2

% T3 QL (10 ML per 30 days)

PAZEO OPHTHALMIC (EYE) DROPS 0.7 % T3

promethazine injection solution 25 mg/ml, 50

mg/ml T3

promethazine injection syringe 25 mg/ml T3

promethazine oral syrup 6.25 mg/5 ml T3

promethazine oral tablet 12.5 mg, 25 mg, 50 mg T2

ANTIHYPERGLYCEMICS

acarbose oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (90 EA per 30 days)

BYDUREON BCISE SUBCUTANEOUS

AUTO-INJECTOR 2 MG/0.85 ML T3 MD; QL (3.4 ML per 28 days)

BYDUREON SUBCUTANEOUS PEN

INJECTOR 2 MG/0.65 ML T3 MD; QL (4 EA per 28 days)




BYDUREON SUBCUTANEOUS

SUSPENSION,EXTENDED REL RECON 2 MG T3 MD; QL (4 EA per 28 days)

BYETTA SUBCUTANEOUS PEN INJECTOR

10 MCG/DOSE(250 MCG/ML) 2.4 ML T3 MD; QL (2.4 ML per 28 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5

MCG/DOSE (250 MCG/ML) 1.2 ML T3 MD; QL (1.2 ML per 30 days)

chlorpropamide oral tablet 100 mg, 250 mg T2 MD

CYCLOSET ORAL TABLET 0.8 MG T4 PA; MD; QL (180 EA per 30 days)

FIASP FLEXTOUCH U-100 INSULIN

SUBCUTANEOUS INSULIN PEN 100

UNIT/ML (3 ML)

T3 MD; QL (60 ML per 30 days)

FIASP U-100 INSULIN SUBCUTANEOUS

SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)

glimepiride oral tablet 1 mg T1 MD; QL (240 EA per 30 days)



glipizide oral tablet 10 mg T1 MD; QL (120 EA per 30 days)

glipizide oral tablet 5 mg T1 MD; QL (240 EA per 30 days)

glipizide oral tablet extended release 24hr 10 mg,

2.5 mg, 5 mg T1 MD; QL (60 EA per 30 days)

glipizide-metformin oral tablet 2.5-250 mg T2 MD; QL (240 EA per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg T2 MD; QL (120 EA per 30 days)

glyburide micronized oral tablet 1.5 mg, 3 mg T2 MD; QL (120 EA per 30 days)

glyburide micronized oral tablet 6 mg T2 MD; QL (60 EA per 30 days)

glyburide oral tablet 1.25 mg T2 MD; QL (480 EA per 30 days)

glyburide oral tablet 2.5 mg T2 MD; QL (240 EA per 30 days)

glyburide oral tablet 5 mg T2 MD; QL (60 EA per 30 days)

glyburide-metformin oral tablet 1.25-250 mg T2 MD; QL (240 EA per 30 days)

glyburide-metformin oral tablet 2.5-500 mg, 5-


GLYXAMBI ORAL TABLET 10-5 MG, 25-5

MG T3 MD

HUMULIN R U-500 (CONC) INSULIN

SUBCUTANEOUS SOLUTION 500 UNIT/ML T5 (SP) MD; QL (20 ML per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG T3 MD; QL (30 EA per 30 days)

JENTADUETO ORAL TABLET 2.5-1,000 MG,

2.5-500 MG, 2.5-850 MG T3 MD; QL (60 EA per 30 days)




LANTUS SOLOSTAR U-100 INSULIN


UNIT/ML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS


LEVEMIR FLEXTOUCH U-100 INSULN


UNIT/ML (3 ML)


LEVEMIR U-100 INSULIN SUBCUTANEOUS


metformin oral tablet 1,000 mg T1 MD; QL (60 EA per 30 days)

metformin oral tablet 500 mg T1 MD; QL (150 EA per 30 days)

metformin oral tablet 850 mg T1 MD; QL (90 EA per 30 days)

metformin oral tablet extended release 24 hr 500


metformin oral tablet extended release 24 hr 750


miglitol oral tablet 100 mg, 25 mg, 50 mg T4 MD; QL (90 EA per 30 days)

nateglinide oral tablet 120 mg, 60 mg T3 MD; QL (90 EA per 30 days)

NOVOLIN 70/30 U-100 INSULIN

SUBCUTANEOUS SUSPENSION 100

UNIT/ML (70-30)


NOVOLIN N NPH U-100 INSULIN

SUBCUTANEOUS SUSPENSION 100

UNIT/ML


NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)

NOVOLOG FLEXPEN U-100 INSULIN


UNIT/ML


NOVOLOG MIX 70-30 U-100 INSULN

SUBCUTANEOUS SOLUTION 100 UNIT/ML

(70-30)


NOVOLOG MIX 70-30FLEXPEN U-100


UNIT/ML (70-30)


NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE 100 UNIT/ML T3 MD; QL (60 ML per 30 days)

NOVOLOG U-100 INSULIN ASPART

SUBCUTANEOUS SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG(2 MG/1.5 ML) T3 MD; QL (1.5 ML per 28 days)




OZEMPIC SUBCUTANEOUS PEN INJECTOR

1 MG/0.75 ML (2 MG/1.5 ML) T3 MD; QL (3 ML per 28 days)

pioglitazone oral tablet 15 mg, 30 mg, 45 mg T2 MD; QL (30 EA per 30 days)

pioglitazone-glimepiride oral tablet 30-2 mg, 30-


pioglitazone-metformin oral tablet 15-500 mg,

15-850 mg T3 MD; QL (90 EA per 30 days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg T2 MD; QL (90 EA per 30 days)

SEGLUROMET ORAL TABLET 2.5-1,000 MG,

2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG T3 MD; QL (60 EA per 30 days)

STEGLATRO ORAL TABLET 15 MG, 5 MG T3 MD; QL (30 EA per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR 2,700 MCG/2.7 ML T5 (SP) MD

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR 1,500 MCG/1.5 ML T5 (SP) MD

SYNJARDY ORAL TABLET 12.5-1,000 MG,

12.5-500 MG, 5-1,000 MG, 5-500 MG T3 MD

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,

25-1,000 MG, 5-1,000 MG

T3 MD

TANZEUM SUBCUTANEOUS PEN

INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML T3 MD; QL (4 EA per 28 days)

TOUJEO SOLOSTAR U-300 INSULIN


UNIT/ML (1.5 ML)


TRADJENTA ORAL TABLET 5 MG T3 MD; QL (30 EA per 30 days)

TRESIBA FLEXTOUCH U-100


UNIT/ML (3 ML)




UNIT/ML (3 ML)


VICTOZA 2-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) T3 MD; QL (9 ML per 30 days)

VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) T3 MD; QL (9 ML per 30 days)

ANTIINFECTIVES/MISCELLANEOU

S

ALBENZA ORAL TABLET 200 MG T5 (SP)




ALINIA ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML T4 PA

ALINIA ORAL TABLET 500 MG T4 PA

atovaquone oral suspension 750 mg/5 ml T5 (SP)

atovaquone-proguanil oral tablet 250-100 mg,

62.5-25 mg T4

benznidazole oral tablet 100 mg, 12.5 mg T2 PA

BILTRICIDE ORAL TABLET 600 MG T4

chloroquine phosphate oral tablet 250 mg, 500

mg T2 MD

COARTEM ORAL TABLET 20-120 MG T4

DARAPRIM ORAL TABLET 25 MG T3

hydroxychloroquine oral tablet 200 mg T3 MD

ivermectin oral tablet 3 mg T2

mefloquine oral tablet 250 mg T2

paromomycin oral capsule 250 mg T3

PENTAM INJECTION RECON SOLN 300 MG T5 (SP) PA

primaquine oral tablet 26.3 mg T3 QL (30 EA per 30 days)

quinine sulfate oral capsule 324 mg T4

ANTIINFLAM.TUMOR NECROSIS

FACTOR INHIBITING AGENTS

ENBREL SUBCUTANEOUS RECON SOLN 25

MG (1 ML) T5 (SP) PA; MD; QL (8 EA per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5ML (0.51) T5 (SP) PA; MD; QL (4 ML per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 50

MG/ML (0.98 ML) T5 (SP) PA; MD; QL (8 ML per 28 days)

ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR 50 MG/ML (0.98 ML) T5 (SP) PA; MD; QL (8 ML per 28 days)

HUMIRA PEDIATRIC CROHN'S START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML

T5 (SP) PA; MD; QL (3 EA per 180 days)

HUMIRA PEN CROHN'S-UC-HS START

SUBCUTANEOUS PEN INJECTOR KIT 40

MG/0.8 ML


HUMIRA PEN PSORIASIS-UVEITIS

SUBCUTANEOUS PEN INJECTOR KIT 40

MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.8 ML T5 (SP) PA; MD; QL (4 EA per 28 days)




HUMIRA SUBCUTANEOUS SYRINGE KIT 10

MG/0.2 ML, 20 MG/0.4 ML T5 (SP) PA; MD; QL (2 EA per 28 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 40

MG/0.8 ML T5 (SP) PA; MD; QL (4 EA per 28 days)

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION

100 MCG/0.5 ML T5 (SP) PA

ADRUCIL INTRAVENOUS SOLUTION 500

MG/10 ML T3

AFINITOR ORAL TABLET 10 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5

MG T5 (SP) PA; MD

ALIQOPA INTRAVENOUS RECON SOLN 60

MG T5 (SP) PA; MD

anastrozole oral tablet 1 mg T2 MD; QL (30 EA per 30 days)

BAVENCIO INTRAVENOUS SOLUTION 20

MG/ML T5 (SP) PA; MD

bexarotene oral capsule 75 mg T5 (SP) PA; MD

bicalutamide oral tablet 50 mg T2 MD

BUSULFEX INTRAVENOUS SOLUTION 60

MG/10 ML T5 (SP) PA

CALQUENCE ORAL CAPSULE 100 MG T5 (SP) PA; MD

capecitabine oral tablet 150 mg, 500 mg T5 (SP) PA

CAPRELSA ORAL TABLET 100 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

cyclophosphamide oral capsule 25 mg, 50 mg T4

diclofenac sodium topical gel 3 % T5 (SP) PA

EMCYT ORAL CAPSULE 140 MG T5 (SP) PA

ERLEADA ORAL TABLET 60 MG T5 (SP) PA; MD

exemestane oral tablet 25 mg T4 MD

FARESTON ORAL TABLET 60 MG T5 (SP) MD; QL (30 EA per 30 days)

fluorouracil intravenous solution 1 gram/20 ml,

2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml T3

fluorouracil topical cream 5 % T3

fluorouracil topical solution 2 %, 5 % T3

flutamide oral capsule 125 mg T3 MD

GLEEVEC ORAL TABLET 100 MG, 400 MG T5 (SP) PA; MD




HEXALEN ORAL CAPSULE 50 MG T5 (SP) PA

hydroxyurea oral capsule 500 mg T2 MD

IBRANCE ORAL CAPSULE 100 MG, 125 MG,

75 MG T5 (SP) PA; MD; QL (21 EA per 28 days)

IDHIFA ORAL TABLET 100 MG, 50 MG T5 (SP) PA; MD

imatinib oral tablet 100 mg T5 (SP) PA; MD; QL (180 EA per 30 days)

imatinib oral tablet 400 mg T5 (SP) PA; MD; QL (60 EA per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG T5 (SP) PA; QL (120 EA per 30 days)

IMBRUVICA ORAL CAPSULE 70 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

IMBRUVICA ORAL TABLET 140 MG, 280

MG, 420 MG, 560 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

INTRON A INJECTION RECON SOLN 10

MILLION UNIT (1 ML), 18 MILLION UNIT (1

ML), 50 MILLION UNIT (1 ML)

T5 (SP) PA

INTRON A INJECTION SOLUTION 10

MILLION UNIT/ML, 6 MILLION UNIT/ML T5 (SP) PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20

MG, 5 MG T5 (SP) PA; MD

JAKAFI ORAL TABLET 25 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG, 400

MG/DAY(200 MG X 2)-2.5 MG, 600

MG/DAY(200 MG X 3)-2.5 MG

T5 (SP) PA; MD

KISQALI ORAL TABLET 200 MG/DAY (200

MG X 1), 400 MG/DAY (200 MG X 2), 600

MG/DAY (200 MG X 3)

T5 (SP) PA; MD

LENVIMA ORAL CAPSULE 10 MG/DAY (10

MG X 1), 12 MG/DAY (4 MG X 3), 14

MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY

(10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X

2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8

MG/DAY (4 MG X 2)

T5 (SP) PA; MD

letrozole oral tablet 2.5 mg T2 MD

LEUKERAN ORAL TABLET 2 MG T4

leuprolide subcutaneous kit 1 mg/0.2 ml T5 (SP) PA

leuprolide subcutaneous solution 1 mg/0.2 ml T5 (SP) PA; MD

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 22.5 MG T5 (SP) PA; MD; QL (1 EA per 84 days)


INTRAMUSCULAR SYRINGE KIT 30 MG T5 (SP) PA; QL (1 EA per 112 days)





INTRAMUSCULAR SYRINGE KIT 45 MG T5 (SP) PA; QL (1 EA per 168 days)

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 7.5 MG T5 (SP) PA; QL (1 EA per 28 days)

LYNPARZA ORAL CAPSULE 50 MG T5 (SP) PA

LYNPARZA ORAL TABLET 100 MG, 150 MG T5 (SP) PA; MD

LYSODREN ORAL TABLET 500 MG T3

MATULANE ORAL CAPSULE 50 MG T5 (SP)

megestrol oral tablet 20 mg, 40 mg T2

melphalan hcl intravenous recon soln 50 mg T5 (SP)

mercaptopurine oral tablet 50 mg T3 MD

methotrexate sodium (pf) injection recon soln 1

gram T2

methotrexate sodium (pf) injection solution 25

mg/ml T2

methotrexate sodium injection solution 25 mg/ml T2

methotrexate sodium oral tablet 2.5 mg T2 MD

NERLYNX ORAL TABLET 40 MG T5 (SP) PA; MD

NEXAVAR ORAL TABLET 200 MG T5 (SP) PA; QL (120 EA per 30 days)

NILANDRON ORAL TABLET 150 MG T5 (SP) MD

PANRETIN TOPICAL GEL 0.1 % T5 (SP) PA

PICATO TOPICAL GEL 0.015 %, 0.05 % T5 (SP) PA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3

MG, 4 MG T5 (SP) PA; MD

POTELIGEO INTRAVENOUS SOLUTION 4


REVLIMID ORAL CAPSULE 10 MG, 15 MG,

2.5 MG, 20 MG, 25 MG, 5 MG T5 (SP) PA; MD

SPRYCEL ORAL TABLET 100 MG, 140 MG,

20 MG, 50 MG, 70 MG, 80 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG,

37.5 MG, 50 MG T5 (SP) PA; QL (30 EA per 30 days)

TABLOID ORAL TABLET 40 MG T5 (SP) PA

tamoxifen oral tablet 10 mg, 20 mg T2

PA; PA only applies to NCS

eligibility as part of Preventive

Services Coverage (Breast Cancer

Prevention); MD




TARCEVA ORAL TABLET 100 MG, 150 MG,

25 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

TARGRETIN TOPICAL GEL 1 % T5 (SP) PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

temozolomide oral capsule 100 mg, 140 mg, 180

mg, 20 mg, 250 mg, 5 mg T5 (SP) PA

tretinoin (chemotherapy) oral capsule 10 mg T5 (SP) PA

TYKERB ORAL TABLET 250 MG T5 (SP) PA; MD; QL (180 EA per 30 days)

VERZENIO ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG T5 (SP) PA; MD

VOTRIENT ORAL TABLET 200 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

VYXEOS INTRAVENOUS RECON SOLN 44-

100 MG T5 (SP) PA

XALKORI ORAL CAPSULE 200 MG, 250 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

XTANDI ORAL CAPSULE 40 MG T5 (SP) PA; SP; MD; QL (120 EA per 30

days)

YONSA ORAL TABLET 125 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

ZOLINZA ORAL CAPSULE 100 MG T5 (SP) PA; QL (120 EA per 30 days)

ZYTIGA ORAL TABLET 250 MG T5 (SP) PA; SP; MD; QL (120 EA per 30

days)

ZYTIGA ORAL TABLET 500 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

ANTI-OBESITY DRUGS

phentermine oral capsule 15 mg T2 QL (180 EA per 365 days)

phentermine oral capsule 30 mg, 37.5 mg T2 QL (90 EA per 365 days)

phentermine oral tablet 37.5 mg T2 QL (90 EA per 365 days)

ANTIPARKINSON DRUGS

amantadine hcl oral capsule 100 mg T3 MD

amantadine hcl oral tablet 100 mg T3 MD

AZILECT ORAL TABLET 0.5 MG, 1 MG T4 MD

benztropine oral tablet 0.5 mg, 1 mg, 2 mg T2 MD

bromocriptine oral capsule 5 mg T4 MD

bromocriptine oral tablet 2.5 mg T4 MD

carbidopa oral tablet 25 mg T4 MD

carbidopa-levodopa oral tablet 10-100 mg, 25-

100 mg, 25-250 mg T2 MD

carbidopa-levodopa oral tablet extended release

25-100 mg, 50-200 mg T2 MD

entacapone oral tablet 200 mg T4 MD; QL (240 EA per 30 days)




pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5

mg, 0.75 mg, 1 mg, 1.5 mg T2 MD

pramipexole oral tablet extended release 24 hr

0.375 mg, 0.75 mg, 1.5 mg, 3 mg, 4.5 mg T5 (SP) PA; MD

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg, 5 mg T2 MD

ropinirole oral tablet extended release 24 hr 12

mg, 2 mg, 4 mg, 6 mg, 8 mg T4 MD

selegiline hcl oral capsule 5 mg T2 MD

selegiline hcl oral tablet 5 mg T2 MD

tolcapone oral tablet 100 mg T5 (SP) MD

trihexyphenidyl oral elixir 0.4 mg/ml T2 MD

trihexyphenidyl oral tablet 2 mg, 5 mg T2 MD

ANTIPLATELET DRUGS

anagrelide oral capsule 0.5 mg, 1 mg T3 MD

ASPIRIN LOW-STRENGTH ORAL

TABLET,CHEWABLE 81 MG NCS

aspirin oral tablet,chewable 81 mg NCS MD

aspirin oral tablet,delayed release (dr/ec) 81 mg NCS MD

aspirin-dipyridamole oral capsule, er multiphase

12 hr 25-200 mg T4 MD

BRILINTA ORAL TABLET 60 MG, 90 MG T3 MD

CHILD ASPIRIN ORAL TABLET,CHEWABLE

81 MG NCS

CHILDREN'S ASPIRIN ORAL

TABLET,CHEWABLE 81 MG NCS MD

cilostazol oral tablet 100 mg, 50 mg T2 MD

clopidogrel oral tablet 75 mg T2 MD; QL (30 EA per 30 days)

dipyridamole oral tablet 25 mg, 50 mg, 75 mg T2 MD

EFFIENT ORAL TABLET 10 MG, 5 MG T3 MD

ENTERIC COATED ASPIRIN ORAL

TABLET,DELAYED RELEASE (DR/EC) 81

MG

NCS MD

ticlopidine oral tablet 250 mg T2

ZONTIVITY ORAL TABLET 2.08 MG T3 MD

ANTIVIRALS

abacavir oral solution 20 mg/ml T5 (SP) MD




abacavir oral tablet 300 mg T3 PA; MD

abacavir-lamivudine oral tablet 600-300 mg T5 (SP) PA; MD

abacavir-lamivudine-zidovudine oral tablet 300-

150-300 mg T5 (SP) PA; MD

acyclovir oral capsule 200 mg T2 MD

acyclovir oral suspension 200 mg/5 ml T3 MD

acyclovir oral tablet 400 mg, 800 mg T2 MD

acyclovir topical ointment 5 % T4 QL (60 GM per 30 days)

adefovir oral tablet 10 mg T5 (SP) PA

APTIVUS ORAL CAPSULE 250 MG T5 (SP) PA; MD

APTIVUS ORAL SOLUTION 100 MG/ML T5 (SP) PA; MD

atazanavir oral capsule 150 mg, 200 mg, 300 mg T3 MD

ATRIPLA ORAL TABLET 600-200-300 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

BARACLUDE ORAL SOLUTION 0.05 MG/ML T5 (SP) PA; MD

BIKTARVY ORAL TABLET 50-200-25 MG T5 (SP) MD; QL (30 EA per 30 days)

CIMDUO ORAL TABLET 300-300 MG T5 (SP) MD; QL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG T5 (SP) MD

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T3 PA; MD

DESCOVY ORAL TABLET 200-25 MG T5 (SP) PA; MD

didanosine oral capsule,delayed release(dr/ec)

125 mg, 200 mg, 250 mg, 400 mg T3 PA; MD

EDURANT ORAL TABLET 25 MG T5 (SP) PA; MD

efavirenz oral capsule 200 mg, 50 mg T4 MD

efavirenz oral tablet 600 mg T4 MD

EMTRIVA ORAL CAPSULE 200 MG T3 PA; MD

EMTRIVA ORAL SOLUTION 10 MG/ML T3 PA; MD

entecavir oral tablet 0.5 mg, 1 mg T5 (SP) PA; MD; QL (30 EA per 30 days)

EPCLUSA ORAL TABLET 400-100 MG T5 (SP) PA

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML

(5 MG/ML) T4 PA; MD

EPZICOM ORAL TABLET 600-300 MG T5 (SP) PA; MD

EVOTAZ ORAL TABLET 300-150 MG T5 (SP) PA; MD

famciclovir oral tablet 125 mg, 250 mg, 500 mg T3 MD

fosamprenavir oral tablet 700 mg T5 (SP) PA; MD

FUZEON SUBCUTANEOUS RECON SOLN 90

MG T5 (SP) PA; MD

GENVOYA ORAL TABLET 150-150-200-10

MG T5 (SP) PA; MD




HARVONI ORAL TABLET 90-400 MG T5 (SP) PA

INTELENCE ORAL TABLET 100 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

INTELENCE ORAL TABLET 200 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

INTELENCE ORAL TABLET 25 MG T4 PA; MD

INVIRASE ORAL CAPSULE 200 MG T5 (SP) PA; MD

INVIRASE ORAL TABLET 500 MG T5 (SP) PA; MD

ISENTRESS HD ORAL TABLET 600 MG T5 (SP) PA; MD

ISENTRESS ORAL POWDER IN PACKET 100

MG T5 (SP) PA; MD; QL (180 EA per 30 days)

ISENTRESS ORAL TABLET 400 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 100

MG, 25 MG T5 (SP) PA; MD; QL (180 EA per 30 days)

JULUCA ORAL TABLET 50-25 MG T5 (SP) MD; QL (30 EA per 30 days)

KALETRA ORAL SOLUTION 400-100 MG/5

ML T4 PA; MD

KALETRA ORAL TABLET 100-25 MG T4 PA; MD

KALETRA ORAL TABLET 200-50 MG T5 (SP) PA; MD

lamivudine oral solution 10 mg/ml T3 PA; MD

lamivudine oral tablet 100 mg T4 PA; MD

lamivudine oral tablet 150 mg, 300 mg T3 PA; MD

lamivudine-zidovudine oral tablet 150-300 mg T4 MD

LEXIVA ORAL SUSPENSION 50 MG/ML T4 PA; MD

LEXIVA ORAL TABLET 700 MG T5 (SP) PA; MD

MAVYRET ORAL TABLET 100-40 MG T5 (SP) PA

MODERIBA ORAL TABLET 200 MG T4 PA

nevirapine oral suspension 50 mg/5 ml T3 PA; MD

nevirapine oral tablet 200 mg T3 PA; MD

nevirapine oral tablet extended release 24 hr 100

mg, 400 mg T4 PA; MD

NORVIR ORAL CAPSULE 100 MG T4 PA; MD

NORVIR ORAL POWDER IN PACKET 100

MG T4 MD

NORVIR ORAL SOLUTION 80 MG/ML T4 PA; MD

NORVIR ORAL TABLET 100 MG T4 PA; MD

ODEFSEY ORAL TABLET 200-25-25 MG T5 (SP) PA; MD

oseltamivir oral capsule 30 mg, 45 mg, 75 mg T3 QL (60 EA per 30 days)




PEGINTRON REDIPEN SUBCUTANEOUS

PEN INJECTOR KIT 120 MCG/0.5 ML, 150

MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5

ML

T5 (SP) PA

PEGINTRON SUBCUTANEOUS KIT 120

MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5

ML, 80 MCG/0.5 ML

T5 (SP) PA

PREZCOBIX ORAL TABLET 800-150 MG-MG T5 (SP) PA; MD

PREZISTA ORAL SUSPENSION 100 MG/ML T4 PA; MD

PREZISTA ORAL TABLET 150 MG T4 PA; MD

PREZISTA ORAL TABLET 300 MG, 400 MG T5 (SP) PA

PREZISTA ORAL TABLET 600 MG, 800 MG T5 (SP) PA; MD

PREZISTA ORAL TABLET 75 MG T3 PA; MD

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE 5 MG/ACTUATION T5 (SP) PA; QL (60 EA per 180 days)

RESCRIPTOR ORAL TABLET 200 MG T3 PA; MD

RESCRIPTOR ORAL TABLET, DISPERSIBLE

100 MG T3 PA; MD

RETROVIR INTRAVENOUS SOLUTION 10

MG/ML T4 PA

REYATAZ ORAL CAPSULE 100 MG T5 (SP) PA

REYATAZ ORAL CAPSULE 150 MG, 200 MG,


REYATAZ ORAL POWDER IN PACKET 50

MG T5 (SP) PA; MD

RIBASPHERE ORAL CAPSULE 200 MG T4 PA

RIBASPHERE ORAL TABLET 200 MG T4 PA

ribavirin oral capsule 200 mg T4 PA

ribavirin oral tablet 200 mg T4 PA

rimantadine oral tablet 100 mg T2

ritonavir oral tablet 100 mg T4 MD

SELZENTRY ORAL TABLET 150 MG, 25 MG,

300 MG, 75 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

SOVALDI ORAL TABLET 400 MG T5 (SP) PA; MD

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40

mg T3 PA; MD

stavudine oral recon soln 1 mg/ml T3 PA

STRIBILD ORAL TABLET 150-150-200-300

MG T5 (SP) PA; MD

SUSTIVA ORAL CAPSULE 200 MG, 50 MG T4 PA; MD




SUSTIVA ORAL TABLET 600 MG T4 PA; MD

SYMFI LO ORAL TABLET 400-300-300 MG T5 (SP) MD; QL (30 EA per 30 days)

SYMFI ORAL TABLET 600-300-300 MG T5 (SP) MD; QL (30 EA per 30 days)

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75

MG T4 QL (60 EA per 30 days)

TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION 6 MG/ML T4

tenofovir disoproxil fumarate oral tablet 300 mg T5 (SP) PA; MD

TIVICAY ORAL TABLET 10 MG, 25 MG, 50

MG T5 (SP) PA; MD

trifluridine ophthalmic (eye) drops 1 % T3

TRIUMEQ ORAL TABLET 600-50-300 MG T5 (SP) PA; MD

TRUVADA ORAL TABLET 100-150 MG, 133-

200 MG, 167-250 MG, 200-300 MG T5 (SP) PA; MD

TYZEKA ORAL TABLET 600 MG T5 (SP) PA

valacyclovir oral tablet 1 gram, 500 mg T2 MD; QL (90 EA per 30 days)

VALCYTE ORAL RECON SOLN 50 MG/ML T5 (SP) PA; MD

valganciclovir oral tablet 450 mg T5 (SP) PA; MD

VEREGEN TOPICAL OINTMENT 15 % T3

VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL) T4 PA; MD

VIDEX 4 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL) T4 PA; MD

VIRACEPT ORAL TABLET 250 MG T4 PA; MD

VIRACEPT ORAL TABLET 625 MG T5 (SP) PA; MD

VIREAD ORAL POWDER 40 MG/SCOOP (40

MG/GRAM) T5 (SP) PA; MD

VIREAD ORAL TABLET 150 MG, 200 MG,

250 MG, 300 MG T5 (SP) PA; MD

VITEKTA ORAL TABLET 150 MG, 85 MG T5 (SP) PA; QL (30 EA per 30 days)

ZIAGEN ORAL SOLUTION 20 MG/ML T3 PA; MD

zidovudine oral capsule 100 mg T3 PA; MD

zidovudine oral syrup 10 mg/ml T3 PA; MD

zidovudine oral tablet 300 mg T3 PA; MD

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % T4

AUTONOMIC DRUGS




ADDERALL XR ORAL

CAPSULE,EXTENDED RELEASE 24HR 10

MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG


bethanechol chloride oral tablet 10 mg, 25 mg, 5

mg, 50 mg T3

dextroamphetamine oral capsule, extended

release 10 mg T4 MD; QL (180 EA per 30 days)





dextroamphetamine oral tablet 10 mg, 5 mg T3 MD; QL (180 EA per 30 days)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15 mg, 20

mg, 25 mg, 30 mg, 5 mg


dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15 mg, 20

mg, 25 mg, 30 mg, 5 mg


dextroamphetamine-amphetamine oral tablet 10

mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg T2 MD; QL (90 EA per 30 days)

dextroamphetamine-amphetamine oral tablet 30


donepezil oral tablet 10 mg, 5 mg T2 MD; QL (30 EA per 30 days)

epinephrine injection solution 1 mg/ml T4

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

0.3 MG/0.3 ML T3 QL (4 EA per 30 days)

EPIPEN INJECTION AUTO-INJECTOR 0.3

MG/0.3 ML T3 QL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-

INJECTOR 0.15 MG/0.3 ML T3 QL (4 EA per 30 days)

EPIPEN JR INJECTION AUTO-INJECTOR 0.15

MG/0.3 ML T3 QL (4 EA per 30 days)

galantamine oral capsule,ext rel. pellets 24 hr 16

mg, 24 mg, 8 mg T3 MD; QL (30 EA per 30 days)

galantamine oral solution 4 mg/ml T4 MD; QL (600 ML per 30 days)

galantamine oral tablet 12 mg, 4 mg, 8 mg T3 MD; QL (60 EA per 30 days)

guanidine oral tablet 125 mg T2

methamphetamine oral tablet 5 mg T3 MD; QL (90 EA per 30 days)

midodrine oral tablet 10 mg, 2.5 mg, 5 mg T3

pilocarpine hcl oral tablet 5 mg, 7.5 mg T3 MD

pyridostigmine bromide oral tablet 60 mg T3 MD




pyridostigmine bromide oral tablet extended

release 180 mg T4 MD

rivastigmine tartrate oral capsule 1.5 mg, 3 mg,


BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML NCS

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION 2 LF-(2.5-

5-3-5 MCG)-5LF/0.5 ML

NCS

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5

MCG)-5LF/0.5 ML

NCS

AFLURIA 2018-2019 (PF) INTRAMUSCULAR

SYRINGE 45 MCG (15 MCG X 3)/0.5 ML NCS

AFLURIA 2018-2019 INTRAMUSCULAR

SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML NCS

AFLURIA QUAD 2018-2019 (PF)

INTRAMUSCULAR SYRINGE 60 MCG/0.5

ML

NCS

AFLURIA QUAD 2018-2019

INTRAMUSCULAR SUSPENSION 60

MCG/0.5 ML

NCS

bcg vaccine, live (pf) percutaneous suspension for

reconstitution 50 mg NCS

BEXSERO INTRAMUSCULAR SYRINGE 50-

50-50-25 MCG/0.5 ML NCS

BIOTHRAX INTRAMUSCULAR

SUSPENSION 0.5 ML/DOSE NCS

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML NCS

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML NCS

CARIMUNE NF NANOFILTERED

INTRAVENOUS RECON SOLN 12 GRAM, 6

GRAM

T5 (SP) PA; MD

CERVARIX VACCINE (PF)

INTRAMUSCULAR SYRINGE 20-20 MCG/0.5

ML

NCS




COMVAX (PF) INTRAMUSCULAR

SUSPENSION 5-7.5-125 MCG/0.5 ML NCS

DAPTACEL (DTAP PEDIATRIC) (PF)

INTRAMUSCULAR SUSPENSION 15-10-5 LF-

MCG-LF/0.5ML

NCS

ENGERIX-B (PF) INTRAMUSCULAR

SUSPENSION 20 MCG/ML NCS

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE 20 MCG/ML NCS

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SUSPENSION 10

MCG/0.5 ML

NCS



ML

NCS

FLUAD 2018-2019 (65 YR UP)(PF)

INTRAMUSCULAR SYRINGE 45 MCG (15

MCG X 3)/0.5 ML

NCS

FLUARIX QUAD 2018-2019 (PF)


MCG X 4)/0.5 ML

NCS

FLUBLOK QUAD 2018-2019 (PF)


MCG X 4)/0.5 ML

NCS

FLUCELVAX QUAD 2018-2019 (PF)


MCG X 4)/0.5 ML

NCS

FLUCELVAX QUAD 2018-2019

INTRAMUSCULAR SUSPENSION 60 MCG

(15 MCG X 4)/0.5 ML

NCS

FLULAVAL QUAD 2018-2019 (PF)


MCG X 4)/0.5 ML

NCS

FLULAVAL QUAD 2018-2019


(15 MCG X 4)/0.5 ML

NCS

FLUZONE HIGH-DOSE 2018-19 (PF)


ML

NCS

FLUZONE QUAD 2018-2019 (PF)


(15 MCG X 4)/0.5 ML

NCS




FLUZONE QUAD 2018-2019 (PF)


MCG X 4)/0.5 ML

NCS

FLUZONE QUAD 2018-2019


(15 MCG X 4)/0.5 ML

NCS

FLUZONE QUAD PEDI 2018-19 (PF)

INTRAMUSCULAR SYRINGE 30 MCG (7.5

MCG X 4)/0.25 ML

NCS

GAMMAGARD LIQUID INJECTION

SOLUTION 10 % T5 (SP) PA; MD

GARDASIL (PF) INTRAMUSCULAR

SUSPENSION 20-40-40-20 MCG/0.5 ML NCS

GARDASIL (PF) INTRAMUSCULAR

SYRINGE 20-40-40-20 MCG/0.5 ML NCS

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION 0.5 ML NCS

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE 0.5 ML NCS

GRASTEK SUBLINGUAL TABLET 2,800

BAU T3 MD

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML, 720

ELISA UNIT/0.5 ML

NCS

HAVRIX (PF) INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5

ML

NCS

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN 2.5 UNIT NCS

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION 25-58-10 LF-MCG-LF/0.5ML NCS

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SYRINGE 25-58-10 LF-MCG-LF/0.5ML NCS

IPOL INJECTION SUSPENSION 40-8-32

UNIT/0.5 ML NCS

IXIARO (PF) INTRAMUSCULAR SYRINGE 6

MCG/0.5 ML NCS

KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML NCS




KINRIX (PF) INTRAMUSCULAR SYRINGE

25 LF-58 MCG-10 LF/0.5 ML NCS

MENACTRA (PF) INTRAMUSCULAR

SOLUTION 4 MCG/0.5 ML NCS

MENHIBRIX (PF) INTRAMUSCULAR

RECON SOLN 5-2.5 MCG/0.5 ML NCS

MENOMUNE - A/C/Y/W-135 (PF)

SUBCUTANEOUS RECON SOLN 50 MCG NCS

MENOMUNE - A/C/Y/W-135

SUBCUTANEOUS RECON SOLN 50 MCG NCS

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5 MCG/0.5 ML NCS

MENVEO MENA COMPONENT (PF)

INTRAMUSCULAR RECON SOLN 10 MCG

/0.5 ML (FINAL)

NCS

MENVEO MENCYW-135 COMPNT (PF)

INTRAMUSCULAR RECON SOLN 5 MCG X

3/ 0.5 ML (FINAL)

NCS

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN 1,000-12,500 TCID50/0.5 ML NCS

PALYNZIQ SUBCUTANEOUS SYRINGE 10

MG/0.5 ML, 20 MG/ML T5 (SP) PA; MD

PALYNZIQ SUBCUTANEOUS SYRINGE 2.5

MG/0.5 ML T5 (SP) PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

10 MCG-25LF-25 MCG-10LF/0.5 ML NCS

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION 7.5 MCG/0.5 ML NCS

PENTACEL (PF) INTRAMUSCULAR KIT 15

LF UNIT-20 MCG-5 LF/0.5 ML NCS

PENTACEL ACTHIB COMPONENT (PF)

INTRAMUSCULAR RECON SOLN 10

MCG/0.5 ML

NCS

PENTACEL DTAP-IPV COMPNT (PF)

INTRAMUSCULAR SUSPENSION 15 LF-48

MCG- 5 LF UNIT/0.5ML

NCS

PNEUMOVAX 23 INJECTION SOLUTION 25

MCG/0.5 ML NCS

PNEUMOVAX 23 INJECTION SYRINGE 25

MCG/0.5 ML NCS

PREVNAR 13 (PF) INTRAMUSCULAR

SYRINGE 0.5 ML NCS

QL (0.5 ML Max Qty Per Fill

Retail)




PROQUAD (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION

10EXP3-4.3-3- 3.99 TCID50/0.5

NCS

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5 LF

UNIT/0.5ML

NCS

RABAVERT (PF) INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 2.5

UNIT

NCS

RAGWITEK SUBLINGUAL TABLET 12 AMB

A 1 UNIT T3 MD

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML, 5

MCG/0.5 ML

NCS

RECOMBIVAX HB (PF) INTRAMUSCULAR

SYRINGE 10 MCG/ML, 5 MCG/0.5 ML NCS

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION 10EXP6 CCID50/ML NCS

ROTATEQ VACCINE ORAL SOLUTION 2 ML NCS

SHINGRIX (PF) INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 50

MCG/0.5 ML

NCS

SHINGRIX GE ANTIGEN COMPONENT

INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION 50 MCG

NCS

TAKHZYRO SUBCUTANEOUS SOLUTION

300 MG/2 ML (150 MG/ML) T5 (SP) PA; MD

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML NCS

TENIVAC (PF) INTRAMUSCULAR SYRINGE

5-2 LF UNIT/0.5 ML NCS

tetanus toxoid adsorbed intramuscular solution 5

lf unit/0.5 ml NCS

tetanus toxoid fluid injection solution 5 lf unit NCS

tetanus toxoid fluid injection syringe 5 lf unit NCS

tetanus toxoid,adsorbed (pf) intramuscular

suspension 5 lf unit/0.5 ml NCS

tetanus,diphtheria tox ped(pf) intramuscular

suspension 5-25 lf unit/0.5 ml NCS




tetanus-diphtheria toxoids-td intramuscular

suspension 2-2 lf unit/0.5 ml NCS

THYMOGLOBULIN INTRAVENOUS RECON

SOLN 25 MG T5 (SP) PA

TRIHIBIT (PF) INTRAMUSCULAR KIT 6.7-

46.8-5-10 LF-MCG-LF-MCG NCS

TRIPEDIA (PF) INTRAMUSCULAR

SUSPENSION 6.7-46.8-5 LF-MCG-LF/0.5ML NCS

TRUMENBA INTRAMUSCULAR SYRINGE

120 MCG/0.5 ML NCS

TWINRIX (PF) INTRAMUSCULAR

SUSPENSION 720 ELISA UNIT- 20 MCG/ML NCS

TWINRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT- 20 MCG/ML NCS

TYPHIM VI INTRAMUSCULAR SOLUTION

25 MCG/0.5 ML NCS

TYPHIM VI INTRAMUSCULAR SYRINGE 25

MCG/0.5 ML NCS

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML NCS

VAQTA (PF) INTRAMUSCULAR SYRINGE

25 UNIT/0.5 ML, 50 UNIT/ML NCS

VARIVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 1,350

UNIT/0.5 ML

NCS

VARIZIG INTRAMUSCULAR RECON SOLN

125 UNIT NCS

VARIZIG INTRAMUSCULAR SOLUTION 125

UNIT/1.2 ML NCS

VIVOTIF BERNA VACCINE ORAL

CAPSULE,DELAYED RELEASE(DR/EC) 2

BILLION UNIT

NCS

VIVOTIF ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 2 BILLION UNIT NCS

YF-VAX (PF) SUBCUTANEOUS


EXP4.74 UNIT/0.5 ML

NCS

ZOSTAVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 19,400

UNIT/0.65 ML

NCS

BLOOD




DROXIA ORAL CAPSULE 200 MG, 300 MG,

400 MG T4 MD

ENDARI ORAL POWDER IN PACKET 5

GRAM T5 (SP) PA

pentoxifylline oral tablet extended release 400 mg T2 MD

tranexamic acid intravenous solution 1,000 mg/10

ml (100 mg/ml) T3 PA

tranexamic acid oral tablet 650 mg T2 MD

CARDIAC DRUGS

AFEDITAB CR ORAL TABLET EXTENDED

RELEASE 30 MG, 60 MG T2 MD

amiodarone oral tablet 200 mg T2 MD

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg T1 MD

CARTIA XT ORAL CAPSULE,EXTENDED

RELEASE 24HR 120 MG, 180 MG, 240 MG,

300 MG

T2 MD

DIGITEK ORAL TABLET 125 MCG, 250 MCG T2 MD

DIGOX ORAL TABLET 125 MCG, 250 MCG T2 MD

digoxin oral solution 0.25 mg/5 ml (5 ml) T3

digoxin oral solution 50 mcg/ml T3 MD

digoxin oral tablet 125 mcg, 250 mcg T2 MD

diltiazem hcl oral capsule,ext.rel 24h degradable

120 mg, 180 mg, 240 mg T2 MD

diltiazem hcl oral capsule,extended release 12 hr

120 mg, 60 mg, 90 mg T2 MD

diltiazem hcl oral capsule,extended release 24 hr

120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420

mg

T2 MD

diltiazem hcl oral capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg T2 MD

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg,

90 mg T2 MD

diltiazem hcl oral tablet extended release 24 hr

180 mg, 240 mg, 300 mg, 360 mg, 420 mg T3 MD

DILT-XR ORAL CAPSULE,EXT.REL 24H

DEGRADABLE 120 MG, 180 MG, 240 MG T2 MD

disopyramide phosphate oral capsule 100 mg,

150 mg T2 MD




dofetilide oral capsule 125 mcg, 250 mcg, 500

mcg T4 MD

felodipine oral tablet extended release 24 hr 10

mg, 2.5 mg, 5 mg T2 MD

flecainide oral tablet 100 mg, 150 mg, 50 mg T2 MD

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg T3 MD

isosorbide dinitrate oral tablet extended release

40 mg T3 MD

isosorbide mononitrate oral tablet 10 mg, 20 mg T2 MD

isosorbide mononitrate oral tablet extended

release 24 hr 120 mg, 30 mg, 60 mg T2 MD

isradipine oral capsule 2.5 mg, 5 mg T3 MD

MATZIM LA ORAL TABLET EXTENDED


360 MG, 420 MG

T3 MD

mexiletine oral capsule 150 mg, 200 mg, 250 mg T2 MD

MINITRAN TRANSDERMAL PATCH 24

HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR,

0.6 MG/HR

T2 MD

MULTAQ ORAL TABLET 400 MG T3 MD

nicardipine oral capsule 20 mg, 30 mg T3 MD

NIFEDICAL XL ORAL TABLET EXTENDED

RELEASE 24HR 30 MG, 60 MG T2

nifedipine oral capsule 10 mg, 20 mg T2 MD

nifedipine oral tablet extended release 24hr 30

mg, 60 mg, 90 mg T2 MD

nifedipine oral tablet extended release 30 mg, 60

mg, 90 mg T2 MD

nimodipine oral capsule 30 mg T2

nisoldipine oral tablet extended release 24 hr 17

mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg T3 MD

NITRO-BID TRANSDERMAL OINTMENT 2 % T4 MD

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6

mg T2 MD

nitroglycerin transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr T2 MD

NITROSTAT SUBLINGUAL TABLET 0.3 MG,

0.4 MG, 0.6 MG T3 MD

NORPACE CR ORAL CAPSULE, EXTENDED

RELEASE 100 MG, 150 MG T5 (SP) PA; MD




procainamide injection solution 100 mg/ml, 500

mg/ml T3

propafenone oral capsule,extended release 12 hr

225 mg, 325 mg, 425 mg T3 MD

propafenone oral tablet 150 mg, 225 mg, 300 mg T2 MD

quinidine gluconate oral tablet extended release

324 mg T4 MD

quinidine sulfate oral tablet 200 mg, 300 mg T2 MD

quinidine sulfate oral tablet extended release 300

mg T3

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR 1,000 MG, 500 MG T4 MD

TAZTIA XT ORAL CAPSULE,EXTENDED


300 MG, 360 MG

T2 MD

verapamil oral capsule, 24 hr er pellet ct 100 mg,

200 mg, 300 mg T2 MD

verapamil oral capsule,ext rel. pellets 24 hr 120

mg, 180 mg, 240 mg, 360 mg T2 MD

verapamil oral tablet 120 mg, 40 mg, 80 mg T2 MD

verapamil oral tablet extended release 120 mg,

180 mg, 240 mg T2 MD

CARDIOVASCULAR

acebutolol oral capsule 200 mg, 400 mg T2 MD

ADCIRCA ORAL TABLET 20 MG T5 (SP) PA; MD

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5

MG, 2 MG, 2.5 MG T5 (SP) PA; MD

amlodipine-benazepril oral capsule 10-20 mg, 10-

40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg T2 MD; QL (30 EA per 30 days)

amlodipine-olmesartan oral tablet 10-20 mg, 10-

40 mg, 5-20 mg, 5-40 mg T3 MD

amlodipine-valsartan oral tablet 10-160 mg, 10-

320 mg, 5-160 mg, 5-320 mg T2 MD; QL (30 EA per 30 days)

amlodipine-valsartan-hcthiazid oral tablet 10-

160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-

160-12.5 mg, 5-160-25 mg


AMTURNIDE ORAL TABLET 150-5-12.5 MG,

300-10-12.5 MG, 300-10-25 MG, 300-5-12.5

MG, 300-5-25 MG

T3




atenolol oral tablet 100 mg, 25 mg, 50 mg T1 MD

atenolol-chlorthalidone oral tablet 100-25 mg,

50-25 mg T2 MD

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80


AZOR ORAL TABLET 10-20 MG, 10-40 MG,

5-20 MG, 5-40 MG T3 MD

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1 MD

benazepril-hydrochlorothiazide oral tablet 10-

12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg T2 MD

BENICAR HCT ORAL TABLET 20-12.5 MG,

40-12.5 MG, 40-25 MG T3 MD

BENICAR ORAL TABLET 20 MG, 40 MG, 5

MG T3 MD

betaxolol oral tablet 10 mg, 20 mg T2 MD

bisoprolol fumarate oral tablet 10 mg, 5 mg T2 MD

bisoprolol-hydrochlorothiazide oral tablet 10-

6.25 mg, 2.5-6.25 mg, 5-6.25 mg T2 MD

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20

MG, 5 MG T3 MD

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg T3 MD; QL (30 EA per 30 days)

candesartan-hydrochlorothiazid oral tablet 16-

12.5 mg, 32-12.5 mg, 32-25 mg T3 MD; QL (30 EA per 30 days)

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50

mg T2 MD

captopril-hydrochlorothiazide oral tablet 25-15

mg, 25-25 mg, 50-15 mg, 50-25 mg T2 MD

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,

6.25 mg T1 MD

cholestyramine (with sugar) oral powder 4 gram T3 MD

cholestyramine (with sugar) oral powder in

packet 4 gram T3 MD

CHOLESTYRAMINE LIGHT ORAL POWDER

4 GRAM T3 MD

CHOLESTYRAMINE LIGHT ORAL POWDER

IN PACKET 4 GRAM T3 MD

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg T1 MD

clonidine transdermal patch weekly 0.1 mg/24 hr,

0.2 mg/24 hr, 0.3 mg/24 hr T3 MD; QL (4 EA per 28 days)

colesevelam oral tablet 625 mg T3 MD




colestipol oral granules 5 gram T3 MD

colestipol oral tablet 1 gram T3 MD

COREG CR ORAL CAPSULE, ER

MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG,

80 MG

T3 MD

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg T2 MD; QL (60 EA per 30 days)

enalapril maleate oral tablet 10 mg, 2.5 mg, 20

mg, 5 mg T1 MD

enalapril-hydrochlorothiazide oral tablet 10-25

mg, 5-12.5 mg T1 MD

ENTRESTO ORAL TABLET 24-26 MG, 49-51

MG, 97-103 MG T4 PA; MD; QL (60 EA per 30 days)

ergoloid oral tablet 1 mg T3 MD

ezetimibe oral tablet 10 mg T3 MD; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg T2 MD

fenofibrate nanocrystallized oral tablet 145 mg,

48 mg T2 MD

fenofibrate oral tablet 160 mg, 54 mg T2 MD

fenofibric acid (choline) oral capsule,delayed

release(dr/ec) 135 mg T3 MD

fenofibric acid (choline) oral capsule,delayed

release(dr/ec) 45 mg T2 MD

fluvastatin oral capsule 20 mg, 40 mg T3 MD

fosinopril oral tablet 10 mg, 20 mg, 40 mg T2 MD

fosinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg T2 MD

gemfibrozil oral tablet 600 mg T2 MD

guanfacine oral tablet 1 mg, 2 mg T2 MD

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg T2 MD

irbesartan oral tablet 150 mg, 300 mg, 75 mg T1 MD

irbesartan-hydrochlorothiazide oral tablet 150-

12.5 mg, 300-12.5 mg T1 MD

labetalol oral tablet 100 mg, 200 mg, 300 mg T2 MD

LETAIRIS ORAL TABLET 10 MG, 5 MG T5 (SP) PA; MD

LEVATOL ORAL TABLET 20 MG T4 MD




lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30


lisinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg T1 MD

losartan oral tablet 100 mg T1 MD; QL (30 EA per 30 days)

losartan oral tablet 25 mg, 50 mg T1 MD; QL (60 EA per 30 days)

losartan-hydrochlorothiazide oral tablet 100-12.5

mg, 100-25 mg T1 MD; QL (30 EA per 30 days)

losartan-hydrochlorothiazide oral tablet 50-12.5


lovastatin oral tablet 10 mg T1 MD; QL (30 EA per 30 days)

lovastatin oral tablet 20 mg, 40 mg T1 MD; QL (60 EA per 30 days)

methyldopa oral tablet 250 mg, 500 mg T2 MD

methyldopa-hydrochlorothiazide oral tablet 250-

15 mg, 250-25 mg T2 MD

metoprolol succinate oral tablet extended release

24 hr 100 mg, 200 mg, 25 mg, 50 mg T2 MD; QL (60 EA per 30 days)

metoprolol ta-hydrochlorothiaz oral tablet 100-25

mg, 100-50 mg, 50-25 mg T2 MD

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg T1 MD

minoxidil oral tablet 10 mg, 2.5 mg T2 MD

moexipril oral tablet 15 mg, 7.5 mg T3 MD

moexipril-hydrochlorothiazide oral tablet 15-12.5

mg, 15-25 mg, 7.5-12.5 mg T3 MD

nadolol oral tablet 20 mg, 40 mg, 80 mg T2 MD; QL (30 EA per 30 days)

niacin oral tablet extended release 24 hr 1,000

mg, 500 mg, 750 mg T3 MD

NIACOR ORAL TABLET 500 MG T2 MD

olmesartan oral tablet 20 mg, 40 mg, 5 mg T3 MD

olmesartan-amlodipin-hcthiazid oral tablet 20-5-

12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5

mg, 40-5-25 mg

T3 MD

olmesartan-hydrochlorothiazide oral tablet 20-

12.5 mg, 40-12.5 mg, 40-25 mg T3 MD

perindopril erbumine oral tablet 2 mg, 4 mg, 8

mg T3 MD

pindolol oral tablet 10 mg, 5 mg T3 MD

PRALUENT PEN SUBCUTANEOUS PEN

INJECTOR 150 MG/ML, 75 MG/ML T5 (SP) PA; MD; QL (2 ML per 28 days)




PRALUENT SYRINGE SUBCUTANEOUS

SYRINGE 150 MG/ML, 75 MG/ML T5 (SP) PA; QL (2 ML per 28 days)

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80


prazosin oral capsule 1 mg, 2 mg, 5 mg T2 MD

PREVALITE ORAL POWDER 4 GRAM T3 MD

PREVALITE ORAL POWDER IN PACKET 4

GRAM T3 MD

propranolol oral capsule,extended release 24 hr

120 mg, 160 mg, 60 mg, 80 mg T2 MD

propranolol oral solution 20 mg/5 ml (4 mg/ml),

40 mg/5 ml (8 mg/ml) T3 MD

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60

mg, 80 mg T2 MD

propranolol-hydrochlorothiazid oral tablet 40-25

mg, 80-25 mg T2 MD

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1 MD

quinapril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg T2 MD

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5

mg T1 MD

REMODULIN INJECTION SOLUTION 1

MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML T5 (SP) PA

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR 420 MG/3.5 ML T5 (SP) PA; MD; QL (3.5 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR 140 MG/ML T5 (SP) PA; MD; QL (3 ML per 28 days)

REPATHA SYRINGE SUBCUTANEOUS

SYRINGE 140 MG/ML T5 (SP) PA; MD; QL (3 ML per 28 days)

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5


sildenafil (antihypertensive) oral tablet 20 mg T4 PA; MD; QL (90 EA per 30 days)

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5

mg, 80 mg T1 MD; QL (30 EA per 30 days)

SORINE ORAL TABLET 120 MG, 160 MG, 240

MG, 80 MG T2 MD

SOTALOL AF ORAL TABLET 120 MG, 160

MG, 80 MG T2 MD




sotalol oral tablet 120 mg, 160 mg, 240 mg, 80

mg T2 MD

tadalafil (antihypertensive) oral tablet 20 mg T5 (SP) PA; MD

TEKAMLO ORAL TABLET 150-10 MG, 150-5

MG, 300-10 MG, 300-5 MG T3

TEKTURNA HCT ORAL TABLET 150-12.5

MG, 150-25 MG, 300-12.5 MG, 300-25 MG T3 MD

TEKTURNA ORAL TABLET 150 MG, 300 MG T3 MD

telmisartan oral tablet 20 mg, 40 mg, 80 mg T2 MD

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg T2 MD; QL (60 EA per 30 days)

timolol maleate oral tablet 10 mg, 20 mg, 5 mg T2 MD

TRACLEER ORAL TABLET 125 MG, 62.5 MG T5 (SP) PA; MD

TRACLEER ORAL TABLET FOR

SUSPENSION 32 MG T5 (SP) PA; MD

trandolapril oral tablet 1 mg, 2 mg, 4 mg T2 MD

TRIBENZOR ORAL TABLET 20-5-12.5 MG,

40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG,

40-5-25 MG

T3 MD

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80

mg T2 MD

valsartan-hydrochlorothiazide oral tablet 160-

12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg,

80-12.5 mg

T2 MD

VENTAVIS INHALATION SOLUTION FOR

NEBULIZATION 10 MCG/ML, 20 MCG/ML T5 (SP) PA; MD

VYTORIN 10-10 ORAL TABLET 10-10 MG T4 MD; QL (30 EA per 30 days)




WELCHOL ORAL POWDER IN PACKET 3.75

GRAM T4 ST; MD

WELCHOL ORAL TABLET 625 MG T4 ST; MD

ZETIA ORAL TABLET 10 MG T3 MD; QL (30 EA per 30 days)

CNS DRUGS

APTIOM ORAL TABLET 200 MG, 400 MG,

600 MG, 800 MG T4 PA; MD

AUSTEDO ORAL TABLET 12 MG T5 (SP) PA; MD; QL (120 EA per 30 days)

AUSTEDO ORAL TABLET 6 MG, 9 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT 30 MCG T5 (SP) PA; MD; QL (4 EA per 28 days)




AVONEX INTRAMUSCULAR PEN

INJECTOR KIT 30 MCG/0.5 ML T5 (SP) PA; MD; QL (4 EA per 28 days)

AVONEX INTRAMUSCULAR SYRINGE KIT

30 MCG/0.5 ML T5 (SP) PA; MD; QL (1 EA per 28 days)

BANZEL ORAL SUSPENSION 40 MG/ML T5 (SP) PA; MD; QL (2400 ML per 30

days)

BANZEL ORAL TABLET 200 MG T5 (SP) PA; MD; QL (90 EA per 30 days)

BANZEL ORAL TABLET 400 MG T5 (SP) PA; MD; QL (240 EA per 30 days)

BETASERON SUBCUTANEOUS KIT 0.3 MG T5 (SP) PA; MD; QL (14 EA per 28 days)

carbamazepine oral capsule, er multiphase 12 hr

100 mg, 200 mg, 300 mg T3 MD

carbamazepine oral suspension 100 mg/5 ml, 100

mg/5 ml (5 ml), 200 mg/10 ml T3 MD

carbamazepine oral tablet 200 mg T2 MD

carbamazepine oral tablet extended release 12 hr

100 mg, 200 mg, 400 mg T3 MD

carbamazepine oral tablet,chewable 100 mg T2 MD

CELONTIN ORAL CAPSULE 300 MG T4 MD

clonazepam oral tablet 0.5 mg, 1 mg T2 MD; QL (90 EA per 30 days)

clonazepam oral tablet 2 mg T2 MD; QL (300 EA per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 20


COPAXONE SUBCUTANEOUS SYRINGE 40

MG/ML T5 (SP) PA; MD; QL (12 ML per 30 days)

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg,

5-7.5-10 mg T4

divalproex oral capsule, delayed rel sprinkle 125

mg T2 MD

divalproex oral tablet extended release 24 hr 250

mg, 500 mg T2 MD

divalproex oral tablet,delayed release (dr/ec) 125

mg, 250 mg, 500 mg T2 MD

ethosuximide oral capsule 250 mg T3 MD

ethosuximide oral solution 250 mg/5 ml T3 MD

felbamate oral suspension 600 mg/5 ml T5 (SP) MD

felbamate oral tablet 400 mg, 600 mg T5 (SP) MD

FYCOMPA ORAL SUSPENSION 0.5 MG/ML T4 PA; MD




FYCOMPA ORAL TABLET 10 MG, 12 MG, 4

MG, 6 MG, 8 MG T4 PA; MD; QL (30 EA per 30 days)

FYCOMPA ORAL TABLET 2 MG T4 PA; MD; QL (60 EA per 30 days)

FYCOMPA ORAL TABLETS,DOSE PACK 2

MG (7)- 4 MG (7) T4 PA

gabapentin oral capsule 100 mg, 300 mg, 400 mg T2 MD; QL (270 EA per 30 days)

gabapentin oral solution 250 mg/5 ml, 250 mg/5

ml (5 ml), 300 mg/6 ml (6 ml) T2 MD; QL (2160 ML per 30 days)

gabapentin oral tablet 600 mg T2 MD; QL (180 EA per 30 days)

gabapentin oral tablet 800 mg T2 MD; QL (120 EA per 30 days)

GABITRIL ORAL TABLET 12 MG, 16 MG T5 (SP) MD

GILENYA ORAL CAPSULE 0.5 MG T5 (SP) PA; MD; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED

RELEASE 300 MG, 600 MG T4 PA; MD; QL (60 EA per 30 days)

lamotrigine oral tablet 100 mg, 150 mg, 200 mg,

25 mg T2 MD

lamotrigine oral tablet disintegrating, dose pk 25

mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100

mg (7), 50 mg (42) -100 mg (14)

T3

lamotrigine oral tablet, chewable dispersible 25

mg, 5 mg T2 MD

lamotrigine oral tablet,disintegrating 100 mg,

200 mg, 25 mg, 50 mg T3 MD; QL (90 EA per 30 days)

lamotrigine oral tablets,dose pack 25 mg (35), 25

mg (42) -100 mg (7), 25 mg (84) -100 mg (14) T3

levetiracetam oral solution 100 mg/ml, 500 mg/5

ml (5 ml) T2 MD

levetiracetam oral tablet 1,000 mg, 250 mg, 500

mg, 750 mg T2 MD

levetiracetam oral tablet extended release 24 hr


levetiracetam oral tablet extended release 24 hr


LYRICA ORAL CAPSULE 100 MG, 150 MG,

200 MG, 25 MG, 50 MG, 75 MG T4 MD; QL (90 EA per 30 days)

LYRICA ORAL CAPSULE 225 MG, 300 MG T4 MD; QL (60 EA per 30 days)

memantine oral capsule,sprinkle,er 24hr 14 mg,


memantine oral solution 2 mg/ml T4 MD; QL (300 ML per 30 days)

memantine oral tablet 10 mg, 5 mg T2 MD; QL (60 EA per 30 days)




memantine oral tablets,dose pack 5-10 mg T2

oxcarbazepine oral suspension 300 mg/5 ml (60

mg/ml) T2 MD

oxcarbazepine oral tablet 150 mg, 300 mg, 600

mg T2 MD

PEGANONE ORAL TABLET 250 MG T4 MD

phenytoin oral suspension 100 mg/4 ml, 125 mg/5

ml T2 MD

phenytoin sodium extended oral capsule 100 mg,

200 mg, 300 mg T2 MD

POTIGA ORAL TABLET 200 MG, 300 MG,

400 MG T5 (SP) PA; QL (90 EA per 30 days)

POTIGA ORAL TABLET 50 MG T5 (SP) PA; QL (270 EA per 30 days)

primidone oral tablet 250 mg, 50 mg T2 MD

SABRIL ORAL TABLET 500 MG T5 (SP) PA

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG T5 (SP) PA; MD; QL (14 EA per 365 days)


RELEASE(DR/EC) 120 MG (14)- 240 MG (46) T5 (SP) PA; QL (60 EA per 365 days)


RELEASE(DR/EC) 240 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

tiagabine oral tablet 12 mg, 16 mg T4 MD

tiagabine oral tablet 2 mg, 4 mg T5 (SP) MD

topiramate oral capsule, sprinkle 15 mg, 25 mg T3 MD

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50

mg T2 MD

valproic acid (as sodium salt) oral solution 250

mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10

ml)

T2 MD

valproic acid (as sodium salt) oral syringe 250

mg/5 ml T2

valproic acid oral capsule 250 mg T2 MD

vigabatrin oral powder in packet 500 mg T5 (SP) PA; MD

VIMPAT ORAL SOLUTION 10 MG/ML T5 (SP) PA; MD; QL (1200 ML per 30

days)

VIMPAT ORAL TABLET 100 MG, 150 MG,


VIMPAT ORAL TABLETS,DOSE PACK 50

MG (14)- 100 MG (14) T5 (SP) PA




zonisamide oral capsule 100 mg, 25 mg, 50 mg T2 MD

COLONY STIMULATING FACTORS

DOPTELET ORAL TABLET 20 MG T5 (SP) PA; QL (15 EA per 90 days)

LEUKINE INJECTION RECON SOLN 250

MCG T5 (SP) PA

MULPLETA ORAL TABLET 3 MG T5 (SP) PA; QL (7 EA per 90 days)

NEULASTA SUBCUTANEOUS SYRINGE 6

MG/0.6ML T5 (SP) PA

NEULASTA SUBCUTANEOUS SYRINGE, W/

WEARABLE INJECTOR 6 MG/0.6 ML T5 (SP) PA

NEUPOGEN INJECTION SOLUTION 300

MCG/ML, 480 MCG/1.6 ML T5 (SP) PA

NEUPOGEN INJECTION SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML T5 (SP) PA

PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML,

3,000 UNIT/ML, 4,000 UNIT/ML, 40,000

UNIT/ML

T5 (SP) PA; MD; QL (14 ML per 30 days)

PROMACTA ORAL TABLET 12.5 MG, 25 MG,


CONTRACEPTIVES

AFTERA ORAL TABLET 1.5 MG NCS

ALTAVERA (28) ORAL TABLET 0.15-0.03

MG NCS MD

alyacen 1/35 (28) oral tablet 1-35 mg-mcg NCS MD

ALYACEN 7/7/7 (28) ORAL TABLET

0.5/0.75/1 MG- 35 MCG NCS MD

AMETHIA LO ORAL TABLETS,DOSE

PACK,3 MONTH 0.10 MG-20 MCG (84)/10

MCG (7)

NCS MD

AMETHIA ORAL TABLETS,DOSE PACK,3

MONTH 0.15 MG-30 MCG (84)/10 MCG (7) NCS MD

AMETHYST ORAL TABLET 90-20 MCG NCS MD

APRI ORAL TABLET 0.15-0.03 MG NCS MD

ARANELLE (28) ORAL TABLET 0.5/1/0.5-35

MG-MCG NCS MD

ASHLYNA ORAL TABLETS,DOSE PACK,3


AUBRA ORAL TABLET 0.1-20 MG-MCG NCS MD

AVIANE ORAL TABLET 0.1-20 MG-MCG NCS MD




AZURETTE (28) ORAL TABLET 0.15-0.02

MGX21 /0.01 MG X 5 NCS MD

BALZIVA (28) ORAL TABLET 0.4-35 MG-

MCG NCS MD

BEKYREE (28) ORAL TABLET 0.15-0.02


BEYAZ ORAL TABLET 3-0.02-0.451 MG (24)

(4) T4 MD

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG

(24)/75 MG (4) NCS MD

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-

20 MCG (21)/75 MG (7) NCS MD

BRIELLYN ORAL TABLET 0.4-35 MG-MCG NCS MD

CAMILA ORAL TABLET 0.35 MG NCS MD

CAMRESE LO ORAL TABLETS,DOSE

PACK,3 MONTH 0.10 MG-20 MCG (84)/10

MCG (7)

NCS MD

CAMRESE ORAL TABLETS,DOSE PACK,3


CAYA CONTOURED VAGINAL

DIAPHRAGM 60-85 MM NCS

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25

MG-MCG NCS MD

CHATEAL ORAL TABLET 0.15-0.03 MG NCS MD

CONCEPTROL VAGINAL GEL 4 % NCS

CRYSELLE (28) ORAL TABLET 0.3-30 MG-

MCG NCS MD

CYCLAFEM 1/35 (28) ORAL TABLET 1-35

MG-MCG NCS MD

CYCLAFEM 7/7/7 (28) ORAL TABLET

0.5/0.75/1 MG- 35 MCG NCS MD

CYRED ORAL TABLET 0.15-0.03 MG NCS MD

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-

MCG NCS MD

DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1

MG- 35 MCG NCS MD

DAYSEE ORAL TABLETS,DOSE PACK,3


DEBLITANE ORAL TABLET 0.35 MG NCS MD




DELYLA (28) ORAL TABLET 0.1-20 MG-

MCG NCS MD

desog-e.estradiol/e.estradiol oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 NCS MD

desogestrel-ethinyl estradiol oral tablet 0.15-0.03

mg NCS MD

drospirenone-ethinyl estradiol oral tablet 3-0.02

mg, 3-0.03 mg NCS MD

ECONTRA EZ ORAL TABLET 1.5 MG NCS

ELINEST ORAL TABLET 0.3-30 MG-MCG NCS MD

ELLA ORAL TABLET 30 MG NCS

EMOQUETTE ORAL TABLET 0.15-0.03 MG NCS MD

ENPRESSE ORAL TABLET 50-30 (6)/75-40

(5)/125-30(10) NCS MD

ENSKYCE ORAL TABLET 0.15-0.03 MG NCS MD

ERRIN ORAL TABLET 0.35 MG NCS MD

ESTARYLLA ORAL TABLET 0.25-35 MG-

MCG NCS MD

FALLBACK SOLO ORAL TABLET 1.5 MG NCS

FALMINA (28) ORAL TABLET 0.1-20 MG-

MCG NCS MD

FC2 FEMALE CONDOM NCS

FEMCAP VAGINAL DEVICE 22 MM, 26 MM,

30 MM NCS

GENERESS FE ORAL TABLET,CHEWABLE

0.8MG-25MCG(24) AND 75 MG (4) T4 MD

GIANVI (28) ORAL TABLET 3-0.02 MG NCS MD

GILDAGIA ORAL TABLET 0.4-35 MG-MCG NCS

GILDESS 1.5/30 (21) ORAL TABLET 1.5-30

MG-MCG NCS

GILDESS 1/20 (21) ORAL TABLET 1-20 MG-

MCG NCS

GILDESS 24 FE ORAL TABLET 1 MG-20

MCG (24)/75 MG (4) NCS

GILDESS FE 1.5/30 (28) ORAL TABLET 1.5

MG-30 MCG (21)/75 MG (7) NCS

GILDESS FE 1/20 (28) ORAL TABLET 1 MG-

20 MCG (21)/75 MG (7) NCS

GYNOL II VAGINAL GEL 3 % NCS

HEATHER ORAL TABLET 0.35 MG NCS MD




INTROVALE ORAL TABLETS,DOSE PACK,3

MONTH 0.15 MG-30 MCG NCS MD

JENCYCLA ORAL TABLET 0.35 MG NCS MD

JOLESSA ORAL TABLETS,DOSE PACK,3


JOLIVETTE ORAL TABLET 0.35 MG NCS MD

JULEBER ORAL TABLET 0.15-0.03 MG NCS MD

JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-

MCG NCS MD

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-

MCG NCS MD

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-

30 MCG (21)/75 MG (7) NCS MD

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20

MCG (21)/75 MG (7) NCS MD

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG

(24)/75 MG (4) NCS MD

KARIVA (28) ORAL TABLET 0.15-0.02


KELNOR 1/35 (28) ORAL TABLET 1-35 MG-

MCG NCS MD

KIMIDESS (28) ORAL TABLET 0.15-0.02

MGX21 /0.01 MG X 5 NCS

KURVELO ORAL TABLET 0.15-0.03 MG NCS MD

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),

0.15 mg-30 mcg (84)/10 mcg (7)

NCS MD

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-

MCG NCS MD

LARIN 1/20 (21) ORAL TABLET 1-20 MG-

MCG NCS MD

LARIN 24 FE ORAL TABLET 1 MG-20 MCG

(24)/75 MG (4) NCS MD

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-

30 MCG (21)/75 MG (7) NCS MD

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20


LAYOLIS FE ORAL TABLET,CHEWABLE

0.8MG-25MCG(24) AND 75 MG (4) NCS MD




LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-

MCG NCS MD

LESSINA ORAL TABLET 0.1-20 MG-MCG NCS MD

LEVONEST (28) ORAL TABLET 50-30 (6)/75-

40 (5)/125-30(10) NCS MD

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-0.03 mg, 90-20 mcg NCS MD

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month 0.15 mg-30 mcg NCS MD

levonorg-eth estrad triphasic oral tablet 50-30

(6)/75-40 (5)/125-30(10) NCS MD

LEVORA-28 ORAL TABLET 0.15-0.03 MG NCS MD

LO LOESTRIN FE ORAL TABLET 1 MG-10

MCG (24)/10 MCG (2) T4 MD

LOMEDIA 24 FE ORAL TABLET 1 MG-20

MCG (24)/75 MG (4) NCS

LORYNA (28) ORAL TABLET 3-0.02 MG NCS MD

LOW-OGESTREL (28) ORAL TABLET 0.3-30

MG-MCG NCS MD

LUTERA (28) ORAL TABLET 0.1-20 MG-

MCG NCS MD

LYZA ORAL TABLET 0.35 MG NCS MD

MARLISSA ORAL TABLET 0.15-0.03 MG NCS MD

medroxyprogesterone intramuscular suspension

150 mg/ml NCS MD

medroxyprogesterone intramuscular syringe 150

mg/ml NCS MD

MICROGESTIN 1.5/30 (21) ORAL TABLET

1.5-30 MG-MCG NCS MD

MICROGESTIN 1/20 (21) ORAL TABLET 1-20

MG-MCG NCS MD

MICROGESTIN FE 1.5/30 (28) ORAL TABLET

1.5 MG-30 MCG (21)/75 MG (7) NCS MD

MICROGESTIN FE 1/20 (28) ORAL TABLET 1

MG-20 MCG (21)/75 MG (7) NCS MD

MINASTRIN 24 FE ORAL

TABLET,CHEWABLE 1 MG-20 MCG(24) /75

MG (4)

T4 MD

MIRENA INTRAUTERINE INTRAUTERINE

DEVICE 20 MCG/24 HR (5 YEARS) NCS MD




MONO-LINYAH ORAL TABLET 0.25-35 MG-

MCG NCS MD

MONONESSA (28) ORAL TABLET 0.25-35

MG-MCG NCS MD

MY WAY ORAL TABLET 1.5 MG NCS

MYZILRA ORAL TABLET 50-30 (6)/75-40

(5)/125-30(10) NCS MD

NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/

2 MG-3 MG/1 MG T3 MD

NECON 0.5/35 (28) ORAL TABLET 0.5-35

MG-MCG NCS MD

NECON 1/35 (28) ORAL TABLET 1-35 MG-

MCG NCS

NECON 1/50 (28) ORAL TABLET 1-50 MG-

MCG NCS

NECON 10/11 (28) ORAL TABLET 0.5-35/1-35

MG-MCG/MG-MCG NCS

NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1

MG- 35 MCG NCS

NEXPLANON SUBDERMAL IMPLANT 68

MG NCS

NEXT CHOICE ONE DOSE ORAL TABLET

1.5 MG NCS

NIKKI (28) ORAL TABLET 3-0.02 MG NCS MD

NORA-BE ORAL TABLET 0.35 MG NCS MD

noreth-ethinyl estradiol-iron oral tablet,chewable

0.8mg-25mcg(24) and 75 mg (4) NCS MD

norethindrone (contraceptive) oral tablet 0.35 mg NCS MD

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg NCS MD

norethindrone-e.estradiol-iron oral tablet 1 mg-

20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg

(4)

NCS MD

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-

35 mcg (28), 0.25-35 mg-mcg

NCS MD

NORINYL 1+50 (28) ORAL TABLET 1-50 MG-

MCG T3

NORLYROC ORAL TABLET 0.35 MG NCS MD




NORTREL 0.5/35 (28) ORAL TABLET 0.5-35

MG-MCG NCS MD

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-

MCG NCS MD

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-

MCG NCS MD

NORTREL 7/7/7 (28) ORAL TABLET

0.5/0.75/1 MG- 35 MCG NCS MD

NUVARING VAGINAL RING 0.12-0.015

MG/24 HR NCS MD

OCELLA ORAL TABLET 3-0.03 MG NCS MD

OGESTREL (28) ORAL TABLET 0.5-50 MG-

MCG NCS MD

OPCICON ONE-STEP ORAL TABLET 1.5 MG NCS

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG NCS MD

PARAGARD T 380A INTRAUTERINE

INTRAUTERINE DEVICE 380 SQUARE MM NCS MD

PHILITH ORAL TABLET 0.4-35 MG-MCG NCS MD

PIMTREA (28) ORAL TABLET 0.15-0.02


PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35

MCG, 1-35 MG-MCG NCS MD

PLAN B ONE-STEP ORAL TABLET 1.5 MG NCS

PORTIA ORAL TABLET 0.15-0.03 MG NCS MD

PREVIFEM ORAL TABLET 0.25-35 MG-MCG NCS MD

QUASENSE ORAL TABLETS,DOSE PACK,3


RECLIPSEN (28) ORAL TABLET 0.15-0.03

MG NCS MD

SAFYRAL ORAL TABLET 3-0.03-0.451 MG

(21) (7) T3 MD

SETLAKIN ORAL TABLETS,DOSE PACK,3


SHAROBEL ORAL TABLET 0.35 MG NCS MD

SKYLA INTRAUTERINE INTRAUTERINE

DEVICE 14 MCG/24 HOUR (3 YEARS) T3 MD

SPRINTEC (28) ORAL TABLET 0.25-35 MG-

MCG NCS MD

SRONYX ORAL TABLET 0.1-20 MG-MCG NCS MD

SYEDA ORAL TABLET 3-0.03 MG NCS MD




TAKE ACTION ORAL TABLET 1.5 MG NCS

TARINA FE 1/20 (28) ORAL TABLET 1 MG-20


TILIA FE ORAL TABLET 1-20(5)/1-30(7)

/1MG-35MCG (9) NCS MD

TODAY CONTRACEPTIVE SPONGE

VAGINAL CONTRACEPTIVE SPONGE 1,000

MG

NCS

TRI-ESTARYLLA ORAL TABLET

0.18/0.215/0.25 MG-35 MCG (28) NCS MD

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-

30(7) /1MG-35MCG (9) NCS MD

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25

MG-35 MCG (28) NCS MD

TRI-LO-SPRINTEC ORAL TABLET

0.18/0.215/0.25 MG-25 MCG NCS MD

TRINESSA (28) ORAL TABLET

0.18/0.215/0.25 MG-35 MCG (28) NCS MD

TRI-PREVIFEM (28) ORAL TABLET

0.18/0.215/0.25 MG-35 MCG (28) NCS MD

TRI-SPRINTEC (28) ORAL TABLET

0.18/0.215/0.25 MG-35 MCG (28) NCS MD

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40

(5)/125-30(10) NCS MD

VELIVET TRIPHASIC REGIMEN (28) ORAL

TABLET 0.1/.125/.15-25 MG-MCG NCS MD

VESTURA (28) ORAL TABLET 3-0.02 MG NCS

VIORELE (28) ORAL TABLET 0.15-0.02


VYFEMLA (28) ORAL TABLET 0.4-35 MG-

MCG NCS MD

WERA (28) ORAL TABLET 0.5-35 MG-MCG NCS MD

WIDE-SEAL DIAPHRAGM 60 VAGINAL

DIAPHRAGM 60 MM NCS


DIAPHRAGM 65 MM NCS


DIAPHRAGM 70 MM NCS





DIAPHRAGM 75 MM NCS


DIAPHRAGM 80 MM NCS


DIAPHRAGM 85 MM NCS


DIAPHRAGM 90 MM NCS


DIAPHRAGM 95 MM NCS

WYMZYA FE ORAL TABLET,CHEWABLE

0.4MG-35MCG(21) AND 75 MG (7) NCS MD

XULANE TRANSDERMAL PATCH WEEKLY

150-35 MCG/24 HR NCS MD

YASMIN (28) ORAL TABLET 3-0.03 MG T4 MD

YAZ (28) ORAL TABLET 3-0.02 MG T4 MD

ZARAH ORAL TABLET 3-0.03 MG NCS MD

ZENCHENT (28) ORAL TABLET 0.4-35 MG-

MCG NCS MD

ZENCHENT FE ORAL TABLET,CHEWABLE

0.4MG-35MCG(21) AND 75 MG (7) NCS

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-

MCG NCS MD

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-

MCG NCS

COUGH/COLD PREPARATIONS

benzonatate oral capsule 100 mg, 150 mg, 200

mg T2

BROMFED DM ORAL SYRUP 2-30-10 MG/5

ML T3

brompheniramine-pseudoeph-dm oral syrup 2-30-

10 mg/5 ml T3 QL (1200 ML per 30 days)

hydrocodone-homatropine oral syrup 5-1.5 mg/5

ml (5 ml) T2

hydrocodone-homatropine oral tablet 5-1.5 mg T2

HYDROMET ORAL SYRUP 5-1.5 MG/5 ML T2

PROMETHAZINE VC-CODEINE ORAL

SYRUP 6.25-5-10 MG/5 ML T3

promethazine-codeine oral syrup 6.25-10 mg/5 ml T3

promethazine-dm oral syrup 6.25-15 mg/5 ml T2




promethazine-phenyleph-codeine oral syrup 6.25-

5-10 mg/5 ml T3

DIAGNOSTIC

FREESTYLE INSULINX TEST STRIPS STRIP T3 MD; QL (200 EA per 30 days)

FREESTYLE LITE STRIPS STRIP T3 MD; QL (200 EA per 30 days)

FREESTYLE TEST STRIP T3 MD; QL (200 EA per 30 days)

GLUCAGEN DIAGNOSTIC KIT INJECTION

RECON SOLN 1 MG/ML T3 QL (4 EA per 30 days)

PRECISION XTRA TEST STRIP T3 MD; QL (200 EA per 30 days)

DIURETICS

acetazolamide oral tablet 125 mg, 250 mg T3 MD

acetazolamide sodium injection recon soln 500

mg T3

amiloride oral tablet 5 mg T2 MD

amiloride-hydrochlorothiazide oral tablet 5-50

mg T2 MD

ammonium chloride intravenous solution 5

meq/ml T2

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg T2 MD

chlorothiazide oral tablet 250 mg, 500 mg T2 MD

chlorthalidone oral tablet 25 mg, 50 mg T2 MD

DYRENIUM ORAL CAPSULE 100 MG, 50 MG T4 MD

EDECRIN ORAL TABLET 25 MG T5 (SP) PA; MD

eplerenone oral tablet 25 mg, 50 mg T3 MD

furosemide oral solution 10 mg/ml T2 MD

furosemide oral solution 40 mg/4 ml, 40 mg/5 ml

(8 mg/ml) T1 MD

furosemide oral tablet 20 mg, 40 mg, 80 mg T1 MD

hydrochlorothiazide oral capsule 12.5 mg T1 MD

hydrochlorothiazide oral tablet 12.5 mg, 25 mg,

50 mg T1 MD

indapamide oral tablet 1.25 mg, 2.5 mg T2 MD

JYNARQUE ORAL TABLETS, SEQUENTIAL

45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30

MG (PM), 90 MG (AM)/ 30 MG (PM)


methazolamide oral tablet 25 mg, 50 mg T4 MD

methyclothiazide oral tablet 5 mg T3 MD




metolazone oral tablet 10 mg, 2.5 mg, 5 mg T2 MD

SAMSCA ORAL TABLET 15 MG, 30 MG T5 (SP) PA

spironolactone oral tablet 100 mg, 25 mg, 50 mg T2 MD

spironolacton-hydrochlorothiaz oral tablet 25-25

mg T2 MD

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg T2 MD

triamterene-hydrochlorothiazid oral capsule

37.5-25 mg T2 MD

triamterene-hydrochlorothiazid oral tablet 37.5-

25 mg, 75-50 mg T2 MD

EENT PREPS

ACETASOL HC OTIC (EAR) DROPS 1-2 % T3

acetic acid otic (ear) solution 2 % T2

ALOCRIL OPHTHALMIC (EYE) DROPS 2 % T4

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1

% T4

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 % T4 MD; QL (15 ML per 30 days)

ALREX OPHTHALMIC (EYE)


antipyrine-benzocaine otic (ear) drops 5.4-1.4 % T2

apraclonidine ophthalmic (eye) drops 0.5 % T2

atropine ophthalmic (eye) drops 1 % T2 MD

atropine sulfate (pf) ophthalmic (eye) drops 1 % T2

azelastine nasal aerosol,spray 137 mcg (0.1 %) T3 MD; QL (60 ML per 30 days)

azelastine nasal spray,non-aerosol 0.15 % (205.5

mcg) T3 MD; QL (60 ML per 30 days)

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION 1 % T3 MD; QL (15 ML per 30 days)

betaxolol ophthalmic (eye) drops 0.5 % T3 MD

BETIMOL OPHTHALMIC (EYE) DROPS 0.25

%, 0.5 % T3 MD

BETOPTIC S OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.25 % T4 MD

brimonidine ophthalmic (eye) drops 0.15 % T3 MD

brimonidine ophthalmic (eye) drops 0.2 % T1 MD

bromfenac ophthalmic (eye) drops 0.09 % T3

carteolol ophthalmic (eye) drops 1 % T2 MD




COMBIGAN OPHTHALMIC (EYE) DROPS

0.2-0.5 % T3 MD; QL (10 ML per 30 days)

CORTANE-B TOPICAL LOTION 1-1-0.1 % T4

COSOPT (PF) OPHTHALMIC (EYE)

DROPPERETTE 2-0.5 % T3 MD; QL (60 EA per 30 days)

cromolyn ophthalmic (eye) drops 4 % T2

cyclopentolate ophthalmic (eye) drops 1 %, 2 % T2

dexamethasone sodium phosphate ophthalmic

(eye) drops 0.1 % T2

diclofenac sodium ophthalmic (eye) drops 0.1 % T2

dorzolamide ophthalmic (eye) drops 2 % T2 MD

dorzolamide-timolol ophthalmic (eye) drops 22.3-

6.8 mg/ml T2 MD

DUREZOL OPHTHALMIC (EYE) DROPS 0.05

% T4

flunisolide nasal spray,non-aerosol 25 mcg

(0.025 %) T3 MD; QL (50 ML per 30 days)

fluocinolone acetonide oil otic (ear) drops 0.01 % T3

fluorometholone ophthalmic (eye)

drops,suspension 0.1 % T2

flurbiprofen sodium ophthalmic (eye) drops 0.03

% T2

fluticasone nasal spray,suspension 50

mcg/actuation T2 MD; QL (16 GM per 30 days)

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

0.1 % T4

HOMATROPAIRE OPHTHALMIC (EYE)

DROPS 5 % T3 MD

homatropine hbr ophthalmic (eye) drops 5 % T3 MD

hydrocortisone-acetic acid otic (ear) drops 1-2 % T3

ILEVRO OPHTHALMIC (EYE)


ipratropium bromide nasal spray,non-aerosol

0.03 % T2 MD; QL (30 ML per 30 days)

ipratropium bromide nasal spray,non-aerosol 42

mcg (0.06 %) T2 QL (30 ML per 30 days)

ISTALOL OPHTHALMIC (EYE) DROPS,

ONCE DAILY 0.5 % T4 MD

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % T2




latanoprost ophthalmic (eye) drops 0.005 % T1 MD

levobunolol ophthalmic (eye) drops 0.5 % T2 MD

LOTEMAX OPHTHALMIC (EYE)

DROPS,GEL 0.5 % T4

LOTEMAX OPHTHALMIC (EYE)


LOTEMAX OPHTHALMIC (EYE) OINTMENT

0.5 % T4

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

% T3 MD; QL (5 ML per 30 days)

metipranolol ophthalmic (eye) drops 0.3 % T2 MD

mometasone nasal spray,non-aerosol 50

mcg/actuation T4 MD

naphazoline ophthalmic (eye) drops 0.1 % T2

NEVANAC OPHTHALMIC (EYE)


olopatadine nasal spray,non-aerosol 0.6 % T4

PHOSPHOLINE IODIDE OPHTHALMIC

(EYE) DROPS 0.125 % T3 MD

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 % T3 MD

prednisolone acetate ophthalmic (eye)

drops,suspension 1 % T2

prednisolone sodium phosphate ophthalmic (eye)

drops 1 % T2

proparacaine ophthalmic (eye) drops 0.5 % T3

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 0.05 % T3 MD; QL (60 EA per 30 days)

SIMBRINZA OPHTHALMIC (EYE)

DROPS,SUSPENSION 1-0.2 % T3 MD

timolol maleate ophthalmic (eye) drops 0.25 %,

0.5 % T2 MD

TRAVATAN Z OPHTHALMIC (EYE) DROPS

0.004 % T3 MD; QL (5 ML per 30 days)

tropicamide ophthalmic (eye) drops 0.5 %, 1 % T3

TYZINE NASAL DROPS 0.05 % T3

VERAMYST NASAL SPRAY,SUSPENSION

27.5 MCG/ACTUATION T3 QL (10 GM per 30 days)

VEXOL OPHTHALMIC (EYE)

DROPS,SUSPENSION 1 % T4




ZIOPTAN (PF) OPHTHALMIC (EYE)

DROPPERETTE 0.0015 % T4 MD

ELECT/CALORIC/H2O

calcium acetate oral capsule 667 mg T2 MD

CYTRA-2 ORAL SOLUTION 500-334 MG/5

ML T2

CYTRA-3 ORAL SOLUTION 550-500-334

MG/5 ML T4

DENTA 5000 PLUS DENTAL CREAM 1.1 % T2 MD

DENTAGEL DENTAL GEL 1.1 % T2 MD

fluoride (sodium) dental solution 0.2 % T2

fluoride (sodium) oral drops 0.5 mg (1.1 mg

sod.fluorid)/ml NCS MD

fluoride (sodium) oral tablet 1 mg (2.2 mg sod.

fluoride) NCS

fluoride (sodium) oral tablet,chewable 0.25

mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium

fluorid), 1 mg (2.2 mg sod. fluoride)

NCS MD

FLUORITAB ORAL TABLET,CHEWABLE 0.5

MG (1.1 MG SODIUM FLUORID), 1 MG (2.2

MG SOD. FLUORIDE)

NCS MD

FOSRENOL ORAL TABLET,CHEWABLE

1,000 MG, 500 MG, 750 MG T3 ST; MD

GLUCAGEN HYPOKIT INJECTION RECON

SOLN 1 MG T3 QL (4 EA per 30 days)

GLUCAGEN INJECTION RECON SOLN 1 MG T3 QL (4 EA per 30 days)

GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION RECON SOLN 1 MG T3

ISOLYTE S PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION T2

KALEXATE ORAL POWDER IN PACKET 15

GRAM T3

KIONEX (WITH SORBITOL) ORAL

SUSPENSION 15-19.3 GRAM/60 ML T2

KIONEX ORAL POWDER T3

KLOR-CON 10 ORAL TABLET EXTENDED

RELEASE 10 MEQ T2 MD

KLOR-CON 8 ORAL TABLET EXTENDED

RELEASE 8 MEQ T2 MD




KLOR-CON M10 ORAL TABLET,ER

PARTICLES/CRYSTALS 10 MEQ T2 MD





KLOR-CON ORAL PACKET 20 MEQ T2 MD

KLOR-CON SPRINKLE ORAL CAPSULE,

EXTENDED RELEASE 10 MEQ T2

KLOR-CON SPRINKLE ORAL CAPSULE,

EXTENDED RELEASE 8 MEQ T2 MD

KLOR-CON/25 ORAL PACKET 25 MEQ T2

LUDENT FLUORIDE ORAL

TABLET,CHEWABLE 0.25 MG(0.55 MG SOD.

FLUORIDE), 0.5 MG (1.1 MG SODIUM

FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

NCS MD

NORMAL SALINE FLUSH INJECTION

SYRINGE T2

phospha 250 neutral oral tablet 250 mg T2

potassium chloride oral capsule, extended release

10 meq, 8 meq T2 MD

potassium chloride oral liquid 20 meq/15 ml, 40

meq/15 ml T2 MD

potassium chloride oral packet 20 meq T2 MD

potassium chloride oral tablet extended release

10 meq, 20 meq, 8 meq T2 MD

potassium chloride oral tablet,er

particles/crystals 10 meq, 20 meq T2 MD

potassium citrate oral tablet extended release 10

meq (1,080 mg), 15 meq, 5 meq (540 mg) T3 MD

PREVIDENT 5000 BOOSTER PLUS DENTAL

PASTE 1.1 % T4 MD

PREVIDENT 5000 DRY MOUTH DENTAL

GEL 1.1 % T4 MD

PREVIDENT 5000 ENAMEL PROTECT

DENTAL PASTE 1.1-5 % T4 MD

PREVIDENT 5000 PLUS DENTAL CREAM 1.1

% T4 MD

PREVIDENT 5000 SENSITIVE DENTAL

PASTE 1.1-5 % T4 MD

PREVIDENT DENTAL GEL 1.1 % T4 MD




PREVIDENT DENTAL SOLUTION 0.2 % T4 MD

PROGLYCEM ORAL SUSPENSION 50

MG/ML T4 MD

RENAGEL ORAL TABLET 400 MG T3 ST

RENAGEL ORAL TABLET 800 MG T3 ST; MD

RENVELA ORAL POWDER IN PACKET 0.8

GRAM, 2.4 GRAM T5 (SP) ST; MD

RENVELA ORAL TABLET 800 MG T5 (SP) ST; MD

SF 5000 PLUS DENTAL CREAM 1.1 % T2 MD

SF DENTAL GEL 1.1 % T2 MD

sodium chloride 0.9 % injection solution T2

sodium chloride 0.9 % injection syringe T2

sodium chloride 0.9 % intravenous parenteral

solution T2

SODIUM POLYSTYRENE (SORB FREE)

ORAL SUSPENSION 15 GRAM/60 ML T3

sodium polystyrene sulfonate oral powder T3

sodium polystyrene sulfonate oral suspension 15

gram/60 ml T2

SPS (WITH SORBITOL) ORAL SUSPENSION

15-20 GRAM/60 ML T2

TRICITRATES ORAL SOLUTION 550-500-334

MG/5 ML T4

GASTROINTESTINAL

ALOPHEN ORAL TABLET,DELAYED

RELEASE (DR/EC) 5 MG NCS

alosetron oral tablet 0.5 mg, 1 mg T5 (SP) PA; QL (60 EA per 30 days)

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG T3 MD; QL (60 EA per 30 days)

ANALPRAM ADVANCED KIT 2.5 %-1 %/ 630

MG/1 %-1 % T4 QL (4 EA per 30 days)

ANUCORT-HC RECTAL SUPPOSITORY 25

MG T3

ANZEMET ORAL TABLET 100 MG, 50 MG T5 (SP) PA

aprepitant oral capsule 125 mg, 40 mg, 80 mg T4 QL (60 EA per 30 days)

aprepitant oral capsule,dose pack 125 mg (1)- 80

mg (2) T4 QL (60 EA per 30 days)

APRISO ORAL CAPSULE,EXTENDED

RELEASE 24HR 0.375 GRAM T3 MD; QL (120 EA per 30 days)




atropine injection syringe 0.05 mg/ml, 0.1 mg/ml T4

balsalazide oral capsule 750 mg T3

bisacodyl oral tablet,delayed release (dr/ec) 5 mg NCS

BISA-LAX ORAL TABLET,DELAYED


BUPHENYL ORAL TABLET 500 MG T5 (SP) PA; MD

CANASA RECTAL SUPPOSITORY 1,000 MG T5 (SP) MD

CANTIL ORAL TABLET 25 MG T4

CARAFATE ORAL SUSPENSION 100 MG/ML T4 MD

CESAMET ORAL CAPSULE 1 MG T5 (SP) PA

chlordiazepoxide-clidinium oral capsule 5-2.5 mg T3

cimetidine hcl oral solution 300 mg/5 ml T2 MD

cimetidine oral tablet 200 mg, 300 mg, 400 mg,

800 mg T2 MD

CITRATE OF MAGNESIA ORAL SOLUTION NCS

CITROMA ORAL SOLUTION NCS

CLEARLAX ORAL POWDER 17

GRAM/DOSE NCS

CLENPIQ ORAL SOLUTION 10 MG-3.5

GRAM -12 GRAM/160 ML T3

COMPRO RECTAL SUPPOSITORY 25 MG T4

CONSTULOSE ORAL SOLUTION 10

GRAM/15 ML T2 MD

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 12,000-38,000 -60,000

UNIT, 24,000-76,000 -120,000 UNIT, 3,000-

9,500- 15,000 UNIT, 36,000-114,000- 180,000

UNIT, 6,000-19,000 -30,000 UNIT

T3 MD

dicyclomine oral capsule 10 mg T1 MD

dicyclomine oral solution 10 mg/5 ml T2

dicyclomine oral tablet 20 mg T1 MD

DIPENTUM ORAL CAPSULE 250 MG T5 (SP) MD

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5

ml T2

diphenoxylate-atropine oral tablet 2.5-0.025 mg T2

DONNATAL ORAL TABLET 16.2-0.1037 -

0.0194 MG T4

dronabinol oral capsule 10 mg T5 (SP) PA

dronabinol oral capsule 2.5 mg, 5 mg T4 PA




DUCODYL ORAL TABLET,DELAYED


EMEND ORAL CAPSULE 125 MG, 40 MG, 80

MG T4 PA; QL (60 EA per 30 days)

EMEND ORAL CAPSULE,DOSE PACK 125

MG (1)- 80 MG (2) T4 PA; QL (60 EA per 30 days)

ENULOSE ORAL SOLUTION 10 GRAM/15

ML T2 MD

famotidine oral suspension 40 mg/5 ml (8 mg/ml) T3 MD

famotidine oral tablet 10 mg, 20 mg, 40 mg T2 MD

FLEET LAXATIVE ORAL

TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS

GAVILAX ORAL POWDER 17 GRAM/DOSE NCS

GAVILYTE-C ORAL RECON SOLN 240-

22.72-6.72 -5.84 GRAM NCS

GAVILYTE-G ORAL RECON SOLN 236-

22.74-6.74 -5.86 GRAM NCS

GAVILYTE-H AND BISACODYL ORAL KIT

5-210 MG-GRAM NCS

GAVILYTE-N ORAL RECON SOLN 420

GRAM NCS

GENERLAC ORAL SOLUTION 10 GRAM/15

ML T2 MD

GENTLE LAXATIVE ORAL


GENTLELAX ORAL POWDER 17

GRAM/DOSE NCS

GLYCOLAX ORAL POWDER 17

GRAM/DOSE NCS

glycopyrrolate oral tablet 1 mg, 2 mg T2 MD

granisetron hcl oral tablet 1 mg T3

HEALTHYLAX ORAL POWDER IN PACKET

17 GRAM NCS

hydrocortisone acetate rectal suppository 25 mg,

30 mg T3

hydrocortisone-pramoxine rectal cream 1-1 %,

2.5-1 % T3

hyoscyamine sulfate oral drops 0.125 mg/ml T2 MD

hyoscyamine sulfate oral elixir 0.125 mg/5 ml T2 MD




hyoscyamine sulfate oral tablet 0.125 mg T2 MD

hyoscyamine sulfate oral tablet extended release

12 hr 0.375 mg T2 MD

hyoscyamine sulfate oral tablet,disintegrating

0.125 mg T2 MD

hyoscyamine sulfate sublingual tablet 0.125 mg T2 MD

HYOSYNE ORAL DROPS 0.125 MG/ML T2 MD

KEPIVANCE INTRAVENOUS RECON SOLN

6.25 MG T5 (SP)

KRISTALOSE ORAL PACKET 10 GRAM, 20

GRAM T3 MD

lactulose oral solution 10 gram/15 ml, 10

gram/15 ml (15 ml), 20 gram/30 ml T2 MD

lansoprazole oral capsule,delayed release(dr/ec)

15 mg, 30 mg T2 MD; QL (30 EA per 30 days)

LAXACLEAR ORAL POWDER 17

GRAM/DOSE NCS

LAXATIVE (BISACODYL) ORAL TABLET 5

MG NCS

LAXATIVE (BISACODYL) ORAL


LAXATIVE FEMININE ORAL TABLET 5 MG NCS

LAXATIVE PEG 3350 ORAL POWDER 17

GRAM/DOSE NCS

LIALDA ORAL TABLET,DELAYED

RELEASE (DR/EC) 1.2 GRAM T3 MD; QL (120 EA per 30 days)

lidocaine hcl-hydrocortison ac rectal cream 3-0.5

% T2

lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %,

3-1 % (7 gram) T4 QL (4 EA per 30 days)

lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55

% T2

lidocaine-hydrocortisone-aloe rectal kit 2-2 %, 3-

2.5 % (7 gram) T4 QL (4 EA per 30 days)

LINZESS ORAL CAPSULE 145 MCG, 290

MCG T3 MD

LINZESS ORAL CAPSULE 72 MCG T3 MD; QL (30 EA per 30 days)

loperamide oral capsule 2 mg T2 MD

magnesium citrate oral solution NCS

meclizine oral tablet 12.5 mg, 25 mg T2




mesalamine rectal enema 4 gram/60 ml T4 MD

mesalamine with cleansing wipe rectal enema kit

4 gram/60 ml T4

methscopolamine oral tablet 2.5 mg, 5 mg T2

metoclopramide hcl oral solution 5 mg/5 ml T2

metoclopramide hcl oral tablet 10 mg, 5 mg T2

MILK OF MAGNESIA CONCENTRATED

ORAL SUSPENSION 2,400 MG/10 ML NCS

MILK OF MAGNESIA ORAL SUSPENSION

400 MG/5 ML NCS

MIRALAX ORAL POWDER IN PACKET 17

GRAM NCS

misoprostol oral tablet 100 mcg, 200 mcg T2 MD

MOTOFEN ORAL TABLET 1-0.025 MG T4

MOVIPREP ORAL POWDER IN PACKET 100-

7.5-2.691 GRAM T4

nizatidine oral capsule 150 mg, 300 mg T2 MD

nizatidine oral solution 150 mg/10 ml T2 MD

omega-3 acid ethyl esters oral capsule 1 gram T3 MD

omeprazole oral capsule,delayed release(dr/ec)

10 mg, 20 mg, 40 mg T2 MD

omeprazole oral tablet,delayed release (dr/ec) 20

mg T2 MD

ondansetron hcl oral solution 4 mg/5 ml T2

ondansetron hcl oral tablet 24 mg T2 QL (30 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg T2 QL (60 EA per 30 days)

ondansetron oral tablet,disintegrating 4 mg, 8 mg T3

ORAL SALINE LAXATIVE ORAL LIQUID

7.2-2.7 GRAM/15 ML NCS

ORAL SALINE LAXATIVE ORAL SOLUTION NCS

OSCIMIN SR ORAL TABLET EXTENDED

RELEASE 12 HR 0.375 MG T2 MD

OSMOPREP ORAL TABLET 1.5 GRAM T4

pantoprazole oral tablet,delayed release (dr/ec)


peg 3350-electrolytes oral recon soln 236-22.74-

6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram NCS




PEG-3350 WITH FLAVOR PACKS ORAL

RECON SOLN 420 GRAM NCS

peg-electrolyte soln oral recon soln 420 gram NCS

PEG-PREP ORAL KIT 5-210 MG-GRAM NCS

PHENADOZ RECTAL SUPPOSITORY 12.5

MG, 25 MG T3

PHENERGAN RECTAL SUPPOSITORY 12.5

MG, 25 MG, 50 MG T3

PHOSPHATE LAXATIVE ORAL LIQUID 7.2-

2.7 GRAM/15 ML NCS

polyethylene glycol 3350 oral powder 17

gram/dose NCS

polyethylene glycol 3350 oral powder in packet

17 gram NCS

POWDERLAX ORAL POWDER 17

GRAM/DOSE NCS

PREPARATION CLEANSING ORAL LIQUID

7.2-2.7 GRAM/15 ML NCS

prochlorperazine edisylate injection solution 10

mg/2 ml (5 mg/ml) T4

prochlorperazine maleate oral tablet 10 mg, 5 mg T2

prochlorperazine rectal suppository 25 mg T4

PROCORT RECTAL CREAM 1.85-1.15 % T3

PROCTOFOAM HC RECTAL FOAM 1-1 % T4

PROCTOSOL HC RECTAL CREAM WITH

APPLICATOR 2.5 % T2

promethazine rectal suppository 12.5 mg, 25 mg,

50 mg T3

PROMETHEGAN RECTAL SUPPOSITORY

12.5 MG, 25 MG, 50 MG T3

propantheline oral tablet 15 mg T3

PURELAX ORAL POWDER 17 GRAM/DOSE NCS

PURELAX ORAL POWDER IN PACKET 17

GRAM NCS

rabeprazole oral tablet,delayed release (dr/ec) 20


ranitidine hcl oral syrup 15 mg/ml T2 MD

ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg T2 MD

RECTIV RECTAL OINTMENT 0.4 % (W/W) T4




scopolamine base transdermal patch 3 day 1 mg

over 3 days T4

SMOOTHLAX ORAL POWDER 17

GRAM/DOSE NCS

SMOOTHLAX ORAL POWDER IN PACKET

17 GRAM NCS

sodium phenylbutyrate oral tablet 500 mg T5 (SP) PA; MD

sucralfate oral suspension 100 mg/ml T3 MD

sucralfate oral tablet 1 gram T2 MD

sulfasalazine oral tablet 500 mg T2 MD

SULFAZINE ORAL TABLET 500 MG T2

SUPREP BOWEL PREP KIT ORAL RECON

SOLN 17.5-3.13-1.6 GRAM T3

TIGAN INTRAMUSCULAR SOLUTION 100

MG/ML T4 PA

TRILYTE WITH FLAVOR PACKETS ORAL

RECON SOLN 420 GRAM NCS

trimethobenzamide oral capsule 300 mg T2

ursodiol oral capsule 300 mg T4 MD

ursodiol oral tablet 250 mg, 500 mg T4 MD

VASCEPA ORAL CAPSULE 1 GRAM T3 MD

WOMAN'S LAXATIVE ORAL TABLET 5 MG NCS

WOMAN'S LAXATIVE ORAL


WOMEN'S GENTLE LAXATIVE(BISAC)

ORAL TABLET,DELAYED RELEASE

(DR/EC) 5 MG

NCS

WOMEN'S LAXATIVE (BISACODYL) ORAL

TABLET 5 MG NCS

WOMEN'S LAXATIVE (BISACODYL) ORAL


HORMONES

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25

GRAM (1.62 %)

T3 PA; MD; QL (150 GM per 30

days)

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62

% (40.5 MG/2.5 GRAM)

T3 PA; MD; QL (60 GM per 30 days)




budesonide oral capsule,delayed,extend.release 3

mg T5 (SP)

budesonide oral tablet,delayed and ext.release 9


cabergoline oral tablet 0.5 mg T3 MD; QL (16 EA per 28 days)

calcitonin (salmon) nasal spray,non-aerosol 200

unit/actuation T3 MD; QL (3.7 ML per 30 days)

CLIMARA PRO TRANSDERMAL PATCH

WEEKLY 0.045-0.015 MG/24 HR T4 MD

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25

MG/24 HR

T3 MD

cortisone oral tablet 25 mg T2

danazol oral capsule 100 mg, 200 mg, 50 mg T4

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5

MG/ML T3

desmopressin nasal spray with pump 10

mcg/spray (0.1 ml) T3 MD

desmopressin nasal spray,non-aerosol 10

mcg/spray (0.1 ml) T3 MD

desmopressin oral tablet 0.1 mg, 0.2 mg T3 MD

dexamethasone oral solution 0.5 mg/5 ml T3

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,

1.5 mg, 2 mg, 4 mg, 6 mg T2

dexamethasone sodium phosphate injection

solution 10 mg/ml, 4 mg/ml T2

dexamethasone sodium phosphate injection

syringe 4 mg/ml T3

DIVIGEL TRANSDERMAL GEL IN PACKET

0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5

GRAM (0.1 %), 1 MG/GRAM (0.1 %)

T4 MD

DUAVEE ORAL TABLET 0.45-20 MG T3 MD

ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG,

0.625 MG, 0.9 MG, 1.25 MG T3

ESTRACE VAGINAL CREAM 0.01 % (0.1

MG/GRAM) T3 MD

estradiol oral tablet 0.5 mg, 1 mg, 2 mg T2 MD

estradiol transdermal patch semiweekly 0.025

mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075

mg/24 hr, 0.1 mg/24 hr





estradiol transdermal patch weekly 0.025 mg/24

hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24

hr, 0.075 mg/24 hr, 0.1 mg/24 hr


estradiol vaginal tablet 10 mcg T3 MD

estradiol-norethindrone acet oral tablet 0.5-0.1

mg, 1-0.5 mg T2 MD

ESTROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 1.25

GRAM/ACTUATION

T4 MD

estrogens-methyltestosterone oral tablet 0.625-

1.25 mg, 1.25-2.5 mg T3 MD

estropipate oral tablet 0.75 mg T2 MD

estropipate oral tablet 1.5 mg, 3 mg T2

fludrocortisone oral tablet 0.1 mg T2 MD

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg T2 MD

hydrocortisone rectal enema 100 mg/60 ml T4

INCRELEX SUBCUTANEOUS SOLUTION 10

MG/ML T5 (SP) PA

JINTELI ORAL TABLET 1-5 MG-MCG T3 MD

LOPREEZA ORAL TABLET 0.5-0.1 MG, 1-0.5

MG T3 MD


INTRAMUSCULAR SYRINGE KIT 11.25 MG T5 (SP) PA; QL (1 EA per 84 days)

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG T5 (SP) PA; QL (1 EA per 28 days)

LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 11.25 MG,

30 MG

T5 (SP) PA; QL (1 EA per 84 days)

LUPRON DEPOT-PED INTRAMUSCULAR

KIT 11.25 MG, 15 MG, 7.5 MG (PED) T5 (SP) PA; QL (1 EA per 28 days)

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5

mg T2 MD

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG, 2.5 MG T4 PA; MD

methylergonovine oral tablet 0.2 mg T3

methylprednisolone acetate injection suspension

40 mg/ml, 80 mg/ml T2

methylprednisolone oral tablet 16 mg, 32 mg, 4

mg, 8 mg T2




methylprednisolone oral tablets,dose pack 4 mg T2

MILLIPRED DP ORAL TABLETS,DOSE

PACK 5 MG (21 TABS) T3

MIMVEY LO ORAL TABLET 0.5-0.1 MG T3 MD

MIMVEY ORAL TABLET 1-0.5 MG T3 MD

norethindrone acetate oral tablet 5 mg T2 MD

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg T3 MD

octreotide acetate injection solution 1,000

mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500

mcg/ml

T5 (SP) PA; MD

OMNITROPE SUBCUTANEOUS CARTRIDGE

10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3

MG/ML)

T5 (SP) PA; MD

OMNITROPE SUBCUTANEOUS RECON

SOLN 5.8 MG T5 (SP) PA; MD

oxandrolone oral tablet 10 mg T5 (SP) PA; MD; QL (120 EA per 30 days)

oxandrolone oral tablet 2.5 mg T5 (SP) PA; MD; QL (60 EA per 30 days)

prednisolone oral solution 15 mg/5 ml T2

prednisolone sodium phosphate oral solution 15

mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml

(5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

T2

prednisolone sodium phosphate oral

tablet,disintegrating 10 mg, 15 mg, 30 mg T4

PREDNISONE INTENSOL ORAL

CONCENTRATE 5 MG/ML T2

prednisone oral solution 5 mg/5 ml T2

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20

mg, 5 mg, 50 mg T1

prednisone oral tablets,dose pack 10 mg, 5 mg T2

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,

0.625 MG, 0.9 MG, 1.25 MG T3 MD

PREMARIN VAGINAL CREAM 0.625

MG/GRAM T3 MD

PREMPHASE ORAL TABLET 0.625 MG (14)/

0.625MG-5MG(14) T3 MD

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-

1.5 MG, 0.625-2.5 MG, 0.625-5 MG T3 MD

progesterone intramuscular oil 50 mg/ml T2

progesterone micronized oral capsule 100 mg,

200 mg T2 MD




SANDOSTATIN LAR DEPOT

INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 10

MG, 20 MG, 30 MG

T5 (SP) PA; MD

SIGNIFOR LAR INTRAMUSCULAR


MG, 20 MG, 30 MG, 40 MG, 60 MG

T5 (SP) PA; MD

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90

MG/0.3 ML

T5 (SP) PA; MD

SYNAREL NASAL SPRAY,NON-AEROSOL 2

MG/ML T5 (SP)

testosterone cypionate intramuscular oil 100

mg/ml T3 MD; QL (10 ML per 28 days)

testosterone cypionate intramuscular oil 200

mg/ml T3 MD; QL (4 ML per 28 days)

testosterone enanthate intramuscular oil 200

mg/ml T3 QL (5 ML per 28 days)

testosterone transdermal gel 50 mg/5 gram (1 %) T3 MD; QL (60 GM per 30 days)

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1 %) T3 MD; QL (75 GM per 30 days)

testosterone transdermal gel in packet 1 % (25

mg/2.5gram) T3 MD; QL (150 GM per 30 days)

testosterone transdermal gel in packet 1 % (50

mg/5 gram) T3 MD; QL (60 GM per 30 days)

triamcinolone acetonide injection suspension 40

mg/ml T4

TYMLOS SUBCUTANEOUS PEN INJECTOR

80 MCG (3,120 MCG/1.56 ML) T5 (SP) PA; MD

VAGIFEM VAGINAL TABLET 10 MCG T3 MD

IMMUNOSUPPRESSANTS

azathioprine oral tablet 50 mg T2 MD

cyclosporine modified oral capsule 100 mg, 25

mg, 50 mg T3 MD

cyclosporine modified oral solution 100 mg/ml T3 MD

cyclosporine oral capsule 100 mg, 25 mg T3 MD

ELIDEL TOPICAL CREAM 1 % T4

GENGRAF ORAL CAPSULE 100 MG, 25 MG T3 MD

GENGRAF ORAL CAPSULE 50 MG T3




GENGRAF ORAL SOLUTION 100 MG/ML T3 MD

mycophenolate mofetil oral capsule 250 mg T3 MD

mycophenolate mofetil oral suspension for

reconstitution 200 mg/ml T4 MD

mycophenolate mofetil oral tablet 500 mg T3 MD

mycophenolate sodium oral tablet,delayed release

(dr/ec) 180 mg, 360 mg T4 MD

NULOJIX INTRAVENOUS RECON SOLN 250

MG T5 (SP) PA; MD

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5

MG T4 MD

RAPAMUNE ORAL SOLUTION 1 MG/ML T5 (SP) MD

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg T4 MD

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T3 MD

tacrolimus topical ointment 0.03 %, 0.1 % T4 PA

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,

0.75 MG T5 (SP) PA; MD

MISCELLANEOUS MEDICAL

SUPPLIES, DEVICES, NON-DRUG

ASSURE ID INSULIN SAFETY SYRINGE 1

ML 29 GAUGE X 1/2" T3 MD; QL (200 EA per 30 days)

BD LANCET DEVICE T3

CURITY GAUZE TOPICAL BANDAGE 2 X 2 " T3

FREESTYLE FREEDOM LITE KIT T3 MD

FREESTYLE INSULINX T3 MD

FREESTYLE LANCETS 28 GAUGE T3 MD; QL (200 EA per 30 days)

FREESTYLE LITE METER KIT T3 MD

insulin syringe-needle u-100 syringe 0.3 ml 29

gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge T3 MD; QL (200 EA per 30 days)

lancets T3 MD; QL (200 EA per 30 days)

PEN NEEDLE NEEDLE 31 GAUGE X 5/16" T3 MD; QL (200 EA per 30 days)

PENTIPS NEEDLE 31 GAUGE X 5/16" T3 MD; QL (200 EA per 30 days)

PRECISION XTRA MONITOR T3 MD

MUSCLE RELAXANTS

baclofen oral tablet 10 mg, 20 mg T2 MD

carisoprodol oral tablet 350 mg T2 QL (30 EA per 30 days)

chlorzoxazone oral tablet 500 mg T2 QL (120 EA per 30 days)

cyclobenzaprine oral tablet 10 mg, 5 mg T2 QL (90 EA per 30 days)




dantrolene oral capsule 100 mg, 25 mg, 50 mg T3 MD

metaxalone oral tablet 800 mg T4 QL (120 EA per 30 days)

methocarbamol oral tablet 500 mg, 750 mg T2

orphenadrine citrate oral tablet extended release


tizanidine oral tablet 2 mg, 4 mg T2 MD

PRE-NATAL VITAMINS

PNV 29-1 ORAL TABLET 29 MG IRON- 1 MG T3 MD

PRENATABS FA ORAL TABLET 29-1 MG T2 MD

PRENATABS RX ORAL TABLET 29 MG

IRON- 1 MG T4 MD

PRETAB ORAL TABLET 29-1 MG T2 MD

VITAFOL-OB+DHA ORAL COMBO PACK 65-

1-250 MG T3 MD

PSYCHOTHERAPEUTIC DRUGS

alprazolam oral tablet 0.25 mg, 0.5 mg T2 QL (120 EA per 30 days)

alprazolam oral tablet 1 mg T2 QL (240 EA per 30 days)

alprazolam oral tablet 2 mg T2 QL (150 EA per 30 days)

alprazolam oral tablet extended release 24 hr 0.5


alprazolam oral tablet extended release 24 hr 1


amitriptyline oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg T2 MD

amitriptyline-chlordiazepoxide oral tablet 12.5-5

mg, 25-10 mg T2 MD

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50

mg T2 MD

aripiprazole oral solution 1 mg/ml T4 MD

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20


aripiprazole oral tablet,disintegrating 10 mg, 15


armodafinil oral tablet 150 mg, 200 mg, 250 mg,

50 mg T4 PA; MD; QL (30 EA per 30 days)

BRINTELLIX ORAL TABLET 10 MG, 20 MG,

5 MG T3 QL (30 EA per 30 days)

bupropion hcl oral tablet 100 mg, 75 mg T2 MD




bupropion hcl oral tablet extended release 24 hr


bupropion hcl oral tablet extended release 24 hr


bupropion hcl oral tablet sustained-release 12 hr


bupropion hcl oral tablet sustained-release 12 hr


buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,

7.5 mg T2 MD

chlordiazepoxide hcl oral capsule 10 mg, 25 mg,

5 mg T2

chlorpromazine oral tablet 10 mg, 100 mg, 200


citalopram oral solution 10 mg/5 ml T2 MD; QL (600 ML per 30 days)

citalopram oral tablet 10 mg, 40 mg T1 MD; QL (30 EA per 30 days)

citalopram oral tablet 20 mg T1 MD; QL (60 EA per 30 days)

clomipramine oral capsule 25 mg, 50 mg, 75 mg T4 MD

clorazepate dipotassium oral tablet 15 mg T2 QL (180 EA per 30 days)

clorazepate dipotassium oral tablet 3.75 mg, 7.5


clozapine oral tablet 100 mg, 200 mg, 25 mg, 50

mg T2 MD

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 150 mg, 200 mg, 25 mg T4 PA; MD

DAYTRANA TRANSDERMAL PATCH 24

HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9

HR, 30 MG/9 HR


desipramine oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg T2 MD

desvenlafaxine oral tablet extended release 24 hr

100 mg, 50 mg T4 MD

desvenlafaxine oral tablet extended release 24hr

100 mg, 50 mg T4 MD

desvenlafaxine succinate oral tablet extended

release 24 hr 100 mg, 25 mg, 50 mg T4 MD

dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg T3 MD; QL (30 EA per 30 days)

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5





DIAZEPAM INTENSOL ORAL

CONCENTRATE 5 MG/ML T4 PA

diazepam oral concentrate 5 mg/ml T4 PA

diazepam oral solution 5 mg/5 ml (1 mg/ml) T4

diazepam oral tablet 10 mg T2 QL (120 EA per 30 days)

diazepam oral tablet 2 mg, 5 mg T2 QL (90 EA per 30 days)

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25


doxepin oral concentrate 10 mg/ml T2 MD

duloxetine oral capsule,delayed release(dr/ec) 20


duloxetine oral capsule,delayed release(dr/ec) 30


EMSAM TRANSDERMAL PATCH 24 HOUR

12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR T5 (SP) PA; MD; QL (30 EA per 30 days)

escitalopram oxalate oral solution 5 mg/5 ml T3 MD; QL (600 ML per 30 days)

escitalopram oxalate oral tablet 10 mg, 20 mg, 5


FANAPT ORAL TABLET 1 MG, 10 MG, 12

MG, 2 MG, 4 MG, 6 MG, 8 MG T4 PA; MD; QL (60 EA per 30 days)

FANAPT ORAL TABLETS,DOSE PACK

1MG(2)-2MG(2)- 4MG(2)-6MG(2) T4 PA; QL (8 EA per 28 days)

fluoxetine oral capsule 10 mg, 20 mg T2 MD; QL (90 EA per 30 days)

fluoxetine oral capsule 40 mg T2 MD; QL (60 EA per 30 days)

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) T2 MD; QL (600 ML per 30 days)

fluoxetine oral tablet 10 mg T3 MD; QL (240 EA per 30 days)

fluoxetine oral tablet 20 mg T3 MD; QL (120 EA per 30 days)

fluphenazine hcl oral concentrate 5 mg/ml T3

fluphenazine hcl oral elixir 2.5 mg/5 ml T3 MD

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg,

5 mg T2 MD

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (90 EA per 30 days)

FOCALIN XR ORAL CAPSULE,ER BIPHASIC

50-50 25 MG, 35 MG T4 MD; QL (30 EA per 30 days)

guanfacine oral tablet extended release 24 hr 1

mg, 2 mg, 3 mg, 4 mg T3 MD; QL (30 EA per 30 days)

haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml T2 MD




haloperidol lactate injection solution 5 mg/ml T2

haloperidol lactate oral concentrate 2 mg/ml T2 MD

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2


imipramine hcl oral tablet 10 mg, 25 mg, 50 mg T2 MD

imipramine pamoate oral capsule 100 mg, 125

mg, 150 mg, 75 mg T4 MD

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234

MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

T5 (SP) PA; MD

LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG T4 MD; QL (30 EA per 30 days)

LATUDA ORAL TABLET 80 MG T4 MD; QL (60 EA per 30 days)

lithium carbonate oral capsule 150 mg, 300 mg,

600 mg T1 MD

lithium carbonate oral tablet 300 mg T2 MD

lithium carbonate oral tablet extended release

300 mg, 450 mg T2 MD

lithium citrate oral solution 8 meq/5 ml T2 MD

lorazepam oral concentrate 2 mg/ml T2

lorazepam oral tablet 0.5 mg, 1 mg T2 QL (180 EA per 30 days)

lorazepam oral tablet 2 mg T2 QL (150 EA per 30 days)

loxapine succinate oral capsule 10 mg, 25 mg, 5

mg, 50 mg T2 MD

maprotiline oral tablet 25 mg, 50 mg, 75 mg T3 MD

MARPLAN ORAL TABLET 10 MG T4 MD

meprobamate oral tablet 200 mg, 400 mg T3

methylphenidate hcl oral capsule,er biphasic 50-

50 20 mg, 30 mg T3 MD; QL (60 EA per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-

50 40 mg T3 MD; QL (30 EA per 30 days)

methylphenidate hcl oral solution 10 mg/5 ml, 5

mg/5 ml T2 MD

methylphenidate hcl oral tablet 10 mg, 20 mg, 5


methylphenidate hcl oral tablet extended release








24hr 18 mg, 27 mg, 36 mg, 54 mg T3 MD; QL (30 EA per 30 days)

mirtazapine oral tablet 15 mg, 7.5 mg T2 MD; QL (90 EA per 30 days)

mirtazapine oral tablet 30 mg, 45 mg T2 MD; QL (30 EA per 30 days)

mirtazapine oral tablet,disintegrating 15 mg, 30


modafinil oral tablet 100 mg, 200 mg T4 PA; MD; QL (30 EA per 30 days)

nefazodone oral tablet 100 mg, 150 mg, 250 mg,


nefazodone oral tablet 200 mg T2 MD; QL (90 EA per 30 days)

nortriptyline oral capsule 10 mg, 25 mg, 50 mg,

75 mg T1 MD

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20

mg, 5 mg, 7.5 mg T2 MD; QL (30 EA per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15


olanzapine-fluoxetine oral capsule 12-25 mg, 12-

50 mg, 3-25 mg, 6-25 mg, 6-50 mg T4 MD

paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg, 9 mg T5 (SP) PA; MD; QL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr 6

mg T5 (SP) PA; MD; QL (60 EA per 30 days)

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg,


paroxetine hcl oral tablet extended release 24 hr

12.5 mg T3 MD; QL (30 EA per 30 days)

paroxetine hcl oral tablet extended release 24 hr

25 mg, 37.5 mg T3 MD; QL (60 EA per 30 days)

PAXIL ORAL SUSPENSION 10 MG/5 ML T4 MD; QL (900 ML per 30 days)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg T2 MD

perphenazine-amitriptyline oral tablet 2-10 mg,

2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg T2 MD

PEXEVA ORAL TABLET 10 MG, 20 MG, 30

MG, 40 MG T4 MD

phenelzine oral tablet 15 mg T3 MD

pimozide oral tablet 1 mg, 2 mg T3 MD

PRISTIQ ORAL TABLET EXTENDED

RELEASE 24 HR 100 MG, 25 MG, 50 MG T3 MD; QL (30 EA per 30 days)

protriptyline oral tablet 10 mg, 5 mg T3 MD




quetiapine oral tablet 100 mg, 200 mg, 25 mg,


quetiapine oral tablet extended release 24 hr 150

mg, 200 mg, 300 mg, 400 mg, 50 mg T4 PA; MD

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5

MG/2 ML, 50 MG/2 ML

T4 PA; MD; QL (4 EA per 28 days)

risperidone oral solution 1 mg/ml T2 MD

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2


risperidone oral tablet,disintegrating 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg T3 MD; QL (120 EA per 30 days)

SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 10 MG, 5 MG T4 PA

SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5

MG, 5 MG T4 PA; MD

SEROQUEL XR ORAL TABLET EXTENDED


400 MG, 50 MG

T4 PA; MD

sertraline oral concentrate 20 mg/ml T2 MD; QL (300 ML per 30 days)

sertraline oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (60 EA per 30 days)

STRATTERA ORAL CAPSULE 10 MG, 18

MG, 25 MG, 40 MG T3 MD; QL (60 EA per 30 days)

STRATTERA ORAL CAPSULE 100 MG, 60

MG, 80 MG T3 MD; QL (30 EA per 30 days)

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg T2 MD

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg T2 MD

tranylcypromine oral tablet 10 mg T3 MD

trazodone oral tablet 100 mg, 150 mg, 50 mg T2 MD

trazodone oral tablet 300 mg T4 MD

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5

mg T2 MD

trimipramine oral capsule 100 mg, 25 mg, 50 mg T4 MD

TRINTELLIX ORAL TABLET 10 MG, 20 MG,

5 MG T3 MD; QL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr


venlafaxine oral capsule,extended release 24hr





venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg,


VIIBRYD ORAL TABLET 10 MG, 20 MG, 40

MG T4 ST; MD; QL (30 EA per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40

MG (16)

T4 ST; QL (30 EA per 30 days)

VYVANSE ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG, 50 MG, 60 MG, 70 MG T3 MD; QL (30 EA per 30 days)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60


SEDATIVE/HYPNOTICS

BELSOMRA ORAL TABLET 10 MG, 15 MG,

20 MG, 5 MG T4 PA

estazolam oral tablet 1 mg, 2 mg T2

eszopiclone oral tablet 1 mg, 2 mg, 3 mg T2 QL (30 EA per 30 days)

flurazepam oral capsule 15 mg, 30 mg T2

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) T2 MD

phenobarbital oral tablet 100 mg, 15 mg, 16.2

mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg T2 MD

SILENOR ORAL TABLET 3 MG, 6 MG T4

temazepam oral capsule 15 mg, 30 mg T2 QL (30 EA per 30 days)

triazolam oral tablet 0.125 mg, 0.25 mg T2

XYREM ORAL SOLUTION 500 MG/ML T5 (SP) PA

zaleplon oral capsule 10 mg, 5 mg T2 QL (30 EA per 30 days)

zolpidem oral tablet 10 mg, 5 mg T2 QL (30 EA per 30 days)

SKIN PREPS

8-MOP ORAL CAPSULE 10 MG T5 (SP)

ACANYA TOPICAL GEL 1.2-2.5 % T4

acitretin oral capsule 10 mg, 17.5 mg, 25 mg T5 (SP) PA

adapalene topical cream 0.1 % T3

adapalene topical gel 0.1 % T3

alclometasone topical cream 0.05 % T3

alclometasone topical ointment 0.05 % T3

ALTABAX TOPICAL OINTMENT 1 % T4

aluminum chloride topical solution 20 % T2

amcinonide topical cream 0.1 % T4




ammonium lactate topical cream 12 % T2

ammonium lactate topical lotion 12 % T2

AMNESTEEM ORAL CAPSULE 10 MG, 20

MG, 40 MG T5 (SP)

benzoyl peroxide topical cleanser 6 % T2

benzoyl peroxide topical cleanser 7 % T3

benzoyl peroxide topical foam 5.3 %, 9.8 % T2

benzoyl peroxide topical gel 10 %, 2.5 % T2

betamethasone dipropionate topical cream 0.05

% T3

betamethasone dipropionate topical lotion 0.05 % T2

betamethasone dipropionate topical ointment

0.05 % T3

betamethasone valerate topical cream 0.1 % T2

betamethasone valerate topical lotion 0.1 % T3

betamethasone valerate topical ointment 0.1 % T2

betamethasone, augmented topical cream 0.05 % T2

betamethasone, augmented topical gel 0.05 % T2

betamethasone, augmented topical lotion 0.05 % T3

betamethasone, augmented topical ointment 0.05

% T2

calcipotriene scalp solution 0.005 % T4

calcipotriene topical cream 0.005 % T4

calcipotriene topical ointment 0.005 % T4

calcipotriene-betamethasone topical ointment

0.005-0.064 % T4

calcitriol topical ointment 3 mcg/gram T5 (SP) PA

CAPEX TOPICAL SHAMPOO 0.01 % T3

CLARAVIS ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG T4

clindamycin-benzoyl peroxide topical gel 1-5 %,

1.2 %(1 % base) -5 % T4

clobetasol scalp solution 0.05 % T3

clobetasol topical cream 0.05 % T4

clobetasol topical gel 0.05 % T4

clobetasol topical lotion 0.05 % T4

clobetasol topical ointment 0.05 % T4

clobetasol topical shampoo 0.05 % T4




clobetasol-emollient topical cream 0.05 % T4

clocortolone pivalate topical cream 0.1 % T4

CLODAN TOPICAL SHAMPOO 0.05 % T4

CONDYLOX TOPICAL GEL 0.5 % T4

CORDRAN TAPE LARGE ROLL TOPICAL

TAPE 4 MCG/CM2 T4

CORDRAN TAPE SMALL ROLL TOPICAL

TAPE 4 MCG/CM2 T4

CORDRAN TOPICAL LOTION 0.05 % T4

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE 150 MG/ML T5 (SP) PA; MD

COSENTYX PEN (2 PENS) SUBCUTANEOUS

PEN INJECTOR 150 MG/ML T5 (SP) PA; MD

COSENTYX PEN SUBCUTANEOUS PEN

INJECTOR 150 MG/ML T5 (SP) PA; MD

COSENTYX SUBCUTANEOUS SYRINGE 150


desonide topical cream 0.05 % T4

desonide topical lotion 0.05 % T4

desonide topical ointment 0.05 % T4

desoximetasone topical cream 0.05 %, 0.25 % T3

desoximetasone topical gel 0.05 % T3

desoximetasone topical ointment 0.05 %, 0.25 % T3

diclofenac sodium topical gel 1 % T3 MD

diflorasone topical cream 0.05 % T4

DUPIXENT SUBCUTANEOUS SYRINGE 300

MG/2 ML T5 (SP) PA; MD

ELETONE TOPICAL CREAM T4

EPICERAM TOPICAL EMULSION,

EXTENDED RELEASE T4

EPIDUO TOPICAL GEL 0.1-2.5 % T4

EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5

% T4

EPIFOAM TOPICAL FOAM 1-1 % T4

EUCRISA TOPICAL OINTMENT 2 % T4

FINACEA TOPICAL GEL 15 % T4

fluocinolone and shower cap scalp oil 0.01 % T3




fluocinolone topical cream 0.01 %, 0.025 % T3

fluocinolone topical oil 0.01 % T3

fluocinolone topical ointment 0.025 % T3

fluocinolone topical solution 0.01 % T3

fluocinonide topical cream 0.05 % T3

fluocinonide topical gel 0.05 % T3

fluocinonide topical ointment 0.05 % T3

fluocinonide topical solution 0.05 % T3

FLUOCINONIDE-E TOPICAL CREAM 0.05 % T3

fluticasone topical cream 0.05 % T2

fluticasone topical lotion 0.05 % T3

fluticasone topical ointment 0.005 % T2

halobetasol propionate topical cream 0.05 % T4

halobetasol propionate topical ointment 0.05 % T4

HALOG TOPICAL OINTMENT 0.1 % T4

HPR PLUS TOPICAL CREAM T4

HPR PLUS TOPICAL FOAM T4

HPR TOPICAL FOAM T4

hydrocortisone acetate topical cream 1 % T2

hydrocortisone butyrate topical cream 0.1 % T2

hydrocortisone butyrate topical ointment 0.1 % T4

hydrocortisone butyrate topical solution 0.1 % T4

hydrocortisone butyr-emollient topical cream 0.1

% T4

hydrocortisone topical cream 0.5 %, 1 %, 2.5 % T2

hydrocortisone topical cream with perineal

applicator 1 %, 2.5 % T2

hydrocortisone topical lotion 1 % T1

hydrocortisone topical lotion 2.5 % T3

hydrocortisone topical ointment 0.5 %, 1 %, 2.5

% T2

hydrocortisone valerate topical cream 0.2 % T4

hydrocortisone valerate topical ointment 0.2 % T2

HYLATOPIC TOPICAL FOAM T4

HYLATOPICPLUS TOPICAL CREAM T4

HYLATOPICPLUS TOPICAL FOAM T4

imiquimod topical cream in packet 5 % T4 QL (20 EA per 28 days)




iodoquinol-hc topical cream 1-1 % T3

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40

mg T4

lindane topical lotion 1 % T3

lindane topical shampoo 1 % T3

LOCOID TOPICAL LOTION 0.1 % T4

malathion topical lotion 0.5 % T3

methoxsalen oral capsule,liqd-filled,rapid rel 10

mg T5 (SP)

metronidazole topical cream 0.75 % T3

metronidazole topical gel 0.75 % T3

metronidazole topical gel 1 % T4

metronidazole topical gel with pump 1 % T4

metronidazole topical lotion 0.75 % T4

mometasone topical cream 0.1 % T2

mometasone topical ointment 0.1 % T2

mometasone topical solution 0.1 % T2

MYORISAN ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG T4

NEOSALUS TOPICAL FOAM T4

OXSORALEN TOPICAL LOTION 1 % T3

permethrin topical cream 5 % T4

PHYSIOLYTE IRRIGATION SOLUTION 140-

5-3-98 MEQ/L T4

podofilox topical solution 0.5 % T3

PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1

% T4

prednicarbate topical cream 0.1 % T3

prednicarbate topical ointment 0.1 % T3

PROCTO-PAK TOPICAL CREAM WITH

PERINEAL APPLICATOR 1 % T2

PROCTOZONE-HC TOPICAL CREAM WITH

PERINEAL APPLICATOR 2.5 % T2

PROMISEB TOPICAL CREAM T4

PRUTECT TOPICAL EMULSION T3

REGRANEX TOPICAL GEL 0.01 % T4 PA

REMEVEN TOPICAL CREAM 50 % T2




ringer's irrigation solution T2

salicylic acid topical cream,extended release 6 % T2

salicylic acid topical foam 6 % T2

salicylic acid topical gel 6 % T2

salicylic acid topical lotion,extended release 6 % T2

salicylic acid topical shampoo 6 % T2

SANTYL TOPICAL OINTMENT 250

UNIT/GRAM T4

selenium sulfide topical lotion 2.5 % T2

selenium sulfide topical shampoo 2.25 % T4

SKLICE TOPICAL LOTION 0.5 % T4

sodium chloride irrigation solution 0.9 % T2

sulfacetamide sodium (acne) topical suspension

10 % T2

sulfacetamide sodium topical cleanser 10 % T4

sulfacetamide sodium topical cleanser, gel 10 % T4

sulfacetamide sodium topical shampoo 10 % T4

tazarotene topical cream 0.1 % T4

TAZORAC TOPICAL CREAM 0.05 %, 0.1 % T4

TAZORAC TOPICAL GEL 0.05 %, 0.1 % T4

tretinoin (emollient) topical cream 0.05 % T3

tretinoin microspheres topical gel 0.04 %, 0.1 % T3

tretinoin microspheres topical gel with pump 0.04

%, 0.1 % T3

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % T3

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % T3

triamcinolone acetonide topical aerosol 0.147

mg/gram T4

triamcinolone acetonide topical cream 0.025 %,

0.1 %, 0.5 % T2

triamcinolone acetonide topical lotion 0.025 %,

0.1 % T2

triamcinolone acetonide topical ointment 0.025

%, 0.1 %, 0.5 % T2

ULESFIA TOPICAL LOTION 5 % T4

urea topical cream 10 %, 20 %, 39 %, 40 %, 45

%, 47 %, 50 % T2

urea topical foam 35 % T2




urea topical gel 40 %, 45 % T2

urea topical lotion 10 %, 40 %, 45 % T2

urea topical nail film suspension 40 % T2

VELTIN TOPICAL GEL 1.2-0.025 % T5 (SP)

water for irrigation, sterile irrigation solution T2

ZENATANE ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG T4

ZIANA TOPICAL GEL 1.2-0.025 % T5 (SP)

ZONALON TOPICAL CREAM 5 % T4

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet

extended release 12 hr 150 mg NCS QL (336 EA per 365 days)

CHANTIX CONTINUING MONTH BOX

ORAL TABLET 1 MG NCS QL (340 EA per 365 days)

CHANTIX CONTINUING MONTH PAK ORAL

TABLET 1 MG NCS QL (340 EA per 365 days)

CHANTIX ORAL TABLET 0.5 MG, 1 MG NCS QL (340 EA per 365 days)

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK 0.5 MG (11)- 1 MG

(42)

NCS QL (106 EA per 365 days)

CHANTIX STARTING MONTH PAK ORAL

TABLETS,DOSE PACK 0.5 MG (11)- 1 MG

(42)

NCS QL (106 EA per 365 days)

nicotine (polacrilex) buccal gum 2 mg, 4 mg NCS QL (2800 EA per 365 days)

nicotine (polacrilex) buccal lozenge 2 mg, 4 mg NCS QL (2448 EA per 365 days)

nicotine transdermal patch 24 hour 14 mg/24 hr,

21 mg/24 hr NCS QL (84 EA per 365 days)

nicotine transdermal patch 24 hour 7 mg/24 hr NCS QL (28 EA per 365 days)

NICOTROL INHALATION CARTRIDGE 10

MG NCS QL (2688 EA per 365 days)

NICOTROL NS NASAL SPRAY,NON-

AEROSOL 10 MG/ML NCS QL (6720 ML per 365 days)

THYROID PREPS

ARMOUR THYROID ORAL TABLET 120 MG,

15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60

MG, 90 MG

T3 MD




levothyroxine oral tablet 100 mcg, 112 mcg, 125

mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25

mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

T2 MD

LEVOXYL ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175

MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,

88 MCG

T2 MD

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg T2 MD

methimazole oral tablet 10 mg, 5 mg T1 MD

NATURE-THROID ORAL TABLET 113.75

MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG,

195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG,

65 MG, 81.25 MG, 97.5 MG

T2 MD

NP THYROID ORAL TABLET 30 MG, 60 MG,

90 MG T2 MD

propylthiouracil oral tablet 50 mg T3 MD

SYNTHROID ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175


75 MCG, 88 MCG

T3 MD

UNITHROID ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175


75 MCG, 88 MCG

T2 MD

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

333 mg T4 MD

ADAGEN INTRAMUSCULAR SOLUTION 250

UNIT/ML T5 (SP) PA

alendronate oral tablet 10 mg, 40 mg, 5 mg T2 MD; QL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg T1 MD; QL (4 EA per 28 days)

alfuzosin oral tablet extended release 24 hr 10 mg T2 MD; QL (30 EA per 30 days)

ARCALYST SUBCUTANEOUS RECON SOLN


buprenorphine hcl sublingual tablet 2 mg, 8 mg T3 PA; QL (90 EA per 30 days)

CHEMET ORAL CAPSULE 100 MG T4

chlorhexidine gluconate mucous membrane

mouthwash 0.12 % T2

CYSTAGON ORAL CAPSULE 150 MG, 50 MG T4 PA; MD

disulfiram oral tablet 250 mg, 500 mg T2 MD




doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5

mcg T3 PA; MD

doxycycline hyclate oral tablet 20 mg T2

dutasteride oral capsule 0.5 mg T3 MD; QL (30 EA per 30 days)

dutasteride-tamsulosin oral capsule, er

multiphase 24 hr 0.5-0.4 mg T3 MD; QL (30 EA per 30 days)

ESBRIET ORAL CAPSULE 267 MG T5 (SP) PA; MD

ESBRIET ORAL TABLET 267 MG, 801 MG T5 (SP) PA; MD

etidronate disodium oral tablet 200 mg, 400 mg T3 MD

EXJADE ORAL TABLET, DISPERSIBLE 125

MG, 250 MG, 500 MG T5 (SP) PA; MD

FERRIPROX ORAL TABLET 500 MG T5 (SP) PA

finasteride oral tablet 5 mg T2 MD

flavoxate oral tablet 100 mg T2 MD

FORTEO SUBCUTANEOUS PEN INJECTOR

20 MCG/DOSE - 600 MCG/2.4 ML T5 (SP) PA; MD; QL (2.4 ML per 28 days)

ibandronate oral tablet 150 mg T2 MD; QL (1 EA per 28 days)

KALYDECO ORAL GRANULES IN PACKET


KALYDECO ORAL TABLET 150 MG T5 (SP) PA; MD; QL (60 EA per 30 days)

KUVAN ORAL TABLET,SOLUBLE 100 MG T5 (SP) PA; MD

leucovorin calcium oral tablet 10 mg, 15 mg, 25

mg, 5 mg T4

levocarnitine (with sugar) oral solution 100

mg/ml T3 MD

levocarnitine oral tablet 330 mg T3 MD

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) T2 MD

megestrol oral suspension 625 mg/5 ml T4 MD

miglustat oral capsule 100 mg T5 (SP) PA; MD

NAGLAZYME INTRAVENOUS SOLUTION 5

MG/5 ML T5 (SP) PA; MD

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5

MG T5 (SP) PA; MD

ORKAMBI ORAL GRANULES IN PACKET

100-125 MG, 150-188 MG T5 (SP) PA; MD

ORKAMBI ORAL TABLET 100-125 MG, 200-





oxybutynin chloride oral tablet 5 mg T2 MD; QL (120 EA per 30 days)

oxybutynin chloride oral tablet extended release

24hr 10 mg, 5 mg T2 MD; QL (30 EA per 30 days)

oxybutynin chloride oral tablet extended release

24hr 15 mg T2 MD; QL (60 EA per 30 days)

pamidronate intravenous recon soln 30 mg, 90

mg T5 (SP) PA

pamidronate intravenous solution 30 mg/10 ml (3

mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9

mg/ml)

T5 (SP) PA

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg T4 PA; MD

PAROEX ORAL RINSE MUCOUS

MEMBRANE MOUTHWASH 0.12 % T2

polyethylene glycol 3350(bulk) powder T2

prolia subcutaneous syringe 60 mg/ml T5 (SP) MD; QL (1 ML per 180 days)

PULMOZYME INHALATION SOLUTION 1

MG/ML T5 (SP)

PA; MD; QL (150 ML per 30

days)

raloxifene oral tablet 60 mg T3

PA; PA only applies to NCS

eligibility as part of Preventive

Services Coverage (Breast Cancer

Prevention); MD; QL (30 EA per

30 days)

risedronate oral tablet 150 mg T4 MD; QL (1 EA per 30 days)

risedronate oral tablet 30 mg T4 QL (30 EA per 30 days)



SAVELLA ORAL TABLET 100 MG, 12.5 MG,

25 MG, 50 MG T4 MD; QL (60 EA per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK 12.5

MG (5)-25 MG(8)-50 MG(42) T4 QL (55 EA per 30 days)

SENSIPAR ORAL TABLET 30 MG, 60 MG T5 (SP) MD; QL (60 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG T5 (SP) MD; QL (120 EA per 30 days)

sodium chloride inhalation solution for

nebulization 0.9 %, 10 %, 3 %, 7 % T2

somavert subcutaneous recon soln 10 mg T5 (SP) PA; MD

SOMAVERT SUBCUTANEOUS RECON

SOLN 15 MG, 20 MG, 25 MG, 30 MG T5 (SP) PA; MD

SUBOXONE SUBLINGUAL FILM 12-3 MG T3 PA; MD; QL (60 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG,

4-1 MG, 8-2 MG T3 PA; MD; QL (90 EA per 30 days)




SYPRINE ORAL CAPSULE 250 MG T5 (SP)

tamsulosin oral capsule 0.4 mg T2 MD

TAVALISSE ORAL TABLET 100 MG, 150 MG T5 (SP) PA; QL (60 EA per 30 days)

tolterodine oral tablet 1 mg, 2 mg T3 MD; QL (60 EA per 30 days)

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HR 4 MG, 8 MG T4 MD; QL (30 EA per 30 days)

triamcinolone acetonide dental paste 0.1 % T3

trientine oral capsule 250 mg T5 (SP)

trospium oral capsule,extended release 24hr 60


trospium oral tablet 20 mg T4 MD

TYBOST ORAL TABLET 150 MG T3 MD; QL (30 EA per 30 days)

VESICARE ORAL TABLET 10 MG, 5 MG T3 MD; QL (30 EA per 30 days)

ZAVESCA ORAL CAPSULE 100 MG T5 (SP) PA; MD

ZEMAIRA INTRAVENOUS RECON SOLN

1,000 MG T5 (SP) PA; MD

zoledronic acid-mannitol-water intravenous

piggyback 5 mg/100 ml T5 (SP) PA

VITAMINS

calcitriol oral capsule 0.25 mcg, 0.5 mcg T2 MD

calcitriol oral solution 1 mcg/ml T2 MD

ergocalciferol (vitamin d2) oral capsule 50,000

unit NCS MD; QL (4 EA per 28 days)

folic acid oral tablet 1 mg, 400 mcg, 800 mcg NCS MD

MULTI-VITAMIN WITH FLUORIDE ORAL

DROPS 0.25 MG/ML, 0.5 MG/ML NCS

MULTIVITAMINS WITH FLUORIDE ORAL

TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG NCS

niacin oral tablet 500 mg T2

niacin oral tablet extended release 750 mg T3

VITAMIN D2 ORAL CAPSULE 50,000 UNIT NCS MD; QL (4 EA per 28 days)


Index

8 8-MOP .................................... 92

A abacavir .................................. 36

abacavir-lamivudine ............... 36

abacavir-lamivudine-zidovudine

............................................ 36

acamprosate ............................ 99

ACANYA ............................... 92

acarbose .................................. 26

acebutolol ............................... 49

acetaminophen-codeine ............ 9

ACETASOL HC .................... 68

acetazolamide ......................... 67

acetazolamide sodium ............ 67

acetic acid ............................... 68

acetylcysteine ......................... 14

acitretin ................................... 92

ACTHIB (PF) ......................... 41

ACTIMMUNE ....................... 31

acyclovir ................................. 36

ADACEL(TDAP

ADOLESN/ADULT)(PF) .. 41

ADAGEN ............................... 99

adapalene ................................ 92

ADCIRCA .............................. 49

ADDERALL XR .................... 40

adefovir................................... 36

ADEMPAS ............................. 49

ADRUCIL .............................. 31

ADVAIR DISKUS ................. 14

ADVAIR HFA ....................... 14

AFEDITAB CR ...................... 47

AFINITOR ............................. 31

AFLURIA 2018-2019 ............ 41

AFLURIA 2018-2019 (PF) .... 41

AFLURIA QUAD 2018-2019 41

AFLURIA QUAD 2018-2019

(PF) ..................................... 41

AFTERA ................................ 58

AK-POLY-BAC ..................... 16

ALBENZA ............................. 30

albuterol sulfate ...................... 14

alclometasone ......................... 92

alendronate ............................. 99

alfuzosin ................................. 99

ALINIA .................................. 30

ALIQOPA .............................. 31

allopurinol .............................. 12

almotriptan malate .................... 9

ALOCRIL ............................... 68

ALOMIDE.............................. 68

ALOPHEN ............................. 74

alosetron ................................. 74

ALPHAGAN P ....................... 68

alprazolam ........................ 85, 86

ALREX ................................... 68

ALTABAX ............................. 92

ALTAVERA (28) ................... 58

aluminum chloride .................. 92

alyacen 1/35 (28) .................... 58

ALYACEN 7/7/7 (28) ............ 58

amantadine hcl ........................ 34

amcinonide ............................. 92

AMETHIA.............................. 59

AMETHIA LO ....................... 59

AMETHYST .......................... 59

amiloride ................................. 67

amiloride-hydrochlorothiazide67

aminophylline ......................... 14

amiodarone ............................. 47

AMITIZA ............................... 74

amitriptyline ........................... 86

amitriptyline-chlordiazepoxide

............................................ 86

amlodipine .............................. 47

amlodipine-benazepril ............ 50

amlodipine-olmesartan ........... 50

amlodipine-valsartan .............. 50

amlodipine-valsartan-hcthiazid

............................................ 50

ammonium chloride ................ 67

ammonium lactate .................. 92

AMNESTEEM ....................... 92

amoxapine .............................. 86

amoxicillin .............................. 16

amoxicillin-pot clavulanate .... 16

ampicillin ................................ 17

AMTURNIDE ........................ 50

anagrelide ............................... 35

ANALPRAM ADVANCED .. 74

anastrozole .............................. 31

ANDROGEL .......................... 80

ANORO ELLIPTA................. 14

antipyrine-benzocaine ............ 68

ANUCORT-HC ...................... 74

ANZEMET ............................. 74

apraclonidine .......................... 68

aprepitant ................................ 74

APRI ....................................... 59

APRISO .................................. 74

APTIOM ................................. 55

APTIVUS ............................... 36

ARANELLE (28) ................... 59

ARCALYST ........................... 99

ARCAPTA NEOHALER ....... 14

aripiprazole ............................. 86

armodafinil ............................. 86

ARMOUR THYROID............ 98

ARNUITY ELLIPTA ............. 14

ASCOMP WITH CODEINE .... 9

ASHLYNA ............................. 59

ASMANEX HFA ................... 14

ASMANEX TWISTHALER .. 14

aspirin ................................. 9, 35

ASPIRIN LOW-STRENGTH 35

aspirin-dipyridamole............... 35

ASSURE ID INSULIN

SAFETY ............................. 84

atazanavir ................................ 36

atenolol ................................... 50

atenolol-chlorthalidone ........... 50

atorvastatin ............................. 50

atovaquone .............................. 30

atovaquone-proguanil ............. 30

ATRIPLA ............................... 36

atropine ............................. 68, 74

atropine sulfate (pf) ................ 68

ATROVENT HFA.................. 14

AUBRA .................................. 59

AUSTEDO ............................. 55

AVAR ..................................... 17

AVAR-E ................................. 17

AVAR-E GREEN ................... 17

AVIANE ................................. 59

AVONEX ............................... 55

AVONEX (WITH ALBUMIN)

............................................ 55

AZASITE ............................... 17

azathioprine ............................ 84

azelastine .................... 26, 68, 69

AZILECT ............................... 34

azithromycin ........................... 17

AZOPT ................................... 69

AZOR ..................................... 50

AZURETTE (28) .................... 59


B bacitracin ................................ 17

bacitracin-polymyxin b .......... 17

baclofen .................................. 85

BACTROBAN NASAL ......... 17

balsalazide .............................. 74

BALZIVA (28) ....................... 59

BANZEL ................................ 55

BARACLUDE ....................... 36

BAVENCIO ........................... 31

BAYER ASPIRIN .................... 9

bcg vaccine, live (pf) .............. 41

BD LANCET DEVICE .......... 85

BEKYREE (28) ...................... 59

BELSOMRA .......................... 91

benazepril ............................... 50

benazepril-hydrochlorothiazide

............................................ 50

BENICAR .............................. 50

BENICAR HCT ..................... 50

BENZAMYCINPAK ............. 17

benznidazole ........................... 30

benzonatate ............................. 67

benzoyl peroxide .................... 92

benztropine ............................. 34

BEPREVE .............................. 26

BESIVANCE ......................... 17

betamethasone dipropionate ... 92

betamethasone valerate .......... 92

betamethasone, augmented.... 92,

93

BETASERON ........................ 55

betaxolol ........................... 50, 69

bethanechol chloride .............. 40

BETIMOL .............................. 69

BETOPTIC S.......................... 69

bexarotene .............................. 31

BEXSERO .............................. 41

BEYAZ................................... 59

bicalutamide ........................... 31

BIKTARVY ........................... 36

BILTRICIDE .......................... 30

BIOTHRAX ........................... 42

bisacodyl................................. 74

BISA-LAX ............................. 74

bisoprolol fumarate ................ 50

bisoprolol-hydrochlorothiazide

............................................ 50

BLEPHAMIDE S.O.P. ........... 17

BLISOVI 24 FE...................... 59

BLISOVI FE 1/20 (28) ........... 59

BOOSTRIX TDAP................. 42

BREO ELLIPTA .................... 14

BRIELLYN ............................ 59

BRILINTA ............................. 35

brimonidine ............................ 69

BRINTELLIX ........................ 86

BROMFED DM ..................... 67

bromfenac ............................... 69

bromocriptine ......................... 34

brompheniramine-pseudoeph-

dm ....................................... 67

BROVANA ............................ 14

budesonide ........................ 14, 80

bumetanide ............................. 67

BUPHENYL ........................... 74

buprenorphine hcl ................... 99

bupropion hcl .......................... 86

bupropion hcl (smoking deter)97

buspirone ................................ 86

BUSULFEX ........................... 31

BUTALBITAL COMPOUND

W/CODEINE........................ 9

BUTALBITAL COMPOUND-

CODEINE ............................ 9

butalbital-acetaminop-caf-cod .. 9

butalbital-acetaminophen ......... 9

butalbital-acetaminophen-caff .. 9

butalbital-aspirin-caffeine ........ 9

butorphanol tartrate .................. 9

BUTRANS ............................... 9

BYDUREON .......................... 27

BYDUREON BCISE ............. 27

BYETTA ................................ 27

BYSTOLIC ............................ 50

C cabergoline ............................. 80

calcipotriene ........................... 93

calcipotriene-betamethasone .. 93

calcitonin (salmon) ................. 80

calcitriol .......................... 93, 102

calcium acetate ....................... 71

CALQUENCE ........................ 31

CAMILA ................................ 59

CAMRESE ............................. 59

CAMRESE LO ....................... 59

CANASA................................ 74

candesartan ............................. 50

candesartan-hydrochlorothiazid

............................................ 50

CANTIL ................................. 74

capecitabine ............................ 31

CAPEX ................................... 93

CAPRELSA ............................ 31

captopril .................................. 50

captopril-hydrochlorothiazide 50

CARAFATE ........................... 74

carbamazepine ........................ 55

carbidopa ................................ 35

carbidopa-levodopa ................ 35

carbinoxamine maleate ........... 26

CARIMUNE NF

NANOFILTERED .............. 42

carisoprodol ............................ 85

carteolol .................................. 69

CARTIA XT ........................... 47

carvedilol ................................ 50

caspofungin............................. 24

CAYA CONTOURED ........... 59

CAYSTON ............................. 17

CAZIANT (28) ....................... 59

cefaclor ................................... 17

cefadroxil ................................ 17

cefazolin ................................. 17

cefdinir .................................... 17

cefixime .................................. 17

cefpodoxime ........................... 18

cefprozil .................................. 18

CEFTIN .................................. 18

ceftriaxone .............................. 18

cefuroxime axetil .................... 18

cefuroxime sodium ................. 18

celecoxib ................................. 12

CELONTIN ............................ 55

cephalexin ............................... 18

CERVARIX VACCINE (PF) . 42

CESAMET ............................. 74

CHANTIX .............................. 98

CHANTIX CONTINUING

MONTH BOX .................... 97

CHANTIX CONTINUING

MONTH PAK .................... 97

CHANTIX STARTING

MONTH BOX .................... 98

CHANTIX STARTING

MONTH PAK .................... 98

CHATEAL ............................. 59


CHEMET ............................... 99

CHILD ASPIRIN ................... 35

CHILDREN'S ASPIRIN ........ 35

chlordiazepoxide hcl .............. 86

chlordiazepoxide-clidinium .... 74

chlorhexidine gluconate ......... 99

chloroquine phosphate............ 30

chlorothiazide ......................... 67

chlorpromazine ....................... 86

chlorpropamide....................... 27

chlorthalidone ......................... 67

chlorzoxazone......................... 85

cholestyramine (with sugar) ... 51

CHOLESTYRAMINE LIGHT

............................................ 51

CICLODAN ........................... 24

ciclopirox ................................ 24

cilostazol................................. 35

CILOXAN .............................. 18

CIMDUO ................................ 36

cimetidine ............................... 74

cimetidine hcl ......................... 74

CIPRO HC.............................. 18

CIPRODEX ............................ 18

ciprofloxacin........................... 18

ciprofloxacin (mixture) .......... 18

ciprofloxacin hcl ..................... 18

citalopram ............................... 86

CITRATE OF MAGNESIA ... 74

CITROMA ............................. 74

CLARAVIS ............................ 93

clarithromycin ........................ 18

CLEARLAX........................... 74

clemastine ............................... 26

CLENPIQ ............................... 74

CLEOCIN............................... 18

CLIMARA PRO ..................... 80

CLINDACIN ETZ.................. 18

CLINDACIN P ....................... 18

clindamycin hcl ...................... 19

clindamycin palmitate hcl ...... 19

clindamycin phosphate ........... 19

clindamycin-benzoyl peroxide93

clobetasol ................................ 93

clobetasol-emollient ............... 93

clocortolone pivalate .............. 93

CLODAN ............................... 93

clomipramine .......................... 86

clonazepam ............................. 55

clonidine ................................. 51

clonidine hcl ........................... 51

clopidogrel .............................. 35

clorazepate dipotassium ......... 86

clotrimazole ............................ 24

clotrimazole-betamethasone ... 24

clozapine ................................. 87

COARTEM ............................ 30

codeine sulfate .......................... 9

codeine-butalbital-asa-caff ....... 9

colchicine................................ 12

colesevelam ............................ 51

colestipol ................................ 51

COLY-MYCIN S ................... 19

COMBIGAN .......................... 69

COMBIPATCH ...................... 80

COMBIVENT RESPIMAT ... 14

COMPLERA .......................... 36

COMPRO ............................... 74

COMVAX (PF) ...................... 42

CONCEPTROL ...................... 59

CONDYLOX.......................... 93

CONSTULOSE ...................... 75

COPAXONE .......................... 55

CORDRAN ............................ 93

CORDRAN TAPE LARGE

ROLL.................................. 93

CORDRAN TAPE SMALL

ROLL.................................. 93

COREG CR ............................ 51

CORTANE-B ......................... 69

cortisone ................................. 80

CORTISPORIN ...................... 19

CORTISPORIN-TC ............... 19

COSENTYX ........................... 93

COSENTYX (2 SYRINGES) 93

COSENTYX PEN .................. 93

COSENTYX PEN (2 PENS) .. 93

COSOPT (PF)......................... 69

CREON .................................. 75

CRIXIVAN ............................ 36

cromolyn ..................... 12, 15, 69

CRYSELLE (28) .................... 60

CURITY GAUZE................... 85

CYCLAFEM 1/35 (28) .......... 60

CYCLAFEM 7/7/7 (28) ......... 60

cyclobenzaprine ...................... 85

cyclopentolate ......................... 69

cyclophosphamide .................. 31

cycloserine .............................. 19

CYCLOSET ........................... 27

cyclosporine............................ 84

cyclosporine modified ............ 84

cyproheptadine ....................... 26

CYRED................................... 60

CYSTAGON .......................... 99

CYTRA-2 ............................... 71

CYTRA-3 ............................... 71

D danazol .................................... 80

dantrolene ............................... 85

dapsone ................................... 19

DAPTACEL (DTAP

PEDIATRIC) (PF) .............. 42

DARAPRIM ........................... 30

DASETTA 1/35 (28) .............. 60

DASETTA 7/7/7 (28) ............. 60

DAYSEE ................................ 60

DAYTRANA .......................... 87

DEBLITANE .......................... 60

DELYLA (28) ........................ 60

demeclocycline ....................... 19

DENTA 5000 PLUS ............... 71

DENTAGEL ........................... 71

DEPEN TITRATABS ............ 12

DEPO-ESTRADIOL .............. 80

DESCOVY ............................. 36

desipramine............................. 87

desloratadine ........................... 26

desmopressin .......................... 80

desog-e.estradiol/e.estradiol ... 60

desogestrel-ethinyl estradiol ... 60

desonide .................................. 94

desoximetasone....................... 94

desvenlafaxine ........................ 87

desvenlafaxine succinate ........ 87

dexamethasone ................. 80, 81

dexamethasone sodium

phosphate ...................... 69, 81

dexmethylphenidate ................ 87

dextroamphetamine ................ 40

dextroamphetamine-

amphetamine....................... 40

diazepam ........................... 55, 87

DIAZEPAM INTENSOL ....... 87

diclofenac potassium ................ 9

diclofenac sodium 12, 13, 31, 69,

94

dicloxacillin ............................ 19

dicyclomine ............................ 75

didanosine ............................... 36

DIFICID ................................. 19

diflorasone .............................. 94

DIGITEK ................................ 47


DIGOX ................................... 47

digoxin .................................... 47

dihydroergotamine ............. 9, 10

diltiazem hcl ..................... 47, 48

DILT-XR ................................ 48

DIPENTUM ........................... 75

diphenhydramine hcl .............. 26

diphenoxylate-atropine ........... 75

dipyridamole........................... 35

disopyramide phosphate ......... 48

disulfiram ............................... 99

divalproex ............................... 56

DIVIGEL ................................ 81

dofetilide................................. 48

donepezil ................................ 40

DONNATAL .......................... 75

DOPTELET ............................ 58

dorzolamide ............................ 69

dorzolamide-timolol ............... 69

doxazosin ................................ 51

doxepin ................................... 87

doxercalciferol ........................ 99

doxycycline hyclate .......... 19, 99

doxycycline monohydrate ...... 19

dronabinol............................... 75

drospirenone-ethinyl estradiol 60

DROXIA ................................ 47

DUAVEE ............................... 81

DUCODYL ............................ 75

DULERA ................................ 15

duloxetine ............................... 87

DUPIXENT ............................ 94

DUREZOL ............................. 69

dutasteride .............................. 99

dutasteride-tamsulosin ............ 99

DYRENIUM .......................... 67

E E.E.S. 200 ............................... 19

E.E.S. 400 ............................... 19

E.E.S. GRANULES ............... 19

econazole ................................ 24

ECONTRA EZ ....................... 60

EDECRIN............................... 67

EDURANT ............................. 36

efavirenz ................................. 36

EFFIENT ................................ 35

ELETONE .............................. 94

ELIDEL .................................. 84

ELINEST ................................ 60

ELIQUIS ................................ 23

ELLA ...................................... 60

ELMIRON .............................. 10

EMADINE.............................. 26

EMCYT .................................. 31

EMEND .................................. 75

EMOQUETTE........................ 60

EMSAM ................................. 87

EMTRIVA .............................. 36

enalapril maleate..................... 51

enalapril-hydrochlorothiazide 51

ENBREL ................................ 30

ENBREL SURECLICK ......... 30

ENDARI ................................. 47

ENDOCET ............................. 10

ENGERIX-B (PF) .................. 42


............................................ 42

ENJUVIA ............................... 81

enoxaparin .............................. 23

ENPRESSE ............................ 60

ENSKYCE.............................. 60

entacapone .............................. 35

entecavir ................................. 36

ENTERIC COATED ASPIRIN

............................................ 36

ENTRESTO............................ 51

ENULOSE .............................. 75

EPCLUSA .............................. 36

EPICERAM ............................ 94

EPIDUO ................................. 94

EPIFOAM .............................. 94

epinastine ................................ 26

epinephrine ............................. 40

EPIPEN .................................. 40

EPIPEN 2-PAK ...................... 40

EPIPEN JR ............................. 41

EPIPEN JR 2-PAK ................. 40

EPIVIR HBV .......................... 36

eplerenone .............................. 68

EPZICOM .............................. 36

ergocalciferol (vitamin d2) ... 102

ergoloid ................................... 51

ERGOMAR ............................ 10

ERLEADA ............................. 31

ERRIN .................................... 60

ERTACZO.............................. 24

ERY PADS ............................. 19

ERY-TAB ............................... 19

ERYTHROCIN (AS

STEARATE) ...................... 19

erythromycin........................... 20

erythromycin ethylsuccinate ... 19

erythromycin with ethanol ...... 20

erythromycin-benzoyl peroxide

............................................ 20

ESBRIET ................................ 99

escitalopram oxalate ............... 87

ESTARYLLA ......................... 60

estazolam ................................ 91

ESTRACE .............................. 81

estradiol .................................. 81

estradiol-norethindrone acet ... 81

ESTROGEL ............................ 81

estrogens-methyltestosterone . 81

estropipate............................... 81

eszopiclone ............................. 91

ethambutol .............................. 20

ethosuximide........................... 56

etidronate disodium ................ 99

etodolac................................... 13

EUCRISA ............................... 94

EVOTAZ ................................ 37

exemestane ............................. 31

EXJADE ................................. 99

ezetimibe................................. 51

F FALLBACK SOLO................ 60

FALMINA (28) ...................... 60

famciclovir .............................. 37

famotidine ............................... 75

FANAPT........................... 87, 88

FARESTON ........................... 32

FC2 FEMALE CONDOM ..... 60

felbamate ................................ 56

felodipine ................................ 48

FEMCAP ................................ 60

fenofibrate............................... 51

fenofibrate micronized ............ 51

fenofibrate nanocrystallized ... 51

fenofibric acid (choline) ......... 51

fenoprofen............................... 13

fentanyl ................................... 10

fentanyl citrate ........................ 10

FERRIPROX .......................... 99

FIASP FLEXTOUCH U-100

INSULIN ............................ 27

FIASP U-100 INSULIN ......... 27


FINACEA............................... 94

finasteride ............................... 99

FIRVANQ .............................. 20

flavoxate ................................. 99

flecainide ................................ 48

FLEET LAXATIVE ............... 75

FLOVENT DISKUS .............. 15

FLOVENT HFA ..................... 15

FLUAD 2018-2019 (65 YR

UP)(PF) .............................. 42

FLUARIX QUAD 2018-2019

(PF) ..................................... 42

FLUBLOK QUAD 2018-2019

(PF) ..................................... 42

FLUCELVAX QUAD 2018-

2019 .................................... 42

FLUCELVAX QUAD 2018-

2019 (PF) ............................ 42

fluconazole ............................. 24

flucytosine .............................. 24

fludrocortisone ....................... 81


............................................ 43


(PF) ..................................... 43

flunisolide ............................... 69

fluocinolone ............................ 94

fluocinolone acetonide oil ...... 69

fluocinolone and shower cap .. 94

fluocinonide ............................ 94

FLUOCINONIDE-E .............. 94

fluoride (sodium) .................... 71

FLUORITAB ......................... 71

fluorometholone ..................... 69

fluorouracil ............................. 32

fluoxetine ................................ 88

fluphenazine hcl ..................... 88

flurazepam .............................. 91

flurbiprofen............................. 13

flurbiprofen sodium ................ 69

flutamide................................. 32

fluticasone ........................ 69, 94

fluvastatin ............................... 51

fluvoxamine ............................ 88

FLUZONE HIGH-DOSE 2018-

19 (PF) ................................ 43


............................................ 43


(PF) ..................................... 43

FLUZONE QUAD PEDI 2018-

19 (PF) ................................ 43

FML S.O.P. ............................ 70

FOCALIN XR ........................ 88

folic acid ............................... 102

fondaparinux ........................... 23

FORTEO ................................ 99

fosamprenavir ......................... 37

fosinopril ................................ 51

fosinopril-hydrochlorothiazide

............................................ 51

FOSRENOL ........................... 71

FREESTYLE FREEDOM LITE

............................................ 85

FREESTYLE INSULINX ...... 85

FREESTYLE INSULINX TEST

STRIPS ............................... 67

FREESTYLE LANCETS ....... 85

FREESTYLE LITE METER.. 85

FREESTYLE LITE STRIPS .. 67

FREESTYLE TEST ............... 67

frovatriptan ............................. 10

furosemide .............................. 68

FUZEON ................................ 37

FYCOMPA ............................. 56

G gabapentin .............................. 56

GABITRIL ............................. 56

galantamine ............................ 41

GAMMAGARD LIQUID ...... 43

GARDASIL (PF) .................... 43

GARDASIL 9 (PF) ................. 43

gatifloxacin ............................. 20

GAVILAX .............................. 75

GAVILYTE-C ........................ 75

GAVILYTE-G........................ 75

GAVILYTE-H AND

BISACODYL ..................... 75

GAVILYTE-N........................ 75

gemfibrozil ............................. 52

GENERESS FE ...................... 60

GENERLAC ........................... 76

GENGRAF ............................. 84

GENTAK................................ 20

gentamicin .............................. 20

GENTLE LAXATIVE ........... 76

GENTLELAX ........................ 76

GENVOYA ............................ 37

GIANVI (28) .......................... 61

GILDAGIA ............................ 61

GILDESS 1.5/30 (21) ............. 61

GILDESS 1/20 (21) ................ 61

GILDESS 24 FE ..................... 61

GILDESS FE 1.5/30 (28) ....... 61

GILDESS FE 1/20 (28) .......... 61

GILENYA .............................. 56

GLEEVEC .............................. 32

glimepiride .............................. 27

glipizide .................................. 27

glipizide-metformin ................ 27

GLUCAGEN .......................... 72

GLUCAGEN DIAGNOSTIC

KIT ..................................... 67

GLUCAGEN HYPOKIT........ 72

GLUCAGON EMERGENCY

KIT (HUMAN) ................... 72

glyburide ................................. 27

glyburide micronized .............. 27

glyburide-metformin............... 27

GLYCOLAX .......................... 76

glycopyrrolate ......................... 76

GLYXAMBI........................... 27

granisetron hcl ........................ 76

GRASTEK .............................. 43

griseofulvin microsize ............ 24

guanfacine......................... 52, 88

guanidine ................................ 41

GYNAZOLE-1 ....................... 24

GYNOL II .............................. 61

H halobetasol propionate ............ 94

HALOG .................................. 94

haloperidol .............................. 88

haloperidol decanoate ............. 88

haloperidol lactate .................. 88

HARVONI .............................. 37

HAVRIX (PF) ........................ 43

HEALTHYLAX ..................... 76

HEATHER ............................. 61

heparin (porcine) .................... 23

heparin, porcine (pf) ............... 23

HEXALEN ............................. 32

HOMATROPAIRE ................ 70

homatropine hbr...................... 70

HORIZANT ............................ 56

HPR ........................................ 95

HPR PLUS.............................. 94

HUMIRA ................................ 31

HUMIRA PEDIATRIC

CROHN'S START ............. 30

HUMIRA PEN ....................... 31


HUMIRA PEN CROHN'S-UC-

HS START ......................... 31

HUMIRA PEN PSORIASIS-

UVEITIS ............................ 31

HUMULIN R U-500 (CONC)

INSULIN ............................ 28

hydralazine ............................. 52

hydrochlorothiazide ................ 68

hydrocodone-acetaminophen . 10

hydrocodone-homatropine ..... 67

hydrocodone-ibuprofen .......... 10

hydrocortisone .................. 81, 95

hydrocortisone acetate ...... 76, 95

hydrocortisone butyrate .......... 95

hydrocortisone butyr-emollient

............................................ 95

hydrocortisone valerate .......... 95

hydrocortisone-acetic acid...... 70

hydrocortisone-pramoxine ..... 76

HYDROMET ......................... 67

hydromorphone ...................... 10

hydroxychloroquine ............... 30

hydroxyurea ............................ 32

hydroxyzine hcl ...................... 26

hydroxyzine pamoate ............. 26

HYLATOPIC ......................... 95

HYLATOPICPLUS ............... 95

hyoscyamine sulfate ............... 76

HYOSYNE ............................. 76

I ibandronate ............................. 99

IBRANCE .............................. 32

ibuprofen ................................ 13

ibuprofen-oxycodone ............. 10

IDHIFA .................................. 32

ILEVRO ................................. 70

imatinib................................... 32

IMBRUVICA ......................... 32

imipramine hcl........................ 88

imipramine pamoate ............... 88

imiquimod .............................. 95

IMOVAX RABIES VACCINE

(PF) ..................................... 43

INCRELEX ............................ 81

indapamide ............................. 68

indomethacin .......................... 13

INFANRIX (DTAP) (PF)....... 44

insulin syringe-needle u-100 .. 85

INTELENCE .......................... 37

INTRON A ............................. 32

INTROVALE ......................... 61

INVEGA SUSTENNA ........... 88

INVIRASE ............................. 37

iodoquinol-hc.......................... 95

IPOL ....................................... 44

ipratropium bromide ......... 15, 70

ipratropium-albuterol.............. 15

irbesartan ................................ 52

irbesartan-hydrochlorothiazide

............................................ 52

ISENTRESS ........................... 37

ISENTRESS HD .................... 37

ISOLYTE S PH 7.4 ................ 72

isoniazid.................................. 20

isosorbide dinitrate ................. 48

isosorbide mononitrate ........... 48

isotretinoin .............................. 95

isradipine ................................ 48

ISTALOL ............................... 70

itraconazole ............................ 25

ivermectin ............................... 30

IXIARO (PF) .......................... 44

J JAKAFI .................................. 32

JANTOVEN ........................... 24

JARDIANCE .......................... 28

JENCYCLA............................ 61

JENTADUETO ...................... 28

JINTELI.................................. 81

JOLESSA ............................... 61

JOLIVETTE ........................... 61

JULEBER ............................... 61

JULUCA ................................. 37

JUNEL 1.5/30 (21) ................. 61

JUNEL 1/20 (21) .................... 61

JUNEL FE 1.5/30 (28) ........... 61

JUNEL FE 1/20 (28) .............. 61

JUNEL FE 24 ......................... 61

JYNARQUE ........................... 68

K KALETRA ............................. 37

KALEXATE ........................... 72

KALYDECO ........................ 100

KARIVA (28) ......................... 61

KELNOR 1/35 (28) ................ 61

KEPIVANCE ......................... 76

ketoconazole ........................... 25

ketoprofen ............................... 13

ketorolac ........................... 10, 70

KIMIDESS (28)...................... 61

KINRIX (PF) .......................... 44

KIONEX ................................. 72

KIONEX (WITH SORBITOL)

............................................ 72

KISQALI ................................ 32

KISQALI FEMARA CO-PACK

............................................ 32

KLOR-CON ........................... 72

KLOR-CON 10 ...................... 72

KLOR-CON 8 ........................ 72

KLOR-CON M10 ................... 72

KLOR-CON M15 ................... 72

KLOR-CON M20 ................... 72

KLOR-CON SPRINKLE ....... 72

KLOR-CON/25 ...................... 72

KRISTALOSE ........................ 76

KURVELO ............................. 61

KUVAN ................................ 100

L l norgest/e.estradiol-e.estrad ... 62

labetalol .................................. 52

lactulose .................................. 76

lamivudine .............................. 37

lamivudine-zidovudine ........... 37

lamotrigine .............................. 56

lancets ..................................... 85

lansoprazole ............................ 76

LANTUS SOLOSTAR U-100

INSULIN ............................ 28

LANTUS U-100 INSULIN .... 28

LARIN 1.5/30 (21) ................. 62

LARIN 1/20 (21) .................... 62

LARIN 24 FE ......................... 62

LARIN FE 1.5/30 (28) ........... 62

LARIN FE 1/20 (28) .............. 62

LASTACAFT ......................... 26

latanoprost .............................. 70

LATUDA ................................ 88

LAXACLEAR ........................ 76

LAXATIVE (BISACODYL) . 76

LAXATIVE FEMININE ........ 76

LAXATIVE PEG 3350 .......... 77

LAYOLIS FE ......................... 62

LEENA 28 .............................. 62

leflunomide ............................. 13

LENVIMA .............................. 32

LESSINA ................................ 62


LETAIRIS .............................. 52

letrozole .................................. 32

leucovorin calcium ............... 100

LEUKERAN .......................... 32

LEUKINE............................... 58

leuprolide ................................ 33

levalbuterol hcl ....................... 15

LEVATOL ............................. 52

LEVEMIR FLEXTOUCH U-

100 INSULN ...................... 28

LEVEMIR U-100 INSULIN .. 28

levetiracetam .................... 56, 57

levobunolol ............................. 70

levocarnitine ......................... 100

levocarnitine (with sugar)..... 100

levocetirizine .......................... 26

levofloxacin ............................ 20

LEVONEST (28).................... 62

levonorgestrel-ethinyl estrad .. 62

levonorg-eth estrad triphasic .. 62

LEVORA-28 .......................... 62

levorphanol tartrate ................ 10

levothyroxine .......................... 98

LEVOXYL ............................. 98

LEXIVA ................................. 37

LIALDA ................................. 77

lidocaine ................................. 12

lidocaine hcl ........................... 12

lidocaine hcl-hydrocortison ac 77

LIDOCAINE VISCOUS ........ 12

lidocaine-hydrocortisone-aloe 77

lidocaine-prilocaine ................ 12

lindane .................................... 95

linezolid .................................. 20

LINZESS ................................ 77

liothyronine ............................ 98

lisinopril ................................. 52

lisinopril-hydrochlorothiazide 52

LITE COAT ASPIRIN ........... 10

lithium carbonate .................... 88

lithium citrate ......................... 88

LO LOESTRIN FE................. 62

LOCOID ................................. 95

LOMEDIA 24 FE ................... 62

loperamide .............................. 77

LOPREEZA ........................... 81

lorazepam ......................... 88, 89

LORYNA (28)........................ 62

losartan ................................... 52

losartan-hydrochlorothiazide .. 52

LOTEMAX ............................ 70

lovastatin ................................ 52

LOW-OGESTREL (28) ......... 62

loxapine succinate .................. 89

LUDENT FLUORIDE ........... 72

LUMIGAN ............................. 70

LUPRON DEPOT ............ 33, 82


...................................... 33, 82


............................................ 33


............................................ 33

LUPRON DEPOT-PED ......... 82

LUPRON DEPOT-PED (3

MONTH) ............................ 82

LUTERA (28)......................... 62

LYNPARZA ........................... 33

LYRICA ................................. 57

LYSODREN ........................... 33

LYZA ..................................... 62

M magnesium citrate................... 77

malathion ................................ 95

maprotiline.............................. 89

MARLISSA ............................ 62

MARPLAN ............................ 89

MATULANE.......................... 33

MATZIM LA ......................... 48

MAVYRET ............................ 37

meclizine ................................ 77

meclofenamate........................ 13

medroxyprogesterone . 62, 63, 82

mefenamic acid....................... 10

mefloquine .............................. 30

megestrol ........................ 33, 100

meloxicam .............................. 13

melphalan hcl ......................... 33

memantine .............................. 57

MENACTRA (PF) ................. 44

MENEST ................................ 82

MENHIBRIX (PF) ................. 44


............................................ 44


(PF) ..................................... 44

MENTAX ............................... 25

MENVEO A-C-Y-W-135-DIP

(PF) ..................................... 44

MENVEO MENA

COMPONENT (PF) ........... 44

MENVEO MENCYW-135

COMPNT (PF) ................... 44

meperidine .............................. 10

meprobamate .......................... 89

mercaptopurine ....................... 33

mesalamine ............................. 77

mesalamine with cleansing wipe

............................................ 77

metaproterenol ........................ 15

metaxalone .............................. 85

metformin ............................... 28

methadone............................... 10

methamphetamine................... 41

methazolamide ........................ 68

methenamine hippurate .......... 20

methimazole ........................... 98

methocarbamol ....................... 85

methotrexate sodium .............. 33

methotrexate sodium (pf) ....... 33

methoxsalen ............................ 95

methscopolamine .................... 77

methyclothiazide..................... 68

methyldopa ............................. 52

methyldopa-hydrochlorothiazide

............................................ 52

methylergonovine ................... 82

methylphenidate hcl................ 89

methylprednisolone ................ 82

methylprednisolone acetate .... 82

metipranolol ............................ 70

metoclopramide hcl ................ 77

metolazone .............................. 68

metoprolol succinate ............... 52

metoprolol ta-hydrochlorothiaz

............................................ 52

metoprolol tartrate .................. 52

metronidazole ................... 20, 95

mexiletine ............................... 48

MICROGESTIN 1.5/30 (21) .. 63

MICROGESTIN 1/20 (21) ..... 63

MICROGESTIN FE 1.5/30 (28)

............................................ 63

MICROGESTIN FE 1/20 (28)63

midodrine ................................ 41

MIGERGOT ........................... 10

miglitol ................................... 28

miglustat ............................... 100

MILK OF MAGNESIA .......... 77

MILK OF MAGNESIA

CONCENTRATED ............ 77

MILLIPRED DP ..................... 82


MIMVEY ............................... 82

MIMVEY LO ......................... 82

MINASTRIN 24 FE ............... 63

MINITRAN ............................ 48

minocycline ............................ 20

minoxidil ................................ 52

MIRALAX ............................. 77

MIRENA ................................ 63

mirtazapine ............................. 89

misoprostol ............................. 77

M-M-R II (PF) ........................ 44

modafinil ................................ 89

MODERIBA........................... 37

moexipril ................................ 52

moexipril-hydrochlorothiazide

............................................ 52

mometasone ................ 70, 95, 96

MONO-LINYAH ................... 63

MONONESSA (28) ............... 63

montelukast ............................ 15

MONUROL ............................ 20

morphine........................... 10, 11

morphine concentrate ............. 10

MOTOFEN............................. 77

MOVANTIK .......................... 24

MOVIPREP ............................ 77

MOXEZA ............................... 20

MULPLETA........................... 58

MULTAQ ............................... 48

MULTI-VITAMIN WITH

FLUORIDE ...................... 102

MULTIVITAMINS WITH

FLUORIDE ...................... 102

mupirocin ............................... 20

MY WAY ............................... 63

mycophenolate mofetil ........... 84

mycophenolate sodium ........... 84

MYORISAN........................... 96

MYZILRA .............................. 63

N nabumetone ............................ 13

nadolol .................................... 52

naftifine .................................. 25

NAFTIN ................................. 25

NAGLAZYME..................... 100

naloxone ................................. 24

naltrexone ............................... 24

naphazoline............................. 70

naproxen ................................. 13

naratriptan ............................... 11

NATACYN ............................ 25

NATAZIA .............................. 63

nateglinide .............................. 28

NATURE-THROID ............... 98

NECON 0.5/35 (28) ............... 63

NECON 1/35 (28) .................. 63

NECON 1/50 (28) .................. 63

NECON 10/11 (28) ................ 63

NECON 7/7/7 (28) ................. 63

nefazodone.............................. 89

neomycin ................................ 20

neomycin-bacitracin-poly-hc.. 21

neomycin-bacitracin-polymyxin

............................................ 21

neomycin-polymyxin b-

dexameth ............................ 21

neomycin-polymyxin-

gramicidin ........................... 21

neomycin-polymyxin-hc ........ 21

NEOSALUS ........................... 96

NERLYNX ............................. 33

NEULASTA ........................... 58

NEUPOGEN .......................... 58

NEVANAC ............................ 70

nevirapine ............................... 37

NEXAVAR ............................ 33

NEXPLANON........................ 63

NEXT CHOICE ONE DOSE . 63

niacin .............................. 52, 102

NIACOR ................................. 52

nicardipine .............................. 48

nicotine ................................... 98

nicotine (polacrilex) ............... 98

NICOTROL ............................ 98

NICOTROL NS ...................... 98

NIFEDICAL XL..................... 48

nifedipine ................................ 48

NIKKI (28) ............................. 63

NILANDRON ........................ 33

nimodipine .............................. 48

nisoldipine .............................. 49

NITRO-BID............................ 49

nitrofurantoin .......................... 21

nitrofurantoin macrocrystal .... 21

nitrofurantoin monohyd/m-cryst

............................................ 21

nitroglycerin ........................... 49

NITROSTAT .......................... 49

nizatidine ................................ 77

NORA-BE .............................. 64

noreth-ethinyl estradiol-iron ... 64

norethindrone (contraceptive) 64

norethindrone acetate .............. 82

norethindrone ac-eth estradiol

...................................... 64, 82

norethindrone-e.estradiol-iron 64

norgestimate-ethinyl estradiol 64

NORINYL 1+50 (28) ............. 64

NORLYROC .......................... 64

NORMAL SALINE FLUSH .. 72

NORPACE CR ....................... 49

NORTREL 0.5/35 (28) ........... 64

NORTREL 1/35 (21) .............. 64

NORTREL 1/35 (28) .............. 64

NORTREL 7/7/7 (28) ............. 64

nortriptyline ............................ 89

NORVIR ................................. 38

NOVOLIN 70/30 U-100

INSULIN ............................ 28

NOVOLIN N NPH U-100

INSULIN ............................ 28

NOVOLIN R REGULAR U-

100 INSULN ...................... 28

NOVOLOG FLEXPEN U-100

INSULIN ............................ 28

NOVOLOG MIX 70-30 U-100

INSULN ............................. 28

NOVOLOG MIX 70-

30FLEXPEN U-100 ........... 28

NOVOLOG PENFILL U-100

INSULIN ............................ 29

NOVOLOG U-100 INSULIN

ASPART ............................. 29

NOXAFIL............................... 25

NP THYROID ........................ 98

NUCYNTA............................. 11

NUCYNTA ER ...................... 11

NULOJIX ............................... 84

NUVARING ........................... 64

nystatin ................................... 25

nystatin-triamcinolone ............ 25

NYSTOP................................. 25

O OCELLA ................................ 64

octreotide acetate .................... 82

ODEFSEY .............................. 38

ofloxacin ................................. 21


OGESTREL (28) .................... 64

olanzapine............................... 89

olanzapine-fluoxetine ............. 89

olmesartan .............................. 53

olmesartan-amlodipin-hcthiazid

............................................ 53

olmesartan-hydrochlorothiazide

............................................ 53

olopatadine ....................... 26, 70

omega-3 acid ethyl esters ....... 77

omeprazole ............................. 78

OMNITROPE......................... 82

ondansetron ............................ 78

ondansetron hcl ...................... 78

OPANA ER ............................ 11

OPCICON ONE-STEP .......... 64

ORAL SALINE LAXATIVE 78

ORFADIN ............................ 100

ORKAMBI ........................... 100

orphenadrine citrate ................ 85

ORSYTHIA ............................ 64

OSCIMIN SR ......................... 78

oseltamivir .............................. 38

OSMOPREP ........................... 78

OTEZLA ................................ 13

OTEZLA STARTER.............. 13

oxandrolone ............................ 82

oxaprozin ................................ 13

oxcarbazepine ......................... 57

oxiconazole............................. 25

OXSORALEN ........................ 96

oxybutynin chloride.............. 100

oxycodone .............................. 11

oxycodone-acetaminophen ..... 11

oxycodone-aspirin .................. 11

oxymorphone .......................... 11

OZEMPIC .............................. 29

P paliperidone ...................... 89, 90

PALYNZIQ ............................ 44

pamidronate .......................... 100

PANRETIN ............................ 33

pantoprazole ........................... 78

PARAGARD T 380A............. 64

paricalcitol ............................ 100

PAROEX ORAL RINSE ..... 100

paromomycin .......................... 30

paroxetine hcl ......................... 90

PATADAY ............................. 26

PAXIL .................................... 90

PAZEO ................................... 26

PEDIARIX (PF) ..................... 44

PEDVAX HIB (PF) ................ 44

peg 3350-electrolytes ............. 78

PEG-3350 WITH FLAVOR

PACKS ............................... 78

PEGANONE .......................... 57

peg-electrolyte soln ................ 78

PEGINTRON ......................... 38

PEGINTRON REDIPEN ....... 38

PEG-PREP.............................. 78

PEN NEEDLE ........................ 85

penicillin v potassium ............. 21

PENTACEL (PF) ................... 44

PENTACEL ACTHIB

COMPONENT (PF) ........... 45

PENTACEL DTAP-IPV

COMPNT (PF) ................... 45

PENTAM................................ 30

pentazocine-naloxone ............. 11

PENTIPS ................................ 85

pentoxifylline.......................... 47

perindopril erbumine .............. 53

permethrin .............................. 96

perphenazine ........................... 90

perphenazine-amitriptyline ..... 90

PEXEVA ................................ 90

PHENADOZ .......................... 78

phenazopyridine ..................... 12

phenelzine ............................... 90

PHENERGAN ........................ 78

phenobarbital .................... 91, 92

phentermine ............................ 34

phenytoin ................................ 57

phenytoin sodium extended .... 57

PHILITH ................................ 64

phospha 250 neutral................ 72

PHOSPHATE LAXATIVE .... 78

PHOSPHOLINE IODIDE ...... 70

PHYSIOLYTE ....................... 96

PICATO.................................. 33

pilocarpine hcl .................. 41, 70

pimozide ................................. 90

PIMTREA (28) ....................... 64

pindolol ................................... 53

pioglitazone ............................ 29

pioglitazone-glimepiride ........ 29

pioglitazone-metformin .......... 29

PIRMELLA ............................ 64

piroxicam ................................ 13

PLAN B ONE-STEP .............. 64

PNEUMOVAX 23 ................. 45

PNV 29-1 ................................ 85

podofilox................................. 96

polyethylene glycol 3350 ....... 78

polyethylene glycol 3350(bulk)

.......................................... 100

polymyxin b sulfate ................ 21

polymyxin b sulf-trimethoprim

............................................ 21

POMALYST........................... 33

PORTIA .................................. 64

potassium chloride ............ 72, 73

potassium citrate ..................... 73

POTELIGEO .......................... 33

POTIGA ................................. 57

POWDERLAX ....................... 78

PRADAXA ............................. 24

PRALUENT PEN ................... 53

PRALUENT SYRINGE ......... 53

pramipexole ............................ 35

PRAMOSONE ....................... 96

pravastatin............................... 53

prazosin................................... 53

PRECISION XTRA MONITOR

............................................ 85

PRECISION XTRA TEST ..... 67

prednicarbate .......................... 96

prednisolone ........................... 82

prednisolone acetate ............... 70

prednisolone sodium phosphate

................................ 70, 82, 83

prednisone............................... 83

PREDNISONE INTENSOL ... 83

PREMARIN ........................... 83

PREMPHASE......................... 83

PREMPRO ............................. 83

PRENATABS FA ................... 85

PRENATABS RX .................. 85

PREPARATION CLEANSING

............................................ 78

PRETAB ................................. 85

PREVALITE .......................... 53

PREVIDENT .......................... 73

PREVIDENT 5000 BOOSTER

PLUS .................................. 73

PREVIDENT 5000 DRY

MOUTH ............................. 73

PREVIDENT 5000 ENAMEL

PROTECT .......................... 73

PREVIDENT 5000 PLUS ...... 73

PREVIDENT 5000 SENSITIVE

............................................ 73


PREVIFEM ............................ 64

PREVNAR 13 (PF) ................ 45

PREZCOBIX .......................... 38

PREZISTA ............................. 38

PRIFTIN ................................. 21

primaquine .............................. 30

primidone ............................... 57

PRISTIQ ................................. 90

probenecid .............................. 13

probenecid-colchicine ............ 13

procainamide .......................... 49

prochlorperazine ..................... 78

prochlorperazine edisylate...... 78

prochlorperazine maleate ....... 78

PROCORT ............................. 79

PROCRIT ............................... 58

PROCTOFOAM HC .............. 79

PROCTO-PAK ....................... 96

PROCTOSOL HC .................. 79

PROCTOZONE-HC............... 96

progesterone ........................... 83

progesterone micronized ........ 83

PROGLYCEM ....................... 73

PROGRAF ............................. 84

prolia..................................... 100

PROMACTA .......................... 58

promethazine .................... 26, 79

PROMETHAZINE VC .......... 26

PROMETHAZINE VC-

CODEINE .......................... 67

promethazine-codeine ............ 67

promethazine-dm .................... 67

promethazine-phenyleph-

codeine ............................... 67

promethazine-phenylephrine .. 26

PROMETHEGAN .................. 79

PROMISEB ............................ 96

propafenone ............................ 49

propantheline .......................... 79

proparacaine ........................... 71

propranolol ............................. 53

propranolol-hydrochlorothiazid

............................................ 53

propylthiouracil ...................... 98

PROQUAD (PF) .................... 45

protriptyline ............................ 90

PRUTECT .............................. 96

PULMOZYME..................... 100

PURELAX ............................. 79

pyrazinamide .......................... 21

pyridostigmine bromide ......... 41

Q QUADRACEL (PF) ............... 45

QUASENSE ........................... 65

quetiapine ............................... 90

quinapril.................................. 53

quinapril-hydrochlorothiazide 53

quinidine gluconate ................ 49

quinidine sulfate ..................... 49

quinine sulfate ........................ 30

R RABAVERT (PF) .................. 45

rabeprazole ............................. 79

RAGWITEK ........................... 45

raloxifene .............................. 101

ramipril ................................... 53

RANEXA ............................... 49

ranitidine hcl ........................... 79

RAPAMUNE.......................... 84

RECLIPSEN (28) ................... 65

RECOMBIVAX HB (PF) ...... 45

RECTIV.................................. 79

REGRANEX .......................... 96

RELENZA DISKHALER ...... 38

RELPAX ................................ 11

REMEVEN ............................. 96

REMODULIN ........................ 53

RENAGEL ............................. 73

RENVELA ............................. 73

repaglinide .............................. 29

REPATHA PUSHTRONEX .. 53

REPATHA SURECLICK ...... 53

REPATHA SYRINGE ........... 54

RESCRIPTOR ........................ 38

RESTASIS.............................. 71

RETROVIR ............................ 38

REVLIMID ............................ 33

REYATAZ ............................. 38

RIBASPHERE........................ 38

ribavirin .................................. 38

RIDAURA .............................. 13

rifabutin .................................. 21

rifampin .................................. 21

rimantadine ............................. 38

ringer's .................................... 96

risedronate ............................ 101

RISPERDAL CONSTA ......... 90

risperidone .............................. 90

ritonavir .................................. 38

rivastigmine tartrate ................ 41

rizatriptan ................................ 11

ropinirole ................................ 35

ROSANIL ............................... 21

ROSULA CLEANSING

CLOTHS............................. 21

rosuvastatin ............................. 54

ROTARIX .............................. 45

ROTATEQ VACCINE ........... 45

S SABRIL .................................. 57

SAFYRAL .............................. 65

salicylic acid ........................... 96

SAMSCA ................................ 68

SANDOSTATIN LAR DEPOT

............................................ 83

SANTYL ................................ 96

SAPHRIS ................................ 90

SAPHRIS (BLACK CHERRY)

............................................ 90

SAVELLA ............................ 101

scopolamine base .................... 79

SEGLUROMET ..................... 29

selegiline hcl ........................... 35

selenium sulfide ...................... 96

SELZENTRY ......................... 39

SENSIPAR ........................... 101

SEREVENT DISKUS ............ 15

SEROQUEL XR ..................... 90

sertraline ................................. 90

SETLAKIN............................. 65

SF ............................................ 73

SF 5000 PLUS ........................ 73

SHAROBEL ........................... 65

SHINGRIX (PF) ..................... 45

SHINGRIX GE ANTIGEN

COMPONENT ................... 45

SIGNIFOR LAR ..................... 83

sildenafil (antihypertensive) ... 54

SILENOR ............................... 92

silver sulfadiazine ................... 22

SIMBRINZA .......................... 71

simvastatin .............................. 54

sirolimus ................................. 84

SKLICE .................................. 96

SKYLA ................................... 65

SMOOTHLAX ....................... 79

sodium chloride .............. 96, 101


sodium chloride 0.9 % ............ 73

sodium phenylbutyrate ........... 79

SODIUM POLYSTYRENE

(SORB FREE) .................... 73

sodium polystyrene sulfonate . 73

SOMATULINE DEPOT ........ 83

somavert ............................... 101

SOMAVERT ........................ 101

SORINE ................................. 54

sotalol ..................................... 54

SOTALOL AF........................ 54

SOVALDI .............................. 39

SPIRIVA RESPIMAT ........... 15

SPIRIVA WITH

HANDIHALER .................. 15

spironolactone ........................ 68

spironolacton-hydrochlorothiaz

............................................ 68

SPRINTEC (28) ..................... 65

SPRYCEL .............................. 33

SPS (WITH SORBITOL)....... 73

SRONYX ............................... 65

SSD......................................... 22

SSS 10-5 ................................. 22

stavudine................................. 39

STEGLATRO......................... 29

STIOLTO RESPIMAT .......... 15

STRATTERA ......................... 91

streptomycin ........................... 22

STRIBILD .............................. 39

STRIVERDI RESPIMAT ...... 15

SUBOXONE ........................ 101

sucralfate ................................ 79

sulfacetamide sodium ....... 22, 96

sulfacetamide sodium (acne) .. 96

sulfacetamide sodium-sulfur .. 22

sulfacetamide sod-sulfur-urea 22

sulfadiazine............................. 22

sulfamethoxazole-trimethoprim

............................................ 22

SULFAMYLON..................... 22

sulfasalazine ........................... 79

SULFAZINE .......................... 79

sulindac................................... 13

sumatriptan succinate ............. 11

SUPREP BOWEL PREP KIT 79

SUSTIVA ............................... 39

SUTENT................................. 34

SYEDA................................... 65

SYMBICORT......................... 16

SYMFI .................................... 39

SYMFI LO ............................. 39

SYMLINPEN 120 .................. 29

SYMLINPEN 60 .................... 29

SYNAREL.............................. 83

SYNERA ................................ 12

SYNJARDY ........................... 29

SYNJARDY XR..................... 29

SYNTHROID ......................... 98

SYPRINE ............................. 101

T TABLOID .............................. 34

tacrolimus ............................... 84

tadalafil (antihypertensive) ..... 54

TAKE ACTION ..................... 65

TAKHZYRO .......................... 45

TAMIFLU .............................. 39

tamoxifen ................................ 34

tamsulosin ............................. 101

TANZEUM ............................ 29

TARCEVA ............................. 34

TARGRETIN ......................... 34

TARINA FE 1/20 (28) ........... 65

TASIGNA .............................. 34

TAVALISSE ........................ 101

tazarotene................................ 97

TAZORAC ............................. 97

TAZTIA XT ........................... 49

TECFIDERA .......................... 57

TEKAMLO ............................ 54

TEKTURNA .......................... 54

TEKTURNA HCT ................. 54

telmisartan .............................. 54

temazepam .............................. 92

temozolomide ......................... 34

TENIVAC (PF) ................ 45, 46

tenofovir disoproxil fumarate . 39

terazosin.................................. 54

terbinafine hcl ......................... 25

terbutaline ............................... 16

terconazole.............................. 25

testosterone ....................... 83, 84

testosterone cypionate ............ 83

testosterone enanthate............. 83

tetanus toxoid adsorbed .......... 46

tetanus toxoid fluid ................. 46

tetanus toxoid,adsorbed (pf) ... 46

tetanus,diphtheria tox ped(pf). 46

tetanus-diphtheria toxoids-td .. 46

tetracycline ............................. 22

THALOMID ........................... 22

theophylline ............................ 16

THERMAZENE ..................... 22

thioridazine ............................. 91

thiothixene .............................. 91

THYMOGLOBULIN ............. 46

tiagabine ................................. 57

ticlopidine ............................... 36

TIGAN .................................... 79

TILIA FE ................................ 65

timolol maleate ................. 54, 71

TIVICAY ................................ 39

tizanidine ................................ 85

TOBRADEX .......................... 22

TOBRADEX ST ..................... 22

tobramycin .............................. 23

tobramycin in 0.225 % nacl .... 22

tobramycin-dexamethasone .... 23

TODAY CONTRACEPTIVE

SPONGE............................. 65

tolcapone................................. 35

tolmetin ................................... 13

tolterodine ............................. 101

topiramate ............................... 57

torsemide ................................ 68

TOUJEO SOLOSTAR U-300

INSULIN ............................ 29

TOVIAZ ............................... 101

TRACLEER ........................... 54

TRADJENTA ......................... 29

tramadol .................................. 11

tramadol-acetaminophen ........ 12

trandolapril ............................. 54

tranexamic acid ....................... 47

tranylcypromine ...................... 91

TRAVATAN Z ....................... 71

trazodone ................................ 91

TRECATOR ........................... 23

TRELEGY ELLIPTA ............. 16


............................................ 29


............................................ 29

tretinoin................................... 97

tretinoin (chemotherapy) ........ 34

tretinoin (emollient) ................ 97

tretinoin microspheres ............ 97

triamcinolone acetonide... 84, 97,

101

triamterene-hydrochlorothiazid

............................................ 68

triazolam ................................. 92

TRIBENZOR .......................... 54


TRICITRATES ...................... 74

trientine................................. 101

TRI-ESTARYLLA ................. 65

trifluoperazine ........................ 91

trifluridine............................... 39

trihexyphenidyl....................... 35

TRIHIBIT (PF) ....................... 46

TRI-LEGEST FE.................... 65

TRI-LINYAH ......................... 65

TRI-LO-SPRINTEC............... 65

TRILYTE WITH FLAVOR

PACKETS .......................... 79

trimethobenzamide ................. 79

trimethoprim ........................... 23

trimipramine ........................... 91

TRINESSA (28) ..................... 65

TRINTELLIX......................... 91

TRIPEDIA (PF)...................... 46

TRI-PREVIFEM (28) ............. 65

TRI-SPRINTEC (28).............. 65

TRIUMEQ .............................. 39

TRIVORA (28) ...................... 65

tropicamide ............................. 71

trospium ................................ 101

TRUMENBA ......................... 46

TRUVADA ............................ 39

TWINRIX (PF) ...................... 46

TYBOST .............................. 101

TYKERB ................................ 34

TYMLOS ............................... 84

TYPHIM VI ........................... 46

TYZEKA ................................ 39

TYZINE ................................. 71

U ULESFIA ............................... 97

ULORIC ................................. 13

UNITHROID .......................... 99

urea ......................................... 97

ursodiol ................................... 79

V VAGIFEM .............................. 84

valacyclovir ............................ 39

VALCYTE ............................. 39

valganciclovir ......................... 39

valproic acid ........................... 58

valproic acid (as sodium salt) . 58

valsartan ................................. 54

valsartan-hydrochlorothiazide 54

vancomycin ............................ 23

VAQTA (PF) .......................... 46

VARIVAX (PF) ..................... 46

VARIZIG................................ 46

VASCEPA .............................. 80

VELIVET TRIPHASIC

REGIMEN (28) .................. 66

VELTIN.................................. 97

venlafaxine ............................. 91

VENTAVIS ............................ 54

VENTOLIN HFA ................... 16

VERAMYST .......................... 71

verapamil ................................ 49

VEREGEN ............................. 39

VERZENIO ............................ 34

VESICARE .......................... 101

VESTURA (28) ...................... 66

VEXOL .................................. 71

VICTOZA 2-PAK .................. 29

VICTOZA 3-PAK .................. 30

VIDEX 2 GRAM PEDIATRIC

............................................ 39

VIDEX 4 GRAM PEDIATRIC

............................................ 39

vigabatrin ................................ 58

VIGAMOX ............................. 23

VIIBRYD ............................... 91

VIMPAT ................................. 58

VIORELE (28) ....................... 66

VIRACEPT ............................ 39

VIREAD ........................... 39, 40

VITAFOL-OB+DHA ............. 85

VITAMIN D2 ....................... 102

VITEKTA ............................... 40

VIVOTIF ................................ 47

VIVOTIF BERNA VACCINE

............................................ 46

voriconazole ........................... 25

VOTRIENT ............................ 34

VUSION ................................. 25

VYFEMLA (28) ..................... 66

VYTORIN 10-10 .................... 54

VYTORIN 10-20 .................... 54

VYTORIN 10-40 .................... 54

VYTORIN 10-80 .................... 54

VYVANSE ............................. 91

VYXEOS ................................ 34

W warfarin .................................. 24

water for irrigation, sterile ...... 97

WELCHOL............................. 55

WERA (28) ............................. 66

WIDE-SEAL DIAPHRAGM 60

............................................ 66


............................................ 66


............................................ 66


............................................ 66


............................................ 66


............................................ 66


............................................ 66


............................................ 66

WOMAN'S LAXATIVE ........ 80

WOMEN'S GENTLE

LAXATIVE(BISAC) ......... 80

WOMEN'S LAXATIVE

(BISACODYL)................... 80

WYMZYA FE ........................ 66

X XALKORI .............................. 34

XARELTO ............................. 24

XELJANZ............................... 13

XELJANZ XR ........................ 14

XIFAXAN .............................. 23

XOLAIR ................................. 16

XTAMPZA ER ....................... 12

XTANDI ................................. 34

XULANE ................................ 66

XYREM .................................. 92

Y YASMIN (28) ......................... 66

YAZ (28) ................................ 66

YF-VAX (PF) ......................... 47

YONSA .................................. 34

Z zafirlukast ............................... 16

zaleplon................................... 92

ZARAH .................................. 66

ZAVESCA ............................ 101

ZEMAIRA ............................ 102

ZENATANE ........................... 97

ZENCHENT (28) ................... 66

ZENCHENT FE ..................... 66


ZETIA .................................... 55

ZIAGEN ................................. 40

ZIANA ................................... 97

zidovudine .............................. 40

ZIOPTAN (PF) ....................... 71

ziprasidone hcl........................ 91

ZIRGAN ................................. 40

ZOHYDRO ER ...................... 12

zoledronic acid-mannitol-water

.......................................... 102

ZOLINZA ............................... 34

zolmitriptan ............................ 12

zolpidem ................................. 92

ZOMIG ................................... 12

ZONALON ............................. 97

zonisamide .............................. 58

ZONTIVITY .......................... 36

ZORTRESS ............................ 84

ZOSTAVAX (PF) .................. 47

ZOVIA 1/35E (28) ................. 66

ZOVIA 1/50E (28) ................. 66

ZYFLO ................................... 16

ZYFLO CR ............................. 16

ZYLET ................................... 23

ZYTIGA ................................. 34


This formulary was updated on 11/01/2018. For more recent information or other questions, please call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m. or visit myFHCA.org.

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36194_MPINFO324FH (08/2017)

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Si oumenm oswa yon moun w ap ede gen kesyon konsènan Florida Hospital Care Advantage, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 844-522-5279.

Vietnamese:

Nếu Quý vị, hay người mà Quý vị đang giúp đỡ, có câu hỏi về Florida Hospital Care Advantage thì Quý vị có quyền được trợ giúp và được biết thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với thông dịch viên, xin gọi số 844-522-5279.

Portuguese:

Você ou alguém que você estiver ajudando tem o direito de tirar dúvidas e obter informações sobre os Florida Hospital Care Advantage no seu idioma e sem custos. Para falar com um tradutor, ligue para 844-522-5279.

Chinese:

如果您，或是您正在協助的對象，有與 Florida Hospital Care Advantage 相關的問題，您有權以

您的母語免費取得幫助和資訊。請致電 844-522-5279 與翻譯員洽談。

French:

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Florida Hospital Care Advantage, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 844-522-5279.

Tagalog:

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Florida Hospital Care Advantage, may karapatan ka na humingi ng tulong at impormasyon sa iyong wika nang libre. Upang makausap ang isang tagasalin, tumawag sa 844-522-5279.

Russian:

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Florida Hospital Care Advantage, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 844-522-5279.

Arabic:

، فلديك الحق في الحصول على Florida Hospital Care Advantageإن كان لديك أو لدى شخص تساعده أسئلة بخصوص 5279-522-844المساعدةوالمعلومات الضرورية بلغتك من دون أية تكلفة. للتحدث مع مترجم اتصل بالرقم

Italian:

Se lei o qualcuno che sta aiutando avete domande su Florida Hospital Care Advantage, ha il diritto di ottenere aiuto e informazioni nella sua lingua gratuitamente. Per parlare con un interprete, può chiamare il numero 844-522-5279.

German:

Falls Sie oder jemand, dem Sie helfen, Fragen zum Florida Hospital Care Advantage haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 844-522-5279 an.

Korean:

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Florida Hospital Care Advantage에 관해서 질문이

있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가

있습니다. 그렇게 통역사와 얘기하기 위해서는 844-522-5279로 전화하십시오.

Polish:

Jeśli Ty lub osoba, której pomagasz, macie pytania na temat Florida Hospital Care Advantage, macie Państwo prawo do bezpłatnego uzyskania informacji i pomocy w języku ojczystym. Aby porozmawiać z tłumaczem, prosimy zadzwonić pod numer 844-522-5279.

Gujarati:

જો તમે અથવા તમ ેકોઇને મદદ કરી રહ્યા હો તેમાાંથી કોઇન ેફ્લોરિડા હોસ્પિટલ કેિ એડવાાંટેજ વવશે પ્રશ્નો હોય

તો તમને તમારી ભાષામાાં વવના મલૂ્યે મદદ અન ેમાહહતી મેળવવાનો અવિકાર છે. દુભાવષયા સાથ ેવાત કરવા માટે 844-522-5279 પર કૉલ કરો. Thai:

หากคณุหรอืคนทีค่ณุก าลงัชว่ยเหลอืมคี าถามเกีย่วกบั Florida Hospital Care Advantage

คุณมสีทิธทิีจ่ะไดร้บัความชว่ยเหลอืและขอ้มลูในภาษาของคณุไดโ้ดยไมม่คี่าใชจ้า่ย หากตอ้งการพูดคุยกบัล่าม โปรดโทร 844-522-5279.


36194_MPINFO109FH (10/2016)

2018 commercial formulary fdb - health first · 2018-11-15 · 2018 commercial/tpa 5 tier formulary...

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