2020 drug formulary - kaiser permanentethe drug formulary is updated periodically and is subject to...

Effective April 2020

2020 Drug Formulary

For members with individual and family plans

or covered through small employer groups (1–50 employees)

Core

Access PPO

HIOS ISSUER ID: 25768 and 80473

Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.

How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.

How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.

Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.

Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.

Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of thedrug.

Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

http://www.kp.org/wa/

http://www.ghc.org/

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date.

Drug Formulary Tiers

Tier Description

Tier P Preventative drugs and preferred contraceptives:

The Affordable Care Act (ACA) requires that preventative drugs recommended by the U.S. Preventative Services Task Force (USPSTF) are covered in full.

Tier 1 Preferred generic:

Generic drugs are copies of brand name drugs in safety, effectiveness, and quality. They contain the same exact quantities of the same active ingredients and are more affordable than the brand name drug.

Tier 2 Preferred brand:

Preferred brand drugs do not have a generic alternative, but were determined by the P&T Committee to have high value in their therapeutic class.

Tier 3 Non-preferred:

Non-preferred drugs were determined by the P&T Committee to have higher value alternatives in preferred tiers.

Tier 4 Specialty:

Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor.

Tier C Oral chemotherapy:

Washington State law requires that cancer drugs be covered at a comparable level when received at a doctor’s office or picked up from the pharmacy. This tier was created to ensure comparable coverage of preferred anti-cancer drugs regardless where the drug was received.

Tier M Medical benefit:

These drugs are usually given at the provider’s office and are covered under the medical benefit.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST)

Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL)

A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies

Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:

• Preferred blood glucose strips:

o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required

• Disposable insulin syringes and needles

• Lancing devices and lancets

Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order

Pharmacy PO Box 34383

http://www.kp.org/wa/formulary

Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non- preferred contraceptive will be covered in full.

Excluded Prescription Products for Medications that have Over-The-Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), and fluticasone propionate nasal spray (Flonase).

Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.

The most current drug formulary is available at www.kp.org/wa/formulary.




9

Table of Contents

Analgesics - Drugs for Pain and Inflammation ........................................................................ 11

Analgesics - Drugs for Pain .......................................................................................................... 12

Anesthetics ....................................................................................................................................... 15

Anti-Addiction / Substance Abuse Treatment Agents........................................................... 16

Antibacterials .................................................................................................................................... 16

Anticoagulants ................................................................................................................................. 21

Anticonvulsants - Drugs for Seizures ........................................................................................ 21

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 23

Antidepressants ............................................................................................................................... 23

Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 25

Antifungals ........................................................................................................................................ 25

Antigout Agents ............................................................................................................................... 27

Anti-inflammatory Agents ............................................................................................................. 27

Antimigraine Agents ....................................................................................................................... 27

Antimyasthenic Agents .................................................................................................................. 28

Antimycobacterials ......................................................................................................................... 28

Antineoplastics - Drugs for Cancer ............................................................................................ 28

Antiparasitics .................................................................................................................................... 32

Antiparkinson Agents ..................................................................................................................... 33

Antiplatelets ...................................................................................................................................... 33

Antipsychotics - Drugs for Mood Disorders ............................................................................ 33

Antivirals ............................................................................................................................................ 34

Anxiolytics - Drugs for Anxiety .................................................................................................... 36

Bipolar Agents - Drugs for Mood Disorders ............................................................................. 37

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 37

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 38

Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 43

Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 44

Central Nervous System Agents - Miscellaneous .................................................................. 45

Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 45

Dermatological Agents - Drugs for Skin Conditions ............................................................. 45

Diabetes - Antidiabetic Agents .................................................................................................... 52

Diabetes - Glucose Monitoring .................................................................................................... 53

Diabetes - Glycemic Agents ......................................................................................................... 54

Diabetes - Insulins ........................................................................................................................... 54

Electrolytes / Minerals / Metals / Vitamins ................................................................................ 56

10

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 57

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 58

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 60

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 60

Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 61

Hormonal Agents - Adrenal .......................................................................................................... 61

Hormonal Agents - Men's Health ................................................................................................. 63

Hormonal Agents - Osteoporosis ............................................................................................... 63

Hormonal Agents - Pituitary ......................................................................................................... 63

Hormonal Agents - Prostaglandins ............................................................................................ 64

Hormonal Agents - Sex Hormones and Birth Control ........................................................... 64

Hormonal Agents - Thyroid ........................................................................................................... 68

Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 69

Immunological Agents - Drugs for Vaccination ...................................................................... 71

Inflammatory Bowel Disease Agents ......................................................................................... 72

Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 72

Metabolic Bone Disease Agents - Other ................................................................................... 73

Miscellaneous Therapeutic Agents ............................................................................................ 73

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 75

Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 76

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 77

Otic Agents - Drugs for Ear Conditions ..................................................................................... 78

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 79

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 80

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 82

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 82

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 83

Sleep Disorder Agents ................................................................................................................... 83

Index of Drugs .................................................................................................................................. 86

Effective Date: 04/01/2020 11

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

adult aspirin regimen P

ARTHROTEC 3

aspirin adult P

aspirin adult low strength oral tablet delayed release

P

aspirin childrens P

aspirin ec P

aspirin ec low dose P

aspirin ec low strength P

aspirin low dose P

aspirin oral tablet P

aspirin oral tablet delayed release

P

BAYER ASPIRIN P

BAYER ASPIRIN EC LOW DOSE

P

CALDOLOR INTRAVENOUS SOLUTION 800 MG/8ML

M

CAMBIA 3 PA

CELEBREX 3

celecoxib oral 1

choline-mag trisalicylate 1

DAYPRO 3

DICLOFENAC EPOLAMINE

3

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 %

3

diclofenac sodium transdermal solution

3

diclofenac-misoprostol 3

DICLOFONO 3

diflunisal oral 1

DUEXIS 4 PA; QL

Drug Name Drug Tier

Notes

EC-NAPROSYN 3

ec-naproxen 3

etodolac 1

etodolac er 3

FELDENE 3

fenoprofen calcium oral 3

fenortho 3

FLECTOR 3

flurbiprofen oral 1

goodsense aspirin low dose

P

ibu 1

ibuprofen lysine M

ibuprofen oral suspension 3

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN 3

indomethacin er 1

INDOMETHACIN ORAL CAPSULE 20 MG

3

indomethacin oral capsule 25 mg, 50 mg

1

indomethacin sodium M

ketoprofen er 3

ketoprofen oral capsule 25 mg

3

ketorolac tromethamine injection

1

ketorolac tromethamine oral

3

KETOROLAC TROMETHAMINE SOLUTION 60 MG/2ML INTRAMUSCULAR

M

ketorolac tromethamine solution 60 mg/2ml intramuscular

M

LODINE 3

meclofenamate sodium oral

1

medique aspirin P


Drug Name Drug Tier

Notes

mefenamic acid oral 3

meloxicam oral 1

MOBIC 3

nabumetone oral 1

NALFON ORAL CAPSULE

3

NAPRELAN 3

NAPROSYN ORAL SUSPENSION

3

naproxen dr 3

naproxen oral 1

naproxen sodium er 3

naproxen sodium oral tablet 275 mg, 550 mg

1

naproxen-esomeprazole 4 QL

oxaprozin 3

PENNSAID 3

piroxicam oral 1

qc aspirin low dose oral tablet delayed release

P

QMIIZ ODT 3

RELAFEN DS 3 PA

REXAPHENAC 3

salsalate oral 1

SPRIX 3

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE

P

sulindac oral 1

TIVORBEX 3

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet

3

VIMOVO 4 PA; QL

VIVLODEX 3

VOLTAREN 3

ZIPSOR 3 PA

ZORVOLEX 3 PA

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain

ABSTRAL 4 PA; QL

acetaminophen-codeine 1 QL

acetaminophen-codeine #2

1 QL


1 QL


1 QL

ACTIQ 4 PA; QL

ALLZITAL 3

APADAZ 3 QL

apap-caff-dihydrocodeine 3 QL

ARYMO ER 3 PA; QL

ascomp-codeine 3 QL

BELBUCA 3 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

3 QL

BUPAP 3

BUPRENEX M

buprenorphine hcl injection

M

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

3 PA; QL

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

3 PA; QL

butalbital-acetaminophen capsule 50-300 mg oral

3

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

3

butalbital-acetaminophen oral tablet

3

butalbital-apap-caff-cod 3 QL

butalbital-apap-caffeine oral capsule

3

butalbital-apap-caffeine oral tablet

1


Drug Name Drug Tier

Notes

butalbital-asa-caff-codeine

3 QL

butalbital-aspirin-caffeine 1

butorphanol tartrate injection

M

butorphanol tartrate nasal 3

BUTRANS 3 PA; QL

carisoprodol-aspirin-codeine

3 PA

clonidine hcl (analgesia) M

codeine sulfate 1 QL

CONZIP 3 ST; QL

DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 75 MG/1.5ML, 75 MG/ML

M

DILAUDID INJECTION M

DILAUDID ORAL 3 QL

DOLOPHINE 3 ST; QL

DURAGESIC-100 3 PA; QL





duramorph M

duraxin 3

DVORAH 3 QL

endocet 1 QL

ESGIC ORAL TABLET 3

fentanyl citrate buccal lozenge on a handle

4 PA; QL

FENTANYL CITRATE BUCCAL TABLET

4 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

Drug Name Drug Tier

Notes

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

3 PA; QL

FENTORA 4 PA; QL

FIORICET 3

FIORICET/CODEINE 3 QL

FIORINAL 3

FIORINAL/CODEINE #3 3 QL

hydrocodone bitartrate er 3 QL

hydrocodone-acetaminophen oral solution 10-325 mg/15ml

3 QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

3 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 QL

hydrocodone-ibuprofen 3 QL

hydromorphone hcl er 3 ST; QL

hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml

M

hydromorphone hcl oral 1 QL

hydromorphone hcl pf M

hydromorphone hcl rectal 1

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION

M

hydromorphone hcl solution 1 mg/ml injection

M

HYSINGLA ER 3 PA; QL

INFUMORPH 200 M

INFUMORPH 500 M

KADIAN 3 PA; QL


Drug Name Drug Tier

Notes

LAZANDA 4 PA; QL

levorphanol tartrate oral 1 PA; QL

lorcet 1 QL

lorcet hd 1 QL

lorcet plus 1 QL

LORTAB 3 QL

meperidine hcl injection M

meperidine hcl oral tablet 3 QL

methadone hcl injection M ST

methadone hcl intensol 1 ST; QL

methadone hcl oral 1 ST; QL

methadose oral concentrate 10 mg/ml

3 ST; QL

methadose oral tablet soluble

1 ST; QL

methadose sugar-free 3 ST; QL

mitigo M

MORPHABOND ER 3 PA; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate (pf) M

morphine sulfate er beads 3 ST; QL

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

3 PA; QL

morphine sulfate er oral capsule extended release 24 hour 40 mg

3 QL

morphine sulfate er oral tablet extended release

1 ST; QL

MORPHINE SULFATE INJECTION

M

morphine sulfate intramuscular

M

morphine sulfate intravenous solution 25 mg/ml, 50 mg/ml

M

morphine sulfate oral 1 QL

morphine sulfate rectal 1

Drug Name Drug Tier

Notes

MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS

M

morphine sulfate solution 1 mg/ml intravenous

M

MS CONTIN 3 ST; QL

nalbuphine hcl injection M

NALOCET 3 QL

NORCO 3 QL

NUCYNTA 3 PA; QL

NUCYNTA ER 3 ST; QL

OPANA 3 QL

OXAYDO 3 QL

OXYCODONE HCL ER 2 ST; QL

oxycodone hcl oral capsule

3 QL

oxycodone hcl oral concentrate 100 mg/5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet 1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

oxycodone-acetaminophen oral tablet 2.5-300 mg

3 QL

oxycodone-aspirin 1 QL

oxycodone-ibuprofen 3 QL

OXYCONTIN 2 ST; QL

oxymorphone hcl 3 QL

oxymorphone hcl er 3 ST; QL

pentazocine-naloxone hcl 3

PERCOCET 3 QL

PRIALT M

PRIMLEV 3 QL

PROBUPHINE IMPLANT KIT

M

PROLATE 3 QL

ROXICODONE 3 QL


Drug Name Drug Tier

Notes

SUBSYS 4 PA; QL

tencon 3

tramadol hcl er (biphasic) 3 ST; QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3 ST; QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

3 ST; QL

tramadol hcl er oral tablet extended release 24 hour

3 ST; QL

tramadol hcl ir 1 QL

tramadol-acetaminophen 1 QL

TREZIX 3 QL

TYLENOL WITH CODEINE #3

3 QL

ULTRACET 3 QL

ULTRAM 3 QL

vicodin hp 3 QL

XTAMPZA ER 4 PA; QL

ZOHYDRO ER 3 PA; QL

Anesthetics

ASTERO 3

EHA 3

ethyl chloride 3

FLEXIN 3

GEBAUERS PAIN EASE 3

GEBAUERS SPRAY AND STRETCH

3

GEN7T 3

glydo 1

LDO PLUS 3

LEVATIO 3

lidocaine external ointment

3

lidocaine external patch 5 %

1

Drug Name Drug Tier

Notes

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %

3

lidocaine hcl external cream 3 %

3

LIDOCAINE HCL EXTERNAL CREAM 4.12 %

3

lidocaine hcl external lotion

3 PA

lidocaine hcl external solution

3

lidocaine hcl injection solution

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

3

lidocaine hcl urethral/mucosal

1

lidocaine-epinephrine injection solution 1 %-1:100000

3

lidocaine-prilocaine 1

LIDODERM 3

lidopin external cream 3 %

3

LIDORX 3 PA

LIDO-SORB 3 PA

LIDOTHOL EXTERNAL PATCH

3

LIDOTRAL 3

LIDOZION 3 PA

MEDI-PATCH RX 3

premium lidocaine 3

prilovix ultralite 1

prilovix ultralite plus 1

RENOVO 3

SOOTHEE 3

SYNERA 3

XYLOCAINE 3


Drug Name Drug Tier

Notes

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 1 %-1:100000

3

XYLOCAINE-MPF 3

ZIONODIL 3 PA

ZIONODIL 100 3 PA

ZTLIDO 3

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium 1

ANTABUSE 3

BUNAVAIL 3

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual film

3

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1

bupropion hcl er (smoking det)

P

CHANTIX P

CHANTIX CONTINUING MONTH PAK

P

CHANTIX STARTING MONTH PAK

P

disulfiram oral 1

EVZIO 3

LUCEMYRA 4 PA; QL

naloxone hcl injection solution

1

NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR

3

naloxone hcl injection solution cartridge

1

naloxone hcl injection solution prefilled syringe

1

naltrexone hcl oral 1

NARCAN 1

Drug Name Drug Tier

Notes

NICORETTE MOUTH/THROAT GUM 2 MG

P

nicotine polacrilex mouth/throat

P

nicotine step 1 P

nicotine step 2 P

nicotine step 3 P

NICOTROL P

NICOTROL NS P

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML

M

SUBOXONE 3

VIVITROL 4 QL

ZUBSOLV 3

Antibacterials

ACTICLATE 3

AEMCOLO 3 PA

ALTABAX 3

amikacin sulfate injection M

amoxicillin 1

amoxicillin-potassium clavulanate er

3

amoxicillin-potassium clavulanate oral

1

ampicillin 1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg

1

ampicillin sodium injection solution reconstituted 2 gm

M

ampicillin sodium intravenous

M

ampicillin-sulbactam sodium

M

ARIKAYCE 3

AUGMENTIN 3


Drug Name Drug Tier

Notes

AUGMENTIN ES-600 3

AVELOX M

avidoxy 1

AVYCAZ M

azithromycin intravenous M

azithromycin oral 1

BACTRIM 3

BACTRIM DS 3

BAXDELA INTRAVENOUS

M

BAXDELA ORAL 4 PA; QL

BICILLIN C-R M

BICILLIN C-R 900/300 M

BICILLIN L-A 2

cefaclor 3

cefaclor er 3

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm

1

cefazolin sodium injection solution reconstituted 10 gm, 100 gm, 300 gm, 500 mg

M

cefazolin sodium intravenous solution reconstituted

M

cefazolin sodium-dextrose M

cefdinir 1

cefditoren pivoxil 3

cefepime hcl injection solution reconstituted 1 gm

3

cefepime hcl injection solution reconstituted 2 gm

M

cefepime hcl intravenous M

cefepime-dextrose M

cefixime 1

cefotaxime sodium M

Drug Name Drug Tier

Notes

cefotetan disodium M

cefotetan disodium-dextrose

M

cefoxitin sodium M

CEFOXITIN SODIUM-DEXTROSE

M

cefpodoxime proxetil 3

cefprozil 1

ceftazidime and dextrose M

ceftazidime injection solution reconstituted 1 gm

1

ceftazidime injection solution reconstituted 2 gm, 6 gm

M

ceftriaxone sodium in dextrose

M

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

1

ceftriaxone sodium injection solution reconstituted 100 gm

M

ceftriaxone sodium intravenous

M

ceftriaxone sodium-dextrose

M

cefuroxime axetil 1

cefuroxime sodium M

CENTANY 3

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral capsule 750 mg

3

cephalexin oral suspension reconstituted

1

cephalexin oral tablet 3

chloramphenicol sod succinate

M


Drug Name Drug Tier

Notes

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

2

CIPRO ORAL TABLET 3

ciprofloxacin hcl oral 1

ciprofloxacin in d5w M

clarithromycin er 3

clarithromycin oral 1

CLEOCIN 3

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML

3

CLEOCIN PHOSPHATE INTRAVENOUS

M

clindamycin hcl oral 1

clindamycin palmitate hcl 1

clindamycin phosphate in d5w

M

CLINDAMYCIN PHOSPHATE IN NACL

M

clindamycin phosphate injection solution 300 mg/2ml

1

clindamycin phosphate injection solution 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

M

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

1

COLY-MYCIN M 3

coremino 3 PA

DALVANCE M

daptomycin intravenous solution reconstituted 500 mg

M

demeclocycline hcl 3

dicloxacillin sodium 1

DIFICID 4 PA; QL

Drug Name Drug Tier

Notes

DORYX 3

DORYX MPC 3

doxy 100 M

doxycycline hyclate intravenous

M

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline hyclate oral tablet delayed release

3

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral suspension reconstituted

3

doxycycline monohydrate oral tablet

1

E.E.S. GRANULES 3

ertapenem sodium M

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN LACTOBIONATE

M

ERYTHROCIN STEARATE

3

erythromycin base 3

erythromycin ethylsuccinate oral

3

erythromycin oral 3

FIRVANQ 2

FLAGYL 3

gentamicin in saline M

gentamicin sulfate external

1

gentamicin sulfate injection solution 10 mg/ml

M


Drug Name Drug Tier

Notes

gentamicin sulfate injection solution 40 mg/ml

1

HIPREX 3

imipenem-cilastatin M

INVANZ M PA

KEFLEX 3

LEVAQUIN ORAL TABLET 500 MG, 750 MG

3

levofloxacin in d5w M

levofloxacin intravenous M

levofloxacin oral 1

LINCOCIN 3

lincomycin hcl injection 3

linezolid in sodium chloride

M

linezolid intravenous M

linezolid oral 1 QL

MACROBID 3

MACRODANTIN 3

mafenide acetate external 3

meropenem M

MEROPENEM-SODIUM CHLORIDE

M

methenamine hippurate 1

methenamine mandelate oral

3

metronidazole in nacl M

metronidazole oral capsule

3

metronidazole oral tablet 1

metronidazole vaginal 1

MINOCIN INTRAVENOUS

M

MINOCIN ORAL CAPSULE 50 MG

3

minocycline hcl er oral tablet extended release 24 hour

3 PA

Drug Name Drug Tier

Notes

minocycline hcl oral capsule

1

minocycline hcl oral tablet 3

MINOLIRA 3 PA

mondoxyne nl 1

MONUROL 3

morgidox oral 1

moxifloxacin hcl in nacl M

MOXIFLOXACIN HCL INTRAVENOUS

M

moxifloxacin hcl oral 1

mupirocin calcium 1

mupirocin external 1

NAFCILLIN SODIUM IN DEXTROSE

M

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

M

nafcillin sodium intravenous

M

neomycin sulfate oral 1

neomycin-polymyxin b gu 3

nitrofurantoin 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

NUVESSA 3

NUZYRA ORAL 4 PA; QL

ofloxacin oral 3

okebo 1

ORBACTIV M

oxacillin sodium M

OXACILLIN SODIUM IN DEXTROSE

M

paromomycin sulfate oral 3

PENICILLIN G POT IN DEXTROSE

M

penicillin g potassium M


Drug Name Drug Tier

Notes

penicillin g procaine M

penicillin g sodium M

penicillin v potassium 1

piperacillin sod-tazobactam so

M

polymyxin b sulfate injection

M

PRIMSOL 2

SEYSARA 4 PA; QL

SILVADENE 3

silver nitrate external 3

silver sulfadiazine external

1

SIVEXTRO INTRAVENOUS

M

SIVEXTRO ORAL 4 QL

SOLODYN 3 PA

SOLOSEC 3

SPECTRACEF 3

ssd 1

streptomycin sulfate intramuscular

3

sulfadiazine oral 3

sulfamethoxazole-trimethoprim intravenous

M

sulfamethoxazole-trimethoprim oral

1

SULFAMYLON 3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

SUPRAX ORAL TABLET CHEWABLE

3

Drug Name Drug Tier

Notes

SYNERCID M

TARGADOX 3

tazicef injection solution reconstituted 1 gm

1

tazicef injection solution reconstituted 2 gm, 6 gm

M

TAZICEF SOLUTION RECONSTITUTED 1 GM INTRAVENOUS

M

tazicef solution reconstituted 1 gm intravenous

M

TAZICEF SOLUTION RECONSTITUTED 2 GM INTRAVENOUS

M

tazicef solution reconstituted 2 gm intravenous

M

TEFLARO M

tetracycline hcl oral 3

tinidazole oral 3

tobramycin sulfate injection

M

trimethoprim oral 1

VABOMERE M

VANCOCIN HCL 4 PA; QL

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%

M

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%

M

VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS

M

vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous

M


Drug Name Drug Tier

Notes

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 10 gm, 100 gm, 250 mg, 5 gm, 500 mg, 750 mg

M

vancomycin hcl oral capsule

1 QL

vancomycin hcl oral solution reconstituted

1

vandazole 1

VIBATIV M

VIBRAMYCIN 3

XENLETA ORAL 3 PA

XEPI 3

XIFAXAN 4 PA; QL

XIMINO 3 PA

ZERBAXA M

ZITHROMAX ORAL 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZOSYN INTRAVENOUS SOLUTION

M

ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML

M

ZYVOX ORAL 4 PA; QL

Anticoagulants

ACTIVASE M

ARIXTRA 4 PA; QL

COUMADIN 3

DEFITELIO M

ELIQUIS 3 PA

ELIQUIS DVT/PE STARTER PACK

3 PA

enoxaparin sodium 1 QL

fondaparinux sodium 4 QL

Drug Name Drug Tier

Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

3

FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML

3 PA

heparin (porcine) in nacl intravenous solution 25000-0.45 ut/250ml-%

M

heparin sod (porcine) in d5w intravenous solution 100 unit/ml, 40-5 unit/ml-%

M

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) injection solution 20000 unit/ml

M

heparin sodium (porcine) pf

1

jantoven 1

LOVENOX 1 QL

PRADAXA 2

SAVAYSA 3 PA

THROMBATE III M

TNKASE M

warfarin sodium oral 1

XARELTO 2 PA

XARELTO STARTER PACK

2 PA

Anticonvulsants - Drugs for Seizures

APTIOM 4 PA; QL

BANZEL 4 PA; QL

BRIVIACT INTRAVENOUS

M


Drug Name Drug Tier

Notes

BRIVIACT ORAL 4 PA; QL

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 2

clobazam 4 QL

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIACOMIT 4 PA; QL

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 1

diazepam rectal 1

DILANTIN INFATABS 3

DILANTIN ORAL CAPSULE 100 MG

3

DILANTIN ORAL CAPSULE 30 MG

2

DILANTIN ORAL SUSPENSION

3

divalproex sodium er 1

divalproex sodium oral 1

EPIDIOLEX 4 PA; QL

epitol 1

EQUETRO 3

ethosuximide oral 1

felbamate 3 QL

FELBATOL 4 PA; QL

fosphenytoin sodium M

FYCOMPA 3 ST; QL

gabapentin oral 1

GABITRIL 3

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL 3

LAMICTAL ODT ORAL TABLET DISPERSIBLE

3

LAMICTAL STARTER 3

Drug Name Drug Tier

Notes

LAMICTAL XR 3

lamotrigine er 3

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

3

lamotrigine starter kit-blue 3

lamotrigine starter kit-green

3

lamotrigine starter kit-orange

3

levetiracetam er 1

levetiracetam in nacl M

levetiracetam intravenous M

levetiracetam oral 1

MYSOLINE 4 QL

NAYZILAM 4 PA; QL

NEMBUTAL 3

NEURONTIN 3

ONFI 4 PA; QL

oxcarbazepine 1

OXTELLAR XR 3

PEGANONE 3

pentobarbital sodium injection

3

phenobarbital oral 1

phenobarbital sodium injection solution 130 mg/ml

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral 1

phenytoin sodium extended oral capsule 100 mg

1

phenytoin sodium extended oral capsule 200 mg, 300 mg

3


Drug Name Drug Tier

Notes

phenytoin sodium injection

1

primidone oral 1 QL

QUDEXY XR 3 PA

roweepra 1

roweepra xr 1

SABRIL 4 PA; QL

SPRITAM 3

subvenite 1

subvenite starter kit-blue 3

subvenite starter kit-green 3

subvenite starter kit-orange

3

SYMPAZAN 4

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl 3

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 3 PA

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 PA

valproic acid oral 1

VALTOCO 10 MG DOSE 2



VALTOCO 5 MG DOSE 2

vigabatrin oral packet 4 PA; QL

vigabatrin oral tablet 4 QL

vigadrone 4 PA; QL

VIMPAT ORAL 3

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT 3

Drug Name Drug Tier

Notes

donepezil hcl oral tablet 10 mg, 5 mg

1

donepezil hcl oral tablet 23 mg

3

donepezil hcl oral tablet dispersible

3

EXELON 3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 3 PA

memantine hcl oral solution

3

memantine hcl oral tablet 10 mg, 5 mg

1

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

3

NAMENDA 3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 PA

NAMENDA XR TITRATION PACK

3 PA

NAMZARIC 3

RAZADYNE 3

RAZADYNE ER 3

rivastigmine 3

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN 3

BRISDELLE 3

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1


Drug Name Drug Tier

Notes

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

3 ST

bupropion hcl oral 1

CELEXA 3

chlordiazepoxide-amitriptyline

3

citalopram hydrobromide 1

clomipramine hcl oral 1

CYMBALTA 3

desipramine hcl oral 1

DESVENLAFAXINE ER 3 PA

desvenlafaxine succinate er

3 PA

doxepin hcl oral capsule 1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3

duloxetine hcl oral 1

EFFEXOR XR 3

EMSAM 4 PA; QL

escitalopram oxalate 1

FETZIMA 3 ST

FETZIMA TITRATION 3 PA

fluoxetine hcl (pmdd) 3

fluoxetine hcl oral capsule 1

fluoxetine hcl oral capsule delayed release

3

fluoxetine hcl oral solution 1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

fluvoxamine maleate er 3

FORFIVO XL 3 ST

imipramine hcl oral 1

imipramine pamoate 3

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

Drug Name Drug Tier

Notes

mirtazapine oral 1

NARDIL 3

nefazodone hcl 3

NORPRAMIN 3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl 3

PAMELOR 3

PARNATE 3

paroxetine hcl 1

paroxetine hcl er 3

paroxetine mesylate 3

PAXIL CR 3

PAXIL ORAL SUSPENSION

2

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA 3

phenelzine sulfate oral 1

PRISTIQ 3 PA

protriptyline hcl 1

PROZAC 3

REMERON 3

REMERON SOLTAB 3

SARAFEM 3

sertraline hcl oral 1

SYMBYAX 3

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral 3

TRINTELLIX 3 ST

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

venlafaxine hcl er oral tablet extended release 24 hour

3


Drug Name Drug Tier

Notes

VIIBRYD 3 ST

VIIBRYD STARTER PACK

3 ST

WELLBUTRIN SR 3

WELLBUTRIN XL 3

ZOLOFT 3

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS

M

AKYNZEO ORAL 3

ALOXI M PA

ANZEMET 3

aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1

aprepitant oral capsule 40 mg

3

BONJESTA 3 PA

CINVANTI M

compro 1

DICLEGIS 3 PA

dimenhydrinate injection 1

doxylamine-pyridoxine 3 PA

dronabinol 1

droperidol injection M

EMEND INTRAVENOUS M

EMEND ORAL 3

EMEND TRI-PACK 3

fosaprepitant dimeglumine

M

granisetron hcl intravenous

M

granisetron hcl oral 3 PA

meclizine hcl oral tablet 3

metoclopramide hcl injection

1

metoclopramide hcl oral solution

1

Drug Name Drug Tier

Notes

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

3

ondansetron hcl injection 1

ondansetron hcl oral 1

ondansetron odt 1

palonosetron hcl intravenous solution 0.25 mg/5ml

M

perphenazine oral 1

prochlorperazine 1

prochlorperazine edisylate injection

1

prochlorperazine maleate oral

1

REGLAN 3

SANCUSO 3 PA

scopolamine 3

SUSTOL M

SYNDROS 3

TIGAN 3

TRANSDERM SCOP (1.5 MG)

3

TRANSDERM-SCOP (1.5 MG)

3

trimethobenzamide hcl oral

3

VARUBI 3 PA

ZOFRAN 3

ZUPLENZ 3

Antifungals

ABELCET M

AMBISOME M

ANCOBON 4 PA; QL

BIO-STATIN ORAL CAPSULE

3

bio-statin oral powder 3

caspofungin acetate M

ciclodan 1


Drug Name Drug Tier

Notes

ciclopirox external gel 1

ciclopirox external shampoo

3

ciclopirox external solution

1

ciclopirox olamine external

1

clotrimazole external 3

clotrimazole mouth/throat 1

clotrimazole-betamethasone

1

CRESEMBA INTRAVENOUS

M

CRESEMBA ORAL 4 PA; QL

DIFLUCAN 3

econazole nitrate external 3

ECOZA 3

ERAXIS M

ERTACZO 3

EXELDERM 3

exoderm external lotion 3

EXTINA 3

fluconazole in sodium chloride

M

fluconazole oral 1

flucytosine oral 4 QL

griseofulvin microsize oral 1

griseofulvin ultramicrosize 1

GYNAZOLE-1 3

itraconazole oral 1 PA

JUBLIA 3 PA

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

3

ketoconazole external shampoo

1

ketoconazole oral 1

ketodan external foam 3

Drug Name Drug Tier

Notes

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT 0.77 % (SUSP)

3

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LOTRISONE 3

LULICONAZOLE 3

LUZU 3

miconazole 3 vaginal suppository

3

MICONAZOLE-ZINC OXIDE-PETROLAT

3

MYCAMINE M

naftifine hcl 3

NAFTIN 3

NIZORAL 3

NOXAFIL INTRAVENOUS

M

NOXAFIL ORAL SUSPENSION

4 PA; QL

NOXAFIL ORAL TABLET DELAYED RELEASE

4 PA

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 1

nystatin-triamcinolone 1

nystop 1

ORAVIG 3

oxiconazole nitrate 3

OXISTAT 3

posaconazole 4 PA

SPORANOX 3 PA

SPORANOX PULSEPAK 3 PA

SULCONAZOLE NITRATE

3

terbinafine hcl oral 1


Drug Name Drug Tier

Notes

terconazole 3

TOLSURA 3 PA

VFEND 4 PA

voriconazole intravenous M

voriconazole oral 1 PA

VUSION 3

XOLEGEL 3

Antigout Agents

allopurinol oral 1

allopurinol sodium M

COLCHICINE ORAL CAPSULE

1

colchicine tablet 0.6 mg oral

1

COLCHICINE TABLET 0.6 MG ORAL (authorized generic)

2

colchicine-probenecid 1

COLCRYS 2

febuxostat oral tablet 40 mg

3 QL

febuxostat oral tablet 80 mg

3

GLOPERBA 3

KRYSTEXXA M PA

MITIGARE 3

probenecid 1

ULORIC ORAL TABLET 40 MG

3 PA; QL

ULORIC ORAL TABLET 80 MG

3 PA

ZYLOPRIM 3

Anti-inflammatory Agents

EMFLAZA 4 PA; QL

Antimigraine Agents

AIMOVIG 3 PA

AJOVY 3 PA

almotriptan malate 3 ST

AMERGE 3

Drug Name Drug Tier

Notes

CAFERGOT 3

D.H.E. 45 4 PA; QL

dihydroergotamine mesylate injection

1 QL

dihydroergotamine mesylate nasal

4

eletriptan hydrobromide 3 ST

EMGALITY 3 PA

EMGALITY (300 MG DOSE)

3 PA

ERGOMAR 2

ergotamine-caffeine 1

FROVA 3 ST

frovatriptan succinate 3 ST

IMITREX 3

IMITREX STATDOSE REFILL

3

IMITREX STATDOSE SYSTEM

3

MAXALT 3

MAXALT-MLT 3

MIGERGOT 2

MIGRANAL 4

naratriptan hcl 1

RELPAX 3 ST

REYVOW 3 PA

rizatriptan benzoate 1

sumatriptan nasal 1

sumatriptan succinate oral

1

sumatriptan succinate refill

1

sumatriptan succinate subcutaneous

1

sumatriptan-naproxen sodium

3 ST

TOSYMRA 3

TREXIMET 3 ST

UBRELVY 3 PA

ZEMBRACE SYMTOUCH 3


Drug Name Drug Tier

Notes

zolmitriptan oral 1

ZOMIG 3

ZOMIG ZMT 3

Antimyasthenic Agents

BLOXIVERZ M

GUANIDINE HCL 3

MESTINON ORAL SOLUTION

2

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml

M

pyridostigmine bromide er 1

pyridostigmine bromide oral

1

REGONOL M

Antimycobacterials

CAPASTAT SULFATE M

cycloserine oral 3

dapsone oral 1

ethambutol hcl oral 1

isoniazid injection M

isoniazid oral 1

MYAMBUTOL 3

MYCOBUTIN 3

PASER 3

PRIFTIN 2

pyrazinamide oral 1

rifabutin 1

RIFADIN ORAL 3

RIFAMATE 3

rifampin intravenous M

rifampin oral 1

RIFATER 3

SIRTURO 4 PA; QL

Drug Name Drug Tier

Notes

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate C QL

ABRAXANE M

ADCETRIS M PA

adriamycin M

adrucil M

AFINITOR C PA; QL

AFINITOR DISPERZ C PA; QL

ALECENSA C PA; QL

ALIMTA M

ALIQOPA M PA

ALKERAN ORAL C QL

ALUNBRIG C PA; QL

anastrozole oral P

ARIMIDEX C PA

AROMASIN C PA

ARRANON M

arsenic trioxide intravenous

M

ARZERRA M PA

AVASTIN M

AYVAKIT C PA; QL

azacitidine M

BALVERSA C PA; QL

BAVENCIO M PA

BELEODAQ M PA

BELRAPZO M PA

BENDAMUSTINE HCL M PA

BENDEKA M PA

BESPONSA M PA

bexarotene C PA; QL

bicalutamide C

BICNU M

bleomycin sulfate M

BLINCYTO M

BORTEZOMIB M

BOSULIF C PA; QL


Drug Name Drug Tier

Notes

BRAFTOVI C PA; QL

BRUKINSA C PA; QL

busulfan M

CABOMETYX C PA

CALQUENCE C PA; QL

CAMPATH M PA

CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15ML

M

capecitabine C QL

CAPRELSA C PA; QL

carboplatin M

carmustine M

CASODEX C PA

cisplatin intravenous solution

M

cladribine M

clofarabine M

COMETRIQ (100 MG DAILY DOSE)

C PA; QL


C PA; QL


C PA; QL

COPIKTRA C PA; QL

COTELLIC C PA; QL

cyclophosphamide injection

M

cyclophosphamide oral C

CYRAMZA M PA

cytarabine M

cytarabine (pf) M

dacarbazine M

dactinomycin M

DARZALEX M PA

daunorubicin hcl M

DAURISMO C PA; QL

decitabine M

docetaxel M

Drug Name Drug Tier

Notes

doxorubicin hcl M

doxorubicin hcl liposomal M

DROXIA C

ELITEK M

EMCYT C PA; QL

EMPLICITI M PA

epirubicin hcl M

ERBITUX M

ERIVEDGE C PA

ERLEADA C PA; QL

erlotinib hcl C PA; QL

ERWINAZE M

ETOPOPHOS M

etoposide intravenous M

etoposide oral C QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

C PA; QL

EVOMELA M

exemestane P

FARESTON C PA

FARYDAK C PA; QL

FASLODEX M

FEMARA C PA

floxuridine injection M

fludarabine phosphate M

fluorouracil intravenous M

flutamide C

FOLOTYN M

fulvestrant M

GAZYVA M PA

gemcitabine hcl M

GILOTRIF C PA; QL

GLEEVEC C QL

GLEOSTINE C

GLIADEL WAFER M

HALAVEN M PA

HERCEPTIN M


Drug Name Drug Tier

Notes

HYCAMTIN ORAL C PA; QL

HYDREA 3 PA

hydroxyurea oral 1

IBRANCE ORAL CAPSULE

C PA; QL

ICLUSIG C PA; QL

idarubicin hcl M

IDHIFA C PA; QL

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM

M

ifosfamide M

imatinib mesylate C QL

IMBRUVICA C PA; QL

IMFINZI M PA

IMLYGIC M PA

INLYTA C PA; QL

INREBIC C PA; QL

IRESSA C PA; QL

irinotecan hcl M

ISTODAX (OVERFILL) M

IXEMPRA KIT M

JAKAFI C PA; QL

JEVTANA M PA

KADCYLA M PA

KEYTRUDA M PA

KHAPZORY M PA

KISQALI (200 MG DOSE) C PA



KISQALI FEMARA (400 MG DOSE)

C PA

KISQALI FEMARA (600 MG DOSE)

C PA

KISQALI FEMARA(200 MG DOSE)

C PA

KYPROLIS M PA

LARTRUVO M PA

LENVIMA (10 MG DAILY DOSE)

C PA; QL

Drug Name Drug Tier

Notes


C PA; QL


C PA; QL


C PA; QL


C PA; QL


C PA; QL


C PA; QL


C PA; QL

letrozole oral C

leucovorin calcium injection solution reconstituted

M

leucovorin calcium oral C

LEUKERAN C

levoleucovorin calcium M

levoleucovorin calcium pf M

LONSURF C PA; QL

LORBRENA C PA; QL

LUTATHERA M PA

LYNPARZA C PA; QL

LYSODREN C PA

MARQIBO M

MATULANE C QL

MEKINIST C PA; QL

MEKTOVI C PA; QL

melphalan C QL

melphalan hcl M

mercaptopurine oral C

mesna 1

MESNEX ORAL C

mitomycin intravenous M

mitoxantrone hcl M

mutamycin M

MYLERAN C QL


Drug Name Drug Tier

Notes

MYLOTARG M PA

NERLYNX C PA; QL

NEXAVAR C PA; QL

NILANDRON C PA

nilutamide C PA

NINLARO C PA; QL

NIPENT M

NUBEQA C PA; QL

ODOMZO C PA; QL

ONCASPAR M

ONIVYDE M

OPDIVO M PA

oxaliplatin M

paclitaxel M

PANRETIN C PA; QL

paraplatin M

PERJETA M PA

PHOTOFRIN M

PIQRAY (200 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL

POMALYST C PA; QL

PORTRAZZA M PA

POTELIGEO M PA

PROLEUKIN M

PURIXAN C PA

QUADRAMET M

REVLIMID C PA; QL

RITUXAN M PA

RITUXAN HYCELA M PA

ROMIDEPSIN M

ROZLYTREK C PA; QL

RUBRACA C PA; QL

RYDAPT C PA; QL

SIKLOS 4 PA; QL

SOLTAMOX C PA

Drug Name Drug Tier

Notes

SPRYCEL C PA; QL

STIVARGA C PA; QL

SUTENT C PA; QL

SYLVANT M PA

SYNRIBO M PA

TABLOID C

TAFINLAR C PA; QL

TAGRISSO C PA; QL

TALZENNA C PA; QL

tamoxifen citrate oral P

TARCEVA C PA; QL

TARGRETIN C PA; QL

TASIGNA C PA; QL

TAXOTERE M

TAZVERIK C PA; QL

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML

M PA

TEMODAR INTRAVENOUS

M

TEMODAR ORAL C PA; QL

temozolomide C QL

teniposide M

TEPADINA M

THALOMID C PA; QL

thiotepa injection M

TIBSOVO C PA; QL

toposar M

topotecan hcl M

toremifene citrate C

TREANDA M PA

tretinoin oral C QL

TRISENOX M

TURALIO C PA; QL

TYKERB C PA; QL

UNITUXIN M

VALCHLOR 4 PA; QL

valrubicin M


Drug Name Drug Tier

Notes

VALSTAR M

VECTIBIX M PA

VENCLEXTA C PA; QL

VENCLEXTA STARTING PACK

C PA; QL

VERZENIO C PA; QL

vinblastine sulfate M

vincristine sulfate M

vinorelbine tartrate M

VITRAKVI C PA; QL

VIZIMPRO C PA; QL

VORAXAZE M

VOTRIENT C PA; QL

VYXEOS M PA

XALKORI C PA; QL

XELODA C PA; QL

XOFIGO M PA

XOSPATA C PA; QL

XPOVIO (100 MG ONCE WEEKLY)

C PA; QL


C PA; QL


C PA; QL

XPOVIO (80 MG TWICE WEEKLY)

C PA; QL

XTANDI C PA; QL

YERVOY M PA

YESCARTA M PA

YONDELIS M PA

YONSA C PA; QL

ZALTRAP M PA

ZANOSAR M

ZEJULA C PA; QL

ZELBORAF C PA; QL

ZOLINZA C PA; QL

ZYDELIG C PA; QL

ZYKADIA C PA; QL

ZYTIGA C PA; QL

Drug Name Drug Tier

Notes

Antiparasitics

albendazole oral 1

ALBENZA 3

ALINIA 2

atovaquone oral 4 QL

atovaquone-proguanil hcl 3 PA

BENZNIDAZOLE 3 PA; QL

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 1

DARAPRIM 4 PA; QL

ELIMITE 3

EMVERM 3

hydroxychloroquine sulfate oral

1

IMPAVIDO 4 PA; QL

ivermectin oral 3

KRINTAFEL 2

lindane 3

MALARONE 3 PA

malathion 3

mefloquine hcl 3 PA

MEPRON 4 PA; QL

NATROBA 3

NEBUPENT 3

OVIDE 3

PENTAM 3

pentamidine isethionate 3

permethrin external 1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate 1

QUALAQUIN 3

quinine sulfate oral 3

SKLICE 3


Drug Name Drug Tier

Notes

spinosad 3

STROMECTOL 3

ULESFIA 2

Antiparkinson Agents

amantadine hcl oral 1

APOKYN 4 PA; QL

AZILECT 3 PA

benztropine mesylate 1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa er 1

carbidopa-levodopa oral tablet

1

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

1

carbidopa-levodopa oral tablet dispersible 25-250 mg

3

carbidopa-levodopa-entacapone

1

COGENTIN 3

COMTAN 3

DUOPA 4 PA; QL

entacapone 1

GOCOVRI 4 PA; QL

INBRIJA 4 PA; QL

LODOSYN 3

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

NOURIANZ 4 PA; QL

OSMOLEX ER 3 PA

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

3

rasagiline mesylate oral 1 PA

Drug Name Drug Tier

Notes

REQUIP XL 3

ropinirole hcl 1

ropinirole hcl er 3

RYTARY 3 PA

selegiline hcl oral 1

SINEMET 3

SINEMET CR 3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR 4 PA; QL

tolcapone 4 PA; QL

trihexyphenidyl hcl 1

XADAGO 3 PA

ZELAPAR 4 PA; QL

Antiplatelets

AGGRASTAT M

AGGRENOX 3

aspirin-dipyridamole er 1

ASPIRIN-OMEPRAZOLE 3

BRILINTA 2

CABLIVI 4 PA; QL

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

DURLAZA 3

EFFIENT 3

PLAVIX 3

prasugrel hcl 1

YOSPRALA 3

ZONTIVITY 3

Antipsychotics - Drugs for Mood Disorders

ABILIFY 3


Drug Name Drug Tier

Notes

ABILIFY MAINTENA 4 QL

ABILIFY MYCITE 3

aripiprazole oral solution 1

aripiprazole oral tablet 1

aripiprazole oral tablet dispersible

3

ARISTADA 4 QL

ARISTADA INITIO 4 QL

CAPLYTA 4 PA; QL

chlorpromazine hcl injection

1

chlorpromazine hcl oral 1

clozapine oral tablet 1

clozapine oral tablet dispersible

3

CLOZARIL ORAL TABLET 100 MG, 25 MG

3

FANAPT 3 ST

FANAPT TITRATION PACK

3 ST

fluphenazine decanoate injection

1

fluphenazine hcl 1

GEODON 3

HALDOL 3

HALDOL DECANOATE 3

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1

INVEGA 3 ST

INVEGA SUSTENNA 4

INVEGA TRINZA 4

LATUDA 4 PA; QL

loxapine succinate 1

molindone hcl 3

NUPLAZID 4 PA; QL

olanzapine 1

paliperidone er 3 ST

Drug Name Drug Tier

Notes

PERSERIS 4

pimozide 1

quetiapine fumarate 1

quetiapine fumarate er 1

REXULTI 3 PA

RISPERDAL 3

RISPERDAL CONSTA 2

risperidone oral solution 1

risperidone oral tablet 1

risperidone oral tablet dispersible

3

SAPHRIS 3 ST

SECUADO 3 PA

SEROQUEL 3

SEROQUEL XR 3

thioridazine hcl oral 3

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3

VRAYLAR 4 PA; QL

ziprasidone hcl 1

ziprasidone mesylate 3

ZYPREXA 3

ZYPREXA RELPREVV 2

ZYPREXA ZYDIS 3

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

4 QL

acyclovir external 3

acyclovir oral 1

acyclovir sodium M

adefovir dipivoxil 1 QL

APTIVUS ORAL CAPSULE

4 QL


Drug Name Drug Tier

Notes

APTIVUS ORAL SOLUTION

4 PA; QL

atazanavir sulfate 1 QL

ATRIPLA 4 QL

BARACLUDE ORAL SOLUTION

4 QL

BARACLUDE ORAL TABLET

4 PA; QL

BIKTARVY 4 QL

cidofovir intravenous M

CIMDUO 4 QL

COMBIVIR 3

COMPLERA 4 PA; QL

CRIXIVAN 2

DELSTRIGO 4 PA; QL

DENAVIR 3

DESCOVY 4 QL

didanosine 1

DOVATO 4 QL

EDURANT 2

efavirenz 1

EMTRIVA 2

entecavir 1 QL

EPCLUSA 4 PA; QL

EPIVIR 3

EPIVIR HBV ORAL SOLUTION

2

EPIVIR HBV ORAL TABLET

3

EPZICOM 4 PA; QL

EVOTAZ 4 PA; QL

famciclovir 3

fosamprenavir calcium 4 QL

FOSCAVIR M

FUZEON 4 PA; QL

GANCICLOVIR M

ganciclovir sodium intravenous solution reconstituted

M

Drug Name Drug Tier

Notes

GENVOYA 4 QL

HARVONI 4 PA; QL

HEPSERA 4 PA; QL

INTELENCE 2

INTRON A C QL

INVIRASE 2

ISENTRESS HD 2

ISENTRESS ORAL PACKET

3

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA 4 QL

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET 2

lamivudine 1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

4 PA; QL

LEXIVA 4 QL

lopinavir-ritonavir 1

MAVYRET 4 PA; QL

nevirapine er 1

nevirapine oral suspension

3

nevirapine oral tablet 1

NORVIR ORAL PACKET 2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET 3

ODEFSEY 4 QL

oseltamivir phosphate oral

1

PEGASYS 4 QL

PEGASYS PROCLICK 4 QL

PEGINTRON 4 QL

PIFELTRO 4 PA; QL


Drug Name Drug Tier

Notes

PREVYMIS INTRAVENOUS

M

PREVYMIS ORAL 4 PA; QL

PREZCOBIX 2 QL

PREZISTA 2

RAPIVAB M

RELENZA DISKHALER 2

RETROVIR INTRAVENOUS

M

RETROVIR ORAL 3

REYATAZ ORAL CAPSULE

4 QL

REYATAZ ORAL PACKET

2

ribavirin inhalation 3

ribavirin oral 1 QL

rimantadine hcl 1

ritonavir 1

SELZENTRY 4 QL

SITAVIG 3

SOFOSBUVIR-VELPATASVIR

4 PA; QL

SOVALDI 4 PA; QL

stavudine 1

STRIBILD 4 PA; QL

SUSTIVA 3

SYLATRON C PA; QL

SYMFI 1

SYMFI LO 1

SYMTUZA 4 QL

TAMIFLU 2

TEMIXYS 4 QL

tenofovir disoproxil fumarate

1

TIVICAY 2

TRIUMEQ 4 QL

TRIZIVIR 4 PA; QL

TRUVADA 4 QL

TYBOST 2 PA

Drug Name Drug Tier

Notes

valacyclovir hcl oral 1

VALCYTE 4 PA; QL

valganciclovir hcl oral solution reconstituted

4 PA; QL

valganciclovir hcl oral tablet

4 QL

VALTREX 3

VEMLIDY 4 PA; QL

VIDEX 2

VIDEX EC 3

VIEKIRA PAK 4 PA; QL

VIRACEPT 2

VIRAMUNE 3

VIRAMUNE XR 3

VIRAZOLE 3

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VIREAD ORAL TABLET 300 MG

3

VOSEVI 4 PA; QL

XERESE 3

XOFLUZA 3

ZEPATIER 4 PA; QL

ZIAGEN 3

zidovudine 1

ZOVIRAX 3

Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam intensol 3

alprazolam oral tablet 1

alprazolam oral tablet dispersible

3

alprazolam xr 1

ATIVAN INJECTION SOLUTION 2 MG/ML

3

ATIVAN ORAL 3

buspirone hcl oral 1


Drug Name Drug Tier

Notes

chlordiazepoxide hcl 1

clonazepam oral 1

clorazepate dipotassium 1

diazepam injection 1

diazepam intensol 3

diazepam intramuscular 1

diazepam oral concentrate

3

diazepam oral solution 1

diazepam oral tablet 1

DORAL 3

estazolam 3

HALCION 3

hydroxyzine hcl intramuscular

M

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

KLONOPIN 3

lorazepam injection solution 2 mg/ml

1

lorazepam intensol 1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 1

meprobamate 3

midazolam hcl (pf) injection solution 10 mg/2ml, 5 mg/ml

1

midazolam hcl injection solution 10 mg/2ml, 5 mg/ml

1

midazolam hcl oral 3

oxazepam 1

quazepam 3

TRANXENE-T 3

triazolam 1

VALIUM 3

VISTARIL 3

XANAX 3

Drug Name Drug Tier

Notes

XANAX XR 3

Bipolar Agents - Drugs for Mood Disorders

lithium 1

lithium carbonate er 1

lithium carbonate oral 1

LITHOBID 3

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADVATE M PA

ADYNOVATE M PA

AFSTYLA M PA

AGRYLIN 3

ALPHANATE/VWF COMPLEX/HUMAN

M PA

ALPHANINE SD M PA

ALPROLIX M PA

AMICAR 3

aminocaproic acid intravenous

M

aminocaproic acid oral 3

anagrelide hcl 1

ARANESP (ALBUMIN FREE)

3 PA

BENEFIX M PA

CEPROTIN M

COAGADEX M PA

CORIFACT M PA

DOPTELET 4 PA; QL

ELOCTATE M PA

EPOGEN 2 PA

FIBRYGA M

FULPHILA 4 PA; QL

GRANIX SUBCUTANEOUS SOLUTION

4 QL

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

4 PA; QL

HEMLIBRA 4 PA; QL


Drug Name Drug Tier

Notes

HEMOFIL M M PA

HESPAN M

hetastarch-nacl M

HEXTEND M

HUMATE-P M PA

IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

M PA

IXINITY M PA

KCENTRA M

KOATE M PA

KOATE-DVI M PA

KOGENATE FS M PA

KOVALTRY M PA

LEUKINE M

LYSTEDA 3 QL

MIRCERA 3 PA

MONONINE M PA

MOZOBIL M PA

MULPLETA 4 PA; QL

NEULASTA 4 PA; QL

NEULASTA ONPRO 4 PA; QL

NEUPOGEN 4 QL

NIVESTYM 4 PA; QL

NOVOEIGHT M PA

NOVOSEVEN RT M PA

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 500 MCG

M PA

NUWIQ M PA

OBIZUR M PA

PANHEMATIN M

PROCRIT 2 PA

PROFILNINE M PA

PROFILNINE SD M PA

Drug Name Drug Tier

Notes

PROMACTA 4 PA; QL

REBINYN M PA

RECOMBINATE M PA

RETACRIT 3 PA

RIASTAP M

RIXUBIS M PA

SOLIRIS M PA

TAVALISSE 4 PA; QL

tranexamic acid intravenous

M

tranexamic acid oral 1 QL

TRETTEN M PA

UDENYCA 4 PA; QL

ULTOMIRIS M

VONVENDI M PA

WILATE M PA

XYNTHA M PA

XYNTHA SOLOFUSE M PA

ZARXIO 4 QL

ZIEXTENZO 4 PA; QL

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

acetazolamide sodium 3

ADALAT CC 3

ALDACTAZIDE ORAL TABLET 25-25 MG

3

ALDACTAZIDE ORAL TABLET 50-50 MG

2

ALDACTONE 3

aliskiren fumarate 3 ST

alprostadil injection 1

ALTACE 3

ALTOPREV 3

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1


Drug Name Drug Tier

Notes

amiodarone hcl oral tablet 100 mg, 400 mg

3

amiodarone hcl oral tablet 200 mg

1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

3 ST

amlodipine-atorvastatin 3

amlodipine-olmesartan 1

amlodipine-valsartan-hctz 3

ANTARA 3

ATACAND 3

ATACAND HCT 3

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

AVALIDE 3

AVAPRO 3

AZOR 3

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1

BENICAR 3

BENICAR HCT 3

BETAPACE 3

BETAPACE AF 3

betaxolol hcl oral 1

BIDIL 3

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide injection M

bumetanide oral 1

BUMEX 3

BYSTOLIC 3

CADUET 3

Drug Name Drug Tier

Notes

CALAN SR 3

candesartan cilexetil 3

candesartan cilexetil-hctz 3

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 3

CATAPRES 3

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorothiazide oral 1

chlorthalidone 1

cholestyramine light packets

1

cholestyramine oral packets

1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 3

COLESTID 3

COLESTID FLAVORED 3

colestipol hcl 1

CONSENSI 4 PA; QL

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA

COZAAR 3

CRESTOR 3


Drug Name Drug Tier

Notes

DEMSER 3

DIBENZYLINE 4 PA; QL

digitek 1

digox 1

digoxin injection 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 3

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

diltiazem hcl er coated beads oral tablet extended release 24 hour

3

diltiazem hcl er oral capsule extended release 12 hour

1

diltiazem hcl oral 1

dilt-xr 1

DIOVAN 3

DIOVAN HCT 3

disopyramide phosphate 1

DIURIL 2

dofetilide 3 PA

doxazosin mesylate oral 1

DUTOPROL 3

DYAZIDE 3

DYRENIUM 3

EDARBI 3 ST

EDARBYCLOR 3 ST

EDECRIN 3 PA

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 PA

EPANED 3

epinephrine pf 1

eplerenone 1

eprosartan mesylate 3 ST

Drug Name Drug Tier

Notes

ethacrynate sodium M

ethacrynic acid 1 PA

ETHAMOLIN M

EXFORGE 3 ST

EXFORGE HCT 3

EZALLOR SPRINKLE 3

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized 1

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral capsule 150 mg, 50 mg

3

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg

3

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid oral capsule delayed release

3

fenofibric acid oral tablet 1

FENOGLIDE 3

FIBRICOR 3

flecainide acetate 1

FLOLIPID 3

fluvastatin sodium 3

fluvastatin sodium er 3

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide injection 1

furosemide oral 1

gemfibrozil oral 1

GIAPREZA M

GONITRO 3

guanfacine hcl 1

HEMANGEOL C PA

hydralazine hcl oral 1


Drug Name Drug Tier

Notes

hydrochlorothiazide oral 1

HYZAAR 3

indapamide 1

INDERAL LA 3

INDERAL XL 3

INNOPRAN XL 3

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

isoproterenol hcl injection 3

ISORDIL TITRADOSE ORAL TABLET 40 MG

2

ISORDIL TITRADOSE ORAL TABLET 5 MG

3

isosorbide dinitrate 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

isradipine 1

ISUPREL 3

JUXTAPID 4 PA; QL

KAPSPARGO SPRINKLE 3

KATERZIA 3

labetalol hcl oral 1

LANOXIN 3

LANOXIN PEDIATRIC 3

LASIX 3

LESCOL XL 3

LIPITOR 3

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3

LOPID 3

LOPRESSOR 3

LOPRESSOR HCT 3

losartan potassium 1

Drug Name Drug Tier

Notes

losartan potassium-hctz 1

LOTENSIN HCT 3

LOTENSIN ORAL TABLET 20 MG, 40 MG

3

LOTREL 3

lovastatin 1

LOVAZA 3

matzim la 3

MAXZIDE 3

MAXZIDE-25 3

methyldopa 1

methyldopa-hydrochlorothiazide

3

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

milrinone lactate M

milrinone lactate in dextrose

M

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral 1

niacin (antihyperlipidemic) 3

niacin er (antihyperlipidemic)

3

niacor 3

NIASPAN 3

nicardipine hcl oral 1

nifedipine er 1


Drug Name Drug Tier

Notes

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 3

NITRO-BID 2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual 3

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

nitro-time oral capsule extended release 9 mg

1

NORPACE 3

NORPACE CR 2

NORTHERA 4 PA; QL

NORVASC 3

NYMALIZE 4 PA; QL

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

3

omega-3-acid ethyl esters 3

pacerone oral tablet 100 mg, 400 mg

3

pacerone oral tablet 200 mg

1

papaverine hcl injection 1

pentoxifylline er 1

Drug Name Drug Tier

Notes

perindopril erbumine 1

phenoxybenzamine hcl oral

4 QL

phentolamine mesylate injection

1

pindolol 1

PRALUENT 4 PA; QL

PRAVACHOL 3

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3

prevalite 1

PRINIVIL 3

procainamide hcl injection 1

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 3

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

PROSTIN VR 3

QBRELIS 3

QUESTRAN 3

QUESTRAN LIGHT 3

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate 1

ramipril 1

RANEXA 3 PA

ranolazine er 3 PA

RECTIV 2

REPATHA 3 PA

REPATHA PUSHTRONEX SYSTEM

3 PA

REPATHA SURECLICK 3 PA


Drug Name Drug Tier

Notes

rosuvastatin calcium 1

RYTHMOL SR 3

SIMVASTATIN ORAL SUSPENSION

3

simvastatin oral tablet 1

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

sotalol hydrochloride 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR 3

TARKA 3

taztia xt 3

TEKTURNA 3 ST

TEKTURNA HCT 3 ST

telmisartan 3

telmisartan-amlodipine 3

telmisartan-hctz 3

TENORETIC 100 3

TENORETIC 50 3

TENORMIN 3

tiadylt er 3

TIAZAC 3

TIKOSYN 3 PA

timolol maleate oral 1

TOPROL XL 3

torsemide 1

trandolapril 1

trandolapril-verapamil hcl er

3

triamterene oral 1

triamterene-hctz 1

TRIBENZOR 3

TRICOR 3

TRIGLIDE 3

Drug Name Drug Tier

Notes

TRILIPIX 3

TWYNSTA 3

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA ORAL CAPSULE 0.5 GM

3 PA

VASCEPA ORAL CAPSULE 1 GM

3

VASERETIC 3

VASOTEC 3

VECAMYL 4 PA; QL

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

3

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VYNDAMAX 4 PA; QL

VYNDAQEL 4 PA; QL

VYTORIN 3

WELCHOL 3

ZESTORETIC 3

ZESTRIL 3

ZETIA 3

ZIAC 3

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3

ZYPITAMAG 3

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3

ADDERALL XR 1 QL


Drug Name Drug Tier

Notes

ADHANSIA XR 3 ST; QL

ADZENYS ER 3 PA

ADZENYS XR-ODT 3 PA

AMPHETAMINE ER 3 PA

amphetamine sulfate 3 PA

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1 QL

APTENSIO XR 3 ST; QL

atomoxetine hcl 1

clonidine hcl er 3

CONCERTA 3 QL

COTEMPLA XR-ODT 3 PA; QL

DAYTRANA 3 ST; QL

DESOXYN 3

DEXEDRINE 3 QL

dexmethylphenidate hcl 1

dexmethylphenidate hcl er

3 ST; QL

dextroamphetamine sulfate er

1 QL

dextroamphetamine sulfate oral solution

3

dextroamphetamine sulfate oral tablet

1

DYANAVEL XR 3 ST

EVEKEO 3 PA

EVEKEO ODT 3 PA

FOCALIN 3

FOCALIN XR 3 ST; QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 PA; QL

KAPVAY 3

metadate er 1 QL

methamphetamine hcl 3

METHYLIN 3

methylphenidate hcl er 1 QL

Drug Name Drug Tier

Notes

methylphenidate hcl er (cd)

1 QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg

3 ST; QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg

1 ST; QL

methylphenidate hcl oral solution

3

methylphenidate hcl oral tablet

1

methylphenidate hcl oral tablet chewable

3

MYDAYIS 3 PA; QL

PROCENTRA 3

QUILLICHEW ER 3 PA

QUILLIVANT XR 3 ST; QL

relexxii 1 QL

RITALIN 3

RITALIN LA 3 ST; QL

STRATTERA 3 ST

VYVANSE 3 PA; QL

zenzedi oral tablet 10 mg, 5 mg

1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 4 PA; QL

AUBAGIO 4 PA; QL

AVONEX PEN 4 PA; QL

AVONEX PREFILLED 4 PA; QL

BETASERON 4 PA; QL

COPAXONE 4 PA; QL

dalfampridine er 4 PA; QL

EXTAVIA 4 QL

GILENYA 4 PA; QL

glatiramer acetate 4 QL

glatopa 4 QL


Drug Name Drug Tier

Notes

LEMTRADA M PA

MAVENCLAD (10 TABS) 4 PA; QL







MAYZENT 4 PA; QL

MAYZENT STARTER PACK

4 PA; QL

OCREVUS M PA

PLEGRIDY 4 PA; QL

PLEGRIDY STARTER PACK

4 PA; QL

REBIF 4 QL

REBIF REBIDOSE 4 QL

REBIF REBIDOSE TITRATION PACK

4 QL

REBIF TITRATION PACK 4 QL

TECFIDERA 4 PA; QL

TYSABRI M PA

VUMERITY 4 PA; QL

VUMERITY (STARTER) 4 PA; QL

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA; QL

AUSTEDO 4 PA; QL

caffeine citrate oral 1

GRALISE 3

GRALISE STARTER 3

HORIZANT 3

INGREZZA 4 PA; QL

LYRICA 3 QL

LYRICA CR 3 PA

NUEDEXTA 3 PA

pregabalin oral 1 QL

RADICAVA M PA

RILUTEK 4 PA; QL

Drug Name Drug Tier

Notes

riluzole 1 QL

SAVELLA 3 ST

SAVELLA TITRATION PACK

3 ST

TEGSEDI 4 PA; QL

tetrabenazine 4 PA; QL

TIGLUTIK 4 QL

XENAZINE 4 PA; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

BOCASAL 3

cevimeline hcl 3

chlorhexidine gluconate mouth/throat

1

DEBACTEROL 3

EVOXAC 3

FIRST-MOUTHWASH BLM

3

KEPIVANCE M

lidocaine hcl mouth/throat 3

lidocaine viscous hcl 1

MUCOSITISRX 3

NEUTRASAL 3

oralone 1

paroex 1

periogard 1

pilocarpine hcl oral tablet 5 mg

1

pilocarpine hcl oral tablet 7.5 mg

3

SALAGEN 3

SALIVAMAX 3

triamcinolone acetonide mouth/throat

1

XEROSTOMIA RELIEF SPRAY

3

Dermatological Agents - Drugs for Skin Conditions

ABSORICA 3

ABSORICA LD 3


Drug Name Drug Tier

Notes

ACANYA 3

acitretin 1 QL

ACZONE 3

adapalene external cream 1

adapalene external gel 1

ADAPALENE EXTERNAL PAD

3

ADAPALENE EXTERNAL SOLUTION

3

adapalene-benzoyl peroxide

3

ADVANCED ALLERGY COLLECTION

3

AKLIEF 3 PA

ala-cort external cream 1 %

3

ala-cort external cream 2.5 %

1

alclometasone dipropionate

1

ALDARA 3

ALTRENO 3

amcinonide 3

AMELUZ 2 QL

amlactin external cream 12 %

3

ammonium lactate external

3

amnesteem 1

AMZEEQ 3

ANACAINE 3

arzol silver nit applicators 3

ATOPADERM 3

ATOPICLAIR 3

ATRALIN 3

avar cleanser 1

avita 1

azelaic acid external 1

AZELEX 2

Drug Name Drug Tier

Notes

balsam peru-castor oil 3

BENSAL HP 3

BENZACLIN 3

BENZACLIN WITH PUMP 3

BENZAMYCIN 3

benzepro foaming cloths 3

BENZIQ 3

BENZIQ LS 3

BENZOYL PEROX-HYDROCORTISONE

3

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %

3

BENZOYL PEROXIDE FORTE- HC

3

benzoyl peroxide-erythromycin

1

beser external lotion 3

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

betamethasone valerate external

1

bp 10-1 3

bp cleansing wash 3

BPCO 3

BRYHALI 3

calcipotriene external cream

1

CALCIPOTRIENE EXTERNAL FOAM

3

calcipotriene external ointment

1

calcipotriene external solution

1

calcipotriene-betameth diprop external ointment

3

CALCIPOTRIENE-BETAMETH DIPROP EXTERNAL SUSPENSION

3


Drug Name Drug Tier

Notes

calcitrene 1

calcitriol external 1

CAPEX 2

CARAC 2

cem-urea 3

CERACADE 3

ceramax external cream 3

claravis 1

CLEOCIN-T 3

clindacin etz external swab

1

clindacin-p 1

CLINDAGEL 3

clindamycin phos-benzoyl perox external gel 1.2-2.5 %, 1.2-5 %

3

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external foam

3

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

3

clindamycin phosphate gel 1 % external

1

clindamycin-tretinoin 3

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

3

clobetasol propionate external cream

1 ST

clobetasol propionate external foam

3

Drug Name Drug Tier

Notes

clobetasol propionate external gel

1

clobetasol propionate external liquid

3

clobetasol propionate external lotion

1

clobetasol propionate external ointment

1

clobetasol propionate external shampoo

3

clobetasol propionate external solution

1

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 3

clodan external shampoo 3

CLODERM 3

CONDYLOX 2

CORDRAN EXTERNAL CREAM 0.05 %

3

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

2

CORTISPORIN EXTERNAL CREAM

3

CORTISPORIN EXTERNAL OINTMENT

2

CUTIVATE 3

dapsone external gel 5 % 3

dapsone gel 7.5 % external

3

DAPSONE GEL 7.5 % EXTERNAL

3

DERMA-SMOOTHE/FS BODY

3

DERMA-SMOOTHE/FS SCALP

3

DERMULCERA 3

DESONATE 3


Drug Name Drug Tier

Notes

desonide external 1

DESOWEN 3

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

3

desoximetasone external ointment

1

DEXERYL 3

diclofenac sodium transdermal gel 3 %

3

DIFFERIN EXTERNAL CREAM

1

DIFFERIN EXTERNAL GEL 0.3 %

3

DIFFERIN EXTERNAL LOTION

2

diflorasone diacetate 3

DIPROLENE 3

DIPROLENE AF 3

DOVONEX 3

doxepin hcl external 3

doxycycline 3

DRYSOL 2

DUPIXENT 4 PA; QL

EFUDEX C PA

ELETONE 3

ELIDEL 1

ELOCON 3

EMULSION SB 3

ENSTILAR 3

ENTTY SPRAY EMULSION

3

EPICERAM 3

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

Drug Name Drug Tier

Notes

ery 3

ERYGEL 3

erythromycin external 1

EUCRISA 3 PA; QL

EVOCLIN 3

FABIOR 3

FINACEA EXTERNAL FOAM

2

FINACEA EXTERNAL GEL

3

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external cream 0.05 %

1

fluocinonide external cream 0.1 %

3

fluocinonide external gel 1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

C

fluorouracil external solution

C

flurandrenolide 3

fluticasone propionate external cream

1

fluticasone propionate external lotion

3

fluticasone propionate external ointment

3


Drug Name Drug Tier

Notes

grafco silver nit applicator 3

halcinonide 3

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

3

halobetasol propionate external ointment

1

HALOG 3

HPR 3

HPR PLUS 3

hydrocortisone ace-pramoxine external

1

hydrocortisone butyr lipo base

3

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

3

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 1 %

3

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone valerate 1

HYLATOPIC PLUS EXTERNAL CREAM

3

HYLATOPIC PLUS EXTERNAL FOAM

3

HYLINATE 3

imiquimod external 1

IMIQUIMOD PUMP 3

IMPOYZ 3 PA

isotretinoin oral 1

Drug Name Drug Tier

Notes

ivermectin external 3

KAMDOY 3

KENALOG EXTERNAL 3

KIVIK 3

KLARON 3

lactic acid e 3

lactic acid external 3

LEVULAN KERASTICK 2 QL

LEXETTE 3

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL

3

LIDOTREX 3

LOCOID 3

LOCOID LIPOCREAM 3

LUXIQ 3

methoxsalen rapid 4 QL

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole external cream

1

metronidazole external gel 0.75 %

1

metronidazole external gel 1 %

3

metronidazole external lotion

3

MIMYX 3

MIRVASO 3

mometasone furoate external

1

myorisan 1

NEOCERA 3

NEOSALUS CP 3

NEOSALUS EXTERNAL CREAM

3

NEOSALUS EXTERNAL FOAM

3


Drug Name Drug Tier

Notes

NEO-SYNALAR EXTERNAL CREAM

3

neuac external gel 3

NIVATOPIC PLUS 3

nolix 3

NORITATE 3

NOVACORT 3

NUCORT 3

OLUX 3

OLUX-E 3

ONEXTON 3

ORACEA 3 PA

OVACE PLUS EXTERNAL CREAM

3

OVACE PLUS EXTERNAL FOAM

3

OXSORALEN ULTRA 4 PA; QL

PANDEL 3

PENLEN 3

PHLAG SPRAY 3

PICATO C QL

pimecrolimus cream 1 % external

1

PIMECROLIMUS CREAM 1 % EXTERNAL

2

PLEXION CLEANSING CLOTH

3

podocon 3

podofilox external 1

PRAMOSONE EXTERNAL CREAM 1-1 %

2

PRAMOSONE EXTERNAL CREAM 1-2.5 %

3

PRAMOSONE EXTERNAL LOTION

2

pramox 3

prednicarbate 3

PRESERA 3

Drug Name Drug Tier

Notes

PROMISEB 3

PROTEXA 3

PROTOPIC 3

PRUCLAIR 3

PRUDOXIN 3

PRUMYX 3

PSORCON 3

QBREXZA 3 PA

REGENECARE 3

REGRANEX 4 PA; QL

RETIN-A 1

RETIN-A MICRO GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

3

RHOFADE 3

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

3

salicylic acid external cream

3

salicylic acid external foam

3

salicylic acid external gel 3

salicylic acid external liquid

3

salicylic acid external lotion

3

salicylic acid external shampoo

3

salicylic acid external solution 26 %

3

salicylic acid wart remover

3

salimez 3

SALIMEZ FORTE 3


Drug Name Drug Tier

Notes

SANTYL 2

selenium sulfide external lotion

1

selenium sulfide external shampoo 2.25 %

3

SERNIVO 3

sodium hyaluronate external

3

sodium sulfacetamide 1

sodium sulfacetamide wash liquid 10 % external

3

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL

3

SOOLANTRA 3

SORIATANE 4 PA; QL

SORILUX 3

sss 10-5 3

sulfacetamide sodium (acne)

1

sulfacetamide sodium external

3

sulfacetamide sodium-sulfur external cream

3

sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external liquid

3

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide sodium-sulfur external lotion 9.8-4.8 %

3

sulfacetamide sodium-sulfur external pad

3

sulfacetamide sodium-sulfur external suspension

3

sulfacetamide-sulfur in urea

1

sulfacleanse 8/4 3

sulfamez wash 3

Drug Name Drug Tier

Notes

SUVICORT 3

synalar external cream 1

synalar external ointment 1

SYNALAR EXTERNAL SOLUTION

3

SYNERDERM 3

TACLONEX 3

tacrolimus external ointment

1

tazarotene external 1

TAZORAC EXTERNAL CREAM 0.05 %

2

TAZORAC EXTERNAL CREAM 0.1 %

1

TAZORAC EXTERNAL GEL

2

TEMOVATE EXTERNAL CREAM

3 ST

TEMOVATE EXTERNAL OINTMENT

3

TETRIX 3

TEXACORT 3

TOLAK C PA

TOPICORT 3

TOPICORT SPRAY 3

tovet external foam 3

tretinoin external cream 1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin external gel 0.05 %

3

tretinoin microsphere 1

tretinoin microsphere pump

1

triamcinolone acetonide external aerosol solution

3

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1


Drug Name Drug Tier

Notes

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide external ointment 0.05 %

3

trianex 3

triderm 1

TRIDESILON 3

ULTRAVATE 3

urea external cream 39 %, 41 %, 45 %, 47 %

3

urea external cream 40 % 1

UREA EXTERNAL FOAM 3 PA

urea external suspension 3

urea hydrating 3

urea nail 3

uredeb 3

uremez-40 1

URESOL 3

UTOPIC 3

VANOS 3

VANOXIDE-HC 3

VECTICAL 1

VELTIN 3

VENELEX 3

VERDESO 3

VEREGEN 3

XALIX 3

XERALUX 3

xurea 3

zaclir cleansing 3

zenatane 1

ZIANA 3

ZITHRANOL 3

ZONALON 3

ZYCLARA 3

ZYCLARA PUMP 3

Drug Name Drug Tier

Notes

Diabetes - Antidiabetic Agents

acarbose oral 1

ACTOPLUS MET 3

ACTOS 3

ADLYXIN 3 PA; QL

ADLYXIN STARTER PACK

3 PA; QL

ALOGLIPTIN BENZOATE 3 PA

ALOGLIPTIN-METFORMIN HCL

3 PA

ALOGLIPTIN-PIOGLITAZONE

3 PA

AMARYL 3

AVANDIA 3

BYDUREON 3 PA; QL

BYDUREON BCISE AUTOINJECTOR

3 PA; QL

BYETTA 10 MCG PEN 3 PA; QL

BYETTA 5 MCG PEN 3 PA; QL

CYCLOSET 3 ST

DUETACT 3

FARXIGA 3 PA; QL

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG

3 PA

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG

3

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUMETZA 3 PA

glyburide micronized 3

glyburide oral 1


Drug Name Drug Tier

Notes

glyburide-metformin 3

GLYNASE 3

GLYSET 3

GLYXAMBI 3 ST

INVOKAMET 3 PA; QL

INVOKAMET XR 3 PA; QL

INVOKANA 3 PA; QL

JANUMET 3 PA

JANUMET XR 3 PA

JANUVIA 3 PA

JARDIANCE 2 PA; QL

JENTADUETO 3 ST

JENTADUETO XR 3 ST

KAZANO 3 PA

KOMBIGLYZE XR 3 PA

metformin hcl er 1

metformin hcl er (mod) 3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg

3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 500 mg

3

METFORMIN HCL ORAL SOLUTION

2

metformin hcl oral tablet 1

miglitol 3

nateglinide 3

NESINA 3 PA

ONGLYZA 3 PA

OSENI 3 PA

OZEMPIC 3 PA; QL

pioglitazone hcl 3

pioglitazone hcl-glimepiride

3

pioglitazone hcl-metformin hcl

3

PRECOSE 3

QTERN 3 PA; QL

repaglinide 3

Drug Name Drug Tier

Notes

RIOMET 2

RIOMET ER 3 PA

RYBELSUS 3 PA

SEGLUROMET 3 PA; QL

SOLIQUA 3 PA; QL

STARLIX 3

STEGLATRO 3 PA; QL

STEGLUJAN 3 PA; QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3 PA; QL

SYNJARDY XR 3 PA; QL

tolbutamide 1

TRADJENTA 3 ST

TRULICITY 3 PA; QL

VICTOZA 3 PA; QL

XIGDUO XR 3 PA; QL

XULTOPHY 3 PA

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO

1

ACCU-CHEK COMPACT PLUS CONTROL

1

ACCU-CHEK FASTCLIX LANCET KIT

1

ACCU-CHEK GUIDE CONTROL

1

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

1

ACCU-CHEK SMARTVIEW CONTROL

1

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

1

AGAMATRIX CONTROL LEVEL 2

1

AGAMATRIX CONTROL LEVEL 4

1

AUTOLET LANCING DEVICE

1

CARETOUCH LANCING/EJECTOR

1


Drug Name Drug Tier

Notes

CONTOUR CONTROL 1

CONTOUR NEXT CONTROL

1

CONTOUR NEXT TEST 1 PA; QL

DIATHRIVE GLUCOSE CONTROL SOLN

1

DIATHRIVE LANCING DEVICE

1

EASYMAX CONTROL 1

EMBRACE TALK GLUCOSE CONTROL

1

FORTISCARE CONTROL 1

FREESTYLE TEST 1 PA; QL

GENTEEL LANCING KIT (BLUE)

1

GOJJI CONTROL 1

GOJJI LANCING DEVICE/CLEAR CAP

1

LANCETS 1

LANCETS KIT 1

MICROLET NEXT LANCING DEVICE

1

OMNIPOD DASH SYSTEM

3 PA

OMNIPOD STARTER 3 PA

ONETOUCH DELICA LANCING DEV

1

ONETOUCH DELICA PLUS LANCING

1

ONETOUCH ULTRA BLUE TEST STRIPS

1 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

1

ONETOUCH VERIO TEST STRIPS

1 QL

SURESTEP PRO HIGH GLUCOSE

1

SURESTEP PRO LOW GLUCOSE

1

SURESTEP PRO NORMAL GLUCOSE

1

TRUE METRIX LEVEL 1 1

Drug Name Drug Tier

Notes



UNISTRIP CONTROL IN VITRO SOLUTION LOW

1

V-GO 20 3 PA

V-GO 30 3 PA

V-GO 40 3 PA

VIVAGUARD INO CONTROL SOLUTION

1

VIVAGUARD LANCING DEVICE

1

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 3 PA

BAQSIMI TWO PACK 3 PA

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT INJECTION KIT

2

GVOKE PFS 4 PA; QL

PROGLYCEM 2

Diabetes - Insulins

ABOUTTIME PEN NEEDLE

1

ADMELOG 3 PA

ADMELOG SOLOSTAR 3 PA

AFREZZA 3 PA

APIDRA SOLOSTAR 3

APIDRA VIAL 3

BASAGLAR KWIKPEN 3 PA

BD AUTOSHIELD DUO PEN NEEDLES

1

BD ULTRA-FINE INSULIN SYRINGES

1

BD ULTRA-FINE PEN NEEDLES

1

FIASP 3 PA

FIASP FLEXTOUCH 3 PA

HUMALOG 2

HUMALOG KWIKPEN 2


Drug Name Drug Tier

Notes

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 50/50 VIAL

3

HUMALOG MIX 75/25 KWIKPEN

3

HUMALOG MIX 75/25 VIAL

3

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMULIN 70/30 KWIKPEN

1

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 1

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN

1

HUMULIN R U-500 VIAL (CONCENTRATED)

1

HUMULIN R VIAL 1

INSULIN ASP PROT & ASP FLEXPEN

3

INSULIN ASPART 3

INSULIN ASPART FLEXPEN

3

INSULIN ASPART PENFILL

3

INSULIN ASPART PROT & ASPART

3

INSULIN LISPRO 2

INSULIN LISPRO (1 UNIT DIAL)

2

INSULIN PEN NEEDLES 1

Drug Name Drug Tier

Notes

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

1

LANTUS SOLOSTAR 2 PA

LANTUS U-100 VIAL 2 PA

LEVEMIR U-100 FLEXTOUCH

2 PA

LEVEMIR U-100 VIAL 2 PA

MAXICOMFORT SYR 27G X 1/2"

1

MICRODOT PEN NEEDLE 31G X 6 MM , 33G X 4 MM

1

NOVOFINE AUTOCOVER PEN NEEDLE

1

NOVOFINE PEN NEEDLE

1

NOVOFINE PLUS PEN NEEDLE

1

NOVOLIN 70/30 RELION 3 ST

NOVOLIN 70/30 VIAL 3 ST

NOVOLIN N RELION 3 ST

NOVOLIN N VIAL 3 ST

NOVOLIN R RELION 3 ST

NOVOLIN R VIAL 3 ST

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 FLEXPEN

3

NOVOLOG MIX 70/30 VIAL

3

NOVOLOG PENFILL 3

NOVOLOG U-100 VIAL 3


Drug Name Drug Tier

Notes

NOVOTWIST PEN NEEDLE

1

PURE COMFORT PEN NEEDLE

1

TOUJEO MAX SOLOSTAR

3 PA

TOUJEO SOLOSTAR 3 PA

TRESIBA 3 PA

TRESIBA FLEXTOUCH 3 PA

ULTIGUARD SAFEPACK PEN NEEDLE

1

Electrolytes / Minerals / Metals / Vitamins

argyle sterile saline 1

argyle sterile water 3

CARBAGLU 4 PA; QL

CARNITOR INTRAVENOUS

M

CARNITOR ORAL SOLUTION

1

CARNITOR ORAL TABLET

3

CARNITOR SF 1

CHEMET 3 PA

clovique 4 PA; QL

curity sterile saline 1

cyanocobalamin injection solution 1000 mcg/ml

1

cytra k crystals 1

deferasirox 4 QL

DRISDOL 3

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

3

ergocalciferol oral capsule 1

EXJADE 4 PA; QL

FERAHEME M PA

FERRIPROX ORAL SOLUTION

3 PA

Drug Name Drug Tier

Notes

FERRIPROX ORAL TABLET

4 PA; QL

ferrous sulfate oral solution

P

ferrous sulfate oral tablet 325 (65 fe) mg

P

ferrous sulfate oral tablet delayed release

P

FLUORABON P

fluoritab P

FLURA-DROPS P

folic acid injection P

folic acid oral tablet P

gnp folic acid P

INJECTAFER M PA

iodine strong oral 3

JADENU 4 PA; QL

JADENU SPRINKLE 4 PA; QL

JYNARQUE 4 PA; QL

kionex 1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 2

klor-con m20 1

klor-con sprinkle 1

klor-con/ef 3

K-PHOS 3

K-PHOS NO 2 3

k-prime 3

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

2

levocarnitine oral solution 1

levocarnitine oral tablet 1

levocarnitine sf 1


Drug Name Drug Tier

Notes

LOKELMA 4 PA; QL

ludent P

MEPHYTON 1

MIFEPREX 3

mifepristone 3

multi prenatal P

na ferric gluc cplx in sucrose

M

nafrinse P

nafrinse drops P

ONE-A-DAY WOMENS PRENATAL 1

P

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

PHYSIOLYTE 3

PHYSIOSOL IRRIGATION

3

phytonadione injection 1

phytonadione oral 1

pot bicarb-pot chloride 3

potassium bicarbonate oral

3

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

potassium citrate-citric acid

1

prenatal multi +dha oral capsule 27-0.8-228 mg, 27-0.8-250 mg

P

prenatal oral tablet 27-0.8 mg, 28-0.8 mg

P

PRENATVITE RX P

ra iron oral tablet 325 (65 fe) mg

P

SAMSCA 4 PA; QL

Drug Name Drug Tier

Notes

sod citrate-citric acid 1

sodium chloride (pf) 1

sodium chloride irrigation 1

sodium fluoride oral P

sodium polystyrene sulfonate oral

1

sodium polystyrene sulfonate rectal

3

sps 1

sterile water for irrigation 3

SYPRINE 4 PA; QL

taron-crystals 1

tricitrates 1

trientine hcl 4 PA; QL

TRIFERIC HEMODIALYSIS PACKET

M

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

VELTASSA 3 PA

VENOFER M

virt-phos 250 neutral 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

water for irrigation, sterile 3

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX 3 ST

ACIPHEX SPRINKLE 3 PA

CARAFATE ORAL SUSPENSION

1

CARAFATE ORAL TABLET

3

cimetidine hcl 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 3 PA


Drug Name Drug Tier

Notes

esomeprazole magnesium oral capsule delayed release 20 mg

3

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

FIRST-LANSOPRAZOLE 3

FIRST-OMEPRAZOLE 3

lansoprazole oral capsule delayed release

1

lansoprazole oral tablet delayed release dispersible

3 PA

misoprostol oral 1

NEXIUM ORAL PACKET 3 PA

nizatidine 3

omeprazole oral capsule delayed release

1

OMEPRAZOLE+SYRSPEND SF ALKA

3

omeprazole-sodium bicarbonate oral packet

3 PA

pantoprazole sodium oral 1

PEPCID 3

PREVACID 3

PREVACID SOLUTAB 3 PA

PRILOSEC 3

PROTONIX ORAL 3

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

3 PA

rabeprazole sodium oral tablet delayed release

1 ST

ranitidine hcl oral capsule 3

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral 1

ZEGERID ORAL PACKET

3 PA

Drug Name Drug Tier

Notes

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL 3

alosetron hcl 4 PA; QL

AMITIZA 3 PA; QL

amoxicill-clarithro-lansopraz

3

belladonna alkaloids-opium

1

BENTYL 3

bisacodyl ec P

CHENODAL 4 PA; QL

chlordiazepoxide-clidinium

1

citroma P

clearlax P

CLENPIQ 3

constulose 1

cromolyn sodium oral 3

CUVPOSA 3

dicyclomine hcl intramuscular

3

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spaz 3

ENTEREG 3

enulose 1

EX-LAX ULTRA P

GASTROCROM 3

GATTEX 4 PA; QL

gavilax oral powder P

gavilyte-c P

gavilyte-g P

gavilyte-h 3

gavilyte-n with flavor pack P

generlac 1

gentle laxative oral P

GLYCATE 3


Drug Name Drug Tier

Notes

glycolax P

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GLYCOPYRROLATE ORAL TABLET 1.5 MG

3

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

2

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

hyoscyamine sulfate er 3

hyoscyamine sulfate injection

3

hyoscyamine sulfate oral 3

hyoscyamine sulfate sl 3

hyoscyamine sulfate sublingual

3

hyosyne 3

KRISTALOSE 3

lactulose encephalopathy 1

lactulose oral packet 3

lactulose oral solution 1

LEVSIN INJECTION 3

LIBRAX 3

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

3 PA; QL

LINZESS ORAL CAPSULE 72 MCG

3 PA

LOMOTIL 3

loperamide hcl oral capsule

1

LOTRONEX 4 PA; QL

magnesium citrate oral solution

P

methscopolamine bromide oral

3

Drug Name Drug Tier

Notes

MOTEGRITY 3 PA

MOTOFEN 3

MOVANTIK 3 PA; QL

MOVIPREP 3

MYTESI 3

nulev 3

NULYTELY WITH FLAVOR PACKS

3

OMECLAMOX-PAK 3

opium 1

oscimin 3

oscimin sr 3

OSMOPREP 3

paregoric 3

peg 3350-kcl-na bicarb-nacl

P

peg-3350/electrolytes P

peg-prep 3

PLENVU 3

PREPOPIK 3

propantheline bromide oral

1

PYLERA 2

qc magnesium citrate P

RELISTOR ORAL 3 PA

RELISTOR SUBCUTANEOUS

2

SEROSTIM 4 PA; QL

SUPREP BOWEL PREP KIT

3

SYMAX DUOTAB 3

symax-sl 3

symax-sr 3

SYMPROIC 3 PA

TALICIA 3

trilyte P

TRULANCE 3 PA

URSO 250 3


Drug Name Drug Tier

Notes

URSO FORTE 3

ursodiol oral 1

VIBERZI 3 PA

XERMELO 4 PA; QL

ZELNORM 3 PA

ZORBTIVE 4 PA; QL

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

ALDURAZYME M PA

BUPHENYL 4 PA; QL

CERDELGA 4 PA; QL

CEREZYME M PA

CHOLBAM 4 PA; QL

CREON 2

CRYSVITA 4 PA; QL

CYSTADANE 3

CYSTAGON 2 PA

ELAPRASE M PA

ELELYSO M PA

EXONDYS 51 M PA

FABRAZYME M PA

GALAFOLD 4 PA; QL

KANUMA M PA

KUVAN 4 PA; QL

LUMIZYME M PA

MEPSEVII M PA

miglustat 4 PA; QL

MYALEPT 4 PA; QL

NAGLAZYME M PA

nitisinone 4 QL

NITYR 4 PA; QL

OCALIVA 4 PA; QL

ORFADIN 4 PA; QL

PALYNZIQ 4 PA; QL

PANCREAZE 3

PERTZYE 3

PROCYSBI 4 PA; QL

RAVICTI 4 PA; QL

Drug Name Drug Tier

Notes

sodium phenylbutyrate oral powder

4 PA; QL

sodium phenylbutyrate oral tablet

4 QL

STRENSIQ 4 PA; QL

SUCRAID 4 PA; QL

VIMIZIM M PA

VIOKACE 3

VPRIV M PA

ZAVESCA 4 PA; QL

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation 1

aminoacetic acid M

AURYXIA 4 PA; QL

bethanechol chloride oral 1

calcium acetate (phos binder)

1

calcium acetate oral tablet 667 mg

1

CERVIDIL 2

CIALIS 3 PA

CUPRIMINE 4 PA; QL

darifenacin hydrobromide er

1 ST

DEPEN TITRATABS 4 PA; QL

DETROL 3

DETROL LA 3

DITROPAN XL 3

ELMIRON 2

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

3

FEM PH 3

flavoxate hcl 1

FOSRENOL ORAL PACKET

3


Drug Name Drug Tier

Notes

FOSRENOL ORAL TABLET CHEWABLE

4 PA; QL

GELNIQUE 3 ST

glycine irrigation M

glycine urologic M

hyophen 3

INTRAROSA 3 PA; QL

lanthanum carbonate 4 QL

LITHOSTAT 3

me/naphos/mb/hyo1 3

MYRBETRIQ 3 ST

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST

penicillamine oral capsule 4 PA; QL

penicillamine oral tablet 4 QL

PENTOSAN POLYSULFATE SODIUM ORAL

2

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PHOSLYRA 3

phosphasal 3

PREPIDIL 2

PROSTIN E2 2

RENACIDIN 3

RENAGEL 3

RENVELA 3

RIMSO-50 3

sevelamer carbonate 1

sevelamer hcl 1

solifenacin succinate 1

tadalafil oral 3 PA

THIOLA 4 PA; QL

THIOLA EC 4 PA

tolterodine tartrate 1

Drug Name Drug Tier

Notes

tolterodine tartrate er 1

TOVIAZ 3 ST

trospium chloride 1

trospium chloride er 1

URECHOLINE 3

urelle 3

uretron d/s 3

uribel 3

urin ds 3

uro-mp 3

ustell 3

uticap 3

utira-c 3

utrona-c 3

VELPHORO 4 PA; QL

VESICARE 3

vilamit mb 3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3

dutasteride oral 1

dutasteride-tamsulosin hcl 3

finasteride oral tablet 5 mg

1

FLOMAX 3

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 3

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 3

Hormonal Agents - Adrenal

betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml

3


Drug Name Drug Tier

Notes

CELESTONE SOLUSPAN

3

CORTEF 3

cortisone acetate oral 1

DECADRON 3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

2

DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML

3

DEXAMETHASONE (LA) 3

dexamethasone intensol 1

dexamethasone oral elixir 1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone oral tablet therapy pack

3

dexamethasone sod phosphate pf injection solution

1

dexamethasone sodium phosphate injection

1

DEXPAK 10 DAY 3

DEXPAK 13 DAY 3

DEXPAK 6 DAY 3

DXEVO 11-DAY 3

fludrocortisone acetate oral

1

HIDEX 6-DAY 3

hydrocortisone oral 1

KENALOG INJECTION 3

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

Drug Name Drug Tier

Notes

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

1

methylprednisolone oral 1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 40 mg, 500 mg

M

methylprednisolone sodium succ injection solution reconstituted 125 mg

1

MILLIPRED 3

MILLIPRED DP 3

MILLIPRED DP 12-DAY 3

ORAPRED ODT 3

PEDIAPRED 3

prednisolone oral solution 1

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml

3

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible

3

prednisone intensol 3

prednisone oral 1

RAYOS 3 PA

SOLU-CORTEF 2

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 2 GM, 40 MG, 500 MG

M

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 125 MG

3

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY 3


Drug Name Drug Tier

Notes

TAPERDEX 7-DAY 3

triamcinolone acetonide suspension 40 mg/ml injection

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION

3

ZILRETTA M

Hormonal Agents - Men's Health

ANADROL-50 4 PA; QL

ANDRODERM 3 PA; QL

ANDROGEL 3 PA; QL

ANDROGEL PUMP 3 PA; QL

AVEED M PA

danazol oral 1

DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)

1 PA

FORTESTA 3 PA; QL

JATENZO 3 PA

METHITEST 3 PA

methyltestosterone oral 3 PA

NATESTO 3 PA; QL

oxandrolone oral 3

STRIANT 3 PA; QL

TESTIM 3 PA; QL

TESTONE CIK 3

TESTOPEL M PA

TESTOSTERONE CYPIONATE INJECTION

1 PA

testosterone cypionate intramuscular

1 PA

testosterone enanthate intramuscular

1 PA

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

3 PA; QL

Drug Name Drug Tier

Notes

testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

1 PA; QL

testosterone transdermal solution

3 PA; QL

VOGELXO 3 PA; QL

VOGELXO PUMP 3 PA; QL

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3 PA

OSPHENA 3 PA

raloxifene hcl P

Hormonal Agents - Pituitary

ACTHAR 4 PA; QL

cabergoline 1

carboprost tromethamine M

DDAVP 3

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate spray

1

EGRIFTA 4 PA; QL

EGRIFTA SV 4 PA; QL

ELIGARD C PA

FIRMAGON M PA

GENOTROPIN 4 PA; QL

GENOTROPIN MINIQUICK

4 PA; QL

HEMABATE M

HUMATROPE 4 PA; QL

INCRELEX 4 PA; QL

leuprolide acetate injection

C

LUPRON DEPOT (1-MONTH)

C


Drug Name Drug Tier

Notes

LUPRON DEPOT (3-MONTH)

C

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

C

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

C

LUPRON DEPOT-PED (1-MONTH)

2

LUPRON DEPOT-PED (3-MONTH)

2

NOCDURNA 3 PA

NOCTIVA 2

NORDITROPIN FLEXPRO

4 PA; QL

NUTROPIN AQ NUSPIN 10

4 PA; QL


4 PA; QL


4 PA; QL

octreotide acetate 1

OMNITROPE 4 PA; QL

ORILISSA 4 PA; QL

SAIZEN 4 PA; QL

SAIZENPREP 4 PA; QL

SANDOSTATIN 3

SANDOSTATIN LAR DEPOT

C QL

SIGNIFOR 4 PA; QL

SIGNIFOR LAR M PA

SOMATULINE DEPOT 4 PA; QL

SOMAVERT 4 PA; QL

STIMATE 2

SUPPRELIN LA M PA

SYNAREL 3 QL

TRELSTAR MIXJECT M PA

TRIPTODUR M PA

VANTAS M PA

Drug Name Drug Tier

Notes

ZOLADEX M PA

ZOMACTON 4 PA; QL

Hormonal Agents - Prostaglandins

KORLYM 4 PA; QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA 3

afirmelle P

ALORA 3

altavera P

alyacen 1/35 P

alyacen 7/7/7 P

amabelz 3

amethia P

amethia lo P

amethyst P

ANGELIQ 3

ANNOVERA P

apri P

aranelle P

ashlyna P

aubra P

aubra eq P

aurovela 1.5/30 P

aurovela 1/20 P

aurovela 24 fe P

aurovela fe 1.5/30 P

aurovela fe 1/20 P

aviane P

AYGESTIN 3

ayuna P

azurette P

BALCOLTRA P

balziva P

bekyree P

BEYAZ 3

BIJUVA 3


Drug Name Drug Tier

Notes

blisovi 24 fe P

blisovi fe 1.5/30 P

blisovi fe 1/20 P

briellyn P

camila P

camrese P

camrese lo P

caziant P

chateal P

chateal eq P

CLIMARA 1

CLIMARA PRO 3

COMBIPATCH 3

covaryx 3

covaryx hs 3

CRINONE 3

cryselle-28 P

cyclafem 1/35 P

cyclafem 7/7/7 P

cyred P

cyred eq P

dasetta 1/35 P

dasetta 7/7/7 P

daysee P

deblitane P

DELESTROGEN 2

delyla P

DEPO-ESTRADIOL 2

DEPO-PROVERA 3

DEPO-SUBQ PROVERA 104

P

desogestrel-ethinyl estradiol

P

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM

3

Drug Name Drug Tier

Notes

dotti 3

drospiren-eth estrad-levomefol

P

drospirenone-ethinyl estradiol

P

DUAVEE 3

eemt 3

eemt hs 3

ELESTRIN 3

elinest P

ELLA P

eluryng P

emoquette P

ENDOMETRIN 3

enpresse-28 P

enskyce P

errin P

est estrogens-methyltest 3

est estrogens-methyltest ds

3

est estrogens-methyltest hs

3

estarylla P

ESTRACE 3

estradiol oral 1

estradiol transdermal patch twice weekly

3

estradiol transdermal patch weekly

1

estradiol vaginal 1

estradiol valerate intramuscular

1

estradiol-norethindrone acet

3

ESTRING 2

ESTROGEL 3

ESTROSTEP FE 3

ethynodiol diac-eth estradiol

P


Drug Name Drug Tier

Notes

etonogestrel-ethinyl estradiol

P

EVAMIST 3

falmina P

fayosim P

FEMHRT LOW DOSE 3

FEMRING 2

femynor P

FIRST-PROGESTERONE VGS

3

fyavolv 3

GENERESS FE 3

gianvi P

hailey 1.5/30 P

hailey 24 fe P

heather P

hydroxyprogesterone caproate intramuscular oil

1

hydroxyprogesterone caproate intramuscular solution

M PA

IMVEXXY MAINTENANCE PACK

3 PA

IMVEXXY STARTER PACK

3 PA

incassia P

introvale P

isibloom P

jaimiess P

jasmiel P

jencycla P

jinteli 3

jolessa P

juleber P

junel 1.5/30 P

junel 1/20 P

junel fe 1.5/30 P

junel fe 1/20 P

junel fe 24 P

Drug Name Drug Tier

Notes

kaitlib fe P

kalliga P

kariva P

kelnor 1/35 P

kelnor 1/50 P

kurvelo P

KYLEENA P

larin 1.5/30 P

larin 1/20 P

larin 24 fe P

larin fe 1.5/30 P

larin fe 1/20 P

larissia P

layolis fe P

leena P

lessina P

levonest P

levonorgest-eth est & eth est

P

levonorgest-eth estrad 91-day

P

levonorgestrel P

levonorgestrel-ethinyl estrad

P

levonorg-eth estrad triphasic

P

levora 0.15/30 (28) P

LILETTA (52 MG) P

lillow P

LO LOESTRIN FE P

LOESTRIN 1.5/30 (21) 3

LOESTRIN 1/20 (21) 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

lojaimiess P

lopreeza 3

loryna P


Drug Name Drug Tier

Notes

LOSEASONIQUE 3

low-ogestrel P

lo-zumandimine P

lutera P

lyza P

MAKENA INTRAMUSCULAR

3

MAKENA SUBCUTANEOUS

4 QL

marlissa P

medroxyprogesterone acetate intramuscular

P

medroxyprogesterone acetate oral

1

MEGACE ES 3

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral suspension 625 mg/5ml

3

megestrol acetate oral tablet

1

melodetta 24 fe P

MENEST 3

MENOSTAR 3

mibelas 24 fe P

microgestin 1.5/30 P

microgestin 1/20 P

microgestin fe 1.5/30 P

microgestin fe 1/20 P

mili P

mimvey 3

MINASTRIN 24 FE 3

MINIVELLE 3

MIRCETTE 3

MIRENA (52 MG) P

mono-linyah P

NATAZIA P

necon 0.5/35 (28) P

Drug Name Drug Tier

Notes

NEXPLANON P

nikki P

nora-be P

norethin ace-eth estrad-fe P

norethindrone acetate oral

1

norethindrone acet-ethinyl est

P

norethindrone oral P

norethindrone-eth estradiol (generic Jinteli)

3

norethin-eth estradiol-fe P

norgestimate-eth estradiol P

norgestimate-ethinyl estradiol triphasic

P

norlyda P

norlyroc P

nortrel 0.5/35 (28) P

nortrel 1/35 (21) P

nortrel 1/35 (28) P

nortrel 7/7/7 P

NUVARING P

ocella P

ogestrel P

orsythia P

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN LO 3

ORTHO-NOVUM 1/35 (28)

3

ORTHO-NOVUM 7/7/7 (28)

3

PARAGARD INTRAUTERINE COPPER

P

philith P

pimtrea P

pirmella 1/35 P

pirmella 7/7/7 P

PLAN B ONE-STEP 3


Drug Name Drug Tier

Notes

portia-28 P

PREFEST 3

PREMARIN ORAL 3 ST

PREMARIN VAGINAL 2

PREMPHASE 3

PREMPRO 3

preventeza P

previfem P

progesterone intramuscular

1

progesterone micronized oral

1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3

reclipsen P

rivelsa P

SAFYRAL P

SEASONIQUE 3

setlakin P

sharobel P

simliya P

simpesse P

SKYLA P

SLYND P

sprintec 28 P

sronyx P

syeda P

tarina 24 fe P

tarina fe 1/20 P

tarina fe 1/20 eq P

TAYTULLA P

tilia fe P

tri femynor P

tri-estarylla P

tri-legest fe P

tri-linyah P

Drug Name Drug Tier

Notes

tri-lo-estarylla P

tri-lo-marzia P

tri-lo-mili P

tri-lo-sprintec P

tri-mili P

tri-previfem P

tri-sprintec P

trivora (28) P

tri-vylibra P

tri-vylibra lo P

tulana P

tydemy P

VAGIFEM 3

velivet P

vienva P

viorele P

VIVELLE-DOT 3

volnea P

vyfemla P

vylibra P

wera P

wymzya fe P

xulane P

YASMIN 28 3

YAZ 3

yuvafem 1

zarah P

zovia 1/35e (28) P

zumandimine P

Hormonal Agents - Thyroid

ARMOUR THYROID 3

CYTOMEL 3

euthyrox 3

levo-t 3

levothyroxine sodium oral 1

levoxyl 3


Drug Name Drug Tier

Notes

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3

np thyroid 3

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

3

TIROSINT 3

TIROSINT-SOL 3

unithroid 3

WESTHROID 3

WP THYROID 3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 4 PA; QL

ACTEMRA INTRAVENOUS

M PA

ACTEMRA SUBCUTANEOUS

4 PA; QL

ACTIMMUNE 4 PA; QL

ALFERON N 3

ARAVA 3

ARCALYST 4 PA; QL

ASTAGRAF XL 3

ATGAM M

AZASAN 3

azathioprine oral 1

azathioprine sodium M

BENLYSTA INTRAVENOUS

M PA

BENLYSTA SUBCUTANEOUS

4 PA; QL

BERINERT 4 PA; QL

BIVIGAM M PA

CARIMUNE NF M PA

CELLCEPT 3

Drug Name Drug Tier

Notes

CIMZIA 4 PA; QL

CIMZIA PREFILLED KIT 4 PA; QL

CIMZIA STARTER KIT 4 PA; QL

CINRYZE 4 PA; QL

COSENTYX (300 MG DOSE)

4 PA; QL

COSENTYX 150 MG/ML 4 PA; QL

COSENTYX SENSOREADY (300 MG)

4 PA; QL

COSENTYX SENSOREADY PEN

4 PA; QL

CUTAQUIG 4 PA; QL

CUVITRU 4 PA; QL

cyclosporine intravenous M

cyclosporine modified 1

cyclosporine oral 1

CYTOGAM M PA

ENBREL 4 PA; QL

ENBREL MINI 4 PA; QL

ENBREL SURECLICK 4 PA; QL

ENTYVIO M PA

ENVARSUS XR 3

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

4 QL

FIRAZYR 4 PA; QL

FLEBOGAMMA DIF M PA

GAMASTAN M PA

GAMASTAN S/D M PA

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML

M

GAMIFANT INTRAVENOUS SOLUTION 50 MG/10ML

M PA

GAMMAGARD M PA

GAMMAGARD S/D LESS IGA

M PA

GAMMAKED M PA

GAMMAPLEX M PA

GAMUNEX-C M PA


Drug Name Drug Tier

Notes

gengraf 1

HAEGARDA 4 PA; QL

HEPAGAM B 3

HIZENTRA 4 PA; QL

HUMIRA 4 PA; QL

HUMIRA PEDIATRIC CROHNS START

4 PA; QL

HUMIRA PEN 4 PA; QL

HUMIRA CITRATE FREE 4 PA; QL

HUMIRA PEN-PS/UV/ADOL HS START

4 PA; QL

HYPERHEP B S/D 2

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

3

HYPERRAB S/D 3

HYPERRHO S/D M PA

HYPERTET S/D 3

HYQVIA 4 PA; QL

icatibant acetate 4 QL

ILARIS M PA

ILUMYA M PA

IMOGAM RABIES-HT 3

IMURAN 3

INFLECTRA M PA

KALBITOR M PA

KEDRAB 3

KEVZARA 4 PA; QL

KINERET 4 PA; QL

KYMRIAH M PA

leflunomide oral 1

methotrexate oral 1

methotrexate sodium 1

methotrexate sodium (pf) 1

MICRHOGAM ULTRA-FILTERED PLUS

M PA

mycophenolate mofetil 1

mycophenolate mofetil hcl M

mycophenolate sodium 1

Drug Name Drug Tier

Notes

MYFORTIC 3

NABI-HB 2

NEORAL 3

NULOJIX M PA

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML

M PA

OLUMIANT 4 PA; QL

ORENCIA CLICKJECT 4 PA; QL

ORENCIA INTRAVENOUS

M PA

ORENCIA SUBCUTANEOUS

4 PA; QL

OTEZLA 4 PA; QL

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

3 PA

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML

3

PRIVIGEN M PA

PROGRAF INTRAVENOUS

M

PROGRAF ORAL 3

PROVENGE M PA

RAPAMUNE 3

RASUVO 2

REMICADE M PA

RENFLEXIS M PA

RHOGAM ULTRA-FILTERED PLUS

M PA

RHOPHYLAC 3


Drug Name Drug Tier

Notes

RIDAURA 4 QL

RINVOQ 4 PA; QL

RUCONEST 4 PA; QL

SANDIMMUNE ORAL 3

SILIQ 4 PA; QL

SIMPONI 4 PA; QL

SIMPONI ARIA M PA

SIMULECT M

sirolimus oral 1

SKYRIZI (150 MG DOSE) 4 PA; QL

STELARA INTRAVENOUS

M PA

STELARA SUBCUTANEOUS

4 PA; QL

SYNAGIS M PA

tacrolimus oral 1

TAKHZYRO 4 PA; QL

TALTZ 4 PA; QL

temsirolimus M

THYMOGLOBULIN M

TORISEL M

TREMFYA 4 PA; QL

TREXALL C PA

VARIZIG 3

WINRHO SDF M PA

XATMEP C PA; QL

XELJANZ 4 PA; QL

XELJANZ XR 4 PA; QL

XEMBIFY 4 PA; QL

ZINPLAVA M PA

ZORTRESS 4 PA; QL

Immunological Agents - Drugs for Vaccination

ACTHIB P

ADACEL P

AFLURIA QUADRIVALENT

P

BEXSERO P

BIOTHRAX 3

Drug Name Drug Tier

Notes

BOOSTRIX P

DAPTACEL P

DIPHTHERIA-TETANUS TOXOIDS DT

P

ENGERIX-B P

FLUAD P

FLUARIX QUADRIVALENT

P

FLUBLOK QUADRIVALENT

P

FLUCELVAX QUADRIVALENT

P

FLULAVAL QUADRIVALENT

P

FLUZONE HIGH-DOSE P

FLUZONE QUADRIVALENT

P

GARDASIL 9 P

HAVRIX P

HEPLISAV-B P

HIBERIX P

INFANRIX P

IPOL P

KINRIX P

MENACTRA P

MENVEO P

M-M-R II P

PEDIARIX P

PEDVAX HIB P

PENTACEL P

PNEUMOVAX 23 P

PREVNAR 13 P

PROQUAD P

QUADRACEL P

RECOMBIVAX HB P

ROTARIX P

ROTATEQ P

SHINGRIX P


Drug Name Drug Tier

Notes

TDVAX P

TENIVAC P

TRUMENBA P

TWINRIX P

VAQTA P

VARIVAX P

ZOSTAVAX P

Inflammatory Bowel Disease Agents

ANALPRAM-HC 3

anucort-hc 3

ANUSOL-HC RECTAL CREAM

3

anusol-hc rectal suppository

3

APRISO 3 ST

ASACOL HD 3 ST

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide er 4 PA; QL

budesonide oral 3 PA

CANASA 3

COLAZAL 3

colocort 1

CORTENEMA 3

CORTIFOAM 2

DELZICOL 3 ST

DIPENTUM 4 PA; QL

ENTOCORT EC 4 PA

hemmorex-hc 3

hydrocortisone ace-pramoxine rectal cream 1-1 %

3

hydrocortisone acetate rectal

3

hydrocortisone rectal cream 1 %

3

hydrocortisone rectal cream 2.5 %

1

Drug Name Drug Tier

Notes

hydrocortisone rectal enema

1

LIALDA 3 ST

lidocaine-hydrocortisone ace rectal cream

3

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %

3

mesalamine er 3 ST

mesalamine oral capsule delayed release

3 ST

mesalamine oral tablet delayed release

1 ST

mesalamine rectal 1

mesalamine-cleanser 3

PENTASA 2 ST

PROCORT 3

PROCTOCORT RECTAL CREAM

3

PROCTOFOAM HC 2

procto-med hc 1

procto-pak 3

proctosol hc 1

proctozone-hc 1

ROWASA 3

SFROWASA 3

sulfasalazine oral 1

UCERIS ORAL 4 PA; QL

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL 3 ST

alendronate sodium 1

ATELVIA 3 ST

BINOSTO 3

BONIVA ORAL 3

calcitonin (salmon) 3

FORTEO 4 PA; QL

FOSAMAX 3


Drug Name Drug Tier

Notes

FOSAMAX PLUS D 3

ibandronate sodium intravenous

M PA

ibandronate sodium oral 1

MIACALCIN INJECTION 3

pamidronate disodium M

PROLIA M PA

RAYALDEE 3 PA

risedronate sodium oral tablet

1 ST

risedronate sodium oral tablet delayed release

3 ST

TYMLOS 4 PA

zoledronic acid intravenous concentrate

M PA

zoledronic acid intravenous solution

M

Metabolic Bone Disease Agents - Other

calcitriol intravenous M

calcitriol oral 1

cinacalcet hcl 1 PA; QL

doxercalciferol intravenous

M

doxercalciferol oral 3

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML

M

NATPARA 4 PA; QL

paricalcitol intravenous M

paricalcitol oral 3

PARSABIV M PA

ROCALTROL 3

SENSIPAR 4 PA; QL

ZEMPLAR ORAL 3

Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS PAD , 70 %

1

AMPHADASE M PA

Drug Name Drug Tier

Notes

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

M PA

BOTOX M PA

BREATHE EASE LARGE 2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL 2

BREATHERITE 2

CAYA P

COMPACT SPACE CHAMBER/LG MASK

2

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

deferoxamine mesylate injection solution reconstituted 2 gm

M

deferoxamine mesylate injection solution reconstituted 500 mg

1

DESFERAL 3

DIGIFAB M

diluent for treprostinil M

DYSPORT M PA

EASIVENT 2

ENDARI 4 PA; QL

ergoloid mesylates oral 3

EUFLEXXA M PA

FEMCAP P

FIRDAPSE 4 PA; QL

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2

GEL-ONE M PA

GELSYN-3 M PA


Drug Name Drug Tier

Notes

GENVISC 850 M PA

GLUCAGEN DIAGNOSTIC

2

GLUCAGON HCL (DIAGNOSTIC)

2

GRASTEK 3 PA

heparin lock flush intravenous solution 10 unit/ml

M

heparin sodium lock flush M

HYALGAN M PA

HYLENEX M PA

INFED M

MASK VORTEX 2

methergine 1

methylergonovine maleate

1

MICROCHAMBER DEVICE

2

MONOVISC M PA

MYOBLOC M PA

ODACTRA 3 PA

OMNIPOD 5 PACK 3 PA

OMNIPOD DASH 5 PACK

3 PA

OPTIONS CONCEPTROL

P

ORALAIR 3 PA

ORALAIR ADULT SAMPLE KIT

3 PA

ORALAIR ADULT STARTER PACK

3 PA

ORALAIR CHILDRENS SAMPLE KIT

3 PA

ORALAIR CHILDRENS STARTER PACK

3 PA

ORTHOVISC M PA

OXBRYTA 4 PA; QL

PALFORZIA (12 MG DAILY DOSE)

4 PA; QL


4 PA; QL

Drug Name Drug Tier

Notes


4 PA; QL


4 PA; QL


4 PA; QL


4 PA; QL


4 PA; QL

PALFORZIA (300 MG MAINTENANCE)

4 PA; QL

PALFORZIA (300 MG TITRATION)

4 PA; QL


4 PA; QL


4 PA; QL


4 PA; QL

PALFORZIA INITIAL ESCALATION

4 PA; QL

PANDA MASK LARGE 2

PANDA MASK MEDIUM 2

PANDA MASK SMALL 2

PEDIATRIC PANDA MASK

2

pocket spacer 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

PURE COMFORT ALCOHOL PREP

1

RAGWITEK 3 PA

RUZURGI 4 PA; QL

SODIUM HYALURONATE INTRA-ARTICULAR

M PA


Drug Name Drug Tier

Notes

STERILE DILUENT FLOLAN PH 12

M

sterile diluent/epoprostenol

M

sterile water for injection injection

1

SUPARTZ FX M PA

SYNVISC M PA

SYNVISC ONE M PA

TRILURON M PA

TRIVISC M PA

vcf vaginal contraceptive vaginal gel

P

VISCO-3 M PA

VISTOGARD 4 PA; QL

VITRASE M PA

WIDE-SEAL DIAPHRAGM 60

P


P


P


P


P


P


P


P

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 200 UNIT, 50 UNIT

M PA

XIAFLEX M PA

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR 2

ACULAR LS 3

ACUVAIL 3

Drug Name Drug Tier

Notes

ALOCRIL 3

ALOMIDE 2

ALREX 3

AZASITE 3

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1

BEPREVE 3

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

3

BROMSITE 3

CILOXAN OPHTHALMIC OINTMENT

2

CILOXAN OPHTHALMIC SOLUTION

3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

DUREZOL 2

epinastine hcl 3

erythromycin ophthalmic 1

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak 1

gentamicin sulfate ophthalmic

1


Drug Name Drug Tier

Notes

ILEVRO 3

ILUVIEN M

INVELTYS 3

ketorolac tromethamine ophthalmic

1

KLARITY-A 3

KLARITY-B 3

KLARITY-L 3

levofloxacin ophthalmic 3

LOTEMAX 3

LOTEMAX SM 3

loteprednol etabonate 3

MAXIDEX 3

MOXEZA 2

moxifloxacin hcl (2x day) 1

moxifloxacin hcl ophthalmic

1

NATACYN 2

NEVANAC 3

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic solution 0.1 %

1

olopatadine hcl ophthalmic solution 0.2 %

3

OZURDEX M

PAZEO 3

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 2

PREDNISOL ACE-MOXIFLOX-BROMFEN

3

prednisolone acetate ophthalmic

1

prednisolone acetate p-f 1

prednisolone sodium phosphate ophthalmic

3

Drug Name Drug Tier

Notes

PREDNISOLON-MOXIFLOX-NEPAFENAC

3

PROLENSA 3

RETISERT M

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX OPHTHALMIC OINTMENT

2

TOBREX OPHTHALMIC SOLUTION

3

TRIESENCE M

trifluridine 1

VIGAMOX 2

ZERVIATE 3

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P 3

apraclonidine hcl 3

AZOPT 2

betaxolol hcl ophthalmic 1

BETIMOL 3

BETOPTIC-S 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic solution 0.15 %

3

brimonidine tartrate ophthalmic solution 0.2 %

1

BRIMONIDINE-DORZOLAMIDE

3

carteolol hcl 1

COMBIGAN 3

COSOPT 3

COSOPT PF 3


Drug Name Drug Tier

Notes

dorzolamide hcl ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

3

IOPIDINE 3

ISOPTO CARPINE 3

ISTALOL 3

KEVEYIS 4 PA; QL

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

3

levobunolol hcl 1

LUMIGAN 2

methazolamide oral 1

PHOSPHOLINE IODIDE 3

pilocarpine hcl ophthalmic 1

RHOPRESSA 3 PA

ROCKLATAN 3 PA

SIMBRINZA 3

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.5 % (daily)

3

TIMOLOL-BRIMON-DORZOL-LATANOPR

3

TIMOLOL-BRIMONIDINE-DORZOLAMID

3

TIMOLOL-DORZOLAMID-LATANOPROST

3

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

Drug Name Drug Tier

Notes

TRAVATAN Z 1

travoprost (bak free) 1

TRUSOPT 3

VYZULTA 3 PA

XALATAN 3

XELPROS 3

ZIOPTAN 3

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ACUICYN 3

ak-poly-bac 1

AKTEN 3

ALCAINE 3

altacaine 3

altafrin 1

ATROPINE SULFATE OPHTHALMIC EMULSION

1

atropine sulfate ophthalmic ointment

1

atropine sulfate ophthalmic solution

1

AVENOVA 3

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

CEQUA 3 PA

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

2 PA

CYSTARAN 4 PA; QL

EYLEA INTRAVITREAL SOLUTION

M PA

GELFILM OPHTHALMIC 3


Drug Name Drug Tier

Notes

homatropaire 1

homatropine hbr 1

HYPOCYN 3

JETREA M PA

LACRISERT 2

LASTACAFT 3

LUCENTIS M PA

LUXTURNA M PA

MACUGEN M

MAXITROL 3

neomycin-bacitracin zn-polymyx

3

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin

1

neomycin-polymyxin-hc ophthalmic

3

neo-polycin 3

neo-polycin hc 1

OMIDRIA M

OXERVATE 4 PA; QL

phenylephrine hcl ophthalmic

1

polycin 1

polymyxin b-trimethoprim 1

POLYTRIM 3

PRED-G 2

PRED-G S.O.P. 2

PREDNISOLONE ACETATE-NEPAFENAC

3

PREDNISOLONE ACET-MOXIFLOXACIN

3

PREDNISOLONE-BROMFENAC

3

PREDNISOLONE-GATIFLOXACIN

3

Drug Name Drug Tier

Notes

PREDNISOLON-GATIFLOX-BROMFENAC

3

PREDNISOLON-MOXIFLOX-BROMFENAC

3

proparacaine hcl ophthalmic

3

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

sulfacetamide-prednisolone ophthalmic solution

1

tetcaine 3

tetracaine hcl ophthalmic 3

tetravisc 3

tetravisc forte 3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX OPHTHALMIC SUSPENSION

3

TOBRADEX ST 3

tobramycin-dexamethasone

1

TROPICAMIDE-CYCLOPENTOLATE-PE

3

TROPICAMIDE-PHENYLEPHRINE

3 PA

TROPIC-PROPARACA-PE-KETOROLAC

3

VISUDYNE M

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3

CIPRO HC 2

CIPRODEX 2

ciprofloxacin hcl otic 3


Drug Name Drug Tier

Notes

CIPROFLOXACIN-FLUOCINOLONE PF

3

COLY-MYCIN S 3

DERMOTIC 3

flac 3

fluocinolone acetonide otic

3

hydrocortisone-acetic acid 3

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTIPRIO M

OTOVEL 3

PRAMOTIC 3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL 3

ASTEPRO 3

azelastine hcl nasal 1

azelastine-fluticasone 3

BECONASE AQ 3 PA

benzonatate oral capsule 100 mg, 200 mg

1

benzonatate oral capsule 150 mg

3

bromfed dm 3

brompheniramine tannate 3

carbinoxamine maleate 1

cetirizine hcl oral solution 3

CINQAIR M PA

CLARINEX 3

CLARINEX-D 12 HOUR 3

clemastine fumarate oral tablet 2.68 mg

1

CUROSURF 3

cyproheptadine hcl oral 1

DERMACINRX AZENASE PAK

3

desloratadine 1

Drug Name Drug Tier

Notes

diphen oral elixir 3

diphenhydramine hcl injection

1

diphenhydramine hcl oral elixir

3

DYMISTA 3

FASENRA M PA

FASENRA PEN 4 PA; QL

flunisolide nasal 1

hydrocodone polst-cpm polst er

3

hydrocodone-homatropine

1

hydromet 1

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %

3

INFASURF 3

ipratropium bromide nasal 1

KARBINAL ER 3

levocetirizine dihydrochloride oral

1

mometasone furoate nasal

3 PA

NASONEX 3 PA

nebusal inhalation nebulization solution 3 %

1

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

3

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

4 PA; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

4 PA; QL

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED

M PA

olopatadine hcl nasal 3


Drug Name Drug Tier

Notes

OMNARIS 3 PA

PATANASE 3

phenadoz 1

PHENERGAN 3

promethazine hcl injection 3

promethazine hcl oral 1

promethazine hcl rectal 1

promethazine-codeine 3 PA

promethazine-dm 1

promethazine-dm oral solution 6.25-15 mg/5ml

1

promethazine-phenyleph-codeine

3 PA

promethazine-phenylephrine

1

promethegan 1

PROPEL M PA

PROPEL MINI M PA

pseudoephedrine-bromphen-dm

3

pulmosal 1

QNASL 3 PA

QNASL CHILDRENS 3 PA

ryvent 1

SEMPREX-D 3

SINUVA M PA

sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %

1

sodium chloride inhalation nebulization solution 10 %

3

SSKI 2

SURVANTA 2

TESSALON PERLES 3

TUSSICAPS 3

TUXARIN ER 3 PA; QL

TUZISTRA XR 3 PA

XHANCE 3 PA

Drug Name Drug Tier

Notes

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED

M PA

ZETONNA 3 PA

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation 1

ADVAIR DISKUS 1

ADVAIR HFA 2

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP II 3

ADYPHREN II 3

AIRDUO RESPICLICK 113/14

3 PA


3 PA


3 PA

albuterol sulfate er 3

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1 QL

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

3 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

3 QL

albuterol sulfate inhalation 1

albuterol sulfate oral 1

ALVESCO 2

aminophylline intravenous M

ANORO ELLIPTA 3 PA

ARALAST NP M PA

ARCAPTA NEOHALER 3

ARNUITY ELLIPTA 3 PA


Drug Name Drug Tier

Notes

ASMANEX (120 METERED DOSES)

2 ST


2 ST


2 ST


2 ST


2 ST

ASMANEX HFA 2 ST

ATROVENT HFA 2

AUVI-Q 3 PA

BEVESPI AEROSPHERE 3 PA

BREO ELLIPTA 3 PA

BROVANA 3 PA

budesonide inhalation 1

BUDESONIDE-FORMOTEROL FUMARATE

3 PA

COMBIVENT RESPIMAT 2

cromolyn sodium inhalation

1

DALIRESP 3

difil-g forte 3

DUAKLIR PRESSAIR 3 PA

DULERA 3 PA

ELIXOPHYLLIN 3

epinephrine injection solution auto-injector

1

EPINEPHRINE PROFESSIONAL

3

EPINEPHRINESNAP-EMS

3

EPINEPHRINESNAP-V 3

EPIPEN 2-PAK 2

EPIPEN JR 2-PAK 3

EPISNAP 3

ESBRIET 4 PA; QL

FLOVENT DISKUS 2 PA

Drug Name Drug Tier

Notes

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

2 PA

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 PA

GLASSIA M PA

INCRUSE ELLIPTA 3 PA

ipratropium bromide inhalation

1

ipratropium-albuterol 1

levalbuterol hcl inhalation 3

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

3 QL

LONHALA MAGNAIR REFILL KIT

3 PA

LONHALA MAGNAIR STARTER KIT

3 PA

metaproterenol sulfate oral

1

montelukast sodium oral 1

OFEV 4 PA; QL

PERFOROMIST 3

PROAIR DIGIHALER 3 QL

PROAIR HFA 3 QL

PROAIR RESPICLICK 3 QL

PROLASTIN-C M PA

PROVENTIL HFA 3 QL


Drug Name Drug Tier

Notes

PULMICORT FLEXHALER

3 PA

PULMICORT SUSPENSION

3

QVAR REDIHALER 3 PA

SEEBRI NEOHALER 3 PA

SEREVENT DISKUS 2 ST

SINGULAIR 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 ST

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2 PA

SYMBICORT 3 PA

SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML

3

terbutaline sulfate injection

3

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

theophylline er 1

theophylline in d5w M

TRELEGY ELLIPTA 3 PA

TUDORZA PRESSAIR 3

UTIBRON NEOHALER 3 PA

VENTOLIN HFA 2 QL

XOPENEX 3

XOPENEX CONCENTRATE

3

XOPENEX HFA 3 QL

YUPELRI 3 PA

Drug Name Drug Tier

Notes

zafirlukast 3

ZEMAIRA M PA

zileuton er 4 PA; QL

ZYFLO 4 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS 4 PA; QL

CAYSTON 4 PA; QL

KALYDECO 4 PA; QL

KITABIS PAK 4 PA; QL

ORKAMBI 4 PA; QL

PULMOZYME 4 QL

SYMDEKO 4 PA; QL

TOBI NEBULIZER 4 PA; QL

TOBI PODHALER 4 PA; QL

tobramycin nebulization solution 300 mg/5ml inhalation

4 PA; QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

4 PA; QL

TRIKAFTA 4 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA 4 PA; QL

ADEMPAS 4 PA; QL

alyq 4 PA; QL

ambrisentan 1 PA; QL

bosentan 1 PA; QL

epoprostenol sodium M PA

LETAIRIS 4 PA; QL

OPSUMIT 4 PA; QL

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG

3 PA; QL

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG

4 PA; QL


Drug Name Drug Tier

Notes

REVATIO ORAL SUSPENSION RECONSTITUTED

4 PA; QL

REVATIO ORAL TABLET 4 PA

sildenafil citrate intravenous

M

sildenafil citrate oral suspension reconstituted

4 QL

sildenafil citrate oral tablet 20 mg

4 PA

tadalafil (pah) 4 PA; QL

TRACLEER 4 PA; QL

TYVASO 4 PA; QL

TYVASO REFILL 4 PA; QL

TYVASO STARTER 4 PA; QL

UPTRAVI 4 PA; QL

VELETRI M PA

VENTAVIS 4 PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX 3 PA; QL

baclofen intrathecal M

baclofen oral 1

carisoprodol oral 3 PA; QL

carisoprodol-aspirin 3 PA

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg

3 QL

cyclobenzaprine hcl er 3 PA; QL

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1 QL

cyclobenzaprine hcl oral tablet 7.5 mg

3 QL

DANTRIUM ORAL 3

dantrolene sodium oral 1

FEXMID 3 QL

FIRST-BACLOFEN 3

GABLOFEN M

LIORESAL M

LORZONE 3 QL

metaxalone 3 QL

Drug Name Drug Tier

Notes

methocarbamol injection 1

methocarbamol oral 1 QL

NORGESIC FORTE 3 QL

orphenadrine citrate er 1 QL

orphenadrine citrate injection

3

orphenadrine-aspirin-caffeine

3 QL

ORPHENGESIC FORTE 3 QL

OZOBAX 3

ROBAXIN 3

ROBAXIN-750 3 QL

SKELAXIN 3 QL

SOMA 3 PA; QL

tizanidine hcl oral capsule 3

tizanidine hcl oral tablet 1

ZANAFLEX 3

Sleep Disorder Agents

AMBIEN 3

AMBIEN CR 3

AMYTAL SODIUM 3

armodafinil 3 PA

BELSOMRA 3 PA

doxepin hcl oral tablet 3

EDLUAR 3

eszopiclone 1

flurazepam hcl 1

HETLIOZ 4 PA; QL

INTERMEZZO 3

LUNESTA 3

modafinil 1

NUVIGIL 3 PA

PROVIGIL 3

ramelteon 3

RESTORIL 3

ROZEREM 3

SECONAL 2


Drug Name Drug Tier

Notes

SILENOR 3

SUNOSI 4 PA; QL

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

1

temazepam oral capsule 22.5 mg

3

WAKIX 4 PA; QL

XYREM 4 PA; QL

zaleplon 1

zolpidem tartrate er 3

zolpidem tartrate oral 1

zolpidem tartrate sublingual

3

ZOLPIMIST 3

86

Index of Drugs

A abacavir sulfate ............... 34 abacavir sulfate-lamivudine

.................................... 34 abacavir-lamivudine-

zidovudine ................... 34 ABELCET ........................ 25 ABILIFY ........................... 33 ABILIFY MAINTENA ........ 34 ABILIFY MYCITE ............ 34 abiraterone acetate.......... 28 ABOUTTIME PEN NEEDLE

.................................... 54 ABRAXANE ..................... 28 ABSORICA ...................... 45 ABSORICA LD ................ 45 ABSTRAL ........................ 12 acamprosate calcium ....... 16 ACANYA ......................... 45 acarbose ......................... 52 ACCOLATE ..................... 80 ACCU-CHEK AVIVA

DEVICE ....................... 53 ACCU-CHEK COMPACT

PLUS CONTROL ......... 53 ACCU-CHEK FASTCLIX

LANCET KIT ................ 53 ACCU-CHEK GUIDE

CONTROL ................... 53 ACCU-CHEK MULTICLIX

LANCET DEVICE KIT .. 53 ACCU-CHEK SMARTVIEW

CONTROL ................... 53 ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT .. 53 ACCUPRIL ...................... 38 ACCURETIC ................... 38 acebutolol hcl .................. 38 acetaminophen-codeine .. 12 acetaminophen-codeine #2

.................................... 12 acetaminophen-codeine #3

.................................... 12 acetaminophen-codeine #4

.................................... 12 acetazolamide ................. 76 acetazolamide er ............. 76 acetazolamide sodium ..... 38 acetic acid ................. 60, 78 acetylcysteine .................. 80 ACIPHEX ........................ 57 ACIPHEX SPRINKLE ...... 57 acitretin ............................ 46

ACTEMRA....................... 69 ACTEMRA ACTPEN ....... 69 ACTHAR ......................... 63 ACTHIB ........................... 71 ACTICLATE .................... 16 ACTIGALL ....................... 58 ACTIMMUNE .................. 69 ACTIQ ............................. 12 ACTIVASE ...................... 21 ACTIVELLA ..................... 64 ACTONEL ....................... 72 ACTOPLUS MET ............ 52 ACTOS ............................ 52 ACUICYN ........................ 77 ACULAR ......................... 75 ACULAR LS .................... 75 ACUVAIL ......................... 75 acyclovir .......................... 34 acyclovir sodium .............. 34 ACZONE ......................... 46 ADACEL .......................... 71 ADALAT CC .................... 38 adapalene ....................... 46 ADAPALENE ................... 46 adapalene-benzoyl peroxide

.................................... 46 ADCETRIS ...................... 28 ADCIRCA ........................ 82 ADDERALL ..................... 43 ADDERALL XR ............... 43 ADDYI ............................. 45 adefovir dipivoxil .............. 34 ADEMPAS....................... 82 ADHANSIA XR ................ 43 ADLYXIN ......................... 52 ADLYXIN STARTER PACK

.................................... 52 ADMELOG ...................... 54 ADMELOG SOLOSTAR .. 54 ADRENALIN .................... 79 adriamycin ....................... 28 adrucil ............................. 28 adult aspirin regimen ....... 11 ADVAIR DISKUS............. 80 ADVAIR HFA ................... 80 ADVANCED ALLERGY

COLLECTION ............. 46 ADVATE .......................... 37 ADYNOVATE .................. 37 ADYPHREN .................... 80 ADYPHREN AMP............ 80 ADYPHREN AMP II ......... 80 ADYPHREN II ................. 80

ADZENYS ER ................. 44 ADZENYS XR-ODT ........ 44 AEMCOLO ...................... 16 AFINITOR ....................... 28 AFINITOR DISPERZ ....... 28 afirmelle .......................... 64 AFLURIA QUADRIVALENT

.................................... 71 AFREZZA........................ 54 AFSTYLA ........................ 37 AGAMATRIX CONTROL

LEVEL 2 ...................... 53 AGAMATRIX CONTROL

LEVEL 4 ...................... 53 AGGRASTAT .................. 33 AGGRENOX ................... 33 AGRYLIN ........................ 37 AIMOVIG......................... 27 AIRDUO RESPICLICK

113/14 ......................... 80 AIRDUO RESPICLICK

232/14 ......................... 80 AIRDUO RESPICLICK

55/14 ........................... 80 AJOVY ............................ 27 AKLIEF ........................... 46 ak-poly-bac ..................... 77 AKTEN ............................ 77 AKYNZEO ....................... 25 ala-cort ............................ 46 albendazole ..................... 32 ALBENZA........................ 32 albuterol sulfate ............... 80 albuterol sulfate er ........... 80 albuterol sulfate hfa ......... 80 ALBUTEROL SULFATE

HFA ............................. 80 ALCAINE......................... 77 alclometasone dipropionate

.................................... 46 ALCOHOL PREP PADS .. 73 ALDACTAZIDE ............... 38 ALDACTONE .................. 38 ALDARA ......................... 46 ALDURAZYME ............... 60 ALECENSA ..................... 28 alendronate sodium ......... 72 ALFERON N ................... 69 alfuzosin hcl er ................ 61 ALIMTA ........................... 28 ALINIA ............................ 32 ALIQOPA ........................ 28 aliskiren fumarate ............ 38

87

ALKERAN ....................... 28 allopurinol ........................ 27 allopurinol sodium ........... 27 ALLZITAL ........................ 12 almotriptan malate ........... 27 ALOCRIL ......................... 75 ALOGLIPTIN BENZOATE

.................................... 52 ALOGLIPTIN-METFORMIN

HCL ............................. 52 ALOGLIPTIN-

PIOGLITAZONE .......... 52 ALOMIDE ........................ 75 ALORA ............................ 64 alosetron hcl .................... 58 ALOXI.............................. 25 ALPHAGAN P ................. 76 ALPHANATE/VWF

COMPLEX/HUMAN ..... 37 ALPHANINE SD .............. 37 alprazolam ....................... 36 alprazolam er ................... 36 alprazolam intensol.......... 36 alprazolam xr ................... 36 ALPROLIX ....................... 37 alprostadil ........................ 38 ALREX ............................ 75 ALTABAX ........................ 16 altacaine .......................... 77 ALTACE .......................... 38 altafrin ............................. 77 altavera ........................... 64 ALTOPREV ..................... 38 ALTRENO ....................... 46 ALUNBRIG ...................... 28 ALVESCO ....................... 80 alyacen 1/35 .................... 64 alyacen 7/7/7 ................... 64 alyq ................................. 82 amabelz ........................... 64 amantadine hcl ................ 33 AMARYL ......................... 52 AMBIEN .......................... 83 AMBIEN CR .................... 83 AMBISOME ..................... 25 ambrisentan..................... 82 amcinonide ...................... 46 AMELUZ .......................... 46 AMERGE ......................... 27 amethia ........................... 64 amethia lo ........................ 64 amethyst .......................... 64 AMICAR .......................... 37 amikacin sulfate ............... 16 amiloride hcl .................... 38

amiloride-hydrochlorothiazide ..... 38

aminoacetic acid ............. 60 aminocaproic acid ........... 37 aminophylline .................. 80 amiodarone hcl ................ 39 AMITIZA .......................... 58 amitriptyline hcl ............... 23 amlactin ........................... 46 amlodipine besylate ......... 39 amlodipine besylate-

benazepril hcl .............. 39 amlodipine besylate-

valsartan ...................... 39 amlodipine-atorvastatin ... 39 amlodipine-olmesartan .... 39 amlodipine-valsartan-hctz 39 ammonium lactate ........... 46 amnesteem ..................... 46 amoxapine....................... 23 amoxicill-clarithro-lansopraz

.................................... 58 amoxicillin ....................... 16 amoxicillin-potassium

clavulanate .................. 16 amoxicillin-potassium

clavulanate er .............. 16 AMPHADASE .................. 73 AMPHETAMINE ER ........ 44 amphetamine sulfate ....... 44 amphetamine-

dextroamphetamine ..... 44 amphetamine-

dextroamphetamine er . 44 ampicillin ......................... 16 ampicillin sodium ............. 16 ampicillin-sulbactam sodium

.................................... 16 AMPYRA ......................... 44 AMRIX ............................. 83 AMYTAL SODIUM ........... 83 AMZEEQ ......................... 46 ANACAINE ...................... 46 ANADROL-50 .................. 63 ANAFRANIL .................... 23 anagrelide hcl .................. 37 ANALPRAM-HC .............. 72 anastrozole...................... 28 ANCOBON ...................... 25 ANDEXXA ....................... 73 ANDRODERM ................. 63 ANDROGEL .................... 63 ANDROGEL PUMP ......... 63 ANGELIQ ........................ 64 ANNOVERA .................... 64

ANORO ELLIPTA ............ 80 ANTABUSE ..................... 16 ANTARA ......................... 39 anucort-hc ....................... 72 anusol-hc ........................ 72 ANUSOL-HC ................... 72 ANZEMET ....................... 25 APADAZ ......................... 12 apap-caff-dihydrocodeine 12 APIDRA SOLOSTAR ...... 54 APIDRA VIAL .................. 54 APLENZIN ...................... 23 APOKYN ......................... 33 apraclonidine hcl ............. 76 aprepitant ........................ 25 apri .................................. 64 APRISO .......................... 72 APTENSIO XR ................ 44 APTIOM .......................... 21 APTIVUS................... 34, 35 ARALAST NP .................. 80 aranelle ........................... 64 ARANESP (ALBUMIN

FREE) ......................... 37 ARAVA ............................ 69 ARCALYST ..................... 69 ARCAPTA NEOHALER ... 80 argyle sterile saline ......... 56 argyle sterile water .......... 56 ARICEPT ........................ 23 ARIKAYCE ...................... 16 ARIMIDEX ....................... 28 aripiprazole ..................... 34 ARISTADA ...................... 34 ARISTADA INITIO ........... 34 ARIXTRA ........................ 21 armodafinil ...................... 83 ARMOUR THYROID ....... 68 ARNUITY ELLIPTA ......... 80 AROMASIN ..................... 28 ARRANON ...................... 28 arsenic trioxide ................ 28 ARTHROTEC .................. 11 ARYMO ER ..................... 12 ARZERRA ....................... 28 arzol silver nit applicators 46 ASACOL HD ................... 72 ascomp-codeine .............. 12 ashlyna ........................... 64 ASMANEX (120 METERED

DOSES) ...................... 81 ASMANEX (14 METERED

DOSES) ...................... 81 ASMANEX (30 METERED

DOSES) ...................... 81

88

ASMANEX (60 METERED DOSES) ....................... 81

ASMANEX (7 METERED DOSES) ....................... 81

ASMANEX HFA ............... 81 aspirin.............................. 11 aspirin adult ..................... 11 aspirin adult low strength . 11 aspirin childrens .............. 11 aspirin ec ......................... 11 aspirin ec low dose .......... 11 aspirin ec low strength ..... 11 aspirin low dose ............... 11 aspirin-dipyridamole er .... 33 ASPIRIN-OMEPRAZOLE 33 ASTAGRAF XL ................ 69 ASTEPRO ....................... 79 ASTERO ......................... 15 ATACAND ....................... 39 ATACAND HCT ............... 39 atazanavir sulfate ............ 35 ATELVIA ......................... 72 atenolol ............................ 39 atenolol-chlorthalidone .... 39 ATGAM ........................... 69 ATIVAN ........................... 36 atomoxetine hcl ............... 44 ATOPADERM .................. 46 ATOPICLAIR ................... 46 atorvastatin calcium ......... 39 atovaquone ..................... 32 atovaquone-proguanil hcl 32 ATRALIN ......................... 46 ATRIPLA ......................... 35 atropine sulfate ................ 77 ATROPINE SULFATE ..... 77 ATROVENT HFA ............. 81 AUBAGIO ........................ 44 aubra ............................... 64 aubra eq .......................... 64 AUGMENTIN ................... 16 AUGMENTIN ES-600 ...... 17 aurovela 1.5/30 ................ 64 aurovela 1/20................... 64 aurovela 24 fe .................. 64 aurovela fe 1.5/30 ............ 64 aurovela fe 1/20 ............... 64 AURYXIA ........................ 60 AUSTEDO ....................... 45 AUTOLET LANCING

DEVICE ....................... 53 AUVI-Q ............................ 81 AVALIDE ......................... 39 AVANDIA ........................ 52 AVAPRO ......................... 39

avar cleanser ................... 46 AVASTIN ......................... 28 AVEED ............................ 63 AVELOX .......................... 17 AVENOVA ....................... 77 aviane ............................. 64 avidoxy ............................ 17 avita ................................ 46 AVODART ....................... 61 AVONEX PEN ................. 44 AVONEX PREFILLED ..... 44 AVYCAZ .......................... 17 AYGESTIN ...................... 64 ayuna .............................. 64 AYVAKIT ......................... 28 azacitidine ....................... 28 AZASAN .......................... 69 AZASITE ......................... 75 azathioprine ..................... 69 azathioprine sodium ........ 69 azelaic acid ..................... 46 azelastine hcl ............ 75, 79 azelastine-fluticasone ...... 79 AZELEX .......................... 46 AZILECT ......................... 33 azithromycin .................... 17 AZOPT ............................ 76 AZOR .............................. 39 AZULFIDINE ................... 72 AZULFIDINE EN-TABS ... 72 azurette ........................... 64 B bacitracin ......................... 75 bacitracin-polymyxin b ..... 77 bacitra-neomycin-

polymyxin-hc ............... 77 baclofen .......................... 83 BACTRIM ........................ 17 BACTRIM DS .................. 17 BALCOLTRA ................... 64 balsalazide disodium ....... 72 balsam peru-castor oil ..... 46 BALVERSA ..................... 28 balziva ............................. 64 BANZEL .......................... 21 BAQSIMI ONE PACK ...... 54 BAQSIMI TWO PACK ..... 54 BARACLUDE .................. 35 BASAGLAR KWIKPEN.... 54 BAVENCIO...................... 28 BAXDELA ....................... 17 BAYER ASPIRIN ............. 11 BAYER ASPIRIN EC LOW

DOSE .......................... 11

BD AUTOSHIELD DUO PEN NEEDLES ........... 54

BD ULTRA-FINE INSULIN SYRINGES.................. 54

BD ULTRA-FINE PEN NEEDLES ................... 54

BECONASE AQ .............. 79 bekyree ........................... 64 BELBUCA ....................... 12 BELEODAQ .................... 28 belladonna alkaloids-opium

.................................... 58 BELRAPZO ..................... 28 BELSOMRA .................... 83 benazepril hcl .................. 39 benazepril-

hydrochlorothiazide ..... 39 BENDAMUSTINE HCL .... 28 BENDEKA ....................... 28 BENEFIX......................... 37 BENICAR ........................ 39 BENICAR HCT ................ 39 BENLYSTA ..................... 69 BENSAL HP .................... 46 BENTYL .......................... 58 BENZACLIN .................... 46 BENZACLIN WITH PUMP

.................................... 46 BENZAMYCIN ................ 46 benzepro foaming cloths . 46 BENZHYDROCODONE-

ACETAMINOPHEN ..... 12 BENZIQ .......................... 46 BENZIQ LS ..................... 46 BENZNIDAZOLE ............. 32 benzonatate .................... 79 BENZOYL PEROX-

HYDROCORTISONE .. 46 BENZOYL PEROXIDE .... 46 BENZOYL PEROXIDE

FORTE- HC ................. 46 benzoyl peroxide-

erythromycin ................ 46 benztropine mesylate ...... 33 BEPREVE ....................... 75 BERINERT ...................... 69 beser ............................... 46 BESIVANCE ................... 75 BESPONSA .................... 28 BETADINE OPHTHALMIC

PREP .......................... 75 betamethasone

dipropionate ................ 46 betamethasone

dipropionate aug ......... 46

89

betamethasone sod phos & acet ............................. 61

betamethasone valerate .. 46 BETAPACE ..................... 39 BETAPACE AF ................ 39 BETASERON .................. 44 betaxolol hcl .............. 39, 76 bethanechol chloride ....... 60 BETHKIS ......................... 82 BETIMOL ........................ 76 BETOPTIC-S ................... 76 BEVESPI AEROSPHERE81 bexarotene ...................... 28 BEXSERO ....................... 71 BEYAZ ............................ 64 bicalutamide .................... 28 BICILLIN C-R .................. 17 BICILLIN C-R 900/300 ..... 17 BICILLIN L-A ................... 17 BICNU ............................. 28 BIDIL ............................... 39 BIJUVA ............................ 64 BIKTARVY ...................... 35 BILTRICIDE..................... 32 bimatoprost ..................... 76 BINOSTO ........................ 72 bio-statin .......................... 25 BIO-STATIN .................... 25 BIOTHRAX ...................... 71 bisacodyl ec..................... 58 bisoprolol fumarate .......... 39 bisoprolol-

hydrochlorothiazide ..... 39 BIVIGAM ......................... 69 bleomycin sulfate ............. 28 BLEPH-10 ....................... 75 BLEPHAMIDE ................. 77 BLEPHAMIDE S.O.P. ...... 77 BLINCYTO ...................... 28 blisovi 24 fe ..................... 65 blisovi fe 1.5/30 ............... 65 blisovi fe 1/20 .................. 65 BLOXIVERZ .................... 28 BOCASAL ....................... 45 BONIVA ........................... 72 BONJESTA ..................... 25 BOOSTRIX ...................... 71 BORTEZOMIB ................. 28 bosentan ......................... 82 BOSULIF ......................... 28 BOTOX ............................ 73 bp 10-1 ............................ 46 bp cleansing wash ........... 46 BPCO .............................. 46 BRAFTOVI ...................... 28

BREATHE EASE LARGE 73 BREATHE EASE MEDIUM

.................................... 73 BREATHE EASE SMALL 73 BREATHERITE ............... 73 BREO ELLIPTA ............... 81 briellyn ............................. 65 BRILINTA ........................ 33 brimonidine tartrate ......... 76 BRIMONIDINE-

DORZOLAMIDE .......... 76 BRISDELLE .................... 23 BRIVIACT ................. 21, 22 bromfed dm ..................... 79 bromfenac sodium (once-

daily) ........................... 75 bromocriptine mesylate ... 33 brompheniramine tannate 79 BROMSITE ..................... 75 BROVANA....................... 81 BRUKINSA ...................... 29 BRYHALI ......................... 46 budesonide................ 72, 81 budesonide er ................. 72 BUDESONIDE-

FORMOTEROL FUMARATE................. 81

bumetanide ..................... 39 BUMEX ........................... 39 BUNAVAIL ...................... 16 BUPAP ............................ 12 BUPHENYL ..................... 60 BUPRENEX .................... 12 buprenorphine ................. 12 BUPRENORPHINE ......... 12 buprenorphine hcl...... 12, 16 buprenorphine hcl-naloxone

hcl ............................... 16 bupropion hcl ................... 24 bupropion hcl er (smoking

det) .............................. 16 bupropion hcl er (sr) ........ 23 bupropion hcl er (xl) ......... 23 BUPROPION HCL ER (XL)

.................................... 24 buspirone hcl ................... 36 busulfan .......................... 29 butalbital-acetaminophen 12 BUTALBITAL-

ACETAMINOPHEN ..... 12 butalbital-apap-caff-cod ... 12 butalbital-apap-caffeine ... 12 butalbital-asa-caff-codeine

.................................... 13 butalbital-aspirin-caffeine . 13

butorphanol tartrate ......... 13 BUTRANS ....................... 13 BYDUREON .................... 52 BYDUREON BCISE

AUTOINJECTOR ........ 52 BYETTA 10 MCG PEN .... 52 BYETTA 5 MCG PEN...... 52 BYSTOLIC ...................... 39 C cabergoline ..................... 63 CABLIVI .......................... 33 CABOMETYX ................. 29 CADUET ......................... 39 CAFERGOT .................... 27 caffeine citrate ................. 45 CALAN SR ...................... 39 calcipotriene .................... 46 CALCIPOTRIENE ........... 46 calcipotriene-betameth

diprop .......................... 46 CALCIPOTRIENE-

BETAMETH DIPROP .. 46 calcitonin (salmon) .......... 72 calcitrene......................... 46 calcitriol ..................... 47, 73 calcium acetate ............... 60 calcium acetate (phos

binder) ......................... 60 CALDOLOR .................... 11 CALQUENCE .................. 29 CAMBIA .......................... 11 camila ............................. 65 CAMPATH ...................... 29 CAMPTOSAR ................. 29 camrese .......................... 65 camrese lo ...................... 65 CANASA ......................... 72 candesartan cilexetil ........ 39 candesartan cilexetil-hctz 39 CAPASTAT SULFATE .... 28 capecitabine .................... 29 CAPEX ............................ 47 CAPLYTA........................ 34 CAPRELSA ..................... 29 captopril .......................... 39 captopril-

hydrochlorothiazide ..... 39 CARAC ........................... 47 CARAFATE ..................... 57 CARBAGLU .................... 56 carbamazepine ............... 22 carbamazepine er ........... 22 CARBATROL .................. 22 carbidopa ........................ 33 carbidopa-levodopa ......... 33

90

carbidopa-levodopa er ..... 33 carbidopa-levodopa-

entacapone .................. 33 carbinoxamine maleate ... 79 carboplatin ....................... 29 carboprost tromethamine . 63 CARDIZEM ..................... 39 CARDIZEM CD ............... 39 CARDIZEM LA ................ 39 CARDURA ...................... 39 CARDURA XL ................. 61 CARETOUCH

LANCING/EJECTOR ... 53 CARIMUNE NF ............... 69 carisoprodol ..................... 83 carisoprodol-aspirin ......... 83 carisoprodol-aspirin-codeine

.................................... 13 carmustine ....................... 29 CARNITOR ..................... 56 CARNITOR SF ................ 56 CAROSPIR ..................... 39 carteolol hcl ..................... 76 cartia xt ............................ 39 carvedilol ......................... 39 carvedilol phosphate er ... 39 CASODEX ....................... 29 caspofungin acetate ........ 25 CATAPRES ..................... 39 CATAPRES-TTS-1 .......... 39 CATAPRES-TTS-2 .......... 39 CATAPRES-TTS-3 .......... 39 CAYA .............................. 73 CAYSTON ....................... 82 caziant ............................. 65 cefaclor ............................ 17 cefaclor er ....................... 17 cefadroxil ......................... 17 cefazolin sodium .............. 17 cefazolin sodium-dextrose

.................................... 17 cefdinir............................. 17 cefditoren pivoxil .............. 17 cefepime hcl .................... 17 cefepime-dextrose ........... 17 cefixime ........................... 17 cefotaxime sodium........... 17 cefotetan disodium .......... 17 cefotetan disodium-dextrose

.................................... 17 cefoxitin sodium ............... 17 CEFOXITIN SODIUM-

DEXTROSE ................. 17 cefpodoxime proxetil ........ 17 cefprozil ........................... 17

ceftazidime ...................... 17 ceftazidime and dextrose . 17 ceftriaxone sodium .......... 17 ceftriaxone sodium in

dextrose ...................... 17 ceftriaxone sodium-dextrose

.................................... 17 cefuroxime axetil ............. 17 cefuroxime sodium .......... 17 CELEBREX ..................... 11 celecoxib ......................... 11 CELESTONE SOLUSPAN

.................................... 62 CELEXA .......................... 24 CELLCEPT...................... 69 CELONTIN ...................... 22 cem-urea ......................... 47 CENTANY ....................... 17 cephalexin ....................... 17 CEPROTIN...................... 37 CEQUA ........................... 77 CERACADE .................... 47 ceramax .......................... 47 CERDELGA .................... 60 CEREZYME .................... 60 CERVIDIL ....................... 60 cetirizine hcl .................... 79 CETRAXAL ..................... 78 cevimeline hcl .................. 45 CHANTIX ........................ 16 CHANTIX CONTINUING

MONTH PAK ............... 16 CHANTIX STARTING

MONTH PAK ............... 16 chateal ............................ 65 chateal eq ....................... 65 CHEMET ......................... 56 CHENODAL .................... 58 chloramphenicol sod

succinate ..................... 17 chlordiazepoxide hcl ........ 37 chlordiazepoxide-

amitriptyline ................. 24 chlordiazepoxide-clidinium

.................................... 58 chlorhexidine gluconate ... 45 chloroquine phosphate .... 32 chlorothiazide .................. 39 chlorpromazine hcl .......... 34 chlorthalidone .................. 39 chlorzoxazone ................. 83 CHOLBAM ...................... 60 cholestyramine ................ 39 cholestyramine light ......... 39 choline-mag trisalicylate .. 11

CIALIS ............................ 60 ciclodan ........................... 25 ciclopirox ......................... 26 ciclopirox olamine ............ 26 cidofovir .......................... 35 cilostazol ......................... 33 CILOXAN ........................ 75 CIMDUO ......................... 35 cimetidine ........................ 57 cimetidine hcl .................. 57 CIMZIA ............................ 69 CIMZIA PREFILLED KIT . 69 CIMZIA STARTER KIT .... 69 cinacalcet hcl .................. 73 CINQAIR ......................... 79 CINRYZE ........................ 69 CINVANTI ....................... 25 CIPRO ............................ 18 CIPRO HC ...................... 78 CIPRODEX ..................... 78 ciprofloxacin hcl... 18, 75, 78 ciprofloxacin in d5w ......... 18 CIPROFLOXACIN-

FLUOCINOLONE PF .. 79 cisplatin ........................... 29 citalopram hydrobromide . 24 citroma ............................ 58 cladribine......................... 29 claravis ............................ 47 CLARINEX ...................... 79 CLARINEX-D 12 HOUR .. 79 clarithromycin .................. 18 clarithromycin er .............. 18 clearlax ........................... 58 clemastine fumarate ........ 79 CLENPIQ ........................ 58 CLEOCIN ........................ 18 CLEOCIN PHOSPHATE . 18 CLEOCIN-T ..................... 47 CLIMARA ........................ 65 CLIMARA PRO ............... 65 clindacin etz .................... 47 clindacin-p ....................... 47 CLINDAGEL .................... 47 clindamycin hcl ................ 18 clindamycin palmitate hcl 18 clindamycin phosphate ... 18,

47 CLINDAMYCIN

PHOSPHATE .............. 47 clindamycin phosphate in

d5w ............................. 18 CLINDAMYCIN

PHOSPHATE IN NACL 18

91

clindamycin phosphate-benzoyl peroxide ......... 47

clindamycin-tretinoin ........ 47 CLINDESSE .................... 18 clobazam ......................... 22 clobetasol prop emollient

base ............................ 47 clobetasol propionate ...... 47 clobetasol propionate e ... 47 clobetasol propionate

emulsion ...................... 47 CLOBEX .......................... 47 CLOBEX SPRAY ............. 47 clocortolone pivalate ........ 47 clodan.............................. 47 CLODERM ...................... 47 clofarabine ....................... 29 clomipramine hcl ............. 24 clonazepam ..................... 37 clonidine .......................... 39 clonidine hcl .................... 39 clonidine hcl (analgesia) .. 13 clonidine hcl er ................ 44 clopidogrel bisulfate ......... 33 clorazepate dipotassium .. 37 clotrimazole ..................... 26 clotrimazole-betamethasone

.................................... 26 clovique ........................... 56 clozapine ......................... 34 CLOZARIL ....................... 34 COAGADEX .................... 37 COARTEM ...................... 32 codeine sulfate ................ 13 COGENTIN ..................... 33 COLAZAL ........................ 72 colchicine ........................ 27 COLCHICINE .................. 27 colchicine-probenecid ...... 27 COLCRYS ....................... 27 colesevelam hcl ............... 39 COLESTID ...................... 39 COLESTID FLAVORED .. 39 colestipol hcl .................... 39 colistimethate sodium (cba)

.................................... 18 colocort ............................ 72 COLY-MYCIN M .............. 18 COLY-MYCIN S .............. 79 COMBIGAN ..................... 76 COMBIPATCH ................ 65 COMBIVENT RESPIMAT 81 COMBIVIR ...................... 35 COMETRIQ (100 MG

DAILY DOSE) .............. 29

COMETRIQ (140 MG DAILY DOSE) .............. 29

COMETRIQ (60 MG DAILY DOSE) ......................... 29

COMPACT SPACE CHAMBER/LG MASK .. 73

COMPACT SPACE CHAMBER/MED MASK .................................... 73

COMPACT SPACE CHAMBER/SM MASK . 73

COMPLERA .................... 35 compro ............................ 25 COMTAN ........................ 33 CONCERTA .................... 44 CONDYLOX .................... 47 CONSENSI ..................... 39 constulose ....................... 58 CONTOUR CONTROL .... 54 CONTOUR NEXT

CONTROL ................... 54 CONTOUR NEXT TEST .. 54 CONZIP .......................... 13 COPAXONE .................... 44 COPIKTRA ...................... 29 CORDRAN ...................... 47 COREG ........................... 39 COREG CR ..................... 39 coremino ......................... 18 CORGARD ...................... 39 CORIFACT ...................... 37 CORLANOR .................... 39 CORTEF ......................... 62 CORTENEMA ................. 72 CORTIFOAM ................... 72 cortisone acetate ............. 62 CORTISPORIN ............... 47 COSENTYX (300 MG

DOSE) ......................... 69 COSENTYX 150 MG/ML . 69 COSENTYX

SENSOREADY (300 MG) .................................... 69

COSENTYX SENSOREADY PEN ... 69

COSOPT ......................... 76 COSOPT PF ................... 76 COTELLIC....................... 29 COTEMPLA XR-ODT ...... 44 COUMADIN ..................... 21 covaryx ............................ 65 covaryx hs ....................... 65 COZAAR ......................... 39 CREON ........................... 60 CRESEMBA .................... 26

CRESTOR ...................... 39 CRINONE ....................... 65 CRIXIVAN ....................... 35 cromolyn sodium . 58, 75, 81 crotan .............................. 32 cryselle-28 ....................... 65 CRYSVITA ...................... 60 CUPRIMINE .................... 60 curity sterile saline ........... 56 CUROSURF .................... 79 CUTAQUIG ..................... 69 CUTIVATE ...................... 47 CUVITRU ........................ 69 CUVPOSA ...................... 58 cyanocobalamin .............. 56 cyclafem 1/35 .................. 65 cyclafem 7/7/7 ................. 65 cyclobenzaprine hcl ......... 83 cyclobenzaprine hcl er..... 83 CYCLOGYL .................... 77 CYCLOMYDRIL .............. 77 cyclopentolate hcl ............ 77 cyclophosphamide .......... 29 cycloserine ...................... 28 CYCLOSET ..................... 52 cyclosporine .................... 69 CYCLOSPORINE IN

KLARITY ..................... 77 cyclosporine modified ...... 69 CYMBALTA ..................... 24 cyproheptadine hcl .......... 79 CYRAMZA ...................... 29 cyred ............................... 65 cyred eq .......................... 65 CYSTADANE .................. 60 CYSTAGON .................... 60 CYSTARAN .................... 77 cytarabine ....................... 29 cytarabine (pf) ................. 29 CYTOGAM ...................... 69 CYTOMEL ....................... 68 CYTOTEC ....................... 57 cytra k crystals ................ 56 D D.H.E. 45 ........................ 27 dacarbazine .................... 29 dactinomycin ................... 29 dalfampridine er .............. 44 DALIRESP ...................... 81 DALVANCE ..................... 18 danazol ........................... 63 DANTRIUM ..................... 83 dantrolene sodium ........... 83 dapsone .................... 28, 47 DAPSONE ...................... 47

92

DAPTACEL ..................... 71 daptomycin ...................... 18 DARAPRIM ..................... 32 darifenacin hydrobromide er

.................................... 60 DARZALEX ..................... 29 dasetta 1/35 .................... 65 dasetta 7/7/7.................... 65 daunorubicin hcl .............. 29 DAURISMO ..................... 29 DAYPRO ......................... 11 daysee............................. 65 DAYTRANA ..................... 44 DDAVP ............................ 63 DEBACTEROL ................ 45 deblitane .......................... 65 DECADRON .................... 62 decitabine ........................ 29 deferasirox ...................... 56 deferoxamine mesylate ... 73 DEFITELIO ...................... 21 DELESTROGEN ............. 65 DELSTRIGO.................... 35 delyla ............................... 65 DELZICOL ....................... 72 demeclocycline hcl .......... 18 DEMEROL ...................... 13 DEMSER ......................... 39 DENAVIR ........................ 35 DEPAKOTE ..................... 22 DEPAKOTE ER ............... 22 DEPAKOTE SPRINKLES 22 DEPEN TITRATABS ....... 60 DEPO-ESTRADIOL ......... 65 DEPO-MEDROL .............. 62 DEPO-PROVERA ........... 65 DEPO-SUBQ PROVERA

104 .............................. 65 DEPO-TESTOSTERONE 63 DERMACINRX AZENASE

PAK ............................. 79 DERMA-SMOOTHE/FS

BODY .......................... 47 DERMA-SMOOTHE/FS

SCALP ........................ 47 DERMOTIC ..................... 79 DERMULCERA ............... 47 DESCOVY ....................... 35 DESFERAL ..................... 73 desipramine hcl ............... 24 desloratadine ................... 79 desmopressin ace spray

refrig ............................ 63 desmopressin acetate ..... 63

desmopressin acetate spray .................................... 63

desogestrel-ethinyl estradiol .................................... 65

DESONATE .................... 47 desonide ......................... 48 DESOWEN...................... 48 desoximetasone .............. 48 DESOXYN....................... 44 DESVENLAFAXINE ER .. 24 desvenlafaxine succinate er

.................................... 24 DETROL ......................... 60 DETROL LA .................... 60 dexamethasone ............... 62 DEXAMETHASONE (LA) 62 dexamethasone intensol.. 62 dexamethasone sod

phosphate pf................ 62 dexamethasone sodium

phosphate ............. 62, 75 DEXEDRINE ................... 44 DEXERYL ....................... 48 DEXILANT....................... 57 dexmethylphenidate hcl ... 44 dexmethylphenidate hcl er

.................................... 44 DEXPAK 10 DAY ............ 62 DEXPAK 13 DAY ............ 62 DEXPAK 6 DAY .............. 62 dextroamphetamine sulfate

.................................... 44 dextroamphetamine sulfate

er ................................. 44 DIACOMIT....................... 22 DIASTAT ACUDIAL ......... 22 DIASTAT PEDIATRIC ..... 22 DIATHRIVE GLUCOSE

CONTROL SOLN ........ 54 DIATHRIVE LANCING

DEVICE ....................... 54 diazepam .................. 22, 37 diazepam intensol ........... 37 DIBENZYLINE ................. 39 DICLEGIS ....................... 25 DICLOFENAC EPOLAMINE

.................................... 11 diclofenac potassium ....... 11 diclofenac sodium 11, 48, 75 diclofenac sodium er ....... 11 diclofenac-misoprostol ..... 11 DICLOFONO ................... 11 dicloxacillin sodium .......... 18 dicyclomine hcl ................ 58 didanosine ....................... 35

DIFFERIN ....................... 48 DIFICID ........................... 18 difil-g forte ....................... 81 diflorasone diacetate ....... 48 DIFLUCAN ...................... 26 diflunisal .......................... 11 DIGIFAB ......................... 73 digitek ............................. 40 digox ............................... 40 digoxin ............................ 40 dihydroergotamine mesylate

.................................... 27 DILANTIN........................ 22 DILANTIN INFATABS ..... 22 DILATRATE-SR .............. 40 DILAUDID ....................... 13 diltiazem hcl .................... 40 diltiazem hcl er ................ 40 diltiazem hcl er beads ..... 40 diltiazem hcl er coated

beads .......................... 40 dilt-xr ............................... 40 diluent for treprostinil ....... 73 dimenhydrinate ............... 25 DIOVAN .......................... 40 DIOVAN HCT .................. 40 DIPENTUM ..................... 72 diphen ............................. 79 diphenhydramine hcl ....... 79 diphenoxylate-atropine .... 58 DIPHTHERIA-TETANUS

TOXOIDS DT .............. 71 DIPROLENE ................... 48 DIPROLENE AF .............. 48 dipyridamole .................... 33 disopyramide phosphate . 40 disulfiram......................... 16 DITROPAN XL ................ 60 DIURIL ............................ 40 divalproex sodium ........... 22 divalproex sodium er ....... 22 DIVIGEL .......................... 65 docetaxel......................... 29 dofetilide ......................... 40 DOLOPHINE ................... 13 donepezil hcl ................... 23 DOPTELET ..................... 37 DORAL ........................... 37 DORYX ........................... 18 DORYX MPC .................. 18 dorzolamide hcl ............... 77 dorzolamide hcl-timolol mal

.................................... 77 dorzolamide hcl-timolol mal

pf ................................. 77

93

dotti ................................. 65 DOVATO ......................... 35 DOVONEX ...................... 48 doxazosin mesylate ......... 40 doxepin hcl .......... 24, 48, 83 doxercalciferol ................. 73 doxorubicin hcl ................ 29 doxorubicin hcl liposomal. 29 doxy 100 .......................... 18 doxycycline ...................... 48 doxycycline hyclate.......... 18 doxycycline monohydrate 18 doxylamine-pyridoxine ..... 25 DRISDOL ........................ 56 DRIZALMA SPRINKLE .... 24 dronabinol ....................... 25 droperidol ........................ 25 drospiren-eth estrad-

levomefol ..................... 65 drospirenone-ethinyl

estradiol ....................... 65 DROXIA .......................... 29 DRYSOL ......................... 48 DUAKLIR PRESSAIR ...... 81 DUAVEE ......................... 65 DUETACT ....................... 52 DUEXIS ........................... 11 DULERA .......................... 81 duloxetine hcl .................. 24 DUOPA ........................... 33 DUPIXENT ...................... 48 DURAGESIC-100 ............ 13 DURAGESIC-12 .............. 13 DURAGESIC-25 .............. 13 DURAGESIC-50 .............. 13 DURAGESIC-75 .............. 13 duramorph ....................... 13 duraxin ............................ 13 DUREZOL ....................... 75 DURLAZA ....................... 33 dutasteride ...................... 61 dutasteride-tamsulosin hcl

.................................... 61 DUTOPROL .................... 40 DVORAH ......................... 13 DXEVO 11-DAY .............. 62 DYANAVEL XR ............... 44 DYAZIDE ......................... 40 DYMISTA ........................ 79 DYRENIUM ..................... 40 DYSPORT ....................... 73 E E.E.S. GRANULES.......... 18 EASIVENT ...................... 73 EASYMAX CONTROL ..... 54

EC-NAPROSYN .............. 11 ec-naproxen .................... 11 econazole nitrate ............. 26 ECOZA ............................ 26 EDARBI ........................... 40 EDARBYCLOR ............... 40 EDECRIN ........................ 40 EDLUAR ......................... 83 ed-spaz ........................... 58 EDURANT ....................... 35 eemt ................................ 65 eemt hs ........................... 65 efavirenz ......................... 35 effer-k .............................. 56 EFFER-K ......................... 56 EFFEXOR XR ................. 24 EFFIENT ......................... 33 EFUDEX ......................... 48 EGRIFTA ........................ 63 EGRIFTA SV ................... 63 EHA................................. 15 ELAPRASE ..................... 60 ELELYSO ........................ 60 ELESTRIN....................... 65 ELETONE ....................... 48 eletriptan hydrobromide ... 27 ELIDEL ............................ 48 ELIGARD ........................ 63 ELIMITE .......................... 32 elinest .............................. 65 ELIQUIS .......................... 21 ELIQUIS DVT/PE

STARTER PACK ......... 21 ELITEK ............................ 29 ELIXOPHYLLIN ............... 81 ELLA ............................... 65 ELMIRON ........................ 60 ELOCON ......................... 48 ELOCTATE ..................... 37 eluryng ............................ 65 EMBRACE TALK

GLUCOSE CONTROL 54 EMCYT ........................... 29 EMEND ........................... 25 EMEND TRI-PACK .......... 25 EMFLAZA ....................... 27 EMGALITY ...................... 27 EMGALITY (300 MG

DOSE) ......................... 27 emoquette ....................... 65 EMPLICITI....................... 29 EMSAM ........................... 24 EMTRIVA ........................ 35 EMULSION SB ................ 48 EMVERM ........................ 32

ENABLEX ....................... 60 enalapril maleate ............. 40 enalapril-

hydrochlorothiazide ..... 40 ENBREL ......................... 69 ENBREL MINI ................. 69 ENBREL SURECLICK .... 69 ENDARI .......................... 73 endocet ........................... 13 ENDOMETRIN ................ 65 ENGERIX-B .................... 71 enoxaparin sodium .......... 21 enpresse-28 .................... 65 enskyce ........................... 65 ENSTILAR ...................... 48 entacapone ..................... 33 entecavir ......................... 35 ENTEREG ....................... 58 ENTOCORT EC .............. 72 ENTRESTO .................... 40 ENTTY SPRAY EMULSION

.................................... 48 ENTYVIO ........................ 69 enulose ........................... 58 ENVARSUS XR .............. 69 EPANED ......................... 40 EPCLUSA ....................... 35 EPICERAM ..................... 48 EPIDIOLEX ..................... 22 EPIDUO .......................... 48 EPIDUO FORTE ............. 48 EPIFOAM ........................ 48 epinastine hcl .................. 75 epinephrine ..................... 81 epinephrine pf ................. 40 EPINEPHRINE

PROFESSIONAL ........ 81 EPINEPHRINESNAP-EMS

.................................... 81 EPINEPHRINESNAP-V ... 81 EPIPEN 2-PAK ............... 81 EPIPEN JR 2-PAK .......... 81 epirubicin hcl ................... 29 EPISNAP ........................ 81 epitol ............................... 22 EPIVIR ............................ 35 EPIVIR HBV .................... 35 eplerenone ...................... 40 EPOGEN......................... 37 epoprostenol sodium ....... 82 eprosartan mesylate ........ 40 EPZICOM........................ 35 EQUETRO ...................... 22 ERAXIS ........................... 26 ERBITUX ........................ 29

94

ergocalciferol ................... 56 ergoloid mesylates........... 73 ERGOMAR ...................... 27 ergotamine-caffeine ......... 27 ERIVEDGE ...................... 29 ERLEADA ....................... 29 erlotinib hcl ...................... 29 errin ................................. 65 ERTACZO ....................... 26 ertapenem sodium ........... 18 ERWINAZE ..................... 29 ery ................................... 48 ERYGEL .......................... 48 ERYPED 200 ................... 18 ERYPED 400 ................... 18 ERY-TAB ......................... 18 ERYTHROCIN

LACTOBIONATE ......... 18 ERYTHROCIN STEARATE

.................................... 18 erythromycin ........ 18, 48, 75 erythromycin base ........... 18 erythromycin ethylsuccinate

.................................... 18 ESBRIET ......................... 81 escitalopram oxalate ........ 24 ESGIC ............................. 13 esomeprazole magnesium

.................................... 58 est estrogens-methyltest . 65 est estrogens-methyltest ds

.................................... 65 est estrogens-methyltest hs

.................................... 65 estarylla ........................... 65 estazolam ........................ 37 ESTRACE ....................... 65 estradiol ........................... 65 estradiol valerate ............. 65 estradiol-norethindrone acet

.................................... 65 ESTRING ........................ 65 ESTROGEL ..................... 65 ESTROSTEP FE ............. 65 eszopiclone ..................... 83 ethacrynate sodium ......... 40 ethacrynic acid ................ 40 ethambutol hcl ................. 28 ETHAMOLIN ................... 40 ethosuximide ................... 22 ethyl chloride ................... 15 ethynodiol diac-eth estradiol

.................................... 65 etodolac ........................... 11 etodolac er ...................... 11

etonogestrel-ethinyl estradiol ....................... 66

ETOPOPHOS ................. 29 etoposide ........................ 29 EUCRISA ........................ 48 EUFLEXXA ..................... 73 euthyrox .......................... 68 EVAMIST ........................ 66 EVEKEO ......................... 44 EVEKEO ODT ................. 44 everolimus ................. 29, 69 EVISTA ........................... 63 EVOCLIN ........................ 48 EVOMELA ....................... 29 EVOTAZ .......................... 35 EVOXAC ......................... 45 EVZIO ............................. 16 EXELDERM .................... 26 EXELON ......................... 23 exemestane ..................... 29 EXFORGE....................... 40 EXFORGE HCT .............. 40 EXJADE .......................... 56 EX-LAX ULTRA ............... 58 exoderm .......................... 26 EXONDYS 51 .................. 60 EXTAVIA ......................... 44 EXTINA ........................... 26 EYLEA ............................ 77 EZALLOR SPRINKLE ..... 40 ezetimibe ......................... 40 ezetimibe-simvastatin ...... 40 F FABIOR ........................... 48 FABRAZYME .................. 60 falmina ............................ 66 famciclovir ....................... 35 famotidine ....................... 58 FANAPT .......................... 34 FANAPT TITRATION PACK

.................................... 34 FARESTON ..................... 29 FARXIGA ........................ 52 FARYDAK ....................... 29 FASENRA ....................... 79 FASENRA PEN ............... 79 FASLODEX ..................... 29 fayosim ............................ 66 febuxostat ....................... 27 felbamate ........................ 22 FELBATOL ...................... 22 FELDENE ....................... 11 felodipine er ..................... 40 FEM PH .......................... 60 FEMARA ......................... 29

FEMCAP ......................... 73 FEMHRT LOW DOSE ..... 66 FEMRING ....................... 66 femynor ........................... 66 fenofibrate ....................... 40 fenofibrate micronized ..... 40 fenofibric acid .................. 40 FENOGLIDE ................... 40 fenoprofen calcium .......... 11 fenortho ........................... 11 fentanyl ........................... 13 fentanyl citrate ................. 13 FENTANYL CITRATE ..... 13 FENTORA ....................... 13 FERAHEME .................... 56 FERRIPROX ................... 56 ferrous sulfate ................. 56 FETZIMA......................... 24 FETZIMA TITRATION ..... 24 FEXMID .......................... 83 FIASP ............................. 54 FIASP FLEXTOUCH ....... 54 FIBRICOR ....................... 40 FIBRYGA ........................ 37 FINACEA ........................ 48 finasteride ....................... 61 FIORICET ....................... 13 FIORICET/CODEINE ...... 13 FIORINAL ....................... 13 FIORINAL/CODEINE #3 . 13 FIRAZYR......................... 69 FIRDAPSE ...................... 73 FIRMAGON ..................... 63 FIRST-BACLOFEN ......... 83 FIRST-LANSOPRAZOLE 58 FIRST-MOUTHWASH BLM

.................................... 45 FIRST-OMEPRAZOLE .... 58 FIRST-PROGESTERONE

VGS ............................ 66 FIRVANQ ........................ 18 flac .................................. 79 FLAGYL .......................... 18 FLAREX .......................... 75 flavoxate hcl .................... 60 FLEBOGAMMA DIF ........ 69 flecainide acetate ............ 40 FLECTOR ....................... 11 FLEXICHAMBER ADULT

MASK/SMALL ............. 73 FLEXICHAMBER CHILD

MASK/LARGE ............. 73 FLEXICHAMBER CHILD

MASK/SMALL ............. 73 FLEXIN ........................... 15

95

FLOLIPID ........................ 40 FLOMAX ......................... 61 FLOVENT DISKUS.......... 81 FLOVENT HFA ................ 81 floxuridine ........................ 29 FLUAD ............................ 71 FLUARIX QUADRIVALENT

.................................... 71 FLUBLOK QUADRIVALENT

.................................... 71 FLUCELVAX

QUADRIVALENT ......... 71 fluconazole ...................... 26 fluconazole in sodium

chloride ........................ 26 flucytosine ....................... 26 fludarabine phosphate ..... 29 fludrocortisone acetate .... 62 FLULAVAL

QUADRIVALENT ......... 71 flunisolide ........................ 79 fluocinolone acetonide .... 48,

79 fluocinolone acetonide body

.................................... 48 fluocinolone acetonide scalp

.................................... 48 fluocinonide ..................... 48 fluocinonide emulsified base

.................................... 48 FLUORABON .................. 56 fluoritab ........................... 56 fluorometholone ............... 75 FLUOROPLEX ................ 48 fluorouracil ................. 29, 48 FLUOROURACIL ............ 48 fluoxetine hcl ................... 24 fluoxetine hcl (pmdd) ....... 24 fluphenazine decanoate .. 34 fluphenazine hcl .............. 34 FLURA-DROPS ............... 56 flurandrenolide ................. 48 flurazepam hcl ................. 83 flurbiprofen ...................... 11 flurbiprofen sodium .......... 75 flutamide .......................... 29 fluticasone propionate ..... 48 fluticasone-salmeterol ...... 81 FLUTICASONE-

SALMETEROL ............ 81 fluvastatin sodium ............ 40 fluvastatin sodium er ........ 40 fluvoxamine maleate ........ 24 fluvoxamine maleate er ... 24 FLUZONE HIGH-DOSE .. 71

FLUZONE QUADRIVALENT ........ 71

FML ................................. 75 FML FORTE .................... 75 FML LIQUIFILM .............. 75 FOCALIN ........................ 44 FOCALIN XR ................... 44 folic acid .......................... 56 FOLOTYN ....................... 29 fondaparinux sodium ....... 21 FORFIVO XL ................... 24 FORTAMET .................... 52 FORTEO ......................... 72 FORTESTA ..................... 63 FORTISCARE CONTROL

.................................... 54 FOSAMAX....................... 73 FOSAMAX PLUS D ......... 73 fosamprenavir calcium .... 35 fosaprepitant dimeglumine

.................................... 25 FOSCAVIR ...................... 35 fosinopril sodium ............. 40 fosinopril sodium-hctz ...... 40 fosphenytoin sodium ....... 22 FOSRENOL .............. 60, 61 FRAGMIN ....................... 21 FREESTYLE TEST ......... 54 FROVA ............................ 27 frovatriptan succinate ...... 27 FULPHILA ....................... 37 fulvestrant ....................... 29 furosemide ...................... 40 FUZEON ......................... 35 fyavolv ............................. 66 FYCOMPA ...................... 22 G gabapentin ...................... 22 GABITRIL ........................ 22 GABLOFEN ..................... 83 GALAFOLD ..................... 60 galantamine hydrobromide

.................................... 23 galantamine hydrobromide

er ................................. 23 GAMASTAN .................... 69 GAMASTAN S/D ............. 69 GAMIFANT...................... 69 GAMMAGARD ................ 69 GAMMAGARD S/D LESS

IGA .............................. 69 GAMMAKED ................... 69 GAMMAPLEX ................. 69 GAMUNEX-C .................. 69 GANCICLOVIR ............... 35

ganciclovir sodium ........... 35 GARDASIL 9 ................... 71 GASTROCROM .............. 58 gatifloxacin ...................... 75 GATTEX ......................... 58 gavilax ............................. 58 gavilyte-c ......................... 58 gavilyte-g......................... 58 gavilyte-h......................... 58 gavilyte-n with flavor pack 58 GAZYVA ......................... 29 GEBAUERS PAIN EASE 15 GEBAUERS SPRAY AND

STRETCH ................... 15 GELFILM......................... 77 GELNIQUE ..................... 61 GEL-ONE ........................ 73 GELSYN-3 ...................... 73 gemcitabine hcl ............... 29 gemfibrozil ....................... 40 GEN7T ............................ 15 GENERESS FE............... 66 generlac .......................... 58 gengraf ............................ 70 GENOTROPIN ................ 63 GENOTROPIN MINIQUICK

.................................... 63 gentak ............................. 75 gentamicin in saline ......... 18 gentamicin sulfate 18, 19, 75 GENTEEL LANCING KIT

(BLUE) ........................ 54 gentle laxative ................. 58 GENVISC 850 ................. 74 GENVOYA ...................... 35 GEODON ........................ 34 gianvi .............................. 66 GIAPREZA ...................... 40 GILENYA ........................ 44 GILOTRIF ....................... 29 GLASSIA......................... 81 glatiramer acetate ........... 44 glatopa ............................ 44 GLEEVEC ....................... 29 GLEOSTINE ................... 29 GLIADEL WAFER ........... 29 glimepiride ....................... 52 glipizide er ....................... 52 glipizide ir ........................ 52 glipizide xl ....................... 52 glipizide-metformin hcl..... 52 GLOPERBA .................... 27 GLUCAGEN DIAGNOSTIC

.................................... 74 GLUCAGEN HYPOKIT ... 54

96

GLUCAGON EMERGENCY KIT ............................... 54

GLUCAGON HCL (DIAGNOSTIC) ............ 74

GLUCOTROL .................. 52 GLUCOTROL XL ............. 52 GLUMETZA ..................... 52 glyburide .......................... 52 glyburide micronized ........ 52 glyburide-metformin ......... 53 GLYCATE ....................... 58 glycine ............................. 61 glycine urologic ................ 61 glycolax ........................... 59 glycopyrrolate .................. 59 GLYCOPYRROLATE ...... 59 glydo ............................... 15 GLYNASE ....................... 53 GLYSET .......................... 53 GLYXAMBI ...................... 53 gnp folic acid ................... 56 GOCOVRI ....................... 33 GOJJI CONTROL ............ 54 GOJJI LANCING

DEVICE/CLEAR CAP .. 54 GOLYTELY ..................... 59 GONITRO ....................... 40 goodsense aspirin low dose

.................................... 11 grafco silver nit applicator 49 GRALISE ......................... 45 GRALISE STARTER ....... 45 granisetron hcl ................. 25 GRANIX .......................... 37 GRASTEK ....................... 74 griseofulvin microsize ...... 26 griseofulvin ultramicrosize26 guanfacine hcl ................. 40 guanfacine hcl er ............. 44 GUANIDINE HCL ............ 28 GVOKE PFS.................... 54 GYNAZOLE-1 .................. 26 H HAEGARDA .................... 70 hailey 1.5/30 .................... 66 hailey 24 fe ...................... 66 HALAVEN ....................... 29 halcinonide ...................... 49 HALCION ........................ 37 HALDOL .......................... 34 HALDOL DECANOATE ... 34 halobetasol propionate .... 49 HALOBETASOL

PROPIONATE ............. 49 HALOG ............................ 49

haloperidol ...................... 34 haloperidol decanoate ..... 34 haloperidol lactate ........... 34 HARVONI ........................ 35 HAVRIX ........................... 71 heather ............................ 66 HECTOROL .................... 73 HEMABATE .................... 63 HEMANGEOL ................. 40 HEMLIBRA ...................... 37 hemmorex-hc .................. 72 HEMOFIL M .................... 38 HEPAGAM B ................... 70 heparin (porcine) in nacl .. 21 heparin lock flush ............ 74 heparin sod (porcine) in d5w

.................................... 21 heparin sodium (porcine) . 21 heparin sodium (porcine) pf

.................................... 21 heparin sodium lock flush 74 HEPLISAV-B ................... 71 HEPSERA ....................... 35 HERCEPTIN ................... 29 HESPAN ......................... 38 hetastarch-nacl ................ 38 HETLIOZ ......................... 83 HEXTEND ....................... 38 HIBERIX .......................... 71 HIDEX 6-DAY .................. 62 HIPREX ........................... 19 HIZENTRA ...................... 70 homatropaire ................... 78 homatropine hbr .............. 78 HORIZANT ...................... 45 HPR ................................ 49 HPR PLUS ...................... 49 HUMALOG ...................... 54 HUMALOG KWIKPEN ..... 54 HUMALOG MIX 50/50

KWIKPEN .................... 55 HUMALOG MIX 50/50 VIAL

.................................... 55 HUMALOG MIX 75/25

KWIKPEN .................... 55 HUMALOG MIX 75/25 VIAL

.................................... 55 HUMALOG U-100 JUNIOR

KWIKPEN .................... 55 HUMATE-P ..................... 38 HUMATROPE ................. 63 HUMIRA .......................... 70 HUMIRA PEDIATRIC

CROHNS START ........ 70 HUMIRA PEN .................. 70

HUMIRA PEN-CD/UC/HS STARTER ................... 70

HUMIRA PEN-PS/UV/ADOL HS START .................. 70

HUMULIN 70/30 KWIKPEN .................................... 55

HUMULIN 70/30 VIAL ..... 55 HUMULIN N KWIKPEN ... 55 HUMULIN N VIAL ........... 55 HUMULIN R U-500

KWIKPEN ................... 55 HUMULIN R U-500 VIAL

(CONCENTRATED) .... 55 HUMULIN R VIAL ........... 55 HYALGAN ....................... 74 HYCAMTIN ..................... 29 hydralazine hcl ................ 40 HYDREA ......................... 30 hydrochlorothiazide ......... 40 hydrocodone bitartrate er 13 hydrocodone polst-cpm

polst er ........................ 79 hydrocodone-

acetaminophen ............ 13 hydrocodone-homatropine

.................................... 79 hydrocodone-ibuprofen ... 13 hydrocortisone .... 49, 62, 72 hydrocortisone ace-

pramoxine ............. 49, 72 hydrocortisone acetate .... 72 hydrocortisone butyr lipo

base ............................ 49 hydrocortisone butyrate ... 49 hydrocortisone valerate ... 49 hydrocortisone-acetic acid

.................................... 79 hydromet ......................... 79 hydromorphone hcl ......... 13 HYDROMORPHONE HCL

.................................... 13 hydromorphone hcl er ..... 13 hydromorphone hcl pf ..... 13 hydroxychloroquine sulfate

.................................... 32 hydroxyprogesterone

caproate ...................... 66 hydroxyurea .................... 30 hydroxyzine hcl ............... 37 hydroxyzine pamoate ...... 37 HYLATOPIC PLUS ......... 49 HYLENEX ....................... 74 HYLINATE ...................... 49 hyophen .......................... 61 hyoscyamine sulfate ........ 59

97

hyoscyamine sulfate er .... 59 hyoscyamine sulfate sl .... 59 hyosyne ........................... 59 HYPERHEP B S/D .......... 70 HYPERRAB..................... 70 HYPERRAB S/D .............. 70 HYPERRHO S/D ............. 70 HYPERSAL ..................... 79 HYPERTET S/D .............. 70 HYPOCYN ...................... 78 HYQVIA ........................... 70 HYSINGLA ER ................ 13 HYZAAR .......................... 40 I ibandronate sodium ......... 73 IBRANCE ........................ 30 ibu ................................... 11 ibuprofen ......................... 11 ibuprofen lysine ............... 11 icatibant acetate .............. 70 ICLUSIG .......................... 30 idarubicin hcl ................... 30 IDELVION ....................... 38 IDHIFA ............................ 30 IFEX ................................ 30 ifosfamide ........................ 30 ILARIS ............................. 70 ILEVRO ........................... 76 ILUMYA ........................... 70 ILUVIEN .......................... 76 imatinib mesylate ............. 30 IMBRUVICA .................... 30 IMFINZI ........................... 30 imipenem-cilastatin .......... 19 imipramine hcl ................. 24 imipramine pamoate ........ 24 imiquimod ........................ 49 IMIQUIMOD PUMP ......... 49 IMITREX .......................... 27 IMITREX STATDOSE

REFILL ........................ 27 IMITREX STATDOSE

SYSTEM ...................... 27 IMLYGIC ......................... 30 IMOGAM RABIES-HT ..... 70 IMPAVIDO ....................... 32 IMPOYZ .......................... 49 IMURAN .......................... 70 IMVEXXY MAINTENANCE

PACK .......................... 66 IMVEXXY STARTER PACK

.................................... 66 INBRIJA .......................... 33 incassia ........................... 66 INCRELEX ...................... 63

INCRUSE ELLIPTA ......... 81 indapamide...................... 41 INDERAL LA ................... 41 INDERAL XL ................... 41 INDOCIN ......................... 11 indomethacin ................... 11 INDOMETHACIN............. 11 indomethacin er ............... 11 indomethacin sodium ...... 11 INFANRIX ....................... 71 INFASURF ...................... 79 INFED ............................. 74 INFLECTRA .................... 70 INFUMORPH 200............ 13 INFUMORPH 500............ 13 INGREZZA ...................... 45 INJECTAFER .................. 56 INLYTA ........................... 30 INNOPRAN XL ................ 41 INREBIC ......................... 30 INSPRA ........................... 41 INSULIN ASP PROT & ASP

FLEXPEN .................... 55 INSULIN ASPART ........... 55 INSULIN ASPART

FLEXPEN .................... 55 INSULIN ASPART PENFILL

.................................... 55 INSULIN ASPART PROT &

ASPART ...................... 55 INSULIN LISPRO ............ 55 INSULIN LISPRO (1 UNIT

DIAL) ........................... 55 INSULIN PEN NEEDLES 55 INSULIN SYRINGES ....... 55 INTELENCE .................... 35 INTERMEZZO ................. 83 INTRAROSA ................... 61 INTRON A ....................... 35 introvale .......................... 66 INTUNIV .......................... 44 INVANZ ........................... 19 INVEGA .......................... 34 INVEGA SUSTENNA ...... 34 INVEGA TRINZA ............. 34 INVELTYS ....................... 76 INVIRASE ....................... 35 INVOKAMET ................... 53 INVOKAMET XR ............. 53 INVOKANA...................... 53 iodine strong .................... 56 IOPIDINE ........................ 77 IPOL ................................ 71 ipratropium bromide .. 79, 81 ipratropium-albuterol ....... 81

irbesartan ........................ 41 irbesartan-

hydrochlorothiazide ..... 41 IRESSA ........................... 30 irinotecan hcl ................... 30 ISENTRESS .................... 35 ISENTRESS HD .............. 35 isibloom ........................... 66 isoniazid .......................... 28 isoproterenol hcl .............. 41 ISOPTO CARPINE .......... 77 ISORDIL TITRADOSE .... 41 isosorbide dinitrate .......... 41 isosorbide mononitrate .... 41 isosorbide mononitrate er 41 isotretinoin ....................... 49 isradipine......................... 41 ISTALOL ......................... 77 ISTODAX (OVERFILL) .... 30 ISUPREL......................... 41 itraconazole ..................... 26 ivermectin.................. 32, 49 IXEMPRA KIT ................. 30 IXINITY ........................... 38 J JADENU ......................... 56 JADENU SPRINKLE ....... 56 jaimiess ........................... 66 JAKAFI ............................ 30 JALYN ............................. 61 jantoven .......................... 21 JANUMET ....................... 53 JANUMET XR ................. 53 JANUVIA ......................... 53 JARDIANCE .................... 53 jasmiel ............................. 66 JATENZO........................ 63 jencycla ........................... 66 JENTADUETO ................ 53 JENTADUETO XR .......... 53 JETREA .......................... 78 JEVTANA ........................ 30 jinteli ................................ 66 jolessa ............................. 66 JORNAY PM ................... 44 JUBLIA ............................ 26 juleber ............................. 66 JULUCA .......................... 35 junel 1.5/30 ..................... 66 junel 1/20 ........................ 66 junel fe 1.5/30 ................. 66 junel fe 1/20 .................... 66 junel fe 24 ....................... 66 JUXTAPID ....................... 41 JYNARQUE .................... 56

98

K KADCYLA ....................... 30 KADIAN ........................... 13 kaitlib fe ........................... 66 KALBITOR ...................... 70 KALETRA ........................ 35 kalliga .............................. 66 KALYDECO ..................... 82 KAMDOY ......................... 49 KANUMA ......................... 60 KAPSPARGO SPRINKLE41 KAPVAY .......................... 44 KARBINAL ER ................. 79 kariva .............................. 66 KATERZIA ....................... 41 KAZANO ......................... 53 KCENTRA ....................... 38 KEDRAB ......................... 70 KEFLEX .......................... 19 kelnor 1/35 ...................... 66 kelnor 1/50 ...................... 66 KENALOG ................. 49, 62 KEPIVANCE .................... 45 KEPPRA .......................... 22 KEPPRA XR .................... 22 KERYDIN ........................ 26 ketoconazole ................... 26 ketodan ........................... 26 ketoprofen ....................... 11 ketoprofen er ................... 11 ketorolac tromethamine .. 11,

76 KETOROLAC

TROMETHAMINE ....... 11 KEVEYIS ......................... 77 KEVZARA ....................... 70 KEYTRUDA ..................... 30 KHAPZORY..................... 30 KINERET ......................... 70 KINRIX ............................ 71 kionex .............................. 56 KISQALI (200 MG DOSE)30 KISQALI (400 MG DOSE)30 KISQALI (600 MG DOSE)30 KISQALI FEMARA (400 MG

DOSE) ......................... 30 KISQALI FEMARA (600 MG

DOSE) ......................... 30 KISQALI FEMARA(200 MG

DOSE) ......................... 30 KITABIS PAK .................. 82 KIVIK ............................... 49 KLARITY-A ...................... 76 KLARITY-B ...................... 76 KLARITY-L ...................... 76

KLARON ......................... 49 KLONOPIN...................... 37 klor-con ........................... 56 klor-con 10 ...................... 56 klor-con m10 ................... 56 KLOR-CON M15 ............. 56 klor-con m20 ................... 56 klor-con sprinkle .............. 56 klor-con/ef ....................... 56 KOATE ............................ 38 KOATE-DVI ..................... 38 KOGENATE FS ............... 38 KOMBIGLYZE XR ........... 53 KORLYM ......................... 64 KOVALTRY ..................... 38 K-PHOS .......................... 56 K-PHOS NO 2 ................. 56 k-prime ............................ 56 KRINTAFEL .................... 32 KRISTALOSE .................. 59 KRYSTEXXA ................... 27 K-TAB ............................. 56 kurvelo ............................ 66 KUVAN ............................ 60 KYLEENA ....................... 66 KYMRIAH ........................ 70 KYPROLIS ...................... 30 L labetalol hcl ..................... 41 LACRISERT .................... 78 lactic acid ........................ 49 lactic acid e ..................... 49 lactulose .......................... 59 lactulose encephalopathy 59 LAMICTAL....................... 22 LAMICTAL ODT .............. 22 LAMICTAL STARTER ..... 22 LAMICTAL XR ................. 22 lamivudine ....................... 35 lamivudine-zidovudine ..... 35 lamotrigine....................... 22 lamotrigine er .................. 22 lamotrigine starter kit-blue22 lamotrigine starter kit-green

.................................... 22 lamotrigine starter kit-

orange ......................... 22 LANCETS ....................... 54 LANOXIN ........................ 41 LANOXIN PEDIATRIC .... 41 lansoprazole .................... 58 lanthanum carbonate ....... 61 LANTUS SOLOSTAR ...... 55 LANTUS U-100 VIAL ....... 55 larin 1.5/30 ...................... 66

larin 1/20 ......................... 66 larin 24 fe ........................ 66 larin fe 1.5/30 .................. 66 larin fe 1/20 ..................... 66 larissia ............................. 66 LARTRUVO .................... 30 LASIX .............................. 41 LASTACAFT ................... 78 latanoprost ...................... 77 LATANOPROST-TIMOLOL

MALEATE ................... 77 LATUDA .......................... 34 layolis fe .......................... 66 LAZANDA ....................... 14 LDO PLUS ...................... 15 LEDIPASVIR-

SOFOSBUVIR ............. 35 leena ............................... 66 leflunomide ...................... 70 LEMTRADA .................... 44 LENVIMA (10 MG DAILY

DOSE) ......................... 30 LENVIMA (12 MG DAILY







DOSE) ......................... 30 LESCOL XL .................... 41 lessina ............................. 66 LETAIRIS ........................ 82 letrozole .......................... 30 leucovorin calcium ........... 30 LEUKERAN ..................... 30 LEUKINE......................... 38 leuprolide acetate ............ 63 levalbuterol hcl ................ 81 LEVALBUTEROL HFA .... 81 LEVAQUIN ...................... 19 LEVATIO ......................... 15 LEVEMIR U-100

FLEXTOUCH .............. 55 LEVEMIR U-100 VIAL ..... 55 levetiracetam ................... 22 levetiracetam er............... 22 levetiracetam in nacl ....... 22 levobunolol hcl ................ 77

99

levocarnitine .................... 56 levocarnitine sf ................ 56 levocetirizine

dihydrochloride ............ 79 levofloxacin ............... 19, 76 levofloxacin in d5w .......... 19 levoleucovorin calcium .... 30 levoleucovorin calcium pf. 30 levonest ........................... 66 levonorgest-eth est & eth

est ............................... 66 levonorgest-eth estrad 91-

day .............................. 66 levonorgestrel .................. 66 levonorgestrel-ethinyl estrad

.................................... 66 levonorg-eth estrad triphasic

.................................... 66 levora 0.15/30 (28) .......... 66 levorphanol tartrate.......... 14 levo-t ............................... 68 levothyroxine sodium ....... 68 levoxyl ............................. 68 LEVSIN ........................... 59 LEVULAN KERASTICK ... 49 LEXAPRO ....................... 24 LEXETTE ........................ 49 LEXIVA ............................ 35 LIALDA ............................ 72 LIBRAX ........................... 59 lidocaine .......................... 15 lidocaine hcl .............. 15, 45 LIDOCAINE HCL ............. 15 lidocaine hcl (pf) .............. 15 lidocaine hcl

urethral/mucosal .......... 15 lidocaine viscous hcl ........ 45 lidocaine-epinephrine ...... 15 lidocaine-hydrocortisone

ace .............................. 72 LIDOCAINE-

HYDROCORTISONE ACE ............................. 49

lidocaine-prilocaine .......... 15 LIDODERM ..................... 15 lidopin .............................. 15 LIDORX ........................... 15 LIDO-SORB..................... 15 LIDOTHOL ...................... 15 LIDOTRAL ....................... 15 LIDOTREX ...................... 49 LIDOZION ....................... 15 LILETTA (52 MG) ............ 66 lillow ................................ 66 LINCOCIN ....................... 19

lincomycin hcl .................. 19 lindane ............................ 32 linezolid ........................... 19 linezolid in sodium chloride

.................................... 19 LINZESS ......................... 59 LIORESAL....................... 83 liothyronine sodium ......... 69 LIPITOR .......................... 41 LIPOFEN ......................... 41 lisinopril ........................... 41 lisinopril-hydrochlorothiazide

.................................... 41 lithium .............................. 37 lithium carbonate ............. 37 lithium carbonate er ......... 37 LITHOBID ....................... 37 LITHOSTAT .................... 61 LIVALO ........................... 41 LO LOESTRIN FE ........... 66 LOCOID .......................... 49 LOCOID LIPOCREAM .... 49 LODINE ........................... 11 LODOSYN....................... 33 LOESTRIN 1.5/30 (21) .... 66 LOESTRIN 1/20 (21) ....... 66 LOESTRIN FE 1.5/30 ...... 66 LOESTRIN FE 1/20 ......... 66 lojaimiess ........................ 66 LOKELMA ....................... 57 LOMOTIL ........................ 59 LONHALA MAGNAIR

REFILL KIT ................. 81 LONHALA MAGNAIR

STARTER KIT ............. 81 LONSURF ....................... 30 loperamide hcl ................. 59 LOPID ............................. 41 lopinavir-ritonavir ............. 35 lopreeza .......................... 66 LOPRESSOR .................. 41 LOPRESSOR HCT .......... 41 LOPROX ......................... 26 lorazepam ....................... 37 lorazepam intensol .......... 37 LORBRENA .................... 30 lorcet ............................... 14 lorcet hd .......................... 14 lorcet plus ........................ 14 LORTAB .......................... 14 loryna .............................. 66 LORZONE ....................... 83 losartan potassium .......... 41 losartan potassium-hctz... 41 LOSEASONIQUE ............ 67

LOTEMAX ....................... 76 LOTEMAX SM ................ 76 LOTENSIN ...................... 41 LOTENSIN HCT .............. 41 loteprednol etabonate ..... 76 LOTREL .......................... 41 LOTRISONE ................... 26 LOTRONEX .................... 59 lovastatin ......................... 41 LOVAZA .......................... 41 LOVENOX ....................... 21 low-ogestrel ..................... 67 loxapine succinate ........... 34 lo-zumandimine ............... 67 LUCEMYRA .................... 16 LUCENTIS ...................... 78 ludent .............................. 57 LULICONAZOLE ............. 26 LUMIGAN........................ 77 LUMIZYME ..................... 60 LUNESTA ....................... 83 LUPRON DEPOT (1-

MONTH) ...................... 63 LUPRON DEPOT (3-

MONTH) ...................... 64 LUPRON DEPOT (4-

MONTH) INTRAMUSCULAR KIT 30MG .......................... 64

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 64

LUPRON DEPOT-PED (1-MONTH) ...................... 64

LUPRON DEPOT-PED (3-MONTH) ...................... 64

LUTATHERA ................... 30 lutera ............................... 67 LUXIQ ............................. 49 LUXTURNA ..................... 78 LUZU .............................. 26 LYNPARZA ..................... 30 LYRICA ........................... 45 LYRICA CR ..................... 45 LYSODREN .................... 30 LYSTEDA........................ 38 lyza ................................. 67 M MACROBID ..................... 19 MACRODANTIN ............. 19 MACUGEN ...................... 78 mafenide acetate ............. 19 magnesium citrate ........... 59 MAKENA ......................... 67

100

MALARONE .................... 32 malathion ......................... 32 maprotiline hcl ................. 24 marlissa ........................... 67 MARPLAN ....................... 24 MARQIBO ....................... 30 MASK VORTEX .............. 74 MATULANE ..................... 30 matzim la ......................... 41 MAVENCLAD (10 TABS). 45 MAVENCLAD (4 TABS) .. 45 MAVENCLAD (5 TABS) .. 45 MAVENCLAD (6 TABS) .. 45 MAVENCLAD (7 TABS) .. 45 MAVENCLAD (8 TABS) .. 45 MAVENCLAD (9 TABS) .. 45 MAVYRET ....................... 35 MAXALT .......................... 27 MAXALT-MLT .................. 27 MAXICOMFORT SYR 27G

X 1/2 ............................ 55 MAXIDEX ........................ 76 MAXITROL ...................... 78 MAXZIDE ........................ 41 MAXZIDE-25 ................... 41 MAYZENT ....................... 45 MAYZENT STARTER

PACK .......................... 45 me/naphos/mb/hyo1 ........ 61 meclizine hcl .................... 25 meclofenamate sodium ... 11 MEDI-PATCH RX ............ 15 medique aspirin ............... 11 MEDROL ......................... 62 medroxyprogesterone

acetate ........................ 67 mefenamic acid ............... 12 mefloquine hcl ................. 32 MEGACE ES ................... 67 megestrol acetate ............ 67 MEKINIST ....................... 30 MEKTOVI ........................ 30 melodetta 24 fe ................ 67 meloxicam ....................... 12 melphalan ........................ 30 melphalan hcl .................. 30 memantine hcl ................. 23 memantine hcl er ............. 23 MENACTRA .................... 71 MENEST ......................... 67 MENOSTAR .................... 67 MENVEO ......................... 71 meperidine hcl ................. 14 MEPHYTON .................... 57 meprobamate .................. 37

MEPRON ........................ 32 MEPSEVII ....................... 60 mercaptopurine ............... 30 meropenem ..................... 19 MEROPENEM-SODIUM

CHLORIDE .................. 19 mesalamine ..................... 72 mesalamine er ................. 72 mesalamine-cleanser ...... 72 mesna ............................. 30 MESNEX ......................... 30 MESTINON ..................... 28 metadate er ..................... 44 metaproterenol sulfate ..... 81 metaxalone...................... 83 metformin hcl er .............. 53 metformin hcl er (mod) .... 53 metformin hcl er (osm) .... 53 metformin hcl ir ................ 53 METFORMIN HCL IR ...... 53 methadone hcl ................. 14 methadone hcl intensol ... 14 methadose ...................... 14 methadose sugar-free ..... 14 methamphetamine hcl ..... 44 methazolamide ................ 77 methenamine hippurate ... 19 methenamine mandelate . 19 methergine ...................... 74 methimazole .................... 69 METHITEST .................... 63 methocarbamol ............... 83 methotrexate ................... 70 methotrexate sodium ....... 70 methotrexate sodium (pf) . 70 methoxsalen rapid ........... 49 methscopolamine bromide

.................................... 59 methyldopa...................... 41 methyldopa-

hydrochlorothiazide ..... 41 methylergonovine maleate

.................................... 74 METHYLIN ...................... 44 methylphenidate hcl ........ 44 methylphenidate hcl er .... 44 methylphenidate hcl er (cd)

.................................... 44 methylphenidate hcl er (la)

.................................... 44 methylprednisolone ......... 62 methylprednisolone acetate

.................................... 62 methylprednisolone sodium

succ ............................. 62

methyltestosterone .......... 63 metoclopramide hcl ......... 25 metolazone ..................... 41 metoprolol succinate er ... 41 metoprolol tartrate ........... 41 metoprolol-

hydrochlorothiazide ..... 41 METROCREAM .............. 49 METROGEL .................... 49 METROLOTION .............. 49 metronidazole ........... 19, 49 metronidazole in nacl ...... 19 mexiletine hcl .................. 41 MIACALCIN .................... 73 mibelas 24 fe ................... 67 MICARDIS ...................... 41 MICARDIS HCT .............. 41 miconazole 3 ................... 26 MICONAZOLE-ZINC

OXIDE-PETROLAT ..... 26 MICRHOGAM ULTRA-

FILTERED PLUS......... 70 MICROCHAMBER .......... 74 MICRODOT PEN NEEDLE

.................................... 55 microgestin 1.5/30 ........... 67 microgestin 1/20 .............. 67 microgestin fe 1.5/30 ....... 67 microgestin fe 1/20 .......... 67 MICROLET NEXT

LANCING DEVICE ...... 54 midazolam hcl ................. 37 midazolam hcl (pf) ........... 37 midodrine hcl ................... 41 MIFEPREX ...................... 57 mifepristone .................... 57 MIGERGOT .................... 27 miglitol ............................. 53 miglustat ......................... 60 MIGRANAL ..................... 27 mili .................................. 67 MILLIPRED ..................... 62 MILLIPRED DP ............... 62 MILLIPRED DP 12-DAY .. 62 milrinone lactate .............. 41 milrinone lactate in dextrose

.................................... 41 mimvey ........................... 67 MIMYX ............................ 49 MINASTRIN 24 FE .......... 67 MINIPRESS .................... 41 minitran ........................... 41 MINIVELLE ..................... 67 MINOCIN ........................ 19 minocycline hcl ................ 19

101

minocycline hcl er ............ 19 MINOLIRA ....................... 19 minoxidil .......................... 41 MIRAPEX ........................ 33 MIRAPEX ER .................. 33 MIRCERA ........................ 38 MIRCETTE ...................... 67 MIRENA (52 MG) ............ 67 mirtazapine ...................... 24 MIRVASO ........................ 49 misoprostol ...................... 58 MITIGARE ....................... 27 mitigo .............................. 14 mitomycin ........................ 30 mitoxantrone hcl .............. 30 M-M-R II .......................... 71 MOBIC ............................ 12 modafinil .......................... 83 moexipril hcl .................... 41 molindone hcl .................. 34 mometasone furoate .. 49, 79 mondoxyne nl .................. 19 mono-linyah ..................... 67 MONONINE..................... 38 MONOVISC ..................... 74 montelukast sodium ......... 81 MONUROL ...................... 19 morgidox ......................... 19 MORPHABOND ER ........ 14 morphine sulfate .............. 14 MORPHINE SULFATE .... 14 morphine sulfate

(concentrate) ............... 14 morphine sulfate (pf) ........ 14 morphine sulfate er .......... 14 morphine sulfate er beads

.................................... 14 MOTEGRITY ................... 59 MOTOFEN ...................... 59 MOVANTIK ..................... 59 MOVIPREP ..................... 59 MOXEZA ......................... 76 moxifloxacin hcl ......... 19, 76 MOXIFLOXACIN HCL ..... 19 moxifloxacin hcl (2x day) . 76 moxifloxacin hcl in nacl .... 19 MOZOBIL ........................ 38 MS CONTIN .................... 14 MUCOSITISRX ............... 45 MULPLETA ..................... 38 MULTAQ ......................... 41 multi prenatal ................... 57 mupirocin ......................... 19 mupirocin calcium ............ 19 mutamycin ....................... 30

MYALEPT ....................... 60 MYAMBUTOL ................. 28 MYCAMINE ..................... 26 MYCOBUTIN ................... 28 mycophenolate mofetil .... 70 mycophenolate mofetil hcl

.................................... 70 mycophenolate sodium ... 70 MYDAYIS ........................ 44 MYFORTIC ..................... 70 MYLERAN ....................... 30 MYLOTARG .................... 31 MYOBLOC ...................... 74 myorisan ......................... 49 MYRBETRIQ ................... 61 MYSOLINE...................... 22 MYTESI ........................... 59 N na ferric gluc cplx in sucrose

.................................... 57 NABI-HB ......................... 70 nabumetone .................... 12 nadolol ............................ 41 nafcillin sodium ................ 19 NAFCILLIN SODIUM IN

DEXTROSE................. 19 nafrinse ........................... 57 nafrinse drops ................. 57 naftifine hcl ...................... 26 NAFTIN ........................... 26 NAGLAZYME .................. 60 nalbuphine hcl ................. 14 NALFON ......................... 12 NALOCET ....................... 14 naloxone hcl .................... 16 NALOXONE HCL ............ 16 naltrexone hcl .................. 16 NAMENDA ...................... 23 NAMENDA TITRATION

PAK ............................. 23 NAMENDA XR ................ 23 NAMENDA XR TITRATION

PACK .......................... 23 NAMZARIC ..................... 23 NAPRELAN ..................... 12 NAPROSYN .................... 12 naproxen ......................... 12 naproxen dr ..................... 12 naproxen sodium ............. 12 naproxen sodium er ......... 12 naproxen-esomeprazole .. 12 naratriptan hcl ................. 27 NARCAN ......................... 16 NARDIL ........................... 24 NASONEX....................... 79

NATACYN ....................... 76 NATAZIA ......................... 67 nateglinide ....................... 53 NATESTO ....................... 63 NATPARA ....................... 73 NATROBA ....................... 32 NATURE-THROID .......... 69 NAYZILAM ...................... 22 NEBUPENT .................... 32 nebusal ........................... 79 NEBUSAL ....................... 79 necon 0.5/35 (28) ............ 67 nefazodone hcl ................ 24 NEMBUTAL .................... 22 NEOCERA ...................... 49 neomycin sulfate ............. 19 neomycin-bacitracin zn-

polymyx ....................... 78 neomycin-polymyxin b gu 19 neomycin-polymyxin-

dexameth .................... 78 neomycin-polymyxin-

gramicidin .................... 78 neomycin-polymyxin-hc .. 78,

79 neo-polycin ...................... 78 neo-polycin hc ................. 78 NEORAL ......................... 70 NEOSALUS .................... 49 NEOSALUS CP............... 49 neostigmine methylsulfate

.................................... 28 NEO-SYNALAR .............. 50 NERLYNX ....................... 31 NESINA .......................... 53 neuac .............................. 50 NEULASTA ..................... 38 NEULASTA ONPRO ....... 38 NEUPOGEN ................... 38 NEUPRO......................... 33 NEURONTIN ................... 22 NEUTRASAL .................. 45 NEVANAC ....................... 76 nevirapine ....................... 35 nevirapine er ................... 35 NEXAVAR ....................... 31 NEXIUM .......................... 58 NEXPLANON .................. 67 niacin (antihyperlipidemic)

.................................... 41 niacin er

(antihyperlipidemic) ..... 41 niacor .............................. 41 NIASPAN ........................ 41 nicardipine hcl ................. 41

102

NICORETTE.................... 16 nicotine polacrilex ............ 16 nicotine step 1 ................. 16 nicotine step 2 ................. 16 nicotine step 3 ................. 16 NICOTROL ...................... 16 NICOTROL NS ................ 16 nifedipine ......................... 42 nifedipine er ..................... 41 nifedipine er osmotic

release ........................ 41 nikki ................................. 67 NILANDRON ................... 31 nilutamide ........................ 31 nimodipine ....................... 42 NINLARO ........................ 31 NIPENT ........................... 31 nisoldipine er ................... 42 nitisinone ......................... 60 NITRO-BID ...................... 42 NITRO-DUR .................... 42 nitrofurantoin ................... 19 nitrofurantoin macrocrystal

.................................... 19 nitrofurantoin monohydrate

macrocrystals .............. 19 nitroglycerin ..................... 42 NITROLINGUAL .............. 42 NITROMIST..................... 42 NITROSTAT .................... 42 nitro-time ......................... 42 NITYR ............................. 60 NIVATOPIC PLUS ........... 50 NIVESTYM ...................... 38 nizatidine ......................... 58 NIZORAL ......................... 26 NOCDURNA.................... 64 NOCTIVA ........................ 64 nolix ................................. 50 nora-be ............................ 67 NORCO ........................... 14 NORDITROPIN FLEXPRO

.................................... 64 norethin ace-eth estrad-fe 67 norethindrone .................. 67 norethindrone acetate ...... 67 norethindrone acet-ethinyl

est ............................... 67 norethindrone-eth estradiol

.................................... 67 norethin-eth estradiol-fe ... 67 NORGESIC FORTE ........ 83 norgestimate-eth estradiol

.................................... 67

norgestimate-ethinyl estradiol triphasic ........ 67

NORITATE ...................... 50 norlyda ............................ 67 norlyroc ........................... 67 NORPACE ...................... 42 NORPACE CR ................ 42 NORPRAMIN .................. 24 NORTHERA .................... 42 nortrel 0.5/35 (28) ............ 67 nortrel 1/35 (21) ............... 67 nortrel 1/35 (28) ............... 67 nortrel 7/7/7 ..................... 67 nortriptyline hcl ................ 24 NORVASC ...................... 42 NORVIR .......................... 35 NOURIANZ ..................... 33 NOVACORT .................... 50 NOVOEIGHT ................... 38 NOVOFINE AUTOCOVER

PEN NEEDLE .............. 55 NOVOFINE PEN NEEDLE

.................................... 55 NOVOFINE PLUS PEN

NEEDLE ...................... 55 NOVOLIN 70/30 RELION 55 NOVOLIN 70/30 VIAL ..... 55 NOVOLIN N RELION ...... 55 NOVOLIN N VIAL ............ 55 NOVOLIN R RELION ...... 55 NOVOLIN R VIAL ............ 55 NOVOLOG FLEXPEN ..... 55 NOVOLOG MIX 70/30

FLEXPEN .................... 55 NOVOLOG MIX 70/30 VIAL

.................................... 55 NOVOLOG PENFILL ....... 55 NOVOLOG U-100 VIAL ... 55 NOVOSEVEN RT ............ 38 NOVOTWIST PEN

NEEDLE ...................... 56 NOXAFIL ......................... 26 np thyroid ........................ 69 NPLATE .......................... 38 NUBEQA ......................... 31 NUCALA ......................... 79 NUCORT ......................... 50 NUCYNTA ....................... 14 NUCYNTA ER ................. 14 NUEDEXTA ..................... 45 nulev ............................... 59 NULOJIX ......................... 70 NULYTELY WITH FLAVOR

PACKS ........................ 59 NUPLAZID ...................... 34

NUTROPIN AQ NUSPIN 10 .................................... 64



NUVARING ..................... 67 NUVESSA ....................... 19 NUVIGIL ......................... 83 NUWIQ ........................... 38 NUZYRA ......................... 19 nyamyc ........................... 26 NYMALIZE ...................... 42 nystatin ........................... 26 nystatin-triamcinolone ..... 26 nystop ............................. 26 O OBIZUR .......................... 38 OCALIVA ........................ 60 ocella .............................. 67 OCREVUS ...................... 45 OCTAGAM ...................... 70 octreotide acetate ............ 64 OCUFLOX ....................... 76 ODACTRA ...................... 74 ODEFSEY ....................... 35 ODOMZO ........................ 31 OFEV .............................. 81 ofloxacin .............. 19, 76, 79 ogestrel ........................... 67 okebo .............................. 19 olanzapine ....................... 34 olanzapine-fluoxetine hcl . 24 olmesartan medoxomil .... 42 olmesartan medoxomil-hctz

.................................... 42 olmesartan-amlodipine-hctz

.................................... 42 olopatadine hcl .......... 76, 79 OLUMIANT ..................... 70 OLUX .............................. 50 OLUX-E .......................... 50 OMECLAMOX-PAK ........ 59 omega-3-acid ethyl esters42 omeprazole ..................... 58 OMEPRAZOLE+SYRSPEN

D SF ALKA .................. 58 omeprazole-sodium

bicarbonate ................. 58 OMIDRIA......................... 78 OMNARIS ....................... 80 OMNIPOD 5 PACK ......... 74 OMNIPOD DASH 5 PACK

.................................... 74

103

OMNIPOD DASH SYSTEM .................................... 54

OMNIPOD STARTER ...... 54 OMNITROPE ................... 64 ONCASPAR .................... 31 ondansetron hcl ............... 25 ondansetron odt .............. 25 ONE-A-DAY WOMENS

PRENATAL 1............... 57 ONETOUCH DELICA

LANCING DEV ............ 54 ONETOUCH DELICA PLUS

LANCING .................... 54 ONETOUCH ULTRA BLUE

TEST STRIPS ............. 54 ONETOUCH VERIO KIT

W/DEVICE ................... 54 ONEXTON ...................... 50 ONFI ............................... 22 ONGLYZA ....................... 53 ONIVYDE ........................ 31 OPANA ............................ 14 OPDIVO .......................... 31 opium .............................. 59 OPSUMIT ........................ 82 OPTIONS CONCEPTROL

.................................... 74 ORACEA ......................... 50 ORACIT ........................... 57 ORALAIR ........................ 74 ORALAIR ADULT SAMPLE

KIT ............................... 74 ORALAIR ADULT

STARTER PACK ......... 74 ORALAIR CHILDRENS

SAMPLE KIT ............... 74 ORALAIR CHILDRENS

STARTER PACK ......... 74 oralone ............................ 45 ORAPRED ODT .............. 62 ORAVIG .......................... 26 ORBACTIV ...................... 19 ORENCIA ........................ 70 ORENCIA CLICKJECT .... 70 ORENITRAM ................... 82 ORFADIN ........................ 60 ORILISSA ........................ 64 ORKAMBI ........................ 82 orphenadrine citrate ......... 83 orphenadrine citrate er .... 83 orphenadrine-aspirin-

caffeine ........................ 83 ORPHENGESIC FORTE . 83 orsythia ............................ 67 ORTHO MICRONOR ....... 67

ORTHO TRI-CYCLEN LO67 ORTHO-NOVUM 1/35 (28)

.................................... 67 ORTHO-NOVUM 7/7/7 (28)

.................................... 67 ORTHOVISC ................... 74 oscimin ............................ 59 oscimin sr ........................ 59 oseltamivir phosphate ..... 35 OSENI ............................. 53 OSMOLEX ER ................ 33 OSMOPREP ................... 59 OSPHENA....................... 63 OTEZLA .......................... 70 OTIPRIO ......................... 79 OTOVEL ......................... 79 OTREXUP ....................... 70 OVACE PLUS ................. 50 OVIDE ............................. 32 oxacillin sodium ............... 19 OXACILLIN SODIUM IN

DEXTROSE................. 19 oxaliplatin ........................ 31 oxandrolone .................... 63 oxaprozin ........................ 12 OXAYDO ......................... 14 oxazepam ....................... 37 OXBRYTA ....................... 74 oxcarbazepine ................. 22 OXERVATE ..................... 78 oxiconazole nitrate .......... 26 OXISTAT ......................... 26 OXSORALEN ULTRA ..... 50 OXTELLAR XR ............... 22 oxybutynin chloride .......... 61 oxybutynin chloride er ..... 61 oxycodone hcl ................. 14 OXYCODONE HCL ER ... 14 oxycodone-acetaminophen

.................................... 14 oxycodone-aspirin ........... 14 oxycodone-ibuprofen ....... 14 OXYCONTIN ................... 14 oxymorphone hcl ............. 14 oxymorphone hcl er ......... 14 OXYTROL ....................... 61 OZEMPIC ........................ 53 OZOBAX ......................... 83 OZURDEX....................... 76 P pacerone ......................... 42 paclitaxel ......................... 31 PALFORZIA (12 MG DAILY

DOSE) ......................... 74

PALFORZIA (120 MG DAILY DOSE) ............. 74


PALFORZIA (20 MG DAILY DOSE) ......................... 74




PALFORZIA (300 MG MAINTENANCE) ......... 74

PALFORZIA (300 MG TITRATION) ................ 74




PALFORZIA INITIAL ESCALATION ............. 74

paliperidone er ................ 34 palonosetron hcl .............. 25 PALYNZIQ ...................... 60 PAMELOR ...................... 24 pamidronate disodium ..... 73 PANCREAZE .................. 60 PANDA MASK LARGE .... 74 PANDA MASK MEDIUM . 74 PANDA MASK SMALL .... 74 PANDEL ......................... 50 PANHEMATIN ................ 38 PANRETIN ...................... 31 pantoprazole sodium ....... 58 papaverine hcl ................. 42 PARAGARD

INTRAUTERINE COPPER ..................... 67

paraplatin ........................ 31 paregoric ......................... 59 paricalcitol ....................... 73 PARLODEL ..................... 33 PARNATE ....................... 24 paroex ............................. 45 paromomycin sulfate ....... 19 paroxetine hcl .................. 24 paroxetine hcl er.............. 24 paroxetine mesylate ........ 24 PARSABIV ...................... 73 PASER ............................ 28 PATANASE ..................... 80 PAXIL .............................. 24

104

PAXIL CR ........................ 24 PAZEO ............................ 76 PEDIAPRED.................... 62 PEDIARIX ....................... 71 PEDIATRIC PANDA MASK

.................................... 74 PEDVAX HIB ................... 71 peg 3350-kcl-na bicarb-nacl

.................................... 59 peg-3350/electrolytes ...... 59 PEGANONE .................... 22 PEGASYS ....................... 35 PEGASYS PROCLICK .... 35 PEGINTRON ................... 35 peg-prep .......................... 59 penicillamine.................... 61 PENICILLIN G POT IN

DEXTROSE ................. 19 penicillin g potassium ...... 19 penicillin g procaine ......... 20 penicillin g sodium ........... 20 penicillin v potassium ....... 20 PENLEN .......................... 50 PENNSAID ...................... 12 PENTACEL ..................... 71 PENTAM ......................... 32 pentamidine isethionate ... 32 PENTASA ....................... 72 pentazocine-naloxone hcl 14 pentobarbital sodium ....... 22 PENTOSAN

POLYSULFATE SODIUM .................................... 61

pentoxifylline er ............... 42 PEPCID ........................... 58 PERCOCET .................... 14 PERFOROMIST .............. 81 perindopril erbumine ........ 42 periogard ......................... 45 PERJETA ........................ 31 permethrin ....................... 32 perphenazine................... 25 perphenazine-amitriptyline

.................................... 24 PERSERIS ...................... 34 PERTZYE ........................ 60 PEXEVA .......................... 24 phenadoz ........................ 80 phenazo .......................... 61 phenazopyridine hcl ......... 61 phenelzine sulfate ........... 24 PHENERGAN .................. 80 phenobarbital................... 22 phenobarbital sodium ...... 22 phenoxybenzamine hcl .... 42

phentolamine mesylate ... 42 phenylephrine hcl ............ 78 PHENYTEK ..................... 22 phenytoin ........................ 22 phenytoin infatabs ........... 22 phenytoin sodium ............ 23 phenytoin sodium extended

.................................... 22 philith............................... 67 PHLAG SPRAY ............... 50 PHOSLYRA ..................... 61 phospha 250 neutral ........ 57 phosphasal ...................... 61 PHOSPHOLINE IODIDE . 77 phosphorous ................... 57 phospho-trin 250 neutral.. 57 PHOTOFRIN ................... 31 PHYSIOLYTE .................. 57 PHYSIOSOL IRRIGATION

.................................... 57 phytonadione ................... 57 PICATO ........................... 50 PIFELTRO....................... 35 pilocarpine hcl ........... 45, 77 pimecrolimus ................... 50 PIMECROLIMUS............. 50 pimozide .......................... 34 pimtrea ............................ 67 pindolol ............................ 42 pioglitazone hcl ............... 53 pioglitazone hcl-glimepiride

.................................... 53 pioglitazone hcl-metformin

hcl ............................... 53 piperacillin sod-tazobactam

so ................................ 20 PIQRAY (200 MG DAILY

DOSE) ......................... 31 PIQRAY (250 MG DAILY

DOSE) ......................... 31 PIQRAY (300 MG DAILY

DOSE) ......................... 31 pirmella 1/35 .................... 67 pirmella 7/7/7 ................... 67 piroxicam ......................... 12 PLAN B ONE-STEP ........ 67 PLAQUENIL .................... 32 PLAVIX ........................... 33 PLEGRIDY ...................... 45 PLEGRIDY STARTER

PACK .......................... 45 PLENVU .......................... 59 PLEXION CLEANSING

CLOTH ........................ 50 PNEUMOVAX 23 ............ 71

pocket spacer .................. 74 podocon .......................... 50 podofilox ......................... 50 polycin ............................. 78 polymyxin b sulfate .......... 20 polymyxin b-trimethoprim 78 POLYTRIM ...................... 78 POMALYST .................... 31 portia-28 .......................... 68 PORTRAZZA .................. 31 posaconazole .................. 26 pot bicarb-pot chloride ..... 57 potassium bicarbonate .... 57 potassium chloride .......... 57 potassium chloride crys er

.................................... 57 potassium chloride er ...... 57 potassium citrate er ......... 57 potassium citrate-citric acid

.................................... 57 POTELIGEO ................... 31 POVIDONE-IODINE ........ 76 PRADAXA ....................... 21 PRALUENT ..................... 42 pramipexole dihydrochloride

.................................... 33 pramipexole dihydrochloride

er ................................. 33 PRAMOSONE ................. 50 PRAMOTIC ..................... 79 pramox ............................ 50 prasugrel hcl ................... 33 PRAVACHOL .................. 42 pravastatin sodium .......... 42 praziquantel .................... 32 prazosin hcl ..................... 42 PRECOSE ...................... 53 PRED FORTE ................. 76 PRED MILD .................... 76 PRED-G .......................... 78 PRED-G S.O.P................ 78 prednicarbate .................. 50 PREDNISOL ACE-

MOXIFLOX-BROMFEN .................................... 76

prednisolone ................... 62 prednisolone acetate ....... 76 prednisolone acetate p-f .. 76 PREDNISOLONE

ACETATE-NEPAFENAC .................................... 78

PREDNISOLONE ACET-MOXIFLOXACIN ......... 78

prednisolone sodium phosphate ............. 62, 76

105

PREDNISOLONE-BROMFENAC.............. 78

PREDNISOLONE-GATIFLOXACIN .......... 78

PREDNISOLON-GATIFLOX-BROMFENAC.............. 78

PREDNISOLON-MOXIFLOX-BROMFENAC.............. 78

PREDNISOLON-MOXIFLOX-NEPAFENAC............... 76

prednisone ...................... 62 prednisone intensol ......... 62 PREFEST ........................ 68 pregabalin ....................... 45 PREMARIN ..................... 68 premium lidocaine ........... 15 PREMPHASE .................. 68 PREMPRO ...................... 68 prenatal ........................... 57 prenatal multi +dha .......... 57 PRENATVITE RX ............ 57 PREPIDIL ........................ 61 PREPOPIK ...................... 59 PRESERA ....................... 50 PRESTALIA..................... 42 PREVACID ...................... 58 PREVACID SOLUTAB .... 58 prevalite ........................... 42 preventeza ...................... 68 previfem .......................... 68 PREVNAR 13 .................. 71 PREVYMIS ...................... 36 PREZCOBIX.................... 36 PREZISTA ....................... 36 PRIALT ............................ 14 PRIFTIN .......................... 28 PRILOSEC ...................... 58 prilovix ultralite ................. 15 prilovix ultralite plus ......... 15 primaquine phosphate ..... 32 primidone ........................ 23 PRIMLEV ........................ 14 PRIMSOL ........................ 20 PRINIVIL ......................... 42 PRISTIQ .......................... 24 PRIVIGEN ....................... 70 PRO COMFORT SPACER

ADULT ........................ 74 PRO COMFORT SPACER

CHILD ......................... 74 PROAIR DIGIHALER ...... 81 PROAIR HFA .................. 81

PROAIR RESPICLICK .... 81 probenecid ...................... 27 PROBUPHINE IMPLANT

KIT .............................. 14 procainamide hcl ............. 42 PROCARDIA ................... 42 PROCARDIA XL ............. 42 PROCARE

SPACER/ADULT MASK .................................... 74

PROCARE SPACER/CHILD MASK .......................... 74

PROCENTRA .................. 44 prochlorperazine ............. 25 prochlorperazine edisylate

.................................... 25 prochlorperazine maleate 25 PROCORT ...................... 72 PROCRIT ........................ 38 PROCTOCORT ............... 72 PROCTOFOAM HC ........ 72 procto-med hc ................. 72 procto-pak ....................... 72 proctosol hc ..................... 72 proctozone-hc ................. 72 PROCYSBI...................... 60 PROFILNINE ................... 38 PROFILNINE SD ............. 38 progesterone ................... 68 progesterone micronized . 68 PROGLYCEM ................. 54 PROGRAF ...................... 70 PROLASTIN-C ................ 81 PROLATE ....................... 14 PROLENSA ..................... 76 PROLEUKIN ................... 31 PROLIA ........................... 73 PROMACTA .................... 38 promethazine hcl ............. 80 promethazine-codeine ..... 80 promethazine-dm ............ 80 promethazine-phenyleph-

codeine ........................ 80 promethazine-

phenylephrine .............. 80 promethegan ................... 80 PROMETRIUM ................ 68 PROMISEB ..................... 50 propafenone hcl .............. 42 propafenone hcl er .......... 42 propantheline bromide ..... 59 proparacaine hcl .............. 78 PROPEL ......................... 80 PROPEL MINI ................. 80 propranolol hcl ................. 42

propranolol hcl er ............ 42 propranolol-hctz .............. 42 propylthiouracil ................ 69 PROQUAD ...................... 71 PROSCAR ...................... 61 PROSTIN E2 ................... 61 PROSTIN VR .................. 42 PROTEXA ....................... 50 PROTONIX ..................... 58 PROTOPIC ..................... 50 protriptyline hcl ................ 24 PROVENGE .................... 70 PROVENTIL HFA ............ 81 PROVERA ...................... 68 PROVIGIL ....................... 83 PROZAC ......................... 24 PRUCLAIR ...................... 50 PRUDOXIN ..................... 50 PRUMYX......................... 50 pseudoephedrine-

bromphen-dm .............. 80 PSORCON ...................... 50 PULMICORT FLEXHALER

.................................... 82 PULMICORT

SUSPENSION ............. 82 pulmosal ......................... 80 PULMOZYME ................. 82 PURE COMFORT

ALCOHOL PREP ........ 74 PURE COMFORT PEN

NEEDLE ...................... 56 PURIXAN ........................ 31 PYLERA .......................... 59 pyrazinamide ................... 28 pyridostigmine bromide ... 28 pyridostigmine bromide er28 Q QBRELIS ........................ 42 QBREXZA ....................... 50 qc aspirin low dose .......... 12 qc magnesium citrate ...... 59 QMIIZ ODT ..................... 12 QNASL ............................ 80 QNASL CHILDRENS ...... 80 QTERN ........................... 53 QUADRACEL .................. 71 QUADRAMET ................. 31 QUALAQUIN ................... 32 QUARTETTE .................. 68 quazepam ....................... 37 QUDEXY XR ................... 23 QUESTRAN .................... 42 QUESTRAN LIGHT ......... 42 quetiapine fumarate ........ 34

106

quetiapine fumarate er ..... 34 QUILLICHEW ER ............ 44 QUILLIVANT XR ............. 44 quinapril hcl ..................... 42 quinapril-

hydrochlorothiazide ..... 42 quinidine gluconate er ..... 42 quinidine sulfate .............. 42 quinine sulfate ................. 32 QVAR REDIHALER ......... 82 R ra iron .............................. 57 rabeprazole sodium ......... 58 RABEPRAZOLE SODIUM

.................................... 58 RADICAVA ...................... 45 RAGWITEK ..................... 74 raloxifene hcl ................... 63 ramelteon ........................ 83 ramipril ............................ 42 RANEXA ......................... 42 ranitidine hcl .................... 58 ranolazine er.................... 42 RAPAFLO ....................... 61 RAPAMUNE .................... 70 RAPIVAB ......................... 36 rasagiline mesylate .......... 33 RASUVO ......................... 70 RAVICTI .......................... 60 RAYALDEE ..................... 73 RAYOS ............................ 62 RAZADYNE ..................... 23 RAZADYNE ER ............... 23 REBIF.............................. 45 REBIF REBIDOSE .......... 45 REBIF REBIDOSE

TITRATION PACK ....... 45 REBIF TITRATION PACK45 REBINYN ........................ 38 reclipsen .......................... 68 RECOMBINATE .............. 38 RECOMBIVAX HB........... 71 RECTIV ........................... 42 REGENECARE ............... 50 REGLAN ......................... 25 REGONOL ...................... 28 REGRANEX .................... 50 RELAFEN DS .................. 12 RELENZA DISKHALER ... 36 relexxii ............................. 44 RELISTOR ...................... 59 RELPAX .......................... 27 REMERON ...................... 24 REMERON SOLTAB ....... 24 REMICADE ..................... 70

RENACIDIN .................... 61 RENAGEL ....................... 61 RENFLEXIS .................... 70 RENOVO ........................ 15 RENVELA ....................... 61 repaglinide ...................... 53 REPATHA ....................... 42 REPATHA PUSHTRONEX

SYSTEM ..................... 42 REPATHA SURECLICK .. 42 REQUIP XL ..................... 33 RESTASIS ...................... 78 RESTASIS MULTIDOSE . 78 RESTORIL ...................... 83 RETACRIT ...................... 38 RETIN-A .......................... 50 RETIN-A MICRO GEL 0.04

%, 0.1 % ...................... 50 RETIN-A MICRO PUMP .. 50 RETISERT ...................... 76 RETROVIR...................... 36 REVATIO ........................ 83 REVLIMID ....................... 31 REXAPHENAC ............... 12 REXULTI ......................... 34 REYATAZ ....................... 36 REYVOW ........................ 27 RHOFADE....................... 50 RHOGAM ULTRA-

FILTERED PLUS ......... 70 RHOPHYLAC .................. 71 RHOPRESSA .................. 77 RIASTAP ......................... 38 ribavirin ........................... 36 RIDAURA ........................ 71 rifabutin ........................... 28 RIFADIN .......................... 28 RIFAMATE ...................... 28 rifampin ........................... 28 RIFATER ......................... 28 RILUTEK ......................... 45 riluzole ............................. 45 rimantadine hcl ................ 36 RIMSO-50 ....................... 61 RINVOQ .......................... 71 RIOMET .......................... 53 RIOMET ER .................... 53 risedronate sodium .......... 73 RISPERDAL .................... 34 RISPERDAL CONSTA .... 34 risperidone ...................... 34 RITALIN .......................... 44 RITALIN LA ..................... 44 ritonavir ........................... 36 RITUXAN ........................ 31

RITUXAN HYCELA ......... 31 rivastigmine ..................... 23 rivastigmine tartrate ......... 23 rivelsa ............................. 68 RIXUBIS ......................... 38 rizatriptan benzoate ......... 27 ROBAXIN ........................ 83 ROBAXIN-750 ................. 83 ROCALTROL .................. 73 ROCKLATAN .................. 77 ROMIDEPSIN ................. 31 ropinirole hcl .................... 33 ropinirole hcl er ............... 33 rosadan ........................... 50 ROSADAN ...................... 50 rosuvastatin calcium ........ 42 ROTARIX ........................ 71 ROTATEQ ....................... 71 ROWASA ........................ 72 roweepra ......................... 23 roweepra xr ..................... 23 ROXICODONE................ 14 ROZEREM ...................... 83 ROZLYTREK .................. 31 RUBRACA ...................... 31 RUCONEST .................... 71 RUZURGI........................ 74 RYBELSUS ..................... 53 RYDAPT ......................... 31 RYTARY ......................... 33 RYTHMOL SR ................ 43 ryvent .............................. 80 S SABRIL ........................... 23 SAFYRAL........................ 68 SAIZEN ........................... 64 SAIZENPREP ................. 64 SALAGEN ....................... 45 salicylic acid .................... 50 salicylic acid wart remover

.................................... 50 salimez ............................ 50 SALIMEZ FORTE ............ 50 SALIVAMAX .................... 45 salsalate .......................... 12 SAMSCA ......................... 57 SANCUSO ...................... 25 SANDIMMUNE................ 71 SANDOSTATIN............... 64 SANDOSTATIN LAR

DEPOT ........................ 64 SANTYL .......................... 51 SAPHRIS ........................ 34 SARAFEM ....................... 24 SAVAYSA ....................... 21

107

SAVELLA ........................ 45 SAVELLA TITRATION

PACK .......................... 45 scopolamine .................... 25 SEASONIQUE ................. 68 SECONAL ....................... 83 SECUADO ...................... 34 SEEBRI NEOHALER ....... 82 SEGLUROMET ............... 53 selegiline hcl .................... 33 selenium sulfide ............... 51 SELZENTRY ................... 36 SEMPREX-D ................... 80 SENSIPAR ...................... 73 SEREVENT DISKUS ....... 82 SERNIVO ........................ 51 SEROQUEL .................... 34 SEROQUEL XR .............. 34 SEROSTIM ..................... 59 sertraline hcl .................... 24 setlakin ............................ 68 sevelamer carbonate ....... 61 sevelamer hcl .................. 61 SEYSARA ....................... 20 SFROWASA .................... 72 sharobel .......................... 68 SHINGRIX ....................... 72 SIGNIFOR ....................... 64 SIGNIFOR LAR ............... 64 SIKLOS ........................... 31 sildenafil citrate ................ 83 SILENOR ........................ 84 SILIQ ............................... 71 silodosin .......................... 61 SILVADENE .................... 20 silver nitrate ..................... 20 silver sulfadiazine ............ 20 SIMBRINZA ..................... 77 simliya ............................. 68 simpesse ......................... 68 SIMPONI ......................... 71 SIMPONI ARIA ................ 71 SIMULECT ...................... 71 simvastatin ...................... 43 SIMVASTATIN ................ 43 SINEMET ........................ 33 SINEMET CR .................. 33 SINGULAIR ..................... 82 SINUVA ........................... 80 sirolimus .......................... 71 SIRTURO ........................ 28 SITAVIG .......................... 36 SIVEXTRO ...................... 20 SKELAXIN ....................... 83 SKLICE ........................... 32

SKYLA ............................ 68 SKYRIZI (150 MG DOSE)71 SLYND ............................ 68 sod citrate-citric acid ........ 57 sodium chloride ......... 57, 80 sodium chloride (pf) ......... 57 sodium fluoride ................ 57 sodium hyaluronate ......... 51 SODIUM HYALURONATE

.................................... 74 sodium phenylbutyrate .... 60 sodium polystyrene

sulfonate ...................... 57 sodium sulfacetamide ...... 51 sodium sulfacetamide wash

.................................... 51 SODIUM

SULFACETAMIDE WASH ......................... 51

SOFOSBUVIR-VELPATASVIR ............ 36

solifenacin succinate ....... 61 SOLIQUA ........................ 53 SOLIRIS .......................... 38 SOLODYN....................... 20 SOLOSEC ....................... 20 SOLTAMOX .................... 31 SOLU-CORTEF .............. 62 SOLU-MEDROL .............. 62 SOMA ............................. 83 SOMATULINE DEPOT .... 64 SOMAVERT .................... 64 SOOLANTRA .................. 51 SOOTHEE....................... 15 SORIATANE ................... 51 SORILUX ........................ 51 sorine .............................. 43 sotalol hcl ........................ 43 sotalol hcl (af) .................. 43 sotalol hydrochloride ....... 43 SOTYLIZE ....................... 43 SOVALDI ........................ 36 SPECTRACEF ................ 20 spinosad .......................... 33 SPIRIVA HANDIHALER .. 82 SPIRIVA RESPIMAT ....... 82 spironolactone ................. 43 spironolactone-hctz ......... 43 SPORANOX .................... 26 SPORANOX PULSEPAK 26 sprintec 28....................... 68 SPRITAM ........................ 23 SPRIX ............................. 12 SPRYCEL ....................... 31 sps .................................. 57

sronyx ............................. 68 ssd .................................. 20 SSKI ................................ 80 sss 10-5 .......................... 51 ST JOSEPH LOW DOSE 12 STALEVO 100 ................ 33 STALEVO 125 ................ 33 STALEVO 150 ................ 33 STALEVO 200 ................ 33 STALEVO 50 .................. 33 STALEVO 75 .................. 33 STARLIX ......................... 53 stavudine......................... 36 STEGLATRO .................. 53 STEGLUJAN ................... 53 STELARA........................ 71 STERILE DILUENT

FLOLAN PH 12 ........... 75 sterile diluent/epoprostenol

.................................... 75 sterile water for injection .. 75 sterile water for irrigation . 57 STIMATE ........................ 64 STIOLTO RESPIMAT...... 82 STIVARGA ...................... 31 STRATTERA ................... 44 STRENSIQ ...................... 60 streptomycin sulfate ........ 20 STRIANT......................... 63 STRIBILD ........................ 36 STRIVERDI RESPIMAT .. 82 STROMECTOL ............... 33 SUBLOCADE .................. 16 SUBOXONE .................... 16 SUBSYS ......................... 15 subvenite......................... 23 subvenite starter kit-blue . 23 subvenite starter kit-green

.................................... 23 subvenite starter kit-orange

.................................... 23 SUCRAID ........................ 60 sucralfate ........................ 58 SULAR ............................ 43 SULCONAZOLE NITRATE

.................................... 26 sulfacetamide sodium 51, 76 sulfacetamide sodium

(acne) .......................... 51 sulfacetamide sodium-sulfur

.................................... 51 sulfacetamide-prednisolone

.................................... 78 sulfacetamide-sulfur in urea

.................................... 51

108

sulfacleanse 8/4 .............. 51 sulfadiazine ..................... 20 sulfamethoxazole-

trimethoprim ................ 20 sulfamez wash ................. 51 SULFAMYLON ................ 20 sulfasalazine.................... 72 sulfatrim pediatric ............ 20 sulindac ........................... 12 sumatriptan ..................... 27 sumatriptan succinate ...... 27 sumatriptan succinate refill

.................................... 27 sumatriptan-naproxen

sodium ......................... 27 SUNOSI .......................... 84 SUPARTZ FX .................. 75 SUPPRELIN LA ............... 64 SUPRAX ......................... 20 SUPREP BOWEL PREP

KIT ............................... 59 SURESTEP PRO HIGH

GLUCOSE ................... 54 SURESTEP PRO LOW

GLUCOSE ................... 54 SURESTEP PRO NORMAL

GLUCOSE ................... 54 SURVANTA ..................... 80 SUSTIVA ......................... 36 SUSTOL .......................... 25 SUTENT .......................... 31 SUVICORT ...................... 51 syeda .............................. 68 SYLATRON ..................... 36 SYLVANT ........................ 31 SYMAX DUOTAB ............ 59 symax-sl .......................... 59 symax-sr .......................... 59 SYMBICORT ................... 82 SYMBYAX ....................... 24 SYMDEKO ...................... 82 SYMFI ............................. 36 SYMFI LO ....................... 36 SYMJEPI ......................... 82 SYMLINPEN 120 ............. 53 SYMLINPEN 60 ............... 53 SYMPAZAN..................... 23 SYMPROIC ..................... 59 SYMTUZA ....................... 36 SYNAGIS ........................ 71 synalar............................. 51 SYNALAR ....................... 51 SYNAREL ....................... 64 SYNDROS ...................... 25 SYNERA ......................... 15

SYNERCID...................... 20 SYNERDERM ................. 51 SYNJARDY ..................... 53 SYNJARDY XR ............... 53 SYNRIBO ........................ 31 SYNTHROID ................... 69 SYNVISC ........................ 75 SYNVISC ONE ................ 75 SYPRINE ........................ 57 T TABLOID ......................... 31 TACLONEX ..................... 51 tacrolimus .................. 51, 71 tadalafil ............................ 61 tadalafil (pah) .................. 83 TAFINLAR ....................... 31 TAGRISSO...................... 31 TAKHZYRO ..................... 71 TALICIA .......................... 59 TALTZ ............................. 71 TALZENNA ..................... 31 TAMIFLU ......................... 36 tamoxifen citrate .............. 31 tamsulosin hcl ................. 61 TAPAZOLE ..................... 69 TAPERDEX 12-DAY ....... 62 TAPERDEX 6-DAY ......... 62 TAPERDEX 7-DAY ......... 63 TARCEVA ....................... 31 TARGADOX .................... 20 TARGRETIN ................... 31 tarina 24 fe ...................... 68 tarina fe 1/20 ................... 68 tarina fe 1/20 eq .............. 68 TARKA ............................ 43 taron-crystals ................... 57 TASIGNA ........................ 31 TASMAR ......................... 33 TAVALISSE ..................... 38 TAXOTERE ..................... 31 TAYTULLA ...................... 68 tazarotene ....................... 51 tazicef .............................. 20 TAZICEF ......................... 20 TAZORAC ....................... 51 taztia xt ............................ 43 TAZVERIK....................... 31 TDVAX ............................ 72 TECENTRIQ ................... 31 TECFIDERA .................... 45 TEFLARO ....................... 20 TEGRETOL ..................... 23 TEGRETOL-XR ............... 23 TEGSEDI ........................ 45 TEKTURNA ..................... 43

TEKTURNA HCT ............ 43 telmisartan ...................... 43 telmisartan-amlodipine .... 43 telmisartan-hctz ............... 43 temazepam ..................... 84 TEMIXYS ........................ 36 TEMODAR ...................... 31 TEMOVATE .................... 51 temozolomide .................. 31 temsirolimus .................... 71 tencon ............................. 15 teniposide........................ 31 TENIVAC ........................ 72 tenofovir disoproxil fumarate

.................................... 36 TENORETIC 100 ............ 43 TENORETIC 50 .............. 43 TENORMIN ..................... 43 TEPADINA ...................... 31 terazosin hcl .................... 61 terbinafine hcl .................. 26 terbutaline sulfate ............ 82 terconazole ..................... 27 TESSALON PERLES ...... 80 TESTIM ........................... 63 TESTONE CIK ................ 63 TESTOPEL ..................... 63 testosterone .................... 63 testosterone cypionate .... 63 TESTOSTERONE

CYPIONATE ............... 63 testosterone enanthate.... 63 tetcaine ........................... 78 tetrabenazine .................. 45 tetracaine hcl ................... 78 tetracycline hcl ................ 20 tetravisc .......................... 78 tetravisc forte .................. 78 TETRIX ........................... 51 TEXACORT .................... 51 THALOMID ..................... 31 THEO-24 ......................... 82 theophylline ..................... 82 theophylline er ................. 82 theophylline in d5w .......... 82 THIOLA ........................... 61 THIOLA EC ..................... 61 thioridazine hcl ................ 34 thiotepa ........................... 31 thiothixene ....................... 34 THROMBATE III .............. 21 THYMOGLOBULIN ......... 71 thyroid ............................. 69 tiadylt er .......................... 43 tiagabine hcl .................... 23

109

TIAZAC ........................... 43 TIBSOVO ........................ 31 TIGAN ............................. 25 TIGLUTIK ........................ 45 TIKOSYN ........................ 43 tilia fe ............................... 68 timolol maleate .......... 43, 77 TIMOLOL-BRIMON-

DORZOL-LATANOPR . 77 TIMOLOL-BRIMONIDINE-

DORZOLAMID ............. 77 TIMOLOL-DORZOLAMID-

LATANOPROST .......... 77 TIMOPTIC ....................... 77 TIMOPTIC OCUDOSE .... 77 TIMOPTIC-XE ................. 77 tinidazole ......................... 20 TIROSINT ....................... 69 TIROSINT-SOL ............... 69 TIVICAY .......................... 36 TIVORBEX ...................... 12 tizanidine hcl.................... 83 TNKASE .......................... 21 TOBI NEBULIZER ........... 82 TOBI PODHALER ........... 82 TOBRADEX..................... 78 TOBRADEX ST ............... 78 tobramycin ................. 76, 82 TOBRAMYCIN ................ 82 tobramycin sulfate ........... 20 tobramycin-dexamethasone

.................................... 78 TOBREX ......................... 76 TOLAK ............................ 51 tolbutamide ...................... 53 tolcapone ......................... 33 tolmetin sodium ............... 12 TOLSURA ....................... 27 tolterodine tartrate ........... 61 tolterodine tartrate er ....... 61 TOPAMAX ....................... 23 TOPAMAX SPRINKLE .... 23 TOPICORT ...................... 51 TOPICORT SPRAY ......... 51 topiramate ....................... 23 topiramate er ................... 23 toposar ............................ 31 topotecan hcl ................... 31 TOPROL XL .................... 43 toremifene citrate ............. 31 TORISEL ......................... 71 torsemide ........................ 43 TOSYMRA ...................... 27 TOUJEO MAX SOLOSTAR

.................................... 56

TOUJEO SOLOSTAR ..... 56 tovet ................................ 51 TOVIAZ ........................... 61 TRACLEER ..................... 83 TRADJENTA ................... 53 tramadol hcl er ................ 15 TRAMADOL HCL ER ...... 15 tramadol hcl er (biphasic) 15 tramadol hcl ir .................. 15 tramadol-acetaminophen . 15 trandolapril ...................... 43 trandolapril-verapamil hcl er

.................................... 43 tranexamic acid ............... 38 TRANSDERM SCOP (1.5

MG) ............................. 25 TRANSDERM-SCOP (1.5

MG) ............................. 25 TRANXENE-T ................. 37 tranylcypromine sulfate ... 24 TRAVATAN Z .................. 77 travoprost (bak free) ........ 77 trazodone hcl ................... 24 TREANDA ....................... 31 TRECATOR .................... 28 TRELEGY ELLIPTA ........ 82 TRELSTAR MIXJECT ..... 64 TREMFYA ....................... 71 TRESIBA ......................... 56 TRESIBA FLEXTOUCH .. 56 tretinoin ..................... 31, 51 tretinoin microsphere ....... 51 tretinoin microsphere pump

.................................... 51 TRETTEN ....................... 38 TREXALL ........................ 71 TREXIMET ...................... 27 TREZIX ........................... 15 tri femynor ....................... 68 triamcinolone acetonide.. 45,

51, 52, 63 TRIAMCINOLONE

ACETONIDE ............... 63 triamterene ...................... 43 triamterene-hctz .............. 43 trianex ............................. 52 triazolam ......................... 37 TRIBENZOR ................... 43 tricitrates ......................... 57 TRICOR .......................... 43 triderm ............................. 52 TRIDESILON ................... 52 trientine hcl ...................... 57 TRIESENCE .................... 76 tri-estarylla....................... 68

TRIFERIC ....................... 57 trifluoperazine hcl ............ 34 trifluridine ........................ 76 TRIGLIDE ....................... 43 trihexyphenidyl hcl ........... 33 TRIKAFTA ....................... 82 tri-legest fe ...................... 68 TRILEPTAL ..................... 23 tri-linyah .......................... 68 TRILIPIX ......................... 43 tri-lo-estarylla .................. 68 tri-lo-marzia ..................... 68 tri-lo-mili .......................... 68 tri-lo-sprintec ................... 68 TRILURON ...................... 75 trilyte ............................... 59 trimethobenzamide hcl .... 25 trimethoprim .................... 20 tri-mili .............................. 68 trimipramine maleate ....... 24 TRINTELLIX .................... 24 tri-previfem ...................... 68 TRIPTODUR ................... 64 TRISENOX ...................... 31 tri-sprintec ....................... 68 TRIUMEQ ....................... 36 TRIVISC .......................... 75 trivora (28) ....................... 68 tri-vylibra ......................... 68 tri-vylibra lo ...................... 68 TRIZIVIR ......................... 36 TROKENDI XR................ 23 TROPICAMIDE-

CYCLOPENTOLATE-PE .................................... 78

TROPICAMIDE-PHENYLEPHRINE ...... 78

TROPIC-PROPARACA-PE-KETOROLAC .............. 78

trospium chloride ............. 61 trospium chloride er ......... 61 TRUE METRIX LEVEL 1 . 54 TRUE METRIX LEVEL 2 . 54 TRUE METRIX LEVEL 3 . 54 TRULANCE ..................... 59 TRULICITY ..................... 53 TRUMENBA .................... 72 TRUSOPT ....................... 77 TRUVADA ....................... 36 TUDORZA PRESSAIR .... 82 tulana .............................. 68 TURALIO ........................ 31 TUSSICAPS .................... 80 TUXARIN ER .................. 80 TUZISTRA XR ................ 80

110

TWINRIX ......................... 72 TWYNSTA ....................... 43 TYBOST .......................... 36 tydemy ............................. 68 TYKERB .......................... 31 TYLENOL WITH CODEINE

#3 ................................ 15 TYMLOS ......................... 73 TYSABRI ......................... 45 TYVASO .......................... 83 TYVASO REFILL ............. 83 TYVASO STARTER ........ 83 U UBRELVY ....................... 27 UCERIS ........................... 72 UDENYCA ....................... 38 ULESFIA ......................... 33 ULORIC ........................... 27 ULTIGUARD SAFEPACK

PEN NEEDLE .............. 56 ULTOMIRIS ..................... 38 ULTRACET ..................... 15 ULTRAM ......................... 15 ULTRAVATE ................... 52 UNISTRIP CONTROL ..... 54 unithroid .......................... 69 UNITUXIN ....................... 31 UPTRAVI ......................... 83 urea ................................. 52 UREA .............................. 52 urea hydrating ................. 52 urea nail .......................... 52 URECHOLINE ................. 61 uredeb ............................. 52 urelle ............................... 61 uremez-40 ....................... 52 URESOL ......................... 52 uretron d/s ....................... 61 uribel ............................... 61 urin ds ............................. 61 UROCIT-K 10 .................. 57 UROCIT-K 15 .................. 57 UROCIT-K 5 .................... 57 uro-mp ............................. 61 UROXATRAL .................. 61 URSO 250 ....................... 59 URSO FORTE ................. 60 ursodiol ............................ 60 ustell ................................ 61 UTIBRON NEOHALER .... 82 uticap .............................. 61 utira-c .............................. 61 UTOPIC ........................... 52 utrona-c ........................... 61

V VABOMERE .................... 20 VAGIFEM ........................ 68 valacyclovir hcl ................ 36 VALCHLOR ..................... 31 VALCYTE ........................ 36 valganciclovir hcl ............. 36 VALIUM ........................... 37 valproic acid .................... 23 valrubicin ......................... 31 valsartan ......................... 43 valsartan-

hydrochlorothiazide ..... 43 VALSTAR ........................ 32 VALTOCO 10 MG DOSE 23 VALTOCO 15 MG DOSE 23 VALTOCO 20 MG DOSE 23 VALTOCO 5 MG DOSE .. 23 VALTREX ........................ 36 VANCOCIN HCL ............. 20 vancomycin hcl ................ 21 vancomycin hcl in dextrose

.................................... 20 vancomycin hcl in nacl .... 20 VANCOMYCIN HCL IN

NACL .......................... 20 vandazole ........................ 21 VANOS ........................... 52 VANOXIDE-HC ............... 52 VANTAS .......................... 64 VAQTA ............................ 72 VARIVAX ........................ 72 VARIZIG .......................... 71 VARUBI ........................... 25 VASCEPA ....................... 43 VASERETIC .................... 43 VASOTEC ....................... 43 vcf vaginal contraceptive . 75 VECAMYL ....................... 43 VECTIBIX ........................ 32 VECTICAL....................... 52 VELETRI ......................... 83 velivet .............................. 68 VELPHORO .................... 61 VELTASSA...................... 57 VELTIN ........................... 52 VEMLIDY ........................ 36 VENCLEXTA ................... 32 VENCLEXTA STARTING

PACK .......................... 32 VENELEX ....................... 52 venlafaxine hcl ................ 24 venlafaxine hcl er ............ 24 VENOFER ....................... 57 VENTAVIS ...................... 83

VENTOLIN HFA .............. 82 verapamil hcl ................... 43 verapamil hcl er ............... 43 VERDESO ...................... 52 VEREGEN ...................... 52 VERELAN ....................... 43 VERELAN PM ................. 43 VERSACLOZ .................. 34 VERZENIO ...................... 32 VESICARE ...................... 61 VFEND ............................ 27 V-GO 20 .......................... 54 V-GO 30 .......................... 54 V-GO 40 .......................... 54 VIBATIV .......................... 21 VIBERZI .......................... 60 VIBRAMYCIN .................. 21 vicodin hp ........................ 15 VICTOZA ........................ 53 VIDEX ............................. 36 VIDEX EC ....................... 36 VIEKIRA PAK .................. 36 vienva ............................. 68 vigabatrin ........................ 23 vigadrone ........................ 23 VIGAMOX ....................... 76 VIIBRYD ......................... 25 VIIBRYD STARTER PACK

.................................... 25 vilamit mb ........................ 61 VIMIZIM .......................... 60 VIMOVO ......................... 12 VIMPAT .......................... 23 vinblastine sulfate ............ 32 vincristine sulfate ............. 32 vinorelbine tartrate .......... 32 VIOKACE ........................ 60 viorele ............................. 68 VIRACEPT ...................... 36 VIRAMUNE ..................... 36 VIRAMUNE XR ............... 36 VIRAZOLE ...................... 36 VIREAD .......................... 36 virt-phos 250 neutral ....... 57 VISCO-3 ......................... 75 VISTARIL ........................ 37 VISTOGARD ................... 75 VISUDYNE ...................... 78 vitamin d (ergocalciferol) . 57 vitamin k1 ........................ 57 VITRAKVI........................ 32 VITRASE......................... 75 VIVAGUARD INO

CONTROL SOLUTION 54

111

VIVAGUARD LANCING DEVICE ....................... 54

VIVELLE-DOT ................. 68 VIVITROL ........................ 16 VIVLODEX ...................... 12 VIZIMPRO ....................... 32 VOGELXO ....................... 63 VOGELXO PUMP ........... 63 volnea.............................. 68 VOLTAREN ..................... 12 VONVENDI ..................... 38 VORAXAZE ..................... 32 voriconazole .................... 27 VOSEVI ........................... 36 VOTRIENT ...................... 32 VPRIV ............................. 60 VRAYLAR ....................... 34 VUMERITY ...................... 45 VUMERITY (STARTER) .. 45 VUSION .......................... 27 vyfemla ............................ 68 vylibra .............................. 68 VYNDAMAX .................... 43 VYNDAQEL ..................... 43 VYTORIN ........................ 43 VYVANSE ....................... 44 VYXEOS ......................... 32 VYZULTA ........................ 77 W WAKIX ............................. 84 warfarin sodium ............... 21 water for irrigation, sterile 57 WELCHOL ...................... 43 WELLBUTRIN SR ........... 25 WELLBUTRIN XL ............ 25 wera ................................ 68 WESTHROID .................. 69 WIDE-SEAL DIAPHRAGM

60 ................................ 75 WIDE-SEAL DIAPHRAGM







95 ................................ 75 WILATE ........................... 38 WINRHO SDF ................. 71

WP THYROID ................. 69 wymzya fe ....................... 68 X XADAGO ......................... 33 XALATAN ........................ 77 XALIX .............................. 52 XALKORI ........................ 32 XANAX ............................ 37 XANAX XR ...................... 37 XARELTO ....................... 21 XARELTO STARTER PACK

.................................... 21 XATMEP ......................... 71 XELJANZ ........................ 71 XELJANZ XR .................. 71 XELODA ......................... 32 XELPROS ....................... 77 XEMBIFY ........................ 71 XENAZINE ...................... 45 XENLETA ........................ 21 XEOMIN .......................... 75 XEPI ................................ 21 XERALUX ....................... 52 XERESE ......................... 36 XERMELO....................... 60 XEROSTOMIA RELIEF

SPRAY ........................ 45 XHANCE ......................... 80 XIAFLEX ......................... 75 XIFAXAN ......................... 21 XIGDUO XR .................... 53 XIIDRA ............................ 78 XIMINO ........................... 21 XOFIGO .......................... 32 XOFLUZA ....................... 36 XOLAIR ........................... 80 XOLEGEL ....................... 27 XOPENEX ....................... 82 XOPENEX

CONCENTRATE ......... 82 XOPENEX HFA ............... 82 XOSPATA ....................... 32 XPOVIO (100 MG ONCE

WEEKLY) .................... 32 XPOVIO (60 MG ONCE

WEEKLY) .................... 32 XPOVIO (80 MG ONCE

WEEKLY) .................... 32 XPOVIO (80 MG TWICE

WEEKLY) .................... 32 XTAMPZA ER ................. 15 XTANDI ........................... 32 xulane ............................. 68 XULTOPHY ..................... 53 xurea ............................... 52

XYLOCAINE ................... 15 XYLOCAINE/EPINEPHRIN

E ................................. 16 XYLOCAINE-MPF ........... 16 XYNTHA ......................... 38 XYNTHA SOLOFUSE ..... 38 XYOSTED ....................... 63 XYREM ........................... 84 Y YASMIN 28 ..................... 68 YAZ ................................. 68 YERVOY ......................... 32 YESCARTA ..................... 32 YONDELIS ...................... 32 YONSA ........................... 32 YOSPRALA ..................... 33 YUPELRI......................... 82 yuvafem .......................... 68 Z zaclir cleansing ............... 52 zafirlukast ........................ 82 zaleplon .......................... 84 ZALTRAP ........................ 32 ZANAFLEX ..................... 83 ZANOSAR ....................... 32 zarah ............................... 68 ZARONTIN ...................... 23 ZARXIO .......................... 38 ZAVESCA ....................... 60 ZEGERID ........................ 58 ZEJULA .......................... 32 ZELAPAR........................ 33 ZELBORAF ..................... 32 ZELNORM ...................... 60 ZEMAIRA ........................ 82 ZEMBRACE SYMTOUCH

.................................... 27 ZEMPLAR ....................... 73 zenatane ......................... 52 ZENPEP ......................... 60 zenzedi ........................... 44 ZENZEDI......................... 44 ZEPATIER ...................... 36 ZERBAXA ....................... 21 ZERVIATE ...................... 76 ZESTORETIC ................. 43 ZESTRIL ......................... 43 ZETIA .............................. 43 ZETONNA ....................... 80 ZIAC ................................ 43 ZIAGEN .......................... 36 ZIANA ............................. 52 zidovudine ....................... 36 ZIEXTENZO .................... 38 zileuton er ....................... 82

112

ZILRETTA ....................... 63 ZINPLAVA ....................... 71 ZIONODIL ....................... 16 ZIONODIL 100 ................ 16 ZIOPTAN ......................... 77 ziprasidone hcl ................ 34 ziprasidone mesylate ....... 34 ZIPSOR ........................... 12 ZIRGAN ........................... 76 ZITHRANOL .................... 52 ZITHROMAX ................... 21 ZITHROMAX TRI-PAK .... 21 ZITHROMAX Z-PAK ........ 21 ZOCOR ........................... 43 ZOFRAN ......................... 25 ZOHYDRO ER ................ 15 ZOLADEX ....................... 64 zoledronic acid ................ 73 ZOLINZA ......................... 32

zolmitriptan ...................... 27 ZOLOFT .......................... 25 zolpidem tartrate ............. 84 zolpidem tartrate er ......... 84 ZOLPIMIST ..................... 84 ZOMACTON .................... 64 ZOMIG ............................ 28 ZOMIG ZMT .................... 28 ZONALON ....................... 52 ZONEGRAN .................... 23 zonisamide ...................... 23 ZONTIVITY ..................... 33 ZORBTIVE ...................... 60 ZORTRESS ..................... 71 ZORVOLEX ..................... 12 ZOSTAVAX ..................... 72 ZOSYN ............................ 21 zovia 1/35e (28) .............. 68 ZOVIRAX ........................ 36

ZTLIDO ........................... 16 ZUBSOLV ....................... 16 zumandimine ................... 68 ZUPLENZ........................ 25 ZYCLARA ....................... 52 ZYCLARA PUMP ............ 52 ZYDELIG......................... 32 ZYFLO ............................ 82 ZYKADIA......................... 32 ZYLET ............................. 78 ZYLOPRIM ...................... 27 ZYMAXID ........................ 76 ZYPITAMAG ................... 43 ZYPREXA ....................... 34 ZYPREXA RELPREVV ... 34 ZYPREXA ZYDIS ............ 34 ZYTIGA ........................... 32 ZYVOX ............................ 21

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አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد

XB0001444-56-18

2020 drug formulary - kaiser permanentethe drug formulary is updated periodically and is subject to...

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