effective september 2020 - total health carethe total health care (thc) medicaid formulary was...

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MEDICAID FORMULARY Effective January 2021

Provided by Elixir

Introduction

The Total Health Care (THC) Medicaid Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.

In order to streamline drug coverage policies for Medicaid members and providers, the Michigan Department of Health and Human Services (MDHHS) has worked with Medicaid health plan providers, including Total Health Care, to create a formulary that is common across all contracted Medicaid Health. This is known as the Michigan Medicaid Managed Care Common Formulary.

Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature.

This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary

Drug Name

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The

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brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

Requirements/Limits

This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Medicaid Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA)

Drug requires prior authorization through a specific physician request process.

Over the Counter Drugs (OTC)

Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider.

Specialty Drugs (SP)

Drug requires processing through THC’s contracted specialty pharmacy, Elixir Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction (GR) Drug coverage may depend on patient gender.

Step Therapy Required (ST)

Drug coverage requires that an alternative or trial of another drug be used before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved

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criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not found on the Total Health Care Medicaid Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug

selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to:

Drug products used for cosmetic purposes. Drug products for sexual dysfunction. Drug products for infertility treatment. Experimental drug products or any drug product used in an experimental manner. Drug products identified by the Drug Efficacy Study Implementation (DESI) as being category 5

(less-than-effective for all indications) or category 6 (removed from the market). Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

Medicaid Fee-For-Service Carve Out List The State of Michigan has a carve-out list for the Medicaid formulary. The carve-out drugs include mental health, HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at https://michigan.fhsc.com/Providers/DrugInfo.asp. Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA-approved generic drug product is available. The brand names listed in the formulary are for reference only.

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Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.

Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Elixir Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Elixir Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Elixir at 1-866-422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, Elixir obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Elixir Specialty Pharmacy. Then, Elixir Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact Elixir at 1-844-222-5584 or Elixir Specialty Pharmacy at 1-877-437-9012.

Contact Information

The Total Health Care Medicaid formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862.

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Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

Gender Restrictions

Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step-Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria

Acne Therapy Topical – Retinoids & Derivatives

DIFFERIN 0.1% OVER-THE-COUNTER GEL

tretinoin 0.025% cream Requires prior trial and failure of 2 fills in the last 90 days.

Antianginal – Coronary Vasodilators - Nitrates

nitroglycerine 0.3mg Tablet sublingual nitroglycerine 0.4mg Tablet sublingual nitroglycerine 0.4mg Tablet sublingual

nitroglycerine 0.4mg spray

Requires trial and failure of a 7 day supply of one of the following agents within the last 180 days.

Immunosuppressive – Inosine Monophosphate Dehydrogenase Inhibitors

mycophenolate 250mg capsule mycophenolate 500mg capsule mycophenolate

Mycophenolic Acid DR 180mg tablet Mycophenolic Acid DR 360mg tablet

Requires trial and failure of one of the following agents within the last 180 days

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Therapy Class First Line Second Line Step Therapy Criteria

200mg/mL suspension

Non-Steroidal Anti-Inflammatory – COX II Inhibitors

Ibuprofen 400mg tablet diclofenac Sod DR 75mg tablet

Preferred Drug: celecoxib Non-Preferred Drug (PA required): CELEBREX

Requires prior trial and failure of a 30-day supply each with 2 or more NSAIDS covered on the Common Formulary in the last 180 days.

Scabicide & Pediculicide Single Agnets

permethrin 1% lotion

malathion 0.5% lotion SPINOSAD 0.9% SUSPENSION

Requires trial and failure of OTC Permethrin 1% within the last 180 days.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Elixir. The presence of a medication on this formulary list does not guarantee coverage.

CURRENT AS OF 1/1/2021

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

StatusT1 = Covered

Notes = Preferred = PDL Non-PreferredAL = Age LimitGR-F = Female OnlyGR-M = Male OnlyPA = Prior AuthorizationQL = Quantity LimitST = Step Therapy

Drug Status Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*caffeine citrate oral solution 20 mg/ml T1 AL (Max 1 Years)

*Allergenic Extracts/Biologicals Misc*PALFORZIA (12 MG DAILY DOSE) ORAL 2 X 1 MG & 10 MG T1

PA; AL (Min 4 Years and Max 17 Years)

PALFORZIA (120 MG DAILY DOSE) ORAL20 MG & 100 MG T1


PALFORZIA (160 MG DAILY DOSE) ORAL3 X 20 MG & 100 MG T1


PALFORZIA (20 MG DAILY DOSE) ORAL20 MG T1


PALFORZIA (200 MG DAILY DOSE) ORAL2 X 100 MG T1


PALFORZIA (240 MG DAILY DOSE) ORAL2 X 20 MG & 2 X 100 MG T1


PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG T1








PALFORZIA INITIAL ESCALATION ORAL0.5 & 1 & 1.5 & 3 & 6 MG T1


*Aminoglycosides*BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML T1

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML T1

neomycin sulfate oral tablet 500 mg T1 PA

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Drug Status Notesparomomycin sulfate oral capsule 250 mg T1

TOBI INHALATION NEBULIZATION SOLUTION 300 MG/5ML T1 PA

TOBI PODHALER INHALATION CAPSULE28 MG T1

tobramycin inhalation nebulization solution 300 mg/5ml

T1 PA

tobramycin pak inhalation nebulization solution300 mg/5ml

T1 PA

*Analgesics - Anti-Inflammatory*ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

T1 PA

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML T1 PA

ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 75-0.2 MG T1 PA

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG T1 PA; ST; QL (30 EA per 30 days)

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

T1 ST; QL (30 EA per 30 days)

childrens ibuprofen oral suspension 100 mg/5ml T1

DAYPRO ORAL TABLET 600 MG T1 PA

diclofenac potassium oral tablet 50 mg T1 PA

diclofenac sodium er oral tablet extended release 24 hour 100 mg

T1 PA

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

T1

diclofenac-misoprostol oral tablet delayed release50-0.2 mg, 75-0.2 mg

T1 PA

DUEXIS ORAL TABLET 800-26.6 MG T1 PA

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML T1

ENBREL SUBCUTANEOUS KIT 25 MG T1 QL (4 EA per 28 days)

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML T1

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

T1

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG T1

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML T1

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Drug Status Notesetodolac er oral tablet extended release 24 hour400 mg, 500 mg, 600 mg

T1 PA

etodolac oral capsule 200 mg, 300 mg T1 PA

etodolac oral tablet 400 mg, 500 mg T1 PA

FELDENE ORAL CAPSULE 10 MG, 20 MG T1 PA

fenoprofen calcium oral capsule 400 mg T1 PA

fenoprofen calcium oral tablet 600 mg T1 PA

flurbiprofen oral tablet 100 mg, 50 mg T1 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML T1

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

T1

ibuprofen junior strength oral tablet chewable100 mg

T1

ibuprofen oral capsule 200 mg T1

ibuprofen oral suspension 100 mg/5ml T1

ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg

T1

INDOCIN ORAL SUSPENSION 25 MG/5ML T1 PA

INDOCIN RECTAL SUPPOSITORY 50 MG T1 PA

indomethacin er oral capsule extended release 75 mg

T1 PA

indomethacin oral capsule 25 mg, 50 mg T1

infants ibuprofen oral suspension 50 mg/1.25ml T1

ketoprofen er oral capsule extended release 24 hour 200 mg

T1 PA

ketoprofen oral capsule 50 mg, 75 mg T1

ketorolac tromethamine nasal solution 15.75 mg/spray

T1 PA; QL (5 EA per 30 days)

ketorolac tromethamine oral tablet 10 mg T1 QL (21 EA per 30 days)

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 MG/1.14ML

T1 PA

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML

T1 PA

leflunomide oral tablet 10 mg, 20 mg T1 QL (30 EA per 30 days)

meclofenamate sodium oral capsule 100 mg, 50 mg

T1 PA

mefenamic acid oral capsule 250 mg T1 PA

meloxicam oral tablet 15 mg, 7.5 mg T1

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Drug Status NotesMOBIC ORAL TABLET 15 MG, 7.5 MG T1 PA

nabumetone oral tablet 500 mg, 750 mg T1

NALFON ORAL CAPSULE 400 MG T1 PA

NALFON ORAL TABLET 600 MG T1 PA

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG, 750 MG

T1 PA

naproxen dr oral tablet delayed release 375 mg, 500 mg

T1 PA

naproxen oral suspension 125 mg/5ml T1 PA

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

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

T1 PA

naproxen sodium oral capsule 220 mg T1

naproxen sodium oral tablet 220 mg T1

naproxen sodium oral tablet 275 mg, 550 mg T1 PA

naproxen-esomeprazole oral tablet delayed release 375-20 mg, 500-20 mg

T1 PA

OLUMIANT ORAL TABLET 1 MG, 2 MG T1 PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML T1 PA

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

T1 PA

OTEZLA ORAL TABLET 30 MG T1 PA

OTEZLA ORAL TABLET THERAPY PACK10 & 20 & 30 MG T1 PA

oxaprozin oral tablet 600 mg T1 PA

piroxicam oral capsule 10 mg, 20 mg T1 PA

QMIIZ ODT ORAL TABLET DISPERSIBLE15 MG, 7.5 MG T1 PA

RELAFEN DS ORAL TABLET 1000 MG T1 PA

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG T1 PA

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML T1 PA

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

T1 PA

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

T1 PA

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Drug Status Notessm ibuprofen jr oral tablet 100 mg T1

sm ibuprofen oral tablet 200 mg T1

SPRIX NASAL SOLUTION 15.75 MG/SPRAY T1 PA; QL (5 EA per 30 days)

sulindac oral tablet 150 mg, 200 mg T1

TIVORBEX ORAL CAPSULE 20 MG, 40 MG T1 PA

tolmetin sodium oral capsule 400 mg T1 PA

tolmetin sodium oral tablet 200 mg, 600 mg T1 PA

VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 500-20 MG T1 PA

VIVLODEX ORAL CAPSULE 10 MG, 5 MG T1 PA

XELJANZ ORAL TABLET 10 MG, 5 MG T1 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG, 22 MG T1 PA

ZIPSOR ORAL CAPSULE 25 MG T1 PA

ZORVOLEX ORAL CAPSULE 18 MG, 35 MG T1 PA

*Analgesics - Nonnarcotic*ACEPHEN RECTAL SUPPOSITORY 325 MG T1

acetaminophen 8 hour oral tablet 650 mg T1

acetaminophen er oral tablet extended release650 mg

T1

acetaminophen extra strength oral tablet 500 mg T1

acetaminophen oral elixir 160 mg/5ml T1

acetaminophen oral liquid 160 mg/5ml T1

acetaminophen oral solution 160 mg/5ml T1

acetaminophen oral suspension 160 mg/5ml T1

acetaminophen oral tablet 325 mg T1

acetaminophen oral tablet chewable 80 mg T1

acetaminophen rapid tabs child oral tablet dispersible 80 mg

T1

acetaminophen rectal suppository 120 mg, 650 mg

T1

apap 500 oral liquid 500 mg/5ml T1

aspirin ec low dose oral tablet delayed release 81 mg

T1 QL (30 EA per 30 days)

aspirin ec oral tablet delayed release 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

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Drug Status Notesaspirin oral tablet chewable 81 mg T1 QL (30 EA per 30 days)

aspirin rectal suppository 300 mg, 600 mg T1

buffered aspirin oral tablet 325 mg T1AL (Min 40 Years and Max 79 Years)

butalbital-acetaminophen oral tablet 50-325 mg T1QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years)

butalbital-apap-caffeine oral tablet 50-325-40 mg T1QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years)

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

T1QL (120 EA per 30 days); AL (Max 64 Years)

choline-mag trisalicylate oral liquid 500 mg/5ml T1

diflunisal oral tablet 500 mg T1 PA

eq acetaminophen junior oral tablet dispersible160 mg

T1

extra strength acetaminophen oral capsule 500 mg

T1

infants pain relief oral suspension 80 mg/0.8ml T1

non-aspirin extra strength oral tablet dispersible500 mg

T1

pain relief childrens oral suspension 160 mg/5ml T1

q-pap infants oral solution 80 mg/0.8ml T1

*Analgesics - Opioid*ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG

T1 PA

acetaminophen-codeine #2 oral tablet 300-15 mg T1



acetaminophen-codeine oral solution 120-12 mg/5ml

T1

ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG T1 PA

apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

T1 PA

apap-caff-dihydrocodeine oral tablet 325-30-16 mg

T1 PA

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG

T1 PA

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Drug Status NotesBELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG


benzhydrocodone-acetaminophen oral tablet4.08-325 mg, 6.12-325 mg, 8.16-325 mg

T1 PA

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr


butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

T1 PA

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

T1 PA

butorphanol tartrate nasal solution 10 mg/ml T1 PA; QL (15 ML per 30 days)

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR


codeine sulfate oral tablet 15 mg, 30 mg, 60 mg T1 QL (180 EA per 30 days)

CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

T1 PA

DILAUDID ORAL LIQUID 1 MG/ML T1 PA; QL (120 ML per 30 days)

DILAUDID ORAL TABLET 2 MG, 4 MG T1 PA; QL (180 EA per 30 days)

DILAUDID ORAL TABLET 8 MG T1 PA; QL (90 EA per 30 days)

DOLOPHINE ORAL TABLET 10 MG, 5 MG T1 PA

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR T1 PA; QL (10 EA per 30 days)





EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

T1 PA

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl citrate buccal tablet 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


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


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Drug Status Notesfentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

T1 PA

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG T1 PA; QL (120 EA per 30 days)

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG T1 PA

FIORINAL/CODEINE #3 ORAL CAPSULE50-325-40-30 MG T1 PA

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

T1 PA

hydrocodone bitartrate er oral capsule extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

T1 PA

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

T1

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

T1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

T1 PA

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

T1 PA

hydromorphone hcl er oral tablet extended release 24 hour 12 mg, 32 mg, 8 mg

T1 PA

hydromorphone hcl oral liquid 1 mg/ml T1 QL (120 ML per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg T1 QL (180 EA per 30 days)

hydromorphone hcl oral tablet 8 mg T1 QL (90 EA per 30 days)

hydromorphone hcl rectal suppository 3 mg T1 PA

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

T1 PA

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

T1 PA

levorphanol tartrate oral tablet 2 mg, 3 mg T1 PA

LORTAB ORAL ELIXIR 10-300 MG/15ML T1 PA

meperidine hcl oral solution 50 mg/5ml T1 PA; QL (240 ML per 30 days)

meperidine hcl oral tablet 100 mg T1 PA

meperidine hcl oral tablet 50 mg T1 PA; QL (120 EA per 30 days)

methadone hcl injection solution 10 mg/ml T1 PA

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Drug Status NotesMETHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML T1 PA

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml T1 PA

methadone hcl oral tablet 10 mg, 5 mg T1 PA

methadone hcl oral tablet soluble 40 mg T1 PA

METHADOSE ORAL CONCENTRATE 10 MG/ML T1 PA

METHADOSE ORAL TABLET SOLUBLE40 MG T1 PA

MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 100 MG, 15 MG, 30 MG, 60 MG

T1

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

T1 QL (120 ML per 30 days)

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

T1 PA

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

T1 PA

morphine sulfate er oral tablet extended release100 mg, 15 mg, 200 mg, 30 mg, 60 mg

T1

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml


morphine sulfate oral tablet 15 mg, 30 mg T1 QL (180 EA per 30 days)

morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

T1

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

T1 PA

nalocet oral tablet 2.5-300 mg T1 PA

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG T1 PA

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG

T1 PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG T1 PA

OPANA ORAL TABLET 10 MG T1 PA; QL (120 EA per 30 days)

OXAYDO ORAL TABLET 7.5 MG T1 PA

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg


9

Drug Status Notesoxycodone hcl oral capsule 5 mg T1 PA; QL (90 EA per 30 days)

oxycodone hcl oral concentrate 10 mg/0.5ml T1 PA; QL (120 EA per 30 days)

oxycodone hcl oral concentrate 100 mg/5ml T1 PA; QL (120 ML per 30 days)

oxycodone hcl oral solution 5 mg/5ml T1 QL (240 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 15 mg, 5 mg T1 QL (90 EA per 30 days)

oxycodone hcl oral tablet 20 mg, 30 mg T1 PA; QL (120 EA per 30 days)

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

T1

oxycodone-aspirin oral tablet 4.8355-325 mg T1 PA

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

T1 PA

oxymorphone hcl oral tablet 10 mg, 5 mg T1 PA; QL (120 EA per 30 days)

panlor oral tablet 325-30-16 mg T1 PA

pentazocine-naloxone hcl oral tablet 50-0.5 mg T1 PA

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG T1 PA

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG T1 PA

PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG T1 PA

ROXICODONE ORAL TABLET 15 MG, 5 MG T1 PA; QL (90 EA per 30 days)

ROXICODONE ORAL TABLET 30 MG T1 PA; QL (120 EA per 30 days)

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG T1 PA; QL (90 EA per 30 days)

ROXYBOND ORAL TABLET ABUSE-DETERRENT 30 MG T1 PA; QL (120 EA per 30 days)

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

T1 PA

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

T1 PA

tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

T1 PA

tramadol hcl oral tablet 100 mg, 50 mg T1

tramadol-acetaminophen oral tablet 37.5-325 mg T1 PA

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG T1 PA

ULTRACET ORAL TABLET 37.5-325 MG T1 PA

10

Drug Status NotesULTRAM ORAL TABLET 50 MG T1 PA

VICODIN HP ORAL TABLET 10-300 MG T1 PA

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG


ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

T1 PA

*Androgens-Anabolic*ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR T1 PA; PDL-NP

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) T1 PA; PDL-P

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

T1 PA; PDL-P

danazol oral capsule 100 mg, 200 mg, 50 mg T1

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) T1 PA; PDL-NP

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) T1 PA; PDL-NP

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

T1

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

T1 PA; PDL-NP

testosterone transdermal solution 30 mg/act T1 PA; PDL-NP

VOGELXO PUMP TRANSDERMAL GEL12.5 MG/ACT (1%) T1 PA; PDL-NP

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) T1 PA; PDL-NP

*Anorectal And Related Products*hydrocortisone rectal enema 100 mg/60ml T1

*Antacids*ACID GONE ORAL SUSPENSION 95-358 MG/15ML T1

aluminum hydroxide gel oral suspension 320 mg/5ml

T1

antacid calcium extra strength oral tablet chewable 750 mg

T1

antacid plus anti-gas fast act oral suspension200-200-20 mg/5ml

T1

11

Drug Status Notesantacid/simethicone ds oral suspension 400-400-40 mg/5ml

T1

calcium antacid ultra oral tablet chewable 1000 mg

T1

calcium carbonate antacid oral tablet chewable500 mg

T1

magnesium oxide oral capsule 400 mg T1

magnesium oxide oral tablet 250 mg, 400 mg T1

MAOX ORAL TABLET 420 MG T1

ri-mox oral suspension 225-200 mg/5ml T1

sodium bicarbonate oral tablet 325 mg, 650 mg T1

URO-MAG ORAL CAPSULE 140 MG T1

*Anthelmintics*benznidazole oral tablet 100 mg, 12.5 mg T1 PA

ivermectin oral tablet 3 mg T1

PIN-X ORAL SUSPENSION 50 MG/ML T1

PIN-X ORAL TABLET CHEWABLE 720.5 MG T1

*Antianginal Agents*isosorbide dinitrate er oral tablet extended release 40 mg

T1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

T1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

T1

isosorbide mononitrate oral tablet 10 mg, 20 mg T1

NITRO-BID TRANSDERMAL OINTMENT 2 % T1

nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

T1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

T1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr


nitroglycerin translingual solution 0.4 mg/spray T1 ST

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG T1 PA

*Antianxiety Agents*hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml

T1

hydroxyzine hcl oral syrup 10 mg/5ml T1

12

Drug Status Noteshydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

T1

VISTARIL ORAL CAPSULE 25 MG, 50 MG T1 PA

*Antiarrhythmics*amiodarone hcl oral tablet 100 mg T1 QL (30 EA per 30 days)

amiodarone hcl oral tablet 200 mg, 400 mg T1

disopyramide phosphate oral capsule 100 mg, 150 mg

T1 AL (Max 64 Years)

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

T1

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

T1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

T1

quinidine sulfate er oral tablet extended release300 mg

T1

quinidine sulfate oral tablet 200 mg, 300 mg T1

*Antiasthmatic And Bronchodilator Agents*ACCOLATE ORAL TABLET 10 MG, 20 MG T1 PA

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

T1 QL (12 GM per 30 days)

AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT


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

T1 PA; QL (36 GM per 30 days)

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

T1

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT T1 PA

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

T1 PA

13

Drug Status NotesARCAPTA NEOHALER INHALATION CAPSULE 75 MCG T1 PA

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

T1 PA

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

T1


T1




T1


T1

ASMANEX HFA INHALATION AEROSOL100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

T1 PA

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT T1 QL (27 GM per 30 days)

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT T1

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH


BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML T1 PA

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

T1

budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg/act, 80-4.5 mcg/act

T1 PA; QL (10.2 GM per 30 days)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT T1

cromolyn sodium inhalation nebulization solution20 mg/2ml

T1

DALIRESP ORAL TABLET 250 MCG, 500 MCG T1 PA

14

Drug Status NotesDUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT

T1 PA

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT T1 QL (13 GM per 30 days)

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

T1 PA

FLOVENT HFA INHALATION AEROSOL110 MCG/ACT T1 QL (63 GM per 30 days)



fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 mcg/act






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


INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

T1 PA

ipratropium bromide inhalation solution 0.02 % T1

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

T1

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

T1 PA

levalbuterol tartrate inhalation aerosol 45 mcg/act

T1 PA; QL (27 GM per 30 days)

LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 25 MCG/ML T1 PA

LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 25 MCG/ML T1 PA

metaproterenol sulfate oral tablet 10 mg, 20 mg T1

montelukast sodium oral packet 4 mg T1 PA; AL (Max 5 Years)

montelukast sodium oral tablet 10 mg T1

15

Drug Status Notesmontelukast sodium oral tablet chewable 4 mg T1 AL (Max 5 Years)

montelukast sodium oral tablet chewable 5 mg T1 AL (Max 14 Years)

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML T1 PA

PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 MCG/ACT


PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT T1 QL (36 GM per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT


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

T1 QL (36 GM per 30 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT


PULMICORT INHALATION SUSPENSION0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML T1 PA

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

T1 PA

SEEBRI NEOHALER INHALATION CAPSULE 15.6 MCG T1 PA

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


SINGULAIR ORAL PACKET 4 MG T1 PA; AL (Max 5 Years)

SINGULAIR ORAL TABLET 10 MG T1 PA

SINGULAIR ORAL TABLET CHEWABLE 4 MG T1 PA; AL (Max 5 Years)

SINGULAIR ORAL TABLET CHEWABLE 5 MG T1 PA; AL (Max 14 Years)

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG T1 QL (60 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

T1 PA

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT T1

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT T1 PA

16

Drug Status NotesSYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT, 80-4.5 MCG/ACT T1 QL (10.2 GM per 30 days)

terbutaline sulfate oral tablet 2.5 mg, 5 mg T1

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 200 MG T1

theophylline er oral tablet extended release 12 hour 100 mg, 300 mg, 450 mg

T1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

T1

theophylline oral elixir 80 mg/15ml T1

theophylline oral solution 80 mg/15ml T1

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 MCG/INH

T1 PA

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

T1 PA

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG T1 PA

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT T1 PA; QL (36 GM per 30 days)

WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML

T1 PA

XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML

T1 PA

YUPELRI INHALATION SOLUTION 175 MCG/3ML T1 PA

zafirlukast oral tablet 10 mg, 20 mg T1 PA

zileuton er oral tablet extended release 12 hour600 mg

T1 PA

ZYFLO ORAL TABLET 600 MG T1 PA

*Anticoagulants*ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML

T1 PA

BEVYXXA ORAL CAPSULE 40 MG, 80 MG T1PA; QL (43 EA per 42 days); AL (Min 18 Years)

17

Drug Status NotesCOUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

T1 PA

ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG T1

ELIQUIS ORAL TABLET 2.5 MG, 5 MG T1

enoxaparin sodium injection solution 300 mg/3ml T1

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

T1

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

T1 PA

FRAGMIN SUBCUTANEOUS SOLUTION10000 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, 95000 UNIT/3.8ML

T1 PA

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

T1

heparin sodium (porcine) pf injection solution5000 unit/0.5ml

T1

LOVENOX INJECTION SOLUTION 300 MG/3ML T1 PA

LOVENOX SUBCUTANEOUS SOLUTION100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML

T1 PA

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG T1

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG T1 PA

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

T1

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG T1

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG T1

*Antidiabetics*acarbose oral tablet 100 mg, 25 mg, 50 mg T1

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG T1 PA

18

Drug Status NotesACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG

T1 PA

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG T1 PA

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML

T1 PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML T1 PA

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

ADMELOG SUBCUTANEOUS SOLUTION100 UNIT/ML T1 PA; QL (90 ML per 30 days)

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT


alogliptin benzoate tablet 12.5 mg oral 12.5 mg T1 PA

alogliptin benzoate tablet 25 mg oral 25 mg T1 PA

alogliptin benzoate tablet 6.25 mg oral 6.25 mg T1 PA

alogliptin-metformin hcl tablet 12.5-1000 mg oral12.5-1000 mg

T1 PA

alogliptin-metformin hcl tablet 12.5-500 mg oral12.5-500 mg

T1 PA

alogliptin-pioglitazone tablet 12.5-15 mg oral12.5-15 mg

T1 PA


T1 PA


T1 PA

alogliptin-pioglitazone tablet 25-15 mg oral 25-15 mg

T1 PA


T1 PA


T1 PA

AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG T1 PA

APIDRA INJECTION SOLUTION 100 UNIT/ML T1 QL (90 ML per 30 days)

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

AVANDIA ORAL TABLET 2 MG, 4 MG T1 PA

19

Drug Status NotesBAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE T1

QL (2 EA per 30 days); AL (Min 4 Years)

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE T1

QL (2 EA per 30 days); AL (Min 4 Years)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML T1 PA

BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG T1

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

T1

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML T1

chlorpropamide oral tablet 100 mg T1 AL (Max 64 Years)

chlorpropamide oral tablet 250 mg T1 PA

DUETACT ORAL TABLET 30-2 MG, 30-4 MG T1 PA

FARXIGA ORAL TABLET 10 MG, 5 MG T1 PDL-P

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG T1 PA

glimepiride oral tablet 1 mg, 2 mg, 4 mg T1

glipizide er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

T1

glipizide oral tablet 10 mg, 5 mg T1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

T1 PA

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG T1 QL (1 EA per 30 days)

glucagon emergency injection kit 1 mg T1 QL (2 EA per 30 days)

GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 MG T1 PA

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

T1 PA

GLUCOTROL ORAL TABLET 10 MG, 5 MG T1 PA

20

Drug Status NotesGLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

T1 PA

GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG T1 PA

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

T1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

T1

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG T1 PA

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG T1

GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML

T1QL (0.2 ML per 30 days); AL (Min 2 Years)

GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML


GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML

T1 QL (0.2 ML per 30 days)

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 UNIT/ML T1 PA; QL (90 ML per 30 days)

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMALOG SUBCUTANEOUS SOLUTION100 UNIT/ML T1 QL (90 ML per 30 days)

21

Drug Status NotesHUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

T1 PA; QL (90 ML per 30 days)

HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMULIN R INJECTION SOLUTION 100 UNIT/ML T1 QL (90 ML per 30 days)

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T1 QL (90 ML per 30 days)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML


insulin asp prot & asp flexpen subcutaneous suspension pen-injector (70-30) 100 unit/ml


insulin aspart flexpen subcutaneous solution pen-injector 100 unit/ml


insulin aspart penfill subcutaneous solution cartridge 100 unit/ml


insulin aspart prot & aspart subcutaneous suspension (70-30) 100 unit/ml


insulin aspart subcutaneous solution 100 unit/ml T1 PA; QL (90 ML per 30 days)

insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml


insulin lispro junior kwikpen subcutaneous solution pen-injector 100 unit/ml


insulin lispro prot & lispro subcutaneous suspension pen-injector (75-25) 100 unit/ml


insulin lispro subcutaneous solution 100 unit/ml T1 PA; QL (90 ML per 30 days)

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG T1

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

T1 PA

INVOKANA ORAL TABLET 100 MG, 300 MG T1 PDL-P

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T1 QL (60 EA per 30 days)

22

Drug Status NotesJANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG

T1

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T1 QL (60 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG T1 PDL-P

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG T1

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG

T1 PA

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG

T1 PA

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML T1 QL (90 ML per 30 days)

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

LEVEMIR SUBCUTANEOUS SOLUTION100 UNIT/ML T1 QL (90 ML per 30 days)

metformin hcl er (mod) oral tablet extended release 24 hour 1000 mg, 500 mg

T1 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

T1 PA

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

T1

metformin hcl oral solution 500 mg/5ml T1 PA

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

T1

miglitol oral tablet 100 mg, 25 mg, 50 mg T1

nateglinide oral tablet 120 mg, 60 mg T1

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

23

Drug Status NotesNOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML


NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML


NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR100 UNIT/ML


NOVOLIN R INJECTION SOLUTION 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T1 QL (90 ML per 30 days)

NOVOLOG SUBCUTANEOUS SOLUTION100 UNIT/ML T1 QL (90 ML per 30 days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG T1 PA

OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

T1 PA

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T1 PA

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg T1

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

T1 PA

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

T1 PA

PRANDIN ORAL TABLET 1 MG, 2 MG T1 PA

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA

QTERN ORAL TABLET 10-5 MG, 5-5 MG T1 PA

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg T1

repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

T1 PA

24

Drug Status NotesRIOMET ER ORAL SUSPENSION RECONSTITUTED ER 500 MG/5ML T1 PA

RIOMET ORAL SOLUTION 500 MG/5ML T1

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG T1 PA

SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG T1 PA

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML T1 PA

STARLIX ORAL TABLET 120 MG, 60 MG T1 PA

STEGLATRO ORAL TABLET 15 MG, 5 MG T1 PA; PDL-NP

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG T1 PA

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

T1

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

T1

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG T1 PA; PDL-NP

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG

T1 PA; PDL-NP

TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG T1 PA; QL (4 EA per 28 days)

tolazamide oral tablet 250 mg, 500 mg T1

tolbutamide oral tablet 500 mg T1 PA

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML


TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML T1 PA; QL (90 ML per 30 days)

TRADJENTA ORAL TABLET 5 MG T1

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML


TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML T1 PA; QL (90 ML per 30 days)

TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5-2.5-1000 MG

T1 PA

25

Drug Status NotesTRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML

T1 PA

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML T1

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG

T1

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML T1 PA

*Antidiarrheal/Probiotic Agents*anti-diarrheal oral tablet 2 mg T1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

T1

diphenoxylate-atropine oral tablet 2.5-0.025 mg T1

hm anti-diarrheal oral tablet 2 mg T1

loperamide hcl oral capsule 2 mg T1

loperamide hcl oral suspension 1 mg/7.5ml T1

pink bismuth maximum strength oral suspension525 mg/15ml

T1

pink bismuth oral suspension 262 mg/15ml T1

pink bismuth oral tablet chewable 262 mg T1

qc anti-diarrheal oral tablet 2 mg T1

sm anti-diarrheal oral tablet 2 mg T1

SOOTHE ORAL TABLET 262 MG T1

*Antidotes And Specific Antagonists*CHEMET ORAL CAPSULE 100 MG T1

naloxone hcl injection solution 0.4 mg/ml T1 QL (2 ML per 90 days)

naloxone hcl injection solution cartridge 0.4 mg/ml


naloxone hcl injection solution prefilled syringe 2 mg/2ml


NARCAN NASAL LIQUID 4 MG/0.1ML T1 QL (2 EA per 90 days)

*Antiemetics*AKYNZEO ORAL CAPSULE 300-0.5 MG T1 PA; QL (1 EA per 28 days)

aprepitant oral capsule 125 mg, 40 mg T1PA; QL (1 EA per 28 days); AL (Min 12 Years)

aprepitant oral capsule 80 & 125 mg T1PA; QL (3 EA per 28 days); AL (Min 12 Years)

aprepitant oral capsule 80 mg T1PA; QL (2 EA per 28 days); AL (Min 12 Years)

26

Drug Status Notesdimenhydrinate oral tablet 50 mg T1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg T1 PA

EMEND ORAL CAPSULE 40 MG T1QL (1 EA per 28 days); AL (Min 12 Years)

EMEND ORAL CAPSULE 80 MG T1QL (2 EA per 28 days); AL (Min 12 Years)

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML T1 PA; AL (Min 12 Years)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG T1

PA; QL (3 EA per 28 days); AL (Min 12 Years)

granisetron hcl oral tablet 1 mg T1

meclizine hcl oral tablet 12.5 mg, 25 mg T1

meclizine hcl oral tablet chewable 25 mg T1

ondansetron hcl oral solution 4 mg/5ml T1 QL (75 ML per 30 days)

ondansetron hcl oral tablet 24 mg T1 QL (30 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg T1 QL (15 EA per 25 days)

ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (15 EA per 25 days)

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR T1 PA; QL (6 EA per 30 days)

VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X 90 MG T1 PA; QL (2 EA per 7 days)

ZOFRAN ORAL TABLET 4 MG, 8 MG T1 PA; QL (15 EA per 25 days)

ZUPLENZ ORAL FILM 4 MG, 8 MG T1 PA

*Antifungals*ANCOBON ORAL CAPSULE 250 MG, 500 MG T1 PA

CRESEMBA ORAL CAPSULE 186 MG T1 PA

DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML T1 PA

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG T1 PA

DIFLUCAN ORAL TABLET 150 MG T1 PA; QL (2 EA per 28 days)

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

T1

fluconazole oral tablet 100 mg, 200 mg, 50 mg T1

fluconazole oral tablet 150 mg T1 QL (2 EA per 28 days)

flucytosine oral capsule 250 mg, 500 mg T1 PA

griseofulvin microsize oral suspension 125 mg/5ml

T1

griseofulvin microsize oral tablet 500 mg T1 PA

27

Drug Status Notesgriseofulvin ultramicrosize oral tablet 125 mg, 250 mg

T1 PA

itraconazole oral capsule 100 mg T1 PA; QL (84 EA per 30 days)

itraconazole oral solution 10 mg/ml T1 PA

ketoconazole oral tablet 200 mg T1 PA

NOXAFIL ORAL SUSPENSION 40 MG/ML T1 PA

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG T1 PA

nystatin oral tablet 500000 unit T1 PA

ONMEL ORAL TABLET 200 MG T1 PA

posaconazole oral tablet delayed release 100 mg T1 PA

SPORANOX ORAL CAPSULE 100 MG T1 PA; QL (84 EA per 30 days)

SPORANOX ORAL SOLUTION 10 MG/ML T1 PA; QL (840 ML per 30 days)

terbinafine hcl oral tablet 250 mg T1 QL (84 EA per 30 days)

tolsura oral capsule 65 mg T1 PA

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML T1 PA

VFEND ORAL TABLET 200 MG, 50 MG T1 PA

voriconazole oral suspension reconstituted 40 mg/ml

T1 PA

voriconazole oral tablet 200 mg, 50 mg T1 PA

*Antihistamines*aller-ease oral tablet 60 mg T1 PA

allergy relief childrens oral solution 1 mg/ml T1

allergy relief oral capsule 10 mg T1 PA

allergy relief oral tablet 5 mg T1

carbinoxamine maleate oral solution 4 mg/5ml T1

carbinoxamine maleate oral tablet 4 mg T1

cetirizine hcl allergy child oral solution 5 mg/5ml T1

cetirizine hcl childrens oral solution 5 mg/5ml T1 PA

cetirizine hcl oral solution 1 mg/ml T1

cetirizine hcl oral tablet 10 mg, 5 mg T1

cetirizine hcl oral tablet chewable 10 mg, 5 mg T1 PA

childrens loratadine oral syrup 5 mg/5ml T1

chlorpheniramine maleate er oral tablet extended release 12 mg

T1

chlorpheniramine maleate oral tablet 4 mg T1

CLARINEX ORAL TABLET 5 MG T1 PA

clemastine fumarate oral syrup 0.67 mg/5ml T1

28

Drug Status Notesclemastine fumarate oral tablet 1.34 mg, 2.68 mg T1

cyproheptadine hcl oral syrup 2 mg/5ml T1 AL (Max 64 Years)

cyproheptadine hcl oral tablet 4 mg T1 AL (Max 64 Years)

desloratadine oral tablet 5 mg T1 PA

desloratadine oral tablet dispersible 2.5 mg T1 PA; AL (Max 11 Years)

desloratadine oral tablet dispersible 5 mg T1 PA

diphenhydramine cough oral syrup 12.5 mg/5ml T1

diphenhydramine hcl injection solution 50 mg/ml T1 AL (Max 64 Years)

diphenhydramine hcl oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

diphenhydramine hcl oral liquid 12.5 mg/5ml T1

diphenhydramine hcl oral tablet 25 mg T1 AL (Max 64 Years)

fexofenadine hcl childrens oral suspension 30 mg/5ml

T1 PA

fexofenadine hcl oral tablet 180 mg, 60 mg T1 PA

gnp all day allergy childrens oral solution 1 mg/ml

T1

gnp allergy relief oral tablet dispersible 10 mg T1

gnp loratadine childrens oral tablet chewable 5 mg

T1

goodsense all day allergy oral solution 5 mg/5ml T1

goodsense aller-ease oral tablet 180 mg T1 PA

hm all day allergy oral solution 5 mg/5ml T1

hm cetirizine hcl childrens oral solution 5 mg/5ml T1

hm fexofenadine hcl oral tablet 180 mg, 60 mg T1 PA

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

T1 PA

levocetirizine dihydrochloride oral tablet 5 mg T1

loratadine oral capsule 10 mg T1

loratadine oral tablet 10 mg T1

promethazine hcl oral syrup 6.25 mg/5ml T1AL (Min 2 Years and Max 64 Years)

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

T1AL (Min 2 Years and Max 64 Years)

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg

T1AL (Min 2 Years and Max 64 Years)

qc childrens allergy oral solution 5 mg/5ml T1

qc fexofenadine hydrochloride oral tablet 180 mg T1 PA

sm all day allergy childrens oral solution 5 mg/5ml

T1

sm allergy relief oral tablet dispersible 10 mg T1

29

Drug Status Notessm fexofenadine hcl oral tablet 180 mg, 60 mg T1 PA

*Antihyperlipidemics*ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 40 MG, 60 MG T1 PA

ANTARA ORAL CAPSULE 30 MG, 90 MG T1 PA

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


atorvastatin calcium oral tablet 80 mg T1

cholestyramine light oral packet 4 gm T1

cholestyramine oral packet 4 gm T1

cholestyramine oral powder 4 gm/dose T1

colesevelam hcl oral packet 3.75 gm T1 PA

colesevelam hcl oral tablet 625 mg T1 PA

COLESTID FLAVORED ORAL GRANULES5 GM T1 PA

COLESTID FLAVORED ORAL PACKET 5 GM T1 PA

COLESTID ORAL GRANULES 5 GM T1 PA

COLESTID ORAL PACKET 5 GM T1 PA

COLESTID ORAL TABLET 1 GM T1 PA

colestipol hcl oral granules 5 gm T1 PA

colestipol hcl oral packet 5 gm T1 PA

colestipol hcl oral tablet 1 gm T1

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG T1 PA

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG T1 PA

ezetimibe oral tablet 10 mg T1

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

T1 PA

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

T1 PA

fenofibrate oral capsule 150 mg, 50 mg T1 PA

fenofibrate oral tablet 120 mg, 40 mg T1 PA

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

T1

fenofibric acid oral capsule delayed release 135 mg, 45 mg

T1 PA

fenofibric acid oral tablet 105 mg T1 PA

FENOGLIDE ORAL TABLET 120 MG, 40 MG T1 PA

30

Drug Status NotesFIBRICOR ORAL TABLET 105 MG, 35 MG T1 PA

fluvastatin sodium er oral tablet extended release 24 hour 80 mg


fluvastatin sodium oral capsule 20 mg, 40 mg T1 PA; QL (30 EA per 30 days)

gemfibrozil oral tablet 600 mg T1

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG T1 PA

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG T1 PA; QL (30 EA per 30 days)

LIPITOR ORAL TABLET 80 MG T1 PA

LIPOFEN ORAL CAPSULE 150 MG, 50 MG T1 PA

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG T1 PA; QL (30 EA per 30 days)

LOPID ORAL TABLET 600 MG T1 PA

lovastatin oral tablet 10 mg, 20 mg, 40 mg T1

LOVAZA ORAL CAPSULE 1 GM T1 PA

NEXLETOL ORAL TABLET 180 MG T1 PA; AL (Min 18 Years)

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

T1 PA

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG T1

omega-3-acid ethyl esters oral capsule 1 gm T1 PA

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML T1

PA; PDL-NP; QL (2 ML per 28 days)

PRAVACHOL ORAL TABLET 20 MG, 40 MG T1 PA; QL (30 EA per 30 days)

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


pravastatin sodium oral tablet 80 mg T1

PREVALITE ORAL POWDER 4 GM/DOSE T1

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE T1 PA

QUESTRAN ORAL PACKET 4 GM T1 PA

QUESTRAN ORAL POWDER 4 GM/DOSE T1 PA

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE420 MG/3.5ML

T1PA; PDL-P; QL (35 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML T1

PA; PDL-P; QL (2 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML T1


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

T1

31

Drug Status Notessimvastatin oral tablet 10 mg, 20 mg, 5 mg T1 QL (30 EA per 30 days)

simvastatin oral tablet 40 mg, 80 mg T1

TRICOR ORAL TABLET 145 MG, 48 MG T1 PA

TRIGLIDE ORAL TABLET 160 MG T1 PA

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG T1 PA

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM T1 PA

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG T1 PA

WELCHOL ORAL PACKET 3.75 GM T1 PA

WELCHOL ORAL TABLET 625 MG T1 PA

ZETIA ORAL TABLET 10 MG T1 PA

ZOCOR ORAL TABLET 10 MG, 20 MG T1 PA; QL (30 EA per 30 days)

ZOCOR ORAL TABLET 40 MG, 80 MG T1 PA

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG T1 PA

*Antihypertensives*ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG T1 PA

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG T1 PA

aliskiren fumarate oral tablet 150 mg, 300 mg T1 PA

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG T1 PA

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

T1

amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

T1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

T1 PA

amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

T1

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG T1 PA

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG T1 PA

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

T1

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG T1 PA

32

Drug Status NotesAVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG T1 PA

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG T1 PA

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

T1

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG T1 PA

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG T1 PA

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

T1

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

T1 PA

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

T1 PA

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

T1 PA

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

T1 PA

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG T1 PA; PDL-NP

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG T1 PA

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR T1 QL (4 EA per 30 days)



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

clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr


CORZIDE ORAL TABLET 40-5 MG, 80-5 MG T1 PA

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

T1 PA

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG T1 PA

33

Drug Status Notesdoxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

T1 PDL-P

EDARBI ORAL TABLET 40 MG, 80 MG T1 PA

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG T1 PA

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

T1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

T1 PA

EPANED ORAL SOLUTION 1 MG/ML T1 PA

eprosartan mesylate oral tablet 600 mg T1 PA

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

T1 PA

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG T1 PA

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg T1 PA

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

T1 PA

guanfacine hcl oral tablet 1 mg, 2 mg T1

hydralazine hcl injection solution 20 mg/ml T1

hydralazine hcl oral tablet 10 mg, 25 mg, 50 mg T1 QL (120 EA per 30 days)

hydralazine hcl oral tablet 100 mg T1 QL (90 EA per 30 days)

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG T1 PA

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

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

T1 PA

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

T1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

T1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

T1

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG T1 PA

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG T1 PA

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG T1 PA

34

Drug Status Notesmethyldopa oral tablet 250 mg, 500 mg T1

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

T1 PA

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

T1 PA

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG T1 PA

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG T1 PA

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG T1 PA; PDL-NP

minoxidil oral tablet 10 mg, 2.5 mg T1

moexipril hcl oral tablet 15 mg, 7.5 mg T1 PA

nadolol-bendroflumethiazide oral tablet 80-5 mg T1 PA

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

T1 PA

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

T1 PA

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

T1 PA

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

T1 PA

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg T1 PDL-P

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG T1 PA

propranolol-hctz oral tablet 40-25 mg, 80-25 mg T1 PA

QBRELIS ORAL SOLUTION 1 MG/ML T1 PA

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1 PA

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1 PA

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

T1 PA

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG T1 PA

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG T1 PA

TEKTURNA ORAL TABLET 150 MG, 300 MG T1 PA

telmisartan oral tablet 20 mg, 40 mg, 80 mg T1 PA

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

T1 PA

35

Drug Status Notestelmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

T1 PA

TENORETIC 100 ORAL TABLET 100-25 MG T1 PA

TENORETIC 50 ORAL TABLET 50-25 MG T1 PA

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

T1 PDL-P

trandolapril oral tablet 1 mg, 2 mg, 4 mg T1 PA

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

T1 PA

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

T1 PA

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

T1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

T1

VASERETIC ORAL TABLET 10-25 MG T1 PA

VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG T1 PA

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG T1 PA

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG T1 PA

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG T1 PA

*Anti-Infective Agents - Misc.*atovaquone oral suspension 750 mg/5ml T1 PA

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG T1

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

T1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml


dapsone oral tablet 100 mg, 25 mg T1

FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML T1

FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML T1

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML T1

FLAGYL ORAL CAPSULE 375 MG T1 PA

36

Drug Status NotesFLAGYL ORAL TABLET 250 MG, 500 MG T1 PA

linezolid oral suspension reconstituted 100 mg/5ml

T1 PA

linezolid oral tablet 600 mg T1 QL (28 EA per 30 days)

methenamine hippurate oral tablet 1 gm T1

methenamine mandelate oral tablet 0.5 gm, 1 gm T1

metronidazole oral capsule 375 mg T1 PA

metronidazole oral tablet 250 mg, 500 mg T1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg


nitrofurantoin monohyd macro oral capsule 100 mg


nitrofurantoin oral suspension 25 mg/5ml T1 AL (Max 12 Years)

SIVEXTRO ORAL TABLET 200 MG T1 PA; QL (14 EA per 30 days)

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

T1

tinidazole oral tablet 250 mg, 500 mg T1 PA

trimethoprim oral tablet 100 mg T1

VANCOCIN HCL ORAL CAPSULE 125 MG T1 PA

VANCOCIN ORAL CAPSULE 250 MG T1 PA

vancomycin hcl intravenous solution reconstituted10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg

T1

vancomycin hcl oral capsule 125 mg, 250 mg T1

vancomycin hcl oral solution reconstituted 250 mg/5ml

T1 PA

XIFAXAN ORAL TABLET 200 MG T1PA; QL (9 EA per 30 days); AL (Min 12 Years)

XIFAXAN ORAL TABLET 550 MG T1 PA; AL (Min 18 Years)

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML T1 PA

ZYVOX ORAL TABLET 600 MG T1 PA; QL (28 EA per 30 days)

*Antimalarials*chloroquine phosphate oral tablet 250 mg, 500 mg


hydroxychloroquine sulfate oral tablet 200 mg T1

KRINTAFEL ORAL TABLET 150 MG T1PA; QL (60 EA per 30 days); AL (Min 16 Years)

mefloquine hcl oral tablet 250 mg T1 PA

primaquine phosphate oral tablet 26.3 mg T1

37

Drug Status Notes

*Antimyasthenic/Cholinergic Agents*MESTINON ORAL SYRUP 60 MG/5ML T1 AL (Max 12 Years)

pyridostigmine bromide oral tablet 60 mg T1

*Antimycobacterial Agents*cycloserine oral capsule 250 mg T1 QL (12 EA per 30 days)

ethambutol hcl oral tablet 100 mg, 400 mg T1

isoniazid oral syrup 50 mg/5ml T1 AL (Max 12 Years)

isoniazid oral tablet 100 mg, 300 mg T1

pretomanid oral tablet 200 mg T1PA; QL (30 EA per 30 days); AL (Min 18 Years)

PRIFTIN ORAL TABLET 150 MG T1 QL (24 EA per 28 days)

pyrazinamide oral tablet 500 mg T1

rifabutin oral capsule 150 mg T1

rifampin oral capsule 150 mg, 300 mg T1

TRECATOR ORAL TABLET 250 MG T1

*Antineoplastics And Adjunctive Therapies*AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG T1 PA; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 10 MG T1 PA; QL (30 EA per 30 days)

ALKERAN ORAL TABLET 2 MG T1 PA

anastrozole oral tablet 1 mg T1

bexarotene oral capsule 75 mg T1 PA

bicalutamide oral tablet 50 mg T1

BRAFTOVI ORAL CAPSULE 50 MG T1 PA

capecitabine oral tablet 150 mg, 500 mg T1 PA

cyclophosphamide oral capsule 25 mg, 50 mg T1 QL (60 EA per 30 days)

DAURISMO ORAL TABLET 100 MG, 25 MG T1 PA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML T1 PA

EMCYT ORAL CAPSULE 140 MG T1 PA

ERIVEDGE ORAL CAPSULE 150 MG T1 PA; QL (30 EA per 30 days)

ERLEADA ORAL TABLET 60 MG T1 PA; QL (120 EA per 30 days)

etoposide oral capsule 50 mg T1 PA

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg T1 PA; QL (30 EA per 30 days)

exemestane oral tablet 25 mg T1

FARESTON ORAL TABLET 60 MG T1 PA

38

Drug Status NotesFARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG T1 PA

flutamide oral capsule 125 mg T1 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG T1 PA

HEXALEN ORAL CAPSULE 50 MG T1 PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG T1 PA

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

T1 PA; PDL-P

hydroxyurea oral capsule 500 mg T1

IDHIFA ORAL TABLET 100 MG, 50 MG T1 PA

INTRON A INJECTION SOLUTION10000000 UNIT/ML, 6000000 UNIT/ML T1 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

T1 PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG T1 PA; QL (60 EA per 30 days)

letrozole oral tablet 2.5 mg T1QL (30 EA per 30 days); AL (Min 18 Years)

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

T1

LEUKERAN ORAL TABLET 2 MG T1 PA

leuprolide acetate injection kit 1 mg/0.2ml T1 PA

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG T1 PA

LYSODREN ORAL TABLET 500 MG T1 PA

MATULANE ORAL CAPSULE 50 MG T1 PA

megestrol acetate oral suspension 400 mg/10ml T1

megestrol acetate oral tablet 20 mg, 40 mg T1

mercaptopurine oral tablet 50 mg T1

MESNEX ORAL TABLET 400 MG T1 PA

methotrexate oral tablet 2.5 mg T1

methotrexate sodium (pf) injection solution 25 mg/ml, 50 mg/2ml

T1

methotrexate sodium injection solution 25 mg/ml, 50 mg/2ml

T1

MYLERAN ORAL TABLET 2 MG T1 PA

nilutamide oral tablet 150 mg T1 PA

NUBEQA ORAL TABLET 300 MG T1 PA

39

Drug Status NotesODOMZO ORAL CAPSULE 200 MG T1 PA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG T1 PA; QL (30 EA per 30 days)

TABLOID ORAL TABLET 40 MG T1 PA

tamoxifen citrate oral tablet 10 mg, 20 mg T1 QL (60 EA per 30 days)

TAZVERIK ORAL TABLET 200 MG T1 PA

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

T1 PA

TIBSOVO ORAL TABLET 250 MG T1 PA; QL (60 EA per 30 days)

tretinoin oral capsule 10 mg T1 PA

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG T1 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

T1 PA

XATMEP ORAL SOLUTION 2.5 MG/ML T1 PA

XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA



XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA

XTANDI ORAL CAPSULE 40 MG T1 PA; QL (120 EA per 30 days)

ZOLINZA ORAL CAPSULE 100 MG T1 PA

ZYTIGA ORAL TABLET 250 MG T1 PA; QL (120 EA per 30 days)

*Antiparkinson And Related Therapy Agents*amantadine hcl oral capsule 100 mg T1

amantadine hcl oral syrup 50 mg/5ml T1

amantadine hcl oral tablet 100 mg T1 PA

AZILECT ORAL TABLET 0.5 MG, 1 MG T1 PA; AL (Min 18 Years)

bromocriptine mesylate oral capsule 5 mg T1 PA

bromocriptine mesylate oral tablet 2.5 mg T1 PA

carbidopa oral tablet 25 mg T1 PA

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

T1 PA

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

T1

40

Drug Status Notescarbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

T1 PA

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

T1 PA

COMTAN ORAL TABLET 200 MG T1 PA

DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML T1 PA

entacapone oral tablet 200 mg T1 PA

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG, 68.5 MG T1 PA

INBRIJA INHALATION CAPSULE 42 MG T1 PA

LODOSYN ORAL TABLET 25 MG T1 PA

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

T1 PA

MIRAPEX ORAL TABLET 1.5 MG T1 PA

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

T1 PA

NOURIANZ ORAL TABLET 20 MG, 40 MG T1 PA

OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG, 193 MG, 258 MG

T1 PA

PARLODEL ORAL CAPSULE 5 MG T1 PA

PARLODEL ORAL TABLET 2.5 MG T1 PA

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

T1 PA

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

T1

rasagiline mesylate oral tablet 0.5 mg, 1 mg T1 PA; AL (Min 18 Years)

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 4 MG, 6 MG, 8 MG

T1 PA

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

T1 PA

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

T1

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

T1 PA

41

Drug Status Notesselegiline hcl oral capsule 5 mg T1 PA

selegiline hcl oral tablet 5 mg T1 PA

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG T1 PA

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG T1 PA

STALEVO 100 ORAL TABLET 25-100-200 MG T1 PA

STALEVO 125 ORAL TABLET 31.25-125-200 MG T1 PA


STALEVO 200 ORAL TABLET 50-200-200 MG T1 PA



TASMAR ORAL TABLET 100 MG T1 PA

tolcapone oral tablet 100 mg T1 PA

XADAGO ORAL TABLET 100 MG, 50 MG T1 PA

ZELAPAR ORAL TABLET DISPERSIBLE1.25 MG T1 PA

*Antipsychotics/Antimanic Agents*prochlorperazine maleate oral tablet 10 mg, 5 mg T1 QL (120 EA per 30 days)

prochlorperazine rectal suppository 25 mg T1 QL (60 EA per 30 days)

*Antiseptics & Disinfectants*povidone-iodine external solution 10 % T1

*Antivirals*acyclovir oral capsule 200 mg T1

acyclovir oral suspension 200 mg/5ml T1

acyclovir oral tablet 400 mg, 800 mg T1

adefovir dipivoxil oral tablet 10 mg T1 QL (30 EA per 30 days)

entecavir oral tablet 0.5 mg, 1 mg T1 QL (30 EA per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg T1

FLUMADINE ORAL TABLET 100 MG T1 PA

lamivudine oral tablet 100 mg T1 QL (30 EA per 30 days)

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg


42

Drug Status Notesoseltamivir phosphate oral suspension reconstituted 6 mg/ml


RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER


rimantadine hcl oral tablet 100 mg T1

SITAVIG BUCCAL TABLET 50 MG T1 PA

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG T1 QL (14 EA per 30 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML T1 QL (120 ML per 30 days)

valacyclovir hcl oral tablet 1 gm, 500 mg T1

valganciclovir hcl oral tablet 450 mg T1 PA; QL (60 EA per 30 days)

VALTREX ORAL TABLET 1 GM, 500 MG T1 PA

VEMLIDY ORAL TABLET 25 MG T1 PA; QL (30 EA per 30 days)

XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 X 20 MG T1

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 X 40 MG T1

ZOVIRAX ORAL SUSPENSION 200 MG/5ML T1 PA

*Beta Blockers*acebutolol hcl oral capsule 200 mg, 400 mg T1 PA

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

BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG T1 PA

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG T1 PA

betaxolol hcl oral tablet 10 mg, 20 mg T1 PA

bisoprolol fumarate oral tablet 10 mg, 5 mg T1 PA

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG T1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

T1

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

T1 PA

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG

T1 PA

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG T1 PA

43

Drug Status NotesCORGARD ORAL TABLET 20 MG, 40 MG, 80 MG T1 PA

HEMANGEOL ORAL SOLUTION 4.28 MG/ML T1 PA

INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG

T1 PA

INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG T1 PA

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

T1 PA

KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG

T1 PA

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg T1

LOPRESSOR ORAL TABLET 100 MG, 50 MG T1 PA

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

T1

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

T1

nadolol oral tablet 20 mg, 40 mg, 80 mg T1 PA

pindolol oral tablet 10 mg, 5 mg T1 PA

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

T1

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

T1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

T1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg T1

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

T1

SOTYLIZE ORAL SOLUTION 5 MG/ML T1 PA

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA

timolol maleate oral tablet 10 mg, 20 mg, 5 mg T1 PA

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

T1 PA

*Calcium Channel Blockers*ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG T1 PA

44

Drug Status Notesamlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

T1

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG T1 PA

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

T1 PA

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

T1 PA

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG T1 PA

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

T1

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

T1

diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg

T1

diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 360 mg, 420 mg

T1 PA

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

T1

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

T1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

T1

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

T1

felodipine er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

T1 PA

isradipine oral capsule 2.5 mg, 5 mg T1 PA

KATERZIA ORAL SUSPENSION 1 MG/ML T1 PA

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

T1 PA

nicardipine hcl oral capsule 20 mg, 30 mg T1 PA

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG T1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg, 90 mg

T1

nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 mg

T1

45

Drug Status Notesnifedipine oral capsule 10 mg, 20 mg T1

nimodipine oral capsule 30 mg T1 QL (21 EA per 365 days)

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

T1 PA

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG T1 PA

PROCARDIA ORAL CAPSULE 10 MG T1 PA

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

T1 PA

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG T1 PA

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

T1

TIADYLT ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

T1 PA

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

T1 PA

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

T1 PA

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

T1

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg T1

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

T1 PA

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

T1 PA

*Cardiotonics*digoxin oral tablet 125 mcg, 250 mcg T1

*Cardiovascular Agents - Misc.*ADCIRCA ORAL TABLET 20 MG T1 PA

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG T1 PA

ALYQ ORAL TABLET 20 MG T1 PA

ambrisentan oral tablet 10 mg, 5 mg T1 PA

46

Drug Status Notesamlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

T1 PA

bosentan oral tablet 125 mg, 62.5 mg T1 PA

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

T1 PA

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG T1 QL (60 EA per 30 days)

LETAIRIS ORAL TABLET 10 MG, 5 MG T1 PA

niacin flush free oral capsule 500 mg T1

NIACIN FLUSH-FREE EX ST ORAL CAPSULE 750 MG T1

OPSUMIT ORAL TABLET 10 MG T1 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

T1 PA

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML T1 PA

REVATIO ORAL TABLET 20 MG T1 PA

sildenafil citrate oral suspension reconstituted 10 mg/ml

T1 PA

sildenafil citrate oral tablet 20 mg T1 PA

tadalafil (pah) oral tablet 20 mg T1 PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG T1 PA

TRACLEER ORAL TABLET SOLUBLE 32 MG T1 PA

TYVASO INHALATION SOLUTION 0.6 MG/ML T1 PA

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML T1 PA

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML T1 PA

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

T1 PA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG T1 PA

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML T1 PA

47

Drug Status Notes

VYNDAMAX ORAL CAPSULE 61 MG T1PA; QL (30 EA per 30 days); AL (Min 18 Years)

VYNDAQEL ORAL CAPSULE 20 MG T1PA; QL (120 EA per 30 days); AL (Min 18 Years)

*Cephalosporins*cefaclor er oral tablet extended release 12 hour500 mg


cefaclor oral capsule 250 mg, 500 mg T1 PA; QL (42 EA per 30 days)

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

T1 PA

cefadroxil oral capsule 500 mg T1 QL (28 EA per 30 days)

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

T1

cefadroxil oral tablet 1 gm T1 PA; QL (28 EA per 30 days)

cefdinir oral capsule 300 mg T1 QL (28 EA per 30 days)

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cefixime oral capsule 400 mg T1 PA

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

T1

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

T1 PA

cefpodoxime proxetil oral tablet 100 mg, 200 mg T1 PA; QL (28 EA per 30 days)

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cefprozil oral tablet 250 mg, 500 mg T1 QL (28 EA per 30 days)

ceftriaxone sodium injection solution reconstituted 250 mg


cefuroxime axetil oral tablet 250 mg, 500 mg T1 QL (42 EA per 30 days)

cephalexin oral capsule 250 mg, 500 mg, 750 mg T1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cephalexin oral tablet 250 mg, 500 mg T1

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG T1 PA

SUPRAX ORAL CAPSULE 400 MG T1 PA

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML, 500 MG/5ML

T1 PA

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG T1 PA

48

Drug Status Notes

*Contraceptives*AMETHYST ORAL TABLET 90-20 MCG T1

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG T1

AVIANE ORAL TABLET 0.1-20 MG-MCG T1

BALZIVA ORAL TABLET 0.4-35 MG-MCG T1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

T1

ELLA ORAL TABLET 30 MG T1

ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg

T1

GIANVI ORAL TABLET 3-0.02 MG T1

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG T1

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) T1

LARIN 24 FE ORAL TABLET 1-20 MG-MCG(24) T1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

T1

levonorgestrel oral tablet 0.75 mg T1 GR-F

levonorgestrel oral tablet 1.5 mg T1

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG T1

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG T1

medroxyprogesterone acetate intramuscular suspension 150 mg/ml


MICROGESTIN FE 1.5/30 ORAL TABLET1.5-30 MG-MCG T1

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG T1

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG T1

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG T1

NECON 10/11 (28) ORAL TABLET 35 MCG T1 GR-F

NORA-BE ORAL TABLET 0.35 MG T1

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

T1

norethindrone acet-ethinyl est oral tablet 1.5-30 mg-mcg

T1

49

Drug Status Notesnorethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

T1

norethin-eth estradiol-fe tablet chewable 0.4-35 mg-mcg oral 0.4-35 mg-mcg

T1

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG T1

NUVARING VAGINAL RING 0.12-0.015 MG/24HR T1 QL (3 EA per 84 days)

OGESTREL ORAL TABLET 0.5-50 MG-MCG T1 GR-F

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG T1

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG T1

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG T1

TRINESSA LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG T1

TRI-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-35 MCG T1

TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG T1

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG T1

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR T1 QL (9 EA per 84 days)

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG T1

*Corticosteroids*budesonide er oral tablet extended release 24 hour 9 mg

T1 PA

dexamethasone oral elixir 0.5 mg/5ml T1

dexamethasone oral solution 0.5 mg/5ml T1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

T1

EMFLAZA ORAL SUSPENSION 22.75 MG/ML T1 PA; AL (Min 2 Years)

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG T1 PA; AL (Min 2 Years)

fludrocortisone acetate oral tablet 0.1 mg T1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg T1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

T1

50

Drug Status Notesmethylprednisolone oral tablet therapy pack 4 mg T1

prednisolone oral solution 15 mg/5ml T1

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

T1

prednisone (pak) oral tablet 5 mg T1

prednisone oral solution 5 mg/5ml T1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

T1

prednisone oral tablet therapy pack 10 mg (21), 5 mg (21)

T1

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG T1 PA

*Cough/Cold/Allergy*acetylcysteine inhalation solution 10 %, 20 % T1

cheratussin ac oral solution 100-10 mg/5ml T1 QL (240 ML per 30 days)

cheratussin dac oral solution 30-10-100 mg/5ml T1 QL (240 ML per 30 days)

dextromethorphan-guaifenesin oral solution 10-100 mg/5ml


guaifenesin oral solution 100 mg/5ml T1

guaifenesin oral syrup 100 mg/5ml T1

guaifenesin oral tablet 200 mg, 400 mg T1

guaifenesin-dm oral syrup 100-10 mg/5ml T1 QL (240 ML per 30 days)

loratadine-d 12hr oral tablet extended release 12 hour 5-120 mg

T1

loratadine-d 24hr oral tablet extended release 24 hour 10-240 mg

T1

promethazine-dm oral syrup 6.25-15 mg/5ml T1 QL (240 ML per 30 days)

pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml


sodium chloride inhalation nebulization solution0.9 %, 7 %

T1

tussin dm max adult oral liquid 10-200 mg/5ml T1 QL (240 ML per 30 days)

*Dermatologicals*ACANYA EXTERNAL GEL 1.2-2.5 % T1 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg T1 PA

acyclovir external cream 5 % T1 PA

acyclovir external ointment 5 % T1 PA

ALA SCALP EXTERNAL LOTION 2 % T1 PA

ala-cort external cream 1 % T1 PA

51

Drug Status Notesalclometasone dipropionate external cream 0.05 %

T1 PA

alclometasone dipropionate external ointment0.05 %

T1 PA

amcinonide external cream 0.1 % T1 PA

amcinonide external lotion 0.1 % T1 PA

ammonium lactate external cream 12 % T1 QL (140 GM per 30 days)

ammonium lactate external lotion 12 % T1 QL (225 GM per 30 days)

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

ANECREAM CREAM 4 % EXTERNAL 4 % T1

antifungal external cream 1 % T1

anti-itch maximum strength external cream 1 % T1

APEXICON E EXTERNAL CREAM 0.05 % T1 PA

AQUA GLYCOLIC HC SCALP & BODY EXTERNAL KIT 2 % T1 PA

ASPERCREME LIDOCAINE PATCH 4 % EXTERNAL 4 % T1 QL (30 EA per 30 days)

ASPERCREME W/LIDOCAINE CREAM 4 % EXTERNAL 4 % T1

bacitracin external ointment 500 unit/gm T1

bacitracin zinc external ointment 500 unit/gm T1

BASIS OVERNIGHT EXTERNAL CREAM T1

BENZACLIN EXTERNAL GEL 1-5 % T1 PA

BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % T1 PA

benzoyl peroxide creamy wash external liquid† 4 %

T1

benzoyl peroxide external gel 10 % T1 QL (113.4 GM per 30 days)

benzoyl peroxide external gel 2.5 %, 5 % T1

benzoyl peroxide wash external liquid 10 %, 5 % T1

BESER EXTERNAL KIT 0.05 % T1 PA

BESER EXTERNAL LOTION 0.05 % T1 PA

betamethasone dipropionate aug external cream0.05 %

T1 PA

betamethasone dipropionate aug external gel 0.05 %

T1 PA

betamethasone dipropionate aug external lotion0.05 %

T1 PA

betamethasone dipropionate aug external ointment 0.05 %

T1 PA

52

Drug Status Notesbetamethasone dipropionate external cream 0.05 %

T1 PA

betamethasone dipropionate external lotion 0.05 %

T1 PA

betamethasone dipropionate external ointment0.05 %

T1 PA

betamethasone valerate external cream 0.1 % T1

betamethasone valerate external foam 0.12 % T1 PA

betamethasone valerate external lotion 0.1 % T1

betamethasone valerate external ointment 0.1 % T1

BRYHALI EXTERNAL LOTION 0.01 % T1 PA

butenafine hcl external cream 1 % T1 PA

calcipotriene external ointment 0.005 % T1 PA; QL (120 GM per 30 days)

calcipotriene external solution 0.005 % T1 PA; QL (60 ML per 30 days)

CAPEX EXTERNAL SHAMPOO 0.01 % T1 PA

capsaicin external cream 0.025 %, 0.075 %, 0.1 %

T1

CENTANY AT EXTERNAL KIT 2 % T1 PA

CENTANY EXTERNAL OINTMENT 2 % T1 PA

CICLODAN CREAM EXTERNAL KIT 0.77 % T1 PA

CICLODAN EXTERNAL CREAM 0.77 % T1 PA

CICLODAN SOLUTION EXTERNAL KIT 8 % T1 PA

ciclopirox external gel 0.77 % T1 PA

ciclopirox external shampoo 1 % T1 PA

ciclopirox external solution 8 % T1 PA

ciclopirox olamine external cream 0.77 % T1 PA

ciclopirox olamine external suspension 0.77 % T1

ciclopirox treatment external kit 8 % T1 PA

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG T1 PA; QL (60 EA per 30 days)

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 %

T1 PA

clindamycin phosphate external solution 1 % T1 QL (180 ML per 30 days)

clindamycin phosphate external swab 1 % T1 QL (60 EA per 30 days)

clobetasol propionate e external cream 0.05 % T1 PA

clobetasol propionate emulsion external foam0.05 %

T1 PA

clobetasol propionate external cream 0.05 % T1

53

Drug Status Notesclobetasol propionate external foam 0.05 % T1 PA

clobetasol propionate external gel 0.05 % T1

clobetasol propionate external liquid 0.05 % T1 PA

clobetasol propionate external lotion 0.05 % T1 PA

clobetasol propionate external ointment 0.05 % T1

clobetasol propionate external shampoo 0.05 % T1 PA

clobetasol propionate external solution 0.05 % T1

CLOBEX EXTERNAL LOTION 0.05 % T1 PA

CLOBEX EXTERNAL SHAMPOO 0.05 % T1 PA

CLOBEX SPRAY EXTERNAL LIQUID 0.05 % T1 PA

clocortolone pivalate external cream 0.1 % T1 PA

clocortolone pivalate pump external cream 0.1 % T1 PA

CLODAN EXTERNAL KIT 0.05 % T1 PA

CLODAN EXTERNAL SHAMPOO 0.05 % T1 PA

CLODERM EXTERNAL CREAM 0.1 % T1 PA

CLODERM PUMP EXTERNAL CREAM 0.1 % T1 PA

clotrimazole external cream 1 % T1

clotrimazole external solution 1 % T1

clotrimazole-betamethasone external cream 1-0.05 %

T1

clotrimazole-betamethasone external lotion 1-0.05 %

T1 PA

CORDRAN EXTERNAL TAPE 4 MCG/SQCM T1 PA

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

T1

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

T1

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

T1

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML T1

CUTIVATE EXTERNAL CREAM 0.05 % T1 PA

CUTIVATE EXTERNAL LOTION 0.05 % T1 PA

DENAVIR EXTERNAL CREAM 1 % T1

54

Drug Status NotesDERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % T1 PA

DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % T1 PA

DERMASORB HC EXTERNAL KIT 2 % T1 PA

DERMASORB TA EXTERNAL KIT 0.1 % T1 PA

DERMATOP EXTERNAL OINTMENT 0.1 % T1 PA

DESONATE EXTERNAL GEL 0.05 % T1 PA

desonide external cream 0.05 % T1 PA

desonide external lotion 0.05 % T1 PA

desonide external ointment 0.05 % T1 PA

DESOWEN EXTERNAL CREAM 0.05 % T1 PA

desoximetasone external cream 0.05 %, 0.25 % T1 PA

desoximetasone external gel 0.05 % T1 PA

desoximetasone external liquid 0.25 % T1 PA

desoximetasone external ointment 0.05 %, 0.25 % T1 PA

diclofenac epolamine transdermal patch 1.3 % T1 PA; QL (60 EA per 30 days)

diclofenac sodium transdermal gel 1 % T1

diclofenac sodium transdermal gel 3 % T1 PA

diclofenac sodium transdermal solution 1.5 % T1

DIFFERIN GEL 0.1 % EXTERNAL (OTC)0.1 % T1 QL (45 GM per 30 days)

diflorasone diacetate external cream 0.05 % T1 PA

diflorasone diacetate external ointment 0.05 % T1 PA

DIPROLENE EXTERNAL OINTMENT 0.05 % T1 PA

docosanol external cream 10 % T1

DRYSOL EXTERNAL SOLUTION 20 % T1

DUAC EXTERNAL GEL 1.2-5 % T1 PA

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML

T1 PA

econazole nitrate external cream 1 % T1 PA

ELIDEL EXTERNAL CREAM 1 % T1PA; QL (30 GM per 30 days); AL (Min 2 Years)

ELOCON EXTERNAL CREAM 0.1 % T1 PA

ERTACZO EXTERNAL CREAM 2 % T1 PA

erythromycin external solution 2 % T1

EUCERIN EXTERNAL CREAM T1

55

Drug Status NotesEUCRISA EXTERNAL OINTMENT 2 % T1 PA; QL (100 GM per 30 days)

EXELDERM EXTERNAL CREAM 1 % T1 PA

EXELDERM EXTERNAL SOLUTION 1 % T1 PA

EXTINA EXTERNAL FOAM 2 % T1 PA

FLECTOR TRANSDERMAL PATCH 1.3 % T1 PA; QL (60 EA per 30 days)

fluocinolone acetonide body external oil 0.01 % T1 PA

fluocinolone acetonide external cream 0.01 %, 0.025 %

T1 PA

fluocinolone acetonide external ointment 0.025 % T1 PA

fluocinolone acetonide external solution 0.01 % T1 PA

fluocinolone acetonide scalp external oil 0.01 % T1 PA

fluocinonide external cream 0.05 %, 0.1 % T1 PA

fluocinonide external gel 0.05 % T1 PA

fluocinonide external ointment 0.05 % T1 PA

fluocinonide external solution 0.05 % T1 PA

fluocinonide-e external cream 0.05 % T1 PA

fluorouracil external cream 0.5 %, 5 % T1 PA

flurandrenolide external cream 0.05 % T1 PA

flurandrenolide external lotion 0.05 % T1 PA

flurandrenolide external ointment 0.05 % T1 PA

fluticasone propionate external cream 0.05 % T1

fluticasone propionate external lotion 0.05 % T1 PA

fluticasone propionate external ointment 0.005 % T1

FUNGOID-D EXTERNAL CREAM 1 % T1 PA

gentamicin sulfate external cream 0.1 % T1

gentamicin sulfate external ointment 0.1 % T1

gnp hydrocortisone/aloe external cream 1 % T1

gnp tolnaftate external cream 1 % T1

halcinonide external cream 0.1 % T1 PA

halobetasol propionate external cream 0.05 % T1

halobetasol propionate external foam 0.05 % T1 PA

halobetasol propionate external ointment 0.05 % T1

HALOG EXTERNAL CREAM 0.1 % T1 PA

HALOG EXTERNAL OINTMENT 0.1 % T1 PA

hm hydrocortisone-aloe max st external cream 1 %

T1

hydrocortisone acetate external ointment 1 % T1

hydrocortisone butyr lipo base external cream 0.1 %

T1 PA

56

Drug Status Noteshydrocortisone butyrate external cream 0.1 % T1 PA

hydrocortisone butyrate external lotion 0.1 % T1 PA

hydrocortisone butyrate external ointment 0.1 % T1 PA

hydrocortisone butyrate external solution 0.1 % T1 PA

hydrocortisone external cream 0.5 %, 1 %, 2.5 % T1

hydrocortisone external lotion 1 %, 2.5 % T1

hydrocortisone external ointment 0.5 %, 1 %, 2.5 %

T1

hydrocortisone max st/12 moist external cream 1 %

T1

hydrocortisone valerate external cream 0.2 % T1 PA

hydrocortisone valerate external ointment 0.2 % T1 PA

hydrocortisone-aloe external cream 0.5 % T1

hydrocortisone-aloe external cream 1 % T1 PA

ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML T1 PA

imiquimod external cream 5 % T1 QL (12 EA per 28 days)

isopropyl alcohol wipes external 70 % T1

isotretinoin capsule 10 mg oral 10 mg T1 PA; QL (60 EA per 30 days)




JUBLIA EXTERNAL SOLUTION 10 % T1 PA

KENALOG EXTERNAL AEROSOL SOLUTION 0.147 MG/GM T1 PA

KERYDIN EXTERNAL SOLUTION 5 % T1 PA

ketoconazole external cream 2 % T1

ketoconazole external foam 2 % T1 PA

ketoconazole external shampoo 2 % T1

KETODAN EXTERNAL FOAM 2 % T1 PA

KETODAN EXTERNAL KIT 2 % T1 PA

lc-4 lidocaine cream 4 % external 4 % T1

LEXETTE EXTERNAL FOAM 0.05 % T1 PA

lice killing maximum strength external shampoo0.33-4 %


lice treatment external liquid 0.33-4 % T1 QL (60 ML per 30 days)

lice treatment external liquid 1 % T1 QL (120 ML per 30 days)

LICIDE TREATMENT COMBINATION KITT1 QL (1 EA per 30 days)

lidocaine cream 4 % external 4 % T1

57

Drug Status Noteslidocaine hcl external gel 2 % T1

lidocaine-prilocaine external cream 2.5-2.5 % T1 QL (30 GM per 30 days)

LIDOCREAM CREAM 4 % EXTERNAL 4 % T1

lindane external lotion 1 % T1 QL (60 ML per 30 days)

lindane external shampoo 1 % T1 QL (60 ML per 30 days)

LMX 4 CREAM 4 % EXTERNAL 4 % T1

LOCOID EXTERNAL CREAM 0.1 % T1 PA

LOCOID EXTERNAL LOTION 0.1 % T1 PA

LOCOID EXTERNAL SOLUTION 0.1 % T1 PA

LOCOID LIPOCREAM EXTERNAL CREAM 0.1 % T1 PA

LOPROX EXTERNAL CREAM 0.77 % T1 PA

LOPROX EXTERNAL KIT 0.77 %, 0.77 % (SUSP) T1 PA

LOPROX EXTERNAL SHAMPOO 1 % T1 PA

LOPROX EXTERNAL SUSPENSION 0.77 % T1 PA

LOTRIMIN AF EXTERNAL CREAM 1 % T1 PA

LOTRISONE EXTERNAL CREAM 1-0.05 % T1 PA

luliconazole external cream 1 % T1 PA

LUXIQ EXTERNAL FOAM 0.12 % T1 PA

LUZU EXTERNAL CREAM 1 % T1 PA

malathion external lotion 0.5 % T1 ST; QL (59 ML per 30 days)

MENTAX EXTERNAL CREAM 1 % T1 PA

metronidazole external cream 0.75 % T1

metronidazole external gel 0.75 % T1

miconazole nitrate external cream 2 % T1

miconazole-zinc oxide-petrolat external ointment0.25-15-81.35 %

T1 PA

MICORT-HC EXTERNAL CREAM 2.5 % T1 PA

mometasone furoate external cream 0.1 % T1

mometasone furoate external ointment 0.1 % T1

mometasone furoate external solution 0.1 % T1

mupirocin calcium external cream 2 % T1 PA

mupirocin external ointment 2 % T1

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

MYORISAN ORAL CAPSULE 30 MG T1 PA

naftifine hcl external cream 1 %, 2 % T1 PA

naftifine hcl external gel 1 % T1 PA

58

Drug Status NotesNAFTIN EXTERNAL CREAM 2 % T1 PA

NAFTIN EXTERNAL GEL 1 %, 2 % T1 PA

NEUAC EXTERNAL GEL 1.2-5 % T1 PA

NEUAC EXTERNAL KIT 1.2-5 % T1 PA

NIZORAL EXTERNAL SHAMPOO 2 % T1 PA

nystatin external cream 100000 unit/gm T1

nystatin external ointment 100000 unit/gm T1

nystatin external powder 100000 unit/gm T1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

T1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

T1

OLUX EXTERNAL FOAM 0.05 % T1 PA

OLUX-E EXTERNAL FOAM 0.05 % T1 PA

ONEXTON EXTERNAL GEL 1.2-3.75 % T1 PA

oxiconazole nitrate external cream 1 % T1 PA

OXISTAT EXTERNAL CREAM 1 % T1 PA

OXISTAT EXTERNAL LOTION 1 % T1 PA

PANDEL EXTERNAL CREAM 0.1 % T1 PA

PENNSAID TRANSDERMAL SOLUTION 2 % T1 PA

permethrin external cream 5 % T1 QL (60 GM per 30 days)

permethrin lice treatment external lotion 1 % T1 QL (59 ML per 30 days)

pimecrolimus external cream 1 % T1PA; QL (30 GM per 30 days); AL (Min 2 Years)

podofilox external solution 0.5 % T1

prednicarbate external cream 0.1 % T1 PA

prednicarbate external ointment 0.1 % T1 PA

PROTOPIC EXTERNAL OINTMENT 0.03 % T1PA; QL (30 GM per 30 days); AL (Min 2 Years)

PROTOPIC EXTERNAL OINTMENT 0.1 % T1PA; QL (30 GM per 30 days); AL (Min 15 Years)

psorcon external cream 0.05 % T1 PA

qc tolnaftate external cream 1 % T1

RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 % T1 QL (177 ML per 30 days)

sanadermrx skin repair external kit 0.1 & 5 % T1 PA

SANTYL EXTERNAL OINTMENT 250 UNIT/GM T1 QL (60 GM per 30 days)

59

Drug Status NotesSCALPICIN MAXIMUM STRENGTH EXTERNAL SOLUTION 1 % T1 PA

selenium sulfide external lotion 2.5 % T1

SERNIVO EXTERNAL EMULSION 0.05 % T1 PA

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML T1 PA

silver sulfadiazine external cream 1 % T1

SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML T1 PA

sm antifungal tolnaftate external cream 1 % T1

sm hydrocortisone external cream 1 % T1 PA

spinosad external suspension 0.9 % T1 ST; QL (240 ML per 180 days)

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML T1 PA

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

T1 PA

sulfacetamide sodium (acne) external lotion 10 % T1

sulfacetamide sodium-sulfur external emulsion10-5 %

T1

SYNALAR (CREAM) EXTERNAL KIT 0.025 % T1 PA

SYNALAR (OINTMENT) EXTERNAL KIT0.025 % T1 PA

SYNALAR EXTERNAL CREAM 0.025 % T1 PA

SYNALAR EXTERNAL OINTMENT 0.025 % T1 PA

SYNALAR EXTERNAL SOLUTION 0.01 % T1 PA

SYNALAR TS EXTERNAL KIT 0.01 % T1 PA

tacrolimus external ointment 0.03 % T1PA; QL (30 GM per 30 days); AL (Min 2 Years)

tacrolimus external ointment 0.1 % T1PA; QL (30 GM per 30 days); AL (Min 15 Years)

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML T1 PA

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 80 MG/ML T1 PA

TEMOVATE EXTERNAL CREAM 0.05 % T1 PA

TEMOVATE EXTERNAL OINTMENT 0.05 % T1 PA

terbinafine hcl external cream 1 % T1

TEXACORT EXTERNAL SOLUTION 2.5 % T1 PA

60

Drug Status Notestolnaftate external aerosol powder 1 % T1

tolnaftate external cream 1 % T1

tolnaftate external powder 1 % T1

TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % T1 PA

TOPICORT EXTERNAL GEL 0.05 % T1 PA

TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % T1 PA

TOPICORT SPRAY EXTERNAL LIQUID0.25 % T1 PA

TOVET EXTERNAL FOAM 0.05 % T1 PA

TOVET EXTERNAL KIT 0.05 % T1 PA

TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 MG/ML T1 PA

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML T1 PA

tretinoin external cream 0.025 % T1 QL (20 GM per 30 days)

triamcinolone acetonide external aerosol solution0.147 mg/gm

T1 PA

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

T1

triamcinolone acetonide external lotion 0.025 %, 0.1 %

T1

triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 %, 0.5 %

T1

TRIANEX EXTERNAL OINTMENT 0.05 % T1 PA

triple antibiotic external ointment 3.5-400-5000 T1

trixaicin external cream 0.025 % T1

ULTRAVATE EXTERNAL CREAM 0.05 % T1 PA

ULTRAVATE EXTERNAL LOTION 0.05 % T1 PA

ULTRAVATE EXTERNAL OINTMENT 0.05 % T1 PA

ULTRAVATE X (CREAM) EXTERNAL KIT0.05 & 10 % T1 PA

ULTRAVATE X (OINTMENT) EXTERNAL KIT 0.05 & 10 % T1 PA

urea external cream 40 % T1 QL (85 GM per 30 days)

VANOS EXTERNAL CREAM 0.1 % T1 PA

vitamin e external liquid 24000 unit T1

vitamin e skin external oil 56000 unit T1

VOLTAREN TRANSDERMAL GEL 1 % T1 PA

61

Drug Status NotesVUSION EXTERNAL OINTMENT 0.25-15-81.35 % T1 PA

XERESE EXTERNAL CREAM 5-1 % T1 PA

ZENATANE ORAL CAPSULE 10 MG T1 PA

ZENATANE ORAL CAPSULE 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

ZOVIRAX EXTERNAL CREAM 5 % T1

ZOVIRAX EXTERNAL OINTMENT 5 % T1 PA

*Diagnostic Products*BAYER CONTOUR NEXT TEST IN VITRO STRIP T1

FREESTYLE LITE TEST IN VITRO STRIP T1

FREESTYLE TEST IN VITRO STRIP T1

GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1

GLUCOCARD VITAL TEST IN VITRO STRIP T1

GLUCONAVII BLOOD GLUCOSE TEST IN VITRO STRIP T1

ketone test in vitro strip T1

KETOSTIX IN VITRO STRIP T1

ONETOUCH ULTRA BLUE IN VITRO STRIP T1

ONETOUCH VERIO STRIP IN VITRO T1

PRECISION XTRA KETONE IN VITRO STRIP T1

*Dietary Products/Dietary Management Products*CARDIOTEK RX ORAL TABLET T1

CEREFOLIN ORAL TABLET 6-1-50-5 MG T1

FOLBIC ORAL TABLET 2.5-25-2 MG T1

l-methylfolate-b6-b12 oral tablet 1.13-25-2 mg, 3-35-2 mg

T1

methylfol-algae-b12-acetylcyst oral tablet 6-90.314-2-600 mg

T1

PROSTAMEN ORAL CAPSULE T1

VITA-RESPA ORAL TABLET 2.2-25-1.3 MG T1

62

Drug Status Notes

*Digestive Aids*CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

T1 PA; PDL-P

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

T1 PA; PDL-NP

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

T1 PA; PDL-NP

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT T1 PA; PDL-NP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT

T1 PDL-P

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

T1 PA; PDL-P

*Diuretics*acetazolamide er oral capsule extended release 12 hour 500 mg


acetazolamide oral tablet 125 mg, 250 mg T1 QL (120 EA per 30 days)

amiloride hcl oral tablet 5 mg T1 QL (120 EA per 30 days)

amiloride-hydrochlorothiazide oral tablet 5-50 mg


bumetanide oral tablet 0.5 mg, 1 mg, 2 mg T1

CAROSPIR ORAL SUSPENSION 25 MG/5ML T1 AL (Max 12 Years)

chlorothiazide oral tablet 250 mg, 500 mg T1

chlorthalidone oral tablet 25 mg, 50 mg T1 QL (120 EA per 30 days)

DIURIL ORAL SUSPENSION 250 MG/5ML T1 AL (Max 12 Years)

furosemide oral solution 10 mg/ml, 8 mg/ml T1 AL (Max 12 Years)

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

hydrochlorothiazide oral capsule 12.5 mg T1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

T1

indapamide oral tablet 1.25 mg, 2.5 mg T1 QL (30 EA per 30 days)

methyclothiazide oral tablet 5 mg T1

63

Drug Status Notesmetolazone oral tablet 10 mg, 2.5 mg, 5 mg T1 QL (30 EA per 30 days)

spironolactone oral tablet 100 mg, 25 mg, 50 mg T1 QL (60 EA per 30 days)

spironolactone-hctz oral tablet 25-25 mg T1 QL (90 EA per 30 days)

torsemide oral tablet 10 mg, 20 mg T1 QL (120 EA per 30 days)

torsemide oral tablet 100 mg, 5 mg T1 QL (60 EA per 30 days)

triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg

T1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg T1

*Endocrine And Metabolic Agents - Misc.*ACTONEL ORAL TABLET 150 MG T1 PA

ACTONEL ORAL TABLET 35 MG T1 PA; QL (4 EA per 28 days)

alendronate sodium oral solution 70 mg/75ml T1 PA

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg

T1

alendronate sodium oral tablet 35 mg, 70 mg T1 QL (4 EA per 28 days)

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG T1 PA; QL (4 EA per 30 days)

BINOSTO ORAL TABLET EFFERVESCENT 70 MG T1 PA

BONIVA INTRAVENOUS SOLUTION 3 MG/3ML T1 PA

BONIVA ORAL TABLET 150 MG T1 PA; QL (12 EA per 30 days)

cabergoline oral tablet 0.5 mg T1

calcitonin (salmon) nasal solution 200 unit/act T1

calcitriol oral capsule 0.25 mcg, 0.5 mcg T1 QL (120 EA per 30 days)

calcitriol oral solution 1 mcg/ml T1 AL (Max 12 Years)

DDAVP RHINAL TUBE NASAL SOLUTION0.01 % T1 PA

desmopressin ace spray refrig nasal solution 0.01 %

T1 PA

desmopressin acetate oral tablet 0.1 mg, 0.2 mg T1 QL (180 EA per 30 days)

desmopressin acetate spray nasal solution 0.01 % T1 PA

EVISTA ORAL TABLET 60 MG T1 PA

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML T1 PA; QL (2.4 ML per 30 days)

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 600 MCG/2.4ML T1 PA

FOSAMAX ORAL TABLET 70 MG T1 PA; QL (4 EA per 28 days)

FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT T1 PA; QL (4 EA per 28 days)

64

Drug Status NotesGENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

T1 PA; PDL-P

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

T1 PA; PDL-P

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

T1 PA; PDL-NP

ibandronate sodium oral tablet 150 mg T1 PA; QL (12 EA per 30 days)

INCRELEX SUBCUTANEOUS SOLUTION40 MG/4ML T1 PA

MIACALCIN INJECTION SOLUTION 200 UNIT/ML T1 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

T1 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

T1 PA; PDL-P

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML T1 PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/2ML

T1 PA; PDL-NP



T1 PA; PDL-NP



T1 PA; PDL-NP

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

T1 PA

OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML

T1 PA; PDL-NP

65

Drug Status NotesOMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG T1 PA; PDL-NP

ORILISSA ORAL TABLET 150 MG, 200 MG T1 PA; AL (Min 18 Years)

raloxifene hcl oral tablet 60 mg T1

risedronate sodium oral tablet 150 mg, 30 mg, 5 mg

T1 PA

risedronate sodium oral tablet 35 mg T1 PA; QL (4 EA per 28 days)

risedronate sodium oral tablet delayed release 35 mg


SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG T1 PA; PDL-NP

SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG T1 PA; PDL-NP

SENSIPAR ORAL TABLET 30 MG, 60 MG T1 PA; QL (60 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG T1 PA; QL (120 EA per 30 days)

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG T1 PA; PDL-NP

STIMATE NASAL SOLUTION 1.5 MG/ML T1 PA

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML T1 PA

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 5 MG T1 PA; PDL-NP

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG T1 PA; PDL-NP

*Estrogens*estradiol oral tablet 0.5 mg, 1 mg, 2 mg T1 AL (Max 64 Years)

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg


estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg T1 AL (Max 64 Years)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG T1 AL (Max 64 Years)

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg


PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG T1

QL (30 EA per 30 days); AL (Max 64 Years)

66

Drug Status Notes

PREMPHASE ORAL TABLET 0.625-5 MG T1QL (30 EA per 30 days); AL (Max 64 Years)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG T1

QL (30 EA per 30 days); AL (Max 64 Years)

*Fluoroquinolones*AVELOX ORAL TABLET 400 MG T1 PA; QL (14 EA per 30 days)

BAXDELA ORAL TABLET 450 MG T1 PA

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)

T1

CIPRO ORAL TABLET 250 MG, 500 MG T1 PA; QL (42 EA per 30 days)

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg


ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

T1 PA

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 mg

T1 PA

LEVAQUIN ORAL TABLET 500 MG T1 PA; QL (14 EA per 30 days)

LEVAQUIN ORAL TABLET 750 MG T1 PA; QL (28 EA per 30 days)

levofloxacin oral solution 25 mg/ml T1

levofloxacin oral tablet 250 mg, 500 mg T1 QL (14 EA per 30 days)

levofloxacin oral tablet 750 mg T1 QL (28 EA per 30 days)

moxifloxacin hcl oral tablet 400 mg T1 PA; QL (14 EA per 30 days)

ofloxacin oral tablet 300 mg, 400 mg T1 PA

*Gastrointestinal Agents - Misc.*ACTIGALL ORAL CAPSULE 300 MG T1 PA

alosetron hcl oral tablet 0.5 mg, 1 mg T1 PA

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG T1

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM T1

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG T1 PA

AURYXIA ORAL TABLET 1 GM 210 MG(FE) T1 PA; PDL-NP

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG T1 PA

AZULFIDINE ORAL TABLET 500 MG T1 PA

balsalazide disodium oral capsule 750 mg T1 PA

calcium acetate (phos binder) oral capsule 667 mg

T1 PA; PDL-P

67

Drug Status Notescalcium acetate (phos binder) oral tablet 667 mg T1 PA; PDL-P

CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML T1 PA

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML T1 PA

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG T1 PA

COLAZAL ORAL CAPSULE 750 MG T1 PA

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG T1 PA

DIPENTUM ORAL CAPSULE 250 MG T1 PA

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG T1 PA

FOSRENOL ORAL PACKET 1000 MG, 750 MG T1 PA; PDL-NP

FOSRENOL ORAL TABLET CHEWABLE1000 MG, 500 MG, 750 MG T1 PA; PDL-NP

gas relief oral liquid 40 mg/0.6ml T1

infants gas relief oral suspension 40 mg/0.6ml T1

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

T1 PA; PDL-NP

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM T1

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG T1

LOTRONEX ORAL TABLET 0.5 MG, 1 MG T1 PA

mesalamine er oral capsule extended release 24 hour 0.375 gm

T1 PA

mesalamine oral capsule delayed release 400 mg T1 PA

mesalamine oral tablet delayed release 1.2 gm, 800 mg

T1 PA

mesalamine rectal enema 4 gm T1

metoclopramide hcl oral solution 5 mg/5ml T1

metoclopramide hcl oral tablet 10 mg, 5 mg T1

MOTEGRITY ORAL TABLET 1 MG, 2 MG T1 PA

MOVANTIK ORAL TABLET 12.5 MG, 25 MG T1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG T1 PA

PHOSLYRA ORAL SOLUTION 667 MG/5ML T1 PA; PDL-NP

RELISTOR ORAL TABLET 150 MG T1 PA

68

Drug Status NotesRELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML T1 PA

RENAGEL ORAL TABLET 400 MG, 800 MG T1 PA

RENVELA ORAL PACKET 0.8 GM, 2.4 GM T1 PA; PDL-NP

RENVELA ORAL TABLET 800 MG T1 PA; PDL-NP

sevelamer carbonate oral packet 0.8 gm, 2.4 gm T1 PA; PDL-P

sevelamer carbonate oral tablet 800 mg T1 PA; PDL-P

sevelamer hcl oral tablet 400 mg, 800 mg T1 PA; PDL-P

simethicone oral tablet chewable 125 mg, 80 mg T1

STELARA INTRAVENOUS SOLUTION 130 MG/26ML T1 PA

sulfasalazine oral tablet 500 mg T1

sulfasalazine oral tablet delayed release 500 mg T1

SYMPROIC ORAL TABLET 0.2 MG T1 PA

TRULANCE ORAL TABLET 3 MG T1 PA

URSO 250 ORAL TABLET 250 MG T1 PA

URSO FORTE ORAL TABLET 500 MG T1 PA

ursodiol oral capsule 300 mg T1

ursodiol oral tablet 250 mg, 500 mg T1

VELPHORO ORAL TABLET CHEWABLE500 MG T1 PA; PDL-NP

VIBERZI ORAL TABLET 100 MG, 75 MG T1 PA; QL (60 EA per 30 days)

ZELNORM ORAL TABLET 6 MG T1 PA

*Genitourinary Agents - Miscellaneous*alfuzosin hcl er oral tablet extended release 24 hour 10 mg

T1 PDL-P

AVODART ORAL CAPSULE 0.5 MG T1 PA

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG T1 PA; PDL-NP

cytra-2 oral solution 500-334 mg/5ml T1

cytra-k oral solution 1100-334 mg/5ml T1

dutasteride oral capsule 0.5 mg T1

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

T1 PA

ELMIRON ORAL CAPSULE 100 MG T1 PA; QL (90 EA per 30 days)

finasteride oral tablet 5 mg T1 GR-M

FLOMAX ORAL CAPSULE 0.4 MG T1 PA; PDL-NP

JALYN ORAL CAPSULE 0.5-0.4 MG T1 PA

K-PHOS NO 2 ORAL TABLET 305-700 MG T1

PHENAZO ORAL TABLET 200 MG T1

69

Drug Status Notesphenazopyridine hcl oral tablet 100 mg T1

potassium citrate er oral tablet extended release10 meq (1080 mg), 5 meq (540 mg)

T1

PROSCAR ORAL TABLET 5 MG T1 PA

RAPAFLO ORAL CAPSULE 4 MG, 8 MG T1 PA; PDL-NP

silodosin oral capsule 4 mg, 8 mg T1 PA; PDL-NP

sodium chloride irrigation solution 0.9 % T1

tamsulosin hcl oral capsule 0.4 mg T1 PDL-P

TARON-CRYSTALS ORAL PACKET 3300-1002 MG T1

*Gout Agents*allopurinol oral tablet 100 mg, 300 mg T1

colchicine oral capsule 0.6 mg T1 PA

colchicine oral tablet 0.6 mg T1 PA

colchicine-probenecid oral tablet 0.5-500 mg T1

COLCRYS ORAL TABLET 0.6 MG T1 PA

febuxostat oral tablet 40 mg, 80 mg T1 PA

GLOPERBA ORAL SOLUTION 0.6 MG/5ML T1 PA

MITIGARE ORAL CAPSULE 0.6 MG T1

probenecid oral tablet 500 mg T1

ULORIC ORAL TABLET 40 MG, 80 MG T1 PA

ZYLOPRIM ORAL TABLET 100 MG, 300 MG T1 PA

*Hematological Agents - Misc.*AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG T1 PA

anagrelide hcl oral capsule 0.5 mg, 1 mg T1

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

T1 PA

BRILINTA ORAL TABLET 60 MG, 90 MG T1

cilostazol oral tablet 100 mg, 50 mg T1 QL (60 EA per 30 days)

clopidogrel bisulfate oral tablet 300 mg, 75 mg T1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg T1 PA

EFFIENT ORAL TABLET 10 MG, 5 MG T1 PA; AL (Max 75 Years)

pentoxifylline er oral tablet extended release 400 mg

T1

PLAVIX ORAL TABLET 75 MG T1 PA

prasugrel hcl oral tablet 10 mg, 5 mg T1 AL (Max 75 Years)

YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 81-40 MG T1 PA

70

Drug Status NotesZONTIVITY ORAL TABLET 2.08 MG T1 PA

*Hematopoietic Agents*ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 150 MCG/0.75ML

T1 PA

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

T1 PA; PDL-P

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

T1 PA; PDL-P

b-12 oral tablet 500 mcg T1

cyanocobalamin injection solution 1000 mcg/ml T1

D 1000 PLUS ALOE ORAL TABLET T1

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG T1

ENDARI ORAL PACKET 5 GM T1 PA

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

T1 PA; PDL-NP

fabb oral tablet 2.2-25-1 mg T1

ferronate oral tablet 325 mg T1

ferrous gluconate oral tablet 225 (27 fe) mg, 240 (27 fe) mg, 324 (37.5 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg

T1

ferrous sulfate oral elixir 220 (44 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral liquid 220 (44 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral solution 75 (15 fe) mg/ml T1 AL (Max 12 Years)

ferrous sulfate oral syrup 300 (60 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

T1

folbee oral tablet 2.5-25-1 mg T1

FOLGARD ORAL TABLET T1

folic acid oral tablet 1 mg, 800 mcg T1

folic acid oral tablet 400 mcg T1 QL (30 EA per 30 days)

folinic-plus oral tablet 4-50-2 mg T1

folplex 2.2 oral tablet 2.2-25-0.5 mg T1

71

Drug Status NotesFOLTABS 800 ORAL TABLET 800-10-115 MCG-MG-MCG T1

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML T1 QL (0.6 ML per 14 days)

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6ML T1 PA

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

hm iron oral tablet 200 (65 fe) mg T1

hm slow release iron oral tablet extended release45 mg

T1

homocysteine formula oral tablet 800-50-100 mcg-mg-mcg

T1

iron 100 plus oral tablet 100-250-0.025-1 mg T1

iron oral tablet 325 (65 fe) mg T1

LEUKINE INJECTION SOLUTION RECONSTITUTED 250 MCG T1 PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML T1 PA; QL (0.6 ML per 14 days)

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML T1 PA; QL (0.6 ML per 14 days)

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML T1

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML T1 PA

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

OXBRYTA ORAL TABLET 500 MG T1 PA; QL (90 EA per 30 days)

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

T1 PA; PDL-P

slow iron oral tablet extended release 160 (50 fe) mg

T1

slow release iron oral tablet extended release47.5 mg

T1

sm slow release iron oral tablet extended release142 (45 fe) mg

T1

72

Drug Status NotesUDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML T1 QL (0.6 ML per 14 days)

vitamin b-12 oral tablet 1000 mcg T1

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML T1 PA; QL (0.6 ML per 14 days)

*Hypnotics/Sedatives/Sleep Disorder Agents*midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml


*Laxatives*bisacodyl ec oral tablet delayed release 5 mg T1

bisacodyl rectal suppository 10 mg T1

cvs laxative dietary supplemnt oral tablet 500 mg T1

cvs senna-extra oral tablet 17.2 mg T1

cvs stool softener oral capsule 50 mg T1

docusate calcium oral capsule 240 mg T1

docusate sodium oral capsule 100 mg, 250 mg T1

docusate sodium oral liquid 150 mg/15ml T1

docusate sodium oral tablet 100 mg T1

DOCUSOL MINI RECTAL ENEMA 283 MG/5ML T1

enema rectal enema T1

ENEMEEZ PLUS RECTAL ENEMA 20-283 MG T1

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM T1

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

T1

geri-mucil oral powder 68 % T1

lactulose oral solution 10 gm/15ml T1

magnesium citrate oral solution 1.745 gm/30ml T1

METAMUCIL MULTIHEALTH FIBER ORAL POWDER 63 % T1

milk of magnesia oral suspension 400 mg/5ml T1

mineral oil rectal enema T1

natural fiber laxative oral powder 28.3 %, 58.6 % T1

73

Drug Status Notesnatural fiber therapy oral powder 48.57 % T1

peg 3350/electrolytes oral solution reconstituted240 gm

T1

polyethylene glycol 3350 oral powder 17 gm/scoop

T1

qc natural vegetable oral powder 95 % T1

senna laxative oral tablet 25 mg T1

senna oral capsule 8.6 mg T1

senna oral syrup 8.8 mg/5ml T1

senna oral tablet 8.6 mg T1

SENNA SMOOTH ORAL TABLET 15 MG T1

senna-docusate sodium oral tablet 8.6-50 mg T1

sen-o-tabs oral tablet 187 mg T1

*Macrolides*azithromycin oral packet 1 gm T1 QL (2 EA per 28 days)

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml


azithromycin oral tablet 250 mg T1 QL (6 EA per 28 days)



clarithromycin er oral tablet extended release 24 hour 500 mg

T1 PA

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

clarithromycin oral tablet 250 mg, 500 mg T1 QL (28 EA per 30 days)

DIFICID ORAL TABLET 200 MG T1 PA

E.E.S. 400 ORAL TABLET 400 MG T1 PA

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML T1

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML T1 PA

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML T1 PA

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG T1 PA

ERYTHROCIN STEARATE ORAL TABLET250 MG T1

erythromycin base oral capsule delayed release particles 250 mg

T1 PA

erythromycin base oral tablet 250 mg, 500 mg T1 PA

74

Drug Status Noteserythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

T1 PA

erythromycin ethylsuccinate oral tablet 400 mg T1 PA

erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg

T1 PA

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

T1 PA; AL (Max 12 Years)

ZITHROMAX ORAL TABLET 250 MG T1 PA; QL (6 EA per 28 days)

ZITHROMAX ORAL TABLET 500 MG T1 PA; QL (3 EA per 28 days)

ZITHROMAX TRI-PAK ORAL TABLET 500 MG T1 PA; QL (3 EA per 28 days)

ZITHROMAX Z-PAK ORAL TABLET 250 MG T1 PA; QL (6 EA per 28 days)

*Medical Devices And Supplies*ACCU-CHEK MULTICLIX LANCETS T1

adult aerosol mask T1 QL (4 EA per 365 days)

ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM T1 QL (200 EA per 30 days)

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL T1

BD AUTOSHIELD 29G X 5MM , 29G X 8MM T1 QL (200 EA per 30 days)

BD AUTOSHIELD DUO 30G X 5 MM T1 QL (200 EA per 30 days)

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, U-100 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.3 ML, 28G X 1/2" 0.5 ML


BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE U-40 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML T1 QL (200 EA per 30 days)

BD INTEGRA SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days)

BD LANCET DEVICE T1

BD PEN T1 QL (1 EA per 365 days)

CAREFINE PEN NEEDLES 30G X 8 MM , 32G X 5 MM T1 QL (200 EA per 30 days)

75

Drug Status Notescareone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 1 ml


CAYA VAGINAL DIAPHRAGM T1

COMFORT ASSIST INSULIN SYRINGE29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML


condoms T1 QL (36 EA per 30 days)

CURITY ALCOHOL PREPS PAD 70 % T1

EASIVENT T1 QL (4 EA per 365 days)

EASIVENT MASK LARGE T1 QL (4 EA per 365 days)

EASIVENT MASK MEDIUM T1 QL (4 EA per 365 days)

EASIVENT MASK SMALL T1 QL (4 EA per 365 days)

easy comfort insulin syringe 30g x 5/16" 1 ml T1 QL (200 EA per 30 days)

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML T1 QL (200 EA per 30 days)

elite-thin insulin syringe 28g x 5/16" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml


EXEL COMFORT POINT INSULIN SYR29G X 1/2" 0.5 ML, 29G 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


FC2 FEMALE CONDOM T1 QL (36 EA per 30 days)

FIFTY50 PEN NEEDLES 32G X 6 MM T1 QL (200 EA per 30 days)

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID T1

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION T1

GLUCOCARD EXPRESSION MONITOR KIT W/DEVICE T1 QL (1 EA per 365 days)

GLUCOCARD VITAL MONITOR KITW/DEVICE T1 QL (1 EA per 365 days)

h-e-b incontrol pen needles 31g x 5 mm T1 QL (200 EA per 30 days)

HM ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

IN-CHECK INSPIRATORY FLOW MTR DEVICE T1 QL (4 EA per 365 days)

insulin syringe 29g x 1" 0.3 ml, 29g x 1/2" 1 ml T1 QL (200 EA per 30 days)

kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml


LITETOUCH PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

MASK VORTEX T1 QL (4 EA per 365 days)

76

Drug Status NotesMONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

ONETOUCH DELICA LANCETS 30G T1

ONETOUCH DELICA LANCETS 33G T1

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION T1

ONETOUCH VERIO SOLUTION IN VITRO T1 QL (1 EA per 365 days)

one-way valved inspiratory mouthpiece T1 QL (4 EA per 365 days)

peak flow meter device T1 QL (4 EA per 365 days)

pediatric medium mask T1 QL (4 EA per 365 days)

pediatric small mask T1 QL (4 EA per 365 days)

pen needles 29g x 12mm , 32g x 4 mm T1 QL (200 EA per 30 days)

premium condoms lubricated T1 QL (36 EA per 30 days)

RELI-ON INSULIN SYRINGE 30G 0.3 ML T1 QL (200 EA per 30 days)

SURE-LANCE THIN LANCETS 28G T1

TECHLITE PEN NEEDLES 31G X 6 MM , 32G X 8 MM T1 QL (200 EA per 30 days)

TRUSTEX NON-LUBRICATED T1 QL (36 EA per 30 days)

ULTICARE INSULIN SYRINGE 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML T1 QL (200 EA per 30 days)

ULTICARE MICRO PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

VORTEX HOLDING CHAMBER/MASK DEVICE T1 QL (4 EA per 365 days)

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % T1








77

Drug Status Notes

*Migraine Products*AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML T1 PA; QL (1 ML per 30 days)

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML T1 PA; QL (2 ML per 30 days)

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 MG/1.5ML T1 PA; QL (1.5 ML per 30 days)

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML T1 PA; QL (1.5 ML per 30 days)

almotriptan malate oral tablet 12.5 mg, 6.25 mg T1 PA; QL (9 EA per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG T1 PA; QL (9 EA per 30 days)

eletriptan hydrobromide oral tablet 20 mg, 40 mg T1 PA; QL (12 EA per 30 days)

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML


EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML T1


EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML T1


FROVA ORAL TABLET 2.5 MG T1 PA; QL (18 EA per 30 days)

frovatriptan succinate oral tablet 2.5 mg T1 PA; QL (18 EA per 30 days)

IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT T1 PA; QL (6 EA per 30 days)

IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA; QL (18 EA per 30 days)

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE4 MG/0.5ML, 6 MG/0.5ML


IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML T1 PA; QL (2 ML per 28 days)

MAXALT ORAL TABLET 10 MG T1 PA; QL (12 EA per 30 days)

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG T1 PA; QL (12 EA per 30 days)

naratriptan hcl oral tablet 1 mg, 2.5 mg T1 PA; QL (9 EA per 30 days)

NURTEC ORAL TABLET DISPERSIBLE 75 MG T1

PA; PDL-P; QL (15 EA per 30 days); AL (Min 18 Years)

ONZETRA XSAIL NASAL EXHALER POWDER 11 MG/NOSEPC T1 PA

RELPAX ORAL TABLET 20 MG, 40 MG T1 QL (12 EA per 30 days)

78

Drug Status Notes

REYVOW ORAL TABLET 100 MG, 50 MG T1PA; PDL-NP; QL (8 EA per 30 days); AL (Min 18 Years)

rizatriptan benzoate oral tablet 10 mg, 5 mg T1 QL (12 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg


sumatriptan nasal solution 20 mg/act, 5 mg/act T1 PA; QL (6 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


sumatriptan-naproxen sodium oral tablet 85-500 mg

T1 PA

TOSYMRA NASAL SOLUTION 10 MG/ACT T1 PA

TREXIMET ORAL TABLET 85-500 MG T1 PA

UBRELVY ORAL TABLET 100 MG, 50 MG T1PA; PDL-NP; QL (16 EA per 30 days); AL (Min 18 Years)

ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML

T1 PA

zolmitriptan oral tablet 2.5 mg, 5 mg T1 PA; QL (12 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg T1 PA; QL (12 EA per 30 days)

ZOMIG NASAL SOLUTION 2.5 MG, 5 MG T1

ZOMIG ORAL TABLET 2.5 MG, 5 MG T1 PA; QL (12 EA per 30 days)

ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG T1 PA; QL (12 EA per 30 days)

*Minerals & Electrolytes*BEELITH ORAL TABLET 362-20 MG T1

cal-citrate plus vitamin d oral tablet 250-100 mg-unit

T1

calcium + d3 oral tablet 600-200 mg-unit T1

calcium 500 + d oral tablet 500-125 mg-unit T1

calcium 500 + d3 oral tablet 500-600 mg-unit T1

calcium 500+d oral tablet 500-200 mg-unit T1

calcium 500+d3 oral tablet 500-400 mg-unit T1

calcium 600 + d oral tablet 600-200 mg-unit T1

79

Drug Status Notescalcium 600 oral tablet 1500 (600 ca) mg T1

calcium 600+d oral tablet 600-800 mg-unit T1

calcium 600+d3 oral tablet 600-400 mg-unit T1

calcium carbonate oral suspension 1250 (500 ca) mg/5ml

T1

calcium carbonate oral tablet 1250 (500 ca) mg, 600 mg

T1

calcium carbonate oral tablet chewable 260 mg T1

calcium carbonate-vitamin d oral tablet 600-200 mg-unit, 600-400 mg-unit

T1

calcium citrate + d3 maximum oral tablet 315-250 mg-unit

T1

calcium citrate oral granules 760 mg/3.5gm T1

calcium citrate oral tablet 200 mg, 950 (200 ca) mg

T1

calcium citrate-vitamin d oral tablet 315-200 mg-unit

T1

calcium oral tablet 600-200 mg-unit T1

calcium oral tablet chewable 500 mg T1

calcium/vitamin d3 gummies oral tablet chewable200-200 mg-unit

T1

chelated magnesium oral tablet 100 mg T1

DISNEY CALCIUM + VITAMIN D3 ORAL TABLET CHEWABLE 250-135-200 MG-MG-UNIT

T1

GLYCOPHOS INTRAVENOUS SOLUTION1 MMOLE/ML T1

K-PHOS ORAL TABLET 500 MG T1

mag glycinate oral tablet 100 mg T1

MAG64 ORAL TABLET DELAYED RELEASE 64 MG T1

MAGINEX ORAL TABLET DELAYED RELEASE 615 MG T1

magnesium chloride injection solution 200 mg/ml T1

magnesium citrate oral tablet 100 mg T1

magnesium gluconate oral tablet 27.5 mg, 500 mg, 550 mg

T1

magnesium oral capsule 300 mg, 400 mg T1

magnesium oral tablet 200 mg, 250 mg, 30 mg T1

magnesium oxide -mg supplement oral capsule400 mg

T1

80

Drug Status Notesmagnesium oxide -mg supplement oral tablet 250 mg

T1

magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg

T1

magnesium sulfate in d5w intravenous solution10-5 mg/ml-%

T1

magnesium sulfate injection solution 50 % T1

magnesium sulfate intravenous solution 2 gm/50ml, 4 gm/50ml

T1

MAGONATE ORAL LIQUID 54 (MAG EQUIV) MG/5ML T1

MAGONATE ORAL TABLET 500 (27 MG) MG T1

MAG-TAB SR ORAL TABLET EXTENDED RELEASE 84 MG (7MEQ) T1

ORALYTE ORAL SOLUTION T1

oyster shell calcium 250+d oral tablet 250-125 mg-unit

T1

oyster shell calcium oral tablet 500 mg T1

oyster shell calcium plus d oral tablet 500-125 mg-unit

T1

oyster shell calcium/d oral tablet 250-125 mg-unit T1

oyster shell calcium/d3 oral tablet 500-400 mg-unit

T1

oyster shell/d oral tablet 500-200 mg-unit T1

phos-nak oral packet 280-160-250 mg T1

PHOSPHA 250 NEUTRAL ORAL TABLET155-852-130 MG T1

pot bicarb-pot chloride oral tablet effervescent 25 meq

T1

potassium bicarbonate oral tablet effervescent 25 meq

T1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

T1

potassium chloride er oral capsule extended release 10 meq, 8 meq

T1

potassium chloride er oral tablet extended release10 meq, 20 meq, 8 meq

T1

potassium phosphates intravenous solution 15 mmole/5ml, 150 mmole/50ml, 45 mmole/15ml

T1

ra magnesium oral capsule 500 mg T1

ra oyster shell calcium/d oral tablet 500-200 mg-unit

T1

81

Drug Status Notesslow magnesium/calcium oral tablet delayed release 64-106 mg

T1

SLOW-MAG ORAL TABLET DELAYED RELEASE 71.5-119 MG T1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml T1QL (120 ML per 30 days); AL (Max 16 Years)

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg


sodium phosphate intravenous solution 3 mmole/ml

T1

*Miscellaneous Therapeutic Classes*azathioprine oral tablet 50 mg T1 QL (240 EA per 30 days)

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

T1

cyclosporine modified oral solution 100 mg/ml T1 AL (Max 12 Years)

cyclosporine oral capsule 100 mg, 25 mg T1

mycophenolate mofetil oral capsule 250 mg T1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml


mycophenolate mofetil oral tablet 500 mg T1

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG T1 PA; QL (30 EA per 30 days)

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg T1

sodium polystyrene sulfonate oral powder T1

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

T1

SPS ORAL SUSPENSION 15 GM/60ML T1

sterile water for irrigation irrigation solution T1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T1

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG T1 PA

*Mouth/Throat/Dental Agents*chlorhexidine gluconate mouth/throat solution0.12 %

T1

clotrimazole mouth/throat lozenge 10 mg T1

DENTAGEL DENTAL GEL 1.1 % T1

lidocaine viscous mouth/throat solution 2 % T1

nystatin mouth/throat suspension 100000 unit/ml T1

ORAVIG BUCCAL TABLET 50 MG T1 PA

pilocarpine hcl oral tablet 5 mg, 7.5 mg T1

sf 5000 plus dental cream 1.1 % T1

82

Drug Status Notestriamcinolone acetonide mouth/throat paste 0.1 % T1 QL (5 GM per 30 days)

*Multivitamins*APETIGEN ORAL ELIXIR T1

APETIGEN-PLUS ORAL SOLUTION T1

b complex formula 1 oral tablet T1

b complex oral capsule T1

b complex-c oral tablet T1

b complex-c-biotin-e-fa oral tablet 0.4 mg T1

b-100 complex oral tablet T1

b-100 complex oral tablet extended release T1

b-100 cr oral tablet extended release T1

b-complex/b-12 sublingual liquid T1

benfotiamine multi-b oral capsule T1

bp folinatal plus b oral tablet 1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

brewers yeast oral tablet T1

childrens chewable vitamins oral tablet chewable T1

childrens multivitamin oral tablet chewable 60 mg

T1

childrens vitamins/iron oral tablet chewable 15 mg

T1

COMPLETE FORMULATION PEDIATRIC ORAL SOLUTION 45 MG/0.5ML T1

cvs prenatal gummy oral tablet chewable 0.4-113.5 mg

T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

daily vitamin formula+iron oral tablet T1

daily vite oral tablet T1

DIALYVITE 3000 ORAL TABLET 3 MG T1

DIALYVITE 5000 ORAL TABLET 5 MG T1

DIALYVITE 800 PLUS D ORAL WAFER 800 MCG T1

DIALYVITE 800/ZINC ORAL TABLET 0.8 MG T1

DIALYVITE SUPREME D ORAL TABLET 3 MG T1

DIALYVITE/ZINC ORAL TABLET T1

DINO-LIFE W/IRON-ZINC ORAL TABLET CHEWABLE 30-200-3 T1

e-400/selenium oral capsule 400-50 unit-mcg T1

83

Drug Status Notesecee plus oral tablet T1

eql one daily womens oral tablet T1

FOLBEE PLUS CZ ORAL TABLET 5 MG T1

gnp b-complex plus vitamin c oral tablet T1

hm vitamin b100 complex oral tablet T1

multi adult gummies oral tablet chewable T1

multi-delyn/iron oral liquid T1

multi-vit/fluoride oral solution 0.25 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

multi-vitamin hp/minerals oral capsule T1

multi-vitamin/fluoride oral solution 0.5 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg


multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

T1QL (60 ML per 30 days); AL (Max 12 Years)

multivitamins pediatric oral solution T1

multivitamins/fluoride oral tablet chewable 0.5 mg


MYKIDZ IRON ORAL SUSPENSION 10 MG/2ML T1

mynatal plus oral tablet T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

mynate 90 plus oral tablet extended release T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

NEPHROCAPS QT ORAL TABLET DISPERSIBLE 1 MG T1

NEPHRONEX ORAL LIQUID T1

NEPHRONEX TABLET ORAL T1

NEWGEN ORAL TABLET 32-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

niacin flush free oral capsule 400-100 mg T1

OBSTETRIX DHA ORAL 29-1 & 387 MG T1GR-F; QL (60 EA per 30 days); AL (Min 12 Years and Max 55 Years)

OBSTETRIX EC ORAL TABLET 29-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

polyvitamin oral solution 35 mg/ml T1

84

Drug Status Notespoly-vitamin/iron oral solution 10 mg/ml T1

prenatal 19 oral tablet chewable 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal complete oral tablet 14-0.4 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal low iron oral tablet 27-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal multi +dha oral capsule 27-0.8-228 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal oral tablet 27-0.8 mg, 28-0.8 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal plus iron oral tablet 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

PRENATAL-U ORAL CAPSULE 106.5-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

pretab oral tablet 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

qc childrens vitamins/extra c oral tablet chewableT1

ra b-complex/vitamin c cr oral tablet extended release

T1

rabano yodado oral liquid T1

RENAL ORAL CAPSULE 1 MG T1

renal vitamin oral tablet 0.8 mg T1

rena-vite rx tablet 1 mg oral (otc) 1 mg T1

SCOOBY-DOO ONE A DAY ORAL TABLET CHEWABLE T1

SUPERVITE ORAL LIQUID T1

TARON-BC ORAL 20-1 MG & 2 X 25 MG T1GR-F; QL (90 EA per 30 days); AL (Min 12 Years and Max 55 Years)

trinatal rx 1 oral tablet 60-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

85

Drug Status Notes

TRINATE ORAL TABLET T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

tri-tabs dha oral 32-1 mg T1GR-F; QL (60 EA per 30 days); AL (Min 12 Years and Max 55 Years)

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML T1

tri-vi-floro oral suspension 0.5 mg/ml T1

tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml


tri-vit/fluoride/iron oral solution 0.25-10 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

tri-vitamin oral solution 1500-400-35 T1 QL (50 ML per 25 days)

tri-vite pediatric oral solution 750-400-35 unit-mg/ml

T1

VINATE II ORAL TABLET 29-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

VINATE M ORAL TABLET 27-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

vita-bee/c oral tablet T1

VITAL-D RX ORAL TABLET 1 MG T1

vitamin b complex-c oral capsule T1

vitamin b-complex 100 injection injectable T1

vitamin b-complex oral tablet T1

vita-min oral capsule T1

vol-care rx tablet 1 mg oral 1 mg T1

vp-heme ob oral tablet 28-6-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

vp-vite rx tablet 1 mg oral 1 mg T1

*Musculoskeletal Therapy Agents*AMRIX ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 MG, 30 MG T1 PA

baclofen oral tablet 10 mg, 20 mg, 5 mg T1

chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg

T1

cyclobenzaprine hcl er oral capsule extended release 24 hour 15 mg, 30 mg

T1 PA

86

Drug Status Notescyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg

T1

DANTRIUM ORAL CAPSULE 25 MG, 50 MG T1 PA

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

T1 PA

FEXMID ORAL TABLET 7.5 MG T1 PA

LORZONE ORAL TABLET 375 MG, 750 MG T1 PA

METAXALL ORAL TABLET 800 MG T1 PA

metaxalone oral tablet 400 mg, 800 mg T1 PA

methocarbamol oral tablet 500 mg, 750 mg T1 PA

norgesic forte oral tablet 50-770-60 mg T1 PA

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

T1

ROBAXIN-750 ORAL TABLET 750 MG T1 PA

SKELAXIN ORAL TABLET 800 MG T1 PA

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg T1 PA

tizanidine hcl oral tablet 2 mg, 4 mg T1

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG T1 PA

ZANAFLEX ORAL TABLET 4 MG T1 PA

*Nasal Agents - Systemic And Topical*allergy relief nasal suspension 50 mcg/act T1 PA

allergy spray 24 hour nasal aerosol 55 mcg/act T1 PA

azelastine hcl nasal solution 0.1 %, 0.15 % T1

azelastine-fluticasone nasal suspension 137-50 mcg/act

T1 PA

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY T1 PA

budesonide nasal suspension 32 mcg/act T1 PA

childrens silfedrine oral liquid 15 mg/5ml T1

cromolyn sodium nasal aerosol solution 5.2 mg/act

T1

cvs nasal allergy spray nasal aerosol 55 mcg/act T1 PA

DYMISTA NASAL SUSPENSION 137-50 MCG/ACT T1 PA

eq nasal allergy nasal aerosol 55 mcg/act T1 PA

FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 MCG/ACT T1 PA

FLONASE SENSIMIST NASAL SUSPENSION 27.5 MCG/SPRAY T1 PA

87

Drug Status Notesflunisolide nasal solution 25 mcg/act (0.025%) T1 PA

fluticasone propionate nasal suspension 50 mcg/act

T1

gnp 24 hour nasal allergy nasal aerosol 55 mcg/act

T1 PA

goodsense nasal allergy spray nasal aerosol 55 mcg/act

T1 PA

hm allergy relief nasal suspension 50 mcg/act T1 PA

ipratropium bromide nasal solution 0.03 %, 0.06 %

T1

long acting nasal spray nasal solution 0.05 % T1

mometasone furoate nasal suspension 50 mcg/act T1 PA

NASACORT ALLERGY 24HR CHILDREN NASAL AEROSOL 55 MCG/ACT T1 QL (10.8 ML per 30 days)

NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT T1 QL (16.9 ML per 30 days)

nasal allergy 24 hour nasal aerosol 55 mcg/act T1 PA

nasal decongestant oral liquid 30 mg/5ml T1

NASONEX NASAL SUSPENSION 50 MCG/ACT T1 PA

olopatadine hcl nasal solution 0.6 % T1 PA

OMNARIS NASAL SUSPENSION 50 MCG/ACT T1 PA

PATANASE NASAL SOLUTION 0.6 % T1 PA

pseudoephedrine hcl er oral tablet extended release 12 hour 120 mg

T1

qc allergy relief nasal suspension 50 mcg/act T1 PA

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT T1 PA

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT T1 PA

ra nasal allergy nasal aerosol 55 mcg/act T1 PA

saline mist spray nasal solution 0.65 % T1

sm allergy relief nasal suspension 50 mcg/act T1 PA

triamcinolone acetonide nasal aerosol 55 mcg/act T1 PA

XHANCE NASAL EXHALER SUSPENSION93 MCG/ACT T1 PA

ZETONNA NASAL AEROSOL SOLUTION37 MCG/ACT T1 PA

*Nutrients*alba-lybe nr oral liquid 325-10-50 mg/5ml T1

88

Drug Status Notesfish oil oral capsule 1000 mg, 1200 mg, 500 mg T1

fish oil oral capsule delayed release 1000 mg, 1200 mg

T1

prenatal dha oral capsule 200 mg T1

*Ophthalmic Agents*ACULAR LS OPHTHALMIC SOLUTION 0.4 % T1 PA

ACULAR OPHTHALMIC SOLUTION 0.5 % T1

ACUVAIL OPHTHALMIC SOLUTION 0.45 % T1 PA

allergy eye ophthalmic solution 0.025-0.3 % T1

ALOCRIL OPHTHALMIC SOLUTION 2 % T1 PA

ALOMIDE OPHTHALMIC SOLUTION 0.1 % T1 PA

ALPHAGAN P OPHTHALMIC SOLUTION0.1 %, 0.15 % T1 PA

ALREX OPHTHALMIC SUSPENSION 0.2 % T1 PA

apraclonidine hcl ophthalmic solution 0.5 % T1

artificial tears ophthalmic ointment 83-15 % T1

artificial tears ophthalmic solution 0.1-0.3 %, 0.4 %

T1

atropine sulfate ophthalmic ointment 1 % T1

atropine sulfate ophthalmic solution 1 % T1

AZASITE OPHTHALMIC SOLUTION 1 % T1 PA

azelastine hcl ophthalmic solution 0.05 % T1 PA

AZOPT OPHTHALMIC SUSPENSION 1 % T1

bacitracin ophthalmic ointment 500 unit/gm T1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

T1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

T1

BEPREVE OPHTHALMIC SOLUTION 1.5 % T1 PA

BESIVANCE OPHTHALMIC SUSPENSION0.6 % T1 PA

betaxolol hcl ophthalmic solution 0.5 % T1 PA

BETOPTIC-S OPHTHALMIC SUSPENSION0.25 % T1

bimatoprost ophthalmic solution 0.03 % T1 PA

BIOLLE GEL TEARS OPHTHALMIC GEL1 % T1

89

Drug Status Notesbrimonidine tartrate ophthalmic solution 0.15 % T1 PA

brimonidine tartrate ophthalmic solution 0.2 % T1

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

T1 PA

BROMSITE OPHTHALMIC SOLUTION0.075 % T1 PA

carteolol hcl ophthalmic solution 1 % T1

CILOXAN OPHTHALMIC OINTMENT 0.3 % T1 PA

CILOXAN OPHTHALMIC SOLUTION 0.3 % T1 PA

ciprofloxacin hcl ophthalmic solution 0.3 % T1

COMBIGAN OPHTHALMIC SOLUTION0.2-0.5 % T1

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML T1 PA

COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % T1 PA

cromolyn sodium ophthalmic solution 4 % T1

cvs lubricant drops ophthalmic gel 1 % T1

cyclopentolate hcl ophthalmic solution 1 %, 2 % T1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

T1

diclofenac sodium ophthalmic solution 0.1 % T1

dorzolamide hcl ophthalmic solution 2 % T1

dorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 mg/ml

T1

dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 %

T1

epinastine hcl ophthalmic solution 0.05 % T1 PA

erythromycin ophthalmic ointment 5 mg/gm T1

eye allergy relief ophthalmic solution 0.027-0.315 %

T1

fluorometholone ophthalmic suspension 0.1 % T1 QL (15 ML per 30 days)

flurbiprofen sodium ophthalmic solution 0.03 % T1

gatifloxacin ophthalmic solution 0.5 % T1 PA

GENTAK OPHTHALMIC OINTMENT 0.3 % T1

gentamicin sulfate ophthalmic solution 0.3 % T1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % T1

90

Drug Status NotesILEVRO OPHTHALMIC SUSPENSION 0.3 % T1 PA

IOPIDINE OPHTHALMIC SOLUTION 0.5 %, 1 % T1 PA

ISTALOL OPHTHALMIC SOLUTION 0.5 % T1 PA

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

T1

ketotifen fumarate ophthalmic solution 0.025 % T1

LASTACAFT OPHTHALMIC SOLUTION0.25 % T1 PA

latanoprost ophthalmic solution 0.005 % T1

levobunolol hcl ophthalmic solution 0.5 % T1 PA

levofloxacin ophthalmic solution 0.5 % T1 PA

lubricant drops ophthalmic solution 1.4 % T1

lubricant drops/dual-action ophthalmic solution0.5-0.9 %

T1

lubricant eye drops ophthalmic solution 0.4-0.3 %, 0.5 %, 0.6 %

T1

lubricant eye ophthalmic ointment T1

LUMIGAN OPHTHALMIC SOLUTION 0.01 % T1 PA

metipranolol ophthalmic solution 0.3 % T1

MOXEZA OPHTHALMIC SOLUTION 0.5 % T1 PA

moxifloxacin hcl (2x day) ophthalmic solution 0.5 %

T1 PA

moxifloxacin hcl ophthalmic solution 0.5 % T1 PA

naphazoline hcl ophthalmic solution 0.1 % T1

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

T1

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

T1

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

T1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

T1

NEVANAC OPHTHALMIC SUSPENSION0.1 % T1 PA

OCUFLOX OPHTHALMIC SOLUTION 0.3 % T1 PA

ofloxacin ophthalmic solution 0.3 % T1

olopatadine hcl ophthalmic solution 0.1 %, 0.2 % T1

91

Drug Status NotesOXERVATE OPHTHALMIC SOLUTION0.002 % T1 PA; QL (28 ML per 28 days)

PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % T1 PA

PATANOL OPHTHALMIC SOLUTION 0.1 % T1 PA

PAZEO OPHTHALMIC SOLUTION 0.7 % T1 PA

phenylephrine hcl ophthalmic solution 2.5 % T1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 % T1

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

T1

polymyxin b-trimethoprim ophthalmic solution10000-0.1 unit/ml-%

T1

prednisolone acetate ophthalmic suspension 1 % T1

prednisolone sodium phosphate ophthalmic solution 1 %

T1

PROLENSA OPHTHALMIC SOLUTION0.07 % T1 PA

proparacaine hcl ophthalmic solution 0.5 % T1

px artificial tears ophthalmic solution 5-6 mg/ml T1

ra artificial tears ophthalmic solution 1-0.3 % T1

REFRESH LIQUIGEL OPHTHALMIC SOLUTION 1 % T1

REFRESH OPTIVE SENSITIVE OPHTHALMIC SOLUTION 0.5-0.9 % T1

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % T1

RESTASIS OPHTHALMIC EMULSION 0.05 % T1 QL (60 EA per 30 days)

RHOPRESSA OPHTHALMIC SOLUTION0.02 % T1

ROCKLATAN OPHTHALMIC SOLUTION0.02-0.005 % T1

SIMBRINZA OPHTHALMIC SUSPENSION1-0.2 % T1

sm dry eye relief ophthalmic solution 0.2-0.2-1 % T1

sodium chloride (hypertonic) ophthalmic ointment5 %

T1

sodium chloride (hypertonic) ophthalmic solution5 %

T1

sulfacetamide sodium ophthalmic ointment 10 % T1

92

Drug Status Notessulfacetamide sodium ophthalmic solution 10 % T1

sulfacetamide-prednisolone ophthalmic solution10-0.23 %

T1

SYSTANE OPHTHALMIC GEL 0.4-0.3 % T1

timolol maleate ophthalmic gel forming solution0.25 %, 0.5 %

T1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

T1

timolol maleate ophthalmic solution 0.5 % (daily) T1 PA

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 % T1 PA

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % T1 PA

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 % T1 PA

tobramycin ophthalmic solution 0.3 % T1

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

T1

TRAVATAN Z OPHTHALMIC SOLUTION0.004 % T1

travoprost (bak free) ophthalmic solution 0.004 % T1 PA

tropicamide ophthalmic solution 0.5 %, 1 % T1

TRUSOPT OPHTHALMIC SOLUTION 2 % T1 PA

VIGAMOX OPHTHALMIC SOLUTION 0.5 % T1

VYZULTA OPHTHALMIC SOLUTION0.024 % T1 PA

XALATAN OPHTHALMIC SOLUTION0.005 % T1 PA

XELPROS OPHTHALMIC EMULSION0.005 % T1 PA

ZADITOR OPHTHALMIC SOLUTION 0.025 % T1

ZERVIATE OPHTHALMIC SOLUTION 0.24 % T1 PA

ZIOPTAN OPHTHALMIC SOLUTION0.0015 % T1 PA

ZYMAXID OPHTHALMIC SOLUTION 0.5 % T1 PA

*Otic Agents*acetic acid otic solution 2 % T1

acetic acid-aluminum acetate otic solution 2 % T1

93

Drug Status Notesantipyrine-benzocaine otic solution 5.4-1.4 % T1

CIPRO HC OTIC SUSPENSION 0.2-1 % T1 PA

CIPRODEX OTIC SUSPENSION 0.3-0.1 % T1

ciprofloxacin hcl otic solution 0.2 % T1 PA

ciprofloxacin-dexamethasone otic suspension 0.3-0.1 %

T1 PA

ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 %

T1 PA

hydrocortisone-acetic acid otic solution 1-2 % T1

neomycin-polymyxin-hc otic solution 3.5-10000-1 T1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

T1

ofloxacin otic solution 0.3 % T1

OTOVEL OTIC SOLUTION 0.3-0.025 % T1 PA

*Oxytocics*

methylergonovine maleate oral tablet 0.2 mg T1QL (28 EA per 180 days); AL (Min 12 Years)

*Passive Immunizing And Treatment Agents*RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

T1 GR-F

SYNAGIS INTRAMUSCULAR SOLUTION100 MG/ML, 50 MG/0.5ML T1 PA

*Penicillins*amoxicillin oral capsule 250 mg, 500 mg T1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

T1

amoxicillin oral tablet 500 mg, 875 mg T1

amoxicillin oral tablet chewable 125 mg, 250 mg T1 AL (Max 12 Years)

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

T1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

T1

amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg, 400-57 mg


ampicillin oral capsule 250 mg, 500 mg T1

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

dicloxacillin sodium oral capsule 250 mg, 500 mg T1

94

Drug Status Notespenicillin v potassium oral solution reconstituted125 mg/5ml, 250 mg/5ml

T1

penicillin v potassium oral tablet 250 mg, 500 mg T1

*Pharmaceutical Adjuvants*cherry oral syrup T1

ORA-BLEND ORAL SUSPENSION T1

ORA-SWEET ORAL SYRUP T1

simple syrup oral syrup T1

*Progestins*AYGESTIN ORAL TABLET 5 MG T1 PA; PDL-NP

hydroxyprogesterone caproate intramuscular oil250 mg/ml

T1 PA; PDL-P

MAKENA INTRAMUSCULAR OIL 250 MG/ML T1 PA; PDL-NP

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML T1 PA; PDL-NP

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

T1

MEGACE ES ORAL SUSPENSION 625 MG/5ML T1 PA

megestrol acetate oral suspension 625 mg/5ml T1 PA

norethindrone acetate oral tablet 5 mg T1 PDL-P

progesterone intramuscular oil 50 mg/ml T1 PA

progesterone micronized oral capsule 100 mg, 200 mg

T1

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG T1 PA

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG T1 PA

*Psychotherapeutic And Neurological Agents - Misc.*ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG T1 PA

AUBAGIO ORAL TABLET 14 MG, 7 MG T1 PA

AVONEX INTRAMUSCULAR KIT 30 MCG T1 QL (4 EA per 30 days)

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML T1

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML T1 QL (4 EA per 30 days)

BETASERON SUBCUTANEOUS KIT 0.3 MG T1

95

Drug Status Notesbupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg


CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG T1 QL (60 EA per 30 days)

CHANTIX ORAL TABLET 0.5 MG, 1 MG T1 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 T1 QL (60 EA per 30 days)

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML T1

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML T1 PA

dalfampridine er oral tablet extended release 12 hour 10 mg

T1PA; QL (60 EA per 30 days); AL (Min 18 Years and Max 70 Years)

dimethyl fumarate oral capsule delayed release120 mg, 240 mg

T1 PA

donepezil hcl oral tablet 10 mg, 5 mg T1

donepezil hcl oral tablet 23 mg T1 PA

donepezil hcl oral tablet dispersible 10 mg, 5 mg T1

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

T1

EXTAVIA SUBCUTANEOUS KIT 0.3 MG T1 PA

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

T1 PA

galantamine hydrobromide oral solution 4 mg/ml T1 PA

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

T1

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG T1

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml

T1 PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML T1 PA

GRALISE ORAL TABLET 300 MG, 600 MG T1 PA

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG T1 PA

LUCEMYRA ORAL TABLET 0.18 MG T1PA; QL (224 EA per 14 days); AL (Min 18 Years)

MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 10 MG T1 PA


96

Drug Status NotesMAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK 10 MG T1 PA





MAYZENT ORAL TABLET 0.25 MG, 2 MG T1 PA

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG T1 PA

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

T1 PA

memantine hcl oral solution 10 mg/5ml, 2 mg/ml T1

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

T1

NAMENDA ORAL TABLET 10 MG, 5 MG T1 PA

NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 10 MG T1 PA

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

T1 PA

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR7 & 14 & 21 &28 MG

T1 PA

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG T1 PA

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

T1 PA

nicotine polacrilex mouth/throat gum 2 mg T1 QL (900 EA per 30 days)

nicotine polacrilex mouth/throat gum 4 mg T1 QL (720 EA per 30 days)

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg


nicotine step 1 transdermal patch 24 hour 21 mg/24hr


nicotine transdermal kit 21-14-7 mg/24hr T1 QL (56 EA per 56 days)

nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr


NICOTROL INHALATION INHALER 10 MG T1 QL (168 EA per 30 days)

97

Drug Status NotesPLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

T1 PA

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML

T1 PA

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML T1 PA

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML T1 PA

RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG

T1 PA

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG T1 PA

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

T1

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

T1

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML T1

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 44 MCG/0.5ML T1 QL (7 ML per 28 days)

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

T1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

T1

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

T1 PA

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG T1

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG T1

TECFIDERA ORAL 120 & 240 MG T1

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG T1

VUMERITY (STARTER) ORAL CAPSULE DELAYED RELEASE 231 MG T1 PA

XYREM ORAL SOLUTION 500 MG/ML T1 PA; QL (540 ML per 30 days)

98

Drug Status Notes

*Respiratory Agents - Misc.*PULMOZYME INHALATION SOLUTION 1 MG/ML T1 PA

*Tetracyclines*doxycycline hyclate oral capsule 100 mg T1

doxycycline hyclate oral capsule 50 mg T1 QL (1 EA per 75 days)

doxycycline hyclate oral tablet 100 mg T1

doxycycline monohydrate oral capsule 100 mg, 50 mg

T1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml


doxycycline monohydrate oral tablet 100 mg, 50 mg

T1

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

T1

*Thyroid Agents*ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG


levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

T1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

T1

methimazole oral tablet 10 mg, 5 mg T1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


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


np thyroid oral tablet 15 mg T1

propylthiouracil oral tablet 50 mg T1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

thyroid oral tablet 65 mg T1

99

Drug Status NotesUNITHROID DIRECT ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

UNITHROID ORAL TABLET 137 MCG T1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG T1 AL (Max 64 Years)

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


*Ulcer Drugs/Antispasmodics/Anticholinergics*ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG T1 PA

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG T1 PA

amoxicill-clarithro-lansopraz oral T1 PA; QL (224 EA per 14 days)

cimetidine 200 oral tablet 200 mg T1

cimetidine hcl oral solution 300 mg/5ml T1 AL (Max 12 Years)

cimetidine oral tablet 300 mg, 400 mg, 800 mg T1

DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG T1 PA

dicyclomine hcl oral capsule 10 mg T1 AL (Max 64 Years)

dicyclomine hcl oral solution 10 mg/5ml T1 AL (Max 64 Years)

dicyclomine hcl oral tablet 20 mg T1 AL (Max 64 Years)

esomeprazole magnesium oral capsule delayed release 40 mg

T1 PA

esomeprazole strontium oral capsule delayed release 49.3 mg

T1 PA

famotidine oral suspension reconstituted 40 mg/5ml


famotidine oral tablet 10 mg, 20 mg, 40 mg T1

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML T1 AL (Max 12 Years)

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML T1 AL (Max 12 Years)

glycopyrrolate oral tablet 1 mg, 2 mg T1

gnp omeprazole oral tablet delayed release 20 mg T1 PA

hm omeprazole oral tablet delayed release 20 mg T1 PA

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg


100

Drug Status Noteshyoscyamine sulfate oral elixir 0.125 mg/5ml T1 AL (Max 64 Years)

hyoscyamine sulfate oral solution 0.125 mg/ml T1 AL (Max 64 Years)

hyoscyamine sulfate oral tablet 0.125 mg T1 AL (Max 64 Years)

hyoscyamine sulfate oral tablet dispersible 0.125 mg


hyoscyamine sulfate sublingual tablet sublingual0.125 mg


lansoprazole oral capsule delayed release 15 mg, 30 mg

T1 PA

lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg

T1 PA

misoprostol oral tablet 100 mcg, 200 mcg T1 QL (120 EA per 30 days)

NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 MG T1 PA

NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG T1 PA

OMECLAMOX-PAK ORAL 500-500-20 MG T1 PA

omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg

T1 PA

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

T1

omeprazole oral tablet delayed release 20 mg T1 PA

omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40-1100 mg

T1 PA

omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40-1680 mg

T1 PA

pantoprazole sodium oral tablet delayed release20 mg, 40 mg

T1

PREVACID 24HR ORAL CAPSULE DELAYED RELEASE 15 MG T1 PA

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG T1 PA

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE 15 MG, 30 MG

T1 PA

PRILOSEC ORAL PACKET 10 MG, 2.5 MG T1 PA

PROTONIX ORAL PACKET 40 MG T1 PA

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG T1 PA

PYLERA ORAL CAPSULE 140-125-125 MG T1

rabeprazole sodium oral tablet delayed release 20 mg

T1 PA

101

Drug Status Notessucralfate oral tablet 1 gm T1 QL (120 EA per 30 days)

TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 MG T1 PA

ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG T1 PA

ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG T1 PA

*Urinary Antispasmodics*bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg


darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

T1 PA

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG T1 PA

DETROL ORAL TABLET 1 MG, 2 MG T1 PA

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 5 MG

T1 PA

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG, 7.5 MG T1 PA

flavoxate hcl oral tablet 100 mg T1

GELNIQUE PUMP TRANSDERMAL GEL10 % T1 PA

GELNIQUE TRANSDERMAL GEL 10 % T1 PA

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG T1 PA

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

T1

oxybutynin chloride oral syrup 5 mg/5ml T1

oxybutynin chloride oral tablet 5 mg T1

solifenacin succinate oral tablet 10 mg, 5 mg T1

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

T1 PA

tolterodine tartrate oral tablet 1 mg, 2 mg T1 PA

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG T1

trospium chloride oral tablet 20 mg T1 PA

VESICARE ORAL TABLET 10 MG, 5 MG T1 PA

*Vaccines*AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION T1

QL (0.5 ML per 365 days); AL (Min 6 Months)

102

Drug Status NotesAFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML

T1QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T1QL (0.5 ML per 365 days); AL (Min 6 Months)

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML T1

QL (0.5 ML per 365 days); AL (Min 65 Years)

FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE0.5 ML


FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T1 QL (0.5 ML per 365 days)

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML


FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION T1

QL (0.5 ML per 365 days); AL (Min 4 Years)

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML


FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 0.5 ML T1

QL (0.5 ML per 365 days); AL (Min 6 Months)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


HAVRIX INTRAMUSCULAR SUSPENSION1440 EL U/ML T1

QL (2 ML per 365 days); AL (Min 19 Years)

HAVRIX INTRAMUSCULAR SUSPENSION720 EL U/0.5ML T1


SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

T1 QL (2 EA per 1 lifetime)

VAQTA INTRAMUSCULAR SUSPENSION25 UNIT/0.5ML T1


VAQTA INTRAMUSCULAR SUSPENSION50 UNIT/ML T1


103

Drug Status NotesZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML T1 AL (Min 60 Years)

*Vaginal And Related Products*CLEOCIN VAGINAL CREAM 2 % T1 PA

CLEOCIN VAGINAL SUPPOSITORY 100 MG T1

clindamycin phosphate vaginal cream 2 % T1 PA; GR-F

CLINDESSE VAGINAL CREAM 2 % T1

clotrimazole 3 vaginal cream 2 % T1 GR-F

clotrimazole vaginal cream 1 % T1 GR-F

CRINONE VAGINAL GEL 4 % T1 PA; PDL-NP

CRINONE VAGINAL GEL 8 % T1 PA

estradiol vaginal cream 0.1 mg/gm T1 GR-F; QL (42.5 GM per 30 days)

METROGEL-VAGINAL VAGINAL GEL0.75 % T1 PA

metronidazole vaginal gel 0.75 % T1 PA; GR-F

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

T1 GR-F

miconazole 7 vaginal cream 2 % T1 GR-F

miconazole 7 vaginal suppository 100 mg T1 GR-F

NUVESSA VAGINAL GEL 1.3 % T1

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 3 % T1

ra miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm)

T1 GR-F

terconazole vaginal cream 0.4 %, 0.8 % T1 GR-F

TODAY SPONGE VAGINAL 1000 MG T1

VANDAZOLE VAGINAL GEL 0.75 % T1

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % T1

YUVAFEM VAGINAL TABLET 10 MCG T1

*Vasopressors*epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml


epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml


epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml


EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML T1 PA; QL (4 EA per 30 days)

EPIPEN INJECTION 0.3 MG/0.3ML T1 PA; QL (4 EA per 30 days)

104

Drug Status NotesEPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML T1 PA; QL (4 EA per 30 days)

EPIPEN JR INJECTION 0.15 MG/0.3ML T1 PA; QL (4 EA per 30 days)

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg T1 QL (90 EA per 30 days)

SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 MG/0.3ML

T1 PA

SYMJEPI SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML INJECTION 0.3 MG/0.3ML

T1 PA

*Vitamins*AQUA-E ORAL LIQUID 30-2 MG/ML T1

aqueous vitamin e oral solution 15 unit/0.3ml T1 AL (Max 12 Years)

arkaliox oral capsule 200 mg T1

biotin maximum strength oral tablet 10000 mcg T1

biotin oral capsule 1 mg, 2500 mcg, 5 mg T1

biotin oral tablet 1000 mcg, 300 mcg, 5000 mcg, 800 mcg

T1

CALCIFEROL ORAL SOLUTION 8000 UNIT/ML T1 QL (60 ML per 30 days)

CYTO B7 ORAL LIQUID 5 MG/ML T1

d 2000 oral tablet 50 mcg (2000 ut) T1

d 400 oral tablet 10 mcg (400 unit) T1

d3-1000 oral tablet 25 mcg (1000 ut) T1

e-400 oral capsule 400 unit T1

gnp niacin oral tablet 250 mg T1

gnp vitamin d oral tablet chewable 10 mcg (400 unit)

T1

LIQUI-E ORAL LIQUID 400 UNIT/15ML T1

mega biotin oral capsule 10 mg T1

MEPHYTON ORAL TABLET 5 MG T1 QL (3 EA per 30 days)

natural vitamin d-3 oral tablet 125 mcg (5000 ut) T1

niacin er oral capsule extended release 250 mg T1

niacin er oral capsule extended release 500 mg T1 PA

niacin er oral tablet extended release 1000 mg, 750 mg

T1

niacin er oral tablet extended release 500 mg T1 PA

niacin oral tablet 100 mg T1 PA

niacin oral tablet 50 mg T1

niacinamide oral tablet 100 mg, 500 mg T1

105

Drug Status Notesniacinamide oral tablet extended release 500 mg T1

pyridoxine hcl oral tablet 100 mg, 25 mg T1

ra niacin oral tablet 500 mg T1 PA

SLO-NIACIN ORAL TABLET EXTENDED RELEASE 500 MG T1

sm niacin cr oral tablet extended release 250 mg T1

vitamin b1 oral tablet 100 mg T1 QL (30 EA per 30 days)

vitamin b-1 oral tablet 100 mg T1 QL (30 EA per 30 days)

vitamin b-1 oral tablet 50 mg T1



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

T1

vitamin d oral liquid 400 unit/ml T1

vitamin d3 oral capsule 1.25 mg (50000 ut), 10 mcg (400 unit), 125 mcg (5000 ut), 25 mcg (1000 ut), 50 mcg (2000 ut)

T1

vitamin d3 oral tablet 1.25 mg (50000 ut) T1

vitamin e oral capsule 100 unit, 1000 unit, 200 unit, 600 unit

T1

vitamin e oral oil 100 unt/0.25ml T1

vitamin e oral tablet 100 unit, 200 unit, 400 unit T1

wheat germ oil oral oil T1

106

IndexABSTRAL ................................... 6ACANYA ................................... 51acarbose ......................................18ACCOLATE ..............................13ACCU-CHEK MULTICLIX LANCETS ................................. 75ACCUPRIL ............................... 32ACCURETIC ............................ 32acebutolol hcl ..............................43ACEPHEN ...................................5acetaminophen ..............................5acetaminophen 8 hour .................. 5acetaminophen er ..........................5acetaminophen extra strength .......5acetaminophen rapid tabs child ....5acetaminophen-codeine ................ 6acetaminophen-codeine #2 ........... 6acetaminophen-codeine #3 ........... 6acetaminophen-codeine #4 ........... 6acetazolamide ............................. 63acetazolamide er .........................63acetic acid ...................................93acetic acid-aluminum acetate ..... 93acetylcysteine .............................. 51ACID GONE ............................. 11ACIPHEX ................................100ACIPHEX SPRINKLE .......... 100acitretin .......................................51ACTEMRA ..................................2ACTEMRA ACTPEN ................ 2ACTIGALL ............................... 67ACTIQ ......................................... 6ACTONEL .................................64ACTOPLUS MET .................... 18ACTOPLUS MET XR ..............19ACTOS .......................................19ACULAR ................................... 89ACULAR LS ............................. 89ACUVAIL ..................................89acyclovir ................................42, 51ADALAT CC .............................44ADCIRCA ..................................46adefovir dipivoxil ........................ 42ADEMPAS .................................46ADLYXIN ..................................19ADLYXIN STARTER PACK . 19ADMELOG ............................... 19ADMELOG SOLOSTAR ........ 19adult aerosol mask ......................75ADVAIR DISKUS .................... 13ADVAIR HFA ...........................13

ADVOCATE INSULIN PEN NEEDLES ..................................75AFINITOR ................................ 38AFINITOR DISPERZ .............. 38AFLURIA QUADRIVALENT...........................................102, 103AFREZZA ................................. 19AGGRENOX .............................70AIMOVIG ................................. 78AIRDUO DIGIHALER ............13AJOVY .......................................78AKYNZEO ................................ 26ALA SCALP ..............................51ala-cort ....................................... 51alba-lybe nr .................................88albuterol sulfate .......................... 13albuterol sulfate hfa ....................13alclometasone dipropionate ........52alendronate sodium .................... 64alfuzosin hcl er ............................69aliskiren fumarate .......................32ALKERAN ................................ 38aller-ease .................................... 28allergy eye ...................................89allergy relief ..........................28, 87allergy relief childrens ................28allergy spray 24 hour ..................87allopurinol .................................. 70almotriptan malate ......................78ALOCRIL ..................................89alogliptin benzoate ......................19alogliptin-metformin hcl ............. 19alogliptin-pioglitazone ................19ALOMIDE .................................89alosetron hcl ............................... 67ALPHAGAN P .......................... 89ALREX ...................................... 89ALTACE ....................................32ALTOPREV .............................. 30aluminum hydroxide gel ..............11ALVESCO ................................. 13ALYQ .........................................46amantadine hcl ............................40AMARYL .................................. 19ambrisentan ................................ 46amcinonide ..................................52AMERGE .................................. 78AMETHYST ............................. 49amiloride hcl ...............................63amiloride-hydrochlorothiazide ... 63amiodarone hcl ........................... 13

AMITIZA .................................. 67amlodipine besy-benazepril hcl .. 32amlodipine besylate .................... 45amlodipine besylate-valsartan ....32amlodipine-atorvastatin ..............47amlodipine-olmesartan ............... 32amlodipine-valsartan-hctz .......... 32ammonium lactate .......................52AMNESTEEM .......................... 52amoxicill-clarithro-lansopraz ...100amoxicillin .................................. 94amoxicillin-pot clavulanate ........ 94ampicillin .................................... 94AMRIX ...................................... 86anagrelide hcl ............................. 70anastrozole ..................................38ANCOBON ................................27ANDRODERM ..........................11ANDROGEL ............................. 11ANDROGEL PUMP .................11ANECREAM .............................52ANORO ELLIPTA ...................13antacid calcium extra strength ... 11antacid plus anti-gas fast act ......11antacid/simethicone ds ................12ANTARA ................................... 30anti-diarrheal ..............................26antifungal ....................................52anti-itch maximum strength ........ 52antipyrine-benzocaine .................94APADAZ ......................................6apap 500 ....................................... 5apap-caff-dihydrocodeine .............6APETIGEN ............................... 83APETIGEN-PLUS ....................83APEXICON E ........................... 52APIDRA .....................................19APIDRA SOLOSTAR .............. 19apraclonidine hcl ........................ 89aprepitant ....................................26APRISO ..................................... 67AQUA GLYCOLIC HC SCALP & BODY ...................... 52AQUA-E ...................................105aqueous vitamin e ..................... 105ARANELLE .............................. 49ARANESP (ALBUMIN FREE) ........................................ 71ARCAPTA NEOHALER .........14ARICEPT .................................. 95ARIXTRA ..................................17

107

arkaliox ..................................... 105ARMOUR THYROID ..............99ARNUITY ELLIPTA ............... 14ARTHROTEC .............................2artificial tears ............................. 89ARYMO ER ................................ 6ASACOL HD .............................67ASMANEX (120 METERED DOSES) ......................................14ASMANEX (14 METERED DOSES) ......................................14ASMANEX (30 METERED DOSES) ......................................14ASMANEX (60 METERED DOSES) ......................................14ASMANEX HFA .......................14ASPERCREME LIDOCAINE 52ASPERCREME W/LIDOCAINE ........................ 52aspirin ....................................... 5, 6aspirin ec ...................................... 5aspirin ec low dose ....................... 5aspirin-dipyridamole er .............. 70ASSURE DOSE CONTROL ... 75ATACAND ................................ 32ATACAND HCT .......................32ATELVIA .................................. 64atenolol ....................................... 43atenolol-chlorthalidone .............. 32atorvastatin calcium ................... 30atovaquone ..................................36atropine sulfate ........................... 89ATROVENT HFA .................... 14AUBAGIO ................................. 95AURYXIA ..................................67AVALIDE ..................................32AVANDIA ..................................19AVAPRO ................................... 33AVELOX ................................... 67AVIANE .....................................49AVODART ................................ 69AVONEX ................................... 95AVONEX PEN .......................... 95AVONEX PREFILLED ........... 95AYGESTIN ............................... 95AZASITE ...................................89azathioprine ................................ 82azelastine hcl ........................ 87, 89azelastine-fluticasone ................. 87AZILECT .................................. 40azithromycin ............................... 74AZOPT .......................................89

AZOR .........................................33AZULFIDINE ........................... 67AZULFIDINE EN-TABS .........67b complex .................................... 83b complex formula 1 ................... 83b complex-c ................................. 83b complex-c-biotin-e-fa ...............83b-100 complex .............................83b-100 cr .......................................83b-12 ............................................. 71bacitracin ..............................52, 89bacitracin zinc ............................ 52bacitracin-polymyxin b ............... 89bacitra-neomycin-polymyxin-hc . 89baclofen .......................................86balsalazide disodium .................. 67BALZIVA .................................. 49BAQSIMI ONE PACK .............20BAQSIMI TWO PACK ........... 20BASAGLAR KWIKPEN ......... 20BASIS OVERNIGHT ...............52BAXDELA .................................67BAYER CONTOUR NEXT TEST .......................................... 62b-complex/b-12 ........................... 83BD AUTOSHIELD ................... 75BD AUTOSHIELD DUO ......... 75BD INSULIN SYR ULTRAFINE II .........................75BD INSULIN SYRINGE ..........75BD INSULIN SYRINGE MICROFINE .............................75BD INSULIN SYRINGE U/F .. 75BD INSULIN SYRINGE U-40 .75BD INSULIN SYRINGE U-500 .............................................. 75BD INTEGRA SYRINGE ........75BD LANCET DEVICE .............75BD PEN ......................................75BECONASE AQ ....................... 87BEELITH .................................. 79BELBUCA ................................... 7benazepril hcl ..............................33benazepril-hydrochlorothiazide ..33benfotiamine multi-b ...................83BENICAR ..................................33BENICAR HCT ........................ 33BENZACLIN .............................52BENZACLIN WITH PUMP ....52benzhydrocodone-acetaminophen ..............................7benznidazole ............................... 12

benzoyl peroxide ......................... 52benzoyl peroxide creamy wash ... 52benzoyl peroxide wash ................52BEPREVE ................................. 89BESER ....................................... 52BESIVANCE ............................. 89betamethasone dipropionate .......53betamethasone dipropionate aug .............................................. 52betamethasone valerate .............. 53BETAPACE ...............................43BETAPACE AF ........................ 43BETASERON ............................95betaxolol hcl ..........................43, 89bethanechol chloride .................102BETHKIS .................................... 1BETOPTIC-S ............................ 89BEVESPI AEROSPHERE .......14BEVYXXA .................................17bexarotene ...................................38bicalutamide ............................... 38bimatoprost ................................. 89BINOSTO .................................. 64BIOLLE GEL TEARS ............. 89biotin ......................................... 105biotin maximum strength .......... 105bisacodyl ..................................... 73bisacodyl ec .................................73bisoprolol fumarate .................... 43bisoprolol-hydrochlorothiazide .. 33BONIVA .................................... 64bosentan ......................................47bp folinatal plus b ....................... 83BRAFTOVI ............................... 38BREO ELLIPTA ...................... 14brewers yeast .............................. 83BRILINTA .................................70brimonidine tartrate ....................90bromfenac sodium (once-daily) .. 90bromocriptine mesylate ...............40BROMSITE ...............................90BROVANA ................................ 14BRYHALI ..................................53budesonide ............................ 14, 87budesonide er ..............................50budesonide-formoterol fumarate 14buffered aspirin .............................6bumetanide ..................................63buprenorphine ...............................7bupropion hcl er (smoking det) ...96butalbital-acetaminophen ............. 6butalbital-apap-caff-cod ............... 7

108

butalbital-apap-caffeine ............... 6butalbital-asa-caff-codeine ...........7butalbital-aspirin-caffeine ............ 6butenafine hcl ..............................53butorphanol tartrate ..................... 7BUTRANS ................................... 7BYDUREON ............................. 20BYDUREON BCISE ................ 20BYETTA 10 MCG PEN ........... 20BYETTA 5 MCG PEN ............. 20BYSTOLIC ................................43cabergoline ................................. 64CADUET ................................... 47caffeine citrate .............................. 1CALAN SR ................................ 45CALCIFEROL ........................105calcipotriene ............................... 53calcitonin (salmon) ..................... 64cal-citrate plus vitamin d ............ 79calcitriol ......................................64calcium ........................................80calcium + d3 ............................... 79calcium 500 + d .......................... 79calcium 500 + d3 ........................ 79calcium 500+d ............................ 79calcium 500+d3 .......................... 79calcium 600 .................................80calcium 600 + d .......................... 79calcium 600+d ............................ 80calcium 600+d3 .......................... 80calcium acetate (phos binder)...............................................67, 68calcium antacid ultra ..................12calcium carbonate .......................80calcium carbonate antacid ..........12calcium carbonate-vitamin d ...... 80calcium citrate ............................ 80calcium citrate + d3 maximum ... 80calcium citrate-vitamin d ............80calcium/vitamin d3 gummies ...... 80candesartan cilexetil ...................33candesartan cilexetil-hctz ........... 33capecitabine ................................38CAPEX .......................................53capsaicin ..................................... 53captopril ......................................33captopril-hydrochlorothiazide ....33carbidopa ....................................40carbidopa-levodopa ..............40, 41carbidopa-levodopa er ................40carbidopa-levodopa-entacapone 41carbinoxamine maleate ...............28

CARDIOTEK RX .....................62CARDIZEM .............................. 45CARDIZEM CD ....................... 45CARDIZEM LA ........................45CARDURA ................................ 33CARDURA XL ..........................69CAREFINE PEN NEEDLES ...75careone insulin syringe ...............76CAROSPIR ............................... 63carteolol hcl ................................ 90CARTIA XT .............................. 45carvedilol .................................... 43carvedilol phosphate er .............. 43CATAPRES ...............................33CATAPRES-TTS-1 ...................33CATAPRES-TTS-2 ...................33CATAPRES-TTS-3 ...................33CAYA .........................................76CAYSTON .................................36cefaclor ....................................... 48cefaclor er ...................................48cefadroxil .................................... 48cefdinir ........................................48cefixime ....................................... 48cefpodoxime proxetil ...................48cefprozil ...................................... 48ceftriaxone sodium ......................48cefuroxime axetil .........................48CELEBREX ................................ 2celecoxib ....................................... 2CENTANY .................................53CENTANY AT .......................... 53cephalexin ................................... 48CEREFOLIN .............................62cetirizine hcl ................................28cetirizine hcl allergy child .......... 28cetirizine hcl childrens ................28CHANTIX ................................. 96CHANTIX CONTINUING MONTH PAK ........................... 96CHANTIX STARTING MONTH PAK ........................... 96chelated magnesium ....................80CHEMET ...................................26cheratussin ac ............................. 51cheratussin dac ........................... 51cherry ..........................................95childrens chewable vitamins .......83childrens ibuprofen .......................2childrens loratadine ....................28childrens multivitamin ................ 83childrens silfedrine ..................... 87

childrens vitamins/iron ............... 83chlorhexidine gluconate ..............82chloroquine phosphate ................37chlorothiazide ............................. 63chlorpheniramine maleate .......... 28chlorpheniramine maleate er ......28chlorpropamide ...........................20chlorthalidone .............................63chlorzoxazone ............................. 86cholestyramine ............................30cholestyramine light ....................30choline-mag trisalicylate .............. 6CICLODAN ...............................53CICLODAN CREAM ...............53CICLODAN SOLUTION ........ 53ciclopirox .................................... 53ciclopirox olamine ...................... 53ciclopirox treatment ....................53cilostazol ..................................... 70CILOXAN ................................. 90cimetidine ..................................100cimetidine 200 ...........................100cimetidine hcl ............................100CIMZIA ..................................... 68CIMZIA PREFILLED ............. 68CIMZIA STARTER KIT .........68CIPRO ....................................... 67CIPRO HC ................................ 94CIPRODEX ............................... 94ciprofloxacin ............................... 67ciprofloxacin hcl ............. 67, 90, 94ciprofloxacin-ciproflox hcl er ..... 67ciprofloxacin-dexamethasone ..... 94ciprofloxacin-fluocinolone pf ......94CLARAVIS ............................... 53CLARINEX ............................... 28clarithromycin .............................74clarithromycin er ........................ 74clemastine fumarate ..............28, 29CLEOCIN ................................104clindamycin hcl ...........................36clindamycin palmitate hcl ...........36clindamycin phos-benzoyl perox .53clindamycin phosphate ....... 53, 104CLINDESSE ............................104clobetasol propionate ........... 53, 54clobetasol propionate e ...............53clobetasol propionate emulsion ..53CLOBEX ................................... 54CLOBEX SPRAY ..................... 54clocortolone pivalate .................. 54clocortolone pivalate pump ........ 54

109

CLODAN ................................... 54CLODERM ............................... 54CLODERM PUMP ...................54clonidine ..................................... 33clonidine hcl ................................33clopidogrel bisulfate ................... 70clotrimazole .................. 54, 82, 104clotrimazole 3 ........................... 104clotrimazole-betamethasone ....... 54codeine sulfate .............................. 7COLAZAL .................................68colchicine ....................................70colchicine-probenecid .................70COLCRYS .................................70colesevelam hcl ........................... 30COLESTID ................................30COLESTID FLAVORED ........ 30colestipol hcl ...............................30COMBIGAN ............................. 90COMBIVENT RESPIMAT ..... 14COMFORT ASSIST INSULIN SYRINGE ................ 76COMPLETE FORMULATION PEDIATRIC ..............................83COMTAN .................................. 41condoms ...................................... 76CONZIP .......................................7COPAXONE ............................. 96CORDRAN ................................54COREG ......................................43COREG CR ...............................43CORGARD ................................44CORZIDE ..................................33COSENTYX .............................. 54COSENTYX (300 MG DOSE) .54COSENTYX SENSOREADY (300 MG) ....................................54COSENTYX SENSOREADY PEN ............................................ 54COSOPT ....................................90COSOPT PF .............................. 90COUMADIN ..............................18COZAAR ................................... 33CREON ......................................63CRESEMBA ..............................27CRESTOR ................................. 30CRINONE ............................... 104cromolyn sodium .............14, 87, 90CURITY ALCOHOL PREPS . 76CUTIVATE ............................... 54cvs laxative dietary supplemnt ....73

cvs lubricant drops ..................... 90cvs nasal allergy spray ............... 87cvs prenatal gummy .................... 83cvs senna-extra ........................... 73cvs stool softener .........................73cyanocobalamin ..........................71cyclobenzaprine hcl .................... 87cyclobenzaprine hcl er ................ 86cyclopentolate hcl ....................... 90cyclophosphamide .......................38cycloserine .................................. 38cyclosporine ................................82cyclosporine modified .................82cyproheptadine hcl ......................29CYTO B7 ................................. 105cytra-2 .........................................69cytra-k ......................................... 69D 1000 PLUS ALOE .................71d 2000 ....................................... 105d 400 ......................................... 105d3-1000 ..................................... 105daily vitamin formula+iron ........ 83daily vite ......................................83dalfampridine er ......................... 96DALIRESP ................................ 14danazol ........................................11DANTRIUM ..............................87dantrolene sodium ...................... 87dapsone ....................................... 36darifenacin hydrobromide er ....102DAURISMO .............................. 38DAYPRO ..................................... 2DDAVP RHINAL TUBE ......... 64DELZICOL ............................... 68DENAVIR ..................................54DENTAGEL ..............................82DEPO-PROVERA .................... 38DERMA-SMOOTHE/FS BODY .........................................55DERMA-SMOOTHE/FS SCALP ....................................... 55DERMASORB HC ................... 55DERMASORB TA ....................55DERMATOP ............................. 55desloratadine .............................. 29desmopressin ace spray refrig .... 64desmopressin acetate .................. 64desmopressin acetate spray ........ 64DESONATE .............................. 55desonide ...................................... 55DESOWEN ................................55desoximetasone ........................... 55

DETROL ................................. 102DETROL LA ...........................102dexamethasone ............................50dexamethasone sodium phosphate ....................................90DEXILANT ............................. 100dextromethorphan-guaifenesin ... 51DIALYVITE 3000 .....................83DIALYVITE 5000 .....................83DIALYVITE 800 PLUS D ........83DIALYVITE 800/ZINC ............83DIALYVITE SUPREME D ..... 83DIALYVITE/ZINC ...................83diclofenac epolamine .................. 55diclofenac potassium .................... 2diclofenac sodium ............. 2, 55, 90diclofenac sodium er .....................2diclofenac-misoprostol ................. 2dicloxacillin sodium ....................94dicyclomine hcl ......................... 100DIFFERIN ................................. 55DIFICID .....................................74diflorasone diacetate .................. 55DIFLUCAN ............................... 27diflunisal ....................................... 6digoxin ........................................ 46DILAUDID .................................. 7diltiazem hcl ................................45diltiazem hcl er ........................... 45diltiazem hcl er beads ................. 45diltiazem hcl er coated beads ......45dilt-xr .......................................... 45dimenhydrinate ........................... 27dimethyl fumarate ....................... 96DINO-LIFE W/IRON-ZINC ... 83DIOVAN .................................... 33DIOVAN HCT .......................... 33DIPENTUM ...............................68diphenhydramine cough ..............29diphenhydramine hcl ...................29diphenoxylate-atropine ............... 26DIPROLENE .............................55dipyridamole ............................... 70DISNEY CALCIUM + VITAMIN D3 ............................ 80disopyramide phosphate ............. 13DITROPAN XL ...................... 102DIURIL ......................................63docosanol ....................................55docusate calcium .........................73docusate sodium ..........................73DOCUSOL MINI ......................73

110

DOLOPHINE ..............................7donepezil hcl ............................... 96dorzolamide hcl .......................... 90dorzolamide hcl-timolol mal .......90dorzolamide hcl-timolol mal pf ...90doxazosin mesylate ..................... 34doxycycline hyclate ..................... 99doxycycline monohydrate ........... 99dronabinol ...................................27drospirenone-ethinyl estradiol ....49DROXIA .................................... 71DRYSOL ....................................55DUAC .........................................55DUAKLIR PRESSAIR .............15DUETACT .................................20DUEXIS ....................................... 2DULERA ................................... 15DUOPA ...................................... 41DUPIXENT ............................... 55DURAGESIC-100 ....................... 7DURAGESIC-12 ......................... 7DURAGESIC-25 ......................... 7DURAGESIC-50 ......................... 7DURAGESIC-75 ......................... 7dutasteride .................................. 69dutasteride-tamsulosin hcl ..........69DYMISTA ................................. 87E.E.S. 400 ...................................74E.E.S. GRANULES ...................74e-400 ......................................... 105e-400/selenium ............................83EASIVENT ................................76EASIVENT MASK LARGE ....76EASIVENT MASK MEDIUM 76EASIVENT MASK SMALL ....76easy comfort insulin syringe ....... 76EASY TOUCH INSULIN SYRINGE .................................. 76ecee plus ......................................84econazole nitrate .........................55EDARBI .....................................34EDARBYCLOR ........................34EFFIENT ................................... 70eletriptan hydrobromide ............. 78ELIDEL ..................................... 55ELIQUIS ....................................18ELIQUIS DVT/PE STARTER PACK ..................... 18elite-thin insulin syringe ............. 76ELLA ......................................... 49ELMIRON .................................69ELOCON ................................... 55

EMBEDA .....................................7EMCYT ..................................... 38EMEND ..................................... 27EMEND TRI-PACK .................27EMFLAZA ................................ 50EMGALITY .............................. 78EMGALITY (300 MG DOSE) .78ENABLEX ............................... 102enalapril maleate ........................ 34enalapril-hydrochlorothiazide ....34ENBREL ......................................2ENBREL MINI ........................... 2ENBREL SURECLICK ............. 2ENDARI .....................................71enema ..........................................73ENEMEEZ PLUS ..................... 73enoxaparin sodium ......................18entacapone ..................................41entecavir ......................................42ENTRESTO ...............................47ENTYVIO ..................................68EPANED ....................................34epinastine hcl .............................. 90epinephrine ............................... 104EPIPEN ....................................104EPIPEN 2-PAK .......................104EPIPEN JR ..............................105EPIPEN JR 2-PAK ................. 105EPOGEN ................................... 71eprosartan mesylate ....................34eq acetaminophen junior .............. 6eq nasal allergy ...........................87eql one daily womens ..................84ERIVEDGE ............................... 38ERLEADA .................................38ERTACZO .................................55ERYPED 200 .............................74ERYPED 400 .............................74ERY-TAB .................................. 74ERYTHROCIN STEARATE .. 74erythromycin ................... 55, 75, 90erythromycin base .......................74erythromycin ethylsuccinate ....... 75esomeprazole magnesium ......... 100esomeprazole strontium ............ 100estradiol .............................. 66, 104estradiol-norethindrone acet ...... 66estropipate .................................. 66ethambutol hcl ............................ 38ethynodiol diac-eth estradiol ...... 49etodolac .........................................3etodolac er .................................... 3

etoposide ..................................... 38EUCERIN ..................................55EUCRISA .................................. 56everolimus ...................................38EVISTA ..................................... 64EXEL COMFORT POINT INSULIN SYR ...........................76EXELDERM ............................. 56EXELON ................................... 96exemestane ..................................38EXFORGE .................................34EXFORGE HCT .......................34EXTAVIA ..................................96EXTINA .....................................56extra strength acetaminophen .......6eye allergy relief ......................... 90EZALLOR SPRINKLE ........... 30ezetimibe ..................................... 30ezetimibe-simvastatin ..................30fabb ............................................. 71famciclovir .................................. 42famotidine ................................. 100FARESTON ...............................38FARXIGA ..................................20FARYDAK ................................ 39FC2 FEMALE CONDOM ....... 76febuxostat ....................................70FELDENE ................................... 3felodipine er ................................ 45fenofibrate ...................................30fenofibrate micronized ................ 30fenofibric acid .............................30FENOGLIDE ............................ 30fenoprofen calcium ....................... 3fentanyl ..................................... 7, 8fentanyl citrate .............................. 7FENTORA ...................................8ferronate ..................................... 71ferrous gluconate ........................ 71ferrous sulfate ............................. 71FEXMID .................................... 87fexofenadine hcl .......................... 29fexofenadine hcl childrens .......... 29FIASP .........................................20FIASP FLEXTOUCH .............. 20FIASP PENFILL ...................... 20FIBRICOR ................................ 31FIFTY50 PEN NEEDLES ........76finasteride ................................... 69FIORICET/CODEINE ...............8FIORINAL/CODEINE #3 ..........8FIRST-LANSOPRAZOLE .... 100

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FIRST-OMEPRAZOLE ........ 100FIRST-VANCOMYCIN 25 ......36FIRST-VANCOMYCIN 50 ......36FIRVANQ ..................................36fish oil ......................................... 89FLAGYL ..............................36, 37flavoxate hcl ..............................102flecainide acetate ........................ 13FLECTOR ................................. 56FLOMAX ...................................69FLONASE ALLERGY RELIEF ..................................... 87FLONASE SENSIMIST ...........87FLOVENT DISKUS ................. 15FLOVENT HFA ........................15FLUAD .....................................103FLUAD QUADRIVALENT ...103FLUARIX QUADRIVALENT...................................................103FLUBLOK QUADRIVALENT ................. 103FLUCELVAX QUADRIVALENT ................. 103fluconazole ..................................27flucytosine ................................... 27fludrocortisone acetate ............... 50FLULAVAL QUADRIVALENT ................. 103FLUMADINE ............................42flunisolide ................................... 88fluocinolone acetonide ................56fluocinolone acetonide body ....... 56fluocinolone acetonide scalp ...... 56fluocinonide ................................ 56fluocinonide-e ............................. 56fluorometholone ..........................90fluorouracil ................................. 56flurandrenolide ........................... 56flurbiprofen ................................... 3flurbiprofen sodium .................... 90flutamide ..................................... 39fluticasone propionate .......... 56, 88fluticasone-salmeterol .................15fluvastatin sodium .......................31fluvastatin sodium er ...................31FLUZONE HIGH-DOSE QUADRIVALENT ................. 103FLUZONE QUADRIVALENT ................. 103folbee ...........................................71FOLBEE PLUS CZ .................. 84FOLBIC ..................................... 62

FOLGARD ................................ 71folic acid ..................................... 71folinic-plus .................................. 71folplex 2.2 ................................... 71FOLTABS 800 ...........................72fondaparinux sodium .................. 18FORTAMET ............................. 20FORTEO ................................... 64FORTESTA ...............................11FOSAMAX ................................ 64FOSAMAX PLUS D ................. 64fosinopril sodium ........................ 34fosinopril sodium-hctz ................ 34FOSRENOL .............................. 68FRAGMIN .................................18FREESTYLE CONTROL SOLUTION ............................... 76FREESTYLE LITE TEST .......62FREESTYLE TEST ................. 62FROVA ...................................... 78frovatriptan succinate .................78FULPHILA ................................72FUNGOID-D ............................. 56furosemide ...................................63galantamine hydrobromide .........96galantamine hydrobromide er .... 96gas relief ..................................... 68gatifloxacin ................................. 90GAVILYTE-G ...........................73GAVILYTE-N WITH FLAVOR PACK ....................... 73GELNIQUE .............................102GELNIQUE PUMP ................ 102gemfibrozil .................................. 31GENOTROPIN ......................... 65GENOTROPIN MINIQUICK .65GENTAK ................................... 90gentamicin sulfate .................56, 90geri-mucil ....................................73GIANVI ..................................... 49GILENYA ..................................96glatiramer acetate .......................96GLATOPA .................................96GLEOSTINE .............................39glimepiride ..................................20glipizide .......................................20glipizide er .................................. 20glipizide-metformin hcl ...............20GLOPERBA ..............................70GLUCAGEN HYPOKIT ......... 20glucagon emergency ................... 20

GLUCOCARD EXPRESSION CONTROL ......76GLUCOCARD EXPRESSION MONITOR ......76GLUCOCARD EXPRESSION TEST ................62GLUCOCARD VITAL MONITOR ................................ 76GLUCOCARD VITAL TEST . 62GLUCONAVII BLOOD GLUCOSE TEST ......................62GLUCOPHAGE ....................... 20GLUCOPHAGE XR .................20GLUCOTROL .......................... 20GLUCOTROL XL ....................21GLUMETZA ............................. 21glyburide ..................................... 21glyburide micronized .................. 21glyburide-metformin ................... 21GLYCOPHOS ...........................80glycopyrrolate ...........................100GLYNASE ................................. 21GLYSET .................................... 21GLYXAMBI ..............................21gnp 24 hour nasal allergy ...........88gnp all day allergy childrens ...... 29gnp allergy relief .........................29gnp b-complex plus vitamin c ..... 84gnp hydrocortisone/aloe ............. 56gnp loratadine childrens .............29gnp niacin ................................. 105gnp omeprazole .........................100gnp tolnaftate .............................. 56gnp vitamin d ............................ 105GOCOVRI .................................41goodsense all day allergy ........... 29goodsense aller-ease ...................29goodsense nasal allergy spray ....88GRALISE .................................. 96granisetron hcl ............................27GRANIX .................................... 72griseofulvin microsize .................27griseofulvin ultramicrosize ......... 28guaifenesin ..................................51guaifenesin-dm ............................51guanfacine hcl .............................34GVOKE HYPOPEN 1-PACK . 21GVOKE PFS ............................. 21halcinonide ................................. 56halobetasol propionate ............... 56HALOG ..................................... 56HAVRIX .................................. 103

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h-e-b incontrol pen needles .........76HEMANGEOL ......................... 44heparin sodium (porcine) ............18heparin sodium (porcine) pf ....... 18HEXALEN .................................39hm all day allergy ....................... 29hm allergy relief ..........................88hm anti-diarrheal ........................26hm cetirizine hcl childrens ..........29hm fexofenadine hcl .................... 29hm hydrocortisone-aloe max st ...56hm iron ........................................72hm omeprazole ..........................100hm slow release iron ...................72HM ULTICARE INSULIN SYRINGE .................................. 76hm vitamin b100 complex ........... 84HOMATROPAIRE .................. 90homocysteine formula .................72HORIZANT ...............................96HUMALOG .........................21, 22HUMALOG JUNIOR KWIKPEN .................................21HUMALOG KWIKPEN .......... 21HUMALOG MIX 50/50 ........... 21HUMALOG MIX 50/50 KWIKPEN .................................21HUMALOG MIX 75/25 ........... 21HUMALOG MIX 75/25 KWIKPEN .................................21HUMATROPE ..........................65HUMIRA ..................................... 3HUMIRA PEN ............................ 3HUMULIN 70/30 ...................... 22HUMULIN 70/30 KWIKPEN ..22HUMULIN N .............................22HUMULIN N KWIKPEN ........22HUMULIN R .............................22HUMULIN R U-500 (CONCENTRATED) ................22HUMULIN R U-500 KWIKPEN .................................22HYCAMTIN ..............................39hydralazine hcl ............................34hydrochlorothiazide ....................63hydrocodone bitartrate er .............8hydrocodone-acetaminophen ........8hydrocodone-ibuprofen .................8hydrocortisone ................ 11, 50, 57hydrocortisone acetate ................56hydrocortisone butyr lipo base ... 56hydrocortisone butyrate ..............57

hydrocortisone max st/12 moist .. 57hydrocortisone valerate .............. 57hydrocortisone-acetic acid ......... 94hydrocortisone-aloe ....................57hydromorphone hcl .......................8hydromorphone hcl er ...................8hydroxychloroquine sulfate .........37hydroxyprogesterone caproate...............................................39, 95hydroxyurea ................................ 39hydroxyzine hcl ..................... 12, 13hydroxyzine pamoate .................. 13hyoscyamine sulfate .................. 101hyoscyamine sulfate er ..............100HYSINGLA ER .......................... 8HYZAAR ................................... 34ibandronate sodium .................... 65ibuprofen .......................................3ibuprofen junior strength ..............3IDHIFA ......................................39ILEVRO .....................................91ILUMYA ....................................57imiquimod ................................... 57IMITREX .................................. 78IMITREX STATDOSE REFILL ..................................... 78IMITREX STATDOSE SYSTEM ....................................78INBRIJA ....................................41IN-CHECK INSPIRATORY FLOW MTR ..............................76INCRELEX ............................... 65INCRUSE ELLIPTA ................15indapamide ................................. 63INDERAL LA ........................... 44INDERAL XL ........................... 44INDOCIN .....................................3indomethacin .................................3indomethacin er ............................ 3infants gas relief ......................... 68infants ibuprofen ...........................3infants pain relief ..........................6INNOPRAN XL ........................ 44insulin asp prot & asp flexpen .... 22insulin aspart .............................. 22insulin aspart flexpen ..................22insulin aspart penfill ................... 22insulin aspart prot & aspart ....... 22insulin lispro ............................... 22insulin lispro (1 unit dial) ........... 22insulin lispro junior kwikpen ...... 22insulin lispro prot & lispro ......... 22

insulin syringe .............................76INTRON A ................................ 39INVOKAMET ...........................22INVOKAMET XR .................... 22INVOKANA .............................. 22IOPIDINE ..................................91ipratropium bromide .............15, 88ipratropium-albuterol ................. 15irbesartan ....................................34irbesartan-hydrochlorothiazide ..34iron ..............................................72iron 100 plus ............................... 72isoniazid ......................................38isopropyl alcohol wipes .............. 57isosorbide dinitrate .....................12isosorbide dinitrate er .................12isosorbide mononitrate ............... 12isosorbide mononitrate er ...........12isotretinoin ..................................57isradipine .................................... 45ISTALOL ...................................91itraconazole ................................ 28ivermectin ....................................12JAKAFI ..................................... 39JALYN ....................................... 69JANUMET .................................22JANUMET XR ..........................23JANUVIA .................................. 23JARDIANCE .............................23JENTADUETO ......................... 23JENTADUETO XR .................. 23JUBLIA ......................................57JUNEL 1/20 ............................... 49KADIAN ...................................... 8KAPSPARGO SPRINKLE ......44KARIVA .................................... 49KATERZIA ............................... 45KEFLEX ....................................48KENALOG ................................57KERYDIN ................................. 57ketoconazole ..........................28, 57KETODAN ................................ 57ketone test ................................... 62ketoprofen ..................................... 3ketoprofen er .................................3ketorolac tromethamine .......... 3, 91KETOSTIX ............................... 62ketotifen fumarate ....................... 91KEVZARA .................................. 3KITABIS PAK ............................ 1kmart valu insulin syringe 30g ... 76KOMBIGLYZE XR ................. 23

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K-PHOS ..................................... 80K-PHOS NO 2 ........................... 69KRINTAFEL .............................37labetalol hcl ................................ 44lactulose ......................................73lamivudine ...................................42lansoprazole ..............................101lanthanum carbonate .................. 68LANTUS .................................... 23LANTUS SOLOSTAR ............. 23LARIN 24 FE ............................ 49LASTACAFT ............................ 91latanoprost ..................................91lc-4 lidocaine .............................. 57leflunomide ................................... 3LESCOL XL ..............................31LETAIRIS ................................. 47letrozole ...................................... 39leucovorin calcium ......................39LEUKERAN ..............................39LEUKINE ..................................72leuprolide acetate ....................... 39levalbuterol hcl ........................... 15levalbuterol tartrate ....................15LEVAQUIN ...............................67LEVEMIR ................................. 23LEVEMIR FLEXTOUCH .......23levobunolol hcl ............................91levocetirizine dihydrochloride .... 29levofloxacin ...........................67, 91levonorgest-eth estrad 91-day .... 49levonorgestrel ............................. 49LEVORA 0.15/30 (28) .............. 49levorphanol tartrate ......................8levothyroxine sodium .................. 99LEVOXYL .................................99LEXETTE ................................. 57LIALDA .....................................68lice killing maximum strength .....57lice treatment .............................. 57LICIDE TREATMENT ........... 57lidocaine ..................................... 57lidocaine hcl ................................58lidocaine viscous .........................82lidocaine-prilocaine ....................58LIDOCREAM ........................... 58lindane ........................................ 58linezolid .......................................37LINZESS ................................... 68liothyronine sodium .................... 99LIPITOR ................................... 31LIPOFEN ...................................31

LIQUI-E ...................................105lisinopril ......................................34lisinopril-hydrochlorothiazide ....34LITETOUCH PEN NEEDLES ..................................76LIVALO .....................................31l-methylfolate-b6-b12 ..................62LMX 4 ........................................ 58LOCOID .................................... 58LOCOID LIPOCREAM .......... 58LODOSYN .................................41long acting nasal spray ...............88LONHALA MAGNAIR REFILL KIT ............................. 15LONHALA MAGNAIR STARTER KIT ......................... 15LONSURF ................................. 39loperamide hcl ............................ 26LOPID ........................................31LOPRESSOR ............................ 44LOPROX ................................... 58loratadine ....................................29loratadine-d 12hr ........................51loratadine-d 24hr ........................51LORTAB ..................................... 8LORZONE ................................ 87losartan potassium ......................34losartan potassium-hctz .............. 34LOTENSIN ................................34LOTENSIN HCT ...................... 34LOTREL ....................................34LOTRIMIN AF .........................58LOTRISONE .............................58LOTRONEX ............................. 68lovastatin .....................................31LOVAZA ................................... 31LOVENOX ................................ 18LOW-OGESTREL ................... 49lubricant drops ............................91lubricant drops/dual-action ........ 91lubricant eye ............................... 91lubricant eye drops ..................... 91LUCEMYRA .............................96luliconazole .................................58LUMIGAN .................................91LUXIQ ....................................... 58LUZU ......................................... 58LYSODREN .............................. 39mag glycinate ..............................80MAG64 .......................................80MAGINEX .................................80magnesium .................................. 80

magnesium chloride ....................80magnesium citrate .................73, 80magnesium gluconate ................. 80magnesium oxide ...................12, 81magnesium oxide -mg supplement ............................ 80, 81magnesium sulfate ...................... 81magnesium sulfate in d5w ...........81MAGONATE ............................ 81MAG-TAB SR ...........................81MAKENA .................................. 95malathion .................................... 58MAOX ........................................12MASK VORTEX ...................... 76MATULANE ............................. 39MATZIM LA ............................ 45MAVENCLAD (10 TABS) .......96MAVENCLAD (4 TABS) .........96MAVENCLAD (5 TABS) .........97MAVENCLAD (6 TABS) .........97MAVENCLAD (7 TABS) .........97MAVENCLAD (8 TABS) .........97MAVENCLAD (9 TABS) .........97MAXALT ...................................78MAXALT-MLT ........................ 78MAYZENT ................................97MAYZENT STARTER PACK ......................................... 97meclizine hcl ............................... 27meclofenamate sodium ..................3medroxyprogesterone acetate...............................................49, 95mefenamic acid ............................. 3mefloquine hcl .............................37mega biotin ............................... 105MEGACE ES ............................ 95megestrol acetate .................. 39, 95meloxicam ..................................... 3memantine hcl .............................97memantine hcl er .........................97MENEST ................................... 66MENTAX ...................................58meperidine hcl ...............................8MEPHYTON ...........................105mercaptopurine ...........................39mesalamine ................................. 68mesalamine er .............................68MESNEX ................................... 39MESTINON ...............................38METAMUCIL MULTIHEALTH FIBER ........ 73metaproterenol sulfate ................ 15

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METAXALL ............................. 87metaxalone ..................................87metformin hcl .............................. 23metformin hcl er ..........................23metformin hcl er (mod) ............... 23metformin hcl er (osm) ................23methadone hcl ...........................8, 9METHADONE HCL INTENSOL ..................................9METHADOSE ............................ 9methenamine hippurate ...............37methenamine mandelate ............. 37methimazole ................................ 99methocarbamol ........................... 87methotrexate ................................39methotrexate sodium ...................39methotrexate sodium (pf) ............ 39methyclothiazide ......................... 63methyldopa ..................................35methyldopa-hydrochlorothiazide ....................35methylergonovine maleate .......... 94methylfol-algae-b12-acetylcyst ...62methylprednisolone ...............50, 51metipranolol ................................91metoclopramide hcl .....................68metolazone .................................. 64metoprolol succinate er .............. 44metoprolol tartrate ......................44metoprolol-hydrochlorothiazide . 35METROGEL-VAGINAL .......104metronidazole ............... 37, 58, 104mexiletine hcl .............................. 13MIACALCIN ............................ 65MICARDIS ................................35MICARDIS HCT ...................... 35miconazole 3 combo pack ......... 104miconazole 7 ............................. 104miconazole nitrate ...................... 58miconazole-zinc oxide-petrolat ...58MICORT-HC ............................ 58MICROGESTIN FE 1.5/30 ......49MICROGESTIN FE 1/20 .........49midazolam hcl .............................73midodrine hcl ............................ 105miglitol ........................................23milk of magnesia ......................... 73mineral oil ...................................73MINIPRESS .............................. 35minocycline hcl ........................... 99minoxidil ..................................... 35MIRAPEX ................................. 41

MIRAPEX ER ...........................41misoprostol ............................... 101MITIGARE ............................... 70MOBIC ........................................ 4moexipril hcl ............................... 35mometasone furoate ..............58, 88MONOJECT INSULIN SYRINGE .................................. 77montelukast sodium .............. 15, 16MORPHABOND ER .................. 9morphine sulfate ........................... 9morphine sulfate (concentrate) .....9morphine sulfate er ....................... 9morphine sulfate er beads .............9MOTEGRITY ........................... 68MOVANTIK ............................. 68MOXEZA .................................. 91moxifloxacin hcl ....................67, 91moxifloxacin hcl (2x day) ............91MS CONTIN ............................... 9multi adult gummies ....................84multi-delyn/iron .......................... 84multi-vit/fluoride ......................... 84multi-vitamin hp/minerals ...........84multivitamin/fluoride .................. 84multi-vitamin/fluoride ................. 84multi-vitamin/fluoride/iron ......... 84multivitamins pediatric ............... 84multivitamins/fluoride .................84mupirocin ....................................58mupirocin calcium ...................... 58mycophenolate mofetil ................ 82MYKIDZ IRON ........................ 84MYLERAN ................................39mynatal plus ................................84mynate 90 plus ............................ 84MYORISAN .............................. 58MYRBETRIQ ......................... 102nabumetone ...................................4nadolol ........................................ 44nadolol-bendroflumethiazide ......35naftifine hcl ................................. 58NAFTIN ..................................... 59NALFON ..................................... 4nalocet ...........................................9naloxone hcl ................................26NAMENDA ................................97NAMENDA TITRATION PAK ............................................97NAMENDA XR .........................97NAMENDA XR TITRATION PACK ......................................... 97

NAMZARIC ..............................97naphazoline hcl ...........................91NAPRELAN ................................ 4naproxen ....................................... 4naproxen dr ...................................4naproxen sodium ...........................4naproxen sodium er ...................... 4naproxen-esomeprazole ................4naratriptan hcl ............................ 78NARCAN ................................... 26NASACORT ALLERGY 24HR .......................................... 88NASACORT ALLERGY 24HR CHILDREN ....................88nasal allergy 24 hour ..................88nasal decongestant ......................88NASONEX .................................88nateglinide .................................. 23natural fiber laxative .................. 73natural fiber therapy ...................74natural vitamin d-3 ................... 105NATURE-THROID ..................99NECON 0.5/35 (28) ................... 49NECON 1/35 (28) ...................... 49NECON 10/11 (28) .................... 49neomycin sulfate ........................... 1neomycin-bacitracin zn-polymyx ....................................... 91neomycin-polymyxin-dexameth ...91neomycin-polymyxin-gramicidin 91neomycin-polymyxin-hc .............. 94NEPHROCAPS QT .................. 84NEPHRONEX ...........................84NEUAC ...................................... 59NEULASTA ...............................72NEULASTA ONPRO ............... 72NEUPOGEN ..............................72NEUPRO ................................... 41NEVANAC ................................ 91NEWGEN .................................. 84NEXIUM ..................................101NEXLETOL .............................. 31niacin ........................................ 105niacin er .................................... 105niacin er (antihyperlipidemic) .... 31niacin flush free .................... 47, 84NIACIN FLUSH-FREE EX ST ............................................... 47niacinamide .......................105, 106NIASPAN ...................................31nicardipine hcl ............................ 45nicotine ....................................... 97

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nicotine polacrilex ...................... 97nicotine step 1 ............................. 97NICOTROL ...............................97NIFEDICAL XL ....................... 45nifedipine .................................... 46nifedipine er ................................ 45nifedipine er osmotic release ...... 45nilutamide ................................... 39nimodipine .................................. 46nisoldipine er .............................. 46NITRO-BID ...............................12nitrofurantoin ..............................37nitrofurantoin macrocrystal ........37nitrofurantoin monohyd macro ...37nitroglycerin ............................... 12nitroglycerin er ........................... 12NIVESTYM ...............................72NIZORAL ..................................59non-aspirin extra strength ............ 6NORA-BE ..................................49NORCO ....................................... 9NORDITROPIN FLEXPRO ... 65norethin ace-eth estrad-fe ...........49norethindrone acetate .................95norethindrone acet-ethinyl est .... 49norethindrone-eth estradiol ........ 66norethin-eth estradiol-fe ............. 50norgesic forte .............................. 87NORTREL 7/7/7 ....................... 50NORVASC .................................46NOURIANZ ...............................41NOVOLIN 70/30 ....................... 23NOVOLIN 70/30 FLEXPEN ... 23NOVOLIN 70/30 FLEXPEN RELION .....................................23NOVOLIN 70/30 RELION ...... 23NOVOLIN N ............................. 24NOVOLIN N FLEXPEN ..........24NOVOLIN N FLEXPEN RELION .....................................24NOVOLIN R ............................. 24NOVOLIN R FLEXPEN ..........24NOVOLIN R FLEXPEN RELION .....................................24NOVOLOG ............................... 24NOVOLOG FLEXPEN ............24NOVOLOG MIX 70/30 ............ 24NOVOLOG MIX 70/30 FLEXPEN ..................................24NOVOLOG PENFILL ............. 24NOXAFIL ..................................28np thyroid ....................................99

NUBEQA ................................... 39NUCYNTA .................................. 9NUCYNTA ER ............................9NURTEC ................................... 78NUTROPIN AQ NUSPIN 10 ... 65NUTROPIN AQ NUSPIN 20 ... 65NUTROPIN AQ NUSPIN 5 ..... 65NUVARING .............................. 50NUVESSA ................................104nystatin ............................28, 59, 82nystatin-triamcinolone ................59OBSTETRIX DHA ................... 84OBSTETRIX EC ...................... 84octreotide acetate ........................65OCUFLOX ................................ 91ODOMZO ..................................40ofloxacin ......................... 67, 91, 94OGESTREL .............................. 50olmesartan medoxomil ................35olmesartan medoxomil-hctz ........ 35olmesartan-amlodipine-hctz ....... 35olopatadine hcl ..................... 88, 91OLUMIANT ................................4OLUX .........................................59OLUX-E .....................................59OMECLAMOX-PAK .............101omega-3-acid ethyl esters ........... 31omeprazole ................................101omeprazole magnesium .............101omeprazole-sodium bicarbonate...................................................101OMNARIS ................................. 88OMNITROPE ..................... 65, 66ondansetron ................................ 27ondansetron hcl .......................... 27ONETOUCH DELICA LANCETS 30G ......................... 77ONETOUCH DELICA LANCETS 33G ......................... 77ONETOUCH ULTRA BLUE .. 62ONETOUCH ULTRA CONTROL ................................ 77ONETOUCH VERIO .........62, 77one-way valved inspiratory .........77ONEXTON ................................ 59ONGLYZA ................................ 24ONMEL ..................................... 28ONZETRA XSAIL ................... 78OPANA ........................................ 9OPSUMIT ..................................47OPTIONS GYNOL II CONTRACEPTIVE ............... 104

ORA-BLEND ............................ 95ORALYTE .................................81ORA-SWEET ............................95ORAVIG ....................................82ORENCIA ................................... 4ORENCIA CLICKJECT ........... 4ORENITRAM ........................... 47ORILISSA ................................. 66orphenadrine citrate er ...............87oseltamivir phosphate ...........42, 43OSMOLEX ER ......................... 41OTEZLA ......................................4OTOVEL ................................... 94oxaprozin ...................................... 4OXAYDO .....................................9OXBRYTA ................................ 72OXERVATE ..............................92oxiconazole nitrate ......................59OXISTAT .................................. 59oxybutynin chloride ...................102oxybutynin chloride er .............. 102oxycodone hcl ............................. 10oxycodone hcl er ........................... 9oxycodone-acetaminophen ..........10oxycodone-aspirin .......................10OXYCONTIN ........................... 10oxymorphone hcl .........................10oxymorphone hcl er .................... 10oyster shell calcium .................... 81oyster shell calcium 250+d .........81oyster shell calcium plus d ..........81oyster shell calcium/d ................. 81oyster shell calcium/d3 ............... 81oyster shell/d ...............................81OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 24OZEMPIC (1 MG/DOSE) ........24pain relief childrens ......................6PALFORZIA (12 MG DAILY DOSE) .......................................... 1PALFORZIA (120 MG DAILY DOSE) ............................ 1PALFORZIA (160 MG DAILY DOSE) ............................ 1PALFORZIA (20 MG DAILY DOSE) .......................................... 1PALFORZIA (200 MG DAILY DOSE) ............................ 1PALFORZIA (240 MG DAILY DOSE) ............................ 1PALFORZIA (3 MG DAILY DOSE) .......................................... 1

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PALFORZIA (40 MG DAILY DOSE) .......................................... 1PALFORZIA (6 MG DAILY DOSE) .......................................... 1PALFORZIA (80 MG DAILY DOSE) .......................................... 1PALFORZIA INITIAL ESCALATION ............................1PANCREAZE ........................... 63PANDEL ....................................59panlor ..........................................10pantoprazole sodium .................101PARLODEL .............................. 41paromomycin sulfate .....................2PATADAY .................................92PATANASE ...............................88PATANOL .................................92PAZEO .......................................92peak flow meter ...........................77pediatric medium mask ............... 77pediatric small mask ................... 77peg 3350/electrolytes .................. 74pen needles ..................................77penicillin v potassium ................. 95PENNSAID ................................59PENTASA ..................................68pentazocine-naloxone hcl ........... 10pentoxifylline er .......................... 70PERCOCET .............................. 10PERFOROMIST .......................16perindopril erbumine .................. 35permethrin ...................................59permethrin lice treatment ............59PERTZYE ................................. 63PHENAZO .................................69phenazopyridine hcl ....................70phenylephrine hcl ........................92PHOSLYRA .............................. 68phos-nak ......................................81PHOSPHA 250 NEUTRAL ..... 81PHOSPHOLINE IODIDE ....... 92pilocarpine hcl ...................... 82, 92pimecrolimus ...............................59pindolol ....................................... 44pink bismuth ................................26pink bismuth maximum strength . 26PIN-X ......................................... 12pioglitazone hcl ...........................24pioglitazone hcl-glimepiride .......24pioglitazone hcl-metformin hcl ... 24piroxicam ...................................... 4PLAVIX ..................................... 70

PLEGRIDY ............................... 98PLEGRIDY STARTER PACK ......................................... 98podofilox ..................................... 59polyethylene glycol 3350 ............ 74polymyxin b-trimethoprim ...........92polyvitamin ................................. 84poly-vitamin/iron ........................ 85POMALYST ..............................40posaconazole ...............................28pot bicarb-pot chloride ............... 81potassium bicarbonate ................81potassium chloride crys er ..........81potassium chloride er ................. 81potassium citrate er .................... 70potassium phosphates ................. 81povidone-iodine .......................... 42PRADAXA .................................18PRALUENT .............................. 31pramipexole dihydrochloride ......41pramipexole dihydrochloride er . 41PRANDIN ..................................24prasugrel hcl ...............................70PRAVACHOL ...........................31pravastatin sodium ......................31prazosin hcl .................................35PRECISION XTRA KETONE ................................... 62PRECOSE ................................. 24prednicarbate ..............................59prednisolone ............................... 51prednisolone acetate ...................92prednisolone sodium phosphate...............................................51, 92prednisone ...................................51prednisone (pak) ......................... 51PREMARIN .............................. 66premium condoms lubricated ......77PREMPHASE ........................... 67PREMPRO ................................ 67prenatal .......................................85prenatal 19 ..................................85prenatal complete ....................... 85prenatal dha ................................89prenatal low iron ........................ 85prenatal multi +dha ....................85prenatal plus iron ....................... 85PRENATAL-U .......................... 85pretab ..........................................85pretomanid ..................................38PREVACID ............................. 101PREVACID 24HR .................. 101

PREVACID SOLUTAB ......... 101PREVALITE ............................. 31PRIFTIN ....................................38PRILOSEC ..............................101primaquine phosphate ................ 37PRIMLEV ................................. 10PRINIVIL ..................................35PROAIR DIGIHALER ............ 16PROAIR HFA ........................... 16PROAIR RESPICLICK ...........16probenecid .................................. 70PROCARDIA ............................46PROCARDIA XL ..................... 46prochlorperazine .........................42prochlorperazine maleate ...........42PROCRIT ..................................72progesterone ............................... 95progesterone micronized .............95PROLATE ................................. 10PROLENSA ...............................92promethazine hcl .........................29promethazine-dm ........................ 51PROMETRIUM ........................95propafenone hcl .......................... 13proparacaine hcl .........................92propranolol hcl ........................... 44propranolol hcl er .......................44propranolol-hctz ......................... 35propylthiouracil .......................... 99PROSCAR ................................. 70PROSTAMEN ...........................62PROTONIX .............................101PROTOPIC ............................... 59PROVENTIL HFA ................... 16PROVERA .................................95pseudoeph-bromphen-dm ............51pseudoephedrine hcl er ...............88psorcon ....................................... 59PULMICORT ........................... 16PULMICORT FLEXHALER ..16PULMOZYME ......................... 99px artificial tears .........................92PYLERA ..................................101pyrazinamide ...............................38pyridostigmine bromide .............. 38pyridoxine hcl ........................... 106QBRELIS ...................................35qc allergy relief ...........................88qc anti-diarrheal .........................26qc childrens allergy .................... 29qc childrens vitamins/extra c ...... 85qc fexofenadine hydrochloride ....29

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qc natural vegetable ....................74qc tolnaftate ................................ 59QMIIZ ODT ................................ 4QNASL .......................................88QNASL CHILDRENS ..............88q-pap infants ................................. 6QTERN ...................................... 24QUESTRAN .............................. 31QUESTRAN LIGHT ................ 31quinapril hcl ................................35quinapril-hydrochlorothiazide ....35quinidine sulfate ..........................13quinidine sulfate er ..................... 13QVAR REDIHALER ............... 16ra artificial tears .........................92ra b-complex/vitamin c cr ........... 85ra magnesium ..............................81ra miconazole 3 combo pack app ............................................ 104ra nasal allergy ...........................88ra niacin ....................................106ra oyster shell calcium/d .............81rabano yodado ............................ 85rabeprazole sodium .................. 101raloxifene hcl .............................. 66ramipril ....................................... 35RANEXA ................................... 12RAPAFLO ................................. 70rasagiline mesylate ..................... 41RAZADYNE ..............................98RAZADYNE ER ....................... 98REBIF ........................................ 98REBIF REBIDOSE .................. 98REBIF REBIDOSE TITRATION PACK ................. 98REBIF TITRATION PACK ....98RECLIPSEN ............................. 50REFRESH LIQUIGEL ............ 92REFRESH OPTIVE SENSITIVE ............................... 92RELAFEN DS ............................. 4RELENZA DISKHALER ........ 43RELI-ON INSULIN SYRINGE .................................. 77RELISTOR ..........................68, 69RELPAX ....................................78RENAGEL .................................69RENAL ...................................... 85renal vitamin ...............................85rena-vite rx ..................................85RENVELA .................................69repaglinide ..................................24

repaglinide-metformin hcl .......... 24REPATHA .................................31REPATHA PUSHTRONEX SYSTEM ....................................31REPATHA SURECLICK ........ 31REQUIP XL .............................. 41RESTASIS ................................. 92RESTASIS MULTIDOSE ........92REVATIO ..................................47REVLIMID ............................... 82REYVOW ..................................79RHOGAM ULTRA-FILTERED PLUS .....................94RHOPRESSA ............................92RID ESSENTIAL LICE ELIMINATION ........................ 59rifabutin ...................................... 38rifampin .......................................38rimantadine hcl ...........................43ri-mox ..........................................12RINVOQ ......................................4RIOMET ....................................25RIOMET ER ............................. 25risedronate sodium ..................... 66rivastigmine ................................ 98rivastigmine tartrate ................... 98rizatriptan benzoate .................... 79ROBAXIN-750 .......................... 87ROCKLATAN .......................... 92ropinirole hcl .............................. 41ropinirole hcl er ..........................41rosuvastatin calcium ...................31ROXICODONE ........................ 10ROXYBOND ............................. 10RYBELSUS ............................... 25RYTARY ................................... 41SAIZEN ..................................... 66SAIZENPREP ........................... 66saline mist spray ......................... 88sanadermrx skin repair ...............59SANCUSO ................................. 27SANTYL .................................... 59SAVAYSA ................................. 18SAVELLA ................................. 98SAVELLA TITRATION PACK ......................................... 98SCALPICIN MAXIMUM STRENGTH .............................. 60SCOOBY-DOO ONE A DAY ..85SEEBRI NEOHALER ..............16SEGLUROMET ........................25selegiline hcl ............................... 42

selenium sulfide .......................... 60senna ........................................... 74senna laxative ............................. 74SENNA SMOOTH ....................74senna-docusate sodium ...............74sen-o-tabs ....................................74SENSIPAR .................................66SEREVENT DISKUS ...............16SERNIVO .................................. 60SEROSTIM ............................... 66sevelamer carbonate ...................69sevelamer hcl .............................. 69sf 5000 plus ................................. 82SHINGRIX .............................. 103sildenafil citrate .......................... 47SILIQ ......................................... 60silodosin ......................................70silver sulfadiazine ....................... 60SIMBRINZA ............................. 92simethicone ................................. 69simple syrup ................................ 95SIMPONI .....................................4SIMPONI ARIA ..........................4simvastatin .................................. 32SINEMET ..................................42SINEMET CR ........................... 42SINGULAIR ..............................16sirolimus ..................................... 82SITAVIG ................................... 43SIVEXTRO ............................... 37SKELAXIN ............................... 87SKYRIZI (150 MG DOSE) ...... 60SLO-NIACIN .......................... 106slow iron ..................................... 72slow magnesium/calcium ............ 82slow release iron .........................72SLOW-MAG ............................. 82sm all day allergy childrens ........29sm allergy relief .................... 29, 88sm anti-diarrheal ........................ 26sm antifungal tolnaftate .............. 60sm dry eye relief ..........................92sm fexofenadine hcl .....................30sm hydrocortisone .......................60sm ibuprofen ................................. 5sm ibuprofen jr ..............................5sm niacin cr ...............................106sm slow release iron ................... 72sodium bicarbonate .................... 12sodium chloride .................... 51, 70sodium chloride (hypertonic) ......92sodium fluoride ........................... 82

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sodium phosphate ....................... 82sodium polystyrene sulfonate ......82solifenacin succinate .................102SOLIQUA ..................................25SOOTHE ................................... 26sotalol hcl ....................................44sotalol hcl (af) .............................44SOTYLIZE ................................44spinosad ...................................... 60SPIRIVA HANDIHALER ....... 16SPIRIVA RESPIMAT ..............16spironolactone ............................ 64spironolactone-hctz .....................64SPORANOX ..............................28SPRINTEC 28 ........................... 50SPRIX .......................................... 5SPS ............................................. 82STALEVO 100 .......................... 42STALEVO 125 .......................... 42STALEVO 150 .......................... 42STALEVO 200 .......................... 42STALEVO 50 ............................ 42STALEVO 75 ............................ 42STARLIX ...................................25STEGLATRO ........................... 25STEGLUJAN ............................ 25STELARA ........................... 60, 69sterile water for irrigation .......... 82STIMATE ..................................66STIOLTO RESPIMAT ............ 16STRIVERDI RESPIMAT ........ 16sucralfate .................................. 102SULAR .......................................46sulfacetamide sodium ............92, 93sulfacetamide sodium (acne) ...... 60sulfacetamide sodium-sulfur .......60sulfacetamide-prednisolone ........93sulfamethoxazole-trimethoprim .. 37sulfasalazine ............................... 69sulindac .........................................5sumatriptan ................................. 79sumatriptan succinate .................79sumatriptan succinate refill ........ 79sumatriptan-naproxen sodium .... 79SUPERVITE ............................. 85SUPRAX .................................... 48SURE-LANCE THIN LANCETS 28G ......................... 77SYMBICORT ............................17SYMJEPI .................................105SYMLINPEN 120 ..................... 25SYMLINPEN 60 ....................... 25

SYMPROIC ...............................69SYNAGIS ...................................94SYNALAR ................................. 60SYNALAR (CREAM) .............. 60SYNALAR (OINTMENT) ....... 60SYNALAR TS ........................... 60SYNJARDY ...............................25SYNJARDY XR ........................ 25SYNTHROID ............................ 99SYSTANE ..................................93TABLOID ..................................40tacrolimus ............................. 60, 82tadalafil (pah) ............................. 47TALICIA ................................. 102TALTZ .......................................60TAMIFLU ................................. 43tamoxifen citrate ......................... 40tamsulosin hcl ............................. 70TANZEUM ................................25TARKA ......................................35TARON-BC ............................... 85TARON-CRYSTALS ............... 70TASMAR ................................... 42TAZTIA XT .............................. 46TAZVERIK ............................... 40TECFIDERA .............................98TECHLITE PEN NEEDLES ...77TEKTURNA ..............................35TEKTURNA HCT .................... 35telmisartan .................................. 35telmisartan-amlodipine ...............35telmisartan-hctz .......................... 36TEMOVATE ............................. 60temozolomide .............................. 40TENORETIC 100 ..................... 36TENORETIC 50 ....................... 36TENORMIN ..............................44terazosin hcl ................................36terbinafine hcl .......................28, 60terbutaline sulfate ....................... 17terconazole ................................104TESTIM .....................................11testosterone ................................. 11testosterone cypionate .................11TEXACORT ..............................60THALOMID ..............................82THEOCHRON ..........................17theophylline .................................17theophylline er ............................ 17thyroid .........................................99TIADYLT ER ............................46TIAZAC .....................................46

TIBSOVO .................................. 40timolol maleate ..................... 44, 93TIMOPTIC ................................93TIMOPTIC OCUDOSE ...........93TIMOPTIC-XE .........................93tinidazole .....................................37TIVORBEX ................................. 5tizanidine hcl ...............................87TOBI ............................................ 2TOBI PODHALER .....................2tobramycin .............................. 2, 93tobramycin pak ............................. 2tobramycin-dexamethasone ........ 93TODAY SPONGE .................. 104tolazamide ...................................25tolbutamide ................................. 25tolcapone .....................................42tolmetin sodium .............................5tolnaftate ..................................... 61tolsura ......................................... 28tolterodine tartrate ....................102tolterodine tartrate er ............... 102TOPICORT ............................... 61TOPICORT SPRAY .................61TOPROL XL .............................44torsemide .....................................64TOSYMRA ................................79TOUJEO MAX SOLOSTAR ...25TOUJEO SOLOSTAR ............. 25TOVET ...................................... 61TOVIAZ ...................................102TRACLEER .............................. 47TRADJENTA ............................25tramadol hcl ................................10tramadol hcl er ........................... 10tramadol hcl er (biphasic) .......... 10tramadol-acetaminophen ............10trandolapril .................................36trandolapril-verapamil hcl er ..... 36TRAVATAN Z .......................... 93travoprost (bak free) ................... 93TRECATOR ..............................38TRELEGY ELLIPTA .............. 17TREMFYA ................................ 61TRESIBA ...................................25TRESIBA FLEXTOUCH ........ 25tretinoin .................................40, 61TREXIMET ...............................79triamcinolone acetonide . 61, 83, 88triamterene-hctz ..........................64TRIANEX ..................................61TRIBENZOR ............................ 36

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TRICOR .................................... 32TRIGLIDE ................................ 32TRIJARDY XR .........................25TRI-LEGEST FE ......................50TRILIPIX .................................. 32trimethoprim ............................... 37trinatal rx 1 ................................. 85TRINATE .................................. 86TRINESSA LO ..........................50triple antibiotic ........................... 61TRI-SPRINTEC ........................50tri-tabs dha ..................................86TRI-VI-FLOR ........................... 86tri-vi-floro ................................... 86tri-vit/fluoride ............................. 86tri-vit/fluoride/iron ......................86tri-vitamin ................................... 86tri-vite pediatric .......................... 86TRIVORA (28) ..........................50trixaicin .......................................61tropicamide ................................. 93trospium chloride ......................102TRULANCE ..............................69TRULICITY ..............................26TRUSOPT ................................. 93TRUSTEX NON-LUBRICATED ..........................77TUDORZA PRESSAIR ............17tussin dm max adult .................... 51TYLENOL WITH CODEINE #3 ................................................ 10TYMLOS ................................... 66TYVASO ....................................47TYVASO REFILL ....................47TYVASO STARTER ................47UBRELVY .................................79UCERIS ..................................... 51UDENYCA ................................ 73ULORIC .................................... 70ULTICARE INSULIN SYRINGE .................................. 77ULTICARE MICRO PEN NEEDLES ..................................77ULTRACET .............................. 10ULTRAM ...................................11ULTRAVATE ........................... 61ULTRAVATE X (CREAM) .....61ULTRAVATE X (OINTMENT) ........................... 61UNITHROID ...........................100UNITHROID DIRECT .......... 100UPTRAVI .................................. 47

urea ............................................. 61URO-MAG ................................ 12URSO 250 .................................. 69URSO FORTE .......................... 69ursodiol ....................................... 69UTIBRON NEOHALER ..........17valacyclovir hcl ...........................43valganciclovir hcl ....................... 43valsartan ..................................... 36valsartan-hydrochlorothiazide ... 36VALTREX .................................43VANCOCIN .............................. 37VANCOCIN HCL .....................37vancomycin hcl ........................... 37VANDAZOLE .........................104VANOS ...................................... 61VAQTA ....................................103VARUBI (180 MG DOSE) ....... 27VASCEPA ................................. 32VASERETIC ............................. 36VASOTEC ................................. 36VCF VAGINAL CONTRACEPTIVE ............... 104VELIVET .................................. 50VELPHORO ............................. 69VEMLIDY ................................. 43VENCLEXTA ........................... 40VENCLEXTA STARTING PACK ......................................... 40VENTAVIS ................................47VENTOLIN HFA ......................17verapamil hcl .............................. 46verapamil hcl er ..........................46VERELAN .................................46VERELAN PM ..........................46VESICARE ..............................102VFEND .......................................28VIBERZI ................................... 69VICODIN HP ............................ 11VICTOZA ..................................26VIGAMOX ................................ 93VIMOVO ..................................... 5VINATE II .................................86VINATE M ................................ 86VIOKACE ................................. 63VISTARIL ................................. 13vita-bee/c .....................................86VITAL-D RX .............................86vita-min ....................................... 86vitamin b complex-c .................... 86vitamin b1 ................................. 106vitamin b-1 ................................ 106

vitamin b-12 ................................ 73vitamin b-2 ................................ 106vitamin b-6 ................................ 106vitamin b-complex .......................86vitamin b-complex 100 ................86vitamin d ................................... 106vitamin d (ergocalciferol) ......... 106vitamin d3 ................................. 106vitamin e ..............................61, 106vitamin e skin .............................. 61VITA-RESPA ............................62VIVLODEX .................................5VOGELXO ................................11VOGELXO PUMP ................... 11vol-care rx ...................................86VOLTAREN ..............................61voriconazole ................................28VORTEX HOLDING CHAMBER/MASK .................. 77vp-heme ob ..................................86vp-vite rx ..................................... 86VUMERITY (STARTER) ........98VUSION .....................................62VYNDAMAX ............................ 48VYNDAQEL ............................. 48VYTORIN ................................. 32VYZULTA .................................93warfarin sodium ..........................18WELCHOL ............................... 32WESTHROID ......................... 100wheat germ oil .......................... 106WIDE-SEAL DIAPHRAGM 60 ................................................ 77WIDE-SEAL DIAPHRAGM 65 ................................................ 77WIDE-SEAL DIAPHRAGM 70 ................................................ 77WIDE-SEAL DIAPHRAGM 75 ................................................ 77WIDE-SEAL DIAPHRAGM 80 ................................................ 77WIDE-SEAL DIAPHRAGM 85 ................................................ 77WIDE-SEAL DIAPHRAGM 90 ................................................ 77WIDE-SEAL DIAPHRAGM 95 ................................................ 77WIXELA INHUB ......................17WP THYROID ........................100XADAGO ...................................42XALATAN .................................93XARELTO .................................18

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XARELTO STARTER PACK 18XATMEP ................................... 40XELJANZ ....................................5XELJANZ XR .............................5XELPROS ................................. 93XERESE .................................... 62XHANCE ................................... 88XIFAXAN ..................................37XIGDUO XR ............................. 26XOFLUZA (40 MG DOSE) ..... 43XOFLUZA (80 MG DOSE) ..... 43XOPENEX .................................17XOPENEX CONCENTRATE .17XPOVIO (100 MG ONCE WEEKLY) ................................. 40XPOVIO (60 MG ONCE WEEKLY) ................................. 40XPOVIO (80 MG ONCE WEEKLY) ................................. 40XPOVIO (80 MG TWICE WEEKLY) ................................. 40XTAMPZA ER ..........................11XTANDI .....................................40XULANE ................................... 50XULTOPHY ..............................26XYREM ..................................... 98YOSPRALA .............................. 70YUPELRI .................................. 17YUVAFEM ..............................104ZADITOR ..................................93zafirlukast ................................... 17ZANAFLEX .............................. 87ZARXIO .................................... 73ZEGERID ................................102ZELAPAR ................................. 42ZELNORM ................................69ZEMBRACE SYMTOUCH .....79ZENATANE .............................. 62ZENPEP .....................................63ZERVIATE ............................... 93ZESTORETIC .......................... 36ZESTRIL ................................... 36ZETIA ........................................32ZETONNA .................................88ZIAC .......................................... 36ZIEXTENZO .............................73zileuton er ................................... 17ZIOPTAN .................................. 93ZIPSOR ....................................... 5ZITHROMAX ...........................75ZITHROMAX TRI-PAK .........75ZITHROMAX Z-PAK ............. 75

ZOCOR ......................................32ZOFRAN ................................... 27ZOHYDRO ER ......................... 11ZOLINZA ..................................40zolmitriptan .................................79ZOMACTON ............................ 66ZOMIG ...................................... 79ZOMIG ZMT ............................ 79ZONTIVITY ............................. 71ZORBTIVE ............................... 66ZORVOLEX ............................... 5ZOSTAVAX ............................ 104ZOVIA 1/35E (28) .....................50ZOVIRAX ........................... 43, 62ZUPLENZ ................................. 27ZYFLO .......................................17ZYLOPRIM .............................. 70ZYMAXID .................................93ZYPITAMAG ........................... 32ZYTIGA .....................................40ZYVOX ......................................37

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effective september 2020 - total health carethe total health care (thc) medicaid formulary was...

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