gateway health 2018 medicaid formulary · iv non-formulary drugs a non-formulary drug is one that...

i

Gateway HealthSM

2018 Medicaid Formulary

ii

INTRODUCTION The Gateway Health (Gateway) formulary is a list of FDA-approved covered medications which have been reviewed and approved by our Pharmacy and Therapeutics (P&T) Committee and the Pennsylvania Department of Human Services (DHS). The P&T Committee is made up of actively participating network physicians, pharmacists and Medical Assistance (MA) program consumer representatives who select products on the basis of their safety, efficacy, quality and cost to the plan. Physicians are requested to prescribe medications included in the formulary whenever medically appropriate. Providers can contact Gateway Pharmacy Services with any questions related to a member’s prescription coverage limitations. The drug formulary is divided into major therapeutic categories (chapters) for easy use. Products that are approved for more than one therapeutic indication may be included in more than one chapter. Covered formulary drugs are listed in the first column under the Drug heading. The notes column in the formulary will tell you which drugs may have any additional requirements or limits on them. The P&T Committee meets on a quarterly basis to review and revise the formulary. All providers (both participating pharmacies and physicians) are provided access to the Gateway formulary and are periodically notified of formulary updates. Providers may request the addition of a medication to the formulary. Requests must include the drug name, rationale for inclusion on the formulary, role in therapy and formulary medications that may be replaced by the addition. The committee will review requests. All requests should be forwarded in writing to:

Gateway Health -P&T Committee Pharmacy Department Four Gateway Center 444 Liberty Avenue

Suite 2100 Pittsburgh, PA 15222

The formulary is accessible online at www.GatewayHealthPlan.com. It may be searched by drug name or drug class. Future updates to the formulary will be available, both by provider publication and online. Additional hard copies of the formulary may be printed directly from the formulary website, or requested as follows:

Physician Practices: 1-800-392-1147 Pharmacy Network Providers: 1-800-392-1147

Questions about the formulary can be directed to:

Pharmacy Services Department…….1-800-392-1147

iii

PHARMACY CO-PAYMENTS Co-payments will apply to Gateway members 21 years of age and older. These co-payments do not apply to any member who is pregnant or in a nursing home. Please note, members cannot be denied a service if they are unable to pay their co-pay. Practitioners can verify a member’s medical assistance benefit eligibility through the Department of Human Services PROMISe TM Eligibility Verification System (EVS). For Medical Assistance (MA) members 21 years of age and older, the benefit structure for prescription drugs is as follows:

$1.00 for formulary generic prescription drugs $3.00 for formulary brand prescription drugs Copays will apply to any approved prior authorization for a non-formulary drug Medications within the following specified therapeutic categories will be excluded from the

copay requirements for MA recipients only, which will be noted at the point of sale transaction:

o Antipsychotics o Family Planning o Antidiabetic Agents, including Insulin o Antineoplastic Agents (Cancer medications) o Antiparkinson Agents o Antiglaucoma Agents o Antihypertensive Agents o Anticonvulsants o HIV/AIDS medications o Cardiovascular preparations (Antiarrhythmics, Antianginals, Anticoagulants, Lipid

Lowering Agents) o Naloxone o Smoking cessation products o Influenza, Pneumonia and Zoster vaccines

FORMULARY MEDICATION COVERAGE Approved Medications

Only FDA-approved medications are eligible for coverage.

Investigational/Experimental Drug Use Drugs prescribed for investigational or experimental purposes are not eligible for reimbursement.

Formulary Drugs Formulary drugs are those reviewed and recommended for inclusion in the formulary by Gateway’s P&T Committee. These drugs are selected based upon their safety, efficacy, quality and cost. Physicians should use formulary drugs when they believe it medically appropriate to do so.

iv

Non-formulary Drugs

A non-formulary drug is one that has not been recommended for inclusion in the formulary by Gateway’s P&T Committee on the basis of safety, efficacy, quality and cost. Physicians are requested to comply with the formulary when prescribing medications for members when medically appropriate. A physician may request a non-formulary medication only if medical necessity or failure of formulary alternatives are documented by the physician on the Gateway Medicaid Drug Exception Form. When presented a prescription for a non-formulary drug, a pharmacist should attempt to contact the prescribing physician in order to suggest formulary alternatives. If the physician is unavailable, the pharmacist should contact Gateway at 1-800-392-1147 to help secure a formulary alternative.

Request for Non-Formulary Drug Coverage If changing to a formulary medication is not medically advisable for a patient, a physician must initiate a Request for Non-formulary Drug Coverage by faxing the request form found on our website to: 1-888-245-2049 or by calling 1-800-392-1147 with all of the information requested on the form. All requests for exception will receive a response within 24 hours. In the event a member’s prescription for a medication is not filled when a prescription is presented to the pharmacist due to a Prior Authorization requirement, Gateway will authorize a temporary supply of the non-formulary medication. For new therapies, up to a 5 day supply may be dispensed. If the member is currently taking a medication, it qualifies as ongoing. The pharmacist may dispense up to a 15-day supply for ongoing medications. Members have the right to appeal any decision regarding prescription drug coverage.

Generic Substitution When there is a generic version of a brand name drug available, Gateway requires the generic drug be given. Generic drugs are subject to specific reimbursement levels, such as Maximum Allowable Cost (MAC) price reimbursements. Drugs that are available in generic form will appear in bold in the formulary. The bold font indicates that the generic drug product is on the formulary but the branded product is not. Requests for “Brand Necessary” medications will be considered a non-formulary medication request and will require authorization. The Gateway Medicaid Drug Exception Form must be submitted with sufficient documentation to substantiate medical necessity of the Brand Name medication. Physicians are encouraged to prescribe generic medications whenever clinically appropriate.

Prior Authorization Prior Authorization (prior approval) is necessary for coverage of certain medications. In these cases, clinical criteria, based on current medical information and approved by Gateway’s P&T Committee and the Department of Human Services, must be met or additional information must be provided before coverage is approved. In the event a member’s prescription for a medication is not filled when a prescription is presented to the pharmacist due to a Prior Authorization requirement, Gateway will authorize a temporary supply of the medication. For new therapies, up to a 5 day supply may be dispensed. To avoid interruptions in therapy for ongoing medication, Gateway will provide a 15-day supply of the medication to the member. Prior authorizations are processed by calling Gateway at 1-800-392-1147 or physicians may

v

complete a drug specific prior authorization form by accessing the website at www.GatewayHealthPlan.com. Physicians should fax the completed prior authorization form to 1-888-245-2049 for processing. All requests for prior authorization will receive a response within 24 hours.

Quantity Limits

For certain drugs, Gateway has established quantity limits (limits on the amount of drug you can have filled). Quantity limits are put in place to ensure that you do not receive a quantity greater than the recommended limit (daily, monthly or yearly based on FDA recommendations) and to promote efficient drug dosing regimens. Prescriptions in excess of the covered quantity require a medical exception request from the prescribing physician. For example, Gateway provides coverage for 9 tablets of sumatriptan (generic Imitrex) 100mg every 30 days. Medications with quantity limits are denoted by QL in the formulary.

Once Daily Medications (Dose Optimization) Some medications are indicated to be taken as a once daily dose rather than several times throughout the day. In these situations, Gateway will cover only the larger dose for 30 days. This is a type of quantity limit called dose optimization. For example, your physician writes you a prescription to take a 5mg tablet twice a day. If a 10mg tablet exists in that medication, Gateway will cover this strength rather than two of the 5mg tablets. Should there be a medical explanation as to why you would need to take a lesser dose twice a day; your physician may call Gateway at 1-800-392-1147 or fax 1-888-245-2049 to request an exception. These medications are denoted by QL in the formulary.

Step Therapy In some cases, Gateway requires you to first try certain drugs to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Gateway may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Gateway will then cover Drug B. Step therapy medications may also be requested through the prior authorization process. Drugs on the formulary that require step therapy with be identified with a ST indicator.

Specialty Pharmacy Information

Some medications, including those that require special handling and some injectable medications, listed in the formulary are available through a specialty pharmacy network. These medications are denoted as SPN in the formulary. To find a participating specialty pharmacy, use the Specialty Pharmacy List, which is located on our website at https://www.gatewayhealthplan.com/provider/pharmacy-tools. If you have questions regarding the status of a particular pharmacy, please contact: Gateway Member Services at 1-800-392-1147.

Compounded Prescriptions

A claim for a compounded prescription should be submitted with all NDCs used in the compound. Only valid NDCs are permitted. The compound cost will automatically calculate based upon coverage of the submitted ingredients. Payment will only be made for FDA approved drugs and drugs not excluded from payment by Medical Assistance. A compounded medication may require prior authorization to determine medical necessity. Prior authorizations are processed by calling Gateway at 1-800-392-1147 or physicians may complete a Medicaid

vi

Drug Exception Form by accessing the website at www.GatewayHealthPlan.com. Physicians should fax the completed form to 1-888-245-2049 for processing. All requests will receive a response within 24 hours.

Over-the-counter (OTC) Medications

Gateway provides coverage for a number of OTC medications written as a prescription. Please refer to the OTC Formulary referenced on page xviii in this introduction for a specific listing of covered categories.

Drug Efficacy Study Implementation (DESI) Drug A DESI drug is one that was approved by the FDA solely on the basis of safety prior to 1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs. Gateway excludes all DESI drugs as defined by the FDA.

Drugs Not Eligible for Federal Rebates Gateway, by direction of DHS, excludes coverage for any drug marketed by a drug company who does not participate in the Medicaid Drug Rebate Program.

Medications Covered by Other Insurers (Coordination of Benefits and Third Party Liability) As an agent of the Commonwealth of Pennsylvania Medical Assistance Program, Gateway is always the payer of last resort in the event that a member receives a medication that is covered by another payer source. The claim must be billed to the primary insurance, and subsequently billed on-line or submitted on a Universal Claim Form (UCF) to Gateway for any outstanding balance.

Non-covered Drugs

Non-covered drugs include the following categories: Drugs and other items prescribed for obesity or appetite control Over the counter drugs in the form of troches, lozenges, throat tablets, cough drops,

chewing gum, mouthwashes and similar items Pharmaceutical services provided to a hospitalized person Drugs and devices classified as experimental by the FDA or whose use is classified as

experimental by the FDA Drugs and devices not approved by the FDA or whose use is not approved by the FDA Placebos Prescription and over the counter soaps, cleansing agents, dentifrices, mouthwashes, douche

solutions, diluents, ear wax removal agents, deodorants, liniments, antiseptics, irrigants, emollients and other personal care items

Durable Medical Equipment (DME) items (with the exception of preferred diabetic supplies, syringes, lancets and condoms)

Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program

vii

Prescriptions or orders filled by a pharmacy other than the one to which a recipient has been restricted

DESI drugs and identical, similar or related products or combinations of these products FDA approved pharmaceutical products whose indicated use is not to treat or manage a

medical condition, illness or disorder Prescription and over-the-counter pharmaceutical products distributed by a company that

has not entered into a National rebate agreement with the Federal government Fertility promoting agents Erectile dysfunction drugs unless used for an FDA approved indication other than for the

treatment of sexual or erectile dysfunction Agents prescribed for cosmetic purposes or approved by the FDA for cosmetic purposes

only

PROVIDER NUMBER When processing a prescription claim for a Gateway member, a valid NPI number is required.

DAYS SUPPLY DISPENSING LIMITATIONS Members may receive up to a 34-day supply of a pharmaceutical product per prescription or refill. A 34-day supply shall be interpreted to mean consecutive 34-day supply, i.e., if a physician prescribes a medication b.i.d. (two times a day), a 34-day supply corresponds to a quantity of 68. The prescriber is urged to prescribe in amounts that adhere to FDA guidelines and accepted standards of care. The dispensing pharmacist must accurately calculate the days supply. A 90-day supply is available for select generic maintenance medications. These medications are designated as 90 in the formulary.

VACATION SUPPLIES All requests for an early refill or a quantity in excess of a 34-day supply due to upcoming travel must be made by the prescribing physician. The physician must include the following in a request for a vacation supply of maintenance medication: your destination, your departure and return dates, any travel documentation including flight reservations or hotel confirmations, the dose, strength, frequency, and quantity of the medications that are being requested. Medications being requested that have abuse potential will be reviewed on a case by case basis with the prescribing physician and Gateway Clinical Pharmacist and/or Medical Director. In addition, members may get their prescriptions filled anywhere in the United States at a participating network pharmacy, potentially eliminating the need for a vacation override.

RECIPIENT RESTRICTION PROGRAM Gateway’s Recipient Restriction Program is a program to detect and deter member misutilization and/or fraud/abuse. This program restricts members to one PCP and/or one Participating

viii

Pharmacy of the member’s choice for a period of five years. Gateway contacts the member’s physician and pharmacy of choice to ask if they would be willing to accept a restricted member. Our program interfaces with the DHS (Department of Human Services) centralized Recipient Restriction program. This enables DHS to continue the restrictions for a five-year period across the Pennsylvania Medical Assistance Program. Once a member is identified for this program through referrals from participating pharmacies or physicians or generated utilization reports, a complete review of pharmacy and medical claims data is performed. Upon completion of the review, if misutilization, fraud and/or abuse can be documented and has met the DHS approved restriction criteria, the member is recommended for restriction to a PCP and/or Participating Pharmacy. Upon approval from Gateway’s Recipient Restriction Committee and DHS, the member is then restricted or “locked-in” to one PCP and/or one Participating Pharmacy. Please note: the restriction is not enforced in the case of an emergency. Please contact Gateway for assistance if this situation occurs. If you suspect member misutilization and/or fraud and/or abuse please contact our Pharmacy Services Department at 1-800-392-1147 or our Special Investigations Unit at 1-800-685-5235. APPEALS AND COMPLAINTS Gateway members and providers have the right to appeal any denial made by the plan. Details regarding appeals, complaints, and grievances may be found in the Member Handbook or the Provider Manual. To request a Member or Provider Handbook, call 1-800-392-1147. Both manuals are available online at www.GatewayHealthPlan.com.

PHARMACY BENEFIT INQUIRIES Members or providers having questions regarding the pharmacy benefit, please call 1-800-392-1147. (TTY/TDD users: 711).

ix

GATEWAY HEALTH OTC FORMULARY (FOR COVERAGE, DRUGS MUST BE WRITTEN AS A PRESCRIPTION)

Drugs are listed alphabetically by category. Specific OTC drugs are listed as examples and are not inclusive of all covered products.

Analgesics

Acetaminophen Acetaminophen combinations Aspirin Aspirin combinations Ibuprofen Naproxen Magnesium Salicylate

Dermatologicals/Topical Therapy

Acne (benzoyl peroxide) Anesthetics (benzocaine, dibucaine, lidocaine,

pramoxine, tetracaine) Antibacterials (bacitracin, neomycin, triple

antibiotic preparation, povidone-iodine) Anti-inflammatory agents (hydrocortisone 1%) Dermatological baths (colloidal oatmeal)

Fungicides (clotrimazole, miconazole, tolnaftate, terbinafine, undecylenic acid, salicylic acid, triacetin)

Tar preparations (not including soaps and cleansing agents)

Wet dressings (aluminum acetate) Scabicides/pediculicides (permethrin, RID)

Endocrine/Diabetes

Insulin Insulin needles and syringes Glucose meters (FreeStyle Lite, FreeStyle

InsuLinx, and Precision Xtra products) Diabetic supplies (FreeStyle Lite, FreeStyle

InsuLinx, and Precision Xtra products, lancets, alcohol swabs)

Gastroenterology

Antacids Antidiarrheals (kaolin-pectin combinations,

loperamide) Antiflatulents (simethicone) Antinauseants (meclizine, dimenhydrinate) Laxatives and stool softeners (Miralax, Milk of

Magnesia, bisacodyl, docusate) Histamine-2 receptor antagonists Omeprazole OTC Lansoprazole OTC

Obstetrics & Gynecology

Contraceptives (condoms, contraceptive jellies) Vaginal fungicides(clotrimazole, miconazole,

tioconazole)

Ophthalmic Preparations

Ocular lubricants (polyvinyl alcohol or cellulose derivatives)

Antihistamine (ketotifen OTC) Decongestants (Naphcon, Visine)

Sodium chloride hypertonic

Respiratory, Allergy, Cough & Cold

Antihistamines (diphenhydramine, loratadine, cetirizine, fexofendadine)

Cough and cold products Nasal preparations (oxymetazoline,

phenylephrine, saline) Saline for inhalation

Smoking Cessation Products

Nicotine replacement

Vitamins, Hematinics & Electrolytes

Vitamins Prenatal vitamins Calcium salts Iron products (not including long-acting products) Niacin Oral electrolyte mixtures

Medical Supplies

Please check with Gateway HealthSM for coverage

Gateway Health PA Medicaid Formulary

Table of Contents

ANTIHISTAMINE DRUGS......................................................................................................................................3ANTI-INFECTIVE AGENTS....................................................................................................................................4ANTINEOPLASTIC AGENTS............................................................................................................................... 17ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES.....................................................................................19AUTONOMIC DRUGS...........................................................................................................................................19BLOOD FORMATION, COAGULATION, THROMBOSIS................................................................................ 25CARDIOVASCULAR DRUGS.............................................................................................................................. 32CENTRAL NERVOUS SYSTEM AGENTS..........................................................................................................52DEVICES.................................................................................................................................................................71ELECTROLYTIC, CALORIC, AND WATER BALANCE...................................................................................79ENZYMES...............................................................................................................................................................85EYE, EAR, NOSE AND THROAT (EENT) PREPS.............................................................................................. 85GASTROINTESTINAL DRUGS............................................................................................................................90GOLD COMPOUNDS.............................................................................................................................................94HEAVY METAL ANTAGONISTS........................................................................................................................ 94HORMONES AND SYNTHETIC SUBSTITUTES............................................................................................... 94LOCAL ANESTHETICS (PARENTERAL).........................................................................................................109MISCELLANEOUS THERAPEUTIC AGENTS................................................................................................. 109NON-FRF...............................................................................................................................................................116OXYTOCICS.........................................................................................................................................................120PHARMACEUTICAL AIDS.................................................................................................................................120RESPIRATORY TRACT AGENTS......................................................................................................................126SKIN AND MUCOUS MEMBRANE AGENTS..................................................................................................132SMOOTH MUSCLE RELAXANTS.....................................................................................................................142VITAMINS............................................................................................................................................................ 143

1

Gateway Health PA Medicaid Formulary

CURRENT AS OF 10/1/2018

Drug Name Tier NotesANTIHISTAMINE DRUGS

ETHANOLAMINE DERIVATIVES

DimenhyDRINATE Oral Tablet 50 MG 1

DiphenhydrAMINE HCl Injection Solution 50 MG/ML 1

DiphenhydrAMINE HCl Oral Capsule 25 MG, 50 MG 1

DiphenhydrAMINE HCl Oral Elixir 12.5 MG/5ML 1

DiphenhydrAMINE HCl Powder 1

Pharbedryl Oral Capsule 50 MG 1

ETHYLENEDIAMINE DERIVATIVES

Tripelennamine HCl Powder 1

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

Cyproheptadine HCl Oral Syrup 2 MG/5ML 1

Cyproheptadine HCl Oral Tablet 4 MG 1

FIRST GENERATION ANTIHISTAMINES









PHENOTHIAZINE DERIVATIVES

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG

1

Promethazine HCl Oral Solution 6.25 MG/5ML 1

Promethazine HCl Oral Syrup 6.25 MG/5ML 1

Promethazine HCl Oral Tablet 12.5 MG, 25 MG, 50 MG 1

3

Drug Name Tier NotesPromethazine HCl Rectal Suppository 12.5 MG, 25 MG, 50 MG 1

Promethazine VC Oral Syrup 6.25-5 MG/5ML 1

Promethazine VC/Codeine Oral Syrup 6.25-5-10 MG/5ML 1 PA; QL (1000 ML per 30 days)

Promethazine-DM Oral Syrup 6.25-15 MG/5ML 1

Promethazine-Phenyleph-Codeine Oral Syrup6.25-5-10 MG/5ML 1 PA; QL (1000 ML per 30 days)

Promethazine-Phenylephrine Oral Syrup 6.25-5 MG/5ML 1

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG

1

PIPERAZINE DERIVATIVES

HydrOXYzine HCl Oral Syrup 10 MG/5ML 1

HydrOXYzine HCl Oral Tablet 10 MG, 25 MG, 50 MG 1

HydrOXYzine Pamoate Oral Capsule 100 MG, 25 MG, 50 MG 1

Meclizine HCl Oral Tablet 12.5 MG, 25 MG 1

Meclizine HCl Oral Tablet Chewable 25 MG 1

SECOND GENERATION ANTIHISTAMINES

Cetirizine HCl Allergy Child Oral Solution 5 MG/5ML 1

Cetirizine HCl Oral Solution 1 MG/ML 1

SEMPREX-D ORAL CAPSULE 8-60 MG 1

ANTI-INFECTIVE AGENTS

1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

Cefadroxil Oral Capsule 500 MG 1

Cefadroxil Oral Suspension Reconstituted 250 MG/5ML, 500 MG/5ML 1

Cefadroxil Oral Tablet 1 GM 1

CeFAZolin Sodium Injection Solution Reconstituted 1 GM, 10 GM, 500 MG 1

CeFAZolin Sodium Intravenous Solution Reconstituted 1 GM 1

Cephalexin Oral Capsule 250 MG, 500 MG 1

Cephalexin Oral Suspension Reconstituted 125 MG/5ML, 250 MG/5ML 1

Cephalexin Oral Tablet 250 MG, 500 MG 1

4

Drug Name Tier Notes2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

Cefaclor ER Oral Tablet Extended Release 12 Hour 500 MG 1

Cefaclor Oral Capsule 250 MG, 500 MG 1

Cefaclor Oral Suspension Reconstituted 125 MG/5ML, 250 MG/5ML, 375 MG/5ML 1

CefoTEtan Disodium Injection Solution Reconstituted 1 GM, 10 GM, 2 GM 1

CefOXitin Sodium Injection Solution Reconstituted 10 GM 1

CefOXitin Sodium Intravenous Solution Reconstituted 1 GM, 2 GM 1

Cefprozil Oral Suspension Reconstituted 125 MG/5ML, 250 MG/5ML 1

Cefprozil Oral Tablet 250 MG, 500 MG 1

Cefuroxime Axetil Oral Tablet 250 MG, 500 MG 1

Cefuroxime Sodium Injection Solution Reconstituted 7.5 GM, 750 MG 1

Cefuroxime Sodium Intravenous Solution Reconstituted 1.5 GM 1

3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

Cefdinir Oral Capsule 300 MG 1

Cefdinir Oral Suspension Reconstituted 125 MG/5ML, 250 MG/5ML 1

Cefixime Oral Suspension Reconstituted 100 MG/5ML 1

Cefpodoxime Proxetil Oral Suspension Reconstituted 100 MG/5ML, 50 MG/5ML 1

Cefpodoxime Proxetil Oral Tablet 100 MG, 200 MG 1

CefTAZidime Injection Solution Reconstituted1 GM, 2 GM, 6 GM 1

CefTRIAXone Sodium in Dextrose Intravenous Solution 20 MG/ML, 40 MG/ML 1

CefTRIAXone Sodium Injection Solution Reconstituted 1 GM, 2 GM, 250 MG, 500 MG 1

CefTRIAXone Sodium Intravenous Solution Reconstituted 1 GM, 10 GM, 2 GM 1

TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM, 6 GM

1

5

Drug Name Tier NotesTAZICEF INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 2 GM

1

4TH GENERATION CEPHALOSPORIN ANTIBIOTICS

Cefepime HCl Injection Solution Reconstituted1 GM, 2 GM 1

Cefepime HCl Intravenous Solution 1 GM/50ML, 2 GM/100ML 1

ADAMANTANE ANTIVIRALS

Amantadine HCl Oral Capsule 100 MG 1

Amantadine HCl Oral Syrup 50 MG/5ML 1

Amantadine HCl Oral Tablet 100 MG 1

ALLYLAMINE ANTIFUNGALS

Terbinafine HCl Oral Tablet 250 MG 1 QL (90 EA per 365 days)

AMEBICIDES

MetroNIDAZOLE Benzoate Powder 1

MetroNIDAZOLE Oral Capsule 375 MG 1

MetroNIDAZOLE Oral Tablet 250 MG, 500 MG 1

Paromomycin Sulfate Oral Capsule 250 MG 1

AMINOGLYCOSIDE ANTIBIOTICS

Gentamicin in Saline Intravenous Solution 0.8-0.9 MG/ML-%, 1-0.9 MG/ML-%, 1.2-0.9 MG/ML-%, 1.6-0.9 MG/ML-%, 2-0.9 MG/ML-%

1

Gentamicin Sulfate Injection Solution 40 MG/ML 1

Neomycin Sulfate Oral Tablet 500 MG 1

Paromomycin Sulfate Oral Capsule 250 MG 1

Streptomycin Sulfate Powder 1

Tobramycin Inhalation Nebulization Solution300 MG/5ML 1 SPN

Tobramycin Sulfate Injection Solution 1.2 GM/30ML, 2 GM/50ML, 80 MG/2ML 1 SPN

AMINOPENICILLIN ANTIBIOTICS

Amoxicill-Clarithro-Lansopraz Oral 1

Amoxicillin Oral Capsule 250 MG, 500 MG 1

Amoxicillin Oral Suspension Reconstituted 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML

1

Amoxicillin Oral Tablet 500 MG, 875 MG 1

6

Drug Name Tier NotesAmoxicillin Oral Tablet Chewable 125 MG, 250 MG 1

Amoxicillin-Pot Clavulanate ER Oral Tablet Extended Release 12 Hour 1000-62.5 MG 1

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

1

Amoxicillin-Pot Clavulanate Oral Tablet 250-125 MG, 500-125 MG, 875-125 MG 1

Amoxicillin-Pot Clavulanate Oral Tablet Chewable 200-28.5 MG, 400-57 MG 1

Ampicillin Oral Capsule 500 MG 1

Ampicillin Sodium Injection Solution Reconstituted 1 GM, 125 MG, 2 GM, 250 MG, 500 MG

1

Ampicillin Sodium Intravenous Solution Reconstituted 1 GM, 2 GM 1

Ampicillin-Sulbactam Sodium Injection Solution Reconstituted 1.5 (1-0.5) GM, 15 (10-5) GM, 3 (2-1) GM

1

Ampicillin-Sulbactam Sodium Intravenous Solution Reconstituted 1.5 (1-0.5) GM, 15 (10-5) GM, 3 (2-1) GM

1

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

1

ANTHELMINTICS

Albendazole Oral Tablet 200 MG 1

Levamisole HCl Powder 1 PA

Praziquantel Oral Tablet 600 MG 1

ANTIFUNGALS, MISCELLANEOUS

Griseofulvin Microsize Oral Suspension 125 MG/5ML 1

Griseofulvin Microsize Oral Tablet 500 MG 1

Griseofulvin Ultramicrosize Oral Tablet 125 MG, 250 MG 1

SSKI ORAL SOLUTION 1 GM/ML 1

Triacetin Liquid 1

ANTIMALARIALS

Atovaquone-Proguanil HCl Oral Tablet 250-100 MG, 62.5-25 MG 1

Chloroquine Phosphate Oral Tablet 250 MG, 500 MG 1

7

Drug Name Tier NotesDARAPRIM ORAL TABLET 25 MG 1 PA; SPN

Hydroxychloroquine Sulfate Oral Tablet 200 MG 1

Mefloquine HCl Oral Tablet 250 MG 1

Primaquine Phosphate Oral Tablet 26.3 MG 1

QuiNIDine Gluconate ER Oral Tablet Extended Release 324 MG 1

QuiNIDine Sulfate Oral Tablet 200 MG, 300 MG 1

QuiNINE Sulfate Oral Capsule 324 MG 1

ANTIMYCOBACTERIALS, MISCELLANEOUS

Dapsone Oral Tablet 100 MG, 25 MG 1

ANTIPROTOZOALS, MISCELLANEOUS

Atovaquone Oral Suspension 750 MG/5ML 1

Dapsone Oral Tablet 100 MG, 25 MG 1

MetroNIDAZOLE Benzoate Powder 1

MetroNIDAZOLE Oral Capsule 375 MG 1

MetroNIDAZOLE Oral Tablet 250 MG, 500 MG 1

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

1

ANTITUBERCULOSIS AGENTS

Ciprofloxacin HCl Oral Tablet 100 MG 1 QL (28 EA per 30 days)

Ciprofloxacin HCl Oral Tablet 250 MG, 500 MG, 750 MG 1

Ciprofloxacin in D5W Intravenous Solution200 MG/100ML, 400 MG/200ML 1

Ciprofloxacin Oral Suspension Reconstituted500 MG/5ML (10%) 1

Clarithromycin ER Oral Tablet Extended Release 24 Hour 500 MG 1 QL (28 EA per 30 days)

Clarithromycin Oral Suspension Reconstituted125 MG/5ML, 250 MG/5ML 1

Clarithromycin Oral Tablet 250 MG, 500 MG 1 QL (28 EA per 30 days)

CycloSERINE Oral Capsule 250 MG 1

Ethambutol HCl Oral Tablet 100 MG, 400 MG 1

Isoniazid Oral Syrup 50 MG/5ML 1 90

Isoniazid Oral Tablet 100 MG, 300 MG 1 90

LevoFLOXacin Oral Solution 25 MG/ML 1

LevoFLOXacin Oral Tablet 250 MG, 500 MG 1

8

Drug Name Tier NotesLevoFLOXacin Oral Tablet 750 MG 1 QL (10 EA per 30 days)

Moxifloxacin HCl in NaCl Intravenous Solution 400 MG/250ML 1

Moxifloxacin HCl Oral Tablet 400 MG 1 QL (10 EA per 30 days)

PRIFTIN ORAL TABLET 150 MG 1

Pyrazinamide Oral Tablet 500 MG 1

Rifabutin Oral Capsule 150 MG 1

Rifampin Oral Capsule 150 MG, 300 MG 1

SEROMYCIN ORAL CAPSULE 250 MG 1

Streptomycin Sulfate Powder 1

AZOLE ANTIFUNGALS

Fluconazole in Dextrose Intravenous Solution200 MG/100ML, 400 MG/200ML 1

Fluconazole in Sodium Chloride Intravenous Solution 200-0.9 MG/100ML-%, 400-0.9 MG/200ML-%

1

Fluconazole Oral Suspension Reconstituted 10 MG/ML, 40 MG/ML 1

Fluconazole Oral Tablet 100 MG, 150 MG, 200 MG, 50 MG 1

Itraconazole Powder 1

Ketoconazole Oral Tablet 200 MG 1

CARBAPENEM ANTIBIOTICS

Imipenem-Cilastatin Intravenous Solution Reconstituted 250 MG, 500 MG 1

Meropenem Intravenous Solution Reconstituted 1 GM, 500 MG 1

CEPHAMYCIN ANTIBIOTICS

CefoTEtan Disodium Injection Solution Reconstituted 1 GM, 10 GM, 2 GM 1

CefOXitin Sodium Injection Solution Reconstituted 10 GM 1

CefOXitin Sodium Intravenous Solution Reconstituted 1 GM, 2 GM 1

CHLORAMPHENICOL ANTIBIOTICS

Chloramphenicol Palmitate Powder 1

ERYTHROMYCIN ANTIBIOTICS

E.E.S. 400 ORAL TABLET 400 MG 1

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

1

9

Drug Name Tier NotesERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

1

ERYTHROCIN STEARATE ORAL TABLET 250 MG

1

Erythromycin Base Oral Capsule Delayed Release Particles 250 MG 1

Erythromycin Base Oral Tablet 250 MG, 500 MG 1

Erythromycin Ethylsuccinate Oral Suspension Reconstituted 200 MG/5ML 1

Erythromycin Ethylsuccinate Oral Tablet 400 MG 1

EXTENDED-SPECTRUM PENICILLINS

Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 2.25 (2-0.25) GM, 3.375 (3-0.375) GM, 40.5 (36-4.5) GM

1

GLYCOPEPTIDE ANTIBIOTICS

Vancomycin HCl in Dextrose Intravenous Solution 500-5 MG/100ML-% 1

Vancomycin HCl Intravenous Solution Reconstituted 10 GM, 250 MG, 500 MG 1

Vancomycin HCl Oral Capsule 125 MG, 250 MG 1

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET ORAL TABLET 100-40 MG 1 PA

ZEPATIER ORAL TABLET 50-100 MG 1 PA; SPN

HCV REPLICATION COMPLEX INHIBITORS

MAVYRET ORAL TABLET 100-40 MG 1 PA

ZEPATIER ORAL TABLET 50-100 MG 1 PA; SPN

HIV INTEGRASE INHIBITOR ANTIRETROVIRALS

BIKTARVY ORAL TABLET 50-200-25 MG 1 SPN

GENVOYA ORAL TABLET 150-150-200-10 MG

1 SPN

ISENTRESS HD ORAL TABLET 600 MG 1 SPN; QL (60 EA per 30 days)

ISENTRESS ORAL TABLET 400 MG 1 SPN; QL (60 EA per 30 days)

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

1 SPN

STRIBILD ORAL TABLET 150-150-200-300 MG

1 SPN; QL (30 EA per 30 days)

10

Drug Name Tier NotesTIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

1 SPN

TRIUMEQ ORAL TABLET 600-50-300 MG 1 SPN; QL (30 EA per 30 days)

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

ATRIPLA ORAL TABLET 600-200-300 MG 1 SPN

COMPLERA ORAL TABLET 200-25-300 MG 1 SPN; QL (30 EA per 30 days)

EDURANT ORAL TABLET 25 MG 1 SPN; QL (30 EA per 30 days)

Efavirenz Oral Capsule 200 MG, 50 MG 1 SPN

Efavirenz Oral Tablet 600 MG 1 SPN

INTELENCE ORAL TABLET 100 MG, 200 MG 1 SPN

Nevirapine ER Oral Tablet Extended Release 24 Hour 400 MG 1 SPN; QL (30 EA per 30 days)

Nevirapine Oral Suspension 50 MG/5ML 1

Nevirapine Oral Tablet 200 MG 1 SPN

ODEFSEY ORAL TABLET 200-25-25 MG 1 SPN

RESCRIPTOR ORAL TABLET 200 MG 1 SPN

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

Abacavir Sulfate Oral Solution 20 MG/ML 1

Abacavir Sulfate Oral Tablet 300 MG 1 SPN

Abacavir Sulfate-Lamivudine Oral Tablet 600-300 MG 1 SPN

Abacavir-Lamivudine-Zidovudine Oral Tablet300-150-300 MG 1 SPN

ATRIPLA ORAL TABLET 600-200-300 MG 1 SPN

COMPLERA ORAL TABLET 200-25-300 MG 1 SPN; QL (30 EA per 30 days)

DESCOVY ORAL TABLET 200-25 MG 1 SPN

Didanosine Oral Capsule Delayed Release 200 MG, 250 MG, 400 MG 1 SPN

EMTRIVA ORAL CAPSULE 200 MG 1 SPN

EMTRIVA ORAL SOLUTION 10 MG/ML 1 SPN

EPIVIR HBV ORAL SOLUTION 5 MG/ML 1 SPN

GENVOYA ORAL TABLET 150-150-200-10 MG

1 SPN

LamiVUDine Oral Solution 10 MG/ML 1 SPN

LamiVUDine Oral Tablet 100 MG, 150 MG, 300 MG 1 SPN

Lamivudine-Zidovudine Oral Tablet 150-300 MG 1 SPN

ODEFSEY ORAL TABLET 200-25-25 MG 1 SPN

11

Drug Name Tier NotesStavudine Oral Capsule 15 MG, 20 MG, 30 MG, 40 MG 1 SPN

STRIBILD ORAL TABLET 150-150-200-300 MG


TRIUMEQ ORAL TABLET 600-50-300 MG 1 SPN; QL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

1 SPN

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

1 SPN

VIREAD ORAL TABLET 300 MG 1 SPN

Zidovudine Oral Capsule 100 MG 1 SPN

Zidovudine Oral Syrup 50 MG/5ML 1 SPN

Zidovudine Oral Tablet 300 MG 1 SPN

HIV PROTEASE INHIBITOR ANTIRETROVIRALS

APTIVUS ORAL CAPSULE 250 MG 1 SPN

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 1 SPN

EVOTAZ ORAL TABLET 300-150 MG 1 SPN; QL (30 EA per 30 days)

Fosamprenavir Calcium Oral Tablet 700 MG 1

INVIRASE ORAL CAPSULE 200 MG 1 SPN

INVIRASE ORAL TABLET 500 MG 1 SPN

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

1 SPN

Lopinavir-Ritonavir Oral Solution 400-100 MG/5ML 1

NORVIR ORAL PACKET 100 MG 1 SPN

NORVIR ORAL SOLUTION 80 MG/ML 1 SPN

PREZCOBIX ORAL TABLET 800-150 MG 1 SPN

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

1 SPN

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

1 SPN

Ritonavir Oral Tablet 100 MG 1 SPN

VIRACEPT ORAL TABLET 250 MG, 625 MG 1 SPN

INTERFERON ANTIVIRALS

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

1 PA; SPN

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

1 PA; SPN

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML

1 PA; SPN

12

Drug Name Tier NotesLINCOMYCIN ANTIBIOTICS

CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 600 MG/4ML

1

Clindamycin HCl Oral Capsule 150 MG, 300 MG, 75 MG 1

Clindamycin Palmitate HCl Oral Solution Reconstituted 75 MG/5ML 1

Clindamycin Phosphate Injection Solution 600 MG/4ML 1

Clindamycin Phosphate Intravenous Solution300 MG/2ML, 600 MG/4ML, 900 MG/6ML 1

MACROLIDE ANTIBIOTICS

E.E.S. 400 ORAL TABLET 400 MG 1

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

1

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

1

ERYTHROCIN STEARATE ORAL TABLET 250 MG

1

Erythromycin Base Oral Capsule Delayed Release Particles 250 MG 1

Erythromycin Base Oral Tablet 250 MG, 500 MG 1

Erythromycin Ethylsuccinate Oral Suspension Reconstituted 200 MG/5ML 1

Erythromycin Ethylsuccinate Oral Tablet 400 MG 1

MONOCLONAL ANTIBODY ANTIVIRALS

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML

1 PA; SPN; QL (1 ML per 30 days)

SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML

1PA; SPN; QL (0.5 ML per 30 days)

NATURAL PENICILLIN ANTIBIOTICS

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

1

Penicillin V Potassium Oral Solution Reconstituted 125 MG/5ML, 250 MG/5ML 1

Penicillin V Potassium Oral Tablet 250 MG, 500 MG 1

13

Drug Name Tier NotesNEURAMINIDASE INHIBITOR ANTIVIRALS

Oseltamivir Phosphate Oral Capsule 30 MG, 45 MG, 75 MG 1 QL (10 EA per 180 days)

Oseltamivir Phosphate Oral Suspension Reconstituted 6 MG/ML 1 QL (180 ML per 180 days)

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

1 QL (20 EA per 180 days)

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS

Acyclovir Oral Capsule 200 MG 1

Acyclovir Oral Suspension 200 MG/5ML 1

Acyclovir Oral Tablet 400 MG, 800 MG 1

Adefovir Dipivoxil Oral Tablet 10 MG 1 PA; SPN

Entecavir Oral Tablet 0.5 MG, 1 MG 1 PA; SPN

Famciclovir Oral Tablet 125 MG, 250 MG, 500 MG 1

MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG

1 SPN

MODERIBA ORAL TABLET 200 MG 1 SPN

REBETOL ORAL SOLUTION 40 MG/ML 1 SPN

RIBASPHERE ORAL CAPSULE 200 MG 1 SPN

RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG

1 SPN

RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG

1 SPN

Ribavirin Oral Capsule 200 MG 1 SPN

Ribavirin Oral Tablet 200 MG 1 SPN

ValACYclovir HCl Oral Tablet 1 GM 1 QL (30 EA per 30 days)

ValACYclovir HCl Oral Tablet 500 MG 1 QL (60 EA per 30 days)

ValGANciclovir HCl Oral Tablet 450 MG 1

OTHER MACROLIDE ANTIBIOTICS


Azithromycin Oral Packet 1 GM 1

Azithromycin Oral Suspension Reconstituted100 MG/5ML, 200 MG/5ML 1

Azithromycin Oral Tablet 250 MG, 500 MG, 600 MG 1

Clarithromycin ER Oral Tablet Extended Release 24 Hour 500 MG 1 QL (28 EA per 30 days)

14

Drug Name Tier NotesClarithromycin Oral Suspension Reconstituted125 MG/5ML, 250 MG/5ML 1

Clarithromycin Oral Tablet 250 MG, 500 MG 1 QL (28 EA per 30 days)

ZITHROMAX ORAL PACKET 1 GM 1

OXAZOLIDINONE ANTIBIOTICS

Linezolid Oral Suspension Reconstituted 100 MG/5ML 1 PA

Linezolid Oral Tablet 600 MG 1 PA

PENICILLINASE-RESISTANT PENICILLINS

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

1

Dicloxacillin Sodium Oral Capsule 250 MG, 500 MG 1

Nafcillin Sodium Injection Solution Reconstituted 1 GM, 2 GM 1

Nafcillin Sodium Intravenous Solution Reconstituted 1 GM, 2 GM 1

Oxacillin Sodium Injection Solution Reconstituted 1 GM, 10 GM, 2 GM 1

POLYENE ANTIFUNGALS

Amphotericin B Injection Solution Reconstituted 50 MG 1

Amphotericin B Powder , 905 UNIT/MG 1

Nystatin Mouth/Throat Suspension 100000 UNIT/ML 1

Nystatin Oral Tablet 500000 UNIT 1

PYRIMIDINE ANTIFUNGALS

Flucytosine Oral Capsule 250 MG, 500 MG 1

QUINOLONE ANTIBIOTICS

Ciprofloxacin HCl Oral Tablet 100 MG 1 QL (28 EA per 30 days)

Ciprofloxacin HCl Oral Tablet 250 MG, 500 MG, 750 MG 1

Ciprofloxacin in D5W Intravenous Solution200 MG/100ML, 400 MG/200ML 1

Ciprofloxacin Oral Suspension Reconstituted500 MG/5ML (10%) 1

LevoFLOXacin Oral Solution 25 MG/ML 1

LevoFLOXacin Oral Tablet 250 MG, 500 MG 1

LevoFLOXacin Oral Tablet 750 MG 1 QL (10 EA per 30 days)

Moxifloxacin HCl in NaCl Intravenous Solution 400 MG/250ML 1

15

Drug Name Tier NotesMoxifloxacin HCl Oral Tablet 400 MG 1 QL (10 EA per 30 days)

Ofloxacin Oral Tablet 300 MG 1

Ofloxacin Oral Tablet 400 MG 1 QL (28 EA per 30 days)

RIFAMYCIN ANTIBIOTICS

PRIFTIN ORAL TABLET 150 MG 1

Rifabutin Oral Capsule 150 MG 1

Rifampin Oral Capsule 150 MG, 300 MG 1

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

Sulfacetamide Powder 1

SulfADIAZINE Oral Tablet 500 MG 1

Sulfamethoxazole-Trimethoprim Oral Suspension 200-40 MG/5ML 1

Sulfamethoxazole-Trimethoprim Oral Tablet400-80 MG, 800-160 MG 1

SulfaSALAzine Oral Tablet 500 MG 1

SulfaSALAzine Oral Tablet Delayed Release500 MG 1

SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML

1

SULFAZINE ORAL TABLET 500 MG 1

TETRACYCLINE ANTIBIOTICS

Demeclocycline HCl Oral Tablet 150 MG, 300 MG 1

Doxycycline Hyclate Oral Capsule 100 MG, 50 MG 1

Doxycycline Hyclate Oral Tablet 100 MG 1

Doxycycline Monohydrate Oral Suspension Reconstituted 25 MG/5ML 1

Minocycline HCl Oral Capsule 100 MG, 50 MG, 75 MG 1

Minocycline HCl Oral Tablet 100 MG, 50 MG, 75 MG 1

MORGIDOX ORAL CAPSULE 100 MG, 50 MG 1

Tetracycline HCl Oral Capsule 250 MG, 500 MG 1

VIBRAMYCIN ORAL SYRUP 50 MG/5ML 1

URINARY ANTI-INFECTIVES

Methenamine Mandelate Oral Tablet 0.5 GM, 1 GM 1

Nitrofurantoin Anhydrous Powder 1

16

Drug Name Tier NotesNitrofurantoin Macrocrystal Oral Capsule 100 MG, 25 MG, 50 MG 1

Nitrofurantoin Monohyd Macro Oral Capsule100 MG 1

Nitrofurantoin Oral Suspension 25 MG/5ML 1

PRIMSOL ORAL SOLUTION 50 MG/5ML 1

Trimethoprim Oral Tablet 100 MG 1

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

ALECENSA ORAL CAPSULE 150 MG 1 PA; SPN

Anastrozole Oral Tablet 1 MG 1

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

1 PA; SPN

Bicalutamide Oral Tablet 50 MG 1

Capecitabine Oral Tablet 150 MG, 500 MG 1 PA; SPN

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

1

FARESTON ORAL TABLET 60 MG 1

Fludarabine Phosphate Intravenous Solution Reconstituted 50 MG 1 PA; SPN

FLUOROPLEX EXTERNAL CREAM 1 % 1

Fluorouracil External Cream 5 % 1 SPN

Fluorouracil External Solution 2 %, 5 % 1 SPN

Flutamide Oral Capsule 125 MG 1

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

1 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

1 SPN

Hydroxyurea Oral Capsule 500 MG 1

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

1 PA

Imatinib Mesylate Oral Tablet 100 MG, 400 MG 1 PA; SPN

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

1 PA; SPN; QL (30 EA per 30 days)

IMBRUVICA ORAL TABLET 420 MG, 560 MG


IRESSA ORAL TABLET 250 MG 1 PA

Letrozole Oral Tablet 2.5 MG 1

LEUKERAN ORAL TABLET 2 MG 1

Leuprolide Acetate Injection Kit 1 MG/0.2ML 1 PA; SPN; QL (2 EA per 30 days)

17

Drug Name Tier NotesLeuprolide Acetate Powder 1 SPN

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG




LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG




LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG


LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED)


MATULANE ORAL CAPSULE 50 MG 1 SPN

Megestrol Acetate Oral Suspension 40 MG/ML, 400 MG/10ML 1

Megestrol Acetate Oral Tablet 20 MG, 40 MG 1

MEKINIST ORAL TABLET 0.5 MG, 2 MG 1 PA; SPN

Melphalan Oral Tablet 2 MG 1

Mercaptopurine Oral Tablet 50 MG 1

Methotrexate Oral Tablet 2.5 MG 1

Methotrexate Sodium (PF) Injection Solution 1 GM/40ML, 250 MG/10ML, 50 MG/2ML 1 PA

Methotrexate Sodium Injection Solution 50 MG/2ML 1 PA

Methotrexate Sodium Injection Solution Reconstituted 1 GM 1 PA

Mitomycin Powder 1 SPN

MYLERAN ORAL TABLET 2 MG 1

NEXAVAR ORAL TABLET 200 MG 1 PA

Nilutamide Oral Tablet 150 MG 1

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

1 PA

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

1 PA

TABLOID ORAL TABLET 40 MG 1

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 1PA; SPN; QL (120 EA per 30 days)

Tamoxifen Citrate Oral Tablet 10 MG, 20 MG 1

18

Drug Name Tier NotesTARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

1 PA

TARGRETIN EXTERNAL GEL 1 % 1 PA; SPN

Temozolomide Oral Capsule 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG 1 SPN

Tretinoin Oral Capsule 10 MG 1 SPN

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

1

TYKERB ORAL TABLET 250 MG 1 PA

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ANTITOXINS AND IMMUNE GLOBULINS

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

1

AUTONOMIC DRUGS

ALPHA- AND BETA-ADRENERGIC AGONISTS

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

1

ePHEDrine HCl Powder 1

ePHEDrine Sulfate Powder 1

EPINEPHrine Injection Solution Auto-Injector 0.15 MG/0.3ML 1 QL (2 EA per 30 days)


EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML


EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML


MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HOUR 60-600 MG

1

Pseudoeph-Bromphen-DM Oral Syrup 30-2-10 MG/5ML 1

Pseudoephedrine HCl Oral Tablet 30 MG, 60 MG 1


ALPHA-ADRENERGIC AGONISTS

Biotuss Oral Liquid 10-15-300 MG/5ML 1

BIOTUSS PEDIATRIC ORAL LIQUID 2.5-5-50 MG/ML

1

CloNIDine HCl Oral Tablet 0.1 MG, 0.2 MG, 0.3 MG 1 90

19

Drug Name Tier NotesMethyldopa Oral Tablet 250 MG, 500 MG 1

Methyldopa-Hydrochlorothiazide Oral Tablet250-15 MG, 250-25 MG 1





ANTIMUSCARINICS/ANTISPASMODICS

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

1 QL (25.8 GM per 30 days)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

1 QL (8 GM per 30 days)

Dicyclomine HCl Oral Capsule 10 MG 1

Dicyclomine HCl Oral Solution 10 MG/5ML 1

Dicyclomine HCl Oral Tablet 20 MG 1

Diphenoxylate-Atropine Oral Liquid 2.5-0.025 MG/5ML 1

Diphenoxylate-Atropine Oral Tablet 2.5-0.025 MG 1

Hydrocodone-Homatropine Oral Syrup 5-1.5 MG/5ML 1 QL (900 ML per 30 days)

Hydrocodone-Homatropine Oral Tablet 5-1.5 MG 1 QL (180 EA per 30 days)

Hydromet Oral Syrup 5-1.5 MG/5ML 1 QL (900 ML per 30 days)

Ipratropium Bromide Inhalation Solution 0.02 % 1 QL (300 ML per 30 days)

Ipratropium-Albuterol Inhalation Solution0.5-2.5 (3) MG/3ML 1 QL (360 ML per 30 days)

PB-Hyoscy-Atropine-Scopolamine Oral Tablet16.2 MG 1

PHENOHYTRO ORAL TABLET 16.2 MG 1

Propantheline Bromide Oral Tablet 15 MG 1

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


STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

1

20

Drug Name Tier NotesANTIPARKINSONIAN AGENTS

Benztropine Mesylate Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Trihexyphenidyl HCl Oral Elixir 0.4 MG/ML 1

Trihexyphenidyl HCl Oral Tablet 2 MG, 5 MG 1

AUTONOMIC DRUGS, MISCELLANEOUS

NICOTROL INHALATION INHALER 10 MG 1

NICOTROL NS NASAL SOLUTION 10 MG/ML

1

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

Chlorzoxazone Oral Tablet 500 MG 1

Cyclobenzaprine HCl Oral Tablet 10 MG, 5 MG 1

Methocarbamol Oral Tablet 500 MG, 750 MG 1

TiZANidine HCl Oral Tablet 2 MG, 4 MG 1

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

Dantrolene Sodium Oral Capsule 100 MG, 25 MG, 50 MG 1

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

Baclofen Oral Tablet 10 MG, 20 MG, 5 MG 1

NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS

Carvedilol Oral Tablet 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 1 90

Labetalol HCl Oral Tablet 100 MG, 200 MG, 300 MG 1

Nadolol Oral Tablet 20 MG, 40 MG, 80 MG 1

Pindolol Oral Tablet 10 MG, 5 MG 1

Propranolol HCl ER Oral Capsule Extended Release 24 Hour 120 MG, 160 MG, 60 MG, 80 MG

1

Propranolol HCl Oral Solution 20 MG/5ML, 40 MG/5ML 1 90

Propranolol HCl Oral Tablet 10 MG, 20 MG, 40 MG, 60 MG, 80 MG 1 90

Propranolol-HCTZ Oral Tablet 40-25 MG, 80-25 MG 1

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

1

21

Drug Name Tier NotesSotalol HCl (AF) Oral Tablet 120 MG, 160 MG, 80 MG 1

Sotalol HCl Oral Tablet 120 MG, 160 MG, 240 MG, 80 MG 1

Timolol Maleate Oral Tablet 10 MG, 20 MG, 5 MG 1

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS

Doxazosin Mesylate Oral Tablet 1 MG, 2 MG, 4 MG, 8 MG 1

Prazosin HCl Oral Capsule 1 MG, 2 MG, 5 MG 1

Terazosin HCl Oral Capsule 1 MG, 10 MG, 2 MG, 5 MG 1

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

Dihydroergotamine Mesylate Injection Solution 1 MG/ML 1

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

1

Ergotamine-Caffeine Oral Tablet 1-100 MG 1

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

1

Phenoxybenzamine HCl Oral Capsule 10 MG 1

Phentolamine Mesylate Powder 1

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

Bethanechol Chloride Oral Tablet 10 MG, 25 MG, 5 MG, 50 MG 1

Cevimeline HCl Oral Capsule 30 MG 1

Donepezil HCl Oral Tablet 10 MG, 5 MG 1 90; QL (60 EA per 30 days)

Donepezil HCl Oral Tablet 23 MG 1 90

Donepezil HCl Oral Tablet Dispersible 10 MG, 5 MG 1 QL (30 EA per 30 days)

Galantamine Hydrobromide Oral Tablet 12 MG, 4 MG, 8 MG 1 QL (60 EA per 30 days)

MESTINON ORAL SYRUP 60 MG/5ML 1

Pilocarpine HCl Oral Tablet 5 MG 1

Pyridostigmine Bromide ER Oral Tablet Extended Release 180 MG 1

Pyridostigmine Bromide Oral Tablet 60 MG 1

22

Drug Name Tier NotesRivastigmine Tartrate Oral Capsule 1.5 MG, 3 MG, 4.5 MG, 6 MG 1 QL (60 EA per 30 days)

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

Alfuzosin HCl ER Oral Tablet Extended Release 24 Hour 10 MG 1



Tamsulosin HCl Oral Capsule 0.4 MG 1 90; QL (30 EA per 30 days)

SELECTIVE BETA-2-ADRENERGIC AGONISTS

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


Albuterol Sulfate ER Oral Tablet Extended Release 12 Hour 4 MG, 8 MG 1

Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% 1 QL (375 ML per 30 days)

Albuterol Sulfate Inhalation Nebulization Solution (5 MG/ML) 0.5% 1 QL (80 EA per 30 days)

Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML, 1.25 MG/3ML 1 QL (360 ML per 30 days)

Albuterol Sulfate Oral Syrup 2 MG/5ML 1

Albuterol Sulfate Oral Tablet 2 MG, 4 MG 1

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

1



Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT



Metaproterenol Sulfate Oral Syrup 10 MG/5ML 1

Metaproterenol Sulfate Oral Tablet 10 MG, 20 MG 1

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


23

Drug Name Tier NotesSEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

1

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT


Terbutaline Sulfate Oral Tablet 2.5 MG, 5 MG 1

Terbutaline Sulfate Powder 1

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


SELECTIVE BETA-ADRENERGIC BLOCKING AGENT

Acebutolol HCl Oral Capsule 200 MG, 400 MG 1

Atenolol Oral Tablet 100 MG, 25 MG, 50 MG 1 90

Atenolol-Chlorthalidone Oral Tablet 100-25 MG, 50-25 MG 1 90

Betaxolol HCl Oral Tablet 10 MG, 20 MG 1

Bisoprolol Fumarate Oral Tablet 10 MG, 5 MG 1

Bisoprolol-Hydrochlorothiazide Oral Tablet10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 1 90

Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG, 200 MG, 25 MG, 50 MG

1 90

Metoprolol Tartrate Oral Tablet 100 MG, 25 MG, 50 MG 1 90

Metoprolol-Hydrochlorothiazide Oral Tablet100-25 MG, 100-50 MG, 50-25 MG 1

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT

1 PA; SPN

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

1 PA; SPN

Orphenadrine Citrate ER Oral Tablet Extended Release 12 Hour 100 MG 1

24

Drug Name Tier NotesBLOOD FORMATION, COAGULATION, THROMBOSIS

COUMARIN DERIVATIVES

COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

Warfarin Sodium Oral Tablet 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

DIRECT FACTOR XA INHIBITORS

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 1

ELIQUIS STARTER PACK ORAL TABLET 5 MG

1

Fondaparinux Sodium Subcutaneous Solution10 MG/0.8ML 1 QL (8 ML per 30 days)

Fondaparinux Sodium Subcutaneous Solution2.5 MG/0.5ML 1 QL (5 ML per 30 days)

Fondaparinux Sodium Subcutaneous Solution5 MG/0.4ML 1 QL (4 ML per 30 days)

Fondaparinux Sodium Subcutaneous Solution7.5 MG/0.6ML 1 QL (6 ML per 30 days)

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

1

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

1

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

1

HEMATOPOIETIC AGENTS

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

1 PA; SPN

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

1 PA; SPN

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

1 PA; SPN

PROCRIT SOLUTION 10000 UNIT/ML INJECTION 10000 UNIT/ML

1 PA; SPN


1 PA; SPN

25

Drug Name Tier NotesPROCRIT SOLUTION 20000 UNIT/ML INJECTION 20000 UNIT/ML

1 PA; SPN


1 PA; SPN


1 PA; SPN


1 PA


1 PA; SPN

HEMORRHEOLOGIC AGENTS

Pentoxifylline ER Oral Tablet Extended Release 400 MG 1

HEMOSTATICS

AMICAR ORAL SOLUTION 0.25 GM/ML 1

AMICAR ORAL TABLET 1000 MG, 500 MG 1

Desmopressin Ace Spray Refrig Nasal Solution0.01 % 1

Desmopressin Acetate Injection Solution 4 MCG/ML 1

Desmopressin Acetate Oral Tablet 0.1 MG, 0.2 MG 1

NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

1 PA; SPN

HEPARINS

Enoxaparin Sodium Injection Solution 300 MG/3ML 1 QL (84 ML per 28 days)

Enoxaparin Sodium Subcutaneous Solution100 MG/ML, 150 MG/ML 1 QL (28 ML per 30 days)

Enoxaparin Sodium Subcutaneous Solution120 MG/0.8ML, 80 MG/0.8ML 1 QL (22.4 ML per 30 days)

Enoxaparin Sodium Subcutaneous Solution 30 MG/0.3ML 1 QL (8.4 ML per 30 days)



FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML

1 QL (10 ML per 30 days)

FRAGMIN SUBCUTANEOUS SOLUTION 12500 UNIT/0.5ML


26

Drug Name Tier NotesFRAGMIN SUBCUTANEOUS SOLUTION 15000 UNIT/0.6ML


FRAGMIN SUBCUTANEOUS SOLUTION 18000 UNT/0.72ML

1 QL (7.2 ML per 30 days)

FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML






Heparin (Porcine) in D5W Intravenous Solution 40-5 UNIT/ML-%, 50-5 UNIT/ML-% 1

Heparin (Porcine) in NaCl Injection Solution100-0.45 UNIT/ML-%, 2-0.9 UNIT/ML-%, 50-0.45 UNIT/ML-%

1

Heparin (Porcine) in NaCl Intravenous Solution 100-0.45 UT/100ML-%, 1000-0.9 UNIT/L-%, 25000-0.45 UT/250ML-%, 25000-0.9 UT/250ML-%

1

Heparin Lock Flush Intravenous Solution 10 UNIT/ML, 100 UNIT/ML 1

Heparin Sod (Porcine) in D5W Intravenous Solution 100 UNIT/ML 1

Heparin Sodium (Porcine) Injection Solution10000 UNIT/ML, 20000 UNIT/ML, 5000 UNIT/ML

1

Heparin Sodium Flush Intravenous Kit 100-0.9 UNIT/ML-% 1

Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML 1

Heparin Sodium/D5W Intravenous Solution50-5 UNIT/ML-% 1

Sash Kit Intravenous Kit 100-0.9 UNIT/ML-% 1

IRON PREPARATIONS

BACMIN ORAL TABLET 1

BAL-CARE DHA ORAL 27-1 & 430 MG 1

B-Plex Plus Oral Tablet 1

CITRANATAL 90 DHA ORAL 90-1 & 300 MG 1

CITRANATAL ASSURE ORAL 35-1 & 300 MG 1

CITRANATAL B-CALM ORAL 20-1 & 25 (2) MG

1

CITRANATAL DHA ORAL 27-1 & 250 MG 1

27

Drug Name Tier NotesCITRANATAL HARMONY ORAL CAPSULE 27-1-260 MG

1

CITRANATAL RX ORAL TABLET 27-1 MG 1

C-Nate DHA Oral Capsule 28-1-200 MG 1

CompleteNate Oral Tablet Chewable 29-1 MG 1

CO-NATAL FA ORAL TABLET 1

CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG

1

CONCEPT OB ORAL CAPSULE 130-92.4-1 MG

1

Dothelle DHA Oral Capsule 53.5-38-1 MG 1

Ferocon Oral Capsule 1

Ferotrinsic Oral Capsule 1

FERROCITE PLUS ORAL TABLET 106-1 MG 1

Ferrous Fumarate Powder 1

Ferrous Gluconate Dihydrate Granules 1

Ferrous Gluconate Dihydrate Powder 1

Ferrous Gluconate Powder 1

Ferrous Sulfate Granules 1

FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG

1

Foltrin Oral Capsule 1

FORTAVIT ORAL CAPSULE 1

Hematinic Plus Vit/Minerals Oral Tablet 106-1 MG 1

Hematinic/Folic Acid Oral Tablet 324-1 MG 1

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG

1

HEMATOGEN FORTE ORAL CAPSULE 460-60-0.01-1 MG

1

HemeNatal OB + DHA Oral 28-6-1 & 203 MG 1

HemeNatal OB Oral Tablet 28-6-1 MG 1

HEMOCYTE-F ORAL TABLET 324-1 MG 1

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG

1

IFEREX 150 FORTE ORAL CAPSULE 150-25-1 MG-MCG-MG

1

INFED INJECTION SOLUTION 50 MG/ML 1

Multi-Vit/Iron/Fluoride Oral Solution 0.25-10 MG/ML 1

28

Drug Name Tier NotesMultivitamin/Fluoride/Iron Oral Solution0.25-10 MG/ML 1

Multi-Vitamin/Fluoride/Iron Oral Solution0.25-10 MG/ML 1

M-VIT ORAL TABLET 1

Myferon 150 Forte Oral Capsule 150-25-1 MG-MCG-MG 1

MYNATAL ADVANCE ORAL TABLET 1

MYNATAL ORAL CAPSULE 1

Mynatal Plus Oral Tablet 1

Mynatal-Z Oral Tablet 1

NATALVIT ORAL TABLET 1

NATELLE ONE ORAL CAPSULE 28-1-250 MG

1

NEPHRON FA ORAL TABLET 1

NESTABS DHA ORAL 32-1 MG 1

NESTABS ORAL TABLET 32-1 MG 1

NEWGEN ORAL TABLET 32-1 MG 1

NEXA PLUS ORAL CAPSULE 29-1.25-350 MG 1

NIVA-PLUS ORAL TABLET 27-1 MG 1

NUTRICAP ORAL TABLET 1

NUTRIVIT ORAL LIQUID 1

OBSTETRIX DHA ORAL 29-1 & 387 MG 1

O-CAL FA ORAL TABLET 27-1 MG 1

O-CAL PRENATAL ORAL TABLET 1

PNV Folic Acid + Iron Oral Tablet 27-1 MG 1

PNV OB+DHA Oral 27-1 & 250 MG 1

PNV Prenatal Plus Multivitamin Oral Tablet27-1 MG 1

PNV Tabs 29-1 Oral Tablet 29-1 MG 1

PNV-DHA Oral Capsule 27-0.6-0.4-300 MG 1

PNV-DHA+Docusate Oral Capsule 27-1.25-300 MG 1

PNV-Omega Oral Capsule 28-0.6-0.4-340 MG 1

PNV-Select Oral Tablet 27-0.6-0.4 MG 1

Poly-Iron 150 Forte Oral Capsule 150-25-1 MG-MCG-MG 1

Polysaccharide Iron Forte Oral Capsule 150-25-1 MG-MCG-MG 1

29

Drug Name Tier NotesPR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR)

1

PR NATAL 400 ORAL 29-1-200 & 400 MG 1

PR NATAL 430 EC ORAL 29-1-200 & 430 MG (DR)

1

PR NATAL 430 ORAL 29-1-200 & 430 MG 1

Prena 1 True Oral 30-1.4 & 300 MG 1

Prena1 Pearl Oral Capsule Extended Release30-1.4-200 MG 1

Prenaissance Oral Capsule 29-1.25-325 MG 1

Prenaissance Plus Oral Capsule 28-1-250 MG 1

PRENATABS RX ORAL TABLET 29-1 MG 1

Prenatal 19 Oral Tablet , 29-1 MG 1

Prenatal 19 Oral Tablet Chewable , 29-1 MG 1

Prenatal Low Iron Oral Tablet 27-1 MG 1

Prenatal Oral Tablet 27-0.8 MG, 27-1 MG 1

Prenatal Plus Iron Oral Tablet 29-1 MG 1

Prenatal Plus Oral Tablet 27-1 MG 1

Prenatal Plus/Iron Oral Tablet 27-1 MG 1

Prenatal Vitamin Plus Low Iron Oral Tablet27-1 MG 1

PrePLUS Oral Tablet 27-1 MG 1

PreTAB Oral Tablet 29-1 MG 1

PROTECT PLUS ORAL CAPSULE 1

PureFe OB Plus Oral Capsule 162-115.2-1 MG 1

R-NATAL OB ORAL CAPSULE 20-1-320 MG 1

SELECT-OB+DHA ORAL 29-1 & 250 MG 1

Se-Natal 19 Oral Tablet Chewable 29-1 MG 1

SIDEROL ORAL TABLET 1

STROVITE FORTE ORAL TABLET 1

TARON-BC ORAL 20-1 & 25 (2) MG 1

TARON-C DHA ORAL CAPSULE 53.5-38-1 MG

1

TARON-PREX ORAL CAPSULE 30-1.2-265 MG

1

Thrivite 19 Oral Tablet 29-1 MG 1

Thrivite Rx Oral Tablet 29-1 MG 1

TL Icon Oral Capsule 1

TL-Care DHA Oral Capsule 27-1-500 MG 1

TL-Select Oral Capsule 29-1.25-325 MG 1

30

Drug Name Tier NotesTRICARE ORAL TABLET 1

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

1

TRICON ORAL CAPSULE 1

Trigels-F Forte Oral Capsule 460-60-0.01-1 MG 1

Trinatal Rx 1 Oral Tablet 60-1 MG 1

TRINATE ORAL TABLET 1

Tri-Tabs DHA Oral 32-1 MG 1

TRIVEEN-DUO DHA ORAL 29-1-200 & 400 MG

1

UltimateCare ONE Oral Capsule 27-1 MG 1

Vena-Bal DHA Oral 27-1 & 430 MG 1

VINATE II ORAL TABLET 29-1 MG 1

VINATE M ORAL TABLET 27-1 MG 1

VINATE ONE ORAL TABLET 60-1 MG 1

Virt-C DHA Oral Capsule 53.5-38-1 MG 1

Virt-Nate DHA Oral Capsule 28-1-200 MG 1

Virt-PN DHA Oral Capsule 27-0.6-0.4-300 MG 1

Virt-PN Oral Tablet 27-0.6-0.4 MG 1

Virt-PN Plus Oral Capsule 28-0.6-0.4-340 MG 1

VITA S FORTE ORAL TABLET 1

VITAFOL ORAL TABLET 1

VITAFOL-OB ORAL TABLET 1

VITAFOL-OB+DHA ORAL 65-1 & 250 MG 1

VITAFOL-ONE ORAL CAPSULE 29-1-200 MG 1

VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG

1

VITAPEARL ORAL CAPSULE EXTENDED RELEASE 30-1.4-200 MG

1

VITATRUE ORAL 30-1.4 & 300 MG 1

VIVA DHA ORAL CAPSULE 28-1-200 MG 1

Vol-Nate Oral Tablet 28-1 MG 1

Vol-Plus Oral Tablet 27-1 MG 1

Vol-Tab Rx Oral Tablet 29-1 MG 1

VP-Heme OB + DHA Oral 28-6-1 & 203 MG 1

ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG

1

ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG

1

31

Drug Name Tier NotesPLATELET-AGGREGATION INHIBITORS

Aspirin-Dipyridamole ER Oral Capsule Extended Release 12 Hour 25-200 MG 1

Butalbital-ASA-Caffeine Oral Capsule 50-325-40 MG 1

Butalbital-Aspirin-Caffeine Oral Capsule 50-325-40 MG 1

Butalbital-Aspirin-Caffeine Oral Tablet 50-325-40 MG 1

Cilostazol Oral Tablet 100 MG, 50 MG 1

Clopidogrel Bisulfate Oral Tablet 300 MG, 75 MG 1 90; QL (30 EA per 30 days)

Dipyridamole Oral Tablet 25 MG, 50 MG, 75 MG 1

PLATELET-REDUCING AGENTS

Anagrelide HCl Oral Capsule 0.5 MG, 1 MG 1

THROMBOLYTIC AGENTS




CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS




Prazosin HCl Oral Capsule 1 MG, 2 MG, 5 MG 1


ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN)



32

Drug Name Tier NotesPrazosin HCl Oral Capsule 1 MG, 2 MG, 5 MG 1


ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)

Irbesartan Oral Tablet 150 MG, 75 MG 1 90; QL (60 EA per 30 days)

Irbesartan Oral Tablet 300 MG 1 90

Irbesartan-Hydrochlorothiazide Oral Tablet150-12.5 MG, 300-12.5 MG 1

Losartan Potassium Oral Tablet 100 MG, 25 MG, 50 MG 1 90

Losartan Potassium-HCTZ Oral Tablet 100-12.5 MG, 100-25 MG, 50-12.5 MG 1 90

ANGIOTENSIN II RECEPTOR ANTAGONISTS

Irbesartan Oral Tablet 150 MG, 75 MG 1 90; QL (60 EA per 30 days)

Irbesartan Oral Tablet 300 MG 1 90


Losartan Potassium Oral Tablet 100 MG, 25 MG, 50 MG 1 90


Valsartan Oral Tablet 160 MG, 320 MG, 40 MG, 80 MG 1

ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN)

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

1

Benazepril HCl Oral Tablet 10 MG, 20 MG, 40 MG, 5 MG 1 90

Benazepril-Hydrochlorothiazide Oral Tablet10-12.5 MG, 20-12.5 MG, 20-25 MG, 5-6.25 MG

1

Captopril Oral Tablet 100 MG, 12.5 MG, 25 MG, 50 MG 1 90

Captopril-Hydrochlorothiazide Oral Tablet25-15 MG, 25-25 MG, 50-15 MG, 50-25 MG 1 90

Enalapril Maleate Oral Tablet 10 MG, 2.5 MG, 20 MG, 5 MG 1 90

33

Drug Name Tier NotesEnalapril-Hydrochlorothiazide Oral Tablet 10-25 MG, 5-12.5 MG 1 90

Fosinopril Sodium Oral Tablet 10 MG, 20 MG, 40 MG 1 90

Fosinopril Sodium-HCTZ Oral Tablet 10-12.5 MG, 20-12.5 MG 1

Lisinopril Oral Tablet 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG 1 90

Lisinopril-Hydrochlorothiazide Oral Tablet10-12.5 MG, 20-12.5 MG, 20-25 MG 1 90

Quinapril HCl Oral Tablet 10 MG, 20 MG, 5 MG 1 90; QL (60 EA per 30 days)

Quinapril HCl Oral Tablet 40 MG 1 90

Quinapril-Hydrochlorothiazide Oral Tablet10-12.5 MG 1 QL (60 EA per 30 days)

Quinapril-Hydrochlorothiazide Oral Tablet20-12.5 MG, 20-25 MG 1

Ramipril Oral Capsule 1.25 MG, 10 MG, 2.5 MG, 5 MG 1 90

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS


1

Benazepril HCl Oral Tablet 10 MG, 20 MG, 40 MG, 5 MG 1 90


1

Captopril Oral Tablet 100 MG, 12.5 MG, 25 MG, 50 MG 1 90


Enalapril Maleate Oral Tablet 10 MG, 2.5 MG, 20 MG, 5 MG 1 90

Enalapril-Hydrochlorothiazide Oral Tablet 10-25 MG, 5-12.5 MG 1 90

Fosinopril Sodium Oral Tablet 10 MG, 20 MG, 40 MG 1 90


Lisinopril Oral Tablet 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG 1 90

34

Drug Name Tier NotesLisinopril-Hydrochlorothiazide Oral Tablet10-12.5 MG, 20-12.5 MG, 20-25 MG 1 90

Quinapril HCl Oral Tablet 10 MG, 20 MG, 5 MG 1 90; QL (60 EA per 30 days)

Quinapril HCl Oral Tablet 40 MG 1 90



Ramipril Oral Capsule 1.25 MG, 10 MG, 2.5 MG, 5 MG 1 90

ANTIARRHYTHMIC AGENTS

Adenosine Powder 1

ANTIARRHYTHMICS, MISCELLANEOUS

DIGITEK ORAL TABLET 125 MCG, 250 MCG 1

DIGOX ORAL TABLET 125 MCG, 250 MCG 1

Digoxin Injection Solution 0.25 MG/ML 1

Digoxin Oral Solution 0.05 MG/ML 1

Digoxin Oral Tablet 125 MCG, 250 MCG 1

LANOXIN INJECTION SOLUTION 0.25 MG/ML

1

LANOXIN ORAL TABLET 125 MCG, 250 MCG

1

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

1

ANTILIPEMIC AGENTS, MISCELLANEOUS

Niacin ER (Antihyperlipidemic) Oral Tablet Extended Release 1000 MG, 500 MG, 750 MG 1

Niacin Powder 1

NIACOR ORAL TABLET 500 MG 1

BETA-ADRENERGIC BLOCKING AGENTS







35

Drug Name Tier NotesCarvedilol Oral Tablet 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 1 90



1 90






1





1

Sotalol HCl (AF) Oral Tablet 120 MG, 160 MG, 80 MG 1



BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN)







36

Drug Name Tier NotesLabetalol HCl Oral Tablet 100 MG, 200 MG, 300 MG 1


1 90






1





1




BILE ACID SEQUESTRANTS

Cholestyramine Light Oral Packet 4 GM 1

Cholestyramine Light Oral Powder 4 GM/DOSE 1

Cholestyramine Oral Packet 4 GM 1

Cholestyramine Oral Powder 4 GM/DOSE 1

Colestipol HCl Oral Granules 5 GM 1

Colestipol HCl Oral Packet 5 GM 1

Colestipol HCl Oral Tablet 1 GM 1

PREVALITE ORAL PACKET 4 GM 1

PREVALITE ORAL POWDER 4 GM/DOSE 1

37

Drug Name Tier NotesCALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)

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

1

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 180 MG


Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

1

DilTIAZem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 120 MG, 240 MG, 300 MG, 360 MG

1

DilTIAZem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 180 MG 1 QL (60 EA per 30 days)

Diltiazem HCl ER Oral Capsule Extended Release 12 Hour 120 MG, 60 MG, 90 MG 1


Diltiazem HCl Intravenous Solution Reconstituted 100 MG 1

Diltiazem HCl Oral Tablet 120 MG, 30 MG, 60 MG, 90 MG 1

Dilt-XR Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG 1

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

1

Verapamil HCl ER Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG, 360 MG

1

Verapamil HCl ER Oral Tablet Extended Release 120 MG, 180 MG, 240 MG 1 QL (30 EA per 30 days)

Verapamil HCl Oral Tablet 120 MG, 40 MG, 80 MG 1

CALCIUM-CHANNEL BLOCKING AGENTS

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG



1


1

38

Drug Name Tier NotesAmLODIPine Besylate Oral Tablet 10 MG, 2.5 MG, 5 MG 1 90


1




1


1







Felodipine ER Oral Tablet Extended Release 24 Hour 10 MG, 2.5 MG, 5 MG 1

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG

1

NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MG 1 QL (60 EA per 30 days)

NIFEdipine ER Oral Tablet Extended Release 24 Hour 60 MG, 90 MG 1

NIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 30 MG, 60 MG, 90 MG

1

NiMODipine Oral Capsule 30 MG 1


1


1


39

Drug Name Tier NotesVerapamil HCl Oral Tablet 120 MG, 40 MG, 80 MG 1

CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)


1




1


1








1


1



CALCIUM-CHANNEL BLOCKING AGENTS, MISC.


1



40

Drug Name Tier NotesDiltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

1


1








1


1



CARBONIC ANHYDRASE INHIBITORS(HYPOTEN)

AcetaZOLAMIDE Oral Tablet 125 MG, 250 MG 1

CARDIAC DRUGS, MISCELLANEOUS

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG


RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 500 MG


CARDIOTONIC AGENTS

DIGITEK ORAL TABLET 125 MCG, 250 MCG 1

DIGOX ORAL TABLET 125 MCG, 250 MCG 1

Digoxin Injection Solution 0.25 MG/ML 1

Digoxin Oral Solution 0.05 MG/ML 1

Digoxin Oral Tablet 125 MCG, 250 MCG 1

41

Drug Name Tier NotesLANOXIN INJECTION SOLUTION 0.25 MG/ML

1

LANOXIN ORAL TABLET 125 MCG, 250 MCG

1

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

1

CENTRAL ALPHA-AGONISTS

CloNIDine HCl Oral Tablet 0.1 MG, 0.2 MG, 0.3 MG 1 90

GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 1 MG, 2 MG, 3 MG, 4 MG 1 QL (30 EA per 30 days)

GuanFACINE HCl Oral Tablet 1 MG, 2 MG 1

Methyldopa Oral Tablet 250 MG, 500 MG 1


CHOLESTEROL ABSORPTION INHIBITORS

Ezetimibe Oral Tablet 10 MG 1 PA; QL (30 EA per 30 days)

CLASS IA ANTIARRHYTHMICS

Disopyramide Phosphate Oral Capsule 100 MG, 150 MG 1

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

1

QuiNIDine Gluconate ER Oral Tablet Extended Release 324 MG 1

QuiNIDine Sulfate Oral Tablet 200 MG, 300 MG 1

CLASS IB ANTIARRHYTHMICS

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

1

DILANTIN ORAL CAPSULE 100 MG, 30 MG 1

DILANTIN ORAL SUSPENSION 125 MG/5ML 1

Mexiletine HCl Oral Capsule 150 MG, 200 MG, 250 MG 1

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

1

PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG

1

Phenytoin Oral Suspension 125 MG/5ML 1

Phenytoin Oral Tablet Chewable 50 MG 1

Phenytoin Sodium Extended Oral Capsule 100 MG, 200 MG, 300 MG 1

42

Drug Name Tier NotesPhenytoin Sodium Injection Solution 50 MG/ML 1

Phenytoin Sodium Powder 1

CLASS IC ANTIARRHYTHMICS

Flecainide Acetate Oral Tablet 100 MG, 150 MG, 50 MG 1

Propafenone HCl Oral Tablet 150 MG, 225 MG, 300 MG 1

CLASS II ANTIARRHYTHMICS










1 90






1





1

43

Drug Name Tier NotesSotalol HCl (AF) Oral Tablet 120 MG, 160 MG, 80 MG 1



CLASS III ANTIARRHYTHMICS

Amiodarone HCl Intravenous Solution 150 MG/3ML 1

Amiodarone HCl Oral Tablet 100 MG, 200 MG, 400 MG 1

Dofetilide Oral Capsule 125 MCG, 250 MCG, 500 MCG 1

MULTAQ ORAL TABLET 400 MG 1

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

1


1



CLASS IV ANTIARRHYTHMICS

Adenosine Powder 1


1




1


1





44

Drug Name Tier NotesDiltiazem HCl Oral Tablet 120 MG, 30 MG, 60 MG, 90 MG 1



1


1



DIHYDROPYRIDINES




1


1

AmLODIPine Besylate Oral Tablet 10 MG, 2.5 MG, 5 MG 1 90



1




1


DIHYDROPYRIDINES (ANTIHYPERTENSIVE)




1

45

Drug Name Tier NotesAmlodipine Besy-Benazepril HCl Oral Capsule 10-20 MG, 10-40 MG, 2.5-10 MG, 5-10 MG, 5-20 MG, 5-40 MG

1




1




1


DIRECT VASODILATORS

HydrALAZINE HCl Oral Tablet 10 MG, 100 MG, 25 MG, 50 MG 1

Minoxidil Oral Tablet 10 MG, 2.5 MG 1

DIURETICS, MISCELLANEOUS (HYPOTENSIVE)

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 1

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

1

Theophylline ER Oral Tablet Extended Release 12 Hour 100 MG, 200 MG, 300 MG, 450 MG

1

Theophylline ER Oral Tablet Extended Release 24 Hour 400 MG, 600 MG 1

Theophylline in D5W Intravenous Solution0.8-5 MG/ML-% 1

Theophylline Oral Solution 80 MG/15ML 1

FIBRIC ACID DERIVATIVES

Fenofibrate Micronized Oral Capsule 134 MG, 200 MG, 67 MG 1

Fenofibrate Oral Tablet 145 MG, 160 MG, 48 MG, 54 MG 1

Gemfibrozil Oral Tablet 600 MG 1

TRIGLIDE ORAL TABLET 160 MG 1

46

Drug Name Tier NotesHMG-COA REDUCTASE INHIBITORS

Atorvastatin Calcium Oral Tablet 10 MG, 20 MG, 40 MG, 80 MG 1 90; QL (30 EA per 30 days)

Lovastatin Oral Tablet 10 MG, 20 MG, 40 MG 1 90

Pravastatin Sodium Oral Tablet 10 MG, 20 MG, 40 MG, 80 MG 1 90

Rosuvastatin Calcium Oral Tablet 10 MG, 20 MG, 40 MG, 5 MG 1

Simvastatin Oral Tablet 10 MG, 20 MG, 40 MG, 5 MG, 80 MG 1 90

HYPOTENSIVE AGENTS, MISCELLANEOUS





1


1







1




1


Phenoxybenzamine HCl Oral Capsule 10 MG 1

Phentolamine Mesylate Powder 1


47

Drug Name Tier NotesPropranolol HCl ER Oral Capsule Extended Release 24 Hour 120 MG, 160 MG, 60 MG, 80 MG

1




1





LOOP DIURETICS (HYPOTENSIVE AGENTS)

Bumetanide Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Ethacrynic Acid Oral Tablet 25 MG 1

Furosemide Oral Solution 10 MG/ML, 8 MG/ML 1 90

Furosemide Oral Tablet 20 MG, 40 MG, 80 MG 1 90

Torsemide Oral Tablet 10 MG, 100 MG, 20 MG, 5 MG 1

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

Spironolactone Oral Tablet 100 MG, 25 MG, 50 MG 1

Spironolactone-HCTZ Oral Tablet 25-25 MG 1

MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT)



NITRATES AND NITRITES

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG

1

ISORDIL TITRADOSE ORAL TABLET 40 MG 1

Isosorbide Dinitrate ER Oral Tablet Extended Release 40 MG 1

48

Drug Name Tier NotesIsosorbide Dinitrate Oral Tablet 10 MG, 20 MG, 30 MG, 5 MG 1

Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 120 MG, 30 MG, 60 MG

1

Isosorbide Mononitrate Oral Tablet 10 MG, 20 MG 1

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

1

NITRO-BID TRANSDERMAL OINTMENT 2 % 1

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

1

Nitroglycerin ER Oral Capsule Extended Release 2.5 MG, 6.5 MG, 9 MG 1

Nitroglycerin Sublingual Tablet Sublingual 0.3 MG, 0.4 MG, 0.6 MG 1

Nitroglycerin Transdermal Patch 24 Hour 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR 1

Nitroglycerin Translingual Solution 0.4 MG/SPRAY 1

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY

1

NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG

1

Sodium Nitrite Granules 1

OSMOTIC DIURETICS (HYPOTENSIVE AGENTS)

Mannitol Powder 1

PHOSPHODIESTERASE TYPE 5 INHIBITORS

Cilostazol Oral Tablet 100 MG, 50 MG 1

Sildenafil Citrate Oral Tablet 20 MG 1 ST; SPN; QL (90 EA per 30 days)

Tadalafil (PAH) Oral Tablet 20 MG 1 PA; SPN; QL (60 EA per 30 days)

POTASSIUM-SPARING DIURETICS (HYPOTEN)

AMILoride HCl Oral Tablet 5 MG 1

Amiloride-Hydrochlorothiazide Oral Tablet 5-50 MG 1

DYRENIUM ORAL CAPSULE 100 MG, 50 MG 1



49

Drug Name Tier NotesTriamterene-HCTZ Oral Capsule 37.5-25 MG 1

Triamterene-HCTZ Oral Tablet 37.5-25 MG, 75-50 MG 1

THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)



1



Chlorothiazide Oral Tablet 250 MG, 500 MG 1

DIURIL ORAL SUSPENSION 250 MG/5ML 1



HydroCHLOROthiazide Oral Capsule 12.5 MG 1 90

HydroCHLOROthiazide Oral Tablet 12.5 MG, 25 MG, 50 MG 1 90




Methyclothiazide Oral Tablet 5 MG 1







Triamterene-HCTZ Oral Capsule 37.5-25 MG 1

50

Drug Name Tier NotesTriamterene-HCTZ Oral Tablet 37.5-25 MG, 75-50 MG 1

THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT)


Chlorthalidone Oral Tablet 25 MG, 50 MG 1

Indapamide Oral Tablet 1.25 MG, 2.5 MG 1

Metolazone Oral Tablet 10 MG, 2.5 MG, 5 MG 1

VASODILATING AGENTS, MISCELLANEOUS




1

Alprostadil Injection Solution 500 MCG/ML 1


1




1




1


1






51

Drug Name Tier NotesDilt-XR Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG 1

Dipyridamole Oral Tablet 25 MG, 50 MG, 75 MG 1

Epoprostenol Sodium Intravenous Solution Reconstituted 0.5 MG, 1.5 MG 1 PA; SPN


LETAIRIS ORAL TABLET 10 MG, 5 MG 1 PA; SPN; QL (30 EA per 30 days)


1




1



1

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

1 PA


1



CENTRAL NERVOUS SYSTEM AGENTS

ADAMANTANES (CNS)

Amantadine HCl Oral Capsule 100 MG 1

Amantadine HCl Oral Syrup 50 MG/5ML 1

Amantadine HCl Oral Tablet 100 MG 1

AMPHETAMINES

Amphetamine-Dextroamphet ER Oral Capsule Extended Release 24 Hour 10 MG, 15 MG, 5 MG


Amphetamine-Dextroamphet ER Oral Capsule Extended Release 24 Hour 20 MG, 25 MG, 30 MG


52

Drug Name Tier NotesAmphetamine-Dextroamphetamine Oral Tablet 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG


Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG 1 QL (60 EA per 30 days)



Dextroamphetamine Sulfate Oral Tablet 10 MG 1 QL (180 EA per 30 days)

Dextroamphetamine Sulfate Oral Tablet 5 MG 1 QL (90 EA per 30 days)

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG


VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


ZENZEDI ORAL TABLET 10 MG 1 QL (180 EA per 30 days)

ZENZEDI ORAL TABLET 5 MG 1 QL (90 EA per 30 days)

ANALGESICS AND ANTIPYRETICS, MISC.

Acetaminophen-Codeine #2 Oral Tablet 300-15 MG 1 PA; QL (180 EA per 30 days)



Acetaminophen-Codeine Oral Solution 120-12 MG/5ML 1 PA; QL (2700 ML per 30 days)

Acetaminophen-Codeine Oral Tablet 300-15 MG, 300-60 MG 1 PA; QL (180 EA per 30 days)

Butalbital-Acetaminophen Oral Tablet 50-325 MG 1 QL (360 EA per 30 days)

Butalbital-APAP Oral Tablet 50-325 MG 1 QL (360 EA per 30 days)

Butalbital-APAP-Caff-Cod Oral Capsule 50-325-40-30 MG 1 PA; QL (360 EA per 30 days)

Butalbital-APAP-Caffeine Oral Capsule 50-325-40 MG 1 QL (360 EA per 30 days)

Butalbital-APAP-Caffeine Oral Tablet 50-325-40 MG 1 QL (360 EA per 30 days)

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

1 PA; QL (150 EA per 30 days)

53

Drug Name Tier NotesESGIC ORAL CAPSULE 50-325-40 MG 1 QL (360 EA per 30 days)

Gabapentin Oral Capsule 100 MG, 300 MG, 400 MG 1 QL (180 EA per 30 days)

Gabapentin Oral Solution 250 MG/5ML, 300 MG/6ML 1 QL (2160 ML per 30 days)

Gabapentin Oral Tablet 600 MG 1 QL (180 EA per 30 days)


Hydrocodone-Acetaminophen Oral Solution2.5-108 MG/5ML, 5-217 MG/10ML, 7.5-325 MG/15ML

1 PA; QL (2700 ML per 30 days)

Hydrocodone-Acetaminophen Oral Tablet 10-325 MG, 5-325 MG, 7.5-325 MG 1 PA; QL (180 EA per 30 days)

LORCET HD ORAL TABLET 10-325 MG 1 PA; QL (180 EA per 30 days)

LORCET ORAL TABLET 5-325 MG 1 PA; QL (180 EA per 30 days)

LORCET PLUS ORAL TABLET 7.5-325 MG 1 PA; QL (180 EA per 30 days)

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 225 MG, 300 MG 1 PA; QL (60 EA per 30 days)

Oxycodone-Acetaminophen Oral Tablet 10-325 MG, 5-325 MG, 7.5-325 MG 1 PA; QL (120 EA per 30 days)

TENCON ORAL TABLET 50-325 MG 1 QL (360 EA per 30 days)

Tramadol-Acetaminophen Oral Tablet 37.5-325 MG 1 PA; QL (240 EA per 30 days)

ZEBUTAL ORAL CAPSULE 50-325-40 MG 1 QL (360 EA per 30 days)

ANTICHOLINERGIC AGENTS (CNS)

Benztropine Mesylate Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Trihexyphenidyl HCl Oral Elixir 0.4 MG/ML 1

Trihexyphenidyl HCl Oral Tablet 2 MG, 5 MG 1

ANTICONVULSANTS, MISCELLANEOUS

CarBAMazepine ER Oral Tablet Extended Release 12 Hour 100 MG, 200 MG, 400 MG 1

CarBAMazepine Oral Suspension 100 MG/5ML 1

CarBAMazepine Oral Tablet 200 MG 1

CarBAMazepine Oral Tablet Chewable 100 MG 1

DEPACON INTRAVENOUS SOLUTION 100 MG/ML

1

DEPAKENE ORAL CAPSULE 250 MG 1

DEPAKENE ORAL SOLUTION 250 MG/5ML 1

54

Drug Name Tier NotesDivalproex Sodium ER Oral Tablet Extended Release 24 Hour 250 MG, 500 MG 1

Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG 1

Divalproex Sodium Oral Tablet Delayed Release 125 MG, 250 MG, 500 MG 1

EPITOL ORAL TABLET 200 MG 1

Felbamate Oral Suspension 600 MG/5ML 1

Felbamate Oral Tablet 400 MG, 600 MG 1

Gabapentin Oral Capsule 100 MG, 300 MG, 400 MG 1 QL (180 EA per 30 days)

Gabapentin Oral Solution 250 MG/5ML, 300 MG/6ML 1 QL (2160 ML per 30 days)



LamoTRIgine Oral Tablet 100 MG, 150 MG, 200 MG, 25 MG 1

LamoTRIgine Oral Tablet Chewable 25 MG, 5 MG 1

LamoTRIgine Starter Kit-Blue Oral Kit 25 (35) MG 1

LamoTRIgine Starter Kit-Green Oral Kit 25 (84)-100(14) MG 1

LamoTRIgine Starter Kit-Orange Oral Kit 25 (42)-100 (7) MG 1

LevETIRAcetam Oral Solution 100 MG/ML 1

LevETIRAcetam Oral Tablet 1000 MG, 250 MG, 500 MG, 750 MG 1




OXcarbazepine Oral Tablet 150 MG, 300 MG, 600 MG 1

ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG

1

TEGRETOL ORAL SUSPENSION 100 MG/5ML

1

TEGRETOL ORAL TABLET 200 MG 1

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

1

TiaGABine HCl Oral Tablet 12 MG, 16 MG, 2 MG, 4 MG 1

55

Drug Name Tier NotesTopiramate Oral Capsule Sprinkle 15 MG, 25 MG 1 QL (120 EA per 30 days)

Topiramate Oral Tablet 100 MG, 200 MG, 25 MG, 50 MG 1 QL (120 EA per 30 days)

Valproate Sodium Intravenous Solution 100 MG/ML, 500 MG/5ML 1

Valproate Sodium Oral Solution 250 MG/5ML 1

Valproic Acid Oral Capsule 250 MG 1

Valproic Acid Oral Solution 250 MG/5ML 1

Zonisamide Oral Capsule 100 MG, 25 MG, 50 MG 1

ANTIDEPRESSANTS, MISCELLANEOUS

BuPROPion HCl ER (Smoking Det) Oral Tablet Extended Release 12 Hour 150 MG 1 90

BuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 100 MG, 150 MG, 200 MG

1 90

BuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG, 300 MG 1 90

BuPROPion HCl Oral Tablet 100 MG, 75 MG 1 90

Mirtazapine Oral Tablet 15 MG, 30 MG, 45 MG, 7.5 MG 1 90; QL (30 EA per 30 days)

ANTIMANIC AGENTS


1



Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 250 MG, 500 MG 1



Lithium Carbonate ER Oral Tablet Extended Release 300 MG, 450 MG 1

Lithium Carbonate Oral Capsule 150 MG, 300 MG, 600 MG 1

Lithium Carbonate Oral Tablet 300 MG 1

Lithium Oral Solution 8 MEQ/5ML 1

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

1

56

Drug Name Tier NotesValproate Sodium Intravenous Solution 100 MG/ML, 500 MG/5ML 1




ANTIMIGRAINE AGENTS, MISCELLANEOUS








1



Dihydroergotamine Mesylate Injection Solution 1 MG/ML 1

Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 250 MG, 500 MG 1



ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

1

Ergotamine-Caffeine Oral Tablet 1-100 MG 1

ESGIC ORAL CAPSULE 50-325-40 MG 1 QL (360 EA per 30 days)

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

1


1


57

Drug Name Tier NotesPropranolol HCl Oral Tablet 10 MG, 20 MG, 40 MG, 60 MG, 80 MG 1 90



Valproate Sodium Intravenous Solution 100 MG/ML, 500 MG/5ML 1





ANTIPSYCHOTICS, MISCELLANEOUS

Loxapine Succinate Oral Capsule 10 MG, 25 MG, 5 MG, 50 MG 1 PA

Pimozide Oral Tablet 1 MG, 2 MG 1 PA

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

BusPIRone HCl Oral Tablet 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG 1

Droperidol Injection Solution 2.5 MG/ML 1

Eszopiclone Oral Tablet 1 MG, 2 MG, 3 MG 1 QL (30 EA per 30 days)

HydrOXYzine HCl Oral Syrup 10 MG/5ML 1

HydrOXYzine HCl Oral Tablet 10 MG, 25 MG, 50 MG 1

HydrOXYzine Pamoate Oral Capsule 100 MG, 25 MG, 50 MG 1

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG

1




Promethazine HCl Rectal Suppository 12.5 MG, 25 MG, 50 MG 1

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG

1

Zaleplon Oral Capsule 10 MG, 5 MG 1 QL (30 EA per 30 days)

Zolpidem Tartrate Oral Tablet 10 MG, 5 MG 1 QL (30 EA per 30 days)

58

Drug Name Tier NotesATYPICAL ANTIPSYCHOTICS

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG


ARIPiprazole Oral Tablet 10 MG 1 PA

ARIPiprazole Oral Tablet 15 MG, 5 MG 1 PA; QL (60 EA per 30 days)

ARIPiprazole Oral Tablet 2 MG, 20 MG, 30 MG 1 PA; QL (30 EA per 30 days)

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML


ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML








CloZAPine Oral Tablet 100 MG 1 PA; QL (270 EA per 30 days)




INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 156 MG/ML








INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML








59

Drug Name Tier NotesLATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

1 ST; QL (30 EA per 30 days)

LATUDA ORAL TABLET 80 MG 1 ST; QL (60 EA per 30 days)

OLANZapine Oral Tablet 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG 1 PA; QL (30 EA per 30 days)

QUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG, 200 MG, 300 MG, 400 MG, 50 MG


QUEtiapine Fumarate Oral Tablet 100 MG, 200 MG, 25 MG, 300 MG, 50 MG 1 PA; QL (90 EA per 30 days)

QUEtiapine Fumarate Oral Tablet 400 MG 1 PA; QL (60 EA per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG


RisperiDONE Oral Solution 1 MG/ML 1 PA; QL (180 ML per 30 days)

RisperiDONE Oral Tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG 1 PA; QL (60 EA per 30 days)

RisperiDONE Oral Tablet Dispersible 0.25 MG 1 PA; QL (60 EA per 30 days)

Ziprasidone HCl Oral Capsule 20 MG, 40 MG, 80 MG 1 PA; QL (60 EA per 30 days)

Ziprasidone HCl Oral Capsule 60 MG 1 PA; QL (90 EA per 30 days)

BARBITURATES (ANTICONVULSANTS)

MYSOLINE ORAL TABLET 250 MG, 50 MG 1


PHENobarbital Oral Elixir 20 MG/5ML 1

PHENobarbital Oral Solution 20 MG/5ML 1

PHENobarbital Oral Tablet 100 MG, 15 MG, 16.2 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG

1


Primidone Oral Tablet 250 MG, 50 MG 1

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

Butalbital-Acetaminophen Oral Tablet 50-325 MG 1 QL (360 EA per 30 days)

Butalbital-APAP Oral Tablet 50-325 MG 1 QL (360 EA per 30 days)



60

Drug Name Tier NotesButalbital-APAP-Caffeine Oral Tablet 50-325-40 MG 1 QL (360 EA per 30 days)






PHENobarbital Oral Elixir 20 MG/5ML 1

PHENobarbital Oral Solution 20 MG/5ML 1

PHENobarbital Oral Tablet 100 MG, 15 MG, 16.2 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG

1

PHENobarbital Sodium Powder 1


TENCON ORAL TABLET 50-325 MG 1 QL (360 EA per 30 days)


BENZODIAZEPINES (ANTICONVULSANTS)

ClonazePAM Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Clorazepate Dipotassium Oral Tablet 15 MG, 3.75 MG, 7.5 MG 1

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

1

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 1

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

1

Diazepam Oral Concentrate 5 MG/ML 1

DiazePAM Oral Tablet 10 MG, 2 MG, 5 MG 1

DiazePAM Rectal Gel 10 MG, 2.5 MG, 20 MG 1

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

1

LORazepam Oral Concentrate 2 MG/ML 1

LORazepam Oral Tablet 0.5 MG, 1 MG, 2 MG 1

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

1

61

Drug Name Tier NotesALPRAZolam Oral Tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG 1

ChlordiazePOXIDE HCl Oral Capsule 10 MG, 25 MG, 5 MG 1

ClonazePAM Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Clorazepate Dipotassium Oral Tablet 15 MG, 3.75 MG, 7.5 MG 1

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

1

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 1

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

1

Diazepam Oral Concentrate 5 MG/ML 1

DiazePAM Oral Tablet 10 MG, 2 MG, 5 MG 1

DiazePAM Rectal Gel 10 MG, 2.5 MG, 20 MG 1

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

1

LORazepam Oral Concentrate 2 MG/ML 1

LORazepam Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Oxazepam Oral Capsule 10 MG, 15 MG, 30 MG 1

Temazepam Oral Capsule 15 MG, 30 MG, 7.5 MG 1

Triazolam Oral Tablet 0.125 MG, 0.25 MG 1

BUTYROPHENONES

Haloperidol Decanoate Intramuscular Solution100 MG/ML, 50 MG/ML 1 PA

Haloperidol Lactate Injection Solution 5 MG/ML 1 PA

Haloperidol Lactate Oral Concentrate 2 MG/ML 1 PA

Haloperidol Oral Tablet 0.5 MG, 1 MG, 10 MG, 2 MG, 20 MG, 5 MG 1 PA

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

Entacapone Oral Tablet 200 MG 1

CENTRAL NERVOUS SYSTEM AGENTS, MISC.

Atomoxetine HCl Oral Capsule 10 MG, 18 MG, 25 MG, 40 MG 1 QL (60 EA per 30 days)

62

Drug Name Tier NotesAtomoxetine HCl Oral Capsule 100 MG, 60 MG, 80 MG 1 QL (30 EA per 30 days)

GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 1 MG, 2 MG, 3 MG, 4 MG 1 QL (30 EA per 30 days)

GuanFACINE HCl Oral Tablet 1 MG, 2 MG 1

Riluzole Oral Tablet 50 MG 1

Tetrabenazine Oral Tablet 12.5 MG, 25 MG 1

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

Celecoxib Oral Capsule 100 MG 1 QL (60 EA per 30 days)

Celecoxib Oral Capsule 200 MG 1 QL (30 EA per 30 days)

Celecoxib Oral Capsule 400 MG, 50 MG 1

DOPAMINE PRECURSORS

Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG, 50-200 MG 1

Carbidopa-Levodopa Oral Tablet 10-100 MG, 25-100 MG, 25-250 MG 1

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

Bromocriptine Mesylate Oral Capsule 5 MG 1

Bromocriptine Mesylate Oral Tablet 2.5 MG 1

FIBROMYALGIA AGENTS

DULoxetine HCl Oral Capsule Delayed Release Particles 20 MG, 30 MG, 60 MG 1 QL (60 EA per 30 days)




HYDANTOINS

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

1

DILANTIN ORAL CAPSULE 100 MG, 30 MG 1

DILANTIN ORAL SUSPENSION 125 MG/5ML 1

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

1

PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG

1

Phenytoin Oral Suspension 125 MG/5ML 1

Phenytoin Oral Tablet Chewable 50 MG 1

Phenytoin Sodium Extended Oral Capsule 100 MG, 200 MG, 300 MG 1

63

Drug Name Tier NotesPhenytoin Sodium Injection Solution 50 MG/ML 1

Phenytoin Sodium Powder 1

INHALATION ANESTHETICS

Sevoflurane Inhalation Solution 1

SUPRANE INHALATION SOLUTION 1

MONOAMINE OXIDASE B INHIBITORS

Selegiline HCl Oral Capsule 5 MG 1

Selegiline HCl Oral Tablet 5 MG 1

MONOAMINE OXIDASE INHIBITORS

Phenelzine Sulfate Oral Tablet 15 MG 1

Selegiline HCl Oral Capsule 5 MG 1

Selegiline HCl Oral Tablet 5 MG 1

Tranylcypromine Sulfate Oral Tablet 10 MG 1

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

Pramipexole Dihydrochloride Oral Tablet0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

1

ROPINIRole HCl Oral Tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG 1

OPIATE AGONISTS




Acetaminophen-Codeine Oral Solution 120-12 MG/5ML 1 PA; QL (2700 ML per 30 days)

Acetaminophen-Codeine Oral Tablet 300-15 MG, 300-60 MG 1 PA; QL (180 EA per 30 days)

Belladonna Alkaloids-Opium Rectal Suppository 16.2-60 MG 1 PA

Belladonna-Opium Rectal Suppository 16.2-30 MG 1 PA


Codeine Sulfate Oral Tablet 15 MG, 30 MG, 60 MG 1 PA; QL (180 EA per 30 days)

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


64

Drug Name Tier NotesFentaNYL Citrate Powder 1 PA

FentaNYL Transdermal Patch 72 Hour 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR


HYDROcodone Bitartrate Crystals 1 PA

Hydrocodone-Acetaminophen Oral Solution2.5-108 MG/5ML, 5-217 MG/10ML, 7.5-325 MG/15ML

1 PA; QL (2700 ML per 30 days)

Hydrocodone-Acetaminophen Oral Tablet 10-325 MG, 5-325 MG, 7.5-325 MG 1 PA; QL (180 EA per 30 days)



Hydrocodone-Ibuprofen Oral Tablet 7.5-200 MG 1 PA; QL (150 EA per 30 days)

HYDROmorphone HCl Oral Liquid 1 MG/ML 1 PA; QL (2400 ML per 30 days)

HYDROmorphone HCl Oral Tablet 2 MG, 4 MG, 8 MG 1 PA; QL (180 EA per 30 days)

LORCET HD ORAL TABLET 10-325 MG 1 PA; QL (180 EA per 30 days)

LORCET ORAL TABLET 5-325 MG 1 PA; QL (180 EA per 30 days)

LORCET PLUS ORAL TABLET 7.5-325 MG 1 PA; QL (180 EA per 30 days)

Methadone HCl Oral Tablet 10 MG, 5 MG 1 PA; QL (90 EA per 30 days)

Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML, 20 MG/ML 1 PA; QL (180 ML per 30 days)

Morphine Sulfate ER Oral Tablet Extended Release 100 MG, 15 MG, 200 MG, 30 MG, 60 MG


Morphine Sulfate Oral Solution 10 MG/5ML, 20 MG/5ML 1 PA; QL (900 ML per 30 days)

Morphine Sulfate Oral Tablet 15 MG, 30 MG 1 PA; QL (180 EA per 30 days)

OxyCODONE HCl Oral Capsule 5 MG 1 PA; QL (180 EA per 30 days)

OxyCODONE HCl Oral Concentrate 100 MG/5ML 1 PA; QL (180 ML per 30 days)

OxyCODONE HCl Oral Solution 5 MG/5ML 1 PA; QL (2700 ML per 30 days)

OxyCODONE HCl Oral Tablet 10 MG, 15 MG, 20 MG, 30 MG, 5 MG 1 PA; QL (180 EA per 30 days)

Oxycodone-Acetaminophen Oral Tablet 10-325 MG, 5-325 MG, 7.5-325 MG 1 PA; QL (120 EA per 30 days)

Oxycodone-Aspirin Oral Tablet 4.8355-325 MG 1 PA; QL (120 EA per 30 days)

65

Drug Name Tier NotesOxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG


Oxymorphone HCl Oral Tablet 10 MG, 5 MG 1 PA; QL (180 EA per 30 days)


Promethazine-Codeine Oral Syrup 6.25-10 MG/5ML 1 QL (1000 ML per 30 days)


TraMADol HCl Oral Tablet 50 MG 1 PA; QL (240 EA per 30 days)


OPIATE ANTAGONISTS

Naloxone HCl Injection Solution 0.4 MG/ML, 4 MG/10ML 1

Naloxone HCl Injection Solution Cartridge 0.4 MG/ML 1

Naloxone HCl Injection Solution Prefilled Syringe 2 MG/2ML 1

Naltrexone HCl Oral Tablet 50 MG 1

NARCAN NASAL LIQUID 4 MG/0.1ML 1

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG


OPIATE PARTIAL AGONISTS

Buprenorphine HCl Sublingual Tablet Sublingual 2 MG, 8 MG 1 PA; QL (60 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG


ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG


OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

Diclofenac Sodium ER Oral Tablet Extended Release 24 Hour 100 MG 1

Diclofenac Sodium Oral Tablet Delayed Release 25 MG, 50 MG, 75 MG 1

Diclofenac Sodium Transdermal Gel 1 % 1 PA; QL (1000 GM per 30 days)

Diflunisal Oral Tablet 500 MG 1

Etodolac ER Oral Tablet Extended Release 24 Hour 400 MG, 500 MG, 600 MG 1

Etodolac Oral Capsule 200 MG, 300 MG 1

66

Drug Name Tier NotesEtodolac Oral Tablet 400 MG, 500 MG 1

Flurbiprofen Oral Tablet 100 MG, 50 MG 1

Hydrocodone-Ibuprofen Oral Tablet 7.5-200 MG 1 PA; QL (150 EA per 30 days)

Ibuprofen Oral Suspension 100 MG/5ML 1

Ibuprofen Oral Tablet 400 MG, 600 MG, 800 MG 1

Indomethacin ER Oral Capsule Extended Release 75 MG 1

Indomethacin Oral Capsule 25 MG, 50 MG 1

Ketoprofen ER Oral Capsule Extended Release 24 Hour 200 MG 1

Meloxicam Oral Tablet 15 MG, 7.5 MG 1 90

Nabumetone Oral Tablet 500 MG, 750 MG 1

Naproxen DR Oral Tablet Delayed Release 375 MG, 500 MG 1

Naproxen Oral Suspension 125 MG/5ML 1

Naproxen Oral Tablet 250 MG, 375 MG, 500 MG 1

Naproxen Sodium Oral Tablet 275 MG, 550 MG 1

Piroxicam Oral Capsule 10 MG, 20 MG 1

Sulindac Oral Tablet 150 MG, 200 MG 1

PHENOTHIAZINES

ChlorproMAZINE HCl Oral Tablet 10 MG, 100 MG, 200 MG, 25 MG, 50 MG 1 PA

COMPRO RECTAL SUPPOSITORY 25 MG 1

FluPHENAZine Decanoate Injection Solution25 MG/ML 1 PA; SPN

FluPHENAZine HCl Oral Concentrate 5 MG/ML 1 PA

FluPHENAZine HCl Oral Elixir 2.5 MG/5ML 1 PA

FluPHENAZine HCl Oral Tablet 1 MG, 10 MG, 2.5 MG, 5 MG 1 PA

Perphenazine Oral Tablet 16 MG, 2 MG, 4 MG, 8 MG 1 PA

Prochlorperazine Maleate Oral Tablet 10 MG, 5 MG 1 PA

Prochlorperazine Rectal Suppository 25 MG 1

Thioridazine HCl Oral Tablet 10 MG, 100 MG, 25 MG, 50 MG 1

67

Drug Name Tier NotesTrifluoperazine HCl Oral Tablet 1 MG, 10 MG, 2 MG, 5 MG 1

RESPIRATORY AND CNS STIMULANTS







Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG


Dexmethylphenidate HCl Oral Tablet 10 MG, 2.5 MG, 5 MG 1 QL (60 EA per 30 days)


METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG


Methylphenidate HCl ER (CD) Oral Capsule Extended Release 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


Methylphenidate HCl ER Oral Tablet Extended Release 10 MG, 36 MG 1 QL (60 EA per 30 days)

Methylphenidate HCl ER Oral Tablet Extended Release 18 MG, 27 MG, 54 MG, 72 MG


Methylphenidate HCl ER Oral Tablet Extended Release 20 MG 1 QL (120 EA per 30 days)

Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 18 MG, 27 MG, 54 MG


Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 36 MG 1 QL (60 EA per 30 days)

Methylphenidate HCl Oral Solution 10 MG/5ML, 5 MG/5ML 1 QL (900 ML per 30 days)

Methylphenidate HCl Oral Tablet 10 MG, 5 MG 1 QL (90 EA per 30 days)

Methylphenidate HCl Oral Tablet 20 MG 1 QL (120 EA per 30 days)


68

Drug Name Tier NotesSALICYLATES





Choline-Mag Trisalicylate Oral Liquid 500 MG/5ML 1

Oxycodone-Aspirin Oral Tablet 4.8355-325 MG 1 PA; QL (120 EA per 30 days)

Salsalate Oral Tablet 500 MG, 750 MG 1

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

Desvenlafaxine Succinate ER Oral Tablet Extended Release 24 Hour 100 MG, 50 MG 1 90; QL (30 EA per 30 days)

DULoxetine HCl Oral Capsule Delayed Release Particles 20 MG, 30 MG, 60 MG 1 QL (60 EA per 30 days)

Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 MG 1 90; QL (60 EA per 30 days)

Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MG, 75 MG 1 90; QL (30 EA per 30 days)

Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 225 MG 1 90; QL (30 EA per 30 days)

Venlafaxine HCl Oral Tablet 100 MG, 25 MG, 37.5 MG, 50 MG, 75 MG 1 90

SELECTIVE SEROTONIN AGONISTS

Rizatriptan Benzoate Oral Tablet 10 MG, 5 MG 1 QL (18 EA per 30 days)

Rizatriptan Benzoate Oral Tablet Dispersible10 MG, 5 MG 1 QL (18 EA per 30 days)

SUMAtriptan Nasal Solution 20 MG/ACT, 5 MG/ACT 1 QL (6 EA per 30 days)

SUMAtriptan Succinate Oral Tablet 100 MG 1 QL (9 EA per 30 days)

SUMAtriptan Succinate Oral Tablet 25 MG, 50 MG 1 QL (18 EA per 30 days)

SUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 4 MG/0.5ML, 6 MG/0.5ML 1 QL (4 ML per 30 days)

SUMAtriptan Succinate Subcutaneous Solution 6 MG/0.5ML 1 QL (4 ML per 30 days)

69

Drug Name Tier NotesSUMAtriptan Succinate Subcutaneous Solution Auto-Injector 4 MG/0.5ML, 6 MG/0.5ML


SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

Citalopram Hydrobromide Oral Solution 10 MG/5ML 1 90

Citalopram Hydrobromide Oral Tablet 10 MG, 20 MG, 40 MG 1 90; QL (30 EA per 30 days)

Escitalopram Oxalate Oral Tablet 10 MG, 20 MG, 5 MG 1 90; QL (30 EA per 30 days)

FLUoxetine HCl (PMDD) Oral Capsule 10 MG 1 90; QL (60 EA per 30 days)

FLUoxetine HCl (PMDD) Oral Capsule 20 MG 1 90

FLUoxetine HCl (PMDD) Oral Tablet 10 MG 1 QL (60 EA per 30 days)

FLUoxetine HCl (PMDD) Oral Tablet 20 MG 1

FLUoxetine HCl Oral Capsule 10 MG 1 90; QL (60 EA per 30 days)

FLUoxetine HCl Oral Capsule 20 MG 1 90; QL (120 EA per 30 days)

FLUoxetine HCl Oral Capsule 40 MG 1 90

FLUoxetine HCl Oral Solution 20 MG/5ML 1 90

FLUoxetine HCl Oral Tablet 10 MG 1 90; QL (60 EA per 30 days)

FLUoxetine HCl Oral Tablet 20 MG 1 90

FluvoxaMINE Maleate Oral Tablet 100 MG 1 90

FluvoxaMINE Maleate Oral Tablet 25 MG, 50 MG 1 90; QL (30 EA per 30 days)

PARoxetine HCl Oral Tablet 10 MG, 20 MG, 40 MG 1 90; QL (30 EA per 30 days)

PARoxetine HCl Oral Tablet 30 MG 1 90; QL (60 EA per 30 days)

PAXIL ORAL SUSPENSION 10 MG/5ML 1

Sertraline HCl Oral Concentrate 20 MG/ML 1 90

Sertraline HCl Oral Tablet 100 MG 1 90; QL (60 EA per 30 days)

Sertraline HCl Oral Tablet 25 MG, 50 MG 1 90; QL (30 EA per 30 days)

SEROTONIN MODULATORS

Nefazodone HCl Oral Tablet 100 MG, 150 MG, 200 MG, 250 MG, 50 MG 1

TraZODone HCl Oral Tablet 100 MG, 150 MG, 300 MG, 50 MG 1 90

SUCCINIMIDES

Ethosuximide Oral Capsule 250 MG 1

Ethosuximide Oral Solution 250 MG/5ML 1

ZARONTIN ORAL CAPSULE 250 MG 1

ZARONTIN ORAL SOLUTION 250 MG/5ML 1

70

Drug Name Tier NotesTHIOXANTHENES

Thiothixene Oral Capsule 1 MG, 10 MG, 2 MG, 5 MG 1 PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORS

Amitriptyline HCl Oral Tablet 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 1

Amoxapine Oral Tablet 100 MG, 150 MG, 25 MG, 50 MG 1

ClomiPRAMINE HCl Oral Capsule 25 MG, 50 MG, 75 MG 1

Desipramine HCl Oral Tablet 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 1

Doxepin HCl Oral Capsule 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 1 90

Doxepin HCl Oral Concentrate 10 MG/ML 1 90

Imipramine HCl Oral Tablet 10 MG, 25 MG, 50 MG 1 90

Maprotiline HCl Oral Tablet 25 MG, 50 MG, 75 MG 1

Nortriptyline HCl Oral Capsule 10 MG, 25 MG, 50 MG, 75 MG 1 90

Nortriptyline HCl Oral Solution 10 MG/5ML 1 90

Protriptyline HCl Oral Tablet 10 MG, 5 MG 1

Trimipramine Maleate Oral Capsule 100 MG, 25 MG, 50 MG 1

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

Tetrabenazine Oral Tablet 12.5 MG, 25 MG 1

WAKEFULNESS-PROMOTING AGENTS

Modafinil Oral Tablet 100 MG, 200 MG 1 ST; QL (30 EA per 30 days)

DEVICES

DEVICES

ACCU-CHEK FLEXLINK PLUS 10MM 1



ACCU-CHEK PLASTIC CARTRIDGE 1

ACCU-CHEK RAPID-D INFUSION SET 1

ACCU-CHEK TENDER I SET 24" 1



71

Drug Name Tier NotesACCU-CHEK TENDER II SET 24" 1

ACCU-CHEK TENDER II SET 31" 1

ACCU-CHEK TENDER II SET 43" 1

ACCU-CHEK ULTRAFLEX INF SET 1

ACTICOAT 7 2"X2" EXTERNAL PAD 1


ACTICOAT ABSORBENT 4"X5" EXTERNAL PAD

1

ACTICOAT ANTIMICROBIAL 2"X2" EXTERNAL PAD

1

ACTICOAT ANTIMICROBIAL 4"X4" EXTERNAL PAD

1

ACTICOAT FLEX 3 4"X4" EXTERNAL PAD 1

AEROCHAMBER MINI CHAMBER DEVICE 1

AEROCHAMBER MV 1

AEROCHAMBER PLUS FLO-VU 1

AEROCHAMBER W/FLOWSIGNAL 1

AEROCHAMBER Z-STAT PLUS CHAMBR 1

ALCOH-GLOVE CONTOURED WIPE PAD 1

ALEVICYN ANTIPRURITIC EXTERNAL GEL 1

ALLEVYN AG ADHESIVE EXTERNAL PAD 1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

1

ATOPICLAIR EXTERNAL CREAM 1

ATRAPRO HYDROGEL EXTERNAL GEL 1

AUTOSOFT 30 INFUSION SET 1

AUTOSOFT 90 INFUSION SET 1

BD INTEGRA NEEDLE 25G X 5/8" 1

BD PEN NEEDLE NANO U/F 32G X 4 MM 1

BD SAFETYGLIDE SHIELDED NEEDLE 21G X 1-1/2" , 22G X 1-1/2" 10 ML

1

BD SAFETYGLIDE SYRINGE/NEEDLE 21G X 1-1/2"

1

BD SAFETY-LOK SET 1

BD SYRINGE BLUNT CANNULA 17G 5 ML 1

BD SYRINGE LUER-LOK 3 ML , 30 ML , 5 ML

1

BD SYRINGE SLIP TIP 20 ML , 3 ML 1

BD SYRINGE TIP CAP 1

BD VACUTAINER SET 1

72

Drug Name Tier NotesCartridge IR 1000 3ml 1

Cartridge IR 1200 1

Cartridge Pump 1

CERAMAX EXTERNAL CREAM 1

CLEO 90 INFUSION SET 24"/6MM 1




COMFORT INFUSION SET 23"/17MM 1




COMFORT SHORT INF SET 23"/13MM 1




CONTACT DETACH INF SET 23" 6MM 1


CONTACT DETACH INF SET 23"/6MM 1






CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD

1

DELTEC COZMO CLEO SET 24" 6MM 1






ELETONE EXTERNAL CREAM 1

ELETONE TWINPACK EXTERNAL CREAM 1

ENLITE SERTER 1

Filter Needle 18G X 1-1/2" 1

FREESTYLE LIBRE READER DEVICE 1 ST; QL (1 EA per 365 days)

FREESTYLE LIBRE SENSOR SYSTEM 1 ST; QL (3 EA per 30 days)

73

Drug Name Tier NotesHeparin (Porcine) in NaCl Injection Solution2-0.9 UNIT/ML-% 1

Heparin (Porcine) in NaCl Intravenous Solution 100-0.45 UT/100ML-%, 1000-0.9 UNIT/L-%

1

Heparin Lock Flush Intravenous Solution 10 UNIT/ML, 100 UNIT/ML 1

Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML 1

HPR PLUS EXTERNAL CREAM 1

HUMAPEN LUXURA HD DEVICE 1

HYDROFERA BLUE 4"X4" EXTERNAL PAD 1

HYDROFERA BLUE 6"X6" EXTERNAL PAD 1

HYDROFERA BLUE FOAM DRESSING EXTERNAL PAD

1

HYDROFERA BLUE FOAM/TUNNELING EXTERNAL PAD

1

HYDROFERA BLUE MRF DRESSING EXTERNAL PAD

1

HYLATOPIC PLUS EXTERNAL CREAM 1

Infusion Catheter Soft 23" 1



Infusion Set 1

Infusion Set 23" Comfort 1

INSET 30 INFUSION SET 23" 1

INSET 30 INFUSION SET 43" 1

INSET INFUSION SET 23" 6MM 1




Insulin Cartridge 3ML 1

I-PORT ADVANCE 6MM 1

I-PORT ADVANCE 9MM 1

Loutrex External Cream 1

LUXAMEND EXTERNAL CREAM 1

LYCELLE EXTERNAL GEL 1

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G 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

1

74

Drug Name Tier NotesMAGELLAN TUBERCULIN SYRINGE 27G X 1/2" 1 ML, 28G X 1/2" 1 ML

1

MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

1

MEDIHONEY CA ALGINATE 2"X2" EXTERNAL PAD

1

MEDIHONEY CA ALGINATE 4"X5" EXTERNAL PAD

1

MEDIHONEY WOUND/BURN DRESSING EXTERNAL PAD

1

MILLEX-FG FILTER/TEFLON 1

MINIMED PUMP RESERVOIR 3ML 1

MINIMED RESERVOIR 1.8ML 1

MINIMED RESERVOIR 3ML 1

MIO INFUSION SET 18" 6MM 1




MONOJECT ALLERGIST TRAY KIT 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

1

MONOJECT BLUNTIP CANNULA 20G X 1-1/2" , 21G X 1"

1

MONOJECT CONTROL SYRINGE 12 ML 1

MONOJECT FILTER ASPIRATOR 1

MONOJECT FILTER NEEDLE 18G X 1-1/2" , 20G X 1-1/2"

1

MONOJECT HYPODERMIC NEEDLE 14G X 1" , 14G X 1-1/2" , 14G X 2" , 16G X 1" , 16G X 1-1/2" , 16G X 3/4" , 16G X 5/8" , 18G X 1" , 18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 20G X 1" , 20G X 1-1/2" , 21G X 1" , 21G X 1-1/2" , 21G X 2" , 22G X 1" , 22G X 1-1/2" , 23G X 1" , 23G X 3/4" , 25G X 1" , 25G X 1-1/2" , 25G X 1-1/4" , 25G X 2" , 25G X 5/8" , 26G X 1-1/2" , 26G X 1/2" , 27G X 1-1/2" , 27G X 1-1/4" , 27G X 1/2" , 30G X 3/4"

1

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G 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, U-100 1 ML

1

MONOJECT LIFESHIELD CANNULA 1

75

Drug Name Tier NotesMONOJECT LIFESHIELD SYRINGE 18G X 1" 3 ML

1

MONOJECT MAGELLAN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML

1

MONOJECT PHARMACY TRAY 12 ML , 20 ML , 3 ML , 35 ML , 6 ML , 60 ML

1

MONOJECT PISTON SYRINGE 140 ML 1

MONOJECT SMARTIP SYR/CANNULA 1

MONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 3 ML, 22G X 1-1/2" 6 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML , 6 ML

1

MONOJECT SYRINGE CATH TIP 35 ML , 60 ML

1

MONOJECT SYRINGE ECC LUER 20 ML , 35 ML

1

MONOJECT SYRINGE ECCENTRIC TIP 60 ML

1

MONOJECT SYRINGE LUER LOCK 20 ML , 35 ML , 6 ML , 60 ML

1

MONOJECT SYRINGE LUER-LOCK TIP 140 ML , 60 ML

1

MONOJECT SYRINGE PHARMACY TRAY 1 ML

1

MONOJECT SYRINGE REG LUER 12 ML , 20 ML , 3 ML , 35 ML , 6 ML

1

MONOJECT SYRINGE REGULAR TIP 20 ML , 3 ML , 6 ML , 60 ML

1

MONOJECT SYRINGE TOOMEY TYPE 60 ML

1

MONOJECT TB SAFETY SYRINGE 25G X 5/8" 1 ML, 28G X 1/2" 1 ML

1

MONOJECT TB SYRINGE 1 ML , 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

1

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

1

MONOJECT VIAL ACCESS CANNULA 1

76

Drug Name Tier NotesMulti-Draw Needle 20G X 1" , 21G X 1" , 22G X 1" 1

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 %

1

NEOCERA EXTERNAL CREAM 1

NEOSALUS CP EXTERNAL CREAM 1

NEOSALUS EXTERNAL CREAM 1

NIVATOPIC PLUS EXTERNAL CREAM 1

NOVOPEN ECHO DEVICE 1

PARADIGM POLYFIN QR/WINGS 24" 1

PARADIGM POLYFIN QR/WINGS 42" 1

PARADIGM PUMP RESERVOIR 1.8ML 1

PARADIGM PUMP RESERVOIR 3ML 1

PARADIGM QUICK-SET 18" 6MM 1







PARADIGM SILHOUETTE 18" 13MM 1

PARADIGM SILHOUETTE 32" 17MM 1

PARADIGM SILHOUETTE COMBO 23" 1

PARADIGM SILHOUETTE COMBO 43" 1

PARADIGM SILHOUETTE FULL 23" 1

PARADIGM SILHOUETTE FULL 43" 1

PARADIGM SOF-SET MICRO QR 24" 1

PARADIGM SOF-SET MICRO QR 42" 1

PARADIGM SOF-SET ULT QR 24" 1

PARADIGM SOF-SET ULT QR 42" 1

PARADIGM SURE-T 23" 6MM 1

PARADIGM SURE-T 23" 8MM 1

PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

1

PHASEAL ASSEMBLY FIXTURE 1

PHASEAL CONNECTOR LUER LOCK 1

PHASEAL INFUSION ADAPTER 1

PHASEAL INFUSION CLAMP 1

PHASEAL INJECTOR LUER LOCK 1

77

Drug Name Tier NotesPHASEAL PROTECTOR 14 1

PHASEAL PROTECTOR 21 1



PHASEAL SECONDARY SET 1

PHASEAL Y-SITE CONNECTOR 1

POLYFIN INFUSION SET 24" 1

POLYFIN INFUSION SET 42" 1

POLYFIN QR INFUSION SET 24" 1

POLYFIN QR INFUSION SET 42" 1

POLYFIN TUBING SET 60" 1

Pro Comfort Pen Needles 32G X 5 MM 1

PROMISEB EXTERNAL CREAM 1

PRUCLAIR EXTERNAL CREAM 1

PRUMYX EXTERNAL CREAM 1

QUICK-SET INFUSION 23" 6MM 1




RADIAPLEXRX EXTERNAL GEL 1

RESTORE SILVER DRESSING EXTERNAL PAD

1

Sash Kit Intravenous Kit 100-0.9 UNIT/ML-% 1

SILHOUETTE 13MM 1

SILHOUETTE 17MM 1

SILHOUETTE INFUSION SET 23" 1

SILHOUETTE INFUSION SET 43" 1

SILVASORB EXTERNAL GEL 1

Sodium Chloride Inhalation Nebulization Solution 0.9 %, 3 % 1

Sodium Chloride Injection Solution 0.9 % 1

SOF-SET INFUSION SET 24" 1

SOF-SET INFUSION SET 42" 1

SOF-SET MICRO QR INFUSION 24" 1

SOF-SET MICRO QR INFUSION 42" 1

SOF-SET ULTIMATE QR 24" 1

SOF-SET ULTIMATE QR 42" 1

SP Antipruritic External Gel 1

78

Drug Name Tier NotesSYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML


SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML


Syringe Filter/Millex-GS/25mm 1

Syringe Luer Lock 30 ML 1

Syringe Luer Slip 1 ML 1

T:30 INFUSION SET 1

T:90 INFUSION SET 1

T:FLEX INSULIN CARTRIDGE 4.8ML 1

T:SLIM G4 INSULIN CARTRIDGE 1

T:SLIM INSULIN CARTRIDGE 3ML 1

TB Syringe 1 ML 1

TEGADERM AG MESH 4"X8" EXTERNAL PAD

1

Toomey Syringe 70 ML 1

TRUSTEEL INFUSION SET 1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

1

VARISOFT INFUSION SET 1

Zanabin Hydrogel External Gel 1

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS

Av-Phos 250 Neutral Oral Tablet 155-852-130 MG 1

PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG

1

PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET 155-852-130 MG

1

Virt-Phos 250 Neutral Oral Tablet 155-852-130 MG 1

ALKALINIZING AGENTS

Potassium Bicarbonate Granules 1

Potassium Citrate ER Oral Tablet Extended Release 10 MEQ (1080 MG), 5 MEQ (540 MG) 1

AMMONIA DETOXICANTS

Constulose Oral Solution 10 GM/15ML 1

Enulose Oral Solution 10 GM/15ML 1

Generlac Oral Solution 10 GM/15ML 1

79

Drug Name Tier NotesLactulose Encephalopathy Oral Solution 10 GM/15ML 1 PA

Lactulose Oral Solution 10 GM/15ML, 20 GM/30ML 1

CALORIC AGENTS

LYSIPLEX PLUS ORAL TABLET 1

CARBONIC ANHYDRASE INHIBITORS


DIURETICS, MISCELLANEOUS



1


1




IRRIGATING SOLUTIONS

Acetic Acid Irrigation Solution 0.25 % 1

RENACIDIN IRRIGATION SOLUTION 1

RESECTISOL IRRIGATION SOLUTION 5 % 1

LOOP DIURETICS

Bumetanide Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Ethacrynic Acid Oral Tablet 25 MG 1

Furosemide Oral Solution 10 MG/ML, 8 MG/ML 1 90

Furosemide Oral Tablet 20 MG, 40 MG, 80 MG 1 90

Torsemide Oral Tablet 10 MG, 100 MG, 20 MG, 5 MG 1

OSMOTIC DIURETICS

Mannitol Powder 1

PHOSPHATE-REMOVING AGENTS

Calcium Acetate (Phos Binder) Oral Capsule667 MG 1

Calcium Acetate (Phos Binder) Oral Tablet667 MG 1

80

Drug Name Tier NotesRENAGEL ORAL TABLET 800 MG 1

Sevelamer Carbonate Oral Tablet 800 MG 1

POTASSIUM-REMOVING AGENTS

KIONEX ORAL SUSPENSION 15 GM/60ML 1

Sodium Polystyrene Sulfonate Oral Powder 1

Sodium Polystyrene Sulfonate Oral Suspension15 GM/60ML 1

Sodium Polystyrene Sulfonate Rectal Suspension 30 GM/120ML, 50 GM/200ML 1

SPS ORAL SUSPENSION 15 GM/60ML 1

POTASSIUM-SPARING DIURETICS

AMILoride HCl Oral Tablet 5 MG 1


DYRENIUM ORAL CAPSULE 100 MG, 50 MG 1





REPLACEMENT PREPARATIONS


Calcium Sulfate Hemihydrate Powder 1

Calcium Sulfate Powder 1



EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ

1

Effervescent Pot Chloride Oral Tablet Effervescent 25 MEQ 1

K-Effervescent Oral Tablet Effervescent 25 MEQ 1

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

1

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ

1


1


1

81

Drug Name Tier NotesKLOR-CON ORAL PACKET 20 MEQ 1

KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ

1

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ

1

KLOR-CON/EF ORAL TABLET EFFERVESCENT 25 MEQ

1

K-PRIME ORAL TABLET EFFERVESCENT 25 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ

1

K-Vescent Oral Tablet Effervescent 25 MEQ 1

Magnesium Gluconate Powder 1







1

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 %

1












Pot Bicarb-Pot Chloride Oral Tablet Effervescent 25 MEQ 1

Potassium Bicarbonate Oral Tablet Effervescent 25 MEQ 1

Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ, 20 MEQ 1

82

Drug Name Tier NotesPotassium Chloride ER Oral Capsule Extended Release 10 MEQ, 8 MEQ 1

Potassium Chloride ER Oral Tablet Extended Release 10 MEQ, 8 MEQ 1

Potassium Chloride Oral Packet 20 MEQ 1

Potassium Chloride Oral Solution 20 MEQ/15ML (10%), 40 MEQ/15ML (20%) 1

Potassium Gluconate Anhydrous Powder 1


1

PR NATAL 400 ORAL 29-1-200 & 400 MG 1


1

PR NATAL 430 ORAL 29-1-200 & 430 MG 1




Prenatal 19 Oral Tablet Chewable 1









Saline Bacteriostatic Injection Solution 0.9 % 1

Saline-Benzyl Alcohol Injection Solution 0.9 % 1


Sodium Chloride Bacteriostatic Injection Solution 0.9 % 1

Sodium Chloride Granules 1

Sodium Chloride Inhalation Nebulization Solution 0.9 %, 3 % 1

Sodium Chloride Injection Solution 0.9 % 1

Sodium Chloride Powder 1




83

Drug Name Tier NotesTRINATE ORAL TABLET 1



1












1

THIAZIDE DIURETICS



1



Chlorothiazide Oral Tablet 250 MG, 500 MG 1

DIURIL ORAL SUSPENSION 250 MG/5ML 1



HydroCHLOROthiazide Oral Capsule 12.5 MG 1 90

HydroCHLOROthiazide Oral Tablet 12.5 MG, 25 MG, 50 MG 1 90




84

Drug Name Tier NotesMethyclothiazide Oral Tablet 5 MG 1









THIAZIDE-LIKE DIURETICS


Chlorthalidone Oral Tablet 25 MG, 50 MG 1

Indapamide Oral Tablet 1.25 MG, 2.5 MG 1

Metolazone Oral Tablet 10 MG, 2.5 MG, 5 MG 1

URICOSURIC AGENTS

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG

1 PA

Probenecid Oral Tablet 500 MG 1

ENZYMES

ENZYMES

PULMOZYME INHALATION SOLUTION 1 MG/ML

1PA; SPN; QL (150 ML per 30 days)

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

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

1

Brimonidine Tartrate Ophthalmic Solution0.15 %, 0.2 % 1

ANTIALLERGIC AGENTS

ALOMIDE OPHTHALMIC SOLUTION 0.1 % 1

Azelastine HCl Nasal Solution 0.1 %, 0.15 %, 137 MCG/SPRAY 1

Cromolyn Sodium Ophthalmic Solution 4 % 1

85

Drug Name Tier NotesKetotifen Fumarate Ophthalmic Solution 0.025 % 1

Olopatadine HCl Ophthalmic Solution 0.2 % 1 QL (2.5 ML per 25 days)

ANTIBACTERIALS (EENT)

Bacitracin Ophthalmic Ointment 500 UNIT/GM 1

Bacitracin-Polymyxin B Ophthalmic Ointment500-10000 UNIT/GM 1

Bacitra-Neomycin-Polymyxin-HC Ophthalmic Ointment 1 % 1

BACTROBAN NASAL NASAL OINTMENT 2 %

1

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

1

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

1

CILOXAN OPHTHALMIC OINTMENT 0.3 % 1

CIPRODEX OTIC SUSPENSION 0.3-0.1 % 1

Ciprofloxacin HCl Ophthalmic Solution 0.3 % 1

Doxycycline Hyclate Oral Tablet 20 MG 1

Erythromycin Ophthalmic Ointment 5 MG/GM 1

GENTAK OPHTHALMIC OINTMENT 0.3 % 1

Gentamicin Sulfate Ophthalmic Solution 0.3 % 1

MOXEZA OPHTHALMIC SOLUTION 0.5 % 1 QL (3 ML per 25 days)

Moxifloxacin HCl Ophthalmic Solution 0.5 % 1

Neomycin-Bacitracin Zn-Polymyx Ophthalmic Ointment 5-400-10000 1

Neomycin-Polymyxin-Dexameth Ophthalmic Ointment 3.5-10000-0.1 1

Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 3.5-10000-0.1 1

Neomycin-Polymyxin-HC Ophthalmic Suspension 3.5-10000-1 1

Neomycin-Polymyxin-HC Otic Solution 1 %, 3.5-10000-1 1

Neomycin-Polymyxin-HC Otic Suspension 3.5-10000-1 1

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 %

1

86

Drug Name Tier NotesNEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000

1

Ofloxacin Ophthalmic Solution 0.3 % 1

Ofloxacin Otic Solution 0.3 % 1

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM

1

Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 UNIT/ML-% 1

Sulfacetamide Sodium Ophthalmic Ointment10 % 1

Sulfacetamide Sodium Ophthalmic Solution 10 % 1

Sulfacetamide-Prednisolone Ophthalmic Solution 10-0.23 % 1

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

1

Tobramycin Ophthalmic Solution 0.3 % 1

Tobramycin-Dexamethasone Ophthalmic Suspension 0.3-0.1 % 1

TOBREX OPHTHALMIC OINTMENT 0.3 % 1

ANTIVIRALS (EENT)

Trifluridine Ophthalmic Solution 1 % 1

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

Betaxolol HCl Ophthalmic Solution 0.5 % 1

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

1

Carteolol HCl Ophthalmic Solution 1 % 1

Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML 1

Levobunolol HCl Ophthalmic Solution 0.5 % 1

Timolol Maleate Ophthalmic Gel Forming Solution 0.25 %, 0.5 % 1

Timolol Maleate Ophthalmic Solution 0.25 %, 0.5 % 1

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 %

1

CARBONIC ANHYDRASE INHIBITORS (EENT)


Dorzolamide HCl Ophthalmic Solution 2 % 1

87

Drug Name Tier NotesDorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML 1

Methazolamide Oral Tablet 25 MG, 50 MG 1

CORTICOSTEROIDS (EENT)

ACETASOL HC OTIC SOLUTION 2-1 % 1

Bacitra-Neomycin-Polymyxin-HC Ophthalmic Ointment 1 % 1

CIPRODEX OTIC SUSPENSION 0.3-0.1 % 1

Dexamethasone Sodium Phosphate Ophthalmic Solution 0.1 % 1

FLAREX OPHTHALMIC SUSPENSION 0.1 % 1

Fluorometholone Ophthalmic Suspension 0.1 % 1

Fluticasone Propionate Nasal Suspension 50 MCG/ACT 1 QL (16 GM per 30 days)

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

1

Hydrocortisone-Acetic Acid Otic Solution 1-2 % 1

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

1

Neomycin-Polymyxin-Dexameth Ophthalmic Ointment 3.5-10000-0.1 1

Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 3.5-10000-0.1 1

Neomycin-Polymyxin-HC Ophthalmic Suspension 3.5-10000-1 1

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 %

1

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

1

PrednisoLONE Acetate Ophthalmic Suspension 1 % 1

PrednisoLONE Sodium Phosphate Ophthalmic Solution 1 % 1

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

1

Tobramycin-Dexamethasone Ophthalmic Suspension 0.3-0.1 % 1

Triamcinolone Acetonide Nasal Aerosol 55 MCG/ACT 1

88

Drug Name Tier NotesEENT ANTI-INFECTIVES, MISCELLANEOUS

ACETASOL HC OTIC SOLUTION 2-1 % 1

Acetic Acid Otic Solution 2 % 1

Chlorhexidine Gluconate Mouth/Throat Solution 0.12 % 1

Hydrocortisone-Acetic Acid Otic Solution 1-2 % 1

PAROEX MOUTH/THROAT SOLUTION 0.12 %

1

EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

1 ST

RESTASIS OPHTHALMIC EMULSION 0.05 % 1 ST

EENT DRUGS, MISCELLANEOUS

Apraclonidine HCl Ophthalmic Solution 0.5 % 1

IOPIDINE OPHTHALMIC SOLUTION 1 % 1

Ipratropium Bromide Nasal Solution 0.03 %, 0.06 % 1 QL (30 ML per 30 days)

LACRISERT OPHTHALMIC INSERT 5 MG 1

Polyvinyl Alcohol Ophthalmic Solution 1.4 % 1

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

Diclofenac Sodium Ophthalmic Solution 0.1 % 1

Flurbiprofen Sodium Ophthalmic Solution0.03 % 1

Ketorolac Tromethamine Ophthalmic Solution0.4 %, 0.5 % 1

LOCAL ANESTHETICS (EENT)

GLYDO EXTERNAL GEL 2 % 1

Lidocaine HCl External Gel 2 % 1

Lidocaine Viscous Mouth/Throat Solution 2 % 1

MIOTICS

Acetylcholine Chloride Powder 1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

1

Pilocarpine HCl Ophthalmic Solution 1 %, 2 %, 4 % 1

MYDRIATICS

Atropine Sulfate Ophthalmic Ointment 1 % 1

89

Drug Name Tier NotesAtropine Sulfate Ophthalmic Solution 1 % 1

Cyclopentolate HCl Ophthalmic Solution 0.5 %, 1 %, 2 % 1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 %

1

Homatropine HBr Ophthalmic Solution 5 % 1

Tropicamide Ophthalmic Solution 0.5 %, 1 % 1

OSMOTIC AGENTS

Mannitol Powder 1

PROSTAGLANDIN ANALOGS

Latanoprost Ophthalmic Solution 0.005 % 1

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

1

VASOCONSTRICTORS

ADRENALIN NASAL SOLUTION 0.1 % 1

ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 %

1

Naphazoline HCl Powder 1

Phenylephrine HCl Ophthalmic Solution 10 %, 2.5 % 1

GASTROINTESTINAL DRUGS

5-HT3 RECEPTOR ANTAGONISTS

Ondansetron HCl Oral Solution 4 MG/5ML 1

Ondansetron HCl Oral Tablet 24 MG, 4 MG, 8 MG 1

Ondansetron Oral Tablet Dispersible 4 MG, 8 MG 1

ANTIDIARRHEA AGENTS



Loperamide HCl Oral Capsule 2 MG 1

ANTIHISTAMINES (GI DRUGS)

COMPRO RECTAL SUPPOSITORY 25 MG 1


Meclizine HCl Oral Tablet 12.5 MG, 25 MG 1

Meclizine HCl Oral Tablet Chewable 25 MG 1

Prochlorperazine Maleate Oral Tablet 10 MG, 5 MG 1 PA

Prochlorperazine Rectal Suppository 25 MG 1

90

Drug Name Tier NotesANTI-INFLAMMATORY AGENTS (GI DRUGS)

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

1

Balsalazide Disodium Oral Capsule 750 MG 1

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

1

DIPENTUM ORAL CAPSULE 250 MG 1

Mesalamine Oral Tablet Delayed Release 800 MG 1

Mesalamine Rectal Enema 4 GM 1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

1

SFROWASA RECTAL ENEMA 4 GM/60ML 1




CATHARTICS AND LAXATIVES

Castor Oil Oil 1



CITRANATAL HARMONY ORAL CAPSULE 27-1-260 MG

1


Docusate Sodium Powder 1

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM

1

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

1

Mineral Oil Heavy Oral Oil 1

PEG 3350-KCl-Na Bicarb-NaCl Oral Solution Reconstituted 420 GM 1



Polyethylene Glycol 3350 Oral Packet 1

Polyethylene Glycol 3350 Oral Powder 1



91

Drug Name Tier NotesTARON-PREX ORAL CAPSULE 30-1.2-265 MG

1





1

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

1

CHOLELITHOLYTIC AGENTS

Ursodiol Oral Capsule 300 MG 1

Ursodiol Oral Tablet 250 MG, 500 MG 1

DIGESTANTS

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

1

GI DRUGS, MISCELLANEOUS

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML


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


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML


92

Drug Name Tier NotesLINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

1

MOVANTIK ORAL TABLET 12.5 MG, 25 MG 1

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1 PA; SPN

HISTAMINE H2-ANTAGONISTS

Cimetidine HCl Oral Solution 300 MG/5ML 1

Cimetidine Oral Tablet 200 MG, 300 MG, 400 MG, 800 MG 1

Famotidine Intravenous Solution 20 MG/2ML 1

Famotidine Oral Tablet 20 MG, 40 MG 1

Famotidine Premixed Intravenous Solution 20-0.9 MG/50ML-% 1

PEPCID ORAL TABLET 20 MG 1

Ranitidine HCl Oral Capsule 150 MG, 300 MG 1

Ranitidine HCl Oral Syrup 15 MG/ML, 150 MG/10ML, 75 MG/5ML 1

RaNITidine HCl Oral Tablet 150 MG, 300 MG 1

ZANTAC ORAL TABLET 150 MG 1

PROKINETIC AGENTS

Metoclopramide HCl Oral Solution 10 MG/10ML, 5 MG/5ML 1

Metoclopramide HCl Oral Tablet 10 MG, 5 MG 1

PROSTAGLANDINS

Misoprostol Oral Tablet 100 MCG, 200 MCG 1

PROTECTANTS

CARAFATE ORAL SUSPENSION 1 GM/10ML 1

Sucralfate Oral Tablet 1 GM 1

PROTON-PUMP INHIBITORS


Lansoprazole Oral Capsule Delayed Release 15 MG, 30 MG 1 QL (60 EA per 30 days)

NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG


Omeprazole Oral Capsule Delayed Release 10 MG, 20 MG, 40 MG 1 QL (60 EA per 30 days)

Pantoprazole Sodium Oral Tablet Delayed Release 20 MG, 40 MG 1 QL (60 EA per 30 days)

93

Drug Name Tier NotesPREVACID ORAL CAPSULE DELAYED RELEASE 15 MG


GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA ORAL CAPSULE 3 MG 1

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CHEMET ORAL CAPSULE 100 MG 1

DEPEN TITRATABS ORAL TABLET 250 MG 1 PA; SPN

GALZIN ORAL CAPSULE 25 MG, 50 MG 1

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS



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

1

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




ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH






Betamethasone Powder 1


1

Budesonide Inhalation Suspension 0.25 MG/2ML, 0.5 MG/2ML 1 QL (120 ML per 30 days)

Budesonide Inhalation Suspension 1 MG/2ML 1 QL (60 ML per 30 days)

Cortisone Acetate Oral Tablet 25 MG 1

94

Drug Name Tier NotesDELTASONE ORAL TABLET 20 MG 1

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

1

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

1

Dexamethasone Oral Elixir 0.5 MG/5ML 1

Dexamethasone Oral Solution 0.5 MG/5ML 1

Dexamethasone Oral Tablet 0.5 MG, 0.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 MG 1

Dexamethasone Oral Tablet Therapy Pack 1.5 MG (21), 1.5 MG (35), 1.5 MG (51) 1

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


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT






Fludrocortisone Acetate Oral Tablet 0.1 MG 1

Hydrocortisone Oral Tablet 10 MG, 20 MG, 5 MG 1

MEDROL ORAL TABLET 2 MG 1

MethylPREDNISolone Acetate Injection Suspension 40 MG/ML, 50 MG/ML, 80 MG/ML

1

MethylPREDNISolone Oral Tablet 16 MG, 32 MG, 4 MG, 8 MG 1

MethylPREDNISolone Oral Tablet Therapy Pack 4 MG 1

MethylPREDNISolone Sodium Succ Injection Solution Reconstituted 1000 MG, 125 MG, 40 MG

1

MILLIPRED ORAL TABLET 5 MG 1

PrednisoLONE Oral Solution 15 MG/5ML 1

PrednisoLONE Oral Syrup 15 MG/5ML 1

PrednisoLONE Sodium Phosphate Oral Solution 15 MG/5ML, 6.7 (5 Base) MG/5ML 1

95

Drug Name Tier NotesPREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

1

PredniSONE Oral Solution 5 MG/5ML 1

PredniSONE Oral Tablet 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50 MG 1

PredniSONE Oral Tablet Therapy Pack 10 MG (21), 10 MG (48), 5 MG (21), 5 MG (48) 1

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

1

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

1

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG

1

Triamcinolone Diacet Micronize Powder 1

Triamcinolone Diacetate Powder 1

ALPHA-GLUCOSIDASE INHIBITORS

Acarbose Oral Tablet 100 MG, 25 MG, 50 MG 1

Miglitol Oral Tablet 100 MG, 25 MG, 50 MG 1

ANDROGENS

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR

1

COVARYX ORAL TABLET 1.25-2.5 MG 1

Danazol Oral Capsule 100 MG, 200 MG, 50 MG 1

EEMT ORAL TABLET 1.25-2.5 MG 1

Est Estrogens-Methyltest DS Oral Tablet 1.25-2.5 MG 1

Est Estrogens-Methyltest Oral Tablet 1.25-2.5 MG 1

Methitest Oral Tablet 10 MG 1

MethylTESTOSTERone Oral Capsule 10 MG 1

STRIANT BUCCAL 30 MG 1

Testosterone Cypionate Intramuscular Solution 100 MG/ML, 200 MG/ML 1

Testosterone Enanthate Intramuscular Solution 200 MG/ML 1

Testosterone Propionate Powder 1

ANTIESTROGENS

Anastrozole Oral Tablet 1 MG 1

Letrozole Oral Tablet 2.5 MG 1

96

Drug Name Tier NotesANTIPARATHYROID AGENTS

Calcitonin (Salmon) Nasal Solution 200 UNIT/ACT 1 SPN

ANTITHYROID AGENTS

MethIMAzole Oral Tablet 10 MG, 5 MG 1

Propylthiouracil Oral Tablet 50 MG 1


BIGUANIDES

Alogliptin-Metformin HCl Oral Tablet 12.5-1000 MG, 12.5-500 MG 1 ST; QL (60 EA per 30 days)

GlipiZIDE-MetFORMIN HCl Oral Tablet 2.5-500 MG, 5-500 MG 1

GlyBURIDE-MetFORMIN Oral Tablet 1.25-250 MG, 2.5-500 MG, 5-500 MG 1 90

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG


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


MetFORMIN HCl ER Oral Tablet Extended Release 24 Hour 500 MG, 750 MG 1 90

MetFORMIN HCl Oral Tablet 1000 MG, 500 MG, 850 MG 1 90

Pioglitazone HCl-Metformin HCl Oral Tablet15-500 MG, 15-850 MG 1 QL (90 EA per 30 days)

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


SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG


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


CONTRACEPTIVES

ALTAVERA ORAL TABLET 0.15-30 MG-MCG

1

Alyacen 1/35 Oral Tablet 1-35 MG-MCG 1

Alyacen 7/7/7 Oral Tablet 0.5/0.75/1-35 MG-MCG 1

APRI ORAL TABLET 0.15-30 MG-MCG 1

AUBRA ORAL TABLET 0.1-20 MG-MCG 1

AVIANE ORAL TABLET 0.1-20 MG-MCG 1

97

Drug Name Tier NotesAZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

1

BALZIVA ORAL TABLET 0.4-35 MG-MCG 1

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

1

BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24)

1

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG

1

Briellyn Oral Tablet 0.4-35 MG-MCG 1

CAMILA ORAL TABLET 0.35 MG 1

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG

1

CESIA ORAL TABLET 0.1/0.125/0.15 -0.025 MG

1

CHATEAL ORAL TABLET 0.15-30 MG-MCG 1

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

1

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

1

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

CYRED ORAL TABLET 0.15-30 MG-MCG 1

DASETTA 1/35 ORAL TABLET 1-35 MG-MCG

1

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

DEBLITANE ORAL TABLET 0.35 MG 1

DELYLA ORAL TABLET 0.1-20 MG-MCG 1

Desogestrel-Ethinyl Estradiol Oral Tablet0.15-0.02/0.01 MG (21/5), 0.15-30 MG-MCG 1

ELINEST ORAL TABLET 0.3-30 MG-MCG 1

ELLA ORAL TABLET 30 MG 1

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

1

ENPRESSE-28 ORAL TABLET 1

ENSKYCE ORAL TABLET 0.15-30 MG-MCG 1

ERRIN ORAL TABLET 0.35 MG 1

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

1

98

Drug Name Tier NotesEthynodiol Diac-Eth Estradiol Oral Tablet 1-35 MG-MCG, 1-50 MG-MCG 1

FALMINA ORAL TABLET 0.1-20 MG-MCG 1

FEMYNOR ORAL TABLET 0.25-35 MG-MCG 1

GILDESS FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG

1

HEATHER ORAL TABLET 0.35 MG 1

INTROVALE ORAL TABLET 0.15-0.03 MG 1

ISIBLOOM ORAL TABLET 0.15-30 MG-MCG 1

JENCYCLA ORAL TABLET 0.35 MG 1

JOLESSA ORAL TABLET 0.15-0.03 MG 1

JOLIVETTE ORAL TABLET 0.35 MG 1

JULEBER ORAL TABLET 0.15-30 MG-MCG 1

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

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

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

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

JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24)

1

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

1

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG 1

KURVELO ORAL TABLET 0.15-30 MG-MCG 1

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

LARIN 1/20 ORAL TABLET 1-20 MG-MCG 1

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

1

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG 1

LARISSIA ORAL TABLET 0.1-20 MG-MCG 1

LESSINA ORAL TABLET 0.1-20 MG-MCG 1

LEVONEST ORAL TABLET 1

Levonorgest-Eth Estrad 91-Day Oral Tablet0.15-0.03 MG 1

Levonorgestrel Oral Tablet 1.5 MG 1 QL (1 EA per 30 days)

99

Drug Name Tier NotesLevonorgestrel-Ethinyl Estrad Oral Tablet0.1-20 MG-MCG, 0.15-30 MG-MCG 1

Levonorg-Eth Estrad Triphasic Oral Tablet 1

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

1

LILLOW ORAL TABLET 0.15-30 MG-MCG 1

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG

1

LUTERA ORAL TABLET 0.1-20 MG-MCG 1

LYZA ORAL TABLET 0.35 MG 1

Marlissa Oral Tablet 0.15-30 MG-MCG 1

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

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

1

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

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

1

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG

1

MONONESSA ORAL TABLET 0.25-35 MG-MCG

1

MYZILRA ORAL TABLET 1

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

1

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

1

NORA-BE ORAL TABLET 0.35 MG 1

Norethin Ace-Eth Estrad-FE Oral Tablet 1-20 MG-MCG, 1-20 MG-MCG(24) 1

Norethindrone Acet-Ethinyl Est Oral Tablet 1-20 MG-MCG 1

Norethindrone Oral Tablet 0.35 MG 1

Norgestimate-Eth Estradiol Oral Tablet 0.25-35 MG-MCG 1

Norgestim-Eth Estrad Triphasic Oral Tablet0.18/0.215/0.25 MG-35 MCG 1

NORLYDA ORAL TABLET 0.35 MG 1

NORLYROC ORAL TABLET 0.35 MG 1

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

1

100

Drug Name Tier NotesNORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

1

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

1

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

1

NUVARING VAGINAL RING 0.12-0.015 MG/24HR


OGESTREL ORAL TABLET 0.5-50 MG-MCG 1

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 1

PHILITH ORAL TABLET 0.4-35 MG-MCG 1

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

1

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG

1

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG 1

PREVIFEM ORAL TABLET 0.25-35 MG-MCG 1

QUASENSE ORAL TABLET 0.15-0.03 MG 1

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG

1

SETLAKIN ORAL TABLET 0.15-0.03 MG 1

SHAROBEL ORAL TABLET 0.35 MG 1

SOLIA ORAL TABLET 0.15-30 MG-MCG 1

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

1

SRONYX ORAL TABLET 0.1-20 MG-MCG 1

TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG

1

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

1

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

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

1

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

101

Drug Name Tier NotesTRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRIVORA (28) ORAL TABLET 1

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

1

VIENVA ORAL TABLET 0.1-20 MG-MCG 1

Viorele Oral Tablet 0.15-0.02/0.01 MG (21/5) 1

VYFEMLA ORAL TABLET 0.4-35 MG-MCG 1

WERA ORAL TABLET 0.5-35 MG-MCG 1

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

1

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

Alogliptin Benzoate Oral Tablet 12.5 MG, 25 MG, 6.25 MG 1 ST; QL (30 EA per 30 days)

Alogliptin-Metformin HCl Oral Tablet 12.5-1000 MG, 12.5-500 MG 1 ST; QL (60 EA per 30 days)

Alogliptin-Pioglitazone Oral Tablet 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG


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


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


ESTROGEN AGONIST-ANTAGONISTS

FARESTON ORAL TABLET 60 MG 1

Raloxifene HCl Oral Tablet 60 MG 1

Tamoxifen Citrate Oral Tablet 10 MG, 20 MG 1

ESTROGENS

ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

1

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

1

COVARYX ORAL TABLET 1.25-2.5 MG 1

102

Drug Name Tier NotesEEMT ORAL TABLET 1.25-2.5 MG 1

Est Estrogens-Methyltest DS Oral Tablet 1.25-2.5 MG 1

Est Estrogens-Methyltest Oral Tablet 1.25-2.5 MG 1

Estradiol Oral Tablet 0.5 MG, 1 MG, 2 MG 1

Estradiol Transdermal Patch Twice Weekly0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

1

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

1

ESTRING VAGINAL RING 2 MG 1

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG, 1-5 MG-MCG

1

Jevantique Lo Oral Tablet 0.5-2.5 MG-MCG 1

JINTELI ORAL TABLET 1-5 MG-MCG 1

MENEST ORAL TABLET 0.3 MG, 1.25 MG 1

MENEST ORAL TABLET 0.625 MG 1 QL (60 EA per 30 days)

Norethindrone-Eth Estradiol Oral Tablet 0.5-2.5 MG-MCG, 1-5 MG-MCG 1

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG


PREMARIN VAGINAL CREAM 0.625 MG/GM 1 QL (30 GM per 30 days)

PREMPHASE ORAL TABLET 0.625-5 MG 1

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

1

GLYCOGENOLYTIC AGENTS

GLUCAGON EMERGENCY INJECTION KIT 1 MG


GONADOTROPINS


Leuprolide Acetate Powder 1 SPN









103

Drug Name Tier NotesLUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG




SYNAREL NASAL SOLUTION 2 MG/ML 1 SPN

GONADOTROPINS AND ANTIGONADOTROPINS










LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG




SYNAREL NASAL SOLUTION 2 MG/ML 1 SPN

INCRETIN MIMETICS

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE, 1 MG/DOSE

1 ST

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML

1 ST; QL (9 ML per 30 days)

INSULINS

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML


BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


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


104

Drug Name Tier NotesHUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML




HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML


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


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


TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML


LONG-ACTING INSULINS

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


TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML


MEGLITINIDES

Repaglinide Oral Tablet 0.5 MG, 1 MG, 2 MG 1

PARATHYROID AND ANTIPARATHYROID AGENTS


PITUITARY

DDAVP RHINAL TUBE NASAL SOLUTION 0.01 %

1

Desmopressin Ace Spray Refrig Nasal Solution0.01 % 1

Desmopressin Acetate Injection Solution 4 MCG/ML 1

Desmopressin Acetate Oral Tablet 0.1 MG, 0.2 MG 1

Desmopressin Acetate Spray Nasal Solution0.01 % 1

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

1 PA; SPN

105

Drug Name Tier NotesPROGESTINS

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

1

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG, 1-5 MG-MCG

1

Hydroxyprogesterone Caproate Intramuscular Solution 1.25 GM/5ML 1 PA

Hydroxyprogesterone Caproate Powder 1 PA

Jevantique Lo Oral Tablet 0.5-2.5 MG-MCG 1

JINTELI ORAL TABLET 1-5 MG-MCG 1

MAKENA INTRAMUSCULAR OIL 250 MG/ML

1 PA; SPN

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML

1 PA; SPN

MedroxyPROGESTERone Acetate Intramuscular Suspension 150 MG/ML 1 QL (1 ML per 90 days)

MedroxyPROGESTERone Acetate Intramuscular Suspension Prefilled Syringe150 MG/ML


MedroxyPROGESTERone Acetate Oral Tablet 10 MG, 2.5 MG, 5 MG 1

Megestrol Acetate Oral Suspension 40 MG/ML, 400 MG/10ML 1

Megestrol Acetate Oral Tablet 20 MG, 40 MG 1

Norethindrone Acetate Oral Tablet 5 MG 1

Norethindrone-Eth Estradiol Oral Tablet 0.5-2.5 MG-MCG, 1-5 MG-MCG 1

Progesterone Intramuscular Oil 50 MG/ML 1

RAPID-ACTING INSULINS

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML








106

Drug Name Tier NotesHUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML


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


SHORT-ACTING INSULINS

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML


SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

JARDIANCE ORAL TABLET 10 MG, 25 MG 1 ST; QL (30 EA per 30 days)

STEGLATRO ORAL TABLET 15 MG, 5 MG 1 ST; QL (30 EA per 30 days)

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG


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


SOMATOSTATIN AGONISTS

Octreotide Acetate Injection Solution 100 MCG/ML, 1000 MCG/ML, 200 MCG/ML, 50 MCG/ML, 500 MCG/ML

1

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

1 PA; SPN

SULFONYLUREAS

Glimepiride Oral Tablet 1 MG, 2 MG 1 90; QL (60 EA per 30 days)

Glimepiride Oral Tablet 4 MG 1 90

GlipiZIDE ER Oral Tablet Extended Release 24 Hour 10 MG, 2.5 MG, 5 MG 1 90; QL (30 EA per 30 days)

GlipiZIDE Oral Tablet 10 MG, 5 MG 1 90

GlipiZIDE XL Oral Tablet Extended Release 24 Hour 10 MG, 2.5 MG, 5 MG 1 90; QL (30 EA per 30 days)

GlipiZIDE-MetFORMIN HCl Oral Tablet 2.5-500 MG, 5-500 MG 1

GlyBURIDE Micronized Oral Tablet 1.5 MG, 3 MG, 6 MG 1 90

GlyBURIDE Oral Tablet 1.25 MG, 2.5 MG, 5 MG 1 90

GlyBURIDE-MetFORMIN Oral Tablet 1.25-250 MG, 2.5-500 MG, 5-500 MG 1 90

107

Drug Name Tier NotesPioglitazone HCl-Glimepiride Oral Tablet 30-2 MG, 30-4 MG 1 QL (30 EA per 30 days)

THIAZOLIDINEDIONES

Alogliptin-Pioglitazone Oral Tablet 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


AVANDIA ORAL TABLET 2 MG, 4 MG 1 QL (30 EA per 30 days)

Pioglitazone HCl Oral Tablet 15 MG 1 90; QL (60 EA per 30 days)

Pioglitazone HCl Oral Tablet 30 MG, 45 MG 1 90; QL (30 EA per 30 days)

Pioglitazone HCl-Glimepiride Oral Tablet 30-2 MG, 30-4 MG 1 QL (30 EA per 30 days)

Pioglitazone HCl-Metformin HCl Oral Tablet15-500 MG, 15-850 MG 1 QL (90 EA per 30 days)

THYROID AGENTS

LEVO-T 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

1 90

Levothyroxine Sodium Intravenous Solution Reconstituted 200 MCG, 500 MCG 1 90

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

1 90

Levothyroxine-Liothyronine Oral Tablet 30 MG, 60 MG, 90 MG 1

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

1 90

Liothyronine Sodium Oral Tablet 25 MCG, 5 MCG, 50 MCG 1

NP Thyroid Oral Tablet 120 MG, 15 MG, 30 MG, 60 MG, 90 MG 1

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

1 90

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)

1

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)

1

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)

1

108

Drug Name Tier NotesTHYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)

1

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)

1

UNITHROID 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

1 90

LOCAL ANESTHETICS (PARENTERAL)

LOCAL ANESTHETICS (PARENTERAL)

Lidocaine Crystals 1

Lidocaine HCl (PF) Injection Solution 0.5 %, 1 %, 2 %, 4 % 1

Lidocaine HCl Injection Solution 0.5 %, 1 %, 2 % 1

Lidocaine HCl Monohydrate Powder 1

Lidocaine HCl Powder 1

Lidocaine Powder 1

Tetracaine HCl Powder 1

Tetracaine Powder 1

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

Dutasteride Oral Capsule 0.5 MG 1

Finasteride Oral Tablet 5 MG 1

ALCOHOL DETERRENTS

Disulfiram Oral Tablet 250 MG, 500 MG 1

Naltrexone HCl Oral Tablet 50 MG 1

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG


ANTIDOTES

CHEMET ORAL CAPSULE 100 MG 1

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

1

GLUCAGON EMERGENCY INJECTION KIT 1 MG


KIONEX ORAL SUSPENSION 15 GM/60ML 1

Leucovorin Calcium Injection Solution Reconstituted 500 MG 1 PA

Leucovorin Calcium Oral Tablet 10 MG, 15 MG, 25 MG, 5 MG 1

109

Drug Name Tier NotesNaloxone HCl Injection Solution 0.4 MG/ML, 4 MG/10ML 1

Naloxone HCl Injection Solution Cartridge 0.4 MG/ML 1

Naloxone HCl Injection Solution Prefilled Syringe 2 MG/2ML 1

NARCAN NASAL LIQUID 4 MG/0.1ML 1

RENAGEL ORAL TABLET 800 MG 1

Sevelamer Carbonate Oral Tablet 800 MG 1

Sodium Polystyrene Sulfonate Oral Powder 1

Sodium Polystyrene Sulfonate Oral Suspension15 GM/60ML 1

Sodium Polystyrene Sulfonate Rectal Suspension 30 GM/120ML, 50 GM/200ML 1

SPS ORAL SUSPENSION 15 GM/60ML 1


Toluidine Blue O Powder 1

ANTIGOUT AGENTS

Allopurinol Oral Tablet 100 MG, 300 MG 1 90

Colchicine Oral Tablet 0.6 MG 1

Indomethacin ER Oral Capsule Extended Release 75 MG 1

Indomethacin Oral Capsule 25 MG, 50 MG 1

Naproxen DR Oral Tablet Delayed Release 375 MG, 500 MG 1

Naproxen Oral Suspension 125 MG/5ML 1

Naproxen Oral Tablet 250 MG, 375 MG, 500 MG 1

Naproxen Sodium Oral Tablet 275 MG, 550 MG 1

Probenecid Oral Tablet 500 MG 1

BONE RESORPTION INHIBITORS

Alendronate Sodium Oral Tablet 10 MG, 35 MG, 40 MG, 5 MG, 70 MG 1 90


Etidronate Disodium Oral Tablet 200 MG, 400 MG 1

PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML

1 PA; SPN

Raloxifene HCl Oral Tablet 60 MG 1

110

Drug Name Tier NotesRisedronate Sodium Oral Tablet 150 MG, 30 MG, 35 MG, 5 MG 1

Zoledronic Acid Intravenous Concentrate 4 MG/5ML 1 SPN

CARIOSTATIC AGENTS

CAVAREST DENTAL GEL 1.1 % 1

DENTA 5000 PLUS DENTAL CREAM 1.1 % 1

DENTAGEL DENTAL GEL 1.1 % 1

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

1

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

1

Fluoritab Oral Solution 0.275 (0.125 F) MG/DROP 1

Fluoritab Oral Tablet Chewable 1.1 (0.5 F) MG, 2.2 (1 F) MG 1

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

1

LUDENT ORAL TABLET CHEWABLE 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG

1

Multi-Vit/Fluoride Oral Solution 0.25 MG/ML 1


Multivitamin/Fluoride Oral Solution 0.25 MG/ML, 0.5 MG/ML 1

Multi-Vitamin/Fluoride Oral Solution 0.25 MG/ML, 0.5 MG/ML 1

Multivitamin/Fluoride Oral Tablet Chewable0.25 MG, 0.5 MG, 1 MG 1

Multivitamin/Fluoride/Iron Oral Solution0.25-10 MG/ML 1


Multivitamins/Fluoride Oral Tablet Chewable0.5 MG 1

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML

1

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

SF 5000 Plus Dental Cream 1.1 % 1

SF Dental Gel 1.1 % 1

111

Drug Name Tier NotesSodium Fluoride Oral Solution 1.1 (0.5 F) MG/ML 1

Sodium Fluoride Oral Tablet 1.1 (0.5 F) MG, 2.2 (1 F) MG 1

Sodium Fluoride Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG 1

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

AzaTHIOprine Oral Tablet 50 MG 1 SPN

AzaTHIOprine Powder 1 SPN

CycloSPORINE Modified Oral Capsule 100 MG, 25 MG, 50 MG 1 SPN

CycloSPORINE Modified Oral Solution 100 MG/ML 1 SPN

CycloSPORINE Oral Capsule 100 MG, 25 MG 1 SPN

DEPEN TITRATABS ORAL TABLET 250 MG 1 PA; SPN

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML


GENGRAF ORAL CAPSULE 100 MG, 25 MG 1 SPN

GENGRAF ORAL SOLUTION 100 MG/ML 1 SPN


Leflunomide Oral Tablet 10 MG 1 QL (60 EA per 30 days)






NEORAL ORAL CAPSULE 100 MG, 25 MG 1 SPN

NEORAL ORAL SOLUTION 100 MG/ML 1 SPN

112

Drug Name Tier NotesREMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1 PA; SPN


SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

1 SPN

SANDIMMUNE ORAL SOLUTION 100 MG/ML

1 SPN





1

IMMUNOMODULATORY AGENTS

AVONEX INTRAMUSCULAR KIT 30 MCG 1 PA; SPN; QL (4 EA per 30 days)

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML


AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

1 PA; SPN



COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML

















GILENYA ORAL CAPSULE 0.5 MG 1 PA; SPN; QL (30 EA per 30 days)

113

Drug Name Tier NotesGlatiramer Acetate Subcutaneous Solution Prefilled Syringe 20 MG/ML 1 PA; QL (30 ML per 30 days)

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML












1 PA; SPN



1 SPN


1 SPN




TECFIDERA ORAL 120 & 240 MG 1 PA; SPN; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG


TECFIDERA ORAL CAPSULE DELAYED RELEASE 240 MG



1

XELJANZ ORAL TABLET 10 MG, 5 MG 1 PA; SPN; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG


IMMUNOSUPPRESSIVE AGENTS



114

Drug Name Tier NotesCyclophosphamide Oral Capsule 25 MG, 50 MG 1 PA






Mercaptopurine Oral Tablet 50 MG 1





Mycophenolate Mofetil Oral Capsule 250 MG 1 SPN

Mycophenolate Mofetil Oral Suspension Reconstituted 200 MG/ML 1 SPN

Mycophenolate Mofetil Oral Tablet 500 MG 1 SPN



PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

1 SPN

RAPAMUNE ORAL SOLUTION 1 MG/ML 1 SPN


1 SPN


1 SPN

Sirolimus Oral Tablet 0.5 MG, 1 MG, 2 MG 1 SPN

Tacrolimus Oral Capsule 0.5 MG, 1 MG, 5 MG 1 SPN


1

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

Acetylcysteine Inhalation Solution 10 %, 20 % 1

AP-Zel Oral Tablet 1

BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT

1 PA; SPN

115

Drug Name Tier NotesBOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

1 PA; SPN

CERDELGA ORAL CAPSULE 84 MG 1 PA; SPN; QL (60 EA per 30 days)

DEMSER ORAL CAPSULE 250 MG 1

EVOTAZ ORAL TABLET 300-150 MG 1 SPN; QL (30 EA per 30 days)

LevOCARNitine Oral Solution 1 GM/10ML 1

LevOCARNitine Oral Tablet 330 MG 1

NICADAN ORAL TABLET 1

NICAZEL FORTE ORAL TABLET 1

NICAZEL ORAL TABLET 1

Octreotide Acetate Injection Solution 100 MCG/ML, 1000 MCG/ML, 200 MCG/ML, 50 MCG/ML, 500 MCG/ML

1

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

1 SPN

PREZCOBIX ORAL TABLET 800-150 MG 1 SPN


1 PA; SPN

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

1 PA; SPN

PROTECTIVE AGENTS

ELMIRON ORAL CAPSULE 100 MG 1

MESNEX ORAL TABLET 400 MG 1 SPN

NON-FRF

NON-FRF

ACCU-CHEK RAPID-D LINK 1

ACCU-CHEK SPIRIT CARTRIDGE 1

ACCU-CHEK ULTRAFLEX-1 INF SET 1

ADRENAL C FORMULA ORAL TABLET 1

Advanced Base Plus External Cream 1

ALLEVYN AG GENTLE BORDER EXTERNAL PAD

1

ALLEVYN AG NON-ADHESIVE EXTERNAL PAD

1

ALLEVYN AG SACRUM EXTERNAL PAD 1

ALLEVYN GENTLE EXTERNAL PAD 1

AMINOPMRMS ORAL CAPSULE 1

Anesthesia Needle 23Gx1-3/8" 1

Antibiotic Ear Otic Solution 3.5-10000-1 1

116

Drug Name Tier NotesARGYLE EXTENSION TUBE 20" 1

ASILNASAL RMS ORAL CAPSULE 1

ATREVIS HYDROGEL EXTERNAL CREAM 1

Bacon Flavor Liquid 1

BD OSGOOD BIOPSY NEEDLE 18G X 1" 1

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML

1

Beef Flavor Liquid 1

Beef Type Flavor Natural Liquid 1

Bio-Statin Oral Powder 1

Chicken Flavor Oil Soluble Liquid 1

Chicken Flavor Water Miscible Liquid 1

Clear Glass Vials 5ml 1

Clotrimazole Vaginal Cream 2 % 1

CORNWALL SYR PIPET OUTFIT 10ML 1




DiazePAM Oral Solution 5 MG/5ML 1

Diphenatol Oral Tablet 2.5-0.025 MG 1

EASYGEL DENTAL GEL 0.4 % 1

Erythromycin Stearate Oral Tablet 250 MG 1

Essentra Wipes 9x9" External 70 % 1

Fish Flavor Liquid 1

Fluoritab Oral Tablet Chewable 0.55 (0.25 F) MG 1

GLUCOPRO SYR RES 3ML 22GX3/8" 1

Glycerine Liquid 1

GUAIFENEX LA ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG

1

Ham Flavor Liquid 1

Hemocyte-Plus Oral Tablet 106-1 MG 1

Heparin (Porcine) in NaCl Intravenous Solution Prefilled Syringe 50-0.9 UNT/50ML-%

1

HYDROFERA BLUE READY FOAM EXTERNAL PAD

1

Infusion Needle 15Gx2" 1

Infusion Set 23" 1

Infusion Set 23" 10MM 1

117

Drug Name Tier NotesInfusion Set 23" 8MM 1




Infusion Set 43" 1


KANGAROO BURETTE SET 1

KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD

1


1


1

Liver Flavor Liquid 1

LLX EXTENSION NEEDLE 1

MINIMED PRO-SET INFUSION 24" 1

MINIMED PRO-SET INFUSION 42" 1

MONOJECT BLUNTIP SYR/CANNULA 3 ML , 6 ML

1

MONOJECT CONTROL SYRINGE 20 ML 1

MONOJECT HYPODERMIC NEEDLE TIP 1

MONOJECT LIFESHIELD SYRINGE 18G X 1" 12 ML

1

MONOJECT MAGELLAN SAFETY NDL 18G X 1" , 18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 20G X 1" , 20G X 1-1/2" , 21G X 1" , 21G X 1-1/2" , 22G X 1" , 22G X 1-1/2" , 23G X 1" , 23G X 5/8" , 25G X 1" , 25G X 5/8"

1

MONOJECT MAGELLAN SYRINGE 18G X 1" 12 ML, 18G X 1" 6 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 3 ML, 22G X 1-1/2" 6 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 5/8" 3 ML

1

MONOJECT MED PREP CANNULA 1

Morphine Sulfate (Concentrate) Oral Solution10 MG/0.5ML 1 QL (1000 EA per 30 days)

Multi Vit/Fl Oral Tablet Chewable 0.25 MG 1

Multiple Vitamins/Fluoride Oral Tablet Chewable 1 MG 1

118

Drug Name Tier NotesMult-Vitamin/Fluoride Oral Tablet Chewable0.5 MG 1

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP

1

NAFRINSE ORAL TABLET CHEWABLE 2.2 (1 F) MG

1

Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 0.1 % 1

NUTRIFAC ZX ORAL TABLET 1

OxyCODONE HCl Oral Concentrate 10 MG/0.5ML 1 QL (1000 EA per 30 days)

PenSomal External Cream 1

Pentaphene Base External Cream 1

PHASEAL CAP FOR INJECTOR 1

PHASEAL IV BAG HANGER 1

PHASEAL SYRINGE TRAY 1

Polyvitamin/Fluoride Oral Solution 0.25 MG/ML 1

Poly-Vitamin/Fluoride Oral Solution 0.5 MG/ML 1

Polyvitamin/Fluoride Oral Tablet Chewable0.5 MG 1

Premium Lidocaine External Ointment 5 % 1 QL (180 GM per 30 days)

PRENATAL/FOLIC ACID ORAL TABLET 1

Pro Comfort Pen Needles 31G X 8 MM , 32G X 4 MM 1

PROCTOCARE-HC RECTAL CREAM 2.5 % 1

P-Siloxan DS External Cream 1

Reusable Syringe Barrel 1.5oz 1

Reusable Syringe Barrel 1oz 1




ROBB-TYPE ANGIO SYRINGE 80CC 1

RTD WOUND CARE DRESSING EXTERNAL PAD

1

Shrimp Flavor Liquid 1

Silprotex Plus External Cream 1

Solvatech Sweet SF Oral Syrup 1

Sucralfate Oral Suspension 1 GM/10ML 1

119

Drug Name Tier NotesSulfacetamide-Prednisolone Ophthalmic Suspension 10-0.2 % 1

Syringe Caps 1

Syringe Filter 0.2 Micron/32mm 1

Syringe Filter 0.45 Micron 1

Syringe Filter/0.2 Micron/25mm 1

Syringe Filter/0.2 Micron/30mm 1

Syringe Filter/Millex/25mm 1

Syringe Filter/Millex-GV/33mm 1


1


1


1

THERAHONEY EXTERNAL GEL 1

Tightening Base External Cream 1

TOPEX TOPICAL ANESTHETIC MOUTH/THROAT AEROSOL 20 %

1

ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML

1

UNITHROID 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

1

Vacuum Filter 0.20um/150ml 1

Vial Stopper 1

Vita-Min Oral Capsule 1

VITAROCA PLUS ORAL TABLET 1

VP DermaBase External Cream 1

XERALUX EXTERNAL CREAM 1

OXYTOCICS

OXYTOCICS

METHERGINE ORAL TABLET 0.2 MG 1

PHARMACEUTICAL AIDS

PHARMACEUTICAL AIDS

1st Base External Cream 1

5-Hydroxy-L-Tryptophan Powder 1


ALBA-DERM EXTERNAL CREAM 1

120

Drug Name Tier NotesAllantoin Powder 1

Almond Oil Bitter Flavor Liquid 1

ALTADERM EXTERNAL CREAM 1

Ammonium Lactate Solution 70 % 1

Anise Extract Liquid 1

APOTHESAR 2 EXTERNAL CREAM 1

Apothesar Plus External Cream 1

APOTHESIL EXTERNAL CREAM 1

Apple Flavor Liquid 1

Apricot Flavor Liquid 1

AUXIPRO VANISHING EXTERNAL CREAM 1

Banana Concentrate Liquid 1

Banana Cream Flavor Liquid 1

Banana Creme Flavor Liquid 1

Banana Flavor Liquid 1

Base W301 External Cream 1

Benzethonium Chloride Powder 1

Benzoic Acid Crystals 1

Benzoic Acid Powder 1

Benzoin Compound External Tincture 1

Benzoin External Tincture 1

Biotin Powder 1

Bitter Stop Flavor Liquid 1

Bitterness Mask Flavor Liquid 1

Bitterness Suppressor Flavor Liquid 1

Blackberry Flavor Liquid 1

Blueberry Flavor Liquid 1

Bubble Gum Concentrate Liquid 1

Bubble Gum Flavor Liquid 1

Butter Flavor Liquid 1

Butter Rum Flavor Liquid 1

Butterscotch Flavor Liquid 1

Caramel Flavor Liquid 1

CARRASYN HYDROGEL WOUND DRESS EXTERNAL GEL

1

Cela Base External Cream 1

Cheesecake Flavor Liquid 1

Cherry Flavor Liquid 1

121

Drug Name Tier NotesCherry Oral Syrup 1

Chlorobutanol Anhydrous Powder 1

Chlorobutanol Hemihydrate Powder 1

Chlorobutanol Powder 1

Chloroxylenol Powder 1

Chocolate Flavor Liquid 1

Chocolate Hazelnut Flavor Liquid 1

CHRYSADERM DAY EXTERNAL CREAM 1

CHRYSADERM NIGHT EXTERNAL CREAM 1

Coconut Flavor Liquid 1

Coffee Flavor Liquid 1

Cola Flavor Liquid 1

Cotton Candy Flavor Liquid 1

Cran-Raspberry Flavor Liquid 1

Cream Base External Cream 1

Cream Concentrate External Cream 1

Creme DeMenthe Flavor Liquid 1

Cutis Plus External Cream 1

DIAB EXTERNAL GEL 1

DIAB F.D.G. FREEZE-DRIED EXTERNAL GEL

1

EMOLIVAN EXTERNAL CREAM 1

Emollient Base External Cream 1

English Toffee Flavor Liquid 1

Eugenol Flavor Liquid 1

Fagron LS Plus External Cream 1

Fagron Natural External Cream 1

Fagron Supreme External Cream 1

FD&C Yellow #5 Powder 1

FD&C Yellow #6 Aluminum Lake Powder 1

FDC Yellow 6 Powder 1

Ferric Ammonium Citrate Powder 1

Ferric Chloride Hexahydrate 1

FITALITE EXTERNAL CREAM 1

Flavor Plus Oral Liquid 1

Flavor Sweet Oral Syrup 1

Flavor Sweet-SF Oral Syrup 1

Food Color Orange Powder 1

122

Drug Name Tier NotesFood Color Yellow Powder 1

Freedom AdaptaDerm External Cream 1

Freedom Derma Serum External Cream 1

FREEDOM DERMA-D EXTERNAL CREAM 1

FREEDOM DERMA-N EXTERNAL CREAM 1

Gluconolactone Powder 1

Glycerin Liquid 1

Glycerol Formal Liquid 1

Grape Flavor Liquid 1

Guava Flavor Liquid 1

Honey Flavor Liquid 1

Hydroxypropyl Cellulose Powder 1

Hydroxytryptophan L-5 Powder 1

Hydroxytryptophan Powder 1

Ichthammol Powder 1

Kahlua Flavor Liquid 1

KENDALL AMORPHOUS WOUND EXTERNAL GEL

1

KERAGEL EXTERNAL GEL 1

KERAGELT EXTERNAL GEL 1

Lemon Extract Liquid 1

Licorice Flavor Liquid 1

LIOPEN ABSORPTION ENHANCING EXTERNAL CREAM

1

Lipo Cream Base External Cream 1

Lipopen Ultra Base External Cream 1

LipoSomal Heavy External Cream 1

LipoSomal Regular External Cream 1

L-Menthol Crystals 1

Mango Flavor Liquid 1

Maple Flavor Liquid 1

Marshmallow Flavor Liquid 1

MEDIDERM EXTERNAL CREAM 1

Menthol Crystals 1

Mint Chocolate Chip Flavor Liquid 1

MultiUse Base External Cream 1

NOURILITE EXTERNAL CREAM 1

NOURIVAN ANTIOX BASE EXTERNAL CREAM

1

123

Drug Name Tier NotesNoxi-K External Cream 1

Orange Cream Flavor Liquid 1

Orange Flavor Liquid 1

Orange Oil Flavor Liquid 1

ORA-PLUS ORAL LIQUID 1

ORA-SWEET ORAL SYRUP 1

ORA-SWEET SF ORAL SYRUP 1

PCCA ALADERM BASE EXTERNAL CREAM 1

PCCA ANHYDROUS LIPODERM BASE EXTERNAL CREAM

1

PCCA BIOPEPTIDE BASE EXTERNAL CREAM

1

PCCA COSMETIC HRT BASE EXTERNAL CREAM

1

PCCA LIPODERM BASE EXTERNAL CREAM 1

PCCA MVC BASE EXTERNAL CREAM 1

PCCA NATACREAM EXTERNAL CREAM 1

PCCA PRACASIL TM-PLUS BASE EXTERNAL CREAM

1

PCCA SWEETNESS ENHANCER LIQUID 1

PCCA SWEET-SF ORAL SYRUP 1

PCCA SYRUP VEHICLE ORAL SYRUP 1

PCCA VANISHING CREAM BASE EXTERNAL CREAM

1

PCCA VANISHING CREAM LIGHT EXTERNAL CREAM

1

PCCA VANPEN BASE EXTERNAL CREAM 1

Peach Flavor Liquid 1

Peanut Butter Flavor Liquid 1

PENCREAM EXTERNAL CREAM 1

PenDerm External Cream 1

PHARMABASE COSMETIC EXTERNAL CREAM

1

PHARMABASE HEAVY EXTERNAL CREAM 1

PHYTOBASE EXTERNAL CREAM 1

Pina Colada Flavor Liquid 1

Pineapple Flavor Liquid 1

Polyethylene Glycol 3350 Powder 1

Potassium Bromide Crystals 1

Pralines and Cream Flavor Liquid 1

124

Drug Name Tier NotesPropylene Glycol External Solution 1

Propylene Glycol Liquid 1

Pumpkin Flavor Liquid 1

RADIAGEL EXTERNAL GEL 1

Raspberry Flavor Liquid 1

Rejuvacare Plus External Cream 1

RESTORE SILVER DRESSING EXTERNAL PAD

1

Root Beer Flavor Liquid 1

SA3 Derm External Cream 1

Salt Durable Cream External Cream 1

SALT STABLE LO EXTERNAL CREAM 1

SALT STABLE LS ADVANCED EXTERNAL CREAM

1

SANARE ADVANCED SCAR THERAPY EXTERNAL CREAM

1

Sanare Scar Therapy External Cream 1

SEDANARE EXTERNAL CREAM 1

Skyy Derm External Cream 1

Stera Base External Cream 1

Sterile Water for Injection Injection Solution 1

Stevia Glycerite Extract Liquid 1

Strawberry Flavor Liquid 1

SYRPALTA (RED) ORAL SYRUP 1

Syrpalta Oral Syrup 1

SYRSPEND SF ORAL LIQUID 1

Syrup Vehicle Oral Syrup 1

Syrup Vehicle SF Oral Syrup 1

TeroDerm External Cream 1

TeroDerm-Plus External Cream 1

Thimerosal Powder 1

Titanium Dioxide Powder 1

Tropical Punch Flavor Liquid 1

Trypsin Powder 1

Tutti Frutti Flavor Liquid 1

Tutti-Frutti Flavor Liquid 1

Ultraderm External Cream 1

Vanilla Butternut Flavor Liquid 1

Vanilla Flavor Liquid 1

125

Drug Name Tier NotesVanishing Cream Botanical Base External Cream 1

Vanishing External Cream 1

Vanish-Pen External Cream 1

VASCUDERM HYDROGEL EXTERNAL GEL 1

VERSAFREE ORAL SYRUP 1

VERSAPLUS ORAL SYRUP 1

VERSAPRO EXTERNAL CREAM 1

Versatile Cream Base External Cream 1

VERSATILE RICH BASE EXTERNAL CREAM

1

Watermelon Flavor Liquid 1

Wild Cherry Flavor Liquid 1

XEMATOP BASE EXTERNAL CREAM 1

ZOE SCRIPTS IDEALBASE EXTERNAL CREAM

1

RESPIRATORY TRACT AGENTS

ALPHA AND BETA ADRENERGIC AGONIST(RESPR)


1

ePHEDrine HCl Powder 1

ePHEDrine Sulfate Powder 1



EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML


EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML



1


Pseudoephedrine HCl Oral Tablet 30 MG, 60 MG 1


ANTICHOLINERGIC AGENTS (RESPIR.TRACT)

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT


126

Drug Name Tier NotesCOMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT




Ipratropium Bromide Inhalation Solution 0.02 % 1 QL (300 ML per 30 days)


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


ANTITUSSIVES

Benzonatate Oral Capsule 100 MG, 200 MG 1



1


1

Codeine Sulfate Oral Tablet 15 MG, 30 MG, 60 MG 1 PA; QL (180 EA per 30 days)



Hydromet Oral Syrup 5-1.5 MG/5ML 1 QL (900 ML per 30 days)

MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HOUR 30-600 MG

1






EXPECTORANTS



1

127

Drug Name Tier NotesGuaiFENesin ER Oral Tablet Extended Release 12 Hour 600 MG 1


1

MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HOUR 30-600 MG

1


FIRST GENERATION ANTIHIST.(RESPIR TRACT)


1



















LEUKOTRIENE MODIFIERS

Montelukast Sodium Oral Packet 4 MG 1 90; QL (30 EA per 30 days)

128

Drug Name Tier NotesMontelukast Sodium Oral Tablet 10 MG 1 90; QL (30 EA per 30 days)

Montelukast Sodium Oral Tablet Chewable 4 MG, 5 MG 1 90; QL (30 EA per 30 days)

Zafirlukast Oral Tablet 10 MG, 20 MG 1 QL (60 EA per 30 days)

MAST-CELL STABILIZERS

Cromolyn Sodium Inhalation Nebulization Solution 20 MG/2ML 1 QL (240 ML per 30 days)

Cromolyn Sodium Ophthalmic Solution 4 % 1

MUCOLYTIC AGENTS

Acetylcysteine Inhalation Solution 10 %, 20 % 1

PULMOZYME INHALATION SOLUTION 1 MG/ML

1PA; SPN; QL (150 ML per 30 days)

NASAL PREPARATIONS (STEROIDS)

Fluticasone Propionate Nasal Suspension 50 MCG/ACT 1 QL (16 GM per 30 days)

Triamcinolone Acetonide Nasal Aerosol 55 MCG/ACT 1

ORALLY INHALED PREPARATIONS (STEROIDS)



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

1





ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH







1

129

Drug Name Tier NotesBudesonide Inhalation Suspension 0.25 MG/2ML, 0.5 MG/2ML 1 QL (120 ML per 30 days)

Budesonide Inhalation Suspension 1 MG/2ML 1 QL (60 ML per 30 days)

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


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST








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

1

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

1

PULMONARY SURFACTANTS

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-%

1

SECOND GENERATION ANTIHIST(RESPIR TRACT)

Cetirizine HCl Allergy Child Oral Solution 5 MG/5ML 1

Cetirizine HCl Oral Solution 1 MG/ML 1


SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)



Albuterol Sulfate ER Oral Tablet Extended Release 12 Hour 4 MG, 8 MG 1

Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% 1 QL (375 ML per 30 days)

Albuterol Sulfate Inhalation Nebulization Solution (5 MG/ML) 0.5% 1 QL (80 EA per 30 days)

Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML, 1.25 MG/3ML 1 QL (360 ML per 30 days)

130

Drug Name Tier NotesAlbuterol Sulfate Oral Syrup 2 MG/5ML 1

Albuterol Sulfate Oral Tablet 2 MG, 4 MG 1


1




Metaproterenol Sulfate Oral Syrup 10 MG/5ML 1

Metaproterenol Sulfate Oral Tablet 10 MG, 20 MG 1

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


Terbutaline Sulfate Oral Tablet 2.5 MG, 5 MG 1

Terbutaline Sulfate Powder 1

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


VASODILATING AGENTS (RESPIRATORY TRACT)

Epoprostenol Sodium Intravenous Solution Reconstituted 0.5 MG, 1.5 MG 1 PA; SPN

LETAIRIS ORAL TABLET 10 MG, 5 MG 1 PA; SPN; QL (30 EA per 30 days)

Sildenafil Citrate Oral Tablet 20 MG 1 ST; SPN

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

1 PA

XANTHINE DERIVATIVES



1


1




131

Drug Name Tier NotesSKIN AND MUCOUS MEMBRANE AGENTS

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

AKTIPAK EXTERNAL PACKET 5-3 % 1

Benzoyl Peroxide-Erythromycin External Gel5-3 % 1

CENTANY EXTERNAL OINTMENT 2 % 1

CLEOCIN VAGINAL SUPPOSITORY 100 MG 1

CLINDACIN ETZ EXTERNAL SWAB 1 % 1

CLINDACIN-P EXTERNAL SWAB 1 % 1

Clindamycin Phosphate External Gel 1 % 1

Clindamycin Phosphate External Lotion 1 % 1

Clindamycin Phosphate External Solution 1 % 1

Clindamycin Phosphate External Swab 1 % 1

Clindamycin Phosphate Vaginal Cream 2 % 1

Ery External Pad 2 % 1

Erythromycin External Gel 2 % 1

Erythromycin External Pad 2 % 1

Erythromycin External Solution 2 % 1

Gentamicin Sulfate External Cream 0.1 % 1

Gentamicin Sulfate External Ointment 0.1 % 1

MetroNIDAZOLE External Cream 0.75 % 1

MetroNIDAZOLE External Gel 0.75 %, 1 % 1

MetroNIDAZOLE External Lotion 0.75 % 1

MetroNIDAZOLE Vaginal Gel 0.75 % 1

Mupirocin External Ointment 2 % 1

ROSADAN EXTERNAL CREAM 0.75 % 1

ROSADAN EXTERNAL GEL 0.75 % 1

VANDAZOLE VAGINAL GEL 0.75 % 1

ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC

Gentian Violet Powder 1

Zinc Undecylenate Powder 1

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

Ala-Cort External Cream 1 %, 2.5 % 1

Betamethasone Dipropionate Aug External Cream 0.05 % 1

132

Drug Name Tier NotesBetamethasone Dipropionate Aug External Gel0.05 % 1

Betamethasone Dipropionate Aug External Ointment 0.05 % 1

Betamethasone Dipropionate External Cream0.05 % 1

Betamethasone Dipropionate External Lotion0.05 % 1

Betamethasone Dipropionate External Ointment 0.05 % 1

Betamethasone Valerate External Cream 0.1 % 1

Betamethasone Valerate External Lotion 0.1 % 1

Betamethasone Valerate External Ointment0.1 % 1

Clobetasol Prop Emollient Base External Cream 0.05 % 1

Clobetasol Propionate E External Cream 0.05 % 1

Clobetasol Propionate External Cream 0.05 % 1

Clobetasol Propionate External Gel 0.05 % 1

Clobetasol Propionate External Ointment 0.05 % 1

Clobetasol Propionate External Solution 0.05 % 1

Clotrimazole-Betamethasone External Cream1-0.05 % 1

COLOCORT RECTAL ENEMA 100 MG/60ML 1

CORDRAN EXTERNAL TAPE 4 MCG/SQCM 1

CORTIFOAM RECTAL FOAM 10 % 1

Desonide External Cream 0.05 % 1

Desonide External Lotion 0.05 % 1

Desonide External Ointment 0.05 % 1

Desonide Powder 1

Desoximetasone External Cream 0.05 %, 0.25 % 1

Desoximetasone External Gel 0.05 % 1

Desoximetasone External Ointment 0.25 % 1

EPIFOAM EXTERNAL FOAM 1-1 % 1

EUCRISA EXTERNAL OINTMENT 2 % 1 ST

133

Drug Name Tier NotesFluocinolone Acetonide Body External Oil 0.01 % 1

Fluocinolone Acetonide External Cream 0.01 %, 0.025 % 1

Fluocinolone Acetonide External Ointment0.025 % 1

Fluocinolone Acetonide External Solution 0.01 % 1

Fluocinolone Acetonide Powder 1

Fluocinolone Acetonide Scalp External Oil0.01 % 1

Fluocinonide Emulsified Base External Cream0.05 % 1

Fluocinonide External Cream 0.05 % 1

Fluocinonide External Gel 0.05 % 1

Fluocinonide External Ointment 0.05 % 1

Fluocinonide External Solution 0.05 % 1

Hydrocortisone External Cream 1 %, 2.5 % 1

Hydrocortisone External Lotion 2.5 % 1

Hydrocortisone External Ointment 1 %, 2.5 % 1

Hydrocortisone Rectal Cream 1 %, 2.5 % 1

Hydrocortisone Rectal Enema 100 MG/60ML 1

Hydrocortisone Valerate External Cream 0.2 % 1

Hydrocortisone Valerate External Ointment0.2 % 1

Lidocaine-Hydrocortisone Ace Rectal Cream3-0.5 % 1

Mometasone Furoate External Cream 0.1 % 1

Mometasone Furoate External Ointment 0.1 % 1

Mometasone Furoate External Solution 0.1 % 1

ORALONE MOUTH/THROAT PASTE 0.1 % 1

PROCTOCORT RECTAL CREAM 1 % 1

PROCTOFOAM HC RECTAL FOAM 1-1 % 1

PROCTO-MED HC RECTAL CREAM 2.5 % 1

PROCTO-PAK RECTAL CREAM 1 % 1

PROCTOSOL HC RECTAL CREAM 2.5 % 1

PROCTOZONE-HC RECTAL CREAM 2.5 % 1

TEXACORT EXTERNAL SOLUTION 2.5 % 1

Triamcinolone Acetonide External Aerosol Solution 0.147 MG/GM 1

134

Drug Name Tier NotesTriamcinolone Acetonide External Cream0.025 %, 0.1 %, 0.5 % 1

Triamcinolone Acetonide External Lotion0.025 %, 0.1 % 1

Triamcinolone Acetonide External Ointment0.025 %, 0.1 %, 0.5 % 1

Triamcinolone Acetonide Mouth/Throat Paste0.1 % 1

TRIANEX EXTERNAL OINTMENT 0.05 % 1

TRIDERM EXTERNAL CREAM 0.1 %, 0.5 % 1

ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA EXTERNAL OINTMENT 2 % 1 ST

ANTIPRURITICS AND LOCAL ANESTHETICS


Lidocaine External Ointment 5 % 1 QL (180 GM per 30 days)

Lidocaine External Patch 5 % 1 PA; QL (90 EA per 30 days)

Lidocaine HCl External Cream 3 % 1

Lidocaine PAK External Ointment 5 % 1 QL (180 GM per 30 days)


Lidopin External Cream 3 % 1

PHENAZO ORAL TABLET 200 MG 1

Phenazopyridine HCl Oral Tablet 100 MG, 200 MG 1

PRAMOX EXTERNAL GEL 1 % 1


ASTRINGENTS

DRYSOL EXTERNAL SOLUTION 20 % 1

AZOLES (SKIN AND MUCOUS MEMBRANE)

Clotrimazole Anti-Fungal External Cream 1 % 1

Clotrimazole External Cream 1 % 1

Clotrimazole External Solution 1 % 1

Clotrimazole Mouth/Throat Lozenge 10 MG 1

Clotrimazole Mouth/Throat Troche 10 MG 1


Econazole Nitrate External Cream 1 % 1

135

Drug Name Tier NotesEconazole Nitrate Powder 1

GYNAZOLE-1 VAGINAL CREAM 2 % 1

Ketoconazole External Cream 2 % 1

Ketoconazole External Shampoo 2 % 1

Miconazole 3 Vaginal Suppository 200 MG 1

Miconazole Powder 1

Terconazole Vaginal Cream 0.4 %, 0.8 % 1

BASIC LOTIONS AND LINIMENTS

Ammonium Lactate External Lotion 12 % 1

ATOPICLAIR EXTERNAL CREAM 1

Calamine Powder 1

Lactic Acid External Lotion 10 % 1

PRUCLAIR EXTERNAL CREAM 1

BASIC OILS AND OTHER SOLVENTS

Castor Oil Oil 1


BASIC OINTMENTS AND PROTECTANTS

Ammonium Lactate External Cream 12 % 1

Benzoin Compound External Tincture 1

DEXERYL EXTERNAL CREAM 1

ELETONE EXTERNAL CREAM 1

ELETONE TWINPACK EXTERNAL CREAM 1

Emollient Base External Cream 1

LAC-HYDRIN EXTERNAL CREAM 12 % 1

Lactic Acid E External Cream 10-3500 %-UNT/30GM 1


NEOCERA EXTERNAL CREAM 1

NUTRASEB EXTERNAL CREAM 1

TETRIX EXTERNAL CREAM 1

CELL STIMULANTS AND PROLIFERANTS

AVITA EXTERNAL CREAM 0.025 % 1

AVITA EXTERNAL GEL 0.025 % 1

Tretinoin External Cream 0.025 %, 0.05 %, 0.1 % 1

Tretinoin External Gel 0.01 %, 0.025 % 1

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

Ala-Cort External Cream 1 %, 2.5 % 1

136

Drug Name Tier NotesBetamethasone Dipropionate Aug External Cream 0.05 % 1

Betamethasone Dipropionate Aug External Gel0.05 % 1

Betamethasone Dipropionate Aug External Ointment 0.05 % 1

Betamethasone Dipropionate External Cream0.05 % 1

Betamethasone Dipropionate External Lotion0.05 % 1

Betamethasone Dipropionate External Ointment 0.05 % 1

Betamethasone Valerate External Cream 0.1 % 1

Betamethasone Valerate External Lotion 0.1 % 1

Betamethasone Valerate External Ointment0.1 % 1

Clobetasol Prop Emollient Base External Cream 0.05 % 1

Clobetasol Propionate E External Cream 0.05 % 1

Clobetasol Propionate External Cream 0.05 % 1

Clobetasol Propionate External Gel 0.05 % 1

Clobetasol Propionate External Ointment 0.05 % 1

Clobetasol Propionate External Solution 0.05 % 1


COLOCORT RECTAL ENEMA 100 MG/60ML 1

CORDRAN EXTERNAL TAPE 4 MCG/SQCM 1

CORTIFOAM RECTAL FOAM 10 % 1

Desonide External Cream 0.05 % 1

Desonide External Lotion 0.05 % 1

Desonide External Ointment 0.05 % 1

Desonide Powder 1

Desoximetasone External Cream 0.05 %, 0.25 % 1

Desoximetasone External Gel 0.05 % 1

Desoximetasone External Ointment 0.25 % 1


137

Drug Name Tier NotesFluocinolone Acetonide Body External Oil 0.01 % 1

Fluocinolone Acetonide External Cream 0.01 %, 0.025 % 1

Fluocinolone Acetonide External Ointment0.025 % 1

Fluocinolone Acetonide External Solution 0.01 % 1

Fluocinolone Acetonide Powder 1

Fluocinolone Acetonide Scalp External Oil0.01 % 1

Fluocinonide Emulsified Base External Cream0.05 % 1

Fluocinonide External Cream 0.05 % 1

Fluocinonide External Gel 0.05 % 1

Fluocinonide External Ointment 0.05 % 1

Fluocinonide External Solution 0.05 % 1

Hydrocortisone External Cream 1 %, 2.5 % 1

Hydrocortisone External Lotion 2.5 % 1

Hydrocortisone External Ointment 1 %, 2.5 % 1

Hydrocortisone Rectal Cream 1 %, 2.5 % 1

Hydrocortisone Rectal Enema 100 MG/60ML 1

Hydrocortisone Valerate External Cream 0.2 % 1

Hydrocortisone Valerate External Ointment0.2 % 1


Mometasone Furoate External Cream 0.1 % 1

Mometasone Furoate External Ointment 0.1 % 1

Mometasone Furoate External Solution 0.1 % 1

ORALONE MOUTH/THROAT PASTE 0.1 % 1

PROCTOCORT RECTAL CREAM 1 % 1


PROCTO-MED HC RECTAL CREAM 2.5 % 1

PROCTO-PAK RECTAL CREAM 1 % 1

PROCTOSOL HC RECTAL CREAM 2.5 % 1

PROCTOZONE-HC RECTAL CREAM 2.5 % 1

TEXACORT EXTERNAL SOLUTION 2.5 % 1

Triamcinolone Acetonide External Aerosol Solution 0.147 MG/GM 1

138

Drug Name Tier NotesTriamcinolone Acetonide External Cream0.025 %, 0.1 %, 0.5 % 1

Triamcinolone Acetonide External Lotion0.025 %, 0.1 % 1

Triamcinolone Acetonide External Ointment0.025 %, 0.1 %, 0.5 % 1

Triamcinolone Acetonide Mouth/Throat Paste0.1 % 1

TRIANEX EXTERNAL OINTMENT 0.05 % 1

TRIDERM EXTERNAL CREAM 0.1 %, 0.5 % 1

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

Glycerin Liquid 1

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

Ciclopirox Olamine Powder 1

KERATOLYTIC AGENTS

Acne Medication 5 External Gel 5 % 1

AVAR CLEANSER EXTERNAL EMULSION 10-5 %

1

AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 %

1

AVAR-E GREEN EXTERNAL CREAM 10-5 % 1

Benzoyl Peroxide External Gel 10 %, 5 % 1

Podophyllum Resin Powder 1

ROSANIL CLEANSER EXTERNAL EMULSION 10-5 %

1

SSS 10-5 External Cream 10-5 % 1

Sulfacetamide Sodium-Sulfur External Cream10-5 % 1

Sulfacetamide Sodium-Sulfur External Emulsion 10-5 % 1

Sulfacetamide Sodium-Sulfur External Lotion10-5 % 1

Sulfacetamide Sodium-Sulfur External Suspension 10-5 % 1

Sulfur Powder 1

Sulfur Precipitated Powder 1

Sulfur Sublimed Powder 1

KERATOPLASTIC AGENTS

Coal Tar External Solution 20 % 1

139

Drug Name Tier NotesCoal Tar Extract Solution 20 % 1

Coal Tar Solution , 20 % 1

DRITHO-CREME HP EXTERNAL CREAM 1 %

1

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVAR CLEANSER EXTERNAL EMULSION 10-5 %

1

AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 %

1

AVAR-E GREEN EXTERNAL CREAM 10-5 % 1

AVC VAGINAL VAGINAL CREAM 15 % 1

Iodine Tincture External Tincture 2 % 1

Povidone-Iodine Flakes 1

ROSANIL CLEANSER EXTERNAL EMULSION 10-5 %

1

Selenium Sulfide External Lotion 2.5 % 1

Selenium Sulfide External Shampoo 2.25 % 1

Silver Protein Mild Powder 1

Silver Sulfadiazine External Cream 1 % 1

SSD EXTERNAL CREAM 1 % 1

SSS 10-5 External Cream 10-5 % 1

Sulfacetamide Sodium (Acne) External Lotion10 % 1

Sulfacetamide Sodium-Sulfur External Cream10-5 % 1

Sulfacetamide Sodium-Sulfur External Emulsion 10-5 % 1

Sulfacetamide Sodium-Sulfur External Lotion10-5 % 1

Sulfacetamide Sodium-Sulfur External Suspension 10-5 % 1

THERMAZENE EXTERNAL CREAM 1 % 1

NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN)


PIGMENTING AGENTS

Methoxsalen Oral Capsule 10 MG 1 SPN

Methoxsalen Rapid Oral Capsule 10 MG 1 SPN

140

Drug Name Tier NotesPOLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC EXTERNAL POWDER 100000 UNIT/GM

1

Nystatin External Cream 100000 UNIT/GM 1

Nystatin External Ointment 100000 UNIT/GM 1

Nystatin External Powder 100000 UNIT/GM 1

Nystatin-Triamcinolone External Cream100000-0.1 UNIT/GM-% 1

Nystatin-Triamcinolone External Ointment100000-0.1 UNIT/GM-% 1

NYSTOP EXTERNAL POWDER 100000 UNIT/GM

1

SCABICIDES AND PEDICULICIDES

EURAX EXTERNAL CREAM 10 % 1

Lindane External Shampoo 1 % 1

Malathion External Lotion 0.5 % 1

NATROBA EXTERNAL SUSPENSION 0.9 % 1

Permethrin External Cream 5 % 1 QL (120 GM per 30 days)

Spinosad External Suspension 0.9 % 1

Sulfur Powder 1

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

Acitretin Oral Capsule 10 MG, 17.5 MG, 25 MG 1 SPN

Adapalene External Cream 0.1 % 1

Adapalene External Gel 0.1 %, 0.3 % 1

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG

1

Benzoin External Tincture 1

Calcipotriene External Cream 0.005 % 1

Calcipotriene External Ointment 0.005 % 1

Calcipotriene External Solution 0.005 % 1

CALCITRENE EXTERNAL OINTMENT 0.005 %

1

Camphor Crystals 1

Camphor Granules 1

CARRASYN HYDROGEL WOUND DRESS EXTERNAL GEL

1

141

Drug Name Tier NotesCLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

CONDYLOX EXTERNAL GEL 0.5 % 1












FLUOROPLEX EXTERNAL CREAM 1 % 1

Fluorouracil External Cream 5 % 1 SPN

Fluorouracil External Solution 2 %, 5 % 1 SPN

Imiquimod External Cream 5 % 1

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

Podocon External Solution 25 % 1

Podofilox External Solution 0.5 % 1


1 PA; SPN

SANTYL EXTERNAL OINTMENT 250 UNIT/GM


Tacrolimus External Ointment 0.03 %, 0.1 % 1 PA; SPN

TARGRETIN EXTERNAL GEL 1 % 1 PA; SPN

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

SUNSCREEN AGENTS

Zinc Oxide Powder 1

THIOCARBAMATES(SKIN AND MUCOUS MEMBRANE)

Tolnaftate Powder 1

SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

FlavoxATE HCl Oral Tablet 100 MG 1

Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG, 15 MG 1 QL (60 EA per 30 days)

142

Drug Name Tier NotesOxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG 1 QL (30 EA per 30 days)

Oxybutynin Chloride Oral Syrup 5 MG/5ML 1

Oxybutynin Chloride Oral Tablet 5 MG 1

Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 2 MG, 4 MG 1 QL (30 EA per 30 days)

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

1

RESPIRATORY SMOOTH MUSCLE RELAXANTS



1


1




VITAMINS

MULTIVITAMIN PREPARATIONS



Biocel Oral Tablet 1

B-Plex Plus Oral Tablet 1



CITRANATAL B-CALM ORAL 20-1 & 25 (2) MG

1



1



Complete Natal DHA Oral 29-1-200 & 250 MG 1




1

143

Drug Name Tier NotesCONCEPT OB ORAL CAPSULE 130-92.4-1 MG

1

CORVITE FREE ORAL TABLET 1


FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

1


1

FORTAVIT ORAL CAPSULE 1



INATAL GT ORAL TABLET 1

Multi-Vit/Fluoride Oral Solution 0.25 MG/ML 1


Multivitamin/Fluoride Oral Solution 0.25 MG/ML, 0.5 MG/ML 1

Multi-Vitamin/Fluoride Oral Solution 0.25 MG/ML, 0.5 MG/ML 1

Multivitamin/Fluoride Oral Tablet Chewable0.25 MG, 0.5 MG, 1 MG 1

Multivitamin/Fluoride/Iron Oral Solution0.25-10 MG/ML 1


Multivitamins/Fluoride Oral Tablet Chewable0.5 MG 1

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

M-VIT ORAL TABLET 1



MYNATAL ORAL TABLET 90-1 MG 1



Mynate 90 Plus Oral Tablet Extended Release 1



1



144

Drug Name Tier NotesNEWGEN ORAL TABLET 32-1 MG 1

















1

PR NATAL 400 ORAL 29-1-200 & 400 MG 1


1

PR NATAL 430 ORAL 29-1-200 & 430 MG 1














PRENATAL-U ORAL CAPSULE 106.5-1 MG 1

145

Drug Name Tier NotesPrePLUS Oral Tablet 27-1 MG 1


PROTECT PLUS ORAL CAPSULE 1


QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML

1

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

REQ 49+ ORAL TABLET 1



Se-Natal 19 Oral Tablet 29-1 MG 1



STROVITE ONE ORAL TABLET 1

Support Oral Liquid 1



1

TARON-PREX ORAL CAPSULE 30-1.2-265 MG

1





TRICARE ORAL TABLET 1


1





1


Urosex Oral Tablet 1

V-C Forte Oral Capsule 1


Vicap Forte Oral Capsule 1

VIC-FORTE ORAL CAPSULE 1


146

Drug Name Tier NotesVINATE M ORAL TABLET 27-1 MG 1








VITACEL ORAL TABLET 1




VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG

1


1

Vita-Rx Diabetic Vitamin Oral Capsule 1








1


1

VITAMIN A

Cod Liver Oil Oral Oil 1

VITAMIN B COMPLEX

ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

1

AP-Zel Oral Tablet 1



Biocel Oral Tablet 1

B-Plex Oral Tablet 1



147

Drug Name Tier NotesCITRANATAL B-CALM ORAL 20-1 & 25 (2) MG

1



1






1

CONCEPT OB ORAL CAPSULE 130-92.4-1 MG

1

CORVITE FREE ORAL TABLET 1

Cyanocobalamin Injection Solution 1000 MCG/ML 1



Folbee Plus Oral Tablet 1

Folic Acid Injection Solution 5 MG/ML 1

Folic Acid Oral Tablet 1 MG 1


1


Hematinic/Folic Acid Oral Tablet 324-1 MG 1


1


1



HEMOCYTE-F ORAL TABLET 324-1 MG 1

Hydroxocobalamin HCl Powder 1

Hydroxocobalamin Powder 1


1

IFEREX 150 FORTE ORAL CAPSULE 150-25-1 MG-MCG-MG

1

M-VIT ORAL TABLET 1

148

Drug Name Tier NotesMyferon 150 Forte Oral Capsule 150-25-1 MG-MCG-MG 1





Mynephrocaps Oral Capsule 1 MG 1

MYNEPHRON ORAL CAPSULE 1 MG 1

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

1



1





Niacinamide Powder 1

NICADAN ORAL TABLET 1

NICAZEL FORTE ORAL TABLET 1

NICAZEL ORAL TABLET 1

Nicotinamide Powder 1















Poly-Iron 150 Forte Oral Capsule 150-25-1 MG-MCG-MG 1

149

Drug Name Tier NotesPolysaccharide Iron Forte Oral Capsule 150-25-1 MG-MCG-MG 1


1

PR NATAL 400 ORAL 29-1-200 & 400 MG 1


1

PR NATAL 430 ORAL 29-1-200 & 430 MG 1

















Pyridoxine HCl Powder 1

RENAL ORAL CAPSULE 1 MG 1

Reno Caps Oral Capsule 1 MG 1

Riboflavin-5-Phosphate Sodium Powder 1







SUPPORT-500 ORAL CAPSULE 1



1

150

Drug Name Tier NotesTARON-PREX ORAL CAPSULE 30-1.2-265 MG

1

Thiamine HCl Powder 1





TRICARE ORAL TABLET 1


1




Triphrocaps Oral Capsule 1 MG 1



1


Urosex Oral Tablet 1

V-C Forte Oral Capsule 1


Vicap Forte Oral Capsule 1

VIC-FORTE ORAL CAPSULE 1


VINATE M ORAL TABLET 27-1 MG 1



Virt-Caps Oral Capsule 1 MG 1






VITACEL ORAL TABLET 1




151

Drug Name Tier NotesVITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG

1


1

Vita-Rx Diabetic Vitamin Oral Capsule 1








1


1

VITAMIN C

B-Plex Oral Tablet 1


Folbee Plus Oral Tablet 1



1


1


1

Mynephrocaps Oral Capsule 1 MG 1

MYNEPHRON ORAL CAPSULE 1 MG 1

RENAL ORAL CAPSULE 1 MG 1

Reno Caps Oral Capsule 1 MG 1


Sodium Ascorbate Granules 1

SUPPORT-500 ORAL CAPSULE 1


Triphrocaps Oral Capsule 1 MG 1

Virt-Caps Oral Capsule 1 MG 1

VITAMIN D

Calcitriol Oral Capsule 0.25 MCG, 0.5 MCG 1

152

Drug Name Tier NotesCalcitriol Oral Solution 1 MCG/ML 1

Cod Liver Oil Oral Oil 1

Ergocal Oral Capsule 2500 UNIT 1

Ergocalciferol Oral Capsule 50000 UNIT 1

Ergocalciferol Powder 1


Vitamin D (Ergocalciferol) Oral Capsule 50000 UNIT 1

VITAMIN K ACTIVITY

Phytonadione Oral Tablet 5 MG 1

153

Index1st Base .................................... 1205-Hydroxy-L-Tryptophan ......120Abacavir Sulfate ........................11Abacavir Sulfate-Lamivudine ..11Abacavir-Lamivudine-Zidovudine .................................11ABANEU-SL............................147ABILIFY MAINTENA.............. 59ABSORICA.............................. 141Acarbose .................................... 96ACCU-CHEK FLEXLINK PLUS 10MM.............................. 71ACCU-CHEK FLEXLINK PLUS 6MM................................ 71ACCU-CHEK FLEXLINK PLUS 8MM................................ 71ACCU-CHEK PLASTIC CARTRIDGE............................. 71ACCU-CHEK RAPID-D INFUSION SET..........................71ACCU-CHEK RAPID-D LINK116ACCU-CHEK SPIRIT CARTRIDGE........................... 116ACCU-CHEK TENDER I SET 24"...............................................71ACCU-CHEK TENDER I SET 31"...............................................71ACCU-CHEK TENDER I SET 43"...............................................71ACCU-CHEK TENDER II SET 24"...............................................72ACCU-CHEK TENDER II SET 31"...............................................72ACCU-CHEK TENDER II SET 43"...............................................72ACCU-CHEK ULTRAFLEX INF SET......................................72ACCU-CHEK ULTRAFLEX-1 INF SET....................................116Acebutolol HCl ..24, 35, 36, 43, 47Acetaminophen-Codeine .... 53, 64Acetaminophen-Codeine #253, 64Acetaminophen-Codeine #353, 64Acetaminophen-Codeine #453, 64ACETASOL HC...................88, 89AcetaZOLAMIDE ........ 41, 80, 87Acetic Acid ...........................80, 89Acetylcholine Chloride ............. 89Acetylcysteine .................. 115, 129Acitretin ................................... 141Acne Medication 5 .................. 139

ACTICOAT 7 2"X2".................. 72ACTICOAT 7 4"X5".......... 72, 120ACTICOAT ABSORBENT 4"X5".......................................... 72ACTICOAT ANTIMICROBIAL 2"X2"......... 72ACTICOAT ANTIMICROBIAL 4"X4"......... 72ACTICOAT FLEX 3 4"X4"....... 72Acyclovir ....................................14Adapalene ................................ 141Adefovir Dipivoxil .....................14Adenosine .............................35, 44ADMELOG...................... 104, 106ADMELOG SOLOSTAR.104, 106ADRENAL C FORMULA....... 116ADRENALIN............................. 90ADVAIR DISKUS23, 94, 129, 130Advanced Base Plus ................116AEROCHAMBER MINI CHAMBER.................................72AEROCHAMBER MV.............. 72AEROCHAMBER PLUS FLO-VU...............................................72AEROCHAMBER W/FLOWSIGNAL......................72AEROCHAMBER Z-STAT PLUS CHAMBR........................ 72AFEDITAB CR........ 38, 45, 47, 51AKTIPAK.................................132Ala-Cort ........................... 132, 136ALBA-DERM...........................120Albendazole ................................. 7Albuterol Sulfate .......23, 130, 131Albuterol Sulfate ER ........ 23, 130ALCOH-GLOVE CONTOURED WIPE.................72ALECENSA............................... 17Alendronate Sodium ...............110ALEVICYN ANTIPRURITIC... 72Alfuzosin HCl ER ..................... 23Allantoin .................................. 121ALLEVYN AG ADHESIVE......72ALLEVYN AG GENTLE BORDER.................................. 116ALLEVYN AG NON-ADHESIVE.............................. 116ALLEVYN AG SACRUM.......116ALLEVYN GENTLE............... 116Allopurinol ...............................110Almond Oil Bitter Flavor .......121

Alogliptin Benzoate .................102Alogliptin-Metformin HCl97, 102Alogliptin-Pioglitazone ... 102, 108ALOMIDE..................................85ALORA.....................................102ALPHAGAN P........................... 85ALPRAZolam ........................... 62ALPRAZOLAM INTENSOL.....61Alprostadil ................................. 51ALTADERM............................ 121ALTAFRIN.................................90ALTAVERA...............................97Alyacen 1/35 .............................. 97Alyacen 7/7/7 ............................. 97Amantadine HCl ................... 6, 52AMICAR.................................... 26AMILoride HCl .................. 49, 81Amiloride-Hydrochlorothiazide...................................49, 50, 81, 84AMINOPMRMS.......................116Amiodarone HCl .......................44Amitriptyline HCl .....................71Amlodipine Besy-Benazepril HCl ......... 33, 34, 38, 45, 46, 47, 51AmLODIPine Besylate.............................39, 45, 46, 47, 51Ammonium Lactate ........ 121, 136AMNESTEEM......................... 141Amoxapine .................................71Amoxicill-Clarithro-Lansopraz ........................ 6, 14, 93Amoxicillin ...............................6, 7Amoxicillin-Pot Clavulanate ......7Amoxicillin-Pot Clavulanate ER .................................................7Amphetamine-Dextroamphet ER ...............................................52Amphetamine-Dextroamphetamine ................. 53Amphotericin B .........................15Ampicillin .................................... 7Ampicillin Sodium ...................... 7Ampicillin-Sulbactam Sodium ...7Anagrelide HCl ......................... 32Anastrozole ..........................17, 96ANDRODERM...........................96Anesthesia Needle 23Gx1-3/8"...................................................116Anise Extract ...........................121Antibiotic Ear ..........................116

155

APOTHESAR 2........................121Apothesar Plus ........................ 121APOTHESIL.............................121Apple Flavor ............................121Apraclonidine HCl ....................89APRI........................................... 97Apricot Flavor .........................121APTIVUS................................... 12AP-Zel .............................. 115, 147ARGYLE EXTENSION TUBE 20".............................................117ARIPiprazole .............................59ARISTADA................................ 59ARISTADA INITIO................... 59ARNUITY ELLIPTA......... 94, 129ASACOL HD..............................91ASILNASAL RMS...................117ASMANEX 120 METERED DOSES................................94, 129ASMANEX 14 METERED DOSES................................94, 129ASMANEX 30 METERED DOSES................................94, 129ASMANEX 60 METERED DOSES................................94, 129ASMANEX 7 METERED DOSES................................94, 129Aspirin-Dipyridamole ER.........................................32, 51, 69ASSURE ID INSULIN SAFETY SYR............................ 72Atenolol ....................24, 35, 36, 43Atenolol-Chlorthalidone.......................24, 35, 36, 43, 51, 85Atomoxetine HCl .................62, 63ATOPICLAIR.....................72, 136Atorvastatin Calcium ............... 47Atovaquone ..................................8Atovaquone-Proguanil HCl ....... 7ATRAPRO HYDROGEL...........72ATREVIS HYDROGEL...........117ATRIPLA................................... 11Atropine Sulfate .................. 89, 90ATROVENT HFA..............20, 126AUBRA...................................... 97AUGMENTIN.............................. 7AUTOSOFT 30 INFUSION SET............................................. 72AUTOSOFT 90 INFUSION SET............................................. 72AUXIPRO VANISHING......... 121AVANDIA................................108

AVAR CLEANSER......... 139, 140AVAR-E EMOLLIENT... 139, 140AVAR-E GREEN.............139, 140AVASTIN...................................17AVC VAGINAL.......................140AVIANE..................................... 97AVITA......................................136AVONEX..................................113AVONEX PEN.........................113AVONEX PREFILLED........... 113Av-Phos 250 Neutral .................79AzaTHIOprine ........ 112, 113, 114Azelastine HCl ...........................85Azithromycin .............................14AZURETTE................................98Bacitracin ...................................86Bacitracin-Polymyxin B ........... 86Bacitra-Neomycin-Polymyxin-HC ........................................ 86, 88Baclofen ..................................... 21BACMIN.................... 27, 143, 147Bacon Flavor ........................... 117BACTOCILL IN DEXTROSE...15BACTROBAN NASAL............. 86BAL-CARE DHA.27, 81, 143, 147Balsalazide Disodium ................91BALZIVA...................................98Banana Concentrate ............... 121Banana Cream Flavor ............ 121Banana Creme Flavor ............ 121Banana Flavor .........................121BASAGLAR KWIKPEN......... 104Base W301 ............................... 121BD INTEGRA NEEDLE............72BD OSGOOD BIOPSY NEEDLE...................................117BD PEN NEEDLE NANO U/F..72BD SAFETYGLIDE INSULIN SYRINGE................................. 117BD SAFETYGLIDE SHIELDED NEEDLE................ 72BD SAFETYGLIDE SYRINGE/NEEDLE.................. 72BD SAFETY-LOK SET............. 72BD SYRINGE BLUNT CANNULA 17G.........................72BD SYRINGE LUER-LOK........72BD SYRINGE SLIP TIP............ 72BD SYRINGE TIP CAP.............72BD VACUTAINER SET............72Beef Flavor ...............................117Beef Type Flavor Natural .......117

BEKYREE..................................98Belladonna Alkaloids-Opium .. 64Belladonna-Opium ....................64Benazepril HCl ....................33, 34Benazepril-Hydrochlorothiazide...................................33, 34, 50, 84Benzethonium Chloride ..........121Benzoic Acid ............................ 121Benzoin .............................121, 141Benzoin Compound ........ 121, 136Benzonatate ............................. 127Benzoyl Peroxide .....................139Benzoyl Peroxide-Erythromycin .......................... 132Benztropine Mesylate ......... 21, 54Betamethasone .......................... 94Betamethasone Dipropionate...........................................133, 137Betamethasone Dipropionate Aug ........................... 132, 133, 137Betamethasone Valerate .133, 137Betaxolol HCl.......................24, 35, 36, 43, 47, 87Bethanechol Chloride ............... 22BETOPTIC-S..............................87Bicalutamide ..............................17BICILLIN L-A............................13BIKTARVY................................10Biocel ................................143, 147Bio-Statin ................................. 117Biotin ........................................121Biotuss ................................19, 127BIOTUSS PEDIATRIC......19, 127Bisoprolol Fumarate...................................24, 35, 36, 43Bisoprolol-Hydrochlorothiazide.......................24, 35, 36, 43, 50, 84Bitter Stop Flavor ................... 121Bitterness Mask Flavor .......... 121Bitterness Suppressor Flavor .121Blackberry Flavor ...................121BLEPHAMIDE...........................86BLEPHAMIDE S.O.P................ 86BLISOVI 24 FE..........................98BLISOVI FE 1.5/30....................98BLISOVI FE 1/20.......................98Blueberry Flavor .....................121BOTOX...............................24, 116BOTOX COSMETIC......... 24, 115B-Plex ............................... 147, 152

156

B-Plex Plus .........................27, 143BREO ELLIPTA.. 23, 94, 129, 131Briellyn .......................................98Brimonidine Tartrate ............... 85BROMFED DM..19, 126, 127, 128Bromocriptine Mesylate ........... 63Bubble Gum Concentrate ...... 121Bubble Gum Flavor ................ 121Budesonide .........................94, 130Bumetanide ..........................48, 80Buprenorphine HCl .................. 66BuPROPion HCl ....................... 56BuPROPion HCl ER (Smoking Det) ............................56BuPROPion HCl ER (SR) ........56BuPROPion HCl ER (XL) ....... 56BusPIRone HCl .........................58Butalbital-Acetaminophen . 53, 60Butalbital-APAP ................. 53, 60Butalbital-APAP-Caff-Cod.............................53, 57, 60, 64, 68Butalbital-APAP-Caffeine.............................53, 57, 60, 61, 68Butalbital-ASA-Caffeine.............................32, 57, 61, 68, 69Butalbital-Aspirin-Caffeine.............................32, 57, 61, 68, 69Butter Flavor ...........................121Butter Rum Flavor ..................121Butterscotch Flavor ................ 121Calamine ..................................136Calcipotriene ........................... 141Calcitonin (Salmon) .. 97, 105, 110CALCITRENE......................... 141Calcitriol .......................... 152, 153Calcium Acetate (Phos Binder) ....................................... 80Calcium Sulfate .........................81Calcium Sulfate Hemihydrate . 81CAMILA.....................................98Camphor ..................................141Capecitabine ..............................17Captopril ..............................33, 34Captopril-Hydrochlorothiazide...................................33, 34, 50, 84CARAFATE............................... 93Caramel Flavor ....................... 121CarBAMazepine ........................54CarBAMazepine ER .................54Carbidopa-Levodopa ................63Carbidopa-Levodopa ER ......... 63

CARRASYN HYDROGEL WOUND DRESS..............121, 141Carteolol HCl ............................ 87CARTIA XT....... 38, 39, 40, 44, 51Cartridge IR 1000 3ml ..............73Cartridge IR 1200 ..................... 73Cartridge Pump ........................ 73Carvedilol .... 21, 23, 32, 36, 43, 47Castor Oil .......................... 91, 136CAVAREST............................. 111CAZIANT...................................98Cefaclor ........................................5Cefaclor ER ................................. 5Cefadroxil .................................... 4CeFAZolin Sodium ..................... 4Cefdinir ........................................5Cefepime HCl .............................. 6Cefixime ....................................... 5CefoTEtan Disodium .............. 5, 9CefOXitin Sodium .................. 5, 9Cefpodoxime Proxetil ................. 5Cefprozil ...................................... 5CefTAZidime ...............................5CefTRIAXone Sodium ............... 5CefTRIAXone Sodium in Dextrose ....................................... 5Cefuroxime Axetil ....................... 5Cefuroxime Sodium .................... 5Cela Base ..................................121Celecoxib ....................................63CENTANY............................... 132Cephalexin ................................... 4CERAMAX................................ 73CERDELGA............................. 116CESIA.........................................98Cetirizine HCl ..................... 4, 130Cetirizine HCl Allergy Child...............................................4, 130Cevimeline HCl ......................... 22CHATEAL..................................98Cheesecake Flavor .................. 121CHEMET............................94, 109Cherry ......................................122Cherry Flavor ..........................121Chicken Flavor Oil Soluble ....117Chicken Flavor Water Miscible ....................................117Chloramphenicol Palmitate ....... 9ChlordiazePOXIDE HCl ..........62Chlorhexidine Gluconate ......... 89Chlorobutanol ......................... 122Chlorobutanol Anhydrous ..... 122

Chlorobutanol Hemihydrate ..122Chloroquine Phosphate .............. 7Chlorothiazide .....................50, 84Chloroxylenol .......................... 122ChlorproMAZINE HCl ............67Chlorthalidone .................... 51, 85Chlorzoxazone ...........................21Chocolate Flavor .....................122Chocolate Hazelnut Flavor .... 122Cholestyramine ......................... 37Cholestyramine Light ...............37Choline-Mag Trisalicylate ........69CHRYSADERM DAY.............122CHRYSADERM NIGHT......... 122Ciclopirox Olamine .................139Cilostazol ............................. 32, 49CILOXAN.................................. 86Cimetidine ................................. 93Cimetidine HCl ......................... 93CIPRODEX.......................... 86, 88Ciprofloxacin .........................8, 15Ciprofloxacin HCl ...........8, 15, 86Ciprofloxacin in D5W ...........8, 15Citalopram Hydrobromide ...... 70CITRANATAL 90 DHA...............................27, 91, 143, 147CITRANATAL ASSURE...............................27, 91, 143, 147CITRANATAL B-CALM.....................................27, 143, 148CITRANATAL DHA. 27, 143, 148CITRANATAL HARMONY...............................28, 91, 143, 148CITRANATAL RX.........................28, 81, 91, 143, 148CLARAVIS.............................. 142Clarithromycin ......................8, 15Clarithromycin ER ............... 8, 14Clear Glass Vials 5ml ............. 117CLEO 90 INFUSION SET 24"/6MM.....................................73CLEO 90 INFUSION SET 24"/9MM.....................................73CLEO 90 INFUSION SET 31"/6MM.....................................73CLEO 90 INFUSION SET 31"/9MM.....................................73CLEOCIN................................. 132CLEOCIN PHOSPHATE...........13CLINDACIN ETZ.................... 132CLINDACIN-P.........................132Clindamycin HCl ...................... 13

157

Clindamycin Palmitate HCl .....13Clindamycin Phosphate ....13, 132Clobetasol Prop Emollient Base .................................. 133, 137Clobetasol Propionate .... 133, 137Clobetasol Propionate E .133, 137ClomiPRAMINE HCl ...............71ClonazePAM ........................61, 62CloNIDine HCl ....................19, 42Clopidogrel Bisulfate ................ 32Clorazepate Dipotassium ... 61, 62Clotrimazole .................... 117, 135Clotrimazole Anti-Fungal ...... 135Clotrimazole-Betamethasone...................................133, 135, 137CloZAPine ................................. 59C-Nate DHA .............. 28, 143, 148Coal Tar ...........................139, 140Coal Tar Extract ..................... 140Coconut Flavor ........................122Cod Liver Oil ...................147, 153Codeine Sulfate ................. 64, 127Coffee Flavor ........................... 122Cola Flavor .............................. 122Colchicine ................................ 110Colestipol HCl ........................... 37COLOCORT.....................133, 137COMBIPATCH................ 102, 106COMBIVENT RESPIMAT...............................20, 23, 127, 131COMFORT INFUSION SET 23"/17MM...................................73COMFORT INFUSION SET 31"/17MM...................................73COMFORT INFUSION SET 32"/17MM...................................73COMFORT INFUSION SET 43"/17MM...................................73COMFORT SHORT INF SET 23"/13MM...................................73COMFORT SHORT INF SET 31"/13MM...................................73COMFORT SHORT INF SET 32"/13MM...................................73COMFORT SHORT INF SET 43"/13MM...................................73COMPLERA...............................11Complete Natal DHA ..............143CompleteNate ............ 28, 143, 148COMPRO............................. 67, 90CO-NATAL FA....28, 81, 143, 148CONCEPT DHA........ 28, 143, 148

CONCEPT OB............28, 144, 148CONDYLOX............................142Constulose ..................................79CONTACT DETACH INF SET 23" 6MM.....................................73CONTACT DETACH INF SET 23" 8MM.....................................73CONTACT DETACH INF SET 23"/6MM.....................................73CONTACT DETACH INF SET 23"/8MM.....................................73CONTACT DETACH INF SET 32"/6MM.....................................73CONTACT DETACH INF SET 32"/8MM.....................................73CONTACT DETACH INF SET 43" 6MM.....................................73CONTACT DETACH INF SET 43" 8MM.....................................73COPAXONE.............................113CORDRAN.......................133, 137CORNWALL SYR PIPET OUTFIT 10ML......................... 117CORNWALL SYR PIPET OUTFIT 1ML........................... 117CORNWALL SYR PIPET OUTFIT 2ML........................... 117CORNWALL SYR PIPET OUTFIT 5ML........................... 117CORTIFOAM...................133, 137Cortisone Acetate ......................94CORVITE FREE.............. 144, 148Cotton Candy Flavor ..............122COUMADIN.............................. 25COVARYX.........................96, 102Cran-Raspberry Flavor ..........122Cream Base ..............................122Cream Concentrate .................122Creme DeMenthe Flavor ........122CREON.......................................92CRIXIVAN.................................12Cromolyn Sodium .............85, 129CRYSELLE-28...........................98CURITY NACL DRESSING 6"X6-3/4"....................................73Cutis Plus .................................122Cyanocobalamin ..................... 148CYCLAFEM 1/35...................... 98CYCLAFEM 7/7/7..................... 98Cyclobenzaprine HCl ............... 21Cyclopentolate HCl ...................90Cyclophosphamide ..................115

CycloSERINE ..............................8CycloSPORINE .......112, 113, 115CycloSPORINE Modified...................................112, 113, 115Cyproheptadine HCl .......... 3, 128CYRED.......................................98Danazol ...................................... 96Dantrolene Sodium ................... 21Dapsone ........................................8DARAPRIM................................. 8DASETTA 1/35.......................... 98DASETTA 7/7/7.........................98DDAVP RHINAL TUBE......... 105DEBLITANE..............................98DELTASONE.............................95DELTEC COZMO CLEO SET 24" 6MM.....................................73DELTEC COZMO CLEO SET 24" 9MM.....................................73DELTEC COZMO CLEO SET 31" 6MM.....................................73DELTEC COZMO CLEO SET 31" 9MM.....................................73DELTEC COZMO CLEO SET 42" 6MM.....................................73DELTEC COZMO CLEO SET 42" 9MM.....................................73DELYLA.................................... 98DELZICOL.................................91Demeclocycline HCl ..................16DEMSER.................................. 116DENTA 5000 PLUS................. 111DENTAGEL............................. 111DEPACON..................... 54, 56, 57DEPAKENE................... 54, 56, 57DEPEN TITRATABS........ 94, 112DEPO-MEDROL........................95DESCOVY................................. 11Desipramine HCl ...................... 71Desmopressin Ace Spray Refrig ..................................26, 105Desmopressin Acetate .......26, 105Desmopressin Acetate Spray ..105Desogestrel-Ethinyl Estradiol .. 98Desonide ...........................133, 137Desoximetasone ............... 133, 137Desvenlafaxine Succinate ER ...69Dexamethasone ..........................95DEXAMETHASONE INTENSOL.................................95Dexamethasone Sodium Phosphate ...................................88

158

DEXERYL................................136Dexmethylphenidate HCl .........68Dexmethylphenidate HCl ER .. 68Dextroamphetamine Sulfate .... 53Dextroamphetamine Sulfate ER ...............................................53DIAB.........................................122DIAB F.D.G. FREEZE-DRIED122DIASTAT ACUDIAL.......... 61, 62DIASTAT PEDIATRIC....... 61, 62Diazepam ............................. 61, 62DiazePAM ....................61, 62, 117DIAZEPAM INTENSOL..... 61, 62Diclofenac Sodium...............................66, 89, 140, 142Diclofenac Sodium ER ..............66Dicloxacillin Sodium .................15Dicyclomine HCl ....................... 20Didanosine ................................. 11Diflunisal ....................................66DIGIFAB............................ 19, 109DIGITEK.............................. 35, 41DIGOX..................................35, 41Digoxin ................................. 35, 41Dihydroergotamine Mesylate...............................................22, 57DILANTIN........................... 42, 63DILANTIN INFATABS.......42, 63DILATRATE-SR........................48Diltiazem HCl.................38, 39, 40, 41, 44, 45, 51Diltiazem HCl ER.......................38, 39, 40, 41, 44, 51Diltiazem HCl ER Beads.......................38, 39, 40, 41, 44, 51DilTIAZem HCl ER Coated Beads ............ 38, 39, 40, 41, 44, 51Dilt-XR .........38, 39, 40, 41, 45, 52DimenhyDRINATE ...... 3, 90, 128DIPENTUM................................91Diphenatol ............................... 117DiphenhydrAMINE HCl ....3, 128Diphenoxylate-Atropine.......................................20, 90, 127Dipyridamole .......................32, 52Disopyramide Phosphate ..........42Disulfiram ................................109DIURIL.................................50, 84Divalproex Sodium ....... 55, 56, 57Divalproex Sodium ER .55, 56, 57Docusate Sodium .......................91Dofetilide ....................................44

Donepezil HCl ........................... 22Dorzolamide HCl ...................... 87Dorzolamide HCl-Timolol Mal ....................................... 87, 88Dothelle DHA ............ 28, 144, 148Doxazosin Mesylate .......22, 32, 47Doxepin HCl .............................. 71Doxycycline Hyclate ............16, 86Doxycycline Monohydrate ....... 16DRITHO-CREME HP.............. 140Droperidol ................................. 58DROXIA.....................................17DRYSOL.................................. 135DULoxetine HCl ..................63, 69Dutasteride .............................. 109DUZALLO..................................85DYRENIUM.........................49, 81E.E.S. 400............................... 9, 13EASYGEL................................ 117Econazole Nitrate ............135, 136EDURANT................................. 11EEMT................................. 96, 103Efavirenz ....................................11EFFER-K.................................... 81Effervescent Pot Chloride ........ 81ELETONE.......................... 73, 136ELETONE TWINPACK.... 73, 136ELINEST.................................... 98ELIQUIS.....................................25ELIQUIS STARTER PACK...... 25ELIXOPHYLLIN. 46, 80, 131, 143ELLA.......................................... 98ELMIRON................................ 116EMOLIVAN............................. 122Emollient Base .................122, 136EMOQUETTE............................98EMTRIVA.................................. 11Enalapril Maleate ............... 33, 34Enalapril-Hydrochlorothiazide .....34, 50, 84ENBREL...................112, 113, 142ENBREL MINI.........112, 113, 142ENBREL SURECLICK...................................112, 113, 142ENDOCET............................53, 64English Toffee Flavor ............. 122ENLITE SERTER...................... 73Enoxaparin Sodium .................. 26ENPRESSE-28........................... 98ENSKYCE..................................98Entacapone ................................ 62Entecavir ....................................14

Enulose .......................................79ePHEDrine HCl ................ 19, 126ePHEDrine Sulfate ............19, 126EPIFOAM.................133, 135, 137EPINEPHrine ....................19, 126EPIPEN 2-PAK.................. 19, 126EPIPEN JR 2-PAK............. 19, 126EPITOL.......................................55EPIVIR HBV.............................. 11Epoprostenol Sodium ....... 52, 131Ergocal ..................................... 153Ergocalciferol .......................... 153ERGOMAR.......................... 22, 57Ergotamine-Caffeine .......... 22, 57ERRIN........................................ 98Ery ............................................132ERYPED 400..........................9, 13ERY-TAB............................. 10, 13ERYTHROCIN STEARATE10, 13Erythromycin .................... 86, 132Erythromycin Base ............. 10, 13Erythromycin Ethylsuccinate...............................................10, 13Erythromycin Stearate ...........117Escitalopram Oxalate ............... 70ESGIC.......................54, 57, 61, 68Essentra Wipes 9x9" ...............117Est Estrogens-Methyltest . 96, 103Est Estrogens-Methyltest DS.............................................96, 103ESTARYLLA............................. 98Estradiol ...................................103ESTRING................................. 103Eszopiclone ................................ 58Ethacrynic Acid .................. 48, 80Ethambutol HCl ..........................8Ethosuximide .............................70Ethynodiol Diac-Eth Estradiol 99Etidronate Disodium .............. 110Etodolac ............................... 66, 67Etodolac ER ...............................66EUCRISA......................... 133, 135Eugenol Flavor ........................ 122EURAX.....................................141EVOTAZ............................ 12, 116Ezetimibe ................................... 42Fagron LS Plus ........................122Fagron Natural ........................122Fagron Supreme ......................122FALMINA.................................. 99Famciclovir ................................14Famotidine .................................93

159

Famotidine Premixed ............... 93FARESTON........................17, 102FD&C Yellow #5 ..................... 122FD&C Yellow #6 Aluminum Lake ..........................................122FDC Yellow 6 .......................... 122Felbamate .................................. 55Felodipine ER ....39, 45, 46, 47, 52FEMYNOR.................................99Fenofibrate ................................ 46Fenofibrate Micronized ............46FentaNYL .................................. 65FentaNYL Citrate ..................... 65Ferocon ...................................... 28Ferotrinsic ..................................28Ferric Ammonium Citrate ..... 122Ferric Chloride Hexahydrate 122FERROCITE PLUS....28, 148, 152Ferrous Fumarate ..................... 28Ferrous Gluconate .................... 28Ferrous Gluconate Dihydrate ..28Ferrous Sulfate ..........................28Filter Needle .............................. 73Finasteride ............................... 109Fish Flavor ...............................117FITALITE.................................122FLAREX.....................................88Flavor Plus ...............................122Flavor Sweet ............................ 122Flavor Sweet-SF ...................... 122FlavoxATE HCl ...................... 142Flecainide Acetate ..................... 43FLORIVA PLUS.............. 111, 144FLOVENT DISKUS...........95, 130FLOVENT HFA................. 95, 130Fluconazole ..................................9Fluconazole in Dextrose ..............9Fluconazole in Sodium Chloride ....................................... 9Flucytosine .................................15Fludarabine Phosphate ............ 17Fludrocortisone Acetate ........... 95Fluocinolone Acetonide .. 134, 138Fluocinolone Acetonide Body...........................................134, 138Fluocinolone Acetonide Scalp...........................................134, 138Fluocinonide .................... 134, 138Fluocinonide Emulsified Base...........................................134, 138FLUORABON..........................111Fluoritab .......................... 111, 117

Fluorometholone ....................... 88FLUOROPLEX.................. 17, 142Fluorouracil .......................17, 142FLUoxetine HCl ........................ 70FLUoxetine HCl (PMDD) ........ 70FluPHENAZine Decanoate ...... 67FluPHENAZine HCl .................67FLURA-DROPS....................... 111Flurbiprofen .............................. 67Flurbiprofen Sodium ................ 89Flutamide ...................................17Fluticasone Propionate .....88, 129Fluticasone-Salmeterol ............. 23FluvoxaMINE Maleate .............70FML FORTE.............................. 88Folbee Plus .......................148, 152Folic Acid .................................148FOLIVANE-OB..........28, 144, 148Foltrin ........................................ 28Fondaparinux Sodium ..............25Food Color Orange ................. 122Food Color Yellow .................. 123FORTAVIT.........................28, 144Fosamprenavir Calcium ...........12Fosinopril Sodium .....................34Fosinopril Sodium-HCTZ.........................................34, 50, 84FRAGMIN............................26, 27Freedom AdaptaDerm ............123Freedom Derma Serum .......... 123FREEDOM DERMA-D............123FREEDOM DERMA-N............123FREESTYLE LIBRE READER.73FREESTYLE LIBRE SENSOR SYSTEM.....................................73Furosemide .......................... 48, 80FYAVOLV....................... 103, 106Gabapentin .......................... 54, 55Galantamine Hydrobromide ....22GALZIN......................................94GAVILYTE-C............................ 91GAVILYTE-N WITH FLAVOR PACK.........................91Gemfibrozil ................................46Generlac .....................................79GENGRAF............... 112, 113, 115GENTAK....................................86Gentamicin in Saline ...................6Gentamicin Sulfate ....... 6, 86, 132Gentian Violet ......................... 132GENVOYA...........................10, 11GILDESS FE 1.5/30................... 99

GILDESS FE 1/20...................... 99GILENYA.................................113GILOTRIF.................................. 17Glatiramer Acetate ................. 114GLATOPA................................114GLEOSTINE.............................. 17Glimepiride ..............................107GlipiZIDE ................................107GlipiZIDE ER ......................... 107GlipiZIDE XL ......................... 107GlipiZIDE-MetFORMIN HCl.............................................97, 107GLUCAGON EMERGENCY...........................................103, 109Gluconolactone ........................123GLUCOPRO SYR RES 3ML 22GX3/8"..................................117GlyBURIDE .............................107GlyBURIDE Micronized ........ 107GlyBURIDE-MetFORMIN.............................................97, 107Glycerin ........................... 123, 139Glycerine ..................................117Glycerol Formal ...................... 123GLYDO...................................... 89GRANIX.....................................25Grape Flavor ........................... 123Griseofulvin Microsize ............... 7Griseofulvin Ultramicrosize .......7GuaiFENesin ER .....................128GUAIFENEX LA..................... 117GuanFACINE HCl ............. 42, 63GuanFACINE HCl ER .......42, 63Guava Flavor ...........................123GYNAZOLE-1......................... 136Haloperidol ................................62Haloperidol Decanoate ............. 62Haloperidol Lactate .................. 62Ham Flavor ..............................117HEATHER..................................99Hematinic Plus Vit/Minerals.....................................28, 148, 152Hematinic/Folic Acid ........ 28, 148HEMATOGEN FA.....28, 148, 152HEMATOGEN FORTE.....................................28, 148, 152HemeNatal OB .......... 28, 144, 148HemeNatal OB + DHA.....................................28, 144, 148HEMOCYTE-F...................28, 148Hemocyte-Plus .........................117Heparin (Porcine) in D5W ....... 27

160

Heparin (Porcine) in NaCl.......................................27, 74, 117Heparin Lock Flush ............27, 74Heparin Sod (Porcine) in D5W ........................................... 27Heparin Sodium (Porcine) ....... 27Heparin Sodium Flush ............. 27Heparin Sodium Lock Flush...............................................27, 74Heparin Sodium/D5W .............. 27HOMATROPAIRE.....................90Homatropine HBr .....................90Honey Flavor ...........................123HPR PLUS..................................74HUMALOG MIX 50/50... 104, 106HUMALOG MIX 50/50 KWIKPEN........................104, 106HUMALOG MIX 75/25... 105, 107HUMALOG MIX 75/25 KWIKPEN........................105, 106HUMAPEN LUXURA HD........ 74HUMIRA.................................... 92HUMIRA PEDIATRIC CROHNS START...................... 92HUMIRA PEN............................92HUMIRA PEN-CD/UC/HS STARTER...................................92HUMIRA PEN-PS/UV/ADOL HS START..................................92HUMULIN R U-500 (CONCENTRATED)........105, 107HydrALAZINE HCl .................46HydroCHLOROthiazide ....50, 84HYDROcodone Bitartrate ....... 65Hydrocodone-Acetaminophen...............................................54, 65Hydrocodone-Homatropine.......................................20, 65, 127Hydrocodone-Ibuprofen .....65, 67Hydrocortisone ..........95, 134, 138Hydrocortisone Valerate 134, 138Hydrocortisone-Acetic Acid...............................................88, 89HYDROFERA BLUE 4"X4"..... 74HYDROFERA BLUE 6"X6"..... 74HYDROFERA BLUE FOAM DRESSING.................................74HYDROFERA BLUE FOAM/TUNNELING.................74HYDROFERA BLUE MRF DRESSING.................................74

HYDROFERA BLUE READY FOAM.......................................117Hydromet ...........................20, 127HYDROmorphone HCl ............65Hydroxocobalamin ................. 148Hydroxocobalamin HCl ......... 148Hydroxychloroquine Sulfate.......................................8, 112, 114Hydroxyprogesterone Caproate .................................. 106Hydroxypropyl Cellulose ....... 123Hydroxytryptophan ................123Hydroxytryptophan L-5 .........123Hydroxyurea ............................. 17HydrOXYzine HCl ............... 4, 58HydrOXYzine Pamoate ........4, 58HYLATOPIC PLUS...................74IBRANCE...................................17Ibuprofen ................................... 67ICAR-C PLUS............ 28, 148, 152Ichthammol ............................. 123IFEREX 150 FORTE..........28, 148Imatinib Mesylate ..................... 17IMBRUVICA............................. 17Imipenem-Cilastatin ................... 9Imipramine HCl ........................71Imiquimod ............................... 142INATAL GT............................. 144Indapamide ..........................51, 85Indomethacin .....................67, 110Indomethacin ER .............. 67, 110INFASURF............................... 130INFED.........................................28Infusion Catheter Soft 23" .......74Infusion Catheter Soft 31" .......74Infusion Catheter Soft 43" .......74Infusion Needle 15Gx2" ......... 117Infusion Set ................................74Infusion Set 23" .......................117Infusion Set 23" 10MM .......... 117Infusion Set 23" 8MM ............ 118Infusion Set 23" Comfort .........74Infusion Set 24" 6MM ............ 118Infusion Set 42" 6MM ............ 118Infusion Set 42" 9MM ............ 118Infusion Set 43" .......................118Infusion Set 43" 10MM .......... 118INSET 30 INFUSION SET 23"..74INSET 30 INFUSION SET 43"..74INSET INFUSION SET 23" 6MM........................................... 74

INSET INFUSION SET 23" 9MM........................................... 74INSET INFUSION SET 43" 6MM........................................... 74INSET INFUSION SET 43" 9MM........................................... 74Insulin Cartridge 3ML ............. 74INTELENCE.............................. 11INTROVALE..............................99INVEGA SUSTENNA............... 59INVEGA TRINZA..................... 59INVIRASE..................................12Iodine Tincture ........................140IOPIDINE................................... 89I-PORT ADVANCE 6MM.........74I-PORT ADVANCE 9MM.........74Ipratropium Bromide .20, 89, 127Ipratropium-Albuterol...............................20, 23, 127, 131Irbesartan .................................. 33Irbesartan-Hydrochlorothiazide .....33, 50, 84IRESSA.......................................17ISENTRESS............................... 10ISENTRESS HD.........................10ISIBLOOM................................. 99Isoniazid .......................................8ISORDIL TITRADOSE............. 48Isosorbide Dinitrate .................. 49Isosorbide Dinitrate ER ........... 48Isosorbide Mononitrate ............ 49Isosorbide Mononitrate ER ..... 49Itraconazole ................................. 9JANTOVEN................................25JANUMET..........................97, 102JANUMET XR................... 97, 102JANUVIA................................. 102JARDIANCE............................ 107JENCYCLA................................99Jevantique Lo .................. 103, 106JINTELI............................103, 106JOLESSA....................................99JOLIVETTE................................99JULEBER................................... 99JUNEL 1.5/30............................. 99JUNEL 1/20................................ 99JUNEL FE 1.5/30....................... 99JUNEL FE 1/20.......................... 99JUNEL FE 24............................. 99Kahlua Flavor ......................... 123KALETRA..................................12KANGAROO BURETTE SET 118

161

KARIVA.....................................99K-Effervescent ...........................81KELNOR 1/35............................ 99KENDALL ALGINATE DRESS 2"X2"...........................118KENDALL ALGINATE DRESS 4"X4"...........................118KENDALL ALGINATE DRESS 4"X8"...........................118KENDALL AMORPHOUS WOUND................................... 123KERAGEL................................123KERAGELT............................. 123Ketoconazole ........................9, 136Ketoprofen ER .......................... 67Ketorolac Tromethamine ......... 89Ketotifen Fumarate ...................86KIONEX............................. 81, 109KLOR-CON................................82KLOR-CON 10...........................81KLOR-CON M10....................... 81KLOR-CON M15....................... 81KLOR-CON M20....................... 81KLOR-CON SPRINKLE............82KLOR-CON/EF..........................82K-PRIME....................................82K-TAB........................................ 82KURVELO................................. 99K-Vescent ...................................82Labetalol HCl.......................21, 23, 32, 36, 37, 43LAC-HYDRIN..........................136LACRISERT...............................89Lactic Acid ...............................136Lactic Acid E ........................... 136Lactulose ....................................80Lactulose Encephalopathy ....... 80LamiVUDine ............................. 11Lamivudine-Zidovudine ...........11LamoTRIgine ............................ 55LamoTRIgine Starter Kit-Blue .............................................55LamoTRIgine Starter Kit-Green ..........................................55LamoTRIgine Starter Kit-Orange ....................................... 55LANOXIN............................ 35, 42LANOXIN PEDIATRIC...... 35, 42Lansoprazole ............................. 93LARIN 1.5/30............................. 99LARIN 1/20................................ 99LARIN 24 FE............................. 99

LARIN FE 1.5/30....................... 99LARIN FE 1/20.......................... 99LARISSIA.................................. 99Latanoprost ............................... 90LATUDA....................................60Leflunomide .....................112, 114Lemon Extract .........................123LESSINA....................................99LETAIRIS...........................52, 131Letrozole .............................. 17, 96Leucovorin Calcium ............... 109LEUKERAN...............................17Leuprolide Acetate...............................17, 18, 103, 104Levamisole HCl ...........................7LevETIRAcetam ....................... 55Levobunolol HCl .......................87LevOCARNitine ......................116LevoFLOXacin ..................8, 9, 15LEVONEST................................99Levonorgest-Eth Estrad 91-Day ............................................. 99Levonorgestrel ...........................99Levonorgestrel-Ethinyl Estrad .......................................100Levonorg-Eth Estrad Triphasic ..................................100LEVORA 0.15/30 (28)............. 100LEVO-T....................................108Levothyroxine Sodium ........... 108Levothyroxine-Liothyronine ..108LEVOXYL................................108Licorice Flavor ........................ 123Lidocaine ......................... 109, 135Lidocaine HCl ........... 89, 109, 135Lidocaine HCl (PF) .................109Lidocaine HCl Monohydrate . 109Lidocaine PAK ........................ 135Lidocaine Viscous ..................... 89Lidocaine-Hydrocortisone Ace ............................134, 135, 138Lidopin .....................................135LILLOW................................... 100Lindane .................................... 141Linezolid .................................... 15LINZESS.................................... 93LIOPEN ABSORPTION ENHANCING...........................123Liothyronine Sodium ..............108Lipo Cream Base .....................123Lipopen Ultra Base ................. 123LipoSomal Heavy ....................123

LipoSomal Regular .................123Lisinopril ................................... 34Lisinopril-Hydrochlorothiazide...................................34, 35, 50, 84Lithium ...................................... 56Lithium Carbonate ................... 56Lithium Carbonate ER .............56LITHOBID..................................56Liver Flavor .............................118LLX EXTENSION NEEDLE...118L-Menthol ................................123Loperamide HCl ....................... 90Lopinavir-Ritonavir ................. 12LORazepam .........................61, 62LORAZEPAM INTENSOL. 61, 62LORCET...............................54, 65LORCET HD........................ 54, 65LORCET PLUS.................... 54, 65Losartan Potassium .................. 33Losartan Potassium-HCTZ.........................................33, 50, 84Loutrex .......................................74Lovastatin .................................. 47LOW-OGESTREL....................100Loxapine Succinate ...................58LUDENT.................................. 111LUPRON DEPOT (1-MONTH).....................................18, 103, 104LUPRON DEPOT (3-MONTH).....................................18, 103, 104LUPRON DEPOT (4-MONTH).....................................18, 103, 104LUPRON DEPOT (6-MONTH).....................................18, 103, 104LUPRON DEPOT-PED (1-MONTH)............................ 18, 104LUPRON DEPOT-PED (3-MONTH)............................ 18, 104LUTERA...................................100LUXAMEND......................74, 136LYCELLE...................................74LYRICA......................... 54, 55, 63LYSIPLEX PLUS.......................80LYZA........................................100MAGELLAN INSULIN SAFETY SYR............................ 74MAGELLAN TUBERCULIN SYRINGE................................... 75Magnesium Gluconate ..............82MAKENA.................................106Malathion .................................141

162

Mango Flavor .......................... 123Mannitol .........................49, 80, 90Maple Flavor ........................... 123Maprotiline HCl ........................71MARATHON MEDICAL PENTIPS.....................................75Marlissa ................................... 100Marshmallow Flavor .............. 123MATULANE..............................18MAVYRET.................................10MAXIDEX..................................88Meclizine HCl ........................4, 90MEDIDERM.............................123MEDIHONEY CA ALGINATE 2"X2".......................................... 75MEDIHONEY CA ALGINATE 4"X5".......................................... 75MEDIHONEY WOUND/BURN DRESSING.... 75MEDROL................................... 95MedroxyPROGESTERone Acetate ......................................106Mefloquine HCl ...........................8Megestrol Acetate ............. 18, 106MEKINIST................................. 18Meloxicam ..................................67Melphalan ..................................18MENEST.................................. 103Menthol ....................................123Mercaptopurine ................ 18, 115Meropenem ..................................9Mesalamine ................................91MESNEX..................................116MESTINON................................22METADATE ER........................ 68Metaproterenol Sulfate .....23, 131MetFORMIN HCl .....................97MetFORMIN HCl ER .............. 97Methadone HCl .........................65Methazolamide ..........................88Methenamine Mandelate ..........16METHERGINE........................ 120MethIMAzole ............................ 97Methitest .................................... 96Methocarbamol ......................... 21Methotrexate ..... 18, 112, 114, 115Methotrexate Sodium.............................18, 112, 114, 115Methotrexate Sodium (PF).............................18, 112, 114, 115Methoxsalen .............................140Methoxsalen Rapid ................. 140

Methyclothiazide .................50, 85Methyldopa ..........................20, 42Methyldopa-Hydrochlorothiazide...................................20, 42, 50, 85Methylphenidate HCl ............... 68Methylphenidate HCl ER .........68Methylphenidate HCl ER (CD) ............................................68MethylPREDNISolone ............. 95MethylPREDNISolone Acetate ........................................95MethylPREDNISolone Sodium Succ .............................. 95MethylTESTOSTERone .......... 96Metoclopramide HCl ................ 93Metolazone ...........................51, 85Metoprolol Succinate ER...................................24, 36, 37, 43Metoprolol Tartrate24, 36, 37, 43Metoprolol-Hydrochlorothiazide.......................24, 36, 37, 43, 50, 85MetroNIDAZOLE .......... 6, 8, 132MetroNIDAZOLE Benzoate ..6, 8Mexiletine HCl .......................... 42Miconazole ...............................136Miconazole 3 ............................136MICROGESTIN 1.5/30............100MICROGESTIN 1/20...............100MICROGESTIN FE 1.5/30...... 100MICROGESTIN FE 1/20......... 100MIGERGOT......................... 22, 57Miglitol .......................................96MILLEX-FG FILTER/TEFLON...................... 75MILLIPRED............................... 95Mineral Oil Heavy .................... 91MINIMED PRO-SET INFUSION 24"......................... 118MINIMED PRO-SET INFUSION 42"......................... 118MINIMED PUMP RESERVOIR 3ML..................... 75MINIMED RESERVOIR 1.8ML......................................... 75MINIMED RESERVOIR 3ML.. 75MINITRAN................................ 49Minocycline HCl ....................... 16Minoxidil ....................................46Mint Chocolate Chip Flavor .. 123

MIO INFUSION SET 18" 6MM........................................... 75MIO INFUSION SET 23" 6MM........................................... 75MIO INFUSION SET 32" 6MM........................................... 75MIO INFUSION SET 32" 9MM........................................... 75Mirtazapine ............................... 56Misoprostol ................................93Mitomycin ..................................18Modafinil ................................... 71MODERIBA............................... 14MODERIBA 1200 DOSE PACK..........................................14Mometasone Furoate ...... 134, 138MONOJECT ALLERGIST TRAY......................................... 75MONOJECT BLUNTIP CANNULA.................................75MONOJECT BLUNTIP SYR/CANNULA......................118MONOJECT CONTROL SYRINGE........................... 75, 118MONOJECT FILTER ASPIRATOR.............................. 75MONOJECT FILTER NEEDLE.....................................75MONOJECT HYPODERMIC NEEDLE.....................................75MONOJECT HYPODERMIC NEEDLE TIP............................118MONOJECT INSULIN SYRINGE................................... 75MONOJECT LIFESHIELD CANNULA.................................75MONOJECT LIFESHIELD SYRINGE........................... 76, 118MONOJECT MAGELLAN SAFETY NDL.......................... 118MONOJECT MAGELLAN SYRINGE........................... 76, 118MONOJECT MED PREP CANNULA...............................118MONOJECT PHARMACY TRAY......................................... 76MONOJECT PISTON SYRINGE................................... 76MONOJECT SMARTIP SYR/CANNULA........................76MONOJECT SYRINGE.............76

163

MONOJECT SYRINGE CATH TIP.............................................. 76MONOJECT SYRINGE ECC LUER..........................................76MONOJECT SYRINGE ECCENTRIC TIP....................... 76MONOJECT SYRINGE LUER LOCK......................................... 76MONOJECT SYRINGE LUER-LOCK TIP.......................76MONOJECT SYRINGE PHARMACY TRAY..................76MONOJECT SYRINGE REG LUER..........................................76MONOJECT SYRINGE REGULAR TIP.......................... 76MONOJECT SYRINGE TOOMEY TYPE........................ 76MONOJECT TB SAFETY SYRINGE................................... 76MONOJECT TB SYRINGE.......76MONOJECT ULTRA COMFORT SYRINGE...............76MONOJECT VIAL ACCESS CANNULA.................................76MONO-LINYAH......................100MONONESSA......................... 100Montelukast Sodium .......128, 129MORGIDOX.............................. 16Morphine Sulfate ...................... 65Morphine Sulfate (Concentrate) .....................65, 118Morphine Sulfate ER ................65MOVANTIK...............................93MOXEZA................................... 86Moxifloxacin HCl ............9, 16, 86Moxifloxacin HCl in NaCl ....9, 15MUCINEX D..............19, 126, 128MUCINEX DM................ 127, 128MULTAQ................................... 44Multi Vit/Fl ..............................118Multi-Draw Needle ................... 77Multiple Vitamins/Fluoride ... 118MultiUse Base ..........................123Multi-Vit/Fluoride .......... 111, 144Multi-Vit/Iron/Fluoride.....................................28, 111, 144Multivitamin/Fluoride ....111, 144Multi-Vitamin/Fluoride ..111, 144Multivitamin/Fluoride/Iron.....................................29, 111, 144

Multi-Vitamin/Fluoride/Iron.....................................29, 111, 144Multivitamins/Fluoride .. 111, 144Mult-Vitamin/Fluoride ...........119Mupirocin ................................ 132MVC-FLUORIDE............ 111, 144M-VIT.........................29, 144, 148Mycophenolate Mofetil ...........115MYDAYIS..................................53Myferon 150 Forte ............ 29, 149MYLERAN.................................18MYNATAL.......... 29, 82, 144, 149MYNATAL ADVANCE...............................29, 82, 144, 149Mynatal Plus ........29, 82, 144, 149Mynatal-Z ............29, 82, 144, 149Mynate 90 Plus ........................144Mynephrocaps .................149, 152MYNEPHRON................. 149, 152MYORISAN............................. 142MYSOLINE................................60MYZILRA................................ 100Nabumetone ...............................67Nadolol ..................... 21, 36, 37, 43Nafcillin Sodium ........................15NAFRINSE...............................119NAFRINSE DROPS.................119Naloxone HCl .................... 66, 110Naltrexone HCl ................. 66, 109Naphazoline HCl .......................90Naproxen ........................... 67, 110Naproxen DR .....................67, 110Naproxen Sodium ............. 67, 110NARCAN........................... 66, 110NASCOBAL.............................149NATALVIT.......... 29, 82, 144, 149NATELLE ONE... 29, 82, 144, 149NATROBA............................... 141NEBUPENT................................. 8NEBUSAL............................77, 82NECON 0.5/35 (28)..................100NECON 1/35 (28).....................100Nefazodone HCl ........................ 70NEOCERA......................... 77, 136Neomycin Sulfate ........................ 6Neomycin-Bacitracin Zn-Polymyx ..................................... 86Neomycin-Polymyxin-Dexameth ..................... 86, 88, 119Neomycin-Polymyxin-HC .. 86, 88NEO-POLYCIN..........................87NEO-POLYCIN HC.............86, 88

NEORAL.................. 112, 114, 115NEOSALUS............................... 77NEOSALUS CP..........................77NEPHRON FA........................... 29NESTABS.............29, 82, 144, 149NESTABS DHA...29, 82, 144, 149NEUPOGEN...............................25Nevirapine ................................. 11Nevirapine ER ...........................11NEWGEN............. 29, 82, 145, 149NEXA PLUS.............. 29, 145, 149NEXAVAR.................................18NEXIUM.................................... 93Niacin ......................................... 35Niacin ER (Antihyperlipidemic) ................ 35Niacinamide .............................149NIACOR..................................... 35NICADAN........................116, 149NICAZEL......................... 116, 149NICAZEL FORTE............116, 149Nicotinamide ........................... 149NICOTROL................................ 21NICOTROL NS.......................... 21NIFEDICAL XL.39, 45, 46, 47, 52NIFEdipine ER ..39, 45, 46, 47, 52NIFEdipine ER Osmotic Release ................39, 45, 46, 47, 52Nilutamide ................................. 18NiMODipine ...... 39, 45, 46, 47, 52NITRO-BID................................49NITRO-DUR.............................. 49Nitrofurantoin ........................... 17Nitrofurantoin Anhydrous .......16Nitrofurantoin Macrocrystal ... 17Nitrofurantoin Monohyd Macro ......................................... 17Nitroglycerin ..............................49Nitroglycerin ER .......................49NITROMIST...............................49NITRO-TIME............................. 49NIVA-PLUS......... 29, 82, 145, 149NIVATOPIC PLUS.................... 77NORA-BE.................................100NORDITROPIN FLEXPRO.... 105Norethin Ace-Eth Estrad-FE . 100Norethindrone ......................... 100Norethindrone Acetate ........... 106Norethindrone Acet-Ethinyl Est .............................................100

164

Norethindrone-Eth Estradiol...........................................103, 106Norgestimate-Eth Estradiol ... 100Norgestim-Eth Estrad Triphasic ..................................100NORLYDA...............................100NORLYROC............................ 100NORPACE CR........................... 42NORTREL 0.5/35 (28)............. 100NORTREL 1/35 (21)................ 101NORTREL 1/35 (28)................ 101NORTREL 7/7/7.......................101Nortriptyline HCl ......................71NORVIR..................................... 12NOURILITE............................. 123NOURIVAN ANTIOX BASE..123NOVOEIGHT.............................26NOVOLOG MIX 70/30....105, 107NOVOLOG MIX 70/30 FLEXPEN.........................105, 107NOVOPEN ECHO..................... 77Noxi-K ......................................124NP Thyroid .............................. 108NUTRASEB............................. 136NUTRICAP................ 29, 145, 149NUTRIFAC ZX........................ 119NUTRIVIT..................29, 145, 149NUVARING............................. 101NYAMYC.................................141Nystatin ..............................15, 141Nystatin-Triamcinolone ......... 141NYSTOP...................................141OBSTETRIX DHA.....29, 145, 149O-CAL FA............ 29, 82, 145, 149O-CAL PRENATAL...............................29, 82, 145, 149Octreotide Acetate .......... 107, 116ODEFSEY.................................. 11Ofloxacin ..............................16, 87OGESTREL..............................101OLANZapine .............................60Olopatadine HCl ....................... 86Omeprazole ................................93Ondansetron ..............................90Ondansetron HCl ......................90ORALONE....................... 134, 138Orange Cream Flavor ............ 124Orange Flavor ......................... 124Orange Oil Flavor ...................124ORA-PLUS...............................124ORA-SWEET........................... 124ORA-SWEET SF......................124

ORFADIN.................................116Orphenadrine Citrate ER ........ 24ORSYTHIA.............................. 101Oseltamivir Phosphate ............. 14Oxacillin Sodium .......................15Oxazepam .................................. 62OXcarbazepine ..........................55Oxybutynin Chloride ..............143Oxybutynin Chloride ER142, 143OxyCODONE HCl ............65, 119Oxycodone-Acetaminophen...............................................54, 65Oxycodone-Aspirin ............. 65, 69Oxymorphone HCl ....................66OxyMORphone HCl ER .......... 66OZEMPIC.................................104PACERONE............................... 44Pantoprazole Sodium ................93PARADIGM POLYFIN QR/WINGS 24".......................... 77PARADIGM POLYFIN QR/WINGS 42".......................... 77PARADIGM PUMP RESERVOIR 1.8ML.................. 77PARADIGM PUMP RESERVOIR 3ML..................... 77PARADIGM QUICK-SET 18" 6MM........................................... 77PARADIGM QUICK-SET 23" 6MM........................................... 77PARADIGM QUICK-SET 23" 9MM........................................... 77PARADIGM QUICK-SET 32" 6MM........................................... 77PARADIGM QUICK-SET 32" 9MM........................................... 77PARADIGM QUICK-SET 43" 6MM........................................... 77PARADIGM QUICK-SET 43" 9MM........................................... 77PARADIGM SILHOUETTE 18" 13MM...................................77PARADIGM SILHOUETTE 32" 17MM...................................77PARADIGM SILHOUETTE COMBO 23"............................... 77PARADIGM SILHOUETTE COMBO 43"............................... 77PARADIGM SILHOUETTE FULL 23"....................................77PARADIGM SILHOUETTE FULL 43"....................................77

PARADIGM SOF-SET MICRO QR 24".......................... 77PARADIGM SOF-SET MICRO QR 42".......................... 77PARADIGM SOF-SET ULT QR 24"........................................ 77PARADIGM SOF-SET ULT QR 42"........................................ 77PARADIGM SURE-T 23" 6MM........................................... 77PARADIGM SURE-T 23" 8MM........................................... 77PAROEX.................................... 89Paromomycin Sulfate ................. 6PARoxetine HCl ........................70PAXIL.........................................70PB-Hyoscy-Atropine-Scopolamine ...................20, 60, 61PCCA ALADERM BASE........124PCCA ANHYDROUS LIPODERM BASE...................124PCCA BIOPEPTIDE BASE.....124PCCA COSMETIC HRT BASE...................................................124PCCA LIPODERM BASE....... 124PCCA MVC BASE...................124PCCA NATACREAM..............124PCCA PRACASIL TM-PLUS BASE........................................ 124PCCA SWEETNESS ENHANCER.............................124PCCA SWEET-SF....................124PCCA SYRUP VEHICLE........124PCCA VANISHING CREAM BASE........................................ 124PCCA VANISHING CREAM LIGHT...................................... 124PCCA VANPEN BASE........... 124Peach Flavor ............................124Peanut Butter Flavor ..............124PEG 3350-KCl-Na Bicarb-NaCl ........................................... 91PEGASYS...................................12PEGASYS PROCLICK..............12PEGINTRON..............................12PENCREAM.............................124PenDerm .................................. 124Penicillin V Potassium ..............13PenSomal ................................. 119Pentaphene Base ..................... 119PENTASA.................................. 91PENTIPS.....................................77

165

Pentoxifylline ER ...................... 26PEPCID.......................................93Permethrin ...............................141Perphenazine ............................. 67Pharbedryl ...........................3, 128PHARMABASE COSMETIC..124PHARMABASE HEAVY........ 124PHASEAL ASSEMBLY FIXTURE................................... 77PHASEAL CAP FOR INJECTOR............................... 119PHASEAL CONNECTOR LUER LOCK.............................. 77PHASEAL INFUSION ADAPTER..................................77PHASEAL INFUSION CLAMP.......................................77PHASEAL INJECTOR LUER LOCK......................................... 77PHASEAL IV BAG HANGER 119PHASEAL PROTECTOR 14..... 78PHASEAL PROTECTOR 21..... 78PHASEAL PROTECTOR 28..... 78PHASEAL PROTECTOR 50..... 78PHASEAL SECONDARY SET.78PHASEAL SYRINGE TRAY.. 119PHASEAL Y-SITE CONNECTOR............................78PHENADOZ...........................3, 58PHENAZO................................135Phenazopyridine HCl ............. 135Phenelzine Sulfate .....................64PHENobarbital ................... 60, 61PHENobarbital Sodium ........... 61PHENOHYTRO............. 20, 60, 61Phenoxybenzamine HCl ..... 22, 47Phentolamine Mesylate .......22, 47Phenylephrine HCl ................... 90PHENYTEK......................... 42, 63Phenytoin ............................. 42, 63PHENYTOIN INFATABS...42, 63Phenytoin Sodium ...............43, 64Phenytoin Sodium Extended...............................................42, 63PHILITH...................................101PHOSPHA 250 NEUTRAL....... 79PHOSPHOLINE IODIDE.......... 89PHOSPHO-TRIN 250 NEUTRAL..................................79PHYTOBASE...........................124Phytonadione ...........................153Pilocarpine HCl ...................22, 89

Pimozide .....................................58PIMTREA.................................101Pina Colada Flavor ................. 124Pindolol .............. 21, 36, 37, 43, 47Pineapple Flavor ..................... 124Pioglitazone HCl ..................... 108Pioglitazone HCl-Glimepiride108Pioglitazone HCl-Metformin HCl ..................................... 97, 108Piperacillin Sod-Tazobactam So ................................................ 10PIRMELLA 1/35...................... 101PIRMELLA 7/7/7..................... 101Piroxicam ...................................67PNV Folic Acid + Iron.....................................29, 145, 149PNV OB+DHA.........................29, 82, 91, 145, 149PNV Prenatal Plus Multivitamin ........29, 82, 145, 149PNV Tabs 29-1 .... 29, 82, 145, 149PNV-DHA ..................29, 145, 149PNV-DHA+Docusate.........................29, 82, 91, 145, 149PNV-Omega .........29, 82, 145, 149PNV-Select .................29, 145, 149Podocon ....................................142Podofilox .................................. 142Podophyllum Resin .................139POLYCIN................................... 87Polyethylene Glycol 3350 . 91, 124POLYFIN INFUSION SET 24". 78POLYFIN INFUSION SET 42". 78POLYFIN QR INFUSION SET 24"...............................................78POLYFIN QR INFUSION SET 42"...............................................78POLYFIN TUBING SET 60".....78Poly-Iron 150 Forte ...........29, 149Polymyxin B-Trimethoprim .... 87Polysaccharide Iron Forte 29, 150Polyvinyl Alcohol ...................... 89Polyvitamin/Fluoride ..............119Poly-Vitamin/Fluoride ............119PORTIA-28...............................101Pot Bicarb-Pot Chloride ...........82Potassium Bicarbonate .......79, 82Potassium Bromide .................124Potassium Chloride ...................83Potassium Chloride Crys ER ...82Potassium Chloride ER ............ 83Potassium Citrate ER ............... 79

Potassium Gluconate Anhydrous ................................. 83Povidone-Iodine ...................... 140PR NATAL 400....30, 83, 145, 150PR NATAL 400 EC...............................30, 83, 145, 150PR NATAL 430....30, 83, 145, 150PR NATAL 430 EC...............................30, 83, 145, 150Pralines and Cream Flavor ....124Pramipexole Dihydrochloride ..64PRAMOX................................. 135Pravastatin Sodium .................. 47Praziquantel ................................ 7Prazosin HCl ................. 22, 32, 33PRED MILD...............................88PrednisoLONE ..........................95PrednisoLONE Acetate ............ 88PrednisoLONE Sodium Phosphate .............................88, 95PredniSONE ..............................96PREDNISONE INTENSOL.......96PREMARIN..............................103Premium Lidocaine ................ 119PREMPHASE...........................103PREMPRO................................103Prena 1 True ..............30, 145, 150Prena1 Pearl .............. 30, 145, 150Prenaissance .. 30, 83, 91, 145, 150Prenaissance Plus.........................30, 83, 91, 145, 150PRENATABS RX 30, 83, 145, 150Prenatal ................30, 83, 145, 150Prenatal 19 ...........30, 83, 145, 150Prenatal Low Iron...............................30, 83, 145, 150Prenatal Plus ....... 30, 83, 145, 150Prenatal Plus Iron...............................30, 83, 145, 150Prenatal Plus/Iron...............................30, 83, 145, 150Prenatal Vitamin Plus Low Iron .......................30, 83, 145, 150PRENATAL/FOLIC ACID...... 119PRENATAL-U......................... 145PrePLUS .............. 30, 83, 146, 150PreTAB ................ 30, 83, 146, 150PREVACID................................ 94PREVALITE...............................37PREVIFEM...............................101PREZCOBIX...................... 12, 116PREZISTA..................................12

166

PRIFTIN................................. 9, 16Primaquine Phosphate ............... 8Primidone .................................. 60PRIMSOL................................... 17Pro Comfort Pen Needles . 78, 119PROAIR RESPICLICK..............23Probenecid ......................... 85, 110Prochlorperazine .................67, 90Prochlorperazine Maleate ..67, 90PROCRIT............................. 25, 26PROCTOCARE-HC................. 119PROCTOCORT................134, 138PROCTOFOAM HC 134, 135, 138PROCTO-MED HC..........134, 138PROCTO-PAK................. 134, 138PROCTOSOL HC............ 134, 138PROCTOZONE-HC......... 134, 138Progesterone ............................ 106PROGRAF................................115PROLIA....................................110Promethazine HCl .....3, 4, 58, 128Promethazine VC ..........4, 20, 128Promethazine VC/Codeine...........................4, 20, 66, 127, 128Promethazine-Codeine.....................................66, 127, 128Promethazine-DM .......4, 127, 128Promethazine-Phenyleph-Codeine ............ 4, 20, 66, 127, 128Promethazine-Phenylephrine.........................................4, 20, 128PROMETHEGAN.................. 4, 58PROMISEB................................ 78Propafenone HCl ...................... 43Propantheline Bromide ............ 20Propranolol HCl.................21, 36, 37, 43, 48, 57, 58Propranolol HCl ER.......................21, 36, 37, 43, 48, 57Propranolol-HCTZ.......................21, 36, 37, 43, 50, 85Propylene Glycol .....................125Propylthiouracil ........................ 97PROTECT PLUS................30, 146Protriptyline HCl ...................... 71PRUCLAIR.........................78, 136PRUMYX................................... 78Pseudoeph-Bromphen-DM.............................19, 126, 127, 128Pseudoephedrine HCl .......19, 126P-Siloxan DS ............................119

PULMICORT FLEXHALER.............................................96, 130PULMOZYME................... 85, 129Pumpkin Flavor ...................... 125PureFe OB Plus .........30, 146, 150Pyrazinamide ...............................9Pyridostigmine Bromide .......... 22Pyridostigmine Bromide ER ....22Pyridoxine HCl ........................150QUASENSE............................. 101QUEtiapine Fumarate .............. 60QUEtiapine Fumarate ER ....... 60QUFLORA PEDIATRIC..111, 146QUICK-SET INFUSION 23" 6MM........................................... 78QUICK-SET INFUSION 23" 9MM........................................... 78QUICK-SET INFUSION 43" 6MM........................................... 78QUICK-SET INFUSION 43" 9MM........................................... 78Quinapril HCl ..................... 34, 35Quinapril-Hydrochlorothiazide...................................34, 35, 50, 85QuiNIDine Gluconate ER .... 8, 42QuiNIDine Sulfate ................ 8, 42QuiNINE Sulfate .........................8QVAR REDIHALER......... 96, 130RADIAGEL..............................125RADIAPLEXRX........................ 78Raloxifene HCl ................ 102, 110Ramipril ...............................34, 35RANEXA....................................41Ranitidine HCl .......................... 93RaNITidine HCl ........................93RAPAMUNE............................115Raspberry Flavor ....................125REBETOL.................................. 14RECLIPSEN............................. 101Rejuvacare Plus .......................125RELENZA DISKHALER...........14REMICADE93, 113, 114, 116, 142RENACIDIN.............................. 80RENAGEL..........................81, 110RENAL............................. 150, 152Reno Caps ........................150, 152Repaglinide ..............................105REQ 49+................................... 146RESCRIPTOR............................ 11RESECTISOL.............................80RESTASIS..................................89

RESTASIS MULTIDOSE..........89RESTORE SILVER DRESSING.........................78, 125Reusable Syringe Barrel 1.5oz...................................................119Reusable Syringe Barrel 1oz ..119Reusable Syringe Barrel 2oz ..119Reusable Syringe Barrel 3oz ..119Reusable Syringe Barrel 4oz ..119REVLIMID.................................18REYATAZ..................................12RIBASPHERE............................14RIBASPHERE RIBAPAK......... 14Ribavirin ....................................14Riboflavin-5-Phosphate Sodium ..................................... 150RIDAURA.................. 94, 113, 114Rifabutin ................................9, 16Rifampin ................................ 9, 16Riluzole ...................................... 63Risedronate Sodium ................111RISPERDAL CONSTA..............60RisperiDONE ............................ 60Ritonavir ....................................12Rivastigmine Tartrate .............. 23Rizatriptan Benzoate ................ 69R-NATAL OB............ 30, 146, 150ROBB-TYPE ANGIO SYRINGE 80CC.......................119Root Beer Flavor .....................125ROPINIRole HCl ...................... 64ROSADAN............................... 132ROSANIL CLEANSER... 139, 140Rosuvastatin Calcium ...............47ROWEEPRA.............................. 55RTD WOUND CARE DRESSING...............................119RUBRACA................................. 18SA3 Derm .................................125Saline Bacteriostatic ................. 83Saline-Benzyl Alcohol ...............83Salsalate ..................................... 69Salt Durable Cream ................125SALT STABLE LO..................125SALT STABLE LS ADVANCED............................125SANARE ADVANCED SCAR THERAPY................................125Sanare Scar Therapy ..............125SANDIMMUNE.......113, 114, 115

167

SANDOSTATIN LAR DEPOT...........................................107, 116SANTYL...................................142Sash Kit ................................27, 78SAVAYSA................................. 25SEDANARE............................. 125SEGLUROMET......................... 97SELECT-OB+DHA....30, 146, 150Selegiline HCl ............................ 64Selenium Sulfide ......................140SEMPREX-D..........4, 19, 126, 130Se-Natal 19 ...........30, 83, 146, 150SEREVENT DISKUS........ 24, 131SEROMYCIN...............................9Sertraline HCl ........................... 70SETLAKIN...............................101Sevelamer Carbonate ....... 81, 110Sevoflurane ................................64SF ..............................................111SF 5000 Plus ............................ 111SFROWASA...............................91SHAROBEL............................. 101Shrimp Flavor ......................... 119SIDEROL................... 30, 150, 152Sildenafil Citrate ...............49, 131SILHOUETTE 13MM................78SILHOUETTE 17MM................78SILHOUETTE INFUSION SET 23"...............................................78SILHOUETTE INFUSION SET 43"...............................................78Silprotex Plus .......................... 119SILVASORB.............................. 78Silver Protein Mild ................. 140Silver Sulfadiazine .................. 140Simvastatin ................................ 47Sirolimus ..................................115Skyy Derm ............................... 125Sodium Ascorbate ...................152Sodium Chloride ................. 78, 83Sodium Chloride Bacteriostatic .............................83Sodium Fluoride ......................112Sodium Nitrite ...........................49Sodium Polystyrene Sulfonate.............................................81, 110SOF-SET INFUSION SET 24".. 78SOF-SET INFUSION SET 42".. 78SOF-SET MICRO QR INFUSION 24"........................... 78SOF-SET MICRO QR INFUSION 42"........................... 78

SOF-SET ULTIMATE QR 24".. 78SOF-SET ULTIMATE QR 42".. 78SOLIA.......................................101SOLU-MEDROL........................96Solvatech Sweet SF ................. 119SORINE........21, 36, 37, 43, 44, 48Sotalol HCl ........ 22, 36, 37, 44, 48Sotalol HCl (AF)22, 36, 37, 44, 48SP Antipruritic ..........................78Spinosad ...................................141SPIRIVA RESPIMAT........ 20, 127Spironolactone ...............48, 49, 81Spironolactone-HCTZ.............................48, 49, 50, 81, 85SPRINTEC 28.......................... 101SPS......................................81, 110SRONYX..................................101SSD........................................... 140SSKI........................7, 97, 110, 128SSS 10-5 ........................... 139, 140Stavudine ................................... 12STEGLATRO........................... 107Stera Base ................................ 125Sterile Water for Injection ..... 125Stevia Glycerite Extract ......... 125STIOLTO RESPIMAT.........20, 24Strawberry Flavor .................. 125Streptomycin Sulfate .............. 6, 9STRIANT................................... 96STRIBILD............................ 10, 12STROVITE FORTE... 30, 146, 150STROVITE ONE......146, 150, 153SUBOXONE...............................66Sucralfate ...........................93, 119Sulfacetamide ............................ 16Sulfacetamide Sodium .............. 87Sulfacetamide Sodium (Acne) 140Sulfacetamide Sodium-Sulfur...........................................139, 140Sulfacetamide-Prednisolone.............................................87, 120SulfADIAZINE ......................... 16Sulfamethoxazole-Trimethoprim ............................16SulfaSALAzine ....16, 91, 113, 114SULFATRIM PEDIATRIC........16SULFAZINE.........16, 91, 113, 114Sulfur ............................... 139, 141Sulfur Precipitated ..................139Sulfur Sublimed ...................... 139Sulindac ..................................... 67SUMAtriptan .............................69

SUMAtriptan Succinate ..... 69, 70SUMAtriptan Succinate Refill .69Support .................................... 146SUPPORT-500................. 150, 152SUPRANE.................................. 64SYMBICORT............................. 24SYNAGIS................................... 13SYNAREL................................104SYNJARDY....................... 97, 107SYNJARDY XR.................97, 107SYNTHROID........................... 108SYNVISC................................... 79SYNVISC ONE.......................... 79Syringe Caps ............................120Syringe Filter 0.2 Micron/32mm ..........................120Syringe Filter 0.45 Micron ..... 120Syringe Filter/0.2 Micron/25mm ..........................120Syringe Filter/0.2 Micron/30mm ..........................120Syringe Filter/Millex/25mm ...120Syringe Filter/Millex-GS/25mm ................................... 79Syringe Filter/Millex-GV/33mm .................................120Syringe Luer Lock .................... 79Syringe Luer Slip ...................... 79Syrpalta ....................................125SYRPALTA (RED).................. 125SYRSPEND SF........................ 125Syrup Vehicle .......................... 125Syrup Vehicle SF .....................125T:30 INFUSION SET................. 79T:90 INFUSION SET................. 79T:FLEX INSULIN CARTRIDGE 4.8ML................. 79T:SLIM G4 INSULIN CARTRIDGE............................. 79T:SLIM INSULIN CARTRIDGE 3ML.................... 79TABLOID...................................18Tacrolimus .......................115, 142Tadalafil (PAH) .........................49TAFINLAR.................................18Tamoxifen Citrate .............18, 102Tamsulosin HCl ........................ 23TARCEVA................................. 19TARGRETIN......................19, 142TARINA FE 1/20..................... 101TARON-BC..........30, 83, 146, 150TARON-C DHA.........30, 146, 150

168

TARON-PREX..... 30, 92, 146, 151TAZICEF..................................5, 6TAZTIA XT..38, 39, 40, 41, 45, 52TB Syringe 1 ML ...................... 79TECFIDERA............................ 114TEGADERM AG MESH 2"X2"........................................ 120TEGADERM AG MESH 4"X5"........................................ 120TEGADERM AG MESH 4"X8".......................................... 79TEGADERM AG MESH 8"X8"........................................ 120TEGRETOL................................55TEGRETOL-XR.........................55Temazepam ................................62Temozolomide ........................... 19TENCON.............................. 54, 61Terazosin HCl ......... 22, 32, 33, 48Terbinafine HCl .......................... 6Terbutaline Sulfate ........... 24, 131Terconazole ..............................136TeroDerm ................................ 125TeroDerm-Plus ........................125Testosterone Cypionate ............ 96Testosterone Enanthate ............96Testosterone Propionate ...........96Tetrabenazine ......................63, 71Tetracaine ................................109Tetracaine HCl ........................109Tetracycline HCl .......................16TETRIX.................................... 136TEXACORT..................... 134, 138THEOCHRON......46, 80, 131, 143Theophylline ........46, 80, 131, 143Theophylline ER . 46, 80, 131, 143Theophylline in D5W...............................46, 80, 131, 143THERAHONEY....................... 120THERMAZENE....................... 140Thiamine HCl ..........................151Thimerosal ...............................125Thioridazine HCl ...................... 67Thiothixene ................................71Thrivite 19 ........... 30, 92, 146, 151Thrivite Rx ................ 30, 146, 151THYROLAR-1......................... 108THYROLAR-1/2...................... 108THYROLAR-1/4...................... 108THYROLAR-2......................... 109THYROLAR-3......................... 109TiaGABine HCl .........................55

Tightening Base .......................120TILIA FE.................................. 101Timolol Maleate.................22, 36, 37, 44, 48, 58, 87TIMOPTIC OCUDOSE..............87Titanium Dioxide .................... 125TIVICAY....................................11TiZANidine HCl ........................21TL Icon ...................................... 30TL-Care DHA ..... 30, 92, 146, 151TL-Select ........30, 83, 92, 146, 151TOBRADEX.........................87, 88Tobramycin ........................... 6, 87Tobramycin Sulfate .................... 6Tobramycin-Dexamethasone...............................................87, 88TOBREX.................................... 87Tolnaftate .................................142Tolterodine Tartrate ER ........ 143Toluidine Blue O ..................... 110Toomey Syringe ........................ 79TOPEX TOPICAL ANESTHETIC..........................120Topiramate ................................ 56Torsemide ............................ 48, 80TOUJEO MAX SOLOSTAR... 105TOUJEO SOLOSTAR..............105TOVIAZ....................................143TraMADol HCl ......................... 66Tramadol-Acetaminophen.........................................54, 58, 66Tranylcypromine Sulfate ......... 64TRAVATAN Z...........................90TraZODone HCl ....................... 70Tretinoin ............................ 19, 136TREXALL.......... 19, 113, 114, 115TRI FEMYNOR....................... 101Triacetin .......................................7Triamcinolone Acetonide.............88, 129, 134, 135, 138, 139Triamcinolone Diacet Micronize ................................... 96Triamcinolone Diacetate .......... 96Triamterene-HCTZ 50, 51, 81, 85TRIANEX.........................135, 139Triazolam ...................................62TRICARE................... 31, 146, 151TRICARE PRENATAL DHA ONE...................... 31, 92, 146, 151TRICON..................................... 31TRIDERM........................ 135, 139TRI-ESTARYLLA................... 101

Trifluoperazine HCl ................. 68Trifluridine ................................87Trigels-F Forte .......... 31, 151, 152TRIGLIDE..................................46Trihexyphenidyl HCl ..........21, 54TRI-LEGEST FE...................... 101TRI-LINYAH........................... 101TRILYTE....................................92Trimethoprim ............................17Trimipramine Maleate ............. 71Trinatal Rx 1 ....... 31, 83, 146, 151TRINATE............. 31, 84, 146, 151TRINESSA (28)........................101Tripelennamine HCl ...................3Triphrocaps ..................... 151, 152TRI-PREVIFEM.......................102TRI-SPRINTEC........................102Tri-Tabs DHA ..... 31, 84, 146, 151TRIUMEQ............................ 11, 12TRIVEEN-DUO DHA...............................31, 84, 146, 151TRIVORA (28).........................102Tropical Punch Flavor ........... 125Tropicamide .............................. 90TRUSTEEL INFUSION SET.....79TRUVADA.................................12Trypsin .....................................125Tutti Frutti Flavor .................. 125Tutti-Frutti Flavor ..................125TYKERB.................................... 19ULTICARE INSULIN SAFETY SYR............................ 79ULTILET INSULIN SYRINGE...................................................120UltimateCare ONE...............................31, 84, 146, 151Ultraderm ................................ 125UNITHROID............................ 109UNITHROID DIRECT.............120Urosex .............................. 146, 151Ursodiol ......................................92Vacuum Filter 0.20um/150ml 120ValACYclovir HCl ....................14ValGANciclovir HCl .................14Valproate Sodium ......... 56, 57, 58Valproic Acid ................ 56, 57, 58Valsartan ................................... 33Vancomycin HCl .......................10Vancomycin HCl in Dextrose ...10VANDAZOLE..........................132Vanilla Butternut Flavor ........125Vanilla Flavor ..........................125

169

Vanishing ................................. 126Vanishing Cream Botanical Base .......................................... 126Vanish-Pen ...............................126VARISOFT INFUSION SET..... 79VASCUDERM HYDROGEL.. 126V-C Forte ......................... 146, 151VELETRI............................52, 131VELIVET..................................102Vena-Bal DHA .... 31, 84, 146, 151Venlafaxine HCl ........................69Venlafaxine HCl ER ................. 69VENTOLIN HFA............... 24, 131Verapamil HCl .. 38, 40, 41, 45, 52Verapamil HCl ER.......................38, 39, 40, 41, 45, 52VERSAFREE........................... 126VERSAPLUS........................... 126VERSAPRO............................. 126Versatile Cream Base ............. 126VERSATILE RICH BASE.......126Vial Stopper .............................120VIBRAMYCIN...........................16Vicap Forte ...................... 146, 151VIC-FORTE..................... 146, 151VICTOZA.................................104VIDEX........................................12VIENVA................................... 102VINATE II............31, 84, 146, 151VINATE M.................31, 147, 151VINATE ONE...... 31, 84, 147, 151Viorele ......................................102VIRACEPT.................................12VIREAD..................................... 12Virt-C DHA ............... 31, 147, 151Virt-Caps ......................... 151, 152Virt-Nate DHA .......... 31, 147, 151Virt-Phos 250 Neutral ...............79Virt-PN .......................31, 147, 151Virt-PN DHA .............31, 147, 151Virt-PN Plus ........ 31, 84, 147, 151VITA S FORTE..........31, 147, 151VITACEL......................... 147, 151VITAFOL................................... 31VITAFOL-OB...... 31, 84, 147, 151VITAFOL-OB+DHA...............................31, 84, 147, 151VITAFOL-ONE..........31, 147, 151VITAMEDMD ONE RX/QUATREFOLIC..31, 147, 152Vita-Min ...................................120Vitamin D (Ergocalciferol) .....153

VITAPEARL.............. 31, 147, 152VITAROCA PLUS...................120Vita-Rx Diabetic Vitamin...........................................147, 152VITATRUE................ 31, 147, 152VIVA DHA.................31, 147, 152VIVITROL..........................66, 109Vol-Nate ............... 31, 84, 147, 152Vol-Plus ................31, 84, 147, 152Vol-Tab Rx .......... 31, 84, 147, 152VP DermaBase ........................ 120VP-Heme OB + DHA 31, 147, 152VYFEMLA............................... 102VYVANSE................................. 53Warfarin Sodium ...................... 25Watermelon Flavor .................126WERA.......................................102Wild Cherry Flavor ................ 126XARELTO..................................25XARELTO STARTER PACK... 25XELJANZ.................................114XELJANZ XR.......................... 114XEMATOP BASE....................126XERALUX............................... 120Zafirlukast ............................... 129Zaleplon ..................................... 58Zanabin Hydrogel .....................79ZANTAC.................................... 93ZARONTIN................................70ZATEAN-PN DHA.... 31, 147, 152ZATEAN-PN PLUS...............................31, 84, 147, 152ZEBUTAL................ 54, 58, 61, 68ZENATANE............................. 142ZENZEDI....................................53ZEPATIER................................. 10Zidovudine .................................12Zinc Oxide ............................... 142Zinc Undecylenate .................. 132Ziprasidone HCl ........................60ZITHROMAX............................ 15ZOE SCRIPTS IDEALBASE...126Zoledronic Acid .......................111Zolpidem Tartrate .................... 58Zonisamide ................................ 56ZOVIA 1/35E (28)....................102ZUBSOLV..................................66

170

gateway health 2018 medicaid formulary · iv non-formulary drugs a non-formulary drug is one that...

Documents