july 10, 2017 ahcccs pharmacy and therapeutics committee ... · july 10, 2017 ahcccs pharmacy and...

July 10, 2017 AHCCCS Pharmacy and Therapeutics Committee Preferred Drug List Decisions Effective October 1, 2017

Therapeutic Class / Market Basket

National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code

(NDC) First DataBank GCN Generic Name Brand Name

Preferred Drug List Status

ON = Preferred Drug

NPD = Non Preferred Drug

STIMULANTS AND RELATED AGENTS 00115168501 61400016107040 00115168501 24735 DEXMETHYLPHENIDATE ER 20 MG CP DEXMETHYLPHENIDATE HCL ER NPD





STIMULANTS AND RELATED AGENTS 00078043205 61400016107040 00078043205 24735 FOCALIN XR 20 MG CAPSULE FOCALIN XR ON


STIMULANTS AND RELATED AGENTS 68462027030 61354015100170 68462027030 26538 ATOMOXETINE HCL 80 MG CAPSULE ATOMOXETINE HCL NPD




STIMULANTS AND RELATED AGENTS 00002325030 61354015100170 00002325030 26538 STRATTERA 80 MG CAPSULE STRATTERA ON






STIMULANTS AND RELATED AGENTS 00406184001 61400020100240 00406184001 26734 METHYLPHENIDATE ER 40 MG CAP METHYLPHENIDATE HCL ER ON


STIMULANTS AND RELATED AGENTS 62175015437 61400020100240 62175015437 26734 METHYLPHENIDATE CD 40 MG CAP METHYLPHENIDATE HCL CD ON

STIMULANTS AND RELATED AGENTS 53014058207 61400020100240 53014058207 26734 METADATE CD 40 MG CAPSULE METADATE CD NPD












STIMULANTS AND RELATED AGENTS 68968555201 26801 DAYTRANA 10 MG/9 HR PATCH DAYTRANA ON

STIMULANTS AND RELATED AGENTS 68968555203 61400020005910 68968555203 26801 DAYTRANA 10 MG/9 HR PATCH DAYTRANA ON

STIMULANTS AND RELATED AGENTS 68968555303 61400020005915 68968555303 26802 DAYTRANA 15 MG/9 HR PATCH DAYTRANA ON

7/26/2017 1



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


STIMULANTS AND RELATED AGENTS 68968555403 61400020005920 68968555403 26803 DAYTRANA 20 MG/9 HOUR PATCH DAYTRANA ON

STIMULANTS AND RELATED AGENTS 68968555401 26803 DAYTRANA 20 MG/9 HOUR PATCH DAYTRANA ON

STIMULANTS AND RELATED AGENTS 68968555503 61400020005930 68968555503 26804 DAYTRANA 30 MG/9 HOUR PATCH DAYTRANA ON

STIMULANTS AND RELATED AGENTS 00781545101 61353030107520 00781545101 27576 GUANFACINE HCL ER 1 MG TABLET GUANFACINE HCL ER ON




STIMULANTS AND RELATED AGENTS 54092051302 61353030107520 54092051302 27576 INTUNIV ER 1 MG TABLET INTUNIV NPD




























7/26/2017 2



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug







STIMULANTS AND RELATED AGENTS 57844011701 61109902100307 57844011701 29007 ADDERALL 7.5 MG TABLET ADDERALL ON

STIMULANTS AND RELATED AGENTS 57664064208 61109902100307 57664064208 29007 DEXTROAMP-AMPHETAM 7.5 MG TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON

STIMULANTS AND RELATED AGENTS 57844011201 61109902100312 57844011201 29008 ADDERALL 12.5 MG TABLET ADDERALL ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON


DEXTROAMPHETAMINE-

AMPHETAMINE ON

STIMULANTS AND RELATED AGENTS 64720013410 61109902100315 64720013410 29009

DEXTROAMP-AMPHETAMIN 15 MG

TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON

STIMULANTS AND RELATED AGENTS 57844011501 61109902100315 57844011501 29009 ADDERALL 15 MG TABLET ADDERALL ON

7/26/2017 3



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON

STIMULANTS AND RELATED AGENTS 00228424106 61353020107420 00228424106 29319 CLONIDINE HCL ER 0.1 MG TABLET CLONIDINE HCL ER NPD



STIMULANTS AND RELATED AGENTS 59212065860 61353020107420 59212065860 29319 KAPVAY ER 0.1 MG TABLET KAPVAY ON











STIMULANTS AND RELATED AGENTS 24478021030 61400020101920 24478021030 33887 QUILLIVANT XR 25 MG/5 ML SUSP QUILLIVANT XR ON




STIMULANTS AND RELATED AGENTS 24338085010 61100020100303 24338085010 34734 ZENZEDI 2.5 MG TABLET ZENZEDI NPD

STIMULANTS AND RELATED AGENTS 24338085210 61100020100308 24338085210 34735 ZENZEDI 7.5 MG TABLET ZENZEDI NPD

STIMULANTS AND RELATED AGENTS 51862026730 61400020107048 51862026730 36195 METHYLPHENIDATE LA 60 MG CAP METHYLPHENIDATE LA ON

STIMULANTS AND RELATED AGENTS 24338085510 61100020100330 24338085510 36463 ZENZEDI 20 MG TABLET ZENZEDI NPD


STIMULANTS AND RELATED AGENTS 59417010110 61100025100110 59417010110 37674 VYVANSE 10 MG CAPSULE VYVANSE ON

STIMULANTS AND RELATED AGENTS 27808010201 6110001000G120 27808010201 39686 DYANAVEL XR 2.5 MG/ML SUSP DYANAVEL XR NPD

STIMULANTS AND RELATED AGENTS 24478012001 6140002010H220 24478012001 40289 QUILLICHEW ER 20 MG CHEW TAB QUILLICHEW ER ON



STIMULANTS AND RELATED AGENTS 70165000530 6110001000H410 70165000530 40647 ADZENYS XR-ODT 3.1 MG TABLET ADZENYS XR-ODT NPD

7/26/2017 4



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




STIMULANTS AND RELATED AGENTS 00591271830 61400020100480 00591271830 12248 METHYLPHENIDATE ER 54 MG TAB METHYLPHENIDATE ER ON





STIMULANTS AND RELATED AGENTS 50458058701 61400020100480 50458058701 12248 CONCERTA ER 54 MG TABLET CONCERTA NPD











STIMULANTS AND RELATED AGENTS 54092038301 61109902107010 54092038301 14635 ADDERALL XR 10 MG CAPSULE ADDERALL XR ON

STIMULANTS AND RELATED AGENTS 68084081595 61109902107010 68084081595 14635 DEXTROAMP-AMPHET ER 10 MG CAP

DEXTROAMPHETAMINE-AMPHET

ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD

7/26/2017 5



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ER NPD



ER NPD



ER NPD



ER NPD




ER NPD



ER NPD




ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD

STIMULANTS AND RELATED AGENTS 10702010601 61400016100320 10702010601 14973 DEXMETHYLPHENIDATE 2.5 MG TAB DEXMETHYLPHENIDATE HCL NPD




STIMULANTS AND RELATED AGENTS 00078038005 61400016100320 00078038005 14973 FOCALIN 2.5 MG TABLET FOCALIN ON



7/26/2017 6



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


STIMULANTS AND RELATED AGENTS 43386086001 61400016100330 43386086001 14974 DEXMETHYLPHENIDATE 5 MG TAB DEXMETHYLPHENIDATE HCL NPD


STIMULANTS AND RELATED AGENTS 00078038105 61400016100330 00078038105 14974 FOCALIN 5 MG TABLET FOCALIN ON







STIMULANTS AND RELATED AGENTS 00078038205 61400016100340 00078038205 14975 FOCALIN 10 MG TABLET FOCALIN ON





STIMULANTS AND RELATED AGENTS 00781574901 61400020100310 00781574901 15911 METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE HCL ON












STIMULANTS AND RELATED AGENTS 00078044005 61400020100310 00078044005 15911 RITALIN 10 MG TABLET RITALIN NPD









7/26/2017 7



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug























STIMULANTS AND RELATED AGENTS 65580059401 61400020100405 65580059401 16180 METADATE ER 20 MG TABLET METADATE ER NPD

STIMULANTS AND RELATED AGENTS 10702007606 61400020100405 10702007606 16180 METHYLPHENIDATE ER 20 MG TAB METHYLPHENIDATE ER NPD











ER NPD



ER NPD

7/26/2017 8



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ER NPD



ER NPD



ER NPD



ER NPD




ER NPD



ER NPD



ER NPD



ER NPD




ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD



ER NPD




ER NPD

7/26/2017 9



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



























STIMULANTS AND RELATED AGENTS 24338002110 61100010100320 24338002110 19821 EVEKEO 10 MG TABLET EVEKEO NPD




STIMULANTS AND RELATED AGENTS 00555095502 61100020107010 00555095502 19850 D-AMPHETAMINE ER 10 MG CAPSULE

DEXTROAMPHETAMINE SULFATE

ER ON



ER ON

STIMULANTS AND RELATED AGENTS 52054051309 61100020107010 52054051309 19850 DEXEDRINE SPANSULE 10 MG DEXEDRINE NPD

7/26/2017 10



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ER ON



ER ON



ER ON



ER ON




ER ON



ER ON



ER ON



ER ON



ER ON



ER ON



ER ON



ER ON




ER ON



ER ON

STIMULANTS AND RELATED AGENTS 10702006606 61100020100310 10702006606 19880 DEXTROAMPHETAMINE 10 MG TAB DEXTROAMPHETAMINE SULFATE ON





7/26/2017 11



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



STIMULANTS AND RELATED AGENTS 52054021610 61100020100310 52054021610 19880 DEXEDRINE 10 MG TABLET DEXEDRINE NPD












STIMULANTS AND RELATED AGENTS 52054021510 61100020100305 52054021510 19881 DEXEDRINE 5 MG TABLET DEXEDRINE NPD





STIMULANTS AND RELATED AGENTS 00054038925 61100030100305 00054038925 19932 METHAMPHETAMINE 5 MG TABLET METHAMPHETAMINE HCL NPD

STIMULANTS AND RELATED AGENTS 55292010201 61100030100305 55292010201 19932 DESOXYN 5 MG TABLET DESOXYN NPD

STIMULANTS AND RELATED AGENTS 55292010401 61100030100305 55292010401 19932 DESOXYN 5 MG TABLET DESOXYN NPD















7/26/2017 12



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug








STIMULANTS AND RELATED AGENTS 00781236201 61400020107020 00781236201 20387 METHYLPHENIDATE ER 20 MG CAP METHYLPHENIDATE ER ON

STIMULANTS AND RELATED AGENTS 00078037005 61400020107020 00078037005 20387 RITALIN LA 20 MG CAPSULE RITALIN LA NPD













STIMULANTS AND RELATED AGENTS 00078042405 61400020107010 00078042405 21763 RITALIN LA 10 MG CAPSULE RITALIN LA ON

STIMULANTS AND RELATED AGENTS 43386057001 61400020100510 43386057001 22682 METHYLPHENIDATE 2.5 MG CHEW TB METHYLPHENIDATE HCL NPD

STIMULANTS AND RELATED AGENTS 59630076010 61400020100510 59630076010 22682 METHYLIN 2.5 MG CHEWABLE TAB METHYLIN ON

STIMULANTS AND RELATED AGENTS 43386057101 61400020100520 43386057101 22683 METHYLPHENIDATE 5 MG CHEW TAB METHYLPHENIDATE HCL NPD

STIMULANTS AND RELATED AGENTS 59630076110 61400020100520 59630076110 22683 METHYLIN 5 MG CHEWABLE TABLET METHYLIN ON

STIMULANTS AND RELATED AGENTS 59630076210 61400020100530 59630076210 22684 METHYLIN 10 MG CHEWABLE TABLET METHYLIN ON

STIMULANTS AND RELATED AGENTS 43386057201 61400020100530 43386057201 22684 METHYLPHENIDATE 10 MG CHEW TAB METHYLPHENIDATE HCL NPD

STIMULANTS AND RELATED AGENTS 00406300550 61400020102020 00406300550 22685 METHYLPHENIDATE 5 MG/5 ML SOLN METHYLPHENIDATE HCL NPD






STIMULANTS AND RELATED AGENTS 59630075050 61400020102020 59630075050 22685 METHYLIN 5 MG/5 ML SOLUTION METHYLIN ON

STIMULANTS AND RELATED AGENTS 10702016450 61400020102030 10702016450 22686 METHYLPHENIDATE 10 MG/5 ML SOL METHYLPHENIDATE HCL NPD

7/26/2017 13



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug






STIMULANTS AND RELATED AGENTS 59630075550 61400020102030 59630075550 22686 METHYLIN 10 MG/5 ML SOLUTION METHYLIN ON


STIMULANTS AND RELATED AGENTS 00378408001 61400016107020 00378408001 24733 DEXMETHYLPHENIDATE ER 5 MG CAP DEXMETHYLPHENIDATE HCL ER NPD
















STIMULANTS AND RELATED AGENTS 59417011501 61100025100510 59417011501 42969 VYVANSE 10 MG CHEWABLE TABLET VYVANSE NPD






STIMULANTS AND RELATED AGENTS 54092046801 61109902107060 54092046801 43538 MYDAYIS ER 12.5 MG CAPSULE MYDAYIS NPD

STIMULANTS AND RELATED AGENTS 54092047101 61109902107065 54092047101 43539 MYDAYIS ER 25 MG CAPSULE MYDAYIS NPD

STIMULANTS AND RELATED AGENTS 54092047401 61109902107070 54092047401 43542 MYDAYIS ER 37.5 MG CAPSULE MYDAYIS NPD

STIMULANTS AND RELATED AGENTS 54092047701 61109902107075 54092047701 43543 MYDAYIS ER 50 MG CAPSULE MYDAYIS NPD


DEXTROAMP-AMPHETAMINE 5 MG

TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON

7/26/2017 14



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON

7/26/2017 15



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON



TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON

7/26/2017 16



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




TAB

DEXTROAMPHETAMINE-

AMPHETAMINE ON












STIMULANTS AND RELATED AGENTS 42858040145 61400020107055 42858040145 97234 APTENSIO XR 10 MG CAPSULE APTENSIO XR ON













STIMULANTS AND RELATED AGENTS 76181000225 61100020102020 76181000225 99801 DEXTROAMPHETAMINE 5 MG/5 ML DEXTROAMPHETAMINE SULFATE NPD

STIMULANTS AND RELATED AGENTS 27808008501 61100020102020 27808008501 99801 DEXTROAMPHETAMINE 5 MG/5 ML DEXTROAMPHETAMINE SULFATE NPD

STIMULANTS AND RELATED AGENTS 21724070105 61100020102020 21724070105 99801 PROCENTRA 5 MG/5 ML SOLUTION PROCENTRA NPD

GROWTH HORMONE 00002814801 30100020002132 00002814801 575 HUMATROPE 12 MG CARTRIDGE HUMATROPE NPD

GROWTH HORMONE 00013264681 30100020002134 00013264681 10554 GENOTROPIN 12 MG CARTRIDGE GENOTROPIN ON

GROWTH HORMONE 44087108801 30100020102130 44087108801 12767 SAIZEN 8.8 MG VIAL SAIZEN NPD

GROWTH HORMONE 44087338807 30100020102132 44087338807 12767 ZORBTIVE 8.8 MG VIAL ZORBTIVE NPD

GROWTH HORMONE 00013265402 30100020002176 00013265402 21450 GENOTROPIN MINIQUICK 1.2 MG GENOTROPIN ON


7/26/2017 17



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




GROWTH HORMONE 00013265802 30100020002184 00013265802 21454 GENOTROPIN MINIQUICK 2 MG GENOTROPIN ON

GROWTH HORMONE 44087108001 30100020102130 44087108001 23695 SAIZEN 8.8 MG CLICK.EASY CARTG SAIZEN NPD

GROWTH HORMONE 44087001601 30100020102130 44087001601 23695 SAIZEN 8.8 MG SAIZENPREP CART SAIZEN-SAIZENPREP NPD

GROWTH HORMONE 00169770421 30100020002050 00169770421 24145 NORDITROPIN FLEXPRO 5 MG/1.5 NORDITROPIN FLEXPRO ON



GROWTH HORMONE 00169770321 30100020002066 00169770321 25816 NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN FLEXPRO ON

GROWTH HORMONE 44087100502 30100020102120 44087100502 25955 SAIZEN 5 MG VIAL SAIZEN NPD

GROWTH HORMONE 44087000507 30100020102121 44087000507 25955 SEROSTIM 5 MG VIAL SEROSTIM NPD


GROWTH HORMONE 55566180101 30100020002121 55566180101 25955 ZOMACTON 5 MG VIAL ZOMACTON NPD




GROWTH HORMONE 00002733511 30100020002120 00002733511 25963 HUMATROPE 5 MG VIAL HUMATROPE NPD

GROWTH HORMONE 55566190101 30100020002140 55566190101 25967 ZOMACTON 10 MG VIAL ZOMACTON NPD


GROWTH HORMONE 50242007501 30100020002015 50242007501 27846 NUTROPIN AQ NUSPIN 5 INJECTOR NUTROPIN AQ NUSPIN NPD







GROWTH HORMONE 00013265302 30100020002174 00013265302 50217 GENOTROPIN MINIQUICK 1 MG GENOTROPIN ON



GROWTH HORMONE 00013262681 30100020002121 00013262681 63408 GENOTROPIN 5 MG CARTRIDGE GENOTROPIN ON

GROWTH HORMONE 00781300407 30100020002056 00781300407 92366 OMNITROPE 10 MG/1.5 ML CRTG OMNITROPE NPD

GROWTH HORMONE 00781300107 30100020002050 00781300107 92386 OMNITROPE 5 MG/1.5 ML CRTG OMNITROPE NPD

GROWTH HORMONE 00781400436 30100020002123 00781400436 93215 OMNITROPE 5.8 MG VIAL OMNITROPE NPD

ANTIPSYCHOTICS 00378735005 59400085100120 00378735005 13331 ZIPRASIDONE HCL 20 MG CAPSULE ZIPRASIDONE HCL ON


7/26/2017 18



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


ANTIPSYCHOTICS 00049396060 59400085100120 00049396060 13331 GEODON 20 MG CAPSULE GEODON NPD



































7/26/2017 19



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug

































ANTIPSYCHOTICS 18860012101 59152020001820 18860012101 14336 VERSACLOZ 50 MG/ML SUSPENSION VERSACLOZ NPD

ANTIPSYCHOTICS 66993068230 59157060000315 66993068230 15081 OLANZAPINE 7.5 MG TABLET OLANZAPINE ON



7/26/2017 20



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug











ANTIPSYCHOTICS 00002411630 59157060000315 00002411630 15081 ZYPREXA 7.5 MG TABLET ZYPREXA NPD





ANTIPSYCHOTICS 00093577001 59157060000320 00093577001 15082 OLANZAPINE 10 MG TABLET OLANZAPINE ON



ANTIPSYCHOTICS 00002411730 59157060000320 00002411730 15082 ZYPREXA 10 MG TABLET ZYPREXA NPD


















7/26/2017 21



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 22



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug








ANTIPSYCHOTICS 00002411230 59157060000305 00002411230 15084 ZYPREXA 2.5 MG TABLET ZYPREXA NPD





























7/26/2017 23



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



























ANTIPSYCHOTICS 65162067384 59070070002010 65162067384 16135 RISPERIDONE 1 MG/ML SOLUTION RISPERIDONE ON





ANTIPSYCHOTICS 50458030503 59070070002010 50458030503 16135 RISPERDAL 1 MG/ML SOLUTION RISPERDAL NPD




ANTIPSYCHOTICS 00378351105 59070070000310 00378351105 16136 RISPERIDONE 1 MG TABLET RISPERIDONE ON

7/26/2017 24



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug












ANTIPSYCHOTICS 50458030050 59070070000310 50458030050 16136 RISPERDAL 1 MG TABLET RISPERDAL NPD

























7/26/2017 25



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 26



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 27



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ANTIPSYCHOTICS 00310028139 59153070107515 00310028139 16193 SEROQUEL XR 150 MG TABLET SEROQUEL XR NPD

ANTIPSYCHOTICS 16729010912 59153070107515 16729010912 16193 QUETIAPINE ER 150 MG TABLET QUETIAPINE FUMARATE ER NPD






ANTIPSYCHOTICS 00591252801 59152020000320 00591252801 18141 CLOZAPINE 25 MG TABLET CLOZAPINE ON










ANTIPSYCHOTICS 00078012661 59152020000320 00078012661 18141 CLOZARIL 25 MG TABLET CLOZARIL NPD
















7/26/2017 28



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




















ANTIPSYCHOTICS 27241005303 59250015000320 27241005303 18537 ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE ON













ANTIPSYCHOTICS 59148000813 59250015000320 59148000813 18537 ABILIFY 10 MG TABLET ABILIFY NPD




7/26/2017 29



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 30



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 31



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


















ANTIPSYCHOTICS 00781531108 59070070007230 00781531108 19178 RISPERIDONE 1 MG ODT RISPERIDONE ODT ON

ANTIPSYCHOTICS 50458031530 59070070007230 50458031530 19178 RISPERDAL M-TAB 1 MG ODT RISPERDAL M-TAB NPD










ANTIPSYCHOTICS 00781531106 19178 RISPERIDONE 1 MG ODT RISPERIDONE ODT ON








7/26/2017 32



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





ANTIPSYCHOTICS 00378604328 59070070007220 00378604328 19541 RISPERIDONE 0.5 MG ODT RISPERIDONE ODT ON







ANTIPSYCHOTICS 50458039530 59070070007220 50458039530 19541 RISPERDAL M-TAB 0.5 MG ODT RISPERDAL M-TAB NPD

ANTIPSYCHOTICS 50458039528 59070070007220 50458039528 19541 RISPERDAL M-TAB 0.5 MG ODT RISPERDAL M-TAB NPD

ANTIPSYCHOTICS 00781531006 19541 RISPERIDONE 0.5 MG ODT RISPERIDONE ODT ON























7/26/2017 33



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug







ANTIPSYCHOTICS 50458030611 59070070101920 50458030611 20217 RISPERDAL CONSTA 25 MG SYR RISPERDAL CONSTA ON

ANTIPSYCHOTICS 50458030711 59070070101930 50458030711 20218 RISPERDAL CONSTA 37.5 MG SYR RISPERDAL CONSTA ON

ANTIPSYCHOTICS 50458030811 59070070101940 50458030811 20219 RISPERDAL CONSTA 50 MG SYR RISPERDAL CONSTA ON

ANTIPSYCHOTICS 00002323130 62995002500120 00002323130 20868 SYMBYAX 6-25 MG CAPSULE SYMBYAX NPD

ANTIPSYCHOTICS 49884025011 62995002500120 49884025011 20868 OLANZAPINE-FLUOXETINE 6-25 MG OLANZAPINE-FLUOXETINE HCL NPD















ANTIPSYCHOTICS 00456240560 59155015100720 00456240560 21636 SAPHRIS 5 MG TAB SL BLK CHERRY SAPHRIS ON



ANTIPSYCHOTICS 00456240506 21636 SAPHRIS 5 MG TAB SL BLK CHERRY SAPHRIS ON

ANTIPSYCHOTICS 00093301219 59152020007220 00093301219 21784 CLOZAPINE ODT 25 MG TABLET CLOZAPINE ODT ON




ANTIPSYCHOTICS 18860010201 59152020007220 18860010201 21784 FAZACLO 25 MG ODT FAZACLO NPD



7/26/2017 34



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug











ANTIPSYCHOTICS 54838057059 59250015002020 54838057059 24062 ARIPIPRAZOLE 1 MG/ML SOLUTION ARIPIPRAZOLE ON



ANTIPSYCHOTICS 59148001315 59250015002020 59148001315 24062 ABILIFY 1 MG/ML SOLUTION ABILIFY NPD























7/26/2017 35



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug

























ANTIPSYCHOTICS 00054022931 59153070100314 00054022931 26409 QUETIAPINE FUMARATE 50 MG TAB QUETIAPINE FUMARATE ON












7/26/2017 36



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug








ANTIPSYCHOTICS 00310027810 59153070100314 00310027810 26409 SEROQUEL 50 MG TABLET SEROQUEL NPD





























7/26/2017 37



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug














ANTIPSYCHOTICS 59148064023 59250015007220 59148064023 26445 ABILIFY DISCMELT 10 MG TABLET ABILIFY DISCMELT NPD

ANTIPSYCHOTICS 13811069230 59250015007220 13811069230 26445 ARIPIPRAZOLE ODT 10 MG TABLET ARIPIPRAZOLE ODT ON




ANTIPSYCHOTICS 59148064123 59250015007230 59148064123 26448 ABILIFY DISCMELT 15 MG TABLET ABILIFY DISCMELT NPD

ANTIPSYCHOTICS 50458056001 59070050101837 50458056001 27414 INVEGA SUSTENNA 39 MG/0.25 ML INVEGA SUSTENNA ON



ANTIPSYCHOTICS 50458056303 27417 INVEGA SUSTENNA 156 MG/ML SYRG INVEGA SUSTENNA ON

ANTIPSYCHOTICS 50458056301 59070050101840 50458056301 27417 INVEGA SUSTENNA 156 MG/ML SYRG INVEGA SUSTENNA ON


ANTIPSYCHOTICS 00456241011 27528 SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS ON

ANTIPSYCHOTICS 00456241060 59155015100730 00456241060 27528 SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS ON

ANTIPSYCHOTICS 00456241063 59155015100730 00456241063 27528 SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS ON

ANTIPSYCHOTICS 00456241006 27528 SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS ON

ANTIPSYCHOTICS 00378397893 59070050007505 00378397893 27685 PALIPERIDONE ER 1.5 MG TABLET PALIPERIDONE ER NPD



ANTIPSYCHOTICS 50458055401 59070050007505 50458055401 27685 INVEGA ER 1.5 MG TABLET INVEGA NPD

ANTIPSYCHOTICS 00002763711 59157060101970 00002763711 27848 ZYPREXA RELPREVV 405 MG VL KIT ZYPREXA RELPREVV NPD



7/26/2017 38



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


ANTIPSYCHOTICS 00078059620 59070035000320 00078059620 28026 FANAPT 2 MG TABLET FANAPT NPD









ANTIPSYCHOTICS 00093308619 28873 CLOZAPINE ODT 150 MG TABLET CLOZAPINE ODT ON



ANTIPSYCHOTICS 00093308719 28874 CLOZAPINE ODT 200 MG TABLET CLOZAPINE ODT ON



ANTIPSYCHOTICS 63402030430 59400023100320 63402030430 29366 LATUDA 40 MG TABLET LATUDA ON
















ANTIPSYCHOTICS 00093524719 59157060007230 00093524719 34022 OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT ON



ANTIPSYCHOTICS 00002445585 59157060007230 00002445585 34022 ZYPREXA ZYDIS 15 MG TABLET ZYPREXA ZYDIS NPD

7/26/2017 39



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug










ANTIPSYCHOTICS 65862065810 34022 OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT ON



























7/26/2017 40



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





ANTIPSYCHOTICS 59148001870 59250015001920 59148001870 34284 ABILIFY MAINTENA ER 300 MG VL ABILIFY MAINTENA ON







ANTIPSYCHOTICS 59148004580 59250015001920 59148004580 37681 ABILIFY MAINTENA ER 300 MG SYR ABILIFY MAINTENA ON

ANTIPSYCHOTICS 59148007292 37682 ABILIFY MAINTENA ER 400 MG SYR ABILIFY MAINTENA ON

ANTIPSYCHOTICS 59148007280 59250015001930 59148007280 37682 ABILIFY MAINTENA ER 400 MG SYR ABILIFY MAINTENA ON

ANTIPSYCHOTICS 59148003513 59250020000310 59148003513 38278 REXULTI 0.25 MG TABLET REXULTI NPD

ANTIPSYCHOTICS 59148003613 59250020000320 59148003613 38476 REXULTI 0.5 MG TABLET REXULTI NPD

ANTIPSYCHOTICS 00456240206 59155015100710 00456240206 38479 SAPHRIS 2.5 MG TAB SL BLK CHRY SAPHRIS ON

ANTIPSYCHOTICS 00456240211 38479 SAPHRIS 2.5 MG TAB SL BLK CHRY SAPHRIS ON

ANTIPSYCHOTICS 00456240260 59155015100710 00456240260 38479 SAPHRIS 2.5 MG TAB SL BLK CHRY SAPHRIS ON

ANTIPSYCHOTICS 59148003713 59250020000330 59148003713 38589 REXULTI 1 MG TABLET REXULTI NPD




ANTIPSYCHOTICS 50458060601 59070050101850 50458060601 38697 INVEGA TRINZA 273 MG/0.875 ML INVEGA TRINZA ON




ANTIPSYCHOTICS 61874011511 59400018100120 61874011511 39579 VRAYLAR 1.5 MG CAPSULE VRAYLAR NPD



ANTIPSYCHOTICS 61874013030 59400018100130 61874013030 39582 VRAYLAR 3 MG CAPSULE VRAYLAR NPD





ANTIPSYCHOTICS 65757040103 5925001520E420 65757040103 39726 ARISTADA ER 441 MG/1.6 ML SYRN ARISTADA ON

7/26/2017 41



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug







ANTIPSYCHOTICS 61874017008 5940001810B220 61874017008 40683 VRAYLAR 1.5 MG-3 MG PACK VRAYLAR NPD

ANTIPSYCHOTICS 63090017060 59400028200320 63090017060 41264 NUPLAZID 17 MG TABLET NUPLAZID NPD

ANTIPSYCHOTICS 65757040401 43488 ARISTADA ER 1064 MG/3.9 ML SYR ARISTADA ON

ANTIPSYCHOTICS 65757040403 5925001520E450 65757040403 43488 ARISTADA ER 1064 MG/3.9 ML SYR ARISTADA ON



























7/26/2017 42



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 43



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 44



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 45



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 46



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug







ANTIPSYCHOTICS 65862011905 59070070000303 65862011905 92872 RISPERIDONE 0.25 MG TABLET RISPERIDONE ON




ANTIPSYCHOTICS 50458030150 59070070000303 50458030150 92872 RISPERDAL 0.25 MG TABLET RISPERDAL NPD


























7/26/2017 47



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug
























ANTIPSYCHOTICS 42292002601 97769 PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER NPD

ANTIPSYCHOTICS 00378397993 59070050007510 00378397993 97769 PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER NPD

ANTIPSYCHOTICS 50458055010 59070050007510 50458055010 97769 INVEGA ER 3 MG TABLET INVEGA NPD











7/26/2017 48



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug






ANTIPSYCHOTICS 42292002701 97770 PALIPERIDONE ER 6 MG TABLET PALIPERIDONE ER NPD








ANTIPSYCHOTICS 50458030911 59070070101910 50458030911 98414 RISPERDAL CONSTA 12.5 MG SYR RISPERDAL CONSTA ON























7/26/2017 49



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ANTIPSYCHOTICS 18860010110 59152020007210 18860010110 98791 FAZACLO 12.5 MG ODT FAZACLO NPD

ANTIPSYCHOTICS 00093301101 59152020007210 00093301101 98791 CLOZAPINE ODT 12.5 MG TABLET CLOZAPINE ODT ON






ANTIPSYCHOTICS 00310028060 59153070107505 00310028060 98994 SEROQUEL XR 50 MG TABLET SEROQUEL XR NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751659 2710400500E220 00002751659 5678 HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751601 2710400500E220 00002751601 5678 HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751001 27104005002020 00002751001 5679 HUMALOG 100 UNITS/ML VIAL HUMALOG ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751017 27104005002020 00002751017 5679 HUMALOG 100 UNITS/ML VIAL HUMALOG ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002850101 27104010002015 00002850101 9633 HUMULIN R 500 UNITS/ML VIAL HUMULIN R U-500 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002821501 27104010002005 00002821501 11642 HUMULIN R 100 UNITS/ML VIAL HUMULIN R ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183302 27104010002005 00169183302 11642 RELION NOVOLIN R 100 UNIT/ML NOVOLIN R NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002821517 27104010002005 00002821517 11642 HUMULIN R 100 UNITS/ML VIAL HUMULIN R ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183311 27104010002005 00169183311 11642 NOVOLIN R 100 UNITS/ML VIAL NOVOLIN R NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002831501 27104020001805 00002831501 11660 HUMULIN N 100 UNITS/ML VIAL HUMULIN N ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002831517 27104020001805 00002831517 11660 HUMULIN N 100 UNITS/ML VIAL HUMULIN N ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183402 27104020001805 00169183402 11660 RELION NOVOLIN N 100 UNIT/ML NOVOLIN N NPD

7/26/2017 50



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug

NPD = Non Preferred DrugHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183411 27104020001805 00169183411 11660 NOVOLIN N 100 UNITS/ML VIAL NOVOLIN N NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088502101 27104003002020 00088502101 13072 LANTUS 100 UNIT/ML VIAL LANTUS ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088222033 27104003002020 00088222033 13072 LANTUS 100 UNIT/ML VIAL LANTUS ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169369619 2710407000D320 00169369619 17075 NOVOLOG MIX 70-30 FLEXPEN SYRN NOVOLOG MIX 70-30 FLEXPEN ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002880501 2710402000D320 00002880501 18488 HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N KWIKPEN NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002880559 2710402000D320 00002880559 18488 HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N KWIKPEN NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169368512 27104070001820 00169368512 19057 NOVOLOG MIX 70-30 VIAL NOVOLOG MIX 70-30 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751101 27104080001820 00002751101 22681 HUMALOG MIX 75-25 VIAL HUMALOG MIX 75-25 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169643897 22836 LEVEMIR FLEXTOUCH 100 UNITS/ML LEVEMIR FLEXTOUCH ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169643890 22836 LEVEMIR FLEXTOUCH 100 UNITS/ML LEVEMIR FLEXTOUCH ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169643810 2710400600D220 00169643810 22836 LEVEMIR FLEXTOUCH 100 UNITS/ML LEVEMIR FLEXTOUCH ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002880359 2710409000D320 00002880359 24486 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 KWIKPEN NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002880301 2710409000D320 00002880301 24486 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 KWIKPEN NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169368712 27104006002020 00169368712 25305 LEVEMIR 100 UNITS/ML VIAL LEVEMIR ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088250033 27104004002022 00088250033 25936 APIDRA 100 UNITS/ML VIAL APIDRA NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088250205 2710400400D220 00088250205 26508 APIDRA SOLOSTAR 100 UNITS/ML APIDRA SOLOSTAR NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169266015 2710400700D210 00169266015 35836 TRESIBA FLEXTOUCH 100 UNITS/ML TRESIBA FLEXTOUCH U-100 NPD

7/26/2017 51



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


RELATED AGENTS 00169266097 35836 TRESIBA FLEXTOUCH 100 UNITS/ML TRESIBA FLEXTOUCH U-100 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169255097 35837 TRESIBA FLEXTOUCH 200 UNITS/ML TRESIBA FLEXTOUCH U-200 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169255013 2710400700D220 00169255013 35837 TRESIBA FLEXTOUCH 200 UNITS/ML TRESIBA FLEXTOUCH U-200 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 47918087490 27104010002940 47918087490 37619 AFREZZA 4 UNIT CARTRIDGE AFREZZA NPDHYPOGLYCEMICS, INSULIN AND


RELATED AGENTS 47918088463 27104010002975 47918088463 37622 AFREZZA 60-4 UNIT / 30-8 UNIT AFREZZA NPDHYPOGLYCEMICS, INSULIN AND



RELATED AGENTS 00002771227 2710400500D230 00002771227 37798 HUMALOG 200 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-200 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002771299 37798 HUMALOG 200 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-200 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002771201 2710400500D230 00002771201 37798 HUMALOG 200 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-200 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00024586903 2710400300D230 00024586903 37988 TOUJEO SOLOSTAR 300 UNITS/ML TOUJEO SOLOSTAR NPDHYPOGLYCEMICS, INSULIN AND



RELATED AGENTS 00002882401 2710401000D250 00002882401 40542 HUMULIN R 500 UNITS/ML KWIKPEN HUMULIN R U-500 KWIKPEN ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002882427 2710401000D250 00002882427 40542 HUMULIN R 500 UNITS/ML KWIKPEN HUMULIN R U-500 KWIKPEN ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 47918090218 27104010002990 47918090218 42833 AFREZZA 4 UNIT/8 UNIT/12 UNIT AFREZZA NPD

7/26/2017 52



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


RELATED AGENTS 00002871517 27104090001810 00002871517 50001 HUMULIN 70-30 VIAL HUMULIN 70-30 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002871501 27104090001810 00002871501 50001 HUMULIN 70-30 VIAL HUMULIN 70-30 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183702 27104090001810 00169183702 50001 RELION NOVOLIN 70-30 VIAL NOVOLIN 70-30 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169183711 27104090001810 00169183711 50001 NOVOLIN 70-30 100 UNIT/ML VIAL NOVOLIN 70-30 NPDHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002879859 2710408000D340 00002879859 50461 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 50-50 KWIKPEN ONHYPOGLYCEMICS, INSULIN AND


RELATED AGENTS 00169750111 27104002002020 00169750111 92326 NOVOLOG 100 UNIT/ML VIAL NOVOLOG ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169633910 2710400200D220 00169633910 92336 NOVOLOG 100 UNITS/ML FLEXPEN NOVOLOG FLEXPEN ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00169330312 2710400200E220 00169330312 92886 NOVOLOG 100 UNIT/ML CARTRIDGE NOVOLOG ONHYPOGLYCEMICS, INSULIN AND



RELATED AGENTS 00002879959 2710400500D220 00002879959 96719 HUMALOG 100 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-100 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002879901 2710400500D220 00002879901 96719 HUMALOG 100 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-100 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002751201 27104080001840 00002751201 97507 HUMALOG MIX 50-50 VIAL HUMALOG MIX 50-50 ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088502005 2710400300D220 00088502005 98637 LANTUS SOLOSTAR 100 UNIT/ML LANTUS SOLOSTAR ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00088221905 2710400300D220 00088221905 98637 LANTUS SOLOSTAR 100 UNIT/ML LANTUS SOLOSTAR ONHYPOGLYCEMICS, INSULIN AND

RELATED AGENTS 00002771501 2710400300D220 00002771501 98637 BASAGLAR 100 UNIT/ML KWIKPEN BASAGLAR KWIKPEN U-100 NPD

7/26/2017 53



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


RELATED AGENTS 00002771559 2710400300D220 00002771559 98637 BASAGLAR 100 UNIT/ML KWIKPEN BASAGLAR KWIKPEN U-100 NPD

GLUCOCORTICOIDS, INHALED 00591376730 44400015001830 00591376730 17957 BUDESONIDE 0.25 MG/2 ML SUSP BUDESONIDE NPD


GLUCOCORTICOIDS, INHALED 00186198804 44400015001830 00186198804 17957 PULMICORT 0.25 MG/2 ML RESPUL PULMICORT ON







GLUCOCORTICOIDS, INHALED 00186198904 44400015001840 00186198904 17958 PULMICORT 0.5 MG/2 ML RESPULE PULMICORT ON







GLUCOCORTICOIDS, INHALED 00085134101 44400036208020 00085134101 18987 ASMANEX TWISTHALR 220 MCG #120 ASMANEX ON

GLUCOCORTICOIDS, INHALED 63402071101 44400017003420 63402071101 24149 ALVESCO 80 MCG INHALER ALVESCO NPD

GLUCOCORTICOIDS, INHALED 63402071201 44400017003440 63402071201 24152 ALVESCO 160 MCG INHALER ALVESCO NPD

GLUCOCORTICOIDS, INHALED 00085134106 44400036208020 00085134106 24927 ASMANEX TWISTHALER 220 MCG #14 ASMANEX ON



GLUCOCORTICOIDS, INHALED 00085720601 44209902903220 00085720601 28766 DULERA 100 MCG/5 MCG INHALER DULERA ON




GLUCOCORTICOIDS, INHALED 00173085914 44209902758020 00173085914 34647 BREO ELLIPTA 100-25 MCG INH BREO ELLIPTA NPD


GLUCOCORTICOIDS, INHALED 75989055006 35718 AEROSPAN 80 MCG INHALER AEROSPAN NPD

GLUCOCORTICOIDS, INHALED 00037759012 44400030123420 00037759012 35718 AEROSPAN 80 MCG INHALER AEROSPAN NPD

GLUCOCORTICOIDS, INHALED 00037759063 44400030123420 00037759063 35718 AEROSPAN 80 MCG INHALER AEROSPAN NPD



7/26/2017 54



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


GLUCOCORTICOIDS, INHALED 00173087410 44400033108020 00173087410 37007 ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA NPD




GLUCOCORTICOIDS, INHALED 00085433401 44400036203230 00085433401 37565 ASMANEX HFA 200 MCG INHALER ASMANEX HFA NPD

GLUCOCORTICOIDS, INHALED 00085433301 44400036203220 00085433301 37566 ASMANEX HFA 100 MCG INHALER ASMANEX HFA NPD

GLUCOCORTICOIDS, INHALED 59310080506 44209902708010 59310080506 42956 AIRDUO RESPICLICK 55-14 MCG AIRDUO RESPICLICK NPD

GLUCOCORTICOIDS, INHALED 00093360782 44209902708010 00093360782 42956 FLUTICASONE-SALMETEROL 55-14 FLUTICASONE-SALMETEROL NPD





GLUCOCORTICOIDS, INHALED 00173069500 44209902708020 00173069500 50584 ADVAIR 100-50 DISKUS ADVAIR DISKUS ON






GLUCOCORTICOIDS, INHALED 00173060202 44400033208020 00173060202 53633 FLOVENT 100 MCG DISKUS FLOVENT DISKUS NPD





GLUCOCORTICOIDS, INHALED 00173071920 44400033223230 00173071920 53636 FLOVENT HFA 110 MCG INHALER FLOVENT HFA ON



GLUCOCORTICOIDS, INHALED 00781751787 44400015001850 00781751787 62980 BUDESONIDE 1 MG/2 ML INH SUSP BUDESONIDE NPD




GLUCOCORTICOIDS, INHALED 00186199004 44400015001850 00186199004 62980 PULMICORT 1 MG/2 ML RESPULE PULMICORT ON

GLUCOCORTICOIDS, INHALED 59310020212 44400010103408 59310020212 80128 QVAR 40 MCG ORAL INHALER QVAR ON

GLUCOCORTICOIDS, INHALED 59310020412 44400010103428 59310020412 80131 QVAR 80 MCG ORAL INHALER QVAR ON

GLUCOCORTICOIDS, INHALED 00173071522 44209902703250 00173071522 97135 ADVAIR HFA 45-21 MCG INHALER ADVAIR HFA NPD


7/26/2017 55



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug






GLUCOCORTICOIDS, INHALED 00186091706 44400015008009 00186091706 98024 PULMICORT 90 MCG FLEXHALER PULMICORT FLEXHALER NPD

GLUCOCORTICOIDS, INHALED 00186091612 44400015008018 00186091612 98025 PULMICORT 180 MCG FLEXHALER PULMICORT FLEXHALER NPD

GLUCOCORTICOIDS, INHALED 00186037220 44209902413220 00186037220 98499 SYMBICORT 80-4.5 MCG INHALER SYMBICORT ON






HEPATITIS C AGENTS 65862029056 12353070000120 65862029056 14179 RIBAVIRIN 200 MG CAPSULE RIBAVIRIN ON


HEPATITIS C AGENTS 66435010156 12353070000120 66435010156 14179 RIBASPHERE 200 MG CAPSULE RIBASPHERE ON















HEPATITIS C AGENTS 00004035730 12353060052040 00004035730 17887 PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS ON

HEPATITIS C AGENTS 00004035009 12353060052020 00004035009 18287 PEGASYS 180 MCG/ML VIAL PEGASYS ON

HEPATITIS C AGENTS 00004008694 12353070000320 00004008694 18969 COPEGUS 200 MG TABLET COPEGUS NPD

HEPATITIS C AGENTS 66435010216 12353070000320 66435010216 18969 RIBASPHERE 200 MG TABLET RIBASPHERE ON

HEPATITIS C AGENTS 00781517728 12353070000320 00781517728 18969 RIBAVIRIN 200 MG TABLET RIBAVIRIN ON

HEPATITIS C AGENTS 00074319716 12353070000320 00074319716 18969 MODERIBA 200 MG TABLET MODERIBA ON

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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




HEPATITIS C AGENTS 00085131801 12353070002020 00085131801 20907 REBETOL 40 MG/ML SOLUTION REBETOL NPD

HEPATITIS C AGENTS 66435010356 12353070000340 66435010356 26119 RIBASPHERE 400 MG TABLET RIBASPHERE NPD

HEPATITIS C AGENTS 66435010456 12353070000360 66435010456 26122 RIBASPHERE 600 MG TABLET RIBASPHERE NPD

HEPATITIS C AGENTS 66435010699 12353070006320 66435010699 26123 RIBASPHERE RIBAPAK 600-400 MG RIBASPHERE RIBAPAK NPD



HEPATITIS C AGENTS 00004036530 12353060052040 00004036530 30738 PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK ON

HEPATITIS C AGENTS 00004036030 12353060052030 00004036030 30739 PEGASYS PROCLICK 135 MCG/0.5 PEGASYS PROCLICK ON


HEPATITIS C AGENTS 00074322414 32109 MODERIBA 200-400 MG DOSEPACK MODERIBA NPD


HEPATITIS C AGENTS 00074322456 12353070006315 00074322456 32109 MODERIBA 200-400 MG DOSEPACK MODERIBA NPD










HEPATITIS C AGENTS 59676022528 12353077100120 59676022528 35648 OLYSIO 150 MG CAPSULE OLYSIO NPD

HEPATITIS C AGENTS 61958150101 12353080000320 61958150101 35708 SOVALDI 400 MG TABLET SOVALDI NPD

HEPATITIS C AGENTS 00003021301 12353025100320 00003021301 37073 DAKLINZA 30 MG TABLET DAKLINZA NPD


HEPATITIS C AGENTS 61958180101 12359902400320 61958180101 37179 HARVONI 90-400 MG TABLET HARVONI ON

HEPATITIS C AGENTS 00074309328 1235990460B720 00074309328 37614 VIEKIRA PAK VIEKIRA PAK ON

HEPATITIS C AGENTS 00074308228 12359903600320 00074308228 37844 TECHNIVIE DOSE PACK TECHNIVIE ON

HEPATITIS C AGENTS 00006307401 12359902300320 00006307401 40615 ZEPATIER 50-100 MG TABLET ZEPATIER ON

HEPATITIS C AGENTS 00006307402 12359902300320 00006307402 40615 ZEPATIER 50-100 MG TABLET ZEPATIER ON


HEPATITIS C AGENTS 61958220101 12359902650330 61958220101 41729 EPCLUSA 400 MG-100 MG TABLET EPCLUSA ON

HEPATITIS C AGENTS 00074006328 12359904607530 00074006328 41932 VIEKIRA XR TABLET VIEKIRA XR ON

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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


HEPATITIS C AGENTS 00085435301 12353060106410 00085435301 89389 PEGINTRON 50 MCG KIT PEGINTRON ON

ANTICOAGULANTS 00703853021 83101020102012 00703853021 420 ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN SODIUM ON







ANTICOAGULANTS 00075062430 83101020102012 00075062430 420 LOVENOX 30 MG/0.3 ML SYRINGE LOVENOX NPD






ANTICOAGULANTS 50458058010 83370060000320 50458058010 14427 XARELTO 10 MG TABLET XARELTO ON


ANTICOAGULANTS 67457069310 83103030102020 67457069310 15494 FONDAPARINUX 2.5 MG/0.5 ML SYR FONDAPARINUX SODIUM NPD


ANTICOAGULANTS 67457059200 83103030102020 67457059200 15494 ARIXTRA 2.5 MG/0.5 ML SYRINGE ARIXTRA NPD




ANTICOAGULANTS 55111067811 15494 FONDAPARINUX 2.5 MG/0.5 ML SYR FONDAPARINUX SODIUM NPD





ANTICOAGULANTS 55111067902 83103030102035 55111067902 23775 FONDAPARINUX 5 MG/0.4 ML SYR FONDAPARINUX SODIUM NPD


ANTICOAGULANTS 67457059300 83103030102035 67457059300 23775 ARIXTRA 5 MG/0.4 ML SYRINGE ARIXTRA NPD



ANTICOAGULANTS 55111067911 23775 FONDAPARINUX 5 MG/0.4 ML SYR FONDAPARINUX SODIUM NPD



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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug














ANTICOAGULANTS 55111068011 23776 FONDAPARINUX 7.5 MG/0.6 ML SYR FONDAPARINUX SODIUM NPD










ANTICOAGULANTS 55111068111 23777 FONDAPARINUX 10 MG/0.8 ML SYR FONDAPARINUX SODIUM NPD



ANTICOAGULANTS 00056017401 83200030200325 00056017401 25790 COUMADIN 10 MG TABLET COUMADIN NPD

ANTICOAGULANTS 00832121950 83200030200325 00832121950 25790 JANTOVEN 10 MG TABLET JANTOVEN ON

ANTICOAGULANTS 57237012701 83200030200325 57237012701 25790 WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM ON








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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































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National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 61



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug










ANTICOAGULANTS 00832121301 83200030200310 00832121301 25794 JANTOVEN 2.5 MG TABLET JANTOVEN ON

ANTICOAGULANTS 00056017601 83200030200310 00056017601 25794 COUMADIN 2.5 MG TABLET COUMADIN NPD

ANTICOAGULANTS 00093171401 83200030200310 00093171401 25794 WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM ON

























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National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































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National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































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National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


ANTICOAGULANTS 00597013554 83337030200140 00597013554 29166 PRADAXA 150 MG CAPSULE PRADAXA ON


ANTICOAGULANTS 00003089331 83370010000320 00003089331 30239 ELIQUIS 2.5 MG TABLET ELIQUIS ON

ANTICOAGULANTS 00003089321 83370010000320 00003089321 30239 ELIQUIS 2.5 MG TABLET ELIQUIS ON







ANTICOAGULANTS 00003089421 83370010000330 00003089421 33935 ELIQUIS 5 MG TABLET ELIQUIS ON



ANTICOAGULANTS 50458058451 8337006000B720 50458058451 37212 XARELTO STARTER PACK XARELTO ON

ANTICOAGULANTS 65597020130 83370030200315 65597020130 37675 SAVAYSA 15 MG TABLET SAVAYSA NPD







ANTICOAGULANTS 62037086620 83101020102020 62037086620 42071 ENOXAPARIN 150 MG/ML SYRINGE ENOXAPARIN SODIUM ON

ANTICOAGULANTS 00075802510 83101020102020 00075802510 42071 LOVENOX 150 MG/ML SYRINGE LOVENOX NPD













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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































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National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


















ANTICOAGULANTS 00069019601 83101010102040 00069019601 63431 FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN NPD


















ANTICOAGULANTS 00069022002 83101010102053 00069022002 93952 FRAGMIN 12,500 UNITS/0.5 ML FRAGMIN NPD

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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug









ANTICOAGULANTS 00069021702 83101010102015 00069021702 95075 FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN NPD

ANTICOAGULANTS 00069021701 83101010102015 00069021701 95075 FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN NPD

ANTICOAGULANTS 00069023201 83101010102080 00069023201 95776 FRAGMIN 95,000 UNITS/3.8 ML VL FRAGMIN NPD

ANTICOAGULANTS 63323056586 83101020102050 63323056586 96334 ENOXAPARIN 300 MG/3 ML VIAL ENOXAPARIN SODIUM ON


ANTICOAGULANTS 00075062603 83101020102050 00075062603 96334 LOVENOX 300 MG/3 ML VIAL LOVENOX NPD



ANTICOAGULANTS 00075803001 83101020102050 00075803001 96334 LOVENOX 300 MG/3 ML VIAL LOVENOX NPD




CYTOKINE AND CAM ANTAGONISTS 66658023401 6626001000E520 66658023401 14867 KINERET 100 MG/0.67 ML SYRINGE KINERET NPD



CYTOKINE AND CAM ANTAGONISTS 00074379902 6627001500F820 00074379902 18924 HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA ON

CYTOKINE AND CAM ANTAGONISTS 00074379906 6627001500F820 00074379906 18924 HUMIRA PEDIATRIC CROHN'S START HUMIRA PEDIATRIC CROHN'S ON

CYTOKINE AND CAM ANTAGONISTS 00074379903 6627001500F820 00074379903 18924 HUMIRA PEDIATRIC CROHN'S START HUMIRA PEDIATRIC CROHN'S ON

CYTOKINE AND CAM ANTAGONISTS 57894006002 90250585002020 57894006002 19903 STELARA 45 MG/0.5 ML VIAL STELARA NPD

CYTOKINE AND CAM ANTAGONISTS 57894007002 6627004000D520 57894007002 22533 SIMPONI 50 MG/0.5 ML PEN INJEC SIMPONI NPD

CYTOKINE AND CAM ANTAGONISTS 57894007001 6627004000E520 57894007001 22536 SIMPONI 50 MG/0.5 ML SYRINGE SIMPONI NPD

CYTOKINE AND CAM ANTAGONISTS 50474071079 52505020106440 50474071079 23471 CIMZIA 200 MG/ML SYRINGE KIT CIMZIA NPD

CYTOKINE AND CAM ANTAGONISTS 50474071081 52505020106460 50474071081 23471 CIMZIA 200 MG/ML STARTER KIT CIMZIA NPD

CYTOKINE AND CAM ANTAGONISTS 58406043504 6629003000E530 58406043504 23574 ENBREL 50 MG/ML SYRINGE ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 58406043501 6629003000E530 58406043501 23574 ENBREL 50 MG/ML SYRINGE ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 00003218710 66400010002120 00003218710 26306 ORENCIA 250 MG VIAL ORENCIA NPD

CYTOKINE AND CAM ANTAGONISTS 50242013501 66500070002030 50242013501 27366 ACTEMRA 80 MG/4 ML VIAL ACTEMRA NPD


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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



CYTOKINE AND CAM ANTAGONISTS 00078058261 66460020002120 00078058261 27445 ILARIS 180 MG VIAL ILARIS NPD

CYTOKINE AND CAM ANTAGONISTS 57894006003 9025058500E520 57894006003 28158 STELARA 45 MG/0.5 ML SYRINGE STELARA NPD

CYTOKINE AND CAM ANTAGONISTS 57894006103 9025058500E540 57894006103 28159 STELARA 90 MG/ML SYRINGE STELARA NPD

CYTOKINE AND CAM ANTAGONISTS 00003218811 6640001000E520 00003218811 30289 ORENCIA 125 MG/ML SYRINGE ORENCIA NPD

CYTOKINE AND CAM ANTAGONISTS 00069100101 66603065100320 00069100101 33617 XELJANZ 5 MG TABLET XELJANZ NPD

CYTOKINE AND CAM ANTAGONISTS 57894007101 6627004000E540 57894007101 34697 SIMPONI 100 MG/ML SYRINGE SIMPONI NPD

CYTOKINE AND CAM ANTAGONISTS 57894035001 66270040002015 57894035001 34983 SIMPONI ARIA 50 MG/4 ML VIAL SIMPONI ARIA NPD

CYTOKINE AND CAM ANTAGONISTS 57894007102 6627004000D540 57894007102 35001 SIMPONI 100 MG/ML PEN INJECTOR SIMPONI NPD

CYTOKINE AND CAM ANTAGONISTS 50242013801 6650007000E520 50242013801 35486 ACTEMRA 162 MG/0.9 ML SYRINGE ACTEMRA NPD

CYTOKINE AND CAM ANTAGONISTS 59572063106 66700015000330 59572063106 36172 OTEZLA 30 MG TABLET OTEZLA NPD

CYTOKINE AND CAM ANTAGONISTS 59572063128 36172 OTEZLA 30 MG TABLET OTEZLA NPD

CYTOKINE AND CAM ANTAGONISTS 64764030020 52503080002120 64764030020 36544 ENTYVIO 300 MG VIAL ENTYVIO NPD


CYTOKINE AND CAM ANTAGONISTS 59572063255 6670001500B720 59572063255 37765 OTEZLA 28 DAY STARTER PACK OTEZLA NPD

CYTOKINE AND CAM ANTAGONISTS 00078063998 9025057500E520 00078063998 37788 COSENTYX 300 MG DOSE-2 SYRINGE COSENTYX (2 SYRINGES) NPD

CYTOKINE AND CAM ANTAGONISTS 00078063997 9025057500E520 00078063997 37788 COSENTYX 150 MG/ML SYRINGE COSENTYX SYRINGE NPD

CYTOKINE AND CAM ANTAGONISTS 00078063941 9025057500D520 00078063941 37789 COSENTYX 300 MG DOSE-2 PENS COSENTYX PEN (2 PENS) NPD

CYTOKINE AND CAM ANTAGONISTS 00078063968 9025057500D520 00078063968 37789 COSENTYX 150 MG/ML PEN INJECT COSENTYX PEN NPD

CYTOKINE AND CAM ANTAGONISTS 00069050114 66603065107530 00069050114 38086 XELJANZ XR 11 MG TABLET XELJANZ XR NPD

CYTOKINE AND CAM ANTAGONISTS 00069050130 66603065107530 00069050130 38086 XELJANZ XR 11 MG TABLET XELJANZ XR NPD

CYTOKINE AND CAM ANTAGONISTS 00002144501 9025055400D520 00002144501 40848 TALTZ 80 MG/ML AUTOINJECTOR TALTZ AUTOINJECTOR NPD

CYTOKINE AND CAM ANTAGONISTS 00002144509 9025055400D520 00002144509 40848 TALTZ 80 MG/ML AUTOINJ (3-PK) TALTZ AUTOINJECTOR (3 PACK) NPD

CYTOKINE AND CAM ANTAGONISTS 00002144511 9025055400D520 00002144511 40848 TALTZ 80 MG/ML AUTOINJECTOR TALTZ AUTOINJECTOR NPD

CYTOKINE AND CAM ANTAGONISTS 00002144527 9025055400D520 00002144527 40848 TALTZ 80 MG/ML AUTOINJ (2-PK) TALTZ AUTOINJECTOR (2 PACK) NPD

CYTOKINE AND CAM ANTAGONISTS 00002772409 9025055400E520 00002772409 40849 TALTZ 80 MG/ML SYRINGE (3-PK) TALTZ SYRINGE (3 PACK) NPD

CYTOKINE AND CAM ANTAGONISTS 00002772401 9025055400E520 00002772401 40849 TALTZ 80 MG/ML SYRINGE TALTZ SYRINGE NPD

CYTOKINE AND CAM ANTAGONISTS 00002772427 9025055400E520 00002772427 40849 TALTZ 80 MG/ML SYRINGE (2-PK) TALTZ SYRINGE (2 PACK) NPD

CYTOKINE AND CAM ANTAGONISTS 00002772411 9025055400E520 00002772411 40849 TALTZ 80 MG/ML SYRINGE TALTZ SYRINGE NPD

CYTOKINE AND CAM ANTAGONISTS 00069080901 52505040202120 00069080901 40977 INFLECTRA 100 MG VIAL INFLECTRA NPD

CYTOKINE AND CAM ANTAGONISTS 00003218851 6640001000D520 00003218851 41656 ORENCIA CLICKJECT 125 MG/ML ORENCIA CLICKJECT NPD

CYTOKINE AND CAM ANTAGONISTS 57894005427 52504070002020 57894005427 42351 STELARA 130 MG/26 ML VIAL STELARA NPD

CYTOKINE AND CAM ANTAGONISTS 00187000400 9025052000E520 00187000400 43055 SILIQ 210 MG/1.5 ML SYRINGE SILIQ NPD

CYTOKINE AND CAM ANTAGONISTS 00187000402 9025052000E520 00187000402 43055 SILIQ 210 MG/1.5 ML SYRINGE SILIQ NPD

CYTOKINE AND CAM ANTAGONISTS 00078073461 66460020002015 00078073461 43148 ILARIS 150 MG/ML VIAL ILARIS NPD

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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


CYTOKINE AND CAM ANTAGONISTS 00024590801 6650006000E520 00024590801 43223 KEVZARA 150 MG/1.14 ML SYRINGE KEVZARA NPD

CYTOKINE AND CAM ANTAGONISTS 00024591001 6650006000E530 00024591001 43224 KEVZARA 200 MG/1.14 ML SYRINGE KEVZARA NPD

CYTOKINE AND CAM ANTAGONISTS 00003281411 6640001000E510 00003281411 43389 ORENCIA 50 MG/0.4 ML SYRINGE ORENCIA NPD

CYTOKINE AND CAM ANTAGONISTS 00003281811 6640001000E515 00003281811 43397 ORENCIA 87.5 MG/0.7 ML SYRINGE ORENCIA NPD

CYTOKINE AND CAM ANTAGONISTS 58406042534 66290030002120 58406042534 52651 ENBREL 25 MG KIT ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 58406042541 66290030002120 58406042541 52651 ENBREL 25 MG KIT ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 57894003001 52505040002120 57894003001 61501 REMICADE 100 MG VIAL REMICADE NPD

CYTOKINE AND CAM ANTAGONISTS 00074433906 6627001500F420 00074433906 97005 HUMIRA CROHNS STARTER PACK

HUMIRA PEN CROHN-UC-HS

STARTER ON

CYTOKINE AND CAM ANTAGONISTS 00074433907 6627001500F420 00074433907 97005 HUMIRA PEN PSORIASIS-UVEITIS HUMIRA PEN PSORIASIS-UVEITIS ON

CYTOKINE AND CAM ANTAGONISTS 00074433902 6627001500F420 00074433902 97005 HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN ON

CYTOKINE AND CAM ANTAGONISTS 58406044504 6629003000D530 58406044504 97724 ENBREL 50 MG/ML SURECLICK SYR ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 58406044501 6629003000D530 58406044501 97724 ENBREL 50 MG/ML SURECLICK SYR ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 58406045504 6629003000E525 58406045504 98398 ENBREL 25 MG/0.5 ML SYRINGE ENBREL ON

CYTOKINE AND CAM ANTAGONISTS 58406045501 6629003000E525 58406045501 98398 ENBREL 25 MG/0.5 ML SYRINGE ENBREL ON


CYTOKINE AND CAM ANTAGONISTS 61755000101 66450060002120 61755000101 99473 ARCALYST 220 MG INJECTION ARCALYST NPD

CYTOKINE AND CAM ANTAGONISTS 50474070062 52505020106420 50474070062 99615 CIMZIA 200 MG VIAL KIT CIMZIA NPD

COPD AGENTS 76204060012 44209902012015 76204060012 13456 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML IPRATROPIUM-ALBUTEROL ON

COPD AGENTS 00378967164 13456 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML IPRATROPIUM-ALBUTEROL ON
















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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug














COPD AGENTS 00597007547 44100080100120 00597007547 17853 SPIRIVA 18 MCG CP-HANDIHALER SPIRIVA ON



COPD AGENTS 00597008717 44100030123420 00597008717 24621 ATROVENT HFA INHALER ATROVENT HFA ON

COPD AGENTS 00310009530 44450065000320 00310009530 28934 DALIRESP 500 MCG TABLET DALIRESP NPD



COPD AGENTS 00597002402 44209902013420 00597002402 32395 COMBIVENT RESPIMAT INHAL SPRAY COMBIVENT RESPIMAT ON

COPD AGENTS 00310080060 44100007108020 00310080060 33084 TUDORZA PRESSAIR 400 MCG INH TUDORZA PRESSAIR NPD



COPD AGENTS 00173086906 44209902958020 00173086906 35903 ANORO ELLIPTA 62.5-25 MCG INH ANORO ELLIPTA NPD

COPD AGENTS 00173086910 44209902958020 00173086910 35903 ANORO ELLIPTA 62.5-25 MCG INH ANORO ELLIPTA NPD

COPD AGENTS 00173087310 44100090208030 00173087310 36574 INCRUSE ELLIPTA 62.5 MCG INH INCRUSE ELLIPTA NPD

COPD AGENTS 00173087306 44100090208030 00173087306 36574 INCRUSE ELLIPTA 62.5 MCG INH INCRUSE ELLIPTA NPD

COPD AGENTS 00597015531 38687 STIOLTO RESPIMAT INHAL SPRAY STIOLTO RESPIMAT NPD

COPD AGENTS 00597015561 44209902923420 00597015561 38687 STIOLTO RESPIMAT INHAL SPRAY STIOLTO RESPIMAT NPD

COPD AGENTS 00597016061 44100080103410 00597016061 39587 SPIRIVA RESPIMAT 1.25 MCG INH SPIRIVA RESPIMAT NPD

COPD AGENTS 00078066219 44100020100107 00078066219 39997 SEEBRI NEOHALER 15.6 MCG INHAL SEEBRI NEOHALER NPD

COPD AGENTS 00078066406 40093 UTIBRON NEOHALER 27.5-15.6 MCG UTIBRON NEOHALER NPD

COPD AGENTS 00078066419 44209902600110 00078066419 40093 UTIBRON NEOHALER 27.5-15.6 MCG UTIBRON NEOHALER NPD

COPD AGENTS 00310460012 44209902543220 00310460012 41199 BEVESPI AEROSPHERE INHALER BEVESPI AEROSPHERE NPD

COPD AGENTS 00487980130 44100030102020 00487980130 42235 IPRATROPIUM BR 0.02% SOLN IPRATROPIUM BROMIDE ON

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(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug















COPD AGENTS 00378797031 42235 IPRATROPIUM BR 0.02% SOLN IPRATROPIUM BROMIDE ON











COPD AGENTS 00597010061 44100080103420 00597010061 98921 SPIRIVA RESPIMAT 2.5 MCG INH SPIRIVA RESPIMAT NPD

COPD AGENTS 00597010028 98921 SPIRIVA RESPIMAT 2.5 MCG INH SPIRIVA RESPIMAT NPD

PANCREATIC ENZYMES 00032120601 51200024006720 00032120601 26176 CREON DR 6,000 UNITS CAPSULE CREON ON






PANCREATIC ENZYMES 39822020501 51200024006715 39822020501 27726 PANCRELIPASE DR 5,000 UNIT CAP PANCRELIPASE 5,000 ON

PANCREATIC ENZYMES 42865030002 51200024006715 42865030002 27726 ZENPEP DR 5,000 UNITS CAPSULE ZENPEP ON


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MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug







PANCREATIC ENZYMES 58914011210 51200024000330 58914011210 31581 VIOKACE 10,440-39,150 UNITS TB VIOKACE NPD

PANCREATIC ENZYMES 58914011710 51200024000360 58914011710 31582 VIOKACE 20,880-78,300 UNITS TB VIOKACE NPD

PANCREATIC ENZYMES 59767000801 51200024006725 59767000801 32298 PERTZYE DR 8,000 UNITS CAPSULE PERTZYE NPD

PANCREATIC ENZYMES 59767000802 51200024006725 59767000802 32298 PERTZYE DR 8,000 UNITS CAPSULE PERTZYE NPD

PANCREATIC ENZYMES 59767001601 51200024006749 59767001601 32299 PERTZYE DR 16,000 UNITS CAPS PERTZYE NPD

PANCREATIC ENZYMES 59767001602 51200024006749 59767001602 32299 PERTZYE DR 16,000 UNITS CAPS PERTZYE NPD




PANCREATIC ENZYMES 50458034360 51200024006750 50458034360 42317 PANCREAZE DR 16,800 UNIT CAP PANCREAZE NPD





PANCREATIC ENZYMES 59767000401 51200024006709 59767000401 42634 PERTZYE DR 4,000 UNIT CAPSULE PERTZYE NPD

ANALGESICS, NARCOTICS LONG 59011026410 65100055100480 59011026410 16078 MS CONTIN 200 MG TABLET MS CONTIN NPD

ANALGESICS, NARCOTICS LONG 42858080501 65100055100480 42858080501 16078 MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE ER ON









ANALGESICS, NARCOTICS LONG 00228311611 65100055207025 00228311611 16212 MORPHINE SULFATE ER 45 MG CAP MORPHINE SULFATE ER NPD


ANALGESICS, NARCOTICS LONG 00054355563 65100050102010 00054355563 16400 METHADONE 5 MG/5 ML SOLUTION METHADONE HCL NPD



7/26/2017 73



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



ANALGESICS, NARCOTICS LONG 00054355344 65100050101310 00054355344 16415 METHADONE INTENSOL 10 MG/ML METHADONE INTENSOL NPD

ANALGESICS, NARCOTICS LONG 00054039268 65100050101310 00054039268 16415 METHADONE 10 MG/ML ORAL CONC METHADONE HCL NPD


ANALGESICS, NARCOTICS LONG 00406872510 65100050101310 00406872510 16415 METHADOSE 10 MG/ML ORAL CONC METHADOSE NPD


ANALGESICS, NARCOTICS LONG 00406052710 65100050101310 00406052710 16415 METHADOSE 10 MG/ML ORAL CONC METHADOSE NPD



ANALGESICS, NARCOTICS LONG 68084073801 65100050100310 68084073801 16420 METHADONE HCL 10 MG TABLET METHADONE HCL NPD









ANALGESICS, NARCOTICS LONG 00054421925 65100050100310 00054421925 16420 DOLOPHINE HCL 10 MG TABLET DOLOPHINE HCL NPD





ANALGESICS, NARCOTICS LONG 00054421825 65100050100305 00054421825 16422 DOLOPHINE HCL 5 MG TABLET DOLOPHINE HCL NPD







ANALGESICS, NARCOTICS LONG 00406054034 65100050107320 00406054034 16423 METHADOSE 40 MG TABLET DISPR METHADOSE NPD

ANALGESICS, NARCOTICS LONG 00054453825 65100050107320 00054453825 16423 DISKETS 40 MG TABLET DISPR DISKETS NPD

ANALGESICS, NARCOTICS LONG 66689089840 65100050107320 66689089840 16423 METHADONE 40 MG TABLET DISPR METHADONE HCL NPD

ANALGESICS, NARCOTICS LONG 00406254001 65100050107320 00406254001 16423 METHADONE 40 MG TABLET DISPR METHADONE HCL NPD


7/26/2017 74



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





































7/26/2017 75



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


































ANALGESICS, NARCOTICS LONG 60505701102 65100025008620 60505701102 19200 FENTANYL 25 MCG/HR PATCH FENTANYL ON



7/26/2017 76



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug






ANALGESICS, NARCOTICS LONG 50458009105 65100025008620 50458009105 19200 DURAGESIC 25 MCG/HR PATCH DURAGESIC NPD































7/26/2017 77



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




































ANALGESICS, NARCOTICS LONG 00093360040 65200010008820 00093360040 25308 BUPRENORPHINE 5 MCG/HR PATCH BUPRENORPHINE NPD

7/26/2017 78



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



ANALGESICS, NARCOTICS LONG 59011075004 65200010008820 59011075004 25308 BUTRANS 5 MCG/HR PATCH BUTRANS ON










ANALGESICS, NARCOTICS LONG 00378415293 65100095107520 00378415293 26387 TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER NPD






ANALGESICS, NARCOTICS LONG 52544001160 65100055107010 52544001160 26490 KADIAN ER 10 MG CAPSULE KADIAN NPD
















ANALGESICS, NARCOTICS LONG 00228322711 65100080107405 00228322711 27247 OXYMORPHONE HCL ER 5 MG TABLET OXYMORPHONE HCL ER NPD


7/26/2017 79



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ANALGESICS, NARCOTICS LONG 00228322811 65100080107410 00228322811 27248 OXYMORPHONE HCL ER 10 MG TAB OXYMORPHONE HCL ER NPD












ANALGESICS, NARCOTICS LONG 00406331201 6510003510A830 00406331201 28427 HYDROMORPHONE HCL ER 12 MG TAB HYDROMORPHONE ER NPD


ANALGESICS, NARCOTICS LONG 23635041201 6510003510A830 23635041201 28427 EXALGO ER 12 MG TABLET EXALGO NPD



ANALGESICS, NARCOTICS LONG 50458086001 65100091107420 50458086001 29787 NUCYNTA ER 50 MG TABLET NUCYNTA ER NPD





ANALGESICS, NARCOTICS LONG 68025007130 65100095107070 68025007130 30382 CONZIP 100 MG CAPSULE CONZIP NPD

ANALGESICS, NARCOTICS LONG 13811068930 65100095107070 13811068930 30382 TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER NPD










7/26/2017 80



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug












ANALGESICS, NARCOTICS LONG 63481081360 6510008010A707 63481081360 33832 OPANA ER 7.5 MG TABLET OPANA ER NPD

ANALGESICS, NARCOTICS LONG 63481081560 6510008010A715 63481081560 33833 OPANA ER 15 MG TABLET OPANA ER NPD










ANALGESICS, NARCOTICS LONG 42858035340 65200010008825 42858035340 36946 BUPRENORPHINE 7.5 MCG/HR PATCH BUPRENORPHINE NPD

ANALGESICS, NARCOTICS LONG 59011075704 65200010008825 59011075704 36946 BUTRANS 7.5 MCG/HR PATCH BUTRANS ON

ANALGESICS, NARCOTICS LONG 00093573101 6510007510A710 00093573101 37158 OXYCODONE HCL ER 10 MG TABLET OXYCODONE HCL ER NPD

ANALGESICS, NARCOTICS LONG 59011041020 6510007510A710 59011041020 37158 OXYCONTIN 10 MG TABLET OXYCONTIN ON











7/26/2017 81



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



























ANALGESICS, NARCOTICS LONG 59011027160 6510003010A810 59011027160 37539 HYSINGLA ER 20 MG TABLET HYSINGLA ER ON







ANALGESICS, NARCOTICS LONG 60793043020 65100055700220 60793043020 37685 EMBEDA ER 20-0.8 MG CAPSULE EMBEDA ON


ANALGESICS, NARCOTICS LONG 60793043320 65100055700240 60793043320 37687 EMBEDA ER 50-2 MG CAPSULE EMBEDA ON

7/26/2017 82



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug




ANALGESICS, NARCOTICS LONG 60793043720 65100055700270 60793043720 37692 EMBEDA ER 100-4 MG CAPSULE EMBEDA ON

ANALGESICS, NARCOTICS LONG 00378912616 37947 FENTANYL 62.5 MCG/HR PATCH FENTANYL NPD

ANALGESICS, NARCOTICS LONG 00378912698 65100025008635 00378912698 37947 FENTANYL 62.5 MCG/HR PATCH FENTANYL NPD





ANALGESICS, NARCOTICS LONG 65224031060 6510003010A310 65224031060 38057 ZOHYDRO ER 10 MG CAPSULE ZOHYDRO ER NPD






ANALGESICS, NARCOTICS LONG 65597030110 6510005510A720 65597030110 39853 MORPHABOND ER 15 MG TABLET MORPHABOND ER NPD




ANALGESICS, NARCOTICS LONG 63481016160 65200010108210 63481016160 39959 BELBUCA 75 MCG FILM BELBUCA NPD

ANALGESICS, NARCOTICS LONG 63481016101 39959 BELBUCA 75 MCG FILM BELBUCA NPD













ANALGESICS, NARCOTICS LONG 24510011010 6510007500A310 24510011010 41272 XTAMPZA ER 9 MG CAPSULE XTAMPZA ER NPD

ANALGESICS, NARCOTICS LONG 24510011510 6510007500A315 24510011510 41273 XTAMPZA ER 13.5 MG CAPSULE XTAMPZA ER NPD

7/26/2017 83



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug





ANALGESICS, NARCOTICS LONG 69344011111 6510005510A620 69344011111 42932 ARYMO ER 15 MG TABLET ARYMO ER NPD



























ANALGESICS, NARCOTICS LONG 47335053183 65100095107560 47335053183 99151 TRAMADOL ER 100 MG TABLET TRAMADOL HCL ER NPD





7/26/2017 84



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug






ANALGESICS, NARCOTICS LONG 00115131513 65100080107407 00115131513 99492 OXYMORPHONE HCL ER 7.5 MG TAB OXYMORPHONE HCL ER NPD

ANALGESICS, NARCOTICS LONG 00115131501 65100080107407 00115131501 99492 OXYMORPHONE HCL ER 7.5 MG TAB OXYMORPHONE HCL ER NPD







ANALGESICS, NARCOTICS LONG 00228326311 65100080107430 00228326311 99494 OXYMORPHONE HCL ER 30 MG TAB OXYMORPHONE HCL ER NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310651201 2717002000D220 00310651201 24613 BYETTA 5 MCG DOSE PEN INJ BYETTA ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310652401 2717002000D240 00310652401 24614 BYETTA 10 MCG DOSE PEN INJ BYETTA ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00169406013 2717005000D220 00169406013 26189 VICTOZA 3-PAK 18 MG/3 ML PEN VICTOZA 3-PAK ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00169406012 2717005000D220 00169406012 26189 VICTOZA 2-PAK 18 MG/3 ML PEN VICTOZA 2-PAK ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310610030 27550065100320 00310610030 27393 ONGLYZA 2.5 MG TABLET ONGLYZA ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310610090 27550065100320 00310610090 27393 ONGLYZA 2.5 MG TABLET ONGLYZA ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310610550 27550065100330 00310610550 27394 ONGLYZA 5 MG TABLET ONGLYZA ONHYPOGLYCEMICS, INCRETIN



MIMETICS/ENHANCERS 00310613530 27992502607530 00310613530 29118 KOMBIGLYZE XR 5-500 MG TABLET KOMBIGLYZE XR ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310614530 27992502607540 00310614530 29224 KOMBIGLYZE XR 5-1,000 MG TAB KOMBIGLYZE XR ON

7/26/2017 85



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug

NPD = Non Preferred DrugHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310612560 27992502607520 00310612560 29225 KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00597014090 27550050000320 00597014090 29890 TRADJENTA 5 MG TABLET TRADJENTA ONHYPOGLYCEMICS, INCRETIN



MIMETICS/ENHANCERS 66780022601 2717002000G220 66780022601 31304 BYDUREON 2 MG VIAL BYDUREON ONHYPOGLYCEMICS, INCRETIN



MIMETICS/ENHANCERS 00597014618 27992502400320 00597014618 31315 JENTADUETO 2.5 MG-500 MG TAB JENTADUETO ONHYPOGLYCEMICS, INCRETIN






MIMETICS/ENHANCERS 00006007861 27992502707520 00006007861 31339 JANUMET XR 50-500 MG TABLET JANUMET XR ONHYPOGLYCEMICS, INCRETIN



MIMETICS/ENHANCERS 00006008061 27992502707530 00006008061 31340 JANUMET XR 50-1,000 MG TABLET JANUMET XR ON

7/26/2017 86



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


MIMETICS/ENHANCERS 00006008062 27992502707530 00006008062 31340 JANUMET XR 50-1,000 MG TABLET JANUMET XR ONHYPOGLYCEMICS, INCRETIN





MIMETICS/ENHANCERS 64764025030 27550010100330 64764025030 34076 NESINA 25 MG TABLET NESINA NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802015065 27550010100330 45802015065 34076 ALOGLIPTIN 25 MG TABLET ALOGLIPTIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764025103 27994002100340 64764025103 34077 OSENI 25-15 MG TABLET OSENI NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802035165 27994002100340 45802035165 34077 ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLITAZONE NPDHYPOGLYCEMICS, INCRETIN





MIMETICS/ENHANCERS 45802023865 27994002100320 45802023865 34080 ALOGLIPTIN-PIOGLIT 12.5-15 MG ALOGLIPTIN-PIOGLITAZONE NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764012103 27994002100320 64764012103 34080 OSENI 12.5-15 MG TABLET OSENI NPDHYPOGLYCEMICS, INCRETIN


MIMETICS/ENHANCERS 64764012303 27994002100325 64764012303 34083 OSENI 12.5-30 MG TABLET OSENI NPD

7/26/2017 87



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



MIMETICS/ENHANCERS 64764012403 27994002100330 64764012403 34084 OSENI 12.5-45 MG TABLET OSENI NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802010365 27550010100320 45802010365 34085 ALOGLIPTIN 12.5 MG TABLET ALOGLIPTIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764012530 27550010100320 64764012530 34085 NESINA 12.5 MG TABLET NESINA NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802008765 27550010100310 45802008765 34086 ALOGLIPTIN 6.25 MG TABLET ALOGLIPTIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764062530 27550010100310 64764062530 34086 NESINA 6.25 MG TABLET NESINA NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802016972 27992502100320 45802016972 34087 ALOGLIPTIN-METFORMIN 12.5-500 ALOGLIPTIN-METFORMIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764033560 27992502100320 64764033560 34087 KAZANO 12.5-500 MG TABLET KAZANO NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 64764033760 27992502100330 64764033760 34088 KAZANO 12.5-1,000 MG TABLET KAZANO NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 45802021172 27992502100330 45802021172 34088 ALOGLIPTIN-METFORMIN 12.5-1000 ALOGLIPTIN-METFORMIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00024574702 2717005600D230 00024574702 35687 ADLYXIN 20 MCG MAINTENANCE PK ADLYXIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00024574502 2717005600F420 00024574502 35688 ADLYXIN 10-20 MCG STARTER PACK ADLYXIN NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310653004 2717002000D120 00310653004 36352 BYDUREON 2 MG PEN INJECT BYDUREON PEN ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00173086601 2717001000D120 00173086601 36615 TANZEUM 30 MG PEN INJECT TANZEUM NPDHYPOGLYCEMICS, INCRETIN


MIMETICS/ENHANCERS 00173086602 36615 TANZEUM 30 MG PEN INJECT TANZEUM NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00173086701 2717001000D130 00173086701 36616 TANZEUM 50 MG PEN INJECT TANZEUM NPD

7/26/2017 88



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


MIMETICS/ENHANCERS 00173086702 36616 TANZEUM 50 MG PEN INJECT TANZEUM NPDHYPOGLYCEMICS, INCRETIN


MIMETICS/ENHANCERS 00002143380 2717001500D220 00002143380 37169 TRULICITY 0.75 MG/0.5 ML PEN TRULICITY NPDHYPOGLYCEMICS, INCRETIN




MIMETICS/ENHANCERS 00597018230 27996502300320 00597018230 37832 GLYXAMBI 10 MG-5 MG TABLET GLYXAMBI NPDHYPOGLYCEMICS, INCRETIN






MIMETICS/ENHANCERS 00169291115 2799100225D220 00169291115 38348 XULTOPHY 100 UNIT-3.6MG/ML PEN XULTOPHY 100-3.6 NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00597027073 27992502407520 00597027073 41637 JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00597027094 27992502407520 00597027094 41637 JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00597027533 27992502407530 00597027533 41639 JENTADUETO XR 5 MG-1,000 MG TB JENTADUETO XR NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00597027581 27992502407530 00597027581 41639 JENTADUETO XR 5 MG-1,000 MG TB JENTADUETO XR NPD

7/26/2017 89



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


MIMETICS/ENHANCERS 00024576105 2799100235D220 00024576105 42676 SOLIQUA 100 UNIT-33 MCG/ML PEN SOLIQUA 100-33 NPDHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00006022154 27550070100320 00006022154 97398 JANUVIA 25 MG TABLET JANUVIA ONHYPOGLYCEMICS, INCRETIN















MIMETICS/ENHANCERS 00006057562 27992502700320 00006057562 98306 JANUMET 50-500 MG TABLET JANUMET ON

7/26/2017 90



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


MIMETICS/ENHANCERS 00006057582 27992502700320 00006057582 98306 JANUMET 50-500 MG TABLET JANUMET ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00006057561 27992502700320 00006057561 98306 JANUMET 50-500 MG TABLET JANUMET ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00006057782 27992502700340 00006057782 98307 JANUMET 50-1,000 MG TABLET JANUMET ONHYPOGLYCEMICS, INCRETIN



MIMETICS/ENHANCERS 00310662702 2715005010D240 00310662702 99450 SYMLINPEN 120 PEN INJECTOR SYMLINPEN 120 ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 66780012102 2715005010D240 66780012102 99450 SYMLINPEN 120 PEN INJECTOR SYMLINPEN 120 ONHYPOGLYCEMICS, INCRETIN

MIMETICS/ENHANCERS 00310661502 2715005010D220 00310661502 99514 SYMLINPEN 60 PEN INJECTOR SYMLINPEN 60 ON

OPIATE DEPENDENCE TREATMENTS 51285027502 93400030100305 51285027502 17070 REVIA 50 MG TABLET REVIA ON

OPIATE DEPENDENCE TREATMENTS 00185003901 93400030100305 00185003901 17070 NALTREXONE 50 MG TABLET NALTREXONE HCL ON













OPIATE DEPENDENCE TREATMENTS 00409178269 9340002010E210 00409178269 17140 NALOXONE 0.4 MG/ML CARPUJECT NALOXONE HCL ON

OPIATE DEPENDENCE TREATMENTS 00409178203 17140 NALOXONE 0.4 MG/ML CARPUJECT NALOXONE HCL ON

OPIATE DEPENDENCE TREATMENTS 76329146901 9340002010E540 76329146901 17142 NALOXONE 2 MG/2 ML SYRINGE NALOXONE HCL ON



7/26/2017 91



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


OPIATE DEPENDENCE TREATMENTS 67457059902 93400020102010 67457059902 17150 NALOXONE 0.4 MG/ML VIAL NALOXONE HCL ON



OPIATE DEPENDENCE TREATMENTS 00409121925 93400020102030 00409121925 17150 NALOXONE 4 MG/10 ML VIAL NALOXONE HCL ON









OPIATE DEPENDENCE TREATMENTS 00054018813 65200010200720 00054018813 18973 BUPRENORPHN-NALOXN 2-0.5 MG SL BUPRENORPHINE-NALOXONE NPD






OPIATE DEPENDENCE TREATMENTS 00093572156 65200010200740 00093572156 18974 BUPRENORPHIN-NALOXON 8-2 MG SL BUPRENORPHINE-NALOXONE NPD






OPIATE DEPENDENCE TREATMENTS 65757030202 27095 VIVITROL 380 MG VIAL VIVITROL ON

OPIATE DEPENDENCE TREATMENTS 65757030001 93400030001920 65757030001 27095 VIVITROL 380 MG VIAL + DILUENT VIVITROL ON

OPIATE DEPENDENCE TREATMENTS 12496120201 65200010208220 12496120201 28958 SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE ON

OPIATE DEPENDENCE TREATMENTS 12496120203 65200010208220 12496120203 28958 SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE ON

OPIATE DEPENDENCE TREATMENTS 12496120803 65200010208240 12496120803 28959 SUBOXONE 8 MG-2 MG SL FILM SUBOXONE ON






OPIATE DEPENDENCE TREATMENTS 54123091430 65200010200715 54123091430 34904 ZUBSOLV 1.4-0.36 MG TABLET SL ZUBSOLV NPD

7/26/2017 92



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug



OPIATE DEPENDENCE TREATMENTS 59385001201 65200010208260 59385001201 36677 BUNAVAIL 2.1-0.3 MG FILM BUNAVAIL NPD




OPIATE DEPENDENCE TREATMENTS 59385001630 65200010208280 59385001630 36679 BUNAVAIL 6.3-1 MG FILM BUNAVAIL NPD

OPIATE DEPENDENCE TREATMENTS 59385001601 65200010208280 59385001601 36679 BUNAVAIL 6.3-1 MG FILM BUNAVAIL NPD




OPIATE DEPENDENCE TREATMENTS 69547035302 93400020100920 69547035302 40233 NARCAN 4 MG NASAL SPRAY NARCAN ON

OPIATE DEPENDENCE TREATMENTS 58284010014 65200010102320 58284010014 41432 PROBUPHINE 74.2 MG IMPLANT PROBUPHINE NPD


OPIATE DEPENDENCE TREATMENTS 69547021224 43001 NARCAN 2 MG NASAL SPRAY NARCAN ON

OPIATE DEPENDENCE TREATMENTS 69547021204 43001 NARCAN 2 MG NASAL SPRAY NARCAN ON

OPIATE DEPENDENCE TREATMENTS 62756045983 65200010100760 62756045983 64672 BUPRENORPHINE 2 MG TABLET SL BUPRENORPHINE HCL NPD












PROGESTATIONAL AGENTS 64011024301 26000010101710 64011024301 39946 MAKENA 1,250 MG/5 ML VIAL MAKENA ON

PROGESTATIONAL AGENTS 64011024702 26000010101710 64011024702 40784 MAKENA 250 MG/ML VIAL MAKENA ON

EPINEPHRINE, SELF-INJECTED 49502010101 3890004000D520 49502010101 19861 EPINEPHRINE 0.15 MG AUTO-INJCT EPINEPHRINE NPD

EPINEPHRINE, SELF-INJECTED 49502010102 3890004000D520 49502010102 19861 EPINEPHRINE 0.15 MG AUTO-INJCT EPINEPHRINE NPD

EPINEPHRINE, SELF-INJECTED 49502050102 3890004000D520 49502050102 19861 EPIPEN JR 2-PAK 0.15 MG INJCTR EPIPEN JR 2-PAK ON

EPINEPHRINE, SELF-INJECTED 54505010201 3890004000D540 54505010201 19862 EPINEPHRINE 0.3 MG AUTO-INJECT EPINEPHRINE ON



7/26/2017 93



National Drug Code

(NDC) MediSpan

MediSpan Generic

Product Indicator

National Drug Code



ON = Preferred Drug


EPINEPHRINE, SELF-INJECTED 49502050002 3890004000D540 49502050002 19862 EPIPEN 2-PAK 0.3 MG AUTO-INJCT EPIPEN 2-PAK ON

EPINEPHRINE, SELF-INJECTED 49502010202 3890004000D540 49502010202 19862 EPINEPHRINE 0.3 MG AUTO-INJECT EPINEPHRINE NPD

EPINEPHRINE, SELF-INJECTED 52054080402 3890004000D540 52054080402 19862 ADRENACLICK 0.3 MG AUTO-INJECT ADRENACLICK NPD

EPINEPHRINE, SELF-INJECTED 49502010201 3890004000D540 49502010201 19862 EPINEPHRINE 0.3 MG AUTO-INJECT EPINEPHRINE NPD

EPINEPHRINE, SELF-INJECTED 52054080302 3890004000D530 52054080302 28038 ADRENACLICK 0.15 MG AUTO-INJCT ADRENACLICK NPD

EPINEPHRINE, SELF-INJECTED 54505010101 3890004000D530 54505010101 28038 EPINEPHRINE 0.15 MG AUTO-INJCT EPINEPHRINE ON



ANTIBIOTICS, INHALED 10122082056 07000070002530 10122082056 16122 BETHKIS 300 MG/4 ML AMPULE BETHKIS ON



ANTIBIOTICS, INHALED 61958090101 16000005402120 61958090101 28039 CAYSTON 75 MG INHAL SOLUTION CAYSTON NPD

ANTIBIOTICS, INHALED 00078063035 07000070000120 00078063035 30025 TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER NPD




ANTIBIOTICS, INHALED 70644089999 07000070002520 70644089999 37569 TOBRAMYCIN PAK 300 MG/5 ML TOBRAMYCIN NPD

ANTIBIOTICS, INHALED 24492085056 07000070002520 24492085056 37569 KITABIS PAK 300 MG/5 ML KITABIS PAK ON

ANTIBIOTICS, INHALED 00781717156 07000070002520 00781717156 61551 TOBRAMYCIN 300 MG/5 ML AMPULE TOBRAMYCIN NPD

ANTIBIOTICS, INHALED 00781717184 61551 TOBRAMYCIN 300 MG/5 ML AMPULE TOBRAMYCIN NPD


ANTIBIOTICS, INHALED 00078049471 07000070002520 00078049471 61551 TOBI 300 MG/5 ML SOLUTION TOBI NPD



ANTIBIOTICS, INHALED 00781717175 61551 TOBRAMYCIN 300 MG/5 ML AMPULE TOBRAMYCIN NPD

ANTIBIOTICS, INHALED 00078049461 07000070002520 00078049461 61551 TOBI 300 MG/5 ML SOLUTION TOBI NPD

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july 10, 2017 ahcccs pharmacy and therapeutics committee ... · july 10, 2017 ahcccs pharmacy and...

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