medicaid formulary crystal run health plans · 2019-04-15 · medicaid formulary. crystal run...

Medicaid FormularyCrystal Run Health PlansAdministered by MedImpact

Effective April 2019

ForewordThis document represents the efforts of the MedImpactHealthcare Systems Pharmacy and Therapeutics (P & T) andFormulary Committees to provide physicians and pharmacistswith a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. Astructured approach to the drug selection process is essential inensuring continuing patient access to rational drug therapies.The ultimate goal of the Standard Formulary is to provide aprocess and framework to support the dynamic evolution of thisdocument to guide prescribing decisions that reflect the mostcurrent clinical consensus associated with drug therapydecisions. This is accomplished through the auspices of the MedImpact P& T and Formulary Committees. These committees meetquarterly and more often as warranted to ensure clinicalrelevancy of the Formulary. To accommodate changes to thisdocument, updates are made accessible as necessary. As you use this Formulary, you are encouraged to review theinformation and provide your input and comments to theMedImpact P & T and Formulary Committees. Access to the most current version of the MedImpactStandard Formulary can be obtained by visitingwww.medimpact.com. The MedImpact P & T and Formulary Committees use thefollowing criteria in the evaluation of drug selection for theMedicaid Formulary:

• Drug safety profile• Drug efficacy• Comparison of relevant therapeutic benefits to currentformulary agents of similar use, and to minimize therapeuticduplication where possible

• Cost-effectiveness relative to comparable therapies

How to Use the FormularyThe Formulary is a list of medications available to MedImpactmembers under their pharmacy benefit. All drugs are listed bytheir generic names and most common proprietary (branded)name. The Formulary may be accessed by using the index,either by generic or proprietary name and by therapeutic drug

category. In situations where an FDA approved genericequivalent is available, brand names are listed for referencepurposes only, and do not denote coverage for the brand, unlessspecifically noted. Any drug not found in this Formularylisting, or any Formulary updates published by MedImpact shallbe considered a Non-Formulary drug. All drugs are listed in each category in alphabetical order bygeneric name. Where an FDA approved generic is available forthe listed generic name, the generic name is italicized. For certain agents within the Formulary, a recommendedprescribing guideline may apply. These are denoted throughoutthe document using the following symbols:

Symbol Guideline Description

AGE Age Edit Coverage may depend on patientage

G Gender Edit Coverage may depend on patientgender

PA PriorAuthorization

Requires specific physician requestprocess

QL QuantityLimit

Coverage may be limited to specificquantities per prescription and/ortime period

ST Step Therapy Coverage may depend on previoususe of another drug

Please refer to the prescribing guideline appendix within thisdocument for details regarding specific agents.

Benefit Coverage and LimitationsThis printed Formulary does not provide information regardingthe specific coverage and limitations an individual member maybe subject to. Many members have specific benefit inclusions,exclusions, copays, or a lack of coverage, which are notreflected in the Formulary. The Formulary applies only to outpatient drugs provided tomembers, and does not apply to medications used in inpatientsettings. If a member has any specific questions regarding their

Crystal Run Health Plans - April 2019 of 183

coverage, they should contact their Plan Sponsor or MedImpactat (888) 672-7166.

Depending upon a member’s specificbenefit parameters, the following topicsmay apply:

1.Generic SubstitutionWhen available, FDA approved generic drugs are to be usedin all situations, regardless of the brand name indicated.The generic names are italicized in the formulary listingwherever an FDA approved generic drug product isavailable. Greater economy is realized through the use ofgeneric equivalents. This policy is not meant to preclude orsupplant any state statutes that may exist. All drugs that areor become available generically are subject to review byMedImpact’s Pharmacy and Therapeutics Committee.MedImpact approves such multi-source drugs for additionto the MAC list based on the following criteria:

• A multi-source drug product manufactured by at leastone (1) nationally marketed company.

• At least one (1) of the generic manufacturer’s productsmust have an “A” rating or the generic product has beendetermined to be unassociated with efficacy, safety orbioequivalency concerns by the MedImpact P & TCommittee.

• Drug product will be approved for generic substitutionby the MedImpact P & T Committee.

This list is reviewed and updated periodically based on theclinical literature and pharmacokinetic characteristics ofcurrently available versions of these drug products.

2.Tier Benefit DesignThe Formulary may be applied to a tier benefit design,where the member shares the cost of prescription drugtherapy based on the drug’s tier and copayment orcoinsurance. In most instances, generically available drugswill be covered in a separate lower tier (low copay),preferred branded drugs listed on the Formulary will becovered under a higher tier, and branded drugs not on theFormulary will be covered under a separate non-preferredbranded drug copay tier. Essential healthbenefit/preventative medications, if available on your plansformulary, will be covered without cost sharing (zerocopay).

TIER DEFINITIONS: TIER 1: Preferred generic medications (formulary agents)TIER 2: Preferred brand medications (formulary agents)TIER 3: Non-preferred medications (non-formularyagents)TIER 4: EHB Zero CopayTIER 5: OTC medications

3.Medication Request ProcessDepending upon plan benefit design, a medication requestprocess may apply as follows:

A. Coverage Exceptions:Drugs that are listed in the Formulary with associatedPrior Authorization (PA) require evaluation, perMedImpact P & T Committee Prior Authorizationguidelines prior to dispensing at a network pharmacy.Each request will be reviewed on an individual patientneed basis. If the request does not meet the guidelinesestablished by the P & T Committee, the request willnot be approved and alternative therapy may berecommended.

B. Obtaining CoverageCoverage, questions or information regarding themedication request or formulary process may beobtained by:1. Faxing a completed Medication Request Form to

MedImpact at (858) 790-7100.2. Contacting MedImpact at (800) 788-2949 and

providing all necessary information requested. MedImpact will provide an authorization number,specific for the medical need, for all approvedrequests. Non-approved requests may be appealed.The prescriber must provide information to support theappeal on the basis of medical necessity. PriorAuthorization is generally not available for drugs thatare specifically excluded by benefit design.

4.General Exclusions

A.Over the Counter (OTC) medications or theirequivalents, unless the individual’s pharmacy benefitoffers coverage of OTC medications.

B. Drugs specifically listed as not covered.C. Any drug products used for cosmetic purposes..D. Experimental drug products or any drug product used

in an experimental manner.E. Replacement of lost or stolen medication.F. Non-self-administered injectable drug products unless

otherwise specified in the Formulary listing.


G. Foreign sourced drugs or drugs not approved by theUnited States Food & Drug Administration, except incertain cases of drug shortage, when allowed under theindividual’s pharmacy benefit.

The P & T and Formulary Committees recognize that notall medical needs can be met with this document andencourage inquiries about alternative therapies.

5.Pharmacist and Physician Communication

The Formulary is a tool to promote cost-effectiveprescription drug use. The P & T and FormularyCommittees have made every attempt to create a documentthat meets all therapeutic needs; however, the art ofmedicine makes this a formidable task. MedImpactwelcomes the participation of physicians, pharmacists, andancillary medical providers, in this dynamic process.Physicians and pharmacists are encouraged to direct anysuggestions, comments or formulary additions toMedImpact at the following address:

Chairperson, Pharmacy & Therapeutics CommitteeMedImpact Healthcare Systems, Inc.10181 Scripps Gateway CourtSan Diego, CA 92131


Drug Name Tier Requirements/Limits

ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

cetirizine hcl/pseudoephedrine

ZYRTEC-D (5MG-120MG)(TAB ER 12H)(OTC)

5

loratadine/pseudoephedrine

CLARITIN-D 12HOUR (5 MG-120MG) (TAB ER12H) (OTC)

5

loratadine/pseudoephedrine

CLARITIN-D 24HOUR (10MG-240MG) (TAB ER24H) (OTC)

5

ALLERGENIC EXTRACTS, THERAPEUTICS

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (100IR) (TAB SUBL) 2 PA

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (300IR) (TAB SUBL) 2 PA

GRASS POLLEN-TIMOTHY, STANDARD GRASTEK 2 PAMITE,D.FARINAE-D.PTERONYSSINUS ODACTRA 2 PAWEED POLLEN-SHORT RAGWEED RAGWITEK 2 PA

ANTIHISTAMINES - 1ST GENERATION

carbinoxamine maleate CLISTIN (4 MG)(TABLET) 1 AGE: >= 2 YEARS

carbinoxamine maleate CLISTIN (4 MG/5ML) (LIQUID) 4 AGE: >= 2 YEARS

carbinoxamine maleate PALGIC 1 AGE: >= 2 YEARS

chlorpheniramine maleate

CHLOR-TRIMETON (2MG/5 ML)(SYRUP) (OTC)

4

chlorpheniramine maleate

CHLOR-TRIMETON (4MG) (TABLET)(OTC)

4

chlorpheniramine maleateCHLOR-TRIMETONALLERGY

1

clemastine fumarate TAVIST 4clemastine fumarate TAVIST-1 1cyproheptadine hcl PERIACTIN 1diphenhydramine hcl (12.5mg/5ml) (elixir)(otc) 1

diphenhydramine hcl (12.5mg/5ml) (liquid)(otc) 4

diphenhydramine hcl (12.5mg/5ml) (syrup)(otc) 4

diphenhydramine hcl (25 mg) (capsule) (otc) 4diphenhydramine hcl (25 mg) (tablet) (otc) 4

Crystal Run Health Plans of 183

Drug Name Tier Requirements/Limitsdiphenhydramine hcl (50 mg) (capsule) (otc) 4diphenhydramine hcl (6.25mg/ml) (drops)(otc) 5

hydroxyzine hcl ATARAX 4hydroxyzine pamoate VISTARIL 4

promethazine hclPHENERGAN(12.5 MG)(TABLET)

1

promethazine hcl PHENERGAN (25MG) (TABLET) 1

promethazine hcl PHENERGAN (50MG) (TABLET) 1

promethazine hcl PHENERGAN VC 1ANTIHISTAMINES - 2ND GENERATION

cetirizine hcl

CHILDREN'SZYRTEC (1MG/ML)(SOLUTION)(OTC)

5

cetirizine hcl

CHILDREN'SZYRTEC (5 MG/5ML)(SOLUTION)(OTC)

5

cetirizine hcl

ZYRTEC (1MG/ML)(SOLUTION)(OTC)

5

cetirizine hclZYRTEC (10 MG)(TAB CHEW)(OTC)

5

cetirizine hcl ZYRTEC (10 MG)(TABLET) (OTC) 5

cetirizine hclZYRTEC (5 MG)(TAB CHEW)(OTC)

5

cetirizine hcl ZYRTEC (5 MG)(TABLET) (OTC) 5

cetirizine hcl

ZYRTEC (5 MG/5ML)(SOLUTION)(OTC)

5

desloratadine CLARINEX (5MG) (TABLET) 1 QL: 1 IN 1 DAY

fexofenadine hcl

ALLEGRA (30MG/5 ML)(ORAL SUSP)(OTC)

5 QL: 10mL IN 1 DAY

fexofenadine hcl ALLEGRAALLERGY (180 5


Drug Name Tier Requirements/LimitsMG) (TABLET)(OTC)

fexofenadine hcl

ALLEGRAALLERGY (60MG) (TABLET)(OTC)

5

levocetirizine dihydrochlorideXYZAL (2.5MG/5ML)(SOLUTION)

1 ST, QL: 10mL IN 1 DAY

levocetirizine dihydrochloride XYZAL (5 MG)(TABLET) 1

levocetirizine dihydrochloride XYZAL (5 MG)(TABLET) (OTC) 5

loratadine

CHILDREN'SCLARITIN (5MG/5 ML)(SOLUTION)(OTC)

5

loratadineCLARITIN (10MG) (CAPSULE)(OTC)

5

loratadineCLARITIN (10MG) (TABLET)(OTC)

5

loratadine

CLARITIN (5MG/5 ML)(SOLUTION)(OTC)

5

NASAL ANTIHISTAMINEazelastine hcl ASTELIN 1 QL: 60mL IN 30 DAYSolopatadine hcl PATANASE 1 ST, QL: 30.5gm IN 30 DAYS

NASAL ANTI-INFLAMMATORY STEROIDSBECLOMETHASONE DIPROPIONATE QNASL 2 ST, QL: 10.6gm IN 30 DAYS

BECLOMETHASONE DIPROPIONATE QNASLCHILDREN 2 ST, QL: 608gm IN 30 DAYS

flunisolide NASALIDE 1 QL: 25mL IN 30 DAYS

fluticasone propionateCHILDREN'SFLONASEALLERGY RLF

1 QL: 16mL IN 30 DAYS

fluticasone propionate FLONASE 1 QL: 16gm IN 30 DAYS

fluticasone propionateFLONASEALLERGYRELIEF


mometasone furoate NASONEX 1 QL: 17gm IN 30 DAYSNASAL MAST CELL STABILIZERS AGENTS

cromolyn sodium

NASALCROM(5.2 MG)(SPRAY/PUMP)(OTC)

5



ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTS

aprepitant EMEND (125MG) (CAPSULE) 1 QL: 1 IN 21 DAYS

aprepitantEMEND (125MG-80MG) (CAP DSPK)

1 QL: 3 IN 21 DAYS

aprepitant EMEND (40 MG)(CAPSULE) 1 QL: 1 IN 28 DAYS

aprepitant EMEND (80 MG)(CAPSULE) 1 QL: 2 IN 21 DAYS

dimenhydrinateDRAMAMINE(50 MG)(TABLET) (OTC)

5

dronabinol MARINOL 1 ST, QL: 2 IN 1 DAYgranisetron hcl KYTRIL 1 ST, QL: 8 IN 30 DAYSmeclizine hcl (12.5 mg) (tablet) 1meclizine hcl (12.5 mg) (tablet) (otc) 1meclizine hcl (25 mg) (tab chew) (otc) 5meclizine hcl (25 mg) (tablet) 1meclizine hcl (25 mg) (tablet) (otc) 1NETUPITANT/PALONOSETRON HCL AKYNZEO 2 QL: 1 IN 28 DAYSondansetron ZOFRAN ODT 1ondansetron hcl (24 mg) (tablet) 1ondansetron hcl (4 mg) (tablet) 1ondansetron hcl (4 mg/5 ml) (solution) 1 QL: 50mL IN 15 DAYSondansetron hcl (8 mg) (tablet) 1prochlorperazine COMPAZINE 1prochlorperazine maleate COMPAZINE 1promethazine hcl PHENERGAN 1trimethobenzamide hcl TIGAN 1

ASTHMA AND COPDANTICHOLINERGIC, ORALLY INHALED SHORT ACTING

ipratropium bromide ATROVENT 1IPRATROPIUM BROMIDE ATROVENT HFA 2 QL: 2 INHALERS IN 30 DAYS

ANTICHOLINERGICS, ORALLY INHALED LONG ACTING

TIOTROPIUM BROMIDE SPIRIVARESPIMAT 2 QL: 1 INHALER IN 30 DAYS

UMECLIDINIUM BROMIDE INCRUSEELLIPTA 2 QL: 30 IN 30 DAYS

BETA-ADRENERGIC AGENTSalbuterol sulfate 1metaproterenol sulfate ALUPENT 1terbutaline sulfate (2.5 mg) (tablet) 1terbutaline sulfate (5 mg) (tablet) 1

BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGalbuterol sulfate (0.63mg/3ml) (vial-neb) 1albuterol sulfate (1.25mg/3ml) (vial-neb) 1albuterol sulfate (2.5 mg/0.5) (vial-neb) 1


Drug Name Tier Requirements/Limitsalbuterol sulfate (2.5 mg/3ml) (vial-neb) 1albuterol sulfate (5 mg/ml) (solution) 1albuterol sulfate (90 mcg) (hfa aer ad) 1

ALBUTEROL SULFATEVENTOLIN HFA(90 MCG) (HFAAER AD)

1

levalbuterol hcl XOPENEX 1

levalbuterol hcl XOPENEXCONCENTRATE 1

BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING

OLODATEROL HCL STRIVERDIRESPIMAT 2 QL: 1 INHALER IN 30 DAYS

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGFORMOTEROL FUMARATE PERFOROMIST 2 QL: 120mL IN 30 DAYS

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS

IPRATROPIUM/ALBUTEROL SULFATE COMBIVENTRESPIMAT 2

ipratropium/albuterol sulfate DUONEB 1

TIOTROPIUM BR/OLODATEROL HCL STIOLTORESPIMAT 2 QL: 1 INHALER IN 30 DAYS

UMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA 2 QL: 60 IN 30 DAYSBETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS

fluticasone/salmeterol ADVAIR DISKUS 1 QL: 60 IN 30 DAYSFLUTICASONE/SALMETEROL ADVAIR HFA 2 QL: 1 INHALER IN 30 DAYS

fluticasone/salmeterol AIRDUORESPICLICK 1 QL: 1 IN 30 DAYS

FLUTICASONE/VILANTEROL BREO ELLIPTA 2 QL: 60 IN 30 DAYSMOMETASONE/FORMOTEROL DULERA 2 QL: 1 INHALER IN 30 DAYS

BETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED

FLUTICASONE/UMECLIDIN/VILANTER TRELEGYELLIPTA 2 QL: 60 IN 30 DAYS

GLUCOCORTICOIDS, ORALLY INHALED

budesonidePULMICORT(0.25MG/2ML)(AMPUL-NEB)


budesonidePULMICORT (0.5MG/2ML)(AMPUL-NEB)


budesonidePULMICORT (1MG/2 ML)(AMPUL-NEB)


FLUTICASONE FUROATE ARNUITYELLIPTA 2 QL: 30 IN 30 DAYS

FLUTICASONE PROPIONATEFLOVENT HFA(110 MCG) (AERW/ADAP)

2 QL: 1 INHALER IN 30 DAYS


2 QL: 2 INHALERS IN 30 DAYS




2 QL: 2 INHALERS IN 30 DAYS

LEUKOTRIENE RECEPTOR ANTAGONISTSmontelukast sodium SINGULAIR 1zafirlukast ACCOLATE 1

MAST CELL STABILIZERScromolyn sodium GASTROCROM 1

MAST CELL STABILIZERS, ORALLY INHALEDcromolyn sodium 1

PHOSPHODIESTERASE-4 (PDE4) INHIBITORSROFLUMILAST DALIRESP 2 ST, QL: 1 IN 1 DAY

RESPIRATORY AIDS,DEVICES,EQUIPMENT

COMPRESSOR, FOR NEBULIZER DEVILBISSCOMPACT 1

COMPRESSOR, FOR NEBULIZER DEVILBISSPULMO-AIDE 1

COMPRESSOR, FOR NEBULIZER DEVILBISSPULMOMATE 1

COMPRESSOR, FOR NEBULIZER DEVILBLISS 1

COMPRESSOR, FOR NEBULIZER EBASECONTROLLER 1

COMPRESSOR, FOR NEBULIZER PULMO-AIDE 1

COMPRESSOR, FOR NEBULIZERSUNRISECOMPRESSOR-NEBULIZER

1

HUMIDIFIER COOL MIST 1

HUMIDIFIER COOL MISTHUMIDIFIER 1

HUMIDIFIER HEALTHMIST 1HUMIDIFIER 1

HUMIDIFIER PURE COMFORTHUMIDIFIER 1

HUMIDIFIER VICKS COOLMIST 1

INHALER, ASSIST DEVICESACE AEROSOLCLOUDENHANCER

1

INHALER, ASSIST DEVICES AEROCHAMBERMINI 1

INHALER, ASSIST DEVICES AEROCHAMBERMV 1

INHALER, ASSIST DEVICES AEROCHAMBERPLUS FLOW-VU 1

INHALER, ASSIST DEVICESAEROCHAMBERWITHFLOWSIGNAL

1

INHALER, ASSIST DEVICES AEROCHAMBERZ-STAT PLUS 1



INHALER, ASSIST DEVICES AEROTRACHPLUS 1

INHALER, ASSIST DEVICES AEROVENTPLUS 1

INHALER, ASSIST DEVICES BREATHERITE 1INHALER, ASSIST DEVICES BREATHRITE 1

INHALER, ASSIST DEVICESCOMPACTSPACECHAMBER

1

INHALER, ASSIST DEVICESCOMPACTSPACECHAMBER PLUS

1

INHALER, ASSIST DEVICES EASIVENT 1INHALER, ASSIST DEVICES E-Z SPACER 1

INHALER, ASSIST DEVICES FLEXICHAMBER 1

INHALER, ASSIST DEVICES INSPIRACHAMBER 1

INHALER, ASSIST DEVICES LITEAIRE 1

INHALER, ASSIST DEVICES MICROCHAMBER 1

INHALER, ASSIST DEVICES MICROSPACER 1

INHALER, ASSIST DEVICES OPTICHAMBERDIAMOND 1

INHALER, ASSIST DEVICES POCKETCHAMBER 1

INHALER, ASSIST DEVICES PRIMEAIRE 1INHALER, ASSIST DEVICES PROCHAMBER 1INHALER, ASSIST DEVICES RITEFLO 1

INHALER, ASSIST DEVICES SPACECHAMBER PLUS 1

INHALER, ASSIST DEVICES VORTEX 1

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBERPLUS FLOW-VU 1

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBERZ-STAT PLUS 1

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-INFANTMASK

1

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-NEONATE MSK

1

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-SMCHLD MSK

1

INHALER,ASSIST DEV,SMALL MASK

CLEVERCHOICEHOLDINGCHAMBER

1



INHALER,ASSIST DEV,SMALL MASKCOMPACTSPACECHAMBER

1

INHALER,ASSIST DEV,SMALL MASK INSPIRACHAMBER 1

INHALER,ASSIST DEV,SMALL MASK OPTICHAMBERDIAMOND 1

INHALER,ASSIST DEV,SMALL MASKPRO COMFORTSPACER WITHMASK

1

INHALER,ASSIST DEV,SMALL MASK

VORTEXHOLDINGCHAMBER-TODDLER

1

INHALER,ASSIST DEV,SMALL MASKVORTEX VHCLADYBUGMASK

1

INHALER,ASSIST DEVICE,ACCESORY EASIVENT 1

INHALER,ASSIST DEVICE,ACCESORY FLEXICHAMBER MASK 1

INHALER,ASSIST DEVICE,ACCESORY LITETOUCH 1INHALER,ASSIST DEVICE,ACCESORY MOUTHPIECE 1

INHALER,ASSIST DEVICE,ACCESORY ONE WAYMOUTHPIECE 1

INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER 1INHALER,ASSIST DEVICE,ACCESORY PANDA MASK 1

INHALER,ASSIST DEVICE,ACCESORY PEDIATRICMASK 1

INHALER,ASSIST DEVICE,ACCESORY PEDIATRICPANDA MASK 1

INHALER,ASSIST DEVICE,ACCESORY SIDESTREAMPEDIATRIC 1

INHALER,ASSIST DEVICE,ACCESORY SILICONE MASK 1INHALER,ASSIST DEVICE,ACCESORY VORTEX 1

INHALER,ASSIST DEVICE,ACCESORY VORTEX FROGMASK 1

INHALER,ASSIST DEVICE,ACCESORYVORTEXLADYBUGMASK

1

INHALER,ASSIST DEVICE,LG MASK AEROCHAMBERPLUS FLOW-VU 1

INHALER,ASSIST DEVICE,LG MASK AEROCHAMBERZ-STAT PLUS 1

INHALER,ASSIST DEVICE,LG MASKBREATHERITESPACER-ADULTMASK

1

INHALER,ASSIST DEVICE,LG MASK


1



INHALER,ASSIST DEVICE,LG MASKCOMPACTSPACECHAMBER

1

INHALER,ASSIST DEVICE,LG MASK INSPIRACHAMBER 1

INHALER,ASSIST DEVICE,LG MASK OPTICHAMBERDIAMOND 1

INHALER,ASSIST DEVICE,LG MASKPRO COMFORTSPACER WITHMASK

1

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBERPLUS FLOW-VU 1

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBERZ-STAT PLUS 1

INHALER,ASSIST DEVICE,MED MASKBREATHERITESPACER-LGCHLD MSK

1

INHALER,ASSIST DEVICE,MED MASK


1

INHALER,ASSIST DEVICE,MED MASKCOMPACTSPACECHAMBER

1

INHALER,ASSIST DEVICE,MED MASK INSPIRACHAMBER 1

INHALER,ASSIST DEVICE,MED MASK OPTICHAMBERDIAMOND 1

INHALER,ASSIST DEVICE,MED MASK

VORTEXHOLDINGCHAMBER-CHILD

1

INHALER,ASSIST DEVICE,MED MASK VORTEX VHCFROG MASK 1

MUCUS CLEARING DEVICE AEROBIKA 1MUCUS CLEARING DEVICE QUAKE 1

NASAL AIRFLOW STRIPS BREATHERIGHT 1

NASAL AIRFLOW STRIPS NASAL STRIPS 1NASAL EXHALATION RESISTANC.DEV PROVENT 1NEBULIZER AEROECLIPSE II 1

NEBULIZER AERONEB GONEBULIZER 1

NEBULIZERAIRSDISPOSABLENEBULIZER

1

NEBULIZER ALTERANEBULIZER 1

NEBULIZER BABYNEBULIZER 1



NEBULIZERCOMPACTCOMPRESSORNEBULIZER

1

NEBULIZERCOMPACTULTRASONICNEBULIZER

1

NEBULIZERDEVILBISSDISPOSABLENEBULIZER

1

NEBULIZER ERAPIDNEBULIZER 1

NEBULIZER FLYPNEBULIZER 1

NEBULIZER INNOSPIRE GONEBULIZER 1

NEBULIZER LC DNEBULIZER SET 1

NEBULIZER LC PLUS 1

NEBULIZERLC PLUSNEBULIZER-PED MASK

1

NEBULIZER LC SPRINTNEBULIZER 1

NEBULIZER LC STAR 1NEBULIZER MICRO AIR 1

NEBULIZER MINI PLUSNEBULIZER 1

NEBULIZERMINICOMPCOMPRESSORNEBULIZER

1

NEBULIZER PARI LC SPRINTSINUS 1

NEBULIZER PRODIGY MINI-MIST 1

NEBULIZER SIDESTREAM 1

NEBULIZER SIDESTREAMNEBULIZER 1

NEBULIZER SIDESTREAMPLUS 1

NEBULIZER SINUSTAR 1

NEBULIZERSOOTHENEBMESHNEBULIZER

1

NEBULIZER TRUNEBNEBULIZER 1

NEBULIZER VIXONENEBULIZER 1

NEBULIZER AND COMPRESSORCLEVERCHOICENEBULIZER

1



NEBULIZER AND COMPRESSOR

CLEVERCHOICEWHISPER AIREPED

1

NEBULIZER AND COMPRESSORCOMP-AIRNEBULIZERCOMPRESSOR

1

NEBULIZER AND COMPRESSORDEVILBISSPULMONEB LTCOMP-NEB

1

NEBULIZER AND COMPRESSOR DEVILBISSTRAVELER 1

NEBULIZER AND COMPRESSOR EASY AIR 1


HOMENEBULIZERPLUSSIDESTREAM

1

NEBULIZER AND COMPRESSOR INNOSPIREDELUXE 1

NEBULIZER AND COMPRESSOR INNOSPIREELEGANCE 1

NEBULIZER AND COMPRESSOR INNOSPIREESSENCE 1

NEBULIZER AND COMPRESSOR INNOSPIREMINI 1

NEBULIZER AND COMPRESSORMY MDIPORTABLENEBULISER

1

NEBULIZER AND COMPRESSOROMBRACOMPRESSORSYSTEM

1

NEBULIZER AND COMPRESSORPARI SINUSAEROSOLSYSTEM

1

NEBULIZER AND COMPRESSORPEDIATRICDINOSAURNEBULIZER

1

NEBULIZER AND COMPRESSOR PEDIATRIC DOGNEBULIZER 1

NEBULIZER AND COMPRESSORPEDIATRICFROGNEBULIZER

1

NEBULIZER AND COMPRESSORPORTABLENEBULIZERSYSTEM

1

NEBULIZER AND COMPRESSORPROCARECOMPRESSORNEBULIZER

1

NEBULIZER AND COMPRESSOR PRONEB ULTRAII 1



NEBULIZER AND COMPRESSORPULMONEB LTCOMPRESSORNEBUL

1

NEBULIZER AND COMPRESSOR SAMI THE SEAL 1NEBULIZER AND COMPRESSOR SINUSTAR 1

NEBULIZER AND COMPRESSORSOOTHENEBCOMPRESSORNEBULIZER

1

NEBULIZER AND COMPRESSOR TREK S COMBOPACK 1

NEBULIZER AND COMPRESSORTREK SCOMPACTCOMPRESSOR

1

NEBULIZER AND COMPRESSORVIOS AEROSOLDELIVERYSYSTEM

1


WILLIS THEWHALECOMPRESSRNEB

1

PEAK FLOW METER AIRZONE PEAKFLOW METER 1

PEAK FLOW METER ASTHMACHECK 1

PEAK FLOW METERIN-CHECKNASAL WITHMASK

1

PEAK FLOW METER IN-CHECKORAL 1

PEAK FLOW METER MICROLIFEPEAK FLOW 1

PEAK FLOW METERMINI-WRIGHTPEAK FLOWMETER

1

PEAK FLOW METER PEAK-AIR 1

PEAK FLOW METER PERSONALBEST 1

PEAK FLOW METER PIKO 1 1PEAK FLOW METER POCKET PEAK 1

PEAK FLOW METER TRUZONE PEAKFLOW METER 1

PEAK FLOW METER/INH ASSIT DEVAEROGEARASTHMAACTION KIT

1

PEAK FLOW METER/INH ASSIT DEV ASTHMAPACKCHILDREN'S 1

SPIROMETER/DRUG DELIVERY ADAPT MISTASSIST KIT 1SPIROMETERS AND ACCESSORIES IN-CHECK DIAL 1SPIROMETERS AND ACCESSORIES MISTASSIST 1SPIROMETERS AND ACCESSORIES PFLEX TRAINER 1



SPIROMETERS AND ACCESSORIES THRESHOLDIMT 1

SPIROMETERS AND ACCESSORIES THRESHOLDPEP 1

SPIROMETERS AND ACCESSORIES WINDMILLTRAINER 1

VAPORIZER 1

VAPORIZERVICKS WARMSTEAMVAPORIZER

1

VAPORIZER WARM STEAMVAPORIZER 1

VAPORIZER-HUMIDIFIER SUPPLIES KAZ INHALANT 1

VAPORIZER-HUMIDIFIER SUPPLIESVAPORIZERCLEANINGTABLETS

1

VAPORIZER-HUMIDIFIER SUPPLIES VAPORIZERINHALANT 1

XANTHINEScaffeine citrate CAFCIT 1theophylline anhydrous ELIXOPHYLLIN 1theophylline anhydrous SLO-PHYLLIN 1THEOPHYLLINE ANHYDROUS THEO-24 2theophylline anhydrous THEO-DUR 1theophylline anhydrous UNIPHYL 1

AUTONOMIC NERVOUS SYSTEM DISORDERSALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

memantine hcl NAMENDA (10MG) (TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (2MG/ML)(SOLUTION)


memantine hcl NAMENDA (5MG) (TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (5MG-10 MG) (TABDS PK)

1 QL: 49 IN 28 DAYS

memantine hclNAMENDA XR(14 MG) (CAPSPR 24)

1 QL: 1 IN 1 DAY


1 QL: 1 IN 1 DAY


1 QL: 1 IN 1 DAY

memantine hclNAMENDA XR(7 MG) (CAP SPR24)

1 QL: 1 IN 1 DAY



MEMANTINE HCLNAMENDA XR(7-14-21-28)(CAP24 DSPK)

2 QL: 28 IN 28 DAYS

ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC(14MG-10MG)(CAP SPR 24)

2 ST, QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (21MG-10MG) (CAPSPR 24)


MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (28MG-10MG) (CAPSPR 24)


MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (7MG-10 MG) (CAPSPR 24)


MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (7-10/14-10) (CAP24DSPK)

2 ST, QL: 28 IN 28 DAYS

CHOLINESTERASE INHIBITORSdonepezil hcl ARICEPT 1donepezil hcl ARICEPT ODT 1

galantamine hbr RAZADYNE (12MG) (TABLET) 1 QL: 2 IN 1 DAY


galantamine hbrRAZADYNE (4MG/ML)(SOLUTION)



galantamine hbr RAZADYNE ER 1 QL: 1 IN 1 DAY

pyridostigmine bromideMESTINON (180MG) (TABLETER)

1

pyridostigmine bromide MESTINON (60MG) (TABLET) 1

PYRIDOSTIGMINE BROMIDEMESTINON (60MG/5 ML)(SYRUP)

2

rivastigmine EXELON 1 QL: 1 IN 1 DAYrivastigmine tartrate EXELON 1

BEHAVIORAL HEALTH - ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS

mirtazapine 4MAOIS - NON-SELECTIVE & IRREVERSIBLE

ISOCARBOXAZID MARPLAN 4phenelzine sulfate NARDIL 4tranylcypromine sulfate PARNATE 4


Drug Name Tier Requirements/LimitsNOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)

BUPROPION HBR APLENZIN 4 ST, QL: 1 IN 1 DAYbupropion hcl (100 mg) (tab sr 12h) 4bupropion hcl (100 mg) (tablet) 4bupropion hcl (150 mg) (tab er 24h) 4bupropion hcl (150 mg) (tab sr 12h) 4bupropion hcl (200 mg) (tab er 12h) 4bupropion hcl (200 mg) (tab sr 12h) 4bupropion hcl (300 mg) (tab er 24h) 4bupropion hcl (75 mg) (tablet) 4

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)citalopram hydrobromide CELEXA 4escitalopram oxalate LEXAPRO 4fluoxetine hcl 4fluoxetine hcl PROZAC 4

fluoxetine hcl PROZACWEEKLY 4

fluvoxamine maleate LUVOX 4fluvoxamine maleate LUVOX CR 4 ST, QL: 2 IN 1 DAYparoxetine hcl PAXIL 4PAROXETINE HCL PAXIL 4paroxetine hcl PAXIL CR 4paroxetine mesylate BRISDELLE 4 ST, QL: 1 IN 1 DAYPAROXETINE MESYLATE PEXEVA 4 ST, QL: 1 IN 1 DAYsertraline hcl ZOLOFT 4

SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)nefazodone hcl SERZONE 4trazodone hcl DESYREL 4

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)DESVENLAFAXINE ER 4 ST, QL: 1 IN 1 DAYdesvenlafaxine KHEDEZLA 4 ST, QL: 1 IN 1 DAYDESVENLAFAXINE FUMARATE ER 4 ST, QL: 1 IN 1 DAYdesvenlafaxine succinate PRISTIQ 4 QL: 1 IN 1 DAYduloxetine hcl (20 mg) (capsule dr) 4 QL: 2 IN 1 DAYduloxetine hcl (30 mg) (capsule dr) 4 QL: 2 IN 1 DAYduloxetine hcl (60 mg) (capsule dr) 4 QL: 2 IN 1 DAYLEVOMILNACIPRAN HCL FETZIMA 4 ST, QL: 1 IN 1 DAYvenlafaxine hcl EFFEXOR 4venlafaxine hcl EFFEXOR XR 4venlafaxine hcl er 4

SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT

VILAZODONE HCL VIIBRYD (10MG) (TABLET) 4 ST, QL: 1 IN 1 DAY



SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTVORTIOXETINE HYDROBROMIDE TRINTELLIX 4 ST, QL: 1 IN 1 DAY


Drug Name Tier Requirements/LimitsTRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS

amitriptyline/chlordiazepoxide LIMBITROL 4amitriptyline/chlordiazepoxide LIMBITROL DS 4

TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNSperphenazine/amitriptyline hcl ETRAFON-A 4perphenazine/amitriptyline hcl TRIAVIL 2-10 4perphenazine/amitriptyline hcl TRIAVIL 2-25 4perphenazine/amitriptyline hcl TRIAVIL 4-25 4perphenazine/amitriptyline hcl TRIAVIL 4-50 4

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBamitriptyline hcl ELAVIL 4amoxapine ASENDIN 4clomipramine hcl ANAFRANIL 4desipramine hcl NORPRAMIN 4doxepin hcl SINEQUAN 4imipramine hcl TOFRANIL 4imipramine pamoate TOFRANIL-PM 4maprotiline hcl LUDIOMIL 4nortriptyline hcl PAMELOR 4protriptyline hcl VIVACTIL 4trimipramine maleate SURMONTIL 4

BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE

dextroamphetamine sulfateDEXEDRINE (10MG) (CAPSULEER)

1 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (10MG) (TABLET) 1 QL: 6 IN 1 DAY


1 QL: 4 IN 1 DAY


1 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (5MG) (TABLET) 1 QL: 3 IN 1 DAY

dextroamphetamine sulfate PROCENTRA 1 QL: 1800mL IN 30 DAYSdextroamphetamine/amphetamine ADDERALL 1 QL: 2 IN 1 DAY

dextroamphetamine/amphetamineADDERALL XR(10 MG) (CAP ER24H)

1 QL: 1 IN 1 DAY


1 QL: 1 IN 1 DAY


1 QL: 2 IN 1 DAY


1 QL: 2 IN 1 DAY




1 QL: 2 IN 1 DAY


1 QL: 1 IN 1 DAY

LISDEXAMFETAMINE DIMESYLATE VYVANSE 2 ST, QL: 1 IN 1 DAYmethamphetamine hcl DESOXYN 1 QL: 5 IN 1 DAY

ANTI-ALCOHOLIC PREPARATIONSdisulfiram ANTABUSE 1NALTREXONE MICROSPHERES VIVITROL 2

ANTI-ANXIETY - BENZODIAZEPINESalprazolam 4ALPRAZOLAM INTENSOL 4chlordiazepoxide hcl 4clorazepate dipotassium 4diazepam 4lorazepam 4oxazepam 4

ANTI-ANXIETY DRUGSbuspirone hcl BUSPAR 4meprobamate 4

ANTI-MANIA DRUGSCARBAMAZEPINE EQUETRO 4lithium carbonate 4LITHIUM CARBONATE LITHOBID 4lithium citrate 4

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESpimozide ORAP 4

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED

aripiprazoleABILIFY (1MG/ML)(SOLUTION)


aripiprazole ABILIFY (10 MG)(TABLET) 4 QL: 1 IN 1 DAY






aripiprazole

ABILIFYDISCMELT (10MG) (TABRAPDIS)




aripiprazole

ABILIFYDISCMELT (15MG) (TABRAPDIS)


ARIPIPRAZOLE ABILIFYMAINTENA 4 QL: 1 IN 26 DAYS

ARIPIPRAZOLE ABILIFYMYCITE 4 PA

ARIPIPRAZOLE LAUROXILARISTADA(1064MG/3.9)(SUSER SYR)

4 QL: 3.9mL IN 14 DAYS

ARIPIPRAZOLE LAUROXILARISTADA (441MG/1.6) (SUSERSYR)






ARIPIPRAZOLE LAUROXIL,SUBMICR. ARISTADAINITIO 4

ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTSLOXAPINE ADASUVE 4loxapine succinate LOXITANE 4

ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAGASENAPINE MALEATE SAPHRIS 4 ST, QL: 2 IN 1 DAYclozapine 4 QL: 3 IN 1 DAYclozapine CLOZARIL 4 QL: 3 IN 1 DAYclozapine FAZACLO 4 ST, QL: 3 IN 1 DAYCLOZAPINE VERSACLOZ 4 ST, QL: 18mL IN 1 DAY

ILOPERIDONE FANAPT (1 MG)(TABLET) 4 ST, QL: 2 IN 1 DAY



ILOPERIDONEFANAPT (1-2-4-6MG) (TAB DSPK)






LURASIDONE HCL LATUDA (120MG) (TABLET) 4 ST, QL: 1 IN 1 DAY



LURASIDONE HCL LATUDA (20 MG)(TABLET) 4 ST, QL: 1 IN 1 DAY




olanzapine ZYPREXA 4 QL: 1 IN 1 DAY

olanzapine ZYPREXAZYDIS 4 QL: 1 IN 1 DAY

OLANZAPINE PAMOATEZYPREXARELPREVV (210MG) (VIAL)

4 QL: 1 IN 14 DAYS


4 QL: 1 IN 14 DAYS


4 QL: 1 IN 28 DAYS

paliperidone INVEGA (1.5MG) (TAB ER 24) 4 ST, QL: 1 IN 1 DAY

paliperidone INVEGA (3 MG)(TAB ER 24) 4 ST, QL: 1 IN 1 DAY



PALIPERIDONE PALMITATE

INVEGASUSTENNA(117MG/0.75)(SYRINGE)



INVEGASUSTENNA (156MG/ML)(SYRINGE)









INVEGASUSTENNA(78MG/0.5ML)(SYRINGE)


PALIPERIDONE PALMITATE INVEGATRINZA 4 QL: 0.875mL IN 84 DAYS


Drug Name Tier Requirements/Limits(273MG/.875)(SYRINGE)


INVEGATRINZA(410/1.315)(SYRINGE)



INVEGATRINZA(546MG/1.75)(SYRINGE)



INVEGATRINZA(819/2.625)(SYRINGE)


quetiapine fumarate SEROQUEL 4 QL: 3 IN 1 DAY

quetiapine fumarateSEROQUEL XR(150 MG) (TABER 24H)

4 QL: 1 IN 1 DAY


4 QL: 1 IN 1 DAY


4 QL: 1 IN 1 DAY


4 QL: 1 IN 1 DAY

quetiapine fumarateSEROQUEL XR(50 MG) (TAB ER24H)

4 QL: 1 IN 1 DAY

RISPERIDONE PERSERIS 4 QL: 1 IN 30 DAYSrisperidone (0.25 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (0.25 mg) (tablet) 4 QL: 2 IN 1 DAYrisperidone (0.5 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (0.5 mg) (tablet) 4 QL: 2 IN 1 DAYrisperidone (1 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (1 mg) (tablet) 4 QL: 2 IN 1 DAYrisperidone (1 mg/ml) (solution) 4 QL: 8mL IN 1 DAYrisperidone (2 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (2 mg) (tablet) 4 QL: 2 IN 1 DAYrisperidone (3 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (3 mg) (tablet) 4 QL: 2 IN 1 DAYrisperidone (4 mg) (tab rapdis) 4 QL: 2 IN 1 DAYrisperidone (4 mg) (tablet) 4 QL: 2 IN 1 DAY

RISPERIDONE MICROSPHERES RISPERDALCONSTA 4 QL: 1 IN 14 DAYS

ziprasidone hcl GEODON 4 QL: 2 IN 1 DAYZIPRASIDONE MESYLATE GEODON 4

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENESthiothixene NAVANE 4


Drug Name Tier Requirements/LimitsANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES

haloperidol HALDOL 4haloperidol decanoate HALDOL 4

haloperidol decanoate HALDOLDECANOATE 100 4

haloperidol decanoate HALDOLDECANOATE 50 4

haloperidol lactate 4ANTI-PSYCHOTICS,PHENOTHIAZINES

chlorpromazine hcl THORAZINE 4

fluphenazine decanoate PROLIXINDECANOATE 4

fluphenazine hcl PROLIXIN 4perphenazine TRILAFON 4thioridazine hcl MELLARIL 4trifluoperazine hcl STELAZINE 4

BARBITURATES

BUTABARBITAL SODIUM BUTISOLSODIUM 4

phenobarbital 4

SECOBARBITAL SODIUM SECONALSODIUM 4

HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSRAMELTEON ROZEREM 4 ST, QL: 1 IN 1 DAYTASIMELTEON HETLIOZ 4 PA

MONOAMINE OXIDASE(MAO) INHIBITORSSELEGILINE EMSAM 4 QL: 1 IN 1 DAY

NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTSmodafinil PROVIGIL 1 QL: 2 IN 1 DAY

NARCOTIC ANTAGONISTSnaloxone hcl 1NALOXONE HCL NARCAN 2 QL: 4 IN 30 DAYSnaltrexone hcl REVIA 1

SEDATIVE-HYPNOTICS - BENZODIAZEPINESestazolam 4flurazepam hcl 4midazolam hcl 1quazepam DORAL 4temazepam RESTORIL 4triazolam 4

SEDATIVE-HYPNOTICS,NON-BARBITURATE

diphenhydramine hclBENADRYL (25MG) (TABLET)(OTC)

4

diphenhydramine hclZZZQUIL (25MG) (CAPSULE)(OTC)

4

DOXEPIN HCL SILENOR 4 ST, QL: 1 IN 1 DAY

doxylamine succinate UNISOM (25 MG)(TABLET) (OTC) 5



doxylamine succinateUNISOM SLEEPAID (25 MG)(TABLET) (OTC)

5

eszopiclone LUNESTA 4 QL: 1 IN 1 DAYSUVOREXANT BELSOMRA 4 ST, QL: 1 IN 1 DAYzaleplon 4 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN 4 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN CR 4 QL: 1 IN 1 DAYZOLPIDEM TARTRATE EDLUAR 4 ST, QL: 1 IN 1 DAYzolpidem tartrate INTERMEZZO 4 ST, QL: 1 IN 1 DAYZOLPIDEM TARTRATE ZOLPIMIST 4 ST, QL: 7.7mL IN 30 DAYS

SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMBolanzapine/fluoxetine hcl 4 QL: 1 IN 1 DAY

TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONISTclonidine hcl KAPVAY 1 QL: 4 IN 1 DAYguanfacine hcl INTUNIV 1 QL: 1 IN 1 DAY

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYdexmethylphenidate hcl FOCALIN 1 QL: 2 IN 1 DAY

dexmethylphenidate hcl FOCALIN XR 1 AGE: <= 18 YEARS, QL: 1 IN1 DAY

methylphenidate hcl (10 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN1 DAY


methylphenidate hcl (10 mg) (tab chew) 1 QL: 3 IN 1 DAY

methylphenidate hcl (10 mg) (tablet er) 1 AGE: <= 18 YEARS, QL: 3 IN1 DAY

methylphenidate hcl (10 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg/5 ml) (solution) 1

methylphenidate hcl (18 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN1 DAY

methylphenidate hcl (2.5 mg) (tab chew) 1 QL: 3 IN 1 DAY



methylphenidate hcl (20 mg) (tablet er) 1 AGE: <= 18 YEARS, QL: 3 IN1 DAY

methylphenidate hcl (20 mg) (tablet) 1 QL: 3 IN 1 DAY









methylphenidate hcl (5 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg/5 ml) (solution) 1





METHYLPHENIDATE HCLQUILLIVANT XR(5 MG/ML) (SUER RC24)

2 ST, QL: 1 BOTTLE IN 30DAYS, 60 mL BOTTLE

METHYLPHENIDATE HCLQUILLIVANT XR(5 MG/ML) (SUER RC24)

2ST, QL: 2 BOTTLES IN 30DAYS, 120mL, 150mL, 180mLBOTTLE

TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE

atomoxetine hcl STRATTERA (10MG) (CAPSULE) 1 QL: 2 IN 1 DAY

atomoxetine hclSTRATTERA(100 MG)(CAPSULE)

1 QL: 1 IN 1 DAY






CARDIOVASCULAR DISEASE - ARRHYTHMIAANTIARRHYTHMICS

amiodarone hcl CORDARONE 1disopyramide phosphate NORPACE 1DISOPYRAMIDE PHOSPHATE NORPACE CR 2dofetilide TIKOSYN 1DRONEDARONE HCL MULTAQ 2flecainide acetate TAMBOCOR 1mexiletine hcl MEXITIL 1propafenone hcl RYTHMOL 1propafenone hcl RYTHMOL SR 1quinidine gluconate QUINAGLUTE 1quinidine sulfate 1



CARDIOVASCULAR DISEASE - CARDIAC STIMULANTADRENERGIC AGENTS,CATECHOLAMINES

epinephrine 1DIGITALIS GLYCOSIDES

digoxin (125 mcg) (tablet) 1digoxin (250 mcg) (tablet) 1DIGOXIN (50 MCG/ML) (SOLUTION) 2

CARDIOVASCULAR DISEASE - HYPERTENSIONACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

amlodipine besylate/benazepril LOTREL 1trandolapril/verapamil hcl 1

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICbenazepril/hydrochlorothiazide LOTENSIN HCT 1captopril/hydrochlorothiazide CAPOZIDE 1enalapril/hydrochlorothiazide VASERETIC 1fosinopril/hydrochlorothiazide MONOPRIL-HCT 1lisinopril/hydrochlorothiazide ZESTORETIC 1quinapril/hydrochlorothiazide ACCURETIC 1

ALPHA/BETA-ADRENERGIC BLOCKING AGENTScarvedilol COREG 1carvedilol phosphate COREG CR 1labetalol hcl 1

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate CARDURA 1phenoxybenzamine hcl DIBENZYLINE 1 PAprazosin hcl MINIPRESS 1terazosin hcl HYTRIN 1

ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CBamlodipine/valsartan/hcthiazid EXFORGE HCT 1

ANGIOTENSIN II RECEPTOR BLOCKER-BETA BLOCKER COMB.NEBIVOLOL HCL/VALSARTAN BYVALSON 2

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBirbesartan/hydrochlorothiazide AVALIDE 1losartan/hydrochlorothiazide HYZAAR 1olmesartan/hydrochlorothiazide BENICAR HCT 1valsartan/hydrochlorothiazide DIOVAN HCT 1

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRamlodipine besylate/valsartan EXFORGE 1

ANTIHYPERTENSIVES, ACE INHIBITORSbenazepril hcl LOTENSIN 1enalapril maleate VASOTEC 1fosinopril sodium MONOPRIL 1lisinopril PRINIVIL 1lisinopril ZESTRIL 1moexipril hcl UNIVASC 1perindopril erbumine ACEON 1quinapril hcl ACCUPRIL 1ramipril ALTACE 1trandolapril MAVIK 1


Drug Name Tier Requirements/LimitsANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST

irbesartan AVAPRO 1losartan potassium COZAAR 1olmesartan medoxomil BENICAR 1telmisartan MICARDIS 1valsartan DIOVAN 1

ANTIHYPERTENSIVES, SYMPATHOLYTIC

clonidine CATAPRES-TTS1 1



clonidine hcl CATAPRES 1guanfacine hcl TENEX 1methyldopa ALDOMET 1methyldopa/hydrochlorothiazide ALDORIL 15 1methyldopa/hydrochlorothiazide ALDORIL 25 1

ANTIHYPERTENSIVES, VASODILATORShydralazine hcl APRESOLINE 1minoxidil LONITEN 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl SECTRAL 1atenolol TENORMIN 1betaxolol hcl KERLONE 1bisoprolol fumarate ZEBETA 1metoprolol succinate TOPROL XL 1metoprolol tartrate (100 mg) (tablet) 1metoprolol tartrate (25 mg) (tablet) 1metoprolol tartrate (50 mg) (tablet) 1NEBIVOLOL HCL BYSTOLIC 2pindolol VISKEN 1

propranolol hcl INDERAL (10MG) (TABLET) 1


propranolol hclINDERAL (20MG/5 ML)(SOLUTION)

1


propranolol hclINDERAL(40MG/5ML)(SOLUTION)

1



propranolol hcl INDERAL LA 1sotalol hcl 1


Drug Name Tier Requirements/Limitstimolol maleate BLOCADREN 1

BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATEDatenolol/chlorthalidone TENORETIC 100 1atenolol/chlorthalidone TENORETIC 50 1bisoprolol/hydrochlorothiazide ZIAC 1

metoprolol/hydrochlorothiazide LOPRESSORHCT 1

nadolol/bendroflumethiazide CORZIDE 1propranolol/hydrochlorothiazid INDERIDE-40/25 1propranolol/hydrochlorothiazid INDERIDE-80/25 1

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate NORVASC 1

diltiazem hcl CARDIZEM (120MG) (TABLET) 1




diltiazem hcl CARDIZEM CD 1diltiazem hcl CARDIZEM SR 1diltiazem hcl DILACOR XR 1diltiazem hcl TIAZAC 1felodipine PLENDIL 1isradipine DYNACIRC 1nicardipine hcl 1nifedipine ADALAT CC 1nifedipine PROCARDIA 1

nifedipinePROCARDIA XL(30 MG) (TAB ER24)

1


1


1

nimodipine NIMOTOP 1NIMODIPINE NYMALIZE 2 PAverapamil hcl CALAN 1verapamil hcl CALAN SR 1verapamil hcl VERELAN 1verapamil hcl VERELAN PM 1

LOOP DIURETICS

bumetanide BUMEX (0.5 MG)(TABLET) 1

bumetanide BUMEX (1 MG)(TABLET) 1



bumetanide BUMEX (2 MG)(TABLET) 1

furosemide LASIX 1torsemide DEMADEX 1

POTASSIUM SPARING DIURETICSamiloride hcl MIDAMOR 1spironolactone ALDACTONE 1

POTASSIUM SPARING DIURETICS IN COMBINATION

amiloride/hydrochlorothiazide MODURETIC 5-50 1

spironolact/hydrochlorothiazidALDACTAZIDE(25 MG-25MG)(TABLET)

1

triamterene/hydrochlorothiazid DYAZIDE 1triamterene/hydrochlorothiazid MAXZIDE 1

triamterene/hydrochlorothiazid MAXZIDE-25MG 1

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATORRIOCIGUAT ADEMPAS 2 PA

PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB

SILDENAFIL CITRATEREVATIO (10MG/ML) (SUSPRECON)

2 PA

sildenafil citrate REVATIO (20MG) (TABLET) 1 PA

tadalafil ADCIRCA 1 PAPULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST

AMBRISENTAN LETAIRIS 2 PABOSENTAN TRACLEER 2 PAMACITENTAN OPSUMIT 2 PA

PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEILOPROST TROMETHAMINE VENTAVIS 2 PASELEXIPAG UPTRAVI 2 PATREPROSTINIL TYVASO 2 PATREPROSTINIL DIOLAMINE ORENITRAM ER 2 PATREPROSTINIL SODIUM REMODULIN 2 PA

TREPROSTINIL/NEB ACCESSORIES TYVASO REFILLKIT 2 PA

TREPROSTINIL/NEBULIZER/ACCESORTYVASOINSTITUTIONALSTART KIT

2 PA

TREPROSTINIL/NEBULIZER/ACCESOR TYVASOSTARTER KIT 2 PA

THIAZIDE AND RELATED DIURETICS

chlorothiazide DIURIL (250 MG)(TABLET) 1

chlorothiazide DIURIL (500 MG)(TABLET) 1

chlorthalidone HYGROTON 1hydrochlorothiazide 1


Drug Name Tier Requirements/Limitsindapamide LOZOL 1methyclothiazide 1metolazone ZAROXOLYN 1

VASODILATORS, COMBINATIONISOSORBIDE DINIT/HYDRALAZINE BIDIL 2

CARDIOVASCULAR DISEASE - LIPID IRREGULARITYANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS

atorvastatin calcium LIPITOR (10 MG)(TABLET) 1

AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORYOF CARDIOVASCULARDISEASE PREVENTIONMEDICATIONS IN 120 DAYS,QL: 1 IN 1 DAY

atorvastatin calcium LIPITOR (20 MG)(TABLET) 1


atorvastatin calcium LIPITOR (40 MG)(TABLET) 1 QL: 1 IN 1 DAY

atorvastatin calcium LIPITOR (80 MG)(TABLET) 1 QL: 1 IN 1 DAY

lovastatin MEVACOR 1


pravastatin sodium PRAVACHOL 1


rosuvastatin calcium CRESTOR (10MG) (TABLET) 1


rosuvastatin calcium CRESTOR (20MG) (TABLET) 1 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (40MG) (TABLET) 1 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (5MG) (TABLET) 1




simvastatin (10 mg) (tablet) 1








simvastatin (80 mg) (tablet) 1 ST, QL: 1 IN 1 DAYANTIHYPERLIPIDEMIC - MTP INHIBITOR

LOMITAPIDE MESYLATE JUXTAPID 2 PAANTIHYPERLIPIDEMIC - PCSK9 INHIBITORS

EVOLOCUMAB REPATHAPUSHTRONEX 2 PA

EVOLOCUMAB

REPATHASURECLICK (140MG/ML) (PENINJCTR)

2 PA

EVOLOCUMAB

REPATHASYRINGE (140MG/ML)(SYRINGE)

2 PA

BILE SALT SEQUESTRANTScholestyramine (with sugar) QUESTRAN 1

cholestyramine/aspartame QUESTRANLIGHT 1

colesevelam hcl WELCHOL 1

colestipol hcl COLESTID (1 G)(TABLET) 1

colestipol hcl COLESTID (5 G)(GRANULES) 1

colestipol hcl COLESTID (5 G)(PACKET) 1

LIPOTROPICSezetimibe ZETIA 1 QL: 1 IN 1 DAY


Drug Name Tier Requirements/Limitsfenofibrate FENOGLIDE 1fenofibrate LOFIBRA 1fenofibrate nanocrystallized TRICOR 1fenofibrate,micronized LOFIBRA 1fenofibric acid FIBRICOR 1fenofibric acid (choline) TRILIPIX 1gemfibrozil LOPID 1

ICOSAPENT ETHYLVASCEPA (0.5GRAM)(CAPSULE)

2 QL: 8 IN 1 DAY

ICOSAPENT ETHYL VASCEPA (1 G)(CAPSULE) 2 QL: 4 IN 1 DAY

niacin NIACOR 1niacin NIASPAN 1 STomega-3 acid ethyl esters LOVAZA 1 QL: 4 IN 1 DAY

NIACIN PREPARATIONSniacin sa 1

niacinNIACOR (500MG) (TABLET)(OTC)

5

niacinNIASPAN (500MG) (CAPSULEER) (OTC)

5

niacin

SLO-NIACIN(500 MG)(TABLET ER)(OTC)

5

niacinamide (500 mg) (tablet) (otc) 5CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS

ADRENERGIC VASOPRESSOR AGENTSDROXIDOPA NORTHERA 2 PAmidodrine hcl PROAMATINE 1

ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)SACUBITRIL/VALSARTAN ENTRESTO 2 QL: 2 IN 1 DAY

ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

RANOLAZINERANEXA (1000MG) (TAB ER12H)

2 QL: 2 IN 1 DAY

RANOLAZINERANEXA (500MG) (TAB ER12H)

2 QL: 4 IN 1 DAY

ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CBamlodipine/atorvastatin CADUET 1 QL: 1 IN 1 DAY

CARDIOVASCULAR DISEASE - VASODILATIONVASODILATORS,CORONARY

amyl nitrite 1isosorbide dinitrate ISOCHRON 1

isosorbide dinitrate ISORDIL (10 MG)(TABLET) 1





ISOSORBIDE DINITRATE ISORDIL (40 MG)(TABLET) 2

isosorbide dinitrate ISORDILTITRADOSE 1

isosorbide mononitrate IMDUR 1isosorbide mononitrate MONOKET 1NITROGLYCERIN NITRO-BID 2

nitroglycerinNITRO-DUR(0.1MG/HR)(PATCH TD24)

1


1

NITROGLYCERINNITRO-DUR (0.3MG/HR) (PATCHTD24)

2


1


1

NITROGLYCERINNITRO-DUR(0.8MG/HR)(PATCH TD24)

2

nitroglycerin NITROSTAT 1nitroglycerin NITRO-TIME 1

VASODILATORS,PERIPHERALergoloid mesylates HYDERGINE 1isoxsuprine hcl 1papaverine hcl 1

CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 4 QL: 1 IN 28 DAYSCONTRACEPTIVES,IMPLANTABLE

ETONOGESTREL NEXPLANON 4 QL: 1 IN 365 DAYSCONTRACEPTIVES,INJECTABLE

medroxyprogesterone acetate DEPO-PROVERA 4 QL: 1mL IN 84 DAYS

MEDROXYPROGESTERONE ACETATE DEPO-SUBQPROVERA 104 4 QL: 0.65mL IN 84 DAYS

CONTRACEPTIVES,INTRAVAGINALnonoxynol 9 CONCEPTROL 4nonoxynol 9 DELFEN 4NONOXYNOL 9 GYNOL II 4



NONOXYNOL 9TODAYCONTRACEPTIVE SPONGE

4

NONOXYNOL 9 VCF 4CONTRACEPTIVES,ORAL

desog-e.estradiol/e.estradiol MIRCETTE 4desogestrel-ethinyl estradiol CYCLESSA 4desogestrel-ethinyl estradiol DESOGEN 4desogestrel-ethinyl estradiol ORTHO-CEPT 4drospir/eth estra/levomefol ca BEYAZ 4drospir/eth estra/levomefol ca SAFYRAL 4ESTRADIOL VALERATE/DIENOGEST NATAZIA 4ethinyl estradiol/drospirenone YASMIN 28 4ethinyl estradiol/drospirenone YAZ 4ethynodiol d-ethinyl estradiol DEMULEN 4

ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 4

LEVONORGEST/ETH.ESTRADIOL/IRON BALCOLTRA 4 QL: 28 IN 28 DAYS

levonorgestrel PLAN B ONE-STEP 4 QL: 6 IN 365 DAYS

levonorgestrel-ethin estradiol (0.1-0.02mg)(tablet) 4

levonorgestrel-ethin estradiol (0.15-0.03)(tablet) 4

levonorgestrel-ethin estradiol (0.15-0.03)(tbdspk 3mo) 4 QL: 91 IN 84 DAYS

levonorgestrel-ethin estradiol (6-5-10)(tablet) 4

levonorgestrel-ethin estradiol (90-20 mcg)(tablet) 4

l-norgest/e.estradiol-e.estrad LOSEASONIQUE 4 QL: 91 IN 84 DAYSl-norgest/e.estradiol-e.estrad QUARTETTE 4l-norgest/e.estradiol-e.estrad SEASONIQUE 4 QL: 91 IN 84 DAYSnoreth-ethinyl estradiol/iron FEMCON FE 4noreth-ethinyl estradiol/iron GENERESS FE 4norethindrone NOR-Q-D 4

norethindrone ORTHOMICRONOR 4

norethindrone ac-eth estradiol LOESTRIN 4norethindrone-e.estradiol-iron ESTROSTEP FE 4

NORETHINDRONE-E.ESTRADIOL-IRON LO LOESTRINFE 4

norethindrone-e.estradiol-iron LOESTRIN 24 FE 4norethindrone-e.estradiol-iron LOESTRIN FE 4

norethindrone-e.estradiol-iron MINASTRIN 24FE 4

NORETHINDRONE-E.ESTRADIOL-IRON TAYTULLA 4norethindrone-ethinyl estrad MODICON 4norethindrone-ethinyl estrad ORTHO-NOVUM 4norethindrone-ethinyl estrad OVCON-35 4


Drug Name Tier Requirements/Limitsnorethindrone-ethinyl estrad TRI-NORINYL 4

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN 4

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO 4

norgestimate-ethinyl estradiol ORTHO-CYCLEN 4norgestrel-ethinyl estradiol LO-OVRAL-28 4norgestrel-ethinyl estradiol LO-OVRAL-8 4norgestrel-ethinyl estradiol OVRAL 4ULIPRISTAL ACETATE ELLA 4 QL: 6 IN 365 DAYS

CONTRACEPTIVES,TRANSDERMALnorelgestromin/ethin.estradiol ORTHO EVRA 4 QL: 3 IN 28 DAYS

DIAPHRAGMS/CERVICAL CAPCERVICAL CAP FEMCAP 4

DIAPHRAGMS, CONTOURED CAYACONTOURED 4

DIAPHRAGMS, WIDE SEAL WIDE SEALDIAPHRAGM 4

OXYTOCICSmethylergonovine maleate 1 QL: 28 IN 30 DAYS

COUGH AND COLD1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

brompheniramine/phenylephrine (1-2.5 mg/5)(solution) (otc) 5

chlorpheniramine/phenylephrine (1mg-2mg/ml) (drops) 1

chlorpheniramine/phenylephrine (4mg-10mg)(tablet) (otc) 5

chlorpheniramine/pseudoephed (4 mg-60 mg)(tablet) (otc) 5

phenylephrine hcl/prometh hcl PHENERGAN VC 1phenylephrine hcl/prometh hcl PHEN-TUSS AD 1triprolidine/pseudoephedrine (2.5mg-60mg)(tablet) (otc) 5

1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMBpseudoephed/chlor-mal/bell alk 1

ANTITUSSIVES,NON-NARCOTICbenzonatate TESSALON 1

benzonatate TESSALONPERLE 1

dextromethorphan polistirex

CHILDREN'SDELSYMCOUGH (30MG/5 ML) (SUSER 12H) (OTC)

5

dextromethorphan polistirexDELSYM (30MG/5 ML) (SUSER 12H) (OTC)

5


Drug Name Tier Requirements/LimitsDECONGESTANT-EXPECTORANT COMBINATIONS

guaifenesin/phenylephrine hcl (400mg-10mg)(tablet) (otc) 5

DECONGESTANTS, ORALphenylephrine hcl (10 mg) (tablet) (otc) 5

EXPECTORANTSguaifenesin (100 mg/5ml) (liquid) (otc) 5guaifenesin (1200 mg) (tab er 12h) (otc) 5guaifenesin (200 mg) (tablet) (otc) 5guaifenesin (400 mg) (tablet) (otc) 5guaifenesin (600 mg) (tab er 12h) (otc) 5

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTbromphenira/pseudoephed/codein 1 AGE: >= 12 YEARShydrocodone/cpm/pseudoephed 1 AGE: >= 18 YEARS

promethazine/phenyleph/codeine PENTAZINE VCWITH CODEINE 1 AGE: >= 18 YEARS

promethazine/phenyleph/codeine PHENERGAN VCWITH CODEINE 1 AGE: >= 18 YEARS

NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMBpseudoephed/codeine/guaifen TUSNEL C 1 AGE: >= 12 YEARS

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINEhydrocodone/chlorphen p-stirex TUSSIONEX 1 AGE: >= 18 YEARS

promethazine hcl/codeine PHENERGANWITH CODEINE 1 AGE: >= 18 YEARS

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.hydrocodone bit/homatrop me-br (5 mg-1.5mg) (tablet) 1 AGE: >= 18 YEARS

NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB

dm/pe/acetaminophen/chlorphenr

COMTREXCOLD-COUGHNIGHTTIME (10-5-325-2)(TABLET) (OTC)

5

dm/pe/acetaminophen/chlorphenrTHERAFLU (10-5-325-2)(TABLET) (OTC)

5

NON-NARC ANTITUSS-1ST GEN ANTIHIST-ANALGESIC COMB.dm/acetaminophen/doxylamine (15mg-325mg) (capsule) (otc) 5

NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTbrompheniram/phenylephrine/dm (1-2.5-5/5)(solution) (otc) 5

brompheniramine/pseudoephed/dm (1-15-5mg/5) (elixir) (otc) 5

chlorpheniramin/pseudoephed/dm PEDIACARECOUGH-COLD 5

NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.chlorpheniramine/dextromethorp (4 mg-30mg) (tablet) (otc) 5


Drug Name Tier Requirements/LimitsNON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB

guaifen/dextromethorphan/pe (100-10-5mg)(liquid) (otc) 5

GUAIFEN/DEXTROMETHORPHAN/PE VANATAB DM 5NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.

guaifenesin/dextromethorphan (100-10mg/5)(liquid) (otc) 5

guaifenesin/dextromethorphan (100-10mg/5)(syrup) (otc) 5

guaifenesin/dextromethorphan (100-5 mg/5)(liquid) (otc) 5

guaifenesin/dextromethorphan (1200-60mg)(tab er 12h) (otc) 5

guaifenesin/dextromethorphan (200-10mg/5)(liquid) (otc) 5

guaifenesin/dextromethorphan (400mg-20mg)(tablet) (otc) 5

GUAIFENESIN/DEXTROMETHORPHAN

MUCINEX DM(1200-60MG)(TAB ER 12H)(OTC)

5

NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC CBd-methorphan/pe/acetaminophen (10-5-325mg) (capsule) (otc) 5

d-methorphan/pe/acetaminophen (20-10-500)(powd pack) (otc) 5

NOSE PREPARATIONS, VASOCONSTRICTORS(OTC)oxymetazoline hcl (0.05 %) (mist) (otc) 5oxymetazoline hcl (0.05 %) (spray) (otc) 5

SYMPATHOMIMETIC AGENTSpseudoephedrine hcl (15 mg/5 ml) (liquid)(otc) 5

pseudoephedrine hcl (30 mg) (tablet) (otc) 5pseudoephedrine hcl (30 mg/5 ml) (liquid)(otc) 5

DERMATOLOGY - ACNEACNE AGENTS,SYSTEMIC

isotretinoin 1ACNE AGENTS,TOPICAL

clindamycin phos/benzoyl peroxBENZACLIN (1%-5 %) (GEL(GRAM))

1

clindamycin phos/benzoyl perox DUAC 1KERATOLYTIC-GLUCOCORTICOID COMBINATIONS

BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 2ROSACEA AGENTS, TOPICAL

metronidazole METROCREAM 1metronidazole METROGEL 1metronidazole METROLOTION 1metronidazole ROSADAN 1


Drug Name Tier Requirements/LimitsTOPICAL PREPARATIONS,ANTIBACTERIALS

BENZALKONIUM CHLORIDE REVITADERM 1

BENZETHONIUM CHLORIDE ANTISEPTICWOUND-SKIN 1

chloroxylenol PERIGIENE 1hydrocortisone/iodoquinol DERMAZENE 1iodine/potassium iodide (5%-10%) (solution) 1iodine/potassium iodide (5%-10%) (solution)(otc) 1

SILVER SILVASORB 1SILVERMED (GEL ER(ML)) (OTC) 1silver chloride 1silver nitrate 1

VITAMIN A DERIVATIVESadapalene DIFFERIN 1 AGE: <= 25 YEARSTRETINOIN ALTRENO 2 AGE: <= 25 YEARStretinoin RETIN-A 1 AGE: <= 25 YEARStretinoin microspheres RETIN-A MICRO 1 AGE: <= 25 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.04 %)(GEL W/PUMP)

1 AGE: <= 25 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.1 %)(GEL W/PUMP)

1 AGE: <= 25 YEARS

VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTSTAZAROTENE FABIOR 2 AGE: >= 12 YEARS

DERMATOLOGY - ANTIINFECTIVEINSECT REPELLANTS

3(N-BUTY-N-ACET)AMINOPROP ETHYCOLEMANSKINSMARTINSECT REP

5

diethyltoluamide (15 %) (aero powd) (otc) 5 QL: 2 BOTTLES IN 180 DAYSdiethyltoluamide (15 %) (spray) (otc) 5 QL: 2 BOTTLES IN 180 DAYSdiethyltoluamide (25 %) (spray) (otc) 5 QL: 2 BOTTLES IN 180 DAYSdiethyltoluamide (40 %) (spray) (otc) 5 QL: 2 BOTTLES IN 180 DAYSdiethyltoluamide (7 %) (spray) (otc) 5 QL: 2 BOTTLES IN 180 DAYS

lemon eucalyptus oilCOLEMANBOTANICALSINSECT REP

5

TOPICAL ANTIBIOTICSbacitracin (500 unit/g) (oint. (g)) (otc) 5bacitracin (500 unit/g) (packet) (otc) 5bacitracin zinc (500 unit/g) (oint. (g)) (otc) 5bacitracin zinc (500 unit/g) (packet) (otc) 5clindamycin phosphate CLEOCIN T 1clindamycin phosphate CLINDACIN ETZ 1clindamycin phosphate CLINDACIN P 1clindamycin phosphate EVOCLIN 1erythromycin base in ethanol 1


Drug Name Tier Requirements/LimitsERYTHROMYCIN/BENZOYL PEROXIDE AKTIPAK 2erythromycin/benzoyl peroxide BENZAMYCIN 1gentamicin sulfate 1mupirocin BACTROBAN 1mupirocin CENTANY 1mupirocin calcium BACTROBAN 1neomycin/bacitracin/polymyxinb (3.5-400-5k)(oint pack) (otc) 5

neomycin/bacitracin/polymyxinb (3.5-400-5k)(oint. (g)) (otc) 5

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENTclotrimazole/betamethasone dip LOTRISONE 1

TOPICAL ANTIFUNGALSciclopirox CICLODAN 1ciclopirox LOPROX 1ciclopirox PENLAC 1ciclopirox olamine CICLODAN 1ciclopirox olamine LOPROX 1ciclopirox/urea/camph/men/euc CICLODAN 1CLOTRIMAZOLE ALEVAZOL 5clotrimazole (1 %) (cream (g)) 1clotrimazole (1 %) (cream (g)) (otc) 5clotrimazole (1 %) (solution) 1econazole nitrate SPECTAZOLE 1gentian violet/brgreen/proflav 1ketoconazole EXTINA 1ketoconazole NIZORAL 1miconazole nitrate (2 %) (cream (g)) (otc) 5

naftifine hcl NAFTIN (1 %)(CREAM (G)) 1

NAFTIFINE HCL NAFTIN (1 %)(GEL (GRAM)) 2

naftifine hcl NAFTIN (2 %)(CREAM (G)) 1

nystatin MYCOSTATIN 1nystatin NYAMYC 1nystatin NYSTEX 1nystatin NYSTOP 1nystatin/triamcin (100000-0.1) (cream (g)) 1nystatin/triamcin (100000-0.1) (oint. (g)) 1sodium thiosulfate/sal acid VERSICLEAR 1SULCONAZOLE NITRATE EXELDERM 2TERBINAFINE HCL LAMISIL 2

terbinafine hclLAMISIL AT (1%) (CREAM (G))(OTC)

5

tolnaftate (1 %) (aero powd) (otc) 5tolnaftate (1 %) (cream (g)) (otc) 5tolnaftate (1 %) (powder) (otc) 5


Drug Name Tier Requirements/LimitsTOPICAL ANTIPARASITICS

DIETHYLTOLUAMIDEULTRATHONINSECTREPELLENT

5

ICARIDIN NATRAPEL 5 QL: 2 BOTTLES IN 180 DAYSlindane KWELL 1permethrin (1 %) (liquid) (otc) 5permethrin (5 %) (cream (g)) 1piperonyl butoxide/pyrethrins (4%-0.33%)(shampoo) (otc) 5

TOPICAL ANTIVIRALSacyclovir ZOVIRAX 1

DOCOSANOLABREVA (10 %)(CREAM (G))(OTC)

5

TOPICAL SULFONAMIDESmafenide acetate 1

MAFENIDE ACETATESULFAMYLON(8.5 %) (CREAM(G))

2

silver sulfadiazine SILVADENE 1silver sulfadiazine THERMAZENE 1

DERMATOLOGY - ANTIINFLAMMATORYTOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL

NEOMYC/BACIT/POLYMYX/HYDROCORT CORTISPORIN 2

NEOMYCIN/POLYMYXINB/HYDROCORT CORTISPORIN 2

TOPICAL ANTI-INFLAMMATORY STEROIDALalclometasone dipropionate ACLOVATE 1amcinonide CYCLOCORT 1betamethasone dipropionate DIPROLENE 1betamethasone valerate VALISONE 1betamethasone/propylene glyc DIPROLENE 1betamethasone/propylene glyc DIPROLENE AF 1clobetasol propionate CLOBEX 1clobetasol propionate CLODAN 1clobetasol propionate OLUX 1clobetasol propionate TEMOVATE 1clobetasol propionate/emoll OLUX-E 1clobetasol propionate/emoll TEMOVATE E 1

clobetasol propionate/emoll TEMOVATEEMOLLIENT 1

clocortolone pivalate CLODERM 1desonide 1

desoximetasone TOPICORT (0.05%) (CREAM (G)) 1

desoximetasone TOPICORT (0.25%) (CREAM (G)) 1


Drug Name Tier Requirements/LimitsDIFLORASONE DIACETATE/EMOLL APEXICON E 2

fluocinolone acetonide DERMA-SMOOTHE-FS 1

fluocinolone acetonide SYNALAR 1

fluocinolone/shower cap DERMA-SMOOTHE-FS 1

fluocinonide LIDEX 1fluocinonide VANOS 1fluocinonide/emollient base LIDEX-E 1

flurandrenolide CORDRAN (0.05%) (CREAM (G)) 1

flurandrenolide CORDRAN (0.05%) (LOTION) 1

flurandrenolide CORDRAN (0.05%) (OINT. (G)) 1

FLURANDRENOLIDECORDRAN(4MCG/SQ CM)(MED. TAPE)


flurandrenolide NOLIX 1

fluticasone propionate CUTIVATE (0.005%) (OINT. (G)) 1

fluticasone propionate CUTIVATE (0.05%) (CREAM (G)) 1

halobetasol propionate (0.05 %) (cream (g)) 1halobetasol propionate (0.05 %) (oint. (g)) 1hydrocort/min oil/petrolat,wht 1HYDROCORT/SAL ACID/SULF/SHAMP1 SCALACORT DK 2hydrocortisone (1 %) (cream (g)) 1hydrocortisone (1 %) (cream (g)) (otc) 5hydrocortisone (1 %) (cream pack) (otc) 5hydrocortisone (1 %) (oint. (g)) (otc) 5hydrocortisone (2 %) (lotion) 1hydrocortisone (2.5 %) (cream (g)) 1hydrocortisone (2.5 %) (crm/pe app) 1hydrocortisone (2.5 %) (lotion) 1hydrocortisone (2.5 %) (oint. (g)) 1HYDROCORTISONE TEXACORT 2hydrocortisone acetate (1 %) (cream (g))(otc) 5

hydrocortisone butyrate LOCOID (0.1 %)(CREAM (G)) 1

hydrocortisone butyrate LOCOID (0.1 %)(OINT. (G)) 1

hydrocortisone butyrate LOCOID (0.1 %)(SOLUTION) 1

HYDROCORTISONE PROBUTATE PANDEL 2hydrocortisone valerate 1hydrocortisone/aloe vera (1 %) (cream (g))(otc) 5

mometasone furoate ELOCON 1


Drug Name Tier Requirements/Limitsprednicarbate DERMATOP 1triamcinolone acetonide 1

TOPICAL ANTI-INFLAMMATORY, NSAIDS

diclofenac sodium PENNSAID (1.5%) (DROPS) 1

diclofenac sodium VOLTAREN 1DERMATOLOGY - MISCELLANEOUS

ANTISEPTICS,GENERALALCOHOL ANTISEPTIC PADS ALCOHOL PADS 1

ANTISEPTICS,MISCELLANEOUS

PHENOLCASTELLANIPAINTMODIFIED

5

DEODORANTS

OSTOMY SUPPLYODORELIMINATORDROPS

1

OSTOMY SUPPLY ULTRA-FRESH 1SODIUM CITRATE M9 1

EMOLLIENTSALOE VERA/COLLAGEN ALOE VESTA 1

ALOE VERA/COLLAGEN ALOE VESTACLEANSING 1

ALOE VERA/COLLAGEN PERISCENT 1ALOE VERA/COLLAGEN SENSI-CARE 1ALOE/LA/CERAMID/SILICONES/TAPE SILICONE SCAR 1ALOE/LAC AC/CERAMIDES 3,3B,6,1 HYPER-HEAL 1ammonium lactate (12 %) (cream (g)) 1ammonium lactate (12 %) (cream (g)) (otc) 1ammonium lactate (12 %) (lotion) 1ammonium lactate (12 %) (lotion) (otc) 1emol53/namgfs/ha/nahypochlorit 1emollient combination no.10 BIAFINE 1emollient combination no.35 MIMYX 1

EMOLLIENT COMBINATION NO.36 RESTORE SKINCONDITIONING 1

EMOLLIENT COMBINATION NO.60 ATRAPROHYDROGEL 1

EMOLLIENT COMBINATION NO.60 SEBUDERM 1EMOLLIENT COMBOS NO.47, NO.60 ATRAPRO CP 1EMOLLIENT NO56/HYALURONIC ACID DERMAPLEX 1glycerin/dimethicone 1lanolin alcohol/mo/w.pet/ceres EUCERIN 1

LANOLIN/ALOE VERA/PROP GLY SOOTHE &COOL 1

LANOLIN/ALOE VERA/PROP GLY

SOOTHE &COOLPERINEALWASH

1


Drug Name Tier Requirements/Limitsmineral oil/petrolatum,white (cream (g)) (otc) 1MINERAL,LANOLIN OILS/PROP GLYC BALNEOL 1pantothenic acid/aloe vera 1petrolatum,white 1SILICONES/ADHESIVE TAPE SILICONE DISC 1SILICONES/ADHESIVE TAPE SILICONE ROLL 1

SILICONES/ADHESIVE TAPE SILICONESHEET 1

SILICONES/ADHESIVE TAPE SILICONESHEET 1

SILICONES/ADHESIVE TAPE SILICONE TAPE 1vitamin e (oil) (otc) 1VITAMIN E/ALOE VERA WOUND GEL 1vite ac/grape/hyaluronic acid ATOPICLAIR 1

IODINE ANTISEPTICSpovidone-iodine (10 %) (liquid pkt) (otc) 1povidone-iodine (10 %) (solution) (otc) 1povidone-iodine (10 %) (spray) (otc) 1povidone-iodine (7.5 %) (solution) (otc) 1

IRRIGANTSacetic acid 1mannitol/sorbitol solution 1neomycin sulf/polymyxin b sulf 1PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOLYTE 1PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOSOL 1ringer's solution 1sodium chloride irrig solution 1sorbitol solution 1water for irrigation,sterile 1

IRRITANTS/COUNTER-IRRITANTScapsaicin (0.025 %) (adh. patch) (otc) 5capsaicin (0.025 %) (cream (g)) (otc) 5capsaicin (0.033 %) (cream (g)) (otc) 5capsaicin (0.075 %) (cream (g)) (otc) 5capsaicin (0.1 %) (cream (g)) (otc) 5capsaicin (0.15 %) (liquid) (otc) 5MENTHOL/BANDAGES, TUBULAR ICY HOT 1me-salicylate/isoprop.alcohol 1methyl salicylate (liquid) (otc) 1methyl salicylate (oil) (otc) 1

KERATOLYTICSbenzoyl peroxide (10 %) (gel (gram)) (otc) 5benzoyl peroxide (5 %) (gel (gram)) (otc) 5

PODOFILOXCONDYLOX (0.5%) (GEL(GRAM))

2 ST

podofilox CONDYLOX (0.5%) (SOLUTION) 1


Drug Name Tier Requirements/LimitsOXIDIZING AGENTS

hydrogen peroxide 1PROTECTIVES

BENZETHONIUM CHLORIDENEW SKIN (0.2%) (LIQ-FILM)(OTC)

1

benzoin 1CARBIT/EQUIS XT/ETHAN/CHIT/MSM GENADUR 1dimethicone (2 %) (lotion) (otc) 1

HYALURONATE SODIUM BIONECT (0.2 %)(CREAM (G)) 1

HYALURONATE SODIUM BIONECT (0.2 %)(GEL (GRAM)) 1

hyaluronate sodium/he-cell/peg 1HYALURONATE SODIUM/HE-CELL/PEG HYGEL 1HYALURONATE/ALLANTOIN/ALOE EXT RADIAPLEXRX 1petrolatum,white (oint pack) 1petrolatum,white (oint pack) (otc) 1petrolatum,white (oint. (g)) (otc) 1protectives2/ceramide 1,3,6-11 TETRIX 1zinc acetate/meadowsweet/oak 1zinc oxide (20 %) (oint. (g)) (otc) 5

TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETICHYDROCORTISONE/PRAMOXINE ANALPRAM HC 2

HYDROCORTISONE/PRAMOXINE PRAMOSONE (1%-1 %) (LOTION) 2

HYDROCORTISONE/PRAMOXINEPRAMOSONE (1%-1 %) (OINT.(G))

2

hydrocortisone/pramoxinePRAMOSONE(2.5 %-1 %)(CREAM (G))

1

HYDROCORTISONE/PRAMOXINEPRAMOSONE(2.5 %-1 %)(LOTION)

2

HYDROCORTISONE/PRAMOXINEPRAMOSONE(2.5 %-1 %)(OINT. (G))

2

lidocaine/hydrocortisone ac LIDAMANTLEHC 1

TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTSALITRETINOIN PANRETIN 2BEXAROTENE TARGRETIN 2 PAdiclofenac sodium SOLARAZE 1 QL: 100gm PER FILLfluorouracil EFUDEX 1

INGENOL MEBUTATE PICATO (0.015 %)(GEL (EA)) 2 ST, QL: 3 IN 28 DAYS

INGENOL MEBUTATE PICATO (0.05 %)(GEL (EA)) 2 ST, QL: 2 IN 28 DAYS

MECHLORETHAMINE HCL VALCHLOR 2 PA


Drug Name Tier Requirements/LimitsTOPICAL LOCAL ANESTHETICS

dyclonine hcl/benzethonium cl 1ethyl chloride 1LIDOCAINE (3 %) (CREAM (G)) (OTC) 5lidocaine (4 %) (adh. patch) (otc) 5lidocaine (4 %) (cream (g)) (otc) 5lidocaine (5 %) (adh. patch) 1 QL: 3 IN 1 DAYlidocaine (5 %) (oint. (g)) 1 ST, QL: 240gm IN 30 DAYSlidocaine hcl (3 %) (cream (g)) 1lidocaine hcl (4 %) (cream (g)) (otc) 5lidocaine hcl (4 %) (solution) 1LIDOCAINE HCL/COLLAGEN REGENECARE 1lidocaine/aloe vera (0.5 %) (gel (gram)) (otc) 5lidocaine/prilocaine EMLA 1VIT E/LIDOCAINE/ALOE/COLLAGEN LIDOTREX 1VIT E/LIDOCAINE/ALOE/COLLAGEN REGENECARE 1

TOPICAL PREPARATIONS,MISCELLANEOUSbenzethonium chloride 1calcium acetate/aluminum sulf (952-1347mg)(powd pack) (otc) 5

CALCIUM CARB/SOD HYPOCHLORITE NAIL SCRUB 1HONEY MEDIHONEY 1

SKIN CLEANSERDERMALWOUNDCLEANSER

1

DERMATOLOGY - PSORIASIS/ECZEMAANTIPSORIATIC AGENTS,SYSTEMIC

acitretin SORIATANE 1methoxsalen (10 mg) (cap lq rap) 1

SECUKINUMAB COSENTYX (2SYRINGES) 2 PA

SECUKINUMAB COSENTYX PEN 2 PA

SECUKINUMAB COSENTYX PEN(2 PENS) 2 PA

SECUKINUMAB COSENTYXSYRINGE 2 PA

ANTIPSORIATICS AGENTS

ANTHRALIN DRITHOCREMEHP 2 ST

calcipotriene DOVONEX 1 STcalcitriol VECTICAL 1 ST

TAZAROTENE TAZORAC (0.05%) (CREAM (G)) 2

TAZAROTENETAZORAC (0.05%) (GEL(GRAM))

2

tazarotene TAZORAC (0.1%) (CREAM (G)) 1



TAZAROTENETAZORAC (0.1%) (GEL(GRAM))

2

TOPICAL AGENTS,MISCELLANEOUScollagen,bovine 1SKIN CLEANSER BABY WASH 1SKIN CLEANSER CETAKLENZ 1SKIN CLEANSER CETAPHIL 1SKIN CLEANSER MEDERMA AG 1

SKIN CLEANSER PERIANALCLEANSING 1

SKIN CLEANSER PERIFRESH 1SKIN CLEANSER Z-CLINZ 1

SKIN CLEANSER COMB NO.20 RESTORE SKINCLEANSER 1

SKIN CLEANSER COMB NO.21RESTOREWOUNDCLEANSER

1

TOPICAL IMMUNOSUPPRESSIVE AGENTStacrolimus PROTOPIC 1 ST, AGE: >= 2 YEARS

TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDAL

calcipotriene/betamethasoneTACLONEX(0.005-.064)(OINT. (G))

1 ST

DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.

LINAGLIPTIN/METFORMIN HCL JENTADUETO 2 QL: 2 IN 1 DAY

LINAGLIPTIN/METFORMIN HCLJENTADUETOXR (2.5-1000MG)(TAB BP 24H)

2 QL: 2 IN 1 DAY

LINAGLIPTIN/METFORMIN HCL

JENTADUETOXR (5MG-1000MG) (TABBP 24H)

2 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(100-1000MG)(TBMP 24HR)

2 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(50-1000 MG)(TBMP 24HR)

2 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(50MG-500MG)(TBMP 24HR)

2 QL: 2 IN 1 DAY

ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)DULAGLUTIDE TRULICITY 2 ST, QL: 2mL IN 28 DAYSLIRAGLUTIDE VICTOZA 2-PAK 2 ST, QL: 9mL IN 30 DAYSLIRAGLUTIDE VICTOZA 3-PAK 2 ST, QL: 9mL IN 30 DAYS

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBCANAGLIFLOZIN INVOKANA 2 ST, QL: 1 IN 1 DAY


Drug Name Tier Requirements/LimitsEMPAGLIFLOZIN JARDIANCE 2 ST, QL: 1 IN 1 DAYERTUGLIFLOZIN PIDOLATE STEGLATRO 2 ST, QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)acarbose PRECOSE 1

ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPEPRAMLINTIDE ACETATE SYMLINPEN 120 2PRAMLINTIDE ACETATE SYMLINPEN 60 2

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSLINAGLIPTIN TRADJENTA 2 QL: 1 IN 1 DAYSITAGLIPTIN PHOSPHATE JANUVIA 2 QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEchlorpropamide DIABINESE 1glimepiride AMARYL 1glipizide GLUCOTROL 1glipizide GLUCOTROL XL 1glyburide 1glyburide,micronized GLYNASE 1nateglinide STARLIX 1repaglinide PRANDIN 1

tolazamide TOLINASE (250MG) (TABLET) 1

tolbutamide ORINASE 1ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)

pioglitazone hcl ACTOS 1ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.

EMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI 2 ST, QL: 1 IN 1 DAYANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)

metformin hcl (1000 mg) (tablet) 1metformin hcl (500 mg) (tab er 24h) 1metformin hcl (500 mg) (tablet) 1metformin hcl (500 mg/5ml) (solution) 1metformin hcl (750 mg) (tab er 24h) 1metformin hcl (850 mg) (tablet) 1

ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONISTINSULIN GLARGINE/LIXISENATIDE SOLIQUA 100-33 2 ST, QL: 30mL IN 28 DAYS

ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMBglipizide/metformin hcl METAGLIP 1glyburide/metformin hcl 1repaglinide/metformin hcl PRANDIMET 1

ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKERMIFEPRISTONE KORLYM 2 PA

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBCANAGLIFLOZIN/METFORMIN HCL INVOKAMET 2 ST, QL: 2 IN 1 DAYCANAGLIFLOZIN/METFORMIN HCL INVOKAMET XR 2 ST, QL: 2 IN 1 DAYEMPAGLIFLOZIN/METFORMIN HCL SYNJARDY 2 ST, QL: 2 IN 1 DAY

EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(10-1000 MG)(TAB BP 24H)




EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(12.5-1000) (TABBP 24H)


EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(25-1000 MG)(TAB BP 24H)


EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(5MG-1000MG)(TAB BP 24H)


ERTUGLIFLOZIN/METFORMIN SEGLUROMET 2 ST, QL: 2 IN 1 DAYANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB

pioglitazone hcl/metformin hclACTOPLUS MET(15MG-500MG)(TABLET)

1 ST

pioglitazone hcl/metformin hclACTOPLUS MET(15MG-850MG)(TABLET)

1 ST

PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS METXR 2 ST

BLOOD SUGAR DIAGNOSTICS

BLOOD SUGAR DIAGNOSTICFREESTYLEINSULINX(STRIP) (OTC)

1 QL: 200 IN 30 DAYS

BLOOD SUGAR DIAGNOSTICFREESTYLEINSULINX TESTSTRIPS


BLOOD SUGAR DIAGNOSTICFREESTYLELITE STRIPS(STRIP) (OTC)


BLOOD SUGAR DIAGNOSTICFREESTYLEPRECISION NEO(STRIP) (OTC)


BLOOD SUGAR DIAGNOSTICFREESTYLETEST STRIPS(STRIP) (OTC)


BLOOD SUGAR DIAGNOSTICPRECISIONXTRA (STRIP)(OTC)


DIABETIC SUPPLIES

BLOOD-GLUCOSE METERFREESTYLEFREEDOM LITE(KIT) (OTC)

1

BLOOD-GLUCOSE METERFREESTYLELITE METER(KIT) (OTC)

1

BLOOD-GLUCOSE METER

FREESTYLEPRECISION NEOMETER (EACH)(OTC)

1



BLOOD-GLUCOSE METERPRECISIONXTRA (EACH)(OTC)

1

DIABETIC SUPPLIES,MISCELL ALKALINEBATTERIES 1

DIABETIC SUPPLIES,MISCELL CHEMSTRIP BGDIARY 1

DIABETIC SUPPLIES,MISCELL ENLITE SERTER 1DIABETIC SUPPLIES,MISCELL EZ-VAC 1

DIABETIC SUPPLIES,MISCELL GLUCOCOMAUTOLINK 1

DIABETIC SUPPLIES,MISCELL GUARDIAN RTCHARGER 1

DIABETIC SUPPLIES,MISCELL GUARDIAN RTSTARTER KIT 1

DIABETIC SUPPLIES,MISCELL GUARDIAN RTSYSTEM 1

DIABETIC SUPPLIES,MISCELL GUARDIANTEST PLUG 1

DIABETIC SUPPLIES,MISCELLGUARDIANTRANSMITTERTAPE

1

DIABETIC SUPPLIES,MISCELL INSUL-CAP 1DIABETIC SUPPLIES,MISCELL INSUL-EZE 1

DIABETIC SUPPLIES,MISCELL MAGNI-GUIDEMAGNIFIER 1

DIABETIC SUPPLIES,MISCELLMEDTRONICREMOTECONTROL

1

DIABETIC SUPPLIES,MISCELL MINIMEDQUICK-SERTER 1

DIABETIC SUPPLIES,MISCELL OVAL TAPE 1

DIABETIC SUPPLIES,MISCELLPARADIGMREMOTECONTROL

1

DIABETIC SUPPLIES,MISCELLREPLACEMENTPEDIATRICMONITOR

1

DIABETIC SUPPLIES,MISCELL SEN-SERTER 1DIABETIC SUPPLIES,MISCELL SIL-SERTER 1DIABETIC SUPPLIES,MISCELL SOF-SERTER 1HOME HEMOGLOBIN A1C MONITOR AT HOME A1C 1INFUSION SET FOR INSULIN PUMP COMFORT 1INSULIN ADMIN. SUPPLIES AUTOJECT 2 1INSULIN ADMIN. SUPPLIES AUTOPEN 1

INSULIN ADMIN. SUPPLIES INPEN (FORHUMALOG) 1

INSULIN ADMIN. SUPPLIES INPEN (FORNOVOLOG) 1

INSULIN ADMIN. SUPPLIES NOVOPEN ECHO 1



INSULIN PUMP CONTROLLER OMNIPOD DASHPDM KIT 1

INSULIN PUMP/INFUS. SET/METER ACCU-CHEK 1

LANCETS ONETOUCHSURESOFT 1

LANCING DEVICEADJUSTABLELANCINGDEVICE

1

LANCING DEVICEADVOCATELANCINGDEVICE

1

LANCING DEVICE ADVOCATERAPID-SAFE 1

LANCING DEVICEALTERNATESITE LANCINGDEVICE

1

LANCING DEVICEAQUA LANCELANCINGDEVICE

1

LANCING DEVICE AUTO-LANCETMINI 1

LANCING DEVICEAUTOLETLANCINGDEVICE

1

LANCING DEVICE AUTOLET PLUS 1

LANCING DEVICECARELANCEULT LANCINGDEVICE

1

LANCING DEVICE CAREONE 1

LANCING DEVICECARESENSPREM LANCINGDEVICE

1

LANCING DEVICECARETOUCHLANCINGDEVICE

1

LANCING DEVICEDROPLETLANCINGDEVICE

1

LANCING DEVICEEASY MINIEJECT LANCINGDEVICE

1

LANCING DEVICEEASY TOUCHLANCINGDEVICE

1

LANCING DEVICE FORA LANCINGDEVICE 1

LANCING DEVICEHEALTHYACCENTSAUTOLET

1



LANCING DEVICEINCONTROLLANCINGDEVICE

1

LANCING DEVICE 1

LANCING DEVICE LANCINGSYSTEM 1

LANCING DEVICE LITE TOUCH 1

LANCING DEVICE MINI LANCINGDEVICE 1

LANCING DEVICEON CALLLANCINGDEVICE

1

LANCING DEVICEON CALL PLUSLANCINGDEVICE

1

LANCING DEVICEPRODIGYLANCINGDEVICE

1

LANCING DEVICERELIAMED MINILANCINGDEVICE

1

LANCING DEVICE RIGHTESTGD500 1

LANCING DEVICE SMARTDIABETES VANTAGE 1

LANCING DEVICE SURE COMFORTLANCING PEN 1

LANCING DEVICE SUREFLEX 1LANCING DEVICE SURE-PEN 1LANCING DEVICE TRUEDRAW 1LANCING DEVICE ULTI-LANCE 1LANCING DEVICE/LANCETS ACCU-CHEK 1

LANCING DEVICE/LANCETSACCU-CHEKFASTCLIXLANCING DEV

1

LANCING DEVICE/LANCETS ACCU-CHEKSOFTCLIX 1

LANCING DEVICE/LANCETSADVANCEDLANCINGDEVICE

1

LANCING DEVICE/LANCETS AUTOLETIMPRESSION 1

LANCING DEVICE/LANCETS HYPOLANCE 1

LANCING DEVICE/LANCETS LANCINGDEVICE 1

LANCING DEVICE/LANCETS LANZO 1LANCING DEVICE/LANCETS MICROLET 2 1

LANCING DEVICE/LANCETSMICROLETNEXT LANCINGDEVICE

1


Drug Name Tier Requirements/LimitsLANCING DEVICE/LANCETS MULTI-LANCET 1

LANCING DEVICE/LANCETS ONETOUCHDELICA 1

LANCING DEVICE/LANCETSSOLUS V2LANCINGDEVICE

1

LANCING DEVICE/LANCETS SUREFLEX 1LANCING DEVICE/LANCETS ULTI-LANCE 1LANCING DEVICE/LANCETS UNISTIK 2 1

LANCING DEVICE/LANCETS UNISTIK 2EXTRA 1

LANCING DEVICE/LANCETS UNISTIK 2NORMAL 1

LANCING DEVICE/LANCETS UNISTIK 3 1

LANCING DEVICE/LANCETS UNISTIK 3COMFORT 1

LANCING DEVICE/LANCETS UNISTIK 3NEONATAL 1

NEEDLE CLIP AND STORAGE DEVICE SAFE-CLIP 1SUB-Q INSULIN DEVICE, 20 UNIT V-GO 20 1SUB-Q INSULIN DEVICE, 30 UNIT V-GO 30 1SUB-Q INSULIN DEVICE, 40 UNIT V-GO 40 1SUBQ INSULIN PUMP,GLUC.MON.SYS ANIMAS VIBE 1

DIABETIC ULCER PREPARATIONS,TOPICALBECAPLERMIN REGRANEX 1

HYPERGLYCEMICSdextrose (4 g) (tab chew) (otc) 5

GLUCAGON,HUMAN RECOMBINANTGLUCAGONEMERGENCYKIT

2

INSULINS

INSULIN GLARGINE,HUM.REC.ANLOG BASAGLARKWIKPEN U-100 2 QL: 30mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO MAXSOLOSTAR 2 QL: 18mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG TOUJEOSOLOSTAR 2 QL: 13.5mL IN 28 DAYS

INSULIN LISPRO ADMELOG 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO ADMELOGSOLOSTAR 2 QL: 30mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX50-50 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX50-50 KWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX75-25 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX75-25 KWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30KWIKPEN 5 QL: 30mL IN 28 DAYS


Drug Name Tier Requirements/LimitsINSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30 5 QL: 40mL IN 28 DAYSINSULIN NPH HUM/REG INSULIN HM NOVOLIN 70-30 5 ST, QL: 40mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM NOVOLIN 70-30FLEXPEN 5 ST, QL: 30mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE HUMULIN N 5 QL: 40mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE HUMULIN NKWIKPEN 5 QL: 30mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE NOVOLIN N 5 ST, QL: 40mL IN 28 DAYSINSULIN REGULAR, HUMAN HUMULIN R 5 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R U-500 2 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R U-500 KWIKPEN 2 QL: 24mL IN 28 DAYS

INSULIN REGULAR, HUMAN NOVOLIN R 5 ST, QL: 40mL IN 28 DAYSURINE GLUCOSE TEST AIDS

URINE GLUCOSE TEST STRIP DIASTIXREAGENT 1

URINE GLUCOSE TEST STRIP NO-STICKGLUCOSE 1

URINE GLUCOSE/ACETONE TEST AIDS,STRIPS

URINE GLUCOSE-ACET TEST STRIP KETO-DIASTIXREAGENT 1

EAR - GENERAL DISORDERSEAR PREPARATIONS ANTI-INFLAMMATORY

fluocinolone acetonide oil DERMOTIC 1EAR PREPARATIONS, MISC. ANTI-INFECTIVES

acetic acid VOSOL 1hydrocortisone/acetic acid VOSOL HC 1

EAR PREPARATIONS,ANTIBIOTICSciprofloxacin hcl CETRAXAL 1neomycin/polymyxin b/hydrocort 1ofloxacin 1

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSCIPROFLOXACIN HCL/DEXAMETH CIPRODEX 2

ELECTROLYTE REGULATIONARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS

TOLVAPTAN JYNARQUE 2 PAELECTROLYTE DEPLETERS

calcium acetate ELIPHOS 1calcium acetate PHOSLO 1calcium carb/mag carb/folic ac 5

CALCIUM CARBONATE/MAG CARB MAGNEBIND300 5

sevelamer carbonate RENVELA 1sodium polystyrene sulfon/sorb 1sodium polystyrene sulfonate 1

ELECTROLYTE MAINTENANCE

electrolytes/dextrose ENFAMILENFALYTE 5


Drug Name Tier Requirements/Limits(SOLUTION)(OTC)

electrolytes/dextrosePEDIALYTE(SOLUTION)(OTC)

5

electrolytes/dextrose

PEDIALYTEADVANCEDCARE(SOLUTION)(OTC)

5


PEDIALYTEELECTROLYTESINGLES(SOLUTION)(OTC)

5


PEDIATRICELECTROLYTE(SOLUTION)(OTC)

5

POTASSIUM REPLACEMENTpotassium bicarbonate/cit ac KLOR-CON-EF 1potassium chloride 1

SODIUM/SALINE PREPARATIONS0.9 % sodium chloride (0.9 %) (cartridge) 10.9 % sodium chloride (0.9 %) (iv soln) 10.9 % sodium chloride (0.9 %) (syringe) 10.9 % sodium chloride (0.9 %) (vial) 10.9 % sodium chloride (pggybk prt) 10.9 % sodium chloride (pgy vl prt) 1bacteriostatic sodium chloride 1sodium chloride (1000 mg) (tablet sol) (otc) 5sodium chloride 0.45 % 1

ENDOCRINE DISORDER - FERTILITYDRUGS TO TREAT IMPOTENCY

tadalafil CIALIS (2.5 MG)(TABLET) 1 PA, BPH ONLY

tadalafil CIALIS (5 MG)(TABLET) 1 PA, BPH ONLY

FERTILITY STIMULATING PREPARATIONS,NON-FSHclomiphene citrate SEROPHENE 1 PA

HUMAN CHORIONIC GONADOTROPIN (HCG)

CHORIONIC GONADOTROPIN, HUMANCHORIONICGONADOTROPIN

2 PA

CHORIONIC GONADOTROPIN, HUMAN NOVAREL (10000UNIT) (VIAL) 2 PA

CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2 PAPREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL

PROGESTERONE, MICRONIZED CRINONE 2 PAPROGESTERONE, MICRONIZED ENDOMETRIN 2 PA



ENDOCRINE DISORDER - OTHERANTIDIURETIC AND VASOPRESSOR HORMONES

desmopressin (nonrefrigerated) DDAVP 1DESMOPRESSIN ACETATE DDAVP 2desmopressin acetate 1

ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.GOSERELIN ACETATE ZOLADEX 2 PAHISTRELIN ACETATE VANTAS 2 PALEUPROLIDE ACETATE ELIGARD 2 PAleuprolide acetate 1 PALEUPROLIDE ACETATE LUPRON DEPOT 2 PATRIPTORELIN PAMOATE TRELSTAR 2 PA

BONE FORMATION STIM. AGENTS - PARATHYROID HORMONETERIPARATIDE FORTEO 2 PA, QL: 2.4mL IN 28 DAYS

BONE FORMATION STIMULATING AGTS - PTH REL PEPTIDESABALOPARATIDE TYMLOS 2 PA

BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS

ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUSD 2

BONE RESORPTION INHIBITORS

alendronate sodium FOSAMAX (10MG) (TABLET) 1





alendronate sodiumFOSAMAX (70MG/75ML)(SOLUTION)


calcitonin,salmon,syntheticMIACALCIN(200/SPRAY)(SPRAY/PUMP)

1

etidronate disodium DIDRONEL 1ibandronate sodium BONIVA 1raloxifene hcl EVISTA 1 PA, QL: 1 IN 1 DAY

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER

CINACALCET HCL SENSIPAR (30MG) (TABLET) 2 QL: 2 IN 1 DAY



GROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOMAVERT 2


Drug Name Tier Requirements/LimitsGROWTH HORMONES

SOMATROPIN NORDITROPINFLEXPRO 2 PA

SOMATROPIN SEROSTIM 2 PASOMATROPIN ZORBTIVE 2 PA

HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPEdoxercalciferol 1paricalcitol 1

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONESMECASERMIN INCRELEX 2 PA

LEPTIN HORMONE ANALOGSMETRELEPTIN MYALEPT 2 QL: 1 IN 1 DAY

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSLEUPROLIDE ACETATE LUPRON DEPOT 2 PA

LEUPROLIDE ACETATE LUPRON DEPOT(LUPANETA) 2 PA

NAFARELIN ACETATE SYNAREL 2 PALHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS

ELAGOLIX SODIUM ORILISSA 2 PALHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY

HISTRELIN ACETATE SUPPRELIN LA 2 PA

LEUPROLIDE ACETATE LUPRON DEPOT-PED 2 PA

TRIPTORELIN PAMOATE TRIPTODUR 2 PAPITUITARY SUPPRESSIVE AGENTS

cabergoline DOSTINEX 1danazol DANOCRINE 1

ENDOCRINE DISORDER - THYROIDANTITHYROID PREPARATIONS

methimazole TAPAZOLE 1propylthiouracil 1

IODINE CONTAINING AGENTSpotassium iodide (1 g/ml) (solution) 1potassium iodide/iodine 1

THYROID HORMONESlevothyroxine sodium 1liothyronine sodium 1

THYROID,PORK ARMOURTHYROID 2

thyroid,pork (113.75 mg) (tablet) 1thyroid,pork (130 mg) (tablet) 1thyroid,pork (146.25 mg) (tablet) 1thyroid,pork (15 mg) (tablet) 1thyroid,pork (16.25 mg) (tablet) 1thyroid,pork (162.5 mg) (tablet) 1thyroid,pork (195 mg) (tablet) 1thyroid,pork (260 mg) (tablet) 1thyroid,pork (30 mg) (tablet) 1thyroid,pork (32.5 mg) (tablet) 1


Drug Name Tier Requirements/Limitsthyroid,pork (325 mg) (tablet) 1thyroid,pork (48.75 mg) (tablet) 1thyroid,pork (60 mg) (tablet) 1thyroid,pork (65 mg) (tablet) 1thyroid,pork (81.25 mg) (tablet) 1thyroid,pork (90 mg) (tablet) 1thyroid,pork (97.5 mg) (tablet) 1

EYE - GENERAL DISORDERSEYE ANTIBIOTIC-CORTICOID COMBINATIONS

neomycin/bacit/p-myx/hydrocort 1neomycin/polymyxin b/dexametha 1neomycin/polymyxin b/hydrocort 1

tobramycin/dexamethasoneTOBRADEX (0.3%-0.1%) (DROPSSUSP)

1

TOBRAMYCIN/DEXAMETHASONETOBRADEX (0.3%-0.1%) (OINT.(G))

2

TOBRAMYCIN/LOTEPRED ETAB ZYLET 2EYE ANTIHISTAMINES

azelastine hcl OPTIVAR 1epinastine hcl ELESTAT 1olopatadine hcl PATANOL 1

EYE ANTIINFLAMMATORY AGENTSdexamethasone sodium phosphate 1diclofenac sodium VOLTAREN 1DIFLUPREDNATE DUREZOL 2fluorometholone FML 1FLUOROMETHOLONE FML FORTE 2FLUOROMETHOLONE FML S.O.P. 2FLUOROMETHOLONE ACETATE FLAREX 2flurbiprofen sodium OCUFEN 1ketorolac tromethamine ACULAR 1ketorolac tromethamine ACULAR LS 1LOTEPREDNOL ETABONATE ALREX 2LOTEPREDNOL ETABONATE LOTEMAX 2NEPAFENAC ILEVRO 2NEPAFENAC NEVANAC 2prednisolone acetate OMNIPRED 1prednisolone acetate PRED FORTE 1PREDNISOLONE ACETATE PRED MILD 2prednisolone sodium phosphate 1

EYE ANTIVIRALSGANCICLOVIR ZIRGAN 2trifluridine VIROPTIC 1

EYE LOCAL ANESTHETICS

benoxinate hcl/fluorescein sod FLUORESCEIN-BENOXINATE 1

benoxinate hcl/fluorescein sod FLURESS 1


Drug Name Tier Requirements/Limitsbenoxinate hcl/fluorescein sod FLUROX 1proparacaine hcl 1proparacaine/fluorescein sod 1tetracaine hcl TETCAINE 1

tetracaine hcl/pfTETRACAINEHYDROCHLORIDE

1

EYE SULFONAMIDES

sulfacetamide sodium SODIUMSULAMYD 1

SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE 2

SULFACETAMIDE/PREDNISOLONE BLEPHAMIDES.O.P. 2

sulfacetamide/prednisolone sp 1EYE VASOCONSTRICTORS (RX ONLY)

phenylephrine hcl 1OPHTHALMIC ANTIBIOTICS

bacitracin 1bacitracin/polymyxin b sulfate 1BESIFLOXACIN HCL BESIVANCE 2

ciprofloxacin hcl CILOXAN (0.3 %)(DROPS) 1

CIPROFLOXACIN HCL CILOXAN (0.3 %)(OINT. (G)) 2

erythromycin base ILOTYCIN 1gatifloxacin ZYMAXID 1gentamicin sulfate GARAMYCIN 1gentamicin sulfate GENTAK 1levofloxacin 1moxifloxacin hcl VIGAMOX 1neomycin sulf/bacitracin/poly NEO-POLYCIN 1neomycin/polymyxn b/gramicidin NEOSPORIN 1ofloxacin OCUFLOX 1polymyxin b sulf/trimethoprim POLYTRIM 1

tobramycin TOBREX (0.3 %)(DROPS) 1

TOBRAMYCIN TOBREX (0.3 %)(OINT. (G)) 2

OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPELIFITEGRAST XIIDRA 2 QL: 2 IN 1 DAY

OPHTHALMIC MAST CELL STABILIZERScromolyn sodium OPTICROM 1LODOXAMIDE TROMETHAMINE ALOMIDE 2NEDOCROMIL SODIUM ALOCRIL 2

OPHTHALMIC PREPARATIONS, MISCELLANEOUSsodium chloride (2 %) (drops) (otc) 5sodium chloride (5 %) (drops) (otc) 5sodium chloride (5 %) (oint. (g)) (otc) 5



EYE - GLAUCOMACARBONIC ANHYDRASE INHIBITORS

acetazolamide 1MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS

apraclonidine hcl IOPIDINE (0.5 %)(DROPS) 1

betaxolol hcl BETOPTIC 1

BIMATOPROST LUMIGAN (0.01%) (DROPS) 2 QL: 1mL IN 12 DAYS

bimatoprost LUMIGAN (0.03%) (DROPS) 1 QL: 1mL IN 12 DAYS

brimonidine tartrate ALPHAGAN 1

BRIMONIDINE TARTRATE ALPHAGAN P(0.1 %) (DROPS) 2

brimonidine tartrate ALPHAGAN P(0.15 %) (DROPS) 1

BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN 2BRINZOLAMIDE AZOPT 2BRINZOLAMIDE/BRIMONIDINE TART SIMBRINZA 2carteolol hcl OCUPRESS 1dorzolamide hcl TRUSOPT 1

dorzolamide hcl/timolol maleat COSOPT (22.3-6.8/1) (DROPS) 1

latanoprost XALATAN 1levobunolol hcl BETAGAN 1metipranolol OPTIPRANOLOL 1

pilocarpine hcl ISOPTOCARPINE 1

timolol maleate TIMOPTIC 1timolol maleate TIMOPTIC-XE 1TRAVOPROST TRAVATAN Z 2 QL: 1mL IN 12 DAYS

MYDRIATICSatropine sulfate 1

atropine sulfate ISOPTOATROPINE 1

cyclopentolate hcl CYCLOGYL 1

homatropine hbr ISOPTOHOMATROPINE 1

tropicamide MYDRIACYL 1EYE - MISCELLANEOUS

ARTIFICIAL TEARS

CARBOXYMETHYL/GLY/POLY80/PF REFRESHOPTIVE MEGA-3 5

CARBOXYMETHYL/GLYCERIN/POLY80

REFRESHOPTIVEADVANCED (0.5-1-0.5%) (DROPS)(OTC)

5



CARBOXYMETHYLCELL/GLYCERIN/PFREFRESHOPTIVESENSITIVE

5

carboxymethylcellulose sodium (0.5 %)(droperette) (otc) 5

carboxymethylcellulose sodium (0.5 %)(drops) (otc) 5

CARBOXYMETHYLCELLULOSESODIUM

REFRESHCELLUVISC 5

CARBOXYMETHYLCELLULOSESODIUM

THERA TEARS(0.25 %)(DROPERETTE)(OTC)

5

dextran 70/hypromellose (0.1%-0.3%) (drops)(otc) 5

DEXTRAN 70/HYPROMELLOSE/PF GENTEALTEARS 5

DEXTRAN/HYPROMELLOSE/GLYCERIN GENTEALTEARS 5

HYPROMELLOSE GENTEALTEARS SEVERE 5

HYPROMELLOSE SYSTANE 5polyvinyl alcohol (1.4 %) (drops) (otc) 5polyvinyl alcohol/povidone (0.5%-0.6%)(drops) (otc) 5

POLYVINYL ALCOHOL/POVIDONE/PF REFRESHCLASSIC 5

PROPYLENE GLYCOL

SYSTANEBALANCE (0.6%) (DROPS)(OTC)

5

PROPYLENE GLYCOL

SYSTANECOMPLETE (0.6%) (DROPS)(OTC)

5

propylene glycol/peg 400SYSTANE (0.3 %-0.4%) (DROPS)(OTC)

5

propylene glycol/peg 400

SYSTANEULTRA (0.3 %-0.4%) (DROPS)(OTC)

5

propylene glycol/peg 400/pf

SYSTANE (0.3 %-0.4%)(DROPERETTE)(OTC)

5

propylene glycol/peg 400/pf

SYSTANEULTRA (0.3 %-0.4%)(DROPERETTE)(OTC)

5


Drug Name Tier Requirements/LimitsEYE DIAGNOSTIC AGENTS

fluorescein sodium 1lissamine green 1

EYE IRRIGATIONSbalanced salt soln non-surg 6 1

EYE PREPARATIONS, MISCELLANEOUS (OTC)

EYELID CLEANSER COMBINATION 5 CLEANSINGEYELID PADS 1

EYELID CLEANSER COMBINATION 5 CLEANSINGEYELID WIPES 1

EYELID CLEANSER COMBINATION 6 EYELID WIPES 1mineral oil/petrolatum,white (15 %-83 %)(oint. (g)) (otc) 5

mineral oil/petrolatum,white (15%-85%)(oint. (g)) (otc) 5

mineral oil/petrolatum,white (42.5-57.3%)(oint. (g)) (otc) 5

MINERAL OIL/PETROLATUM,WHITE REFRESHLACRI-LUBE 5

MINERAL OIL/PETROLATUM,WHITE SYSTANE 5OPHTHALMIC CYSTINE DEPLETING AGENTS

CYSTEAMINE HCL CYSTARAN 2 PAFLUID REPLACEMENT

NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTSURIDINE TRIACETATE XURIDEN 2 PA

GOUT AND RELATED DISEASESCOLCHICINE

colchicine COLCRYS 1 QL: 4 IN 1 DAYprobenecid/colchicine 1

HYPERURICEMIA TX - PURINE INHIBITORSallopurinol ZYLOPRIM 1FEBUXOSTAT ULORIC 2 QL: 1 IN 1 DAY

URICOSURIC AGENTSprobenecid BENEMID 1

HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE

warfarin sodium 1ANTIFIBRINOLYTIC AGENTS

aminocaproic acid 1tranexamic acid LYSTEDA 1

ANTIHEMOPHILIC FACTORSANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA 2ANTIHEMO.FVIII,FULL LENGTH PEG ADYNOVATE 2ANTIHEMOPH.FVIII REC,FC FUSION ELOCTATE 2ANTIHEMOPH.FVIII,B-DOM TRUNCAT NOVOEIGHT 2ANTIHEMOPH.FVIII,B-DOMAIN DEL XYNTHA 2

ANTIHEMOPH.FVIII,B-DOMAIN DEL XYNTHASOLOFUSE 2

ANTIHEMOPH.FVIII,HEK B-DELETE NUWIQ 2


Drug Name Tier Requirements/LimitsANTIHEMOPHIL.FVIII,FULL LENGTH ADVATE 2ANTIHEMOPHIL.FVIII,FULL LENGTH HELIXATE FS 2ANTIHEMOPHIL.FVIII,FULL LENGTH KOGENATE FS 2ANTIHEMOPHIL.FVIII,FULL LENGTH KOVALTRY 2ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE 2ANTIHEMOPHILIC FACTOR, HUMAN HEMOFIL M 2ANTIHEMOPHILIC FACTOR, HUMAN KOATE 2ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P 2ANTIHEMOPHILIC FACTOR/VWF ALPHANATE 2ANTIHEMOPHILIC FACTOR/VWF HUMATE-P 2ANTIHEMOPHILIC FACTOR/VWF WILATE 2ANTIHEMOPHILIC FVIII,REC PORC OBIZUR 2ANTI-INHIBITOR COAGULANT COMP. FEIBA NF 2COAGULATION FACTOR VIIA,RECOMB NOVOSEVEN RT 2FVIII REC,B-DOM DELET PEG-AUCL JIVI 2

BLOOD FACTORS,MISCELLANEOUSFACTOR XIII CORIFACT 2VON WILLEBRAND FACTOR VONVENDI 2

CITRATES AS ANTICOAGULANTScitrate phosphate dextros soln 1sodium citrate (4 g/100 ml) (solution) 1

DIRECT FACTOR XA INHIBITORS

APIXABAN ELIQUIS (2.5MG) (TABLET) 2 QL: 2 IN 1 DAY

APIXABANELIQUIS (5 MG(74)) (TAB DSPK)

2 QL: 74 IN 30 DAYS

APIXABAN ELIQUIS (5 MG)(TABLET) 2 QL: 74 IN 30 DAYS

RIVAROXABAN XARELTO (10MG) (TABLET) 2 QL: 1 IN 1 DAY

RIVAROXABAN XARELTO (15MG) (TABLET) 2 QL: 42 IN 21 DAYS THEN 1

IN 1 DAY

RIVAROXABANXARELTO (15MG-20MG) (TABDS PK)

2 QL: 51 IN 30 DAYS

RIVAROXABAN XARELTO (2.5MG) (TABLET) 2 QL: 2 IN 1 DAY

RIVAROXABAN XARELTO (20MG) (TABLET) 2 QL: 1 IN 1 DAY

FACTOR IX PREPARATIONSFACTOR IX ALPHANINE SD 2FACTOR IX MONONINE 2FACTOR IX CPLX(PCC)NO4,3FACTOR PROFILNINE 2FACTOR IX HUMAN REC,PEGYLATED REBINYN 2FACTOR IX HUMAN RECOMB,THR 148 IXINITY 2FACTOR IX HUMAN RECOMBINANT BENEFIX 2FACTOR IX HUMAN RECOMBINANT RIXUBIS 2FACTOR IX REC, FC FUSION PROTN ALPROLIX 2FACTOR IX RECOM,ALBUMIN FUSION IDELVION 2


Drug Name Tier Requirements/LimitsFACTOR X PREPARATIONS

COAGULATION FACTOR X COAGADEX 2FACTOR XIII PREPARATIONS

FACTOR XIII A-SUBUNIT,RECOMB TRETTEN 2HEMATINICS,OTHER

EPOETIN ALFA-EPBX RETACRIT 2 PAHEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT

EMICIZUMAB-KXWH HEMLIBRA 2 PAHEMORRHEOLOGIC AGENTS

pentoxifylline TRENTAL 1HEPARIN AND RELATED PREPARATIONS

DALTEPARIN SODIUM,PORCINEFRAGMIN(10000/ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINEFRAGMIN(12500/0.5)(SYRINGE)






DALTEPARIN SODIUM,PORCINEFRAGMIN(2500/0.2ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINEFRAGMIN(25000/ML)(VIAL)






enoxaparin sodiumLOVENOX (100MG/ML)(SYRINGE)


enoxaparin sodiumLOVENOX(120MG/.8ML)(SYRINGE)


enoxaparin sodiumLOVENOX (150MG/ML)(SYRINGE)


enoxaparin sodiumLOVENOX(300MG/3ML)(VIAL)


enoxaparin sodiumLOVENOX(30MG/0.3ML)(SYRINGE)










fondaparinux sodiumARIXTRA(10MG/0.8ML)(SYRINGE)


fondaparinux sodiumARIXTRA (2.5MG/0.5)(SYRINGE)


fondaparinux sodiumARIXTRA(5MG/0.4ML)(SYRINGE)


fondaparinux sodiumARIXTRA(7.5MG/0.6)(SYRINGE)


heparin sod,porcine/0.9 % nacl (100/ml) (kit) 1heparin sodium,porcine 1heparin sodium,porcine/d5w 1heparin sodium,porcine/pf (1 unit/ml)(syringe) 1

heparin sodium,porcine/pf (10 unit/ml)(syringe) 1

heparin sodium,porcine/pf (10 unit/ml) (vial) 1heparin sodium,porcine/pf (100/ml (1))(syringe) 1

heparin sodium,porcine/pf (100/ml (1)) (vial) 1heparin sodium,porcine/pf (1000/10 ml)(syringe) 1

heparin sodium,porcine/pf (1000/ml) (vial) 1heparin sodium,porcine/pf (200/2 ml)(syringe) 1

heparin sodium,porcine/pf (300/3 ml)(syringe) 1

heparin sodium,porcine/pf (500/5 ml)(syringe) 1

heparin sodium,porcine/pf (5000/0.5ml)(cartridge) 1

LEUKOCYTE (WBC) STIMULANTSFILGRASTIM NEUPOGEN 2 PA

FILGRASTIM-AAFINIVESTYM(300MCG/0.5)(SYRINGE)

2 PA

FILGRASTIM-SNDZ ZARXIO 2 PAPEGFILGRASTIM NEULASTA 2 PA


Drug Name Tier Requirements/LimitsPEGFILGRASTIM-JMDB FULPHILA 2 PASARGRAMOSTIM LEUKINE 2 PATBO-FILGRASTIM GRANIX 2 PA

PLATELET AGGREGATION INHIBITORSaspirin 4 QL: 100 PER FILL

aspirinBAYERCHEWABLEASPIRIN

4 QL: 100 PER FILL

aspirin ECOTRIN 4 QL: 100 PER FILLcilostazol PLETAL 1clopidogrel bisulfate (300 mg) (tablet) 1 QL: 4 IN 30 DAYSclopidogrel bisulfate (75 mg) (tablet) 1dipyridamole PERSANTINE 1prasugrel hcl EFFIENT 1 QL: 1 IN 1 DAYTICAGRELOR BRILINTA 2 QL: 2 IN 1 DAY

PLATELET REDUCING AGENTSanagrelide hcl AGRYLIN 1

SICKLE CELL ANEMIA AGENTSHYDROXYUREA DROXIA 2

HYDROXYUREA SIKLOS (100MG) (TABLET) 2 QL: 2 IN 1 DAY

HYDROXYUREA SIKLOS (1000MG) (TABLET) 2 ST

THROMBOPOIETIN RECEPTOR AGONISTSELTROMBOPAG OLAMINE PROMACTA 2 PA

TOPICAL HEMOSTATICSthromb-cal-cell-dressing,hemos 1thrombin (bovine) 1thrombin/cal/cmc/gel/dress,hem 1

VITAMIN K PREPARATIONSphytonadione (vit k1) (10 mg/ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (syringe) 1phytonadione (vit k1) (5 mg) (tablet) 1

HORMONAL DEFICIENCYANDROGENIC AGENTS

methyltestosterone ANDROID 1 PAmethyltestosterone TESTRED 1 PAoxandrolone OXANDRIN 1 PATESTOSTERONE ANDRODERM 2 PAtestosterone ANDROGEL 1 PAtestosterone AXIRON 1 PAtestosterone FORTESTA 1 PAtestosterone TESTIM 1 PAtestosterone VOGELXO 1 PA

testosterone cypionate DEPO-TESTOSTERONE 1 PA

testosterone enanthate DELATESTRYL 1 PATESTOSTERONE UNDECANOATE AVEED 2 PA


Drug Name Tier Requirements/LimitsESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB

ESTROGENS,CONJ/BAZEDOXIFENE DUAVEE 2ESTROGEN/ANDROGEN COMBINATIONS

estrogen,ester/me-testosterone COVARYX 1estrogen,ester/me-testosterone COVARYX H.S. 1

ESTROGENIC AGENTSestradiol CLIMARA 1 QL: 1 IN 7 DAYSestradiol ESTRACE 1estradiol MINIVELLE 1 QL: 2 IN 7 DAYSestradiol VIVELLE-DOT 1 QL: 2 IN 7 DAYS

ESTRADIOL CYPIONATE DEPO-ESTRADIOL 2

estradiol valerateDELESTROGEN(20 MG/ML)(VIAL)

1

estradiol valerateDELESTROGEN(40 MG/ML)(VIAL)

1

estradiol/norethindrone acet ACTIVELLA 1ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 2 QL: 2 IN 7 DAYSESTROGEN,CON/M-PROGEST ACET PREMPHASE 2ESTROGEN,CON/M-PROGEST ACET PREMPRO 2ESTROGENS, CONJUGATED PREMARIN 2ESTROGENS,ESTERIFIED MENEST 2norethindrone ac-eth estradiol FEMHRT 1norethindrone ac-eth estradiol JEVANTIQUE 1

LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB

LEUPROLIDE/NORETHINDRONE ACET LUPANETAPACK 2 PA

PROGESTATIONAL AGENTSmedroxyprogesterone acetate PROVERA 1norethindrone acetate AYGESTIN 1progesterone 1progesterone, micronized PROMETRIUM 1

IMMUNIZATIONANTISERA

IGG/HYALURONIDASE,RECOMBINANT HYQVIA 2 PAIMMUN GLOB G(IGG)/GLY/IGA OV50 CUVITRU 2 PA

IMMUN GLOB G(IGG)/GLY/IGA OV50 GAMMAGARDLIQUID 2 PA

IMMUN GLOB G(IGG)/GLY/IGA OV50 HYQVIA IGCOMPONENT 2 PA

IMMUN GLOB G(IGG)/PRO/IGA 0-50 HIZENTRA 2 PAGRAM NEGATIVE COCCI VACCINES

MENING VAC A,C,Y,W-135 DIP/PF MENACTRA 4 AGE: 11-23 YEARS, QL:0.5mL IN 365 DAYS

MENING VAC A,C,Y,W-135 DIP/PF MENVEO A-C-Y-W-135-DIP 4 AGE: 11-23 YEARS, QL: 1 IN

365 DAYS



MENINGOCOCCAL B VACCINE,4-COMP BEXSERO 4 AGE: 16-23 YEARS, QL: 1mLIN 365 DAYS

N.MENINGITIDIS B,LIPID FHBP RC TRUMENBA 4 AGE: 16-23 YEARS, QL:1.5mL IN 365 DAYS

GRAM POSITIVE COCCI VACCINES

PNEUMOC 13-VAL CONJ-DIP CRM/PF PREVNAR 13 4 AGE: >= 65 YEARS, QL:0.5mL IN 365 DAYS

PNEUMOCOCCAL 23-VAL P-SAC VAC PNEUMOVAX 23 4 AGE: >= 65 YEARS, QL:0.5mL IN 365 DAYS

INFLUENZA VIRUS VACCINES

FLU VAC QS 18-19 (4YR UP) CELL FLUCELVAXQUAD 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VAC QS 18-19(4YR UP)CEL/PF FLUCELVAXQUAD 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VAC QV 2018(18YR UP)RCM/PF FLUBLOK QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QS 2018 (6-35MOS)/PF FLUZONE QUADPEDI 2018-2019 4 QL: 0.25mL IN 180 DAYS

FLU VACC QS2018-19 36MOS UP/PF FLUZONE QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QS2018-19(6MOS UP)/PF AFLURIA QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QS2018-19(6MOS UP)/PF FLUARIX QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QS2018-19(6MOS UP)/PF FLULAVALQUAD 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(6MOS UP) AFLURIA QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(6MOS UP) FLULAVALQUAD 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(6MOS UP) FLUZONE QUAD2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC QV LIVE 2018(2-49YRS) FLUMIST QUAD2018-2019 4 QL: 1 IN 180 DAYS

FLU VACC TS 2018-19 (6 MOS UP) AFLURIA 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC TS2018(65UP)/MF59C/PF FLUAD 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC TS2018-19(65YR UP)/PF FLUZONE HIGH-DOSE 2018-2019 4 QL: 0.5mL IN 180 DAYS

FLU VACC TS2018-19(6MOS UP)/PF AFLURIA 2018-2019 4 QL: 0.5mL IN 180 DAYS

VACCINE/TOXOID PREPARATIONS,COMBINATIONS

DIPH,PERTUSS(ACELL),TET VAC/PF ADACEL TDAP 4 AGE: >= 18 YEARS, QL:0.5mL IN 365 DAYS

DIPHTH,PERTUSS(ACELL),TET VAC BOOSTRIXTDAP 4 AGE: >= 18 YEARS, QL:

0.5mL IN 365 DAYS

MEASLES,MUMPS,RUB,VARICELLA/PF PROQUAD 4 AGE: >= 18 YEARS, QL: 2 IN365 DAYS



MEASLES,MUMPS,RUBELLA VACC/PF M-M-R IIVACCINE 4 AGE: >= 18 YEARS, QL: 2 IN

365 DAYS

TETANUS, DIPHTHERIA TOX,ADULTTETANUSDIPHTHERIATOXOIDS

4 AGE: >= 18 YEARS, QL:0.5mL IN 365 DAYS

TETANUS-DIPHTHERIA TOXOIDS/PF TENIVAC 4 AGE: >= 18 YEARS, QL:0.5mL IN 365 DAYS

VIRAL/TUMORIGENIC VACCINES

HEPATITIS A AND B VACCINE/PF TWINRIX 4 AGE: >= 18 YEARS, QL: 4mLIN 365 DAYS

HEPATITIS A VIRUS VACCINE/PF HAVRIX 4 AGE: >= 18 YEARS, QL: 2mLIN 365 DAYS

HEPATITIS A VIRUS VACCINE/PF VAQTA 4 AGE: >= 18 YEARS, QL: 2mLIN 365 DAYS

HEPATITIS B VACCINE/CPG1018/PF HEPLISAV-B 4 AGE: >= 18 YEARS, QL: 1mLIN 365 DAYS

HEPATITIS B VIRUS VACCINE/PF ENGERIX-BADULT 4 AGE: >= 18 YEARS, QL: 3mL

IN 365 DAYS

HEPATITIS B VIRUS VACCINE/PF RECOMBIVAXHB 4 AGE: >= 18 YEARS, QL: 3mL

IN 365 DAYS

HPV VACCINE 9-VALENT/PF GARDASIL 9 4 AGE: 9-26 YEARS, QL: 1.5mLIN 365 DAYS

VARICELLA VACCINE LIVE/PF VARIVAXVACCINE 4 AGE: >= 18 YEARS, QL: 2 IN

365 DAYS

VARICELLA-ZOSTER GE VAC,2 OF 2SHINGRIX GEANTIGENCOMPONENT

4 AGE: >= 50 YEARS, QL: 2 IN365 DAYS

VARICELLA-ZOSTER GE/AS01B/PF SHINGRIX 4 AGE: >= 50 YEARS, QL: 2 IN365 DAYS

ZOSTER VACCINE LIVE/PF ZOSTAVAX 4 AGE: >= 60 YEARS, QL: 1 IN365 DAYS

IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS

imiquimod ALDARA 1 QL: 24 IN 30 DAYSINTERFERON ALFA-2B,RECOMB. INTRON A 2 PAINTERFERON ALFA-N3 ALFERON N 2INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE 2

IMMUNOSUPPRESSIVESazathioprine IMURAN 1cyclosporine 1

CYCLOSPORINESANDIMMUNE(100 MG/ML)(SOLUTION)

2

cyclosporine, modified 1EVEROLIMUS ZORTRESS 2mycophenolate mofetil CELLCEPT 1mycophenolate sodium MYFORTIC 1sirolimus 1TACROLIMUS ASTAGRAF XL 2tacrolimus 1



INFECTIOUS DISEASE - BACTERIALABSORBABLE SULFONAMIDES

sulfamethoxazole/trimethoprim 1BETALACTAMS

AZTREONAM LYSINE CAYSTON 2 PACEPHALOSPORINS - 1ST GENERATION

cefadroxil DURICEF 1cephalexin KEFLEX 1

CEPHALOSPORINS - 2ND GENERATIONcefaclor CECLOR 1cefaclor CECLOR CD 1cefprozil CEFZIL 1cefuroxime axetil CEFTIN 1

CEPHALOSPORINS - 3RD GENERATIONcefdinir OMNICEF 1cefditoren pivoxil SPECTRACEF 1

CEFIXIMESUPRAX (100MG) (TABCHEW)

2

cefiximeSUPRAX (100MG/5ML) (SUSPRECON)

1

CEFIXIMESUPRAX (200MG) (TABCHEW)

2

cefiximeSUPRAX (200MG/5ML) (SUSPRECON)

1

CEFIXIME SUPRAX (400MG) (CAPSULE) 2

CEFIXIMESUPRAX (500MG/5ML) (SUSPRECON)

2

cefpodoxime proxetil VANTIN 1CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.

meth/meblue/sod phos/psal/hyos 1METH/MEBLUE/SOD PHOS/PSAL/HYOS PHOSPHASAL 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URETRON D-S 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URIN D.S. 2methen/mblue/sal/sod phos/hyos 1methenam/m.blue/salicyl/hyoscy 1methenam/sod phos/mblue/hyoscy URYL 1methenamine hippurate HIPREX 1methenamine mandelate MANDELAMINE 1TRIMETHOPRIM PRIMSOL 2trimethoprim PROLOPRIM 1TRIMETHOPRIM TRIMPEX 2

MACROLIDESazithromycin 1


Drug Name Tier Requirements/Limitsclarithromycin BIAXIN 1clarithromycin BIAXIN XL 1ERYTHROMYCIN BASE ERY-TAB 2erythromycin base 1erythromycin ethylsuccinate E.E.S. 200 1erythromycin ethylsuccinate E.E.S. 400 1erythromycin ethylsuccinate ERYPED 200 1ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2

erythromycin stearate ERYTHRCINSTEARATE 1

FIDAXOMICIN DIFICID 2 ST, QL: 20 IN 30 DAYSNITROFURAN DERIVATIVES

nitrofurantoin FURADANTIN 1

nitrofurantoin macrocrystalMACRODANTIN(100 MG)(CAPSULE)

1


1 QL: 4 IN 1 DAY


1

nitrofurantoin monohyd/m-cryst MACROBID 1OXAZOLIDINONES

linezolid ZYVOX 1TEDIZOLID PHOSPHATE SIVEXTRO 2 ST, QL: 6 IN 6 DAYS

PENICILLINSamoxicillin AMOXIL 1

AMOXICILLIN/POTASSIUM CLAVAUGMENTIN(125-31.25/)(SUSP RECON)

2 ST, QL: 150mL IN 30 DAYS

amoxicillin/potassium clavAUGMENTIN(200-28.5/5)(SUSP RECON)

1

amoxicillin/potassium clavAUGMENTIN(200-28.5MG)(TAB CHEW)

1

amoxicillin/potassium clavAUGMENTIN(250-125 MG)(TABLET)

1

amoxicillin/potassium clavAUGMENTIN(250-62.5/5)(SUSP RECON)

1

amoxicillin/potassium clavAUGMENTIN(400-57MG) (TABCHEW)

1

amoxicillin/potassium clavAUGMENTIN(400-57MG/5)(SUSP RECON)

1




1


1

amoxicillin/potassium clav AUGMENTINES-600 1

amoxicillin/potassium clav AUGMENTIN XR 1ampicillin trihydrate AMPICILLIN 1dicloxacillin sodium PATHOCIL 1PENICILLIN G BENZATHINE BICILLIN L-A 2penicillin v potassium 1penicillin v potassium VEETIDS 1

QUINOLONESCIPROFLOXACIN CIPRO 2ciprofloxacin 1ciprofloxacin hcl CIPRO 1ciprofloxacin/ciprofloxa hcl CIPRO XR 1levofloxacin LEVAQUIN 1moxifloxacin hcl AVELOX 1

moxifloxacin hcl AVELOX ABCPACK 1

ofloxacin FLOXIN 1TETRACYCLINES

demeclocycline hcl DECLOMYCIN 1DOXYCYCLINE CALCIUM VIBRAMYCIN 2doxycycline hyclate MORGIDOX 1 QL: 2 IN 1 DAYdoxycycline hyclate VIBRAMYCIN 1 QL: 2 IN 1 DAY

doxycycline hyclateVIBRA-TABS(100 MG)(TABLET)

1 QL: 2 IN 1 DAY

doxycycline monohydrate ADOXA (150MG) (TABLET) 1 QL: 2 IN 1 DAY

doxycycline monohydrate AVIDOXY 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (100MG) (CAPSULE) 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (50MG) (CAPSULE) 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (50MG) (TABLET) 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (75MG) (TABLET) 1 QL: 2 IN 1 DAY

doxycycline monohydrate ORACEA 1 ST, AGE: >= 18 YEARS, QL: 1IN 1 DAY

doxycycline monohydrate VIBRAMYCIN 1minocycline hcl (100 mg) (capsule) 1minocycline hcl (100 mg) (tablet) 1minocycline hcl (50 mg) (capsule) 1minocycline hcl (50 mg) (tablet) 1


Drug Name Tier Requirements/Limitsminocycline hcl (75 mg) (capsule) 1minocycline hcl (75 mg) (tablet) 1tetracycline hcl PANMYCIN 1tetracycline hcl SUMYCIN 1

INFECTIOUS DISEASE - FUNGALANTIFUNGAL AGENTS

clotrimazole MYCELEX 1fluconazole DIFLUCAN 1flucytosine ANCOBON 1itraconazole SPORANOX 1ketoconazole NIZORAL 1terbinafine hcl 1voriconazole VFEND 1

ANTIFUNGAL ANTIBIOTICS

griseofulvin, microsizeGRIFULVIN V(125 MG/5ML)(ORAL SUSP)

1

nystatin MYCOSTATIN 1INFECTIOUS DISEASE - MISCELLANEOUS

AMINOGLYCOSIDESneomycin sulfate 1

TOBRAMYCIN TOBIPODHALER 2 PA

tobramycin in 0.225% sod chlor TOBI 1 PAANTIBACTERIAL AGENTS,MISCELLANEOUS

glycine urologic solution AMINOACETICACID 1

ANTILEPROTICSdapsone 1THALIDOMIDE THALOMID 2 PA, QL: 2 IN 1 DAY

ANTI-MYCOBACTERIUM AGENTSAMINOSALICYLIC ACID PASER 4ethambutol hcl MYAMBUTOL 4ETHIONAMIDE TRECATOR 4isoniazid 4pyrazinamide 4rifabutin MYCOBUTIN 4

ANTITUBERCULAR ANTIBIOTICSBEDAQUILINE FUMARATE SIRTURO 4 PAcycloserine SEROMYCIN 4rifampin RIFADIN 4RIFAMPIN/ISONIAZID RIFAMATE 4RIFAPENTINE PRIFTIN 4

LINCOSAMIDESclindamycin hcl CLEOCIN HCL 1

clindamycin palmitate hcl CLEOCINPALMITATE 1


Drug Name Tier Requirements/LimitsRIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS

RIFAXIMIN XIFAXAN (550MG) (TABLET) 2 PA

VANCOMYCIN AND DERIVATIVES

VANCOMYCIN HCLFIRVANQ (25MG/ML) (SOLNRECON)

2 QL: 300mL PER FILL

VANCOMYCIN HCLFIRVANQ (50MG/ML) (SOLNRECON)

2 QL: 600mL PER FILL

vancomycin hcl (125 mg) (capsule) 1 QL: 56 PER FILLvancomycin hcl (250 mg) (capsule) 1 QL: 112 PER FILL

INFECTIOUS DISEASE - PARASITIC2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

tinidazole TINDAMAX 1AMEBACIDES

paromomycin sulfate HUMATIN 1ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS

metronidazole FLAGYL 1ANTHELMINTICS

albendazole ALBENZA 1ivermectin STROMECTOL 1MEBENDAZOLE EMVERM 2 PApraziquantel BILTRICIDE 1

ANTIMALARIAL DRUGSatovaquone/proguanil hcl MALARONE 1chloroquine phosphate 1hydroxychloroquine sulfate PLAQUENIL 1mefloquine hcl LARIAM 1PRIMAQUINE PHOSPHATE PRIMAQUINE 2PYRIMETHAMINE DARAPRIM 2 PAquinine sulfate QUALAQUIN 1TAFENOQUINE SUCCINATE KRINTAFEL 2 QL: 2 PER FILL

ANTIPROTOZOAL DRUGS,MISCELLANEOUSatovaquone MEPRON 1MILTEFOSINE IMPAVIDO 2 PAPENTAMIDINE ISETHIONATE NEBUPENT 2

INFECTIOUS DISEASE - VIRALANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB.

DOLUTEGRAVIR/RILPIVIRINE JULUCA 2 QL: 1 IN 1 DAYANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.

DARUNAVIR/COB/EMTRI/TENOF ALAF SYMTUZA 2 QL: 1 IN 1 DAYANTIVIRALS, GENERAL

acyclovir ZOVIRAX 1BALOXAVIR MARBOXIL XOFLUZA 2 QL: 4 IN 180 DAYSfamciclovir FAMVIR 1oseltamivir phosphate TAMIFLU 1ribavirin VIRAZOLE 1rimantadine hcl FLUMADINE 1


Drug Name Tier Requirements/Limitsvalacyclovir hcl VALTREX 1

valganciclovir hcl VALCYTE (450MG) (TABLET) 1

ZANAMIVIR RELENZA 3ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB

DARUNAVIR ETHANOLATEPREZISTA (100MG/ML) (ORALSUSP)


DARUNAVIR ETHANOLATE PREZISTA (150MG) (TABLET) 2 QL: 8 IN 1 DAY




DARUNAVIR/COBICISTAT PREZCOBIX 2 QL: 1 IN 1 DAYTIPRANAVIR APTIVUS 2 QL: 4 IN 1 DAYTIPRANAVIR/VITAMIN E TPGS APTIVUS 2 QL: 380mL IN 30 DAYS

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGEMTRICITABINE/TENOFOV ALAFENAM DESCOVY 2 QL: 1 IN 1 DAYEMTRICITABINE/TENOFOVIR (TDF) TRUVADA 2 QL: 1 IN 1 DAYLAMIVUDINE/TENOFOVIR DISOP FUM CIMDUO 2 QL: 1 IN 1 DAY

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBabacavir sulfate/lamivudine EPZICOM 1 QL: 1 IN 1 DAYABACAVIR SULFATE/LAMIVUDINE EPZICOM 2 QL: 1 IN 1 DAYabacavir/lamivudine/zidovudine TRIZIVIR 1 QL: 2 IN 1 DAYABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR 2 QL: 2 IN 1 DAYlamivudine/zidovudine COMBIVIR 1 QL: 2 IN 1 DAYLAMIVUDINE/ZIDOVUDINE COMBIVIR 2 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.

MARAVIROC SELZENTRY (150MG) (TABLET) 2 QL: 2 IN 1 DAY

MARAVIROCSELZENTRY (20MG/ML)(SOLUTION)

2 QL: 31mL IN 1 DAY




ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSENFUVIRTIDE FUZEON 2 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIDELAVIRDINE MESYLATE RESCRIPTOR 2DORAVIRINE PIFELTRO 2 QL: 2 IN 1 DAYefavirenz SUSTIVA 1

ETRAVIRINE INTELENCE (100MG) (TABLET) 2 QL: 4 IN 1 DAY





nevirapine VIRAMUNE (200MG) (TABLET) 1 QL: 2 IN 1 DAY

nevirapineVIRAMUNE (50MG/5 ML)(ORAL SUSP)


nevirapineVIRAMUNE XR(100 MG) (TABER 24H)

1 QL: 3 IN 1 DAY

nevirapineVIRAMUNE XR(400 MG) (TABER 24H)

1 QL: 1 IN 1 DAY

RILPIVIRINE HCL EDURANT 2 QL: 1 IN 1 DAYANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI

abacavir sulfateZIAGEN (20MG/ML)(SOLUTION)


ABACAVIR SULFATEZIAGEN (20MG/ML)(SOLUTION)


abacavir sulfate ZIAGEN (300MG) (TABLET) 1 QL: 2 IN 1 DAY

ABACAVIR SULFATE ZIAGEN (300MG) (TABLET) 2 QL: 2 IN 1 DAY

DIDANOSINE VIDEX 2 QL: 600mL IN 30 DAYS

didanosineVIDEX EC (125MG) (CAPSULEDR)

1 QL: 2 IN 1 DAY


1 QL: 2 IN 1 DAY


1 QL: 1 IN 1 DAY


1 QL: 1 IN 1 DAY

EMTRICITABINEEMTRIVA (10MG/ML)(SOLUTION)


EMTRICITABINE EMTRIVA (200MG) (CAPSULE) 2 QL: 1 IN 1 DAY

lamivudineEPIVIR (10MG/ML)(SOLUTION)


LAMIVUDINEEPIVIR (10MG/ML)(SOLUTION)




lamivudine EPIVIR (150 MG)(TABLET) 1 QL: 2 IN 1 DAY

LAMIVUDINE EPIVIR (150 MG)(TABLET) 2 QL: 2 IN 1 DAY

lamivudine EPIVIR (300 MG)(TABLET) 1 QL: 1 IN 1 DAY

LAMIVUDINE EPIVIR (300 MG)(TABLET) 2 QL: 1 IN 1 DAY

stavudine 1 QL: 2 IN 1 DAY

zidovudineRETROVIR (10MG/ML)(SYRUP)


ZIDOVUDINERETROVIR (10MG/ML)(SYRUP)


zidovudine RETROVIR (100MG) (CAPSULE) 1 QL: 6 IN 1 DAY

ZIDOVUDINE RETROVIR (100MG) (CAPSULE) 2 QL: 6 IN 1 DAY

zidovudine RETROVIR (300MG) (TABLET) 1 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI

TENOFOVIR DISOPROXIL FUMARATE VIREAD (150MG) (TABLET) 2 QL: 1 IN 1 DAY



tenofovir disoproxil fumarate VIREAD (300MG) (TABLET) 1 QL: 1 IN 1 DAY

TENOFOVIR DISOPROXIL FUMARATEVIREAD(40MG/SCOOP)(POWDER)

2 QL: 240gm IN 30 DAYS

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB

LOPINAVIR/RITONAVIRKALETRA(100MG-25MG)(TABLET)

2 QL: 2 IN 1 DAY

LOPINAVIR/RITONAVIRKALETRA(200MG-50MG)(TABLET)

2 QL: 4 IN 1 DAY

lopinavir/ritonavirKALETRA (400-100/5)(SOLUTION)


ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS

atazanavir sulfate REYATAZ (150MG) (CAPSULE) 1 QL: 2 IN 1 DAY

ATAZANAVIR SULFATE REYATAZ (150MG) (CAPSULE) 2 QL: 2 IN 1 DAY







ATAZANAVIR SULFATEREYATAZ (50MG) (POWDPACK)

2 QL: 5 IN 1 DAY

ATAZANAVIR SULFATE/COBICISTAT EVOTAZ 2 QL: 1 IN 1 DAY

FOSAMPRENAVIR CALCIUMLEXIVA (50MG/ML) (ORALSUSP)


fosamprenavir calcium LEXIVA (700MG) (TABLET) 1 QL: 4 IN 1 DAY

FOSAMPRENAVIR CALCIUM LEXIVA (700MG) (TABLET) 2 QL: 4 IN 1 DAY

INDINAVIR SULFATE CRIXIVAN 2NELFINAVIR MESYLATE VIRACEPT 2

RITONAVIR NORVIR (100MG) (CAPSULE) 2 QL: 12 IN 1 DAY

RITONAVIRNORVIR (100MG) (POWDPACK)

2 QL: 12 IN 1 DAY

ritonavir NORVIR (100MG) (TABLET) 1 QL: 12 IN 1 DAY

RITONAVIR NORVIR (100MG) (TABLET) 2 QL: 12 IN 1 DAY

RITONAVIRNORVIR (80MG/ML)(SOLUTION)


SAQUINAVIR MESYLATE INVIRASE 2 QL: 4 IN 1 DAYANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR

DOLUTEGRAVIR SODIUM TIVICAY 2 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUMISENTRESS (100MG) (POWDPACK)

2 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUMISENTRESS (100MG) (TABCHEW)

2 QL: 6 IN 1 DAY

RALTEGRAVIR POTASSIUMISENTRESS (25MG) (TABCHEW)

2 QL: 6 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (400MG) (TABLET) 2 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS HD 2 QL: 2 IN 1 DAYARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI

DORAVIRINE/LAMIVU/TENOFOV DISO DELSTRIGO 2 QL: 1 IN 1 DAYEFAVIRENZ/EMTRICIT/TENOFOVR DF ATRIPLA 2 QL: 1 IN 1 DAYEFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI 2 QL: 1 IN 1 DAY


Drug Name Tier Requirements/LimitsEFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI LO 2 QL: 1 IN 1 DAYEMTRICITA/RILPIVIRINE/TENOF DF COMPLERA 2 QL: 1 IN 1 DAYEMTRICITAB/RILPIVIRI/TENOF ALA ODEFSEY 2 QL: 1 IN 1 DAY

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORBICTEGRAV/EMTRICIT/TENOFOV ALA BIKTARVY 2 QL: 1 IN 1 DAYELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 2 QL: 1 IN 1 DAYELVITEG/COB/EMTRI/TENOFO DISOP STRIBILD 2 QL: 1 IN 1 DAY

ARV COMB-NRTIS & INTEGRASE INHIBITORABACAVIR/DOLUTEGRAVIR/LAMIVUDI TRIUMEQ 2 QL: 1 IN 1 DAY

CYTOCHROME P450 INHIBITORSCOBICISTAT TYBOST 2 QL: 1 IN 1 DAY

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.ledipasvir/sofosbuvir 1 PAsofosbuvir/velpatasvir 1 PA

HEPATITIS B TREATMENT AGENTSadefovir dipivoxil HEPSERA 1 QL: 1 IN 1 DAY

ENTECAVIRBARACLUDE(0.05 MG/ML)(SOLUTION)


entecavirBARACLUDE(0.5 MG)(TABLET)

1 QL: 1 IN 1 DAY

entecavir BARACLUDE (1MG) (TABLET) 1 QL: 1 IN 1 DAY

lamivudine EPIVIR HBV (100MG) (TABLET) 1 QL: 1 IN 1 DAY

LAMIVUDINEEPIVIR HBV (25MG/5 ML)(SOLUTION)


HEPATITIS C TREATMENT AGENTSPEGINTERFERON ALFA-2A PEGASYS 2 PA

PEGINTERFERON ALFA-2A PEGASYSPROCLICK 2 PA

RIBAVIRIN REBETOL 2ribavirin (200 mg) (capsule) 1ribavirin (200 mg) (tablet) 1

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBGLECAPREVIR/PIBRENTASVIR MAVYRET 2 PA

INFLAMMATORY DISEASEANTI-ARTHRITIC AND CHELATING AGENTS

PENICILLAMINE DEPEN 2 PAANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS

METHOTREXATE/PFRASUVO(10MG/0.2ML)(AUTO INJCT)

2 ST, QL: 0.8mL IN 28 DAYS

METHOTREXATE/PFRASUVO(12.5/0.25) (AUTOINJCT)
















METHOTREXATE/PFRASUVO(7.5MG/0.15)(AUTO INJCT)


ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONISTRILONACEPT ARCALYST 2

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITORCERTOLIZUMAB PEGOL CIMZIA 2 PAETANERCEPT ENBREL 2 PAETANERCEPT ENBREL MINI 2 PA

ETANERCEPT ENBRELSURECLICK 2 PA

GOLIMUMAB SIMPONI 2 PAANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR

leflunomide ARAVA 1ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.

APREMILAST OTEZLA 2 PAANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR

ABATACEPT ORENCIA 2 PA

ABATACEPT ORENCIACLICKJECT 2 PA

BRADYKININ B2 RECEPTOR ANTAGONISTSICATIBANT ACETATE FIRAZYR 2 PA

C1 ESTERASE INHIBITORSC1 ESTERASE INHIBITOR BERINERT 2 PAC1 ESTERASE INHIBITOR CINRYZE 2 PAC1 ESTERASE INHIBITOR HAEGARDA 2 PAC1 ESTERASE INHIBITOR, RECOMB RUCONEST 2 PA

GLUCOCORTICOIDSbudesonide ENTOCORT EC 1cortisone acetate CORTONE 1dexamethasone (0.5 mg) (tablet) 1dexamethasone (0.5 mg/5ml) (elixir) 1


Drug Name Tier Requirements/Limitsdexamethasone (0.5 mg/5ml) (solution) 1dexamethasone (0.75 mg) (tablet) 1dexamethasone (1 mg) (tablet) 1dexamethasone (1.5 mg) (tablet) 1dexamethasone (1.5mg (21)) (tab ds pk) 1 STdexamethasone (1.5mg (35)) (tab ds pk) 1 STdexamethasone (1.5mg (51)) (tab ds pk) 1 STdexamethasone (2 mg) (tablet) 1dexamethasone (4 mg) (tablet) 1dexamethasone (6 mg) (tablet) 1hydrocortisone CORTEF 1

methylprednisolone MEDROL (16MG) (TABLET) 1

METHYLPREDNISOLONE MEDROL (2 MG)(TABLET) 2

methylprednisolone MEDROL (32MG) (TABLET) 1

methylprednisolone MEDROL (4 MG)(TAB DS PK) 1

methylprednisolone MEDROL (4 MG)(TABLET) 1

methylprednisolone MEDROL (8 MG)(TABLET) 1

PREDNISOLONE MILLIPRED 2PREDNISOLONE MILLIPRED DP 2prednisolone ORAPRED 1prednisolone sodium phosphate (10 mg) (tabrapdis) 1

prednisolone sodium phosphate (15 mg) (tabrapdis) 1

prednisolone sodium phosphate (15 mg/5 ml)(solution) 1


prednisolone sodium phosphate (30 mg) (tabrapdis) 1


prednisone 1PREDNISONE INTENSOL 2

GOLD SALTSAURANOFIN RIDAURA 2

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSTOCILIZUMAB ACTEMRA 2 PA

TOCILIZUMAB ACTEMRAACTPEN 2 PA

JANUS KINASE (JAK) INHIBITORSTOFACITINIB CITRATE XELJANZ 2 PATOFACITINIB CITRATE XELJANZ XR 2 PA


Drug Name Tier Requirements/LimitsMINERALOCORTICOIDS

fludrocortisone acetate FLORINEF 1NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE

celecoxib CELEBREX 1NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE

diclofenac potassium CATAFLAM 1diclofenac sodium VOLTAREN 1diclofenac sodium VOLTAREN-XR 1etodolac LODINE 1etodolac LODINE XL 1flurbiprofen ANSAID 1

ibuprofenADVIL (200 MG)(CAPSULE)(OTC)

5

ibuprofen ADVIL (200 MG)(TABLET) (OTC) 5

ibuprofen

ADVIL LIQUI-GELS (200 MG)(CAPSULE)(OTC)

5

ibuprofen

ADVILMIGRAINE (200MG) (CAPSULE)(OTC)

5

ibuprofen

CHILDREN'SADVIL (100MG/5ML) (ORALSUSP) (OTC)

5

ibuprofen

CHILDREN'SMOTRIN (100MG/5ML) (ORALSUSP) (OTC)

5

ibuprofenMOTRIN (100MG/5ML) (ORALSUSP)

1

ibuprofen MOTRIN (400MG) (TABLET) 1



ibuprofenMOTRIN IB (200MG) (TABLET)(OTC)

5

indomethacin INDOCIN (25MG) (CAPSULE) 1

INDOMETHACININDOCIN (25MG/5 ML)(ORAL SUSP)

2



indomethacin INDOCIN (50MG) (CAPSULE) 1

indomethacin INDOCIN SR 1ketoprofen 1

ketorolac tromethamine TORADOL (10MG) (TABLET) 1 QL: 20 IN 5 DAYS

ketorolac tromethamineTORADOL (15MG/ML)(CARTRIDGE)

1

ketorolac tromethamine TORADOL (15MG/ML) (VIAL) 1

ketorolac tromethamineTORADOL (30MG/ML)(CARTRIDGE)

1

ketorolac tromethamineTORADOL(30MG/ML(1))(VIAL)

1

ketorolac tromethamineTORADOL (60MG/2 ML)(CARTRIDGE)

1

ketorolac tromethamineTORADOL (60MG/2 ML)(VIAL)

1

meclofenamate sodium MECLOMEN 1meloxicam MOBIC 1nabumetone RELAFEN 1naproxen EC-NAPROSYN 1naproxen NAPROSYN 1naproxen sodium ANAPROX 1naproxen sodium ANAPROX DS 1

naproxen sodiumNAPRELAN (500MG) (TBMP24HR)

1

oxaprozin DAYPRO 1piroxicam FELDENE 1sulindac CLINORIL 1tolmetin sodium TOLECTIN 1tolmetin sodium TOLECTIN DS 1

LOCAL ANESTHESIALOCAL ANESTHETICS

lidocaine hcl 1LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT

BOWEL ANTIINFLAMATORY AGENTSsulfadiazine 1

CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXmesalamine CANASA 1mesalamine SFROWASA 1mesalamine w/cleansing wipes ROWASA 1


Drug Name Tier Requirements/LimitsDRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT

balsalazide disodium COLAZAL 1MESALAMINE APRISO 2sulfasalazine AZULFIDINE 1

HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTHhydrocortisone/lidocaine/aloe ANA-LEX HC 1

hydrocortisone/lidocaine/aloe ANAMANTLEHC 1

hydrocortisone/lidocaine/aloe RECTAGEL HC 1

hydrocortisone/pramoxineANALPRAM HC(1 %-1 %)(CREAM/APPL)

1

hydrocortisone/pramoxineANALPRAM HC(2.5 %-1 %)(CREAM/APPL)

1

hydrocortisone/pramoxine PRAMCORT 1

HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 2

lidocaine/hydrocortisone ac ANAMANTLEHC 1

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONISTLINACLOTIDE LINZESS 2 QL: 1 IN 1 DAY

RECTAL PREPARATIONShydrocortisone acetate ANUSOL-HC 1hydrocortisone acetate HEMMOREX-HC 1hydrocortisone acetate PROCTOCORT 1

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)hydrocortisone CORTENEMA 1

LOWER GASTROINTESTINAL DISORDERS - OTHERAMMONIA INHIBITORS

CARGLUMIC ACID CARBAGLU 2GLYCEROL PHENYLBUTYRATE RAVICTI 2 PAlactulose CHRONULAC 1sodium phenylbutyrate BUPHENYL 1

ANTIDIARRHEALSbismuth subsalicylate (262 mg) (tab chew)(otc) 5

bismuth subsalicylate (262mg/15ml) (oralsusp) (otc) 5

diphenoxylate hcl/atropine LOMOTIL 1loperamide hcl (2 mg) (capsule) 1loperamide hcl (2 mg) (capsule) (otc) 5loperamide hcl (2 mg) (tablet) (otc) 5opium tincture 1paregoric 1

BILE SALTSursodiol ACTIGALL 1ursodiol URSO 1ursodiol URSO FORTE 1


Drug Name Tier Requirements/LimitsFARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG

OBETICHOLIC ACID OCALIVA 2 PALAXATIVES AND CATHARTICS

bisac/nacl/nahco3/kcl/peg 3350 HALFLYTELY-BISACODYL 3 AG: TIER 4 FOR 50-75

YEARS OLD

bisacodylCORRECTOL (5MG) (TABLET)(OTC)

5

bisacodylDULCOLAX (5MG) (TABLETDR) (OTC)

5

calcium polycarbophil (625 mg) (tablet) (otc) 5

docusate calcium

KAOPECTATE(240 MG)(CAPSULE)(OTC)

5

docusate calciumSURFAK (240MG) (CAPSULE)(OTC)

5

docusate sodium (100 mg) (capsule) (otc) 5docusate sodium (100 mg) (tablet) (otc) 5docusate sodium (250 mg) (capsule) (otc) 5docusate sodium (50 mg/5 ml) (liquid) (otc) 5docusate sodium (60 mg/15ml) (syrup) (otc) 5FRUCTOOLIGOSACCH/MALTODEXTRIN FIBER-STAT 1FRUCTOOLIGOSACCHARIDES/POLYDEX FIBER-STAT 1

lactulose CHRONULAC 1

LACTULOSE KRISTALOSE (20G) (PACKET) 2 ST, QL: 2 IN 1 DAY

LUBIPROSTONE AMITIZA 2 QL: 2 IN 1 DAYmagnesium citrate (solution) (otc) 5

magnesium hydroxide

PHILLIPS' MILKOF MAGNESIA(400 MG/5ML)(ORAL SUSP)(OTC)

5

methylcelluloseCITRUCEL (500MG) (TABLET)(OTC)

5

methylcellulose (with sugar) 5mineral oil (oil) (otc) 5

PEG3350/SOD SUL/NACL/KCL/ASB/C MOVIPREP 3 AG: TIER 4 FOR 50-75YEARS OLD

PEG3350/SOD SUL/NACL/KCL/ASB/C PLENVU 3 AG: TIER 4 FOR 50-75YEARS OLD

peg3350/sod sulf,bicarb,cl/kclCOLYTE WITHFLAVORPACKETS

1 AG: TIER 4 FOR 50-75YEARS OLD



PEG3350/SOD SULF,BICARB,CL/KCLGOLYTELY(227.1-21.5)(POWD PACK)


peg3350/sod sulf,bicarb,cl/kclGOLYTELY (236-22.74G) (SOLNRECON)


polyethylene glycol 3350GAVILAX(17G/DOSE)(POWDER) (OTC)

5

polyethylene glycol 3350MIRALAX (17G)(POWD PACK)(OTC)

5

polyethylene glycol 3350MIRALAX(17G/DOSE)(POWDER) (OTC)

5

PSYLLIUM HUSKKONSYL (6 G)(POWD PACK)(OTC)

5

PSYLLIUM HUSKKONSYL (6 G/6G) (POWDER)(OTC)

5

psyllium husk (6 g/6 g) (powder) (otc) 5

PSYLLIUM HUSK (WITH DEXTROSE)

KONSYLFORMULA-D(3.4 G/6.5G)(POWDER) (OTC)

5

psyllium husk (with sugar)METAMUCIL(3.4 G/7 G)(POWDER) (OTC)

5

psyllium husk (with sugar)METAMUCIL(3.4G/11G)(POWDER) (OTC)

5

psyllium husk (with sugar)

NATURALVEGETABLEFIBER (3.4 G/7 G)(POWDER) (OTC)

5

psyllium husk (with sugar)

NATURALVEGETABLEFIBER (3.4G/11G)(POWDER) (OTC)

5

psyllium husk/aspartame (3.4g/5.8g)(powder) (otc) 5

psyllium seed METAMUCIL(POWDER) (OTC) 5

psyllium seed (with dextrose) KONSYL-D(POWDER) (OTC) 5

psyllium seed (with sugar) METAMUCIL(POWDER) (OTC) 5

sennosides (8.6 mg) (tablet) (otc) 5



sennosides/docusate sodiumCOLACE 2-IN-1(8.6MG-50MG)(TABLET) (OTC)

5

SOD PHOSPHATE MBAS/SOD PHOS,DI OSMOPREP 3 AG: TIER 4 FOR 50-75YEARS OLD

SOD PICOSULF/MAG OX/CITRIC AC CLENPIQ 2 AG: TIER 4 FOR 50-75YEARS OLD

SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 2 AG: TIER 4 FOR 50-75YEARS OLD

sodium chloride/nahco3/kcl/pegNULYTELYWITH FLAVORPACKS


SODIUM, POTASSIUM,MAG SULFATES SUPREP 3 AG: TIER 4 FOR 50-75YEARS OLD

LAXATIVES, LOCAL/RECTALBISACODYL 5

bisacodyl

DULCOLAX (10MG)(SUPP.RECT)(OTC)

5

docusate sodium (283 mg) (enema) (otc) 5docusate sodium (283 mg/5ml) (enema) (otc) 5docusate sodium/benzocaine DOCUSOL PLUS 5docusate sodium/benzocaine ENEMEEZ 5glycerin (pediatric) (supp.rect) (otc) 5

sodium phosphate,mono-dibasicENEMA (19G-7G/118)(ENEMA) (OTC)

5

NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTINGNALOXEGOL OXALATE MOVANTIK 2 QL: 1 IN 1 DAY

SBS - GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGSTEDUGLUTIDE GATTEX 2 PA

MISCELLANEOUS AGENTSANAPHYLAXIS THERAPY AGENTS

epinephrine (0.15/0.15) (auto injct) 1 QL: 4 PER FILLepinephrine (0.15mg/0.3) (auto injct) 1 QL: 4 PER FILLepinephrine (0.3mg/0.3) (auto injct) 1 QL: 4 PER FILLEPINEPHRINE SYMJEPI 2 QL: 4 PER FILL

PARASYMPATHETIC AGENTSbethanechol chloride URECHOLINE 1guanidine hcl GUANIDINE 1pilocarpine hcl SALAGEN 1

PKU TREATMENT AGENTS - PHENYLALANINE AMMONIA LYASEPEGVALIASE-PQPZ PALYNZIQ 2 PA

PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASESAPROPTERIN DIHYDROCHLORIDE KUVAN 2 PA

NEOPLASTIC DISEASEALKYLATING AGENTS

BUSULFAN MYLERAN 2


Drug Name Tier Requirements/LimitsCARMUSTINE IN POLIFEPROSAN 20 GLIADEL 2CHLORAMBUCIL LEUKERAN 2cyclophosphamide 1hydroxyurea HYDREA 1melphalan ALKERAN 1temozolomide TEMODAR 1 PA

ANTIANDROGENIC AGENTS

abiraterone acetate ZYTIGA (250MG) (TABLET) 1 PA

ABIRATERONE ACETATE ZYTIGA (500MG) (TABLET) 2 PA

APALUTAMIDE ERLEADA 2 PA, QL: 4 IN 1 DAYbicalutamide CASODEX 1ENZALUTAMIDE XTANDI 2 PA, QL: 4 IN 1 DAYflutamide EULEXIN 1nilutamide NILANDRON 1 QL: 2 IN 1 DAY

ANTIMETABOLITES

capecitabine XELODA (150MG) (TABLET) 1 PA, QL: 28 IN 21 DAYS

capecitabine XELODA (500MG) (TABLET) 1 PA, QL: 112 IN 21 DAYS

mercaptopurine PURINETHOL 1MERCAPTOPURINE PURIXAN 2 STmethotrexate sodium FOLEX 1

METHOTREXATE SODIUM TREXALL (10MG) (TABLET) 2


methotrexate sodium TREXALL (2.5MG) (TABLET) 1


METHOTREXATE SODIUM TREXALL (7.5MG) (TABLET) 2

methotrexate sodium/pf FOLEX 1THIOGUANINE TABLOID 2TRIFLURIDINE/TIPIRACIL HCL LONSURF 2 PA

ANTINEOPLASTIC AROMATASE INHIBITORSanastrozole ARIMIDEX 1exemestane AROMASIN 1letrozole FEMARA 1

ANTINEOPLASTIC - BRAF KINASE INHIBITORSDABRAFENIB MESYLATE TAFINLAR 2 PAENCORAFENIB BRAFTOVI 2 PA, QL: 6 IN 1 DAYVEMURAFENIB ZELBORAF 2 PA, QL: 8 IN 1 DAY

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORGLASDEGIB MALEATE DAURISMO 2 PASONIDEGIB PHOSPHATE ODOMZO 2 PAVISMODEGIB ERIVEDGE 2 PA, QL: 1 IN 1 DAY


Drug Name Tier Requirements/LimitsANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS

RUXOLITINIB PHOSPHATE JAKAFI 2 PA, QL: 2 IN 1 DAYANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS

BINIMETINIB MEKTOVI 2 PA, QL: 6 IN 1 DAYCOBIMETINIB FUMARATE COTELLIC 2 PA, QL: 63 IN 28 DAYSTRAMETINIB DIMETHYL SULFOXIDE MEKINIST 2 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORSEVEROLIMUS AFINITOR 2 PA

EVEROLIMUS AFINITORDISPERZ 2 PA

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSTOPOTECAN HCL HYCAMTIN 2

ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT

RIBOCICLIB SUCCINATE/LETROZOLEKISQALIFEMARA CO-PACK

2 PA

ANTINEOPLASTIC IMMUNOMODULATOR AGENTSLENALIDOMIDE REVLIMID 2 PA, QL: 1 IN 1 DAYPEGINTERFERON ALFA-2B SYLATRON 2POMALIDOMIDE POMALYST 2 PA

ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS

DEGARELIX ACETATE FIRMAGON (120MG) (VIAL) 2 QL: 2 IN 365 DAYS

DEGARELIX ACETATE FIRMAGON (80MG) (VIAL) 2 QL: 1 IN 30 DAYS

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSABEMACICLIB VERZENIO 2 PAAFATINIB DIMALEATE GILOTRIF 2 PAALECTINIB HCL ALECENSA 2 PA

AXITINIB INLYTA (1 MG)(TABLET) 2 PA, QL: 6 IN 1 DAY

AXITINIB INLYTA (5 MG)(TABLET) 2 PA, QL: 4 IN 1 DAY

BOSUTINIB BOSULIF (100MG) (TABLET) 2 PA, QL: 3 IN 1 DAY



CABOZANTINIB S-MALATE CABOMETYX 2 PACABOZANTINIB S-MALATE COMETRIQ 2 PA, QL: 112 IN 28 DAYSCERITINIB ZYKADIA 2 PACRIZOTINIB XALKORI 2 PADASATINIB SPRYCEL 2 PAERLOTINIB HCL TARCEVA 2 PAGEFITINIB IRESSA 2 PAGILTERITINIB FUMARATE XOSPATA 2 PAIBRUTINIB IMBRUVICA 2 PAIDELALISIB ZYDELIG 2 PA



imatinib mesylate GLEEVEC (100MG) (TABLET) 1 PA, QL: 3 IN 1 DAY

imatinib mesylate GLEEVEC (400MG) (TABLET) 1 PA, QL: 2 IN 1 DAY

IXAZOMIB CITRATE NINLARO 2 PALAPATINIB DITOSYLATE TYKERB 2 PALAROTRECTINIB SULFATE VITRAKVI 2 PALENVATINIB MESYLATE LENVIMA 2 PALORLATINIB LORBRENA 2 PAMIDOSTAURIN RYDAPT 2 PANILOTINIB HCL TASIGNA 2 PA, QL: 4 IN 1 DAYOLAPARIB LYNPARZA 2 PAOSIMERTINIB MESYLATE TAGRISSO 2 PAPALBOCICLIB IBRANCE 2 PAPAZOPANIB HCL VOTRIENT 2 PA, QL: 4 IN 1 DAY

PONATINIB HCL ICLUSIG (15 MG)(TABLET) 2 PA, QL: 2 IN 1 DAY

PONATINIB HCL ICLUSIG (45 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY

REGORAFENIB STIVARGA 2 PA, QL: 3 IN 1 DAYRIBOCICLIB SUCCINATE KISQALI 2 PASORAFENIB TOSYLATE NEXAVAR 2 PA, QL: 4 IN 1 DAYSUNITINIB MALATE SUTENT 2 PA, QL: 1 IN 1 DAYTALAZOPARIB TOSYLATE TALZENNA 2 PA

VANDETANIB CAPRELSA (100MG) (TABLET) 2 PA, QL: 2 IN 1 DAY

VANDETANIB CAPRELSA (300MG) (TABLET) 2 PA, QL: 1 IN 1 DAY

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDISPANOBINOSTAT LACTATE FARYDAK 2 PAVORINOSTAT ZOLINZA 2

ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORSVENETOCLAX VENCLEXTA 2 PA

VENETOCLAX VENCLEXTASTARTING PACK 2 PA

ANTINEOPLASTICS,MISCELLANEOUSetoposide VEPESID 1MITOTANE LYSODREN 2OMACETAXINE MEPESUCCINATE SYNRIBO 2 PAPROCARBAZINE HCL MATULANE 2tretinoin VESANOID 1

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSleucovorin calcium 1URIDINE TRIACETATE VISTOGARD 2 QL: 24 IN 14 DAYS

INTRAPLEURAL SCLEROSING AGENTS, ANTINEOPLAST. ADJ.

talc STERITALC (5 G)(VIAL) 1

RADIOACTIVE THERAPEUTIC AGENTSsodium iodide-123 (7.4 mbq) (capsule) 1


Drug Name Tier Requirements/LimitsSELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)

tamoxifen citrate NOLVADEX 4TAMOXIFEN CITRATE SOLTAMOX 2toremifene citrate FARESTON 1 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)bexarotene TARGRETIN 1 PA

STEROID ANTINEOPLASTICSESTRAMUSTINE PHOSPHATE SODIUM EMCYT 2megestrol acetate MEGACE 1

NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS

DIMETHYL FUMARATE TECFIDERA 2 PAFINGOLIMOD HCL GILENYA 2 PAglatiramer acetate COPAXONE 1 PAINTERFERON BETA-1A AVONEX 2 PAINTERFERON BETA-1A AVONEX PEN 2 PAINTERFERON BETA-1A/ALBUMIN AVONEX 2 PAINTERFERON BETA-1A/ALBUMIN REBIF 2 PA

INTERFERON BETA-1A/ALBUMIN REBIFREBIDOSE 2 PA

TERIFLUNOMIDE AUBAGIO 2 PAAMYOTROPHIC LATERAL SCLEROSIS AGENTS

riluzole RILUTEK 1FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB

MILNACIPRAN HCL SAVELLA 2MOVEMENT DISORDERS(DRUG THERAPY)

tetrabenazine XENAZINE 1 PAORAL/PHARYNGEAL DISORDERS

DENTAL AIDS AND PREPARATIONSchlorhexidine gluconate 1DENTALSUCTION/CHLRHEX/SWB1/MW Q-CARE RX 1

DENTL SUCTION DEV/CHLORHX/SWB1 Q-CARE RX 1

triamcinolone acetonide KENALOG INORABASE 1

NOSE PREPARATIONS ANTIBIOTICS

MUPIROCIN CALCIUM BACTROBANNASAL 2

NOSE PREPARATIONS, MISCELLANEOUS (RX)ipratropium bromide ATROVENT 1

PERIODONTAL COLLAGENASE INHIBITORSdoxycycline hyclate PERIOSTAT 1

OTHER DRUGSAPPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.

megestrol acetate MEGACE 1megestrol acetate MEGACE ES 1 ST

BLOOD TESTING PREPARATIONS,IN-VITRO

BLOOD KETONE TEST, STRIPS PRECISIONXTRA 1


Drug Name Tier Requirements/LimitsCONDOMS

CONDOMS, FEMALE FC2 FEMALECONDOM 4 QL: 30 IN 30 DAYS

CONDOMS, LATEX, LUBRICATED AIMSCO 4CONDOMS, LATEX, LUBRICATED CONDOMS 4CONDOMS, LATEX, LUBRICATED FANTASY 4

CONDOMS, LATEX, LUBRICATED KIMONOMICROTHIN 4

CONDOMS, LATEX, LUBRICATEDKIMONOMICROTHINAQUA LUBE

4

CONDOMS, LATEX, LUBRICATED KIMONOTEXTURED 4

CONDOMS, LATEX, LUBRICATED TRUSTEXCONDOM 4

CONDOMS, LATEX, LUBRICATEDTRUSTEXLATEXCONDOM

4

CONDOMS, LATEX, LUBRICATED TRUSTEX-RIA 4CONDOMS, LATEX, NON-LUBRICATED KIMONO 4CONDOMS, LATEX, NON-LUBRICATED KIMONO MAXX 4

CONDOMS, LATEX, NON-LUBRICATED KIMONOMICROTHIN 4

CONDOMS, LATEX, NON-LUBRICATED TRUSTEX 4CONDOMS, LATEX, NON-LUBRICATED TRUSTEX-RIA 4

CONDOMS, NON-LATEX, LUBRICATEDDUREX AVANTIBARE REALFEEL

1

DIETARY SUPPLEMENT, MISCELLANEOUSaa/hydrolyzed collagen, whey 1 PAalbumen (egg white) 1 PAamino ac/protein hydr/whey pro 1 PA

AMINO AC/PROTEIN HYDR/WHEY PRO PROSOURCEPLUS 1 PA

AMINO ACID/PROTEIN/VIT C/ZINC PROSOURCEZAC 1 PA

AMINO ACIDS/PROTEIN HYDR/FIBER PRO-STATRENAL CARE 1 PA

amino acids/protein hydrolys 1 PAAMINO ACIDS/PROTEIN HYDROLYS LIQUACEL 100 1 PA

AMINO ACIDS/PROTEIN HYDROLYS PROSOURCE NOCARB 1 PA

AMINO ACIDS/PROTEIN HYDROLYS PRO-STAT AWC 1 PA

AMINO ACIDS/PROTEIN HYDROLYS PRO-STATSUGAR FREE 1 PA

AMINO ACIDS/PROTEIN HYDROLYS PROTEINEX-18 1 PAcaloric supplement 1 PACALORIC SUPPLEMENT DUOCAL 1 PAdietary supplement 1 PAd-mannose MANNOSE 1 PA


Drug Name Tier Requirements/LimitsLACTOSE-REDUCED FOOD BOOST 1 PALACTOSE-REDUCED FOOD BOOST BREEZE 1 PA

LACTOSE-REDUCED FOODBOOSTCALORIESMART

1 PA

LACTOSE-REDUCED FOOD BOOST HIGHPROTEIN 1 PA

LACTOSE-REDUCED FOOD BOOST PLUS 1 PA

LACTOSE-REDUCED FOOD ENSUREACTIVE CLEAR 1 PA

LACTOSE-REDUCED FOODENSUREACTIVE HEARTHEALTH

1 PA

LACTOSE-REDUCED FOODENSUREACTIVE HIGHPROTEIN

1 PA

LACTOSE-REDUCED FOOD ENSUREACTIVE LIGHT 1 PA

LACTOSE-REDUCED FOOD

ENSUREACTIVEMUSCLEHEALTH

1 PA

LACTOSE-REDUCED FOOD

ENSUREACTIVEPROTEIN-MUSCLE

1 PA

LACTOSE-REDUCED FOOD ENSURE CLEAR 1 PA

LACTOSE-REDUCED FOODENSURECLINICALSTRENGTH

1 PA

LACTOSE-REDUCED FOOD ENSURECOMPACT 1 PA

LACTOSE-REDUCED FOOD ENSURE HIGHPROTEIN 1 PA

LACTOSE-REDUCED FOOD ENSURE LIQUID 1 PA

LACTOSE-REDUCED FOOD ENSURE MAXPROTEIN 1 PA

LACTOSE-REDUCED FOODENSUREMUSCLEHEALTH

1 PA

LACTOSE-REDUCED FOOD ENSUREORIGINAL 1 PA

LACTOSE-REDUCED FOOD ENSURE PLUS 1 PA

LACTOSE-REDUCED FOOD ENSUREPOWDER 1 PA

LACTOSE-REDUCED FOOD ISOSOURCE HN 1 PAlactose-reduced food 1 PA

LACTOSE-REDUCED FOOD/FIBER ENSURE WITHFIBER 1 PA



LACTOSE-REDUCED FOOD/FIBER ISOSOURCE 1.5CAL 1 PA

LACTOSE-REDUCED FOOD/FIBER ISOSOURCE 1.5CAL TUBE FEED 1 PA

LACTOSE-REDUCED FOOD/FIBER JEVITY 1 CAL 1 PALACTOSE-REDUCED FOOD/FIBER JEVITY 1.2 CAL 1 PALACTOSE-REDUCED FOOD/FIBER JEVITY 1.5 CAL 1 PAMALTODEXTRIN SOL CARB 1 PA

MALTODEXTRIN/FRUCTOSE ENSURE PRE-SURGERY 1 PA

NUT TX, LACT-REDUCED, IRON BOOST VHC 1 PANUT.SUP,SPEC,LAC-FREE,IRON/FOS TWOCAL HN 1 PANUT.TX.COMP. IMMUNE SYSTM,REG PIVOT 1.5 CAL 1 PA

NUT.TX.IMPAIR DIGES/INULIN/FOSPEPTAMEN 1.5CAL WITHPREBIO1

1 PA

NUT.TX.IMPAIRED DIGEST FXN ENSURE CLEAR 1 PANUT.TX.IMPAIRED DIGEST FXN PEPTAMEN 1 PA

NUT.TX.IMPAIRED DIGEST FXN PEPTAMENJUNIOR 1.5 1 PA

NUTRI.SUPP,LACTO-FREE,IRON/SOY PEDIASUREHARVEST 1 PA

NUTRIT SUPP/INULIN/FOS/FIBER FIBERSOURCEHN 1 PA

NUTRIT SUPP/INULIN/FOS/FIBER NUTREN FIBER1 CAL 1 PA

NUTRIT SUPP/INULIN/FOS/FIBER NUTRENJUNIOR FIBER 1 PA

nutrit supp/inulin/fos/fiber 1 PA

NUTRIT SUPP/INULIN/FOS/FIBER PEPTAMENJUNIOR FIBER 1 PA

NUTRIT SUPP/INULIN/FOS/FIBER REPLETE WITHFIBER 1 PA

NUTRITION SUPP NO.1/FOS/INULIN PEPTAMEN AF 1 PA

NUTRITIONAL SUPP/INULIN/FOSPEPTAMENJUNIOR WITHPREBIO1

1 PA

NUTRITIONAL SUPPLEMENT EO28 SPLASH 1 PANUTRITIONAL SUPPLEMENT HI-CAL 1 PANUTRITIONAL SUPPLEMENT NUTRA-PRO 1 PA

NUTRITIONAL SUPPLEMENT NUTRENJUNIOR 1 PA

NUTRITIONAL SUPPLEMENT OSMOLITE 1CAL 1 PA

NUTRITIONAL SUPPLEMENT OSMOLITE 1.2CAL 1 PA

NUTRITIONAL SUPPLEMENT OSMOLITE 1.5CAL 1 PA



NUTRITIONAL SUPPLEMENTPEDIASUREPEPTIDE 1.0CAL

1 PA

NUTRITIONAL SUPPLEMENTPEDIASUREPEPTIDE 1.5CAL

1 PA

NUTRITIONAL SUPPLEMENT PEPTAMENJUNIOR 1 PA

NUTRITIONAL SUPPLEMENT PROMOTE 1 PANUTRITIONAL SUPPLEMENT RE-GEN 1 PANUTRITIONAL SUPPLEMENT REPLETE 1 PANUTRITIONAL SUPPLEMENT RESOURCE 2.0 1 PA

NUTRITIONAL SUPPLEMENT/FIBER

COMPLEATORGANICBLENDCHICKEN

1 PA

NUTRITIONAL SUPPLEMENT/FIBERCOMPLEATORGANICBLENDS PLANT

1 PA

NUTRITIONAL SUPPLEMENT/FIBERCOMPLEAT PEDORG BLENDCHICKEN

1 PA

NUTRITIONAL SUPPLEMENT/FIBERCOMPLEAT PEDORG BLENDSPLANT

1 PA

NUTRITIONAL SUPPLEMENT/FIBER NOURISH 1 PAnutritional supplement/fiber 1 PA

NUTRITIONAL SUPPLEMENT/FIBER PROMOTE WITHFIBER 1 PA

nutritional supplement/mct 1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBRBOOST KIDESSENTIALS-FIBER

1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBR COMPLEATPEDIATRIC 1 PA

pedi nutrit,iron,lac-free,fibr 1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBR PEDIASURE 1.5WITH FIBER 1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBRPEDIASUREENTERAL WITHFIBER

1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBR PEDIASURESIDEKICKS 1 PA

PEDI NUTRIT,IRON,LAC-FREE,FIBR PEDIASUREWITH FIBER 1 PA

PEDI NUTRIT.,SOY,IRON,LF/FIBERPEDIASMARTORGANICDAIRY

1 PA

PEDI NUTRIT.,SOY,IRON,LF/FIBER PEDIASMARTORGANIC SOY 1 PA



pedi nutrition,iron,lact-free BOOST KIDESSENTIALS 1 PA

PEDI NUTRITION,IRON,LACT-FREE BOOST KIDESSENTIALS 1 PA

pedi nutrition,iron,lact-free PEDIASURE 1 PAPEDI NUTRITION,IRON,LACT-FREE PEDIASURE 1 PAPEDI NUTRITION,IRON,LACT-FREE PEDIASURE 1.5 1 PA

pedi nutrition,iron,lact-free PEDIASUREENTERAL 1 PA

PEDI NUTRITION,IRON,LACT-FREE PEDIASUREENTERAL 1 PA

PEDI NUTRITION,IRON,LACT-FREE PEDIASUREGROW-GAIN 1 PA

PEDI NUTRITION,MILK BASED,IRON PEDIASURESIDEKICKS 1 PA

PEDIATRIC NUTRIT, IRON/DHA/ARA SIMILACLAMEHADRIN 1 PA

PROTEIN SUPPLEMENT BOOST HIGHPROTEIN 1 PA

PROTEIN SUPPLEMENT ENSURE HIGHPROTEIN 1 PA

protein supplement 1 PADRUGS TO TREAT HEREDITARY TYROSINEMIA

NITISINONE NITYR 2 PANITISINONE ORFADIN 2 PA

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGELIGLUSTAT TARTRATE CERDELGA 2 PAmiglustat ZAVESCA 1 PA

GENERAL INHALATION AGENTSSODIUM CHLORIDE FOR INHALATION NEBUSAL 1sodium chloride for inhalation 1

INFANT FORMULASinf form for tyrosinemia, iron 1 PAINF FORM, GLUTARIC ACIDURIA I GLUTAREX-1 1 PAinf form,iron,spc.met,lac-free 1 PA

INF FORM,IRON,SPC.MET,LAC-FREE NUTRAMIGENENFLORA-LGG 1 PA

inf.form,metab,iron methion-fr (13g-475)(powder) (otc) 1 PA

inf.form,metab,iron methion-fr (16.2g-500)(powder) (otc) 1 PA

inf.formula,urea cycle disordr 1 PAinfant form,propionic acidemia 1 PA

INFANT FORM.IRON LAC-F/DHA/ARA SIMILACALIMENTUM 1 PA

infant formula with ironENFAGROWNEXT STEPLIPIL

1 PA

infant formula with iron ENFAMIL A.R.LIPIL 1 PA



infant formula with iron ENFAMILENFACARE 1 PA

infant formula with ironENFAMILGENTLEASELIPIL

1 PA

infant formula with iron ENFAMILPREMIUM LIPIL 1 PA

infant formula with iron GOOD START 1 PAinfant formula with iron PREGESTIMIL 1 PAinfant formula with iron PRO-PHREE 1 PAINFANT FORMULA WITH IRON, MSUD BCAD 1 1 PAINFANT FORMULA WITH IRON, MSUD MSUD ANALOG 1 PAINFANT FORMULA, IRON/DHA/ARA ENFAMIL A.R. 1 PA

INFANT FORMULA, IRON/DHA/ARA GERBER GOODSTART GENTLE 1 PA

INFANT FORMULA, IRON/DHA/ARAGERBERNATURA STAGE1

1 PA

INFANT FORMULA, IRON/DHA/ARAGERBERNATURA STAGE2

1 PA

infant formula, iron/dha/ara 1 PA

INFANT FORMULA, IRON/DHA/ARANEOCATEINFANT DHA-ARA

1 PA

INFANT FORMULA, IRON/DHA/ARA PURE BLISS 1 PA

INFANT FORMULA, IRON/DHA/ARA SIMILACADVANCE 1 PA

INFANT FORMULA, IRON/DHA/ARASIMILACADVANCELAMEHADRIN

1 PA

INFANT FORMULA, IRON/DHA/ARASIMILACSENSITIVE FUSS& GAS

1 PA

infant formula, metabolic,iron 1 PAINTRA-UTERINE DEVICES (IUD'S)

COPPER PARAGARD T380-A 4

LEVONORGESTREL KYLEENA 4LEVONORGESTREL LILETTA 4LEVONORGESTREL MIRENA 4LEVONORGESTREL SKYLA 4

METABOLIC DEFICIENCY AGENTSBETAINE CYSTADANE 2levocarnitine 1 PAlevocarnitine (with sugar) CARNITOR 1 PA

METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIAASFOTASE ALFA STRENSIQ 2 PA

METALLIC POISON,AGENTS TO TREATDEFERASIROX EXJADE 2 PA


Drug Name Tier Requirements/LimitsDEFERIPRONE FERRIPROX 2 PAdeferoxamine mesylate DESFERAL 1 PA

deferoxamine mesylate DESFERALMESYLATE 1 PA

NEUTRALIZING AGENTS FOR DISINFECTANT CLEANERSGLYCINE/SODIUM HYDROXIDE HYDE-OUT 1

NOSE PREPARATIONS, MISCELLANEOUS (OTC)0.9 % sodium chloride 1

NUT.TX PHENYLKETONURIA (PKU) FORMULATIONS

NUT. THERAPY FOR PKU, NO.49 GLYTACTINRESTORE 10 PE 1 PA

NUT. TX FOR PKU WITH IRON #48 PKU TRIO 1 PA

NUT. TX FOR PKU WITH IRON NO.3 PERIFLEXJUNIOR 1 PA

NUT. TX FOR PKU,NO.66

PHENYLADEGMP MIX-IN (80G-334)(POWDER) (OTC)

1 PA

NUT.TX FOR PKU WITH IRON NO.20 PERIFLEXADVANCE 1 PA

NUT.TX FOR PKU WITH IRON NO.27 PHENYLADE40 1 PA

NUT.TX FOR PKU WITH IRON NO.27PHENYLADE60(60G-295)(POWDER) (OTC)

1 PA

NUT.TX FOR PKU WITH IRON NO.27PHENYLADE60(60G-327)(POWDER) (OTC)

1 PA

NUT.TX FOR PKU WITH IRON NO.35

PHENYLADEESSENTIAL(25G-390)(POWDER) (OTC)

1 PA

NUT.TX FOR PKU WITH IRON NO.4 PKU COOLER 10 1 PANUT.TX FOR PKU WITH IRON NO.4 PKU COOLER 15 1 PANUT.TX FOR PKU WITH IRON NO.4 PKU COOLER 20 1 PANUT.TX FOR PKU WITH IRON NO.40 PKU LOPHLEX 1 PANUT.TX FOR PKU WITH IRON NO.42 PKU LOPHLEX 1 PANUT.TX FOR PKU WITH IRON NO.45 PHENYL-FREE 2 1 PA

NUT.TX FOR PKU WITH IRON NO.45 PHENYL-FREE2HP 1 PA

NUT.TX FOR PKU WITH IRON NO.52 PKU EXPRESS15 1 PANUTRITIONAL TX FOR PKU NO.31 PHENYLADE 1 PA

NUTRITIONAL TX FOR PKU NO.31 PHENYLADEMTE 1 PA

NUTRITIONAL TX FOR PKU NO.64 GLYTACTIN RTDLITE 15 1 PA

NUTRITIONAL TX FOR PKU NO.71 PHENYLADEGMP READY 1 PA

NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATIONnut tx for isovaleric acidemia 1 PA



NUT TX FOR TYROSINEMIA W-IRON TYLACTIN RTD15 PE 1 PA

NUT TX FOR TYROSINEMIA W-IRON TYR ANAMIXNEXT 1 PA

NUT TX FOR TYROSINEMIA W-IRON TYR EXPRESS20 1 PANUT TX FOR TYROSINEMIA W-IRON TYR GEL 1 PANUT TX FOR TYROSINEMIA W-IRON TYR LOPHLEX 1 PANUT. TX FOR PROPIONIC ACIDEMIA MMA-PA 1 PA

NUT. TX FOR PROPIONIC ACIDEMIA MMA-PACOOLER15 1 PA

NUT. TX FOR PROPIONIC ACIDEMIA OA2 1 PANUT.GLUC INT,LACT-FREE/FOS/DHA GLUCO BURST 1 PAnut.therap.glutaric aciduria 1 1 PA

NUT.THERAPY,UREA CYCLE DISORDR UCD ANAMIXJUNIOR 1 PA

NUT.THERAPY,UREA CYCLE DISORDR UCD TRIO 1 PANUT.TX KETOGENIC,MILK BASE/SOY KETOCAL 4:1 1 PANUT.TX,ELEMENTAL,LAC-FREE/MCT XTRACAL PLUS 1 PANUT.TX,IMPAIRED RENAL FXN,WHEY RENA START 1 PA

NUT.TX,METAB.DIS,LEUCINE-FREE LEU-FREECOOLER 1 PA

NUT.TX,METABOLIC DIS,METHIO-FR HCU COOLER 1 PANUT.TX,METABOLIC DIS,METHIO-FR HCU LOPHLEX 1 PANUT.TX,METABOLIC DIS,METHIO-FR HOMINEX-2 1 PAnut.tx,metabolic dis,methio-fr 1 PANUT.TX. METABOLIC DISORDER,REG HCU COOLER 1 PANUT.TX. METABOLIC DISORDER,REG HCU COOLER20 1 PANUT.TX. METABOLIC DISORDER,REG TYR COOLER 1 PANUT.TX. METABOLIC DISORDER,REG TYR COOLER20 1 PANUT.TX. METABOLIC DISORDER,SOY PERATIVE 1 PA

NUT.TX.COMP. IMMUNE SYSTM,REG ENSURESURGERY 1 PA

nut.tx.comp. immune systm,regIMPACTPEPTIDE 1.5CAL

1 PA

NUT.TX.GLUC INTOL,LF,SOY/FIBERBOOSTGLUCOSECONTROL

1 PA

NUT.TX.GLUC INTOL,LF,SOY/FIBER DIABETISOURCE AC 1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,REG DIABETISHIELD 1 PANUT.TX.GLUC.INTOLER,LAC-FR,SOY GLUCERNA 1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOY GLUCERNA 1CAL 1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOY GLUCERNA 1.2CAL 1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOY GLUCERNA 1.5CAL 1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOY GLUCERNAADVANCE 1 PA



NUT.TX.GLUC.INTOLER,LAC-FR,SOYGLUCERNAHUNGERSMART

1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOYGLUCERNATHERAPEUTICNUTRITION

1 PA

NUT.TX.GLUC.INTOLER,LAC-FR,SOY GLYTROL 1 PA

NUT.TX.IMP.RENAL FXN,LAC-REDUC NEPRO CARBSTEADY 1 PA

NUT.TX.IMP.RENAL FXN,LAC-REDUC SUPLENA CARBSTEADY 1 PA

NUT.TX.IMPAIRED DIGEST FXN ELECARE JR 1 PANUT.TX.IMPAIRED DIGEST FXN EO28 SPLASH 1 PANUT.TX.IMPAIRED DIGEST FXN LIPISTART 1 PA

NUT.TX.IMPAIRED DIGEST FXN NEOCATEJUNIOR 1 PA

NUT.TX.IMPAIRED DIGEST FXN NEOCATENUTRA 1 PA

NUT.TX.IMPAIRED DIGEST FXN PEPTAMENJUNIOR 1.5 1 PA

NUT.TX.IMPAIRED DIGEST FXN,SOY VIVONEX RTF 1 PA

NUT.TX.IMPAIRED DIGEST/FIBER

NEOCATEJUNIOR WITHPREBIOTICS (16G-459)(POWDER) (OTC)

1 PA

NUT.TX.IMPAIRED DIGEST/FIBER

NEOCATEJUNIOR WITHPREBIOTICS(16G-478)(POWDER) (OTC)

1 PA

NUT.TX.IMPAIRED DIGEST/FIBER VITAL 1.0 CAL 1 PANUT.TX.IMPAIRED DIGEST/FIBER VITAL 1.5 CAL 1 PA

NUT.TX.IMPAIRED DIGEST/FIBER VITAL AF 1.2CAL 1 PA

NUT.TX.IMPAIRED DIGEST/FIBER VITAL PEPTIDE1.5 CAL 1 PA

nut.tx.pulm.disord.reg,lac-fr 1 PA

NUT.TX.PULM.DISORD.REG,LAC-FR NUTRENPULMONARY 1 PA

NUT.TX.PULM.DISORD.REG,LAC-FR OXEPA 1 PAnut.tx.pulm.disord.soy,lacfree 1 PANUTRIT.THERAPY, MSUD WITH IRON BCAD 2 1 PANUTRIT.THERAPY, MSUD WITH IRON MSUD COOLER 1 PA

NUTRIT.THERAPY, MSUD WITH IRON MSUDCOOLER20 1 PA

NUTRIT.THERAPY, MSUD WITH IRON MSUD EXPRESSCOOLER 1 PA

NUTRIT.THERAPY, MSUD WITH IRON MSUDEXPRESS15 1 PA


Drug Name Tier Requirements/LimitsNUTRIT.THERAPY, MSUD WITH IRON MSUD LOPHLEX 1 PAnutritional tx, ketogenic,milk 1 PA

OINTMENT/CREAM BASESCREAM BASE NO.126 PENTRAVAN 1

EMOLLIENT BASE AQUAGLYCOLIC 1

EMOLLIENT BASE DERMABASE 1EMOLLIENT BASE EMOLLIENT 1EMOLLIENT BASE FINGER CREAM 1

EMOLLIENT BASE PCCAEMOLLIENT 1

EMOLLIENT BASE RADIAGEL 1

EMOLLIENT BASE SORBIDONHYDRATE 1

EMOLLIENT BASE VANICREAM 1PETROLATUM, YELLOW PETROLATUM 1petrolatum,white 1

PETROLATUM,WHITE PETROLEUMJELLY 1

PETROLATUM,WHITEPETROLEUMJELLY LIPTREATMENT

1

PETROLATUM,WHITE VASELINE 1

PETROLATUM,WHITE VASELINEPETROLEUM 1

PETROLATUM,WHITE WHITEPETROLEUM 1

PROTEIN REPLACEMENTamino ac/multivit-min/herb 139 1amino acids/rice protein/mv-mn 1 PAINFANT FORM.IRON LAC-F/DHA/ARA ELECARE 1 PANUT.TX.IMPAIRED DIGEST FXN ELECARE JR 1 PAwhey 1 PA

SOLVENTSISOPROPYL ALCOHOL DY-O-DERM 1ISOPROPYL ALCOHOL INSTACLEAN 1ISOPROPYL ALCOHOL ISOPROPANOL 1ISOPROPYL ALCOHOL 1

ISOPROPYL ALCOHOLISOPROPYLRUBBINGALCOHOL

1

ISOPROPYL ALCOHOL RUBBINGALCOHOL 1

PROPYLENE GLYCOL (99.5 %) (LIQUID) 1PROPYLENE GLYCOL (99.5 %) (LIQUID)(OTC) 1

SUPPOSITORY BASE NO.217 POLYBASE(WAX) (OTC) 5

SOMATOSTATIC AGENTSoctreotide acetate 1


Drug Name Tier Requirements/LimitsPASIREOTIDE DIASPARTATE SIGNIFOR 2 PA

SUSPENDING AGENTSCARBOMER/POLYSORBATES SUSPENDOL-S 5

METHYLCELLULOSE 1500CPS METHYLCELLULOSE 5

SILICA GEL,AMORPHOUS SYN MICRO

SILICA GELMICRONIZED(100 %)(POWDER) (OTC)

5

THICKENING AGENTS, ORALCELLULOSE GUM THIK & CLEAR 1

CORN STARCH RESOURCETHICKENUP 1

MALTODEXTRIN/XANTHAN GUMTHICKEN UPCLEAR(POWDER) (OTC)

1

STARCH INSTANT FOODTHICKENER 1

STARCH THICK NOW 1STARCH THICK-IT 1STARCH THICK-IT #2 1

XANTHAN GUMSIMPLYTHICK(120G) (GELPACKET) (OTC)

1

XANTHAN GUMSIMPLYTHICK(15 G) (GEL(GRAM)) (OTC)

1

XANTHAN GUMSIMPLYTHICK(15 G) (GELPACKET) (OTC)

1

XANTHAN GUMSIMPLYTHICK(15 G) (GELW/PUMP) (OTC)

1

XANTHAN GUMSIMPLYTHICK(240 G) (GELPACKET) (OTC)

1

XANTHAN GUMSIMPLYTHICK(30G) (GELPACKET) (OTC)

1

TOPICAL ANTISEPTIC DRYING AGENTSformaldehyde 1

WOUND HEALING AGENTS, LOCALbalsam peru/castor oil 1BALSAM PERU/CASTOR OIL DERMULCERA 1

BALSAM PERU/CASTOR OIL VENELEX(OINT. (G)) 1

OTHER RESPIRATORY DISORDERSANTIFIBROTIC THERAPY - PYRIDONE ANALOGS

PIRFENIDONE ESBRIET 2 PA


Drug Name Tier Requirements/LimitsCYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR

IVACAFTOR KALYDECO 2 PACYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.

LUMACAFTOR/IVACAFTOR ORKAMBI 2 PATEZACAFTOR/IVACAFTOR SYMDEKO 2 PA

MUCOLYTICSacetylcysteine MUCOMYST 1DORNASE ALFA PULMOZYME 2 PA

PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORSNINTEDANIB ESYLATE OFEV 2 PA

PAIN MANAGEMENT - ANALGESICSANALGESIC, NON-SALICYLATE & BARBITURATE COMB.

butalbital/acetaminophen (50mg-325mg)(tablet) 1

ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMBbutalbital/aspirin/caffeine 1

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBbutalb/acetaminophen/caffeine 1

ANALGESIC/ANTIPYRETICS, SALICYLATESaspirin (300 mg) (supp.rect) (otc) 5aspirin (325 mg) (tablet dr) (otc) 4 QL: 100 PER FILLaspirin (325 mg) (tablet) (otc) 4 QL: 100 PER FILLaspirin (600 mg) (supp.rect) (otc) 5

aspirin/acetaminophen/caffeine

EXCEDRINEXTRASTRENGTH (250-250-65)(TABLET) (OTC)

5


EXCEDRINMENSTRUALCOMPLETE (250-250-65)(TABLET) (OTC)

5


EXCEDRINMIGRAINE (250-250-65)(TABLET) (OTC)

5

aspirin/calcium carbonate/mag (325 mg)(tablet) (otc) 5

choline salicyl/mag salicylate 1diflunisal DOLOBID 1salsalate DISALCID 1

ANALGESIC/ANTIPYRETICS,NON-SALICYLATEacetaminophen (120 mg) (supp.rect) (otc) 5acetaminophen (160 mg) (tab chew) (otc) 5acetaminophen (160 mg/5ml) (liquid) (otc) 5acetaminophen (160 mg/5ml) (oral susp)(otc) 5

acetaminophen (325 mg) (supp.rect) (otc) 5acetaminophen (325 mg) (tablet) (otc) 5


Drug Name Tier Requirements/Limitsacetaminophen (500 mg) (capsule) (otc) 5acetaminophen (500 mg) (tablet) (otc) 5acetaminophen (650 mg) (supp.rect) (otc) 5acetaminophen (650 mg) (tablet er) (otc) 5acetaminophen (80 mg) (tab rapdis) (otc) 5acetaminophen (80mg/0.8ml) (drops susp)(otc) 5

ACETAMINOPHEN

FEVERALL (80MG)(SUPP.RECT)(OTC)

5

acetaminophen/caffeine

EXCEDRINTENSIONHEADACHE(500MG-65MG)(TABLET) (OTC)

5

ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATIONhydrocodone/ibuprofen IBUDONE 1hydrocodone/ibuprofen VICOPROFEN 1ibuprofen/oxycodone hcl 1

ANALGESICS,NARCOTICSbuprenorphine BUTRANS 1 QL: 4 IN 28 DAYSbuprenorphine hcl 1butorphanol tartrate STADOL 1carisoprodol/aspirin/codeine 1 AGE: >= 12 YEARScodeine sulfate CODEINE 1 AGE: >= 12 YEARS

fentanylDURAGESIC(100 MCG/HR)(PATCH TD72)

1 PA, QL: 1 IN 3 DAYS

fentanylDURAGESIC (12MCG/HR)(PATCH TD72)


fentanylDURAGESIC (25MCG/HR)(PATCH TD72)


fentanylDURAGESIC(50MCG/HR)(PATCH TD72)


fentanylDURAGESIC(75MCG/HR)(PATCH TD72)


fentanyl citrate ACTIQ 1 PAhydromorphone hcl (1 mg/ml) (liquid) 1hydromorphone hcl (12 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (16 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (2 mg) (tablet) 1hydromorphone hcl (3 mg) (supp.rect) 1hydromorphone hcl (32 mg) (tab er 24h) 1 PA, QL: 2 IN 1 DAYhydromorphone hcl (4 mg) (tablet) 1hydromorphone hcl (8 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAY


Drug Name Tier Requirements/Limitshydromorphone hcl (8 mg) (tablet) 1levorphanol tartrate (2 mg) (tablet) 1

meperidine hclDEMEROL (10MG/ML)(CARTRIDGE)

1

meperidine hcl/pf DEMEROL (100MG/ML) (VIAL) 1



morphine sulfate (10 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (10 mg) (supp.rect) 1morphine sulfate (10 mg/5 ml) (solution) 1morphine sulfate (100 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (100 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (100 mg/5ml) (solution) 1morphine sulfate (10mg/0.7ml) (pen injctr) 1morphine sulfate (120 mg) (cpmp 24hr) 1 QL: 2 IN 1 DAYmorphine sulfate (15 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (15 MG) (TABLET) 2morphine sulfate (20 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (20 mg) (supp.rect) 1morphine sulfate (20 mg/5 ml) (solution) 1morphine sulfate (200 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (30 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (30 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (30 mg) (supp.rect) 1morphine sulfate (30 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (30 MG) (TABLET) 2morphine sulfate (40 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (45 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (5 mg) (supp.rect) 1morphine sulfate (50 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (60 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (75 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (80 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (90 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYnalbuphine hcl 1opium/belladonna alkaloids 1oxycodone hcl (10 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (10 mg) (tablet) 1oxycodone hcl (15 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (15 mg) (tablet) 1oxycodone hcl (20 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (20 mg) (tablet) 1oxycodone hcl (20 mg/ml) (oral conc) 1


Drug Name Tier Requirements/Limitsoxycodone hcl (30 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (30 mg) (tablet) 1oxycodone hcl (40 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (5 mg) (capsule) 1oxycodone hcl (5 mg) (tablet) 1oxycodone hcl (5 mg/5 ml) (solution) 1oxycodone hcl (60 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (80 mg) (tab er 12h) 1 QL: 4 IN 1 DAYOXYCODONE HCL OXYCONTIN 2 QL: 2 IN 1 DAYoxymorphone hcl OPANA 1

oxymorphone hclOPANA ER (10MG) (TAB ER12H)

1 QL: 2 IN 1 DAY


1 QL: 2 IN 1 DAY


1 QL: 2 IN 1 DAY


1 QL: 4 IN 1 DAY


1 QL: 4 IN 1 DAY


1 QL: 2 IN 1 DAY

oxymorphone hclOPANA ER (7.5MG) (TAB ER12H)

1 QL: 2 IN 1 DAY

pentazocine hcl/naloxone hcl TALWIN NX 1TAPENTADOL HCL NUCYNTA 2 QL: 6 IN 1 DAYTAPENTADOL HCL NUCYNTA ER 2 QL: 2 IN 1 DAY

tramadol hclCONZIP (150MG) (CPBP 25-75)

1 ST, AGE: >= 12 YEARS, QL: 1IN 1 DAY

tramadol hcl RYZOLT 1 AGE: >= 12 YEARStramadol hcl ULTRAM 1 AGE: >= 12 YEARStramadol hcl ULTRAM ER 1 AGE: >= 12 YEARS

ANTIMIGRAINE PREPARATIONSdihydroergotamine mesylate D.H.E.45 1 QL: 15mL IN 14 DAYSdihydroergotamine mesylate MIGRANAL 1 QL: 8mL IN 28 DAYSergotamine tartrate/caffeine CAFERGOT 1 QL: 10 IN 7 DAYSrizatriptan benzoate 1 QL: 18 IN 30 DAYSsumatriptan IMITREX 1 QL: 6 IN 15 DAYSsumatriptan succinate (100 mg) (tablet) 1 QL: 9 IN 30 DAYSsumatriptan succinate (25 mg) (tablet) 1 QL: 3 IN 5 DAYSsumatriptan succinate (4 mg/0.5ml)(cartridge) 1 QL: 4mL IN 28 DAYS


Drug Name Tier Requirements/Limitssumatriptan succinate (4 mg/0.5ml) (peninjctr) 1 QL: 4mL IN 28 DAYS

sumatriptan succinate (50 mg) (tablet) 1 QL: 3 IN 5 DAYSsumatriptan succinate (6 mg/0.5ml)(cartridge) 1 QL: 4mL IN 28 DAYS

sumatriptan succinate (6 mg/0.5ml) (peninjctr) 1 QL: 4mL IN 28 DAYS

sumatriptan succinate (6 mg/0.5ml) (syringe) 1 QL: 4mL IN 28 DAYSsumatriptan succinate (6 mg/0.5ml) (vial) 1 QL: 5mL IN 28 DAYS

ZOLMITRIPTAN ZOMIG (2.5 MG)(SPRAY) 2 ST, QL: 12 IN 30 DAYS

ZOLMITRIPTAN ZOMIG (5 MG)(SPRAY) 2 ST, QL: 6 IN 15 DAYS

NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB

butalbit/acetamin/caff/codeine FIORICET WITHCODEINE 1 AGE: >= 12 YEARS

NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE

codeine/butalbital/asa/caffein FIORINAL WITHCODEINE #3 1 AGE: >= 12 YEARS

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBacetaminophen with codeine (120-12mg/5)(solution) 1 AGE: >= 12 YEARS

acetaminophen with codeine (300mg-15mg)(tablet) 1 AGE: >= 12 YEARS



hydrocodone/acetaminophen (10mg-325mg)(tablet) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (2.5-325 mg)(tablet) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (5 mg-325mg)(tablet) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (7.5-325 mg)(tablet) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (7.5-325/15)(solution) 1 QL: 184mL IN 1 DAY

oxycodone hcl/acetaminophen (10mg-325mg)(tablet) 1 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (2.5-325 mg)(tablet) 1 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (5 mg-325mg)(tablet) 1 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (7.5-325 mg)(tablet) 1 QL: 12 IN 1 DAY

tramadol hcl/acetaminophen ULTRACET 1 AGE: >= 12 YEARSNARCOTIC AND SALICYLATE ANALGESIC COMBINATION

oxycodone hcl/aspirin 1


Drug Name Tier Requirements/LimitsNARCOTIC WITHDRAWAL THERAPY AGENTS

buprenorphine hcl SUBUTEX 1 QL: 3 IN 1 DAYBUPRENORPHINE HCL/NALOXONEHCL

BUNAVAIL (2.1-0.3 MG) (FILM) 2 QL: 1 IN 1 DAY

BUPRENORPHINE HCL/NALOXONEHCL

BUNAVAIL (4.2-0.7 MG) (FILM) 2 QL: 2 IN 1 DAY


BUNAVAIL(6.3MG-1MG)(FILM)

2 QL: 2 IN 1 DAY

buprenorphine hcl/naloxone hcl (12 mg-3 mg)(film) 1 QL: 2 IN 1 DAY

buprenorphine hcl/naloxone hcl (2 mg-0.5mg)(film) 1 QL: 1 IN 1 DAY

buprenorphine hcl/naloxone hcl (2 mg-0.5mg)(tab subl) 1 QL: 3 IN 1 DAY

buprenorphine hcl/naloxone hcl (4mg-1mg)(film) 1 QL: 1 IN 1 DAY

buprenorphine hcl/naloxone hcl (8 mg-2 mg)(film) 1 QL: 2 IN 1 DAY

buprenorphine hcl/naloxone hcl (8 mg-2 mg)(tab subl) 1 QL: 3 IN 1 DAY


SUBOXONE (12MG-3 MG)(FILM)

2 QL: 2 IN 1 DAY


SUBOXONE (2MG-0.5MG)(FILM)

2 QL: 1 IN 1 DAY


SUBOXONE(4MG-1MG)(FILM)

2 QL: 1 IN 1 DAY


SUBOXONE (8MG-2 MG)(FILM)

2 QL: 2 IN 1 DAY


ZUBSOLV (0.7-0.18MG) (TABSUBL)

2 QL: 1 IN 1 DAY



2 QL: 1 IN 1 DAY



2 QL: 1 IN 1 DAY



2 QL: 1 IN 1 DAY


ZUBSOLV (5.7-1.4 MG) (TABSUBL)

2 QL: 1 IN 1 DAY


ZUBSOLV (8.6-2.1 MG) (TABSUBL)

2 QL: 2 IN 1 DAY



PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

benztropine mesylate COGENTIN 4trihexyphenidyl hcl ARTANE 4

ANTIPARKINSONISM DRUGS,OTHERamantadine hcl SYMMETREL 1bromocriptine mesylate PARLODEL 1carbidopa/levodopa PARCOPA 1carbidopa/levodopa SINEMET 10-100 1carbidopa/levodopa SINEMET 25-100 1carbidopa/levodopa SINEMET 25-250 1carbidopa/levodopa SINEMET CR 1carbidopa/levodopa/entacapone STALEVO 100 1carbidopa/levodopa/entacapone STALEVO 125 1carbidopa/levodopa/entacapone STALEVO 150 1carbidopa/levodopa/entacapone STALEVO 200 1carbidopa/levodopa/entacapone STALEVO 50 1carbidopa/levodopa/entacapone STALEVO 75 1entacapone COMTAN 1pramipexole di-hcl MIRAPEX 1rasagiline mesylate AZILECT 1 QL: 1 IN 1 DAYropinirole hcl (0.25 mg) (tablet) 1ropinirole hcl (0.5 mg) (tablet) 1ropinirole hcl (1 mg) (tablet) 1ropinirole hcl (12 mg) (tab er 24h) 1 ST, QL: 1 IN 1 DAYropinirole hcl (2 mg) (tab er 24h) 1 ST, QL: 1 IN 1 DAYropinirole hcl (2 mg) (tablet) 1ropinirole hcl (3 mg) (tablet) 1ropinirole hcl (4 mg) (tab er 24h) 1 ST, QL: 1 IN 1 DAYropinirole hcl (4 mg) (tablet) 1ropinirole hcl (5 mg) (tablet) 1ropinirole hcl (6 mg) (tab er 24h) 1 ST, QL: 1 IN 1 DAYropinirole hcl (8 mg) (tab er 24h) 1 ST, QL: 1 IN 1 DAYROTIGOTINE NEUPRO 2 ST, QL: 1 IN 1 DAYselegiline hcl ELDEPRYL 1

DECARBOXYLASE INHIBITORScarbidopa LODOSYN 1

SEIZURE DISORDERANTICONVULSANT - BENZODIAZEPINE TYPE

clobazam ONFI (10 MG)(TABLET) 4 ST, QL: 2 IN 1 DAY

clobazamONFI (2.5MG/ML) (ORALSUSP)


clobazam ONFI (20 MG)(TABLET) 4 ST, QL: 2 IN 1 DAY

CLOBAZAM SYMPAZAN 4 PAclonazepam 4CLONAZEPAM KLONOPIN 4


Drug Name Tier Requirements/LimitsDIAZEPAM DIASTAT 4 QL: 1 PER FILL

DIAZEPAM DIASTATACUDIAL 4 QL: 1 PER FILL

diazepam 4 QL: 1 PER FILLANTICONVULSANT - CANNABINOID TYPE

CANNABIDIOL (CBD) EXTRACT EPIDIOLEX 2 PAANTICONVULSANTS

carbamazepine (100 mg) (cpmp 12hr) 1carbamazepine (100 mg) (tab chew) 4carbamazepine (100 mg) (tab er 12h) 4carbamazepine (100 mg/5ml) (oral susp) 4carbamazepine (200 mg) (cpmp 12hr) 1carbamazepine (200 mg) (tab er 12h) 4carbamazepine (200 mg) (tablet) 4carbamazepine (300 mg) (cpmp 12hr) 4carbamazepine (400 mg) (tab er 12h) 4

CARBAMAZEPINECARBATROL(300 MG) (CPMP12HR)

4

CARBAMAZEPINETEGRETOL XR(100 MG) (TABER 12H)

4

DIVALPROEX SODIUMDEPAKOTE (250MG) (TABLETDR)

4

DIVALPROEX SODIUMDEPAKOTE (500MG) (TABLETDR)

4

divalproex sodium 4

ESLICARBAZEPINE ACETATE APTIOM (200MG) (TABLET) 4 ST, QL: 1 IN 1 DAY




ethosuximide 4ETHOSUXIMIDE ZARONTIN 4ETHOTOIN PEGANONE 4felbamate (400 mg) (tablet) 4 ST, QL: 9 IN 1 DAYfelbamate (600 mg) (tablet) 4 ST, QL: 6 IN 1 DAYfelbamate (600 mg/5ml) (oral susp) 4 ST, QL: 30mL IN 1 DAYgabapentin 4

LACOSAMIDEVIMPAT (10MG/ML)(SOLUTION)


LACOSAMIDE VIMPAT (100MG) (TABLET) 4 ST, QL: 2 IN 1 DAY





LACOSAMIDE VIMPAT (50 MG)(TABLET) 4 ST, QL: 2 IN 1 DAY

LAMOTRIGINE LAMICTAL 4

LAMOTRIGINE LAMICTAL(BLUE) 4

LAMOTRIGINE LAMICTAL(GREEN) 4

LAMOTRIGINE LAMICTAL(ORANGE) 4

LAMOTRIGINELAMICTAL ODT(100 MG) (TABRAPDIS)








LAMOTRIGINE LAMICTAL ODT(BLUE) 4 ST

LAMOTRIGINE LAMICTAL ODT(GREEN) 4 ST

LAMOTRIGINE LAMICTAL ODT(ORANGE) 4 ST

LAMOTRIGINE LAMICTAL XR(BLUE) 4 ST

LAMOTRIGINE LAMICTAL XR(GREEN) 4 ST

LAMOTRIGINE LAMICTAL XR(ORANGE) 4 ST

lamotrigine (100 mg) (tab er 24) 4 ST, QL: 3 IN 1 DAYlamotrigine (100 mg) (tab rapdis) 4 ST, QL: 3 IN 1 DAYlamotrigine (100 mg) (tablet) 4lamotrigine (150 mg) (tablet) 4lamotrigine (200 mg) (tab er 24) 4 ST, QL: 2 IN 1 DAYlamotrigine (200 mg) (tab rapdis) 4 ST, QL: 2 IN 1 DAYlamotrigine (200 mg) (tablet) 4lamotrigine (25 mg) (tab er 24) 4 ST, QL: 6 IN 1 DAYlamotrigine (25 mg) (tab rapdis) 4 ST, QL: 6 IN 1 DAYlamotrigine (25 mg) (tablet) 4lamotrigine (25 mg) (tb chw dsp) 4lamotrigine (25(21)-50) (tb rd dspk) 4 STlamotrigine (25(42)-100) (tab ds pk) 4


Drug Name Tier Requirements/Limitslamotrigine (25(84)-100) (tab ds pk) 4lamotrigine (250 mg) (tab er 24) 4 ST, QL: 2 IN 1 DAYlamotrigine (25-50-100) (tb rd dspk) 4 STlamotrigine (25mg (35)) (tab ds pk) 4lamotrigine (300 mg) (tab er 24) 4 ST, QL: 2 IN 1 DAYlamotrigine (5 mg) (tb chw dsp) 4lamotrigine (50 mg) (tab er 24) 4 ST, QL: 6 IN 1 DAYlamotrigine (50 mg) (tab rapdis) 4 ST, QL: 6 IN 1 DAYlamotrigine (50(42)-100) (tb rd dspk) 4 STLEVETIRACETAM KEPPRA 4LEVETIRACETAM KEPPRA XR 4levetiracetam 4LEVETIRACETAM ROWEEPRA 4LEVETIRACETAM ROWEEPRA XR 4METHSUXIMIDE CELONTIN 4oxcarbazepine 4

OXCARBAZEPINEOXTELLAR XR(150 MG) (TABER 24H)






OXCARBAZEPINE TRILEPTAL 4

PERAMPANEL FYCOMPA (10MG) (TABLET) 4 ST, QL: 1 IN 1 DAY






PHENYTOIN DILANTIN 4PHENYTOIN DILANTIN-125 4phenytoin 4PHENYTOIN SODIUM EXTENDED DILANTIN 4PHENYTOIN SODIUM EXTENDED PHENYTEK 4phenytoin sodium extended 4PREGABALIN LYRICA 4PRIMIDONE MYSOLINE 4primidone 4

RUFINAMIDE BANZEL (200MG) (TABLET) 4 ST, QL: 16 IN 1 DAY



RUFINAMIDEBANZEL (40MG/ML) (ORALSUSP)


RUFINAMIDE BANZEL (400MG) (TABLET) 4 ST, QL: 8 IN 1 DAY

TIAGABINE HCL GABITRIL (12MG) (TABLET) 4 ST, QL: 4 IN 1 DAY




tiagabine hcl (12 mg) (tablet) 4 ST, QL: 4 IN 1 DAYtiagabine hcl (16 mg) (tablet) 4 ST, QL: 3 IN 1 DAYtiagabine hcl (2 mg) (tablet) 4 ST, QL: 4 IN 1 DAYtiagabine hcl (4 mg) (tablet) 4 ST, QL: 4 IN 1 DAY

TOPIRAMATEQUDEXY XR(100 MG) (CAPSPR 24)






TOPIRAMATEQUDEXY XR (25MG) (CAP SPR24)


TOPIRAMATEQUDEXY XR (50MG) (CAP SPR24)


TOPIRAMATE TOPAMAX 4topiramate (100 mg) (cap spr 24) 4 ST, QL: 1 IN 1 DAYtopiramate (100 mg) (tablet) 4topiramate (15 mg) (cap sprink) 4topiramate (150 mg) (cap spr 24) 4 ST, QL: 2 IN 1 DAYtopiramate (200 mg) (cap spr 24) 4 ST, QL: 2 IN 1 DAYtopiramate (200 mg) (tablet) 4topiramate (25 mg) (cap spr 24) 4 ST, QL: 1 IN 1 DAYtopiramate (25 mg) (cap sprink) 4topiramate (25 mg) (tablet) 4topiramate (50 mg) (cap spr 24) 4 ST, QL: 1 IN 1 DAYtopiramate (50 mg) (tablet) 4

TOPIRAMATETROKENDI XR(100 MG) (CAPER 24H)


TOPIRAMATETROKENDI XR(200 MG) (CAPER 24H)




TOPIRAMATETROKENDI XR(25 MG) (CAP ER24H)


TOPIRAMATETROKENDI XR(50 MG) (CAP ER24H)


valproic acid 4valproic acid (as sodium salt) 4VIGABATRIN SABRIL 4 QL: 6 IN 1 DAYvigabatrin 4 QL: 6 IN 1 DAYZONISAMIDE ZONEGRAN 4zonisamide 4

SKELETAL MUSCLE DISORDERAGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH

DICHLORPHENAMIDE KEVEYIS 2 PASKELETAL MUSCLE RELAXANTS

baclofen 1carisoprodol SOMA 1 QL: 4 IN 1 DAY

carisoprodol/aspirin SOMACOMPOUND 1

chlorzoxazone (500 mg) (tablet) 1cyclobenzaprine hcl FEXMID 1cyclobenzaprine hcl FLEXERIL 1dantrolene sodium DANTRIUM 1methocarbamol ROBAXIN 1methocarbamol ROBAXIN-750 1orphenadrine citrate NORFLEX 1

tizanidine hcl ZANAFLEX (2MG) (TABLET) 1

tizanidine hcl ZANAFLEX (4MG) (TABLET) 1

SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

nicotine NICODERM CQ 4 AGE: >= 18 YEARS, QL: 1 IN1 DAY

NICOTINE PATCH 4 AGE: >= 18 YEARS, QL: 1 IN1 DAY

NICOTINE NICOTROL 4 ST, AGE: >= 18 YEARS, QL:1008 IN 90 DAYS

NICOTINE NICOTROL NS 4 ST, AGE: >= 18 YEARS, QL:160mL IN 90 DAYS

nicotine polacrilex 4 AGE: >= 18 YEARS, QL: 720IN 30 DAYS

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST

VARENICLINE TARTRATE CHANTIX 4 AGE: >= 18 YEARS, QL: 2 IN1 DAY

SMOKING DETERRENTS, OTHER

bupropion hcl ZYBAN 4 AGE: >= 18 YEARS, QL: 2 IN1 DAY



UPPER GASTROINTESTINAL DISORDERS - DIGESTIVEANTIFLATULENTS

simethicone (125 mg) (capsule) (otc) 5simethicone (40mg/0.6ml) (drops susp) (otc) 5simethicone (80 mg) (tab chew) (otc) 5

GASTRIC ENZYMESSACROSIDASE SUCRAID 2 PA

PANCREATIC ENZYMESLIPASE/PROTEASE/AMYLASE CREON 2LIPASE/PROTEASE/AMYLASE ZENPEP 2

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASEANTICHOLINERGICS/ANTISPASMODICS

dicyclomine hcl 1BELLADONNA ALKALOIDS

hyoscyamine sulfate HYOSYNE 1hyoscyamine sulfate LEVBID 1hyoscyamine sulfate LEVSIN 1hyoscyamine sulfate LEVSIN-SL 1hyoscyamine sulfate NULEV 1hyoscyamine sulfate SYMAX 1hyoscyamine sulfate SYMAX-SL 1hyoscyamine sulfate SYMAX-SR 1methscopolamine bromide PAMINE 1methscopolamine bromide PAMINE FORTE 1

EMETICSipecac 1

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASEANTACIDS

aluminum hydroxide (320 mg/5ml) (oral susp)(otc) 5

calcium carb/magnesium hydrox (700-300mg) (tab chew) (otc) 5

calcium carbonate (200(500)mg) (tab chew)(otc) 5

calcium carbonate (215(500)mg) (tab chew)(otc) 5

calcium carbonate (260mg(648)) (tablet)(otc) 5

calcium carbonate (300mg(750)) (tab chew)(otc) 5

calcium carbonate (320mg(750)) (tab chew)(otc) 5

calcium carbonate (400(1000)) (tab chew)(otc) 5

MAG CARB/ALUMINUMHYDROX/ALGIN

GAVISCON(237.5-254)(ORAL SUSP)(OTC)

5


Drug Name Tier Requirements/Limitsmag carb/aluminum hydrox/algin (358-95/15)(oral susp) (otc) 5

mag hydrox/aluminum hyd/simeth (200-200-20) (oral susp) (otc) 5

mag hydrox/aluminum hyd/simeth (200-200-25) (tab chew) (otc) 5

mag hydrox/aluminum hyd/simeth (400-400-40) (oral susp) (otc) 5

magnesium oxide (400 mg) (tablet) (otc) 5sodium bicarbonate (650 mg) (tablet) (otc) 5

ANTICHOLINERGICS,QUATERNARY AMMONIUMchlordiazepoxide/clidinium br LIBRAX 1glycopyrrolate (1 mg) (tablet) 1glycopyrrolate (2 mg) (tablet) 1propantheline bromide PRO-BANTHINE 1

ANTI-ULCER PREPARATIONSmisoprostol CYTOTEC 1

sucralfate CARAFATE (1 G)(TABLET) 1

SUCRALFATECARAFATE (1G/10 ML) (ORALSUSP)

2

ANTI-ULCER-H.PYLORI AGENTSlansoprazole/amoxiciln/clarith 1 QL: 112 IN 10 DAYS

HISTAMINE H2-RECEPTOR INHIBITORScimetidine TAGAMET 1

cimetidineTAGAMET HB(200 MG)(TABLET) (OTC)

5

famotidine (10 mg) (tablet) (otc) 5famotidine (20 mg) (tablet) (otc) 5famotidine (40 mg) (tablet) 1nizatidine AXID 1

ranitidine hclZANTAC (15MG/ML)(SYRUP)

1

ranitidine hcl ZANTAC (150MG) (CAPSULE) 1

ranitidine hcl ZANTAC (150MG) (TABLET) 1

ranitidine hclZANTAC (150MG) (TABLET)(OTC)

5

ranitidine hcl ZANTAC (300MG) (CAPSULE) 1

ranitidine hcl ZANTAC (300MG) (TABLET) 1

ranitidine hclZANTAC 75 (75MG) (TABLET)(OTC)

5


Drug Name Tier Requirements/LimitsINTESTINAL MOTILITY STIMULANTS

metoclopramide hcl REGLAN 1PROTON-PUMP INHIBITORS

ESOMEPRAZOLE MAGNESIUMNEXIUM (10MG) (SUSPDRPKT)


ESOMEPRAZOLE MAGNESIUMNEXIUM (2.5MG) (SUSPDRPKT)


esomeprazole magnesiumNEXIUM (20MG) (CAPSULEDR)

1 QL: 1 IN 1 DAY



esomeprazole magnesiumNEXIUM (40MG) (CAPSULEDR)

1 QL: 2 IN 1 DAY



ESOMEPRAZOLE MAGNESIUM NEXIUM (5 MG)(SUSPDR PKT) 2 ST, QL: 1 IN 1 DAY

lansoprazole (15 mg) (capsule dr) 1lansoprazole (15 mg) (capsule dr) (otc) 5lansoprazole (15 mg) (tab rap dr) 1 STlansoprazole (30 mg) (capsule dr) 1lansoprazole (30 mg) (tab rap dr) 1 STomeprazole (10 mg) (capsule dr) 1omeprazole (20 mg) (capsule dr) 1omeprazole (20 mg) (tablet dr) (otc) 5omeprazole (40 mg) (capsule dr) 1omeprazole magnesium (20 mg) (capsule dr)(otc) 5

pantoprazole sodium 1rabeprazole sodium ACIPHEX 1 QL: 1 IN 1 DAY

URINARY TRACT - FUNCTIONAL DISORDERSBENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS

alfuzosin hcl UROXATRAL 1dutasteride AVODART 1finasteride PROSCAR 1tamsulosin hcl FLOMAX 1

BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMBdutasteride/tamsulosin hcl JALYN 1 ST

KIDNEY STONE AGENTSCYSTEAMINE BITARTRATE PROCYSBI 2 PA

URINARY PH MODIFIERScitric acid/sodium citrate (334-500mg)(solution) (otc) 5

potassium citrate UROCIT-K 1


Drug Name Tier Requirements/Limitspotassium citrate/citric acid (1100-334/5)(solution) (otc) 5

potassium citrate/citric acid (3300-1002)(packet) 1

sod phos di, mono/k phos mono

K-PHOSNEUTRAL (250MG) (TABLET)(OTC)

5

sod/pot/k cit/sod cit/cit acid (500-550/5)(solution) (otc) 5

URINARY TRACT ANALGESIC AGENTSPENTOSAN POLYSULFATE SODIUM ELMIRON 2

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)phenazopyridine hcl PYRIDIUM 1

URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.SOLIFENACIN SUCCINATE VESICARE 2 ST

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTFESOTERODINE FUMARATE TOVIAZ 2 STflavoxate hcl URISPAS 1oxybutynin chloride 1tolterodine tartrate DETROL 1 ST

VAGINAL DISORDERSVAGINAL ANTIBIOTICS

clindamycin phosphate CLEOCIN (2 %)(CREAM/APPL) 1

metronidazole METROGEL-VAGINAL 1

VAGINAL ANTIFUNGALSBUTOCONAZOLE NITRATE GYNAZOLE 1 2

clotrimazole

GYNE-LOTRIMIN-7 (1%)(CREAM/APPL)(OTC)

5

miconazole nitrate (100 mg) (supp.vag) (otc) 5miconazole nitrate (2 %) (cream/appl) (otc) 5miconazole nitrate (200 mg) (supp.vag) 1terconazole TERAZOL 3 1terconazole TERAZOL 7 1

VAGINAL ESTROGEN PREPARATIONSestradiol ESTRACE 1estradiol VAGIFEM 1ESTROGENS, CONJUGATED PREMARIN 2

VAGINAL SULFONAMIDESSULFANILAMIDE AVC 2

VITAMIN AND/OR MINERAL DEFICIENCYCALCIUM REPLACEMENT

calcium carbonate (500 mg/5ml) (oral susp)(otc) 5


Drug Name Tier Requirements/Limitscalcium carbonate (500(1250)) (tablet) (otc) 5calcium carbonate (600 mg) (tablet) (otc) 5calcium carbonate/vitamin d3 (500 mg-100)(tab chew) (otc) 5

calcium carbonate/vitamin d3 (500 mg-200)(tablet) (otc) 5

calcium carbonate/vitamin d3 (500 mg-400)(tab chew) (otc) 5




calcium citrate (200(950)mg) (tablet) (otc) 5calcium citrate/vitamin d3 (315 mg-250)(tablet) (otc) 5

calcium gluconate (45(500) mg) (tablet) (otc) 5calcium/mag/d3/b12/fa/b6/boron (500-1.1mg)(tablet) 1

FLUORIDE PREPARATIONSfluoride (sodium) (0.25(0.55)) (tab chew)(otc) 5 AG: TIER 4 FOR 6-72

MONTHSfluoride (sodium) (0.5(1.1)mg) (tab chew)(otc) 5 AG: TIER 4 FOR 6-72

MONTHSfluoride (sodium) (1.1 %) (cream (g)) 1fluoride (sodium) (1.1 %) (gel (gram)) 1fluoride (sodium) (1mg(2.2mg)) (tab chew)(otc) 5 AG: TIER 4 FOR 6-72

MONTHSSODIUM FLUORIDE/VITAMIN D3 FLORIVA 5stannous fluoride 1

FOLIC ACID PREPARATIONS

folic acid (0.4 mg) (tablet) (otc) 4AG: TIER 4 FOR FEMALES<= 55 YEARS OLD, QL: 100PER FILL

folic acid (0.8 mg) (tablet) (otc) 4AG: TIER 4 FOR FEMALES<= 55 YEARS OLD, QL: 100PER FILL

folic acid (1 mg) (tablet) 1folic acid (1 mg) (tablet) (otc) 5folic acid (5 mg/ml) (vial) 1multivit-min/fa/lycopen/lutein BIOCEL 1

GERIATRIC VITAMIN PREPARATIONSb1,b2,b3,b6,b12/dexpan/zn/mang 5multivit with iron,minerals 1multivit with minerals/lutein (tablet) (otc) 1multivit-min/fa/lycopen/lutein (.4-300-250)(tablet) (otc) 5

IRON REPLACEMENTferrous fumarate (324(106)mg) (tablet) (otc) 5


Drug Name Tier Requirements/Limitsferrous gluconate (324(37.5)) (tablet) (otc) 5ferrous gluconate (324(38)mg) (tablet) (otc) 5

ferrous sulfate (15 mg/ml) (drops) (otc) 5 AG: TIER 4 FOR 6-12MONTHS

ferrous sulfate (220 (44)/5) (elixir) (otc) 5ferrous sulfate (300 mg/5ml) (liquid) (otc) 5ferrous sulfate (324(65)mg) (tablet dr) (otc) 5ferrous sulfate (325(65) mg) (tablet dr) (otc) 5ferrous sulfate (325(65) mg) (tablet) (otc) 5ferrous sulfate/vit c/folic ac 1IRON AG,PS/C/FA6/B12/ZN/SA/STO NIFEREX 5iron aspgly,ps/c/succinic acid 1iron fum/docusat/folic/bcomp,c 5iron polysaccharide complex (150 mg)(capsule) (otc) 5

iron/c/b12/calciu/stomach conc 1iron/calcium/e/folic acid/mvit 5iron/liver ext/vit bcomp,c/min 1vit b comp/c/folic/iron/vit e (500-400-18)(tablet) (otc) 5

MAGNESIUM SALTS REPLACEMENTmagnesium (250 mg) (tablet) (otc) 5magnesium chloride (64 mg) (tablet dr) (otc) 5magnesium chloride (71.5 mg) (tablet dr)(otc) 5

magnesium oxide (400 mg) (tablet) (otc) 5magnesium oxide (420 mg) (tablet) (otc) 5magnesium oxide (500 mg) (tablet) (otc) 5

MINERAL REPLACEMENT,MISCELLANEOUSMINERALS/PROTEIN SUPPLEMENT PROVIMIN 1

MULTIVITAMIN PREPARATIONSa/c/e/zinc/sod selenate/copper 5amino acids/mv,tx,iron,mineral PROTECT PLUS 1b-complex with vitamin c (tablet) (otc) 5multivit,calc,mins/iron/folic (9mg-400mcg)(tablet) (otc) 5

multivit,stress formula/zinc

STRESSFORMULAWITH ZINC(TABLET) (OTC)

5

multivitamin (tablet) (otc) 5multivitamin with folic acid (400 mcg)(tablet) (otc) 5

multivitamin with iron (tablet) (otc) 5multivitamin,stress formula (tablet) (otc) 5multivitamin,ther and minerals (tablet) (otc) 5multivitamin,therapeutic (tablet) (otc) 5multivitamin/iron/folic acid (18mg-0.4mg)(tablet) (otc) 5

MULTIVIT-MIN/FA/LUTEIN/ZEAXANT ICAPS MV 5


Drug Name Tier Requirements/LimitsMULTIVIT-MINS 53/FOLIC/K/COQ10 DEKAS PLUS 5MULTIVIT-MINS 56/FOLIC/K/COQ10 DEKAS PLUS 5PEDI MULTIVIT 40/PHYTONADIONE AQUADEKS 5

VIT A/D3/TOCOPHERSOLAN/VIT K DEKASESSENTIAL 5

vit a/vit d3/e/tocophersolan/k 5PEDIATRIC VITAMIN PREPARATIONS

multivitamin (tab chew) (otc) 5multivitamin with iron (tab chew) (otc) 5ped multivit 151/iron/fluoride 5

PED MVIT A,C,D3 NO.38/FLUORIDE

TRI-VI-FLOR(0.25 MG/ML)(DRPS SP BP)(OTC)

5

PED MVIT A,C,D3 NO.38/FLUORIDETRI-VI-FLOR (0.5MG/ML) (DRPSSP BP) (OTC)

5

PEDI MULTIVIT 33/FLUORIDE/IRON

POLY-VI-FLORWITH IRON(0.5MG-10MG)(TAB CHEW)(OTC)

5

PEDI MULTIVIT 37/FLUORIDE/IRON

POLY-VI-FLORWITH IRON(0.25-7MG/1)(DRPS SP BP)(OTC)

5

PEDI MULTIVIT 86/IRON/FLUORIDE ESCAVITE LQ 5PEDI MULTIVIT NO.128/VITAMIN K DEKAS PLUS 5pedi multivit no.17 w-fluoride (0.25 mg) (tabchew) (otc) 5

pedi multivit no.17 w-fluoride (0.5 mg) (tabchew) (otc) 5

pedi multivit no.17 w-fluoride (1 mg) (tabchew) (otc) 5

pedi multivit no.2 w-fluoride (0.5 mg/ml)(drops) (otc) 5

PEDI MULTIVIT NO.33/FLUORIDEPOLY-VI-FLOR(0.25 MG) (TABCHEW) (OTC)

5

PEDI MULTIVIT NO.33/FLUORIDEPOLY-VI-FLOR(0.5 MG) (TABCHEW) (OTC)

5

PEDI MULTIVIT NO.33/FLUORIDEPOLY-VI-FLOR(1 MG) (TABCHEW) (OTC)

5

PEDI MULTIVIT NO.37 W-FLUORIDE

POLY-VI-FLOR(0.25 MG/ML)(DRPS SP BP)(OTC)

5

PEDI MULTIVIT NO.85/FLUORIDE FLORIVA 5



PEDI MV NO.80/FERROUS SULFATE POLY-VI-SOLWITH IRON 5

PEDIATRIC MULTIVITAMIN NO.81 POLY-VI-SOL 5vit a palmitate/vit c/vit d3 (750-35/ml) (drops)(otc) 5

PRENATAL VITAMIN PREPARATIONSmultivit-mins no.61/iron/folic 5multivit-mins no.64/iron/folic 5multivit-mins60/iron fum/folic (27 mg-1 mg)(tablet) (otc) 5

mv, min 59/iron/folic/docusate 5mv-mins no.50/iron,carb/folic 5pnv 11/iron fum/folic acid/om3 1pnv 15/iron fum,ps/folic acid CONCEPT OB 1pnv 16/iron fum,ps/folic/om-3 CONCEPT DHA 1pnv 21/iron ps,heme ppep/folic PREFERA OB 1pnv 39/iron/folic/docusate/dha 1pnv 66/iron/folic/docusate/dha 1

pnv 69/iron/folic/docusate/dha CITRANATALHARMONY 1

pnv 80/iron fum/folic/dss/dha NEXA SELECT 1pnv no.118/iron fumarate/fa 1pnv no.5/ferrous fum/folic ac 1pnv no.66/iron,carb/folic/dha ACTIVE OB 1pnv no.95/ferrous fum/folic ac (28mg-0.8mg)(tablet) (otc) 5

pnv, calcium 70/iron/folic/dha NATELLE ONE 1pnv,calcium 72/iron,carb/folic 1pnv,calcium 72/iron/folic acid 1pnv/ferrous fum/docusate/folic 1pnv/iron,carb/docusat/folic ac 1pnv119/iron fum/folic/docusate 1pnv19/iron bg,s.p/folic ac/om3 1pnv81/iron edta,ps/folic/omeg3 1prenat 115/iron fum/folic/dss 1prenat vit 17/iron/folic/om3,6 1prenatal 12/iron/folic/dss/om3 OBTREX DHA 1

prenatal 34/iron/folic/dss/dha CITRANATALHARMONY 1

prenatal 47/iron/folate 1/dha 1prenatal 53/iron/folic ac/omg3 1prenatal 54/iron/folic ac/omg3 1prenatal 57/iron/folic/dss/dha 1

prenatal 59/iron/folic/dss/dha CITRANATALHARMONY 1

prenatal 68/iron/folic no1/dha 1

prenatal comb no.42/folic acid VITAMEDMDREDICHEW RX 1

prenatal no.52/iron/fa/dha 1prenatal no.75/iron/folate no1 1


Drug Name Tier Requirements/Limitsprenatal no115/iron/folic acid 1prenatal no13/iron ps/folate 1 1prenatal no4/iron fum,ps/folic 1prenatal vit 10/iron/folic/dha 1prenatal vit 14/iron fum/folic 1prenatal vit 55/iron/folic/om3 1prenatal vit no.109/iron/fa 1prenatal vit no.127/iron/folic 1prenatal vit,cal 73/iron/folic 1prenatal vit,cal 74/iron/folic 1prenatal vit,calc76/iron/folic 1PRENATAL VIT,CALC76/IRON/FOLIC THRIVITE RX 1prenatal vit,calc78/iron/folic 1prenatal vit/iron bisgly/folic 1prenatal vit/iron fum/folic ac (65 mg-1 mg)(capsule) 1

prenatal vit/iron fum/folic ac (65 mg-1 mg)(tablet) 1

prenatal vit100/iron/folic/om3 1prenatal vit128/iron/folic acd 1prenatal vit136/iron/folic acd 1

prenatal vit22/iron/folic/om3s PREFERA-OBPLUS DHA 1

prenatal vit27,calcium/iron/fa TRINATAL RX 1 1prenatal vit86/iron/folic acid NESTABS 1prenatal vits15/iron/folic/dss 1prenatal vits16/iron/folic/dss 1prenatal vits18/iron/folic/dss 1prenatal,calc no.65/iron/folic 1prenatal,calc.40/iron/folate 1 1prenatal64/iron/lmfolate/algal NEEVODHA 1

PRENATAL VITAMINS WITHOUT IRONpnv/folic ac/b6/calcium/ginger B-NEXA 1

VITAMIN A PREPARATIONSvitamin a (10000 unit) (capsule) (otc) 5

VITAMIN B PREPARATIONSb comp no3/folic/c/biotin/zinc 5b12/levomefolate calcium/b-6 FOLTX 1biotin (300 mcg) (tablet) (otc) 5biotin (5 mg) (capsule) (otc) 5biotin (5 mg) (tablet) (otc) 5

levomefolate/b6/b12/algal oilMETANX (3-35-2MG) (CAPSULE)(OTC)

5

vitamin b complex (capsule) (otc) 5vitamin b complex (tablet) (otc) 5vitamins b1,b2,b3,b5,and b6 1

VITAMIN B1 PREPARATIONSthiamine hcl (100 mg) (tablet) (otc) 5


Drug Name Tier Requirements/LimitsVITAMIN B12 PREPARATIONS

cyanocobalamin (vitamin b-12) (1000 mcg)(tablet) (otc) 5

cyanocobalamin (vitamin b-12) (1000mcg/ml)(vial) 1

cyanocobalamin (vitamin b-12) (500 mcg)(tablet) (otc) 5

hydroxocobalamin 1VITAMIN B6 PREPARATIONS

pyridoxine hcl (vitamin b6) (100 mg) (tablet)(otc) 5

pyridoxine hcl (vitamin b6) (100 mg/ml)(vial) 1

pyridoxine hcl (vitamin b6) (50 mg) (tablet)(otc) 5

VITAMIN C PREPARATIONSascorbic acid (250 mg) (tab chew) (otc) 5ascorbic acid (250 mg) (tablet) (otc) 5ascorbic acid (500 mg) (tab chew) (otc) 5ascorbic acid (500 mg) (tablet) (otc) 5ascorbic acid (500 mg/ml) (vial) 1ascorbic acid (granules) (otc) 1

VITAMIN D PREPARATIONScalcitriol ROCALTROL 1cholecalciferol (vitamin d3) (1000 unit)(tablet) (otc) 5

cholecalciferol (vitamin d3) (2000 unit)(capsule) (otc) 5

cholecalciferol (vitamin d3) (400/ml) (drops)(otc) 5

ergocalciferol (vitamin d2) (50000 unit)(capsule) 1

ergocalciferol (vitamin d2) (8000/ml) (drops)(otc) 5

VITAMIN E PREPARATIONS

TOCOPHERSOLAN (VIT E TPGS) AQUA-ECONCENTRATE 5

ZINC REPLACEMENTzinc sulfate (220 mg) (tablet) (otc) 1


STEP THERAPY EDITS • ABILIFY (1 MG/ML)(SOLUTION)

Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Citalopram Hydrobromide, Clozapine,Duloxetine HCL, Escitalopram Oxalate, Fluoxetine HCL, Olanzapine,Paroxetine HCL, Paroxetine Mesylate, Paxil, Perseris, Pexeva,Quetiapine Fumarate, Risperidone, Seroquel XR, Sertraline HCL,Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days

• ABILIFY DISCMELT (10 MG)(TAB RAPDIS)


• ABILIFY DISCMELT (15 MG)(TAB RAPDIS)


• ACTOPLUS MET (15MG-500MG)(TABLET)

Must meet any of the following requirements: Avandamet, Avandaryl,Avandia, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL,Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days

• ACTOPLUS MET (15MG-850MG)(TABLET)

Must meet any of the following requirements: Avandamet, Avandaryl,Avandia, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL,Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days

• ACTOPLUS MET XR Must meet any of the following requirements: Avandamet, Avandaryl,Avandia, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL,Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days

• APLENZIN Must meet the following requirement: Bupropion HCL in 120 days• APTIOM (200 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine,

Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid (as Sodium Salt), Valproic Acid, or Zonisamide in 365 days

• APTIOM (400 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid (as Sodium Salt), Valproic Acid, or Zonisamide in 365 days



Medication Prescribing Limitations


• AUGMENTIN (125-31.25/) (SUSPRECON)

Must meet the following requirement: Generic augmentin suspensionof a different strength in 120 days

• BANZEL (200 MG) (TABLET) Must meet any of the following requirements: Divalproex Sodium,Lamictal, Lamictal XR, Lamotrigine, Stavzor, Topiramate, TrokendiXR. or Valproic Acid in 120 days

• BANZEL (40 MG/ML) (ORALSUSP)

Must meet any of the following requirements: Divalproex Sodium,Lamictal, Lamictal XR, Lamotrigine, Stavzor, Topiramate, TrokendiXR. or Valproic Acid in 120 days

• BANZEL (400 MG) (TABLET) Must meet any of the following requirements: Divalproex Sodium,Lamictal, Lamictal XR, Lamotrigine, Stavzor, Topiramate, TrokendiXR. or Valproic Acid in 120 days

• BELSOMRA Must meet any of the following requirements: Eszopiclone, Zaleplon,or Zolpidem Tartrate in 120 days

• BRISDELLE Must meet any of the following requirements: Paroxetine HCL, Paxil,or Venlafaxine HCL in 120 days

• CONDYLOX (0.5 %) (GEL(GRAM)) Must meet the following requirement: Podofilox in 120 days• CONZIP (150 MG) (CPBP 25-75) Must meet the following requirement: Tramadol HCL in 120 days• CORDRAN (4MCG/SQ CM)(MED. TAPE)

Must meet the following requirement: Topical Anti-inflammatorySteroidal in 120 days

• DALIRESP Must meet any of the following requirements: Breo Ellipta,Fluticasone/salmeterol, Incruse Ellipta, Perforomist, Spiriva Respimat,or Striverdi Respimat in 120 days

• DESVENLAFAXINE ER Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• DESVENLAFAXINE FUMARATEER

Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• DETROL Must meet the following requirement: Oxybutynin Chloride in 120days

• DEXAMETHASONE (1.5MG (21))(TAB DS PK) Must meet the following requirement: Dexamethasone in 120 days• DEXAMETHASONE (1.5MG (35))(TAB DS PK) Must meet the following requirement: Dexamethasone in 120 days• DEXAMETHASONE (1.5MG (51))(TAB DS PK) Must meet the following requirement: Dexamethasone in 120 days• DIFICID Must meet the following requirement: Vancomycin HCL in 120 days• DOVONEX Must meet the following requirement: Topical Anti-inflammatory

Steroidal in 120 days• DRITHOCREME HP Must meet the following requirement: Topical Anti-inflammatory

Steroidal in 120 days• EDLUAR Must meet the following requirement: Edluar or Zolpidem Tartrate in

180 days• FANAPT (1 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, Abilify

Mycite, Abilify, Aripiprazole, Clozapine, Olanzapine, QuetiapineFumarate, Seroquel XR, Versacloz. or Ziprasidone HCL in 365 days

• FANAPT (10 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, QuetiapineFumarate, Seroquel XR, Versacloz. or Ziprasidone HCL in 365 days




• FANAPT (1-2-4-6MG) (TAB DSPK)

Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, QuetiapineFumarate, Seroquel XR, Versacloz. or Ziprasidone HCL in 365 days





• FAZACLO Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, Perseris,Quetiapine Fumarate, Risperidone. Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• FELBAMATE (400 MG)(TABLET)

Must meet any of the following requirements: Lamictal, Lamictal XR,Lamotrigine, Topiramate, or Trokendi XR in 120 days

• FELBAMATE (600 MG)(TABLET)


• FELBAMATE (600 MG/5ML)(ORAL SUSP)


• FETZIMA Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fetzima, FluoxetineHCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, orVenlafaxine HCL in 365 days

• FYCOMPA (10 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Fycompa, Gabapentin, Gralise,Lamictal, Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, TrokendiXR, Valproic Acid, or Zonisamide in 365 days








• GABITRIL (12 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in 365 days




• GLYXAMBI Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• INTERMEZZO Must meet the following requirement: Zolpidem Tartrate in 120 days• INVEGA (1.5 MG) (TAB ER 24) Must meet 2 of the following requirements: Abilify Maintena, Abilify

Mycite, Abilify, Aripiprazole, Clozapine, Olanzapine, QuetiapineFumarate, Seroquel XR, Versacloz. or Ziprasidone HCL in 365 days

• INVEGA (3 MG) (TAB ER 24) Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, QuetiapineFumarate, Seroquel XR, Versacloz. or Ziprasidone HCL in 365 days



• INVOKAMET Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,



Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• INVOKAMET XR Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• INVOKANA Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• JALYN Must meet any of the following requirements: Alfuzosin HCL,Doxazosin Mesylate, Finasteride, Prazosin HCL, Silodosin,Tamsulosin HCL, or Terazosin HCL in 120 days

• JARDIANCE Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• KHEDEZLA Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Desvenlafaxine, Desvenlafaxine ER,Escitalopram Oxalate, Fluoxetine HCL, Mirtazapine, Paroxetine HCL,Paxil, Sertraline HCL, or Venlafaxine HCL in 365 days

• KRISTALOSE (20 G) (PACKET) Must meet the following requirement: Lactulose in 120 days• KYTRIL Must meet the following requirement: Ondansetron or Ondansetron

HCL in 120 days• LAMICTAL ODT (100 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (200 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (25 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (50 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (BLUE) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (GREEN) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL ODT (ORANGE) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL XR (BLUE) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL XR (GREEN) Must meet the following requirement: Lamotrigine in 120 days• LAMICTAL XR (ORANGE) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (100 MG) (TABER 24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (100 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (200 MG) (TABER 24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (200 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days



• LAMOTRIGINE (25 MG) (TAB ER24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (25 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (25(21)-50) (TBRD DSPK) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (250 MG) (TABER 24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (25-50-100) (TBRD DSPK) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (300 MG) (TABER 24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (50 MG) (TAB ER24) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (50 MG) (TABRAPDIS) Must meet the following requirement: Lamotrigine in 120 days• LAMOTRIGINE (50(42)-100) (TBRD DSPK) Must meet the following requirement: Lamotrigine in 120 days• LANSOPRAZOLE (15 MG) (TABRAP DR)

Must meet any of the following requirements: Lansoprazole,Omeprazole, or Pantoprazole Sodium in 120 days

• LANSOPRAZOLE (30 MG) (TABRAP DR)

Must meet any of the following requirements: Lansoprazole,Omeprazole, or Pantoprazole Sodium in 120 days

• LATUDA (120 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, Perseris,Quetiapine Fumarate, Risperidone. Seroquel XR, Versacloz, orZiprasidone HCL in 365 days





• LIDOCAINE (5 %) (OINT. (G)) Must meet the following requirement: Lidocaine HCL in 120 days• LUVOX CR Must meet any of the following requirements: Citalopram

Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL, FluvoxamineMaleate, Paroxetine HCL, Paxil, or Sertraline HCL in 120 days

• MARINOL Must meet any of the following requirements: Anzemet, Aprepitant,Dexamethasone Intensol, Dexamethasone, Granisetron HCL, Maxidex,Medrol, Megestrol Acetate, Methylprednisolone, Ondansetron HCL,Ondansetron, Ozurdex, Sancuso, Sustol, or Zuplenz in 120 days

• MEGACE ES Must meet the following requirement: Megestrol Acetate in 120 days



• NAMZARIC (14MG-10MG) (CAPSPR 24)

Must meet 2 of the following requirements: Donepezil HCL,Memantine HCL, or Namenda XR in 365 days

• NAMZARIC (21 MG-10MG) (CAPSPR 24)


• NAMZARIC (28 MG-10MG) (CAPSPR 24)


• NAMZARIC (7 MG-10 MG) (CAPSPR 24)


• NAMZARIC (7-10/14-10) (CAP24DSPK)


• NEUPRO Must meet any of the following requirements: Pramipexole Di-HCL orRopinirole HCL in 120 days

• NEXIUM (10 MG) (SUSPDR PKT)Must meet any of the following requirements: Lansoprazole,Omeprazole, Pantoprazole Sodium, Prilosec OTC, or Protonix in 120days

• NEXIUM (2.5 MG) (SUSPDRPKT)

Must meet any of the following requirements: Lansoprazole,Omeprazole, Pantoprazole Sodium, Prilosec OTC, or Protonix in 120days



• NEXIUM (5 MG) (SUSPDR PKT) Must meet any of the following requirements: Lansoprazole,Omeprazole, Pantoprazole Sodium, Prilosec OTC, or Protonix in 120days

• NIASPAN Must meet any of the following requirements: Altoprev, Antara,Atorvastatin Calcium, Fenofibrate Nanocrystallized, Fenofibrate,Fenofibrate micronized, Flolipid, Gemfibrozil, Lovastatin, PravastatinSodium, Simvastatin, or Triglide in 365 days

• NICOTROL Must meet the following requirement: Nicotine Patch or Nicotine in120 days

• NICOTROL NS Must meet the following requirement: Nicotine Patch or Nicotine in120 days

• NOVOLIN 70-30 Must meet the following requirement: Humulin 70-30 or Humulin70/30 Kwikpen in 120 days

• NOVOLIN 70-30 FLEXPEN Must meet the following requirement: Humulin 70-30 or Humulin70/30 Kwikpen in 120 days

• NOVOLIN N Must meet the following requirement: Humulin N or Humulin NKwikpen in 120 days

• NOVOLIN R Must meet the following requirements: Humulin R or Humulin R U-500 in 120 days

• ONFI (10 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal XR,Lamotrigine, Topiramate, or Trokendi XR in 120 days

• ONFI (2.5 MG/ML) (ORAL SUSP) Must meet any of the following requirements: Lamictal, Lamictal XR,Lamotrigine, Topiramate, or Trokendi XR in 120 days

• ONFI (20 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal XR,Lamotrigine, Topiramate, or Trokendi XR in 120 days

• ORACEA Must meet the following requirement: Doxycycline Monohydrate in120 days



• OXTELLAR XR (150 MG) (TABER 24H)

Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in 365 days





• PATANASE Must meet the following requirement: Azelastine HCL in 120 days• PEXEVA Must meet the following requirement: Paroxetine HCL or Paxil in 120

days• PICATO (0.015 %) (GEL (EA)) Must meet any of the following requirements: Diclofenac Sodium,

Fluorouracil, or Imiquimod in 120 days• PICATO (0.05 %) (GEL (EA)) Must meet any of the following requirements: Diclofenac Sodium,

Fluorouracil, or Imiquimod in 120 days• PROTOPIC Must meet the following requirement: Topical Anti-inflammatory

Steroidal in 120 days• PURIXAN Must meet the following requirement: Mercaptopurine in 120 days• QNASL Must meet any of the following requirements: Flunisolide, Fluticasone

Propionate, or Qnasl Children in 120 days• QNASL CHILDREN Must meet any of the following requirements: Flunisolide, Fluticasone

Propionate, or Qnasl in 120 days• QUDEXY XR (100 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (150 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (200 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (25 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (50 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• QUILLIVANT XR (5 MG/ML) (SUER RC24)

Must meet the following requirement: Methylphenidate HCL in 120days

• QUILLIVANT XR (5 MG/ML) (SUER RC24)

Must meet the following requirement: Methylphenidate HCL in 120days

• RASUVO (10MG/0.2ML) (AUTOINJCT)

Must meet any of the following requirements: Methotrexate Sodium,Methotrexate Sodium/pf, Rheumatrex, or Trexall in 120 days

• RASUVO (12.5/0.25) (AUTOINJCT)
















• RASUVO (7.5MG/0.15) (AUTOINJCT)


• ROPINIROLE HCL (12 MG) (TABER 24H)

Must meet the following requirement: Pramipexole Di-HCL orRopinirole HCL in 120 days









• ROZEREM Must meet any of the following requirements: Eszopiclone, Zaleplon,or Zolpidem Tartrate in 120 days

• SAPHRIS Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, Perseris,Quetiapine Fumarate, Risperidone. Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• SEGLUROMET Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• SIKLOS (1000 MG) (TABLET) Must meet the following requirement: Droxia or Hydroxyurea in 365days

• SILENOR Must meet any of the following requirements: Doxepin HCL,Eszopiclone, Silenor, Zaleplon, or Zolpidem Tartrate in 120 days

• SIMVASTATIN (80 MG)(TABLET)

Must meet the following requirement: Ezetimibe/simvastatin in 365days

• SIVEXTRO Must meet the following requirement: Linezolid in 120 days• SOLIQUA 100-33 Must meet 2 of the following requirements: Actoplus Met XR,

Basaglar Kwikpen U-100, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, PioglitazoneHCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Riomet, Tolazamide, Tolbutamide, Toujeo Max Solostar, ToujeoSolostar, Trulicity, or Victoza in 365 days

• STEGLATRO Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days



• SYNJARDY Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• SYNJARDY XR (10-1000 MG)(TAB BP 24H)

Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• SYNJARDY XR (12.5-1000) (TABBP 24H)


• SYNJARDY XR (25-1000 MG)(TAB BP 24H)


• SYNJARDY XR (5MG-1000MG)(TAB BP 24H)


• TACLONEX (0.005-.064) (OINT.(G))

Must meet the following requirement: Topical Anti-inflammatorySteroidal in 120 days

• TIAGABINE HCL (12 MG)(TABLET)










• TOPIRAMATE (100 MG) (CAPSPR 24) Must meet the following requirement: Topiramate in 120 days• TOPIRAMATE (150 MG) (CAPSPR 24) Must meet the following requirement: Topiramate in 120 days• TOPIRAMATE (200 MG) (CAPSPR 24) Must meet the following requirement: Topiramate in 120 days• TOPIRAMATE (25 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• TOPIRAMATE (50 MG) (CAP SPR24) Must meet the following requirement: Topiramate in 120 days• TOVIAZ Must meet the following requirement: Oxybutynin Chloride in 120

days• TRINTELLIX Must meet 2 of the following requirements: Bupropion HCL,

Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• TROKENDI XR (100 MG) (CAPER 24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (200 MG) (CAPER 24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (25 MG) (CAP ER24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (50 MG) (CAP ER24H) Must meet the following requirement: Topiramate in 120 days• TRULICITY Must meet any of the following requirements: Actoplus Met XR,

Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• VECTICAL Must meet the following requirement: Topical Anti-inflammatorySteroidal in 120 days

• VERSACLOZ Must meet 2 of the following requirements: Abilify Maintena, AbilifyMycite, Abilify, Aripiprazole, Clozapine, Olanzapine, Perseris,Quetiapine Fumarate, Risperidone. Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• VESICARE Must meet the following requirement: Oxybutynin Chloride in 120days

• VICTOZA 2-PAK Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• VICTOZA 3-PAK Must meet any of the following requirements: Actoplus Met XR,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metforminHCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in 120 days

• VIIBRYD (10 MG) (TABLET) Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,



Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• VIIBRYD (20 MG) (TABLET) Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• VIIBRYD (40 MG) (TABLET) Must meet 2 of the following requirements: Bupropion HCL,Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL,Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or VenlafaxineHCL in 365 days

• VIMPAT (10 MG/ML)(SOLUTION)

Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, or ValproicAcid in 365 days

• VIMPAT (100 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine,Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal,Lamictal XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine,Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in 365 days




• VYVANSE Must meet any of the following requirements: Aptensio XR,Citalopram Hydrobromide, Dextroamphetamine/amphetamine,Escitalopram Oxalate, Fluoxetine HCL, Fluvoxamine Maleate,Methylphenidate HCL, Mydayis, Paroxetine HCL, Paxil, QuillichewER, Quillivant XR, Relexxii, Sertraline HCL, Topiramate, or TrokendiXR in 120 days

• XYZAL (2.5 MG/5ML)(SOLUTION)

Must meet any of the following requirements: Desloratadine orLevocetirizine Dihydrochloride in 120 days

• ZOLPIMIST Must meet the following requirement: Zolpidem Tartrate in 120 days• ZOMIG (2.5 MG) (SPRAY) Must meet the following requirement: Rizatriptan Benzoate or

Sumatriptan Succinate in 180 days• ZOMIG (5 MG) (SPRAY) Must meet the following requirement: Rizatriptan Benzoate or

Sumatriptan Succinate in 180 days



- # -0.9 % SODIUM CHLORIDE............................ 55, 980.9 % SODIUM CHLORIDE (0.9 %)(CARTRIDGE)............................................................0.9 % SODIUM CHLORIDE (0.9 %) (IV SOLN)......0.9 % SODIUM CHLORIDE (0.9 %) (SYRINGE)....0.9 % SODIUM CHLORIDE (0.9 %) (VIAL)............0.9 % SODIUM CHLORIDE (PGGYBK PRT)..........0.9 % SODIUM CHLORIDE (PGY VL PRT)............3(N-BUTY-N-ACET)AMINOPROP ETHY........... 39

- A -A/C/E/ZINC/SOD SELENATE/COPPER.............120AA/HYDROLYZED COLLAGEN, WHEY........... 92ABACAVIR SULFATE........................................... 76ABACAVIR SULFATE/LAMIVUDINE.................75ABACAVIR/DOLUTEGRAVIR/LAMIVUDI........ 79ABACAVIR/LAMIVUDINE/ZIDOVUDINE.........75ABALOPARATIDE.................................................56ABATACEPT...........................................................80ABEMACICLIB......................................................89ABILIFY (1 MG/ML) (SOLUTION)..............20, 125ABILIFY (10 MG) (TABLET)................................20ABILIFY (15 MG) (TABLET)................................20ABILIFY (2 MG) (TABLET)..................................20ABILIFY (20 MG) (TABLET)................................20ABILIFY (30 MG) (TABLET)................................20ABILIFY (5 MG) (TABLET)..................................20ABILIFY DISCMELT (10 MG) (TAB RAPDIS)....20, 125ABILIFY DISCMELT (15 MG) (TAB RAPDIS)....21, 125ABILIFY MAINTENA........................................... 21ABILIFY MYCITE................................................. 21ABIRATERONE ACETATE................................... 88ABREVA (10 %) (CREAM (G)) (OTC)................. 41ACARBOSE............................................................ 48ACCOLATE...............................................................9ACCU-CHEK.................................................... 51, 52ACCU-CHEK FASTCLIX LANCING DEV.......... 52ACCU-CHEK SOFTCLIX...................................... 52ACCUPRIL..............................................................27ACCURETIC...........................................................27ACE AEROSOL CLOUD ENHANCER...................9ACEBUTOLOL HCL..............................................28ACEON....................................................................27ACETAMINOPHEN..................................... 103, 104ACETAMINOPHEN (120 MG) (SUPP.RECT)(OTC)...........................................................................ACETAMINOPHEN (160 MG) (TAB CHEW)(OTC)...........................................................................ACETAMINOPHEN (160 MG/5ML) (LIQUID)(OTC)...........................................................................ACETAMINOPHEN (160 MG/5ML) (ORAL SUSP)(OTC)...........................................................................

ACETAMINOPHEN (325 MG) (SUPP.RECT)(OTC)...........................................................................ACETAMINOPHEN (325 MG) (TABLET) (OTC)....ACETAMINOPHEN (500 MG) (CAPSULE) (OTC).....................................................................................ACETAMINOPHEN (500 MG) (TABLET) (OTC)....ACETAMINOPHEN (650 MG) (SUPP.RECT)(OTC)...........................................................................ACETAMINOPHEN (650 MG) (TABLET ER)(OTC)...........................................................................ACETAMINOPHEN (80 MG) (TAB RAPDIS)(OTC)...........................................................................ACETAMINOPHEN (80MG/0.8ML) (DROPSSUSP) (OTC)...............................................................ACETAMINOPHEN WITH CODEINE............... 107ACETAMINOPHEN WITH CODEINE (120-12MG/5) (SOLUTION)...............................................ACETAMINOPHEN WITH CODEINE (300MG-15MG) (TABLET).......................................................ACETAMINOPHEN WITH CODEINE (300MG-30MG) (TABLET).......................................................ACETAMINOPHEN WITH CODEINE (300MG-60MG) (TABLET).......................................................ACETAMINOPHEN/CAFFEINE......................... 104ACETAZOLAMIDE................................................60ACETIC ACID.................................................. 44, 54ACETYLCYSTEINE............................................ 103ACIPHEX.............................................................. 117ACITRETIN............................................................ 46ACLOVATE............................................................. 41ACTEMRA..............................................................81ACTEMRA ACTPEN..............................................81ACTIGALL............................................................. 84ACTIMMUNE.........................................................69ACTIQ................................................................... 104ACTIVE OB.......................................................... 122ACTIVELLA........................................................... 67ACTOPLUS MET (15MG-500MG) (TABLET)....49,125ACTOPLUS MET (15MG-850MG) (TABLET)....49,125ACTOPLUS MET XR.....................................49, 125ACTOS.................................................................... 48ACULAR................................................................. 58ACULAR LS........................................................... 58ACYCLOVIR.................................................... 41, 74ADACEL TDAP...................................................... 68ADALAT CC........................................................... 29ADAPALENE..........................................................39ADASUVE.............................................................. 21ADCIRCA............................................................... 30ADDERALL............................................................19ADDERALL XR (10 MG) (CAP ER 24H).............19ADDERALL XR (15 MG) (CAP ER 24H).............19


Index

ADDERALL XR (20 MG) (CAP ER 24H).............19ADDERALL XR (25 MG) (CAP ER 24H).............19ADDERALL XR (30 MG) (CAP ER 24H).............20ADDERALL XR (5 MG) (CAP ER 24H)...............20ADEFOVIR DIPIVOXIL........................................ 79ADEMPAS...............................................................30ADJUSTABLE LANCING DEVICE......................51ADMELOG............................................................. 53ADMELOG SOLOSTAR........................................ 53ADOXA (150 MG) (TABLET)............................... 72ADVAIR DISKUS..................................................... 8ADVAIR HFA............................................................8ADVANCED LANCING DEVICE.........................52ADVATE.................................................................. 63ADVIL (200 MG) (CAPSULE) (OTC)................... 82ADVIL (200 MG) (TABLET) (OTC)......................82ADVIL LIQUI-GELS (200 MG) (CAPSULE) (OTC)................................................................................. 82ADVIL MIGRAINE (200 MG) (CAPSULE) (OTC)................................................................................. 82ADVOCATE LANCING DEVICE......................... 51ADVOCATE RAPID-SAFE.................................... 51ADYNOVATE..........................................................62AEROBIKA.............................................................12AEROCHAMBER MINI...........................................9AEROCHAMBER MV............................................. 9AEROCHAMBER PLUS FLOW-VU..................9-12AEROCHAMBER WITH FLOWSIGNAL...............9AEROCHAMBER Z-STAT PLUS.......................9-12AEROECLIPSE II................................................... 12AEROGEAR ASTHMA ACTION KIT.................. 15AERONEB GO NEBULIZER.................................12AEROTRACH PLUS...............................................10AEROVENT PLUS................................................. 10AFATINIB DIMALEATE........................................89AFINITOR...............................................................89AFINITOR DISPERZ..............................................89AFLURIA 2018-2019..............................................68AFLURIA QUAD 2018-2019................................. 68AFSTYLA............................................................... 62AGRYLIN................................................................66AIMSCO..................................................................92AIRDUO RESPICLICK............................................8AIRS DISPOSABLE NEBULIZER........................12AIRZONE PEAK FLOW METER..........................15AKTIPAK................................................................ 40AKYNZEO................................................................ 7ALBENDAZOLE.................................................... 74ALBENZA...............................................................74ALBUMEN (EGG WHITE)....................................92ALBUTEROL SULFATE......................................7, 8ALBUTEROL SULFATE (0.63MG/3ML) (VIAL-NEB)............................................................................

ALBUTEROL SULFATE (1.25MG/3ML) (VIAL-NEB)............................................................................ALBUTEROL SULFATE (2.5 MG/0.5) (VIAL-NEB)............................................................................ALBUTEROL SULFATE (2.5 MG/3ML) (VIAL-NEB)............................................................................ALBUTEROL SULFATE (5 MG/ML) (SOLUTION).....................................................................................ALBUTEROL SULFATE (90 MCG) (HFA AERAD)..............................................................................ALCLOMETASONE DIPROPIONATE................. 41ALCOHOL ANTISEPTIC PADS........................... 43ALCOHOL PADS................................................... 43ALDACTAZIDE (25 MG-25MG) (TABLET)........ 30ALDACTONE......................................................... 30ALDARA.................................................................69ALDOMET..............................................................28ALDORIL 15...........................................................28ALDORIL 25...........................................................28ALECENSA............................................................ 89ALECTINIB HCL................................................... 89ALENDRONATE SODIUM....................................56ALENDRONATE SODIUM/VITAMIN D3............56ALEVAZOL.............................................................40ALFERON N........................................................... 69ALFUZOSIN HCL................................................ 117ALITRETINOIN..................................................... 45ALKALINE BATTERIES....................................... 50ALKERAN.............................................................. 88ALLEGRA (30 MG/5 ML) (ORAL SUSP) (OTC)....5ALLEGRA ALLERGY (180 MG) (TABLET) (OTC)............................................................................... 5, 6ALLEGRA ALLERGY (60 MG) (TABLET) (OTC)................................................................................... 6ALLOPURINOL..................................................... 62ALOCRIL................................................................ 59ALOE VERA/COLLAGEN.................................... 43ALOE VESTA......................................................... 43ALOE VESTA CLEANSING................................. 43ALOE/LA/CERAMID/SILICONES/TAPE............ 43ALOE/LAC AC/CERAMIDES 3,3B,6,1................ 43ALOMIDE...............................................................59ALPHAGAN........................................................... 60ALPHAGAN P (0.1 %) (DROPS)...........................60ALPHAGAN P (0.15 %) (DROPS).........................60ALPHANATE..........................................................63ALPHANINE SD.................................................... 63ALPRAZOLAM...................................................... 20ALPRAZOLAM INTENSOL.....................................ALPROLIX..............................................................63ALREX.................................................................... 58ALTACE.................................................................. 27ALTERA NEBULIZER...........................................12


Index

ALTERNATE SITE LANCING DEVICE...............51ALTRENO............................................................... 39ALUMINUM HYDROXIDE................................ 115ALUMINUM HYDROXIDE (320 MG/5ML)(ORAL SUSP) (OTC)..................................................ALUPENT................................................................. 7AMANTADINE HCL............................................109AMARYL................................................................ 48AMBIEN..................................................................25AMBIEN CR........................................................... 25AMBRISENTAN.....................................................30AMCINONIDE........................................................41AMILORIDE HCL..................................................30AMILORIDE/HYDROCHLOROTHIAZIDE.........30AMINO AC/MULTIVIT-MIN/HERB 139............101AMINO AC/PROTEIN HYDR/WHEY PRO..........92AMINO ACID/PROTEIN/VIT C/ZINC..................92AMINO ACIDS/MV,TX,IRON,MINERAL..........120AMINO ACIDS/PROTEIN HYDR/FIBER............ 92AMINO ACIDS/PROTEIN HYDROLYS............... 92AMINO ACIDS/RICE PROTEIN/MV-MN.......... 101AMINOACETIC ACID........................................... 73AMINOCAPROIC ACID........................................ 62AMINOSALICYLIC ACID.................................... 73AMIODARONE HCL............................................. 26AMITIZA................................................................ 85AMITRIPTYLINE HCL......................................... 19AMITRIPTYLINE/CHLORDIAZEPOXIDE......... 19AMLODIPINE BESYLATE................................... 29AMLODIPINE BESYLATE/BENAZEPRIL.......... 27AMLODIPINE BESYLATE/VALSARTAN........... 27AMLODIPINE/ATORVASTATIN...........................33AMLODIPINE/VALSARTAN/HCTHIAZID......... 27AMMONIUM LACTATE........................................43AMMONIUM LACTATE (12 %) (CREAM (G)).......AMMONIUM LACTATE (12 %) (CREAM (G))(OTC)...........................................................................AMMONIUM LACTATE (12 %) (LOTION).............AMMONIUM LACTATE (12 %) (LOTION) (OTC).....................................................................................AMOXAPINE......................................................... 19AMOXICILLIN.......................................................71AMOXICILLIN/POTASSIUM CLAV.............. 71, 72AMOXIL................................................................. 71AMPICILLIN.......................................................... 72AMPICILLIN TRIHYDRATE................................ 72AMYL NITRITE..................................................... 33ANAFRANIL.......................................................... 19ANAGRELIDE HCL...............................................66ANA-LEX HC......................................................... 84ANALPRAM HC.................................................... 45ANALPRAM HC (1 %-1 %) (CREAM/APPL)...... 84ANALPRAM HC (2.5 %-1 %) (CREAM/APPL)....84

ANAMANTLE HC..................................................84ANAPROX.............................................................. 83ANAPROX DS........................................................ 83ANASTROZOLE.....................................................88ANCOBON..............................................................73ANDRODERM........................................................66ANDROGEL........................................................... 66ANDROID............................................................... 66ANIMAS VIBE....................................................... 53ANORO ELLIPTA.................................................... 8ANSAID.................................................................. 82ANTABUSE............................................................ 20ANTHRALIN.......................................................... 46ANTIHEM.FVIII,SIN-CHN,B-DM TRU............... 62ANTIHEMO.FVIII,FULL LENGTH PEG............. 62ANTIHEMOPH.FVIII REC,FC FUSION...............62ANTIHEMOPH.FVIII,B-DOM TRUNCAT........... 62ANTIHEMOPH.FVIII,B-DOMAIN DEL...............62ANTIHEMOPH.FVIII,HEK B-DELETE............... 62ANTIHEMOPHIL.FVIII,FULL LENGTH............. 63ANTIHEMOPHILIC FACTOR, HUM REC...........63ANTIHEMOPHILIC FACTOR, HUMAN..............63ANTIHEMOPHILIC FACTOR/VWF.....................63ANTIHEMOPHILIC FVIII,REC PORC.................63ANTI-INHIBITOR COAGULANT COMP.............63ANTISEPTIC WOUND-SKIN............................... 39ANUSOL-HC.......................................................... 84APALUTAMIDE..................................................... 88APEXICON E..........................................................42APIXABAN.............................................................63APLENZIN......................................................18, 125APRACLONIDINE HCL........................................ 60APREMILAST........................................................ 80APREPITANT........................................................... 7APRESOLINE.........................................................28APRISO................................................................... 84APTIOM (200 MG) (TABLET).................... 110, 125APTIOM (400 MG) (TABLET).................... 110, 125APTIOM (600 MG) (TABLET).................... 110, 125APTIOM (800 MG) (TABLET).................... 110, 125APTIVUS................................................................ 75AQUA GLYCOLIC............................................... 101AQUA LANCE LANCING DEVICE..................... 51AQUADEKS..........................................................121AQUA-E CONCENTRATE...................................124ARAVA.................................................................... 80ARCALYST.............................................................80ARICEPT.................................................................17ARICEPT ODT....................................................... 17ARIMIDEX............................................................. 88ARIPIPRAZOLE...............................................20, 21ARIPIPRAZOLE LAUROXIL................................ 21ARIPIPRAZOLE LAUROXIL,SUBMICR............. 21ARISTADA (1064MG/3.9) (SUSER SYR).............21


Index

ARISTADA (441 MG/1.6) (SUSER SYR)..............21ARISTADA (662 MG/2.4) (SUSER SYR)..............21ARISTADA (882 MG/3.2) (SUSER SYR)..............21ARISTADA INITIO................................................ 21ARIXTRA (10MG/0.8ML) (SYRINGE)................ 65ARIXTRA (2.5 MG/0.5) (SYRINGE).................... 65ARIXTRA (5MG/0.4ML) (SYRINGE).................. 65ARIXTRA (7.5MG/0.6) (SYRINGE)..................... 65ARMOUR THYROID.............................................57ARNUITY ELLIPTA................................................ 8AROMASIN............................................................ 88ARTANE................................................................109ASCORBIC ACID.................................................124ASCORBIC ACID (250 MG) (TAB CHEW) (OTC).....................................................................................ASCORBIC ACID (250 MG) (TABLET) (OTC).......ASCORBIC ACID (500 MG) (TAB CHEW) (OTC).....................................................................................ASCORBIC ACID (500 MG) (TABLET) (OTC).......ASCORBIC ACID (500 MG/ML) (VIAL).................ASCORBIC ACID (GRANULES) (OTC)..................ASENAPINE MALEATE........................................21ASENDIN................................................................19ASFOTASE ALFA.................................................. 97ASPIRIN..........................................................66, 103ASPIRIN (300 MG) (SUPP.RECT) (OTC).................ASPIRIN (325 MG) (TABLET DR) (OTC)................ASPIRIN (325 MG) (TABLET) (OTC).......................ASPIRIN (600 MG) (SUPP.RECT) (OTC).................ASPIRIN/ACETAMINOPHEN/CAFFEINE.........103ASPIRIN/CALCIUM CARBONATE/MAG......... 103ASPIRIN/CALCIUM CARBONATE/MAG (325MG) (TABLET) (OTC)...............................................ASTAGRAF XL...................................................... 69ASTELIN...................................................................6ASTHMA CHECK..................................................15ASTHMAPACK CHILDREN'S.............................. 15AT HOME A1C....................................................... 50ATARAX................................................................... 5ATAZANAVIR SULFATE.................................77, 78ATAZANAVIR SULFATE/COBICISTAT...............78ATENOLOL............................................................ 28ATENOLOL/CHLORTHALIDONE.......................29ATOMOXETINE HCL............................................26ATOPICLAIR.......................................................... 44ATORVASTATIN CALCIUM................................. 31ATOVAQUONE.......................................................74ATOVAQUONE/PROGUANIL HCL...................... 74ATRAPRO CP......................................................... 43ATRAPRO HYDROGEL........................................ 43ATRIPLA.................................................................78ATROPINE SULFATE............................................ 60ATROVENT.........................................................7, 91ATROVENT HFA......................................................7

AUBAGIO............................................................... 91AUGMENTIN (125-31.25/) (SUSP RECON)....71,126AUGMENTIN (200-28.5/5) (SUSP RECON)........ 71AUGMENTIN (200-28.5MG) (TAB CHEW).........71AUGMENTIN (250-125 MG) (TABLET).............. 71AUGMENTIN (250-62.5/5) (SUSP RECON)........ 71AUGMENTIN (400-57MG) (TAB CHEW)............71AUGMENTIN (400-57MG/5) (SUSP RECON)..... 71AUGMENTIN (500-125 MG) (TABLET).............. 72AUGMENTIN (875-125 MG) (TABLET).............. 72AUGMENTIN ES-600............................................ 72AUGMENTIN XR...................................................72AURANOFIN.......................................................... 81AUTOJECT 2.......................................................... 50AUTO-LANCET MINI........................................... 51AUTOLET IMPRESSION...................................... 52AUTOLET LANCING DEVICE.............................51AUTOLET PLUS.................................................... 51AUTOPEN............................................................... 50AVALIDE.................................................................27AVAPRO.................................................................. 28AVC....................................................................... 118AVEED.................................................................... 66AVELOX..................................................................72AVELOX ABC PACK............................................. 72AVIDOXY............................................................... 72AVODART.............................................................117AVONEX................................................................. 91AVONEX PEN.........................................................91AXID..................................................................... 116AXIRON..................................................................66AXITINIB................................................................89AYGESTIN..............................................................67AZATHIOPRINE.................................................... 69AZELASTINE HCL............................................6, 58AZILECT...............................................................109AZITHROMYCIN...................................................70AZOPT.................................................................... 60AZTREONAM LYSINE..........................................70AZULFIDINE..........................................................84

- B -B COMP NO3/FOLIC/C/BIOTIN/ZINC.............. 123B1,B2,B3,B6,B12/DEXPAN/ZN/MANG............. 119B12/LEVOMEFOLATE CALCIUM/B-6..............123BABY NEBULIZER............................................... 12BABY WASH.......................................................... 47BACITRACIN................................................... 39, 59BACITRACIN (500 UNIT/G) (OINT. (G)) (OTC).....BACITRACIN (500 UNIT/G) (PACKET) (OTC).......BACITRACIN ZINC............................................... 39BACITRACIN ZINC (500 UNIT/G) (OINT. (G))(OTC)...........................................................................


Index

BACITRACIN ZINC (500 UNIT/G) (PACKET)(OTC)...........................................................................BACITRACIN/POLYMYXIN B SULFATE........... 59BACLOFEN...........................................................114BACTERIOSTATIC SODIUM CHLORIDE.......... 55BACTROBAN......................................................... 40BACTROBAN NASAL........................................... 91BALANCED SALT SOLN NON-SURG 6............. 62BALCOLTRA..........................................................35BALNEOL...............................................................44BALOXAVIR MARBOXIL.................................... 74BALSALAZIDE DISODIUM.................................84BALSAM PERU/CASTOR OIL........................... 102BANZEL (200 MG) (TABLET).................... 112, 126BANZEL (40 MG/ML) (ORAL SUSP)........ 113, 126BANZEL (400 MG) (TABLET).................... 113, 126BARACLUDE (0.05 MG/ML) (SOLUTION)........ 79BARACLUDE (0.5 MG) (TABLET)...................... 79BARACLUDE (1 MG) (TABLET)......................... 79BASAGLAR KWIKPEN U-100............................. 53BAYER CHEWABLE ASPIRIN............................. 66BCAD 1................................................................... 97BCAD 2................................................................. 100B-COMPLEX WITH VITAMIN C....................... 120B-COMPLEX WITH VITAMIN C (TABLET)(OTC)...........................................................................BECAPLERMIN..................................................... 53BECLOMETHASONE DIPROPIONATE................ 6BEDAQUILINE FUMARATE................................ 73BELSOMRA....................................................25, 126BENADRYL (25 MG) (TABLET) (OTC)...............24BENAZEPRIL HCL................................................ 27BENAZEPRIL/HYDROCHLOROTHIAZIDE....... 27BENEFIX................................................................ 63BENEMID............................................................... 62BENICAR................................................................28BENICAR HCT.......................................................27BENOXINATE HCL/FLUORESCEIN SOD.... 58, 59BENZACLIN (1 %-5 %) (GEL (GRAM)).............. 38BENZALKONIUM CHLORIDE............................ 39BENZAMYCIN.......................................................40BENZETHONIUM CHLORIDE................ 39, 45, 46BENZOIN................................................................45BENZONATATE..................................................... 36BENZOYL PEROXIDE.......................................... 44BENZOYL PEROXIDE (10 %) (GEL (GRAM))(OTC)...........................................................................BENZOYL PEROXIDE (5 %) (GEL (GRAM))(OTC)...........................................................................BENZOYL PEROXIDE/HYDROCORTISON....... 38BENZTROPINE MESYLATE.............................. 109BERINERT.............................................................. 80BESIFLOXACIN HCL............................................59BESIVANCE........................................................... 59

BETAGAN...............................................................60BETAINE.................................................................97BETAMETHASONE DIPROPIONATE................. 41BETAMETHASONE VALERATE......................... 41BETAMETHASONE/PROPYLENE GLYC........... 41BETAXOLOL HCL...........................................28, 60BETHANECHOL CHLORIDE...............................87BETOPTIC.............................................................. 60BEXAROTENE................................................. 45, 91BEXSERO............................................................... 68BEYAZ.................................................................... 35BIAFINE..................................................................43BIAXIN................................................................... 71BIAXIN XL............................................................. 71BICALUTAMIDE................................................... 88BICILLIN L-A.........................................................72BICTEGRAV/EMTRICIT/TENOFOV ALA.......... 79BIDIL.......................................................................31BIKTARVY............................................................. 79BILTRICIDE........................................................... 74BIMATOPROST......................................................60BINIMETINIB........................................................ 89BIOCEL.................................................................119BIONECT (0.2 %) (CREAM (G))...........................45BIONECT (0.2 %) (GEL (GRAM))........................45BIOTIN..................................................................123BIOTIN (300 MCG) (TABLET) (OTC)......................BIOTIN (5 MG) (CAPSULE) (OTC)..........................BIOTIN (5 MG) (TABLET) (OTC).............................BISAC/NACL/NAHCO3/KCL/PEG 3350.............. 85BISACODYL.....................................................85, 87BISMUTH SUBSALICYLATE.............................. 84BISMUTH SUBSALICYLATE (262 MG) (TABCHEW) (OTC).............................................................BISMUTH SUBSALICYLATE (262MG/15ML)(ORAL SUSP) (OTC)..................................................BISOPROLOL FUMARATE.................................. 28BISOPROLOL/HYDROCHLOROTHIAZIDE.......29BLEPHAMIDE........................................................59BLEPHAMIDE S.O.P..............................................59BLOCADREN.........................................................29BLOOD KETONE TEST, STRIPS......................... 91BLOOD SUGAR DIAGNOSTIC............................49BLOOD-GLUCOSE METER........................... 49, 50B-NEXA................................................................ 123BONIVA.................................................................. 56BOOST.................................................................... 93BOOST BREEZE.................................................... 93BOOST CALORIE SMART................................... 93BOOST GLUCOSE CONTROL............................. 99BOOST HIGH PROTEIN..................................93, 96BOOST KID ESSENTIALS....................................96BOOST KID ESSENTIALS-FIBER.......................95BOOST PLUS......................................................... 93


Index

BOOST VHC...........................................................94BOOSTRIX TDAP.................................................. 68BOSENTAN............................................................ 30BOSULIF (100 MG) (TABLET).............................89BOSULIF (400 MG) (TABLET).............................89BOSULIF (500 MG) (TABLET).............................89BOSUTINIB............................................................ 89BRAFTOVI..............................................................88BREATHE RIGHT.................................................. 12BREATHERITE...................................................... 10BREATHERITE SPACER-ADULT MASK............11BREATHERITE SPACER-INFANT MASK...........10BREATHERITE SPACER-LG CHLD MSK...........12BREATHERITE SPACER-NEONATE MSK..........10BREATHERITE SPACER-SM CHLD MSK.......... 10BREATHRITE.........................................................10BREO ELLIPTA........................................................8BRILINTA............................................................... 66BRIMONIDINE TARTRATE..................................60BRIMONIDINE TARTRATE/TIMOLOL...............60BRINZOLAMIDE...................................................60BRINZOLAMIDE/BRIMONIDINE TART............ 60BRISDELLE....................................................18, 126BROMOCRIPTINE MESYLATE.........................109BROMPHENIRA/PSEUDOEPHED/CODEIN.......37BROMPHENIRAM/PHENYLEPHRINE/DM....... 37BROMPHENIRAM/PHENYLEPHRINE/DM (1-2.5-5/5) (SOLUTION) (OTC).....................................BROMPHENIRAMINE/PHENYLEPHRINE........ 36BROMPHENIRAMINE/PHENYLEPHRINE (1-2.5MG/5) (SOLUTION) (OTC).......................................BROMPHENIRAMINE/PSEUDOEPHED/DM..... 37BROMPHENIRAMINE/PSEUDOEPHED/DM (1-15-5MG/5) (ELIXIR) (OTC).......................................BUDESONIDE....................................................8, 80BUMETANIDE................................................. 29, 30BUMEX (0.5 MG) (TABLET)................................ 29BUMEX (1 MG) (TABLET)................................... 29BUMEX (2 MG) (TABLET)................................... 30BUNAVAIL (2.1-0.3 MG) (FILM)........................ 108BUNAVAIL (4.2-0.7 MG) (FILM)........................ 108BUNAVAIL (6.3MG-1MG) (FILM)......................108BUPHENYL............................................................ 84BUPRENORPHINE.............................................. 104BUPRENORPHINE HCL............................. 104, 108BUPRENORPHINE HCL/NALOXONE HCL..... 108BUPRENORPHINE HCL/NALOXONE HCL (12MG-3 MG) (FILM)......................................................BUPRENORPHINE HCL/NALOXONE HCL (2MG-0.5MG) (FILM)....................................................BUPRENORPHINE HCL/NALOXONE HCL (2MG-0.5MG) (TAB SUBL)..........................................BUPRENORPHINE HCL/NALOXONE HCL(4MG-1MG) (FILM)...................................................

BUPRENORPHINE HCL/NALOXONE HCL (8MG-2 MG) (FILM)......................................................BUPRENORPHINE HCL/NALOXONE HCL (8MG-2 MG) (TAB SUBL)............................................BUPROPION HBR..................................................18BUPROPION HCL..........................................18, 114BUPROPION HCL (100 MG) (TAB SR 12H)............BUPROPION HCL (100 MG) (TABLET)..................BUPROPION HCL (150 MG) (TAB ER 24H)...........BUPROPION HCL (150 MG) (TAB SR 12H)............BUPROPION HCL (200 MG) (TAB ER 12H)...........BUPROPION HCL (200 MG) (TAB SR 12H)............BUPROPION HCL (300 MG) (TAB ER 24H)...........BUPROPION HCL (75 MG) (TABLET)....................BUSPAR.................................................................. 20BUSPIRONE HCL.................................................. 20BUSULFAN.............................................................87BUTABARBITAL SODIUM...................................24BUTALB/ACETAMINOPHEN/CAFFEINE........ 103BUTALBIT/ACETAMIN/CAFF/CODEINE........ 107BUTALBITAL/ACETAMINOPHEN.................... 103BUTALBITAL/ACETAMINOPHEN (50MG-325MG) (TABLET).....................................................BUTALBITAL/ASPIRIN/CAFFEINE.................. 103BUTISOL SODIUM................................................24BUTOCONAZOLE NITRATE............................. 118BUTORPHANOL TARTRATE.............................104BUTRANS.............................................................104BYSTOLIC..............................................................28BYVALSON............................................................ 27

- C -C1 ESTERASE INHIBITOR...................................80C1 ESTERASE INHIBITOR, RECOMB................80CABERGOLINE..................................................... 57CABOMETYX........................................................ 89CABOZANTINIB S-MALATE...............................89CADUET................................................................. 33CAFCIT................................................................... 16CAFERGOT.......................................................... 106CAFFEINE CITRATE.............................................16CALAN....................................................................29CALAN SR..............................................................29CALCIPOTRIENE.................................................. 46CALCIPOTRIENE/BETAMETHASONE.............. 47CALCITONIN,SALMON,SYNTHETIC................56CALCITRIOL..................................................46, 124CALCIUM ACETATE.............................................54CALCIUM ACETATE/ALUMINUM SULF.......... 46CALCIUM ACETATE/ALUMINUM SULF (952-1347MG) (POWD PACK) (OTC)................................CALCIUM CARB/MAG CARB/FOLIC AC..........54CALCIUM CARB/MAGNESIUM HYDROX......115CALCIUM CARB/MAGNESIUM HYDROX (700-300MG) (TAB CHEW) (OTC)....................................


Index

CALCIUM CARB/SOD HYPOCHLORITE.......... 46CALCIUM CARBONATE.................... 115, 118, 119CALCIUM CARBONATE (200(500)MG) (TABCHEW) (OTC).............................................................CALCIUM CARBONATE (215(500)MG) (TABCHEW) (OTC).............................................................CALCIUM CARBONATE (260MG(648))(TABLET) (OTC)........................................................CALCIUM CARBONATE (300MG(750)) (TABCHEW) (OTC).............................................................CALCIUM CARBONATE (320MG(750)) (TABCHEW) (OTC).............................................................CALCIUM CARBONATE (400(1000)) (TABCHEW) (OTC).............................................................CALCIUM CARBONATE (500 MG/5ML) (ORALSUSP) (OTC)...............................................................CALCIUM CARBONATE (500(1250)) (TABLET)(OTC)...........................................................................CALCIUM CARBONATE (600 MG) (TABLET)(OTC)...........................................................................CALCIUM CARBONATE/MAG CARB................54CALCIUM CARBONATE/VITAMIN D3............ 119CALCIUM CARBONATE/VITAMIN D3 (500 MG-100) (TAB CHEW) (OTC)..........................................CALCIUM CARBONATE/VITAMIN D3 (500 MG-200) (TABLET) (OTC)................................................CALCIUM CARBONATE/VITAMIN D3 (500 MG-400) (TAB CHEW) (OTC)..........................................CALCIUM CARBONATE/VITAMIN D3 (500 MG-400) (TABLET) (OTC)................................................CALCIUM CARBONATE/VITAMIN D3 (600 MG-200) (TABLET) (OTC)................................................CALCIUM CARBONATE/VITAMIN D3 (600 MG-400) (TABLET) (OTC)................................................CALCIUM CITRATE........................................... 119CALCIUM CITRATE (200(950)MG) (TABLET)(OTC)...........................................................................CALCIUM CITRATE/VITAMIN D3................... 119CALCIUM CITRATE/VITAMIN D3 (315 MG-250)(TABLET) (OTC)........................................................CALCIUM GLUCONATE.................................... 119CALCIUM GLUCONATE (45(500) MG) (TABLET)(OTC)...........................................................................CALCIUM POLYCARBOPHIL............................. 85CALCIUM POLYCARBOPHIL (625 MG)(TABLET) (OTC)........................................................CALCIUM/MAG/D3/B12/FA/B6/BORON.......... 119CALCIUM/MAG/D3/B12/FA/B6/BORON (500-1.1MG) (TABLET)......................................................CALORIC SUPPLEMENT..................................... 92CANAGLIFLOZIN................................................. 47CANAGLIFLOZIN/METFORMIN HCL............... 48CANASA................................................................. 83CANNABIDIOL (CBD) EXTRACT.....................110

CAPECITABINE.....................................................88CAPOZIDE..............................................................27CAPRELSA (100 MG) (TABLET)......................... 90CAPRELSA (300 MG) (TABLET)......................... 90CAPSAICIN............................................................ 44CAPSAICIN (0.025 %) (ADH. PATCH) (OTC).........CAPSAICIN (0.025 %) (CREAM (G)) (OTC)...........CAPSAICIN (0.033 %) (CREAM (G)) (OTC)...........CAPSAICIN (0.075 %) (CREAM (G)) (OTC)...........CAPSAICIN (0.1 %) (CREAM (G)) (OTC)...............CAPSAICIN (0.15 %) (LIQUID) (OTC)....................CAPTOPRIL/HYDROCHLOROTHIAZIDE..........27CARAFATE (1 G) (TABLET)...............................116CARAFATE (1 G/10 ML) (ORAL SUSP)............ 116CARBAGLU............................................................84CARBAMAZEPINE....................................... 20, 110CARBAMAZEPINE (100 MG) (CPMP 12HR).........CARBAMAZEPINE (100 MG) (TAB CHEW)..........CARBAMAZEPINE (100 MG) (TAB ER 12H).........CARBAMAZEPINE (100 MG/5ML) (ORAL SUSP).....................................................................................CARBAMAZEPINE (200 MG) (CPMP 12HR).........CARBAMAZEPINE (200 MG) (TAB ER 12H).........CARBAMAZEPINE (200 MG) (TABLET)................CARBAMAZEPINE (300 MG) (CPMP 12HR).........CARBAMAZEPINE (400 MG) (TAB ER 12H).........CARBATROL (300 MG) (CPMP 12HR)..............110CARBIDOPA.........................................................109CARBIDOPA/LEVODOPA.................................. 109CARBIDOPA/LEVODOPA/ENTACAPONE....... 109CARBINOXAMINE MALEATE..............................4CARBIT/EQUIS XT/ETHAN/CHIT/MSM............45CARBOMER/POLYSORBATES..........................102CARBOXYMETHYL/GLY/POLY80/PF................60CARBOXYMETHYL/GLYCERIN/POLY80......... 60CARBOXYMETHYLCELL/GLYCERIN/PF.........61CARBOXYMETHYLCELLULOSE SODIUM......61CARBOXYMETHYLCELLULOSE SODIUM (0.5%) (DROPERETTE) (OTC)........................................CARBOXYMETHYLCELLULOSE SODIUM (0.5%) (DROPS) (OTC).....................................................CARDIZEM (120 MG) (TABLET).........................29CARDIZEM (30 MG) (TABLET)...........................29CARDIZEM (60 MG) (TABLET)...........................29CARDIZEM (90 MG) (TABLET)...........................29CARDIZEM CD......................................................29CARDIZEM SR.......................................................29CARDURA..............................................................27CARELANCE ULT LANCING DEVICE.............. 51CAREONE.............................................................. 51CARESENS PREM LANCING DEVICE.............. 51CARETOUCH LANCING DEVICE...................... 51CARGLUMIC ACID...............................................84CARISOPRODOL.................................................114


Index

CARISOPRODOL/ASPIRIN................................ 114CARISOPRODOL/ASPIRIN/CODEINE............. 104CARMUSTINE IN POLIFEPROSAN 20...............88CARNITOR............................................................. 97CARTEOLOL HCL.................................................60CARVEDILOL........................................................ 27CARVEDILOL PHOSPHATE................................ 27CASODEX.............................................................. 88CASTELLANI PAINT MODIFIED........................43CATAFLAM............................................................ 82CATAPRES..............................................................28CATAPRES-TTS 1.................................................. 28CATAPRES-TTS 2.................................................. 28CATAPRES-TTS 3.................................................. 28CAYA CONTOURED............................................. 36CAYSTON...............................................................70CECLOR..................................................................70CECLOR CD........................................................... 70CEFACLOR.............................................................70CEFADROXIL.........................................................70CEFDINIR...............................................................70CEFDITOREN PIVOXIL........................................70CEFIXIME.............................................................. 70CEFPODOXIME PROXETIL................................. 70CEFPROZIL............................................................ 70CEFTIN................................................................... 70CEFUROXIME AXETIL........................................ 70CEFZIL....................................................................70CELEBREX.............................................................82CELECOXIB........................................................... 82CELEXA..................................................................18CELLCEPT..............................................................69CELLULOSE GUM.............................................. 102CELONTIN........................................................... 112CENTANY...............................................................40CEPHALEXIN........................................................ 70CERDELGA............................................................ 96CERITINIB..............................................................89CERTOLIZUMAB PEGOL.................................... 80CERVICAL CAP.....................................................36CETAKLENZ.......................................................... 47CETAPHIL.............................................................. 47CETIRIZINE HCL.................................................... 5CETIRIZINE HCL/PSEUDOEPHEDRINE............. 4CETRAXAL............................................................ 54CHANTIX............................................................. 114CHEMSTRIP BG DIARY.......................................50CHILDREN'S ADVIL (100 MG/5ML) (ORALSUSP) (OTC)...........................................................82CHILDREN'S CLARITIN (5 MG/5 ML)(SOLUTION) (OTC)................................................. 6CHILDREN'S DELSYM COUGH (30 MG/5 ML)(SUS ER 12H) (OTC)..............................................36CHILDREN'S FLONASE ALLERGY RLF............. 6

CHILDREN'S MOTRIN (100 MG/5ML) (ORALSUSP) (OTC)...........................................................82CHILDREN'S ZYRTEC (1 MG/ML) (SOLUTION)(OTC).........................................................................5CHILDREN'S ZYRTEC (5 MG/5 ML)(SOLUTION) (OTC)................................................. 5CHLORAMBUCIL................................................. 88CHLORDIAZEPOXIDE HCL................................ 20CHLORDIAZEPOXIDE/CLIDINIUM BR.......... 116CHLORHEXIDINE GLUCONATE........................91CHLOROQUINE PHOSPHATE............................. 74CHLOROTHIAZIDE...............................................30CHLOROXYLENOL.............................................. 39CHLORPHENIRAMIN/PSEUDOEPHED/DM......37CHLORPHENIRAMINE MALEATE.......................4CHLORPHENIRAMINE/DEXTROMETHORP....37CHLORPHENIRAMINE/DEXTROMETHORP (4MG-30 MG) (TABLET) (OTC)...................................CHLORPHENIRAMINE/PHENYLEPHRINE...... 36CHLORPHENIRAMINE/PHENYLEPHRINE(1MG-2MG/ML) (DROPS).........................................CHLORPHENIRAMINE/PHENYLEPHRINE(4MG-10MG) (TABLET) (OTC)................................CHLORPHENIRAMINE/PSEUDOEPHED...........36CHLORPHENIRAMINE/PSEUDOEPHED (4 MG-60 MG) (TABLET) (OTC)..........................................CHLORPROMAZINE HCL....................................24CHLORPROPAMIDE............................................. 48CHLORTHALIDONE.............................................30CHLOR-TRIMETON (2 MG/5 ML) (SYRUP)(OTC).........................................................................4CHLOR-TRIMETON (4 MG) (TABLET) (OTC).....4CHLOR-TRIMETON ALLERGY............................ 4CHLORZOXAZONE............................................ 114CHLORZOXAZONE (500 MG) (TABLET)..............CHOLECALCIFEROL (VITAMIN D3)............... 124CHOLECALCIFEROL (VITAMIN D3) (1000UNIT) (TABLET) (OTC)............................................CHOLECALCIFEROL (VITAMIN D3) (2000UNIT) (CAPSULE) (OTC).........................................CHOLECALCIFEROL (VITAMIN D3) (400/ML)(DROPS) (OTC)..........................................................CHOLESTYRAMINE (WITH SUGAR)................ 32CHOLESTYRAMINE/ASPARTAME.................... 32CHOLINE SALICYL/MAG SALICYLATE........ 103CHORIONIC GONADOTROPIN...........................55CHORIONIC GONADOTROPIN, HUMAN..........55CHRONULAC...................................................84, 85CIALIS (2.5 MG) (TABLET)..................................55CIALIS (5 MG) (TABLET).....................................55CICLODAN.............................................................40CICLOPIROX..........................................................40CICLOPIROX OLAMINE...................................... 40CICLOPIROX/UREA/CAMPH/MEN/EUC........... 40


Index

CILOSTAZOL......................................................... 66CILOXAN (0.3 %) (DROPS).................................. 59CILOXAN (0.3 %) (OINT. (G)).............................. 59CIMDUO................................................................. 75CIMETIDINE........................................................ 116CIMZIA................................................................... 80CINACALCET HCL............................................... 56CINRYZE................................................................ 80CIPRO......................................................................72CIPRO XR............................................................... 72CIPRODEX............................................................. 54CIPROFLOXACIN..................................................72CIPROFLOXACIN HCL.............................54, 59, 72CIPROFLOXACIN HCL/DEXAMETH................. 54CIPROFLOXACIN/CIPROFLOXA HCL...............72CITALOPRAM HYDROBROMIDE...................... 18CITRANATAL HARMONY................................. 122CITRATE PHOSPHATE DEXTROS SOLN.......... 63CITRIC ACID/SODIUM CITRATE..................... 117CITRIC ACID/SODIUM CITRATE (334-500MG)(SOLUTION) (OTC)...................................................CITRUCEL (500 MG) (TABLET) (OTC)...............85CLARINEX (5 MG) (TABLET)............................... 5CLARITHROMYCIN............................................. 71CLARITIN (10 MG) (CAPSULE) (OTC).................6CLARITIN (10 MG) (TABLET) (OTC)................... 6CLARITIN (5 MG/5 ML) (SOLUTION) (OTC)...... 6CLARITIN-D 12 HOUR (5 MG-120MG) (TAB ER12H) (OTC)................................................................4CLARITIN-D 24 HOUR (10MG-240MG) (TAB ER24H) (OTC)................................................................4CLEANSING EYELID PADS................................ 62CLEANSING EYELID WIPES.............................. 62CLEMASTINE FUMARATE................................... 4CLENPIQ................................................................ 87CLEOCIN (2 %) (CREAM/APPL)....................... 118CLEOCIN HCL....................................................... 73CLEOCIN PALMITATE..........................................73CLEOCIN T.............................................................39CLEVER CHOICE HOLDING CHAMBER.....10-12CLEVER CHOICE NEBULIZER...........................13CLEVER CHOICE WHISPER AIRE PED............ 14CLIMARA...............................................................67CLINDACIN ETZ................................................... 39CLINDACIN P........................................................ 39CLINDAMYCIN HCL............................................ 73CLINDAMYCIN PALMITATE HCL......................73CLINDAMYCIN PHOS/BENZOYL PEROX........ 38CLINDAMYCIN PHOSPHATE..................... 39, 118CLINORIL...............................................................83CLISTIN (4 MG) (TABLET).................................... 4CLISTIN (4 MG/5 ML) (LIQUID)........................... 4CLOBAZAM......................................................... 109CLOBETASOL PROPIONATE...............................41

CLOBETASOL PROPIONATE/EMOLL................41CLOBEX................................................................. 41CLOCORTOLONE PIVALATE..............................41CLODAN.................................................................41CLODERM..............................................................41CLOMIPHENE CITRATE...................................... 55CLOMIPRAMINE HCL......................................... 19CLONAZEPAM.....................................................109CLONIDINE............................................................28CLONIDINE HCL.............................................25, 28CLOPIDOGREL BISULFATE................................66CLOPIDOGREL BISULFATE (300 MG) (TABLET).....................................................................................CLOPIDOGREL BISULFATE (75 MG) (TABLET).....................................................................................CLORAZEPATE DIPOTASSIUM.......................... 20CLOTRIMAZOLE.................................... 40, 73, 118CLOTRIMAZOLE (1 %) (CREAM (G))....................CLOTRIMAZOLE (1 %) (CREAM (G)) (OTC)........CLOTRIMAZOLE (1 %) (SOLUTION).....................CLOTRIMAZOLE/BETAMETHASONE DIP....... 40CLOZAPINE........................................................... 21CLOZARIL..............................................................21COAGADEX........................................................... 64COAGULATION FACTOR VIIA,RECOMB......... 63COAGULATION FACTOR X.................................64COBICISTAT...........................................................79COBIMETINIB FUMARATE.................................89CODEINE..............................................................104CODEINE SULFATE............................................ 104CODEINE/BUTALBITAL/ASA/CAFFEIN......... 107COGENTIN...........................................................109COLACE 2-IN-1 (8.6MG-50MG) (TABLET) (OTC)................................................................................. 87COLAZAL...............................................................84COLCHICINE......................................................... 62COLCRYS............................................................... 62COLEMAN BOTANICALS INSECT REP............ 39COLEMAN SKINSMART INSECT REP.............. 39COLESEVELAM HCL........................................... 32COLESTID (1 G) (TABLET)..................................32COLESTID (5 G) (GRANULES)........................... 32COLESTID (5 G) (PACKET)..................................32COLESTIPOL HCL................................................ 32COLLAGEN,BOVINE............................................ 47COLYTE WITH FLAVOR PACKETS.................... 85COMBIGAN............................................................60COMBIPATCH........................................................67COMBIVENT RESPIMAT....................................... 8COMBIVIR............................................................. 75COMETRIQ............................................................ 89COMFORT.............................................................. 50COMPACT COMPRESSOR NEBULIZER............13COMPACT SPACE CHAMBER....................... 10-12


Index

COMPACT SPACE CHAMBER PLUS.................. 10COMPACT ULTRASONIC NEBULIZER............. 13COMP-AIR NEBULIZER COMPRESSOR........... 14COMPAZINE............................................................ 7COMPLEAT ORGANIC BLEND CHICKEN........95COMPLEAT ORGANIC BLENDS PLANT...........95COMPLEAT PED ORG BLEND CHICKEN......... 95COMPLEAT PED ORG BLENDS PLANT............95COMPLEAT PEDIATRIC.......................................95COMPLERA............................................................79COMPRESSOR, FOR NEBULIZER........................9COMTAN.............................................................. 109COMTREX COLD-COUGH NIGHTTIME (10-5-325-2) (TABLET) (OTC).........................................37CONCEPT DHA................................................... 122CONCEPT OB.......................................................122CONCEPTROL....................................................... 34CONDOMS............................................................. 92CONDOMS, FEMALE........................................... 92CONDOMS, LATEX, LUBRICATED....................92CONDOMS, LATEX, NON-LUBRICATED..........92CONDOMS, NON-LATEX, LUBRICATED..........92CONDYLOX (0.5 %) (GEL (GRAM))........... 44, 126CONDYLOX (0.5 %) (SOLUTION).......................44CONZIP (150 MG) (CPBP 25-75)................ 106, 126COOL MIST..............................................................9COOL MIST HUMIDIFIER..................................... 9COPAXONE............................................................91COPPER.................................................................. 97CORDARONE.........................................................26CORDRAN (0.05 %) (CREAM (G))...................... 42CORDRAN (0.05 %) (LOTION)............................ 42CORDRAN (0.05 %) (OINT. (G)).......................... 42CORDRAN (4MCG/SQ CM) (MED. TAPE)....42,126COREG....................................................................27COREG CR............................................................. 27CORIFACT.............................................................. 63CORN STARCH....................................................102CORRECTOL (5 MG) (TABLET) (OTC).............. 85CORTEF.................................................................. 81CORTENEMA.........................................................84CORTISONE ACETATE.........................................80CORTISPORIN....................................................... 41CORTONE...............................................................80CORZIDE................................................................ 29COSENTYX (2 SYRINGES)..................................46COSENTYX PEN................................................... 46COSENTYX PEN (2 PENS)................................... 46COSENTYX SYRINGE..........................................46COSOPT (22.3-6.8/1) (DROPS)............................. 60COTELLIC.............................................................. 89COVARYX...............................................................67COVARYX H.S....................................................... 67

COZAAR.................................................................28CREAM BASE NO.126........................................ 101CREON..................................................................115CRESTOR (10 MG) (TABLET)..............................31CRESTOR (20 MG) (TABLET)..............................31CRESTOR (40 MG) (TABLET)..............................31CRESTOR (5 MG) (TABLET)................................31CRINONE................................................................55CRIXIVAN.............................................................. 78CRIZOTINIB...........................................................89CROMOLYN SODIUM.................................. 6, 9, 59CUTIVATE (0.005 %) (OINT. (G)).........................42CUTIVATE (0.05 %) (CREAM (G)).......................42CUVITRU................................................................67CYANOCOBALAMIN (VITAMIN B-12)............124CYANOCOBALAMIN (VITAMIN B-12) (1000MCG) (TABLET) (OTC).............................................CYANOCOBALAMIN (VITAMIN B-12)(1000MCG/ML) (VIAL).............................................CYANOCOBALAMIN (VITAMIN B-12) (500MCG) (TABLET) (OTC).............................................CYCLESSA.............................................................35CYCLOBENZAPRINE HCL................................114CYCLOCORT......................................................... 41CYCLOGYL............................................................60CYCLOPENTOLATE HCL.................................... 60CYCLOPHOSPHAMIDE....................................... 88CYCLOSERINE......................................................73CYCLOSPORINE................................................... 69CYCLOSPORINE, MODIFIED..............................69CYPROHEPTADINE HCL....................................... 4CYSTADANE..........................................................97CYSTARAN............................................................ 62CYSTEAMINE BITARTRATE.............................117CYSTEAMINE HCL...............................................62CYTOTEC............................................................. 116

- D -D.H.E.45................................................................ 106DABRAFENIB MESYLATE.................................. 88DALIRESP........................................................ 9, 126DALTEPARIN SODIUM,PORCINE...................... 64DANAZOL.............................................................. 57DANOCRINE..........................................................57DANTRIUM..........................................................114DANTROLENE SODIUM.................................... 114DAPSONE............................................................... 73DARAPRIM............................................................ 74DARUNAVIR ETHANOLATE............................... 75DARUNAVIR/COB/EMTRI/TENOF ALAF.......... 74DARUNAVIR/COBICISTAT.................................. 75DASATINIB............................................................ 89DAURISMO............................................................ 88DAYPRO..................................................................83DDAVP.................................................................... 56


Index

DECLOMYCIN.......................................................72DEFERASIROX...................................................... 97DEFERIPRONE...................................................... 98DEFEROXAMINE MESYLATE............................ 98DEGARELIX ACETATE........................................ 89DEKAS ESSENTIAL............................................121DEKAS PLUS....................................................... 121DELATESTRYL......................................................66DELAVIRDINE MESYLATE.................................75DELESTROGEN (20 MG/ML) (VIAL)................. 67DELESTROGEN (40 MG/ML) (VIAL)................. 67DELFEN.................................................................. 34DELSTRIGO........................................................... 78DELSYM (30 MG/5 ML) (SUS ER 12H) (OTC)....36DEMADEX............................................................. 30DEMECLOCYCLINE HCL....................................72DEMEROL (10 MG/ML) (CARTRIDGE)............105DEMEROL (100 MG/ML) (VIAL).......................105DEMEROL (25 MG/ML) (VIAL).........................105DEMEROL (50 MG/ML) (VIAL).........................105DEMULEN..............................................................35DEMULEN 1-50-21................................................ 35DENTAL SUCTION/CHLRHEX/SWB1/MW....... 91DENTL SUCTION DEV/CHLORHX/SWB1........ 91DEPAKOTE (250 MG) (TABLET DR).................110DEPAKOTE (500 MG) (TABLET DR).................110DEPEN.................................................................... 79DEPO-ESTRADIOL............................................... 67DEPO-PROVERA................................................... 34DEPO-SUBQ PROVERA 104.................................34DEPO-TESTOSTERONE....................................... 66DERMABASE.......................................................101DERMAL WOUND CLEANSER.......................... 46DERMAPLEX.........................................................43DERMA-SMOOTHE-FS.........................................42DERMATOP............................................................43DERMAZENE.........................................................39DERMOTIC.............................................................54DERMULCERA....................................................102DESCOVY...............................................................75DESFERAL............................................................. 98DESFERAL MESYLATE....................................... 98DESIPRAMINE HCL............................................. 19DESLORATADINE...................................................5DESMOPRESSIN (NONREFRIGERATED)......... 56DESMOPRESSIN ACETATE................................. 56DESOG-E.ESTRADIOL/E.ESTRADIOL.............. 35DESOGEN...............................................................35DESOGESTREL-ETHINYL ESTRADIOL........... 35DESONIDE............................................................. 41DESOXIMETASONE............................................. 41DESOXYN.............................................................. 20DESVENLAFAXINE..............................................18

DESVENLAFAXINE ER......................................126DESVENLAFAXINE FUMARATE....................... 18DESVENLAFAXINE FUMARATE ER............... 126DESVENLAFAXINE SUCCINATE....................... 18DESYREL............................................................... 18DETROL........................................................118, 126DEVILBISS COMPACT........................................... 9DEVILBISS DISPOSABLE NEBULIZER............ 13DEVILBISS PULMO-AIDE..................................... 9DEVILBISS PULMOMATE..................................... 9DEVILBISS PULMONEB LT COMP-NEB...........14DEVILBISS TRAVELER........................................14DEVILBLISS............................................................ 9DEXAMETHASONE........................................80, 81DEXAMETHASONE (0.5 MG) (TABLET)...............DEXAMETHASONE (0.5 MG/5ML) (ELIXIR)........DEXAMETHASONE (0.5 MG/5ML) (SOLUTION).....................................................................................DEXAMETHASONE (0.75 MG) (TABLET).............DEXAMETHASONE (1 MG) (TABLET)..................DEXAMETHASONE (1.5 MG) (TABLET)...............DEXAMETHASONE (1.5MG (21)) (TAB DS PK)............................................................................... 126DEXAMETHASONE (1.5MG (35)) (TAB DS PK)............................................................................... 126DEXAMETHASONE (1.5MG (51)) (TAB DS PK)............................................................................... 126DEXAMETHASONE (2 MG) (TABLET)..................DEXAMETHASONE (4 MG) (TABLET)..................DEXAMETHASONE (6 MG) (TABLET)..................DEXAMETHASONE SODIUM PHOSPHATE..... 58DEXEDRINE (10 MG) (CAPSULE ER)................19DEXEDRINE (10 MG) (TABLET).........................19DEXEDRINE (15 MG) (CAPSULE ER)................19DEXEDRINE (5 MG) (CAPSULE ER)..................19DEXEDRINE (5 MG) (TABLET)...........................19DEXMETHYLPHENIDATE HCL..........................25DEXTRAN 70/HYPROMELLOSE........................ 61DEXTRAN 70/HYPROMELLOSE (0.1%-0.3%)(DROPS) (OTC)..........................................................DEXTRAN 70/HYPROMELLOSE/PF...................61DEXTRAN/HYPROMELLOSE/GLYCERIN........ 61DEXTROAMPHETAMINE SULFATE.................. 19DEXTROAMPHETAMINE/AMPHETAMINE....19,20DEXTROMETHORPHAN POLISTIREX..............36DEXTROSE.............................................................53DEXTROSE (4 G) (TAB CHEW) (OTC)...................DIABETIC SUPPLIES,MISCELL..........................50DIABETISHIELD................................................... 99DIABETISOURCE AC........................................... 99DIABINESE............................................................ 48DIAPHRAGMS, CONTOURED............................ 36DIAPHRAGMS, WIDE SEAL................................36


Index

DIASTAT............................................................... 110DIASTAT ACUDIAL............................................ 110DIASTIX REAGENT..............................................54DIAZEPAM..................................................... 20, 110DIBENZYLINE.......................................................27DICHLORPHENAMIDE...................................... 114DICLOFENAC POTASSIUM................................. 82DICLOFENAC SODIUM......................43, 45, 58, 82DICLOXACILLIN SODIUM..................................72DICYCLOMINE HCL.......................................... 115DIDANOSINE.........................................................76DIDRONEL............................................................. 56DIETARY SUPPLEMENT......................................92DIETHYLTOLUAMIDE...................................39, 41DIETHYLTOLUAMIDE (15 %) (AERO POWD)(OTC)...........................................................................DIETHYLTOLUAMIDE (15 %) (SPRAY) (OTC).....DIETHYLTOLUAMIDE (25 %) (SPRAY) (OTC).....DIETHYLTOLUAMIDE (40 %) (SPRAY) (OTC).....DIETHYLTOLUAMIDE (7 %) (SPRAY) (OTC).......DIFFERIN............................................................... 39DIFICID...........................................................71, 126DIFLORASONE DIACETATE/EMOLL................ 42DIFLUCAN............................................................. 73DIFLUNISAL........................................................103DIFLUPREDNATE................................................. 58DIGOXIN................................................................ 27DIGOXIN (125 MCG) (TABLET)..............................DIGOXIN (250 MCG) (TABLET)..............................DIGOXIN (50 MCG/ML) (SOLUTION)....................DIHYDROERGOTAMINE MESYLATE............. 106DILACOR XR......................................................... 29DILANTIN............................................................ 112DILANTIN-125.....................................................112DILTIAZEM HCL...................................................29DIMENHYDRINATE............................................... 7DIMETHICONE......................................................45DIMETHICONE (2 %) (LOTION) (OTC)..................DIMETHYL FUMARATE......................................91DIOVAN.................................................................. 28DIOVAN HCT......................................................... 27DIPH,PERTUSS(ACELL),TET VAC/PF................ 68DIPHENHYDRAMINE HCL......................... 4, 5, 24DIPHENHYDRAMINE HCL (12.5MG/5ML)(ELIXIR) (OTC)..........................................................DIPHENHYDRAMINE HCL (12.5MG/5ML)(LIQUID) (OTC).........................................................DIPHENHYDRAMINE HCL (12.5MG/5ML)(SYRUP) (OTC)..........................................................DIPHENHYDRAMINE HCL (25 MG) (CAPSULE)(OTC)...........................................................................DIPHENHYDRAMINE HCL (25 MG) (TABLET)(OTC)...........................................................................

DIPHENHYDRAMINE HCL (50 MG) (CAPSULE)(OTC)...........................................................................DIPHENHYDRAMINE HCL (6.25MG/ML)(DROPS) (OTC)..........................................................DIPHENOXYLATE HCL/ATROPINE................... 84DIPHTH,PERTUSS(ACELL),TET VAC................ 68DIPROLENE........................................................... 41DIPROLENE AF..................................................... 41DIPYRIDAMOLE................................................... 66DISALCID.............................................................103DISOPYRAMIDE PHOSPHATE........................... 26DISULFIRAM.........................................................20DIURIL (250 MG) (TABLET)................................ 30DIURIL (500 MG) (TABLET)................................ 30DIVALPROEX SODIUM......................................110DM/ACETAMINOPHEN/DOXYLAMINE............37DM/ACETAMINOPHEN/DOXYLAMINE (15MG-325MG) (CAPSULE) (OTC).......................................DM/PE/ACETAMINOPHEN/CHLORPHENR...... 37D-MANNOSE......................................................... 92D-METHORPHAN/PE/ACETAMINOPHEN.........38D-METHORPHAN/PE/ACETAMINOPHEN (10-5-325MG) (CAPSULE) (OTC).......................................D-METHORPHAN/PE/ACETAMINOPHEN (20-10-500) (POWD PACK) (OTC)........................................DOCOSANOL.........................................................41DOCUSATE CALCIUM......................................... 85DOCUSATE SODIUM......................................85, 87DOCUSATE SODIUM (100 MG) (CAPSULE)(OTC)...........................................................................DOCUSATE SODIUM (100 MG) (TABLET) (OTC).....................................................................................DOCUSATE SODIUM (250 MG) (CAPSULE)(OTC)...........................................................................DOCUSATE SODIUM (283 MG) (ENEMA) (OTC).....................................................................................DOCUSATE SODIUM (283 MG/5ML) (ENEMA)(OTC)...........................................................................DOCUSATE SODIUM (50 MG/5 ML) (LIQUID)(OTC)...........................................................................DOCUSATE SODIUM (60 MG/15ML) (SYRUP)(OTC)...........................................................................DOCUSATE SODIUM/BENZOCAINE................. 87DOCUSOL PLUS....................................................87DOFETILIDE.......................................................... 26DOLOBID............................................................. 103DOLUTEGRAVIR SODIUM..................................78DOLUTEGRAVIR/RILPIVIRINE..........................74DONEPEZIL HCL.................................................. 17DORAL....................................................................24DORAVIRINE......................................................... 75DORAVIRINE/LAMIVU/TENOFOV DISO.......... 78DORNASE ALFA................................................. 103DORZOLAMIDE HCL........................................... 60


Index

DORZOLAMIDE HCL/TIMOLOL MALEAT.......60DOSTINEX............................................................. 57DOVONEX......................................................46, 126DOXAZOSIN MESYLATE.................................... 27DOXEPIN HCL.................................................19, 24DOXERCALCIFEROL........................................... 57DOXYCYCLINE CALCIUM................................. 72DOXYCYCLINE HYCLATE........................... 72, 91DOXYCYCLINE MONOHYDRATE.....................72DOXYLAMINE SUCCINATE..........................24, 25DRAMAMINE (50 MG) (TABLET) (OTC)............. 7DRITHOCREME HP...................................... 46, 126DRONABINOL......................................................... 7DRONEDARONE HCL.......................................... 26DROPLET LANCING DEVICE.............................51DROSPIR/ETH ESTRA/LEVOMEFOL CA.......... 35DROXIA.................................................................. 66DROXIDOPA.......................................................... 33DUAC...................................................................... 38DUAVEE..................................................................67DULAGLUTIDE..................................................... 47DULCOLAX (10 MG) (SUPP.RECT) (OTC).........87DULCOLAX (5 MG) (TABLET DR) (OTC)..........85DULERA................................................................... 8DULOXETINE HCL...............................................18DULOXETINE HCL (20 MG) (CAPSULE DR)........DULOXETINE HCL (30 MG) (CAPSULE DR)........DULOXETINE HCL (60 MG) (CAPSULE DR)........DUOCAL.................................................................92DUONEB...................................................................8DURAGESIC (100 MCG/HR) (PATCH TD72)....104DURAGESIC (12 MCG/HR) (PATCH TD72)......104DURAGESIC (25 MCG/HR) (PATCH TD72)......104DURAGESIC (50MCG/HR) (PATCH TD72).......104DURAGESIC (75MCG/HR) (PATCH TD72).......104DUREX AVANTI BARE REAL FEEL...................92DUREZOL...............................................................58DURICEF................................................................ 70DUTASTERIDE.................................................... 117DUTASTERIDE/TAMSULOSIN HCL.................117DYAZIDE................................................................ 30DYCLONINE HCL/BENZETHONIUM CL.......... 46DYNACIRC............................................................. 29DY-O-DERM......................................................... 101

- E -E.E.S. 200................................................................ 71E.E.S. 400................................................................ 71EASIVENT........................................................10, 11EASY AIR............................................................... 14EASY MINI EJECT LANCING DEVICE..............51EASY TOUCH LANCING DEVICE......................51EBASE CONTROLLER............................................9EC-NAPROSYN......................................................83ECONAZOLE NITRATE........................................40

ECOTRIN................................................................ 66EDLUAR......................................................... 25, 126EDURANT.............................................................. 76EFAVIRENZ............................................................75EFAVIRENZ/EMTRICIT/TENOFOVR DF............78EFAVIRENZ/LAMIVU/TENOFOV DISOP.....78, 79EFFEXOR................................................................18EFFEXOR XR......................................................... 18EFFIENT................................................................. 66EFUDEX..................................................................45ELAGOLIX SODIUM............................................ 57ELAVIL................................................................... 19ELDEPRYL........................................................... 109ELECARE............................................................. 101ELECARE JR................................................ 100, 101ELECTROLYTES/DEXTROSE........................54, 55ELESTAT.................................................................58ELIGARD................................................................56ELIGLUSTAT TARTRATE.....................................96ELIPHOS.................................................................54ELIQUIS (2.5 MG) (TABLET)............................... 63ELIQUIS (5 MG (74)) (TAB DS PK)......................63ELIQUIS (5 MG) (TABLET).................................. 63ELIXOPHYLLIN.................................................... 16ELLA....................................................................... 36ELMIRON............................................................. 118ELOCON................................................................. 42ELOCTATE............................................................. 62ELTROMBOPAG OLAMINE.................................66ELVITEG/COB/EMTRI/TENOF ALAFEN........... 79ELVITEG/COB/EMTRI/TENOFO DISOP.............79EMCYT................................................................... 91EMEND (125 MG) (CAPSULE)...............................7EMEND (125MG-80MG) (CAP DS PK)..................7EMEND (40 MG) (CAPSULE).................................7EMEND (80 MG) (CAPSULE).................................7EMICIZUMAB-KXWH..........................................64EMLA...................................................................... 46EMOL53/NAMGFS/HA/NAHYPOCHLORIT...... 43EMOLLIENT........................................................ 101EMOLLIENT BASE............................................. 101EMOLLIENT COMBINATION NO.10..................43EMOLLIENT COMBINATION NO.35..................43EMOLLIENT COMBINATION NO.36..................43EMOLLIENT COMBINATION NO.60..................43EMOLLIENT COMBOS NO.47, NO.60................ 43EMOLLIENT NO56/HYALURONIC ACID.......... 43EMPAGLIFLOZIN..................................................48EMPAGLIFLOZIN/LINAGLIPTIN........................48EMPAGLIFLOZIN/METFORMIN HCL..........48, 49EMSAM...................................................................24EMTRICITA/RILPIVIRINE/TENOF DF............... 79EMTRICITAB/RILPIVIRI/TENOF ALA...............79EMTRICITABINE...................................................76


Index

EMTRICITABINE/TENOFOV ALAFENAM........75EMTRICITABINE/TENOFOVIR (TDF)................75EMTRIVA (10 MG/ML) (SOLUTION)..................76EMTRIVA (200 MG) (CAPSULE)......................... 76EMVERM................................................................74ENALAPRIL MALEATE........................................27ENALAPRIL/HYDROCHLOROTHIAZIDE......... 27ENBREL..................................................................80ENBREL MINI........................................................80ENBREL SURECLICK...........................................80ENCORAFENIB..................................................... 88ENDOMETRIN.......................................................55ENEMA (19G-7G/118) (ENEMA) (OTC)..............87ENEMEEZ...............................................................87ENFAGROW NEXT STEP LIPIL...........................96ENFAMIL A.R........................................................ 97ENFAMIL A.R. LIPIL.............................................96ENFAMIL ENFACARE.......................................... 97ENFAMIL ENFALYTE (SOLUTION) (OTC)....54,55ENFAMIL GENTLEASE LIPIL............................. 97ENFAMIL PREMIUM LIPIL................................. 97ENFUVIRTIDE....................................................... 75ENGERIX-B ADULT..............................................69ENLITE SERTER....................................................50ENOXAPARIN SODIUM................................. 64, 65ENSURE ACTIVE CLEAR.................................... 93ENSURE ACTIVE HEART HEALTH....................93ENSURE ACTIVE HIGH PROTEIN......................93ENSURE ACTIVE LIGHT..................................... 93ENSURE ACTIVE MUSCLE HEALTH................ 93ENSURE ACTIVE PROTEIN-MUSCLE............... 93ENSURE CLEAR..............................................93, 94ENSURE CLINICAL STRENGTH........................ 93ENSURE COMPACT.............................................. 93ENSURE HIGH PROTEIN............................... 93, 96ENSURE LIQUID................................................... 93ENSURE MAX PROTEIN......................................93ENSURE MUSCLE HEALTH................................93ENSURE ORIGINAL..............................................93ENSURE PLUS....................................................... 93ENSURE POWDER................................................ 93ENSURE PRE-SURGERY......................................94ENSURE SURGERY.............................................. 99ENSURE WITH FIBER.......................................... 93ENTACAPONE..................................................... 109ENTECAVIR........................................................... 79ENTOCORT EC...................................................... 80ENTRESTO............................................................. 33ENZALUTAMIDE.................................................. 88EO28 SPLASH................................................ 94, 100EPIDIOLEX.......................................................... 110EPINASTINE HCL................................................. 58EPINEPHRINE..................................................27, 87

EPINEPHRINE (0.15/0.15) (AUTO INJCT)..............EPINEPHRINE (0.15MG/0.3) (AUTO INJCT)..........EPINEPHRINE (0.3MG/0.3) (AUTO INJCT)............EPIVIR (10 MG/ML) (SOLUTION).......................76EPIVIR (150 MG) (TABLET).................................77EPIVIR (300 MG) (TABLET).................................77EPIVIR HBV (100 MG) (TABLET)....................... 79EPIVIR HBV (25 MG/5 ML) (SOLUTION).......... 79EPOETIN ALFA-EPBX.......................................... 64EPZICOM................................................................75EQUETRO...............................................................20ERAPID NEBULIZER............................................13ERGOCALCIFEROL (VITAMIN D2)................. 124ERGOCALCIFEROL (VITAMIN D2) (50000UNIT) (CAPSULE).....................................................ERGOCALCIFEROL (VITAMIN D2) (8000/ML)(DROPS) (OTC)..........................................................ERGOLOID MESYLATES.....................................34ERGOTAMINE TARTRATE/CAFFEINE............ 106ERIVEDGE............................................................. 88ERLEADA...............................................................88ERLOTINIB HCL................................................... 89ERTUGLIFLOZIN PIDOLATE.............................. 48ERTUGLIFLOZIN/METFORMIN......................... 49ERYPED 200........................................................... 71ERYPED 400........................................................... 71ERY-TAB................................................................. 71ERYTHRCIN STEARATE......................................71ERYTHROMYCIN BASE................................ 59, 71ERYTHROMYCIN BASE IN ETHANOL............. 39ERYTHROMYCIN ETHYLSUCCINATE..............71ERYTHROMYCIN STEARATE.............................71ERYTHROMYCIN/BENZOYL PEROXIDE......... 40ESBRIET............................................................... 102ESCAVITE LQ...................................................... 121ESCITALOPRAM OXALATE................................18ESLICARBAZEPINE ACETATE......................... 110ESOMEPRAZOLE MAGNESIUM...................... 117ESTAZOLAM......................................................... 24ESTRACE........................................................67, 118ESTRADIOL................................................... 67, 118ESTRADIOL CYPIONATE.................................... 67ESTRADIOL VALERATE...................................... 67ESTRADIOL VALERATE/DIENOGEST.............. 35ESTRADIOL/NORETHINDRONE ACET.............67ESTRAMUSTINE PHOSPHATE SODIUM.......... 91ESTROGEN,CON/M-PROGEST ACET................ 67ESTROGEN,ESTER/ME-TESTOSTERONE.........67ESTROGENS, CONJUGATED...................... 67, 118ESTROGENS,CONJ/BAZEDOXIFENE................ 67ESTROGENS,ESTERIFIED...................................67ESTROSTEP FE......................................................35ESZOPICLONE...................................................... 25ETANERCEPT........................................................ 80


Index

ETHAMBUTOL HCL.............................................73ETHINYL ESTRADIOL/DROSPIRENONE......... 35ETHIONAMIDE..................................................... 73ETHOSUXIMIDE................................................. 110ETHOTOIN........................................................... 110ETHYL CHLORIDE............................................... 46ETHYNODIOL D-ETHINYL ESTRADIOL..........35ETIDRONATE DISODIUM....................................56ETODOLAC............................................................ 82ETONOGESTREL.................................................. 34ETONOGESTREL/ETHINYL ESTRADIOL.........34ETOPOSIDE............................................................90ETRAFON-A...........................................................19ETRAVIRINE....................................................75, 76EUCERIN................................................................ 43EULEXIN................................................................ 88EVEROLIMUS..................................................69, 89EVISTA................................................................... 56EVOCLIN................................................................39EVOLOCUMAB..................................................... 32EVOTAZ.................................................................. 78EXCEDRIN EXTRA STRENGTH (250-250-65)(TABLET) (OTC).................................................. 103EXCEDRIN MENSTRUAL COMPLETE (250-250-65) (TABLET) (OTC)............................................103EXCEDRIN MIGRAINE (250-250-65) (TABLET)(OTC).....................................................................103EXCEDRIN TENSION HEADACHE (500MG-65MG) (TABLET) (OTC)..................................... 104EXELDERM............................................................40EXELON................................................................. 17EXEMESTANE....................................................... 88EXFORGE...............................................................27EXFORGE HCT......................................................27EXJADE.................................................................. 97EXTINA...................................................................40EYELID CLEANSER COMBINATION 5............. 62EYELID CLEANSER COMBINATION 6............. 62EYELID WIPES......................................................62E-Z SPACER............................................................10EZETIMIBE............................................................ 32EZ-VAC................................................................... 50

- F -FABIOR................................................................... 39FACTOR IX.............................................................63FACTOR IX CPLX(PCC)NO4,3FACTOR............. 63FACTOR IX HUMAN REC,PEGYLATED............63FACTOR IX HUMAN RECOMB,THR 148...........63FACTOR IX HUMAN RECOMBINANT...............63FACTOR IX REC, FC FUSION PROTN................63FACTOR IX RECOM,ALBUMIN FUSION...........63FACTOR XIII.......................................................... 63FACTOR XIII A-SUBUNIT,RECOMB.................. 64FAMCICLOVIR...................................................... 74

FAMOTIDINE.......................................................116FAMOTIDINE (10 MG) (TABLET) (OTC)................FAMOTIDINE (20 MG) (TABLET) (OTC)................FAMOTIDINE (40 MG) (TABLET)...........................FAMVIR.................................................................. 74FANAPT (1 MG) (TABLET).......................... 21, 126FANAPT (10 MG) (TABLET)........................ 21, 126FANAPT (12 MG) (TABLET)........................ 21, 127FANAPT (1-2-4-6MG) (TAB DS PK).............21, 127FANAPT (2 MG) (TABLET).......................... 21, 127FANAPT (4 MG) (TABLET).......................... 21, 127FANAPT (6 MG) (TABLET).......................... 21, 127FANAPT (8 MG) (TABLET).......................... 21, 127FANTASY................................................................92FARESTON............................................................. 91FARYDAK...............................................................90FAZACLO....................................................... 21, 127FC2 FEMALE CONDOM.......................................92FEBUXOSTAT........................................................ 62FEIBA NF................................................................63FELBAMATE........................................................110FELBAMATE (400 MG) (TABLET).................... 127FELBAMATE (600 MG) (TABLET).................... 127FELBAMATE (600 MG/5ML) (ORAL SUSP).....127FELDENE................................................................83FELODIPINE.......................................................... 29FEMARA.................................................................88FEMCAP................................................................. 36FEMCON FE........................................................... 35FEMHRT................................................................. 67FENOFIBRATE.......................................................33FENOFIBRATE NANOCRYSTALLIZED............. 33FENOFIBRATE,MICRONIZED.............................33FENOFIBRIC ACID............................................... 33FENOFIBRIC ACID (CHOLINE).......................... 33FENOGLIDE...........................................................33FENTANYL...........................................................104FENTANYL CITRATE......................................... 104FERRIPROX............................................................98FERROUS FUMARATE.......................................119FERROUS FUMARATE (324(106)MG) (TABLET)(OTC)...........................................................................FERROUS GLUCONATE.....................................120FERROUS GLUCONATE (324(37.5)) (TABLET)(OTC)...........................................................................FERROUS GLUCONATE (324(38)MG) (TABLET)(OTC)...........................................................................FERROUS SULFATE............................................120FERROUS SULFATE (15 MG/ML) (DROPS) (OTC).....................................................................................FERROUS SULFATE (220 (44)/5) (ELIXIR) (OTC).....................................................................................FERROUS SULFATE (300 MG/5ML) (LIQUID)(OTC)...........................................................................


Index

FERROUS SULFATE (324(65)MG) (TABLET DR)(OTC)...........................................................................FERROUS SULFATE (325(65) MG) (TABLET DR)(OTC)...........................................................................FERROUS SULFATE (325(65) MG) (TABLET)(OTC)...........................................................................FERROUS SULFATE/VIT C/FOLIC AC............. 120FESOTERODINE FUMARATE........................... 118FETZIMA........................................................ 18, 127FEVERALL (80 MG) (SUPP.RECT) (OTC)........ 104FEXMID................................................................ 114FEXOFENADINE HCL........................................ 5, 6FIBERSOURCE HN............................................... 94FIBER-STAT........................................................... 85FIBRICOR...............................................................33FIDAXOMICIN.......................................................71FILGRASTIM......................................................... 65FILGRASTIM-AAFI...............................................65FILGRASTIM-SNDZ..............................................65FINASTERIDE......................................................117FINGER CREAM..................................................101FINGOLIMOD HCL............................................... 91FIORICET WITH CODEINE............................... 107FIORINAL WITH CODEINE #3..........................107FIRAZYR................................................................ 80FIRMAGON (120 MG) (VIAL)..............................89FIRMAGON (80 MG) (VIAL)................................89FIRVANQ (25 MG/ML) (SOLN RECON)..............74FIRVANQ (50 MG/ML) (SOLN RECON)..............74FLAGYL..................................................................74FLAREX..................................................................58FLAVOXATE HCL................................................118FLECAINIDE ACETATE........................................26FLEXERIL............................................................ 114FLEXICHAMBER.................................................. 10FLEXICHAMBER MASK......................................11FLOMAX.............................................................. 117FLONASE................................................................. 6FLONASE ALLERGY RELIEF............................... 6FLORINEF.............................................................. 82FLORIVA.......................................................119, 121FLOVENT HFA (110 MCG) (AER W/ADAP).........8FLOVENT HFA (220 MCG) (AER W/ADAP).........8FLOVENT HFA (44 MCG) (AER W/ADAP)...........9FLOXIN...................................................................72FLU VAC QS 18-19 (4YR UP) CELL.................... 68FLU VAC QS 18-19(4YR UP)CEL/PF................... 68FLU VAC QV 2018(18YR UP)RCM/PF................ 68FLU VACC QS 2018 (6-35MOS)/PF...................... 68FLU VACC QS2018-19 36MOS UP/PF..................68FLU VACC QS2018-19(6MOS UP)/PF..................68FLU VACC QUAD 2018-19(6MOS UP)................ 68FLU VACC QV LIVE 2018(2-49YRS)...................68FLU VACC TS 2018-19 (6 MOS UP).....................68

FLU VACC TS2018(65UP)/MF59C/PF..................68FLU VACC TS2018-19(65YR UP)/PF................... 68FLU VACC TS2018-19(6MOS UP)/PF.................. 68FLUAD 2018-2019..................................................68FLUARIX QUAD 2018-2019................................. 68FLUBLOK QUAD 2018-2019................................ 68FLUCELVAX QUAD 2018-2019............................68FLUCONAZOLE.................................................... 73FLUCYTOSINE...................................................... 73FLUDROCORTISONE ACETATE......................... 82FLULAVAL QUAD 2018-2019...............................68FLUMADINE..........................................................74FLUMIST QUAD 2018-2019..................................68FLUNISOLIDE......................................................... 6FLUOCINOLONE ACETONIDE...........................42FLUOCINOLONE ACETONIDE OIL................... 54FLUOCINOLONE/SHOWER CAP........................42FLUOCINONIDE....................................................42FLUOCINONIDE/EMOLLIENT BASE................ 42FLUORESCEIN SODIUM..................................... 62FLUORESCEIN-BENOXINATE............................58FLUORIDE (SODIUM)........................................ 119FLUORIDE (SODIUM) (0.25(0.55)) (TAB CHEW)(OTC)...........................................................................FLUORIDE (SODIUM) (0.5(1.1)MG) (TABCHEW) (OTC).............................................................FLUORIDE (SODIUM) (1.1 %) (CREAM (G)).........FLUORIDE (SODIUM) (1.1 %) (GEL (GRAM))......FLUORIDE (SODIUM) (1MG(2.2MG)) (TABCHEW) (OTC).............................................................FLUOROMETHOLONE.........................................58FLUOROMETHOLONE ACETATE...................... 58FLUOROURACIL...................................................45FLUOXETINE HCL................................................18FLUPHENAZINE DECANOATE...........................24FLUPHENAZINE HCL.......................................... 24FLURANDRENOLIDE.......................................... 42FLURAZEPAM HCL.............................................. 24FLURBIPROFEN....................................................82FLURBIPROFEN SODIUM................................... 58FLURESS................................................................ 58FLUROX..................................................................59FLUTAMIDE...........................................................88FLUTICASONE FUROATE..................................... 8FLUTICASONE PROPIONATE.................6, 8, 9, 42FLUTICASONE/SALMETEROL.............................8FLUTICASONE/UMECLIDIN/VILANTER........... 8FLUTICASONE/VILANTEROL..............................8FLUVOXAMINE MALEATE.................................18FLUZONE HIGH-DOSE 2018-2019...................... 68FLUZONE QUAD 2018-2019................................ 68FLUZONE QUAD PEDI 2018-2019.......................68FLYP NEBULIZER.................................................13FML......................................................................... 58


Index

FML FORTE............................................................58FML S.O.P............................................................... 58FOCALIN................................................................ 25FOCALIN XR......................................................... 25FOLEX.................................................................... 88FOLIC ACID......................................................... 119FOLIC ACID (0.4 MG) (TABLET) (OTC).................FOLIC ACID (0.8 MG) (TABLET) (OTC).................FOLIC ACID (1 MG) (TABLET)...............................FOLIC ACID (1 MG) (TABLET) (OTC)....................FOLIC ACID (5 MG/ML) (VIAL)..............................FOLTX...................................................................123FONDAPARINUX SODIUM..................................65FORA LANCING DEVICE.................................... 51FORMALDEHYDE.............................................. 102FORMOTEROL FUMARATE.................................. 8FORTEO.................................................................. 56FORTESTA..............................................................66FOSAMAX (10 MG) (TABLET)............................ 56FOSAMAX (35 MG) (TABLET)............................ 56FOSAMAX (40 MG) (TABLET)............................ 56FOSAMAX (5 MG) (TABLET).............................. 56FOSAMAX (70 MG) (TABLET)............................ 56FOSAMAX (70 MG/75ML) (SOLUTION)............56FOSAMAX PLUS D............................................... 56FOSAMPRENAVIR CALCIUM.............................78FOSINOPRIL SODIUM......................................... 27FOSINOPRIL/HYDROCHLOROTHIAZIDE........ 27FRAGMIN (10000/ML) (SYRINGE)..................... 64FRAGMIN (12500/0.5) (SYRINGE)...................... 64FRAGMIN (15000/0.6) (SYRINGE)...................... 64FRAGMIN (18000/0.72) (SYRINGE).................... 64FRAGMIN (2500/0.2ML) (SYRINGE).................. 64FRAGMIN (25000/ML) (VIAL)............................. 64FRAGMIN (5000/0.2ML) (SYRINGE).................. 64FRAGMIN (7500/0.3ML) (SYRINGE).................. 64FREESTYLE FREEDOM LITE (KIT) (OTC)....... 49FREESTYLE INSULINX (STRIP) (OTC)............. 49FREESTYLE INSULINX TEST STRIPS...............49FREESTYLE LITE METER (KIT) (OTC)............. 49FREESTYLE LITE STRIPS (STRIP) (OTC)......... 49FREESTYLE PRECISION NEO (STRIP) (OTC)....49FREESTYLE PRECISION NEO METER (EACH)(OTC).......................................................................49FREESTYLE TEST STRIPS (STRIP) (OTC)........ 49FRUCTOOLIGOSACCH/MALTODEXTRIN........85FRUCTOOLIGOSACCHARIDES/POLYDEX...... 85FULPHILA.............................................................. 66FURADANTIN....................................................... 71FUROSEMIDE........................................................30FUZEON..................................................................75FVIII REC,B-DOM DELET PEG-AUCL...............63FYCOMPA (10 MG) (TABLET)...................112, 127

FYCOMPA (12 MG) (TABLET)...................112, 127FYCOMPA (2 MG) (TABLET).....................112, 127FYCOMPA (4 MG) (TABLET).....................112, 127FYCOMPA (6 MG) (TABLET).....................112, 128FYCOMPA (8 MG) (TABLET).....................112, 128

- G -GABAPENTIN......................................................110GABITRIL (12 MG) (TABLET)...................113, 128GABITRIL (16 MG) (TABLET)...................113, 128GABITRIL (2 MG) (TABLET).....................113, 128GABITRIL (4 MG) (TABLET).....................113, 128GALANTAMINE HBR...........................................17GAMMAGARD LIQUID........................................67GANCICLOVIR...................................................... 58GARAMYCIN.........................................................59GARDASIL 9.......................................................... 69GASTROCROM........................................................9GATIFLOXACIN.................................................... 59GATTEX..................................................................87GAVILAX (17G/DOSE) (POWDER) (OTC)..........86GAVISCON (237.5-254) (ORAL SUSP) (OTC)....115GEFITINIB..............................................................89GEMFIBROZIL.......................................................33GENADUR..............................................................45GENERESS FE....................................................... 35GENTAK................................................................. 59GENTAMICIN SULFATE.................................40, 59GENTEAL TEARS................................................. 61GENTEAL TEARS SEVERE................................. 61GENTIAN VIOLET/BRGREEN/PROFLAV..........40GENVOYA.............................................................. 79GEODON................................................................ 23GERBER GOOD START GENTLE....................... 97GERBER NATURA STAGE 1................................ 97GERBER NATURA STAGE 2................................ 97GILENYA................................................................ 91GILOTRIF............................................................... 89GILTERITINIB FUMARATE.................................89GLASDEGIB MALEATE....................................... 88GLATIRAMER ACETATE..................................... 91GLECAPREVIR/PIBRENTASVIR........................ 79GLEEVEC (100 MG) (TABLET)........................... 90GLEEVEC (400 MG) (TABLET)........................... 90GLIADEL................................................................ 88GLIMEPIRIDE........................................................48GLIPIZIDE.............................................................. 48GLIPIZIDE/METFORMIN HCL............................48GLUCAGON EMERGENCY KIT......................... 53GLUCAGON,HUMAN RECOMBINANT.............53GLUCERNA............................................................99GLUCERNA 1 CAL................................................99GLUCERNA 1.2 CAL.............................................99GLUCERNA 1.5 CAL.............................................99


Index

GLUCERNA ADVANCE........................................99GLUCERNA HUNGER SMART......................... 100GLUCERNA THERAPEUTIC NUTRITION.......100GLUCO BURST......................................................99GLUCOCOM AUTOLINK..................................... 50GLUCOTROL......................................................... 48GLUCOTROL XL................................................... 48GLUTAREX-1.........................................................96GLYBURIDE...........................................................48GLYBURIDE,MICRONIZED.................................48GLYBURIDE/METFORMIN HCL.........................48GLYCERIN..............................................................87GLYCERIN (PEDIATRIC) (SUPP.RECT) (OTC)......GLYCERIN/DIMETHICONE.................................43GLYCEROL PHENYLBUTYRATE.......................84GLYCINE UROLOGIC SOLUTION......................73GLYCINE/SODIUM HYDROXIDE.......................98GLYCOPYRROLATE........................................... 116GLYCOPYRROLATE (1 MG) (TABLET).................GLYCOPYRROLATE (2 MG) (TABLET).................GLYNASE............................................................... 48GLYTACTIN RESTORE 10 PE.............................. 98GLYTACTIN RTD LITE 15.................................... 98GLYTROL............................................................. 100GLYXAMBI.................................................... 48, 128GOLIMUMAB........................................................ 80GOLYTELY (227.1-21.5) (POWD PACK)............. 86GOLYTELY (236-22.74G) (SOLN RECON)......... 86GOOD START.........................................................97GOSERELIN ACETATE.........................................56GR POL-ORC/SW VER/RYE/KENT/TIM.............. 4GRANISETRON HCL.............................................. 7GRANIX..................................................................66GRASS POLLEN-TIMOTHY, STANDARD............4GRASTEK.................................................................4GRIFULVIN V (125 MG/5ML) (ORAL SUSP)..... 73GRISEOFULVIN, MICROSIZE............................. 73GUAIFEN/DEXTROMETHORPHAN/PE............. 38GUAIFEN/DEXTROMETHORPHAN/PE (100-10-5MG) (LIQUID) (OTC)...............................................GUAIFENESIN....................................................... 37GUAIFENESIN (100 MG/5ML) (LIQUID) (OTC)....GUAIFENESIN (1200 MG) (TAB ER 12H) (OTC).....................................................................................GUAIFENESIN (200 MG) (TABLET) (OTC)............GUAIFENESIN (400 MG) (TABLET) (OTC)............GUAIFENESIN (600 MG) (TAB ER 12H) (OTC).....GUAIFENESIN/DEXTROMETHORPHAN.......... 38GUAIFENESIN/DEXTROMETHORPHAN (100-10MG/5) (LIQUID) (OTC)..........................................GUAIFENESIN/DEXTROMETHORPHAN (100-10MG/5) (SYRUP) (OTC)...........................................GUAIFENESIN/DEXTROMETHORPHAN (100-5MG/5) (LIQUID) (OTC)..............................................

GUAIFENESIN/DEXTROMETHORPHAN (1200-60MG) (TAB ER 12H) (OTC).....................................GUAIFENESIN/DEXTROMETHORPHAN (200-10MG/5) (LIQUID) (OTC)..........................................GUAIFENESIN/DEXTROMETHORPHAN(400MG-20MG) (TABLET) (OTC)............................GUAIFENESIN/PHENYLEPHRINE HCL............ 37GUAIFENESIN/PHENYLEPHRINE HCL (400MG-10MG) (TABLET) (OTC)...........................................GUANFACINE HCL.........................................25, 28GUANIDINE........................................................... 87GUANIDINE HCL.................................................. 87GUARDIAN RT CHARGER.................................. 50GUARDIAN RT STARTER KIT............................ 50GUARDIAN RT SYSTEM......................................50GUARDIAN TEST PLUG...................................... 50GUARDIAN TRANSMITTER TAPE.....................50GYNAZOLE 1.......................................................118GYNE-LOTRIMIN-7 (1 %) (CREAM/APPL) (OTC)............................................................................... 118GYNOL II................................................................34

- H -HAEGARDA........................................................... 80HALDOL.................................................................24HALDOL DECANOATE 100................................. 24HALDOL DECANOATE 50................................... 24HALFLYTELY-BISACODYL.................................85HALOBETASOL PROPIONATE........................... 42HALOBETASOL PROPIONATE (0.05 %) (CREAM(G))..............................................................................HALOBETASOL PROPIONATE (0.05 %) (OINT.(G))..............................................................................HALOPERIDOL..................................................... 24HALOPERIDOL DECANOATE............................ 24HALOPERIDOL LACTATE................................... 24HAVRIX.................................................................. 69HCU COOLER........................................................99HCU COOLER20....................................................99HCU LOPHLEX......................................................99HEALTHMIST.......................................................... 9HEALTHY ACCENTS AUTOLET.........................51HELIXATE FS.........................................................63HEMLIBRA............................................................ 64HEMMOREX-HC................................................... 84HEMOFIL M........................................................... 63HEPARIN SOD,PORCINE/0.9 % NACL............... 65HEPARIN SOD,PORCINE/0.9 % NACL (100/ML)(KIT)............................................................................HEPARIN SODIUM,PORCINE............................. 65HEPARIN SODIUM,PORCINE/D5W....................65HEPARIN SODIUM,PORCINE/PF........................65HEPARIN SODIUM,PORCINE/PF (1 UNIT/ML)(SYRINGE).................................................................


Index

HEPARIN SODIUM,PORCINE/PF (10 UNIT/ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (10 UNIT/ML)(VIAL).........................................................................HEPARIN SODIUM,PORCINE/PF (100/ML (1))(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (100/ML (1))(VIAL).........................................................................HEPARIN SODIUM,PORCINE/PF (1000/10 ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (1000/ML)(VIAL).........................................................................HEPARIN SODIUM,PORCINE/PF (200/2 ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (300/3 ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (500/5 ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE/PF (5000/0.5ML)(CARTRIDGE)............................................................HEPATITIS A AND B VACCINE/PF ..................... 69HEPATITIS A VIRUS VACCINE/PF ......................69HEPATITIS B VACCINE/CPG1018/PF..................69HEPATITIS B VIRUS VACCINE/PF......................69HEPLISAV-B...........................................................69HEPSERA................................................................79HETLIOZ................................................................ 24HI-CAL....................................................................94HIPREX...................................................................70HISTRELIN ACETATE.................................... 56, 57HIZENTRA............................................................. 67HOMATROPINE HBR............................................60HOME HEMOGLOBIN A1C MONITOR..............50HOME NEBULIZER PLUS SIDESTREAM......... 14HOMINEX-2........................................................... 99HONEY................................................................... 46HPV VACCINE 9-VALENT/PF..............................69HUMALOG MIX 50-50..........................................53HUMALOG MIX 50-50 KWIKPEN...................... 53HUMALOG MIX 75-25..........................................53HUMALOG MIX 75-25 KWIKPEN...................... 53HUMATE-P............................................................. 63HUMATIN...............................................................74HUMIDIFIER............................................................9HUMULIN 70/30 KWIKPEN.................................53HUMULIN 70-30.................................................... 54HUMULIN N...........................................................54HUMULIN N KWIKPEN....................................... 54HUMULIN R...........................................................54HUMULIN R U-500................................................54HUMULIN R U-500 KWIKPEN............................ 54HYALURONATE SODIUM....................................45HYALURONATE SODIUM/HE-CELL/PEG......... 45HYALURONATE/ALLANTOIN/ALOE EXT........45

HYCAMTIN............................................................89HYDE-OUT.............................................................98HYDERGINE.......................................................... 34HYDRALAZINE HCL............................................28HYDREA.................................................................88HYDROCHLOROTHIAZIDE................................ 30HYDROCODONE BIT/HOMATROP ME-BR.......37HYDROCODONE BIT/HOMATROP ME-BR (5MG-1.5MG) (TABLET)..............................................HYDROCODONE/ACETAMINOPHEN..............107HYDROCODONE/ACETAMINOPHEN (10MG-325MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (2.5-325MG) (TABLET)...........................................................HYDROCODONE/ACETAMINOPHEN (5 MG-325MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (7.5-325MG) (TABLET)...........................................................HYDROCODONE/ACETAMINOPHEN (7.5-325/15) (SOLUTION).................................................HYDROCODONE/CHLORPHEN P-STIREX.......37HYDROCODONE/CPM/PSEUDOEPHED........... 37HYDROCODONE/IBUPROFEN......................... 104HYDROCORT/MIN OIL/PETROLAT,WHT..........42HYDROCORT/SAL ACID/SULF/SHAMP1..........42HYDROCORTISONE................................. 42, 81, 84HYDROCORTISONE (1 %) (CREAM (G))...............HYDROCORTISONE (1 %) (CREAM (G)) (OTC).....................................................................................HYDROCORTISONE (1 %) (CREAM PACK)(OTC)...........................................................................HYDROCORTISONE (1 %) (OINT. (G)) (OTC).......HYDROCORTISONE (2 %) (LOTION).....................HYDROCORTISONE (2.5 %) (CREAM (G))............HYDROCORTISONE (2.5 %) (CRM/PE APP).........HYDROCORTISONE (2.5 %) (LOTION)..................HYDROCORTISONE (2.5 %) (OINT. (G))................HYDROCORTISONE ACETATE.....................42, 84HYDROCORTISONE ACETATE (1 %) (CREAM(G)) (OTC)...................................................................HYDROCORTISONE BUTYRATE....................... 42HYDROCORTISONE PROBUTATE......................42HYDROCORTISONE VALERATE........................42HYDROCORTISONE/ACETIC ACID................... 54HYDROCORTISONE/ALOE VERA..................... 42HYDROCORTISONE/ALOE VERA (1 %)(CREAM (G)) (OTC)..................................................HYDROCORTISONE/IODOQUINOL...................39HYDROCORTISONE/LIDOCAINE/ALOE.......... 84HYDROCORTISONE/PRAMOXINE.............. 45, 84HYDROGEN PEROXIDE.......................................45HYDROMORPHONE HCL..........................104, 105HYDROMORPHONE HCL (1 MG/ML) (LIQUID).....................................................................................


Index

HYDROMORPHONE HCL (12 MG) (TAB ER24H).............................................................................HYDROMORPHONE HCL (16 MG) (TAB ER24H).............................................................................HYDROMORPHONE HCL (2 MG) (TABLET)........HYDROMORPHONE HCL (3 MG) (SUPP.RECT).....................................................................................HYDROMORPHONE HCL (32 MG) (TAB ER24H).............................................................................HYDROMORPHONE HCL (4 MG) (TABLET)........HYDROMORPHONE HCL (8 MG) (TAB ER 24H).....................................................................................HYDROMORPHONE HCL (8 MG) (TABLET)........HYDROXOCOBALAMIN....................................124HYDROXYCHLOROQUINE SULFATE............... 74HYDROXYUREA.............................................66, 88HYDROXYZINE HCL..............................................5HYDROXYZINE PAMOATE................................... 5HYGEL....................................................................45HYGROTON........................................................... 30HYOSCYAMINE SULFATE.................................115HYOSYNE............................................................ 115HYPER-HEAL........................................................ 43HYPOLANCE......................................................... 52HYPROMELLOSE................................................. 61HYQVIA..................................................................67HYQVIA IG COMPONENT.................................. 67HYTRIN.................................................................. 27HYZAAR.................................................................27

- I -IBANDRONATE SODIUM.....................................56IBRANCE................................................................90IBRUTINIB............................................................. 89IBUDONE............................................................. 104IBUPROFEN........................................................... 82IBUPROFEN/OXYCODONE HCL...................... 104ICAPS MV.............................................................120ICARIDIN............................................................... 41ICATIBANT ACETATE.......................................... 80ICLUSIG (15 MG) (TABLET)................................90ICLUSIG (45 MG) (TABLET)................................90ICOSAPENT ETHYL............................................. 33ICY HOT................................................................. 44IDELALISIB........................................................... 89IDELVION...............................................................63IGG/HYALURONIDASE,RECOMBINANT......... 67ILEVRO...................................................................58ILOPERIDONE.......................................................21ILOPROST TROMETHAMINE............................. 30ILOTYCIN...............................................................59IMATINIB MESYLATE......................................... 90IMBRUVICA...........................................................89IMDUR.................................................................... 34IMIPRAMINE HCL................................................ 19

IMIPRAMINE PAMOATE......................................19IMIQUIMOD...........................................................69IMITREX...............................................................106IMMUN GLOB G(IGG)/GLY/IGA OV50..............67IMMUN GLOB G(IGG)/PRO/IGA 0-50................ 67IMPACT PEPTIDE 1.5 CAL...................................99IMPAVIDO.............................................................. 74IMURAN................................................................. 69IN-CHECK DIAL....................................................15IN-CHECK NASAL WITH MASK........................ 15IN-CHECK ORAL.................................................. 15INCONTROL LANCING DEVICE........................52INCRELEX..............................................................57INCRUSE ELLIPTA..................................................7INDAPAMIDE.........................................................31INDERAL (10 MG) (TABLET).............................. 28INDERAL (20 MG) (TABLET).............................. 28INDERAL (20 MG/5 ML) (SOLUTION)...............28INDERAL (40 MG) (TABLET).............................. 28INDERAL (40MG/5ML) (SOLUTION).................28INDERAL (60 MG) (TABLET).............................. 28INDERAL (80 MG) (TABLET).............................. 28INDERAL LA......................................................... 28INDERIDE-40/25.................................................... 29INDERIDE-80/25.................................................... 29INDINAVIR SULFATE........................................... 78INDOCIN (25 MG) (CAPSULE)............................82INDOCIN (25 MG/5 ML) (ORAL SUSP).............. 82INDOCIN (50 MG) (CAPSULE)............................83INDOCIN SR...........................................................83INDOMETHACIN............................................ 82, 83INF FORM FOR TYROSINEMIA, IRON..............96INF FORM, GLUTARIC ACIDURIA I.................. 96INF FORM,IRON,SPC.MET,LAC-FREE...............96INF.FORM,METAB,IRON METHION-FR............ 96INF.FORM,METAB,IRON METHION-FR (13G-475) (POWDER) (OTC)..............................................INF.FORM,METAB,IRON METHION-FR (16.2G-500) (POWDER) (OTC)..............................................INF.FORMULA,UREA CYCLE DISORDR.......... 96INFANT FORM,PROPIONIC ACIDEMIA............96INFANT FORM.IRON LAC-F/DHA/ARA.... 96, 101INFANT FORMULA WITH IRON.................. 96, 97INFANT FORMULA WITH IRON, MSUD...........97INFANT FORMULA, IRON/DHA/ARA............... 97INFANT FORMULA, METABOLIC,IRON...........97INFUSION SET FOR INSULIN PUMP.................50INGENOL MEBUTATE..........................................45INHALER, ASSIST DEVICES...........................9, 10INHALER,ASSIST DEV,SMALL MASK........10, 11INHALER,ASSIST DEVICE,ACCESORY............11INHALER,ASSIST DEVICE,LG MASK.........11, 12INHALER,ASSIST DEVICE,MED MASK........... 12INLYTA (1 MG) (TABLET)................................... 89


Index

INLYTA (5 MG) (TABLET)................................... 89INNOSPIRE DELUXE........................................... 14INNOSPIRE ELEGANCE...................................... 14INNOSPIRE ESSENCE.......................................... 14INNOSPIRE GO NEBULIZER.............................. 13INNOSPIRE MINI.................................................. 14INPEN (FOR HUMALOG).....................................50INPEN (FOR NOVOLOG)......................................50INSPIRACHAMBER.........................................10-12INSTACLEAN.......................................................101INSTANT FOOD THICKENER........................... 102INSUL-CAP............................................................ 50INSUL-EZE.............................................................50INSULIN ADMIN. SUPPLIES...............................50INSULIN GLARGINE,HUM.REC.ANLOG..........53INSULIN GLARGINE/LIXISENATIDE................48INSULIN LISPRO...................................................53INSULIN LISPRO PROTAMIN/LISPRO...............53INSULIN NPH HUM/REG INSULIN HM...... 53, 54INSULIN NPH HUMAN ISOPHANE................... 54INSULIN PUMP CONTROLLER.......................... 51INSULIN PUMP/INFUS. SET/METER................. 51INSULIN REGULAR, HUMAN............................ 54INTELENCE (100 MG) (TABLET)........................75INTELENCE (200 MG) (TABLET)........................76INTELENCE (25 MG) (TABLET)..........................76INTERFERON ALFA-2B,RECOMB......................69INTERFERON ALFA-N3....................................... 69INTERFERON BETA-1A....................................... 91INTERFERON BETA-1A/ALBUMIN....................91INTERFERON GAMMA-1B,RECOMB................69INTERMEZZO................................................25, 128INTRON A.............................................................. 69INTUNIV.................................................................25INVEGA (1.5 MG) (TAB ER 24)................... 22, 128INVEGA (3 MG) (TAB ER 24)...................... 22, 128INVEGA (6 MG) (TAB ER 24)...................... 22, 128INVEGA (9 MG) (TAB ER 24)...................... 22, 128INVEGA SUSTENNA (117MG/0.75) (SYRINGE)................................................................................. 22INVEGA SUSTENNA (156 MG/ML) (SYRINGE)................................................................................. 22INVEGA SUSTENNA (234MG/1.5) (SYRINGE)....22INVEGA SUSTENNA (39MG/0.25) (SYRINGE)....22INVEGA SUSTENNA (78MG/0.5ML) (SYRINGE)................................................................................. 22INVEGA TRINZA (273MG/.875) (SYRINGE)....22,23INVEGA TRINZA (410/1.315) (SYRINGE)..........23INVEGA TRINZA (546MG/1.75) (SYRINGE)..... 23INVEGA TRINZA (819/2.625) (SYRINGE)..........23INVIRASE...............................................................78

INVOKAMET................................................. 48, 128INVOKAMET XR...........................................48, 129INVOKANA.................................................... 47, 129IODINE/POTASSIUM IODIDE..............................39IODINE/POTASSIUM IODIDE (5%-10%)(SOLUTION)...............................................................IODINE/POTASSIUM IODIDE (5%-10%)(SOLUTION) (OTC)...................................................IOPIDINE (0.5 %) (DROPS)...................................60IPECAC................................................................. 115IPRATROPIUM BROMIDE................................7, 91IPRATROPIUM/ALBUTEROL SULFATE.............. 8IRBESARTAN.........................................................28IRBESARTAN/HYDROCHLOROTHIAZIDE.......27IRESSA....................................................................89IRON AG,PS/C/FA6/B12/ZN/SA/STO.................120IRON ASPGLY,PS/C/SUCCINIC ACID.............. 120IRON FUM/DOCUSAT/FOLIC/BCOMP,C......... 120IRON POLYSACCHARIDE COMPLEX............. 120IRON POLYSACCHARIDE COMPLEX (150 MG)(CAPSULE) (OTC).....................................................IRON/C/B12/CALCIU/STOMACH CONC..........120IRON/CALCIUM/E/FOLIC ACID/MVIT............ 120IRON/LIVER EXT/VIT BCOMP,C/MIN............. 120ISENTRESS (100 MG) (POWD PACK).................78ISENTRESS (100 MG) (TAB CHEW)................... 78ISENTRESS (25 MG) (TAB CHEW)..................... 78ISENTRESS (400 MG) (TABLET).........................78ISENTRESS HD......................................................78ISOCARBOXAZID.................................................17ISOCHRON............................................................. 33ISONIAZID............................................................. 73ISOPROPANOL.................................................... 101ISOPROPYL ALCOHOL......................................101ISOPROPYL RUBBING ALCOHOL...................101ISOPTO ATROPINE............................................... 60ISOPTO CARPINE................................................. 60ISOPTO HOMATROPINE......................................60ISORDIL (10 MG) (TABLET)................................33ISORDIL (20 MG) (TABLET)................................34ISORDIL (30 MG) (TABLET)................................34ISORDIL (40 MG) (TABLET)................................34ISORDIL TITRADOSE.......................................... 34ISOSORBIDE DINIT/HYDRALAZINE................ 31ISOSORBIDE DINITRATE..............................33, 34ISOSORBIDE MONONITRATE............................34ISOSOURCE 1.5 CAL............................................ 94ISOSOURCE 1.5 CAL TUBE FEED......................94ISOSOURCE HN.................................................... 93ISOTRETINOIN......................................................38ISOXSUPRINE HCL.............................................. 34ISRADIPINE........................................................... 29ITRACONAZOLE...................................................73IVACAFTOR......................................................... 103


Index

IVERMECTIN.........................................................74IXAZOMIB CITRATE............................................90IXINITY.................................................................. 63

- J -JAKAFI....................................................................89JALYN........................................................... 117, 129JANUMET...............................................................47JANUMET XR (100-1000MG) (TBMP 24HR)......47JANUMET XR (50-1000 MG) (TBMP 24HR).......47JANUMET XR (50MG-500MG) (TBMP 24HR)....47JANUVIA................................................................ 48JARDIANCE................................................... 48, 129JENTADUETO........................................................ 47JENTADUETO XR (2.5-1000MG) (TAB BP 24H)....47JENTADUETO XR (5MG-1000MG) (TAB BP 24H)................................................................................. 47JEVANTIQUE......................................................... 67JEVITY 1 CAL........................................................94JEVITY 1.2 CAL.....................................................94JEVITY 1.5 CAL.....................................................94JIVI.......................................................................... 63JULUCA.................................................................. 74JUXTAPID...............................................................32JYNARQUE............................................................ 54

- K -KALETRA (100MG-25MG) (TABLET)................ 77KALETRA (200MG-50MG) (TABLET)................ 77KALETRA (400-100/5) (SOLUTION)...................77KALYDECO..........................................................103KAOPECTATE (240 MG) (CAPSULE) (OTC)...... 85KAPVAY..................................................................25KAZ INHALANT................................................... 16KEFLEX.................................................................. 70KENALOG IN ORABASE..................................... 91KEPPRA................................................................ 112KEPPRA XR......................................................... 112KERLONE...............................................................28KETOCAL 4:1.........................................................99KETOCONAZOLE........................................... 40, 73KETO-DIASTIX REAGENT..................................54KETOPROFEN........................................................83KETOROLAC TROMETHAMINE.................. 58, 83KEVEYIS.............................................................. 114KHEDEZLA.................................................... 18, 129KIMONO.................................................................92KIMONO MAXX....................................................92KIMONO MICROTHIN..........................................92KIMONO MICROTHIN AQUA LUBE.................. 92KIMONO TEXTURED...........................................92KISQALI................................................................. 90KISQALI FEMARA CO-PACK..............................89KLONOPIN...........................................................109

KLOR-CON-EF.......................................................55KOATE.................................................................... 63KOGENATE FS.......................................................63KONSYL (6 G) (POWD PACK) (OTC)..................86KONSYL (6 G/6 G) (POWDER) (OTC).................86KONSYL FORMULA-D (3.4 G/6.5G) (POWDER)(OTC).......................................................................86KONSYL-D (POWDER) (OTC)............................. 86KORLYM.................................................................48KOVALTRY.............................................................63K-PHOS NEUTRAL (250 MG) (TABLET) (OTC)....118KRINTAFEL........................................................... 74KRISTALOSE (20 G) (PACKET)................... 85, 129KUVAN................................................................... 87KWELL................................................................... 41KYLEENA...............................................................97KYTRIL.............................................................7, 129

- L -LABETALOL HCL................................................. 27LACOSAMIDE............................................. 110, 111LACTOSE-REDUCED FOOD............................... 93LACTOSE-REDUCED FOOD/FIBER............. 93, 94LACTULOSE.................................................... 84, 85LAMICTAL........................................................... 111LAMICTAL (BLUE).............................................111LAMICTAL (GREEN).......................................... 111LAMICTAL (ORANGE).......................................111LAMICTAL ODT (100 MG) (TAB RAPDIS)....111,129LAMICTAL ODT (200 MG) (TAB RAPDIS)....111,129LAMICTAL ODT (25 MG) (TAB RAPDIS)....111,129LAMICTAL ODT (50 MG) (TAB RAPDIS)....111,129LAMICTAL ODT (BLUE)............................111, 129LAMICTAL ODT (GREEN).........................111, 129LAMICTAL ODT (ORANGE)..................... 111, 129LAMICTAL XR (BLUE).............................. 111, 129LAMICTAL XR (GREEN)........................... 111, 129LAMICTAL XR (ORANGE)........................ 111, 129LAMISIL................................................................. 40LAMISIL AT (1 %) (CREAM (G)) (OTC)............. 40LAMIVUDINE............................................76, 77, 79LAMIVUDINE/TENOFOVIR DISOP FUM.......... 75LAMIVUDINE/ZIDOVUDINE.............................. 75LAMOTRIGINE............................................111, 112LAMOTRIGINE (100 MG) (TAB ER 24)............ 129LAMOTRIGINE (100 MG) (TAB RAPDIS)........ 129LAMOTRIGINE (100 MG) (TABLET)......................LAMOTRIGINE (150 MG) (TABLET)......................LAMOTRIGINE (200 MG) (TAB ER 24)............ 129LAMOTRIGINE (200 MG) (TAB RAPDIS)........ 129


Index

LAMOTRIGINE (200 MG) (TABLET)......................LAMOTRIGINE (25 MG) (TAB ER 24).............. 130LAMOTRIGINE (25 MG) (TAB RAPDIS).......... 130LAMOTRIGINE (25 MG) (TABLET)........................LAMOTRIGINE (25 MG) (TB CHW DSP)...............LAMOTRIGINE (25(21)-50) (TB RD DSPK)..... 130LAMOTRIGINE (25(42)-100) (TAB DS PK).............LAMOTRIGINE (25(84)-100) (TAB DS PK).............LAMOTRIGINE (250 MG) (TAB ER 24)............ 130LAMOTRIGINE (25-50-100) (TB RD DSPK).....130LAMOTRIGINE (25MG (35)) (TAB DS PK)............LAMOTRIGINE (300 MG) (TAB ER 24)............ 130LAMOTRIGINE (5 MG) (TB CHW DSP).................LAMOTRIGINE (50 MG) (TAB ER 24).............. 130LAMOTRIGINE (50 MG) (TAB RAPDIS).......... 130LAMOTRIGINE (50(42)-100) (TB RD DSPK)....130LANCETS............................................................... 51LANCING DEVICE..........................................51, 52LANCING DEVICE/LANCETS.......................52, 53LANCING SYSTEM...............................................52LANOLIN ALCOHOL/MO/W.PET/CERES..........43LANOLIN/ALOE VERA/PROP GLY.................... 43LANSOPRAZOLE................................................ 117LANSOPRAZOLE (15 MG) (CAPSULE DR)...........LANSOPRAZOLE (15 MG) (CAPSULE DR)(OTC)...........................................................................LANSOPRAZOLE (15 MG) (TAB RAP DR)...... 130LANSOPRAZOLE (30 MG) (CAPSULE DR)...........LANSOPRAZOLE (30 MG) (TAB RAP DR)...... 130LANSOPRAZOLE/AMOXICILN/CLARITH......116LANZO....................................................................52LAPATINIB DITOSYLATE....................................90LARIAM..................................................................74LAROTRECTINIB SULFATE................................ 90LASIX......................................................................30LATANOPROST..................................................... 60LATUDA (120 MG) (TABLET)......................21, 130LATUDA (20 MG) (TABLET)........................22, 130LATUDA (40 MG) (TABLET)........................22, 130LATUDA (60 MG) (TABLET)........................22, 130LATUDA (80 MG) (TABLET)........................22, 130LC D NEBULIZER SET......................................... 13LC PLUS................................................................. 13LC PLUS NEBULIZER-PED MASK.....................13LC SPRINT NEBULIZER...................................... 13LC STAR................................................................. 13LEDIPASVIR/SOFOSBUVIR................................ 79LEFLUNOMIDE.....................................................80LEMON EUCALYPTUS OIL.................................39LENALIDOMIDE................................................... 89LENVATINIB MESYLATE.................................... 90LENVIMA...............................................................90LETAIRIS................................................................30

LETROZOLE.......................................................... 88LEUCOVORIN CALCIUM.................................... 90LEU-FREE COOLER............................................. 99LEUKERAN............................................................88LEUKINE................................................................ 66LEUPROLIDE ACETATE.................................56, 57LEUPROLIDE/NORETHINDRONE ACET.......... 67LEVALBUTEROL HCL............................................8LEVAQUIN............................................................. 72LEVBID.................................................................115LEVETIRACETAM.............................................. 112LEVOBUNOLOL HCL...........................................60LEVOCARNITINE................................................. 97LEVOCARNITINE (WITH SUGAR).....................97LEVOCETIRIZINE DIHYDROCHLORIDE........... 6LEVOFLOXACIN.............................................59, 72LEVOMEFOLATE/B6/B12/ALGAL OIL............ 123LEVOMILNACIPRAN HCL.................................. 18LEVONORGEST/ETH.ESTRADIOL/IRON..........35LEVONORGESTREL.......................................35, 97LEVONORGESTREL-ETHIN ESTRADIOL........ 35LEVONORGESTREL-ETHIN ESTRADIOL (0.1-0.02MG) (TABLET)....................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03) (TABLET)..........................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03) (TBDSPK 3MO).................................................LEVONORGESTREL-ETHIN ESTRADIOL (6-5-10) (TABLET).............................................................LEVONORGESTREL-ETHIN ESTRADIOL (90-20MCG) (TABLET)........................................................LEVORPHANOL TARTRATE............................. 105LEVORPHANOL TARTRATE (2 MG) (TABLET).....................................................................................LEVOTHYROXINE SODIUM............................... 57LEVSIN................................................................. 115LEVSIN-SL........................................................... 115LEXAPRO............................................................... 18LEXIVA (50 MG/ML) (ORAL SUSP)....................78LEXIVA (700 MG) (TABLET)............................... 78LIBRAX................................................................ 116LIDAMANTLE HC.................................................45LIDEX..................................................................... 42LIDEX-E..................................................................42LIDOCAINE............................................................46LIDOCAINE (3 %) (CREAM (G)) (OTC)..................LIDOCAINE (4 %) (ADH. PATCH) (OTC)...............LIDOCAINE (4 %) (CREAM (G)) (OTC)..................LIDOCAINE (5 %) (ADH. PATCH)...........................LIDOCAINE (5 %) (OINT. (G))........................... 130LIDOCAINE HCL.............................................46, 83LIDOCAINE HCL (3 %) (CREAM (G))....................LIDOCAINE HCL (4 %) (CREAM (G)) (OTC).........LIDOCAINE HCL (4 %) (SOLUTION).....................


Index

LIDOCAINE HCL/COLLAGEN............................ 46LIDOCAINE/ALOE VERA....................................46LIDOCAINE/ALOE VERA (0.5 %) (GEL (GRAM))(OTC)...........................................................................LIDOCAINE/HYDROCORTISONE AC..........45, 84LIDOCAINE/PRILOCAINE...................................46LIDOTREX............................................................. 46LIFITEGRAST........................................................ 59LILETTA................................................................. 97LIMBITROL............................................................19LIMBITROL DS......................................................19LINACLOTIDE....................................................... 84LINAGLIPTIN.........................................................48LINAGLIPTIN/METFORMIN HCL...................... 47LINDANE................................................................41LINEZOLID............................................................ 71LINZESS................................................................. 84LIOTHYRONINE SODIUM...................................57LIPASE/PROTEASE/AMYLASE.........................115LIPISTART............................................................100LIPITOR (10 MG) (TABLET)................................ 31LIPITOR (20 MG) (TABLET)................................ 31LIPITOR (40 MG) (TABLET)................................ 31LIPITOR (80 MG) (TABLET)................................ 31LIQUACEL 100.......................................................92LIRAGLUTIDE.......................................................47LISDEXAMFETAMINE DIMESYLATE...............20LISINOPRIL............................................................27LISINOPRIL/HYDROCHLOROTHIAZIDE..........27LISSAMINE GREEN..............................................62LITE TOUCH.......................................................... 52LITEAIRE............................................................... 10LITETOUCH........................................................... 11LITHIUM CARBONATE........................................20LITHIUM CITRATE............................................... 20LITHOBID.............................................................. 20L-NORGEST/E.ESTRADIOL-E.ESTRAD............ 35LO LOESTRIN FE.................................................. 35LOCOID (0.1 %) (CREAM (G)).............................42LOCOID (0.1 %) (OINT. (G)).................................42LOCOID (0.1 %) (SOLUTION)..............................42LODINE.................................................................. 82LODINE XL............................................................ 82LODOSYN............................................................ 109LODOXAMIDE TROMETHAMINE..................... 59LOESTRIN.............................................................. 35LOESTRIN 24 FE................................................... 35LOESTRIN FE........................................................ 35LOFIBRA................................................................ 33LOMITAPIDE MESYLATE................................... 32LOMOTIL............................................................... 84LONITEN................................................................ 28LONSURF............................................................... 88LO-OVRAL-28........................................................36

LO-OVRAL-8..........................................................36LOPERAMIDE HCL...............................................84LOPERAMIDE HCL (2 MG) (CAPSULE)................LOPERAMIDE HCL (2 MG) (CAPSULE) (OTC)....LOPERAMIDE HCL (2 MG) (TABLET) (OTC).......LOPID......................................................................33LOPINAVIR/RITONAVIR...................................... 77LOPRESSOR HCT..................................................29LOPROX..................................................................40LORATADINE.......................................................... 6LORATADINE/PSEUDOEPHEDRINE................... 4LORAZEPAM......................................................... 20LORBRENA............................................................90LORLATINIB..........................................................90LOSARTAN POTASSIUM..................................... 28LOSARTAN/HYDROCHLOROTHIAZIDE...........27LOSEASONIQUE...................................................35LOTEMAX..............................................................58LOTENSIN..............................................................27LOTENSIN HCT.....................................................27LOTEPREDNOL ETABONATE.............................58LOTREL.................................................................. 27LOTRISONE........................................................... 40LOVASTATIN..........................................................31LOVAZA..................................................................33LOVENOX (100 MG/ML) (SYRINGE)................. 64LOVENOX (120MG/.8ML) (SYRINGE)............... 64LOVENOX (150 MG/ML) (SYRINGE)................. 64LOVENOX (300MG/3ML) (VIAL)........................64LOVENOX (30MG/0.3ML) (SYRINGE)............... 64LOVENOX (40MG/0.4ML) (SYRINGE)............... 65LOVENOX (60MG/0.6ML) (SYRINGE)............... 65LOVENOX (80MG/0.8ML) (SYRINGE)............... 65LOXAPINE............................................................. 21LOXAPINE SUCCINATE.......................................21LOXITANE..............................................................21LOZOL.................................................................... 31LUBIPROSTONE....................................................85LUDIOMIL..............................................................19LUMACAFTOR/IVACAFTOR.............................103LUMIGAN (0.01 %) (DROPS)............................... 60LUMIGAN (0.03 %) (DROPS)............................... 60LUNESTA............................................................... 25LUPANETA PACK..................................................67LUPRON DEPOT..............................................56, 57LUPRON DEPOT (LUPANETA)............................57LUPRON DEPOT-PED........................................... 57LURASIDONE HCL.........................................21, 22LUVOX....................................................................18LUVOX CR..................................................... 18, 130LYNPARZA.............................................................90LYRICA.................................................................112LYSODREN............................................................ 90LYSTEDA................................................................62


Index

- M -M9............................................................................43MACITENTAN....................................................... 30MACROBID............................................................ 71MACRODANTIN (100 MG) (CAPSULE)............. 71MACRODANTIN (25 MG) (CAPSULE)............... 71MACRODANTIN (50 MG) (CAPSULE)............... 71MAFENIDE ACETATE.......................................... 41MAG CARB/ALUMINUM HYDROX/ALGIN....115, 116MAG CARB/ALUMINUM HYDROX/ALGIN (358-95/15) (ORAL SUSP) (OTC)......................................MAG HYDROX/ALUMINUM HYD/SIMETH....116MAG HYDROX/ALUMINUM HYD/SIMETH(200-200-20) (ORAL SUSP) (OTC)...........................MAG HYDROX/ALUMINUM HYD/SIMETH(200-200-25) (TAB CHEW) (OTC)............................MAG HYDROX/ALUMINUM HYD/SIMETH(400-400-40) (ORAL SUSP) (OTC)...........................MAGNEBIND 300.................................................. 54MAGNESIUM.......................................................120MAGNESIUM (250 MG) (TABLET) (OTC)..............MAGNESIUM CHLORIDE..................................120MAGNESIUM CHLORIDE (64 MG) (TABLETDR) (OTC)...................................................................MAGNESIUM CHLORIDE (71.5 MG) (TABLETDR) (OTC)...................................................................MAGNESIUM CITRATE....................................... 85MAGNESIUM CITRATE (SOLUTION) (OTC)........MAGNESIUM HYDROXIDE................................ 85MAGNESIUM OXIDE..................................116, 120MAGNESIUM OXIDE (400 MG) (TABLET) (OTC).....................................................................................MAGNESIUM OXIDE (420 MG) (TABLET) (OTC).....................................................................................MAGNESIUM OXIDE (500 MG) (TABLET) (OTC).....................................................................................MAGNI-GUIDE MAGNIFIER............................... 50MALARONE...........................................................74MALTODEXTRIN.................................................. 94MALTODEXTRIN/FRUCTOSE.............................94MALTODEXTRIN/XANTHAN GUM.................102MANDELAMINE................................................... 70MANNITOL/SORBITOL SOLUTION.................. 44MANNOSE..............................................................92MAPROTILINE HCL..............................................19MARAVIROC..........................................................75MARINOL.........................................................7, 130MARPLAN..............................................................17MATULANE........................................................... 90MAVIK.................................................................... 27MAVYRET.............................................................. 79MAXZIDE...............................................................30

MAXZIDE-25 MG.................................................. 30MEASLES,MUMPS,RUB,VARICELLA/PF..........68MEASLES,MUMPS,RUBELLA VACC/PF........... 69MEBENDAZOLE................................................... 74MECASERMIN.......................................................57MECHLORETHAMINE HCL................................45MECLIZINE HCL.....................................................7MECLIZINE HCL (12.5 MG) (TABLET)..................MECLIZINE HCL (12.5 MG) (TABLET) (OTC).......MECLIZINE HCL (25 MG) (TAB CHEW) (OTC)....MECLIZINE HCL (25 MG) (TABLET).....................MECLIZINE HCL (25 MG) (TABLET) (OTC)..........MECLOFENAMATE SODIUM............................. 83MECLOMEN.......................................................... 83MEDERMA AG...................................................... 47MEDIHONEY......................................................... 46MEDROL (16 MG) (TABLET)...............................81MEDROL (2 MG) (TABLET).................................81MEDROL (32 MG) (TABLET)...............................81MEDROL (4 MG) (TAB DS PK)............................ 81MEDROL (4 MG) (TABLET).................................81MEDROL (8 MG) (TABLET).................................81MEDROXYPROGESTERONE ACETATE...... 34, 67MEDTRONIC REMOTE CONTROL.....................50MEFLOQUINE HCL.............................................. 74MEGACE.................................................................91MEGACE ES...................................................91, 130MEGESTROL ACETATE....................................... 91MEKINIST.............................................................. 89MEKTOVI............................................................... 89MELLARIL............................................................. 24MELOXICAM.........................................................83MELPHALAN.........................................................88MEMANTINE HCL..........................................16, 17MEMANTINE HCL/DONEPEZIL HCL................17MENACTRA........................................................... 67MENEST................................................................. 67MENING VAC A,C,Y,W-135 DIP/PF.....................67MENINGOCOCCAL B VACCINE,4-COMP.........68MENTHOL/BANDAGES, TUBULAR.................. 44MENVEO A-C-Y-W-135-DIP.................................67MEPERIDINE HCL.............................................. 105MEPERIDINE HCL/PF.........................................105MEPROBAMATE................................................... 20MEPRON.................................................................74MERCAPTOPURINE............................................. 88MESALAMINE.................................................83, 84MESALAMINE W/CLEANSING WIPES............. 83ME-SALICYLATE/ISOPROP.ALCOHOL.............44MESTINON (180 MG) (TABLET ER)...................17MESTINON (60 MG) (TABLET)...........................17MESTINON (60 MG/5 ML) (SYRUP)................... 17METAGLIP..............................................................48METAMUCIL (3.4 G/7 G) (POWDER) (OTC)...... 86


Index

METAMUCIL (3.4G/11G) (POWDER) (OTC)...... 86METAMUCIL (POWDER) (OTC)..........................86METANX (3-35-2 MG) (CAPSULE) (OTC)........123METAPROTERENOL SULFATE.............................7METFORMIN HCL................................................ 48METFORMIN HCL (1000 MG) (TABLET)...............METFORMIN HCL (500 MG) (TAB ER 24H)..........METFORMIN HCL (500 MG) (TABLET).................METFORMIN HCL (500 MG/5ML) (SOLUTION).....................................................................................METFORMIN HCL (750 MG) (TAB ER 24H)..........METFORMIN HCL (850 MG) (TABLET).................METH/MEBLUE/SOD PHOS/PSAL/HYOS......... 70METHAMPHETAMINE HCL................................20METHEN/MBLUE/SAL/SOD PHOS/HYOS.........70METHENAM/M.BLUE/SALICYL/HYOSCY.......70METHENAM/SOD PHOS/MBLUE/HYOSCY..... 70METHENAMINE HIPPURATE............................. 70METHENAMINE MANDELATE.......................... 70METHIMAZOLE.................................................... 57METHOCARBAMOL...........................................114METHOTREXATE SODIUM.................................88METHOTREXATE SODIUM/PF........................... 88METHOTREXATE/PF......................................79, 80METHOXSALEN................................................... 46METHOXSALEN (10 MG) (CAP LQ RAP)..............METHSCOPOLAMINE BROMIDE.................... 115METHSUXIMIDE................................................ 112METHYCLOTHIAZIDE.........................................31METHYL SALICYLATE....................................... 44METHYL SALICYLATE (LIQUID) (OTC)...............METHYL SALICYLATE (OIL) (OTC)......................METHYLCELLULOSE..................................85, 102METHYLCELLULOSE (WITH SUGAR)............. 85METHYLCELLULOSE 1500CPS........................102METHYLDOPA...................................................... 28METHYLDOPA/HYDROCHLOROTHIAZIDE.... 28METHYLERGONOVINE MALEATE................... 36METHYLPHENIDATE HCL............................25, 26METHYLPHENIDATE HCL (10 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (10 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (10 MG) (TABCHEW)........................................................................METHYLPHENIDATE HCL (10 MG) (TABLETER)...............................................................................METHYLPHENIDATE HCL (10 MG) (TABLET)....METHYLPHENIDATE HCL (10 MG/5 ML)(SOLUTION)...............................................................METHYLPHENIDATE HCL (18 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (2.5 MG) (TABCHEW)........................................................................

METHYLPHENIDATE HCL (20 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (20 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (20 MG) (TABLETER)...............................................................................METHYLPHENIDATE HCL (20 MG) (TABLET)....METHYLPHENIDATE HCL (27 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (30 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (30 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (36 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (40 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (40 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (5 MG) (TAB CHEW).....................................................................................METHYLPHENIDATE HCL (5 MG) (TABLET)......METHYLPHENIDATE HCL (5 MG/5 ML)(SOLUTION)...............................................................METHYLPHENIDATE HCL (50 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (54 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (60 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (72 MG) (TAB ER 24).....................................................................................METHYLPREDNISOLONE.................................. 81METHYLTESTOSTERONE...................................66METIPRANOLOL.................................................. 60METOCLOPRAMIDE HCL................................. 117METOLAZONE...................................................... 31METOPROLOL SUCCINATE................................28METOPROLOL TARTRATE..................................28METOPROLOL TARTRATE (100 MG) (TABLET).....................................................................................METOPROLOL TARTRATE (25 MG) (TABLET)....METOPROLOL TARTRATE (50 MG) (TABLET)....METOPROLOL/HYDROCHLOROTHIAZIDE.....29METRELEPTIN...................................................... 57METROCREAM..................................................... 38METROGEL............................................................38METROGEL-VAGINAL....................................... 118METROLOTION.....................................................38METRONIDAZOLE................................. 38, 74, 118MEVACOR.............................................................. 31MEXILETINE HCL................................................ 26MEXITIL.................................................................26MIACALCIN (200/SPRAY) (SPRAY/PUMP)....... 56


Index

MICARDIS..............................................................28MICONAZOLE NITRATE............................. 40, 118MICONAZOLE NITRATE (100 MG) (SUPP.VAG)(OTC)...........................................................................MICONAZOLE NITRATE (2 %) (CREAM (G))(OTC)...........................................................................MICONAZOLE NITRATE (2 %) (CREAM/APPL)(OTC)...........................................................................MICONAZOLE NITRATE (200 MG) (SUPP.VAG).....................................................................................MICRO AIR............................................................ 13MICROCHAMBER.................................................10MICROLET 2.......................................................... 52MICROLET NEXT LANCING DEVICE...............52MICROLIFE PEAK FLOW.................................... 15MICROSPACER......................................................10MIDAMOR..............................................................30MIDAZOLAM HCL................................................24MIDODRINE HCL................................................. 33MIDOSTAURIN......................................................90MIFEPRISTONE.....................................................48MIGLUSTAT........................................................... 96MIGRANAL..........................................................106MILLIPRED............................................................ 81MILLIPRED DP......................................................81MILNACIPRAN HCL.............................................91MILTEFOSINE....................................................... 74MIMYX................................................................... 43MINASTRIN 24 FE.................................................35MINERAL OIL....................................................... 85MINERAL OIL (OIL) (OTC)......................................MINERAL OIL/PETROLATUM,WHITE........ 44, 62MINERAL OIL/PETROLATUM,WHITE (15 %-83%) (OINT. (G)) (OTC).................................................MINERAL OIL/PETROLATUM,WHITE (15%-85%) (OINT. (G)) (OTC).............................................MINERAL OIL/PETROLATUM,WHITE (42.5-57.3%) (OINT. (G)) (OTC)..........................................MINERAL OIL/PETROLATUM,WHITE (CREAM(G)) (OTC)...................................................................MINERAL,LANOLIN OILS/PROP GLYC............ 44MINERALS/PROTEIN SUPPLEMENT.............. 120MINI LANCING DEVICE......................................52MINI PLUS NEBULIZER...................................... 13MINICOMP COMPRESSOR NEBULIZER.......... 13MINIMED QUICK-SERTER..................................50MINIPRESS............................................................ 27MINIVELLE............................................................67MINI-WRIGHT PEAK FLOW METER.................15MINOCYCLINE HCL...................................... 72, 73MINOCYCLINE HCL (100 MG) (CAPSULE)..........MINOCYCLINE HCL (100 MG) (TABLET).............MINOCYCLINE HCL (50 MG) (CAPSULE)............MINOCYCLINE HCL (50 MG) (TABLET)...............

MINOCYCLINE HCL (75 MG) (CAPSULE)............MINOCYCLINE HCL (75 MG) (TABLET)...............MINOXIDIL............................................................28MIRALAX (17G) (POWD PACK) (OTC).............. 86MIRALAX (17G/DOSE) (POWDER) (OTC).........86MIRAPEX............................................................. 109MIRCETTE............................................................. 35MIRENA..................................................................97MIRTAZAPINE.......................................................17MISOPROSTOL....................................................116MISTASSIST...........................................................15MISTASSIST KIT................................................... 15MITE,D.FARINAE-D.PTERONYSSINUS.............. 4MITOTANE............................................................. 90MMA-PA................................................................. 99MMA-PA COOLER15............................................ 99M-M-R II VACCINE............................................... 69MOBIC.................................................................... 83MODAFINIL........................................................... 24MODICON.............................................................. 35MODURETIC 5-50................................................. 30MOEXIPRIL HCL...................................................27MOMETASONE FUROATE...............................6, 42MOMETASONE/FORMOTEROL............................8MONOCLATE-P..................................................... 63MONODOX (100 MG) (CAPSULE)...................... 72MONODOX (50 MG) (CAPSULE)........................ 72MONODOX (50 MG) (TABLET)...........................72MONODOX (75 MG) (TABLET)...........................72MONOKET............................................................. 34MONONINE............................................................63MONOPRIL............................................................ 27MONOPRIL-HCT................................................... 27MONTELUKAST SODIUM.....................................9MORGIDOX........................................................... 72MORPHINE SULFATE.........................................105MORPHINE SULFATE (10 MG) (CAP ER PEL)......MORPHINE SULFATE (10 MG) (SUPP.RECT)........MORPHINE SULFATE (10 MG/5 ML)(SOLUTION)...............................................................MORPHINE SULFATE (100 MG) (CAP ER PEL)....MORPHINE SULFATE (100 MG) (TABLET ER).....MORPHINE SULFATE (100 MG/5ML)(SOLUTION)...............................................................MORPHINE SULFATE (10MG/0.7ML) (PENINJCTR)......................................................................MORPHINE SULFATE (120 MG) (CPMP 24HR).....MORPHINE SULFATE (15 MG) (TABLET ER).......MORPHINE SULFATE (15 MG) (TABLET).............MORPHINE SULFATE (20 MG) (CAP ER PEL)......MORPHINE SULFATE (20 MG) (SUPP.RECT)........MORPHINE SULFATE (20 MG/5 ML)(SOLUTION)...............................................................MORPHINE SULFATE (200 MG) (TABLET ER).....


Index

MORPHINE SULFATE (30 MG) (CAP ER PEL)......MORPHINE SULFATE (30 MG) (CPMP 24HR).......MORPHINE SULFATE (30 MG) (SUPP.RECT)........MORPHINE SULFATE (30 MG) (TABLET ER).......MORPHINE SULFATE (30 MG) (TABLET).............MORPHINE SULFATE (40 MG) (CAP ER PEL)......MORPHINE SULFATE (45 MG) (CPMP 24HR).......MORPHINE SULFATE (5 MG) (SUPP.RECT)..........MORPHINE SULFATE (50 MG) (CAP ER PEL)......MORPHINE SULFATE (60 MG) (CAP ER PEL)......MORPHINE SULFATE (60 MG) (CPMP 24HR).......MORPHINE SULFATE (60 MG) (TABLET ER).......MORPHINE SULFATE (75 MG) (CPMP 24HR).......MORPHINE SULFATE (80 MG) (CAP ER PEL)......MORPHINE SULFATE (90 MG) (CPMP 24HR).......MOTRIN (100 MG/5ML) (ORAL SUSP).............. 82MOTRIN (400 MG) (TABLET).............................. 82MOTRIN (600 MG) (TABLET).............................. 82MOTRIN (800 MG) (TABLET).............................. 82MOTRIN IB (200 MG) (TABLET) (OTC)............. 82MOUTHPIECE........................................................11MOVANTIK............................................................ 87MOVIPREP............................................................. 85MOXIFLOXACIN HCL....................................59, 72MSUD ANALOG.................................................... 97MSUD COOLER...................................................100MSUD COOLER20...............................................100MSUD EXPRESS COOLER.................................100MSUD EXPRESS15..............................................100MSUD LOPHLEX.................................................101MUCINEX DM (1200-60MG) (TAB ER 12H)(OTC).......................................................................38MUCOMYST........................................................ 103MUCUS CLEARING DEVICE.............................. 12MULTAQ................................................................. 26MULTI-LANCET....................................................53MULTIVIT WITH IRON,MINERALS.................119MULTIVIT WITH MINERALS/LUTEIN............119MULTIVIT WITH MINERALS/LUTEIN(TABLET) (OTC)........................................................MULTIVIT,CALC,MINS/IRON/FOLIC...............120MULTIVIT,CALC,MINS/IRON/FOLIC (9MG-400MCG) (TABLET) (OTC).......................................MULTIVIT,STRESS FORMULA/ZINC.............. 120MULTIVITAMIN.......................................... 120, 121MULTIVITAMIN (TAB CHEW) (OTC).....................MULTIVITAMIN (TABLET) (OTC)..........................MULTIVITAMIN WITH FOLIC ACID............... 120MULTIVITAMIN WITH FOLIC ACID (400 MCG)(TABLET) (OTC)........................................................MULTIVITAMIN WITH IRON.................... 120, 121MULTIVITAMIN WITH IRON (TAB CHEW)(OTC)...........................................................................MULTIVITAMIN WITH IRON (TABLET) (OTC)....

MULTIVITAMIN,STRESS FORMULA.............. 120MULTIVITAMIN,STRESS FORMULA (TABLET)(OTC)...........................................................................MULTIVITAMIN,THER AND MINERALS........120MULTIVITAMIN,THER AND MINERALS(TABLET) (OTC)........................................................MULTIVITAMIN,THERAPEUTIC......................120MULTIVITAMIN,THERAPEUTIC (TABLET)(OTC)...........................................................................MULTIVITAMIN/IRON/FOLIC ACID................ 120MULTIVITAMIN/IRON/FOLIC ACID (18MG-0.4MG) (TABLET) (OTC)..........................................MULTIVIT-MIN/FA/LUTEIN/ZEAXANT.......... 120MULTIVIT-MIN/FA/LYCOPEN/LUTEIN........... 119MULTIVIT-MIN/FA/LYCOPEN/LUTEIN (.4-300-250) (TABLET) (OTC)................................................MULTIVIT-MINS 53/FOLIC/K/COQ10.............. 121MULTIVIT-MINS 56/FOLIC/K/COQ10.............. 121MULTIVIT-MINS NO.61/IRON/FOLIC.............. 122MULTIVIT-MINS NO.64/IRON/FOLIC.............. 122MULTIVIT-MINS60/IRON FUM/FOLIC............ 122MULTIVIT-MINS60/IRON FUM/FOLIC (27 MG-1MG) (TABLET) (OTC)...............................................MUPIROCIN........................................................... 40MUPIROCIN CALCIUM..................................40, 91MV, MIN 59/IRON/FOLIC/DOCUSATE............. 122MV-MINS NO.50/IRON,CARB/FOLIC...............122MY MDI PORTABLE NEBULISER...................... 14MYALEPT...............................................................57MYAMBUTOL........................................................73MYCELEX.............................................................. 73MYCOBUTIN......................................................... 73MYCOPHENOLATE MOFETIL............................69MYCOPHENOLATE SODIUM............................. 69MYCOSTATIN..................................................40, 73MYDRIACYL......................................................... 60MYFORTIC.............................................................69MYLERAN..............................................................87MYSOLINE...........................................................112

- N -N.MENINGITIDIS B,LIPID FHBP RC..................68NABUMETONE......................................................83NADOLOL/BENDROFLUMETHIAZIDE.............29NAFARELIN ACETATE.........................................57NAFTIFINE HCL....................................................40NAFTIN (1 %) (CREAM (G))................................ 40NAFTIN (1 %) (GEL (GRAM))..............................40NAFTIN (2 %) (CREAM (G))................................ 40NAIL SCRUB.......................................................... 46NALBUPHINE HCL............................................. 105NALOXEGOL OXALATE......................................87NALOXONE HCL.................................................. 24NALTREXONE HCL.............................................. 24NALTREXONE MICROSPHERES........................20


Index

NAMENDA (10 MG) (TABLET)........................... 16NAMENDA (2 MG/ML) (SOLUTION)................. 16NAMENDA (5 MG) (TABLET)............................. 16NAMENDA (5 MG-10 MG) (TAB DS PK)............16NAMENDA XR (14 MG) (CAP SPR 24)............... 16NAMENDA XR (21 MG) (CAP SPR 24)............... 16NAMENDA XR (28 MG) (CAP SPR 24)............... 16NAMENDA XR (7 MG) (CAP SPR 24)................. 16NAMENDA XR (7-14-21-28) (CAP24 DSPK)...... 17NAMZARIC (14MG-10MG) (CAP SPR 24)....17,131NAMZARIC (21 MG-10MG) (CAP SPR 24)....17,131NAMZARIC (28 MG-10MG) (CAP SPR 24)....17,131NAMZARIC (7 MG-10 MG) (CAP SPR 24)....17,131NAMZARIC (7-10/14-10) (CAP24 DSPK).... 17, 131NAPRELAN (500 MG) (TBMP 24HR)..................83NAPROSYN............................................................ 83NAPROXEN............................................................ 83NAPROXEN SODIUM........................................... 83NARCAN.................................................................24NARDIL.................................................................. 17NASAL AIRFLOW STRIPS...................................12NASAL EXHALATION RESISTANC.DEV.......... 12NASAL STRIPS...................................................... 12NASALCROM (5.2 MG) (SPRAY/PUMP) (OTC)....6NASALIDE............................................................... 6NASONEX................................................................ 6NATAZIA.................................................................35NATEGLINIDE....................................................... 48NATELLE ONE.....................................................122NATRAPEL............................................................. 41NATURAL VEGETABLE FIBER (3.4 G/7 G)(POWDER) (OTC).................................................. 86NATURAL VEGETABLE FIBER (3.4G/11G)(POWDER) (OTC).................................................. 86NAVANE..................................................................23NEBIVOLOL HCL..................................................28NEBIVOLOL HCL/VALSARTAN......................... 27NEBULIZER..................................................... 12, 13NEBULIZER AND COMPRESSOR.................13-15NEBUPENT............................................................ 74NEBUSAL...............................................................96NEDOCROMIL SODIUM...................................... 59NEEDLE CLIP AND STORAGE DEVICE............53NEEVODHA......................................................... 123NEFAZODONE HCL..............................................18NELFINAVIR MESYLATE.................................... 78NEOCATE INFANT DHA-ARA............................ 97NEOCATE JUNIOR..............................................100

NEOCATE JUNIOR WITH PREBIOTICS (16 G-459) (POWDER) (OTC)........................................ 100NEOCATE JUNIOR WITH PREBIOTICS (16G-478) (POWDER) (OTC)........................................ 100NEOCATE NUTRA.............................................. 100NEOMYC/BACIT/POLYMYX/HYDROCORT..... 41NEOMYCIN SULF/BACITRACIN/POLY.............59NEOMYCIN SULF/POLYMYXIN B SULF..........44NEOMYCIN SULFATE.......................................... 73NEOMYCIN/BACIT/P-MYX/HYDROCORT....... 58NEOMYCIN/BACITRACIN/POLYMYXINB....... 40NEOMYCIN/BACITRACIN/POLYMYXINB (3.5-400-5K) (OINT PACK) (OTC)....................................NEOMYCIN/BACITRACIN/POLYMYXINB (3.5-400-5K) (OINT. (G)) (OTC)........................................NEOMYCIN/POLYMYXIN B/DEXAMETHA..... 58NEOMYCIN/POLYMYXIN B/HYDROCORT....41,54, 58NEOMYCIN/POLYMYXN B/GRAMICIDIN....... 59NEO-POLYCIN.......................................................59NEOSPORIN...........................................................59NEPAFENAC.......................................................... 58NEPRO CARB STEADY......................................100NESTABS..............................................................123NETUPITANT/PALONOSETRON HCL................. 7NEULASTA.............................................................65NEUPOGEN............................................................65NEUPRO....................................................... 109, 131NEVANAC...............................................................58NEVIRAPINE......................................................... 76NEW SKIN (0.2 %) (LIQ-FILM) (OTC)................ 45NEXA SELECT.....................................................122NEXAVAR...............................................................90NEXIUM (10 MG) (SUSPDR PKT).............117, 131NEXIUM (2.5 MG) (SUSPDR PKT)............117, 131NEXIUM (20 MG) (CAPSULE DR).................... 117NEXIUM (20 MG) (SUSPDR PKT).............117, 131NEXIUM (40 MG) (CAPSULE DR).................... 117NEXIUM (40 MG) (SUSPDR PKT).............117, 131NEXIUM (5 MG) (SUSPDR PKT)...............117, 131NEXPLANON.........................................................34NIACIN................................................................... 33NIACIN SA.................................................................NIACINAMIDE.......................................................33NIACINAMIDE (500 MG) (TABLET) (OTC)...........NIACOR.................................................................. 33NIACOR (500 MG) (TABLET) (OTC)...................33NIASPAN........................................................ 33, 131NIASPAN (500 MG) (CAPSULE ER) (OTC)........ 33NICARDIPINE HCL...............................................29NICODERM CQ................................................... 114NICOTINE.............................................................114NICOTINE PATCH.....................................................NICOTINE POLACRILEX...................................114


Index

NICOTROL................................................... 114, 131NICOTROL NS............................................. 114, 131NIFEDIPINE........................................................... 29NIFEREX.............................................................. 120NILANDRON..........................................................88NILOTINIB HCL.................................................... 90NILUTAMIDE.........................................................88NIMODIPINE..........................................................29NIMOTOP............................................................... 29NINLARO............................................................... 90NINTEDANIB ESYLATE.................................... 103NITISINONE...........................................................96NITRO-BID............................................................. 34NITRO-DUR (0.1MG/HR) (PATCH TD24)........... 34NITRO-DUR (0.2MG/HR) (PATCH TD24)........... 34NITRO-DUR (0.3 MG/HR) (PATCH TD24).......... 34NITRO-DUR (0.4MG/HR) (PATCH TD24)........... 34NITRO-DUR (0.6MG/HR) (PATCH TD24)........... 34NITRO-DUR (0.8MG/HR) (PATCH TD24)........... 34NITROFURANTOIN.............................................. 71NITROFURANTOIN MACROCRYSTAL............. 71NITROFURANTOIN MONOHYD/M-CRYST......71NITROGLYCERIN................................................. 34NITROSTAT............................................................ 34NITRO-TIME.......................................................... 34NITYR..................................................................... 96NIVESTYM (300MCG/0.5) (SYRINGE)...............65NIZATIDINE.........................................................116NIZORAL..........................................................40, 73NOLIX.....................................................................42NOLVADEX............................................................ 91NONOXYNOL 9...............................................34, 35NORDITROPIN FLEXPRO....................................57NORELGESTROMIN/ETHIN.ESTRADIOL........ 36NORETH-ETHINYL ESTRADIOL/IRON............ 35NORETHINDRONE............................................... 35NORETHINDRONE ACETATE............................. 67NORETHINDRONE AC-ETH ESTRADIOL....35,67NORETHINDRONE-E.ESTRADIOL-IRON......... 35NORETHINDRONE-ETHINYL ESTRAD...... 35, 36NORFLEX.............................................................114NORGESTIMATE-ETHINYL ESTRADIOL.........36NORGESTREL-ETHINYL ESTRADIOL............. 36NORPACE............................................................... 26NORPACE CR.........................................................26NORPRAMIN......................................................... 19NOR-Q-D................................................................ 35NORTHERA............................................................33NORTRIPTYLINE HCL......................................... 19NORVASC............................................................... 29NORVIR (100 MG) (CAPSULE)............................78NORVIR (100 MG) (POWD PACK).......................78NORVIR (100 MG) (TABLET)...............................78

NORVIR (80 MG/ML) (SOLUTION).................... 78NO-STICK GLUCOSE........................................... 54NOURISH................................................................95NOVAREL (10000 UNIT) (VIAL)..........................55NOVOEIGHT.......................................................... 62NOVOLIN 70-30............................................. 54, 131NOVOLIN 70-30 FLEXPEN...........................54, 131NOVOLIN N....................................................54, 131NOVOLIN R....................................................54, 131NOVOPEN ECHO...................................................50NOVOSEVEN RT................................................... 63NUCYNTA............................................................ 106NUCYNTA ER...................................................... 106NULEV..................................................................115NULYTELY WITH FLAVOR PACKS....................87NUT TX FOR ISOVALERIC ACIDEMIA............. 98NUT TX FOR TYROSINEMIA W-IRON.............. 99NUT TX, LACT-REDUCED, IRON....................... 94NUT. THERAPY FOR PKU, NO.49...................... 98NUT. TX FOR PKU WITH IRON #48................... 98NUT. TX FOR PKU WITH IRON NO.3................ 98NUT. TX FOR PKU,NO.66.....................................98NUT. TX FOR PROPIONIC ACIDEMIA...............99NUT.GLUC INT,LACT-FREE/FOS/DHA..............99NUT.SUP,SPEC,LAC-FREE,IRON/FOS................94NUT.THERAP.GLUTARIC ACIDURIA 1............. 99NUT.THERAPY,UREA CYCLE DISORDR..........99NUT.TX FOR PKU WITH IRON NO.20............... 98NUT.TX FOR PKU WITH IRON NO.27............... 98NUT.TX FOR PKU WITH IRON NO.35............... 98NUT.TX FOR PKU WITH IRON NO.4................. 98NUT.TX FOR PKU WITH IRON NO.40............... 98NUT.TX FOR PKU WITH IRON NO.42............... 98NUT.TX FOR PKU WITH IRON NO.45............... 98NUT.TX FOR PKU WITH IRON NO.52............... 98NUT.TX KETOGENIC,MILK BASE/SOY............ 99NUT.TX,ELEMENTAL,LAC-FREE/MCT.............99NUT.TX,IMPAIRED RENAL FXN,WHEY...........99NUT.TX,METAB.DIS,LEUCINE-FREE................99NUT.TX,METABOLIC DIS,METHIO-FR.............99NUT.TX. METABOLIC DISORDER,REG............ 99NUT.TX. METABOLIC DISORDER,SOY............ 99NUT.TX.COMP. IMMUNE SYSTM,REG....... 94, 99NUT.TX.GLUC INTOL,LF,SOY/FIBER................99NUT.TX.GLUC.INTOLER,LAC-FR,REG............. 99NUT.TX.GLUC.INTOLER,LAC-FR,SOY..... 99, 100NUT.TX.IMP.RENAL FXN,LAC-REDUC.......... 100NUT.TX.IMPAIR DIGES/INULIN/FOS................ 94NUT.TX.IMPAIRED DIGEST FXN.......94, 100, 101NUT.TX.IMPAIRED DIGEST FXN,SOY............ 100NUT.TX.IMPAIRED DIGEST/FIBER................. 100NUT.TX.PULM.DISORD.REG,LAC-FR............. 100NUT.TX.PULM.DISORD.SOY,LACFREE.......... 100NUTRAMIGEN ENFLORA-LGG......................... 96


Index

NUTRA-PRO...........................................................94NUTREN FIBER 1 CAL.........................................94NUTREN JUNIOR..................................................94NUTREN JUNIOR FIBER......................................94NUTREN PULMONARY..................................... 100NUTRI.SUPP,LACTO-FREE,IRON/SOY.............. 94NUTRIT SUPP/INULIN/FOS/FIBER.................... 94NUTRIT.THERAPY, MSUD WITH IRON....100,101NUTRITION SUPP NO.1/FOS/INULIN................94NUTRITIONAL SUPP/INULIN/FOS.................... 94NUTRITIONAL SUPPLEMENT......................94, 95NUTRITIONAL SUPPLEMENT/FIBER............... 95NUTRITIONAL SUPPLEMENT/MCT..................95NUTRITIONAL TX FOR PKU NO.31.................. 98NUTRITIONAL TX FOR PKU NO.64.................. 98NUTRITIONAL TX FOR PKU NO.71.................. 98NUTRITIONAL TX, KETOGENIC,MILK.......... 101NUVARING.............................................................34NUWIQ....................................................................62NYAMYC................................................................ 40NYMALIZE............................................................ 29NYSTATIN........................................................ 40, 73NYSTATIN/TRIAMCIN......................................... 40NYSTATIN/TRIAMCIN (100000-0.1) (CREAM(G))..............................................................................NYSTATIN/TRIAMCIN (100000-0.1) (OINT. (G)).....................................................................................NYSTEX..................................................................40NYSTOP..................................................................40

- O -OA2..........................................................................99OBETICHOLIC ACID............................................ 85OBIZUR.................................................................. 63OBTREX DHA......................................................122OCALIVA................................................................85OCTREOTIDE ACETATE.................................... 101OCUFEN................................................................. 58OCUFLOX...............................................................59OCUPRESS............................................................. 60ODACTRA................................................................ 4ODEFSEY............................................................... 79ODOMZO................................................................88ODOR ELIMINATOR DROPS............................... 43OFEV.....................................................................103OFLOXACIN...............................................54, 59, 72OLANZAPINE........................................................ 22OLANZAPINE PAMOATE.....................................22OLANZAPINE/FLUOXETINE HCL..................... 25OLAPARIB..............................................................90OLMESARTAN MEDOXOMIL.............................28OLMESARTAN/HYDROCHLOROTHIAZIDE.....27OLODATEROL HCL................................................ 8OLOPATADINE HCL......................................... 6, 58

OLUX...................................................................... 41OLUX-E.................................................................. 41OMACETAXINE MEPESUCCINATE................... 90OMBRA COMPRESSOR SYSTEM...................... 14OMEGA-3 ACID ETHYL ESTERS....................... 33OMEPRAZOLE.................................................... 117OMEPRAZOLE (10 MG) (CAPSULE DR)...............OMEPRAZOLE (20 MG) (CAPSULE DR)...............OMEPRAZOLE (20 MG) (TABLET DR) (OTC).......OMEPRAZOLE (40 MG) (CAPSULE DR)...............OMEPRAZOLE MAGNESIUM...........................117OMEPRAZOLE MAGNESIUM (20 MG)(CAPSULE DR) (OTC)...............................................OMNICEF............................................................... 70OMNIPOD DASH PDM KIT..................................51OMNIPRED............................................................ 58ON CALL LANCING DEVICE............................. 52ON CALL PLUS LANCING DEVICE...................52ONDANSETRON......................................................7ONDANSETRON HCL.............................................7ONDANSETRON HCL (24 MG) (TABLET).............ONDANSETRON HCL (4 MG) (TABLET)...............ONDANSETRON HCL (4 MG/5 ML) (SOLUTION).....................................................................................ONDANSETRON HCL (8 MG) (TABLET)...............ONE WAY MOUTHPIECE.....................................11ONETOUCH DELICA............................................53ONETOUCH SURESOFT...................................... 51ONFI (10 MG) (TABLET)............................ 109, 131ONFI (2.5 MG/ML) (ORAL SUSP)..............109, 131ONFI (20 MG) (TABLET)............................ 109, 131OPANA.................................................................. 106OPANA ER (10 MG) (TAB ER 12H)....................106OPANA ER (15 MG) (TAB ER 12H)....................106OPANA ER (20 MG) (TAB ER 12H)....................106OPANA ER (30 MG) (TAB ER 12H)....................106OPANA ER (40 MG) (TAB ER 12H)....................106OPANA ER (5 MG) (TAB ER 12H)......................106OPANA ER (7.5 MG) (TAB ER 12H)...................106OPIUM TINCTURE................................................84OPIUM/BELLADONNA ALKALOIDS.............. 105OPSUMIT................................................................30OPTICHAMBER.....................................................11OPTICHAMBER DIAMOND........................... 10-12OPTICROM.............................................................59OPTIPRANOLOL................................................... 60OPTIVAR.................................................................58ORACEA......................................................... 72, 131ORALAIR (100 IR) (TAB SUBL)............................ 4ORALAIR (300 IR) (TAB SUBL)............................ 4ORAP.......................................................................20ORAPRED...............................................................81ORENCIA................................................................80ORENCIA CLICKJECT......................................... 80


Index

ORENITRAM ER................................................... 30ORFADIN................................................................96ORILISSA............................................................... 57ORINASE................................................................ 48ORKAMBI............................................................ 103ORPHENADRINE CITRATE...............................114ORTHO EVRA........................................................36ORTHO MICRONOR............................................. 35ORTHO TRI-CYCLEN........................................... 36ORTHO TRI-CYCLEN LO.....................................36ORTHO-CEPT.........................................................35ORTHO-CYCLEN.................................................. 36ORTHO-NOVUM....................................................35OSELTAMIVIR PHOSPHATE............................... 74OSIMERTINIB MESYLATE..................................90OSMOLITE 1 CAL................................................. 94OSMOLITE 1.2 CAL.............................................. 94OSMOLITE 1.5 CAL.............................................. 94OSMOPREP............................................................ 87OSTOMY SUPPLY................................................. 43OTEZLA..................................................................80OVAL TAPE............................................................ 50OVCON-35.............................................................. 35OVRAL....................................................................36OXANDRIN............................................................ 66OXANDROLONE................................................... 66OXAPROZIN...........................................................83OXAZEPAM............................................................20OXCARBAZEPINE.............................................. 112OXEPA...................................................................100OXTELLAR XR (150 MG) (TAB ER 24H)....112,132OXTELLAR XR (300 MG) (TAB ER 24H)....112,132OXTELLAR XR (600 MG) (TAB ER 24H)....112,132OXYBUTYNIN CHLORIDE................................118OXYCODONE HCL..................................... 105, 106OXYCODONE HCL (10 MG) (TAB ER 12H)...........OXYCODONE HCL (10 MG) (TABLET).................OXYCODONE HCL (15 MG) (TAB ER 12H)...........OXYCODONE HCL (15 MG) (TABLET).................OXYCODONE HCL (20 MG) (TAB ER 12H)...........OXYCODONE HCL (20 MG) (TABLET).................OXYCODONE HCL (20 MG/ML) (ORAL CONC).....................................................................................OXYCODONE HCL (30 MG) (TAB ER 12H)...........OXYCODONE HCL (30 MG) (TABLET).................OXYCODONE HCL (40 MG) (TAB ER 12H)...........OXYCODONE HCL (5 MG) (CAPSULE).................OXYCODONE HCL (5 MG) (TABLET)...................OXYCODONE HCL (5 MG/5 ML) (SOLUTION)....OXYCODONE HCL (60 MG) (TAB ER 12H)...........OXYCODONE HCL (80 MG) (TAB ER 12H)...........

OXYCODONE HCL/ACETAMINOPHEN.......... 107OXYCODONE HCL/ACETAMINOPHEN (10MG-325MG) (TABLET).....................................................OXYCODONE HCL/ACETAMINOPHEN (2.5-325MG) (TABLET)...........................................................OXYCODONE HCL/ACETAMINOPHEN (5 MG-325MG) (TABLET).....................................................OXYCODONE HCL/ACETAMINOPHEN (7.5-325MG) (TABLET)...........................................................OXYCODONE HCL/ASPIRIN............................ 107OXYCONTIN........................................................106OXYMETAZOLINE HCL...................................... 38OXYMETAZOLINE HCL (0.05 %) (MIST) (OTC).....................................................................................OXYMETAZOLINE HCL (0.05 %) (SPRAY) (OTC).....................................................................................OXYMORPHONE HCL....................................... 106

- P -PALBOCICLIB....................................................... 90PALGIC..................................................................... 4PALIPERIDONE..................................................... 22PALIPERIDONE PALMITATE.........................22, 23PALYNZIQ.............................................................. 87PAMELOR...............................................................19PAMINE................................................................ 115PAMINE FORTE...................................................115PANDA MASK........................................................11PANDEL..................................................................42PANMYCIN............................................................ 73PANOBINOSTAT LACTATE..................................90PANRETIN..............................................................45PANTOPRAZOLE SODIUM................................117PANTOTHENIC ACID/ALOE VERA....................44PAPAVERINE HCL.................................................34PARADIGM REMOTE CONTROL....................... 50PARAGARD T 380-A............................................. 97PARCOPA..............................................................109PAREGORIC........................................................... 84PARI LC SPRINT SINUS....................................... 13PARI SINUS AEROSOL SYSTEM........................ 14PARICALCITOL.....................................................57PARLODEL...........................................................109PARNATE................................................................17PAROMOMYCIN SULFATE..................................74PAROXETINE HCL................................................18PAROXETINE MESYLATE................................... 18PASER..................................................................... 73PASIREOTIDE DIASPARTATE........................... 102PATANASE........................................................6, 132PATANOL................................................................58PATHOCIL.............................................................. 72PAXIL......................................................................18PAXIL CR................................................................18PAZOPANIB HCL...................................................90


Index

PCCA EMOLLIENT............................................. 101PEAK FLOW METER............................................ 15PEAK FLOW METER/INH ASSIT DEV...............15PEAK-AIR...............................................................15PED MULTIVIT 151/IRON/FLUORIDE............. 121PED MVIT A,C,D3 NO.38/FLUORIDE.............. 121PEDI MULTIVIT 33/FLUORIDE/IRON..............121PEDI MULTIVIT 37/FLUORIDE/IRON..............121PEDI MULTIVIT 40/PHYTONADIONE............. 121PEDI MULTIVIT 86/IRON/FLUORIDE..............121PEDI MULTIVIT NO.128/VITAMIN K...............121PEDI MULTIVIT NO.17 W-FLUORIDE............. 121PEDI MULTIVIT NO.17 W-FLUORIDE (0.25 MG)(TAB CHEW) (OTC)...................................................PEDI MULTIVIT NO.17 W-FLUORIDE (0.5 MG)(TAB CHEW) (OTC)...................................................PEDI MULTIVIT NO.17 W-FLUORIDE (1 MG)(TAB CHEW) (OTC)...................................................PEDI MULTIVIT NO.2 W-FLUORIDE............... 121PEDI MULTIVIT NO.2 W-FLUORIDE (0.5MG/ML) (DROPS) (OTC)...........................................PEDI MULTIVIT NO.33/FLUORIDE..................121PEDI MULTIVIT NO.37 W-FLUORIDE............. 121PEDI MULTIVIT NO.85/FLUORIDE..................121PEDI MV NO.80/FERROUS SULFATE.............. 122PEDI NUTRIT,IRON,LAC-FREE,FIBR.................95PEDI NUTRIT.,SOY,IRON,LF/FIBER................... 95PEDI NUTRITION,IRON,LACT-FREE................. 96PEDI NUTRITION,MILK BASED,IRON..............96PEDIACARE COUGH-COLD................................37PEDIALYTE (SOLUTION) (OTC).........................55PEDIALYTE ADVANCED CARE (SOLUTION)(OTC).......................................................................55PEDIALYTE ELECTROLYTE SINGLES(SOLUTION) (OTC)............................................... 55PEDIASMART ORGANIC DAIRY........................95PEDIASMART ORGANIC SOY............................ 95PEDIASURE........................................................... 96PEDIASURE 1.5..................................................... 96PEDIASURE 1.5 WITH FIBER..............................95PEDIASURE ENTERAL........................................ 96PEDIASURE ENTERAL WITH FIBER................ 95PEDIASURE GROW-GAIN................................... 96PEDIASURE HARVEST........................................ 94PEDIASURE PEPTIDE 1.0 CAL........................... 95PEDIASURE PEPTIDE 1.5 CAL........................... 95PEDIASURE SIDEKICKS............................... 95, 96PEDIASURE WITH FIBER....................................95PEDIATRIC DINOSAUR NEBULIZER................ 14PEDIATRIC DOG NEBULIZER............................ 14PEDIATRIC ELECTROLYTE (SOLUTION) (OTC)................................................................................. 55PEDIATRIC FROG NEBULIZER.......................... 14PEDIATRIC MASK................................................ 11

PEDIATRIC MULTIVITAMIN NO.81.................122PEDIATRIC NUTRIT, IRON/DHA/ARA...............96PEDIATRIC PANDA MASK.................................. 11PEG3350/SOD SUL/NACL/KCL/ASB/C...............85PEG3350/SOD SULF,BICARB,CL/KCL......... 85, 86PEGANONE..........................................................110PEGASYS................................................................79PEGASYS PROCLICK...........................................79PEGFILGRASTIM..................................................65PEGFILGRASTIM-JMDB......................................66PEGINTERFERON ALFA-2A................................79PEGINTERFERON ALFA-2B................................89PEGVALIASE-PQPZ.............................................. 87PEGVISOMANT.....................................................56PENICILLAMINE.................................................. 79PENICILLIN G BENZATHINE..............................72PENICILLIN V POTASSIUM................................ 72PENLAC..................................................................40PENNSAID (1.5 %) (DROPS)................................ 43PENTAMIDINE ISETHIONATE............................74PENTAZINE VC WITH CODEINE....................... 37PENTAZOCINE HCL/NALOXONE HCL........... 106PENTOSAN POLYSULFATE SODIUM..............118PENTOXIFYLLINE................................................64PENTRAVAN........................................................ 101PEPTAMEN.............................................................94PEPTAMEN 1.5 CAL WITH PREBIO1.................94PEPTAMEN AF...................................................... 94PEPTAMEN JUNIOR............................................. 95PEPTAMEN JUNIOR 1.5............................... 94, 100PEPTAMEN JUNIOR FIBER................................. 94PEPTAMEN JUNIOR WITH PREBIO1.................94PERAMPANEL..................................................... 112PERATIVE.............................................................. 99PERFOROMIST........................................................8PERIACTIN...............................................................4PERIANAL CLEANSING...................................... 47PERIFLEX ADVANCE...........................................98PERIFLEX JUNIOR............................................... 98PERIFRESH............................................................ 47PERIGIENE.............................................................39PERINDOPRIL ERBUMINE................................. 27PERIOSTAT.............................................................91PERISCENT............................................................ 43PERMETHRIN........................................................41PERMETHRIN (1 %) (LIQUID) (OTC).....................PERMETHRIN (5 %) (CREAM (G)).........................PERPHENAZINE....................................................24PERPHENAZINE/AMITRIPTYLINE HCL...........19PERSANTINE.........................................................66PERSERIS............................................................... 23PERSONAL BEST.................................................. 15PETROLATUM..................................................... 101PETROLATUM, YELLOW.................................. 101


Index

PETROLATUM,WHITE........................... 44, 45, 101PETROLATUM,WHITE (OINT PACK).....................PETROLATUM,WHITE (OINT PACK) (OTC).........PETROLATUM,WHITE (OINT. (G)) (OTC).............PETROLEUM JELLY........................................... 101PETROLEUM JELLY LIP TREATMENT........... 101PEXEVA.......................................................... 18, 132PFLEX TRAINER...................................................15PHENAZOPYRIDINE HCL................................. 118PHENELZINE SULFATE....................................... 17PHENERGAN........................................................... 7PHENERGAN (12.5 MG) (TABLET)...................... 5PHENERGAN (25 MG) (TABLET)......................... 5PHENERGAN (50 MG) (TABLET)......................... 5PHENERGAN VC...............................................5, 36PHENERGAN VC WITH CODEINE.....................37PHENERGAN WITH CODEINE........................... 37PHENOBARBITAL.................................................24PHENOL..................................................................43PHENOXYBENZAMINE HCL..............................27PHEN-TUSS AD..................................................... 36PHENYLADE......................................................... 98PHENYLADE ESSENTIAL (25G-390) (POWDER)(OTC).......................................................................98PHENYLADE GMP MIX-IN (80 G-334)(POWDER) (OTC).................................................. 98PHENYLADE GMP READY................................. 98PHENYLADE MTE................................................98PHENYLADE40..................................................... 98PHENYLADE60 (60G-295) (POWDER) (OTC)....98PHENYLADE60 (60G-327) (POWDER) (OTC)....98PHENYLEPHRINE HCL..................................37, 59PHENYLEPHRINE HCL (10 MG) (TABLET)(OTC)...........................................................................PHENYLEPHRINE HCL/PROMETH HCL...........36PHENYL-FREE 2................................................... 98PHENYL-FREE 2HP.............................................. 98PHENYTEK.......................................................... 112PHENYTOIN.........................................................112PHENYTOIN SODIUM EXTENDED................. 112PHILLIPS' MILK OF MAGNESIA (400 MG/5ML)(ORAL SUSP) (OTC)..............................................85PHOSLO..................................................................54PHOSPHASAL........................................................70PHYSIOLOGICAL IRRIG SOLN NO.1................ 44PHYSIOLYTE......................................................... 44PHYSIOSOL........................................................... 44PHYTONADIONE (VIT K1)..................................66PHYTONADIONE (VIT K1) (10 MG/ML)(AMPUL).....................................................................PHYTONADIONE (VIT K1) (1MG/0.5ML)(AMPUL).....................................................................PHYTONADIONE (VIT K1) (1MG/0.5ML)(SYRINGE).................................................................

PHYTONADIONE (VIT K1) (5 MG) (TABLET)......PICATO (0.015 %) (GEL (EA))...................... 45, 132PICATO (0.05 %) (GEL (EA))........................ 45, 132PIFELTRO............................................................... 75PIKO 1..................................................................... 15PILOCARPINE HCL........................................ 60, 87PIMOZIDE.............................................................. 20PINDOLOL............................................................. 28PIOGLITAZONE HCL............................................48PIOGLITAZONE HCL/METFORMIN HCL......... 49PIPERONYL BUTOXIDE/PYRETHRINS.............41PIPERONYL BUTOXIDE/PYRETHRINS (4%-0.33%) (SHAMPOO) (OTC).......................................PIRFENIDONE..................................................... 102PIROXICAM........................................................... 83PIVOT 1.5 CAL.......................................................94PKU COOLER 10................................................... 98PKU COOLER 15................................................... 98PKU COOLER 20................................................... 98PKU EXPRESS15................................................... 98PKU LOPHLEX...................................................... 98PKU TRIO............................................................... 98PLAN B ONE-STEP............................................... 35PLAQUENIL........................................................... 74PLENDIL.................................................................29PLENVU..................................................................85PLETAL...................................................................66PNEUMOC 13-VAL CONJ-DIP CRM/PF..............68PNEUMOCOCCAL 23-VAL P-SAC VAC............. 68PNEUMOVAX 23....................................................68PNV 11/IRON FUM/FOLIC ACID/OM3............. 122PNV 15/IRON FUM,PS/FOLIC ACID................. 122PNV 16/IRON FUM,PS/FOLIC/OM-3.................122PNV 21/IRON PS,HEME PPEP/FOLIC............... 122PNV 39/IRON/FOLIC/DOCUSATE/DHA........... 122PNV 66/IRON/FOLIC/DOCUSATE/DHA........... 122PNV 69/IRON/FOLIC/DOCUSATE/DHA........... 122PNV 80/IRON FUM/FOLIC/DSS/DHA............... 122PNV NO.118/IRON FUMARATE/FA.................. 122PNV NO.5/FERROUS FUM/FOLIC AC..............122PNV NO.66/IRON,CARB/FOLIC/DHA.............. 122PNV NO.95/FERROUS FUM/FOLIC AC............122PNV NO.95/FERROUS FUM/FOLIC AC (28MG-0.8MG) (TABLET) (OTC)..........................................PNV, CALCIUM 70/IRON/FOLIC/DHA............. 122PNV,CALCIUM 72/IRON,CARB/FOLIC............ 122PNV,CALCIUM 72/IRON/FOLIC ACID............. 122PNV/FERROUS FUM/DOCUSATE/FOLIC........ 122PNV/FOLIC AC/B6/CALCIUM/GINGER...........123PNV/IRON,CARB/DOCUSAT/FOLIC AC.......... 122PNV119/IRON FUM/FOLIC/DOCUSATE.......... 122PNV19/IRON BG,S.P/FOLIC AC/OM3............... 122PNV81/IRON EDTA,PS/FOLIC/OMEG3............ 122POCKET CHAMBER............................................. 10


Index

POCKET PEAK...................................................... 15PODOFILOX...........................................................44POLYBASE (WAX) (OTC)................................... 101POLYETHYLENE GLYCOL 3350.........................86POLYMYXIN B SULF/TRIMETHOPRIM............59POLYTRIM............................................................. 59POLY-VI-FLOR (0.25 MG) (TAB CHEW) (OTC)....121POLY-VI-FLOR (0.25 MG/ML) (DRPS SP BP)(OTC).....................................................................121POLY-VI-FLOR (0.5 MG) (TAB CHEW) (OTC)....121POLY-VI-FLOR (1 MG) (TAB CHEW) (OTC)....121POLY-VI-FLOR WITH IRON (0.25-7MG/1) (DRPSSP BP) (OTC)........................................................ 121POLY-VI-FLOR WITH IRON (0.5MG-10MG) (TABCHEW) (OTC).......................................................121POLYVINYL ALCOHOL.......................................61POLYVINYL ALCOHOL (1.4 %) (DROPS) (OTC).....................................................................................POLYVINYL ALCOHOL/POVIDONE................. 61POLYVINYL ALCOHOL/POVIDONE (0.5%-0.6%)(DROPS) (OTC)..........................................................POLYVINYL ALCOHOL/POVIDONE/PF............61POLY-VI-SOL....................................................... 122POLY-VI-SOL WITH IRON................................. 122POMALIDOMIDE.................................................. 89POMALYST............................................................ 89PONATINIB HCL................................................... 90PORTABLE NEBULIZER SYSTEM..................... 14POTASSIUM BICARBONATE/CIT AC................ 55POTASSIUM CHLORIDE...................................... 55POTASSIUM CITRATE........................................117POTASSIUM CITRATE/CITRIC ACID...............118POTASSIUM CITRATE/CITRIC ACID (1100-334/5) (SOLUTION) (OTC)........................................POTASSIUM CITRATE/CITRIC ACID (3300-1002)(PACKET)....................................................................POTASSIUM IODIDE............................................ 57POTASSIUM IODIDE (1 G/ML) (SOLUTION)........POTASSIUM IODIDE/IODINE..............................57POVIDONE-IODINE.............................................. 44POVIDONE-IODINE (10 %) (LIQUID PKT) (OTC).....................................................................................POVIDONE-IODINE (10 %) (SOLUTION) (OTC).....................................................................................POVIDONE-IODINE (10 %) (SPRAY) (OTC)..........POVIDONE-IODINE (7.5 %) (SOLUTION) (OTC).....................................................................................PRAMCORT............................................................84PRAMIPEXOLE DI-HCL.....................................109PRAMLINTIDE ACETATE.................................... 48PRAMOSONE (1 %-1 %) (LOTION).....................45PRAMOSONE (1 %-1 %) (OINT. (G))...................45

PRAMOSONE (2.5 %-1 %) (CREAM (G))............45PRAMOSONE (2.5 %-1 %) (LOTION)..................45PRAMOSONE (2.5 %-1 %) (OINT. (G))................45PRANDIMET.......................................................... 48PRANDIN................................................................48PRASUGREL HCL................................................. 66PRAVACHOL.......................................................... 31PRAVASTATIN SODIUM.......................................31PRAZIQUANTEL................................................... 74PRAZOSIN HCL.....................................................27PRECISION XTRA.................................................91PRECISION XTRA (EACH) (OTC).......................50PRECISION XTRA (STRIP) (OTC).......................49PRECOSE................................................................48PRED FORTE..........................................................58PRED MILD............................................................58PREDNICARBATE.................................................43PREDNISOLONE................................................... 81PREDNISOLONE ACETATE.................................58PREDNISOLONE SODIUM PHOSPHATE.....58, 81PREDNISOLONE SODIUM PHOSPHATE (10 MG)(TAB RAPDIS)............................................................PREDNISOLONE SODIUM PHOSPHATE (15 MG)(TAB RAPDIS)............................................................PREDNISOLONE SODIUM PHOSPHATE (15MG/5 ML) (SOLUTION)............................................PREDNISOLONE SODIUM PHOSPHATE (25MG/5 ML) (SOLUTION)............................................PREDNISOLONE SODIUM PHOSPHATE (30 MG)(TAB RAPDIS)............................................................PREDNISOLONE SODIUM PHOSPHATE (5 MG/5ML) (SOLUTION)......................................................PREDNISONE........................................................ 81PREDNISONE INTENSOL........................................PREFERA OB....................................................... 122PREFERA-OB PLUS DHA.................................. 123PREGABALIN...................................................... 112PREGESTIMIL....................................................... 97PREGNYL...............................................................55PREMARIN.....................................................67, 118PREMPHASE..........................................................67PREMPRO...............................................................67PRENAT 115/IRON FUM/FOLIC/DSS................122PRENAT VIT 17/IRON/FOLIC/OM3,6................122PRENATAL 12/IRON/FOLIC/DSS/OM3............. 122PRENATAL 34/IRON/FOLIC/DSS/DHA.............122PRENATAL 47/IRON/FOLATE 1/DHA...............122PRENATAL 53/IRON/FOLIC AC/OMG3............ 122PRENATAL 54/IRON/FOLIC AC/OMG3............ 122PRENATAL 57/IRON/FOLIC/DSS/DHA.............122PRENATAL 59/IRON/FOLIC/DSS/DHA.............122PRENATAL 68/IRON/FOLIC NO1/DHA............ 122PRENATAL COMB NO.42/FOLIC ACID............122PRENATAL NO.52/IRON/FA/DHA..................... 122


Index

PRENATAL NO.75/IRON/FOLATE NO1............ 122PRENATAL NO115/IRON/FOLIC ACID.............123PRENATAL NO13/IRON PS/FOLATE 1............. 123PRENATAL NO4/IRON FUM,PS/FOLIC............ 123PRENATAL VIT 10/IRON/FOLIC/DHA..............123PRENATAL VIT 14/IRON FUM/FOLIC..............123PRENATAL VIT 55/IRON/FOLIC/OM3..............123PRENATAL VIT NO.109/IRON/FA..................... 123PRENATAL VIT NO.127/IRON/FOLIC...............123PRENATAL VIT,CAL 73/IRON/FOLIC...............123PRENATAL VIT,CAL 74/IRON/FOLIC...............123PRENATAL VIT,CALC76/IRON/FOLIC............. 123PRENATAL VIT,CALC78/IRON/FOLIC............. 123PRENATAL VIT/IRON BISGLY/FOLIC............. 123PRENATAL VIT/IRON FUM/FOLIC AC............ 123PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1MG) (CAPSULE)........................................................PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1MG) (TABLET)...........................................................PRENATAL VIT100/IRON/FOLIC/OM3.............123PRENATAL VIT128/IRON/FOLIC ACD............. 123PRENATAL VIT136/IRON/FOLIC ACD............. 123PRENATAL VIT22/IRON/FOLIC/OM3S.............123PRENATAL VIT27,CALCIUM/IRON/FA............123PRENATAL VIT86/IRON/FOLIC ACID..............123PRENATAL VITS15/IRON/FOLIC/DSS..............123PRENATAL VITS16/IRON/FOLIC/DSS..............123PRENATAL VITS18/IRON/FOLIC/DSS..............123PRENATAL,CALC NO.65/IRON/FOLIC.............123PRENATAL,CALC.40/IRON/FOLATE 1............. 123PRENATAL64/IRON/LMFOLATE/ALGAL........ 123PREPOPIK.............................................................. 87PREVNAR 13..........................................................68PREZCOBIX........................................................... 75PREZISTA (100 MG/ML) (ORAL SUSP)..............75PREZISTA (150 MG) (TABLET)........................... 75PREZISTA (600 MG) (TABLET)........................... 75PREZISTA (75 MG) (TABLET)............................. 75PREZISTA (800 MG) (TABLET)........................... 75PRIFTIN.................................................................. 73PRIMAQUINE........................................................ 74PRIMAQUINE PHOSPHATE.................................74PRIMEAIRE............................................................10PRIMIDONE......................................................... 112PRIMSOL................................................................ 70PRINIVIL................................................................ 27PRISTIQ.................................................................. 18PRO COMFORT SPACER WITH MASK........ 11, 12PROAMATINE........................................................33PRO-BANTHINE.................................................. 116PROBENECID........................................................ 62PROBENECID/COLCHICINE............................... 62PROCARBAZINE HCL.......................................... 90PROCARDIA.......................................................... 29

PROCARDIA XL (30 MG) (TAB ER 24)...............29PROCARDIA XL (60 MG) (TAB ER 24)...............29PROCARDIA XL (90 MG) (TAB ER 24)...............29PROCARE COMPRESSOR NEBULIZER............ 14PROCENTRA..........................................................19PROCHAMBER......................................................10PROCHLORPERAZINE...........................................7PROCHLORPERAZINE MALEATE....................... 7PROCTOCORT....................................................... 84PROCTOFOAM-HC............................................... 84PROCYSBI............................................................117PRODIGY LANCING DEVICE............................. 52PRODIGY MINI-MIST...........................................13PROFILNINE.......................................................... 63PROGESTERONE...................................................67PROGESTERONE, MICRONIZED..................55, 67PROLIXIN...............................................................24PROLIXIN DECANOATE...................................... 24PROLOPRIM...........................................................70PROMACTA............................................................66PROMETHAZINE HCL....................................... 5, 7PROMETHAZINE HCL/CODEINE.......................37PROMETHAZINE/PHENYLEPH/CODEINE....... 37PROMETRIUM.......................................................67PROMOTE...............................................................95PROMOTE WITH FIBER.......................................95PRONEB ULTRA II................................................ 14PROPAFENONE HCL............................................ 26PROPANTHELINE BROMIDE............................116PROPARACAINE HCL.......................................... 59PROPARACAINE/FLUORESCEIN SOD.............. 59PRO-PHREE............................................................97PROPRANOLOL HCL........................................... 28PROPRANOLOL/HYDROCHLOROTHIAZID.....29PROPYLENE GLYCOL..................................61, 101PROPYLENE GLYCOL (99.5 %) (LIQUID).............PROPYLENE GLYCOL (99.5 %) (LIQUID) (OTC).....................................................................................PROPYLENE GLYCOL/PEG 400..........................61PROPYLENE GLYCOL/PEG 400/PF.................... 61PROPYLTHIOURACIL.......................................... 57PROQUAD.............................................................. 68PROSCAR............................................................. 117PROSOURCE NO CARB....................................... 92PROSOURCE PLUS............................................... 92PROSOURCE ZAC................................................. 92PRO-STAT AWC..................................................... 92PRO-STAT RENAL CARE..................................... 92PRO-STAT SUGAR FREE......................................92PROTECT PLUS................................................... 120PROTECTIVES2/CERAMIDE 1,3,6-11.................45PROTEIN SUPPLEMENT...................................... 96PROTEINEX-18...................................................... 92PROTOPIC...................................................... 47, 132


Index

PROTRIPTYLINE HCL..........................................19PROVENT............................................................... 12PROVERA............................................................... 67PROVIGIL............................................................... 24PROVIMIN............................................................120PROZAC..................................................................18PROZAC WEEKLY................................................ 18PSEUDOEPHED/CHLOR-MAL/BELL ALK........36PSEUDOEPHED/CODEINE/GUAIFEN................37PSEUDOEPHEDRINE HCL...................................38PSEUDOEPHEDRINE HCL (15 MG/5 ML)(LIQUID) (OTC).........................................................PSEUDOEPHEDRINE HCL (30 MG) (TABLET)(OTC)...........................................................................PSEUDOEPHEDRINE HCL (30 MG/5 ML)(LIQUID) (OTC).........................................................PSYLLIUM HUSK................................................. 86PSYLLIUM HUSK (6 G/6 G) (POWDER) (OTC).....PSYLLIUM HUSK (WITH DEXTROSE)..............86PSYLLIUM HUSK (WITH SUGAR).....................86PSYLLIUM HUSK/ASPARTAME......................... 86PSYLLIUM HUSK/ASPARTAME (3.4G/5.8G)(POWDER) (OTC)......................................................PSYLLIUM SEED.................................................. 86PSYLLIUM SEED (WITH DEXTROSE).............. 86PSYLLIUM SEED (WITH SUGAR)......................86PULMICORT (0.25MG/2ML) (AMPUL-NEB)....... 8PULMICORT (0.5 MG/2ML) (AMPUL-NEB)........ 8PULMICORT (1 MG/2 ML) (AMPUL-NEB).......... 8PULMO-AIDE.......................................................... 9PULMONEB LT COMPRESSOR NEBUL............ 15PULMOZYME...................................................... 103PURE BLISS........................................................... 97PURE COMFORT HUMIDIFIER............................ 9PURINETHOL........................................................ 88PURIXAN........................................................88, 132PYRAZINAMIDE................................................... 73PYRIDIUM............................................................118PYRIDOSTIGMINE BROMIDE............................ 17PYRIDOXINE HCL (VITAMIN B6)....................124PYRIDOXINE HCL (VITAMIN B6) (100 MG)(TABLET) (OTC)........................................................PYRIDOXINE HCL (VITAMIN B6) (100 MG/ML)(VIAL).........................................................................PYRIDOXINE HCL (VITAMIN B6) (50 MG)(TABLET) (OTC)........................................................PYRIMETHAMINE................................................74

- Q -Q-CARE RX............................................................91QNASL.............................................................. 6, 132QNASL CHILDREN.........................................6, 132QUAKE....................................................................12QUALAQUIN..........................................................74QUARTETTE.......................................................... 35

QUAZEPAM............................................................24QUDEXY XR (100 MG) (CAP SPR 24)...... 113, 132QUDEXY XR (150 MG) (CAP SPR 24)...... 113, 132QUDEXY XR (200 MG) (CAP SPR 24)...... 113, 132QUDEXY XR (25 MG) (CAP SPR 24)........ 113, 132QUDEXY XR (50 MG) (CAP SPR 24)........ 113, 132QUESTRAN............................................................ 32QUESTRAN LIGHT............................................... 32QUETIAPINE FUMARATE................................... 23QUILLIVANT XR (5 MG/ML) (SU ER RC24)....26,132QUINAGLUTE........................................................26QUINAPRIL HCL................................................... 27QUINAPRIL/HYDROCHLOROTHIAZIDE.......... 27QUINIDINE GLUCONATE....................................26QUINIDINE SULFATE...........................................26QUININE SULFATE...............................................74

- R -RABEPRAZOLE SODIUM..................................117RADIAGEL........................................................... 101RADIAPLEXRX..................................................... 45RAGWITEK.............................................................. 4RALOXIFENE HCL............................................... 56RALTEGRAVIR POTASSIUM...............................78RAMELTEON......................................................... 24RAMIPRIL.............................................................. 27RANEXA (1000 MG) (TAB ER 12H).................... 33RANEXA (500 MG) (TAB ER 12H)...................... 33RANITIDINE HCL............................................... 116RANOLAZINE........................................................33RASAGILINE MESYLATE..................................109RASUVO (10MG/0.2ML) (AUTO INJCT).... 79, 132RASUVO (12.5/0.25) (AUTO INJCT)............79, 132RASUVO (15MG/0.3ML) (AUTO INJCT).... 80, 132RASUVO (17.5/0.35) (AUTO INJCT)............80, 132RASUVO (20MG/0.4ML) (AUTO INJCT).... 80, 133RASUVO (22.5/0.45) (AUTO INJCT)............80, 133RASUVO (25MG/0.5ML) (AUTO INJCT).... 80, 133RASUVO (30MG/0.6ML) (AUTO INJCT).... 80, 133RASUVO (7.5MG/0.15) (AUTO INJCT)....... 80, 133RAVICTI..................................................................84RAZADYNE (12 MG) (TABLET)..........................17RAZADYNE (4 MG) (TABLET)............................17RAZADYNE (4 MG/ML) (SOLUTION)................17RAZADYNE (8 MG) (TABLET)............................17RAZADYNE ER..................................................... 17REBETOL............................................................... 79REBIF...................................................................... 91REBIF REBIDOSE................................................. 91REBINYN................................................................63RECOMBINATE..................................................... 63RECOMBIVAX HB................................................ 69RECTAGEL HC...................................................... 84REFRESH CELLUVISC.........................................61


Index

REFRESH CLASSIC.............................................. 61REFRESH LACRI-LUBE....................................... 62REFRESH OPTIVE ADVANCED (0.5-1-0.5%)(DROPS) (OTC)...................................................... 60REFRESH OPTIVE MEGA-3................................ 60REFRESH OPTIVE SENSITIVE........................... 61RE-GEN...................................................................95REGENECARE.......................................................46REGLAN............................................................... 117REGORAFENIB..................................................... 90REGRANEX............................................................53RELAFEN............................................................... 83RELENZA............................................................... 75RELIAMED MINI LANCING DEVICE................52REMODULIN......................................................... 30RENA START..........................................................99RENVELA...............................................................54REPAGLINIDE....................................................... 48REPAGLINIDE/METFORMIN HCL..................... 48REPATHA PUSHTRONEX.................................... 32REPATHA SURECLICK (140 MG/ML) (PENINJCTR).................................................................. 32REPATHA SYRINGE (140 MG/ML) (SYRINGE)....32REPLACEMENT PEDIATRIC MONITOR........... 50REPLETE................................................................ 95REPLETE WITH FIBER........................................ 94RESCRIPTOR......................................................... 75RESOURCE 2.0...................................................... 95RESOURCE THICKENUP...................................102RESTORE SKIN CLEANSER................................47RESTORE SKIN CONDITIONING....................... 43RESTORE WOUND CLEANSER..........................47RESTORIL.............................................................. 24RETACRIT.............................................................. 64RETIN-A................................................................. 39RETIN-A MICRO................................................... 39RETIN-A MICRO PUMP (0.04 %) (GEL W/PUMP)................................................................................. 39RETIN-A MICRO PUMP (0.1 %) (GEL W/PUMP)................................................................................. 39RETROVIR (10 MG/ML) (SYRUP)....................... 77RETROVIR (100 MG) (CAPSULE)....................... 77RETROVIR (300 MG) (TABLET).......................... 77REVATIO (10 MG/ML) (SUSP RECON)...............30REVATIO (20 MG) (TABLET)............................... 30REVIA..................................................................... 24REVITADERM....................................................... 39REVLIMID..............................................................89REYATAZ (150 MG) (CAPSULE)......................... 77REYATAZ (200 MG) (CAPSULE)................... 77, 78REYATAZ (300 MG) (CAPSULE)......................... 78REYATAZ (50 MG) (POWD PACK)...................... 78RIBAVIRIN....................................................... 74, 79

RIBAVIRIN (200 MG) (CAPSULE)...........................RIBAVIRIN (200 MG) (TABLET)..............................RIBOCICLIB SUCCINATE....................................90RIBOCICLIB SUCCINATE/LETROZOLE............89RIDAURA............................................................... 81RIFABUTIN............................................................ 73RIFADIN................................................................. 73RIFAMATE..............................................................73RIFAMPIN...............................................................73RIFAMPIN/ISONIAZID......................................... 73RIFAPENTINE........................................................73RIFAXIMIN.............................................................74RIGHTEST GD500................................................. 52RILONACEPT.........................................................80RILPIVIRINE HCL.................................................76RILUTEK................................................................ 91RILUZOLE..............................................................91RIMANTADINE HCL............................................ 74RINGER'S SOLUTION.......................................... 44RIOCIGUAT............................................................30RISPERDAL CONSTA........................................... 23RISPERIDONE....................................................... 23RISPERIDONE (0.25 MG) (TAB RAPDIS)...............RISPERIDONE (0.25 MG) (TABLET).......................RISPERIDONE (0.5 MG) (TAB RAPDIS).................RISPERIDONE (0.5 MG) (TABLET).........................RISPERIDONE (1 MG) (TAB RAPDIS)....................RISPERIDONE (1 MG) (TABLET)............................RISPERIDONE (1 MG/ML) (SOLUTION)...............RISPERIDONE (2 MG) (TAB RAPDIS)....................RISPERIDONE (2 MG) (TABLET)............................RISPERIDONE (3 MG) (TAB RAPDIS)....................RISPERIDONE (3 MG) (TABLET)............................RISPERIDONE (4 MG) (TAB RAPDIS)....................RISPERIDONE (4 MG) (TABLET)............................RISPERIDONE MICROSPHERES........................ 23RITEFLO.................................................................10RITONAVIR............................................................ 78RIVAROXABAN.....................................................63RIVASTIGMINE..................................................... 17RIVASTIGMINE TARTRATE................................ 17RIXUBIS................................................................. 63RIZATRIPTAN BENZOATE................................ 106ROBAXIN............................................................. 114ROBAXIN-750...................................................... 114ROCALTROL........................................................ 124ROFLUMILAST....................................................... 9ROPINIROLE HCL...............................................109ROPINIROLE HCL (0.25 MG) (TABLET)................ROPINIROLE HCL (0.5 MG) (TABLET)..................ROPINIROLE HCL (1 MG) (TABLET).....................ROPINIROLE HCL (12 MG) (TAB ER 24H)...... 133ROPINIROLE HCL (2 MG) (TAB ER 24H)........ 133ROPINIROLE HCL (2 MG) (TABLET).....................


Index

ROPINIROLE HCL (3 MG) (TABLET).....................ROPINIROLE HCL (4 MG) (TAB ER 24H)........ 133ROPINIROLE HCL (4 MG) (TABLET).....................ROPINIROLE HCL (5 MG) (TABLET).....................ROPINIROLE HCL (6 MG) (TAB ER 24H)........ 133ROPINIROLE HCL (8 MG) (TAB ER 24H)........ 133ROSADAN.............................................................. 38ROSUVASTATIN CALCIUM.................................31ROTIGOTINE........................................................109ROWASA.................................................................83ROWEEPRA..........................................................112ROWEEPRA XR................................................... 112ROZEREM...................................................... 24, 133RUBBING ALCOHOL......................................... 101RUCONEST............................................................ 80RUFINAMIDE...............................................112, 113RUXOLITINIB PHOSPHATE................................ 89RYDAPT..................................................................90RYTHMOL..............................................................26RYTHMOL SR........................................................26RYZOLT................................................................ 106

- S -SABRIL................................................................. 114SACROSIDASE.................................................... 115SACUBITRIL/VALSARTAN..................................33SAFE-CLIP..............................................................53SAFYRAL............................................................... 35SALAGEN...............................................................87SALSALATE.........................................................103SAMI THE SEAL....................................................15SANDIMMUNE (100 MG/ML) (SOLUTION)......69SAPHRIS.........................................................21, 133SAPROPTERIN DIHYDROCHLORIDE............... 87SAQUINAVIR MESYLATE................................... 78SARGRAMOSTIM................................................. 66SAVELLA................................................................91SCALACORT DK................................................... 42SEASONIQUE........................................................ 35SEBUDERM............................................................43SECOBARBITAL SODIUM...................................24SECONAL SODIUM.............................................. 24SECTRAL................................................................28SECUKINUMAB.................................................... 46SEGLUROMET...............................................49, 133SELEGILINE.......................................................... 24SELEGILINE HCL............................................... 109SELEXIPAG............................................................ 30SELZENTRY (150 MG) (TABLET)....................... 75SELZENTRY (20 MG/ML) (SOLUTION).............75SELZENTRY (25 MG) (TABLET)......................... 75SELZENTRY (300 MG) (TABLET)....................... 75SELZENTRY (75 MG) (TABLET)......................... 75SENNOSIDES.........................................................86SENNOSIDES (8.6 MG) (TABLET) (OTC)...............

SENNOSIDES/DOCUSATE SODIUM.................. 87SEN-SERTER..........................................................50SENSI-CARE.......................................................... 43SENSIPAR (30 MG) (TABLET)............................. 56SENSIPAR (60 MG) (TABLET)............................. 56SENSIPAR (90 MG) (TABLET)............................. 56SEROMYCIN..........................................................73SEROPHENE.......................................................... 55SEROQUEL.............................................................23SEROQUEL XR (150 MG) (TAB ER 24H)............23SEROQUEL XR (200 MG) (TAB ER 24H)............23SEROQUEL XR (300 MG) (TAB ER 24H)............23SEROQUEL XR (400 MG) (TAB ER 24H)............23SEROQUEL XR (50 MG) (TAB ER 24H)..............23SEROSTIM..............................................................57SERTRALINE HCL................................................ 18SERZONE............................................................... 18SEVELAMER CARBONATE................................ 54SFROWASA............................................................ 83SHINGRIX.............................................................. 69SHINGRIX GE ANTIGEN COMPONENT........... 69SIDESTREAM........................................................ 13SIDESTREAM NEBULIZER................................. 13SIDESTREAM PEDIATRIC...................................11SIDESTREAM PLUS............................................. 13SIGNIFOR.............................................................102SIKLOS (100 MG) (TABLET)................................66SIKLOS (1000 MG) (TABLET)......................66, 133SILDENAFIL CITRATE.........................................30SILENOR........................................................ 24, 133SILICA GEL MICRONIZED (100 %) (POWDER)(OTC).....................................................................102SILICA GEL,AMORPHOUS SYN MICRO.........102SILICONE DISC..................................................... 44SILICONE MASK...................................................11SILICONE ROLL....................................................44SILICONE SCAR....................................................43SILICONE SHEET..................................................44SILICONE TAPE.................................................... 44SILICONES/ADHESIVE TAPE............................. 44SIL-SERTER........................................................... 50SILVADENE............................................................41SILVASORB............................................................ 39SILVER....................................................................39SILVER CHLORIDE...............................................39SILVER NITRATE.................................................. 39SILVER SULFADIAZINE...................................... 41SILVERMED (GEL ER(ML)) (OTC).........................SIMBRINZA........................................................... 60SIMETHICONE.................................................... 115SIMETHICONE (125 MG) (CAPSULE) (OTC)........SIMETHICONE (40MG/0.6ML) (DROPS SUSP)(OTC)...........................................................................SIMETHICONE (80 MG) (TAB CHEW) (OTC)........


Index

SIMILAC ADVANCE............................................. 97SIMILAC ADVANCE LAMEHADRIN................. 97SIMILAC ALIMENTUM........................................96SIMILAC LAMEHADRIN..................................... 96SIMILAC SENSITIVE FUSS & GAS.................... 97SIMPLYTHICK (120G) (GEL PACKET) (OTC)....102SIMPLYTHICK (15 G) (GEL (GRAM)) (OTC)....102SIMPLYTHICK (15 G) (GEL PACKET) (OTC)....102SIMPLYTHICK (15 G) (GEL W/PUMP) (OTC)....102SIMPLYTHICK (240 G) (GEL PACKET) (OTC)....102SIMPLYTHICK (30G) (GEL PACKET) (OTC)....102SIMPONI.................................................................80SIMVASTATIN........................................................32SIMVASTATIN (10 MG) (TABLET)..........................SIMVASTATIN (20 MG) (TABLET)..........................SIMVASTATIN (40 MG) (TABLET)..........................SIMVASTATIN (5 MG) (TABLET)............................SIMVASTATIN (80 MG) (TABLET)....................133SINEMET 10-100..................................................109SINEMET 25-100..................................................109SINEMET 25-250..................................................109SINEMET CR........................................................109SINEQUAN............................................................. 19SINGULAIR..............................................................9SINUSTAR........................................................ 13, 15SIROLIMUS............................................................69SIRTURO.................................................................73SITAGLIPTIN PHOS/METFORMIN HCL............ 47SITAGLIPTIN PHOSPHATE..................................48SIVEXTRO......................................................71, 133SKIN CLEANSER............................................ 46, 47SKIN CLEANSER COMB NO.20..........................47SKIN CLEANSER COMB NO.21..........................47SKYLA.................................................................... 97SLO-NIACIN (500 MG) (TABLET ER) (OTC)..... 33SLO-PHYLLIN....................................................... 16SMARTDIABETES VANTAGE............................. 52SOD PHOS DI, MONO/K PHOS MONO............ 118SOD PHOSPHATE MBAS/SOD PHOS,DI............87SOD PICOSULF/MAG OX/CITRIC AC................87SOD/POT/K CIT/SOD CIT/CIT ACID.................118SOD/POT/K CIT/SOD CIT/CIT ACID (500-550/5)(SOLUTION) (OTC)...................................................SODIUM BICARBONATE...................................116SODIUM BICARBONATE (650 MG) (TABLET)(OTC)...........................................................................SODIUM CHLORIDE...................................... 55, 59

SODIUM CHLORIDE (1000 MG) (TABLET SOL)(OTC)...........................................................................SODIUM CHLORIDE (2 %) (DROPS) (OTC)..........SODIUM CHLORIDE (5 %) (DROPS) (OTC)..........SODIUM CHLORIDE (5 %) (OINT. (G)) (OTC)......SODIUM CHLORIDE 0.45 %................................ 55SODIUM CHLORIDE FOR INHALATION.......... 96SODIUM CHLORIDE IRRIG SOLUTION........... 44SODIUM CHLORIDE/NAHCO3/KCL/PEG......... 87SODIUM CITRATE.......................................... 43, 63SODIUM CITRATE (4 G/100 ML) (SOLUTION).....SODIUM FLUORIDE/VITAMIN D3...................119SODIUM IODIDE-123........................................... 90SODIUM IODIDE-123 (7.4 MBQ) (CAPSULE).......SODIUM PHENYLBUTYRATE............................84SODIUM PHOSPHATE,MONO-DIBASIC........... 87SODIUM POLYSTYRENE SULFON/SORB........ 54SODIUM POLYSTYRENE SULFONATE.............54SODIUM SULAMYD.............................................59SODIUM THIOSULFATE/SAL ACID...................40SODIUM, POTASSIUM,MAG SULFATES........... 87SOFOSBUVIR/VELPATASVIR............................. 79SOF-SERTER.......................................................... 50SOL CARB..............................................................94SOLARAZE............................................................ 45SOLIFENACIN SUCCINATE...............................118SOLIQUA 100-33............................................48, 133SOLTAMOX............................................................ 91SOLUS V2 LANCING DEVICE............................ 53SOMA....................................................................114SOMA COMPOUND............................................114SOMATROPIN........................................................57SOMAVERT............................................................ 56SONIDEGIB PHOSPHATE.................................... 88SOOTHE & COOL..................................................43SOOTHE & COOL PERINEAL WASH................. 43SOOTHENEB COMPRESSOR NEBULIZER....... 15SOOTHENEB MESH NEBULIZER...................... 13SORAFENIB TOSYLATE...................................... 90SORBIDON HYDRATE....................................... 101SORBITOL SOLUTION.........................................44SORIATANE........................................................... 46SOTALOL HCL.......................................................28SPACE CHAMBER PLUS......................................10SPECTAZOLE.........................................................40SPECTRACEF.........................................................70SPIRIVA RESPIMAT................................................ 7SPIROMETER/DRUG DELIVERY ADAPT......... 15SPIROMETERS AND ACCESSORIES........... 15, 16SPIRONOLACT/HYDROCHLOROTHIAZID.......30SPIRONOLACTONE..............................................30SPORANOX............................................................73SPRYCEL................................................................ 89STADOL................................................................104


Index

STALEVO 100.......................................................109STALEVO 125.......................................................109STALEVO 150.......................................................109STALEVO 200.......................................................109STALEVO 50.........................................................109STALEVO 75.........................................................109STANNOUS FLUORIDE......................................119STARCH................................................................102STARLIX.................................................................48STAVUDINE........................................................... 77STEGLATRO...................................................48, 133STELAZINE............................................................24STERITALC (5 G) (VIAL)..................................... 90STIOLTO RESPIMAT...............................................8STIVARGA..............................................................90STRATTERA (10 MG) (CAPSULE)...................... 26STRATTERA (100 MG) (CAPSULE).................... 26STRATTERA (18 MG) (CAPSULE)...................... 26STRATTERA (25 MG) (CAPSULE)...................... 26STRATTERA (40 MG) (CAPSULE)...................... 26STRATTERA (60 MG) (CAPSULE)...................... 26STRATTERA (80 MG) (CAPSULE)...................... 26STRENSIQ.............................................................. 97STRESS FORMULA WITH ZINC (TABLET)(OTC).....................................................................120STRIBILD............................................................... 79STRIVERDI RESPIMAT.......................................... 8STROMECTOL.......................................................74SUBOXONE (12 MG-3 MG) (FILM)...................108SUBOXONE (2 MG-0.5MG) (FILM)...................108SUBOXONE (4MG-1MG) (FILM).......................108SUBOXONE (8 MG-2 MG) (FILM).....................108SUB-Q INSULIN DEVICE, 20 UNIT.................... 53SUB-Q INSULIN DEVICE, 30 UNIT.................... 53SUB-Q INSULIN DEVICE, 40 UNIT.................... 53SUBQ INSULIN PUMP,GLUC.MON.SYS............53SUBUTEX.............................................................108SUCRAID..............................................................115SUCRALFATE...................................................... 116SULCONAZOLE NITRATE...................................40SULFACETAMIDE SODIUM................................ 59SULFACETAMIDE/PREDNISOLONE................. 59SULFACETAMIDE/PREDNISOLONE SP............ 59SULFADIAZINE.....................................................83SULFAMETHOXAZOLE/TRIMETHOPRIM....... 70SULFAMYLON (8.5 %) (CREAM (G)).................41SULFANILAMIDE............................................... 118SULFASALAZINE................................................. 84SULINDAC............................................................. 83SUMATRIPTAN....................................................106SUMATRIPTAN SUCCINATE.....................106, 107SUMATRIPTAN SUCCINATE (100 MG)(TABLET)....................................................................

SUMATRIPTAN SUCCINATE (25 MG) (TABLET).....................................................................................SUMATRIPTAN SUCCINATE (4 MG/0.5ML)(CARTRIDGE)............................................................SUMATRIPTAN SUCCINATE (4 MG/0.5ML) (PENINJCTR)......................................................................SUMATRIPTAN SUCCINATE (50 MG) (TABLET).....................................................................................SUMATRIPTAN SUCCINATE (6 MG/0.5ML)(CARTRIDGE)............................................................SUMATRIPTAN SUCCINATE (6 MG/0.5ML) (PENINJCTR)......................................................................SUMATRIPTAN SUCCINATE (6 MG/0.5ML)(SYRINGE).................................................................SUMATRIPTAN SUCCINATE (6 MG/0.5ML)(VIAL).........................................................................SUMYCIN...............................................................73SUNITINIB MALATE............................................ 90SUNRISE COMPRESSOR-NEBULIZER................9SUPLENA CARB STEADY................................. 100SUPPOSITORY BASE NO.217............................101SUPPRELIN LA......................................................57SUPRAX (100 MG) (TAB CHEW)........................ 70SUPRAX (100 MG/5ML) (SUSP RECON)............70SUPRAX (200 MG) (TAB CHEW)........................ 70SUPRAX (200 MG/5ML) (SUSP RECON)............70SUPRAX (400 MG) (CAPSULE)........................... 70SUPRAX (500 MG/5ML) (SUSP RECON)............70SUPREP...................................................................87SURE COMFORT LANCING PEN....................... 52SUREFLEX....................................................... 52, 53SURE-PEN.............................................................. 52SURFAK (240 MG) (CAPSULE) (OTC)................85SURMONTIL.......................................................... 19SUSPENDOL-S.....................................................102SUSTIVA................................................................. 75SUTENT.................................................................. 90SUVOREXANT...................................................... 25SYLATRON.............................................................89SYMAX.................................................................115SYMAX-SL...........................................................115SYMAX-SR...........................................................115SYMDEKO............................................................103SYMFI..................................................................... 78SYMFI LO...............................................................79SYMJEPI................................................................. 87SYMLINPEN 120................................................... 48SYMLINPEN 60..................................................... 48SYMMETREL.......................................................109SYMPAZAN..........................................................109SYMTUZA.............................................................. 74SYNALAR...............................................................42SYNAREL............................................................... 57SYNJARDY.....................................................48, 134


Index

SYNJARDY XR (10-1000 MG) (TAB BP 24H)....48,134SYNJARDY XR (12.5-1000) (TAB BP 24H)....49,134SYNJARDY XR (25-1000 MG) (TAB BP 24H)....49,134SYNJARDY XR (5MG-1000MG) (TAB BP 24H)....49, 134SYNRIBO................................................................90SYSTANE..........................................................61, 62SYSTANE (0.3 %-0.4%) (DROPERETTE) (OTC)....61SYSTANE (0.3 %-0.4%) (DROPS) (OTC)............. 61SYSTANE BALANCE (0.6 %) (DROPS) (OTC)....61SYSTANE COMPLETE (0.6 %) (DROPS) (OTC)....61SYSTANE ULTRA (0.3 %-0.4%) (DROPERETTE)(OTC).......................................................................61SYSTANE ULTRA (0.3 %-0.4%) (DROPS) (OTC)................................................................................. 61

- T -TABLOID................................................................ 88TACLONEX (0.005-.064) (OINT. (G))...........47, 134TACROLIMUS.................................................. 47, 69TADALAFIL..................................................... 30, 55TAFENOQUINE SUCCINATE...............................74TAFINLAR..............................................................88TAGAMET............................................................ 116TAGAMET HB (200 MG) (TABLET) (OTC).......116TAGRISSO.............................................................. 90TALAZOPARIB TOSYLATE................................. 90TALC....................................................................... 90TALWIN NX......................................................... 106TALZENNA.............................................................90TAMBOCOR........................................................... 26TAMIFLU................................................................74TAMOXIFEN CITRATE.........................................91TAMSULOSIN HCL.............................................117TAPAZOLE............................................................. 57TAPENTADOL HCL.............................................106TARCEVA............................................................... 89TARGRETIN..................................................... 45, 91TASIGNA................................................................ 90TASIMELTEON...................................................... 24TAVIST...................................................................... 4TAVIST-1................................................................... 4TAYTULLA.............................................................35TAZAROTENE............................................39, 46, 47TAZORAC (0.05 %) (CREAM (G))........................46TAZORAC (0.05 %) (GEL (GRAM)).....................46TAZORAC (0.1 %) (CREAM (G))..........................46TAZORAC (0.1 %) (GEL (GRAM)).......................47TBO-FILGRASTIM................................................ 66

TECFIDERA........................................................... 91TEDIZOLID PHOSPHATE.....................................71TEDUGLUTIDE..................................................... 87TEGRETOL XR (100 MG) (TAB ER 12H)..........110TELMISARTAN......................................................28TEMAZEPAM.........................................................24TEMODAR..............................................................88TEMOVATE.............................................................41TEMOVATE E......................................................... 41TEMOVATE EMOLLIENT.....................................41TEMOZOLOMIDE................................................. 88TENEX.................................................................... 28TENIVAC................................................................ 69TENOFOVIR DISOPROXIL FUMARATE............77TENORETIC 100.................................................... 29TENORETIC 50...................................................... 29TENORMIN............................................................ 28TERAZOL 3.......................................................... 118TERAZOL 7.......................................................... 118TERAZOSIN HCL.................................................. 27TERBINAFINE HCL........................................ 40, 73TERBUTALINE SULFATE...................................... 7TERBUTALINE SULFATE (2.5 MG) (TABLET)......TERBUTALINE SULFATE (5 MG) (TABLET).........TERCONAZOLE.................................................. 118TERIFLUNOMIDE.................................................91TERIPARATIDE..................................................... 56TESSALON.............................................................36TESSALON PERLE................................................36TESTIM...................................................................66TESTOSTERONE................................................... 66TESTOSTERONE CYPIONATE............................ 66TESTOSTERONE ENANTHATE.......................... 66TESTOSTERONE UNDECANOATE.................... 66TESTRED................................................................66TETANUS DIPHTHERIA TOXOIDS.................... 69TETANUS, DIPHTHERIA TOX,ADULT.............. 69TETANUS-DIPHTHERIA TOXOIDS/PF.............. 69TETCAINE..............................................................59TETRABENAZINE.................................................91TETRACAINE HCL............................................... 59TETRACAINE HCL/PF..........................................59TETRACAINE HYDROCHLORIDE..................... 59TETRACYCLINE HCL.......................................... 73TETRIX................................................................... 45TEXACORT............................................................ 42TEZACAFTOR/IVACAFTOR.............................. 103THALIDOMIDE..................................................... 73THALOMID............................................................ 73THEO-24................................................................. 16THEO-DUR.............................................................16THEOPHYLLINE ANHYDROUS......................... 16THERA TEARS (0.25 %) (DROPERETTE) (OTC)................................................................................. 61


Index

THERAFLU (10-5-325-2) (TABLET) (OTC).........37THERMAZENE...................................................... 41THIAMINE HCL...................................................123THIAMINE HCL (100 MG) (TABLET) (OTC).........THICK NOW.........................................................102THICKEN UP CLEAR (POWDER) (OTC)..........102THICK-IT.............................................................. 102THICK-IT #2......................................................... 102THIK & CLEAR....................................................102THIOGUANINE......................................................88THIORIDAZINE HCL............................................ 24THIOTHIXENE.......................................................23THORAZINE.......................................................... 24THRESHOLD IMT................................................. 16THRESHOLD PEP..................................................16THRIVITE RX...................................................... 123THROMB-CAL-CELL-DRESSING,HEMOS........66THROMBIN (BOVINE)..........................................66THROMBIN/CAL/CMC/GEL/DRESS,HEM.........66THYROID,PORK..............................................57, 58THYROID,PORK (113.75 MG) (TABLET)...............THYROID,PORK (130 MG) (TABLET)....................THYROID,PORK (146.25 MG) (TABLET)...............THYROID,PORK (15 MG) (TABLET)......................THYROID,PORK (16.25 MG) (TABLET).................THYROID,PORK (162.5 MG) (TABLET).................THYROID,PORK (195 MG) (TABLET)....................THYROID,PORK (260 MG) (TABLET)....................THYROID,PORK (30 MG) (TABLET)......................THYROID,PORK (32.5 MG) (TABLET)...................THYROID,PORK (325 MG) (TABLET)....................THYROID,PORK (48.75 MG) (TABLET).................THYROID,PORK (60 MG) (TABLET)......................THYROID,PORK (65 MG) (TABLET)......................THYROID,PORK (81.25 MG) (TABLET).................THYROID,PORK (90 MG) (TABLET)......................THYROID,PORK (97.5 MG) (TABLET)...................TIAGABINE HCL.................................................113TIAGABINE HCL (12 MG) (TABLET)............... 134TIAGABINE HCL (16 MG) (TABLET)............... 134TIAGABINE HCL (2 MG) (TABLET)................. 134TIAGABINE HCL (4 MG) (TABLET)................. 134TIAZAC...................................................................29TICAGRELOR........................................................ 66TIGAN.......................................................................7TIKOSYN................................................................26TIMOLOL MALEATE......................................29, 60TIMOPTIC.............................................................. 60TIMOPTIC-XE........................................................60TINDAMAX............................................................74TINIDAZOLE......................................................... 74TIOTROPIUM BR/OLODATEROL HCL................ 8TIOTROPIUM BROMIDE........................................7TIPRANAVIR..........................................................75

TIPRANAVIR/VITAMIN E TPGS......................... 75TIVICAY................................................................. 78TIZANIDINE HCL............................................... 114TOBI........................................................................ 73TOBI PODHALER..................................................73TOBRADEX (0.3 %-0.1%) (DROPS SUSP).......... 58TOBRADEX (0.3 %-0.1%) (OINT. (G))................ 58TOBRAMYCIN.................................................59, 73TOBRAMYCIN IN 0.225% SOD CHLOR............ 73TOBRAMYCIN/DEXAMETHASONE..................58TOBRAMYCIN/LOTEPRED ETAB...................... 58TOBREX (0.3 %) (DROPS).................................... 59TOBREX (0.3 %) (OINT. (G))................................59TOCILIZUMAB......................................................81TOCOPHERSOLAN (VIT E TPGS).................... 124TODAY CONTRACEPTIVE SPONGE..................35TOFACITINIB CITRATE....................................... 81TOFRANIL..............................................................19TOFRANIL-PM.......................................................19TOLAZAMIDE....................................................... 48TOLBUTAMIDE.....................................................48TOLECTIN..............................................................83TOLECTIN DS........................................................83TOLINASE (250 MG) (TABLET).......................... 48TOLMETIN SODIUM............................................ 83TOLNAFTATE........................................................ 40TOLNAFTATE (1 %) (AERO POWD) (OTC)............TOLNAFTATE (1 %) (CREAM (G)) (OTC)..............TOLNAFTATE (1 %) (POWDER) (OTC)..................TOLTERODINE TARTRATE............................... 118TOLVAPTAN...........................................................54TOPAMAX............................................................ 113TOPICORT (0.05 %) (CREAM (G)).......................41TOPICORT (0.25 %) (CREAM (G)).......................41TOPIRAMATE.............................................. 113, 114TOPIRAMATE (100 MG) (CAP SPR 24)............ 135TOPIRAMATE (100 MG) (TABLET)........................TOPIRAMATE (15 MG) (CAP SPRINK)..................TOPIRAMATE (150 MG) (CAP SPR 24)............ 135TOPIRAMATE (200 MG) (CAP SPR 24)............ 135TOPIRAMATE (200 MG) (TABLET)........................TOPIRAMATE (25 MG) (CAP SPR 24).............. 135TOPIRAMATE (25 MG) (CAP SPRINK)..................TOPIRAMATE (25 MG) (TABLET)..........................TOPIRAMATE (50 MG) (CAP SPR 24).............. 135TOPIRAMATE (50 MG) (TABLET)..........................TOPOTECAN HCL.................................................89TOPROL XL............................................................28TORADOL (10 MG) (TABLET).............................83TORADOL (15 MG/ML) (CARTRIDGE)..............83TORADOL (15 MG/ML) (VIAL)...........................83TORADOL (30 MG/ML) (CARTRIDGE)..............83TORADOL (30MG/ML(1)) (VIAL)....................... 83TORADOL (60 MG/2 ML) (CARTRIDGE)...........83


Index

TORADOL (60 MG/2 ML) (VIAL)........................83TOREMIFENE CITRATE.......................................91TORSEMIDE...........................................................30TOUJEO MAX SOLOSTAR...................................53TOUJEO SOLOSTAR............................................. 53TOVIAZ.........................................................118, 135TRACLEER.............................................................30TRADJENTA...........................................................48TRAMADOL HCL................................................106TRAMADOL HCL/ACETAMINOPHEN.............107TRAMETINIB DIMETHYL SULFOXIDE............89TRANDOLAPRIL...................................................27TRANDOLAPRIL/VERAPAMIL HCL..................27TRANEXAMIC ACID............................................ 62TRANYLCYPROMINE SULFATE........................17TRAVATAN Z..........................................................60TRAVOPROST........................................................ 60TRAZODONE HCL................................................18TRECATOR.............................................................73TREK S COMBO PACK.........................................15TREK S COMPACT COMPRESSOR.................... 15TRELEGY ELLIPTA................................................ 8TRELSTAR............................................................. 56TRENTAL............................................................... 64TREPROSTINIL..................................................... 30TREPROSTINIL DIOLAMINE..............................30TREPROSTINIL SODIUM.....................................30TREPROSTINIL/NEB ACCESSORIES.................30TREPROSTINIL/NEBULIZER/ACCESOR...........30TRETINOIN...................................................... 39, 90TRETINOIN MICROSPHERES.............................39TRETTEN................................................................64TREXALL (10 MG) (TABLET)............................. 88TREXALL (15 MG) (TABLET)............................. 88TREXALL (2.5 MG) (TABLET)............................ 88TREXALL (5 MG) (TABLET)............................... 88TREXALL (7.5 MG) (TABLET)............................ 88TRIAMCINOLONE ACETONIDE.................. 43, 91TRIAMTERENE/HYDROCHLOROTHIAZID......30TRIAVIL 2-10..........................................................19TRIAVIL 2-25..........................................................19TRIAVIL 4-25..........................................................19TRIAVIL 4-50..........................................................19TRIAZOLAM..........................................................24TRICOR...................................................................33TRIFLUOPERAZINE HCL.................................... 24TRIFLURIDINE......................................................58TRIFLURIDINE/TIPIRACIL HCL........................ 88TRIHEXYPHENIDYL HCL................................. 109TRILAFON..............................................................24TRILEPTAL.......................................................... 112TRILIPIX.................................................................33TRIMETHOBENZAMIDE HCL.............................. 7TRIMETHOPRIM...................................................70

TRIMIPRAMINE MALEATE................................ 19TRIMPEX................................................................70TRINATAL RX 1...................................................123TRI-NORINYL........................................................36TRINTELLIX.................................................. 18, 135TRIPROLIDINE/PSEUDOEPHEDRINE............... 36TRIPROLIDINE/PSEUDOEPHEDRINE (2.5MG-60MG) (TABLET) (OTC)...........................................TRIPTODUR........................................................... 57TRIPTORELIN PAMOATE.............................. 56, 57TRIUMEQ............................................................... 79TRI-VI-FLOR (0.25 MG/ML) (DRPS SP BP) (OTC)............................................................................... 121TRI-VI-FLOR (0.5 MG/ML) (DRPS SP BP) (OTC)............................................................................... 121TRIZIVIR................................................................ 75TROKENDI XR (100 MG) (CAP ER 24H)....113,135TROKENDI XR (200 MG) (CAP ER 24H)....113,135TROKENDI XR (25 MG) (CAP ER 24H)....114, 135TROKENDI XR (50 MG) (CAP ER 24H)....114, 135TROPICAMIDE...................................................... 60TRUEDRAW........................................................... 52TRULICITY.................................................... 47, 135TRUMENBA........................................................... 68TRUNEB NEBULIZER.......................................... 13TRUSOPT................................................................60TRUSTEX............................................................... 92TRUSTEX CONDOM.............................................92TRUSTEX LATEX CONDOM............................... 92TRUSTEX-RIA....................................................... 92TRUVADA...............................................................75TRUZONE PEAK FLOW METER.........................15TUSNEL C.............................................................. 37TUSSIONEX........................................................... 37TWINRIX................................................................ 69TWOCAL HN......................................................... 94TYBOST..................................................................79TYKERB................................................................. 90TYLACTIN RTD 15 PE.......................................... 99TYMLOS.................................................................56TYR ANAMIX NEXT............................................ 99TYR COOLER........................................................ 99TYR COOLER20.................................................... 99TYR EXPRESS20................................................... 99TYR GEL.................................................................99TYR LOPHLEX...................................................... 99TYVASO..................................................................30TYVASO INSTITUTIONAL START KIT..............30TYVASO REFILL KIT........................................... 30TYVASO STARTER KIT........................................30

- U -UCD ANAMIX JUNIOR........................................ 99


Index

UCD TRIO...............................................................99ULIPRISTAL ACETATE.........................................36ULORIC.................................................................. 62ULTI-LANCE....................................................52, 53ULTRACET........................................................... 107ULTRA-FRESH.......................................................43ULTRAM...............................................................106ULTRAM ER.........................................................106ULTRATHON INSECT REPELLENT................... 41UMECLIDINIUM BRM/VILANTEROL TR...........8UMECLIDINIUM BROMIDE..................................7UNIPHYL................................................................16UNISOM (25 MG) (TABLET) (OTC).................... 24UNISOM SLEEP AID (25 MG) (TABLET) (OTC)................................................................................. 25UNISTIK 2.............................................................. 53UNISTIK 2 EXTRA................................................ 53UNISTIK 2 NORMAL............................................ 53UNISTIK 3.............................................................. 53UNISTIK 3 COMFORT.......................................... 53UNISTIK 3 NEONATAL.........................................53UNIVASC................................................................ 27UPTRAVI.................................................................30URECHOLINE........................................................87URETRON D-S....................................................... 70URIDINE TRIACETATE.................................. 62, 90URIN D.S................................................................ 70URINE GLUCOSE TEST STRIP........................... 54URINE GLUCOSE-ACET TEST STRIP................54URISPAS............................................................... 118UROCIT-K.............................................................117UROXATRAL....................................................... 117URSO.......................................................................84URSO FORTE......................................................... 84URSODIOL............................................................. 84URYL.......................................................................70

- V -VAGIFEM..............................................................118VALACYCLOVIR HCL..........................................75VALCHLOR............................................................ 45VALCYTE (450 MG) (TABLET)........................... 75VALGANCICLOVIR HCL..................................... 75VALISONE..............................................................41VALPROIC ACID................................................. 114VALPROIC ACID (AS SODIUM SALT)............. 114VALSARTAN.......................................................... 28VALSARTAN/HYDROCHLOROTHIAZIDE........ 27VALTREX................................................................75VANATAB DM........................................................38VANCOMYCIN HCL............................................. 74VANCOMYCIN HCL (125 MG) (CAPSULE)...........VANCOMYCIN HCL (250 MG) (CAPSULE)...........VANDETANIB........................................................ 90VANICREAM........................................................101

VANOS.................................................................... 42VANOXIDE-HC...................................................... 38VANTAS.................................................................. 56VANTIN...................................................................70VAPORIZER........................................................... 16VAPORIZER CLEANING TABLETS....................16VAPORIZER INHALANT......................................16VAPORIZER-HUMIDIFIER SUPPLIES................16VAQTA.................................................................... 69VARENICLINE TARTRATE................................ 114VARICELLA VACCINE LIVE/PF......................... 69VARICELLA-ZOSTER GE VAC,2 OF 2................69VARICELLA-ZOSTER GE/AS01B/PF.................. 69VARIVAX VACCINE..............................................69VASCEPA (0.5 GRAM) (CAPSULE).....................33VASCEPA (1 G) (CAPSULE)................................. 33VASELINE............................................................ 101VASELINE PETROLEUM................................... 101VASERETIC............................................................27VASOTEC................................................................27VCF..........................................................................35VECTICAL......................................................46, 135VEETIDS.................................................................72VEMURAFENIB.................................................... 88VENCLEXTA..........................................................90VENCLEXTA STARTING PACK.......................... 90VENELEX (OINT. (G))........................................ 102VENETOCLAX.......................................................90VENLAFAXINE HCL............................................ 18VENLAFAXINE HCL ER..........................................VENTAVIS.............................................................. 30VENTOLIN HFA (90 MCG) (HFA AER AD)..........8VEPESID.................................................................90VERAPAMIL HCL................................................. 29VERELAN...............................................................29VERELAN PM........................................................29VERSACLOZ..................................................21, 135VERSICLEAR.........................................................40VERZENIO............................................................. 89VESANOID.............................................................90VESICARE....................................................118, 135VFEND.................................................................... 73V-GO 20...................................................................53V-GO 30...................................................................53V-GO 40...................................................................53VIBRAMYCIN........................................................72VIBRA-TABS (100 MG) (TABLET)...................... 72VICKS COOL MIST.................................................9VICKS WARM STEAM VAPORIZER.................. 16VICOPROFEN...................................................... 104VICTOZA 2-PAK............................................47, 135VICTOZA 3-PAK............................................47, 135VIDEX.....................................................................76VIDEX EC (125 MG) (CAPSULE DR)..................76


Index

VIDEX EC (200 MG) (CAPSULE DR)..................76VIDEX EC (250 MG) (CAPSULE DR)..................76VIDEX EC (400 MG) (CAPSULE DR)..................76VIGABATRIN....................................................... 114VIGAMOX.............................................................. 59VIIBRYD (10 MG) (TABLET)....................... 18, 135VIIBRYD (20 MG) (TABLET)....................... 18, 136VIIBRYD (40 MG) (TABLET)....................... 18, 136VILAZODONE HCL.............................................. 18VIMPAT (10 MG/ML) (SOLUTION)...........110, 136VIMPAT (100 MG) (TABLET)..................... 110, 136VIMPAT (150 MG) (TABLET)..................... 111, 136VIMPAT (200 MG) (TABLET)..................... 111, 136VIMPAT (50 MG) (TABLET)....................... 111, 136VIOS AEROSOL DELIVERY SYSTEM............... 15VIRACEPT..............................................................78VIRAMUNE (200 MG) (TABLET)........................ 76VIRAMUNE (50 MG/5 ML) (ORAL SUSP)......... 76VIRAMUNE XR (100 MG) (TAB ER 24H)...........76VIRAMUNE XR (400 MG) (TAB ER 24H)...........76VIRAZOLE............................................................. 74VIREAD (150 MG) (TABLET).............................. 77VIREAD (200 MG) (TABLET).............................. 77VIREAD (250 MG) (TABLET).............................. 77VIREAD (300 MG) (TABLET).............................. 77VIREAD (40MG/SCOOP) (POWDER)..................77VIROPTIC............................................................... 58VISKEN...................................................................28VISMODEGIB........................................................ 88VISTARIL................................................................. 5VISTOGARD.......................................................... 90VIT A PALMITATE/VIT C/VIT D3..................... 122VIT A PALMITATE/VIT C/VIT D3 (750-35/ML)(DROPS) (OTC)..........................................................VIT A/D3/TOCOPHERSOLAN/VIT K................121VIT A/VIT D3/E/TOCOPHERSOLAN/K............ 121VIT B COMP/C/FOLIC/IRON/VIT E.................. 120VIT B COMP/C/FOLIC/IRON/VIT E (500-400-18)(TABLET) (OTC)........................................................VIT E/LIDOCAINE/ALOE/COLLAGEN.............. 46VITAL 1.0 CAL.....................................................100VITAL 1.5 CAL.....................................................100VITAL AF 1.2 CAL...............................................100VITAL PEPTIDE 1.5 CAL....................................100VITAMEDMD REDICHEW RX.......................... 122VITAMIN A.......................................................... 123VITAMIN A (10000 UNIT) (CAPSULE) (OTC).......VITAMIN B COMPLEX.......................................123VITAMIN B COMPLEX (CAPSULE) (OTC)............VITAMIN B COMPLEX (TABLET) (OTC)..............VITAMIN E.............................................................44VITAMIN E (OIL) (OTC)...........................................VITAMIN E/ALOE VERA..................................... 44VITAMINS B1,B2,B3,B5,AND B6...................... 123

VITE AC/GRAPE/HYALURONIC ACID.............. 44VITRAKVI.............................................................. 90VIVACTIL............................................................... 19VIVELLE-DOT....................................................... 67VIVITROL...............................................................20VIVONEX RTF..................................................... 100VIXONE NEBULIZER...........................................13VOGELXO.............................................................. 66VOLTAREN.................................................43, 58, 82VOLTAREN-XR......................................................82VON WILLEBRAND FACTOR............................. 63VONVENDI............................................................ 63VORICONAZOLE.................................................. 73VORINOSTAT.........................................................90VORTEX............................................................10, 11VORTEX FROG MASK......................................... 11VORTEX HOLDING CHAMBER-CHILD............ 12VORTEX HOLDING CHAMBER-TODDLER......11VORTEX LADYBUG MASK.................................11VORTEX VHC FROG MASK................................ 12VORTEX VHC LADYBUG MASK....................... 11VORTIOXETINE HYDROBROMIDE................... 18VOSOL.................................................................... 54VOSOL HC..............................................................54VOTRIENT..............................................................90VYVANSE.......................................................20, 136

- W -WARFARIN SODIUM............................................ 62WARM STEAM VAPORIZER............................... 16WATER FOR IRRIGATION,STERILE.................. 44WEED POLLEN-SHORT RAGWEED.................... 4WELCHOL..............................................................32WHEY................................................................... 101WHITE PETROLEUM..........................................101WIDE SEAL DIAPHRAGM...................................36WILATE.................................................................. 63WILLIS THE WHALE COMPRESSR NEB.......... 15WINDMILL TRAINER.......................................... 16WOUND GEL......................................................... 44

- X -XALATAN...............................................................60XALKORI............................................................... 89XANTHAN GUM................................................. 102XARELTO (10 MG) (TABLET)............................. 63XARELTO (15 MG) (TABLET)............................. 63XARELTO (15 MG-20MG) (TAB DS PK).............63XARELTO (2.5 MG) (TABLET)............................ 63XARELTO (20 MG) (TABLET)............................. 63XELJANZ................................................................ 81XELJANZ XR......................................................... 81XELODA (150 MG) (TABLET)............................. 88XELODA (500 MG) (TABLET)............................. 88XENAZINE............................................................. 91XIFAXAN (550 MG) (TABLET)............................74


Index

XIIDRA................................................................... 59XOFLUZA...............................................................74XOPENEX.................................................................8XOPENEX CONCENTRATE...................................8XOSPATA................................................................ 89XTANDI.................................................................. 88XTRACAL PLUS....................................................99XURIDEN............................................................... 62XYNTHA................................................................ 62XYNTHA SOLOFUSE........................................... 62XYZAL (2.5 MG/5ML) (SOLUTION).............6, 136XYZAL (5 MG) (TABLET)...................................... 6XYZAL (5 MG) (TABLET) (OTC)...........................6

- Y -YASMIN 28............................................................. 35YAZ..........................................................................35

- Z -ZAFIRLUKAST........................................................ 9ZALEPLON.............................................................25ZANAFLEX (2 MG) (TABLET)...........................114ZANAFLEX (4 MG) (TABLET)...........................114ZANAMIVIR...........................................................75ZANTAC (15 MG/ML) (SYRUP)......................... 116ZANTAC (150 MG) (CAPSULE)......................... 116ZANTAC (150 MG) (TABLET)............................116ZANTAC (150 MG) (TABLET) (OTC)................ 116ZANTAC (300 MG) (CAPSULE)......................... 116ZANTAC (300 MG) (TABLET)............................116ZANTAC 75 (75 MG) (TABLET) (OTC)............. 116ZARONTIN........................................................... 110ZAROXOLYN......................................................... 31ZARXIO.................................................................. 65ZAVESCA............................................................... 96Z-CLINZ..................................................................47ZEBETA.................................................................. 28ZELBORAF.............................................................88ZENPEP.................................................................115ZESTORETIC......................................................... 27ZESTRIL................................................................. 27ZETIA......................................................................32ZIAC........................................................................ 29ZIAGEN (20 MG/ML) (SOLUTION).....................76ZIAGEN (300 MG) (TABLET)...............................76ZIDOVUDINE.........................................................77ZINC ACETATE/MEADOWSWEET/OAK........... 45ZINC OXIDE...........................................................45ZINC OXIDE (20 %) (OINT. (G)) (OTC)...................ZINC SULFATE.................................................... 124ZINC SULFATE (220 MG) (TABLET) (OTC)...........ZIPRASIDONE HCL.............................................. 23ZIPRASIDONE MESYLATE................................. 23ZIRGAN.................................................................. 58ZOFRAN ODT.......................................................... 7ZOLADEX.............................................................. 56

ZOLINZA................................................................ 90ZOLMITRIPTAN.................................................. 107ZOLOFT.................................................................. 18ZOLPIDEM TARTRATE........................................ 25ZOLPIMIST.................................................... 25, 136ZOMIG (2.5 MG) (SPRAY).......................... 107, 136ZOMIG (5 MG) (SPRAY)............................. 107, 136ZONEGRAN......................................................... 114ZONISAMIDE...................................................... 114ZORBTIVE..............................................................57ZORTRESS..............................................................69ZOSTAVAX............................................................. 69ZOSTER VACCINE LIVE/PF................................ 69ZOVIRAX..........................................................41, 74ZUBSOLV (0.7-0.18MG) (TAB SUBL)............... 108ZUBSOLV (1.4-0.36MG) (TAB SUBL)............... 108ZUBSOLV (11.4-2.9MG) (TAB SUBL)............... 108ZUBSOLV (2.9-0.71MG) (TAB SUBL)............... 108ZUBSOLV (5.7-1.4 MG) (TAB SUBL)................ 108ZUBSOLV (8.6-2.1 MG) (TAB SUBL)................ 108ZYBAN..................................................................114ZYDELIG................................................................ 89ZYKADIA............................................................... 89ZYLET.....................................................................58ZYLOPRIM.............................................................62ZYMAXID.............................................................. 59ZYPREXA...............................................................22ZYPREXA RELPREVV (210 MG) (VIAL)...........22ZYPREXA RELPREVV (300 MG) (VIAL)...........22ZYPREXA RELPREVV (405 MG) (VIAL)...........22ZYPREXA ZYDIS.................................................. 22ZYRTEC (1 MG/ML) (SOLUTION) (OTC).............5ZYRTEC (10 MG) (TAB CHEW) (OTC)................. 5ZYRTEC (10 MG) (TABLET) (OTC).......................5ZYRTEC (5 MG) (TAB CHEW) (OTC)................... 5ZYRTEC (5 MG) (TABLET) (OTC).........................5ZYRTEC (5 MG/5 ML) (SOLUTION) (OTC)..........5ZYRTEC-D (5 MG-120MG) (TAB ER 12H) (OTC)................................................................................... 4ZYTIGA (250 MG) (TABLET)...............................88ZYTIGA (500 MG) (TABLET)...............................88ZYVOX....................................................................71ZZZQUIL (25 MG) (CAPSULE) (OTC)................ 24


Index

medicaid formulary crystal run health plans · 2019-04-15 · medicaid formulary. crystal run...

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