pharmacy benefit guide - children's community health plan · internal reference: tog member...

Pharmacy Benefit Guide

Together with CCHP

PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997

Toll-free: 1-844-201-4677 | togetherCCHP.org

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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201)

Pharmacy Program Overview

The pharmacy program of Together with Children’s Community Health Plan (CCHP) offers a variety of high-quality, effective generic

and brand-name prescription drugs. This guide provides information that applies to most members. For information specific to your

plan, please read your Schedule of Benefits.

When you need a prescription drug, you and your doctor can choose from six different levels, or “tiers”. Each tier has a different

copayment or coinsurance. This gives you and your doctor the freedom to choose the drug that is right for you. At the same time, this

will help you budget your health care dollars and may save you money.

This guide provides an overview of your pharmacy benefit with Together with CCHP. It tells you the process for getting certain drugs

covered, your options for filling prescriptions, important phone numbers, and more. For a complete listing of benefits, exclusions, and

limitations, please refer to the Schedule of Benefits for your plan. In the event there are discrepancies with the information in this

guide, the terms and conditions of the coverage documents will govern.

Contact Numbers

• Current Together with CCHP Members:

o Customer Service: 1-844-201-4672

o Pharmacy Services (for practitioners and pharmacies): 1-844-201-4677

o Hearing-impaired members: 1-844-531-4856

• Prospective Together with CCHP Members:

o Prospective members should direct their questions to Together with CCHP Sales Team at 1-844-708-3837. Online

information is available at togetherCCHP.org/formulary.

Read your contract carefully to determine which health care services are covered.

This Pharmacy Benefit Guide is current as of December 01, 2017.

For the latest information on the Together with CCHP drug formulary and other pharmacy benefits, go to:

togetherCCHP.org/formulary. You may also call our Customer Service at the number listed above or on the back of your member ID

card.

Together with CCHP



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Understanding Coverage and Cost Sharing

Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. Our Health Plan’s Pharmacy and

Therapeutics (P&T) Committee researches and evaluates drugs it may cover. Committee members include doctors and pharmacists

who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug’s safety,

effectiveness, and cost.

Together with CCHP prescription drugs are organized into six formulary tiers:

• Tier 1 includes a majority of generic medications. Generic drugs offer the same level of safety and quality as their brand-

name equivalents. They have the same number of active ingredients as brand name medications. Together with CCHP

requires you to use a generic version of the drug if one is available. This means that if you get a brand-name drug when a

generic is available, you must pay the brand copayment and the retail cost difference between the brand- name and

generic forms of the drug.

• Tier 2 is for preferred-brand medications. Together with CCHP classifies these drugs as “preferred” because of their value

and effectiveness.

• Tier 3 is for non-preferred brand medications.

• Tier 4 is for specialty medications, for which you will have the highest level of cost sharing. Specialty medications usually

treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs

can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or

inhalant). Specialty drugs require close management by a physician. Physicians need to monitor these drugs because of

potential side effects and the need for frequent dosage adjustments.

• Tier 5 is for select generic medications. Select generic medications are offered at no additional cost share to you, once

your deductible is met. Many of these medications can help you avoid getting sick and improve your overall health.

• Tier 6 is for zero cost-share preventive drugs. In accordance with the Patient Protection and Affordable Care Act of 2010

(PPACA), many select preventive medications are covered at no cost to you.

About Generic Drugs

Generic drugs have the same active ingredients as brand-name drugs, but cost much less. Not all drugs have a generic equivalent.

Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same

drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since

the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their

drugs. As a result, generic drug makers can pass these savings on to you.

Generic drugs have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic

drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to

shape the tablets. Inactive ingredients do not affect how the generic drug works.

The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name drugs. The generic drug must pass strict

FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name

counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the

brand name drug.

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Formulary Overview

The most commonly prescribed Together with CCHP drugs are listed in the formulary section of this guide. Please note there are other

drugs that Together with CCHP covers in addition to the ones listed in this guide. For the latest information on the complete Together

with CCHP formulary and other pharmacy benefits, visit our website at togetherCCHP.org/formulary. (Select “Together with CCHP” to

access the searchable drug list.)

You may also call our Customer Service at the number listed on your member ID card or on the first page of this guide. If you are a

current Together with CCHP member, refer to your Schedule of Benefits for your applicable coinsurance or copayment amounts. I f

you did not receive a Schedule of Benefits, contact our Customer Service at the number on your member ID card. Your member ID

card should also list your applicable coinsurance or copayment amounts.

For Prospective Members

If you are thinking about joining CCHP and would like information about applicable coinsurance or copayment amounts, go to the

Summary of Benefits and Coverage (SBC) on the Together with CCHP website at togetherCCHP.org or call the sales team at the

number listed on the first page of this guide.

Getting Your Prescriptions Filled

I. Retail

Together with CCHP’s network of retail pharmacies includes hundreds of locations, independent pharmacies, as well as multi -

store chains throughout the region. You can take your drug to any pharmacy in the network. You must use 75 percent of your

drug before you can get a refill. Go to togetherCCHP.org/pharmacy for specific pharmacy names, locations, and telephone

numbers. You may also call our Customer Service at the number is listed on your member ID card and on the first page of this

guide.

II. Mail Order

If you take maintenance drugs for a chronic condition, you can get them through a mail-order pharmacy. Maintenance drugs

are drugs that are taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma,

high cholesterol, and more.

With convenient mail-order service, you:

• Receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor.

• Usually pay a lower out-of-pocket cost for a 90- day supply at a mail-order pharmacy than you would pay at a retail

pharmacy.

• Get these drugs delivered right to your door.

Most mail-order prescriptions are written for a 90-day supply. If your doctor writes for a 30-day supply with two refills, the mail

order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should write,

“Do Not want a 90-day Supply” on the mail-order form. For a new medication, the first time you get a prescription or a new

drug, Together with CCHP recommends that you try a 30-day supply of the drug from a retail pharmacy. That way your

practitioner has a chance to make sure that it is the right dose for you and that it does not cause any side effects.

Once you’re confident that the drug is appropriate, ask your practitioner to write a prescription for a 90- day supply of each

maintenance drug that you need (plus refills if appropriate). Then order the supply through the mail-order pharmacy. To avoid

running out of your mail-order prescription, reorder your drug while you still have drugs to use for about two weeks, allowing a

few weeks for processing and delivery. To request refills, you may order online or over the telephone. You can ask for a mail-

order form by calling our Customer Service, or by requesting the form through togetherCCHP.org.

http://togethercchp.org/

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III. Specialty Provider

Most specialty drugs must be obtained through our designated specialty provider. When you are prescribed a specialty drug

and use a specialty provider, you get mail-order delivery and better access to drugs, because many retail pharmacies do not

have these types of drugs. Specialty drugs that require special handling, provider coordination, or patient education that

cannot be provided by a retail pharmacy must be obtained through our designated specialty provider. A specialty provider

offers cost-saving health care, and drug management and compliance programs.

IV. Drug supplies not covered

If you'll be away from home for a long period of time, you may want to use our mail-order service to get a 90-day supply

before you leave.

• No authorizations will be provided for drugs reported by the member, provider, or pharmacy to be lost, misplaced,

stolen, destroyed, or damaged.

• Drugs received at no charge to the member (workers’ compensation, drugs purchased with a manufacturer’s coupon)

will not be covered.

• Prescriptions that are written more than a year ago will not be covered. Your practitioner will need to write a new

prescription.

V. Medications not covered

The following medications are benefit exclusions and will not be covered under the pharmacy benefit:

• Antimalarial agents when used for prevention

• Anti-obesity medications, including, but not limited to appetite suppressants and lipase inhibitors

• Blood or blood plasma products*

• Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies

and compounded narcotic analgesics)

• Drugs labeled for investigational use

• Fertility agents

• Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications**

• Needles/Syringes (other than insulin)*

• Nutrition and dietary supplements*

• Therapeutic devices/appliances*

• Urine strips. (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood

glucose, urine strips are not a covered benefit.)

This is not a complete list and there may be other medications that are not covered. For more information, please contact

Customer Service at the phone number on the back of your member ID card or on the first page of this guide.

*Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you

can contact our Customer Service at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Customer

Service number listed on the first page of this guide. **Additional OTC medications may be covered in accordance with the Pat ient Protection and

Affordable Care Act. The Preventive Services Guide is available on our website contains information regarding this coverage.

VI. Filling your prescription when traveling

When you travel outside of your network area, many pharmacies across the country will accept your Together with CCHP

member ID card. To find a participating pharmacy, call our Customer Service. The number is on your member ID card, on the

first page of this guide or online at togetherCCHP.org/formulary.

To fill a prescription at a participating out-of-area pharmacy, show them your Together with CCHP member ID card. Some

pharmacies may ask you to pay the full price of the drug. If that happens and your claim is approved, you will be refunded

the amount that you paid for the drug, less your copayment. You can request a “Pharmacy Program Direct Reimbursement

Claim Form” by calling our Customer Service or requesting the form on our member portal, CCHP Connect.

Drug Exceptions Time Frames and Enrollee Responsibilities

http://togethercchp.org/formulary

https://childrenscommunityhealthplan.org/Members/MyCCHP/marketplace/CCHP-Connect-Together

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If the drug you take is not on the list of covered drugs for your benefit plan (also called a “formulary”), you can ask us to cover it. This

is called a “non-formulary exception.” A request for a non-formulary exception will only be approved if there is documented

evidence that the formulary alternatives are not effective in treating your condition; the formulary alternatives would cause adverse

side effects; or a contraindication exists such that you cannot safely try the formulary drug.

As a first step, you can contact Customer Service for a list of similar drugs that are covered by your plan or you can go to

togetherCCHP.org/formulary for this information. When you have the list, show it to your doctor and see whether he or she is able to

prescribe one of the drugs on this list.

If you need to request a non-formulary exception, contact Customer Service or access the exception request form in the CCHP

Connect member portal. When you make this request, we may contact your prescriber or physician for information to support your

request. After CCHP receives your request, we will make our decision within 72 hours. You can request a faster (expedited) decision if

you or your doctor believe that waiting up to 72 hours for a decision could seriously harm your health. If your request to expedite is

granted, we must give you a decision no later than 24 hours from when we received your request.

If we deny your request for a non-formulary exception, you may first request an internal review of that decision by contacting

Customer Service. If the denial of the non-formulary exception request is upheld through an internal review, you may then request an

external review by an Independent Review Organization (IRO). You can also request an external review by contacting Customer

Service at 1-844-201-4672.

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Non-Discrimination Statement and Information

Children’s Community Health Plan (CCHP) complies with all applicable civil rights laws and does not discriminate on the basis

of race, color, national origin, sex, age, disability, or other legally protected status, in its administration of the plan, including

enrollment and benefit determinations.

Children’s Community Health Plan provides appropriate auxiliary aids and services, including qualified interpreters for

individuals with disabilities and who have language services needs and information in alternate formats, free of charge and

in a timely manner, when such aids and services are necessary to ensure an equal opportunity to participate to individuals

with disabilities.

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin; sex, age

or disability may file a grievance in person, by mail, fax or email. The grievance must be filed with 60 days of the person f iling

the grievance becomes aware of the alleged discriminatory action. It is against the law for Children’s Community Health Plan

to retaliate against anyone who files a grievance, or who participates in the investigation of a grievance. Members can

request Children’s Community Health Plan’s grievance procedure by contacting the Section 1557 Coordinator:

Director, Corporate Compliance

Mail Station C760

P.O. Box 1997

Milwaukee, WI 53201-1997

Telephone: (414) 266-2215

TDD-TTY (for the hearing impaired): (414) 266-2465

Fax: (414) 266-6409

[email protected]

Members must submit their complaints in writing with their name, address, the problem or action alleged to be discriminatory

and the remedy or relief sought. Members can also file a complaint of discrimination electronically through the Office for Civil

Rights Complaint Portal, which is available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:

U.S. Department of Health and Human Services

200 Independence Avenue

SW Room 509F

HHH Building

Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

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Language Access

ENGLISH: If you or someone you’re helping has questions about Together with CCHP, you have the right to get help and

information in your language at no cost. To talk to an interpreter, call 1-844-201-4672. TTY users, call 1-844-531-4856.

SPANISH: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Together with CCHP tiene derecho a

obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-201-4672.

HMONG: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Together with CCHP, koj muaj cai kom lawv muab

cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau

1-844-201-4672.

CHINESE: 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱Together with CCHP面的問題，您有權利免費以您的母語得到幫

助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字1-844-201-4672.

GERMAN: Falls Sie oder jemand, dem Sie helfen, Fragen zum Together with CCHP haben, haben Sie das Recht, kostenlose

Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-

844-201-4672 an.

ARABIC: بخصوص أسئلة تساعده شخص لدى أو لديك كان إن ) Together with CCHP (، والمعلومات المساعدة على الحصول في الحق فلديك

4672-201-844-1 ( ب اتصل مترجم مع للتحدث .تكلفة اية دون من بلغتك الضرورية

FRENCH: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Together with CCHP vous avez le

droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-201-4672.

TAGALOG: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Together with CCHP, may karapatan

ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin,

tumawag sa 1-844-201-4672.

ALBAINIAN: Nëse ju, ose dikush që po ndihmoni, ka pyetje për Together with CCHP, keni të drejtë të merrni ndihmë dhe

informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 1-844-201-4672.

HINDI: यदि आपके ,या आप द्वारा सहायता ककए जा रहे ककसी व्यक्तत के Together with CCHP के बारे में प्रश्न हैं ,तो आपके पास अपनी भाषा में मुफ्त में सहायता और सूचना प्राप्त करने का अधिकार है। ककसी िुुुभाषषए से बात करने के लिए 1-844-201-4672.पर कॉिु करें।

POLISH: Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Together with CCHP, masz prawo do uzyskania

bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-201-4672.

VIETNAMESE: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Together with CCHP, quý vị sẽ có quyền được giúp

và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-201-4672.

PENNSYLVANIA DUTCH: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Together with CCHP,

hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me

Interpreter schwetze witt, kannscht du 1-844-201-4672 uffrufe.

LAOTIAN: ້ າທ່ານ, ຫ ້ ້ ຄົນທ ້່ ທ່ານກໍາລັງຊ່ວຍເຫ ້ ້ ອ, ມ ຄໍ າຖາມກ່ຽວກັບ Together with CCHP, ທ່ານມ ສິ ດທ ້່ ຈະໄດ ຮັບການຊ່ວຍເຫ ້ ້ ອ

ແລະຂໍ ມູນຂ່າວສານທ ້່ ເປັນພາສາຂອງທ່ານບໍ່ ມ ຄ່າໃຊ ຈ່າຍ. ການໂອ ລົມກັບນາຍພາສາ, ໃຫ ໂທຫາ 1-844-201-4672.

KOREAN: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Together with CCHP에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를

귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1-844-201-4672 로 전화하십시오.

RUSSIAN: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Together with CCHP, то вы имеете

право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните

по телефону 1-844-201-4672.

1

Table of Contents

ANTI - INFECTIVES .......................................................................................................................................... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 17 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 24 CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 41

DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 51

DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 58 EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 61 ENDOCRINE/DIABETES ................................................................................................................................ 62 GASTROENTEROLOGY ................................................................................................................................. 71

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 78

MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 85 OBSTETRICS & GYNECOLOGY ................................................................................................................... 87 OPHTHALMOLOGY ........................................................................................................................................ 95 RESPIRATORY, ALLERGY, COUGH & COLD .......................................................................................... 101 UROLOGICALS .............................................................................................................................................. 107

VITAMINS, HEMATINICS & ELECTROLYTES ........................................................................................ 109

Index ................................................................................................................................................................. 120

2

List of Abbreviations

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more

information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.

This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we

may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat

your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for

you, we will then cover Drug B.

You can find information on what the symbols and abbreviations on this table mean by going to the beginning

of this table.

3

Drug Name Drug Tier Requirements / Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET INTRAVENOUS SUSPENSION 3

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

3

amphotericin b injection recon soln 1

CANCIDAS INTRAVENOUS RECON SOLN 3

caspofungin intravenous recon soln 50 mg 3

CASPOFUNGIN INTRAVENOUS RECON

SOLN 70 MG

3

clotrimazole mucous membrane troche 1

CRESEMBA INTRAVENOUS RECON SOLN 4 QL

CRESEMBA ORAL CAPSULE 4 QL

ERAXIS(WATER DILUENT) INTRAVENOUS

RECON SOLN

3

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml, 400 mg/200 ml

1

fluconazole oral suspension for reconstitution 1

fluconazole oral tablet 1 QL

flucytosine oral capsule 4

griseofulvin microsize oral suspension 1

griseofulvin microsize oral tablet 1

griseofulvin ultramicrosize oral tablet 1

itraconazole oral capsule 1 PA; QL

ketoconazole oral tablet 1

MYCAMINE INTRAVENOUS RECON SOLN 3

NOXAFIL ORAL SUSPENSION 4 PA

NOXAFIL ORAL TABLET,DELAYED

RELEASE (DR/EC)

4 PA; QL

nystatin oral powder 150 million unit, 500 million

unit

1

nystatin oral suspension 1

nystatin oral tablet 1


of this table.

4


ONMEL ORAL TABLET 3 PA; QL

ORAVIG BUCCAL MUCO-ADHESIVE

BUCCAL TABLET

3 PA; QL

SPORANOX ORAL SOLUTION 3 PA

terbinafine hcl oral tablet 1 QL

voriconazole intravenous solution 1

voriconazole oral suspension for reconstitution 4 QL

voriconazole oral tablet 4 QL

ANTIVIRALS

abacavir oral solution 1 QL

abacavir oral tablet 1 QL

abacavir-lamivudine oral tablet 1 QL

abacavir-lamivudine-zidovudine oral tablet 1 QL

acyclovir oral capsule 1

acyclovir oral suspension 200 mg/5 ml 1

acyclovir oral tablet 1

acyclovir sodium intravenous solution 1

adefovir oral tablet 4 PA

amantadine hcl oral capsule 1

amantadine hcl oral solution 1

amantadine hcl oral tablet 1

APTIVUS ORAL CAPSULE 4 QL

APTIVUS ORAL SOLUTION 4 QL

ATRIPLA ORAL TABLET 4 QL

BARACLUDE ORAL SOLUTION 4 PA

cidofovir intravenous solution 1

COMPLERA ORAL TABLET 4 QL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL

DAKLINZA ORAL TABLET 4 PA; LA; QL

DESCOVY ORAL TABLET 4 QL

didanosine oral capsule,delayed release(dr/ec) 1 QL


of this table.

5


EDURANT ORAL TABLET 4 QL

EMTRIVA ORAL CAPSULE 2 QL

EMTRIVA ORAL SOLUTION 2 QL

entecavir oral tablet 4 PA

EPCLUSA ORAL TABLET 4 PA; LA; QL

EPIVIR HBV ORAL SOLUTION 2 PA

EVOTAZ ORAL TABLET 4 QL

famciclovir oral tablet 1 QL

fosamprenavir oral tablet 1 QL

foscarnet intravenous solution 1

FUZEON SUBCUTANEOUS RECON SOLN 4 QL

ganciclovir sodium intravenous recon soln 1

GENVOYA ORAL TABLET 4 QL

HARVONI ORAL TABLET 4 PA; LA; QL

INTELENCE ORAL TABLET 4 QL

INVIRASE ORAL CAPSULE 4 QL

INVIRASE ORAL TABLET 4 QL

ISENTRESS HD ORAL TABLET 4 QL

ISENTRESS ORAL POWDER IN PACKET 4 QL

ISENTRESS ORAL TABLET 4 QL

ISENTRESS ORAL TABLET,CHEWABLE 4 QL

KALETRA ORAL TABLET 4 QL

lamivudine oral solution 1 QL

lamivudine oral tablet 100 mg 1

lamivudine oral tablet 150 mg, 300 mg 1 QL

lamivudine-zidovudine oral tablet 1 QL

LEXIVA ORAL SUSPENSION 4 QL

LEXIVA ORAL TABLET 4 QL

lopinavir-ritonavir oral solution 1 QL

MAVYRET ORAL TABLET 4 PA; LA; QL

nevirapine oral suspension 1 QL


of this table.

6


nevirapine oral tablet 1 QL

nevirapine oral tablet extended release 24 hr 1 QL

NORVIR ORAL CAPSULE 2 QL

NORVIR ORAL SOLUTION 2 QL

NORVIR ORAL TABLET 2 QL

ODEFSEY ORAL TABLET 4 QL

OLYSIO ORAL CAPSULE 4 PA; LA; QL

oseltamivir oral capsule 1 QL

PREZCOBIX ORAL TABLET 4 QL

PREZISTA ORAL SUSPENSION 4 QL

PREZISTA ORAL TABLET 150 MG, 600 MG,

75 MG, 800 MG

4 QL

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE

3 QL

RESCRIPTOR ORAL TABLET 2 QL

RESCRIPTOR ORAL TABLET, DISPERSIBLE 2 QL

RETROVIR INTRAVENOUS SOLUTION 4 QL

REYATAZ ORAL CAPSULE 150 MG, 200 MG,

300 MG

4 QL

REYATAZ ORAL POWDER IN PACKET 4 QL

rimantadine oral tablet 1

SELZENTRY ORAL SOLUTION 4 PA; QL

SELZENTRY ORAL TABLET 4 PA; QL

SOVALDI ORAL TABLET 4 PA; LA; QL

stavudine oral capsule 1 QL

stavudine oral recon soln 1 QL

STRIBILD ORAL TABLET 4 QL

SUSTIVA ORAL CAPSULE 4 QL

SUSTIVA ORAL TABLET 4 QL

SYNAGIS INTRAMUSCULAR SOLUTION 4 PA; LA; QL

TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION

3 QL

TECHNIVIE ORAL TABLET 4 PA; LA; QL


of this table.

7


TIVICAY ORAL TABLET 4 QL

TRIUMEQ ORAL TABLET 4 QL

TRUVADA ORAL TABLET 4 QL

TYBOST ORAL TABLET 2

valacyclovir oral tablet 1 QL

valganciclovir oral recon soln 4

valganciclovir oral tablet 3

VEMLIDY ORAL TABLET 4 PA; QL

VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN

2 QL

VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; LA; QL

VIEKIRA XR ORAL TABLET, IR - ER,

BIPHASIC 24HR

4 PA; LA; QL

VIRACEPT ORAL TABLET 4 QL

VIRAMUNE XR ORAL TABLET EXTENDED

RELEASE 24 HR 100 MG

4 QL

VIREAD ORAL POWDER 4 QL

VIREAD ORAL TABLET 4 QL

VOSEVI ORAL TABLET 4 PA; LA; QL

ZEPATIER ORAL TABLET 4 PA; LA; QL

zidovudine oral capsule 1 QL

zidovudine oral syrup 1 QL

zidovudine oral tablet 1 QL

CEPHALOSPORINS

CEDAX ORAL CAPSULE 3

cefaclor oral capsule 1

cefaclor oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

1

cefaclor oral tablet extended release 12 hr 1

cefadroxil oral capsule 1

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1


of this table.

8


CEFAZOLIN IN 0.9% SOD CHLORIDE

INTRAVENOUS PIGGYBACK

3

cefazolin in dextrose (iso-os) intravenous

piggyback 1 gram/50 ml, 2 gram/50 ml

1

CEFAZOLIN IN DEXTROSE 5 %

INTRAVENOUS PIGGYBACK 2 GRAM/50 ML

3

cefazolin injection recon soln 1

cefazolin intravenous recon soln 1

cefdinir oral capsule 1

cefdinir oral suspension for reconstitution 1

cefditoren pivoxil oral tablet 1

CEFEPIME IN DEXTROSE 5 %


3

cefepime in dextrose,iso-osm intravenous

piggyback

3

cefepime injection recon soln 3

cefixime oral suspension for reconstitution 1

cefotaxime injection recon soln 1

cefotetan injection recon soln 1

cefotetan intravenous recon soln 1

cefoxitin in dextrose, iso-osm intravenous

piggyback

1

cefoxitin intravenous recon soln 1

cefpodoxime oral suspension for reconstitution 1

cefpodoxime oral tablet 1

cefprozil oral suspension for reconstitution 1

cefprozil oral tablet 1

CEFTAZIDIME IN D5W INTRAVENOUS

PIGGYBACK

3

ceftazidime injection recon soln 1

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION

3

ceftriaxone in dextrose,iso-os intravenous

piggyback

1


of this table.

9


ceftriaxone injection recon soln 1 gram, 10 gram,

2 gram, 250 mg, 500 mg

1

ceftriaxone intravenous recon soln 1

cefuroxime axetil oral tablet 1

cefuroxime sodium injection recon soln 750 mg 1

cefuroxime sodium intravenous recon soln 1

cephalexin oral capsule 250 mg, 500 mg 5

cephalexin oral capsule 750 mg 1

cephalexin oral suspension for reconstitution 125

mg/5 ml

1 QL

cephalexin oral suspension for reconstitution 250

mg/5 ml

1

cephalexin oral tablet 1

MAXIPIME INTRAVENOUS RECON SOLN 3

SPECTRACEF ORAL TABLET 400 MG 3

SUPRAX ORAL CAPSULE 3

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML, 500 MG/5

ML

3

SUPRAX ORAL TABLET,CHEWABLE 3

TEFLARO INTRAVENOUS RECON SOLN 3

ZINACEF IN STERILE WATER


3

ERYTHROMYCINS & OTHER MACROLIDES

azithromycin intravenous recon soln 1

azithromycin oral packet 1

azithromycin oral suspension for reconstitution 1

azithromycin oral tablet 1

clarithromycin oral suspension for reconstitution 1

clarithromycin oral tablet 1

clarithromycin oral tablet extended release 24 hr 1

DIFICID ORAL TABLET 4 ST; QL

e.e.s. 400 oral tablet 1


of this table.

10


ERYPED 200 ORAL SUSPENSION FOR

RECONSTITUTION

3

ERYPED 400 ORAL SUSPENSION FOR

RECONSTITUTION

3

ery-tab oral tablet,delayed release (dr/ec) 250 mg,

333 mg

1

erythrocin (as stearate) oral tablet 250 mg 1

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

3

erythromycin ethylsuccinate oral suspension for

reconstitution

3

erythromycin ethylsuccinate oral tablet 1

erythromycin oral capsule,delayed release(dr/ec) 1

erythromycin oral tablet 1

MISCELLANEOUS ANTIINFECTIVES

ALBENZA ORAL TABLET 2

ALINIA ORAL SUSPENSION FOR

RECONSTITUTION

2

ALINIA ORAL TABLET 2

amikacin injection solution 1,000 mg/4 ml, 500

mg/2 ml

1

atovaquone oral suspension 1

atovaquone-proguanil oral tablet 1 PA

AZACTAM IN DEXTROSE (ISO-OSM)


3

aztreonam injection recon soln 1

baciim intramuscular recon soln 1

bacitracin intramuscular recon soln 1

BETHKIS INHALATION SOLUTION FOR

NEBULIZATION

4 QL

BILTRICIDE ORAL TABLET 2

CAPASTAT INJECTION RECON SOLN 3

CAYSTON INHALATION SOLUTION FOR

NEBULIZATION

4 QL


of this table.

11


chloramphenicol sod succinate intravenous recon

soln

1

chloroquine phosphate oral tablet 1 PA

clindamycin hcl oral capsule 1

CLINDAMYCIN IN 0.9 % SOD CHLOR


3

clindamycin in 5 % dextrose intravenous

piggyback

1

clindamycin palmitate hcl oral recon soln 1

clindamycin pediatric oral recon soln 1

clindamycin phosphate injection solution 1

clindamycin phosphate intravenous solution 1

COARTEM ORAL TABLET 2

colistin (colistimethate na) injection recon soln 1

CUBICIN INTRAVENOUS RECON SOLN 3

CYCLOSERINE ORAL CAPSULE 3

dapsone oral tablet 1

daptomycin intravenous recon soln 1

DARAPRIM ORAL TABLET 3 PA

DORIBAX INTRAVENOUS RECON SOLN 3

DORIPENEM INTRAVENOUS RECON SOLN 3

ethambutol oral tablet 1

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50

ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

1

GENTAMICIN IN NACL (ISO-OSM)

INTRAVENOUS PIGGYBACK 100 MG/50 ML,

120 MG/100 ML

3

gentamicin injection solution 1

gentamicin sulfate (ped) (pf) injection solution 1

gentamicin sulfate (pf) intravenous solution 100

mg/10 ml

1

GENTAMICIN SULFATE (PF) INTRAVENOUS

SOLUTION 60 MG/6 ML

1


of this table.

12


hydroxychloroquine oral tablet 1

imipenem-cilastatin intravenous recon soln 1

INVANZ INJECTION RECON SOLN 3

INVANZ INTRAVENOUS RECON SOLN 3

isoniazid injection solution 1

isoniazid oral solution 1

isoniazid oral tablet 1

ivermectin oral tablet 1

LINCOCIN INJECTION SOLUTION 3

lincomycin injection solution 1

linezolid intravenous parenteral solution 1

linezolid oral suspension for reconstitution 4 QL

linezolid oral tablet 4 QL

linezolid-0.9% sodium chloride intravenous

parenteral solution

1

mefloquine oral tablet 1 PA

meropenem intravenous recon soln 1

metro i.v. intravenous piggyback 1

metronidazole in nacl (iso-os) intravenous

piggyback

1

metronidazole oral capsule 1

metronidazole oral tablet 1

NEBUPENT INHALATION RECON SOLN 2

neomycin oral tablet 1

paromomycin oral capsule 1

PASER ORAL GRANULES DR FOR SUSP IN

PACKET

2

PENTAM INJECTION RECON SOLN 3

polymyxin b sulfate injection recon soln 1

PRIFTIN ORAL TABLET 3

PRIMAQUINE ORAL TABLET 3 PA

pyrazinamide oral tablet 1


of this table.

13


quinine sulfate oral capsule 1 PA

rifabutin oral capsule 1

RIFAMATE ORAL CAPSULE 3

rifampin intravenous recon soln 1

rifampin oral capsule 1

RIFATER ORAL TABLET 3

SIRTURO ORAL TABLET 4 PA

SIVEXTRO INTRAVENOUS RECON SOLN 4 QL

SIVEXTRO ORAL TABLET 4 QL

STREPTOMYCIN INTRAMUSCULAR RECON

SOLN

3

STROMECTOL ORAL TABLET 2

SYNERCID INTRAVENOUS RECON SOLN 3

TIGECYCLINE INTRAVENOUS RECON SOLN 3

tinidazole oral tablet 1

TOBI PODHALER INHALATION CAPSULE 4 QL

TOBI PODHALER INHALATION CAPSULE,

W/INHALATION DEVICE

4 QL

tobramycin in 0.225 % nacl inhalation solution for

nebulization

4 QL

tobramycin in 0.9 % nacl intravenous piggyback

60 mg/50 ml

1

tobramycin sulfate injection recon soln 1

tobramycin sulfate injection solution 1

TRECATOR ORAL TABLET 3

TYGACIL INTRAVENOUS RECON SOLN 3

XIFAXAN ORAL TABLET 200 MG 3 QL

XIFAXAN ORAL TABLET 550 MG 4 PA; QL

ZYVOX INTRAVENOUS PARENTERAL

SOLUTION 200 MG/100 ML

3

PENICILLINS

amoxicillin oral capsule 5

amoxicillin oral suspension for reconstitution 1


of this table.

14


amoxicillin oral tablet 1

amoxicillin oral tablet,chewable 125 mg, 250 mg 1

amoxicillin-pot clavulanate oral suspension for

reconstitution

1

amoxicillin-pot clavulanate oral tablet 1

amoxicillin-pot clavulanate oral tablet extended

release 12 hr

1

amoxicillin-pot clavulanate oral tablet,chewable 1

ampicillin oral capsule 5

ampicillin sodium injection recon soln 1

ampicillin sodium intravenous recon soln 1

ampicillin-sulbactam injection recon soln 1

ampicillin-sulbactam intravenous recon soln 1.5

gram

1

AUGMENTIN ORAL SUSPENSION FOR

RECONSTITUTION 125-31.25 MG/5 ML

3

BICILLIN C-R INTRAMUSCULAR SYRINGE 3

BICILLIN L-A INTRAMUSCULAR SYRINGE 3

dicloxacillin oral capsule 1

nafcillin in dextrose iso-osm intravenous

piggyback

1

nafcillin injection recon soln 1 gram, 10 gram 1

nafcillin injection recon soln 2 gram 1 QL

nafcillin intravenous recon soln 1

oxacillin in dextrose(iso-osm) intravenous

piggyback

1

oxacillin injection recon soln 1

oxacillin intravenous recon soln 2 gram 1

PENICILLIN G POT IN DEXTROSE


3

penicillin g potassium injection recon soln 1

penicillin g procaine intramuscular syringe 1

penicillin g sodium injection recon soln 1


of this table.

15


penicillin v potassium oral recon soln 1

penicillin v potassium oral tablet 250 mg 5

penicillin v potassium oral tablet 500 mg 1

pfizerpen-g injection recon soln 1

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1

QUINOLONES

AVELOX IN NACL (ISO-OSMOTIC)


3

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

3

ciprofloxacin (mixture) oral tablet, er multiphase

24 hr

1 QL

ciprofloxacin hcl oral tablet 100 mg, 750 mg 1

ciprofloxacin hcl oral tablet 250 mg, 500 mg 5

ciprofloxacin in 5 % dextrose intravenous

piggyback

1

ciprofloxacin lactate intravenous solution 1

ciprofloxacin oral suspension,microcapsule recon 1

FACTIVE ORAL TABLET 3 QL

levofloxacin in d5w intravenous piggyback 1

levofloxacin intravenous solution 1

levofloxacin oral solution 1

levofloxacin oral tablet 1

moxifloxacin oral tablet 1

MOXIFLOXACIN-SOD.ACE,SUL-WATER


3

ofloxacin oral tablet 300 mg, 400 mg 1

SULFA'S & RELATED AGENTS

sulfadiazine oral tablet 1

sulfamethoxazole-trimethoprim intravenous

solution

1

sulfamethoxazole-trimethoprim oral suspension 1


of this table.

16


sulfamethoxazole-trimethoprim oral tablet 1

sulfatrim oral suspension 1

TETRACYCLINES

demeclocycline oral tablet 1

doxy-100 intravenous recon soln 1

doxycycline hyclate oral capsule 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline monohydrate oral capsule 100 mg, 50

mg

1

doxycycline monohydrate oral suspension for

reconstitution

1

doxycycline monohydrate oral tablet 1

MINOCIN INTRAVENOUS RECON SOLN 3

minocycline oral capsule 1

morgidox oral capsule 100 mg 1

tetracycline oral capsule 1

URINARY TRACT AGENTS

methenamine hippurate oral tablet 1

methenamine mandelate oral tablet 1

nitrofurantoin macrocrystal oral capsule 1

nitrofurantoin monohyd/m-cryst oral capsule 1

trimethoprim oral tablet 1

VANCOMYCIN

VANCOMYCIN IN 0.9% SODIUM CL


3

VANCOMYCIN IN 0.9% SODIUM CL

INTRAVENOUS SOLUTION 1 GRAM/250 ML,

1.25 GRAM/250 ML, 1.5 GRAM/250 ML, 1.5

GRAM/500 ML, 1.75 GRAM/250 ML, 1.75

GRAM/500 ML, 2 GRAM/500 ML, 750 MG/150

ML, 750 MG/250 ML

3

VANCOMYCIN IN DEXTROSE 5 %

INTRAVENOUS PIGGYBACK 500 MG/100 ML

2


of this table.

17


VANCOMYCIN IN DEXTROSE 5 %

INTRAVENOUS PIGGYBACK 750 MG/150 ML

3

vancomycin intravenous recon soln 1

vancomycin oral capsule 4

VIBATIV INTRAVENOUS RECON SOLN 750

MG

3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

amifostine crystalline intravenous recon soln 4

dexrazoxane hcl intravenous recon soln 4 LA

ELITEK INTRAVENOUS RECON SOLN 4 LA

KEPIVANCE INTRAVENOUS RECON SOLN 4

leucovorin calcium oral tablet 1

mesna intravenous solution 4 LA

MESNEX ORAL TABLET 4

XGEVA SUBCUTANEOUS SOLUTION 4 PA; QL

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ABRAXANE INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

4 LA

adriamycin intravenous solution 4 LA

adrucil intravenous solution 4 LA

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION

4 PA; QL

AFINITOR ORAL TABLET 4 PA; QL

ALECENSA ORAL CAPSULE 4 PA; LA; QL

ALIMTA INTRAVENOUS RECON SOLN 4 LA

ALUNBRIG ORAL TABLET 4 PA; LA; QL

anastrozole oral tablet 1

ARRANON INTRAVENOUS SOLUTION 4 LA

AVASTIN INTRAVENOUS SOLUTION 4 LA

azathioprine oral tablet 1

azathioprine sodium injection recon soln 1


of this table.

18


bexarotene oral capsule 4 PA

bicalutamide oral tablet 1

BICNU INTRAVENOUS RECON SOLN 4 LA

bleo 15k injection recon soln 4

bleomycin injection recon soln 4 LA

BOSULIF ORAL TABLET 4 PA; QL

busulfan intravenous solution 4 LA

BUSULFEX INTRAVENOUS SOLUTION 4 LA

CABOMETYX ORAL TABLET 4 PA; LA; QL

capecitabine oral tablet 4 PA

CAPRELSA ORAL TABLET 4 PA; QL

carboplatin intravenous solution 4 LA

CELLCEPT INTRAVENOUS INTRAVENOUS

RECON SOLN

4

CELLCEPT ORAL SUSPENSION FOR

RECONSTITUTION

4

cisplatin intravenous solution 4 LA

cladribine intravenous solution 4 LA

COMETRIQ ORAL CAPSULE 4 PA; QL

COTELLIC ORAL TABLET 4 PA; LA; QL

cyclophosphamide intravenous recon soln 4 LA

CYCLOPHOSPHAMIDE ORAL CAPSULE 4

cyclosporine intravenous solution 4

cyclosporine modified oral capsule 1

cyclosporine modified oral solution 1

cyclosporine oral capsule 1

cytarabine (pf) injection solution 4 LA

cytarabine injection solution 4 LA

dacarbazine intravenous recon soln 4 LA

daunorubicin intravenous recon soln 4 LA

daunorubicin intravenous solution 4 LA

doxorubicin intravenous recon soln 4 LA


of this table.

19


doxorubicin intravenous solution 4 LA

doxorubicin, peg-liposomal intravenous

suspension

1 LA

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE

4 PA; QL


SYRINGE

4 PA; QL


SYRINGE

4 PA; QL

ELIGARD SUBCUTANEOUS SYRINGE 4 PA; QL

EMCYT ORAL CAPSULE 4 PA

epirubicin intravenous recon soln 200 mg 4 LA

epirubicin intravenous solution 4 LA

ERBITUX INTRAVENOUS SOLUTION 4 LA

ERIVEDGE ORAL CAPSULE 4 PA; LA; QL

ETOPOPHOS INTRAVENOUS RECON SOLN 4 LA

etoposide intravenous solution 4 PA; LA

etoposide oral capsule 4 PA

exemestane oral tablet 1

FARESTON ORAL TABLET 4

FARYDAK ORAL CAPSULE 4 PA; LA; QL

FASLODEX INTRAMUSCULAR SYRINGE 4 LA

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN

4 PA; LA; QL

floxuridine injection recon soln 4 LA

fludarabine intravenous recon soln 4 LA

fludarabine intravenous solution 4 LA

fluorouracil intravenous solution 4 LA

flutamide oral capsule 1

gemcitabine intravenous recon soln 4 LA

gemcitabine intravenous solution 4 LA

gengraf oral capsule 1

gengraf oral solution 1


of this table.

20


GILOTRIF ORAL TABLET 4 PA; LA; QL

GLEEVEC ORAL TABLET 4 PA; QL

GLEOSTINE ORAL CAPSULE 4 PA

HEXALEN ORAL CAPSULE 3

HYCAMTIN ORAL CAPSULE 4 PA

hydroxyurea oral capsule 1

IBRANCE ORAL CAPSULE 4 PA; LA; QL

ICLUSIG ORAL TABLET 4 PA; QL

idarubicin intravenous solution 4 LA; QL

IDHIFA ORAL TABLET 4 PA; LA

ifosfamide intravenous recon soln 4 LA

ifosfamide intravenous solution 4 LA

ifosfamide-mesna intravenous kit 4 LA

IMBRUVICA ORAL CAPSULE 4 PA; QL

INLYTA ORAL TABLET 4 PA; LA; QL

IODOPEN INTRAVENOUS SOLUTION 3

IRESSA ORAL TABLET 4 PA; LA; QL

irinotecan intravenous solution 4 LA

IXEMPRA INTRAVENOUS RECON SOLN 4 LA

JAKAFI ORAL TABLET 4 PA; LA; QL

KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; LA; QL

KISQALI ORAL TABLET 4 PA; LA; QL

LENVIMA ORAL CAPSULE 4 PA; LA; QL

letrozole oral tablet 1 QL

LEUKERAN ORAL TABLET 2

leuprolide subcutaneous kit 4 PA; LA

lipodox intravenous suspension 4 LA

LONSURF ORAL TABLET 4 PA; LA

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT

4 PA; LA; QL



4 PA; LA; QL


of this table.

21




4 PA; LA; QL

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT

4 PA; LA; QL

LUPRON DEPOT-PED (3 MONTH)


4 PA; LA; QL

LUPRON DEPOT-PED INTRAMUSCULAR KIT 4 PA; LA; QL

LYNPARZA ORAL CAPSULE 4 PA; QL

LYNPARZA ORAL TABLET 4 PA; LA; QL

LYSODREN ORAL TABLET 4 PA; LA

MATULANE ORAL CAPSULE 3

megestrol oral suspension 400 mg/10 ml (40

mg/ml)

1

megestrol oral tablet 1

MEKINIST ORAL TABLET 4 PA; LA; QL

melphalan oral tablet 1

mercaptopurine oral tablet 1

methotrexate sodium (pf) injection recon soln 4

methotrexate sodium (pf) injection solution 4

methotrexate sodium injection solution 4

methotrexate sodium oral tablet 1

mitomycin intravenous recon soln 4 LA

mitoxantrone intravenous concentrate 4 LA

MUSTARGEN INJECTION RECON SOLN 4 LA

mycophenolate mofetil hcl intravenous recon soln 4

mycophenolate mofetil oral capsule 1

mycophenolate mofetil oral suspension for

reconstitution

4

mycophenolate mofetil oral tablet 1

mycophenolate sodium oral tablet,delayed release

(dr/ec)

1

MYLERAN ORAL TABLET 2 LA

NERLYNX ORAL TABLET 4 PA; LA; QL


of this table.

22


NEXAVAR ORAL TABLET 4 PA; LA; QL

nilutamide oral tablet 4 PA; LA

NINLARO ORAL CAPSULE 4 PA; LA; QL

NULOJIX INTRAVENOUS RECON SOLN 4 PA; LA

octreotide acetate injection solution 4 LA

octreotide acetate injection syringe 4 LA

ODOMZO ORAL CAPSULE 4 PA; LA; QL

ONCASPAR INJECTION SOLUTION 4 LA

oxaliplatin intravenous recon soln 4 LA

oxaliplatin intravenous solution 4 LA

paclitaxel intravenous concentrate 4 LA

PHOTOFRIN INTRAVENOUS RECON SOLN 4 LA

PROGRAF INTRAVENOUS SOLUTION 4

RAPAMUNE ORAL SOLUTION 4 PA

RITUXAN HYCELA SUBCUTANEOUS

SOLUTION

4 PA

RITUXAN INTRAVENOUS CONCENTRATE 4 PA; LA

RUBRACA ORAL TABLET 4 PA; QL

RYDAPT ORAL CAPSULE 4 PA; LA; QL

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON

4 PA; LA; QL

SIGNIFOR LAR INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION

4 PA; LA; QL

SIGNIFOR SUBCUTANEOUS SOLUTION 4 PA; LA; QL

SIMULECT INTRAVENOUS RECON SOLN 4 LA

sirolimus oral tablet 1

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE

4 PA; LA; QL

SPRYCEL ORAL TABLET 4 PA; QL

STIVARGA ORAL TABLET 4 PA; LA; QL

SUPPRELIN LA IMPLANT KIT 4 PA; LA; QL

SUTENT ORAL CAPSULE 4 PA; LA; QL


of this table.

23


SYLVANT INTRAVENOUS RECON SOLN 4 PA; LA

TABLOID ORAL TABLET 2 PA

tacrolimus oral capsule 1

TAFINLAR ORAL CAPSULE 4 PA; LA; QL

TAGRISSO ORAL TABLET 4 PA; LA; QL

tamoxifen oral tablet 1

TARCEVA ORAL TABLET 100 MG, 150 MG 4 PA; LA; QL

TARCEVA ORAL TABLET 25 MG 4 PA; LA

TARGRETIN TOPICAL GEL 4 PA

TASIGNA ORAL CAPSULE 4 PA; QL

TEMODAR INTRAVENOUS RECON SOLN 4

temozolomide oral capsule 4 PA; LA

THALOMID ORAL CAPSULE 4 PA; LA; QL

toposar intravenous solution 4 LA

topotecan intravenous recon soln 4 LA

topotecan intravenous solution 4 LA

TORISEL INTRAVENOUS RECON SOLN 4 LA

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 11.25 MG, 3.75 MG

4 PA; QL

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 22.5 MG

4 PA; LA; QL

TRELSTAR INTRAMUSCULAR SYRINGE 4 PA; LA; QL

tretinoin (chemotherapy) oral capsule 4

TRISENOX INTRAVENOUS SOLUTION 4 LA

TYKERB ORAL TABLET 4 PA; LA; QL

VANTAS IMPLANT KIT 4 PA; LA; QL

VENCLEXTA ORAL TABLET 100 MG 4 PA; QL

vinblastine intravenous solution 4 LA

vincasar pfs intravenous solution 4 LA

vincristine intravenous solution 4 LA

vinorelbine intravenous solution 4 LA

VOTRIENT ORAL TABLET 4 PA; LA; QL


of this table.

24


XALKORI ORAL CAPSULE 4 PA; LA; QL

XERMELO ORAL TABLET 4 PA; QL

XTANDI ORAL CAPSULE 4 PA; LA; QL

ZANOSAR INTRAVENOUS RECON SOLN 4 LA

ZEJULA ORAL CAPSULE 4 PA; QL

ZELBORAF ORAL TABLET 4 PA; LA; QL

ZOLADEX SUBCUTANEOUS IMPLANT 4 PA; LA; QL

ZOLINZA ORAL CAPSULE 4 PA; LA; QL

ZORTRESS ORAL TABLET 4

ZYDELIG ORAL TABLET 4 PA; QL

ZYKADIA ORAL CAPSULE 4 PA; LA; QL

ZYTIGA ORAL TABLET 4 PA; LA; QL

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET 3 PA; QL

BANZEL ORAL SUSPENSION 3 PA

BANZEL ORAL TABLET 3 PA

BRIVIACT INTRAVENOUS SOLUTION 3 PA; QL

BRIVIACT ORAL SOLUTION 3 PA; QL

BRIVIACT ORAL TABLET 3 PA; QL

carbamazepine oral capsule, er multiphase 12 hr 1

carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 1

carbamazepine oral tablet extended release 12 hr 1

carbamazepine oral tablet,chewable 1

CELONTIN ORAL CAPSULE 300 MG 2

clonazepam oral tablet 1

clonazepam oral tablet,disintegrating 1 ST

diazepam rectal kit 1

DILANTIN ORAL CAPSULE 30 MG 2

divalproex oral capsule, delayed rel sprinkle 1


of this table.

25


divalproex oral tablet extended release 24 hr 1

divalproex oral tablet,delayed release (dr/ec) 1

epitol oral tablet 1

ethosuximide oral capsule 1

ethosuximide oral solution 1

felbamate oral suspension 1

felbamate oral tablet 1

fosphenytoin injection solution 1

FYCOMPA ORAL SUSPENSION 3 PA; QL

FYCOMPA ORAL TABLET 3 PA; QL

gabapentin oral capsule 1

gabapentin oral solution 250 mg/5 ml 1

gabapentin oral tablet 600 mg, 800 mg 1

GRALISE 30-DAY STARTER PACK ORAL

TABLET EXTENDED RELEASE 24 HR

3 PA; QL

GRALISE ORAL TABLET EXTENDED

RELEASE 24 HR

3 PA; QL

lamotrigine oral tablet 1

lamotrigine oral tablet, chewable dispersible 1 QL

levetiracetam in nacl (iso-os) intravenous

piggyback

1

levetiracetam intravenous solution 1

levetiracetam oral solution 1

levetiracetam oral tablet 1

levetiracetam oral tablet extended release 24 hr 1 QL

LYRICA ORAL CAPSULE 3 PA; QL

LYRICA ORAL SOLUTION 3 PA; QL

ONFI ORAL SUSPENSION 3 PA; QL

ONFI ORAL TABLET 10 MG, 20 MG 3 PA; QL

oxcarbazepine oral suspension 1

oxcarbazepine oral tablet 1

PEGANONE ORAL TABLET 3


of this table.

26


phenobarbital oral elixir 1

phenobarbital oral tablet 1

phenytoin oral suspension 125 mg/5 ml 1

phenytoin oral tablet,chewable 1

phenytoin sodium extended oral capsule 1

phenytoin sodium intravenous solution 1

phenytoin sodium intravenous syringe 1

primidone oral tablet 1 QL

roweepra oral tablet 1

SABRIL ORAL TABLET 4 PA; LA; QL

tiagabine oral tablet 1

topiramate oral capsule, sprinkle 1 QL

topiramate oral tablet 1

valproate sodium intravenous solution 1

valproic acid (as sodium salt) oral solution 250

mg/5 ml

1

valproic acid oral capsule 1

vigabatrin oral powder in packet 4 PA; LA; QL

VIMPAT INTRAVENOUS SOLUTION 3 PA

VIMPAT ORAL SOLUTION 3 PA

VIMPAT ORAL TABLET 3 PA

zonisamide oral capsule 1

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE 4 PA; QL

benztropine injection solution 1

benztropine oral tablet 1

bromocriptine oral capsule 1

bromocriptine oral tablet 1

carbidopa oral tablet 1 ST

carbidopa-levodopa oral tablet 1

carbidopa-levodopa oral tablet extended release 1


of this table.

27


carbidopa-levodopa oral tablet,disintegrating 1

carbidopa-levodopa-entacapone oral tablet 1

DUOPA J-TUBE INTESTINAL PUMP

SUSPENSION

4 PA; LA

entacapone oral tablet 1

pramipexole oral tablet 1

rasagiline oral tablet 1

ropinirole oral tablet 1

ropinirole oral tablet extended release 24 hr 1 ST

selegiline hcl oral capsule 1

selegiline hcl oral tablet 1

tolcapone oral tablet 1 ST

trihexyphenidyl oral elixir 1

trihexyphenidyl oral tablet 1

MIGRAINE & CLUSTER HEADACHE THERAPY

almotriptan malate oral tablet 3 ST; QL

dihydroergotamine injection solution 3

dihydroergotamine nasal spray,non-aerosol 3 QL

eletriptan hbr oral tablet 3 ST; QL

ERGOMAR SUBLINGUAL TABLET 3 PA; QL

frovatriptan oral tablet 3 ST; QL

isometh-dichloral-acetaminophn oral capsule 1

naratriptan oral tablet 3 QL

nodolor oral capsule 1

rizatriptan oral tablet 10 mg 1 QL

rizatriptan oral tablet 5 mg 3 QL

rizatriptan oral tablet,disintegrating 10 mg 1 QL

rizatriptan oral tablet,disintegrating 5 mg 3 QL

sumatriptan nasal spray,non-aerosol 3 QL

sumatriptan succinate oral tablet 1 QL

sumatriptan succinate subcutaneous cartridge 2 QL


of this table.

28


sumatriptan succinate subcutaneous pen injector 4

mg/0.5 ml

2 PA; QL

sumatriptan succinate subcutaneous pen injector 6

mg/0.5 ml

2 QL

sumatriptan succinate subcutaneous solution 2 QL

zolmitriptan oral tablet 3 QL

zolmitriptan oral tablet,disintegrating 3 QL

ZOMIG NASAL SPRAY,NON-AEROSOL 3 QL

MISCELLANEOUS NEUROLOGICAL THERAPY

AMPYRA ORAL TABLET EXTENDED

RELEASE 12 HR

4 PA; LA; QL

AUSTEDO ORAL TABLET 4 PA; QL

donepezil oral tablet 10 mg, 5 mg 1 PA

donepezil oral tablet,disintegrating 1 PA

galantamine oral capsule,ext rel. pellets 24 hr 1 PA

galantamine oral solution 1 PA

galantamine oral tablet 1 PA

HORIZANT ORAL TABLET EXTENDED

RELEASE

3 PA; QL

KEVEYIS ORAL TABLET 4 PA; QL

memantine oral solution 1 PA

memantine oral tablet 1 PA

MEMANTINE ORAL TABLETS,DOSE PACK 2 PA

NAMENDA TITRATION PAK ORAL

TABLETS,DOSE PACK

2 PA

NUEDEXTA ORAL CAPSULE 4 PA; QL

rivastigmine tartrate oral capsule 1 PA

rivastigmine transdermal patch 24 hour 1 PA

tetrabenazine oral tablet 4 PA; LA; QL

TYSABRI INTRAVENOUS SOLUTION 4 PA; LA; QL

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

baclofen oral tablet 1

carisoprodol oral tablet 350 mg 1


of this table.

29


carisoprodol-aspirin oral tablet 3

chlorzoxazone oral tablet 500 mg 1

cyclobenzaprine oral tablet 10 mg, 5 mg 1

dantrolene oral capsule 1

meprobamate oral tablet 1

metaxall oral tablet 3 PA; QL

metaxalone oral tablet 800 mg 3 PA; QL

methocarbamol injection solution 1

methocarbamol oral tablet 1

orphenadrine citrate injection solution 1

orphenadrine citrate oral tablet extended release 1

pyridostigmine bromide oral tablet 1

pyridostigmine bromide oral tablet extended

release

4 PA

regonol injection solution 1

ROBAXIN INJECTION SOLUTION 3

tizanidine oral tablet 1

NARCOTIC ANALGESICS

ABSTRAL SUBLINGUAL TABLET 4 PA; QL

acetaminophen-codeine oral solution 120-12 mg/5

ml

1 PA < 18 years of age; QL

acetaminophen-codeine oral tablet 1 PA < 18 years of age; QL

ascomp with codeine oral capsule 1 PA < 18 years of age; QL

astramorph-pf injection solution 1 mg/ml 1 PA < 18 years of age

BUPRENEX INJECTION SOLUTION 3 PA < 18 years of age

buprenorphine hcl injection solution 1 PA < 18 years of age

buprenorphine hcl injection syringe 1 PA < 18 years of age

buprenorphine hcl sublingual tablet 1 PA; QL

BUPRENORPHINE TRANSDERMAL PATCH

WEEKLY

3 PA; QL

butalbital compound w/codeine oral capsule 1 PA < 18 years of age; QL

butalbital-acetaminop-caf-cod oral capsule 1 PA < 18 years of age; QL


of this table.

30


butalbital-acetaminophen oral tablet 50-325 mg 1

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

1

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

1

butalbital-aspirin-caffeine oral capsule 1

butalbital-aspirin-caffeine oral tablet 1

BUTRANS TRANSDERMAL PATCH WEEKLY 3 PA; QL

capacet oral capsule 1

codeine sulfate oral tablet 1 PA < 18 years of age; QL

DEMEROL (PF) INJECTION SOLUTION 100

MG/2 ML, 25 MG/0.5 ML, 75 MG/1.5 ML

3 PA < 18 years of age

demerol (pf) injection solution 100 mg/ml 3 PA < 18 years of age

DEMEROL (PF) INJECTION SYRINGE 3 PAPA < 18 years of age

DEMEROL INJECTION SOLUTION 3 PA < 18 years of age

diskets oral tablet,soluble 1 PA < 18 years of age; QL

duramorph (pf) injection solution 1 PA < 18 years of age

EMBEDA ORAL CAPSULE,ORAL

ONLY,EXT.REL PELL

3 PA; QL

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325

mg, 7.5-325 mg


fentanyl citrate (pf) intravenous syringe 100 mcg/2

ml (50 mcg/ml)


fentanyl citrate buccal lozenge on a handle 4 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


FENTORA BUCCAL TABLET,

EFFERVESCENT

4 PA; QL

hydrocodone-acetaminophen oral solution 7.5-325

mg/15 ml


hydrocodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


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

200 mg, 7.5-200 mg


hydromorphone (pf) injection solution 1 PA < 18 years of age


of this table.

31


hydromorphone in 0.9 % nacl intravenous pt

controlled analgesia syring 15 mg/30 ml (0.5

mg/ml)


hydromorphone injection solution 1 PA < 18 years of age

HYDROMORPHONE INJECTION SYRINGE

0.5 MG/0.5 ML


hydromorphone injection syringe 1 mg/ml, 2

mg/ml, 4 mg/ml


hydromorphone oral tablet 1 PA < 18 years of age; QL

hydromorphone oral tablet extended release 24 hr 1 PA; QL

hydromorphone rectal suppository 1 PA < 18 years of age

ibuprofen-oxycodone oral tablet 1 PA < 18 years of age; QL

LAZANDA NASAL SPRAY,NON-AEROSOL

100 MCG/SPRAY, 400 MCG/SPRAY

4 PA; QL

levorphanol tartrate oral tablet 1 PA < 18 years of age; QL

lorcet (hydrocodone) oral tablet 1 PA < 18 years of age; QL

lorcet hd oral tablet 1 PA < 18 years of age; QL

lorcet plus oral tablet 7.5-325 mg 1 PA < 18 years of age; QL

marten-tab oral tablet 1

meperidine (pf) injection solution 100 mg/ml, 25

mg/ml, 50 mg/ml


meperidine injection cartridge 1 PA < 18 years of age

meperidine oral solution 1 PA < 18 years of age; QL

meperidine oral tablet 1 PA < 18 years of age; QL

methadone injection solution 1 PA < 18 years of age

methadone oral concentrate 1 PA < 18 years of age; QL

methadone oral solution 1 PA < 18 years of age; QL

methadone oral tablet 1 PA < 18 years of age; QL

methadone oral tablet,soluble 1 PA < 18 years of age; QL

methadose oral concentrate 1 PA < 18 years of age; QL

methadose oral tablet,soluble 1 PA < 18 years of age; QL

morphine (pf) injection solution 0.5 mg/ml, 1

mg/ml



of this table.

32


morphine (pf) intravenous patient

control.analgesia soln


morphine concentrate oral solution 1 PA < 18 years of age; QL

morphine injection solution 15 mg/ml, 8 mg/ml 1 PA < 18 years of age

morphine injection syringe 10 mg/ml, 2 mg/ml, 4

mg/ml, 5 mg/ml, 8 mg/ml


MORPHINE INTRAMUSCULAR PEN

INJECTOR


morphine intravenous cartridge 10 mg/ml, 2

mg/ml, 4 mg/ml


MORPHINE INTRAVENOUS CARTRIDGE 8

MG/ML


morphine intravenous pt controlled analgesia

syring


morphine intravenous solution 10 mg/ml, 100

mg/4 ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml


morphine intravenous syringe 2 mg/ml, 4 mg/ml 1 PA < 18 years of age

morphine oral solution 1 PA < 18 years of age; QL

morphine oral tablet 1 PA < 18 years of age; QL

morphine oral tablet extended release 1 PA < 18 years of age; QL

morphine rectal suppository 1 PA < 18 years of age

oxycodone oral capsule 1 PA < 18 years of age; QL

oxycodone oral concentrate 1 PA < 18 years of age; QL

oxycodone oral solution 1 PA < 18 years of age; QL

oxycodone oral tablet 1 PA < 18 years of age; QL

OXYCODONE ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR

3 PA; QL

oxycodone-acetaminophen oral solution 1 PA < 18 years of age; QL

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 1 PA < 18 years of age; QL

OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR

3 PA; QL

oxymorphone oral tablet 1 PA < 18 years of age; QL


of this table.

33


oxymorphone oral tablet extended release 12 hr 1 PA < 18 years of age; QL

PROBUPHINE SUBDERMAL IMPLANT 4 PA; QL

SUBSYS SUBLINGUAL SPRAY,NON-

AEROSOL

4 PA; QL

tencon oral tablet 50-325 mg 1

verdrocet oral tablet 1 PA < 18 years of age; QL

XTAMPZA ER ORAL

CAPSULE,SPRINKLE,ER 12HR TMPRR


NON-NARCOTIC ANALGESICS

aspir-81 oral tablet,delayed release (dr/ec) 6 ACA; OTC

aspirin low dose oral tablet,delayed release

(dr/ec)

6 ACA; OTC

aspirin oral tablet 6 ACA; OTC

aspirin oral tablet,chewable 6 ACA; OTC

aspirin oral tablet,delayed release (dr/ec) 325 mg,

81 mg

6 ACA; OTC

aspir-low oral tablet,delayed release (dr/ec) 6 ACA; OTC

aspir-trin oral tablet,delayed release (dr/ec) 6 ACA; OTC

bayer aspirin oral tablet 6 ACA; OTC

BUNAVAIL BUCCAL FILM 3 PA; QL

buprenorphine-naloxone sublingual tablet 3 PA; QL

butorphanol tartrate injection solution 1 PA < 18 years of age

butorphanol tartrate nasal spray,non-aerosol 1 PA < 18 years of age; QL

CALDOLOR INTRAVENOUS RECON SOLN

800 MG/8 ML (100 MG/ML)

3

celecoxib oral capsule 2 ST; QL

children's aspirin oral tablet,chewable 6 ACA; OTC

choline,magnesium salicylate oral liquid 1

diclofenac potassium oral tablet 1

diclofenac sodium oral tablet extended release 24

hr

1

diclofenac sodium oral tablet,delayed release

(dr/ec)

1


of this table.

34


diclofenac sodium topical gel 1 % 1 QL

diclofenac-misoprostol oral tablet,ir,delayed

rel,biphasic

1

diflunisal oral tablet 1

e.c. prin oral tablet,delayed release (dr/ec) 6 ACA; OTC

ecotrin low strength oral tablet,delayed release

(dr/ec)

6 ACA; OTC

ecotrin oral tablet,delayed release (dr/ec) 6 ACA; OTC

etodolac oral capsule 1

etodolac oral tablet 1

etodolac oral tablet extended release 24 hr 1

EUFLEXXA INTRA-ARTICULAR SYRINGE 4 PA; LA; QL

EVZIO INJECTION AUTO-INJECTOR 4 PA; QL

fenoprofen oral tablet 3 PA

flurbiprofen oral tablet 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

indomethacin oral capsule 1

indomethacin oral capsule, extended release 1

ketoprofen oral capsule 1

ketorolac injection cartridge 1 QL

ketorolac injection solution 1 QL

ketorolac injection syringe 1 QL

ketorolac intramuscular solution 1 QL

ketorolac intramuscular syringe 1 QL

ketorolac oral tablet 1 QL

lite coat aspirin oral tablet 6 ACA; OTC

meclofenamate oral capsule 50 mg 3 PA

mefenamic acid oral capsule 3 PA

meloxicam oral suspension 3

meloxicam oral tablet 1

nabumetone oral tablet 1

nalbuphine injection solution 1 PA < 18 years of age


of this table.

35


naloxone injection solution 1 QL

naloxone injection syringe 1

naltrexone oral tablet 1

naproxen oral suspension 1

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec) 1

naproxen sodium oral tablet 275 mg, 550 mg 1

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION

2 QL

oxaprozin oral tablet 1

pentazocine-naloxone oral tablet 1 PA < 18 years of age; QL

piroxicam oral capsule 3

salsalate oral tablet 1

SUBOXONE SUBLINGUAL FILM 2 PA; QL

sulindac oral tablet 1

TALWIN INJECTION SOLUTION 3 PA < 18 years of age

tolmetin oral tablet 200 mg 3 PA

tramadol oral tablet 1 PA < 18 years of age; QL

tramadol oral tablet extended release 24 hr 1 PA < 18 years of age; QL

tramadol oral tablet, er multiphase 24 hr 1 PA < 18 years of age; QL

tramadol-acetaminophen oral tablet 1 PA < 18 years of age; QL

VIVITROL INTRAMUSCULAR


4 PA; LA; QL

ZUBSOLV SUBLINGUAL TABLET 2 PA; QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR


4 ST < 12 years of age; QL

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING


ADDERALL XR ORAL CAPSULE,EXTENDED

RELEASE 24HR

1 PA < 4 and ≥ 18 years of age; QL

ADDYI ORAL TABLET 4 PA; QL

alprazolam intensol oral concentrate 1


of this table.

36


alprazolam oral tablet 1

alprazolam oral tablet extended release 24 hr 1

alprazolam oral tablet,disintegrating 1 ST

amitriptyline oral tablet 1

amitriptyline-chlordiazepoxide oral tablet 1

amoxapine oral tablet 1

aripiprazole oral solution 1 PA; QL

aripiprazole oral tablet 1 PA < 12 years of age; QL

aripiprazole oral tablet,disintegrating 1 PA; QL

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING


armodafinil oral tablet 3 PA; QL

atomoxetine oral capsule 1 QL

bupropion hcl oral tablet 1

bupropion hcl oral tablet extended release 12 hr

100 mg, 200 mg

1

bupropion hcl oral tablet extended release 12 hr

150 mg

5

bupropion hcl oral tablet extended release 24 hr 1

buspirone oral tablet 1

chlordiazepoxide hcl oral capsule 1

chlorpromazine injection solution 1 PA < 12 years of age

chlorpromazine oral tablet 1 PA < 12 years of age

citalopram oral solution 1

citalopram oral tablet 1 QL

clomipramine oral capsule 1 ST

clonidine hcl oral tablet extended release 12 hr 1 ST; QL

clorazepate dipotassium oral tablet 1

clozapine oral tablet 1 PA < 12 years of age

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 25 mg

1 PA < 12 years of age; ST; QL

CLOZAPINE ORAL

TABLET,DISINTEGRATING 150 MG, 200 MG



of this table.

37


CONCERTA ORAL TABLET EXTENDED

RELEASE 24HR


desipramine oral tablet 1

DESVENLAFAXINE FUMARATE ORAL

TABLET EXTENDED RELEASE 24HR

3 ST; QL

DESVENLAFAXINE ORAL TABLET

EXTENDED RELEASE 24 HR

3 ST; QL

desvenlafaxine succinate oral tablet extended

release 24 hr (generic Pristiq)

1 ST; QL

dexmethylphenidate oral capsule,er biphasic 50-

50


dexmethylphenidate oral tablet 1 QL

dextroamphetamine oral capsule, extended release 3 PA < 4 and ≥ 18 years of age; QL

dextroamphetamine oral tablet 1 PA < 4 and ≥ 18 years of age; QL

dextroamphetamine-amphetamine oral tablet 1 QL

diazepam injection solution 1

diazepam injection syringe 1

diazepam intensol oral concentrate 1

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1

diazepam oral tablet 1

doxepin oral capsule 1

doxepin oral concentrate 1

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 30 mg, 60 mg

1 QL

EMSAM TRANSDERMAL PATCH 24 HOUR 3 PA; QL

ergoloid oral tablet 1

escitalopram oxalate oral solution 1 QL

escitalopram oxalate oral tablet 1 QL

estazolam oral tablet 1

eszopiclone oral tablet 1 QL

FANAPT ORAL TABLET 3 PA; QL

FANAPT ORAL TABLETS,DOSE PACK 3 PA; QL


of this table.

38


FETZIMA ORAL CAPSULE,EXT REL 24HR

DOSE PACK

3 PA; QL

FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR

3 PA; QL

flumazenil intravenous solution 1

fluoxetine oral capsule 1

fluoxetine oral solution 1

fluoxetine oral tablet 10 mg, 20 mg 1

fluphenazine decanoate injection solution 1 PA < 12 years of age

fluphenazine hcl injection solution 1 PA < 12 years of age

fluphenazine hcl oral concentrate 1 PA < 12 years of age

fluphenazine hcl oral elixir 1 PA < 12 years of age

fluphenazine hcl oral tablet 1 PA < 12 years of age

flurazepam oral capsule 1

fluvoxamine oral tablet 1

GEODON INTRAMUSCULAR RECON SOLN 3 PA < 12 years of age

guanfacine oral tablet extended release 24 hr 1 QL

guanidine oral tablet 1

haloperidol decanoate intramuscular solution 1 PA < 12 years of age

haloperidol lactate injection solution 1 PA < 12 years of age

haloperidol lactate oral concentrate 1 PA < 12 years of age

haloperidol oral tablet 1 PA < 12 years of age

HETLIOZ ORAL CAPSULE 4 PA; LA; QL

imipramine hcl oral tablet 1

imipramine pamoate oral capsule 1

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE


INVEGA TRINZA INTRAMUSCULAR

SYRINGE


KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24HR

3 ST; QL

LATUDA ORAL TABLET 3 PA < 12 years of age; ST; QL

lithium carbonate oral capsule 1


of this table.

39


lithium carbonate oral tablet 1

lithium carbonate oral tablet extended release 1

lithium citrate oral solution 8 meq/5 ml 1

lorazepam intensol oral concentrate 1

lorazepam oral concentrate 1

lorazepam oral tablet 1

loxapine succinate oral capsule 1 PA < 12 years of age

maprotiline oral tablet 1

MARPLAN ORAL TABLET 3

metadate er oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL

methamphetamine oral tablet 1 PA < 4 and ≥ 18 years of age; QL

methylphenidate hcl oral capsule, er biphasic 30-

70


methylphenidate hcl oral capsule,er biphasic 50-

50


methylphenidate hcl oral solution 3 PA < 4 and ≥ 18 years of age; QL

methylphenidate hcl oral tablet 1 QL

methylphenidate hcl oral tablet extended release

10 mg


methylphenidate hcl oral tablet extended release

20 mg


methylphenidate hcl oral tablet,chewable 1 PA < 4 and ≥ 18 years of age; QL

midazolam oral syrup 2 mg/ml 1

mirtazapine oral tablet 1

mirtazapine oral tablet,disintegrating 1

modafinil oral tablet 3 PA; QL

nefazodone oral tablet 1

nortriptyline oral capsule 1

nortriptyline oral solution 1

NUPLAZID ORAL TABLET 4 PA; LA; QL

olanzapine intramuscular recon soln 1 PA < 12 years of age

olanzapine oral tablet 1 PA < 12 years of age; QL

olanzapine oral tablet,disintegrating 1 PA < 12 years of age; QL


of this table.

40


olanzapine-fluoxetine oral capsule 1 PA; QL

oxazepam oral capsule 1

paliperidone oral tablet extended release 24hr 1 PA; QL

paroxetine hcl oral tablet 1

perphenazine oral tablet 1 PA < 12 years of age

perphenazine-amitriptyline oral tablet 1

phenelzine oral tablet 1

pimozide oral tablet 1 PA < 12 years of age

protriptyline oral tablet 1

quazepam oral tablet 1

quetiapine oral tablet 1 PA < 12 years of age; QL

quetiapine oral tablet extended release 24 hr 1 PA < 12 years of age; QL

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE


risperidone oral solution 1 PA < 12 years of age

risperidone oral tablet 1 PA < 12 years of age; QL

risperidone oral tablet,disintegrating 1 PA < 12 years of age; QL

ROZEREM ORAL TABLET 3 PA; QL

SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET


sertraline oral concentrate 1

sertraline oral tablet 1

temazepam oral capsule 15 mg, 30 mg 1

thioridazine oral tablet 1 PA < 12 years of age

thiothixene oral capsule 1 PA < 12 years of age

tranylcypromine oral tablet 1

trazodone oral tablet 100 mg, 150 mg, 50 mg 1

triazolam oral tablet 1

trifluoperazine oral tablet 1 PA < 12 years of age

trimipramine oral capsule 1

TRINTELLIX ORAL TABLET 3 PA < 12 years of age; QL

venlafaxine oral capsule,extended release 24hr 1 QL


of this table.

41


venlafaxine oral tablet 1

VIIBRYD ORAL TABLET 3 PA; QL

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)

3 PA; QL

VRAYLAR ORAL CAPSULE 4 PA < 12 years of age; QL

VRAYLAR ORAL CAPSULE,DOSE PACK 4 PA < 12 years of age; QL

VYVANSE ORAL CAPSULE 3 PA; QL

VYVANSE ORAL TABLET,CHEWABLE 3 PA; QL

XYREM ORAL SOLUTION 4 PA; LA; QL

zaleplon oral capsule 1

ziprasidone hcl oral capsule 1 PA < 12 years of age; QL

zolpidem oral tablet 1 QL

ZYPREXA RELPREVV INTRAMUSCULAR



CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral tablet 1

disopyramide phosphate oral capsule 1

dofetilide oral capsule 1

flecainide oral tablet 1

mexiletine oral capsule 1

MULTAQ ORAL TABLET 2

pacerone oral tablet 100 mg, 200 mg, 400 mg 1

propafenone oral capsule,extended release 12 hr 1

propafenone oral tablet 1

quinidine gluconate injection solution 1

quinidine gluconate oral tablet extended release 1

quinidine sulfate oral tablet 1

sotalol af oral tablet 1

SOTALOL INTRAVENOUS SOLUTION 3

sotalol oral tablet 1

ANTIHYPERTENSIVE THERAPY


of this table.

42


acebutolol oral capsule 1

afeditab cr oral tablet extended release 1

amiloride oral tablet 1

amiloride-hydrochlorothiazide oral tablet 1

amlodipine oral tablet 1

amlodipine-benazepril oral capsule 1

atenolol oral tablet 5

atenolol-chlorthalidone oral tablet 5

benazepril oral tablet 5

benazepril-hydrochlorothiazide oral tablet 3

betaxolol oral tablet 1

bisoprolol fumarate oral tablet 1

bisoprolol-hydrochlorothiazide oral tablet 5

bumetanide injection solution 1

bumetanide oral tablet 0.5 mg, 1 mg 5

bumetanide oral tablet 2 mg 1

BYSTOLIC ORAL TABLET 3 PA

BYVALSON ORAL TABLET 3 PA

candesartan oral tablet 1

candesartan-hydrochlorothiazid oral tablet 1

captopril oral tablet 3

captopril-hydrochlorothiazide oral tablet 3

cartia xt oral capsule,extended release 24hr 1

carvedilol oral tablet 5

chlorothiazide oral tablet 1

chlorothiazide sodium intravenous recon soln 1

chlorthalidone oral tablet 25 mg, 50 mg 1

clonidine hcl oral tablet 1

clonidine transdermal patch weekly 1

DEMSER ORAL CAPSULE 4 PA

diltiazem hcl oral capsule,ext.rel 24h degradable

240 mg

1


of this table.

43


diltiazem hcl oral capsule,extended release 12 hr 1

diltiazem hcl oral capsule,extended release 24 hr

240 mg, 420 mg

1

diltiazem hcl oral capsule,extended release 24hr 1

diltiazem hcl oral tablet 1

diltiazem hcl oral tablet extended release 24 hr

180 mg, 240 mg, 300 mg, 360 mg

1

dilt-xr oral capsule,ext.rel 24h degradable 1

DIURIL ORAL SUSPENSION 3

doxazosin oral tablet 1

DYRENIUM ORAL CAPSULE 3 ST

EDARBI ORAL TABLET 3 PA

EDARBYCLOR ORAL TABLET 3 PA

enalapril maleate oral tablet 1

enalaprilat intravenous solution 1

enalapril-hydrochlorothiazide oral tablet 1

eplerenone oral tablet 1

epoprostenol (glycine) intravenous recon soln 4 PA; LA

eprosartan oral tablet 1

esmolol intravenous solution 1

ethacrynic acid oral tablet 3 ST

felodipine oral tablet extended release 24 hr 1

FLOLAN INTRAVENOUS RECON SOLN 4 PA; LA; QL

fosinopril oral tablet 1

fosinopril-hydrochlorothiazide oral tablet 1

furosemide injection solution 1

furosemide injection syringe 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1

furosemide oral tablet 5

guanfacine oral tablet 1

hydralazine injection solution 1


of this table.

44


hydralazine oral tablet 1

hydrochlorothiazide oral capsule 5

hydrochlorothiazide oral tablet 12.5 mg 1

hydrochlorothiazide oral tablet 25 mg, 50 mg 5

indapamide oral tablet 1

irbesartan oral tablet 1

irbesartan-hydrochlorothiazide oral tablet 1

isradipine oral capsule 1

labetalol intravenous solution 1

labetalol intravenous syringe 20 mg/4 ml (5

mg/ml)

1

labetalol oral tablet 1

LEVATOL ORAL TABLET 3 ST

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

lisinopril oral tablet 30 mg, 40 mg 1

lisinopril-hydrochlorothiazide oral tablet 5

losartan oral tablet 1

losartan-hydrochlorothiazide oral tablet 1

methyclothiazide oral tablet 1

methyldopa oral tablet 1

methyldopa-hydrochlorothiazide oral tablet 1

methyldopate intravenous solution 1

metolazone oral tablet 1

metoprolol succinate oral tablet extended release

24 hr

1

metoprolol ta-hydrochlorothiaz oral tablet 1

metoprolol tartrate intravenous solution 1

metoprolol tartrate intravenous syringe 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

5

minoxidil oral tablet 1

moexipril oral tablet 1


of this table.

45


moexipril-hydrochlorothiazide oral tablet 1

nadolol oral tablet 1

nadolol-bendroflumethiazide oral tablet 1

nicardipine intravenous solution 1

nicardipine oral capsule 1

nifedipine oral capsule 1

nifedipine oral tablet extended release 1

nifedipine oral tablet extended release 24hr 1

nimodipine oral capsule 1

nisoldipine oral tablet extended release 24 hr 1 ST

olmesartan oral tablet 1 PA

ORENITRAM ORAL TABLET EXTENDED

RELEASE

4 PA; LA

papaverine injection solution 1

perindopril erbumine oral tablet 1

phenoxybenzamine oral capsule 4 PA

phentolamine injection recon soln 1

pindolol oral tablet 1

prazosin oral capsule 1

propranolol intravenous solution 1

propranolol oral capsule,extended release 24 hr 1

propranolol oral solution 1

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

mg

5

propranolol oral tablet 60 mg 1

propranolol-hydrochlorothiazid oral tablet 1

quinapril oral tablet 1

quinapril-hydrochlorothiazide oral tablet 1

ramipril oral capsule 1

REMODULIN INJECTION SOLUTION 4 PA; LA

spironolactone oral tablet 100 mg, 50 mg 1

spironolactone oral tablet 25 mg 5


of this table.

46


spironolacton-hydrochlorothiaz oral tablet 1

taztia xt oral capsule,extended release 24 hr 1

TEKTURNA HCT ORAL TABLET 2 ST

TEKTURNA ORAL TABLET 2 ST

telmisartan oral tablet 1

telmisartan-amlodipine oral tablet 1

telmisartan-hydrochlorothiazid oral tablet 1

terazosin oral capsule 1

timolol maleate oral tablet 1

torsemide oral tablet 1

trandolapril oral tablet 1

trandolapril-verapamil oral tablet, ir - er, biphasic

24hr

1

triamterene-hydrochlorothiazid oral capsule 37.5-

25 mg

5

triamterene-hydrochlorothiazid oral capsule 50-25

mg

1

triamterene-hydrochlorothiazid oral tablet 5

UPTRAVI ORAL TABLET 4 PA; LA; QL

UPTRAVI ORAL TABLETS,DOSE PACK 4 PA; LA; QL

valsartan oral tablet 1

valsartan-hydrochlorothiazide oral tablet 1

veletri intravenous recon soln 4 PA; LA

verapamil intravenous solution 1

verapamil intravenous syringe 1

verapamil oral capsule,ext rel. pellets 24 hr 120

mg, 180 mg, 240 mg

1

verapamil oral tablet 1

verapamil oral tablet extended release 1

CARDIAC GLYCOSIDES

digitek oral tablet 1

digox oral tablet 1


of this table.

47


digoxin injection solution 1

digoxin injection syringe 1

digoxin oral solution 50 mcg/ml 1

digoxin oral tablet 1

COAGULATION THERAPY

aminocaproic acid intravenous solution 1

aspirin-dipyridamole oral capsule, er multiphase

12 hr

1

bivalirudin intravenous recon soln 1

BRILINTA ORAL TABLET 2 QL

cilostazol oral tablet 1

clopidogrel oral tablet 1

dipyridamole oral tablet 1

ELIQUIS ORAL TABLET 2 QL

enoxaparin subcutaneous solution 4 QL

enoxaparin subcutaneous syringe 4 QL

fondaparinux subcutaneous syringe 4 QL

FRAGMIN SUBCUTANEOUS SOLUTION 4 QL

FRAGMIN SUBCUTANEOUS SYRINGE 4 QL

hep flush-10 (pf) intravenous solution 1

HEPARIN (PORCINE) IN 0.9% NACL

INTRAVENOUS PARENTERAL SOLUTION

1,000 UNIT/1000 ML (1 UNIT/ML), 2,000

UNIT/500 ML (4 UNIT/ML), 4000 UNIT/1000

ML (4 UNIT/ML), 6,000 UNIT/1000 ML (6

UNIT/ML)

3

heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml (40

unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000

unit/500 ml (50 unit/ml)

1

heparin (porcine) in nacl (pf) intravenous

parenteral solution

1

heparin (porcine) injection cartridge 1

heparin (porcine) injection solution 1


of this table.

48


heparin (porcine) injection syringe 5,000 unit/ml 1

heparin flush(porcine)-0.9nacl intravenous kit 1

heparin lock flush (porcine) intravenous solution

100 unit/ml

1

heparin lock flush intravenous solution 1

heparin lock flush intravenous syringe 1

heparin lockflush(porcine)(pf) intravenous syringe 1

HEPARIN(PORCINE) IN 0.45% NACL

INTRAVENOUS PARENTERAL SOLUTION

12,500 UNIT/250 ML

3

heparin(porcine) in 0.45% nacl intravenous

parenteral solution 25,000 unit/250 ml, 25,000

unit/500 ml

1

heparin, porcine (pf) injection solution 1

heparin, porcine (pf) injection syringe 1

heparin, porcine (pf) intravenous solution 100

unit/ml (1 ml)

1

heparin, porcine (pf) intravenous syringe 1

jantoven oral tablet 1

MEPHYTON ORAL TABLET 3

NPLATE SUBCUTANEOUS RECON SOLN 4 PA; LA

pentoxifylline oral tablet extended release 1

PRADAXA ORAL CAPSULE 3 QL

prasugrel oral tablet 1 QL

PROMACTA ORAL TABLET 4 PA; LA; QL

protamine intravenous solution 1

ticlopidine oral tablet 1

tranexamic acid intravenous solution 1

vitamin k injection solution 1

vitamin k1 injection solution 1

warfarin oral tablet 1

XARELTO ORAL TABLET 2 QL

XARELTO ORAL TABLETS,DOSE PACK 2 QL


of this table.

49


ZONTIVITY ORAL TABLET 3 PA; QL

LIPID/CHOLESTEROL LOWERING AGENTS

atorvastatin oral tablet 1

cholestyramine (with sugar) oral powder 3

cholestyramine (with sugar) oral powder in packet 3

cholestyramine light oral powder 3

cholestyramine light oral powder in packet 3

colestipol oral granules 3

colestipol oral packet 3

colestipol oral tablet 3

ezetimibe oral tablet 1

fenofibrate micronized oral capsule 134 mg, 43

mg, 67 mg

1

fenofibrate micronized oral capsule 200 mg 3

fenofibrate nanocrystallized oral tablet 1

fenofibrate oral tablet 160 mg, 54 mg 1

fenofibric acid (choline) oral capsule,delayed

release(dr/ec)

3

fenofibric acid oral tablet 3

fluvastatin oral capsule 3

gemfibrozil oral tablet 1

JUXTAPID ORAL CAPSULE 4 PA; QL

KYNAMRO SUBCUTANEOUS SYRINGE 4 PA; LA; QL

LIVALO ORAL TABLET 3 PA

lovastatin oral tablet 1

niacin oral tablet extended release 24 hr 3

omega-3 acid ethyl esters oral capsule 2

PRALUENT PEN SUBCUTANEOUS PEN

INJECTOR

4 PA; LA; QL

pravastatin oral tablet 1

prevalite oral powder 3

prevalite oral powder in packet 3


of this table.

50


REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR

4 PA; QL

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR

4 PA; QL

REPATHA SYRINGE SUBCUTANEOUS

SYRINGE

4 PA; QL

rosuvastatin oral tablet 1 ST

simvastatin oral tablet 1

triklo oral capsule 2

VASCEPA ORAL CAPSULE 2

WELCHOL ORAL POWDER IN PACKET 2

WELCHOL ORAL TABLET 2

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET 3 PA; QL

ENTRESTO ORAL TABLET 2 PA; QL

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR

2

NITRATES

isosorbide dinitrate oral tablet 1

isosorbide dinitrate oral tablet extended release 1

isosorbide mononitrate oral tablet 1

isosorbide mononitrate oral tablet extended

release 24 hr

1

nitro-bid transdermal ointment 1

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

3

nitroglycerin in 5 % dextrose intravenous solution 1

nitroglycerin intravenous solution 1

nitroglycerin oral capsule, extended release 1

nitroglycerin sublingual tablet 1

nitroglycerin transdermal patch 24 hour 1

nitroglycerin translingual aerosol,spray 1

nitroglycerin translingual spray,non-aerosol 1


of this table.

51


nitro-time oral capsule, extended release 1

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin oral capsule 4 ST

calcipotriene scalp solution 3

calcipotriene topical cream 3

calcipotriene topical ointment 3

calcitrene topical ointment 3

calcitriol topical ointment 3 QL

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE

4 PA; LA; QL

COSENTYX PEN (2 PENS) SUBCUTANEOUS

PEN INJECTOR

4 PA; LA; QL

COSENTYX PEN SUBCUTANEOUS PEN

INJECTOR

4 PA; LA; QL

COSENTYX SUBCUTANEOUS SYRINGE 4 PA; LA; QL

drithocreme hp topical cream 1

hydrocortisone-pramoxine topical cream 1

seb-prev topical cleanser 1

selenium sulfide topical lotion 1

selenium sulfide topical shampoo 2.25 % 1

SILIQ SUBCUTANEOUS SYRINGE 4 PA; LA; QL

STELARA INTRAVENOUS SOLUTION 4 PA; LA; QL

STELARA SUBCUTANEOUS SOLUTION 4 PA; LA; QL

STELARA SUBCUTANEOUS SYRINGE 4 PA; LA; QL

sulfacetamide sodium topical cleanser 1

TACLONEX TOPICAL SUSPENSION 3 PA

TALTZ AUTOINJECTOR (2 PACK)

SUBCUTANEOUS AUTO-INJECTOR

4 PA; LA; QL

TALTZ AUTOINJECTOR (3 PACK)

SUBCUTANEOUS AUTO-INJECTOR

4 PA; LA; QL

TALTZ AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR

4 PA; LA; QL


of this table.

52


TALTZ SYRINGE (2 PACK) SUBCUTANEOUS

SYRINGE

4 PA; LA; QL

TALTZ SYRINGE (3 PACK) SUBCUTANEOUS

SYRINGE

4 PA; LA; QL

TALTZ SYRINGE SUBCUTANEOUS

SYRINGE

4 PA; LA; QL

TREMFYA SUBCUTANEOUS SYRINGE 4 PA; LA; QL

BURN THERAPY

silver sulfadiazine topical cream 1

ssd topical cream 1

KERATOLYTICS

salicylic acid topical cream 1

salicylic acid topical cream,extended release 1

salicylic acid topical film forming liquid w/appl 1

salicylic acid topical liquid 26 % 1

salicylic acid topical lotion 1

salicylic acid topical shampoo 1

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate topical cream 1

avo cream topical emulsion 1

doxepin topical cream 3

DUPIXENT SUBCUTANEOUS SYRINGE 4 PA; QL

ELIDEL TOPICAL CREAM 3 PA

EUCRISA TOPICAL OINTMENT 3 PA; QL

fluorouracil topical cream 5 % 1

fluorouracil topical solution 1

methoxsalen oral capsule,liqd-filled,rapid rel 4 PA

PANRETIN TOPICAL GEL 4 PA

podofilox topical solution 1

prudoxin topical cream 3

prutect topical emulsion 1

QUTENZA TOPICAL KIT 4 PA; QL


of this table.

53


REGRANEX TOPICAL GEL 3 QL

silver nitrate applicators topical stick 1

silver nitrate topical ointment 1

silver nitrate topical solution 1

tacrolimus topical ointment 3

urea topical cream 40 %, 50 % 1

urea topical lotion 40 % 1

ure-k topical cream 1

UVADEX INJECTION SOLUTION 3

VALCHLOR TOPICAL GEL 4 PA; LA

THERAPY FOR ACNE

adapalene topical cream 1 PA > 35 years of age

adapalene topical gel 0.1 % 1 PA > 35 years of age

adapalene-benzoyl peroxide topical gel with pump 3 PA

amnesteem oral capsule 3

AVAR LS TOPICAL PADS, MEDICATED 3 PA

AVAR TOPICAL PADS, MEDICATED 3 PA

avita topical cream 1

claravis oral capsule 3

clindacin p topical swab 1

clindamycin phosphate topical gel 1

clindamycin phosphate topical lotion 1

clindamycin phosphate topical solution 1

clindamycin phosphate topical swab 1

clindamycin-benzoyl peroxide topical gel 1-5 % 1 PA

clindamycin-tretinoin topical gel 3 PA

ery pads topical swab 1

erythromycin with ethanol topical gel 3

erythromycin with ethanol topical solution 1

erythromycin with ethanol topical swab 1

FINACEA TOPICAL FOAM 3 PA


of this table.

54


FINACEA TOPICAL GEL 3 PA

metronidazole topical cream 1

metronidazole topical gel 1

metronidazole topical gel with pump 1

metronidazole topical lotion 1

MIRVASO TOPICAL GEL 3 PA

MIRVASO TOPICAL GEL WITH PUMP 3 PA

RHOFADE TOPICAL CREAM 3 PA

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

1

sulfacetamide sod-sulfur-urea topical cleanser 1

sulfact na-sul-avobnz-otn-ocsa topical combo

pack,cleanser and cream

1

tazarotene topical cream 0.1% 1 PA

TAZORAC TOPICAL CREAM 3 PA

TAZORAC TOPICAL GEL 3 PA

tretinoin topical cream 1

tretinoin topical gel 0.01 %, 0.025 % 1

zenatane oral capsule 3

TOPICAL ANESTHETICS

ethyl chloride topical aerosol,spray 1

glydo mucous membrane jelly in applicator 1

lidocaine (pf) injection solution 1

lidocaine hcl injection solution 1

lidocaine hcl injection syringe 10 mg/ml (1 %) 1

lidocaine hcl laryngotracheal solution 1

lidocaine hcl mucous membrane jelly 1

lidocaine hcl mucous membrane jelly in applicator 1

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

1 QL

lidocaine hcl topical cream 3 % 1

lidocaine hcl topical lotion 1


of this table.

55


lidocaine hcl-hydrocortison ac topical cream 1

lidocaine topical adhesive patch,medicated 3 ST; QL

lidocaine topical ointment 3

lidocaine viscous mucous membrane solution 1

lidocaine-epinephrine injection solution 1

lidocaine-prilocaine topical cream 1

lidocaine-prilocaine topical kit 1

lido-k topical lotion 1

lidopin topical cream 3 % 1

lta pre-attached laryngotracheal solution 1

SYNERA TOPICAL PATCH, MEDICATED

SELF-HEATING

3 PA

XYLOCAINE-MPF INJECTION SOLUTION 15

MG/ML (1.5 %)

3

TOPICAL ANTIBACTERIALS

ALTABAX TOPICAL OINTMENT 3

CORTISPORIN TOPICAL CREAM 3

CORTISPORIN TOPICAL OINTMENT 3

gentamicin topical cream 1

gentamicin topical ointment 1

mupirocin calcium topical cream 1

mupirocin topical ointment 1

SILVRSTAT TOPICAL GEL 3

sulfacetamide sodium (acne) topical suspension 1

SULFAMYLON TOPICAL CREAM 3

TOPICAL ANTIFUNGALS

ciclodan topical cream 1

ciclodan topical solution 1

ciclopirox topical cream 1

ciclopirox topical solution 1

clotrimazole-betamethasone topical cream 1

clotrimazole-betamethasone topical lotion 3


of this table.

56


econazole topical cream 3

EXELDERM TOPICAL CREAM 3

EXELDERM TOPICAL SOLUTION 3

ketoconazole topical cream 1

ketoconazole topical shampoo 1

LUZU TOPICAL CREAM 3 PA

MENTAX TOPICAL CREAM 3 PA

NAFTIN TOPICAL GEL 1 % 3 PA

nyamyc topical powder 1

nyata topical powder 1

nystatin topical cream 1

nystatin topical ointment 1

nystatin topical powder 1

nystatin-triamcinolone topical cream 3

nystatin-triamcinolone topical ointment 3

nystop topical powder 1

oxiconazole topical cream 3 PA

TOPICAL ANTIVIRALS

acyclovir topical ointment 3

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 2.5 % 1

alclometasone topical cream 1

alclometasone topical ointment 1

amcinonide topical cream 3 ST

amcinonide topical lotion 3 ST

amcinonide topical ointment 3 ST

betamethasone dipropionate topical cream 1

betamethasone dipropionate topical lotion 1

betamethasone dipropionate topical ointment 1

betamethasone valerate topical cream 1

betamethasone valerate topical lotion 1


of this table.

57


betamethasone valerate topical ointment 1

betamethasone, augmented topical cream 1

betamethasone, augmented topical gel 3

betamethasone, augmented topical lotion 3

betamethasone, augmented topical ointment 3

clobetasol scalp solution 1

clobetasol topical cream 3

clobetasol topical gel 1

clobetasol topical ointment 3

CLODERM TOPICAL CREAM 3 PA

cormax scalp solution 1

desonide topical cream 3

desonide topical ointment 3

desoximetasone topical cream 3 ST

desoximetasone topical gel 3 ST

desoximetasone topical ointment 3 ST

diflorasone topical cream 3 ST

diflorasone topical ointment 3 ST

fluocinolone and shower cap scalp oil 1

fluocinolone topical cream 1

fluocinolone topical oil 1

fluocinolone topical ointment 1

fluocinolone topical solution 1

fluocinonide topical cream 0.05 % 1

fluocinonide topical gel 1

fluocinonide topical ointment 3

fluocinonide topical solution 1

fluocinonide-e topical cream 1

fluocinonide-emollient topical cream 1

fluticasone topical cream 1

fluticasone topical ointment 1


of this table.

58


halobetasol propionate topical cream 1

halobetasol propionate topical ointment 3

hydrocortisone butyrate topical ointment 1

hydrocortisone butyrate topical solution 1

hydrocortisone topical cream 2.5 % 1

hydrocortisone topical lotion 2.5 % 1

hydrocortisone topical ointment 2.5 % 1

hydrocortisone valerate topical cream 1

hydrocortisone valerate topical ointment 3

mometasone topical cream 1

mometasone topical ointment 1

mometasone topical solution 1

prednicarbate topical cream 1

prednicarbate topical ointment 1

triamcinolone acetonide topical cream 1

triamcinolone acetonide topical lotion 1

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

1

triderm topical cream 1

TOPICAL ENZYMES

SANTYL TOPICAL OINTMENT 3 PA

TOPICAL SCABICIDES / PEDICULICIDES

EURAX TOPICAL CREAM 3

EURAX TOPICAL LOTION 3

lindane topical shampoo 3

malathion topical lotion 3

permethrin topical cream 3

SKLICE TOPICAL LOTION 3 PA

spinosad topical suspension 1

ULESFIA TOPICAL LOTION 3

DIAGNOSTICS & MISCELLANEOUS AGENTS


of this table.

59


IRRIGATING SOLUTIONS

lactated ringers irrigation solution 1

neomycin-polymyxin b gu irrigation solution 1

ringer's irrigation solution 1

tis-u-sol pentalyte irrigation solution 1

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec) 1

acetic acid irrigation solution 1

ADAGEN INTRAMUSCULAR SOLUTION 4 PA

alendronate oral tablet 40 mg 1

anagrelide oral capsule 1

ARALAST NP INTRAVENOUS RECON SOLN 4 PA; LA

BUPHENYL ORAL POWDER 4 PA; LA

CARBAGLU ORAL TABLET, DISPERSIBLE 4 PA; LA

cevimeline oral capsule 1

CHEMET ORAL CAPSULE 3 PA

disulfiram oral tablet 1

etidronate disodium oral tablet 1

EXJADE ORAL TABLET, DISPERSIBLE 4 PA; LA

FERRIPROX ORAL SOLUTION 4 PA

FERRIPROX ORAL TABLET 4 PA

GLASSIA INTRAVENOUS SOLUTION 4 PA; LA

INCRELEX SUBCUTANEOUS SOLUTION 4 PA; LA

JADENU ORAL TABLET 4 PA

JADENU SPRINKLE ORAL GRANULES IN

PACKET

4 PA

levocarnitine (with sugar) oral solution 1

levocarnitine oral tablet 1

midodrine oral tablet 1

NITYR ORAL TABLET 4 PA

NORTHERA ORAL CAPSULE 4 PA; LA; QL


of this table.

60


ORFADIN ORAL CAPSULE 4 PA

ORFADIN ORAL SUSPENSION 4 PA

pilocarpine hcl oral tablet 5 mg 1

PROLASTIN-C INTRAVENOUS RECON SOLN 4 PA

RAVICTI ORAL LIQUID 4 PA; LA; QL

riluzole oral tablet 4 PA; QL

risedronate oral tablet 30 mg 3 ST

sodium chloride 0.9 % injection solution 1

sodium chloride 0.9 % injection syringe 1

sodium chloride 0.9 % intravenous parenteral

solution

1

sodium chloride 0.9 % intravenous piggyback 1

sodium chloride irrigation solution 1

sodium ferric gluconat-sucrose intravenous

solution

1

sodium phenylbutyrate oral powder 4 PA; LA

sodium phenylbutyrate oral tablet 4 PA; LA

SOLIRIS INTRAVENOUS SOLUTION 4 PA; LA

SYPRINE ORAL CAPSULE 4 PA

THIOLA ORAL TABLET 3

water for irrigation, sterile irrigation solution 1

XURIDEN ORAL GRANULES IN PACKET 4 PA; QL

ZEMAIRA INTRAVENOUS RECON SOLN 4 PA; LA

zoledronic acid-mannitol-water intravenous

piggyback

4 LA; QL

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended

release 12 hr

6 ACA; QL

CHANTIX CONTINUING MONTH BOX ORAL

TABLET

6 ST; ACA; QL

CHANTIX ORAL TABLET 6 ST; ACA; QL

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK

6 ST; ACA; QL


of this table.

61


nicorelief buccal gum 6 ACA; OTC; QL

nicorette buccal gum 4 mg 6 ACA; OTC; QL

nicotine (polacrilex) buccal gum 6 ACA; OTC; QL

nicotine (polacrilex) buccal lozenge 6 ACA; OTC; QL

nicotine (polacrilex) buccal mini lozenge 6 ACA; OTC; QL

nicotine transdermal patch 24 hour 14 mg/24 hr,

21 mg/24 hr, 7 mg/24 hr

6 ACA; OTC; QL

nicotine transdermal patch, td daily, sequential 6 ACA; OTC; QL

NICOTROL INHALATION CARTRIDGE 6 ST; ACA; QL

NICOTROL NS NASAL SPRAY,NON-

AEROSOL

6 ST; ACA; QL

nts step 1 transdermal patch 24 hour 6 ACA; OTC; QL

quit 2 buccal gum 6 ACA; OTC; QL

quit 4 buccal gum 6 ACA; OTC; QL

stop smoking aid buccal lozenge 6 ACA; OTC; QL

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal aerosol,spray 1

azelastine nasal spray,non-aerosol 1

chlorhexidine gluconate mucous membrane

mouthwash

1

denta 5000 plus dental cream 1

dentagel dental gel 1

GELCLAIR MUCOUS MEMBRANE GEL IN

PACKET

3

ipratropium bromide nasal spray,non-aerosol 1

olopatadine nasal spray,non-aerosol 1 ST

oralone dental paste 1

ORAMAGICRX MUCOUS MEMBRANE

MOUTHWASH

3

paroex oral rinse mucous membrane mouthwash 1

periogard mucous membrane mouthwash 1

pilocarpine hcl oral tablet 7.5 mg 1


of this table.

62


sf 5000 plus dental cream 1

sf dental gel 1

triamcinolone acetonide dental paste 1

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution 1

ciprofloxacin hcl otic (ear) dropperette 1

floxin otic (ear) drops 1

fluocinolone acetonide oil otic (ear) drops 1

hydrocortisone-acetic acid otic (ear) drops 1

ofloxacin otic (ear) drops 1

OTIC STEROID / ANTIBIOTIC

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 2

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2

COLY-MYCIN S OTIC (EAR)

DROPS,SUSPENSION

3

neomycin-polymyxin-hc otic (ear)

drops,suspension

1

neomycin-polymyxin-hc otic (ear) solution 1

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. INJECTION GEL 4 PA; LA; QL

betamethasone acet,sod phos injection suspension 1

cortisone oral tablet 1

deltasone oral tablet 20 mg 1

DEPO-MEDROL INJECTION SUSPENSION 20

MG/ML

3

dexamethasone intensol oral drops 1

dexamethasone oral elixir 1

dexamethasone oral solution 1

dexamethasone oral tablet 1

dexamethasone sodium phosphate injection

solution

1


of this table.

63


dexamethasone sodium phosphate injection

syringe

1

EMFLAZA ORAL SUSPENSION 4 PA

EMFLAZA ORAL TABLET 4 PA

fludrocortisone oral tablet 1

hydrocortisone oral tablet 1

KENALOG INJECTION SUSPENSION 3

methylprednisolone acetate injection suspension 1

methylprednisolone oral tablet 1

methylprednisolone oral tablets,dose pack 1

millipred dp oral tablets,dose pack 1

prednisolone oral solution 15 mg/5 ml 1

prednisolone sodium phosphate oral solution 15

mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg

base/5 ml (6.7 mg/5 ml)

1

prednisone intensol oral concentrate 1

prednisone oral solution 1

prednisone oral tablet 1

prednisone oral tablets,dose pack 1

triamcinolone acetonide injection suspension 1

TRIESENCE (PF) INTRAOCULAR

SUSPENSION

3

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1

propylthiouracil oral tablet 1

SSKI ORAL SOLUTION 3

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES

ONETOUCH ULTRA TEST STRIP 2 OTC; QL

ONETOUCH VERIO STRIP 2 OTC; QL

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT

AEROCHAMBER MINI SPACER 3 QL

AEROCHAMBER PLUS FLOW-VU SPACER 3 QL


of this table.

64


AEROCHAMBER PLUS Z STAT SM MSK

SPACER

3 QL

EASIVENT HOLDING CHAMBER SPACER 3 QL

GLUCAGEN DIAGNOSTIC KIT INJECTION

RECON SOLN

2 QL

GLUCAGON HCL INJECTION RECON SOLN 2 QL

INSPIRACHAMBER WITH MASK-LARGE

SPACER

3 QL

INSULIN SYRINGE-NEEDLE U-100 SYRINGE

0.5 ML 29 GAUGE X 1/2"

2

LITEAIRE MDI CHAMBER SPACER 3 QL

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT INJECTION RECON

SOLN

2 QL

GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION KIT

2 QL

PROGLYCEM ORAL SUSPENSION 3

INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU

LANCETS 33 GAUGE 2 OTC; QL

LANCING DEVICE 2 OTC

ONETOUCH ULTRA2 KIT 2 OTC

ONETOUCH ULTRAMINI KIT 2 OTC

ONETOUCH VERIO FLEX 2 OTC

ONETOUCH VERIO IQ METER 2 OTC

ONETOUCH VERIO SYSTEM 2 OTC

PEN NEEDLE NEEDLE 31 GAUGE X 1/4" 2 OTC

INSULIN THERAPY

AFREZZA INHALATION CARTRIDGE WITH

INHALER

3 PA

APIDRA SOLOSTAR SUBCUTANEOUS

INSULIN PEN

3 ST; QL

APIDRA SUBCUTANEOUS SOLUTION 3 ST; QL

BASAGLAR KWIKPEN SUBCUTANEOUS

INSULIN PEN

3 QL


of this table.

65


HUMALOG JUNIOR KWIKPEN

SUBCUTANEOUS INSULIN PEN, HALF-UNIT

2 QL

HUMALOG KWIKPEN SUBCUTANEOUS

INSULIN PEN

2 QL

HUMALOG MIX 50-50 KWIKPEN

SUBCUTANEOUS INSULIN PEN

2 QL

HUMALOG MIX 50-50 SUBCUTANEOUS

SUSPENSION

2 QL

HUMALOG MIX 75-25 KWIKPEN


2 QL

HUMALOG MIX 75-25 SUBCUTANEOUS

SUSPENSION

2 QL

HUMALOG SUBCUTANEOUS CARTRIDGE 2 QL

HUMALOG SUBCUTANEOUS SOLUTION 2 QL

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

INSULIN PEN

2 QL

HUMULIN 70/30 SUBCUTANEOUS

SUSPENSION

2 QL

HUMULIN N KWIKPEN SUBCUTANEOUS

INSULIN PEN

2 QL

HUMULIN N SUBCUTANEOUS SUSPENSION 2 QL

HUMULIN R U-100 INJECTION SOLUTION 2 QL

HUMULIN R U-500 (CONC) KWIKPEN


2 QL

HUMULIN R U-500 (CONCENTRATED)

SUBCUTANEOUS SOLUTION

2 QL

LANTUS SOLOSTAR SUBCUTANEOUS

INSULIN PEN

2 QL

LANTUS SUBCUTANEOUS SOLUTION 2 QL

LEVEMIR FLEXTOUCH SUBCUTANEOUS

INSULIN PEN

2 QL

LEVEMIR SUBCUTANEOUS SOLUTION 2 QL

NOVOLOG FLEXPEN SUBCUTANEOUS

INSULIN PEN

2 QL

NOVOLOG MIX 70-30 FLEXPEN


2 QL


of this table.

66


NOVOLOG MIX 70-30 SUBCUTANEOUS

SOLUTION

2 QL

NOVOLOG PENFILL SUBCUTANEOUS

CARTRIDGE

2 QL

NOVOLOG SUBCUTANEOUS SOLUTION 2 QL

TOUJEO SOLOSTAR SUBCUTANEOUS

INSULIN PEN

2 QL

TRESIBA FLEXTOUCH U-100


2 QL

TRESIBA FLEXTOUCH U-200


2 QL

XULTOPHY 100/3.6 SUBCUTANEOUS

INSULIN PEN

2 QL

MISCELLANEOUS HORMONES

ALDURAZYME INTRAVENOUS SOLUTION 4 PA; LA

ANADROL-50 ORAL TABLET 3 PA

ANDRODERM TRANSDERMAL PATCH 24

HOUR

3 PA

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25 GRAM

(1.62 %)

2 PA

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62

% (40.5 MG/2.5 GRAM)

2 PA

AVEED INTRAMUSCULAR SOLUTION 3 PA

cabergoline oral tablet 1

calcitonin (salmon) nasal spray,non-aerosol 1

calcitriol intravenous solution 1 mcg/ml 1

calcitriol oral capsule 1

calcitriol oral solution 1

CERDELGA ORAL CAPSULE 4 PA; LA; QL

CEREZYME INTRAVENOUS RECON SOLN

400 UNIT

4 PA; LA

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR RECON SOLN

4 PA


of this table.

67


danazol oral capsule 1 PA

desmopressin nasal solution 1

desmopressin nasal spray,non-aerosol 1

desmopressin oral tablet 1

doxercalciferol intravenous solution 1

doxercalciferol oral capsule 1

ELAPRASE INTRAVENOUS SOLUTION 4 PA; LA

ELELYSO INTRAVENOUS RECON SOLN 4 PA

FABRAZYME INTRAVENOUS RECON SOLN 4 PA; LA

FORTESTA TRANSDERMAL GEL IN

METERED-DOSE PUMP

3 PA

HECTOROL INTRAVENOUS SOLUTION 3

KANUMA INTRAVENOUS SOLUTION 4 PA; LA

KORLYM ORAL TABLET 4 PA; QL

KUVAN ORAL POWDER IN PACKET 500 MG 4 PA; LA

KUVAN ORAL TABLET,SOLUBLE 4 PA; LA

LUMIZYME INTRAVENOUS RECON SOLN 4 PA; LA

METHITEST ORAL TABLET 4 PA

methyltestosterone oral capsule 4 PA

MYALEPT SUBCUTANEOUS RECON SOLN 4 PA; LA; QL

NAGLAZYME INTRAVENOUS SOLUTION 4 PA; LA

NATPARA SUBCUTANEOUS CARTRIDGE 4 PA; LA; QL

oxandrolone oral tablet 1 PA

pamidronate intravenous recon soln 4 LA

pamidronate intravenous solution 4 LA

PARICALCITOL HEMODIALYSIS PORT

INJECTION SOLUTION

3

paricalcitol intravenous solution 1

paricalcitol oral capsule 1

SAMSCA ORAL TABLET 4 PA; LA; QL

SENSIPAR ORAL TABLET 2


of this table.

68


SOMAVERT SUBCUTANEOUS RECON SOLN

15 MG, 20 MG, 25 MG, 30 MG

4 PA; LA; QL

STIMATE NASAL SPRAY,NON-AEROSOL 4

STRENSIQ SUBCUTANEOUS SOLUTION 4 PA

STRIANT BUCCAL MUCOADHESIVE

SYSTEM ER 12 HR

3 PA

SYNAREL NASAL SPRAY,NON-AEROSOL 4 PA; QL

TESTIM TRANSDERMAL GEL 3 PA

testosterone cypionate intramuscular oil 1 PA

testosterone enanthate intramuscular oil 1 PA

TESTOSTERONE TRANSDERMAL GEL IN

METERED-DOSE PUMP 10 MG/0.5 GRAM

/ACTUATION

3 PA

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1 %)

2 PA

testosterone transdermal gel in packet 2 PA

testosterone transdermal solution in metered pump

w/app

1 PA

VIMIZIM INTRAVENOUS SOLUTION 4 PA; LA

VPRIV INTRAVENOUS RECON SOLN 4 PA; LA

ZAVESCA ORAL CAPSULE 4 PA; LA

zoledronic acid intravenous recon soln 4 LA

zoledronic acid intravenous solution 4 LA

ZOLEDRONIC AC-MANNITOL-0.9NACL


4 ST; LA

ZOMETA INTRAVENOUS PIGGYBACK 4 LA

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose oral tablet 1 QL

ADLYXIN SUBCUTANEOUS PEN INJECTOR 3 ST; QL

BYDUREON SUBCUTANEOUS PEN

INJECTOR

3 ST; QL

BYDUREON SUBCUTANEOUS


3 ST; QL

BYETTA SUBCUTANEOUS PEN INJECTOR 3 ST; QL


of this table.

69


chlorpropamide oral tablet 1 QL

CYCLOSET ORAL TABLET 3

FARXIGA ORAL TABLET 3 PA; QL

glimepiride oral tablet 1 QL

glipizide oral tablet 1 QL

glipizide oral tablet extended release 24hr 1 QL

glipizide-metformin oral tablet 1 QL

glyburide micronized oral tablet 1 QL

glyburide oral tablet 1 QL

glyburide-metformin oral tablet 1 QL

GLYXAMBI ORAL TABLET 2 QL

INVOKAMET ORAL TABLET 2 QL

INVOKAMET XR ORAL TABLET, IR - ER,

BIPHASIC 24HR

2 QL

INVOKANA ORAL TABLET 2 QL

JANUMET ORAL TABLET 2 QL

JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR

2 QL

JANUVIA ORAL TABLET 2 QL

JARDIANCE ORAL TABLET 2 QL

JENTADUETO ORAL TABLET 2 QL

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR

2 QL

metformin oral tablet 1 QL

metformin oral tablet extended release 24 hr

(generic Glucophage XR)

1 QL

miglitol oral tablet 1 QL

nateglinide oral tablet 1 QL

pioglitazone oral tablet 1 QL

pioglitazone-metformin oral tablet 15-500 mg 1 QL

pioglitazone-metformin oral tablet 15-850 mg 1 QL

repaglinide oral tablet 1 QL

repaglinide-metformin oral tablet 1 QL


of this table.

70


SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR

2 ST; QL

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR

2 ST; QL

SYNJARDY ORAL TABLET 2 QL

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR

2 QL

TANZEUM SUBCUTANEOUS PEN INJECTOR 3 ST; QL

tolazamide oral tablet 1 QL

tolbutamide oral tablet 1 QL

TRADJENTA ORAL TABLET 2 QL

TRULICITY SUBCUTANEOUS PEN

INJECTOR

2

VICTOZA 2-PAK SUBCUTANEOUS PEN

INJECTOR

2

VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR

2

THYROID HORMONES

ARMOUR THYROID ORAL TABLET 3

LEVOTHYROXINE INTRAVENOUS RECON

SOLN 100 MCG

3

levothyroxine intravenous recon soln 200 mcg,

500 mcg

1

levothyroxine oral tablet 100 mcg, 112 mcg, 125

mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25

mcg, 50 mcg, 75 mcg, 88 mcg

5

levothyroxine oral tablet 300 mcg 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

5

liothyronine intravenous solution 1

liothyronine oral tablet 1

nature-throid oral tablet 1

np thyroid oral tablet 1

thyroid (pork) oral tablet 1


of this table.

71


THYROLAR-1 ORAL TABLET 3

THYROLAR-1/2 ORAL TABLET 3

THYROLAR-1/4 ORAL TABLET 3



unithroid oral tablet 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65

mg, 97.5 mg

1

WP THYROID ORAL TABLET 3

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz oral tablet,disintegrating 1

atropine injection solution 1

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1

belladonna alkaloids-opium rectal suppository 1 PA < 18 years of age

belladonna-opium rectal suppository 1 PA < 18 years of age

chlordiazepoxide-clidinium oral capsule 1

CUVPOSA ORAL SOLUTION 4 PA

dicyclomine intramuscular solution 1

dicyclomine oral capsule 1

dicyclomine oral solution 1

dicyclomine oral tablet 1

diphenoxylate-atropine oral liquid 1

diphenoxylate-atropine oral tablet 1

ed-spaz oral tablet,disintegrating 1

glycopyrrolate injection solution 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

hyoscyamine sulfate oral drops 1

hyoscyamine sulfate oral elixir 1

hyoscyamine sulfate oral tablet 1

hyoscyamine sulfate oral tablet extended release

12 hr

1


of this table.

72


hyoscyamine sulfate oral tablet,disintegrating 1

hyoscyamine sulfate sublingual tablet 1

hyosyne oral drops 1

hyosyne oral elixir 1

LEVSIN INJECTION SOLUTION 3

loperamide oral capsule 1

methscopolamine oral tablet 1

MYTESI ORAL TABLET,DELAYED RELEASE

(DR/EC)

4 PA; QL

oscimin oral tablet 1

oscimin oral tablet,disintegrating 1

oscimin sl sublingual tablet 1

oscimin sr oral tablet extended release 12 hr 1

paregoric oral liquid 1

propantheline oral tablet 1

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO ORAL CAPSULE 3 QL

alophen oral tablet,delayed release (dr/ec) 6 ACA; OTC

alosetron oral tablet 4 PA

ALOXI INTRAVENOUS SOLUTION 3 ST; QL

AMITIZA ORAL CAPSULE 3 QL

anucort-hc rectal suppository 1

ANZEMET ORAL TABLET 3 ST; QL

aprepitant oral capsule 1 QL

aprepitant oral capsule,dose pack 1 QL

APRISO ORAL CAPSULE,EXTENDED

RELEASE 24HR

2

ASACOL HD ORAL TABLET,DELAYED

RELEASE (DR/EC)

2

AURYXIA ORAL TABLET 2

balsalazide oral capsule 1

bisacodyl oral tablet,delayed release (dr/ec) 6 ACA; OTC


of this table.

73


bisa-lax oral tablet,delayed release (dr/ec) 6 ACA; OTC

budesonide oral capsule,delayed,extend.release 1

calcium acetate oral capsule 1

calcium acetate oral tablet 667 mg 1

CANASA RECTAL SUPPOSITORY 3

CESAMET ORAL CAPSULE 3 ST

CIMZIA SUBCUTANEOUS SYRINGE KIT 4 PA; LA; QL

citrate of magnesia oral solution 6 ACA; OTC

citroma oral solution 6 ACA; OTC

clearlax oral powder 6 ACA; OTC

colocort rectal enema 1

compro rectal suppository 1

constulose oral solution 1

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

2

cromolyn oral concentrate 1

CYSTADANE ORAL POWDER 4 PA

DELZICOL ORAL CAPSULE (WITH DEL REL

TABLETS)

2

dimenhydrinate injection solution 1

DIPENTUM ORAL CAPSULE 3 ST

dronabinol oral capsule 3

droperidol injection solution 1

ducodyl oral tablet,delayed release (dr/ec) 6 ACA; OTC

eliphos oral tablet 1

EMEND (FOSAPREPITANT) INTRAVENOUS

RECON SOLN

3 QL

EMEND ORAL SUSPENSION FOR

RECONSTITUTION

2 QL

ENTYVIO INTRAVENOUS RECON SOLN 4 PA; LA; QL

enulose oral solution 1

fleet laxative oral tablet,delayed release (dr/ec) 6 ACA; OTC

FOSRENOL ORAL POWDER IN PACKET 3 ST


of this table.

74


GATTEX 30-VIAL SUBCUTANEOUS KIT 4 PA; LA; QL

gavilax oral powder 6 ACA; OTC

gavilyte-c oral recon soln 6 ACA

gavilyte-g oral recon soln 6 ACA

gavilyte-n oral recon soln 6 ACA

generlac oral solution 1

gentle laxative oral tablet,delayed release (dr/ec) 6 ACA; OTC

gentlelax oral powder 6 ACA; OTC

glycolax oral powder 6 ACA; OTC

granisetron (pf) intravenous solution 1 ST

granisetron hcl intravenous solution 1 ST

granisetron hcl oral tablet 3 ST; QL

healthylax oral powder in packet 6 ACA; OTC

hemmorex-hc rectal suppository 25 mg 1

hydrocortisone acetate rectal suppository 25 mg 1

hydrocortisone rectal enema 1

hydrocortisone topical cream with perineal

applicator

1

hydrocortisone-pramoxine rectal cream 1

kionex (with sorbitol) oral suspension 1

kionex oral powder 1

lactulose oral solution 10 gram/15 ml 1

lanthanum oral tablet,chewable 1 ST

laxaclear oral powder 6 ACA; OTC

laxative (bisacodyl) oral tablet 6 ACA; OTC

laxative (bisacodyl) oral tablet,delayed release

(dr/ec)

6 ACA; OTC

laxative feminine oral tablet 6 ACA; OTC

laxative peg 3350 oral powder 6 ACA; OTC

LIALDA ORAL TABLET,DELAYED RELEASE

(DR/EC)

3 ST

lidocaine hcl-hydrocortison ac rectal cream 3-0.5

%

1


of this table.

75


LINZESS ORAL CAPSULE 2 QL

magnesium citrate oral solution 6 ACA; OTC

meclizine oral tablet 12.5 mg, 25 mg 1

mesalamine rectal enema 1

mesalamine with cleansing wipe rectal enema kit 1

metoclopramide hcl injection solution 1

metoclopramide hcl injection syringe 1

metoclopramide hcl oral solution 1

metoclopramide hcl oral tablet 1

milk of magnesia concentrated oral suspension 6 ACA; OTC

milk of magnesia oral suspension 6 ACA; OTC

miralax oral powder in packet 6 ACA; OTC

MOVANTIK ORAL TABLET 2 QL

MOVIPREP ORAL POWDER IN PACKET 2

OCALIVA ORAL TABLET 4 PA; LA; QL

ondansetron hcl (pf) injection solution 1

ondansetron hcl (pf) injection syringe 1

ondansetron hcl intravenous solution 1

ondansetron hcl oral solution 1

ondansetron hcl oral tablet 1 QL

ondansetron oral tablet,disintegrating 1 QL

oral saline laxative oral liquid 6 ACA; OTC

OSMOPREP ORAL TABLET 3

peg 3350-electrolytes oral recon soln 6 ACA

peg3350 oral powder 6 ACA; OTC

peg-electrolyte soln oral recon soln 6 ACA

peg-prep oral kit 6 ACA

PENTASA ORAL CAPSULE, EXTENDED

RELEASE

3

phosphate laxative oral liquid 6 ACA; OTC

polyethylene glycol 3350 oral powder 6 ACA

powderlax oral powder 6 ACA; OTC


of this table.

76


pramcort rectal cream 1

PREPOPIK ORAL POWDER IN PACKET 3

prochlorperazine edisylate injection solution 1

prochlorperazine maleate oral tablet 1

prochlorperazine rectal suppository 1

procto-med hc topical cream with perineal

applicator

1

proctosol hc topical cream with perineal

applicator

1

proctozone-hc topical cream with perineal

applicator

1

purelax oral powder 6 ACA; OTC

purelax oral powder in packet 6 ACA; OTC

RECTIV RECTAL OINTMENT 3 PA

RELISTOR ORAL TABLET 4 PA; QL

RELISTOR SUBCUTANEOUS SOLUTION 4 PA; QL

RELISTOR SUBCUTANEOUS SYRINGE 4 PA; QL

REMICADE INTRAVENOUS RECON SOLN 4 PA; LA

RENAGEL ORAL TABLET 2

SANCUSO TRANSDERMAL PATCH WEEKLY 3 ST; QL

scopolamine base transdermal patch 3 day 1

sevelamer carbonate oral powder in packet 1

sevelamer carbonate oral tablet 1

smoothlax oral powder 6 ACA; OTC

smoothlax oral powder in packet 6 ACA; OTC

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 1

sodium polystyrene sulfonate rectal enema 30

gram/120 ml

1

SODIUM POLYSTYRENE SULFONATE

RECTAL ENEMA 50 GRAM/200 ML

3

sps (with sorbitol) oral suspension 1

sps (with sorbitol) rectal enema 1


of this table.

77


SUCRAID ORAL SOLUTION 4 PA; LA

sulfasalazine oral tablet 1

sulfasalazine oral tablet,delayed release (dr/ec) 1

SUPREP BOWEL PREP KIT ORAL RECON

SOLN

2

TIGAN INTRAMUSCULAR SOLUTION 3

trilyte with flavor packets oral recon soln 6 ACA

trimethobenzamide oral capsule 1

UCERIS ORAL TABLET,DELAYED AND

EXT.RELEASE

3 PA

UCERIS RECTAL FOAM 3 PA

ursodiol oral capsule 1

ursodiol oral tablet 1

VELPHORO ORAL TABLET,CHEWABLE 3 ST

VELTASSA ORAL POWDER IN PACKET 4 PA; LA; QL

VIBERZI ORAL TABLET 4 PA; QL

woman's laxative oral tablet,delayed release

(dr/ec)

6 ACA; OTC

women's laxative (bisacodyl) oral tablet 6 ACA; OTC

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

3 ST

ULCER THERAPY

amoxicil-clarithromy-lansopraz oral combo pack 1

CARAFATE ORAL SUSPENSION 3

cimetidine hcl oral solution 1

cimetidine oral tablet 1

DEXILANT ORAL CAPSULE,BIPHASE

DELAYED RELEAS

3 PA; QL

esomeprazole sodium intravenous recon soln 1 QL

famotidine (pf) intravenous solution 1

famotidine (pf)-nacl (iso-os) intravenous

piggyback

1

famotidine intravenous solution 1


of this table.

78


famotidine oral suspension 1

famotidine oral tablet 20 mg, 40 mg 1

lansoprazole oral capsule,delayed release(dr/ec) 1 QL

misoprostol oral tablet 1

NEXIUM IV INTRAVENOUS RECON SOLN 40

MG

3 QL

NEXIUM ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

1 ST; QL

NEXIUM PACKET ORAL GRANULES DR

FOR SUSP IN PACKET

3 ST; QL

nizatidine oral capsule 1

nizatidine oral solution 1

omeprazole oral capsule,delayed release(dr/ec) 1

omeprazole-sodium bicarbonate oral capsule 1 PA; QL

omeprazole-sodium bicarbonate oral packet 1 PA; QL

pantoprazole intravenous recon soln 1 QL

pantoprazole oral tablet,delayed release (dr/ec) 1

rabeprazole oral tablet,delayed release (dr/ec) 1 QL

ranitidine hcl injection solution 1

ranitidine hcl oral capsule 3

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg 5

ranitidine hcl oral tablet 300 mg 1

sucralfate oral tablet 1

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN POLYSORBATE) INJECTION

SOLUTION

4 PA; LA

ARANESP (IN POLYSORBATE) INJECTION

SYRINGE

4 PA; LA

EPOGEN INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML

4 PA; LA


of this table.

79


GRANIX SUBCUTANEOUS SYRINGE 4 PA; LA

LEUKINE INJECTION RECON SOLN 4 LA

MOZOBIL SUBCUTANEOUS SOLUTION 4 PA; LA; QL

NEULASTA SUBCUTANEOUS SYRINGE 4 PA; LA

NEULASTA SUBCUTANEOUS SYRINGE, W/

WEARABLE INJECTOR

4 PA; LA

NEUPOGEN INJECTION SOLUTION 4 PA; LA

NEUPOGEN INJECTION SYRINGE 4 PA; LA

PROCRIT INJECTION SOLUTION 4 PA; LA

ZARXIO INJECTION SYRINGE 4 PA; LA

GROWTH HORMONES

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR

4 PA

SEROSTIM SUBCUTANEOUS RECON SOLN 4

MG, 5 MG, 6 MG

4 PA

ZORBTIVE SUBCUTANEOUS RECON SOLN 4 PA

INTERFERONS

AUBAGIO ORAL TABLET 4 PA; LA; QL

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT

4 QL

AVONEX INTRAMUSCULAR PEN INJECTOR

KIT

4 QL

AVONEX INTRAMUSCULAR SYRINGE KIT 4 QL

BETASERON SUBCUTANEOUS KIT 4 ST; QL

COPAXONE SUBCUTANEOUS SYRINGE 4 QL

GILENYA ORAL CAPSULE 4 PA; LA; QL

LEMTRADA INTRAVENOUS SOLUTION 4 PA; LA

moderiba oral tablet 4 LA; QL

OCREVUS INTRAVENOUS SOLUTION 4 PA; LA

PEGASYS PROCLICK SUBCUTANEOUS PEN

INJECTOR

4 PA; QL

PEGASYS SUBCUTANEOUS SOLUTION 4 PA; LA; QL

PEGASYS SUBCUTANEOUS SYRINGE 4 PA; LA; QL


of this table.

80


PEGINTRON SUBCUTANEOUS KIT 50

MCG/0.5 ML

4 PA; LA; QL

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 4 QL

PLEGRIDY SUBCUTANEOUS SYRINGE 4 QL

POMALYST ORAL CAPSULE 4 PA; LA; QL

REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE

4 ST; QL

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR

4 ST; QL

REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE

4 ST; QL

REVLIMID ORAL CAPSULE 4 PA; LA; QL

ribasphere oral capsule 4 LA; QL

ribasphere oral tablet 4 LA; QL

ribavirin oral capsule 4 LA; QL

ribavirin oral tablet 200 mg 4 LA; QL

SYLATRON SUBCUTANEOUS KIT 4 LA

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

4 PA; LA; QL

ZINBRYTA SUBCUTANEOUS SYRINGE 4 PA; QL

INTERLEUKINS

ACTIMMUNE SUBCUTANEOUS SOLUTION 4 PA; LA

ALFERON N INJECTION SOLUTION 4 PA; LA

ARCALYST SUBCUTANEOUS RECON SOLN 4 PA; LA; QL

ILARIS (PF) SUBCUTANEOUS RECON SOLN 4 PA; LA; QL

ILARIS (PF) SUBCUTANEOUS SOLUTION 4 PA; LA; QL

imiquimod topical cream in packet 1

INTRON A INJECTION RECON SOLN 4 LA

INTRON A INJECTION SOLUTION 4 LA

KINERET SUBCUTANEOUS SYRINGE 4 PA; QL

PROLEUKIN INTRAVENOUS RECON SOLN 4 LA

VACCINES & MISCELLANEOUS IMMUNOLOGICALS


of this table.

81


ACTHIB (PF) INTRAMUSCULAR RECON

SOLN

6 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION

6 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE

6 ACA

AFLURIA 2017-2018 (PF) INTRAMUSCULAR

SYRINGE

6 ACA

AFLURIA 2017-2018 INTRAMUSCULAR

SUSPENSION

6 ACA

AFLURIA QUAD 2017-2018 (PF)


6 ACA

AFLURIA QUAD 2017-2018


6 ACA

ATGAM INTRAVENOUS SOLUTION 4 LA

BCG VACCINE, LIVE (PF) PERCUTANEOUS


6 ACA; LA

BIOTHRAX INTRAMUSCULAR SUSPENSION 6 ACA

BIVIGAM INTRAVENOUS SOLUTION 4 PA; LA

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION

6 ACA

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE

6 ACA

BOTOX INJECTION RECON SOLN 4 PA; LA; QL

CARIMUNE NF NANOFILTERED

INTRAVENOUS RECON SOLN 12 GRAM, 6

GRAM

4 PA; LA

DAPTACEL (DTAP PEDIATRIC) (PF)


6 ACA

DYSPORT INTRAMUSCULAR RECON SOLN 4 PA; LA; QL

ENGERIX-B (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

6 ACA

ENGERIX-B PEDIATRIC (PF)


6 ACA


of this table.

82


FLEBOGAMMA DIF INTRAVENOUS

SOLUTION

4 PA; LA

FLUAD 2017-2018 (65 YR UP)(PF)


6 ACA

FLUARIX QUAD 2017-2018 (PF)


6 ACA

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR

SOLUTION

6 ACA

FLUBLOK QUAD 2017-2018 (PF)


6 ACA

FLUCELVAX QUAD 2017-2018 (PF)


6 ACA

FLUCELVAX QUAD 2017-2018


6 ACA

FLULAVAL QUAD 2017-2018 (PF)


6 ACA

FLULAVAL QUAD 2017-2018


6 ACA

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR

SYRINGE

6 ACA

FLUVIRIN 2017-2018 INTRAMUSCULAR

SUSPENSION

6 ACA

FLUZONE HIGH-DOSE 2017-18 (PF)


6 ACA

FLUZONE INTRADERM QUAD 2017-18

INTRADERMAL SYRINGE

6 ACA

FLUZONE QUAD 2017-2018 (PF)


6 ACA

FLUZONE QUAD 2017-2018 (PF)


6 ACA

FLUZONE QUAD 2017-2018


6 ACA

FLUZONE QUAD PEDI 2017-18 (PF)


6 ACA

GAMASTAN S/D INTRAMUSCULAR

SOLUTION

4 PA; LA


of this table.

83


GAMMAGARD LIQUID INJECTION

SOLUTION

4 PA; LA

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN

4 PA; LA

GAMMAKED INJECTION SOLUTION 4 PA; LA

GAMMAPLEX (WITH SORBITOL)

INTRAVENOUS SOLUTION

4 PA; LA

GAMMAPLEX INTRAVENOUS SOLUTION 4 PA; LA

GAMUNEX-C INJECTION SOLUTION 4 PA; LA

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE

6 ACA

GRASTEK SUBLINGUAL TABLET 4 PA; QL

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN

6 ACA

HIZENTRA SUBCUTANEOUS SOLUTION 4 PA; LA

HYQVIA SUBCUTANEOUS SOLUTION 4 PA; LA

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SYRINGE

6 ACA

IPOL INJECTION SUSPENSION 6 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 ACA

KINRIX (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

6 ACA

MENHIBRIX (PF) INTRAMUSCULAR RECON

SOLN

6 ACA


of this table.

84


MENOMUNE - A/C/Y/W-135 (PF)


6 ACA

MENOMUNE - A/C/Y/W-135


6 ACA

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN

6 ACA

MYOBLOC INTRAMUSCULAR SOLUTION 4 PA; LA; QL

OCTAGAM INTRAVENOUS SOLUTION 4 PA; LA

ORALAIR SUBLINGUAL TABLET 300 INDX

REACTIVITY

4 PA; QL

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 6 ACA

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION

6 ACA

PENTACEL (PF) INTRAMUSCULAR KIT 6 ACA

PENTACEL ACTHIB COMPONENT (PF)

INTRAMUSCULAR RECON SOLN

6 ACA

PNEUMOVAX 23 INJECTION SOLUTION 6 ACA

PNEUMOVAX 23 INJECTION SYRINGE 6 ACA

PREVNAR 13 (PF) INTRAMUSCULAR

SYRINGE

6

PRIVIGEN INTRAVENOUS SOLUTION 4 PA; LA; QL

PROQUAD (PF) SUBCUTANEOUS


6 ACA

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

RAGWITEK SUBLINGUAL TABLET 4 PA; QL

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR

SYRINGE

6 ACA

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION

6 ACA

ROTATEQ VACCINE ORAL SOLUTION 6

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION

6 ACA


of this table.

85


TENIVAC (PF) INTRAMUSCULAR SYRINGE 6 ACA

TETANUS,DIPHTHERIA TOX PED(PF)


6 ACA

TETANUS-DIPHTHERIA TOXOIDS-TD


6 ACA

THYMOGLOBULIN INTRAVENOUS RECON

SOLN

4 LA

TWINRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION 6 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE 6 ACA

VAQTA (PF) INTRAMUSCULAR

SUSPENSION

6 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE 6 ACA

VARIVAX (PF) SUBCUTANEOUS


6 ACA

VARIZIG INTRAMUSCULAR RECON SOLN 6 ACA

XEOMIN INTRAMUSCULAR RECON SOLN 4 PA; LA; QL

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION

6 ACA

ZOSTAVAX (PF) SUBCUTANEOUS


6 ACA

MUSCULOSKELETAL & RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 1

allopurinol sodium intravenous recon soln 1

aloprim intravenous recon soln 1

COLCRYS ORAL TABLET 2

DUZALLO ORAL TABLET 3 PA; QL

KRYSTEXXA INTRAVENOUS SOLUTION 4 PA; LA; QL

probenecid oral tablet 1

probenecid-colchicine oral tablet 1

ULORIC ORAL TABLET 40 MG 2 ST; QL

ULORIC ORAL TABLET 80 MG 2 ST


of this table.

86


ZURAMPIC ORAL TABLET 3 PA; QL

OSTEOPOROSIS THERAPY

alendronate oral solution 1 QL

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1

FORTEO SUBCUTANEOUS PEN INJECTOR 4 PA; LA; QL

ibandronate intravenous solution 3 ST; QL

ibandronate intravenous syringe 3 ST; QL

ibandronate oral tablet 1 QL

PROLIA SUBCUTANEOUS SYRINGE 4 LA; QL

raloxifene oral tablet 1

risedronate oral tablet 150 mg, 35 mg 3 ST; QL

risedronate oral tablet 5 mg 3 ST

risedronate oral tablet,delayed release (dr/ec) 3 ST; QL

TYMLOS SUBCUTANEOUS PEN INJECTOR 4 PA; LA; QL

OTHER RHEUMATOLOGICALS

ACTEMRA INTRAVENOUS SOLUTION 4 PA; LA; QL

ACTEMRA SUBCUTANEOUS SYRINGE 4 PA; LA; QL

BENLYSTA INTRAVENOUS RECON SOLN 4 PA; LA

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR

4 PA; LA; QL

BENLYSTA SUBCUTANEOUS SYRINGE 4 PA; LA; QL

DEPEN TITRATABS ORAL TABLET 4 PA

ENBREL SUBCUTANEOUS RECON SOLN 4 PA; QL

ENBREL SUBCUTANEOUS SYRINGE 4 PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR

4 PA; QL

HUMIRA PEDIATRIC CROHN'S START

SUBCUTANEOUS SYRINGE KIT

4 PA; LA; QL

HUMIRA PEN CROHN'S-UC-HS START

SUBCUTANEOUS PEN INJECTOR KIT

4 PA; QL

HUMIRA PEN SUBCUTANEOUS PEN

INJECTOR KIT

4 PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT 4 PA; QL


of this table.

87


KEVZARA SUBCUTANEOUS SYRINGE 4 PA; LA; QL

leflunomide oral tablet 1

ORENCIA (WITH MALTOSE) INTRAVENOUS

RECON SOLN

4 PA

ORENCIA CLICKJECT SUBCUTANEOUS

AUTO-INJECTOR

4 PA; QL

ORENCIA SUBCUTANEOUS SYRINGE 4 PA; QL

OTEZLA ORAL TABLET 4 PA; LA; QL

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47)

4 PA; LA; QL

OTREXUP (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15

MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML,

22.5 MG/0.4 ML, 25 MG/0.4 ML

4 PA; QL

RASUVO (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML,

15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4

ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30

MG/0.6 ML, 7.5 MG/0.15 ML

4 PA; QL

RIDAURA ORAL CAPSULE 4

SAVELLA ORAL TABLET 3 PA; QL

SAVELLA ORAL TABLETS,DOSE PACK 3 PA; QL

SIMPONI ARIA INTRAVENOUS SOLUTION 4 PA; LA

SIMPONI SUBCUTANEOUS PEN INJECTOR 4 PA; QL

SIMPONI SUBCUTANEOUS SYRINGE 4 PA; QL

XELJANZ ORAL TABLET 4 PA; QL

XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HR

4 PA; QL

OBSTETRICS & GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED VAGINAL DIAPHRAGM 6 ACA

FC2 FEMALE CONDOM 6 ACA; OTC

FEMCAP VAGINAL DEVICE 22 MM 6 ACA

WIDE-SEAL DIAPHRAGM 6 ACA


of this table.

88


ESTROGENS & PROGESTINS

amabelz oral tablet 1

camila oral tablet 6 ACA

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY

3 QL

covaryx h.s. oral tablet 1

covaryx oral tablet 1

CRINONE VAGINAL GEL 4 % 3

deblitane oral tablet 6 ACA

DEPO-ESTRADIOL INTRAMUSCULAR OIL 3

DUAVEE ORAL TABLET 2

eemt hs oral tablet 1

eemt oral tablet 1

errin oral tablet 6 ACA

ESTRACE VAGINAL CREAM 3

estradiol oral tablet 1

estradiol transdermal patch semiweekly 1 QL

estradiol transdermal patch weekly 1 QL

estradiol vaginal tablet 1

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

1

estradiol-norethindrone acet oral tablet 1

ESTROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP

3 QL

estrogens-methyltestosterone oral tablet 1

estropipate oral tablet 1

FEMRING VAGINAL RING 3 QL

fyavolv oral tablet 1

heather oral tablet 6 ACA

jencycla oral tablet 6 ACA

jevantique lo oral tablet 1

jinteli oral tablet 1


of this table.

89


jolivette oral tablet 6 ACA

lopreeza oral tablet 1

lyza oral tablet 6 ACA

MAKENA INTRAMUSCULAR OIL 4 PA; LA

medroxyprogesterone intramuscular suspension 6 ACA; QL

medroxyprogesterone intramuscular syringe 6 ACA; QL

medroxyprogesterone oral tablet 1

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG

3

MENOSTAR TRANSDERMAL PATCH

WEEKLY

3 QL

mimvey lo oral tablet 1

mimvey oral tablet 1

nora-be oral tablet 6 ACA

norethindrone (contraceptive) oral tablet 6 ACA

norethindrone acetate oral tablet 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg

1

norlyda oral tablet 6 ACA

norlyroc oral tablet 6 ACA

PREMARIN INJECTION RECON SOLN 3

PREMARIN ORAL TABLET 2

PREMARIN VAGINAL CREAM 2

PREMPHASE ORAL TABLET 2

PREMPRO ORAL TABLET 2

progesterone micronized oral capsule 1

sharobel oral tablet 6 ACA

yuvafem vaginal tablet 1

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal cream 1

CONCEPTROL VAGINAL GEL 6 ACA; OTC

fem ph vaginal gel 1


of this table.

90


GYNAZOLE-1 VAGINAL CREAM 3

gynol ii vaginal gel 6 ACA; OTC

isoxsuprine oral tablet 1

LUPANETA PACK (1 MONTH) KIT. SYRINGE

AND TABLET

4 PA; QL

LUPANETA PACK (3 MONTH) KIT. SYRINGE

AND TABLET

4 PA; QL

metronidazole vaginal gel 1

NUVARING VAGINAL RING 6 ACA; QL

OSPHENA ORAL TABLET 3 PA; QL

terconazole vaginal cream 1

terconazole vaginal suppository 1

TODAY CONTRACEPTIVE SPONGE

VAGINAL CONTRACEPTIVE SPONGE

6 ACA; OTC

tranexamic acid oral tablet 1 PA; QL

vaginal contraceptive foam vaginal foam 6 ACA; OTC

vandazole vaginal gel 1

xulane transdermal patch weekly 6 ACA

ORAL CONTRACEPTIVES & RELATED AGENTS

altavera (28) oral tablet 6 ACA

alyacen 1/35 (28) oral tablet 6 ACA

alyacen 7/7/7 (28) oral tablet 6 ACA

amethia lo oral tablets,dose pack,3 month 6 ACA; QL

amethia oral tablets,dose pack,3 month 6 ACA; QL

amethyst oral tablet 6 ACA

apri oral tablet 6 ACA

aranelle (28) oral tablet 6 ACA

ashlyna oral tablets,dose pack,3 month 6 ACA; QL

aubra oral tablet 6 ACA

aviane oral tablet 6 ACA

azurette (28) oral tablet 6 ACA

balziva (28) oral tablet 6 ACA


of this table.

91


bekyree (28) oral tablet 6 ACA

blisovi 24 fe oral tablet 6 ACA

blisovi fe 1.5/30 (28) oral tablet 6 ACA

blisovi fe 1/20 (28) oral tablet 6 ACA

briellyn oral tablet 6 ACA

camrese lo oral tablets,dose pack,3 month 6 ACA; QL

camrese oral tablets,dose pack,3 month 6 ACA; QL

caziant (28) oral tablet 6 ACA

chateal oral tablet 6 ACA

cryselle (28) oral tablet 6 ACA

cyclafem 1/35 (28) oral tablet 6 ACA

cyclafem 7/7/7 (28) oral tablet 6 ACA

cyred oral tablet 6 ACA

dasetta 1/35 (28) oral tablet 6 ACA

dasetta 7/7/7 (28) oral tablet 6 ACA

daysee oral tablets,dose pack,3 month 6 ACA; QL

delyla (28) oral tablet 6 ACA

desog-e.estradiol/e.estradiol oral tablet 6 ACA

desogestrel-ethinyl estradiol oral tablet 6 ACA

drospirenone-e.estradiol-lm.fa oral tablet 6 ACA

drospirenone-ethinyl estradiol oral tablet 6 ACA

econtra ez oral tablet 6 ACA; OTC

elinest oral tablet 6 ACA

ELLA ORAL TABLET 6 ACA

emoquette oral tablet 6 ACA

enpresse oral tablet 6 ACA

enskyce oral tablet 6 ACA

estarylla oral tablet 6 ACA

ethynodiol diac-eth estradiol oral tablet 6 ACA

falmina (28) oral tablet 6 ACA

fayosim oral tablets,dose pack,3 month 6 ACA; QL


of this table.

92


femynor oral tablet 6 ACA

gianvi (28) oral tablet 6 ACA

gildagia oral tablet 6 ACA

introvale oral tablets,dose pack,3 month 6 ACA; QL

isibloom oral tablet 6 ACA

jolessa oral tablets,dose pack,3 month 6 ACA; QL

juleber oral tablet 6 ACA

junel 1.5/30 (21) oral tablet 6 ACA

junel 1/20 (21) oral tablet 6 ACA

junel fe 1.5/30 (28) oral tablet 6 ACA

junel fe 1/20 (28) oral tablet 6 ACA

junel fe 24 oral tablet 6 ACA

kaitlib fe oral tablet,chewable 6 ACA

kariva (28) oral tablet 6 ACA

kelnor 1/35 (28) oral tablet 6 ACA

kimidess (28) oral tablet 6 ACA

kurvelo oral tablet 6 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month

6 ACA; QL

larin 1.5/30 (21) oral tablet 6 ACA

larin 1/20 (21) oral tablet 6 ACA

larin 24 fe oral tablet 6 ACA

larin fe 1.5/30 (28) oral tablet 6 ACA

larin fe 1/20 (28) oral tablet 6 ACA

larissia oral tablet 6 ACA

layolis fe oral tablet,chewable 6 ACA

leena 28 oral tablet 6 ACA

lessina oral tablet 6 ACA

levonest (28) oral tablet 6 ACA

levonorgestrel-ethinyl estrad oral tablet 6 ACA

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

6 ACA


of this table.

93


levonorg-eth estrad triphasic oral tablet 6 ACA

levora-28 oral tablet 6 ACA

lillow oral tablet 6 ACA

LO LOESTRIN FE ORAL TABLET 3

lomedia 24 fe oral tablet 6 ACA

loryna (28) oral tablet 6 ACA

low-ogestrel (28) oral tablet 6 ACA

lutera (28) oral tablet 6 ACA

marlissa oral tablet 6 ACA

melodetta 24 fe oral tablet,chewable 6 ACA

mibelas 24 fe oral tablet,chewable 6 ACA

microgestin 1.5/30 (21) oral tablet 6 ACA

microgestin 1/20 (21) oral tablet 6 ACA

microgestin fe 1.5/30 (28) oral tablet 6 ACA

microgestin fe 1/20 (28) oral tablet 6 ACA

MINASTRIN 24 FE ORAL

TABLET,CHEWABLE

3

mono-linyah oral tablet 6 ACA

mononessa (28) oral tablet 6 ACA

my way oral tablet 6 ACA; OTC

myzilra oral tablet 6 ACA

NATAZIA ORAL TABLET 2

necon 0.5/35 (28) oral tablet 6 ACA

necon 1/50 (28) oral tablet 6 ACA

necon 7/7/7 (28) oral tablet 6 ACA

next choice one dose oral tablet 6 ACA; OTC

nikki (28) oral tablet 6 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable 6 ACA

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg

6 ACA

norethindrone-e.estradiol-iron oral tablet 6 ACA


of this table.

94


norethindrone-e.estradiol-iron oral

tablet,chewable

6 ACA

norgestimate-ethinyl estradiol oral tablet 6 ACA

nortrel 0.5/35 (28) oral tablet 6 ACA

nortrel 1/35 (21) oral tablet 6 ACA

nortrel 1/35 (28) oral tablet 6 ACA

nortrel 7/7/7 (28) oral tablet 6 ACA

ocella oral tablet 6 ACA

ogestrel (28) oral tablet 6 ACA

opcicon one-step oral tablet 6 ACA; OTC

option-2 oral tablet 6 ACA; OTC

orsythia oral tablet 6 ACA

philith oral tablet 6 ACA

pimtrea (28) oral tablet 6 ACA

pirmella oral tablet 6 ACA

portia oral tablet 6 ACA

previfem oral tablet 6 ACA

quasense oral tablets,dose pack,3 month 6 ACA; QL

rajani oral tablet 6 ACA

reclipsen (28) oral tablet 6 ACA

rivelsa oral tablets,dose pack,3 month 6 ACA; QL

SAFYRAL ORAL TABLET 2

setlakin oral tablets,dose pack,3 month 6 ACA; QL

sprintec (28) oral tablet 6 ACA

sronyx oral tablet 6 ACA

syeda oral tablet 6 ACA

tarina fe 1/20 (28) oral tablet 6 ACA

tilia fe oral tablet 6 ACA

tri femynor oral tablet 6 ACA

tri-estarylla oral tablet 6 ACA

tri-legest fe oral tablet 6 ACA

tri-linyah oral tablet 6 ACA


of this table.

95


tri-lo-estarylla oral tablet 6 ACA

tri-lo-marzia oral tablet 6 ACA

tri-lo-sprintec oral tablet 6 ACA

trinessa (28) oral tablet 6 ACA

trinessa lo oral tablet 6 ACA

tri-previfem (28) oral tablet 6 ACA

tri-sprintec (28) oral tablet 6 ACA

trivora (28) oral tablet 6 ACA

velivet triphasic regimen (28) oral tablet 6 ACA

vestura (28) oral tablet 6 ACA

vienva oral tablet 6 ACA

viorele (28) oral tablet 6 ACA

vyfemla (28) oral tablet 6 ACA

wera (28) oral tablet 6 ACA

wymzya fe oral tablet,chewable 6 ACA

zarah oral tablet 6 ACA

zenchent (28) oral tablet 6 ACA

zovia 1/35e (28) oral tablet 6 ACA

zovia 1/50e (28) oral tablet 6 ACA

OXYTOCICS

methergine oral tablet 1

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE OPHTHALMIC (EYE) DROPS 3

bacitracin ophthalmic (eye) ointment 1

bacitracin-polymyxin b ophthalmic (eye) ointment 1

BESIVANCE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

BETADINE OPHTHALMIC PREP

OPHTHALMIC (EYE) SOLUTION

3

CILOXAN OPHTHALMIC (EYE) OINTMENT 3

ciprofloxacin hcl ophthalmic (eye) drops 1


of this table.

96


erythromycin ophthalmic (eye) ointment 1

gatifloxacin ophthalmic (eye) drops 1

gentak ophthalmic (eye) ointment 1

gentamicin ophthalmic (eye) drops 1

gentamicin ophthalmic (eye) ointment 1

levofloxacin ophthalmic (eye) drops 1

MOXEZA OPHTHALMIC (EYE) DROPS,

VISCOUS

3

moxifloxacin ophthalmic (eye) drops 1

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment

1

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops

1

neo-polycin ophthalmic (eye) ointment 1

ofloxacin ophthalmic (eye) drops 1

polycin ophthalmic (eye) ointment 1

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops

1

tobramycin ophthalmic (eye) drops 1

TOBREX OPHTHALMIC (EYE) OINTMENT 3

ANTIVIRALS

trifluridine ophthalmic (eye) drops 1

ZIRGAN OPHTHALMIC (EYE) GEL 2

BETA-BLOCKERS

betaxolol ophthalmic (eye) drops 1

BETOPTIC S OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

carteolol ophthalmic (eye) drops 1

levobunolol ophthalmic (eye) drops 0.5 % 1

metipranolol ophthalmic (eye) drops 1

timolol maleate ophthalmic (eye) drops 1


of this table.

97


timolol maleate ophthalmic (eye) gel forming

solution

3

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE OPHTHALMIC (EYE)

DROPS

3

CYCLOPLEGIC MYDRIATICS

atropine ophthalmic (eye) drops 1

atropine ophthalmic (eye) ointment 1

cyclopentolate ophthalmic (eye) drops 1

homatropaire ophthalmic (eye) drops 1

homatropine hbr ophthalmic (eye) drops 1

tropicamide ophthalmic (eye) drops 1

DIRECT ACTING MIOTICS

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

1

MISCELLANEOUS OPHTHALMOLOGICS

ALOCRIL OPHTHALMIC (EYE) DROPS 3

ALOMIDE OPHTHALMIC (EYE) DROPS 3

altacaine ophthalmic (eye) drops 1

altafluor ophthalmic (eye) drops 1

azelastine ophthalmic (eye) drops 1

BEPREVE OPHTHALMIC (EYE) DROPS 3

cromolyn ophthalmic (eye) drops 1

CYSTARAN OPHTHALMIC (EYE) DROPS 4 PA; QL

EMADINE OPHTHALMIC (EYE) DROPS 3

epinastine ophthalmic (eye) drops 1

EYLEA INTRAVITREAL SOLUTION 4 PA; LA

flucaine ophthalmic (eye) drops 1

fluorescein-proparacaine ophthalmic (eye) drops 1

flurox ophthalmic (eye) drops 1

JETREA (PF) INTRAVITREAL SOLUTION

0.125 MG/0.1 ML (1.25 MG/ML)

4 PA; QL


of this table.

98


LACRISERT OPHTHALMIC (EYE) INSERT 3 PA

LASTACAFT OPHTHALMIC (EYE) DROPS 3

LUCENTIS INTRAVITREAL SOLUTION 4 PA; LA

LUCENTIS INTRAVITREAL SYRINGE 4 PA; LA

MACUGEN INTRAVITREAL SYRINGE 4 PA; LA

olopatadine ophthalmic (eye) drops 1 ST

PAZEO OPHTHALMIC (EYE) DROPS 3

proparacaine ophthalmic (eye) drops 1

RESTASIS MULTIDOSE OPHTHALMIC (EYE)

DROPS

2 QL

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE

2 QL

tetcaine ophthalmic (eye) drops 1

tetracaine hcl (pf) ophthalmic (eye) drops 1

tetracaine hcl ophthalmic (eye) drops 1

TETRAVISC OPHTHALMIC (EYE)

DROPPERETTE,VISCOUS

3

TETRAVISC OPHTHALMIC (EYE) DROPS,

VISCOUS

3

VITRASE INJECTION SOLUTION 3

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 2 QL

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACUVAIL (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 QL

bromfenac ophthalmic (eye) drops 1

diclofenac sodium ophthalmic (eye) drops 1

flurbiprofen sodium ophthalmic (eye) drops 1

ILEVRO OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

ketorolac ophthalmic (eye) drops 1

NEVANAC OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

PROLENSA OPHTHALMIC (EYE) DROPS 3


of this table.

99


ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule, extended release 1

acetazolamide oral tablet 1

acetazolamide sodium injection recon soln 1

methazolamide oral tablet 1

OTHER GLAUCOMA DRUGS

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 ST

bimatoprost ophthalmic (eye) drops 2 ST

COMBIGAN OPHTHALMIC (EYE) DROPS 2

COSOPT (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 ST

dorzolamide ophthalmic (eye) drops 1

dorzolamide-timolol ophthalmic (eye) drops 1

latanoprost ophthalmic (eye) drops 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%

2

miostat intraocular solution 1

SIMBRINZA OPHTHALMIC (EYE)

DROPS,SUSPENSION

2

TRAVATAN Z OPHTHALMIC (EYE) DROPS 3 ST

ZIOPTAN (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 ST

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment

1

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension

1

neomycin-polymyxin b-dexameth ophthalmic (eye)

ointment

1

neomycin-polymyxin-hc ophthalmic (eye)

drops,suspension

1

neo-polycin hc ophthalmic (eye) ointment 1


of this table.

100


PRED-G OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

PRED-G S.O.P. OPHTHALMIC (EYE)

OINTMENT

3

TOBRADEX OPHTHALMIC (EYE)

OINTMENT

3

TOBRADEX ST OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

tobramycin-dexamethasone ophthalmic (eye)

drops,suspension

1

ZYLET OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

STEROIDS

ALREX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

dexamethasone sodium phosphate ophthalmic

(eye) drops

1

DUREZOL OPHTHALMIC (EYE) DROPS 2

FLAREX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

fluorometholone ophthalmic (eye)

drops,suspension

1

FML FORTE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 3

ILUVIEN INTRAVITREAL IMPLANT 4 PA; LA; QL

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 3

LOTEMAX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

LOTEMAX OPHTHALMIC (EYE) OINTMENT 3

MAXIDEX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

PRED MILD OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

prednisolone acetate ophthalmic (eye)

drops,suspension

1


of this table.

101


prednisolone sodium phosphate ophthalmic (eye)

drops

1

STEROID-SULFONAMIDE COMBINATIONS

BLEPHAMIDE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)

OINTMENT

3

sulfacetamide-prednisolone ophthalmic (eye)

drops

1

SULFONAMIDES

sulfacetamide sodium ophthalmic (eye) drops 1

sulfacetamide sodium ophthalmic (eye) ointment 1

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

2

apraclonidine ophthalmic (eye) drops 1

brimonidine ophthalmic (eye) drops 0.15 % 2

brimonidine ophthalmic (eye) drops 0.2 % 1

VASOCONSTRICTOR DECONGESTANTS

phenylephrine hcl ophthalmic (eye) drops 1

RESPIRATORY, ALLERGY, COUGH & COLD

ANTIHISTAMINE & ANTIALLERGENIC AGENTS

adrenalin injection solution 1

carbinoxamine maleate oral liquid 1

carbinoxamine maleate oral tablet 1

cetirizine oral solution 1 mg/ml 1

clemastine oral tablet 2.68 mg 1

cyproheptadine oral syrup 1

cyproheptadine oral tablet 1

diphenhydramine hcl injection solution 50 mg/ml 1

diphenhydramine hcl injection syringe 1


of this table.

102


EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.3 ML, 0.3 MG/0.3 ML (generic

EpiPen)

1

epinephrine injection solution 1

epinephrine injection syringe 0.1 mg/ml 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 2

EPIPEN JR 2-PAK INJECTION AUTO-

INJECTOR

2

hydroxyzine hcl intramuscular solution 1

hydroxyzine hcl oral solution 10 mg/5 ml 1

hydroxyzine hcl oral tablet 1

hydroxyzine pamoate oral capsule 1

levocetirizine oral solution 1

levocetirizine oral tablet 1

phenadoz rectal suppository 1

phenergan rectal suppository 12.5 mg, 25 mg 1

phenergan rectal suppository 50 mg 3

promethazine injection solution 1

promethazine oral syrup 1

promethazine oral tablet 1

promethazine rectal suppository 12.5 mg, 25 mg 1

promethazine rectal suppository 50 mg 3

promethegan rectal suppository 12.5 mg, 25 mg 1

promethegan rectal suppository 50 mg 3

COUGH & COLD THERAPY

benzonatate oral capsule 100 mg, 200 mg 1

brompheniramine-pseudoeph-dm oral syrup 1

centergy oral drops 1

cheratussin ac oral liquid 1

codeine-guaifenesin oral liquid 1

FLOWTUSS ORAL SOLUTION 3

g tussin ac oral liquid 1


of this table.

103


guaiatussin ac oral liquid 1

guaifenesin ac oral liquid 1

guaifenesin dac oral syrup 1

hydrocodone-chlorpheniramine oral

suspension,extended rel 12 hr

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5

ml

1

hydrocodone-homatropine oral tablet 1

hydromet oral syrup 1

lortuss ex oral syrup 1

m-clear wc oral liquid 1

promethazine vc-codeine oral syrup 1

promethazine-codeine oral syrup 1

promethazine-dm oral syrup 1

promethazine-phenyleph-codeine oral syrup 1

promethazine-phenylephrine oral syrup 1

relcof c oral liquid 1

rydex oral liquid 1

tusnel c oral syrup 1

tussigon oral tablet 1

virtussin ac oral liquid 1

virtussin dac oral syrup 1

PULMONARY AGENTS

acetylcysteine solution 1

ADCIRCA ORAL TABLET 4 PA; QL

ADEMPAS ORAL TABLET 4 PA; LA; QL

ADRENALIN NASAL SOLUTION 3

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE

2

ADVAIR HFA INHALATION HFA AEROSOL

INHALER

2

albuterol sulfate inhalation solution for

nebulization

1


of this table.

104


albuterol sulfate oral syrup 1

albuterol sulfate oral tablet 1

albuterol sulfate oral tablet extended release 12 hr 1

ALVESCO INHALATION HFA AEROSOL

INHALER

3 ST

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE

2

ARCAPTA NEOHALER INHALATION

CAPSULE, W/INHALATION DEVICE

3 ST

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE

2

ASMANEX HFA INHALATION HFA

AEROSOL INHALER

2

ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED

2

ATROVENT HFA INHALATION HFA

AEROSOL INHALER

3

BERINERT INTRAVENOUS KIT 4 PA; LA

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE

2

BROVANA INHALATION SOLUTION FOR

NEBULIZATION

3

budesonide inhalation suspension for nebulization 1

budesonide nasal spray,non-aerosol 1

CINRYZE INTRAVENOUS RECON SOLN 4 PA; LA; QL

COMBIVENT RESPIMAT INHALATION MIST 2

cromolyn inhalation solution for nebulization 1

DALIRESP ORAL TABLET 3 PA

ESBRIET ORAL CAPSULE 4 PA; LA; QL

ESBRIET ORAL TABLET 4 PA; LA; QL

FIRAZYR SUBCUTANEOUS SYRINGE 4 PA; LA; QL

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE

2

FLOVENT HFA INHALATION HFA AEROSOL

INHALER

2


of this table.

105


flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)

1

fluticasone nasal spray,suspension 1

FLUTICASONE-SALMETEROL INHALATION


1

HAEGARDA SUBCUTANEOUS RECON SOLN 4 PA; LA

HYPER-SAL INHALATION SOLUTION FOR

NEBULIZATION 3.5 %

2

INCRUSE ELLIPTA INHALATION BLISTER

WITH DEVICE

2

ipratropium bromide inhalation solution 1

ipratropium-albuterol inhalation solution for

nebulization

1

KALBITOR SUBCUTANEOUS SOLUTION 4 PA; LA

KALYDECO ORAL GRANULES IN PACKET 4 PA; LA; QL

KALYDECO ORAL TABLET 4 PA; LA; QL

LETAIRIS ORAL TABLET 4 PA; LA; QL

levalbuterol hcl inhalation solution for

nebulization

1

LEVALBUTEROL TARTRATE INHALATION

HFA AEROSOL INHALER

3 PA; QL

metaproterenol oral syrup 1

metaproterenol oral tablet 1

montelukast oral granules in packet 1 QL

montelukast oral tablet 1 QL

montelukast oral tablet,chewable 1 QL

nebusal inhalation solution for nebulization 3 % 1

NEBUSAL INHALATION SOLUTION FOR

NEBULIZATION 6 %

2

NUCALA SUBCUTANEOUS RECON SOLN 4 PA; LA; QL

OFEV ORAL CAPSULE 4 PA; LA; QL

OPSUMIT ORAL TABLET 4 PA; LA; QL

ORKAMBI ORAL TABLET 4 PA; LA; QL


of this table.

106


PERFOROMIST INHALATION SOLUTION

FOR NEBULIZATION

3

PROAIR HFA INHALATION HFA AEROSOL

INHALER

3 PA; QL

PROVENTIL HFA INHALATION HFA

AEROSOL INHALER

3 PA; QL

pulmosal inhalation solution for nebulization 1

PULMOZYME INHALATION SOLUTION 4 PA; LA; QL

QVAR INHALATION AEROSOL 3 PA

RUCONEST INTRAVENOUS RECON SOLN 4 PA; LA

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE

2

sildenafil (antihypertensive) oral tablet 4 PA; QL

sodium chloride inhalation solution for

nebulization 10 %, 3 %, 7 %

1

SPIRIVA RESPIMAT INHALATION MIST 2

SPIRIVA WITH HANDIHALER INHALATION

CAPSULE, W/INHALATION DEVICE

2

STIOLTO RESPIMAT INHALATION MIST 2

STRIVERDI RESPIMAT INHALATION MIST 3

terbutaline oral tablet 1

terbutaline subcutaneous solution 1

theochron oral tablet extended release 12 hr 1

theophylline oral elixir 1

theophylline oral solution 1

theophylline oral tablet extended release 12 hr 1

theophylline oral tablet extended release 24 hr 1

TRACLEER ORAL TABLET 4 PA; LA; QL

TUDORZA PRESSAIR INHALATION


3 PA

TYVASO INHALATION SOLUTION FOR

NEBULIZATION

4 PA; LA

TYVASO REFILL KIT INHALATION

SOLUTION FOR NEBULIZATION

4 PA; LA


of this table.

107


TYVASO STARTER KIT INHALATION

SOLUTION FOR NEBULIZATION

4 PA; LA

VENTAVIS INHALATION SOLUTION FOR

NEBULIZATION

4 PA; LA

VENTOLIN HFA INHALATION HFA

AEROSOL INHALER

2 QL

XOLAIR SUBCUTANEOUS RECON SOLN 4 PA; LA; QL

XOPENEX HFA INHALATION HFA AEROSOL

INHALER

3 PA; QL

zafirlukast oral tablet 1

zileuton oral tablet, er multiphase 12 hr 4 ST; QL

ZYFLO CR ORAL TABLET, ER MULTIPHASE

12 HR

4 ST; QL

UROLOGICALS

ANTICHOLINERGICS & ANTISPASMODICS

darifenacin oral tablet extended release 24 hr 3 ST

flavoxate oral tablet 1

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HR

2 QL

oxybutynin chloride oral syrup 1

oxybutynin chloride oral tablet 1

oxybutynin chloride oral tablet extended release

24hr

1

tolterodine oral capsule,extended release 24hr 1

tolterodine oral tablet 1

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HR

2

trospium oral capsule,extended release 24hr 1

trospium oral tablet 1

VESICARE ORAL TABLET 2

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

alfuzosin oral tablet extended release 24 hr 1

CIALIS ORAL TABLET 5 MG 3 PA; QL

dutasteride oral capsule 3


of this table.

108


dutasteride-tamsulosin oral capsule, er multiphase

24 hr

3

finasteride oral tablet 5 mg 1

RAPAFLO ORAL CAPSULE 3 ST

tamsulosin oral capsule,extended release 24hr 1

CHOLINERGIC STIMULANTS

bethanechol chloride oral tablet 1

MISCELLANEOUS UROLOGICALS

CYSTAGON ORAL CAPSULE 4

cytra k crystals oral packet 1

cytra-2 oral solution 1

cytra-3 oral solution 1

cytra-k oral solution 1

ELMIRON ORAL CAPSULE 3

hyophen oral tablet 1

methen-sod phos-meth blue-hyos oral tablet 1

pot,sodium citrate-citric acid oral solution 1

potassium citrate oral tablet extended release 1

potassium citrate-citric acid oral packet 1

potassium citrate-citric acid oral solution 1

PROCYSBI ORAL CAPSULE, DELAYED REL

SPRINKLE

4 PA; LA; QL

sodium citrate-citric acid oral solution 1

tricitrates oral solution 1

uretron d-s oral tablet 81.6-10.8-40.8 mg 1

urin ds oral tablet 1

urogesic-blue oral tablet 1

urophen mb oral tablet 1

uryl oral tablet 1

virtrate-2 oral solution 1

virtrate-3 oral solution 1

virtrate-k oral solution 1


of this table.

109


URINARY ANESTHETICS

phenazopyridine oral tablet 100 mg, 200 mg 1

VITAMINS, HEMATINICS & ELECTROLYTES

ELECTROLYTES

calcium 500 + d oral tablet 500 mg(1,250mg) -200

unit

6 ACA; OTC

calcium 500 + d oral tablet,chewable 6 ACA; OTC

calcium 500 with d oral tablet 6 ACA; OTC

calcium 600 + d(3) oral capsule 6 ACA; OTC

calcium 600 + d(3) oral tablet 600 mg(1,500mg) -

200 unit, 600 mg(1,500mg) -400 unit

6 ACA; OTC

calcium 600 with vitamin d3 oral capsule 6 ACA; OTC

calcium 600 with vitamin d3 oral tablet,chewable 6 ACA; OTC

calcium carb and citrate-vitd3 oral tablet extended

release

6 ACA; OTC

calcium carbonate-vitamin d3 oral capsule 600

mg(1,500mg) -400 unit

6 ACA; OTC

calcium carbonate-vitamin d3 oral tablet 500

mg(1,250mg) -125 unit, 500 mg(1,250mg) -200

unit, 500 mg(1,250mg) -400 unit, 500mg

(1,250mg) -600 unit, 600 mg(1,500mg) -200 unit,

600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -

800 unit

6 ACA; OTC

calcium carbonate-vitamin d3 oral

tablet,chewable 500-100 mg-unit

6 ACA; OTC

calcium citrate + d oral tablet 6 ACA; OTC

calcium citrate-vitamin d2 oral tablet 6 ACA; OTC

calcium citrate-vitamin d3 oral tablet 6 ACA; OTC

citrus calcium oral tablet 6 ACA; OTC

effer-k oral tablet, effervescent 25 meq 1

GALZIN ORAL CAPSULE 3 PA

GLYCOPHOS INTRAVENOUS SOLUTION 3

hi-cal plus vit d oral tablet 6 ACA; OTC

k-effervescent oral tablet, effervescent 1


of this table.

110


klor-con 10 oral tablet extended release 1

klor-con 8 oral tablet extended release 1

klor-con m10 oral tablet,er particles/crystals 1



klor-con oral packet 1

klor-con sprinkle oral capsule, extended release 1

klor-con/ef oral tablet, effervescent 1

k-phos-neutral oral tablet 1

k-tab oral tablet extended release 8 meq 1

NORMOSOL-R INTRAVENOUS

PARENTERAL SOLUTION

3

oysco 500/d oral tablet 6 ACA; OTC

oyster shell + d3 oral tablet 6 ACA; OTC

oyster shell calcium-vit d3 oral tablet 6 ACA; OTC

oystercal-d oral tablet 6 ACA; OTC

phospha 250 neutral oral tablet 1

potassium acetate intravenous solution 2 meq/ml 1

potassium bicarb and chloride oral tablet,

effervescent

1

potassium bicarb-citric acid oral tablet,

effervescent

1

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution

1

potassium chloride in 0.9%nacl intravenous

parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in 5 % dex intravenous

parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

1

potassium chloride in lr-d5 intravenous parenteral

solution

1

potassium chloride intravenous piggyback 1

potassium chloride intravenous solution 1

potassium chloride oral capsule, extended release 1


of this table.

111


potassium chloride oral liquid 1

potassium chloride oral packet 1

potassium chloride oral tablet extended release 1

potassium chloride oral tablet,er particles/crystals 1

potassium chloride-0.45 % nacl intravenous

parenteral solution

1

potassium chloride-d5-0.2%nacl intravenous

parenteral solution

1


parenteral solution 20 meq/l

1


parenteral solution

1

potassium phosphate m-/d-basic intravenous

solution

1

sodium chloride 0.45 % intravenous parenteral

solution

1

sodium chloride 0.45 % intravenous piggyback 1

sodium chloride 3 % intravenous parenteral

solution

1

sodium chloride 5 % intravenous parenteral

solution

1

sodium chloride intravenous parenteral solution 1

SODIUM PHOSPHATE IN 0.9 % NACL

INTRAVENOUS SOLUTION 15 MMOL/250

ML, 7.5 MMOL/100 ML

4

sodium phosphate intravenous solution 1

virt-phos 250 neutral oral tablet 1

MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

3

PLASMA-LYTE 148 INTRAVENOUS

PARENTERAL SOLUTION

3

PLASMA-LYTE A INTRAVENOUS

PARENTERAL SOLUTION

3

VITAMINS & HEMATINICS


of this table.

112


b complex-vitamin b12 oral tablet 6 ACA; OTC

b complex-vitamin c-folic acid oral tablet 6 ACA; OTC

balanced b-100 complex oral tablet extended

release 100 mg

6 ACA; OTC

balanced b-100 oral tablet 0.4 mg 6 ACA; OTC

balanced b-50 oral tablet 6 ACA; OTC

bal-care dha oral combo pack,tablet and cap,dr 1

b-complex with vitamin c oral tablet 6 ACA; OTC

calcium pnv oral capsule 1

calcium-folic acid-vitamin d oral wafer 1

cholecalciferol (vitamin d3) oral capsule 1,000

unit

6 ACA; OTC

cholecalciferol (vitamin d3) oral drops 400 unit/ml 6 ACA; OTC

cholecalciferol (vitamin d3) oral tablet 1,000 unit,

400 unit

6 ACA; OTC

cholecalciferol (vitamin d3) oral tablet,chewable

1,000 unit

6 ACA; OTC

classic prenatal oral tablet 6 ACA; OTC

c-nate dha oral capsule 1

complete natal dha oral combo pack 1

completenate oral tablet,chewable 1

complex b-100 oral tablet extended release 6 ACA; OTC

corvita 150 oral tablet 1

cyanocobalamin (vitamin b-12) injection solution 1

DECARA ORAL CAPSULE 50,000 UNIT 3 OTC

delta d3 oral tablet 6 ACA; OTC

dialyvite 800 oral tablet 6 ACA; OTC

dialyvite oral tablet 1

dothelle dha oral capsule 1

d-vi-sol oral drops 6 ACA; OTC

elite-ob oral tablet 1

ergocalciferol (vitamin d2) oral capsule 1

ergocalciferol (vitamin d2) oral tablet 400 unit 6 ACA; OTC


of this table.

113


ferocon oral capsule 1

ferraplus 90 oral tablet 1

ferrex 150 forte oral capsule 1

ferrex 150 forte plus oral capsule 1

ferrex 28 oral tablet 1

fluor-a-day (with xylitol) oral tablet,chewable 0.25

mg f (0.55 mg)-236.79mg

6 ACA

fluor-a-day (with xylitol) oral tablet,chewable 1

mg f (2.2 mg)-236.79 mg

1

fluoride (sodium) oral drops 6 ACA

fluoride (sodium) oral tablet,chewable 0.25

mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium

fluorid)

6 ACA

fluoride (sodium) oral tablet,chewable 1 mg (2.2

mg sod. fluoride)

1

fluoritab oral tablet,chewable 0.5 mg (1.1 mg

sodium fluorid)

6 ACA

fluoritab oral tablet,chewable 1 mg (2.2 mg sod.

fluoride)

1

focalgin 90 dha oral combo pack 1

focalgin ca oral combo pack 1

focalgin dss oral tablet 1

folbee oral tablet 1

folbee plus oral tablet 5 mg 1

folbic oral tablet 1

folic acid injection solution 1

folic acid oral tablet 1 mg 1

folic acid oral tablet 400 mcg, 800 mcg 6 ACA; OTC

folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg 1

folivane-f oral capsule 1

folivane-ob oral capsule 1

folivane-plus oral capsule 1

folplex 2.2 oral tablet 1


of this table.

114


foltabs 800 oral tablet 6 ACA; OTC

full spectrum b-vitamin c oral tablet 6 ACA; OTC

FUSION PLUS ORAL CAPSULE 3

hematinic/folic acid oral tablet 1

hematogen fa oral capsule 1

hematogen forte oral capsule 1

hematogen oral capsule 1

hemenatal ob + dha oral combo pack 1

hemenatal ob oral tablet 1

hemetab oral tablet 1

hydroxocobalamin intramuscular solution 1

iferex 150 forte oral capsule 1

infed injection solution 1

kobee oral tablet 6 ACA; OTC

kpn oral tablet 6 ACA; OTC

levomefolate dha oral capsule 1

ludent fluoride oral tablet,chewable 0.25 mg(0.55

mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

6 ACA

ludent fluoride oral tablet,chewable 1 mg (2.2 mg

sod. fluoride)

1

multigen folic oral tablet 1

multigen plus oral tablet 1

multi-vit with fluoride-iron oral drops 1

multi-vitamin with fluoride oral drops 6 ACA

multi-vitamin with fluoride oral tablet,chewable

0.25 mg, 0.5 mg

6 ACA

multi-vitamin with fluoride oral tablet,chewable 1

mg

1

multivitamins with fluoride oral tablet,chewable

0.25 mg, 0.5 mg

6 ACA

multivitamins with fluoride oral tablet,chewable 1

mg

1

multivit-fluor (vit e acetate) oral drops 6 ACA


of this table.

115


mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg 6 ACA

mvc-fluoride oral tablet,chewable 1 mg 1

myferon 150 forte oral capsule 1

mynatal advance oral tablet 1

mynatal oral capsule 1

mynatal oral tablet 1

mynatal plus oral tablet 1

mynatal-z oral tablet 1

mynate 90 plus oral tablet extended release 1

mynephrocaps oral capsule 1

mynephron oral capsule 1

natural b-100 complex oral tablet 6 ACA; OTC

nephplex rx oral tablet 1

nephro-vite rx oral tablet 1

newgen oral tablet 1

NEXAVIR INJECTION SOLUTION 3

obstetrix dha oral combo pack,tablet and cap,dr 1

one daily prenatal oral combo pack 28-800-440

mg-mcg-mg

6 ACA; OTC

oyster shell calcium-vit d2 oral tablet 250 (625)-

125 mg-unit

6 ACA; OTC

perry prenatal oral capsule 6 ACA; OTC

pnv 29-1 oral tablet 1

pnv ob+dha oral combo pack 27-1-50-250 mg 1

pnv-dha + docusate oral capsule 1

pnv-dha oral capsule 1

pnv-ferrous fumarate-docu-fa oral tablet 1

pnv-omega oral capsule 1

pnv-select oral tablet 1

pnv-vp-u oral capsule 1

poly-iron 150 forte oral capsule 1

pr natal 400 ec oral combo pack,tablet and cap,dr 1


of this table.

116


pr natal 400 oral combo pack 1

pr natal 430 ec oral combo pack,tablet and cap,dr 1

pr natal 430 oral combo pack 1

prena1 chew oral tablet,chew,ir - dr,biphase 1

prenaissance oral capsule 1

prenaissance plus oral capsule 1

prenatabs fa oral tablet 1

prenatabs rx oral tablet 1

prenatal 19 oral tablet,chewable 1 OTC

prenatal complete oral tablet 6 ACA; OTC

prenatal formula oral tablet 28 mg iron- 800 mcg 6 ACA; OTC

prenatal multi-dha (algal oil) oral capsule 6 ACA; OTC

prenatal one daily oral tablet 6 ACA; OTC

prenatal oral tablet 28 mg iron- 800 mcg 6 ACA; OTC

prenatal plus (calcium carb) oral tablet 1

prenatal plus oral tablet 1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg 6 ACA; OTC

prenatal vitamin plus low iron oral tablet 1

prenatal vitamin with minerals oral tablet 6 ACA; OTC

prenatal vits96-iron fum-folic oral tablet 6 ACA; OTC

prenatal-u oral capsule 1

preplus oral tablet 1

pretab oral tablet 1

purevit dualfe plus oral capsule 1

relnate dha oral capsule 1

renal caps oral capsule 1

rena-vite oral tablet 6 ACA; OTC

rena-vite rx oral tablet 1

reno caps oral capsule 1

risacal-d oral tablet 6 ACA; OTC

se-natal 19 (with docusate) oral tablet 1


of this table.

117


se-natal 19 oral tablet,chewable 1

se-tan plus oral capsule 1

stress formula oral tablet 6 ACA; OTC

stress formula with iron oral tablet 6 ACA; OTC

stress formula with iron(sulf) oral tablet 6 ACA; OTC

super b complex-vitamin c oral tablet 6 ACA; OTC

super b maxi complex oral tablet 6 ACA; OTC

super b-50 complex plus oral tablet 6 ACA; OTC

super quints b-50 oral tablet 6 ACA; OTC

super quints oral tablet 6 ACA; OTC

superplex-t oral tablet 6 ACA; OTC

taron forte oral capsule 1

taron-c dha oral capsule 1

taron-prex prenatal-dha oral capsule 1

thrivite-19 oral tablet 1

tl gard rx oral tablet 1

tl icon oral capsule 1

tl-hem 150 oral tablet extended release 24 hr 1

total b/c oral tablet 6 ACA; OTC

tricon oral capsule 1

trigels-f forte oral capsule 1

trinatal gt oral tablet 1

trinatal rx 1 oral tablet 1

trinate oral tablet 1

triphrocaps oral capsule 1

tri-tabs dha oral combo pack 1

triveen-duo dha oral combo pack 1

tri-vit with fluoride and iron oral drops 1

tri-vitamin with fluoride oral drops 6 ACA

trust natal dha oral combo pack 1

ultimatecare one nf oral capsule 1


of this table.

118


ultimatecare one oral capsule 1

ultra b-100 complex oral tablet 6 ACA; OTC

vemavite-prx-2 oral capsule 1

VENOFER INTRAVENOUS SOLUTION 3

vinate care oral tablet,chewable 1

vinate ii oral tablet 1

vinate m oral tablet 1

vinate one oral tablet 1

virt-advance oral tablet 1

virt-c dha oral capsule 1

virt-gard oral tablet 1

virt-nate dha oral capsule 1

virt-nate oral tablet 1

virt-pn dha oral capsule 1

virt-pn oral tablet 1

virt-pn plus oral capsule 1

virt-select oral capsule 1

virt-vite forte oral tablet 1

virt-vite gt oral tablet 1

virt-vite oral tablet 1

vit 3 oral capsule 1

vit b complex-folic acid oral tablet 6 ACA; OTC

vitamin b complex oral tablet 6 ACA; OTC

vitamin d3 oral capsule 1,000 unit, 400 unit 6 ACA; OTC

vitamin d3 oral tablet 1,000 unit, 400 unit 6 ACA; OTC

vitamin d3 oral tablet,chewable 6 ACA; OTC

vitamins a,c,d and fluoride oral drops 6 ACA

vol-care rx oral tablet 1

vol-nate oral tablet 1

vol-plus oral tablet 1

vol-tab rx oral tablet 1


of this table.

119


vp-ch plus oral capsule 1

vp-ch-pnv oral capsule 1

vp-ggr-b6 oral tablet 1

vp-heme ob oral tablet 1

vp-heme one oral capsule 1

vp-vite rx oral tablet 1

zatean-ch oral capsule 1

zatean-pn dha oral capsule 1

zatean-pn plus oral capsule 1

zingiber oral tablet 1

120

Index

A abacavir .................................. 4

abacavir-lamivudine ............... 4

abacavir-lamivudine-

zidovudine .......................... 4

ABELCET .............................. 3

ABILIFY MAINTENA ........ 35

ABRAXANE ........................ 17

ABSTRAL ............................ 29

acamprosate .......................... 59

acarbose ................................ 68

acebutolol ............................. 42

acetaminophen-codeine ........ 29

acetazolamide ....................... 99

acetazolamide sodium .......... 99

acetic acid ....................... 59, 62

acetylcysteine ..................... 103

acitretin ................................. 51

ACTEMRA .......................... 86

ACTHAR H.P. ..................... 62

ACTHIB (PF) ....................... 81

ACTIMMUNE ..................... 80

ACUVAIL (PF) .................... 98

acyclovir ........................... 4, 56

acyclovir sodium .................... 4

ADACEL(TDAP

ADOLESN/ADULT)(PF) 81

ADAGEN ............................. 59

adapalene .............................. 53

adapalene-benzoyl peroxide . 53

ADCIRCA .......................... 103

ADDERALL XR .................. 35

ADDYI ................................. 35

adefovir................................... 4

ADEMPAS ......................... 103

ADLYXIN ............................ 68

adrenalin ............................. 101

ADRENALIN..................... 103

adriamycin ............................ 17

adrucil ................................... 17

ADVAIR DISKUS ............. 103

ADVAIR HFA ................... 103

AEROCHAMBER MINI ..... 63

AEROCHAMBER PLUS

FLOW-VU ....................... 63

AEROCHAMBER PLUS Z

STAT SM MSK ............... 64

afeditab cr ............................. 42

AFINITOR ........................... 17

AFINITOR DISPERZ .......... 17

AFLURIA 2017-2018 .......... 81

AFLURIA 2017-2018 (PF) .. 81


.......................................... 81


(PF) ................................... 81

AFREZZA ............................ 64

AKYNZEO ........................... 72

ala-cort .................................. 56

ALBENZA ........................... 10

albuterol sulfate .......... 103, 104

alclometasone ....................... 56

ALDURAZYME .................. 66

ALECENSA ......................... 17

alendronate ..................... 59, 86

ALFERON N ........................ 80

alfuzosin ............................. 107

ALIMTA .............................. 17

ALINIA ................................ 10

allopurinol ............................ 85

allopurinol sodium ................ 85

almotriptan malate ................ 27

ALOCRIL ............................. 97

ALOMIDE............................ 97

alophen ................................. 72

aloprim.................................. 85

alosetron ............................... 72

ALOXI.................................. 72

ALPHAGAN P ................... 101

alprazolam ............................ 36

alprazolam intensol............... 35

ALREX ............................... 100

ALTABAX ........................... 55

altacaine ................................ 97

altafluor ................................ 97

altavera (28) .......................... 90

ALUNBRIG ......................... 17

ALVESCO.......................... 104

alyacen 1/35 (28) .................. 90

alyacen 7/7/7 (28) ................. 90

amabelz ................................. 88

amantadine hcl ........................ 4

AMBISOME .......................... 3

amcinonide ........................... 56

amethia ................................. 90

amethia lo ............................. 90

amethyst ................................ 90

amifostine crystalline............ 17

amikacin ............................... 10

amiloride ............................... 42

amiloride-hydrochlorothiazide

.......................................... 42

aminocaproic acid ................. 47

amiodarone ........................... 41

AMITIZA ............................. 72

amitriptyline ......................... 36

amitriptyline-chlordiazepoxide

.......................................... 36

amlodipine ............................ 42

amlodipine-benazepril .......... 42

ammonium lactate ................ 52

amnesteem ............................ 53

amoxapine............................. 36

amoxicil-clarithromy-lansopraz

.......................................... 77

amoxicillin ...................... 13, 14

amoxicillin-pot clavulanate .. 14

amphotericin b ........................ 3

ampicillin .............................. 14

ampicillin sodium ................. 14

ampicillin-sulbactam ............ 14

AMPYRA ............................. 28

ANADROL-50 ..................... 66

anagrelide ............................. 59

anaspaz ................................. 71

anastrozole ............................ 17

ANDRODERM .................... 66

ANDROGEL ........................ 66

ANORO ELLIPTA ............. 104

anucort-hc ............................. 72

ANZEMET ........................... 72

APIDRA ............................... 64

APIDRA SOLOSTAR.......... 64

APOKYN ............................. 26

apraclonidine ...................... 101

aprepitant .............................. 72

apri ........................................ 90

APRISO ................................ 72

APTIOM ............................... 24

APTIVUS ............................... 4

ARALAST NP...................... 59

121

aranelle (28).......................... 90

ARANESP (IN

POLYSORBATE) ............ 78

ARCALYST ......................... 80

ARCAPTA NEOHALER ... 104

aripiprazole ........................... 36

ARISTADA .......................... 36

armodafinil ........................... 36

ARMOUR THYROID ......... 70

ARNUITY ELLIPTA ......... 104

ARRANON .......................... 17

ASACOL HD ....................... 72

ascomp with codeine ............ 29

ashlyna .................................. 90

ASMANEX HFA ............... 104

ASMANEX TWISTHALER

........................................ 104

aspir-81 ................................. 33

aspirin ................................... 33

aspirin low dose .................... 33

aspirin-dipyridamole ............ 47

aspir-low ............................... 33

aspir-trin ............................... 33

astramorph-pf ....................... 29

atenolol ................................. 42

atenolol-chlorthalidone......... 42

ATGAM ............................... 81

atomoxetine .......................... 36

atorvastatin ........................... 49

atovaquone ........................... 10

atovaquone-proguanil ........... 10

ATRIPLA ............................... 4

atropine ........................... 71, 97

ATROVENT HFA ............. 104

AUBAGIO ........................... 79

aubra ..................................... 90

AUGMENTIN ...................... 14

AURYXIA ........................... 72

AUSTEDO ........................... 28

AVAR................................... 53

AVAR LS ............................. 53

AVASTIN ............................ 17

AVEED ................................ 66

AVELOX IN NACL (ISO-

OSMOTIC)....................... 15

aviane ................................... 90

avita ...................................... 53

avo cream ............................. 52

AVONEX ............................. 79

AVONEX (WITH ALBUMIN)

.......................................... 79

AZACTAM IN DEXTROSE

(ISO-OSM) ....................... 10

AZASITE ............................. 95

azathioprine .......................... 17

azathioprine sodium ............. 17

azelastine ........................ 61, 97

azithromycin ........................... 9

AZOPT ................................. 99

aztreonam ............................. 10

azurette (28) .......................... 90

B b complex-vitamin b12 ....... 112

b complex-vitamin c-folic acid

........................................ 112

baciim ................................... 10

bacitracin ........................ 10, 95

bacitracin-polymyxin b......... 95

baclofen ................................ 28

balanced b-100 ................... 112

balanced b-100 complex ..... 112

balanced b-50 ..................... 112

bal-care dha ........................ 112

balsalazide ............................ 72

balziva (28) ........................... 90

BANZEL .............................. 24

BARACLUDE........................ 4

BASAGLAR KWIKPEN ..... 64

bayer aspirin ......................... 33

BCG VACCINE, LIVE (PF) 81

b-complex with vitamin c ... 112

bekyree (28) .......................... 91

belladonna alkaloids-opium . 71

belladonna-opium ................. 71

benazepril ............................. 42

benazepril-hydrochlorothiazide

.......................................... 42

BENLYSTA ......................... 86

benzonatate ......................... 102

benztropine ........................... 26

BEPREVE ............................ 97

BERINERT ........................ 104

BESIVANCE........................ 95

BETADINE OPHTHALMIC

PREP ................................ 95

betamethasone acet,sod phos 62

betamethasone dipropionate . 56

betamethasone valerate... 56, 57

betamethasone, augmented ... 57

BETASERON....................... 79

betaxolol ......................... 42, 96

bethanechol chloride ........... 108

BETHKIS ............................. 10

BETOPTIC S ........................ 96

bexarotene............................. 18

bicalutamide ......................... 18

BICILLIN C-R ..................... 14

BICILLIN L-A ..................... 14

BICNU .................................. 18

BILTRICIDE ........................ 10

bimatoprost ........................... 99

BIOTHRAX ......................... 81

bisacodyl ............................... 72

bisa-lax ................................. 73

bisoprolol fumarate ............... 42

bisoprolol-hydrochlorothiazide

.......................................... 42

bivalirudin............................. 47

BIVIGAM............................. 81

bleo 15k ................................ 18

bleomycin ............................. 18

BLEPHAMIDE .................. 101

BLEPHAMIDE S.O.P. ....... 101

blisovi 24 fe .......................... 91

blisovi fe 1.5/30 (28) ............ 91

blisovi fe 1/20 (28) ............... 91

BOOSTRIX TDAP ............... 81

BOSULIF ............................. 18

BOTOX ................................ 81

BREO ELLIPTA ................ 104

briellyn .................................. 91

BRILINTA ........................... 47

brimonidine......................... 101

BRIVIACT ........................... 24

bromfenac ............................. 98

bromocriptine ....................... 26

brompheniramine-pseudoeph-

dm ................................... 102

BROVANA ........................ 104

budesonide .................... 73, 104

bumetanide ........................... 42

BUNAVAIL ......................... 33

BUPHENYL ......................... 59

BUPRENEX ......................... 29

BUPRENORPHINE ............. 29

buprenorphine hcl ................. 29

buprenorphine-naloxone ....... 33

bupropion hcl ........................ 36

122

bupropion hcl (smoking deter)

.......................................... 60

buspirone .............................. 36

busulfan ................................ 18

BUSULFEX ......................... 18

butalbital compound w/codeine

.......................................... 29

butalbital-acetaminop-caf-cod

.......................................... 29

butalbital-acetaminophen ..... 30

butalbital-acetaminophen-caff

.......................................... 30

butalbital-aspirin-caffeine .... 30

butorphanol tartrate .............. 33

BUTRANS ........................... 30

BYDUREON ........................ 68

BYETTA .............................. 68

BYSTOLIC .......................... 42

BYVALSON ........................ 42

C cabergoline ........................... 66

CABOMETYX..................... 18

calcipotriene ......................... 51

calcitonin (salmon) ............... 66

calcitrene .............................. 51

calcitriol .......................... 51, 66

calcium 500 + d .................. 109

calcium 500 with d ............. 109

calcium 600 + d(3) ............. 109

calcium 600 with vitamin d3

........................................ 109

calcium acetate ..................... 73

calcium carb and citrate-vitd3

........................................ 109

calcium carbonate-vitamin d3

........................................ 109

calcium citrate + d .............. 109

calcium citrate-vitamin d2 .. 109

calcium citrate-vitamin d3 .. 109

calcium pnv ........................ 112

calcium-folic acid-vitamin d

........................................ 112

CALDOLOR ........................ 33

camila ................................... 88

camrese ................................. 91

camrese lo ............................. 91

CANASA ............................. 73

CANCIDAS ........................... 3

candesartan ........................... 42

candesartan-hydrochlorothiazid

.......................................... 42

capacet .................................. 30

CAPASTAT ......................... 10

capecitabine .......................... 18

CAPRELSA.......................... 18

captopril ................................ 42

captopril-hydrochlorothiazide

.......................................... 42

CARAFATE ......................... 77

CARBAGLU ........................ 59

carbamazepine ...................... 24

carbidopa .............................. 26

carbidopa-levodopa ........ 26, 27

carbidopa-levodopa-

entacapone ........................ 27

carbinoxamine maleate ....... 101

carboplatin ............................ 18

CARIMUNE NF

NANOFILTERED............ 81

carisoprodol .......................... 28

carisoprodol-aspirin .............. 29

carteolol ................................ 96

cartia xt ................................. 42

carvedilol .............................. 42

caspofungin ............................ 3

CASPOFUNGIN .................... 3

CAYA CONTOURED ......... 87

CAYSTON ........................... 10

caziant (28) ........................... 91

CEDAX .................................. 7

cefaclor ................................... 7

cefadroxil ................................ 7

cefazolin ................................. 8

CEFAZOLIN IN 0.9% SOD

CHLORIDE ........................ 8

cefazolin in dextrose (iso-os) . 8

CEFAZOLIN IN DEXTROSE

5 % ...................................... 8

cefdinir.................................... 8

cefditoren pivoxil ................... 8

cefepime ................................. 8

CEFEPIME IN DEXTROSE 5

% ......................................... 8

cefepime in dextrose,iso-osm . 8

cefixime .................................. 8

cefotaxime .............................. 8

cefotetan ................................. 8

cefoxitin .................................. 8

cefoxitin in dextrose, iso-osm 8

cefpodoxime ........................... 8

cefprozil .................................. 8

ceftazidime ............................. 8

CEFTAZIDIME IN D5W....... 8

CEFTIN .................................. 8

ceftriaxone .............................. 9

ceftriaxone in dextrose,iso-os . 8

cefuroxime axetil .................... 9

cefuroxime sodium ................. 9

celecoxib ............................... 33

CELLCEPT .......................... 18

CELLCEPT INTRAVENOUS

.......................................... 18

CELONTIN .......................... 24

centergy .............................. 102

cephalexin ............................... 9

CERDELGA ......................... 66

CEREZYME......................... 66

CESAMET ........................... 73

cetirizine ............................. 101

cevimeline............................. 59

CHANTIX ............................ 60

CHANTIX CONTINUING

MONTH BOX .................. 60

CHANTIX STARTING

MONTH BOX .................. 60

chateal ................................... 91

CHEMET .............................. 59

cheratussin ac...................... 102

children's aspirin ................... 33

chloramphenicol sod succinate

.......................................... 11

chlordiazepoxide hcl ............. 36

chlordiazepoxide-clidinium .. 71

chlorhexidine gluconate ........ 61

chloroquine phosphate .......... 11

chlorothiazide ....................... 42

chlorothiazide sodium .......... 42

chlorpromazine ..................... 36

chlorpropamide ..................... 69

chlorthalidone ....................... 42

chlorzoxazone ....................... 29

cholecalciferol (vitamin d3)112

cholestyramine (with sugar) . 49

cholestyramine light ............. 49

choline,magnesium salicylate

.......................................... 33

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 66

123

CIALIS ............................... 107

ciclodan ................................ 55

ciclopirox .............................. 55

cidofovir ................................. 4

cilostazol............................... 47

CILOXAN ............................ 95

cimetidine ............................. 77

cimetidine hcl ....................... 77

CIMZIA ................................ 73

CINRYZE........................... 104

CIPRO .................................. 15

CIPRO HC............................ 62

CIPRODEX .......................... 62

ciprofloxacin......................... 15

ciprofloxacin (mixture) ........ 15

ciprofloxacin hcl ....... 15, 62, 95

ciprofloxacin in 5 % dextrose

.......................................... 15

ciprofloxacin lactate ............. 15

cisplatin ................................ 18

citalopram ............................. 36

citrate of magnesia ............... 73

citroma .................................. 73

citrus calcium ..................... 109

cladribine .............................. 18

claravis ................................. 53

clarithromycin ........................ 9

classic prenatal ................... 112

clearlax ................................. 73

clemastine ........................... 101

clindacin p ............................ 53

clindamycin hcl .................... 11

CLINDAMYCIN IN 0.9 %

SOD CHLOR ................... 11

clindamycin in 5 % dextrose 11

clindamycin palmitate hcl .... 11

clindamycin pediatric ........... 11

clindamycin phosphate .. 11, 53,

89

clindamycin-benzoyl peroxide

.......................................... 53

clindamycin-tretinoin ........... 53

clobetasol .............................. 57

CLODERM .......................... 57

clomipramine ........................ 36

clonazepam ........................... 24

clonidine ............................... 42

clonidine hcl ................... 36, 42

clopidogrel ............................ 47

clorazepate dipotassium ....... 36

clotrimazole ............................ 3

clotrimazole-betamethasone . 55

clozapine ............................... 36

CLOZAPINE ........................ 36

c-nate dha ........................... 112

COARTEM .......................... 11

codeine sulfate ...................... 30

codeine-guaifenesin ............ 102

COLCRYS............................ 85

colestipol .............................. 49

colistin (colistimethate na) ... 11

colocort ................................. 73

COLY-MYCIN S ................. 62

COMBIGAN ........................ 99

COMBIPATCH .................... 88

COMBIVENT RESPIMAT 104

COMETRIQ ......................... 18

COMPLERA .......................... 4

complete natal dha .............. 112

completenate ....................... 112

complex b-100 .................... 112

compro .................................. 73

CONCEPTROL .................... 89

CONCERTA ........................ 37

constulose ............................. 73

COPAXONE ........................ 79

CORLANOR ........................ 50

cormax .................................. 57

cortisone ............................... 62

CORTISPORIN .................... 55

corvita 150 .......................... 112

COSENTYX ......................... 51

COSENTYX (2 SYRINGES)

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

COSENTYX PEN ................ 51

COSENTYX PEN (2 PENS) 51

COSOPT (PF)....................... 99

COTELLIC ........................... 18

covaryx ................................. 88

covaryx h.s............................ 88

CREON ................................ 73

CRESEMBA .......................... 3

CRINONE ............................ 88

CRIXIVAN ............................ 4

cromolyn ................. 73, 97, 104

cryselle (28) .......................... 91

CUBICIN.............................. 11

CUVPOSA ........................... 71

cyanocobalamin (vitamin b-12)

........................................ 112

cyclafem 1/35 (28) ................ 91

cyclafem 7/7/7 (28)............... 91

cyclobenzaprine .................... 29

cyclopentolate ....................... 97

cyclophosphamide ................ 18

CYCLOPHOSPHAMIDE .... 18

CYCLOSERINE................... 11

CYCLOSET ......................... 69

cyclosporine .......................... 18

cyclosporine modified .......... 18

cyproheptadine ................... 101

cyred ..................................... 91

CYSTADANE ...................... 73

CYSTAGON ...................... 108

CYSTARAN......................... 97

cytarabine ............................. 18

cytarabine (pf) ...................... 18

cytra k crystals .................... 108

cytra-2 ................................. 108

cytra-3 ................................. 108

cytra-k ................................. 108

D dacarbazine ........................... 18

DAKLINZA ........................... 4

DALIRESP ......................... 104

danazol .................................. 67

dantrolene ............................. 29

dapsone ................................. 11

DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 81

daptomycin ........................... 11

DARAPRIM ......................... 11

darifenacin .......................... 107

dasetta 1/35 (28) ................... 91

dasetta 7/7/7 (28) .................. 91

daunorubicin ......................... 18

daysee ................................... 91

deblitane ............................... 88

DECARA ............................ 112

delta d3 ............................... 112

deltasone ............................... 62

delyla (28) ............................. 91

DELZICOL........................... 73

demeclocycline ..................... 16

DEMEROL ........................... 30

demerol (pf) .......................... 30

DEMEROL (PF) ................... 30

DEMSER .............................. 42

denta 5000 plus ..................... 61

dentagel................................. 61

124

DEPEN TITRATABS .......... 86

DEPO-ESTRADIOL ............ 88

DEPO-MEDROL ................. 62

DESCOVY ............................. 4

desipramine .......................... 37

desmopressin ........................ 67

desog-e.estradiol/e.estradiol . 91

desogestrel-ethinyl estradiol . 91

desonide ................................ 57

desoximetasone .................... 57

DESVENLAFAXINE .......... 37

DESVENLAFAXINE

FUMARATE .................... 37

desvenlafaxine succinate ...... 37

dexamethasone ..................... 62

dexamethasone intensol........ 62

dexamethasone sodium

phosphate ............ 62, 63, 100

DEXILANT .......................... 77

dexmethylphenidate ............. 37

dexrazoxane hcl .................... 17

dextroamphetamine .............. 37

dextroamphetamine-

amphetamine .................... 37

dialyvite .............................. 112

dialyvite 800 ....................... 112

diazepam......................... 24, 37

diazepam intensol ................. 37

diclofenac potassium ............ 33

diclofenac sodium .... 33, 34, 98

diclofenac-misoprostol ......... 34

dicloxacillin .......................... 14

dicyclomine .......................... 71

didanosine............................... 4

DIFICID ................................. 9

diflorasone ............................ 57

diflunisal ............................... 34

digitek ................................... 46

digox ..................................... 46

digoxin .................................. 47

dihydroergotamine ............... 27

DILANTIN ........................... 24

diltiazem ......................... 42, 43

dilt-xr .................................... 43

dimenhydrinate ..................... 73

DIPENTUM ......................... 73

diphenhydramine hcl .......... 101

diphenoxylate-atropine ......... 71

dipyridamole......................... 47

diskets ................................... 30

disopyramide phosphate ....... 41

disulfiram.............................. 59

DIURIL ................................ 43

divalproex ....................... 24, 25

dofetilide ............................... 41

donepezil .............................. 28

DORIBAX ............................ 11

DORIPENEM ....................... 11

dorzolamide .......................... 99

dorzolamide-timolol ............. 99

dothelle dha ........................ 112

doxazosin .............................. 43

doxepin ........................... 37, 52

doxercalciferol ...................... 67

doxorubicin ..................... 18, 19

doxorubicin, peg-liposomal .. 19

doxy-100 ............................... 16

doxycycline hyclate .............. 16

doxycycline monohydrate .... 16

drithocreme hp ...................... 51

dronabinol ............................. 73

droperidol ............................. 73

drospirenone-e.estradiol-lm.fa

.......................................... 91

drospirenone-ethinyl estradiol

.......................................... 91

DUAVEE.............................. 88

ducodyl ................................. 73

duloxetine ............................. 37

DUOPA ................................ 27

DUPIXENT .......................... 52

duramorph (pf) ..................... 30

DUREZOL ......................... 100

dutasteride .......................... 107

dutasteride-tamsulosin ........ 108

DUZALLO ........................... 85

d-vi-sol................................ 112

DYRENIUM ........................ 43

DYSPORT ............................ 81

E e.c. prin ................................. 34

e.e.s. 400 ................................. 9

EASIVENT HOLDING

CHAMBER ...................... 64

econazole .............................. 56

econtra ez .............................. 91

ecotrin ................................... 34

ecotrin low strength .............. 34

EDARBI ............................... 43

EDARBYCLOR ................... 43

ed-spaz .................................. 71

EDURANT ............................. 5

eemt ...................................... 88

eemt hs .................................. 88

effer-k ................................. 109

ELAPRASE .......................... 67

ELELYSO ............................ 67

eletriptan hbr ......................... 27

ELIDEL ................................ 52

ELIGARD............................. 19

ELIGARD (3 MONTH) ....... 19



elinest .................................... 91

eliphos................................... 73

ELIQUIS............................... 47

ELITEK ................................ 17

elite-ob ................................ 112

ELLA .................................... 91

ELMIRON .......................... 108

EMADINE ............................ 97

EMBEDA ............................. 30

EMCYT ................................ 19

EMEND ................................ 73

EMEND (FOSAPREPITANT)

.......................................... 73

EMFLAZA ........................... 63

emoquette ............................. 91

EMSAM ............................... 37

EMTRIVA .............................. 5

enalapril maleate ................... 43

enalaprilat ............................. 43

enalapril-hydrochlorothiazide

.......................................... 43

ENBREL............................... 86

ENBREL SURECLICK ....... 86

endocet .................................. 30

ENGERIX-B (PF) ................ 81

ENGERIX-B PEDIATRIC

(PF) ................................... 81

enoxaparin ............................ 47

enpresse ................................ 91

enskyce ................................. 91

entacapone ............................ 27

entecavir ................................. 5

ENTRESTO .......................... 50

ENTYVIO ............................ 73

enulose .................................. 73

EPCLUSA .............................. 5

epinastine .............................. 97

125

epinephrine ......................... 102

EPINEPHRINE .................. 102

EPIPEN 2-PAK .................. 102

EPIPEN JR 2-PAK ............. 102

epirubicin .............................. 19

epitol ..................................... 25

EPIVIR HBV.......................... 5

eplerenone ............................ 43

EPOGEN .............................. 78

epoprostenol (glycine) .......... 43

eprosartan ............................. 43

ERAXIS(WATER DILUENT)

............................................ 3

ERBITUX............................. 19

ergocalciferol (vitamin d2) . 112

ergoloid................................. 37

ERGOMAR .......................... 27

ERIVEDGE .......................... 19

errin ...................................... 88

ery pads ................................ 53

ERYPED 200 ....................... 10

ERYPED 400 ....................... 10

ery-tab................................... 10

ERYTHROCIN .................... 10

erythrocin (as stearate) ......... 10

erythromycin .................. 10, 96

erythromycin ethylsuccinate 10

erythromycin with ethanol ... 53

ESBRIET ............................ 104

escitalopram oxalate ............. 37

esmolol ................................. 43

esomeprazole sodium ........... 77

estarylla ................................ 91

estazolam .............................. 37

ESTRACE ............................ 88

estradiol ................................ 88

estradiol valerate .................. 88

estradiol-norethindrone acet . 88

ESTROGEL ......................... 88

estrogens-methyltestosterone88

estropipate ............................ 88

eszopiclone ........................... 37

ethacrynic acid...................... 43

ethambutol ............................ 11

ethosuximide ........................ 25

ethyl chloride ........................ 54

ethynodiol diac-eth estradiol 91

etidronate disodium .............. 59

etodolac ................................ 34

ETOPOPHOS ....................... 19

etoposide ............................... 19

EUCRISA ............................. 52

EUFLEXXA ......................... 34

EURAX ................................ 58

EVOTAZ ................................ 5

EVZIO .................................. 34

EXELDERM ........................ 56

exemestane ........................... 19

EXJADE ............................... 59

EYLEA ................................. 97

ezetimibe .............................. 49

F FABRAZYME ..................... 67

FACTIVE ............................. 15

falmina (28) .......................... 91

famciclovir.............................. 5

famotidine ....................... 77, 78

famotidine (pf) ...................... 77

famotidine (pf)-nacl (iso-os) 77

FANAPT .............................. 37

FARESTON ......................... 19

FARXIGA ............................ 69

FARYDAK ........................... 19

FASLODEX ......................... 19

fayosim ................................. 91

FC2 FEMALE CONDOM ... 87

felbamate .............................. 25

felodipine .............................. 43

fem ph ................................... 89

FEMCAP .............................. 87

FEMRING ............................ 88

femynor ................................ 92

fenofibrate ............................ 49

fenofibrate micronized ......... 49

fenofibrate nanocrystallized . 49

fenofibric acid....................... 49

fenofibric acid (choline) ....... 49

fenoprofen ............................ 34

fentanyl ................................. 30

fentanyl citrate ...................... 30

fentanyl citrate (pf) ............... 30

FENTORA............................ 30

ferocon ................................ 113

ferraplus 90 ......................... 113

ferrex 150 forte ................... 113

ferrex 150 forte plus ........... 113

ferrex 28 ............................. 113

FERRIPROX ........................ 59

FETZIMA ............................. 38

FINACEA ....................... 53, 54

finasteride ........................... 108

FIRAZYR ........................... 104

FIRMAGON KIT W

DILUENT SYRINGE ...... 19

FLAREX............................. 100

flavoxate ............................. 107

FLEBOGAMMA DIF .......... 82

flecainide .............................. 41

fleet laxative ......................... 73

FLOLAN .............................. 43

FLOVENT DISKUS .......... 104

FLOVENT HFA ................. 104

FLOWTUSS ....................... 102

floxin..................................... 62

floxuridine ............................ 19

FLUAD 2017-2018 (65 YR

UP)(PF)............................. 82

FLUARIX QUAD 2017-2018

(PF) ................................... 82

FLUBLOK 2017-2018 (PF) . 82

FLUBLOK QUAD 2017-2018

(PF) ................................... 82

flucaine ................................. 97

FLUCELVAX QUAD 2017-

2018 .................................. 82

FLUCELVAX QUAD 2017-

2018 (PF) .......................... 82

fluconazole ............................. 3

fluconazole in nacl (iso-osm) . 3

flucytosine .............................. 3

fludarabine ............................ 19

fludrocortisone ...................... 63

FLULAVAL QUAD 2017-

2018 .................................. 82

FLULAVAL QUAD 2017-

2018 (PF) .......................... 82

flumazenil ............................. 38

flunisolide ........................... 105

fluocinolone .......................... 57

fluocinolone acetonide oil .... 62

fluocinolone and shower cap 57

fluocinonide .......................... 57

fluocinonide-e ....................... 57

fluocinonide-emollient ......... 57

fluor-a-day (with xylitol) .... 113

fluorescein-proparacaine ...... 97

fluoride (sodium) ................ 113

fluoritab .............................. 113

fluorometholone ................. 100

fluorouracil ..................... 19, 52

126

fluoxetine .............................. 38

fluphenazine decanoate ........ 38

fluphenazine hcl ................... 38

flurazepam ............................ 38

flurbiprofen........................... 34

flurbiprofen sodium .............. 98

flurox .................................... 97

flutamide............................... 19

fluticasone .................... 57, 105

FLUTICASONE-

SALMETEROL ............. 105

fluvastatin ............................. 49

FLUVIRIN 2017-2018 ......... 82

FLUVIRIN 2017-2018 (PF) . 82

fluvoxamine .......................... 38

FLUZONE HIGH-DOSE

2017-18 (PF) .................... 82

FLUZONE INTRADERM

QUAD 2017-18 ................ 82


.......................................... 82


(PF) ................................... 82

FLUZONE QUAD PEDI

2017-18 (PF) .................... 82

FML FORTE ...................... 100

FML S.O.P. ........................ 100

focalgin 90 dha ................... 113

focalgin ca .......................... 113

focalgin dss ......................... 113

folbee .................................. 113

folbee plus .......................... 113

folbic................................... 113

folic acid ............................. 113

folic acid-vit b6-vit b12 ...... 113

folivane-f ............................ 113

folivane-ob ......................... 113

folivane-plus ....................... 113

folplex 2.2........................... 113

foltabs 800 .......................... 114

fondaparinux......................... 47

FORTEO .............................. 86

FORTESTA .......................... 67

fosamprenavir ......................... 5

foscarnet ................................. 5

fosinopril .............................. 43

fosinopril-hydrochlorothiazide

.......................................... 43

fosphenytoin ......................... 25

FOSRENOL ......................... 73

FRAGMIN............................ 47

frovatriptan ........................... 27

full spectrum b-vitamin c ... 114

furosemide ............................ 43

FUSION PLUS ................... 114

FUZEON ................................ 5

fyavolv .................................. 88

FYCOMPA ........................... 25

G g tussin ac ........................... 102

gabapentin ............................ 25

galantamine .......................... 28

GALZIN ............................. 109

GAMASTAN S/D ................ 82

GAMMAGARD LIQUID .... 83

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 83

GAMMAKED ...................... 83

GAMMAPLEX .................... 83

GAMMAPLEX (WITH

SORBITOL) ..................... 83

GAMUNEX-C...................... 83

ganciclovir sodium ................. 5

GARDASIL 9 (PF) ............... 83

gatifloxacin ........................... 96

GATTEX 30-VIAL .............. 74

gavilax .................................. 74

gavilyte-c .............................. 74

gavilyte-g .............................. 74

gavilyte-n .............................. 74

GELCLAIR .......................... 61

gemcitabine .......................... 19

gemfibrozil ........................... 49

generlac ................................ 74

gengraf .................................. 19

gentak ................................... 96

gentamicin ................ 11, 55, 96

gentamicin in nacl (iso-osm) 11

GENTAMICIN IN NACL

(ISO-OSM) ....................... 11

gentamicin sulfate (ped) (pf) 11

gentamicin sulfate (pf).......... 11

GENTAMICIN SULFATE

(PF) ................................... 11

gentle laxative....................... 74

gentlelax ............................... 74

GENVOYA ............................ 5

GEODON ............................. 38

gianvi (28) ............................ 92

gildagia ................................. 92

GILENYA ............................ 79

GILOTRIF ............................ 20

GLASSIA ............................. 59

GLEEVEC ............................ 20

GLEOSTINE ........................ 20

glimepiride ............................ 69

glipizide ................................ 69

glipizide-metformin .............. 69

GLUCAGEN DIAGNOSTIC

KIT ................................... 64

GLUCAGEN HYPOKIT...... 64

GLUCAGON EMERGENCY

KIT (HUMAN) ................. 64

GLUCAGON HCL ............... 64

glyburide ............................... 69

glyburide micronized ............ 69

glyburide-metformin............. 69

glycolax ................................ 74

GLYCOPHOS .................... 109

glycopyrrolate ....................... 71

glydo ..................................... 54

GLYXAMBI......................... 69

GRALISE ............................. 25

GRALISE 30-DAY STARTER

PACK ............................... 25

granisetron (pf) ..................... 74

granisetron hcl ...................... 74

GRANIX............................... 79

GRASTEK ............................ 83

griseofulvin microsize ............ 3

griseofulvin ultramicrosize ..... 3

guaiatussin ac...................... 103

guaifenesin ac ..................... 103

guaifenesin dac ................... 103

guanfacine....................... 38, 43

guanidine .............................. 38

GYNAZOLE-1 ..................... 90

gynol ii .................................. 90

H HAEGARDA ...................... 105

halobetasol propionate .......... 58

haloperidol ............................ 38

haloperidol decanoate ........... 38

haloperidol lactate ................ 38

HARVONI .............................. 5

HAVRIX (PF) ...................... 83

healthylax ............................. 74

heather .................................. 88

HECTOROL ......................... 67

hematinic/folic acid ............ 114

127

hematogen .......................... 114

hematogen fa ...................... 114

hematogen forte .................. 114

hemenatal ob ...................... 114

hemenatal ob + dha ............ 114

hemetab .............................. 114

hemmorex-hc ........................ 74

hep flush-10 (pf) ................... 47

heparin (porcine) ............ 47, 48

HEPARIN (PORCINE) IN

0.9% NACL ...................... 47

heparin (porcine) in 5 % dex 47

heparin (porcine) in nacl (pf) 47

heparin flush(porcine)-0.9nacl

.......................................... 48

heparin lock flush ................. 48

heparin lock flush (porcine) . 48

heparin lockflush(porcine)(pf)

.......................................... 48

heparin(porcine) in 0.45% nacl

.......................................... 48

HEPARIN(PORCINE) IN

0.45% NACL .................... 48

heparin, porcine (pf) ............. 48

HETLIOZ ............................. 38

HEXALEN ........................... 20

HIBERIX (PF)...................... 83

hi-cal plus vit d ................... 109

HIZENTRA .......................... 83

homatropaire......................... 97

homatropine hbr ................... 97

HORIZANT ......................... 28

HUMALOG ......................... 65

HUMALOG JUNIOR

KWIKPEN ....................... 65

HUMALOG KWIKPEN ...... 65

HUMALOG MIX 50-50 ...... 65

HUMALOG MIX 50-50

KWIKPEN ....................... 65

HUMALOG MIX 75-25 ...... 65

HUMALOG MIX 75-25

KWIKPEN ....................... 65

HUMIRA .............................. 86

HUMIRA PEDIATRIC

CROHN'S START ........... 86

HUMIRA PEN ..................... 86

HUMIRA PEN CROHN'S-

UC-HS START ................ 86

HUMULIN 70/30 ................. 65

HUMULIN 70/30 KWIKPEN

.......................................... 65

HUMULIN N ....................... 65

HUMULIN N KWIKPEN .... 65

HUMULIN R U-100 ............ 65

HUMULIN R U-500 (CONC)

KWIKPEN........................ 65

HUMULIN R U-500

(CONCENTRATED) ....... 65

HYCAMTIN ........................ 20

hydralazine ..................... 43, 44

hydrochlorothiazide .............. 44

hydrocodone-acetaminophen 30

hydrocodone-chlorpheniramine

........................................ 103

hydrocodone-homatropine.. 103

hydrocodone-ibuprofen ........ 30

hydrocortisone .......... 58, 63, 74

hydrocortisone acetate .......... 74

hydrocortisone butyrate ........ 58

hydrocortisone valerate ........ 58

hydrocortisone-acetic acid .... 62

hydrocortisone-pramoxine... 51,

74

hydromet ............................. 103

hydromorphone .................... 31

HYDROMORPHONE ......... 31

hydromorphone (pf) ............. 30

hydromorphone in 0.9 % nacl

.......................................... 31

hydroxocobalamin .............. 114

hydroxychloroquine.............. 12

hydroxyurea .......................... 20

hydroxyzine hcl .................. 102

hydroxyzine pamoate ......... 102

hyophen .............................. 108

hyoscyamine sulfate ....... 71, 72

hyosyne ................................. 72

HYPER-SAL ...................... 105

HYQVIA .............................. 83

I ibandronate ........................... 86

IBRANCE ............................ 20

ibuprofen .............................. 34

ibuprofen-oxycodone............ 31

ICLUSIG .............................. 20

idarubicin .............................. 20

IDHIFA ................................ 20

iferex 150 forte ................... 114

ifosfamide ............................. 20

ifosfamide-mesna ................. 20

ILARIS (PF) ......................... 80

ILEVRO ............................... 98

ILUVIEN ............................ 100

IMBRUVICA ....................... 20

imipenem-cilastatin .............. 12

imipramine hcl ...................... 38

imipramine pamoate ............. 38

imiquimod............................. 80

INCRELEX .......................... 59

INCRUSE ELLIPTA .......... 105

indapamide ........................... 44

indomethacin ........................ 34

INFANRIX (DTAP) (PF) ..... 83

infed .................................... 114

INLYTA ............................... 20

INSPIRACHAMBER WITH

MASK-LARGE ................ 64

INSULIN SYRINGE-

NEEDLE U-100 ............... 64

INTELENCE .......................... 5

INTRON A ........................... 80

introvale ................................ 92

INVANZ ............................... 12

INVEGA SUSTENNA ......... 38

INVEGA TRINZA ............... 38

INVIRASE ............................. 5

INVOKAMET ...................... 69

INVOKAMET XR ............... 69

INVOKANA......................... 69

IODOPEN............................. 20

IPOL ..................................... 83

ipratropium bromide ..... 61, 105

ipratropium-albuterol .......... 105

irbesartan .............................. 44

irbesartan-hydrochlorothiazide

.......................................... 44

IRESSA ................................ 20

irinotecan .............................. 20

ISENTRESS ........................... 5

ISENTRESS HD .................... 5

isibloom ................................ 92

ISOLYTE-S ........................ 111

isometh-dichloral-

acetaminophn .................... 27

isoniazid ................................ 12

isosorbide dinitrate ............... 50

isosorbide mononitrate ......... 50

isoxsuprine ............................ 90

isradipine .............................. 44

128

itraconazole ............................ 3

ivermectin ............................. 12

IXEMPRA ............................ 20

IXIARO (PF) ........................ 83

J JADENU .............................. 59

JADENU SPRINKLE .......... 59

JAKAFI ................................ 20

jantoven ................................ 48

JANUMET ........................... 69

JANUMET XR ..................... 69

JANUVIA............................. 69

JARDIANCE ........................ 69

jencycla................................. 88

JENTADUETO .................... 69

JENTADUETO XR.............. 69

JETREA (PF) ....................... 97

jevantique lo ......................... 88

jinteli..................................... 88

jolessa ................................... 92

jolivette ................................. 89

juleber ................................... 92

junel 1.5/30 (21) ................... 92

junel 1/20 (21) ...................... 92

junel fe 1.5/30 (28) ............... 92

junel fe 1/20 (28) .................. 92

junel fe 24 ............................. 92

JUXTAPID ........................... 49

K kaitlib fe................................ 92

KALBITOR ........................ 105

KALETRA ............................. 5

KALYDECO ...................... 105

KANUMA ............................ 67

kariva (28) ............................ 92

k-effervescent ..................... 109

kelnor 1/35 (28) .................... 92

KENALOG........................... 63

KEPIVANCE ....................... 17

ketoconazole ..................... 3, 56

ketoprofen............................. 34

ketorolac ......................... 34, 98

KEVEYIS ............................. 28

KEVZARA ........................... 87

KHEDEZLA......................... 38

kimidess (28) ........................ 92

KINERET ............................. 80

KINRIX (PF) ........................ 83

kionex ................................... 74

kionex (with sorbitol) ........... 74

KISQALI .............................. 20

KISQALI FEMARA CO-

PACK ............................... 20

klor-con .............................. 110

klor-con 10 ......................... 110

klor-con 8 ........................... 110

klor-con m10 ...................... 110

klor-con m15 ...................... 110

klor-con m20 ...................... 110

klor-con sprinkle................. 110

klor-con/ef .......................... 110

kobee .................................. 114

KORLYM ............................. 67

k-phos-neutral ..................... 110

kpn ...................................... 114

KRYSTEXXA ...................... 85

k-tab .................................... 110

kurvelo .................................. 92

KUVAN................................ 67

KYNAMRO ......................... 49

L l norgest/e.estradiol-e.estrad . 92

labetalol ................................ 44

LACRISERT ........................ 98

lactated ringers ..................... 59

lactulose ................................ 74

lamivudine .............................. 5

lamivudine-zidovudine ........... 5

lamotrigine............................ 25

LANCETS ............................ 64

LANCING DEVICE ............ 64

lansoprazole .......................... 78

lanthanum ............................. 74

LANTUS .............................. 65

LANTUS SOLOSTAR......... 65

larin 1.5/30 (21) .................... 92

larin 1/20 (21) ....................... 92

larin 24 fe.............................. 92

larin fe 1.5/30 (28) ................ 92

larin fe 1/20 (28) ................... 92

larissia ................................... 92

LASTACAFT ....................... 98

latanoprost ............................ 99

LATUDA.............................. 38

laxaclear................................ 74

laxative (bisacodyl) .............. 74

laxative feminine .................. 74

laxative peg 3350.................. 74

layolis fe ............................... 92

LAZANDA ........................... 31

leena 28 ................................. 92

leflunomide ........................... 87

LEMTRADA ........................ 79

LENVIMA ............................ 20

lessina ................................... 92

LETAIRIS .......................... 105

letrozole ................................ 20

leucovorin calcium ............... 17

LEUKERAN......................... 20

LEUKINE ............................. 79

leuprolide .............................. 20

levalbuterol hcl ................... 105

LEVALBUTEROL

TARTRATE ................... 105

LEVATOL ............................ 44

LEVEMIR ............................ 65

LEVEMIR FLEXTOUCH.... 65

levetiracetam ......................... 25

levetiracetam in nacl (iso-os) 25

levobunolol ........................... 96

levocarnitine ......................... 59

levocarnitine (with sugar) ..... 59

levocetirizine ...................... 102

levofloxacin .................... 15, 96

levofloxacin in d5w .............. 15

levomefolate dha ................ 114

levonest (28) ......................... 92

levonorgestrel-ethinyl estrad 92

levonorg-eth estrad triphasic 93

levora-28 ............................... 93

levorphanol tartrate ............... 31

levothyroxine ........................ 70

LEVOTHYROXINE ............ 70

levoxyl .................................. 70

LEVSIN ................................ 72

LEXIVA ................................. 5

LIALDA ............................... 74

lidocaine ............................... 55

lidocaine (pf) ........................ 54

lidocaine hcl.......................... 54

lidocaine hcl-hydrocortison ac

.................................... 55, 74

lidocaine viscous .................. 55

lidocaine-epinephrine ........... 55

lidocaine-prilocaine .............. 55

lido-k..................................... 55

lidopin ................................... 55

lillow ..................................... 93

LINCOCIN ........................... 12

lincomycin ............................ 12

129

lindane .................................. 58

linezolid ................................ 12

linezolid-0.9% sodium chloride

.......................................... 12

LINZESS .............................. 75

liothyronine .......................... 70

lipodox .................................. 20

lisinopril ............................... 44

lisinopril-hydrochlorothiazide

.......................................... 44

lite coat aspirin ..................... 34

LITEAIRE MDI CHAMBER

.......................................... 64

lithium carbonate ............ 38, 39

lithium citrate ....................... 39

LIVALO ............................... 49

LO LOESTRIN FE............... 93

lomedia 24 fe ........................ 93

LONSURF ............................ 20

loperamide ............................ 72

lopinavir-ritonavir .................. 5

lopreeza ................................ 89

lorazepam ............................. 39

lorazepam intensol................ 39

lorcet (hydrocodone) ............ 31

lorcet hd ................................ 31

lorcet plus ............................. 31

lortuss ex ............................ 103

loryna (28) ............................ 93

losartan ................................. 44

losartan-hydrochlorothiazide 44

LOTEMAX ........................ 100

lovastatin .............................. 49

low-ogestrel (28) .................. 93

loxapine succinate ................ 39

lta pre-attached ..................... 55

LUCENTIS........................... 98

ludent fluoride .................... 114

LUMIGAN ........................... 99

LUMIZYME ........................ 67

LUPANETA PACK (1

MONTH) .......................... 90

LUPANETA PACK (3

MONTH) .......................... 90

LUPRON DEPOT ................ 21

LUPRON DEPOT (3

MONTH) .......................... 20

LUPRON DEPOT (4

MONTH) .......................... 20

LUPRON DEPOT (6

MONTH) .......................... 21

LUPRON DEPOT-PED ....... 21

LUPRON DEPOT-PED (3

MONTH) .......................... 21

lutera (28) ............................. 93

LUZU ................................... 56

LYNPARZA ......................... 21

LYRICA ............................... 25

LYSODREN ......................... 21

lyza ....................................... 89

M MACUGEN .......................... 98

magnesium citrate................. 75

MAKENA ............................ 89

malathion .............................. 58

maprotiline............................ 39

marlissa ................................. 93

MARPLAN .......................... 39

marten-tab ............................. 31

MATULANE........................ 21

MAVYRET ............................ 5

MAXIDEX ......................... 100

MAXIPIME ............................ 9

m-clear wc .......................... 103

meclizine .............................. 75

meclofenamate...................... 34

medroxyprogesterone ........... 89

mefenamic acid..................... 34

mefloquine ............................ 12

megestrol .............................. 21

MEKINIST ........................... 21

melodetta 24 fe ..................... 93

meloxicam ............................ 34

melphalan ............................. 21

memantine ............................ 28

MEMANTINE...................... 28

MENACTRA (PF) ............... 83

MENEST .............................. 89

MENHIBRIX (PF) ............... 83


.......................................... 84


(PF) ................................... 84

MENOSTAR ........................ 89

MENTAX ............................. 56

meperidine ............................ 31

meperidine (pf) ..................... 31

MEPHYTON ........................ 48

meprobamate ........................ 29

mercaptopurine ..................... 21

meropenem ........................... 12

mesalamine ........................... 75

mesalamine with cleansing

wipe .................................. 75

mesna .................................... 17

MESNEX .............................. 17

metadate er............................ 39

metaproterenol .................... 105

metaxall ................................ 29

metaxalone ............................ 29

metformin ............................. 69

methadone............................. 31

methadose ............................. 31

methamphetamine................. 39

methazolamide ...................... 99

methenamine hippurate ........ 16

methenamine mandelate ....... 16

methen-sod phos-meth blue-

hyos................................. 108

methergine ............................ 95

methimazole ......................... 63

METHITEST ........................ 67

methocarbamol ..................... 29

methotrexate sodium ............ 21

methotrexate sodium (pf) ..... 21

methoxsalen .......................... 52

methscopolamine .................. 72

methyclothiazide................... 44

methyldopa ........................... 44

methyldopa-

hydrochlorothiazide .......... 44

methyldopate ........................ 44

methylphenidate hcl.............. 39

methylprednisolone .............. 63

methylprednisolone acetate .. 63

methyltestosterone ................ 67

metipranolol .......................... 96

metoclopramide hcl .............. 75

metolazone ............................ 44

metoprolol succinate ............. 44

metoprolol ta-hydrochlorothiaz

.......................................... 44

metoprolol tartrate ................ 44

metro i.v. ............................... 12

metronidazole ........... 12, 54, 90

metronidazole in nacl (iso-os)

.......................................... 12

mexiletine ............................. 41

mibelas 24 fe......................... 93

130

microgestin 1.5/30 (21) ........ 93

microgestin 1/20 (21) ........... 93

microgestin fe 1.5/30 (28) .... 93

microgestin fe 1/20 (28) ....... 93

midazolam ............................ 39

midodrine ............................. 59

miglitol ................................. 69

milk of magnesia .................. 75

milk of magnesia concentrated

.......................................... 75

millipred dp .......................... 63

mimvey ................................. 89

mimvey lo ............................. 89

MINASTRIN 24 FE ............. 93

MINOCIN ............................ 16

minocycline .......................... 16

minoxidil .............................. 44

miostat .................................. 99

miralax .................................. 75

mirtazapine ........................... 39

MIRVASO ........................... 54

misoprostol ........................... 78

mitomycin............................. 21

mitoxantrone......................... 21

M-M-R II (PF) ...................... 84

modafinil .............................. 39

moderiba ............................... 79

moexipril .............................. 44

moexipril-hydrochlorothiazide

.......................................... 45

mometasone .......................... 58

mono-linyah ......................... 93

mononessa (28) .................... 93

montelukast ........................ 105

morgidox .............................. 16

morphine............................... 32

MORPHINE ......................... 32

morphine (pf).................. 31, 32

morphine concentrate ........... 32

MOVANTIK ........................ 75

MOVIPREP .......................... 75

MOXEZA ............................. 96

moxifloxacin................... 15, 96

MOXIFLOXACIN-

SOD.ACE,SUL-WATER . 15

MOZOBIL ............................ 79

MULTAQ ............................. 41

multigen folic ..................... 114

multigen plus ...................... 114

multi-vit with fluoride-iron 114

multi-vitamin with fluoride 114

multivitamins with fluoride 114

multivit-fluor (vit e acetate) 114

mupirocin.............................. 55

mupirocin calcium ................ 55

MUSTARGEN ..................... 21

mvc-fluoride ....................... 115

my way ................................. 93

MYALEPT ........................... 67

MYCAMINE .......................... 3

mycophenolate mofetil ......... 21

mycophenolate mofetil hcl ... 21

mycophenolate sodium ......... 21

myferon 150 forte ............... 115

MYLERAN .......................... 21

mynatal ............................... 115

mynatal advance ................. 115

mynatal plus ....................... 115

mynatal-z ............................ 115

mynate 90 plus.................... 115

mynephrocaps ..................... 115

mynephron .......................... 115

MYOBLOC .......................... 84

MYRBETRIQ .................... 107

MYTESI ............................... 72

myzilra .................................. 93

N nabumetone .......................... 34

nadolol .................................. 45

nadolol-bendroflumethiazide 45

nafcillin ................................. 14

nafcillin in dextrose iso-osm 14

NAFTIN ............................... 56

NAGLAZYME ..................... 67

nalbuphine ............................ 34

naloxone ............................... 35

naltrexone ............................. 35

NAMENDA TITRATION

PAK .................................. 28

naproxen ............................... 35

naproxen sodium .................. 35

naratriptan ............................. 27

NARCAN ............................. 35

NATACYN .......................... 96

NATAZIA ............................ 93

nateglinide ............................ 69

NATPARA ........................... 67

natural b-100 complex ........ 115

nature-throid ......................... 70

NEBUPENT ......................... 12

nebusal ................................ 105

NEBUSAL .......................... 105

necon 0.5/35 (28) .................. 93

necon 1/50 (28) ..................... 93

necon 7/7/7 (28) .................... 93

nefazodone ............................ 39

neomycin .............................. 12

neomycin-bacitracin-poly-hc 99

neomycin-bacitracin-

polymyxin ......................... 96

neomycin-polymyxin b gu .... 59

neomycin-polymyxin b-

dexameth........................... 99

neomycin-polymyxin-

gramicidin ......................... 96

neomycin-polymyxin-hc. 62, 99

neo-polycin ........................... 96

neo-polycin hc ...................... 99

nephplex rx ......................... 115

nephro-vite rx ..................... 115

NERLYNX ........................... 21

NEULASTA ......................... 79

NEUPOGEN......................... 79

NEVANAC........................... 98

nevirapine ........................... 5, 6

newgen ................................ 115

NEXAVAR........................... 22

NEXAVIR .......................... 115

NEXIUM .............................. 78

NEXIUM IV ......................... 78

NEXIUM PACKET.............. 78

next choice one dose ............. 93

niacin .................................... 49

nicardipine ............................ 45

nicorelief ............................... 61

nicorette ................................ 61

nicotine ................................. 61

nicotine (polacrilex) .............. 61

NICOTROL .......................... 61

NICOTROL NS .................... 61

nifedipine .............................. 45

nikki (28) .............................. 93

nilutamide ............................. 22

nimodipine ............................ 45

NINLARO ............................ 22

nisoldipine ............................ 45

nitro-bid ................................ 50

NITRO-DUR ........................ 50

nitrofurantoin macrocrystal .. 16

131

nitrofurantoin monohyd/m-

cryst .................................. 16

nitroglycerin ......................... 50

nitroglycerin in 5 % dextrose50

nitro-time .............................. 51

NITYR .................................. 59

nizatidine .............................. 78

nodolor ................................. 27

nora-be .................................. 89

NORDITROPIN FLEXPRO 79

noreth-ethinyl estradiol-iron . 93

norethindrone (contraceptive)

.......................................... 89

norethindrone acetate ........... 89

norethindrone ac-eth estradiol

.................................... 89, 93

norethindrone-e.estradiol-iron

.................................... 93, 94

norgestimate-ethinyl estradiol

.......................................... 94

norlyda .................................. 89

norlyroc ................................ 89

NORMOSOL-R ................. 110

NORTHERA ........................ 59

nortrel 0.5/35 (28) ................ 94

nortrel 1/35 (21) ................... 94

nortrel 1/35 (28) ................... 94

nortrel 7/7/7 (28) .................. 94

nortriptyline .......................... 39

NORVIR................................. 6

NOVOLOG .......................... 66

NOVOLOG FLEXPEN........ 65

NOVOLOG MIX 70-30 ....... 66

NOVOLOG MIX 70-30

FLEXPEN ........................ 65

NOVOLOG PENFILL ......... 66

NOXAFIL .............................. 3

np thyroid ............................. 70

NPLATE............................... 48

nts step 1 ............................... 61

NUCALA ........................... 105

NUEDEXTA ........................ 28

NULOJIX ............................. 22

NUPLAZID .......................... 39

NUVARING......................... 90

nyamyc ................................. 56

nyata ..................................... 56

nystatin ............................. 3, 56

nystatin-triamcinolone .......... 56

nystop ................................... 56

O obstetrix dha ....................... 115

OCALIVA ............................ 75

ocella .................................... 94

OCREVUS ........................... 79

OCTAGAM .......................... 84

octreotide acetate .................. 22

ODEFSEY .............................. 6

ODOMZO ............................ 22

OFEV.................................. 105

ofloxacin ................... 15, 62, 96

ogestrel (28) .......................... 94

olanzapine ............................. 39

olanzapine-fluoxetine ........... 40

olmesartan ............................ 45

olopatadine ..................... 61, 98

OLYSIO ................................. 6

omega-3 acid ethyl esters ..... 49

omeprazole ........................... 78

omeprazole-sodium

bicarbonate ....................... 78

ONCASPAR ......................... 22

ondansetron .......................... 75

ondansetron hcl..................... 75

ondansetron hcl (pf).............. 75

one daily prenatal ............... 115

ONETOUCH ULTRA TEST

.......................................... 63

ONETOUCH ULTRA2 ........ 64

ONETOUCH ULTRAMINI. 64

ONETOUCH VERIO ........... 63

ONETOUCH VERIO FLEX 64

ONETOUCH VERIO IQ

METER ............................ 64

ONETOUCH VERIO

SYSTEM .......................... 64

ONFI ..................................... 25

ONMEL .................................. 4

opcicon one-step ................... 94

OPSUMIT .......................... 105

option-2 ................................ 94

oral saline laxative ................ 75

ORALAIR ............................ 84

oralone .................................. 61

ORAMAGICRX ................... 61

ORAVIG ................................ 4

ORENCIA ............................ 87

ORENCIA (WITH

MALTOSE) ...................... 87

ORENCIA CLICKJECT ...... 87

ORENITRAM ...................... 45

ORFADIN ............................ 60

ORKAMBI ......................... 105

orphenadrine citrate .............. 29

orsythia ................................. 94

oscimin ................................. 72

oscimin sl .............................. 72

oscimin sr.............................. 72

oseltamivir .............................. 6

OSMOPREP ......................... 75

OSPHENA ............................ 90

OTEZLA............................... 87

OTEZLA STARTER ............ 87

OTREXUP (PF).................... 87

oxacillin ................................ 14

oxacillin in dextrose(iso-osm)

.......................................... 14

oxaliplatin ............................. 22

oxandrolone .......................... 67

oxaprozin .............................. 35

oxazepam .............................. 40

oxcarbazepine ....................... 25

oxiconazole ........................... 56

oxybutynin chloride ............ 107

oxycodone............................. 32

OXYCODONE ..................... 32

oxycodone-acetaminophen ... 32

oxycodone-aspirin ................ 32

OXYCONTIN ...................... 32

oxymorphone .................. 32, 33

oysco 500/d ......................... 110

oyster shell + d3.................. 110

oyster shell calcium-vit d2.. 115

oyster shell calcium-vit d3.. 110

oystercal-d .......................... 110

P pacerone ................................ 41

paclitaxel............................... 22

paliperidone .......................... 40

pamidronate .......................... 67

PANRETIN .......................... 52

pantoprazole ......................... 78

papaverine............................. 45

paregoric ............................... 72

paricalcitol ............................ 67

PARICALCITOL ................. 67

paroex oral rinse ................... 61

paromomycin ........................ 12

paroxetine hcl ....................... 40

PASER .................................. 12

132

PAZEO ................................. 98

PEDIARIX (PF) ................... 84

PEDVAX HIB (PF) .............. 84

peg 3350-electrolytes ........... 75

peg3350 ................................ 75

PEGANONE ........................ 25

PEGASYS ............................ 79

PEGASYS PROCLICK ....... 79

peg-electrolyte soln .............. 75

PEGINTRON ....................... 80

peg-prep ................................ 75

PEN NEEDLE ...................... 64

PENICILLIN G POT IN

DEXTROSE ..................... 14

penicillin g potassium........... 14

penicillin g procaine ............. 14

penicillin g sodium ............... 14

penicillin v potassium........... 15

PENTACEL (PF) ................. 84

PENTACEL ACTHIB

COMPONENT (PF) ......... 84

PENTAM ............................. 12

PENTASA ............................ 75

pentazocine-naloxone ........... 35

pentoxifylline ....................... 48

PERFOROMIST ................ 106

perindopril erbumine ............ 45

periogard............................... 61

permethrin ............................ 58

perphenazine......................... 40

perphenazine-amitriptyline... 40

perry prenatal...................... 115

pfizerpen-g ........................... 15

phenadoz............................. 102

phenazopyridine ................. 109

phenelzine............................. 40

phenergan ........................... 102

phenobarbital ........................ 26

phenoxybenzamine ............... 45

phentolamine ........................ 45

phenylephrine hcl ............... 101

phenytoin .............................. 26

phenytoin sodium ................. 26

phenytoin sodium extended .. 26

philith ................................... 94

phospha 250 neutral ........... 110

phosphate laxative ................ 75

PHOSPHOLINE IODIDE .... 97

PHOTOFRIN ....................... 22

pilocarpine hcl .......... 60, 61, 97

pimozide ............................... 40

pimtrea (28) .......................... 94

pindolol ................................. 45

pioglitazone .......................... 69

pioglitazone-metformin ........ 69

piperacillin-tazobactam ........ 15

pirmella ................................. 94

piroxicam .............................. 35

PLASMA-LYTE 148 ......... 111

PLASMA-LYTE A ............ 111

PLEGRIDY .......................... 80

PNEUMOVAX 23 ............... 84

pnv 29-1 .............................. 115

pnv ob+dha ......................... 115

pnv-dha ............................... 115

pnv-dha + docusate ............. 115

pnv-ferrous fumarate-docu-fa

........................................ 115

pnv-omega .......................... 115

pnv-select............................ 115

pnv-vp-u ............................. 115

podofilox .............................. 52

polycin .................................. 96

polyethylene glycol 3350 ..... 75

poly-iron 150 forte.............. 115

polymyxin b sulfate .............. 12

polymyxin b sulf-trimethoprim

.......................................... 96

POMALYST ........................ 80

portia ..................................... 94

pot,sodium citrate-citric acid

........................................ 108

potassium acetate ................ 110

potassium bicarb and chloride

........................................ 110

potassium bicarb-citric acid 110

potassium chlorid-d5-

0.45%nacl ....................... 110

potassium chloride ...... 110, 111

potassium chloride in 0.9%nacl

........................................ 110

potassium chloride in 5 % dex

........................................ 110

potassium chloride in lr-d5 . 110

potassium chloride-0.45 % nacl

........................................ 111

potassium chloride-d5-

0.2%nacl ......................... 111


0.3%nacl ......................... 111


0.9%nacl ......................... 111

potassium citrate ................. 108

potassium citrate-citric acid 108

potassium phosphate m-/d-

basic ................................ 111

powderlax ............................. 75

pr natal 400 ......................... 116

pr natal 400 ec .................... 115

pr natal 430 ......................... 116

pr natal 430 ec .................... 116

PRADAXA ........................... 48

PRALUENT PEN ................. 49

pramcort ................................ 76

pramipexole .......................... 27

prasugrel ............................... 48

pravastatin............................. 49

prazosin................................. 45

PRED MILD ....................... 100

PRED-G .............................. 100

PRED-G S.O.P. .................. 100

prednicarbate ........................ 58

prednisolone ......................... 63

prednisolone acetate ........... 100

prednisolone sodium phosphate

.................................. 63, 101

prednisone............................. 63

prednisone intensol ............... 63

PREMARIN ......................... 89

PREMPHASE....................... 89

PREMPRO ........................... 89

prena1 chew ........................ 116

prenaissance ........................ 116

prenaissance plus ................ 116

prenatabs fa ......................... 116

prenatabs rx ........................ 116

prenatal ............................... 116

prenatal 19 .......................... 116

prenatal complete ................ 116

prenatal formula.................. 116

prenatal multi-dha (algal oil)

........................................ 116

prenatal one daily ............... 116

prenatal plus........................ 116

prenatal plus (calcium carb)116

prenatal vitamin .................. 116

prenatal vitamin plus low iron

........................................ 116

prenatal vitamin with minerals

........................................ 116

133

prenatal vits96-iron fum-folic

........................................ 116

prenatal-u ............................ 116

preplus ................................ 116

PREPOPIK ........................... 76

pretab .................................. 116

prevalite ................................ 49

previfem ............................... 94

PREVNAR 13 (PF) .............. 84

PREZCOBIX .......................... 6

PREZISTA ............................. 6

PRIFTIN ............................... 12

PRIMAQUINE ..................... 12

primidone ............................. 26

PRIVIGEN ........................... 84

PROAIR HFA .................... 106

probenecid ............................ 85

probenecid-colchicine .......... 85

PROBUPHINE ..................... 33

prochlorperazine ................... 76

prochlorperazine edisylate.... 76

prochlorperazine maleate ..... 76

PROCRIT ............................. 79

procto-med hc ....................... 76

proctosol hc .......................... 76

proctozone-hc ....................... 76

PROCYSBI ........................ 108

progesterone micronized ...... 89

PROGLYCEM ..................... 64

PROGRAF ........................... 22

PROLASTIN-C .................... 60

PROLENSA ......................... 98

PROLEUKIN ....................... 80

PROLIA ............................... 86

PROMACTA ........................ 48

promethazine ...................... 102

promethazine vc-codeine.... 103

promethazine-codeine ........ 103

promethazine-dm ................ 103

promethazine-phenyleph-

codeine ........................... 103

promethazine-phenylephrine

........................................ 103

promethegan ....................... 102

propafenone .......................... 41

propantheline ........................ 72

proparacaine ......................... 98

propranolol ........................... 45

propranolol-hydrochlorothiazid

.......................................... 45

propylthiouracil .................... 63

PROQUAD (PF)................... 84

protamine .............................. 48

protriptyline .......................... 40

PROVENTIL HFA ............. 106

prudoxin................................ 52

prutect ................................... 52

pulmosal ............................. 106

PULMOZYME ................... 106

purelax .................................. 76

purevit dualfe plus .............. 116

pyrazinamide ........................ 12

pyridostigmine bromide ....... 29

Q QUADRACEL (PF) ............. 84

quasense................................ 94

quazepam .............................. 40

quetiapine ............................. 40

quinapril................................ 45

quinapril-hydrochlorothiazide

.......................................... 45

quinidine gluconate .............. 41

quinidine sulfate ................... 41

quinine sulfate ...................... 13

quit 2 ..................................... 61

quit 4 ..................................... 61

QUTENZA ........................... 52

QVAR ................................. 106

R rabeprazole ........................... 78

RAGWITEK ......................... 84

rajani ..................................... 94

raloxifene .............................. 86

ramipril ................................. 45

RANEXA ............................. 50

ranitidine hcl ......................... 78

RAPAFLO .......................... 108

RAPAMUNE........................ 22

rasagiline .............................. 27

RASUVO (PF) ..................... 87

RAVICTI .............................. 60

REBIF (WITH ALBUMIN) . 80

REBIF REBIDOSE .............. 80

REBIF TITRATION PACK . 80

reclipsen (28) ........................ 94

RECOMBIVAX HB (PF) .... 84

RECTIV................................ 76

regonol .................................. 29

REGRANEX ........................ 53

relcof c ................................ 103

RELENZA DISKHALER ...... 6

RELISTOR ........................... 76

relnate dha .......................... 116

REMICADE ......................... 76

REMODULIN ...................... 45

RENAGEL ........................... 76

renal caps ............................ 116

rena-vite .............................. 116

rena-vite rx.......................... 116

reno caps ............................. 116

repaglinide ............................ 69

repaglinide-metformin .......... 69

REPATHA PUSHTRONEX 50

REPATHA SURECLICK .... 50

REPATHA SYRINGE ......... 50

RESCRIPTOR ........................ 6

RESTASIS ............................ 98

RESTASIS MULTIDOSE.... 98

RETROVIR ............................ 6

REVLIMID........................... 80

REYATAZ ............................. 6

RHOFADE ........................... 54

ribasphere ............................. 80

ribavirin ................................ 80

RIDAURA ............................ 87

rifabutin ................................ 13

RIFAMATE .......................... 13

rifampin ................................ 13

RIFATER ............................. 13

riluzole .................................. 60

rimantadine ............................. 6

ringer's .................................. 59

risacal-d .............................. 116

risedronate ...................... 60, 86

RISPERDAL CONSTA ....... 40

risperidone ............................ 40

RITUXAN ............................ 22

RITUXAN HYCELA ........... 22

rivastigmine .......................... 28

rivastigmine tartrate .............. 28

rivelsa ................................... 94

rizatriptan .............................. 27

ROBAXIN ............................ 29

ropinirole .............................. 27

rosuvastatin ........................... 50

ROTARIX ............................ 84

ROTATEQ VACCINE ......... 84

roweepra ............................... 26

ROZEREM ........................... 40

RUBRACA ........................... 22

134

RUCONEST ....................... 106

RYDAPT .............................. 22

rydex ................................... 103

S SABRIL ................................ 26

SAFYRAL ............................ 94

salicylic acid ......................... 52

salsalate ................................ 35

SAMSCA ............................. 67

SANCUSO ........................... 76

SANDOSTATIN LAR

DEPOT ............................. 22

SANTYL .............................. 58

SAPHRIS (BLACK

CHERRY) ........................ 40

SAVELLA ............................ 87

scopolamine base.................. 76

seb-prev ................................ 51

selegiline hcl ......................... 27

selenium sulfide.................... 51

SELZENTRY ......................... 6

se-natal 19 .......................... 117

se-natal 19 (with docusate) . 116

SENSIPAR ........................... 67

SEREVENT DISKUS ........ 106

SEROSTIM .......................... 79

sertraline ............................... 40

se-tan plus ........................... 117

setlakin ................................. 94

sevelamer carbonate ............. 76

sf 62

sf 5000 plus .......................... 62

sharobel ................................ 89

SIGNIFOR ........................... 22

SIGNIFOR LAR .................. 22

sildenafil (antihypertensive)

........................................ 106

SILIQ .................................... 51

silver nitrate .......................... 53

silver nitrate applicators ....... 53

silver sulfadiazine ................. 52

SILVRSTAT ........................ 55

SIMBRINZA ........................ 99

SIMPONI ............................. 87

SIMPONI ARIA ................... 87

SIMULECT .......................... 22

simvastatin ............................ 50

sirolimus ............................... 22

SIRTURO ............................. 13

SIVEXTRO .......................... 13

SKLICE ................................ 58

smoothlax ............................. 76

sodium chloride .... 60, 106, 111

sodium chloride 0.45 % ...... 111

sodium chloride 0.9 % .......... 60

sodium chloride 3 % ........... 111

sodium chloride 5 % ........... 111

sodium citrate-citric acid .... 108

sodium ferric gluconat-sucrose

.......................................... 60

sodium phenylbutyrate ......... 60

sodium phosphate ............... 111

SODIUM PHOSPHATE IN

0.9 % NACL ................... 111

sodium polystyrene sulfonate

.......................................... 76

SODIUM POLYSTYRENE

SULFONATE ................... 76

SOLIRIS ............................... 60

SOMATULINE DEPOT ...... 22

SOMAVERT ........................ 68

sotalol ................................... 41

SOTALOL ............................ 41

sotalol af ............................... 41

SOVALDI .............................. 6

SPECTRACEF ....................... 9

spinosad ................................ 58

SPIRIVA RESPIMAT ........ 106

SPIRIVA WITH

HANDIHALER .............. 106

spironolactone ...................... 45

spironolacton-hydrochlorothiaz

.......................................... 46

SPORANOX .......................... 4

sprintec (28) .......................... 94

SPRYCEL ............................ 22

sps (with sorbitol) ................. 76

sronyx ................................... 94

ssd ......................................... 52

SSKI ..................................... 63

stavudine ................................. 6

STELARA ............................ 51

STIMATE ............................. 68

STIOLTO RESPIMAT....... 106

STIVARGA .......................... 22

stop smoking aid ................... 61

STRENSIQ ........................... 68

STREPTOMYCIN ............... 13

stress formula ..................... 117

stress formula with iron ...... 117

stress formula with iron(sulf)

........................................ 117

STRIANT ............................. 68

STRIBILD .............................. 6

STRIVERDI RESPIMAT .. 106

STROMECTOL ................... 13

SUBOXONE ........................ 35

SUBSYS ............................... 33

SUCRAID............................. 77

sucralfate............................... 78

sulfacetamide sodium ... 51, 101

sulfacetamide sodium (acne) 55

sulfacetamide sodium-sulfur 54

sulfacetamide sod-sulfur-urea

.......................................... 54

sulfacetamide-prednisolone 101

sulfact na-sul-avobnz-otn-ocsa

.......................................... 54

sulfadiazine ........................... 15

sulfamethoxazole-trimethoprim

.................................... 15, 16

SULFAMYLON ................... 55

sulfasalazine ......................... 77

sulfatrim ................................ 16

sulindac ................................. 35

sumatriptan ........................... 27

sumatriptan succinate ..... 27, 28

super b complex-vitamin c . 117

super b maxi complex ......... 117

super b-50 complex plus ..... 117

super quints ......................... 117

super quints b-50 ................ 117

superplex-t .......................... 117

SUPPRELIN LA .................. 22

SUPRAX ................................ 9

SUPREP BOWEL PREP KIT

.......................................... 77

SUSTIVA ............................... 6

SUTENT ............................... 22

syeda ..................................... 94

SYLATRON ......................... 80

SYLVANT ........................... 23

SYMLINPEN 120 ................ 70

SYMLINPEN 60 .................. 70

SYNAGIS ............................... 6

SYNAREL ............................ 68

SYNERA .............................. 55

SYNERCID .......................... 13

SYNJARDY ......................... 70

SYNJARDY XR ................... 70

135

SYPRINE ............................. 60

T TABLOID ............................ 23

TACLONEX ........................ 51

tacrolimus ....................... 23, 53

TAFINLAR .......................... 23

TAGRISSO .......................... 23

TALTZ AUTOINJECTOR .. 51

TALTZ AUTOINJECTOR (2

PACK) .............................. 51

TALTZ AUTOINJECTOR (3

PACK) .............................. 51

TALTZ SYRINGE ............... 52

TALTZ SYRINGE (2 PACK)

.......................................... 52

TALTZ SYRINGE (3 PACK)

.......................................... 52

TALWIN .............................. 35

TAMIFLU .............................. 6

tamoxifen .............................. 23

tamsulosin........................... 108

TANZEUM .......................... 70

TARCEVA ........................... 23

TARGRETIN ....................... 23

tarina fe 1/20 (28) ................. 94

taron forte ........................... 117

taron-c dha .......................... 117

taron-prex prenatal-dha ...... 117

TASIGNA ............................ 23

tazarotene ............................. 54

TAZORAC ........................... 54

taztia xt ................................. 46

TECFIDERA ........................ 80

TECHNIVIE........................... 6

TEFLARO .............................. 9

TEKTURNA ........................ 46

TEKTURNA HCT ............... 46

telmisartan ............................ 46

telmisartan-amlodipine ......... 46

telmisartan-hydrochlorothiazid

.......................................... 46

temazepam ............................ 40

TEMODAR .......................... 23

temozolomide ....................... 23

tencon ................................... 33

TENIVAC (PF) .............. 84, 85

terazosin ............................... 46

terbinafine hcl ......................... 4

terbutaline ........................... 106

terconazole ........................... 90

TESTIM................................ 68

testosterone ........................... 68

TESTOSTERONE................ 68

testosterone cypionate .......... 68

testosterone enanthate........... 68

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 85

TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 85

tetcaine.................................. 98

tetrabenazine ......................... 28

tetracaine hcl......................... 98

tetracaine hcl (pf).................. 98

tetracycline ........................... 16

TETRAVISC ........................ 98

THALOMID ......................... 23

theochron ............................ 106

theophylline ........................ 106

THIOLA ............................... 60

thioridazine ........................... 40

thiothixene ............................ 40

thrivite-19 ........................... 117

THYMOGLOBULIN ........... 85

thyroid (pork) ....................... 70

THYROLAR-1 ..................... 71

THYROLAR-1/2 .................. 71

THYROLAR-1/4 .................. 71

THYROLAR-2 ..................... 71

THYROLAR-3 ..................... 71

tiagabine ............................... 26

ticlopidine ............................. 48

TIGAN.................................. 77

TIGECYCLINE.................... 13

tilia fe .................................... 94

timolol maleate ......... 46, 96, 97

tinidazole .............................. 13

tis-u-sol pentalyte ................. 59

TIVICAY................................ 7

tizanidine .............................. 29

tl gard rx ............................. 117

tl icon .................................. 117

tl-hem 150........................... 117

TOBI PODHALER .............. 13

TOBRADEX ...................... 100

TOBRADEX ST................. 100

tobramycin ............................ 96

tobramycin in 0.225 % nacl .. 13

tobramycin in 0.9 % nacl ...... 13

tobramycin sulfate ................ 13

tobramycin-dexamethasone 100

TOBREX .............................. 96

TODAY CONTRACEPTIVE

SPONGE........................... 90

tolazamide............................. 70

tolbutamide ........................... 70

tolcapone............................... 27

tolmetin ................................. 35

tolterodine ........................... 107

topiramate ............................. 26

toposar .................................. 23

topotecan............................... 23

TORISEL .............................. 23

torsemide .............................. 46

total b/c ............................... 117

TOUJEO SOLOSTAR ......... 66

TOVIAZ ............................. 107

TRACLEER ....................... 106

TRADJENTA ....................... 70

tramadol ................................ 35

tramadol-acetaminophen ...... 35

trandolapril ........................... 46

trandolapril-verapamil .......... 46

tranexamic acid ............... 48, 90

tranylcypromine .................... 40

TRAVATAN Z ..................... 99

trazodone .............................. 40

TRECATOR ......................... 13

TRELSTAR .......................... 23

TREMFYA ........................... 52

TRESIBA FLEXTOUCH U-

100 .................................... 66

TRESIBA FLEXTOUCH U-

200 .................................... 66

tretinoin................................. 54

tretinoin (chemotherapy) ...... 23

tri femynor ............................ 94

triamcinolone acetonide . 58, 62,

63

triamterene-hydrochlorothiazid

.......................................... 46

triazolam ............................... 40

tricitrates ............................. 108

tricon ................................... 117

triderm .................................. 58

TRIESENCE (PF) ................ 63

tri-estarylla ............................ 94

trifluoperazine....................... 40

trifluridine ............................. 96

trigels-f forte ....................... 117

trihexyphenidyl ..................... 27

136

triklo ..................................... 50

tri-legest fe............................ 94

tri-linyah ............................... 94

tri-lo-estarylla ....................... 95

tri-lo-marzia .......................... 95

tri-lo-sprintec ........................ 95

trilyte with flavor packets ..... 77

trimethobenzamide ............... 77

trimethoprim ......................... 16

trimipramine ......................... 40

trinatal gt ............................ 117

trinatal rx 1 ......................... 117

trinate .................................. 117

trinessa (28) .......................... 95

trinessa lo.............................. 95

TRINTELLIX....................... 40

triphrocaps .......................... 117

tri-previfem (28) ................... 95

TRISENOX .......................... 23

tri-sprintec (28) ..................... 95

tri-tabs dha .......................... 117

TRIUMEQ .............................. 7

triveen-duo dha ................... 117

tri-vit with fluoride and iron

........................................ 117

tri-vitamin with fluoride ..... 117

trivora (28)............................ 95

tropicamide ........................... 97

trospium .............................. 107

TRULICITY ......................... 70

trust natal dha ..................... 117

TRUVADA ............................ 7

TUDORZA PRESSAIR ..... 106

tusnel c................................ 103

tussigon............................... 103

TWINRIX (PF) .................... 85

TYBOST ................................ 7

TYGACIL ............................ 13

TYKERB .............................. 23

TYMLOS ............................. 86

TYPHIM VI ......................... 85

TYSABRI ............................. 28

TYVASO ............................ 106

TYVASO REFILL KIT ..... 106

TYVASO STARTER KIT . 107

U UCERIS ................................ 77

ULESFIA ............................. 58

ULORIC ............................... 85

ultimatecare one ................. 118

ultimatecare one nf ............. 117

ultra b-100 complex............ 118

unithroid ............................... 71

UPTRAVI ............................. 46

urea ....................................... 53

ure-k...................................... 53

uretron d-s........................... 108

urin ds ................................. 108

urogesic-blue ...................... 108

urophen mb ......................... 108

ursodiol ................................. 77

uryl...................................... 108

UVADEX ............................. 53

V vaginal contraceptive foam .. 90

valacyclovir ............................ 7

VALCHLOR ........................ 53

valganciclovir ......................... 7

valproate sodium .................. 26

valproic acid ......................... 26

valproic acid (as sodium salt)

.......................................... 26

valsartan................................ 46

valsartan-hydrochlorothiazide

.......................................... 46

vancomycin .......................... 17

VANCOMYCIN IN 0.9%

SODIUM CL .................... 16

VANCOMYCIN IN

DEXTROSE 5 % ........ 16, 17

vandazole .............................. 90

VANTAS .............................. 23

VAQTA (PF) ........................ 85

VARIVAX (PF) ................... 85

VARIZIG.............................. 85

VASCEPA ............................ 50

veletri .................................... 46

velivet triphasic regimen (28)

.......................................... 95

VELPHORO ......................... 77

VELTASSA.......................... 77

vemavite-prx-2 ................... 118

VEMLIDY.............................. 7

VENCLEXTA ...................... 23

venlafaxine ..................... 40, 41

VENOFER.......................... 118

VENTAVIS ........................ 107

VENTOLIN HFA ............... 107

verapamil .............................. 46

verdrocet ............................... 33

VESICARE......................... 107

vestura (28) ........................... 95

VIBATIV .............................. 17

VIBERZI .............................. 77

VICTOZA 2-PAK ................ 70

VICTOZA 3-PAK ................ 70

VIDEX 2 GRAM PEDIATRIC

............................................ 7

VIEKIRA PAK ....................... 7

VIEKIRA XR ......................... 7

vienva ................................... 95

vigabatrin .............................. 26

VIIBRYD ............................. 41

VIMIZIM .............................. 68

VIMPAT ............................... 26

vinate care ........................... 118

vinate ii ............................... 118

vinate m .............................. 118

vinate one............................ 118

vinblastine............................. 23

vincasar pfs ........................... 23

vincristine ............................. 23

vinorelbine ............................ 23

viorele (28) ........................... 95

VIRACEPT............................. 7

VIRAMUNE XR .................... 7

VIREAD ................................. 7

virt-advance ........................ 118

virt-c dha ............................. 118

virt-gard .............................. 118

virt-nate............................... 118

virt-nate dha ........................ 118

virt-phos 250 neutral........... 111

virt-pn ................................. 118

virt-pn dha .......................... 118

virt-pn plus.......................... 118

virtrate-2 ............................. 108

virtrate-3 ............................. 108

virtrate-k ............................. 108

virt-select ............................ 118

virtussin ac .......................... 103

virtussin dac ........................ 103

virt-vite ............................... 118

virt-vite forte ....................... 118

virt-vite gt ........................... 118

vit 3 ..................................... 118

vit b complex-folic acid ...... 118

vitamin b complex .............. 118

vitamin d3 ........................... 118

vitamin k ............................... 48

137

vitamin k1 ............................. 48

vitamins a,c,d and fluoride . 118

VITRASE ............................. 98

VIVITROL ........................... 35

vol-care rx .......................... 118

vol-nate ............................... 118

vol-plus ............................... 118

vol-tab rx ............................ 118

voriconazole ........................... 4

VOSEVI ................................. 7

VOTRIENT .......................... 23

vp-ch plus ........................... 119

vp-ch-pnv ........................... 119

vp-ggr-b6 ............................ 119

vp-heme ob ......................... 119

vp-heme one ....................... 119

VPRIV .................................. 68

vp-vite rx ............................ 119

VRAYLAR........................... 41

vyfemla (28) ......................... 95

VYVANSE ........................... 41

W warfarin ................................ 48

water for irrigation, sterile .... 60

WELCHOL .......................... 50

wera (28) .............................. 95

westhroid .............................. 71

WIDE-SEAL DIAPHRAGM

.......................................... 87

woman's laxative .................. 77

women's laxative (bisacodyl)77

WP THYROID ..................... 71

wymzya fe ............................ 95

X XALKORI ............................ 24

XARELTO ........................... 48

XELJANZ ............................ 87

XELJANZ XR ...................... 87

XEOMIN .............................. 85

XERMELO ........................... 24

XGEVA ................................ 17

XIFAXAN ............................ 13

XIIDRA ................................ 98

XOLAIR ............................. 107

XOPENEX HFA ................ 107

XTAMPZA ER..................... 33

XTANDI ............................... 24

xulane ................................... 90

XULTOPHY 100/3.6 ........... 66

XURIDEN ............................ 60

XYLOCAINE-MPF ............. 55

XYREM................................ 41

Y YF-VAX (PF) ....................... 85

yuvafem ................................ 89

Z zafirlukast ........................... 107

zaleplon ................................ 41

ZANOSAR ........................... 24

zarah ..................................... 95

ZARXIO ............................... 79

zatean-ch ............................. 119

zatean-pn dha ...................... 119

zatean-pn plus ..................... 119

ZAVESCA............................ 68

ZEJULA ............................... 24

ZELBORAF ......................... 24

ZEMAIRA ............................ 60

zenatane ................................ 54

zenchent (28) ........................ 95

ZENPEP ............................... 77

ZEPATIER ............................. 7

zidovudine .............................. 7

zileuton ............................... 107

ZINACEF IN STERILE

WATER .............................. 9

ZINBRYTA .......................... 80

zingiber ............................... 119

ZIOPTAN (PF) ..................... 99

ziprasidone hcl ...................... 41

ZIRGAN ............................... 96

ZOLADEX ........................... 24

zoledronic acid...................... 68

zoledronic acid-mannitol-water

.......................................... 60

ZOLEDRONIC AC-

MANNITOL-0.9NACL.... 68

ZOLINZA ............................. 24

zolmitriptan........................... 28

zolpidem ............................... 41

ZOMETA ............................. 68

ZOMIG ................................. 28

zonisamide ............................ 26

ZONTIVITY......................... 49

ZORBTIVE .......................... 79

ZORTRESS .......................... 24

ZOSTAVAX (PF) ................ 85

zovia 1/35e (28) .................... 95

zovia 1/50e (28) .................... 95

ZUBSOLV ............................ 35

ZURAMPIC ......................... 86

ZYDELIG ............................. 24

ZYFLO CR ......................... 107

ZYKADIA ............................ 24

ZYLET ............................... 100

ZYPREXA RELPREVV ...... 41

ZYTIGA ............................... 24

ZYVOX ................................ 13

pharmacy benefit guide - children's community health plan · internal reference: tog member...

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