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Tufts Health RITogether

Pharmacy program and Preferred Drug List

December 1, 2017

Introduction

Pharmacy program

We aim to provide high-quality, cost-effective options for drug therapy. We work with your health care providers and pharmacists to make sure we cover the most important

and useful drugs for a variety of conditions and diseases. We cover both first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your provider writes a prescription and it is filled at a pharmacy.

Our pharmacy program does not cover all drugs and prescriptions. Some drugs must

meet certain clinical guidelines before we can cover them. Your provider must ask us for prior approval before we will cover these drugs.

Preferred Drug List (PDL)

We list all drugs according to their therapeutic category and drug class, followed by generic or brand drug name. Use the index to find a drug according to its generic or

brand name. In general, we cover brand-name medications only when a generic medication is not available or if we give prior approval for the brand-name drug.

Co-payments

Outpatient drugs that are medically necessary are covered when they are prescribed by

a provider who is licensed to prescribe drugs. Some drugs on the

Tufts Health RITogether formulary are only covered when your provider submits a prior approval request. Eligibility for outpatient prescription drug benefits and co-payment amounts are based on your individual benefit plan.

The PDL applies only to drugs you get at retail and specialty pharmacies. The PDL does not apply to drugs you get if you are in the hospital. Drugs you get while in the hospital are covered as part of your stay.

For the most current PDL coverage information, please visit tuftshealthplan.com or call us at 866.738.4116 (TTY: 711).

Prior approval

Some drugs always require prior approval, which means your provider must ask us for

approval before we will cover the drug. One of our clinicians will review this request. We will cover the drug according to our clinical guidelines if:

There is a medical reason you need the particular drug

Depending on the drug, other drugs on the PDL have not worked

If we do not approve the request for prior approval, you or your authorized

representative, if you identify one, can appeal the decision. See your Member Handbook for our member grievances and appeals information.

Step therapy program

We cover some types of drugs only through our step therapy program. Our step

therapy program requires you to try first-level drugs before we will cover another drug of that type. If you and your provider feel a certain drug is not appropriate for treating your health condition, your provider can ask us for prior approval for the other drug.

One of our clinicians will review the request. We will cover the drug according to our clinical guidelines. If we do not approve the request for prior approval, you or your authorized representative, if you identify one, can appeal the decision. See your

Member Handbook for our grievances and appeals information.

Quantity limit

To make sure the drugs you take are safe and that you are getting the right amount,

we may limit how much you can get at one time. Your provider can ask us for prior

approval if you need more than we cover. One of our clinicians will review the request. We will cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we do not approve the request for prior approval,

you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

Generic drugs

Generic drugs have the same active ingredients and work the same as brand-name

drugs. Rhode Island has a Generic First Program and requires that all members use generic drugs first. When generic drugs are available, we will not cover the brand-name drug without giving prior approval. If you and your provider feel a generic drug is not

right for treating your health condition and that the brand-name drug is medically necessary, your provider can ask for prior approval. One of our clinicians will review the request. If we do not approve the request for prior approval, you or your authorized

representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

New-to-market drugs

We review new drugs for safety and effectiveness before we add them to our PDL.

Coverage limits

The Requirements/Limits column in the PDL shows when a drug has a certain

requirement or limit for coverage. Coverage limits include:

AGE — Age restriction may apply

This medication requires prior approval if the drug is not covered based on your age. Your provider should send us a prior approval request if the drug is

medically necessary.

PA — Prior approval

This medication requires prior approval. Your provider may prescribe a different

medication on the PDL or send us a prior approval request.

QL — Quantity limit

This medication is limited to a specific amount. If a larger amount is medically necessary, your provider should send us a prior approval request.

ST — Step therapy

This medication requires prior approval if you have not already used a first-line medication on the PDL. Your provider may prescribe another medication on the

PDL or send us a prior approval request.

Specialty pharmacy program

A specialty pharmacy may supply you with some drugs often used to treat chronic

conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These

pharmacies can give extra support to members and providers.

CVS Specialty is our specialty pharmacy and can provide you with these drugs. In

addition to providing specific specialty drugs, CVS Specialty will:

Deliver drugs to your home, provider’s office or any delivery address you choose (except for a P.O. box)

Answer your questions and offer help with your drugs

Give you information, materials and ongoing support to help you manage your

health condition and make sure you take your drugs the right way

Have staff pharmacists available who can help you at 800.237.2767.

THP-OCR-NOTICE-0716

DISCRIMINATION IS AGAINST THE LAW

Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate

on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not

exclude people or treat them differently because of race, color, national origin, age, disability,

or sex.

Tufts Health Plan:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

— Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

— Qualified interpreters

— Information written in other languages

If you need these services, contact Tufts Health Plan at 888.257.1985.

If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way

on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 711 or 800.439.2370]

Fax: 617.972.9048

Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a

grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint

Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

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

tuftshealthplan.com | 888.257.1985

THP-OCR-NOTICE-0716

LA DISCRIMINACIÓN ES

CONTRA LA LEY

Tufts Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina

por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Tufts Health Plan no

excluye a las personas ni las trata de forma diferente debido a su raza, color, nacionalidad,

edad, discapacidad o sexo.

Tufts Health Plan:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:

— Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)

Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

— Intérpretes capacitados

— Información escrita en otros idiomas

Si necesita recibir estos servicios, comuníquese con Servicios para Miembros de Tufts Health Plan a 888.257.1985.

Si considera que Tufts Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de

raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 866-930-9252]

Fax: 617.972.9048

Email: [email protected]

Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el

coordinador de derechos civiles con Tufts Health Plan está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles)

del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera

electrónica a través de Office for Civil Rights Complaint Portal, disponible en

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los

números que figuran a continuación:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

tuftshealthplan.com | 888.257.1985

For no-cost translation in English, call 866.738.4116.

Arabic 866.738.4116 الرقم على االتصال یرجى العربیة، باللغة المجانیة الترجمة خدمة على للحصول

Chinese 若需免費的中文版本，請撥打 866.738.4116。

French Pour demander une traduction gratuite en français, composez le 866.738.4116.

German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die folgende Telefonnummer

an: 866.738.4116.

Greek Για δωρεάν μετάφραση στα ελληνικά, καλέστε στο 866.738.4116.

Haitian Creole Pou tradiksyon gratis nan Kreyòl Ayisyen, rele 866.738.4116.

Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero 866.738.4116.

Japanese 日本語の無料翻訳については 866.738.4116 に電話してください。

Khmer (Cambodian) សមរាបស់សវាបកបបរបសោយឥតគតិថ្ ៃ លជា ភាោ ប ្ប មរ សមូទរូសព័្ទសៅកានស់សម 866.738.4116 ។

Korean 한국어로 무료 통역을 원하시면, 866.738.4116 로 전화하십시오.

Laotian ໍ ສາໍ ລບການແປພາສາເໍ ປນພາສາລາ ວທໍ ໍ

ບໄ ໍ ດເສຍ ຄາໃ ໍ ຊຈາຍ , ໃໍ ຫໂທຫາເ ບ 866.738.4116.

Navajo Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 866.738.4116.

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List-Languages-THP-Number-07/16

Table of Contents

BLOOD DISORDER................................................................................................................................................. 3CALORIC UNDERNUTRITION..............................................................................................................................7CHRONIC LUNG OR BREATHING PASSAGE PROBLEM................................................................................ 8COLD SYMPTOMS................................................................................................................................................12COLLAGEN VASCULAR DISEASE.................................................................................................................... 14CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM...........................................................16DISEASE AFFECTING THE BODY'S METABOLISM.......................................................................................24DISEASE OF THE HEART AND BLOOD VESSELS..........................................................................................33DISEASE OF THE URINARY TRACT................................................................................................................. 42DISORDER OF NERVE......................................................................................................................................... 45DISORDER OF NERVOUS SYSTEM................................................................................................................... 55DISORDER OF REPRODUCTIVE SYSTEM....................................................................................................... 65DISORDER OF RESPIRATORY SYSTEM...........................................................................................................73DISORDER OF THE DIGESTIVE SYSTEM........................................................................................................ 78DISORDER OF THE ENDOCRINE GLANDS......................................................................................................86EAR PROBLEM......................................................................................................................................................91EYE DISORDER..................................................................................................................................................... 92FEVER..................................................................................................................................................................... 94INFECTION.............................................................................................................................................................94INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY.............................................................102INFLAMMATORY DISORDER.......................................................................................................................... 103INJURY..................................................................................................................................................................119INJURY TO A MUCOUS MEMBRANE............................................................................................................. 119LUNG DISEASE................................................................................................................................................... 120MARGINAL ZONE LYMPHOMA...................................................................................................................... 125MUSCLE OR BONE DISORDER........................................................................................................................ 125NEUROPSYCHIATRIC DISORDER...................................................................................................................135NOT FEELING WELL..........................................................................................................................................145NUTRITIONAL DISORDER................................................................................................................................145OTHER OVER-THE-COUNTER DRUGS...........................................................................................................146OTHER PRESCRIPTION DRUGS.......................................................................................................................151OVERDOSE...........................................................................................................................................................169PAIN.......................................................................................................................................................................170PATIENT DEMOGRAPHICS...............................................................................................................................178PREGNANCY....................................................................................................................................................... 179PROCEDURE........................................................................................................................................................ 180REACTION DUE TO AN ALLERGEN............................................................................................................... 183RECENT OPERATION.........................................................................................................................................185SKIN CONDITION............................................................................................................................................... 187SLOW DRUG ELIMINATION BY KIDNEY......................................................................................................196TUMOR................................................................................................................................................................. 196

1

Drug Status NotesBLOOD DISORDER

ACTIMMUNE SUBCUTANEOUS SOLUTION Brand PA; SP

ADEMPAS ORAL TABLET Brand PA; SP

Advate Intravenous SOLUTION RECONSTITUTED

MB/RX SP

Adynovate Intravenous SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT, 750 UNIT

MB/RX SP

Adynovate Intravenous SOLUTION RECONSTITUTED 3000 UNIT

MB/RX

Afstyla Intravenous KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

MB/RX SP

Afstyla Intravenous KIT 1500 UNIT, 2500 UNIT MB/RX

Alphanate/VWF Complex/Human Intravenous SOLUTION RECONSTITUTED

MB/RX SP

AlphaNine SD Intravenous SOLUTION RECONSTITUTED

MB/RX SP

Alprolix Intravenous SOLUTION RECONSTITUTED

MB/RX SP

ANADROL-50 ORAL TABLET Brand PA

anagrelide hcl oral capsule Generic

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Brand SP; QL (4 ML per 30 days)

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML


aspirin-dipyridamole er oral capsule extended release 12 hour

Generic PA; QL (60 EA per 30 days)

AURYXIA ORAL TABLET Brand PA

Bebulin Intravenous SOLUTION RECONSTITUTED

MB/RX SP

BeneFIX Intravenous KIT MB/RX SP

BRILINTA ORAL TABLET 60 MG Brand QL (60 EA per 30 days)

^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy

3

Drug Status NotesBRILINTA ORAL TABLET 60 MG, 90 MG Brand PA; QL (60 EA per 30 days)

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM

Medical Benefit PA; SP

Coagadex Intravenous SOLUTION RECONSTITUTED

MB/RX

Corifact Intravenous KIT MB/RX SP

dipyridamole oral tablet Generic

DROXIA ORAL CAPSULE Brand

ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)

Eloctate Intravenous SOLUTION RECONSTITUTED

MB/RX

enoxaparin sodium injection solution Generic

enoxaparin sodium subcutaneous solution Generic

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Brand SP

FARYDAK ORAL CAPSULE Brand PA; SP

Feiba Intravenous SOLUTION RECONSTITUTED

MB/RX SP

folic acid oral tablet 1 mg Generic

fondaparinux sodium subcutaneous solution Generic

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED


GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

Medical Benefit PA

GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA

GAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

Helixate FS Intravenous KIT MB/RX SP

Hemofil M Intravenous SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP


4

Drug Status Notesheparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Generic

Humate-P Intravenous SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

MB/RX SP

Idelvion Intravenous SOLUTION RECONSTITUTED

MB/RX SP

IMBRUVICA ORAL CAPSULE Brand PA

IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)

Ixinity Intravenous SOLUTION RECONSTITUTED

MB/RX SP

JADENU ORAL TABLET Brand PA; SP

JADENU SPRINKLE ORAL PACKET Brand PA

JAKAFI ORAL TABLET Brand PA; SP

Koate-DVI Intravenous SOLUTION RECONSTITUTED

MB/RX SP

Kogenate FS Bio-Set Intravenous KIT MB/RX SP

Kogenate FS Intravenous KIT MB/RX SP

Kovaltry Intravenous SOLUTION RECONSTITUTED

MB/RX SP

leucovorin calcium oral tablet Generic

LEUKERAN ORAL TABLET Brand

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG Medical Benefit PA; SP


Monoclate-P Intravenous KIT 1000 UNIT, 1500 UNIT

MB/RX SP

Mononine Intravenous SOLUTION RECONSTITUTED 1000 UNIT

MB/RX SP

NEULASTA DELIVERY KIT SUBCUTANEOUS PREFILLED SYRINGE KIT

Brand SP

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP


5

Drug Status NotesNEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand SP

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE Brand SP

NINLARO ORAL CAPSULE Brand PA; SP

Novoeight Intravenous SOLUTION RECONSTITUTED

MB/RX SP

NovoSeven RT Intravenous SOLUTION RECONSTITUTED

MB/RX SP

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

Nuwiq Intravenous KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

Nuwiq Intravenous KIT 2500 UNIT, 3000 UNIT, 4000 UNIT

MB/RX

Nuwiq Intravenous SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

Nuwiq Intravenous SOLUTION RECONSTITUTED 2500 UNIT, 3000 UNIT, 4000 UNIT

MB/RX

Obizur Intravenous SOLUTION RECONSTITUTED

MB/RX SP

OCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML


POMALYST ORAL CAPSULE Brand PA; SP

PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

prasugrel hcl oral tablet Generic PA

PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA

PROCRIT INJECTION SOLUTION Brand SP

Profilnine Intravenous SOLUTION RECONSTITUTED

MB/RX SP

Profilnine SD Intravenous SOLUTION RECONSTITUTED

MB/RX SP

PROMACTA ORAL TABLET Brand PA; SP

Recombinate Intravenous SOLUTION RECONSTITUTED

MB/RX SP


6

Drug Status NotesRixubis Intravenous SOLUTION RECONSTITUTED

MB/RX SP

SAVAYSA ORAL TABLET Brand PA

SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP

TABLOID ORAL TABLET Brand

THALOMID ORAL CAPSULE Brand SP

Tretten Intravenous SOLUTION RECONSTITUTED

MB/RX SP

VENCLEXTA ORAL TABLET Brand PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK Brand PA

Vonvendi Intravenous SOLUTION RECONSTITUTED

MB/RX SP

warfarin sodium oral tablet Generic

Wilate Intravenous KIT MB/RX SP

XARELTO ORAL TABLET Brand PA; QL (30 EA per 30 days)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand

PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)

XATMEP ORAL SOLUTION Brand PA

Xyntha Intravenous KIT MB/RX SP

Xyntha Solofuse Intravenous KIT MB/RX SP

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE Brand SP

ZONTIVITY ORAL TABLET Brand PA

ZYDELIG ORAL TABLET Brand

CALORIC UNDERNUTRITION


calcium acetate (phos binder) oral capsule Generic

calcium acetate (phos binder) oral tablet Generic

cyanocobalamin injection solution Generic

ergocalciferol oral capsule Generic

folbee oral tablet Generic



levocarnitine oral solution Generic


7

Drug Status Noteslevocarnitine oral tablet Generic

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

Generic

multi vitamin/fluoride oral tablet chewable Brand

multi vitamin/minerals oral tablet Generic

multi-vit/fluoride oral solution Generic

multi-vit/fluoride/iron oral solution Generic

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

Generic

multi-vitamin/fluoride oral tablet chewable 0.5 mg

Brand

mynephrocaps oral capsule Generic

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP

RENAL ORAL CAPSULE Generic

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP

tri-vit/fluoride/iron oral solution Brand

tri-vitamin/fluoride oral solution Generic

vitamin d (ergocalciferol) oral capsule Generic

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP

CHRONIC LUNG OR BREATHING PASSAGE PROBLEM

ADCIRCA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)


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

BrandPA; Age Limit (Min 4 Years and Max 11 Years)

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

Brand PA

ADVAIR HFA INHALATION AEROSOL Brand PA

albuterol sulfate er oral tablet extended release 12 hour

Generic

albuterol sulfate inhalation nebulization solution Generic

albuterol sulfate oral syrup Generic


8

Drug Status Notesalbuterol sulfate oral tablet Generic

ALVESCO INHALATION AEROSOL SOLUTION Brand

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA

ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand


Brand


Brand


Brand


Brand

ASMANEX HFA INHALATION AEROSOL Brand

ATROVENT HFA INHALATION AEROSOL SOLUTION Brand

azelastine hcl nasal solution 0.1 % Brand

BECONASE AQ NASAL SUSPENSION Brand PA

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)

budesonide inhalation suspension Generic

CAYSTON INHALATION SOLUTION RECONSTITUTED Brand

CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA

CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Brand

cromolyn sodium inhalation nebulization solution Generic


9

Drug Status NotesDALIRESP ORAL TABLET Brand PA; STPA

DULERA INHALATION AEROSOL Brand

epoprostenol sodium intravenous solution reconstituted 0.5 mg

Medical Benefit PA; SP; QL (4 EA per 30 days)



ESBRIET ORAL CAPSULE Brand PA; SP; QL (270 EA per 30 days)

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

FLOVENT HFA INHALATION AEROSOL Brand

fluticasone propionate nasal suspension Generic

fluticasone-salmeterol inhalation aerosol powder breath activated

Generic

FORADIL AEROLIZER INHALATION CAPSULE Brand

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

ipratropium bromide inhalation solution Generic

ipratropium bromide nasal solution Generic

ipratropium-albuterol inhalation solution Generic

KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)

KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

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

Generic

levalbuterol tartrate inhalation aerosol Generic PA

metaproterenol sulfate oral syrup Generic

metaproterenol sulfate oral tablet Generic

montelukast sodium oral packet Generic

montelukast sodium oral tablet Generic

montelukast sodium oral tablet chewable Generic

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA


10

Drug Status NotesOFEV ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

OMNARIS NASAL SUSPENSION Brand PA

OPSUMIT ORAL TABLET Brand PA; SP

ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA

ORKAMBI ORAL TABLET 200-125 MG Brand PA; SP; QL (120 EA per 30 days)

PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand

PROAIR HFA INHALATION AEROSOL SOLUTION Brand PA

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA

PROVENTIL HFA INHALATION AEROSOL SOLUTION Brand PA

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

PULMOZYME INHALATION SOLUTION Brand SP

QVAR INHALATION AEROSOL SOLUTION Brand

REMODULIN INJECTION SOLUTION Medical Benefit PA; SP

REVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION Brand

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand

SYMBICORT INHALATION AEROSOL Brand

terbutaline sulfate oral tablet Generic


11

Drug Status Notestheophylline er oral tablet extended release 12 hour

Generic

theophylline er oral tablet extended release 24 hour

Generic

theophylline oral solution Generic

TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)

tobramycin inhalation nebulization solution Generic

TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

Tyvaso INHALATION SOLUTION MB/RX PA; SP

Tyvaso Refill INHALATION SOLUTION MB/RX PA; SP

Tyvaso Starter INHALATION SOLUTION MB/RX PA; SP

UPTRAVI ORAL TABLET Brand PA; SP

UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

Ventavis INHALATION SOLUTION MB/RX PA; SP; QL (9 Vials per 1 day)

VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)

zafirlukast oral tablet Brand

ZETONNA NASAL AEROSOL SOLUTION Brand PA

COLD SYMPTOMS



benzonatate oral capsule 100 mg, 200 mg Generic

budesonide nasal suspension Generic PA

cetirizine hcl oral solution Generic PA

cetirizine hcl oral syrup 1 mg/ml Generic PA

CLARINEX ORAL SYRUP Brand PA


clemastine fumarate oral tablet 2.68 mg Generic

cyproheptadine hcl oral syrup Generic

cyproheptadine hcl oral tablet Generic


12

Drug Status Notesdesloratadine oral tablet Generic PA

flunisolide nasal solution 25 mcg/act (0.025%) Generic


guaifenesin er oral tablet extended release 12 hour 600 mg

Generic

hydrocod polst-cpm polst er oral suspension extended release

Generic

hydrocodone-homatropine oral syrup Generic

hydrocodone-homatropine oral tablet Generic

hydromet oral syrup Generic


levocetirizine dihydrochloride oral solution Generic PA

levocetirizine dihydrochloride oral tablet Generic PA

mometasone furoate nasal suspension Generic PA






phenyleph-promethazine-cod oral syrup Generic

promethazine vc plain oral syrup Generic

promethazine vc/codeine oral syrup Generic

promethazine-codeine oral syrup Generic

promethazine-dm oral syrup Generic

promethazine-phenylephrine oral syrup Generic

pseudoephedrine hcl oral tablet 60 mg Generic

QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA

QNASL NASAL AEROSOL SOLUTION Brand PA

SEMPREX-D ORAL CAPSULE Brand PA

triamcinolone acetonide nasal aerosol Generic

TUSSIGON ORAL TABLET Generic

VERAMYST NASAL SUSPENSION Brand PA



13

Drug Status NotesCOLLAGEN VASCULAR DISEASE

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)



ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (4 syringes per 28 days)

azathioprine oral tablet Generic

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA

celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)

cevimeline hcl oral capsule Generic

CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)

CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand

PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)

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

Brand PA; SP

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP

diclofenac sodium er oral tablet extended release 24 hour

Generic

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand



14

Drug Status NotesENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand


ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


etodolac er oral tablet extended release 24 hour Generic

flurbiprofen oral tablet Generic

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

Brand PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)

hydroxychloroquine sulfate oral tablet Generic

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

ketoprofen er oral capsule extended release 24 hour

Generic

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)

leflunomide oral tablet Generic

meloxicam oral suspension Generic

meloxicam oral tablet Generic

methotrexate oral tablet Generic

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)

nabumetone oral tablet Generic

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)


15

Drug Status NotesORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit

PA; SP; QL (4 VIALS per 28 days)

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)

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

Brand PA; QL (1.6 ML per 28 days)

oxaprozin oral tablet Generic

PANRETIN EXTERNAL GEL Brand PA

pilocarpine hcl oral tablet Generic

piroxicam oral capsule Generic

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP

salsalate oral tablet Generic

SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand

PA; SP; QL (1 syringe per 28 days)

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


sulfasalazine oral tablet delayed release Generic

tolmetin sodium oral capsule Generic

tolmetin sodium oral tablet Generic

TREXALL ORAL TABLET Brand

XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)

CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM

abacavir sulfate oral solution Generic

abacavir sulfate oral tablet Generic

abacavir sulfate-lamivudine oral tablet Brand

abacavir-lamivudine-zidovudine oral tablet Brand


16

Drug Status NotesACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)







MB/RX SP

APTIVUS ORAL CAPSULE Brand

APTIVUS ORAL SOLUTION Brand

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)

ATRIPLA ORAL TABLET Brand





Berinert Intravenous KIT MB/RX SP

BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML Medical Benefit PA










17

Drug Status NotesCOMPLERA ORAL TABLET Brand

cortisone acetate oral tablet Generic


Brand PA; SP


CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand

cromolyn sodium oral concentrate Generic

Cuvitru Subcutaneous SOLUTION MB/RX PA

cyclosporine modified oral capsule Generic

cyclosporine modified oral solution Generic

cyclosporine oral capsule Generic

DESCOVY ORAL TABLET Brand


Generic

didanosine oral capsule delayed release Generic

dronabinol oral capsule Generic

EDURANT ORAL TABLET Brand


EMTRIVA ORAL CAPSULE Brand

EMTRIVA ORAL SOLUTION Brand





ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand







EVOTAZ ORAL TABLET Brand

FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)


18

Drug Status NotesFLEBOGAMMA DIF INTRAVENOUS SOLUTION Medical Benefit PA


fosamprenavir calcium oral tablet Generic

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP

Gammagard INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML

MB/RX PA

Gammagard INJECTION SOLUTION 20 GM/200ML

MB/RX PA; SP




Medical Benefit PA



GENGRAF ORAL CAPSULE Generic

GENGRAF ORAL SOLUTION Generic

GENVOYA ORAL TABLET Brand


guanidine hcl oral tablet Brand PA

Hizentra Subcutaneous SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

MB/RX PA; SP


MB/RX SP






19

Drug Status NotesHUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)


hydrocortisone oral tablet Generic


Hyqvia Subcutaneous KIT MB/RX PA; SP

ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED


ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP


INTELENCE ORAL TABLET Brand

INVIRASE ORAL CAPSULE Brand

INVIRASE ORAL TABLET Brand

ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)

ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)

ISENTRESS ORAL TABLET Brand

ISENTRESS ORAL TABLET CHEWABLE Brand

KALETRA ORAL SOLUTION Brand

KALETRA ORAL TABLET Brand


Generic



lamivudine oral solution Brand

lamivudine oral tablet 150 mg, 300 mg Brand

lamivudine-zidovudine oral tablet Brand


LEXIVA ORAL SUSPENSION Brand


Generic



20

Drug Status Notesmeloxicam oral tablet Generic


methylprednisolone oral tablet Generic

methylprednisolone oral tablet therapy pack Generic

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

Generic


mycophenolate mofetil oral capsule Generic

mycophenolate mofetil oral suspension reconstituted

Generic

mycophenolate mofetil oral tablet Generic

mycophenolic acid oral tablet delayed release Generic

MYLERAN ORAL TABLET Brand



Brand SP



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


nevirapine er oral tablet extended release 24 hour Generic

nevirapine oral suspension Generic

nevirapine oral tablet Generic


NORVIR ORAL CAPSULE Brand

NORVIR ORAL SOLUTION Brand

NORVIR ORAL TABLET Brand

NOXAFIL ORAL SUSPENSION Brand PA

NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA


21

Drug Status NotesNPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP


MB/RX SP

OCTAGAM INTRAVENOUS SOLUTION Medical Benefit PA; SP

ODEFSEY ORAL TABLET Brand


ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit









prednisolone oral solution Generic

prednisolone oral syrup 15 mg/5ml Generic

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

Generic

prednisolone sodium phosphate oral tablet dispersible

Generic

PREZCOBIX ORAL TABLET Brand

PREZISTA ORAL SUSPENSION Brand

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



pyridostigmine bromide er oral tablet extended release

Generic

pyridostigmine bromide oral tablet Generic

RAPAMUNE ORAL SOLUTION Brand



22

Drug Status NotesRENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

RESCRIPTOR ORAL TABLET Brand

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG Brand

REYATAZ ORAL PACKET Brand


Ruconest Intravenous SOLUTION RECONSTITUTED

MB/RX SP


SELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET Brand







sirolimus oral tablet Generic


stavudine oral capsule Brand

stavudine oral solution reconstituted Brand

STRIBILD ORAL TABLET Brand


SUSTIVA ORAL CAPSULE Brand

SUSTIVA ORAL TABLET Brand

SYNDROS ORAL SOLUTION Brand PA

tacrolimus oral capsule Generic

TIVICAY ORAL TABLET Brand




TRIUMEQ ORAL TABLET Brand


23

Drug Status NotesTRUVADA ORAL TABLET 200-300 MG Brand

TYBOST ORAL TABLET Brand

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand

VIRACEPT ORAL TABLET Brand

VIREAD ORAL POWDER Brand

VIREAD ORAL TABLET Brand





zidovudine oral capsule Brand

zidovudine oral syrup Brand

zidovudine oral tablet Brand


ZORTRESS ORAL TABLET Brand SP

DISEASE AFFECTING THE BODY'S METABOLISM

acarbose oral tablet Generic

acetazolamide oral tablet Generic

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

alendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)

ALLI ORAL CAPSULE Brand PA

allopurinol oral tablet Generic

alogliptin benzoate oral tablet Generic PA; QL (30 EA per 30 days)

alogliptin-metformin hcl oral tablet Generic PA; QL (60 EA per 30 days)

alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)

amiloride hcl oral tablet Generic


24

Drug Status Notesamlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)

ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)


atorvastatin calcium oral tablet Generic


AVANDAMET ORAL TABLET 2-1000 MG Brand PA

AVANDIA ORAL TABLET Brand PA

BELVIQ ORAL TABLET Brand PA

BELVIQ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

benzphetamine hcl oral tablet Generic PA


bumetanide oral tablet Generic

BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION Brand PA

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA



calcitriol oral capsule Generic

calcitriol oral solution Generic



captopril oral tablet Generic

CARBAGLU ORAL TABLET Brand PA


CERDELGA ORAL CAPSULE Brand PA; QL (30 EA per 30 days)


25

Drug Status NotesCEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT Medical Benefit PA; SP



chlorothiazide oral tablet Generic

chlorpropamide oral tablet Generic

chlorthalidone oral tablet 25 mg, 50 mg Generic

CHOLBAM ORAL CAPSULE Brand PA

cholestyramine light oral packet Generic

cholestyramine light oral powder Generic

cholestyramine oral packet Generic

cholestyramine oral powder Generic

Cinryze Intravenous SOLUTION RECONSTITUTED

MB/RX PA

colchicine oral tablet Generic

colchicine-probenecid oral tablet Generic

colestipol hcl oral packet Generic

colestipol hcl oral tablet Generic

constulose oral solution Generic

CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA

CYSTAGON ORAL CAPSULE Brand PA; SP

danazol oral capsule Generic

desmopressin ace rhinal tube nasal solution Generic

desmopressin ace spray refrig nasal solution Generic

desmopressin acetate oral tablet Generic

desmopressin acetate spray nasal solution Generic

diethylpropion hcl er oral tablet extended release 24 hour

Generic PA

diethylpropion hcl oral tablet Generic PA


DUZALLO ORAL TABLET Brand PA



26

Drug Status NotesELELYSO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

enulose oral solution Generic

ethacrynic acid oral tablet Generic PA

etidronate disodium oral tablet Generic

ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)

ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

FARXIGA ORAL TABLET Brand PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 130 mg, 43 mg


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

Generic QL (30 EA per 30 days)

fenofibrate oral capsule Generic PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg


fenofibrate oral tablet 160 mg, 54 mg Generic QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)

fenofibric acid oral tablet Generic PA; QL (30 EA per 30 days)


flolipid oral suspension Brand PA

fluvastatin sodium er oral tablet extended release 24 hour


fluvastatin sodium oral capsule Generic PA; QL (30 EA per 30 days)

furosemide injection solution 10 mg/ml Generic

furosemide oral solution 10 mg/ml, 8 mg/ml Generic

furosemide oral tablet Generic

gemfibrozil oral tablet Generic

generlac oral solution Generic

glimepiride oral tablet Generic

glipizide er oral tablet extended release 24 hour Generic

glipizide oral tablet Generic

glipizide xl oral tablet extended release 24 hour Generic

glipizide-metformin hcl oral tablet Generic


27

Drug Status NotesGLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand

GLUCAGON EMERGENCY INJECTION KIT Brand

glyburide micronized oral tablet Generic

glyburide oral tablet Generic

glyburide-metformin oral tablet Generic

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Brand




indapamide oral tablet Generic

indomethacin er oral capsule extended release Generic

indomethacin oral capsule Generic

INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand

PA; STPA; QL (60 Tablets per 30 days)

INVOKANA ORAL TABLET 100 MG BrandPA; STPA; QL (30 EA per 30 days)


JUXTAPID ORAL CAPSULE Brand PA; QL (30 EA per 30 days)



KANUMA INTRAVENOUS SOLUTION Medical Benefit PA

KEVEYIS ORAL TABLET Brand PA

KIONEX ORAL POWDER Generic

KIONEX ORAL SUSPENSION Generic

KORLYM ORAL TABLET Brand PA


28

Drug Status NotesKRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP

KUVAN ORAL TABLET SOLUBLE Brand PA; SP

KYNAMRO SUBCUTANEOUS SOLUTION Brand PA; SP; QL (4 EA per 28 days)

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (4 EA per 28 days)

lactulose encephalopathy oral solution Generic

lactulose oral solution Generic



LIVALO ORAL TABLET Brand PA; QL (30 EA per 30 days)

lovastatin oral tablet Generic

LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)


Generic

metformin hcl er (mod) oral tablet extended release 24 hour

Generic PA

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

Generic PA

metformin hcl er oral tablet extended release 24 hour

Generic

metformin hcl oral tablet Generic

methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)

methyclothiazide oral tablet Generic

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

Generic

metoclopramide hcl oral tablet Generic

metolazone oral tablet Generic

micronized colestipol hcl oral tablet Generic

miglitol oral tablet Generic


nateglinide oral tablet Generic


29

Drug Status Notes

NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)

niacin er (antihyperlipidemic) oral tablet extended release

Generic

niacin er oral capsule extended release Generic

NIACOR ORAL TABLET Generic


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

Generic PA; SP; QL (30 ML per 30 days)

octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)


oxandrolone oral tablet 10 mg Generic PA; QL (60 EA per 30 days)

oxandrolone oral tablet 2.5 mg Generic PA; QL (240 EA per 30 days)

phendimetrazine tartrate er oral capsule extended release 24 hour

Generic PA

phendimetrazine tartrate oral tablet Generic PA

phentermine hcl oral capsule Generic PA

phentermine hcl oral tablet Generic PA

PHOSPHA 250 NEUTRAL ORAL TABLET Generic

pioglitazone hcl oral tablet Generic

pioglitazone hcl-glimepiride oral tablet Generic

pioglitazone hcl-metformin hcl oral tablet Generic

pot bicarb-pot chloride oral tablet effervescent Generic

potassium bicarbonate oral tablet effervescent Generic

potassium chloride crys er oral tablet extended release

Generic

potassium chloride er oral capsule extended release

Generic

potassium chloride er oral tablet extended release Generic

potassium chloride oral packet Generic

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

Generic


30

Drug Status NotesPRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)

pravastatin sodium oral tablet Generic

probenecid oral tablet Generic


QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA

RAVICTI ORAL LIQUID Brand PA; SP

repaglinide oral tablet Generic

repaglinide-metformin hcl oral tablet Generic

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand

PA; SP; # (Preferred product); QL (1 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


risedronate sodium oral tablet 30 mg Generic PA; QL (30 EA per 30 days)

rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)


MB/RX SP

SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA


simvastatin oral tablet Generic

sodium polystyrene sulfonate oral powder Generic

sodium polystyrene sulfonate oral suspension Generic

sodium polystyrene sulfonate rectal suspension Generic

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)

spironolactone oral tablet Generic

spironolactone-hctz oral tablet Generic

SPS ORAL SUSPENSION Generic

STRENSIQ SUBCUTANEOUS SOLUTION Brand PA; QL (24 Vials per 28 days)

SUPRENZA ORAL TABLET DISPERSIBLE Brand PA


31

Drug Status NotesSYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA


SYPRINE ORAL CAPSULE Brand PA

TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA



tolazamide oral tablet Generic

tolbutamide oral tablet Generic

torsemide oral tablet Generic

triamterene-hctz oral capsule Generic

triamterene-hctz oral tablet Generic

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

VELTASSA ORAL PACKET Brand PA

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

WELCHOL ORAL TABLET Brand PA

XENICAL ORAL CAPSULE Brand PA

XGEVA SUBCUTANEOUS SOLUTION Medical Benefit PA; SP; QL (1 vial per 30 days)

XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


XURIDEN ORAL PACKET Brand PA; QL (120 Packets per 30 days)


ZURAMPIC ORAL TABLET Brand PA


32

Drug Status NotesDISEASE OF THE HEART AND BLOOD VESSELS

acebutolol hcl oral capsule Generic



almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)


MB/RX SP

amiloride hcl oral tablet Generic

amiloride-hydrochlorothiazide oral tablet Generic

aminocaproic acid oral tablet Generic

amiodarone hcl oral tablet Generic

amlodipine besy-benazepril hcl oral capsule Generic QL (30 EA per 30 days)

amlodipine besylate oral tablet Generic

amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)

amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)

amlodipine-olmesartan oral tablet Generic PA

amlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)




atenolol oral tablet Generic

atenolol-chlorthalidone oral tablet Generic

benazepril hcl oral tablet Generic

benazepril-hydrochlorothiazide oral tablet Generic

betaxolol hcl oral tablet Generic

BIDIL ORAL TABLET Brand PA

bisoprolol fumarate oral tablet Generic

bisoprolol-hydrochlorothiazide oral tablet Generic

BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP


BRILINTA ORAL TABLET 60 MG, 90 MG Brand PA; QL (60 EA per 30 days)

bumetanide oral tablet Generic


33

Drug Status Notes

BYSTOLIC ORAL TABLET BrandPA; STPA; QL (30 EA per 30 days)

candesartan cilexetil oral tablet Generic PA


captopril-hydrochlorothiazide oral tablet Generic

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA



carvedilol oral tablet Generic

cilostazol oral tablet Generic

clonidine hcl oral tablet Generic

clonidine hcl transdermal patch weekly Generic

clopidogrel bisulfate oral tablet Generic

CLORPRES ORAL TABLET Generic

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand STPA; QL (30 EA per 30 days)

CORLANOR ORAL TABLET Brand PA

DEMSER ORAL CAPSULE Brand

DIGITEK ORAL TABLET Generic

DIGOX ORAL TABLET Generic

digoxin oral solution Generic

digoxin oral tablet Generic

dihydroergotamine mesylate nasal solution Generic

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

Generic

diltiazem hcl er beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral tablet extended release 24 hour

Generic

diltiazem hcl er oral capsule extended release 12 hour

Generic

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

Generic


34

Drug Status Notesdiltiazem hcl oral tablet Generic

disopyramide phosphate oral capsule Generic

divalproex sodium er oral tablet extended release 24 hour

Generic

divalproex sodium oral capsule delayed release sprinkle

Generic

divalproex sodium oral tablet delayed release Generic

dofetilide oral capsule Generic

doxazosin mesylate oral tablet Generic

EDARBI ORAL TABLET Brand PA

eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)


enalapril maleate oral tablet Generic

enalapril-hydrochlorothiazide oral tablet Generic



ENTRESTO ORAL TABLET Brand PA

epinephrine hcl injection solution 1 mg/ml Generic

eplerenone oral tablet Generic PA; QL (60 EA per 30 days)





eprosartan mesylate oral tablet Generic PA


Feiba Intravenous SOLUTION RECONSTITUTED

MB/RX SP

felodipine er oral tablet extended release 24 hour Generic

flecainide acetate oral tablet Generic



fosinopril sodium oral tablet Generic

fosinopril sodium-hctz oral tablet Generic

frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)


35

Drug Status Notesfurosemide oral solution 10 mg/ml, 8 mg/ml Generic

furosemide oral tablet Generic




Medical Benefit PA



guanfacine hcl oral tablet Generic

HEMMOREX-HC RECTAL SUPPOSITORY Generic

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

Generic


MB/RX SP

hydralazine hcl oral tablet Generic

hydrochlorothiazide oral capsule Generic

hydrochlorothiazide oral tablet Generic

hydrocortisone ace-pramoxine external cream2.5-1 %

Generic

hydrocortisone ace-pramoxine rectal cream Generic

hydrocortisone acetate rectal suppository Generic

Hydroxyprogesterone Caproate Intramuscular Oil MB/RX

Hydroxyprogesterone Caproate Intramuscular SOLUTION

MB/RX

indapamide oral tablet Generic


irbesartan oral tablet Generic STPA

irbesartan-hydrochlorothiazide oral tablet Generic STPA

isosorbide dinitrate er oral tablet extended release

Generic

isosorbide dinitrate oral tablet Generic


36

Drug Status Notesisosorbide mononitrate er oral tablet extended release 24 hour

Generic

isosorbide mononitrate oral tablet Generic

isradipine oral capsule Generic PA

labetalol hcl oral tablet Generic


lisinopril oral tablet Generic

lisinopril-hydrochlorothiazide oral tablet Generic

losartan potassium oral tablet Generic

losartan potassium-hctz oral tablet Generic



MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA

meclizine hcl oral tablet Generic

medroxyprogesterone acetate oral tablet Generic

MESNEX ORAL TABLET Brand

methyldopa oral tablet Generic

methyldopa-hydrochlorothiazide oral tablet Generic

methylergonovine maleate oral tablet Generic

metoprolol succinate er oral tablet extended release 24 hour

Generic

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

Generic

metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA

metoprolol-hydrochlorothiazide oral tablet Generic

mexiletine hcl oral capsule Generic

midodrine hcl oral tablet Generic

MIGERGOT RECTAL SUPPOSITORY Generic

minoxidil oral tablet Generic

moexipril hcl oral tablet Generic

moexipril-hydrochlorothiazide oral tablet Generic

nadolol oral tablet 20 mg, 40 mg, 80 mg Generic


37

Drug Status Notesnadolol-bendroflumethiazide oral tablet Generic

naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)

NATAZIA ORAL TABLET Generic

nicardipine hcl oral capsule Generic

nifedipine er oral tablet extended release 24 hour Generic

nifedipine er osmotic release oral tablet extended release 24 hour

Generic

nifedipine oral capsule Generic

nimodipine oral capsule Generic PA

nisoldipine er oral tablet extended release 24 hour

Generic

nitroglycerin sublingual tablet sublingual Generic

nitroglycerin transdermal patch 24 hour Generic

nitroglycerin translingual aerosol solution Generic

nitroglycerin translingual solution Generic

norethindrone acetate oral tablet Generic

NORTHERA ORAL CAPSULE Brand PA

NovoSeven RT Intravenous SOLUTION RECONSTITUTED

MB/RX SP



MB/RX SP



olmesartan medoxomil oral tablet Generic STPA

olmesartan medoxomil-hctz oral tablet Generic STPA

omeprazole-sodium bicarbonate oral packet Generic PA




pentoxifylline er oral tablet extended release Generic

perindopril erbumine oral tablet Generic


38

Drug Status Notesphenoxybenzamine hcl oral capsule Generic

pindolol oral tablet Generic


PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)

pramcort rectal cream Generic


prazosin hcl oral capsule Generic


progesterone intramuscular oil Generic PA


propafenone hcl er oral capsule extended release 12 hour

Generic

propafenone hcl oral tablet Generic

propranolol hcl er oral capsule extended release 24 hour

Generic

propranolol hcl oral solution 40 mg/5ml Generic

propranolol hcl oral tablet Generic

propranolol-hctz oral tablet Generic

quinapril hcl oral tablet Generic

quinapril-hydrochlorothiazide oral tablet Generic

quinidine gluconate er oral tablet extended release

Generic

quinidine sulfate er oral tablet extended release Generic

quinidine sulfate oral tablet Generic

ramipril oral capsule Generic

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)

ranitidine hcl oral capsule Generic

ranitidine hcl oral syrup Generic

ranitidine hcl oral tablet 150 mg, 300 mg Generic


REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand


REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand



39

Drug Status NotesREPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


reserpine oral tablet Generic


rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)




sotalol hcl (af) oral tablet 120 mg, 80 mg Generic

sotalol hcl oral tablet Generic


spironolactone-hctz oral tablet Generic

sumatriptan nasal solution Generic QL (6 Units per 30 days)

sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge


sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


TEKTURNA HCT ORAL TABLET Brand PA; QL (30 EA per 30 days)

TEKTURNA ORAL TABLET Brand PA; QL (30 EA per 30 days)

telmisartan oral tablet Generic PA

telmisartan-hctz oral tablet Generic PA

terazosin hcl oral capsule Generic

timolol maleate oral tablet Generic

topiramate er oral capsule er 24 hour sprinkle Generic PA

topiramate oral capsule sprinkle 15 mg Generic

topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)

topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)

topiramate oral tablet 200 mg Generic


40

Drug Status Notestopiramate oral tablet 25 mg Generic QL (180 EA per 30 days)

torsemide oral tablet Generic


trandolapril oral tablet Generic

trandolapril-verapamil hcl er oral tablet extended release

Generic

tranexamic acid oral tablet Generic PA

triamterene-hctz oral capsule Generic

triamterene-hctz oral tablet Generic

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA






valsartan oral tablet Generic STPA

valsartan-hydrochlorothiazide oral tablet Generic STPA



verapamil hcl er oral capsule extended release 24 hour

Generic

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

Generic

verapamil hcl oral tablet Generic

warfarin sodium oral tablet Generic





zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)

zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)

ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)


41

Drug Status NotesZONTIVITY ORAL TABLET Brand PA

DISEASE OF THE URINARY TRACT

AFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

alfuzosin hcl er oral tablet extended release 24 hour

Generic








bethanechol chloride oral tablet Generic




clindamycin phosphate vaginal cream Generic




darifenacin hydrobromide er oral tablet extended release 24 hour

Generic PA



doxercalciferol oral capsule Generic

dutasteride oral capsule Generic PA; QL (30 EA per 30 days)

dutasteride-tamsulosin hcl oral capsule Generic PA; QL (30 EA per 30 days)

ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP

EMCYT ORAL CAPSULE Brand


42

Drug Status NotesEPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Brand SP


finasteride oral tablet 5 mg Generic

flavoxate hcl oral tablet Generic

GELNIQUE TRANSDERMAL GEL Brand PA



GLYDO EXTERNAL GEL Generic



MB/RX

imipramine hcl oral tablet Generic

leuprolide acetate injection kit Medical Benefit PA; SP

lidocaine hcl external gel 2 % Generic



LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Medical Benefit PA; SP




methenamine hippurate oral tablet Generic

methenamine mandelate oral tablet Generic

metolazone oral tablet Generic

metronidazole vaginal gel Generic

miconazole 3 vaginal suppository Generic



Generic



43

Drug Status Notesmycophenolic acid oral tablet delayed release Generic

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA



OSPHENA ORAL TABLET Brand PA

oxybutynin chloride er oral tablet extended release 24 hour

Generic

oxybutynin chloride oral syrup Generic

oxybutynin chloride oral tablet Generic

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA

paricalcitol oral capsule Generic PA

phenazopyridine hcl oral tablet 100 mg, 200 mg Generic

PREMARIN VAGINAL CREAM Brand

PREMPHASE ORAL TABLET Brand

PREMPRO ORAL TABLET Brand



RAPAFLO ORAL CAPSULE Brand PA


SENSIPAR ORAL TABLET Brand PA




tamsulosin hcl oral capsule Generic


terconazole vaginal cream Generic

terconazole vaginal suppository Generic

tinidazole oral tablet Generic

tolterodine tartrate er oral capsule extended release 24 hour

Generic

tolterodine tartrate oral tablet Generic


44

Drug Status NotesTOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

tranexamic acid oral tablet Generic PA

trimethoprim oral tablet Generic

trospium chloride er oral capsule extended release 24 hour

Generic

trospium chloride oral tablet Generic

VANDAZOLE VAGINAL GEL Generic

VESICARE ORAL TABLET 10 MG Generic PA

VESICARE ORAL TABLET 10 MG, 5 MG Brand PA

ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; SP; QL (1 EA per 84 days)

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Medical Benefit PA; SP; QL (1 EA per 28 days)


DISORDER OF NERVE

AFINITOR DISPERZ ORAL TABLET SOLUBLE Brand PA; SP; QL (60 EA per 30 days)


amantadine hcl oral capsule Generic

amantadine hcl oral syrup Generic

amantadine hcl oral tablet Generic


amphetamine-dextroamphet er oral capsule extended release 24 hour

GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)

amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand

PA; SP; QL (60 Tablets per 30 days)

APTIOM ORAL TABLET Brand PA

armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)

armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)



atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)


45

Drug Status Notesatropine sulfate ophthalmic solution Generic

AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)

AVONEX INTRAMUSCULAR KIT Brand SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP

baclofen oral tablet Generic

BELSOMRA ORAL TABLET Brand PA

benztropine mesylate oral tablet Generic

BETASERON SUBCUTANEOUS KIT Brand SP

BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP


BRIVIACT ORAL SOLUTION Brand PA

BRIVIACT ORAL TABLET Brand PA

bromocriptine mesylate oral capsule Generic

bromocriptine mesylate oral tablet Generic

caffeine citrate oral solution Generic

carbamazepine er oral capsule extended release 12 hour

Generic

carbamazepine er oral tablet extended release 12 hour

Generic

carbamazepine oral suspension Generic

carbamazepine oral tablet Generic

carbamazepine oral tablet chewable Generic

carbidopa oral tablet Generic

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

Generic

carbidopa-levodopa oral tablet Generic

carbidopa-levodopa oral tablet dispersible Generic

carbidopa-levodopa-entacapone oral tablet Generic

chlordiazepoxide hcl oral capsule Generic

clonazepam oral tablet Generic


46

Drug Status Notesclonidine hcl er oral tablet extended release 12 hour


clorazepate dipotassium oral tablet Generic


COPAXONE SUBCUTANEOUS KIT Brand SP

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

dantrolene sodium oral capsule Generic

DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)

DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg


dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg


dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)

dextroamphetamine sulfate er oral capsule extended release 24 hour


dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)

dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

DIAZEPAM INTENSOL ORAL CONCENTRATE Generic

diazepam oral concentrate Generic

diazepam oral solution 1 mg/ml Generic

diazepam oral tablet Generic

diazepam rectal gel Generic QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)


47

Drug Status Notesdiphenhydramine hcl oral capsule 25 mg Brand

diphenhydramine hcl oral capsule 50 mg Generic

diphenhydramine hcl oral elixir Brand


Generic


Generic


donepezil hcl oral tablet 10 mg, 5 mg Generic

donepezil hcl oral tablet dispersible Generic

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)

DYSPORT (GLABELLAR LINES) INTRAMUSCULAR SOLUTION RECONSTITUTED


DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP

EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)


EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)

EMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)

entacapone oral tablet Generic


EPITOL ORAL TABLET Generic

ergoloid mesylates oral tablet Generic

estazolam oral tablet 1 mg Generic

eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)

ethosuximide oral capsule Generic

ethosuximide oral solution Generic

EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA

EXTAVIA SUBCUTANEOUS KIT Brand

flurazepam hcl oral capsule Generic


FYCOMPA ORAL SUSPENSION Brand PA

FYCOMPA ORAL TABLET Brand PA


48

Drug Status Notesgabapentin oral capsule Generic

gabapentin oral solution 250 mg/5ml Generic

gabapentin oral tablet Generic

galantamine hydrobromide er oral capsule extended release 24 hour

Generic

galantamine hydrobromide oral solution Generic

galantamine hydrobromide oral tablet Generic


MB/RX PA


MB/RX PA; SP


GILENYA ORAL CAPSULE Brand PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Generic

GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)

GRALISE STARTER ORAL Brand PA

guanfacine hcl er oral tablet extended release 24 hour

Generic PA


HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)

hydroxyzine hcl oral syrup Generic

hydroxyzine hcl oral tablet Generic

hydroxyzine pamoate oral capsule Generic

INCRELEX SUBCUTANEOUS SOLUTION Brand PA; SP

INGREZZA ORAL CAPSULE Brand PA




lamotrigine er oral tablet extended release 24 hour


lamotrigine odt oral tablet dispersible Generic


49

Drug Status Noteslamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg

Generic

lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)

lamotrigine oral tablet 200 mg Generic

lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)

lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)

lamotrigine oral tablet dispersible Generic

lamotrigine starter kit-blue oral kit Generic

lamotrigine starter kit-green oral kit Generic

lamotrigine starter kit-orange oral kit Generic

lamotrigine titration oral kit Generic

LEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA

levetiracetam er oral tablet extended release 24 hour 500 mg




levetiracetam oral solution Generic

levetiracetam oral tablet Generic

lidocaine external patch 5 % Generic




memantine hcl oral solution Generic

memantine hcl oral tablet Generic


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl er (cd) oral capsule extended release 30 mg


methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg



50

Drug Status Notes

methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg




methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 54 mg


methylphenidate hcl er oral tablet extended release 24 hour


methylphenidate hcl er oral tablet extended release 36 mg


methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)

methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)


modafinil oral tablet Generic PA; QL (30 EA per 30 days)

MYOBLOC INTRAMUSCULAR SOLUTION Medical Benefit PA; SP


NEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)



NUPLAZID ORAL TABLET BrandPA; SP; QL (60 Tablets per 30 days)

OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA




ONFI ORAL SUSPENSION Brand PA


51

Drug Status NotesONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)

oxazepam oral capsule Generic

oxcarbazepine oral suspension Generic

oxcarbazepine oral tablet Generic

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

Brand PA; QL (30 EA per 30 days)

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)

PEGANONE ORAL TABLET Brand PA

PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic

phenytoin oral suspension 125 mg/5ml Generic

phenytoin oral tablet chewable Generic

phenytoin sodium extended oral capsule Generic

pimozide oral tablet Generic PA

POTIGA ORAL TABLET Brand PA

pramipexole dihydrochloride er oral tablet extended release 24 hour

Generic

pramipexole dihydrochloride oral tablet Generic


Generic

propranolol hcl oral solution Generic



Generic


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)

rasagiline mesylate oral tablet Generic

REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP


52

Drug Status NotesREBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Brand SP

REBIF SUBCUTANEOUS SOLUTION Brand SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Brand SP

riluzole oral tablet Generic

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Brand PA; QL (30 EA per 30 days)

rivastigmine tartrate oral capsule Generic

rivastigmine transdermal patch 24 hour Generic



ropinirole hcl er oral tablet extended release 24 hour

Generic

ropinirole hcl oral tablet Generic

ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)

SABRIL ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)

selegiline hcl oral capsule Generic

selegiline hcl oral tablet Generic



SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)






53

Drug Status Notessumatriptan succinate subcutaneous solution 6 mg/0.5ml







TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)

temazepam oral capsule Generic

tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)

tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)

tiagabine hcl oral tablet Generic

tolcapone oral tablet Generic PA; QL (180 EA per 30 days)






topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)

trihexyphenidyl hcl oral elixir Generic

trihexyphenidyl hcl oral tablet Generic


TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)

valproic acid oral capsule Generic

valproic acid oral solution Generic

valproic acid oral syrup Generic

vigabatrin oral packet Generic PA; QL (180 EA per 30 days)

VIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)

VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP


54

Drug Status NotesXIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)


XYREM ORAL SOLUTION Brand PA

zaleplon oral capsule Generic QL (30 EA per 30 days)

ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)

ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Injection per 30 days)



zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)

zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)

zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)


zonisamide oral capsule Generic


DISORDER OF NERVOUS SYSTEM














55

Drug Status Notesarmodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)





atropine sulfate ophthalmic solution Generic

AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)


AVONEX INTRAMUSCULAR KIT Brand SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP

baclofen oral tablet Generic

BELSOMRA ORAL TABLET Brand PA

benztropine mesylate oral tablet Generic

BETASERON SUBCUTANEOUS KIT Brand SP

BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP


BRIVIACT ORAL SOLUTION Brand PA

BRIVIACT ORAL TABLET Brand PA





Generic


Generic





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

Generic


56

Drug Status Notescarbidopa-levodopa oral tablet Generic

carbidopa-levodopa oral tablet dispersible Generic

carbidopa-levodopa-entacapone oral tablet Generic



clonidine hcl er oral tablet extended release 12 hour





COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

















57

Drug Status Notesdiazepam oral tablet Generic

diazepam rectal gel Generic QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)

diphenhydramine hcl oral capsule 25 mg Brand




Generic


Generic








EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)




entacapone oral tablet Generic




estazolam oral tablet 1 mg Generic

eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)

ethosuximide oral capsule Generic

ethosuximide oral solution Generic



58

Drug Status NotesEXTAVIA SUBCUTANEOUS KIT Brand

flurazepam hcl oral capsule Generic




gabapentin oral capsule Generic




Generic




MB/RX PA


MB/RX PA; SP


GILENYA ORAL CAPSULE Brand PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Generic




Generic PA


HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)









59

Drug Status Noteslactulose oral solution Generic

lamotrigine er oral tablet extended release 24 hour



lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg

Generic










LEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA

















60

Drug Status Notes






















NEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)




61

Drug Status Notes


OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA





ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)


oxcarbazepine oral suspension Generic

oxcarbazepine oral tablet Generic

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

Brand PA; QL (30 EA per 30 days)

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)


PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic

phenytoin oral suspension 125 mg/5ml Generic

phenytoin oral tablet chewable Generic

phenytoin sodium extended oral capsule Generic


POTIGA ORAL TABLET Brand PA


Generic

pramipexole dihydrochloride oral tablet Generic


Generic




Generic




62

Drug Status Notesrasagiline mesylate oral tablet Generic

REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Brand SP

REBIF SUBCUTANEOUS SOLUTION Brand SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Brand SP







ropinirole hcl er oral tablet extended release 24 hour

Generic

ropinirole hcl oral tablet Generic

ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)


selegiline hcl oral capsule Generic

selegiline hcl oral tablet Generic



SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA


63

Drug Status NotesSPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)












TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)

temazepam oral capsule Generic



tiagabine hcl oral tablet Generic








trihexyphenidyl hcl oral elixir Generic

trihexyphenidyl hcl oral tablet Generic



valproic acid oral capsule Generic

valproic acid oral solution Generic

valproic acid oral syrup Generic



64

Drug Status NotesVIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)






zaleplon oral capsule Generic QL (30 EA per 30 days)

ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)


ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Injection per 30 days)



zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)

zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)

zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)


zonisamide oral capsule Generic


DISORDER OF REPRODUCTIVE SYSTEM


alendronate sodium oral tablet 10 mg, 5 mg Generic QL (30 EA per 30 days)


ALTAVERA ORAL TABLET Generic

alyacen 1/35 oral tablet Generic

alyacen 7/7/7 oral tablet Generic

AMETHIA LO ORAL TABLET Generic

AMETHIA ORAL TABLET Generic

AMETHYST ORAL TABLET Generic


65

Drug Status NotesANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) Brand PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

Brand PA

ANDROXY ORAL TABLET Brand PA

APRI ORAL TABLET Generic

ARANELLE ORAL TABLET Generic

ASHLYNA ORAL TABLET Generic

AUBRA ORAL TABLET Generic

AVIANE ORAL TABLET Generic

AZURETTE ORAL TABLET Generic

BALZIVA ORAL TABLET Generic

BEKYREE ORAL TABLET Generic

BLISOVI 24 FE ORAL TABLET Generic

BLISOVI FE 1.5/30 ORAL TABLET Generic

BLISOVI FE 1/20 ORAL TABLET Generic

briellyn oral tablet Generic

calcitonin (salmon) nasal solution Generic

CAMILA ORAL TABLET Generic

CAMRESE LO ORAL TABLET Generic

CAMRESE ORAL TABLET Generic

CAZIANT ORAL TABLET Generic

CHATEAL ORAL TABLET Generic

CIALIS ORAL TABLET 5 MG Brand PA; QL (30 EA per 30 days)


clomiphene citrate oral tablet Generic PA

CRINONE VAGINAL GEL 8 % Brand PA

CRYSELLE-28 ORAL TABLET Generic

CYCLAFEM 1/35 ORAL TABLET Generic

CYCLAFEM 7/7/7 ORAL TABLET Generic

CYRED ORAL TABLET Generic

danazol oral capsule Generic


66

Drug Status NotesDASETTA 1/35 ORAL TABLET Generic

DASETTA 7/7/7 ORAL TABLET Generic

DAYSEE ORAL TABLET Generic

DEBLITANE ORAL TABLET Generic

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

$0

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Generic

drospirenone-ethinyl estradiol oral tablet Generic

DUAVEE ORAL TABLET Brand PA

ELINEST ORAL TABLET Generic

ELLA ORAL TABLET Brand

EMOQUETTE ORAL TABLET Generic

ENPRESSE-28 ORAL TABLET Generic

ENSKYCE ORAL TABLET Generic

ERRIN ORAL TABLET Generic

ESTARYLLA ORAL TABLET Generic

estradiol oral tablet Generic

estradiol transdermal patch twice weekly Generic

estradiol transdermal patch weekly Generic

estropipate oral tablet Generic

exemestane oral tablet Generic

FALMINA ORAL TABLET Generic

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Brand PA; SP; QL (1 vial per 30 days)

FOSAMAX PLUS D ORAL TABLET Brand PA; QL (4 EA per 28 days)

GIANVI ORAL TABLET Generic

GILDAGIA ORAL TABLET Generic

GILDESS 1.5/30 ORAL TABLET Generic

GILDESS 1/20 ORAL TABLET Generic

GILDESS 24 FE ORAL TABLET Generic

GILDESS FE 1.5/30 ORAL TABLET Generic

GILDESS FE 1/20 ORAL TABLET Generic

HEATHER ORAL TABLET Generic



67

Drug Status NotesHydroxyprogesterone Caproate Intramuscular SOLUTION

MB/RX

ibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)

INTROVALE ORAL TABLET Generic

JENCYCLA ORAL TABLET Generic

JOLESSA ORAL TABLET Generic

JOLIVETTE ORAL TABLET Generic

JULEBER ORAL TABLET Generic

JUNEL 1.5/30 ORAL TABLET Generic

JUNEL 1/20 ORAL TABLET Generic

JUNEL FE 1.5/30 ORAL TABLET Generic

JUNEL FE 1/20 ORAL TABLET Generic

JUNEL FE 24 ORAL TABLET Generic

KAITLIB FE ORAL TABLET CHEWABLE Generic

KARIVA ORAL TABLET Generic

KELNOR 1/35 ORAL TABLET Generic

KIMIDESS ORAL TABLET Generic

KURVELO ORAL TABLET Generic

LARIN 1.5/30 ORAL TABLET Generic

LARIN 1/20 ORAL TABLET Generic

LARIN 24 FE ORAL TABLET Generic

LARIN FE 1.5/30 ORAL TABLET Generic

LARIN FE 1/20 ORAL TABLET Generic

LAYOLIS FE ORAL TABLET CHEWABLE Generic

LEENA ORAL TABLET Generic

LESSINA ORAL TABLET Generic

letrozole oral tablet Generic

LEVONEST ORAL TABLET Generic

levonorgest-eth estrad 91-day oral tablet Generic

levonorgestrel oral tablet 1.5 mg Generic

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

Generic

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet Generic


68

Drug Status NotesLEVORA 0.15/30 (28) ORAL TABLET Generic

LO LOESTRIN FE ORAL TABLET Generic

LOMEDIA 24 FE ORAL TABLET Generic

LORYNA ORAL TABLET Generic

LOW-OGESTREL ORAL TABLET Generic



LUTERA ORAL TABLET Generic

LYNPARZA ORAL CAPSULE Brand PA

LYZA ORAL TABLET Generic

marlissa oral tablet Generic


mefenamic acid oral capsule Generic PA


methitest oral tablet Brand PA

methyltestosterone oral capsule Generic


MIACALCIN INJECTION SOLUTION Brand


MICROGESTIN 1.5/30 ORAL TABLET Generic

MICROGESTIN 1/20 ORAL TABLET Generic

MICROGESTIN 24 FE ORAL TABLET Generic

MICROGESTIN FE 1.5/30 ORAL TABLET Generic

MICROGESTIN FE 1/20 ORAL TABLET Generic

MONO-LINYAH ORAL TABLET Generic

MONONESSA ORAL TABLET Generic

MY WAY ORAL TABLET Generic

MYZILRA ORAL TABLET Generic


NECON 0.5/35 (28) ORAL TABLET Generic

NECON 1/35 (28) ORAL TABLET Generic

NECON 1/50 (28) ORAL TABLET Generic


69

Drug Status NotesNECON 10/11 (28) ORAL TABLET Generic

NECON 7/7/7 ORAL TABLET Generic

NEXT CHOICE ONE DOSE ORAL TABLET Generic

NIKKI ORAL TABLET Generic

NORA-BE ORAL TABLET Generic

norethin ace-eth estrad-fe oral tablet Generic

norethin ace-eth estrad-fe oral tablet chewable Generic


norethindrone acet-ethinyl est oral tablet Generic

norethindrone oral tablet Generic

norethindrone-eth estradiol oral tablet Generic

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

Generic

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Generic

norgestim-eth estrad triphasic oral tablet Generic

NORTREL 0.5/35 (28) ORAL TABLET Generic

NORTREL 1/35 (21) ORAL TABLET Generic

NORTREL 1/35 (28) ORAL TABLET Generic

NORTREL 7/7/7 ORAL TABLET Generic

NUVARING VAGINAL RING Brand

OCELLA ORAL TABLET Generic

OGESTREL ORAL TABLET Generic

ORSYTHIA ORAL TABLET Generic


PHILITH ORAL TABLET Generic

PIMTREA ORAL TABLET Generic

PIRMELLA 1/35 ORAL TABLET Generic

PIRMELLA 7/7/7 ORAL TABLET Generic

PORTIA-28 ORAL TABLET Generic

PREMARIN ORAL TABLET Brand





70

Drug Status NotesPREVIFEM ORAL TABLET Generic


progesterone micronized oral capsule Generic

PROLIA SUBCUTANEOUS SOLUTION Medical BenefitPA; SP; QL (1 syringe per 180 days)

QUASENSE ORAL TABLET Generic

raloxifene hcl oral tablet Generic

RECLIPSEN ORAL TABLET Generic




risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)

RUBRACA ORAL TABLET 200 MG, 300 MG Brand PA; SP; QL (120 EA per 30 days)

RUBRACA ORAL TABLET 250 MG Brand PA; QL (120 EA per 30 days)

SETLAKIN ORAL TABLET Generic

SHAROBEL ORAL TABLET Generic

SOLTAMOX ORAL SOLUTION Brand

SPRINTEC 28 ORAL TABLET Generic

SRONYX ORAL TABLET Generic

STRIANT BUCCAL Brand PA

SYEDA ORAL TABLET Generic

SYNAREL NASAL SOLUTION Brand PA

tamoxifen citrate oral tablet Generic

TARINA FE 1/20 ORAL TABLET Generic



TESTOPEL IMPLANT PELLET Brand PA

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

Generic PA

testosterone enanthate intramuscular solution Generic PA

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

Generic PA

testosterone transdermal solution Generic PA

TILIA FE ORAL TABLET Generic



71

Drug Status Notestranexamic acid oral tablet Generic PA

TRI-ESTARYLLA ORAL TABLET Generic

TRI-LEGEST FE ORAL TABLET Generic

TRI-LINYAH ORAL TABLET Generic

TRI-LO-ESTARYLLA ORAL TABLET Generic

TRI-LO-MARZIA ORAL TABLET Generic

TRI-LO-SPRINTEC ORAL TABLET Generic

TRINESSA (28) ORAL TABLET Generic

TRINESSA LO ORAL TABLET Generic

TRI-PREVIFEM ORAL TABLET Generic

TRI-SPRINTEC ORAL TABLET Generic

TRIVORA (28) ORAL TABLET Generic

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; QL (2 ML per 30 days)


VELIVET ORAL TABLET Generic

VESTURA ORAL TABLET Generic

VIENVA ORAL TABLET Generic

viorele oral tablet Generic

VYFEMLA ORAL TABLET Generic

WERA ORAL TABLET Generic

WYMZYA FE ORAL TABLET CHEWABLE Generic

XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA

XULANE TRANSDERMAL PATCH WEEKLY Generic

ZARAH ORAL TABLET Generic

ZENCHENT FE ORAL TABLET CHEWABLE Generic

ZENCHENT ORAL TABLET Generic


ZOVIA 1/35E (28) ORAL TABLET Generic

ZOVIA 1/50E (28) ORAL TABLET Generic


72

Drug Status NotesDISORDER OF RESPIRATORY SYSTEM


acetylcysteine inhalation solution Generic






Brand PA



Generic



albuterol sulfate oral tablet Generic



Brand PA





Brand


Brand


Brand


Brand


73

Drug Status NotesASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand













chlorpromazine hcl oral tablet Generic





clotrimazole mouth/throat lozenge Generic

clotrimazole mouth/throat troche Generic





DALIRESP ORAL TABLET Brand PA; STPA

desloratadine oral tablet Generic PA




74

Drug Status Notesepoprostenol sodium intravenous solution reconstituted 0.5 mg








Brand





Generic





Generic


Generic





Brand








75

Drug Status Noteslevalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

Generic




lidocaine external ointment Generic QL (50 GM per 30 days)












OFEV ORAL CAPSULE Brand PA; QL (60 EA per 30 days)







PASER ORAL PACKET Brand PA



PRIFTIN ORAL TABLET Brand PA



76

Drug Status NotesPROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA









Brand











Brand



SIRTURO ORAL TABLET Brand PA





77

Drug Status NotesSYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP; QL (5 ML per 1 Season)



Generic


Generic














VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand








DISORDER OF THE DIGESTIVE SYSTEM

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE Brand PA

adefovir dipivoxil oral tablet Generic



78

Drug Status NotesAKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)

alosetron hcl oral tablet Generic

AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

amoxicill-clarithro-lansopraz oral Generic

ANZEMET ORAL TABLET 100 MG Brand PA; QL (10 EA per 1 fill)


APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand

balsalazide disodium oral capsule Generic

BARACLUDE ORAL SOLUTION Brand

BILTRICIDE ORAL TABLET Brand

budesonide oral capsule delayed release particles Generic

CANTIL ORAL TABLET Brand PA

CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)

CESAMET ORAL CAPSULE Brand PA


chlordiazepoxide-clidinium oral capsule Generic

chlorhexidine gluconate mouth/throat solution Generic

CHOLBAM ORAL CAPSULE Brand PA

cimetidine hcl oral solution Generic

cimetidine oral tablet Generic





CLINPRO 5000 DENTAL PASTE Generic

COLOCORT RECTAL ENEMA Generic

COMPRO RECTAL SUPPOSITORY Generic


CREON ORAL CAPSULE DELAYED RELEASE PARTICLES Brand



79

Drug Status Notescyclosporine modified oral solution Generic


DAKLINZA ORAL TABLET BrandPA; SP; QL (28 TABS per 28 days)

DENAVIR EXTERNAL CREAM Brand PA; QL (5 GM per 1 Fill)

DENTA 5000 PLUS DENTAL CREAM Generic

DENTAGEL DENTAL GEL Generic

DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG Brand PA

DICLEGIS ORAL TABLET DELAYED RELEASE Brand PA

dicyclomine hcl oral capsule Generic

dicyclomine hcl oral solution Generic

dicyclomine hcl oral tablet Generic

DIFICID ORAL TABLET Brand PA; QL (20 EA per 1 Fill)

dimenhydrinate oral tablet Generic

DIPENTUM ORAL CAPSULE Brand

diphenoxylate-atropine oral liquid Generic

diphenoxylate-atropine oral tablet Generic


EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)

EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)

entecavir oral tablet Generic

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP


EPCLUSA ORAL TABLET BrandPA; SP; # (Genotypes 2-6); QL (28 EA per 28 days)

famotidine oral suspension reconstituted Generic

famotidine oral tablet 20 mg, 40 mg Generic

FLUOR-A-DAY ORAL SOLUTION Generic

FLUORIDEX DAILY DEFENSE DENTAL GEL Generic

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE Generic


80

Drug Status NotesFLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP Generic

GAMASTAN S/D INTRAMUSCULAR INJECTABLE Medical Benefit PA; SP



GATTEX SUBCUTANEOUS KIT Brand PA; SP; QL (1 Kit per 1 day)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic

GAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic

GAVILYTE-H ORAL KIT Generic




GIAZO ORAL TABLET Brand PA

granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)

HARVONI ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)









Generic

hydrocortisone ace-pramoxine rectal cream Generic


hydrocortisone rectal enema Generic


81

Drug Status NotesINFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

ivermectin oral tablet Generic



lamivudine oral tablet 100 mg Generic

lansoprazole oral capsule delayed release Generic PA

LINZESS ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

LONSURF ORAL TABLET Brand PA; SP

loperamide hcl oral capsule Generic


mesalamine oral tablet delayed release 1.2 gm GenericPA; STPA; QL (120 EA per 30 days)

mesalamine oral tablet delayed release 800 mg Generic

mesalamine rectal enema Generic

methscopolamine bromide oral tablet Generic PA


Generic


misoprostol oral tablet Generic

MOVANTIK ORAL TABLET Brand PA





Generic

multi-vitamin/fluoride oral tablet chewable 0.5 mg

Brand



Generic


neomycin sulfate oral tablet Generic

NEXIUM ORAL PACKET Brand PA

nizatidine oral capsule Generic


82

Drug Status Notesnizatidine oral solution Generic

OCALIVA ORAL TABLET BrandPA; SP; QL (30 TABS per 30 days)




OLYSIO ORAL CAPSULE Brand PA; QL (28 EA per 28 days)

omeprazole oral capsule delayed release Generic


ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

Generic

ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)

ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

Brand

paregoric oral tincture Generic

PAROEX MOUTH/THROAT SOLUTION Generic

paromomycin sulfate oral capsule Generic

peg 3350/electrolytes oral solution reconstituted Generic

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Generic

peg-3350/electrolytes oral solution reconstituted Generic

PENTASA ORAL CAPSULE EXTENDED RELEASE Brand

PERIOGARD MOUTH/THROAT SOLUTION Generic

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES Brand

PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic


polyethylene glycol 3350 oral powder Generic

pramcort rectal cream Generic

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE Brand PA; Age Limit (Max 2 Years)


83

Drug Status NotesPRILOSEC ORAL PACKET Brand PA

prochlorperazine edisylate injection solution Generic

prochlorperazine maleate oral tablet Generic

prochlorperazine rectal suppository Generic


promethazine hcl oral solution Generic

promethazine hcl oral syrup Generic

promethazine hcl oral tablet Generic

promethazine hcl rectal suppository Generic

rabeprazole sodium oral tablet delayed release Generic PA




RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA



RIBASPHERE ORAL CAPSULE Generic QL (210 EA per 30 days)

RIBASPHERE ORAL TABLET 200 MG Generic QL (210 EA per 30 days)

ribavirin oral capsule Generic

ribavirin oral tablet 200 mg Generic

SANCUSO TRANSDERMAL PATCH Brand PA

sf 5000 plus dental cream Generic

sf dental gel Generic

sodium fluoride oral solution Generic

sodium fluoride oral tablet chewable Generic

SOVALDI ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)


STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Syringe per 84 days)


84

Drug Status Notessucralfate oral tablet Generic

sulfasalazine oral tablet Generic





TECHNIVIE ORAL TABLET Brand PA; QL (56 EA per 28 days)


TRILYTE ORAL SOLUTION RECONSTITUTED Generic

trimethobenzamide hcl oral capsule Generic




UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

UCERIS RECTAL FOAM Brand PA

ursodiol oral capsule Generic

ursodiol oral tablet Generic

VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VIBERZI ORAL TABLET Brand PA

VIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; QL (1 EA per 28 days)

VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (1 EA per 28 days)



XERMELO ORAL TABLET Brand PA



ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 20000-63000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT

Brand


85

Drug Status NotesZEPATIER ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)

ZINPLAVA INTRAVENOUS SOLUTION Medical Benefit PA


DISORDER OF THE ENDOCRINE GLANDS

acarbose oral tablet Generic

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA





alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)

ANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) Brand PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

Brand PA

ANDROXY ORAL TABLET Brand PA


AVANDAMET ORAL TABLET 2-1000 MG Brand PA

AVANDIA ORAL TABLET Brand PA



BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA




86

Drug Status NotesBYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION Brand PA


cabergoline oral tablet Generic





chlorpropamide oral tablet Generic


CRINONE VAGINAL GEL 8 % Brand PA

desmopressin ace rhinal tube nasal solution Generic

desmopressin ace spray refrig nasal solution Generic


desmopressin acetate spray nasal solution Generic

dexamethasone oral elixir Generic

dexamethasone oral solution Generic

dexamethasone oral tablet Generic



estradiol transdermal patch weekly Generic

estropipate oral tablet Generic


fludrocortisone acetate oral tablet Generic



glimepiride oral tablet Generic

glipizide er oral tablet extended release 24 hour Generic

glipizide oral tablet Generic

glipizide xl oral tablet extended release 24 hour Generic

glipizide-metformin hcl oral tablet Generic

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand


87

Drug Status NotesGLUCAGON EMERGENCY INJECTION KIT Brand

glyburide micronized oral tablet Generic

glyburide oral tablet Generic

glyburide-metformin oral tablet Generic

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Brand




MB/RX



INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand

PA; STPA; QL (60 Tablets per 30 days)



KORLYM ORAL TABLET Brand PA


LEVO-T ORAL TABLET Generic

levothyroxine sodium oral tablet Generic

liothyronine sodium oral tablet Generic

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT Medical Benefit PA; SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT Medical Benefit PA; SP



LYSODREN ORAL TABLET Brand



88

Drug Status Notesmetformin hcl er (mod) oral tablet extended release 24 hour

Generic PA

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

Generic PA

metformin hcl er oral tablet extended release 24 hour

Generic

metformin hcl oral tablet Generic

methimazole oral tablet Generic

methitest oral tablet Brand PA




Generic



Generic




nateglinide oral tablet Generic

NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)










pioglitazone hcl oral tablet Generic

pioglitazone hcl-glimepiride oral tablet Generic

pioglitazone hcl-metformin hcl oral tablet Generic


89

Drug Status Notesprednisolone oral solution Generic



Generic


Generic

PREMARIN ORAL TABLET Brand






propylthiouracil oral tablet Generic










SIGNIFOR SUBCUTANEOUS SOLUTION Brand PA; QL (60 ML per 30 days)


STRIANT BUCCAL Brand PA



SYNAREL NASAL SOLUTION Brand PA

TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA

TESTOPEL IMPLANT PELLET Brand PA


90

Drug Status Notestestosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Generic PA

testosterone enanthate intramuscular solution Generic PA

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

Generic PA


tolazamide oral tablet Generic

tolbutamide oral tablet Generic

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA


UNITHROID ORAL TABLET 137 MCG Generic

UNITHROID ORAL TABLET 50 MCG, 75 MCG, 88 MCG Brand

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


EAR PROBLEM

ACETASOL HC OTIC SOLUTION Generic

acetic acid otic solution Generic

acetic acid-aluminum acetate otic solution Generic


CIPRO HC OTIC SUSPENSION Brand PA

CIPRODEX OTIC SUSPENSION Brand PA

dexamethasone sodium phosphate ophthalmic solution

Generic

fluocinolone acetonide otic oil Generic

hydrocortisone-acetic acid otic solution Generic





91

Drug Status Notesneomycin-polymyxin-hc otic solution Generic

neomycin-polymyxin-hc otic suspension Generic

ofloxacin otic solution Generic

EYE DISORDER


ALOCRIL OPHTHALMIC SOLUTION Brand PA

ALPHAGAN P OPHTHALMIC SOLUTION0.1 % Brand PA


azelastine hcl ophthalmic solution Generic PA

AZOPT OPHTHALMIC SUSPENSION Brand PA

bacitracin ophthalmic ointment Generic

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Generic

BEPREVE OPHTHALMIC SOLUTION Brand PA

betaxolol hcl ophthalmic solution Generic

bimatoprost ophthalmic solution Generic PA

brimonidine tartrate ophthalmic solution 0.15 % Generic PA

bromfenac sodium (once-daily) ophthalmic solution

Generic

bromfenac sodium ophthalmic solution Generic

carteolol hcl ophthalmic solution Generic


COMBIGAN OPHTHALMIC SOLUTION Brand PA

cromolyn sodium ophthalmic solution Generic

cyclopentolate hcl ophthalmic solution Generic QL (2 ML per 30 days)


Generic

diclofenac sodium ophthalmic solution Generic

dorzolamide hcl ophthalmic solution Generic

dorzolamide hcl-timolol mal ophthalmic solution Generic

EMADINE OPHTHALMIC SOLUTION Brand PA

epinastine hcl ophthalmic solution Generic PA

erythromycin ophthalmic ointment Generic

fluorometholone ophthalmic suspension Generic


92

Drug Status Notesflurbiprofen sodium ophthalmic solution Generic



HOMATROPAIRE OPHTHALMIC SOLUTION Generic

homatropine hbr ophthalmic solution Generic

ketorolac tromethamine ophthalmic solution Generic

ketotifen fumarate ophthalmic solution Generic

LASTACAFT OPHTHALMIC SOLUTION Brand PA

latanoprost ophthalmic solution Generic

levobunolol hcl ophthalmic solution 0.5 % Generic

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Brand PA

methazolamide oral tablet Generic

metipranolol ophthalmic solution Generic

naphazoline hcl ophthalmic solution Generic

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Generic

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Generic

NEO-POLYCIN OPHTHALMIC OINTMENT Generic

olopatadine hcl ophthalmic solution Generic PA

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Generic


polymyxin b-trimethoprim ophthalmic solution Generic

polyvinyl alcohol ophthalmic solution Generic

prednisolone acetate ophthalmic suspension Generic

proparacaine hcl ophthalmic solution Generic

RESCULA OPHTHALMIC SOLUTION Brand PA

RESTASIS OPHTHALMIC EMULSION Brand PA; QL (60 EA per 30 days)

SIMBRINZA OPHTHALMIC SUSPENSION Brand PA

sulfacetamide sodium ophthalmic ointment Generic

sulfacetamide sodium ophthalmic solution Generic


93

Drug Status Notessulfacetamide-prednisolone ophthalmic solution Generic

timolol maleate ophthalmic gel forming solution Generic

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Generic

tobramycin-dexamethasone ophthalmic suspension

Generic

TRAVATAN Z OPHTHALMIC SOLUTION Brand PA

trifluridine ophthalmic solution Generic

tropicamide ophthalmic solution Generic


ZIOPTAN OPHTHALMIC SOLUTION Brand PA

ZIRGAN OPHTHALMIC GEL Brand PA

FEVER




INFECTION


abacavir sulfate oral tablet Generic



acyclovir external ointment Generic


ALFERON N INJECTION SOLUTION Medical Benefit PA





APTIVUS ORAL CAPSULE Brand

APTIVUS ORAL SOLUTION Brand

atovaquone-proguanil hcl oral tablet Generic

ATRIPLA ORAL TABLET Brand



94

Drug Status Notesbacitracin ophthalmic ointment Generic

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Generic




BILTRICIDE ORAL TABLET Brand





chloroquine phosphate oral tablet Generic

CICLODAN EXTERNAL CREAM Generic

CICLODAN EXTERNAL SOLUTION Generic

ciclopirox external gel Generic

ciclopirox external solution Brand

ciclopirox olamine external cream Generic

ciclopirox olamine external suspension Generic PA

CIPRODEX OTIC SUSPENSION Brand PA





clotrimazole anti-fungal external cream Generic

clotrimazole external cream Generic

clotrimazole external solution Generic



clotrimazole-betamethasone external cream Generic

clotrimazole-betamethasone external lotion Generic

COARTEM ORAL TABLET Brand QL (24 EA per 30 days)

COMPLERA ORAL TABLET Brand

CRESEMBA ORAL CAPSULE Brand PA


95

Drug Status NotesCRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand




dapsone oral tablet Brand


DESCOVY ORAL TABLET Brand


didanosine oral capsule delayed release Generic



econazole nitrate external cream Generic

ECOZA EXTERNAL FOAM Brand PA

EDURANT ORAL TABLET Brand


EMTRIVA ORAL CAPSULE Brand

EMTRIVA ORAL SOLUTION Brand




erythromycin ophthalmic ointment Generic

ethambutol hcl oral tablet Generic

EVOTAZ ORAL TABLET Brand

EXELDERM EXTERNAL CREAM Brand PA

EXELDERM EXTERNAL SOLUTION Brand PA




FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP

gabapentin oral capsule Generic


96

Drug Status Notesgabapentin oral solution 250 mg/5ml Generic



gentamicin sulfate external cream Generic

gentamicin sulfate external ointment Generic

GENVOYA ORAL TABLET Brand



griseofulvin microsize oral suspension Generic

griseofulvin microsize oral tablet Generic

griseofulvin ultramicrosize oral tablet Generic


Generic



Generic




imiquimod external cream Generic

IMPAVIDO ORAL CAPSULE Brand

INTELENCE ORAL TABLET Brand

INVIRASE ORAL CAPSULE Brand

INVIRASE ORAL TABLET Brand


ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)

ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)

ISENTRESS ORAL TABLET Brand

ISENTRESS ORAL TABLET CHEWABLE Brand

isoniazid oral syrup Generic

isoniazid oral tablet Generic


JUBLIA EXTERNAL SOLUTION Brand PA

KALETRA ORAL SOLUTION Brand


97

Drug Status NotesKALETRA ORAL TABLET Brand

ketoconazole external cream Generic

ketoconazole external shampoo Generic

LAMISIL ORAL PACKET BrandPA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)



lamivudine oral tablet 150 mg, 300 mg Brand

lamivudine-zidovudine oral tablet Brand



LEXIVA ORAL SUSPENSION Brand


lindane external lotion Generic

lindane external shampoo Generic

LUZU EXTERNAL CREAM Brand PA

malathion external lotion Generic

mefloquine hcl oral tablet Generic


Generic

methenamine hippurate oral tablet Generic

methenamine mandelate oral tablet Generic







mupirocin calcium external cream Generic PA

mupirocin external ointment Generic

naftifine hcl external cream Generic PA

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Generic

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Generic


98

Drug Status NotesNEO-POLYCIN OPHTHALMIC OINTMENT Generic

nevirapine er oral tablet extended release 24 hour Generic

nevirapine oral suspension Generic

nevirapine oral tablet Generic


NORVIR ORAL CAPSULE Brand

NORVIR ORAL SOLUTION Brand

NORVIR ORAL TABLET Brand



NYAMYC EXTERNAL POWDER Generic

nystatin external cream Generic

nystatin external ointment Generic

nystatin external powder Generic

nystatin mouth/throat suspension Generic

nystatin oral powder Generic

nystatin oral tablet Generic

nystatin-triamcinolone external cream Generic

nystatin-triamcinolone external ointment Generic

NYSTOP EXTERNAL POWDER Generic

ODEFSEY ORAL TABLET Brand




oseltamivir phosphate oral capsule 30 mg Generic QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg Generic QL (10 EA per 1 Fill)

oxiconazole nitrate external cream Generic PA

OXISTAT EXTERNAL LOTION Brand PA


paromomycin sulfate oral capsule Generic



99

Drug Status NotesPERIOGARD MOUTH/THROAT SOLUTION Generic

permethrin external cream Generic


podofilox external solution Generic


PREZCOBIX ORAL TABLET Brand

PREZISTA ORAL SUSPENSION Brand

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









pyrazinamide oral tablet Generic



RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand¥ (Max of 2 fills per year); QL (20 Blisters per 1 Rx)

RESCRIPTOR ORAL TABLET Brand

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG Brand

REYATAZ ORAL PACKET Brand





rifabutin oral capsule Generic

rimantadine hcl oral tablet Generic


100

Drug Status NotesSELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET Brand



silver sulfadiazine external cream Generic


SKLICE EXTERNAL LOTION BrandPA; STPA; QL (117 GM per 1 day)


spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)

SSD EXTERNAL CREAM Generic

stavudine oral capsule Brand

stavudine oral solution reconstituted Brand

STRIBILD ORAL TABLET Brand



SUSTIVA ORAL CAPSULE Brand

SUSTIVA ORAL TABLET Brand

SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP; QL (5 ML per 1 Season)


TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML Brand

¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)





TIVICAY ORAL TABLET Brand




Generic

TRECATOR ORAL TABLET Brand PA



101

Drug Status Notestrifluridine ophthalmic solution Generic

trimethoprim oral tablet Generic

TRIUMEQ ORAL TABLET Brand

TRUVADA ORAL TABLET 200-300 MG Brand


TYBOST ORAL TABLET Brand

ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)



VEREGEN EXTERNAL OINTMENT Brand PA

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand



VIRACEPT ORAL TABLET Brand





ZEPATIER ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)


zidovudine oral capsule Brand

zidovudine oral syrup Brand

zidovudine oral tablet Brand




INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY



102

Drug Status NotesINFLAMMATORY DISORDER











Brand PA


alclometasone dipropionate external cream Generic

alclometasone dipropionate external ointment Generic




MB/RX SP


amcinonide external cream Generic PA

amcinonide external lotion Generic PA

amcinonide external ointment Generic PA



Brand PA

APEXICON E EXTERNAL CREAM Brand PA

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand


103

Drug Status NotesARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)



Brand


Brand


Brand


Brand


Brand





balsalazide disodium oral capsule Generic








betamethasone dipropionate aug external cream Generic

betamethasone dipropionate aug external gel Generic

betamethasone dipropionate aug external lotion Generic


104

Drug Status Notesbetamethasone dipropionate aug external ointment

Generic

betamethasone dipropionate external cream Generic

betamethasone dipropionate external lotion Generic

betamethasone dipropionate external ointment Generic

betamethasone valerate external cream Generic

betamethasone valerate external lotion Generic

betamethasone valerate external ointment Generic



Generic




budesonide oral capsule delayed release particles Generic

CAPEX EXTERNAL SHAMPOO Brand PA

CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)







chlordiazepoxide-clidinium oral capsule Generic

choline-mag trisalicylate oral liquid Generic


ciclopirox external gel Generic

ciclopirox external shampoo Brand PA



cimetidine hcl oral solution Generic

cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic


105

Drug Status NotesCIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)








clobetasol propionate e external cream Generic

clobetasol propionate external cream Generic PA

clobetasol propionate external foam Generic

clobetasol propionate external gel Generic PA

clobetasol propionate external lotion Generic

clobetasol propionate external ointment Generic PA

clocortolone pivalate external cream Generic PA

clocortolone pivalate pump external cream Generic PA







clotrimazole-betamethasone external lotion Generic



COLOCORT RECTAL ENEMA Generic

CORDRAN EXTERNAL TAPE Brand PA



Brand PA; SP



106

Drug Status Notescromolyn sodium inhalation nebulization solution Generic







desonide external cream Generic PA

desonide external lotion Generic PA

desonide external ointment Generic PA

desoximetasone external cream 0.05 % Generic PA

desoximetasone external cream 0.25 % Generic

desoximetasone external gel Generic

desoximetasone external ointment 0.05 % Generic PA

desoximetasone external ointment 0.25 % Generic


Generic

diclofenac potassium oral tablet Generic


Generic


diclofenac sodium transdermal gel 1 % Generic STPA

diclofenac sodium transdermal solution Generic PA


diflorasone diacetate external cream Generic PA

diflorasone diacetate external ointment Generic PA

DIPENTUM ORAL CAPSULE Brand


DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (4 ML per 28 days)





107

Drug Status NotesEGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP

ELIDEL EXTERNAL CREAM Brand PA















ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP




etodolac oral capsule Generic

etodolac oral tablet Generic

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP




FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)


Brand




108

Drug Status Notesfluocinolone acetonide body external oil Generic

fluocinolone acetonide external cream Generic

fluocinolone acetonide external ointment Generic

fluocinolone acetonide external solution Generic


fluocinolone acetonide scalp external oil Generic

fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)

fluocinonide external cream 0.1 % Generic PA; QL (120 GM per 30 days)

fluocinonide external gel Generic QL (60 GM per 30 days)

fluocinonide external ointment Generic QL (60 GM per 30 days)

fluocinonide external solution Generic QL (60 ML per 30 days)

fluorometholone ophthalmic suspension Generic

flurandrenolide external cream Generic PA

flurandrenolide external lotion Generic PA

flurandrenolide external ointment Generic PA


fluticasone propionate external cream Generic

fluticasone propionate external lotion Generic

fluticasone propionate external ointment Generic



Generic




MB/RX PA


MB/RX PA; SP




109

Drug Status NotesGAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

Medical Benefit PA



GIAZO ORAL TABLET Brand PA


Generic


halobetasol propionate external cream Generic PA

halobetasol propionate external ointment Generic PA

HALOG EXTERNAL CREAM Brand PA

HALOG EXTERNAL OINTMENT Brand PA



HOMATROPAIRE OPHTHALMIC SOLUTION Generic

homatropine hbr ophthalmic solution Generic


MB/RX SP








Generic




110

Drug Status Noteshydrocortisone ace-pramoxine external cream2.5-1 %

Generic


hydrocortisone butyrate external cream Generic PA

hydrocortisone butyrate external ointment Generic PA

hydrocortisone butyrate external solution Generic PA

hydrocortisone external cream 1 %, 2.5 % Generic

hydrocortisone external lotion Generic

hydrocortisone external ointment 1 %, 2.5 % Generic


hydrocortisone rectal cream Generic

hydrocortisone rectal enema Generic

hydrocortisone valerate external cream Generic

hydrocortisone valerate external ointment Generic



ibuprofen oral suspension Generic

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






Brand







ketoconazole external foam Generic



111

Drug Status NotesKETODAN EXTERNAL FOAM Generic


Generic

ketoprofen oral capsule Generic





KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP



lansoprazole oral capsule delayed release Generic PA






meclofenamate sodium oral capsule Generic





mesalamine rectal enema Generic





Generic

metronidazole external cream Generic

metronidazole external gel 0.75 % Generic

metronidazole external gel 1 % Generic PA


112

Drug Status Notesmetronidazole external lotion Generic

MIRVASO EXTERNAL GEL Brand PA

mometasone furoate external cream Generic

mometasone furoate external ointment Generic

mometasone furoate external solution Generic










naproxen dr oral tablet delayed release Generic

naproxen oral suspension Generic

naproxen oral tablet Generic

naproxen sodium oral tablet Generic

nizatidine oral capsule Generic

nizatidine oral solution Generic

NORITATE EXTERNAL CREAM Brand PA












113

Drug Status NotesNYSTOP EXTERNAL POWDER Generic


MB/RX SP





omeprazole oral capsule delayed release Generic










OTEZLA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

OTEZLA ORAL TABLET THERAPY PACK Brand PA; SP; QL (60 EA per 30 days)






PENNSAID TRANSDERMAL SOLUTION 2 % Brand PA

PENTASA ORAL CAPSULE EXTENDED RELEASE Brand





114

Drug Status Notespiroxicam oral capsule Generic



prednicarbate external cream Generic

prednisolone acetate ophthalmic suspension Generic

prednisolone oral solution Generic



Generic


Generic

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE Brand PA; Age Limit (Max 2 Years)


PRILOSEC ORAL PACKET Brand PA



PROCTO-PAK RECTAL CREAM Generic

PROCTOSOL HC RECTAL CREAM Generic

PROCTOZONE-HC RECTAL CREAM Generic









Brand


Generic





115

Drug Status NotesQVAR INHALATION AEROSOL SOLUTION Brand














SAVELLA ORAL TABLET Brand STPA; QL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL Brand STPA; QL (60 EA per 30 days)

selenium sulfide external lotion Generic

selenium sulfide external shampoo Generic

selenium sulf-pyrithione-urea external shampoo Generic



Brand








SOOLANTRA EXTERNAL CREAM Brand PA


116

Drug Status NotesSOVALDI ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)






sucralfate oral tablet Generic



sulfacetamide-prednisolone ophthalmic solution Generic

sulfasalazine oral tablet Generic


sulindac oral tablet Generic



SYNALAR (CREAM) EXTERNAL KIT Brand PA

SYNALAR (OINTMENT) EXTERNAL KIT Brand PA

tacrolimus external ointment Generic PA

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand

PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand




Generic


Generic





Generic


117

Drug Status Notestolmetin sodium oral capsule Generic



triamcinolone acetonide external aerosol solution Generic PA

triamcinolone acetonide external cream Generic

triamcinolone acetonide external lotion Generic

triamcinolone acetonide external ointment Generic





UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

UCERIS RECTAL FOAM Brand PA













ZEPATIER ORAL TABLET Brand PA; SP; QL (28 EA per 28 days)






118

Drug Status NotesINJURY

CIDALEAZE EXTERNAL CREAM Generic

FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)

lidocaine hcl external cream 3 % Generic

lidocaine hcl external lotion Generic




INJURY TO A MUCOUS MEMBRANE









doxycycline hyclate oral tablet 20 mg Generic








nystatin mouth/throat suspension Generic

nystatin oral powder Generic

nystatin oral tablet Generic




PERIOGARD MOUTH/THROAT SOLUTION Generic


119

Drug Status Notespolymyxin b-trimethoprim ophthalmic solution Generic







triamcinolone acetonide mouth/throat paste Generic


LUNG DISEASE








Brand PA



Generic



albuterol sulfate oral tablet Generic



Brand PA





120

Drug Status NotesASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand


Brand


Brand


Brand


Brand





















121

Drug Status Notesethacrynic acid oral tablet Generic PA



Brand



Generic





Generic


Generic





Brand






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

Generic








122

Drug Status Notesmontelukast sodium oral packet Generic






OFEV ORAL CAPSULE Brand PA; QL (60 EA per 30 days)










PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA






Brand





123

Drug Status NotesREMODULIN INJECTION SOLUTION Medical Benefit PA; SP




Brand










Generic


Generic














124

Drug Status NotesVENTOLIN HFA INHALATION AEROSOL SOLUTION Brand






MARGINAL ZONE LYMPHOMA


MUSCLE OR BONE DISORDER









alendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)












125

Drug Status Notesbaclofen oral tablet Generic







carisoprodol oral tablet 350 mg Generic

carisoprodol-aspirin oral tablet Generic


chlorzoxazone oral tablet 500 mg Generic

choline-mag trisalicylate oral liquid Generic












Brand PA; SP


cyclobenzaprine hcl oral tablet 10 mg, 5 mg Generic



Generic PA



126

Drug Status Notes

















Generic




duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg

Generic STPA; QL (60 EA per 30 days)

duloxetine hcl oral capsule delayed release particles 30 mg





127

Drug Status NotesDYSPORT (GLABELLAR LINES) INTRAMUSCULAR SOLUTION RECONSTITUTED
















etidronate disodium oral tablet Generic




EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP


FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)







MB/RX PA


128

Drug Status NotesGammagard INJECTION SOLUTION 20 GM/200ML

MB/RX PA; SP

GELNIQUE TRANSDERMAL GEL Brand PA



Generic PA




















Generic





129

Drug Status NotesKINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)

KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP



Generic

















metaxalone oral tablet 800 mg Generic STPA; QL (120 EA per 30 days)


methocarbamol oral tablet Generic







130

Drug Status Notes


















MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


naproxen dr oral tablet delayed release Generic









131

Drug Status NotesORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)






orphenadrine citrate er oral tablet extended release 12 hour

Generic




oxybutynin chloride er oral tablet extended release 24 hour

Generic

oxybutynin chloride oral syrup Generic

oxybutynin chloride oral tablet Generic

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA











Generic





132

Drug Status NotesREMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA




risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)
















SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)





sulindac oral tablet Generic



133

Drug Status Notes







tizanidine hcl oral tablet Generic




Generic

tolterodine tartrate oral tablet Generic

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


trospium chloride er oral capsule extended release 24 hour

Generic

trospium chloride oral tablet Generic


VESICARE ORAL TABLET 10 MG Generic PA

VESICARE ORAL TABLET 10 MG, 5 MG Brand PA








XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA



134

Drug Status Notes



NEUROPSYCHIATRIC DISORDER

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 400 MG

Medical Benefit PA

acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)

alprazolam er oral tablet extended release 24 hour

Generic

alprazolam oral tablet Generic

alprazolam oral tablet dispersible Generic

alprazolam xr oral tablet extended release 24 hour

Generic

amoxapine oral tablet Generic




aripiprazole oral solution Generic PA; QL (750 ML per 30 days)

aripiprazole oral tablet Generic PA; QL (30 EA per 30 days)

aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE Medical Benefit PA

ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)



BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 6.3-1 MG Brand

PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine hcl sublingual tablet sublingual Generic PA


135

Drug Status Notesbuprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg

Generic¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg

Generic¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

bupropion hcl er (smoking det) oral tablet extended release 12 hour

Generic

bupropion hcl er (sr) oral tablet extended release 12 hour

Generic

bupropion hcl er (xl) oral tablet extended release 24 hour

Generic

bupropion hcl oral tablet Generic

buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg

Generic

buspirone hcl oral tablet 30 mg Generic PA

butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)

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


butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)

butalbital-aspirin-caffeine oral capsule Generic QL (180 EA per 30 days)


Generic


Generic


CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)



citalopram hydrobromide oral solution Generic

citalopram hydrobromide oral tablet Generic

clomipramine hcl oral capsule Generic



136

Drug Status Notesclonidine hcl er oral tablet extended release 12 hour



clozapine oral tablet Generic

clozapine oral tablet dispersible Generic QL (60 EA per 30 days)


desipramine hcl oral tablet Generic

desvenlafaxine er oral tablet extended release 24 hour

Generic PA; STPA

desvenlafaxine fumarate er oral tablet extended release 24 hour

Brand PA; STPA















disulfiram oral tablet Generic


137

Drug Status Notesdivalproex sodium er oral tablet extended release 24 hour

Generic


Generic




doxepin hcl oral capsule Generic

doxepin hcl oral concentrate Generic

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

Generic






EMSAM TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)

eq nicotine mouth/throat lozenge Generic

eq nicotine polacrilex mouth/throat gum Generic

eq nicotine polacrilex mouth/throat lozenge Generic

eq nicotine step 3 transdermal patch 24 hour Generic

eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Generic

eql nicotine polacrilex mouth/throat gum Generic

eql nicotine polacrilex mouth/throat lozenge Generic

eql nicotine transdermal patch 24 hour Generic


escitalopram oxalate oral solution Generic

escitalopram oxalate oral tablet Generic

FANAPT ORAL TABLET Brand PA; QL (60 EA per 30 days)

FANAPT TITRATION PACK ORAL TABLET Brand PA

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)


138

Drug Status NotesFETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)

fluoxetine hcl (pmdd) oral capsule Generic PA

fluoxetine hcl (pmdd) oral tablet Generic PA

fluoxetine hcl oral capsule Generic

fluoxetine hcl oral solution Generic

fluoxetine hcl oral tablet 10 mg, 20 mg Generic PA

fluphenazine decanoate injection solution Generic

fluphenazine hcl oral concentrate Generic

fluphenazine hcl oral elixir Generic

fluphenazine hcl oral tablet Generic

fluvoxamine maleate er oral capsule extended release 24 hour


fluvoxamine maleate oral tablet Generic


Generic




gnp nicotine mini mouth/throat lozenge Generic

gnp nicotine polacrilex mouth/throat gum Generic

gnp nicotine polacrilex mouth/throat lozenge Generic


Generic PA

haloperidol decanoate intramuscular solution Generic

haloperidol lactate injection solution Generic

haloperidol lactate oral concentrate Generic

haloperidol oral tablet Generic

hm nicotine polacrilex mouth/throat gum Generic

hm nicotine polacrilex mouth/throat lozenge Generic

hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr

Generic





139

Drug Status Notesimipramine hcl oral tablet Generic

imipramine pamoate oral capsule Generic PA

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION Medical Benefit

PA; ¥ (2 vials for first month); QL (1 vial per 30 days)

INVEGA TRINZA INTRAMUSCULAR SUSPENSION Medical Benefit PA



Generic










LATUDA ORAL TABLET Brand PA; QL (30 EA per 30 days)

lithium carbonate er oral tablet extended release Generic

lithium carbonate oral capsule Generic

lithium carbonate oral tablet Generic

lithium oral solution Generic

LORAZEPAM INTENSOL ORAL CONCENTRATE Generic

lorazepam oral concentrate Generic

lorazepam oral tablet Generic


loxapine succinate oral capsule Generic

maprotiline hcl oral tablet Generic



meprobamate oral tablet Generic PA

METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)


140

Drug Status Notesmethadone hcl oral concentrate Generic QL (6 ML per 1 day)

methadone hcl oral solution 10 mg/5ml Generic QL (30 ML per 1 day)


methadone hcl oral tablet 10 mg Generic QL (6 EA per 1 day)























141

Drug Status Notesmirtazapine oral tablet Generic

mirtazapine oral tablet dispersible Generic

naltrexone hcl oral tablet Generic

nefazodone hcl oral tablet Generic

NICORELIEF MOUTH/THROAT GUM Generic

nicotine mini mouth/throat lozenge Generic

nicotine polacrilex mouth/throat gum Generic

nicotine polacrilex mouth/throat lozenge Generic

nicotine step 1 transdermal patch 24 hour Generic



nicotine transdermal patch 24 hour Generic

NICOTROL INHALATION INHALER Brand PA

NICOTROL NS NASAL SOLUTION Brand PA


nortriptyline hcl oral capsule Generic

nortriptyline hcl oral solution Generic

NUEDEXTA ORAL CAPSULE Brand PA


olanzapine oral tablet Generic QL (30 EA per 30 days)

olanzapine oral tablet dispersible Generic QL (30 EA per 30 days)

olanzapine-fluoxetine hcl oral capsule Generic PA; QL (30 EA per 30 days)

OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; STPA


paliperidone er oral tablet extended release 24 hour


paroxetine hcl er oral tablet extended release 24 hour


paroxetine hcl oral tablet Generic

perphenazine oral tablet Generic

phenelzine sulfate oral tablet Generic



142

Drug Status NotesPRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG Brand STPA

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT Medical Benefit PA

protriptyline hcl oral tablet Generic PA

quetiapine fumarate er oral tablet extended release 24 hour

Generic PA

quetiapine fumarate oral tablet Generic QL (90 EA per 30 days)


ra mini nicotine mouth/throat lozenge Generic

ra nicotine mouth/throat gum Generic

ra nicotine polacrilex mouth/throat gum Generic

ra nicotine polacrilex mouth/throat lozenge Generic

ra nicotine transdermal patch 24 hour Generic

REXULTI ORAL TABLET Brand PA; QL (30 EA per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit PA; QL (2 injections per 28 days)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic

risperidone oral solution Generic

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet 4 mg Generic

risperidone oral tablet dispersible Generic




SAPHRIS SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (60 EA per 30 days)

sertraline hcl oral concentrate Generic

sertraline hcl oral tablet Generic

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG Brand



143

Drug Status Notes

SUBOXONE SUBLINGUAL FILM 2-0.5 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 8-2 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)



tgt nicotine mouth/throat gum 4 mg Generic

tgt nicotine polacrilex mouth/throat gum Generic

tgt nicotine polacrilex mouth/throat lozenge Generic

tgt nicotine step one transdermal patch 24 hour Generic

tgt nicotine step three transdermal patch 24 hour Generic

tgt nicotine step two transdermal patch 24 hour Generic

thioridazine hcl oral tablet Generic

thiothixene oral capsule Generic

tranylcypromine sulfate oral tablet Generic

trazodone hcl oral tablet Generic

trifluoperazine hcl oral tablet Generic

trimipramine maleate oral capsule Generic PA

TRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour

Generic

venlafaxine hcl er oral tablet extended release 24 hour

Generic STPA

venlafaxine hcl oral tablet Generic


VIIBRYD ORAL TABLET Brand PA; QL (30 EA per 30 days)

VIIBRYD STARTER PACK ORAL KIT Brand PA

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit PA

VRAYLAR ORAL CAPSULE Brand PA

VRAYLAR ORAL CAPSULE THERAPY PACK Brand PA



144

Drug Status Notes


ziprasidone hcl oral capsule Generic QL (60 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG

BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG Brand


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG

Medical Benefit PA; QL (2 vials per 28 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 405 MG Medical Benefit PA; QL (1 vial per 28 days)

NOT FEELING WELL


NUTRITIONAL DISORDER




cyanocobalamin injection solution Generic

ergocalciferol oral capsule Generic

folbee oral tablet Generic




levocarnitine oral tablet Generic


Generic


multi vitamin/minerals oral tablet Generic




Generic


145

Drug Status Notesmulti-vitamin/fluoride oral tablet chewable 0.5 mg

Brand

mynephrocaps oral capsule Generic


RENAL ORAL CAPSULE Generic




vitamin d (ergocalciferol) oral capsule Generic


OTHER OVER-THE-COUNTER DRUGS

ACCU-CHEK SAFE-T PRO LANCETS Brand

ACCU-CHEK SOFT TOUCH LANCETS Brand

ACCU-CHEK SOFTCLIX LANCETS Brand

AT LAST LANCETS Brand

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 29G X 1/2" 2 ML, U-100 1 ML

Brand

BD INSULIN SYRINGE MICROFINE Brand

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML

Brand

BD LANCET ULTRAFINE 33G Brand

BD SAFETY-LOK INSULIN SYRINGE Brand

BD SYRINGE SLIP TIP 3 ML Brand

CLEANLET LANCETS 28G Brand


comfort lancets Brand

daily multi oral tablet Brand


eq nicotine mouth/throat gum 4 mg Generic


146

Drug Status Noteseq nicotine polacrilex mouth/throat lozenge Generic


eq nicotine transdermal patch 24 hour 7 mg/24hr Generic

EZ-LETS LANCETS 26G Brand

FINGERSTIX LANCETS Brand

FREESTYLE INSULINX TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE LANCETS Brand

FREESTYLE LITE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

GENTLE-LET GP LANCETS Brand

GENTLE-LET LANCETS Brand

GLUCOSOURCE LANCETS Brand

gnp lancets Brand

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Brand

HAEMOLANCE LOW FLOW LANCETS Brand

hm nicotine transdermal patch 24 hour 7 mg/24hr Generic

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION Brand

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR Brand

HUMULIN N SUBCUTANEOUS SUSPENSION Brand

HUMULIN R INJECTION SOLUTION Brand

HY-VEE LANCETS Brand

hy-vee thin lancets Brand

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Brand


147

Drug Status Notesinsulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml Brand

insulin syringe/needle Brand

kinney lancets Brand

kinney thin lancets Brand

kinray insulin syringe 29g x 1/2" 0.5 ml Brand

lancets Brand

lancets thin Brand


LIFESCAN UNISTIK II LANCETS Brand

lite touch lancets Brand

longs lancets thin Brand

MEDISENSE THIN LANCETS Brand

MEIJER LANCETS Brand

MICROTAINER SAFETY FLOW LANCET Brand

MONOJECT FILTER ASPIRATOR Brand

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML

Brand

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Brand

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

MONOJECT PISTON SYRINGE Brand

MONOJECT SAFETY SYRINGE/SHIELD 12 ML , 20G X 1-1/2" 12 ML, 21G X 1" 3 ML, 21G X 1-1/2" 3 ML, 3 ML

Brand

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

Brand

MONOJECT SYRINGE CATH TIP Brand

MONOJECT SYRINGE ECC LUER 35 ML Brand


148

Drug Status NotesMONOJECT SYRINGE LUER LOCK Brand

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

MONOJECT TB SAFETY SYRINGE 28G X 1/2" 1 ML Brand

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

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML Brand

MONOLET LANCETS Brand

MULTI COMPLETE ORAL CAPSULE Generic

n-acetyl-l-cysteine oral capsule Generic

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION Brand

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION Brand

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION Brand

NOVOLIN N SUBCUTANEOUS SUSPENSION Brand

NOVOLIN R INJECTION SOLUTION Brand

NOVOLIN R RELION INJECTION SOLUTION Brand

ONETOUCH CLUB LANCETS FINE PT Brand

ONETOUCH FINEPOINT LANCETS Brand

ONETOUCH LANCETS Brand

ONETOUCH ULTRASOFT LANCETS Brand

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML

Brand

PRECISION THIN LANCETS Brand

PRECISION THINS GP LANCETS Brand

PRECISION ULTRA LANCET Brand

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP $0 QL (150 strips per 30 days)

preferred plus lancets colored Brand

preferred plus lancets thin Brand


149

Drug Status Notesprenatal 19 oral tablet Generic

prenatal 19 oral tablet chewable Generic

PSS SELECT GP LANCETS Brand

PSS SELECT SAFETY LANCETS Brand

qc nicotine polacrilex mouth/throat gum Generic

reality lancets Brand

reality trigger lancets Brand

sb lancets thin Brand

sb lancets ultra thin Brand

sr nicotine mouth/throat gum Generic

super thin lancets Brand

sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Brand

SURELITE LANCETS Brand

tb syringe 1 ml Brand

TECHLITE LANCETS Brand

tgt nicotine mouth/throat gum Generic

THINLETS GP LANCETS Brand

THINLETS LANCET Brand

topco insulin syringe Brand

ULTILET CLASSIC LANCETS Brand

ULTILET LANCETS Brand

ULTRA-THIN II AUTO LANCET Brand

ULTRA-THIN II LANCETS Brand

UNILET COMFORTOUCH LANCET Brand

UNILET G.P. LANCET Brand

UNILET G.P. SUPERLITE LANCET Brand

UNILET LANCET Brand

UNILET SUPERLITE LANCET Brand

UNISTIK 1 Brand

VITALET PRO LANCETS Brand

VITALET PRO PLUS LANCETS Brand

W&F LANCETS 26G Brand


150

Drug Status NotesW&F LANCETS COLORED 21G Brand

weight loss daily multi oral tablet Generic

OTHER PRESCRIPTION DRUGS




acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)

acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetazolamide er oral capsule extended release 12 hour

Generic


acitretin oral capsule Generic QL (60 EA per 30 days)



acyclovir oral capsule Generic

acyclovir oral suspension Generic

acyclovir oral tablet Generic



ALBENZA ORAL TABLET Brand

ALECENSA ORAL CAPSULE Brand PA; SP




alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 25-30 mg, 25-45 mg


ALOMIDE OPHTHALMIC SOLUTION Brand PA

alosetron hcl oral tablet 0.5 mg Generic

ALUNBRIG ORAL TABLET Brand PA

amiodarone hcl oral tablet 100 mg Generic

amitriptyline hcl oral tablet Generic

amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)

amlodipine-olmesartan oral tablet Generic PA


151

Drug Status Notesamlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)


amoxicillin oral capsule Generic

amoxicillin oral suspension reconstituted Generic

amoxicillin oral tablet Generic

amoxicillin oral tablet chewable 125 mg, 250 mg Generic

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

Generic

amoxicillin-pot clavulanate oral suspension reconstituted

Generic

amoxicillin-pot clavulanate oral tablet Generic

amoxicillin-pot clavulanate oral tablet chewable Generic

amphetamine-dextroamphetamine oral tablet 12.5 mg, 15 mg, 7.5 mg


ampicillin oral capsule Generic

ampicillin oral suspension reconstituted Generic

anastrozole oral tablet Generic


Brand PA

ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)

antipyrine-benzocaine otic solution 5.4-1.4 %, 54-14 mg/ml

Generic

APIDRA INJECTION SOLUTION Brand

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION Brand

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION CARTRIDGE Brand

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand


aripiprazole oral tablet 2 mg Generic PA; QL (30 EA per 30 days)

aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)





152

Drug Status Notesatovaquone oral suspension Generic

AUBRA ORAL TABLET Generic


AVAR CLEANSER EXTERNAL EMULSION Generic

azithromycin oral packet Generic

azithromycin oral suspension reconstituted Generic

azithromycin oral tablet 250 mg, 500 mg, 600 mg Generic

bacitra-neomycin-polymyxin-hc ophthalmic ointment

Generic

BANZEL ORAL SUSPENSION Brand PA

BANZEL ORAL TABLET Brand PA

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

benzphetamine hcl oral tablet 25 mg Generic PA

bexarotene oral capsule Generic

bicalutamide oral tablet Generic

bimatoprost ophthalmic solution Generic PA

BOSULIF ORAL TABLET 100 MG Brand PA; SP; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 500 MG Brand PA; SP; QL (30 EA per 30 days)

bp multinatal plus oral tablet chewable Generic

BRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)


Generic

budesonide inhalation suspension 1 mg/2ml Generic

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



CABOMETYX ORAL TABLET Brand PA; SP

calcipotriene-betameth diprop external ointment Generic PA

capecitabine oral tablet Generic

CAPRELSA ORAL TABLET 100 MG Brand PA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG Brand PA; QL (30 EA per 30 days)

carbamazepine er oral tablet extended release 12 hour 100 mg

Generic



153

Drug Status Notescefaclor oral capsule Generic

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

Generic

cefadroxil oral capsule Generic

cefadroxil oral suspension reconstituted Generic

cefadroxil oral tablet Generic

cefdinir oral capsule Generic

cefdinir oral suspension reconstituted Generic

cefditoren pivoxil oral tablet 200 mg Generic

cefixime oral suspension reconstituted Generic

cefpodoxime proxetil oral suspension reconstituted

Generic

cefpodoxime proxetil oral tablet Generic

cefprozil oral suspension reconstituted Generic

cefprozil oral tablet Generic

ceftibuten oral capsule Generic

CEFTIN ORAL SUSPENSION RECONSTITUTED Brand PA

cefuroxime axetil oral tablet Generic


cephalexin oral capsule Generic

cephalexin oral suspension reconstituted Generic

cephalexin oral tablet Generic

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT Medical Benefit PA; SP

CEROVEL EXTERNAL LOTION Generic

chlorthalidone oral tablet 100 mg Generic

choline & mag trisalicylate oral tablet 1000 mg Generic

ciprofloxacin hcl ophthalmic solution Generic

ciprofloxacin hcl oral tablet Generic

ciprofloxacin oral suspension reconstituted Generic

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour

Generic

clarithromycin er oral tablet extended release 24 hour

Generic


154

Drug Status Notesclarithromycin oral suspension reconstituted Generic

clarithromycin oral tablet Generic

clindamycin hcl oral capsule Generic

clindamycin palmitate hcl oral solution reconstituted

Generic

clobetasol propionate external liquid Generic PA





clozapine oral tablet dispersible 150 mg, 200 mg Generic QL (60 EA per 30 days)

COMETRIQ (100 MG DAILY DOSE) ORAL KIT Brand PA




COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML Brand SP

CORTISPORIN-TC OTIC SUSPENSION Brand PA

COTELLIC ORAL TABLET Brand PA; SP

cyclopentolate hcl ophthalmic solution 0.5 % Generic QL (2 ML per 30 days)

cyclophosphamide oral capsule Generic

cycloserine oral capsule Generic

cytra-2 oral solution Generic


Generic PA

demeclocycline hcl oral tablet Generic PA

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

$0

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Generic




155

Drug Status Notesdexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg



diazepam oral solution 5 mg/5ml Generic

diclofenac sodium oral tablet delayed release Generic


diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)


dicloxacillin sodium oral capsule Generic

dicyclomine hcl oral solution Generic


Generic


doxepin hcl external cream Generic QL (45 grams per 1 Fill)


doxycycline hyclate oral capsule Generic

doxycycline hyclate oral tablet 100 mg Generic

doxycycline monohydrate oral capsule 100 mg, 50 mg

Generic

doxycycline monohydrate oral suspension reconstituted

Generic

doxycycline monohydrate oral tablet 100 mg, 50 mg

Generic

drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg

Generic


Generic








E.E.S. 400 ORAL TABLET Generic


156

Drug Status NotesECOZA EXTERNAL FOAM Brand PA



ERYPED 400 ORAL SUSPENSION RECONSTITUTED Generic

ERY-TAB ORAL TABLET DELAYED RELEASE Generic

ERYTHROCIN STEARATE ORAL TABLET250 MG Generic

erythromycin base oral capsule delayed release particles

Generic

erythromycin base oral tablet Generic

erythromycin ethylsuccinate oral suspension reconstituted

Generic

erythromycin ethylsuccinate oral tablet Generic

est estrogens-methyltest hs oral tablet Generic

est estrogens-methyltest oral tablet Generic


estradiol-norethindrone acet oral tablet Generic


etoposide oral capsule Generic

ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)

ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)

FABIOR EXTERNAL FOAM Brand PA

famciclovir oral tablet Generic

FARESTON ORAL TABLET Brand


felbamate oral suspension Generic PA

felbamate oral tablet Generic PA

fenofibrate oral capsule Generic PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 40 mg Generic PA; QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)


157

Drug Status NotesFIRST-LANSOPRAZOLE ORAL SUSPENSION Brand PA

FIRST-OMEPRAZOLE ORAL SUSPENSION Brand PA

fluconazole oral suspension reconstituted Generic

fluconazole oral tablet Generic

flucytosine oral capsule Generic PA


FLUORIDEX ENHANCED WHITENING DENTAL GEL Generic

fluoxetine hcl (pmdd) oral tablet Generic PA


flurandrenolide external lotion Generic PA

flutamide oral capsule Generic

fluvastatin sodium er oral tablet extended release 24 hour





gatifloxacin ophthalmic solution Generic

gentamicin sulfate ophthalmic ointment Generic

gentamicin sulfate ophthalmic solution Generic

GILOTRIF ORAL TABLET Brand PA

GLEOSTINE ORAL CAPSULE 5 MG Brand

glycopyrrolate oral tablet 1 mg, 2 mg Generic


Hemofil M Intravenous SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

heparin sodium (porcine) injection solution 2500 unit/ml

Generic

HEXALEN ORAL CAPSULE Brand

Hizentra Subcutaneous SOLUTION 10 GM/50ML

MB/RX PA; SP


158

Drug Status NotesHUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

Brand

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION Brand

HUMALOG PEN SUBCUTANEOUS SOLUTION Brand

HUMALOG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

HUMALOG SUBCUTANEOUS SOLUTION Brand

HYCAMTIN ORAL CAPSULE 0.25 MG Brand PA; SP; QL (15 EA per 21 days)

HYCAMTIN ORAL CAPSULE 1 MG Brand PA; SP; QL (25 EA per 21 days)

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml

Generic QL (480 ML per 1 day)

hydrocortisone external ointment 1 % Generic



HYOPHEN ORAL TABLET Generic

hyoscyamine sulfate er oral tablet extended release 12 hour

Generic


159

Drug Status Noteshyoscyamine sulfate oral elixir Generic

hyoscyamine sulfate oral solution Generic

hyoscyamine sulfate oral tablet Generic

hyoscyamine sulfate oral tablet dispersible Generic

hyoscyamine sulfate sublingual tablet sublingual Generic

hyosyne oral elixir Generic

hyosyne oral solution Generic

IBRANCE ORAL CAPSULE Brand PA; SP

ICLUSIG ORAL TABLET Brand PA

IDHIFA ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

imatinib mesylate oral tablet 100 mg Generic

imatinib mesylate oral tablet 400 mg Brand


INLYTA ORAL TABLET Brand PA; SP

IRESSA ORAL TABLET Brand PA

isometheptene-dichloral-apap oral capsule Generic QL (300 EA per 30 days)

itraconazole oral capsule Generic


ketoconazole oral tablet Generic

KISQALI 200 DOSE ORAL TABLET Brand PA



Kogenate FS Intravenous KIT MB/RX SP



LARIN FE 1.5/30 ORAL TABLET Generic

LARIN FE 1/20 ORAL TABLET Generic

LATRIX EXTERNAL SUSPENSION Generic

LATUDA ORAL TABLET 60 MG Brand PA; QL (30 EA per 30 days)

LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA




160

Drug Status NotesLENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA


levofloxacin ophthalmic solution Generic

levofloxacin oral solution Generic

levofloxacin oral tablet Generic

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg

Generic

levonorgestrel oral tablet 1.5 mg Generic

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet Generic


linezolid oral suspension reconstituted Generic QL (840 ML per 14 days)

linezolid oral tablet Generic QL (28 EA per 14 days)

LOMEDIA 24 FE ORAL TABLET Generic

lomustine oral capsule Generic

LUPRON INJECTION KIT Medical Benefit PA; SP

LUPRON SUBCUTANEOUS SOLUTION Medical Benefit PA; SP


LYNPARZA ORAL TABLET Brand PA

LYZA ORAL TABLET Generic

MATULANE ORAL CAPSULE Brand

me/naphos/mb/hyo1 oral tablet Generic

megestrol acetate oral suspension 625 mg/5ml Generic

megestrol acetate oral tablet Generic

MEKINIST ORAL TABLET Brand PA; SP

melphalan oral tablet Generic



meperidine hcl oral tablet 100 mg Generic QL (12 EA per 1 day)

mercaptopurine oral tablet Generic




161

Drug Status Notesmetformin hcl er (mod) oral tablet extended release 24 hour

Generic PA

methoxsalen rapid oral capsule Generic



metronidazole oral capsule Generic

metronidazole oral tablet Generic


minocycline hcl oral capsule Generic



Monoclate-P Intravenous KIT 1500 UNIT MB/RX SP

MONOJECT CONTROL SYRINGE Brand

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

Brand

MONOJECT SAFETY SYRINGE/SHIELD21G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML Brand

MONOJECT SYRINGE 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML, 3 ML , 6 ML Brand

MONOJECT SYRINGE LUER LOCK 6 ML , 60 ML Brand

MONOJECT SYRINGE REG LUER 12 ML Brand

Mononine Intravenous SOLUTION RECONSTITUTED 1000 UNIT

MB/RX SP

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg

Generic PA; QL (2 EA per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 30 mg









162

Drug Status Notesmorphine sulfate er oral capsule extended release 24 hour 10 mg


moxifloxacin hcl oral tablet Generic



multivitamin/fluoride oral tablet chewable Generic


Generic



neomycin-polymyxin-dexameth ophthalmic ointment

Generic

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Generic

neomycin-polymyxin-hc otic solution 1 % Generic

NEO-POLYCIN HC OPHTHALMIC OINTMENT Generic

NERLYNX ORAL TABLET Brand PA

nevirapine er oral tablet extended release 24 hour400 mg

Generic

NEXAVAR ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)

niacin er (antihyperlipidemic) oral tablet extended release

Generic

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG Generic

nilutamide oral tablet Generic

nitrofurantoin macrocrystal oral capsule Generic

nitrofurantoin monohyd macro oral capsule Generic

nitrofurantoin oral suspension Generic

NODOLOR ORAL CAPSULE Generic QL (300 EA per 30 days)

norethin ace-eth estrad-fe oral tablet Generic

norethin ace-eth estrad-fe oral tablet chewable Generic

norethindrone acet-ethinyl est oral tablet Generic


norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

Generic


163

Drug Status Notesnorgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg

Generic

norgestrel-ethinyl estradiol oral tablet Generic

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION Brand

NOVOLOG SUBCUTANEOUS SOLUTION Brand


np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg

Generic

ofloxacin ophthalmic solution Generic

ofloxacin oral tablet 400 mg Generic

olmesartan medoxomil oral tablet Generic STPA

olmesartan medoxomil-hctz oral tablet Generic STPA



OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION Brand PA



ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)

opium oral tincture Generic


oseltamivir phosphate oral capsule 30 mg Generic QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg Generic QL (10 EA per 1 Fill)

otic care otic solution Generic


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


oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )


164

Drug Status NotesOXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)

paliperidone er oral tablet extended release 24 hour


PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

Brand

pantoprazole sodium oral tablet delayed release Generic



penicillin g procaine intramuscular suspension Generic

penicillin v potassium oral solution reconstituted Generic

penicillin v potassium oral tablet Generic


phenobarbital oral elixir Generic

phenobarbital oral solution Generic

phenobarbital oral tablet Generic

PHENOHYTRO ORAL TABLET Generic

phenoxybenzamine hcl oral capsule Generic


phenylephrine-guaifenesin oral liquid Generic

PHOS-FLUR DENTAL GEL Generic

PHOSPHASAL ORAL TABLET Generic

pimozide oral tablet 2 mg Generic PA

PIMTREA ORAL TABLET Generic

PIRMELLA 7/7/7 ORAL TABLET Generic

potassium chloride er oral tablet extended release20 meq

Generic

potassium chloride oral packet Generic

potassium citrate er oral tablet extended release Generic


Generic



Generic


165

Drug Status Notesprednisone oral solution Generic

prednisone oral tablet Generic

prednisone oral tablet therapy pack Generic

premium lidocaine external ointment Generic QL (50 GM per 30 days)

primidone oral tablet Generic



progesterone micronized transdermal cream Generic

promethazine hcl rectal suppository 50 mg Generic


PROTONIX ORAL PACKET Brand PA

PURIXAN ORAL SUSPENSION Brand


Generic

quetiapine fumarate er oral tablet extended release 24 hour

Generic PA

quinine sulfate oral capsule Generic PA



rasagiline mesylate oral tablet Generic

REA LO 40 EXTERNAL CREAM Generic

REA LO 40 EXTERNAL LOTION Generic

REMEVEN EXTERNAL CREAM Generic



REVLIMID ORAL CAPSULE Brand PA; SP

rifabutin oral capsule Generic

rifampin oral capsule Generic


risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)



RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic


166

Drug Status Notesrivastigmine transdermal patch 24 hour 4.6 mg/24hr, 9.5 mg/24hr

Generic

Rixubis Intravenous SOLUTION RECONSTITUTED

MB/RX SP

ROSANIL CLEANSER EXTERNAL EMULSION Generic

rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)

RYDAPT ORAL CAPSULE Brand PA




SIVEXTRO ORAL TABLET Brand PA; QL (6 EA per 365 days)

sodium fluoride oral tablet 2.2 (1 f) mg Generic

sodium polystyrene sulfonate oral powder Generic


SPRYCEL ORAL TABLET 100 MG, 140 MG Brand PA; SP; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG Brand PA; SP; QL (60 EA per 30 days)

STIVARGA ORAL TABLET Brand PA; SP; QL (84 EA per 28 days)

sulfacetamide sodium-sulfur external emulsion Generic

sulfacetamide sodium-sulfur external lotion 10-5 %

Generic

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

Generic

sulfamethoxazole-trimethoprim oral tablet Generic


SUPRAX ORAL CAPSULE Brand PA

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML Brand PA

SUPRAX ORAL TABLET CHEWABLE Brand PA

SUTENT ORAL CAPSULE Brand PA; SP


TAFINLAR ORAL CAPSULE Brand PA; SP

TAGRISSO ORAL TABLET 40 MG Brand PA; QL (30 Tablets per 30 days)

TAGRISSO ORAL TABLET 80 MG Brand PA


167

Drug Status NotesTARCEVA ORAL TABLET 100 MG, 150 MG Brand SP; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG Brand SP; QL (90 EA per 30 days)

TASIGNA ORAL CAPSULE Brand PA; SP


telmisartan-hctz oral tablet Generic PA

temozolomide oral capsule Generic

terbinafine hcl oral tablet Generic¥ (Max of 90 tablets per 365 days); QL (30 EA per 30 days)

testosterone transdermal gel 10 mg/act (2%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

Generic PA




tetracycline hcl oral capsule Generic

TIVICAY ORAL TABLET 50 MG Brand


tobramycin ophthalmic solution Generic



Generic

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

tretinoin external gel 0.05 % Generic PA; Age Limit (Max 26 Years)

tretinoin oral capsule Generic


TRI-LO-SPRINTEC ORAL TABLET Generic



TYKERB ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)

UNITHROID DIRECT ORAL TABLET Generic

UNITHROID ORAL TABLET 137 MCG Generic

urea external cream 40 %, 50 % Generic

urea external lotion 40 % Generic


168

Drug Status Notesurea external suspension Generic

urea nail film external suspension Generic

urea-c40 external lotion Generic

ure-k external cream Generic

URIMAR-T ORAL TABLET Generic

UROLET MB ORAL TABLET Generic

UROPHEN MB ORAL TABLET Generic

URYL ORAL TABLET Generic

valacyclovir hcl oral tablet Generic

valganciclovir hcl oral solution reconstituted Generic

valganciclovir hcl oral tablet Generic

valsartan oral tablet Generic STPA

vancomycin hcl oral capsule Generic QL (40 EA per 10 days)


voriconazole oral suspension reconstituted Generic PA

voriconazole oral tablet Generic PA; QL (180 EA per 30 days)

VOTRIENT ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)

VYFEMLA ORAL TABLET Generic

XALKORI ORAL CAPSULE Brand PA; SP

XTANDI ORAL CAPSULE Brand PA; SP; QL (120 EA per 30 days)

ZEJULA ORAL CAPSULE Brand PA

ZELBORAF ORAL TABLET Brand PA; SP

ZOMIG NASAL SOLUTION 2.5 MG BrandPA; STPA; QL (6 Units per 30 days)

ZOVIRAX EXTERNAL CREAM Brand PA; QL (5 GM per 1 Rx)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG Brand


ZYKADIA ORAL CAPSULE Brand PA; SP

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

OVERDOSE


AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

EVZIO INJECTION SOLUTION AUTO-INJECTOR Brand

PA; ¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)


169

Drug Status NotesFERRIPROX ORAL SOLUTION Brand PA

FERRIPROX ORAL TABLET Brand PA




MOVANTIK ORAL TABLET Brand PA

naloxone hcl injection solution 0.4 mg/ml Generic

RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA


VISTOGARD ORAL PACKET Brand QL (20 EA per 30 days)

PAIN

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA

acetaminophen-codeine #2 oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)



acetaminophen-codeine oral solution Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)


amlodipine besylate oral tablet Generic

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT Brand PA

ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)

atenolol oral tablet Generic

BELBUCA BUCCAL FILM Brand PA; QL (60 Films per 30 days)





170

Drug Status Notesbromfenac sodium (once-daily) ophthalmic solution

Generic


buprenorphine transdermal patch weekly Generic PA; QL (4 EA per 28 days)

butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)

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


butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)


butorphanol tartrate injection solution Generic

butorphanol tartrate nasal solution Generic

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA



cimetidine oral tablet 200 mg Generic

clopidogrel bisulfate oral tablet Generic

codeine sulfate oral tablet Generic QL (360 mg per 1 day)



diflunisal oral tablet Generic


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

Generic

diltiazem hcl er beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral capsule extended release 24 hour

Generic


Generic

diltiazem hcl er oral capsule extended release 12 hour

Generic

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

Generic

diltiazem hcl oral tablet Generic


171

Drug Status Notesdivalproex sodium er oral tablet extended release 24 hour

Generic


Generic







EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG Brand PA; QL (2 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 20-0.8 MG Brand PA; QL (12 EA per 1 day)


EMBEDA ORAL CAPSULE EXTENDED RELEASE 50-2 MG, 60-2.4 MG Brand PA; QL (4 EA per 1 day)




eplerenone oral tablet Generic PA; QL (60 EA per 30 days)



famotidine oral suspension reconstituted Generic

famotidine oral tablet 20 mg, 40 mg Generic

fenoprofen calcium oral tablet Generic

fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)

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


fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr


FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)

flavoxate hcl oral tablet Generic



172

Drug Status Notesgabapentin oral capsule Generic






hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml


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

Generic QL (12 EA per 1 day)

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


hydromorphone hcl er oral tablet er 24 hour abuse-deterrent

Generic PA; QL (64 mg per 1 day)

hydromorphone hcl oral liquid Generic QL (120 mg per 1 day)

hydromorphone hcl oral tablet Generic QL (120 mg per 1 day)

hydromorphone hcl rectal suppository Generic

IBUDONE ORAL TABLET Generic QL (5 EA per 1 day)



isosorbide dinitrate er oral tablet extended release

Generic

isosorbide dinitrate oral tablet Generic

isosorbide mononitrate er oral tablet extended release 24 hour

Generic

isosorbide mononitrate oral tablet Generic

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (1 EA per 1 day)

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG Brand PA; QL (6 EA per 1 day)


ketorolac tromethamine intramuscular solution60 mg/2ml

Generic¥ (Max of 5 days per Rx); QL (120 mg per 1 day)


ketorolac tromethamine oral tablet Generic QL (20 EA per 30 days)



173

Drug Status Noteslidocaine hcl external cream 3 % Generic



MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA


mefenamic acid oral capsule Generic PA

meperidine hcl oral solution Generic QL (120 ML per 1 day)



METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)

methadone hcl oral concentrate Generic QL (6 ML per 1 day)





metoprolol succinate er oral tablet extended release 24 hour

Generic

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

Generic

metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA


MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (60 EA per 30 days)

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


morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg











174

Drug Status Notesmorphine sulfate er oral capsule extended release 24 hour 10 mg


morphine sulfate er oral capsule extended release 24 hour 100 mg






morphine sulfate er oral capsule extended release 24 hour 50 mg, 60 mg




morphine sulfate er oral tablet extended release100 mg










morphine sulfate oral solution 10 mg/5ml Generic QL (120 ML per 1 day)

morphine sulfate oral solution 20 mg/5ml Generic QL (60 ML per 1 day)

morphine sulfate oral tablet 15 mg Generic QL (16 EA per 1 day)

morphine sulfate oral tablet 30 mg Generic QL (8 EA per 1 day)

nadolol oral tablet 20 mg, 40 mg, 80 mg Generic





nicardipine hcl oral capsule Generic

nifedipine er oral tablet extended release 24 hour Generic

nifedipine er osmotic release oral tablet extended release 24 hour

Generic

nifedipine oral capsule Generic

nitroglycerin sublingual tablet sublingual Generic


175

Drug Status Notesnitroglycerin transdermal patch 24 hour Generic

nitroglycerin translingual aerosol solution Generic

nitroglycerin translingual solution Generic


NUCYNTA ORAL TABLET Brand PA

OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (80 mg per 1 day)


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


oxycodone hcl er oral tablet er 12 hour abuse-deterrent 15 mg

Brand QL (90 EA per 30 days)

oxycodone hcl oral capsule Generic QL (160 mg per 1 day)

oxycodone hcl oral concentrate 100 mg/5ml Generic QL (160 mg per 1 day)

oxycodone hcl oral solution Generic

oxycodone hcl oral tablet Generic QL (160 mg per 1 day)

oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

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

Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-aspirin oral tablet 4.8355-325 mg Generic

oxycodone-ibuprofen oral tablet Generic PA

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)

oxymorphone hcl er oral tablet extended release 12 hour

Generic PA; QL (80 mg per 1 day)

oxymorphone hcl oral tablet Generic PA; QL (80 mg per 1 day)


perindopril erbumine oral tablet Generic

phenazopyridine hcl oral tablet 100 mg, 200 mg Generic





176

Drug Status Notespromethazine hcl oral solution Generic





Generic

propranolol hcl oral solution 40 mg/5ml Generic


RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)





SPRIX NASAL SOLUTION BrandPA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)












timolol maleate oral tablet Generic







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

Generic PA


177

Drug Status Notestramadol hcl er oral tablet extended release 24 hour


tramadol hcl oral tablet Generic QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet Generic QL (240 EA per 30 days)

trandolapril oral tablet Generic


verapamil hcl oral tablet Generic

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (120 mg per 1 day)





PATIENT DEMOGRAPHICS

bupropion hcl er (smoking det) oral tablet extended release 12 hour

Generic

CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

eq nicotine mouth/throat lozenge Generic

eq nicotine polacrilex mouth/throat gum Generic

eq nicotine polacrilex mouth/throat lozenge Generic


eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Generic

eql nicotine polacrilex mouth/throat gum Generic

eql nicotine polacrilex mouth/throat lozenge Generic

eql nicotine transdermal patch 24 hour Generic

gnp nicotine mini mouth/throat lozenge Generic

gnp nicotine polacrilex mouth/throat gum Generic

gnp nicotine polacrilex mouth/throat lozenge Generic

hm nicotine polacrilex mouth/throat gum Generic


178

Drug Status Noteshm nicotine polacrilex mouth/throat lozenge Generic

hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr

Generic

NICORELIEF MOUTH/THROAT GUM Generic

nicotine mini mouth/throat lozenge Generic

nicotine polacrilex mouth/throat gum Generic

nicotine polacrilex mouth/throat lozenge Generic




nicotine transdermal patch 24 hour Generic

NICOTROL INHALATION INHALER Brand PA

NICOTROL NS NASAL SOLUTION Brand PA

ra mini nicotine mouth/throat lozenge Generic

ra nicotine mouth/throat gum Generic

ra nicotine polacrilex mouth/throat gum Generic

ra nicotine polacrilex mouth/throat lozenge Generic

ra nicotine transdermal patch 24 hour Generic

tgt nicotine mouth/throat gum 4 mg Generic

tgt nicotine polacrilex mouth/throat gum Generic

tgt nicotine polacrilex mouth/throat lozenge Generic

tgt nicotine step one transdermal patch 24 hour Generic

tgt nicotine step three transdermal patch 24 hour Generic

tgt nicotine step two transdermal patch 24 hour Generic

PREGNANCY


DICLEGIS ORAL TABLET DELAYED RELEASE Brand PA

ELITE-OB ORAL TABLET Generic

INATAL ADVANCE ORAL TABLET Generic

Makena Intramuscular Oil MB/RX PA; QL (1 ML per 7 days)

methylergonovine maleate oral tablet Generic

prenatabs fa oral tablet Generic

prenatal 19 oral tablet Generic


179

Drug Status Notesprenatal 19 oral tablet chewable Generic

prenatal oral tablet 27-0.8 mg Generic

TRINATE ORAL TABLET Generic

PROCEDURE


MB/RX SP








Generic







Generic








FERRIPROX ORAL SOLUTION Brand PA

FERRIPROX ORAL TABLET Brand PA

flurbiprofen sodium ophthalmic solution Generic



GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic


180

Drug Status NotesGAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic




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

Generic


MB/RX SP







ketorolac tromethamine intramuscular solution60 mg/2ml








lidocaine hcl external solution Generic

lidocaine viscous mouth/throat solution Generic

lidocaine-prilocaine external cream Generic

lidocaine-prilocaine external kit Generic

liothyronine sodium oral tablet Generic



Generic





181

Drug Status Notesneomycin sulfate oral tablet Generic


Brand SP




Generic


peg 3350/electrolytes oral solution reconstituted Generic

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Generic

peg-3350/electrolytes oral solution reconstituted Generic



Generic










quinidine gluconate er oral tablet extended release

Generic

quinidine sulfate er oral tablet extended release Generic

quinidine sulfate oral tablet Generic






182

Drug Status Notes












REACTION DUE TO AN ALLERGEN






















183

Drug Status Notesepinastine hcl ophthalmic solution Generic PA


epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml

Generic QL (2 EA per 1 Fill)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)




Generic




















MB/RX SP





184

Drug Status NotesXOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)


RECENT OPERATION


MB/RX SP






Generic







Generic



flurbiprofen sodium ophthalmic solution Generic







MB/RX SP






185

Drug Status Notesketorolac tromethamine intramuscular solution60 mg/2ml








lidocaine hcl external solution Generic

lidocaine viscous mouth/throat solution Generic

lidocaine-prilocaine external cream Generic

lidocaine-prilocaine external kit Generic



Generic




neomycin sulfate oral tablet Generic


Generic




Generic











186

Drug Status Notes








SKIN CONDITION

ABSORICA ORAL CAPSULE Brand PA

acitretin oral capsule Generic QL (60 EA per 30 days)

acne medication 5 external gel Generic

acyclovir external ointment Generic

ACZONE EXTERNAL GEL Brand PA; QL (60 GM per 30 days)

adapalene external cream Generic STPA

adapalene external gel Generic STPA

adapalene external lotion Generic STPA

alclometasone dipropionate external cream Generic

alclometasone dipropionate external ointment Generic


amcinonide external cream Generic PA

amcinonide external lotion Generic PA

amcinonide external ointment Generic PA

ammonium lactate external cream Generic

ammonium lactate external lotion Generic

APEXICON E EXTERNAL CREAM Brand PA

AVITA EXTERNAL CREAM Generic PA; Age Limit (Max 26 Years)

AVITA EXTERNAL GEL Generic PA; Age Limit (Max 26 Years)

AZELEX EXTERNAL CREAM Brand PA; QL (30 grams per 1 fill)





187

Drug Status Notesbenzoyl peroxide cleanser external lotion 6 % Generic PA

benzoyl peroxide external gel 10 %, 5 % Generic

benzoyl peroxide wash external liquid 10 % Generic

benzoyl peroxide-erythromycin external gel Generic QL (23 GM per 30 days)


betamethasone dipropionate aug external cream Generic

betamethasone dipropionate aug external gel Generic

betamethasone dipropionate aug external lotion Generic

betamethasone dipropionate aug external ointment

Generic

betamethasone dipropionate external cream Generic

betamethasone dipropionate external lotion Generic

betamethasone dipropionate external ointment Generic

betamethasone valerate external cream Generic

betamethasone valerate external foam Generic

betamethasone valerate external lotion Generic

betamethasone valerate external ointment Generic



bp foaming wash external liquid Generic

bp wash external liquid 2.5 % Generic

bpo external gel Brand PA

calcipotriene external cream Generic

calcipotriene external ointment Generic

calcipotriene external solution Generic

calcipotriene-betameth diprop external ointment Generic PA

CALCITRENE EXTERNAL OINTMENT Generic

calcitriol external ointment Generic

CAPEX EXTERNAL SHAMPOO Brand PA




CICLODAN EXTERNAL SOLUTION Generic


188

Drug Status Notesciclopirox external gel Generic

ciclopirox external shampoo Brand PA

ciclopirox external solution Brand








CLARAVIS ORAL CAPSULE GenericPA; ¥ (Max of 5 months); QL (60 EA per 30 days)


clindamycin phos-benzoyl perox external gel Generic PA; QL (50 GM per 30 days)

clindamycin phosphate external foam Generic PA

clindamycin phosphate external gel Generic

clindamycin phosphate external lotion Generic

clindamycin phosphate external solution Generic

clobetasol propionate e external cream Generic

clobetasol propionate external cream Generic PA

clobetasol propionate external foam Generic

clobetasol propionate external gel Generic PA

clobetasol propionate external liquid Generic PA

clobetasol propionate external lotion Generic

clobetasol propionate external ointment Generic PA

clobetasol propionate external shampoo Generic

clobetasol propionate external solution Generic PA








189

Drug Status Notesclotrimazole-betamethasone external lotion Generic

CORDRAN EXTERNAL TAPE Brand PA


Brand PA; SP




dapsone oral tablet Brand


desonide external cream Generic PA

desonide external lotion Generic PA

desonide external ointment Generic PA

desoximetasone external cream 0.05 % Generic PA

desoximetasone external cream 0.25 % Generic

desoximetasone external gel Generic

desoximetasone external ointment 0.05 % Generic PA

desoximetasone external ointment 0.25 % Generic

diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)

diflorasone diacetate external cream Generic PA

diflorasone diacetate external ointment Generic PA


Generic

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (4 ML per 28 days)






ELIDEL EXTERNAL CREAM Brand PA


190

Drug Status NotesENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand










ERIVEDGE ORAL CAPSULE Brand PA; SP

erythromycin external gel Generic

erythromycin external solution Generic



FABIOR EXTERNAL FOAM Brand PA


FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)


fluocinolone acetonide body external oil Generic

fluocinolone acetonide external cream Generic

fluocinolone acetonide external ointment Generic

fluocinolone acetonide external solution Generic


fluocinolone acetonide scalp external oil Generic

fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)


fluocinonide external gel Generic QL (60 GM per 30 days)

fluocinonide external ointment Generic QL (60 GM per 30 days)

fluocinonide external solution Generic QL (60 ML per 30 days)

fluorouracil external cream Generic

fluorouracil external solution Generic



191

Drug Status Notesflurandrenolide external lotion Generic PA

flurandrenolide external ointment Generic PA

fluticasone propionate external cream Generic

fluticasone propionate external lotion Generic

fluticasone propionate external ointment Generic



gentamicin sulfate external cream Generic

gentamicin sulfate external ointment Generic


griseofulvin microsize oral suspension Generic

griseofulvin microsize oral tablet Generic

griseofulvin ultramicrosize oral tablet Generic

halobetasol propionate external cream Generic PA

halobetasol propionate external ointment Generic PA

HALOG EXTERNAL CREAM Brand PA

HALOG EXTERNAL OINTMENT Brand PA








Generic

hydrocortisone butyrate external cream Generic PA

hydrocortisone butyrate external ointment Generic PA

hydrocortisone butyrate external solution Generic PA

hydrocortisone external cream 1 %, 2.5 % Generic

hydrocortisone external lotion Generic


192

Drug Status Noteshydrocortisone external ointment 1 %, 2.5 % Generic


hydrocortisone valerate external cream Generic

hydrocortisone valerate external ointment Generic


hydroxyurea oral capsule Generic


IMPAVIDO ORAL CAPSULE Brand




ketoconazole external foam Generic


KETODAN EXTERNAL FOAM Generic







lindane external lotion Generic

lindane external shampoo Generic



malathion external lotion Generic


methoxsalen rapid oral capsule Generic

metronidazole external cream Generic

metronidazole external gel 0.75 % Generic

metronidazole external gel 1 % Generic PA

metronidazole external lotion Generic



193

Drug Status Notesmometasone furoate external cream Generic

mometasone furoate external ointment Generic

mometasone furoate external solution Generic



MYORISAN ORAL CAPSULE Generic PA


NEUAC EXTERNAL GEL Brand PA


NORITATE EXTERNAL CREAM Brand PA







NYSTOP EXTERNAL POWDER Generic

ODOMZO ORAL CAPSULE Brand PA












permethrin external cream Generic

PICATO EXTERNAL GEL Brand PA; QL (1 Box per 1 Rx)



194

Drug Status Notesprednicarbate external cream Generic

PROCTO-PAK RECTAL CREAM Generic





RETIN-A MICRO PUMP EXTERNAL GEL0.08 % Brand PA; Age Limit (Max 26 Years)


MB/RX SP


selenium sulfide external shampoo Generic

selenium sulf-pyrithione-urea external shampoo Generic


SOOLANTRA EXTERNAL CREAM Brand PA

spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)




sulfacetamide sodium (acne) external lotion Generic

sulfacetamide sodium external suspension Generic

SYNALAR (CREAM) EXTERNAL KIT Brand PA

SYNALAR (OINTMENT) EXTERNAL KIT Brand PA

TACLONEX EXTERNAL SUSPENSION Brand PA






TAZORAC EXTERNAL CREAM Brand PA; STPA


195

Drug Status NotesTAZORAC EXTERNAL GEL Brand PA; STPA

TILIA FE ORAL TABLET Generic

tretinoin external cream Generic PA; Age Limit (Max 26 Years)

tretinoin external gel Generic PA; Age Limit (Max 26 Years)

tretinoin microsphere external gel Generic PA; Age Limit (Max 26 Years)

tretinoin microsphere pump external gel Generic PA; Age Limit (Max 26 Years)



triamcinolone acetonide external cream Generic

triamcinolone acetonide external lotion Generic

triamcinolone acetonide external ointment Generic

TRI-LEGEST FE ORAL TABLET Generic

ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)





ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG Generic PA

ZENATANE ORAL CAPSULE 40 MG Brand PA

ZOLINZA ORAL CAPSULE Brand PA; SP

ZYCLARA EXTERNAL CREAM Brand PA; QL (28 EA per 14 days)

ZYCLARA PUMP EXTERNAL CREAM Brand PA; QL (2 Pumps per 1 day)

SLOW DRUG ELIMINATION BY KIDNEY


TUMOR

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA



AKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)


196

Drug Status Notesalfuzosin hcl er oral tablet extended release 24 hour

Generic










CESAMET ORAL CAPSULE Brand PA

DEMSER ORAL CAPSULE Brand





ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP

EMCYT ORAL CAPSULE Brand


EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Brand SP

ERIVEDGE ORAL CAPSULE Brand PA; SP

exemestane oral tablet Generic


FARYDAK ORAL CAPSULE Brand PA; SP

fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)


197

Drug Status NotesFENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)

finasteride oral tablet 5 mg Generic

fluorouracil external cream 5 % Generic

fluorouracil external solution 5 % Generic

granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)




MB/RX

hydroxyurea oral capsule Generic



JAKAFI ORAL TABLET Brand PA; SP

letrozole oral tablet Generic

LEUKERAN ORAL TABLET Brand


LONSURF ORAL TABLET Brand PA; SP





LYNPARZA ORAL CAPSULE Brand PA

LYSODREN ORAL TABLET Brand



Brand SP




198

Drug Status NotesNEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand SP


NINLARO ORAL CAPSULE Brand PA; SP




ODOMZO ORAL CAPSULE Brand PA


Generic

ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)

ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)


phenoxybenzamine hcl oral capsule Generic


POMALYST ORAL CAPSULE Brand PA; SP



RAPAFLO ORAL CAPSULE Brand PA


RUBRACA ORAL TABLET 200 MG, 300 MG Brand PA; SP; QL (120 EA per 30 days)

RUBRACA ORAL TABLET 250 MG Brand PA; QL (120 EA per 30 days)

SANCUSO TRANSDERMAL PATCH Brand PA

SOLTAMOX ORAL SOLUTION Brand


TABLOID ORAL TABLET Brand

tamoxifen citrate oral tablet Generic

tamsulosin hcl oral capsule Generic


THALOMID ORAL CAPSULE Brand SP

VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VENCLEXTA ORAL TABLET Brand PA


199

Drug Status NotesVENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK Brand PA


XERMELO ORAL TABLET Brand PA



ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; SP; QL (1 EA per 84 days)


ZOLINZA ORAL CAPSULE Brand PA; SP



200

Indexabacavir sulfate ............ 16, 94, 151abacavir sulfate-lamivudine.......................................16, 94, 151abacavir-lamivudine-zidovudine.......................................16, 94, 151ABILIFY MAINTENA .......... 135ABSORICA ............................. 187ABSTRAL ....................... 170, 196acamprosate calcium ........ 135, 151acarbose ................................24, 86ACCU-CHEK SAFE-T PRO LANCETS ............................... 146ACCU-CHEK SOFT TOUCH LANCETS ............................... 146ACCU-CHEK SOFTCLIX LANCETS ............................... 146acebutolol hcl ..............................33acetaminophen-codeine .... 151, 170acetaminophen-codeine #2 ....... 170acetaminophen-codeine #3 ....... 170acetaminophen-codeine #4 ....... 170ACETASOL HC ....................... 91acetazolamide ......... 24, 73, 92, 120acetazolamide er .......................151acetic acid ...................................91acetic acid-aluminum acetate ..... 91acetylcysteine .............. 73, 120, 169ACIPHEX SPRINKLE.....................................78, 103, 151acitretin .............................151, 187acne medication 5 ..................... 187ACTEMRA ..14, 17, 103, 125, 151ACTIMMUNE .............. 3, 17, 125ACTOPLUS MET XR ........24, 86acyclovir ......................94, 151, 187ACZONE ................................. 187adapalene ..................................187ADCIRCA ................8, 33, 73, 120adefovir dipivoxil .. 78, 94, 103, 151ADEMPAS ...3, 8, 33, 73, 120, 151ADLYXIN ............................24, 86ADLYXIN STARTER PACK...............................................24, 86ADVAIR DISKUS 8, 73, 103, 120ADVAIR HFA .......8, 73, 103, 120Advate...........................................3

Adynovate.....................................3AFINITOR ............ 42, 65, 78, 196AFINITOR DISPERZ 45, 55, 196Afstyla...........................................3AKYNZEO ........................ 79, 196ALBENZA ............................... 151albuterol sulfate .......... 8, 9, 73, 120albuterol sulfate er ..........8, 73, 120alclometasone dipropionate...........................................103, 187ALECENSA .............................151alendronate sodium 24, 65, 86, 125ALFERON N .............94, 103, 187alfuzosin hcl er ....................42, 197ALLI ...........................................24allopurinol .................... 24, 42, 197almotriptan malate.........................33, 45, 55, 151, 170ALOCRIL ..........92, 103, 119, 183alogliptin benzoate ........24, 86, 151alogliptin-metformin hcl.......................................24, 86, 151alogliptin-pioglitazone ..24, 86, 151ALOMIDE ...............................151alosetron hcl ....................... 79, 151ALPHAGAN P .......................... 92Alphanate/VWF Complex/Human...................3, 17, 33, 103, 180, 185AlphaNine SD...............................3alprazolam ................................ 135alprazolam er ............................135alprazolam xr ............................135Alprolix.........................................3ALTAVERA ..............................65ALUNBRIG .............................151ALVESCO ............. 9, 73, 103, 120alyacen 1/35 ................................65alyacen 7/7/7 ...............................65amantadine hcl ................45, 55, 94amcinonide ........................103, 187AMETHIA .................................65AMETHIA LO .......................... 65AMETHYST ............................. 65amiloride hcl .........................24, 33amiloride-hydrochlorothiazide ... 33

aminocaproic acid ...... 33, 180, 185amiodarone hcl ................... 33, 151AMITIZA .......................... 79, 169amitriptyline hcl ........................151amlodipine besy-benazepril hcl .. 33amlodipine besylate ............ 33, 170amlodipine besylate-valsartan.............................................33, 151amlodipine-atorvastatin...................................25, 33, 45, 55amlodipine-olmesartan ....... 33, 151amlodipine-valsartan-hctz .. 33, 152ammonium lactate .....................187amoxapine .................................135amoxicill-clarithro-lansopraz...............................79, 94, 103, 152amoxicillin ................................ 152amoxicillin-pot clavulanate ...... 152amoxicillin-pot clavulanate er ..152amphetamine-dextroamphet er...............................45, 55, 125, 135amphetamine-dextroamphetamine.......................45, 55, 125, 135, 152ampicillin .................................. 152AMPYRA .....................45, 55, 125ANADROL-50 .............................3anagrelide hcl ................. 3, 33, 197anastrozole ................................152ANDRODERM ....................66, 86ANDROGEL ....................... 66, 86ANDROGEL PUMP ...........66, 86ANDROXY ..........................66, 86ANORO ELLIPTA.........................9, 73, 103, 120, 152ANTARA ........................... 25, 152antipyrine-benzocaine ...............152ANZEMET ........................ 79, 197APEXICON E ................. 103, 187APIDRA ...................................152APIDRA OPTICLIK ..............152APIDRA SOLOSTAR ............ 152APRI ...........................................66APRISO ............................. 79, 103APTIOM ......................45, 55, 152APTIVUS .............................17, 94


201

ARANELLE .............................. 66ARANESP (ALBUMIN FREE) ............................ 3, 42, 197ARCALYST .......... 17, 25, 91, 104ARCAPTA NEOHALER.................................9, 73, 104, 120aripiprazole .......................135, 152ARISTADA ............................. 135armodafinil ............. 45, 56, 73, 120ARYMO ER ............................ 170ASCOMP-CODEINE ..... 135, 170ASHLYNA .................................66ASMANEX 120 METERED DOSES ................... 9, 73, 104, 121ASMANEX 14 METERED DOSES ................... 9, 73, 104, 121ASMANEX 30 METERED DOSES ................... 9, 73, 104, 121ASMANEX 60 METERED DOSES ................... 9, 73, 104, 121ASMANEX 7 METERED DOSES ................... 9, 74, 104, 121ASMANEX HFA ...9, 74, 104, 121aspirin-dipyridamole er.....................3, 33, 45, 56, 152, 180AT LAST LANCETS ............. 146atenolol ............................... 33, 170atenolol-chlorthalidone .............. 33atomoxetine hcl.......................45, 56, 125, 135, 152atorvastatin calcium ................... 25atovaquone ................................153atovaquone-proguanil hcl ...........94ATRIPLA ............................ 17, 94atropine sulfate ....... 46, 56, 92, 125ATROVENT HFA ........ 9, 74, 121AUBAGIO ........................... 46, 56AUBRA .............................. 66, 153AURYXIA.........3, 7, 25, 42, 86, 125, 145, 153AUSTEDO ........... 46, 56, 125, 135AVANDAMET ....................25, 86AVANDIA ............................25, 86AVAR CLEANSER ................ 153AVIANE .....................................66AVITA ..................................... 187AVONEX ............................. 46, 56

AVONEX PEN .................... 46, 56AVONEX PREFILLED ..... 46, 56azathioprine.........14, 17, 42, 104, 125, 180, 185azelastine hcl.......9, 12, 74, 92, 94, 104, 119, 183AZELEX ..................................187azithromycin ............................. 153AZOPT .......................................92AZURETTE .............................. 66bacitracin ..............................92, 95bacitracin-polymyxin b ......... 92, 95bacitra-neomycin-polymyxin-hc153baclofen .........................46, 56, 126balsalazide disodium .......... 79, 104BALZIVA .................................. 66BANZEL ..................................153BARACLUDE ............. 79, 95, 104BASAGLAR KWIKPEN ....... 153BD INSULIN SYRINGE ........146BD INSULIN SYRINGE MICROFINE ...........................146BD INSULIN SYRINGE ULTRAFINE ...........................146BD LANCET ULTRAFINE 33G ........................................... 146BD SAFETY-LOK INSULIN SYRINGE ................................ 146BD SYRINGE SLIP TIP ........ 146Bebulin..........................................3BECONASE AQ.............9, 12, 74, 95, 104, 119, 183BEKYREE .................................66BELBUCA ............................... 170BELSOMRA ....................... 46, 56BELVIQ .....................................25BELVIQ XR .............................. 25benazepril hcl ..............................33benazepril-hydrochlorothiazide ..33BeneFIX........................................3BENLYSTA .........14, 17, 104, 187benzonatate ..... 12, 74, 95, 104, 121benzoyl peroxide ....................... 188benzoyl peroxide cleanser .........188benzoyl peroxide wash ..............188benzoyl peroxide-erythromycin .188benzphetamine hcl ...............25, 153

benztropine mesylate .............46, 56BEPREVE ......... 92, 104, 119, 183Berinert................. 17, 25, 183, 188betamethasone dipropionate...........................................105, 188betamethasone dipropionate aug ............................ 104, 105, 188betamethasone valerate .... 105, 188BETASERON ......................46, 56betaxolol hcl ..........................33, 92bethanechol chloride ...................42bexarotene .................153, 188, 197bicalutamide ............................. 153BIDIL ......................................... 33BILTRICIDE ...................... 79, 95bimatoprost ......................... 92, 153bisoprolol fumarate .................... 33bisoprolol-hydrochlorothiazide .. 33BIVIGAM ..................................17BLISOVI 24 FE .........................66BLISOVI FE 1.5/30 .................. 66BLISOVI FE 1/20 ..................... 66BOSULIF .................................153BOTOX ..........33, 46, 56, 170, 188bp foaming wash ....................... 188bp multinatal plus ..................... 153bp wash ..................................... 188bpo ............................................ 188BREO ELLIPTA .. 9, 74, 105, 121briellyn ........................................66BRILINTA .3, 4, 33, 170, 180, 185brimonidine tartrate ....................92BRINTELLIX ......................... 153BRIVIACT .......................... 46, 56bromfenac sodium.....................92, 105, 171, 180, 185bromfenac sodium (once-daily).............92, 105, 153, 171, 180, 185bromocriptine mesylate ...46, 56, 86budesonide9, 12, 74, 79, 95, 105, 121, 153, 183bumetanide ............................25, 33BUNAVAIL ............................. 135buprenorphine ...................153, 171buprenorphine hcl .....................135


202

buprenorphine hcl-naloxone hcl...................................................136bupropion hcl ............................136bupropion hcl er (smoking det)...........................................136, 178bupropion hcl er (sr) .................136bupropion hcl er (xl) .................136buspirone hcl ............................ 136butalbital-acetaminophen . 136, 171butalbital-apap-caffeine ... 136, 171butalbital-asa-caff-codeine...........................................136, 171butalbital-aspirin-caffeine...................................136, 153, 171butorphanol tartrate ................. 171BYDUREON ....................... 25, 86BYETTA 10 MCG PEN ..... 25, 86BYETTA 5 MCG PEN ....... 25, 87BYSTOLIC ................................34cabergoline ................................. 87CABOMETYX ........................153caffeine citrate.................46, 56, 74, 121, 145, 179calcipotriene ............................. 188calcipotriene-betameth diprop...........................................153, 188calcitonin (salmon) ....... 66, 87, 126CALCITRENE ........................188calcitriol ..............................25, 188calcium acetate (phos binder).....................7, 25, 42, 87, 126, 145CAMILA ....................................66CAMRESE ................................ 66CAMRESE LO ..........................66candesartan cilexetil ...................34CANTIL .....................................79capecitabine ..............................153CAPEX .............................105, 188CAPRELSA .............................153captopril ....................25, 34, 42, 87captopril-hydrochlorothiazide ....34CARAFATE ...................... 79, 105CARBAGLU ............................. 25carbamazepine ......46, 56, 126, 136carbamazepine er ..46, 56, 136, 153carbidopa ......................46, 56, 153carbidopa-levodopa ..............46, 57

carbidopa-levodopa er ..........46, 56carbidopa-levodopa-entacapone...............................................46, 57CARDIZEM LA ................34, 171CARIMUNE NF ......4, 17, 34, 105carisoprodol ..............................126carisoprodol-aspirin ................. 126carteolol hcl ................................ 92carvedilol .................................... 34CAYSTON ...............9, 25, 74, 121CAZIANT ..................................66cefaclor ..................................... 154cefadroxil .................................. 154cefdinir ......................................154cefditoren pivoxil ...................... 154cefixime ..................................... 154cefpodoxime proxetil .................154cefprozil .................................... 154ceftibuten ...................................154CEFTIN ................................... 154cefuroxime axetil .......................154celecoxib ....... 14, 17, 105, 126, 154cephalexin ................................. 154CERDELGA ..............................25CEREZYME ..................... 26, 154CEROVEL ...............................154CESAMET .........................79, 197cetirizine hcl...........12, 26, 74, 95, 105, 183, 188cevimeline hcl ... 14, 17, 79, 92, 105CHANTIX ....................... 136, 178CHANTIX CONTINUING MONTH PAK ................. 136, 178CHANTIX STARTING MONTH PAK ................. 136, 178CHATEAL .................................66chlordiazepoxide hcl .....46, 57, 136chlordiazepoxide-clidinium 79, 105chlorhexidine gluconate79, 95, 119chloroquine phosphate ................95chlorothiazide ............................. 26chlorpromazine hcl ..... 74, 121, 136chlorpropamide .....................26, 87chlorthalidone .....................26, 154chlorzoxazone ........................... 126CHOLBAM ......................... 26, 79cholestyramine ............................26

cholestyramine light ....................26choline & mag trisalicylate ...... 154choline-mag trisalicylate .. 105, 126CIALIS .......................................66CICLODAN ...............95, 105, 188ciclopirox .................... 95, 105, 189ciclopirox olamine ...... 95, 105, 189CIDALEAZE...................119, 171, 180, 185, 189cilostazol ..................... 34, 126, 171cimetidine ....................79, 105, 171cimetidine hcl ......................79, 105CIMZIA . 14, 17, 79, 106, 126, 189CIMZIA PREFILLED.................14, 17, 79, 106, 126, 189CIMZIA STARTER KIT.................14, 17, 79, 106, 126, 189CINQAIR ...............9, 74, 106, 121Cinryze........................................26CIPRO HC ................................ 91CIPRODEX ......................... 91, 95ciprofloxacin ............................. 154ciprofloxacin hcl ....................... 154ciprofloxacin-ciproflox hcl er ... 154citalopram hydrobromide ......... 136CLARAVIS ............................. 189CLARINEX ... 12, 74, 95, 106, 183CLARINEX-D 12 HOUR.....................9, 12, 74, 95, 106, 183clarithromycin ...........................155clarithromycin er ...................... 154CLEANLET LANCETS 28G 146clemastine fumarate.................12, 74, 95, 106, 183, 189clindamycin hcl .........................155clindamycin palmitate hcl .........155clindamycin phos-benzoyl perox...................................................189clindamycin phosphate.................................42, 66, 95, 189CLINPRO 5000 .........................79clobetasol propionate106, 155, 189clobetasol propionate e .....106, 189clocortolone pivalate 106, 155, 189clocortolone pivalate pump...................................106, 155, 189clomiphene citrate .......................66


203

clomipramine hcl ...................... 136clonazepam ........... 46, 57, 126, 136clonidine hcl ................................34clonidine hcl er.......................47, 57, 126, 137, 155clopidogrel bisulfate ........... 34, 171clorazepate dipotassium47, 57, 137CLORPRES ...............................34clotrimazole .. 74, 95, 106, 119, 189clotrimazole anti-fungal.............................95, 106, 146, 189clotrimazole-betamethasone.............................95, 106, 189, 190clozapine ........................... 137, 155Coagadex...................................... 4COARTEM ............................... 95codeine sulfate .......................... 171colchicine ....................26, 106, 126colchicine-probenecid .26, 106, 126colestipol hcl ...............................26COLOCORT ..................... 79, 106COMBIGAN ............................. 92COMBIVENT RESPIMAT.........................................9, 74, 121COMETRIQ (100 MG DAILY DOSE) ........................ 155COMETRIQ (140 MG DAILY DOSE) ........................ 155COMETRIQ (60 MG DAILY DOSE) ...................................... 155comfort lancets ..........................146COMPLERA ....................... 18, 95COMPRO .................................. 79constulose ................. 26, 47, 57, 79CONTRAVE ............................. 26COPAXONE ............... 47, 57, 155CORDRAN ......................106, 190COREG CR ...............................34Corifact......................................... 4CORLANOR ............................. 34cortisone acetate ...........18, 87, 106CORTISPORIN-TC ............... 155COSENTYX 14, 18, 106, 126, 190COSENTYX SENSOREADY PEN .............. 14, 18, 106, 126, 190COTELLIC ............................. 155CREON ......................................79

CRESEMBA ..............................95CRINONE ........................... 66, 87CRIXIVAN ..........................18, 96cromolyn sodium.....9, 18, 74, 92, 107, 119, 121, 183CRYSELLE-28 ......................... 66Cuvitru........................................ 18cyanocobalamin ....................7, 145CYCLAFEM 1/35 ..................... 66CYCLAFEM 7/7/7 .................... 66cyclobenzaprine hcl .................. 126cyclopentolate hcl ............... 92, 155cyclophosphamide .....................155cycloserine ................................ 155cyclosporine ....18, 42, 80, 180, 185cyclosporine modified...................18, 42, 79, 80, 180, 185cyproheptadine hcl.................12, 74, 96, 107, 183, 190CYRED ...................................... 66CYSTAGON ..............................26cytra-2 .......................................155daily multi ................................. 146DAKLINZA .................80, 96, 107DALIRESP .......... 10, 74, 107, 121danazol ..................................26, 66dantrolene sodium .. 47, 57, 94, 126dapsone ............................... 96, 190darifenacin hydrobromide er.....................................42, 126, 155DASETTA 1/35 ......................... 67DASETTA 7/7/7 ........................ 67DAYSEE .................................... 67DAYTRANA ........47, 57, 126, 137DEBLITANE .............................67demeclocycline hcl ....................155DEMSER ........................... 34, 197DENAVIR ....................80, 96, 190DENTA 5000 PLUS .................. 80DENTAGEL ..............................80DESCOVY ...........................18, 96desipramine hcl .........................137desloratadine .. 13, 74, 96, 107, 183desmopressin ace rhinal tube26, 87desmopressin ace spray refrig...............................................26, 87desmopressin acetate ...... 26, 42, 87

desmopressin acetate spray .. 26, 87desogestrel-ethinyl estradiol.............................................67, 155desonide ............................ 107, 190desoximetasone ................. 107, 190desvenlafaxine er ...................... 137desvenlafaxine fumarate er .......137dexamethasone ............................87dexamethasone sodium phosphate ......91, 92, 107, 180, 185DEXEDRINE ...... 47, 57, 127, 137DEXILANT ............................... 80dexmethylphenidate hcl...............................47, 57, 127, 137dexmethylphenidate hcl er...............47, 57, 127, 137, 155, 156dextroamphetamine sulfate...............................47, 57, 127, 137dextroamphetamine sulfate er...............................47, 57, 127, 137diazepam . 47, 57, 58, 127, 137, 156DIAZEPAM INTENSOL...............................47, 57, 127, 137DICLEGIS .........................80, 179diclofenac potassium 107, 127, 171diclofenac sodium

92, 107, 127, 156, 171, 180, 185, 190diclofenac sodium er...............................14, 18, 107, 127dicloxacillin sodium ..................156dicyclomine hcl ................... 80, 156didanosine .............................18, 96diethylpropion hcl .......................26diethylpropion hcl er ...................26DIFICID .......................80, 96, 107diflorasone diacetate ........ 107, 190diflunisal ................................... 171DIGITEK ...................................34DIGOX .......................................34digoxin ........................................ 34dihydroergotamine mesylate.................................34, 47, 58, 171DILANTIN .......................... 47, 58diltiazem cd .........................34, 171diltiazem hcl ........................35, 171diltiazem hcl er ................... 34, 171diltiazem hcl er beads ......... 34, 171


204

diltiazem hcl er coated beads.....................................34, 156, 171dimenhydrinate ........................... 80DIPENTUM .......................80, 107diphenhydramine hcl...............................48, 58, 146, 183diphenoxylate-atropine ............... 80dipyridamole ................................. 4disopyramide phosphate ............. 35disulfiram ..................................137divalproex sodium.........................35, 48, 58, 138, 172divalproex sodium er.........................35, 48, 58, 138, 172dofetilide ..................... 35, 156, 180donepezil hcl ................. 48, 58, 138dorzolamide hcl .......................... 92dorzolamide hcl-timolol mal .......92doxazosin mesylate ....... 35, 42, 197doxepin hcl ........................138, 156doxercalciferol ......42, 87, 156, 180doxycycline hyclate ........... 119, 156doxycycline monohydrate ......... 156dronabinol .........18, 26, 80, 96, 197drospiren-eth estrad-levomefol .156drospirenone-ethinyl estradiol.............................67, 138, 156, 190DROXIA ...................................... 4DUAVEE ................... 67, 127, 156DULERA ............. 10, 74, 107, 121duloxetine hcl ....127, 138, 156, 172DUPIXENT ..................... 107, 190dutasteride .................. 42, 156, 197dutasteride-tamsulosin hcl.....................................42, 156, 197DUZALLO .................26, 107, 127DYANAVEL XR .48, 58, 127, 138DYSPORT ........... 48, 58, 128, 190DYSPORT (GLABELLAR LINES) ................. 48, 58, 128, 190E.E.S. 400 .................................156econazole nitrate .........96, 107, 190ECOZA .............. 96, 107, 157, 190EDARBI .....................................35EDLUAR ............................. 48, 58EDURANT ...........................18, 96EGRIFTA ........ 14, 18, 26, 96, 108

ELELYSO ................................. 27eletriptan hydrobromide.........................35, 48, 58, 157, 172ELIDEL ........................... 108, 190ELIGARD ..........................42, 197ELINEST ................................... 67ELIQUIS ..........4, 35, 74, 121, 180ELITE-OB ............................... 179ELLA ......................................... 67Eloctate......................................... 4EMADINE ......... 92, 108, 119, 183EMBEDA .................................172EMCYT ............................. 42, 197EMEND ............. 80, 180, 185, 197EMFLAZA .......... 48, 58, 108, 128EMOQUETTE .......................... 67EMSAM ................................... 138EMTRIVA ........................... 18, 96enalapril maleate ........................ 35enalapril-hydrochlorothiazide ....35ENBREL 14, 15, 18, 108, 128, 191ENBREL SURECLICK.......................15, 18, 108, 128, 191enoxaparin sodium ..4, 35, 172, 180ENPRESSE-28 .......................... 67ENSKYCE ................................. 67entacapone ............................48, 58entecavir ................80, 96, 108, 157ENTRESTO ...............................35ENTYVIO ..........................80, 108enulose ...................... 27, 48, 58, 80EPCLUSA ....................80, 96, 108epinastine hcl ...... 92, 108, 119, 184epinephrine ............................... 184epinephrine hcl ............. 35, 96, 184EPIPEN JR 2-PAK ................. 184EPITOL ....................... 48, 58, 128eplerenone ...........................35, 172EPOGEN ....................... 4, 43, 197epoprostenol sodium.................................10, 35, 75, 121eprosartan mesylate ....................35eq nicotine .........138, 146, 147, 178eq nicotine polacrilex138, 147, 178eq nicotine step 3 ...... 138, 147, 178eql nicotine ........................138, 178eql nicotine polacrilex ...... 138, 178

ergocalciferol ........................7, 145ergoloid mesylates ........ 48, 58, 138ERIVEDGE ..................... 191, 197ERRIN ....................................... 67ERYPED 400 ...........................157ERY-TAB ................................ 157ERYTHROCIN STEARATE 157erythromycin ................. 92, 96, 191erythromycin base .....................157erythromycin ethylsuccinate ..... 157ESBRIET ..................... 10, 75, 121escitalopram oxalate .................138est estrogens-methyltest ............ 157est estrogens-methyltest hs ........157ESTARYLLA ............................67estazolam .............................. 48, 58estradiol ........................ 67, 87, 157estradiol-norethindrone acet .... 157estropipate ............................ 67, 87eszopiclone ............................48, 58ethacrynic acid27, 35, 75, 122, 157ethambutol hcl ............................ 96ethosuximide ......................... 48, 58etidronate disodium ............ 27, 128etodolac .....................108, 128, 172etodolac er ............ 15, 18, 108, 128etoposide ................................... 157EUFLEXXA .................... 108, 128EVOTAZ ............................. 18, 96EVZIO ..................................... 169EXELDERM ............. 96, 108, 191exemestane ..........................67, 197EXONDYS 51 ......48, 58, 108, 128EXTAVIA ............................48, 59ezetimibe ............................. 27, 157ezetimibe-simvastatin ..........27, 157EZ-LETS LANCETS 26G ..... 147FABIOR ...........................157, 191FABRAZYME .....27, 43, 191, 197FALMINA ................................. 67famciclovir ................................ 157famotidine ........................... 80, 172FANAPT .................................. 138FANAPT TITRATION PACK ....................................... 138FARESTON .............................157FARXIGA ....................27, 87, 157


205

FARYDAK .......................... 4, 197Feiba....................................... 4, 35felbamate ...................................157felodipine er ................................ 35fenofibrate ...........................27, 157fenofibrate micronized ................ 27fenofibric acid .....................27, 157fenoprofen calcium ................... 172fentanyl ..................................... 172fentanyl citrate .................. 172, 197FENTORA .......................172, 198FERRIPROX ...................170, 180FETZIMA ........................138, 157FETZIMA TITRATION 139, 157FINACEA ........................ 108, 191finasteride ........................... 43, 198FINGERSTIX LANCETS ......147FIRAZYR ............ 18, 27, 184, 191FIRST-LANSOPRAZOLE .... 158FIRST-OMEPRAZOLE ........ 158flavoxate hcl ........................43, 172FLEBOGAMMA DIF .............. 19flecainide acetate ........................ 35FLECTOR ....................... 119, 128FLOLAN ................10, 35, 75, 122flolipid .........................................27FLOVENT DISKUS...............................10, 75, 108, 122FLOVENT HFA ..10, 75, 108, 122fluconazole ................................158flucytosine ................................. 158fludrocortisone acetate ............... 87flunisolide ....... 13, 75, 96, 108, 184fluocinolone acetonide 91, 109, 191fluocinolone acetonide body...........................................109, 191fluocinolone acetonide scalp...........................................109, 191fluocinonide .............. 109, 158, 191FLUOR-A-DAY ........................ 80FLUORIDEX DAILY DEFENSE ..................................80FLUORIDEX ENHANCED WHITENING ..........................158FLUORIDEX SENSITIVITY RELIEF ..................................... 80fluorometholone ..................92, 109

fluorouracil ....................... 191, 198fluoxetine hcl .............................139fluoxetine hcl (pmdd) ........ 139, 158fluphenazine decanoate .............139fluphenazine hcl ........................ 139FLURA-DROPS ........................81flurandrenolide . 109, 158, 191, 192flurazepam hcl ...................... 48, 59flurbiprofen ........... 15, 19, 109, 128flurbiprofen sodium .... 93, 180, 185flutamide ................................... 158fluticasone propionate...................10, 13, 75, 96, 109, 192fluticasone-salmeterol...............................10, 75, 109, 122fluvastatin sodium .......................27fluvastatin sodium er ...........27, 158fluvoxamine maleate ................. 139fluvoxamine maleate er .............139folbee .....................................7, 145folic acid ........................... 4, 7, 145fondaparinux sodium.................................4, 35, 180, 185FORADIL AEROLIZER...............................10, 75, 109, 122FORTEO ..................... 67, 87, 128FOSAMAX PLUS D ... 67, 87, 128fosamprenavir calcium . 19, 96, 158fosinopril sodium ........................ 35fosinopril sodium-hctz ................ 35FREESTYLE INSULINX TEST ........................................ 147FREESTYLE LANCETS .......147FREESTYLE LITE TEST .....147FREESTYLE PRECISION NEO TEST .............................. 147FREESTYLE TEST ............... 147frovatriptan succinate.........................35, 48, 59, 158, 172furosemide ...............27, 36, 75, 122FUZEON ..............................19, 96FYCOMPA ..........48, 59, 128, 158gabapentin ........ 49, 59, 96, 97, 173galantamine hydrobromide.......................................49, 59, 139

galantamine hydrobromide er.......................................49, 59, 139GAMASTAN S/D ........81, 97, 109Gammagard.................19, 49, 59, 109, 128, 129GAMMAGARD S/D LESS IGA.4, 19, 36, 81, 93, 94, 109, 119, 192GAMMAKED ......... 4, 19, 36, 110GAMMAPLEX ....... 4, 19, 36, 110GAMUNEX-C ......... 4, 19, 36, 110gatifloxacin ............................... 158GATTEX ................... 81, 180, 185GAVILYTE-C ...................81, 180GAVILYTE-G ...................81, 181GAVILYTE-H ...........................81GELNIQUE .......................43, 129gemfibrozil .................................. 27generlac .................... 27, 49, 59, 81GENGRAF .... 19, 43, 81, 181, 185gentamicin sulfate .......97, 158, 192GENTLE-LET GP LANCETS ............................... 147GENTLE-LET LANCETS .... 147GENVOYA ..........................19, 97GIANVI ..................... 67, 139, 192GIAZO ............................... 81, 110GILDAGIA ................................67GILDESS 1.5/30 ........................67GILDESS 1/20 ...........................67GILDESS 24 FE ........................67GILDESS FE 1.5/30 ..................67GILDESS FE 1/20 .....................67GILENYA ............................49, 59GILOTRIF .............................. 158GLATOPA ...........................49, 59GLEOSTINE ...........................158glimepiride ............................27, 87glipizide .................................27, 87glipizide er ............................ 27, 87glipizide xl .............................27, 87glipizide-metformin hcl .........27, 87GLUCAGEN HYPOKIT ... 28, 87GLUCAGON EMERGENCY...............................................28, 88


206

GLUCOSOURCE LANCETS...................................................147glyburide ............................... 28, 88glyburide micronized ............ 28, 88glyburide-metformin ............. 28, 88glycopyrrolate ...........................158GLYDO.......43, 75, 122, 129, 173, 181, 185gnp lancets ................................ 147gnp nicotine mini .............. 139, 178gnp nicotine polacrilex ..... 139, 178gnp ultra com insulin syringe ... 147GRALISE .............. 49, 59, 97, 173GRALISE STARTER.................................49, 59, 97, 173granisetron hcl ....................81, 198GRANIX ................ 4, 19, 158, 198griseofulvin microsize .........97, 192griseofulvin ultramicrosize . 97, 192guaifenesin er ..13, 75, 97, 110, 122guanfacine hcl .............................36guanfacine hcl er .. 49, 59, 129, 139guanidine hcl .. 19, 49, 59, 110, 129HAEGARDA ............................. 28HAEMOLANCE LOW FLOW LANCETS .................. 147halobetasol propionate ..... 110, 192HALOG ........................... 110, 192haloperidol ................................139haloperidol decanoate .............. 139haloperidol lactate ....................139HARVONI ................... 81, 97, 110HEATHER ................................ 67Helixate FS................................... 4HEMMOREX-HC ...... 36, 81, 110Hemofil M............................ 4, 158heparin sodium (porcine).................................5, 36, 158, 181HETLIOZ ............................49, 59HEXALEN ...............................158Hizentra...............................19, 158hm nicotine ................139, 147, 179hm nicotine polacrilex...................................139, 178, 179HOMATROPAIRE .......... 93, 110homatropine hbr ................. 93, 110HORIZANT .........................49, 59

HUMALOG .............................159HUMALOG KWIKPEN ........ 159HUMALOG MIX 50/50 ......... 159HUMALOG MIX 50/50 KWIKPEN ...............................159HUMALOG MIX 50/50 PEN 159HUMALOG MIX 75/25 ......... 159HUMALOG MIX 75/25 KWIKPEN ...............................159HUMALOG MIX 75/25 PEN 159HUMALOG PEN ....................159Humate-P.. 5, 19, 36, 110, 181, 185HUMIRA15, 20, 81, 110, 129, 192HUMIRA PEDIATRIC CROHNS START.................15, 19, 81, 110, 129, 192HUMIRA PEN.................15, 19, 81, 110, 129, 192HUMIRA PEN-CROHNS STARTER.................15, 19, 81, 110, 129, 192HUMIRA PEN-PSORIASIS STARTER.................15, 20, 81, 110, 129, 192HUMULIN 70/30 .................... 147HUMULIN 70/30 KWIKPEN 147HUMULIN N ...........................147HUMULIN N KWIKPEN ......147HUMULIN R ...........................147HUMULIN R U-500 (CONCENTRATED) ..........28, 88HUMULIN R U-500 KWIKPEN ...........................28, 88HYCAMTIN ............................159hydralazine hcl ............................36hydrochlorothiazide ....................36hydrocod polst-cpm polst er.................13, 75, 97, 110, 122, 184hydrocodone-acetaminophen...........................................159, 173hydrocodone-homatropine.........................13, 75, 97, 110, 122hydrocodone-ibuprofen .............173hydrocortisone.........20, 81, 88, 111, 159, 192, 193

hydrocortisone ace-pramoxine...............................36, 81, 111, 192hydrocortisone acetate ..36, 81, 111hydrocortisone butyrate ....111, 192hydrocortisone valerate .... 111, 193hydrocortisone-acetic acid ......... 91hydromet ......... 13, 75, 97, 111, 122hydromorphone hcl ...................173hydromorphone hcl er ...............173hydroxychloroquine sulfate.......................15, 20, 111, 129, 193Hydroxyprogesterone Caproate.............36, 43, 67, 68, 88, 159, 198hydroxyurea ...................... 193, 198hydroxyzine hcl.......................49, 59, 139, 181, 185hydroxyzine pamoate.......................49, 59, 139, 181, 185HYOPHEN .............................. 159hyoscyamine sulfate .................. 160hyoscyamine sulfate er ..............159hyosyne ......................................160Hyqvia.........................................20HY-VEE LANCETS ...............147hy-vee thin lancets .................... 147ibandronate sodium ...... 68, 88, 129IBRANCE ................................160IBUDONE ................................173ibuprofen ...................111, 129, 173ICLUSIG ................................. 160Idelvion......................................... 5IDHIFA ....................................160ILARIS ...........20, 28, 91, 111, 129ILARIS (150MG DELIVERED)20, 28, 91, 111, 129imatinib mesylate ...................... 160IMBRUVICA .............. 5, 160, 198imipramine hcl .................... 43, 140imipramine pamoate ................. 140imiquimod ........... 97, 111, 193, 198IMPAVIDO ....................... 97, 193INATAL ADVANCE ..............179INCRELEX ................... 49, 59, 88INCRUSE ELLIPTA...............................10, 75, 111, 122indapamide ........................... 28, 36indomethacin ...............28, 111, 129


207

indomethacin er .......... 28, 111, 129INFLECTRA.................15, 20, 82, 111, 129, 193INGREZZA ................. 49, 59, 129INLYTA ...................................160insulin syringe ...................147, 148insulin syringe/needle ............... 148INTELENCE .......................20, 97INTROVALE ............................ 68INVEGA SUSTENNA ............ 140INVEGA TRINZA ..................140INVIRASE ...........................20, 97INVOKAMET .....................28, 88INVOKAMET XR .............. 28, 88INVOKANA ........................ 28, 88ipratropium bromide...........10, 13, 75, 97, 111, 122, 184ipratropium-albuterol ... 10, 75, 122IPRIVASK .............5, 36, 181, 185irbesartan ....................................36irbesartan-hydrochlorothiazide ..36IRESSA ....................................160ISENTRESS ........................ 20, 97ISENTRESS HD ................. 20, 97isometheptene-dichloral-apap .. 160isoniazid ......................................97isosorbide dinitrate .............36, 173isosorbide dinitrate er .........36, 173isosorbide mononitrate ....... 37, 173isosorbide mononitrate er ...37, 173isradipine .................................... 37itraconazole .............................. 160ivermectin ......................82, 97, 160Ixinity............................................5JADENU ...................... 5, 170, 181JADENU SPRINKLE .5, 170, 181JAKAFI ............................... 5, 198JENCYCLA ...............................68JOLESSA ...................................68JOLIVETTE ............................. 68JUBLIA ......................97, 111, 193JULEBER ..................................68JUNEL 1.5/30 ............................ 68JUNEL 1/20 ............................... 68JUNEL FE 1.5/30 ...................... 68JUNEL FE 1/20 ......................... 68JUNEL FE 24 ............................ 68

JUXTAPID ................................ 28KADIAN .................................. 173KAITLIB FE ............................. 68KALETRA .....................20, 97, 98KALYDECO ......... 10, 28, 75, 122KANUMA ..................................28KARIVA .................................... 68KELNOR 1/35 ...........................68ketoconazole ........98, 111, 160, 193KETODAN ...................... 112, 193ketoprofen ................. 112, 129, 173ketoprofen er .........15, 20, 112, 129ketorolac tromethamine.....................93, 112, 173, 181, 186ketotifen fumarate93, 112, 119, 184KEVEYIS .............. 28, 49, 59, 129KEVZARA .......... 15, 20, 112, 129KIMIDESS ................................ 68KINERET ............15, 20, 112, 130kinney lancets ............................148kinney thin lancets .................... 148kinray insulin syringe ............... 148KIONEX .................................... 28KISQALI 200 DOSE .............. 160KISQALI 400 DOSE .............. 160KISQALI 600 DOSE .............. 160Koate-DVI.................................... 5Kogenate FS..........................5, 160Kogenate FS Bio-Set.................... 5KORLYM ............................28, 88Kovaltry........................................ 5KRYSTEXXA ........... 29, 112, 130KURVELO ................................ 68KUVAN ......................................29KYNAMRO ...............................29labetalol hcl ................................ 37lactulose ....................29, 49, 60, 82lactulose encephalopathy...................................29, 49, 59, 82LAMISIL ................... 98, 112, 193lamivudine .......20, 82, 98, 112, 160lamivudine-zidovudine ..........20, 98lamotrigine ............50, 60, 130, 140lamotrigine er ....................... 49, 60lamotrigine odt ......49, 60, 130, 140

lamotrigine starter kit-blue...............................50, 60, 130, 140lamotrigine starter kit-green...............................50, 60, 130, 140lamotrigine starter kit-orange...............................50, 60, 130, 140lamotrigine titration...............................50, 60, 130, 140lancets ....................................... 148lancets thin ................................148lansoprazole ........................82, 112LARIN 1.5/30 ............................ 68LARIN 1/20 ............................... 68LARIN 24 FE ............................ 68LARIN FE 1.5/30 .............. 68, 160LARIN FE 1/20 ................. 68, 160LASTACAFT .... 93, 112, 119, 184latanoprost ..................................93LATRIX ...................................160LATUDA ......................... 140, 160LAYOLIS FE ............................ 68LEENA .......................................68leflunomide ........... 15, 20, 112, 130LEMTRADA ....................... 50, 60LENVIMA 10 MG DAILY DOSE ....................................... 160LENVIMA 14 MG DAILY DOSE ....................................... 160LENVIMA 20 MG DAILY DOSE ....................................... 160LENVIMA 24 MG DAILY DOSE ....................................... 161LESSINA ................................... 68LETAIRIS ............. 10, 37, 75, 122letrozole .............................. 68, 198leucovorin calcium ....5, 7, 145, 170LEUKERAN ........................5, 198leuprolide acetate ......... 43, 88, 198levalbuterol hcl ............. 10, 76, 122levalbuterol tartrate...............................10, 76, 122, 161levetiracetam .................50, 60, 130levetiracetam er .................... 50, 60levobunolol hcl ............................93levocarnitine ............. 7, 8, 145, 148


208

levocetirizine dihydrochloride...........13, 29, 76, 98, 112, 184, 193levofloxacin ...............................161LEVONEST ...............................68levonorgest-eth estrad 91-day.............................................68, 161levonorgestrel ..................... 68, 161levonorgestrel-ethinyl estrad.............................................68, 161levonorg-eth estrad triphasic.............................................68, 161LEVORA 0.15/30 (28) .............. 69LEVO-T ..................................... 88levothyroxine sodium .................. 88LEXIVA ...............................20, 98lidocaine

50, 60, 76, 98, 122, 161, 173, 181, 186, 193lidocaine hcl

43, 76, 119, 122, 130, 174, 181, 186, 193lidocaine viscous ...............181, 186lidocaine-prilocaine ..........181, 186LIFESCAN UNISTIK II LANCETS ............................... 148lindane ................................ 98, 193linezolid .....................................161LINZESS ................................... 82liothyronine sodium ............ 88, 181lisinopril ......................................37lisinopril-hydrochlorothiazide ....37lite touch lancets ....................... 148lithium ....................................... 140lithium carbonate ......................140lithium carbonate er ................. 140LIVALO .....................................29LO LOESTRIN FE ...................69LOMEDIA 24 FE ..............69, 161lomustine ...................................161longs lancets thin ...................... 148LONSURF ......................... 82, 198loperamide hcl ............................ 82lorazepam ................................. 140LORAZEPAM INTENSOL ...140LORYNA ................... 69, 140, 193losartan potassium ......................37losartan potassium-hctz .............. 37lovastatin .....................................29LOW-OGESTREL ................... 69

loxapine succinate .....................140LUMIGAN .................................93LUPRON ................................. 161LUPRON DEPOT (1-MONTH) ........... 5, 37, 43, 69, 198LUPRON DEPOT (3-MONTH) ........... 5, 37, 43, 69, 198LUPRON DEPOT (4-MONTH) ........................... 43, 198LUPRON DEPOT (6-MONTH) ........................... 43, 198LUPRON DEPOT-PED (1-MONTH) ................................... 88LUPRON DEPOT-PED (3-MONTH) ................................... 88LUTERA ....................................69LUZU ................. 98, 112, 161, 193LYNPARZA .............. 69, 161, 198LYRICA ...................29, 50, 60, 88LYSODREN ...................... 88, 198LYZA ................................. 69, 161Makena......................................179malathion ............................ 98, 193maprotiline hcl ..........................140marlissa .......................................69MATULANE ........................... 161MATZIM LA .................... 37, 174me/naphos/mb/hyo1 .................. 161meclizine hcl ............. 37, 50, 60, 82meclofenamate sodium...................................112, 130, 174MEDISENSE THIN LANCETS ............................... 148medroxyprogesterone acetate...................................37, 43, 69, 88mefenamic acid ................... 69, 174mefloquine hcl .............................98megestrol acetate.....................8, 20, 29, 98, 145, 161MEIJER LANCETS ...............148MEKINIST ..............................161meloxicam ....... 15, 20, 21, 112, 130melphalan ................................. 161memantine hcl .......50, 60, 140, 161meperidine hcl ...................161, 174meprobamate ............................ 140mercaptopurine .........................161

mesalamine ................. 82, 112, 161MESNEX ............... 37, 43, 69, 198metaproterenol sulfate .. 10, 76, 122metaxalone ................................130metformin hcl ........................ 29, 89metformin hcl er ....................29, 89metformin hcl er (mod) . 29, 89, 162metformin hcl er (osm) ..........29, 89methadone hcl ...................141, 174METHADONE HCL INTENSOL ......................140, 174methamphetamine hcl.........................29, 50, 60, 130, 141methazolamide ............................ 93methenamine hippurate .........43, 98methenamine mandelate ....... 43, 98methimazole ................................ 89methitest ................................69, 89methocarbamol ......................... 130methotrexate ..15, 21, 112, 130, 193methoxsalen rapid .............162, 193methscopolamine bromide .......... 82methyclothiazide ......................... 29methyldopa ..................................37methyldopa-hydrochlorothiazide ....................37methylergonovine maleate .. 37, 179methylphenidate hcl.......................51, 61, 131, 141, 162methylphenidate hcl er...............................51, 61, 131, 141methylphenidate hcl er (cd).........................50, 60, 61, 130, 141methylphenidate hcl er (la).........................50, 51, 61, 131, 141methylprednisolone .......21, 89, 112methylprednisolone sodium succ.......................................21, 89, 112methyltestosterone ........ 69, 89, 162metipranolol ................................93metoclopramide hcl .........29, 82, 89metolazone ............................ 29, 43metoprolol succinate er ...... 37, 174metoprolol tartrate ..............37, 174metoprolol-hydrochlorothiazide . 37


209

metronidazole.........43, 69, 98, 112, 113, 162, 193mexiletine hcl .............................. 37MIACALCIN .............. 69, 89, 131miconazole 3 ................... 43, 69, 98MICROGESTIN 1.5/30 ............69MICROGESTIN 1/20 ...............69MICROGESTIN 24 FE ............69MICROGESTIN FE 1.5/30 ......69MICROGESTIN FE 1/20 .........69micronized colestipol hcl ............ 29MICROTAINER SAFETY FLOW LANCET .................... 148midodrine hcl .............................. 37MIGERGOT ......... 37, 51, 61, 174miglitol ..........................29, 89, 162minocycline hcl ......................... 162minoxidil ..................................... 37mirtazapine ............................... 142MIRVASO ............... 113, 162, 193misoprostol ................................. 82modafinil ................. 51, 61, 76, 122moexipril hcl ............................... 37moexipril-hydrochlorothiazide ... 37mometasone furoate.........13, 76, 98, 113, 162, 184, 194Monoclate-P..........................5, 162MONOJECT CONTROL SYRINGE ................................ 162MONOJECT FILTER ASPIRATOR ...........................148MONOJECT INSULIN SYRINGE ........................ 148, 162MONOJECT PHARMACY TRAY ....................................... 148MONOJECT PISTON SYRINGE ................................ 148MONOJECT SAFETY SYRINGE/SHIELD ........148, 162MONOJECT SYRINGE 148, 162MONOJECT SYRINGE CATH TIP ............................... 148MONOJECT SYRINGE ECC LUER ....................................... 148MONOJECT SYRINGE LUER LOCK .................. 149, 162

MONOJECT SYRINGE REG LUER ............................... 149, 162MONOJECT TB SAFETY SYRINGE ................................ 149MONOJECT TB SYRINGE ..149MONOJECT ULTRA COMFORT SYRINGE .......... 149MONOLET LANCETS ..........149MONO-LINYAH ...................... 69MONONESSA ...........................69Mononine..............................5, 162montelukast sodium...........10, 13, 76, 98, 113, 123, 184MORPHABOND ER .............. 174morphine sulfate ....................... 175morphine sulfate (concentrate) .174morphine sulfate er ........... 163, 175morphine sulfate er beads .162, 174MOVANTIK ..................... 82, 170moxifloxacin hcl ........................163MULTI COMPLETE .............149multi vitamin/fluoride ..... 8, 82, 145multi vitamin/minerals .......... 8, 145multi-vit/fluoride ..... 8, 82, 145, 163multi-vit/fluoride/iron.................................8, 82, 145, 163multivitamin/fluoride.................................8, 82, 145, 163multi-vitamin/fluoride ..... 8, 82, 146mupirocin ....................98, 113, 194mupirocin calcium ...... 98, 113, 194MY WAY ...................................69MYALEPT ............ 15, 21, 29, 113mycophenolate mofetil.................21, 43, 82, 163, 181, 186mycophenolic acid.......................21, 44, 163, 181, 186MYLERAN ................21, 181, 186mynephrocaps ....................... 8, 146MYOBLOC ................. 51, 61, 131MYORISAN ............................ 194MYRBETRIQ ................... 44, 131MYZILRA ................................. 69nabumetone ...........15, 21, 113, 131n-acetyl-l-cysteine .....................149nadolol ................................ 37, 175nadolol-bendroflumethiazide ......38

naftifine hcl ......... 98, 113, 163, 194naloxone hcl ..............................170naltrexone hcl ........................... 142naphazoline hcl ...........................93naproxen ................... 113, 131, 175naproxen dr .......................113, 131naproxen sodium .......113, 131, 175naratriptan hcl ........ 38, 51, 61, 175NATAZIA ......................38, 44, 69nateglinide ............................ 29, 89NATPARA ...........................30, 89NECON 0.5/35 (28) ................... 69NECON 1/35 (28) ...................... 69NECON 1/50 (28) ...................... 69NECON 10/11 (28) .................... 70NECON 7/7/7 .............................70nefazodone hcl .......................... 142neomycin sulfate ......... 82, 182, 186neomycin-polymyxin-dexameth .163neomycin-polymyxin-gramicidin...............................................93, 98neomycin-polymyxin-hc.................................92, 93, 98, 163NEO-POLYCIN ..................93, 99NEO-POLYCIN HC ...............163NERLYNX ...............................163NEUAC .................................... 194NEULASTA ...........5, 21, 182, 198NEULASTA DELIVERY KIT ......................... 5, 21, 182, 198NEULASTA ONPRO.................................5, 21, 182, 198NEUPOGEN ..................6, 21, 199NEUPRO ............................. 51, 61nevirapine ............................. 21, 99nevirapine er .................21, 99, 163NEXAVAR .............................. 163NEXIUM ....................................82NEXT CHOICE ONE DOSE .. 70niacin er ...................................... 30niacin er (antihyperlipidemic).............................................30, 163NIACOR .................................... 30nicardipine hcl .................... 38, 175NICORELIEF ................. 142, 179nicotine ............................. 142, 179nicotine mini ..................... 142, 179


210

nicotine polacrilex ............ 142, 179nicotine step 1 ................... 142, 179nicotine step 2 ................... 142, 179nicotine step 3 ................... 142, 179NICOTROL .....................142, 179NICOTROL NS .............. 142, 179NIFEDIAC CC ........................163nifedipine ............................ 38, 175nifedipine er ........................ 38, 175nifedipine er osmotic release.............................................38, 175NIKKI ........................ 70, 142, 194nilutamide ................................. 163nimodipine .............. 38, 51, 61, 119NINLARO ........................... 6, 199nisoldipine er .............................. 38nitrofurantoin ............................163nitrofurantoin macrocrystal ......163nitrofurantoin monohyd macro .163nitroglycerin ............... 38, 175, 176nizatidine .......................82, 83, 113NODOLOR ..............................163NORA-BE ..................................70NORDITROPIN FLEXPRO.......................8, 21, 30, 89, 99, 146norethin ace-eth estrad-fe ...70, 163norethindrone ............................. 70norethindrone acetate...................................38, 44, 70, 89norethindrone acet-ethinyl est.............................................70, 163norethindrone-eth estradiol...............................70, 89, 131, 163norethin-eth estradiol-fe ..... 70, 163norgestimate-eth estradiol .......... 70norgestim-eth estrad triphasic.............................................70, 164norgestrel-ethinyl estradiol ...... 164NORITATE ..................... 113, 194NORTHERA ............................. 38NORTREL 0.5/35 (28) ..............70NORTREL 1/35 (21) .................70NORTREL 1/35 (28) .................70NORTREL 7/7/7 ....................... 70nortriptyline hcl ........................ 142NORVIR .............................. 21, 99Novoeight..................................... 6

NOVOLIN 70/30 ..................... 149NOVOLIN 70/30 RELION .... 149NOVOLIN N ........................... 149NOVOLIN N RELION ...........149NOVOLIN R ........................... 149NOVOLIN R RELION ...........149NOVOLOG ............................. 164NOVOLOG FLEXPEN ..........164NOVOLOG MIX 70/30 .......... 164NOVOLOG MIX 70/30 FLEXPEN ................................164NovoSeven RT........................6, 38NOXAFIL.........21, 76, 99, 113, 119, 123, 164np thyroid ..................................164NPLATE .................. 6, 22, 38, 113NUCALA ............. 10, 76, 113, 123NUCYNTA .............................. 176NUCYNTA ER 30, 51, 61, 89, 176NUEDEXTA ............................142NUPLAZID ................. 51, 62, 142NUVARING .............................. 70Nuwiq........................................... 6NYAMYC .................. 99, 113, 194nystatin ................99, 113, 119, 194nystatin-triamcinolone 99, 113, 194NYSTOP .................... 99, 114, 194Obizur....................... 6, 22, 38, 114OCALIVA ................................. 83OCELLA ................................... 70OCREVUS ...........................51, 62OCTAGAM ............. 6, 22, 38, 114octreotide acetate.............30, 51, 62, 83, 89, 131, 199ODEFSEY ........................... 22, 99ODOMZO ........................194, 199OFEV ........................... 11, 76, 123ofloxacin ............................. 92, 164OGESTREL .............................. 70olanzapine .................................142olanzapine-fluoxetine hcl ..........142OLEPTRO ...............................142olmesartan medoxomil ........38, 164olmesartan medoxomil-hctz 38, 164olopatadine hcl.....................93, 114, 119, 164, 184OLYSIO ...............83, 99, 114, 164

omeprazole ..........................83, 114OMEPRAZOLE+SYRSPEND SF ALKA ............................. 164omeprazole-sodium bicarbonate...............................38, 83, 114, 164OMNARIS...................11, 13, 76, 99, 114, 184ondansetron ........................ 83, 199ondansetron hcl .. 83, 182, 186, 199ONETOUCH CLUB LANCETS FINE PT ...............149ONETOUCH FINEPOINT LANCETS ............................... 149ONETOUCH LANCETS ....... 149ONETOUCH ULTRASOFT LANCETS ............................... 149ONFI ...................... 51, 52, 62, 164OPANA ER ..............................176opium ........................................ 164OPSUMIT ......11, 38, 76, 123, 164ORALAIR11, 13, 76, 99, 114, 184ORENCIA ... 16, 22, 114, 132, 194ORENCIA CLICKJECT.......................15, 22, 114, 132, 194ORENITRAM ....... 11, 38, 76, 123ORKAMBI ............ 11, 30, 76, 123orphenadrine citrate er .............132ORSYTHIA ............................... 70oseltamivir phosphate .........99, 164OSPHENA ..... 44, 70, 89, 119, 176OTEZLA ..................114, 132, 194otic care .................................... 164oxandrolone ................................ 30oxaprozin .............. 16, 22, 114, 132oxazepam ...................... 52, 62, 142oxcarbazepine ....................... 52, 62oxiconazole nitrate.............................99, 114, 164, 194OXISTAT .................. 99, 114, 194OXTELLAR XR ................. 52, 62oxybutynin chloride .............44, 132oxybutynin chloride er ........ 44, 132oxycodone hcl ........................... 176oxycodone hcl er ............... 164, 176oxycodone-acetaminophen164, 176oxycodone-aspirin .....................176oxycodone-ibuprofen 176, 182, 186


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OXYCONTIN ................. 165, 176oxymorphone hcl .......................176oxymorphone hcl er .................. 176OXYTROL ........................ 44, 132paliperidone er ..................142, 165PANCREAZE ................... 83, 165PANRETIN . 16, 22, 114, 194, 199pantoprazole sodium .................165paregoric .....................................83paricalcitol ....................44, 89, 165PAROEX ..................... 83, 99, 119paromomycin sulfate .............83, 99paroxetine hcl ........................... 142paroxetine hcl er ....................... 142PASER ................. 76, 99, 114, 123peg 3350/electrolytes .......... 83, 182peg 3350-kcl-na bicarb-nacl.............................................83, 182peg-3350/electrolytes ..........83, 182PEGANONE ........52, 62, 132, 165penicillin g procaine ................. 165penicillin v potassium ............... 165PENNSAID ..............114, 132, 165PENTASA ..........................83, 114pentoxifylline er .......... 38, 132, 176PERFOROMIST .11, 76, 114, 123perindopril erbumine .......... 38, 176PERIOGARD ............83, 100, 119permethrin .........................100, 194perphenazine .............................142PERTZYE ................................. 83phenazopyridine hcl ............44, 176phendimetrazine tartrate ............ 30phendimetrazine tartrate er ........ 30phenelzine sulfate ......................142PHENERGAN ...83, 176, 182, 186phenobarbital ............................165PHENOHYTRO ..................... 165phenoxybenzamine hcl 39, 165, 199phentermine hcl ...........................30phenyleph-promethazine-cod...............13, 76, 100, 114, 123, 165phenylephrine-guaifenesin ........165phenytoin ...............................52, 62PHENYTOIN INFATABS .52, 62phenytoin sodium extended ...52, 62PHILITH ................................... 70

PHOS-FLUR ........................... 165PHOSPHA 250 NEUTRAL ..... 30PHOSPHASAL ....................... 165PICATO ...................................194pilocarpine hcl...16, 22, 83, 93, 114, 182, 186, 199pimozide ........52, 62, 132, 142, 165PIMTREA ......................... 70, 165pindolol ....................................... 39pioglitazone hcl .....................30, 89pioglitazone hcl-glimepiride .30, 89pioglitazone hcl-metformin hcl...............................................30, 89PIRMELLA 1/35 .......................70PIRMELLA 7/7/7 ..............70, 165piroxicam .............. 16, 22, 115, 132podofilox ................... 100, 115, 194polyethylene glycol 3350 ............ 83polymyxin b-trimethoprim.............................93, 100, 115, 120polyvinyl alcohol .........................93POMALYST ........................6, 199PORTIA-28 ............................... 70pot bicarb-pot chloride ............... 30potassium bicarbonate ................30potassium chloride ..............30, 165potassium chloride crys er ..........30potassium chloride er ......... 30, 165potassium citrate er .................. 165POTIGA ...............................52, 62PRADAXA .....................6, 39, 182PRALUENT ........................ 31, 39pramcort ............................... 39, 83pramipexole dihydrochloride52, 62pramipexole dihydrochloride er.......................................52, 62, 165prasugrel hcl.................6, 39, 165, 176, 182, 186pravastatin sodium ......................31prazosin hcl .................................39PRECISION SURE-DOSE SYRINGE ................................ 149PRECISION THIN LANCETS ............................... 149PRECISION THINS GP LANCETS ............................... 149

PRECISION ULTRA LANCET ..................................149PRECISION XTRA BLOOD GLUCOSE ...............................149prednicarbate ....................115, 195prednisolone ................. 22, 90, 115prednisolone acetate ...........93, 115prednisolone sodium phosphate...............................22, 90, 115, 165prednisone .................................166preferred plus lancets colored .. 149preferred plus lancets thin ........ 149PREMARIN .. 44, 70, 90, 120, 176premium lidocaine .................... 166PREMPHASE ....... 44, 70, 90, 120PREMPRO ............ 44, 70, 90, 120prenatabs fa .............................. 179prenatal .....................................180prenatal 19 ................150, 179, 180PREVACID SOLUTAB ... 83, 115PREVIFEM ............................... 71PREZCOBIX .....................22, 100PREZISTA ........................ 22, 100PRIFTIN ............76, 100, 115, 123PRILOSEC ........................84, 115primidone ..................................166PRISTIQ ..................................143PRIVIGEN .............. 6, 22, 39, 115PROAIR HFA ............. 11, 76, 123PROAIR RESPICLICK.......................................11, 77, 123probenecid .. 31, 115, 132, 182, 196PROBUPHINE IMPLANT KIT ........................................... 143prochlorperazine .........................84prochlorperazine edisylate ......... 84prochlorperazine maleate ...........84PROCRIT ......................6, 44, 199PROCTO-PAK ............... 115, 195PROCTOSOL HC .. 115, 166, 195PROCTOZONE-HC...................................115, 166, 195Profilnine...................................... 6Profilnine SD................................ 6progesterone ............. 39, 44, 71, 90progesterone micronized .....71, 166PROLIA .......................71, 90, 132


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PROMACTA.....................6, 22, 39, 84, 100, 115promethazine hcl.....................84, 166, 177, 182, 186promethazine vc plain.......................13, 77, 100, 115, 184promethazine vc/codeine.......................13, 77, 100, 115, 123promethazine-codeine...............13, 77, 100, 115, 123, 184promethazine-dm...............13, 77, 100, 115, 123, 184promethazine-phenylephrine...............13, 77, 100, 115, 166, 184propafenone hcl .......................... 39propafenone hcl er ......................39proparacaine hcl .........93, 182, 186propranolol hcl.........................39, 52, 62, 132, 177propranolol hcl er ...39, 52, 62, 177propranolol-hctz ......................... 39propylthiouracil .......................... 90PROTONIX .............................166protriptyline hcl ........................ 143PROVENTIL HFA ..... 11, 77, 123pseudoephedrine hcl...............................13, 77, 100, 115PSS SELECT GP LANCETS 150PSS SELECT SAFETY LANCETS ............................... 150PULMICORT FLEXHALER...............................11, 77, 115, 123PULMOZYME ..... 11, 31, 77, 123PURIXAN ................................166pyrazinamide .............................100pyridostigmine bromide.........................22, 52, 62, 115, 132pyridostigmine bromide er.................22, 52, 62, 115, 132, 166qc nicotine polacrilex ................150QNASL .........13, 77, 100, 115, 184QNASL CHILDRENS.......................13, 77, 100, 115, 184QSYMIA ....................................31QUASENSE ...............................71quetiapine fumarate .................. 143quetiapine fumarate er ......143, 166

QUILLIVANT XR...............................52, 62, 132, 143quinapril hcl ................................39quinapril-hydrochlorothiazide ....39quinidine gluconate er ........ 39, 182quinidine sulfate ..................39, 182quinidine sulfate er ............. 39, 182quinine sulfate ...........................166QVAR ...................11, 77, 116, 123ra mini nicotine .................143, 179ra nicotine .........................143, 179ra nicotine polacrilex ........143, 179rabeprazole sodium .... 84, 116, 166raloxifene hcl 71, 90, 132, 166, 199ramipril ....................................... 39RANEXA ........................... 39, 177ranitidine hcl .................39, 84, 116RAPAFLO ......................... 44, 199RAPAMUNE.................22, 44, 77, 123, 182, 186rasagiline mesylate ....... 52, 63, 166RAVICTI ................................... 31REA LO 40 .............................. 166reality lancets ............................150reality trigger lancets ............... 150REBIF .................................. 53, 63REBIF REBIDOSE ............ 52, 63REBIF REBIDOSE TITRATION PACK ..... 52, 53, 63REBIF TITRATION PACK...............................................53, 63RECLIPSEN ............................. 71Recombinate................................. 6RELENZA DISKHALER ...... 100RELISTOR ........................84, 170REMEVEN ..............................166REMICADE.................16, 22, 84, 116, 133, 195REMODULIN ....... 11, 39, 77, 124RENAL ................................ 8, 146RENFLEXIS.................16, 23, 84, 116, 133, 195repaglinide ....................31, 90, 166repaglinide-metformin hcl.......................................31, 90, 166REPATHA ...........................31, 39

REPATHA PUSHTRONEX SYSTEM ..............................31, 39REPATHA SURECLICK .. 31, 40RESCRIPTOR .................. 23, 100RESCULA ................................. 93reserpine ..................................... 40RESTASIS ................. 93, 116, 120RETIN-A MICRO PUMP ......195REVATIO ..............11, 40, 77, 124REVLIMID ............................. 166REXULTI ................................ 143REYATAZ .........................23, 100RIBASPHERE .......... 84, 100, 116ribavirin ...................... 84, 100, 116rifabutin ............................ 100, 166rifampin .....................................166riluzole .......................... 53, 63, 133rimantadine hcl .........................100risedronate sodium.........................31, 71, 90, 133, 166RISPERDAL CONSTA ..........143risperidone ................................143RISPERIDONE M-TAB 143, 166RITALIN LA .......53, 63, 133, 143RITUXAN ....16, 23, 116, 133, 199rivastigmine .......... 53, 63, 143, 167rivastigmine tartrate ..... 53, 63, 143Rixubis..................................7, 167rizatriptan benzoate 40, 53, 63, 177ropinirole hcl ........................ 53, 63ropinirole hcl er ....................53, 63ROSANIL CLEANSER ......... 167rosuvastatin calcium ...........31, 167ROZEREM ..........................53, 63RUBRACA ........................ 71, 199Ruconest............... 23, 31, 184, 195RYDAPT ..................................167SABRIL ....................... 53, 63, 133salsalate ................ 16, 23, 116, 133SANCUSO ......................... 84, 199SAPHRIS ................................. 143SAVAYSA ............... 7, 40, 77, 124SAVELLA ............... 116, 133, 177SAVELLA TITRATION PACK ....................... 116, 133, 177SAXENDA ................................. 31sb lancets thin ........................... 150


213

sb lancets ultra thin .................. 150selegiline hcl ......................... 53, 63selenium sulfide ........ 116, 167, 195selenium sulf-pyrithione-urea...........................................116, 195SELZENTRY .................... 23, 101SEMPREX-D.......................13, 77, 101, 116, 184SENSIPAR ...................44, 90, 182SEREVENT DISKUS...............................11, 77, 116, 124SEROSTIM8, 23, 31, 90, 101, 146sertraline hcl .............................143SETLAKIN ................................71sf ..................................................84sf 5000 plus ................................. 84SHAROBEL .............................. 71SIGNIFOR .................................90sildenafil citrate ...... 11, 40, 77, 124silver sulfadiazine...........................101, 119, 182, 186SIMBRINZA ............................. 93SIMPONI .............16, 23, 116, 133SIMPONI ARIA...............16, 23, 116, 133, 167, 195simvastatin .................................. 31sirolimus.........23, 44, 77, 124, 167, 182, 186SIRTURO .......... 77, 101, 116, 124SIVEXTRO ............................. 167SKLICE ................................... 101sodium fluoride ................... 84, 167sodium polystyrene sulfonate.............................................31, 167SOLIRIS.........7, 23, 40, 44, 53, 63, 116, 133SOLTAMOX ..................... 71, 199SOMAVERT ... 31, 53, 63, 90, 133SOOLANTRA ................. 116, 195sotalol hcl ....................................40sotalol hcl (af) .............................40SOVALDI .......... 84, 101, 117, 167spinosad ............................ 101, 195SPINRAZA ..........................53, 63SPIRIVA RESPIMAT...............................11, 77, 117, 124spironolactone ........ 31, 40, 84, 102

spironolactone-hctz ...............31, 40SPRINTEC 28 ........................... 71SPRITAM ....................53, 64, 133SPRIX ...................... 177, 183, 187SPRYCEL ................................167SPS ............................................. 31sr nicotine ................................. 150SRONYX ................................... 71SSD ................... 101, 119, 183, 187stavudine ............................. 23, 101STELARA ......... 84, 117, 133, 195STIVARGA ............................. 167STRENSIQ ................................ 31STRIANT .............................71, 90STRIBILD ......................... 23, 101STRIVERDI RESPIMAT...............................11, 77, 117, 124SUBOXONE ....................143, 144sucralfate ............................ 85, 117sulfacetamide sodium.....................93, 101, 117, 120, 195sulfacetamide sodium (acne) .... 195sulfacetamide sodium-sulfur .....167sulfacetamide-prednisolone 94, 117sulfamethoxazole-trimethoprim 167sulfasalazine.................16, 23, 85, 117, 133, 167sulindac .............................117, 133sumatriptan ............. 40, 53, 64, 177sumatriptan succinate...........................40, 53, 54, 64, 177sumatriptan succinate refill.................................40, 53, 64, 177super thin lancets ......................150SUPRAX .................................. 167SUPRENZA ...............................31sure comfort insulin syringe ..... 150SURELITE LANCETS .......... 150SUSTIVA ........................... 23, 101SUTENT .................................. 167SYEDA .......................................71SYMBICORT ......11, 77, 117, 124SYMLINPEN 120 ............... 32, 90SYMLINPEN 60 ................. 32, 90SYNAGIS ...........78, 101, 117, 124SYNALAR (CREAM) .... 117, 195

SYNALAR (OINTMENT)...........................................117, 195SYNAREL ........................... 71, 90SYNDROS ..... 23, 32, 85, 101, 199SYPRINE .32, 54, 64, 85, 133, 170TABLOID ............................7, 199TACLONEX ............................195tacrolimus.23, 44, 85, 117, 167, 183, 187, 195TAFINLAR ............................. 167TAGRISSO ..............................167TALTZ .....................117, 134, 195TAMIFLU ............................... 101tamoxifen citrate ................. 71, 199tamsulosin hcl ..................... 44, 199TANZEUM ..........................32, 90TARCEVA ...............................168TARINA FE 1/20 ...................... 71TASIGNA ................................ 168TAZORAC ...................... 195, 196tb syringe 1 ml .......................... 150TECFIDERA .......................54, 64TECHLITE LANCETS ..........150TECHNIVIE ............. 85, 101, 117TEKTURNA ..............................40TEKTURNA HCT .................... 40telmisartan .................. 40, 168, 177telmisartan-hctz .................. 40, 168temazepam ............................ 54, 64temozolomide ............................ 168terazosin hcl ..................40, 44, 199terbinafine hcl ...........................168terbutaline sulfate ......... 11, 78, 124terconazole ....................44, 71, 101TESTOPEL ......................... 71, 90testosterone ................... 71, 91, 168testosterone cypionate ...........71, 91testosterone enanthate .......... 71, 91tetrabenazine .54, 64, 134, 144, 168tetracycline hcl ..........................168tgt nicotine ................ 144, 150, 179tgt nicotine polacrilex ....... 144, 179tgt nicotine step one .......... 144, 179tgt nicotine step three ........144, 179tgt nicotine step two .......... 144, 179THALOMID ........................7, 199theophylline ...........12, 78, 117, 124


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theophylline er ...... 12, 78, 117, 124THINLETS GP LANCETS ... 150THINLETS LANCET ............ 150thioridazine hcl ......................... 144thiothixene .................................144tiagabine hcl ......................... 54, 64TILIA FE ...........................71, 196timolol maleate ............. 40, 94, 177tinidazole .................44, 71, 85, 101TIVICAY ................... 23, 101, 168tizanidine hcl .............................134TOBI PODHALER.................12, 32, 78, 101, 117, 124tobramycin.........12, 32, 78, 101, 117, 124, 168tobramycin-dexamethasone.....................................94, 101, 117tolazamide .............................32, 91tolbutamide ........................... 32, 91tolcapone .......................54, 64, 168tolmetin sodium .....16, 23, 118, 134tolterodine tartrate ..............44, 134tolterodine tartrate er . 44, 134, 168topco insulin syringe .................150topiramate .........40, 41, 54, 64, 177topiramate er .......... 40, 54, 64, 177torsemide ...............................32, 41TOVIAZ .............................45, 134TRACLEER .......... 12, 41, 78, 124tramadol hcl ..............................178tramadol hcl er ......................... 178tramadol hcl er (biphasic) ........ 177tramadol-acetaminophen ..........178trandolapril .........................41, 178trandolapril-verapamil hcl er ..... 41tranexamic acid ...............41, 45, 72tranylcypromine sulfate ............ 144TRAVATAN Z .......................... 94trazodone hcl ............................ 144TRECATOR ............................101TRESIBA FLEXTOUCH ...... 168tretinoin .............................168, 196tretinoin microsphere ................196tretinoin microsphere pump ......196Tretten...........................................7TREXALL ... 16, 23, 118, 134, 196

triamcinolone acetonide13, 78, 101, 118, 120, 168, 184, 196triamterene-hctz ....................32, 41TRI-ESTARYLLA ................... 72trifluoperazine hcl .....................144trifluridine ...........94, 102, 118, 120trihexyphenidyl hcl ................54, 64TRI-LEGEST FE ..............72, 196TRI-LINYAH ............................72TRI-LO-ESTARYLLA ............ 72TRI-LO-MARZIA .................... 72TRI-LO-SPRINTEC .........72, 168TRILYTE .................. 85, 168, 183trimethobenzamide hcl 85, 183, 187trimethoprim ....................... 45, 102trimipramine maleate ................144TRINATE ................................ 180TRINESSA (28) .........................72TRINESSA LO ..........................72TRINTELLIX ......................... 144TRI-PREVIFEM .......................72TRI-SPRINTEC ........................72TRIUMEQ .........................23, 102tri-vit/fluoride/iron ..........8, 85, 146tri-vitamin/fluoride ......... 8, 85, 146TRIVORA (28) ..........................72TROKENDI XR.........................41, 54, 64, 168, 178tropicamide ................................. 94trospium chloride ................45, 134trospium chloride er ........... 45, 134TRULICITY ........................32, 91TRUVADA ........................ 24, 102TUSSIGON ..13, 78, 102, 118, 124TYBOST ............................ 24, 102TYKERB ................................. 168TYMLOS ..................... 72, 91, 134TYSABRI ...............54, 64, 85, 118Tyvaso.....................12, 41, 78, 124Tyvaso Refill .......... 12, 41, 78, 124Tyvaso Starter.........12, 41, 78, 124UCERIS ............................. 85, 118ULESFIA ......................... 102, 196ULTILET CLASSIC LANCETS ............................... 150ULTILET LANCETS .............150

ULTRA-THIN II AUTO LANCET ..................................150ULTRA-THIN II LANCETS .150UNILET COMFORTOUCH LANCET ..................................150UNILET G.P. LANCET .........150UNILET G.P. SUPERLITE LANCET ..................................150UNILET LANCET ................. 150UNILET SUPERLITE LANCET ..................................150UNISTIK 1 .............................. 150UNITHROID .....................91, 168UNITHROID DIRECT .......... 168UPTRAVI .............. 12, 41, 78, 124urea ................................... 168, 169urea nail film .............................169urea-c40 ....................................169ure-k ..........................................169URIMAR-T ..............................169UROLET MB .......................... 169UROPHEN MB .......................169ursodiol ....................................... 85URYL ....................................... 169valacyclovir hcl .........................169valganciclovir hcl ..................... 169valproic acid ......................... 54, 64valsartan ............................. 41, 169valsartan-hydrochlorothiazide ... 41vancomycin hcl ......................... 169VANDAZOLE .............45, 72, 102VARUBI .............................85, 199VELETRI .............. 12, 41, 78, 124VELIVET .................................. 72VELTASSA ............................... 32VENCLEXTA ..................... 7, 199VENCLEXTA STARTING PACK ................................... 7, 200venlafaxine hcl .......................... 144venlafaxine hcl er ......................144Ventavis.................. 12, 41, 78, 124VENTOLIN HFA ........12, 78, 125VERAMYST13, 78, 102, 118, 184verapamil hcl ...................... 41, 178verapamil hcl er ..........................41VEREGEN ...............102, 118, 196VESICARE ........................45, 134


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VESTURA ................. 72, 144, 196VIBERZI ................................... 85VICTOZA ............................32, 91VIDEX ............................... 24, 102VIEKIRA PAK ......... 85, 102, 118VIEKIRA XR ............ 85, 102, 118VIENVA .....................................72vigabatrin ..............54, 64, 134, 169VIIBRYD ................................. 144VIIBRYD STARTER PACK .144VIMPAT .............................. 54, 65viorele ......................................... 72VIRACEPT ....................... 24, 102VIREAD ...............24, 85, 102, 118VISTOGARD .......................... 170VITALET PRO LANCETS ... 150VITALET PRO PLUS LANCETS ............................... 150vitamin d (ergocalciferol) ..... 8, 146VIVITROL .............................. 144Vonvendi.......................................7voriconazole ..............................169VOTRIENT ............................. 169VPRIV ........................................32VRAYLAR .............................. 144VYFEMLA ........................ 72, 169VYVANSE ........... 54, 65, 134, 144W&F LANCETS 26G .............150W&F LANCETS COLORED 21G ........................................... 151warfarin sodium ......................7, 41weight loss daily multi .............. 151WELCHOL ............................... 32WERA ........................................72Wilate........7, 24, 41, 118, 183, 187WYMZYA FE ........................... 72XALKORI ............................... 169XARELTO .......7, 41, 78, 125, 183XARELTO STARTER PACK...........................7, 41, 78, 125, 183XATMEP ............. 7, 118, 134, 200XELJANZ ............16, 24, 118, 134XELJANZ XR .....16, 24, 118, 134XENICAL ..................................32XEOMIN ....... 54, 65, 94, 134, 196XERMELO ........................85, 200XGEVA ......................32, 134, 200

XIAFLEX .......................... 72, 134XIFAXAN ........32, 55, 65, 85, 102XIGDUO XR ....................... 32, 91XOLAIR.........12, 32, 78, 118, 125, 185, 196XTANDI ...................................169XULANE ................................... 72XURIDEN ..................................32Xyntha...........................................7Xyntha Solofuse............................7XYREM ....................... 55, 65, 134zafirlukast ............. 12, 78, 118, 125zaleplon .................................55, 65ZARAH ......................................72ZARXIO ........................ 7, 24, 200ZEJULA ...................................169ZELAPAR ........................... 55, 65ZELBORAF ............................ 169ZENATANE ............................ 196ZENCHENT ..............................72ZENCHENT FE ........................72ZENPEP .....................................85ZENZEDI ............ 55, 65, 135, 145ZEPATIER ................86, 102, 118ZETONNA.................12, 13, 78, 102, 118, 185zidovudine ........................... 24, 102ZINBRYTA ......................... 55, 65ZINPLAVA ............... 86, 102, 118ZIOPTAN .................................. 94ziprasidone hcl ..........................145ZIRGAN .................... 94, 102, 118ZOHYDRO ER ....................... 178ZOLADEX ...................45, 72, 200ZOLINZA ........................196, 200zolmitriptan .............41, 55, 65, 178zolpidem tartrate ...................55, 65zolpidem tartrate er .............. 55, 65ZOMIG .......... 41, 55, 65, 169, 178zonisamide ............................ 55, 65ZONTIVITY.............7, 42, 55, 65, 178, 183, 187ZORBTIVE8, 24, 32, 91, 102, 146ZORTRESS ... 24, 45, 86, 183, 187ZOVIA 1/35E (28) .....................72ZOVIA 1/50E (28) .....................72ZOVIRAX ............................... 169

ZUBSOLV ....................... 145, 169ZURAMPIC .............. 32, 118, 135ZYCLARA ...............................196ZYCLARA PUMP .................. 196ZYDELIG ....................7, 125, 200ZYKADIA ............................... 169ZYPREXA RELPREVV ........ 145ZYTIGA ...................................169


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