preferredrx drug list | healthpartnershp/@public/... · weight loss benefit wl oncology benefit...

HealthPartners® PreferredRx

2018 Formulary

(List of covered drugs)

For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy.

Effective: April 1, 2018

©2017 HealthPartners

What’s the PreferredRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a

team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety,

effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3.

Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you

less. Some generic medicines are very low-cost.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Status can be used to determine how much a medicine will cost you. For exact cost information,

Find the status for your medicine.

Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Status. Or,

Log on to your myHealthPartners account to check your pharmacy benefits.

F $ – Formulary Low Cost Generics

F $$ – Formulary High Cost Generics

F $$$ – Formulary Brands

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.

These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.

Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than

non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan

tab to check your benefits for specialty medicines.

What do the abbreviations in the More details column mean?

This column gives special information about the medicine you’re searching for. The abbreviations let you know there might be a

special program or rule for the medicine. Use this key to help you navigate the drug list:

Prior Authorization Required PA

Step Therapy Required ST

Age Edit AE

Gender Edit Female GE Female

Gender Edit Male GE Male

Quantity Limit QL

Smoking Cessation Benefit SC

Trial Drug Program TD

Weight Loss Benefit WL

Oncology Benefit ONC

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (9/15) ©2015 HealthPartners

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they

need to meet the HealthPartners prior authorization

criteria in order for the medicine to be covered by your

pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try

one or more other medicines first. HealthPartners

covers a medicine with step therapy, if you've already

tried the other medicine(s). If you haven't, you or your

doctor will need to get approval from HealthPartners

before the medicine will be covered by your lowest

brand, generic or specialty copay or coinsurance.

What’s an Age Edit (AE)? An age edit means some medicines are only covered if

you’re within a specific age range. If you're not in the

approved age range, you or your doctor will need to

request approval from HealthPartners for your

medicine to be covered.

What’s a Gender Edit (GE)? A gender edit means some medicines are covered for

males or females only. If you're not in the approved

gender group, you or your doctor will need to request

approval from HealthPartners for your medicine to be

covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the

medicine you'll get each time you fill your prescription.

The quantity limit may be less than the days supply

listed in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for

certain medicines that may not be well tolerated due

to:

Side effects

High cost

High potential for waste

Your first 6 fills of a trial drug may be limited to less

than a month supply. If the medicine works well, you’ll

get the rest of your month supply. If a copay applies to

the medicine, you’ll pay no more than one copay for

each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount

you get or may not be covered under all plans. Log on to

your myHealthPartners account and click on My plan

benefits on the Medical Plan tab to check your benefits

for weight loss. Weight Loss medicines are listed on the

drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

Table of Contents

Alcohol Dependency ................................................................................................................................................................. 6Allergy ....................................................................................................................................................................................... 6Alpha-1 Antitrypsin Deficiency .................................................................................................................................................6Anti-Addiction/Substance Abuse Treatment Agents .............................................................................................................. 7Anti-Infective ............................................................................................................................................................................ 7Arthritis ................................................................................................................................................................................... 12Asthma & Copd ....................................................................................................................................................................... 12Behavioral Health ................................................................................................................................................................... 14Birth Control ............................................................................................................................................................................17Bleeding Disorders ..................................................................................................................................................................20Blood Modifier ........................................................................................................................................................................ 20Blood Thinner ..........................................................................................................................................................................22Bone Health ............................................................................................................................................................................ 22Cancer ......................................................................................................................................................................................23Corticosteroids ........................................................................................................................................................................25Cough & Cold .......................................................................................................................................................................... 26Cystic Fibrosis ..........................................................................................................................................................................26Dementia .................................................................................................................................................................................26Diabetes .................................................................................................................................................................................. 26Ear Conditions .........................................................................................................................................................................28Enzyme Replacement ............................................................................................................................................................. 29Eye Conditions ........................................................................................................................................................................ 29Gout .........................................................................................................................................................................................31Heart Health ............................................................................................................................................................................31Hereditary Angioedema ......................................................................................................................................................... 35Idiopathic Pulmonary Fibrosis ................................................................................................................................................36Immune Deficiency ................................................................................................................................................................. 36Immune Suppressant ..............................................................................................................................................................36Kidney Failure ......................................................................................................................................................................... 37Men's Health ...........................................................................................................................................................................37Migraine .................................................................................................................................................................................. 37Mouth & Throat ...................................................................................................................................................................... 38Multiple Sclerosis ....................................................................................................................................................................38Muscle Relaxant ......................................................................................................................................................................39Other Conditions .....................................................................................................................................................................39Pain ..........................................................................................................................................................................................40Parkinson's .............................................................................................................................................................................. 42Pulmonary Hypertension ........................................................................................................................................................43Seizures / Epilepsy .................................................................................................................................................................. 43Skin Conditions ....................................................................................................................................................................... 45Sleep Disorders ....................................................................................................................................................................... 48Smoking Cessation ..................................................................................................................................................................49Stomach / Gastrointestinal .................................................................................................................................................... 49Thyroid .................................................................................................................................................................................... 51Urinary & Bladder Health ....................................................................................................................................................... 51Vaccines .................................................................................................................................................................................. 52Vitamins And Minerals ........................................................................................................................................................... 54Weight Loss ............................................................................................................................................................................. 56Women's Health ..................................................................................................................................................................... 56

4

Drug Status More Details

Alcohol Dependency

Alcohol Dependency

acamprosate oral F$$

disulfiram oral F$$

naltrexone oral F$$

Allergy

Allergy, Eye

azelastine ophthalmic (eye) F$$

cromolyn ophthalmic (eye) F$$

epinastine ophthalmic (eye) F$$

olopatadine ophthalmic (eye) drops 0.1 % F$$

Allergy, Injection

epinephrine injection auto-injector F$$

Allergy, Other Nasal

azelastine nasal aerosol,spray F$$

ipratropium bromide nasal F$$

Allergy, Other Oral

GRASTEK SUBLINGUAL F$$$ PA

ODACTRA SUBLINGUAL F$$$ PA

RAGWITEK SUBLINGUAL F$$$ PA

Antihistamines, Oral

cyproheptadine oral F$$

hydroxyzine hcl oral solution 10 mg/5 ml F$$ QL; AE

hydroxyzine hcl oral tablet F$ QL; AE

hydroxyzine pamoate oral F$$ QL; AE

promethazine oral syrup F$$ QL; AE

promethazine oral tablet F$$ QL; AE

Corticosteroids, Nasal

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) F$$

fluticasone nasal F$

QNASL NASAL F$$$

Alpha-1 Antitrypsin Deficiency

Alpha-1 Antitrypsin Deficiency

ARALAST NP INTRAVENOUS F$$$ PA; Specialty

GLASSIA INTRAVENOUS F$$$ PA; Specialty

PROLASTIN-C INTRAVENOUS F$$$ PA; Specialty

ZEMAIRA INTRAVENOUS F$$$ PA; Specialty

PreferredRx: April 1, 2018

6


Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents

naloxone injection syringe 1 mg/ml F$$

NARCAN NASAL F$$$

Anti-Infective

Antibiotics, Cephalosporins

cefadroxil oral capsule F$$

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

F$$

cefadroxil oral tablet F$$

cefdinir oral F$$

cefprozil oral F$$

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION F$$$

cefuroxime axetil oral tablet F$$

cephalexin oral capsule 250 mg, 500 mg F$

cephalexin oral suspension for reconstitution F$$

SUPRAX ORAL CAPSULE F$$$ QL

Antibiotics, Macrolides

azithromycin oral suspension for reconstitution F$$

azithromycin oral tablet 250 mg, 500 mg F$

azithromycin oral tablet 600 mg F$$

clarithromycin oral suspension for reconstitution F$$

clarithromycin oral tablet F$$

DIFICID ORAL F$$$ PA

Antibiotics, Other

clindamycin hcl oral capsule 150 mg, 300 mg F$

clindamycin hcl oral capsule 75 mg F$$

clindamycin palmitate hcl oral F$$

linezolid oral F$$ PA

neomycin oral F$$

sulfamethoxazole-trimethoprim oral suspension F$$

sulfamethoxazole-trimethoprim oral tablet F$

trimethoprim oral F$$

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg

F$$

vancomycin oral capsule F$$

XIFAXAN ORAL F$$$ PA


7


Antibiotics, Penicillins

amoxicillin oral capsule F$

amoxicillin oral suspension for reconstitution F$

amoxicillin oral tablet F$

amoxicillin oral tablet,chewable 125 mg, 250 mg F$

amoxicillin-pot clavulanate oral suspension for reconstitution

F$$

amoxicillin-pot clavulanate oral tablet F$$

amoxicillin-pot clavulanate oral tablet,chewable F$$

ampicillin oral F$

dicloxacillin oral F$$

penicillin v potassium oral recon soln F$$

penicillin v potassium oral tablet F$

Antibiotics, Quinolones

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON F$$$

ciprofloxacin hcl oral F$

ciprofloxacin oral F$$

levofloxacin oral solution F$$

levofloxacin oral tablet F$

moxifloxacin oral F$$

Antibiotics, Tetracyclines

demeclocycline oral F$$

doxycycline hyclate oral capsule F$$

doxycycline hyclate oral tablet 100 mg, 20 mg F$$

doxycycline monohydrate oral capsule 100 mg, 50 mg F$$

doxycycline monohydrate oral tablet 100 mg, 50 mg F$$

minocycline oral capsule F$$

tetracycline oral F$$

Antifungals

clotrimazole mucous membrane F$$

CRESEMBA ORAL F$$$ PA

fluconazole oral suspension for reconstitution F$$

fluconazole oral tablet 100 mg, 200 mg F$$

fluconazole oral tablet 150 mg, 50 mg F$

griseofulvin microsize oral F$$

griseofulvin ultramicrosize oral F$$

itraconazole oral F$$ PA

ketoconazole oral F$$


8


NOXAFIL ORAL F$$$ PA

nystatin oral suspension F$$

nystatin oral tablet F$$

terbinafine hcl oral F$

voriconazole oral F$$ PA

Anti-Infective, Other

ALBENZA ORAL F$$$ PA

atovaquone oral F$$

BILTRICIDE ORAL F$$$

dapsone oral F$$

ivermectin oral F$$

rifabutin oral F$$

SIVEXTRO ORAL F$$$ PA

Antiprotozoals

ALINIA ORAL F$$$ ST

atovaquone-proguanil oral F$$

chloroquine phosphate oral F$$

hydroxychloroquine oral F$$

mefloquine oral F$$

metronidazole oral tablet F$$

Antiviral, Hepatitis B

adefovir oral F$$

BARACLUDE ORAL SOLUTION F$$$

entecavir oral F$$

EPIVIR HBV ORAL SOLUTION F$$$

lamivudine oral tablet 100 mg F$$

TYZEKA ORAL F$$$

VEMLIDY ORAL F$$$

Antiviral, Hepatitis C

EPCLUSA ORAL F$$$ PA; Specialty

HARVONI ORAL F$$$ PA; Specialty

INTRON A INJECTION F$$$ Specialty

MAVYRET ORAL F$$$ PA; Specialty

OLYSIO ORAL F$$$ PA; Specialty

PEGASYS PROCLICK SUBCUTANEOUS F$$$ PA; Specialty

PEGASYS SUBCUTANEOUS F$$$ PA; Specialty

PEGINTRON REDIPEN SUBCUTANEOUS F$$$ PA; Specialty

PEGINTRON SUBCUTANEOUS F$$$ PA; Specialty


9


REBETOL ORAL SOLUTION F$$$ Specialty

ribavirin oral capsule F$$ Specialty

ribavirin oral tablet 200 mg F$$ Specialty

SOVALDI ORAL F$$$ PA; Specialty

VOSEVI ORAL F$$$ PA; Specialty

Antiviral, Hiv

abacavir oral F$$

abacavir-lamivudine oral F$$

abacavir-lamivudine-zidovudine oral F$$

APTIVUS ORAL F$$$

atazanavir oral F$$

ATRIPLA ORAL F$$$

COMPLERA ORAL F$$$

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG F$$$

DESCOVY ORAL F$$$

didanosine oral F$$

EDURANT ORAL F$$$

efavirenz oral F$$

EMTRIVA ORAL F$$$

EVOTAZ ORAL F$$$

fosamprenavir oral F$$

FUZEON SUBCUTANEOUS RECON SOLN F$$$ Specialty

GENVOYA ORAL F$$$

INTELENCE ORAL F$$$

INVIRASE ORAL F$$$

ISENTRESS HD ORAL F$$$

ISENTRESS ORAL F$$$

JULUCA ORAL F$$$

KALETRA ORAL TABLET F$$$

lamivudine oral solution F$$

lamivudine oral tablet 150 mg, 300 mg F$$

lamivudine-zidovudine oral F$$

LEXIVA ORAL SUSPENSION F$$$

lopinavir-ritonavir oral F$$

nevirapine oral F$$

NORVIR ORAL SOLUTION F$$$

NORVIR ORAL TABLET F$$$


10


ODEFSEY ORAL F$$$

PREZCOBIX ORAL F$$$

PREZISTA ORAL F$$$

RESCRIPTOR ORAL F$$$

REYATAZ ORAL POWDER IN PACKET F$$$

SELZENTRY ORAL F$$$

stavudine oral F$$

STRIBILD ORAL F$$$

tenofovir disoproxil fumarate oral F$$

TIVICAY ORAL F$$$

TRIUMEQ ORAL F$$$

TRUVADA ORAL F$$$

TYBOST ORAL F$$$

VIDEX 2 GRAM PEDIATRIC ORAL F$$$

VIDEX 4 GRAM PEDIATRIC ORAL F$$$

VIRACEPT ORAL TABLET F$$$

VIREAD ORAL POWDER F$$$

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG F$$$

VITEKTA ORAL F$$$

ZERIT ORAL RECON SOLN F$$$

zidovudine oral F$$

Antiviral, Other

acyclovir oral capsule F$$

acyclovir oral suspension 200 mg/5 ml F$$

acyclovir oral tablet F$$

amantadine hcl oral F$$

famciclovir oral F$$

oseltamivir oral capsule 30 mg, 45 mg, 75 mg F$$ QL

oseltamivir oral suspension for reconstitution F$$ QL

PREVYMIS ORAL F$$$

RELENZA DISKHALER INHALATION F$$$ QL

rimantadine oral F$$

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG F$$$ QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION F$$$ QL

valacyclovir oral F$$

valganciclovir oral F$$

Tuberculosis

cycloserine oral F$$ PA


11


ethambutol oral F$$

isoniazid oral F$

PRIFTIN ORAL F$$$

pyrazinamide oral F$$

rifampin oral F$$

SIRTURO ORAL F$$$ PA

TRECATOR ORAL F$$$ PA

Urinary Anti-Infectives

MONUROL ORAL F$$$

nitrofurantoin macrocrystal oral F$$ QL; AE

nitrofurantoin monohyd/m-cryst oral F$$ QL; AE

nitrofurantoin oral F$$ QL; AE

Arthritis

Arthritis, Other

DEPEN TITRATABS ORAL F$$$

Disease Modifying Agents

ACTEMRA SUBCUTANEOUS F$$$ PA; Specialty

ENBREL SUBCUTANEOUS F$$$ PA; Specialty

ENBREL SURECLICK SUBCUTANEOUS F$$$ PA; Specialty

HUMIRA PEN SUBCUTANEOUS F$$$ PA; Specialty

HUMIRA SUBCUTANEOUS F$$$ PA; Specialty

KINERET SUBCUTANEOUS F$$$ PA; Specialty

leflunomide oral F$$

methotrexate sodium (pf) injection solution F$$

methotrexate sodium injection F$$

methotrexate sodium oral F$$

ORENCIA CLICKJECT SUBCUTANEOUS F$$$ PA; Specialty

ORENCIA SUBCUTANEOUS F$$$ PA; Specialty

OTEZLA ORAL F$$$ PA; Specialty

OTEZLA STARTER ORAL F$$$ PA; Specialty

RASUVO (PF) SUBCUTANEOUS F$$$ PA

RIDAURA ORAL F$$$

Asthma & Copd

Asthma & Copd, Other

ATROVENT HFA INHALATION F$$$

cromolyn inhalation F$$

DALIRESP ORAL TABLET 500 MCG F$$$ PA

ipratropium bromide inhalation F$$


12


montelukast oral granules in packet F$$

montelukast oral tablet F$

montelukast oral tablet,chewable F$$

Bronchodilators, Inhaled

albuterol sulfate inhalation solution for nebulization0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

F$$

INCRUSE ELLIPTA INHALATION F$$$

SEREVENT DISKUS INHALATION F$$$

STRIVERDI RESPIMAT INHALATION F$$$

VENTOLIN HFA INHALATION F$$$

Bronchodilators, Oral

albuterol sulfate oral F$$

theophylline oral tablet extended release 12 hr F$$

theophylline oral tablet extended release 600 mg F$$

Combination Agents, Inhaled

ADVAIR DISKUS INHALATION F$$$

ADVAIR HFA INHALATION F$$$

ANORO ELLIPTA INHALATION F$$$

BREO ELLIPTA INHALATION F$$$

COMBIVENT RESPIMAT INHALATION F$$$

DULERA INHALATION F$$$ PA

fluticasone-salmeterol inhalation F$$

ipratropium-albuterol inhalation F$$

TRELEGY ELLIPTA INHALATION F$$$

Corticosteroids, Inhaled

ARNUITY ELLIPTA INHALATION F$$$

ASMANEX HFA INHALATION F$$$

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

F$$$

budesonide inhalation F$$

FLOVENT DISKUS INHALATION F$$$

FLOVENT HFA INHALATION F$$$

PULMICORT FLEXHALER INHALATION F$$$

QVAR INHALATION F$$$

QVAR REDIHALER INHALATION F$$$


13


Behavioral Health

Antipsychotic

aripiprazole oral solution F$$ AE

aripiprazole oral tablet F$$ AE

aripiprazole oral tablet,disintegrating F$$ PA; AE

clozapine oral tablet F$$ AE

clozapine oral tablet,disintegrating F$$ PA; AE

FANAPT ORAL F$$$ PA

fluphenazine hcl oral concentrate F$ AE

fluphenazine hcl oral elixir F$ AE

fluphenazine hcl oral tablet F$$ AE

haloperidol lactate oral F$$ AE

haloperidol oral F$$ AE

LATUDA ORAL TABLET 120 MG, 40 MG, 60 MG, 80 MG

F$$$ PA; QL

LATUDA ORAL TABLET 20 MG F$$$ PA

loxapine succinate oral F$$ AE

NUPLAZID ORAL F$$$ PA; Specialty

olanzapine oral tablet F$$ AE

olanzapine oral tablet,disintegrating F$$ PA; AE

paliperidone oral F$$ PA

perphenazine oral F$$ AE

quetiapine oral tablet F$$ AE

quetiapine oral tablet extended release 24 hr F$$ PA; AE

REXULTI ORAL F$$$ PA

risperidone oral solution F$$ AE

risperidone oral tablet F$$ AE

risperidone oral tablet,disintegrating F$$ PA; AE

SAPHRIS (BLACK CHERRY) SUBLINGUAL F$$$ PA

thioridazine oral F$$ AE

thiothixene oral F$$ AE

trifluoperazine oral F$$ AE

VERSACLOZ ORAL F$$$ PA; AE

ziprasidone hcl oral F$$ AE

Anxiety

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg F$ QL

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

F$$ QL


14


buspirone oral F$$

chlordiazepoxide hcl oral capsule 10 mg, 25 mg F$ QL

chlordiazepoxide hcl oral capsule 5 mg F$$ QL

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

F$$ QL

diazepam intensol oral F$$ QL

diazepam oral solution 5 mg/5 ml (1 mg/ml) F$$ QL

diazepam oral tablet 10 mg, 2 mg, 5 mg F$ QL

diazepam rectal F$$ QL

lorazepam oral concentrate F$$ QL

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL

Attention Deficit/Hyperactivity Disorder (Adhd)

adderall xr oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

F$$ QL

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

F$$ QL

clonidine hcl oral tablet extended release 12 hr F$$ PA; QL

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

F$$ QL

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg F$$ QL

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg

F$$ QL

dextroamphetamine oral tablet F$$ QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

F$$ QL

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

F$$ QL

metadate er oral F$$ QL

methylphenidate hcl oral capsule, er biphasic 30-7010 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

F$$ QL

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

F$$ QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg F$$ QL

methylphenidate hcl oral tablet extended release 10 mg, 20 mg

F$$ QL

methylphenidate hcl oral tablet extended release 24hr18 mg, 27 mg, 36 mg, 54 mg

F$$ QL

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG

F$$$ QL

QUILLIVANT XR 25 MG/5 ML SUSP 300 MG F$$$ QL


15





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

F$$$ QL

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

F$$$ QL

Bipolar Disorder

divalproex oral F$$

lithium carbonate oral F$$

lithium citrate oral solution 8 meq/5 ml F$$

Depression, Atypical Antidepressants

bupropion hcl oral F$$

mirtazapine oral tablet F$$

Depression, Maois

EMSAM TRANSDERMAL F$$$ PA

phenelzine oral F$$

tranylcypromine oral F$$

Depression, Serotonin Modulators

nefazodone oral F$$

trazodone oral F$

Depression, Snris

desvenlafaxine succinate oral F$$

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

F$$

venlafaxine oral capsule,extended release 24hr F$$

venlafaxine oral tablet F$$

Depression, Ssris

citalopram oral solution F$$

citalopram oral tablet F$

escitalopram oxalate oral solution F$$

escitalopram oxalate oral tablet F$

fluoxetine oral capsule F$

fluoxetine oral solution F$$

fluvoxamine oral tablet F$$

paroxetine hcl oral tablet F$

PAXIL ORAL SUSPENSION F$$$

sertraline oral concentrate F$$

sertraline oral tablet F$


16


Depression, Tricyclic & Tetracyclic Antidepressants

amitriptyline oral F$$ AE

clomipramine oral F$$ AE

desipramine oral F$$

doxepin oral F$$ AE

imipramine hcl oral F$$ AE

nortriptyline oral F$$

Birth Control

Contraceptives, Other

NUVARING VAGINAL F$$$

xulane transdermal F$$

Emergency Contraception

ELLA ORAL F$$$

levonorgestrel oral tablet 1.5 mg F$$

my way oral F$$

next choice one dose oral F$$

Oral Contraceptives

altavera (28) oral F$$

alyacen 1/35 (28) oral F$$

alyacen 7/7/7 (28) oral F$$

apri oral F$$

aranelle (28) oral F$$

aubra oral F$$

aviane oral F$$

azurette (28) oral F$$

balziva (28) oral F$$

blisovi fe 1.5/30 (28) oral F$$

blisovi fe 1/20 (28) oral F$$

brevicon (28) oral F$$

briellyn oral F$$

camila oral F$$

caziant (28) oral F$$

chateal oral F$$

cryselle (28) oral F$$

cyclafem 1/35 (28) oral F$$

cyclafem 7/7/7 (28) oral F$$

dasetta 1/35 (28) oral F$$


17


dasetta 7/7/7 (28) oral F$$

desogestrel-ethinyl estradiol oral F$$

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg F$$

elinest oral F$$

emoquette oral F$$

enpresse oral F$$

enskyce oral F$$

errin oral F$$

estarylla oral F$$

falmina (28) oral F$$

gianvi (28) oral F$$

gildagia oral F$$

gildess 1.5/30 (21) oral F$$

gildess 1/20 (21) oral F$$

gildess fe 1.5/30 (28) oral F$$

gildess fe 1/20 (28) oral F$$

heather oral F$$

introvale oral F$$

jencycla oral F$$

jolessa oral F$$

jolivette oral F$$

junel 1.5/30 (21) oral F$$

junel 1/20 (21) oral F$$

junel fe 1.5/30 (28) oral F$$

junel fe 1/20 (28) oral F$$

kariva (28) oral F$$

kelnor 1/35 (28) oral F$$

kurvelo oral F$$

larin 1/20 (21) oral F$$

larin fe 1.5/30 (28) oral F$$

larin fe 1/20 (28) oral F$$

leena 28 oral F$$

lessina oral F$$

levonest (28) oral F$$

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

F$$

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

F$$

levora-28 oral F$$


18


loryna (28) oral F$$

low-ogestrel (28) oral F$$

lutera (28) oral F$$

lyza oral F$$

marlissa oral F$$

microgestin 1.5/30 (21) oral F$$

microgestin 1/20 (21) oral F$$

microgestin fe 1.5/30 (28) oral F$$

microgestin fe 1/20 (28) oral F$$

mono-linyah oral F$$

mononessa (28) oral F$$

myzilra oral F$$

necon 0.5/35 (28) oral F$$

necon 1/35 (28) oral F$$



necon 7/7/7 (28) oral F$$

nora-be oral F$$

norethindrone (contraceptive) oral F$$

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

F$$

norgestimate-ethinyl estradiol oral F$$

norinyl 1/35 (28) oral F$$

nortrel 0.5/35 (28) oral F$$

nortrel 1/35 (21) oral F$$

nortrel 1/35 (28) oral F$$

nortrel 7/7/7 (28) oral F$$

ocella oral F$$

ogestrel (28) oral F$$

orsythia oral F$$

philith oral F$$

pimtrea (28) oral F$$

pirmella oral F$$

portia oral F$$

previfem oral F$$

quasense oral F$$

reclipsen (28) oral F$$

sprintec (28) oral F$$


19


sronyx oral F$$

syeda oral F$$

tilia fe oral F$$

tri-estarylla oral F$$

tri-legest fe oral F$$

tri-linyah oral F$$

tri-lo-estarylla oral F$$

tri-lo-sprintec oral F$$

trinessa (28) oral F$$

trinessa lo oral F$$

tri-previfem (28) oral F$$

tri-sprintec (28) oral F$$

trivora (28) oral F$$

velivet triphasic regimen (28) oral F$$

vestura (28) oral F$$

viorele (28) oral F$$

vyfemla (28) oral F$$

wera (28) oral F$$

zarah oral F$$

zenchent (28) oral F$$

zovia 1/35e (28) oral F$$

zovia 1/50e (28) oral F$$

Bleeding Disorders

Bleeding Disorders, Hemophilia

STIMATE NASAL F$$$ PA

Bleeding Disorders, Other

AMICAR ORAL SOLUTION F$$$

AMICAR ORAL TABLET 500 MG F$$$

Blood Modifier

Blood Modifiers

ARANESP (IN POLYSORBATE) INJECTION F$$$ Specialty

GRANIX SUBCUTANEOUS F$$$ Specialty; ONC

LEUKINE INJECTION RECON SOLN F$$$ Specialty

NEULASTA SUBCUTANEOUS F$$$ Specialty

NEUPOGEN INJECTION F$$$ Specialty

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

F$$$ Specialty


20


PROMACTA ORAL F$$$ PA; Specialty

REBINYN INTRAVENOUS F$$$ Specialty

ZARXIO INJECTION F$$$ Specialty

Clotting Disorders

ADVATE INTRAVENOUS F$$$ Specialty

ADYNOVATE INTRAVENOUS F$$$ Specialty

AFSTYLA INTRAVENOUS F$$$ Specialty

ALPHANATE INTRAVENOUS F$$$ Specialty

ALPHANINE SD INTRAVENOUS F$$$ Specialty

ALPROLIX INTRAVENOUS F$$$ Specialty

BEBULIN INTRAVENOUS F$$$ Specialty

BENEFIX INTRAVENOUS F$$$ Specialty

COAGADEX INTRAVENOUS F$$$ Specialty

CORIFACT INTRAVENOUS F$$$ Specialty

ELOCTATE INTRAVENOUS F$$$ Specialty

FEIBA NF INTRAVENOUS F$$$ Specialty

HELIXATE FS INTRAVENOUS F$$$ Specialty

HEMOFIL M HIGH INTRAVENOUS F$$$ Specialty

HEMOFIL M LOW INTRAVENOUS F$$$ Specialty

HEMOFIL M MID INTRAVENOUS F$$$ Specialty

HEMOFIL M SUPER HIGH INTRAVENOUS F$$$ Specialty

HUMATE-P INTRAVENOUS F$$$ Specialty

IDELVION INTRAVENOUS F$$$ Specialty

IXINITY INTRAVENOUS F$$$ Specialty

KOATE-DVI INTRAVENOUS RECON SOLN F$$$ Specialty

KOGENATE FS INTRAVENOUS F$$$ Specialty

KOVALTRY INTRAVENOUS F$$$ Specialty

MONOCLATE-P INTRAVENOUS F$$$ Specialty

NOVOEIGHT INTRAVENOUS F$$$ Specialty

NOVOSEVEN RT INTRAVENOUS F$$$ Specialty

NUWIQ INTRAVENOUS F$$$ Specialty

OBIZUR INTRAVENOUS F$$$ Specialty

PLASMANATE INTRAVENOUS F$$$ Specialty

PROFILNINE INTRAVENOUS F$$$ Specialty

RECOMBINATE INTRAVENOUS F$$$ Specialty

RIXUBIS INTRAVENOUS F$$$ Specialty

THROMBATE III INTRAVENOUS F$$$ Specialty

TRETTEN INTRAVENOUS F$$$ Specialty


21


VONVENDI INTRAVENOUS F$$$ Specialty

WILATE INTRAVENOUS F$$$ Specialty

XYNTHA INTRAVENOUS F$$$ Specialty

XYNTHA SOLOFUSE INTRAVENOUS F$$$ Specialty

Blood Thinner

Anticoagulants

ELIQUIS ORAL F$$$

enoxaparin subcutaneous F$$ QL

fondaparinux subcutaneous F$$ PA

heparin (porcine) injection cartridge F$$

heparin (porcine) injection solution F$$

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

heparin, porcine (pf) injection syringe F$$

jantoven oral F$

PRADAXA ORAL F$$$ PA

warfarin oral F$

XARELTO ORAL F$$$

Platelet Inhibitors

anagrelide oral F$$

aspirin-dipyridamole oral F$$

BRILINTA ORAL F$$$

cilostazol oral F$$

clopidogrel oral tablet 75 mg F$

dipyridamole oral F$$

pentoxifylline oral F$$

prasugrel oral F$$

ZONTIVITY ORAL F$$$ PA

Bone Health

Bone Health, Other

etidronate disodium oral F$$

Osteoporosis

alendronate oral solution F$$

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg F$

alendronate oral tablet 40 mg F$$

calcitonin (salmon) nasal F$$

FORTEO SUBCUTANEOUS F$$$ PA; Specialty

FORTICAL NASAL F$$$

ibandronate oral F$$


22


raloxifene oral F$$

risedronate oral tablet F$$ ST

TYMLOS SUBCUTANEOUS F$$$ PA; Specialty

Cancer

Cancer, Alkylating Agents

EMCYT ORAL F$$$

GLEOSTINE ORAL F$$$

HEXALEN ORAL F$$$ Specialty; ONC

LEUKERAN ORAL F$$$

MATULANE ORAL F$$$ PA; Specialty; ONC

melphalan oral F$$

MYLERAN ORAL F$$$

temozolomide oral F$$ Specialty; ONC

VALCHLOR TOPICAL F$$$ PA; Specialty; ONC; QL

Cancer, Antiandrogens

bicalutamide oral F$$

flutamide oral F$$

XTANDI ORAL F$$$ PA; Specialty; TD; ONC

ZYTIGA ORAL F$$$ PA; Specialty; TD; ONC

Cancer, Antimetabolites

capecitabine oral F$$ Specialty; ONC

hydroxyurea oral F$$

LONSURF ORAL F$$$ PA; Specialty; ONC

mercaptopurine oral F$$

TABLOID ORAL F$$$

Cancer, Aromatase Inhibitors

anastrozole oral F$

exemestane oral F$$

letrozole oral F$$

Cancer, Hdac Inhibitors

ZOLINZA ORAL F$$$ PA; Specialty; TD; ONC

Cancer, Immunosuppressives

AFINITOR DISPERZ ORAL F$$$ Specialty; TD; ONC

AFINITOR ORAL F$$$ Specialty; TD; ONC

CYCLOPHOSPHAMIDE ORAL CAPSULE F$$$





23


POMALYST ORAL F$$$ PA; Specialty; ONC

REVLIMID ORAL F$$$ Specialty; ONC

THALOMID ORAL F$$$ Specialty; ONC

Cancer, Interferons

SYLATRON SUBCUTANEOUS F$$$ Specialty; ONC

Cancer, Natural And Semi-Synthetic

etoposide oral F$$

HYCAMTIN INTRAVENOUS F$$$ Specialty; ONC

HYCAMTIN ORAL F$$$ Specialty; ONC

Cancer, Other Agents

megestrol oral tablet F$$

ODOMZO ORAL F$$$ PA; Specialty; ONC

ZEJULA ORAL F$$$ PA; Specialty; ONC

Cancer, Retinoids

tretinoin (chemotherapy) oral F$$ Specialty; ONC

Cancer, Serms

SOLTAMOX ORAL F$$$

tamoxifen oral F$$

Cancer, Signal Transduction Inhibitors

ALECENSA ORAL F$$$ PA; Specialty

BOSULIF ORAL F$$$ PA; Specialty; TD; ONC

CABOMETYX ORAL F$$$ PA; Specialty; TD; ONC

CAPRELSA ORAL F$$$ Specialty; ONC

COMETRIQ ORAL F$$$ PA; Specialty; ONC

COTELLIC ORAL F$$$ PA; Specialty; ONC

ERIVEDGE ORAL F$$$ PA; Specialty; TD; ONC

GILOTRIF ORAL F$$$ PA; Specialty; ONC

IBRANCE ORAL F$$$ PA; Specialty; ONC

ICLUSIG ORAL F$$$ PA; Specialty; ONC

IDHIFA ORAL F$$$ PA; Specialty; ONC

imatinib oral F$$ Specialty; TD; ONC

IMBRUVICA ORAL F$$$ PA; Specialty; ONC

INLYTA ORAL F$$$ PA; Specialty; TD; ONC

IRESSA ORAL F$$$ PA; Specialty; TD; ONC

JAKAFI ORAL F$$$ PA; Specialty; TD; ONC

KISQALI FEMARA CO-PACK ORAL F$$$ PA; Specialty; ONC

KISQALI ORAL F$$$ PA; Specialty; ONC

MEKINIST ORAL F$$$ PA; Specialty; ONC


24


NERLYNX ORAL F$$$ PA; Specialty; ONC

NEXAVAR ORAL F$$$ Specialty; TD; ONC

NINLARO ORAL F$$$ PA; Specialty; ONC

RYDAPT ORAL F$$$ PA; Specialty; ONC

SPRYCEL ORAL F$$$ Specialty; TD; ONC

STIVARGA ORAL F$$$ PA; Specialty; ONC

SUTENT ORAL F$$$ Specialty; TD; ONC

TAFINLAR ORAL F$$$ PA; Specialty; ONC

TARCEVA ORAL F$$$ Specialty; TD; ONC

TASIGNA ORAL F$$$ Specialty; TD; ONC

TYKERB ORAL F$$$ Specialty; ONC

VERZENIO ORAL F$$$ PA; Specialty; ONC

VOTRIENT ORAL F$$$ Specialty; TD; ONC

XALKORI ORAL F$$$ PA; Specialty; TD; ONC

ZELBORAF ORAL F$$$ PA; Specialty; ONC

ZYKADIA ORAL F$$$ PA; Specialty; TD; ONC

Corticosteroids

Corticosteroids, Injectable

dexamethasone sodium phosphate injection solution4 mg/ml

F$$

Corticosteroids, Oral

DEXAMETHASONE INTENSOL ORAL F$$$

dexamethasone oral elixir F$$

dexamethasone oral solution F$$

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg

F$

dexamethasone oral tablet 2 mg F$$

fludrocortisone oral F$$

hydrocortisone oral F$$

MEDROL ORAL TABLET 2 MG F$$$

methylprednisolone oral F$$

MILLIPRED ORAL TABLET F$$$

prednisolone oral solution 15 mg/5 ml F$$

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

F$$

PREDNISONE INTENSOL ORAL F$$$

prednisone oral solution F$$

prednisone oral tablet F$


25


prednisone oral tablets,dose pack F$

Cough & Cold

Cough & Cold

benzonatate oral capsule 100 mg, 200 mg F$$

codeine-guaifenesin oral F$$ QL; AE

promethazine vc oral F$

promethazine-dm oral F$

Cystic Fibrosis

Cystic Fibrosis

acetylcysteine F$$

CAYSTON INHALATION F$$$ PA; Specialty

KALYDECO ORAL F$$$ PA; Specialty

ORKAMBI ORAL F$$$ PA; Specialty

PULMOZYME INHALATION F$$$ PA; Specialty; QL

tobramycin in 0.225 % nacl inhalation F$$ PA; Specialty

Dementia

Dementia

donepezil oral tablet 10 mg, 5 mg F$$

donepezil oral tablet,disintegrating F$$

galantamine oral F$$

memantine oral solution F$$

memantine oral tablet F$$

memantine oral tablets,dose pack F$$

rivastigmine tartrate oral F$$

rivastigmine transdermal F$$

Diabetes

Diabetes, Alpha-Glucosidase Inhibitors

acarbose oral F$$

miglitol oral F$$

Diabetes, Biguanides

metformin oral tablet F$

metformin oral tablet extended release 24 hr F$

Diabetes, Dpp-4 Inhibitor / Biguanide Combinations

JENTADUETO ORAL F$$$

JENTADUETO XR ORAL F$$$

Diabetes, Dpp-4 Inhibitors

TRADJENTA ORAL F$$$


26


Diabetes, Glp-1 Agonists

BYDUREON BCISE SUBCUTANEOUS F$$$ QL

BYDUREON SUBCUTANEOUS F$$$ QL

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML

F$$$ QL

TRULICITY SUBCUTANEOUS F$$$ QL

VICTOZA 2-PAK SUBCUTANEOUS F$$$ QL

VICTOZA 3-PAK SUBCUTANEOUS F$$$ QL

Diabetes, Intermediate-Acting Insulins

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS

F$$$

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS F$$$

Diabetes, Long-Acting Insulins

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS

F$$$

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS

F$$$ ST

LEVEMIR U-100 INSULIN SUBCUTANEOUS F$$$ ST

Diabetes, Meglitinides

nateglinide oral F$$

repaglinide oral F$$

Diabetes, Other Oral Agents

CYCLOSET ORAL F$$$ PA

Diabetes, Pre-Mixed Insulins

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS

F$$$

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS F$$$

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS F$$$

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS

F$$$

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS F$$$

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS F$$$

Diabetes, Rapid-Acting Insulins

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS F$$$

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS F$$$

HUMALOG U-100 INSULIN SUBCUTANEOUS F$$$

Diabetes, Rescue Agents

GLUCAGEN HYPOKIT INJECTION F$$$


27


GLUCAGEN INJECTION F$$$

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION F$$$

Diabetes, Sglt2 Inhibitor / Biguanide Combinations

INVOKAMET ORAL F$$$ ST

INVOKAMET XR ORAL F$$$ ST

SYNJARDY ORAL F$$$ ST

SYNJARDY XR ORAL F$$$ ST

Diabetes, Sglt2 Inhibitors

INVOKANA ORAL F$$$ ST

JARDIANCE ORAL F$$$ ST

Diabetes, Short-Acting Insulins

HUMULIN R REGULAR U-100 INSULN INJECTION F$$$

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS F$$$

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS

F$$$

Diabetes, Sulfonylurea / Biguanide Combination

glipizide-metformin oral F$$

Diabetes, Sulfonylureas

glimepiride oral F$

glipizide oral tablet F$

glipizide oral tablet extended release 24hr F$$

glyburide micronized oral F$$ GE Female; AE

glyburide oral F$$ GE Female; AE

Diabetes, Thiazolidinedione / Biguanide Combinations

pioglitazone-metformin oral F$$

Diabetes, Thiazolidinedione / Sulfonylurea Combinations

pioglitazone-glimepiride oral F$$

Diabetes, Thiazolidinediones

pioglitazone oral F$

Ear Conditions

Anti-Infectives, Ear

acetic acid otic (ear) F$$

CIPRO HC OTIC (EAR) F$$$

CIPRODEX OTIC (EAR) F$$$

neomycin-polymyxin-hc otic (ear) F$$


28


ofloxacin otic (ear) F$$

Ear Conditions, Other

fluocinolone acetonide oil otic (ear) F$$

Enzyme Replacement

Enzyme Replacement

CERDELGA ORAL F$$$ PA; Specialty

CREON ORAL F$$$

STRENSIQ SUBCUTANEOUS F$$$ PA; Specialty

SUCRAID ORAL F$$$ PA; Specialty

ZAVESCA ORAL F$$$ PA; Specialty

Eye Conditions

Anti-Infectives, Eye

AZASITE OPHTHALMIC (EYE) F$$$

bacitracin ophthalmic (eye) F$$

bacitracin-polymyxin b ophthalmic (eye) F$$

BESIVANCE OPHTHALMIC (EYE) F$$$ PA

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) F$$$

CILOXAN OPHTHALMIC (EYE) OINTMENT F$$$

ciprofloxacin hcl ophthalmic (eye) F$$

erythromycin ophthalmic (eye) F$$

gatifloxacin ophthalmic (eye) F$$

gentamicin ophthalmic (eye) ointment F$$

moxifloxacin ophthalmic (eye) F$$

neomycin-bacitracin-polymyxin ophthalmic (eye) F$$

neomycin-polymyxin b-dexameth ophthalmic (eye) F$$

neomycin-polymyxin-gramicidin ophthalmic (eye) F$$

ofloxacin ophthalmic (eye) F$$

polymyxin b sulf-trimethoprim ophthalmic (eye) F$$

sulfacetamide sodium ophthalmic (eye) F$$

sulfacetamide-prednisolone ophthalmic (eye) F$$

TOBRADEX OPHTHALMIC (EYE) OINTMENT F$$$

tobramycin ophthalmic (eye) F$$

tobramycin-dexamethasone ophthalmic (eye) F$$

TOBREX OPHTHALMIC (EYE) OINTMENT F$$$

trifluridine ophthalmic (eye) F$$

ZIRGAN OPHTHALMIC (EYE) F$$$

Anti-Inflammatories, Eye

ACUVAIL (PF) OPHTHALMIC (EYE) F$$$ PA


29


bromfenac ophthalmic (eye) F$$

dexamethasone sodium phosphate ophthalmic (eye) F$$

diclofenac sodium ophthalmic (eye) F$$

fluorometholone ophthalmic (eye) F$$

flurbiprofen sodium ophthalmic (eye) F$

FML S.O.P. OPHTHALMIC (EYE) F$$$

ILEVRO OPHTHALMIC (EYE) F$$$

ketorolac ophthalmic (eye) F$$

LOTEMAX OPHTHALMIC (EYE) F$$$

NEVANAC OPHTHALMIC (EYE) F$$$

PRED FORTE OPHTHALMIC (EYE) F$$$

PRED MILD OPHTHALMIC (EYE) F$$$

prednisolone acetate ophthalmic (eye) F$$

prednisolone sodium phosphate ophthalmic (eye) F$$

PROLENSA OPHTHALMIC (EYE) F$$$

Eye Conditions, Other

atropine ophthalmic (eye) F$$

cyclopentolate ophthalmic (eye) drops 1 %, 2 % F$$

CYSTARAN OPHTHALMIC (EYE) F$$$ PA; Specialty

homatropaire ophthalmic (eye) F$$

LACRISERT OPHTHALMIC (EYE) F$$$

phenylephrine hcl ophthalmic (eye) F$$

RESTASIS MULTIDOSE OPHTHALMIC (EYE) F$$$

RESTASIS OPHTHALMIC (EYE) F$$$

Glaucoma

acetazolamide oral F$$

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % F$$$

AZOPT OPHTHALMIC (EYE) F$$$

betaxolol ophthalmic (eye) F$$

BETOPTIC S OPHTHALMIC (EYE) F$$$

bimatoprost ophthalmic (eye) F$$

brimonidine ophthalmic (eye) F$$

carteolol ophthalmic (eye) F$

COMBIGAN OPHTHALMIC (EYE) F$$$

COSOPT (PF) OPHTHALMIC (EYE) F$$$ PA

dorzolamide ophthalmic (eye) F$$

dorzolamide-timolol ophthalmic (eye) F$$

latanoprost ophthalmic (eye) F$$


30


levobunolol ophthalmic (eye) drops 0.5 % F$$

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % F$$$

methazolamide oral F$$

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) F$$$

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % F$$

SIMBRINZA OPHTHALMIC (EYE) F$$$

timolol maleate ophthalmic (eye) drops F$

timolol maleate ophthalmic (eye) gel forming solution F$$

TRAVATAN Z OPHTHALMIC (EYE) F$$$

travoprost (benzalkonium) ophthalmic (eye) F$$

ZIOPTAN (PF) OPHTHALMIC (EYE) F$$$ PA

Gout

Gout

allopurinol oral F$$

colchicine oral F$$

probenecid oral F$$

probenecid-colchicine oral F$$

ULORIC ORAL F$$$ ST

Heart Health

Angina

ISORDIL ORAL F$$$

isosorbide dinitrate oral F$$

isosorbide mononitrate oral tablet F$

isosorbide mononitrate oral tablet extended release 24 hr

F$$

NITRO-BID TRANSDERMAL F$$$

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

F$$$

nitroglycerin sublingual F$$

nitroglycerin transdermal patch 24 hour F$$

Antiarrhythmics

amiodarone oral F$$

disopyramide phosphate oral capsule F$$

dofetilide oral F$$

flecainide oral F$$

mexiletine oral F$$

MULTAQ ORAL F$$$ PA

NORPACE CR ORAL F$$$


31


propafenone oral tablet F$$

quinidine gluconate oral F$$

quinidine sulfate oral F$$

sotalol af oral F$$

sotalol oral F$$

Blood Pressure, Acei & Arb

amlodipine-benazepril oral F$$

amlodipine-valsartan oral F$$

amlodipine-valsartan-hcthiazid oral F$$ ST

benazepril oral F$

benazepril-hydrochlorothiazide oral F$$

captopril oral F$$

captopril-hydrochlorothiazide oral F$$

enalapril maleate oral F$$

enalapril-hydrochlorothiazide oral F$

fosinopril oral F$

fosinopril-hydrochlorothiazide oral F$$

irbesartan oral F$$

irbesartan-hydrochlorothiazide oral F$$

lisinopril oral F$

lisinopril-hydrochlorothiazide oral F$

losartan oral F$

losartan-hydrochlorothiazide oral F$

moexipril oral F$$

moexipril-hydrochlorothiazide oral F$$

olmesartan oral F$$

olmesartan-hydrochlorothiazide oral F$$

perindopril erbumine oral F$$

quinapril oral F$

quinapril-hydrochlorothiazide oral F$$

ramipril oral F$

trandolapril oral F$$

valsartan oral F$$

valsartan-hydrochlorothiazide oral F$$

Blood Pressure, Beta Blockers

atenolol oral F$

atenolol-chlorthalidone oral F$$

bisoprolol fumarate oral F$$


32


bisoprolol-hydrochlorothiazide oral F$

carvedilol oral F$

carvedilol phosphate oral F$$ ST

labetalol oral F$$

metoprolol succinate oral F$$

metoprolol ta-hydrochlorothiaz oral F$$

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

nadolol oral F$$

propranolol oral F$$

propranolol-hydrochlorothiazid oral F$$

Blood Pressure, Calcium Channel Blockers

amlodipine oral F$

amlodipine-benazepril oral F$$

amlodipine-valsartan oral F$$

amlodipine-valsartan-hcthiazid oral F$$ ST

cartia xt oral F$$

diltiazem hcl oral capsule,ext.rel 24h degradable F$$

diltiazem hcl oral capsule,extended release 24 hr F$$

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

F$$

diltiazem hcl oral tablet F$$

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

F$$

nifedipine oral tablet extended release F$$

nifedipine oral tablet extended release 24hr F$$

nimodipine oral F$$

taztia xt oral F$$

verapamil oral capsule,ext rel. pellets 24 hr F$$

verapamil oral tablet F$

verapamil oral tablet extended release F$$

Blood Pressure, Other

clonidine hcl oral tablet F$

clonidine transdermal F$$

doxazosin oral F$$

guanfacine oral tablet F$

hydralazine oral F$$

methyldopa oral F$$

midodrine oral F$$

minoxidil oral F$$


33


phenoxybenzamine oral F$$ PA

prazosin oral F$$

reserpine oral F$$

terazosin oral F$

Cholesterol Lowering, Bile Acid Resins

cholestyramine (with sugar) oral F$$

cholestyramine light oral F$$

colestipol oral tablet F$$

prevalite oral F$$

Cholesterol Lowering, Other

ezetimibe oral F$$

JUXTAPID ORAL F$$$ PA; Specialty

KYNAMRO SUBCUTANEOUS F$$$ PA; Specialty

REPATHA PUSHTRONEX SUBCUTANEOUS F$$$ PA; Specialty

REPATHA SURECLICK SUBCUTANEOUS F$$$ PA; Specialty

REPATHA SYRINGE SUBCUTANEOUS F$$$ PA; Specialty

Cholesterol Lowering, Statins

atorvastatin oral F$

ezetimibe-simvastatin oral F$$

lovastatin oral F$

pravastatin oral F$

rosuvastatin oral F$$

simvastatin oral tablet 10 mg, 20 mg, 5 mg F$

simvastatin oral tablet 40 mg F$ QL

simvastatin oral tablet 80 mg F$ PA

Diuretics


ALDACTAZIDE ORAL TABLET 50-50 MG F$$$

amiloride oral F$$

amiloride-hydrochlorothiazide oral F$$

bumetanide oral F$$

chlorothiazide oral F$$

chlorthalidone oral tablet 25 mg, 50 mg F$$

DIURIL ORAL F$$$

eplerenone oral F$$

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

F$

furosemide oral tablet F$


34


hydrochlorothiazide oral F$

indapamide oral F$$

metolazone oral F$$

spironolactone oral F$$

spironolacton-hydrochlorothiaz oral F$$

torsemide oral F$$

triamterene-hydrochlorothiazid oral F$

Heart Health, Other

DIGOXIN ORAL SOLUTION 50 MCG/ML F$$$

digoxin oral tablet 125 mcg F$$

digoxin oral tablet 250 mcg F$$ AE

ENTRESTO ORAL F$$$

klor-con m10 oral F$$

klor-con m15 oral F$$

KLOR-CON/25 ORAL F$$$

potassium chloride oral capsule, extended release F$$

potassium chloride oral liquid F$$

potassium chloride oral packet F$$

potassium chloride oral tablet extended release 10 meq, 8 meq

F$$

potassium chloride oral tablet,er particles/crystals F$$

potassium cl er 20 meq tablet F$$

Triglyceride Lowering

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

F$$

fenofibrate nanocrystallized oral F$$

fenofibrate oral tablet 160 mg, 54 mg F$$

gemfibrozil oral F$

omega-3 acid ethyl esters oral F$$ ST

Hereditary Angioedema

Hereditary Angioedema

BERINERT INTRAVENOUS F$$$ PA; Specialty

CINRYZE INTRAVENOUS F$$$ PA; Specialty

FIRAZYR SUBCUTANEOUS F$$$ PA; Specialty; QL

HAEGARDA SUBCUTANEOUS F$$$ PA; Specialty

KALBITOR SUBCUTANEOUS F$$$ PA; Specialty

RUCONEST INTRAVENOUS F$$$ PA; Specialty


35


Idiopathic Pulmonary Fibrosis

Idiopathic Pulmonary Fibrosis

ESBRIET ORAL F$$$ PA; Specialty

OFEV ORAL F$$$ PA; Specialty

Immune Deficiency

Immune Deficiency

BIVIGAM INTRAVENOUS F$$$ PA; Specialty

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM

F$$$ PA; Specialty

CUVITRU SUBCUTANEOUS F$$$ PA; Specialty

FLEBOGAMMA DIF INTRAVENOUS F$$$ PA; Specialty

GAMASTAN S/D INTRAMUSCULAR F$$$ PA; Specialty

GAMMAGARD LIQUID INJECTION F$$$ PA; Specialty

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS F$$$ PA; Specialty

GAMMAKED INJECTION F$$$ PA; Specialty

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS F$$$ PA; Specialty

GAMMAPLEX INTRAVENOUS F$$$ PA; Specialty

GAMUNEX-C INJECTION F$$$ PA; Specialty

HIZENTRA SUBCUTANEOUS F$$$ PA; Specialty

HYQVIA HY COMPONENT SUBCUTANEOUS F$$$ PA; Specialty

HYQVIA IG COMPONENT SUBCUTANEOUS F$$$ PA; Specialty

HYQVIA SUBCUTANEOUS F$$$ PA; Specialty

OCTAGAM INTRAVENOUS F$$$ PA; Specialty

PRIVIGEN INTRAVENOUS F$$$ PA; Specialty

Immune Suppressant

Immune Suppressant

azathioprine oral F$$

cyclosporine modified oral F$$

cyclosporine oral capsule F$$

gengraf oral capsule 100 mg, 25 mg F$$

gengraf oral solution F$$




mycophenolate mofetil oral F$$

RAPAMUNE ORAL SOLUTION F$$$

sirolimus oral F$$

tacrolimus oral F$$


36


Kidney Failure

Kidney Failure

calcium acetate oral capsule F$$

PHOSLYRA ORAL F$$$

SENSIPAR ORAL F$$$

sevelamer carbonate oral F$$

Men's Health

Benign Prostatic Hypertrophy

alfuzosin oral F$$

doxazosin oral F$$

dutasteride oral F$$

dutasteride-tamsulosin oral F$$

finasteride oral tablet 5 mg F$

prazosin oral F$$

tamsulosin oral F$$

terazosin oral F$

Sexual Dysfunction

sildenafil (antihypertensive) oral F$$ QL

Testosterone Deficiency

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

F$$$ PA; GE Male

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

F$$$ PA; GE Male

androxy oral F$$ QL

testosterone cypionate intramuscular F$$ PA; GE Male

testosterone enanthate intramuscular F$$ PA; GE Male

testosterone transdermal gel F$$ PA; GE Male

testosterone transdermal gel in metered-dose pump F$$ PA; GE Male

testosterone transdermal gel in packet F$$ PA; GE Male

Migraine

Migraine, Other

ERGOMAR SUBLINGUAL F$$$ QL

ergotamine-caffeine oral F$$ QL

isometh-dichloral-acetaminophn oral F$$ QL

nodolor oral F$$ QL

Migraine, Preventives

divalproex oral F$$

propranolol oral F$$


37


Migraine, Triptans

naratriptan oral F$$ QL

rizatriptan oral F$$ QL

sumatriptan nasal F$$ QL

sumatriptan succinate oral F$$ QL

sumatriptan succinate subcutaneous cartridge F$$ QL

sumatriptan succinate subcutaneous pen injector F$$ QL

sumatriptan succinate subcutaneous solution F$$ QL

Mouth & Throat

Dental Health

chlorhexidine gluconate mucous membrane F$

periogard mucous membrane F$$

triamcinolone acetonide dental F$$

Dry Mouth

cevimeline oral F$$

pilocarpine hcl oral F$$

Pain

lidocaine hcl mucous membrane jelly F$$

lidocaine hcl mucous membrane jelly in applicator F$$

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

F$$

lidocaine viscous mucous membrane F$$

Multiple Sclerosis

Multiple Sclerosis, Injection

AVONEX (WITH ALBUMIN) INTRAMUSCULAR F$$$ Specialty; QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT F$$$ Specialty; QL

AVONEX INTRAMUSCULAR SYRINGE KIT F$$$ Specialty; QL

EXTAVIA SUBCUTANEOUS KIT F$$$ Specialty; QL

glatiramer subcutaneous syringe 40 mg/ml F$$ Specialty; QL

glatopa subcutaneous syringe 20 mg/ml F$$ Specialty; QL

PLEGRIDY SUBCUTANEOUS F$$$ Specialty; QL

REBIF (WITH ALBUMIN) SUBCUTANEOUS F$$$ Specialty; QL

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

F$$$ Specialty; QL

REBIF TITRATION PACK SUBCUTANEOUS F$$$ Specialty; QL

Multiple Sclerosis, Oral

AMPYRA ORAL F$$$ PA; Specialty


38


AUBAGIO ORAL F$$$ Specialty; QL

GILENYA ORAL F$$$ Specialty; QL

TECFIDERA ORAL F$$$ Specialty; QL

Muscle Relaxant

Muscle Relaxants

baclofen oral F$$

chlorzoxazone oral tablet 500 mg F$$ AE

cyclobenzaprine oral tablet 10 mg, 5 mg F$ AE

dantrolene oral F$$

methocarbamol oral F$$ AE

tizanidine oral tablet F$$

Other Conditions

Other Agents

ACTHAR H.P. INJECTION F$$$ PA; Specialty

ALFERON N INJECTION F$$$ Specialty

ARCALYST SUBCUTANEOUS F$$$ PA; Specialty

AUSTEDO ORAL F$$$ PA; Specialty

CARNITOR (SUGAR-FREE) ORAL F$$$

CHEMET ORAL F$$$

CYSTAGON ORAL F$$$

desmopressin nasal F$$ PA

desmopressin oral F$$ AE

EXJADE ORAL F$$$ PA; Specialty; TD

FERRIPROX ORAL F$$$ PA; Specialty

ILARIS (PF) SUBCUTANEOUS F$$$ PA; Specialty

INGREZZA ORAL F$$$ PA; Specialty

JADENU ORAL F$$$ PA; Specialty; TD

JADENU SPRINKLE ORAL F$$$ PA; Specialty; TD

kionex oral F$$

KUVAN ORAL F$$$ PA; Specialty

leucovorin calcium oral F$$

levocarnitine (with sugar) oral F$$

levocarnitine oral tablet F$$

megestrol oral suspension 400 mg/10 ml (40 mg/ml) F$$

nifedipine oral capsule F$$ GE Female; AE

octreotide acetate injection F$$ Specialty

pyridostigmine bromide oral F$$

riluzole oral F$$


39


SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

F$$$ Specialty

SIGNIFOR SUBCUTANEOUS F$$$ PA; Specialty

sodium phenylbutyrate oral powder F$$ PA

sodium polystyrene (sorb free) oral F$$

sodium polystyrene sulfonate oral F$$

tetrabenazine oral F$$ PA; Specialty

VISTOGARD ORAL F$$$ PA; Specialty

Pain

Fibromyalgia / Neuropathic Pain

gabapentin oral capsule 100 mg, 300 mg, 400 mg F$$ QL

gabapentin oral solution F$$ QL

gabapentin oral tablet 600 mg, 800 mg F$$ QL

lidocaine topical adhesive patch,medicated F$$ PA; QL

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

F$$$ ST; QL

LYRICA ORAL SOLUTION F$$$ ST; QL

SAVELLA ORAL F$$$ ST

Non-Steroidal Anti-Inflammatories

celecoxib oral F$$

diclofenac potassium oral F$$

diclofenac sodium oral F$$

etodolac oral F$$

flurbiprofen oral F$$

ibuprofen oral tablet 400 mg, 600 mg, 800 mg F$

INDOCIN ORAL F$$$ QL; AE

indomethacin oral capsule F$ QL; AE

ketorolac oral F$$ QL

meloxicam oral F$

nabumetone oral F$$

naproxen oral suspension F$$

naproxen oral tablet F$

naproxen oral tablet,delayed release (dr/ec) F$$

piroxicam oral F$$

salsalate oral F$$

sulindac oral F$$

Pain, Opioids

acetaminophen-codeine oral solution 120-12 mg/5 ml F$ QL; AE


40


acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml

F$$ QL; AE

acetaminophen-codeine oral tablet F$$ QL; AE

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg

F$$ QL

codeine sulfate oral tablet F$$ QL; AE

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg F$$ QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour

F$$ PA

fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr

F$$ QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

F$$ QL

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

F$$ QL

hydrocodone-ibuprofen oral tablet 7.5-200 mg F$$ QL

hydromorphone oral liquid F$$ QL

hydromorphone oral tablet 2 mg, 4 mg, 8 mg F$$ QL

hydromorphone rectal F$$ QL

methadone oral concentrate F$$ QL

methadone oral solution 10 mg/5 ml, 5 mg/5 ml F$$ QL

methadone oral tablet 10 mg, 5 mg F$$ QL

methadone oral tablet,soluble F$$ PA

morphine concentrate oral solution F$$ QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

F$$ QL

MORPHINE ORAL TABLET 15 MG, 30 MG F$$$ QL

morphine oral tablet extended release 100 mg, 200 mg, 60 mg

F$$ PA

morphine oral tablet extended release 15 mg, 30 mg F$$ QL

morphine rectal F$$ QL

oxycodone oral capsule F$$ QL

oxycodone oral concentrate F$$ QL

oxycodone oral solution F$$ QL

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg F$$ QL

oxycodone oral tablet 30 mg F$$ PA

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg

F$$ QL

oxycodone oral tablet,oral only,ext.rel.12 hr 40 mg, 60 mg, 80 mg

F$$ PA


41


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

F$$ QL

oxycodone-aspirin oral F$$ QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG

F$$$ QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG

F$$$ PA

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

F$$$ QL

Pain, Other

butalbital-acetaminophen oral tablet 50-325 mg F$$ QL

butalbital-acetaminophen-caff oral capsule 50-325-40 mg

F$$ QL

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

F$$ QL

butalbital-aspirin-caffeine oral capsule F$$ QL

tramadol oral tablet F$ QL

Pain, Topical

diclofenac sodium topical gel 1 % F$$

lidocaine-prilocaine topical cream F$$ QL

Parkinson's

Parkinson's

amantadine hcl oral F$$

benztropine oral F$$

bromocriptine oral F$$

carbidopa oral F$$

carbidopa-levodopa oral F$$

carbidopa-levodopa-entacapone oral F$$

entacapone oral F$$

NEUPRO TRANSDERMAL F$$$ PA

pramipexole oral tablet F$$

pramipexole oral tablet extended release 24 hr F$$ PA

rasagiline oral F$$ PA

ropinirole oral tablet F$$

ropinirole oral tablet extended release 24 hr F$$ PA

RYTARY ORAL F$$$ PA

selegiline hcl oral F$$

trihexyphenidyl oral F$$


42


Pulmonary Hypertension

Pulmonary Hypertension

ADEMPAS ORAL F$$$ PA; Specialty

epoprostenol (glycine) intravenous recon soln 1.5 mg F$$ PA; Specialty

FLOLAN INTRAVENOUS RECON SOLN 1.5 MG F$$$ PA; Specialty

LETAIRIS ORAL F$$$ PA; Specialty

OPSUMIT ORAL F$$$ PA; Specialty

REMODULIN INJECTION F$$$ PA; Specialty

sildenafil (antihypertensive) oral F$$ PA; QL

TRACLEER ORAL F$$$ PA; Specialty

TYVASO INHALATION F$$$ PA; Specialty

TYVASO REFILL KIT INHALATION F$$$ PA; Specialty

TYVASO STARTER KIT INHALATION F$$$ PA; Specialty

UPTRAVI ORAL F$$$ PA; Specialty

VELETRI INTRAVENOUS F$$$ PA; Specialty

VENTAVIS INHALATION F$$$ PA; Specialty

Seizures / Epilepsy

Seizures / Epilepsy


APTIOM ORAL F$$$ PA

BANZEL ORAL SUSPENSION F$$$ PA; QL

BANZEL ORAL TABLET 200 MG, 400 MG F$$$ PA; QL

BRIVIACT ORAL F$$$ PA

carbamazepine oral capsule, er multiphase 12 hr F$$

carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml)

F$$

carbamazepine oral tablet F$$

carbamazepine oral tablet extended release 12 hr F$$

carbamazepine oral tablet,chewable F$$

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

F$$ QL

diazepam intensol oral F$$ QL

diazepam oral solution 5 mg/5 ml (1 mg/ml) F$$ QL

diazepam oral tablet 10 mg, 2 mg, 5 mg F$ QL

diazepam rectal F$$ QL

DILANTIN KAPSEAL ORAL CAPSULE 30 MG F$$$

DILANTIN ORAL F$$$


43


divalproex oral F$$

ethosuximide oral F$$

felbamate oral F$$

FYCOMPA ORAL SUSPENSION F$$$ PA

FYCOMPA ORAL TABLET F$$$ PA

gabapentin oral capsule 100 mg, 300 mg, 400 mg F$$ QL

gabapentin oral solution F$$ QL

gabapentin oral tablet 600 mg, 800 mg F$$ QL

GABITRIL ORAL TABLET 12 MG, 16 MG F$$$

lamotrigine oral tablet F$$

lamotrigine oral tablet disintegrating, dose pk F$$ PA

lamotrigine oral tablet, chewable dispersible F$$

lamotrigine oral tablet,disintegrating F$$ PA

levetiracetam oral solution 100 mg/ml F$$

levetiracetam oral tablet F$$

levetiracetam oral tablet extended release 24 hr F$$

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

F$$$ ST; QL

LYRICA ORAL SOLUTION F$$$ ST; QL

ONFI ORAL SUSPENSION F$$$ QL

ONFI ORAL TABLET 10 MG, 20 MG F$$$ QL

oxcarbazepine oral F$$

phenobarbital oral elixir F$$

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60 mg

F$$

phenytoin oral suspension 125 mg/5 ml F$$

phenytoin oral tablet,chewable F$$

phenytoin sodium extended oral F$$

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG

F$$$ QL

primidone oral F$$

SABRIL ORAL TABLET F$$$ PA; Specialty

tiagabine oral tablet 2 mg, 4 mg F$$

topiramate oral capsule, sprinkle F$$

topiramate oral tablet F$

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)

F$$

valproic acid oral F$$

VIGABATRIN ORAL F$$$ PA; Specialty


44


VIMPAT ORAL SOLUTION F$$$ QL

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

F$$$ QL

zonisamide oral F$$

Skin Conditions

Acne, Oral

amnesteem oral F$$

claravis oral F$$

myorisan oral capsule 10 mg, 20 mg, 40 mg F$$

zenatane oral capsule 10 mg, 20 mg, 40 mg F$$

Acne, Topical

ACZONE TOPICAL GEL WITH PUMP F$$$ PA

adapalene topical cream F$$

adapalene topical gel 0.3 % F$$

adapalene topical gel with pump F$$

avita topical F$$

clindamycin phosphate topical gel F$$

clindamycin phosphate topical lotion F$$

clindamycin phosphate topical solution F$$

clindamycin phosphate topical swab F$$

DAPSONE TOPICAL F$$$ PA

DIFFERIN 0.1% GEL (OTC) F$$$

erythromycin with ethanol topical gel F$$

erythromycin with ethanol topical solution F$$

sulfacetamide sodium (acne) topical F$$

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

F$$

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w)

F$$

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

F$$

sulfacetamide sod-sulfur-urea topical cleanser F$$

tretinoin topical cream F$$

tretinoin topical gel 0.01 %, 0.025 % F$$

Antifungals, Topical

ciclopirox topical cream F$$

ciclopirox topical gel F$$

ciclopirox topical solution F$$

ciclopirox topical suspension F$$


45


ketoconazole topical cream F$$

ketoconazole topical shampoo F$$

nystatin topical F$$

Anti-Infectives, Topical

ALTABAX TOPICAL F$$$ ST

gentamicin topical F$$

mupirocin calcium topical F$$

mupirocin topical F$$

silver sulfadiazine topical F$$

Corticosteroids, Topical

alclometasone topical F$$

betamethasone dipropionate topical F$$

betamethasone valerate topical cream F$$

betamethasone valerate topical lotion F$$

betamethasone valerate topical ointment F$$

betamethasone, augmented topical F$$

clobetasol scalp F$$

clobetasol topical cream F$$

clobetasol topical gel F$$

clobetasol topical ointment F$$

clobetasol-emollient topical cream F$$

CORDRAN TAPE LARGE ROLL TOPICAL F$$$ PA

CORDRAN TAPE SMALL ROLL TOPICAL F$$$ PA

desonide topical F$$

desoximetasone topical cream F$$

desoximetasone topical gel F$$

desoximetasone topical ointment 0.25 % F$$

fluocinolone and shower cap scalp F$$

fluocinolone topical cream F$$

fluocinolone topical oil F$$

fluocinolone topical ointment F$$

fluocinonide topical cream 0.05 % F$$

fluocinonide topical gel F$$

fluocinonide topical ointment F$$

fluocinonide topical solution F$$

fluocinonide-e topical F$$

fluticasone topical cream F$$

fluticasone topical ointment F$$


46


hydrocortisone topical cream 2.5 % F$$

hydrocortisone topical lotion 2.5 % F$$

hydrocortisone topical ointment 2.5 % F$

hydrocortisone valerate topical F$$

hydrocortisone-pramoxine topical F$$

iodoquinol-hc topical F$$

mometasone topical F$$

triamcinolone acetonide topical cream F$$

triamcinolone acetonide topical lotion F$$

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

F$$

trianex topical F$$

triderm topical cream F$$

Lice / Scabies, Topical

EURAX TOPICAL F$$$

malathion topical F$$

permethrin topical cream F$$

Psoriasis, Other

acitretin oral F$$

COSENTYX PEN SUBCUTANEOUS F$$$ PA; Specialty

COSENTYX SUBCUTANEOUS F$$$ PA; Specialty

ENBREL MINI SUBCUTANEOUS F$$$ PA; Specialty

ENBREL SUBCUTANEOUS F$$$ PA; Specialty

ENBREL SURECLICK SUBCUTANEOUS F$$$ PA; Specialty






Psoriasis, Topical

calcipotriene scalp F$$

calcipotriene topical ointment F$$

calcitriol topical F$$ PA

DRITHOCREME HP TOPICAL F$$$

ENSTILAR TOPICAL F$$$ PA

TACLONEX TOPICAL SUSPENSION F$$$ PA

tazarotene topical F$$ QL

TAZORAC TOPICAL CREAM 0.05 % F$$$ QL


47


TAZORAC TOPICAL GEL F$$$ QL

Rosacea

FINACEA TOPICAL F$$$

metronidazole topical cream F$$

metronidazole topical gel F$$

metronidazole topical lotion F$$

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

F$$

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w)

F$$

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

F$$

sulfacetamide sod-sulfur-urea topical cleanser F$$

Skin Conditions, Other

ammonium lactate topical F$$

CONDYLOX TOPICAL GEL F$$$

DRYSOL DAB-O-MATIC TOPICAL F$$$

DRYSOL TOPICAL F$$$

DUPIXENT SUBCUTANEOUS F$$$ PA; Specialty

ELIDEL TOPICAL F$$$

EUCRISA TOPICAL F$$$ PA; QL

FLUOROPLEX TOPICAL F$$$

fluorouracil topical cream 5 % F$$

fluorouracil topical solution F$$

granulex topical F$$

imiquimod topical F$$

OXSORALEN TOPICAL F$$$

PICATO TOPICAL F$$$ PA

podofilox topical F$$

selenium sulfide topical lotion F$$

tacrolimus topical F$$

urea topical cream 40 % F$$

urea topical gel 40 % F$$

urea topical lotion 40 % F$$

urea topical nail film suspension F$$

Sleep Disorders

Insomnia

eszopiclone oral F$$ QL; AE

temazepam oral capsule 15 mg, 30 mg F$ QL


48


zaleplon oral F$$ QL; AE

zolpidem oral tablet F$ QL; AE

zolpidem oral tablet,ext release multiphase F$$ ST; QL; AE

Narcolepsy / Excessive Sleepiness

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

F$$ QL

modafinil oral F$$ QL

XYREM ORAL F$$$ PA; Specialty; QL

Smoking Cessation

Nicotine Replacement

nicotine (polacrilex) buccal gum F$$ SC

nicotine (polacrilex) buccal lozenge F$$ SC

nicotine transdermal patch 24 hour F$$ SC

NICOTROL INHALATION F$$$ SC

NICOTROL NS NASAL F$$$ SC

Smoking Cessation, Other

buproban oral F$$ SC

CHANTIX CONTINUING MONTH BOX ORAL F$$$ SC; QL

CHANTIX ORAL F$$$ SC; QL

CHANTIX STARTING MONTH BOX ORAL F$$$ SC; QL

Stomach / Gastrointestinal

Bowel Prep

gavilyte-c oral F$$

gavilyte-g oral F$$

gavilyte-n oral F$$

MOVIPREP ORAL F$$$

Constipation

AMITIZA ORAL F$$$ QL

enulose oral F$$

lactulose oral solution 10 gram/15 ml F$$

LINZESS ORAL F$$$ QL

polyethylene glycol 3350 oral powder F$$

SYMPROIC ORAL F$$$ PA

Crohn's Disease / Ulcerative Colitis

balsalazide oral F$$

budesonide oral F$$

CANASA RECTAL F$$$

DELZICOL ORAL F$$$


49




lialda oral F$$

mesalamine oral tablet,delayed release (dr/ec) 800 mg

F$$

mesalamine rectal F$$

PENTASA ORAL F$$$

sulfasalazine oral F$$

Nausea / Vomiting

aprepitant oral capsule 80 mg F$$

aprepitant oral capsule,dose pack F$$

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg F$$ QL

EMEND ORAL CAPSULE 125 MG, 40 MG F$$$

EMEND ORAL SUSPENSION FOR RECONSTITUTION F$$$

metoclopramide hcl oral solution F$

metoclopramide hcl oral tablet F$

ondansetron hcl oral F$$

ondansetron oral F$$

prochlorperazine maleate oral F$

prochlorperazine rectal F$$

promethazine oral syrup F$$ QL; AE

promethazine oral tablet F$$ QL; AE

promethazine rectal F$$

scopolamine base transdermal F$$

trimethobenzamide oral F$$

Stomach / Gastrointestinal, Other

alosetron oral F$$ PA

CARBAGLU ORAL F$$$ PA; Specialty

CHOLBAM ORAL F$$$ PA; Specialty

CUVPOSA ORAL F$$$ PA

dicyclomine oral capsule F$

dicyclomine oral solution F$

dicyclomine oral tablet F$

diphenoxylate-atropine oral liquid F$$ QL

diphenoxylate-atropine oral tablet F$$ QL

FULYZAQ ORAL F$$$ PA

glycopyrrolate oral tablet 1 mg, 2 mg F$$

hyoscyamine sulfate oral F$$


50


hyoscyamine sulfate sublingual F$$

MOVANTIK ORAL F$$$ PA; QL

paregoric oral F$$ QL

propantheline oral F$$

ursodiol oral F$$

XERMELO ORAL F$$$ PA; Specialty

Stomach / Gastrointestinal, Rectal

hydrocortisone acetate rectal suppository 25 mg F$$

hydrocortisone rectal F$$

hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % F$$

PROCTOFOAM HC RECTAL F$$$

proctosol hc rectal F$$

proctozone-hc topical F$$

Ulcers / Heartburn / Gerd

CARAFATE ORAL SUSPENSION F$$$

cimetidine hcl oral F$$

cimetidine oral tablet 300 mg, 400 mg, 800 mg F$$

famotidine oral tablet 20 mg, 40 mg F$

lansoprazole oral capsule,delayed release(dr/ec) F$$

misoprostol oral F$$

omeprazole oral capsule,delayed release(dr/ec) F$$

pantoprazole oral F$

PREVACID SOLUTAB ORAL F$$$ AE

rabeprazole oral F$$

ranitidine hcl oral syrup F$

ranitidine hcl oral tablet 150 mg, 300 mg F$

sucralfate oral F$$

Thyroid

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg F$

propylthiouracil oral F$$

Thyroid Agents

levothyroxine oral F$$

liothyronine oral F$$

SYNTHROID ORAL F$$$

Urinary & Bladder Health

Overactive Bladder

MYRBETRIQ ORAL F$$$


51


oxybutynin chloride oral F$$

tolterodine oral F$$

trospium oral tablet F$$

Urinary & Bladder Health, Other

bethanechol chloride oral F$$

ELMIRON ORAL F$$$

phenazopyridine oral tablet 100 mg, 200 mg F$

phospha 250 neutral oral F$$

potassium citrate oral F$$

virt-phos 250 neutral oral F$$

Vaccines

Vaccines

ACTHIB (PF) INTRAMUSCULAR F$$$

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR

F$$$

ADENOVIRUS VAC LIVE TYPE-4, 7 ORAL F$$$

ADENOVIRUS VACCINE LIVE TYPE-4 ORAL F$$$

ADENOVIRUS VACCINE LIVE TYPE-7 ORAL F$$$

AFLURIA 2017-2018 (PF) INTRAMUSCULAR F$$$

AFLURIA 2017-2018 INTRAMUSCULAR F$$$

AFLURIA QUAD 2016-2017 INTRAMUSCULAR F$$$

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR F$$$

AFLURIA QUAD 2017-2018 INTRAMUSCULAR F$$$

BEXSERO INTRAMUSCULAR F$$$

BOOSTRIX TDAP INTRAMUSCULAR F$$$

CERVARIX VACCINE (PF) INTRAMUSCULAR F$$$

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR F$$$

ENGERIX-B (PF) INTRAMUSCULAR F$$$

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR F$$$

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR F$$$

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR F$$$

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUMIST QUAD 2017-2018 NASAL F$$$

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUVIRIN 2017-2018 INTRAMUSCULAR F$$$


52


FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR F$$$

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL F$$$

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR F$$$

FLUZONE QUAD 2017-2018 INTRAMUSCULAR F$$$

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR F$$$

GARDASIL (PF) INTRAMUSCULAR F$$$

GARDASIL 9 (PF) INTRAMUSCULAR F$$$

HAVRIX (PF) INTRAMUSCULAR F$$$

HIBERIX (PF) INTRAMUSCULAR F$$$

INFANRIX (DTAP) (PF) INTRAMUSCULAR F$$$

KINRIX (PF) INTRAMUSCULAR F$$$

MENACTRA (PF) INTRAMUSCULAR SOLUTION F$$$

MENHIBRIX (PF) INTRAMUSCULAR F$$$

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS F$$$

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR F$$$

PEDIARIX (PF) INTRAMUSCULAR F$$$

PEDVAX HIB (PF) INTRAMUSCULAR F$$$

PENTACEL (PF) INTRAMUSCULAR F$$$

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR F$$$

PNEUMOVAX 23 INJECTION F$$$

PREVNAR 13 (PF) INTRAMUSCULAR F$$$

PROQUAD (PF) SUBCUTANEOUS F$$$

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 40 MCG/ML

F$$$

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE F$$$

SHINGRIX (PF) INTRAMUSCULAR F$$$

SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR

F$$$

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR

F$$$

TENIVAC (PF) INTRAMUSCULAR SYRINGE F$$$

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR

F$$$

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR

F$$$

TRUMENBA INTRAMUSCULAR F$$$

TWINRIX (PF) INTRAMUSCULAR F$$$

VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML

F$$$

VAQTA (PF) INTRAMUSCULAR SYRINGE F$$$


53


VARIVAX (PF) SUBCUTANEOUS F$$$

VAXCHORA BUFFER COMPONENT ORAL F$$$

VAXCHORA VACCINE ORAL F$$$

VIVOTIF BERNA VACCINE ORAL F$$$

ZOSTAVAX (PF) SUBCUTANEOUS F$$$

Vitamins And Minerals

Vitamins And Minerals

calcitriol oral F$$

completenate oral F$$

cyanocobalamin (vitamin b-12) injection F$

denta 5000 plus dental F$

dentagel dental F$

DIALYVITE 5000 ORAL F$$$

dialyvite oral F$

fabb oral F$$

fluoride (sodium) dental F$

fluoride (sodium) oral drops F$

fluoride (sodium) oral tablet,chewable F$

fluoridex daily defense dental gel F$

folbee oral F$$

folbee plus oral F$$

FOLGARD RX ORAL F$$$ PA

folic acid oral tablet 1 mg F$

folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg, 2.5-25-1 mg

F$$

folplex 2.2 oral F$$

ludent fluoride oral F$

MEPHYTON ORAL F$$$ QL

multi vit-fluoride-iron oral F$

multi-vitamin with fluoride oral F$

multivitamins with fluoride oral F$

mvc-fluoride oral F$

mynatal advance oral F$

mynatal oral tablet F$

mynatal plus oral F$

mynatal-z oral F$

mynate 90 plus oral F$

mynephrocaps oral F$$


54


nephro-vite rx oral F$$

o-cal prenatal oral F$

PRENATA ORAL F$$$

prenatabs fa oral F$

prenatabs rx oral F$$

prenatal low iron oral F$$

prenatal plus (calcium carb) oral F$

prenatal plus oral F$

PRENATE ELITE ORAL F$$$

purefe ob plus oral F$

purefe plus oral F$

QUFLORA PEDIATRIC DROPS ORAL F$$$

renal caps oral F$$

rena-vite rx oral F$$

reno caps oral F$$

se-natal 19 (with docusate) oral F$

se-natal 19 oral F$

sf 5000 plus dental F$

sf dental F$

tl gard rx oral F$$

triadvance oral F$

trinatal gt oral F$

trinate oral F$$

triphrocaps oral F$$

triple vitamin with fluoride oral F$

triveen-prx rnf oral F$$

tri-vitamin with fluoride oral F$

vinate care oral F$

vinate gt oral F$

vinate m oral F$

vinate one oral F$

vinate ultra oral F$

virt-caps oral F$$

virt-vite oral F$$

vitamin b-12 injection F$

vitamin d2 oral F$

vitamins a,c,d and fluoride oral F$$

vol-care rx oral F$$


55


vol-nate oral F$$

vol-tab rx oral F$$

Weight Loss

Weight Loss

ALLI ORAL F$$$ PA; WL

lomaira oral F$$ WL; QL

phentermine oral capsule 15 mg, 30 mg, 37.5 mg F$$ WL; QL

phentermine oral tablet F$$ WL; QL

XENICAL ORAL F$$$ PA; WL

Women's Health

Anti-Infectives, Vaginal

CLEOCIN VAGINAL SUPPOSITORY F$$$

clindamycin phosphate vaginal F$$

metronidazole vaginal F$$

terconazole vaginal F$$

VANDAZOLE VAGINAL F$$$

Estrogens, Vaginal

estradiol vaginal cream F$$

ESTRING VAGINAL F$$$

PREMARIN VAGINAL F$$$

yuvafem vaginal F$$

Hormone Replacement

CLIMARA PRO TRANSDERMAL F$$$

COMBIPATCH TRANSDERMAL F$$$

estradiol oral F$

estradiol transdermal F$$

estradiol-norethindrone acet oral F$$

estropipate oral F$$

jinteli oral F$$

medroxyprogesterone oral F$

mimvey lo oral F$$

mimvey oral F$$

norethindrone acetate oral F$$

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg

F$$

PREMARIN ORAL F$$$

PREMPHASE ORAL F$$$

PREMPRO ORAL F$$$


56


progesterone micronized oral F$$

Women's Health, Other

cabergoline oral F$$

danazol oral F$$

METHERGINE ORAL F$$$

methylergonovine oral F$$

nifedipine oral capsule F$$ GE Female; AE

raloxifene oral F$$

tranexamic acid oral F$$ QL


57

Index abacavir ........................................... 10abacavir-lamivudine ........................ 10abacavir-lamivudine-zidovudine ......10acamprosate ...................................... 6acarbose ...........................................26acetaminophen-codeine ............ 40, 41acetazolamide ......................30, 34, 43acetic acid ........................................ 28acetylcysteine .................................. 26acitretin ............................................47ACTEMRA .........................................12ACTHAR H.P. ....................................39ACTHIB (PF) ......................................52ACUVAIL (PF) ................................... 29acyclovir ........................................... 11ACZONE ........................................... 45ADACEL(TDAP ADOLESN/ADULT)(PF) .....................52adapalene ........................................ 45adderall xr ........................................15adefovir ..............................................9ADEMPAS ........................................ 43ADENOVIRUS VAC LIVE TYPE-4, 7 ... 52ADENOVIRUS VACCINE LIVE TYPE-4 ....................................................... 52ADENOVIRUS VACCINE LIVE TYPE-7 ....................................................... 52ADVAIR DISKUS ............................... 13ADVAIR HFA .....................................13ADVATE ............................................21ADYNOVATE .................................... 21AFINITOR ......................................... 23AFINITOR DISPERZ ...........................23AFLURIA 2017-2018 .........................52AFLURIA 2017-2018 (PF) ................. 52AFLURIA QUAD 2016-2017 ..............52AFLURIA QUAD 2017-2018 ..............52AFLURIA QUAD 2017-2018 (PF) ...... 52AFSTYLA ...........................................21ALBENZA ............................................ 9albuterol sulfate ...............................13alclometasone ..................................46ALDACTAZIDE .................................. 34ALECENSA ........................................ 24alendronate ..................................... 22ALFERON N ...................................... 39alfuzosin ...........................................37ALINIA ................................................9ALLI .................................................. 56allopurinol ........................................31alosetron ..........................................50ALPHAGAN P ................................... 30

ALPHANATE ..................................... 21ALPHANINE SD .................................21alprazolam ....................................... 14ALPROLIX ......................................... 21ALTABAX ..........................................46altavera (28) .................................... 17alyacen 1/35 (28) ............................. 17alyacen 7/7/7 (28) ........................... 17amantadine hcl .......................... 11, 42AMICAR ........................................... 20amiloride ..........................................34amiloride-hydrochlorothiazide .........34amiodarone ......................................31AMITIZA ...........................................49amitriptyline .....................................17amlodipine ....................................... 33amlodipine-benazepril ............... 32, 33amlodipine-valsartan ................. 32, 33amlodipine-valsartan-hcthiazid . 32, 33ammonium lactate ...........................48amnesteem ...................................... 45amoxicillin .......................................... 8amoxicillin-pot clavulanate ................8ampicillin ............................................8AMPYRA .......................................... 38anagrelide ........................................ 22anastrozole ...................................... 23ANDROGEL .......................................37androxy ............................................ 37ANORO ELLIPTA ...............................13aprepitant ........................................ 50apri ...................................................17APTIOM ........................................... 43APTIVUS ...........................................10ARALAST NP .......................................6aranelle (28) .....................................17ARANESP (IN POLYSORBATE) ..........20ARCALYST ........................................ 39aripiprazole ...................................... 14armodafinil ...................................... 49ARNUITY ELLIPTA ............................ 13ASMANEX HFA .................................13ASMANEX TWISTHALER .................. 13aspirin-dipyridamole ........................ 22atazanavir ........................................ 10atenolol ............................................32atenolol-chlorthalidone ................... 32atomoxetine .....................................15atorvastatin ..................................... 34atovaquone ........................................9atovaquone-proguanil ....................... 9ATRIPLA ........................................... 10

atropine ........................................... 30ATROVENT HFA ............................... 12AUBAGIO ......................................... 39aubra ................................................17AUSTEDO ......................................... 39aviane .............................................. 17avita ................................................. 45AVONEX ........................................... 38AVONEX (WITH ALBUMIN) ..............38AZASITE ............................................29azathioprine .....................................36azelastine ........................................... 6azithromycin ...................................... 7AZOPT .............................................. 30azurette (28) .................................... 17bacitracin ......................................... 29bacitracin-polymyxin b .....................29baclofen ........................................... 39balsalazide ....................................... 49balziva (28) .......................................17BANZEL ............................................ 43BARACLUDE ....................................... 9BASAGLAR KWIKPEN U-100 INSULIN ............................................27BEBULIN ...........................................21benazepril ........................................ 32benazepril-hydrochlorothiazide ....... 32BENEFIX ........................................... 21benzonatate .....................................26benztropine ...................................... 42BERINERT .........................................35BESIVANCE .......................................29betamethasone dipropionate .......... 46betamethasone valerate ..................46betamethasone, augmented ............46betaxolol .......................................... 30bethanechol chloride ....................... 52BETOPTIC S ...................................... 30BEXSERO .......................................... 52bicalutamide .................................... 23BILTRICIDE ......................................... 9bimatoprost ..................................... 30bisoprolol fumarate ......................... 32bisoprolol-hydrochlorothiazide ........ 33BIVIGAM .......................................... 36BLEPHAMIDE S.O.P. .........................29blisovi fe 1.5/30 (28) ........................ 17blisovi fe 1/20 (28) ........................... 17BOOSTRIX TDAP .............................. 52BOSULIF ........................................... 24BREO ELLIPTA .................................. 13brevicon (28) .................................... 17


58

briellyn ............................................. 17BRILINTA ..........................................22brimonidine ......................................30BRIVIACT ..........................................43bromfenac ........................................30bromocriptine .................................. 42budesonide .................................13, 49bumetanide ......................................34buprenorphine-naloxone ................. 41buproban ......................................... 49bupropion hcl ................................... 16buspirone ......................................... 15butalbital-acetaminophen ............... 42butalbital-acetaminophen-caff ........42butalbital-aspirin-caffeine ............... 42BYDUREON ...................................... 27BYDUREON BCISE ............................ 27BYETTA .............................................27cabergoline ...................................... 57CABOMETYX .................................... 24calcipotriene .................................... 47calcitonin (salmon) ...........................22calcitriol ......................................47, 54calcium acetate ................................37camila .............................................. 17CANASA ........................................... 49capecitabine .....................................23CAPRELSA ........................................ 24captopril ...........................................32captopril-hydrochlorothiazide ..........32CARAFATE ........................................51CARBAGLU ....................................... 50carbamazepine ................................ 43carbidopa ......................................... 42carbidopa-levodopa ......................... 42carbidopa-levodopa-entacapone .....42CARIMUNE NF NANOFILTERED ....... 36CARNITOR (SUGAR-FREE) ................39carteolol ........................................... 30cartia xt ............................................33carvedilol ..........................................33carvedilol phosphate ........................33CAYSTON ......................................... 26caziant (28) ...................................... 17cefadroxil ........................................... 7cefdinir ............................................... 7cefprozil ..............................................7CEFTIN ................................................7cefuroxime axetil ................................7celecoxib .......................................... 40cephalexin .......................................... 7CERDELGA ........................................29CERVARIX VACCINE (PF) ..................52

cevimeline ........................................ 38CHANTIX .......................................... 49CHANTIX CONTINUING MONTH BOX .................................................. 49CHANTIX STARTING MONTH BOX ...49chateal ............................................. 17CHEMET ........................................... 39chlordiazepoxide hcl .........................15chlorhexidine gluconate ...................38chloroquine phosphate ...................... 9chlorothiazide .................................. 34chlorthalidone ..................................34chlorzoxazone .................................. 39CHOLBAM ........................................ 50cholestyramine (with sugar) ............ 34cholestyramine light ........................ 34ciclopirox ..........................................45cilostazol .......................................... 22CILOXAN .......................................... 29cimetidine ........................................ 51cimetidine hcl ...................................51CINRYZE ........................................... 35CIPRO ................................................. 8CIPRO HC ......................................... 28CIPRODEX ........................................ 28ciprofloxacin .......................................8ciprofloxacin hcl ........................... 8, 29citalopram ........................................16claravis .............................................45clarithromycin .................................... 7CLEOCIN ........................................... 56CLIMARA PRO ..................................56clindamycin hcl ...................................7clindamycin palmitate hcl .................. 7clindamycin phosphate .............. 45, 56clobetasol .........................................46clobetasol-emollient ........................ 46clomipramine ................................... 17clonazepam ................................15, 43clonidine ...........................................33clonidine hcl ............................... 15, 33clopidogrel ....................................... 22clotrimazole ....................................... 8clozapine .......................................... 14COAGADEX ...................................... 21codeine sulfate .................................41codeine-guaifenesin .........................26colchicine ......................................... 31colestipol ..........................................34COMBIGAN ...................................... 30COMBIPATCH ...................................56COMBIVENT RESPIMAT ...................13COMETRIQ ....................................... 24

COMPLERA .......................................10completenate ...................................54CONDYLOX .......................................48CORDRAN TAPE LARGE ROLL .......... 46CORDRAN TAPE SMALL ROLL ..........46CORIFACT .........................................21COSENTYX ........................................47COSENTYX PEN ................................ 47COSOPT (PF) .................................... 30COTELLIC ..........................................24CREON ..............................................29CRESEMBA ......................................... 8CRIXIVAN ......................................... 10cromolyn ...................................... 6, 12cryselle (28) ......................................17CUVITRU .......................................... 36CUVPOSA ......................................... 50cyanocobalamin (vitamin b-12) ....... 54cyclafem 1/35 (28) ........................... 17cyclafem 7/7/7 (28) ..........................17cyclobenzaprine ............................... 39cyclopentolate ..................................30CYCLOPHOSPHAMIDE ..................... 23cycloserine ....................................... 11CYCLOSET .........................................27cyclosporine ..................................... 36cyclosporine modified ...................... 36cyproheptadine .................................. 6CYSTAGON .......................................39CYSTARAN ....................................... 30DALIRESP ......................................... 12danazol ............................................ 57dantrolene ........................................39dapsone ..............................................9DAPSONE ......................................... 45DAPTACEL (DTAP PEDIATRIC) (PF) .. 52dasetta 1/35 (28) ............................. 17dasetta 7/7/7 (28) ............................18DELZICOL ..........................................49demeclocycline ...................................8denta 5000 plus ............................... 54dentagel ...........................................54DEPEN TITRATABS ........................... 12DESCOVY ..........................................10desipramine ..................................... 17desmopressin ................................... 39desogestrel-ethinyl estradiol ............18desonide ...........................................46desoximetasone ............................... 46desvenlafaxine succinate ................. 16dexamethasone ............................... 25DEXAMETHASONE INTENSOL ......... 25


59

dexamethasone sodium phosphate....................................................25, 30dexmethylphenidate ........................ 15dextroamphetamine ........................ 15dextroamphetamine-amphetamine .15dialyvite ............................................54DIALYVITE 5000 ............................... 54diazepam ....................................15, 43diazepam intensol ......................15, 43diclofenac potassium ....................... 40diclofenac sodium ................ 30, 40, 42dicloxacillin .........................................8dicyclomine ...................................... 50didanosine ........................................10DIFFERIN .......................................... 45DIFICID ............................................... 7DIGOXIN .......................................... 35digoxin ............................................. 35DILANTIN ......................................... 43DILANTIN KAPSEAL ..........................43diltiazem hcl .....................................33dilt-xr ................................................33diphenoxylate-atropine ....................50dipyridamole .................................... 22disopyramide phosphate ................. 31disulfiram ........................................... 6DIURIL .............................................. 34divalproex .............................16, 37, 44dofetilide .......................................... 31donepezil ..........................................26dorzolamide ..................................... 30dorzolamide-timolol .........................30doxazosin ................................... 33, 37doxepin ............................................ 17doxycycline hyclate ............................ 8doxycycline monohydrate .................. 8DRITHOCREME HP ........................... 47dronabinol ........................................50drospirenone-ethinyl estradiol .........18DRYSOL ............................................ 48DRYSOL DAB-O-MATIC .................... 48DULERA ............................................13duloxetine ........................................ 16DUPIXENT ........................................ 48dutasteride .......................................37dutasteride-tamsulosin .................... 37EDURANT .........................................10efavirenz .......................................... 10ELIDEL .............................................. 48elinest ...............................................18ELIQUIS ............................................ 22ELLA ................................................. 17ELMIRON ......................................... 52

ELOCTATE ........................................ 21EMCYT ..............................................23EMEND .............................................50emoquette ........................................18EMSAM ............................................ 16EMTRIVA ..........................................10enalapril maleate .............................32enalapril-hydrochlorothiazide ..........32ENBREL .......................................12, 47ENBREL MINI ................................... 47ENBREL SURECLICK ....................12, 47endocet ............................................ 41ENGERIX-B (PF) ................................52ENGERIX-B PEDIATRIC (PF) ..............52enoxaparin ....................................... 22enpresse ...........................................18enskyce .............................................18ENSTILAR ......................................... 47entacapone ...................................... 42entecavir ............................................ 9ENTRESTO ........................................35enulose .............................................49EPCLUSA ............................................ 9epinastine .......................................... 6epinephrine ........................................ 6EPIVIR HBV ........................................ 9eplerenone ....................................... 34epoprostenol (glycine) ..................... 43ERGOMAR ........................................37ergotamine-caffeine ........................ 37ERIVEDGE .........................................24errin ..................................................18erythromycin ....................................29erythromycin with ethanol ...............45ESBRIET ............................................36escitalopram oxalate ....................... 16estarylla ........................................... 18estradiol ........................................... 56estradiol-norethindrone acet ........... 56ESTRING ...........................................56estropipate .......................................56eszopiclone .......................................48ethambutol ...................................... 12ethosuximide ....................................44etidronate disodium .........................22etodolac ........................................... 40etoposide ......................................... 24EUCRISA ...........................................48EURAX ..............................................47EVOTAZ ............................................10exemestane ......................................23EXJADE .............................................39EXTAVIA ...........................................38

ezetimibe ..........................................34ezetimibe-simvastatin ......................34fabb ..................................................54falmina (28) ......................................18famciclovir ........................................11famotidine ........................................51FANAPT ............................................14FEIBA NF .......................................... 21felbamate .........................................44fenofibrate ....................................... 35fenofibrate micronized .....................35fenofibrate nanocrystallized ............ 35fentanyl ............................................41FERRIPROX .......................................39FINACEA ...........................................48finasteride ........................................ 37FIRAZYR ........................................... 35FLEBOGAMMA DIF .......................... 36flecainide ..........................................31FLOLAN ............................................ 43FLOVENT DISKUS ............................. 13FLOVENT HFA .................................. 13FLUAD 2017-2018 (65 YR UP)(PF) ... 52FLUBLOK 2017-2018 (PF) .................52FLUBLOK QUAD 2017-2018 (PF) ......52FLUCELVAX QUAD 2017-2018 ......... 52FLUCELVAX QUAD 2017-2018 (PF) ..52fluconazole .........................................8fludrocortisone .................................25FLULAVAL QUAD 2017-2018 (PF) ....52FLUMIST QUAD 2017-2018 ............. 52flunisolide ...........................................6fluocinolone ..................................... 46fluocinolone acetonide oil ................29fluocinolone and shower cap ........... 46fluocinonide ..................................... 46fluocinonide-e .................................. 46fluoride (sodium) ..............................54fluoridex daily defense ..................... 54fluorometholone .............................. 30FLUOROPLEX ....................................48fluorouracil .......................................48fluoxetine ......................................... 16fluphenazine hcl ............................... 14flurbiprofen ...................................... 40flurbiprofen sodium ......................... 30flutamide ..........................................23fluticasone ....................................6, 46fluticasone-salmeterol ..................... 13FLUVIRIN 2017-2018 ........................52FLUVIRIN 2017-2018 (PF) ................ 52fluvoxamine ..................................... 16FLUZONE HIGH-DOSE 2017-18 (PF) .53


60

FLUZONE INTRADERM QUAD 2017-18 ............................................53FLUZONE QUAD 2017-2018 .............53FLUZONE QUAD 2017-2018 (PF) ..... 53FLUZONE QUAD PEDI 2017-18 (PF) .53FML S.O.P. ....................................... 30folbee ............................................... 54folbee plus ........................................54FOLGARD RX .................................... 54folic acid ...........................................54folic acid-vit b6-vit b12 .....................54folplex 2.2 ........................................ 54fondaparinux ....................................22FORTEO ............................................22FORTICAL ......................................... 22fosamprenavir ..................................10fosinopril .......................................... 32fosinopril-hydrochlorothiazide .........32FULYZAQ ..........................................50furosemide ....................................... 34FUZEON ............................................10FYCOMPA ........................................ 44gabapentin .................................40, 44GABITRIL .......................................... 44galantamine .....................................26GAMASTAN S/D .............................. 36GAMMAGARD LIQUID .....................36GAMMAGARD S-D (IGA < 1 MCG/ML) ..................36GAMMAKED .................................... 36GAMMAPLEX ...................................36GAMMAPLEX (WITH SORBITOL) ..... 36GAMUNEX-C .................................... 36GARDASIL (PF) ................................. 53GARDASIL 9 (PF) .............................. 53gatifloxacin ...................................... 29gavilyte-c ..........................................49gavilyte-g ......................................... 49gavilyte-n ......................................... 49gemfibrozil ....................................... 35gengraf ............................................ 36gentamicin ................................. 29, 46GENVOYA .........................................10gianvi (28) ........................................ 18gildagia ............................................ 18gildess 1.5/30 (21) ........................... 18gildess 1/20 (21) .............................. 18gildess fe 1.5/30 (28) ....................... 18gildess fe 1/20 (28) .......................... 18GILENYA ...........................................39GILOTRIF .......................................... 24GLASSIA ............................................. 6glatiramer ........................................ 38

glatopa .............................................38GLEOSTINE .......................................23glimepiride ....................................... 28glipizide ............................................28glipizide-metformin ..........................28GLUCAGEN .......................................28GLUCAGEN HYPOKIT ....................... 27GLUCAGON EMERGENCY KIT (HUMAN) ......................................... 28glyburide .......................................... 28glyburide micronized ........................28glycopyrrolate .................................. 50GRANIX ............................................ 20granulex ........................................... 48GRASTEK ............................................ 6griseofulvin microsize .........................8griseofulvin ultramicrosize .................8guanfacine ................................. 15, 33HAEGARDA ...................................... 35haloperidol .......................................14haloperidol lactate ...........................14HARVONI ........................................... 9HAVRIX (PF) ..................................... 53heather .............................................18HELIXATE FS .....................................21HEMOFIL M HIGH ............................ 21HEMOFIL M LOW .............................21HEMOFIL M MID ..............................21HEMOFIL M SUPER HIGH ................ 21heparin (porcine) ..............................22heparin, porcine (pf) ........................ 22HEXALEN ..........................................23HIBERIX (PF) .....................................53HIZENTRA .........................................36homatropaire ...................................30HUMALOG JUNIOR KWIKPEN U-100 ................................................... 27HUMALOG KWIKPEN INSULIN ........ 27HUMALOG MIX 50-50 INSULN U-100 ................................................... 27HUMALOG MIX 50-50 KWIKPEN .....27HUMALOG MIX 75-25 KWIKPEN .....27HUMALOG MIX 75-25(U-100)INSULN ..................................... 27HUMALOG U-100 INSULIN .............. 27HUMATE-P .......................................21HUMIRA ............................... 12, 47, 50HUMIRA PEN ....................... 12, 47, 50HUMULIN 70/30 U-100 INSULIN .....27HUMULIN 70/30 U-100 KWIKPEN ...27HUMULIN N NPH INSULIN KWIKPEN ......................................... 27HUMULIN N NPH U-100 INSULIN ....27

HUMULIN R REGULAR U-100 INSULN .............................................28HUMULIN R U-500 (CONC) INSULIN ............................................28HUMULIN R U-500 (CONC) KWIKPEN ......................................... 28HYCAMTIN .......................................24hydralazine .......................................33hydrochlorothiazide ......................... 35hydrocodone-acetaminophen ..........41hydrocodone-ibuprofen ................... 41hydrocortisone ..................... 25, 47, 51hydrocortisone acetate .................... 51hydrocortisone valerate ...................47hydrocortisone-pramoxine .........47, 51hydromorphone ............................... 41hydroxychloroquine ........................... 9hydroxyurea ..................................... 23hydroxyzine hcl .................................. 6hydroxyzine pamoate .........................6hyoscyamine sulfate ...................50, 51HYQVIA ............................................ 36HYQVIA HY COMPONENT ............... 36HYQVIA IG COMPONENT ................ 36ibandronate ..................................... 22IBRANCE ...........................................24ibuprofen ..........................................40ICLUSIG ............................................ 24IDELVION ......................................... 21IDHIFA ..............................................24ILARIS (PF) ........................................39ILEVRO ............................................. 30imatinib ............................................24IMBRUVICA ......................................24imipramine hcl ................................. 17imiquimod ........................................ 48INCRUSE ELLIPTA ............................. 13indapamide ...................................... 35INDOCIN .......................................... 40indomethacin ................................... 40INFANRIX (DTAP) (PF) ..................... 53INGREZZA .........................................39INLYTA ............................................. 24INTELENCE ....................................... 10INTRON A ...........................................9introvale ...........................................18INVIRASE ..........................................10INVOKAMET .................................... 28INVOKAMET XR ............................... 28INVOKANA .......................................28iodoquinol-hc ................................... 47ipratropium bromide ....................6, 12ipratropium-albuterol ...................... 13


61

irbesartan .........................................32irbesartan-hydrochlorothiazide ....... 32IRESSA ..............................................24ISENTRESS ........................................10ISENTRESS HD ..................................10isometh-dichloral-acetaminophn .....37isoniazid ........................................... 12ISORDIL ............................................ 31isosorbide dinitrate .......................... 31isosorbide mononitrate ....................31itraconazole ....................................... 8ivermectin .......................................... 9IXINITY ............................................. 21JADENU ............................................39JADENU SPRINKLE ........................... 39JAKAFI .............................................. 24jantoven ........................................... 22JARDIANCE .......................................28jencycla ............................................ 18JENTADUETO ................................... 26JENTADUETO XR ..............................26jinteli ................................................ 56jolessa .............................................. 18jolivette ............................................ 18JULUCA ............................................ 10junel 1.5/30 (21) .............................. 18junel 1/20 (21) ................................. 18junel fe 1.5/30 (28) .......................... 18junel fe 1/20 (28) ............................. 18JUXTAPID ......................................... 34KALBITOR .........................................35KALETRA .......................................... 10KALYDECO ........................................26kariva (28) ........................................18kelnor 1/35 (28) ............................... 18ketoconazole ................................ 8, 46ketorolac .................................... 30, 40KINERET ........................................... 12KINRIX (PF) ...................................... 53kionex ...............................................39KISQALI ............................................ 24KISQALI FEMARA CO-PACK ............. 24klor-con m10 .................................... 35klor-con m15 .................................... 35KLOR-CON/25 .................................. 35KOATE-DVI .......................................21KOGENATE FS .................................. 21KOVALTRY ........................................21kurvelo ............................................. 18KUVAN ............................................. 39KYNAMRO ....................................... 34labetalol ........................................... 33LACRISERT ........................................30

lactulose ...........................................49lamivudine ....................................9, 10lamivudine-zidovudine ..................... 10lamotrigine .......................................44lansoprazole .....................................51larin 1/20 (21) .................................. 18larin fe 1.5/30 (28) ........................... 18larin fe 1/20 (28) .............................. 18latanoprost ...................................... 30LATUDA ............................................14leena 28 ........................................... 18leflunomide ...................................... 12lessina .............................................. 18LETAIRIS ...........................................43letrozole ........................................... 23leucovorin calcium ........................... 39LEUKERAN ........................................23LEUKINE ........................................... 20LEVEMIR FLEXTOUCH U-100 INSULN .............................................27LEVEMIR U-100 INSULIN ................. 27levetiracetam ................................... 44levobunolol .......................................31levocarnitine .................................... 39levocarnitine (with sugar) ................ 39levofloxacin ........................................ 8levonest (28) .................................... 18levonorgestrel .................................. 17levonorgestrel-ethinyl estrad ...........18levora-28 ..........................................18levothyroxine ................................... 51LEXIVA ..............................................10lialda ................................................ 50lidocaine ...........................................40lidocaine hcl ..................................... 38lidocaine viscous .............................. 38lidocaine-prilocaine ..........................42linezolid ..............................................7LINZESS ............................................ 49liothyronine ......................................51lisinopril ............................................32lisinopril-hydrochlorothiazide .......... 32lithium carbonate .............................16lithium citrate .................................. 16lomaira .............................................56LONSURF ..........................................23lopinavir-ritonavir ............................ 10lorazepam ........................................ 15loryna (28) ........................................19losartan ............................................32losartan-hydrochlorothiazide ...........32LOTEMAX .........................................30lovastatin ......................................... 34

low-ogestrel (28) ..............................19loxapine succinate ............................14ludent fluoride ..................................54LUMIGAN .........................................31lutera (28) ........................................ 19LYRICA ........................................40, 44lyza ...................................................19malathion .........................................47marlissa ............................................19MATULANE ...................................... 23MAVYRET ...........................................9MEDROL ...........................................25medroxyprogesterone ......................56mefloquine ......................................... 9megestrol ................................... 24, 39MEKINIST ......................................... 24meloxicam ........................................40melphalan ........................................ 23memantine .......................................26MENACTRA (PF) ...............................53MENHIBRIX (PF) ...............................53MENOMUNE - A/C/Y/W-135 .......... 53MENVEO A-C-Y-W-135-DIP (PF) ...... 53MEPHYTON ......................................54mercaptopurine ............................... 23mesalamine ......................................50metadate er ..................................... 15metformin ........................................ 26methadone .......................................41methazolamide ................................ 31METHERGINE ...................................57methimazole .................................... 51methocarbamol ............................... 39methotrexate sodium .....12, 23, 36, 47methotrexate sodium (pf)........................................12, 23, 36, 47methyldopa ......................................33methylergonovine ............................ 57methylphenidate hcl ........................ 15methylprednisolone ......................... 25metoclopramide hcl ......................... 50metolazone ...................................... 35metoprolol succinate ....................... 33metoprolol ta-hydrochlorothiaz .......33metoprolol tartrate ..........................33metronidazole ........................ 9, 48, 56mexiletine ........................................ 31microgestin 1.5/30 (21) ................... 19microgestin 1/20 (21) ...................... 19microgestin fe 1.5/30 (28) ............... 19microgestin fe 1/20 (28) .................. 19midodrine .........................................33miglitol .............................................26


62

MILLIPRED ....................................... 25mimvey ............................................ 56mimvey lo .........................................56minocycline ........................................ 8minoxidil ...........................................33mirtazapine ......................................16misoprostol ...................................... 51modafinil ..........................................49moexipril .......................................... 32moexipril-hydrochlorothiazide ......... 32mometasone .................................... 47MONOCLATE-P ................................ 21mono-linyah ..................................... 19mononessa (28) ............................... 19montelukast ..................................... 13MONUROL ....................................... 12morphine ..........................................41MORPHINE .......................................41morphine concentrate ..................... 41MOVANTIK ...................................... 51MOVIPREP ....................................... 49moxifloxacin .................................8, 29MULTAQ .......................................... 31multi vit-fluoride-iron .......................54multi-vitamin with fluoride .............. 54multivitamins with fluoride ..............54mupirocin ......................................... 46mupirocin calcium ............................46mvc-fluoride ..................................... 54my way .............................................17mycophenolate mofetil .................... 36MYLERAN .........................................23mynatal ............................................54mynatal advance ............................. 54mynatal plus .................................... 54mynatal-z ......................................... 54mynate 90 plus .................................54mynephrocaps ..................................54myorisan .......................................... 45MYRBETRIQ ..................................... 51myzilra ............................................. 19nabumetone .....................................40nadolol ............................................. 33naloxone ............................................ 7naltrexone ..........................................6naproxen .......................................... 40naratriptan .......................................38NARCAN .............................................7nateglinide ....................................... 27necon 0.5/35 (28) .............................19necon 1/35 (28) ................................19necon 1/50 (28) ................................19necon 10/11 (28) ..............................19

necon 7/7/7 (28) .............................. 19nefazodone ...................................... 16neomycin ............................................7neomycin-bacitracin-polymyxin .......29neomycin-polymyxin b-dexameth ....29neomycin-polymyxin-gramicidin ......29neomycin-polymyxin-hc ................... 28nephro-vite rx ...................................55NERLYNX ..........................................25NEULASTA ........................................20NEUPOGEN ...................................... 20NEUPRO ........................................... 42NEVANAC .........................................30nevirapine ........................................ 10NEXAVAR ......................................... 25next choice one dose ........................17nicotine ............................................ 49nicotine (polacrilex) ..........................49NICOTROL ........................................ 49NICOTROL NS ...................................49nifedipine ............................. 33, 39, 57nimodipine ....................................... 33NINLARO ..........................................25NITRO-BID ........................................31NITRO-DUR ...................................... 31nitrofurantoin .................................. 12nitrofurantoin macrocrystal .............12nitrofurantoin monohyd/m-cryst .....12nitroglycerin .....................................31nodolor .............................................37nora-be ............................................ 19norethindrone (contraceptive) .........19norethindrone acetate ..................... 56norethindrone ac-eth estradiol .. 19, 56norgestimate-ethinyl estradiol ........ 19norinyl 1/35 (28) .............................. 19NORPACE CR ....................................31nortrel 0.5/35 (28) ........................... 19nortrel 1/35 (21) .............................. 19nortrel 1/35 (28) .............................. 19nortrel 7/7/7 (28) .............................19nortriptyline ..................................... 17NORVIR ............................................ 10NOVOEIGHT .....................................21NOVOSEVEN RT ............................... 21NOXAFIL .............................................9NUPLAZID ........................................ 14NUVARING .......................................17NUWIQ .............................................21nystatin ........................................ 9, 46OBIZUR ............................................ 21o-cal prenatal ...................................55ocella ................................................19

OCTAGAM ........................................36octreotide acetate ............................39ODACTRA ...........................................6ODEFSEY .......................................... 11ODOMZO ......................................... 24OFEV ................................................ 36ofloxacin ...........................................29ogestrel (28) .....................................19olanzapine ........................................14olmesartan .......................................32olmesartan-hydrochlorothiazide ......32olopatadine ........................................6OLYSIO ............................................... 9omega-3 acid ethyl esters ................35omeprazole ...................................... 51ondansetron .....................................50ondansetron hcl ............................... 50ONFI .................................................44OPSUMIT ......................................... 43ORENCIA .......................................... 12ORENCIA CLICKJECT .........................12ORKAMBI .........................................26orsythia ............................................ 19oseltamivir ....................................... 11OTEZLA .............................................12OTEZLA STARTER ............................. 12oxcarbazepine ..................................44OXSORALEN .....................................48oxybutynin chloride ..........................52oxycodone ........................................41oxycodone-acetaminophen ..............42oxycodone-aspirin ............................42OXYCONTIN ..................................... 42paliperidone ..................................... 14pantoprazole ....................................51paregoric ..........................................51paroxetine hcl .................................. 16PAXIL ................................................16PEDIARIX (PF) .................................. 53PEDVAX HIB (PF) ..............................53PEGASYS ............................................ 9PEGASYS PROCLICK ........................... 9PEGINTRON ....................................... 9PEGINTRON REDIPEN ........................ 9penicillin v potassium .........................8PENTACEL (PF) ................................. 53PENTACEL DTAP-IPV COMPNT (PF) .53PENTASA ..........................................50pentoxifylline ....................................22perindopril erbumine ....................... 32periogard ......................................... 38permethrin ....................................... 47perphenazine ................................... 14


63

phenazopyridine .............................. 52phenelzine ........................................16phenobarbital .................................. 44phenoxybenzamine .......................... 34phentermine .....................................56phenylephrine hcl .............................30phenytoin ......................................... 44phenytoin sodium extended .............44philith ............................................... 19PHOSLYRA ........................................37phospha 250 neutral ........................52PHOSPHOLINE IODIDE .....................31PICATO .............................................48pilocarpine hcl ............................31, 38pimtrea (28) ..................................... 19pioglitazone ..................................... 28pioglitazone-glimepiride .................. 28pioglitazone-metformin ................... 28pirmella ............................................19piroxicam ......................................... 40PLASMANATE .................................. 21PLEGRIDY ......................................... 38PNEUMOVAX 23 ..............................53podofilox .......................................... 48polyethylene glycol 3350 ................. 49polymyxin b sulf-trimethoprim .........29POMALYST .......................................24portia ............................................... 19potassium chloride ...........................35potassium citrate ............................. 52POTIGA ............................................ 44PRADAXA .........................................22pramipexole ..................................... 42prasugrel ..........................................22pravastatin .......................................34prazosin ......................................34, 37PRED FORTE .....................................30PRED MILD .......................................30prednisolone .................................... 25prednisolone acetate ....................... 30prednisolone sodium phosphate 25, 30prednisone ................................. 25, 26PREDNISONE INTENSOL .................. 25PREMARIN ....................................... 56PREMPHASE .....................................56PREMPRO ........................................ 56PRENATA ......................................... 55prenatabs fa .....................................55prenatabs rx .....................................55prenatal low iron ..............................55prenatal plus .................................... 55prenatal plus (calcium carb) ............ 55PRENATE ELITE ................................ 55

PREVACID SOLUTAB ........................ 51prevalite ........................................... 34previfem ...........................................19PREVNAR 13 (PF) ............................. 53PREVYMIS ........................................ 11PREZCOBIX .......................................11PREZISTA ..........................................11PRIFTIN ............................................ 12primidone .........................................44PRIVIGEN ......................................... 36probenecid ....................................... 31probenecid-colchicine ...................... 31prochlorperazine ..............................50prochlorperazine maleate ................50PROCRIT ...........................................20PROCTOFOAM HC ........................... 51proctosol hc ......................................51proctozone-hc .................................. 51PROFILNINE ..................................... 21progesterone micronized ................. 57PROLASTIN-C ..................................... 6PROLENSA ........................................30PROMACTA ......................................21promethazine ...............................6, 50promethazine vc ...............................26promethazine-dm ............................ 26propafenone .................................... 32propantheline ...................................51propranolol ................................ 33, 37propranolol-hydrochlorothiazid ....... 33propylthiouracil ................................51PROQUAD (PF) .................................53PULMICORT FLEXHALER .................. 13PULMOZYME ................................... 26purefe ob plus .................................. 55purefe plus ....................................... 55pyrazinamide ................................... 12pyridostigmine bromide ...................39QNASL ................................................6quasense .......................................... 19quetiapine ........................................ 14QUFLORA PEDIATRIC DROPS .......... 55QUILLICHEW ER ............................... 15QUILLIVANT XR ..........................15, 16quinapril ...........................................32quinapril-hydrochlorothiazide ..........32quinidine gluconate ......................... 32quinidine sulfate .............................. 32QVAR ............................................... 13QVAR REDIHALER ............................ 13rabeprazole ......................................51RAGWITEK ......................................... 6raloxifene ................................... 23, 57

ramipril ............................................ 32ranitidine hcl .................................... 51RAPAMUNE ..................................... 36rasagiline ......................................... 42RASUVO (PF) ....................................12REBETOL .......................................... 10REBIF (WITH ALBUMIN) .................. 38REBIF REBIDOSE .............................. 38REBIF TITRATION PACK ................... 38REBINYN .......................................... 21reclipsen (28) ....................................19RECOMBINATE ................................ 21RECOMBIVAX HB (PF) ......................53RELENZA DISKHALER ....................... 11REMODULIN .................................... 43renal caps .........................................55rena-vite rx .......................................55reno caps ..........................................55repaglinide ....................................... 27REPATHA PUSHTRONEX .................. 34REPATHA SURECLICK .......................34REPATHA SYRINGE .......................... 34RESCRIPTOR .....................................11reserpine .......................................... 34RESTASIS ..........................................30RESTASIS MULTIDOSE ..................... 30REVLIMID .........................................24REXULTI ........................................... 14REYATAZ .......................................... 11ribavirin ............................................10RIDAURA ..........................................12rifabutin ............................................. 9rifampin ........................................... 12riluzole ............................................. 39rimantadine ..................................... 11risedronate .......................................23risperidone ....................................... 14rivastigmine ..................................... 26rivastigmine tartrate ........................26RIXUBIS ............................................21rizatriptan ........................................ 38ropinirole ..........................................42rosuvastatin ..................................... 34RUCONEST ....................................... 35RYDAPT ............................................25RYTARY ............................................ 42SABRIL ..............................................44salsalate ...........................................40SANDOSTATIN LAR DEPOT ..............40SAPHRIS (BLACK CHERRY) ............... 14SAVELLA ...........................................40scopolamine base ............................ 50selegiline hcl .....................................42


64

selenium sulfide ............................... 48SELZENTRY .......................................11se-natal 19 ....................................... 55se-natal 19 (with docusate) ............. 55SENSIPAR ......................................... 37SEREVENT DISKUS ........................... 13sertraline ..........................................16sevelamer carbonate ....................... 37sf ...................................................... 55sf 5000 plus ...................................... 55SHINGRIX (PF) ..................................53SHINGRIX ADJUVANT COMPONENT-PF ..............................53SHINGRIX GE ANTIGEN COMPONENT ................................... 53SIGNIFOR ......................................... 40sildenafil (antihypertensive) .......37, 43silver sulfadiazine .............................46SIMBRINZA ...................................... 31simvastatin .......................................34sirolimus ...........................................36SIRTURO .......................................... 12SIVEXTRO ...........................................9sodium phenylbutyrate .................... 40sodium polystyrene (sorb free) ........ 40sodium polystyrene sulfonate .......... 40SOLTAMOX ...................................... 24sotalol .............................................. 32sotalol af .......................................... 32SOVALDI ...........................................10spironolactone ................................. 35spironolacton-hydrochlorothiaz .......35sprintec (28) ..................................... 19SPRYCEL ........................................... 25sronyx ...............................................20stavudine ..........................................11STIMATE .......................................... 20STIVARGA ........................................ 25STRENSIQ .........................................29STRIBILD ...........................................11STRIVERDI RESPIMAT ...................... 13SUBOXONE ...................................... 42SUCRAID .......................................... 29sucralfate ......................................... 51sulfacetamide sodium ......................29sulfacetamide sodium (acne) ........... 45sulfacetamide sodium-sulfur ......45, 48sulfacetamide sod-sulfur-urea ... 45, 48sulfacetamide-prednisolone .............29sulfamethoxazole-trimethoprim ........ 7sulfasalazine .................................... 50sulindac ............................................ 40sumatriptan ..................................... 38

sumatriptan succinate ..................... 38SUPRAX ..............................................7SUTENT ............................................ 25syeda ................................................20SYLATRON ........................................24SYMPROIC ........................................49SYNJARDY ........................................ 28SYNJARDY XR ...................................28SYNTHROID ......................................51TABLOID ...........................................23TACLONEX ........................................47tacrolimus .................................. 36, 48TAFINLAR .........................................25TAMIFLU .......................................... 11tamoxifen .........................................24tamsulosin ........................................37TARCEVA ..........................................25TASIGNA .......................................... 25tazarotene ........................................47TAZORAC ....................................47, 48taztia xt ............................................ 33TECFIDERA ....................................... 39temazepam ...................................... 48temozolomide .................................. 23TENIVAC (PF) ................................... 53tenofovir disoproxil fumarate .......... 11terazosin .................................... 34, 37terbinafine hcl .................................... 9terconazole ...................................... 56testosterone .....................................37testosterone cypionate .................... 37testosterone enanthate ................... 37TETANUS,DIPHTHERIA TOX PED(PF) ............................................ 53TETANUS-DIPHTHERIA TOXOIDS-TD .....................................................53tetrabenazine ...................................40tetracycline ........................................ 8THALOMID .......................................24theophylline ..................................... 13thioridazine ...................................... 14thiothixene ....................................... 14THROMBATE III ................................21tiagabine ..........................................44tilia fe ............................................... 20timolol maleate ................................31TIVICAY ............................................ 11tizanidine ......................................... 39tl gard rx ...........................................55TOBRADEX ....................................... 29tobramycin .......................................29tobramycin in 0.225 % nacl ..............26tobramycin-dexamethasone ............29

TOBREX ............................................29tolterodine ....................................... 52topiramate ....................................... 44torsemide ......................................... 35TRACLEER .........................................43TRADJENTA ......................................26tramadol .......................................... 42trandolapril ...................................... 32tranexamic acid ............................... 57tranylcypromine ...............................16TRAVATAN Z .................................... 31travoprost (benzalkonium) ...............31trazodone .........................................16TRECATOR ........................................12TRELEGY ELLIPTA ............................. 13tretinoin ........................................... 45tretinoin (chemotherapy) .................24TRETTEN ...........................................21triadvance ........................................ 55triamcinolone acetonide ............ 38, 47triamterene-hydrochlorothiazid .......35trianex ..............................................47triderm ............................................. 47tri-estarylla .......................................20trifluoperazine ..................................14trifluridine ........................................ 29trihexyphenidyl ................................ 42tri-legest fe .......................................20tri-linyah ...........................................20tri-lo-estarylla .................................. 20tri-lo-sprintec ................................... 20trimethobenzamide ..........................50trimethoprim ......................................7trinatal gt .........................................55trinate .............................................. 55trinessa (28) ..................................... 20trinessa lo .........................................20triphrocaps .......................................55triple vitamin with fluoride .............. 55tri-previfem (28) ...............................20tri-sprintec (28) ................................ 20TRIUMEQ ......................................... 11triveen-prx rnf .................................. 55tri-vitamin with fluoride ...................55trivora (28) ....................................... 20trospium ...........................................52TRULICITY ........................................ 27TRUMENBA ......................................53TRUVADA .........................................11TWINRIX (PF) ................................... 53TYBOST ............................................ 11TYKERB .............................................25TYMLOS ........................................... 23


65

TYVASO ............................................43TYVASO REFILL KIT .......................... 43TYVASO STARTER KIT ...................... 43TYZEKA ...............................................9ULORIC .............................................31UPTRAVI .......................................... 43urea ..................................................48ursodiol ............................................ 51valacyclovir ...................................... 11VALCHLOR ....................................... 23valganciclovir ................................... 11valproic acid .....................................44valproic acid (as sodium salt) ...........44valsartan .......................................... 32valsartan-hydrochlorothiazide .........32vancomycin ........................................ 7VANDAZOLE .....................................56VAQTA (PF) ...................................... 53VARIVAX (PF) ...................................54VAXCHORA BUFFER COMPONENT ..54VAXCHORA VACCINE .......................54VELETRI ............................................ 43velivet triphasic regimen (28) .......... 20VEMLIDY ............................................ 9venlafaxine .......................................16VENTAVIS .........................................43VENTOLIN HFA .................................13verapamil ......................................... 33VERSACLOZ ...................................... 14VERZENIO ........................................ 25vestura (28) ......................................20VICTOZA 2-PAK ................................27VICTOZA 3-PAK ................................27VIDEX 2 GRAM PEDIATRIC .............. 11VIDEX 4 GRAM PEDIATRIC .............. 11VIGABATRIN .................................... 44VIMPAT ............................................45vinate care ....................................... 55vinate gt ...........................................55vinate m ........................................... 55vinate one ........................................ 55vinate ultra .......................................55viorele (28) ....................................... 20VIRACEPT ......................................... 11VIREAD .............................................11virt-caps ........................................... 55virt-phos 250 neutral ....................... 52virt-vite .............................................55VISTOGARD ......................................40vitamin b-12 .....................................55vitamin d2 ........................................ 55vitamins a,c,d and fluoride ...............55VITEKTA ........................................... 11

VIVOTIF BERNA VACCINE ................ 54vol-care rx ........................................ 55vol-nate ............................................56vol-tab rx ..........................................56VONVENDI ....................................... 22voriconazole .......................................9VOSEVI .............................................10VOTRIENT ........................................ 25vyfemla (28) ..................................... 20VYVANSE ..........................................16warfarin ........................................... 22wera (28) ..........................................20WILATE ............................................ 22XALKORI ...........................................25XARELTO .......................................... 22XENICAL ........................................... 56XERMELO ......................................... 51XIFAXAN ............................................ 7XTANDI ............................................ 23xulane .............................................. 17XYNTHA ........................................... 22XYNTHA SOLOFUSE ......................... 22XYREM ............................................. 49yuvafem ........................................... 56zaleplon ............................................49zarah ................................................ 20ZARXIO .............................................21ZAVESCA .......................................... 29ZEJULA ............................................. 24ZELBORAF ........................................ 25ZEMAIRA ............................................6zenatane .......................................... 45zenchent (28) ................................... 20

..........................................ZERIT ................................................ 11zidovudine ........................................11ZIOPTAN (PF) ................................... 31ziprasidone hcl ................................. 14ZIRGAN ............................................ 29ZOLINZA ...........................................23zolpidem ...........................................49zonisamide ....................................... 45ZONTIVITY ....................................... 22ZOSTAVAX (PF) ................................ 54zovia 1/35e (28) ............................... 20zovia 1/50e (28) ............................... 20ZYKADIA ...........................................25ZYTIGA ............................................. 23


66

preferredrx drug list | healthpartnershp/@public/... · weight loss benefit wl oncology benefit...

Documents