supremo (hmo snp) 2016 formulary (list of … mmm-pha-qrg-769-04-041116-e supremo (hmo snp) 2016...

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MMM-PHA-QRG-769-04-041116-E

Supremo (HMO SNP)

2016 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS ID: 16518, Version # 20 This formulary was updated on May 1, 2016. For more recent information or other questions, please contact Medicare y Mucho Más Member Services Department at 787-620-2397 (Metro Area), 1-866-333-5470 (toll free) or, for TTY users, 1-866-333-5469, Monday through Sunday from 8:00 a.m. to 8:00 p.m., or visit www.mmm-pr.com. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Medicare y Mucho Más. When it refers to “plan” or “our plan,” it means Supremo (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of May 1, 2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.

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What is the Supremo Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at our plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC). Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of May 1, 2016. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, all affected members will be notified via mail (at least 60 days before the change becomes effective). In addition, an updated version of our printed formulary will be updated the first week of the effective month and posted on our website at www.mmm-pr.com. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins 7. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 134. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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What are generic drugs?

Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For

example, our plan provides 30 tablets per prescription for losartan. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Supremo formulary?” on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

• You can ask our plan to make an exception and cover your drug. See below for information about how to

request an exception.

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How do I request an exception to the Supremo Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty

tier. If approved, this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our

plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least 91 and up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your

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drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For those members that are released from a hospital, or other care facility to their home, or if your ability to get your drugs is limited, our plan will cover a temporary 30-day supply for the drugs that are not in our formulary, while you ask your physician to prescribe a similar drug that is covered by our plan. For more information For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. Supremo Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 134. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUMET) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

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Tier Level Structure Before the total yearly drug costs (paid by you and our plan) reach $3,310.00, you pay the following for prescription drugs

Supremo (HMO SNP)

Tier Level Drug Retail

copayment (30 days)

Retail copayment (90 days)

Mail Order copayment (90 days)

1 Preferred Generic $3.00 $9.00 $6.00 2 Generic $7.00 $21.00 $14.00 3 Preferred Brand $35.00 $105.00 $70.00 4 Non Preferred Brand $45.00 $135.00 $90.00 5 Specialty 33% 33% 33%

After your total yearly drug costs reach $3,310.00, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 45% for the plan's costs for brand drugs and 58% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,850.00. The plan offers additional coverage in the gap for the following tiers

Supremo (HMO SNP)

Tier Level Drug Retail

copayment (30 days)

Retail copayment (90 days)

Mail Order copayment (90 days)

1 Preferred Generic $3.00 $9.00 $6.00 2 Generic $7.00 $21.00 $14.00 3 Preferred Brand $35.00 $105.00 $70.00 4 Non Preferred Brand $45.00 $135.00 $90.00

After your yearly out-of-pocket drug costs reach $4,850.00, you pay the greater of:

• 5% coinsurance, or • $2.95 for generic drugs (including brand drugs treated as generic) and $7.40 for all other drugs

For more information on how the tier level is applied, please review your Evidence of Coverage (EOC). Symbols and abbreviations used in the formulary PA - drugs that need prior authorization QL (##/##) - drugs with quantity limit; the quantity in parenthesis specifies the quantity limit for the maximum days of supply ST - step therapy LA - drugs with limited access (ex. Specialty Drugs) MT - maintenance drugs (ex. Contracted pharmacies and Mail Order, 90 day supply) CG – drugs covered during the coverage gap

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Table of Contents Analgesics .................................................................................................................................................................. 9

Anesthetics .............................................................................................................................................................. 13

Anti-Addiction/ Substance Abuse Treatment Agents ......................................................................................... 13

Antibacterials .......................................................................................................................................................... 14

Anticonvulsants ...................................................................................................................................................... 24

Antidementia Agents .............................................................................................................................................. 29

Antidepressants ...................................................................................................................................................... 30

Antiemetics .............................................................................................................................................................. 34

Antifungals .............................................................................................................................................................. 36

Antigout Agents ...................................................................................................................................................... 38

Anti-Inflammatory Agents .................................................................................................................................... 38

Antimigraine Agents .............................................................................................................................................. 40

Antimyasthenic Agents .......................................................................................................................................... 42

Antimycobacterials................................................................................................................................................. 42

Antineoplastics ........................................................................................................................................................ 43

Antiparasitics .......................................................................................................................................................... 51

Antiparkinson Agents ............................................................................................................................................ 52

Antipsychotics ......................................................................................................................................................... 54

Antispasticity Agents.............................................................................................................................................. 58

Antivirals ................................................................................................................................................................. 58

Anxiolytics ............................................................................................................................................................... 64

Bipolar Agents ........................................................................................................................................................ 66

Blood Glucose Regulators ...................................................................................................................................... 68

Blood Products/ Modifiers/ Volume Expanders .................................................................................................. 72

Cardiovascular Agents ........................................................................................................................................... 74

Central Nervous System Agents............................................................................................................................ 83

Dental And Oral Agents ........................................................................................................................................ 86

Dermatological Agents ........................................................................................................................................... 87

Enzyme Replacement/ Modifiers .......................................................................................................................... 89

Gastrointestinal Agents.......................................................................................................................................... 90

Genitourinary Agents ............................................................................................................................................ 93

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ................................................................... 95

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) ................................................................. 98

Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) ....................................................... 99

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ..................................... 99

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ................................................................. 106

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Hormonal Agents, Suppressant (Adrenal) ......................................................................................................... 106

Hormonal Agents, Suppressant (Parathyroid) .................................................................................................. 106

Hormonal Agents, Suppressant (Pituitary) ....................................................................................................... 107

Hormonal Agents, Suppressant (Thyroid) ......................................................................................................... 108

Immunological Agents ......................................................................................................................................... 108

Inflammatory Bowel Disease Agents .................................................................................................................. 114

Metabolic Bone Disease Agents ........................................................................................................................... 115

Non-Frf .................................................................................................................................................................. 116

Ophthalmic Agents ............................................................................................................................................... 117

Otic Agents ............................................................................................................................................................ 120

Respiratory Tract/ Pulmonary Agents ............................................................................................................... 121

Skeletal Muscle Relaxants ................................................................................................................................... 127

Sleep Disorder Agents .......................................................................................................................................... 127

Therapeutic Nutrients/ Minerals/ Electrolytes .................................................................................................. 128

You can find information on what the symbols and abbreviations on this table mean by going to page 6. CG - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. LA - This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-866-333-5470, Monday through Sunday; from 8:00 a.m. to 8:00 p.m. TTY users should call 1-866-333-5469.

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Drug Name

Brand Reference Drug Tier Requirements/Limits

Analgesics

Analgesics

acetaminophen-codeine #2 oral tablet 300-15 mg

2 QL (180 EA per 30 days)


TYLENOL WITH CODEINE #3



TYLENOL WITH CODEINE #4


acetaminophen-codeine oral solution 120-12 mg/5ml

2 QL (5000 ML per 30 days)

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


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

HYCET 4 QL (5400 ML per 30 days)

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

NORCO 2 QL (180 EA per 30 days)

hydrocodone-ibuprofen oral tablet 7.5-200 mg

VICOPROFEN 3 QL (120 EA per 30 days)

lorcet hd oral tablet 10-325 mg 2 QL (180 EA per 30 days)

lorcet oral tablet 5-325 mg 2 QL (180 EA per 30 days)

lorcet plus oral tablet 7.5-325 mg 2 QL (180 EA per 30 days)

lortab oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


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

ENDOCET 3 QL (180 EA per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325 mg

PERCOCET 3 QL (180 EA per 30 days)

oxycodone-acetaminophen oral tablet 5-325 mg

ROXICET 3 QL (180 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325 mg

ULTRACET 2 QL (40 EA per 5 days)


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Drug Name


Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

CELEBREX 4 PA; QL (60 EA per 30 days)

diclofenac potassium oral tablet 50 mg CATAFLAM 1

diclofenac sodium er oral tablet extended release 24 hr* 100 mg

VOLTAREN-XR 1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

diflunisal oral tablet 500 mg 3

etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg

4

etodolac oral capsule 200 mg, 300 mg 3

etodolac oral tablet 400 mg, 500 mg 3

flurbiprofen oral tablet 100 mg, 50 mg 2

ibuprofen oral suspension 100 mg/5ml CHILDRENS MEDI-

PROFEN 3

ketoprofen oral capsule 50 mg, 75 mg 2

meloxicam oral suspension 7.5 mg/5ml MOBIC 4

nabumetone oral tablet 500 mg, 750 mg 1

naproxen dr oral tablet delayed release 375 mg, 500 mg

EC-NAPROSYN 2

naproxen oral suspension 125 mg/5ml NAPROSYN 3

oxaprozin oral tablet 600 mg DAYPRO 2

piroxicam oral capsule 10 mg, 20 mg FELDENE 3

sulindac oral tablet 150 mg 2

sulindac oral tablet 200 mg CLINORIL 2

VOLTAREN TRANSDERMAL 1 % 3

Opioid Analgesics, Long-Acting

duramorph injection solution 0.5 mg/ml, 1 mg/ml

ASTRAMORPH 3 PA

fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

ACTIQ 5 PA; QL (120 EA per 30 days)


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Drug Name


fentanyl transdermal patch 72 hr 100 mcg/hr

DURAGESIC-100 4 PA; QL (10 EA per 30 days)









FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

5 PA; QL (120 EA per 30 days)

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


methadone hcl oral tablet 10 mg, 5 mg DOLOPHINE 2 QL (240 EA per 30 days)

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


morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

AVINZA 4 QL (60 EA per 30 days)

morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg

KADIAN 4 QL (60 EA per 30 days)

morphine sulfate er oral capsule extended release 24 hour 100 mg, 80 mg

KADIAN 5 QL (60 EA per 30 days)

morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 30 mg

MS CONTIN 4 QL (90 EA per 30 days)

morphine sulfate er oral tablet extendedrelease* 200 mg, 60 mg

MS CONTIN 4 QL (60 EA per 30 days)

morphine sulfate oral solution 10 mg/5ml 3 QL (1800 ML per 30 days)

morphine sulfate oral solution 20 mg/5ml 3 QL (900 ML per 30 days)


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Drug Name


morphine sulfate oral tablet 15 mg 3 QL (240 EA per 30 days)

morphine sulfate oral tablet 30 mg 3 QL (120 EA per 30 days)

Opioid Analgesics, Short-Acting

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

4

DEMEROL INJECTION SOLUTION 50 MG/ML

4 PA; QL (720 ML per 30 days)

fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

ACTIQ 5 PA; QL (120 EA per 30 days)











FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


hydromorphone hcl oral liquid† 1 mg/ml DILAUDID-5 4

hydromorphone hcl oral tablet 2 mg, 4 mg DILAUDID 3 QL (180 EA per 30 days)

hydromorphone hcl oral tablet 8 mg DILAUDID 3 QL (90 EA per 30 days)

hydromorphone hcl pf injection solution 500 mg/50ml

DILAUDID-HP 4 PA

morphine sulfate (pf) intravenous* solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

3 PA


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Drug Name


oxycodone hcl oral capsule 5 mg 4 QL (180 EA per 30 days)

oxycodone hcl oral concentrate 100 mg/5ml

4

oxycodone hcl oral solution 5 mg/5ml 4 QL (2700 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 20 mg 3 QL (180 EA per 30 days)

oxycodone hcl oral tablet 15 mg ROXICODONE 3 QL (120 EA per 30 days)



tramadol hcl oral tablet 50 mg ULTRAM 2 QL (240 EA per 30 days)

Anesthetics

Local Anesthetics

LIDOCAINE EXTERNAL OINTMENT 5 %

3

lidocaine external patch 5 % LIDODERM 4 PA; QL (90 EA per 30 days)

lidocaine hcl (pf) injection solution 0.5 % XYLOCAINE-MPF 2 PA

lidocaine hcl external 2 % REGENECARE HA 2

lidocaine hcl injection solution 2 % XYLOCAINE 2 PA

lidocaine-prilocaine external cream 2.5-2.5 %

EMLA 3 PA

Anti-Addiction/ Substance Abuse Treatment Agents

Alcohol Deterrents/ Anti-Craving

acamprosate calcium oral tablet delayed release 333 mg

CAMPRAL 4

disulfiram oral tablet 250 mg, 500 mg ANTABUSE 4 CG

naltrexone hcl oral tablet 50 mg REVIA 3


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Drug Name


Opioid Dependence Treatments

buprenorphine hcl sublingual tablet sublingual 2 mg

4

buprenorphine hcl sublingual tablet sublingual 8 mg


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

SUBOXONE 4 PA; QL (120 EA per 30 days)

naltrexone hcl oral tablet 50 mg REVIA 3

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


Opioid Reversal Agents

naloxone hcl injection solution 1 mg/ml 3

naloxone hcl injection solution 0.4 mg/ml 1

Smoking Cessation Agents

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG


CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

4 PA

NICOTROL INHALATION INHALER 10 MG

4

NICOTROL NS NASAL SOLUTION 10 MG/ML

4

Antibacterials

Aminoglycosides

amikacin sulfate injection solution 500 mg/2ml

3

gentak ophthalmic ointment 0.3 % 2


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Drug Name


gentamicin in saline intravenous* solution 0.8-0.9 mg/ml-%, 0.9-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.4-0.9 mg/ml-%, 1.6-0.9 mg/ml-%

2

gentamicin sulfate external cream 0.1 % 3

gentamicin sulfate external ointment 0.1 %

3

gentamicin sulfate injection solution 40 mg/ml

2

gentamicin sulfate intravenous* solution 10 mg/ml

2

gentamicin sulfate ophthalmic ointment 0.3 %

GARAMYCIN 2

gentamicin sulfate ophthalmic solution 0.3 %

GARAMYCIN 2

neomycin sulfate oral tablet 500 mg 3

paromomycin sulfate oral capsule 250 mg 4

streptomycin sulfate intramuscular* solution reconstituted 1 gm

4

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

3

tobramycin inhalation nebulization solution 300 mg/5ml

TOBI 5 PA; QL (280 ML per 28 days)

tobramycin ophthalmic solution 0.3 % TOBREX 2

tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml

3 PA

TOBREX OPHTHALMIC OINTMENT 0.3 %

4

ZANOSAR INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM

5 PA

Antibacterials, Other

acetic acid otic solution 2 % VOSOL 3

bacitracin ophthalmic ointment 500 unit/gm

3


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Drug Name


chloramphenicol sod succinate intravenous* solution reconstituted 1 gm

2 PA

clindamax external 1 % 1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

CLEOCIN 4

clindamycin phosphate external 1 % CLEOCIN-T 4

clindamycin phosphate external lotion 1 %

CLEOCIN-T 4

clindamycin phosphate external solution 1 %

CLEOCIN-T 3

clindamycin phosphate external swab 1 % CLINDACIN ETZ 3

clindamycin phosphate in d5w intravenous* solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

CLEOCIN IN D5W 3

clindamycin phosphate vaginal cream 2 % CLEOCIN 4

CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

5 PA

linezolid intravenous* solution 2 mg/ml ZYVOX 5

linezolid oral suspension reconstituted 100 mg/5ml

ZYVOX 5 PA

linezolid oral tablet 600 mg ZYVOX 5 PA

methenamine hippurate oral tablet 1 gm UREX 3

metronidazole external 0.75 % ROSADAN 4

METRONIDAZOLE EXTERNAL 1 % METROGEL 4

metronidazole external cream 0.75 % METROCREAM 4

metronidazole external lotion 0.75 % METROLOTION 4

metronidazole in nacl intravenous* solution 500-0.79 mg/100ml-%

2

metronidazole oral tablet 250 mg, 500 mg FLAGYL 2

metronidazole vaginal 0.75 % METROGEL-VAGINAL 3

mupirocin calcium external cream 2 % BACTROBAN 2

mupirocin external ointment 2 % BACTROBAN 2


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Drug Name


nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

MACRODANTIN 4 PA

NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 25 MG

MACRODANTIN 4 PA

NITROFURANTOIN MONOHYD MACRO ORAL CAPSULE 100 MG

MACROBID 4 PA

SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 200 MG


SIVEXTRO ORAL TABLET 200 MG 5 PA; QL (6 EA per 15 days)

SULFAMYLON EXTERNAL CREAM 85 MG/GM

4

trimethoprim oral tablet 100 mg 2

TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

5 PA

vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg

3 PA

vancomycin hcl oral capsule 125 mg, 250 mg

VANCOCIN HCL 5

VANDAZOLE VAGINAL 0.75 % 3

XIFAXAN ORAL TABLET 200 MG, 550 MG

5 PA

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

5 PA

Antibacterials

colistimethate sodium injection solution reconstituted 150 mg

COLY-MYCIN M 4 PA

SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED 150-350 MG

5 PA

Beta-Lactam, Cephalosporins

cefaclor er oral tablet extended release 12 hr* 500 mg

4

cefaclor oral capsule 250 mg, 500 mg 3


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Drug Name


cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

4

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

3

cefadroxil oral tablet 1 gm 4

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg

3

cefazolin sodium intravenous* solution 1-5 gm-%

3

cefdinir oral capsule 300 mg 3

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

4

cefepime hcl injection solution reconstituted 1 gm, 2 gm

MAXIPIME 4

CEFIXIME ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

SUPRAX 3

cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg

CLAFORAN 4

cefoxitin sodium injection solution reconstituted 10 gm

4

cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm

4 PA

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

4

cefpodoxime proxetil oral tablet 100 mg, 200 mg

4

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

3

cefprozil oral tablet 250 mg, 500 mg 3

ceftazidime and dextrose intravenous* solution reconstituted 1 gm/50ml, 2 gm/50ml

4

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

FORTAZ 4


19

Drug Name


ceftriaxone sodium injection solution reconstituted 250 mg

3 PA

ceftriaxone sodium injection solution reconstituted 500 mg

ROCEPHIN 3 PA

ceftriaxone sodium intravenous* solution reconstituted 1 gm

3 PA

ceftriaxone sodium intravenous* solution reconstituted 10 gm, 2 gm

3

cefuroxime axetil oral tablet 250 mg, 500 mg

CEFTIN 3

cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg

ZINACEF 3 PA

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

3

cephalexin oral tablet 250 mg, 500 mg 1

SUPRAX ORAL CAPSULE 400 MG 3

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

3

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

4

TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG

4 PA

Beta-Lactam, Other

AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM

4

AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 2 GM

5 PA

aztreonam injection solution reconstituted 1 gm

AZACTAM 3

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

5 PA; LA


20

Drug Name


imipenem-cilastatin intravenous* solution reconstituted 250 mg, 500 mg

PRIMAXIN IV 4 PA

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

4 PA

meropenem intravenous* solution reconstituted 500 mg

MERREM 4 PA

Beta-Lactam, Penicillins

amoxicillin oral tablet chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate er oral tablet extended release 12 hr* 1000-62.5 mg

AUGMENTIN XR 4

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml

3

amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml

AUGMENTIN 3

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml

AUGMENTIN ES-600 3

amoxicillin-pot clavulanate oral tablet 250-125 mg

2

amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg

AUGMENTIN 2

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg

AUGMENTIN 3

amoxicillin-pot clavulanate oral tablet chewable 400-57 mg

3

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

3

ampicillin sodium injection solution reconstituted 1 gm, 125 mg

4 PA

ampicillin sodium intravenous* solution reconstituted 10 gm

4 PA

ampicillin-sulbactam sodium injection solution reconstituted 3 (2-1) gm

UNASYN 4 PA


21

Drug Name


ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm

4 PA

BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML

3

BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML

3

BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

4

dicloxacillin sodium oral capsule 250 mg, 500 mg

3

nafcillin sodium injection solution reconstituted 1 gm

4 PA

nafcillin sodium injection solution reconstituted 10 gm

5

oxacillin sodium injection solution reconstituted 10 gm

5

oxacillin sodium injection solution reconstituted 2 gm

4

penicillin g pot in dextrose intravenous* solution 40000 unit/ml, 60000 unit/ml

4

penicillin g potassium injection solution reconstituted 5000000 unit

PFIZERPEN-G 4

penicillin g procaine intramuscular* suspension 600000 unit/ml

4

penicillin g sodium injection solution reconstituted 5000000 unit

4

piperacillin sod-tazobactam so intravenous* solution reconstituted 3-0.375 gm, 4-0.5 gm

ZOSYN 4

Macrolides

azithromycin intravenous* solution reconstituted 500 mg

ZITHROMAX 3

azithromycin oral packet 1 gm ZITHROMAX 3


22

Drug Name


azithromycin oral suspension reconstituted 100 mg/5ml

ZITHROMAX 3 QL (75 ML per 30 days)

azithromycin oral suspension reconstituted 200 mg/5ml

ZITHROMAX 3 QL (68 ML per 30 days)

azithromycin oral tablet 250 mg (6 pack) ZITHROMAX Z-PAK 1 QL (6 EA per 5 days)

clarithromycin er oral tablet extended release 24 hr* 500 mg

BIAXIN XL PAC 3

clarithromycin oral suspension reconstituted 125 mg/5ml

4

clarithromycin oral suspension reconstituted 250 mg/5ml

BIAXIN 4

clarithromycin oral tablet 250 mg, 500 mg BIAXIN 4

DIFICID ORAL TABLET 200 MG 5 ST

E.E.S. 400 ORAL TABLET 400 MG 4

ery external pad 2 % 3

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

4

ERYTHROCIN LACTOBIONATE INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

4 PA

ERYTHROCIN STEARATE ORAL TABLET 250 MG

4

ERYTHROMYCIN BASE ORAL CAPSULE DELAYED RELEASE PARTICLES 250 MG

3

erythromycin base oral tablet 250 mg, 500 mg

4

erythromycin ethylsuccinate oral tablet 400 mg

E.E.S. 400 4

erythromycin external 2 % ERYGEL 3

erythromycin external solution 2 % 3

erythromycin ophthalmic ointment 5 mg/gm

ILOTYCIN 2

ilotycin ophthalmic ointment 5 mg/gm 2


23

Drug Name


Quinolones

CILOXAN OPHTHALMIC OINTMENT 0.3 %

3

ciprofloxacin hcl ophthalmic solution 0.3 %

CILOXAN 2

ciprofloxacin in d5w intravenous* solution 200 mg/100ml

CIPRO IN D5W 4

ciprofloxacin intravenous* solution 400 mg/40ml

4

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

CIPRO 4

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg, 500 mg

CIPRO XR 4

gatifloxacin ophthalmic solution 0.5 % ZYMAXID 4

levofloxacin in d5w intravenous* solution 500 mg/100ml

LEVAQUIN 3

LEVOFLOXACIN IN D5W INTRAVENOUS* SOLUTION 750 MG/150ML

LEVAQUIN 3

levofloxacin intravenous* solution 25 mg/ml

4

levofloxacin oral solution 25 mg/ml LEVAQUIN 4

MOXEZA OPHTHALMIC SOLUTION 0.5 %

3

moxifloxacin hcl oral tablet 400 mg AVELOX ABC PACK 2 QL (21 EA per 21 days)

ofloxacin ophthalmic solution 0.3 % OCUFLOX 2

ofloxacin otic solution 0.3 % 2

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

3

Sulfonamides

silver sulfadiazine external cream 1 % THERMAZENE 2

ssd external cream 1 % 2


24

Drug Name


sulfacetamide sodium external suspension 10 %

KLARON 3

sulfacetamide sodium ophthalmic ointment 10 %

3

sulfacetamide sodium ophthalmic solution 10 %

BLEPH-10 3

sulfadiazine oral tablet 500 mg 4

sulfamethoxazole-trimethoprim intravenous* solution 400-80 mg/5ml

4

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

SULFATRIM PEDIATRIC

3

Tetracyclines

DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

4

doxycycline hyclate intravenous* solution reconstituted 100 mg

DOXY 100 4 PA

doxycycline hyclate oral capsule 100 mg VIBRAMYCIN 3

doxycycline hyclate oral capsule 50 mg 3

doxycycline hyclate oral tablet 100 mg, 20 mg

3

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg

ADOXA 3

doxycycline monohydrate oral tablet 150 mg

ADOXA PAK 1/150 3

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

MINOCIN 2

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

DYNACIN 2

Anticonvulsants

Anticonvulsants, Other

diazepam 10 mg, 20 mg DIASTAT ACUDIAL 4

diazepam 2.5 mg DIASTAT PEDIATRIC 4

levetiracetam er oral tablet extended release 24 hr* 500 mg, 750 mg

KEPPRA XR 4 CG


25

Drug Name


levetiracetam intravenous* solution 500 mg/5ml

KEPPRA 4 CG

LEVETIRACETAM ORAL SOLUTION 100 MG/ML

KEPPRA 3 MT; CG

LEVETIRACETAM ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG

KEPPRA 3 MT; CG

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG

5

POTIGA ORAL TABLET 50 MG 4

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE 300 MG 4 MT

ETHOSUXIMIDE ORAL CAPSULE 250 MG

ZARONTIN 4 MT; CG

ETHOSUXIMIDE ORAL SOLUTION 250 MG/5ML

ZARONTIN 4 MT; CG

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

3 PA

LYRICA ORAL SOLUTION 20 MG/ML 3 PA

ZONISAMIDE ORAL CAPSULE 100 MG, 25 MG

ZONEGRAN 3 MT; CG

ZONISAMIDE ORAL CAPSULE 50 MG 3 MT; CG

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents

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

2 CG

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

TRANXENE-T 2 CG

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

3

diazepam oral solution 1 mg/ml 3 CG

DIVALPROEX SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 MG, 500 MG

DEPAKOTE ER 4 MT; CG


26

Drug Name


DIVALPROEX SODIUM ORAL CAPSULE SPRINKLE 125 MG

DEPAKOTE SPRINKLES

4 MT; CG

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

DEPAKOTE 2 MT; CG

gabapentin oral capsule 100 mg, 300 mg, 400 mg

NEURONTIN 1 MT; CG

gabapentin oral solution 250 mg/5ml NEURONTIN 1 MT; CG

gabapentin oral tablet 600 mg, 800 mg NEURONTIN 1 MT; CG

GABITRIL ORAL TABLET 12 MG, 16 MG

4 MT

LAMOTRIGINE ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG

LAMICTAL ODT 3 MT

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

3

ONFI ORAL SUSPENSION 2.5 MG/ML 4

ONFI ORAL TABLET 10 MG 4

ONFI ORAL TABLET 20 MG 5

phenobarbital oral elixir 20 mg/5ml 4 PA

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

4 PA

primidone oral tablet 250 mg, 50 mg MYSOLINE 2 MT; CG

SABRIL ORAL PACKET 500 MG 5 PA; LA

SABRIL ORAL TABLET 500 MG 5 PA; LA

TIAGABINE HCL ORAL TABLET 2 MG, 4 MG

GABITRIL 4 MT; CG

valproate sodium intravenous* solution 500 mg/5ml

DEPACON 4 CG

VALPROIC ACID ORAL CAPSULE 250 MG

DEPAKENE 3 MT; CG

valproic acid oral syrup 250 mg/5ml DEPAKENE 2 MT; CG

Glutamate Reducing Agents

felbamate oral suspension 600 mg/5ml FELBATOL 5


27

Drug Name


FELBAMATE ORAL TABLET 400 MG FELBATOL 4 MT; CG

FELBAMATE ORAL TABLET 600 MG FELBATOL 4 MT

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4 PA

LAMOTRIGINE ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

LAMICTAL XR 4 MT; CG

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

LAMICTAL 2 MT; CG

LAMOTRIGINE ORAL TABLET CHEWABLE 25 MG, 5 MG

LAMICTAL 3 MT; CG

topiramate er oral 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

QUDEXY XR 2 MT

TOPIRAMATE ORAL CAPSULE SPRINKLE 15 MG, 25 MG

TOPAMAX SPRINKLE 4 MT; CG

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

TOPAMAX 2 MT; CG

Sodium Channel Agents

APTIOM ORAL TABLET 200 MG 4 PA

APTIOM ORAL TABLET 400 MG, 800 MG


APTIOM ORAL TABLET 600 MG 5 PA; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML

5 PA

BANZEL ORAL TABLET 200 MG 4 PA

BANZEL ORAL TABLET 400 MG 5 PA

CARBAMAZEPINE ER ORAL TABLET EXTENDED RELEASE 12 HR* 200 MG, 400 MG

TEGRETOL XR 4 MT; CG

carbamazepine oral suspension 100 mg/5ml

TEGRETOL 4 MT; CG

carbamazepine oral tablet 200 mg TEGRETOL 3 MT; CG


28

Drug Name


carbamazepine oral tablet chewable 100 mg

3 MT; CG

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

3 MT

DILANTIN ORAL CAPSULE 100 MG 3 MT

DILANTIN ORAL CAPSULE 30 MG 3 MT

DILANTIN ORAL SUSPENSION 125 MG/5ML

3 MT

EPITOL ORAL TABLET 200 MG 3 MT; CG

OXCARBAZEPINE ORAL SUSPENSION 300 MG/5ML

TRILEPTAL 4 MT; CG

OXCARBAZEPINE ORAL TABLET 150 MG, 300 MG, 600 MG

TRILEPTAL 3 MT; CG

PEGANONE ORAL TABLET 250 MG 4 MT

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

3 MT

phenytoin oral suspension 125 mg/5ml DILANTIN 3 MT; CG

phenytoin oral tablet chewable 50 mg PHENYTOIN INFATABS

3 MT; CG

phenytoin sodium extended oral capsule 100 mg

DILANTIN 3 MT; CG

phenytoin sodium extended oral capsule 200 mg, 300 mg

PHENYTEK 3 MT; CG

phenytoin sodium injection solution 50 mg/ml

3 CG

TEGRETOL ORAL SUSPENSION 100 MG/5ML

4

TEGRETOL ORAL TABLET 200 MG 4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 200 MG, 400 MG

4


29

Drug Name


VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML

4

VIMPAT ORAL SOLUTION 10 MG/ML 4 MT

VIMPAT ORAL TABLET 100 MG 4 QL (60 EA per 30 days)

VIMPAT ORAL TABLET 150 MG 5 QL (60 EA per 30 days)

VIMPAT ORAL TABLET 200 MG 5

VIMPAT ORAL TABLET 50 MG 4

Antidementia Agents

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg

ARICEPT 1 MT; CG; QL (30 EA per 30 days)

donepezil hcl oral tablet dispersible 10 mg, 5 mg

ARICEPT ODT 1 MT; CG; QL (30 EA per 30 days)

EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

4 PA; MT; QL (30 EA per 30 days)

GALANTAMINE HYDROBROMIDE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG

RAZADYNE ER 4 MT; CG; QL (30 EA per 30 days)

GALANTAMINE HYDROBROMIDE ORAL SOLUTION 4 MG/ML

RAZADYNE 4 MT; CG

GALANTAMINE HYDROBROMIDE ORAL TABLET 12 MG, 4 MG, 8 MG

RAZADYNE 4 MT; CG

RIVASTIGMINE TARTRATE ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

EXELON 4 MT; CG

N-Methyl-D-Aspartate (Nmda) Receptor Antagonist

MEMANTINE HCL ORAL SOLUTION 2 MG/ML

NAMENDA 3 PA; MT; CG

MEMANTINE HCL ORAL TABLET 10 MG, 5 MG

NAMENDA 3 PA; MT; CG


30

Drug Name


MEMANTINE HCL ORAL TABLET 5 (28)-10 (21) MG

NAMENDA TITRATION PAK

3 PA; MT; CG

NAMENDA ORAL SOLUTION 10 MG/5ML

3 PA; MT; QL (300 ML per 30 days)

NAMENDA ORAL TABLET 10 MG, 5 MG

4 PA; MT

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG


NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG


Antidepressants

Antidepressants, Other

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG

5 PA

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 5 MG

5 PA

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

ABILIFY 5

aripiprazole oral tablet dispersible 10 mg, 15 mg

ABILIFY DISCMELT 5

BUPROBAN ORAL TABLET EXTENDED RELEASE 12 HR* 150 MG

3 MT; CG

bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg

BUDEPRION SR 2 MT; CG

bupropion hcl er (sr) oral tablet extended release 12 hr* 150 mg, 200 mg

WELLBUTRIN SR 2 MT; CG

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG

WELLBUTRIN XL 3 MT; CG

BUPROPION HCL ORAL TABLET 100 MG, 75 MG

WELLBUTRIN 3 MT; CG


31

Drug Name


maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

4 CG

mirtazapine oral tablet 15 mg, 30 mg, 45 mg

REMERON 2 MT; CG

mirtazapine oral tablet 7.5 mg 2 MT; CG

MIRTAZAPINE ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG

REMERON SOLTAB 3 MT; CG

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

4 CG

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG


Antidepressants

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

SYMBYAX 2 MT; CG

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

2 PA

Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR


MARPLAN ORAL TABLET 10 MG 4 MT

PHENELZINE SULFATE ORAL TABLET 15 MG

NARDIL 3 MT; CG

TRANYLCYPROMINE SULFATE ORAL TABLET 10 MG

PARNATE 4 MT; CG

Ssris/ Snris

BRINTELLIX ORAL TABLET 10 MG, 5 MG

4 ST; QL (60 EA per 30 days)


32

Drug Name


BRINTELLIX ORAL TABLET 20 MG 4 ST; QL (30 EA per 30 days)

CITALOPRAM HYDROBROMIDE ORAL SOLUTION 10 MG/5ML

3 MT; CG

desvenlafaxine er oral tablet extended release 24 hr* 100 mg, 50 mg

KHEDEZLA 2 MT

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

CYMBALTA 3 MT; CG

duloxetine hcl oral capsule delayed release particles 40 mg

IRENKA 3 MT

ESCITALOPRAM OXALATE ORAL SOLUTION 5 MG/5ML

LEXAPRO 4 MT; CG; QL (600 ML per 30 days)

escitalopram oxalate oral tablet 10 mg LEXAPRO 2 MT; CG; QL (60 EA per 30 days)



FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG


FETZIMA TITRATION ORAL 20 & 40 MG

4 ST

fluoxetine hcl oral capsule delayed release 90 mg

PROZAC WEEKLY 1 MT; CG; QL (4 EA per 28 days)

FLUOXETINE HCL ORAL SOLUTION 20 MG/5ML

3 MT; CG

FLUOXETINE HCL ORAL TABLET 10 MG, 20 MG

3 MT; CG

FLUVOXAMINE MALEATE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 150 MG

LUVOX CR 3 MT

FLUVOXAMINE MALEATE ORAL TABLET 100 MG, 25 MG, 50 MG

3 MT; CG


33

Drug Name


paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg

PAXIL CR 1 MT; CG

PAXIL ORAL SUSPENSION 10 MG/5ML

4 ST

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG

3 ST; MT; QL (30 EA per 30 days)

SERTRALINE HCL ORAL CONCENTRATE 20 MG/ML

ZOLOFT 3 MT; CG

venlafaxine hcl er oral capsule extended release 24 hour 150 mg

EFFEXOR XR 2 MT; CG; QL (60 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg


venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 37.5 mg, 75 mg

2 MT; CG

VENLAFAXINE HCL ORAL TABLET 100 MG, 25 MG, 37.5 MG, 50 MG, 75 MG

3 MT; CG

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG


Tricyclics

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

4 PA

AMOXAPINE ORAL TABLET 100 MG, 150 MG, 25 MG, 50 MG

3 MT; CG

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

ANAFRANIL 4 PA

DESIPRAMINE HCL ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG

NORPRAMIN 4 MT; CG

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

4 PA

doxepin hcl oral concentrate 10 mg/ml 4 PA


34

Drug Name


imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

TOFRANIL 4 PA

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

TOFRANIL-PM 2 PA

NORTRIPTYLINE HCL ORAL SOLUTION 10 MG/5ML

4 MT

PROTRIPTYLINE HCL ORAL TABLET 10 MG, 5 MG

VIVACTIL 4 MT; CG

PRUDOXIN EXTERNAL CREAM 5 % 4

SILENOR ORAL TABLET 3 MG, 6 MG 3 ST; QL (30 EA per 30 days)

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

4 PA

TRIMIPRAMINE MALEATE ORAL CAPSULE 100 MG, 25 MG, 50 MG

SURMONTIL 3 PA; CG

Antiemetics

Antiemetics, Other

chlorpromazine hcl injection solution 50 mg/2ml

4 CG

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

4 CG

COMPRO SUPPOSITORY 25 MG 4

diphenhydramine hcl injection solution 50 mg/ml

2

hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml

4 PA

meclizine hcl oral tablet 12.5 mg, 25 mg ANTIVERT 2

metoclopramide hcl injection solution 5 mg/ml

2

metoclopramide hcl oral solution 5 mg/5ml

2

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

4 CG

phenadoz suppository 12.5 mg 2 PA


35

Drug Name


prochlorperazine edisylate injection solution 5 mg/ml

3

prochlorperazine suppository 25 mg COMPRO 4

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

2 PA

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HR 1 MG/3DAYS


Emetogenic Therapy Adjuncts

dronabinol oral capsule 10 mg MARINOL 5 PA; QL (60 EA per 30 days)

dronabinol oral capsule 2.5 mg, 5 mg MARINOL 4 PA; QL (60 EA per 30 days)

EMEND INTRAVENOUS* SOLUTION RECONSTITUTED 150 MG

4 PA

EMEND ORAL CAPSULE 125 MG 4 PA; QL (2 EA per 30 days)


EMEND ORAL CAPSULE 80 & 125 MG 4 PA; QL (3 EA per 3 days)


granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml

3

granisetron hcl oral tablet 1 mg 4 PA; QL (60 EA per 30 days)

ondansetron hcl injection solution 4 mg/2ml

3 PA

ondansetron hcl oral solution 4 mg/5ml ZOFRAN 4 PA; QL (150 ML per 5 days)

ondansetron hcl oral tablet 24 mg 3 PA; QL (18 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg ZOFRAN 3 PA; QL (15 EA per 5 days)


36

Drug Name


ondansetron oral tablet dispersible 4 mg, 8 mg

ZOFRAN ODT 2 PA; QL (15 EA per 5 days)

Antifungals

Antifungals

ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML

5 PA

AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG

5 PA

amphotericin b injection solution reconstituted 50 mg

4 PA

CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG

5 PA

ciclopirox external 0.77 % LOPROX 4

ciclopirox external shampoo 1 % LOPROX 4

ciclopirox olamine external cream 0.77 % CICLODAN 3

ciclopirox olamine external suspension 0.77 %

3

clotrimazole external cream 1 % LOTRIMIN AF 1

clotrimazole external solution 1 % FUNGICURE

INTENSIVE/NAILGUARD

1

clotrimazole mouth/throat troche 10 mg 4

econazole nitrate external cream 1 % 4

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

DIFLUCAN 3

fluconazole oral tablet 100 mg, 200 mg, 50 mg

DIFLUCAN 2

fluconazole oral tablet 150 mg DIFLUCAN 2 QL (2 EA per 15 days)

flucytosine oral capsule 250 mg, 500 mg ANCOBON 5

griseofulvin microsize oral suspension 125 mg/5ml

3

griseofulvin microsize oral tablet 500 mg GRIFULVIN V 4


37

Drug Name


griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

GRIS-PEG 4

itraconazole oral capsule 100 mg SPORANOX PULSEPAK


ketoconazole external cream 2 % 3

ketoconazole external shampoo 2 % NIZORAL 2

ketoconazole oral tablet 200 mg 3

MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG

5 PA

NATACYN OPHTHALMIC SUSPENSION 5 %

4

NOXAFIL ORAL SUSPENSION 40 MG/ML

5

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

5

NYAMYC EXTERNAL POWDER 100000 UNIT/GM

3

nystatin external cream 100000 unit/gm 3

nystatin external ointment 100000 unit/gm 3

nystatin external powder 100000 unit/gm NYSTOP 3

nystatin mouth/throat suspension 100000 unit/ml

3

nystatin oral tablet 500000 unit 3

NYSTOP EXTERNAL POWDER 100000 UNIT/GM

3

terbinafine hcl oral tablet 250 mg LAMISIL 2 QL (90 EA per 365 days)

terconazole vaginal cream 0.4 % TERAZOL 7 3

terconazole vaginal cream 0.8 % TERAZOL 3 3

terconazole vaginal suppository 80 mg TERAZOL 3 4 QL (3 EA per 15 days)

voriconazole intravenous* solution reconstituted 200 mg

VFEND IV 4


38

Drug Name


voriconazole oral suspension reconstituted 40 mg/ml

VFEND 5

voriconazole oral tablet 200 mg, 50 mg VFEND 5

ZAZOLE VAGINAL CREAM 0.8 % 3

ZOLINZA ORAL CAPSULE 100 MG 5 PA

Antigout Agents

Antigout Agents

COLCHICINE ORAL CAPSULE 0.6 MG MITIGARE 3 MT

COLCHICINE ORAL TABLET 0.6 MG COLCRYS 3 MT

COLCHICINE-PROBENECID ORAL TABLET 0.5-500 MG

3 MT; CG

COLCRYS ORAL TABLET 0.6 MG 3 MT

probenecid oral tablet 500 mg 3 CG

ULORIC ORAL TABLET 40 MG, 80 MG

3 MT

Anti-Inflammatory Agents

Glucocorticoids

a-hydrocort injection solution reconstituted 100 mg

2

betamethasone dipropionate aug external 0.05 %

4

betamethasone dipropionate aug external cream 0.05 %

DIPROLENE AF 3

betamethasone dipropionate aug external lotion 0.05 %

DIPROLENE 4

betamethasone dipropionate aug external ointment 0.05 %

DIPROLENE 4

betamethasone dipropionate external cream 0.05 %

3

betamethasone dipropionate external lotion 0.05 %

3

betamethasone dipropionate external ointment 0.05 %

4


39

Drug Name


betamethasone valerate external cream 0.1 %

3

betamethasone valerate external lotion 0.1 %

3

betamethasone valerate external ointment 0.1 %

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

4

cortisone acetate oral tablet 25 mg 4

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

3

dexamethasone oral elixir 0.5 mg/5ml BAYCADRON 3

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

2

dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

2

hydrocortisone oral tablet 20 mg, 5 mg CORTEF 3

KENALOG INJECTION SUSPENSION 40 MG/ML

3

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

DEPO-MEDROL 2

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

MEDROL 3

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

SOLU-MEDROL 3

prednisolone sodium phosphate ophthalmic solution 1 %

3

prednisolone sodium phosphate oral solution 15 mg/5ml

ORAPRED 2


2

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

PEDIAPRED 2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

3


40

Drug Name


prednisone oral solution 5 mg/5ml 3

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 250 MG

4

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

2

Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

CELEBREX 4 PA; QL (60 EA per 30 days)

diclofenac potassium oral tablet 50 mg CATAFLAM 1

diclofenac sodium er oral tablet extended release 24 hr* 100 mg

VOLTAREN-XR 1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

diflunisal oral tablet 500 mg 3

etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg

4

etodolac oral capsule 200 mg 3

etodolac oral tablet 400 mg, 500 mg 3

flurbiprofen oral tablet 100 mg, 50 mg 2

ibuprofen oral suspension 100 mg/5ml CHILDRENS MEDI-

PROFEN 3

ketoprofen oral capsule 50 mg, 75 mg 2

nabumetone oral tablet 500 mg, 750 mg 1

naproxen dr oral tablet delayed release 375 mg, 500 mg

EC-NAPROSYN 2

naproxen oral suspension 125 mg/5ml NAPROSYN 3

oxaprozin oral tablet 600 mg DAYPRO 2

piroxicam oral capsule 10 mg, 20 mg FELDENE 3

sulindac oral tablet 150 mg 2

sulindac oral tablet 200 mg CLINORIL 2

Antimigraine Agents

Antimigraine Agents


41

Drug Name


methylergonovine maleate oral tablet 0.2 mg

METHERGINE 4

Ergot Alkaloids

dihydroergotamine mesylate injection solution 1 mg/ml

D.H.E. 45 3

ergomar sublingual tablet sublingual 2 mg 2

Prophylactic

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT

4 PA

divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg


divalproex sodium oral capsule sprinkle 125 mg

DEPAKOTE SPRINKLES

4 MT; CG


DEPAKOTE 2 MT; CG

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

3 MT; CG

topiramate oral capsule sprinkle 15 mg, 25 mg

TOPAMAX SPRINKLE 4 MT; CG

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

TOPAMAX 2 MT; CG

valproic acid oral capsule 250 mg DEPAKENE 3 MT; CG


Serotonin (5-Ht) 1B/1D Receptor Agonists

naratriptan hcl oral tablet 1 mg, 2.5 mg AMERGE 3 QL (18 EA per 28 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg

MAXALT 3 QL (18 EA per 28 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

MAXALT-MLT 3 QL (18 EA per 28 days)

sumatriptan nasal solution 20 mg/act IMITREX 4 QL (12 EA per 28 days)


42

Drug Name


sumatriptan nasal solution 5 mg/act IMITREX 4 QL (24 EA per 28 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

IMITREX 2 QL (9 EA per 28 days)

sumatriptan succinate subcutaneous* 6 mg/0.5ml

ALSUMA 4 QL (6 ML per 28 days)

SUMATRIPTAN SUCCINATE SUBCUTANEOUS* 6 MG/0.5ML (AUTO-INJECTOR)


sumatriptan succinate subcutaneous* solution 6 mg/0.5ml


zolmitriptan oral tablet 2.5 mg, 5 mg ZOMIG 4 QL (12 EA per 28 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg

ZOMIG ZMT 4 QL (12 EA per 28 days)

Antimyasthenic Agents

Parasympathomimetics

guanidine hcl oral tablet 125 mg 2

MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG

4

PYRIDOSTIGMINE BROMIDE ER ORAL TABLET EXTENDEDRELEASE* 180 MG

MESTINON 4

PYRIDOSTIGMINE BROMIDE ORAL TABLET 60 MG

MESTINON 3

Antimycobacterials

Antimycobacterials, Other

dapsone oral tablet 100 mg, 25 mg 3

rifabutin oral capsule 150 mg MYCOBUTIN 4

Antituberculars

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

4

ethambutol hcl oral tablet 100 mg, 400 mg MYAMBUTOL 3

isoniazid injection solution 100 mg/ml 3


43

Drug Name


isoniazid oral syrup 50 mg/5ml 4

PASER ORAL PACKET 4 GM 3

pyrazinamide oral tablet 500 mg 4

rifampin intravenous* solution reconstituted 600 mg

RIFADIN 4

rifampin oral capsule 150 mg, 300 mg RIFADIN 3

RIFATER ORAL TABLET 50-120-300 MG

4

SIRTURO ORAL TABLET 100 MG 5 PA

TRECATOR ORAL TABLET 250 MG 4

Antineoplastics

Alkylating Agents

BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML

5 PA

cyclophosphamide oral capsule 25 mg, 50 mg

4 PA

HEXALEN ORAL CAPSULE 50 MG 5 PA

LEUKERAN ORAL TABLET 2 MG 4

MATULANE ORAL CAPSULE 50 MG 5 PA

melphalan hcl intravenous* solution reconstituted 50 mg

ALKERAN 5 PA

thiotepa injection solution reconstituted 15 mg

5 PA

TREANDA INTRAVENOUS* SOLUTION 45 MG/0.5ML

5 PA

VALCHLOR EXTERNAL 0.016 % 5 PA; LA

Antiandrogens

bicalutamide oral tablet 50 mg CASODEX 3 CG

flutamide oral capsule 125 mg 4 CG

NILANDRON ORAL TABLET 150 MG 5

XTANDI ORAL CAPSULE 40 MG 5 PA; QL (120 EA per 30 days)

ZYTIGA ORAL TABLET 250 MG 5 PA


44

Drug Name


Antiangiogenic Agents

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

5 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

5 PA; LA

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

5 PA

Antiestrogens/Modifiers

EMCYT ORAL CAPSULE 140 MG 4

FARESTON ORAL TABLET 60 MG 5

SOLTAMOX ORAL SOLUTION 10 MG/5ML

4 PA

Antimetabolites

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

3

gemcitabine hcl intravenous* solution reconstituted 1 gm

GEMZAR 5 PA

HYDROXYUREA ORAL CAPSULE 500 MG

HYDREA 3 MT; CG

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

5 PA

PURIXAN ORAL SUSPENSION 2000 MG/100ML

5

TABLOID ORAL TABLET 40 MG 4

Antineoplastics, Other

amifostine intravenous* solution reconstituted 500 mg

ETHYOL 5 PA

fludarabine phosphate intravenous* solution reconstituted 50 mg

FLUDARA 4 PA

leucovorin calcium injection solution reconstituted 100 mg, 350 mg

4 PA; CG

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

3 CG


45

Drug Name


mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml

3 PA; CG

REVLIMID ORAL CAPSULE 2.5 MG, 20 MG

5 PA; LA

SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG

5 PA

YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML

5 PA; LA

ZALTRAP INTRAVENOUS* SOLUTION 100 MG/4ML

5 PA

Antineoplastics

ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

5 PA

AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML

5 PA

azacitidine injection suspension reconstituted 100 mg

VIDAZA 5 PA

BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

5 PA

BICNU INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

4 PA

bleomycin sulfate injection solution reconstituted 30 unit

3 PA

carboplatin intravenous* solution 150 mg/15ml

4 PA

cisplatin intravenous* solution 100 mg/100ml

3 PA

cladribine intravenous* solution 1 mg/ml 5 PA

cytarabine injection solution 20 mg/ml 3 PA

dacarbazine intravenous* solution reconstituted 200 mg

3 PA

daunorubicin hcl intravenous* injectable 5 mg/ml

3 PA


46

Drug Name


DAUNOXOME INTRAVENOUS* INJECTABLE 2 MG/ML

4 PA

dexrazoxane intravenous* solution reconstituted 250 mg

ZINECARD 5 PA

docetaxel intravenous* concentrate 80 mg/4ml

TAXOTERE 5 PA

docetaxel intravenous* solution 80 mg/8ml

5 PA

doxorubicin hcl intravenous* solution 2 mg/ml

ADRIAMYCIN 3 PA

ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG

5 PA

epirubicin hcl intravenous* solution 50 mg/25ml

ELLENCE 4 PA

FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML

5 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

4 MT

GLEOSTINE ORAL CAPSULE 5 MG 4 MT

HALAVEN INTRAVENOUS* SOLUTION 1 MG/2ML

5 PA

HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 440 MG

5 PA

idarubicin hcl intravenous* solution 10 mg/10ml

IDAMYCIN PFS 5 PA

ifosfamide intravenous* solution reconstituted 1 gm

IFEX 4 PA

irinotecan hcl intravenous* solution 100 mg/5ml

CAMPTOSAR 4 PA

ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG

5 PA

KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

5 PA

LYNPARZA ORAL CAPSULE 50 MG 5 PA

mesna intravenous* solution 100 mg/ml MESNEX 4 PA


47

Drug Name


MESNEX ORAL TABLET 400 MG 5

mitomycin intravenous* solution reconstituted 20 mg

4 PA

MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG

4 PA

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG


NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG

5 PA

oxaliplatin intravenous* solution 100 mg/20ml

ELOXATIN 5 PA

paclitaxel intravenous* concentrate 300 mg/50ml

4 PA

PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED 22000000 UNIT

5 PA

TREANDA INTRAVENOUS* SOLUTION 45 MG/0.5ML

5 PA

TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

5 PA

TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML

5 PA

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

5 PA

vinblastine sulfate intravenous* solution 1 mg/ml

3 PA

vincasar pfs intravenous* solution 1 mg/ml

2 PA

vincristine sulfate intravenous* solution 1 mg/ml

VINCASAR PFS 2 PA

vinorelbine tartrate intravenous* solution 50 mg/5ml

NAVELBINE 3 PA

Aromatase Inhibitors, 3Rd Generation

anastrozole oral tablet 1 mg ARIMIDEX 2 MT; CG

EXEMESTANE ORAL TABLET 25 MG AROMASIN 4 MT; CG


48

Drug Name


LETROZOLE ORAL TABLET 2.5 MG FEMARA 3 MT; CG

Enzyme Inhibitors

etoposide intravenous* solution 500 mg/25ml

TOPOSAR 3 PA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG


IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


TOPOSAR INTRAVENOUS* SOLUTION 1 GM/50ML

3 PA

topotecan hcl intravenous* solution reconstituted 4 mg

HYCAMTIN 5 PA

ZOLINZA ORAL CAPSULE 100 MG 5 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG

5 PA; LA; QL (60 EA per 30 days)

Molecular Target Inhibitors

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

5 PA

ALECENSA ORAL CAPSULE 150 MG 5 PA; QL (240 EA per 30 days)

BOSULIF ORAL TABLET 100 MG, 500 MG


CAPRELSA ORAL TABLET 100 MG, 300 MG

5 LA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

5 PA; LA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

5 PA; LA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

5 PA; LA

COTELLIC ORAL TABLET 20 MG 5 PA; QL (63 EA per 28 days)

ERIVEDGE ORAL CAPSULE 150 MG 5 PA; LA


49

Drug Name


GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

5 PA; LA

GLEEVEC ORAL TABLET 100 MG, 400 MG

5 PA

ICLUSIG ORAL TABLET 15 MG 5 PA; LA

ICLUSIG ORAL TABLET 45 MG 5 PA; QL (30 EA per 30 days)

imatinib mesylate oral tablet 100 mg, 400 mg

GLEEVEC 5 PA

IMBRUVICA ORAL CAPSULE 140 MG 5 PA; LA

INLYTA ORAL TABLET 1 MG, 5 MG 5 PA; LA

IRESSA ORAL TABLET 250 MG 5 PA; QL (30 EA per 30 days)

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

5 PA; LA

LENVIMA 10 MG DAILY DOSE ORAL 10 MG


LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG


LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG


LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG


MEKINIST ORAL TABLET 0.5 MG, 2 MG

5 PA; LA

NEXAVAR ORAL TABLET 200 MG 5 PA; LA

ODOMZO ORAL CAPSULE 200 MG 5 PA; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

5 PA

STIVARGA ORAL TABLET 40 MG 5 PA; LA; QL (120 EA per 30 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

5 PA


50

Drug Name


TAFINLAR ORAL CAPSULE 50 MG, 75 MG

5 PA; LA

TAGRISSO ORAL TABLET 40 MG, 80 MG


TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

5 PA; LA

TASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA

TYKERB ORAL TABLET 250 MG 5 PA; LA

VOTRIENT ORAL TABLET 200 MG 5 PA; LA

XALKORI ORAL CAPSULE 200 MG, 250 MG

5 PA; LA

ZELBORAF ORAL TABLET 240 MG 5 PA; LA

ZYKADIA ORAL CAPSULE 150 MG 5 PA; LA

Monoclonal Antibodies

CYRAMZA INTRAVENOUS* SOLUTION 100 MG/10ML, 500 MG/50ML

5 PA

DARZALEX INTRAVENOUS* SOLUTION 100 MG/5ML

5 PA

EMPLICITI INTRAVENOUS* SOLUTION RECONSTITUTED 300 MG, 400 MG

5 PA

keytruda intravenous* solution 100 mg/4ml

5 PA

KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

5 PA

OPDIVO INTRAVENOUS* SOLUTION 40 MG/4ML

5 PA

RITUXAN INTRAVENOUS* SOLUTION 500 MG/50ML

5 PA; LA

Retinoids

AVITA EXTERNAL 0.025 % 4

AVITA EXTERNAL CREAM 0.025 % 4 PA


51

Drug Name


bexarotene oral capsule 75 mg TARGRETIN 5 PA

PANRETIN EXTERNAL 0.1 % 5 PA

TARGRETIN EXTERNAL 1 % 5 PA

TARGRETIN ORAL CAPSULE 75 MG 5 PA

tretinoin external 0.01 %, 0.025 % RETIN-A 4 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

RETIN-A 4 PA

tretinoin oral capsule 10 mg 5

Antiparasitics

Anthelmintics

ALBENZA ORAL TABLET 200 MG 4

BILTRICIDE ORAL TABLET 600 MG 3

ivermectin oral tablet 3 mg STROMECTOL 3

Antiprotozoals

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

4

ALINIA ORAL TABLET 500 MG 4

atovaquone oral suspension 750 mg/5ml MEPRON 5 PA

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

MALARONE 4

chloroquine phosphate oral tablet 250 mg 3

chloroquine phosphate oral tablet 500 mg ARALEN 3

COARTEM ORAL TABLET 20-120 MG 4 QL (24 EA per 30 days)

DARAPRIM ORAL TABLET 25 MG 4

hydroxychloroquine sulfate oral tablet 200 mg

PLAQUENIL 4

mefloquine hcl oral tablet 250 mg 3

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

4 PA

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

4 PA


52

Drug Name


primaquine phosphate oral tablet 26.3 mg 3

quinine sulfate oral capsule 324 mg QUALAQUIN 4

Pediculicides/ Scabicides

EURAX EXTERNAL CREAM 10 % 4

EURAX EXTERNAL LOTION 10 % 4

lindane external lotion 1 % 2

lindane external shampoo 1 % 2

malathion external lotion 0.5 % OVIDE 4

permethrin external cream 5 % ELIMITE 3

Antiparkinson Agents

Anticholinergics

benztropine mesylate injection solution 1 mg/ml

COGENTIN 2

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

2 PA


2

trihexyphenidyl hcl oral elixir 0.4 mg/ml 2 PA

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 2 PA

Antiparkinson Agents, Other

amantadine hcl oral capsule 100 mg 4

amantadine hcl oral syrup 50 mg/5ml 2 MT

amantadine hcl oral tablet 100 mg 4

entacapone oral tablet 200 mg COMTAN 4

Antiparkinson Agents

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

STALEVO 50 4 CG


STALEVO 75 4 CG

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

STALEVO 100 4 CG


53

Drug Name



STALEVO 125 4 CG


STALEVO 150 4 CG

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg

STALEVO 200 4 CG

Dopamine Agonists

APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML

5 PA; LA

BROMOCRIPTINE MESYLATE ORAL CAPSULE 5 MG

PARLODEL 4 MT; CG

BROMOCRIPTINE MESYLATE ORAL TABLET 2.5 MG

PARLODEL 4 MT; CG

NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR


pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg

MIRAPEX ER 2 MT

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

MIRAPEX 2 MT; CG

ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

REQUIP XL 2 MT; CG

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

REQUIP 2 MT; CG

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors

CARBIDOPA-LEVODOPA ER ORAL TABLET EXTENDEDRELEASE* 25-100 MG, 50-200 MG

SINEMET CR 3 MT; CG

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

SINEMET 2 MT; CG


54

Drug Name


carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

PARCOPA 2 MT; CG

Monoamine Oxidase B (Mao-B) Inhibitors

AZILECT ORAL TABLET 0.5 MG, 1 MG

3 MT

SELEGILINE HCL ORAL CAPSULE 5 MG

ELDEPRYL 4 MT; CG

SELEGILINE HCL ORAL TABLET 5 MG

4 MT; CG

Antipsychotics

1St Generation/ Typical

chlorpromazine hcl injection solution 50 mg/2ml

4 CG

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

4 CG

fluphenazine decanoate injection solution 25 mg/ml

4 CG

fluphenazine hcl injection solution 2.5 mg/ml

4 CG

fluphenazine hcl oral concentrate 5 mg/ml 4 CG

fluphenazine hcl oral elixir 2.5 mg/5ml 4 CG

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

2 MT; CG

haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml

HALDOL DECANOATE 3 CG

haloperidol lactate injection solution 5 mg/ml

HALDOL 3 CG

HALOPERIDOL LACTATE ORAL CONCENTRATE 2 MG/ML

3 MT; CG

HALOPERIDOL ORAL TABLET 0.5 MG, 1 MG, 10 MG, 2 MG, 20 MG, 5 MG

3 MT; CG

LOXAPINE SUCCINATE ORAL CAPSULE 10 MG, 25 MG, 5 MG, 50 MG

LOXITANE 3 MT; CG


55

Drug Name


molindone hcl oral tablet 10 mg, 25 mg, 5 mg

2 CG

ORAP ORAL TABLET 1 MG, 2 MG 4

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

4 CG

pimozide oral tablet 1 mg, 2 mg ORAP 2 CG

prochlorperazine edisylate injection solution 5 mg/ml

3

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

4 PA

THIOTHIXENE ORAL CAPSULE 1 MG, 10 MG, 2 MG, 5 MG

3 PA; MT

TRIFLUOPERAZINE HCL ORAL TABLET 1 MG, 10 MG, 2 MG, 5 MG

3 MT; CG

2Nd Generation/ Atypical

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG

5 PA

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 5 MG

5 PA

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 5 mg

ABILIFY 5

aripiprazole oral tablet 30 mg ABILIFY 5 PA

aripiprazole oral tablet dispersible 10 mg, 15 mg

ABILIFY DISCMELT 5

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4 PA

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG

4 PA

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG

4 PA

INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG

4 PA


56

Drug Name


INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML

5 PA; QL (0.75 ML per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 MG/ML








LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

4 PA

olanzapine intramuscular* solution reconstituted 10 mg

ZYPREXA 4 CG

OLANZAPINE ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG

ZYPREXA 3 MT; CG

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

ZYPREXA ZYDIS 4 CG

PALIPERIDONE ER ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG

INVEGA 4 CG

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

SEROQUEL 1 MT; CG

quetiapine fumarate oral tablet 25 mg, 50 mg

SEROQUEL 1 PA; MT; CG

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG



57

Drug Name


RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG


RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 50 MG


risperidone oral solution 1 mg/ml RISPERDAL 4 CG; QL (480 ML per 30 days)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

RISPERDAL 2 MT; CG

risperidone oral tablet dispersible 0.25 mg 4 CG

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg

RISPERIDONE M-TAB 4 CG

risperidone oral tablet dispersible 3 mg, 4 mg

RISPERDAL M-TAB 4 CG

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

4 PA





VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG


VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

GEODON 4 CG

Treatment-Resistant

clozapine oral tablet 100 mg, 25 mg CLOZARIL 2 CG

clozapine oral tablet 200 mg, 50 mg 2 CG

clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg

FAZACLO 4 CG


58

Drug Name


clozapine oral tablet dispersible 150 mg, 200 mg

FAZACLO 4

VERSACLOZ ORAL SUSPENSION 50 MG/ML

5

Antispasticity Agents

Antispasticity Agents

baclofen oral tablet 10 mg, 20 mg 2 CG

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT

4 PA

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

DANTRIUM 4

tizanidine hcl oral tablet 2 mg 2

tizanidine hcl oral tablet 4 mg ZANAFLEX 2

Antivirals

Anti-Cytomegalovirus (Cmv) Agents

ganciclovir sodium intravenous* solution reconstituted 500 mg

CYTOVENE 3 PA

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

5

valganciclovir hcl oral tablet 450 mg VALCYTE 5

ZIRGAN OPHTHALMIC 0.15 % 3

Anti-Hepatitis B (Hbv) Agents

adefovir dipivoxil oral tablet 10 mg HEPSERA 5 PA

BARACLUDE ORAL SOLUTION 0.05 MG/ML

3 PA; MT

entecavir oral tablet 0.5 mg, 1 mg BARACLUDE 5 PA

EPIVIR HBV ORAL SOLUTION 5 MG/ML

4

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

5 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

5 PA

lamivudine oral solution 10 mg/ml EPIVIR 3 CG


59

Drug Name


lamivudine oral tablet 100 mg EPIVIR HBV 4 CG

lamivudine oral tablet 150 mg, 300 mg EPIVIR 3 CG

REBETOL ORAL SOLUTION 40 MG/ML

5

RIBASPHERE ORAL CAPSULE 200 MG

4 PA

RIBASPHERE ORAL TABLET 200 MG 4 PA



ribavirin oral capsule 200 mg REBETOL 2 PA

ribavirin oral tablet 200 mg COPEGUS 2 PA

TYZEKA ORAL TABLET 600 MG 5 PA

VIREAD ORAL POWDER 40 MG/GM 5

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

5

Anti-Hepatitis C (Hcv) Agents

HARVONI ORAL TABLET 90-400 MG 5 PA; QL (28 EA per 28 days)

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

5 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

5 PA

MODERIBA 800 DOSE PACK ORAL TABLET 400 MG

5

MODERIBA ORAL TABLET 200 MG 4

PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML

5 PA

REBETOL ORAL SOLUTION 40 MG/ML

5

RIBASPHERE ORAL CAPSULE 200 MG

4 PA



60

Drug Name




RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG

5 PA

ribavirin oral capsule 200 mg REBETOL 2 PA

ribavirin oral tablet 200 mg COPEGUS 2 PA

SOVALDI ORAL TABLET 400 MG 5 PA; QL (28 EA per 28 days)

SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG

5 PA

Antiherpetic Agents

acyclovir external ointment 5 % ZOVIRAX 4

acyclovir oral capsule 200 mg ZOVIRAX 2

acyclovir oral suspension 200 mg/5ml ZOVIRAX 4

acyclovir oral tablet 400 mg, 800 mg ZOVIRAX 2

acyclovir sodium intravenous* solution 50 mg/ml

4 PA

famciclovir oral tablet 125 mg, 500 mg FAMVIR 4 QL (21 EA per 30 days)

famciclovir oral tablet 250 mg FAMVIR 4 QL (60 EA per 30 days)

trifluridine ophthalmic solution 1 % VIROPTIC 4

valacyclovir hcl oral tablet 1 gm, 500 mg VALTREX 3 QL (30 EA per 30 days)

Anti-Hiv Agents, Integrase Inhibitors (Insti)

GENVOYA ORAL TABLET 150-150-200-10 MG

5

ISENTRESS ORAL PACKET 100 MG 3

ISENTRESS ORAL TABLET 400 MG 5

ISENTRESS ORAL TABLET CHEWABLE 100 MG

5


61

Drug Name


ISENTRESS ORAL TABLET CHEWABLE 25 MG

3

STRIBILD ORAL TABLET 150-150-200-300 MG

5

TIVICAY ORAL TABLET 50 MG 5

VITEKTA ORAL TABLET 150 MG, 85 MG

5

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti)

COMPLERA ORAL TABLET 200-25-300 MG

5

EDURANT ORAL TABLET 25 MG 5

INTELENCE ORAL TABLET 100 MG, 200 MG

5

INTELENCE ORAL TABLET 25 MG 4

nevirapine er oral tablet extended release 24 hr* 100 mg

VIRAMUNE XR 2 CG

nevirapine er oral tablet extended release 24 hr* 400 mg

VIRAMUNE XR 4 CG

nevirapine oral suspension 50 mg/5ml VIRAMUNE 4 CG

nevirapine oral tablet 200 mg VIRAMUNE 3 CG

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

4

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

3

SUSTIVA ORAL TABLET 600 MG 5

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG

4

Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti)

abacavir sulfate oral tablet 300 mg ZIAGEN 3 CG

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

TRIZIVIR 5


62

Drug Name


ATRIPLA ORAL TABLET 600-200-300 MG

5

didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg

VIDEX EC 4 CG

EMTRIVA ORAL CAPSULE 200 MG 3

EMTRIVA ORAL SOLUTION 10 MG/ML

3

EPZICOM ORAL TABLET 600-300 MG 5

lamivudine oral solution 10 mg/ml EPIVIR 3 CG

lamivudine oral tablet 100 mg EPIVIR HBV 4 CG

lamivudine oral tablet 150 mg, 300 mg EPIVIR 3 CG

lamivudine-zidovudine oral tablet 150-300 mg

COMBIVIR 5

RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML

3

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

ZERIT 4 CG

stavudine oral solution reconstituted 1 mg/ml

ZERIT 4 CG

TRUVADA ORAL TABLET 200-300 MG


VIDEX ORAL SOLUTION RECONSTITUTED 2 GM

4

VIREAD ORAL POWDER 40 MG/GM 5

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

5

ZIAGEN ORAL SOLUTION 20 MG/ML 3

zidovudine oral capsule 100 mg RETROVIR 3 CG

zidovudine oral syrup 50 mg/5ml RETROVIR 3 CG

zidovudine oral tablet 300 mg RETROVIR 3 CG

Anti-Hiv Agents, Other

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG

5


63

Drug Name


SELZENTRY ORAL TABLET 150 MG, 300 MG

5

TRIUMEQ ORAL TABLET 600-50-300 MG

5

TYBOST ORAL TABLET 150 MG 3

Anti-Hiv Agents, Protease Inhibitors

APTIVUS ORAL CAPSULE 250 MG 5

APTIVUS ORAL SOLUTION 100 MG/ML

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

4

EVOTAZ ORAL TABLET 300-150 MG 5

INVIRASE ORAL CAPSULE 200 MG 5

INVIRASE ORAL TABLET 500 MG 5

KALETRA ORAL SOLUTION 400-100 MG/5ML

5

KALETRA ORAL TABLET 100-25 MG 3

KALETRA ORAL TABLET 200-50 MG 5

LEXIVA ORAL SUSPENSION 50 MG/ML

4

LEXIVA ORAL TABLET 700 MG 5

NORVIR ORAL CAPSULE 100 MG 3

NORVIR ORAL SOLUTION 80 MG/ML 3

NORVIR ORAL TABLET 100 MG 3

PREZCOBIX ORAL TABLET 800-150 MG

5

PREZISTA ORAL SUSPENSION 100 MG/ML

5

PREZISTA ORAL TABLET 150 MG, 75 MG

3

PREZISTA ORAL TABLET 600 MG, 800 MG

5


64

Drug Name


REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

5

REYATAZ ORAL PACKET 50 MG 5

VIRACEPT ORAL TABLET 250 MG, 625 MG

5

Anti-Influenza Agents

amantadine hcl oral capsule 100 mg 4

amantadine hcl oral syrup 50 mg/5ml 2 MT

amantadine hcl oral tablet 100 mg 4

RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER


rimantadine hcl oral tablet 100 mg FLUMADINE 3

TAMIFLU ORAL CAPSULE 30 MG 3 QL (84 EA per 180 days)



TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML


Anxiolytics

Anxiolytics, Other

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

3 CG

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

4 PA


hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml

4 PA

SILENOR ORAL TABLET 3 MG, 6 MG 3 ST; QL (30 EA per 30 days)

Benzodiazepines


65

Drug Name


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

2 CG

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

TRANXENE-T 2 CG

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

3

diazepam oral solution 1 mg/ml 3 CG

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

3

Ssris/ Snris

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

CYMBALTA 3 MT; CG

duloxetine hcl oral capsule delayed release particles 40 mg

IRENKA 3 MT

escitalopram oxalate oral solution 5 mg/5ml

LEXAPRO 4 MT; CG; QL (600 ML per 30 days)




paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg

PAXIL CR 1 MT; CG

PAXIL ORAL SUSPENSION 10 MG/5ML

4 ST

sertraline hcl oral concentrate 20 mg/ml ZOLOFT 3 MT; CG

venlafaxine hcl er oral capsule extended release 24 hour 150 mg


venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg


venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 37.5 mg, 75 mg

2 MT; CG

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

3 MT; CG


66

Drug Name


Bipolar Agents

Bipolar Agents, Other

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG

4 PA

olanzapine intramuscular* solution reconstituted 10 mg

ZYPREXA 4 CG

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

ZYPREXA 3 MT; CG

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

ZYPREXA ZYDIS 4 CG

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

SEROQUEL 1 MT; CG

quetiapine fumarate oral tablet 25 mg, 50 mg

SEROQUEL 1 PA; MT; CG

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG


RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG


RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 50 MG


risperidone oral solution 1 mg/ml RISPERDAL 4 CG; QL (480 ML per 30 days)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

RISPERDAL 2 MT; CG

risperidone oral tablet dispersible 0.25 mg 4 CG

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg

RISPERIDONE M-TAB 4 CG

risperidone oral tablet dispersible 3 mg, 4 mg

RISPERDAL M-TAB 4 CG

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

4 PA


67

Drug Name






ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

GEODON 4 CG

Mood Stabilizers

CARBAMAZEPINE ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

CARBATROL 4 MT; CG

CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML

TEGRETOL 4 MT; CG

CARBAMAZEPINE ORAL TABLET 200 MG

TEGRETOL 3 MT; CG

CARBAMAZEPINE ORAL TABLET CHEWABLE 100 MG

3 MT; CG

divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg


divalproex sodium oral capsule sprinkle 125 mg

DEPAKOTE SPRINKLES

4 MT; CG


DEPAKOTE 2 MT; CG

EPITOL ORAL TABLET 200 MG 3 MT; CG

lamotrigine er oral tablet extended release 24 hr* 50 mg

LAMICTAL XR 4 MT; CG

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

LAMICTAL 2 MT; CG

lamotrigine oral tablet chewable 25 mg, 5 mg

LAMICTAL 3 MT; CG

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

LAMICTAL ODT 3 MT

lithium carbonate er oral tablet extendedrelease* 300 mg

LITHOBID 2 MT; CG


68

Drug Name


lithium carbonate er oral tablet extendedrelease* 450 mg

2 MT; CG

lithium carbonate oral tablet 300 mg 2 MT; CG

LITHIUM ORAL SOLUTION 8 MEQ/5ML

3 MT

TEGRETOL ORAL SUSPENSION 100 MG/5ML

4

TEGRETOL ORAL TABLET 200 MG 4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 200 MG, 400 MG

4

valproic acid oral capsule 250 mg DEPAKENE 3 MT; CG


Blood Glucose Regulators

Antidiabetic Agents

ACARBOSE ORAL TABLET 100 MG, 25 MG, 50 MG

PRECOSE 3 MT; CG; QL (90 EA per 30 days)

BYDUREON SUBCUTANEOUS* 2 MG 3 QL (4 EA per 28 days)

BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG


BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML


BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML


FARXIGA ORAL TABLET 10 MG 3 PA; MT; QL (30 EA per 30 days)

FARXIGA ORAL TABLET 5 MG 3 PA; MT; QL (60 EA per 30 days)

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

4 MT; QL (90 EA per 30 days)

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG



69

Drug Name


INVOKAMET ORAL TABLET 50-500 MG


INVOKANA ORAL TABLET 100 MG 3 MT; QL (90 EA per 30 days)

INVOKANA ORAL TABLET 300 MG 3 PA; MT; QL (30 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG


ONGLYZA ORAL TABLET 2.5 MG, 5 MG


SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML


SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML


tolazamide oral tablet 250 mg 1 MT; CG; QL (120 EA per 30 days)

tolazamide oral tablet 500 mg 1 MT; CG; QL (60 EA per 30 days)

tolbutamide oral tablet 500 mg 1 MT; CG; QL (180 EA per 30 days)

TRADJENTA ORAL TABLET 5 MG 3 PA; MT; QL (30 EA per 30 days)

VICTOZA SUBCUTANEOUS* 18 MG/3ML


WELCHOL ORAL PACKET 3.75 GM 3 MT

WELCHOL ORAL TABLET 625 MG 3 MT

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HR* 10-1000 MG, 10-500 MG, 5-1000 MG, 5-500 MG


Blood Glucose Regulators

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG



70

Drug Name


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG, 50-500 MG


KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG


KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG


metformin hcl er (osm) oral tablet extended release 24 hr* 1000 mg

FORTAMET 1 MT; CG; QL (60 EA per 30 days)

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

DUETACT 1 MT; CG; QL (30 EA per 30 days)

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

ACTOPLUS MET 1 MT; CG; QL (90 EA per 30 days)

repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

PRANDIMET 2 CG; QL (150 EA per 30 days)

Glycemic Agents

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

3

GLUCAGON EMERGENCY INJECTION KIT 1 MG

3

KORLYM ORAL TABLET 300 MG 5 PA; QL (120 EA per 30 days)

PROGLYCEM ORAL SUSPENSION 50 MG/ML

4

Insulins

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML


EXEL PEN NEEDLES 1/2" 29G X 12MM

CAREFINE PEN NEEDLES



71

Drug Name


HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML


HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* (50-50) 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML


HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML


HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML


HUMULIN 70/30 KWIKPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML


HUMULIN N KWIKPEN SUBCUTANEOUS* 100 UNIT/ML


HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML


LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML


LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML



72

Drug Name


LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML


LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML


preferred plus insulin syringe 28g x 1/2" 0.5 ml

TRUEPLUS INSULIN SYRINGE


Blood Products/ Modifiers/ Volume Expanders

Anticoagulants

COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

4 MT

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3 PA; MT

enoxaparin sodium injection solution 300 mg/3ml

LOVENOX 4 PA; QL (30 ML per 30 days)

enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml


enoxaparin sodium subcutaneous* solution 120 mg/0.8ml










fondaparinux sodium subcutaneous* solution 10 mg/0.8ml

ARIXTRA 5 PA; QL (24 ML per 30 days)

fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml


fondaparinux sodium subcutaneous* solution 5 mg/0.4ml


fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml



73

Drug Name


heparin (porcine) in d5w intravenous* solution 40-5 unit/ml-%, 50-5 unit/ml-%

3 PA

heparin sod (porcine) in d5w intravenous* solution 100 unit/ml

3 PA

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

3 PA

PRADAXA ORAL CAPSULE 110 MG 3

PRADAXA ORAL CAPSULE 150 MG, 75 MG

3 PA; MT

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

3 PA; MT

XARELTO STARTER PACK ORAL 15 & 20 MG

3 PA; MT

Blood Formation Modifiers

anagrelide hcl oral capsule 0.5 mg AGRYLIN 4 CG

anagrelide hcl oral capsule 1 mg 4 CG

GRANIX SUBCUTANEOUS* 300 MCG/0.5ML, 480 MCG/0.8ML

5 PA

LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG

5 PA

MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML

5 PA

NEUPOGEN INJECTION 300 MCG/0.5ML


NEUPOGEN INJECTION 480 MCG/0.8ML


NEUPOGEN INJECTION SOLUTION 300 MCG/ML


NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML


PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

3 PA


74

Drug Name


PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

5 PA

PROMACTA ORAL TABLET 12.5 MG 5 PA; LA; QL (360 EA per 30 days)

PROMACTA ORAL TABLET 25 MG 5 PA; LA; QL (180 EA per 30 days)



Coagulants

tranexamic acid intravenous* solution 100 mg/ml

CYKLOKAPRON 3

tranexamic acid oral tablet 650 mg LYSTEDA 4

Platelet Modifying Agents

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

4 MT

ASPIRIN-DIPYRIDAMOLE ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

AGGRENOX 3 MT; CG

BRILINTA ORAL TABLET 60 MG, 90 MG

3 PA

cilostazol oral tablet 100 mg, 50 mg PLETAL 2 MT; CG

clopidogrel bisulfate oral tablet 75 mg PLAVIX 1 MT; CG

EFFIENT ORAL TABLET 10 MG, 5 MG 4 PA

ZONTIVITY ORAL TABLET 2.08 MG 4

Cardiovascular Agents

Alpha-Adrenergic Agonists

clonidine hcl transdermal patch weekly 0.1 mg/24hr

CATAPRES-TTS-1 4


CATAPRES-TTS-2 4


75

Drug Name



CATAPRES-TTS-3 4

guanfacine hcl oral tablet 1 mg, 2 mg TENEX 1 MT

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

4 CG

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

5 PA

Alpha-Adrenergic Blocking Agents

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

CARDURA 1 MT; CG

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

MINIPRESS 2 MT; CG

Angiotensin Ii Receptor Antagonists

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG


candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

ATACAND 1 MT; CG; QL (30 EA per 30 days)

Antiarrhythmics

amiodarone hcl intravenous* solution 150 mg/3ml

2

amiodarone hcl oral tablet 400 mg PACERONE 4 CG

FLECAINIDE ACETATE ORAL TABLET 100 MG, 150 MG, 50 MG

TAMBOCOR 3 MT; CG

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

4 CG

MULTAQ ORAL TABLET 400 MG 4 QL (60 EA per 30 days)

PACERONE ORAL TABLET 100 MG, 400 MG

4 CG

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

RYTHMOL SR 4 CG

PROPAFENONE HCL ORAL TABLET 150 MG, 225 MG

RYTHMOL 3 MT; CG


76

Drug Name


PROPAFENONE HCL ORAL TABLET 300 MG

3 MT; CG

quinidine gluconate er oral tablet extendedrelease* 324 mg

4 CG

quinidine sulfate oral tablet 200 mg, 300 mg

2 MT; CG

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

2 MT; CG

SOTALOL HCL (AF) ORAL TABLET 120 MG

BETAPACE AF 3 MT; CG

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg

SORINE 2 MT; CG

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

4

Beta-Adrenergic Blocking Agents

acebutolol hcl oral capsule 200 mg, 400 mg

SECTRAL 2 MT; CG

betaxolol hcl oral tablet 10 mg, 20 mg KERLONE 1 MT; CG

BISOPROLOL FUMARATE ORAL TABLET 10 MG, 5 MG

ZEBETA 3 MT; CG

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

4 MT

LABETALOL HCL ORAL TABLET 100 MG, 200 MG, 300 MG

TRANDATE 3 MT; CG

metoprolol succinate er oral tablet extended release 24 hr* 100 mg

TOPROL XL 1 MT; CG; QL (45 EA per 30 days)

metoprolol succinate er oral tablet extended release 24 hr* 200 mg

TOPROL XL 1 MT; CG

metoprolol succinate er oral tablet extended release 24 hr* 25 mg, 50 mg

TOPROL XL 1 MT; CG; QL (60 EA per 30 days)

metoprolol tartrate intravenous* solution 1 mg/ml

LOPRESSOR 1 CG

NADOLOL ORAL TABLET 20 MG, 40 MG, 80 MG

CORGARD 4 MT; CG


77

Drug Name


PINDOLOL ORAL TABLET 10 MG, 5 MG

3 MT; CG

PROPRANOLOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG

INDERAL LA 4 MT; CG

propranolol hcl intravenous* solution 1 mg/ml

3 CG

PROPRANOLOL HCL ORAL SOLUTION 20 MG/5ML, 40 MG/5ML

3 MT; CG

TIMOLOL MALEATE ORAL TABLET 10 MG, 20 MG, 5 MG

3 MT; CG

Calcium Channel Blocking Agents

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

3 MT; CG

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

3 MT; CG

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 360 mg, 420 mg

TIAZAC 2 MT; CG

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg

CARDIZEM CD 2 MT; CG

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

2 MT; CG

diltiazem hcl intravenous* solution 50 mg/10ml

2

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

CARDIZEM 2 MT; CG

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg

2 MT; CG

dilt-xr oral capsule extended release 24 hour 240 mg

DILACOR XR 2 MT; CG


78

Drug Name


FELODIPINE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG

3 MT; CG

ISRADIPINE ORAL CAPSULE 2.5 MG, 5 MG

4 MT; CG

matzim la oral tablet extended release 24 hr* 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

2 MT; CG

NICARDIPINE HCL ORAL CAPSULE 20 MG, 30 MG

4 MT; CG

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

3 MT; CG

nifedipine er osmotic release oral tablet extended release 24 hr* 30 mg, 60 mg

NIFEDICAL XL 3 MT; CG

NIFEDIPINE ER OSMOTIC RELEASE ORAL TABLET EXTENDED RELEASE 24 HR* 90 MG

PROCARDIA XL 3 MT; CG

nimodipine oral capsule 30 mg NIMOTOP 2 MT

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

3 MT; CG

VERAPAMIL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

VERELAN PM 3 MT; CG

VERAPAMIL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

VERELAN 3 MT; CG

verapamil hcl er oral tablet extendedrelease* 120 mg

CALAN SR 2 CG

verapamil hcl er oral tablet extendedrelease* 120 mg (24hr)

CALAN SR 2


CALAN SR 2 MT; CG


79

Drug Name



ISOPTIN SR 2 MT; CG

verapamil hcl intravenous* solution 2.5 mg/ml

4

Cardiovascular Agents, Other

DIGITEK ORAL TABLET 125 MCG 3 QL (30 EA per 30 days)

DIGITEK ORAL TABLET 250 MCG 3

digoxin injection solution 0.25 mg/ml LANOXIN 3

digoxin oral solution 0.05 mg/ml 3

digoxin oral tablet 125 mcg DIGOX 3 QL (30 EA per 30 days)

digoxin oral tablet 250 mcg DIGOX 3

PENTOXIFYLLINE ER ORAL TABLET EXTENDEDRELEASE* 400 MG

TRENTAL 3 MT; CG

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG


TEKTURNA ORAL TABLET 150 MG, 300 MG


UPTRAVI ORAL 200 & 800 MCG 5 PA

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


Cardiovascular Agents

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2 MT; CG

ATENOLOL-CHLORTHALIDONE ORAL TABLET 100-25 MG

TENORETIC 100 3 MT; CG

ATENOLOL-CHLORTHALIDONE ORAL TABLET 50-25 MG

TENORETIC 50 3 MT; CG

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG


BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG



80

Drug Name


candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

ATACAND HCT 1 MT; CG; QL (30 EA per 30 days)

DEMSER ORAL CAPSULE 250 MG 5

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 50-25 mg

LOPRESSOR HCT 1 MT; CG

metoprolol-hydrochlorothiazide oral tablet 100-50 mg

1 MT; CG

PROPRANOLOL-HCTZ ORAL TABLET 40-25 MG, 80-25 MG

3 MT; CG

SPIRONOLACTONE-HCTZ ORAL TABLET 25-25 MG

ALDACTAZIDE 3 MT; CG

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 300-12.5 MG, 300-25 MG


TEKTURNA HCT ORAL TABLET 150-25 MG


triamterene-hctz oral capsule 50-25 mg 1 MT

Diuretics, Carbonic Anhydrase Inhibitors

ACETAZOLAMIDE ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 500 MG

DIAMOX SEQUELS 3 MT; CG

ACETAZOLAMIDE ORAL TABLET 125 MG, 250 MG

3 MT; CG

methazolamide oral tablet 25 mg, 50 mg NEPTAZANE 4 CG

Diuretics, Loop

bumetanide injection solution 0.25 mg/ml 3 CG

BUMETANIDE ORAL TABLET 0.5 MG, 1 MG, 2 MG

BUMEX 3 MT; CG

furosemide injection solution 10 mg/ml 1

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

1 MT; CG

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

DEMADEX 2 MT; CG

Diuretics, Potassium-Sparing


81

Drug Name


AMILORIDE HCL ORAL TABLET 5 MG

3 MT; CG

EPLERENONE ORAL TABLET 25 MG, 50 MG

INSPRA 4 MT; CG

Diuretics, Thiazide

CHLOROTHIAZIDE ORAL TABLET 250 MG, 500 MG

3 MT; CG

CHLORTHALIDONE ORAL TABLET 25 MG, 50 MG

3 MT; CG

indapamide oral tablet 1.25 mg, 2.5 mg 2 MT; CG

METHYCLOTHIAZIDE ORAL TABLET 5 MG

3 MT

METOLAZONE ORAL TABLET 10 MG 3 MT; CG

METOLAZONE ORAL TABLET 2.5 MG, 5 MG

ZAROXOLYN 3 MT; CG

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 130 mg, 43 mg

ANTARA 1 MT

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

LOFIBRA 1 MT; CG

fenofibrate oral tablet 145 mg, 48 mg TRICOR 2 MT; CG; QL (30 EA per 30 days)

fenofibrate oral tablet 160 mg, 54 mg LOFIBRA 1 MT; CG; QL (30 EA per 30 days)

FENOFIBRIC ACID ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG

TRILIPIX 4 MT; QL (30 EA per 30 days)

gemfibrozil oral tablet 600 mg LOPID 2 MT; CG

Dyslipidemics, Hmg Coa Reductase Inhibitors

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG


fluvastatin sodium oral capsule 20 mg LESCOL 1 MT; CG; QL (30 EA per 30 days)


82

Drug Name


fluvastatin sodium oral capsule 40 mg LESCOL 1 MT; CG; QL (60 EA per 30 days)

Dyslipidemics, Other

CHOLESTYRAMINE LIGHT ORAL PACKET 4 GM

QUESTRAN LIGHT 4 MT; CG

COLESTIPOL HCL ORAL GRANULES 5 GM

COLESTID 4 MT; CG

COLESTIPOL HCL ORAL TABLET 1 GM

COLESTID 3 MT; CG

JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 5 MG, 60 MG


JUXTAPID ORAL CAPSULE 20 MG 5 PA; QL (90 EA per 30 days)

KYNAMRO SUBCUTANEOUS* 200 MG/ML

5 PA; LA

niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 750 mg

NIASPAN 4 QL (60 EA per 30 days)

niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 mg

NIASPAN 4 QL (90 EA per 30 days)

NIACOR ORAL TABLET 500 MG 3

OMEGA-3-ACID ETHYL ESTERS ORAL CAPSULE 1 GM

LOVAZA 4 PA; MT; QL (120 EA per 30 days)

PREVALITE ORAL POWDER 4 GM/DOSE

4 MT; CG

VASCEPA ORAL CAPSULE 1 GM 4 MT

WELCHOL ORAL PACKET 3.75 GM 3 MT

WELCHOL ORAL TABLET 625 MG 3 MT

ZETIA ORAL TABLET 10 MG 3 ST; MT; QL (30 EA per 30 days)

Vasodilators, Direct-Acting Arterial/ Venous

isosorbide dinitrate er oral tablet extendedrelease* 40 mg

2 MT; CG


83

Drug Name


isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg

2 MT; CG

isosorbide dinitrate oral tablet 5 mg ISORDIL TITRADOSE 2 MT; CG

isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg

IMDUR 1 MT; CG

isosorbide mononitrate oral tablet 10 mg, 20 mg

1 MT; CG

MINITRAN TRANSDERMAL PATCH 24 HR 0.1 MG/HR, 0.4 MG/HR

3 MT

MINITRAN TRANSDERMAL PATCH 24 HR 0.2 MG/HR, 0.6 MG/HR

3 MT; CG

NITRO-BID TRANSDERMAL OINTMENT 2 %

3 MT; CG

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

4 MT

nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

MINITRAN 3 MT; CG

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

3 MT

Vasodilators, Direct-Acting Arterial

hydralazine hcl injection solution 20 mg/ml

3 CG

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

2 CG

minoxidil oral tablet 10 mg, 2.5 mg 2 CG

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 5 mg

ADDERALL XR 4 QL (90 EA per 30 days)

amphetamine-dextroamphet er oral capsule extended release 24 hour 15 mg, 20 mg, 25 mg, 30 mg

ADDERALL XR 4 QL (30 EA per 30 days)


84

Drug Name


amphetamine-dextroamphetamine oral tablet 10 mg

ADDERALL 3 PA; QL (180 EA per 30 days)

amphetamine-dextroamphetamine oral tablet 12.5 mg





ADDERALL 3 QL (90 EA per 30 days)


ADDERALL 3 QL (60 EA per 30 days)



amphetamine-dextroamphetamine oral tablet 7.5 mg


dextroamphetamine sulfate oral tablet 10 mg, 5 mg

DEXEDRINE 2 PA

Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

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

INTUNIV 4 PA

METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG


methylphenidate hcl er oral tablet extendedrelease* 10 mg


methylphenidate hcl er oral tablet extendedrelease* 20 mg

RITALIN SR 4 QL (90 EA per 30 days)

methylphenidate hcl oral solution 10 mg/5ml

METHYLIN 4 QL (900 ML per 30 days)

methylphenidate hcl oral solution 5 mg/5ml

METHYLIN 4 QL (1800 ML per 30 days)

methylphenidate hcl oral tablet 10 mg, 5 mg

RITALIN 3 QL (180 EA per 30 days)

methylphenidate hcl oral tablet 20 mg RITALIN 3 QL (90 EA per 30 days)


85

Drug Name


STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG


STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG


Central Nervous System, Other

estazolam oral tablet 1 mg, 2 mg 1 QL (30 EA per 30 days)

NUEDEXTA ORAL CAPSULE 20-10 MG

3

riluzole oral tablet 50 mg RILUTEK 4 PA

tetrabenazine oral tablet 12.5 mg XENAZINE 5 PA; MT; QL (240 EA per 30 days)

tetrabenazine oral tablet 25 mg XENAZINE 5 PA; MT; QL (120 EA per 30 days)

XENAZINE ORAL TABLET 12.5 MG 5 PA; LA; QL (240 EA per 30 days)

XENAZINE ORAL TABLET 25 MG 5 PA; LA; QL (120 EA per 30 days)

Fibromyalgia Agents

DULOXETINE HCL ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG

CYMBALTA 3 MT; CG

DULOXETINE HCL ORAL CAPSULE DELAYED RELEASE PARTICLES 40 MG

IRENKA 3 MT

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

3 PA

LYRICA ORAL SOLUTION 20 MG/ML 3 PA

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

4 PA

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

4 PA

Multiple Sclerosis Agents


86

Drug Name


AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG


BETASERON SUBCUTANEOUS* KIT 0.3 MG


COPAXONE SUBCUTANEOUS* 20 MG/ML


COPAXONE SUBCUTANEOUS* 40 MG/ML


GILENYA ORAL CAPSULE 0.5 MG 5 PA; QL (30 EA per 30 days)

mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml

3 PA; CG

TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML

5 PA; LA

Dental And Oral Agents

Dental And Oral Agents

cevimeline hcl oral capsule 30 mg EVOXAC 4

CUVPOSA ORAL SOLUTION 1 MG/5ML

4

doxycycline hyclate oral capsule 100 mg VIBRAMYCIN 3


doxycycline hyclate oral tablet 100 mg, 20 mg

3

doxycycline monohydrate oral tablet 150 mg

ADOXA PAK 1/150 3

doxycycline monohydrate oral tablet 50 mg, 75 mg

ADOXA 3

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

MINOCIN 2

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

DYNACIN 2

pilocarpine hcl oral tablet 5 mg, 7.5 mg SALAGEN 4

triamcinolone acetonide mouth/throat paste 0.1 %

ORALONE 3


87

Drug Name


Dermatological Agents

Dermatological Agents

8-MOP ORAL CAPSULE 10 MG 4 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

SORIATANE 5 PA

adapalene external 0.1 % DIFFERIN 4 PA

ADAPALENE EXTERNAL 0.3 % DIFFERIN 4

adapalene external cream 0.1 % DIFFERIN 4 PA

ammonium lactate external cream 12 % LAC-HYDRIN 3

ammonium lactate external lotion 12 % LAC-HYDRIN 2

AVITA EXTERNAL 0.025 % 4

AVITA EXTERNAL CREAM 0.025 % 4 PA

benzoyl peroxide-erythromycin external 5-3 %

BENZAMYCIN 4

betamethasone dipropionate external lotion 0.05 %

3

calcipotriene external cream 0.005 % DOVONEX 4

calcipotriene external ointment 0.005 % CALCITRENE 4

calcipotriene external solution 0.005 % 4

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

4

clindamax external 1 % 1

clotrimazole-betamethasone external cream 1-0.05 %

LOTRISONE 1


doxycycline monohydrate oral tablet 100 mg, 50 mg

ADOXA 3

ELIDEL EXTERNAL CREAM 1 % 4 PA

FLUOCINONIDE EXTERNAL CREAM 0.1 %

VANOS 4

FLUOROURACIL EXTERNAL CREAM 0.5 %

CARAC 4

fluorouracil external cream 5 % EFUDEX 4


88

Drug Name


fluorouracil external solution 2 %, 5 % 4

fluorouracil intravenous* solution 2.5 gm/50ml

ADRUCIL 3 PA

fluticasone propionate external cream 0.05 %

CUTIVATE 2

fluticasone propionate external lotion 0.05 %

CUTIVATE 2

fluticasone propionate external ointment 0.005 %

CUTIVATE 2

imiquimod external cream 5 % ALDARA 4

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

4

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

2

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

2

podofilox external solution 0.5 % CONDYLOX 3

PRUDOXIN EXTERNAL CREAM 5 % 4

REGRANEX EXTERNAL 0.01 % 5 PA; QL (30 GM per 30 days)

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

4

selenium sulfide external lotion 2.5 % SELSUN 2

tacrolimus external ointment 0.03 %, 0.1 %

PROTOPIC 4 PA

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %

4 PA

tretinoin external 0.01 %, 0.025 % RETIN-A 4 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

RETIN-A 4 PA

VALCHLOR EXTERNAL 0.016 % 5 PA; LA

VOLTAREN TRANSDERMAL 1 % 3

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG

4


89

Drug Name


Enzyme Replacement/ Modifiers

Enzyme Replacement/ Modifiers

ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML

5 PA; LA

ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML

5 PA; LA

CERDELGA ORAL CAPSULE 84 MG 5

CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

5 PA; LA

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

3 MT

CYSTADANE ORAL POWDER 5 LA

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

4 LA

FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG

5 PA; LA

KANUMA INTRAVENOUS* SOLUTION 20 MG/10ML

5 PA

KUVAN ORAL PACKET 500 MG 5 PA

KUVAN ORAL TABLET SOLUBLE 100 MG

5 PA; LA

NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML

5 PA; LA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

5 PA; LA

RAVICTI ORAL LIQUID† 1.1 GM/ML 5 PA

SUCRAID ORAL SOLUTION 8500 UNIT/ML

5 LA

VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

5 PA

ZAVESCA ORAL CAPSULE 100 MG 5 PA; LA; QL (90 EA per 30 days)


90

Drug Name


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

4

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 5000 UNIT

4

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

dicyclomine hcl oral solution 10 mg/5ml 3

glycopyrrolate injection solution 4 mg/20ml

ROBINUL 4

glycopyrrolate oral tablet 1 mg ROBINUL 3

glycopyrrolate oral tablet 2 mg ROBINUL-FORTE 3

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HR 1 MG/3DAYS


Gastrointestinal Agents, Other

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml

3

diphenoxylate-atropine oral tablet 2.5-0.025 mg

LONOX 3

GATTEX SUBCUTANEOUS* KIT 5 MG

5 PA

loperamide hcl oral capsule 2 mg 2

metoclopramide hcl injection solution 5 mg/ml

2

metoclopramide hcl oral solution 5 mg/5ml

2

proctozone-hc cream 2.5 % 2

RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML

5 PA

UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9 MG

5

URSODIOL ORAL CAPSULE 300 MG ACTIGALL 4 MT


91

Drug Name


URSODIOL ORAL TABLET 250 MG URSO 250 4 MT

URSODIOL ORAL TABLET 500 MG URSO FORTE 4 MT

XIFAXAN ORAL TABLET 200 MG 5 PA

Gastrointestinal Agents


5

Histamine2 (H2) Receptor Antagonists

CIMETIDINE HCL ORAL SOLUTION 300 MG/5ML

3

CIMETIDINE ORAL TABLET 300 MG, 400 MG

3

cimetidine oral tablet 800 mg 3

CIMETIDINE TABLET 200 MG ORAL (OTC) 200 MG

TAGAMET HB 3

famotidine intravenous* solution 20 mg/2ml

2

famotidine oral suspension reconstituted 40 mg/5ml

PEPCID 4

famotidine premixed intravenous* solution 20-0.9 mg/50ml-%

2

nizatidine oral capsule 150 mg, 300 mg AXID 2

nizatidine oral solution 15 mg/ml AXID 2

ranitidine hcl injection solution 150 mg/6ml

ZANTAC 3 PA

ranitidine hcl oral capsule 150 mg, 300 mg

1

ranitidine hcl oral syrup 15 mg/ml ZANTAC 3

Irritable Bowel Syndrome Agents

alosetron hcl oral tablet 0.5 mg, 1 mg LOTRONEX 5 PA

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG


BUDESONIDE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 MG

ENTOCORT EC 4


92

Drug Name


DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG


LINZESS ORAL CAPSULE 145 MCG, 290 MCG



5

Laxatives

constulose oral solution 10 gm/15ml 2

enulose oral solution 10 gm/15ml 2

gavilyte-c oral solution reconstituted 240 gm

2

gavilyte-g oral solution reconstituted 236 gm

2

gavilyte-h oral kit 5-210 mg-gm 2

gavilyte-n with flavor pack oral solution reconstituted 420 gm

2

generlac oral solution 10 gm/15ml 2

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

3

lactulose oral solution 10 gm/15ml 2

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

4

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM

3

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

TRILYTE 2

peg-3350/electrolytes oral solution reconstituted 236 gm

GOLYTELY 2

polyethylene glycol 3350 oral powder PEGYLAX 2

trilyte oral solution reconstituted 420 gm 2

Protectants

misoprostol oral tablet 100 mcg, 200 mcg CYTOTEC 3

sucralfate oral tablet 1 gm CARAFATE 3


93

Drug Name


Proton Pump Inhibitors

DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG


esomeprazole sodium intravenous* solution reconstituted 20 mg, 40 mg

NEXIUM I.V. 4

lansoprazole capsule delayed release 15 mg oral (otc) 15 mg

HEARTBURN RELIEF 24 HOUR


lansoprazole oral capsule delayed release 30 mg

PREVACID 1 QL (30 EA per 30 days)

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

PROTONIX 1 QL (30 EA per 30 days)

Genitourinary Agents

Antispasmodics, Urinary

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 MG, 50 MG


OXYBUTYNIN CHLORIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 15 MG

DITROPAN XL 3 MT; CG

OXYBUTYNIN CHLORIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 5 MG

DITROPAN XL 3 MT; CG; QL (30 EA per 30 days)

OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG

3 MT; CG

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

DETROL LA 4 QL (30 EA per 30 days)

tolterodine tartrate oral tablet 1 mg, 2 mg DETROL 4

trospium chloride oral tablet 20 mg SANCTURA 4 CG; QL (60 EA per 30 days)

VESICARE ORAL TABLET 10 MG, 5 MG


Benign Prostatic Hypertrophy Agents

alfuzosin hcl er oral tablet extended release 24 hr* 10 mg

UROXATRAL 2 MT; CG; QL (30 EA per 30 days)


94

Drug Name


AVODART ORAL CAPSULE 0.5 MG 4 MT; QL (30 EA per 30 days)

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

CARDURA 1 MT; CG

DUTASTERIDE ORAL CAPSULE 0.5 MG

AVODART 3 CG

DUTASTERIDE-TAMSULOSIN HCL ORAL CAPSULE 0.5-0.4 MG

JALYN 3 MT; CG

finasteride oral tablet 5 mg PROSCAR 2 MT; CG

JALYN ORAL CAPSULE 0.5-0.4 MG 4 MT; QL (30 EA per 30 days)

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

MINIPRESS 2 MT; CG

tamsulosin hcl oral capsule 0.4 mg FLOMAX 1 MT; CG

Genitourinary Agents, Other

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

URECHOLINE 3 CG

DEPEN TITRATABS ORAL TABLET 250 MG

5

ELMIRON ORAL CAPSULE 100 MG 4

potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg)

UROCIT-K 10 4

POTASSIUM CITRATE ER ORAL TABLET EXTENDEDRELEASE* 15 MEQ (1620 MG)

UROCIT-K 15 4

potassium citrate er oral tablet extendedrelease* 5 meq (540 mg)

UROCIT-K 5 4

sodium phenylbutyrate oral powder 3 gm/tsp

BUPHENYL 5 PA

Phosphate Binders

calcium acetate (phos binder) oral capsule 667 mg

PHOSLO 2

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

5


95

Drug Name


RENVELA ORAL TABLET 800 MG 5

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)


2

alclometasone dipropionate external cream 0.05 %

ACLOVATE 3

alclometasone dipropionate external ointment 0.05 %

3

betamethasone dipropionate aug external 0.05 %

4

betamethasone dipropionate aug external cream 0.05 %

DIPROLENE AF 3

betamethasone dipropionate aug external lotion 0.05 %

DIPROLENE 4

betamethasone dipropionate aug external ointment 0.05 %

DIPROLENE 4

betamethasone dipropionate external cream 0.05 %

3

betamethasone dipropionate external ointment 0.05 %

4

betamethasone valerate external cream 0.1 %

3

betamethasone valerate external lotion 0.1 %

3

betamethasone valerate external ointment 0.1 %

3

clobetasol propionate e external cream 0.05 %

TEMOVATE E 4

clobetasol propionate external 0.05 % TEMOVATE 4

clobetasol propionate external ointment 0.05 %

TEMOVATE 4


96

Drug Name


clobetasol propionate external solution 0.05 %

CORMAX SCALP APPLICATION

4


desonide external cream 0.05 % DESOWEN 4

desonide external lotion 0.05 % DESOWEN 4

desonide external ointment 0.05 % DESOWEN 4

desoximetasone external 0.05 % TOPICORT 4

desoximetasone external cream 0.05 %, 0.25 %

TOPICORT 4

desoximetasone external ointment 0.05 %, 0.25 %

TOPICORT 4


3



2

dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

2

diflorasone diacetate external cream 0.05 %

4

diflorasone diacetate external ointment 0.05 %

APEXICON 4

fludrocortisone acetate oral tablet 0.1 mg 2 CG

fluocinolone acetonide body external oil 0.01 %

DERMA-SMOOTHE/FS BODY

4

fluocinolone acetonide external cream 0.01 %

3

fluocinolone acetonide external cream 0.025 %

SYNALAR 3

fluocinolone acetonide external ointment 0.025 %

SYNALAR 3

fluocinolone acetonide external solution 0.01 %

SYNALAR 4

fluocinolone acetonide otic oil 0.01 % DERMOTIC 4


97

Drug Name


fluocinonide external 0.05 % 3

FLUOCINONIDE EXTERNAL CREAM 0.1 %

VANOS 4

fluocinonide external ointment 0.05 % 4

fluocinonide external solution 0.05 % 4

fluocinonide-e external cream 0.05 % 4

fluticasone propionate external cream 0.05 %

CUTIVATE 2


CUTIVATE 2

fluticasone propionate external ointment 0.005 %

CUTIVATE 2

halobetasol propionate external cream 0.05 %

ULTRAVATE 4

halobetasol propionate external ointment 0.05 %

ULTRAVATE 4

hydrocortisone butyr lipo base external cream 0.1 %

LOCOID LIPOCREAM 1

hydrocortisone butyrate external ointment 0.1 %

LOCOID 4

hydrocortisone butyrate external solution 0.1 %

LOCOID 4

hydrocortisone external lotion 2.5 % 3

hydrocortisone oral tablet 10 mg CORTEF 1


hydrocortisone valerate external cream 0.2 %

4

hydrocortisone valerate external ointment 0.2 %

WESTCORT 4

KENALOG INJECTION SUSPENSION 40 MG/ML

3

LOKARA EXTERNAL LOTION 0.05 % 4

methylprednisolone (pak) oral tablet 4 mg MEDROL (PAK) 2


98

Drug Name



DEPO-MEDROL 2


MEDROL 3

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

SOLU-MEDROL 3

mometasone furoate external cream 0.1 % ELOCON 3

mometasone furoate external ointment 0.1 %

ELOCON 3


ORAPRED 2


2


PEDIAPRED 2


3


procto-pak cream 1 % 2

proctozone-hc cream 2.5 % 2


4

triamcinolone acetonide external cream 0.025 %, 0.5 %

2

triamcinolone acetonide external cream 0.1 %

TRIDERM 2

triamcinolone acetonide external lotion 0.025 %, 0.1 %

3

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

2

triderm external cream 0.1 % 2

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)


99

Drug Name


Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)

desmopressin ace spray refrig nasal solution 0.01 %

MINIRIN 4 CG

desmopressin acetate injection solution 4 mcg/ml

DDAVP 4 PA; CG

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

DDAVP 3 CG

INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML

5 PA; LA

NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML

5 PA

Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)

misoprostol oral tablet 200 mcg CYTOTEC 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

Anabolic Steroids

oxandrolone oral tablet 10 mg OXANDRIN 5 PA; QL (60 EA per 30 days)

oxandrolone oral tablet 2.5 mg OXANDRIN 3 PA; CG; QL (60 EA per 30 days)

Androgens

ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR


danazol oral capsule 100 mg, 200 mg, 50 mg

4 CG

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

DEPO-TESTOSTERONE

3


100

Drug Name


testosterone enanthate intramuscular* solution 200 mg/ml

3

Estrogens

ESTRACE VAGINAL CREAM 0.1 MG/GM

4

estradiol oral tablet 0.5 mg, 1 mg, 2 mg ESTRACE 4 PA

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

CLIMARA 4 PA

estradiol valerate intramuscular* oil 20 mg/ml

DELESTROGEN 3

estropipate oral tablet 0.75 mg ORTHO-EST 0.625 1 PA

estropipate oral tablet 1.5 mg ORTHO-EST 1.25 1 PA

marlissa oral tablet 0.15-30 mg-mcg KURVELO 3

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG

4 PA

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

4 PA

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

4 PA

PREMARIN VAGINAL CREAM 0.625 MG/GM

4

VAGIFEM VAGINAL TABLET 10 MCG

4

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

APRI ORAL TABLET 0.15-30 MG-MCG 3

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG

3

AUBRA ORAL TABLET 0.1-20 MG-MCG

3

AVIANE ORAL TABLET 0.1-20 MG-MCG

3


101

Drug Name


BALZIVA ORAL TABLET 0.4-35 MG-MCG

3

briellyn oral tablet 0.4-35 mg-mcg GILDAGIA 3


ENTOCORT EC 4

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

3

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

3

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

DEBLITANE ORAL TABLET 0.35 MG 3

DELYLA ORAL TABLET 0.1-20 MG-MCG

3

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

AZURETTE 3

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

ZARAH 3

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

3

enpresse-28 oral tablet 2

estradiol valerate intramuscular* oil 40 mg/ml

DELESTROGEN 3

FALMINA ORAL TABLET 0.1-20 MG-MCG

3

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2 PA

GIANVI ORAL TABLET 3-0.02 MG 3

GILDAGIA ORAL TABLET 0.4-35 MG-MCG

3

GILDESS 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

INTROVALE ORAL TABLET 0.15-0.03 MG

3


102

Drug Name


JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG

3

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG

3

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG

3

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

LARIN 1/20 ORAL TABLET 1-20 MG-MCG

3

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG

3

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG

3

LESSINA ORAL TABLET 0.1-20 MG-MCG

3

levonest oral tablet 2

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

QUASENSE 3

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

3

LORYNA ORAL TABLET 3-0.02 MG 3

LUTERA ORAL TABLET 0.1-20 MG-MCG

3


MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3


103

Drug Name


MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

3

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

3

MONONESSA ORAL TABLET 0.25-35 MG-MCG

3

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

3

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG

3

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG

3

NECON 10/11 (28) ORAL TABLET 35 MCG

3

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

NIKKI ORAL TABLET 3-0.02 MG 3

NORA-BE ORAL TABLET 0.35 MG 3

NORLYROC ORAL TABLET 0.35 MG 3

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

3

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

3

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

3

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

4

OCELLA ORAL TABLET 3-0.03 MG 3

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG

3


104

Drug Name


PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG

3

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG

3

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

4 PA

PREVIFEM ORAL TABLET 0.25-35 MG-MCG

3

QUASENSE ORAL TABLET 0.15-0.03 MG

3

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG

3

SHAROBEL ORAL TABLET 0.35 MG 3

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

3

SRONYX ORAL TABLET 0.1-20 MG-MCG

3

tarina fe 1/20 oral tablet 1-20 mg-mcg 2

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

3

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg

2

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

2

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

2

trivora (28) oral tablet 2

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

3

VESTURA ORAL TABLET 3-0.02 MG 3

VYFEMLA ORAL TABLET 0.4-35 MG-MCG

3


105

Drug Name


ZENCHENT ORAL TABLET 0.4-35 MG-MCG

3

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

3

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG

3

Progestins

CAMILA ORAL TABLET 0.35 MG 3 MT

DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML

4 PA

ERRIN ORAL TABLET 0.35 MG 3

JOLIVETTE ORAL TABLET 0.35 MG 3

LYZA ORAL TABLET 0.35 MG 3


medroxyprogesterone acetate intramuscular* suspension 150 mg/ml

DEPO-PROVERA 2 QL (1 ML per 90 days)

MEGACE ES ORAL SUSPENSION 625 MG/5ML

5 PA; MT

megestrol acetate oral suspension 40 mg/ml

MEGACE ORAL 4 PA

MEGESTROL ACETATE ORAL SUSPENSION 625 MG/5ML

MEGACE ES 4 PA; MT

megestrol acetate oral tablet 20 mg, 40 mg

4 PA

NORETHINDRONE ACETATE ORAL TABLET 5 MG

AYGESTIN 3 MT

norethindrone oral tablet 0.35 mg JOLIVETTE 3 MT

progesterone micronized oral capsule 100 mg

PROMETRIUM 2 MT

progesterone micronized oral capsule 200 mg

PROMETRIUM 1 MT

Selective Estrogen Receptor Modifying Agents


106

Drug Name


RALOXIFENE HCL ORAL TABLET 60 MG

EVISTA 3 MT; CG

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

levothyroxine sodium oral tablet 100 mcg, 150 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

SYNTHROID 1 MT; CG

levothyroxine sodium oral tablet 112 mcg, 125 mcg, 137 mcg, 175 mcg, 200 mcg, 300 mcg

UNITHROID 1 MT; CG

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

2 MT; CG

LIOTHYRONINE SODIUM ORAL TABLET 25 MCG, 5 MCG, 50 MCG

CYTOMEL 3 MT; CG

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

4 MT

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

2 MT; CG

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN ORAL TABLET 500 MG 3

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR ORAL TABLET 30 MG 3 QL (60 EA per 30 days)


107

Drug Name




Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

bromocriptine mesylate oral capsule 5 mg PARLODEL 4 MT; CG

bromocriptine mesylate oral tablet 2.5 mg PARLODEL 4 MT; CG

cabergoline oral tablet 0.5 mg 4 CG; QL (20 EA per 30 days)

leuprolide acetate injection kit 1 mg/0.2ml 3 PA; CG

LUPANETA PACK COMBINATION KIT 11.25 & 5 MG


LUPANETA PACK COMBINATION KIT 3.75 & 5 MG


LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG, 22.5 MG, 3.75 MG, 30 MG, 45 MG, 7.5 MG

5 PA

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG, 15 MG

5 PA

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

SANDOSTATIN 4 PA

octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml, 500 mcg/ml

SANDOSTATIN 5 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 MG, 30 MG

5 PA

SIGNIFOR LAR INTRAMUSCULAR* SUSPENSION RECONSTITUTED 20 MG, 40 MG, 60 MG

5 PA


108

Drug Name


SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

5 PA

SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

5 PA

SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

5 PA; LA

SYNAREL NASAL SOLUTION 2 MG/ML

5 PA

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

5 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg TAPAZOLE 2 MT; CG

PROPYLTHIOURACIL ORAL TABLET 50 MG

3 MT; CG

Immunological Agents

Angioedema (Hae) Agents

CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT

5 PA; LA

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML


Immune Suppressants

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

5 PA

AFINITOR ORAL TABLET 2.5 MG 5 PA

AZATHIOPRINE ORAL TABLET 50 MG

IMURAN 3 PA; MT; CG


109

Drug Name


BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 120 MG

5 PA

CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200 MG/ML

5 PA

CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG

5 PA

cyclosporine intravenous* solution 50 mg/ml

SANDIMMUNE 4 PA; CG

CYCLOSPORINE MODIFIED ORAL CAPSULE 100 MG, 25 MG

GENGRAF 3 PA; MT; CG

CYCLOSPORINE MODIFIED ORAL CAPSULE 50 MG

3 PA; MT; CG

CYCLOSPORINE MODIFIED ORAL SOLUTION 100 MG/ML

GENGRAF 3 PA; MT; CG

CYCLOSPORINE ORAL CAPSULE 100 MG, 25 MG

SANDIMMUNE 4 PA; MT; CG


5

ELIDEL EXTERNAL CREAM 1 % 4 PA

GENGRAF ORAL CAPSULE 100 MG, 25 MG

3 PA; MT; CG

GENGRAF ORAL SOLUTION 100 MG/ML

3 PA; MT; CG

HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML


HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML


HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 40 MG/0.8ML


HUMIRA SUBCUTANEOUS* 20 MG/0.4ML

5 PA; QL (0.8 EA per 30 days)

KINERET SUBCUTANEOUS* 100 MG/0.67ML

5 PA

mercaptopurine oral tablet 50 mg PURINETHOL 3 CG


110

Drug Name


methotrexate oral tablet 2.5 mg 3 PA; CG

methotrexate sodium (pf) injection solution 1 gm/40ml

2 PA; CG

methotrexate sodium (pf) injection solution 25 mg/ml

2 PA; CG

methotrexate sodium injection solution reconstituted 1 gm

2 PA; CG

MYCOPHENOLATE MOFETIL ORAL CAPSULE 250 MG

CELLCEPT 4 PA; MT; CG

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

CELLCEPT 5 PA

MYCOPHENOLATE MOFETIL ORAL TABLET 500 MG

CELLCEPT 4 PA; MT; CG

MYCOPHENOLIC ACID ORAL TABLET DELAYED RELEASE 180 MG

MYFORTIC 4 PA; MT; CG

mycophenolic acid oral tablet delayed release 360 mg

MYFORTIC 5 PA

NEORAL ORAL CAPSULE 100 MG, 25 MG

3 PA; MT

NEORAL ORAL SOLUTION 100 MG/ML

3 PA; MT

NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG

5 PA

ORENCIA SUBCUTANEOUS* 125 MG/ML

5 PA

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG

4 PA

PROGRAF ORAL CAPSULE 5 MG 5 PA

RAPAMUNE ORAL SOLUTION 1 MG/ML

5 PA

REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

5 PA

SANDIMMUNE ORAL SOLUTION 100 MG/ML

3 PA; MT

sirolimus oral tablet 0.5 mg, 1 mg RAPAMUNE 4 PA


111

Drug Name


sirolimus oral tablet 2 mg RAPAMUNE 5 PA

tacrolimus oral capsule 0.5 mg, 1 mg HECORIA 4 PA; CG

tacrolimus oral capsule 5 mg HECORIA 5 PA

ZORTRESS ORAL TABLET 0.25 MG 4 PA

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG

5 PA

Immunizing Agents, Passive

BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML

5 PA

GAMASTAN S/D INTRAMUSCULAR* INJECTABLE

3 PA

GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML

5 PA

GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/200ML

5 PA

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML

5 PA

HYPERRAB S/D INTRAMUSCULAR* INJECTABLE 150 UNIT/ML

3

PRIVIGEN INTRAVENOUS* SOLUTION 20 GM/200ML

5 PA

SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML

5 PA

Immunological Agents

leflunomide oral tablet 10 mg, 20 mg ARAVA 3 CG; QL (30 EA per 30 days)

SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML

5 PA

Immunomodulators

ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000 UNIT/0.5ML

5 PA; LA

ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG

5 PA


112

Drug Name


ILARIS SUBCUTANEOUS* SOLUTION RECONSTITUTED 180 MG

5 PA

keytruda intravenous* solution 100 mg/4ml

5 PA

KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

5 PA

leflunomide oral tablet 10 mg, 20 mg ARAVA 3 CG; QL (30 EA per 30 days)

TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML

5 PA; LA

Vaccines

ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED

3

ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5 LF-MCG/0.5

3

bcg vaccine injection injectable 3

BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5

3

CERVARIX INTRAMUSCULAR* SUSPENSION

3

DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5

3

diphtheria-tetanus toxoids dt intramuscular* suspension 25-5 lfu/0.5ml

3 PA

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

3 PA

GARDASIL 9 INTRAMUSCULAR* 3

GARDASIL 9 INTRAMUSCULAR* SUSPENSION

3

GARDASIL INTRAMUSCULAR* SUSPENSION

3

HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

3


113

Drug Name


IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5 UNIT/ML

3

INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10

3

IPOL INJECTION INJECTABLE 3

IXIARO INTRAMUSCULAR* SUSPENSION

3

MENACTRA INTRAMUSCULAR* INJECTABLE

3

MENOMUNE SUBCUTANEOUS* INJECTABLE

3

MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED

3

M-M-R II SUBCUTANEOUS* INJECTABLE

3

PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML

3

PROQUAD SUBCUTANEOUS* INJECTABLE

3

RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED

3

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

3 PA

ROTARIX ORAL SUSPENSION RECONSTITUTED

3

ROTATEQ ORAL SOLUTION 3

tenivac intramuscular* injectable 5-2 lfu 2

tetanus-diphtheria toxoids td intramuscular* suspension 2-2 lf/0.5ml

3 PA

TRUMENBA INTRAMUSCULAR* 3

TWINRIX INTRAMUSCULAR* SUSPENSION 720-20

3


114

Drug Name


TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML

3

VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

3

VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML

3

YF-VAX SUBCUTANEOUS* INJECTABLE

3

ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 19400 UNT/0.65ML


Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

3 MT

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

4

balsalazide disodium oral capsule 750 mg COLAZAL 4

CANASA SUPPOSITORY 1000 MG 5

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG


DIPENTUM ORAL CAPSULE 250 MG 5

mesalamine-cleanser kit 4 gm ROWASA 4 CG

Glucocorticoids


2


ENTOCORT EC 4

COLOCORT ENEMA 100 MG/60ML 4



3



115

Drug Name



2

hydrocortisone enema 100 mg/60ml COLOCORT 4

hydrocortisone oral tablet 10 mg CORTEF 1


methylprednisolone (pak) oral tablet 4 mg MEDROL (PAK) 2


DEPO-MEDROL 2


MEDROL 3


ORAPRED 2


PEDIAPRED 2


3


proctosol hc cream 2.5 % 2


4

Sulfonamides

SULFASALAZINE ORAL TABLET 500 MG

SULFAZINE 3 MT

SULFASALAZINE ORAL TABLET DELAYED RELEASE 500 MG

SULFAZINE EC 3 MT

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

CALCITONIN (SALMON) NASAL SOLUTION 200 UNIT/ACT

MIACALCIN 3 MT; CG

calcitriol intravenous* solution 1 mcg/ml CALCIJEX 4 PA; CG

calcitriol oral capsule 0.25 mcg, 0.5 mcg ROCALTROL 3 PA; CG

calcitriol oral solution 1 mcg/ml ROCALTROL 4 PA; CG

etidronate disodium oral tablet 200 mg 2 MT; CG


116

Drug Name


etidronate disodium oral tablet 400 mg DIDRONEL 2 MT; CG

FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML


FORTICAL NASAL SOLUTION 200 UNIT/ACT

3 MT; CG

IBANDRONATE SODIUM ORAL TABLET 150 MG

BONIVA 4 MT; CG; QL (1 EA per 30 days)

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

4 PA

NATPARA SUBCUTANEOUS* 100 MCG, 25 MCG, 50 MCG, 75 MCG


pamidronate disodium intravenous* solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

3 PA; CG

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg

ZEMPLAR 4 PA

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML

4 PA

RISEDRONATE SODIUM ORAL TABLET 150 MG

ACTONEL 3 MT; QL (1 EA per 30 days)

RISEDRONATE SODIUM ORAL TABLET 35 MG

ACTONEL 3 MT; CG; QL (4 EA per 30 days)

RISEDRONATE SODIUM ORAL TABLET DELAYED RELEASE 35 MG

ATELVIA 3 MT; CG; QL (4 EA per 30 days)

XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML

5 PA

zoledronic acid intravenous* concentrate 4 mg/5ml

ZOMETA 4 PA

zoledronic acid intravenous* solution 5 mg/100ml

RECLAST 4 PA

Non-Frf

Non-Frf

ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG

5 PA; LA

naloxone hcl injection solution 0.4 mg/ml 1


117

Drug Name


Ophthalmic Agents

Ophthalmic Agents, Other

atropine sulfate ophthalmic solution 1 % ISOPTO ATROPINE 1

proparacaine hcl ophthalmic solution 0.5 %

ALCAINE 2

RESTASIS OPHTHALMIC EMULSION 0.05 %



3

Ophthalmic Agents

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

POLYCIN 2

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

NEO-POLYCIN HC 3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

4

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

NEO-POLYCIN 3

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

MAXITROL 2

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

MAXITROL 2

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25

NEOSPORIN 3

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

4

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

POLYTRIM 2


3

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

2

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

TOBRADEX 4


118

Drug Name


Ophthalmic Anti-Allergy Agents

azelastine hcl ophthalmic solution 0.05 % OPTIVAR 3

BEPREVE OPHTHALMIC SOLUTION 1.5 %

3

cromolyn sodium ophthalmic solution 4 % 2

LASTACAFT OPHTHALMIC SOLUTION 0.25 %

4

PATADAY OPHTHALMIC SOLUTION 0.2 %

3

PAZEO OPHTHALMIC SOLUTION 0.7 %

4

Ophthalmic Antiglaucoma Agents

acetazolamide oral tablet 125 mg, 250 mg 3 MT; CG

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

3 MT

AZOPT OPHTHALMIC SUSPENSION 1 %

3 MT; QL (10 ML per 30 days)

BETAXOLOL HCL OPHTHALMIC SOLUTION 0.5 %

3 MT; CG

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

3 MT

bimatoprost ophthalmic solution 0.03 % LUMIGAN 2 MT; QL (2.5 ML per 30 days)

BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.15 %

ALPHAGAN P 3 MT; CG

brimonidine tartrate ophthalmic solution 0.2 %

2 MT; CG

carteolol hcl ophthalmic solution 1 % 2 MT; CG

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

3 MT

DORZOLAMIDE HCL OPHTHALMIC SOLUTION 2 %

TRUSOPT 3 MT; CG


119

Drug Name


DORZOLAMIDE HCL-TIMOLOL MAL OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

COSOPT 3 MT; CG

LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.5 %

BETAGAN 3 MT; CG

methazolamide oral tablet 25 mg, 50 mg NEPTAZANE 4 CG

METIPRANOLOL OPHTHALMIC SOLUTION 0.3 %

OPTIPRANOLOL 3 MT; CG

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

4

PILOCARPINE HCL OPHTHALMIC SOLUTION 1 %, 2 %, 4 %

ISOPTO CARPINE 3 MT

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

3 MT

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

TIMOPTIC-XE 4

Ophthalmic Anti-Inflammatories

ALREX OPHTHALMIC SUSPENSION 0.2 %

3

dexamethasone sodium phosphate ophthalmic solution 0.1 %

2

diclofenac sodium ophthalmic solution 0.1 %

VOLTAREN 2

DUREZOL OPHTHALMIC EMULSION 0.05 %

3

fluorometholone ophthalmic suspension 0.1 %

FLUOR-OP 3

flurbiprofen sodium ophthalmic solution 0.03 %

OCUFEN 2

FML OPHTHALMIC OINTMENT 0.1 % 3

ILEVRO OPHTHALMIC SUSPENSION 0.3 %

3

ketorolac tromethamine ophthalmic solution 0.4 %

ACULAR LS 3


120

Drug Name


ketorolac tromethamine ophthalmic solution 0.5 %

ACULAR 3

LOTEMAX OPHTHALMIC 0.5 % 3

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

3

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

3

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

4

prednisolone sodium phosphate ophthalmic solution 1 %

3

Ophthalmic Prostaglandin And Prostamide Analogs

bimatoprost ophthalmic solution 0.03 % LUMIGAN 2 MT; QL (2.5 ML per 30 days)

latanoprost ophthalmic solution 0.005 % XALATAN 1 MT; CG; QL (2.5 ML per 25 days)

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

3 MT; QL (2.5 ML per 25 days)

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

3 MT; QL (2.5 ML per 25 days)

TRAVOPROST OPHTHALMIC SOLUTION 0.004 %

3 MT; CG

Otic Agents

Otic Agents

ACETASOL HC OTIC SOLUTION 2-1 %

3

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

3

HYDROCORTISONE-ACETIC ACID OTIC SOLUTION 1-2 %

VOSOL HC 3

neomycin-polymyxin-hc otic solution 1 % CORTISPORIN 2

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2


121

Drug Name


Respiratory Tract/ Pulmonary Agents

Antihistamines

azelastine hcl nasal solution 0.1 % ASTELIN 3 QL (30 ML per 25 days)

azelastine hcl nasal solution 0.15 % ASTEPRO 3 QL (60 ML per 30 days)

cetirizine hcl oral syrup 1 mg/ml WAL-ZYR CHILDRENS 3

cyproheptadine hcl oral syrup 2 mg/5ml 1

cyproheptadine hcl oral tablet 4 mg 1

desloratadine oral tablet 5 mg CLARINEX 2 QL (30 EA per 30 days)


2

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

XYZAL 4

levocetirizine dihydrochloride oral tablet 5 mg

XYZAL 3 QL (30 EA per 30 days)

olopatadine hcl nasal solution 0.6 % PATANASE 4

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

2 PA

Anti-Inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

3 PA; QL (12 GM per 30 days)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT


budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

PULMICORT 4 PA


122

Drug Name


BUDESONIDE INHALATION SUSPENSION 1 MG/2ML

PULMICORT 4

budesonide nasal suspension 32 mcg/act RHINOCORT AQUA 2

FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST


FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT

3 QL (24 GM per 30 days)

FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT

3 QL (21.2 GM per 30 days)

flunisolide nasal solution 25 mcg/act (0.025%)



CUTIVATE 2

fluticasone propionate nasal suspension 50 mcg/act

FLONASE 2 QL (16 GM per 30 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT


Antileukotrienes

montelukast sodium oral packet 4 mg SINGULAIR 1 CG; QL (30 EA per 30 days)

montelukast sodium oral tablet 10 mg SINGULAIR 1 CG; QL (30 EA per 30 days)

montelukast sodium oral tablet chewable 4 mg, 5 mg

SINGULAIR 1 CG; QL (30 EA per 30 days)

zafirlukast oral tablet 10 mg, 20 mg ACCOLATE 4

Bronchodilators, Anticholinergic


123

Drug Name


ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT

4 QL (25.8 GM per 30 days)

INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH


ipratropium bromide inhalation solution 0.02 %

2 PA

ipratropium bromide nasal solution 0.03 %

ATROVENT 3 QL (30 ML per 30 days)

ipratropium bromide nasal solution 0.06 %

ATROVENT 3 QL (15 ML per 30 days)

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG


SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT


Bronchodilators, Sympathomimetic





albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8 mg

VOSPIRE ER 4

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

2 PA

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml

ACCUNEB 2 PA

albuterol sulfate oral tablet 2 mg, 4 mg 4

BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH



124

Drug Name


epinephrine injection 0.3 mg/0.3ml EPIPEN 2-PAK 2

EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML


EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML


levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml

XOPENEX CONCENTRATE

4 PA

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML

4 PA

SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE


terbutaline sulfate injection solution 1 mg/ml

5

terbutaline sulfate oral tablet 2.5 mg, 5 mg

3 CG

VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT


XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT


Cystic Fibrosis Agents

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

5 PA; LA

KALYDECO ORAL PACKET 50 MG, 75 MG


KALYDECO ORAL TABLET 150 MG 5 PA; QL (60 EA per 30 days)

ORKAMBI ORAL TABLET 200-125 MG


PULMOZYME INHALATION SOLUTION 1 MG/ML

5 PA

Mast Cell Stabilizers


125

Drug Name


cromolyn sodium inhalation nebulization solution 20 mg/2ml

2 PA

cromolyn sodium oral concentrate 100 mg/5ml

GASTROCROM 2

Phosphodiesterase Inhibitors, Airways Disease

aminophylline intravenous* solution 25 mg/ml

3

DALIRESP ORAL TABLET 500 MCG 4 MT

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

4 MT

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

4 MT

THEOPHYLLINE ER ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 300 MG

THEOCHRON 3 MT

THEOPHYLLINE ER ORAL TABLET EXTENDED RELEASE 12 HR* 450 MG

3 MT

THEOPHYLLINE ER ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG, 600 MG

3 MT

THEOPHYLLINE ORAL SOLUTION 80 MG/15ML

4 MT

Pulmonary Antihypertensives

ADCIRCA ORAL TABLET 20 MG 5 PA; QL (60 EA per 30 days)

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


LETAIRIS ORAL TABLET 10 MG, 5 MG


OPSUMIT ORAL TABLET 10 MG 5 PA; LA; QL (30 EA per 30 days)


126

Drug Name


REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

5 PA; LA

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML

5 PA

sildenafil citrate oral tablet 20 mg REVATIO 2 PA; MT; QL (90 EA per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG


Respiratory Tract Agents, Other

acetylcysteine inhalation solution 10 %, 20 %

3 PA

ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5-25 MCG/INH


INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH


LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

5 PA; LA

PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG

5 PA; LA

STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION 2.5-2.5 MCG/ACT


ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG

5 PA; LA

Respiratory Tract/ Pulmonary Agents




127

Drug Name




COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT


ESBRIET ORAL CAPSULE 267 MG 5 PA; QL (270 EA per 30 days)

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

DUONEB 3 PA

NUCALA SUBCUTANEOUS* SOLUTION RECONSTITUTED 100 MG


OFEV ORAL CAPSULE 100 MG, 150 MG


PULMOZYME INHALATION SOLUTION 1 MG/ML

5 PA

SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT


SYMBICORT INHALATION AEROSOL† 80-4.5 MCG/ACT

3 PA; QL (13.8 GM per 30 days)

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG


Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

FLEXERIL 2 PA

cyclobenzaprine hcl oral tablet 7.5 mg FEXMID 2 PA

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

ZANAFLEX 2

Sleep Disorder Agents

Gaba Receptor Modulators

temazepam oral capsule 15 mg, 7.5 mg RESTORIL 2 CG; QL (30 EA per 30 days)

ZALEPLON ORAL CAPSULE 10 MG, 5 MG

SONATA 4 QL (30 EA per 30 days)


128

Drug Name


ZOLPIDEM TARTRATE ER ORAL TABLET EXTENDEDRELEASE* 12.5 MG, 6.25 MG

AMBIEN CR 4 QL (30 EA per 30 days)

zolpidem tartrate oral tablet 10 mg, 5 mg AMBIEN 4 PA; QL (30 EA per 30 days)

Sleep Disorders, Other

doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

4 PA


HETLIOZ ORAL CAPSULE 20 MG 5 PA; QL (30 EA per 30 days)

modafinil oral tablet 100 mg PROVIGIL 3 CG; QL (30 EA per 30 days)

MODAFINIL ORAL TABLET 200 MG PROVIGIL 3 CG; QL (30 EA per 30 days)

NUVIGIL ORAL TABLET 150 MG 4 PA; QL (60 EA per 30 days)

NUVIGIL ORAL TABLET 200 MG, 250 MG


NUVIGIL ORAL TABLET 50 MG 4 PA; QL (150 EA per 30 days)

ROZEREM ORAL TABLET 8 MG 4 QL (30 EA per 30 days)

XYREM ORAL SOLUTION 500 MG/ML

5 PA; LA; QL (540 ML per 30 days)

Therapeutic Nutrients/ Minerals/ Electrolytes

Electrolyte/ Mineral Modifiers

AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7 %

4 PA

AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 %

4 PA

CHEMET ORAL CAPSULE 100 MG 4


5


129

Drug Name


EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

5 PA; LA

FERRIPROX ORAL SOLUTION 100 MG/ML

5 PA

FERRIPROX ORAL TABLET 500 MG 5 PA

FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 %

4 PA

KIONEX ORAL POWDER 4

sodium polystyrene sulfonate oral suspension 15 gm/60ml

SPS 3 CG

SYPRINE ORAL CAPSULE 250 MG 5

Electrolyte/ Mineral Replacement

CARBAGLU ORAL TABLET 200 MG 5 PA; LA

ISOLYTE-S INTRAVENOUS* SOLUTION

4

KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ

3 MT; CG

klor-con m15 oral tablet extendedrelease* 15 meq

2 MT; CG

klor-con m20 oral tablet extendedrelease* 20 meq

2 MT; CG

KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ

3 MT; CG

klor-con sprinkle oral capsule extended release* 10 meq, 8 meq

2 MT; CG

magnesium sulfate injection solution 50 % 2

NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION

4

PLASMA-LYTE 148 INTRAVENOUS* SOLUTION

4

PLASMA-LYTE A INTRAVENOUS* SOLUTION

4

potassium chloride crys er oral tablet extendedrelease* 10 meq

KLOR-CON M10 2 MT; CG


130

Drug Name


potassium chloride crys er oral tablet extendedrelease* 20 meq

KLOR-CON M20 2 MT; CG

potassium chloride er oral capsule extended release* 10 meq, 8 meq

MICRO-K 3 MT

potassium chloride er oral tablet extendedrelease* 8 meq

KLOR-CON 3 MT

potassium chloride in nacl intravenous* solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

2 PA

potassium chloride intravenous* solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml

2 PA

sodium chloride injection solution 2.5 meq/ml

2 PA

sodium chloride intravenous* solution 0.45 %, 0.9 %, 3 %, 5 %

2 PA

sodium fluoride oral tablet 2.2 (1 f) mg 2

SUPREP BOWEL PREP ORAL SOLUTION

4

Therapeutic Nutrients/ Minerals/ Electrolytes

AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 %

4 PA

AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

4 PA

AMINOSYN M INTRAVENOUS* SOLUTION 3.5 %

4 PA

AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

4 PA

AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 %

4 PA

AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 %

4 PA

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 %

4 PA


131

Drug Name



4 PA


4 PA


4 PA


4 PA

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 %

4 PA


4 PA


4 PA

dextrose in lactated ringers intravenous* solution 5 %

2 PA

dextrose intravenous* solution 10 %, 5 % 2 PA

dextrose-nacl intravenous* solution 10-0.2 %

3 PA

dextrose-nacl intravenous* solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

2 PA

HEPATAMINE INTRAVENOUS* SOLUTION 8 %

4 PA

INTRALIPID INTRAVENOUS* EMULSION 20 %

4 PA

INTRALIPID INTRAVENOUS* EMULSION 30 %

4 PA

IONOSOL-B IN D5W INTRAVENOUS* SOLUTION

4

IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION

4

ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION

4


132

Drug Name


kcl in dextrose-nacl intravenous* solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

2 PA

kcl in dextrose-nacl intravenous* solution 20-5-0.225 meq/l-%-%

3 PA

lactated ringers intravenous* solution 2 PA

levocarnitine intravenous* solution 200 mg/ml

CARNITOR 3 PA

levocarnitine oral solution 1 gm/10ml CARNITOR SF 3 PA; CG

levocarnitine oral tablet 330 mg CARNITOR 3 PA; CG

NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 %

4 PA

NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION

4

NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION

4

nutrilipid intravenous* emulsion 20 % LIPOSYN II 4 PA

PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION

4

potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-%

2 PA

PREMASOL INTRAVENOUS* SOLUTION 10 %

4 PA

premasol intravenous* solution 6 % 2 PA

prenatal oral tablet 27-1 mg TRICARE 2

PROCALAMINE INTRAVENOUS* SOLUTION 3 %

4 PA

PROSOL INTRAVENOUS* SOLUTION 20 %

4 PA

ringers intravenous* solution 2


133

Drug Name


sterile water for irrigation irrigation solution

ARGYLE STERILE WATER

3

TPN ELECTROLYTES INTRAVENOUS* SOLUTION

4 PA

TRAVASOL INTRAVENOUS* SOLUTION 10 %

4 PA

TROPHAMINE INTRAVENOUS* SOLUTION 10 %

4 PA

134

8

8-MOP .................................... 87 A

abacavir sulfate ....................... 61 abacavir-lamivudine-zidovudine

............................................ 61 ABELCET .............................. 36 ABILIFY .......................... 30, 55 ABILIFY MAINTENA .... 30, 55 acamprosate calcium .............. 13 ACARBOSE........................... 68 acebutolol hcl ......................... 76 acetaminophen-codeine ............ 9 acetaminophen-codeine #2 ....... 9 acetaminophen-codeine #3 ....... 9 acetaminophen-codeine #4 ....... 9 ACETASOL HC .................. 120 acetazolamide ....................... 118 ACETAZOLAMIDE .............. 80 ACETAZOLAMIDE ER........ 80 acetic acid ............................... 15 acetylcysteine ....................... 126 acitretin ................................... 87 ACTHIB ............................... 112 ACTIMMUNE ..................... 111 acyclovir ................................. 60 acyclovir sodium .................... 60 ADACEL .............................. 112 ADAGEN ............................... 89 adapalene ................................ 87 ADAPALENE ........................ 87 ADCIRCA ............................ 125 adefovir dipivoxil ................... 58 ADEMPAS ........................... 125 ADVAIR DISKUS ...... 121, 123,

126 ADVAIR HFA ..... 121, 123, 127 AFEDITAB CR ...................... 77 AFINITOR ..................... 48, 108 AFINITOR DISPERZ .......... 108 AGGRENOX ......................... 74 a-hydrocort ............... 38, 95, 114 ALBENZA ............................. 51 albuterol sulfate .................... 123 albuterol sulfate er ................ 123 alclometasone dipropionate .... 95 ALDURAZYME .................... 89

ALECENSA ........................... 48 alfuzosin hcl er ....................... 93 ALIMTA ................................ 45 ALINIA .................................. 51 alosetron hcl ........................... 91 ALPHAGAN P ..................... 118 ALREX ................................. 119 amantadine hcl .................. 52, 64 AMBISOME .......................... 36 amifostine ............................... 44 amikacin sulfate ...................... 14 AMILORIDE HCL........... 80, 81 amiloride-hydrochlorothiazide79 aminophylline ....................... 125 AMINOSYN II ..................... 130 AMINOSYN

II/ELECTROLYTES ........ 130 AMINOSYN M .................... 130 AMINOSYN/ELECTROLYTE

S ................................ 128, 130 AMINOSYN-HBC ............... 130 AMINOSYN-PF ................... 130 AMINOSYN-RF .................. 128 amiodarone hcl ....................... 75 AMITIZA ............................... 91 amitriptyline hcl ..................... 33 ammonium lactate .................. 87 AMOXAPINE ........................ 33 amoxicillin .............................. 20 amoxicillin-pot clavulanate .... 20 amoxicillin-pot clavulanate er 20 amphetamine-dextroamphet er

............................................ 83 amphetamine-

dextroamphetamine ............ 84 amphotericin b ........................ 36 ampicillin ................................ 20 ampicillin sodium ................... 20 ampicillin-sulbactam sodium 20,

21 AMPYRA ......................... 85, 86 anagrelide hcl ......................... 73 anastrozole .............................. 47 ANDRODERM ...................... 99 ANORO ELLIPTA............... 126 APOKYN ............................... 53 APRI ..................................... 100

APRISO ................................ 114 APTIOM ................................. 27 APTIVUS ............................... 63 ARALAST NP...................... 116 ARANELLE ......................... 100 ARCALYST ......................... 111 aripiprazole ....................... 30, 55 ARNUITY ELLIPTA ........... 121 ASACOL HD ....................... 114 ASPIRIN-DIPYRIDAMOLE

ER ....................................... 74 ASSURE ID INSULIN

SAFETY SYR .................... 70 ATENOLOL-

CHLORTHALIDONE ....... 79 atovaquone .............................. 51 atovaquone-proguanil hcl ....... 51 ATRIPLA ............................... 62 atropine sulfate ..................... 117 ATROVENT HFA........ 122, 123 AUBRA ................................ 100 AVASTIN............................... 45 AVIANE ............................... 100 AVITA .............................. 50, 87 AVODART............................. 94 azacitidine ............................... 45 AZACTAM IN DEXTROSE . 19 AZATHIOPRINE ................. 108 azelastine hcl ................ 118, 121 AZILECT ............................... 54 azithromycin ..................... 21, 22 AZOPT ................................. 118 AZOR ..................................... 79 aztreonam ............................... 19 B

bacitracin ................................ 15 bacitracin-polymyxin b ......... 117 bacitra-neomycin-polymyxin-hc

.......................................... 117 baclofen .................................. 58 balsalazide disodium ............ 114 BALZIVA............................. 101 BANZEL ................................ 27 BARACLUDE ........................ 58 bcg vaccine ........................... 112 BELEODAQ........................... 45 BENICAR............................... 75

Index of Drugs

135

BENICAR HCT ..................... 79 BENLYSTA ......................... 109 benzoyl peroxide-erythromycin

............................................ 87 benztropine mesylate .............. 52 BEPREVE ............................ 118 betamethasone dipropionate .. 38,

87, 95 betamethasone dipropionate aug

...................................... 38, 95 betamethasone valerate .... 39, 95 BETASERON ........................ 86 betaxolol hcl ........................... 76 BETAXOLOL HCL ............. 118 bethanechol chloride .............. 94 BETOPTIC-S ....................... 118 bexarotene .............................. 51 bicalutamide ........................... 43 BICILLIN C-R ....................... 21 BICILLIN C-R 900/300 ......... 21 BICILLIN L-A ....................... 21 BICNU ................................... 45 BILTRICIDE .......................... 51 bimatoprost ................... 118, 120 BISOPROLOL FUMARATE 76 BIVIGAM ............................ 111 bleomycin sulfate ................... 45 BLEPHAMIDE S.O.P. ... 39, 117 BOOSTRIX .......................... 112 BOSULIF ............................... 48 BOTOX ............................ 41, 58 BREO ELLIPTA .................. 123 briellyn ................................. 101 BRILINTA ............................. 74 brimonidine tartrate .............. 118 BRIMONIDINE TARTRATE

.......................................... 118 BRINTELLIX .................. 31, 32 bromocriptine mesylate ........ 107 BROMOCRIPTINE

MESYLATE....................... 53 budesonide .................... 121, 122 BUDESONIDE .................... 122 BUDESONIDE ER 91, 101, 114 bumetanide ............................. 80 BUMETANIDE ..................... 80 buprenorphine hcl ................... 14 buprenorphine hcl-naloxone hcl

............................................ 14 BUPROBAN .......................... 30

BUPROPION HCL ................ 30 bupropion hcl er (sr) ............... 30 BUPROPION HCL ER (XL) . 30 buspirone hcl .......................... 64 BUSULFEX ........................... 43 butorphanol tartrate ................ 12 BYDUREON .......................... 68 BYETTA 10 MCG PEN......... 68 BYETTA 5 MCG PEN........... 68 BYSTOLIC ............................ 76 C

cabergoline ........................... 107 calcipotriene ........................... 87 CALCITONIN (SALMON) . 115 calcitriol ................................ 115 calcium acetate (phos binder) . 94 CAMILA .............................. 105 CANASA.............................. 114 CANCIDAS............................ 36 candesartan cilexetil ............... 75 candesartan cilexetil-hctz ....... 80 CAPASTAT SULFATE ......... 42 CAPRELSA............................ 48 CARBAGLU ........................ 129 carbamazepine .................. 27, 28 CARBAMAZEPINE .............. 67 CARBAMAZEPINE ER .. 27, 67 carbidopa-levodopa .......... 53, 54 CARBIDOPA-LEVODOPA ER

............................................ 53 carbidopa-levodopa-entacapone

...................................... 52, 53 carboplatin .............................. 45 carteolol hcl .......................... 118 CARTIA XT ........................... 77 CAYSTON ..................... 19, 124 cefaclor ............................. 17, 18 cefaclor er ............................... 17 cefadroxil ................................ 18 cefazolin sodium..................... 18 cefdinir.................................... 18 cefepime hcl ........................... 18 CEFIXIME ............................. 18 cefotaxime sodium ................. 18 cefoxitin sodium ..................... 18 cefpodoxime proxetil .............. 18 cefprozil .................................. 18 ceftazidime ............................. 18 ceftazidime and dextrose ........ 18 ceftriaxone sodium ................. 19

cefuroxime axetil .................... 19 cefuroxime sodium ................. 19 celecoxib ........................... 10, 40 CELONTIN ............................ 25 cephalexin ............................... 19 CERDELGA ........................... 89 CEREZYME........................... 89 CERVARIX .......................... 112 cetirizine hcl ......................... 121 cevimeline hcl ......................... 86 CHANTIX .............................. 14 CHANTIX CONTINUING

MONTH PAK .................... 14 CHANTIX STARTING

MONTH PAK .................... 14 CHEMET .............................. 128 chloramphenicol sod succinate

............................................ 16 chloroquine phosphate ............ 51 CHLOROTHIAZIDE ............. 81 chlorpromazine hcl ........... 34, 54 CHLORTHALIDONE ........... 81 CHOLESTYRAMINE LIGHT

............................................ 82 ciclopirox ................................ 36 ciclopirox olamine .................. 36 cilostazol ................................. 74 CILOXAN .............................. 23 cimetidine ............................... 91 CIMETIDINE ......................... 91 CIMETIDINE HCL ................ 91 CIMZIA ................................ 109 CIMZIA PREFILLED .......... 109 CINRYZE ............................. 108 CIPRODEX .......................... 120 ciprofloxacin ........................... 23 ciprofloxacin hcl ..................... 23 ciprofloxacin in d5w ............... 23 ciprofloxacin-ciproflox hcl er . 23 cisplatin................................... 45 CITALOPRAM

HYDROBROMIDE ........... 32 cladribine ................................ 45 CLARAVIS ............................ 87 clarithromycin......................... 22 clarithromycin er .................... 22 clindamax ......................... 16, 87 clindamycin palmitate hcl....... 16 clindamycin phosphate ........... 16

136

clindamycin phosphate in d5w ............................................ 16

CLINIMIX/DEXTROSE (2.75/5) ............................. 130

CLINIMIX/DEXTROSE (4.25/10) ........................... 131



CLINIMIX/DEXTROSE (4.25/5) ............................. 131

CLINIMIX/DEXTROSE (5/15) .......................................... 131



clobetasol propionate........ 95, 96 clobetasol propionate e ........... 95 clomipramine hcl .................... 33 clonazepam ................. 25, 64, 65 clonidine hcl ..................... 74, 75 clopidogrel bisulfate ............... 74 clorazepate dipotassium ... 25, 65 clotrimazole ............................ 36 clotrimazole-betamethasone ... 87 clozapine........................... 57, 58 COARTEM ............................ 51 COLCHICINE ........................ 38 COLCHICINE-PROBENECID

............................................ 38 COLCRYS ............................. 38 COLESTIPOL HCL ............... 82 colistimethate sodium ............. 17 COLOCORT ........................ 114 COMBIGAN ........................ 118 COMBIVENT RESPIMAT . 127 COMETRIQ (100 MG DAILY

DOSE) ................................ 48 COMETRIQ (140 MG DAILY

DOSE) ................................ 48 COMETRIQ (60 MG DAILY

DOSE) ................................ 48 COMPLERA .......................... 61 COMPRO ............................... 34 constulose ............................... 92 COPAXONE .......................... 86 cortisone acetate ....... 39, 96, 114 COTELLIC............................. 48

COUMADIN .......................... 72 CREON .................................. 89 CRESTOR .............................. 81 CRIXIVAN ............................ 63 cromolyn sodium .. 118, 124, 125 CRYSELLE-28 .................... 101 CUBICIN................................ 16 CUVPOSA ............................. 86 CYCLAFEM 1/35 ................ 101 CYCLAFEM 7/7/7 ............... 101 cyclobenzaprine hcl .............. 127 cyclophosphamide .................. 43 cyclosporine.......................... 109 CYCLOSPORINE ................ 109 CYCLOSPORINE MODIFIED

.......................................... 109 cyproheptadine hcl ............... 121 CYRAMZA ............................ 50 CYSTADANE ........................ 89 CYSTAGON .......................... 89 cytarabine ............................... 45 D

dacarbazine ............................. 45 DALIRESP ........................... 125 danazol.................................... 99 dantrolene sodium .................. 58 dapsone ................................... 42 DAPTACEL ......................... 112 DARAPRIM ........................... 51 DARZALEX .......................... 50 daunorubicin hcl ..................... 45 DAUNOXOME ...................... 46 DEBLITANE........................ 101 DELYLA .............................. 101 DELZICOL .................... 92, 114 DEMEROL ............................. 12 DEMSER ................................ 80 DEPEN TITRATABS ... 94, 109,

128 DEPO-PROVERA................ 105 DESIPRAMINE HCL ............ 33 desloratadine ......................... 121 desmopressin ace spray refrig 98,

99 desmopressin acetate .............. 99 desogestrel-ethinyl estradiol . 101 desonide .................................. 96 desoximetasone ...................... 96 desvenlafaxine er .................... 32 dexamethasone . 39, 96, 114, 115

DEXAMETHASONE INTENSOL........... 39, 96, 114

dexamethasone sodium phosphate .............. 39, 96, 119

DEXILANT ............................ 93 dexrazoxane ............................ 46 dextroamphetamine sulfate ..... 84 dextrose................................. 131 dextrose in lactated ringers ... 131 dextrose-nacl......................... 131 diazepam ..................... 24, 25, 65 DIAZEPAM INTENSOL . 25, 65 diclofenac potassium ........ 10, 40 diclofenac sodium ..... 10, 40, 119 diclofenac sodium er......... 10, 40 dicloxacillin sodium ............... 21 dicyclomine hcl ...................... 90 didanosine ............................... 62 DIFICID ................................. 22 diflorasone diacetate ............... 96 diflunisal ........................... 10, 40 DIGITEK ................................ 79 digoxin .................................... 79 dihydroergotamine mesylate .. 41 DILANTIN ............................. 28 DILANTIN INFATABS ........ 28 diltiazem hcl ........................... 77 diltiazem hcl er ....................... 77 diltiazem hcl er beads ............. 77 diltiazem hcl er coated beads .. 77 dilt-xr ...................................... 77 DIPENTUM ......................... 114 diphenhydramine hcl 34, 52, 121 diphenoxylate-atropine ........... 90 diphtheria-tetanus toxoids dt 112 disulfiram ................................ 13 divalproex sodium ...... 26, 41, 67 DIVALPROEX SODIUM ...... 26 divalproex sodium er ........ 41, 67 DIVALPROEX SODIUM ER 25 docetaxel ................................. 46 donepezil hcl ........................... 29 DORZOLAMIDE HCL ........ 118 DORZOLAMIDE HCL-

TIMOLOL MAL .............. 119 doxazosin mesylate ........... 75, 94 doxepin hcl ............... 33, 64, 128 doxorubicin hcl ....................... 46 DOXY 100.............................. 24 doxycycline hyclate .... 24, 86, 87

137

doxycycline monohydrate 24, 86, 87

dronabinol............................... 35 drospirenone-ethinyl estradiol

.......................................... 101 DROXIA ................................ 44 duloxetine hcl ................... 32, 65 DULOXETINE HCL ............. 85 duramorph .............................. 10 DUREZOL ........................... 119 DUTASTERIDE .................... 94 DUTASTERIDE-

TAMSULOSIN HCL ......... 94 E

E.E.S. 400 ............................... 22 econazole nitrate ..................... 36 EDURANT ............................. 61 EFFIENT ................................ 74 ELIDEL .......................... 87, 109 ELIQUIS ................................ 72 ELITEK .................................. 46 ELIXOPHYLLIN ................. 125 ELMIRON .............................. 94 EMCYT .................................. 44 EMEND .................................. 35 EMOQUETTE ..................... 101 EMPLICITI ............................ 50 EMSAM ................................. 31 EMTRIVA .............................. 62 ENDOCET ............................... 9 ENGERIX-B ........................ 112 enoxaparin sodium ................. 72 enpresse-28 ........................... 101 entacapone .............................. 52 entecavir ................................. 58 enulose .................................... 92 epinephrine ........................... 124 EPIPEN 2-PAK .................... 124 EPIPEN JR 2-PAK ............... 124 epirubicin hcl .......................... 46 EPITOL ............................ 28, 67 EPIVIR HBV.......................... 58 EPLERENONE ...................... 81 EPZICOM .............................. 62 ergomar................................... 41 ERIVEDGE ............................ 48 ERRIN .................................. 105 ery ........................................... 22 ERY-TAB............................... 22

ERYTHROCIN LACTOBIONATE ............. 22

ERYTHROCIN STEARATE . 22 erythromycin .......................... 22 erythromycin base .................. 22 ERYTHROMYCIN BASE .... 22 erythromycin ethylsuccinate... 22 ESBRIET .............................. 127 escitalopram oxalate ......... 32, 65 ESCITALOPRAM OXALATE

............................................ 32 esomeprazole sodium ............. 93 estazolam ................................ 85 ESTRACE ............................ 100 estradiol ................................ 100 estradiol valerate........... 100, 101 estropipate ............................ 100 ethambutol hcl ........................ 42 ETHOSUXIMIDE .................. 25 etidronate disodium ...... 115, 116 etodolac ............................ 10, 40 etodolac er ........................ 10, 40 etoposide ................................. 48 EURAX .................................. 52 EVOTAZ ................................ 63 EXEL PEN NEEDLES 1/2 .... 70 EXELON ................................ 29 EXEMESTANE ..................... 47 EXJADE ............................... 129 F

FABRAZYME ....................... 89 FALMINA ............................ 101 famciclovir.............................. 60 famotidine ............................... 91 famotidine premixed............... 91 FANAPT ................................ 55 FANAPT TITRATION PACK

............................................ 55 FARESTON ........................... 44 FARXIGA .............................. 68 FARYDAK ............................. 48 FASLODEX ........................... 46 felbamate ................................ 26 FELBAMATE ........................ 27 FELODIPINE ER ................... 78 fenofibrate .............................. 81 fenofibrate micronized ........... 81 FENOFIBRIC ACID .............. 81 fentanyl ............................. 11, 12 fentanyl citrate .................. 10, 12

FENTORA ........................ 11, 12 FERRIPROX ........................ 129 FETZIMA ............................... 32 FETZIMA TITRATION ........ 32 finasteride ............................... 94 FIRAZYR ............................. 108 FLECAINIDE ACETATE ..... 75 FLOVENT DISKUS ............ 122 FLOVENT HFA ................... 122 fluconazole ............................. 36 flucytosine .............................. 36 fludarabine phosphate ............. 44 fludrocortisone acetate ............ 96 flunisolide ............................. 122 fluocinolone acetonide............ 96 fluocinolone acetonide body... 96 fluocinonide ............................ 97 FLUOCINONIDE ............ 87, 97 fluocinonide-e ......................... 97 fluorometholone ................... 119 fluorouracil ....................... 87, 88 FLUOROURACIL ................. 87 fluoxetine hcl .......................... 32 FLUOXETINE HCL .............. 32 fluphenazine decanoate .......... 54 fluphenazine hcl...................... 54 flurbiprofen ....................... 10, 40 flurbiprofen sodium .............. 119 flutamide ................................. 43 fluticasone propionate ..... 88, 97,

122 fluvastatin sodium ............ 81, 82 FLUVOXAMINE MALEATE

............................................ 32 FLUVOXAMINE MALEATE

ER ....................................... 32 FML ...................................... 119 fondaparinux sodium .............. 72 FORTEO............................... 116 FORTICAL........................... 116 FREAMINE HBC ................ 129 furosemide .............................. 80 FUZEON ................................ 62 fyavolv .................................. 101 FYCOMPA ............................. 27 G

gabapentin............................... 26 GABITRIL ............................. 26 GALANTAMINE

HYDROBROMIDE ........... 29

138

GALANTAMINE HYDROBROMIDE ER ..... 29

GAMASTAN S/D ................ 111 GAMMAGARD ................... 111 GAMMAPLEX .................... 111 GAMUNEX-C ..................... 111 ganciclovir sodium ................. 58 GARDASIL .......................... 112 GARDASIL 9 ....................... 112 gatifloxacin ............................. 23 GATTEX ................................ 90 gavilyte-c ................................ 92 gavilyte-g ................................ 92 gavilyte-h ................................ 92 gavilyte-n with flavor pack .... 92 gemcitabine hcl ...................... 44 gemfibrozil ............................. 81 generlac .................................. 92 GENGRAF ........................... 109 gentak ..................................... 14 gentamicin in saline ................ 15 gentamicin sulfate .................. 15 GENVOYA ............................ 60 GEODON ......................... 55, 66 GIANVI ................................ 101 GILDAGIA .......................... 101 GILDESS 1.5/30 .................. 101 GILENYA .............................. 86 GILOTRIF .............................. 49 GLEEVEC .............................. 49 GLEOSTINE .......................... 46 GLUCAGEN HYPOKIT ....... 70 GLUCAGON EMERGENCY 70 glycopyrrolate......................... 90 GLYSET................................. 68 GOLYTELY........................... 92 granisetron hcl ........................ 35 GRANIX ................................ 73 griseofulvin microsize ............ 36 griseofulvin ultramicrosize ..... 37 guanfacine hcl ........................ 75 guanfacine hcl er .................... 84 guanidine hcl .......................... 42 H

HALAVEN............................. 46 halobetasol propionate............ 97 HALOPERIDOL .................... 54 haloperidol decanoate ............. 54 haloperidol lactate .................. 54 HALOPERIDOL LACTATE . 54

HARVONI.............................. 59 HAVRIX .............................. 112 heparin (porcine) in d5w ........ 73 heparin sod (porcine) in d5w .. 73 heparin sodium (porcine)........ 73 HEPATAMINE .................... 131 HERCEPTIN .......................... 46 HETLIOZ ............................. 128 HEXALEN ............................. 43 HUMALOG............................ 71 HUMALOG KWIKPEN ........ 71 HUMALOG MIX 50/50 ......... 71 HUMALOG MIX 50/50

KWIKPEN.......................... 71 HUMALOG MIX 75/25 ......... 71 HUMALOG MIX 75/25

KWIKPEN.......................... 71 HUMIRA .............................. 109 HUMIRA PEN ..................... 109 HUMIRA PEN-CROHNS

STARTER ........................ 109 HUMULIN 70/30 ................... 71 HUMULIN 70/30 KWIKPEN 71 HUMULIN N ......................... 71 HUMULIN N KWIKPEN ...... 71 HUMULIN R ......................... 71 HUMULIN R U-500

(CONCENTRATED) ......... 71 hydralazine hcl ....................... 83 hydrocodone-acetaminophen .... 9 hydrocodone-ibuprofen ............ 9 hydrocortisone .......... 39, 97, 115 hydrocortisone butyr lipo base97 hydrocortisone butyrate .......... 97 hydrocortisone valerate .......... 97 HYDROCORTISONE-ACETIC

ACID ................................ 120 hydromorphone hcl................. 12 hydromorphone hcl pf ............ 12 hydroxychloroquine sulfate .... 51 HYDROXYUREA ................. 44 hydroxyzine hcl ................ 34, 64 HYPERRAB S/D ................. 111 I

IBANDRONATE SODIUM 116 IBRANCE .............................. 48 ibuprofen .......................... 10, 40 ICLUSIG ................................ 49 idarubicin hcl .......................... 46 ifosfamide ............................... 46

ILARIS ................................. 112 ILEVRO ............................... 119 ilotycin .................................... 22 imatinib mesylate.................... 49 IMBRUVICA ......................... 49 imipenem-cilastatin ................ 20 imipramine hcl ........................ 34 imipramine pamoate ............... 34 imiquimod............................... 88 IMOVAX RABIES .............. 113 INCRELEX ............................ 99 INCRUSE ELLIPTA .... 123, 126 indapamide ............................. 81 INFANRIX ........................... 113 INLYTA ................................. 49 INTELENCE .......................... 61 INTRALIPID ........................ 131 INTRON A ....................... 58, 59 INTROVALE ....................... 101 INVANZ ................................. 20 INVEGA ................................. 55 INVEGA SUSTENNA ........... 56 INVIRASE ............................. 63 INVOKAMET .................. 68, 69 INVOKANA........................... 69 IONOSOL-B IN D5W .......... 131 IONOSOL-MB IN D5W ...... 131 IPOL ..................................... 113 ipratropium bromide ............. 123 ipratropium-albuterol ............ 127 IRESSA .................................. 49 irinotecan hcl .......................... 46 ISENTRESS ..................... 60, 61 ISOLYTE-P IN D5W ........... 131 ISOLYTE-S .......................... 129 isoniazid ............................ 42, 43 isosorbide dinitrate ................. 83 isosorbide dinitrate er ............. 82 isosorbide mononitrate ........... 83 isosorbide mononitrate er ....... 83 ISRADIPINE .......................... 78 ISTODAX............................... 46 itraconazole............................. 37 ivermectin ............................... 51 IXIARO ................................ 113 J

JAKAFI .................................. 49 JALYN ................................... 94 JANUMET ............................. 69 JANUMET XR ....................... 70

139

JANUVIA............................... 69 JENTADUETO ...................... 69 JOLIVETTE ......................... 105 JUNEL 1.5/30....................... 102 JUNEL 1/20.......................... 102 JUNEL FE 1.5/30 ................. 102 JUNEL FE 1/20 .................... 102 JUXTAPID ............................. 82 K

KADCYLA ............................ 46 KALETRA ............................. 63 KALYDECO ........................ 124 KANUMA .............................. 89 KARIVA .............................. 102 kcl in dextrose-nacl .............. 132 KELNOR 1/35...................... 102 KENALOG....................... 39, 97 ketoconazole ........................... 37 ketoprofen......................... 10, 40 ketorolac tromethamine 119, 120 keytruda .......................... 50, 112 KEYTRUDA .................. 50, 112 KINERET ............................. 109 KIONEX............................... 129 KLOR-CON ......................... 129 KLOR-CON 10 .................... 129 klor-con m15 ........................ 129 klor-con m20 ........................ 129 klor-con sprinkle .................. 129 KOMBIGLYZE XR ............... 70 KORLYM............................... 70 KUVAN ................................. 89 KYNAMRO ........................... 82 L

LABETALOL HCL ............... 76 lactated ringers ..................... 132 lactulose .................................. 92 lamivudine .................. 58, 59, 62 lamivudine-zidovudine ........... 62 lamotrigine ....................... 27, 67 LAMOTRIGINE .............. 26, 27 lamotrigine er ......................... 67 LAMOTRIGINE ER .............. 27 lansoprazole ............................ 93 LANTUS ................................ 71 LANTUS SOLOSTAR .......... 71 LARIN 1.5/30....................... 102 LARIN 1/20.......................... 102 LARIN FE 1.5/30 ................. 102 LARIN FE 1/20 .................... 102

LASTACAFT ....................... 118 latanoprost ............................ 120 LATUDA................................ 56 LEENA ................................. 102 leflunomide ................... 111, 112 LENVIMA 10 MG DAILY

DOSE.................................. 49 LENVIMA 14 MG DAILY



DOSE.................................. 49 LESSINA.............................. 102 LETAIRIS ............................ 125 LETROZOLE ......................... 48 leucovorin calcium ................. 44 LEUKERAN .......................... 43 LEUKINE ............................... 73 leuprolide acetate .................. 107 levalbuterol hcl ..................... 124 LEVEMIR .............................. 72 LEVEMIR FLEXTOUCH ..... 72 levetiracetam .......................... 25 LEVETIRACETAM .............. 25 levetiracetam er ...................... 24 LEVOBUNOLOL HCL ....... 119 levocarnitine ......................... 132 levocetirizine dihydrochloride

.......................................... 121 levofloxacin ............................ 23 levofloxacin in d5w ................ 23 LEVOFLOXACIN IN D5W .. 23 levonest ................................. 102 levonorgest-eth estrad 91-day

.......................................... 102 LEVORA 0.15/30 (28) ......... 102 levothyroxine sodium ........... 106 levoxyl .................................. 106 LEXIVA ................................. 63 lidocaine ................................. 13 LIDOCAINE .......................... 13 lidocaine hcl ........................... 13 lidocaine hcl (pf) .................... 13 lidocaine-prilocaine ................ 13 lindane .................................... 52 linezolid .................................. 16 LINZESS ................................ 92 LIOTHYRONINE SODIUM106 LITHIUM ............................... 68

lithium carbonate .................... 68 lithium carbonate er .......... 67, 68 LOKARA ............................... 97 LONSURF .............................. 44 loperamide hcl ........................ 90 LORAZEPAM INTENSOL .. 26,

65 lorcet ......................................... 9 lorcet hd .................................... 9 lorcet plus ................................. 9 lortab ......................................... 9 LORYNA ............................. 102 LOTEMAX........................... 120 LOXAPINE SUCCINATE ..... 54 LUMIGAN ........................... 120 LUMIZYME......................... 126 LUPANETA PACK ............. 107 LUPRON DEPOT ................ 107 LUPRON DEPOT-PED ....... 107 LUTERA .............................. 102 LYNPARZA ........................... 46 LYRICA ........................... 25, 85 LYSODREN ......................... 106 LYZA ................................... 105 M

magnesium sulfate ................ 129 malathion ................................ 52 maprotiline hcl ........................ 31 marlissa ................. 100, 102, 105 MARPLAN............................. 31 MATULANE .......................... 43 matzim la ................................ 78 MAXIDEX ........................... 120 meclizine hcl ........................... 34 medroxyprogesterone acetate

.......................................... 105 mefloquine hcl ........................ 51 MEGACE ES........................ 105 megestrol acetate .................. 105 MEGESTROL ACETATE ... 105 MEKINIST ............................. 49 meloxicam .............................. 10 melphalan hcl.......................... 43 MEMANTINE HCL ......... 29, 30 MENACTRA ........................ 113 MENEST .............................. 100 MENOMUNE....................... 113 MENVEO ............................. 113 mercaptopurine ..................... 109 meropenem ............................. 20

140

mesalamine-cleanser ............ 114 mesna ...................................... 46 MESNEX ............................... 47 MESTINON ........................... 42 METADATE ER .................... 84 metformin hcl er (osm) ........... 70 methadone hcl ........................ 11 methazolamide ............... 80, 119 methenamine hippurate .......... 16 methimazole ......................... 108 methotrexate ......................... 110 methotrexate sodium ............ 110 methotrexate sodium (pf) ..... 110 METHYCLOTHIAZIDE ....... 81 methylergonovine maleate 40, 41 methylphenidate hcl ............... 84 methylphenidate hcl er ........... 84 methylprednisolone .. 39, 98, 115 methylprednisolone (pak) ...... 97,

115 methylprednisolone acetate ... 39,

98, 115 methylprednisolone sodium succ

...................................... 39, 98 METIPRANOLOL ............... 119 metoclopramide hcl .......... 34, 90 METOLAZONE..................... 81 metoprolol succinate er .......... 76 metoprolol tartrate .................. 76 metoprolol-hydrochlorothiazide

............................................ 80 metronidazole ......................... 16 METRONIDAZOLE .............. 16 metronidazole in nacl ............. 16 mexiletine hcl ......................... 75 MIACALCIN ....................... 116 MICROGESTIN 1.5/30 ....... 102 MICROGESTIN 1/20 .......... 103 MICROGESTIN FE 1.5/30 .. 103 MICROGESTIN FE 1/20 ..... 103 midodrine hcl.......................... 75 MINITRAN ............................ 83 minocycline hcl ................ 24, 86 minoxidil ................................ 83 mirtazapine ............................. 31 MIRTAZAPINE ..................... 31 misoprostol ....................... 92, 99 mitomycin............................... 47 mitoxantrone hcl ............... 45, 86 M-M-R II .............................. 113

modafinil .............................. 128 MODAFINIL........................ 128 MODERIBA ........................... 59 MODERIBA 800 DOSE PACK

............................................ 59 molindone hcl ......................... 55 mometasone furoate ............... 98 MONONESSA ..................... 103 montelukast sodium .............. 122 morphine sulfate ............... 11, 12 morphine sulfate (concentrate)

............................................ 11 morphine sulfate (pf) .............. 12 morphine sulfate er ................. 11 morphine sulfate er beads ....... 11 MOVIPREP ............................ 92 MOXEZA ............................... 23 moxifloxacin hcl ..................... 23 MOZOBIL .............................. 73 MULTAQ ............................... 75 mupirocin................................ 16 mupirocin calcium .................. 16 MUSTARGEN ....................... 47 MYCAMINE .......................... 37 mycophenolate mofetil ......... 110 MYCOPHENOLATE

MOFETIL ......................... 110 mycophenolic acid ................ 110 MYCOPHENOLIC ACID ... 110 MYORISAN ........................... 88 MYRBETRIQ ........................ 93 N

nabumetone ...................... 10, 40 NADOLOL ............................. 76 nafcillin sodium ...................... 21 NAGLAZYME ....................... 89 naloxone hcl ................... 14, 116 naltrexone hcl ................... 13, 14 NAMENDA............................ 30 NAMENDA XR ..................... 30 NAMENDA XR TITRATION

PACK ................................. 30 naproxen ........................... 10, 40 naproxen dr ....................... 10, 40 naratriptan hcl ......................... 41 NATACYN ............................ 37 NATPARA ........................... 116 NEBUPENT ........................... 51 NECON 0.5/35 (28) ............. 103 NECON 1/35 (28) ................ 103

NECON 1/50 (28)................. 103 NECON 10/11 (28)............... 103 NECON 7/7/7 ....................... 103 nefazodone hcl ........................ 31 neomycin sulfate ..................... 15 neomycin-bacitracin zn-

polymyx ............................ 117 neomycin-polymyxin-dexameth

.......................................... 117 neomycin-polymyxin-

gramicidin ......................... 117 neomycin-polymyxin-hc...... 117,

120 NEORAL .............................. 110 NEPHRAMINE .................... 132 NEUPOGEN........................... 73 NEUPRO ................................ 53 NEVANAC........................... 120 nevirapine ............................... 61 nevirapine er ........................... 61 NEXAVAR............................. 49 niacin er (antihyperlipidemic) 82 NIACOR ................................. 82 NICARDIPINE HCL.............. 78 NICOTROL ............................ 14 NICOTROL NS ...................... 14 NIFEDICAL XL ..................... 78 nifedipine er osmotic release .. 78 NIFEDIPINE ER OSMOTIC

RELEASE........................... 78 NIKKI ................................... 103 NILANDRON ........................ 43 nimodipine .............................. 78 NINLARO .............................. 47 NIPENT .................................. 47 NITRO-BID ............................ 83 NITRO-DUR .......................... 83 nitrofurantoin macrocrystal .... 17 NITROFURANTOIN

MACROCRYSTAL ........... 17 NITROFURANTOIN

MONOHYD MACRO........ 17 nitroglycerin ........................... 83 NITROSTAT .......................... 83 nizatidine ................................ 91 NORA-BE ............................ 103 NORDITROPIN FLEXPRO .. 99 norethindrone ........................ 105 NORETHINDRONE

ACETATE ........................ 105

141

NORLYROC ........................ 103 NORMOSOL-M IN D5W .... 132 NORMOSOL-R IN D5W..... 132 NORMOSOL-R PH 7.4 ....... 129 NORTHERA .......................... 75 NORTREL 0.5/35 (28) ......... 103 NORTREL 1/35 (21) ............ 103 NORTREL 1/35 (28) ............ 103 NORTREL 7/7/7 .................. 103 NORTRIPTYLINE HCL ....... 34 NORVIR................................. 63 NOXAFIL .............................. 37 NUCALA ............................. 127 NUEDEXTA .......................... 85 NULOJIX ............................. 110 NULYTELY WITH FLAVOR

PACKS ............................... 92 nutrilipid ............................... 132 NUVARING......................... 103 NUVIGIL ............................. 128 NYAMYC .............................. 37 nystatin ................................... 37 nystatin-triamcinolone ............ 88 NYSTOP ................................ 37 O

OCELLA .............................. 103 octreotide acetate .................. 107 ODOMZO .............................. 49 OFEV ................................... 127 ofloxacin ................................. 23 olanzapine......................... 56, 66 OLANZAPINE....................... 56 olanzapine-fluoxetine hcl ....... 31 olopatadine hcl ..................... 121 OMEGA-3-ACID ETHYL

ESTERS ............................. 82 ondansetron ............................ 36 ondansetron hcl ...................... 35 ONFI....................................... 26 ONGLYZA............................. 69 OPDIVO ................................. 50 OPSUMIT ............................ 125 ORAP ..................................... 55 ORENCIA ............................ 110 ORFADIN .............................. 89 ORKAMBI ........................... 124 ORSYTHIA .......................... 103 oxacillin sodium ..................... 21 oxaliplatin ............................... 47 oxandrolone ............................ 99

oxaprozin .......................... 10, 40 OXCARBAZEPINE ............... 28 OXYBUTYNIN CHLORIDE 93 OXYBUTYNIN CHLORIDE

ER ....................................... 93 oxycodone hcl......................... 13 oxycodone-acetaminophen ....... 9 P

PACERONE ........................... 75 paclitaxel ................................ 47 PALIPERIDONE ER ............. 56 pamidronate disodium .......... 116 PANRETIN ............................ 51 pantoprazole sodium............... 93 paricalcitol ............................ 116 paromomycin sulfate .............. 15 paroxetine hcl er ............... 33, 65 PASER.................................... 43 PATADAY ........................... 118 PAXIL .............................. 33, 65 PAZEO ................................. 118 PEDVAX HIB ...................... 113 peg 3350-kcl-na bicarb-nacl ... 92 peg-3350/electrolytes ............. 92 PEGANONE .......................... 28 PEGASYS .............................. 59 penicillin g pot in dextrose ..... 21 penicillin g potassium ............. 21 penicillin g procaine ............... 21 penicillin g sodium ................. 21 PENTAM................................ 51 PENTOXIFYLLINE ER ........ 79 PERFOROMIST .................. 124 permethrin .............................. 52 perphenazine ..................... 34, 55 perphenazine-amitriptyline ..... 31 phenadoz ................................. 34 PHENELZINE SULFATE ..... 31 phenobarbital .......................... 26 PHENYTEK ........................... 28 phenytoin ................................ 28 phenytoin sodium ................... 28 phenytoin sodium extended .... 28 PHOSPHOLINE IODIDE .... 119 pilocarpine hcl ........................ 86 PILOCARPINE HCL ........... 119 pimozide ................................. 55 PIMTREA ............................ 104 PINDOLOL ............................ 77 pioglitazone hcl-glimepiride... 70

pioglitazone hcl-metformin hcl ............................................ 70

piperacillin sod-tazobactam so21 PIRMELLA 1/35 .................. 104 piroxicam .......................... 10, 40 PLASMA-LYTE 148 ........... 129 PLASMA-LYTE A .............. 129 PLASMA-LYTE-56 IN D5W

.......................................... 132 podofilox................................. 88 polyethylene glycol 3350 ....... 92 polymyxin b-trimethoprim ... 117 POMALYST........................... 44 PORTIA-28 .......................... 104 potassium chloride ................ 130 potassium chloride crys er ... 129,

130 potassium chloride er ............ 130 potassium chloride in dextrose

.......................................... 132 potassium chloride in nacl .... 130 potassium citrate er ................. 94 POTASSIUM CITRATE ER . 94 POTIGA ................................. 25 PRADAXA ............................. 73 pramipexole dihydrochloride .. 53 pramipexole dihydrochloride er

............................................ 53 prazosin hcl ....................... 75, 94 prednisolone sodium phosphate

...................... 39, 98, 115, 120 prednisone................. 40, 98, 115 PREDNISONE INTENSOL .. 39,

98, 115 preferred plus insulin syringe . 72 PREMARIN ......................... 100 premasol ............................... 132 PREMASOL ......................... 132 PREMPRO ........................... 104 prenatal ................................. 132 PREVALITE .......................... 82 PREVIFEM .......................... 104 PREZCOBIX .......................... 63 PREZISTA ............................. 63 primaquine phosphate ............. 52 primidone ................................ 26 PRISTIQ ................................. 33 PRIVIGEN ........................... 111 probenecid .............................. 38 PROCALAMINE ................. 132

142

prochlorperazine ..................... 35 prochlorperazine edisylate 35, 55 PROCRIT ......................... 73, 74 procto-pak............................... 98 proctosol hc .......................... 115 proctozone-hc ................... 90, 98 progesterone micronized ...... 105 PROGLYCEM ....................... 70 PROGRAF ........................... 110 PROLASTIN-C .................... 126 PROLEUKIN ......................... 47 PROLIA ............................... 116 PROMACTA .......................... 74 promethazine hcl ............ 35, 121 PROPAFENONE HCL .... 75, 76 propafenone hcl er .................. 75 proparacaine hcl ................... 117 propranolol hcl ....................... 77 PROPRANOLOL HCL .......... 77 PROPRANOLOL HCL ER .... 77 PROPRANOLOL-HCTZ ....... 80 PROPYLTHIOURACIL ...... 108 PROQUAD........................... 113 PROSOL............................... 132 PROTRIPTYLINE HCL ........ 34 PRUDOXIN ..................... 34, 88 PULMICORT FLEXHALER

.......................................... 122 PULMOZYME............. 124, 127 PURIXAN .............................. 44 pyrazinamide .......................... 43 PYRIDOSTIGMINE

BROMIDE ......................... 42 PYRIDOSTIGMINE

BROMIDE ER ................... 42 Q

QUASENSE ......................... 104 quetiapine fumarate .......... 56, 66 quinidine gluconate er ............ 76 quinidine sulfate ..................... 76 quinine sulfate ........................ 52 R

RABAVERT ........................ 113 RALOXIFENE HCL .... 105, 106 RANEXA ............................... 79 ranitidine hcl ........................... 91 RAPAMUNE ....................... 110 RAVICTI ................................ 89 REBETOL .............................. 59 RECLIPSEN......................... 104

RECOMBIVAX HB............. 113 REGRANEX .......................... 88 RELENZA DISKHALER ...... 64 RELISTOR ............................. 90 REMICADE ......................... 110 REMODULIN ...................... 126 RENVELA ....................... 94, 95 repaglinide-metformin hcl ...... 70 RESCRIPTOR ........................ 61 RESTASIS............................ 117 RETROVIR ............................ 62 REVATIO ............................ 126 REVLIMID ...................... 44, 45 REXULTI ............................... 56 REYATAZ ............................. 64 RIBASPHERE.................. 59, 60 RIBASPHERE RIBAPAK ..... 60 ribavirin ............................ 59, 60 rifabutin .................................. 42 rifampin .................................. 43 RIFATER ............................... 43 riluzole .................................... 85 rimantadine hcl ....................... 64 ringers ................................... 132 RISEDRONATE SODIUM . 116 RISPERDAL CONSTA .. 56, 57,

66 risperidone ........................ 57, 66 RITUXAN .............................. 50 RIVASTIGMINE TARTRATE

............................................ 29 rizatriptan benzoate ................ 41 ropinirole hcl .......................... 53 ropinirole hcl er ...................... 53 ROTARIX ............................ 113 ROTATEQ ........................... 113 ROZEREM ........................... 128 S

SABRIL .................................. 26 SANDIMMUNE .................. 110 SANDOSTATIN LAR DEPOT

.......................................... 107 SANTYL ................................ 88 SAPHRIS.......................... 57, 66 SAVELLA .............................. 85 SAVELLA TITRATION PACK

............................................ 85 SELEGILINE HCL ................ 54 selenium sulfide ...................... 88 SELZENTRY ......................... 63

SENSIPAR ................... 106, 107 SEREVENT DISKUS .......... 124 SEROQUEL XR ......... 31, 57, 67 sertraline hcl ........................... 65 SERTRALINE HCL ............... 33 SHAROBEL ......................... 104 SIGNIFOR ............................ 108 SIGNIFOR LAR ................... 107 sildenafil citrate .................... 126 SILENOR ......................... 34, 64 silver sulfadiazine ................... 23 SIMBRINZA ........................ 119 sirolimus ....................... 110, 111 SIRTURO ............................... 43 SIVEXTRO ............................ 17 sodium chloride .................... 130 sodium fluoride ..................... 130 sodium phenylbutyrate ........... 94 sodium polystyrene sulfonate

.......................................... 129 SOLTAMOX .......................... 44 SOLU-CORTEF ....... 40, 98, 115 SOMATULINE DEPOT ...... 108 SOMAVERT ........................ 108 sorine ...................................... 76 sotalol hcl................................ 76 SOTALOL HCL (AF) ............ 76 SOVALDI............................... 60 SPIRIVA HANDIHALER ... 123 SPIRIVA RESPIMAT .......... 123 SPIRONOLACTONE-HCTZ. 80 SPRINTEC 28 ...................... 104 SPRYCEL............................... 49 SRONYX .............................. 104 ssd ........................................... 23 stavudine ................................. 62 sterile water for irrigation ..... 133 STIOLTO RESPIMAT ......... 126 STIVARGA ............................ 49 STRATTERA ......................... 85 streptomycin sulfate................ 15 STRIBILD .............................. 61 SUBOXONE .......................... 14 SUCRAID............................... 89 sucralfate................................. 92 sulfacetamide sodium ..... 24, 117 sulfacetamide-prednisolone ... 40,

117 sulfadiazine ............................. 24

143

sulfamethoxazole-trimethoprim ............................................ 24

SULFAMYLON..................... 17 SULFASALAZINE .............. 115 sulindac............................. 10, 40 sumatriptan ....................... 41, 42 sumatriptan succinate ............. 42 SUMATRIPTAN SUCCINATE

............................................ 42 SUPRAX ................................ 19 SUPREP BOWEL PREP ..... 130 SURMONTIL......................... 34 SUSTIVA ............................... 61 SUTENT................................. 49 SYLATRON........................... 60 SYMBICORT....................... 127 SYMLINPEN 120 .................. 69 SYMLINPEN 60 .................... 69 SYNAGIS............................. 111 SYNAREL ........................... 108 SYNERCID ............................ 17 SYNRIBO .............................. 45 SYNTHROID ....................... 106 SYPRINE ............................. 129 T

TABLOID .............................. 44 tacrolimus ....................... 88, 111 TAFINLAR ............................ 50 TAGRISSO ............................ 50 TAMIFLU .............................. 64 tamsulosin hcl ......................... 94 TARCEVA ............................. 50 TARGRETIN ......................... 51 tarina fe 1/20......................... 104 TASIGNA .............................. 50 TAZORAC ............................. 88 TAZTIA XT ........................... 78 TEFLARO .............................. 19 TEGRETOL ..................... 28, 68 TEGRETOL-XR .............. 28, 68 TEKTURNA .......................... 79 TEKTURNA HCT ................. 80 temazepam ............................ 127 tenivac .................................. 113 terbinafine hcl ......................... 37 terbutaline sulfate ................. 124 terconazole ............................. 37 testosterone cypionate ............ 99 testosterone enanthate .......... 100 tetanus-diphtheria toxoids td 113

tetrabenazine ........................... 85 THALOMID ........................... 44 THEO-24 .............................. 125 THEOPHYLLINE ................ 125 THEOPHYLLINE ER .......... 125 thioridazine hcl ....................... 55 thiotepa ................................... 43 THIOTHIXENE ..................... 55 TIAGABINE HCL ................. 26 TIKOSYN .............................. 76 timolol maleate ............... 41, 119 TIMOLOL MALEATE .......... 77 TIVICAY................................ 61 tizanidine hcl .................. 58, 127 TOBRADEX .......................... 15 tobramycin .............................. 15 tobramycin sulfate .................. 15 tobramycin-dexamethasone .. 117 TOBREX ................................ 15 tolazamide .............................. 69 tolbutamide ............................. 69 tolterodine tartrate .................. 93 tolterodine tartrate er .............. 93 topiramate ......................... 27, 41 TOPIRAMATE ...................... 27 topiramate er ........................... 27 TOPOSAR .............................. 48 topotecan hcl........................... 48 torsemide ................................ 80 TPN ELECTROLYTES ....... 133 TRACLEER ......................... 126 TRADJENTA ......................... 69 tramadol hcl ............................ 13 tramadol-acetaminophen .......... 9 tranexamic acid....................... 74 TRANSDERM-SCOP (1.5 MG)

...................................... 35, 90 TRANYLCYPROMINE

SULFATE .......................... 31 TRAVASOL ......................... 133 TRAVATAN Z..................... 120 TRAVOPROST .................... 120 TREANDA ....................... 43, 47 TRECATOR ........................... 43 TRELSTAR MIXJECT ........ 108 tretinoin ............................ 51, 88 triamcinolone acetonide ... 86, 98 triamterene-hctz ...................... 80 triderm .................................... 98 TRIFLUOPERAZINE HCL ... 55

trifluridine ............................... 60 trihexyphenidyl hcl ................. 52 TRI-LEGEST FE .................. 104 trilyte....................................... 92 trimethoprim ........................... 17 TRIMIPRAMINE MALEATE

............................................ 34 trinessa (28) .......................... 104 tri-previfem ........................... 104 TRISENOX ............................ 47 tri-sprintec............................. 104 TRIUMEQ .............................. 63 trivora (28) ............................ 104 TROPHAMINE .................... 133 trospium chloride .................... 93 TRUMENBA ........................ 113 TRUVADA............................. 62 TWINRIX ............................. 113 TYBOST................................. 63 TYGACIL............................... 17 TYKERB ................................ 50 TYPHIM VI.......................... 114 TYSABRI ....................... 86, 112 TYZEKA ................................ 59 U

UCERIS ...................... 90, 91, 92 ULORIC ................................. 38 unithroid ............................... 106 UPTRAVI ............................... 79 URSODIOL ...................... 90, 91 V

VAGIFEM ............................ 100 valacyclovir hcl ...................... 60 VALCHLOR .................... 43, 88 VALCYTE ............................. 58 valganciclovir hcl ................... 58 valproate sodium .................... 26 valproic acid ............... 26, 41, 68 VALPROIC ACID ................. 26 vancomycin hcl ....................... 17 VANDAZOLE ....................... 17 VAQTA ................................ 114 VARIVAX ............................ 114 VASCEPA .............................. 82 VELCADE ............................. 47 VELIVET ............................. 104 venlafaxine hcl........................ 65 VENLAFAXINE HCL ........... 33 venlafaxine hcl er ............. 33, 65 VENTOLIN HFA ................. 124

144

verapamil hcl .......................... 79 verapamil hcl er ................ 78, 79 VERAPAMIL HCL ER ......... 78 VERSACLOZ ........................ 58 VESICARE ............................ 93 VESTURA ........................... 104 VICTOZA .............................. 69 VIDEX ................................... 62 VIGAMOX............................. 23 VIIBRYD ............................... 33 VIIBRYD STARTER PACK . 33 VIMPAT................................. 29 vinblastine sulfate ................... 47 vincasar pfs ............................. 47 vincristine sulfate ................... 47 vinorelbine tartrate ................. 47 VIRACEPT ............................ 64 VIRAMUNE XR .................... 61 VIREAD ........................... 59, 62 VITEKTA............................... 61 VOLTAREN .................... 10, 88 voriconazole ..................... 37, 38 VOTRIENT ............................ 50 VPRIV .................................... 89 VRAYLAR............................. 57 VYFEMLA........................... 104

W

WELCHOL ...................... 69, 82 X

XALKORI .............................. 50 XARELTO ............................. 73 XARELTO STARTER PACK

............................................ 73 XENAZINE ............................ 85 XGEVA ................................ 116 XIFAXAN ........................ 17, 91 XIGDUO XR .......................... 69 XOLAIR ............................... 127 XOPENEX HFA .................. 124 XTANDI ................................. 43 XYREM................................ 128 Y

YERVOY ............................... 45 YF-VAX ............................... 114 Z

zafirlukast ............................. 122 ZALEPLON ......................... 127 ZALTRAP .............................. 45 ZANOSAR ............................. 15 ZAVESCA.............................. 89 ZAZOLE ................................ 38 ZELBORAF ........................... 50

ZEMAIRA ............................ 126 ZENATANE ........................... 88 ZENCHENT ......................... 105 ZENPEP ................................. 90 ZETIA..................................... 82 ZIAGEN ................................. 62 zidovudine .............................. 62 ziprasidone hcl .................. 57, 67 ZIRGAN ................................. 58 zoledronic acid...................... 116 ZOLINZA ......................... 38, 48 zolmitriptan............................. 42 zolpidem tartrate ................... 128 ZOLPIDEM TARTRATE ER

.......................................... 128 ZONISAMIDE ....................... 25 ZONTIVITY........................... 74 ZORTRESS .......................... 111 ZOSTAVAX......................... 114 ZOVIA 1/35E (28) ............... 105 ZOVIA 1/50E (28) ............... 105 ZYDELIG ............................... 48 ZYKADIA .............................. 50 ZYTIGA ................................. 43 ZYVOX .................................. 17

145

This formulary was updated on May 1, 2016. For more recent information or other questions, please contact MMM Member Services Department at 787-620-2397 (Metro Area), 1-866-333-5470 (toll free) or, for TTY users, 1-866-333-5469, Monday through Sunday, from 8:00 a.m. to 8:00 p.m., or visit www.mmm-pr.com. MMM Healthcare, LLC is an HMO plan with a Medicare contract. Enrollment in MMM depends on contract renewal. The formulary may change at any time. You will receive notice when necessary. This document may be available in alternate formats such as Braille, large print, audio or other languages. Please contact our Member Services number at 787-620-2397 (Metro Area) or 1-866-333-5470 (toll free) for additional information, Monday through Sunday; from 8:00 a.m. to 8:00 p.m. (TTY users should call 1-866-333-5469). Member Services also offers free language interpreter services available for non-English speaking members. Este documento podría estar disponible en diferentes formatos, incluyendo Braille, letras grandes, audio o en otros idiomas. Por favor comuníquese con nuestro número de Servicios al Afiliado al 787-620-2397(Área Metro), 1-866-333-5470 (libre de cargos) para información adicional, lunes a domingo, de 8:00 a.m. a 8:00 p.m. (Usuarios TTY deben llamar al 1-866-333-5469). Servicios al Afiliado también ofrece servicios de intérprete de idiomas de manera gratuita para afiliados que no hablen inglés. H4003 - MMM Healthcare, LLC Y0049_2016 1085 0003 1 File & Use 08242015 CMS Accepted

supremo (hmo snp) 2016 formulary (list of … mmm-pha-qrg-769-04-041116-e supremo (hmo snp) 2016...

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