2019 formulary (list of covered drugs) · formulary id: 76001.000, version: 19...

VibrantRxTM (PDP)

2019 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 12/01/2019. For more recent information or other questions, please contact VibrantRx Member Services at 1-844-826-3451 or, for TTY users, 711, 24 hours a day, 365 days a year or visit www.MyVibrantRx.com/JPIA. VibrantRx is a Prescription Drug Plan with a Medicare contract offered by MG Insurance Company. Enrollment in VibrantRx depends on contract renewal.

Formulary ID: 76001.000, Version: 19 S3285_19_CF_EGWP_JPIA_C

http://www.myvibrantrx.com/JPIA

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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 MG Insurance Company. When it refers to “plan” or “our plan,” it means VibrantRx.

This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2019. 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, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

What is the VibrantRx Formulary?

A formulary is a list of covered drugs selected by VibrantRx in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. VibrantRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a VibrantRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug:

Drugs removed from the market. 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.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, 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 30 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 31-day supply of the drug.

The enclosed formulary is current as of 12/01/2019. To get updated information about the drugs covered by VibrantRx, please contact us. Our contact information appears on the front and back cover pages. If we make mid-year non-maintenance formulary changes, you will be notified of formulary changes in “Your Monthly Prescription Drug Summary”, also referred to as your Part D Explanation of Benefits (EOB). Formulary changes will appear in the “Formulary Change Notice” within your EOB, or as a separate document if you have no claims activity.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

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Medical Condition

The formulary begins on page 7. 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 on page 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 I-1. 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.

What are generic drugs?

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

Quantity Limits: For certain drugs, VibrantRx limits the amount of the drug that VibrantRx will cover. For example, VibrantRx provides 30 tablets in 30 days per prescription for simvastatin oral tablet 80 mg. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, VibrantRx 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, VibrantRx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, VibrantRx 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 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online a document that explains 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 VibrantRx 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 VibrantRx 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.

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If you learn that VibrantRx does not cover your drug, you have two options:

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

You can ask VibrantRx to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the VibrantRx Formulary?

You can ask VibrantRx 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, VibrantRx 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, VibrantRx 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 one month supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum one month supply of medication. After your first one month 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 and you need a drug that is not on our formulary or if your ability to get your 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 while you pursue a formulary exception.

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If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility) after your first 90 days of membership in our plan, your physician or pharmacy can request a one-time emergency prescription override. This one-time override will provide you with temporary coverage (up to a 31-day supply) for the applicable drug(s).

For more information

For more detailed information about your VibrantRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about VibrantRx, 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.

VibrantRx’s Formulary

The formulary that begins on page 7 provides coverage information about the drugs covered by VibrantRx. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CARAFATE ORAL SUSPENSION and generic drugs are listed in lower-case italics (e.g., sucralfate).

The information in the Requirements/Limits column tells you if VibrantRx has any special requirements for coverage of your drug.

The following abbreviations may be found within the body of this document

COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization

Restriction

You (or your physician) are required to get prior authorization from our plan before you fill your prescription for this drug. Without prior approval, our plan may not cover this drug.

PA BvD

Prior Authorization Restriction for

Part B vs Part D Determination

This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from our plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, our plan may not cover this drug.

PA-HRM

Prior Authorization Restriction for

High Risk Medications

Medicare has deemed this drug to be potentially harmful for beneficiaries 65 years or older, or a “High Risk Medication.” Members age 65 years of age or older are required to get prior authorization from our plan before filling a prescription for this drug. Without prior approval, our plan may not cover this drug.

PA NSO Prior Authorization Restriction for New

Starts Only

If you are a new member, you (or your physician) are required to get prior authorization from our plan before you fill your prescription for this drug. Without prior approval, our plan may not cover this drug.

QL Quantity Limit

Restriction Our plan limits the amount of this drug that is covered per prescription, or within a specific timeframe.

ST Step Therapy

Restriction

Before our plan will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.

Other Special Requirements for Coverage

LA Limited Access

Drug

This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should call 711.

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ABBREVIATION DESCRIPTION EXPLANATION

NM Non-Mail Order

Drug

You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order, generally at a reduced cost share. Drugs not available via your mail order benefit are noted with “NM” in the Requirements/Limits column.

NDS Non-Extended Days Supply

This prescription is limited to a 30 day supply.

EX Excluded Part D Drug

This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for this drug.

GC Gap Coverage We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

Your plan does not have a coverage gap. You will continue to pay your applicable copayment or coinsurance for prescription drugs in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.

Limitations, copayments, and restrictions may apply.

Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

The formulary may change at any time. You will receive notice when necessary.

Your copayment amount during Initial Coverage Phase

Tier Number / Name Up to 30-day supply at Retail

Up to 90-day supply at Retail

Up to a 90-day supply at Mail Order

Tier 1 / Preferred Generic Drugs $5 copayment* $10 copayment* $10 copayment*

Tier 2 / Preferred Brand Drugs $20 copayment $40 copayment $40 copayment

Tier 3 / Non-Preferred Drugs $50 copayment $100 copayment $100 copayment

Tier 4 / Specialty Drugs $50 copayment Long term supply is not available for drugs in Tier 4

Long term supply is not available for drugs in Tier 4

*Select generics are available at $0 copay. Once your out-of-pocket costs for covered Mail Order prescriptions, except covered ED drugs, reach $1000 out-of-pocket maximum, you will no longer pay a copayment for those drugs at Mail Order for the rest of the plan year. Your employer group also covers prescription drugs not normally covered in a Medicare Prescription Drug Plan. Drugs that are excluded from Part D coverage do not count towards your True-Out-of-Pocket expenses. You will continue to pay the applicable tier cost share for these drugs if you reach the Catastrophic stage of your benefit. Drugs excluded from Part D coverage but covered by ACWA JPIA’s supplemental benefit are marked as “EX” in your formulary. See your formulary for details. You pay the copayments above for these drugs, including:

• Cough and Cold, Drug Efficacy Study Implementation (DESI) drugs, Vitamins and Minerals, Lifestyle Drugs

You pay the copayments below for these drugs covered by ACWA JPIA’s supplemental benefit. • Erectile Dysfunction (ED) Drugs (you pay 50% coinsurance – limited to 6 pills per 30 days) • Contraceptive Devices (you pay $20 copayment per covered device) • Fertility Drugs (you pay $50 copayment per 30-day supply)

You can find information on what the symbols and abbreviations in this table mean by going to pages 5 – 6. 7

VibrantRx (PDP) 2019 Part D Formulary Last Updated: December 01, 2019 Formulary ID: 76001.000, Version: 19

Drug Name Drug Tier Requirements/Limits

Analgesics

Analgesics, Miscellaneous

ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA; NM; GC; NDS; QL (120 per 30 days)

acetaminophen-caff-dihydrocod oral capsule 320.5-30-16 mg

1 GC; QL (300 per 30 days)

acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg

4 NM; GC; NDS; QL (300 per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5 ml 1 GC; QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg


acetaminophen-codeine oral tablet 300-60 mg 1 GC; QL (180 per 30 days)

ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


ALLZITAL ORAL TABLET 25-325 MG 1 PA-HRM; GC; QL (360 per 30 days); AGE (Max 64 Years)

ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG

3 ST; GC; QL (90 per 30 days)


4 ST; NM; GC; NDS; QL (90 per 30 days)



ascomp with codeine oral capsule 30-50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG


BUPRENEX INJECTION SOLUTION 0.3 MG/ML 3 GC

buprenorphine hcl injection solution 0.3 mg/ml 1 GC

buprenorphine hcl injection syringe 0.3 mg/ml 1 GC

buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour


butalbital compound w/codeine oral capsule 30-50-325-40 mg

1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

butalbital compound-codeine oral capsule 30-50-325-40 mg


butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg


butalbital-acetaminophen oral capsule 50-300 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg


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





butalbital-acetaminophen-caff oral tablet 50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

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

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml 1 GC; QL (5 per 28 days)

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR


capacet oral capsule 50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 GC; QL (180 per 30 days)

DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 100 MG/ML, 25 MG/0.5 ML, 50 MG/ML, 75 MG/1.5 ML

3 GC

DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 25 MG/ML, 50 MG/ML, 75 MG/ML

3 GC

DEMEROL INJECTION SOLUTION 100 MG/ML, 50 MG/ML

3 GC

DEMEROL ORAL TABLET 100 MG 3 GC; QL (180 per 30 days)

DILAUDID (PF) INJECTION SOLUTION 2 MG/ML, 4 MG/ML

3 GC

DILAUDID (PF) INJECTION SYRINGE 0.5 MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML

3 GC

DILAUDID ORAL LIQUID 1 MG/ML 3 GC; QL (1200 per 30 days)

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG 3 GC; QL (180 per 30 days)

DISKETS ORAL TABLET,SOLUBLE 40 MG 3 GC; QL (30 per 30 days)

DOLOPHINE ORAL TABLET 10 MG 3 GC; QL (120 per 30 days)

DOLOPHINE ORAL TABLET 5 MG 3 GC; QL (180 per 30 days)

DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR, 50 MCG/HR, 75 MCG/HR


DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR


DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML

3 GC

dvorah oral tablet 325-30-16 mg 4 NM; GC; NDS; QL (300 per 30 days)

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG


endocet oral tablet 10-325 mg 1 GC; QL (180 per 30 days)

endocet oral tablet 2.5-325 mg, 5-325 mg 1 GC; QL (360 per 30 days)

endocet oral tablet 7.5-325 mg 1 GC; QL (240 per 30 days)




ESGIC ORAL CAPSULE 50-325-40 MG 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

ESGIC ORAL TABLET 50-325-40 MG 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG


EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 MG


EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 8 MG

3 PA; GC; QL (30 per 30 days)

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl citrate buccal tablet, effervescent 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 75 mcg/hr


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


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


FIORINAL ORAL CAPSULE 50-325-40 MG 3 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

FIORINAL-CODEINE #3 ORAL CAPSULE 30-50-325-40 MG


hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)


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


hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet 2.5-325 mg, 5-300 mg, 5-325 mg


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


hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml

1 GC

hydromorphone oral liquid 1 mg/ml 1 GC; QL (1200 per 30 days)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 GC; QL (180 per 30 days)

hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg


hydromorphone oral tablet extended release 24 hr 16 mg


hydromorphone oral tablet extended release 24 hr 32 mg





HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


ibuprofen-oxycodone oral tablet 400-5 mg 1 GC; QL (28 per 30 days)

INFUMORPH P/F INJECTION SOLUTION 10 MG/ML, 25 MG/ML

3 GC

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG


KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 100 MG, 200 MG, 80 MG


KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 60 MG


LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY


levorphanol tartrate oral tablet 2 mg 4 NM; GC; NDS; QL (150 per 30 days)

levorphanol tartrate oral tablet 3 mg 4 NM; GC; NDS; QL (120 per 30 days)

lorcet (hydrocodone) oral tablet 5-325 mg 1 GC; QL (240 per 30 days)

lorcet hd oral tablet 10-325 mg 1 GC; QL (180 per 30 days)

lorcet plus oral tablet 7.5-325 mg 1 GC; QL (180 per 30 days)

meperidine (pf) injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

1 GC

meperidine injection cartridge 10 mg/ml 1 GC

meperidine oral solution 50 mg/5 ml 1 GC; QL (900 per 30 days)

meperidine oral tablet 100 mg, 50 mg 1 GC; QL (180 per 30 days)

methadone injection solution 10 mg/ml 1 GC

methadone oral concentrate 10 mg/ml 1 GC; QL (120 per 30 days)

methadone oral solution 10 mg/5 ml 1 GC; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 1 GC; QL (1200 per 30 days)

methadone oral tablet 10 mg 1 GC; QL (120 per 30 days)

methadone oral tablet 5 mg 1 GC; QL (180 per 30 days)

methadone oral tablet,soluble 40 mg 1 GC; QL (30 per 30 days)

METHADOSE ORAL CONCENTRATE 10 MG/ML 3 GC; QL (120 per 30 days)

methadose oral tablet,soluble 40 mg 1 GC; QL (30 per 30 days)

mitigo (pf) injection solution 10 mg/ml, 25 mg/ml 1 GC

MORPHABOND ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 100 MG, 15 MG, 30 MG, 60 MG


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

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)


morphine intravenous solution 10 mg/ml 1 GC

morphine intravenous syringe 10 mg/ml 1 GC

morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg





morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 40 mg, 50 mg


morphine oral capsule,extend.release pellets 100 mg, 60 mg, 80 mg


morphine oral solution 10 mg/5 ml 1 GC; QL (700 per 30 days)

morphine oral solution 20 mg/5 ml (4 mg/ml) 1 GC; QL (300 per 30 days)

MORPHINE ORAL TABLET 15 MG 3 GC; QL (180 per 30 days)

MORPHINE ORAL TABLET 30 MG 3 GC; QL (120 per 30 days)

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


morphine oral tablet extended release 15 mg, 30 mg 1 GC; QL (90 per 30 days)

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 200 MG, 60 MG


MS CONTIN ORAL TABLET EXTENDED RELEASE 15 MG, 30 MG


nalbuphine injection solution 10 mg/ml, 20 mg/ml 1 GC

nalocet oral tablet 2.5-300 mg 4 NM; GC; NDS; QL (360 per 30 days)

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG


NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG 2 GC; QL (181 per 30 days)

OPANA INJECTION SOLUTION 1 MG/ML 3 GC

OPANA ORAL TABLET 10 MG 3 GC; QL (120 per 30 days)

OPANA ORAL TABLET 5 MG 3 GC; QL (180 per 30 days)

OXAYDO ORAL TABLET, ORAL ONLY 5 MG 3 GC; QL (180 per 30 days)

OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG 3 GC; QL (120 per 30 days)

oxycodone oral capsule 5 mg 1 GC; QL (180 per 30 days)

oxycodone oral concentrate 20 mg/ml 1 GC; QL (120 per 30 days)

oxycodone oral solution 5 mg/5 ml 1 GC; QL (1300 per 30 days)

oxycodone oral tablet 10 mg, 5 mg 1 GC; QL (180 per 30 days)

oxycodone oral tablet 15 mg, 20 mg, 30 mg 1 GC; QL (120 per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg


oxycodone-acetaminophen oral solution 5-325 mg/5 ml 1 GC; QL (1800 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg 1 GC; QL (180 per 30 days)

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


oxycodone-acetaminophen oral tablet 7.5-325 mg 1 GC; QL (240 per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg 1 GC; QL (360 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


oxymorphone oral tablet 10 mg 1 GC; QL (120 per 30 days)

oxymorphone oral tablet 5 mg 1 GC; QL (180 per 30 days)




oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg


panlor(acetam-caff-dihydrocod) oral tablet 325-30-16 mg


pentazocine-naloxone oral tablet 50-0.5 mg 1 GC; QL (360 per 30 days)

PERCOCET ORAL TABLET 10-325 MG 4 NM; GC; NDS; QL (180 per 30 days)

PERCOCET ORAL TABLET 2.5-325 MG, 5-325 MG 4 NM; GC; NDS; QL (360 per 30 days)

PERCOCET ORAL TABLET 7.5-325 MG 4 NM; GC; NDS; QL (240 per 30 days)

ROXICODONE ORAL TABLET 15 MG, 30 MG 3 GC; QL (120 per 30 days)

ROXICODONE ORAL TABLET 5 MG 3 GC; QL (180 per 30 days)

ROXYBOND ORAL TABLET, ORAL ONLY 15 MG, 30 MG


ROXYBOND ORAL TABLET, ORAL ONLY 5 MG 3 GC; QL (180 per 30 days)

SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 1,600 MCG (800 MCG/SPRAY X 2), 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY


TALWIN INJECTION SOLUTION 30 MG/ML 3 GC; QL (360 per 30 days)

tencon oral tablet 50-325 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

tramadol oral tablet 50 mg 1 GC; QL (240 per 30 days)

tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg


tramadol oral tablet, er multiphase 24 hr 100 mg, 200 mg, 300 mg


tramadol-acetaminophen oral tablet 37.5-325 mg 1 GC; QL (300 per 30 days)

ULTRACET ORAL TABLET 37.5-325 MG 3 GC; QL (300 per 30 days)

ULTRAM ORAL TABLET 50 MG 3 GC; QL (240 per 30 days)

vicodin es oral tablet 7.5-300 mg 1 GC; QL (180 per 30 days)

vicodin hp oral tablet 10-300 mg 1 GC; QL (180 per 30 days)

vicodin oral tablet 5-300 mg 1 GC; QL (240 per 30 days)

XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 13.5 MG, 18 MG, 9 MG


XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 27 MG


XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 36 MG


xylon 10 oral tablet 10-200 mg 1 GC; QL (150 per 30 days)

zebutal oral capsule 50-325-40 mg 1 PA-HRM; GC; QL (180 per 30 days); AGE (Max 64 Years)

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG





Nonsteroidal Anti-Inflammatory Agents

ANAPROX DS ORAL TABLET 550 MG 3 GC

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC 50-200 MG-MCG

3 GC

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC 75-200 MG-MCG

3 GC

CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML)

3 GC

CAMBIA ORAL POWDER IN PACKET 50 MG 3 GC

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG


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


DAYPRO ORAL TABLET 600 MG 3 GC

diclofenac epolamine transdermal patch 12 hour 1.3 % 1 PA; GC

diclofenac potassium oral tablet 50 mg 1 GC

diclofenac sodium oral tablet extended release 24 hr 100 mg

1 GC

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

1 GC

diclofenac sodium topical drops 1.5 % 1 GC; QL (300 per 30 days)

diclofenac sodium topical gel 1 % 1 GC

diclofenac sodium topical gel 3 % 1 PA; GC; QL (100 per 28 days)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

1 GC

diflunisal oral tablet 500 mg 1 GC

DUEXIS ORAL TABLET 800-26.6 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG

3 GC

etodolac oral capsule 200 mg, 300 mg 1 GC

etodolac oral tablet 400 mg, 500 mg 1 GC

FELDENE ORAL CAPSULE 10 MG, 20 MG 3 GC

fenoprofen oral capsule 400 mg 3 GC

fenoprofen oral tablet 600 mg 1 GC

FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % 3 PA; GC

flurbiprofen oral tablet 100 mg, 50 mg 1 GC

ibu oral tablet 400 mg, 600 mg, 800 mg 1 GC

ibuprofen lysine (pf) intravenous solution 20 mg/2 ml 1 GC

ibuprofen oral suspension 100 mg/5 ml 1 GC

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

INDOCIN ORAL SUSPENSION 25 MG/5 ML 3 PA-HRM; GC; AGE (Max 64 Years)

INDOCIN RECTAL SUPPOSITORY 50 MG 4 PA-HRM; NM; GC; NDS; QL (120 per 30 days); AGE (Max 64 Years)




indomethacin oral capsule 25 mg 1 PA-HRM; GC; QL (240 per 30 days); AGE (Max 64 Years)

indomethacin oral capsule 50 mg 1 PA-HRM; GC; QL (120 per 30 days); AGE (Max 64 Years)

indomethacin oral capsule, extended release 75 mg 1 PA-HRM; GC; QL (60 per 30 days); AGE (Max 64 Years)

indomethacin sodium intravenous recon soln 1 mg 1 GC

ketoprofen oral capsule 25 mg, 50 mg, 75 mg 1 GC

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 1 GC

ketorolac injection cartridge 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 days); AGE (Max 64 Years)

ketorolac injection cartridge 30 mg/ml 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac injection solution 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 days); AGE (Max 64 Years)

ketorolac injection solution 30 mg/ml (1 ml) 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac injection syringe 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 days); AGE (Max 64 Years)

ketorolac injection syringe 30 mg/ml 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac intramuscular cartridge 60 mg/2 ml 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac intramuscular solution 60 mg/2 ml 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac intramuscular syringe 60 mg/2 ml 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

ketorolac oral tablet 10 mg 1 PA-HRM; GC; QL (20 per 30 days); AGE (Max 64 Years)

meclofenamate oral capsule 100 mg, 50 mg 1 GC

mefenamic acid oral capsule 250 mg 1 GC

meloxicam oral suspension 7.5 mg/5 ml 3 GC

meloxicam oral tablet 15 mg, 7.5 mg 1 GC

MOBIC ORAL TABLET 15 MG, 7.5 MG 3 GC

nabumetone oral tablet 500 mg, 750 mg 1 GC

NALFON ORAL CAPSULE 400 MG 3 GC

NALFON ORAL TABLET 600 MG 3 GC

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 375 MG, 500 MG, 750 MG

4 NM; GC; NDS

NAPROSYN ORAL TABLET 500 MG 3 GC

naproxen oral suspension 125 mg/5 ml 1 GC

naproxen oral tablet 250 mg, 375 mg, 500 mg 1 GC

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg

1 GC




naproxen sodium oral tablet 275 mg, 550 mg 1 GC

naproxen sodium oral tablet, er multiphase 24 hr 375 mg, 500 mg

4 NM; GC; NDS

NEOPROFEN (IBUPROFEN LYSN)(PF) INTRAVENOUS SOLUTION 20 MG/2 ML

3 GC

oxaprozin oral tablet 600 mg 1 GC

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %)


piroxicam oral capsule 10 mg, 20 mg 1 GC

PROFENO ORAL TABLET 600 MG 3 GC

QMIIZ ODT ORAL TABLET,DISINTEGRATING 15 MG, 7.5 MG

3 ST; GC

SOLARAZE TOPICAL GEL 3 % 4 PA; NM; GC; NDS; QL (100 per 28 days)

SPRIX NASAL SPRAY,NON-AEROSOL 15.75 MG/SPRAY


sulindac oral tablet 150 mg, 200 mg 1 GC

TIVORBEX ORAL CAPSULE 20 MG, 40 MG 3 PA-HRM; GC; QL (90 per 30 days); AGE (Max 64 Years)

tolmetin oral capsule 400 mg 1 GC

tolmetin oral tablet 200 mg, 600 mg 1 GC

VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG


VIVLODEX ORAL CAPSULE 10 MG, 5 MG 3 GC

VOLTAREN TOPICAL GEL 1 % 1 GC

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

3 GC

ZIPSOR ORAL CAPSULE 25 MG 3 GC

ZORVOLEX ORAL CAPSULE 18 MG, 35 MG 3 GC

Anesthetics

Local Anesthetics

glydo mucous membrane jelly in applicator 2 % 1 GC; QL (30 per 30 days)

lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

1 GC

lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %)

1 GC

lidocaine hcl mucous membrane jelly 2 % 1 GC; QL (30 per 30 days)

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

1 GC

lidocaine topical adhesive patch,medicated 5 % 1 PA; GC; QL (90 per 30 days)

lidocaine topical ointment 5 % 1 PA; GC; QL (90 per 30 days)

lidocaine viscous mucous membrane solution 2 % 1 GC

lidocaine-prilocaine topical cream 2.5-2.5 % 1 PA; GC; QL (30 per 30 days)




LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED 5 %


PLIAGLIS TOPICAL CREAM 7-7 % 3 GC; QL (100 per 30 days)

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING 70-70 MG


XYLOCAINE INJECTION SOLUTION 10 MG/ML (1 %), 20 MG/ML (2 %), 5 MG/ML (0.5 %)

3 GC

XYLOCAINE-MPF 2% VIAL 25'S,SDV, LATEX-FREE 20 MG/ML (2 %)

3 GC

XYLOCAINE-MPF INJECTION SOLUTION 10 MG/ML (1 %), 15 MG/ML (1.5 %)

3 GC

xylocaine-mpf injection solution 20 mg/ml (2 %), 5 mg/ml (0.5 %)

3 GC

ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 %


Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents

acamprosate oral tablet,delayed release (dr/ec) 333 mg

1 GC

BUNAVAIL BUCCAL FILM 2.1-0.3 MG 3 GC; QL (30 per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG 3 GC; QL (60 per 30 days)

buprenorphine hcl sublingual tablet 2 mg, 8 mg 1 GC; QL (90 per 30 days)

buprenorphine-naloxone sublingual film 12-3 mg, 8-2 mg


buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg


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


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

1 GC

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG 2 GC; QL (336 per 365 days)

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)


disulfiram oral tablet 250 mg, 500 mg 1 GC

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML, 2 MG/0.4 ML

4 ST; NM; GC; NDS; QL (0.8 per 365 days)

LUCEMYRA ORAL TABLET 0.18 MG 4 NM; GC; NDS; QL (228 per 14 days)

naloxone injection solution 0.4 mg/ml 1 GC

naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1 GC




naltrexone oral tablet 50 mg 1 GC

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


NICOTROL INHALATION CARTRIDGE 10 MG 3 GC; QL (1008 per 90 days)

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML


SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML

4 NM; GC; NDS

SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG 3 GC; QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG 3 GC; QL (30 per 30 days)

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG

4 NM; GC; NDS

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG 2 GC; QL (60 per 30 days)

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR 150 MG

3 GC

Antianxiety Agents

Benzodiazepines

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 GC; QL (120 per 30 days)

alprazolam oral tablet 2 mg 1 GC; QL (150 per 30 days)

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


alprazolam oral tablet extended release 24 hr 3 mg 1 GC; QL (90 per 30 days)

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg


ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML 3 GC; QL (2 per 30 days)

ATIVAN ORAL TABLET 0.5 MG, 1 MG 4 NM; GC; NDS; QL (90 per 30 days)

ATIVAN ORAL TABLET 2 MG 4 NM; GC; NDS; QL (150 per 30 days)

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

1 GC

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1 GC; QL (120 per 30 days)

clobazam oral suspension 2.5 mg/ml 1 PA NSO; GC; QL (480 per 30 days)

clobazam oral tablet 10 mg, 20 mg 1 PA NSO; GC; QL (60 per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg 1 GC; QL (90 per 30 days)

clonazepam oral tablet 2 mg 1 GC; QL (300 per 30 days)

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


clonazepam oral tablet,disintegrating 2 mg 1 GC; QL (300 per 30 days)

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





DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG

3 GC

DIASTAT RECTAL KIT 2.5 MG 3 GC

diazepam injection solution 5 mg/ml 1 GC; QL (10 per 28 days)

diazepam injection syringe 5 mg/ml 1 GC; QL (10 per 28 days)

diazepam intensol oral concentrate 5 mg/ml 1 GC; QL (1200 per 30 days)

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 GC; QL (1200 per 30 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg 1 GC; QL (120 per 30 days)

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg

3 GC

estazolam oral tablet 1 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)

estazolam oral tablet 2 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

flurazepam oral capsule 15 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)

flurazepam oral capsule 30 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

HALCION ORAL TABLET 0.25 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)

KLONOPIN ORAL TABLET 0.5 MG, 1 MG 3 GC; QL (90 per 30 days)

KLONOPIN ORAL TABLET 2 MG 3 GC; QL (300 per 30 days)

lorazepam injection solution 2 mg/ml, 4 mg/ml 1 GC; QL (2 per 30 days)

lorazepam injection syringe 2 mg/ml, 4 mg/ml 1 GC; QL (2 per 30 days)

lorazepam oral concentrate 2 mg/ml 1 GC; QL (150 per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg 1 GC; QL (90 per 30 days)

lorazepam oral tablet 2 mg 1 GC; QL (150 per 30 days)

meprobamate oral tablet 200 mg, 400 mg 1 PA-HRM; GC; AGE (Max 64 Years)

midazolam (pf) injection cartridge 2 mg/2 ml (1 mg/ml), 5 mg/ml





midazolam (pf) injection solution 1 mg/ml, 5 mg/ml 1 GC; QL (2 per 30 days)

midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml), 5 mg/ml


midazolam injection solution 1 mg/ml, 5 mg/ml 1 GC; QL (2 per 30 days)

midazolam oral syrup 2 mg/ml 1 GC; QL (10 per 30 days)

ONFI ORAL SUSPENSION 2.5 MG/ML 4 PA NSO; NM; GC; NDS; QL (480 per 30 days)

ONFI ORAL TABLET 10 MG, 20 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 GC; QL (120 per 30 days)

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG 4 PA-HRM; NM; GC; NDS; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

RESTORIL ORAL CAPSULE 7.5 MG 4 PA-HRM; NM; GC; NDS; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 30 days); AGE (Max 64 Years)

SYMPAZAN ORAL FILM 10 MG, 20 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

SYMPAZAN ORAL FILM 5 MG 3 PA NSO; GC; QL (60 per 30 days)

temazepam oral capsule 15 mg, 22.5 mg, 30 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

temazepam oral capsule 7.5 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 30 days); AGE (Max 64 Years)

TRANXENE T-TAB ORAL TABLET 7.5 MG 3 GC; QL (180 per 30 days)

triazolam oral tablet 0.125 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 30 days); AGE (Max 64 Years)

triazolam oral tablet 0.25 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG 3 GC; QL (120 per 30 days)

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG 3 GC; QL (120 per 30 days)

XANAX ORAL TABLET 2 MG 3 GC; QL (150 per 30 days)




XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 0.5 MG, 1 MG, 2 MG


XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 3 MG


Antibacterials

Aminoglycosides

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 1 GC

ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML

4 PA; NM; GC; NDS; QL (235.2 per 28 days)

BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML

4 PA BvD; NM; GC; NDS

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

1 GC

gentamicin injection solution 20 mg/2 ml, 40 mg/ml 1 GC

gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml

1 GC

gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml

1 GC

neomycin oral tablet 500 mg 1 GC

streptomycin intramuscular recon soln 1 gram 1 GC

TOBI INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML


TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG


tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml


tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml

1 GC

tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml

1 GC

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml


ZEMDRI INTRAVENOUS SOLUTION 50 MG/ML 4 NM; GC; NDS

Antibacterials, Miscellaneous

baciim intramuscular recon soln 50,000 unit 1 GC

bacitracin intramuscular recon soln 50,000 unit 1 GC

chloramphenicol sod succinate intravenous recon soln 1 gram

1 GC

CLEOCIN HCL ORAL CAPSULE 150 MG, 300 MG, 75 MG

3 GC




CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 300 MG/50 ML, 600 MG/50 ML, 900 MG/50 ML

3 GC

CLEOCIN INJECTION SOLUTION 150 MG/ML 3 GC

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 GC

clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml

1 GC

clindamycin palmitate hcl oral recon soln 75 mg/5 ml 1 GC

clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml

1 GC

clindamycin phosphate intravenous solution 600 mg/4 ml

1 GC

colistin (colistimethate na) injection recon soln 150 mg 4 PA BvD; NM; GC; NDS

COLY-MYCIN M PARENTERAL INJECTION RECON SOLN 150 MG


CUBICIN INTRAVENOUS RECON SOLN 500 MG 4 NM; GC; NDS

DALVANCE INTRAVENOUS SOLUTION 500 MG 4 NM; GC; NDS

daptomycin intravenous recon soln 350 mg, 500 mg 4 NM; GC; NDS

FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML

3 GC

FLAGYL ORAL CAPSULE 375 MG 3 GC

FLAGYL ORAL TABLET 250 MG, 500 MG 3 GC

FURADANTIN ORAL SUSPENSION 25 MG/5 ML 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (2400 per 30 days); AGE (Max 64 Years)

HIPREX ORAL TABLET 1 GRAM 3 GC

LINCOCIN INJECTION SOLUTION 300 MG/ML 3 GC

lincomycin injection solution 300 mg/ml 1 GC

linezolid 600 mg/300 ml-0.9% nacl 600 mg/300 ml 4 NM; GC; NDS

linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml

4 NM; GC; NDS

linezolid oral suspension for reconstitution 100 mg/5 ml 4 NM; GC; NDS

linezolid oral tablet 600 mg 1 GC

MACROBID ORAL CAPSULE 100 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years)




MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG

3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years)

methenamine hippurate oral tablet 1 gram 1 GC

metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml

1 GC

metronidazole oral capsule 375 mg 1 GC

metronidazole oral tablet 250 mg, 500 mg 1 GC

MONUROL ORAL PACKET 3 GRAM 3 GC

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years)

nitrofurantoin monohyd/m-cryst oral capsule 100 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years)

nitrofurantoin oral suspension 25 mg/5 ml 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (2400 per 30 days); AGE (Max 64 Years)

ORBACTIV INTRAVENOUS RECON SOLN 400 MG 4 NM; GC; NDS

polymyxin b sulfate injection recon soln 500,000 unit 1 GC

PRIMSOL ORAL SOLUTION 50 MG/5 ML 3 GC

SIVEXTRO INTRAVENOUS RECON SOLN 200 MG 4 NM; GC; NDS

SIVEXTRO ORAL TABLET 200 MG 4 NM; GC; NDS

SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET 2 GRAM

3 ST; GC

SYNERCID INTRAVENOUS RECON SOLN 500 MG 4 NM; GC; NDS

trimethoprim oral tablet 100 mg 1 GC

TRIMPEX ORAL SOLUTION 50 MG/5 ML 3 GC

VANCOCIN ORAL CAPSULE 125 MG, 250 MG 4 NM; GC; NDS

vancomycin intravenous recon soln 1,000 mg, 1.25 gram, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

1 PA BvD; GC

vancomycin oral capsule 125 mg 1 GC

vancomycin oral capsule 250 mg 4 NM; GC; NDS

vancomycin oral recon soln 50 mg/ml 1 GC

VIBATIV INTRAVENOUS RECON SOLN 750 MG 3 GC

XIFAXAN ORAL TABLET 200 MG 4 PA; NM; GC; NDS; QL (9 per 30 days)




XIFAXAN ORAL TABLET 550 MG 4 PA; NM; GC; NDS

ZYVOX INTRAVENOUS PIGGYBACK 200 MG/100 ML, 600 MG/300 ML

4 NM; GC; NDS

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

4 NM; GC; NDS

ZYVOX ORAL TABLET 600 MG 4 NM; GC; NDS

Cephalosporins

AVYCAZ INTRAVENOUS RECON SOLN 2.5 GRAM 4 NM; GC; NDS

CEDAX ORAL CAPSULE 400 MG 3 GC

CEDAX ORAL SUSPENSION FOR RECONSTITUTION 180 MG/5 ML

3 GC

cefaclor oral capsule 250 mg, 500 mg 1 GC

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

1 GC

cefaclor oral tablet extended release 12 hr 500 mg 1 GC

cefadroxil oral capsule 500 mg 1 GC

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

1 GC

cefadroxil oral tablet 1 gram 1 GC

cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml

3 GC

cefazolin injection recon soln 1 gram, 10 gram, 500 mg 1 GC

cefdinir oral capsule 300 mg 1 GC

cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1 GC

cefditoren pivoxil oral tablet 200 mg, 400 mg 1 GC

cefepime injection recon soln 1 gram, 2 gram 3 GC

cefixime oral capsule 400 mg 1 GC

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

1 GC

CEFOTAN INJECTION RECON SOLN 1 GRAM, 2 GRAM

3 GC

cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg

1 GC

cefotetan injection recon soln 1 gram, 2 gram 1 GC

cefotetan intravenous recon soln 10 gram 1 GC

cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram

1 GC

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml

1 GC

cefpodoxime oral tablet 100 mg, 200 mg 1 GC

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1 GC

cefprozil oral tablet 250 mg, 500 mg 1 GC




ceftazidime injection recon soln 1 gram, 2 gram, 6 gram

1 GC

ceftibuten oral capsule 400 mg 3 GC

ceftibuten oral suspension for reconstitution 180 mg/5 ml

3 GC

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML

3 GC

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

1 GC

cefuroxime axetil oral tablet 250 mg, 500 mg 1 GC

cefuroxime sodium injection recon soln 750 mg 1 GC

cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram

1 GC

cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 GC

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1 GC

cephalexin oral tablet 250 mg, 500 mg 1 GC

CLAFORAN INJECTION RECON SOLN 10 GRAM, 2 GRAM

3 GC

FORTAZ INJECTION RECON SOLN 1 GRAM, 500 MG, 6 GRAM

3 GC

FORTAZ INTRAVENOUS RECON SOLN 2 GRAM 3 GC

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG 3 GC

MAXIPIME 1 GM ADD-VANTAGE VL OUTER, LATEX-FREE 1 GRAM

3 GC

MAXIPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM

3 GC

SUPRAX ORAL CAPSULE 400 MG 3 GC

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

3 GC

tazicef injection recon soln 1 gram, 2 gram, 6 gram 1 GC

TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG

4 NM; GC; NDS

ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM 4 NM; GC; NDS

ZINACEF INJECTION RECON SOLN 750 MG 3 GC

ZINACEF INTRAVENOUS RECON SOLN 1.5 GRAM, 7.5 GRAM

3 GC

Macrolides

azithromycin intravenous recon soln 500 mg 1 GC

azithromycin oral packet 1 gram 3 GC

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

1 GC

azithromycin oral tablet 250 mg 1 GC




azithromycin oral tablet 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg

1 GC

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1 GC

clarithromycin oral tablet 250 mg, 500 mg 1 GC

clarithromycin oral tablet extended release 24 hr 500 mg

1 GC

DIFICID ORAL TABLET 200 MG 4 ST; NM; GC; NDS; QL (20 per 10 days)

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg

1 GC

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG

1 GC

erythrocin (as stearate) oral tablet 250 mg 1 GC

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml, 400 mg/5 ml

1 GC

erythromycin oral capsule,delayed release(dr/ec) 250 mg

1 GC

erythromycin oral tablet 250 mg, 500 mg 1 GC

erythromycin oral tablet,delayed release (dr/ec) 250 mg, 333 mg, 500 mg

1 GC

PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG

3 GC

ZITHROMAX INTRAVENOUS RECON SOLN 500 MG 3 GC

ZITHROMAX ORAL PACKET 1 GRAM 3 GC

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML

3 GC

ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG

3 GC

ZITHROMAX TRI-PAK ORAL TABLET 500 MG 3 GC

ZITHROMAX Z-PAK ORAL TABLET 250 MG 3 GC

ZMAX ORAL SUSPENSION,EXTENDED REL RECON 2 GRAM/60 ML

3 GC

Miscellaneous B-Lactam Antibiotics

AZACTAM INJECTION RECON SOLN 1 GRAM, 2 GRAM

3 GC

aztreonam injection recon soln 1 gram, 2 gram 1 GC

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

4 NM; GC; LA; NDS

ertapenem injection recon soln 1 gram 1 GC

imipenem-cilastatin intravenous recon soln 250 mg, 500 mg

1 GC

INVANZ INJECTION RECON SOLN 1 GRAM 3 GC

meropenem intravenous recon soln 1 gram, 500 mg 1 GC




MERREM INTRAVENOUS RECON SOLN 1 GRAM, 500 MG

4 NM; GC; NDS

PRIMAXIN IV INTRAVENOUS RECON SOLN 500 MG 3 GC

VABOMERE INTRAVENOUS RECON SOLN 2 GRAM 4 NM; GC; NDS

Penicillins

amoxicillin oral capsule 250 mg, 500 mg 1 GC

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1 GC

amoxicillin oral tablet 500 mg, 875 mg 1 GC

amoxicillin oral tablet,chewable 125 mg, 250 mg 1 GC

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

1 GC

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1 GC

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

1 GC

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg

1 GC

ampicillin oral capsule 250 mg, 500 mg 1 GC

ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg

1 GC

ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram

1 GC

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION 600-42.9 MG/5 ML

3 GC

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

3 GC

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

3 GC

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR 1,000-62.5 MG

3 GC

BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K)

3 GC

BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML

3 GC

dicloxacillin oral capsule 250 mg, 500 mg 1 GC

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR 775 MG

3 GC

nafcillin 1 gm/ 50 ml inj 1 gram/50 ml 1 GC

nafcillin injection recon soln 1 gram, 2 gram 1 GC

nafcillin injection recon soln 10 gram 4 NM; GC; NDS




oxacillin 1 gm add-vantage vl add-vantage, inner 1 gram

1 GC

oxacillin injection recon soln 1 gram, 10 gram, 2 gram 1 GC

penicillin g potassium injection recon soln 20 million unit

1 GC

penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml

1 GC

penicillin g sodium injection recon soln 5 million unit 1 GC

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml

1 GC

penicillin v potassium oral tablet 250 mg, 500 mg 1 GC

pfizerpen-g injection recon soln 20 million unit 1 GC

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1 PA BvD; GC

UNASYN INJECTION RECON SOLN 1.5 GRAM, 15 GRAM, 3 GRAM

3 GC

ZOSYN 2.25 GRAM VIAL P/F,LTX-FR,INNER,SUV 2.25 GRAM

3 PA BvD; GC

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML

3 PA BvD; GC

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML, 4.5 GRAM/100 ML


ZOSYN INTRAVENOUS RECON SOLN 40.5 GRAM 3 PA BvD; GC

Quinolones

AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/250 ML

3 GC

AVELOX ORAL TABLET 400 MG 3 GC

BAXDELA INTRAVENOUS RECON SOLN 300 MG 4 NM; GC; NDS

BAXDELA ORAL TABLET 450 MG 4 PA; NM; GC; NDS; QL (28 per 14 days)

CIPRO IN D5W INTRAVENOUS PIGGYBACK 400 MG/200 ML

3 GC

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML

3 GC

CIPRO ORAL TABLET 250 MG, 500 MG 3 GC

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 MG, 500 MG

3 GC

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg

1 GC

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1 GC

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

1 GC

ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml

1 GC




ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

1 GC

LEVAQUIN ORAL TABLET 250 MG, 500 MG 3 GC

LEVAQUIN ORAL TABLET 750 MG 3 GC

levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml

1 GC

levofloxacin intravenous solution 25 mg/ml 1 GC

levofloxacin oral solution 250 mg/10 ml 1 GC

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 GC

moxifloxacin 400 mg/250 ml bag 400 mg/250 ml 1 GC

moxifloxacin oral tablet 400 mg 1 GC

moxifloxacin-sod.chloride(iso) intravenous piggyback 400 mg/250 ml

1 GC

ofloxacin oral tablet 300 mg, 400 mg 1 GC

Sulfonamides

BACTRIM DS ORAL TABLET 800-160 MG 3 GC

BACTRIM ORAL TABLET 400-80 MG 3 GC

sulfadiazine oral tablet 500 mg 1 GC

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

1 GC

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

1 GC

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1 GC

sulfatrim oral suspension 200-40 mg/5 ml 3 GC

Tetracyclines

demeclocycline oral tablet 150 mg, 300 mg 1 GC

DORYX MPC ORAL TABLET,DELAYED RELEASE (DR/EC) 120 MG

3 GC

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 200 MG

4 NM; GC; NDS

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 50 MG

3 GC

doxy-100 intravenous recon soln 100 mg 1 GC

doxycycline hyclate intravenous recon soln 100 mg 1 GC

doxycycline hyclate oral capsule 100 mg, 50 mg 1 GC

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 50 mg, 75 mg

1 GC

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

1 GC

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg

1 GC




doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml

1 GC

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1 GC

MINOCIN INTRAVENOUS RECON SOLN 100 MG 2 GC

MINOCIN ORAL CAPSULE 100 MG, 50 MG, 75 MG 3 GC

minocycline oral capsule 100 mg, 50 mg, 75 mg 1 GC

minocycline oral tablet 100 mg, 50 mg, 75 mg 1 GC

minocycline oral tablet extended release 24 hr 105 mg, 115 mg, 135 mg, 45 mg, 65 mg, 80 mg, 90 mg

1 GC

minocycline oral tablet extended release 24 hr 55 mg 3 GC

mondoxyne nl oral capsule 100 mg, 50 mg, 75 mg 1 GC

NUZYRA (7 DAY WITH LOAD DOSE) ORAL TABLET 150 MG


NUZYRA (7 DAY) ORAL TABLET 150 MG 4 NM; GC; NDS; QL (30 per 14 days)

NUZYRA INTRAVENOUS RECON SOLN 100 MG 4 NM; GC; NDS; QL (15 per 14 days)

NUZYRA ORAL TABLET 150 MG 4 NM; GC; NDS; QL (30 per 14 days)

okebo oral capsule 100 mg, 75 mg 1 GC

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE 40 MG

3 GC

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

4 ST; NM; GC; NDS

soloxide oral tablet,delayed release (dr/ec) 150 mg 1 GC

tetracycline oral capsule 250 mg, 500 mg 1 GC

tigecycline intravenous recon soln 50 mg 4 NM; GC; NDS

TYGACIL INTRAVENOUS RECON SOLN 50 MG 4 NM; GC; NDS

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 25 MG/5 ML

3 GC

VIBRAMYCIN ORAL SYRUP 50 MG/5 ML 3 GC

XERAVA INTRAVENOUS RECON SOLN 50 MG 3 GC

XIMINO ORAL CAPSULE,EXTENDED RELEASE 24HR 135 MG, 45 MG, 90 MG

4 ST; NM; GC; NDS

Anticancer Agents

Anticancer Agents

ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG

4 NM; GC; NDS

adriamycin intravenous recon soln 10 mg, 50 mg 1 PA BvD; GC

adriamycin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml

1 PA BvD; GC

adrucil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml

1 PA BvD; GC

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

4 PA NSO; NM; GC; NDS; QL (112 per 28 days)




AFINITOR ORAL TABLET 10 MG 4 PA NSO; NM; GC; NDS; QL (56 per 28 days)

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 4 PA NSO; NM; GC; NDS; QL (28 per 28 days)

ALECENSA ORAL CAPSULE 150 MG 4 PA NSO; NM; GC; NDS; QL (240 per 30 days)

ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG

4 NM; GC; NDS

ALIQOPA INTRAVENOUS RECON SOLN 60 MG 4 PA NSO; NM; GC; NDS; QL (3 per 28 days)

ALKERAN (AS HCL) INTRAVENOUS RECON SOLN 50 MG

4 NM; GC; NDS

ALUNBRIG ORAL TABLET 180 MG, 90 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

ALUNBRIG ORAL TABLET 30 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)


anastrozole oral tablet 1 mg 1 GC

ARIMIDEX ORAL TABLET 1 MG 3 GC

AROMASIN ORAL TABLET 25 MG 4 NM; GC; NDS

ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML

4 NM; GC; NDS

arsenic trioxide intravenous solution 1 mg/ml, 2 mg/ml 4 NM; GC; NDS

ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML, 100 MG/5 ML

4 PA NSO; NM; GC; NDS

AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 4 PA NSO; NM; GC; NDS

azacitidine injection recon soln 100 mg 4 NM; GC; NDS

BALVERSA ORAL TABLET 3 MG 4 PA NSO; NM; GC; NDS; QL (84 per 28 days)



BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML 4 PA NSO; NM; GC; NDS

BELEODAQ INTRAVENOUS RECON SOLN 500 MG 4 PA NSO; NM; GC; NDS

BENDEKA INTRAVENOUS SOLUTION 25 MG/ML 4 PA NSO; NM; GC; NDS

BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL)


bexarotene oral capsule 75 mg 4 PA NSO; NM; GC; NDS; QL (420 per 30 days)

bicalutamide oral tablet 50 mg 1 GC

BICNU INTRAVENOUS RECON SOLN 100 MG 3 GC

bleomycin injection recon soln 15 unit, 30 unit 1 PA BvD; GC

BLINCYTO INTRAVENOUS KIT 35 MCG 4 PA NSO; NM; GC; NDS

BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG


BOSULIF ORAL TABLET 100 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

BRAFTOVI ORAL CAPSULE 50 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG 4 PA NSO; NM; GC; NDS; QL (180 per 30 days)

busulfan intravenous solution 60 mg/10 ml 4 NM; GC; NDS




BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML

4 NM; GC; NDS

CABOMETYX ORAL TABLET 20 MG, 60 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

CABOMETYX ORAL TABLET 40 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

CALQUENCE ORAL CAPSULE 100 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5 ML, 300 MG/15 ML, 40 MG/2 ML

3 GC

CAPRELSA ORAL TABLET 100 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

carboplatin intravenous solution 10 mg/ml 1 GC

carmustine intravenous recon soln 100 mg 1 GC

CASODEX ORAL TABLET 50 MG 3 GC

cisplatin intravenous recon soln 50 mg 1 PA BvD; GC

cisplatin intravenous solution 1 mg/ml 1 PA BvD; GC

cladribine intravenous solution 10 mg/10 ml 1 PA BvD; GC

clofarabine intravenous solution 20 mg/20 ml 4 NM; GC; NDS

CLOLAR INTRAVENOUS SOLUTION 20 MG/20 ML 4 NM; GC; NDS

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


COPIKTRA ORAL CAPSULE 15 MG, 25 MG 4 PA NSO; NM; GC; NDS; QL (56 per 28 days)

COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG 4 NM; GC; NDS

COTELLIC ORAL TABLET 20 MG 4 PA NSO; NM; GC; LA; NDS; QL (63 per 28 days)

cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg


CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG

1 PA BvD; ST; GC

CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML 4 PA NSO; NM; GC; NDS

cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml)

1 PA BvD; GC

cytarabine injection solution 20 mg/ml 1 PA BvD; GC

dacarbazine intravenous recon soln 100 mg, 200 mg 1 GC

DACOGEN INTRAVENOUS RECON SOLN 50 MG 4 NM; GC; NDS

dactinomycin intravenous recon soln 0.5 mg 1 GC

DARZALEX INTRAVENOUS SOLUTION 20 MG/ML 4 PA NSO; NM; GC; LA; NDS

daunorubicin intravenous recon soln 20 mg 1 GC

daunorubicin intravenous solution 5 mg/ml 1 GC

DAURISMO ORAL TABLET 100 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

DAURISMO ORAL TABLET 25 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

decitabine intravenous recon soln 50 mg 4 NM; GC; NDS

DOCEFREZ INTRAVENOUS RECON SOLN 20 MG, 80 MG

4 NM; GC; NDS




docetaxel intravenous solution 20 mg/2 ml (10 mg/ml), 20 mg/ml, 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

4 NM; GC; NDS

DOXIL INTRAVENOUS SUSPENSION 2 MG/ML 4 PA BvD; NM; GC; NDS

doxorubicin intravenous recon soln 10 mg, 50 mg 1 PA BvD; GC

doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml

1 PA BvD; GC

doxorubicin, peg-liposomal intravenous suspension 2 mg/ml


DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3 GC

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG

3 GC

ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG

3 GC

ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG

3 GC

ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH)

3 GC

ELLENCE INTRAVENOUS SOLUTION 200 MG/100 ML, 50 MG/25 ML

3 GC

EMCYT ORAL CAPSULE 140 MG 4 NM; GC; NDS

EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG


epirubicin intravenous solution 200 mg/100 ml, 50 mg/25 ml

1 GC

ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 200 MG/100 ML


ERIVEDGE ORAL CAPSULE 150 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

ERLEADA ORAL TABLET 60 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

erlotinib oral tablet 100 mg, 25 mg 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

erlotinib oral tablet 150 mg 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

ERWINAZE INJECTION RECON SOLN 10,000 UNIT 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG

3 GC

etoposide intravenous solution 20 mg/ml 1 GC

EVOMELA INTRAVENOUS RECON SOLN 50 MG 3 GC

exemestane oral tablet 25 mg 1 GC

FARESTON ORAL TABLET 60 MG 4 NM; GC; NDS

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 4 PA NSO; NM; GC; NDS

FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML

4 NM; GC; NDS

FEMARA ORAL TABLET 2.5 MG 3 GC

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

4 NM; GC; NDS




FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

3 GC

floxuridine injection recon soln 0.5 gram 1 PA BvD; GC

fludarabine intravenous recon soln 50 mg 1 GC

fludarabine intravenous solution 50 mg/2 ml 1 GC

fluorouracil intravenous solution 1 gram/20 ml, 5 gram/100 ml, 500 mg/10 ml

1 PA BvD; GC

flutamide oral capsule 125 mg 1 GC

FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 40 MG/2 ML (20 MG/ML)


fulvestrant intramuscular syringe 250 mg/5 ml 4 NM; GC; NDS

GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML


gemcitabine intravenous recon soln 1 gram, 2 gram, 200 mg

4 NM; GC; NDS

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 NM; GC; NDS

GEMZAR INTRAVENOUS RECON SOLN 1 GRAM, 200 MG

4 NM; GC; NDS

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

GLEEVEC ORAL TABLET 100 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

GLEEVEC ORAL TABLET 400 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 40 MG, 5 MG 3 GC

GLEOSTINE ORAL CAPSULE 100 MG 4 NM; GC; NDS

HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML)


HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10,000 UNIT/5 ML


HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG


HEXALEN ORAL CAPSULE 50 MG 4 NM; GC; NDS

HYCAMTIN INTRAVENOUS RECON SOLN 4 MG 4 NM; GC; NDS

HYDREA ORAL CAPSULE 500 MG 3 GC

hydroxyurea oral capsule 500 mg 1 GC

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 4 PA NSO; NM; GC; NDS; QL (21 per 28 days)

ICLUSIG ORAL TABLET 15 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

ICLUSIG ORAL TABLET 45 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

IDAMYCIN PFS INTRAVENOUS SOLUTION 1 MG/ML 3 GC

idarubicin intravenous solution 1 mg/ml 1 GC

IDHIFA ORAL TABLET 100 MG, 50 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

IFEX INTRAVENOUS RECON SOLN 1 GRAM, 3 GRAM

3 PA BvD; GC

ifosfamide intravenous recon soln 1 gram 1 PA BvD; GC




ifosfamide intravenous solution 1 gram/20 ml, 3 gram/60 ml

1 PA BvD; GC

ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg


imatinib oral tablet 100 mg 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

imatinib oral tablet 400 mg 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

IMBRUVICA ORAL CAPSULE 70 MG 4 PA NSO; NM; GC; NDS; QL (28 per 28 days)

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG


IMFINZI INTRAVENOUS SOLUTION 50 MG/ML 4 PA NSO; NM; GC; NDS

IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML


IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML


INFUGEM INTRAVENOUS PIGGYBACK 1,200 MG/120 ML (10 MG/ML), 1,300 MG/130 ML (10 MG/ML), 1,400 MG/140 ML (10 MG/ML), 1,500 MG/150 ML (10 MG/ML), 1,600 MG/160 ML (10 MG/ML), 1,700 MG/170 ML (10 MG/ML), 1,800 MG/180 ML (10 MG/ML), 1,900 MG/190 ML (10 MG/ML), 2,000 MG/200 ML (10 MG/ML), 2,200 MG/220 ML (10 MG/ML)

4 NM; GC; NDS

INLYTA ORAL TABLET 1 MG 4 PA NSO; NM; GC; NDS; QL (180 per 30 days)

INLYTA ORAL TABLET 5 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

INREBIC ORAL CAPSULE 100 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

IRESSA ORAL TABLET 250 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml

1 GC

ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML


IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG

4 NM; GC; NDS

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


JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION)

4 NM; GC; NDS

KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG


KANJINTI INTRAVENOUS RECON SOLN 420 MG 4 PA NSO; NM; GC; NDS

KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML 4 PA NSO; NM; GC; NDS; QL (8 per 21 days)

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG









KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) 4 PA NSO; NM; GC; NDS; QL (21 per 28 days)



KYPROLIS INTRAVENOUS RECON SOLN 10 MG, 30 MG, 60 MG


LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)


letrozole oral tablet 2.5 mg 1 GC

LEUKERAN ORAL TABLET 2 MG 4 NM; GC; NDS

leuprolide subcutaneous kit 1 mg/0.2 ml 1 GC

LIBTAYO INTRAVENOUS SOLUTION 50 MG/ML 4 PA NSO; NM; GC; NDS; QL (7 per 21 days)

LONSURF ORAL TABLET 15-6.14 MG 4 PA NSO; NM; GC; NDS; QL (100 per 28 days)

LONSURF ORAL TABLET 20-8.19 MG 4 PA NSO; NM; GC; NDS; QL (80 per 28 days)

LORBRENA ORAL TABLET 100 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

LORBRENA ORAL TABLET 25 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

LUMOXITI INTRAVENOUS RECON SOLN 1 MG 4 PA NSO; NM; GC; NDS

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

4 NM; GC; NDS

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

4 NM; GC; NDS

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG

4 NM; GC; NDS

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG

4 NM; GC; NDS

LYNPARZA ORAL CAPSULE 50 MG 4 PA NSO; NM; GC; NDS; QL (448 per 28 days)

LYNPARZA ORAL TABLET 100 MG, 150 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

LYSODREN ORAL TABLET 500 MG 4 NM; GC; NDS

MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL


MATULANE ORAL CAPSULE 50 MG 4 NM; GC; NDS

megestrol oral tablet 20 mg, 40 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

MEKINIST ORAL TABLET 2 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

MEKTOVI ORAL TABLET 15 MG 4 PA NSO; NM; GC; NDS; QL (180 per 30 days)

melphalan hcl intravenous recon soln 50 mg 4 NM; GC; NDS

mercaptopurine oral tablet 50 mg 1 GC

methotrexate sodium (pf) injection recon soln 1 gram 1 PA BvD; GC




methotrexate sodium (pf) injection solution 25 mg/ml 1 PA BvD; GC

methotrexate sodium injection solution 25 mg/ml 1 PA BvD; GC

methotrexate sodium oral tablet 2.5 mg 1 PA BvD; ST; GC

mitomycin intravenous recon soln 20 mg, 40 mg, 5 mg 4 PA BvD; NM; GC; NDS

mitoxantrone intravenous concentrate 2 mg/ml 1 GC

MUSTARGEN INJECTION RECON SOLN 10 MG 4 NM; GC; NDS

mutamycin intravenous recon soln 20 mg, 40 mg, 5 mg 4 PA BvD; NM; GC; NDS

MVASI INTRAVENOUS SOLUTION 25 MG/ML 4 PA NSO; NM; GC; NDS

MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC)


NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/5 ML

3 GC

NERLYNX ORAL TABLET 40 MG 4 PA NSO; NM; GC; NDS; QL (180 per 30 days)

NEXAVAR ORAL TABLET 200 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

NILANDRON ORAL TABLET 150 MG 4 NM; GC; NDS

nilutamide oral tablet 150 mg 4 NM; GC; NDS

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 4 PA NSO; NM; GC; NDS; QL (3 per 28 days)

NIPENT INTRAVENOUS RECON SOLN 10 MG 4 NM; GC; NDS

NUBEQA ORAL TABLET 300 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

ODOMZO ORAL CAPSULE 200 MG 4 PA NSO; NM; GC; LA; NDS

ONCASPAR INJECTION SOLUTION 750 UNIT/ML 4 PA NSO; NM; GC; NDS

ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML 4 PA BvD; NM; GC; NDS

OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML


oxaliplatin intravenous recon soln 100 mg, 50 mg 1 GC

oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml)

1 GC

paclitaxel intravenous concentrate 6 mg/ml 1 PA BvD; GC

PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML)


PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) 4 PA NSO; NM; GC; NDS; QL (28 per 28 days)

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)


POLIVY INTRAVENOUS RECON SOLN 140 MG 4 PA NSO; NM; GC; NDS

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


PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML)


POTELIGEO INTRAVENOUS SOLUTION 4 MG/ML 4 PA NSO; NM; GC; NDS

PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

4 NM; GC; NDS

PURIXAN ORAL SUSPENSION 20 MG/ML 4 NM; GC; NDS




REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

4 PA NSO; NM; GC; LA; NDS; QL (28 per 28 days)

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML)


RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML


romidepsin intravenous recon soln 10 mg/2 ml 4 PA NSO; NM; GC; NDS

ROZLYTREK ORAL CAPSULE 100 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

ROZLYTREK ORAL CAPSULE 200 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

RYDAPT ORAL CAPSULE 25 MG 4 PA NSO; NM; GC; NDS; QL (224 per 28 days)

SOLTAMOX ORAL SOLUTION 10 MG/5 ML 3 GC

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


SPRYCEL ORAL TABLET 20 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

STIVARGA ORAL TABLET 40 MG 4 PA NSO; NM; GC; NDS; QL (84 per 28 days)

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


SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG


SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 4 PA NSO; NM; GC; NDS; QL (28 per 28 days)

TABLOID ORAL TABLET 40 MG 4 NM; GC; NDS

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG 4 PA NSO; NM; GC; LA; NDS; QL (30 per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

TALZENNA ORAL CAPSULE 1 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

tamoxifen oral tablet 10 mg, 20 mg 1 GC

TARCEVA ORAL TABLET 100 MG, 25 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

TARCEVA ORAL TABLET 150 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

TARGRETIN ORAL CAPSULE 75 MG 4 PA NSO; NM; GC; NDS; QL (420 per 30 days)

TARGRETIN TOPICAL GEL 1 % 4 PA NSO; NM; GC; NDS; QL (60 per 28 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG 4 PA NSO; NM; GC; NDS; QL (112 per 28 days)

TASIGNA ORAL CAPSULE 50 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML)

4 NM; GC; NDS

TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML), 840 MG/14 ML (60 MG/ML)


TEMODAR INTRAVENOUS RECON SOLN 100 MG 4 PA NSO; NM; GC; NDS

temsirolimus intravenous recon soln 30 mg/3 ml (10 mg/ml) (first)

4 PA BvD; NM; GC; NDS; QL (4 per 28 days)

thiotepa injection recon soln 15 mg 4 NM; GC; NDS




TIBSOVO ORAL TABLET 250 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

toposar intravenous solution 20 mg/ml 1 GC

topotecan intravenous recon soln 4 mg 4 NM; GC; NDS

topotecan intravenous solution 4 mg/4 ml (1 mg/ml) 4 NM; GC; NDS

toremifene oral tablet 60 mg 4 NM; GC; NDS

TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST)


TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG

4 NM; GC; NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG





4 NM; GC; NDS

tretinoin (chemotherapy) oral capsule 10 mg 4 NM; GC; NDS

TRISENOX INTRAVENOUS SOLUTION 2 MG/ML 4 NM; GC; NDS

TURALIO ORAL CAPSULE 200 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

TYKERB ORAL TABLET 250 MG 4 NM; GC; NDS

UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML 4 PA NSO; NM; GC; NDS

valrubicin intravesical solution 40 mg/ml 4 NM; GC; NDS

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML 4 NM; GC; NDS

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML)


VELCADE INJECTION RECON SOLN 3.5 MG 4 PA NSO; NM; GC; NDS

VENCLEXTA ORAL TABLET 10 MG 3 PA NSO; GC; LA; QL (60 per 30 days)

VENCLEXTA ORAL TABLET 100 MG 4 PA NSO; NM; GC; LA; NDS; QL (180 per 30 days)

VENCLEXTA ORAL TABLET 50 MG 3 PA NSO; GC; LA; QL (30 per 30 days)

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

4 PA NSO; NM; GC; LA; NDS; QL (42 per 28 days)

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


VIDAZA INJECTION RECON SOLN 100 MG 4 NM; GC; NDS

vinblastine intravenous solution 1 mg/ml 1 PA BvD; GC

vincasar pfs intravenous solution 1 mg/ml, 2 mg/2 ml 1 PA BvD; GC

vincristine intravenous solution 1 mg/ml, 2 mg/2 ml 1 PA BvD; GC

vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml 1 GC

VITRAKVI ORAL CAPSULE 100 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

VITRAKVI ORAL CAPSULE 25 MG 4 PA NSO; NM; GC; NDS; QL (180 per 30 days)

VITRAKVI ORAL SOLUTION 20 MG/ML 4 PA NSO; NM; GC; NDS; QL (300 per 30 days)

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

VOTRIENT ORAL TABLET 200 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)




VYXEOS INTRAVENOUS RECON SOLN 44-100 MG 4 PA BvD; NM; GC; NDS

XALKORI ORAL CAPSULE 200 MG, 250 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

XATMEP ORAL SOLUTION 2.5 MG/ML 3 PA BvD; ST; GC

XOSPATA ORAL TABLET 40 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) 4 PA NSO; NM; GC; NDS; QL (20 per 28 days)




XTANDI ORAL CAPSULE 40 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML)


YONDELIS INTRAVENOUS RECON SOLN 1 MG 4 PA NSO; NM; GC; NDS

YONSA ORAL TABLET 125 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML)


ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM 4 NM; GC; NDS

ZEJULA ORAL CAPSULE 100 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

ZELBORAF ORAL TABLET 240 MG 4 PA NSO; NM; GC; NDS; QL (240 per 30 days)

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG 3 GC; QL (1 per 84 days)

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG 3 GC; QL (1 per 28 days)

ZOLINZA ORAL CAPSULE 100 MG 4 NM; GC; NDS

ZYDELIG ORAL TABLET 100 MG, 150 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

ZYKADIA ORAL CAPSULE 150 MG 4 PA NSO; NM; GC; NDS; QL (90 per 30 days)

ZYKADIA ORAL TABLET 150 MG 4 PA NSO; NM; GC; NDS; QL (84 per 28 days)

ZYTIGA ORAL TABLET 250 MG, 500 MG 4 PA NSO; NM; GC; NDS; QL (120 per 30 days)

Anticholinergic Agents

Antimuscarinics/Antispasmodics

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 3 GC

chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE 5-2.5 MG

3 PA-HRM; GC; AGE (Max 64 Years)

propantheline oral tablet 15 mg 1 GC

Anticonvulsants

Anticonvulsants

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

4 NM; GC; NDS

BANZEL ORAL SUSPENSION 40 MG/ML 4 NM; GC; NDS

BANZEL ORAL TABLET 200 MG, 400 MG 4 NM; GC; NDS

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML 3 GC; QL (80 per 30 days)

BRIVIACT ORAL SOLUTION 10 MG/ML 4 NM; GC; NDS; QL (600 per 30 days)

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG





carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

1 GC

carbamazepine oral suspension 100 mg/5 ml 1 GC

carbamazepine oral tablet 200 mg 1 GC

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

1 GC

carbamazepine oral tablet,chewable 100 mg 1 GC

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

3 GC

CELONTIN ORAL CAPSULE 300 MG 3 GC

CEREBYX INJECTION SOLUTION 100 MG PE/2 ML, 500 MG PE/10 ML

3 GC

DEPACON INTRAVENOUS SOLUTION 500 MG/5 ML (100 MG/ML)

3 GC

DEPAKENE ORAL CAPSULE 250 MG 3 GC

DEPAKENE ORAL SOLUTION 250 MG/5 ML 3 GC

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG

3 GC

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG

3 GC

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG

3 GC

DILANTIN ORAL CAPSULE 30 MG 1 GC

DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML 3 GC

divalproex oral capsule, delayed rel sprinkle 125 mg 1 GC

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

1 GC

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

1 GC

EPIDIOLEX ORAL SOLUTION 100 MG/ML 4 PA NSO; NM; GC; NDS

epitol oral tablet 200 mg 1 GC

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

3 GC

ethosuximide oral capsule 250 mg 1 GC

ethosuximide oral solution 250 mg/5 ml 1 GC

felbamate oral suspension 600 mg/5 ml 1 GC

felbamate oral tablet 400 mg, 600 mg 1 GC

FELBATOL ORAL SUSPENSION 600 MG/5 ML 4 NM; GC; NDS

FELBATOL ORAL TABLET 400 MG, 600 MG 4 NM; GC; NDS

fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml

1 GC

FYCOMPA ORAL SUSPENSION 0.5 MG/ML 3 GC

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

4 NM; GC; NDS




FYCOMPA ORAL TABLET 2 MG 3 GC

gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 GC

gabapentin oral solution 250 mg/5 ml 1 GC

gabapentin oral tablet 600 mg, 800 mg 1 GC

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 3 GC

GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69)


GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG


HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG


HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG


KEPPRA INTRAVENOUS SOLUTION 500 MG/5 ML 3 GC

KEPPRA ORAL SOLUTION 100 MG/ML 3 GC

KEPPRA ORAL TABLET 1,000 MG, 250 MG, 500 MG, 750 MG

3 GC

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG

3 GC

LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG

4 NM; GC; NDS

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG (21) -50 MG (7)

3 GC

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (42) -100 MG (14)

3 GC

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG(14)-50 MG (14)-100 MG (7)

3 GC

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

4 NM; GC; NDS

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

4 NM; GC; NDS

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)

3 GC

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)

3 GC

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)

3 GC

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

4 NM; GC; NDS




LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7)

3 GC

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)

3 GC

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7)

3 GC

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 GC

lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg (42) -100 mg (14)

1 GC

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1 GC

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

1 GC

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

1 GC

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14)

1 GC

levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml

1 GC

levetiracetam intravenous solution 500 mg/5 ml 1 GC

levetiracetam oral solution 100 mg/ml 1 GC

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

1 GC

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

1 GC

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


LYRICA ORAL SOLUTION 20 MG/ML 2 GC; QL (900 per 30 days)

MYSOLINE ORAL TABLET 250 MG, 50 MG 4 NM; GC; NDS

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

3 GC

NEURONTIN ORAL SOLUTION 250 MG/5 ML 3 GC

NEURONTIN ORAL TABLET 600 MG, 800 MG 3 GC

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

1 GC

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 GC

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG

3 GC

PEGANONE ORAL TABLET 250 MG 3 GC

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 1 PA NSO-HRM; GC; AGE (Max 64 Years)




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

1 PA NSO-HRM; GC; AGE (Max 64 Years)

phenytoin oral suspension 125 mg/5 ml 1 GC

phenytoin oral tablet,chewable 50 mg 1 GC

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1 GC

phenytoin sodium intravenous solution 50 mg/ml 1 GC

phenytoin sodium intravenous syringe 50 mg/ml 1 GC

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg


pregabalin oral solution 20 mg/ml 1 GC; QL (900 per 30 days)

primidone oral tablet 250 mg, 50 mg 1 GC

ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG

1 GC

SABRIL ORAL POWDER IN PACKET 500 MG 4 NM; GC; NDS

SABRIL ORAL TABLET 500 MG 4 NM; GC; NDS

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG


SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG


subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 GC

subvenite starter (blue) kit oral tablets,dose pack 25 mg (35)

1 GC

subvenite starter (green) kit oral tablets,dose pack 25 mg (84) -100 mg (14)

1 GC

subvenite starter (orange) kit oral tablets,dose pack 25 mg (42) -100 mg (7)

1 GC

TEGRETOL ORAL SUSPENSION 100 MG/5 ML 3 GC

TEGRETOL ORAL TABLET 200 MG 3 GC

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG

3 GC

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 GC

TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG

3 GC

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

3 GC

topiramate oral capsule, sprinkle 15 mg, 25 mg 1 GC

topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

3 GC

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 GC

TRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 MG/ML)

3 GC

TRILEPTAL ORAL TABLET 150 MG 3 GC

TRILEPTAL ORAL TABLET 300 MG, 600 MG 4 NM; GC; NDS




TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG


TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG


valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml)

1 GC

valproic acid (as sodium salt) oral solution 250 mg/5 ml 1 GC

valproic acid oral capsule 250 mg 1 GC

vigabatrin oral powder in packet 500 mg 4 NM; GC; NDS

vigabatrin oral tablet 500 mg 4 NM; GC; NDS

vigadrone oral powder in packet 500 mg 4 NM; GC; NDS

VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML 2 GC; QL (200 per 5 days)

VIMPAT ORAL SOLUTION 10 MG/ML 2 GC; QL (1200 per 30 days)

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


ZARONTIN ORAL CAPSULE 250 MG 3 GC

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG 4 NM; GC; NDS

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 GC

Antidementia Agents

Antidementia Agents

ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG 3 GC; QL (30 per 30 days)

donepezil oral tablet 10 mg, 23 mg, 5 mg 1 GC; QL (30 per 30 days)

donepezil oral tablet,disintegrating 10 mg, 5 mg 1 GC; QL (30 per 30 days)

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


galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg


galantamine oral solution 4 mg/ml 1 GC; QL (200 per 30 days)

galantamine oral tablet 12 mg, 4 mg, 8 mg 1 GC; QL (60 per 30 days)

memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg


memantine oral solution 2 mg/ml 1 GC; QL (360 per 30 days)

memantine oral tablet 10 mg, 5 mg 1 GC; QL (60 per 30 days)

memantine oral tablets,dose pack 5-10 mg 3 GC; QL (49 per 28 days)

NAMENDA ORAL TABLET 10 MG, 5 MG 3 GC; QL (60 per 30 days)

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG


NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG


NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG


NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG





RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR 16 MG, 24 MG, 8 MG


RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG 3 GC; QL (60 per 30 days)

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg


rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr


Antidepressants

Antidepressants

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


amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25-10 mg


amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG 4 PA NSO-HRM; NM; GC; NDS; AGE (Max 64 Years)

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG

4 NM; GC; NDS

bupropion hcl oral tablet 100 mg, 75 mg 1 GC

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

1 GC

bupropion hcl oral tablet extended release 24 hr 450 mg

3 GC

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg

1 GC

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG 3 GC; QL (30 per 30 days)

citalopram oral solution 10 mg/5 ml 1 GC; QL (600 per 30 days)

citalopram oral tablet 10 mg, 20 mg, 40 mg 1 GC; QL (30 per 30 days)

clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG


desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG


DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG


desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg


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


doxepin oral concentrate 10 mg/ml 1 PA NSO-HRM; GC; AGE (Max 64 Years)

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





duloxetine oral capsule,delayed release(dr/ec) 40 mg 1 GC; QL (30 per 30 days)

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG


EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 37.5 MG, 75 MG


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


escitalopram oxalate oral solution 5 mg/5 ml 1 GC

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 GC

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)


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


fluoxetine oral capsule 10 mg, 20 mg, 40 mg 1 GC

fluoxetine oral capsule,delayed release(dr/ec) 90 mg 1 GC; QL (4 per 28 days)

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1 GC

fluoxetine oral tablet 10 mg, 20 mg 1 GC

fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg

1 GC

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 1 GC

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG

3 GC

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

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


KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG


LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG 3 GC

maprotiline oral tablet 25 mg, 50 mg, 75 mg 1 GC

MARPLAN ORAL TABLET 10 MG 3 GC

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 GC

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg

1 GC

NARDIL ORAL TABLET 15 MG 3 GC

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

1 GC

NORPRAMIN ORAL TABLET 10 MG, 25 MG 3 PA NSO-HRM; GC; AGE (Max 64 Years)

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

nortriptyline oral solution 10 mg/5 ml 1 PA NSO-HRM; GC; AGE (Max 64 Years)

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

1 GC

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

4 PA NSO-HRM; NM; GC; NDS; AGE (Max 64 Years)

PARNATE ORAL TABLET 10 MG 3 GC




paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

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


PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG


PAXIL ORAL SUSPENSION 10 MG/5 ML 3 PA NSO-HRM; GC; AGE (Max 64 Years)

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 PA NSO-HRM; GC; AGE (Max 64 Years)

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


PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG


phenelzine oral tablet 15 mg 1 GC

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG


protriptyline oral tablet 10 mg, 5 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG 3 GC

REMERON ORAL TABLET 15 MG, 30 MG, 45 MG 3 GC

REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG

3 GC

sertraline oral concentrate 20 mg/ml 1 GC

sertraline oral tablet 100 mg, 25 mg, 50 mg 1 GC

SPRAVATO NASAL SPRAY,NON-AEROSOL 56 MG (28 MG X 2), 84 MG (28 MG X 3)


SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG


SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG

3 GC

tranylcypromine oral tablet 10 mg 1 GC

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 GC

trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years)

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 2 GC; QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg


venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg


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

1 GC

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

1 GC

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 2 GC; QL (30 per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


WELLBUTRIN SR ORAL TABLET SUSTAINED-RELEASE 12 HR 100 MG, 150 MG, 200 MG

3 GC




WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG

4 NM; GC; NDS

ZOLOFT ORAL CONCENTRATE 20 MG/ML 3 GC

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC

ZULRESSO INTRAVENOUS SOLUTION 5 MG/ML 4 NM; GC; NDS

Antidiabetic Agents

Antidiabetic Agents, Miscellaneous

acarbose oral tablet 100 mg, 25 mg, 50 mg 1 GC; QL (90 per 30 days)

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG


ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG


ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG 3 GC; QL (30 per 30 days)

ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML


alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg 3 GC; QL (30 per 30 days)

alogliptin-metformin oral tablet 12.5-1,000 mg, 12.5-500 mg


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


AVANDAMET ORAL TABLET 2-1,000 MG 3 ST; GC; QL (60 per 30 days)

AVANDIA ORAL TABLET 2 MG, 4 MG 3 ST; GC; QL (30 per 30 days)

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML

3 ST; GC; QL (3.4 per 28 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML


BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG


BYETTA 10 MCG DOSE PEN INJ 10 MCG PER DOSE, SUV 10 MCG/DOSE(250 MCG/ML) 2.4 ML


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


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


CYCLOSET ORAL TABLET 0.8 MG 3 GC; QL (180 per 30 days)

DUETACT ORAL TABLET 30-2 MG, 30-4 MG 3 GC; QL (30 per 30 days)

FARXIGA ORAL TABLET 10 MG, 5 MG 3 ST; GC; QL (30 per 30 days)

FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 MG


FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 MG


GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

2 GC




GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG

3 GC

GLUCOPHAGE ORAL TABLET 1,000 MG 3 GC; QL (75 per 30 days)

GLUCOPHAGE ORAL TABLET 500 MG 3 GC; QL (150 per 30 days)

GLUCOPHAGE ORAL TABLET 850 MG 3 GC; QL (90 per 30 days)

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG


GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG


GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG


GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG


GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC; QL (90 per 30 days)

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG 2 ST; GC; QL (30 per 30 days)

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG


INVOKAMET ORAL TABLET 50-500 MG 2 ST; GC; QL (120 per 30 days)

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG 2 ST; GC; QL (60 per 30 days)

INVOKANA ORAL TABLET 300 MG 2 ST; GC; QL (30 per 30 days)

JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG 2 GC; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 2 GC; QL (30 per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG 2 ST; GC; QL (30 per 30 days)

JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG


KAZANO ORAL TABLET 12.5-1,000 MG, 12.5-500 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG


KORLYM ORAL TABLET 300 MG 4 PA; NM; GC; NDS; QL (112 per 28 days)

metformin oral solution 500 mg/5 ml 1 GC; QL (765 per 30 days)

metformin oral tablet 1,000 mg 1 GC; QL (75 per 30 days)

metformin oral tablet 500 mg 1 GC; QL (150 per 30 days)




metformin oral tablet 850 mg 1 GC; QL (90 per 30 days)

metformin oral tablet extended release 24 hr 500 mg 1 GC; QL (120 per 30 days)

metformin oral tablet extended release 24 hr 750 mg 1 GC; QL (60 per 30 days)

metformin oral tablet extended release 24hr 1,000 mg 1 ST; GC; QL (60 per 30 days)

metformin oral tablet extended release 24hr 500 mg 1 ST; GC; QL (150 per 30 days)

metformin oral tablet,er gast.retention 24 hr 1,000 mg 4 ST; NM; GC; NDS; QL (60 per 30 days)

metformin oral tablet,er gast.retention 24 hr 500 mg 4 ST; NM; GC; NDS; QL (120 per 30 days)

miglitol oral tablet 100 mg, 25 mg, 50 mg 1 GC; QL (90 per 30 days)

nateglinide oral tablet 120 mg, 60 mg 1 GC; QL (90 per 30 days)

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG 3 GC; QL (30 per 30 days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG 3 GC; QL (30 per 30 days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/DOSE (2 MG/1.5 ML)


pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 GC; QL (30 per 30 days)

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg 1 GC; QL (30 per 30 days)

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


PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC; QL (90 per 30 days)

QTERN ORAL TABLET 10-5 MG, 5-5 MG 3 ST; GC; QL (30 per 30 days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1 GC; QL (240 per 30 days)

repaglinide-metformin oral tablet 1-500 mg, 2-500 mg 1 GC; QL (150 per 30 days)

RIOMET ORAL SOLUTION 500 MG/5 ML 3 GC; QL (765 per 30 days)

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG 4 ST; NM; GC; NDS; QL (30 per 30 days)

SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG


STARLIX ORAL TABLET 120 MG, 60 MG 3 GC; QL (90 per 30 days)

STEGLATRO ORAL TABLET 15 MG, 5 MG 3 ST; GC; QL (30 per 30 days)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG 3 ST; GC; QL (30 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML


SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML


SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG


TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML





TRADJENTA ORAL TABLET 5 MG 2 GC; QL (30 per 30 days)

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG


Insulins

ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML


ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML


AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30), 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT, 8 UNIT (60)/ 12 UNIT (30), 8 UNIT (90)/ 12 UNIT (90)

3 PA; GC

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML


APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML


HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)


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


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


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


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





HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML


HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


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


HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML


HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)


insulin lispro subcutaneous insulin pen 100 unit/ml 3 ST; GC; QL (30 per 28 days)

insulin lispro subcutaneous solution 100 unit/ml 3 ST; GC; QL (40 per 28 days)

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)


NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML


NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML


NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)


NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML





NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML


SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML


TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)


TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)

2 GC; QL (13.5 per 28 days)

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)


TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML)


Sulfonylureas

AMARYL ORAL TABLET 1 MG, 2 MG 3 GC; QL (30 per 30 days)

AMARYL ORAL TABLET 4 MG 3 GC; QL (60 per 30 days)

chlorpropamide oral tablet 100 mg, 250 mg 1 PA-HRM; GC; AGE (Max 64 Years)

glimepiride oral tablet 1 mg, 2 mg 1 GC; QL (30 per 30 days)

glimepiride oral tablet 4 mg 1 GC; QL (60 per 30 days)

glipizide oral tablet 10 mg 1 GC; QL (120 per 30 days)

glipizide oral tablet 5 mg 1 GC; QL (60 per 30 days)

glipizide oral tablet extended release 24hr 10 mg 1 GC; QL (60 per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg, 5 mg


glipizide-metformin oral tablet 2.5-250 mg 1 GC; QL (240 per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 GC; QL (120 per 30 days)

GLUCOTROL ORAL TABLET 10 MG 3 GC; QL (120 per 30 days)

GLUCOTROL ORAL TABLET 5 MG 3 GC; QL (60 per 30 days)

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG


GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG, 5 MG


GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG


glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 PA-HRM; GC; AGE (Max 64 Years)

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg


GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG 3 PA-HRM; GC; AGE (Max 64 Years)

tolazamide oral tablet 250 mg 1 GC; QL (120 per 30 days)




tolazamide oral tablet 500 mg 1 GC; QL (60 per 30 days)

tolbutamide oral tablet 500 mg 1 GC; QL (180 per 30 days)

Antifungals

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML 4 PA BvD; NM; GC; NDS

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG


amphotericin b injection recon soln 50 mg 1 PA BvD; GC

ANCOBON ORAL CAPSULE 250 MG, 500 MG 4 NM; GC; NDS

CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG

4 NM; GC; NDS

caspofungin intravenous recon soln 50 mg, 70 mg 4 NM; GC; NDS

ciclopirox topical cream 0.77 % 1 GC

ciclopirox topical gel 0.77 % 1 GC

ciclopirox topical shampoo 1 % 1 GC

ciclopirox topical solution 8 % 1 GC

ciclopirox topical suspension 0.77 % 1 GC

clotrimazole mucous membrane troche 10 mg 1 GC

clotrimazole topical cream 1 % 1 GC

clotrimazole topical solution 1 % 1 GC

clotrimazole-betamethasone topical cream 1-0.05 % 1 GC

clotrimazole-betamethasone topical lotion 1-0.05 % 1 GC

CRESEMBA INTRAVENOUS RECON SOLN 372 MG 4 NM; GC; NDS

CRESEMBA ORAL CAPSULE 186 MG 4 NM; GC; NDS

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML, 40 MG/ML

3 GC

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

3 GC

econazole topical cream 1 % 1 GC

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG

4 NM; GC; NDS

ERTACZO TOPICAL CREAM 2 % 4 NM; GC; NDS

EXELDERM TOPICAL CREAM 1 % 3 GC

EXELDERM TOPICAL SOLUTION 1 % 3 GC

EXTINA TOPICAL FOAM 2 % 3 GC

fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml

1 PA BvD; GC

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

1 GC

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 GC

flucytosine oral capsule 250 mg, 500 mg 4 NM; GC; NDS

griseofulvin microsize oral suspension 125 mg/5 ml 1 GC

griseofulvin microsize oral tablet 500 mg 1 GC




griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 GC

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 125 MG, 250 MG

3 GC

itraconazole oral capsule 100 mg 1 GC

itraconazole oral solution 10 mg/ml 2 GC

JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 %


KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 %


ketoconazole oral tablet 200 mg 1 GC

ketoconazole topical cream 2 % 1 GC

ketoconazole topical foam 2 % 1 GC

ketoconazole topical shampoo 2 % 1 GC

ketodan topical foam 2 % 1 GC

LAMISIL ORAL TABLET 250 MG 3 GC

LOPROX (AS OLAMINE) TOPICAL SUSPENSION 0.77 %

3 GC

LOPROX TOPICAL SHAMPOO 1 % 3 GC

LOTRISONE TOPICAL CREAM 1-0.05 % 3 GC

luliconazole topical cream 1 % 3 GC

LUZU TOPICAL CREAM 1 % 3 GC

MENTAX TOPICAL CREAM 1 % 3 GC

miconazole nitrate-zinc ox-pet topical ointment 0.25-15-81.35 %

3 GC

miconazole-3 vaginal suppository 200 mg 1 GC

MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG

4 NM; GC; NDS

naftifine topical cream 1 %, 2 % 1 GC

naftifine topical gel 1 % 1 GC

NAFTIN TOPICAL CREAM 2 % 3 GC

NAFTIN TOPICAL GEL 1 %, 2 % 3 GC

NIZORAL TOPICAL SHAMPOO 2 % 3 GC

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML

4 NM; GC; NDS

NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)

4 NM; GC; NDS

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG

4 NM; GC; NDS

nyamyc topical powder 100,000 unit/gram 1 GC

nystatin oral suspension 100,000 unit/ml 1 GC

nystatin oral tablet 500,000 unit 1 GC

nystatin topical cream 100,000 unit/gram 1 GC

nystatin topical ointment 100,000 unit/gram 1 GC




nystatin topical powder 100,000 unit/gram 1 GC

nystatin-triamcinolone topical cream 100,000-0.1 unit/g-%

1 GC

nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-%

1 GC

nystop topical powder 100,000 unit/gram 1 GC

ONMEL ORAL TABLET 200 MG 3 GC

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG


oxiconazole topical cream 1 % 1 GC

OXISTAT TOPICAL CREAM 1 % 3 GC

OXISTAT TOPICAL LOTION 1 % 3 GC

posaconazole oral suspension 200 mg/5 ml (40 mg/ml) 4 NM; GC; NDS

posaconazole oral tablet,delayed release (dr/ec) 100 mg

4 NM; GC; NDS

SPORANOX ORAL CAPSULE 100 MG 4 NM; GC; NDS

SPORANOX ORAL SOLUTION 10 MG/ML 4 NM; GC; NDS

terbinafine hcl oral tablet 250 mg 1 GC

TOLSURA ORAL CAPSULE, SOLID DISPERSION 65 MG

4 NM; GC; NDS

VFEND IV INTRAVENOUS RECON SOLN 200 MG 3 PA BvD; GC

VFEND ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML (40 MG/ML)

4 NM; GC; NDS

VFEND ORAL TABLET 200 MG, 50 MG 4 NM; GC; NDS

voriconazole intravenous recon soln 200 mg 4 PA BvD; NM; GC; NDS

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)

4 NM; GC; NDS

voriconazole oral tablet 200 mg, 50 mg 4 NM; GC; NDS

VUSION TOPICAL OINTMENT 0.25-15-81.35 % 3 GC

XOLEGEL TOPICAL GEL 2 % 3 GC

Antigout Agents

Antigout Agents, Other

allopurinol oral tablet 100 mg, 300 mg 1 GC

allopurinol sodium intravenous recon soln 500 mg 1 GC

ALOPRIM INTRAVENOUS RECON SOLN 500 MG 3 GC

colchicine oral capsule 0.6 mg 1 GC

colchicine oral tablet 0.6 mg 1 GC

COLCRYS ORAL TABLET 0.6 MG 3 GC

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG 3 ST; GC; QL (30 per 30 days)

febuxostat oral tablet 40 mg, 80 mg 1 GC; QL (30 per 30 days)

MITIGARE ORAL CAPSULE 0.6 MG 3 GC

probenecid oral tablet 500 mg 1 GC

probenecid-colchicine oral tablet 500-0.5 mg 1 GC




ULORIC ORAL TABLET 40 MG, 80 MG 2 GC; QL (30 per 30 days)

ZURAMPIC ORAL TABLET 200 MG 3 ST; GC; QL (30 per 30 days)

ZYLOPRIM ORAL TABLET 100 MG, 300 MG 3 GC

Antihistamines

Antihistamines

carbinoxamine maleate oral liquid 4 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

carbinoxamine maleate oral tablet 4 mg 1 PA-HRM; GC; AGE (Max 64 Years)

carbinoxamine maleate oral tablet 6 mg 4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

CLARINEX ORAL SYRUP 2.5 MG/5 ML (0.5 MG/ML) 3 GC

CLARINEX ORAL TABLET 5 MG 3 GC

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG

3 GC

clemastine oral tablet 2.68 mg 1 PA-HRM; GC; AGE (Max 64 Years)

cyproheptadine oral syrup 2 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

cyproheptadine oral tablet 4 mg 1 PA-HRM; GC; AGE (Max 64 Years)

desloratadine oral tablet 5 mg 1 GC

desloratadine oral tablet,disintegrating 2.5 mg, 5 mg 1 GC

diphenhydramine hcl injection solution 50 mg/ml 1 GC

diphenhydramine hcl injection syringe 50 mg/ml 1 GC

diphenhydramine hcl oral elixir 12.5 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

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


hydroxyzine hcl oral solution 10 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA-HRM; GC; AGE (Max 64 Years)

KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 HR 4 MG/5 ML


levocetirizine oral solution 2.5 mg/5 ml 1 GC

levocetirizine oral tablet 5 mg 1 GC

promethazine oral syrup 6.25 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

promethazine-phenylephrine oral syrup 6.25-5 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

SEMPREX-D ORAL CAPSULE 8-60 MG 3 GC

Anti-Infectives (Skin And Mucous Membrane)

Anti-Infectives (Skin And Mucous Membrane)

AVC VAGINAL VAGINAL CREAM 15 % 3 GC

CLEOCIN VAGINAL CREAM 2 % 3 GC

CLEOCIN VAGINAL SUPPOSITORY 100 MG 3 GC

clindamycin phosphate vaginal cream 2 % 1 GC

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE 2 %

3 GC

METROGEL VAGINAL VAGINAL GEL 0.75 % 3 GC

metronidazole vaginal gel 0.75 % 1 GC

NUVESSA VAGINAL GEL 1.3 % 3 GC




TERAZOL 7 VAGINAL CREAM 0.4 % 3 GC

terconazole vaginal cream 0.4 %, 0.8 % 1 GC

terconazole vaginal suppository 80 mg 1 GC

VANDAZOLE VAGINAL GEL 0.75 % 3 GC

Antimigraine Agents

Antimigraine Agents

AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML


AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML


AJOVY SUBCUTANEOUS SYRINGE 225 MG/1.5 ML 2 PA; GC; QL (1.5 per 30 days)

almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 GC; QL (12 per 28 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG 3 GC; QL (18 per 28 days)

AXERT ORAL TABLET 12.5 MG, 6.25 MG 3 GC; QL (12 per 28 days)

D.H.E.45 INJECTION SOLUTION 1 MG/ML 4 NM; GC; NDS; QL (24 per 28 days)

dihydroergotamine injection solution 1 mg/ml 4 NM; GC; NDS; QL (24 per 28 days)

dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)


eletriptan oral tablet 20 mg, 40 mg 1 GC; QL (12 per 28 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3)


ERGOMAR SUBLINGUAL TABLET 2 MG 1 GC; QL (40 per 28 days)

ergotamine-caffeine oral tablet 1-100 mg 1 GC; QL (40 per 28 days)

FROVA ORAL TABLET 2.5 MG 3 GC; QL (18 per 28 days)

frovatriptan oral tablet 2.5 mg 1 GC; QL (18 per 28 days)

IMITREX 4 MG/0.5 ML CARTRIDGES 4 MG/0.5 ML 3 GC; QL (4 per 28 days)

IMITREX 6 MG/0.5 ML PEN INJECT 2 STAT DOSE SYR,SDV 6 MG/0.5 ML


IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION


IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC; QL (18 per 28 days)

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML


IMITREX STATDOSE REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5 ML 4 NM; GC; NDS; QL (4 per 28 days)

MAXALT ORAL TABLET 10 MG, 5 MG 3 GC; QL (18 per 28 days)

MAXALT-MLT ORAL TABLET,DISINTEGRATING 10 MG, 5 MG





MIGRANAL NASAL SPRAY,NON-AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML)


naratriptan oral tablet 1 mg, 2.5 mg 1 GC; QL (18 per 28 days)

ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG


RELPAX ORAL TABLET 20 MG, 40 MG 3 GC; QL (12 per 28 days)

rizatriptan oral tablet 10 mg, 5 mg 1 GC; QL (18 per 28 days)

rizatriptan oral tablet,disintegrating 10 mg, 5 mg 1 GC; QL (18 per 28 days)

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation


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


sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml


sumatriptan succinate subcutaneous solution 6 mg/0.5 ml


sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


sumatriptan-naproxen oral tablet 85-500 mg 1 GC; QL (9 per 28 days)

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML, 6 MG/0.5 ML


TREXIMET ORAL TABLET 10-60 MG 3 GC; QL (9 per 30 days)

TREXIMET ORAL TABLET 85-500 MG 3 GC; QL (9 per 28 days)

ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN INJECTOR 3 MG/0.5 ML


zolmitriptan oral tablet 2.5 mg, 5 mg 1 GC; QL (12 per 28 days)

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg 1 GC; QL (12 per 28 days)

ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG


ZOMIG ORAL TABLET 2.5 MG, 5 MG 4 NM; GC; NDS; QL (12 per 28 days)

ZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5 MG, 5 MG


Antimycobacterials

Antimycobacterials

CAPASTAT INJECTION RECON SOLN 1 GRAM 3 GC

dapsone oral tablet 100 mg, 25 mg 1 GC

ethambutol oral tablet 100 mg, 400 mg 1 GC

isoniazid injection solution 100 mg/ml 1 GC

isoniazid oral solution 50 mg/5 ml 1 GC

isoniazid oral tablet 100 mg, 300 mg 1 GC

MYAMBUTOL ORAL TABLET 400 MG 3 GC




MYCOBUTIN ORAL CAPSULE 150 MG 3 GC

PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

3 GC

PRIFTIN ORAL TABLET 150 MG 3 GC

pyrazinamide oral tablet 500 mg 1 GC

rifabutin oral capsule 150 mg 1 GC

RIFADIN INTRAVENOUS RECON SOLN 600 MG 4 NM; GC; NDS

RIFADIN ORAL CAPSULE 150 MG, 300 MG 3 GC

rifampin intravenous recon soln 600 mg 1 GC

rifampin oral capsule 150 mg, 300 mg 1 GC

RIFATER ORAL TABLET 50-120-300 MG 3 GC

SIRTURO ORAL TABLET 100 MG 4 PA; NM; GC; NDS

TRECATOR ORAL TABLET 250 MG 3 GC

Antinausea Agents

Antinausea Agents

AKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN 235-0.25 MG

3 GC

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG

3 PA BvD; GC

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5 ML 3 GC

ANZEMET ORAL TABLET 100 MG, 50 MG 4 PA BvD; NM; GC; NDS

aprepitant oral capsule 125 mg 1 PA BvD; GC; QL (2 per 28 days)



aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)

1 PA BvD; GC; QL (6 per 28 days)

BONJESTA ORAL TABLET,IR,DELAYED REL,BIPHASIC 20-20 MG


CESAMET ORAL CAPSULE 1 MG 4 PA BvD; NM; GC; NDS; QL (180 per 30 days)

CINVANTI INTRAVENOUS EMULSION 7.2 MG/ML 3 GC; QL (36 per 28 days)

compro rectal suppository 25 mg 1 GC

DICLEGIS ORAL TABLET,DELAYED RELEASE (DR/EC) 10-10 MG


dimenhydrinate injection solution 50 mg/ml 1 GC

doxylamine-pyridoxine (vit b6) oral tablet,delayed release (dr/ec) 10-10 mg


dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 PA; GC

EMEND (FOSAPREPITANT) INTRAVENOUS RECON SOLN 150 MG


EMEND ORAL CAPSULE 125 MG 3 PA BvD; GC; QL (2 per 28 days)






EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2)


EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)


fosaprepitant intravenous recon soln 150 mg 1 GC; QL (2 per 28 days)

granisetron (pf) intravenous solution 100 mcg/ml 1 GC

granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml)

1 GC

granisetron hcl oral tablet 1 mg 1 PA BvD; GC

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG 3 PA; GC

meclizine oral tablet 12.5 mg, 25 mg 1 PA-HRM; GC; AGE (Max 64 Years)

ondansetron hcl (pf) injection solution 4 mg/2 ml 1 GC

ondansetron hcl (pf) injection syringe 4 mg/2 ml 1 GC

ondansetron hcl intravenous solution 2 mg/ml 1 GC

ondansetron hcl oral solution 4 mg/5 ml 1 PA BvD; GC

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 PA BvD; GC

ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 PA BvD; GC

PALONOSETRON INTRAVENOUS SOLUTION 0.25 MG/2 ML

3 GC

palonosetron intravenous solution 0.25 mg/5 ml 1 GC

palonosetron intravenous syringe 0.25 mg/5 ml 1 GC

phenadoz rectal suppository 12.5 mg, 25 mg 1 PA-HRM; GC; AGE (Max 64 Years)

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml), 5 mg/ml

1 GC

prochlorperazine maleate oral tablet 10 mg, 5 mg 1 GC

prochlorperazine rectal suppository 25 mg 1 GC

promethazine injection solution 25 mg/ml, 50 mg/ml 1 PA-HRM; GC; AGE (Max 64 Years)

promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA-HRM; GC; AGE (Max 64 Years)

promethazine rectal suppository 12.5 mg, 25 mg, 50 mg


promethegan rectal suppository 12.5 mg, 25 mg, 50 mg


SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR


scopolamine base transdermal patch 3 day 1 mg over 3 days


SUSTOL SUBCUTANEOUS LIQUID,EXTENDED RELEASE SYRING 10 MG/0.4 ML

3 GC

SYNDROS ORAL SOLUTION 5 MG/ML 3 PA; GC

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML 3 GC

TIGAN ORAL CAPSULE 300 MG 3 GC

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS





trimethobenzamide oral capsule 300 mg 1 GC

VARUBI INTRAVENOUS EMULSION 166.5 MG/92.5 ML

3 GC

VARUBI ORAL TABLET 90 MG 3 PA BvD; GC

ZOFRAN INTRAVENOUS SOLUTION 2 MG/ML 3 GC

ZOFRAN ODT ORAL TABLET,DISINTEGRATING 4 MG, 8 MG


ZOFRAN ORAL SOLUTION 4 MG/5 ML 3 PA BvD; GC

ZOFRAN ORAL TABLET 4 MG, 8 MG 4 PA BvD; NM; GC; NDS

ZUPLENZ ORAL FILM 4 MG, 8 MG 3 PA BvD; GC

Antiparasite Agents

Antiparasite Agents

albendazole oral tablet 200 mg 4 NM; GC; NDS

ALBENZA ORAL TABLET 200 MG 4 NM; GC; NDS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

4 NM; GC; NDS

ALINIA ORAL TABLET 500 MG 4 NM; GC; NDS

atovaquone oral suspension 750 mg/5 ml 4 NM; GC; NDS

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

1 GC

BILTRICIDE ORAL TABLET 600 MG 4 NM; GC; NDS

chloroquine phosphate oral tablet 250 mg, 500 mg 1 GC

COARTEM ORAL TABLET 20-120 MG 3 GC

DARAPRIM ORAL TABLET 25 MG 4 PA; NM; GC; NDS

EMVERM ORAL TABLET,CHEWABLE 100 MG 1 GC; QL (6 per 21 days)

hydroxychloroquine oral tablet 200 mg 1 GC

IMPAVIDO ORAL CAPSULE 50 MG 4 PA; NM; GC; NDS; QL (84 per 28 days)

ivermectin oral tablet 3 mg 1 GC

KRINTAFEL ORAL TABLET 150 MG 3 GC

MALARONE ORAL TABLET 250-100 MG 3 GC

MALARONE PEDIATRIC ORAL TABLET 62.5-25 MG 3 GC

mefloquine oral tablet 250 mg 1 GC

MEPRON ORAL SUSPENSION 750 MG/5 ML 4 NM; GC; NDS

NEBUPENT INHALATION RECON SOLN 300 MG 3 PA BvD; GC

paromomycin oral capsule 250 mg 1 GC

PENTAM INJECTION RECON SOLN 300 MG 3 GC

pentamidine injection recon soln 300 mg 1 GC

PLAQUENIL ORAL TABLET 200 MG 3 GC

praziquantel oral tablet 600 mg 1 GC

PRIMAQUINE ORAL TABLET 26.3 MG 1 GC

QUALAQUIN ORAL CAPSULE 324 MG 3 PA; GC; QL (42 per 7 days)

quinine sulfate oral capsule 324 mg 1 PA; GC; QL (42 per 7 days)




STROMECTOL ORAL TABLET 3 MG 3 GC

TINDAMAX ORAL TABLET 500 MG 3 GC

tinidazole oral tablet 250 mg, 500 mg 1 GC

Antiparkinsonian Agents

Antiparkinsonian Agents

amantadine hcl oral capsule 100 mg 1 GC

amantadine hcl oral solution 50 mg/5 ml 1 GC

amantadine hcl oral tablet 100 mg 1 GC

APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML 4 NM; GC; NDS; QL (60 per 30 days)

AZILECT ORAL TABLET 0.5 MG, 1 MG 3 GC

benztropine injection solution 2 mg/2 ml 4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PA-HRM; GC; AGE (Max 64 Years)

bromocriptine oral capsule 5 mg 1 GC

bromocriptine oral tablet 2.5 mg 1 GC

cabergoline oral tablet 0.5 mg 1 GC

carbidopa oral tablet 25 mg 4 NM; GC; NDS

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

1 GC

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

1 GC

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

1 GC

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

3 GC

COGENTIN INJECTION SOLUTION 2 MG/2 ML 3 PA-HRM; GC; AGE (Max 64 Years)

COMTAN ORAL TABLET 200 MG 4 NM; GC; NDS

ELDEPRYL ORAL CAPSULE 5 MG 3 GC

entacapone oral tablet 200 mg 1 GC

GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG


GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 68.5 MG


INBRIJA 42 MG INHALATION CAP 42 MG 4 PA; NM; GC; NDS; QL (300 per 30 days)

INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 MG


LODOSYN ORAL TABLET 25 MG 4 NM; GC; NDS

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

3 GC

MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

3 GC




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


NOURIANZ ORAL TABLET 20 MG, 40 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 129 MG, 193 MG, 258 MG


PARLODEL ORAL CAPSULE 5 MG 3 GC

PARLODEL ORAL TABLET 2.5 MG 3 GC

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

1 GC

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

1 GC

rasagiline oral tablet 0.5 mg, 1 mg 1 GC

REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG

3 GC

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

3 GC

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

1 GC

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

1 GC

RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG


selegiline hcl oral capsule 5 mg 1 GC

selegiline hcl oral tablet 5 mg 1 GC

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG

3 GC

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG

3 GC

STALEVO 100 ORAL TABLET 25-100-200 MG 4 NM; GC; NDS

STALEVO 150 ORAL TABLET 37.5-150-200 MG 4 NM; GC; NDS

TASMAR ORAL TABLET 100 MG 4 NM; GC; NDS

tolcapone oral tablet 100 mg 4 NM; GC; NDS

trihexyphenidyl oral elixir 0.4 mg/ml 1 PA-HRM; GC; AGE (Max 64 Years)

trihexyphenidyl oral tablet 2 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

XADAGO ORAL TABLET 100 MG, 50 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG

4 NM; GC; NDS

Antipsychotic Agents

Antipsychotic Agents

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG





ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG


ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 20 MG, 30 MG, 5 MG


ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 2 MG


ABILIFY ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG, 5 MG


ABILIFY ORAL TABLET 2 MG 4 NM; GC; NDS; QL (60 per 30 days)

ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED 10 MG

4 NM; GC; NDS

aripiprazole oral solution 1 mg/ml 1 GC; QL (900 per 30 days)

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


aripiprazole oral tablet 2 mg 1 GC; QL (60 per 30 days)

aripiprazole oral tablet,disintegrating 10 mg 1 ST; GC; QL (90 per 30 days)

aripiprazole oral tablet,disintegrating 15 mg 1 ST; GC; QL (60 per 30 days)

ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML

4 NM; GC; NDS; QL (4.8 per 365 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML


ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML






chlorpromazine injection solution 25 mg/ml 1 GC

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

1 GC

clozapine oral tablet 100 mg 1 GC; QL (270 per 30 days)

clozapine oral tablet 200 mg 1 GC; QL (135 per 30 days)

clozapine oral tablet 25 mg, 50 mg 1 GC; QL (90 per 30 days)

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


clozapine oral tablet,disintegrating 150 mg 1 ST; GC; QL (180 per 30 days)

clozapine oral tablet,disintegrating 200 mg 1 ST; GC; QL (120 per 30 days)

CLOZARIL ORAL TABLET 100 MG 4 NM; GC; NDS; QL (270 per 30 days)




CLOZARIL ORAL TABLET 25 MG 3 GC; QL (90 per 30 days)

FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 3 ST; GC; QL (60 per 30 days)

FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG 4 ST; NM; GC; NDS; QL (60 per 30 days)

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)


FAZACLO ORAL TABLET,DISINTEGRATING 100 MG 4 ST; NM; GC; NDS; QL (90 per 30 days)

FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG, 25 MG




fluphenazine decanoate injection solution 25 mg/ml 1 GC

fluphenazine hcl injection solution 2.5 mg/ml 1 GC

fluphenazine hcl oral concentrate 5 mg/ml 1 GC

fluphenazine hcl oral elixir 2.5 mg/5 ml 1 GC

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

GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)


GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG


HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

3 GC

HALDOL INJECTION SOLUTION 5 MG/ML 3 GC

haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml (1 ml), 50 mg/ml

1 GC

haloperidol lactate injection solution 5 mg/ml 1 GC

haloperidol lactate intramuscular syringe 5 mg/ml 1 GC

haloperidol lactate oral concentrate 2 mg/ml 1 GC

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1 GC

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


INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML











INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML








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


LATUDA ORAL TABLET 80 MG 2 GC; QL (60 per 30 days)

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1 GC

molindone oral tablet 10 mg 1 GC; QL (240 per 30 days)



NUPLAZID ORAL CAPSULE 34 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

NUPLAZID ORAL TABLET 10 MG 4 PA NSO; NM; GC; NDS; QL (30 per 30 days)

NUPLAZID ORAL TABLET 17 MG 4 PA NSO; NM; GC; NDS; QL (60 per 30 days)

olanzapine intramuscular recon soln 10 mg 1 GC; QL (30 per 30 days)

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


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


ORAP ORAL TABLET 1 MG, 2 MG 3 GC

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6 mg 4 NM; GC; NDS; QL (60 per 30 days)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 GC

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 120 MG, 90 MG


pimozide oral tablet 1 mg, 2 mg 1 GC

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg


quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 50 mg


quetiapine oral tablet extended release 24 hr 300 mg, 400 mg


REXULTI ORAL TABLET 0.25 MG 4 ST; NM; GC; NDS; QL (120 per 30 days)

REXULTI ORAL TABLET 0.5 MG 4 ST; NM; GC; NDS; QL (60 per 30 days)

REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG 4 ST; NM; GC; NDS; QL (30 per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML





RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML, 50 MG/2 ML


RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG


RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 3 MG, 4 MG


RISPERDAL ORAL SOLUTION 1 MG/ML 3 GC; QL (480 per 30 days)

RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG 3 GC; QL (60 per 30 days)

RISPERDAL ORAL TABLET 2 MG, 3 MG, 4 MG 4 NM; GC; NDS; QL (60 per 30 days)

risperidone oral solution 1 mg/ml 1 GC; QL (480 per 30 days)

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


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


risperidone oral tablet,disintegrating 3 mg, 4 mg 1 GC; QL (120 per 30 days)

SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG


SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 50 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG


thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 GC

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 GC

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 GC

VERSACLOZ ORAL SUSPENSION 50 MG/ML 4 ST; NM; GC; NDS; QL (540 per 30 days)

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG


VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)


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


ZYPREXA INTRAMUSCULAR RECON SOLN 10 MG 3 GC; QL (30 per 30 days)

ZYPREXA ORAL TABLET 10 MG, 15 MG, 20 MG 4 NM; GC; NDS; QL (30 per 30 days)

ZYPREXA ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 3 GC; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG









ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10 MG, 5 MG


ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 15 MG, 20 MG


Antivirals (Systemic)

Antiretrovirals

abacavir oral solution 20 mg/ml 1 GC

abacavir oral tablet 300 mg 1 GC

abacavir-lamivudine oral tablet 600-300 mg 1 GC

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

4 NM; GC; NDS

APTIVUS ORAL CAPSULE 250 MG 4 NM; GC; NDS

APTIVUS ORAL SOLUTION 100 MG/ML 4 NM; GC; NDS

atazanavir oral capsule 150 mg, 200 mg, 300 mg 4 NM; GC; NDS

ATRIPLA ORAL TABLET 600-200-300 MG 4 NM; GC; NDS

BIKTARVY ORAL TABLET 50-200-25 MG 4 NM; GC; NDS

CIMDUO ORAL TABLET 300-300 MG 4 NM; GC; NDS

COMBIVIR ORAL TABLET 150-300 MG 4 NM; GC; NDS

COMPLERA ORAL TABLET 200-25-300 MG 4 NM; GC; NDS

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 3 GC

DELSTRIGO ORAL TABLET 100-300-300 MG 4 NM; GC; NDS

DESCOVY ORAL TABLET 200-25 MG 4 NM; GC; NDS

didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg

1 GC

DOVATO ORAL TABLET 50-300 MG 4 NM; GC; NDS

EDURANT ORAL TABLET 25 MG 4 NM; GC; NDS

efavirenz oral capsule 200 mg 4 NM; GC; NDS

efavirenz oral capsule 50 mg 1 GC

efavirenz oral tablet 600 mg 4 NM; GC; NDS

EMTRIVA ORAL CAPSULE 200 MG 3 GC

EMTRIVA ORAL SOLUTION 10 MG/ML 3 GC

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)

3 GC

EPIVIR HBV ORAL TABLET 100 MG 3 GC

EPIVIR ORAL SOLUTION 10 MG/ML 3 GC

EPIVIR ORAL TABLET 150 MG, 300 MG 3 GC

EPZICOM ORAL TABLET 600-300 MG 4 NM; GC; NDS

EVOTAZ ORAL TABLET 300-150 MG 4 NM; GC; NDS

fosamprenavir oral tablet 700 mg 4 NM; GC; NDS

FUZEON SUBCUTANEOUS RECON SOLN 90 MG 4 NM; GC; NDS

GENVOYA ORAL TABLET 150-150-200-10 MG 4 NM; GC; NDS

INTELENCE ORAL TABLET 100 MG, 200 MG 4 NM; GC; NDS

INTELENCE ORAL TABLET 25 MG 3 GC




INVIRASE ORAL CAPSULE 200 MG 4 NM; GC; NDS

INVIRASE ORAL TABLET 500 MG 4 NM; GC; NDS

ISENTRESS HD ORAL TABLET 600 MG 4 NM; GC; NDS

ISENTRESS ORAL POWDER IN PACKET 100 MG 3 GC

ISENTRESS ORAL TABLET 400 MG 4 NM; GC; NDS

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG

3 GC

JULUCA ORAL TABLET 50-25 MG 4 NM; GC; NDS

KALETRA ORAL SOLUTION 400-100 MG/5 ML 4 NM; GC; NDS

KALETRA ORAL TABLET 100-25 MG 3 GC

KALETRA ORAL TABLET 200-50 MG 4 NM; GC; NDS

lamivudine oral solution 10 mg/ml 1 GC

lamivudine oral tablet 100 mg, 150 mg, 300 mg 1 GC

lamivudine-zidovudine oral tablet 150-300 mg 1 GC

LEXIVA ORAL SUSPENSION 50 MG/ML 3 GC

LEXIVA ORAL TABLET 700 MG 4 NM; GC; NDS

lopinavir-ritonavir oral solution 400-100 mg/5 ml 4 NM; GC; NDS

nevirapine oral suspension 50 mg/5 ml 2 GC

nevirapine oral tablet 200 mg 1 GC

nevirapine oral tablet extended release 24 hr 100 mg, 400 mg

1 GC

NORVIR ORAL CAPSULE 100 MG 3 GC

NORVIR ORAL POWDER IN PACKET 100 MG 3 GC

NORVIR ORAL SOLUTION 80 MG/ML 3 GC

NORVIR ORAL TABLET 100 MG 3 GC

ODEFSEY ORAL TABLET 200-25-25 MG 4 NM; GC; NDS

PIFELTRO ORAL TABLET 100 MG 4 NM; GC; NDS

PREZCOBIX ORAL TABLET 800-150 MG-MG 4 NM; GC; NDS

PREZISTA ORAL SUSPENSION 100 MG/ML 4 NM; GC; NDS

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

4 NM; GC; NDS

RESCRIPTOR ORAL TABLET 200 MG 3 GC

RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG

3 GC

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 3 GC

RETROVIR ORAL CAPSULE 100 MG 3 GC

RETROVIR ORAL SYRUP 10 MG/ML 3 GC

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

4 NM; GC; NDS

REYATAZ ORAL POWDER IN PACKET 50 MG 4 NM; GC; NDS

ritonavir oral tablet 100 mg 1 GC

SELZENTRY ORAL SOLUTION 20 MG/ML 3 GC

SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG 4 NM; GC; NDS




SELZENTRY ORAL TABLET 25 MG 3 GC

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 GC

stavudine oral recon soln 1 mg/ml 1 GC

STRIBILD ORAL TABLET 150-150-200-300 MG 4 NM; GC; NDS

SUSTIVA ORAL CAPSULE 200 MG 4 NM; GC; NDS

SUSTIVA ORAL CAPSULE 50 MG 3 GC

SUSTIVA ORAL TABLET 600 MG 4 NM; GC; NDS

SYMFI LO ORAL TABLET 400-300-300 MG 4 NM; GC; NDS

SYMFI ORAL TABLET 600-300-300 MG 4 NM; GC; NDS

SYMTUZA ORAL TABLET 800-150-200-10 MG 4 NM; GC; NDS

TEMIXYS ORAL TABLET 300-300 MG 4 NM; GC; NDS

tenofovir disoproxil fumarate oral tablet 300 mg 4 NM; GC; NDS

TIVICAY ORAL TABLET 10 MG 3 GC

TIVICAY ORAL TABLET 25 MG, 50 MG 4 NM; GC; NDS

TRIUMEQ ORAL TABLET 600-50-300 MG 4 NM; GC; NDS

TRIZIVIR ORAL TABLET 300-150-300 MG 4 NM; GC; NDS

TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML)

4 NM; GC; NDS

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

4 NM; GC; NDS

VEMLIDY ORAL TABLET 25 MG 4 NM; GC; NDS; QL (30 per 30 days)

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)

3 GC

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG, 200 MG, 250 MG, 400 MG

3 GC

VIRACEPT ORAL TABLET 250 MG, 625 MG 4 NM; GC; NDS

VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 3 GC

VIRAMUNE ORAL TABLET 200 MG 3 GC

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

3 GC

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG

4 NM; GC; NDS

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)

4 NM; GC; NDS

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

4 NM; GC; NDS

ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG

3 GC

ZERIT ORAL RECON SOLN 1 MG/ML 3 GC

ZIAGEN ORAL SOLUTION 20 MG/ML 3 GC

ZIAGEN ORAL TABLET 300 MG 3 GC

zidovudine oral capsule 100 mg 1 GC




zidovudine oral syrup 10 mg/ml 1 GC

zidovudine oral tablet 300 mg 1 GC

Antivirals, Miscellaneous

FLUMADINE ORAL TABLET 100 MG 3 GC

foscarnet intravenous solution 24 mg/ml 1 PA BvD; GC

oseltamivir oral capsule 30 mg 1 GC; QL (84 per 180 days)



oseltamivir oral suspension for reconstitution 6 mg/ml 1 GC; QL (540 per 180 days)

PREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML


PREVYMIS INTRAVENOUS SOLUTION 480 MG/24 ML


PREVYMIS ORAL TABLET 240 MG, 480 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION

3 GC

rimantadine oral tablet 100 mg 1 GC

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML

4 PA; NM; GC; NDS

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



TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML


XOFLUZA ORAL TABLET 20 MG, 40 MG 3 GC; QL (4 per 180 days)

Hcv Antivirals

DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

EPCLUSA ORAL TABLET 400-100 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

HARVONI ORAL TABLET 45-200 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

HARVONI ORAL TABLET 90-400 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

ledipasvir-sofosbuvir oral tablet 90-400 mg 4 PA; NM; GC; NDS; QL (30 per 30 days)

MAVYRET ORAL TABLET 100-40 MG 4 PA; NM; GC; NDS; QL (84 per 28 days)

sofosbuvir-velpatasvir oral tablet 400-100 mg 4 PA; NM; GC; NDS; QL (28 per 28 days)

SOVALDI ORAL TABLET 200 MG, 400 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

TECHNIVIE ORAL TABLET 12.5-75-50 MG 4 PA; NM; GC; NDS; QL (56 per 28 days)

VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG


VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG-50 MG- 33.33 MG-200 MG


VOSEVI ORAL TABLET 400-100-100 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

ZEPATIER ORAL TABLET 50-100 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)




Interferons

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)


INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML


PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML

4 NM; GC; NDS

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

4 NM; GC; NDS

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML

4 NM; GC; NDS

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML 4 NM; GC; NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


Nucleosides And Nucleotides

acyclovir oral capsule 200 mg 1 GC

acyclovir oral suspension 200 mg/5 ml 1 GC

acyclovir oral tablet 400 mg, 800 mg 1 GC

acyclovir sodium intravenous recon soln 500 mg 4 PA BvD; NM; GC; NDS

acyclovir sodium intravenous solution 50 mg/ml 1 PA BvD; GC

adefovir oral tablet 10 mg 4 NM; GC; NDS

BARACLUDE ORAL SOLUTION 0.05 MG/ML 4 NM; GC; NDS

BARACLUDE ORAL TABLET 0.5 MG, 1 MG 4 NM; GC; NDS

cidofovir intravenous solution 75 mg/ml 4 NM; GC; NDS

CYTOVENE INTRAVENOUS RECON SOLN 500 MG 3 PA BvD; GC

entecavir oral tablet 0.5 mg, 1 mg 4 NM; GC; NDS

famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 GC

ganciclovir sodium intravenous recon soln 500 mg 1 PA BvD; GC

ganciclovir sodium intravenous solution 50 mg/ml 1 PA BvD; GC

HEPSERA ORAL TABLET 10 MG 4 NM; GC; NDS

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (7)- 400 MG (7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7)

4 NM; GC; NDS

REBETOL ORAL SOLUTION 40 MG/ML 3 GC

ribasphere oral capsule 200 mg 1 GC

ribasphere oral tablet 200 mg 1 GC

ribasphere oral tablet 400 mg, 600 mg 4 NM; GC; NDS

ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)

4 NM; GC; NDS

ribavirin inhalation recon soln 6 gram 4 PA BvD; NM; GC; NDS

ribavirin oral capsule 200 mg 1 GC




ribavirin oral tablet 200 mg 1 GC

valacyclovir oral tablet 1 gram, 500 mg 1 GC

VALCYTE ORAL RECON SOLN 50 MG/ML 4 NM; GC; NDS

VALCYTE ORAL TABLET 450 MG 4 NM; GC; NDS

valganciclovir oral recon soln 50 mg/ml 1 GC

valganciclovir oral tablet 450 mg 4 NM; GC; NDS

VALTREX ORAL TABLET 1 GRAM, 500 MG 3 GC

VIRAZOLE INHALATION RECON SOLN 6 GRAM 4 PA BvD; NM; GC; NDS

ZOVIRAX ORAL CAPSULE 200 MG 3 GC

ZOVIRAX ORAL SUSPENSION 200 MG/5 ML 3 GC

ZOVIRAX ORAL TABLET 400 MG, 800 MG 3 GC

Blood Products/Modifiers/Volume Expanders

Anticoagulants

ARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML

4 NM; GC; NDS

BEVYXXA ORAL CAPSULE 40 MG, 80 MG 3 GC; QL (43 per 42 days)

CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT

4 NM; GC; NDS

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

3 GC

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 2 GC

ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS)

2 GC

enoxaparin subcutaneous solution 300 mg/3 ml 1 GC

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

1 GC

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

4 NM; GC; NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 1 GC

FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML


FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML


FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML















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

1 GC

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

1 GC

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

heparin, porcine (pf) injection solution 1,000 unit/ml 1 GC

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml 1 GC

heparin, porcine (pf) subcutaneous syringe 5,000 unit/0.5 ml

1 GC

IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG 4 PA; NM; GC; NDS; QL (24 per 28 days)

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1 GC

LOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML

3 GC

LOVENOX SUBCUTANEOUS SYRINGE 100 MG/ML, 120 MG/0.8 ML, 150 MG/ML, 80 MG/0.8 ML

4 NM; GC; NDS

LOVENOX SUBCUTANEOUS SYRINGE 30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6 ML

3 GC

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 3 ST; GC; QL (60 per 30 days)

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG 3 GC

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1 GC

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG

2 GC

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)

2 GC

Blood Formation Modifiers

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML


ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML


ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML

3 PA; GC; QL (1.6 per 28 days)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML


ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML











ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML


BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) 4 PA; NM; GC; NDS

CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)

4 PA; NM; GC; NDS

DOPTELET (10 TAB PACK) ORAL TABLET 20 MG 4 PA; NM; GC; NDS



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


EPOGEN INJECTION SOLUTION 20,000 UNIT/ML 4 PA; NM; GC; NDS; QL (12 per 28 days)

FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML 4 NM; GC; NDS

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

4 PA; NM; GC; NDS

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

4 PA; NM; GC; NDS

HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT

4 PA; NM; GC; NDS

LEUKINE INJECTION RECON SOLN 250 MCG 4 NM; GC; NDS

MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML


MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML)

4 NM; GC; NDS

MULPLETA ORAL TABLET 3 MG 4 PA; NM; GC; NDS

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML 4 NM; GC; NDS

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

4 PA; NM; GC; NDS

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

4 PA; NM; GC; NDS

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

4 PA; NM; GC; NDS

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

4 PA; NM; GC; NDS

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


PROCRIT INJECTION SOLUTION 20,000 UNIT/ML 4 PA; NM; GC; NDS; QL (12 per 28 days)

PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 4 PA; NM; GC; NDS; QL (6 per 28 days)

PROMACTA ORAL POWDER IN PACKET 12.5 MG 4 PA; NM; GC; NDS; QL (360 per 30 days)




PROMACTA ORAL TABLET 12.5 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

PROMACTA ORAL TABLET 25 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)



RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML


RETACRIT INJECTION SOLUTION 40,000 UNIT/ML 1 PA; GC; QL (6 per 28 days)

RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT

4 PA; NM; GC; NDS

UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML 4 NM; GC; NDS

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

4 NM; GC; NDS

Hematologic Agents, Miscellaneous

AGRYLIN ORAL CAPSULE 0.5 MG 3 GC

AMICAR ORAL SOLUTION 250 MG/ML (25 %) 4 NM; GC; NDS

AMICAR ORAL TABLET 1,000 MG, 500 MG 4 NM; GC; NDS

aminocaproic acid intravenous solution 250 mg/ml 1 GC

aminocaproic acid oral solution 250 mg/ml (25 %) 4 NM; GC; NDS

aminocaproic acid oral tablet 1,000 mg, 500 mg 4 NM; GC; NDS

anagrelide oral capsule 0.5 mg, 1 mg 1 GC

CYKLOKAPRON INTRAVENOUS SOLUTION 1,000 MG/10 ML (100 MG/ML)

3 GC

LYSTEDA ORAL TABLET 650 MG 3 GC; QL (30 per 30 days)

protamine intravenous solution 10 mg/ml 1 GC

SIKLOS ORAL TABLET 1,000 MG, 100 MG 3 PA; GC

TAVALISSE ORAL TABLET 100 MG, 150 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml)

1 GC

tranexamic acid oral tablet 650 mg 1 GC; QL (30 per 30 days)

Platelet-Aggregation Inhibitors

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR 25-200 MG


aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

1 GC

BRILINTA ORAL TABLET 60 MG, 90 MG 2 GC

cilostazol oral tablet 100 mg, 50 mg 1 GC

clopidogrel oral tablet 300 mg, 75 mg 1 GC

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA-HRM; GC; AGE (Max 64 Years)

EFFIENT ORAL TABLET 10 MG, 5 MG 3 GC; QL (30 per 30 days)

pentoxifylline oral tablet extended release 400 mg 1 GC

PLAVIX ORAL TABLET 300 MG, 75 MG 3 GC

prasugrel oral tablet 10 mg, 5 mg 1 GC; QL (30 per 30 days)

ticlopidine oral tablet 250 mg 1 GC




ZONTIVITY ORAL TABLET 2.08 MG 3 GC

Caloric Agents

Caloric Agents

AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 %

3 PA BvD; GC

AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 %

3 PA BvD; GC

AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 %

3 PA BvD; GC

AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC


3 PA BvD; GC


3 PA BvD; GC

AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 %

3 PA BvD; GC

AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 %

3 PA BvD; GC

AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 %

3 PA BvD; GC

AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 %

3 PA BvD; GC

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 %

3 PA BvD; GC

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 %

3 PA BvD; GC

CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 PA BvD; GC

CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 PA BvD; GC

CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

3 PA BvD; GC

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

3 PA BvD; GC

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

3 PA BvD; GC

CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

3 PA BvD; GC




CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

3 PA BvD; GC

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %

3 PA BvD; GC

CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

3 PA BvD; GC

CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

3 PA BvD; GC


3 PA BvD; GC


3 PA BvD; GC

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

3 PA BvD; GC

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 PA BvD; GC


3 PA BvD; GC


3 PA BvD; GC

dextrose 10 % in water (d10w) intravenous parenteral solution 10 %

3 PA BvD; GC


3 PA BvD; GC

dextrose 25 % in water (d25w) intravenous syringe 3 PA BvD; GC

dextrose 30 % in water (d30w) intravenous parenteral solution

3 PA BvD; GC


3 PA BvD; GC


1 GC

dextrose 5 % in water (d5w) intravenous piggyback 5 %

3 GC


3 PA BvD; GC

dextrose 50 % in water (d50w) intravenous syringe 3 PA BvD; GC


3 PA BvD; GC

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 %

3 PA BvD; GC

FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC

HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 %

3 PA BvD; GC




INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % 3 PA BvD; GC

KABIVEN INTRAVENOUS EMULSION 3.31-9.8-3.9 % 3 PA BvD; GC

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 %

3 PA BvD; GC

NUTRILIPID INTRAVENOUS EMULSION 20 % 3 PA BvD; GC

OMEGAVEN INTRAVENOUS EMULSION 10 % 3 PA BvD; GC

PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 %

3 PA BvD; GC

PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 %

3 PA BvD; GC

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

3 PA BvD; GC

smoflipid intravenous emulsion 20 % 3 PA BvD; GC

TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

3 PA BvD; GC

TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 %

3 PA BvD; GC

Cardiovascular Agents

Alpha-Adrenergic Agents

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 GC

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG

3 GC

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG 3 GC

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24 HR






clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 GC

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr


clonidine transdermal patch weekly 0.3 mg/24 hr 1 GC; QL (8 per 28 days)

clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg 1 GC

DIBENZYLINE ORAL CAPSULE 10 MG 4 NM; GC; NDS

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

guanfacine oral tablet 1 mg, 2 mg 1 PA-HRM; GC; AGE (Max 64 Years)

methyldopa oral tablet 250 mg, 500 mg 1 PA-HRM; GC; AGE (Max 64 Years)

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg


methyldopate intravenous solution 250 mg/5 ml 1 GC




midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1 GC

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG 3 GC

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG


phenoxybenzamine oral capsule 10 mg 4 NM; GC; NDS

phenylephrine hcl injection solution 10 mg/ml 1 GC

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

VAZCULEP INJECTION SOLUTION 10 MG/ML 3 GC

Angiotensin Ii Receptor Antagonists

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG

3 ST; GC

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3 ST; GC

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 ST; GC

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG 3 ST; GC

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

3 GC

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG 3 GC

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 GC

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

1 GC

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG 3 ST; GC

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

3 ST; GC

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

3 ST; GC

EDARBI ORAL TABLET 40 MG, 80 MG 2 GC

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

2 GC

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG


eprosartan oral tablet 600 mg 1 GC

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

3 ST; GC

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 GC

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

1 GC

losartan oral tablet 100 mg, 25 mg, 50 mg 1 GC

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1 GC

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

3 ST; GC

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG 3 ST; GC

olmesartan oral tablet 20 mg, 40 mg, 5 mg 1 GC




olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

1 GC

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

1 GC

telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 GC

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

1 GC

telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

1 GC

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

3 GC

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG


valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 GC

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1 GC

Angiotensin-Converting Enzyme Inhibitors

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

3 GC

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3 GC

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG

3 GC

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GC

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1 GC

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 GC

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1 GC

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1 GC

enalaprilat intravenous solution 1.25 mg/ml 1 GC

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1 GC

EPANED ORAL SOLUTION 1 MG/ML 3 ST; GC

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 GC

fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg

1 GC

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1 GC

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1 GC




LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3 GC

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG 3 GC

moexipril oral tablet 15 mg, 7.5 mg 1 GC

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1 GC

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 GC

PRINIVIL 5 MG TABLET 5 MG 3 GC

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG 3 GC

QBRELIS ORAL SOLUTION 1 MG/ML 3 ST; GC

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GC

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1 GC

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 GC

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 1-240 MG, 2-180 MG, 2-240 MG, 4-240 MG

3 GC

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 GC

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

1 GC

VASERETIC ORAL TABLET 10-25 MG 3 GC

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

4 NM; GC; NDS

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3 GC

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

3 GC

Antiarrhythmic Agents

amiodarone intravenous solution 50 mg/ml 1 GC

amiodarone intravenous syringe 150 mg/3 ml 1 GC

amiodarone oral tablet 100 mg, 200 mg, 400 mg 1 GC

disopyramide phosphate oral capsule 100 mg, 150 mg 1 PA-HRM; GC; AGE (Max 64 Years)

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 GC

flecainide oral tablet 100 mg, 150 mg, 50 mg 1 GC

lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %)

1 GC

mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 GC

MULTAQ ORAL TABLET 400 MG 2 GC

NEXTERONE INTRAVENOUS SOLUTION 150 MG/100 ML (1.5 MG/ML), 360 MG/200 ML (1.8 MG/ML)

3 GC

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG


NORPACE ORAL CAPSULE 100 MG, 150 MG 3 PA-HRM; GC; AGE (Max 64 Years)




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

procainamide injection solution 100 mg/ml, 500 mg/ml 1 GC

procainamide intravenous syringe 100 mg/ml 1 GC

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg

1 GC

propafenone oral tablet 150 mg, 225 mg, 300 mg 1 GC

quinidine gluconate oral tablet extended release 324 mg

1 GC

quinidine sulfate oral tablet 200 mg, 300 mg 1 GC

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR 225 MG, 325 MG, 425 MG

4 NM; GC; NDS

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3 GC

XYLOCAINE-MPF 2% VIAL 25'S,SDV, LATEX-FREE 20 MG/ML (2 %)

3 GC

Beta-Adrenergic Blocking Agents

acebutolol oral capsule 200 mg, 400 mg 1 GC

atenolol oral tablet 100 mg, 25 mg, 50 mg 1 GC

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

1 GC

BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG

3 GC

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG 3 GC

betaxolol oral tablet 10 mg, 20 mg 1 GC

bisoprolol fumarate oral tablet 10 mg, 5 mg 1 GC

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1 GC

BREVIBLOC IN NACL (ISO-OSM) INTRAVENOUS PARENTERAL SOLUTION 2,000 MG/100 ML, 2,500 MG/250 ML (10 MG/ML)

3 PA BvD; GC

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10 ML (10 MG/ML)

3 PA BvD; GC

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

2 GC

BYVALSON ORAL TABLET 5-80 MG 2 GC

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1 GC

carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg

1 GC

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG

3 GC

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG

3 GC

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG 3 GC




CORZIDE ORAL TABLET 40-5 MG, 80-5 MG 3 GC

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

3 GC

esmolol intravenous solution 100 mg/10 ml (10 mg/ml) 4 PA BvD; NM; GC; NDS

HEMANGEOL ORAL SOLUTION 4.28 MG/ML 3 GC

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 160 MG, 60 MG, 80 MG

3 GC

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG

3 GC

KAPSPARGO SPRINKLE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 200 MG, 25 MG, 50 MG

3 GC

labetalol intravenous solution 5 mg/ml 1 GC

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml) 1 GC

labetalol oral tablet 100 mg, 200 mg, 300 mg 1 GC

LEVATOL ORAL TABLET 20 MG 3 GC

LOPRESSOR HCT ORAL TABLET 50-25 MG 3 GC

LOPRESSOR INTRAVENOUS SOLUTION 5 MG/5 ML 3 GC

LOPRESSOR ORAL TABLET 100 MG, 50 MG 3 GC

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1 GC

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1 GC

metoprolol tartrate intravenous solution 5 mg/5 ml 1 GC

metoprolol tartrate intravenous syringe 5 mg/5 ml 1 GC

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1 GC

nadolol oral tablet 20 mg, 40 mg, 80 mg 1 GC

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

1 GC

pindolol oral tablet 10 mg, 5 mg 1 GC

propranolol intravenous solution 1 mg/ml 1 GC

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg

1 GC

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

1 GC

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1 GC

propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg

1 GC

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 GC

sotalol af oral tablet 120 mg, 160 mg, 80 mg 1 GC

SOTALOL INTRAVENOUS SOLUTION 150 MG/10 ML (15 MG/ML)

3 GC




sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 GC

SOTYLIZE ORAL SOLUTION 5 MG/ML 3 GC

TENORETIC 100 ORAL TABLET 100-25 MG 3 GC

TENORETIC 50 ORAL TABLET 50-25 MG 3 GC

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 GC

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG

3 GC

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG

3 GC

Calcium-Channel Blocking Agents

CALAN ORAL TABLET 120 MG, 80 MG 3 GC

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG

3 GC

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

4 NM; GC; NDS

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3 GC

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG 3 GC

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

1 GC

diltiazem hcl intravenous solution 5 mg/ml 1 GC

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

1 GC

diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg

1 GC

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

1 GC

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 GC

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg

1 GC

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

1 GC

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1 GC

TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3 GC

verapamil intravenous solution 2.5 mg/ml 1 GC

verapamil intravenous syringe 2.5 mg/ml 1 GC

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg

1 GC




verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

1 GC

verapamil oral capsule,ext rel. pellets 24 hr 360 mg 3 GC

verapamil oral tablet 120 mg, 40 mg, 80 mg 1 GC

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

1 GC

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 120 MG, 180 MG, 240 MG

3 GC

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG, 200 MG, 300 MG

3 GC

Cardiovascular Agents, Miscellaneous

ADRENALIN INJECTION SOLUTION 1 MG/ML, 1 MG/ML (1 ML)

3 GC

AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML 3 GC

AUVI-Q INJECTION AUTO-INJECTOR 0.1 MG/0.1 ML 4 NM; GC; NDS; QL (2 per 365 days)

AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML


CORLANOR ORAL SOLUTION 5 MG/5 ML 2 GC; QL (560 per 28 days)

CORLANOR ORAL TABLET 5 MG, 7.5 MG 2 GC; QL (60 per 30 days)

DEMSER ORAL CAPSULE 250 MG 4 NM; GC; NDS

digitek oral tablet 125 mcg (0.125 mg) 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 days); AGE (Max 64 Years)

digitek oral tablet 250 mcg (0.25 mg) 1 PA-HRM; GC; AGE (Max 64 Years)

digox oral tablet 125 mcg (0.125 mg) 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 days); AGE (Max 64 Years)

digox oral tablet 250 mcg (0.25 mg) 1 PA-HRM; GC; AGE (Max 64 Years)

digoxin 125 mcg tablet 125 mcg (0.125 mg) 1 PA-HRM; GC; QL (30 per 30 days); AGE (Max 64 Years)

digoxin injection syringe 250 mcg/ml (0.25 mg/ml) 1 PA-HRM; GC; AGE (Max 64 Years)

DIGOXIN ORAL SOLUTION 50 MCG/ML (0.05 MG/ML)


digoxin oral tablet 125 mcg (0.125 mg) 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 days); AGE (Max 64 Years)

digoxin oral tablet 250 mcg (0.25 mg) 1 PA-HRM; GC; AGE (Max 64 Years)

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


EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML





EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML


FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML 4 NM; GC; NDS; QL (18 per 30 days)

hydralazine injection solution 20 mg/ml 1 GC

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 GC

icatibant subcutaneous syringe 30 mg/3 ml 4 NM; GC; NDS; QL (18 per 30 days)

LANOXIN INJECTION SOLUTION 250 MCG/ML (0.25 MG/ML)


LANOXIN ORAL TABLET 125 MCG (0.125 MG) 3 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 days); AGE (Max 64 Years)

LANOXIN ORAL TABLET 187.5 MCG (0.1875 MG) 3 PA-HRM; GC; QL (30 per 30 days); AGE (Max 64 Years)

LANOXIN ORAL TABLET 250 MCG (0.25 MG) 3 PA-HRM; GC; AGE (Max 64 Years)

LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG) 3 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (60 per 30 days); AGE (Max 64 Years)

LANOXIN PEDIATRIC INJECTION SOLUTION 100 MCG/ML (0.1 MG/ML)


LEVOPHED (BITARTRATE) INTRAVENOUS SOLUTION 1 MG/ML

3 PA BvD; GC

milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml)


milrinone intravenous solution 1 mg/ml 4 PA BvD; NM; GC; NDS

norepinephrine bitartrate intravenous solution 1 mg/ml 1 PA BvD; GC

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG

3 GC

ranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg

1 GC

SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 MG/0.3 ML


VECAMYL ORAL TABLET 2.5 MG 4 NM; GC; NDS

VYNDAMAX ORAL CAPSULE 61 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

VYNDAQEL ORAL CAPSULE 20 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)

YOSPRALA ORAL TABLET,IR,DELAYED REL,BIPHASIC 325-40 MG, 81-40 MG


Dihydropyridines

ADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG, 90 MG

3 GC

afeditab cr oral tablet extended release 30 mg 1 GC

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 GC




amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1 GC

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

1 GC

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

1 GC

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

1 GC

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

3 GC

CARDENE IV IN SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 20 MG/200 ML, 40 MG/200 ML

3 GC

CARDENE IV INTRAVENOUS SOLUTION 25 MG/10 ML

3 GC

CLEVIPREX INTRAVENOUS EMULSION 25 MG/50 ML, 50 MG/100 ML

3 GC

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

3 ST; GC

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG

3 ST; GC

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg

1 GC

isradipine oral capsule 2.5 mg, 5 mg 1 GC

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG, 5-40 MG

3 GC

nicardipine intravenous solution 25 mg/10 ml 1 GC

nicardipine oral capsule 20 mg, 30 mg 1 GC

nifedipine oral capsule 10 mg, 20 mg 1 PA-HRM; GC; AGE (Max 64 Years)

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

1 GC

nifedipine oral tablet extended release 30 mg, 60 mg 1 GC

nifedipine oral tablet extended release 90 mg 1 GC

nimodipine oral capsule 30 mg 4 NM; GC; NDS

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

1 GC

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 GC

NYMALIZE 60 MG/20 ML SOLUTION 60 MG/20 ML 4 NM; GC; NDS

NYMALIZE ORAL SOLUTION 30 MG/10 ML 4 NM; GC; NDS

PROCARDIA ORAL CAPSULE 10 MG 3 PA-HRM; GC; AGE (Max 64 Years)

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG, 90 MG

3 GC




SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

3 GC

Diuretics

ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 GC

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 GC

amiloride oral tablet 5 mg 1 GC

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 GC

bumetanide injection solution 0.25 mg/ml 1 GC

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 GC

chlorothiazide oral tablet 250 mg, 500 mg 1 GC

chlorothiazide sodium intravenous recon soln 500 mg 1 GC

chlorthalidone oral tablet 25 mg, 50 mg 1 GC

DEMADEX ORAL TABLET 10 MG, 20 MG 3 GC

DIURIL IV INTRAVENOUS RECON SOLN 500 MG 3 GC

DIURIL ORAL SUSPENSION 250 MG/5 ML 3 GC

DYAZIDE ORAL CAPSULE 37.5-25 MG 3 GC

DYRENIUM ORAL CAPSULE 100 MG, 50 MG 3 GC

EDECRIN ORAL TABLET 25 MG 4 NM; GC; NDS

ethacrynate sodium intravenous recon soln 50 mg 1 GC

ethacrynic acid oral tablet 25 mg 4 NM; GC; NDS

furosemide injection solution 10 mg/ml 1 GC

furosemide injection syringe 10 mg/ml 1 GC

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

1 GC

furosemide oral tablet 20 mg, 40 mg, 80 mg 1 GC

hydrochlorothiazide oral capsule 12.5 mg 1 GC

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 GC

indapamide oral tablet 1.25 mg, 2.5 mg 1 GC

JYNARQUE ORAL TABLET 15 MG, 30 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)

JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)


LASIX ORAL TABLET 20 MG, 40 MG, 80 MG 3 GC

MAXZIDE ORAL TABLET 75-50 MG 3 GC

MAXZIDE-25MG ORAL TABLET 37.5-25 MG 3 GC

methyclothiazide oral tablet 5 mg 1 GC

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 GC

MICROZIDE ORAL CAPSULE 12.5 MG 3 GC

SAMSCA ORAL TABLET 15 MG 4 NM; GC; NDS; QL (30 per 30 days)

SAMSCA ORAL TABLET 30 MG 4 NM; GC; NDS; QL (60 per 30 days)

SODIUM EDECRIN INTRAVENOUS RECON SOLN 50 MG

3 GC

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 GC




spironolacton-hydrochlorothiaz oral tablet 25-25 mg 1 GC

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 GC

triamterene oral capsule 100 mg, 50 mg 1 GC

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg

1 GC

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg

1 GC

VAPRISOL IN 5 % DEXTROSE INTRAVENOUS SOLUTION 20 MG/100 ML

4 NM; GC; NDS

Dyslipidemics

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG

3 GC

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

1 GC

ANTARA ORAL CAPSULE 30 MG, 90 MG 3 GC

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 GC

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

3 GC

cholestyramine (with sugar) oral powder in packet 4 gram

1 GC

cholestyramine light oral powder 4 gram 1 GC

cholestyramine light packet 4 gram 1 GC

colesevelam oral tablet 625 mg 1 GC

COLESTID FLAVORED GRANULES 7.5 GRAM 3 GC

COLESTID ORAL PACKET 5 GRAM 3 GC

COLESTID ORAL TABLET 1 GRAM 3 GC

colestipol oral packet 5 gram 1 GC

colestipol oral tablet 1 gram 1 GC

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

3 GC

EZALLOR SPRINKLE ORAL CAPSULE, SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG


ezetimibe oral tablet 10 mg 1 GC

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

1 GC

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1 GC

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 1 GC

fenofibrate oral capsule 150 mg, 50 mg 1 GC

fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg 1 GC

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

1 GC

fenofibric acid oral tablet 105 mg, 35 mg 1 GC




FENOGLIDE ORAL TABLET 120 MG, 40 MG 3 GC

FIBRICOR ORAL TABLET 105 MG, 35 MG 3 GC

FLOLIPID ORAL SUSPENSION 20 MG/5 ML (4 MG/ML), 40 MG/5 ML (8 MG/ML)

3 ST; GC

fluvastatin oral capsule 20 mg, 40 mg 1 GC

fluvastatin oral tablet extended release 24 hr 80 mg 1 GC

gemfibrozil oral tablet 600 mg 1 GC

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


JUXTAPID ORAL CAPSULE 20 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)

JUXTAPID ORAL CAPSULE 5 MG 4 PA; NM; GC; NDS; QL (45 per 30 days)

KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML 4 PA; NM; GC; NDS; QL (4 per 28 days)

LESCOL ORAL CAPSULE 20 MG, 40 MG 3 GC

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR 80 MG

3 GC

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3 GC

LIPOFEN ORAL CAPSULE 150 MG, 50 MG 3 GC

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 2 GC; QL (30 per 30 days)

LOPID ORAL TABLET 600 MG 3 GC

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 GC

LOVAZA ORAL CAPSULE 1 GRAM 3 ST; GC; QL (120 per 30 days)

niacin oral tablet 500 mg 1 GC

niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg

1 GC

niacor oral tablet 500 mg 1 GC

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 500 MG, 750 MG

3 GC

omega-3 acid ethyl esters oral capsule 1 gram 1 GC; QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML


PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG 3 GC

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 GC

prevalite oral powder in packet 4 gram 1 GC

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML


rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GC

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GC




simvastatin oral tablet 80 mg 1 GC; QL (30 per 30 days)

TRICOR ORAL TABLET 145 MG, 48 MG 3 GC

TRIGLIDE ORAL TABLET 160 MG 3 GC

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC) 135 MG, 45 MG

3 GC

VASCEPA ORAL CAPSULE 0.5 GRAM 2 GC; QL (240 per 30 days)

VASCEPA ORAL CAPSULE 1 GRAM 2 GC; QL (120 per 30 days)

VYTORIN 10-10 ORAL TABLET 10-10 MG 3 GC




WELCHOL ORAL POWDER IN PACKET 3.75 GRAM 1 GC

WELCHOL ORAL TABLET 625 MG 1 GC

ZETIA ORAL TABLET 10 MG 3 GC

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG


ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG 3 ST; GC; QL (30 per 30 days)

Renin-Angiotensin-Aldosterone System Inhibitors

aliskiren oral tablet 150 mg, 300 mg 1 GC

CAROSPIR ORAL SUSPENSION 25 MG/5 ML 3 ST; GC

eplerenone oral tablet 25 mg, 50 mg 1 GC

INSPRA ORAL TABLET 25 MG, 50 MG 3 GC

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

2 ST; GC

TEKTURNA ORAL TABLET 150 MG, 300 MG 3 ST; GC

Vasodilators

BIDIL ORAL TABLET 20-37.5 MG 2 GC

DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG

3 GC

ISORDIL ORAL TABLET 40 MG 4 NM; GC; NDS

ISORDIL TITRADOSE ORAL TABLET 5 MG 3 GC

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

1 GC

isosorbide dinitrate oral tablet extended release 40 mg 1 GC

isosorbide mononitrate oral tablet 10 mg, 20 mg 1 GC

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

1 GC

minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr


minitran transdermal patch 24 hour 0.4 mg/hr 1 GC; QL (60 per 30 days)

minoxidil oral tablet 10 mg, 2.5 mg 1 GC

NITRO-BID TRANSDERMAL OINTMENT 2 % 1 GC




NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR

3 GC

nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml)

1 GC

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg 1 GC

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


nitroglycerin transdermal patch 24 hour 0.4 mg/hr 1 GC; QL (60 per 30 days)

nitroglycerin translingual spray,non-aerosol 400 mcg/spray

1 GC

NITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 MCG/SPRAY

3 GC

NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG

3 GC

PRESTALIA ORAL TABLET 14-10 MG, 7-5 MG 3 GC; QL (30 per 30 days)

PRESTALIA ORAL TABLET 3.5-2.5 MG 3 GC; QL (120 per 30 days)

Central Nervous System Agents

Central Nervous System Agents

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG


ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 20 MG, 25 MG, 30 MG


ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR 1.25 MG/ML


ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG


AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG


APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


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

1 GC

AUBAGIO ORAL TABLET 14 MG, 7 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

AUSTEDO ORAL TABLET 12 MG, 9 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)

AUSTEDO ORAL TABLET 6 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG

4 PA; NM; GC; NDS

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML

4 PA; NM; GC; NDS

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML

4 PA; NM; GC; NDS




BETASERON SUBCUTANEOUS KIT 0.3 MG 4 PA; NM; GC; NDS

CAFCIT INTRAVENOUS SOLUTION 60 MG/3 ML (20 MG/ML)

3 PA BvD; GC

caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml)

1 PA BvD; GC

caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) 1 GC

clonidine hcl oral tablet extended release 12 hr 0.1 mg 1 GC

CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 54 MG


CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 36 MG


COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML 4 PA; NM; GC; NDS; QL (30 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 4 PA; NM; GC; NDS; QL (12 per 28 days)

COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 8.6 MG


COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 25.9 MG


dalfampridine oral tablet extended release 12 hr 10 mg 4 PA; NM; GC; NDS; QL (60 per 30 days)

DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR


DESOXYN ORAL TABLET 5 MG 4 NM; GC; NDS; QL (150 per 30 days)

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 15 MG, 5 MG


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


dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg 1 GC; QL (60 per 30 days)

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


dextroamphetamine oral solution 5 mg/5 ml 1 GC; QL (1800 per 30 days)

dextroamphetamine oral tablet 10 mg, 5 mg 1 GC; QL (180 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg


dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg


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


DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML


EVEKEO ODT ORAL TABLET,DISINTEGRATING 10 MG


EVEKEO ODT ORAL TABLET,DISINTEGRATING 15 MG, 20 MG


EVEKEO ODT ORAL TABLET,DISINTEGRATING 5 MG





EXTAVIA SUBCUTANEOUS KIT 0.3 MG 4 PA; NM; GC; NDS

flumazenil intravenous solution 0.1 mg/ml 1 GC

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 GC; QL (60 per 30 days)

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG


GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

glatiramer subcutaneous syringe 20 mg/ml 4 PA; NM; GC; NDS; QL (30 per 30 days)

glatiramer subcutaneous syringe 40 mg/ml 4 PA; NM; GC; NDS; QL (12 per 28 days)

glatopa subcutaneous syringe 20 mg/ml 4 PA; NM; GC; NDS; QL (30 per 30 days)

glatopa subcutaneous syringe 40 mg/ml 4 PA; NM; GC; NDS; QL (12 per 28 days)

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

1 GC

INGREZZA INITIATION PACK ORAL CAPSULE,DOSE PACK 40 MG (7)- 80 MG (21)

4 PA; NM; GC; NDS

INGREZZA ORAL CAPSULE 40 MG, 80 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG

3 GC

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR 0.1 MG

3 GC

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML

4 PA; NM; GC; NDS

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1 GC

lithium carbonate oral tablet 300 mg 1 GC

lithium carbonate oral tablet extended release 300 mg, 450 mg

1 GC

lithium citrate oral solution 8 meq/5 ml 3 GC

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

3 GC

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG


LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG


MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG

















MAYZENT ORAL TABLET 0.25 MG 4 PA; NM; GC; NDS; QL (112 per 28 days)

MAYZENT ORAL TABLET 2 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

MAYZENT STARTER PACK ORAL TABLETS,DOSE PACK 0.25 MG (12 TABS)

3 PA; GC

metadate er oral tablet extended release 20 mg 1 GC; QL (90 per 30 days)

methamphetamine oral tablet 5 mg 4 NM; GC; NDS; QL (150 per 30 days)

METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML


methylphenidate er 18 mg tab 18 mg 1 GC; QL (30 per 30 days)




methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl oral capsule, er biphasic 30-70 30 mg


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


methylphenidate hcl oral capsule,er biphasic 50-50 30 mg


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


methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 GC; QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 10 mg, 20 mg


methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 54 mg, 72 mg


methylphenidate hcl oral tablet extended release 24hr 36 mg


methylphenidate hcl oral tablet,chewable 10 mg 1 GC; QL (180 per 30 days)

methylphenidate hcl oral tablet,chewable 2.5 mg, 5 mg 1 GC; QL (90 per 30 days)

methylphenidate la 20 mg cap 20 mg 1 GC; QL (30 per 30 days)

methylphenidate la 40 mg cap 40 mg 1 GC; QL (30 per 30 days)

MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG


NUEDEXTA ORAL CAPSULE 20-10 MG 2 PA; GC; QL (60 per 30 days)

OCREVUS INTRAVENOUS SOLUTION 30 MG/ML 4 PA; NM; GC; NDS; QL (20 per 180 days)

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

4 PA; NM; GC; NDS




PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

4 PA; NM; GC; NDS

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


QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)

3 GC

RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

4 PA; NM; GC; NDS

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

4 PA; NM; GC; NDS

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

4 PA; NM; GC; NDS

RILUTEK ORAL TABLET 50 MG 4 NM; GC; NDS

riluzole oral tablet 50 mg 1 GC

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 40 MG


RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 30 MG


RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG 3 GC; QL (90 per 30 days)

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


SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)


STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

3 GC

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG


tetrabenazine oral tablet 12.5 mg, 25 mg 4 PA; NM; GC; NDS; QL (112 per 28 days)

TIGLUTIK ORAL SUSPENSION 50 MG/10 ML 4 PA; NM; GC; NDS; QL (600 per 30 days)

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


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


XENAZINE ORAL TABLET 12.5 MG, 25 MG 4 PA; NM; GC; NDS; QL (112 per 28 days)

Contraceptives

Contraceptives

afirmelle oral tablet 0.1-20 mg-mcg 1 GC

altavera (28) oral tablet 0.15-0.03 mg 1 GC




alyacen 1/35 (28) oral tablet 1-35 mg-mcg 1 GC

alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 GC

amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)


amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)


apri oral tablet 0.15-0.03 mg 1 GC

aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg 1 GC

ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

1 GC

aubra oral tablet 0.1-20 mg-mcg 1 GC

aurovela 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 GC

aurovela 1/20 (21) oral tablet 1-20 mg-mcg 1 GC

aurovela 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC

aurovela fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

aviane oral tablet 0.1-20 mg-mcg 1 GC

ayuna oral tablet 0.15-0.03 mg 1 GC

azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

balziva (28) oral tablet 0.4-35 mg-mcg 1 GC

bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC

blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

briellyn oral tablet 0.4-35 mg-mcg 1 GC

camila oral tablet 0.35 mg 1 GC

caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg 1 GC

chateal (28) oral tablet 0.15-0.03 mg 1 GC

cryselle (28) oral tablet 0.3-30 mg-mcg 1 GC

cyclafem 1/35 (28) oral tablet 1-35 mg-mcg 1 GC

cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 GC

CYCLESSA (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

3 GC

cyred 28 day tablet outer 0.15-0.03 mg 1 GC

cyred eq oral tablet 0.15-0.03 mg 1 GC

dasetta 1/35 (28) oral tablet 1-35 mg-mcg 1 GC

dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 GC

daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)





deblitane oral tablet 0.35 mg 1 GC

delyla (28) oral tablet 0.1-20 mg-mcg 1 GC

desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

1 GC

desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg 1 GC

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

1 GC

elinest oral tablet 0.3-30 mg-mcg 1 GC

ELLA ORAL TABLET 30 MG 3 GC; QL (6 per 365 days)

emoquette oral tablet 0.15-0.03 mg 1 GC

enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) 1 GC

enskyce oral tablet 0.15-0.03 mg 1 GC

errin oral tablet 0.35 mg 1 GC

estarylla oral tablet 0.25-35 mg-mcg 1 GC

ESTROSTEP FE-28 ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

3 GC

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

1 GC

falmina (28) oral tablet 0.1-20 mg-mcg 1 GC

fayosim oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg


femynor oral tablet 0.25-35 mg-mcg 1 GC

GENERESS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

3 GC

gildagia oral tablet 0.4-35 mg-mcg 1 GC

hailey 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC

hailey oral tablet 1.5-30 mg-mcg 1 GC

heather oral tablet 0.35 mg 1 GC

incassia oral tablet 0.35 mg 1 GC

introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)


isibloom oral tablet 0.15-0.03 mg 1 GC

jasmiel (28) oral tablet 3-0.02 mg 1 GC

jencycla oral tablet 0.35 mg 1 GC

jolivette oral tablet 0.35 mg 3 GC

juleber oral tablet 0.15-0.03 mg 1 GC

junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 GC

junel 1/20 (21) oral tablet 1-20 mg-mcg 1 GC

junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC




kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

1 GC

kalliga oral tablet 0.15-0.03 mg 1 GC

kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

kelnor 1/35 (28) oral tablet 1-35 mg-mcg 1 GC

kelnor 1-50 oral tablet 1-50 mg-mcg 1 GC

kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

kurvelo (28) oral tablet 0.15-0.03 mg 1 GC

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7)


larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 GC

larin 1/20 (21) oral tablet 1-20 mg-mcg 1 GC

larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC

larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

larissia oral tablet 0.1-20 mg-mcg 1 GC

layolis fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

3 GC

leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 3 GC

lessina oral tablet 0.1-20 mg-mcg 1 GC

levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) 1 GC

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 90-20 mcg (28)

1 GC

levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg 1 GC; QL (91 per 84 days)

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)


levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 (5)/125-30(10)

1 GC

levora-28 oral tablet 0.15-0.03 mg 1 GC

lillow (28) oral tablet 0.15-0.03 mg 1 GC

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2)

3 GC

loryna (28) oral tablet 3-0.02 mg 1 GC

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)


low-ogestrel (28) oral tablet 0.3-30 mg-mcg 1 GC

lo-zumandimine (28) oral tablet 3-0.02 mg 1 GC

lutera (28) oral tablet 0.1-20 mg-mcg 1 GC

lyza oral tablet 0.35 mg 1 GC

marlissa (28) oral tablet 0.15-0.03 mg 1 GC




melodetta 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

1 GC

mibelas 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

1 GC

microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 GC

microgestin 1/20 (21) oral tablet 1-20 mg-mcg 1 GC

microgestin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

3 GC

microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

mili oral tablet 0.25-35 mg-mcg 1 GC

MINASTRIN 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

3 GC

mono-linyah oral tablet 0.25-35 mg-mcg 1 GC

mononessa (28) oral tablet 0.25-35 mg-mcg 3 GC

myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10) 1 GC

NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG

3 GC

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 GC

nikki (28) oral tablet 3-0.02 mg 1 GC

nora-be oral tablet 0.35 mg 3 GC

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4)

1 GC

norethindrone (contraceptive) oral tablet 0.35 mg 1 GC

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

1 GC

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4)

1 GC

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

1 GC

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1 GC

norlyda oral tablet 0.35 mg 1 GC

norlyroc oral tablet 0.35 mg 1 GC

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 GC

nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) 1 GC

nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 GC

nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 GC

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR 3 GC; QL (1 per 28 days)

ogestrel (28) oral tablet 0.5-50 mg-mcg 1 GC




orsythia oral tablet 0.1-20 mg-mcg 1 GC

ORTHO MICRONOR ORAL TABLET 0.35 MG 3 GC

ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

3 GC

ORTHO TRI-CYCLEN LO (28) ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

3 GC

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG

3 GC

ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG

3 GC

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

3 GC

philith oral tablet 0.4-35 mg-mcg 1 GC

pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg

1 GC

portia 28 oral tablet 0.15-0.03 mg 1 GC

previfem oral tablet 0.25-35 mg-mcg 1 GC

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG


quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)


reclipsen (28) oral tablet 0.15-0.03 mg 1 GC

SAFYRAL ORAL TABLET 3-0.03-0.451 MG (21) (7) 3 GC

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)


sharobel oral tablet 0.35 mg 1 GC

simliya (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

simpesse oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)


sprintec (28) oral tablet 0.25-35 mg-mcg 1 GC

sronyx oral tablet 0.1-20 mg-mcg 1 GC

syeda oral tablet 3-0.03 mg 1 GC

tarina 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 1 GC

tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1 GC

TAYTULLA ORAL CAPSULE 1 MG-20 MCG (24)/75 MG (4)

3 GC

tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) 1 GC

tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GC

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GC

tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) 1 GC




tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GC

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 GC

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 GC

tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 GC

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 GC

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GC

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

3 GC

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg 3 GC

TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

3 GC

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

1 GC

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

1 GC

trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) 1 GC

tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 GC

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GC

tulana oral tablet 0.35 mg 1 GC

tydemy oral tablet 3-0.03-0.451 mg (21) (7) 1 GC

velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-mcg

1 GC

vestura (28) oral tablet 3-0.02 mg 1 GC

vienva oral tablet 0.1-20 mg-mcg 1 GC

viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GC

vyfemla (28) oral tablet 0.4-35 mg-mcg 1 GC

vylibra oral tablet 0.25-35 mg-mcg 1 GC

wera (28) oral tablet 0.5-35 mg-mcg 1 GC

wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

1 GC

xulane transdermal patch weekly 150-35 mcg/24 hr 1 GC; QL (3 per 28 days)

YASMIN (28) ORAL TABLET 3-0.03 MG 3 GC

YAZ (28) ORAL TABLET 3-0.02 MG 3 GC

zarah oral tablet 3-0.03 mg 1 GC

zenchent (28) oral tablet 0.4-35 mg-mcg 1 GC

zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 GC

zovia 1/50e (28) oral tablet 1-50 mg-mcg 1 GC

zumandimine (28) oral tablet 3-0.03 mg 1 GC

Dental And Oral Agents

Dental And Oral Agents

cevimeline oral capsule 30 mg 1 GC

chlorhexidine gluconate mucous membrane mouthwash 0.12 %

1 GC




EVOXAC ORAL CAPSULE 30 MG 3 GC

oralone dental paste 0.1 % 1 GC

paroex oral rinse mucous membrane mouthwash 0.12 %

1 GC

periogard mucous membrane mouthwash 0.12 % 1 GC

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 GC

SALAGEN (PILOCARPINE) ORAL TABLET 5 MG, 7.5 MG

3 GC

triamcinolone acetonide dental paste 0.1 % 1 GC

Dermatological Agents

Dermatological Agents, Other

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

4 NM; GC; NDS

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 GC

acyclovir topical cream 5 % 1 GC; QL (5 per 4 days)

acyclovir topical ointment 5 % 1 GC; QL (30 per 30 days)

ACZONE TOPICAL GEL 5 % 3 GC

ACZONE TOPICAL GEL WITH PUMP 7.5 % 3 GC

ALCOHOL PADS TOPICAL PADS, MEDICATED 1 GC

ALDARA TOPICAL CREAM IN PACKET 5 % 3 PA NSO; GC; QL (24 per 30 days)

ammonium lactate topical cream 12 % 1 GC

ammonium lactate topical lotion 12 % 1 GC

amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 GC

azelaic acid topical gel 15 % 1 GC

AZELEX TOPICAL CREAM 20 % 3 GC

calcipotriene scalp solution 0.005 % 1 GC

calcipotriene topical cream 0.005 % 1 GC

calcipotriene topical ointment 0.005 % 1 GC

calcipotriene-betamethasone topical ointment 0.005-0.064 %

4 NM; GC; NDS

calcitrene topical ointment 0.005 % 1 GC

calcitriol topical ointment 3 mcg/gram 3 GC

CARAC TOPICAL CREAM 0.5 % 4 NM; GC; NDS

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 GC

CONDYLOX TOPICAL GEL 0.5 % 3 GC

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML

4 PA; NM; GC; NDS

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML

4 PA; NM; GC; NDS

dapsone topical gel 5 % 1 GC

DENAVIR TOPICAL CREAM 1 % 4 NM; GC; NDS

DOVONEX TOPICAL CREAM 0.005 % 3 GC

doxepin topical cream 5 % 4 PA; NM; GC; NDS; QL (90 per 30 days)




DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML

4 PA; NM; GC; NDS

EFUDEX TOPICAL CREAM 5 % 3 GC

ENSTILAR TOPICAL FOAM 0.005-0.064 % 4 NM; GC; NDS

FINACEA TOPICAL FOAM 15 % 3 GC

FINACEA TOPICAL GEL 15 % 3 GC

fluorouracil topical cream 0.5 % 4 NM; GC; NDS

fluorouracil topical cream 5 % 1 GC

fluorouracil topical solution 2 %, 5 % 1 GC

imiquimod topical cream in metered-dose pump 3.75 % 4 PA; NM; GC; NDS

imiquimod topical cream in packet 5 % 1 PA NSO; GC; QL (24 per 30 days)

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 GC

LEVULAN TOPICAL SOLUTION 20 % 3 GC

mafenide acetate topical packet 50 gram 1 GC

methoxsalen oral capsule,liqd-filled,rapid rel 10 mg 4 NM; GC; NDS

MIRVASO TOPICAL GEL WITH PUMP 0.33 % 3 GC

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 GC

OXSORALEN ULTRA ORAL CAPSULE,LIQD-FILLED,RAPID REL 10 MG

4 NM; GC; NDS

PANRETIN TOPICAL GEL 0.1 % 4 NM; GC; NDS

PICATO TOPICAL GEL 0.015 % 2 GC; QL (3 per 56 days)

PICATO TOPICAL GEL 0.05 % 2 GC; QL (2 per 56 days)

podofilox topical solution 0.5 % 1 GC

PRUDOXIN TOPICAL CREAM 5 % 4 PA; NM; GC; NDS; QL (90 per 30 days)

QBREXZA TOPICAL TOWELETTE 2.4 % 3 GC; QL (30 per 30 days)

REGRANEX TOPICAL GEL 0.01 % 4 PA; NM; GC; NDS; QL (30 per 30 days)

RHOFADE TOPICAL CREAM 1 % 3 GC

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 3 GC

SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML 4 PA; NM; GC; NDS

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

4 NM; GC; NDS

SORILUX TOPICAL FOAM 0.005 % 3 GC

SULFAMYLON TOPICAL CREAM 85 MG/G 3 GC

SULFAMYLON TOPICAL PACKET 50 GRAM 3 GC

TACLONEX TOPICAL OINTMENT 0.005-0.064 % 4 NM; GC; NDS

TACLONEX TOPICAL SUSPENSION 0.005-0.064 % 4 NM; GC; NDS

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

4 PA; NM; GC; NDS

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML

4 PA; NM; GC; NDS

TOLAK TOPICAL CREAM 4 % 3 GC

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML

4 PA; NM; GC; NDS




TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML 4 PA; NM; GC; NDS

UVADEX INJECTION SOLUTION 20 MCG/ML 3 GC

VALCHLOR TOPICAL GEL 0.016 % 4 NM; GC; NDS

VECTICAL TOPICAL OINTMENT 3 MCG/GRAM 4 NM; GC; NDS

VEREGEN TOPICAL OINTMENT 15 % 4 NM; GC; NDS

XERESE TOPICAL CREAM 5-1 % 4 NM; GC; NDS; QL (5 per 5 days)

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 GC

ZONALON TOPICAL CREAM 5 % 4 PA; NM; GC; NDS; QL (90 per 30 days)

ZOVIRAX TOPICAL CREAM 5 % 4 NM; GC; NDS; QL (5 per 4 days)

ZOVIRAX TOPICAL OINTMENT 5 % 4 NM; GC; NDS; QL (30 per 30 days)

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 %


ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 3.75 %

4 PA; NM; GC; NDS

Dermatological Antibacterials

ACANYA TOPICAL GEL WITH PUMP 1.2-2.5 % 3 GC

AKTIPAK TOPICAL GEL 3-5 % 3 GC; QL (60 per 30 days)

ALTABAX TOPICAL OINTMENT 1 % 3 GC

BACTROBAN NASAL NASAL OINTMENT 2 % 3 GC

BACTROBAN TOPICAL CREAM 2 % 3 GC

BENZACLIN GEL 1-5 % 3 GC

BENZACLIN PUMP TOPICAL GEL WITH PUMP 1-5 %

3 GC

BENZAMYCIN TOPICAL GEL 3-5 % 3 GC

CENTANY TOPICAL OINTMENT 2 % 3 GC

CLEOCIN T TOPICAL GEL 1 % 3 GC

CLEOCIN T TOPICAL LOTION 1 % 3 GC

CLEOCIN T TOPICAL SOLUTION 1 % 3 GC

CLINDAGEL TOPICAL GEL, ONCE DAILY 1 % 4 NM; GC; NDS

clindamycin phosphate topical foam 1 % 1 GC

clindamycin phosphate topical gel 1 % 1 GC

clindamycin phosphate topical lotion 1 % 1 GC

clindamycin phosphate topical solution 1 % 1 GC

clindamycin phosphate topical swab 1 % 1 GC

clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 %

1 GC

clindamycin-benzoyl peroxide topical gel with pump 1.2-2.5 %

3 GC

clindamycin-tretinoin topical gel 1.2-0.025 % 1 GC

CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 MG/G-UNIT/G-%

3 GC

CORTISPORIN TOPICAL OINTMENT 1 % 3 GC

ery pads topical swab 2 % 1 GC




ERYGEL TOPICAL GEL 2 % 3 GC

erythromycin with ethanol topical gel 2 % 1 GC

erythromycin with ethanol topical solution 2 % 1 GC

erythromycin with ethanol topical swab 2 % 1 GC

erythromycin-benzoyl peroxide topical gel 3-5 % 1 GC

EVOCLIN TOPICAL FOAM 1 % 3 GC

gentamicin topical cream 0.1 % 1 GC

gentamicin topical ointment 0.1 % 1 GC

KLARON TOPICAL SUSPENSION 10 % 3 GC

METROCREAM TOPICAL CREAM 0.75 % 3 GC

METROGEL TOPICAL GEL 1 % 3 GC

METROLOTION TOPICAL LOTION 0.75 % 3 GC

metronidazole topical cream 0.75 % 1 GC

metronidazole topical gel 0.75 %, 1 % 1 GC

metronidazole topical lotion 0.75 % 1 GC

mupirocin calcium topical cream 2 % 1 GC

mupirocin topical ointment 2 % 1 GC

neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml

1 GC

neuac topical gel 1.2 %(1 % base) -5 % 1 GC

NORITATE TOPICAL CREAM 1 % 4 NM; GC; NDS

ONEXTON TOPICAL GEL WITH PUMP 1.2 %(1 % BASE) -3.75 %

3 GC

rosadan topical cream 0.75 % 1 GC

selenium sulfide topical lotion 2.5 % 1 GC

silver sulfadiazine topical cream 1 % 3 GC

ssd topical cream 1 % 3 GC

sulfacetamide sodium (acne) topical suspension 10 % 1 GC

VELTIN TOPICAL GEL 1.2-0.025 % 3 GC

XEPI TOPICAL CREAM 1 % 3 GC

ZIANA TOPICAL GEL 1.2-0.025 % 3 GC

Dermatological Anti-Inflammatory Agents

ala-cort topical cream 1 %, 2.5 % 1 GC

ala-scalp topical lotion 2 % 1 GC

alclometasone topical cream 0.05 % 1 GC

alclometasone topical ointment 0.05 % 1 GC

amcinonide topical cream 0.1 % 1 GC

amcinonide topical lotion 0.1 % 1 GC

amcinonide topical ointment 0.1 % 1 GC

APEXICON E TOPICAL CREAM 0.05 % 4 NM; GC; NDS

betamethasone dipropionate topical cream 0.05 % 1 GC

betamethasone dipropionate topical lotion 0.05 % 1 GC




betamethasone dipropionate topical ointment 0.05 % 1 GC

betamethasone valerate topical cream 0.1 % 1 GC

betamethasone valerate topical foam 0.12 % 1 GC

betamethasone valerate topical lotion 0.1 % 1 GC

betamethasone valerate topical ointment 0.1 % 1 GC

betamethasone, augmented topical cream 0.05 % 1 GC

betamethasone, augmented topical gel 0.05 % 1 GC

betamethasone, augmented topical lotion 0.05 % 1 GC

betamethasone, augmented topical ointment 0.05 % 1 GC

BRYHALI TOPICAL LOTION 0.01 % 3 GC

CAPEX TOPICAL SHAMPOO 0.01 % 3 GC

clobetasol scalp solution 0.05 % 1 GC

clobetasol topical cream 0.05 % 1 GC

clobetasol topical foam 0.05 % 1 GC

clobetasol topical gel 0.05 % 1 GC

clobetasol topical lotion 0.05 % 1 GC

clobetasol topical ointment 0.05 % 1 GC

clobetasol topical shampoo 0.05 % 1 GC

clobetasol topical spray,non-aerosol 0.05 % 1 GC

clobetasol-emollient topical cream 0.05 % 1 GC

clobetasol-emollient topical foam 0.05 % 1 GC

CLOBEX TOPICAL LOTION 0.05 % 3 GC

CLOBEX TOPICAL SPRAY,NON-AEROSOL 0.05 % 3 GC

clocortolone pivalate topical cream 0.1 % 3 GC

CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2

3 GC

cormax scalp solution 0.05 % 1 GC

CUTIVATE TOPICAL CREAM 0.05 % 3 GC

CUTIVATE TOPICAL LOTION 0.05 % 3 GC

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL 0.01 %

3 GC

DERMATOP TOPICAL OINTMENT 0.1 % 3 GC

DESONATE TOPICAL GEL 0.05 % 3 GC

desonide topical cream 0.05 % 1 GC

desonide topical lotion 0.05 % 1 GC

desonide topical ointment 0.05 % 1 GC

desoximetasone topical cream 0.05 %, 0.25 % 1 GC

desoximetasone topical gel 0.05 % 1 GC

desoximetasone topical ointment 0.05 %, 0.25 % 1 GC

desoximetasone topical spray,non-aerosol 0.25 % 1 GC

diflorasone topical cream 0.05 % 1 GC

diflorasone topical ointment 0.05 % 1 GC

DIPROLENE TOPICAL OINTMENT 0.05 % 3 GC




DUOBRII TOPICAL LOTION 0.01-0.045 % 4 NM; GC; NDS; QL (200 per 28 days)

ELIDEL TOPICAL CREAM 1 % 3 GC

ELOCON TOPICAL CREAM 0.1 % 3 GC

ELOCON TOPICAL OINTMENT 0.1 % 3 GC

EPIFOAM TOPICAL FOAM 1-1 % 1 GC

EUCRISA TOPICAL OINTMENT 2 % 2 GC

fluocinolone 0.01% body oil 0.01 % 1 GC

fluocinolone and shower cap scalp oil 0.01 % 1 GC

fluocinolone topical cream 0.01 %, 0.025 % 1 GC

fluocinolone topical ointment 0.025 % 1 GC

fluocinolone topical solution 0.01 % 1 GC

fluocinonide topical cream 0.05 % 1 GC

fluocinonide topical cream 0.1 % 4 NM; GC; NDS

fluocinonide topical gel 0.05 % 1 GC

fluocinonide topical ointment 0.05 % 1 GC

fluocinonide topical solution 0.05 % 1 GC

fluocinonide-e topical cream 0.05 % 1 GC

flurandrenolide topical cream 0.05 % 1 GC

flurandrenolide topical lotion 0.05 % 1 GC

flurandrenolide topical ointment 0.05 % 1 GC

fluticasone propionate topical cream 0.05 % 1 GC

fluticasone propionate topical lotion 0.05 % 1 GC

fluticasone propionate topical ointment 0.005 % 1 GC

halcinonide topical cream 0.1 % 1 GC

halobetasol propionate topical cream 0.05 % 1 GC

halobetasol propionate topical foam 0.05 % 4 NM; GC; NDS

halobetasol propionate topical ointment 0.05 % 1 GC

HALOG TOPICAL CREAM 0.1 % 3 GC

HALOG TOPICAL OINTMENT 0.1 % 3 GC

hydrocort buty 0.1% lipo cream 0.1 % 1 GC

hydrocortisone butyrate topical cream 0.1 % 1 GC

hydrocortisone butyrate topical lotion 0.1 % 1 GC

hydrocortisone butyrate topical ointment 0.1 % 1 GC

hydrocortisone butyrate topical solution 0.1 % 1 GC

hydrocortisone topical cream 1 %, 2.5 % 1 GC

hydrocortisone topical lotion 2.5 % 1 GC

hydrocortisone topical ointment 1 %, 2.5 % 1 GC

hydrocortisone valerate topical cream 0.2 % 1 GC

hydrocortisone valerate topical ointment 0.2 % 1 GC

hydrocortisone-pramoxine rectal cream 1-1 % 1 GC

IMPOYZ TOPICAL CREAM 0.025 % 3 GC

KENALOG TOPICAL AEROSOL 0.147 MG/GRAM 3 GC




LEXETTE TOPICAL FOAM 0.05 % 4 NM; GC; NDS

LOCOID 0.1% CREAM 0.1 % 3 GC

LOCOID LIPOCREAM TOPICAL CREAM 0.1 % 3 GC

LOCOID TOPICAL LOTION 0.1 % 3 GC

LOCOID TOPICAL OINTMENT 0.1 % 3 GC

LOCOID TOPICAL SOLUTION 0.1 % 3 GC

LUXIQ TOPICAL FOAM 0.12 % 3 GC

mometasone topical cream 0.1 % 1 GC

mometasone topical ointment 0.1 % 1 GC

mometasone topical solution 0.1 % 1 GC

NOLIX TOPICAL CREAM 0.05 % 4 NM; GC; NDS

NOLIX TOPICAL LOTION 0.05 % 4 NM; GC; NDS

OLUX TOPICAL FOAM 0.05 % 3 GC

OLUX-E TOPICAL FOAM 0.05 % 3 GC

PANDEL TOPICAL CREAM 0.1 % 4 NM; GC; NDS

pimecrolimus topical cream 1 % 1 GC

prednicarbate topical cream 0.1 % 3 GC

prednicarbate topical ointment 0.1 % 1 GC

procto-med hc topical cream with perineal applicator 2.5 %

1 GC

procto-pak topical cream with perineal applicator 1 % 1 GC

proctosol hc topical cream with perineal applicator 2.5 %

1 GC

proctozone-hc topical cream with perineal applicator 2.5 %

1 GC

PROTOPIC TOPICAL OINTMENT 0.03 % 3 GC

PROTOPIC TOPICAL OINTMENT 0.1 % 4 NM; GC; NDS

SERNIVO TOPICAL SPRAY WITH PUMP 0.05 % 4 NM; GC; NDS

SYNALAR 0.025% CREAM KIT 0.025 % 3 GC

SYNALAR TOPICAL CREAM 0.025 % 3 GC

SYNALAR TOPICAL OINTMENT 0.025 % 3 GC

SYNALAR TOPICAL SOLUTION 0.01 % 3 GC

tacrolimus topical ointment 0.03 %, 0.1 % 1 GC

TOPICORT TOPICAL SPRAY,NON-AEROSOL 0.25 % 3 GC

triamcinolone acetonide topical aerosol 0.147 mg/gram 1 GC

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

1 GC

triamcinolone acetonide topical lotion 0.025 %, 0.1 % 1 GC

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

1 GC

trianex topical ointment 0.05 % 1 GC

triderm topical cream 0.1 %, 0.5 % 1 GC

ULTRAVATE TOPICAL CREAM 0.05 % 3 GC




ULTRAVATE TOPICAL LOTION 0.05 % 3 GC

ULTRAVATE TOPICAL OINTMENT 0.05 % 3 GC

VANOS TOPICAL CREAM 0.1 % 4 NM; GC; NDS

Dermatological Retinoids

adapalene 0.3% gel pump 0.3 % 1 GC

adapalene topical cream 0.1 % 1 GC

adapalene topical gel 0.1 %, 0.3 % 1 GC

ADAPALENE TOPICAL SOLUTION 0.1 % 1 GC

adapalene topical swab 0.1 % 4 NM; GC; NDS

adapalene-benzoyl peroxide topical gel with pump 0.1-2.5 %

1 GC

ALTRENO TOPICAL LOTION 0.05 % 3 PA; GC

ATRALIN TOPICAL GEL 0.05 % 3 PA; GC

DIFFERIN TOPICAL CREAM 0.1 % 3 GC

DIFFERIN TOPICAL GEL 0.1 % 3 GC

DIFFERIN TOPICAL GEL WITH PUMP 0.3 % 3 GC

DIFFERIN TOPICAL LOTION 0.1 % 3 GC

EPIDUO FORTE TOPICAL GEL WITH PUMP 0.3-2.5 %

3 GC

EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5 % 3 GC

FABIOR TOPICAL FOAM 0.1 % 3 GC

PLIXDA TOPICAL SWAB 0.1 % 1 GC

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.06 %

3 PA; GC

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %

4 PA; NM; GC; NDS

RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1 % 4 PA; NM; GC; NDS

RETIN-A TOPICAL CREAM 0.025 %, 0.05 %, 0.1 % 3 PA; GC

RETIN-A TOPICAL GEL 0.01 %, 0.025 % 3 PA; GC

tazarotene topical cream 0.1 % 1 GC

TAZORAC TOPICAL CREAM 0.05 %, 0.1 % 3 GC

TAZORAC TOPICAL GEL 0.05 %, 0.1 % 3 GC

tretinoin microspheres topical gel 0.04 %, 0.1 % 1 PA; GC

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1 PA; GC

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % 1 PA; GC

Scabicides And Pediculicides

CROTAN TOPICAL LOTION 10 % 3 GC

ELIMITE TOPICAL CREAM 5 % 3 GC

EURAX TOPICAL CREAM 10 % 3 GC

EURAX TOPICAL LOTION 10 % 3 GC

ivermectin topical cream 1 % 1 GC

lindane topical shampoo 1 % 1 GC

malathion topical lotion 0.5 % 1 GC




NATROBA TOPICAL SUSPENSION 0.9 % 3 GC

permethrin topical cream 5 % 1 GC

SKLICE TOPICAL LOTION 0.5 % 3 GC

SOOLANTRA TOPICAL CREAM 1 % 3 GC

spinosad topical suspension 0.9 % 3 GC

Devices

Devices

ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2"

1 GC

BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32"

1 GC

BD VEO INS 0.3 ML 6MMX31G (1/2) 0.3 ML 31 GAUGE X 15/64"

1 GC

BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64"

1 GC

BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64"

1 GC

GAUZE PAD TOPICAL BANDAGE 2 X 2 " 1 GC

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE

1 GC

PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" 1 GC

NEEDLES, INSULIN DISP., SAFETY 1 GC

Enzyme Replacement/Modifiers

Enzyme Replacement/Modifiers

ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML

4 NM; GC; NDS

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML

4 NM; GC; NDS

CERDELGA ORAL CAPSULE 84 MG 4 PA; NM; GC; NDS

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

4 NM; GC; NDS

CHENODAL ORAL TABLET 250 MG 4 PA; NM; GC; NDS

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

2 GC

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 3 GC

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML 4 NM; GC; NDS

ELELYSO INTRAVENOUS RECON SOLN 200 UNIT 4 NM; GC; NDS

ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG

4 NM; GC; NDS




FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG

4 NM; GC; NDS

GALAFOLD ORAL CAPSULE 123 MG 4 PA; NM; GC; NDS; QL (14 per 28 days)

KANUMA INTRAVENOUS SOLUTION 2 MG/ML 4 PA; NM; GC; NDS

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML 4 PA BvD; NM; GC; NDS

KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG

4 NM; GC; NDS

KUVAN ORAL TABLET,SOLUBLE 100 MG 4 NM; GC; NDS

LUMIZYME INTRAVENOUS RECON SOLN 50 MG 4 NM; GC; NDS

MEPSEVII INTRAVENOUS SOLUTION 2 MG/ML 4 PA; NM; GC; NDS

miglustat oral capsule 100 mg 4 NM; GC; NDS; QL (90 per 30 days)

NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML 4 NM; GC; NDS

nitisinone oral capsule 10 mg, 2 mg, 5 mg 4 PA; NM; GC; NDS

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG 4 PA; NM; GC; NDS

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

4 PA; NM; GC; NDS

ORFADIN ORAL SUSPENSION 4 MG/ML 4 PA; NM; GC; NDS

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML

4 PA; NM; GC; NDS

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

3 GC

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT

4 NM; GC; NDS

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT

3 GC

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG

4 NM; GC; NDS

PULMOZYME INHALATION SOLUTION 1 MG/ML 4 PA BvD; NM; GC; NDS

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5 ML (1.6 MG/ML)

4 PA; NM; GC; NDS

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML

4 PA; NM; GC; LA; NDS

SUCRAID ORAL SOLUTION 8,500 UNIT/ML 4 NM; GC; NDS

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML)

4 PA; NM; GC; NDS

VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT

3 GC

VPRIV INTRAVENOUS RECON SOLN 400 UNIT 4 NM; GC; NDS




XIAFLEX INJECTION RECON SOLN 0.9 MG 4 PA; NM; GC; NDS; QL (2 per 28 days)

ZAVESCA ORAL CAPSULE 100 MG 4 NM; GC; NDS; QL (90 per 30 days)

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000-47,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

2 GC

Eye, Ear, Nose, Throat Agents

Eye, Ear, Nose, Throat Agents, Miscellaneous

AKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 % 3 GC

alcaine ophthalmic (eye) drops 0.5 % 1 GC

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % 3 GC

apraclonidine ophthalmic (eye) drops 0.5 % 1 GC

ASTEPRO NASAL SPRAY,NON-AEROSOL 0.15 % (205.5 MCG)


atropine ophthalmic (eye) drops 1 % 3 GC

azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 GC; QL (30 per 25 days)

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) 1 GC; QL (30 per 25 days)

azelastine ophthalmic (eye) drops 0.05 % 1 GC

BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % 3 ST; GC

cromolyn ophthalmic (eye) drops 4 % 1 GC

cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % 1 GC

CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % 4 NM; GC; NDS

DYMISTA NASAL SPRAY,NON-AEROSOL 137-50 MCG/SPRAY


ELESTAT OPHTHALMIC (EYE) DROPS 0.05 % 3 ST; GC

EMADINE OPHTHALMIC (EYE) DROPS 0.05 % 3 ST; GC

epinastine ophthalmic (eye) drops 0.05 % 1 GC

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 % 3 GC

IOPIDINE OPHTHALMIC (EYE) DROPS 0.5 % 3 GC

ipratropium bromide nasal spray,non-aerosol 0.03 % 1 GC; QL (30 per 28 days)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)


ISOPTO ATROPINE OPHTHALMIC (EYE) DROPS 1 %

3 GC

LACRISERT OPHTHALMIC (EYE) INSERT 5 MG 3 GC

LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % 3 ST; GC

olopatadine nasal spray,non-aerosol 0.6 % 1 GC; QL (30.5 per 30 days)




olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % 1 GC

OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % (0.25 ML)

3 GC

OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % 4 PA; NM; GC; NDS; QL (56 per 28 days)

PATADAY OPHTHALMIC (EYE) DROPS 0.2 % 3 ST; GC

PATANASE NASAL SPRAY,NON-AEROSOL 0.6 % 3 GC; QL (30.5 per 30 days)

PATANOL OPHTHALMIC (EYE) DROPS 0.1 % 3 ST; GC

PAZEO OPHTHALMIC (EYE) DROPS 0.7 % 3 ST; GC

phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % 1 GC

proparacaine ophthalmic (eye) drops 0.5 % 1 GC

Eye, Ear, Nose, Throat Anti-Infectives Agents

acetic acid otic (ear) solution 2 % 1 GC

AZASITE OPHTHALMIC (EYE) DROPS 1 % 3 GC

bacitracin ophthalmic (eye) ointment 500 unit/gram 1 GC

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

1 GC

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 %

3 ST; GC

bleph-10 ophthalmic (eye) drops 10 % 1 GC

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 %

3 GC

CETRAXAL OTIC (EAR) DROPPERETTE 0.2 % 3 GC

CILOXAN OPHTHALMIC (EYE) DROPS 0.3 % 3 GC

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % 3 GC

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %

3 GC

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

2 GC

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1 GC

ciprofloxacin hcl otic (ear) dropperette 0.2 % 3 GC

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML

3 GC

CORTISPORIN-TC OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML

3 GC

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)

1 GC

gatifloxacin ophthalmic (eye) drops 0.5 % 1 GC

gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) 1 GC

gentamicin ophthalmic (eye) drops 0.3 % 1 GC

hydrocortisone-acetic acid otic (ear) drops 1-2 % 1 GC

levofloxacin ophthalmic (eye) drops 0.5 % 1 GC




MAXITROL OPHTHALMIC (EYE) DROPS,SUSPENSION 3.5MG/ML-10,000 UNIT/ML-0.1 %

3 GC

MAXITROL OPHTHALMIC (EYE) OINTMENT 3.5 MG/G-10,000 UNIT/G-0.1 %

3 GC

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 %

2 GC

moxifloxacin ophthalmic (eye) drops 0.5 % 1 GC

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 %

3 GC

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

1 GC

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

1 GC

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

1 GC

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

1 GC

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

1 GC

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

1 GC

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1 GC

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

1 GC

neo-polycin hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

1 GC

neo-polycin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

1 GC

OCUFLOX OPHTHALMIC (EYE) DROPS 0.3 % 3 GC

ofloxacin ophthalmic (eye) drops 0.3 % 1 GC

ofloxacin otic (ear) drops 0.3 % 1 GC

polycin ophthalmic (eye) ointment 500-10,000 unit/gram

1 GC

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

1 GC

POLYTRIM OPHTHALMIC (EYE) DROPS 10,000 UNIT- 1 MG/ML

3 GC

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-1 %

3 GC

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT 0.3-0.6 %

3 GC

sulfacetamide sodium ophthalmic (eye) drops 10 % 1 GC




sulfacetamide sodium ophthalmic (eye) ointment 10 % 1 GC

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)

1 GC

TOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.1 %

3 GC

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %

3 GC

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.05 %

3 GC

tobramycin ophthalmic (eye) drops 0.3 % 1 GC

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

1 GC

TOBREX OPHTHALMIC (EYE) DROPS 0.3 % 3 GC

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % 3 GC

trifluridine ophthalmic (eye) drops 1 % 1 GC

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % 3 GC

VIROPTIC OPHTHALMIC (EYE) DROPS 1 % 3 GC

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 3 GC

ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 %

2 GC

ZYMAXID OPHTHALMIC (EYE) DROPS 0.5 % 3 GC

Eye, Ear, Nose, Throat Anti-Inflammatory Agents

ACULAR LS OPHTHALMIC (EYE) DROPS 0.4 % 3 GC

ACULAR OPHTHALMIC (EYE) DROPS 0.5 % 3 GC

ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 %

3 GC

ALOCRIL OPHTHALMIC (EYE) DROPS 2 % 3 GC

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 %

2 ST; GC

BECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG (0.042 %)


bromfenac ophthalmic (eye) drops 0.09 % 1 GC

BROMSITE OPHTHALMIC (EYE) DROPS 0.075 % 2 GC

CEQUA OPHTHALMIC (EYE) DROPPERETTE 0.09 %


DERMOTIC OIL OTIC (EAR) DROPS 0.01 % 3 GC

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %

1 GC

diclofenac sodium ophthalmic (eye) drops 0.1 % 1 GC

DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % 2 GC

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 1 GC; QL (50 per 25 days)

fluocinolone acetonide oil otic (ear) drops 0.01 % 1 GC




fluorometholone ophthalmic (eye) drops,suspension 0.1 %

3 GC

flurbiprofen sodium ophthalmic (eye) drops 0.03 % 1 GC

fluticasone propionate nasal spray,suspension 50 mcg/actuation

1 GC

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

3 GC

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % 3 GC

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 %

2 GC

INVELTYS OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

2 GC

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 1 GC

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % 2 GC

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 %

3 GC

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % 2 GC

LOTEMAX SM OPHTHALMIC (EYE) DROPS,GEL 0.38 %

2 GC

loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 %

1 GC

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

3 GC

mometasone nasal spray,non-aerosol 50 mcg/actuation


NASONEX NASAL SPRAY,NON-AEROSOL 50 MCG/ACTUATION


NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

3 GC

OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG 3 ST; GC; QL (13 per 30 days)

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

3 GC

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

3 GC

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

1 GC

PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % 2 GC

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION


QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION


RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %





XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % 2 GC; QL (60 per 30 days)

ZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION


Gastrointestinal Agents

Antiulcer Agents And Acid Suppressants

ACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG


ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 10 MG, 5 MG


amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg

1 GC

CARAFATE ORAL SUSPENSION 100 MG/ML 3 GC

CARAFATE ORAL TABLET 1 GRAM 3 GC

cimetidine hcl oral solution 300 mg/5 ml 1 GC

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 GC

CYTOTEC ORAL TABLET 100 MCG, 200 MCG 3 GC

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG

2 ST; GC

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg

1 ST; GC

esomeprazole sodium intravenous recon soln 20 mg, 40 mg

1 GC

famotidine (pf) intravenous solution 20 mg/2 ml 1 GC

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml

1 GC

famotidine intravenous solution 10 mg/ml 1 GC

famotidine oral suspension 40 mg/5 ml (8 mg/ml) 1 GC

famotidine oral tablet 20 mg, 40 mg 1 GC

lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg

1 GC

lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg

1 GC

misoprostol oral tablet 100 mcg, 200 mcg 1 GC

NEXIUM IV INTRAVENOUS RECON SOLN 40 MG 3 GC

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 40 MG

3 ST; GC

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG

3 ST; GC

nizatidine oral capsule 150 mg, 300 mg 1 GC

nizatidine oral solution 150 mg/10 ml 1 GC




OMECLAMOX-PAK ORAL COMBO PACK 20 MG-500 MG- 500 MG (40)

3 GC

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg

1 GC

omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram, 40-1.1 mg-gram


omeprazole-sodium bicarbonate oral packet 20-1,680 mg, 40-1,680 mg


pantoprazole intravenous recon soln 40 mg 1 GC

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg

1 GC

PEPCID ORAL SUSPENSION 40 MG/5 ML (8 MG/ML) 3 GC

PREVACID ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG, 30 MG

3 ST; GC

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL 15 MG, 30 MG

3 ST; GC

PREVPAC ORAL COMBO PACK 500-500-30 MG 4 NM; GC; NDS

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 10 MG, 2.5 MG


PROTONIX INTRAVENOUS RECON SOLN 40 MG 3 GC

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET 40 MG


PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG, 40 MG


rabeprazole oral tablet,delayed release (dr/ec) 20 mg 1 ST; GC; QL (30 per 30 days)

ranitidine hcl injection solution 25 mg/ml, 50 mg/2 ml (25 mg/ml)

1 GC

ranitidine hcl oral capsule 150 mg, 300 mg 1 GC

ranitidine hcl oral syrup 15 mg/ml 1 GC

ranitidine hcl oral tablet 150 mg, 300 mg 1 GC

sucralfate oral tablet 1 gram 1 GC

ZANTAC INJECTION SOLUTION 25 MG/ML, 50 MG/2 ML (25 MG/ML)

3 GC

ZANTAC ORAL TABLET 150 MG, 300 MG 3 GC

ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM, 40-1.1 MG-GRAM


ZEGERID ORAL PACKET 20-1,680 MG, 40-1,680 MG 4 ST; NM; GC; NDS; QL (30 per 30 days)

Gastrointestinal Agents, Other

ACTIGALL ORAL CAPSULE 300 MG 3 GC

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 2 GC; QL (60 per 30 days)

BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML 3 GC

BUPHENYL ORAL POWDER 0.94 GRAM/GRAM 4 NM; GC; NDS

BUPHENYL ORAL TABLET 500 MG 4 NM; GC; NDS

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG 4 NM; GC; NDS




CHOLBAM ORAL CAPSULE 250 MG, 50 MG 4 NM; GC; NDS

constulose oral solution 10 gram/15 ml 1 GC

cromolyn oral concentrate 100 mg/5 ml 1 GC

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML) 3 GC

dicyclomine intramuscular solution 10 mg/ml 1 GC

dicyclomine oral capsule 10 mg 1 GC

dicyclomine oral solution 10 mg/5 ml 1 GC

dicyclomine oral tablet 20 mg 1 GC

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years)

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 PA-HRM; GC; AGE (Max 64 Years)

enulose oral solution 10 gram/15 ml 1 GC

GASTROCROM ORAL CONCENTRATE 100 MG/5 ML

4 NM; GC; NDS

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG 4 PA; NM; GC; NDS

generlac oral solution 10 gram/15 ml 1 GC

glycopyrrolate (pf) in water injection syringe 0.2 mg/ml 1 GC

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

1 GC

glycopyrrolate injection solution 0.2 mg/ml 1 GC

glycopyrrolate oral tablet 1 mg, 2 mg 1 GC

glycopyrrolate oral tablet 1.5 mg 4 NM; GC; NDS

kionex (with sorbitol) oral suspension 15-19.3 gram/60 ml

1 GC

lactulose oral solution 10 gram/15 ml 1 GC

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG


LOKELMA ORAL POWDER IN PACKET 10 GRAM, 5 GRAM


LOMOTIL ORAL TABLET 2.5-0.025 MG 3 PA-HRM; GC; AGE (Max 64 Years)

loperamide oral capsule 2 mg 1 GC

methscopolamine oral tablet 2.5 mg, 5 mg 1 GC

metoclopramide hcl injection solution 5 mg/ml 1 GC

metoclopramide hcl injection syringe 5 mg/ml 1 GC

metoclopramide hcl oral solution 5 mg/5 ml 1 GC

metoclopramide hcl oral tablet 10 mg, 5 mg 1 GC

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg

1 GC

MOTEGRITY ORAL TABLET 1 MG, 2 MG 3 ST; GC; QL (30 per 30 days)

MOTOFEN ORAL TABLET 1-0.025 MG 3 GC

MOVANTIK ORAL TABLET 12.5 MG, 25 MG 2 GC; QL (30 per 30 days)

MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG


NUTRESTORE ORAL POWDER IN PACKET 5 GRAM 4 NM; GC; NDS




OCALIVA ORAL TABLET 10 MG, 5 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

PYLERA ORAL CAPSULE 140-125-125 MG 4 NM; GC; NDS

RAVICTI ORAL LIQUID 1.1 GRAM/ML 4 PA; NM; GC; NDS

REGLAN ORAL TABLET 10 MG, 5 MG 3 GC

RELISTOR ORAL TABLET 150 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML


RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML


ROBINUL FORTE ORAL TABLET 2 MG 3 GC

ROBINUL INJECTION SOLUTION 0.2 MG/ML 3 GC

ROBINUL ORAL TABLET 1 MG 3 GC

sodium phenylbutyrate oral powder 0.94 gram/gram 4 NM; GC; NDS

sodium phenylbutyrate oral tablet 500 mg 4 NM; GC; NDS

sodium polystyrene sulfonate oral powder 1 GC

sps (with sorbitol) oral suspension 15-20 gram/60 ml 1 GC

sps 15 gm/60 ml suspension 15 gram/60 ml 1 GC

SYMPROIC ORAL TABLET 0.2 MG 3 ST; GC; QL (30 per 30 days)

TRULANCE ORAL TABLET 3 MG 3 GC

URSO 250 ORAL TABLET 250 MG 3 GC

URSO FORTE ORAL TABLET 500 MG 3 GC

ursodiol oral capsule 300 mg 1 GC

ursodiol oral tablet 250 mg, 500 mg 1 GC

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM


VIBERZI ORAL TABLET 100 MG, 75 MG 4 ST; NM; GC; NDS; QL (60 per 30 days)

XERMELO ORAL TABLET 250 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)

Laxatives

CLENPIQ ORAL SOLUTION 10 MG-3.5 GRAM -12 GRAM/160 ML

3 GC

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

3 GC

gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram 1 GC

gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram 1 GC

gavilyte-n oral recon soln 420 gram 1 GC

GIALAX ORAL KIT 17 GRAM/ SCOOP 1 GC

GOLYTELY ORAL POWDER IN PACKET 227.1-21.5-6.36 GRAM

3 GC

GOLYTELY ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM

3 GC

MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM

2 GC




NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN 420 GRAM

3 GC

OSMOPREP ORAL TABLET 1.5 GRAM 3 GC

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

1 GC

peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram

3 GC

peg-electrolyte soln oral recon soln 420 gram 1 GC

PLENVU ORAL POWDER IN PACKET, SEQUENTIAL 140-9-5.2 GRAM

3 GC

POLYETHYLENE GLYCOL 3350(BULK) POWDER 1 GC

PREPOPIK ORAL POWDER IN PACKET 10 MG-3.5 GRAM-12 GRAM

3 GC

SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5-3.13-1.6 GRAM

2 GC

trilyte with flavor packets oral recon soln 420 gram 1 GC

Phosphate Binders

AURYXIA ORAL TABLET 210 MG IRON 4 PA; NM; GC; NDS

calcium acetate oral capsule 667 mg 1 GC

calcium acetate oral tablet 667 mg 1 GC

eliphos oral tablet 667 mg 1 GC

FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG

4 NM; GC; NDS

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG

4 NM; GC; NDS

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

4 NM; GC; NDS

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML

3 GC

RENAGEL ORAL TABLET 400 MG, 800 MG 3 GC

RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM

4 NM; GC; NDS

RENVELA ORAL TABLET 800 MG 4 NM; GC; NDS

sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram

4 NM; GC; NDS

sevelamer carbonate oral tablet 800 mg 1 GC

sevelamer hcl oral tablet 400 mg, 800 mg 1 GC

VELPHORO ORAL TABLET,CHEWABLE 500 MG 2 GC

Genitourinary Agents

Antispasmodics, Urinary

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

1 GC




darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg

1 GC

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 2 MG, 4 MG

3 GC

DETROL ORAL TABLET 1 MG, 2 MG 3 GC

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG

3 GC

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG

3 GC

flavoxate oral tablet 100 mg 1 GC

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)


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

2 GC

oxybutynin chloride oral syrup 5 mg/5 ml 1 GC

oxybutynin chloride oral tablet 5 mg 1 GC

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg

1 GC

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 MG/24 HR


solifenacin oral tablet 10 mg, 5 mg 1 GC

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

1 GC

tolterodine oral tablet 1 mg, 2 mg 1 GC

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG

2 GC

trospium oral capsule,extended release 24hr 60 mg 1 GC

trospium oral tablet 20 mg 1 GC

VESICARE ORAL TABLET 10 MG, 5 MG 3 GC

Genitourinary Agents, Miscellaneous

alfuzosin oral tablet extended release 24 hr 10 mg 1 GC

AVODART ORAL CAPSULE 0.5 MG 3 GC

dutasteride oral capsule 0.5 mg 1 GC

dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg


finasteride oral tablet 5 mg 1 GC

FLOMAX ORAL CAPSULE 0.4 MG 3 GC

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG


RAPAFLO ORAL CAPSULE 4 MG, 8 MG 3 GC

silodosin oral capsule 4 mg, 8 mg 1 GC

tamsulosin oral capsule 0.4 mg 1 GC

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 GC




UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR 10 MG

3 GC

Heavy Metal Antagonists

Heavy Metal Antagonists

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 200 MG/ML

4 NM; GC; NDS

CHEMET ORAL CAPSULE 100 MG 4 NM; GC; NDS

clovique oral capsule 250 mg 4 PA; NM; GC; NDS; QL (240 per 30 days)

CUPRIMINE ORAL CAPSULE 250 MG 4 PA; NM; GC; NDS

deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg

4 PA; NM; GC; NDS

deferoxamine injection recon soln 2 gram, 500 mg 1 PA; GC

DEPEN TITRATABS ORAL TABLET 250 MG 4 PA; NM; GC; NDS

DESFERAL INJECTION RECON SOLN 2 GRAM, 500 MG

3 PA; GC

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

4 PA; NM; GC; NDS

FERRIPROX ORAL SOLUTION 100 MG/ML 4 PA; NM; GC; NDS

FERRIPROX ORAL TABLET 1,000 MG, 500 MG 4 PA; NM; GC; NDS

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG 4 PA; NM; GC; NDS

JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG

4 PA; NM; GC; NDS

penicillamine oral capsule 250 mg 4 PA; NM; GC; NDS

SYPRINE ORAL CAPSULE 250 MG 4 PA; NM; GC; NDS; QL (240 per 30 days)

trientine oral capsule 250 mg 4 PA; NM; GC; NDS; QL (240 per 30 days)

Hormonal Agents, Stimulant/Replacement/Modifying

Androgens

ANADROL-50 ORAL TABLET 50 MG 4 PA; NM; GC; NDS

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


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


ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)


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


ANDROID ORAL CAPSULE 10 MG 4 NM; GC; NDS

AVEED INTRAMUSCULAR SOLUTION 750 MG/3 ML (250 MG/ML)

3 PA; GC

AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 30 MG/ACTUATION (1.5 ML)





danazol oral capsule 100 mg, 200 mg, 50 mg 1 GC

methyltestosterone oral capsule 10 mg 4 NM; GC; NDS

NATESTO NASAL GEL IN METERED-DOSE PUMP 5.5 MG/0.122 GRAM/ACTUATION

3 PA; GC

oxandrolone oral tablet 10 mg 4 NM; GC; NDS

oxandrolone oral tablet 2.5 mg 1 GC

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR 30 MG


TESTIM TRANSDERMAL GEL 50 MG/5 GRAM (1 %) 3 PA; GC; QL (300 per 30 days)

testosterone cypionate intramuscular oil 100 mg/ml 1 PA; GC

testosterone cypionate intramuscular oil 200 mg/ml 1 PA; GC

testosterone enanthate intramuscular oil 200 mg/ml 1 PA; GC; QL (5 per 28 days)

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation


testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)


testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %)


testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)


testosterone transdermal gel in packet 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)


testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml)


TESTRED ORAL CAPSULE 10 MG 4 NM; GC; NDS

VOGELXO 50 MG/5 GRAM GEL OUTER 50 MG/5 GRAM (1 %)


VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %)


VOGELXO TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)


XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG/0.5 ML, 50 MG/0.5 ML, 75 MG/0.5 ML


Estrogens And Antiestrogens

ACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG 3 PA-HRM; GC; AGE (Max 64 Years)

ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 PA-HRM; GC; AGE (Max 64 Years)

BIJUVA ORAL CAPSULE 1-100 MG 3 PA-HRM; GC; AGE (Max 64 Years)

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/24 HR





CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.06 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR


DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 MG/ML, 40 MG/ML

3 GC

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML 1 GC

DIVIGEL TRANSDERMAL GEL IN PACKET 1 MG/GRAM (0.1 %)


dotti transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr


DUAVEE ORAL TABLET 0.45-20 MG 2 PA-HRM; GC; AGE (Max 64 Years)

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION


estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA-HRM; GC; AGE (Max 64 Years)

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


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


estradiol vaginal cream 0.01 % (0.1 mg/gram) 1 GC

estradiol vaginal tablet 10 mcg 1 GC; QL (18 per 28 days)

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 GC

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg


ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) 3 GC; QL (1 per 84 days)

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 PA-HRM; GC; AGE (Max 64 Years)

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%)

3 PA-HRM; GC; QL (8.1 per 25 days); AGE (Max 64 Years)

EVISTA ORAL TABLET 60 MG 3 GC

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG


FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR


fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 PA-HRM; GC; AGE (Max 64 Years)

IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 4 MCG


IMVEXXY STARTER PACK VAGINAL INSERT, DOSE PACK 10 MCG, 4 MCG


INTRAROSA VAGINAL INSERT 6.5 MG 3 GC




JEVANTIQUE LO ORAL TABLET 0.5-2.5 MG-MCG 3 PA-HRM; GC; AGE (Max 64 Years)

jinteli oral tablet 1-5 mg-mcg 1 PA-HRM; GC; AGE (Max 64 Years)

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


MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24 HR


mimvey lo oral tablet 0.5-0.1 mg 1 PA-HRM; GC; AGE (Max 64 Years)

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg


OSPHENA ORAL TABLET 60 MG 3 GC

PREMARIN INJECTION RECON SOLN 25 MG 2 GC

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


PREMARIN VAGINAL CREAM 0.625 MG/GRAM 2 GC

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)


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


raloxifene oral tablet 60 mg 1 GC

VAGIFEM VAGINAL TABLET 10 MCG 3 GC; QL (18 per 28 days)

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


yuvafem vaginal tablet 10 mcg 1 GC; QL (18 per 28 days)

Glucocorticoids/Mineralocorticoids

a-hydrocort injection recon soln 100 mg 1 GC

ARISTOSPAN INTRA-ARTICULAR INJECTION SUSPENSION 20 MG/ML

3 GC

ARISTOSPAN INTRALESIONAL INJECTION SUSPENSION 5 MG/ML

3 GC

betamethasone acet,sod phos injection suspension 6 mg/ml

1 GC

CELESTONE SOLUSPAN INJECTION SUSPENSION 6 MG/ML

3 GC

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 3 GC

cortisone oral tablet 25 mg 1 GC

decadron oral elixir 0.5 mg/5 ml 1 PA BvD; GC

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML

3 GC

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

1 GC




dexamethasone oral elixir 0.5 mg/5 ml 1 PA BvD; GC

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

1 PA BvD; GC

dexamethasone oral tablets,dose pack 1.5 mg (21 tabs), 1.5 mg (35 tabs), 1.5 mg (51 tabs)

1 GC

dexamethasone sodium phos (pf) injection solution 10 mg/ml

1 GC

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml

1 GC

dexamethasone sodium phosphate injection syringe 4 mg/ml

1 GC

DXEVO ORAL TABLETS,DOSE PACK 1.5 MG (39 TABS)

1 GC

EMFLAZA ORAL SUSPENSION 22.75 MG/ML 4 PA; NM; GC; NDS; QL (104 per 30 days)

EMFLAZA ORAL TABLET 18 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

fludrocortisone oral tablet 0.1 mg 1 GC

hidex oral tablets,dose pack 1.5 mg (21 tabs) 1 GC

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 GC

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML

3 GC

KENALOG-80 INJECTION SUSPENSION 80 MG/ML 3 GC

MEDROL (PAK) ORAL TABLETS,DOSE PACK 4 MG 3 GC

MEDROL ORAL TABLET 16 MG, 2 MG, 32 MG, 4 MG, 8 MG

3 GC

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

1 GC

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

1 GC

methylprednisolone oral tablets,dose pack 4 mg 1 GC

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

1 GC

methylprednisolone sodium succ intravenous recon soln 1,000 mg, 500 mg

1 GC

ORAPRED ODT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 30 MG

3 PA BvD; GC

prednisolone 15 mg/5 ml soln a/f, d/f 15 mg/5 ml (3 mg/ml)

1 PA BvD; GC

prednisolone oral solution 15 mg/5 ml 1 PA BvD; GC

prednisolone sodium phosphate oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1 PA BvD; GC

prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg, 30 mg

1 PA BvD; GC




prednisone oral solution 5 mg/5 ml 1 PA BvD; GC

prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1 PA BvD; GC

prednisone oral tablet 10 mg 1 PA BvD; GC

prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack)

1 GC

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, 2 MG, 5 MG


SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML

3 GC

SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML

3 GC

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML

3 GC

SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, 2 GRAM

3 GC

taperdex oral tablets,dose pack 1.5 mg (27 tabs) 1 GC

triamcinolone acetonide injection suspension 40 mg/ml 1 GC

ZILRETTA INTRA-ARTICULAR SUSPENSION,EXTENDED REL RECON 32 MG

3 GC

Pituitary

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR RECON SOLN 10,000 UNIT

3 GC

DDAVP INJECTION SOLUTION 4 MCG/ML 3 GC

DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE)

3 GC

DDAVP NASAL SPRAY WITH PUMP 10 MCG/SPRAY (0.1 ML)

3 GC

DDAVP ORAL TABLET 0.1 MG, 0.2 MG 3 GC

desmopressin 10 mcg/0.1 ml spr 10 mcg/spray (0.1 ml) 1 GC

desmopressin injection solution 4 mcg/ml 1 GC

desmopressin nasal solution 0.1 mg/ml (refrigerate) 3 GC

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

1 GC

desmopressin oral tablet 0.1 mg, 0.2 mg 1 GC

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG 4 NM; GC; NDS

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

3 PA; GC

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

4 PA; NM; GC; NDS




GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)

4 PA; NM; GC; NDS

HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)

4 PA; NM; GC; NDS

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG

4 PA; NM; GC; NDS

INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 4 NM; GC; NDS

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET 3.75 MG -5 MG (30)


LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET 11.25 MG -5 MG (90)


LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

4 NM; GC; NDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG

4 NM; GC; NDS

NOCDURNA (MEN) SUBLINGUAL TABLET,DISINTEGRATING 55.3 MCG


NOCDURNA (WOMEN) SUBLINGUAL TABLET,DISINTEGRATING 27.7 MCG


NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY (0.1 ML)


NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML)

4 PA; NM; GC; NDS

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG/1.5 ML (3.3 MG/ML)

3 PA; GC

NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT, 5,000 UNIT

3 GC

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)

4 PA; NM; GC; NDS

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1 GC

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

1 GC

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

4 PA; NM; GC; NDS

OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG

4 PA; NM; GC; NDS

ORILISSA ORAL TABLET 150 MG 4 PA; NM; GC; NDS; QL (28 per 28 days)

ORILISSA ORAL TABLET 200 MG 4 PA; NM; GC; NDS; QL (56 per 28 days)

PREGNYL INTRAMUSCULAR RECON SOLN 10,000 UNIT

3 GC

SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.)

4 PA; NM; GC; NDS




SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG

4 PA; NM; GC; NDS

SANDOSTATIN INJECTION SOLUTION 1,000 MCG/ML, 200 MCG/ML

4 NM; GC; NDS

SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

3 GC

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG

4 NM; GC; NDS

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

4 PA; NM; GC; NDS

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 20 MG, 30 MG, 40 MG, 60 MG

4 NM; GC; NDS

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)


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


SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

4 NM; GC; NDS

STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)

4 NM; GC; NDS

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) 4 NM; GC; NDS; QL (1 per 360 days)

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML 4 NM; GC; NDS

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG


VANTAS IMPLANT KIT 50 MG (50 MCG/DAY) 3 GC; QL (1 per 360 days)

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

3 GC

ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG

4 PA; NM; GC; NDS

ZOMACTON SUBCUTANEOUS RECON SOLN 5 MG 3 PA; GC

ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG 4 PA; NM; GC; NDS

Progestins

DEPO-PROVERA 150 MG/ML VIAL 25'S 150 MG/ML 3 GC; QL (1 per 84 days)

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML


DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML


DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML


hydroxyprogest(pf)(preg presv) intramuscular oil 250 mg/ml (1 ml)

4 PA; NM; GC; NDS




hydroxyprogesterone cap(ppres) intramuscular oil 250 mg/ml


MAKENA (PF) SUBCUTANEOUS AUTO-INJECTOR 275 MG/1.1 ML

4 PA; NM; GC; NDS

MAKENA INTRAMUSCULAR OIL 250 MG/ML, 250 MG/ML (1 ML)

4 PA; NM; GC; NDS

medroxyprogesterone intramuscular suspension 150 mg/ml


medroxyprogesterone intramuscular syringe 150 mg/ml 3 GC; QL (1 per 84 days)

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg 1 GC

MEGACE ES ORAL SUSPENSION 625 MG/5 ML 4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

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


norethindrone acetate oral tablet 5 mg 1 GC

progesterone intramuscular oil 50 mg/ml 1 GC

progesterone micronized oral capsule 100 mg, 200 mg 1 GC

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG 3 GC

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 GC

Thyroid And Antithyroid Agents

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG 3 GC

LEVO-T 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

3 GC

levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg

4 NM; GC; NDS

levothyroxine 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

1 GC

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

3 GC

liothyronine intravenous solution 10 mcg/ml 1 GC

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 GC

methimazole oral tablet 10 mg, 5 mg 1 GC

propylthiouracil oral tablet 50 mg 1 GC

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

3 GC

THYROLAR-1 ORAL TABLET 12.5-50 MCG 3 GC

THYROLAR-1/2 ORAL TABLET 6.25-25 MCG 3 GC

THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG 3 GC

THYROLAR-2 ORAL TABLET 25-100 MCG 3 GC

THYROLAR-3 ORAL TABLET 37.5-150 MCG 3 GC




TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3 GC

TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML

3 GC

TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML 3 GC

UNITHROID 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

3 GC

Immunological Agents

Immunological Agents

ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML

4 PA; NM; GC; NDS

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

4 PA; NM; GC; NDS

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML

4 PA; NM; GC; NDS

ANASCORP INTRAVENOUS RECON SOLN 120 MG 4 NM; GC; NDS

ANTIVENIN, MICRURUS FULVIUS INJECTION RECON SOLN

4 NM; GC; NDS

ARAVA ORAL TABLET 10 MG, 20 MG 4 NM; GC; NDS

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

4 NM; GC; NDS

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG

3 PA BvD; GC

ATGAM INTRAVENOUS SOLUTION 50 MG/ML 4 NM; GC; NDS

azathioprine oral tablet 50 mg 1 PA BvD; GC

azathioprine sodium injection recon soln 100 mg 1 PA BvD; GC

BIVIGAM INTRAVENOUS SOLUTION 10 % 4 PA BvD; NM; GC; NDS

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM


CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG

3 PA BvD; GC

CELLCEPT ORAL CAPSULE 250 MG 4 PA BvD; NM; GC; NDS

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML


CELLCEPT ORAL TABLET 500 MG 4 PA BvD; NM; GC; NDS

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

4 PA; NM; GC; NDS

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

4 PA; NM; GC; NDS




CUTAQUIG SUBCUTANEOUS SOLUTION 16.5 % 4 PA BvD; NM; GC; NDS

CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %)


cyclosporine intravenous solution 250 mg/5 ml 1 PA BvD; GC

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

1 PA BvD; GC

cyclosporine modified oral solution 100 mg/ml 1 PA BvD; GC

cyclosporine oral capsule 100 mg, 25 mg 1 PA BvD; GC

CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML 4 NM; GC; NDS

DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML

4 PA; NM; GC; NDS

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML)

4 PA; NM; GC; NDS

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

4 PA; NM; GC; NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML)

4 PA; NM; GC; NDS

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)

4 PA; NM; GC; NDS

ENTYVIO INTRAVENOUS RECON SOLN 300 MG 4 PA; NM; GC; NDS

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG

3 PA BvD; GC

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 %


GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE

3 PA BvD; GC

GAMMAGARD LIQUID INJECTION SOLUTION 10 % 4 PA BvD; NM; GC; NDS

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM


GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)


GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 %


GAMMAPLEX INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML)


GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %)


gengraf oral capsule 100 mg, 25 mg, 50 mg 1 PA BvD; GC

gengraf oral solution 100 mg/ml 1 PA BvD; GC




HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK)

4 PA; NM; GC; NDS

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

4 PA; NM; GC; NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

4 PA; NM; GC; NDS

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

4 PA; NM; GC; NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

4 PA; NM; GC; NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML

4 PA; NM; GC; NDS

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML

4 PA; NM; GC; NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML

4 PA; NM; GC; NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML

4 PA; NM; GC; NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML

4 PA; NM; GC; NDS

HYPERRAB (PF) INTRAMUSCULAR SOLUTION 300 UNIT/ML

3 GC

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML

3 GC

HYPERRHO S/D INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG)

4 NM; GC; NDS

HYPERRHO S/D INTRAMUSCULAR SYRINGE 250 UNIT (50 MCG)

3 GC

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)


ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MG/ML

4 PA; NM; GC; NDS

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML

4 PA; NM; GC; NDS

ILUMYA SUBCUTANEOUS SYRINGE 100 MG/ML 4 PA; NM; GC; NDS

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML

3 GC




IMURAN ORAL TABLET 50 MG 3 PA BvD; GC

INFLECTRA INTRAVENOUS RECON SOLN 100 MG 4 PA; NM; GC; NDS

KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML

3 GC

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG/1.14 ML, 200 MG/1.14 ML


KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML


KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML


leflunomide oral tablet 10 mg, 20 mg 1 GC

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE 250 UNIT (50 MCG)

3 GC

mycophenolate mofetil hcl intravenous recon soln 500 mg

1 PA BvD; GC

mycophenolate mofetil oral capsule 250 mg 1 PA BvD; GC

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml


mycophenolate mofetil oral tablet 500 mg 1 PA BvD; GC

mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

1 PA BvD; GC

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 180 MG, 360 MG

3 PA BvD; GC

NEORAL ORAL CAPSULE 100 MG, 25 MG 3 PA BvD; GC

NEORAL ORAL SOLUTION 100 MG/ML 3 PA BvD; GC

NULOJIX INTRAVENOUS RECON SOLN 250 MG 4 PA BvD; NM; GC; NDS

OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % 4 PA BvD; NM; GC; NDS

OLUMIANT ORAL TABLET 2 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG

4 PA; NM; GC; NDS

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML

4 PA; NM; GC; NDS

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

4 PA; NM; GC; NDS

OTEZLA ORAL TABLET 30 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)


OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML

2 GC




PANZYGA INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML), 10 % (25 ML), 10 % (300 ML), 10 % (50 ML)


PRIVIGEN INTRAVENOUS SOLUTION 10 % 4 PA BvD; NM; GC; NDS

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML 3 PA BvD; GC

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG 3 PA BvD; GC

PROGRAF ORAL GRANULES IN PACKET 0.2 MG, 1 MG

3 PA BvD; GC

RAPAMUNE ORAL SOLUTION 1 MG/ML 4 PA BvD; NM; GC; NDS

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG 4 PA BvD; NM; GC; NDS

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML

2 GC

REMICADE INTRAVENOUS RECON SOLN 100 MG 4 PA; NM; GC; NDS

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG)

3 GC

RHOPHYLAC INJECTION SYRINGE 1,500 UNIT (300 MCG)/2 ML

4 NM; GC; NDS

RIDAURA ORAL CAPSULE 3 MG 4 NM; GC; NDS

RINVOQ ER ORAL TABLET EXTENDED RELEASE 24 HR 15 MG


SANDIMMUNE INTRAVENOUS SOLUTION 250 MG/5 ML

3 PA BvD; GC

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 PA BvD; GC

SANDIMMUNE ORAL SOLUTION 100 MG/ML 3 PA BvD; GC

SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML

4 PA; NM; GC; NDS

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML

4 PA; NM; GC; NDS

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML

4 PA; NM; GC; NDS

sirolimus oral solution 1 mg/ml 4 PA BvD; NM; GC; NDS

sirolimus oral tablet 0.5 mg, 1 mg 1 PA BvD; GC

sirolimus oral tablet 2 mg 4 PA BvD; NM; GC; NDS

SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 ML 4 PA; NM; GC; NDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2)

4 PA; NM; GC; NDS

STELARA INTRAVENOUS SOLUTION 130 MG/26 ML 4 PA; NM; GC; NDS

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML

4 PA; NM; GC; NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML

4 PA; NM; GC; NDS

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 PA BvD; GC




THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG

4 NM; GC; NDS

TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML 4 PA; NM; GC; LA; NDS; QL (15 per 28 days)

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30 ML (10 MG/ML)

4 PA; NM; GC; NDS

WINRHO SDF INJECTION SOLUTION 1,500 UNIT (300 MCG)/1.3 ML, 15000 UNIT(3000 MCG)/13 ML, 2,500 UNIT (500 MCG)/2.2 ML, 5,000 UNIT(1000 MCG)/4.4 ML

4 NM; GC; NDS

XELJANZ ORAL TABLET 10 MG, 5 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG


XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)


ZINPLAVA INTRAVENOUS SOLUTION 25 MG/ML 4 NM; GC; NDS

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG


Vaccines

ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

2 GC

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

2 GC

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

2 GC

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

2 PA BvD; GC

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML

2 GC

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML

2 GC

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

2 GC

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

2 GC

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML

2 PA BvD; GC

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML

2 PA BvD; GC

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

2 PA BvD; GC




GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML


GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML


HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

2 GC

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

2 GC

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

2 GC

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT

2 PA BvD; GC

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

2 GC

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML

2 GC

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML 2 GC

IPOL INJECTION SYRINGE 40-8-32 UNIT/0.5 ML 2 GC

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML

2 GC

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

2 GC

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML

2 GC

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML

2 GC

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

2 GC

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML

2 GC

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML

2 GC

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML

2 GC

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML

2 GC

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

2 GC

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

2 GC

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

2 GC




RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

2 PA BvD; GC

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML

2 PA BvD; GC

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML

2 PA BvD; GC

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML

2 GC

ROTATEQ VACCINE ORAL SOLUTION 2 ML 2 GC

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML


TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML

2 GC

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML

2 GC

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML

2 GC

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML

2 GC

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG

3 GC

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML

2 GC

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML

2 GC

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML

2 GC

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML

2 GC

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML

2 GC

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML

2 GC

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML


YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

2 GC

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML


Inflammatory Bowel Disease Agents

Inflammatory Bowel Disease Agents

alosetron oral tablet 0.5 mg, 1 mg 4 NM; GC; NDS




APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM

2 GC

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

3 GC

AZULFIDINE ORAL TABLET 500 MG 3 GC

balsalazide oral capsule 750 mg 1 GC

budesonide oral capsule,delayed,extend.release 3 mg 1 GC

budesonide oral tablet,delayed and ext.release 9 mg 4 ST; NM; GC; NDS

CANASA RECTAL SUPPOSITORY 1,000 MG 3 GC

COLAZAL ORAL CAPSULE 750 MG 4 NM; GC; NDS

colocort rectal enema 100 mg/60 ml 1 GC

CORTENEMA RECTAL ENEMA 100 MG/60 ML 3 GC

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG

3 GC

DIPENTUM ORAL CAPSULE 250 MG 4 ST; NM; GC; NDS

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE 3 MG

4 NM; GC; NDS

GIAZO ORAL TABLET 1.1 GRAM 4 ST; NM; GC; NDS

hydrocortisone rectal enema 100 mg/60 ml 1 GC

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM

1 GC

LOTRONEX ORAL TABLET 0.5 MG, 1 MG 4 NM; GC; NDS

mesalamine oral capsule (with del rel tablets) 400 mg 1 GC

mesalamine oral tablet,delayed release (dr/ec) 800 mg 1 GC

mesalamine rectal enema 4 gram/60 ml 1 GC

mesalamine rectal suppository 1,000 mg 1 GC

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

3 ST; GC

ROWASA RECTAL ENEMA KIT 4 GRAM/60 ML 4 NM; GC; NDS

sulfasalazine oral tablet 500 mg 1 GC

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

1 GC

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG

4 ST; NM; GC; NDS

UCERIS RECTAL FOAM 2 MG/ACTUATION 2 GC

Irrigating Solutions

Irrigating Solutions

acetic acid irrigation solution 0.25 % 3 GC

glycine urologic solution irrigation solution 1.5 % 3 GC

LACTATED RINGERS IRRIGATION SOLUTION 3 GC

PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L

3 GC




PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQ/L

3 GC

RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML, 6.602-0.198 GRAM/100 ML

3 GC

RESECTISOL TRANSURETHRAL SOLUTION 5 % 3 GC

sodium chloride irrigation solution 0.9 % 3 GC

TIS-U-SOL PENTALYTE IRRIGATION IRRIGATION SOLUTION 800-40-20-8.75- 6.25 MG/100 ML

3 GC

water for irrigation, sterile irrigation solution 3 GC

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

ACTONEL 35 MG TABLET F/C,DOSEPACK 35 MG 3 GC; QL (4 per 28 days)

ACTONEL ORAL TABLET 150 MG 3 GC; QL (1 per 28 days)

ACTONEL ORAL TABLET 30 MG, 5 MG 3 GC; QL (30 per 30 days)

ACTONEL ORAL TABLET 35 MG 3 GC; QL (4 per 28 days)

alendronate oral solution 70 mg/75 ml 1 GC; QL (300 per 28 days)

alendronate oral tablet 10 mg, 40 mg, 5 mg 1 GC

alendronate oral tablet 35 mg, 70 mg 1 GC; QL (4 per 28 days)

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC) 35 MG


BINOSTO ORAL TABLET, EFFERVESCENT 70 MG 3 GC; QL (4 per 28 days)

BONIVA INTRAVENOUS SYRINGE 3 MG/3 ML 3 GC; QL (3 per 84 days)

BONIVA ORAL TABLET 150 MG 3 GC; QL (1 per 28 days)

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation


calcitriol intravenous solution 1 mcg/ml 1 GC

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 GC

calcitriol oral solution 1 mcg/ml 1 GC

cinacalcet oral tablet 30 mg, 60 mg 4 NM; GC; NDS; QL (60 per 30 days)

cinacalcet oral tablet 90 mg 4 NM; GC; NDS; QL (120 per 30 days)

doxercalciferol intravenous solution 4 mcg/2 ml 1 GC

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 GC

etidronate disodium oral tablet 200 mg, 400 mg 1 GC

EVENITY 105 MG/1.17 ML SYRINGE 105 MG/1.17 ML


EVENITY SUBCUTANEOUS SYRINGE 210MG/2.34ML ( 105MG/1.17MLX2)


FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML


FOSAMAX ORAL TABLET 70 MG 3 GC

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT





HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML, 4 MCG/2 ML

3 GC

HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 MCG

3 GC

ibandronate intravenous solution 3 mg/3 ml 1 GC; QL (3 per 84 days)

ibandronate intravenous syringe 3 mg/3 ml 1 GC; QL (3 per 84 days)

ibandronate oral tablet 150 mg 1 GC; QL (1 per 28 days)

MIACALCIN INJECTION SOLUTION 200 UNIT/ML 3 GC

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE


pamidronate intravenous recon soln 30 mg, 90 mg 1 GC

pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml)

1 GC

paricalcitol hemodialysis port injection solution 2 mcg/ml

1 GC

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML

1 GC

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 GC

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML 2 GC; QL (1 per 180 days)

RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG


RECLAST INTRAVENOUS PIGGYBACK 5 MG/100 ML


risedronate oral tablet 150 mg 1 GC; QL (1 per 28 days)

risedronate oral tablet 30 mg, 5 mg 1 GC; QL (30 per 30 days)

risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)


risedronate oral tablet,delayed release (dr/ec) 35 mg 1 GC; QL (4 per 28 days)

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG 3 GC

ROCALTROL ORAL SOLUTION 1 MCG/ML 3 GC

SENSIPAR ORAL TABLET 30 MG, 60 MG 4 NM; GC; NDS; QL (60 per 30 days)

SENSIPAR ORAL TABLET 90 MG 4 NM; GC; NDS; QL (120 per 30 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)


XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML)

4 PA; NM; GC; NDS

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

3 GC

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG 3 GC

zoledronic acid intravenous recon soln 4 mg 1 GC

zoledronic acid intravenous solution 4 mg/5 ml 1 GC

zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml





zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml

1 GC

ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML 4 NM; GC; NDS

ZOMETA INTRAVENOUS SOLUTION 4 MG/5 ML 4 NM; GC; NDS

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

ACTHAR INJECTION GEL 80 UNIT/ML 4 PA; NM; GC; NDS; QL (35 per 28 days)

ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML

4 NM; GC; NDS

amifostine crystalline intravenous recon soln 500 mg 1 GC

BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG

4 PA; NM; GC; NDS

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML


BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML 4 PA; NM; GC; NDS; QL (4 per 28 days)

BOTOX INJECTION RECON SOLN 100 UNIT 3 PA; GC; QL (4 per 90 days)

BOTOX INJECTION RECON SOLN 200 UNIT 3 PA; GC; QL (1 per 90 days)

BRISDELLE ORAL CAPSULE 7.5 MG 3 PA-HRM; GC; AGE (Max 64 Years)

CABLIVI INJECTION KIT 11 MG 4 PA; NM; GC; NDS

CARNITOR INTRAVENOUS SOLUTION 200 MG/ML 3 GC

CARNITOR ORAL SOLUTION 100 MG/ML 3 GC

CARNITOR ORAL TABLET 330 MG 3 GC

CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG

3 GC

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML

4 NM; GC; NDS

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML 4 NM; GC; NDS

dexrazoxane hcl intravenous recon soln 250 mg, 500 mg

4 NM; GC; NDS

droperidol injection solution 2.5 mg/ml 1 GC

DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT

4 PA; NM; GC; NDS

ELMIRON ORAL CAPSULE 100 MG 3 GC

ENDARI ORAL POWDER IN PACKET 5 GRAM 4 PA; NM; GC; NDS; QL (180 per 30 days)

ergoloid oral tablet 1 mg 1 GC

ETHYOL INTRAVENOUS RECON SOLN 500 MG 4 NM; GC; NDS

EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML 4 PA; NM; GC; LA; NDS

FIRDAPSE ORAL TABLET 10 MG 4 PA; NM; GC; NDS; QL (240 per 30 days)

fomepizole intravenous solution 1 gram/ml 4 NM; GC; NDS

FUSILEV INTRAVENOUS RECON SOLN 50 MG 4 NM; GC; NDS

GRASTEK SUBLINGUAL TABLET 2,800 BAU 3 PA; GC; QL (30 per 30 days)

guanidine oral tablet 125 mg 3 GC




hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg


KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML)

4 NM; GC; NDS

KEPIVANCE INTRAVENOUS RECON SOLN 6.25 MG 4 NM; GC; NDS

KEVEYIS ORAL TABLET 50 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)

KHAPZORY INTRAVENOUS RECON SOLN 175 MG, 300 MG

4 NM; GC; NDS

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg, 500 mg

1 GC

leucovorin calcium injection solution 10 mg/ml 1 GC

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

1 GC

levocarnitine (with sugar) oral solution 100 mg/ml 1 GC

levocarnitine oral tablet 330 mg 1 GC

LEVOLEUCOVORIN CALCIUM INTRAVENOUS RECON SOLN 175 MG

3 GC

levoleucovorin calcium intravenous recon soln 50 mg 4 NM; GC; NDS

LITHOSTAT ORAL TABLET 250 MG 4 NM; GC; NDS

mesna intravenous solution 100 mg/ml 1 GC

MESNEX INTRAVENOUS SOLUTION 100 MG/ML 3 GC

MESNEX ORAL TABLET 400 MG 4 NM; GC; NDS

MESTINON ORAL SYRUP 60 MG/5 ML 4 NM; GC; NDS

MESTINON ORAL TABLET 60 MG 4 NM; GC; NDS

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG

4 NM; GC; NDS

METHERGINE ORAL TABLET 0.2 MG 4 NM; GC; NDS; QL (28 per 7 days)

methylergonovine injection solution 0.2 mg/ml (1 ml) 1 GC

methylergonovine oral tablet 0.2 mg 4 NM; GC; NDS; QL (28 per 7 days)

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)

4 NM; GC; NDS

MYOBLOC INTRAMUSCULAR SOLUTION 10,000 UNIT/2 ML


MYOBLOC INTRAMUSCULAR SOLUTION 2,500 UNIT/0.5 ML


MYOBLOC INTRAMUSCULAR SOLUTION 5,000 UNIT/ML


neostigmine methylsulfate intravenous solution 0.5 mg/ml

1 GC

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 1 MG/ML

1 GC

NPLATE SUBCUTANEOUS RECON SOLN 250 MCG, 500 MCG


ONPATTRO INTRAVENOUS SOLUTION 2 MG/ML 4 PA; NM; GC; NDS




ORALAIR SUBLINGUAL TABLET 100 INDX REACTIVITY, 300 INDX REACTIVITY

3 PA; GC

paroxetine mesylate(menop.sym) oral capsule 7.5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

PROGLYCEM ORAL SUSPENSION 50 MG/ML 4 NM; GC; NDS

PROTOPAM CHLORIDE INJECTION RECON SOLN 1 GRAM

3 GC

pyridostigmine bromide oral syrup 60 mg/5 ml 1 GC

pyridostigmine bromide oral tablet 30 mg, 60 mg 1 GC

pyridostigmine bromide oral tablet extended release 180 mg

1 GC

RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT 3 PA; GC; QL (30 per 30 days)

RECTIV RECTAL OINTMENT 0.4 % (W/W) 3 GC; QL (30 per 30 days)

REGONOL INJECTION SOLUTION 5 MG/ML 3 GC

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG 4 PA; NM; GC; NDS

RUZURGI ORAL TABLET 10 MG 4 PA; NM; GC; NDS; QL (300 per 30 days)

SARAFEM ORAL TABLET 10 MG, 20 MG 3 GC

SIMULECT INTRAVENOUS RECON SOLN 10 MG, 20 MG


SOLIRIS INTRAVENOUS SOLUTION 300 MG/30 ML 4 NM; GC; NDS

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML)

4 PA; NM; GC; NDS

TEGSEDI SUBCUTANEOUS SYRINGE 284 MG/1.5 ML


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


THAM INTRAVENOUS SOLUTION 36 MG/ML (0.3 M) 3 GC

THIOLA EC ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG, 300 MG

4 NM; GC; NDS

THIOLA ORAL TABLET 100 MG 4 NM; GC; NDS

TOTECT INTRAVENOUS RECON SOLN 500 MG 4 NM; GC; NDS

TYBOST ORAL TABLET 150 MG 3 GC; QL (30 per 30 days)

ULESFIA TOPICAL LOTION 5 % 3 GC

VISTARIL ORAL CAPSULE 25 MG, 50 MG 3 PA-HRM; GC; AGE (Max 64 Years)

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 200 UNIT, 50 UNIT


XURIDEN ORAL GRANULES IN PACKET 2 GRAM 4 PA; NM; GC; NDS; QL (120 per 30 days)

ZINECARD (AS HCL) INTRAVENOUS RECON SOLN 250 MG, 500 MG

4 NM; GC; NDS

Ophthalmic Agents

Antiglaucoma Agents

acetazolamide oral capsule, extended release 500 mg 1 GC




acetazolamide oral tablet 125 mg, 250 mg 1 GC

acetazolamide sodium injection recon soln 500 mg 1 GC

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % 2 GC

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 % 3 GC

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

2 GC

BETAGAN OPHTHALMIC (EYE) DROPS 0.5 % 3 GC

betaxolol ophthalmic (eye) drops 0.5 % 1 GC

BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 %

3 GC

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

3 GC

bimatoprost ophthalmic (eye) drops 0.03 % 1 GC

brimonidine ophthalmic (eye) drops 0.15 % 3 GC

brimonidine ophthalmic (eye) drops 0.2 % 1 GC

carteolol ophthalmic (eye) drops 1 % 1 GC

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % 2 GC

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE 2-0.5 %

3 GC

COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML

3 GC

dorzolamide ophthalmic (eye) drops 2 % 1 GC

dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 %

1 GC

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

1 GC

ISOPTO CARPINE OPHTHALMIC (EYE) DROPS 1 %, 2 %, 4 %

3 GC

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 %

3 GC

latanoprost ophthalmic (eye) drops 0.005 % 1 GC

levobunolol ophthalmic (eye) drops 0.5 % 1 GC

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % 2 GC; QL (2.5 per 25 days)

methazolamide oral tablet 25 mg, 50 mg 1 GC

metipranolol ophthalmic (eye) drops 0.3 % 1 GC

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 %

3 GC

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

RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % 2 GC; QL (2.5 per 25 days)

ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 %


SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 %

2 GC

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % 1 GC




timolol maleate ophthalmic (eye) drops, once daily 0.5 %

1 GC

timolol maleate ophthalmic (eye) gel forming solution 0.25 %

1 GC

timolol maleate ophthalmic (eye) gel forming solution 0.5 %

1 GC

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.25 %, 0.5 %

3 GC

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 %

3 GC

TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION 0.25 %, 0.5 %

3 GC

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % 2 GC; QL (2.5 per 25 days)

TRUSOPT OPHTHALMIC (EYE) DROPS 2 % 3 GC

VYZULTA OPHTHALMIC (EYE) DROPS 0.024 % 3 ST; GC; QL (5 per 30 days)

XALATAN OPHTHALMIC (EYE) DROPS 0.005 % 3 GC; QL (2.5 per 25 days)

XELPROS OPHTHALMIC (EYE) DROPS, EMULSION 0.005 %


ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 0.0015 %


Replacement Preparations

Replacement Preparations

AMMONUL INTRAVENOUS SOLUTION 10-10 % 3 GC

calcium chloride intravenous solution 100 mg/ml (10 %)

1 GC

calcium chloride intravenous syringe 100 mg/ml (10 %) 1 GC

d10 %-0.45 % sodium chloride intravenous parenteral solution

3 GC

d5 % and 0.9 % sodium chloride intravenous parenteral solution

3 GC

d5 %-0.45 % sodium chloride intravenous parenteral solution

3 GC

electrolyte-48 in d5w intravenous parenteral solution 3 GC

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 %

3 GC

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 %

3 GC

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 GC

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

3 GC

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

3 GC




KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ

3 GC

klor-con m10 oral tablet,er particles/crystals 10 meq 1 GC



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

1 GC

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

3 GC

LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION

3 GC

magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml

1 GC

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

1 PA BvD; GC

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

1 PA BvD; GC

magnesium sulfate injection solution 4 meq/ml (50 %) 1 PA BvD; GC

magnesium sulfate injection syringe 4 meq/ml 1 PA BvD; GC

NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3 GC

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 GC

NORMOSOL-R IV SOLUTION L/F, SINGLE-USE 3 GC

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

3 GC

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

3 GC

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

3 GC

PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

3 GC

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

3 PA BvD; GC

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l

3 PA BvD; GC

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

3 PA BvD; GC

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

3 PA BvD; GC

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l

3 GC




potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

3 PA BvD; GC

potassium chloride intravenous solution 2 meq/ml 1 PA BvD; GC

potassium chloride intravenous solution 2 meq/ml (20 ml)

1 PA BvD; GC

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

1 GC

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

1 GC

potassium chloride oral packet 20 meq 1 GC

potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq

1 GC

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq

1 GC

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l

1 GC

potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

3 GC

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

3 GC

potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

3 GC

potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)

1 GC

sodium acetate intravenous solution 2 meq/ml 1 GC

sodium benzoate-sod phenylacet intravenous solution 10-10 %

1 GC

sodium chloride 0.45 % intravenous parenteral solution 0.45 %

1 GC

sodium chloride 0.9 % intravenous parenteral solution 1 GC

sodium chloride intravenous parenteral solution 2.5 meq/ml

3 GC

sodium lactate intravenous solution 5 meq/ml 3 GC

sodium phosphate intravenous solution 3 mmol/ml 1 GC

TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV 18-18-5-4.5-35 MEQ/20 ML

3 GC

TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML

3 GC

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1,080 MG)

3 GC

UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ

3 GC




UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ (540 MG)

3 GC

Respiratory Tract Agents

Anti-Inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE


ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 500-50 MCG/DOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION


AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION


AIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION


ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION


ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120)


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (30)


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (60)


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE


budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

1 PA BvD; GC

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION


FLOVENT 100 MCG DISKUS 100 MCG/ACTUATION 2 GC; QL (60 per 30 days)




FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION 2 GC; QL (120 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION






fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION


QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION


QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION


SYMBICORT 160-4.5 MCG INHALER 60 INHALATIONS 160-4.5 MCG/ACTUATION


SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION


SYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION


Antileukotrienes

ACCOLATE ORAL TABLET 10 MG, 20 MG 3 GC

montelukast oral granules in packet 4 mg 1 GC

montelukast oral tablet 10 mg 1 GC

montelukast oral tablet,chewable 4 mg, 5 mg 1 GC

SINGULAIR ORAL GRANULES IN PACKET 4 MG 3 GC

SINGULAIR ORAL TABLET 10 MG 3 GC

SINGULAIR ORAL TABLET,CHEWABLE 4 MG, 5 MG 3 GC

zafirlukast oral tablet 10 mg, 20 mg 1 GC

zileuton oral tablet, er multiphase 12 hr 600 mg 4 NM; GC; NDS

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG

4 NM; GC; NDS

ZYFLO ORAL TABLET 600 MG 4 NM; GC; NDS




Bronchodilators

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation, 90 mcg/actuation (nda020503), 90 mcg/actuation (nda020983)

1 GC

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

1 PA BvD; GC

albuterol sulfate oral syrup 2 mg/5 ml 1 GC

albuterol sulfate oral tablet 2 mg, 4 mg 1 GC

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

1 GC

aminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml

1 GC

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION


ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG


ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION


BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION


DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION


elixophyllin oral elixir 80 mg/15 ml 1 GC

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION

2 GC

ipratropium bromide inhalation solution 0.02 % 1 PA BvD; GC

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation


LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML


metaproterenol oral syrup 10 mg/5 ml 1 GC

metaproterenol oral tablet 10 mg, 20 mg 1 GC

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

1 GC

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION

2 GC

PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION


SEEBRI NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 15.6 MCG





SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE


SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION

2 GC

SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

2 GC

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG

2 GC

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION


STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION


terbutaline oral tablet 2.5 mg, 5 mg 1 GC

terbutaline subcutaneous solution 1 mg/ml 4 NM; GC; NDS

theophylline oral solution 80 mg/15 ml 1 GC

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

1 GC

theophylline oral tablet extended release 24 hr 400 mg, 600 mg

1 GC

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG

2 GC

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT)


UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 27.5-15.6 MCG


VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

3 GC

YUPELRI INHALATION SOLUTION FOR NEBULIZATION 175 MCG/3 ML


Respiratory Tract Agents, Other

acetylcysteine intravenous solution 200 mg/ml (20 %) 1 PA BvD; GC

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

1 PA BvD; GC

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG


CINQAIR INTRAVENOUS SOLUTION 10 MG/ML 4 PA; NM; GC; NDS

cromolyn inhalation solution for nebulization 20 mg/2 ml

1 PA BvD; GC

DALIRESP ORAL TABLET 250 MCG 2 GC; QL (28 per 28 days)

DALIRESP ORAL TABLET 500 MCG 2 GC; QL (30 per 30 days)




ESBRIET ORAL CAPSULE 267 MG 4 PA; NM; GC; NDS; QL (270 per 30 days)

ESBRIET ORAL TABLET 267 MG 4 PA; NM; GC; NDS; QL (270 per 30 days)

ESBRIET ORAL TABLET 801 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)

FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML


FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML 4 PA; NM; GC; NDS; QL (1 per 28 days)

GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)


KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG


KALYDECO ORAL TABLET 150 MG 4 PA; NM; GC; NDS; QL (56 per 28 days)

NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML

4 PA; NM; GC; LA; NDS; QL (3 per 28 days)

NUCALA SUBCUTANEOUS RECON SOLN 100 MG 4 PA; NM; GC; LA; NDS; QL (3 per 28 days)

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML 4 PA; NM; GC; LA; NDS; QL (3 per 28 days)

OFEV ORAL CAPSULE 100 MG, 150 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 4 PA; NM; GC; NDS; QL (120 per 30 days)

PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG


SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)


TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N)


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 4 PA; NM; GC; NDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.5 ML

4 PA; NM; GC; NDS

ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG 4 PA BvD; NM; GC; NDS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR 15 MG

4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR 30 MG

4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

baclofen oral tablet 10 mg, 20 mg, 5 mg 1 GC

carisoprodol oral tablet 250 mg, 350 mg 1 PA-HRM; GC; QL (120 per 30 days); AGE (Max 64 Years)

carisoprodol-asa-codeine oral tablet 200-325-16 mg 1 PA-HRM; GC; QL (240 per 30 days); AGE (Max 64 Years)

carisoprodol-aspirin oral tablet 200-325 mg 1 PA-HRM; GC; QL (240 per 30 days); AGE (Max 64 Years)

chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg





cyclobenzaprine oral capsule,extended release 24hr 15 mg, 30 mg


cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years)

DANTRIUM INTRAVENOUS RECON SOLN 20 MG 3 GC

DANTRIUM ORAL CAPSULE 25 MG, 50 MG 3 GC

dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 GC

metaxall oral tablet 800 mg 1 PA-HRM; GC; AGE (Max 64 Years)

metaxalone oral tablet 400 mg, 800 mg 1 PA-HRM; GC; AGE (Max 64 Years)

methocarbamol injection solution 100 mg/ml 1 PA-HRM; GC; AGE (Max 64 Years)

methocarbamol oral tablet 500 mg, 750 mg 1 PA-HRM; GC; AGE (Max 64 Years)

orphenadrine citrate injection solution 30 mg/ml 1 PA-HRM; GC; AGE (Max 64 Years)

orphenadrine citrate oral tablet extended release 100 mg


revonto intravenous recon soln 20 mg 1 GC

ROBAXIN INJECTION SOLUTION 100 MG/ML 4 PA-HRM; NM; GC; NDS; AGE (Max 64 Years)

ROBAXIN ORAL TABLET 500 MG 3 PA-HRM; GC; AGE (Max 64 Years)

ROBAXIN-750 ORAL TABLET 750 MG 3 PA-HRM; GC; AGE (Max 64 Years)

SKELAXIN ORAL TABLET 800 MG 3 PA-HRM; GC; AGE (Max 64 Years)

SOMA ORAL TABLET 250 MG, 350 MG 3 PA-HRM; GC; QL (120 per 30 days); AGE (Max 64 Years)

tizanidine oral capsule 2 mg, 4 mg, 6 mg 1 GC

tizanidine oral tablet 2 mg, 4 mg 1 GC

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG 3 GC

ZANAFLEX ORAL TABLET 4 MG 3 GC

Sleep Disorder Agents

Sleep Disorder Agents

AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG

3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

AMBIEN ORAL TABLET 10 MG, 5 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 1 PA; GC

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG


BUTISOL ORAL TABLET 30 MG 3 GC; QL (120 per 30 days)




EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

HETLIOZ ORAL CAPSULE 20 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

INTERMEZZO SUBLINGUAL TABLET 1.75 MG, 3.5 MG


LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

modafinil oral tablet 100 mg, 200 mg 1 PA; GC; QL (60 per 30 days)

NEMBUTAL SODIUM INJECTION SOLUTION 50 MG/ML


NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG

3 PA; GC

pentobarbital sodium injection solution 50 mg/ml 4 NM; GC; NDS; QL (2 per 30 days)

PROVIGIL ORAL TABLET 100 MG, 200 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

ramelteon oral tablet 8 mg 1 GC; QL (30 per 30 days)

ROZEREM ORAL TABLET 8 MG 3 GC

SILENOR ORAL TABLET 3 MG, 6 MG 2 GC; QL (30 per 30 days)

SONATA ORAL CAPSULE 10 MG, 5 MG 3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)

SUNOSI ORAL TABLET 150 MG, 75 MG 3 PA; GC; QL (30 per 30 days)

WAKIX ORAL TABLET 17.8 MG, 4.45 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

XYREM ORAL SOLUTION 500 MG/ML 4 NM; GC; LA; NDS; QL (540 per 30 days)

zaleplon oral capsule 10 mg, 5 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years)




zolpidem oral tablet 10 mg, 5 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg


zolpidem sublingual tablet 1.75 mg, 3.5 mg 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years)

ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)

3 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (7.7 per 30 days); AGE (Max 64 Years)

Vasodilating Agents

Vasodilating Agents

ADCIRCA ORAL TABLET 20 MG 4 PA; NM; GC; NDS; QL (60 per 30 days)

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


alyq oral tablet 20 mg 4 PA; NM; GC; NDS; QL (60 per 30 days)

ambrisentan oral tablet 10 mg, 5 mg 4 PA; NM; GC; NDS; QL (30 per 30 days)

CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; GC; QL (30 per 30 days)

epoprostenol (glycine) intravenous recon soln 0.5 mg 1 PA; GC

epoprostenol (glycine) intravenous recon soln 1.5 mg 4 PA; NM; GC; NDS

FLOLAN INTRAVENOUS RECON SOLN 0.5 MG 3 PA; GC

FLOLAN INTRAVENOUS RECON SOLN 1.5 MG 4 PA; NM; GC; NDS

LETAIRIS ORAL TABLET 10 MG, 5 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

OPSUMIT ORAL TABLET 10 MG 4 PA; NM; GC; NDS; QL (30 per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG

2 PA; GC

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG

4 PA; NM; GC; NDS

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

4 PA; NM; GC; NDS

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5 ML 4 PA; NM; GC; NDS; QL (37.5 per 1 day)

REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML


REVATIO ORAL TABLET 20 MG 4 PA; NM; GC; NDS; QL (90 per 30 days)




sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml

4 PA; NM; GC; NDS; QL (37.5 per 1 day)

sildenafil (pulm.hypertension) oral suspension for reconstitution 10 mg/ml


sildenafil (pulm.hypertension) oral tablet 20 mg 1 PA; GC; QL (90 per 30 days)

tadalafil (pulm. hypertension) oral tablet 20 mg 4 PA; NM; GC; NDS; QL (60 per 30 days)

tadalafil oral tablet 2.5 mg, 5 mg 1 PA; GC; QL (30 per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG 4 PA; NM; GC; LA; NDS; QL (60 per 30 days)

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


treprostinil sodium injection solution 1 mg/ml, 10 mg/ml, 2.5 mg/ml, 5 mg/ml

4 PA; NM; GC; NDS

TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

4 PA; NM; GC; NDS

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG


UPTRAVI ORAL TABLET 200 MCG 4 PA; NM; GC; NDS; QL (240 per 30 days)

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)


VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG

4 PA; NM; GC; NDS

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML

4 PA; NM; GC; NDS

Vitamins And Minerals

Vitamins And Minerals

pnv prenatal plus multivit tab s/f, gluten-free (rx) 27 mg iron- 1 mg

2 GC

prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg

2 GC


VibrantRx (PDP) for JPIA 2019 Supplemental Formulary As of: December 01, 2019

VibrantRx for JPIA 2019 Supplemental Drug Coverage

Drug Name Strength Dose Drug Tier

Requirements/Limits

Contraception/Oxytocics

Contraceptives,Implantable NEXPLANON 68 MG IMPLANT 0 EX; QL: 1 IN 365 DAYS

Contraceptives,Intravaginal CONCEPTROL 0.04 GEL/PF APP 0 EX

GYNOL II 0.03 JELLY/APPL 0 EX

TODAY CONTRACEPTIVE SPONGE

1000 MG CON.SPONGE 0 EX

vcf 0.04 GEL/PF APP 0 EX

vcf 0.125 FOAM/APPL 0 EX

VCF 0.28 FILM 0 EX

Diaphragms/Cervical Cap

CAYA CONTOURED 60 MM-85MM

DIAPHRAGM 0 EX

FEMCAP 22MM EACH 0 EX



WIDE SEAL DIAPHRAGM 60MM DIAPHRAGM 0 EX








Contraception Other Drugs

Condoms FC2 FEMALE CONDOM EACH 0 EX; QL: 30 IN 30 DAYS

Intra-Uterine Devices (IUD) KYLEENA 17.5MCG/24 IUD 0 EX

LILETTA 19.5MCG/24 IUD 0 EX

PARAGARD T 380-A 380 SQ MM IUD 0 EX

Cough And Cold

1st Gen Antihistamine & Decongestant Combinations

centergy 1MG-

2MG/ML DROPS 1 EX





Requirements/Limits

1st Gen Antihist-Decongest-Anticholinergic Comb

respa a.r. 90-8-0.24 TAB ER 12H 1 EX

Antitussives,Non-Narcotic benzonatate 100 MG CAPSULE 1 EX

benzonatate 150 MG CAPSULE 1 EX

benzonatate 200 MG CAPSULE 1 EX

TESSALON PERLE 100 MG CAPSULE 3 EX

Narcotic Antituss-1st Gen. Antihistamine-Decongest

CAPCOF 2-5-10MG/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

HISTEX-AC 2.5-10-10 SYRUP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

hydrocod-cpm-pseudoephedrine 5-4-60MG/5 SOLUTION 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

mar-cof bp 2-30-7.5/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

M-END PE 3.33-6.3/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

POLY-TUSSIN AC 4-10-10/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

promethazine vc-codeine 6.25-5-10 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

promethazine-phenyleph-codeine 6.25-5-10 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

PRO-RED AC 1-5-9 MG/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

rydex 1.3-10-6.3 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL DAC 25 1-15-3MG/3 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL DAC 30 1-15MG/3.5 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD









Requirements/Limits

ZODRYL DAC 80 2-30-10/10 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

Narcotic Antituss-Decongestant-Expectorant Comb

CODITUSSIN DAC 30-10-200 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

guaifenesin dac 30-10-100 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

lortuss ex 30-10-100 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

TUSNEL C 30-10-100 SYRUP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

virtussin dac 30-10-100 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL DEC 25 15-3-60/3 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL DEC 30 15-3.5/3.5 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD





ZODRYL DEC 80 30-10MG/10 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

Narcotic Antitussive-1st Generation Antihistamine

hydrocodone-chlorpheniramne er 10-8MG/5ML SUS ER 12H 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

promethazine-codeine 6.25-10/5 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

TUSSICAPS 5MG-4MG CAP ER 12H 3 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

TUSSICAPS 10MG-8MG CAP ER 12H 3 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

TUSSIONEX 10-8MG/5ML SUS ER 12H 3 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

TUZISTRA XR 14.7-2.8/5 SUS ER 12H 3 EX; QL: 200 IN 10 DAYS (MAX OF 200ML PER 10 DAYS); AGE LIMIT: MUST BE AT LEAST 18 YEARS





Requirements/Limits

OLD; ST: TRIAL OF PROMETHAZINE WITH CODEINE SYRUP REQUIRED.

VITUZ 5MG-4MG/5 SOLUTION 3 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

ZODRYL AC 25 1-3MG/3ML ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL AC 30 1-3.5/3.5 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ZODRYL AC 35 1-4MG/4ML ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD


ZODRYL AC 50 2MG-5MG/5 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD


ZODRYL AC 80 2-10MG/10 ORAL SUSP 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

Z-TUSS AC 2 MG-9MG/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

Narcotic Antitussive-Anticholinergic Comb.

hydrocodone-homatropine mbr 5-1.5 MG/5 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

hydrocodone-homatropine mbr 5 MG-1.5MG TABLET 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

hydromet 5-1.5 MG/5 SYRUP 1 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

TUSSIGON 5 MG-1.5MG TABLET 3 EX; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD

Narcotic Antitussive-Expectorant Combination

cheratussin ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

codeine-guaifenesin 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

coditussin ac 10-200MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

g tussin ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

guaiatussin ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD





Requirements/Limits

guaiatussin ac 20-200/10 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

guaiatussin ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

guaifenesin-codeine 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

mar-cof cg 7.5-225/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

M-CLEAR WC 6.3-100/5 LIQUID 3 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

ninjacof-xg 8-200 MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

OBREDON 200-2.5/5 SOLUTION 3

EX; QL: 600 IN 10 DAYS; AGE LIMIT: MUST BE AT LEAST 18 YEARS OLD; ST: TRIAL OF HYDROCODONE/HOMATROPINE METHYLBROMIDE REQUIRED.

robafen ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

virtussin ac 10-100MG/5 LIQUID 1 EX; AGE LIMIT: MUST BE AT LEAST 12 YEARS OLD

Non-Narc Antituss-1st Gen. Antihistamine-Decongest

bromfed dm 2-30-10/5 SYRUP 1 EX

brompheniramine-pseudoephed-dm

2-30-10/5 SYRUP 1 EX

Non-Narc Antituss-1st Gen. Antihistamine-Decongest

centergy dm 1-2-3MG/ML DROPS 1 EX

Non-Narc Antitussive-1st Gen Antihistamine Comb.

promethazine-dm 6.25-15/5 SYRUP 1 EX

Non-Narcotic Antituss-Decongestant-Expectorant Cmb

TUSNEL PEDIATRIC 50-5-15/5 LIQUID 3 EX

Nose Preparations, Vasoconstrictors (Rx)

ADRENALIN CHLORIDE 1 MG/ML SOLUTION 3 EX

TYZINE 0.001 SPRAY 3 EX

TYZINE 0.001 DROPS 3 EX





Requirements/Limits

Diabetes

Blood Sugar Diagnostics

FREESTYLE INSULINX STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

FREESTYLE INSULINX TEST STRIPS

STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

FREESTYLE LITE STRIPS STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

FREESTYLE PRECISION NEO STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

FREESTYLE TEST STRIPS STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

PRECISION XTRA STRIP 0 EX; QL: LIMIT 200 PER 30 DAYS; $0 COPAY

Diabetic Supplies ACCU-CHEK KIT 3 EX

ANIMAS VIBE EACH 3 EX

AUTOSOFT 30 INFUS.SET 3 EX

AUTOSOFT 90 INFUS.SET 3 EX

AUTOSOFT XC INFUS.SET 3 EX

CLEO 90 INFUSION SET INFUS.SET 3 EX

COMFORT INFUS.SET 3 EX

COMFORT SHORT INFUS.SET 3 EX

CONTACT DETACH INFUSION SET

INFUS.SET 3 EX

DEXCOM EACH 3 EX; PA

DEXCOM G4 EACH 3 EX; PA


DEXCOM G5-G4 SENSOR EACH 3 EX; PA


ENLITE EACH 3 EX

ENLITE GLUCOSE SENSOR EACH 3 EX

ENLITE SERTER MISCELL 3 EX

FREESTYLE LIBRE 10 DAY READER

EACH 2 EX; PA

FREESTYLE LIBRE 14 DAY READER

EACH 3 EX; PA

FREESTYLE NAVIGATOR EACH 3 EX

GLUCOCOM AUTOLINK MISCELL 3 EX

GUARDIAN LINK 3 EACH 3 EX

GUARDIAN RT CHARGER EACH 3 EX





Requirements/Limits

GUARDIAN RT STARTER KIT KIT 3 EX

GUARDIAN RT SYSTEM EACH 3 EX

GUARDIAN SENSOR 3 EACH 3 EX

GUARDIAN TEST PLUG EACH 3 EX

INPEN (FOR HUMALOG) INSULN PEN 3 EX

INPEN (FOR NOVOLOG) INSULN PEN 3 EX

INSET 30 INFUSION SET INFUS.SET 3 EX

INSET INFUSION SET INFUS.SET 3 EX

MINILINK REAL-TIME TRANSMITTER

EACH 3 EX

MINIMED INFUS.SET 3 EX

MINIMED 530G EACH 3 EX


MINIMED 630G GUARDIAN START KT

EACH 3 EX


MINIMED PRO-SET INFUS.SET 3 EX

MIO INFUSION SET INFUS.SET 3 EX

ONETOUCH PING EACH 3 EX

ONETOUCH SURESOFT 21 GAUGE EACH 2 EX

PARADIGM REAL-TIME EACH 3 EX

QUICK-SET PARADIGM INFUS.SET 3 EX

REPLACEMENT PEDIATRIC MONITOR

EACH 3 EX

REVEL PROGRAMMABLE PUMP EACH 3 EX

SEN-SERTER EACH 3 EX

SOF-SENSOR EACH 3 EX

SURE-T PARADIGM INFUS.SET 3 EX

T:30 INFUSION SET INFUS.SET 3 EX

T:90 INFUS.SET 3 EX

T:FLEX CARTRIDGE 3 EX

T:SLIM CARTRIDGE 3 EX

T:SLIM G4 EACH 3 EX

T:SLIM X2 EACH 3 EX

T:SLIM X2 WITH BASAL-IQ EACH 3 EX

TRUSTEEL INFUSION SET INFUS.SET 3 EX

UNISTIK 2 NORMAL KIT 3 EX

VARISOFT INFUSION SET INFUS.SET 3 EX





Requirements/Limits

Endocrine Disorder - Fertility

Drugs to Treat Erectile Dysfunction

CAVERJECT 10 MCG KIT 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH

CAVERJECT 20 MCG KIT 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH

CAVERJECT 20 MCG VIAL 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH

CAVERJECT 40 MCG VIAL 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH

CIALIS 10 MG TABLET 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH; ST: TRIAL OF SILDENAFIL (VIAGRA) REQUIRED.

CIALIS 20 MG TABLET 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH; ST: TRIAL OF SILDENAFIL (VIAGRA) REQUIRED.

EDEX 10 MCG KIT 3 EX; QL: 6 INJECTIONS PER 30 DAYS



ife-bimix 30/1 30-1MG/ML VIAL 1 EX

ife-pg20 20 MCG/ML VIAL 1 EX

MUSE 125 MCG SUPP.URETH 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH




papaverine-phentolmn-alprostdl 12-1-10/ML VIAL 1 EX

papaverine-phentolmn-alprostdl 30-1-20/ML VIAL 1 EX

papaverine-phentolamine 30-1MG/ML VIAL 1 EX

sildenafil citrate 25 MG TABLET 1 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH







Requirements/Limits

VIAGRA 25 MG TABLET 3 EX; QL: 1 IN 5 DAYS; LIMIT 6 PER MONTH



Drugs to Treat Sexual Dysfunction

ADDYI 100 MG TABLET 3 EX; PA;

Endocrine Disorder - Fertility

Follicle-Stimulating Hormone (FSH)

BRAVELLE 75 UNIT VIAL 4 EX; ST: TRIAL OF GONAL-F OR GONAL-F-RFF REQUIRED

FOLLISTIM AQ 300/0.36ML CARTRIDGE 4 EX; ST: TRIAL OF GONAL-F OR GONAL-F-RFF REQUIRED



GONAL-F 450 UNIT VIAL 4 EX

GONAL-F 1050 UNIT VIAL 4 EX

GONAL-F RFF 75 UNIT VIAL 4 EX

GONAL-F RFF REDI-JECT 300/0.5ML PEN INJCTR 4 EX

GONAL-F RFF REDI-JECT 450/0.75ML PEN INJCTR 4 EX

GONAL-F RFF REDI-JECT 900/1.5 ML PEN INJCTR 4 EX

Smoking Cessation

Smoking Deterrent Agents (Ganglionic Stim,Others)

NICODERM CQ 7MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

NICODERM CQ 14MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS





Requirements/Limits

NICODERM CQ 21 MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

nicorelief 2 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicorelief 4 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

NICORETTE 2 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

NICORETTE 2 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

NICORETTE 2 MG LOZNG MINI 0 EX

NICORETTE 4 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

NICORETTE 4 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicotine gum 2 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicotine gum 4 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicotine lozenge 2 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicotine lozenge 2 MG LOZNG MINI 0 EX

nicotine lozenge 4 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

nicotine lozenge 4 MG LOZNG MINI 0 EX

nicotine patch 7MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

nicotine patch 14MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

nicotine patch 21 MG/24HR PATCH TD24 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

NICOTINE PATCH 21-14-7MG PATCH DYSQ 0 EX; QL: 1 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

quit 2 2 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

quit 2 2 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS





Requirements/Limits

quit 4 4 MG GUM 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

quit 4 4 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR; AGE LIMIT: >= 18 YEARS

stop smoking aid 2 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

stop smoking aid 4 MG LOZENGE 0 EX; QL: 9 IN 1 DAY; LIMITED TO 180 PER YEAR

Endocrine Disorder - Thyroid

Antithyroid Preparations TAPAZOLE 5 MG TABLET 3 EX

TAPAZOLE 10 MG TABLET 3 EX

Iodine Containing Agents sski 1 G/ML SOLUTION 1 EX

strong iodine 0.05 SOLUTION 1 EX

Thyroid Hormones ARMOUR THYROID 15 MG TABLET 2 EX

ARMOUR THYROID 30 MG TABLET 2 EX







nature-throid 16.25 MG TABLET 1 EX



nature-throid 65 MG TABLET 1 EX










np thyroid 15 MG TABLET 1 EX





Requirements/Limits





thyroid 15 MG TABLET 1 EX





westhroid 32.5 MG TABLET 1 EX

westhroid 65 MG TABLET 1 EX

westhroid 97.5 MG TABLET 1 EX



wp thyroid 16.25 MG TABLET 1 EX



wp thyroid 65 MG TABLET 1 EX




wp thyroid 130 MG TABLET 1 EX

Vitamin And/Or Mineral Deficiency

Calcium Replacement tl g-fol os 500-1.1MG TABLET 1 EX

Fluoride Preparations CLINPRO 5000 0.011 PASTE (G) 3 EX

denta 5000 plus 0.011 CREAM (G) 1 EX

dentagel 0.011 GEL (GRAM) 1 EX

fluoride 0.25(0.55) TAB CHEW 0 EX; AGE LIMIT: <= 6 YEARS

fluoride 0.5(1.1)MG TAB CHEW 0 EX; AGE LIMIT: <= 6 YEARS

fluoride 1MG(2.2MG) TAB CHEW 0 EX; AGE LIMIT: <= 6 YEARS

FLUORIDEX 0.011 PASTE (G) 3 EX

FLURA-DROPS 0.25MG/DRP DROPS 2 EX

PREVIDENT 0.002 SOLUTION 3 EX

PREVIDENT 0.011 PASTE (ML) 3 EX

PREVIDENT 0.011 GEL (GRAM) 3 EX


PREVIDENT 0.011 GEL (GRAM) 3 EX





Requirements/Limits


PREVIDENT 0.011 PASTE (ML) 3 EX

PREVIDENT 5000 0.011 GEL (ML) 3 EX

PREVIDENT 5000 ENAMEL PROTECT

1.1%-5% PASTE (ML) 3 EX

PREVIDENT 5000 PLUS 0.011 CREAM (G) 3 EX

PREVIDENT 5000 SENSITIVE 1.1%-5% PASTE (ML) 3 EX

sf 0.011 GEL (GRAM) 1 EX

sf 5000 plus 0.011 CREAM (G) 1 EX

sodium fluoride 0.5 MG/ML DROPS 0 EX; AGE LIMIT: <= 6 YEARS

sodium fluoride 0.5(1.1)MG TAB CHEW 0 EX; AGE LIMIT: <= 6 YEARS

sodium fluoride 1MG(2.2MG) TAB CHEW 0 EX; AGE LIMIT: <= 6 YEARS

Folic Acid Preparations folic acid 0.4 MG TABLET 0 EX

folic acid 0.8 MG TABLET 0 EX

folic acid 1 MG TABLET 1 EX

folic acid 5 MG/ML VIAL 1 EX

Iron Replacement children's ferrous sulfate 15 MG/ML DROPS 0 EX; AGE LIMIT: < 1 YEARS

children's iron 15 MG/ML DROPS 0 EX; AGE LIMIT: < 1 YEARS

ferrous sulfate 15 MG/ML DROPS 0 EX; AGE LIMIT: < 1 YEARS

pedia iron 15 MG/ML DROPS 0 EX; AGE LIMIT: < 1 YEARS

Vitamin B Preparations POTABA 500 MG CAPSULE 3 EX

I-1

Index of Drugs

1st Gen Antihistamine & Decongestant Combinations............................................ 162

1st Gen Antihist-Decongest-Anticholinergic Comb ...... 163

abacavir .................................... 69 abacavir-lamivudine .................. 69 abacavir-lamivudine-zidovudine 69 ABELCET .................................. 54 ABILIFY ..................................... 65 ABILIFY MAINTENA ........... 64, 65 ABILIFY MYCITE ...................... 65 ABRAXANE .............................. 29 ABSORICA ............................. 105 ABSTRAL .................................... 7 acamprosate ............................. 16 ACANYA ................................. 107 acarbose ................................... 48 ACCOLATE ............................. 154 ACCU-CHEK ........................... 167 ACCUPRIL ................................ 82 ACCURETIC ............................. 82 acebutolol .................................. 84 acetaminophen-caff-dihydrocod .. 7 acetaminophen-codeine .............. 7 acetazolamide ................. 148, 149 acetazolamide sodium ............ 149 acetic acid ....................... 116, 143 acetylcysteine ......................... 156 ACIPHEX ................................ 120 ACIPHEX SPRINKLE .............. 120 acitretin ................................... 105 ACTEMRA .............................. 135 ACTEMRA ACTPEN ............... 135 ACTHAR ................................. 146 ACTHIB (PF) ........................... 140 ACTIGALL ............................... 121 ACTIMMUNE .......................... 146 ACTIQ ......................................... 7 ACTIVELLA ............................. 127 ACTONEL ............................... 144 ACTOPLUS MET ...................... 48 ACTOPLUS MET XR ................ 48 ACTOS ...................................... 48 ACULAR ................................. 118 ACULAR LS ............................ 118

ACUVAIL (PF) ......................... 118 acyclovir ............................ 73, 105 acyclovir sodium ........................ 73 ACZONE ................................. 105 ADACEL(TDAP

ADOLESN/ADULT)(PF) ...... 140 ADAGEN ................................. 113 ADALAT CC .............................. 88 adapalene ............................... 112 ADAPALENE ........................... 112 adapalene-benzoyl peroxide ... 112 ADASUVE ................................. 65 ADCIRCA ................................ 160 ADDERALL XR ......................... 94 ADDYI ..................................... 170 adefovir ..................................... 73 ADEMPAS ............................... 160 ADLYXIN ................................... 48 ADMELOG SOLOSTAR U-100

INSULIN ................................ 51 ADMELOG U-100 INSULIN

LISPRO ................................. 51 ADRENALIN .............................. 87 ADRENALIN CHLORIDE ........ 166 adriamycin ................................. 29 adrucil........................................ 29 ADVAIR DISKUS..................... 153 ADVAIR HFA ........................... 153 ADZENYS ER ........................... 94 ADZENYS XR-ODT ................... 94 AEROSPAN ............................ 153 afeditab cr ................................. 88 AFINITOR ................................. 30 AFINITOR DISPERZ ................. 29 afirmelle ..................................... 98 AFREZZA .................................. 51 AGGRENOX ............................. 77 AGRYLIN .................................. 77 a-hydrocort .............................. 129 AIMOVIG AUTOINJECTOR ...... 58 AIMOVIG AUTOINJECTOR (2

PACK) ................................... 58 AIRDUO RESPICLICK ............ 153 AJOVY ...................................... 58 AKOVAZ .................................... 87 AKTEN (PF) ............................ 115

AKTIPAK ................................ 107 AKYNZEO (FOSNETUPITANT) 60 AKYNZEO (NETUPITANT) ...... 60 ala-cort ................................... 108 ala-scalp ................................. 108 albendazole .............................. 62 ALBENZA ................................. 62 albuterol sulfate ...................... 155 alcaine .................................... 115 alclometasone ........................ 108 ALCOHOL PADS ................... 105 ALDACTAZIDE ......................... 90 ALDACTONE ........................... 90 ALDARA ................................. 105 ALDURAZYME ....................... 113 ALECENSA .............................. 30 alendronate ............................ 144 alfuzosin ................................. 125 ALIMTA .................................... 30 ALINIA ...................................... 62 ALIQOPA .................................. 30 aliskiren .................................... 93 ALKERAN (AS HCL) ................ 30 allopurinol ................................. 56 allopurinol sodium .................... 56 ALLZITAL ................................... 7 almotriptan malate .................... 58 ALOCRIL ................................ 118 alogliptin ................................... 48 alogliptin-metformin .................. 48 alogliptin-pioglitazone ............... 48 ALOMIDE ............................... 115 ALOPRIM ................................. 56 ALORA ................................... 127 alosetron ................................. 142 ALOXI ....................................... 60 ALPHAGAN P ........................ 149 alprazolam ................................ 17 ALREX.................................... 118 ALTABAX ............................... 107 ALTACE ................................... 82 altavera (28) ............................. 98 ALTOPREV .............................. 91 ALTRENO .............................. 112 ALUNBRIG ............................... 30 ALVESCO .............................. 153

I-2

alyacen 1/35 (28) ...................... 99 alyacen 7/7/7 (28) ..................... 99 alyq ......................................... 160 amabelz .................................. 127 amantadine hcl .......................... 63 AMARYL ................................... 53 AMBIEN .................................. 158 AMBIEN CR ............................ 158 AMBISOME ............................... 54 ambrisentan ............................ 160 amcinonide .............................. 108 AMERGE .................................. 58 amethia ..................................... 99 amethia lo ................................. 99 AMICAR .................................... 77 amifostine crystalline ............... 146 amikacin .................................... 20 amiloride ................................... 90 amiloride-hydrochlorothiazide ... 90 aminocaproic acid ..................... 77 aminophylline .......................... 155 AMINOSYN 10 % ...................... 78 AMINOSYN 7 % WITH

ELECTROLYTES ................. 78 AMINOSYN 8.5 % ..................... 78 AMINOSYN 8.5 %-

ELECTROLYTES ................. 78 AMINOSYN II 10 % ................... 78 AMINOSYN II 15 % ................... 78 AMINOSYN II 7 % ..................... 78 AMINOSYN II 8.5 % .................. 78 AMINOSYN II 8.5 %-

ELECTROLYTES ................. 78 AMINOSYN M 3.5 % ................. 78 AMINOSYN-HBC 7% ................ 78 AMINOSYN-PF 10 % ................ 78 AMINOSYN-PF 7 % (SULFITE-

FREE) ................................... 78 AMINOSYN-RF 5.2 % ............... 78 amiodarone ............................... 83 AMITIZA .................................. 121 amitriptyline ............................... 45 amitriptyline-chlordiazepoxide ... 45 amlodipine ................................. 88 amlodipine-atorvastatin ............. 91 amlodipine-benazepril ............... 89 amlodipine-olmesartan .............. 89 amlodipine-valsartan ................. 89 amlodipine-valsartan-hcthiazid .. 89

ammonium lactate ................... 105 AMMONUL .............................. 150 amnesteem ............................. 105 amoxapine ................................. 45 amoxicil-clarithromy-lansopraz 120 amoxicillin .................................. 26 amoxicillin-pot clavulanate ........ 26 amphotericin b ........................... 54 ampicillin ................................... 26 ampicillin sodium ....................... 26 ampicillin-sulbactam .................. 26 AMPYRA ................................... 94 AMRIX ..................................... 157 ANADROL-50 .......................... 126 ANAFRANIL .............................. 45 anagrelide ................................. 77 ANAPROX DS ........................... 13 ANASCORP ............................ 135 anastrozole ................................ 30 ANCOBON ................................ 54 ANDRODERM ......................... 126 ANDROGEL ............................ 126 ANDROID ................................ 126 ANGELIQ ................................ 127 ANIMAS VIBE ......................... 167 ANORO ELLIPTA .................... 155 ANTARA .................................... 91 Antithyroid Preparations ...... 172 Antitussives,Non-Narcotic ... 163 ANTIVENIN, MICRURUS

FULVIUS ............................. 135 ANZEMET ................................. 60 APEXICON E .......................... 108 APIDRA SOLOSTAR U-100

INSULIN ................................ 51 APIDRA U-100 INSULIN ........... 51 APLENZIN ................................. 45 APOKYN ................................... 63 apraclonidine ........................... 115 aprepitant .................................. 60 apri ............................................ 99 APRISO ................................... 143 APTENSIO XR .......................... 94 APTIOM .................................... 39 APTIVUS ................................... 69 ARALAST NP .......................... 156 aranelle (28) .............................. 99 ARANESP (IN POLYSORBATE)

........................................ 75, 76

ARAVA ................................... 135 ARCALYST ............................ 135 ARCAPTA NEOHALER .......... 155 ARICEPT .................................. 44 ARIKAYCE ............................... 20 ARIMIDEX ................................ 30 aripiprazole ............................... 65 ARISTADA ............................... 65 ARISTADA INITIO .................... 65 ARISTOSPAN INTRA-

ARTICULAR ....................... 129 ARISTOSPAN INTRALESIONAL

........................................... 129 ARIXTRA .................................. 74 armodafinil .............................. 158 ARMONAIR RESPICLICK ...... 153 ARMOUR THYROID .............. 172 ARNUITY ELLIPTA ................ 153 AROMASIN .............................. 30 ARRANON ............................... 30 arsenic trioxide ......................... 30 ARTHROTEC 50 ...................... 13 ARTHROTEC 75 ...................... 13 ARYMO ER ................................ 7 ARZERRA ................................ 30 ascomp with codeine .................. 7 ashlyna ..................................... 99 ASMANEX HFA ...................... 153 ASMANEX TWISTHALER ...... 153 aspirin-dipyridamole ................. 77 ASSURE ID INSULIN SAFETY

........................................... 113 ASTAGRAF XL ....................... 135 ASTEPRO .............................. 115 ATACAND ................................ 81 ATACAND HCT ........................ 81 atazanavir ................................. 69 ATELVIA ................................. 144 atenolol ..................................... 84 atenolol-chlorthalidone ............. 84 ATGAM................................... 135 ATIVAN .................................... 17 atomoxetine .............................. 94 atorvastatin ............................... 91 atovaquone ............................... 62 atovaquone-proguanil ............... 62 ATRALIN ................................ 112 ATRIPLA .................................. 69 atropine .............................39, 115

I-3

ATROVENT HFA .................... 155 AUBAGIO .................................. 94 aubra ......................................... 99 AUGMENTIN ............................ 26 AUGMENTIN ES-600 ................ 26 AUGMENTIN XR....................... 26 aurovela 1.5/30 (21) .................. 99 aurovela 1/20 (21) ..................... 99 aurovela 24 fe ........................... 99 aurovela fe 1.5/30 (28) .............. 99 aurovela fe 1-20 (28) ................. 99 AURYXIA ................................ 124 AUSTEDO ................................. 94 AUTOSOFT 30 ....................... 167 AUTOSOFT 90 ....................... 167 AUTOSOFT XC....................... 167 AUVI-Q ...................................... 87 AVALIDE ................................... 81 AVANDAMET ............................ 48 AVANDIA .................................. 48 AVAPRO ................................... 81 AVASTIN ................................... 30 AVC VAGINAL .......................... 57 AVEED .................................... 126 AVELOX .................................... 27 AVELOX IN NACL (ISO-

OSMOTIC) ............................ 27 aviane ....................................... 99 AVODART ............................... 125 AVONEX ................................... 94 AVONEX (WITH ALBUMIN) ...... 94 AVYCAZ .................................... 23 AXERT ...................................... 58 AXIRON .................................. 126 ayuna ........................................ 99 azacitidine ................................. 30 AZACTAM ................................. 25 AZASITE ................................. 116 azathioprine ............................ 135 azathioprine sodium ................ 135 azelaic acid ............................. 105 azelastine ................................ 115 AZELEX .................................. 105 AZILECT ................................... 63 azithromycin ........................ 24, 25 AZOPT .................................... 149 AZOR ........................................ 89 aztreonam ................................. 25 AZULFIDINE ........................... 143

AZULFIDINE EN-TABS ........... 143 azurette (28) .............................. 99 baciim ........................................ 20 bacitracin ........................... 20, 116 bacitracin-polymyxin b ............. 116 baclofen ................................... 157 BACTRIM .................................. 28 BACTRIM DS ............................ 28 BACTROBAN .......................... 107 BACTROBAN NASAL ............. 107 balsalazide .............................. 143 BALVERSA ............................... 30 balziva (28) ................................ 99 BANZEL .................................... 39 BARACLUDE ............................ 73 BASAGLAR KWIKPEN U-100

INSULIN ................................ 51 BAVENCIO ................................ 30 BAXDELA .................................. 27 BCG VACCINE, LIVE (PF) ...... 140 BD ULTRA-FINE NANO PEN

NEEDLE ............................. 113 BD VEO INSULIN SYR HALF

UNIT ................................... 113 BD VEO INSULIN SYRINGE UF

............................................ 113 BECONASE AQ ...................... 118 bekyree (28) .............................. 99 BELBUCA ................................... 7 BELEODAQ .............................. 30 BELSOMRA ............................ 158 benazepril .................................. 82 benazepril-hydrochlorothiazide.. 82 BENDEKA ................................. 30 BENICAR .................................. 81 BENICAR HCT .......................... 81 BENLYSTA ............................. 146 BENTYL .................................. 121 BENZACLIN ............................ 107 BENZACLIN PUMP ................. 107 BENZAMYCIN ......................... 107 benzonatate ............................ 163 benztropine ............................... 63 BEPREVE ............................... 115 BERINERT ................................ 76 BESIVANCE ............................ 116 BESPONSA .............................. 30 BETAGAN ............................... 149 betamethasone acet,sod phos 129

betamethasone dipropionate . 108, 109

betamethasone valerate ......... 109 betamethasone, augmented ... 109 BETAPACE .............................. 84 BETAPACE AF ......................... 84 BETASERON ........................... 95 betaxolol ............................84, 149 bethanechol chloride .............. 124 BETHKIS .................................. 20 BETIMOL ................................ 149 BETOPTIC S .......................... 149 BEVESPI AEROSPHERE ...... 155 BEVYXXA ................................. 74 bexarotene ............................... 30 BEXSERO .............................. 140 bicalutamide ............................. 30 BICILLIN C-R ........................... 26 BICILLIN L-A ............................ 26 BICNU ...................................... 30 BIDIL ........................................ 93 BIJUVA ................................... 127 BIKTARVY ................................ 69 BILTRICIDE .............................. 62 bimatoprost ............................. 149 BINOSTO ............................... 144 bisoprolol fumarate ................... 84 bisoprolol-hydrochlorothiazide .. 84 BIVIGAM ................................ 135 bleomycin ................................. 30 bleph-10 ................................. 116 BLEPHAMIDE ........................ 116 BLINCYTO ............................... 30 blisovi 24 fe .............................. 99 blisovi fe 1.5/30 (28) ................. 99 blisovi fe 1/20 (28) .................... 99 Blood Sugar Diagnostics ..... 167 BONIVA .................................. 144 BONJESTA .............................. 60 BOOSTRIX TDAP .................. 140 BORTEZOMIB .......................... 30 BOSULIF .................................. 30 BOTOX ................................... 146 BRAFTOVI ............................... 30 BRAVELLE ............................. 170 BREO ELLIPTA ...................... 153 BREVIBLOC ............................. 84 BREVIBLOC IN NACL (ISO-OSM)

............................................. 84

I-4

briellyn ....................................... 99 BRILINTA .................................. 77 brimonidine ............................. 149 BRISDELLE ............................ 146 BRIVIACT ................................. 39 bromfed dm ............................. 166 bromfenac ............................... 118 bromocriptine ............................ 63 brompheniramine-pseudoephed-

dm ....................................... 166 BROMSITE ............................. 118 BRYHALI ................................. 109 budesonide ..................... 143, 153 bumetanide ............................... 90 BUNAVAIL ................................ 16 BUPHENYL ............................. 121 BUPRENEX ................................ 7 buprenorphine ............................. 7 buprenorphine hcl ................. 7, 16 buprenorphine-naloxone ........... 16 bupropion hcl ............................ 45 bupropion hcl (smoking deter) ... 16 buspirone .................................. 17 busulfan .................................... 30 BUSULFEX ............................... 31 butalbital compound w/codeine ... 7 butalbital compound-codeine ...... 7 butalbital-acetaminop-caf-cod ..... 7 butalbital-acetaminophen ............ 7 butalbital-acetaminophen-caff . 7, 8 butalbital-aspirin-caffeine ............ 8 BUTISOL ................................. 158 butorphanol tartrate ..................... 8 BUTRANS ................................... 8 BYDUREON .............................. 48 BYDUREON BCISE .................. 48 BYETTA .................................... 48 BYSTOLIC ................................ 84 BYVALSON ............................... 84 cabergoline ............................... 63 CABLIVI .................................. 146 CABOMETYX ........................... 31 CADUET ................................... 91 CAFCIT ..................................... 95 caffeine citrate ........................... 95 CALAN ...................................... 86 CALAN SR ................................ 86 calcipotriene ............................ 105 calcipotriene-betamethasone .. 105

calcitonin (salmon) .................. 144 calcitrene ................................. 105 calcitriol ........................... 105, 144 calcium acetate ....................... 124 calcium chloride ...................... 150 CALCIUM DISODIUM

VERSENATE ...................... 126 Calcium Replacement ........... 173 CALDOLOR .............................. 13 CALQUENCE ............................ 31 CAMBIA .................................... 13 camila ........................................ 99 CAMPTOSAR ........................... 31 CANASA ................................. 143 CANCIDAS ................................ 54 candesartan .............................. 81 candesartan-hydrochlorothiazid 81 capacet ........................................ 8 CAPASTAT ............................... 59 CAPCOF ................................. 163 CAPEX .................................... 109 CAPRELSA ............................... 31 captopril ..................................... 82 captopril-hydrochlorothiazide .... 82 CARAC .................................... 105 CARAFATE ............................. 120 CARBAGLU ............................ 121 carbamazepine .......................... 40 CARBATROL ............................ 40 carbidopa .................................. 63 carbidopa-levodopa ................... 63 carbidopa-levodopa-entacapone

.............................................. 63 carbinoxamine maleate ............. 57 carboplatin ................................. 31 CARDENE IV ............................ 89 CARDENE IV IN SODIUM

CHLORIDE ........................... 89 CARDIZEM ............................... 86 CARDIZEM CD ......................... 86 CARDIZEM LA .......................... 86 CARDURA ................................ 80 CARDURA XL ........................... 80 CARIMUNE NF NANOFILTERED

............................................ 135 carisoprodol ............................. 157 carisoprodol-asa-codeine ........ 157 carisoprodol-aspirin ................. 157 carmustine ................................. 31

CARNITOR ............................. 146 CAROSPIR ............................... 93 carteolol .................................. 149 cartia xt ..................................... 86 carvedilol .................................. 84 carvedilol phosphate................. 84 CASODEX ................................ 31 caspofungin .............................. 54 CATAPRES .............................. 80 CATAPRES-TTS-1 ................... 80 CATAPRES-TTS-2 ................... 80 CATAPRES-TTS-3 ................... 80 CAVERJECT .......................... 169 CAYA CONTOURED .............. 162 CAYSTON ................................ 25 caziant (28) ............................... 99 CEDAX ..................................... 23 cefaclor ..................................... 23 cefadroxil .................................. 23 cefazolin ................................... 23 cefazolin in dextrose (iso-os) .... 23 cefdinir ...................................... 23 cefditoren pivoxil ....................... 23 cefepime ................................... 23 cefixime .................................... 23 CEFOTAN ................................ 23 cefotaxime ................................ 23 cefotetan ................................... 23 cefoxitin .................................... 23 cefpodoxime ............................. 23 cefprozil .................................... 23 ceftazidime ............................... 24 ceftibuten .................................. 24 CEFTIN .................................... 24 ceftriaxone ................................ 24 cefuroxime axetil ...................... 24 cefuroxime sodium ................... 24 CELEBREX .............................. 13 celecoxib .................................. 13 CELESTONE SOLUSPAN ..... 129 CELEXA ................................... 45 CELLCEPT ............................. 135 CELLCEPT INTRAVENOUS .. 135 CELONTIN ............................... 40 CENTANY .............................. 107 centergy........................... 162, 166 centergy dm ............................ 166 cephalexin ................................ 24 CEPROTIN (BLUE BAR) .......... 74

I-5

CEQUA ................................... 118 CERDELGA ............................ 113 CEREBYX ................................. 40 CEREZYME ............................ 113 CESAMET ................................. 60 CETRAXAL ............................. 116 CETYLEV ................................ 146 cevimeline ............................... 104 CHANTIX .................................. 16 CHANTIX CONTINUING MONTH

BOX ...................................... 16 CHANTIX STARTING MONTH

BOX ...................................... 16 chateal (28) ............................... 99 CHEMET ................................. 126 CHENODAL ............................ 113 cheratussin ac ......................... 165 chloramphenicol sod succinate . 20 chlordiazepoxide hcl .................. 17 chlordiazepoxide-clidinium ........ 39 chlorhexidine gluconate .......... 104 chloroquine phosphate .............. 62 chlorothiazide ............................ 90 chlorothiazide sodium ............... 90 chlorpromazine ......................... 65 chlorpropamide ......................... 53 chlorthalidone ............................ 90 chlorzoxazone ......................... 157 CHOLBAM .............................. 122 cholestyramine (with sugar) ...... 91 cholestyramine light .................. 91 CHORIONIC GONADOTROPIN,

HUMAN .............................. 131 CIALIS ............................. 160, 169 ciclopirox ................................... 54 cidofovir ..................................... 73 cilostazol ................................... 77 CILOXAN ................................ 116 CIMDUO ................................... 69 cimetidine ................................ 120 cimetidine hcl .......................... 120 CIMZIA .................................... 135 CIMZIA POWDER FOR

RECONST .......................... 135 cinacalcet ................................ 144 CINQAIR ................................. 156 CINRYZE .................................. 76 CINVANTI ................................. 60 CIPRO ....................................... 27

CIPRO HC ............................... 116 CIPRO IN D5W ......................... 27 CIPRO XR ................................. 27 CIPRODEX ............................. 116 ciprofloxacin .............................. 28 ciprofloxacin (mixture) ............... 27 ciprofloxacin hcl ................. 27, 116 ciprofloxacin in 5 % dextrose ..... 27 ciprofloxacin lactate ................... 27 cisplatin ..................................... 31 citalopram .................................. 45 cladribine ................................... 31 CLAFORAN ............................... 24 claravis .................................... 105 CLARINEX ................................ 57 CLARINEX-D 12 HOUR ............ 57 clarithromycin ............................ 25 clemastine ................................. 57 CLENPIQ ................................ 123 CLEO 90 INFUSION SET ....... 167 CLEOCIN ............................ 21, 57 CLEOCIN HCL .......................... 20 CLEOCIN IN 5 % DEXTROSE .. 21 CLEOCIN T ............................. 107 CLEVIPREX .............................. 89 CLIMARA ................................ 128 CLIMARA PRO ....................... 127 CLINDAGEL ............................ 107 clindamycin hcl .......................... 21 clindamycin in 5 % dextrose ...... 21 clindamycin palmitate hcl .......... 21 clindamycin phosphate 21, 57, 107 clindamycin-benzoyl peroxide . 107 clindamycin-tretinoin................ 107 CLINDESSE .............................. 57 CLINIMIX 5%/D15W SULFITE

FREE .................................... 78 CLINIMIX 5%/D25W SULFITE-

FREE .................................... 78 CLINIMIX 2.75%/D5W SULFIT

FREE .................................... 78 CLINIMIX 4.25%/D10W SULF

FREE .................................... 78 CLINIMIX 4.25%/D5W SULFIT

FREE .................................... 78 CLINIMIX 4.25%-D20W SULF-

FREE .................................... 78 CLINIMIX 4.25%-D25W SULF-

FREE .................................... 79

CLINIMIX 5%-D20W(SULFITE-FREE) .................................. 79

CLINIMIX E 2.75%/D10W SUL FREE ................................... 79

CLINIMIX E 2.75%/D5W SULF FREE ................................... 79



CLINIMIX E 4.25%/D5W SULF FREE ................................... 79

CLINIMIX E 5%/D15W SULFIT FREE ................................... 79



CLINPRO 5000 ...................... 173 clobazam .................................. 17 clobetasol ............................... 109 clobetasol-emollient ................ 109 CLOBEX ................................. 109 clocortolone pivalate ............... 109 clofarabine ................................ 31 CLOLAR ................................... 31 clomipramine ............................ 45 clonazepam .............................. 17 clonidine ................................... 80 clonidine hcl .........................80, 95 clopidogrel ................................ 77 clorazepate dipotassium ........... 17 clorpres..................................... 80 clotrimazole .............................. 54 clotrimazole-betamethasone .... 54 clovique .................................. 126 clozapine .................................. 65 CLOZARIL ...........................65, 66 COARTEM ............................... 62 codeine sulfate ........................... 8 codeine-guaifenesin ............... 165 coditussin ac ........................... 165 CODITUSSIN DAC ................. 164 COGENTIN .............................. 63 COLAZAL ............................... 143 colchicine .................................. 56 COLCRYS ................................ 56 colesevelam ............................. 91 COLESTID ............................... 91

I-6

COLESTID FLAVORED ............ 91 colestipol ................................... 91 colistin (colistimethate na) ......... 21 colocort ................................... 143 COLY-MYCIN M PARENTERAL

.............................................. 21 COLY-MYCIN S ...................... 116 COLYTE WITH FLAVOR PACKS

............................................ 123 COMBIGAN ............................ 149 COMBIPATCH ........................ 128 COMBIVENT RESPIMAT ....... 155 COMBIVIR ................................ 69 COMETRIQ ............................... 31 COMFORT .............................. 167 COMFORT SHORT ................ 167 COMPLERA .............................. 69 compro ...................................... 60 COMTAN .................................. 63 CONCEPTROL ....................... 162 CONCERTA .............................. 95 Condoms ............................... 162 CONDYLOX ............................ 105 constulose ............................... 122 CONTACT DETACH INFUSION

SET ..................................... 167 Contraception Other Drugs .. 162 Contraception/Oxytocics ...... 162 Contraceptives,Implantable . 162 Contraceptives,Intravaginal . 162 COPAXONE .............................. 95 COPIKTRA ................................ 31 CORDRAN TAPE LARGE ROLL

............................................ 109 COREG ..................................... 84 COREG CR ............................... 84 CORGARD ................................ 84 CORLANOR .............................. 87 cormax .................................... 109 CORTEF ................................. 129 CORTENEMA ......................... 143 cortisone ................................. 129 CORTISPORIN ....................... 107 CORTISPORIN-TC ................. 116 CORZIDE .................................. 85 COSENTYX (2 SYRINGES) ... 105 COSENTYX PEN (2 PENS) .... 105 COSMEGEN ............................. 31 COSOPT ................................. 149

COSOPT (PF) ......................... 149 COTELLIC ................................. 31 COTEMPLA XR-ODT ................ 95 Cough And Cold .................... 162 COUMADIN ............................... 74 COZAAR ................................... 81 CREON ................................... 113 CRESEMBA .............................. 54 CRESTOR ................................. 91 CRIXIVAN ................................. 69 cromolyn .................. 115, 122, 156 CROTAN ................................. 112 cryselle (28) ............................... 99 CRYSVITA .............................. 146 CUBICIN ................................... 21 CUPRIMINE ............................ 126 CUTAQUIG ............................. 136 CUTIVATE .............................. 109 CUVITRU ................................ 136 CUVPOSA ............................... 122 cyclafem 1/35 (28) ..................... 99 cyclafem 7/7/7 (28) .................... 99 CYCLESSA (28) ........................ 99 cyclobenzaprine ...................... 158 cyclopentolate ......................... 115 cyclophosphamide..................... 31 CYCLOPHOSPHAMIDE ........... 31 CYCLOSET ............................... 48 cyclosporine ............................ 136 cyclosporine modified .............. 136 CYKLOKAPRON ....................... 77 CYMBALTA ............................... 45 cyproheptadine .......................... 57 CYRAMZA ................................. 31 cyred ......................................... 99 cyred eq .................................... 99 CYSTADANE .......................... 146 CYSTAGON ............................ 113 CYSTARAN ............................. 115 cytarabine .................................. 31 cytarabine (pf) ........................... 31 CYTOGAM .............................. 136 CYTOMEL ............................... 134 CYTOTEC ............................... 120 CYTOVENE .............................. 73 D.H.E.45 .................................... 58 d10 %-0.45 % sodium chloride 150 d5 % and 0.9 % sodium chloride

............................................ 150

d5 %-0.45 % sodium chloride . 150 dacarbazine .............................. 31 DACOGEN ............................... 31 dactinomycin ............................ 31 DAKLINZA ................................ 72 dalfampridine ............................ 95 DALIRESP .............................. 156 DALVANCE .............................. 21 danazol ................................... 127 DANTRIUM ............................ 158 dantrolene .............................. 158 dapsone.............................59, 105 DAPTACEL (DTAP PEDIATRIC)

(PF) .................................... 140 daptomycin ............................... 21 DARAPRIM .............................. 62 darifenacin .............................. 125 DARZALEX .............................. 31 dasetta 1/35 (28) ...................... 99 dasetta 7/7/7 (28) ..................... 99 daunorubicin ............................. 31 DAURISMO .............................. 31 DAYPRO .................................. 13 daysee ...................................... 99 DAYTRANA .............................. 95 DDAVP ................................... 131 deblitane ................................. 100 decadron ................................ 129 decitabine ................................. 31 deferasirox .............................. 126 deferoxamine .......................... 126 DELESTROGEN .................... 128 DELSTRIGO ............................. 69 delyla (28) ............................... 100 DELZICOL .............................. 143 DEMADEX ................................ 90 demeclocycline ......................... 28 DEMEROL .................................. 8 DEMEROL (PF) .......................... 8 DEMSER .................................. 87 DENAVIR ............................... 105 denta 5000 plus ...................... 173 dentagel.................................. 173 DEPACON ................................ 40 DEPAKENE .............................. 40 DEPAKOTE .............................. 40 DEPAKOTE ER ........................ 40 DEPAKOTE SPRINKLES ......... 40 DEPEN TITRATABS .............. 126

I-7

DEPO-ESTRADIOL ................ 128 DEPO-MEDROL ..................... 129 DEPO-PROVERA ................... 133 DEPO-SUBQ PROVERA 104 . 133 DERMA-SMOOTHE/FS BODY

OIL ...................................... 109 DERMATOP ............................ 109 DERMOTIC OIL ...................... 118 DESCOVY ................................ 69 DESFERAL ............................. 126 desipramine .............................. 45 desloratadine ............................ 57 desmopressin .......................... 131 desog-e.estradiol/e.estradiol ... 100 desogestrel-ethinyl estradiol ... 100 DESONATE ............................ 109 desonide ................................. 109 desoximetasone ...................... 109 DESOXYN ................................ 95 DESVENLAFAXINE .................. 45 DESVENLAFAXINE FUMARATE

.............................................. 45 desvenlafaxine succinate .......... 45 DETROL ................................. 125 DETROL LA ............................ 125 dexamethasone ...................... 130 DEXAMETHASONE INTENSOL

............................................ 129 dexamethasone sodium phos (pf)

............................................ 130 dexamethasone sodium

phosphate ................... 118, 130 DEXCOM ................................ 167 DEXCOM G4 .......................... 167 DEXCOM G5 .......................... 167 DEXCOM G5-G4 SENSOR .... 167 DEXCOM G6 .......................... 167 DEXEDRINE SPANSULE ......... 95 DEXILANT .............................. 120 dexmethylphenidate .................. 95 dexrazoxane hcl ...................... 146 dextroamphetamine .................. 95 dextroamphetamine-amphetamine

.............................................. 95 dextrose 10 % in water (d10w) .. 79 dextrose 20 % in water (d20w) .. 79 dextrose 25 % in water (d25w) .. 79 dextrose 30 % in water (d30w) .. 79 dextrose 40 % in water (d40w) .. 79

dextrose 5 % in water (d5w) ...... 79 dextrose 50 % in water (d50w) .. 79 dextrose 70 % in water (d70w) .. 79 Diabetes ................................. 167 Diabetic Supplies .................. 167 Diaphragms/Cervical Cap ..... 162 DIASTAT ................................... 18 DIASTAT ACUDIAL ................... 18 diazepam ................................... 18 diazepam intensol ..................... 18 DIBENZYLINE ........................... 80 DICLEGIS ................................. 60 diclofenac epolamine................. 13 diclofenac potassium ................. 13 diclofenac sodium.............. 13, 118 diclofenac-misoprostol ............... 13 dicloxacillin ................................ 26 dicyclomine ............................. 122 didanosine ................................. 69 DIFFERIN ................................ 112 DIFICID ..................................... 25 diflorasone ............................... 109 DIFLUCAN ................................ 54 diflunisal .................................... 13 digitek ........................................ 87 digox.......................................... 87 digoxin ....................................... 87 DIGOXIN ................................... 87 dihydroergotamine..................... 58 DILANTIN .................................. 40 DILANTIN-125 ........................... 40 DILATRATE-SR ........................ 93 DILAUDID ................................... 8 DILAUDID (PF) ........................... 8 diltiazem hcl .............................. 86 dilt-xr ......................................... 86 dimenhydrinate .......................... 60 DIOVAN .................................... 81 DIOVAN HCT ............................ 81 DIPENTUM ............................. 143 diphenhydramine hcl ................. 57 diphenoxylate-atropine ............ 122 DIPROLENE ........................... 109 dipyridamole .............................. 77 DISKETS ..................................... 8 disopyramide phosphate ........... 83 disulfiram ................................... 16 DITROPAN XL ........................ 125 DIURIL ...................................... 90

DIURIL IV ................................. 90 divalproex ................................. 40 DIVIGEL ................................. 128 DOCEFREZ .............................. 31 docetaxel .................................. 32 dofetilide ................................... 83 DOLOPHINE .............................. 8 donepezil .................................. 44 DOPTELET (10 TAB PACK) .... 76 DOPTELET (15 TAB PACK) .... 76 DOPTELET (30 TAB PACK) .... 76 DORYX..................................... 28 DORYX MPC ............................ 28 dorzolamide ............................ 149 dorzolamide-timolol ................ 149 dorzolamide-timolol (pf) .......... 149 dotti ........................................ 128 DOVATO .................................. 69 DOVONEX ............................. 105 doxazosin ................................. 80 doxepin ..............................45, 105 doxercalciferol ........................ 144 DOXIL....................................... 32 doxorubicin ............................... 32 doxorubicin, peg-liposomal ....... 32 doxy-100 ................................... 28 doxycycline hyclate .................. 28 doxycycline monohydrate ....28, 29 doxylamine-pyridoxine (vit b6) .. 60 dronabinol ................................. 60 droperidol ............................... 146 drospirenone-ethinyl estradiol 100 DROXIA .................................... 32 Drugs to Treat Erectile

Dysfunction ...................... 169 Drugs to Treat Sexual

Dysfunction ...................... 170 DUAKLIR PRESSAIR ............. 155 DUAVEE ................................. 128 DUETACT ................................ 48 DUEXIS .................................... 13 DULERA ................................. 153 duloxetine ............................45, 46 DUOBRII ................................ 110 DUPIXENT ...................... 106, 136 DURAGESIC .............................. 8 DURAMORPH (PF) .................... 8 DUREZOL .............................. 118 dutasteride .............................. 125

I-8

dutasteride-tamsulosin ............ 125 DUTOPROL .............................. 85 DUZALLO ................................. 56 dvorah ......................................... 8 DXEVO ................................... 130 DYANAVEL XR ......................... 95 DYAZIDE .................................. 90 DYMISTA ................................ 115 DYRENIUM ............................... 90 DYSPORT ............................... 146 EC-NAPROSYN ........................ 13 econazole .................................. 54 EDARBI ..................................... 81 EDARBYCLOR ......................... 81 EDECRIN .................................. 90 EDEX ...................................... 169 EDLUAR ................................. 159 EDURANT ................................. 69 efavirenz ................................... 69 EFFEXOR XR ........................... 46 EFFIENT ................................... 77 EFUDEX ................................. 106 EGRIFTA ................................ 131 ELAPRASE ............................. 113 ELDEPRYL ............................... 63 electrolyte-48 in d5w ............... 150 ELELYSO ................................ 113 ELESTAT ................................ 115 ELESTRIN .............................. 128 eletriptan ................................... 58 ELIDEL .................................... 110 ELIGARD .................................. 32 ELIGARD (3 MONTH) ............... 32 ELIGARD (4 MONTH) ............... 32 ELIGARD (6 MONTH) ............... 32 ELIMITE .................................. 112 elinest ...................................... 100 eliphos ..................................... 124 ELIQUIS .................................... 74 ELITEK .................................... 113 elixophyllin .............................. 155 ELLA ....................................... 100 ELLENCE .................................. 32 ELMIRON ................................ 146 ELOCON ................................. 110 EMADINE ................................ 115 EMBEDA ..................................... 8 EMCYT ..................................... 32 EMEND ............................... 60, 61

EMEND (FOSAPREPITANT) .... 60 EMFLAZA ................................ 130 EMGALITY PEN ........................ 58 EMGALITY SYRINGE ............... 58 emoquette ............................... 100 EMPLICITI ................................. 32 EMSAM ..................................... 46 EMTRIVA .................................. 69 EMVERM .................................. 62 ENABLEX ................................ 125 enalapril maleate ....................... 82 enalaprilat .................................. 82 enalapril-hydrochlorothiazide .... 82 ENBREL .................................. 136 ENBREL MINI ......................... 136 ENBREL SURECLICK ............ 136 ENDARI ................................... 146 endocet ....................................... 8 Endocrine Disorder - Fertility

.................................... 169, 170 Endocrine Disorder - Thyroid

............................................ 172 ENGERIX-B (PF)..................... 140 ENGERIX-B PEDIATRIC (PF). 140 ENLITE .................................... 167 ENLITE GLUCOSE SENSOR . 167 ENLITE SERTER .................... 167 enoxaparin ................................ 74 enpresse ................................. 100 enskyce ................................... 100 ENSTILAR ............................... 106 entacapone ............................... 63 entecavir .................................... 73 ENTOCORT EC ...................... 143 ENTRESTO ............................... 81 ENTYVIO ................................ 136 enulose .................................... 122 ENVARSUS XR ...................... 136 EPANED ................................... 82 EPCLUSA ................................. 72 EPIDIOLEX ............................... 40 EPIDUO .................................. 112 EPIDUO FORTE ..................... 112 EPIFOAM ................................ 110 epinastine ................................ 115 epinephrine ............................... 87 EPIPEN 2-PAK .......................... 87 EPIPEN JR 2-PAK .................... 88 epirubicin ................................... 32

epitol ......................................... 40 EPIVIR...................................... 69 EPIVIR HBV ............................. 69 eplerenone ............................... 93 EPOGEN .................................. 76 epoprostenol (glycine) ............ 160 eprosartan ................................ 81 EPZICOM ................................. 69 EQUETRO ................................ 40 ERAXIS(WATER DILUENT) ..... 54 ERBITUX .................................. 32 ergoloid................................... 146 ERGOMAR ............................... 58 ergotamine-caffeine .................. 58 ERIVEDGE ............................... 32 ERLEADA ................................. 32 erlotinib ..................................... 32 errin ........................................ 100 ERTACZO ................................ 54 ertapenem ................................ 25 ERWINAZE .............................. 32 ery pads.................................. 107 ERYGEL ................................. 108 ery-tab ...................................... 25 ERY-TAB .................................. 25 erythrocin (as stearate) ............. 25 erythromycin ......................25, 116 erythromycin ethylsuccinate ..... 25 erythromycin with ethanol ....... 108 erythromycin-benzoyl peroxide 108 ESBRIET ................................ 157 escitalopram oxalate................. 46 ESGIC ........................................ 9 esmolol ..................................... 85 esomeprazole magnesium ..... 120 esomeprazole sodium ............ 120 estarylla .................................. 100 estazolam ................................. 18 estradiol .................................. 128 estradiol valerate .................... 128 estradiol-norethindrone acet ... 128 ESTRING ............................... 128 estropipate .............................. 128 ESTROSTEP FE-28 ............... 100 eszopiclone ............................ 159 ethacrynate sodium .................. 90 ethacrynic acid ......................... 90 ethambutol ................................ 59 ethosuximide ............................ 40

I-9

ethynodiol diac-eth estradiol ... 100 ETHYOL .................................. 146 etidronate disodium ................. 144 etodolac .................................... 13 ETOPOPHOS ........................... 32 etoposide .................................. 32 EUCRISA ................................ 110 EURAX .................................... 112 EVAMIST ................................ 128 EVEKEO ODT ........................... 95 EVENITY ................................. 144 EVISTA ................................... 128 EVOCLIN ................................ 108 EVOMELA ................................. 32 EVOTAZ .................................... 69 EVOXAC ................................. 105 EVZIO ....................................... 16 EXALGO ER ............................... 9 EXELDERM .............................. 54 EXELON ................................... 44 exemestane .............................. 32 EXFORGE ................................ 89 EXFORGE HCT ........................ 89 EXJADE .................................. 126 EXONDYS 51 ......................... 146 EXTAVIA ................................... 96 EXTINA ..................................... 54 EZALLOR SPRINKLE ............... 91 ezetimibe ................................... 91 ezetimibe-simvastatin ................ 91 FABIOR ................................... 112 FABRAZYME .......................... 114 falmina (28) ............................. 100 famciclovir ................................. 73 famotidine ............................... 120 famotidine (pf) ......................... 120 famotidine (pf)-nacl (iso-os) ... 120 FANAPT .................................... 66 FARESTON .............................. 32 FARXIGA .................................. 48 FARYDAK ................................. 32 FASENRA ............................... 157 FASENRA PEN ....................... 157 FASLODEX ............................... 32 fayosim .................................... 100 FAZACLO ................................. 66 FC2 FEMALE CONDOM ......... 162 febuxostat ................................. 56 felbamate .................................. 40

FELBATOL ................................ 40 FELDENE .................................. 13 felodipine ................................... 89 FEMARA ................................... 32 FEMCAP ................................. 162 FEMHRT LOW DOSE ............. 128 FEMRING ................................ 128 femynor ................................... 100 fenofibrate ................................. 91 fenofibrate micronized ............... 91 fenofibrate nanocrystallized ....... 91 fenofibric acid ............................ 91 fenofibric acid (choline) ............. 91 FENOGLIDE ............................. 92 fenoprofen ................................. 13 fentanyl ........................................ 9 fentanyl citrate ............................. 9 FENTORA ................................... 9 FERRIPROX ........................... 126 ferrous sulfate ......................... 174 FETZIMA ................................... 46 FIASP FLEXTOUCH U-100

INSULIN ................................ 51 FIASP U-100 INSULIN .............. 51 FIBRICOR ................................. 92 FINACEA ................................. 106 finasteride ................................ 125 FIORINAL .................................... 9 FIORINAL-CODEINE #3 ............. 9 FIRAZYR ................................... 88 FIRDAPSE .............................. 146 FIRMAGON KIT W DILUENT

SYRINGE ........................ 32, 33 FIRVANQ .................................. 21 FLAGYL .................................... 21 flavoxate .................................. 125 FLEBOGAMMA DIF ................ 136 flecainide ................................... 83 FLECTOR ................................. 13 FLOLAN .................................. 160 FLOLIPID .................................. 92 FLOMAX ................................. 125 FLOVENT DISKUS ......... 153, 154 FLOVENT HFA ....................... 154 floxuridine .................................. 33 fluconazole ................................ 54 fluconazole in nacl (iso-osm) ..... 54 flucytosine ................................. 54 fludarabine ................................ 33

fludrocortisone ........................ 130 FLUMADINE ............................. 72 flumazenil ................................. 96 flunisolide ............................... 118 fluocinolone ............................ 110 fluocinolone acetonide oil ....... 118 fluocinolone and shower cap .. 110 fluocinonide ............................ 110 fluocinonide-e ......................... 110 fluoride.................................... 173 Fluoride Preparations .......... 173 FLUORIDEX ........................... 173 fluorometholone ...................... 119 fluorouracil .........................33, 106 fluoxetine .................................. 46 fluphenazine decanoate ........... 66 fluphenazine hcl ....................... 66 FLURA-DROPS ...................... 173 flurandrenolide ........................ 110 flurazepam ................................ 18 flurbiprofen ............................... 13 flurbiprofen sodium ................. 119 flutamide ................................... 33 fluticasone propionate ..... 110, 119 fluticasone propion-salmeterol 154 fluvastatin ................................. 92 fluvoxamine .............................. 46 FML FORTE ........................... 119 FML S.O.P. ............................. 119 FOCALIN .................................. 96 FOCALIN XR ............................ 96 folic acid ................................. 174 Folic Acid Preparations ....... 174 Follicle-Stimulating Hormone

(FSH) ................................. 170 FOLLISTIM AQ ....................... 170 FOLOTYN ................................ 33 fomepizole .............................. 146 fondaparinux ............................. 74 FORFIVO XL ............................ 46 FORTAMET .............................. 48 FORTAZ ................................... 24 FORTEO ................................ 144 FOSAMAX .............................. 144 FOSAMAX PLUS D ................ 144 fosamprenavir ........................... 69 fosaprepitant ............................. 61 foscarnet ................................... 72 fosinopril ................................... 82

I-10

fosinopril-hydrochlorothiazide ... 82 fosphenytoin .............................. 40 FOSRENOL ............................ 124 FRAGMIN ........................... 74, 75 FREAMINE HBC 6.9 % ............. 79 FREAMINE III 10 % .................. 79 FREESTYLE INSULINX .......... 167 FREESTYLE INSULINX TEST

STRIPS ............................... 167 FREESTYLE LIBRE 10 DAY

READER ............................. 167 FREESTYLE LIBRE 14 DAY

READER ............................. 167 FREESTYLE LITE STRIPS ..... 167 FREESTYLE NAVIGATOR ..... 167 FREESTYLE PRECISION NEO

............................................ 167 FREESTYLE TEST STRIPS ... 167 FROVA ...................................... 58 frovatriptan ................................ 58 FULPHILA ................................. 76 fulvestrant ................................. 33 FURADANTIN ........................... 21 furosemide ................................ 90 FUSILEV ................................. 146 FUZEON ................................... 69 fyavolv ..................................... 128 FYCOMPA .......................... 40, 41 g tussin ac ............................... 165 gabapentin ................................ 41 GABITRIL .................................. 41 GALAFOLD ............................. 114 galantamine .............................. 44 GAMASTAN S/D ..................... 136 GAMMAGARD LIQUID ........... 136 GAMMAGARD S-D (IGA < 1

MCG/ML) ............................ 136 GAMMAKED ........................... 136 GAMMAPLEX ......................... 136 GAMMAPLEX (WITH SORBITOL)

............................................ 136 GAMUNEX-C .......................... 136 ganciclovir sodium..................... 73 GARDASIL 9 (PF) ................... 141 GASTROCROM ...................... 122 gatifloxacin .............................. 116 GATTEX 30-VIAL .................... 122 GAUZE PAD ........................... 113 gavilyte-c ................................. 123

gavilyte-g ................................. 123 gavilyte-n ................................. 123 GAZYVA .................................... 33 GELNIQUE .............................. 125 gemcitabine ............................... 33 gemfibrozil ................................. 92 GEMZAR ................................... 33 GENERESS FE ....................... 100 generlac .................................. 122 gengraf .................................... 136 GENOTROPIN ........................ 132 GENOTROPIN MINIQUICK .... 131 gentak ..................................... 116 gentamicin ................. 20, 108, 116 gentamicin in nacl (iso-osm) ...... 20 gentamicin sulfate (ped) (pf) ...... 20 gentamicin sulfate (pf) ............... 20 GENVOYA ................................ 69 GEODON .................................. 66 GIALAX ................................... 123 GIAZO ..................................... 143 gildagia .................................... 100 GILENYA ................................... 96 GILOTRIF .................................. 33 GLASSIA ................................. 157 glatiramer .................................. 96 glatopa ...................................... 96 GLEEVEC ................................. 33 GLEOSTINE .............................. 33 glimepiride ................................. 53 glipizide ..................................... 53 glipizide-metformin .................... 53 GLUCAGEN HYPOKIT ............. 48 GLUCAGON EMERGENCY KIT

(HUMAN) .............................. 49 GLUCOCOM AUTOLINK ........ 167 GLUCOPHAGE ......................... 49 GLUCOPHAGE XR ................... 49 GLUCOTROL ............................ 53 GLUCOTROL XL....................... 53 GLUCOVANCE ......................... 53 GLUMETZA ............................... 49 glyburide .................................... 53 glyburide micronized ................. 53 glyburide-metformin................... 53 glycine urologic solution .......... 143 glycopyrrolate .......................... 122 glycopyrrolate (pf) in water ...... 122 glydo.......................................... 15

GLYNASE ................................ 53 GLYSET ................................... 49 GLYXAMBI ............................... 49 GOCOVRI ................................ 63 GOLYTELY ............................ 123 GONAL-F ............................... 170 GONAL-F RFF ....................... 170 GONAL-F RFF REDI-JECT .... 170 GRALISE .................................. 41 GRALISE 30-DAY STARTER

PACK ................................... 41 granisetron (pf) ......................... 61 granisetron hcl .......................... 61 GRANIX .................................... 76 GRASTEK .............................. 146 griseofulvin microsize ............... 54 griseofulvin ultramicrosize ........ 55 GRIS-PEG (ULTRAMICROSIZE)

............................................. 55 guaiatussin ac ................. 165, 166 guaifenesin dac ...................... 164 guaifenesin-codeine ............... 166 guanfacine ...........................80, 96 guanidine ................................ 146 GUARDIAN LINK 3................. 167 GUARDIAN RT CHARGER .... 167 GUARDIAN RT STARTER KIT168 GUARDIAN RT SYSTEM ....... 168 GUARDIAN SENSOR 3 ......... 168 GUARDIAN TEST PLUG ........ 168 GYNOL II ................................ 162 HAEGARDA ............................. 76 hailey ...................................... 100 hailey 24 fe ............................. 100 HALAVEN ................................. 33 halcinonide ............................. 110 HALCION ................................. 18 HALDOL ................................... 66 HALDOL DECANOATE ............ 66 halobetasol propionate ........... 110 HALOG ................................... 110 haloperidol ................................ 66 haloperidol decanoate .............. 66 haloperidol lactate .................... 66 HARVONI ................................. 72 HAVRIX (PF) .......................... 141 heather ................................... 100 HECTOROL ........................... 145 HEMANGEOL .......................... 85

I-11

heparin (porcine) ....................... 75 heparin, porcine (pf) .................. 75 HEPATAMINE 8% ..................... 79 HEPSERA ................................. 73 HERCEPTIN ............................. 33 HERCEPTIN HYLECTA ............ 33 HETLIOZ ................................. 159 HEXALEN ................................. 33 HIBERIX (PF) .......................... 141 hidex ....................................... 130 HIPREX ..................................... 21 HISTEX-AC ............................. 163 HIZENTRA .............................. 137 HORIZANT ................................ 41 HUMALOG JUNIOR KWIKPEN U-

100 ........................................ 51 HUMALOG KWIKPEN INSULIN 51 HUMALOG MIX 50-50 INSULN U-

100 ........................................ 51 HUMALOG MIX 50-50 KWIKPEN

.............................................. 51 HUMALOG MIX 75-25 KWIKPEN

.............................................. 51 HUMALOG MIX 75-25(U-

100)INSULN ......................... 51 HUMALOG U-100 INSULIN ...... 52 HUMATROPE ......................... 132 HUMIRA .................................. 137 HUMIRA PEDIATRIC CROHNS

START ................................ 137 HUMIRA PEN ......................... 137 HUMIRA PEN CROHNS-UC-HS

START ................................ 137 HUMIRA PEN PSOR-UVEITS-

ADOL HS ............................ 137 HUMIRA(CF) ........................... 137 HUMIRA(CF) PEDI CROHNS

STARTER ........................... 137 HUMIRA(CF) PEN .................. 137 HUMIRA(CF) PEN CROHNS-UC-

HS ....................................... 137 HUMIRA(CF) PEN PSOR-UV-

ADOL HS ............................ 137 HUMULIN 70/30 U-100 INSULIN

.............................................. 52 HUMULIN 70/30 U-100 KWIKPEN

.............................................. 52 HUMULIN N NPH INSULIN

KWIKPEN ............................. 52

HUMULIN N NPH U-100 INSULIN .............................................. 52

HUMULIN R REGULAR U-100 INSULN ................................. 52

HUMULIN R U-500 (CONC) INSULIN ................................ 52

HUMULIN R U-500 (CONC) KWIKPEN ............................. 52

HYCAMTIN ............................... 33 hydralazine ................................ 88 HYDREA ................................... 33 hydrochlorothiazide ................... 90 hydrocod-cpm-pseudoephedrine

............................................ 163 hydrocodone-acetaminophen ...... 9 hydrocodone-chlorpheniramne er

............................................ 164 hydrocodone-homatropine mbr165 hydrocodone-ibuprofen ............... 9 hydrocortisone ......... 110, 130, 143 hydrocortisone butyrate ........... 110 hydrocortisone butyr-emollient 110 hydrocortisone valerate ........... 110 hydrocortisone-acetic acid ....... 116 hydrocortisone-pramoxine ....... 110 hydromet ................................. 165 hydromorphone ........................... 9 hydromorphone (pf) ..................... 9 hydroxychloroquine ................... 62 hydroxyprogest(pf)(preg presv)

............................................ 133 hydroxyprogesterone cap(ppres)

............................................ 134 hydroxyurea .............................. 33 hydroxyzine hcl ......................... 57 hydroxyzine pamoate .............. 147 HYPERRAB (PF)..................... 137 HYPERRAB S/D (PF) .............. 137 HYPERRHO S/D ..................... 137 HYQVIA ................................... 137 HYSINGLA ER .......................... 10 HYZAAR .................................... 81 ibandronate ............................. 145 IBRANCE .................................. 33 ibu ............................................. 13 ibuprofen ................................... 13 ibuprofen lysine (pf) ................... 13 ibuprofen-oxycodone ................. 10 icatibant ..................................... 88

ICLUSIG ................................... 33 IDAMYCIN PFS ........................ 33 idarubicin .................................. 33 IDHIFA...................................... 33 ife-bimix 30/1 .......................... 169 ife-pg20 .................................. 169 IFEX ......................................... 33 ifosfamide ............................33, 34 ifosfamide-mesna ..................... 34 ILARIS (PF) ............................ 137 ILEVRO .................................. 119 ILUMYA .................................. 137 imatinib ..................................... 34 IMBRUVICA ............................. 34 IMFINZI .................................... 34 imipenem-cilastatin ................... 25 imipramine hcl .......................... 46 imipramine pamoate ................. 46 imiquimod ............................... 106 IMITREX ................................... 58 IMITREX STATDOSE PEN ...... 58 IMITREX STATDOSE REFILL . 58 IMLYGIC ................................... 34 IMOGAM RABIES-HT (PF) .... 137 IMOVAX RABIES VACCINE (PF)

........................................... 141 IMPAVIDO ................................ 62 IMPOYZ .................................. 110 IMURAN ................................. 138 IMVEXXY MAINTENANCE PACK

........................................... 128 IMVEXXY STARTER PACK ... 128 INBRIJA .................................... 63 incassia .................................. 100 INCRELEX ............................. 132 INCRUSE ELLIPTA ................ 155 indapamide ............................... 90 INDERAL LA ............................ 85 INDOCIN .................................. 13 indomethacin ............................ 14 indomethacin sodium................ 14 INFANRIX (DTAP) (PF) .......... 141 INFLECTRA ........................... 138 INFUGEM ................................. 34 INFUMORPH P/F ..................... 10 INGREZZA ............................... 96 INGREZZA INITIATION PACK . 96 INLYTA ..................................... 34 INNOPRAN XL ......................... 85

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INPEN (FOR HUMALOG) ....... 168 INPEN (FOR NOVOLOG) ....... 168 INREBIC ................................... 34 INSET 30 INFUSION SET ...... 168 INSET INFUSION SET ........... 168 INSPRA ..................................... 93 insulin lispro .............................. 52 INSULIN SYRINGE-NEEDLE U-

100 ...................................... 113 INTELENCE .............................. 69 INTERMEZZO ......................... 159 INTRALIPID .............................. 80 INTRAROSA ........................... 128 Intra-Uterine Devices (IUD) ... 162 INTRON A ................................. 73 introvale .................................. 100 INTUNIV ER .............................. 96 INVANZ ..................................... 25 INVEGA .................................... 66 INVEGA SUSTENNA ................ 66 INVEGA TRINZA....................... 67 INVELTYS ............................... 119 INVIRASE ................................. 70 INVOKAMET ............................. 49 INVOKAMET XR ....................... 49 INVOKANA ............................... 49 Iodine Containing Agents ..... 172 IONOSOL-B IN D5W ............... 150 IONOSOL-MB IN D5W ............ 150 IOPIDINE ................................ 115 IPOL ........................................ 141 ipratropium bromide ........ 115, 155 IPRIVASK ................................. 75 irbesartan .................................. 81 irbesartan-hydrochlorothiazide .. 81 IRESSA ..................................... 34 irinotecan .................................. 34 Iron Replacement .................. 174 ISENTRESS .............................. 70 ISENTRESS HD........................ 70 isibloom ................................... 100 ISOLYTE-P IN 5 % DEXTROSE

............................................ 150 ISOLYTE-S ............................. 150 isoniazid .................................... 59 ISOPTO ATROPINE ............... 115 ISOPTO CARPINE .................. 149 ISORDIL .................................... 93 ISORDIL TITRADOSE .............. 93

isosorbide dinitrate .................... 93 isosorbide mononitrate .............. 93 isotretinoin ............................... 106 isradipine ................................... 89 ISTALOL ................................. 149 ISTODAX .................................. 34 itraconazole ............................... 55 ivermectin .......................... 62, 112 IXEMPRA .................................. 34 IXIARO (PF) ............................ 141 JADENU .................................. 126 JADENU SPRINKLE ............... 126 JAKAFI ...................................... 34 JALYN ..................................... 125 jantoven ..................................... 75 JANUMET ................................. 49 JANUMET XR ........................... 49 JANUVIA ................................... 49 JARDIANCE .............................. 49 jasmiel (28) .............................. 100 jencycla ................................... 100 JENTADUETO .......................... 49 JENTADUETO XR .................... 49 JEVANTIQUE LO .................... 129 JEVTANA .................................. 34 jinteli ........................................ 129 jolivette .................................... 100 JUBLIA ...................................... 55 juleber ..................................... 100 JULUCA .................................... 70 junel 1.5/30 (21) ...................... 100 junel 1/20 (21) ......................... 100 junel fe 1.5/30 (28) .................. 100 junel fe 1/20 (28) ..................... 100 junel fe 24 ................................ 100 JUXTAPID ................................. 92 JYNARQUE ............................... 90 KABIVEN ................................... 80 KADCYLA ................................. 34 KADIAN ..................................... 10 kaitlib fe ................................... 101 KALBITOR .............................. 147 KALETRA .................................. 70 kalliga ...................................... 101 KALYDECO ............................. 157 KANJINTI .................................. 34 KANUMA ................................. 114 KAPSPARGO SPRINKLE ......... 85 KAPVAY .................................... 96

KARBINAL ER .......................... 57 kariva (28) .............................. 101 KAZANO ................................... 49 KEDRAB (PF) ......................... 138 KEFLEX .................................... 24 kelnor 1/35 (28) ...................... 101 kelnor 1-50 ............................. 101 KENALOG ....................... 110, 130 KENALOG-80 ......................... 130 KEPIVANCE ........................... 147 KEPPRA ................................... 41 KEPPRA XR ............................. 41 KERYDIN ................................. 55 ketoconazole ............................ 55 ketodan..................................... 55 ketoprofen ................................ 14 ketorolac ............................14, 119 KEVEYIS ................................ 147 KEVZARA ............................... 138 KEYTRUDA .............................. 34 KHAPZORY ............................ 147 KHEDEZLA .............................. 46 kimidess (28) .......................... 101 KINERET ................................ 138 KINRIX (PF) ........................... 141 kionex (with sorbitol) ............... 122 KISQALI ................................... 35 KISQALI FEMARA CO-PACK . 34,

35 KLARON ................................. 108 KLONOPIN ............................... 18 KLOR-CON 10 ....................... 150 KLOR-CON 8 ......................... 151 klor-con m10 ........................... 151 klor-con m15 ........................... 151 klor-con m20 ........................... 151 klor-con sprinkle ..................... 151 KOMBIGLYZE XR .................... 49 KORLYM .................................. 49 KRINTAFEL .............................. 62 KRYSTEXXA .......................... 114 K-TAB ..................................... 151 kurvelo (28) ............................ 101 KUVAN ................................... 114 KYLEENA ............................... 162 KYNAMRO ............................... 92 KYPROLIS ............................... 35 l norgest/e.estradiol-e.estrad .. 101 labetalol .................................... 85

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LACRISERT ............................ 115 LACTATED RINGERS .... 143, 151 lactulose .................................. 122 LAMICTAL ................................ 41 LAMICTAL ODT ........................ 41 LAMICTAL ODT STARTER

(BLUE) .................................. 41 LAMICTAL ODT STARTER

(GREEN) .............................. 41 LAMICTAL ODT STARTER

(ORANGE) ............................ 41 LAMICTAL STARTER (BLUE) KIT

.............................................. 41 LAMICTAL STARTER (GREEN)

KIT ........................................ 41 LAMICTAL STARTER (ORANGE)

KIT ........................................ 41 LAMICTAL XR .......................... 41 LAMICTAL XR STARTER (BLUE)

.............................................. 42 LAMICTAL XR STARTER

(GREEN) .............................. 42 LAMICTAL XR STARTER

(ORANGE) ............................ 42 LAMISIL .................................... 55 lamivudine ................................. 70 lamivudine-zidovudine ............... 70 lamotrigine ................................ 42 LANOXIN .................................. 88 LANOXIN PEDIATRIC .............. 88 lansoprazole ............................ 120 lanthanum ............................... 124 LANTUS SOLOSTAR U-100

INSULIN ............................... 52 LANTUS U-100 INSULIN .......... 52 larin 1.5/30 (21) ....................... 101 larin 1/20 (21) .......................... 101 larin 24 fe ................................ 101 larin fe 1.5/30 (28) ................... 101 larin fe 1/20 (28) ...................... 101 larissia ..................................... 101 LASIX ........................................ 90 LASTACAFT ........................... 115 latanoprost .............................. 149 LATUDA .................................... 67 layolis fe .................................. 101 LAZANDA ................................. 10 ledipasvir-sofosbuvir ................. 72 leena 28 .................................. 101

leflunomide .............................. 138 LEMTRADA ............................... 96 LENVIMA .................................. 35 LESCOL .................................... 92 LESCOL XL ............................... 92 lessina ..................................... 101 LETAIRIS ................................ 160 letrozole ..................................... 35 leucovorin calcium ................... 147 LEUKERAN ............................... 35 LEUKINE ................................... 76 leuprolide ................................... 35 levalbuterol tartrate.................. 155 LEVAQUIN ................................ 28 LEVATOL .................................. 85 LEVEMIR FLEXTOUCH U-100

INSULN ................................. 52 LEVEMIR U-100 INSULIN ......... 52 levetiracetam ............................. 42 levetiracetam in nacl (iso-os) ..... 42 levobunolol .............................. 149 levocarnitine ............................ 147 levocarnitine (with sugar) ........ 147 levocetirizine ............................. 57 levofloxacin ....................... 28, 116 levofloxacin in d5w .................... 28 levoleucovorin calcium ............ 147 LEVOLEUCOVORIN CALCIUM

............................................ 147 levonest (28) ........................... 101 levonorgestrel-ethinyl estrad ... 101 levonorg-eth estrad triphasic ... 101 LEVOPHED (BITARTRATE) ..... 88 levora-28 ................................. 101 levorphanol tartrate ................... 10 LEVO-T ................................... 134 levothyroxine ........................... 134 LEVOXYL ................................ 134 LEVULAN ................................ 106 LEXAPRO ................................. 46 LEXETTE ................................ 111 LEXIVA ...................................... 70 LIALDA .................................... 143 LIBRAX (WITH CLIDINIUM) ...... 39 LIBTAYO ................................... 35 lidocaine .................................... 15 lidocaine (pf) ........................ 15, 83 lidocaine hcl .............................. 15 lidocaine viscous ....................... 15

lidocaine-prilocaine ................... 15 LIDODERM .............................. 16 LILETTA ................................. 162 lillow (28) ................................ 101 LINCOCIN ................................ 21 lincomycin ................................. 21 lindane .................................... 112 linezolid .................................... 21 linezolid in dextrose 5% ............ 21 linezolid-0.9% sodium chloride . 21 LINZESS ................................ 122 liothyronine ............................. 134 LIPITOR ................................... 92 LIPOFEN .................................. 92 lisinopril .................................... 82 lisinopril-hydrochlorothiazide .... 82 lithium carbonate ...................... 96 lithium citrate ............................ 96 LITHOBID ................................. 96 LITHOSTAT ............................ 147 LIVALO ..................................... 92 LO LOESTRIN FE .................. 101 LOCOID .................................. 111 LOCOID LIPOCREAM ............ 111 LODOSYN ................................ 63 LOKELMA .............................. 122 LOMOTIL ................................ 122 LONHALA MAGNAIR STARTER

........................................... 155 LONSURF ................................ 35 loperamide .............................. 122 LOPID....................................... 92 lopinavir-ritonavir ...................... 70 LOPRESSOR ........................... 85 LOPRESSOR HCT ................... 85 LOPROX .................................. 55 LOPROX (AS OLAMINE) ......... 55 lorazepam ................................. 18 LORBRENA .............................. 35 lorcet (hydrocodone)................. 10 lorcet hd.................................... 10 lorcet plus ................................. 10 lortuss ex ................................ 164 loryna (28) .............................. 101 losartan..................................... 81 losartan-hydrochlorothiazide .... 81 LOSEASONIQUE ................... 101 LOTEMAX .............................. 119 LOTEMAX SM ........................ 119

I-14

LOTENSIN ................................ 83 LOTENSIN HCT ........................ 83 loteprednol etabonate ............. 119 LOTREL .................................... 89 LOTRISONE ............................. 55 LOTRONEX ............................ 143 lovastatin ................................... 92 LOVAZA .................................... 92 LOVENOX ................................. 75 low-ogestrel (28) ..................... 101 loxapine succinate..................... 67 lo-zumandimine (28) ............... 101 LUCEMYRA .............................. 16 luliconazole ............................... 55 LUMIGAN ................................ 149 LUMIZYME ............................. 114 LUMOXITI ................................. 35 LUNESTA ............................... 159 LUPANETA PACK (1 MONTH)

............................................ 132 LUPANETA PACK (3 MONTH)

............................................ 132 LUPRON DEPOT ...................... 35 LUPRON DEPOT (3 MONTH) .. 35 LUPRON DEPOT (4 MONTH) .. 35 LUPRON DEPOT (6 MONTH) .. 35 LUPRON DEPOT-PED ........... 132 LUPRON DEPOT-PED (3

MONTH) ............................. 132 lutera (28) ................................ 101 LUXIQ ..................................... 111 LUZU ......................................... 55 LYNPARZA ............................... 35 LYRICA ..................................... 42 LYRICA CR ............................... 96 LYSODREN .............................. 35 LYSTEDA .................................. 77 lyza.......................................... 101 MACROBID ............................... 21 MACRODANTIN ....................... 22 mafenide acetate..................... 106 magnesium sulfate .................. 151 magnesium sulfate in d5w ....... 151 magnesium sulfate in water .... 151 MAKENA ................................. 134 MAKENA (PF) ......................... 134 MALARONE .............................. 62 MALARONE PEDIATRIC .......... 62 malathion ................................ 112

maprotiline ................................. 46 mar-cof bp ............................... 163 mar-cof cg ............................... 166 MARINOL .................................. 61 marlissa (28) ........................... 101 MARPLAN ................................. 46 MARQIBO ................................. 35 MATULANE ............................... 35 matzim la ................................... 86 MAVENCLAD (10 TABLET PACK)

.............................................. 96 MAVENCLAD (4 TABLET PACK)






.............................................. 97 MAVYRET ................................. 72 MAXALT .................................... 58 MAXALT-MLT ........................... 58 MAXIDEX ................................ 119 MAXIPIME ................................. 24 MAXITROL .............................. 117 MAXZIDE .................................. 90 MAXZIDE-25MG ....................... 90 MAYZENT ................................. 97 MAYZENT STARTER PACK ..... 97 M-CLEAR WC ......................... 166 meclizine ................................... 61 meclofenamate .......................... 14 MEDROL ................................. 130 MEDROL (PAK) ...................... 130 medroxyprogesterone ............. 134 mefenamic acid ......................... 14 mefloquine ................................. 62 MEGACE ES ........................... 134 megestrol .......................... 35, 134 MEKINIST ................................. 35 MEKTOVI .................................. 35 melodetta 24 fe ....................... 102 meloxicam ................................. 14 melphalan hcl ............................ 35 memantine ................................ 44

MENACTRA (PF) ................... 141 M-END PE .............................. 163 MENEST ................................ 129 MENOSTAR ........................... 129 MENTAX .................................. 55 MENVEO A-C-Y-W-135-DIP (PF)

........................................... 141 meperidine ................................ 10 meperidine (pf) ......................... 10 meprobamate ........................... 18 MEPRON .................................. 62 MEPSEVII .............................. 114 mercaptopurine ........................ 35 meropenem .............................. 25 MERREM ................................. 26 mesalamine ............................ 143 mesna..................................... 147 MESNEX ................................ 147 MESTINON ............................ 147 MESTINON TIMESPAN ......... 147 metadate er .............................. 97 metaproterenol ....................... 155 metaxall .................................. 158 metaxalone ............................. 158 metformin ............................49, 50 methadone ............................... 10 methadose ................................ 10 METHADOSE ........................... 10 methamphetamine .................... 97 methazolamide ....................... 149 methenamine hippurate ............ 22 METHERGINE ....................... 147 methimazole ........................... 134 methocarbamol ....................... 158 methotrexate sodium ................ 36 methotrexate sodium (pf) .....35, 36 methoxsalen ........................... 106 methscopolamine ................... 122 methyclothiazide ....................... 90 methyldopa ............................... 80 methyldopa-hydrochlorothiazide 80 methyldopate ............................ 80 methylergonovine ................... 147 METHYLIN ............................... 97 methylphenidate hcl ................. 97 methylprednisolone ................ 130 methylprednisolone acetate .... 130 methylprednisolone sodium succ

........................................... 130

I-15

methyltestosterone .................. 127 metipranolol ............................ 149 metoclopramide hcl ................. 122 metolazone ............................... 90 metoprolol succinate ................. 85 metoprolol ta-hydrochlorothiaz .. 85 metoprolol tartrate ..................... 85 METROCREAM ...................... 108 METROGEL ............................ 108 METROGEL VAGINAL ............. 57 METROLOTION ...................... 108 metronidazole ............. 22, 57, 108 metronidazole in nacl (iso-os) ... 22 mexiletine .................................. 83 MIACALCIN ............................ 145 mibelas 24 fe ........................... 102 MICARDIS ................................ 81 MICARDIS HCT ........................ 81 miconazole nitrate-zinc ox-pet... 55 miconazole-3 ............................. 55 MICRHOGAM ULTRA-FILTERED

PLUS .................................. 138 microgestin 1.5/30 (21) ........... 102 microgestin 1/20 (21) .............. 102 microgestin 24 fe ..................... 102 microgestin fe 1.5/30 (28) ....... 102 microgestin fe 1/20 (28) .......... 102 MICROZIDE .............................. 90 midazolam ................................. 19 midazolam (pf) .................... 18, 19 midodrine .................................. 81 miglitol ....................................... 50 miglustat .................................. 114 MIGRANAL ............................... 59 mili........................................... 102 milrinone ................................... 88 milrinone in 5 % dextrose .......... 88 mimvey lo ................................ 129 MINASTRIN 24 FE .................. 102 MINILINK REAL-TIME

TRANSMITTER .................. 168 MINIMED ................................ 168 MINIMED 530G ....................... 168 MINIMED 630G ....................... 168 MINIMED 630G GUARDIAN

START KT .......................... 168 MINIMED 670G ....................... 168 MINIMED PRO-SET ................ 168 MINIPRESS .............................. 81

minitran ..................................... 93 MINIVELLE ............................. 129 MINOCIN ................................... 29 minocycline ............................... 29 minoxidil .................................... 93 MIO INFUSION SET ............... 168 MIRAPEX .................................. 63 MIRAPEX ER ............................ 63 MIRCERA .................................. 76 mirtazapine ................................ 46 MIRVASO ................................ 106 misoprostol .............................. 120 MITIGARE ................................. 56 mitigo (pf) .................................. 10 mitomycin .................................. 36 mitoxantrone ............................. 36 M-M-R II (PF) .......................... 141 MOBIC ...................................... 14 modafinil .................................. 159 MODERIBA DOSE PACK ......... 73 moexipril .................................... 83 moexipril-hydrochlorothiazide .... 83 molindone .................................. 67 mometasone ................... 111, 119 mondoxyne nl ............................ 29 mono-linyah ............................. 102 mononessa (28) ...................... 102 montelukast ............................. 154 MONUROL ................................ 22 MORPHABOND ER .................. 10 morphine ............................. 10, 11 MORPHINE ............................... 11 morphine (pf) ............................. 10 morphine concentrate ................ 10 MOTEGRITY ........................... 122 MOTOFEN .............................. 122 MOVANTIK ............................. 122 MOVIPREP ............................. 123 MOXATAG ................................ 26 MOXEZA ................................. 117 moxifloxacin ...................... 28, 117 moxifloxacin-sod.ace,sul-water . 28 moxifloxacin-sod.chloride(iso) ... 28 MOZOBIL .................................. 76 MS CONTIN .............................. 11 MULPLETA ............................... 76 MULTAQ ................................... 83 mupirocin ................................. 108 mupirocin calcium.................... 108

MUSE ..................................... 169 MUSTARGEN .......................... 36 mutamycin ................................ 36 MVASI ...................................... 36 MYALEPT ............................... 147 MYAMBUTOL ........................... 59 MYCAMINE .............................. 55 MYCOBUTIN ............................ 60 mycophenolate mofetil............ 138 mycophenolate mofetil hcl ...... 138 mycophenolate sodium ........... 138 MYDAYIS ................................. 97 MYFORTIC ............................. 138 MYLOTARG ............................. 36 MYOBLOC ............................. 147 myorisan ................................. 106 MYRBETRIQ .......................... 125 MYSOLINE ............................... 42 MYTESI .................................. 122 myzilra .................................... 102 nabumetone ............................. 14 nadolol ...................................... 85 nadolol-bendroflumethiazide .... 85 nafcillin ..................................... 26 nafcillin in dextrose iso-osm ..... 26 naftifine ..................................... 55 NAFTIN .................................... 55 NAGLAZYME ......................... 114 nalbuphine ................................ 11 NALFON ................................... 14 nalocet ...................................... 11 naloxone ................................... 16 naltrexone ................................. 17 NAMENDA ............................... 44 NAMENDA XR ......................... 44 NAMZARIC ............................... 44 NAPRELAN CR ........................ 14 NAPROSYN ............................. 14 naproxen .................................. 14 naproxen sodium ...................... 15 naratriptan ................................ 59 NARCAN .................................. 17 Narcotic Antituss-1st Gen.

Antihistamine-Decongest 163 Narcotic Antituss-

Decongestant-Expectorant Comb ................................. 164

Narcotic Antitussive-1st Generation Antihistamine 164

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Narcotic Antitussive-Anticholinergic Comb. ..... 165

Narcotic Antitussive-Expectorant Combination 165

NARDIL ..................................... 46 NASONEX .............................. 119 NATACYN ............................... 117 NATAZIA ................................. 102 nateglinide ................................. 50 NATESTO ............................... 127 NATPARA ............................... 145 NATROBA ............................... 113 nature-throid ............................ 172 NAVELBINE .............................. 36 NEBUPENT .............................. 62 necon 0.5/35 (28) .................... 102 nefazodone ............................... 46 NEMBUTAL SODIUM ............. 159 neomycin ................................... 20 neomycin-bacitracin-poly-hc ... 117 neomycin-bacitracin-polymyxin117 neomycin-polymyxin b gu ........ 108 neomycin-polymyxin b-dexameth

............................................ 117 neomycin-polymyxin-gramicidin

............................................ 117 neomycin-polymyxin-hc ........... 117 neo-polycin .............................. 117 neo-polycin hc ......................... 117 NEOPROFEN (IBUPROFEN

LYSN)(PF) ............................ 15 NEORAL ................................. 138 neostigmine methylsulfate ....... 147 NEOSTIGMINE

METHYLSULFATE ............. 147 NEPHRAMINE 5.4 % ................ 80 NERLYNX ................................. 36 NESINA ..................................... 50 neuac ...................................... 108 NEULASTA ............................... 76 NEUPOGEN ............................. 76 NEUPRO ................................... 64 NEURONTIN ............................. 42 NEVANAC ............................... 119 nevirapine ................................. 70 NEXAVAR ................................. 36 NEXIUM .................................. 120 NEXIUM IV .............................. 120 NEXIUM PACKET ................... 120

NEXPLANON .......................... 162 NEXTERONE ............................ 83 niacin ......................................... 92 niacor ........................................ 92 NIASPAN EXTENDED-RELEASE

.............................................. 92 nicardipine ................................. 89 NICODERM CQ .............. 170, 171 nicorelief .................................. 171 NICORETTE ........................... 171 nicotine gum ............................ 171 nicotine lozenge ...................... 171 nicotine patch .......................... 171 NICOTINE PATCH .................. 171 NICOTROL ................................ 17 NICOTROL NS .......................... 17 nifedipine ................................... 89 nikki (28) .................................. 102 NILANDRON ............................. 36 nilutamide .................................. 36 nimodipine ................................. 89 ninjacof-xg ............................... 166 NINLARO .................................. 36 NIPENT ..................................... 36 nisoldipine ................................. 89 nitisinone ................................. 114 NITRO-BID ................................ 93 NITRO-DUR .............................. 94 nitrofurantoin ............................. 22 nitrofurantoin macrocrystal ........ 22 nitrofurantoin monohyd/m-cryst . 22 nitroglycerin ............................... 94 NITROMIST .............................. 94 NITROSTAT .............................. 94 NITYR ..................................... 114 NIVESTYM ................................ 76 nizatidine ................................. 120 NIZORAL ................................... 55 NOCDURNA (MEN) ................ 132 NOCDURNA (WOMEN) .......... 132 NOCTIVA ................................ 132 NOLIX ..................................... 111 Non-Narc Antituss-1st Gen.

Antihistamine-Decongest . 166 Non-Narc Antitussive-1st Gen

Antihistamine Comb. ........ 166 Non-Narcotic Antituss-

Decongestant-Expectorant Cmb .................................... 166

nora-be ................................... 102 NORDITROPIN FLEXPRO ..... 132 norepinephrine bitartrate .......... 88 noreth-ethinyl estradiol-iron .... 102 norethindrone (contraceptive) . 102 norethindrone acetate............. 134 norethindrone ac-eth estradiol 102,

129 norethindrone-e.estradiol-iron 102 norgestimate-ethinyl estradiol . 102 NORITATE ............................. 108 norlyda.................................... 102 norlyroc................................... 102 NORMOSOL-M IN 5 %

DEXTROSE ....................... 151 NORMOSOL-R ....................... 151 NORMOSOL-R IN 5 %

DEXTROSE ....................... 151 NORMOSOL-R PH 7.4 ........... 151 NORPACE ................................ 83 NORPACE CR ......................... 83 NORPRAMIN ........................... 46 NORTHERA ............................. 81 nortrel 0.5/35 (28) ................... 102 nortrel 1/35 (21) ...................... 102 nortrel 1/35 (28) ...................... 102 nortrel 7/7/7 (28) ..................... 102 nortriptyline ............................... 46 NORVASC ................................ 89 NORVIR ................................... 70 Nose Preparations,

Vasoconstrictors (Rx) ...... 166 NOURIANZ ............................... 64 NOVAREL .............................. 132 NOVOLIN 70/30 U-100 INSULIN

............................................. 52 NOVOLIN 70-30 FLEXPEN U-100

............................................. 52 NOVOLIN N NPH U-100 INSULIN

............................................. 52 NOVOLIN R REGULAR U-100

INSULN ................................ 52 NOVOLOG FLEXPEN U-100

INSULIN ............................... 52 NOVOLOG MIX 70-30 U-100

INSULN ................................ 52 NOVOLOG MIX 70-30FLEXPEN

U-100 ................................... 52

I-17

NOVOLOG PENFILL U-100 INSULIN ............................... 52

NOVOLOG U-100 INSULIN ASPART ............................... 53

NOXAFIL ................................... 55 np thyroid ........................ 172, 173 NPLATE .................................. 147 NUBEQA ................................... 36 NUCALA ................................. 157 NUCYNTA ................................. 11 NUCYNTA ER ........................... 11 NUEDEXTA .............................. 97 NULOJIX ................................. 138 NULYTELY WITH FLAVOR

PACKS ............................... 124 NUPLAZID ................................ 67 NUTRESTORE ....................... 122 NUTRILIPID .............................. 80 NUTROPIN AQ NUSPIN ......... 132 NUVARING ............................. 102 NUVESSA ................................. 57 NUVIGIL .................................. 159 NUZYRA ................................... 29 NUZYRA (7 DAY WITH LOAD

DOSE) .................................. 29 NUZYRA (7 DAY) ...................... 29 nyamyc ...................................... 55 NYMALIZE ................................ 89 nystatin ................................ 55, 56 nystatin-triamcinolone ............... 56 nystop ....................................... 56 OBREDON .............................. 166 OCALIVA ................................ 123 OCREVUS ................................ 97 OCTAGAM .............................. 138 octreotide acetate.................... 132 OCUFLOX ............................... 117 ODEFSEY ................................. 70 ODOMZO .................................. 36 OFEV ...................................... 157 ofloxacin ............................ 28, 117 ogestrel (28) ............................ 102 okebo ........................................ 29 olanzapine ................................. 67 olanzapine-fluoxetine ................ 46 olmesartan ................................ 81 olmesartan-amlodipin-hcthiazid. 82 olmesartan-hydrochlorothiazide 82 olopatadine ..................... 115, 116

OLUMIANT .............................. 138 OLUX ...................................... 111 OLUX-E ................................... 111 OMECLAMOX-PAK................. 121 omega-3 acid ethyl esters ......... 92 OMEGAVEN ............................. 80 omeprazole ............................. 121 omeprazole-sodium bicarbonate

............................................ 121 OMNARIS ............................... 119 OMNITROPE .......................... 132 ONCASPAR .............................. 36 ondansetron .............................. 61 ondansetron hcl ......................... 61 ondansetron hcl (pf) .................. 61 ONETOUCH PING .................. 168 ONETOUCH SURESOFT ....... 168 ONEXTON .............................. 108 ONFI.......................................... 19 ONGLYZA ................................. 50 ONIVYDE .................................. 36 ONMEL ..................................... 56 ONPATTRO ............................ 147 ONZETRA XSAIL ...................... 59 OPANA ...................................... 11 OPDIVO .................................... 36 OPSUMIT ................................ 160 ORACEA ................................... 29 ORALAIR ................................ 148 oralone .................................... 105 ORAP ........................................ 67 ORAPRED ODT ...................... 130 ORAVIG .................................... 56 ORBACTIV ................................ 22 ORENCIA ................................ 138 ORENCIA (WITH MALTOSE) . 138 ORENCIA CLICKJECT ........... 138 ORENITRAM ........................... 160 ORFADIN ................................ 114 ORILISSA ................................ 132 ORKAMBI ................................ 157 orphenadrine citrate ................ 158 orsythia .................................... 103 ORTHO MICRONOR .............. 103 ORTHO TRI-CYCLEN (28) ..... 103 ORTHO TRI-CYCLEN LO (28) 103 ORTHO-CYCLEN (28) ............ 103 ORTHO-NOVUM 1/35 (28) ..... 103 ORTHO-NOVUM 7/7/7 (28) .... 103

oseltamivir ................................ 72 OSENI ...................................... 50 OSMOLEX ER .......................... 64 OSMOPREP ........................... 124 OSPHENA .............................. 129 OTEZLA ................................. 138 OTEZLA STARTER ................ 138 OTOVEL ................................. 116 OTREXUP (PF) ...................... 138 oxacillin..................................... 27 oxaliplatin ................................. 36 oxandrolone ............................ 127 oxaprozin .................................. 15 OXAYDO .................................. 11 oxazepam ................................. 19 oxcarbazepine .......................... 42 OXERVATE ............................ 116 oxiconazole .............................. 56 OXISTAT .................................. 56 OXSORALEN ULTRA ............ 106 OXTELLAR XR ......................... 42 oxybutynin chloride ................. 125 oxycodone ................................ 11 oxycodone-acetaminophen ...... 11 oxycodone-aspirin .................... 11 OXYCONTIN ............................ 11 oxymorphone .......................11, 12 OXYTROL .............................. 125 OZEMPIC ................................. 50 pacerone .................................. 84 paclitaxel .................................. 36 paliperidone .............................. 67 palonosetron ............................. 61 PALONOSETRON ................... 61 PALYNZIQ .............................. 114 PAMELOR ................................ 46 pamidronate ........................... 145 PANCREAZE ......................... 114 PANDEL ................................. 111 panlor(acetam-caff-dihydrocod) 12 PANRETIN ............................. 106 pantoprazole ........................... 121 PANZYGA .............................. 139 papaverine-phentolamine ....... 169 papaverine-phentolmn-alprostdl

........................................... 169 PARADIGM REAL-TIME ........ 168 PARAGARD T 380-A.............. 162 paricalcitol .............................. 145

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PARICALCITOL ...................... 145 PARLODEL ............................... 64 PARNATE ................................. 46 paroex oral rinse ..................... 105 paromomycin ............................ 62 paroxetine hcl ............................ 47 paroxetine mesylate(menop.sym)

............................................ 148 PASER ...................................... 60 PATADAY ............................... 116 PATANASE ............................. 116 PATANOL ............................... 116 PAXIL ........................................ 47 PAXIL CR .................................. 47 PAZEO .................................... 116 PCE........................................... 25 pedia iron ................................ 174 PEDIARIX (PF) ....................... 141 PEDVAX HIB (PF) ................... 141 peg 3350-electrolytes .............. 124 PEGANONE .............................. 42 PEGASYS ................................. 73 PEGASYS PROCLICK .............. 73 peg-electrolyte soln ................. 124 PEGINTRON ............................. 73 PEN NEEDLE, DIABETIC ....... 113 penicillamine ........................... 126 penicillin g potassium ................ 27 penicillin g procaine ................... 27 penicillin g sodium ..................... 27 penicillin v potassium ................ 27 PENNSAID ................................ 15 PENTACEL (PF) ..................... 141 PENTACEL DTAP-IPV COMPNT

(PF) ..................................... 141 PENTAM ................................... 62 pentamidine .............................. 62 PENTASA ............................... 143 pentazocine-naloxone ............... 12 pentobarbital sodium ............... 159 pentoxifylline ............................. 77 PEPCID ................................... 121 PERCOCET .............................. 12 PERIKABIVEN .......................... 80 perindopril erbumine ................. 83 periogard ................................. 105 PERJETA .................................. 36 permethrin ............................... 113 perphenazine ............................ 67

perphenazine-amitriptyline ........ 47 PERSERIS ................................ 67 PERTZYE ................................ 114 PEXEVA .................................... 47 pfizerpen-g ................................ 27 phenadoz .................................. 61 phenelzine ................................. 47 phenobarbital ...................... 42, 43 phenoxybenzamine ................... 81 phenylephrine hcl .............. 81, 116 phenytoin ................................... 43 phenytoin sodium ...................... 43 phenytoin sodium extended ...... 43 philith ....................................... 103 PHOSLYRA ............................. 124 PHOSPHOLINE IODIDE ......... 149 PHYSIOLYTE .......................... 143 PHYSIOSOL IRRIGATION ...... 144 PICATO ................................... 106 PIFELTRO ................................. 70 pilocarpine hcl ................. 105, 149 pimecrolimus ........................... 111 pimozide .................................... 67 pimtrea (28) ............................. 103 pindolol ...................................... 85 pioglitazone ............................... 50 pioglitazone-glimepiride ............. 50 pioglitazone-metformin .............. 50 piperacillin-tazobactam .............. 27 PIQRAY ..................................... 36 pirmella .................................... 103 piroxicam ................................... 15 PLAQUENIL .............................. 62 PLASMA-LYTE 148................. 151 PLASMA-LYTE A .................... 151 PLASMA-LYTE-56 IN 5 %

DEXTROSE ........................ 151 PLAVIX ...................................... 77 PLEGRIDY .......................... 97, 98 PLENVU .................................. 124 PLIAGLIS .................................. 16 PLIXDA ................................... 112 podofilox .................................. 106 POLIVY ..................................... 36 polycin ..................................... 117 POLYETHYLENE GLYCOL

3350(BULK) ........................ 124 polymyxin b sulfate .................... 22 polymyxin b sulf-trimethoprim .. 117

POLYTRIM ............................. 117 POLY-TUSSIN AC.................. 163 POMALYST .............................. 36 portia 28 ................................. 103 PORTRAZZA ............................ 36 posaconazole ........................... 56 POTABA ................................. 174 potassium chlorid-d5-0.45%nacl

........................................... 151 potassium chloride ................. 152 potassium chloride in 0.9%nacl

........................................... 151 potassium chloride in 5 % dex 151 potassium chloride in lr-d5 ...... 151 potassium chloride in water .... 152 potassium chloride-0.45 % nacl

........................................... 152 potassium chloride-d5-0.2%nacl



........................................... 152 potassium citrate .................... 152 POTELIGEO ............................. 36 PRADAXA ................................ 75 PRALUENT PEN ...................... 92 pramipexole .............................. 64 prasugrel .................................. 77 PRAVACHOL ........................... 92 pravastatin ................................ 92 praziquantel .............................. 62 prazosin .................................... 81 PRECISION XTRA ................. 167 PRECOSE ................................ 50 PRED MILD ............................ 119 PRED-G ................................. 117 PRED-G S.O.P. ...................... 117 prednicarbate ......................... 111 prednisolone ........................... 130 prednisolone acetate .............. 119 prednisolone sodium phosphate

.................................... 119, 130 prednisone .............................. 131 pregabalin ................................. 43 PREGNYL .............................. 132 PREMARIN ............................ 129 PREMPHASE ......................... 129 PREMPRO ............................. 129

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prenatal plus (calcium carb) .... 161 prenatal vitamin plus low iron .. 161 PREPOPIK .............................. 124 PRESTALIA .............................. 94 PREVACID .............................. 121 PREVACID SOLUTAB ............ 121 prevalite .................................... 92 PREVIDENT ................... 173, 174 PREVIDENT 5000 ................... 174 PREVIDENT 5000 ENAMEL

PROTECT .......................... 174 PREVIDENT 5000 PLUS ........ 174 PREVIDENT 5000 SENSITIVE

............................................ 174 previfem .................................. 103 PREVPAC ............................... 121 PREVYMIS ............................... 72 PREZCOBIX ............................. 70 PREZISTA ................................ 70 PRIFTIN .................................... 60 PRILOSEC .............................. 121 PRIMAQUINE ........................... 62 PRIMAXIN IV ............................ 26 primidone .................................. 43 PRIMSOL .................................. 22 PRINIVIL ................................... 83 PRISTIQ .................................... 47 PRIVIGEN ............................... 139 PROAIR HFA .......................... 155 PROAIR RESPICLICK ............ 155 probenecid ................................ 56 probenecid-colchicine ............... 56 procainamide ............................ 84 PROCALAMINE 3% .................. 80 PROCARDIA ............................. 89 PROCARDIA XL ....................... 89 prochlorperazine ....................... 61 prochlorperazine edisylate ........ 61 prochlorperazine maleate .......... 61 PROCRIT .................................. 76 procto-med hc ......................... 111 procto-pak ............................... 111 proctosol hc ............................. 111 proctozone-hc ......................... 111 PROCYSBI ............................. 114 PROFENO ................................ 15 progesterone ........................... 134 progesterone micronized ......... 134 PROGLYCEM ......................... 148

PROGRAF .............................. 139 PROLASTIN-C ........................ 157 PROLENSA ............................. 119 PROLEUKIN ............................. 36 PROLIA ................................... 145 PROMACTA ........................ 76, 77 promethazine ...................... 57, 61 promethazine vc-codeine ........ 163 promethazine-codeine ............. 164 promethazine-dm .................... 166 promethazine-phenyleph-codeine

............................................ 163 promethazine-phenylephrine ..... 57 promethegan ............................. 61 PROMETRIUM ........................ 134 propafenone .............................. 84 propantheline ............................ 39 proparacaine ........................... 116 propranolol ................................ 85 propranolol-hydrochlorothiazid .. 85 propylthiouracil ........................ 134 PROQUAD (PF) ...................... 141 PRO-RED AC .......................... 163 PROSOL 20 % .......................... 80 protamine .................................. 77 PROTONIX ............................. 121 PROTOPAM CHLORIDE ........ 148 PROTOPIC ............................. 111 protriptyline ................................ 47 PROVENTIL HFA .................... 155 PROVERA ............................... 134 PROVIGIL ............................... 159 PROZAC ................................... 47 PRUDOXIN ............................. 106 PULMICORT FLEXHALER ..... 154 PULMOZYME ......................... 114 PURIXAN .................................. 36 PYLERA .................................. 123 pyrazinamide ............................. 60 pyridostigmine bromide ........... 148 QBRELIS ................................... 83 QBREXZA ............................... 106 QMIIZ ODT ................................ 15 QNASL .................................... 119 QTERN ...................................... 50 QUADRACEL (PF) .................. 141 QUALAQUIN ............................. 62 QUARTETTE .......................... 103 quasense ................................. 103

quetiapine ................................. 67 QUICK-SET PARADIGM ........ 168 QUILLICHEW ER ..................... 98 QUILLIVANT XR ...................... 98 quinapril .................................... 83 quinapril-hydrochlorothiazide .... 83 quinidine gluconate .................. 84 quinidine sulfate ....................... 84 quinine sulfate .......................... 62 quit 2 ...................................... 171 quit 4 ...................................... 172 QVAR ..................................... 154 QVAR REDIHALER ................ 154 RABAVERT (PF) .................... 142 rabeprazole ............................ 121 RADICAVA ............................... 98 RAGWITEK ............................ 148 raloxifene ................................ 129 ramelteon ............................... 159 ramipril...................................... 83 RANEXA ................................... 88 ranitidine hcl ........................... 121 ranolazine ................................. 88 RAPAFLO ............................... 125 RAPAMUNE ........................... 139 rasagiline .................................. 64 RASUVO (PF) ........................ 139 RAVICTI ................................. 123 RAYALDEE ............................ 145 RAYOS ................................... 131 RAZADYNE .............................. 45 RAZADYNE ER ........................ 45 REBETOL ................................. 73 REBIF (WITH ALBUMIN) ......... 98 REBIF REBIDOSE ................... 98 REBIF TITRATION PACK ........ 98 RECLAST ............................... 145 reclipsen (28) .......................... 103 RECOMBIVAX HB (PF) .......... 142 RECTIV .................................. 148 REGLAN ................................. 123 REGONOL ............................. 148 REGRANEX ........................... 106 RELENZA DISKHALER ............ 72 RELISTOR ............................. 123 RELPAX ................................... 59 REMERON ............................... 47 REMERON SOLTAB ................ 47 REMICADE ............................ 139

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REMODULIN .......................... 160 RENACIDIN ............................ 144 RENAGEL ............................... 124 RENFLEXIS ............................ 148 RENVELA ............................... 124 repaglinide ................................ 50 repaglinide-metformin ............... 50 REPATHA PUSHTRONEX ....... 92 REPATHA SURECLICK ............ 92 REPATHA SYRINGE ................ 92 REPLACEMENT PEDIATRIC

MONITOR ........................... 168 REQUIP .................................... 64 REQUIP XL ............................... 64 RESCRIPTOR .......................... 70 RESECTISOL ......................... 144 respa a.r. ................................. 163 RESTASIS .............................. 119 RESTORIL ................................ 19 RETACRIT ................................ 77 RETIN-A .................................. 112 RETIN-A MICRO ..................... 112 RETIN-A MICRO PUMP ......... 112 RETROVIR ............................... 70 REVATIO ................................ 160 REVCOVI ................................ 114 REVEL PROGRAMMABLE PUMP

............................................ 168 REVLIMID ................................. 37 revonto .................................... 158 REXULTI ................................... 67 REYATAZ ................................. 70 RHOFADE .............................. 106 RHOGAM ULTRA-FILTERED

PLUS .................................. 139 RHOPHYLAC .......................... 139 RHOPRESSA ......................... 149 ribasphere ................................. 73 ribasphere ribapak .................... 73 ribavirin ............................... 73, 74 RIDAURA ................................ 139 rifabutin ..................................... 60 RIFADIN .................................... 60 rifampin ..................................... 60 RIFATER ................................... 60 RILUTEK ................................... 98 riluzole ....................................... 98 rimantadine ............................... 72 RINVOQ ER ............................ 139

RIOMET .................................... 50 risedronate .............................. 145 RISPERDAL .............................. 68 RISPERDAL CONSTA ........ 67, 68 RISPERDAL M-TAB .................. 68 risperidone ................................ 68 RITALIN .................................... 98 RITALIN LA ............................... 98 ritonavir ..................................... 70 RITUXAN .................................. 37 RITUXAN HYCELA ................... 37 rivastigmine ............................... 45 rivastigmine tartrate ................... 45 rizatriptan .................................. 59 robafen ac ............................... 166 ROBAXIN ................................ 158 ROBAXIN-750 ......................... 158 ROBINUL ................................ 123 ROBINUL FORTE ................... 123 ROCALTROL .......................... 145 ROCKLATAN .......................... 149 romidepsin ................................. 37 ropinirole ................................... 64 rosadan ................................... 108 rosuvastatin ............................... 92 ROTARIX ................................ 142 ROTATEQ VACCINE .............. 142 ROWASA ................................ 143 ROWEEPRA ............................. 43 ROXICODONE .......................... 12 ROXYBOND .............................. 12 ROZEREM .............................. 159 ROZLYTREK ............................. 37 RUBRACA ................................. 37 RUCONEST .............................. 77 RUZURGI ................................ 148 RYBELSUS ............................... 50 RYDAPT .................................... 37 rydex ....................................... 163 RYTARY .................................... 64 RYTHMOL SR ........................... 84 SABRIL ..................................... 43 SAFYRAL ................................ 103 SAIZEN ................................... 133 SAIZEN SAIZENPREP ............ 132 SALAGEN (PILOCARPINE) .... 105 SAMSCA ................................... 90 SANCUSO ................................ 61 SANDIMMUNE ........................ 139

SANDOSTATIN ...................... 133 SANDOSTATIN LAR DEPOT . 133 SANTYL ................................. 106 SAPHRIS .................................. 68 SARAFEM .............................. 148 SAVAYSA ................................. 75 SAVELLA ................................. 98 scopolamine base .................... 61 SEASONIQUE ........................ 103 SEEBRI NEOHALER.............. 155 SEGLUROMET ........................ 50 selegiline hcl ............................. 64 selenium sulfide ...................... 108 SELZENTRY .......................70, 71 SEMPREX-D ............................ 57 SEN-SERTER ........................ 168 SENSIPAR ............................. 145 SEREVENT DISKUS .............. 156 SERNIVO ............................... 111 SEROQUEL ............................. 68 SEROQUEL XR ....................... 68 SEROSTIM ............................. 133 sertraline ................................... 47 setlakin ................................... 103 sevelamer carbonate .............. 124 sevelamer hcl ......................... 124 sf 174 sf 5000 plus ............................ 174 sharobel.................................. 103 SHINGRIX (PF) ...................... 142 SIGNIFOR .............................. 133 SIGNIFOR LAR ...................... 133 SIKLOS .................................... 77 sildenafil (pulm.hypertension) . 161 sildenafil citrate ....................... 169 SILENOR ................................ 159 SILIQ ...................................... 106 silodosin ................................. 125 silver sulfadiazine ................... 108 SIMBRINZA ............................ 149 simliya (28) ............................. 103 simpesse ................................ 103 SIMPONI ................................ 139 SIMPONI ARIA ....................... 139 SIMULECT ............................. 148 simvastatin ..........................92, 93 SINEMET ................................. 64 SINEMET CR ........................... 64 SINGULAIR ............................ 154

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sirolimus .................................. 139 SIRTURO .................................. 60 SIVEXTRO ................................ 22 SKELAXIN .............................. 158 SKLICE ................................... 113 SKYRIZI .................................. 139 smoflipid .................................... 80 Smoking Cessation ............... 170 Smoking Deterrent Agents

(Ganglionic Stim,Others).. 170 sodium acetate ........................ 152 sodium benzoate-sod phenylacet

............................................ 152 sodium chloride ............... 144, 152 sodium chloride 0.45 % ........... 152 sodium chloride 0.9 % ............. 152 SODIUM EDECRIN ................... 90 sodium fluoride ........................ 174 sodium lactate ......................... 152 sodium phenylbutyrate ............ 123 sodium phosphate ................... 152 sodium polystyrene sulfonate .. 123 sofosbuvir-velpatasvir ............... 72 SOF-SENSOR ........................ 168 SOLARAZE ............................... 15 solifenacin ............................... 125 SOLIQUA 100/33 ...................... 53 SOLIRIS .................................. 148 SOLODYN ................................ 29 SOLOSEC ................................. 22 soloxide ..................................... 29 SOLTAMOX .............................. 37 SOLU-CORTEF (PF) .............. 131 SOLU-MEDROL ...................... 131 SOLU-MEDROL (PF) .............. 131 SOMA ..................................... 158 SOMATULINE DEPOT ........... 133 SOMAVERT ............................ 133 SONATA ................................. 159 SOOLANTRA .......................... 113 SORIATANE ........................... 106 SORILUX ................................ 106 sorine ........................................ 85 sotalol ........................................ 86 SOTALOL ................................. 85 sotalol af .................................... 85 SOTYLIZE ................................. 86 SOVALDI .................................. 72 spinosad .................................. 113

SPIRIVA RESPIMAT ............... 156 SPIRIVA WITH HANDIHALER 156 spironolactone ........................... 90 spironolacton-hydrochlorothiaz . 91 SPORANOX .............................. 56 SPRAVATO ............................... 47 sprintec (28) ............................ 103 SPRITAM .................................. 43 SPRIX ....................................... 15 SPRYCEL ................................. 37 sps (with sorbitol) .................... 123 sronyx...................................... 103 ssd .......................................... 108 sski .......................................... 172 STALEVO 100 ........................... 64 STALEVO 150 ........................... 64 STARLIX ................................... 50 stavudine ................................... 71 STEGLATRO ............................ 50 STEGLUJAN ............................. 50 STELARA ................................ 139 STIMATE ................................. 133 STIOLTO RESPIMAT .............. 156 STIVARGA ................................ 37 stop smoking aid ..................... 172 STRATTERA ............................. 98 STRENSIQ .............................. 114 streptomycin .............................. 20 STRIANT ................................. 127 STRIBILD .................................. 71 STRIVERDI RESPIMAT .......... 156 STROMECTOL ......................... 63 strong iodine ............................ 172 SUBLOCADE ............................ 17 SUBOXONE .............................. 17 SUBSYS .................................... 12 subvenite ................................... 43 subvenite starter (blue) kit ......... 43 subvenite starter (green) kit ....... 43 subvenite starter (orange) kit ..... 43 SUCRAID ................................ 114 sucralfate ................................. 121 SULAR ...................................... 90 sulfacetamide sodium ...... 117, 118 sulfacetamide sodium (acne) .. 108 sulfacetamide-prednisolone .... 118 sulfadiazine ............................... 28 sulfamethoxazole-trimethoprim . 28 SULFAMYLON ........................ 106

sulfasalazine ........................... 143 sulfatrim .................................... 28 sulindac .................................... 15 sumatriptan ............................... 59 sumatriptan succinate............... 59 sumatriptan-naproxen............... 59 SUMAVEL DOSEPRO ............. 59 SUNOSI .................................. 159 SUPPRELIN LA ...................... 133 SUPRAX ................................... 24 SUPREP BOWEL PREP KIT . 124 SURE COMFORT INS. SYR. U-

100 ..................................... 113 SURE-T PARADIGM .............. 168 SURMONTIL ............................ 47 SUSTIVA .................................. 71 SUSTOL ................................... 61 SUTENT ................................... 37 syeda ...................................... 103 SYLATRON .............................. 73 SYLVANT ................................. 37 SYMBICORT .......................... 154 SYMBYAX ................................ 47 SYMDEKO ............................. 157 SYMFI ...................................... 71 SYMFI LO ................................. 71 SYMJEPI .................................. 88 SYMLINPEN 120 ...................... 50 SYMLINPEN 60 ........................ 50 SYMPAZAN .............................. 19 SYMPROIC ............................ 123 SYMTUZA ................................ 71 SYNAGIS ................................. 72 SYNALAR ............................... 111 SYNALAR CREAM KIT .......... 111 SYNAREL ............................... 133 SYNDROS ................................ 61 SYNERA ................................... 16 SYNERCID ............................... 22 SYNJARDY .............................. 50 SYNJARDY XR ........................ 50 SYNRIBO ................................. 37 SYNTHROID .......................... 134 SYPRINE ................................ 126 T

30 INFUSION SET ............. 168 90 168 FLEX .................................. 168 SLIM ................................... 168

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SLIM G4 ............................. 168 SLIM X2 .............................. 168 SLIM X2 WITH BASAL-IQ .. 168

TABLOID ................................... 37 TACLONEX ............................. 106 tacrolimus ........................ 111, 139 tadalafil .................................... 161 tadalafil (pulm. hypertension) .. 161 TAFINLAR ................................. 37 TAGRISSO ............................... 37 TAKHZYRO ............................ 148 TALTZ AUTOINJECTOR ........ 106 TALTZ SYRINGE .................... 106 TALWIN .................................... 12 TALZENNA ............................... 37 TAMIFLU ................................... 72 tamoxifen .................................. 37 tamsulosin ............................... 125 TANZEUM ................................. 50 TAPAZOLE ............................. 172 taperdex .................................. 131 TARCEVA ................................. 37 TARGRETIN ............................. 37 tarina 24 fe .............................. 103 tarina fe 1/20 (28) .................... 103 TARKA ...................................... 83 TASIGNA .................................. 37 TASMAR ................................... 64 TAVALISSE .............................. 77 TAXOTERE ............................... 37 TAYTULLA .............................. 103 tazarotene ............................... 112 tazicef ........................................ 24 TAZORAC ............................... 112 taztia xt ...................................... 86 TDVAX .................................... 142 TECENTRIQ ............................. 37 TECFIDERA .............................. 98 TECHNIVIE ............................... 72 TEFLARO ................................. 24 TEGRETOL ............................... 43 TEGRETOL XR ......................... 43 TEGSEDI ................................ 148 TEKTURNA ............................... 93 TEKTURNA HCT ...................... 93 telmisartan ................................ 82 telmisartan-amlodipine .............. 82 telmisartan-hydrochlorothiazid .. 82 temazepam ............................... 19

TEMIXYS .................................. 71 TEMODAR ................................ 37 temsirolimus .............................. 37 tencon ....................................... 12 TENIVAC (PF) ......................... 142 tenofovir disoproxil fumarate ..... 71 TENORETIC 100....................... 86 TENORETIC 50 ........................ 86 TENORMIN ............................... 86 TERAZOL 7 ............................... 58 terazosin .................................. 125 terbinafine hcl ............................ 56 terbutaline ............................... 156 terconazole ................................ 58 TESSALON PERLE ................ 163 TESTIM ................................... 127 testosterone ............................ 127 testosterone cypionate ............ 127 testosterone enanthate ............ 127 TESTRED ............................... 127 TETANUS,DIPHTHERIA TOX

PED(PF) ............................. 142 tetrabenazine ............................ 98 tetracycline ................................ 29 THALOMID .............................. 148 THAM ...................................... 148 theophylline ............................. 156 THIOLA ................................... 148 THIOLA EC ............................. 148 thioridazine ................................ 68 thiotepa ..................................... 37 thiothixene ................................. 68 THYMOGLOBULIN ................. 140 thyroid ..................................... 173 Thyroid Hormones ................ 172 THYROLAR-1 ......................... 134 THYROLAR-1/2 ...................... 134 THYROLAR-1/4 ...................... 134 THYROLAR-2 ......................... 134 THYROLAR-3 ......................... 134 tiagabine .................................... 43 TIAZAC ..................................... 86 TIBSOVO .................................. 38 TICE BCG ............................... 142 ticlopidine .................................. 77 TIGAN ....................................... 61 tigecycline ................................. 29 TIGLUTIK .................................. 98 TIKOSYN .................................. 84

tilia fe ...................................... 103 timolol maleate .......... 86, 149, 150 TIMOPTIC .............................. 150 TIMOPTIC OCUDOSE (PF) ... 150 TIMOPTIC-XE ........................ 150 TINDAMAX ............................... 63 tinidazole .................................. 63 TIROSINT ............................... 135 TIROSINT-SOL ...................... 135 TIS-U-SOL PENTALYTE ........ 144 TIVICAY ................................... 71 TIVORBEX ............................... 15 tizanidine ................................ 158 tl g-fol os ................................. 173 TOBI ......................................... 20 TOBI PODHALER .................... 20 TOBRADEX ............................ 118 TOBRADEX ST ...................... 118 tobramycin .............................. 118 tobramycin in 0.225 % nacl ...... 20 tobramycin in 0.9 % nacl .......... 20 tobramycin sulfate .................... 20 tobramycin with nebulizer ......... 20 tobramycin-dexamethasone ... 118 TOBREX ................................. 118 TODAY CONTRACEPTIVE

SPONGE ............................ 162 TOLAK.................................... 106 tolazamide ...........................53, 54 tolbutamide ............................... 54 tolcapone .................................. 64 tolmetin ..................................... 15 TOLSURA ................................ 56 tolterodine ............................... 125 TOPAMAX ................................ 43 TOPICORT ............................. 111 topiramate ................................ 43 toposar ..................................... 38 topotecan .................................. 38 TOPROL XL ............................. 86 toremifene ................................ 38 TORISEL .................................. 38 torsemide .................................. 91 TOTECT ................................. 148 TOUJEO MAX U-300 SOLOSTAR

............................................. 53 TOUJEO SOLOSTAR U-300

INSULIN ............................... 53 TOVIAZ .................................. 125

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TPN ELECTROLYTES ............ 152 TPN ELECTROLYTES II ......... 152 TRACLEER ............................. 161 TRADJENTA ............................. 51 tramadol .................................... 12 tramadol-acetaminophen .......... 12 trandolapril ................................ 83 trandolapril-verapamil ................ 83 tranexamic acid ......................... 77 TRANSDERM-SCOP ................ 61 TRANXENE T-TAB ................... 19 tranylcypromine ......................... 47 TRAVASOL 10 % ...................... 80 TRAVATAN Z .......................... 150 trazodone .................................. 47 TREANDA ................................. 38 TRECATOR .............................. 60 TRELEGY ELLIPTA ................ 156 TRELSTAR ............................... 38 TREMFYA ....................... 106, 107 treprostinil sodium ................... 161 TRESIBA FLEXTOUCH U-100 . 53 TRESIBA FLEXTOUCH U-200 . 53 TRESIBA U-100 INSULIN ......... 53 tretinoin ................................... 112 tretinoin (chemotherapy) ........... 38 tretinoin microspheres ............. 112 TREXIMET ................................ 59 tri femynor ............................... 103 triamcinolone acetonide . 105, 111,

131 triamterene ................................ 91 triamterene-hydrochlorothiazid .. 91 trianex ..................................... 111 triazolam ................................... 19 TRIBENZOR ............................. 82 TRICOR .................................... 93 triderm ..................................... 111 trientine ................................... 126 tri-estarylla .............................. 103 trifluoperazine ........................... 68 trifluridine ................................ 118 TRIGLIDE ................................. 93 trihexyphenidyl .......................... 64 TRIKAFTA ............................... 157 tri-legest fe .............................. 103 TRILEPTAL ............................... 43 tri-linyah .................................. 104 TRILIPIX ................................... 93

tri-lo-estarylla ........................... 104 tri-lo-marzia ............................. 104 tri-lo-mili ................................... 104 tri-lo-sprintec ........................... 104 trilyte with flavor packets ......... 124 trimethobenzamide .................... 62 trimethoprim .............................. 22 tri-mili....................................... 104 trimipramine .............................. 47 TRIMPEX .................................. 22 trinessa (28) ............................ 104 trinessa lo ................................ 104 TRI-NORINYL (28) .................. 104 TRINTELLIX .............................. 47 TRIOSTAT .............................. 135 tri-previfem (28) ....................... 104 TRIPTODUR ........................... 133 TRISENOX ................................ 38 tri-sprintec (28) ........................ 104 TRIUMEQ .................................. 71 trivora (28) ............................... 104 tri-vylibra .................................. 104 tri-vylibra lo .............................. 104 TRIZIVIR ................................... 71 TROGARZO .............................. 71 TROKENDI XR .......................... 44 TROPHAMINE 10 % ................. 80 TROPHAMINE 6% .................... 80 trospium .................................. 125 TRULANCE ............................. 123 TRULICITY ................................ 51 TRUMENBA ............................ 142 TRUSOPT ............................... 150 TRUSTEEL INFUSION SET ... 168 TRUVADA ................................. 71 TUDORZA PRESSAIR ............ 156 tulana ...................................... 104 TURALIO ................................... 38 TUSNEL C .............................. 164 TUSNEL PEDIATRIC .............. 166 TUSSICAPS ............................ 164 TUSSIGON ............................. 165 TUSSIONEX ........................... 164 TUZISTRA XR ......................... 164 TWINRIX (PF) ......................... 142 TWYNSTA ................................. 82 TYBOST .................................. 148 tydemy ..................................... 104 TYGACIL ................................... 29

TYKERB ................................... 38 TYMLOS ................................. 145 TYPHIM VI ............................. 142 TYSABRI ................................ 140 TYVASO ................................. 161 TYZINE................................... 166 UCERIS .................................. 143 UDENYCA ................................ 77 ULESFIA ................................ 148 ULORIC .................................... 57 ULTOMIRIS ............................ 140 ULTRACET .............................. 12 ULTRAM ................................... 12 ULTRAVATE ................... 111, 112 UNASYN .................................. 27 UNISTIK 2 NORMAL .............. 168 UNITHROID ........................... 135 UNITUXIN ................................ 38 UPTRAVI ................................ 161 UROCIT-K 10 ......................... 152 UROCIT-K 15 ......................... 152 UROCIT-K 5 ........................... 153 UROXATRAL ......................... 126 URSO 250 .............................. 123 URSO FORTE ........................ 123 ursodiol ................................... 123 UTIBRON NEOHALER ........... 156 UVADEX ................................. 107 VABOMERE ............................. 26 VAGIFEM ............................... 129 valacyclovir ............................... 74 VALCHLOR ............................ 107 VALCYTE ................................. 74 valganciclovir ............................ 74 VALIUM .................................... 19 valproate sodium ...................... 44 valproic acid ............................. 44 valproic acid (as sodium salt) ... 44 valrubicin .................................. 38 valsartan ................................... 82 valsartan-hydrochlorothiazide ... 82 VALSTAR ................................. 38 VALTREX ................................. 74 VANCOCIN .............................. 22 vancomycin .............................. 22 VANDAZOLE ............................ 58 VANOS ................................... 112 VANTAS ................................. 133 VAPRISOL IN 5 % DEXTROSE 91

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VAQTA (PF) ............................ 142 VARISOFT INFUSION SET .... 168 VARIVAX (PF) ........................ 142 VARUBI ..................................... 62 VASCEPA ................................. 93 VASERETIC .............................. 83 VASOSTRICT ......................... 133 VASOTEC ................................. 83 VAZCULEP ............................... 81 vcf ........................................... 162 VCF ......................................... 162 VECAMYL ................................. 88 VECTIBIX .................................. 38 VECTICAL .............................. 107 VELCADE ................................. 38 VELETRI ................................. 161 velivet triphasic regimen (28) .. 104 VELPHORO ............................ 124 VELTASSA ............................. 123 VELTIN ................................... 108 VEMLIDY .................................. 71 VENCLEXTA ............................. 38 VENCLEXTA STARTING PACK

.............................................. 38 venlafaxine ................................ 47 VENTAVIS .............................. 161 VENTOLIN HFA ...................... 156 verapamil ............................ 86, 87 VEREGEN .............................. 107 VERELAN ................................. 87 VERELAN PM ........................... 87 VERSACLOZ ............................ 68 VERZENIO ................................ 38 VESICARE .............................. 125 vestura (28) ............................. 104 VFEND ...................................... 56 VFEND IV ................................. 56 VIAGRA .......................... 169, 170 VIBATIV .................................... 22 VIBERZI .................................. 123 VIBRAMYCIN ............................ 29 vicodin ....................................... 12 vicodin es .................................. 12 vicodin hp .................................. 12 VICTOZA .................................. 51 VIDAZA ..................................... 38 VIDEX 2 GRAM PEDIATRIC..... 71 VIDEX EC ................................. 71 VIEKIRA PAK ............................ 72

VIEKIRA XR .............................. 72 vienva ...................................... 104 vigabatrin ................................... 44 vigadrone .................................. 44 VIGAMOX ............................... 118 VIIBRYD .................................... 47 VIMIZIM ................................... 114 VIMOVO .................................... 15 VIMPAT ..................................... 44 vinblastine ................................. 38 vincasar pfs ............................... 38 vincristine .................................. 38 vinorelbine ................................. 38 VIOKACE ................................ 114 viorele (28) .............................. 104 VIRACEPT ................................ 71 VIRAMUNE ............................... 71 VIRAMUNE XR ......................... 71 VIRAZOLE ................................ 74 VIREAD ..................................... 71 VIROPTIC ............................... 118 virtussin ac .............................. 166 virtussin dac ............................ 164 VISTARIL ................................ 148 VISTOGARD ........................... 148 Vitamin And/Or Mineral

Deficiency .......................... 173 Vitamin B Preparations ......... 174 VITRAKVI .................................. 38 VITUZ ...................................... 165 VIVELLE-DOT ......................... 129 VIVITROL .................................. 17 VIVLODEX ................................ 15 VIZIMPRO ................................. 38 VOGELXO ............................... 127 VOLTAREN ............................... 15 VOLTAREN-XR ......................... 15 voriconazole .............................. 56 VOSEVI ..................................... 72 VOTRIENT ................................ 38 VPRIV ..................................... 114 VRAYLAR ................................. 68 VUSION .................................... 56 vyfemla (28) ............................ 104 vylibra ...................................... 104 VYNDAMAX .............................. 88 VYNDAQEL ............................... 88 VYTORIN 10-10 ........................ 93 VYTORIN 10-20 ........................ 93

VYTORIN 10-40 ....................... 93 VYTORIN 10-80 ....................... 93 VYVANSE ................................ 98 VYXEOS ................................... 39 VYZULTA ............................... 150 WAKIX .................................... 159 warfarin..................................... 75 water for irrigation, sterile ....... 144 WELCHOL ................................ 93 WELLBUTRIN SR .................... 47 WELLBUTRIN XL ..................... 48 wera (28) ................................ 104 westhroid ................................ 173 WIDE SEAL DIAPHRAGM ..... 162 WINRHO SDF ........................ 140 wp thyroid ............................... 173 wymzya fe .............................. 104 XADAGO .................................. 64 XALATAN ............................... 150 XALKORI .................................. 39 XANAX ..................................... 19 XANAX XR ............................... 20 XARELTO ................................. 75 XATMEP ................................... 39 XELJANZ ................................ 140 XELJANZ XR .......................... 140 XELPROS .............................. 150 XEMBIFY ................................ 140 XENAZINE ............................... 98 XEOMIN ................................. 148 XEPI ....................................... 108 XERAVA ................................... 29 XERESE ................................. 107 XERMELO .............................. 123 XGEVA ................................... 145 XHANCE ................................ 120 XIAFLEX ................................. 115 XIFAXAN .............................22, 23 XIGDUO XR ............................. 51 XIIDRA ................................... 120 XIMINO..................................... 29 XOFLUZA ................................. 72 XOLAIR .................................. 157 XOLEGEL ................................. 56 XOSPATA ................................ 39 XPOVIO.................................... 39 XTAMPZA ER .......................... 12 XTANDI .................................... 39 xulane ..................................... 104

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XULTOPHY 100/3.6 .................. 53 XURIDEN ................................ 148 XYLOCAINE ............................. 16 xylocaine-mpf ............................ 16 XYLOCAINE-MPF ............... 16, 84 xylon 10 ..................................... 12 XYOSTED ............................... 127 XYREM ................................... 159 YASMIN (28) ........................... 104 YAZ (28) .................................. 104 YERVOY ................................... 39 YF-VAX (PF) ........................... 142 YONDELIS ................................ 39 YONSA ..................................... 39 YOSPRALA ............................... 88 YUPELRI ................................. 156 yuvafem .................................. 129 zafirlukast ................................ 154 zaleplon ................................... 159 ZALTRAP .................................. 39 ZANAFLEX ............................. 158 ZANOSAR ................................. 39 ZANTAC .................................. 121 zarah ....................................... 104 ZARONTIN ................................ 44 ZARXIO ..................................... 77 ZAVESCA ............................... 115 zebutal ...................................... 12 ZEGERID ................................ 121 ZEJULA ..................................... 39 ZELAPAR .................................. 64 ZELBORAF ............................... 39 ZEMAIRA ................................ 157 ZEMBRACE SYMTOUCH ......... 59 ZEMDRI .................................... 20 ZEMPLAR ............................... 145 zenatane ................................. 107 zenchent (28) .......................... 104 ZENPEP .................................. 115 ZEPATIER ................................ 72 ZERBAXA ................................. 24 ZERIT ........................................ 71 ZESTORETIC ........................... 83 ZESTRIL ................................... 83 ZETIA ........................................ 93 ZETONNA ............................... 120

ZIAC .......................................... 86 ZIAGEN ..................................... 71 ZIANA ...................................... 108 zidovudine ........................... 71, 72 zileuton .................................... 154 ZILRETTA ............................... 131 ZINACEF ................................... 24 ZINECARD (AS HCL) .............. 148 ZINPLAVA ............................... 140 ZIOPTAN (PF) ......................... 150 ziprasidone hcl .......................... 68 ZIPSOR ..................................... 15 ZIRGAN ................................... 118 ZITHROMAX ............................. 25 ZITHROMAX TRI-PAK .............. 25 ZITHROMAX Z-PAK .................. 25 ZMAX ........................................ 25 ZOCOR ..................................... 93 ZODRYL AC 25 ....................... 165 ZODRYL AC 30 ....................... 165 ZODRYL AC 35 ....................... 165 ZODRYL AC 40 ....................... 165 ZODRYL AC 50 ....................... 165 ZODRYL AC 60 ....................... 165 ZODRYL AC 80 ....................... 165 ZODRYL DAC 25 .................... 163 ZODRYL DAC 30 .................... 163 ZODRYL DAC 35 .................... 163 ZODRYL DAC 40 .................... 163 ZODRYL DAC 50 .................... 163 ZODRYL DAC 60 .................... 163 ZODRYL DAC 80 .................... 164 ZODRYL DEC 25 .................... 164 ZODRYL DEC 30 .................... 164 ZODRYL DEC 35 .................... 164 ZODRYL DEC 40 .................... 164 ZODRYL DEC 50 .................... 164 ZODRYL DEC 60 .................... 164 ZODRYL DEC 80 .................... 164 ZOFRAN ................................... 62 ZOFRAN ODT ........................... 62 ZOHYDRO ER .......................... 12 ZOLADEX ................................. 39 zoledronic acid ........................ 145 zoledronic acid-mannitol-water 145 zoledronic ac-mannitol-0.9nacl 146

ZOLINZA .................................. 39 zolmitriptan ............................... 59 ZOLOFT ................................... 48 zolpidem ................................. 160 ZOLPIMIST ............................ 160 ZOMACTON ........................... 133 ZOMETA ................................ 146 ZOMIG...................................... 59 ZOMIG ZMT ............................. 59 ZONALON .............................. 107 ZONEGRAN ............................. 44 zonisamide ............................... 44 ZONTIVITY ............................... 78 ZORBTIVE ............................. 133 ZORTRESS ............................ 140 ZORVOLEX .............................. 15 ZOSTAVAX (PF) .................... 142 ZOSYN ..................................... 27 ZOSYN IN DEXTROSE (ISO-

OSM) .................................... 27 zovia 1/35e (28) ...................... 104 zovia 1/50e (28) ...................... 104 ZOVIRAX ...........................74, 107 ZTLIDO..................................... 16 Z-TUSS AC ............................ 165 ZUBSOLV ................................. 17 ZULRESSO .............................. 48 zumandimine (28) ................... 104 ZUPLENZ ................................. 62 ZURAMPIC ............................... 57 ZYBAN ..................................... 17 ZYCLARA ............................... 107 ZYDELIG .................................. 39 ZYFLO .................................... 154 ZYFLO CR .............................. 154 ZYKADIA .................................. 39 ZYLET .................................... 118 ZYLOPRIM ............................... 57 ZYMAXID ............................... 118 ZYPITAMAG ............................. 93 ZYPREXA ................................. 68 ZYPREXA RELPREVV ............. 68 ZYPREXA ZYDIS ..................... 69 ZYTIGA .................................... 39 ZYVOX ..................................... 23

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact VibrantRx Member Services at 1-844-826-3451 or, for TTY users, 711, 24 hours a day, 365 days a year or visit www.MyVibrantRx.com/JPIA.

http://www.myvibrantrx.com/JPIA

2019 formulary (list of covered drugs) · formulary id: 76001.000, version: 19...

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