2021 essential hix plan formulary

2021 Essential HIX Plan FormularyAn Introduction to Independent Health’s 2021 Essential Plan Formulary
Check your summary of benefits to ensure
this formulary (Essential Plan Formulary) is
associated with your plan prior to using
your prescription drug benefit.
this drug formulary, content may have been
updated since it was last printed. For the
most up-to-date information, please visit
independenthealth.com.
health care providers use the formulary because
all medications included are selected due to their
effectiveness and safety. Use of a formulary also
ensures that premiums are kept to a minimum.
The cost of each medication on the formulary is
balanced with its effectiveness, which means
that medications are not included on the
formulary just because they are inexpensive;
effectiveness is more important that the price of
the medication. If a medication is not capable of
achieving the desired effect, then the price of
treating an illness or condition increases because
other therapies must be used. Likewise, there
are expensive medications that have not been
proven to be any more effective than less costly
alternatives.
Health members have been written from the
formulary in order to qualify for coverage. When
health care providers write a prescription for
Independent Health members, they consult the
formulary and select the medication needed.
Occasionally, members need a medication that is
not on the formulary. In cases when it is
medically necessary for a patient to have a
medication that is not included on the formulary,
health care providers are encouraged to request
a medical exception from Independent Health.
The health care provider will need to complete a
medical exception form and fax it to
Independent Health’s Prior Authorization
Department, who will review the details of the
case.
brand-name and non-preferred brand/generic
coinsurance levels:
This tier contains preferred generic
medications, certain over-the-counter (OTC)
medications and select brand-name
those medications in Tier 2. This tier contains
non-preferred generic medications and
tier contains non-preferred brand-name
covered). To obtain a medication that is non-
formulary your health care provider is
encouraged to submit a prior authorization
request for coverage through the exceptions
process. If the request is approved, that
particular medication will be covered at your
Tier 3 copayment/coinsurance level.
available to you and you will be responsible for
payment of the copayment/coinsurance as
referenced in this document. You will note on
the list that a medication’s
copayment/coinsurance is assigned to a tier.
How this affects your copayment/coinsurance
depends upon what prescription plan you have.
Independent Health reserves the right to modify
the copay/tier of a particular medication as
necessary. For example, when a generic
equivalent becomes available for a covered
brand-name medication, the brand-name
medication becomes non-formulary (not
through the medical exception process.
Independent Health reserves the right to change
through the medical exception process, including
but not limited to the termination of a previously
approved authorization. Approval of a prior
authorization request does not itself guarantee
payment; payment is made based on
plan/benefit design. The generic equivalent
medication will be covered in Tier 1 or Tier 2.
Because of this, the actual
copayment/coinsurance paid may not match the
copayment/coinsurance tier levels as published
in this document. To determine which
prescription plan you have, please refer to your
contract. If you have further questions, you may
contact Independent Health’s Member Services
Department.
medications can be listed here. Independent
Health makes every attempt to provide you with
as accurate a listing of medications as possible,
however the list of medications and availability of
generics can change frequently. Since this list
was created, some medications may have been
added, while others may have been deleted. For
an updated version of the formulary please visit
our website at independenthealth.com.
authorization for certain medications. To obtain
coverage for a medication requiring prior
authorization, a prior authorization request for
medical exception must be submitted by your
health care provider and approved by
Independent Health. Medications that require
prior authorization are listed with a “PA” in the
formulary.
to first try certain medications to treat your
medical condition before we cover another
medication for that condition. Step therapy is a
way to help you get the best quality and value
from your prescription medication benefit. This
usually means that an equally effective generic
medication is prescribed before a more expensive
brand-name medication. Step therapy may also
ensure that two medications are used together if
they are more effective. Medications that require
step therapy are listed with a “ST” in the
formulary.
to a specific quantity per 30 or 90 days. Some
examples of medications with a quantity
limitation are: sumatriptan (generic Imitrex®)
and zolpidem tartrate (generic Ambien®).
Medications with quantity limitations are listed
with a “QL” in the formulary.
For some items that come pre-packaged (for
example: tube/container, inhaler device, single
dose units, or liquid container), one package
size is allowed per fill of these items. If a
quantity limit is designated on the formulary,
this restriction will take precedence over the
pre-packaged limitations, when applicable.
pharmacy benefits, we offer a specialized
prescription medication program for certain
specialty medications through Reliance Rx®
Specialty Pharmacy. Specialty medications
at limited supply and certain oral oncology
medications. These medications are restricted to
designated pharmacies such as Reliance Rx.
Reliance Rx specializes in providing high-quality
service for complex chronic conditions such as
hepatitis, multiple sclerosis, cancer and
rheumatoid arthritis.
medications, Reliance Rx also provides a
convenient way for you to receive the
medication, by arranging delivery at no charge
directly to your home. They can also provide
you with education on the medication you’re
taking, refill reminders and even the necessary
supplies, if applicable. Specialty medications are
listed with an “SP” on the formulary. Reliance
Rx can be reached at 1-800-809-4763.
through designated specialty pharmacies due to
limited distribution placed on the medication by the
manufacturer. These medications are listed with a
“LDD” on the formulary.
Affordable Care Act (ACA)
as preventive services are listed with an “ACA” on
the formulary. Certain restrictions may apply. As
drugs are added or removed from the United
States Preventive Services Task Force
recommendations list, these drugs may not be
available to you through the ACA until you renew
your plan. There is no copayment/coinsurance for
these medications.
Age Restriction
age due to safety reasons or Food and Medication
Administration (FDA) recommended labeling.
“AL” in the formulary.
an “OTC” are available over the counter. A
prescription is required for coverage of the OTC
products. OTC medications are a covered benefit
for Essential Benefit Plans #3 and #4 only.
Copayment will be based on plan benefit.
Dental Formulary
Drugs included in our Dental Formulary are listed
with a “DF” on the formulary. Drugs without a
“DF” will not be covered when written by a dental
provider.
Key
PA – Prior Authorization Required
QL – Quantity Limits Apply
all prescribers except sleep specialists to 14
tablets/capsules per month with a maximum of
3 fills per year (3 fills/365 days).
Compounded Prescription Medications
not commercially manufactured) must be prepared
by a participating pharmacy and contain at least
one prescription component. The dispensing
pharmacy is required to submit for prior approval
and when covered the compounded prescription
will be available at a Tier 2 copayment/
coinsurance. Compounds which cost under $250 do
not require prior authorization if all other
requirements are met. Compounds which cost
more than $250 will require prior authorization.
Coverage is provided in accordance with our
Compounding Medication Products Policy. Bulk
products and powders are excluded from coverage
because they are not prescription medication
products that are approved under sections 505,
505(j) or 507 of the Federal Food, Drug, and
Cosmetic Act.
Diabetic Supplies/Medications
based on your plan. Products not listed require
prior authorization. Copayments vary by plan.
BD needles and syringes are our preferred
needle/syringe products.
and supplies are our preferred diabetic supplies
and do not require prior authorization.
OneTouch will provide a glucose meter to you with
no copayment. Quantities are limited to one meter
per member. You can obtain a meter by calling
LifeScan, Inc. at 1-888-377-5227, offer code
289IHA001. Please have your ID number available
when you call.
100 per 30 days for non-insulin dependent
diabetics. Diabetic test strips are limited to a
maximum of 300 per 30 days for insulin
dependent diabetics.
and sensors are also available at retail
pharmacies, if member is concurrently on
insulin.
system covered with concurrent use of bolus
insulin.
Additional Formulary Information
are excluded from coverage.
prescription) are excluded from coverage.
• Medical foods other than PKU supplements
(which may or may not require a prescription)
are excluded from coverage.
covered.
used to promote fertility are covered:
Bromocriptine, Clomiphene Citrate,
will cover these drugs for infertility. All
other drugs used to promote fertility are
not covered.
when prescribed for the treatment of short
stature.
appropriate care, Independent Health’s drug
coverage criteria is limited to medically-accepted
indications based on FDA approved labeling and
guidelines not otherwise excluded from New
York State Medicaid.
of a 30-day supply per fill.
• Medications that are excluded from coverage
under state and/or federal law are not covered
by Independent Health.
available.
drugs are covered at a $0 copayment. Brand-
name drugs without a generic equivalent are
covered at a $0 copayment. Brand-name drugs
with a generic equivalent are covered at the
copayment based on your plan design. Cervical
caps, diaphragms, condoms, and spermicides
are covered at a $0 copayment. Both
prescription and over-the-counter (OTC)
a licensed health care provider and require a
valid prescription.
covered without restriction may require prior
authorization or may not be covered if it is
determined that they are being used in
conjunction with a procedure or treatment not
covered under the member’s Health Contract.
• Medications not recognized by the FDA without a
National Drug Code (NDC) are excluded from
coverage.
state pharmacy laws. Therapeutic interchange
is not utilized.
medications will depend on where you obtain
these medications. This is a change from your
current coverage:
pharmacy, you will pay your appropriate
pharmacy cost share.
supply provider, you will pay your office
visit cost share.
1 AL
1 QL; AL
amphetamine-dextroamphetamine oral tablet 12.5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
1 AL
APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 50 MG, 60 MG
3
armodafinil oral tablet 1 MM atomoxetine hcl oral capsule 2 AL clonidine hcl er oral tablet extended release 12 hour
1 AL
3 PA
3 PA; AL
1 AL
dexmethylphenidate hcl oral tablet 1 AL dextroamphetamine sulfate er oral capsule extended release 24 hour
1 AL
1 AL
2
1 AL
methylphenidate hcl er (la) oral capsule extended release 24 hour
1 AL
methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg
1 AL
methylphenidate hcl oral solution 2 AL methylphenidate hcl oral tablet 1 QL; AL methylphenidate hcl oral tablet chewable
1 AL
modafinil oral tablet 1 AL MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR
3 ST; AL
3 PA
3 PA
3 ST; AL
3 PA
SUNOSI ORAL TABLET 3 PA VYVANSE ORAL CAPSULE 2 AL VYVANSE ORAL TABLET CHEWABLE 2 AL WAKIX ORAL TABLET 3 PA; LDD
WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR
*Alternative Medicines* melatonin er oral tablet extended release 3 mg
4 OTC
melatonin extra strength oral liquid 4 OTC melatonin oral liquid 1 mg/4ml 4 OTC melatonin oral tablet 1 mg, 3 mg, 5 mg
4 OTC
4 OTC
*Aminoglycosides* ARIKAYCE INHALATION SUSPENSION
3 PA; SP; QL
neomycin sulfate oral tablet 1 paromomycin sulfate oral capsule 2 SP TOBI PODHALER INHALATION CAPSULE
2 PA; SP; QL
1 PA; SP; QL
3 PA; SP
3 PA; SP
celecoxib oral capsule 1 diclofenac potassium oral tablet 50 mg
1
1
1
3 PA; SP
3 PA; SP
3 PA; SP
3 PA; SP
etodolac oral capsule 1 etodolac oral tablet 1 fenoprofen calcium oral tablet 2 flurbiprofen oral tablet 1 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
3 PA; SP
12.01.2021
3
3 PA; SP
3 PA; SP
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML
3 PA; SP
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML
3 PA; SP
ibuprofen oral capsule 4 OTC ibuprofen oral suspension 4 ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1 DF
1
1
2
3 PA; SP
3 PA; SP
3 PA
meclofenamate sodium oral capsule
2
mefenamic acid oral capsule 2 meloxicam oral tablet 1 nabumetone oral tablet 1 naproxen oral tablet 1 DF naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg
3
3 PA; SP
3 PA; SP
OTEZLA ORAL TABLET 3 PA; SP OTEZLA ORAL TABLET THERAPY PACK
3 PA; SP
3 PA; SP
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML
3 PA; SP
3 PA; SP
RIDAURA ORAL CAPSULE 2 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR
3 PA; SP
3 PA; SP
SPRIX NASAL SOLUTION 3 PA; QL; AL sulindac oral tablet 1 XELJANZ ORAL SOLUTION 3 PA; SP XELJANZ ORAL TABLET 3 PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR
3 PA; SP
4 OTC
acetaminophen oral liquid 4 OTC acetaminophen oral solution 160 mg/5ml
4 OTC
acetaminophen oral tablet 4 OTC acetaminophen oral tablet chewable 80 mg
4 OTC
4 OTC
4 OTC
aspirin oral tablet 325 mg 4 OTC aspirin oral tablet chewable 4 OTC aspirin rectal suppository 300 mg 4 OTC butalbital-acetaminophen oral tablet 50-325 mg
1 AL
1 AL
3 AL
1 AL
1 DF; AL
3
12.01.2021
4
1 SUD; QL
1 SUD
1 SUD
2 AL
butorphanol tartrate nasal solution 1 PA codeine sulfate oral tablet 15 mg 1 codeine sulfate oral tablet 30 mg, 60 mg
1 AL
2 PA; PA except Oncology
fentanyl citrate buccal tablet 2 PA; ST; PA except oncology
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
2 ST
1 ST
1 DF
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg
1 DF
3
1 DF
2 ST
hydromorphone hcl oral liquid 1 hydromorphone hcl oral tablet 1 HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT
2 ST
3 PA
methadone hcl oral concentrate 1 methadone hcl oral solution 1 methadone hcl oral tablet 1 methadone hcl oral tablet soluble 1 morphine sulfate (concentrate) oral solution 100 mg/5ml
1 ST
morphine sulfate er beads oral capsule extended release 24 hour
3 ST
morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg
1
morphine sulfate er oral capsule extended release 24 hour 100 mg, 80 mg
1 ST
morphine sulfate er oral tablet extended release 100 mg, 200 mg
1 ST
morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg
1
morphine sulfate oral solution 1 morphine sulfate oral tablet 1 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG
2 ST
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 50 MG
2
NUCYNTA ORAL TABLET 2 oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
1
oxycodone hcl oral tablet 1 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- 325 mg, 7.5-325 mg
1
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG
2
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 MG, 80 MG
2 ST
2 ST
oxymorphone hcl oral tablet 2 PA; PA except Pain Medicine
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg
1 ST
tramadol hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
2 ST
1 ST
tramadol hcl oral tablet 50 mg 1 tramadol-acetaminophen oral tablet
1 PA; PA except Pain Medicine
XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT
3
2 PA
danazol oral capsule 2 methyltestosterone oral capsule 3 PA oxandrolone oral tablet 2 testosterone cypionate injection solution 200 mg/ml
1 PA
1 PA
12.01.2021
5
testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)
2 PA
*Anorectal And Related Products* hydrocortisone rectal enema 1 lidocaine-hydrocortisone ace rectal gel
1
4 OTC
4 OTC
antacid liquid oral suspension 4 OTC antacid oral tablet chewable 500 mg
4 OTC
4 OTC
4 OTC
4 OTC
4 OTC
Infectious Disease or Gastroenterology
benznidazole oral tablet 3 PA; SP EMVERM ORAL TABLET CHEWABLE 3 ivermectin oral tablet 1 praziquantel oral tablet 2
*Antianginal Agents* ISORDIL TITRADOSE ORAL TABLET 40 MG
2
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
1
1
2
3
1
nitroglycerin translingual solution 2 ranolazine er oral tablet extended release 12 hour
2
*Antianxiety Agents* alprazolam er oral tablet extended release 24 hour
1
alprazolam oral tablet 1
alprazolam oral tablet dispersible 1 PA buspirone hcl oral tablet 1 chlordiazepoxide hcl oral capsule 1 AL clorazepate dipotassium oral tablet 1 diazepam oral tablet 1 AL hydroxyzine hcl oral syrup 1 AL hydroxyzine hcl oral tablet 1 AL hydroxyzine pamoate oral capsule 1 AL lorazepam oral tablet 0.5 mg 1 meprobamate oral tablet 200 mg 3 AL oxazepam oral capsule 1
*Antiarrhythmics* amiodarone hcl oral tablet 2 disopyramide phosphate oral capsule
1
dofetilide oral capsule 2 flecainide acetate oral tablet 2 mexiletine hcl oral capsule 2 MULTAQ ORAL TABLET 3 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR
2
2
1
propafenone hcl oral tablet 1 quinidine gluconate er oral tablet extended release
2
*Antiasthmatic And Bronchodilator Agents* ADVAIR HFA INHALATION AEROSOL 2 albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act
1
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml
2
albuterol sulfate oral syrup 1 albuterol sulfate oral tablet 1 arformoterol tartrate inhalation nebulization solution
3 PA
ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
2
2
2
2
2
12.01.2021
6
2
2
2 MM
2
3
budesonide inhalation suspension 2 QL; AL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION
2
1
ELIXOPHYLLIN ORAL ELIXIR 2 FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR
3 PA; SP
2
1 MM
1
3 PA
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml
2 PA
1
montelukast sodium oral packet 1 AL montelukast sodium oral tablet 1 AL montelukast sodium oral tablet chewable 4 mg, 5 mg
1 AL
3 PA; SP
2
2
2 ST
2 AL
2
2
2
SYMBICORT INHALATION AEROSOL 2 terbutaline sulfate oral tablet 1 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR
2
theophylline er oral tablet extended release 12 hour 300 mg, 450 mg
1
1
theophylline oral solution 1 WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED
1 MM
YUPELRI INHALATION SOLUTION 3 PA zafirlukast oral tablet 1 zileuton er oral tablet extended release 12 hour
2 PA; MM
*Anticoagulants* ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK
2
2
than 14 days except when written by
Oncology; QL FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML
3 PA; PA required for duration of greater
than 14 days except when written by
Oncology FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
3 PA
2
JANTOVEN ORAL TABLET 1 PRADAXA ORAL CAPSULE 2 warfarin sodium oral tablet 1 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
2
Drug Name Tier Notes Drug Name Tier Notes
12.01.2021
7
2
*Anticonvulsants* APTIOM ORAL TABLET 3 BRIVIACT ORAL SOLUTION 3 PA; PA except
Neurology BRIVIACT ORAL TABLET 3 PA; PA except
Neurology carbamazepine er oral capsule extended release 12 hour
1
1
carbamazepine oral suspension 1 carbamazepine oral tablet 1 carbamazepine oral tablet chewable
1
CELONTIN ORAL CAPSULE 2 clobazam oral suspension 1 AL clobazam oral tablet 1 AL clonazepam oral tablet 1 clonazepam oral tablet dispersible 0.125 mg
1 PA; MM
clonazepam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg
1 PA
DIACOMIT ORAL CAPSULE 3 PA; LDD DIACOMIT ORAL PACKET 3 PA; LDD diazepam rectal gel 1 PA; PA except
neurology; AL DILANTIN ORAL CAPSULE 30 MG 2 divalproex sodium er oral tablet extended release 24 hour
1
1
EPIDIOLEX ORAL SOLUTION 3 PA; LDD; AL EPITOL ORAL TABLET 1 ethosuximide oral capsule 1 ethosuximide oral solution 1 felbamate oral suspension 2 felbamate oral tablet 2 FINTEPLA ORAL SOLUTION 3 PA; LDD FYCOMPA ORAL SUSPENSION 3 AL FYCOMPA ORAL TABLET 3 AL gabapentin oral capsule 1 gabapentin oral solution 250 mg/5ml
1
gabapentin oral tablet 1 lamotrigine er oral tablet extended release 24 hour
2 AL
lamotrigine oral tablet 1 lamotrigine oral tablet chewable 1 lamotrigine oral tablet dispersible 2 PA lamotrigine starter kit-blue oral kit 2 lamotrigine starter kit-green oral kit
2
2
1
levetiracetam oral solution 1 MO levetiracetam oral tablet 1
NAYZILAM NASAL SOLUTION 3 PA; QL oxcarbazepine oral suspension 1 oxcarbazepine oral tablet 1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR
3 ST
1
phenytoin oral tablet chewable 1 phenytoin sodium extended oral capsule
1
pregabalin oral capsule 1 MM pregabalin oral solution 1 MM primidone oral tablet 1 rufinamide oral suspension 3 AL rufinamide oral tablet 3 AL tiagabine hcl oral tablet 2 topiramate er oral capsule er 24 hour sprinkle
3 PA; PA except neurology
topiramate oral capsule sprinkle 2 PA topiramate oral tablet 1 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR
3 PA
valproic acid oral capsule 1 VALTOCO 10 MG DOSE NASAL LIQUID
3 PA; QL; AL
3 PA; QL; AL
3 PA; QL; AL
3 PA; QL; AL
vigabatrin oral packet 2 PA; SP vigabatrin oral tablet 2 PA; SP VIMPAT ORAL SOLUTION 3 AL VIMPAT ORAL TABLET 3 AL XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG
3 PA; QL
3 PA; QL
XCOPRI ORAL TABLET 3 PA; QL XCOPRI ORAL TABLET THERAPY PACK
3 PA; QL
*Antidepressants* amitriptyline hcl oral tablet 1 amoxapine oral tablet 1 bupropion hcl er (sr) oral tablet extended release 12 hour
1
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
1
1
clomipramine hcl oral capsule 1 desipramine hcl oral tablet 1
12.01.2021
8
2
doxepin hcl oral capsule 1 doxepin hcl oral concentrate 1 duloxetine hcl oral capsule delayed release particles
1
EMSAM TRANSDERMAL PATCH 24 HOUR
3 PA; PA except Psychiatry
escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet 1 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR
3 ST
fluoxetine hcl oral capsule 1 fluoxetine hcl oral capsule delayed release
2
fluoxetine hcl oral solution 1 fluvoxamine maleate oral tablet 1 imipramine hcl oral tablet 1 MARPLAN ORAL TABLET 3 mirtazapine oral tablet 1 mirtazapine oral tablet dispersible 1 nefazodone hcl oral tablet 2 PA nortriptyline hcl oral capsule 1 nortriptyline hcl oral solution 1 paroxetine hcl er oral tablet extended release 24 hour
1 ST
paroxetine hcl oral suspension 1 paroxetine hcl oral tablet 1 PEXEVA ORAL TABLET 3 phenelzine sulfate oral tablet 1 protriptyline hcl oral tablet 2 sertraline hcl oral concentrate 1 sertraline hcl oral tablet 1 tranylcypromine sulfate oral tablet 2 trazodone hcl oral tablet 1 trimipramine maleate oral capsule 1 TRINTELLIX ORAL TABLET 3 ST venlafaxine hcl er oral capsule extended release 24 hour
1
venlafaxine hcl oral tablet 1 VIIBRYD ORAL TABLET 3 VIIBRYD STARTER PACK ORAL KIT 3 QL
*Antidiabetics* acarbose oral tablet 1 BAQSIMI ONE PACK NASAL POWDER
1
1
4 OTC
CYCLOSET ORAL TABLET 3 diazoxide oral suspension 1 PA; PA except
endocrinology FARXIGA ORAL TABLET 2 glimepiride oral tablet 1 glipizide er oral tablet extended release 24 hour
1
glipizide oral tablet 1 glipizide xl oral tablet extended release 24 hour
1
2
glucagon emergency injection kit 2 glucose oral gel 40 % 4 OTC glucose oral tablet chewable 4 OTC glyburide micronized oral tablet 1 glyburide oral tablet 1 glyburide-metformin oral tablet 1 GLYXAMBI ORAL TABLET 2 GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR
1
1
1
2
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML
2
2
2
2
2
2 OTC
2 OTC
2 OTC
HUMULIN R INJECTION SOLUTION 2 OTC HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION
2
2
JARDIANCE ORAL TABLET 2 JENTADUETO ORAL TABLET 2 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR
2
12.01.2021
9
2
2
LYUMJEV INJECTION SOLUTION 2 MM LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR
2 MM
1
metformin hcl oral solution 2 MM metformin hcl oral tablet 1 miglitol oral tablet 1 PA nateglinide oral tablet 1 OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR
2 ST; ST except endocrinology
OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 MG/1.5ML
pioglitazone hcl oral tablet 2 pioglitazone hcl-glimepiride oral tablet
2
2
repaglinide oral tablet 2 RIOMET ORAL SOLUTION 3 RYBELSUS ORAL TABLET 2 ST; ST except
endocrinology SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR
2 ST
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR
2 PA; PA except Endocrinology
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR
2 PA; PA except Endocrinology
SYNJARDY ORAL TABLET 2 SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR
2
2
2
TRADJENTA ORAL TABLET 2 TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS
2 MM
2 MM
TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML
2
2 MM
2
2
2 ST; ST except Endocrinology
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 MG/0.5ML, 4.5 MG/0.5ML
VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR
2
1
*Antidiarrheal/Probiotic Agents* anti-diarrheal oral tablet 4 OTC bismuth oral tablet chewable 4 OTC diarrhea oral suspension 4 OTC diphenoxylate-atropine oral liquid 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg
1
4 OTC
3 PA; SP
opium oral tincture 2 sb bismuth oral tablet 4 OTC
*Antidotes And Specific Antagonists* CHEMET ORAL CAPSULE 3 deferasirox granules oral packet 3 PA; SP; AL deferasirox oral tablet 180 mg, 360 mg
3 PA; SP; AL
deferasirox oral tablet 90 mg 2 PA; SP; AL deferiprone oral tablet 3 PA; LDD FERRIPROX ORAL SOLUTION 3 PA; LDD FERRIPROX ORAL TABLET 3 PA; LDD FERRIPROX TWICE-A-DAY ORAL TABLET
3 PA; LDD
KLOXXADO NASAL LIQUID 2 SUD naloxone hcl injection solution 0.4 mg/ml
1 SUD
1
1 SUD
1 SUD
naltrexone hcl oral tablet 2 NARCAN NASAL LIQUID 2 SUD VISTOGARD ORAL PACKET 2 LDD; QL
*Antiemetics* AKYNZEO ORAL CAPSULE 3 ST; QL
12.01.2021
10
aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg
1 ST; ST except Hematology and
Oncology; QL aprepitant oral capsule 40 mg 1 QL BONJESTA ORAL TABLET EXTENDED RELEASE
2 QL
2 QL
2 ST; QL
granisetron hcl oral tablet 2 ST; QL meclizine hcl oral tablet 12.5 mg 4 meclizine hcl oral tablet 25 mg 1 meclizine hcl oral tablet chewable 4 ondansetron hcl oral solution 1 ondansetron hcl oral tablet 1 ondansetron oral tablet dispersible 1 SANCUSO TRANSDERMAL PATCH 3 ST; QL scopolamine transdermal patch 72 hour
2 QL
1 PA
3 PA; LDD; QL
*Antifungals* fluconazole oral suspension reconstituted
1
1
fluconazole oral tablet 150 mg 1 QL flucytosine oral capsule 2 griseofulvin microsize oral suspension
1
1
Oncology itraconazole oral solution 2 PA; PA except
ID/Hematology or Oncology
ketoconazole oral tablet 1 PA NOXAFIL ORAL SUSPENSION 3 PA nystatin oral tablet 1 posaconazole oral tablet delayed release
2 PA
2 PA; PA except Infectious Disease
voriconazole oral tablet 2 PA; PA except Infectious Disease
*Antihistamines* carbinoxamine maleate oral solution
1 AL
1 AL
cetirizine hcl oral solution 4 cetirizine hcl oral tablet 4 OTC cetirizine hcl oral tablet chewable 4 OTC chlorpheniramine maleate er oral tablet extended release
4 OTC
1
cyproheptadine hcl oral syrup 1 AL cyproheptadine hcl oral tablet 1 AL desloratadine oral tablet 2 PA desloratadine oral tablet dispersible
2 PA; AL
4
1
diphenhydramine hcl oral elixir 4 diphenhydramine hcl oral liquid 12.5 mg/5ml
4 OTC
4 OTC
fexofenadine hcl oral tablet 180 mg 4 OTC levocetirizine dihydrochloride oral solution
2
2
loratadine childrens oral syrup 4 OTC loratadine oral tablet 4 OTC promethazine hcl oral solution 1 AL promethazine hcl oral syrup 1 AL promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
1 AL
1 AL
*Antihyperlipidemics* atorvastatin calcium oral tablet 1 ACA cholestyramine light oral packet 1 cholestyramine light oral powder 1 cholestyramine oral packet 1 cholestyramine oral powder 1 colesevelam hcl oral packet 2 MM colesevelam hcl oral tablet 2 MM colestipol hcl oral granules 1 colestipol hcl oral packet 1 colestipol hcl oral tablet 1 ezetimibe oral tablet 2 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg
2
2 PA
1
1
12.01.2021
11
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
1
1
fluvastatin sodium oral capsule 1 ACA gemfibrozil oral tablet 1 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG
3 PA; LDD
LIVALO ORAL TABLET 3 lovastatin oral tablet 1 ACA NEXLETOL ORAL TABLET 3 PA NEXLIZET ORAL TABLET 3 PA PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR
3 PA; SP; PA requires attestation
pravastatin sodium oral tablet 1 ACA REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE
REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR
rosuvastatin calcium oral tablet 1 ACA simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1 ACA
simvastatin oral tablet 80 mg 1 PA VASCEPA ORAL CAPSULE 2
*Antihypertensives* aliskiren fumarate oral tablet 2 ST amlodipine besy-benazepril hcl oral capsule
1
1
1
1 MM
doxazosin mesylate oral tablet 1 EDARBI ORAL TABLET 3 ST EDARBYCLOR ORAL TABLET 3 ST enalapril maleate oral solution 3 PA enalapril maleate oral tablet 1 enalapril-hydrochlorothiazide oral tablet
1
eplerenone oral tablet 1 PA fosinopril sodium oral tablet 1 guanfacine hcl oral tablet 1 hydralazine hcl oral tablet 1 irbesartan oral tablet 1 irbesartan-hydrochlorothiazide oral tablet
1
losartan potassium oral tablet 1 losartan potassium-hctz oral tablet 1 methyldopa oral tablet 1 metoprolol-hydrochlorothiazide oral tablet
1
metyrosine oral capsule 2 minoxidil oral tablet 1 moexipril hcl oral tablet 1 olmesartan medoxomil oral tablet 1 olmesartan medoxomil-hctz oral tablet
1
2 PA
prazosin hcl oral capsule 1 quinapril hcl oral tablet 1 quinapril-hydrochlorothiazide oral tablet
1
ramipril oral capsule 1 TEKTURNA HCT ORAL TABLET 3 ST telmisartan oral tablet 1 telmisartan-amlodipine oral tablet 3 MO telmisartan-hctz oral tablet 1 terazosin hcl oral capsule 1 trandolapril oral tablet 1 trandolapril-verapamil hcl er oral tablet extended release
3 MM
1
*Anti-Infective Agents - Misc.* AEMCOLO ORAL TABLET DELAYED RELEASE
3 QL
Infectious Disease; AL
atovaquone oral suspension 1 CAYSTON INHALATION SOLUTION RECONSTITUTED
3 PA; LDD; PA except for Cystic Fibrosis
Specialists.; QL; AL clindamycin hcl oral capsule 1 except for infectious
disease specialist; QL clindamycin palmitate hcl oral solution reconstituted
1 DF
3 PA; PA except Infectious Disease or
Gastroenterology fosfomycin tromethamine oral packet
3 QL
LAMPIT ORAL TABLET 3 PA lincomycin hcl injection solution 2 linezolid oral suspension reconstituted
1
12.01.2021
12
linezolid oral tablet 1 methenamine hippurate oral tablet 1 metronidazole oral tablet 1 nitrofurantoin macrocrystal oral capsule
1 AL
1
PRIMSOL ORAL SOLUTION 2 SIVEXTRO ORAL TABLET 3 PA sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
1
1
tinidazole oral tablet 1 trimethoprim oral tablet 1 vancomycin hcl oral capsule 2 PA; PA except
Infectious Disease or Gastroenterology
XIFAXAN ORAL TABLET 200 MG 3 QL XIFAXAN ORAL TABLET 550 MG 3 PA
*Antimalarials* atovaquone-proguanil hcl oral tablet
2
chloroquine phosphate oral tablet 1 COARTEM ORAL TABLET 3 QL hydroxychloroquine sulfate oral tablet 200 mg
1
mefloquine hcl oral tablet 2 pyrimethamine oral tablet 2 PA; LDD; PA except
Infectious Disease quinine sulfate oral capsule 1 PA; QL; AL
*Antimyasthenic/Cholinergic Agents* FIRDAPSE ORAL TABLET 3 PA; LDD pyridostigmine bromide er oral tablet extended release
2
1
RUZURGI ORAL TABLET 3 PA; LDD
*Antimycobacterial Agents* cycloserine oral capsule 2 ethambutol hcl oral tablet 1 isoniazid oral syrup 1 isoniazid oral tablet 1 PASER ORAL PACKET 3 pretomanid oral tablet 3 PA PRIFTIN ORAL TABLET 3 QL pyrazinamide oral tablet 2 rifabutin oral capsule 2 PA; PA except
Infectious Disease rifampin oral capsule 1 SIRTURO ORAL TABLET 3 PA; PA except
Infectious Disease Specialists
*Antineoplastics And Adjunctive Therapies* abiraterone acetate oral tablet 250 mg
2 PA; SP
ACTIMMUNE SUBCUTANEOUS SOLUTION
3 PA; LDD
ALECENSA ORAL CAPSULE 3 PA; LDD ALUNBRIG ORAL TABLET 3 PA; LDD ALUNBRIG ORAL TABLET THERAPY PACK
3 PA; LDD
anastrozole oral tablet 1 PA; PA except Oncology, Oncology Surgery, and Breast
Surgery; ACA AYVAKIT ORAL TABLET 3 PA; LDD BALVERSA ORAL TABLET 3 PA; LDD bexarotene oral capsule 2 PA; SP bicalutamide oral tablet 1 SP BOSULIF ORAL TABLET 3 PA; SP BRAFTOVI ORAL CAPSULE 75 MG 3 PA; LDD BRUKINSA ORAL CAPSULE 3 PA; LDD CABOMETYX ORAL TABLET 3 PA; LDD CALQUENCE ORAL CAPSULE 3 PA; LDD capecitabine oral tablet 2 SP CAPRELSA ORAL TABLET 3 PA; LDD COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 MG
3 PA; LDD
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 MG & 80 MG
3 PA; LDD
3 PA; LDD
COPIKTRA ORAL CAPSULE 3 PA; LDD COTELLIC ORAL TABLET 3 PA; LDD cyclophosphamide oral capsule 2 SP DAURISMO ORAL TABLET 3 PA; LDD EMCYT ORAL CAPSULE 2 SP ERIVEDGE ORAL CAPSULE 3 PA; LDD ERLEADA ORAL TABLET 3 PA; LDD erlotinib hcl oral tablet 2 PA; SP etoposide oral capsule 2 SP everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg
2 PA; SP
everolimus oral tablet soluble 2 PA; SP exemestane oral tablet 1 SP; ACA FARYDAK ORAL CAPSULE 3 PA; LDD flutamide oral capsule 2 SP FOTIVDA ORAL CAPSULE 3 PA; LDD GAVRETO ORAL CAPSULE 3 PA; LDD GILOTRIF ORAL TABLET 3 PA; SP GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG
3
HYCAMTIN ORAL CAPSULE 3 PA; SP hydroxyurea oral capsule 1 IBRANCE ORAL CAPSULE 3 PA; LDD ICLUSIG ORAL TABLET 15 MG, 45 MG
3 PA; SP; LDD
ICLUSIG ORAL TABLET 30 MG 3 PA; SP IDHIFA ORAL TABLET 3 PA; LDD imatinib mesylate oral tablet 2 PA; SP IMBRUVICA ORAL CAPSULE 3 PA; LDD IMBRUVICA ORAL TABLET 3 PA; LDD
12.01.2021
13
INLYTA ORAL TABLET 3 PA; SP INQOVI ORAL TABLET 3 PA; LDD INREBIC ORAL CAPSULE 3 PA; SP INTRON A INJECTION SOLUTION 6000000 UNIT/ML
2 PA; SP
IRESSA ORAL TABLET 3 PA; LDD JAKAFI ORAL TABLET 3 PA; LDD KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK
3 PA; SP
3 PA; SP
3 PA; SP
3 PA; SP
3 PA; SP
3 PA; SP
KOSELUGO ORAL CAPSULE 3 PA; SP lapatinib ditosylate oral tablet 2 PA; SP LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
letrozole oral tablet 1 ACA leucovorin calcium oral tablet 1 LEUKERAN ORAL TABLET 2 SP leuprolide acetate injection kit 2 PA LONSURF ORAL TABLET 3 PA; SP LORBRENA ORAL TABLET 3 PA; LDD LUMAKRAS ORAL TABLET 3 PA; LDD LYNPARZA ORAL TABLET 3 PA; LDD LYSODREN ORAL TABLET 2 SP MATULANE ORAL CAPSULE 3 LDD megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
1 SP
megestrol acetate oral tablet 1 SP MEKINIST ORAL TABLET 3 PA; SP MEKTOVI ORAL TABLET 3 PA; LDD melphalan oral tablet 2 SP mercaptopurine oral tablet 1 MESNEX ORAL TABLET 3 PA; SP; PA except
Oncology methotrexate oral tablet 1 methotrexate sodium (pf) injection solution 50 mg/2ml
1 PA; PA except rheumatology,
dermatology and gastroenterology
1 PA; PA except rheumatology,
dermatology and gastroenterology
NERLYNX ORAL TABLET 3 PA; LDD NEXAVAR ORAL TABLET 3 PA; SP nilutamide oral tablet 2 PA NINLARO ORAL CAPSULE 3 PA; SP; QL NUBEQA ORAL TABLET 3 PA; SP ODOMZO ORAL CAPSULE 3 PA; SP ONUREG ORAL TABLET 3 PA; SP ORGOVYX ORAL TABLET 3 PA; SP PEMAZYRE ORAL TABLET 3 PA; SP PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK
3 PA; SP
3 PA; SP
3 PA; SP
POMALYST ORAL CAPSULE 3 PA; LDD QINLOCK ORAL TABLET 3 PA; SP RETEVMO ORAL CAPSULE 3 PA; SP ROZLYTREK ORAL CAPSULE 3 PA; SP RUBRACA ORAL TABLET 3 PA; LDD RYDAPT ORAL CAPSULE 3 PA; SP SPRYCEL ORAL TABLET 2 PA; SP STIVARGA ORAL TABLET 3 PA; LDD sunitinib malate oral capsule 2 PA; SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED
3 PA; LDD
TABLOID ORAL TABLET 2 TABRECTA ORAL TABLET 3 PA; SP TAFINLAR ORAL CAPSULE 3 PA; LDD TAGRISSO ORAL TABLET 3 PA; LDD TALZENNA ORAL CAPSULE 3 PA; LDD tamoxifen citrate oral tablet 1 ACA TASIGNA ORAL CAPSULE 2 PA; SP TAZVERIK ORAL TABLET 3 PA; LDD temozolomide oral capsule 2 LDD TEPMETKO ORAL TABLET 3 PA; SP TIBSOVO ORAL TABLET 3 PA; LDD toremifene citrate oral tablet 2 SP; MM tretinoin oral capsule 1 SP TREXALL ORAL TABLET 2 TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE THERAPY PACK
3 PA; LDD
3 PA; LDD
3 PA; LDD
3 PA; LDD
TUKYSA ORAL TABLET 3 PA; SP TURALIO ORAL CAPSULE 3 PA; LDD UKONIQ ORAL TABLET 3 PA; SP VENCLEXTA ORAL TABLET 3 PA; LDD VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK
3 PA; LDD
VERZENIO ORAL TABLET 3 PA; LDD VITRAKVI ORAL CAPSULE 3 PA; SP VITRAKVI ORAL SOLUTION 3 PA; SP
12.01.2021
14
VIZIMPRO ORAL TABLET 3 PA; LDD VOTRIENT ORAL TABLET 3 PA; LDD XALKORI ORAL CAPSULE 3 PA; SP XATMEP ORAL SOLUTION 3 PA XOSPATA ORAL TABLET 3 PA; LDD XTANDI ORAL CAPSULE 3 PA; LDD XTANDI ORAL TABLET 3 PA; LDD ZEJULA ORAL CAPSULE 3 PA; LDD ZELBORAF ORAL TABLET 3 PA; SP ZOLINZA ORAL CAPSULE 3 PA; SP ZYDELIG ORAL TABLET 3 PA; SP ZYKADIA ORAL TABLET 3 PA; SP
*Antiparkinson And Related Therapy Agents* amantadine hcl oral capsule 1 amantadine hcl oral tablet 1 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE
3 PA; LDD; PA except Neurology
benztropine mesylate oral tablet 1 bromocriptine mesylate oral capsule
2
bromocriptine mesylate oral tablet 1 carbidopa oral tablet 2 carbidopa-levodopa er oral tablet extended release 25-100 mg, 50- 200 mg
1
1 PA
1
DUOPA ENTERAL SUSPENSION 3 PA; LDD; QL entacapone oral tablet 2 ST GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR
3 PA
INBRIJA INHALATION CAPSULE 3 PA; LDD KYNMOBI SUBLINGUAL FILM 3 PA; SP; PA except
neurology KYNMOBI TITRATION KIT SUBLINGUAL KIT
3 PA; SP; PA except neurology
NEUPRO TRANSDERMAL PATCH 24 HOUR
3 PA
ONGENTYS ORAL CAPSULE 3 ST OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK
3 PA
OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG, 193 MG
3 PA
2 PA
1 PA except neurology
ropinirole hcl oral tablet 2 selegiline hcl oral capsule 1 selegiline hcl oral tablet 1 trihexyphenidyl hcl oral solution 1 AL
trihexyphenidyl hcl oral tablet 1 XADAGO ORAL TABLET 3 PA; SP ZELAPAR ORAL TABLET DISPERSIBLE
3 PA; PA except Neurology
*Antipsychotics/Antimanic Agents* ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET
3 PA; LDD
ABILIFY MYCITE ORAL TABLET 3 PA; LDD ABILIFY MYCITE STARTER KIT ORAL TABLET
3 PA; LDD
aripiprazole oral solution 2 aripiprazole oral tablet 1 asenapine maleate sublingual tablet sublingual
3
CAPLYTA ORAL CAPSULE 3 PA chlorpromazine hcl oral tablet 1 clozapine oral tablet 1 QL; AL clozapine oral tablet dispersible 2 PA; QL; AL FANAPT ORAL TABLET 3 PA; PA except
Psychiatry FANAPT TITRATION PACK ORAL TABLET
3 PA; PA except Psychiatry
fluphenazine decanoate injection solution
2
fluphenazine hcl oral concentrate 1 fluphenazine hcl oral elixir 1 fluphenazine hcl oral tablet 1 haloperidol lactate oral concentrate
1
haloperidol oral tablet 1 LATUDA ORAL TABLET 2 AL lithium carbonate er oral tablet extended release
1
lithium carbonate oral capsule 1 lithium carbonate oral tablet 1 loxapine succinate oral capsule 1 NUPLAZID ORAL CAPSULE 3 PA; LDD NUPLAZID ORAL TABLET 10 MG 3 PA; LDD olanzapine oral tablet 1 olanzapine oral tablet dispersible 1 paliperidone er oral tablet extended release 24 hour
2 PA
1 AL
1
quetiapine fumarate oral tablet 1 REXULTI ORAL TABLET 3 PA risperidone oral solution 1 AL risperidone oral tablet 1 risperidone oral tablet dispersible 1 thioridazine hcl oral tablet 1 thiothixene oral capsule 1 trifluoperazine hcl oral tablet 1 VRAYLAR ORAL CAPSULE 3 PA VRAYLAR ORAL CAPSULE THERAPY PACK
3 PA
12.01.2021
15
*Antiseptics & Disinfectants* chlorhexidine gluconate solution 20 %
4
4 OTC
*Antivirals* abacavir sulfate oral solution 1 abacavir sulfate oral tablet 1 abacavir sulfate-lamivudine oral tablet
2
2 PA
acyclovir oral capsule 1 acyclovir oral suspension 1 acyclovir oral tablet 1 adefovir dipivoxil oral tablet 2 PA; PA except
Gastroenterology or Infectious Disease
APTIVUS ORAL CAPSULE 3 atazanavir sulfate oral capsule 2 BARACLUDE ORAL SOLUTION 3 PA; PA except
Gastroenterology and Infectious
Disease BIKTARVY ORAL TABLET 3 CIMDUO ORAL TABLET 3 COMPLERA ORAL TABLET 3 DELSTRIGO ORAL TABLET 2 DESCOVY ORAL TABLET 3 PA; ACA; PL DOVATO ORAL TABLET 3 PA EDURANT ORAL TABLET 3 efavirenz oral capsule 2 efavirenz oral tablet 2 efavirenz-emtricitab-tenofovir oral tablet
1
emtricitabine oral capsule 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg
1
1 ACA
EMTRIVA ORAL SOLUTION 2 entecavir oral tablet 1 PA; PA except
Gastroenterology and Infectious
Disease EPCLUSA ORAL PACKET 3 PA; SP EPCLUSA ORAL TABLET 3 PA; SP EPIVIR HBV ORAL SOLUTION 3 etravirine oral tablet 2 EVOTAZ ORAL TABLET 3 famciclovir oral tablet 2 fosamprenavir calcium oral tablet 2 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED
3 PA; SP
GENVOYA ORAL TABLET 2
HARVONI ORAL TABLET 3 PA; SP INTELENCE ORAL TABLET 25 MG 2 INVIRASE ORAL TABLET 3 ISENTRESS HD ORAL TABLET 2 ISENTRESS ORAL PACKET 2 ISENTRESS ORAL TABLET 2 ISENTRESS ORAL TABLET CHEWABLE
2
JULUCA ORAL TABLET 3 LDD lamivudine oral solution 1 lamivudine oral tablet 1 lamivudine-zidovudine oral tablet 1 ledipasvir-sofosbuvir oral tablet 2 PA; SP LEXIVA ORAL SUSPENSION 2 LEXIVA ORAL TABLET NF lopinavir-ritonavir oral solution 2 lopinavir-ritonavir oral tablet 2 MAVYRET ORAL PACKET 3 PA; SP MAVYRET ORAL TABLET 3 PA; SP nevirapine er oral tablet extended release 24 hour
2
nevirapine oral suspension 2 nevirapine oral tablet 1 NORVIR ORAL SOLUTION 2 ODEFSEY ORAL TABLET 3 oseltamivir phosphate oral capsule 1 QL oseltamivir phosphate oral suspension reconstituted
1 QL
3 PA; SP
PIFELTRO ORAL TABLET 3 PREVYMIS ORAL TABLET 3 PA; SP PREZCOBIX ORAL TABLET 3 PREZISTA ORAL SUSPENSION 2 ST PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG
2 ST
2 QL
REYATAZ ORAL PACKET 2 ribavirin oral capsule 1 SP ribavirin oral tablet 200 mg 1 SP rimantadine hcl oral tablet 2 ritonavir oral tablet 2 RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR
2
SELZENTRY ORAL SOLUTION 3 PA SELZENTRY ORAL TABLET 3 PA sofosbuvir-velpatasvir oral tablet 2 PA; SP SOVALDI ORAL PACKET 3 PA; SP SOVALDI ORAL TABLET 3 PA; SP stavudine oral capsule 1 STRIBILD ORAL TABLET 2 SYMTUZA ORAL TABLET 2 TEMIXYS ORAL TABLET 2 tenofovir disoproxil fumarate oral tablet
2
TIVICAY ORAL TABLET 2 TIVICAY PD ORAL TABLET SOLUBLE 2 TRIUMEQ ORAL TABLET 2 PA TYBOST ORAL TABLET 2 ST
12.01.2021
16
valacyclovir hcl oral tablet 1 valganciclovir hcl oral solution reconstituted
valganciclovir hcl oral tablet 1 PA; PA except Infectious Disease
VEMLIDY ORAL TABLET 2 PA; PA except Infectious disease
and Gastroenterology
VIRACEPT ORAL TABLET 2 VIREAD ORAL POWDER 3 VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
3
vocabria oral tablet 3 VOSEVI ORAL TABLET 3 PA; SP XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK
3 QL
3 QL
zidovudine oral capsule 1 zidovudine oral syrup 1 zidovudine oral tablet 1
*Beta Blockers* acebutolol hcl oral capsule 1 atenolol oral tablet 1 betaxolol hcl oral tablet 1 bisoprolol fumarate oral tablet 1 carvedilol oral tablet 1 carvedilol phosphate er oral capsule extended release 24 hour
2
HEMANGEOL ORAL SOLUTION 3 PA; SP labetalol hcl oral tablet 1 metoprolol succinate er oral tablet extended release 24 hour
1
metoprolol tartrate oral tablet 1 nadolol oral tablet 20 mg, 40 mg, 80 mg
1
nebivolol hcl oral tablet 2 pindolol oral tablet 3 propranolol hcl er oral capsule extended release 24 hour
1
propranolol hcl oral solution 1 propranolol hcl oral tablet 1 SORINE ORAL TABLET 1 sotalol hcl (af) oral tablet 1 sotalol hcl oral tablet 1 SOTYLIZE ORAL SOLUTION 3 QL timolol maleate oral tablet 1
*Calcium Channel Blockers* AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR
1
amlodipine besylate oral tablet 1 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR
1
diltiazem hcl er beads oral capsule extended release 24 hour
1
diltiazem hcl er coated beads oral capsule extended release 24 hour
1
1
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
1
diltiazem hcl oral tablet 1 dilt-xr oral capsule extended release 24 hour
1
1
isradipine oral capsule 1 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR
2
nicardipine hcl oral capsule 1 nifedipine er oral tablet extended release 24 hour
1
nifedipine er osmotic release oral tablet extended release 24 hour
1
nifedipine oral capsule 1 MM nimodipine oral capsule 2 PA nisoldipine er oral tablet extended release 24 hour
2
1
1
verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg
1
verapamil hcl oral tablet 1
*Cardiotonics* DIGITEK ORAL TABLET 1 DIGOX ORAL TABLET 3 digoxin oral solution 1 digoxin oral tablet 1 LANOXIN ORAL TABLET 62.5 MCG 3
*Cardiovascular Agents - Misc.* ADEMPAS ORAL TABLET 3 PA; SP ambrisentan oral tablet 2 PA; SP amlodipine-atorvastatin oral tablet 2 BIDIL ORAL TABLET 3 bosentan oral tablet 2 PA; SP CORLANOR ORAL SOLUTION 3 PA; AL CORLANOR ORAL TABLET 3 PA; AL ENTRESTO ORAL TABLET 3 OPSUMIT ORAL TABLET 3 PA; LDD ORENITRAM ORAL TABLET EXTENDED RELEASE
3 PA; LDD
2 PA; AL
sildenafil citrate oral tablet 20 mg 2 PA tadalafil 20 mg oral tablet (pah) 2 PA TRACLEER ORAL TABLET SOLUBLE 3 PA; LDD UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
3 PA; SP
3 PA; SP
UPTRAVI TABLET 1000 MCG ORAL 3 PA; LDD UPTRAVI TABLET 200 MCG ORAL 3 PA; LDD UPTRAVI TABLET 400 MCG ORAL 3 PA; LDD
12.01.2021
17
UPTRAVI TABLET 600 MCG ORAL 3 PA; LDD UPTRAVI TABLET 800 MCG ORAL 3 PA; LDD VENTAVIS INHALATION SOLUTION 3 PA; SP VERQUVO ORAL TABLET 3 PA VYNDAMAX ORAL CAPSULE 3 PA; LDD VYNDAQEL ORAL CAPSULE 3 PA; LDD
*Cephalosporins* cefaclor oral capsule 1 cefaclor oral suspension reconstituted
1
1
cefadroxil oral tablet 1 cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 300 gm, 500 mg
2
2
1
2
2
2
cefprozil oral tablet 2 cefuroxime axetil oral tablet 2 cephalexin oral capsule 250 mg, 500 mg
1 DF
*Chemicals* biotin powder 4
*Contraceptives* ALTAVERA ORAL TABLET 1 alyacen 1/35 oral tablet 1 alyacen 7/7/7 oral tablet 1 AMETHIA ORAL TABLET 1 ANNOVERA VAGINAL RING 3 APRI ORAL TABLET 1 ARANELLE ORAL TABLET 1 AUBRA ORAL TABLET 1 AVIANE ORAL TABLET 1 AZURETTE ORAL TABLET 1 BALCOLTRA ORAL TABLET 2 MM briellyn oral tablet 1 CAMRESE LO ORAL TABLET 1 CAMRESE ORAL TABLET 1 CAZIANT ORAL TABLET 1 CESIA ORAL TABLET 1 CHATEAL ORAL TABLET 1 CRYSELLE-28 ORAL TABLET 1 DAYSEE ORAL TABLET 1 drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg
1
1
ELINEST ORAL TABLET 1 ELLA ORAL TABLET 2 QL ELURYNG VAGINAL RING 1 EMOQUETTE ORAL TABLET 1 ENPRESSE-28 ORAL TABLET 1 ENSKYCE ORAL TABLET 0.15-30 MG-MCG
1
ESTARYLLA ORAL TABLET 1 FALMINA ORAL TABLET 1 FAYOSIM ORAL TABLET 1 MM GEMMILY ORAL CAPSULE 2 MM INTROVALE ORAL TABLET 1 JAIMIESS ORAL TABLET 2 JOLESSA ORAL TABLET 1 JUNEL 1.5/30 ORAL TABLET 1 JUNEL FE 1.5/30 ORAL TABLET 1 KARIVA ORAL TABLET 1 KELNOR 1/35 ORAL TABLET 1 KURVELO ORAL TABLET 1 LARIN FE 1.5/30 ORAL TABLET 1 LEENA ORAL TABLET 1 LESSINA ORAL TABLET 1 LEVONEST ORAL TABLET 1 levonorgest-eth est & eth est oral tablet
1
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15- 0.03 mg
1
levonorgestrel oral tablet 1.5 mg 1 OTC; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg- mcg
1
LEVORA 0.15/30 (28) ORAL TABLET 1 LO LOESTRIN FE ORAL TABLET 2 LOJAIMIESS ORAL TABLET 2 LORYNA ORAL TABLET 1 LOW-OGESTREL ORAL TABLET 1 LUTERA ORAL TABLET 1 marlissa oral tablet 1 MIBELAS 24 FE ORAL TABLET CHEWABLE
1
MICROGESTIN 1.5/30 ORAL TABLET 1 MICROGESTIN FE 1.5/30 ORAL TABLET
1
MONO-LINYAH ORAL TABLET 1 NATAZIA ORAL TABLET 2 NECON 0.5/35 (28) ORAL TABLET 1 norethin ace-eth estrad-fe oral capsule
2 MM
1
1
1
1 MM
12.01.2021
18
1
1
NORTREL 0.5/35 (28) ORAL TABLET 1 OCELLA ORAL TABLET 1 ORSYTHIA ORAL TABLET 1 PIMTREA ORAL TABLET 1 PORTIA-28 ORAL TABLET 1 PREVIFEM ORAL TABLET 1 RECLIPSEN ORAL TABLET 1 RIVELSA ORAL TABLET 1 MM SLYND ORAL TABLET 3 MM SOLIA ORAL TABLET 1 SPRINTEC 28 ORAL TABLET 1 SRONYX ORAL TABLET 1 SYEDA ORAL TABLET 1 TILIA FE ORAL TABLET 1 TRI FEMYNOR ORAL TABLET 1 TRI-ESTARYLLA ORAL TABLET 1 TRI-LEGEST FE ORAL TABLET 1 TRI-LINYAH ORAL TABLET 1 TRI-LO-ESTARYLLA ORAL TABLET 1 TRI-LO-MARZIA ORAL TABLET 1 TRI-LO-SPRINTEC ORAL TABLET 1 TRINESSA (28) ORAL TABLET 1 TRI-PREVIFEM ORAL TABLET 1 TRI-SPRINTEC ORAL TABLET 1 TRIVORA (28) ORAL TABLET 1 TRI-VYLIBRA ORAL TABLET 1 TYDEMY ORAL TABLET 1 VELIVET ORAL TABLET 1 viorele oral tablet 1 WERA ORAL TABLET 1 WYMZYA FE ORAL TABLET CHEWABLE
1
ZARAH ORAL TABLET 1 ZOVIA 1/35E (28) ORAL TABLET 1
*Corticosteroids* budesonide er oral tablet extended release 24 hour
2 PA
2 PA; PA except Colorectal
Surgery/Gastroenter ology
2
dexamethasone oral elixir 1 DF dexamethasone oral solution 1 DF dexamethasone oral tablet 1 DF EMFLAZA ORAL SUSPENSION 3 PA; LDD EMFLAZA ORAL TABLET 3 PA; LDD fludrocortisone acetate oral tablet 1 hydrocortisone oral tablet 1 methylprednisolone oral tablet 1 DF MILLIPRED ORAL TABLET 3 prednisolone oral solution 1 prednisolone oral syrup 15 mg/5ml 1
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
3
1
prednisone oral solution 1 DF prednisone oral tablet 1 DF RAYOS ORAL TABLET DELAYED RELEASE
3 PA
1 QL
4 OTC
cold & allergy oral elixir 4 OTC cold multi-symptom day/night oral 4 OTC cold multi-symptom daytime oral tablet
4 OTC
cough & cold oral tablet 4 OTC DIABETIC TUSSIN MAX ST ORAL LIQUID
4 OTC
4 OTC
4 OTC
guaifenesin er oral tablet extended release 12 hour 600 mg
4
4 OTC
guaifenesin oral tablet 4 OTC guaifenesin-dm oral syrup 4 OTC hydrocod polst-cpm polst er oral suspension extended release
2
4 OTC
4 OTC
4 OTC
4 OTC
1
4 OTC
4 OTC
1
SSKI ORAL SOLUTION 3
*Dermatologicals* ABREVA EXTERNAL CREAM 4 OTC acitretin oral capsule 2 PA; PA except
dermatology acne medication 10 external lotion 4 OTC
12.01.2021
19
acne medication 5 external lotion 4 OTC acyclovir external ointment 2 adapalene external cream 1 PA adapalene external gel 1 PA adapalene-benzoyl peroxide external gel
1
AKLIEF EXTERNAL CREAM 3 PA; AL alclometasone dipropionate external cream
1
ALTABAX EXTERNAL OINTMENT 3 ST alum sulfate-ca acetate external packet
4 OTC
amcinonide external lotion 1 AMNESTEEM ORAL CAPSULE 1 PA; PA except
dermatology ARAZLO EXTERNAL LOTION 3 PA azelaic acid external gel 2 AZELEX EXTERNAL CREAM 3 bacitracin external ointment 4 OTC bacitracin zinc external ointment 4 benzoyl peroxide external gel 10 % 1 benzoyl peroxide external gel 5 % 1 OTC betamethasone dipropionate aug external cream
1
1
1
1
1
BRYHALI EXTERNAL LOTION 3 calcipotriene external cream 2 PA; PA except
Dermatology calcipotriene external ointment 2 PA; PA except
Dermatology calcipotriene external solution 2 PA; PA except
Dermatology calcipotriene-betameth diprop external ointment
3 PA; PA except Dermatology
calcipotriene-betameth diprop external suspension
CALCITRENE EXTERNAL OINTMENT 2 PA; PA except Dermatology
calcitriol external ointment 3 castellani paint external liquid 4 OTC ciclopirox external gel 1 ciclopirox external shampoo 1
ciclopirox external solution 1 AL ciclopirox olamine external cream 1 ciclopirox olamine external suspension
1
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %
1
1
1
1 QL
1 QL
CONDYLOX EXTERNAL GEL 3 COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
3 PA; SP
3 PA; SP
3 PA; SP
CROTAN EXTERNAL LOTION 1 dapsone external gel 5 % 2 dapsone external gel 7.5 % 2 ST DENAVIR EXTERNAL CREAM 3 PA desonide external cream 1 desonide external ointment 1 ST desoximetasone external cream 1 desoximetasone external gel 1 desoximetasone external ointment 0.25 %
1
diclofenac sodium external gel 1 % 1 diclofenac sodium external gel 3 % 1 PA; PA except
dermatology diflorasone diacetate external cream
1
12.01.2021
20
2 PA
DRYSOL EXTERNAL SOLUTION 2 DUOBRII EXTERNAL LOTION 3 PA DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML
2 PA; SP
3 PA; SP
2 PA; SP
3 PA; SP
econazole nitrate external cream 1 EPIDUO FORTE EXTERNAL GEL 3 PA erythromycin external gel 1 erythromycin external solution 1 EUCRISA EXTERNAL OINTMENT 3 PA; ST; AL FABIOR EXTERNAL FOAM 3 ST; ST except
dermatology; QL FINACEA EXTERNAL FOAM 3 fluocinolone acetonide body external oil
1
1
fluocinonide external cream 0.05 % 1 fluocinonide external gel 1 fluocinonide external ointment 1 fluocinonide external solution 1 FLUOROPLEX EXTERNAL CREAM 3 fluorouracil external cream 0.5 % 3 ST fluorouracil external cream 5 % 1 fluorouracil external solution 1 flurandrenolide external cream 2 flurandrenolide external lotion 2 fluticasone propionate external cream
1
1
1
hydrocortisone external lotion 1 % 4 OTC hydrocortisone external lotion 2.5 %
1
Urology, OBGYN, and Colorectal Surgery
iodoquinol-hydrocortisone-aloe external cream
isotretinoin capsule 10 mg oral 3 PA; generic for Absorica
isotretinoin oral capsule 10 mg 1 PA; ST; PA except dermatology
isotretinoin oral capsule 20 mg, 30 mg, 40 mg
1 PA; PA except dermatology
isotretinoin oral capsule 25 mg, 35 mg
3 PA; generic for Absorica
ivermectin external cream 2 PA; PA except dermatology
ivermectin external lotion 2 QL JUBLIA EXTERNAL SOLUTION 3 PA ketoconazole external cream 1 ketoconazole external foam 3 ketoconazole external shampoo 2 %
1
4 OTC
lice treatment external liquid 1 % 4 OTC lice treatment external lotion 4 OTC lidocaine external ointment 5 % 1 lidocaine external patch 5 % 2 lidocaine hcl external solution 1 lidocaine-prilocaine external cream 1 LIDOCARE ARM/NECK/LEG EXTERNAL PATCH
2 OTC
12.01.2021
21
lindane external shampoo 1 malathion external lotion 1 MENTAX EXTERNAL CREAM 3 methoxsalen rapid oral capsule 2 metronidazole external cream 1 metronidazole external gel 1 metronidazole external lotion 1 miconazole nitrate external cream 4 mometasone furoate external cream
1
1
mupirocin calcium external cream 1 mupirocin external ointment 1 MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG
2 PA; PA except Dermatology
MYORISAN ORAL CAPSULE 30 MG 2 PA naftifine hcl external cream 2 nystatin external cream 1 nystatin external ointment 1 nystatin external powder 1 nystatin-triamcinolone external cream
1
1
oxiconazole nitrate external cream 2 OXISTAT EXTERNAL LOTION 3 PANRETIN EXTERNAL GEL 3 PA permethrin external cream 1 pimecrolimus external cream 1 AL podofilox external solution 1 prednicarbate external ointment 1 QBREXZA EXTERNAL PAD 3 PA REGRANEX EXTERNAL GEL 3 PA SANTYL EXTERNAL OINTMENT 3 selenium sulfide external lotion 1 SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
silver sulfadiazine external cream 1 SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT
3 PA; SP
3 PA; SP
3 PA; SP
spinosad external suspension 2 QL sulconazole nitrate external cream 3 sulconazole nitrate external solution
3
1 PA
1
tacrolimus external ointment 0.03 %, 0.1 %
2 AL
3 PA; SP
TARGRETIN EXTERNAL GEL 3 PA; SP tavaborole external solution 3 PA tazarotene external cream 1 ST; ST except
dermatology TAZORAC EXTERNAL CREAM 0.05 % 3 ST; ST except
dermatology TAZORAC EXTERNAL GEL 3 ST; ST except
dermatology terbinafine hcl external cream 4 OTC TEXACORT EXTERNAL SOLUTION 3 THERMAZENE EXTERNAL CREAM 1 tolnaftate external aerosol powder 4 OTC tolnaftate external cream 4 OTC tolnaftate external powder 4 OTC TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR
3 PA; SP
3 PA; SP
tretinoin external cream 1 AL tretinoin external gel 0.01 %, 0.025 %
1 AL
2
1
TRIANEX EXTERNAL OINTMENT 3 VALCHLOR EXTERNAL GEL 3 PA; SP VERDESO EXTERNAL FOAM 3 VEREGEN EXTERNAL OINTMENT 3 WINLEVI EXTERNAL CREAM 3 PA zinc oxide external ointment 20 % 4 OTC ZITHRANOL EXTERNAL SHAMPOO 3 PA
*Dietary Products/Dietary Management Products* BOOST ORAL LIQUID 4 OTC ENSURE PUDDING ORAL PUDDING 4 OTC flavor packets oral packet 4 OTC
*Digestive Aids* CREON ORAL CAPSULE DELAYED RELEASE PARTICLES
2
lactase enzyme oral tablet 4 OTC SUCRAID ORAL SOLUTION 3 PA; LDD ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT
2
1
12.01.2021
22
2
1
bumetanide oral tablet 1 chlorthalidone oral tablet 25 mg, 50 mg
1
DIURIL ORAL SUSPENSION 2 DYRENIUM ORAL CAPSULE 3 MM ethacrynic acid oral tablet 2 furosemide oral solution 10 mg/ml, 8 mg/ml
1
furosemide oral tablet 1 hydrochlorothiazide oral capsule 1 hydrochlorothiazide oral tablet 1 indapamide oral tablet 1 KEVEYIS ORAL TABLET 3 PA; LDD methazolamide oral tablet 1 metolazone oral tablet 1 spironolactone oral tablet 1 spironolactone-hctz oral tablet 1 torsemide oral tablet 1 triamterene-hctz oral capsule 37.5- 25 mg
1
*Endocrine And Metabolic Agents - Misc.* alendronate sodium oral solution 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg
1
BUPHENYL ORAL TABLET NF PA cabergoline oral tablet 1 calcitonin (salmon) nasal solution 1 calcitriol oral capsule 1 calcitriol oral solution 1 CARBAGLU ORAL TABLET 3 PA; LDD cinacalcet hcl oral tablet 2 clomiphene citrate oral tablet 1 PA; PA except
OB/GYN and fertility specialist; QL
CYSTADANE ORAL POWDER 3 PA; LDD desmopressin ace spray refrig nasal solution
2
desmopressin acetate oral tablet 2 desmopressin acetate spray nasal solution
2
doxercalciferol oral capsule 1 ST; MM FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG/2.48ML
2 PA; SP
GALAFOLD ORAL CAPSULE 3 PA; LDD; AL GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED
2 PA; SP
INCRELEX SUBCUTANEOUS SOLUTION
3 PA; LDD
ISTURISA ORAL TABLET 3 PA; SP JYNARQUE ORAL TABLET THERAPY PACK
3 PA; LDD
KERENDIA ORAL TABLET 3 PA mifepristone oral tablet 2 MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED
3 PA; LDD
3 PA; LDD
NATPARA SUBCUTANEOUS CARTRIDGE
3 PA; LDD
nitisinone oral capsule 2 PA; LDD NITYR ORAL TABLET 2 PA; LDD octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
2 PA; PA except hematology,
oncology, endocrinology
ORFADIN ORAL CAPSULE 20 MG 2 PA; LDD ORFADIN ORAL SUSPENSION 2 PA; LDD ORILISSA ORAL TABLET 2 PA PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; LDD
paricalcitol oral capsule 1 mcg 1 ST paricalcitol oral capsule 2 mcg, 4 mcg
3 ST
raloxifene hcl oral tablet 1 ACA RAVICTI ORAL LIQUID 3 PA; LDD RAYALDEE ORAL CAPSULE EXTENDED RELEASE
3 ST
risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg
1
1
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG
3 PA; SP
SIGNIFOR SUBCUTANEOUS SOLUTION
3 PA; LDD
1 PA; LDD
sodium phenylbutyrate oral tablet 2 PA; LDD SOMATULINE DEPOT SUBCUTANEOUS SOLUTION
3 PA
2 PA; LDD
3 PA; SP
12.01.2021
23
3 PA; LDD
XGEVA SUBCUTANEOUS SOLUTION 3 PA; LDD XURIDEN ORAL PACKET 3 PA; LDD ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED
3 PA; SP
*Estrogens* AMABELZ ORAL TABLET 1 ANGELIQ ORAL TABLET 2 COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY
3
COVARYX HS ORAL TABLET 1 COVARYX ORAL TABLET 1 DUAVEE ORAL TABLET 3 ELESTRIN TRANSDERMAL GEL 3 est estrogens-methyltest ds oral tablet
1
1
1
1
1
3
JINTELI ORAL TABLET 1 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG
2
3
MYFEMBREE ORAL TABLET 2 PA norethindrone-eth estradiol oral tablet 1-5 mg-mcg
1
2 PA
PREMARIN ORAL TABLET 2 PREMPHASE ORAL TABLET 2 PREMPRO ORAL TABLET 2
*Fluoroquinolones* CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)
3
ciprofloxacin hcl oral tablet 100 mg 2 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg
1
levofloxacin oral solution 2 levofloxacin oral tablet 2 moxifloxacin hcl oral tablet 1 ofloxacin oral tablet 300 mg, 400 mg
2
*Gastrointestinal Agents - Misc.* alosetron hcl oral tablet 2 PA AURYXIA ORAL TABLET 3 balsalazide disodium oral capsule 1 AL
BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE
3 PA; LDD
BYLVAY ORAL CAPSULE 3 PA; LDD CHENODAL ORAL TABLET 3 PA; LDD CHOLBAM ORAL CAPSULE 3 PA; LDD CIMZIA PREFILLED SUBCUTANEOUS KIT
3 PA; SP
3 PA; SP
3 PA; SP
cromolyn sodium oral concentrate 1 DIPENTUM ORAL CAPSULE 3 enulose oral solution 1 generlac oral solution 1 lactulose encephalopathy oral solution
1
2
surgery lubiprostone oral capsule 3 ST; ST except
gastroenterology and colorectal surgery
3 ST
1
1
1
metoclopramide hcl oral tablet 1 metoclopramide hcl oral tablet dispersible 5 mg
2 PA
MOVANTIK ORAL TABLET 3 PA OCALIVA ORAL TABLET 3 PA; LDD PENTASA ORAL CAPSULE EXTENDED RELEASE
2
PHOSLYRA ORAL SOLUTION 2 RELISTOR ORAL TABLET 3 PA RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML
3 PA
sevelamer carbonate oral packet 2 sevelamer carbonate oral tablet 2 sevelamer hcl oral tablet 2 MM SFROWASA RECTAL ENEMA 2 simethicone oral suspension 40 mg/0.6ml
4 OTC
simethicone oral tablet chewable 4 OTC sulfasalazine oral tablet 1 sulfasalazine oral tablet delayed release
1
SYMPROIC ORAL TABLET 3 PA ursodiol oral capsule 300 mg 1
12.01.2021
24
3
VIBERZI ORAL TABLET 3 PA XERMELO ORAL TABLET 3 PA; LDD
*Genitourinary Agents - Miscellaneous* alfuzosin hcl er oral tablet extended release 24 hour
1
3
CYSTAGON ORAL CAPSULE 2 PA; LDD dutasteride oral capsule 1 dutasteride-tamsulosin hcl oral capsule
1
ELMIRON ORAL CAPSULE 2 PA finasteride oral tablet 5 mg 1 phenazopyridine hcl oral tablet 100 mg, 200 mg
1
1
3 PA; LDD
PROCYSBI ORAL PACKET 3 PA; LDD silodosin oral capsule 1 MM sodium chloride irrigation solution 0.9 %
1
tamsulosin hcl oral capsule 1 THIOLA EC ORAL TABLET DELAYED RELEASE
3 PA; LDD
tiopronin oral tablet 3 PA; SP
*Gout Agents* allopurinol oral tablet 1 colchicine oral capsule 2 colchicine oral tablet 2 colchicine-probenecid oral tablet 1 febuxostat oral tablet 2 ST probenecid oral tablet 1
*Hematological Agents - Misc.* anagrelide hcl oral capsule 1 PA; PA except
oncology and hematology
2 PA
BRILINTA ORAL TABLET 2 cilostazol oral tablet 1 clopidogrel bisulfate oral tablet 1 dipyridamole oral tablet 1 HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED
3 PA; LDD
2 PA; SP
ORLADEYO ORAL CAPSULE 3 PA; SP pentoxifylline er oral tablet extended release
1 DF
3 PA; LDD; QL; AL
TAVALISSE ORAL TABLET 3 PA; LDD ZONTIVITY ORAL TABLET 3 PA
*Hematopoietic Agents* ACCRUFER ORAL CAPSULE 3 PA ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML
3 PA; SP
3 PA; SP
CERDELGA ORAL CAPSULE 3 PA; SP cyanocobalamin injection solution 1000 mcg/ml
1
DOPTELET ORAL TABLET 20 MG 3 PA; LDD DROXIA ORAL CAPSULE 1 ferrous gluconate oral tablet 240 (27 fe) mg, 324 (38 fe) mg
4 OTC
folic acid oral tablet 1 mg 1 folic acid oral tablet 400 mcg 4 OTC miglustat oral capsule 2 PA; LDD MOZOBIL SUBCUTANEOUS SOLUTION
3 PA
MULPLETA ORAL TABLET 3 PA; SP MULTIGEN PLUS ORAL TABLET 3 NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
2 SP
OXBRYTA ORAL TABLET 3 PA; SP POLY-IRON 150 ORAL CAPSULE 4 OTC PROMACTA ORAL PACKET 3 PA; SP PROMACTA ORAL TABLET 3 PA; SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
2 PA; SP
SIKLOS ORAL TABLET 3 PA UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
vitamin b-12 oral tablet 1000 mcg 4 OTC ZARXIO INJECTION SOLUTION PREFILLED SYRINGE
2 SP
*Hemostatics* aminocaproic acid oral tablet 2 tranexamic acid oral tablet 1 AL
*Hypnotics/Sedatives/Sleep Disorder Agents* BELSOMRA ORAL TABLET 2 ST; QL DAYVIGO ORAL TABLET 3 PA doxepin hcl oral tablet 3 QL EDLUAR SUBLINGUAL TABLET SUBLINGUAL
3 ST; QL; AL
estazolam oral tablet 1 QL; AL eszopiclone oral tablet 1 QL; AL flurazepam hcl oral capsule 1 QL; AL HETLIOZ LQ ORAL SUSPENSION 3 PA; LDD HETLIOZ ORAL CAPSULE 3 PA; LDD ibuprofen pm oral tablet 4 OTC midazolam hcl oral syrup 1 phenobarbital oral elixir 1 phenobarbital oral tablet 1 AL
12.01.2021
25
quazepam oral tablet 1 QL; AL ramelteon oral tablet 2 QL temazepam oral capsule 1 QL; AL triazolam oral tablet 1 QL; AL zaleplon oral capsule 2 QL; AL zolpidem tartrate er oral tablet extended release
1 QL; AL
zolpidem tartrate oral tablet 1 QL; AL zolpidem tartrate sublingual tablet sublingual
2 ST; QL; AL
4 OTC
CLENPIQ ORAL SOLUTION 2 ACA; QL constulose oral solution 1 docusate calcium oral capsule 4 OTC docusate sodium oral capsule 100 mg
4 OTC
4 OTC
docusate sodium oral tablet 4 OTC enema disposable rectal enema 4 OTC fiber laxative oral tablet 4 OTC fiber therapy oral tablet 4 OTC FLEET BISACODYL RECTAL ENEMA 4 OTC KONSYL-D ORAL POWDER 4 OTC KRISTALOSE ORAL PACKET 20 GM 3 lactulose oral packet 1 lactulose oral solution 1 laxative rectal suppository 4 OTC milk of magnesia oral suspension 400 mg/5ml
4 OTC
mineral oil oral oil 4 OTC natural fiber laxative oral powder 28.3 %, 30.9 %
4 OTC
natural psyllium seed oral powder 4 OTC OSMOPREP ORAL TABLET 3 peg 3350 oral powder 4 OTC peg 3350-kcl-na bicarb-nacl oral solution reconstituted
1 ACA
senna oral syrup 176 mg/5ml 4 OTC senna oral syrup 8.8 mg/5ml 4 sorbitol oral solution 4 OTC sorbitol rectal solution 4 OTC stool softener laxative oral tablet 4 OTC SUPREP BOWEL PREP KIT ORAL SOLUTION
2 ACA; QL
*Macrolides* azithromycin oral packet 1 azithromycin oral suspension reconstituted
1
1
1
1
clarithromycin oral tablet 250 mg 1 clarithromycin oral tablet 500 mg 1 DF
DIFICID ORAL SUSPENSION RECONSTITUTED
3 PA
DIFICID ORAL TABLET 3 PA ERYTHROCIN STEARATE ORAL TABLET 250 MG
2
1
erythromycin base oral tablet 1 DF erythromycin ethylsuccinate oral suspension reconstituted
2
2 DF
*Medical Devices And Supplies* FEMCAP VAGINAL DEVICE 2 OMNIPOD DASH 5 PACK PODS 2 V-GO 20 KIT 2 V-GO 30 KIT 2 V-GO 40 KIT 2 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM
2
2
2
2
2
2
2
2
2 PA
2 PA
2 PA; QL
2 LDD
ergotamine-caffeine oral tablet 2 frovatriptan succinate oral tablet 2 QL naratriptan hcl oral tablet 1 QL NURTEC ORAL TABLET DISPERSIBLE 2 PA REYVOW ORAL TABLET 2 PA rizatriptan benzoate oral tablet 1 QL rizatriptan benzoate oral tablet dispersible
1 QL
sumatriptan nasal solution 1 QL sumatriptan succinate oral tablet 1 QL
12.01.2021
26
1 QL
1 QL
1 QL
UBRELVY ORAL TABLET 2 PA zolmitriptan oral tablet 2 QL ZOMIG NASAL SOLUTION 3 QL
*Minerals & Electrolytes* calcium 1200 oral tablet chewable 4 OTC calcium 500/d oral tablet chewable 4 OTC calcium 500+d oral tablet 500-200 mg-unit
4 OTC
4 OTC
4 OTC
calcium carbonate oral tablet 1250 (500 ca) mg, 1500 (600 ca) mg, 600 mg
4 OTC
4 OTC
calcium citrate +d oral tablet 4 OTC calcium citrate oral granules 4 OTC calcium citrate+d3 petites oral tablet
4 OTC
4 OTC
4 OTC
calcium-folic acid plus d oral wafer 4 calcium-vitamin d oral tablet 500- 400 mg-unit
4 OTC
4 OTC
4 OTC
1
1
1
1
1
4 OTC
4 OTC
magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg
4 OTC
oyster calcium oral tablet 4 OTC oyster shell calcium/vitamin d oral tablet 250-125 mg-unit
4 OTC
pediatric electrolyte oral packet 4 OTC
pediatric electrolyte oral solution 4 OTC phos-nak oral packet 4 OTC potassium chloride crys er oral tablet extended release 10 meq, 20 meq
1
1
1
potassium chloride oral packet 1 potassium oral tablet 99 mg 4 OTC SLOW-MAG ORAL TABLET DELAYED RELEASE
4 OTC
*Miscellaneous Therapeutic Classes* ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR
3 PA
2
azathioprine oral tablet 50 mg 1 BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR
3 PA; SP
3 PA; SP
cyclosporine modified oral capsule 1 cyclosporine modified oral solution 1 cyclosporine oral capsule 1 ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
3 PA
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg
1 PA; PA except renal transplant surgeon
and nephrology GENGRAF ORAL CAPSULE 100 MG, 25 MG
1
GENGRAF ORAL SOLUTION 1 LOKELMA ORAL PACKET 2 LUPKYNIS ORAL CAPSULE 3 PA; SP mycophenolate mofetil oral capsule
1
1
mycophenolate mofetil oral tablet 1 mycophenolate sodium oral tablet delayed release
1 PA; PA except renal transplant surgeon
and nephrology penicillamine oral capsule 2 PA; SP PHYSIOLYTE IRRIGATION SOLUTION 2 PHYSIOSOL IRRIGATION IRRIGATION SOLUTION
1
REVLIMID ORAL CAPSULE 2 PA; LDD REZUROCK ORAL TABLET 3 PA; LDD SANDIMMUNE ORAL SOLUTION 3 sirolimus oral solution 2 PA sirolimus oral tablet 2 PA; PA except Renal
Transplant Surgeons and Nephrology
1
12.01.2021
27
tacrolimus oral capsule 1 THALOMID ORAL CAPSULE 3 LDD trientine hcl oral capsule 2 PA; SP VELTASSA ORAL PACKET 2 ZOKINVY ORAL CAPSULE 3 PA; SP; LDD
*Mouth/Throat/Dental Agents* cevimeline hcl oral capsule 2 chlorhexidine gluconate mouth/throat solution
1
2
1
nystatin mouth/throat suspension 1 DF ORAVIG BUCCAL TABLET 3 PA; AL pilocarpine hcl oral tablet 1 sf 5000 plus dental cream 1 DF triamcinolone acetonide mouth/throat paste
1 DF
*Multivitamins* b complex-c oral tablet 4 OTC b-100 cr oral tablet extended release
4 OTC
b-complex balanced oral tablet 4 OTC b-complex oral tablet 4 OTC b-complex/b-12 sublingual liquid 4 OTC b-complex/vitamin c oral tablet 4 OTC childrens multivitamin/iron oral tablet chewable
4 OTC
CITRANATAL BLOOM ORAL TABLET 3 MM complete multivitamin/mineral oral liquid
4 OTC
daily multivitamin oral capsule 4 OTC DIALYVITE 800 ORAL TABLET 4 OTC DIALYVITE ORAL TABLET 1 PA; PA except
Nephrology LIPOTRIAD ORAL TABLET 4 OTC multiple vitamins/womens oral tablet
4 OTC
4 OTC
one daily multivitamin/iron oral tablet
4 OTC
PEDIAVIT ORAL LIQUID 4 OTC POLY-VI-SOL ORAL SOLUTION 4 OTC prenatal 19 oral tablet 29-1 mg 1 prenatal 19 oral tablet chewable 1 PRENATAL MULTIVITAMIN + DHA ORAL
4 OTC
prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 1 prenatal plus oral tablet 1 prenatal vitamin oral tablet 4 OTC prenatal vitamins oral tablet 28-0.8 mg
4 OTC
4 OTC
1
4 OTC
vitamin b complex-c oral capsule 4 OTC vitamin-b complex oral tablet 4 OTC
*Musculoskeletal Therapy Agents* baclofen oral tablet 1 carisoprodol oral tablet 1 carisoprodol-aspirin-codeine oral tablet
1 AL
chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine hcl oral tablet 1 dantrolene sodium oral capsule 1 metaxalone oral tablet 2 methocarbamol oral tablet 1 orphenadrine citrate er oral tablet extended release 12 hour 100 mg
1
orphenadrine citrate er oral tablet extended release 12 hour 100 mg
1 AL
tizanidine hcl oral capsule 1 tizanidine hcl oral tablet 1
*Nasal Agents - Systemic And Topical* azelastine hcl nasal solution 0.1 %, 0.15 %
1
budesonide nasal suspension 1 OTC cromolyn sodium nasal aerosol solution
4 OTC
1
ipratropium bromide nasal solution 1 nasal decongestant spray nasal solution
4 OTC
olopatadine hcl nasal solution 2 pseudoephedrine hcl er oral tablet extended release 12 hour
4 OTC
4 OTC
4
saline nasal packet 4 OTC saline nasal spray nasal solution 4 OTC squeeze bottle sinus wash nasal kit 4 OTC triamcinolone acetonide nasal aerosol
1
3 PA; LDD
EXSERVAN ORAL FILM 3 PA riluzole oral tablet 2 TIGLUTIK ORAL SUSPENSION 3 SP
12.01.2021
28
1 OTC
ALAWAY OPHTHALMIC SOLUTION 1 OTC ALOCRIL OPHTHALMIC SOLUTION 3 ST ALOMIDE OPHTHALMIC SOLUTION 3 ST apraclonidine hcl ophthalmic solution
2
4 OTC
AZASITE OPHTHALMIC SOLUTION 3 PA azelastine hcl ophthalmic solution 1 bacitracin ophthalmic ointment 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment
1
2
2
1
1
1
DUREZOL OPHTHALMIC EMULSION 3 epinastine hcl ophthalmic solution 1 erythromycin ophthalmic ointment 1 ACA eye lubricant ophthalmic ointment 4 OTC FLAREX OPHTHALMIC SUSPENSION 2 fluorometholone ophthalmic suspension
1
1
3
1
2
4 OTC
4 OTC
1
1
1
1
1
1
proparacaine hcl ophthalmic solution
optometrist; QL
12.01.2021
29
4 OTC
4 OTC
1
1
2
trifluridine ophthalmic solution 1 tropicamide ophthalmic solution 1 UPNEEQ OPHTHALMIC SOLUTION 3 PA VYZULTA OPHTHALMIC SOLUTION 3 ST XIIDRA OPHTHALMIC SOLUTION 2 PA; PA except
ophthalmology; QL ZIOPTAN OPHTHALMIC SOLUTION 3 ZIRGAN OPHTHALMIC GEL 3 ZYLET OPHTHALMIC SUSPENSION 3
*Otic Agents* ACETASOL HC OTIC SOLUTION 1 acetic acid otic solution 1 CIPRO HC OTIC SUSPENSION 3 PA; PA except
otolaryngology ciprofloxacin hcl otic solution 1 ciprofloxacin-dexamethasone otic suspension
2 PA; PA except otolaryngology
CORTISPORIN-TC OTIC SUSPENSION
1
1 QL
3 PA; LDD
1 DF
amoxicillin oral tablet chewable 125 mg, 250 mg
1 DF
1 DF
1 DF
1 DF
ampicillin oral capsule 500 mg 1 dicloxacillin sodium oral capsule 1 penicillin v potassium oral solution reconstituted
1
penicillin v potassium oral tablet 1 DF
*Pharmaceutical Adjuvants* SIMPLYTHICK ORAL GEL 4 OTC THICK-IT #2 ORAL PACKET 4 OTC THICK-IT #2 ORAL POWDER 4 OTC THICK-IT ORAL PACKET 4 OTC THICK-IT ORAL POWDER 4 OTC
*Progestins* medroxyprogesterone acetate oral tablet
1
1 SP; QL
1
AUBAGIO ORAL TABLET 2 PA; SP; PA except Neurology
AUSTEDO ORAL TABLET 3 PA; SP AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT
BAFIERTAM ORAL CAPSULE DELAYED RELEASE
3 PA; SP
BRISDELLE ORAL CAPSULE NF bupropion hcl er (smoking det) oral tablet extended release 12 hour
1 ACA
2 PA; SP
dimethyl fumarate starter pack oral
disulfiram oral tablet 1 donepezil hcl oral tablet 10 mg, 5 mg
2
donepezil hcl oral tablet dispersible 2 ergoloid mesylates oral tablet 2 EXTAVIA SUBCUTANEOUS KIT 3 PA; SP fluoxetine hcl (pmdd) oral tablet 2
12.01.2021
30
2
glatiramer acetate subcutaneous solution prefilled syringe
2 PA; SP; PA except Neurology
GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; SP
GRALISE ORAL TABLET 3 ST INGREZZA ORAL CAPSULE 3 PA; LDD INGREZZA ORAL CAPSULE THERAPY PACK
3 PA; LDD
3 PA; SP
LUCEMYRA ORAL TABLET 3 PA; QL MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK
3 PA; LDD; QL
3 PA; LDD; QL
3 PA; LDD; QL
3 PA; LDD; QL
3 PA; LDD; QL
3 PA; LDD; QL
3 PA; LDD; QL
MAYZENT ORAL TABLET 3 PA; SP; PA except Neurology
MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG
memantine hcl er oral capsule extended release 24 hour
2
2
memantine hcl oral tablet 2 NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK
3 PA
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14- 10 MG, 28-10 MG
3 ST
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 21- 10 MG, 7-10 MG
3
4 ACA; OTC
nicotine transdermal kit 4 ACA; OTC nicotine transdermal patch 24 hour 4 ACA; OTC NICOTROL INHALATION INHALER 2 ACA; QL NICOTROL NS NASAL SOLUTION 2 ACA; QL NUEDEXTA ORAL CAPSULE 2 PA; SP
olanzapine-fluoxetine hcl oral capsule
paroxetine mesylate oral capsule 2 perphenazine-amitriptyline oral tablet
1 AL
pimozide oral tablet 2 AL PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN- INJECTOR
PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR
PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PONVORY ORAL TABLET 2 PA; SP; PA except neurology
PONVORY STARTER PACK ORAL TABLET THERAPY PACK
pregabalin er oral tablet extended release 24 hour
3 MM
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; LDD; PA except neurology
rivastigmine tartrate oral capsule 2 rivastigmine transdermal patch 24 hour
2
SAVELLA ORAL TABLET 2 SAVELLA TITRATION PACK ORAL 2 TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
3 PA; LDD
tetrabenazine oral tablet 2 PA; LDD; QL varenicline tartrate oral tablet 1 ACA; AL VUMERITY ORAL CAPSULE DELAYED RELEASE
3 PA; SP
XYREM ORAL SOLUTION 3 PA; LDD ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK
3 PA; SP
ZEPOSIA ORAL CAPSULE 3 PA; SP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK
3 PA; SP
3 PA
ESBRIET ORAL CAPSULE 3 PA; SP; QL ESBRIET ORAL TABLET 3 PA; SP; QL KALYDECO ORAL PACKET 3 PA; LDD KALYDECO ORAL TABLET 3 PA; LDD OFEV ORAL CAPSULE 3 PA; LDD ORKAMBI ORAL PACKET 3 PA; LDD; AL ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG
3 PA; LDD; AL
12.01.2021
31
3 PA; LDD; AL
3 PA; SP
*Tetracyclines* demeclocycline hcl oral tablet 2 doxycycline hyclate oral capsule 1 DF doxycycline hyclate oral tablet 100 mg, 50 mg
1
1 DF
1
2 PA
minocycline hcl oral capsule 2 tetracycline hcl oral capsule 2
*Thyroid Agents* ARMOUR THYROID ORAL TABLET 2 EUTHYROX ORAL TABLET 1 levothyroxine sodium oral tablet 1 liothyronine sodium oral tablet 1 methimazole oral tablet 1 NATURE-THROID ORAL TABLET 3 MM np thyroid oral tablet 1 propylthiouracil oral tablet 1 SYNTHROID ORAL TABLET 2 UNITHROID ORAL TABLET 1 WP THYROID ORAL TABLET 3
*Ulcer Drugs/Antispasmodics/Anticholinergics* amoxicill-clarithro-lansopraz oral 1 cimetidine hcl oral solution 300 mg/5ml
1
cimetidine oral tablet 200 mg 4 cimetidine oral tablet 300 mg, 400 mg, 800 mg
1
CUVPOSA ORAL SOLUTION 3 PA; ST dicyclomine hcl oral capsule 1 dicyclomine hcl oral solution 2 dicyclomine hcl oral tablet 1 esomeprazole magnesium oral capsule delayed release
1
1
famotidine oral tablet 10 mg 4 OTC famotidine oral tablet 20 mg, 40 mg
1
1 PA
HELIDAC THERAPY ORAL 3 PA hyoscyamine sulfate oral tablet 1 AL lansoprazole oral capsule delayed release 15 mg
4
1
2
misoprostol oral tablet 1 nizatidine oral capsule 1 nizatidine oral solution 1 omeprazole magnesium oral capsule delayed release
4 OTC
1
2 OTC
1
1
2
3
3 AL
3 MM
1
oxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 1 solifenacin succinate oral tablet 1 tolterodine tartrate er oral capsule extended release 24 hour
1
tolterodine tartrate oral tablet 1 trospium chloride er oral capsule extended release 24 hour
1
trospium chloride oral tablet 1 VESICARE LS ORAL SUSPENSION 3 PA
*Vaginal And Related Products* CLEOCIN VAGINAL SUPPOSITORY 3 clindamycin phosphate vaginal cream
1
clotrimazole vaginal cream 1 % 4 OTC ENDOMETRIN VAGINAL INSERT 3 QL estradiol vaginal cream 2 estradiol vaginal tablet 2 ESTRING VAGINAL RING 2 FEMRING VAGINAL RING 2 GYNAZOLE-1 VAGINAL CREAM 3 metronidazole vaginal gel 1 miconazole 3 combo pack app vaginal kit
4 OTC
4 OTC
12.01.2021
32
MONISTAT 3 VAGINAL CREAM 4 OTC NUVESSA VAGINAL GEL 3 PREMARIN VAGINAL CREAM 2 AL terconazole vaginal cream 1 terconazole vaginal suppository 1 VCF VAGINAL CONTRACEPTIVE VAGINAL FILM
4 OTC
*Vasopressors* droxidopa oral capsule 3 PA; LDD epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml
1 QL
midodrine hcl oral tablet 2 SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE
2 QL
*Vitamins* ascorbic acid oral tablet 500 mg 4 OTC biotin oral tablet 300 mcg 4 OTC ergocalciferol oral capsule 1 niacin er oral capsule extended release 500 mg
4 OTC
4 OTC
4 OTC
niacinamide oral tablet 500 mg 4 OTC phytonadione oral tablet 2 vitamin b-1 oral tablet 100 mg, 50 mg
4 OTC
vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg
4 OTC
4 OTC
vitamin c oral tablet 250 mg 4 OTC vitamin c oral tablet chewable 250 mg, 500 mg
4 OTC
4 OTC
1
vitamin d2 oral tablet 4 OTC vitamin d-3 oral capsule 4 OTC vitamin d3 oral capsule 1.25 mg (50000 ut), 125 mcg (5000 ut), 250 mcg (10000 ut), 50 mcg (2000 ut)
4 OTC
vitamin d3 oral tablet 10 mcg (400 unit), 125 mcg (5000 ut), 25 mcg (1000 ut), 50 mcg (2000 ut), 75 mcg (3000 ut)
4 OTC
12.01.2021
33
12.01.2021
34
INDEX
Index
LANGUAGE ASSISTANCE
ATTENTION: Language assistance services, free of charge, are available to you. Call 1-800-501-3439; TTY: 711
English
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-501-3439; TTY: 711 Spanish

1-800-501-3439; TTY: 711 Chinese
. :
TTY: 711 (>3439-501-800-1 Arabic
: ,
1-800-501-3439; TTY: 711 .
Korean
: ,
. 1-800-501-3439 (: TTY 711 Russian
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-800-501-3439; TTY: 711. Italian
ATTENT

2021 essential hix plan formulary

Documents