beaumont health employee health plan custom formulary...

Drug Name Tier Requirements/Limits

ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12HOUR 3 QL: 2 IN 1 DAY

PSEUDOEPHEDRINE HCL/ACRIVAS SEMPREX-D 3ANTIHISTAMINES - 1ST GENERATION

carbinoxamine maleate CLISTIN (4 MG)(TABLET) 2

CARBINOXAMINE MALEATE KARBINAL ER 3 QL: 960mL IN 30 DAYScarbinoxamine maleate PALGIC 2clemastine fumarate TAVIST 2

cyproheptadine hclPERIACTIN (2MG/5 ML)(SYRUP)

2

cyproheptadine hcl PERIACTIN (4MG) (TABLET) 1

hydroxyzine hcl ATARAX (10 MG)(TABLET) 1

hydroxyzine hclATARAX (10MG/5 ML)(SOLUTION)

2



hydroxyzine pamoate VISTARIL (25MG) (CAPSULE) 1

hydroxyzine pamoate VISTARIL (50MG) (CAPSULE) 1

promethazine hclPHENERGAN(12.5 MG)(TABLET)

1

promethazine hcl PHENERGAN (25MG) (TABLET) 1

promethazine hcl PHENERGAN (50MG) (TABLET) 1

promethazine hcl PHENERGAN VC 1NASAL ANTIHISTAMINE

azelastine hcl ASTELIN 2 QL: 60mL IN 30 DAYSazelastine hcl ASTEPRO 2 QL: 60mL IN 30 DAYSolopatadine hcl PATANASE 2 QL: 30.5gm IN 30 DAYS

NASAL ANTI-INFLAMMATORY STEROIDSBECLOMETHASONE DIPROPIONATE QNASL 3 QL: 8.7gm IN 30 DAYS

BECLOMETHASONE DIPROPIONATE QNASLCHILDREN 3 QL: 4.9gm IN 30 DAYS

CICLESONIDE OMNARIS 3 QL: 5gm IN 12 DAYSCICLESONIDE ZETONNA 3 QL: 6.1gm IN 30 DAYSflunisolide NASALIDE 2 QL: 25mL IN 30 DAYSmometasone furoate NASONEX 2 QL: 17gm IN 30 DAYS

Beaumont Health Employee Health Plan Custom Formulary

Beaumont Health Employee Health Plan November 2018 of 160


ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTS

aprepitant EMEND (125MG) (CAPSULE) 2 QL: 1 IN 21 DAYS

aprepitant EMEND (40 MG)(CAPSULE) 2 QL: 1 IN 28 DAYS

aprepitant EMEND (80 MG)(CAPSULE) 2 QL: 2 IN 21 DAYS

DOLASETRON MESYLATE ANZEMET (100MG) (TABLET) 3 QL: 4 PER FILL

DOLASETRON MESYLATE ANZEMET (50MG) (TABLET) 3 QL: 8 PER FILL

DOXYLAMINE SUCCINATE/VIT B6 DICLEGIS 3 QL: 4 IN 1 DAYdronabinol MARINOL 2 QL: 2 IN 1 DAYDRONABINOL SYNDROS 4 ST, QL: 60mL IN 30 DAYSGRANISETRON SANCUSO 3 QL: 1 IN 7 DAYSgranisetron hcl KYTRIL 2 QL: 8 IN 30 DAYSmeclizine hcl (12.5 mg) (tablet) 1meclizine hcl (25 mg) (tablet) 1NABILONE CESAMET 3 QL: 6 IN 1 DAYNETUPITANT/PALONOSETRON HCL AKYNZEO 3 QL: 1 IN 28 DAYSondansetron ZOFRAN ODT 1

ONDANSETRON ZUPLENZ (4 MG)(FILM) 3 QL: 2 IN 3 DAYS

ONDANSETRON ZUPLENZ (8 MG)(FILM) 3 QL: 1 IN 3 DAYS

ondansetron hcl (4 mg) (tablet) 1ondansetron hcl (4 mg/5 ml) (solution) 2 QL: 50mL IN 15 DAYSondansetron hcl (8 mg) (tablet) 1prochlorperazine COMPAZINE 2prochlorperazine maleate COMPAZINE 1promethazine hcl PHENERGAN 1ROLAPITANT HCL VARUBI 3 QL: 2 IN 14 DAYS

scopolamine

TRANSDERM-SCOP (1 MG/3DAY) (PATCH TD3)

2

SCOPOLAMINE

TRANSDERM-SCOP (1 MG/3DAY) (PATCH TD3)

3

trimethobenzamide hcl TIGAN 2ASTHMA AND COPD

5-LIPOXYGENASE INHIBITORSZILEUTON ZYFLO 3 QL: 4 IN 1 DAYzileuton ZYFLO CR 2 QL: 2 IN 1 DAY

ANTICHOLINERGIC, ORALLY INHALED SHORT ACTINGipratropium bromide ATROVENT 1IPRATROPIUM BROMIDE ATROVENT HFA 3 QL: 25.8gm IN 30 DAYS



Drug Name Tier Requirements/LimitsANTICHOLINERGICS, ORALLY INHALED LONG ACTING

ACLIDINIUM BROMIDE TUDORZAPRESSAIR 4 QL: 1 INHALER PER 30

DAYS

TIOTROPIUM BROMIDE SPIRIVA 3 QL: 1 INHALER PER 30DAYS

TIOTROPIUM BROMIDE SPIRIVARESPIMAT 3 QL: 4gm IN 30 DAYS

UMECLIDINIUM BROMIDE INCRUSEELLIPTA 4 QL: 1 INHALER PER 30

DAYSBETA-ADRENERGIC AGENTS

albuterol sulfate (2 mg) (tablet) 1albuterol sulfate (2 mg/5 ml) (syrup) 2albuterol sulfate (4 mg) (tab er 12h) 2albuterol sulfate (4 mg) (tablet) 1albuterol sulfate (8 mg) (tab er 12h) 2terbutaline sulfate 2

BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGalbuterol sulfate 1ALBUTEROL SULFATE PROAIR HFA 3

ALBUTEROL SULFATE PROAIRRESPICLICK 3

ALBUTEROL SULFATE PROVENTIL HFA 4ALBUTEROL SULFATE VENTOLIN HFA 3levalbuterol hcl XOPENEX 2

levalbuterol hcl XOPENEXCONCENTRATE 2

levalbuterol tartrate XOPENEX HFA 2BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING

INDACATEROL MALEATE ARCAPTANEOHALER 3 QL: 1 INHALER PER 30

DAYS

OLODATEROL HCL STRIVERDIRESPIMAT 3 QL: 4gm IN 30 DAYS

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGFORMOTEROL FUMARATE PERFOROMIST 3 QL: 120mL IN 30 DAYS

SALMETEROL XINAFOATE SEREVENTDISKUS 3 QL: 1 INHALER PER 30

DAYSBETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS

IPRATROPIUM/ALBUTEROL SULFATE COMBIVENTRESPIMAT 3

ipratropium/albuterol sulfate DUONEB 1

TIOTROPIUM BR/OLODATEROL HCL STIOLTORESPIMAT 4 QL: 4gm IN 30 DAYS

UMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA 4 QL: 1 INHALER PER 30DAYS

BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONSBUDESONIDE/FORMOTEROLFUMARATE SYMBICORT 3 QL: 10.2gm IN 30 DAYS

FLUTICASONE/SALMETEROL ADVAIR DISKUS 4 QL: 1 INHALER PER 30DAYS

FLUTICASONE/SALMETEROL ADVAIR HFA 4 QL: 12gm IN 30 DAYS




fluticasone/salmeterol AIRDUORESPICLICK 2 QL: 1 INHALER PER 30

DAYS

FLUTICASONE/VILANTEROL BREO ELLIPTA 3 QL: 1 INHALER PER 30DAYS

MOMETASONE/FORMOTEROL DULERA 3 QL: 13gm IN 30 DAYSBETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED

FLUTICASONE/UMECLIDIN/VILANTER TRELEGYELLIPTA 4 QL: 1 INHALER PER 30

DAYSGLUCOCORTICOIDS, ORALLY INHALED

BECLOMETHASONE DIPROPIONATE QVARREDIHALER 3 QL: 21.2gm IN 30 DAYS

budesonidePULMICORT(0.25MG/2ML)(AMPUL-NEB)

2 QL: 120mL IN 30 DAYS

budesonidePULMICORT (0.5MG/2ML)(AMPUL-NEB)


budesonidePULMICORT (1MG/2 ML)(AMPUL-NEB)


BUDESONIDE PULMICORTFLEXHALER 3 QL: 1 INHALER PER 30

DAYSCICLESONIDE ALVESCO 4 QL: 12.2gm IN 30 DAYSFLUNISOLIDE AEROSPAN 3 QL: 17.8gm IN 30 DAYS

FLUTICASONE FUROATE

ARNUITYELLIPTA (100MCG) (BLSTW/DEV)

3 QL: 1 INHALER PER 30DAYS

FLUTICASONE FUROATE

ARNUITYELLIPTA (200MCG) (BLSTW/DEV)


FLUTICASONE PROPIONATE ARMONAIRRESPICLICK 3 QL: 1 INHALER PER 30

DAYS

FLUTICASONE PROPIONATE

FLOVENTDISKUS (100MCG) (BLSTW/DEV)




3 QL: 2 INHALERS PER 30DAYS




FLUTICASONE PROPIONATEFLOVENT HFA(110 MCG) (AERW/ADAP)

4 QL: 12gm IN 30 DAYS





4 QL: 24gm IN 30 DAYS


4 QL: 21.2gm IN 30 DAYS

MOMETASONE FUROATE ASMANEX 3 QL: 1 INHALER PER 30DAYS

MOMETASONE FUROATE ASMANEX HFA 4 QL: 13gm IN 30 DAYSINTERLEUKIN-5(IL-5) RECEPTOR ALPHA ANTAGONIST, MAB

BENRALIZUMAB FASENRA 5 PALEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast sodium SINGULAIR (10MG) (TABLET) 1

montelukast sodiumSINGULAIR (4MG) (GRANPACK)

2

montelukast sodiumSINGULAIR (4MG) (TABCHEW)

1

montelukast sodiumSINGULAIR (5MG) (TABCHEW)

1

zafirlukast ACCOLATE 2MAST CELL STABILIZERS

cromolyn sodium GASTROCROM 2MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)

OMALIZUMAB XOLAIR 3 PAPHOSPHODIESTERASE-4 (PDE4) INHIBITORS

ROFLUMILAST DALIRESP (500MCG) (TABLET) 3 QL: 1 IN 1 DAY

RESPIRATORY AIDS,DEVICES,EQUIPMENT

INHALER, ASSIST DEVICES AEROCHAMBERMINI 3 QL: 2 IN 365 DAYS

INHALER, ASSIST DEVICES AEROCHAMBERMV 3 QL: 2 IN 365 DAYS

INHALER, ASSIST DEVICES AEROCHAMBERPLUS FLOW-VU 3 QL: 2 IN 365 DAYS

INHALER, ASSIST DEVICESAEROCHAMBERWITHFLOWSIGNAL

3 QL: 2 IN 365 DAYS

INHALER, ASSIST DEVICES AEROCHAMBERZ-STAT PLUS 3 QL: 2 IN 365 DAYS

INHALER, ASSIST DEVICES EASIVENT 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBERPLUS FLOW-VU 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBERZ-STAT PLUS 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEVICE,ACCESORY EASIVENT 3 QL: 2 IN 365 DAYS




INHALER,ASSIST DEVICE,LG MASK AEROCHAMBERPLUS FLOW-VU 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEVICE,LG MASK AEROCHAMBERZ-STAT PLUS 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBERPLUS FLOW-VU 3 QL: 2 IN 365 DAYS

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBERZ-STAT PLUS 3 QL: 2 IN 365 DAYS

XANTHINEStheophylline anhydrous ELIXOPHYLLIN 2THEOPHYLLINE ANHYDROUS THEO-24 3theophylline anhydrous THEO-DUR 1theophylline anhydrous UNIPHYL 2AUTONOMIC NERVOUS SYSTEM DISORDERS

ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

memantine hcl NAMENDA (10MG) (TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (2MG/ML)(SOLUTION)


memantine hcl NAMENDA (5MG) (TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (5MG-10 MG) (TABDS PK)

1 QL: 49 IN 28 DAYS

memantine hclNAMENDA XR(14 MG) (CAPSPR 24)

2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY

memantine hclNAMENDA XR(7 MG) (CAP SPR24)

2 QL: 1 IN 1 DAY

MEMANTINE HCLNAMENDA XR(7-14-21-28)(CAP24 DSPK)

3 QL: 28 IN 28 DAYS

ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC(14MG-10MG)(CAP SPR 24)

3 QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (21MG-10MG) (CAPSPR 24)

3 QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (28MG-10MG) (CAPSPR 24)

3 QL: 1 IN 1 DAY




MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (7MG-10 MG) (CAPSPR 24)

3 QL: 1 IN 1 DAY

CHOLINESTERASE INHIBITORSdonepezil hcl ARICEPT 1donepezil hcl ARICEPT ODT 2

galantamine hbr RAZADYNE (12MG) (TABLET) 2 QL: 2 IN 1 DAY



galantamine hbr RAZADYNE ER 2 QL: 1 IN 1 DAY

pyridostigmine bromideMESTINON (180MG) (TABLETER)

2

pyridostigmine bromide MESTINON (60MG) (TABLET) 1

rivastigmine EXELON 2 QL: 1 IN 1 DAYrivastigmine tartrate EXELON 2BEHAVIORAL HEALTH - ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTSmirtazapine (15 mg) (tab rapdis) 2mirtazapine (15 mg) (tablet) 1mirtazapine (30 mg) (tab rapdis) 2mirtazapine (30 mg) (tablet) 1mirtazapine (45 mg) (tab rapdis) 2mirtazapine (45 mg) (tablet) 1mirtazapine (7.5 mg) (tablet) 1

MAOIS - NON-SELECTIVE & IRREVERSIBLEISOCARBOXAZID MARPLAN 3phenelzine sulfate NARDIL 2tranylcypromine sulfate PARNATE 2

NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)BUPROPION HBR APLENZIN 3 QL: 1 IN 1 DAY

bupropion hclFORFIVO XL(450 MG) (TABER 24H)

2 QL: 1 IN 1 DAY

bupropion hcl WELLBUTRIN 1

bupropion hcl WELLBUTRINSR 1

bupropion hcl WELLBUTRINXL 1

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)

citalopram hydrobromide CELEXA (10 MG)(TABLET) 1






escitalopram oxalate LEXAPRO (10MG) (TABLET) 1



escitalopram oxalateLEXAPRO (5MG/5 ML)(SOLUTION)

2

fluoxetine hcl 2

fluoxetine hcl PROZAC (10 MG)(CAPSULE) 1

fluoxetine hcl PROZAC (10 MG)(TABLET) 2


fluoxetine hcl PROZAC (20 MG)(TABLET) 2

fluoxetine hclPROZAC (20MG/5 ML)(SOLUTION)

2


fluoxetine hcl PROZACWEEKLY 2

fluvoxamine maleate LUVOX 1fluvoxamine maleate LUVOX CR 2 QL: 2 IN 1 DAY

paroxetine hcl PAXIL (10 MG)(TABLET) 1




paroxetine hcl PAXIL CR 2paroxetine mesylate BRISDELLE 2 QL: 1 IN 1 DAY

sertraline hcl ZOLOFT (100MG) (TABLET) 1

sertraline hclZOLOFT (20MG/ML) (ORALCONC)

2

sertraline hcl ZOLOFT (25 MG)(TABLET) 1

sertraline hcl ZOLOFT (50 MG)(TABLET) 1

SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)nefazodone hcl SERZONE 2trazodone hcl DESYREL 1



Drug Name Tier Requirements/LimitsSEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)

DESVENLAFAXINE ER 2 QL: 1 IN 1 DAYDESVENLAFAXINE FUMARATE ER 3 QL: 1 IN 1 DAYdesvenlafaxine succinate PRISTIQ 2 QL: 1 IN 1 DAYduloxetine hcl (20 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (30 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (40 mg) (capsule dr) 2 QL: 1 IN 1 DAYduloxetine hcl (60 mg) (capsule dr) 1 QL: 2 IN 1 DAYLEVOMILNACIPRAN HCL FETZIMA 3 ST, QL: 1 IN 1 DAYvenlafaxine hcl EFFEXOR 1venlafaxine hcl EFFEXOR XR 1venlafaxine hcl er (225 mg) (tab er 24) 2venlafaxine hcl er (37.5 mg) (tab er 24) 2venlafaxine hcl er (75 mg) (tab er 24) 2

SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANTVILAZODONE HCL VIIBRYD 4 ST, QL: 1 IN 1 DAY

SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTVORTIOXETINE HYDROBROMIDE TRINTELLIX 3 QL: 1 IN 1 DAY

TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNSperphenazine/amitriptyline hcl ETRAFON-A 2perphenazine/amitriptyline hcl TRIAVIL 4-50 2

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBamitriptyline hcl ELAVIL 1clomipramine hcl ANAFRANIL 2desipramine hcl NORPRAMIN 2

doxepin hcl SINEQUAN (10MG) (CAPSULE) 1






imipramine hcl TOFRANIL 1imipramine pamoate TOFRANIL-PM 2

maprotiline hcl LUDIOMIL (25MG) (TABLET) 2

nortriptyline hcl PAMELOR (10MG) (CAPSULE) 1




protriptyline hcl VIVACTIL 2



Drug Name Tier Requirements/Limitstrimipramine maleate SURMONTIL 2BEHAVIORAL HEALTH - OTHER

ADRENERGICS, AROMATIC, NON-CATECHOLAMINEAMPHETAMINE DYANAVEL XR 3 QL: 240mL IN 30 DAYSamphetamine sulfate EVEKEO 2 PA

dextroamphetamine sulfateDEXEDRINE (10MG) (CAPSULEER)

2 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (10MG) (TABLET) 2 QL: 6 IN 1 DAY


2 QL: 4 IN 1 DAY


2 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (5MG) (TABLET) 2 QL: 3 IN 1 DAY

dextroamphetamine sulfate PROCENTRA 2 QL: 1800mL IN 30 DAYS

DEXTROAMPHETAMINE SULFATE ZENZEDI (15MG) (TABLET) 3 QL: 3 IN 1 DAY

DEXTROAMPHETAMINE SULFATE ZENZEDI (2.5MG) (TABLET) 3 QL: 3 IN 1 DAY



DEXTROAMPHETAMINE SULFATE ZENZEDI (7.5MG) (TABLET) 3 QL: 3 IN 1 DAY

dextroamphetamine/amphetamine ADDERALL 2 QL: 2 IN 1 DAY

dextroamphetamine/amphetamineADDERALL XR(10 MG) (CAP ER24H)

2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY


2 QL: 2 IN 1 DAY


2 QL: 2 IN 1 DAY


2 QL: 2 IN 1 DAY


2 QL: 1 IN 1 DAY

LISDEXAMFETAMINE DIMESYLATE VYVANSE (10MG) (CAPSULE) 3 QL: 1 IN 1 DAY










methamphetamine hcl DESOXYN 2 QL: 5 IN 1 DAYANTI-ALCOHOLIC PREPARATIONS

acamprosate calcium CAMPRAL 2disulfiram ANTABUSE 2

ANTI-ANXIETY - BENZODIAZEPINESalprazolam 2ALPRAZOLAM INTENSOL 3chlordiazepoxide hcl 2clorazepate dipotassium 2diazepam 2lorazepam 2oxazepam 2

ANTI-ANXIETY DRUGSbuspirone hcl BUSPAR 1meprobamate 2

ANTI-MANIA DRUGSCARBAMAZEPINE EQUETRO 3lithium carbonate 1LITHIUM CARBONATE LITHOBID 4lithium citrate 2

ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTSODIUM OXYBATE XYREM 5 PA

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESpimozide ORAP 2

ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED

CARIPRAZINE HCL VRAYLAR (1.5MG) (CAPSULE) 3 ST

CARIPRAZINE HCL VRAYLAR (3MG) (CAPSULE) 3 ST

CARIPRAZINE HCL VRAYLAR (4.5MG) (CAPSULE) 3 ST

CARIPRAZINE HCL VRAYLAR (6MG) (CAPSULE) 3 ST

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXEDaripiprazole ABILIFY 2BREXPIPRAZOLE REXULTI 4

ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTSLOXAPINE ADASUVE 3



Drug Name Tier Requirements/Limitsloxapine succinate LOXITANE 2

ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAGclozapine 2clozapine CLOZARIL 2clozapine FAZACLO 2CLOZAPINE VERSACLOZ 3ILOPERIDONE FANAPT 3 STLURASIDONE HCL LATUDA 4 STolanzapine ZYPREXA 1

olanzapine ZYPREXAZYDIS 2

paliperidone INVEGA 2quetiapine fumarate SEROQUEL 1

quetiapine fumarateSEROQUEL XR(150 MG) (TABER 24H)

2


2


2


2

quetiapine fumarateSEROQUEL XR(50 MG) (TAB ER24H)

2

risperidone (0.25 mg) (tab rapdis) 2risperidone (0.25 mg) (tablet) 1risperidone (0.5 mg) (tab rapdis) 2risperidone (0.5 mg) (tablet) 1risperidone (1 mg) (tab rapdis) 2risperidone (1 mg) (tablet) 1risperidone (1 mg/ml) (solution) 2risperidone (2 mg) (tab rapdis) 2risperidone (2 mg) (tablet) 1risperidone (3 mg) (tab rapdis) 2risperidone (3 mg) (tablet) 1risperidone (4 mg) (tab rapdis) 2risperidone (4 mg) (tablet) 1ziprasidone hcl GEODON 2

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENESthiothixene NAVANE 2

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONEShaloperidol HALDOL 1

ANTI-PSYCHOTICS,PHENOTHIAZINES

fluphenazine hcl PROLIXIN (1MG) (TABLET) 1





fluphenazine hcl PROLIXIN (2.5MG) (TABLET) 1


perphenazine TRILAFON 2thioridazine hcl MELLARIL 2trifluoperazine hcl STELAZINE 2

BARBITURATES

BUTABARBITAL SODIUM BUTISOLSODIUM 3

phenobarbital (100 mg) (tablet) 2phenobarbital (16.2 mg) (tablet) 2phenobarbital (30 mg) (tablet) 2phenobarbital (32.4 mg) (tablet) 2phenobarbital (60 mg) (tablet) 2phenobarbital (64.8 mg) (tablet) 2phenobarbital (97.2mg) (tablet) 2

SECOBARBITAL SODIUM SECONALSODIUM 3

HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSRAMELTEON ROZEREM 4 QL: 1 IN 1 DAYTASIMELTEON HETLIOZ 3 PA

MONOAMINE OXIDASE(MAO) INHIBITORSSELEGILINE EMSAM 3 QL: 1 IN 1 DAY

NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS

armodafinil NUVIGIL (150MG) (TABLET) 2 QL: 1 IN 1 DAY




modafinil PROVIGIL 2 QL: 2 IN 1 DAYNARCOTIC ANTAGONISTS

naloxone hcl NARCAN (0.4MG/ML) (VIAL) 2

NALOXONE HCL NARCAN (4 MG)(SPRAY) 3 QL: 4 IN 30 DAYS

naltrexone hcl REVIA 2SEDATIVE-HYPNOTICS - BENZODIAZEPINES

estazolam 2quazepam DORAL 2temazepam RESTORIL 2triazolam 2

SEDATIVE-HYPNOTICS,NON-BARBITURATEDOXEPIN HCL SILENOR 3 QL: 1 IN 1 DAYeszopiclone LUNESTA 2 QL: 1 IN 1 DAY



Drug Name Tier Requirements/LimitsSUVOREXANT BELSOMRA 4 ST, QL: 1 IN 1 DAYzaleplon SONATA 2 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN 2 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN CR 2 QL: 1 IN 1 DAYZOLPIDEM TARTRATE EDLUAR 3 QL: 1 IN 1 DAYzolpidem tartrate INTERMEZZO 2 QL: 1 IN 1 DAYZOLPIDEM TARTRATE ZOLPIMIST 3 QL: 7.7mL IN 30 DAYS

SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMBolanzapine/fluoxetine hcl SYMBYAX 2

TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONISTclonidine hcl KAPVAY 2 QL: 4 IN 1 DAYguanfacine hcl INTUNIV 1 QL: 1 IN 1 DAY

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYdexmethylphenidate hcl FOCALIN 2 QL: 2 IN 1 DAYdexmethylphenidate hcl FOCALIN XR 2 QL: 1 IN 1 DAYMETHYLPHENIDATE DAYTRANA 3 QL: 1 IN 1 DAYMETHYLPHENIDATE HCL APTENSIO XR 3 QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (cpbp 30-70) 2 QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (cpbp 50-50) 2 QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (tab chew) 2 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg) (tablet er) 2 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg) (tablet) 2 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg/5 ml) (solution) 2methylphenidate hcl (18 mg) (tab er 24) 2 QL: 1 IN 1 DAYmethylphenidate hcl (2.5 mg) (tab chew) 2 QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 30-70) 2 QL: 1 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 50-50) 2 QL: 1 IN 1 DAYmethylphenidate hcl (20 mg) (tablet er) 2 QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (tablet) 2 QL: 3 IN 1 DAYmethylphenidate hcl (27 mg) (tab er 24) 2 QL: 1 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 30-70) 2 QL: 2 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 50-50) 2 QL: 2 IN 1 DAYmethylphenidate hcl (36 mg) (tab er 24) 2 QL: 2 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 30-70) 2 QL: 1 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 50-50) 2 QL: 1 IN 1 DAYmethylphenidate hcl (5 mg) (tab chew) 2 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg) (tablet) 2 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg/5 ml) (solution) 2methylphenidate hcl (50 mg) (cpbp 30-70) 2 QL: 1 IN 1 DAYmethylphenidate hcl (54 mg) (tab er 24) 2 QL: 1 IN 1 DAYmethylphenidate hcl (60 mg) (cpbp 30-70) 2 QL: 1 IN 1 DAY

METHYLPHENIDATE HCLQUILLIVANT XR(5 MG/ML) (SUER RC24)

3 QL: 10mL IN 1 DAY, 150mLBOTTLE










TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE

atomoxetine hcl STRATTERA (10MG) (CAPSULE) 2 QL: 2 IN 1 DAY

atomoxetine hclSTRATTERA(100 MG)(CAPSULE)

2 QL: 1 IN 1 DAY






CARDIOVASCULAR DISEASE - ARRHYTHMIAANTIARRHYTHMICS

amiodarone hcl CORDARONE 1disopyramide phosphate NORPACE 1DISOPYRAMIDE PHOSPHATE NORPACE CR 3dofetilide TIKOSYN 2DRONEDARONE HCL MULTAQ 4flecainide acetate TAMBOCOR 1mexiletine hcl MEXITIL 2propafenone hcl RYTHMOL 1propafenone hcl RYTHMOL SR 2quinidine gluconate 2quinidine sulfate 2CARDIOVASCULAR DISEASE - CARDIAC STIMULANT

ADRENERGIC AGENTS,CATECHOLAMINESepinephrine 2

DIGITALIS GLYCOSIDESdigoxin (125 mcg) (tablet) 1digoxin (250 mcg) (tablet) 1

DIGOXIN LANOXIN (125MCG) (TABLET) 4

DIGOXIN LANOXIN (187.5MCG) (TABLET) 4

DIGOXIN LANOXIN (250MCG) (TABLET) 4

DIGOXIN LANOXIN (62.5MCG) (TABLET) 3




CARDIOVASCULAR DISEASE - HYPERTENSIONACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

amlodipine besylate/benazepril LOTREL 1PERINDOPRIL ARG/AMLODIPINE BES PRESTALIA 3 ST, QL: 1 IN 1 DAYtrandolapril/verapamil hcl 2

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICbenazepril/hydrochlorothiazide LOTENSIN HCT 2enalapril/hydrochlorothiazide VASERETIC 1fosinopril/hydrochlorothiazide MONOPRIL-HCT 2lisinopril/hydrochlorothiazide ZESTORETIC 1moexipril/hydrochlorothiazide UNIRETIC 2

quinapril/hydrochlorothiazideACCURETIC (10-12.5MG)(TABLET)

2

quinapril/hydrochlorothiazideACCURETIC (20MG-25MG)(TABLET)

1

quinapril/hydrochlorothiazideACCURETIC (20-12.5 MG)(TABLET)

2

ALPHA/BETA-ADRENERGIC BLOCKING AGENTScarvedilol COREG 1carvedilol phosphate COREG CR 2labetalol hcl TRANDATE 1

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate CARDURA 1DOXAZOSIN MESYLATE CARDURA XL 3phenoxybenzamine hcl DIBENZYLINE 2prazosin hcl MINIPRESS 1terazosin hcl HYTRIN 1

ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CBamlodipine/valsartan/hcthiazid EXFORGE HCT 2olmesartan/amlodipin/hcthiazid TRIBENZOR 2

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBAZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 4candesartan/hydrochlorothiazid ATACAND HCT 2irbesartan/hydrochlorothiazide AVALIDE 1losartan/hydrochlorothiazide HYZAAR 1olmesartan/hydrochlorothiazide BENICAR HCT 2telmisartan/hydrochlorothiazid MICARDIS HCT 2

valsartan/hydrochlorothiazideDIOVAN HCT(160-12.5MG)(TABLET)

2

valsartan/hydrochlorothiazideDIOVAN HCT(160-25MG)(TABLET)

1


1




valsartan/hydrochlorothiazideDIOVAN HCT(320MG-25MG)(TABLET)

1


2

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRamlodipine bes/olmesartan med AZOR 2amlodipine besylate/valsartan EXFORGE 1telmisartan/amlodipine TWYNSTA 2

ANTIHYPERTENSIVES, ACE INHIBITORSbenazepril hcl LOTENSIN 1captopril CAPOTEN 2enalapril maleate VASOTEC 1fosinopril sodium MONOPRIL 1lisinopril PRINIVIL 1lisinopril ZESTRIL 1moexipril hcl UNIVASC 2perindopril erbumine ACEON 1quinapril hcl ACCUPRIL 1ramipril ALTACE 1trandolapril MAVIK 1

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTAZILSARTAN MEDOXOMIL EDARBI 4candesartan cilexetil ATACAND 2eprosartan mesylate TEVETEN 2irbesartan AVAPRO 1losartan potassium COZAAR 1olmesartan medoxomil BENICAR 2telmisartan MICARDIS 1VALSARTAN DIOVAN 3valsartan 1

ANTIHYPERTENSIVES, GANGLIONIC BLOCKERSMECAMYLAMINE HCL VECAMYL 3 PA

ANTIHYPERTENSIVES, MISCELLANEOUSMETYROSINE DEMSER 3

ANTIHYPERTENSIVES, SYMPATHOLYTIC

clonidine CATAPRES-TTS1 2



clonidine hcl CATAPRES 1clonidine hcl/chlorthalidone COMBIPRES 2guanfacine hcl TENEX 1methyldopa ALDOMET 1

ANTIHYPERTENSIVES, VASODILATORShydralazine hcl APRESOLINE 1



Drug Name Tier Requirements/Limitsminoxidil LONITEN 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl SECTRAL 1atenolol TENORMIN 1betaxolol hcl KERLONE 2bisoprolol fumarate ZEBETA 1metoprolol succinate TOPROL XL 2metoprolol tartrate (100 mg) (tablet) 1metoprolol tartrate (25 mg) (tablet) 1metoprolol tartrate (50 mg) (tablet) 1nadolol CORGARD 2NEBIVOLOL HCL BYSTOLIC 4pindolol VISKEN 1PROPRANOLOL HCL HEMANGEOL 2

propranolol hcl INDERAL (10MG) (TABLET) 1





propranolol hcl INDERAL LA 2PROPRANOLOL HCL INDERAL XL 4PROPRANOLOL HCL INNOPRAN XL 4sotalol hcl 1SOTALOL HCL SOTYLIZE 3

timolol maleate BLOCADREN (20MG) (TABLET) 2

BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATEDatenolol/chlorthalidone TENORETIC 100 1atenolol/chlorthalidone TENORETIC 50 1bisoprolol/hydrochlorothiazide ZIAC 1

metoprolol su/hydrochlorothiazDUTOPROL (100-12.5MG) (TAB ER24H)

2

METOPROLOLSU/HYDROCHLOROTHIAZ

DUTOPROL (100-12.5MG) (TAB ER24H)

4

metoprolol su/hydrochlorothiazDUTOPROL (25-12.5 MG) (TABER 24H)

2


DUTOPROL (25-12.5 MG) (TABER 24H)

4

metoprolol su/hydrochlorothiazDUTOPROL (50-12.5 MG) (TABER 24H)

2





DUTOPROL (50-12.5 MG) (TABER 24H)

4

metoprolol/hydrochlorothiazide LOPRESSORHCT 2

nadolol/bendroflumethiazide CORZIDE 2CALCIUM CHANNEL BLOCKING AGENTS

amlodipine besylate NORVASC 1diltiazem hcl CARDIZEM 1diltiazem hcl CARDIZEM CD 1

DILTIAZEM HCLCARDIZEM LA(120 MG) (TABER 24H)

4

diltiazem hclCARDIZEM LA(180 MG) (TABER 24H)

2


2


2


2


2

diltiazem hcl CARDIZEM SR 2diltiazem hcl DILACOR XR 1

diltiazem hclTIAZAC (120MG) (CAP SA24H)

1


1


1


1


1


2

felodipine PLENDIL 1isradipine DYNACIRC 2nicardipine hcl 2



Drug Name Tier Requirements/Limitsnifedipine ADALAT CC 1nifedipine PROCARDIA 1nifedipine PROCARDIA XL 1

NIMODIPINENYMALIZE (60MG/20ML)(SOLUTION)

3 PA

nisoldipine SULAR (17 MG)(TAB ER 24H) 2

nisoldipine SULAR (34 MG)(TAB ER 24H) 2

nisoldipine SULAR (8.5MG)(TAB ER 24H) 2

verapamil hcl CALAN 1verapamil hcl CALAN SR 1verapamil hcl VERELAN 2verapamil hcl VERELAN PM 2

LOOP DIURETICSbumetanide BUMEX 1ethacrynic acid EDECRIN 2

furosemideLASIX (10MG/ML)(SOLUTION)

1

furosemide LASIX (20 MG)(TABLET) 1



torsemide DEMADEX 1POTASSIUM SPARING DIURETICS

amiloride hcl MIDAMOR 1eplerenone INSPRA 2spironolactone ALDACTONE 1TRIAMTERENE DYRENIUM 3

POTASSIUM SPARING DIURETICS IN COMBINATION

amiloride/hydrochlorothiazide MODURETIC 5-50 1

spironolact/hydrochlorothiazidALDACTAZIDE(25 MG-25MG)(TABLET)

2

SPIRONOLACT/HYDROCHLOROTHIAZID

ALDACTAZIDE(50 MG-50MG)(TABLET)

4

triamterene/hydrochlorothiazid DYAZIDE 1triamterene/hydrochlorothiazid MAXZIDE 1

triamterene/hydrochlorothiazid MAXZIDE-25MG 1

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATORRIOCIGUAT ADEMPAS 5 PA



Drug Name Tier Requirements/LimitsPULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB

SILDENAFIL CITRATEREVATIO (10MG/ML) (SUSPRECON)

3 PA

sildenafil citrate REVATIO (20MG) (TABLET) 2 PA

tadalafil ADCIRCA 2 PAPULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST

AMBRISENTAN LETAIRIS 5 PABOSENTAN TRACLEER 5 PAMACITENTAN OPSUMIT 5 PA

PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEILOPROST TROMETHAMINE VENTAVIS 5 PASELEXIPAG UPTRAVI 5 PATREPROSTINIL TYVASO 5 PA

TREPROSTINIL DIOLAMINEORENITRAM ER(0.125 MG)(TABLET ER)

5 PA


5 PA

TREPROSTINIL DIOLAMINEORENITRAM ER(1 MG) (TABLETER)

5 PA


5 PA

TREPROSTINIL DIOLAMINEORENITRAM ER(5 MG) (TABLETER)

3 PA

TREPROSTINIL/NEB ACCESSORIES TYVASO REFILLKIT 5 PA

TREPROSTINIL/NEBULIZER/ACCESORTYVASOINSTITUTIONALSTART KIT

5 PA

TREPROSTINIL/NEBULIZER/ACCESOR TYVASOSTARTER KIT 5 PA

RENIN INHIBITOR, DIRECTALISKIREN HEMIFUMARATE TEKTURNA 3 PA

RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMBALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT 3 PA

THIAZIDE AND RELATED DIURETICS

chlorothiazide DIURIL (250 MG)(TABLET) 1

CHLOROTHIAZIDEDIURIL (250MG/5ML) (ORALSUSP)

3

chlorothiazide DIURIL (500 MG)(TABLET) 1

chlorthalidone HYGROTON 1



Drug Name Tier Requirements/Limitshydrochlorothiazide 1indapamide LOZOL 1methyclothiazide 2metolazone ZAROXOLYN 2

VASODILATORS, COMBINATIONISOSORBIDE DINIT/HYDRALAZINE BIDIL 3CARDIOVASCULAR DISEASE - LIPID IRREGULARITY

ANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIBezetimibe/simvastatin VYTORIN 2 QL: 1 IN 1 DAY

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS

atorvastatin calcium LIPITOR (10 MG)(TABLET) 1

AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORYOF SECONDARYCARDIOVASCULARDISEASE PREVENTIONMEDICATIONS IN 120 DAYS,QL: 1 IN 1 DAY

atorvastatin calcium LIPITOR (20 MG)(TABLET) 1


atorvastatin calcium LIPITOR (40 MG)(TABLET) 1 QL: 1 IN 1 DAY

atorvastatin calcium LIPITOR (80 MG)(TABLET) 1 QL: 1 IN 1 DAY

fluvastatin sodium LESCOL 2


fluvastatin sodium LESCOL XL 2


lovastatin MEVACOR 1


PITAVASTATIN CALCIUM LIVALO 4 AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY



Drug Name Tier Requirements/LimitsOF SECONDARYCARDIOVASCULARDISEASE PREVENTIONMEDICATIONS IN 120 DAYS,QL: 1 IN 1 DAY

pravastatin sodium PRAVACHOL 1


rosuvastatin calcium CRESTOR (10MG) (TABLET) 2


rosuvastatin calcium CRESTOR (20MG) (TABLET) 2 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (40MG) (TABLET) 2 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (5MG) (TABLET) 2


simvastatin (10 mg) (tablet) 1











simvastatin (80 mg) (tablet) 1 QL: 1 IN 1 DAYANTIHYPERLIPIDEMIC - MTP INHIBITOR

LOMITAPIDE MESYLATE JUXTAPID 5 PAANTIHYPERLIPIDEMIC - PCSK9 INHIBITORS

ALIROCUMAB PRALUENT PEN 3 PA

EVOLOCUMAB REPATHAPUSHTRONEX 3 PA

EVOLOCUMAB REPATHASURECLICK 3 PA

EVOLOCUMAB REPATHASYRINGE 4 PA

BILE SALT SEQUESTRANTScholestyramine (with sugar) QUESTRAN 2

cholestyramine/aspartame QUESTRANLIGHT 2

colesevelam hcl WELCHOL 2

colestipol hcl COLESTID (1 G)(TABLET) 2

colestipol hcl COLESTID (5 G)(GRANULES) 2

colestipol hcl COLESTID (5 G)(PACKET) 2

COLESTIPOL HCL COLESTID (7.5G) (PACKET) 4

LIPOTROPICSezetimibe ZETIA 2 QL: 1 IN 1 DAYfenofibrate FENOGLIDE 2fenofibrate LIPOFEN 2fenofibrate LOFIBRA 1fenofibrate nanocrystallized TRICOR 2FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 4

fenofibrate,micronized ANTARA (130MG) (CAPSULE) 1

FENOFIBRATE,MICRONIZED ANTARA (30MG) (CAPSULE) 3

fenofibrate,micronized ANTARA (43MG) (CAPSULE) 1

FENOFIBRATE,MICRONIZED ANTARA (90MG) (CAPSULE) 3

fenofibrate,micronized LOFIBRA 1fenofibric acid FIBRICOR 2fenofibric acid (choline) TRILIPIX 2gemfibrozil LOPID 1




ICOSAPENT ETHYLVASCEPA (0.5GRAM)(CAPSULE)

4 QL: 8 IN 1 DAY

ICOSAPENT ETHYL VASCEPA (1 G)(CAPSULE) 4 QL: 4 IN 1 DAY

niacin NIASPAN 2omega-3 acid ethyl esters LOVAZA 2 QL: 4 IN 1 DAYCARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS

ADRENERGIC VASOPRESSOR AGENTSDROXIDOPA NORTHERA 5 PAmidodrine hcl PROAMATINE 1

ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)SACUBITRIL/VALSARTAN ENTRESTO 3

ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

RANOLAZINERANEXA (1000MG) (TAB ER12H)

3 QL: 2 IN 1 DAY

RANOLAZINERANEXA (500MG) (TAB ER12H)

3 QL: 4 IN 1 DAY

ANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITORIVABRADINE HCL CORLANOR 3 PA

ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CBamlodipine/atorvastatin CADUET 2 QL: 1 IN 1 DAYCARDIOVASCULAR DISEASE - VASODILATION

VASODILATORS,CORONARYISOSORBIDE DINITRATE DILATRATE-SR 3isosorbide dinitrate ISOCHRON 2

isosorbide dinitrate ISORDIL (10 MG)(TABLET) 1



ISOSORBIDE DINITRATE ISORDIL (40 MG)(TABLET) 4

isosorbide dinitrate ISORDILTITRADOSE 1

isosorbide mononitrate IMDUR 1isosorbide mononitrate MONOKET 1NITROGLYCERIN NITRO-BID 3

nitroglycerinNITRO-DUR(0.1MG/HR)(PATCH TD24)

2


2

NITROGLYCERINNITRO-DUR (0.3MG/HR) (PATCHTD24)

3





2


2

NITROGLYCERINNITRO-DUR(0.8MG/HR)(PATCH TD24)

3

nitroglycerin NITROLINGUAL 2NITROGLYCERIN NITROMIST 4nitroglycerin NITROSTAT 2nitroglycerin NITRO-TIME 1

VASODILATORS,PERIPHERALisoxsuprine hcl 2CONTRACEPTION/OXYTOCICS

CONTRACEPTIVES, INTRAVAGINAL, SYSTEMICETONOGESTREL/ETHINYL ESTRADIOL NUVARING 4 QL: 1 IN 28 DAYS

CONTRACEPTIVES,INJECTABLEmedroxyprogesterone acetate DEPO-PROVERA 2 QL: 1mL IN 84 DAYS

MEDROXYPROGESTERONE ACETATE DEPO-SUBQPROVERA 104 3 QL: 0.65mL IN 84 DAYS

CONTRACEPTIVES,ORALdesog-e.estradiol/e.estradiol MIRCETTE 2desogestrel-ethinyl estradiol CYCLESSA 2desogestrel-ethinyl estradiol DESOGEN 2desogestrel-ethinyl estradiol ORTHO-CEPT 2drospir/eth estra/levomefol ca BEYAZ 2drospir/eth estra/levomefol ca SAFYRAL 2ESTRADIOL VALERATE/DIENOGEST NATAZIA 3ethinyl estradiol/drospirenone YASMIN 28 2ethinyl estradiol/drospirenone YAZ 2ethynodiol d-ethinyl estradiol DEMULEN 2

ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 2

levonorgestrel-ethin estradiol (0.1-0.02mg)(tablet) 1

levonorgestrel-ethin estradiol (0.15-0.03)(tablet) 1

levonorgestrel-ethin estradiol (0.15-0.03)(tbdspk 3mo) 2 QL: 91 IN 84 DAYS

levonorgestrel-ethin estradiol (6-5-10)(tablet) 2

levonorgestrel-ethin estradiol (90-20 mcg)(tablet) 2

l-norgest/e.estradiol-e.estrad LOSEASONIQUE 2 QL: 91 IN 84 DAYSl-norgest/e.estradiol-e.estrad QUARTETTE 2l-norgest/e.estradiol-e.estrad SEASONIQUE 2 QL: 91 IN 84 DAYSnoreth-ethinyl estradiol/iron FEMCON FE 2noreth-ethinyl estradiol/iron GENERESS FE 2



Drug Name Tier Requirements/Limitsnorethindrone NOR-Q-D 1

norethindrone ORTHOMICRONOR 1

norethindrone ac-eth estradiol LOESTRIN 2norethindrone-e.estradiol-iron ESTROSTEP FE 2

NORETHINDRONE-E.ESTRADIOL-IRON LO LOESTRINFE 3

norethindrone-e.estradiol-iron LOESTRIN 24 FE 1norethindrone-e.estradiol-iron LOESTRIN FE 2

norethindrone-e.estradiol-iron MINASTRIN 24FE 2

norethindrone-ethinyl estrad MODICON 2norethindrone-ethinyl estrad ORTHO-NOVUM 2norethindrone-ethinyl estrad OVCON-35 2norethindrone-ethinyl estrad TRI-NORINYL 2

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN 2

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO 2

norgestimate-ethinyl estradiol ORTHO-CYCLEN 2norgestrel-ethinyl estradiol LO-OVRAL-28 2norgestrel-ethinyl estradiol LO-OVRAL-8 2norgestrel-ethinyl estradiol OVRAL 2ULIPRISTAL ACETATE ELLA 3

CONTRACEPTIVES,TRANSDERMALnorelgestromin/ethin.estradiol ORTHO EVRA 2 QL: 3 IN 28 DAYS

OXYTOCICSDINOPROSTONE CERVIDIL 3

DINOPROSTONEPROSTIN E2VAGINALSUPPOSITORY

3

methylergonovine maleate 2COUGH AND COLD

1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSphenylephrine hcl/prometh hcl PHENERGAN VC 2phenylephrine hcl/prometh hcl PHEN-TUSS AD 2

ANTITUSSIVES,NON-NARCOTICbenzonatate TESSALON 1

benzonatate TESSALONPERLE 1

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESThydrocodone/cpm/pseudoephed 2

promethazine/phenyleph/codeine PENTAZINE VCWITH CODEINE 2

promethazine/phenyleph/codeine PHENERGAN VCWITH CODEINE 2

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINECODEINE POLI/CHLORPHENIR POLIS TUZISTRA XR 3 QL: 200mL IN 10 DAYS



Drug Name Tier Requirements/LimitsHYDROCODONE/CHLORPHEN P-STIREX TUSSICAPS 3

hydrocodone/chlorphen p-stirex TUSSIONEX 2HYDROCODONE/CHLORPHENIRAMINE VITUZ 3

promethazine hcl/codeine PHENERGANWITH CODEINE 2

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.hydrocodone bit/homatrop me-br 2

NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONcodeine phosphate/guaifenesin (10-100mg/5)(liquid) (otc) 2

codeine phosphate/guaifenesin (20-200/10)(liquid) (otc) 2

GUAIFENESIN/HYDROCODONE OBREDON 3 QL: 600mL IN 10 DAYSNON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST

brompheniramine/pseudoephed/dm (2-30-10/5) (syrup) 2

NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.promethazine/dextromethorphan PHEN TUSS DM 2

NOSE PREPARATIONS, VASOCONSTRICTORS (RX)

EPINEPHRINE HCL ADRENALINCHLORIDE 3

DERMATOLOGY - ACNEACNE AGENTS,SYSTEMIC

ISOTRETINOIN ABSORICA 3 AGE: <= 35 YEARSisotretinoin 2 AGE: <= 35 YEARS

ACNE AGENTS,TOPICALAZELAIC ACID AZELEX 3 AGE: <= 35 YEARSclindamycin phos/benzoyl perox BENZACLIN 1 AGE: <= 35 YEARSclindamycin phos/benzoyl perox DUAC 2 AGE: <= 35 YEARSCLINDAMYCIN/BENZOYL/EMOLCMB94 NEUAC 3 AGE: <= 35 YEARS

clindamycin/tretinoin VELTIN 2 AGE: <= 35 YEARSclindamycin/tretinoin ZIANA 2 AGE: <= 35 YEARS

dapsone ACZONE (5 %)(GEL (GRAM)) 2

DAPSONE ACZONE (7.5 %)(GEL W/PUMP) 4 AGE: <= 35 YEARS

sulfacetamide sodium KLARON 2 AGE: <= 35 YEARSKERATOLYTIC-GLUCOCORTICOID COMBINATIONS

BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3 AGE: <= 35 YEARSROSACEA AGENTS, TOPICAL

AZELAIC ACID FINACEA (15 %)(GEL (GRAM)) 4 AGE: <= 35 YEARS

BRIMONIDINE TARTRATE MIRVASO 3IVERMECTIN SOOLANTRA 4metronidazole METROCREAM 2metronidazole METROGEL 2metronidazole METROLOTION 2



Drug Name Tier Requirements/LimitsMETRONIDAZOLE NORITATE 4metronidazole ROSADAN 2METRONIDAZOLE/SKIN CLEANSER 23 ROSADAN 3

TOPICAL PREPARATIONS,ANTIBACTERIALSCADEXOMER IODINE IODOFLEX 3CLIOQUINOL/HYDROCORTISONE ALA-QUIN 3hydrocortisone/iodoquinol DERMAZENE 2

hydrocortisone/iodoquinol/aloeVYTONE (1.9 %-1 %) (CREAMPACK)

2

VITAMIN A DERIVATIVESadapalene DIFFERIN 2 AGE: <= 35 YEARStretinoin ATRALIN 2 AGE: <= 35 YEARStretinoin RETIN-A 2 AGE: <= 35 YEARSTRETINOIN TRETIN-X 3 AGE: <= 35 YEARStretinoin microspheres RETIN-A MICRO 2 AGE: <= 35 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.04 %)(GEL W/PUMP)

2 AGE: <= 35 YEARS

TRETINOIN MICROSPHERESRETIN-A MICROPUMP (0.08 %)(GEL W/PUMP)

3 AGE: <= 35 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.1 %)(GEL W/PUMP)

2 AGE: <= 35 YEARS

VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTSTAZAROTENE FABIOR 3 AGE: <= 35 YEARSDERMATOLOGY - ANTIINFECTIVE

TOPICAL ANTIBIOTICSCLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN ETZ 3 AGE: <= 35 YEARSCLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN PAC 3 AGE: <= 35 YEARSclindamycin phosphate CLEOCIN T 2 AGE: <= 35 YEARSclindamycin phosphate CLINDACIN ETZ 2 AGE: <= 35 YEARSclindamycin phosphate CLINDACIN P 2 AGE: <= 35 YEARS

clindamycin phosphate CLINDAGEL (1%) (GEL (ML)) 2 AGE: <= 35 YEARS

clindamycin phosphate EVOCLIN 2 AGE: <= 35 YEARSerythromycin base in ethanol 2 AGE: <= 35 YEARSERYTHROMYCIN/BENZOYL PEROXIDE AKTIPAK 3 AGE: <= 35 YEARSerythromycin/benzoyl peroxide BENZAMYCIN 2 AGE: <= 35 YEARSgentamicin sulfate 2mupirocin BACTROBAN 2mupirocin CENTANY 2MUPIROCIN CENTANY AT 3mupirocin calcium BACTROBAN 2

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENTclotrimazole/betamethasone dip LOTRISONE 2

TOPICAL ANTIFUNGALSBUTENAFINE HCL MENTAX 3



Drug Name Tier Requirements/Limitsciclopirox CICLODAN 2ciclopirox LOPROX 2ciclopirox PENLAC 2ciclopirox olamine CICLODAN 2ciclopirox olamine LOPROX 2CICLOPIROX/SKIN CLEANSER NO.28 CICLODAN 3

CICLOPIROX/SKIN CLEANSER NO.40 LOPROX (0.77 %)(COMBO. PKG) 3

ciclopirox/urea/camph/men/euc CICLODAN 2clotrimazole (1 %) (cream (g)) 2clotrimazole (1 %) (solution) 2ECONAZOLE NITRATE ECOZA 4econazole nitrate SPECTAZOLE 2gentian violet/brgreen/proflav 2ketoconazole EXTINA 2ketoconazole NIZORAL 2KETOCONAZOLE XOLEGEL 4luliconazole LUZU 2 QL: 60gm IN 28 DAYSMICONAZOLE NITRATE/ZINC OX/PET VUSION 3

naftifine hcl NAFTIN (1 %)(CREAM (G)) 2

NAFTIFINE HCL NAFTIN (1 %)(GEL (GRAM)) 3

naftifine hcl NAFTIN (2 %)(CREAM (G)) 2

NAFTIFINE HCL NAFTIN (2 %)(GEL (GRAM)) 3

nystatin MYCOSTATIN 2nystatin NYAMYC 2nystatin NYSTEX 2nystatin NYSTOP 2nystatin/triamcin 2

oxiconazole nitrate OXISTAT (1 %)(CREAM (G)) 2

SERTACONAZOLE NITRATE ERTACZO 3sodium thiosulfate/sal acid VERSICLEAR 2

SULCONAZOLE NITRATE EXELDERM (1%) (SOLUTION) 3

TOPICAL ANTIPARASITICSBENZYL ALCOHOL ULESFIA 3

CROTAMITON EURAX (10 %)(CREAM (G)) 3

IVERMECTIN SKLICE 3lindane KWELL 2malathion OVIDE 2permethrin (5 %) (cream (g)) 2spinosad NATROBA 2

TOPICAL ANTIVIRALS

ACYCLOVIR ZOVIRAX (5 %)(CREAM (G)) 3




acyclovir ZOVIRAX (5 %)(OINT. (G)) 2

PENCICLOVIR DENAVIR 4TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT

ACYCLOVIR/HYDROCORTISONE XERESE 3 QL: 10gm IN 365 DAYSTOPICAL GENITAL WART-HPV TREATMENT AGENTS

SINECATECHINS VEREGEN 3TOPICAL PLEUROMUTILIN DERIVATIVES

RETAPAMULIN ALTABAX 3TOPICAL SULFONAMIDES

mafenide acetate SULFAMYLON(50 G) (PACKET) 2

silver sulfadiazine SILVADENE 2silver sulfadiazine THERMAZENE 2sulfacetamide sod/sulfur/urea (10%-5%-10%)(cleanser) 2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfurAVAR (10-5%(W/W))(CLEANSER)

2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfur AVAR LS (10 %-2%) (CLEANSER) 2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfur BP 10-1 2 AGE: <= 35 YEARSsulfacetamide sodium/sulfur CLARIFOAM EF 2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfurPLEXION (9.8%-4.8%)(CLEANSER)

2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfur PLEXION TS 2 AGE: <= 35 YEARSSULFACETAMIDE SODIUM/SULFUR ROSANIL 2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfur ROSULA (10 %-5%) (MED. PAD) 2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfurSODIUMSULFACETAMIDE-SULFUR

2 AGE: <= 35 YEARS

sulfacetamide sodium/sulfur SUMADAN 2 AGE: <= 35 YEARSsulfacetamide sodium/sulfur SUMAXIN 2 AGE: <= 35 YEARSsulfacetamide sodium/sulfur SUMAXIN TS 2 AGE: <= 35 YEARSsulfacetamide sodium/sulfur ZENCIA 2 AGE: <= 35 YEARSsulfacetamide/sulfur/cleansr23 PLEXION 2 AGE: <= 35 YEARSSULFACETAMIDE/SULFUR/CLEANSR23 SUMAXIN CP 3 AGE: <= 35 YEARSsulfact sod/sulur/avob/otn/oct SUMADAN XLT 2 AGE: <= 35 YEARSDERMATOLOGY - ANTIINFLAMMATORY

TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALNEOMYC/BACIT/POLYMYX/HYDROCORT CORTISPORIN 3

NEOMYCIN SULFATE/FLUOCINOLONE NEO-SYNALAR 3NEOMYCIN/FLUOCINOLONE/EMOLL 65 NEO-SYNALAR 3

TOPICAL ANTI-INFLAMMATORY STEROIDALalclometasone dipropionate ACLOVATE 2




amcinonideCYCLOCORT(0.1 %) (CREAM(G))

2

betamethasone dipropionate DIPROLENE 2betamethasone valerate LUXIQ 2betamethasone valerate VALISONE 2betamethasone/propylene glyc DIPROLENE 2betamethasone/propylene glyc DIPROLENE AF 2clobetasol propionate CLOBEX 2clobetasol propionate CLODAN 2clobetasol propionate OLUX 2clobetasol propionate TEMOVATE 2clobetasol propionate/emoll OLUX-E 2clobetasol propionate/emoll TEMOVATE E 2

clobetasol propionate/emoll TEMOVATEEMOLLIENT 2

CLOBETASOL/SKIN CLEANSER NO.28 CLODAN 3clocortolone pivalate CLODERM 2DESONIDE DESONATE 4desonide 2

desonide DESOWEN (0.05%) (CREAM (G)) 2

desonide DESOWEN (0.05%) (LOTION) 2

DESONIDE VERDESO 4

desoximetasone TOPICORT (0.05%) (CREAM (G)) 2

desoximetasoneTOPICORT (0.05%) (GEL(GRAM))

2

desoximetasone TOPICORT (0.05%) (OINT. (G)) 2

desoximetasone TOPICORT (0.25%) (CREAM (G)) 2

desoximetasone TOPICORT (0.25%) (OINT. (G)) 2

diflorasone diacetate PSORCON 2DIFLORASONE DIACETATE/EMOLL APEXICON E 2

FLUOCINOLONE ACETONIDE CAPEXSHAMPOO 3

fluocinolone acetonide DERMA-SMOOTHE-FS 2

fluocinolone acetonide SYNALAR 2FLUOCINOLONE/EMOL COMB NO.65 SYNALAR 3

fluocinolone/shower cap DERMA-SMOOTHE-FS 2

FLUOCINOLONE/SKIN CLNSR28 SYNALAR TS 3fluocinonide LIDEX 2fluocinonide VANOS 2fluocinonide/emollient base LIDEX-E 2




flurandrenolide CORDRAN (0.05%) (CREAM (G)) 2

flurandrenolide CORDRAN (0.05%) (LOTION) 2

flurandrenolide CORDRAN (0.05%) (OINT. (G)) 2

FLURANDRENOLIDECORDRAN(4MCG/SQ CM)(MED. TAPE)

3 QL: 2 IN 30 DAYS

flurandrenolide NOLIX 2fluticasone propionate CUTIVATE 2

HALCINONIDE HALOG (0.1 %)(OINT. (G)) 3

halobetasol propionateULTRAVATE(0.05 %) (CREAM(G))

2

halobetasol propionateULTRAVATE(0.05 %) (OINT.(G))

2

HALOBETASOL/LACTIC ACID ULTRAVATE X 3HYDROCORT/SAL ACID/SULF/SHAMP1 SCALACORT DK 3hydrocortisone (1 %) (cream (g)) 2hydrocortisone (1 %) (crm/pe app) 2hydrocortisone (2 %) (lotion) 2hydrocortisone (2.5 %) (cream (g)) 2hydrocortisone (2.5 %) (crm/pe app) 2hydrocortisone (2.5 %) (kit) 2hydrocortisone (2.5 %) (lotion) 2hydrocortisone (2.5 %) (oint. (g)) 2HYDROCORTISONE TEXACORT 3HYDROCORTISONE ACET/ALOE VERA NUCORT 3

hydrocortisone butyrate LOCOID (0.1 %)(CREAM (G)) 2

hydrocortisone butyrate LOCOID (0.1 %)(LOTION) 2

hydrocortisone butyrate LOCOID (0.1 %)(OINT. (G)) 4

hydrocortisone butyrate LOCOID (0.1 %)(SOLUTION) 4

hydrocortisone butyrate/emoll LOCOIDLIPOCREAM 4

HYDROCORTISONE PROBUTATE PANDEL 3hydrocortisone valerate 2

HYDROCORTISONE/SKIN CLEANSER35 DERMASORBHC 3

mometasone furoate ELOCON 2prednicarbate DERMATOP 2TRIAMCINOLONE ACETON/SILICONES SILAZONE-II 3triamcinolone acetonide (0.025 %) (cream(g)) 2



Drug Name Tier Requirements/Limitstriamcinolone acetonide (0.025 %) (lotion) 2triamcinolone acetonide (0.025 %) (oint. (g)) 1triamcinolone acetonide (0.1 %) (cream (g)) 2triamcinolone acetonide (0.1 %) (lotion) 2triamcinolone acetonide (0.1 %) (oint. (g)) 1triamcinolone acetonide (0.147mg/g)(aerosol) 2

triamcinolone acetonide (0.5 %) (cream (g)) 2triamcinolone acetonide (0.5 %) (oint. (g)) 1

TRIAMCINOLONE/DIMETH/SILICONE WHYTEDERMTDPAK 3

TRIAMCINOLONE/DIMETH/SILICONE WHYTEDERMTRILASIL PAK 3

TRIAMCINOLONE/EMOLLIENTCOMB86 DERMASORB TA 3

TOPICAL ANTI-INFLAMMATORY, NSAIDS

DICLOFEN SOD/KINESIOLOGY TAPE DICLO GEL-XRYLIX SHEET 3

DICLOFEN SOD/KINESIOLOGY TAPE LEXIXRYL 3DICLOFEN SOD/KINESIOLOGY TAPE XRYLIX 3DICLOFENAC EPOLAMINE FLECTOR 4

diclofenac sodium PENNSAID (1.5%) (DROPS) 2

DICLOFENAC SODIUMPENNSAID(20MG/G(2%))(SOL MD PMP)

4

diclofenac sodium VOLTAREN 2DERMATOLOGY - ANTIPRURITIC DRUGS

ANTIPRURITICS,TOPICALdoxepin hcl PRUDOXIN 2doxepin hcl ZONALON 2DERMATOLOGY - MISCELLANEOUS

ANTIPERSPIRANTSALUMINUM CHLORIDE DRYSOL 2

ANTISEBORRHEIC AGENTSselenium sulfide (2.25 %) (shampoo) 2selenium sulfide (2.5 %) (lotion) 2SELENIUM SULFIDE TERSI FOAM 3

SULFACETAMIDE SODIUM OVACE PLUS (10%) (SHAMPOO) 4 AGE: <= 35 YEARS

sulfacetamide sodium (10 %) (cleanser) 2 AGE: <= 35 YEARSsulfacetamide sodium (10 %) (clnsr gel) 2 AGE: <= 35 YEARSsulfacetamide sodium (10 %) (shampoo) 2 AGE: <= 35 YEARS

EMOLLIENTSammonium lactate (12 %) (cream (g)) 2ammonium lactate (12 %) (lotion) 2

EMOLLIENT COMBINATION NO.60LEVICYNANTIPRURITICSG

3



Drug Name Tier Requirements/LimitsIODINE ANTISEPTICS

povidone-iodine (5 %) (solution) 2KERATOLYTICS

benzoyl peroxide (5.3%) (foam) 2 AGE: <= 35 YEARSbenzoyl peroxide (6 %) (towelette) 2 AGE: <= 35 YEARSbenzoyl peroxide (7 %) (cleanser) 2 AGE: <= 35 YEARSbenzoyl peroxide (9.8 %) (foam) 2 AGE: <= 35 YEARSbenzoyl peroxide microspheres 2 AGE: <= 35 YEARSBENZOYL PEROXIDE/VIT E MIX INOVA 3 AGE: <= 35 YEARS

PODOFILOXCONDYLOX (0.5%) (GEL(GRAM))

3

podofilox CONDYLOX (0.5%) (SOLUTION) 2

podophyllum resin 2SALICYLIC AC/BENZOYL PER/VIT E INOVA 4-1 3 AGE: <= 35 YEARSSALICYLIC AC/BENZOYL PER/VIT E INOVA 8-2 3 AGE: <= 35 YEARSSALICYLIC ACID BENSAL HP 3

SALICYLIC ACID KERALYTSCALP 3 AGE: <= 35 YEARS

salicylic acid (26 %) (liquid) 2 AGE: <= 35 YEARSsalicylic acid (27.5 %) (liq-film) 2 AGE: <= 35 YEARSsalicylic acid (28.5 %) (sol-filmer) 2 AGE: <= 35 YEARSsalicylic acid (6 %) (gel (gram)) 2 AGE: <= 35 YEARS

SALICYLIC ACID/UREA SALVAX DUOPLUS 3

UREA/EMOLLIENT COMBINATION 65 URAMAXIN GT 3TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC

HYDROCORTISONE/PRAMOXINE EPIFOAM 3

hydrocortisone/pramoxinePRAMOSONE(2.5 %-1 %)(CREAM (G))

2

HYDROCORTISONE/PRAMOXINE/EMOLL PRAMOSONE E 3

TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTSALITRETINOIN PANRETIN 3BEXAROTENE TARGRETIN 3 PAdiclofenac sodium SOLARAZE 2 PA, QL: 100gm PER FILLfluorouracil CARAC 2

fluorouracil EFUDEX (5 %)(CREAM (G)) 2

FLUOROURACIL FLUOROPLEX 2FLUOROURACIL TOLAK 2

INGENOL MEBUTATE PICATO (0.015 %)(GEL (EA)) 4 QL: 3 IN 28 DAYS

INGENOL MEBUTATE PICATO (0.05 %)(GEL (EA)) 4 QL: 2 IN 28 DAYS

MECHLORETHAMINE HCL VALCHLOR 5 PATOPICAL LOCAL ANESTHETICS

BENZOCAINE ANACAINE 3



Drug Name Tier Requirements/Limitslidocaine (5 %) (adh. patch) 2lidocaine (5 %) (oint. (g)) 2 QL: 240gm IN 30 DAYSLIDOCAINE LIDOVEX 3LIDOCAINE TRANZAREL 3LIDOCAINE HCL ANASTIA 3lidocaine hcl (3 %) (cream (g)) 2lidocaine hcl (3 %) (lotion) 2lidocaine hcl (3.88 %) (cream (g)) 2lidocaine hcl (4 %) (solution) 2LIDOCAINE HCL LIDOPIN 3LIDOCAINE HCL LIDORX 3LIDOCAINE HCL NUMBONEX 3lidocaine/prilocaine EMLA 2lidocaine/tetracaine PLIAGLIS 2

TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMESCOLLAGENASE CLOSTRIDIUM HIST. SANTYL 3DERMATOLOGY - PSORIASIS/ECZEMA

ANTIPSORIATIC AGENTS,SYSTEMICacitretin SORIATANE 2GUSELKUMAB TREMFYA 3 PAmethoxsalen 2

SECUKINUMAB COSENTYX (2SYRINGES) 3 PA

SECUKINUMAB COSENTYX PEN 3 PA

SECUKINUMAB COSENTYX PEN(2 PENS) 3 PA

SECUKINUMAB COSENTYXSYRINGE 3 PA

ANTIPSORIATICS AGENTS

ANTHRALIN DRITHOCREMEHP 3

ANTHRALIN MICRONIZED ZITHRANOL 3calcipotriene DOVONEX 2CALCIPOTRIENE SORILUX 3calcitriol VECTICAL 2

TAZAROTENE TAZORAC (0.05%) (CREAM (G)) 3 AGE: <= 35 YEARS

TAZAROTENETAZORAC (0.05%) (GEL(GRAM))

3 AGE: <= 35 YEARS

tazarotene TAZORAC (0.1%) (CREAM (G)) 2 AGE: <= 35 YEARS

TAZAROTENETAZORAC (0.1%) (GEL(GRAM))

3 AGE: <= 35 YEARS

TOPICAL IMMUNOSUPPRESSIVE AGENTSPIMECROLIMUS ELIDEL 4tacrolimus PROTOPIC 2



Drug Name Tier Requirements/LimitsTOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDAL

CALCIPOTRIENE/BETAMETHASONE ENSTILAR 3

calcipotriene/betamethasoneTACLONEX(0.005-.064)(OINT. (G))

2

CALCIPOTRIENE/BETAMETHASONETACLONEX(0.005-.064)(SUSPENSION)

3

DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.

alogliptin benz/metformin hcl KAZANO 2 QL: 2 IN 1 DAYLINAGLIPTIN/METFORMIN HCL JENTADUETO 3 QL: 2 IN 1 DAY

SAXAGLIPTIN HCL/METFORMIN HCLKOMBIGLYZEXR (2.5-1000MG)(TBMP 24HR)

4 QL: 2 IN 1 DAY

SAXAGLIPTIN HCL/METFORMIN HCL

KOMBIGLYZEXR (5 MG-500MG) (TBMP24HR)

4 QL: 1 IN 1 DAY

SAXAGLIPTIN HCL/METFORMIN HCL

KOMBIGLYZEXR (5MG-1000MG) (TBMP24HR)

4 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 3 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(100-1000MG)(TBMP 24HR)

3 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(50-1000 MG)(TBMP 24HR)

3 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(50MG-500MG)(TBMP 24HR)

3 QL: 2 IN 1 DAY

ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONEalogliptin benz/pioglitazone OSENI 2 QL: 1 IN 1 DAY

ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)DULAGLUTIDE TRULICITY 4 QL: 2mL IN 28 DAYS

EXENATIDEBYETTA(10MCG/0.04)(PEN INJCTR)

4 QL: 2.4mL IN 30 DAYS

EXENATIDEBYETTA(5MCG/0.02)(PEN INJCTR)


EXENATIDE MICROSPHERES BYDUREON 4 QL: 1 IN 7 DAYSEXENATIDE MICROSPHERES BYDUREON PEN 4 QL: 1 IN 7 DAYSLIRAGLUTIDE VICTOZA 2-PAK 3 QL: 9mL IN 30 DAYSLIRAGLUTIDE VICTOZA 3-PAK 3 QL: 9mL IN 30 DAYS

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBCANAGLIFLOZIN INVOKANA 3 QL: 1 IN 1 DAYDAPAGLIFLOZIN PROPANEDIOL FARXIGA 3 QL: 1 IN 1 DAY



Drug Name Tier Requirements/LimitsEMPAGLIFLOZIN JARDIANCE 3 QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTSBROMOCRIPTINE MESYLATE CYCLOSET 3

ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)acarbose PRECOSE 1miglitol GLYSET 2

ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPEPRAMLINTIDE ACETATE SYMLINPEN 120 3PRAMLINTIDE ACETATE SYMLINPEN 60 4

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSalogliptin benzoate NESINA 2 QL: 1 IN 1 DAYLINAGLIPTIN TRADJENTA 3 QL: 1 IN 1 DAYSAXAGLIPTIN HCL ONGLYZA 3 QL: 1 IN 1 DAYSITAGLIPTIN PHOSPHATE JANUVIA 3 QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEglimepiride AMARYL 1glipizide GLUCOTROL 1glipizide GLUCOTROL XL 1glyburide 1glyburide,micronized GLYNASE 1nateglinide STARLIX 1repaglinide PRANDIN 1tolazamide TOLINASE 2tolbutamide ORINASE 2

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)pioglitazone hcl ACTOS 1ROSIGLITAZONE MALEATE AVANDIA 3

ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.EMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI 4 QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)metformin hcl GLUCOPHAGE 1

metformin hcl GLUCOPHAGEXR 1

metformin hcl RIOMET 2ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONIST

INSULIN DEGLUDEC/LIRAGLUTIDE XULTOPHY 100-3.6 3 QL: 15mL IN 28 DAYS

INSULIN GLARGINE/LIXISENATIDE SOLIQUA 100-33 3 QL: 30mL IN 28 DAYSANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB

glipizide/metformin hcl METAGLIP 1glyburide/metformin hcl 1

ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB.pioglitazone hcl/glimepiride DUETACT 2

ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKERMIFEPRISTONE KORLYM 5 PA

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBCANAGLIFLOZIN/METFORMIN HCL INVOKAMET 3 QL: 2 IN 1 DAYCANAGLIFLOZIN/METFORMIN HCL INVOKAMET XR 3 QL: 2 IN 1 DAY




DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (10-1000 MG) (TABBP 24H)

4 QL: 2 IN 1 DAY

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR(10MG-500MG)(TAB BP 24H)

4 QL: 2 IN 1 DAY

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (5MG-500MG)(TAB BP 24H)

4 QL: 2 IN 1 DAY

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR(5MG-1000MG)(TAB BP 24H)

4 QL: 2 IN 1 DAY

EMPAGLIFLOZIN/METFORMIN HCL SYNJARDY 3 QL: 2 IN 1 DAYANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB

pioglitazone hcl/metformin hcl ACTOPLUS MET 2

PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS METXR 3

HYPERGLYCEMICSDIAZOXIDE PROGLYCEM 3GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 3

GLUCAGON,HUMAN RECOMBINANTGLUCAGONEMERGENCYKIT

3

INSULINS

INSULIN ASPARTNOVOLOG(100/ML)(CARTRIDGE)


INSULIN ASPART NOVOLOG(100/ML) (VIAL) 3 QL: 40mL IN 28 DAYS

INSULIN ASPART NOVOLOGFLEXPEN 3 QL: 30mL IN 28 DAYS

INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX70-30 3 QL: 40mL IN 28 DAYS

INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX70-30 FLEXPEN 3 QL: 30mL IN 28 DAYS

INSULIN DEGLUDECTRESIBAFLEXTOUCH U-100


INSULIN DEGLUDECTRESIBAFLEXTOUCH U-200


INSULIN DETEMIR LEVEMIR 3 QL: 40mL IN 28 DAYS

INSULIN DETEMIR LEVEMIRFLEXTOUCH 3 QL: 30mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG BASAGLARKWIKPEN U-100 3 QL: 30mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 3 QL: 40mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG LANTUSSOLOSTAR 3 QL: 30mL IN 28 DAYS




INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO MAXSOLOSTAR 3 QL: 12mL IN 28 DAYS

INSULIN GLARGINE,HUM.REC.ANLOG TOUJEOSOLOSTAR 3 QL: 12mL IN 28 DAYS

INSULIN GLULISINE APIDRA 3 QL: 40mL IN 28 DAYS

INSULIN GLULISINE APIDRASOLOSTAR 3 QL: 30mL IN 28 DAYS

INSULIN LISPRO ADMELOG 3 QL: 40mL IN 28 DAYS

INSULIN LISPRO ADMELOGSOLOSTAR 3 QL: 30mL IN 28 DAYS

INSULIN LISPROHUMALOG(100/ML)(CARTRIDGE)


INSULIN LISPRO HUMALOG(100/ML) (VIAL) 3 QL: 40mL IN 28 DAYS

INSULIN LISPROHUMALOGJUNIORKWIKPEN


INSULIN LISPRO HUMALOGKWIKPEN U-100 3 QL: 30mL IN 28 DAYS

INSULIN LISPRO HUMALOGKWIKPEN U-200 3 QL: 12mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX50-50 3 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX50-50 KWIKPEN 3 QL: 30mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX75-25 3 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX75-25 KWIKPEN 3 QL: 30mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30KWIKPEN 3 QL: 30mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30 3 QL: 40mL IN 28 DAYSINSULIN NPH HUM/REG INSULIN HM NOVOLIN 70-30 3 QL: 40mL IN 28 DAYSINSULIN NPH HUMAN ISOPHANE HUMULIN N 3 QL: 40mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE HUMULIN NKWIKPEN 3 QL: 30mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE NOVOLIN N 3 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMANAFREZZA (12UNIT) (CARTINHAL)

3 PA, QL: 180 IN 28 DAYS

INSULIN REGULAR, HUMANAFREZZA (4UNIT(60)) (CARTINHAL)


INSULIN REGULAR, HUMANAFREZZA (4UNIT(90)) (CARTINHAL)







INSULIN REGULAR, HUMANAFREZZA (4-8-12(60)) (CARTINHAL)




INSULIN REGULAR, HUMAN HUMULIN R 3 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R U-500 3 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R U-500 KWIKPEN 3 QL: 24mL IN 28 DAYS

INSULIN REGULAR, HUMAN NOVOLIN R 3 QL: 40mL IN 28 DAYSEAR - GENERAL DISORDERS

EAR PREPARATIONS ANTI-INFLAMMATORYfluocinolone acetonide oil DERMOTIC 2

EAR PREPARATIONS, MISC. ANTI-INFECTIVESacetic acid VOSOL 2hydrocortisone/acetic acid VOSOL HC 2HYDROCORTISONE/PRAMOXINE/C-XYL CORTANE-B 3

EAR PREPARATIONS,ANTIBIOTICSciprofloxacin hcl CETRAXAL 2NEOMYC/COLIST/HYDROCORT/THONZN COLY-MYCIN S 3

neomycin/polymyxin b/hydrocort 2ofloxacin 2

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSCIPROFLOXACIN HCL/DEXAMETH CIPRODEX 3CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3ELECTROLYTE REGULATION

ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTSTOLVAPTAN JYNARQUE 5 PA, QL: 30 IN 365 DAYS

TOLVAPTAN SAMSCA (15MG) (TABLET) 3 QL: 30 IN 365 DAYS

TOLVAPTAN SAMSCA (30MG) (TABLET) 3 QL: 60 IN 365 DAYS

ELECTROLYTE DEPLETERScalcium acetate ELIPHOS 2

calcium acetate PHOSLO (667MG) (CAPSULE) 1

calcium acetate PHOSLO (667MG) (TABLET) 2

CALCIUM ACETATE PHOSLYRA 3

lanthanum carbonateFOSRENOL(1000 MG) (TABCHEW)

2

lanthanum carbonateFOSRENOL (500MG) (TABCHEW)

2




lanthanum carbonateFOSRENOL (750MG) (TABCHEW)

2

PATIROMER CALCIUM SORBITEX VELTASSA 3 PA, QL: 1 IN 1 DAYsevelamer carbonate RENVELA 2SEVELAMER HCL RENAGEL 3sodium polystyrene sulfon/sorb 2SODIUM POLYSTYRENE SULFON/SORB SPS 2sodium polystyrene sulfonate 2SUCROFERRIC OXYHYDROXIDE VELPHORO 3

POTASSIUM REPLACEMENTpot chloride/pot bicarb/cit ac 2POTASSIUM BICARBONATE/CIT AC EFFER-K 1potassium bicarbonate/cit ac KLOR-CON-EF 2potassium chloride (10 meq) (capsule er) 1potassium chloride (10 meq) (tab er prt) 1potassium chloride (10 meq) (tablet er) 1potassium chloride (15 meq) (tab er prt) 2potassium chloride (20 meq) (packet) 2potassium chloride (20 meq) (tab er prt) 1potassium chloride (20 meq) (tablet er) 2potassium chloride (20meq/15ml) (liquid) 2potassium chloride (40meq/15ml) (liquid) 2potassium chloride (8 meq) (capsule er) 1potassium chloride (8 meq) (tablet er) 1

SODIUM/SALINE PREPARATIONS0.9 % sodium chloride (0.9 %) (syringe) 2bacteriostatic sodium chloride (0.9 %) (vial) 2ENDOCRINE DISORDER - FERTILITY

FERTILITY STIMULATING PREPARATIONS,NON-FSHclomiphene citrate SEROPHENE 2

FOLLICLE STIM./LUTEINIZING HORMONESMENOTROPINS MENOPUR 3

FOLLICLE-STIMULATING HORMONE (FSH)FOLLITROPIN ALFA, RECOMBINANT GONAL-F 3FOLLITROPIN ALFA, RECOMBINANT GONAL-F RFF 3

FOLLITROPIN ALFA, RECOMBINANT GONAL-F RFFREDI-JECT 3

FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 3UROFOLLITROPIN BRAVELLE 3

HUMAN CHORIONIC GONADOTROPIN (HCG)CHORIOGONADOTROPIN ALFA OVIDREL 3

CHORIONIC GONADOTROPIN, HUMANCHORIONICGONADOTROPIN

3

CHORIONIC GONADOTROPIN, HUMAN NOVAREL (10000UNIT) (VIAL) 3

CHORIONIC GONADOTROPIN, HUMAN PREGNYL 3



Drug Name Tier Requirements/LimitsPREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL

PROGESTERONE, MICRONIZED CRINONE 3PROGESTERONE, MICRONIZED ENDOMETRIN 3ENDOCRINE DISORDER - OTHER

ANTIDIURETIC AND VASOPRESSOR HORMONESdesmopressin (nonrefrigerated) DDAVP 2DESMOPRESSIN ACETATE DDAVP 4desmopressin acetate 2

ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.LEUPROLIDE ACETATE ELIGARD 3 PAleuprolide acetate 2

BONE FORMATION STIM. AGENTS - PARATHYROID HORMONETERIPARATIDE FORTEO 3 PA, QL: 2.4mL IN 28 DAYS

BONE FORMATION STIMULATING AGTS - PTH REL PEPTIDESABALOPARATIDE TYMLOS 3 PA

BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS

ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUSD 3

BONE RESORPTION INHIBITORSALENDRONATE SODIUM BINOSTO 3 QL: 4 IN 28 DAYS

alendronate sodium FOSAMAX (10MG) (TABLET) 1




CALCITONIN,SALMON,SYNTHETIC MIACALCIN(200/ML) (VIAL) 4

calcitonin,salmon,syntheticMIACALCIN(200/SPRAY)(SPRAY/PUMP)

2

DENOSUMAB PROLIA 3 PAibandronate sodium BONIVA 2raloxifene hcl EVISTA 2 PA, QL: 1 IN 1 DAYrisedronate sodium (150 mg) (tablet) 2 QL: 1 IN 30 DAYSrisedronate sodium (30 mg) (tablet) 2 QL: 1 IN 1 DAYrisedronate sodium (35 mg) (tablet dr) 2 QL: 1 IN 7 DAYSrisedronate sodium (35 mg) (tablet) 2 QL: 1 IN 7 DAYSrisedronate sodium (5 mg) (tablet) 2 QL: 1 IN 1 DAY

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCERCINACALCET HCL SENSIPAR 3

GROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOMAVERT 3

GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGSTESAMORELIN ACETATE EGRIFTA 3 PA

GROWTH HORMONESSOMATROPIN GENOTROPIN 3 PA, AGE: <= 18 YEARS



Drug Name Tier Requirements/LimitsSOMATROPIN HUMATROPE 3 PA, AGE: <= 18 YEARS

SOMATROPIN NORDITROPINFLEXPRO 3 PA, AGE: <= 18 YEARS

SOMATROPIN NUTROPIN AQNUSPIN 3 PA, AGE: <= 18 YEARS

SOMATROPIN OMNITROPE 3 PA, AGE: <= 18 YEARSSOMATROPIN SAIZEN 3 PA, AGE: <= 18 YEARS

SOMATROPIN SAIZEN-SAIZENPREP 3 PA, AGE: <= 18 YEARS

SOMATROPIN SEROSTIM 3 PA, AGE: <= 18 YEARSSOMATROPIN ZOMACTON 3 PA, AGE: <= 18 YEARSSOMATROPIN ZORBTIVE 3 PA, AGE: <= 18 YEARS

HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPEdoxercalciferol 2paricalcitol 2

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONESMECASERMIN INCRELEX 5 PA

LEPTIN HORMONE ANALOGSMETRELEPTIN MYALEPT 3 QL: 1 IN 1 DAY

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSLEUPROLIDE ACETATE LUPRON DEPOT 3

LEUPROLIDE ACETATE LUPRON DEPOT(LUPANETA) 3

NAFARELIN ACETATE SYNAREL 3LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS

CETRORELIX ACETATE CETROTIDE 3GANIRELIX ACETATE 3

LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY

LEUPROLIDE ACETATE LUPRON DEPOT-PED 3

PITUITARY SUPPRESSIVE AGENTScabergoline DOSTINEX 2danazol DANOCRINE 2ENDOCRINE DISORDER - THYROID

ANTITHYROID PREPARATIONSmethimazole TAPAZOLE 1propylthiouracil 1

THYROID HORMONESLEVOTHYROXINE SODIUM LEVO-T 3levothyroxine sodium 1LEVOTHYROXINE SODIUM LEVOXYL 3LEVOTHYROXINE SODIUM SYNTHROID 3LEVOTHYROXINE SODIUM TIROSINT 3LEVOTHYROXINE SODIUM UNITHROID 3LIOTHYRONINE SODIUM CYTOMEL 4liothyronine sodium (25 mcg) (tablet) 1liothyronine sodium (5 mcg) (tablet) 1liothyronine sodium (50 mcg) (tablet) 2LIOTRIX THYROLAR-1 3



Drug Name Tier Requirements/LimitsLIOTRIX THYROLAR-1/2 3LIOTRIX THYROLAR-1/4 3LIOTRIX THYROLAR-2 3LIOTRIX THYROLAR-3 3

THYROID,PORK ARMOURTHYROID 3

thyroid,pork (113.75 mg) (tablet) 3thyroid,pork (120 mg) (tablet) 1thyroid,pork (130 mg) (tablet) 1thyroid,pork (146.25 mg) (tablet) 3thyroid,pork (15 mg) (tablet) 1thyroid,pork (16.25 mg) (tablet) 1thyroid,pork (162.5 mg) (tablet) 3thyroid,pork (195 mg) (tablet) 3thyroid,pork (260 mg) (tablet) 3thyroid,pork (30 mg) (tablet) 1thyroid,pork (32.5 mg) (tablet) 1thyroid,pork (325 mg) (tablet) 3thyroid,pork (48.75 mg) (tablet) 3thyroid,pork (60 mg) (tablet) 1thyroid,pork (65 mg) (tablet) 1thyroid,pork (81.25 mg) (tablet) 3thyroid,pork (90 mg) (tablet) 1thyroid,pork (97.5 mg) (tablet) 3EYE - GENERAL DISORDERS

EYE ANTIBIOTIC-CORTICOID COMBINATIONSGENTAMICIN SULF/PREDNISOLONE PRED-G 3neomycin/bacit/p-myx/hydrocort 2neomycin/polymyxin b/dexametha 2

tobramycin/dexamethasoneTOBRADEX (0.3%-0.1%) (DROPSSUSP)

2

TOBRAMYCIN/DEXAMETHASONETOBRADEX (0.3%-0.1%) (OINT.(G))

3

TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 3TOBRAMYCIN/LOTEPRED ETAB ZYLET 3

EYE ANTIHISTAMINESazelastine hcl OPTIVAR 2BEPOTASTINE BESILATE BEPREVE 3 QL: 10mL IN 30 DAYSEMEDASTINE DIFUMARATE EMADINE 3 QL: 10mL IN 30 DAYSepinastine hcl ELESTAT 2olopatadine hcl PATADAY 2 QL: 3mL IN 30 DAYSolopatadine hcl PATANOL 2OLOPATADINE HCL PAZEO 3 QL: 2.5mL IN 30 DAYS

EYE ANTIINFLAMMATORY AGENTSbromfenac sodium 2BROMFENAC SODIUM PROLENSA 4DEXAMETHASONE MAXIDEX 3



Drug Name Tier Requirements/LimitsDIFLUPREDNATE DUREZOL 4fluorometholone FML 2FLUOROMETHOLONE FML FORTE 3FLUOROMETHOLONE FML S.O.P. 3FLUOROMETHOLONE ACETATE FLAREX 3flurbiprofen sodium OCUFEN 2ketorolac tromethamine ACULAR 2ketorolac tromethamine ACULAR LS 2KETOROLAC TROMETHAMINE/PF ACUVAIL 3LOTEPREDNOL ETABONATE ALREX 3LOTEPREDNOL ETABONATE LOTEMAX 3NEPAFENAC ILEVRO 3NEPAFENAC NEVANAC 3prednisolone acetate OMNIPRED 2prednisolone acetate PRED FORTE 2PREDNISOLONE ACETATE PRED MILD 3

EYE ANTIVIRALSGANCICLOVIR ZIRGAN 3trifluridine VIROPTIC 2

EYE LOCAL ANESTHETICS

benoxinate hcl/fluorescein sod FLUORESCEIN-BENOXINATE 2

benoxinate hcl/fluorescein sod FLURESS 2benoxinate hcl/fluorescein sod FLUROX 2LIDOCAINE HCL/PF AKTEN 3proparacaine hcl 2

EYE SULFONAMIDES

sulfacetamide sodiumSODIUMSULAMYD (10%) (DROPS)

2

SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE 3

SULFACETAMIDE/PREDNISOLONE BLEPHAMIDES.O.P. 3

sulfacetamide/prednisolone sp 2EYE VASOCONSTRICTORS (RX ONLY)

phenylephrine hcl 2OPHTHALMIC ANTIBIOTICS

AZITHROMYCIN AZASITE 3bacitracin 2bacitracin/polymyxin b sulfate 2BESIFLOXACIN HCL BESIVANCE 3

ciprofloxacin hcl CILOXAN (0.3 %)(DROPS) 2

CIPROFLOXACIN HCL CILOXAN (0.3 %)(OINT. (G)) 3

erythromycin base ILOTYCIN 2gatifloxacin ZYMAXID 2gentamicin sulfate GARAMYCIN 2gentamicin sulfate GENTAK 2



Drug Name Tier Requirements/Limitsmoxifloxacin hcl VIGAMOX 2NATAMYCIN NATACYN 3neomycin sulf/bacitracin/poly NEO-POLYCIN 2neomycin/polymyxn b/gramicidin NEOSPORIN 2ofloxacin OCUFLOX 2polymyxin b sulf/trimethoprim POLYTRIM 2

tobramycin TOBREX (0.3 %)(DROPS) 2

TOBRAMYCIN TOBREX (0.3 %)(OINT. (G)) 3

OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPECYCLOSPORINE RESTASIS 3 QL: 60 IN 30 DAYS

CYCLOSPORINE RESTASISMULTIDOSE 3 QL: 5.5mL IN 30 DAYS

LIFITEGRAST XIIDRA 3 QL: 60 IN 30 DAYSOPHTHALMIC MAST CELL STABILIZERS

cromolyn sodium OPTICROM 2LODOXAMIDE TROMETHAMINE ALOMIDE 3NEDOCROMIL SODIUM ALOCRIL 3EYE - GLAUCOMA

CARBONIC ANHYDRASE INHIBITORSacetazolamide 2methazolamide NEPTAZANE 2

MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS

apraclonidine hcl IOPIDINE (0.5 %)(DROPS) 2

APRACLONIDINE HCL IOPIDINE (1 %)(DROPERETTE) 3

betaxolol hcl BETOPTIC 2BETAXOLOL HCL BETOPTIC S 4

BIMATOPROST LUMIGAN (0.01%) (DROPS) 3 QL: 1mL IN 12 DAYS

brimonidine tartrate ALPHAGAN 2

BRIMONIDINE TARTRATE ALPHAGAN P(0.1 %) (DROPS) 3

brimonidine tartrate ALPHAGAN P(0.15 %) (DROPS) 2

BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN 4BRINZOLAMIDE AZOPT 3BRINZOLAMIDE/BRIMONIDINE TART SIMBRINZA 4carteolol hcl OCUPRESS 2dorzolamide hcl TRUSOPT 2dorzolamide hcl/timolol maleat COSOPT 2dorzolamide/timolol/pf (2 %-0.5 %)(droperette) 2 QL: 2 IN 1 DAY

ECHOTHIOPHATE IODIDE PHOSPHOLINEIODIDE 3

latanoprost XALATAN 2levobunolol hcl BETAGAN 2



Drug Name Tier Requirements/Limitsmetipranolol OPTIPRANOLOL 2

pilocarpine hcl ISOPTOCARPINE 2

TAFLUPROST/PF ZIOPTAN 3 QL: 1 IN 1 DAYTIMOLOL BETIMOL 3timolol maleate ISTALOL 2timolol maleate TIMOPTIC 2timolol maleate TIMOPTIC-XE 2

TIMOLOL MALEATE/PF TIMOPTICOCUDOSE 2 QL: 2 IN 1 DAY

TRAVOPROST TRAVATAN Z 3 QL: 1mL IN 12 DAYSMYDRIATICS

atropine sulfate ISOPTOATROPINE 2

cyclopentolate hcl CYCLOGYL 2CYCLOPENTOLATE/PHENYLEPHRINE CYCLOMYDRIL 3

homatropine hbr ISOPTOHOMATROPINE 2

tropicamide MYDRIACYL 2OPHTHALMIC ANTIFIBROTIC AGENTS

MITOMYCIN MITOSOL 3EYE - MISCELLANEOUS

ARTIFICIAL TEARSHYDROXYPROPYL CELLULOSE LACRISERT 3

EYE PREPARATIONS, MISCELLANEOUS (OTC)GELATIN GELFILM 3

OPHTHALMIC CYSTINE DEPLETING AGENTSCYSTEAMINE HCL CYSTARAN 3 PAFLUID REPLACEMENT

NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTSURIDINE TRIACETATE XURIDEN 5 PAGOUT AND RELATED DISEASES

COLCHICINEcolchicine COLCRYS 2 QL: 4 IN 1 DAYcolchicine MITIGARE 2 QL: 2 IN 1 DAYprobenecid/colchicine 1

HYPERURICEMIA TX - PURINE INHIBITORSallopurinol ZYLOPRIM 1FEBUXOSTAT ULORIC 3 ST, QL: 1 IN 1 DAY

URICOSURIC AGENTSprobenecid BENEMID 1HEMATOLOGICAL DISORDERS

ANTICOAGULANTS,COUMARIN TYPEWARFARIN SODIUM COUMADIN 3warfarin sodium 1

ANTIFIBRINOLYTIC AGENTStranexamic acid LYSTEDA 2



Drug Name Tier Requirements/LimitsDIRECT FACTOR XA INHIBITORS

APIXABAN ELIQUIS (2.5MG) (TABLET) 3 QL: 2 IN 1 DAY

APIXABAN ELIQUIS (5 MG)(TABLET) 3 QL: 74 IN 30 DAYS

EDOXABAN TOSYLATE SAVAYSA 3 QL: 1 IN 1 DAY

RIVAROXABAN XARELTO (10MG) (TABLET) 3 QL: 1 IN 1 DAY


RIVAROXABANXARELTO (15MG-20MG) (TABDS PK)

3 QL: 51 IN 30 DAYS


HEMATINICS,OTHER

DARBEPOETIN ALFA IN POLYSORBAT ARANESP (100MCG/ML) (VIAL) 3 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP(100MCG/0.5)(SYRINGE)

3 PA


3 PA


3 PA



3 PA



3 PA



3 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP (40MCG/0.4)(SYRINGE)

3 PA


DARBEPOETIN ALFA IN POLYSORBATARANESP (500MCG/ML)(SYRINGE)

3 PA




DARBEPOETIN ALFA IN POLYSORBATARANESP (60MCG/0.3)(SYRINGE)

3 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP(60MCG/ML)(VIAL)

3 PA

EPOETIN ALFA EPOGEN 3 PAEPOETIN ALFA PROCRIT 3 PA

HEMORRHEOLOGIC AGENTSpentoxifylline TRENTAL 1

HEPARIN AND RELATED PREPARATIONS

DALTEPARIN SODIUM,PORCINEFRAGMIN(10000/ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINEFRAGMIN(12500/0.5)(SYRINGE)






DALTEPARIN SODIUM,PORCINEFRAGMIN(2500/0.2ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINEFRAGMIN(25000/ML)(VIAL)






enoxaparin sodiumLOVENOX (100MG/ML)(SYRINGE)


enoxaparin sodiumLOVENOX(120MG/.8ML)(SYRINGE)


enoxaparin sodiumLOVENOX (150MG/ML)(SYRINGE)


enoxaparin sodiumLOVENOX(300MG/3ML)(VIAL)


enoxaparin sodiumLOVENOX(30MG/0.3ML)(SYRINGE)











fondaparinux sodiumARIXTRA(10MG/0.8ML)(SYRINGE)


fondaparinux sodiumARIXTRA (2.5MG/0.5)(SYRINGE)


fondaparinux sodiumARIXTRA(5MG/0.4ML)(SYRINGE)


fondaparinux sodiumARIXTRA(7.5MG/0.6)(SYRINGE)


heparin sodium,porcine (1000/ml) (vial) 2heparin sodium,porcine (10000/ml) (vial) 2heparin sodium,porcine (20000/ml) (vial) 2heparin sodium,porcine (5000/ml(1))(cartridge) 2

heparin sodium,porcine (5000/ml) (syringe) 2heparin sodium,porcine (5000/ml) (vial) 2heparin sodium,porcine/pf (1000/ml) (vial) 2heparin sodium,porcine/pf (5000/0.5ml)(syringe) 2

LEUKOCYTE (WBC) STIMULANTSFILGRASTIM NEUPOGEN 3 PAPEGFILGRASTIM NEULASTA 3 PATBO-FILGRASTIM GRANIX 3 PA

PLATELET AGGREGATION INHIBITORSaspirin/dipyridamole AGGRENOX 2cilostazol PLETAL 1

clopidogrel bisulfate PLAVIX (300MG) (TABLET) 1 QL: 4 IN 30 DAYS

clopidogrel bisulfate PLAVIX (75 MG)(TABLET) 1

dipyridamole PERSANTINE 1prasugrel hcl EFFIENT 2 QL: 1 IN 1 DAYTICAGRELOR BRILINTA 4 QL: 2 IN 1 DAYVORAPAXAR SULFATE ZONTIVITY 3 QL: 1 IN 1 DAY

PLATELET REDUCING AGENTSanagrelide hcl AGRYLIN 2

SICKLE CELL ANEMIA AGENTSHYDROXYUREA DROXIA 3



Drug Name Tier Requirements/LimitsTHROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLE

DABIGATRAN ETEXILATE MESYLATE PRADAXA 3 QL: 2 IN 1 DAYVITAMIN K PREPARATIONS

phytonadione (vit k1) (5 mg) (tablet) 1HORMONAL DEFICIENCY

ANDROGENIC AGENTSmethyltestosterone ANDROID 2 PAMETHYLTESTOSTERONE METHITEST 3 PAmethyltestosterone TESTRED 2 PAoxandrolone OXANDRIN 2 PAOXYMETHOLONE ANADROL-50 3 PATESTOSTERONE ANDRODERM 4 PA

TESTOSTERONEANDROGEL(1.25G-1.62)(GEL PACKET)

4 PA

testosteroneANDROGEL(12.5/1.25G) (GELMD PMP)

2 PA

TESTOSTERONEANDROGEL(2.5G-1.62%)(GEL PACKET)

4 PA

TESTOSTERONEANDROGEL(20.25/1.25) (GELMD PMP)

4 PA

testosteroneANDROGEL(25MG(1%))(GEL PACKET)

2 PA

testosteroneANDROGEL (50MG (1%)) (GELPACKET)

2 PA

testosterone FORTESTA 2 PATESTOSTERONE STRIANT 3 PAtestosterone TESTIM 2 PAtestosterone VOGELXO 2 PA

testosterone cypionate DEPO-TESTOSTERONE 2 PA

testosterone enanthate DELATESTRYL 2 PAESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB

DROSPIRENONE/ESTRADIOL ANGELIQ 3ESTROGEN/ANDROGEN COMBINATIONS

estrogen,ester/me-testosterone COVARYX 2estrogen,ester/me-testosterone COVARYX H.S. 2

ESTROGENIC AGENTSESTRADIOL ALORA 3 QL: 2 IN 7 DAYSestradiol CLIMARA 2 QL: 1 IN 7 DAYSESTRADIOL DIVIGEL 3ESTRADIOL ELESTRIN 4estradiol ESTRACE 1ESTRADIOL ESTROGEL 3ESTRADIOL EVAMIST 4



Drug Name Tier Requirements/LimitsESTRADIOL MENOSTAR 3 QL: 1 IN 7 DAYS

ESTRADIOLMINIVELLE(.025MG/24H)(PATCH TDSW)

4 QL: 2 IN 7 DAYS

ESTRADIOLMINIVELLE(.0375MG/24)(PATCH TDSW)

4 QL: 2 IN 7 DAYS

ESTRADIOLMINIVELLE(.075MG/24H)(PATCH TDSW)

4 QL: 2 IN 7 DAYS

ESTRADIOLMINIVELLE(0.05MG/24H)(PATCH TDSW)

4 QL: 2 IN 7 DAYS

ESTRADIOLMINIVELLE(0.1MG/24HR)(PATCH TDSW)

4 QL: 2 IN 7 DAYS

estradiol VIVELLE-DOT 2 QL: 2 IN 7 DAYS

ESTRADIOL CYPIONATE DEPO-ESTRADIOL 3

ESTRADIOL/LEVONORGESTREL CLIMARA PRO 4 QL: 1 IN 7 DAYSestradiol/norethindrone acet ACTIVELLA 2ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 3 QL: 2 IN 7 DAYSESTRADIOL/NORGESTIMATE PREFEST 3ESTROGEN,CON/M-PROGEST ACET PREMPHASE 3ESTROGEN,CON/M-PROGEST ACET PREMPRO 3ESTROGENS, CONJUGATED PREMARIN 3ESTROGENS,ESTERIFIED MENEST 3estropipate ORTHO-EST 2norethindrone ac-eth estradiol FEMHRT 2norethindrone ac-eth estradiol JEVANTIQUE 2norethindrone ac-eth estradiol JEVANTIQUE LO 2

PROGESTATIONAL AGENTSmedroxyprogesterone acetate PROVERA 1norethindrone acetate AYGESTIN 2progesterone 2PROGESTERONE, MICRONIZED CRINONE 3progesterone, micronized PROMETRIUM 2IMMUNIZATION

ANTISERARHO(D) IMMUNE GLOBULIN HYPERRHO S-D 3

RHO(D) IMMUNE GLOBULINMICRHOGAMULTRA-FILTERED PLUS

3

RHO(D) IMMUNE GLOBULINRHOGAMULTRA-FILTERED PLUS

3

RHO(D) IMMUNE GLOBULIN RHOPHYLAC 3RHO(D) IMMUNE GLOBULIN/MALTOSE WINRHO SDF 3




IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS

ALDESLEUKIN PROLEUKIN 3imiquimod ALDARA 2 QL: 24 IN 30 DAYS

IMIQUIMODZYCLARA (2.5%) (CRM MDPMP)


IMIQUIMODZYCLARA (3.75%) (CREAMPACK)

3 QL: 1 IN 1 DAY

imiquimodZYCLARA (3.75%) (CRM MDPMP)


INTERFERON ALFA-2B,RECOMB. INTRON A 3 PAINTERFERON ALFA-N3 ALFERON N 3INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE 5 PA

IMMUNOSUPPRESSIVESAZATHIOPRINE AZASAN 3azathioprine IMURAN 1cyclosporine 2CYCLOSPORINE SANDIMMUNE 4cyclosporine, modified 2CYCLOSPORINE, MODIFIED NEORAL 4EVEROLIMUS ZORTRESS 3

mycophenolate mofetilCELLCEPT (200MG/ML) (SUSPRECON)

2

mycophenolate mofetil CELLCEPT (250MG) (CAPSULE) 1

mycophenolate mofetil CELLCEPT (500MG) (TABLET) 1

mycophenolate sodium MYFORTIC 2

SIROLIMUS RAPAMUNE (0.5MG) (TABLET) 4

SIROLIMUS RAPAMUNE (1MG) (TABLET) 4

SIROLIMUSRAPAMUNE (1MG/ML)(SOLUTION)

3

SIROLIMUS RAPAMUNE (2MG) (TABLET) 4

sirolimus 2TACROLIMUS ASTAGRAF XL 3TACROLIMUS ENVARSUS XR 3TACROLIMUS PROGRAF 3tacrolimus 2




INFECTIOUS DISEASE - BACTERIALABSORBABLE SULFONAMIDES

sulfamethoxazole/trimethoprim (200-40mg/5)(oral susp) 2

sulfamethoxazole/trimethoprim (400mg-80mg) (tablet) 1

sulfamethoxazole/trimethoprim (800-160 mg)(tablet) 1

sulfamethoxazole/trimethoprim (800-160/20)(oral susp) 2

BETALACTAMSAZTREONAM LYSINE CAYSTON 5 PA

CEPHALOSPORINS - 1ST GENERATION

cefadroxil DURICEF (1 G)(TABLET) 2

cefadroxil DURICEF (500MG) (CAPSULE) 1

cephalexinKEFLEX (125MG/5ML) (SUSPRECON)

2

cephalexin KEFLEX (250MG) (CAPSULE) 1

cephalexinKEFLEX (250MG/5ML) (SUSPRECON)

2



CEPHALOSPORINS - 2ND GENERATION

cefaclor CECLOR (250MG) (CAPSULE) 2

cefaclor CECLOR (500MG) (CAPSULE) 2

cefaclor CECLOR CD 2cefprozil CEFZIL 2cefuroxime axetil CEFTIN 2

CEPHALOSPORINS - 3RD GENERATIONcefdinir OMNICEF 2cefditoren pivoxil SPECTRACEF 2

cefiximeSUPRAX (100MG/5ML) (SUSPRECON)

2

cefiximeSUPRAX (200MG/5ML) (SUSPRECON)

2

CEFIXIMESUPRAX (500MG/5ML) (SUSPRECON)

4




cefpodoxime proxetil VANTIN (100MG) (TABLET) 2

cefpodoxime proxetil VANTIN (200MG) (TABLET) 2

CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.meth/meblue/sod phos/psal/hyos 2METH/MEBLUE/SOD PHOS/PSAL/HYOS PHOSPHASAL 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URETRON D-S 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URIN D.S. 2methen/mblue/sal/sod phos/hyos 2methenam/m.blue/salicyl/hyoscy 2methenam/sod phos/mblue/hyoscy URYL 2METHENAM/SODPHOS/MBLUE/HYOSCY UTA 4

methenamine hippurate HIPREX 2

methenamine mandelate MANDELAMINE(1 G) (TABLET) 2

TRIMETHOPRIM PRIMSOL 3trimethoprim PROLOPRIM 2TRIMETHOPRIM TRIMPEX 3

MACROLIDES

azithromycin ZITHROMAX (1G) (PACKET) 2

azithromycinZITHROMAX(100 MG/5ML)(SUSP RECON)

2

azithromycinZITHROMAX(200 MG/5ML)(SUSP RECON)

2

azithromycinZITHROMAX(250 MG)(TABLET)

1


1


1

azithromycin ZITHROMAXTRI-PAK 1

clarithromycin BIAXIN 2clarithromycin BIAXIN XL 2ERYTHROMYCIN BASE ERY-TAB 3erythromycin base (250 mg) (tablet dr) 2erythromycin base (500 mg) (tablet dr) 2ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 4ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 4ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 3erythromycin ethylsuccinate 2FIDAXOMICIN DIFICID 3 QL: 20 IN 30 DAYS



Drug Name Tier Requirements/LimitsNITROFURAN DERIVATIVES

nitrofurantoin FURADANTIN 2nitrofurantoin macrocrystal MACRODANTIN 2nitrofurantoin monohyd/m-cryst MACROBID 2

OXAZOLIDINONESlinezolid ZYVOX 2

PENICILLINS

amoxicillinAMOXIL (125MG/5ML) (SUSPRECON)

1


1

amoxicillin AMOXIL (250MG) (CAPSULE) 1

amoxicillinAMOXIL (250MG) (TABCHEW)

1


1


1

amoxicillin AMOXIL (500MG) (CAPSULE) 1

amoxicillin AMOXIL (500MG) (TABLET) 1

amoxicillin AMOXIL (875MG) (TABLET) 1

AMOXICILLIN MOXATAG 4

AMOXICILLIN/POTASSIUM CLAVAUGMENTIN(125-31.25/)(SUSP RECON)

4

amoxicillin/potassium clavAUGMENTIN(200-28.5/5)(SUSP RECON)

2

amoxicillin/potassium clavAUGMENTIN(200-28.5MG)(TAB CHEW)

2

amoxicillin/potassium clavAUGMENTIN(250-125 MG)(TABLET)

2

amoxicillin/potassium clavAUGMENTIN(250-62.5/5)(SUSP RECON)

2

amoxicillin/potassium clavAUGMENTIN(400-57MG/5)(SUSP RECON)

2





2


2

amoxicillin/potassium clav AUGMENTINES-600 2

amoxicillin/potassium clav AUGMENTIN XR 2ampicillin trihydrate AMPICILLIN 1dicloxacillin sodium PATHOCIL 1penicillin v potassium 1

penicillin v potassiumVEETIDS (125MG/5ML) (SOLNRECON)

2

penicillin v potassium VEETIDS (250MG) (TABLET) 1

penicillin v potassiumVEETIDS (250MG/5ML) (SOLNRECON)

2

QUINOLONESCIPROFLOXACIN CIPRO 4ciprofloxacin 2ciprofloxacin hcl CIPRO 2ciprofloxacin/ciprofloxa hcl CIPRO XR 2DELAFLOXACIN MEGLUMINE BAXDELA 3 PAGEMIFLOXACIN MESYLATE FACTIVE 3

levofloxacin LEVAQUIN (250MG) (TABLET) 1

levofloxacinLEVAQUIN(250MG/10ML)(SOLUTION)

2



moxifloxacin hcl AVELOX 2

moxifloxacin hcl AVELOX ABCPACK 2

TETRACYCLINESdoxycycline hyclate ACTICLATE 2 QL: 2 IN 1 DAYdoxycycline hyclate MORGIDOX 2 QL: 2 IN 1 DAYdoxycycline hyclate TARGADOX 2 QL: 4 IN 1 DAYdoxycycline hyclate VIBRAMYCIN 2 QL: 2 IN 1 DAYdoxycycline hyclate VIBRA-TABS 2 QL: 2 IN 1 DAYdoxycycline monohydrate ADOXA 1 QL: 2 IN 1 DAYdoxycycline monohydrate AVIDOXY 1 QL: 2 IN 1 DAYdoxycycline monohydrate MONODOX 1 QL: 2 IN 1 DAYdoxycycline monohydrate ORACEA 2 QL: 1 IN 1 DAYdoxycycline monohydrate VIBRAMYCIN 2



Drug Name Tier Requirements/LimitsDOXYCYCLINE/BENZOYL PEROXIDE BENZODOX 30 3 QL: 1 IN 30 DAYSDOXYCYCLINE/BENZOYL PEROXIDE BENZODOX 60 3 QL: 1 IN 30 DAYSDOXYCYCLINE/SALICY/OCT/ZINC OX AVIDOXY DK 3 QL: 1 IN 30 DAYSminocycline hcl (100 mg) (capsule) 1minocycline hcl (100 mg) (tablet) 2minocycline hcl (135 mg) (tab er 24h) 2 QL: 1 IN 1 DAYminocycline hcl (45 mg) (tab er 24h) 2 QL: 1 IN 1 DAYminocycline hcl (50 mg) (capsule) 1minocycline hcl (50 mg) (tablet) 2minocycline hcl (75 mg) (capsule) 1minocycline hcl (75 mg) (tablet) 2minocycline hcl (90 mg) (tab er 24h) 2 QL: 1 IN 1 DAYtetracycline hcl PANMYCIN 2tetracycline hcl SUMYCIN 2INFECTIOUS DISEASE - FUNGAL

ANTIFUNGAL AGENTSclotrimazole MYCELEX 1fluconazole DIFLUCAN 2flucytosine ANCOBON 2ISAVUCONAZONIUM SULFATE CRESEMBA 3ITRACONAZOLE ONMEL 3

itraconazoleSPORANOX (10MG/ML)(SOLUTION)

2

itraconazole SPORANOX (100MG) (CAPSULE) 2

ketoconazole NIZORAL 2MICONAZOLE ORAVIG 3

POSACONAZOLENOXAFIL (200MG/5ML) (ORALSUSP)

3

terbinafine hcl 1voriconazole VFEND 2

ANTIFUNGAL ANTIBIOTICSgriseofulvin ultramicrosize 2griseofulvin, microsize GRIFULVIN V 2nystatin (100000/ml) (oral susp) 2nystatin (500k unit) (tablet) 2INFECTIOUS DISEASE - MISCELLANEOUS

AMINOGLYCOSIDESneomycin sulfate 2TOBRAMYCIN BETHKIS 3 PA

TOBRAMYCIN TOBIPODHALER 5 PA

tobramycin in 0.225% sod chlor TOBI 2 PAtobramycin/nebulizer KITABIS PAK 2 PA

ANTILEPROTICSdapsone 2THALIDOMIDE THALOMID 5 PA, QL: 2 IN 1 DAY



Drug Name Tier Requirements/LimitsANTI-MYCOBACTERIUM AGENTS

AMINOSALICYLIC ACID PASER 3ethambutol hcl MYAMBUTOL 2ETHIONAMIDE TRECATOR 3isoniazid (100 mg) (tablet) 1isoniazid (300 mg) (tablet) 1pyrazinamide 2rifabutin MYCOBUTIN 2

ANTITUBERCULAR ANTIBIOTICSBEDAQUILINE FUMARATE SIRTURO 3 PAcycloserine SEROMYCIN 2RIFAMP/ISONIAZID/PYRAZINAMIDE RIFATER 3rifampin RIFADIN 1RIFAMPIN/ISONIAZID RIFAMATE 3RIFAPENTINE PRIFTIN 3

LINCOSAMIDESclindamycin hcl CLEOCIN HCL 1

clindamycin palmitate hcl CLEOCINPALMITATE 2

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS

RIFAXIMIN XIFAXAN (200MG) (TABLET) 3 QL: 9 PER FILL

RIFAXIMIN XIFAXAN (550MG) (TABLET) 3 PA

VANCOMYCIN AND DERIVATIVES

VANCOMYCIN HCLFIRVANQ (25MG/ML) (SOLNRECON)

3

vancomycin hcl (125 mg) (capsule) 2 QL: 40 IN 30 DAYSvancomycin hcl (250 mg) (capsule) 2 QL: 80 IN 30 DAYSINFECTIOUS DISEASE - PARASITIC

2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIALSECNIDAZOLE SOLOSEC 3 ST, QL: 1 IN 30 DAYStinidazole TINDAMAX 2

ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS

metronidazole FLAGYL (250MG) (TABLET) 1

metronidazole FLAGYL (500MG) (TABLET) 1

ANTHELMINTICS

albendazole ALBENZA (200MG) (TABLET) 2

ivermectin STROMECTOL 2MEBENDAZOLE EMVERM 3 PApraziquantel BILTRICIDE 2

ANTIMALARIAL DRUGSARTEMETHER/LUMEFANTRINE COARTEM 3atovaquone/proguanil hcl MALARONE 2chloroquine phosphate 2



Drug Name Tier Requirements/Limitshydroxychloroquine sulfate PLAQUENIL 2mefloquine hcl LARIAM 2PYRIMETHAMINE DARAPRIM 3 PAquinine sulfate QUALAQUIN 2

ANTIPARASITICSNITAZOXANIDE ALINIA 3

ANTIPROTOZOAL DRUGS,MISCELLANEOUSatovaquone MEPRON 2PENTAMIDINE ISETHIONATE NEBUPENT 3INFECTIOUS DISEASE - VIRAL

ANTIVIRALS, GENERALACYCLOVIR SITAVIG 3 QL: 4 IN 365 DAYS

acyclovir ZOVIRAX (200MG) (CAPSULE) 1

acyclovirZOVIRAX (200MG/5ML) (ORALSUSP)

2

acyclovir ZOVIRAX (400MG) (TABLET) 1

acyclovir ZOVIRAX (800MG) (TABLET) 1

famciclovir FAMVIR 2LETERMOVIR PREVYMIS 4 PA

oseltamivir phosphate TAMIFLU (30MG) (CAPSULE) 2 QL: 40 IN 183 DAYS


oseltamivir phosphateTAMIFLU (6MG/ML) (SUSPRECON)



rimantadine hcl FLUMADINE 2valacyclovir hcl VALTREX 2valganciclovir hcl VALCYTE 2ZANAMIVIR RELENZA 3 QL: 40 IN 183 DAYS

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB

DARUNAVIR ETHANOLATE PREZISTA (150MG) (TABLET) 3 QL: 8 IN 1 DAY




DARUNAVIR/COBICISTAT PREZCOBIX 3 QL: 1 IN 1 DAYTIPRANAVIR APTIVUS 3 QL: 4 IN 1 DAY

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGEMTRICITABINE/TENOFOV ALAFENAM DESCOVY 3 QL: 1 IN 1 DAYEMTRICITABINE/TENOFOVIR (TDF) TRUVADA 3 QL: 1 IN 1 DAY



Drug Name Tier Requirements/LimitsLAMIVUDINE/TENOFOVIR DISOP FUM CIMDUO 3 QL: 1 IN 1 DAY

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBabacavir sulfate/lamivudine EPZICOM 2 QL: 1 IN 1 DAYabacavir/lamivudine/zidovudine TRIZIVIR 2 QL: 2 IN 1 DAYlamivudine/zidovudine COMBIVIR 2 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.

MARAVIROC SELZENTRY (150MG) (TABLET) 3 QL: 2 IN 1 DAY




ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSENFUVIRTIDE FUZEON 3 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIDELAVIRDINE MESYLATE RESCRIPTOR 3efavirenz SUSTIVA 2

ETRAVIRINE INTELENCE (100MG) (TABLET) 3 QL: 4 IN 1 DAY



nevirapine VIRAMUNE (200MG) (TABLET) 2 QL: 2 IN 1 DAY

nevirapineVIRAMUNE (50MG/5 ML)(ORAL SUSP)


nevirapineVIRAMUNE XR(100 MG) (TABER 24H)

2 QL: 3 IN 1 DAY

nevirapineVIRAMUNE XR(400 MG) (TABER 24H)

2 QL: 1 IN 1 DAY

RILPIVIRINE HCL EDURANT 3 QL: 1 IN 1 DAYANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI

abacavir sulfateZIAGEN (20MG/ML)(SOLUTION)


abacavir sulfate ZIAGEN (300MG) (TABLET) 2 QL: 2 IN 1 DAY

DIDANOSINE VIDEX 3 QL: 600mL IN 30 DAYS

didanosineVIDEX EC (125MG) (CAPSULEDR)

2 QL: 2 IN 1 DAY


2 QL: 2 IN 1 DAY





2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY

EMTRICITABINE EMTRIVA (200MG) (CAPSULE) 3 QL: 1 IN 1 DAY

lamivudineEPIVIR (10MG/ML)(SOLUTION)


lamivudine EPIVIR (150 MG)(TABLET) 2 QL: 2 IN 1 DAY

lamivudine EPIVIR (300 MG)(TABLET) 2 QL: 1 IN 1 DAY

STAVUDINEZERIT (1MG/ML) (SOLNRECON)


stavudine ZERIT (15 MG)(CAPSULE) 2 QL: 2 IN 1 DAY




zidovudineRETROVIR (10MG/ML)(SYRUP)


zidovudine RETROVIR (100MG) (CAPSULE) 2 QL: 6 IN 1 DAY

zidovudine RETROVIR (300MG) (TABLET) 2 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI

TENOFOVIR DISOPROXIL FUMARATE VIREAD (150MG) (TABLET) 3 QL: 1 IN 1 DAY



tenofovir disoproxil fumarate VIREAD (300MG) (TABLET) 2 QL: 1 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS

atazanavir sulfate REYATAZ (150MG) (CAPSULE) 2 QL: 2 IN 1 DAY



ATAZANAVIR SULFATE/COBICISTAT EVOTAZ 3 QL: 1 IN 1 DAY




fosamprenavir calcium LEXIVA (700MG) (TABLET) 2 QL: 4 IN 1 DAY

INDINAVIR SULFATE CRIXIVAN 3NELFINAVIR MESYLATE VIRACEPT 3

ritonavir NORVIR (100MG) (TABLET) 2 QL: 12 IN 1 DAY

RITONAVIRNORVIR (80MG/ML)(SOLUTION)


SAQUINAVIR MESYLATE INVIRASE (200MG) (CAPSULE) 3 QL: 10 IN 1 DAY

ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTRDOLUTEGRAVIR SODIUM TIVICAY 3 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (400MG) (TABLET) 3 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS HD 3 QL: 2 IN 1 DAYARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI

EFAVIRENZ/EMTRICIT/TENOFOVR DF ATRIPLA 3 QL: 1 IN 1 DAYEFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI 3 QL: 1 IN 1 DAYEFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI LO 3 QL: 1 IN 1 DAYEMTRICITA/RILPIVIRINE/TENOF DF COMPLERA 3 QL: 1 IN 1 DAYEMTRICITAB/RILPIVIRI/TENOF ALA ODEFSEY 3 QL: 1 IN 1 DAY

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORBICTEGRAV/EMTRICIT/TENOFOV ALA BIKTARVY 3 QL: 1 IN 1 DAYELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 3 QL: 1 IN 1 DAYELVITEG/COB/EMTRI/TENOFO DISOP STRIBILD 3 QL: 1 IN 1 DAY

ARV COMB-NRTIS & INTEGRASE INHIBITORABACAVIR/DOLUTEGRAVIR/LAMIVUDI TRIUMEQ 3 QL: 1 IN 1 DAY

CYTOCHROME P450 INHIBITORSCOBICISTAT TYBOST 3 QL: 1 IN 1 DAY

HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBOSOFOSBUVIR/VELPATAS/VOXILAPREV VOSEVI 3 PA

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.LEDIPASVIR/SOFOSBUVIR HARVONI 3 PASOFOSBUVIR/VELPATASVIR EPCLUSA 3 PA

HEPATITIS B TREATMENT AGENTSadefovir dipivoxil HEPSERA 2 QL: 1 IN 1 DAY

entecavirBARACLUDE(0.5 MG)(TABLET)

2 QL: 1 IN 1 DAY

entecavir BARACLUDE (1MG) (TABLET) 2 QL: 1 IN 1 DAY

lamivudine EPIVIR HBV (100MG) (TABLET) 2 QL: 1 IN 1 DAY

TENOFOVIR ALAFENAMIDEFUMARATE VEMLIDY 3 QL: 1 IN 1 DAY

HEPATITIS C TREATMENT AGENTSPEGINTERFERON ALFA-2A PEGASYS 3 PA

PEGINTERFERON ALFA-2A PEGASYSPROCLICK 3 PA



Drug Name Tier Requirements/LimitsPEGINTERFERON ALFA-2B PEGINTRON 3 PARIBAVIRIN REBETOL 3ribavirin (200 mg) (capsule) 2ribavirin (200 mg) (tablet) 2ribavirin (200-400 mg) (tab ds pk) 2ribavirin (200-400(7)) (tab ds pk) 2ribavirin (400 mg) (tablet) 2ribavirin (400-400 mg) (tab ds pk) 2ribavirin (400-400(7)) (tab ds pk) 2ribavirin (600 mg) (tablet) 2ribavirin (600-400 mg) (tab ds pk) 2ribavirin (600-400(7)) (tab ds pk) 2ribavirin (600-600 mg) (tab ds pk) 4ribavirin (600-600(7)) (tab ds pk) 4

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBGLECAPREVIR/PIBRENTASVIR MAVYRET 3 PAINFLAMMATORY DISEASE

ANTI-ARTHRITIC AND CHELATING AGENTSPENICILLAMINE CUPRIMINE 3 PAPENICILLAMINE DEPEN 3 PA

ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTSMETHOTREXATE/PF OTREXUP 3 QL: 1.6mL IN 28 DAYS

METHOTREXATE/PFRASUVO(10MG/0.2ML)(AUTO INJCT)


METHOTREXATE/PFRASUVO(12.5/0.25) (AUTOINJCT)














METHOTREXATE/PFRASUVO(7.5MG/0.15)(AUTO INJCT)




Drug Name Tier Requirements/LimitsANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR

ADALIMUMAB HUMIRA 3 PA

ADALIMUMABHUMIRAPEDIATRICCROHN'S

3 PA

ADALIMUMABHUMIRA PEN(40MG/0.8ML)(PEN IJ KIT)

3 PA

ADALIMUMAB

HUMIRA PENCROHN-UC-HSSTARTER(40MG/0.8ML)(PEN IJ KIT)

3 PA

ADALIMUMAB

HUMIRA PENPSORIASIS-UVEITIS(40MG/0.8ML)(PEN IJ KIT)

3 PA

CERTOLIZUMAB PEGOL CIMZIA 3 PAETANERCEPT ENBREL 3 PAETANERCEPT ENBREL MINI 3 PA

ETANERCEPT ENBRELSURECLICK 3 PA

GOLIMUMAB SIMPONI 3 PAANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS

CANAKINUMAB/PF ILARIS 3 PAANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR

leflunomide ARAVA 2ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.

APREMILASTOTEZLA (10-20-30MG) (TAB DSPK)

3 PA

APREMILAST OTEZLA (30 MG)(TABLET) 4 PA

ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITORABATACEPT ORENCIA 3 PA

ABATACEPT ORENCIACLICKJECT 3 PA

C1 ESTERASE INHIBITORS

C1 ESTERASE INHIBITORHAEGARDA(2000 UNIT)(VIAL)

5 PA

GLUCOCORTICOIDSbudesonide ENTOCORT EC 2budesonide UCERIS 2dexamethasone (0.5 mg) (tablet) 1dexamethasone (0.5 mg/5ml) (solution) 2dexamethasone (0.75 mg) (tablet) 1dexamethasone (1 mg) (tablet) 1dexamethasone (1.5 mg) (tablet) 1



Drug Name Tier Requirements/Limitsdexamethasone (2 mg) (tablet) 1dexamethasone (4 mg) (tablet) 1dexamethasone (6 mg) (tablet) 1DEXAMETHASONE INTENSOL 3hydrocortisone CORTEF 1

methylprednisolone MEDROL (16MG) (TABLET) 1

METHYLPREDNISOLONE MEDROL (2 MG)(TABLET) 4

methylprednisolone MEDROL (32MG) (TABLET) 1

methylprednisolone MEDROL (4 MG)(TAB DS PK) 1

methylprednisolone MEDROL (4 MG)(TABLET) 1

methylprednisolone MEDROL (8 MG)(TABLET) 1

PREDNISOLONE MILLIPRED DP 3prednisolone ORAPRED 2prednisolone sod phosphate 2prednisone (1 mg) (tablet) 1prednisone (10 mg) (tablet) 1prednisone (2.5 mg) (tablet) 1prednisone (20 mg) (tablet) 1prednisone (5 mg) (tablet) 1prednisone (5 mg/5 ml) (solution) 1prednisone (50 mg) (tablet) 2PREDNISONE INTENSOL 3

GOLD SALTSAURANOFIN RIDAURA 3

IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB

BELIMUMABBENLYSTA (200MG/ML) (AUTOINJCT)

3 PA

BELIMUMABBENLYSTA (200MG/ML)(SYRINGE)

3 PA

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS

TOCILIZUMABACTEMRA (162MG/0.9)(SYRINGE)

3 PA

JANUS KINASE (JAK) INHIBITORS

TOFACITINIB CITRATE XELJANZ (5 MG)(TABLET) 3 PA

TOFACITINIB CITRATE XELJANZ XR 3 PAMINERALOCORTICOIDS

fludrocortisone acetate FLORINEF 1



Drug Name Tier Requirements/LimitsMONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB

USTEKINUMABSTELARA(45MG/0.5ML)(SYRINGE)

3 PA

USTEKINUMABSTELARA (90MG/ML)(SYRINGE)

3 PA

NSAID & TOPICAL IRRITANT COUNTER-IRRITANT COMB.

IBUPROFEN/IRR.COUNT-IRRIT.NO.2 COMFORT PAC-IBUPROFEN 3

MELOXICAM/IRRIT.CNTR-IRR CMB 2 COMFORT PAC-MELOXICAM 3

NAPROXEN/IRRITANT CNTR-IRRIT 2 COMFORT PAC-NAPROXEN 3

NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMBdiclofenac sodium/misoprostol ARTHROTEC 50 2diclofenac sodium/misoprostol ARTHROTEC 75 2

NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPEcelecoxib CELEBREX 2

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPEdiclofenac potassium CATAFLAM 1DICLOFENAC POTASSIUM ZIPSOR 3 QL: 4 IN 1 DAYdiclofenac sodium VOLTAREN 1diclofenac sodium VOLTAREN-XR 1DICLOFENAC SUBMICRONIZED ZORVOLEX 3 QL: 3 IN 1 DAYetodolac LODINE 2etodolac LODINE XL 2fenoprofen calcium FENORTHO 2fenoprofen calcium NALFON 2flurbiprofen ANSAID 2

ibuprofenMOTRIN (100MG/5ML) (ORALSUSP)

2

ibuprofen MOTRIN (400MG) (TABLET) 1



indomethacin INDOCIN (25MG) (CAPSULE) 1

INDOMETHACININDOCIN (25MG/5 ML)(ORAL SUSP)

3

indomethacin INDOCIN (50MG) (CAPSULE) 1

indomethacin INDOCIN SR 1INDOMETHACIN, SUBMICRONIZED TIVORBEX 3 QL: 3 IN 1 DAYketoprofen (50 mg) (capsule) 1ketoprofen (75 mg) (capsule) 1




ketorolac tromethamine TORADOL (10MG) (TABLET) 1

mefenamic acid 2

meloxicam MOBIC (15 MG)(TABLET) 1

meloxicam MOBIC (7.5 MG)(TABLET) 1

MELOXICAM, SUBMICRONIZED VIVLODEX 3 QL: 1 IN 1 DAYnabumetone RELAFEN 1naproxen EC-NAPROSYN 1

naproxenNAPROSYN (125MG/5ML) (ORALSUSP)

2

naproxen NAPROSYN (250MG) (TABLET) 1



naproxen sodium ANAPROX 2naproxen sodium ANAPROX DS 2

naproxen sodiumNAPRELAN (375MG) (TBMP24HR)

2

naproxen sodiumNAPRELAN (500MG) (TBMP24HR)

2

NAPROXEN SODIUMNAPRELAN (750MG) (TBMP24HR)

4

oxaprozin DAYPRO 2piroxicam FELDENE 2sulindac CLINORIL 1LOCAL ANESTHESIA

LOCAL ANESTHETICS

B-CAINE/ZINC CL/PINE/CETYLPYRD BUCALSEP(SOLUTION) 3

lidocaine hcl 2LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT

BOWEL ANTIINFLAMATORY AGENTSsulfadiazine 2

CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXMESALAMINE CANASA 3mesalamine SFROWASA 2mesalamine w/cleansing wipes ROWASA 2

DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATbalsalazide disodium COLAZAL 1MESALAMINE APRISO 3mesalamine ASACOL HD 2



Drug Name Tier Requirements/LimitsMESALAMINE DELZICOL 3mesalamine LIALDA 2MESALAMINE PENTASA 3OLSALAZINE SODIUM DIPENTUM 3sulfasalazine AZULFIDINE 1

HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTHhydrocortisone/lidocaine/aloe RECTAGEL HC 2hydrocortisone/pramoxine ANALPRAM HC 2hydrocortisone/pramoxine PRAMCORT 2

HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 3

IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTSELUXADOLINE VIBERZI 4 PA

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONISTLINACLOTIDE LINZESS 3 QL: 1 IN 1 DAY

LOCAL ANORECTAL NITRATE PREPARATIONSNITROGLYCERIN RECTIV 3

RECTAL PREPARATIONShydrocortisone acetate ANUSOL-HC 2hydrocortisone acetate HEMMOREX-HC 2hydrocortisone acetate PROCTOCORT 2

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)hydrocortisone CORTENEMA 2HYDROCORTISONE ACETATE CORTIFOAM 3LOWER GASTROINTESTINAL DISORDERS - OTHER

AMMONIA INHIBITORSACETOHYDROXAMIC ACID LITHOSTAT 3CARGLUMIC ACID CARBAGLU 5GLYCEROL PHENYLBUTYRATE RAVICTI 3 PAlactulose CHRONULAC 2sodium phenylbutyrate BUPHENYL 2

ANTIDIARRHEALSDIFENOXIN HCL/ATROPINE SULFATE MOTOFEN 3 QL: 8 IN 1 DAYdiphenoxylate hcl/atropine LOMOTIL 2loperamide hcl (2 mg) (capsule) 1opium tincture 2

BILE SALTSCHENODIOL CHENODAL 3CHOLIC ACID CHOLBAM 3 PAursodiol ACTIGALL 2ursodiol URSO 2ursodiol URSO FORTE 2

IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPEalosetron hcl LOTRONEX 2

LAXATIVES AND CATHARTICS

bisac/nacl/nahco3/kcl/peg 3350 HALFLYTELY-BISACODYL 2

lactulose CHRONULAC 2




lactulose KRISTALOSE (10G) (PACKET) 2

LACTULOSE KRISTALOSE (20G) (PACKET) 3

LUBIPROSTONE AMITIZA 3 QL: 2 IN 1 DAYPEG3350/SOD SUL/NACL/KCL/ASB/C MOVIPREP 3

peg3350/sod sulf,bicarb,cl/kclCOLYTE WITHFLAVORPACKETS

2

peg3350/sod sulf,bicarb,cl/kclGOLYTELY (236-22.74G) (SOLNRECON)

2

polyethylene glycol 3350MIRALAX(17G/DOSE)(POWDER)

2

SOD PHOSPHATE MBAS/SOD PHOS,DI OSMOPREP 3SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 3

sodium chloride/nahco3/kcl/pegNULYTELYWITH FLAVORPACKS

2

SODIUM, POTASSIUM,MAG SULFATES SUPREP 3NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING

NALOXEGOL OXALATE MOVANTIK 4 QL: 1 IN 1 DAYMEDICAL SUPPLIES

CATHETERS AND RELATED DEVICES

SYRINGE DISPOSABLE IRRIG,60 ML DOVER BULBSYRINGE 2

SYRINGES AND ACCESSORIES

SAFETY SYRNG,NDL,KIT-TRAY 1 MLEASY TOUCHFLURINGE FLUTRAY

2

SAFETY SYRNG,NDL,KIT-TRAY 1 MLEASY TOUCHSYR ALLERGYTRAY

2

SYR,NDL 0.3 ML,INS,SAFE,D.UNITSAFESNAPINSULINSYRINGE

2

SYR,NDL 1 ML,INS,SAFE,DISP UNTSAFESNAPINSULINSYRINGE

2

SYR,NDL,INS,SAFE 0.5ML,DISP UNSAFESNAPINSULINSYRINGE

2

SYRGE-NDL,INS 0.3 ML HALF MARK INSULINSYRINGE 2

SYRGE-NDL,INS 0.3 ML HALF MARKTECHLITEINSULINSYRINGE

2




SYRGE-NDL,INS 0.3 ML HALF MARKULTICAREINSULINSYRINGE

2

SYRGE-NDL,INS 0.3 ML HALF MARK ULTRACOMFORT 2

SYRGE-NDL,INS 0.3 ML HALF MARK VEO INSULINSYRINGE 2

SYRGE-NDL,INS 0.5 ML HALF MARKTECHLITEINSULINSYRINGE

2

SYRING W-NEEDL 0.5 ML,KIT-TRAY ALLERGISTTRAY 2

SYRING W-NEEDL 0.5 ML,KIT-TRAYALLERGISTTRAY SYR-PERM NEEDLE

2

SYRINGE 3 ML,SAFETY,DISP UNIT SAFESNAPSYRINGE 2

SYRINGE AND NEEDLE,INSULIN,1ML ADVOCATESYRINGES 2

SYRINGE AND NEEDLE,INSULIN,1MLCARETOUCHINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML COMFORT EZ 2

SYRINGE AND NEEDLE,INSULIN,1MLEASY COMFORTINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML EASY TOUCH 2

SYRINGE AND NEEDLE,INSULIN,1MLEASY TOUCHINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLEASY-TOUCHINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML ECLIPSESYRINGE 2

SYRINGE AND NEEDLE,INSULIN,1ML FREESTYLEPRECISION 2

SYRINGE AND NEEDLE,INSULIN,1ML INSULINSYRINGE 2

SYRINGE AND NEEDLE,INSULIN,1ML LITE TOUCH 2

SYRINGE AND NEEDLE,INSULIN,1MLLITETOUCHINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML MAXI-COMFORT 2

SYRINGE AND NEEDLE,INSULIN,1MLMONOJECTINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLPRO COMFORTINSULINSYRINGE

2




SYRINGE AND NEEDLE,INSULIN,1MLPRODIGYINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLSAFETYGLIDEINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML SAFETYGLIDESYRINGE 2

SYRINGE AND NEEDLE,INSULIN,1ML SURE COMFORT 2

SYRINGE AND NEEDLE,INSULIN,1MLSURE COMFORTINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLSURE-JECTINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLTECHLITEINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLTERUMOINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLTHINPROINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLTOPCAREULTRACOMFORT

2

SYRINGE AND NEEDLE,INSULIN,1MLTRUEPLUSINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML ULTICARE 2

SYRINGE AND NEEDLE,INSULIN,1MLULTICAREINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1MLULTILETINSULINSYRINGE

2

SYRINGE AND NEEDLE,INSULIN,1ML ULTRACOMFORT 2

SYRINGE AND NEEDLE,INSULIN,1ML ULTRA-THIN II 2SYRINGE AND NEEDLE,INSULIN,1ML VANISHPOINT 2

SYRINGE AND NEEDLE,INSULIN,1ML VEO INSULINSYRINGE 2

SYRINGE CAP, ENFIT,NON-STERILEMONOJECTENFIT SYRINGECAP

2

SYRINGE DISPOSABLE IRRIG,70 ML TOOMEYSYRINGE 2

SYRINGE DISPOSABLE IRRIGATIONDAVOLIRRIGATIONSYRINGE

2




SYRINGE DISPOSABLE IRRIGATION IRRIGATIONSYRINGE 2

SYRINGE WITH CANNULA, 1 MLLIFESHIELDBLUNTCANNULA

2

SYRINGE WITH CANNULA, 10 ML INTERLINKSYRINGE 2

SYRINGE WITH CANNULA, 10 MLINTERLINKSYRINGE W-CANNULA

2

SYRINGE WITH CANNULA, 3 MLLIFESHIELDBLUNTCANNULA

2

SYRINGE WITH CANNULA, 3 MLMONOJECTSMARTIPCANNULA

2

SYRINGE WITH CANNULA, 3 ML SYRINGE 2

SYRINGE WITH CANNULA, 5 ML INTERLINKSYRINGE 2

SYRINGE WITH CANNULA, 6 MLMONOJECTSMARTIPCANNULA

2

SYRINGE WITH CANNULA,DISP.12MLMONOJECTSMARTIPCANNULA

2

SYRINGE WITH NEEDLE, 0.5 ML ALLERGISTTRAY 2

SYRINGE WITH NEEDLE, 0.5 ML MONOJECT TBSYRINGE 2

SYRINGE WITH NEEDLE, 0.5 ML TUBERCULINSYRINGE 2

SYRINGE WITH NEEDLE, 1 ML ALLERGISTTRAY 2

SYRINGE WITH NEEDLE, 1 ML ALLERGYSYRINGE 2

SYRINGE WITH NEEDLE, 1 ML EASY TOUCH 2

SYRINGE WITH NEEDLE, 1 ML EASY TOUCHFLURINGE 2

SYRINGE WITH NEEDLE, 1 ML ECLIPSE LUER-LOK SYRINGE 2

SYRINGE WITH NEEDLE, 1 MLECLIPSESYRINGE-NEEDLE

2

SYRINGE WITH NEEDLE, 1 ML EXEL TB WITHNEEDLE 2

SYRINGE WITH NEEDLE, 1 MLLUER-LOKSYRINGE-NEEDLE

2

SYRINGE WITH NEEDLE, 1 ML MONOJECT TB 2

SYRINGE WITH NEEDLE, 1 ML MONOJECT TBSYRINGE 2




SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDEALLERGY 2

SYRINGE WITH NEEDLE, 1 MLSAFETYGLIDEALLERGYSYRINGE

2

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDESYRINGE 2

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDETB SYRINGE 2

SYRINGE WITH NEEDLE, 1 ML SYRINGE WITHNEEDLE DISP 2

SYRINGE WITH NEEDLE, 1 MLSYRINGE-PRECISIONGLIDE NEEDLE

2

SYRINGE WITH NEEDLE, 1 ML TB SYRINGE 2

SYRINGE WITH NEEDLE, 1 MLTERUMOALLERGYSYRINGE

2

SYRINGE WITH NEEDLE, 1 ML TUBERCULINSYRINGE 2

SYRINGE WITH NEEDLE, 1 MLTUBERCULINSYRINGE-NEEDLE

2

SYRINGE WITH NEEDLE, 1 ML ULTICARE 2SYRINGE WITH NEEDLE, 1 ML VANISHPOINT 2


2

SYRINGE WITH NEEDLE, 10 ML SAFETYGLIDESYRINGE 2

SYRINGE WITH NEEDLE, 12 ML MONOJECTSYRINGE 2


2

SYRINGE WITH NEEDLE, 5 MLTERUMOHYPODERMICNEEDLE-SYRIN

2

SYRINGE WITH NEEDLE, 5 ML VANISHPOINT 2SYRINGE WITH NEEDLE, 6 ML MONOJECT 2

SYRINGE WITH NEEDLE, 6 ML MONOJECTSYRINGE 2

SYRINGE WITH NEEDLE, INSULINMONOJECTINSULINSAFETY SYRNG

2

SYRINGE WITH NEEDLE,DISPOSABLE MONOJECT 2

SYRINGE W-NEEDLE 1 ML,KIT-TRAYALLERGISTTRAY SYR-DETACH NDL

2




SYRINGE W-NEEDLE 1 ML,KIT-TRAYMONOJECTALLERGYTRAY-NEEDLE

2

SYRINGE W-NEEDLE,DISPOSAB,3 ML EASY TOUCH 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML ECLIPSE LUER-LOK SYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML EXEL SYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML INTEGRASYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 MLLUER-LOKSYRINGE-NEEDLE

2

SYRINGE W-NEEDLE,DISPOSAB,3 ML MONOJECT 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML MONOJECTSYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML PRECISIONGLIDE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML SAFETYGLIDESYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML TERUMOSYRINGE 2

SYRINGE W-NEEDLE,DISPOSAB,3 ML VANISHPOINT 2

SYRINGE, DISPOSABLESYRINGEWITHOUTNEEDLE

2

SYRINGE, DISPOSABLE, 1 ML BULK SYRINGE 2

SYRINGE, DISPOSABLE, 1 MLCAREPOINTLUER SLIPSYRINGE

2

SYRINGE, DISPOSABLE, 1 MLEASY GLIDELUER LOCKSYRINGE

2

SYRINGE, DISPOSABLE, 1 MLEASY GLIDELUER SLIP TBSYRING

2

SYRINGE, DISPOSABLE, 1 MLEASY TOUCHLUER LOCKSYRINGE

2

SYRINGE, DISPOSABLE, 1 MLEXELTUBERCULINSYRINGE

2

SYRINGE, DISPOSABLE, 1 ML LUER SLIP TIPSYRINGE TRAY 2

SYRINGE, DISPOSABLE, 1 ML LUER-LOKSYRINGE 2

SYRINGE, DISPOSABLE, 1 ML LUERSLIPSYRINGE 2

SYRINGE, DISPOSABLE, 1 MLMONOJECTLUER LOCK TBSYRINGE

2




SYRINGE, DISPOSABLE, 1 MLMONOJECTMEGELLAN TBSYRINGE

2

SYRINGE, DISPOSABLE, 1 MLMONOJECTPHARMACYTRAY

2

SYRINGE, DISPOSABLE, 1 ML MONOJECT TBSYRINGE 2

SYRINGE, DISPOSABLE, 1 MLMONOJECTTUBERCULINSYRINGE

2

SYRINGE, DISPOSABLE, 1 MLNORM-JECTTUBERKULINSYRINGE

2

SYRINGE, DISPOSABLE, 1 ML TUBERCULINSYRINGE 2


SYRINGE, DISPOSABLE, 10 MLEASY GLIDEDENTAL IRRIGSYRING

2


2


2

SYRINGE, DISPOSABLE, 10 MLEASY TOUCHSHEATHLOCKSYRINGE

2

SYRINGE, DISPOSABLE, 10 ML EASY TOUCHUNI-SLIP 2

SYRINGE, DISPOSABLE, 10 ML EXEL SYRINGE 2

SYRINGE, DISPOSABLE, 10 ML NORM-JECTSYRINGE 2

SYRINGE, DISPOSABLE, 10 MLSAFETY-LOKSAFETYSYRINGE

2

SYRINGE, DISPOSABLE, 10 ML SYRINGE 2

SYRINGE, DISPOSABLE, 12 MLMONOJECTCONTROLSYRINGE

2

SYRINGE, DISPOSABLE, 12 MLMONOJECTSAFETYSYRINGE

2

SYRINGE, DISPOSABLE, 12 ML MONOJECTSYRINGE 2

SYRINGE, DISPOSABLE, 12 MLSYRINGEWITHOUTNEEDLE

2

SYRINGE, DISPOSABLE, 140 ML MONOJECT 2SYRINGE, DISPOSABLE, 20 ML BULK SYRINGE 2



Drug Name Tier Requirements/LimitsSYRINGE, DISPOSABLE, 20 ML EXEL SYRINGE 2



SYRINGE, DISPOSABLE, 20 ML NORM-JECTSYRINGE 2

SYRINGE, DISPOSABLE, 20 ML SLIP-TIPSYRINGE 2

SYRINGE, DISPOSABLE, 20 ML SYRINGE 2SYRINGE, DISPOSABLE, 20 ML SYRINGE BULK 2


2


2


2


2




SYRINGE, DISPOSABLE, 3 MLMONOJECTSAFETYSYRINGE

2


SYRINGE, DISPOSABLE, 3 ML

MONOJECTSYRINGEPHARMACYTRAY

2


2

SYRINGE, DISPOSABLE, 3 ML SYRINGE 2SYRINGE, DISPOSABLE, 30 ML EXEL SYRINGE 2

SYRINGE, DISPOSABLE, 30 ML LUER LOCKSYRINGE 2

SYRINGE, DISPOSABLE, 30 ML LUER-LOK TIPSYRINGE 2

SYRINGE, DISPOSABLE, 30 ML SYRINGE 2

SYRINGE, DISPOSABLE, 30 ML TERUMOSYRINGE 2

SYRINGE, DISPOSABLE, 35 ML MONOJECT 2



Drug Name Tier Requirements/LimitsSYRINGE, DISPOSABLE, 35 ML SYRINGE 2


2



2


2





2

SYRINGE, DISPOSABLE, 5 ML SYRINGE 2SYRINGE, DISPOSABLE, 50 ML EXEL SYRINGE 2


SYRINGE, DISPOSABLE, 6 ML

MONOJECTSYRINGEPHARMACYTRAY

2

SYRINGE, DISPOSABLE, 60 MLEASY GLIDECATHETER TIPSYRING

2


2

SYRINGE, DISPOSABLE, 60 ML LUER-LOCKSYRINGE 2

SYRINGE, DISPOSABLE, 60 ML MONOJECT 2


SYRINGE, DISPOSABLE, 60 ML SYRINGE 2SYRINGE, DISPOSABLE, 60 ML SYRINGE BULK 2

SYRINGE, DISPOSABLE, 60 ML SYRINGECATHETER TIP 2


2

SYRINGE, ENFIT 1 ML, STERILE MONOJECTENFIT SYRINGE 2









SYRINGE, NEEDLE, CANNULA,10 ML TWINPAK DUALCANNULA 2

SYRINGE, SAFETY 3 MLULTICARESAFETYSYRINGE

2

SYRINGE,ENFIT 1 ML,NON-STERILE MONOJECTENFIT SYRINGE 2

SYRINGE,ENFIT 12ML,NON-STERILE MONOJECTENFIT SYRINGE 2





SYRINGE,ENFIT 60ML,NON-STERILE PISTON ENFITSYRINGE 2

SYRINGE,INSUL U-500,NDL,0.5ML INSULINSYRINGE U-500 2

SYRINGE,INSULIN,NEEDLESS 1 MLEASY TOUCHLUER LOCKINSULIN

2

SYRINGE,INSULIN,NEEDLESS 1 ML EASY TOUCHUNI-SLIP 2

SYRINGE,INSULIN,NEEDLESS 1 ML INSULINSYRINGE 2

SYRINGE,INSULIN,NEEDLESS 1 ML LUER-LOKSYRINGE 2

SYRINGE,NDLE,SAFE 1.5 ML,D.UNT ULTICARESYRINGE 2

SYRINGE,NEEDLE,INSULN,SAFE,1MLASSURE IDINSULINSAFETY

2

SYRINGE,NEEDLE,INSULN,SAFE,1MLEASY TOUCHFLIPLOCKINSULIN

2

SYRINGE,NEEDLE,INSULN,SAFE,1MLEASY TOUCHINSULINSAFETY

2




SYRINGE,NEEDLE,INSULN,SAFE,1MLEASY TOUCHSHEATHLOCKINSULIN

2

SYRINGE,NEEDLE,INSULN,SAFE,1MLMAGELLANINSULINSAFETY SYRNG

2

SYRINGE,NEEDLE,INSULN,SAFE,1MLSAFETYGLIDEINSULINSYRINGE

2

SYRINGE,NEEDLE,INSULN,SF 0.5MLASSURE IDINSULINSAFETY

2

SYRINGE,NEEDLE,INSULN,SF 0.5MLEASY TOUCHINSULINSAFETY

2

SYRINGE,NEEDLE,INSULN,SF 0.5MLMAGELLANINSULINSAFETY SYRNG

2

SYRINGE,NEEDLE,INSULN,SF 0.5MLMAGELLANINSULINSYRINGE

2

SYRINGE,NEEDLE,INSULN,SF 0.5MLSAFETYGLIDEINSULINSYRINGE

2

SYRINGE,NEEDLE,INSULN,SF,0.3MLMAGELLANINSULINSAFETY SYRNG

2

SYRINGE,NEEDLE,INSULN,SF,0.3MLMAGELLANINSULINSYRINGE

2

SYRINGE,NEEDLE,INSULN,SF,0.3MLSAFETYGLIDEINSULINSYRINGE

2

SYRINGE,SAFE 3 ML,DISPOSL UNIT SAFESNAPSYRINGE 2

SYRINGE,SAFE 5 ML,DISPOSL UNIT SAFESNAPSYRINGE 2

SYRINGE,SAFETY 1 ML,DISP UNITSAFESNAPALLERGYSYRINGE

2

SYRINGE,SAFETY 1 ML,DISP UNITSAFESNAPTUBERCULINSYRINGE

2

SYRINGE,SAFETY 10 ML,DISP UNIT SAFESNAPSYRINGE 2

SYRINGE,SAFETY 5 ML, DISP UNIT SAFESNAPSYRINGE 2

SYRINGE,SAFETY NEEDLE,10 MLEASY TOUCHFLIPLOCKSYRINGE

2




SYRINGE,SAFETY NEEDLE,10 MLEASY TOUCHFLIPLOCKSYRINGES

2

SYRINGE,SAFETY NEEDLE,10 MLEASY TOUCHSHEATHLOCKSYRG-NDL

2

SYRINGE,SAFETY NEEDLE,10 MLSAFETY-LOKSAFETYSYRINGES

2

SYRINGE,SAFETY NEEDLE,10 ML TERUMOSURGUARD2 2

SYRINGE,SAFETY NEEDLE,10 ML VANISHPOINTSYRINGE 2

SYRINGE,SAFETY NEEDLE,12 MLMONOJECTSAFETYSYRINGE

2

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLIPLOCKSYRINGES

2

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLURINGEFLIPLOCK

2

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLURINGESHEATHLOCK

2

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHTUBERCULINFLIPLOCK

2

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHTUBERCULINSHEATHLK

2

SYRINGE,SAFETY WITH NEEDLE,1MLMAGELLANSAFETYSYRINGE

2

SYRINGE,SAFETY WITH NEEDLE,1MLMAGELLANTUBERCULINSYRINGE

2

SYRINGE,SAFETY WITH NEEDLE,1ML MONOJECTMAGELLAN 2

SYRINGE,SAFETY WITH NEEDLE,1MLMONOJECTTUBERCULINSAFETY SYR

2

SYRINGE,SAFETY WITH NEEDLE,1MLSAFETY-LOKSAFETYSYRINGES

2

SYRINGE,SAFETY WITH NEEDLE,1ML SYRINGE-NEEDLE 2

SYRINGE,SAFETY WITH NEEDLE,1ML TERUMOSURGUARD2 2




SYRINGE,SAFETY WITH NEEDLE,1MLULTICARE TBSAFETYSYRINGE

2

SYRINGE,SAFETY WITH NEEDLE,3MLEASY TOUCHFLIPLOCKSYRINGE

2


2

SYRINGE,SAFETY WITH NEEDLE,3MLEASY TOUCHSHEATHLOCKSYRG-NDL

2

SYRINGE,SAFETY WITH NEEDLE,3ML ECLIPSE LUER-LOK SYRINGE 2

SYRINGE,SAFETY WITH NEEDLE,3ML ECLIPSESYRINGE 2

SYRINGE,SAFETY WITH NEEDLE,3ML INTEGRASYRINGE 2

SYRINGE,SAFETY WITH NEEDLE,3ML MONOJECT 2

SYRINGE,SAFETY WITH NEEDLE,3ML MONOJECTMAGELLAN 2

SYRINGE,SAFETY WITH NEEDLE,3MLSAFETYSYRINGE WITHSHIELD

2

SYRINGE,SAFETY WITH NEEDLE,3MLSAFETYSYRINGE-NEEDLE

2

SYRINGE,SAFETY WITH NEEDLE,3ML SAFETYGLIDESYRINGE 2


2

SYRINGE,SAFETY WITH NEEDLE,3ML SAFETY-LOKSYRINGES 2


SYRINGE,SAFETY WITH NEEDLE,3MLULTICARESAFETYSYRINGE

2

SYRINGE,SAFETY WITH NEEDLE,5MLEASY TOUCHFLIPLOCKSYRINGE

2


2

SYRINGE,SAFETY WITH NEEDLE,5MLEASY TOUCHSHEATHLOCKSYRG-NDL

2

SYRINGE,SAFETY WITH NEEDLE,5ML SAFETYGLIDESYRINGE 2





2


SYRINGE,SAFETY WITH NEEDLE,5ML VANISHPOINTSYRINGE 2

SYRINGE,SAFETY,10 ML,DISP UNIT SAFESNAPSYRINGE 2

SYRINGE-NEEDLE,INSULIN,0.5 ML ADVOCATESYRINGES 2

SYRINGE-NEEDLE,INSULIN,0.5 MLCARETOUCHINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML COMFORT EZ 2

SYRINGE-NEEDLE,INSULIN,0.5 MLEASY COMFORTINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML EASY TOUCH 2

SYRINGE-NEEDLE,INSULIN,0.5 MLEASY TOUCHINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML FREESTYLEPRECISION 2

SYRINGE-NEEDLE,INSULIN,0.5 ML INSULINSYRINGE 2

SYRINGE-NEEDLE,INSULIN,0.5 ML LITE TOUCH 2

SYRINGE-NEEDLE,INSULIN,0.5 MLLITETOUCHINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML MAXI-COMFORT 2

SYRINGE-NEEDLE,INSULIN,0.5 ML MONOJECT 2

SYRINGE-NEEDLE,INSULIN,0.5 MLMONOJECTINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLPRO COMFORTINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLPRODIGYINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLSAFETYGLIDEINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML SURE COMFORT 2

SYRINGE-NEEDLE,INSULIN,0.5 MLSURE COMFORTINSULINSYRINGE

2




SYRINGE-NEEDLE,INSULIN,0.5 MLSURE-JECTINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLTERUMOINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLTHINPROINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLTOPCAREULTRACOMFORT

2

SYRINGE-NEEDLE,INSULIN,0.5 MLTRUEPLUSINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTICARE 2

SYRINGE-NEEDLE,INSULIN,0.5 MLULTICAREINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 MLULTILETINSULINSYRINGE

2

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTRACOMFORT 2

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTRA-THIN II 2SYRINGE-NEEDLE,INSULIN,0.5 ML VANISHPOINT 2

SYRINGE-NEEDLE,INSULIN,0.5 ML VEO INSULINSYRINGE 2

SYRING-NEEDL,DISP,INSUL,0.3 ML ADVOCATESYRINGES 2

SYRING-NEEDL,DISP,INSUL,0.3 MLCARETOUCHINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML COMFORT EZ 2

SYRING-NEEDL,DISP,INSUL,0.3 MLEASY COMFORTINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML EASY TOUCH 2

SYRING-NEEDL,DISP,INSUL,0.3 MLEASY TOUCHINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML INSULINSYRINGE 2

SYRING-NEEDL,DISP,INSUL,0.3 ML LITE TOUCH 2

SYRING-NEEDL,DISP,INSUL,0.3 MLLITETOUCHINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLMONOJECTINSULINSYRINGE

2




SYRING-NEEDL,DISP,INSUL,0.3 MLPRODIGYINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLSAFETYGLIDEINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML SURE COMFORT 2

SYRING-NEEDL,DISP,INSUL,0.3 MLSURE COMFORTINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLSURE-JECTINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLTERUMOINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLTHINPROINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLTOPCAREULTRACOMFORT

2

SYRING-NEEDL,DISP,INSUL,0.3 MLTRUEPLUSINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTICARE 2

SYRING-NEEDL,DISP,INSUL,0.3 MLULTICAREINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 MLULTILETINSULINSYRINGE

2

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTRACOMFORT 2

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTRA-THIN II 2

SYRING-NEEDL,DISP,INSUL,0.3 ML VEO INSULINSYRINGE 2

MISCELLANEOUS AGENTSANAPHYLAXIS THERAPY AGENTS

EPINEPHRINEAUVI-Q(0.15/0.15) (AUTOINJCT)

3 ST, QL: 2 IN 365 DAYS

EPINEPHRINEAUVI-Q(0.1MG/.1ML)(AUTO INJCT)

3 AGE: < 3 YEARS, QL: 2 PERFILL

epinephrine 2EPINEPHRINE EPIPEN 3EPINEPHRINE EPIPEN 2-PAK 3EPINEPHRINE EPIPEN JR 3EPINEPHRINE EPIPEN JR 2-PAK 3



Drug Name Tier Requirements/LimitsMISCELLANEOUS AGENTS

LIVER EXTRACT (BEEF-PORK) NEXAVIR 3PARASYMPATHETIC AGENTS

bethanechol chloride URECHOLINE 1cevimeline hcl EVOXAC 2pilocarpine hcl SALAGEN 2

PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASESAPROPTERIN DIHYDROCHLORIDE KUVAN 3 PANEOPLASTIC DISEASE

ALKYLATING AGENTSBUSULFAN MYLERAN 3CHLORAMBUCIL LEUKERAN 3cyclophosphamide 2hydroxyurea HYDREA 1LOMUSTINE GLEOSTINE 3temozolomide TEMODAR 2 PA

ANTIANDROGENIC AGENTS

ABIRATERONE ACETATE ZYTIGA (250MG) (TABLET) 3 PA, QL: 4 IN 1 DAY

ABIRATERONE ACETATE ZYTIGA (500MG) (TABLET) 3 PA, QL: 2 IN 1 DAY

APALUTAMIDE ERLEADA 3 PAbicalutamide CASODEX 1ENZALUTAMIDE XTANDI 5 PA, QL: 4 IN 1 DAYflutamide EULEXIN 2nilutamide NILANDRON 2 QL: 150 AFTER 30 DAYS

ANTIMETABOLITES

capecitabine XELODA (150MG) (TABLET) 2 PA, QL: 28 IN 21 DAYS

capecitabine XELODA (500MG) (TABLET) 2 PA, QL: 112 IN 21 DAYS

mercaptopurine PURINETHOL 2MERCAPTOPURINE PURIXAN 3

METHOTREXATE XATMEP 3 ST, AGE: < 12 YEARS, QL:120mL IN 60 DAYS

methotrexate sodium FOLEX 2

METHOTREXATE SODIUM TREXALL (10MG) (TABLET) 3


methotrexate sodium TREXALL (2.5MG) (TABLET) 2


METHOTREXATE SODIUM TREXALL (7.5MG) (TABLET) 3

methotrexate sodium/pf FOLEX (25MG/ML) (VIAL) 2

THIOGUANINE TABLOID 3



Drug Name Tier Requirements/LimitsTRIFLURIDINE/TIPIRACIL HCL LONSURF 3 PA

ANTINEOPLASTIC AROMATASE INHIBITORSanastrozole ARIMIDEX 1exemestane AROMASIN 2letrozole FEMARA 1

ANTINEOPLASTIC - BRAF KINASE INHIBITORSDABRAFENIB MESYLATE TAFINLAR 3 PA

ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORSRUXOLITINIB PHOSPHATE JAKAFI 5 PA, QL: 2 IN 1 DAY

ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORSCOBIMETINIB FUMARATE COTELLIC 3 PA, QL: 63 IN 28 DAYSTRAMETINIB DIMETHYL SULFOXIDE MEKINIST 3 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

EVEROLIMUS AFINITOR (10MG) (TABLET) 3 PA, QL: 2 IN 1 DAY

EVEROLIMUS AFINITOR (2.5MG) (TABLET) 3 PA, QL: 1 IN 1 DAY

EVEROLIMUS AFINITOR (5MG) (TABLET) 3 PA, QL: 1 IN 1 DAY

EVEROLIMUS AFINITOR (7.5MG) (TABLET) 3 PA, QL: 2 IN 1 DAY

EVEROLIMUS AFINITORDISPERZ 3 PA

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSTOPOTECAN HCL HYCAMTIN 4

ANTINEOPLASTIC IMMUNOMODULATOR AGENTSLENALIDOMIDE REVLIMID 5 PA, QL: 1 IN 1 DAYPEGINTERFERON ALFA-2B SYLATRON 3POMALIDOMIDE POMALYST 5 PA

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS

BOSUTINIB BOSULIF (100MG) (TABLET) 5 PA, QL: 4 IN 1 DAY

BOSUTINIB BOSULIF (500MG) (TABLET) 5 PA, QL: 1 IN 1 DAY

CABOZANTINIB S-MALATE CABOMETYX 3 PACABOZANTINIB S-MALATE COMETRIQ 5 PA, QL: 112 IN 28 DAYSCERITINIB ZYKADIA 3 PA

DASATINIB SPRYCEL (100MG) (TABLET) 3 PA, QL: 1 IN 1 DAY









ERLOTINIB HCL TARCEVA (100MG) (TABLET) 3 PA, QL: 3 IN 1 DAY



GEFITINIB IRESSA 3 PAIBRUTINIB IMBRUVICA 5 PA

imatinib mesylate GLEEVEC (100MG) (TABLET) 2 PA, QL: 3 IN 1 DAY

imatinib mesylate GLEEVEC (400MG) (TABLET) 2 PA, QL: 2 IN 1 DAY

LAPATINIB DITOSYLATE TYKERB 3 PALENVATINIB MESYLATE LENVIMA 5 PAMIDOSTAURIN RYDAPT 3 PA

NILOTINIB HCL TASIGNA (150MG) (CAPSULE) 3 PA, QL: 4 IN 1 DAY



NIRAPARIB TOSYLATE ZEJULA 3 PAOLAPARIB LYNPARZA 3 PA, QL: 4 IN 1 DAYOSIMERTINIB MESYLATE TAGRISSO 3 PA, QL: 1 IN 1 DAYPALBOCICLIB IBRANCE 5 PAPAZOPANIB HCL VOTRIENT 3 PA, QL: 4 IN 1 DAY

PONATINIB HCL ICLUSIG (15 MG)(TABLET) 5 PA, QL: 2 IN 1 DAY

PONATINIB HCL ICLUSIG (45 MG)(TABLET) 5 PA, QL: 1 IN 1 DAY

REGORAFENIB STIVARGA 3 PA, QL: 3 IN 1 DAYRIBOCICLIB SUCCINATE KISQALI 3 PARUCAPARIB CAMSYLATE RUBRACA 3 PA, QL: 4 IN 1 DAYSORAFENIB TOSYLATE NEXAVAR 3 PA, QL: 4 IN 1 DAYSUNITINIB MALATE SUTENT 5 PA, QL: 1 IN 1 DAY

VANDETANIB CAPRELSA (100MG) (TABLET) 5 PA, QL: 2 IN 1 DAY

VANDETANIB CAPRELSA (300MG) (TABLET) 5 PA, QL: 1 IN 1 DAY

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDISPANOBINOSTAT LACTATE FARYDAK 3 PAVORINOSTAT ZOLINZA 3 PA

ANTINEOPLASTICS,MISCELLANEOUSMITOTANE LYSODREN 3OMACETAXINE MEPESUCCINATE SYNRIBO 3 PAPROCARBAZINE HCL MATULANE 3tretinoin VESANOID 2 AGE: <= 35 YEARS

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSleucovorin calcium WELLCOVORIN 1MESNA MESNEX 3



Drug Name Tier Requirements/LimitsURIDINE TRIACETATE VISTOGARD 5 QL: 24 IN 14 DAYS

PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONSAMINOLEVULINIC ACID HCL LEVULAN 3

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)tamoxifen citrate NOLVADEX 1TAMOXIFEN CITRATE SOLTAMOX 3TOREMIFENE CITRATE FARESTON 3 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)bexarotene TARGRETIN 2 PA

STEROID ANTINEOPLASTICSESTRAMUSTINE PHOSPHATE SODIUM EMCYT 3megestrol acetate MEGACE 1NEUROLOGICAL DISEASE - MISCELLANEOUS

AGENTS TO TREAT MULTIPLE SCLEROSISDIMETHYL FUMARATE TECFIDERA 5 PA

FINGOLIMOD HCL GILENYA (0.5MG) (CAPSULE) 3 PA

glatiramer acetate COPAXONE 2 PAINTERFERON BETA-1A AVONEX 3 PAINTERFERON BETA-1A AVONEX PEN 3 PAINTERFERON BETA-1A/ALBUMIN AVONEX 3 PAINTERFERON BETA-1A/ALBUMIN REBIF 3 PA

INTERFERON BETA-1A/ALBUMIN REBIFREBIDOSE 3 PA

INTERFERON BETA-1B BETASERON 3 PAINTERFERON BETA-1B EXTAVIA 3 PAPEGINTERFERON BETA-1A PLEGRIDY 5 PAPEGINTERFERON BETA-1A PLEGRIDY PEN 5 PATERIFLUNOMIDE AUBAGIO 5 PA

AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKRdalfampridine AMPYRA 2 PA

AMYOTROPHIC LATERAL SCLEROSIS AGENTSriluzole RILUTEK 2

FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB

MILNACIPRAN HCL SAVELLA (100MG) (TABLET) 4

MILNACIPRAN HCL SAVELLA (12.5MG) (TABLET) 4



MOVEMENT DISORDERS(DRUG THERAPY)

GABAPENTIN ENACARBILHORIZANT (300MG) (TABLETER)

3 QL: 1 IN 1 DAY

GABAPENTIN ENACARBILHORIZANT (600MG) (TABLETER)

3 QL: 2 IN 1 DAY



Drug Name Tier Requirements/Limitstetrabenazine XENAZINE 2 PA

VALBENAZINE TOSYLATE INGREZZA (40MG) (CAPSULE) 5 PA

POSTHERPETIC NEURALGIA AGENTS

GABAPENTINGRALISE (300MG) (TAB ER24H)

3 ST, QL: 3 IN 1 DAY

GABAPENTINGRALISE (600MG) (TAB ER24H)


PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTSDEXTROMETHORPHANHBR/QUINIDINE NUEDEXTA 4 PA

ORAL/PHARYNGEAL DISORDERSDENTAL AIDS AND PREPARATIONS

chlorhexidine gluconate PERIDEX 2

triamcinolone acetonide KENALOG INORABASE 2

NOSE PREPARATIONS, MISCELLANEOUS (RX)ipratropium bromide ATROVENT 2

PERIODONTAL COLLAGENASE INHIBITORSdoxycycline hyclate PERIOSTAT 2OTHER DRUGS

ABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYPMIFEPRISTONE MIFEPREX 3

AGENTS FOR STOMATOLOGICAL USESULFURIC ACID/SULFONAT. PHENOL DEBACTEROL 3

APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.megestrol acetate MEGACE 2megestrol acetate MEGACE ES 2

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGmiglustat ZAVESCA 2 PA

FLAVORING AGENTSETHYL ACETATE 3

GENERAL INHALATION AGENTSSODIUM CHLORIDE FOR INHALATION HYPER-SAL 3SODIUM CHLORIDE FOR INHALATION NEBUSAL 3sodium chloride for inhalation 1

METABOLIC DEFICIENCY AGENTSBETAINE CYSTADANE 3LEVOCARNITINE CARNITOR SF 4levocarnitine (330 mg) (tablet) 2levocarnitine (with sugar) CARNITOR 2

METALLIC POISON,AGENTS TO TREATDEFERASIROX EXJADE 3 PADEFERASIROX JADENU 3 PA

PRUSSIAN BLUE (INSOLUBLE) RADIOGARDASE 3

SUCCIMER CHEMET 3



Drug Name Tier Requirements/Limitstrientine hcl SYPRINE 2 PAZINC ACETATE GALZIN 3

NEEDLES/NEEDLELESS DEVICES

PEN NEEDLE, DIABETIC1ST TIERUNIFINEPENTIPS

2

PEN NEEDLE, DIABETIC1ST TIERUNIFINEPENTIPS PLUS

2

PEN NEEDLE, DIABETIC ADVOCATE PENNEEDLE 2

PEN NEEDLE, DIABETIC ADVOCATE PENNEEDLES 2

PEN NEEDLE, DIABETIC CAREFINE PENNEEDLE 2

PEN NEEDLE, DIABETIC CARETOUCHPEN NEEDLE 2

PEN NEEDLE, DIABETIC CLICKFINE 2PEN NEEDLE, DIABETIC COMFORT EZ 2

PEN NEEDLE, DIABETIC DROPLET PENNEEDLE 2

PEN NEEDLE, DIABETIC EASY COMFORTPEN NEEDLES 2

PEN NEEDLE, DIABETIC EASY GLIDEPEN NEEDLE 2

PEN NEEDLE, DIABETIC EASY TOUCHPEN NEEDLE 2

PEN NEEDLE, DIABETICHEALTHYACCENTSUNIFINE PENTIP

2

PEN NEEDLE, DIABETIC INCONTROLPEN NEEDLE 2

PEN NEEDLE, DIABETIC INSULIN PENNEEDLE 2

PEN NEEDLE, DIABETIC INSUPEN 2PEN NEEDLE, DIABETIC LITE TOUCH 2

PEN NEEDLE, DIABETIC MINI ULTRA-THIN II 2

PEN NEEDLE, DIABETIC NEEDLES 2PEN NEEDLE, DIABETIC NOVOFINE 32 2PEN NEEDLE, DIABETIC NOVOFINE PLUS 2PEN NEEDLE, DIABETIC NOVOTWIST 2PEN NEEDLE, DIABETIC PEN NEEDLE 2PEN NEEDLE, DIABETIC PEN NEEDLES 2PEN NEEDLE, DIABETIC PENTIPS 2

PEN NEEDLE, DIABETIC PRO COMFORTPEN NEEDLE 2

PEN NEEDLE, DIABETIC RELION PENNEEDLES 2

PEN NEEDLE, DIABETIC SURE COMFORT 2




PEN NEEDLE, DIABETIC SURE-FINE PENNEEDLES 2

PEN NEEDLE, DIABETIC TECHLITE PENNEEDLE 2

PEN NEEDLE, DIABETIC TOPCARECLICKFINE 2

PEN NEEDLE, DIABETIC TRUEPLUS PENNEEDLE 2

PEN NEEDLE, DIABETIC ULTICARE PENNEEDLE 2

PEN NEEDLE, DIABETIC ULTILET PENNEEDLE 2

PEN NEEDLE, DIABETICULTRA-FINEMICRO PENNEEDLE

2

PEN NEEDLE, DIABETICULTRA-FINEMINI PENNEEDLE

2

PEN NEEDLE, DIABETICULTRA-FINENANO PENNEEDLE

2

PEN NEEDLE, DIABETICULTRA-FINEORIGINAL PENNEEDLE

2

PEN NEEDLE, DIABETICULTRA-FINESHORT PENNEEDLE

2

PEN NEEDLE, DIABETIC ULTRA-THIN II 2

PEN NEEDLE, DIABETIC UNIFINEPENTIPS 2

PEN NEEDLE, DIABETIC UNIFINEPENTIPS PLUS 2

PEN NEEDLE, DIABETIC, SAFETY ASSURE ID PENNEEDLE 2

PEN NEEDLE, DIABETIC, SAFETY DROPSAFE PENNEEDLE 2

PEN NEEDLE, DIABETIC, SAFETYHEALTHYACCENTSUNIFINE PENTIP

2

PEN NEEDLE, DIABETIC, SAFETY NOVOFINEAUTOCOVER 2

PEN NEEDLE,DUAL SAFETY,DIABETCAUTOSHIELDDUO PENNEEDLE

2

NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATIONGLUTAMINE ENDARI 5 PAGLUTAMINE NUTRESTORE 5 PA

SOMATOSTATIC AGENTS

LANREOTIDE ACETATE SOMATULINEDEPOT 3



Drug Name Tier Requirements/LimitsPASIREOTIDE DIASPARTATE SIGNIFOR 3 PAOTHER RESPIRATORY DISORDERS

ANTIFIBROTIC THERAPY - PYRIDONE ANALOGSPIRFENIDONE ESBRIET 5 PA

CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATORIVACAFTOR KALYDECO 3 PA

CYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.LUMACAFTOR/IVACAFTOR ORKAMBI 5 PA

MUCOLYTICSacetylcysteine MUCOMYST 2DORNASE ALFA PULMOZYME 3 PA

PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORSNINTEDANIB ESYLATE OFEV 5 PAPAIN MANAGEMENT - ANALGESICS

ANALGESIC, NON-SALICYLATE & BARBITURATE COMB.BUTALBITAL/ACETAMINOPHEN ALLZITAL 3 QL: 12 IN 1 DAYbutalbital/acetaminophen (50mg-300mg)(tablet) 2 QL: 6 IN 1 DAY

butalbital/acetaminophen (50mg-325mg)(tablet) 2

ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMBbutalbital/aspirin/caffeine (50-325-40)(capsule) 2

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBbutalb/acetaminophen/caffeine 2

ANALGESIC/ANTIPYRETICS, SALICYLATESdiflunisal DOLOBID 2salsalate DISALCID 2

ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATIONhydrocodone/ibuprofen IBUDONE 2hydrocodone/ibuprofen VICOPROFEN 2ibuprofen/oxycodone hcl 2

ANALGESICS,NARCOTICSbuprenorphine BUTRANS 2 QL: 1 IN 7 DAYSBUPRENORPHINE HCL BELBUCA 3 QL: 2 IN 1 DAY

butorphanol tartrateSTADOL (10MG/ML)(SPRAY)

2

carisoprodol/aspirin/codeine 2

fentanylDURAGESIC(100 MCG/HR)(PATCH TD72)


fentanylDURAGESIC (12MCG/HR)(PATCH TD72)


fentanylDURAGESIC (25MCG/HR)(PATCH TD72)





fentanylDURAGESIC(50MCG/HR)(PATCH TD72)


fentanylDURAGESIC(75MCG/HR)(PATCH TD72)


fentanyl citrate ACTIQ 2 PAFENTANYL CITRATE LAZANDA 3 PAHYDROCODONE BITARTRATE HYSINGLA ER 3 QL: 1 IN 1 DAYHYDROCODONE BITARTRATE ZOHYDRO ER 4 QL: 2 IN 1 DAYhydromorphone hcl (12 mg) (tab er 24h) 2 PA, QL: 1 IN 1 DAYhydromorphone hcl (16 mg) (tab er 24h) 2 PA, QL: 1 IN 1 DAYhydromorphone hcl (2 mg) (tablet) 2hydromorphone hcl (32 mg) (tab er 24h) 2 PA, QL: 2 IN 1 DAYhydromorphone hcl (4 mg) (tablet) 2hydromorphone hcl (8 mg) (tab er 24h) 2 PA, QL: 1 IN 1 DAYhydromorphone hcl (8 mg) (tablet) 2

meperidine hcl DEMEROL (100MG) (TABLET) 2 QL: 6 IN 1 DAY

meperidine hclDEMEROL (50MG/5 ML)(SOLUTION)

2 QL: 30mL IN 1 DAY

MEPERIDINE HCL/PFDEMEROL (75MG/ML)(SYRINGE)

4

methadone hcl (10 mg) (tablet) 2 QL: 4 IN 1 DAYmethadone hcl (10 mg/ml) (oral conc) 2 QL: 4mL IN 1 DAYmethadone hcl (5 mg) (tablet) 2 QL: 8 IN 1 DAY

morphine sulfate KADIAN (10 MG)(CAP ER PEL) 2 QL: 2 IN 1 DAY

morphine sulfateKADIAN (100MG) (CAP ERPEL)

2 QL: 2 IN 1 DAY

MORPHINE SULFATEKADIAN (130MG) (CAP ERPEL)

4 QL: 1 IN 1 DAY


4 QL: 1 IN 1 DAY



4 QL: 1 IN 1 DAY








MORPHINE SULFATE KADIAN (70 MG)(CAP ER PEL) 4 QL: 1 IN 1 DAY


morphine sulfate (10 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (10 mg/5 ml) (solution) 2morphine sulfate (100 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (100 mg) (tablet er) 2 QL: 3 IN 1 DAYmorphine sulfate (100 mg/5ml) (solution) 2morphine sulfate (120 mg) (cpmp 24hr) 2 QL: 2 IN 1 DAYmorphine sulfate (15 mg) (tablet er) 2 QL: 3 IN 1 DAYMORPHINE SULFATE (15 MG) (TABLET) 2morphine sulfate (20 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (20 mg/5 ml) (solution) 2morphine sulfate (200 mg) (tablet er) 2 QL: 3 IN 1 DAYmorphine sulfate (30 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (30 mg) (cpmp 24hr) 2 QL: 1 IN 1 DAYmorphine sulfate (30 mg) (tablet er) 2 QL: 3 IN 1 DAYmorphine sulfate (45 mg) (cpmp 24hr) 2 QL: 1 IN 1 DAYmorphine sulfate (50 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cpmp 24hr) 2 QL: 1 IN 1 DAYmorphine sulfate (60 mg) (tablet er) 2 QL: 3 IN 1 DAYmorphine sulfate (75 mg) (cpmp 24hr) 2 QL: 1 IN 1 DAYmorphine sulfate (80 mg) (cap er pel) 2 QL: 2 IN 1 DAYmorphine sulfate (90 mg) (cpmp 24hr) 2 QL: 1 IN 1 DAY

MORPHINE SULFATE/NALTREXONEEMBEDA(100MG-4MG)(CAP ER PO)

3 QL: 4 IN 1 DAY

MORPHINE SULFATE/NALTREXONEEMBEDA (20MG-0.8MG) (CAP ERPO)

3 QL: 2 IN 1 DAY


3 QL: 2 IN 1 DAY

MORPHINE SULFATE/NALTREXONEEMBEDA (50MG-2 MG) (CAPER PO)

3 QL: 2 IN 1 DAY


3 QL: 2 IN 1 DAY


3 QL: 2 IN 1 DAY

opium/belladonna alkaloids 2

OXYCODONE HCLOXAYDO (7.5MG) (TABLETORL)

3



Drug Name Tier Requirements/Limitsoxycodone hcl (10 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (10 mg) (tablet) 2oxycodone hcl (15 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (15 mg) (tablet) 2oxycodone hcl (20 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (20 mg) (tablet) 2oxycodone hcl (20 mg/ml) (oral conc) 2oxycodone hcl (30 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (30 mg) (tablet) 2oxycodone hcl (40 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (5 mg) (capsule) 2oxycodone hcl (5 mg) (tablet) 2oxycodone hcl (5 mg/5 ml) (solution) 2oxycodone hcl (60 mg) (tab er 12h) 2 QL: 2 IN 1 DAYoxycodone hcl (80 mg) (tab er 12h) 2 QL: 4 IN 1 DAYOXYCODONE HCL OXYCONTIN 3 QL: 2 IN 1 DAYoxymorphone hcl OPANA 2

oxymorphone hclOPANA ER (10MG) (TAB ER12H)

2 QL: 2 IN 1 DAY


2 QL: 2 IN 1 DAY


2 QL: 2 IN 1 DAY


2 QL: 4 IN 1 DAY


2 QL: 4 IN 1 DAY


2 QL: 2 IN 1 DAY

oxymorphone hclOPANA ER (7.5MG) (TAB ER12H)

2 QL: 2 IN 1 DAY

pentazocine hcl/naloxone hcl TALWIN NX 2PENTAZOCINE LACTATE TALWIN 3TAPENTADOL HCL NUCYNTA 3 QL: 6 IN 1 DAYTAPENTADOL HCL NUCYNTA ER 3 QL: 2 IN 1 DAY

tramadol hclCONZIP (100MG) (CPBP 25-75)

2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY





2 QL: 1 IN 1 DAY

tramadol hcl RYZOLT 2tramadol hcl ULTRAM 2tramadol hcl ULTRAM ER 2

ANTIMIGRAINE PREPARATIONSalmotriptan malate 2 QL: 2 IN 5 DAYSDICLOFENAC POTASSIUM CAMBIA 3 QL: 3 IN 10 DAYSdihydroergotamine mesylate D.H.E.45 2 QL: 15mL IN 14 DAYSdihydroergotamine mesylate MIGRANAL 2 QL: 8mL IN 28 DAYSeletriptan hydrobromide RELPAX 2 QL: 2 IN 5 DAYSERGOTAMINE TARTRATE ERGOMAR 3 QL: 10 IN 7 DAYSergotamine tartrate/caffeine CAFERGOT 2 QL: 10 IN 7 DAYSERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 QL: 5 IN 7 DAYSfrovatriptan succinate FROVA 2 QL: 3 IN 5 DAYSisomethept/dichlphn/acetaminop (65-100-325) (capsule) 2

isomethepten/caf/acetaminophen PRODRIN 2naratriptan hcl AMERGE 2 QL: 3 IN 5 DAYSrizatriptan benzoate 2 QL: 3 IN 5 DAYSsumatriptan IMITREX 2 QL: 6 IN 15 DAYS

SUMATRIPTAN SUCC/NAPROXEN SODTREXIMET (10MG-60MG)(TABLET)


sumatriptan succ/naproxen sodTREXIMET(85MG-500MG)(TABLET)


sumatriptan succinate IMITREX (100MG) (TABLET) 2 QL: 3 IN 5 DAYS


sumatriptan succinateIMITREX (4MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (4MG/0.5ML) (PENINJCTR)



sumatriptan succinateIMITREX (6MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (6MG/0.5ML) (PENINJCTR)


sumatriptan succinateIMITREX (6MG/0.5ML)(VIAL)





SUMATRIPTAN SUCCINATE ZEMBRACESYMTOUCH 3 QL: 8mL IN 28 DAYS

ZOLMITRIPTAN ZOMIG (2.5 MG)(SPRAY) 3 QL: 12 IN 30 DAYS

zolmitriptan ZOMIG (2.5 MG)(TABLET) 2 QL: 2 IN 5 DAYS

ZOLMITRIPTAN ZOMIG (5 MG)(SPRAY) 3 QL: 6 IN 15 DAYS

zolmitriptan ZOMIG (5 MG)(TABLET) 2 QL: 2 IN 5 DAYS

zolmitriptan ZOMIG ZMT 2 QL: 2 IN 5 DAYSNARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB

butalbit/acetamin/caff/codeine FIORICET WITHCODEINE 2

NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE

codeine/butalbital/asa/caffein FIORINAL WITHCODEINE #3 2

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBacetaminophen with codeine 2hydrocodone/acetaminophen (10mg-300mg)(tablet) 2 QL: 13 IN 1 DAY

hydrocodone/acetaminophen (10mg-325mg)(tablet) 2 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (2.5-325 mg)(tablet) 2

hydrocodone/acetaminophen (5 mg-300mg)(tablet) 2 QL: 13 IN 1 DAY

hydrocodone/acetaminophen (5 mg-325mg)(tablet) 2 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (7.5-300 mg)(tablet) 2 QL: 13 IN 1 DAY

hydrocodone/acetaminophen (7.5-325 mg)(tablet) 2 QL: 12 IN 1 DAY

hydrocodone/acetaminophen (7.5-325/15)(solution) 2 QL: 184mL IN 1 DAY

HYDROCODONE/ACETAMINOPHEN LORTAB 3oxycodone hcl/acetaminophen (10mg-325mg)(tablet) 2 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (2.5-325 mg)(tablet) 2 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (5 mg-325mg)(tablet) 2 QL: 12 IN 1 DAY

oxycodone hcl/acetaminophen (7.5-325 mg)(tablet) 2 QL: 12 IN 1 DAY

OXYCODONE HCL/ACETAMINOPHEN PRIMLEV 4 QL: 13 IN 1 DAYtramadol hcl/acetaminophen ULTRACET 2

NARCOTIC AND SALICYLATE ANALGESIC COMBINATIONoxycodone hcl/aspirin 2

NARCOTIC WITHDRAWAL THERAPY AGENTSbuprenorphine hcl SUBUTEX 2 PA, QL: 3 IN 1 DAY



Drug Name Tier Requirements/LimitsBUPRENORPHINE HCL/NALOXONEHCL

BUNAVAIL (2.1-0.3 MG) (FILM) 3 QL: 1 IN 1 DAY

BUPRENORPHINE HCL/NALOXONEHCL

BUNAVAIL (4.2-0.7 MG) (FILM) 3 QL: 2 IN 1 DAY


BUNAVAIL(6.3MG-1MG)(FILM)

3 QL: 2 IN 1 DAY


SUBOXONE (12MG-3 MG)(FILM)

3 QL: 2 IN 1 DAY


SUBOXONE (2MG-0.5MG)(FILM)

3 QL: 1 IN 1 DAY

buprenorphine hcl/naloxone hclSUBOXONE (2MG-0.5MG) (TABSUBL)

2 QL: 3 IN 1 DAY


SUBOXONE(4MG-1MG)(FILM)

3 QL: 1 IN 1 DAY


SUBOXONE (8MG-2 MG)(FILM)

3 QL: 2 IN 1 DAY

buprenorphine hcl/naloxone hclSUBOXONE (8MG-2 MG) (TABSUBL)

2 QL: 3 IN 1 DAY


ZUBSOLV (0.7-0.18MG) (TABSUBL)

3 QL: 1 IN 1 DAY



3 QL: 1 IN 1 DAY



3 QL: 1 IN 1 DAY



3 QL: 1 IN 1 DAY


ZUBSOLV (5.7-1.4 MG) (TABSUBL)

3 QL: 1 IN 1 DAY


ZUBSOLV (8.6-2.1 MG) (TABSUBL)

3 QL: 2 IN 1 DAY

PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

benztropine mesylate COGENTIN 1

trihexyphenidyl hcl ARTANE (2 MG)(TABLET) 1

trihexyphenidyl hcl ARTANE (5 MG)(TABLET) 1



Drug Name Tier Requirements/LimitsANTIPARKINSONISM DRUGS,OTHER

amantadine hclSYMMETREL(100 MG)(CAPSULE)

2

amantadine hclSYMMETREL(100 MG)(TABLET)

2

APOMORPHINE HCL APOKYN 5 PA, QL: 2mL IN 1 DAYbromocriptine mesylate PARLODEL 2CARBIDOPA/LEVODOPA DUOPA 3 PAcarbidopa/levodopa PARCOPA 2CARBIDOPA/LEVODOPA RYTARY 3 QL: 10 IN 1 DAYcarbidopa/levodopa SINEMET 10-100 1carbidopa/levodopa SINEMET 25-100 1carbidopa/levodopa SINEMET 25-250 1carbidopa/levodopa SINEMET CR 1carbidopa/levodopa/entacapone STALEVO 100 2carbidopa/levodopa/entacapone STALEVO 125 2carbidopa/levodopa/entacapone STALEVO 150 2carbidopa/levodopa/entacapone STALEVO 200 2carbidopa/levodopa/entacapone STALEVO 50 2carbidopa/levodopa/entacapone STALEVO 75 2entacapone COMTAN 2pramipexole di-hcl MIRAPEX 1pramipexole di-hcl MIRAPEX ER 2 QL: 1 IN 1 DAYrasagiline mesylate AZILECT 2 QL: 1 IN 1 DAYropinirole hcl REQUIP 1ropinirole hcl REQUIP XL 2 QL: 1 IN 1 DAYROTIGOTINE NEUPRO 3 QL: 1 IN 1 DAYselegiline hcl (5 mg) (capsule) 2SELEGILINE HCL ZELAPAR 3 QL: 2 IN 1 DAYtolcapone TASMAR 2 QL: 3 IN 1 DAY

DECARBOXYLASE INHIBITORScarbidopa LODOSYN 2SEIZURE DISORDER

ANTICONVULSANT - BENZODIAZEPINE TYPE

CLOBAZAM ONFI (10 MG)(TABLET) 3 QL: 2 IN 1 DAY

CLOBAZAMONFI (2.5MG/ML) (ORALSUSP)


CLOBAZAM ONFI (20 MG)(TABLET) 3 QL: 2 IN 1 DAY

clonazepam 2CLONAZEPAM KLONOPIN 3DIAZEPAM DIASTAT 3 QL: 1 PER FILL

DIAZEPAM DIASTATACUDIAL 3 QL: 1 PER FILL

diazepam 2 QL: 1 PER FILL



Drug Name Tier Requirements/LimitsANTICONVULSANTS

BRIVARACETAM BRIVIACT (10MG) (TABLET) 3 QL: 2 IN 1 DAY

BRIVARACETAMBRIVIACT (10MG/ML)(SOLUTION)






carbamazepine (100 mg) (cpmp 12hr) 2carbamazepine (100 mg) (tab chew) 1carbamazepine (100 mg) (tab er 12h) 2carbamazepine (200 mg) (cpmp 12hr) 2carbamazepine (200 mg) (tab er 12h) 2carbamazepine (200 mg) (tablet) 1carbamazepine (300 mg) (cpmp 12hr) 2carbamazepine (400 mg) (tab er 12h) 2CARBAMAZEPINE CARBATROL 3CARBAMAZEPINE TEGRETOL 3CARBAMAZEPINE TEGRETOL XR 3DIVALPROEX SODIUM DEPAKOTE 3DIVALPROEX SODIUM DEPAKOTE ER 3

DIVALPROEX SODIUM DEPAKOTESPRINKLE 3

divalproex sodium (125 mg) (cap dr spr) 1divalproex sodium (125 mg) (tablet dr) 1divalproex sodium (250 mg) (tab er 24h) 2divalproex sodium (250 mg) (tablet dr) 1divalproex sodium (500 mg) (tab er 24h) 2divalproex sodium (500 mg) (tablet dr) 1

ESLICARBAZEPINE ACETATE APTIOM (400MG) (TABLET) 3 QL: 1 IN 1 DAY



ethosuximide 2ETHOSUXIMIDE ZARONTIN 3ETHOTOIN PEGANONE 3felbamate (400 mg) (tablet) 2 QL: 9 IN 1 DAYfelbamate (600 mg) (tablet) 2 QL: 6 IN 1 DAY

FELBAMATE FELBATOL (400MG) (TABLET) 3 QL: 9 IN 1 DAY

FELBAMATE FELBATOL (600MG) (TABLET) 3 QL: 6 IN 1 DAY




FELBAMATEFELBATOL (600MG/5ML) (ORALSUSP)

3 QL: 30mL IN 1 DAY

FOSPHENYTOIN SODIUM CEREBYX 3gabapentin (100 mg) (capsule) 1gabapentin (250 mg/5ml) (solution) 2gabapentin (300 mg) (capsule) 1gabapentin (300 mg/6ml) (solution) 2gabapentin (400 mg) (capsule) 1gabapentin (600 mg) (tablet) 1gabapentin (800 mg) (tablet) 1GABAPENTIN NEURONTIN 3GABAPENTIN/LIDOCAINE/MENTHOL ACTIVE-PAC 3

GABAPENTIN/LIDOCAINE/MENTHOL SMARTRXGABAKIT 3

LACOSAMIDEVIMPAT (10MG/ML)(SOLUTION)


LACOSAMIDE VIMPAT (100MG) (TABLET) 3 QL: 2 IN 1 DAY



LACOSAMIDE VIMPAT (50 MG)(TABLET) 3 QL: 2 IN 1 DAY

LAMOTRIGINE LAMICTAL 3

LAMOTRIGINE LAMICTAL(BLUE) 4

LAMOTRIGINE LAMICTAL(GREEN) 4

LAMOTRIGINE LAMICTAL(ORANGE) 4

LAMOTRIGINELAMICTAL ODT(100 MG) (TABRAPDIS)

3 QL: 3 IN 1 DAY


3 QL: 2 IN 1 DAY


3 QL: 6 IN 1 DAY


3 QL: 6 IN 1 DAY

LAMOTRIGINE LAMICTAL ODT(BLUE) 3

LAMOTRIGINE LAMICTAL ODT(GREEN) 3




LAMOTRIGINE LAMICTAL ODT(ORANGE) 3

LAMOTRIGINELAMICTAL XR(100 MG) (TABER 24)

3 QL: 3 IN 1 DAY


3 QL: 2 IN 1 DAY

LAMOTRIGINELAMICTAL XR(25 MG) (TAB ER24)

3 QL: 6 IN 1 DAY


3 QL: 2 IN 1 DAY


3 QL: 2 IN 1 DAY

LAMOTRIGINELAMICTAL XR(50 MG) (TAB ER24)

3 QL: 6 IN 1 DAY

LAMOTRIGINE LAMICTAL XR(BLUE) 3

LAMOTRIGINE LAMICTAL XR(GREEN) 3

LAMOTRIGINE LAMICTAL XR(ORANGE) 3

lamotrigine (100 mg) (tab er 24) 2 QL: 3 IN 1 DAYlamotrigine (100 mg) (tab rapdis) 2 QL: 3 IN 1 DAYlamotrigine (100 mg) (tablet) 2lamotrigine (150 mg) (tablet) 2lamotrigine (200 mg) (tab er 24) 2 QL: 2 IN 1 DAYlamotrigine (200 mg) (tab rapdis) 2 QL: 2 IN 1 DAYlamotrigine (200 mg) (tablet) 2lamotrigine (25 mg) (tab er 24) 2 QL: 6 IN 1 DAYlamotrigine (25 mg) (tab rapdis) 2 QL: 6 IN 1 DAYlamotrigine (25 mg) (tablet) 2lamotrigine (25 mg) (tb chw dsp) 2lamotrigine (25(42)-100) (tab ds pk) 2lamotrigine (25(84)-100) (tab ds pk) 2lamotrigine (250 mg) (tab er 24) 2 QL: 2 IN 1 DAYlamotrigine (25mg (35)) (tab ds pk) 2lamotrigine (300 mg) (tab er 24) 2 QL: 2 IN 1 DAYlamotrigine (5 mg) (tb chw dsp) 2lamotrigine (50 mg) (tab er 24) 2 QL: 6 IN 1 DAYlamotrigine (50 mg) (tab rapdis) 2 QL: 6 IN 1 DAY

LEVETIRACETAMKEPPRA (100MG/ML)(SOLUTION)

3

LEVETIRACETAM KEPPRA (1000MG) (TABLET) 3







LEVETIRACETAM KEPPRA XR 3levetiracetam (100 mg/ml) (solution) 2levetiracetam (1000 mg) (tablet) 2levetiracetam (250 mg) (tablet) 2levetiracetam (500 mg) (tab er 24h) 2levetiracetam (500 mg) (tablet) 2levetiracetam (500 mg/5ml) (solution) 2levetiracetam (750 mg) (tab er 24h) 1levetiracetam (750 mg) (tablet) 2

LEVETIRACETAMROWEEPRA(1000 MG)(TABLET)

2

LEVETIRACETAM ROWEEPRA (750MG) (TABLET) 2

LEVETIRACETAM ROWEEPRA XR 3

LEVETIRACETAM SPRITAM (1000MG) (TAB SUSP) 3 QL: 2 IN 1 DAY




METHSUXIMIDE CELONTIN 3oxcarbazepine (150 mg) (tablet) 1oxcarbazepine (300 mg) (tablet) 1oxcarbazepine (300 mg/5ml) (oral susp) 2oxcarbazepine (600 mg) (tablet) 1

OXCARBAZEPINEOXTELLAR XR(150 MG) (TABER 24H)

3 QL: 1 IN 1 DAY


3 QL: 1 IN 1 DAY


3 QL: 4 IN 1 DAY

OXCARBAZEPINE TRILEPTAL 3

PERAMPANEL FYCOMPA (10MG) (TABLET) 3 QL: 1 IN 1 DAY









PHENYTOIN DILANTIN 3PHENYTOIN DILANTIN-125 3phenytoin 2PHENYTOIN SODIUM EXTENDED DILANTIN 3PHENYTOIN SODIUM EXTENDED PHENYTEK 3phenytoin sodium extended 1

PREGABALIN LYRICA (100MG) (CAPSULE) 3




PREGABALIN LYRICA (25 MG)(CAPSULE) 3




PRIMIDONE MYSOLINE 3primidone 1

RUFINAMIDE BANZEL (200MG) (TABLET) 3 QL: 16 IN 1 DAY

RUFINAMIDEBANZEL (40MG/ML) (ORALSUSP)

3 QL: 80mL IN 1 DAY

RUFINAMIDE BANZEL (400MG) (TABLET) 3 QL: 8 IN 1 DAY

TIAGABINE HCL GABITRIL (12MG) (TABLET) 4 QL: 4 IN 1 DAY




tiagabine hcl (12 mg) (tablet) 2 QL: 4 IN 1 DAYtiagabine hcl (16 mg) (tablet) 2 QL: 3 IN 1 DAYtiagabine hcl (2 mg) (tablet) 2 QL: 4 IN 1 DAYtiagabine hcl (4 mg) (tablet) 2 QL: 4 IN 1 DAY




TOPIRAMATEQUDEXY XR(100 MG) (CAPSPR 24)

4 QL: 1 IN 1 DAY


4 QL: 2 IN 1 DAY


4 QL: 2 IN 1 DAY

TOPIRAMATEQUDEXY XR (25MG) (CAP SPR24)

4 QL: 1 IN 1 DAY

TOPIRAMATEQUDEXY XR (50MG) (CAP SPR24)

4 QL: 1 IN 1 DAY

TOPIRAMATE TOPAMAX 3topiramate (100 mg) (cap spr 24) 2 QL: 1 IN 1 DAYtopiramate (100 mg) (tablet) 1topiramate (15 mg) (cap sprink) 1topiramate (150 mg) (cap spr 24) 2 QL: 2 IN 1 DAYtopiramate (200 mg) (cap spr 24) 2 QL: 2 IN 1 DAYtopiramate (200 mg) (tablet) 1topiramate (25 mg) (cap spr 24) 2 QL: 1 IN 1 DAYtopiramate (25 mg) (cap sprink) 1topiramate (25 mg) (tablet) 1topiramate (50 mg) (cap spr 24) 2 QL: 1 IN 1 DAYtopiramate (50 mg) (tablet) 1

TOPIRAMATETROKENDI XR(100 MG) (CAPER 24H)


TOPIRAMATETROKENDI XR(200 MG) (CAPER 24H)


TOPIRAMATETROKENDI XR(25 MG) (CAP ER24H)


TOPIRAMATETROKENDI XR(50 MG) (CAP ER24H)


VALPROIC ACID DEPAKENE 3valproic acid 1VALPROIC ACID (AS SODIUM SALT) DEPAKENE 3valproic acid (as sodium salt) 2ZONISAMIDE ZONEGRAN 3zonisamide 1SKELETAL MUSCLE DISORDER

AGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INHDICHLORPHENAMIDE KEVEYIS 5 PA



Drug Name Tier Requirements/LimitsSKELETAL MUSCLE RELAX.& TOP.IRRITANT COUNTER-IRRITANT

TIZANIDINE/IRRITANT CNTR-IRRT2 COMFORT PAC-TIZANIDINE 3

SKELETAL MUSCLE RELAXANTSbaclofen (10 mg) (tablet) 1baclofen (20 mg) (tablet) 1carisoprodol SOMA 2 QL: 4 IN 1 DAY

carisoprodol/aspirin SOMACOMPOUND 2

chlorzoxazone (500 mg) (tablet) 1CYCLOBENZAPRINE HCL AMRIX 3cyclobenzaprine hcl FEXMID 1cyclobenzaprine hcl FLEXERIL 1dantrolene sodium DANTRIUM 2

metaxalone SKELAXIN (800MG) (TABLET) 2

methocarbamol ROBAXIN 1methocarbamol ROBAXIN-750 1orphenadrine citrate NORFLEX 1

tizanidine hcl ZANAFLEX (2MG) (CAPSULE) 2

tizanidine hcl ZANAFLEX (2MG) (TABLET) 1


tizanidine hcl ZANAFLEX (4MG) (TABLET) 1


SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

NICOTINE NICOTROL 3 AGE: >= 12 YEARS, QL: 1008IN 90 DAYS

NICOTINE NICOTROL NS 3 AGE: >= 12 YEARS, QL:160mL IN 90 DAYS

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST

VARENICLINE TARTRATE CHANTIX 3 AGE: >= 18 YEARS, QL: 2 IN1 DAY

SMOKING DETERRENTS, OTHERbupropion hcl ZYBAN 1 AGE: >= 18 YEARSUPPER GASTROINTESTINAL DISORDERS - DIGESTIVE

GASTRIC ENZYMESSACROSIDASE SUCRAID 5 PA

PANCREATIC ENZYMESLIPASE/PROTEASE/AMYLASE CREON 3LIPASE/PROTEASE/AMYLASE PANCREAZE 3

LIPASE/PROTEASE/AMYLASEPERTZYE (16K-57.5K)(CAPSULE DR)

3




LIPASE/PROTEASE/AMYLASEPERTZYE (4000-14375)(CAPSULE DR)

3

LIPASE/PROTEASE/AMYLASEPERTZYE (8K-28.75K)(CAPSULE DR)

3

LIPASE/PROTEASE/AMYLASE VIOKACE 3

LIPASE/PROTEASE/AMYLASEZENPEP (10-32-42K) (CAPSULEDR)

3


3


3

LIPASE/PROTEASE/AMYLASEZENPEP (40-126-168) (CAPSULEDR)

3

LIPASE/PROTEASE/AMYLASEZENPEP (5K-17K-24K)(CAPSULE DR)

3

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASEANTICHOLINERGICS/ANTISPASMODICS

dicyclomine hcl (10 mg) (capsule) 1dicyclomine hcl (10 mg/5 ml) (solution) 2dicyclomine hcl (20 mg) (tablet) 1

BELLADONNA ALKALOIDShyoscyamine sulfate HYOSYNE 2hyoscyamine sulfate LEVBID 2hyoscyamine sulfate LEVSIN 1hyoscyamine sulfate LEVSIN-SL 1hyoscyamine sulfate NULEV 1hyoscyamine sulfate SYMAX 1

HYOSCYAMINE SULFATE SYMAXDUOTAB 3

hyoscyamine sulfate SYMAX-SL 1hyoscyamine sulfate SYMAX-SR 2methscopolamine bromide PAMINE 2methscopolamine bromide PAMINE FORTE 2

PHENOBARB/HYOSCY/ATROPINE/SCOPBELLADONNA-PHENOBARBITAL


PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL (16.2MG) (TABLET) 4 QL: 8 IN 1 DAY

PHENOBARB/HYOSCY/ATROPINE/SCOPDONNATAL(16.2MG/5ML)(ELIXIR)


phenobarb/hyoscy/atropine/scop 2 QL: 8 IN 1 DAY




PHENOBARB/HYOSCY/ATROPINE/SCOPPHENOHYTRO(16.2 MG)(TABLET)

2 QL: 8 IN 1 DAY

PHENOBARB/HYOSCY/ATROPINE/SCOPPHENOHYTRO(16.2MG/5ML)(ELIXIR)


UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASEANTICHOLINERGICS,QUATERNARY AMMONIUM

chlordiazepoxide/clidinium br LIBRAX 2GLYCOPYRROLATE CUVPOSA 3glycopyrrolate 2propantheline bromide PRO-BANTHINE 2

ANTI-ULCER PREPARATIONSmisoprostol CYTOTEC 1

sucralfate CARAFATE (1 G)(TABLET) 1

SUCRALFATECARAFATE (1G/10 ML) (ORALSUSP)

3

ANTI-ULCER-H.PYLORI AGENTSBISMUTH/METRONID/TETRACYCLINE PYLERA 3lansoprazole/amoxiciln/clarith 2 QL: 112 IN 10 DAYS

OMEPRAZOLE/CLARITH/AMOXICILLIN OMECLAMOX-PAK 3

HISTAMINE H2-RECEPTOR INHIBITORScimetidine TAGAMET 1

famotidine PEPCID (20 MG)(TABLET) 1

famotidine PEPCID (40 MG)(TABLET) 1

famotidinePEPCID(40MG/5ML)(ORAL SUSP)

2

nizatidine AXID (150 MG)(CAPSULE) 1

nizatidine AXID (300 MG)(CAPSULE) 1

ranitidine hclZANTAC (15MG/ML)(SYRUP)

1

ranitidine hcl ZANTAC (150MG) (CAPSULE) 1

ranitidine hcl ZANTAC (150MG) (TABLET) 1

ranitidine hcl ZANTAC (300MG) (CAPSULE) 1

ranitidine hcl ZANTAC (300MG) (TABLET) 1



Drug Name Tier Requirements/LimitsINTESTINAL MOTILITY STIMULANTS

metoclopramide hclMETOZOLV ODT(10 MG) (TABRAPDIS)

2

metoclopramide hcl REGLAN (10MG) (TABLET) 1

metoclopramide hcl REGLAN (5 MG)(TABLET) 1

PROTON-PUMP INHIBITORS

esomeprazole magnesiumNEXIUM (20MG) (CAPSULEDR)

2 QL: 1 IN 1 DAY

esomeprazole magnesiumNEXIUM (40MG) (CAPSULEDR)

2 QL: 2 IN 1 DAY

lansoprazole (15 mg) (capsule dr) 1lansoprazole (15 mg) (tab rap dr) 2 AGE: <= 12 YEARSlansoprazole (30 mg) (capsule dr) 1lansoprazole (30 mg) (tab rap dr) 2 AGE: <= 12 YEARSomeprazole (10 mg) (capsule dr) 1omeprazole (20 mg) (capsule dr) 1omeprazole (40 mg) (capsule dr) 1

omeprazole/sodium bicarbonate OMEPPI (40MG-1.1G) (CAPSULE) 2 QL: 1 IN 1 DAY

omeprazole/sodium bicarbonateZEGERID(40MG-1.1G)(CAPSULE)

2 QL: 1 IN 1 DAY

pantoprazole sodium 1rabeprazole sodium ACIPHEX 1 QL: 1 IN 1 DAYURINARY TRACT - FUNCTIONAL DISORDERS

BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSalfuzosin hcl UROXATRAL 1dutasteride AVODART 1finasteride PROSCAR 1SILODOSIN RAPAFLO 4tamsulosin hcl FLOMAX 1

BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMBdutasteride/tamsulosin hcl JALYN 2

KIDNEY STONE AGENTSCYSTEAMINE BITARTRATE CYSTAGON 5CYSTEAMINE BITARTRATE PROCYSBI 5 PATIOPRONIN THIOLA 5

OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEPMIRABEGRON MYRBETRIQ 3

URINARY PH MODIFIERSCITRIC AC/GLUCONOLACT/MAG CARB RENACIDIN 3potassium citrate UROCIT-K 2SOD PHOS,M-B/K PHOS,MONOB K-PHOS NO.2 3



Drug Name Tier Requirements/LimitsURINARY TRACT ANALGESIC AGENTS

PENTOSAN POLYSULFATE SODIUM ELMIRON 4URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)

phenazopyridine hcl PYRIDIUM 1URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.

darifenacin hydrobromide ENABLEX 2SOLIFENACIN SUCCINATE VESICARE 3

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTFESOTERODINE FUMARATE TOVIAZ 3flavoxate hcl URISPAS 2OXYBUTYNIN OXYTROL 3OXYBUTYNIN CHLORIDE GELNIQUE 3oxybutynin chloride (10 mg) (tab er 24) 1oxybutynin chloride (15 mg) (tab er 24) 1oxybutynin chloride (5 mg) (tab er 24) 1oxybutynin chloride (5 mg) (tablet) 1oxybutynin chloride (5 mg/5 ml) (syrup) 2tolterodine tartrate DETROL 2tolterodine tartrate DETROL LA 2trospium chloride SANCTURA 2trospium chloride SANCTURA XR 2VAGINAL DISORDERS

VAGINAL ANTIBIOTICS

CLINDAMYCIN PHOSPHATE CLEOCIN (100MG) (SUPP.VAG) 3

clindamycin phosphate CLEOCIN (2 %)(CREAM/APPL) 2

CLINDAMYCIN PHOSPHATE CLINDESSE 3

metronidazole METROGEL-VAGINAL 2

METRONIDAZOLE NUVESSA 4METRONIDAZOLE VANDAZOLE 2

VAGINAL ANTIFUNGALSBUTOCONAZOLE NITRATE GYNAZOLE 1 3terconazole TERAZOL 3 2terconazole TERAZOL 7 2

VAGINAL ANTISEPTICSACETIC ACID/OXYQUINOLINE FEM PH 4ACETIC ACID/OXYQUINOLINE RELAGARD 4

VAGINAL ESTROGEN PREPARATIONSestradiol ESTRACE 2ESTRADIOL ESTRING 3 QL: 1 IN 90 DAYSestradiol VAGIFEM 2ESTRADIOL ACETATE FEMRING 3 QL: 1 IN 84 DAYSESTROGENS, CONJUGATED PREMARIN 3

VAGINAL SULFONAMIDESSULFANILAMIDE AVC 3




VITAMIN AND/OR MINERAL DEFICIENCYFLUORIDE PREPARATIONS

FLUORIDE (SODIUM) CLINPRO 5000 2fluoride (sodium) (1.1 %) (cream (g)) 2fluoride (sodium) (1.1 %) (gel (gram)) 2FLUORIDE (SODIUM) FLUORIDEX 2FLUORIDE (SODIUM) PREVIDENT 3

FLUORIDE (SODIUM) PREVIDENT5000 3

SODIUM FLUORIDE/POTASSIUM NITPREVIDENT5000 ENAMELPROTECT

3

SODIUM FLUORIDE/POTASSIUM NIT PREVIDENT5000 SENSITIVE 3

FOLIC ACID PREPARATIONS

folic acid (1 mg) (tablet) 1 AGE: $0 COPAY IF AGE >= 50YEARS

folic acid (5 mg/ml) (vial) 2 AGE: $0 COPAY IF AGE >= 50YEARS

PRENATAL VITAMIN PREPARATIONSmv, min 59/iron/folic/docusate 1PNV 102/IRON/FOLATE 1/DSS/DHA VITAFOL FE+ 3pnv 11/iron fum/folic acid/om3 1pnv 112/iron/folic/om3/dha/epa 2

PNV 117/IRON/FOLIC/OM3/DHA/EPA DUET DHABALANCED 3

pnv 15/iron fum,ps/folic acid CONCEPT OB 2pnv 16/iron fum,ps/folic/om-3 CONCEPT DHA 2

PNV 19/IRON PS,HEME/FOLIC/DHA PREFERA-OBONE 4

pnv 21/iron ps,heme ppep/folic PREFERA OB 2PNV 22/IRON,GLUC/FOLIC/DSS/DHA PNV OB+DHA 4

PNV 30/IRON CARB,AG/FOLIC/OM3 OB COMPLETEWITH DHA 3

pnv 39/iron/folic/docusate/dha 2PNV 55/IRON FUM,B-G/FOLIC ACID NATACHEW 3pnv 66/iron/folic/docusate/dha 2PNV 67/IRON PS/FOLATE NO.1/DHA VITAFOL ULTRA 3

pnv 69/iron/folic/docusate/dha CITRANATALHARMONY 2

PNV 76/IRON,GLUC/FOLIC/DSS/DHA CITRANATALDHA 3

pnv 80/iron fum/folic/dss/dha NEXA SELECT 2

PNV 85/IRON/FOLIC/DHA/FISH OIL OB COMPLETEONE 3

PNV NO.106/IRON/FOLATE NO6/DHA OB COMPLETEGOLD 3

pnv no.118/iron fumarate/fa (29 mg-1 mg)(tab chew) 3

pnv no.5/ferrous fum/folic ac 2



Drug Name Tier Requirements/Limitspnv no.66/iron,carb/folic/dha ACTIVE OB 2PNV NO.80/IRON/MFOLATE/DSS/DHA FOLET ONE 3

PNV NO.80/IRON/MFOLATE/DSS/DHA OBSTETRIXONE 3

PNV NO.88/IRON PS,HEME/FA/DHA PREFERA-OBPLUS DHA 3

pnv, calcium 70/iron/folic/dha NATELLE ONE 2pnv,calcium 72/iron,carb/folic 1pnv,calcium 72/iron/folic acid 1pnv/ferrous fum/docusate/folic 1pnv/iron,carb/docusat/folic ac 1pnv119/iron fum/folic/docusate 1PNV119/IRON FUM/FOLIC/DOCUSATE PRENATAL 19 1PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS 3

PNV59/IRON,CARB,FUM/FA/DSS/DHA CITRANATALHARMONY 4

PNV72/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL 90DHA 4

PNV73/IRON,GLUC/FOLIC/DSS/DHA CITRANATALASSURE 4

pnv81/iron edta,ps/folic/omeg3 2

PNV83/IRON,CARB,ASP/FOLIC ACID OB COMPLETEPREMIER 3

prenat 115/iron fum/folic/dss (29-1-25 mg)(tablet) 3

prenat vit 17/iron/folic/om3,6 2PRENAT90/IRON FUM,PS/FOLIC/DHA PROVIDA DHA 3prenatal 105/iron/folic ac/dha VITATRUE 2PRENATAL 114/IRON A-G/FOLATE 1 PRENATE ELITE 3prenatal 12/iron/folic/dss/om3 OBTREX DHA 1

PRENATAL 25/IRON/FOLATE 6/DHA VITAMEDMDONE RX 3

PRENATAL 26/IRON PS/FOLIC/DHA VITAFOL-ONE 3

prenatal 34/iron/folic/dss/dha CITRANATALHARMONY 2

PRENATAL 38/IRON/FOLATE 6/DHA PRENATE DHA 3prenatal 47/iron/folate 1/dha 2prenatal 53/iron/folic ac/omg3 1prenatal 57/iron/folic/dss/dha 2

prenatal 59/iron/folic/dss/dha CITRANATALHARMONY 2

prenatal 68/iron/folic no1/dha 2PRENATAL 78/IRON/FOLATE 1/DHA PRENATE DHA 3PRENATAL 86/IRON/FOLIC/DHA/EPA NESTABS ABC 3PRENATAL 87/IRON BIS/FOLIC/DHA NESTABS DHA 4PRENATAL 93/IRON/FOLATE 9/DHA TRISTART DHA 3

prenatal comb no.42/folic acid VITAMEDMDREDICHEW RX 2

PRENATAL NO.123/IRON/FOLIC AC ELITE-OB 1PRENATAL NO.123/IRON/FOLIC AC OB COMPLETE 3



Drug Name Tier Requirements/Limitsprenatal no.52/iron/fa/dha 1prenatal no.75/iron/folate no1 2PRENATAL NO.77/IRON ASP GLY/FA PRENATE STAR 3prenatal no115/iron/folic acid 1prenatal no13/iron ps/folate 1 2

PRENATAL NO35/IRON/FOLATE6/DHA PRENATEESSENTIAL 3

prenatal no4/iron fum,ps/folic 1PRENATAL VIT 10/IRON FUM/FOLIC VITAFOL-OB 3prenatal vit 10/iron/folic/dha 2prenatal vit 14/iron fum/folic 3

PRENATAL VIT 33/IRON/FOLIC/DHA SELECT-OB +DHA 3

PRENATAL VIT 36/IRON/FOLATE 6 PRENATE ELITE 3PRENATAL VIT 65/IRON FUM,PS/FA PROVIDA OB 3

PRENATAL VIT 84/IRON/FA 1/DHA PRENATEESSENTIAL 3

PRENATAL VIT 85/IRON/FA 1/DHA PRENATE PIXIE 3PRENATAL VIT 87/IRON/FOLIC/DHA PRENATE MINI 3

PRENATAL VIT NO.112/FOLATE NO6 PRENATECHEWABLE 3

prenatal vit no.127/iron/folic 1prenatal vit,cal 73/iron/folic 1prenatal vit,cal 74/iron/folic 1prenatal vit,calc76/iron/folic 3PRENATAL VIT,CALC76/IRON/FOLIC THRIVITE RX 3prenatal vit,calc78/iron/folic 1prenatal vit/iron bisgly/folic 1prenatal vit/iron fum/folic ac (65 mg-1 mg)(capsule) 1

prenatal vit/iron fum/folic ac (65 mg-1 mg)(tablet) 1

PRENATAL VIT103/IRON FUM/FOLIC TRICARE 3PRENATAL VIT106/IRON/FOLIC/OM3 DUET DHA 400 3prenatal vit108/iron,crb/folic 2PRENATAL VIT114/FOLATE6/GINGER PRENATE AM 3PRENATAL VIT127/IRON/FOLIC/DSS OBSTETRIX EC 3prenatal vit128/iron/folic acd 2prenatal vit136/iron/folic acd 1

prenatal vit22/iron/folic/om3s PREFERA-OBPLUS DHA 2

prenatal vit27,calcium/iron/fa TRINATAL RX 1 1PRENATAL VIT37/IRON/FOLIC ACID PRENATA 3

PRENATAL VIT68/IRON/FA NO6/DHA PRENATEENHANCE 3

PRENATAL VIT69/IRON/FOLATE6/DH PRENATERESTORE 3

prenatal vit86/iron/folic acid NESTABS 2prenatal vits15/iron/folic/dss 1prenatal vits16/iron/folic/dss 1



Drug Name Tier Requirements/Limitsprenatal vits18/iron/folic/dss 1prenatal,calc no.65/iron/folic 2prenatal,calc.40/iron/folate 1 2

PRENATAL56/IRON/FOLIC ACID/DHA OB COMPLETEPETITE 3

prenatal64/iron/lmfolate/algal NEEVODHA 2prenatal71/iron/folic acid/dha VITAPEARL 2

PRENATAL72/IRON FUM/FA/OM3/DHA PRENATALPLUS-DHA 3

PRENATAL81/IRON/FOLIC/DOCUSATE CITRANATALRX 3

PRENATAL92/IRON/FOLATE8/PS-DHA ENBRACE HR 3PRENATAL VITAMINS WITHOUT IRON

pnv/folic ac/b6/calcium/ginger B-NEXA 2VITAMIN B PREPARATIONS

POTASSIUM AMINOBENZOATE POTABA 3VITAMIN B12 PREPARATIONS

cyanocobalamin (vitamin b-12) (1000mcg/ml)(vial) 2

CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL 3VITAMIN D PREPARATIONS

calcitriolROCALTROL(0.25 MCG)(CAPSULE)

2

calcitriolROCALTROL (0.5MCG)(CAPSULE)

2

ergocalciferol (vitamin d2) (50000 unit)(capsule) 1 AGE: $0 COPAY IF AGE >= 65

YEARSWEIGHT REDUCTION

ANOREXIC AGENTSbenzphetamine hcl DIDREX 2benzphetamine hcl REGIMEX 2diethylpropion hcl 2phendimetrazine tartrate BONTRIL PDM 2phentermine hcl 2PHENTERMINE/TOPIRAMATE QSYMIA 4

ANTI-OBESITY - OPIOID ANTAG/NOREPI & DA REUP INHIBNALTREXONE HCL/BUPROPION HCL CONTRAVE 3

ANTI-OBESITY GLUCAGON-LIKE PEPTIDE-1 RECEP AGONISTLIRAGLUTIDE SAXENDA 3

FAT ABSORPTION DECREASING AGENTSORLISTAT XENICAL 3

SEROTONIN 2C RECEPTOR AGONISTSLORCASERIN HCL BELVIQ 3



STEP THERAPY EDITS • AUVI-Q (0.15/0.15) (AUTOINJCT)

At least 2 prior prescriptions for Epinephrine, Epipen 2-pak, Epipen Jr2-pak, or Epipen in the last 365 days

• BELSOMRA Prior prescription for Eszopiclone, Zaleplon, or Zolpidem Tartrate inthe last 120 days

• FANAPT At least 2 prior prescriptions for Abilify Maintena, Abilify,Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• FETZIMA At least 2 prior prescriptions for Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Mirtazapine,Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in the last365 days

• GRALISE (300 MG) (TAB ER24H) Prior prescription for Gabapentin or Gralise in the last 120 days• GRALISE (600 MG) (TAB ER24H) Prior prescription for Gabapentin or Gralise in the last 120 days• LATUDA At least 2 prior prescriptions for Abilify Maintena, Abilify,

Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• PRESTALIA At least 2 prior prescriptions for Amlodipine Besylate, AmlodipineBesylate/benazepril, Benazepril HCL, Captopril, Enalapril Maleate,Epaned, Fosinopril Sodium, Lisinopril, Moexipril HCL, PerindoprilErbumine, Qbrelis, Quinapril HCL, Ramipril, or Trandolapril in thelast 365 days

• SOLOSEC At least 2 prior prescriptions for Clindamycin HCL, ClindamycinPhosphate, Metronidazole, Tinidazole, or Vandazole in the last 120days

• SYNDROS Prior prescription for Dronabinol in the last 120 days• TREXIMET (10 MG-60MG)(TABLET)

Prior prescription for Alsuma, Onzetra Xsail, Sumatriptan Succinate,Sumatriptan, Sumavel Dosepro, Zecuity, or Zembrace Symtouch in thelast 180 days

• TREXIMET (85MG-500MG)(TABLET)

Prior prescription for Alsuma, Onzetra Xsail, Sumatriptan Succinate,Sumatriptan, Sumavel Dosepro, Zecuity, or Zembrace Symtouch in thelast 180 days

• TROKENDI XR (100 MG) (CAPER 24H) Prior prescription for Topiramate in the last 120 days• TROKENDI XR (200 MG) (CAPER 24H) Prior prescription for Topiramate in the last 120 days• TROKENDI XR (25 MG) (CAP ER24H) Prior prescription for Topiramate in the last 120 days• TROKENDI XR (50 MG) (CAP ER24H) Prior prescription for Topiramate in the last 120 days• ULORIC Prior prescription for Allopurinol or Uloric in the last 120 days• VIIBRYD At least 2 prior prescriptions for Bupropion HCL, Citalopram

Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Mirtazapine,Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in the last365 days

• VRAYLAR (1.5 MG) (CAPSULE) At least 2 prior prescriptions for Abilify Maintena, Abilify,Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,

Medication Prescribing Limitations


Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• VRAYLAR (3 MG) (CAPSULE) At least 2 prior prescriptions for Abilify Maintena, Abilify,Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• VRAYLAR (4.5 MG) (CAPSULE) At least 2 prior prescriptions for Abilify Maintena, Abilify,Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• VRAYLAR (6 MG) (CAPSULE) At least 2 prior prescriptions for Abilify Maintena, Abilify,Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate,Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last365 days

• XATMEP Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf,or Trexall in the last 120 days

Medication Prescribing Limitations


- # -0.9 % SODIUM CHLORIDE.................................. 420.9 % SODIUM CHLORIDE (0.9 %) (SYRINGE)....1ST TIER UNIFINE PENTIPS............................... 921ST TIER UNIFINE PENTIPS PLUS.................... 92

- A -ABACAVIR SULFATE........................................... 62ABACAVIR SULFATE/LAMIVUDINE.................62ABACAVIR/DOLUTEGRAVIR/LAMIVUDI........ 64ABACAVIR/LAMIVUDINE/ZIDOVUDINE.........62ABALOPARATIDE.................................................43ABATACEPT...........................................................66ABILIFY..................................................................11ABIRATERONE ACETATE................................... 87ABSORICA............................................................. 28ACAMPROSATE CALCIUM.................................11ACARBOSE............................................................ 38ACCOLATE...............................................................5ACCUPRIL..............................................................17ACCURETIC (10-12.5MG) (TABLET)..................16ACCURETIC (20 MG-25MG) (TABLET)............. 16ACCURETIC (20-12.5 MG) (TABLET).................16ACEBUTOLOL HCL..............................................18ACEON....................................................................17ACETAMINOPHEN WITH CODEINE................. 99ACETAZOLAMIDE................................................47ACETIC ACID........................................................ 41ACETIC ACID/OXYQUINOLINE.......................112ACETOHYDROXAMIC ACID.............................. 70ACETYLCYSTEINE.............................................. 94ACIPHEX.............................................................. 111ACITRETIN............................................................ 36ACLIDINIUM BROMIDE........................................ 3ACLOVATE............................................................. 31ACTEMRA (162 MG/0.9) (SYRINGE)..................67ACTICLATE............................................................58ACTIGALL............................................................. 70ACTIMMUNE.........................................................54ACTIQ..................................................................... 95ACTIVE OB.......................................................... 114ACTIVELLA........................................................... 53ACTIVE-PAC........................................................ 103ACTOPLUS MET................................................... 39ACTOPLUS MET XR.............................................39ACTOS.................................................................... 38ACULAR................................................................. 46ACULAR LS........................................................... 46ACUVAIL................................................................ 46ACYCLOVIR.............................................. 30, 31, 61ACYCLOVIR/HYDROCORTISONE..................... 31ACZONE (5 %) (GEL (GRAM))............................ 28ACZONE (7.5 %) (GEL W/PUMP)........................ 28ADALAT CC........................................................... 20ADALIMUMAB..................................................... 66

ADAPALENE..........................................................29ADASUVE.............................................................. 11ADCIRCA............................................................... 21ADDERALL............................................................10ADDERALL XR (10 MG) (CAP ER 24H).............10ADDERALL XR (15 MG) (CAP ER 24H).............10ADDERALL XR (20 MG) (CAP ER 24H).............10ADDERALL XR (25 MG) (CAP ER 24H).............10ADDERALL XR (30 MG) (CAP ER 24H).............10ADDERALL XR (5 MG) (CAP ER 24H)...............10ADEFOVIR DIPIVOXIL........................................ 64ADEMPAS...............................................................20ADMELOG............................................................. 40ADMELOG SOLOSTAR........................................ 40ADOXA................................................................... 58ADRENALIN CHLORIDE.....................................28ADVAIR DISKUS..................................................... 3ADVAIR HFA............................................................3ADVOCATE PEN NEEDLE................................... 92ADVOCATE PEN NEEDLES.................................92ADVOCATE SYRINGES............................72, 84, 85AEROCHAMBER MINI...........................................5AEROCHAMBER MV............................................. 5AEROCHAMBER PLUS FLOW-VU................... 5, 6AEROCHAMBER WITH FLOWSIGNAL...............5AEROCHAMBER Z-STAT PLUS........................ 5, 6AEROSPAN...............................................................4AFINITOR (10 MG) (TABLET)............................. 88AFINITOR (2.5 MG) (TABLET)............................ 88AFINITOR (5 MG) (TABLET)............................... 88AFINITOR (7.5 MG) (TABLET)............................ 88AFINITOR DISPERZ..............................................88AFREZZA (12 UNIT) (CART INHAL)..................40AFREZZA (4 UNIT(60)) (CART INHAL).............40AFREZZA (4 UNIT(90)) (CART INHAL).............40AFREZZA (4 UNIT) (CART INHAL)....................40AFREZZA (4-8-12(60)) (CART INHAL)...............41AFREZZA (8 UNIT) (CART INHAL)....................41AGGRENOX........................................................... 51AGRYLIN................................................................51AIRDUO RESPICLICK............................................4AKTEN....................................................................46AKTIPAK................................................................ 29AKYNZEO................................................................ 2ALA-QUIN..............................................................29ALBENDAZOLE.................................................... 60ALBENZA (200 MG) (TABLET)...........................60ALBUTEROL SULFATE..........................................3ALBUTEROL SULFATE (2 MG) (TABLET)............ALBUTEROL SULFATE (2 MG/5 ML) (SYRUP)....ALBUTEROL SULFATE (4 MG) (TAB ER 12H)......ALBUTEROL SULFATE (4 MG) (TABLET)............ALBUTEROL SULFATE (8 MG) (TAB ER 12H)......ALCLOMETASONE DIPROPIONATE................. 31


Index

ALDACTAZIDE (25 MG-25MG) (TABLET)........ 20ALDACTAZIDE (50 MG-50MG) (TABLET)........ 20ALDACTONE......................................................... 20ALDARA.................................................................54ALDESLEUKIN......................................................54ALDOMET..............................................................17ALENDRONATE SODIUM....................................43ALENDRONATE SODIUM/VITAMIN D3............43ALFERON N........................................................... 54ALFUZOSIN HCL................................................ 111ALINIA....................................................................61ALIROCUMAB.......................................................24ALISKIREN HEMIFUMARATE........................... 21ALISKIREN/HYDROCHLOROTHIAZIDE.......... 21ALITRETINOIN..................................................... 35ALLERGIST TRAY.......................................... 72, 74ALLERGIST TRAY SYR-DETACH NDL............. 75ALLERGIST TRAY SYR-PERM NEEDLE...........72ALLERGY SYRINGE............................................ 74ALLOPURINOL..................................................... 48ALLZITAL.............................................................. 94ALMOTRIPTAN MALATE.................................... 98ALOCRIL................................................................ 47ALOGLIPTIN BENZ/METFORMIN HCL............ 37ALOGLIPTIN BENZ/PIOGLITAZONE................ 37ALOGLIPTIN BENZOATE.................................... 38ALOMIDE...............................................................47ALORA....................................................................52ALOSETRON HCL.................................................70ALPHAGAN........................................................... 47ALPHAGAN P (0.1 %) (DROPS)...........................47ALPHAGAN P (0.15 %) (DROPS).........................47ALPRAZOLAM...................................................... 11ALPRAZOLAM INTENSOL.....................................ALREX.................................................................... 46ALTABAX............................................................... 31ALTACE.................................................................. 17ALUMINUM CHLORIDE......................................34ALVESCO................................................................. 4AMANTADINE HCL............................................101AMARYL................................................................ 38AMBIEN..................................................................14AMBIEN CR........................................................... 14AMBRISENTAN.....................................................21AMCINONIDE........................................................32AMERGE................................................................ 98AMILORIDE HCL..................................................20AMILORIDE/HYDROCHLOROTHIAZIDE.........20AMINOLEVULINIC ACID HCL...........................90AMINOSALICYLIC ACID.................................... 60AMIODARONE HCL............................................. 15AMITIZA................................................................ 71AMITRIPTYLINE HCL........................................... 9AMLODIPINE BES/OLMESARTAN MED.......... 17

AMLODIPINE BESYLATE................................... 19AMLODIPINE BESYLATE/BENAZEPRIL.......... 16AMLODIPINE BESYLATE/VALSARTAN........... 17AMLODIPINE/ATORVASTATIN...........................25AMLODIPINE/VALSARTAN/HCTHIAZID......... 16AMMONIUM LACTATE........................................34AMMONIUM LACTATE (12 %) (CREAM (G)).......AMMONIUM LACTATE (12 %) (LOTION).............AMOXICILLIN.......................................................57AMOXICILLIN/POTASSIUM CLAV.............. 57, 58AMOXIL (125 MG/5ML) (SUSP RECON)........... 57AMOXIL (200 MG/5ML) (SUSP RECON)........... 57AMOXIL (250 MG) (CAPSULE)...........................57AMOXIL (250 MG) (TAB CHEW)........................ 57AMOXIL (250 MG/5ML) (SUSP RECON)........... 57AMOXIL (400 MG/5ML) (SUSP RECON)........... 57AMOXIL (500 MG) (CAPSULE)...........................57AMOXIL (500 MG) (TABLET)..............................57AMOXIL (875 MG) (TABLET)..............................57AMPHETAMINE.................................................... 10AMPHETAMINE SULFATE.................................. 10AMPICILLIN.......................................................... 58AMPICILLIN TRIHYDRATE................................ 58AMPYRA................................................................ 90AMRIX.................................................................. 108ANACAINE.............................................................35ANADROL-50.........................................................52ANAFRANIL............................................................ 9ANAGRELIDE HCL...............................................51ANALPRAM HC.................................................... 70ANAPROX.............................................................. 69ANAPROX DS........................................................ 69ANASTIA................................................................36ANASTROZOLE.....................................................88ANCOBON..............................................................59ANDRODERM........................................................52ANDROGEL (1.25G-1.62) (GEL PACKET).......... 52ANDROGEL (12.5/1.25G) (GEL MD PMP)..........52ANDROGEL (2.5G-1.62%) (GEL PACKET).........52ANDROGEL (20.25/1.25) (GEL MD PMP)...........52ANDROGEL (25MG(1%)) (GEL PACKET)..........52ANDROGEL (50 MG (1%)) (GEL PACKET)........52ANDROID............................................................... 52ANGELIQ................................................................52ANORO ELLIPTA.................................................... 3ANSAID.................................................................. 68ANTABUSE............................................................ 11ANTARA (130 MG) (CAPSULE).......................... 24ANTARA (30 MG) (CAPSULE)............................ 24ANTARA (43 MG) (CAPSULE)............................ 24ANTARA (90 MG) (CAPSULE)............................ 24ANTHRALIN.......................................................... 36ANTHRALIN MICRONIZED................................ 36ANUSOL-HC.......................................................... 70


Index

ANZEMET (100 MG) (TABLET)............................ 2ANZEMET (50 MG) (TABLET).............................. 2APALUTAMIDE..................................................... 87APEXICON E..........................................................32APIDRA.................................................................. 40APIDRA SOLOSTAR............................................. 40APIXABAN.............................................................49APLENZIN................................................................7APOKYN...............................................................101APOMORPHINE HCL......................................... 101APRACLONIDINE HCL........................................ 47APREMILAST........................................................ 66APREPITANT........................................................... 2APRESOLINE.........................................................17APRISO................................................................... 69APTENSIO XR....................................................... 14APTIOM (400 MG) (TABLET)............................ 102APTIOM (600 MG) (TABLET)............................ 102APTIOM (800 MG) (TABLET)............................ 102APTIVUS................................................................ 61ARANESP (100 MCG/ML) (VIAL)....................... 49ARANESP (100MCG/0.5) (SYRINGE)................. 49ARANESP (10MCG/0.4) (SYRINGE)................... 49ARANESP (150MCG/0.3) (SYRINGE)................. 49ARANESP (200 MCG/ML) (VIAL)....................... 49ARANESP (200MCG/0.4) (SYRINGE)................. 49ARANESP (25 MCG/ML) (VIAL)......................... 49ARANESP (25MCG/0.42) (SYRINGE)................. 49ARANESP (300 MCG/ML) (VIAL)....................... 49ARANESP (300MCG/0.6) (SYRINGE)................. 49ARANESP (40 MCG/0.4) (SYRINGE).................. 49ARANESP (40 MCG/ML) (VIAL)......................... 49ARANESP (500 MCG/ML) (SYRINGE)............... 49ARANESP (60 MCG/0.3) (SYRINGE).................. 50ARANESP (60MCG/ML) (VIAL).......................... 50ARAVA.................................................................... 66ARCAPTA NEOHALER.......................................... 3ARICEPT...................................................................7ARICEPT ODT......................................................... 7ARIMIDEX............................................................. 88ARIPIPRAZOLE.....................................................11ARIXTRA (10MG/0.8ML) (SYRINGE)................ 51ARIXTRA (2.5 MG/0.5) (SYRINGE).................... 51ARIXTRA (5MG/0.4ML) (SYRINGE).................. 51ARIXTRA (7.5MG/0.6) (SYRINGE)..................... 51ARMODAFINIL..................................................... 13ARMONAIR RESPICLICK......................................4ARMOUR THYROID.............................................45ARNUITY ELLIPTA (100 MCG) (BLST W/DEV)................................................................................... 4ARNUITY ELLIPTA (200 MCG) (BLST W/DEV)................................................................................... 4AROMASIN............................................................ 88ARTANE (2 MG) (TABLET)................................ 100

ARTANE (5 MG) (TABLET)................................ 100ARTEMETHER/LUMEFANTRINE.......................60ARTHROTEC 50.....................................................68ARTHROTEC 75.....................................................68ASACOL HD...........................................................69ASMANEX................................................................5ASMANEX HFA.......................................................5ASPIRIN/DIPYRIDAMOLE.................................. 51ASSURE ID INSULIN SAFETY......................80, 81ASSURE ID PEN NEEDLE....................................93ASTAGRAF XL...................................................... 54ASTELIN...................................................................1ASTEPRO..................................................................1ATACAND...............................................................17ATACAND HCT......................................................16ATARAX (10 MG) (TABLET)..................................1ATARAX (10 MG/5 ML) (SOLUTION)...................1ATARAX (25 MG) (TABLET)..................................1ATARAX (50 MG) (TABLET)..................................1ATAZANAVIR SULFATE.......................................63ATAZANAVIR SULFATE/COBICISTAT...............63ATENOLOL............................................................ 18ATENOLOL/CHLORTHALIDONE.......................18ATOMOXETINE HCL............................................15ATORVASTATIN CALCIUM................................. 22ATOVAQUONE.......................................................61ATOVAQUONE/PROGUANIL HCL...................... 60ATRALIN................................................................ 29ATRIPLA.................................................................64ATROPINE SULFATE............................................ 48ATROVENT.........................................................2, 91ATROVENT HFA......................................................2AUBAGIO............................................................... 90AUGMENTIN (125-31.25/) (SUSP RECON)........ 57AUGMENTIN (200-28.5/5) (SUSP RECON)........ 57AUGMENTIN (200-28.5MG) (TAB CHEW).........57AUGMENTIN (250-125 MG) (TABLET).............. 57AUGMENTIN (250-62.5/5) (SUSP RECON)........ 57AUGMENTIN (400-57MG/5) (SUSP RECON)..... 57AUGMENTIN (500-125 MG) (TABLET).............. 58AUGMENTIN (875-125 MG) (TABLET).............. 58AUGMENTIN ES-600............................................ 58AUGMENTIN XR...................................................58AURANOFIN.......................................................... 67AUTOSHIELD DUO PEN NEEDLE......................93AUVI-Q (0.15/0.15) (AUTO INJCT).............. 86, 117AUVI-Q (0.1MG/.1ML) (AUTO INJCT)................86AVALIDE.................................................................16AVANDIA................................................................38AVAPRO.................................................................. 17AVAR (10-5%(W/W)) (CLEANSER)..................... 31AVAR LS (10 %-2 %) (CLEANSER)..................... 31AVC....................................................................... 112AVELOX..................................................................58


Index

AVELOX ABC PACK............................................. 58AVIDOXY............................................................... 58AVIDOXY DK.........................................................59AVODART.............................................................111AVONEX................................................................. 90AVONEX PEN.........................................................90AXID (150 MG) (CAPSULE)...............................110AXID (300 MG) (CAPSULE)...............................110AYGESTIN..............................................................53AZASAN................................................................. 54AZASITE.................................................................46AZATHIOPRINE.................................................... 54AZELAIC ACID......................................................28AZELASTINE HCL............................................1, 45AZELEX..................................................................28AZILECT...............................................................101AZILSARTAN MED/CHLORTHALIDONE......... 16AZILSARTAN MEDOXOMIL............................... 17AZITHROMYCIN.............................................46, 56AZOPT.................................................................... 47AZOR...................................................................... 17AZTREONAM LYSINE..........................................55AZULFIDINE..........................................................70

- B -BACITRACIN......................................................... 46BACITRACIN/POLYMYXIN B SULFATE........... 46BACLOFEN...........................................................108BACLOFEN (10 MG) (TABLET)...............................BACLOFEN (20 MG) (TABLET)...............................BACTERIOSTATIC SODIUM CHLORIDE.......... 42BACTERIOSTATIC SODIUM CHLORIDE (0.9 %)(VIAL).........................................................................BACTROBAN......................................................... 29BALSALAZIDE DISODIUM.................................69BANZEL (200 MG) (TABLET)............................ 106BANZEL (40 MG/ML) (ORAL SUSP)................ 106BANZEL (400 MG) (TABLET)............................ 106BARACLUDE (0.5 MG) (TABLET)...................... 64BARACLUDE (1 MG) (TABLET)......................... 64BASAGLAR KWIKPEN U-100............................. 39BAXDELA.............................................................. 58B-CAINE/ZINC CL/PINE/CETYLPYRD..............69BECLOMETHASONE DIPROPIONATE............ 1, 4BEDAQUILINE FUMARATE................................ 60BELBUCA...............................................................94BELIMUMAB.........................................................67BELLADONNA-PHENOBARBITAL.................. 109BELSOMRA....................................................14, 117BELVIQ................................................................. 116BENAZEPRIL HCL................................................ 17BENAZEPRIL/HYDROCHLOROTHIAZIDE....... 16BENEMID............................................................... 48BENICAR................................................................17BENICAR HCT.......................................................16

BENLYSTA (200 MG/ML) (AUTO INJCT)...........67BENLYSTA (200 MG/ML) (SYRINGE)................ 67BENOXINATE HCL/FLUORESCEIN SOD.......... 46BENRALIZUMAB....................................................5BENSAL HP............................................................35BENZACLIN...........................................................28BENZAMYCIN.......................................................29BENZOCAINE........................................................35BENZODOX 30...................................................... 59BENZODOX 60...................................................... 59BENZONATATE..................................................... 27BENZOYL PEROXIDE.......................................... 35BENZOYL PEROXIDE (5.3%) (FOAM)...................BENZOYL PEROXIDE (6 %) (TOWELETTE).........BENZOYL PEROXIDE (7 %) (CLEANSER)............BENZOYL PEROXIDE (9.8 %) (FOAM)..................BENZOYL PEROXIDE MICROSPHERES........... 35BENZOYL PEROXIDE/HYDROCORTISON....... 28BENZOYL PEROXIDE/VIT E MIX...................... 35BENZPHETAMINE HCL..................................... 116BENZTROPINE MESYLATE.............................. 100BENZYL ALCOHOL............................................. 30BEPOTASTINE BESILATE....................................45BEPREVE................................................................45BESIFLOXACIN HCL............................................46BESIVANCE........................................................... 46BETAGAN...............................................................47BETAINE.................................................................91BETAMETHASONE DIPROPIONATE................. 32BETAMETHASONE VALERATE......................... 32BETAMETHASONE/PROPYLENE GLYC........... 32BETASERON.......................................................... 90BETAXOLOL HCL...........................................18, 47BETHANECHOL CHLORIDE...............................87BETHKIS................................................................ 59BETIMOL................................................................48BETOPTIC.............................................................. 47BETOPTIC S........................................................... 47BEXAROTENE................................................. 35, 90BEYAZ.................................................................... 26BIAXIN................................................................... 56BIAXIN XL............................................................. 56BICALUTAMIDE................................................... 87BICTEGRAV/EMTRICIT/TENOFOV ALA.......... 64BIDIL.......................................................................22BIKTARVY............................................................. 64BILTRICIDE........................................................... 60BIMATOPROST......................................................47BINOSTO................................................................ 43BISAC/NACL/NAHCO3/KCL/PEG 3350.............. 70BISMUTH/METRONID/TETRACYCLINE........ 110BISOPROLOL FUMARATE.................................. 18BISOPROLOL/HYDROCHLOROTHIAZIDE.......18BLEPHAMIDE........................................................46


Index

BLEPHAMIDE S.O.P..............................................46BLOCADREN (20 MG) (TABLET)....................... 18B-NEXA................................................................ 116BONIVA.................................................................. 43BONTRIL PDM.................................................... 116BOSENTAN............................................................ 21BOSULIF (100 MG) (TABLET).............................88BOSULIF (500 MG) (TABLET).............................88BOSUTINIB............................................................ 88BP 10-1.................................................................... 31BRAVELLE............................................................. 42BREO ELLIPTA........................................................4BREXPIPRAZOLE................................................. 11BRILINTA............................................................... 51BRIMONIDINE TARTRATE............................28, 47BRIMONIDINE TARTRATE/TIMOLOL...............47BRINZOLAMIDE...................................................47BRINZOLAMIDE/BRIMONIDINE TART............ 47BRISDELLE..............................................................8BRIVARACETAM................................................ 102BRIVIACT (10 MG) (TABLET)...........................102BRIVIACT (10 MG/ML) (SOLUTION)...............102BRIVIACT (100 MG) (TABLET).........................102BRIVIACT (25 MG) (TABLET)...........................102BRIVIACT (50 MG) (TABLET)...........................102BRIVIACT (75 MG) (TABLET)...........................102BROMFENAC SODIUM........................................ 45BROMOCRIPTINE MESYLATE...................38, 101BROMPHENIRAMINE/PSEUDOEPHED/DM..... 28BROMPHENIRAMINE/PSEUDOEPHED/DM (2-30-10/5) (SYRUP).......................................................BUCALSEP (SOLUTION)..................................... 69BUDESONIDE....................................................4, 66BUDESONIDE/FORMOTEROL FUMARATE....... 3BULK SYRINGE........................................ 76, 77, 79BUMETANIDE....................................................... 20BUMEX...................................................................20BUNAVAIL (2.1-0.3 MG) (FILM)........................ 100BUNAVAIL (4.2-0.7 MG) (FILM)........................ 100BUNAVAIL (6.3MG-1MG) (FILM)......................100BUPHENYL............................................................ 70BUPRENORPHINE................................................ 94BUPRENORPHINE HCL................................. 94, 99BUPRENORPHINE HCL/NALOXONE HCL..... 100BUPROPION HBR....................................................7BUPROPION HCL............................................7, 108BUSPAR.................................................................. 11BUSPIRONE HCL.................................................. 11BUSULFAN.............................................................87BUTABARBITAL SODIUM...................................13BUTALB/ACETAMINOPHEN/CAFFEINE.......... 94BUTALBIT/ACETAMIN/CAFF/CODEINE.......... 99BUTALBITAL/ACETAMINOPHEN...................... 94

BUTALBITAL/ACETAMINOPHEN (50MG-300MG) (TABLET).....................................................BUTALBITAL/ACETAMINOPHEN (50MG-325MG) (TABLET).....................................................BUTALBITAL/ASPIRIN/CAFFEINE.................... 94BUTALBITAL/ASPIRIN/CAFFEINE (50-325-40)(CAPSULE).................................................................BUTENAFINE HCL............................................... 29BUTISOL SODIUM................................................13BUTOCONAZOLE NITRATE............................. 112BUTORPHANOL TARTRATE...............................94BUTRANS...............................................................94BYDUREON........................................................... 37BYDUREON PEN...................................................37BYETTA (10MCG/0.04) (PEN INJCTR)............... 37BYETTA (5MCG/0.02) (PEN INJCTR)................. 37BYSTOLIC..............................................................18

- C -C1 ESTERASE INHIBITOR...................................66CABERGOLINE..................................................... 44CABOMETYX........................................................ 88CABOZANTINIB S-MALATE...............................88CADEXOMER IODINE......................................... 29CADUET................................................................. 25CAFERGOT............................................................ 98CALAN....................................................................20CALAN SR..............................................................20CALCIPOTRIENE.................................................. 36CALCIPOTRIENE/BETAMETHASONE.............. 37CALCITONIN,SALMON,SYNTHETIC................43CALCITRIOL..................................................36, 116CALCIUM ACETATE.............................................41CAMBIA................................................................. 98CAMPRAL.............................................................. 11CANAGLIFLOZIN................................................. 37CANAGLIFLOZIN/METFORMIN HCL............... 38CANAKINUMAB/PF............................................. 66CANASA................................................................. 69CANDESARTAN CILEXETIL...............................17CANDESARTAN/HYDROCHLOROTHIAZID.....16CAPECITABINE.....................................................87CAPEX SHAMPOO................................................32CAPOTEN............................................................... 17CAPRELSA (100 MG) (TABLET)......................... 89CAPRELSA (300 MG) (TABLET)......................... 89CAPTOPRIL............................................................17CARAC....................................................................35CARAFATE (1 G) (TABLET)...............................110CARAFATE (1 G/10 ML) (ORAL SUSP)............ 110CARBAGLU............................................................70CARBAMAZEPINE....................................... 11, 102CARBAMAZEPINE (100 MG) (CPMP 12HR).........CARBAMAZEPINE (100 MG) (TAB CHEW)..........CARBAMAZEPINE (100 MG) (TAB ER 12H).........


Index

CARBAMAZEPINE (200 MG) (CPMP 12HR).........CARBAMAZEPINE (200 MG) (TAB ER 12H).........CARBAMAZEPINE (200 MG) (TABLET)................CARBAMAZEPINE (300 MG) (CPMP 12HR).........CARBAMAZEPINE (400 MG) (TAB ER 12H).........CARBATROL........................................................102CARBIDOPA.........................................................101CARBIDOPA/LEVODOPA.................................. 101CARBIDOPA/LEVODOPA/ENTACAPONE....... 101CARBINOXAMINE MALEATE..............................1CARDIZEM............................................................ 19CARDIZEM CD......................................................19CARDIZEM LA (120 MG) (TAB ER 24H)............19CARDIZEM LA (180 MG) (TAB ER 24H)............19CARDIZEM LA (240 MG) (TAB ER 24H)............19CARDIZEM LA (300 MG) (TAB ER 24H)............19CARDIZEM LA (360 MG) (TAB ER 24H)............19CARDIZEM LA (420 MG) (TAB ER 24H)............19CARDIZEM SR.......................................................19CARDURA..............................................................16CARDURA XL....................................................... 16CAREFINE PEN NEEDLE.....................................92CAREPOINT LUER SLIP SYRINGE....................76CARETOUCH INSULIN SYRINGE..........72, 84, 85CARETOUCH PEN NEEDLE................................92CARGLUMIC ACID...............................................70CARIPRAZINE HCL..............................................11CARISOPRODOL.................................................108CARISOPRODOL/ASPIRIN................................ 108CARISOPRODOL/ASPIRIN/CODEINE............... 94CARNITOR............................................................. 91CARNITOR SF........................................................91CARTEOLOL HCL.................................................47CARVEDILOL........................................................ 16CARVEDILOL PHOSPHATE................................ 16CASODEX.............................................................. 87CATAFLAM............................................................ 68CATAPRES..............................................................17CATAPRES-TTS 1.................................................. 17CATAPRES-TTS 2.................................................. 17CATAPRES-TTS 3.................................................. 17CAYSTON...............................................................55CECLOR (250 MG) (CAPSULE)........................... 55CECLOR (500 MG) (CAPSULE)........................... 55CECLOR CD........................................................... 55CEFACLOR.............................................................55CEFADROXIL.........................................................55CEFDINIR...............................................................55CEFDITOREN PIVOXIL........................................55CEFIXIME.............................................................. 55CEFPODOXIME PROXETIL................................. 56CEFPROZIL............................................................ 55CEFTIN................................................................... 55CEFUROXIME AXETIL........................................ 55

CEFZIL....................................................................55CELEBREX.............................................................68CELECOXIB........................................................... 68CELEXA (10 MG) (TABLET)..................................7CELEXA (20 MG) (TABLET)..................................7CELEXA (40 MG) (TABLET)..................................7CELLCEPT (200 MG/ML) (SUSP RECON)..........54CELLCEPT (250 MG) (CAPSULE)....................... 54CELLCEPT (500 MG) (TABLET)..........................54CELONTIN........................................................... 105CENTANY...............................................................29CENTANY AT.........................................................29CEPHALEXIN........................................................ 55CEREBYX.............................................................103CERITINIB..............................................................88CERTOLIZUMAB PEGOL.................................... 66CERVIDIL............................................................... 27CESAMET.................................................................2CETRAXAL............................................................ 41CETRORELIX ACETATE...................................... 44CETROTIDE........................................................... 44CEVIMELINE HCL................................................87CHANTIX............................................................. 108CHEMET.................................................................91CHENODAL........................................................... 70CHENODIOL.......................................................... 70CHLORAMBUCIL................................................. 87CHLORDIAZEPOXIDE HCL................................ 11CHLORDIAZEPOXIDE/CLIDINIUM BR.......... 110CHLORHEXIDINE GLUCONATE........................91CHLOROQUINE PHOSPHATE............................. 60CHLOROTHIAZIDE...............................................21CHLORTHALIDONE.............................................21CHLORZOXAZONE............................................ 108CHLORZOXAZONE (500 MG) (TABLET)..............CHOLBAM............................................................. 70CHOLESTYRAMINE (WITH SUGAR)................ 24CHOLESTYRAMINE/ASPARTAME.................... 24CHOLIC ACID........................................................70CHORIOGONADOTROPIN ALFA........................42CHORIONIC GONADOTROPIN...........................42CHORIONIC GONADOTROPIN, HUMAN..........42CHRONULAC.........................................................70CICLESONIDE..................................................... 1, 4CICLODAN.............................................................30CICLOPIROX..........................................................30CICLOPIROX OLAMINE...................................... 30CICLOPIROX/SKIN CLEANSER NO.28..............30CICLOPIROX/SKIN CLEANSER NO.40..............30CICLOPIROX/UREA/CAMPH/MEN/EUC........... 30CILOSTAZOL......................................................... 51CILOXAN (0.3 %) (DROPS).................................. 46CILOXAN (0.3 %) (OINT. (G)).............................. 46CIMDUO................................................................. 62


Index

CIMETIDINE........................................................ 110CIMZIA................................................................... 66CINACALCET HCL............................................... 43CIPRO......................................................................58CIPRO HC............................................................... 41CIPRO XR............................................................... 58CIPRODEX............................................................. 41CIPROFLOXACIN..................................................58CIPROFLOXACIN HCL.............................41, 46, 58CIPROFLOXACIN HCL/DEXAMETH................. 41CIPROFLOXACIN/CIPROFLOXA HCL...............58CIPROFLOXACIN/HYDROCORTISONE............ 41CITALOPRAM HYDROBROMIDE........................ 7CITRANATAL 90 DHA........................................ 114CITRANATAL ASSURE...................................... 114CITRANATAL DHA............................................. 113CITRANATAL HARMONY......................... 113, 114CITRANATAL RX................................................ 116CITRIC AC/GLUCONOLACT/MAG CARB.......111CLARIFOAM EF.................................................... 31CLARINEX-D 12 HOUR..........................................1CLARITHROMYCIN............................................. 56CLEMASTINE FUMARATE................................... 1CLEOCIN (100 MG) (SUPP.VAG)....................... 112CLEOCIN (2 %) (CREAM/APPL)....................... 112CLEOCIN HCL....................................................... 60CLEOCIN PALMITATE..........................................60CLEOCIN T.............................................................29CLICKFINE............................................................ 92CLIMARA...............................................................52CLIMARA PRO...................................................... 53CLINDACIN ETZ................................................... 29CLINDACIN P........................................................ 29CLINDACIN PAC................................................... 29CLINDAGEL (1 %) (GEL (ML))............................29CLINDAMYCIN HCL............................................ 60CLINDAMYCIN PALMITATE HCL......................60CLINDAMYCIN PHOS/BENZOYL PEROX........ 28CLINDAMYCIN PHOS/SKIN CLNSR 19............ 29CLINDAMYCIN PHOSPHATE..................... 29, 112CLINDAMYCIN/BENZOYL/EMOL CMB94....... 28CLINDAMYCIN/TRETINOIN...............................28CLINDESSE..........................................................112CLINORIL...............................................................69CLINPRO 5000..................................................... 113CLIOQUINOL/HYDROCORTISONE................... 29CLISTIN (4 MG) (TABLET).................................... 1CLOBAZAM......................................................... 101CLOBETASOL PROPIONATE...............................32CLOBETASOL PROPIONATE/EMOLL................32CLOBETASOL/SKIN CLEANSER NO.28............32CLOBEX................................................................. 32CLOCORTOLONE PIVALATE..............................32CLODAN.................................................................32

CLODERM..............................................................32CLOMIPHENE CITRATE...................................... 42CLOMIPRAMINE HCL........................................... 9CLONAZEPAM.....................................................101CLONIDINE............................................................17CLONIDINE HCL.............................................14, 17CLONIDINE HCL/CHLORTHALIDONE............. 17CLOPIDOGREL BISULFATE................................51CLORAZEPATE DIPOTASSIUM.......................... 11CLOTRIMAZOLE............................................ 30, 59CLOTRIMAZOLE (1 %) (CREAM (G))....................CLOTRIMAZOLE (1 %) (SOLUTION).....................CLOTRIMAZOLE/BETAMETHASONE DIP....... 29CLOZAPINE........................................................... 12CLOZARIL..............................................................12COARTEM.............................................................. 60COBICISTAT...........................................................64COBIMETINIB FUMARATE.................................88CODEINE PHOSPHATE/GUAIFENESIN.............28CODEINE PHOSPHATE/GUAIFENESIN (10-100MG/5) (LIQUID) (OTC)........................................CODEINE PHOSPHATE/GUAIFENESIN (20-200/10) (LIQUID) (OTC)............................................CODEINE POLI/CHLORPHENIR POLIS.............27CODEINE/BUTALBITAL/ASA/CAFFEIN........... 99COGENTIN...........................................................100COLAZAL...............................................................69COLCHICINE......................................................... 48COLCRYS............................................................... 48COLESEVELAM HCL........................................... 24COLESTID (1 G) (TABLET)..................................24COLESTID (5 G) (GRANULES)........................... 24COLESTID (5 G) (PACKET)..................................24COLESTID (7.5 G) (PACKET)...............................24COLESTIPOL HCL................................................ 24COLLAGENASE CLOSTRIDIUM HIST...............36COLY-MYCIN S..................................................... 41COLYTE WITH FLAVOR PACKETS.................... 71COMBIGAN............................................................47COMBIPATCH........................................................53COMBIPRES...........................................................17COMBIVENT RESPIMAT....................................... 3COMBIVIR............................................................. 62COMETRIQ............................................................ 88COMFORT EZ...................................... 72, 84, 85, 92COMFORT PAC-IBUPROFEN...............................68COMFORT PAC-MELOXICAM............................ 68COMFORT PAC-NAPROXEN............................... 68COMFORT PAC-TIZANIDINE............................108COMPAZINE............................................................ 2COMPLERA............................................................64COMTAN.............................................................. 101CONCEPT DHA................................................... 113CONCEPT OB.......................................................113


Index

CONDYLOX (0.5 %) (GEL (GRAM))................... 35CONDYLOX (0.5 %) (SOLUTION).......................35CONTRAVE.......................................................... 116CONZIP (100 MG) (CPBP 25-75).......................... 97CONZIP (200 MG) (CPBP 25-75).......................... 97CONZIP (300 MG) (CPBP 17-83).......................... 98COPAXONE............................................................90CORDARONE.........................................................15CORDRAN (0.05 %) (CREAM (G))...................... 33CORDRAN (0.05 %) (LOTION)............................ 33CORDRAN (0.05 %) (OINT. (G)).......................... 33CORDRAN (4MCG/SQ CM) (MED. TAPE)......... 33COREG....................................................................16COREG CR............................................................. 16CORGARD..............................................................18CORLANOR........................................................... 25CORTANE-B........................................................... 41CORTEF.................................................................. 67CORTENEMA.........................................................70CORTIFOAM.......................................................... 70CORTISPORIN....................................................... 31CORZIDE................................................................ 19COSENTYX (2 SYRINGES)..................................36COSENTYX PEN................................................... 36COSENTYX PEN (2 PENS)................................... 36COSENTYX SYRINGE..........................................36COSOPT.................................................................. 47COTELLIC.............................................................. 88COUMADIN........................................................... 48COVARYX...............................................................52COVARYX H.S....................................................... 52COZAAR.................................................................17CREON..................................................................108CRESEMBA............................................................59CRESTOR (10 MG) (TABLET)..............................23CRESTOR (20 MG) (TABLET)..............................23CRESTOR (40 MG) (TABLET)..............................23CRESTOR (5 MG) (TABLET)................................23CRINONE..........................................................43, 53CRIXIVAN.............................................................. 64CROMOLYN SODIUM...................................... 5, 47CROTAMITON....................................................... 30CUPRIMINE........................................................... 65CUTIVATE.............................................................. 33CUVPOSA.............................................................110CYANOCOBALAMIN (VITAMIN B-12)............116CYANOCOBALAMIN (VITAMIN B-12)(1000MCG/ML) (VIAL).............................................CYCLESSA.............................................................26CYCLOBENZAPRINE HCL................................108CYCLOCORT (0.1 %) (CREAM (G))....................32CYCLOGYL............................................................48CYCLOMYDRIL.................................................... 48CYCLOPENTOLATE HCL.................................... 48

CYCLOPENTOLATE/PHENYLEPHRINE........... 48CYCLOPHOSPHAMIDE....................................... 87CYCLOSERINE......................................................60CYCLOSET.............................................................38CYCLOSPORINE............................................. 47, 54CYCLOSPORINE, MODIFIED..............................54CYPROHEPTADINE HCL....................................... 1CYSTADANE..........................................................91CYSTAGON.......................................................... 111CYSTARAN............................................................ 48CYSTEAMINE BITARTRATE.............................111CYSTEAMINE HCL...............................................48CYTOMEL.............................................................. 44CYTOTEC............................................................. 110

- D -D.H.E.45.................................................................. 98DABIGATRAN ETEXILATE MESYLATE........... 52DABRAFENIB MESYLATE.................................. 88DALFAMPRIDINE................................................. 90DALIRESP (500 MCG) (TABLET).......................... 5DALTEPARIN SODIUM,PORCINE...................... 50DANAZOL.............................................................. 44DANOCRINE..........................................................44DANTRIUM..........................................................108DANTROLENE SODIUM.................................... 108DAPAGLIFLOZIN PROPANEDIOL...................... 37DAPAGLIFLOZIN/METFORMIN HCL................ 39DAPSONE......................................................... 28, 59DARAPRIM............................................................ 61DARBEPOETIN ALFA IN POLYSORBAT..... 49, 50DARIFENACIN HYDROBROMIDE................... 112DARUNAVIR ETHANOLATE............................... 61DARUNAVIR/COBICISTAT.................................. 61DASATINIB............................................................ 88DAVOL IRRIGATION SYRINGE.......................... 73DAYPRO..................................................................69DAYTRANA............................................................14DDAVP.................................................................... 43DEBACTEROL....................................................... 91DEFERASIROX...................................................... 91DELAFLOXACIN MEGLUMINE......................... 58DELATESTRYL......................................................52DELAVIRDINE MESYLATE.................................62DELZICOL..............................................................70DEMADEX............................................................. 20DEMEROL (100 MG) (TABLET).......................... 95DEMEROL (50 MG/5 ML) (SOLUTION)............. 95DEMEROL (75 MG/ML) (SYRINGE)...................95DEMSER................................................................. 17DEMULEN..............................................................26DEMULEN 1-50-21................................................ 26DENAVIR................................................................ 31DENOSUMAB........................................................ 43DEPAKENE...........................................................107


Index

DEPAKOTE...........................................................102DEPAKOTE ER.....................................................102DEPAKOTE SPRINKLE.......................................102DEPEN.................................................................... 65DEPO-ESTRADIOL............................................... 53DEPO-PROVERA................................................... 26DEPO-SUBQ PROVERA 104.................................26DEPO-TESTOSTERONE....................................... 52DERMA-SMOOTHE-FS.........................................32DERMASORB HC..................................................33DERMASORB TA.................................................. 34DERMATOP............................................................33DERMAZENE.........................................................29DERMOTIC.............................................................41DESCOVY...............................................................61DESIPRAMINE HCL............................................... 9DESLORATADINE/PSEUDOEPHEDRINE............1DESMOPRESSIN (NONREFRIGERATED)......... 43DESMOPRESSIN ACETATE................................. 43DESOG-E.ESTRADIOL/E.ESTRADIOL.............. 26DESOGEN...............................................................26DESOGESTREL-ETHINYL ESTRADIOL........... 26DESONATE.............................................................32DESONIDE............................................................. 32DESOWEN (0.05 %) (CREAM (G))...................... 32DESOWEN (0.05 %) (LOTION).............................32DESOXIMETASONE............................................. 32DESOXYN.............................................................. 11DESVENLAFAXINE................................................9DESVENLAFAXINE ER............................................DESVENLAFAXINE FUMARATE......................... 9DESVENLAFAXINE FUMARATE ER.....................DESVENLAFAXINE SUCCINATE......................... 9DESYREL................................................................. 8DETROL................................................................112DETROL LA......................................................... 112DEXAMETHASONE..................................45, 66, 67DEXAMETHASONE (0.5 MG) (TABLET)...............DEXAMETHASONE (0.5 MG/5ML) (SOLUTION).....................................................................................DEXAMETHASONE (0.75 MG) (TABLET).............DEXAMETHASONE (1 MG) (TABLET)..................DEXAMETHASONE (1.5 MG) (TABLET)...............DEXAMETHASONE (2 MG) (TABLET)..................DEXAMETHASONE (4 MG) (TABLET)..................DEXAMETHASONE (6 MG) (TABLET)..................DEXAMETHASONE INTENSOL.............................DEXEDRINE (10 MG) (CAPSULE ER)................10DEXEDRINE (10 MG) (TABLET).........................10DEXEDRINE (15 MG) (CAPSULE ER)................10DEXEDRINE (5 MG) (CAPSULE ER)..................10DEXEDRINE (5 MG) (TABLET)...........................10DEXMETHYLPHENIDATE HCL..........................14DEXTROAMPHETAMINE SULFATE.................. 10

DEXTROAMPHETAMINE/AMPHETAMINE......10DEXTROMETHORPHAN HBR/QUINIDINE...... 91DIASTAT............................................................... 101DIASTAT ACUDIAL............................................ 101DIAZEPAM..................................................... 11, 101DIAZOXIDE........................................................... 39DIBENZYLINE.......................................................16DICHLORPHENAMIDE...................................... 107DICLEGIS................................................................. 2DICLO GEL-XRYLIX SHEET...............................34DICLOFEN SOD/KINESIOLOGY TAPE..............34DICLOFENAC EPOLAMINE................................ 34DICLOFENAC POTASSIUM........................... 68, 98DICLOFENAC SODIUM............................34, 35, 68DICLOFENAC SODIUM/MISOPROSTOL...........68DICLOFENAC SUBMICRONIZED.......................68DICLOXACILLIN SODIUM..................................58DICYCLOMINE HCL.......................................... 109DICYCLOMINE HCL (10 MG) (CAPSULE)............DICYCLOMINE HCL (10 MG/5 ML)(SOLUTION)...............................................................DICYCLOMINE HCL (20 MG) (TABLET)...............DIDANOSINE...................................................62, 63DIDREX................................................................ 116DIETHYLPROPION HCL.................................... 116DIFENOXIN HCL/ATROPINE SULFATE.............70DIFFERIN............................................................... 29DIFICID...................................................................56DIFLORASONE DIACETATE............................... 32DIFLORASONE DIACETATE/EMOLL................ 32DIFLUCAN............................................................. 59DIFLUNISAL..........................................................94DIFLUPREDNATE................................................. 46DIGOXIN................................................................ 15DIGOXIN (125 MCG) (TABLET)..............................DIGOXIN (250 MCG) (TABLET)..............................DIHYDROERGOTAMINE MESYLATE............... 98DILACOR XR......................................................... 19DILANTIN............................................................ 106DILANTIN-125.....................................................106DILATRATE-SR......................................................25DILTIAZEM HCL...................................................19DIMETHYL FUMARATE......................................90DINOPROSTONE...................................................27DIOVAN.................................................................. 17DIOVAN HCT (160-12.5MG) (TABLET).............. 16DIOVAN HCT (160-25MG) (TABLET)................. 16DIOVAN HCT (320-12.5MG) (TABLET).............. 16DIOVAN HCT (320MG-25MG) (TABLET)...........17DIOVAN HCT (80-12.5MG) (TABLET)................ 17DIPENTUM.............................................................70DIPHENOXYLATE HCL/ATROPINE................... 70DIPROLENE........................................................... 32DIPROLENE AF..................................................... 32


Index

DIPYRIDAMOLE................................................... 51DISALCID...............................................................94DISOPYRAMIDE PHOSPHATE........................... 15DISULFIRAM.........................................................11DIURIL (250 MG) (TABLET)................................ 21DIURIL (250 MG/5ML) (ORAL SUSP)................ 21DIURIL (500 MG) (TABLET)................................ 21DIVALPROEX SODIUM......................................102DIVALPROEX SODIUM (125 MG) (CAP DR SPR).....................................................................................DIVALPROEX SODIUM (125 MG) (TABLET DR).....................................................................................DIVALPROEX SODIUM (250 MG) (TAB ER 24H).....................................................................................DIVALPROEX SODIUM (250 MG) (TABLET DR).....................................................................................DIVALPROEX SODIUM (500 MG) (TAB ER 24H).....................................................................................DIVALPROEX SODIUM (500 MG) (TABLET DR).....................................................................................DIVIGEL................................................................. 52DOFETILIDE.......................................................... 15DOLASETRON MESYLATE...................................2DOLOBID............................................................... 94DOLUTEGRAVIR SODIUM..................................64DONEPEZIL HCL.................................................... 7DONNATAL (16.2 MG) (TABLET)..................... 109DONNATAL (16.2MG/5ML) (ELIXIR)............... 109DORAL....................................................................13DORNASE ALFA................................................... 94DORZOLAMIDE HCL........................................... 47DORZOLAMIDE HCL/TIMOLOL MALEAT.......47DORZOLAMIDE/TIMOLOL/PF........................... 47DORZOLAMIDE/TIMOLOL/PF (2 %-0.5 %)(DROPERETTE).........................................................DOSTINEX............................................................. 44DOVER BULB SYRINGE......................................71DOVONEX..............................................................36DOXAZOSIN MESYLATE.................................... 16DOXEPIN HCL.............................................9, 13, 34DOXERCALCIFEROL........................................... 44DOXYCYCLINE HYCLATE........................... 58, 91DOXYCYCLINE MONOHYDRATE.....................58DOXYCYCLINE/BENZOYL PEROXIDE.............59DOXYCYCLINE/SALICY/OCT/ZINC OX...........59DOXYLAMINE SUCCINATE/VIT B6.................... 2DRITHOCREME HP.............................................. 36DRONABINOL......................................................... 2DRONEDARONE HCL.......................................... 15DROPLET PEN NEEDLE...................................... 92DROPSAFE PEN NEEDLE....................................93DROSPIR/ETH ESTRA/LEVOMEFOL CA.......... 26DROSPIRENONE/ESTRADIOL............................52DROXIA.................................................................. 51

DROXIDOPA.......................................................... 25DRYSOL..................................................................34DUAC...................................................................... 28DUET DHA 400.................................................... 115DUET DHA BALANCED.................................... 113DUETACT............................................................... 38DULAGLUTIDE..................................................... 37DULERA................................................................... 4DULOXETINE HCL.................................................9DULOXETINE HCL (20 MG) (CAPSULE DR)........DULOXETINE HCL (30 MG) (CAPSULE DR)........DULOXETINE HCL (40 MG) (CAPSULE DR)........DULOXETINE HCL (60 MG) (CAPSULE DR)........DUONEB...................................................................3DUOPA..................................................................101DURAGESIC (100 MCG/HR) (PATCH TD72)......94DURAGESIC (12 MCG/HR) (PATCH TD72)........94DURAGESIC (25 MCG/HR) (PATCH TD72)........94DURAGESIC (50MCG/HR) (PATCH TD72).........95DURAGESIC (75MCG/HR) (PATCH TD72).........95DUREZOL...............................................................46DURICEF (1 G) (TABLET).................................... 55DURICEF (500 MG) (CAPSULE)..........................55DUTASTERIDE.................................................... 111DUTASTERIDE/TAMSULOSIN HCL.................111DUTOPROL (100-12.5MG) (TAB ER 24H).......... 18DUTOPROL (25-12.5 MG) (TAB ER 24H)........... 18DUTOPROL (50-12.5 MG) (TAB ER 24H)..... 18, 19DYANAVEL XR......................................................10DYAZIDE................................................................ 20DYNACIRC............................................................. 19DYRENIUM............................................................ 20

- E -E.E.S. 200................................................................ 56EASIVENT................................................................5EASY COMFORT INSULIN SYRINGE....72, 84,85EASY COMFORT PEN NEEDLES....................... 92EASY GLIDE CATHETER TIP SYRING..............79EASY GLIDE DENTAL IRRIG SYRING............. 77EASY GLIDE LUER LOCK SYRINGE...........76-79EASY GLIDE LUER SLIP TB SYRING............... 76EASY GLIDE PEN NEEDLE.................................92EASY TOUCH................................ 72, 74, 76, 84, 85EASY TOUCH FLIPLOCK INSULIN................... 80EASY TOUCH FLIPLOCK SYRINGE............81, 83EASY TOUCH FLIPLOCK SYRINGES..........82, 83EASY TOUCH FLURINGE................................... 74EASY TOUCH FLURINGE FLIPLOCK............... 82EASY TOUCH FLURINGE FLU TRAY............... 71EASY TOUCH FLURINGE SHEATHLOCK........ 82EASY TOUCH INSULIN SAFETY................. 80, 81EASY TOUCH INSULIN SYRINGE.........72, 84, 85EASY TOUCH LUER LOCK INSULIN................80


Index

EASY TOUCH LUER LOCK SYRINGE......... 76-79EASY TOUCH PEN NEEDLE............................... 92EASY TOUCH SHEATHLOCK INSULIN............ 81EASY TOUCH SHEATHLOCK SYRG-NDL....82,83EASY TOUCH SHEATHLOCK SYRINGE..... 77-79EASY TOUCH SYR ALLERGY TRAY................ 71EASY TOUCH TUBERCULIN FLIPLOCK..........82EASY TOUCH TUBERCULIN SHEATHLK........ 82EASY TOUCH UNI-SLIP................................. 77-80EASY-TOUCH INSULIN SYRINGE..................... 72ECHOTHIOPHATE IODIDE..................................47ECLIPSE LUER-LOK SYRINGE.............. 74, 76, 83ECLIPSE SYRINGE......................................... 72, 83ECLIPSE SYRINGE-NEEDLE.............................. 74EC-NAPROSYN......................................................69ECONAZOLE NITRATE........................................30ECOZA.................................................................... 30EDARBI...................................................................17EDARBYCLOR...................................................... 16EDECRIN................................................................ 20EDLUAR................................................................. 14EDOXABAN TOSYLATE...................................... 49EDURANT.............................................................. 62EFAVIRENZ............................................................62EFAVIRENZ/EMTRICIT/TENOFOVR DF............64EFAVIRENZ/LAMIVU/TENOFOV DISOP...........64EFFER-K................................................................. 42EFFEXOR..................................................................9EFFEXOR XR........................................................... 9EFFIENT................................................................. 51EFUDEX (5 %) (CREAM (G))............................... 35EGRIFTA.................................................................43ELAVIL..................................................................... 9ELESTAT.................................................................45ELESTRIN.............................................................. 52ELETRIPTAN HYDROBROMIDE........................ 98ELIDEL................................................................... 36ELIGARD................................................................43ELIPHOS.................................................................41ELIQUIS (2.5 MG) (TABLET)............................... 49ELIQUIS (5 MG) (TABLET).................................. 49ELITE-OB............................................................. 114ELIXOPHYLLIN...................................................... 6ELLA....................................................................... 27ELMIRON............................................................. 112ELOCON................................................................. 33ELUXADOLINE.....................................................70ELVITEG/COB/EMTRI/TENOF ALAFEN........... 64ELVITEG/COB/EMTRI/TENOFO DISOP.............64EMADINE...............................................................45EMBEDA (100MG-4MG) (CAP ER PO)............... 96EMBEDA (20MG-0.8MG) (CAP ER PO).............. 96EMBEDA (30MG-1.2MG) (CAP ER PO).............. 96

EMBEDA (50 MG-2 MG) (CAP ER PO)............... 96EMBEDA (60MG-2.4MG) (CAP ER PO).............. 96EMBEDA (80MG-3.2MG) (CAP ER PO).............. 96EMCYT................................................................... 90EMEDASTINE DIFUMARATE............................. 45EMEND (125 MG) (CAPSULE)...............................2EMEND (40 MG) (CAPSULE).................................2EMEND (80 MG) (CAPSULE).................................2EMLA...................................................................... 36EMOLLIENT COMBINATION NO.60..................34EMPAGLIFLOZIN..................................................38EMPAGLIFLOZIN/LINAGLIPTIN........................38EMPAGLIFLOZIN/METFORMIN HCL................39EMSAM...................................................................13EMTRICITA/RILPIVIRINE/TENOF DF............... 64EMTRICITAB/RILPIVIRI/TENOF ALA...............64EMTRICITABINE...................................................63EMTRICITABINE/TENOFOV ALAFENAM........61EMTRICITABINE/TENOFOVIR (TDF)................61EMTRIVA (200 MG) (CAPSULE)......................... 63EMVERM................................................................60ENABLEX.............................................................112ENALAPRIL MALEATE........................................17ENALAPRIL/HYDROCHLOROTHIAZIDE......... 16ENBRACE HR...................................................... 116ENBREL..................................................................66ENBREL MINI........................................................66ENBREL SURECLICK...........................................66ENDARI.................................................................. 93ENDOMETRIN.......................................................43ENFUVIRTIDE....................................................... 62ENOXAPARIN SODIUM................................. 50, 51ENSTILAR.............................................................. 37ENTACAPONE..................................................... 101ENTECAVIR........................................................... 64ENTOCORT EC...................................................... 66ENTRESTO............................................................. 25ENVARSUS XR...................................................... 54ENZALUTAMIDE.................................................. 87EPCLUSA................................................................64EPIFOAM................................................................35EPINASTINE HCL................................................. 45EPINEPHRINE..................................................15, 86EPINEPHRINE HCL...............................................28EPIPEN....................................................................86EPIPEN 2-PAK........................................................86EPIPEN JR...............................................................86EPIPEN JR 2-PAK...................................................86EPIVIR (10 MG/ML) (SOLUTION).......................63EPIVIR (150 MG) (TABLET).................................63EPIVIR (300 MG) (TABLET).................................63EPIVIR HBV (100 MG) (TABLET)....................... 64EPLERENONE........................................................20EPOETIN ALFA......................................................50


Index

EPOGEN..................................................................50EPROSARTAN MESYLATE.................................. 17EPZICOM................................................................62EQUETRO...............................................................11ERGOCALCIFEROL (VITAMIN D2)................. 116ERGOCALCIFEROL (VITAMIN D2) (50000UNIT) (CAPSULE).....................................................ERGOMAR............................................................. 98ERGOTAMINE TARTRATE...................................98ERGOTAMINE TARTRATE/CAFFEINE.............. 98ERLEADA...............................................................87ERLOTINIB HCL................................................... 89ERTACZO................................................................30ERYPED 200........................................................... 56ERYPED 400........................................................... 56ERY-TAB................................................................. 56ERYTHROMYCIN BASE................................ 46, 56ERYTHROMYCIN BASE (250 MG) (TABLET DR).....................................................................................ERYTHROMYCIN BASE (500 MG) (TABLET DR).....................................................................................ERYTHROMYCIN BASE IN ETHANOL............. 29ERYTHROMYCIN ETHYLSUCCINATE..............56ERYTHROMYCIN/BENZOYL PEROXIDE......... 29ESBRIET................................................................. 94ESCITALOPRAM OXALATE..................................8ESLICARBAZEPINE ACETATE......................... 102ESOMEPRAZOLE MAGNESIUM...................... 111ESTAZOLAM......................................................... 13ESTRACE........................................................52, 112ESTRADIOL............................................. 52, 53, 112ESTRADIOL ACETATE.......................................112ESTRADIOL CYPIONATE.................................... 53ESTRADIOL VALERATE/DIENOGEST.............. 26ESTRADIOL/LEVONORGESTREL..................... 53ESTRADIOL/NORETHINDRONE ACET.............53ESTRADIOL/NORGESTIMATE........................... 53ESTRAMUSTINE PHOSPHATE SODIUM.......... 90ESTRING.............................................................. 112ESTROGEL............................................................. 52ESTROGEN,CON/M-PROGEST ACET................ 53ESTROGEN,ESTER/ME-TESTOSTERONE.........52ESTROGENS, CONJUGATED...................... 53, 112ESTROGENS,ESTERIFIED...................................53ESTROPIPATE........................................................ 53ESTROSTEP FE......................................................27ESZOPICLONE...................................................... 13ETANERCEPT........................................................ 66ETHACRYNIC ACID............................................. 20ETHAMBUTOL HCL.............................................60ETHINYL ESTRADIOL/DROSPIRENONE......... 26ETHIONAMIDE..................................................... 60ETHOSUXIMIDE................................................. 102ETHOTOIN........................................................... 102

ETHYL ACETATE.................................................. 91ETHYNODIOL D-ETHINYL ESTRADIOL..........26ETODOLAC............................................................ 68ETONOGESTREL/ETHINYL ESTRADIOL.........26ETRAFON-A.............................................................9ETRAVIRINE..........................................................62EULEXIN................................................................ 87EURAX (10 %) (CREAM (G))............................... 30EVAMIST................................................................ 52EVEKEO................................................................. 10EVEROLIMUS..................................................54, 88EVISTA................................................................... 43EVOCLIN................................................................29EVOLOCUMAB..................................................... 24EVOTAZ.................................................................. 63EVOXAC................................................................. 87EXEL SYRINGE............................................... 76-79EXEL TB WITH NEEDLE..................................... 74EXEL TUBERCULIN SYRINGE.......................... 76EXELDERM (1 %) (SOLUTION)..........................30EXELON................................................................... 7EXEMESTANE....................................................... 88EXENATIDE........................................................... 37EXENATIDE MICROSPHERES............................ 37EXFORGE...............................................................17EXFORGE HCT......................................................16EXJADE.................................................................. 91EXTAVIA................................................................ 90EXTINA...................................................................30EZETIMIBE............................................................ 24EZETIMIBE/SIMVASTATIN................................. 22

- F -FABIOR................................................................... 29FACTIVE.................................................................58FAMCICLOVIR...................................................... 61FAMOTIDINE.......................................................110FAMVIR.................................................................. 61FANAPT.......................................................... 12, 117FARESTON............................................................. 90FARXIGA................................................................37FARYDAK...............................................................89FASENRA................................................................. 5FAZACLO............................................................... 12FEBUXOSTAT........................................................ 48FELBAMATE................................................102, 103FELBAMATE (400 MG) (TABLET)..........................FELBAMATE (600 MG) (TABLET)..........................FELBATOL (400 MG) (TABLET)........................102FELBATOL (600 MG) (TABLET)........................102FELBATOL (600 MG/5ML) (ORAL SUSP)........ 103FELDENE................................................................69FELODIPINE.......................................................... 19FEM PH................................................................. 112FEMARA.................................................................88


Index

FEMCON FE........................................................... 26FEMHRT................................................................. 53FEMRING............................................................. 112FENOFIBRATE.......................................................24FENOFIBRATE NANOCRYSTALLIZED............. 24FENOFIBRATE,MICRONIZED.............................24FENOFIBRIC ACID............................................... 24FENOFIBRIC ACID (CHOLINE).......................... 24FENOGLIDE...........................................................24FENOPROFEN CALCIUM.................................... 68FENORTHO............................................................ 68FENTANYL.......................................................94, 95FENTANYL CITRATE........................................... 95FESOTERODINE FUMARATE........................... 112FETZIMA.......................................................... 9, 117FEXMID................................................................ 108FIBRICOR...............................................................24FIDAXOMICIN.......................................................56FILGRASTIM......................................................... 51FINACEA (15 %) (GEL (GRAM))......................... 28FINASTERIDE......................................................111FINGOLIMOD HCL............................................... 90FIORICET WITH CODEINE................................. 99FIORINAL WITH CODEINE #3............................99FIRVANQ (25 MG/ML) (SOLN RECON)..............60FLAGYL (250 MG) (TABLET).............................. 60FLAGYL (500 MG) (TABLET).............................. 60FLAREX..................................................................46FLAVOXATE HCL................................................112FLECAINIDE ACETATE........................................15FLECTOR................................................................34FLEXERIL............................................................ 108FLOMAX.............................................................. 111FLORINEF.............................................................. 67FLOVENT DISKUS (100 MCG) (BLST W/DEV)....4FLOVENT DISKUS (250 MCG) (BLST W/DEV)....4FLOVENT DISKUS (50 MCG) (BLST W/DEV).....4FLOVENT HFA (110 MCG) (AER W/ADAP).........4FLOVENT HFA (220 MCG) (AER W/ADAP).........5FLOVENT HFA (44 MCG) (AER W/ADAP)...........5FLUCONAZOLE.................................................... 59FLUCYTOSINE...................................................... 59FLUDROCORTISONE ACETATE......................... 67FLUMADINE..........................................................61FLUNISOLIDE..................................................... 1, 4FLUOCINOLONE ACETONIDE...........................32FLUOCINOLONE ACETONIDE OIL................... 41FLUOCINOLONE/EMOL COMB NO.65............. 32FLUOCINOLONE/SHOWER CAP........................32FLUOCINOLONE/SKIN CLNSR28...................... 32FLUOCINONIDE....................................................32FLUOCINONIDE/EMOLLIENT BASE................ 32

FLUORESCEIN-BENOXINATE............................46FLUORIDE (SODIUM)........................................ 113FLUORIDE (SODIUM) (1.1 %) (CREAM (G)).........FLUORIDE (SODIUM) (1.1 %) (GEL (GRAM))......FLUORIDEX.........................................................113FLUOROMETHOLONE.........................................46FLUOROMETHOLONE ACETATE...................... 46FLUOROPLEX....................................................... 35FLUOROURACIL...................................................35FLUOXETINE HCL..................................................8FLUPHENAZINE HCL.................................... 12, 13FLURANDRENOLIDE.......................................... 33FLURBIPROFEN....................................................68FLURBIPROFEN SODIUM................................... 46FLURESS................................................................ 46FLUROX..................................................................46FLUTAMIDE...........................................................87FLUTICASONE FUROATE..................................... 4FLUTICASONE PROPIONATE.....................4, 5, 33FLUTICASONE/SALMETEROL.........................3, 4FLUTICASONE/UMECLIDIN/VILANTER........... 4FLUTICASONE/VILANTEROL..............................4FLUVASTATIN SODIUM...................................... 22FLUVOXAMINE MALEATE...................................8FML......................................................................... 46FML FORTE............................................................46FML S.O.P............................................................... 46FOCALIN................................................................ 14FOCALIN XR......................................................... 14FOLET ONE..........................................................114FOLEX.................................................................... 87FOLEX (25 MG/ML) (VIAL)................................. 87FOLIC ACID......................................................... 113FOLIC ACID (1 MG) (TABLET)...............................FOLIC ACID (5 MG/ML) (VIAL)..............................FOLLISTIM AQ......................................................42FOLLITROPIN ALFA, RECOMBINANT............. 42FOLLITROPIN BETA,RECOMB...........................42FONDAPARINUX SODIUM..................................51FORFIVO XL (450 MG) (TAB ER 24H)..................7FORMOTEROL FUMARATE.................................. 3FORTEO.................................................................. 43FORTESTA..............................................................52FOSAMAX (10 MG) (TABLET)............................ 43FOSAMAX (35 MG) (TABLET)............................ 43FOSAMAX (5 MG) (TABLET).............................. 43FOSAMAX (70 MG) (TABLET)............................ 43FOSAMAX PLUS D............................................... 43FOSAMPRENAVIR CALCIUM.............................64FOSINOPRIL SODIUM......................................... 17FOSINOPRIL/HYDROCHLOROTHIAZIDE........ 16FOSPHENYTOIN SODIUM................................ 103FOSRENOL (1000 MG) (TAB CHEW)................. 41FOSRENOL (500 MG) (TAB CHEW)................... 41


Index

FOSRENOL (750 MG) (TAB CHEW)................... 42FRAGMIN (10000/ML) (SYRINGE)..................... 50FRAGMIN (12500/0.5) (SYRINGE)...................... 50FRAGMIN (15000/0.6) (SYRINGE)...................... 50FRAGMIN (18000/0.72) (SYRINGE).................... 50FRAGMIN (2500/0.2ML) (SYRINGE).................. 50FRAGMIN (25000/ML) (VIAL)............................. 50FRAGMIN (5000/0.2ML) (SYRINGE).................. 50FRAGMIN (7500/0.3ML) (SYRINGE).................. 50FREESTYLE PRECISION............................... 72, 84FROVA.....................................................................98FROVATRIPTAN SUCCINATE..............................98FURADANTIN....................................................... 57FUROSEMIDE........................................................20FUZEON..................................................................62FYCOMPA (10 MG) (TABLET)...........................105FYCOMPA (12 MG) (TABLET)...........................105FYCOMPA (2 MG) (TABLET).............................105FYCOMPA (4 MG) (TABLET).............................106FYCOMPA (6 MG) (TABLET).............................106FYCOMPA (8 MG) (TABLET).............................106

- G -GABAPENTIN................................................91, 103GABAPENTIN (100 MG) (CAPSULE).....................GABAPENTIN (250 MG/5ML) (SOLUTION)..........GABAPENTIN (300 MG) (CAPSULE).....................GABAPENTIN (300 MG/6ML) (SOLUTION)..........GABAPENTIN (400 MG) (CAPSULE).....................GABAPENTIN (600 MG) (TABLET)........................GABAPENTIN (800 MG) (TABLET)........................GABAPENTIN ENACARBIL................................ 90GABAPENTIN/LIDOCAINE/MENTHOL.......... 103GABITRIL (12 MG) (TABLET)...........................106GABITRIL (16 MG) (TABLET)...........................106GABITRIL (2 MG) (TABLET).............................106GABITRIL (4 MG) (TABLET).............................106GALANTAMINE HBR.............................................7GALZIN.................................................................. 92GANCICLOVIR...................................................... 46GANIRELIX ACETATE......................................... 44GARAMYCIN.........................................................46GASTROCROM........................................................5GATIFLOXACIN.................................................... 46GEFITINIB..............................................................89GELATIN................................................................ 48GELFILM................................................................ 48GELNIQUE........................................................... 112GEMFIBROZIL.......................................................24GEMIFLOXACIN MESYLATE............................. 58GENERESS FE....................................................... 26GENOTROPIN........................................................ 43GENTAK................................................................. 46GENTAMICIN SULF/PREDNISOLONE.............. 45GENTAMICIN SULFATE.................................29, 46

GENTIAN VIOLET/BRGREEN/PROFLAV..........30GENVOYA.............................................................. 64GEODON................................................................ 12GILENYA (0.5 MG) (CAPSULE).......................... 90GLATIRAMER ACETATE..................................... 90GLECAPREVIR/PIBRENTASVIR........................ 65GLEEVEC (100 MG) (TABLET)........................... 89GLEEVEC (400 MG) (TABLET)........................... 89GLEOSTINE........................................................... 87GLIMEPIRIDE........................................................38GLIPIZIDE.............................................................. 38GLIPIZIDE/METFORMIN HCL............................38GLUCAGEN........................................................... 39GLUCAGON EMERGENCY KIT......................... 39GLUCAGON,HUMAN RECOMBINANT.............39GLUCOPHAGE...................................................... 38GLUCOPHAGE XR................................................38GLUCOTROL......................................................... 38GLUCOTROL XL................................................... 38GLUTAMINE..........................................................93GLYBURIDE...........................................................38GLYBURIDE,MICRONIZED.................................38GLYBURIDE/METFORMIN HCL.........................38GLYCEROL PHENYLBUTYRATE.......................70GLYCOPYRROLATE........................................... 110GLYNASE............................................................... 38GLYSET.................................................................. 38GLYXAMBI............................................................ 38GOLIMUMAB........................................................ 66GOLYTELY (236-22.74G) (SOLN RECON)......... 71GONAL-F................................................................42GONAL-F RFF........................................................42GONAL-F RFF REDI-JECT................................... 42GRALISE (300 MG) (TAB ER 24H).............. 91, 117GRALISE (600 MG) (TAB ER 24H).............. 91, 117GRANISETRON....................................................... 2GRANISETRON HCL.............................................. 2GRANIX..................................................................51GRIFULVIN V........................................................ 59GRISEOFULVIN ULTRAMICROSIZE................. 59GRISEOFULVIN, MICROSIZE............................. 59GUAIFENESIN/HYDROCODONE....................... 28GUANFACINE HCL.........................................14, 17GUSELKUMAB......................................................36GYNAZOLE 1.......................................................112

- H -HAEGARDA (2000 UNIT) (VIAL)........................66HALCINONIDE......................................................33HALDOL.................................................................12HALFLYTELY-BISACODYL.................................70HALOBETASOL PROPIONATE........................... 33HALOBETASOL/LACTIC ACID...........................33HALOG (0.1 %) (OINT. (G))..................................33HALOPERIDOL..................................................... 12


Index

HARVONI............................................................... 64HEALTHY ACCENTS UNIFINE PENTIP...... 92, 93HEMANGEOL........................................................ 18HEMMOREX-HC................................................... 70HEPARIN SODIUM,PORCINE............................. 51HEPARIN SODIUM,PORCINE (1000/ML) (VIAL).....................................................................................HEPARIN SODIUM,PORCINE (10000/ML)(VIAL).........................................................................HEPARIN SODIUM,PORCINE (20000/ML)(VIAL).........................................................................HEPARIN SODIUM,PORCINE (5000/ML(1))(CARTRIDGE)............................................................HEPARIN SODIUM,PORCINE (5000/ML)(SYRINGE).................................................................HEPARIN SODIUM,PORCINE (5000/ML) (VIAL).....................................................................................HEPARIN SODIUM,PORCINE/PF........................51HEPARIN SODIUM,PORCINE/PF (1000/ML)(VIAL).........................................................................HEPARIN SODIUM,PORCINE/PF (5000/0.5ML)(SYRINGE).................................................................HEPSERA................................................................64HETLIOZ................................................................ 13HIPREX...................................................................56HOMATROPINE HBR............................................48HORIZANT (300 MG) (TABLET ER)................... 90HORIZANT (600 MG) (TABLET ER)................... 90HUMALOG (100/ML) (CARTRIDGE)..................40HUMALOG (100/ML) (VIAL)...............................40HUMALOG JUNIOR KWIKPEN.......................... 40HUMALOG KWIKPEN U-100.............................. 40HUMALOG KWIKPEN U-200.............................. 40HUMALOG MIX 50-50..........................................40HUMALOG MIX 50-50 KWIKPEN...................... 40HUMALOG MIX 75-25..........................................40HUMALOG MIX 75-25 KWIKPEN...................... 40HUMATROPE......................................................... 44HUMIRA................................................................. 66HUMIRA PEDIATRIC CROHN'S..........................66HUMIRA PEN (40MG/0.8ML) (PEN IJ KIT)........66HUMIRA PEN CROHN-UC-HS STARTER(40MG/0.8ML) (PEN IJ KIT)................................. 66HUMIRA PEN PSORIASIS-UVEITIS(40MG/0.8ML) (PEN IJ KIT)................................. 66HUMULIN 70/30 KWIKPEN.................................40HUMULIN 70-30.................................................... 40HUMULIN N...........................................................40HUMULIN N KWIKPEN....................................... 40HUMULIN R...........................................................41HUMULIN R U-500................................................41HUMULIN R U-500 KWIKPEN............................ 41HYCAMTIN............................................................88HYDRALAZINE HCL............................................17

HYDREA.................................................................87HYDROCHLOROTHIAZIDE................................ 22HYDROCODONE BIT/HOMATROP ME-BR.......28HYDROCODONE BITARTRATE..........................95HYDROCODONE/ACETAMINOPHEN................99HYDROCODONE/ACETAMINOPHEN (10MG-300MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (10MG-325MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (2.5-325MG) (TABLET)...........................................................HYDROCODONE/ACETAMINOPHEN (5 MG-300MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (5 MG-325MG) (TABLET).....................................................HYDROCODONE/ACETAMINOPHEN (7.5-300MG) (TABLET)...........................................................HYDROCODONE/ACETAMINOPHEN (7.5-325MG) (TABLET)...........................................................HYDROCODONE/ACETAMINOPHEN (7.5-325/15) (SOLUTION).................................................HYDROCODONE/CHLORPHEN P-STIREX.......28HYDROCODONE/CHLORPHENIRAMINE........ 28HYDROCODONE/CPM/PSEUDOEPHED........... 27HYDROCODONE/IBUPROFEN........................... 94HYDROCORT/SAL ACID/SULF/SHAMP1..........33HYDROCORTISONE................................. 33, 67, 70HYDROCORTISONE (1 %) (CREAM (G))...............HYDROCORTISONE (1 %) (CRM/PE APP)............HYDROCORTISONE (2 %) (LOTION).....................HYDROCORTISONE (2.5 %) (CREAM (G))............HYDROCORTISONE (2.5 %) (CRM/PE APP).........HYDROCORTISONE (2.5 %) (KIT)..........................HYDROCORTISONE (2.5 %) (LOTION)..................HYDROCORTISONE (2.5 %) (OINT. (G))................HYDROCORTISONE ACET/ALOE VERA.......... 33HYDROCORTISONE ACETATE...........................70HYDROCORTISONE BUTYRATE....................... 33HYDROCORTISONE BUTYRATE/EMOLL........ 33HYDROCORTISONE PROBUTATE......................33HYDROCORTISONE VALERATE........................33HYDROCORTISONE/ACETIC ACID................... 41HYDROCORTISONE/IODOQUINOL...................29HYDROCORTISONE/IODOQUINOL/ALOE.......29HYDROCORTISONE/LIDOCAINE/ALOE.......... 70HYDROCORTISONE/PRAMOXINE.............. 35, 70HYDROCORTISONE/PRAMOXINE/C-XYL....... 41HYDROCORTISONE/PRAMOXINE/EMOLL..... 35HYDROCORTISONE/SKIN CLEANSER35......... 33HYDROMORPHONE HCL....................................95HYDROMORPHONE HCL (12 MG) (TAB ER24H).............................................................................HYDROMORPHONE HCL (16 MG) (TAB ER24H).............................................................................


Index

HYDROMORPHONE HCL (2 MG) (TABLET)........HYDROMORPHONE HCL (32 MG) (TAB ER24H).............................................................................HYDROMORPHONE HCL (4 MG) (TABLET)........HYDROMORPHONE HCL (8 MG) (TAB ER 24H).....................................................................................HYDROMORPHONE HCL (8 MG) (TABLET)........HYDROXYCHLOROQUINE SULFATE............... 61HYDROXYPROPYL CELLULOSE.......................48HYDROXYUREA.............................................51, 87HYDROXYZINE HCL..............................................1HYDROXYZINE PAMOATE................................... 1HYGROTON........................................................... 21HYOSCYAMINE SULFATE.................................109HYOSYNE............................................................ 109HYPERRHO S-D.................................................... 53HYPER-SAL........................................................... 91HYSINGLA ER.......................................................95HYTRIN.................................................................. 16HYZAAR.................................................................16

- I -IBANDRONATE SODIUM.....................................43IBRANCE................................................................89IBRUTINIB............................................................. 89IBUDONE............................................................... 94IBUPROFEN........................................................... 68IBUPROFEN/IRR.COUNT-IRRIT.NO.2................68IBUPROFEN/OXYCODONE HCL........................ 94ICLUSIG (15 MG) (TABLET)................................89ICLUSIG (45 MG) (TABLET)................................89ICOSAPENT ETHYL............................................. 25ILARIS.................................................................... 66ILEVRO...................................................................46ILOPERIDONE.......................................................12ILOPROST TROMETHAMINE............................. 21ILOTYCIN...............................................................46IMATINIB MESYLATE......................................... 89IMBRUVICA...........................................................89IMDUR.................................................................... 25IMIPRAMINE HCL.................................................. 9IMIPRAMINE PAMOATE........................................9IMIQUIMOD...........................................................54IMITREX.................................................................98IMITREX (100 MG) (TABLET).............................98IMITREX (25 MG) (TABLET)...............................98IMITREX (4 MG/0.5ML) (CARTRIDGE)............. 98IMITREX (4 MG/0.5ML) (PEN INJCTR)..............98IMITREX (50 MG) (TABLET)...............................98IMITREX (6 MG/0.5ML) (CARTRIDGE)............. 98IMITREX (6 MG/0.5ML) (PEN INJCTR)..............98IMITREX (6 MG/0.5ML) (VIAL).......................... 98IMURAN................................................................. 54INCONTROL PEN NEEDLE................................. 92INCRELEX..............................................................44

INCRUSE ELLIPTA..................................................3INDACATEROL MALEATE.................................... 3INDAPAMIDE.........................................................22INDERAL (10 MG) (TABLET).............................. 18INDERAL (20 MG) (TABLET).............................. 18INDERAL (40 MG) (TABLET).............................. 18INDERAL (60 MG) (TABLET).............................. 18INDERAL (80 MG) (TABLET).............................. 18INDERAL LA......................................................... 18INDERAL XL......................................................... 18INDINAVIR SULFATE........................................... 64INDOCIN (25 MG) (CAPSULE)............................68INDOCIN (25 MG/5 ML) (ORAL SUSP).............. 68INDOCIN (50 MG) (CAPSULE)............................68INDOCIN SR...........................................................68INDOMETHACIN.................................................. 68INDOMETHACIN, SUBMICRONIZED................68INGENOL MEBUTATE..........................................35INGREZZA (40 MG) (CAPSULE).........................91INHALER, ASSIST DEVICES.................................5INHALER,ASSIST DEV,SMALL MASK................5INHALER,ASSIST DEVICE,ACCESORY..............5INHALER,ASSIST DEVICE,LG MASK.................6INHALER,ASSIST DEVICE,MED MASK............. 6INNOPRAN XL...................................................... 18INOVA..................................................................... 35INOVA 4-1...............................................................35INOVA 8-2...............................................................35INSPRA................................................................... 20INSULIN ASPART..................................................39INSULIN ASPART PROT/INSULN ASP...............39INSULIN DEGLUDEC...........................................39INSULIN DEGLUDEC/LIRAGLUTIDE............... 38INSULIN DETEMIR...............................................39INSULIN GLARGINE,HUM.REC.ANLOG....39, 40INSULIN GLARGINE/LIXISENATIDE................38INSULIN GLULISINE........................................... 40INSULIN LISPRO...................................................40INSULIN LISPRO PROTAMIN/LISPRO...............40INSULIN NPH HUM/REG INSULIN HM............ 40INSULIN NPH HUMAN ISOPHANE................... 40INSULIN PEN NEEDLE........................................ 92INSULIN REGULAR, HUMAN...................... 40, 41INSULIN SYRINGE....................... 71, 72, 80, 84, 85INSULIN SYRINGE U-500....................................80INSUPEN................................................................ 92INTEGRA SYRINGE....................................... 76, 83INTELENCE (100 MG) (TABLET)........................62INTELENCE (200 MG) (TABLET)........................62INTELENCE (25 MG) (TABLET)..........................62INTERFERON ALFA-2B,RECOMB......................54INTERFERON ALFA-N3....................................... 54INTERFERON BETA-1A....................................... 90INTERFERON BETA-1A/ALBUMIN....................90


Index

INTERFERON BETA-1B........................................90INTERFERON GAMMA-1B,RECOMB................54INTERLINK SYRINGE..........................................74INTERLINK SYRINGE W-CANNULA................ 74INTERMEZZO........................................................14INTRON A.............................................................. 54INTUNIV.................................................................14INVEGA.................................................................. 12INVIRASE (200 MG) (CAPSULE)........................ 64INVOKAMET......................................................... 38INVOKAMET XR...................................................38INVOKANA............................................................ 37IODOFLEX............................................................. 29IOPIDINE (0.5 %) (DROPS)...................................47IOPIDINE (1 %) (DROPERETTE).........................47IPRATROPIUM BROMIDE................................2, 91IPRATROPIUM/ALBUTEROL SULFATE.............. 3IRBESARTAN.........................................................17IRBESARTAN/HYDROCHLOROTHIAZIDE.......16IRESSA....................................................................89IRRIGATION SYRINGE........................................ 74ISAVUCONAZONIUM SULFATE.........................59ISENTRESS (400 MG) (TABLET).........................64ISENTRESS HD......................................................64ISOCARBOXAZID...................................................7ISOCHRON............................................................. 25ISOMETHEPT/DICHLPHN/ACETAMINOP........ 98ISOMETHEPT/DICHLPHN/ACETAMINOP (65-100-325) (CAPSULE).................................................ISOMETHEPTEN/CAF/ACETAMINOPHEN....... 98ISONIAZID............................................................. 60ISONIAZID (100 MG) (TABLET).............................ISONIAZID (300 MG) (TABLET).............................ISOPTO ATROPINE............................................... 48ISOPTO CARPINE................................................. 48ISOPTO HOMATROPINE......................................48ISORDIL (10 MG) (TABLET)................................25ISORDIL (20 MG) (TABLET)................................25ISORDIL (30 MG) (TABLET)................................25ISORDIL (40 MG) (TABLET)................................25ISORDIL TITRADOSE.......................................... 25ISOSORBIDE DINIT/HYDRALAZINE................ 22ISOSORBIDE DINITRATE....................................25ISOSORBIDE MONONITRATE............................25ISOTRETINOIN......................................................28ISOXSUPRINE HCL.............................................. 26ISRADIPINE........................................................... 19ISTALOL................................................................. 48ITRACONAZOLE...................................................59IVABRADINE HCL................................................ 25IVACAFTOR........................................................... 94IVERMECTIN.............................................28, 30, 60

- J -JADENU.................................................................. 91

JAKAFI....................................................................88JALYN................................................................... 111JANUMET...............................................................37JANUMET XR (100-1000MG) (TBMP 24HR)......37JANUMET XR (50-1000 MG) (TBMP 24HR).......37JANUMET XR (50MG-500MG) (TBMP 24HR)....37JANUVIA................................................................ 38JARDIANCE........................................................... 38JENTADUETO........................................................ 37JEVANTIQUE......................................................... 53JEVANTIQUE LO...................................................53JUXTAPID...............................................................24JYNARQUE............................................................ 41

- K -KADIAN (10 MG) (CAP ER PEL).........................95KADIAN (100 MG) (CAP ER PEL).......................95KADIAN (130 MG) (CAP ER PEL).......................95KADIAN (150 MG) (CAP ER PEL).......................95KADIAN (20 MG) (CAP ER PEL).........................95KADIAN (200 MG) (CAP ER PEL).......................95KADIAN (30 MG) (CAP ER PEL).........................95KADIAN (40 MG) (CAP ER PEL).........................95KADIAN (50 MG) (CAP ER PEL).........................95KADIAN (60 MG) (CAP ER PEL).........................96KADIAN (70 MG) (CAP ER PEL).........................96KADIAN (80 MG) (CAP ER PEL).........................96KALYDECO............................................................94KAPVAY..................................................................14KARBINAL ER.........................................................1KAZANO................................................................ 37KEFLEX (125 MG/5ML) (SUSP RECON)............ 55KEFLEX (250 MG) (CAPSULE)........................... 55KEFLEX (250 MG/5ML) (SUSP RECON)............ 55KEFLEX (500 MG) (CAPSULE)........................... 55KEFLEX (750 MG) (CAPSULE)........................... 55KENALOG IN ORABASE..................................... 91KEPPRA (100 MG/ML) (SOLUTION)................ 104KEPPRA (1000 MG) (TABLET).......................... 104KEPPRA (250 MG) (TABLET)............................ 105KEPPRA (500 MG) (TABLET)............................ 105KEPPRA (750 MG) (TABLET)............................ 105KEPPRA XR......................................................... 105KERALYT SCALP..................................................35KERLONE...............................................................18KETOCONAZOLE........................................... 30, 59KETOPROFEN........................................................68KETOPROFEN (50 MG) (CAPSULE).......................KETOPROFEN (75 MG) (CAPSULE).......................KETOROLAC TROMETHAMINE.................. 46, 69KETOROLAC TROMETHAMINE/PF...................46KEVEYIS.............................................................. 107KISQALI................................................................. 89KITABIS PAK......................................................... 59


Index

KLARON.................................................................28KLONOPIN...........................................................101KLOR-CON-EF.......................................................42KOMBIGLYZE XR (2.5-1000MG) (TBMP 24HR)................................................................................. 37KOMBIGLYZE XR (5 MG-500MG) (TBMP 24HR)................................................................................. 37KOMBIGLYZE XR (5MG-1000MG) (TBMP 24HR)................................................................................. 37KORLYM.................................................................38K-PHOS NO.2....................................................... 111KRISTALOSE (10 G) (PACKET)........................... 71KRISTALOSE (20 G) (PACKET)........................... 71KUVAN................................................................... 87KWELL................................................................... 30KYTRIL.....................................................................2

- L -LABETALOL HCL................................................. 16LACOSAMIDE..................................................... 103LACRISERT............................................................48LACTULOSE.................................................... 70, 71LAMICTAL........................................................... 103LAMICTAL (BLUE).............................................103LAMICTAL (GREEN).......................................... 103LAMICTAL (ORANGE).......................................103LAMICTAL ODT (100 MG) (TAB RAPDIS)...... 103LAMICTAL ODT (200 MG) (TAB RAPDIS)...... 103LAMICTAL ODT (25 MG) (TAB RAPDIS)........ 103LAMICTAL ODT (50 MG) (TAB RAPDIS)........ 103LAMICTAL ODT (BLUE)....................................103LAMICTAL ODT (GREEN).................................103LAMICTAL ODT (ORANGE)............................. 104LAMICTAL XR (100 MG) (TAB ER 24)............. 104LAMICTAL XR (200 MG) (TAB ER 24)............. 104LAMICTAL XR (25 MG) (TAB ER 24)............... 104LAMICTAL XR (250 MG) (TAB ER 24)............. 104LAMICTAL XR (300 MG) (TAB ER 24)............. 104LAMICTAL XR (50 MG) (TAB ER 24)............... 104LAMICTAL XR (BLUE)...................................... 104LAMICTAL XR (GREEN)................................... 104LAMICTAL XR (ORANGE)................................ 104LAMIVUDINE..................................................63, 64LAMIVUDINE/TENOFOVIR DISOP FUM.......... 62LAMIVUDINE/ZIDOVUDINE.............................. 62LAMOTRIGINE............................................103, 104LAMOTRIGINE (100 MG) (TAB ER 24)..................LAMOTRIGINE (100 MG) (TAB RAPDIS)..............LAMOTRIGINE (100 MG) (TABLET)......................LAMOTRIGINE (150 MG) (TABLET)......................LAMOTRIGINE (200 MG) (TAB ER 24)..................LAMOTRIGINE (200 MG) (TAB RAPDIS)..............LAMOTRIGINE (200 MG) (TABLET)......................LAMOTRIGINE (25 MG) (TAB ER 24)....................LAMOTRIGINE (25 MG) (TAB RAPDIS)................

LAMOTRIGINE (25 MG) (TABLET)........................LAMOTRIGINE (25 MG) (TB CHW DSP)...............LAMOTRIGINE (25(42)-100) (TAB DS PK).............LAMOTRIGINE (25(84)-100) (TAB DS PK).............LAMOTRIGINE (250 MG) (TAB ER 24)..................LAMOTRIGINE (25MG (35)) (TAB DS PK)............LAMOTRIGINE (300 MG) (TAB ER 24)..................LAMOTRIGINE (5 MG) (TB CHW DSP).................LAMOTRIGINE (50 MG) (TAB ER 24)....................LAMOTRIGINE (50 MG) (TAB RAPDIS)................LANOXIN (125 MCG) (TABLET).........................15LANOXIN (187.5 MCG) (TABLET)......................15LANOXIN (250 MCG) (TABLET).........................15LANOXIN (62.5 MCG) (TABLET)........................15LANREOTIDE ACETATE......................................93LANSOPRAZOLE................................................ 111LANSOPRAZOLE (15 MG) (CAPSULE DR)...........LANSOPRAZOLE (15 MG) (TAB RAP DR)............LANSOPRAZOLE (30 MG) (CAPSULE DR)...........LANSOPRAZOLE (30 MG) (TAB RAP DR)............LANSOPRAZOLE/AMOXICILN/CLARITH......110LANTHANUM CARBONATE.........................41, 42LANTUS..................................................................39LANTUS SOLOSTAR............................................ 39LAPATINIB DITOSYLATE....................................89LARIAM..................................................................61LASIX (10 MG/ML) (SOLUTION)........................20LASIX (20 MG) (TABLET)....................................20LASIX (40 MG) (TABLET)....................................20LASIX (80 MG) (TABLET)....................................20LATANOPROST..................................................... 47LATUDA......................................................... 12, 117LAZANDA.............................................................. 95LEDIPASVIR/SOFOSBUVIR................................ 64LEFLUNOMIDE.....................................................66LENALIDOMIDE................................................... 88LENVATINIB MESYLATE.................................... 89LENVIMA...............................................................89LESCOL.................................................................. 22LESCOL XL............................................................22LETAIRIS................................................................21LETERMOVIR........................................................61LETROZOLE.......................................................... 88LEUCOVORIN CALCIUM.................................... 89LEUKERAN............................................................87LEUPROLIDE ACETATE.................................43, 44LEVALBUTEROL HCL............................................3LEVALBUTEROL TARTRATE................................3LEVAQUIN (250 MG) (TABLET)..........................58LEVAQUIN (250MG/10ML) (SOLUTION)...........58LEVAQUIN (500 MG) (TABLET)..........................58LEVAQUIN (750 MG) (TABLET)..........................58LEVBID.................................................................109LEVEMIR................................................................39


Index

LEVEMIR FLEXTOUCH.......................................39LEVETIRACETAM...................................... 104, 105LEVETIRACETAM (100 MG/ML) (SOLUTION)....LEVETIRACETAM (1000 MG) (TABLET)...............LEVETIRACETAM (250 MG) (TABLET).................LEVETIRACETAM (500 MG) (TAB ER 24H)..........LEVETIRACETAM (500 MG) (TABLET).................LEVETIRACETAM (500 MG/5ML) (SOLUTION).....................................................................................LEVETIRACETAM (750 MG) (TAB ER 24H)..........LEVETIRACETAM (750 MG) (TABLET).................LEVICYN ANTIPRURITIC SG............................. 34LEVOBUNOLOL HCL...........................................47LEVOCARNITINE................................................. 91LEVOCARNITINE (330 MG) (TABLET)..................LEVOCARNITINE (WITH SUGAR).....................91LEVOFLOXACIN...................................................58LEVOMILNACIPRAN HCL.................................... 9LEVONORGESTREL-ETHIN ESTRADIOL........ 26LEVONORGESTREL-ETHIN ESTRADIOL (0.1-0.02MG) (TABLET)....................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03) (TABLET)..........................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03) (TBDSPK 3MO).................................................LEVONORGESTREL-ETHIN ESTRADIOL (6-5-10) (TABLET).............................................................LEVONORGESTREL-ETHIN ESTRADIOL (90-20MCG) (TABLET)........................................................LEVO-T................................................................... 44LEVOTHYROXINE SODIUM............................... 44LEVOXYL...............................................................44LEVSIN................................................................. 109LEVSIN-SL........................................................... 109LEVULAN.............................................................. 90LEXAPRO (10 MG) (TABLET)............................... 8LEXAPRO (20 MG) (TABLET)............................... 8LEXAPRO (5 MG) (TABLET)................................. 8LEXAPRO (5 MG/5 ML) (SOLUTION).................. 8LEXIVA (700 MG) (TABLET)............................... 64LEXIXRYL..............................................................34LIALDA...................................................................70LIBRAX................................................................ 110LIDEX..................................................................... 32LIDEX-E..................................................................32LIDOCAINE............................................................36LIDOCAINE (5 %) (ADH. PATCH)...........................LIDOCAINE (5 %) (OINT. (G)).................................LIDOCAINE HCL.............................................36, 69LIDOCAINE HCL (3 %) (CREAM (G))....................LIDOCAINE HCL (3 %) (LOTION)..........................LIDOCAINE HCL (3.88 %) (CREAM (G))...............LIDOCAINE HCL (4 %) (SOLUTION).....................LIDOCAINE HCL/PF............................................. 46

LIDOCAINE/PRILOCAINE...................................36LIDOCAINE/TETRACAINE................................. 36LIDOPIN................................................................. 36LIDORX.................................................................. 36LIDOVEX................................................................36LIFESHIELD BLUNT CANNULA........................74LIFITEGRAST........................................................ 47LINACLOTIDE....................................................... 70LINAGLIPTIN.........................................................38LINAGLIPTIN/METFORMIN HCL...................... 37LINDANE................................................................30LINEZOLID............................................................ 57LINZESS................................................................. 70LIOTHYRONINE SODIUM...................................44LIOTHYRONINE SODIUM (25 MCG) (TABLET).....................................................................................LIOTHYRONINE SODIUM (5 MCG) (TABLET)....LIOTHYRONINE SODIUM (50 MCG) (TABLET).....................................................................................LIOTRIX........................................................... 44, 45LIPASE/PROTEASE/AMYLASE.................108, 109LIPITOR (10 MG) (TABLET)................................ 22LIPITOR (20 MG) (TABLET)................................ 22LIPITOR (40 MG) (TABLET)................................ 22LIPITOR (80 MG) (TABLET)................................ 22LIPOFEN.................................................................24LIRAGLUTIDE...............................................37, 116LISDEXAMFETAMINE DIMESYLATE.........10, 11LISINOPRIL............................................................17LISINOPRIL/HYDROCHLOROTHIAZIDE..........16LITE TOUCH........................................ 72, 84, 85, 92LITETOUCH INSULIN SYRINGE............72, 84, 85LITHIUM CARBONATE........................................11LITHIUM CITRATE............................................... 11LITHOBID.............................................................. 11LITHOSTAT............................................................ 70LIVALO................................................................... 22LIVER EXTRACT (BEEF-PORK).........................87L-NORGEST/E.ESTRADIOL-E.ESTRAD............ 26LO LOESTRIN FE.................................................. 27LOCOID (0.1 %) (CREAM (G)).............................33LOCOID (0.1 %) (LOTION)...................................33LOCOID (0.1 %) (OINT. (G)).................................33LOCOID (0.1 %) (SOLUTION)..............................33LOCOID LIPOCREAM.......................................... 33LODINE.................................................................. 68LODINE XL............................................................ 68LODOSYN............................................................ 101LODOXAMIDE TROMETHAMINE..................... 47LOESTRIN.............................................................. 27LOESTRIN 24 FE................................................... 27LOESTRIN FE........................................................ 27LOFIBRA................................................................ 24LOMITAPIDE MESYLATE................................... 24


Index

LOMOTIL............................................................... 70LOMUSTINE.......................................................... 87LONITEN................................................................ 18LONSURF............................................................... 88LO-OVRAL-28........................................................27LO-OVRAL-8..........................................................27LOPERAMIDE HCL...............................................70LOPERAMIDE HCL (2 MG) (CAPSULE)................LOPID......................................................................24LOPRESSOR HCT..................................................19LOPROX..................................................................30LOPROX (0.77 %) (COMBO. PKG)...................... 30LORAZEPAM......................................................... 11LORCASERIN HCL............................................. 116LORTAB..................................................................99LOSARTAN POTASSIUM..................................... 17LOSARTAN/HYDROCHLOROTHIAZIDE...........16LOSEASONIQUE...................................................26LOTEMAX..............................................................46LOTENSIN..............................................................17LOTENSIN HCT.....................................................16LOTEPREDNOL ETABONATE.............................46LOTREL.................................................................. 16LOTRISONE........................................................... 29LOTRONEX............................................................ 70LOVASTATIN..........................................................22LOVAZA..................................................................25LOVENOX (100 MG/ML) (SYRINGE)................. 50LOVENOX (120MG/.8ML) (SYRINGE)............... 50LOVENOX (150 MG/ML) (SYRINGE)................. 50LOVENOX (300MG/3ML) (VIAL)........................50LOVENOX (30MG/0.3ML) (SYRINGE)............... 50LOVENOX (40MG/0.4ML) (SYRINGE)............... 51LOVENOX (60MG/0.6ML) (SYRINGE)............... 51LOVENOX (80MG/0.8ML) (SYRINGE)............... 51LOXAPINE............................................................. 11LOXAPINE SUCCINATE.......................................12LOXITANE..............................................................12LOZOL.................................................................... 22LUBIPROSTONE....................................................71LUDIOMIL (25 MG) (TABLET)..............................9LUER LOCK SYRINGE.........................................78LUER SLIP TIP SYRINGE TRAY.........................76LUER-LOCK SYRINGE........................................ 79LUER-LOK SYRINGE................................76, 78-80LUER-LOK SYRINGE-NEEDLE.....................74-76LUER-LOK TIP SYRINGE.................................... 78LUERSLIP SYRINGE............................................ 76LULICONAZOLE...................................................30LUMACAFTOR/IVACAFTOR...............................94LUMIGAN (0.01 %) (DROPS)............................... 47LUNESTA............................................................... 13LUPRON DEPOT....................................................44LUPRON DEPOT (LUPANETA)............................44

LUPRON DEPOT-PED........................................... 44LURASIDONE HCL...............................................12LUVOX......................................................................8LUVOX CR............................................................... 8LUXIQ.....................................................................32LUZU.......................................................................30LYNPARZA.............................................................89LYRICA (100 MG) (CAPSULE).......................... 106LYRICA (150 MG) (CAPSULE).......................... 106LYRICA (200 MG) (CAPSULE).......................... 106LYRICA (225 MG) (CAPSULE).......................... 106LYRICA (25 MG) (CAPSULE)............................ 106LYRICA (300 MG) (CAPSULE).......................... 106LYRICA (50 MG) (CAPSULE)............................ 106LYRICA (75 MG) (CAPSULE)............................ 106LYSODREN............................................................ 89LYSTEDA................................................................48

- M -MACITENTAN....................................................... 21MACROBID............................................................ 57MACRODANTIN....................................................57MAFENIDE ACETATE.......................................... 31MAGELLAN INSULIN SAFETY SYRNG........... 81MAGELLAN INSULIN SYRINGE........................81MAGELLAN SAFETY SYRINGE.........................82MAGELLAN TUBERCULIN SYRINGE.............. 82MALARONE...........................................................60MALATHION..........................................................30MANDELAMINE (1 G) (TABLET).......................56MAPROTILINE HCL................................................9MARAVIROC..........................................................62MARINOL.................................................................2MARPLAN................................................................7MATULANE........................................................... 89MAVIK.................................................................... 17MAVYRET.............................................................. 65MAXI-COMFORT............................................ 72, 84MAXIDEX.............................................................. 45MAXZIDE...............................................................20MAXZIDE-25 MG.................................................. 20MEBENDAZOLE................................................... 60MECAMYLAMINE HCL.......................................17MECASERMIN.......................................................44MECHLORETHAMINE HCL................................35MECLIZINE HCL.....................................................2MECLIZINE HCL (12.5 MG) (TABLET)..................MECLIZINE HCL (25 MG) (TABLET).....................MEDROL (16 MG) (TABLET)...............................67MEDROL (2 MG) (TABLET).................................67MEDROL (32 MG) (TABLET)...............................67MEDROL (4 MG) (TAB DS PK)............................ 67MEDROL (4 MG) (TABLET).................................67MEDROL (8 MG) (TABLET).................................67MEDROXYPROGESTERONE ACETATE...... 26, 53


Index

MEFENAMIC ACID...............................................69MEFLOQUINE HCL.............................................. 61MEGACE...........................................................90, 91MEGACE ES...........................................................91MEGESTROL ACETATE................................. 90, 91MEKINIST.............................................................. 88MELLARIL............................................................. 13MELOXICAM.........................................................69MELOXICAM, SUBMICRONIZED...................... 69MELOXICAM/IRRIT.CNTR-IRR CMB 2............. 68MEMANTINE HCL..................................................6MEMANTINE HCL/DONEPEZIL HCL..............6, 7MENEST................................................................. 53MENOPUR..............................................................42MENOSTAR............................................................53MENOTROPINS..................................................... 42MENTAX.................................................................29MEPERIDINE HCL................................................ 95MEPERIDINE HCL/PF...........................................95MEPROBAMATE................................................... 11MEPRON.................................................................61MERCAPTOPURINE............................................. 87MESALAMINE.................................................69, 70MESALAMINE W/CLEANSING WIPES............. 69MESNA................................................................... 89MESNEX.................................................................89MESTINON (180 MG) (TABLET ER).....................7MESTINON (60 MG) (TABLET).............................7METAGLIP..............................................................38METAXALONE....................................................108METFORMIN HCL................................................ 38METH/MEBLUE/SOD PHOS/PSAL/HYOS......... 56METHADONE HCL............................................... 95METHADONE HCL (10 MG) (TABLET).................METHADONE HCL (10 MG/ML) (ORAL CONC).....................................................................................METHADONE HCL (5 MG) (TABLET)...................METHAMPHETAMINE HCL................................11METHAZOLAMIDE.............................................. 47METHEN/MBLUE/SAL/SOD PHOS/HYOS.........56METHENAM/M.BLUE/SALICYL/HYOSCY.......56METHENAM/SOD PHOS/MBLUE/HYOSCY..... 56METHENAMINE HIPPURATE............................. 56METHENAMINE MANDELATE.......................... 56METHIMAZOLE.................................................... 44METHITEST........................................................... 52METHOCARBAMOL...........................................108METHOTREXATE................................................. 87METHOTREXATE SODIUM.................................87METHOTREXATE SODIUM/PF........................... 87METHOTREXATE/PF............................................65METHOXSALEN................................................... 36METHSCOPOLAMINE BROMIDE.................... 109METHSUXIMIDE................................................ 105

METHYCLOTHIAZIDE.........................................22METHYLDOPA...................................................... 17METHYLERGONOVINE MALEATE................... 27METHYLPHENIDATE...........................................14METHYLPHENIDATE HCL............................14, 15METHYLPHENIDATE HCL (10 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (10 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (10 MG) (TABCHEW)........................................................................METHYLPHENIDATE HCL (10 MG) (TABLETER)...............................................................................METHYLPHENIDATE HCL (10 MG) (TABLET)....METHYLPHENIDATE HCL (10 MG/5 ML)(SOLUTION)...............................................................METHYLPHENIDATE HCL (18 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (2.5 MG) (TABCHEW)........................................................................METHYLPHENIDATE HCL (20 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (20 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (20 MG) (TABLETER)...............................................................................METHYLPHENIDATE HCL (20 MG) (TABLET)....METHYLPHENIDATE HCL (27 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (30 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (30 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (36 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (40 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (40 MG) (CPBP 50-50)................................................................................METHYLPHENIDATE HCL (5 MG) (TAB CHEW).....................................................................................METHYLPHENIDATE HCL (5 MG) (TABLET)......METHYLPHENIDATE HCL (5 MG/5 ML)(SOLUTION)...............................................................METHYLPHENIDATE HCL (50 MG) (CPBP 30-70)................................................................................METHYLPHENIDATE HCL (54 MG) (TAB ER 24).....................................................................................METHYLPHENIDATE HCL (60 MG) (CPBP 30-70)................................................................................METHYLPREDNISOLONE.................................. 67METHYLTESTOSTERONE...................................52METIPRANOLOL.................................................. 48METOCLOPRAMIDE HCL................................. 111


Index

METOLAZONE...................................................... 22METOPROLOL SU/HYDROCHLOROTHIAZ....18,19METOPROLOL SUCCINATE................................18METOPROLOL TARTRATE..................................18METOPROLOL TARTRATE (100 MG) (TABLET).....................................................................................METOPROLOL TARTRATE (25 MG) (TABLET)....METOPROLOL TARTRATE (50 MG) (TABLET)....METOPROLOL/HYDROCHLOROTHIAZIDE.....19METOZOLV ODT (10 MG) (TAB RAPDIS)....... 111METRELEPTIN...................................................... 44METROCREAM..................................................... 28METROGEL............................................................28METROGEL-VAGINAL....................................... 112METROLOTION.....................................................28METRONIDAZOLE........................... 28, 29, 60, 112METRONIDAZOLE/SKIN CLEANSER 23.......... 29METYROSINE........................................................17MEVACOR.............................................................. 22MEXILETINE HCL................................................ 15MEXITIL.................................................................15MIACALCIN (200/ML) (VIAL).............................43MIACALCIN (200/SPRAY) (SPRAY/PUMP)....... 43MICARDIS..............................................................17MICARDIS HCT.....................................................16MICONAZOLE....................................................... 59MICONAZOLE NITRATE/ZINC OX/PET............ 30MICRHOGAM ULTRA-FILTERED PLUS........... 53MIDAMOR..............................................................20MIDODRINE HCL................................................. 25MIDOSTAURIN......................................................89MIFEPREX..............................................................91MIFEPRISTONE...............................................38, 91MIGERGOT............................................................ 98MIGLITOL.............................................................. 38MIGLUSTAT........................................................... 91MIGRANAL............................................................98MILLIPRED DP......................................................67MILNACIPRAN HCL.............................................90MINASTRIN 24 FE.................................................27MINI ULTRA-THIN II............................................92MINIPRESS............................................................ 16MINIVELLE (.025MG/24H) (PATCH TDSW)...... 53MINIVELLE (.0375MG/24) (PATCH TDSW)....... 53MINIVELLE (.075MG/24H) (PATCH TDSW)...... 53MINIVELLE (0.05MG/24H) (PATCH TDSW)...... 53MINIVELLE (0.1MG/24HR) (PATCH TDSW)..... 53MINOCYCLINE HCL............................................ 59MINOCYCLINE HCL (100 MG) (CAPSULE)..........MINOCYCLINE HCL (100 MG) (TABLET).............MINOCYCLINE HCL (135 MG) (TAB ER 24H)......MINOCYCLINE HCL (45 MG) (TAB ER 24H)........MINOCYCLINE HCL (50 MG) (CAPSULE)............

MINOCYCLINE HCL (50 MG) (TABLET)...............MINOCYCLINE HCL (75 MG) (CAPSULE)............MINOCYCLINE HCL (75 MG) (TABLET)...............MINOCYCLINE HCL (90 MG) (TAB ER 24H)........MINOXIDIL............................................................18MIRABEGRON.....................................................111MIRALAX (17G/DOSE) (POWDER).................... 71MIRAPEX............................................................. 101MIRAPEX ER....................................................... 101MIRCETTE............................................................. 26MIRTAZAPINE.........................................................7MIRTAZAPINE (15 MG) (TAB RAPDIS).................MIRTAZAPINE (15 MG) (TABLET).........................MIRTAZAPINE (30 MG) (TAB RAPDIS).................MIRTAZAPINE (30 MG) (TABLET).........................MIRTAZAPINE (45 MG) (TAB RAPDIS).................MIRTAZAPINE (45 MG) (TABLET).........................MIRTAZAPINE (7.5 MG) (TABLET)........................MIRVASO................................................................28MISOPROSTOL....................................................110MITIGARE..............................................................48MITOMYCIN..........................................................48MITOSOL................................................................48MITOTANE............................................................. 89MOBIC (15 MG) (TABLET).................................. 69MOBIC (7.5 MG) (TABLET)................................. 69MODAFINIL........................................................... 13MODICON.............................................................. 27MODURETIC 5-50................................................. 20MOEXIPRIL HCL...................................................17MOEXIPRIL/HYDROCHLOROTHIAZIDE..........16MOMETASONE FUROATE...........................1, 5, 33MOMETASONE/FORMOTEROL............................4MONODOX.............................................................58MONOJECT...........................................75-79, 83, 84MONOJECT ALLERGY TRAY-NEEDLE............ 76MONOJECT CONTROL SYRINGE......................77MONOJECT ENFIT SYRINGE....................... 79, 80MONOJECT ENFIT SYRINGE CAP.....................73MONOJECT INSULIN SAFETY SYRNG............ 75MONOJECT INSULIN SYRINGE.............72, 84, 85MONOJECT LUER LOCK TB SYRINGE............ 76MONOJECT MAGELLAN...............................82, 83MONOJECT MEGELLAN TB SYRINGE.............77MONOJECT PHARMACY TRAY......................... 77MONOJECT SAFETY SYRINGE..............77, 78, 82MONOJECT SMARTIP CANNULA..................... 74MONOJECT SYRINGE.................................... 75-79MONOJECT SYRINGE PHARMACY TRAY....78,79MONOJECT TB......................................................74MONOJECT TB SYRINGE..............................74, 77MONOJECT TUBERCULIN SAFETY SYR.........82MONOJECT TUBERCULIN SYRINGE............... 77


Index

MONOKET............................................................. 25MONOPRIL............................................................ 17MONOPRIL-HCT................................................... 16MONTELUKAST SODIUM.....................................5MORGIDOX........................................................... 58MORPHINE SULFATE.....................................95, 96MORPHINE SULFATE (10 MG) (CAP ER PEL)......MORPHINE SULFATE (10 MG/5 ML)(SOLUTION)...............................................................MORPHINE SULFATE (100 MG) (CAP ER PEL)....MORPHINE SULFATE (100 MG) (TABLET ER).....MORPHINE SULFATE (100 MG/5ML)(SOLUTION)...............................................................MORPHINE SULFATE (120 MG) (CPMP 24HR).....MORPHINE SULFATE (15 MG) (TABLET ER).......MORPHINE SULFATE (15 MG) (TABLET).............MORPHINE SULFATE (20 MG) (CAP ER PEL)......MORPHINE SULFATE (20 MG/5 ML)(SOLUTION)...............................................................MORPHINE SULFATE (200 MG) (TABLET ER).....MORPHINE SULFATE (30 MG) (CAP ER PEL)......MORPHINE SULFATE (30 MG) (CPMP 24HR).......MORPHINE SULFATE (30 MG) (TABLET ER).......MORPHINE SULFATE (45 MG) (CPMP 24HR).......MORPHINE SULFATE (50 MG) (CAP ER PEL)......MORPHINE SULFATE (60 MG) (CAP ER PEL)......MORPHINE SULFATE (60 MG) (CPMP 24HR).......MORPHINE SULFATE (60 MG) (TABLET ER).......MORPHINE SULFATE (75 MG) (CPMP 24HR).......MORPHINE SULFATE (80 MG) (CAP ER PEL)......MORPHINE SULFATE (90 MG) (CPMP 24HR).......MORPHINE SULFATE/NALTREXONE............... 96MOTOFEN.............................................................. 70MOTRIN (100 MG/5ML) (ORAL SUSP).............. 68MOTRIN (400 MG) (TABLET).............................. 68MOTRIN (600 MG) (TABLET).............................. 68MOTRIN (800 MG) (TABLET).............................. 68MOVANTIK............................................................ 71MOVIPREP............................................................. 71MOXATAG.............................................................. 57MOXIFLOXACIN HCL....................................47, 58MUCOMYST.......................................................... 94MULTAQ................................................................. 15MUPIROCIN........................................................... 29MUPIROCIN CALCIUM........................................29MV, MIN 59/IRON/FOLIC/DOCUSATE............. 113MYALEPT...............................................................44MYAMBUTOL........................................................60MYCELEX.............................................................. 59MYCOBUTIN......................................................... 60MYCOPHENOLATE MOFETIL............................54MYCOPHENOLATE SODIUM............................. 54MYCOSTATIN........................................................30MYDRIACYL......................................................... 48

MYFORTIC.............................................................54MYLERAN..............................................................87MYRBETRIQ........................................................111MYSOLINE...........................................................106

- N -NABILONE............................................................... 2NABUMETONE......................................................69NADOLOL.............................................................. 18NADOLOL/BENDROFLUMETHIAZIDE.............19NAFARELIN ACETATE.........................................44NAFTIFINE HCL....................................................30NAFTIN (1 %) (CREAM (G))................................ 30NAFTIN (1 %) (GEL (GRAM))..............................30NAFTIN (2 %) (CREAM (G))................................ 30NAFTIN (2 %) (GEL (GRAM))..............................30NALFON................................................................. 68NALOXEGOL OXALATE......................................71NALOXONE HCL.................................................. 13NALTREXONE HCL.............................................. 13NALTREXONE HCL/BUPROPION HCL........... 116NAMENDA (10 MG) (TABLET)............................. 6NAMENDA (2 MG/ML) (SOLUTION)................... 6NAMENDA (5 MG) (TABLET)............................... 6NAMENDA (5 MG-10 MG) (TAB DS PK)..............6NAMENDA XR (14 MG) (CAP SPR 24)................. 6NAMENDA XR (21 MG) (CAP SPR 24)................. 6NAMENDA XR (28 MG) (CAP SPR 24)................. 6NAMENDA XR (7 MG) (CAP SPR 24)................... 6NAMENDA XR (7-14-21-28) (CAP24 DSPK)........ 6NAMZARIC (14MG-10MG) (CAP SPR 24)............6NAMZARIC (21 MG-10MG) (CAP SPR 24)...........6NAMZARIC (28 MG-10MG) (CAP SPR 24)...........6NAMZARIC (7 MG-10 MG) (CAP SPR 24)............7NAPRELAN (375 MG) (TBMP 24HR)..................69NAPRELAN (500 MG) (TBMP 24HR)..................69NAPRELAN (750 MG) (TBMP 24HR)..................69NAPROSYN (125 MG/5ML) (ORAL SUSP).........69NAPROSYN (250 MG) (TABLET)........................ 69NAPROSYN (375 MG) (TABLET)........................ 69NAPROSYN (500 MG) (TABLET)........................ 69NAPROXEN............................................................ 69NAPROXEN SODIUM........................................... 69NAPROXEN/IRRITANT CNTR-IRRIT 2.............. 68NARATRIPTAN HCL............................................. 98NARCAN (0.4 MG/ML) (VIAL)............................ 13NARCAN (4 MG) (SPRAY)................................... 13NARDIL.................................................................... 7NASALIDE............................................................... 1NASCOBAL.......................................................... 116NASONEX................................................................ 1NATACHEW..........................................................113NATACYN...............................................................47NATAMYCIN..........................................................47NATAZIA.................................................................26


Index

NATEGLINIDE....................................................... 38NATELLE ONE.....................................................114NATROBA...............................................................30NAVANE..................................................................12NEBIVOLOL HCL..................................................18NEBUPENT............................................................ 61NEBUSAL...............................................................91NEDOCROMIL SODIUM...................................... 47NEEDLES................................................................92NEEVODHA......................................................... 116NEFAZODONE HCL................................................8NELFINAVIR MESYLATE.................................... 64NEOMYC/BACIT/POLYMYX/HYDROCORT..... 31NEOMYC/COLIST/HYDROCORT/THONZN......41NEOMYCIN SULF/BACITRACIN/POLY.............47NEOMYCIN SULFATE.......................................... 59NEOMYCIN SULFATE/FLUOCINOLONE.......... 31NEOMYCIN/BACIT/P-MYX/HYDROCORT....... 45NEOMYCIN/FLUOCINOLONE/EMOLL 65........31NEOMYCIN/POLYMYXIN B/DEXAMETHA..... 45NEOMYCIN/POLYMYXIN B/HYDROCORT......41NEOMYCIN/POLYMYXN B/GRAMICIDIN....... 47NEO-POLYCIN.......................................................47NEORAL................................................................. 54NEOSPORIN...........................................................47NEO-SYNALAR..................................................... 31NEPAFENAC.......................................................... 46NEPTAZANE.......................................................... 47NESINA...................................................................38NESTABS..............................................................115NESTABS ABC.....................................................114NESTABS DHA.................................................... 114NETUPITANT/PALONOSETRON HCL................. 2NEUAC....................................................................28NEULASTA.............................................................51NEUPOGEN............................................................51NEUPRO............................................................... 101NEURONTIN........................................................ 103NEVANAC...............................................................46NEVIRAPINE......................................................... 62NEXA PLUS......................................................... 114NEXA SELECT.....................................................113NEXAVAR...............................................................89NEXAVIR................................................................87NEXIUM (20 MG) (CAPSULE DR).................... 111NEXIUM (40 MG) (CAPSULE DR).................... 111NIACIN................................................................... 25NIASPAN................................................................ 25NICARDIPINE HCL...............................................19NICOTINE.............................................................108NICOTROL........................................................... 108NICOTROL NS..................................................... 108NIFEDIPINE........................................................... 20NILANDRON..........................................................87

NILOTINIB HCL.................................................... 89NILUTAMIDE.........................................................87NIMODIPINE..........................................................20NINTEDANIB ESYLATE...................................... 94NIRAPARIB TOSYLATE....................................... 89NISOLDIPINE........................................................ 20NITAZOXANIDE....................................................61NITRO-BID............................................................. 25NITRO-DUR (0.1MG/HR) (PATCH TD24)........... 25NITRO-DUR (0.2MG/HR) (PATCH TD24)........... 25NITRO-DUR (0.3 MG/HR) (PATCH TD24).......... 25NITRO-DUR (0.4MG/HR) (PATCH TD24)........... 26NITRO-DUR (0.6MG/HR) (PATCH TD24)........... 26NITRO-DUR (0.8MG/HR) (PATCH TD24)........... 26NITROFURANTOIN.............................................. 57NITROFURANTOIN MACROCRYSTAL............. 57NITROFURANTOIN MONOHYD/M-CRYST......57NITROGLYCERIN..................................... 25, 26, 70NITROLINGUAL....................................................26NITROMIST............................................................26NITROSTAT............................................................ 26NITRO-TIME.......................................................... 26NIZATIDINE.........................................................110NIZORAL..........................................................30, 59NOLIX.....................................................................33NOLVADEX............................................................ 90NORDITROPIN FLEXPRO....................................44NORELGESTROMIN/ETHIN.ESTRADIOL........ 27NORETH-ETHINYL ESTRADIOL/IRON............ 26NORETHINDRONE............................................... 27NORETHINDRONE ACETATE............................. 53NORETHINDRONE AC-ETH ESTRADIOL....27,53NORETHINDRONE-E.ESTRADIOL-IRON......... 27NORETHINDRONE-ETHINYL ESTRAD............ 27NORFLEX.............................................................108NORGESTIMATE-ETHINYL ESTRADIOL.........27NORGESTREL-ETHINYL ESTRADIOL............. 27NORITATE.............................................................. 29NORM-JECT SYRINGE...................................77, 78NORM-JECT TUBERKULIN SYRINGE.............. 77NORPACE............................................................... 15NORPACE CR.........................................................15NORPRAMIN........................................................... 9NOR-Q-D................................................................ 27NORTHERA............................................................25NORTRIPTYLINE HCL........................................... 9NORVASC............................................................... 19NORVIR (100 MG) (TABLET)...............................64NORVIR (80 MG/ML) (SOLUTION).................... 64NOVAREL (10000 UNIT) (VIAL)..........................42NOVOFINE 32........................................................ 92NOVOFINE AUTOCOVER.................................... 93NOVOFINE PLUS.................................................. 92


Index

NOVOLIN 70-30..................................................... 40NOVOLIN N............................................................40NOVOLIN R............................................................41NOVOLOG (100/ML) (CARTRIDGE)...................39NOVOLOG (100/ML) (VIAL)................................39NOVOLOG FLEXPEN........................................... 39NOVOLOG MIX 70-30...........................................39NOVOLOG MIX 70-30 FLEXPEN........................ 39NOVOTWIST.......................................................... 92NOXAFIL (200 MG/5ML) (ORAL SUSP).............59NUCORT................................................................. 33NUCYNTA.............................................................. 97NUCYNTA ER........................................................ 97NUEDEXTA............................................................91NULEV..................................................................109NULYTELY WITH FLAVOR PACKS....................71NUMBONEX.......................................................... 36NUTRESTORE....................................................... 93NUTROPIN AQ NUSPIN....................................... 44NUVARING.............................................................26NUVESSA.............................................................112NUVIGIL (150 MG) (TABLET).............................13NUVIGIL (200 MG) (TABLET).............................13NUVIGIL (250 MG) (TABLET).............................13NUVIGIL (50 MG) (TABLET)...............................13NYAMYC................................................................ 30NYMALIZE (60 MG/20ML) (SOLUTION)...........20NYSTATIN........................................................ 30, 59NYSTATIN (100000/ML) (ORAL SUSP)..................NYSTATIN (500K UNIT) (TABLET)........................NYSTATIN/TRIAMCIN......................................... 30NYSTEX..................................................................30NYSTOP..................................................................30

- O -OB COMPLETE....................................................114OB COMPLETE GOLD........................................113OB COMPLETE ONE.......................................... 113OB COMPLETE PETITE..................................... 116OB COMPLETE PREMIER................................. 114OB COMPLETE WITH DHA...............................113OBREDON.............................................................. 28OBSTETRIX EC................................................... 115OBSTETRIX ONE................................................ 114OBTREX DHA......................................................114OCUFEN................................................................. 46OCUFLOX...............................................................47OCUPRESS............................................................. 47ODEFSEY............................................................... 64OFEV.......................................................................94OFLOXACIN.....................................................41, 47OLANZAPINE........................................................ 12OLANZAPINE/FLUOXETINE HCL..................... 14OLAPARIB..............................................................89OLMESARTAN MEDOXOMIL.............................17

OLMESARTAN/AMLODIPIN/HCTHIAZID........ 16OLMESARTAN/HYDROCHLOROTHIAZIDE.....16OLODATEROL HCL................................................ 3OLOPATADINE HCL......................................... 1, 45OLSALAZINE SODIUM........................................70OLUX...................................................................... 32OLUX-E.................................................................. 32OMACETAXINE MEPESUCCINATE................... 89OMALIZUMAB........................................................5OMECLAMOX-PAK............................................ 110OMEGA-3 ACID ETHYL ESTERS....................... 25OMEPPI (40MG-1.1G) (CAPSULE)....................111OMEPRAZOLE.................................................... 111OMEPRAZOLE (10 MG) (CAPSULE DR)...............OMEPRAZOLE (20 MG) (CAPSULE DR)...............OMEPRAZOLE (40 MG) (CAPSULE DR)...............OMEPRAZOLE/CLARITH/AMOXICILLIN...... 110OMEPRAZOLE/SODIUM BICARBONATE.......111OMNARIS................................................................. 1OMNICEF............................................................... 55OMNIPRED............................................................ 46OMNITROPE.......................................................... 44ONDANSETRON......................................................2ONDANSETRON HCL.............................................2ONDANSETRON HCL (4 MG) (TABLET)...............ONDANSETRON HCL (4 MG/5 ML) (SOLUTION).....................................................................................ONDANSETRON HCL (8 MG) (TABLET)...............ONFI (10 MG) (TABLET).................................... 101ONFI (2.5 MG/ML) (ORAL SUSP)......................101ONFI (20 MG) (TABLET).................................... 101ONGLYZA.............................................................. 38ONMEL................................................................... 59OPANA.................................................................... 97OPANA ER (10 MG) (TAB ER 12H)......................97OPANA ER (15 MG) (TAB ER 12H)......................97OPANA ER (20 MG) (TAB ER 12H)......................97OPANA ER (30 MG) (TAB ER 12H)......................97OPANA ER (40 MG) (TAB ER 12H)......................97OPANA ER (5 MG) (TAB ER 12H)........................97OPANA ER (7.5 MG) (TAB ER 12H).....................97OPIUM TINCTURE................................................70OPIUM/BELLADONNA ALKALOIDS................ 96OPSUMIT................................................................21OPTICROM.............................................................47OPTIPRANOLOL................................................... 48OPTIVAR.................................................................45ORACEA................................................................. 58ORAP.......................................................................11ORAPRED...............................................................67ORAVIG.................................................................. 59ORENCIA................................................................66ORENCIA CLICKJECT......................................... 66ORENITRAM ER (0.125 MG) (TABLET ER).......21


Index

ORENITRAM ER (0.25 MG) (TABLET ER).........21ORENITRAM ER (1 MG) (TABLET ER)..............21ORENITRAM ER (2.5 MG) (TABLET ER)...........21ORENITRAM ER (5 MG) (TABLET ER)..............21ORINASE................................................................ 38ORKAMBI.............................................................. 94ORLISTAT.............................................................116ORPHENADRINE CITRATE...............................108ORTHO EVRA........................................................27ORTHO MICRONOR............................................. 27ORTHO TRI-CYCLEN........................................... 27ORTHO TRI-CYCLEN LO.....................................27ORTHO-CEPT.........................................................26ORTHO-CYCLEN.................................................. 27ORTHO-EST........................................................... 53ORTHO-NOVUM....................................................27OSELTAMIVIR PHOSPHATE............................... 61OSENI......................................................................37OSIMERTINIB MESYLATE..................................89OSMOPREP............................................................ 71OTEZLA (10-20-30MG) (TAB DS PK)..................66OTEZLA (30 MG) (TABLET)................................ 66OTREXUP............................................................... 65OVACE PLUS (10 %) (SHAMPOO)...................... 34OVCON-35.............................................................. 27OVIDE..................................................................... 30OVIDREL................................................................ 42OVRAL....................................................................27OXANDRIN............................................................ 52OXANDROLONE................................................... 52OXAPROZIN...........................................................69OXAYDO (7.5 MG) (TABLET ORL).....................96OXAZEPAM............................................................11OXCARBAZEPINE.............................................. 105OXCARBAZEPINE (150 MG) (TABLET).................OXCARBAZEPINE (300 MG) (TABLET).................OXCARBAZEPINE (300 MG/5ML) (ORAL SUSP).....................................................................................OXCARBAZEPINE (600 MG) (TABLET).................OXICONAZOLE NITRATE................................... 30OXISTAT (1 %) (CREAM (G))...............................30OXTELLAR XR (150 MG) (TAB ER 24H)......... 105OXTELLAR XR (300 MG) (TAB ER 24H)......... 105OXTELLAR XR (600 MG) (TAB ER 24H)......... 105OXYBUTYNIN.....................................................112OXYBUTYNIN CHLORIDE................................112OXYBUTYNIN CHLORIDE (10 MG) (TAB ER 24).....................................................................................OXYBUTYNIN CHLORIDE (15 MG) (TAB ER 24).....................................................................................OXYBUTYNIN CHLORIDE (5 MG) (TAB ER 24).....................................................................................OXYBUTYNIN CHLORIDE (5 MG) (TABLET)......

OXYBUTYNIN CHLORIDE (5 MG/5 ML)(SYRUP)......................................................................OXYCODONE HCL......................................... 96, 97OXYCODONE HCL (10 MG) (TAB ER 12H)...........OXYCODONE HCL (10 MG) (TABLET).................OXYCODONE HCL (15 MG) (TAB ER 12H)...........OXYCODONE HCL (15 MG) (TABLET).................OXYCODONE HCL (20 MG) (TAB ER 12H)...........OXYCODONE HCL (20 MG) (TABLET).................OXYCODONE HCL (20 MG/ML) (ORAL CONC).....................................................................................OXYCODONE HCL (30 MG) (TAB ER 12H)...........OXYCODONE HCL (30 MG) (TABLET).................OXYCODONE HCL (40 MG) (TAB ER 12H)...........OXYCODONE HCL (5 MG) (CAPSULE).................OXYCODONE HCL (5 MG) (TABLET)...................OXYCODONE HCL (5 MG/5 ML) (SOLUTION)....OXYCODONE HCL (60 MG) (TAB ER 12H)...........OXYCODONE HCL (80 MG) (TAB ER 12H)...........OXYCODONE HCL/ACETAMINOPHEN............ 99OXYCODONE HCL/ACETAMINOPHEN (10MG-325MG) (TABLET).....................................................OXYCODONE HCL/ACETAMINOPHEN (2.5-325MG) (TABLET)...........................................................OXYCODONE HCL/ACETAMINOPHEN (5 MG-325MG) (TABLET).....................................................OXYCODONE HCL/ACETAMINOPHEN (7.5-325MG) (TABLET)...........................................................OXYCODONE HCL/ASPIRIN.............................. 99OXYCONTIN..........................................................97OXYMETHOLONE................................................52OXYMORPHONE HCL......................................... 97OXYTROL.............................................................112

- P -PALBOCICLIB....................................................... 89PALGIC..................................................................... 1PALIPERIDONE..................................................... 12PAMELOR (10 MG) (CAPSULE)............................ 9PAMELOR (25 MG) (CAPSULE)............................ 9PAMELOR (50 MG) (CAPSULE)............................ 9PAMELOR (75 MG) (CAPSULE)............................ 9PAMINE................................................................ 109PAMINE FORTE...................................................109PANCREAZE........................................................ 108PANDEL..................................................................33PANMYCIN............................................................ 59PANOBINOSTAT LACTATE..................................89PANRETIN..............................................................35PANTOPRAZOLE SODIUM................................111PARCOPA..............................................................101PARICALCITOL.....................................................44PARLODEL...........................................................101PARNATE..................................................................7PAROXETINE HCL..................................................8


Index

PAROXETINE MESYLATE..................................... 8PASER..................................................................... 60PASIREOTIDE DIASPARTATE............................. 94PATADAY................................................................ 45PATANASE................................................................1PATANOL................................................................45PATHOCIL.............................................................. 58PATIROMER CALCIUM SORBITEX................... 42PAXIL (10 MG) (TABLET)...................................... 8PAXIL (20 MG) (TABLET)...................................... 8PAXIL (30 MG) (TABLET)...................................... 8PAXIL (40 MG) (TABLET)...................................... 8PAXIL CR..................................................................8PAZEO.....................................................................45PAZOPANIB HCL...................................................89PEG3350/SOD SUL/NACL/KCL/ASB/C...............71PEG3350/SOD SULF,BICARB,CL/KCL............... 71PEGANONE..........................................................102PEGASYS................................................................64PEGASYS PROCLICK...........................................64PEGFILGRASTIM..................................................51PEGINTERFERON ALFA-2A................................64PEGINTERFERON ALFA-2B..........................65, 88PEGINTERFERON BETA-1A................................90PEGINTRON...........................................................65PEGVISOMANT.....................................................43PEN NEEDLE......................................................... 92PEN NEEDLE, DIABETIC...............................92, 93PEN NEEDLE, DIABETIC, SAFETY................... 93PEN NEEDLE,DUAL SAFETY,DIABETC........... 93PEN NEEDLES....................................................... 92PENCICLOVIR....................................................... 31PENICILLAMINE.................................................. 65PENICILLIN V POTASSIUM................................ 58PENLAC..................................................................30PENNSAID (1.5 %) (DROPS)................................ 34PENNSAID (20MG/G(2%)) (SOL MD PMP)........34PENTAMIDINE ISETHIONATE............................61PENTASA................................................................70PENTAZINE VC WITH CODEINE....................... 27PENTAZOCINE HCL/NALOXONE HCL............. 97PENTAZOCINE LACTATE....................................97PENTIPS..................................................................92PENTOSAN POLYSULFATE SODIUM..............112PENTOXIFYLLINE................................................50PEPCID (20 MG) (TABLET)................................110PEPCID (40 MG) (TABLET)................................110PEPCID (40MG/5ML) (ORAL SUSP)................. 110PERAMPANEL............................................. 105, 106PERFOROMIST........................................................3PERIACTIN (2 MG/5 ML) (SYRUP)....................... 1PERIACTIN (4 MG) (TABLET)...............................1PERIDEX................................................................ 91PERINDOPRIL ARG/AMLODIPINE BES............16

PERINDOPRIL ERBUMINE................................. 17PERIOSTAT.............................................................91PERMETHRIN........................................................30PERMETHRIN (5 %) (CREAM (G)).........................PERPHENAZINE....................................................13PERPHENAZINE/AMITRIPTYLINE HCL.............9PERSANTINE.........................................................51PERTZYE (16K-57.5K) (CAPSULE DR)............ 108PERTZYE (4000-14375) (CAPSULE DR)........... 109PERTZYE (8K-28.75K) (CAPSULE DR)............ 109PHEN TUSS DM.....................................................28PHENAZOPYRIDINE HCL................................. 112PHENDIMETRAZINE TARTRATE.....................116PHENELZINE SULFATE......................................... 7PHENERGAN........................................................... 2PHENERGAN (12.5 MG) (TABLET)...................... 1PHENERGAN (25 MG) (TABLET)......................... 1PHENERGAN (50 MG) (TABLET)......................... 1PHENERGAN VC...............................................1, 27PHENERGAN VC WITH CODEINE.....................27PHENERGAN WITH CODEINE........................... 28PHENOBARB/HYOSCY/ATROPINE/SCOP....109,110PHENOBARBITAL.................................................13PHENOBARBITAL (100 MG) (TABLET).................PHENOBARBITAL (16.2 MG) (TABLET)................PHENOBARBITAL (30 MG) (TABLET)...................PHENOBARBITAL (32.4 MG) (TABLET)................PHENOBARBITAL (60 MG) (TABLET)...................PHENOBARBITAL (64.8 MG) (TABLET)................PHENOBARBITAL (97.2MG) (TABLET).................PHENOHYTRO (16.2 MG) (TABLET)................110PHENOHYTRO (16.2MG/5ML) (ELIXIR)......... 110PHENOXYBENZAMINE HCL..............................16PHENTERMINE HCL.......................................... 116PHENTERMINE/TOPIRAMATE.........................116PHEN-TUSS AD..................................................... 27PHENYLEPHRINE HCL........................................46PHENYLEPHRINE HCL/PROMETH HCL...........27PHENYTEK.......................................................... 106PHENYTOIN.........................................................106PHENYTOIN SODIUM EXTENDED................. 106PHOSLO (667 MG) (CAPSULE)........................... 41PHOSLO (667 MG) (TABLET).............................. 41PHOSLYRA.............................................................41PHOSPHASAL........................................................56PHOSPHOLINE IODIDE....................................... 47PHYTONADIONE (VIT K1)..................................52PHYTONADIONE (VIT K1) (5 MG) (TABLET)......PICATO (0.015 %) (GEL (EA)).............................. 35PICATO (0.05 %) (GEL (EA))................................ 35PILOCARPINE HCL........................................ 48, 87PIMECROLIMUS................................................... 36PIMOZIDE.............................................................. 11


Index

PINDOLOL............................................................. 18PIOGLITAZONE HCL............................................38PIOGLITAZONE HCL/GLIMEPIRIDE.................38PIOGLITAZONE HCL/METFORMIN HCL......... 39PIRFENIDONE....................................................... 94PIROXICAM........................................................... 69PISTON ENFIT SYRINGE.....................................80PITAVASTATIN CALCIUM................................... 22PLAQUENIL........................................................... 61PLAVIX (300 MG) (TABLET)............................... 51PLAVIX (75 MG) (TABLET)................................. 51PLEGRIDY..............................................................90PLEGRIDY PEN..................................................... 90PLENDIL.................................................................19PLETAL...................................................................51PLEXION................................................................ 31PLEXION (9.8%-4.8%) (CLEANSER).................. 31PLEXION TS...........................................................31PLIAGLIS................................................................36PNV 102/IRON/FOLATE 1/DSS/DHA................ 113PNV 11/IRON FUM/FOLIC ACID/OM3............. 113PNV 112/IRON/FOLIC/OM3/DHA/EPA............. 113PNV 117/IRON/FOLIC/OM3/DHA/EPA............. 113PNV 15/IRON FUM,PS/FOLIC ACID................. 113PNV 16/IRON FUM,PS/FOLIC/OM-3.................113PNV 19/IRON PS,HEME/FOLIC/DHA............... 113PNV 21/IRON PS,HEME PPEP/FOLIC............... 113PNV 22/IRON,GLUC/FOLIC/DSS/DHA.............113PNV 30/IRON CARB,AG/FOLIC/OM3...............113PNV 39/IRON/FOLIC/DOCUSATE/DHA........... 113PNV 55/IRON FUM,B-G/FOLIC ACID...............113PNV 66/IRON/FOLIC/DOCUSATE/DHA........... 113PNV 67/IRON PS/FOLATE NO.1/DHA...............113PNV 69/IRON/FOLIC/DOCUSATE/DHA........... 113PNV 76/IRON,GLUC/FOLIC/DSS/DHA.............113PNV 80/IRON FUM/FOLIC/DSS/DHA............... 113PNV 85/IRON/FOLIC/DHA/FISH OIL................113PNV NO.106/IRON/FOLATE NO6/DHA............ 113PNV NO.118/IRON FUMARATE/FA.................. 113PNV NO.118/IRON FUMARATE/FA (29 MG-1MG) (TAB CHEW).....................................................PNV NO.5/FERROUS FUM/FOLIC AC..............113PNV NO.66/IRON,CARB/FOLIC/DHA.............. 114PNV NO.80/IRON/MFOLATE/DSS/DHA........... 114PNV NO.88/IRON PS,HEME/FA/DHA............... 114PNV OB+DHA......................................................113PNV, CALCIUM 70/IRON/FOLIC/DHA............. 114PNV,CALCIUM 72/IRON,CARB/FOLIC............ 114PNV,CALCIUM 72/IRON/FOLIC ACID............. 114PNV/FERROUS FUM/DOCUSATE/FOLIC........ 114PNV/FOLIC AC/B6/CALCIUM/GINGER...........116PNV/IRON,CARB/DOCUSAT/FOLIC AC.......... 114PNV119/IRON FUM/FOLIC/DOCUSATE.......... 114PNV53/IRON FUM/FA/DOCUSATE/DHA......... 114

PNV59/IRON,CARB,FUM/FA/DSS/DHA...........114PNV72/IRON,GLUC/FOLIC/DSS/DHA..............114PNV73/IRON,GLUC/FOLIC/DSS/DHA..............114PNV81/IRON EDTA,PS/FOLIC/OMEG3............ 114PNV83/IRON,CARB,ASP/FOLIC ACID............. 114PODOFILOX...........................................................35PODOPHYLLUM RESIN.......................................35POLYETHYLENE GLYCOL 3350.........................71POLYMYXIN B SULF/TRIMETHOPRIM............47POLYTRIM............................................................. 47POMALIDOMIDE.................................................. 88POMALYST............................................................ 88PONATINIB HCL................................................... 89POSACONAZOLE..................................................59POT CHLORIDE/POT BICARB/CIT AC.............. 42POTABA................................................................ 116POTASSIUM AMINOBENZOATE...................... 116POTASSIUM BICARBONATE/CIT AC................ 42POTASSIUM CHLORIDE...................................... 42POTASSIUM CHLORIDE (10 MEQ) (CAPSULEER)...............................................................................POTASSIUM CHLORIDE (10 MEQ) (TAB ERPRT).............................................................................POTASSIUM CHLORIDE (10 MEQ) (TABLET ER).....................................................................................POTASSIUM CHLORIDE (15 MEQ) (TAB ERPRT).............................................................................POTASSIUM CHLORIDE (20 MEQ) (PACKET)......POTASSIUM CHLORIDE (20 MEQ) (TAB ERPRT).............................................................................POTASSIUM CHLORIDE (20 MEQ) (TABLET ER).....................................................................................POTASSIUM CHLORIDE (20MEQ/15ML)(LIQUID).....................................................................POTASSIUM CHLORIDE (40MEQ/15ML)(LIQUID).....................................................................POTASSIUM CHLORIDE (8 MEQ) (CAPSULEER)...............................................................................POTASSIUM CHLORIDE (8 MEQ) (TABLET ER).....................................................................................POTASSIUM CITRATE........................................111POVIDONE-IODINE.............................................. 35POVIDONE-IODINE (5 %) (SOLUTION)................PRADAXA.............................................................. 52PRALUENT PEN....................................................24PRAMCORT............................................................70PRAMIPEXOLE DI-HCL.....................................101PRAMLINTIDE ACETATE.................................... 38PRAMOSONE (2.5 %-1 %) (CREAM (G))............35PRAMOSONE E..................................................... 35PRANDIN................................................................38PRASUGREL HCL................................................. 51PRAVACHOL.......................................................... 23PRAVASTATIN SODIUM.......................................23


Index

PRAZIQUANTEL................................................... 60PRAZOSIN HCL.....................................................16PRECISIONGLIDE.................................................76PRECOSE................................................................38PRED FORTE..........................................................46PRED MILD............................................................46PRED-G...................................................................45PREDNICARBATE.................................................33PREDNISOLONE................................................... 67PREDNISOLONE ACETATE.................................46PREDNISOLONE SOD PHOSPHATE.................. 67PREDNISONE........................................................ 67PREDNISONE (1 MG) (TABLET).............................PREDNISONE (10 MG) (TABLET)...........................PREDNISONE (2.5 MG) (TABLET)..........................PREDNISONE (20 MG) (TABLET)...........................PREDNISONE (5 MG) (TABLET).............................PREDNISONE (5 MG/5 ML) (SOLUTION)..............PREDNISONE (50 MG) (TABLET)...........................PREDNISONE INTENSOL........................................PREFERA OB....................................................... 113PREFERA-OB ONE..............................................113PREFERA-OB PLUS DHA.......................... 114, 115PREFEST.................................................................53PREGABALIN...................................................... 106PREGNYL...............................................................42PREMARIN.....................................................53, 112PREMPHASE..........................................................53PREMPRO...............................................................53PRENAT 115/IRON FUM/FOLIC/DSS................114PRENAT 115/IRON FUM/FOLIC/DSS (29-1-25MG) (TABLET)...........................................................PRENAT VIT 17/IRON/FOLIC/OM3,6................114PRENAT90/IRON FUM,PS/FOLIC/DHA............ 114PRENATA..............................................................115PRENATAL 105/IRON/FOLIC AC/DHA.............114PRENATAL 114/IRON A-G/FOLATE 1...............114PRENATAL 12/IRON/FOLIC/DSS/OM3............. 114PRENATAL 19...................................................... 114PRENATAL 25/IRON/FOLATE 6/DHA...............114PRENATAL 26/IRON PS/FOLIC/DHA................114PRENATAL 34/IRON/FOLIC/DSS/DHA.............114PRENATAL 38/IRON/FOLATE 6/DHA...............114PRENATAL 47/IRON/FOLATE 1/DHA...............114PRENATAL 53/IRON/FOLIC AC/OMG3............ 114PRENATAL 57/IRON/FOLIC/DSS/DHA.............114PRENATAL 59/IRON/FOLIC/DSS/DHA.............114PRENATAL 68/IRON/FOLIC NO1/DHA............ 114PRENATAL 78/IRON/FOLATE 1/DHA...............114PRENATAL 86/IRON/FOLIC/DHA/EPA.............114PRENATAL 87/IRON BIS/FOLIC/DHA.............. 114PRENATAL 93/IRON/FOLATE 9/DHA...............114PRENATAL COMB NO.42/FOLIC ACID............114PRENATAL NO.123/IRON/FOLIC AC................114

PRENATAL NO.52/IRON/FA/DHA..................... 115PRENATAL NO.75/IRON/FOLATE NO1............ 115PRENATAL NO.77/IRON ASP GLY/FA..............115PRENATAL NO115/IRON/FOLIC ACID.............115PRENATAL NO13/IRON PS/FOLATE 1............. 115PRENATAL NO35/IRON/FOLATE6/DHA.......... 115PRENATAL NO4/IRON FUM,PS/FOLIC............ 115PRENATAL PLUS-DHA.......................................116PRENATAL VIT 10/IRON FUM/FOLIC..............115PRENATAL VIT 10/IRON/FOLIC/DHA..............115PRENATAL VIT 14/IRON FUM/FOLIC..............115PRENATAL VIT 33/IRON/FOLIC/DHA..............115PRENATAL VIT 36/IRON/FOLATE 6................. 115PRENATAL VIT 65/IRON FUM,PS/FA............... 115PRENATAL VIT 84/IRON/FA 1/DHA................. 115PRENATAL VIT 85/IRON/FA 1/DHA................. 115PRENATAL VIT 87/IRON/FOLIC/DHA..............115PRENATAL VIT NO.112/FOLATE NO6............. 115PRENATAL VIT NO.127/IRON/FOLIC...............115PRENATAL VIT,CAL 73/IRON/FOLIC...............115PRENATAL VIT,CAL 74/IRON/FOLIC...............115PRENATAL VIT,CALC76/IRON/FOLIC............. 115PRENATAL VIT,CALC78/IRON/FOLIC............. 115PRENATAL VIT/IRON BISGLY/FOLIC............. 115PRENATAL VIT/IRON FUM/FOLIC AC............ 115PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1MG) (CAPSULE)........................................................PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1MG) (TABLET)...........................................................PRENATAL VIT103/IRON FUM/FOLIC.............115PRENATAL VIT106/IRON/FOLIC/OM3.............115PRENATAL VIT108/IRON,CRB/FOLIC............. 115PRENATAL VIT114/FOLATE6/GINGER............115PRENATAL VIT127/IRON/FOLIC/DSS..............115PRENATAL VIT128/IRON/FOLIC ACD............. 115PRENATAL VIT136/IRON/FOLIC ACD............. 115PRENATAL VIT22/IRON/FOLIC/OM3S.............115PRENATAL VIT27,CALCIUM/IRON/FA............115PRENATAL VIT37/IRON/FOLIC ACID..............115PRENATAL VIT68/IRON/FA NO6/DHA.............115PRENATAL VIT69/IRON/FOLATE6/DH............ 115PRENATAL VIT86/IRON/FOLIC ACID..............115PRENATAL VITS15/IRON/FOLIC/DSS..............115PRENATAL VITS16/IRON/FOLIC/DSS..............115PRENATAL VITS18/IRON/FOLIC/DSS..............116PRENATAL,CALC NO.65/IRON/FOLIC.............116PRENATAL,CALC.40/IRON/FOLATE 1............. 116PRENATAL56/IRON/FOLIC ACID/DHA............116PRENATAL64/IRON/LMFOLATE/ALGAL........ 116PRENATAL71/IRON/FOLIC ACID/DHA............116PRENATAL72/IRON FUM/FA/OM3/DHA..........116PRENATAL81/IRON/FOLIC/DOCUSATE.......... 116PRENATAL92/IRON/FOLATE8/PS-DHA........... 116PRENATE AM...................................................... 115


Index

PRENATE CHEWABLE....................................... 115PRENATE DHA.................................................... 114PRENATE ELITE..........................................114, 115PRENATE ENHANCE..........................................115PRENATE ESSENTIAL........................................115PRENATE MINI....................................................115PRENATE PIXIE...................................................115PRENATE RESTORE........................................... 115PRENATE STAR................................................... 115PREPOPIK.............................................................. 71PRESTALIA.................................................... 16, 117PREVIDENT......................................................... 113PREVIDENT 5000................................................ 113PREVIDENT 5000 ENAMEL PROTECT............ 113PREVIDENT 5000 SENSITIVE...........................113PREVYMIS............................................................. 61PREZCOBIX........................................................... 61PREZISTA (150 MG) (TABLET)........................... 61PREZISTA (600 MG) (TABLET)........................... 61PREZISTA (75 MG) (TABLET)............................. 61PREZISTA (800 MG) (TABLET)........................... 61PRIFTIN.................................................................. 60PRIMIDONE......................................................... 106PRIMLEV................................................................99PRIMSOL................................................................ 56PRINIVIL................................................................ 17PRISTIQ.................................................................... 9PRO COMFORT INSULIN SYRINGE............ 72, 84PRO COMFORT PEN NEEDLE.............................92PROAIR HFA............................................................ 3PROAIR RESPICLICK............................................. 3PROAMATINE........................................................25PRO-BANTHINE.................................................. 110PROBENECID........................................................ 48PROBENECID/COLCHICINE............................... 48PROCARBAZINE HCL.......................................... 89PROCARDIA.......................................................... 20PROCARDIA XL.................................................... 20PROCENTRA..........................................................10PROCHLORPERAZINE...........................................2PROCHLORPERAZINE MALEATE....................... 2PROCRIT.................................................................50PROCTOCORT....................................................... 70PROCTOFOAM-HC............................................... 70PROCYSBI............................................................111PRODIGY INSULIN SYRINGE................ 73, 84, 86PRODRIN................................................................98PROGESTERONE...................................................53PROGESTERONE, MICRONIZED..................43, 53PROGLYCEM......................................................... 39PROGRAF............................................................... 54PROLENSA.............................................................45PROLEUKIN...........................................................54PROLIA................................................................... 43

PROLIXIN (1 MG) (TABLET)............................... 12PROLIXIN (10 MG) (TABLET)............................. 13PROLIXIN (2.5 MG) (TABLET)............................ 13PROLIXIN (5 MG) (TABLET)............................... 13PROLOPRIM...........................................................56PROMETHAZINE HCL....................................... 1, 2PROMETHAZINE HCL/CODEINE.......................28PROMETHAZINE/DEXTROMETHORPHAN..... 28PROMETHAZINE/PHENYLEPH/CODEINE....... 27PROMETRIUM.......................................................53PROPAFENONE HCL............................................ 15PROPANTHELINE BROMIDE............................110PROPARACAINE HCL.......................................... 46PROPRANOLOL HCL........................................... 18PROPYLTHIOURACIL.......................................... 44PROSCAR............................................................. 111PROSTIN E2 VAGINAL SUPPOSITORY............. 27PROTOPIC.............................................................. 36PROTRIPTYLINE HCL............................................9PROVENTIL HFA.....................................................3PROVERA............................................................... 53PROVIDA DHA.................................................... 114PROVIDA OB........................................................115PROVIGIL............................................................... 13PROZAC (10 MG) (CAPSULE)............................... 8PROZAC (10 MG) (TABLET).................................. 8PROZAC (20 MG) (CAPSULE)............................... 8PROZAC (20 MG) (TABLET).................................. 8PROZAC (20 MG/5 ML) (SOLUTION)................... 8PROZAC (40 MG) (CAPSULE)............................... 8PROZAC WEEKLY.................................................. 8PRUDOXIN............................................................. 34PRUSSIAN BLUE (INSOLUBLE).........................91PSEUDOEPHEDRINE HCL/ACRIVAS...................1PSORCON...............................................................32PULMICORT (0.25MG/2ML) (AMPUL-NEB)....... 4PULMICORT (0.5 MG/2ML) (AMPUL-NEB)........ 4PULMICORT (1 MG/2 ML) (AMPUL-NEB).......... 4PULMICORT FLEXHALER.................................... 4PULMOZYME........................................................ 94PURINETHOL........................................................ 87PURIXAN................................................................87PYLERA................................................................110PYRAZINAMIDE................................................... 60PYRIDIUM............................................................112PYRIDOSTIGMINE BROMIDE.............................. 7PYRIMETHAMINE................................................61

- Q -QNASL...................................................................... 1QNASL CHILDREN.................................................1QSYMIA................................................................116QUALAQUIN..........................................................61QUARTETTE.......................................................... 26QUAZEPAM............................................................13


Index

QUDEXY XR (100 MG) (CAP SPR 24).............. 107QUDEXY XR (150 MG) (CAP SPR 24).............. 107QUDEXY XR (200 MG) (CAP SPR 24).............. 107QUDEXY XR (25 MG) (CAP SPR 24)................ 107QUDEXY XR (50 MG) (CAP SPR 24)................ 107QUESTRAN............................................................ 24QUESTRAN LIGHT............................................... 24QUETIAPINE FUMARATE................................... 12QUILLIVANT XR (5 MG/ML) (SU ER RC24)....14,15QUINAPRIL HCL................................................... 17QUINAPRIL/HYDROCHLOROTHIAZIDE.......... 16QUINIDINE GLUCONATE....................................15QUINIDINE SULFATE...........................................15QUININE SULFATE...............................................61QVAR REDIHALER.................................................4

- R -RABEPRAZOLE SODIUM..................................111RADIOGARDASE..................................................91RALOXIFENE HCL............................................... 43RALTEGRAVIR POTASSIUM...............................64RAMELTEON......................................................... 13RAMIPRIL.............................................................. 17RANEXA (1000 MG) (TAB ER 12H).................... 25RANEXA (500 MG) (TAB ER 12H)...................... 25RANITIDINE HCL............................................... 110RANOLAZINE........................................................25RAPAFLO............................................................. 111RAPAMUNE (0.5 MG) (TABLET).........................54RAPAMUNE (1 MG) (TABLET)............................54RAPAMUNE (1 MG/ML) (SOLUTION)............... 54RAPAMUNE (2 MG) (TABLET)............................54RASAGILINE MESYLATE..................................101RASUVO (10MG/0.2ML) (AUTO INJCT)............ 65RASUVO (12.5/0.25) (AUTO INJCT)....................65RASUVO (15MG/0.3ML) (AUTO INJCT)............ 65RASUVO (17.5/0.35) (AUTO INJCT)....................65RASUVO (20MG/0.4ML) (AUTO INJCT)............ 65RASUVO (22.5/0.45) (AUTO INJCT)....................65RASUVO (25MG/0.5ML) (AUTO INJCT)............ 65RASUVO (30MG/0.6ML) (AUTO INJCT)............ 65RASUVO (7.5MG/0.15) (AUTO INJCT)............... 65RAVICTI..................................................................70RAZADYNE (12 MG) (TABLET)............................7RAZADYNE (4 MG) (TABLET)..............................7RAZADYNE (8 MG) (TABLET)..............................7RAZADYNE ER....................................................... 7REBETOL............................................................... 65REBIF...................................................................... 90REBIF REBIDOSE................................................. 90RECTAGEL HC...................................................... 70RECTIV...................................................................70REGIMEX............................................................. 116REGLAN (10 MG) (TABLET)............................. 111

REGLAN (5 MG) (TABLET)............................... 111REGORAFENIB..................................................... 89RELAFEN............................................................... 69RELAGARD..........................................................112RELENZA............................................................... 61RELION PEN NEEDLES....................................... 92RELPAX.................................................................. 98RENACIDIN..........................................................111RENAGEL............................................................... 42RENVELA...............................................................42REPAGLINIDE....................................................... 38REPATHA PUSHTRONEX.................................... 24REPATHA SURECLICK........................................ 24REPATHA SYRINGE............................................. 24REQUIP.................................................................101REQUIP XL...........................................................101RESCRIPTOR......................................................... 62RESTASIS............................................................... 47RESTASIS MULTIDOSE........................................47RESTORIL.............................................................. 13RETAPAMULIN..................................................... 31RETIN-A................................................................. 29RETIN-A MICRO................................................... 29RETIN-A MICRO PUMP (0.04 %) (GEL W/PUMP)................................................................................. 29RETIN-A MICRO PUMP (0.08 %) (GEL W/PUMP)................................................................................. 29RETIN-A MICRO PUMP (0.1 %) (GEL W/PUMP)................................................................................. 29RETROVIR (10 MG/ML) (SYRUP)....................... 63RETROVIR (100 MG) (CAPSULE)....................... 63RETROVIR (300 MG) (TABLET).......................... 63REVATIO (10 MG/ML) (SUSP RECON)...............21REVATIO (20 MG) (TABLET)............................... 21REVIA..................................................................... 13REVLIMID..............................................................88REXULTI.................................................................11REYATAZ (150 MG) (CAPSULE)......................... 63REYATAZ (200 MG) (CAPSULE)......................... 63REYATAZ (300 MG) (CAPSULE)......................... 63RHO(D) IMMUNE GLOBULIN............................ 53RHO(D) IMMUNE GLOBULIN/MALTOSE.........53RHOGAM ULTRA-FILTERED PLUS................... 53RHOPHYLAC......................................................... 53RIBAVIRIN............................................................. 65RIBAVIRIN (200 MG) (CAPSULE)...........................RIBAVIRIN (200 MG) (TABLET)..............................RIBAVIRIN (200-400 MG) (TAB DS PK).................RIBAVIRIN (200-400(7)) (TAB DS PK)....................RIBAVIRIN (400 MG) (TABLET)..............................RIBAVIRIN (400-400 MG) (TAB DS PK).................RIBAVIRIN (400-400(7)) (TAB DS PK)....................RIBAVIRIN (600 MG) (TABLET)..............................RIBAVIRIN (600-400 MG) (TAB DS PK).................


Index

RIBAVIRIN (600-400(7)) (TAB DS PK)....................RIBAVIRIN (600-600 MG) (TAB DS PK).................RIBAVIRIN (600-600(7)) (TAB DS PK)....................RIBOCICLIB SUCCINATE....................................89RIDAURA............................................................... 67RIFABUTIN............................................................ 60RIFADIN................................................................. 60RIFAMATE..............................................................60RIFAMP/ISONIAZID/PYRAZINAMIDE.............. 60RIFAMPIN...............................................................60RIFAMPIN/ISONIAZID......................................... 60RIFAPENTINE........................................................60RIFATER................................................................. 60RIFAXIMIN.............................................................60RILPIVIRINE HCL.................................................62RILUTEK................................................................ 90RILUZOLE..............................................................90RIMANTADINE HCL............................................ 61RIOCIGUAT............................................................20RIOMET.................................................................. 38RISEDRONATE SODIUM......................................43RISEDRONATE SODIUM (150 MG) (TABLET)......RISEDRONATE SODIUM (30 MG) (TABLET)........RISEDRONATE SODIUM (35 MG) (TABLET DR).....................................................................................RISEDRONATE SODIUM (35 MG) (TABLET)........RISEDRONATE SODIUM (5 MG) (TABLET)..........RISPERIDONE....................................................... 12RISPERIDONE (0.25 MG) (TAB RAPDIS)...............RISPERIDONE (0.25 MG) (TABLET).......................RISPERIDONE (0.5 MG) (TAB RAPDIS).................RISPERIDONE (0.5 MG) (TABLET).........................RISPERIDONE (1 MG) (TAB RAPDIS)....................RISPERIDONE (1 MG) (TABLET)............................RISPERIDONE (1 MG/ML) (SOLUTION)...............RISPERIDONE (2 MG) (TAB RAPDIS)....................RISPERIDONE (2 MG) (TABLET)............................RISPERIDONE (3 MG) (TAB RAPDIS)....................RISPERIDONE (3 MG) (TABLET)............................RISPERIDONE (4 MG) (TAB RAPDIS)....................RISPERIDONE (4 MG) (TABLET)............................RITONAVIR............................................................ 64RIVAROXABAN.....................................................49RIVASTIGMINE....................................................... 7RIVASTIGMINE TARTRATE.................................. 7RIZATRIPTAN BENZOATE.................................. 98ROBAXIN............................................................. 108ROBAXIN-750...................................................... 108ROCALTROL (0.25 MCG) (CAPSULE)..............116ROCALTROL (0.5 MCG) (CAPSULE)................116ROFLUMILAST....................................................... 5ROLAPITANT HCL..................................................2ROPINIROLE HCL...............................................101ROSADAN.............................................................. 29

ROSANIL................................................................ 31ROSIGLITAZONE MALEATE.............................. 38ROSULA (10 %-5 %) (MED. PAD)........................31ROSUVASTATIN CALCIUM.................................23ROTIGOTINE........................................................101ROWASA.................................................................69ROWEEPRA (1000 MG) (TABLET)....................105ROWEEPRA (750 MG) (TABLET)......................105ROWEEPRA XR................................................... 105ROZEREM.............................................................. 13RUBRACA.............................................................. 89RUCAPARIB CAMSYLATE.................................. 89RUFINAMIDE.......................................................106RUXOLITINIB PHOSPHATE................................ 88RYDAPT..................................................................89RYTARY................................................................101RYTHMOL..............................................................15RYTHMOL SR........................................................15RYZOLT.................................................................. 98

- S -SACROSIDASE.................................................... 108SACUBITRIL/VALSARTAN..................................25SAFESNAP ALLERGY SYRINGE....................... 81SAFESNAP INSULIN SYRINGE.......................... 71SAFESNAP SYRINGE............................... 72, 81, 84SAFESNAP TUBERCULIN SYRINGE.................81SAFETY SYRINGE WITH SHIELD..................... 83SAFETY SYRINGE-NEEDLE............................... 83SAFETY SYRNG,NDL,KIT-TRAY 1 ML............. 71SAFETYGLIDE ALLERGY...................................75SAFETYGLIDE ALLERGY SYRINGE................ 75SAFETYGLIDE INSULIN SYRINGE....73, 81, 84,86SAFETYGLIDE SYRINGE..................73, 75, 76, 83SAFETYGLIDE TB SYRINGE..............................75SAFETY-LOK SAFETY SYRINGE................. 77-79SAFETY-LOK SAFETY SYRINGES............... 82-84SAFETY-LOK SYRINGES.....................................83SAFYRAL............................................................... 26SAIZEN................................................................... 44SAIZEN-SAIZENPREP.......................................... 44SALAGEN...............................................................87SALICYLIC AC/BENZOYL PER/VIT E...............35SALICYLIC ACID..................................................35SALICYLIC ACID (26 %) (LIQUID)........................SALICYLIC ACID (27.5 %) (LIQ-FILM)..................SALICYLIC ACID (28.5 %) (SOL-FILMER)............SALICYLIC ACID (6 %) (GEL (GRAM)).................SALICYLIC ACID/UREA......................................35SALMETEROL XINAFOATE..................................3SALSALATE...........................................................94SALVAX DUO PLUS..............................................35SAMSCA (15 MG) (TABLET)............................... 41SAMSCA (30 MG) (TABLET)............................... 41


Index

SANCTURA..........................................................112SANCTURA XR................................................... 112SANCUSO.................................................................2SANDIMMUNE......................................................54SANTYL..................................................................36SAPROPTERIN DIHYDROCHLORIDE............... 87SAQUINAVIR MESYLATE................................... 64SAVAYSA................................................................49SAVELLA (100 MG) (TABLET)............................90SAVELLA (12.5 MG) (TABLET)...........................90SAVELLA (25 MG) (TABLET)..............................90SAVELLA (50 MG) (TABLET)..............................90SAXAGLIPTIN HCL.............................................. 38SAXAGLIPTIN HCL/METFORMIN HCL............37SAXENDA............................................................ 116SCALACORT DK................................................... 33SCOPOLAMINE.......................................................2SEASONIQUE........................................................ 26SECNIDAZOLE......................................................60SECOBARBITAL SODIUM...................................13SECONAL SODIUM.............................................. 13SECTRAL................................................................18SECUKINUMAB.................................................... 36SELECT-OB + DHA............................................. 115SELEGILINE.......................................................... 13SELEGILINE HCL............................................... 101SELEGILINE HCL (5 MG) (CAPSULE)...................SELENIUM SULFIDE............................................34SELENIUM SULFIDE (2.25 %) (SHAMPOO).........SELENIUM SULFIDE (2.5 %) (LOTION)................SELEXIPAG............................................................ 21SELZENTRY (150 MG) (TABLET)....................... 62SELZENTRY (25 MG) (TABLET)......................... 62SELZENTRY (300 MG) (TABLET)....................... 62SELZENTRY (75 MG) (TABLET)......................... 62SEMPREX-D.............................................................1SENSIPAR...............................................................43SEREVENT DISKUS............................................... 3SEROMYCIN..........................................................60SEROPHENE.......................................................... 42SEROQUEL.............................................................12SEROQUEL XR (150 MG) (TAB ER 24H)............12SEROQUEL XR (200 MG) (TAB ER 24H)............12SEROQUEL XR (300 MG) (TAB ER 24H)............12SEROQUEL XR (400 MG) (TAB ER 24H)............12SEROQUEL XR (50 MG) (TAB ER 24H)..............12SEROSTIM..............................................................44SERTACONAZOLE NITRATE.............................. 30SERTRALINE HCL.................................................. 8SERZONE................................................................. 8SEVELAMER CARBONATE................................ 42SEVELAMER HCL................................................ 42SFROWASA............................................................ 69SIGNIFOR...............................................................94

SILAZONE-II..........................................................33SILDENAFIL CITRATE.........................................21SILENOR................................................................ 13SILODOSIN.......................................................... 111SILVADENE............................................................31SILVER SULFADIAZINE...................................... 31SIMBRINZA........................................................... 47SIMPONI.................................................................66SIMVASTATIN..................................................23, 24SIMVASTATIN (10 MG) (TABLET)..........................SIMVASTATIN (20 MG) (TABLET)..........................SIMVASTATIN (40 MG) (TABLET)..........................SIMVASTATIN (5 MG) (TABLET)............................SIMVASTATIN (80 MG) (TABLET)..........................SINECATECHINS.................................................. 31SINEMET 10-100..................................................101SINEMET 25-100..................................................101SINEMET 25-250..................................................101SINEMET CR........................................................101SINEQUAN (10 MG) (CAPSULE)...........................9SINEQUAN (100 MG) (CAPSULE).........................9SINEQUAN (150 MG) (CAPSULE).........................9SINEQUAN (25 MG) (CAPSULE)...........................9SINEQUAN (50 MG) (CAPSULE)...........................9SINEQUAN (75 MG) (CAPSULE)...........................9SINGULAIR (10 MG) (TABLET)............................ 5SINGULAIR (4 MG) (GRAN PACK).......................5SINGULAIR (4 MG) (TAB CHEW).........................5SINGULAIR (5 MG) (TAB CHEW).........................5SIROLIMUS............................................................54SIRTURO.................................................................60SITAGLIPTIN PHOS/METFORMIN HCL............ 37SITAGLIPTIN PHOSPHATE..................................38SITAVIG.................................................................. 61SKELAXIN (800 MG) (TABLET)........................108SKLICE................................................................... 30SLIP-TIP SYRINGE............................................... 78SMARTRX GABAKIT......................................... 103SOD PHOS,M-B/K PHOS,MONOB.................... 111SOD PHOSPHATE MBAS/SOD PHOS,DI............71SOD PICOSULF/MAG OX/CITRIC AC................71SODIUM CHLORIDE FOR INHALATION.......... 91SODIUM CHLORIDE/NAHCO3/KCL/PEG......... 71SODIUM FLUORIDE/POTASSIUM NIT............113SODIUM OXYBATE.............................................. 11SODIUM PHENYLBUTYRATE............................70SODIUM POLYSTYRENE SULFON/SORB........ 42SODIUM POLYSTYRENE SULFONATE.............42SODIUM SULAMYD (10 %) (DROPS)................ 46SODIUM SULFACETAMIDE-SULFUR............... 31SODIUM THIOSULFATE/SAL ACID...................30SODIUM, POTASSIUM,MAG SULFATES........... 71SOFOSBUVIR/VELPATAS/VOXILAPREV..........64SOFOSBUVIR/VELPATASVIR............................. 64


Index

SOLARAZE............................................................ 35SOLIFENACIN SUCCINATE...............................112SOLIQUA 100-33....................................................38SOLOSEC........................................................60, 117SOLTAMOX............................................................ 90SOMA....................................................................108SOMA COMPOUND............................................108SOMATROPIN..................................................43, 44SOMATULINE DEPOT.......................................... 93SOMAVERT............................................................ 43SONATA.................................................................. 14SOOLANTRA......................................................... 28SORAFENIB TOSYLATE...................................... 89SORIATANE........................................................... 36SORILUX................................................................ 36SOTALOL HCL.......................................................18SOTYLIZE.............................................................. 18SPECTAZOLE.........................................................30SPECTRACEF.........................................................55SPINOSAD..............................................................30SPIRIVA.................................................................... 3SPIRIVA RESPIMAT................................................ 3SPIRONOLACT/HYDROCHLOROTHIAZID.......20SPIRONOLACTONE..............................................20SPORANOX (10 MG/ML) (SOLUTION).............. 59SPORANOX (100 MG) (CAPSULE)..................... 59SPRITAM (1000 MG) (TAB SUSP)..................... 105SPRITAM (250 MG) (TAB SUSP)....................... 105SPRITAM (500 MG) (TAB SUSP)....................... 105SPRITAM (750 MG) (TAB SUSP)....................... 105SPRYCEL (100 MG) (TABLET)............................ 88SPRYCEL (140 MG) (TABLET)............................ 88SPRYCEL (20 MG) (TABLET).............................. 88SPRYCEL (50 MG) (TABLET).............................. 88SPRYCEL (70 MG) (TABLET).............................. 88SPRYCEL (80 MG) (TABLET).............................. 88SPS...........................................................................42STADOL (10 MG/ML) (SPRAY)............................94STALEVO 100.......................................................101STALEVO 125.......................................................101STALEVO 150.......................................................101STALEVO 200.......................................................101STALEVO 50.........................................................101STALEVO 75.........................................................101STARLIX.................................................................38STAVUDINE........................................................... 63STELARA (45MG/0.5ML) (SYRINGE)................ 68STELARA (90 MG/ML) (SYRINGE).................... 68STELAZINE............................................................13STIOLTO RESPIMAT...............................................3STIVARGA..............................................................89STRATTERA (10 MG) (CAPSULE)...................... 15STRATTERA (100 MG) (CAPSULE).................... 15STRATTERA (18 MG) (CAPSULE)...................... 15

STRATTERA (25 MG) (CAPSULE)...................... 15STRATTERA (40 MG) (CAPSULE)...................... 15STRATTERA (60 MG) (CAPSULE)...................... 15STRATTERA (80 MG) (CAPSULE)...................... 15STRIANT................................................................ 52STRIBILD............................................................... 64STRIVERDI RESPIMAT.......................................... 3STROMECTOL.......................................................60SUBOXONE (12 MG-3 MG) (FILM)...................100SUBOXONE (2 MG-0.5MG) (FILM)...................100SUBOXONE (2 MG-0.5MG) (TAB SUBL)......... 100SUBOXONE (4MG-1MG) (FILM).......................100SUBOXONE (8 MG-2 MG) (FILM).....................100SUBOXONE (8 MG-2 MG) (TAB SUBL)........... 100SUBUTEX...............................................................99SUCCIMER.............................................................91SUCRAID..............................................................108SUCRALFATE...................................................... 110SUCROFERRIC OXYHYDROXIDE..................... 42SULAR (17 MG) (TAB ER 24H)............................20SULAR (34 MG) (TAB ER 24H)............................20SULAR (8.5MG) (TAB ER 24H)............................20SULCONAZOLE NITRATE...................................30SULFACETAMIDE SOD/SULFUR/UREA........... 31SULFACETAMIDE SOD/SULFUR/UREA (10%-5%-10%) (CLEANSER)..............................................SULFACETAMIDE SODIUM.................... 28, 34, 46SULFACETAMIDE SODIUM (10 %) (CLEANSER).....................................................................................SULFACETAMIDE SODIUM (10 %) (CLNSRGEL)............................................................................SULFACETAMIDE SODIUM (10 %) (SHAMPOO).....................................................................................SULFACETAMIDE SODIUM/SULFUR................31SULFACETAMIDE/PREDNISOLONE................. 46SULFACETAMIDE/PREDNISOLONE SP............ 46SULFACETAMIDE/SULFUR/CLEANSR23......... 31SULFACT SOD/SULUR/AVOB/OTN/OCT...........31SULFADIAZINE.....................................................69SULFAMETHOXAZOLE/TRIMETHOPRIM....... 55SULFAMETHOXAZOLE/TRIMETHOPRIM (200-40MG/5) (ORAL SUSP).............................................SULFAMETHOXAZOLE/TRIMETHOPRIM(400MG-80MG) (TABLET)........................................SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160 MG) (TABLET)....................................................SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20) (ORAL SUSP)................................................SULFAMYLON (50 G) (PACKET)........................ 31SULFANILAMIDE............................................... 112SULFASALAZINE................................................. 70SULFURIC ACID/SULFONAT. PHENOL............ 91SULINDAC............................................................. 69SUMADAN............................................................. 31


Index

SUMADAN XLT.....................................................31SUMATRIPTAN......................................................98SUMATRIPTAN SUCC/NAPROXEN SOD...........98SUMATRIPTAN SUCCINATE.........................98, 99SUMAXIN...............................................................31SUMAXIN CP.........................................................31SUMAXIN TS......................................................... 31SUMYCIN...............................................................59SUNITINIB MALATE............................................ 89SUPRAX (100 MG/5ML) (SUSP RECON)............55SUPRAX (200 MG/5ML) (SUSP RECON)............55SUPRAX (500 MG/5ML) (SUSP RECON)............55SUPREP...................................................................71SURE COMFORT................................. 73, 84, 86, 92SURE COMFORT INSULIN SYRINGE....73, 84, 86SURE-FINE PEN NEEDLES..................................93SURE-JECT INSULIN SYRINGE............. 73, 85, 86SURMONTIL.......................................................... 10SUSTIVA................................................................. 62SUTENT.................................................................. 89SUVOREXANT...................................................... 14SYLATRON.............................................................88SYMAX.................................................................109SYMAX DUOTAB................................................109SYMAX-SL...........................................................109SYMAX-SR...........................................................109SYMBICORT............................................................ 3SYMBYAX..............................................................14SYMFI..................................................................... 64SYMFI LO...............................................................64SYMLINPEN 120................................................... 38SYMLINPEN 60..................................................... 38SYMMETREL (100 MG) (CAPSULE)................ 101SYMMETREL (100 MG) (TABLET)...................101SYNALAR...............................................................32SYNALAR TS.........................................................32SYNAREL............................................................... 44SYNDROS.........................................................2, 117SYNJARDY.............................................................39SYNRIBO................................................................89SYNTHROID.......................................................... 44SYPRINE.................................................................92SYR,NDL 0.3 ML,INS,SAFE,D.UNIT...................71SYR,NDL 1 ML,INS,SAFE,DISP UNT................. 71SYR,NDL,INS,SAFE 0.5ML,DISP UN..................71SYRGE-NDL,INS 0.3 ML HALF MARK........71, 72SYRGE-NDL,INS 0.5 ML HALF MARK..............72SYRING W-NEEDL 0.5 ML,KIT-TRAY............... 72SYRINGE.....................................................74, 77-79SYRINGE 3 ML,SAFETY,DISP UNIT.................. 72SYRINGE AND NEEDLE,INSULIN,1ML......72, 73SYRINGE BULK.............................................. 78, 79SYRINGE CAP, ENFIT,NON-STERILE................73SYRINGE CATHETER TIP....................................79

SYRINGE DISPOSABLE IRRIG,60 ML...............71SYRINGE DISPOSABLE IRRIG,70 ML...............73SYRINGE DISPOSABLE IRRIGATION.........73, 74SYRINGE WITH CANNULA, 1 ML..................... 74SYRINGE WITH CANNULA, 10 ML................... 74SYRINGE WITH CANNULA, 3 ML..................... 74SYRINGE WITH CANNULA, 5 ML..................... 74SYRINGE WITH CANNULA, 6 ML..................... 74SYRINGE WITH CANNULA,DISP.12ML............74SYRINGE WITH NEEDLE DISP.......................... 75SYRINGE WITH NEEDLE, 0.5 ML...................... 74SYRINGE WITH NEEDLE, 1 ML................... 74, 75SYRINGE WITH NEEDLE, 10 ML....................... 75SYRINGE WITH NEEDLE, 12 ML....................... 75SYRINGE WITH NEEDLE, 5 ML......................... 75SYRINGE WITH NEEDLE, 6 ML......................... 75SYRINGE WITH NEEDLE, INSULIN.................. 75SYRINGE WITH NEEDLE,DISPOSABLE...........75SYRINGE WITHOUT NEEDLE...................... 76-79SYRINGE W-NEEDLE 1 ML,KIT-TRAY....... 75, 76SYRINGE W-NEEDLE,DISPOSAB,3 ML............ 76SYRINGE, DISPOSABLE......................................76SYRINGE, DISPOSABLE, 1 ML.....................76, 77SYRINGE, DISPOSABLE, 10 ML.........................77SYRINGE, DISPOSABLE, 12 ML.........................77SYRINGE, DISPOSABLE, 140 ML.......................77SYRINGE, DISPOSABLE, 20 ML...................77, 78SYRINGE, DISPOSABLE, 3 ML...........................78SYRINGE, DISPOSABLE, 30 ML.........................78SYRINGE, DISPOSABLE, 35 ML...................78, 79SYRINGE, DISPOSABLE, 5 ML...........................79SYRINGE, DISPOSABLE, 50 ML.........................79SYRINGE, DISPOSABLE, 6 ML...........................79SYRINGE, DISPOSABLE, 60 ML.........................79SYRINGE, ENFIT 1 ML, STERILE.......................79SYRINGE, ENFIT 12 ML, STERILE.....................79SYRINGE, ENFIT 3 ML, STERILE.......................80SYRINGE, ENFIT 35 ML, STERILE.....................80SYRINGE, ENFIT 6 ML, STERILE.......................80SYRINGE, ENFIT 60 ML, STERILE.....................80SYRINGE, NEEDLE, CANNULA,10 ML.............80SYRINGE, SAFETY 3 ML.....................................80SYRINGE,ENFIT 1 ML,NON-STERILE...............80SYRINGE,ENFIT 12ML,NON-STERILE..............80SYRINGE,ENFIT 3 ML,NON-STERILE...............80SYRINGE,ENFIT 35ML,NON-STERILE..............80SYRINGE,ENFIT 6 ML,NON-STERILE...............80SYRINGE,ENFIT 60ML,NON-STERILE..............80SYRINGE,INSUL U-500,NDL,0.5ML...................80SYRINGE,INSULIN,NEEDLESS 1 ML................ 80SYRINGE,NDLE,SAFE 1.5 ML,D.UNT............... 80SYRINGE,NEEDLE,INSULN,SAFE,1ML...... 80, 81SYRINGE,NEEDLE,INSULN,SF 0.5ML.............. 81SYRINGE,NEEDLE,INSULN,SF,0.3ML...............81


Index

SYRINGE,SAFE 3 ML,DISPOSL UNIT............... 81SYRINGE,SAFE 5 ML,DISPOSL UNIT............... 81SYRINGE,SAFETY 1 ML,DISP UNIT..................81SYRINGE,SAFETY 10 ML,DISP UNIT................81SYRINGE,SAFETY 5 ML, DISP UNIT.................81SYRINGE,SAFETY NEEDLE,10 ML............. 81, 82SYRINGE,SAFETY NEEDLE,12 ML................... 82SYRINGE,SAFETY WITH NEEDLE,1ML.....82, 83SYRINGE,SAFETY WITH NEEDLE,3ML...........83SYRINGE,SAFETY WITH NEEDLE,5ML.....83, 84SYRINGE,SAFETY,10 ML,DISP UNIT................ 84SYRINGE-NEEDLE............................................... 82SYRINGE-NEEDLE,INSULIN,0.5 ML........... 84, 85SYRINGE-PRECISIONGLIDE NEEDLE............. 75SYRING-NEEDL,DISP,INSUL,0.3 ML........... 85, 86

- T -TABLOID................................................................ 87TACLONEX (0.005-.064) (OINT. (G))...................37TACLONEX (0.005-.064) (SUSPENSION)........... 37TACROLIMUS.................................................. 36, 54TADALAFIL........................................................... 21TAFINLAR..............................................................88TAFLUPROST/PF................................................... 48TAGAMET............................................................ 110TAGRISSO.............................................................. 89TALWIN.................................................................. 97TALWIN NX........................................................... 97TAMBOCOR........................................................... 15TAMIFLU (30 MG) (CAPSULE)........................... 61TAMIFLU (45 MG) (CAPSULE)........................... 61TAMIFLU (6 MG/ML) (SUSP RECON)................61TAMIFLU (75 MG) (CAPSULE)........................... 61TAMOXIFEN CITRATE.........................................90TAMSULOSIN HCL.............................................111TAPAZOLE............................................................. 44TAPENTADOL HCL...............................................97TARCEVA (100 MG) (TABLET)............................89TARCEVA (150 MG) (TABLET)............................89TARCEVA (25 MG) (TABLET)..............................89TARGADOX........................................................... 58TARGRETIN..................................................... 35, 90TASIGNA (150 MG) (CAPSULE)..........................89TASIGNA (200 MG) (CAPSULE)..........................89TASIGNA (50 MG) (CAPSULE)............................89TASIMELTEON...................................................... 13TASMAR............................................................... 101TAVIST...................................................................... 1TAZAROTENE..................................................29, 36TAZORAC (0.05 %) (CREAM (G))........................36TAZORAC (0.05 %) (GEL (GRAM)).....................36TAZORAC (0.1 %) (CREAM (G))..........................36TAZORAC (0.1 %) (GEL (GRAM)).......................36TB SYRINGE..........................................................75TBO-FILGRASTIM................................................ 51

TECFIDERA........................................................... 90TECHLITE INSULIN SYRINGE......................71-73TECHLITE PEN NEEDLE..................................... 93TEGRETOL...........................................................102TEGRETOL XR.................................................... 102TEKTURNA............................................................21TEKTURNA HCT...................................................21TELMISARTAN......................................................17TELMISARTAN/AMLODIPINE............................17TELMISARTAN/HYDROCHLOROTHIAZID...... 16TEMAZEPAM.........................................................13TEMODAR..............................................................87TEMOVATE.............................................................32TEMOVATE E......................................................... 32TEMOVATE EMOLLIENT.....................................32TEMOZOLOMIDE................................................. 87TENEX.................................................................... 17TENOFOVIR ALAFENAMIDE FUMARATE.......64TENOFOVIR DISOPROXIL FUMARATE............63TENORETIC 100.................................................... 18TENORETIC 50...................................................... 18TENORMIN............................................................ 18TERAZOL 3.......................................................... 112TERAZOL 7.......................................................... 112TERAZOSIN HCL.................................................. 16TERBINAFINE HCL.............................................. 59TERBUTALINE SULFATE...................................... 3TERCONAZOLE.................................................. 112TERIFLUNOMIDE.................................................90TERIPARATIDE..................................................... 43TERSI FOAM..........................................................34TERUMO ALLERGY SYRINGE...........................75TERUMO HYPODERMIC NEEDLE-SYRIN....... 75TERUMO INSULIN SYRINGE................. 73, 85, 86TERUMO SURGUARD2.................................. 82-84TERUMO SYRINGE........................................ 76, 78TESAMORELIN ACETATE...................................43TESSALON.............................................................27TESSALON PERLE................................................27TESTIM...................................................................52TESTOSTERONE................................................... 52TESTOSTERONE CYPIONATE............................ 52TESTOSTERONE ENANTHATE.......................... 52TESTRED................................................................52TETRABENAZINE.................................................91TETRACYCLINE HCL.......................................... 59TEVETEN............................................................... 17TEXACORT............................................................ 33THALIDOMIDE..................................................... 59THALOMID............................................................ 59THEO-24................................................................... 6THEO-DUR...............................................................6THEOPHYLLINE ANHYDROUS........................... 6THERMAZENE...................................................... 31


Index

THINPRO INSULIN SYRINGE.................73, 85, 86THIOGUANINE......................................................87THIOLA................................................................ 111THIORIDAZINE HCL............................................ 13THIOTHIXENE.......................................................12THRIVITE RX...................................................... 115THYROID,PORK....................................................45THYROID,PORK (113.75 MG) (TABLET)...............THYROID,PORK (120 MG) (TABLET)....................THYROID,PORK (130 MG) (TABLET)....................THYROID,PORK (146.25 MG) (TABLET)...............THYROID,PORK (15 MG) (TABLET)......................THYROID,PORK (16.25 MG) (TABLET).................THYROID,PORK (162.5 MG) (TABLET).................THYROID,PORK (195 MG) (TABLET)....................THYROID,PORK (260 MG) (TABLET)....................THYROID,PORK (30 MG) (TABLET)......................THYROID,PORK (32.5 MG) (TABLET)...................THYROID,PORK (325 MG) (TABLET)....................THYROID,PORK (48.75 MG) (TABLET).................THYROID,PORK (60 MG) (TABLET)......................THYROID,PORK (65 MG) (TABLET)......................THYROID,PORK (81.25 MG) (TABLET).................THYROID,PORK (90 MG) (TABLET)......................THYROID,PORK (97.5 MG) (TABLET)...................THYROLAR-1........................................................ 44THYROLAR-1/2..................................................... 45THYROLAR-1/4..................................................... 45THYROLAR-2........................................................ 45THYROLAR-3........................................................ 45TIAGABINE HCL.................................................106TIAGABINE HCL (12 MG) (TABLET).....................TIAGABINE HCL (16 MG) (TABLET).....................TIAGABINE HCL (2 MG) (TABLET).......................TIAGABINE HCL (4 MG) (TABLET).......................TIAZAC (120 MG) (CAP SA 24H)........................ 19TIAZAC (180 MG) (CAP SA 24H)........................ 19TIAZAC (240 MG) (CAP SA 24H)........................ 19TIAZAC (300 MG) (CAP SA 24H)........................ 19TIAZAC (360 MG) (CAP SA 24H)........................ 19TIAZAC (420 MG) (CAP SA 24H)........................ 19TICAGRELOR........................................................ 51TIGAN.......................................................................2TIKOSYN................................................................15TIMOLOL............................................................... 48TIMOLOL MALEATE......................................18, 48TIMOLOL MALEATE/PF...................................... 48TIMOPTIC.............................................................. 48TIMOPTIC OCUDOSE...........................................48TIMOPTIC-XE........................................................48TINDAMAX............................................................60TINIDAZOLE......................................................... 60TIOPRONIN..........................................................111TIOTROPIUM BR/OLODATEROL HCL................ 3

TIOTROPIUM BROMIDE........................................3TIPRANAVIR..........................................................61TIROSINT............................................................... 44TIVICAY................................................................. 64TIVORBEX............................................................. 68TIZANIDINE HCL............................................... 108TIZANIDINE/IRRITANT CNTR-IRRT2............. 108TOBI........................................................................ 59TOBI PODHALER..................................................59TOBRADEX (0.3 %-0.1%) (DROPS SUSP).......... 45TOBRADEX (0.3 %-0.1%) (OINT. (G))................ 45TOBRADEX ST...................................................... 45TOBRAMYCIN.................................................47, 59TOBRAMYCIN IN 0.225% SOD CHLOR............ 59TOBRAMYCIN/DEXAMETHASONE..................45TOBRAMYCIN/LOTEPRED ETAB...................... 45TOBRAMYCIN/NEBULIZER............................... 59TOBREX (0.3 %) (DROPS).................................... 47TOBREX (0.3 %) (OINT. (G))................................47TOCILIZUMAB......................................................67TOFACITINIB CITRATE....................................... 67TOFRANIL................................................................9TOFRANIL-PM.........................................................9TOLAK....................................................................35TOLAZAMIDE....................................................... 38TOLBUTAMIDE.....................................................38TOLCAPONE........................................................101TOLINASE.............................................................. 38TOLTERODINE TARTRATE............................... 112TOLVAPTAN...........................................................41TOOMEY SYRINGE.............................................. 73TOPAMAX............................................................ 107TOPCARE CLICKFINE......................................... 93TOPCARE ULTRA COMFORT................. 73, 85, 86TOPICORT (0.05 %) (CREAM (G)).......................32TOPICORT (0.05 %) (GEL (GRAM)).................... 32TOPICORT (0.05 %) (OINT. (G))...........................32TOPICORT (0.25 %) (CREAM (G)).......................32TOPICORT (0.25 %) (OINT. (G))...........................32TOPIRAMATE...................................................... 107TOPIRAMATE (100 MG) (CAP SPR 24)..................TOPIRAMATE (100 MG) (TABLET)........................TOPIRAMATE (15 MG) (CAP SPRINK)..................TOPIRAMATE (150 MG) (CAP SPR 24)..................TOPIRAMATE (200 MG) (CAP SPR 24)..................TOPIRAMATE (200 MG) (TABLET)........................TOPIRAMATE (25 MG) (CAP SPR 24)....................TOPIRAMATE (25 MG) (CAP SPRINK)..................TOPIRAMATE (25 MG) (TABLET)..........................TOPIRAMATE (50 MG) (CAP SPR 24)....................TOPIRAMATE (50 MG) (TABLET)..........................TOPOTECAN HCL.................................................88TOPROL XL............................................................18TORADOL (10 MG) (TABLET).............................69


Index

TOREMIFENE CITRATE.......................................90TORSEMIDE...........................................................20TOUJEO MAX SOLOSTAR...................................40TOUJEO SOLOSTAR............................................. 40TOVIAZ.................................................................112TRACLEER.............................................................21TRADJENTA...........................................................38TRAMADOL HCL............................................97, 98TRAMADOL HCL/ACETAMINOPHEN...............99TRAMETINIB DIMETHYL SULFOXIDE............88TRANDATE............................................................ 16TRANDOLAPRIL...................................................17TRANDOLAPRIL/VERAPAMIL HCL..................16TRANEXAMIC ACID............................................ 48TRANSDERM-SCOP (1 MG/3 DAY) (PATCH TD3)................................................................................ 2TRANYLCYPROMINE SULFATE..........................7TRANZAREL..........................................................36TRAVATAN Z..........................................................48TRAVOPROST........................................................ 48TRAZODONE HCL..................................................8TRECATOR.............................................................60TRELEGY ELLIPTA................................................ 4TREMFYA...............................................................36TRENTAL............................................................... 50TREPROSTINIL..................................................... 21TREPROSTINIL DIOLAMINE..............................21TREPROSTINIL/NEB ACCESSORIES.................21TREPROSTINIL/NEBULIZER/ACCESOR...........21TRESIBA FLEXTOUCH U-100.............................39TRESIBA FLEXTOUCH U-200.............................39TRETINOIN...................................................... 29, 89TRETINOIN MICROSPHERES.............................29TRETIN-X...............................................................29TREXALL (10 MG) (TABLET)............................. 87TREXALL (15 MG) (TABLET)............................. 87TREXALL (2.5 MG) (TABLET)............................ 87TREXALL (5 MG) (TABLET)............................... 87TREXALL (7.5 MG) (TABLET)............................ 87TREXIMET (10 MG-60MG) (TABLET)........98, 117TREXIMET (85MG-500MG) (TABLET).......98, 117TRIAMCINOLONE ACETON/SILICONES......... 33TRIAMCINOLONE ACETONIDE............ 33, 34, 91TRIAMCINOLONE ACETONIDE (0.025 %)(CREAM (G))..............................................................TRIAMCINOLONE ACETONIDE (0.025 %)(LOTION)....................................................................TRIAMCINOLONE ACETONIDE (0.025 %)(OINT. (G))..................................................................TRIAMCINOLONE ACETONIDE (0.1 %)(CREAM (G))..............................................................TRIAMCINOLONE ACETONIDE (0.1 %)(LOTION)....................................................................

TRIAMCINOLONE ACETONIDE (0.1 %) (OINT.(G))..............................................................................TRIAMCINOLONE ACETONIDE (0.147MG/G)(AEROSOL)................................................................TRIAMCINOLONE ACETONIDE (0.5 %)(CREAM (G))..............................................................TRIAMCINOLONE ACETONIDE (0.5 %) (OINT.(G))..............................................................................TRIAMCINOLONE/DIMETH/SILICONE............ 34TRIAMCINOLONE/EMOLLIENT COMB86....... 34TRIAMTERENE..................................................... 20TRIAMTERENE/HYDROCHLOROTHIAZID......20TRIAVIL 4-50............................................................9TRIAZOLAM..........................................................13TRIBENZOR...........................................................16TRICARE.............................................................. 115TRICOR...................................................................24TRIENTINE HCL................................................... 92TRIFLUOPERAZINE HCL.................................... 13TRIFLURIDINE......................................................46TRIFLURIDINE/TIPIRACIL HCL........................ 88TRIGLIDE...............................................................24TRIHEXYPHENIDYL HCL................................. 100TRILAFON..............................................................13TRILEPTAL.......................................................... 105TRILIPIX.................................................................24TRIMETHOBENZAMIDE HCL.............................. 2TRIMETHOPRIM...................................................56TRIMIPRAMINE MALEATE................................ 10TRIMPEX................................................................56TRINATAL RX 1...................................................115TRI-NORINYL........................................................27TRINTELLIX............................................................ 9TRISTART DHA................................................... 114TRIUMEQ............................................................... 64TRIZIVIR................................................................ 62TROKENDI XR (100 MG) (CAP ER 24H)....107,117TROKENDI XR (200 MG) (CAP ER 24H)....107,117TROKENDI XR (25 MG) (CAP ER 24H)....107, 117TROKENDI XR (50 MG) (CAP ER 24H)....107, 117TROPICAMIDE...................................................... 48TROSPIUM CHLORIDE...................................... 112TRUEPLUS INSULIN SYRINGE..............73, 85, 86TRUEPLUS PEN NEEDLE.................................... 93TRULICITY............................................................ 37TRUSOPT................................................................47TRUVADA...............................................................61TUBERCULIN SYRINGE..........................74, 75, 77TUBERCULIN SYRINGE-NEEDLE.....................75TUDORZA PRESSAIR.............................................3TUSSICAPS............................................................ 28TUSSIONEX........................................................... 28


Index

TUZISTRA XR....................................................... 27TWINPAK DUAL CANNULA...............................80TWYNSTA.............................................................. 17TYBOST..................................................................64TYKERB................................................................. 89TYMLOS.................................................................43TYVASO..................................................................21TYVASO INSTITUTIONAL START KIT..............21TYVASO REFILL KIT........................................... 21TYVASO STARTER KIT........................................21

- U -UCERIS................................................................... 66ULESFIA.................................................................30ULIPRISTAL ACETATE.........................................27ULORIC.......................................................... 48, 117ULTICARE............................................73, 75, 85, 86ULTICARE INSULIN SYRINGE.........72, 73, 85, 86ULTICARE PEN NEEDLE.....................................93ULTICARE SAFETY SYRINGE..................... 80, 83ULTICARE SYRINGE............................................80ULTICARE TB SAFETY SYRINGE..................... 83ULTILET INSULIN SYRINGE..................73, 85, 86ULTILET PEN NEEDLE........................................ 93ULTRA COMFORT.............................. 72, 73, 85, 86ULTRACET............................................................. 99ULTRA-FINE MICRO PEN NEEDLE................... 93ULTRA-FINE MINI PEN NEEDLE.......................93ULTRA-FINE NANO PEN NEEDLE.....................93ULTRA-FINE ORIGINAL PEN NEEDLE.............93ULTRA-FINE SHORT PEN NEEDLE................... 93ULTRAM.................................................................98ULTRAM ER...........................................................98ULTRA-THIN II....................................73, 85, 86, 93ULTRAVATE (0.05 %) (CREAM (G))....................33ULTRAVATE (0.05 %) (OINT. (G))........................33ULTRAVATE X....................................................... 33UMECLIDINIUM BRM/VILANTEROL TR...........3UMECLIDINIUM BROMIDE..................................3UNIFINE PENTIPS.................................................93UNIFINE PENTIPS PLUS......................................93UNIPHYL..................................................................6UNIRETIC...............................................................16UNITHROID........................................................... 44UNIVASC................................................................ 17UPTRAVI.................................................................21URAMAXIN GT..................................................... 35UREA/EMOLLIENT COMBINATION 65.............35URECHOLINE........................................................87URETRON D-S....................................................... 56URIDINE TRIACETATE.................................. 48, 90URIN D.S................................................................ 56URISPAS............................................................... 112UROCIT-K.............................................................111UROFOLLITROPIN............................................... 42

UROXATRAL....................................................... 111URSO.......................................................................70URSO FORTE......................................................... 70URSODIOL............................................................. 70URYL.......................................................................56USTEKINUMAB.................................................... 68UTA......................................................................... 56

- V -VAGIFEM..............................................................112VALACYCLOVIR HCL..........................................61VALBENAZINE TOSYLATE.................................91VALCHLOR............................................................ 35VALCYTE............................................................... 61VALGANCICLOVIR HCL..................................... 61VALISONE..............................................................32VALPROIC ACID................................................. 107VALPROIC ACID (AS SODIUM SALT)............. 107VALSARTAN.......................................................... 17VALSARTAN/HYDROCHLOROTHIAZIDE....16,17VALTREX................................................................61VANCOMYCIN HCL............................................. 60VANCOMYCIN HCL (125 MG) (CAPSULE)...........VANCOMYCIN HCL (250 MG) (CAPSULE)...........VANDAZOLE....................................................... 112VANDETANIB........................................................ 89VANISHPOINT..................................... 73, 75, 76, 85VANISHPOINT SYRINGE...............................82, 84VANOS.................................................................... 32VANOXIDE-HC...................................................... 28VANTIN (100 MG) (TABLET)...............................56VANTIN (200 MG) (TABLET)...............................56VARENICLINE TARTRATE................................ 108VARUBI.....................................................................2VASCEPA (0.5 GRAM) (CAPSULE).....................25VASCEPA (1 G) (CAPSULE)................................. 25VASERETIC............................................................16VASOTEC................................................................17VECAMYL..............................................................17VECTICAL..............................................................36VEETIDS (125 MG/5ML) (SOLN RECON)..........58VEETIDS (250 MG) (TABLET).............................58VEETIDS (250 MG/5ML) (SOLN RECON)..........58VELPHORO............................................................ 42VELTASSA..............................................................42VELTIN................................................................... 28VEMLIDY............................................................... 64VENLAFAXINE HCL.............................................. 9VENLAFAXINE HCL ER (225 MG) (TAB ER 24).....................................................................................VENLAFAXINE HCL ER (37.5 MG) (TAB ER 24).....................................................................................VENLAFAXINE HCL ER (75 MG) (TAB ER 24).....VENTAVIS.............................................................. 21


Index

VENTOLIN HFA...................................................... 3VEO INSULIN SYRINGE....................72, 73, 85, 86VERAPAMIL HCL................................................. 20VERDESO...............................................................32VEREGEN...............................................................31VERELAN...............................................................20VERELAN PM........................................................20VERSACLOZ..........................................................12VERSICLEAR.........................................................30VESANOID.............................................................89VESICARE............................................................112VFEND.................................................................... 59VIBERZI..................................................................70VIBRAMYCIN........................................................58VIBRA-TABS..........................................................58VICOPROFEN........................................................ 94VICTOZA 2-PAK....................................................37VICTOZA 3-PAK....................................................37VIDEX.....................................................................62VIDEX EC (125 MG) (CAPSULE DR)..................62VIDEX EC (200 MG) (CAPSULE DR)..................62VIDEX EC (250 MG) (CAPSULE DR)..................63VIDEX EC (400 MG) (CAPSULE DR)..................63VIGAMOX.............................................................. 47VIIBRYD...........................................................9, 117VILAZODONE HCL................................................ 9VIMPAT (10 MG/ML) (SOLUTION)...................103VIMPAT (100 MG) (TABLET)............................. 103VIMPAT (150 MG) (TABLET)............................. 103VIMPAT (200 MG) (TABLET)............................. 103VIMPAT (50 MG) (TABLET)............................... 103VIOKACE............................................................. 109VIRACEPT..............................................................64VIRAMUNE (200 MG) (TABLET)........................ 62VIRAMUNE (50 MG/5 ML) (ORAL SUSP)......... 62VIRAMUNE XR (100 MG) (TAB ER 24H)...........62VIRAMUNE XR (400 MG) (TAB ER 24H)...........62VIREAD (150 MG) (TABLET).............................. 63VIREAD (200 MG) (TABLET).............................. 63VIREAD (250 MG) (TABLET).............................. 63VIREAD (300 MG) (TABLET).............................. 63VIROPTIC............................................................... 46VISKEN...................................................................18VISTARIL (25 MG) (CAPSULE).............................1VISTARIL (50 MG) (CAPSULE).............................1VISTOGARD.......................................................... 90VITAFOL FE+.......................................................113VITAFOL ULTRA.................................................113VITAFOL-OB........................................................115VITAFOL-ONE..................................................... 114VITAMEDMD ONE RX....................................... 114VITAMEDMD REDICHEW RX.......................... 114VITAPEARL......................................................... 116VITATRUE............................................................ 114

VITUZ..................................................................... 28VIVACTIL................................................................. 9VIVELLE-DOT....................................................... 53VIVLODEX.............................................................69VOGELXO.............................................................. 52VOLTAREN.......................................................34, 68VOLTAREN-XR......................................................68VORAPAXAR SULFATE....................................... 51VORICONAZOLE.................................................. 59VORINOSTAT.........................................................89VORTIOXETINE HYDROBROMIDE..................... 9VOSEVI...................................................................64VOSOL.................................................................... 41VOSOL HC..............................................................41VOTRIENT..............................................................89VRAYLAR (1.5 MG) (CAPSULE).................11, 117VRAYLAR (3 MG) (CAPSULE)....................11, 118VRAYLAR (4.5 MG) (CAPSULE).................11, 118VRAYLAR (6 MG) (CAPSULE)....................11, 118VUSION.................................................................. 30VYTONE (1.9 %-1 %) (CREAM PACK)............... 29VYTORIN............................................................... 22VYVANSE (10 MG) (CAPSULE).......................... 10VYVANSE (20 MG) (CAPSULE).......................... 11VYVANSE (30 MG) (CAPSULE).......................... 11VYVANSE (40 MG) (CAPSULE).......................... 11VYVANSE (50 MG) (CAPSULE).......................... 11VYVANSE (60 MG) (CAPSULE).......................... 11VYVANSE (70 MG) (CAPSULE).......................... 11

- W -WARFARIN SODIUM............................................ 48WELCHOL..............................................................24WELLBUTRIN......................................................... 7WELLBUTRIN SR................................................... 7WELLBUTRIN XL................................................... 7WELLCOVORIN.................................................... 89WHYTEDERM TDPAK......................................... 34WHYTEDERM TRILASIL PAK............................34WINRHO SDF.........................................................53

- X -XALATAN...............................................................47XARELTO (10 MG) (TABLET)............................. 49XARELTO (15 MG) (TABLET)............................. 49XARELTO (15 MG-20MG) (TAB DS PK).............49XARELTO (20 MG) (TABLET)............................. 49XATMEP......................................................... 87, 118XELJANZ (5 MG) (TABLET)................................ 67XELJANZ XR......................................................... 67XELODA (150 MG) (TABLET)............................. 87XELODA (500 MG) (TABLET)............................. 87XENAZINE............................................................. 91XENICAL..............................................................116XERESE.................................................................. 31XIFAXAN (200 MG) (TABLET)............................60


Index

XIFAXAN (550 MG) (TABLET)............................60XIGDUO XR (10-1000 MG) (TAB BP 24H)......... 39XIGDUO XR (10MG-500MG) (TAB BP 24H)...... 39XIGDUO XR (5 MG-500MG) (TAB BP 24H)....... 39XIGDUO XR (5MG-1000MG) (TAB BP 24H)...... 39XIIDRA................................................................... 47XOLAIR.................................................................... 5XOLEGEL...............................................................30XOPENEX.................................................................3XOPENEX CONCENTRATE...................................3XOPENEX HFA........................................................ 3XRYLIX.................................................................. 34XTANDI.................................................................. 87XULTOPHY 100-3.6...............................................38XURIDEN............................................................... 48XYREM...................................................................11

- Y -YASMIN 28............................................................. 26YAZ..........................................................................26

- Z -ZAFIRLUKAST........................................................ 5ZALEPLON.............................................................14ZANAFLEX (2 MG) (CAPSULE)........................108ZANAFLEX (2 MG) (TABLET)...........................108ZANAFLEX (4 MG) (CAPSULE)........................108ZANAFLEX (4 MG) (TABLET)...........................108ZANAFLEX (6 MG) (CAPSULE)........................108ZANAMIVIR...........................................................61ZANTAC (15 MG/ML) (SYRUP)......................... 110ZANTAC (150 MG) (CAPSULE)......................... 110ZANTAC (150 MG) (TABLET)............................110ZANTAC (300 MG) (CAPSULE)......................... 110ZANTAC (300 MG) (TABLET)............................110ZARONTIN........................................................... 102ZAROXOLYN......................................................... 22ZAVESCA............................................................... 91ZEBETA.................................................................. 18ZEGERID (40MG-1.1G) (CAPSULE)................. 111ZEJULA...................................................................89ZELAPAR..............................................................101ZEMBRACE SYMTOUCH.................................... 99ZENCIA...................................................................31ZENPEP (10-32-42K) (CAPSULE DR)............... 109ZENPEP (20-63-84K) (CAPSULE DR)............... 109ZENPEP (25-79-105K) (CAPSULE DR)............. 109ZENPEP (40-126-168) (CAPSULE DR).............. 109ZENPEP (5K-17K-24K) (CAPSULE DR)............109ZENZEDI (15 MG) (TABLET)...............................10ZENZEDI (2.5 MG) (TABLET)..............................10ZENZEDI (20 MG) (TABLET)...............................10ZENZEDI (30 MG) (TABLET)...............................10ZENZEDI (7.5 MG) (TABLET)..............................10ZERIT (1 MG/ML) (SOLN RECON)..................... 63ZERIT (15 MG) (CAPSULE)................................. 63

ZERIT (20 MG) (CAPSULE)................................. 63ZERIT (30 MG) (CAPSULE)................................. 63ZERIT (40 MG) (CAPSULE)................................. 63ZESTORETIC......................................................... 16ZESTRIL................................................................. 17ZETIA......................................................................24ZETONNA.................................................................1ZIAC........................................................................ 18ZIAGEN (20 MG/ML) (SOLUTION).....................62ZIAGEN (300 MG) (TABLET)...............................62ZIANA..................................................................... 28ZIDOVUDINE.........................................................63ZILEUTON................................................................2ZINC ACETATE......................................................92ZIOPTAN.................................................................48ZIPRASIDONE HCL.............................................. 12ZIPSOR....................................................................68ZIRGAN.................................................................. 46ZITHRANOL.......................................................... 36ZITHROMAX (1 G) (PACKET)............................. 56ZITHROMAX (100 MG/5ML) (SUSP RECON)....56ZITHROMAX (200 MG/5ML) (SUSP RECON)....56ZITHROMAX (250 MG) (TABLET)......................56ZITHROMAX (500 MG) (TABLET)......................56ZITHROMAX (600 MG) (TABLET)......................56ZITHROMAX TRI-PAK......................................... 56ZOFRAN ODT.......................................................... 2ZOHYDRO ER........................................................95ZOLINZA................................................................ 89ZOLMITRIPTAN.................................................... 99ZOLOFT (100 MG) (TABLET)................................ 8ZOLOFT (20 MG/ML) (ORAL CONC)................... 8ZOLOFT (25 MG) (TABLET).................................. 8ZOLOFT (50 MG) (TABLET).................................. 8ZOLPIDEM TARTRATE........................................ 14ZOLPIMIST............................................................ 14ZOMACTON...........................................................44ZOMIG (2.5 MG) (SPRAY).................................... 99ZOMIG (2.5 MG) (TABLET)................................. 99ZOMIG (5 MG) (SPRAY)....................................... 99ZOMIG (5 MG) (TABLET).................................... 99ZOMIG ZMT...........................................................99ZONALON.............................................................. 34ZONEGRAN......................................................... 107ZONISAMIDE...................................................... 107ZONTIVITY............................................................51ZORBTIVE..............................................................44ZORTRESS..............................................................54ZORVOLEX............................................................ 68ZOVIRAX (200 MG) (CAPSULE)......................... 61ZOVIRAX (200 MG/5ML) (ORAL SUSP)............ 61ZOVIRAX (400 MG) (TABLET)............................61


Index

ZOVIRAX (5 %) (CREAM (G))............................. 30ZOVIRAX (5 %) (OINT. (G))................................. 31ZOVIRAX (800 MG) (TABLET)............................61ZUBSOLV (0.7-0.18MG) (TAB SUBL)............... 100ZUBSOLV (1.4-0.36MG) (TAB SUBL)............... 100ZUBSOLV (11.4-2.9MG) (TAB SUBL)............... 100ZUBSOLV (2.9-0.71MG) (TAB SUBL)............... 100ZUBSOLV (5.7-1.4 MG) (TAB SUBL)................ 100ZUBSOLV (8.6-2.1 MG) (TAB SUBL)................ 100ZUPLENZ (4 MG) (FILM)....................................... 2ZUPLENZ (8 MG) (FILM)....................................... 2ZYBAN..................................................................108ZYCLARA (2.5 %) (CRM MD PMP).................... 54ZYCLARA (3.75 %) (CREAM PACK).................. 54ZYCLARA (3.75 %) (CRM MD PMP).................. 54ZYFLO...................................................................... 2ZYFLO CR................................................................ 2ZYKADIA............................................................... 88ZYLET.....................................................................45ZYLOPRIM.............................................................48ZYMAXID.............................................................. 46ZYPREXA...............................................................12ZYPREXA ZYDIS.................................................. 12ZYTIGA (250 MG) (TABLET)...............................87ZYTIGA (500 MG) (TABLET)...............................87ZYVOX....................................................................57


Index

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