comprehensive preferred drug list - sunshine health · 2020-05-14 · page 2 last updated 12/2016...

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COMPREHENSIVE

Preferred Drug List

LAST UPDATED 12/2016

Preferred Drug List The Sunshine Health Preferred Drug List (PDL) is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA). Drugs may be covered through your prescription drug benefit for indications that are evidence based, meaning there is data showing the use for that condition is safe and effective. Generic drugs have the same active ingredient as their brand name counterparts and should be considered the first line of treatment. If there is no generic available, there may be more than one brand name medication to treat a condition. The preferred brand name medications are listed on Tier 2 to help identify prescription drugs that are clinically appropriate, safe and cost effective.

Please note, the preferred drug list is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed or additional requirements may be added in order to approve continued use of a specific drug.

Pharmacy Benefit Manager Sunshine Health works with Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Some drugs on the Sunshine Health PDL may require prior authorization which is performed by Envolve Pharmacy Solutions.

Specialty Drugs Certain medications are only covered when supplied by Sunshine Health’s specialty pharmacy provider AcariaHealth. Most specialty drugs, such as biopharmaceuticals and injectables, require a PA to be approved for payment by Sunshine Health.

Dispensing Limits Drugs may be dispensed up to a maximum of thirty-one (31) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for all drugs.

Filling a Prescription Prescriptions may be filled at a Sunshine Health network pharmacy. To locate a network pharmacy, search on-line or contact Sunshine Health Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their Sunshine Health ID card.

Prescription Drug Benefit Design Sunshine Health Stars

Pharmacy Deductible: $1,500 $5 Copay for generic drug

$25 copay for preferred brand drug, after Pharmacy Deductible has been met

$50 Copay for non-preferred brand drug, after Pharmacy Deductible has been met

25% coinsurance for a Specialty drug after Pharmacy Deductible has been met

Pharmacy Max Out-of-pocket: $2,350

LAST UPDATED 12/2016

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case. Drugs may be covered under different copay tiers depending on your benefit:

Tier 0 – No Copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 – Lowest Copayment for generic drugs that offer the greatest value compared to other agents used to treat similar conditions.

Tier 2 – Medium copayment cover brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions.

Tier 3 – Highest copayment covers higher cost brand name drugs. This tier may also cover those brand name drugs that have a generic alternative.

Tier 4 – Coverage for this tier are for “specialty” drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management.

Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame.

Prior Authorization Prior Authorization required before prescription can be filled.

Step Therapy Requires trial and failure of one or more preferred products prior to coverage.

Gender Limit Drug is limited to specific gender.

Age Limit Drug is limited to specific age.

Max Daily Dose A limit on the number of times the drug can be taken per day

Max Package Limit A limit on the amount of drug covered per prescription.

Max Fill Limit There is a limit on the number of times this drug can be refilled.

Max Days Supply There is a limit on the amount of this drug that is covered.

Custom This drug has unique restrictions

LEGEND

TYPE DESCRIPTION

QL

PA

ST

GL

AL

MDD

MPL

MFL

MDS

C

LAST UPDATED 12/2016 PAGE 4

Exclusions

The following drug categories are not part of the Sunshine Health PDL and are not covered by the 72 hour emergency supply policy:

Anti-Hemophilia Products (anti-hemophilia drugs are only covered as a result of emergency stabilization,during a covered inpatient stay, or when needed before a surgical procedure is performed)

Injectable/Oral drugs administered in an infusion center, mental health center or inpatientsetting.

Prostheses, appliances, and devices (except products for Diabetics and products used forcontraception)

Fertility enhancing drugs Anorexia, weight loss, or weight gain drugs (unless prescribed for an indication other than obesity) Experimental or investigational drugs Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that

are classified as ineffective Oral vitamins and minerals or OTC drugs (except those listed in the PDL) Nutritional supplements Drugs and other agents used for cosmetic purposes or for hair growth Erectile dysfunction drugs DESI drugs that are defined as less than effective by the Food and Drug Administration

Newly Approved Products Sunshine Health reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Sunshine does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Pharmacy Appeals and Grievances If you disagree with a decision regarding coverage of a medication, you, your doctor, or someone that you name to help you, can ask us to change our decision. This is called an appeal. You can ask for an appeal in writing or by calling us. If you want to appeal, you must tell us within thirty (30) days of your notice letter. You can file an appeal by writing us at: Sunshine Health, Appeals and Grievances Coordinator, 1301 International Parkway Suite 400, Sunrise, FL 33323. You may also fax us (866) 534-5972 or call us at (866)796-0530, TTY/TDD (800)955-8770. If you appeal by phone, you must also send in a written, signed appeal within ten (10) calendar days after we get your phone call for an appeal.

You can ask for an “expedited appeal” if you or your doctor think that waiting up to thirty (30) calendar days could put your life or health in danger. You or your doctor should tell us this when asking for an appeal. If we agree, we will make a decision within 72 hours of receiving your appeal. If we are going to reduce, or stop a service we had approved you to receive in the past, you have the right to keep getting the service if we approved you to get the service from the provider and the time limit we approved hasn’t ended.

Disclaimer Coverage of certain products listed in the guide may not apply to Sunshine Health Stars members due to member age. The Affordable Care Act (ACA) makes certain preventative medications available at no cost and these products were included in the guide for completeness. Coverage of any products listed (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider.

TIER DESCRIPTION

0 Preventative

1 Generics

2 Preferred Brands

3 Non-Preferred Drugs

4 Specialty High-Cost Drugs

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of drug covered per

prescription, or within a specific time frame.

PA Prior Authorization Prior Authorization required before prescription can be filled.

ST Step TherapyRequires trial and failure of one or more preferred products

prior to coverage.

GL Gender Limit Drug is limited to specific gender.

AL Age Limit Drug is limited to specific age.

MD Max Daily Dose A limit on the number of times the drug can be taken per day.

MPL Max Package Limit A limit on the amount of drug covered per prescription.

MFL Max Fill LimitThere is a limit on the number of times this drug can be

refilled.

MDS Max Days Supply There is a limit on the amount of this drug that is covered.

C Custom This drug has unique restrictions.

FAL Female Age LimitThis prescription drug may only be covered if you are a female

and meet the minimum or maximum age limit.

PAGE 5 LAST UPDATED 12/2016

LIST OF COVERED OVER-THE-COUNTER MEDICATIONSPRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

aspirin tab delayed release 81 mg generic 0 CCovered for males45- 79 and females55-79 years of age

ibuprofen susp 100 mg/5ml generic 1

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl gel 2% generic 1

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

SMOKING CESSATION AGENTS

nicotine (kit 21-14-7 mg/24hr, td patch24hr 7 mg/24hr)

generic 0

nicotine (patch 24hr 14 mg/24hr, patch24hr 21 mg/24hr)

generic 0 MD 1 per day

nicotine polacrilex (gum 2 mg, gum 4 mg,lozenge 2 mg, lozenge 4 mg)

generic 0

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl (tab 12.5 mg, tab 25 mg) generic 1

ANTIFUNGALS

clotrimazole (topical) (cream, soln) generic 1

clotrimazole vaginal cream 1% generic 1

LOTRIMIN ULTRA BRAND 2

DENTAL AND ORAL AGENTS

stannous fluoride conc 0.63% generic 0


PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS

DERMATOLOGICAL AGENTS

benzoyl peroxide (foam 5.3%, gel 5%, gel10%, liq 10%, lotion 6%)

generic 1 AL At least 12 yrs old

benzoyl peroxide liq 4% generic 3 AL At least 12 yrs old

hydrocortisone (topical) (cream, oint) generic 1

lactic acid (ammonium lactate) (cream,lotion)

generic 1

GASTROINTESTINAL AGENTS

GASTROINTESTINAL AGENTS, OTHER

loperamide hcl cap 2 mg generic 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine generic 1

famotidine tab 20 mg generic 1

ranitidine hcl tab 150 mg generic 1

LAXATIVES

bisacodyl ec tab dr 5 mg generic 1

docusate calcium generic 1

docusate sodium cap 100 mg generic 1

docusate sodium cap 250 mg generic 1

PROTON PUMP INHIBITORS

lansoprazole generic 1 MD 1 per day

NEXIUM 24HR CAP DR 20 MG BRAND 3ST

MD 2 per day

OMEPRAZOLE DELAYED RELEASE TAB 20MG

BRAND 1 MD 2 per day

omeprazole magnesium generic 1 MD 4 per day

omeprazole-sodium bicarbonate generic 1 MD 1 per day



PRILOSEC OTC BRAND 1 MD 4 per day

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)

PROGESTINS

levonorgestrel (emergency oc) generic 0

MISCELLANEOUS THERAPEUTIC AGENTS

AIMSCO LUBRICATED BRAND 0

ELEXA NATURAL FEEL BRAND 0

ELEXA STIMULATING BRAND 0

ELEXA ULTRA SENSITIVE BRAND 0

FANTASY LUBRICATED BRAND 0

FANTASY LUBRICATED/SPERMICIDE BRAND 0

FC FEMALE CONDOM BRAND 0

FC2 FEMALE CONDOM BRAND 0

KAMELEON LUBRICATED BRAND 0

KIMONO BRAND 0

KIMONO MICRO THIN PLUS BRAND 0

KIMONO PLUS BRAND 0

KIMONO PS BRAND 0

KIMONO PS PLUS BRAND 0

KIMONO SENSATION BRAND 0

KIMONO SENSATION PLUS BRAND 0

MAXX BRAND 0

MAXX PLUS BRAND 0

PREMIUM CONDOMS LUBRICATED BRAND 0

REALITY LATEX/ULTRA TEXTURED BRAND 0

REALITY LATEX/ULTRA THIN BRAND 0



TROJAN MAGNUM WARM SENSATIONS BRAND 0

TROJAN SUPRAS SPERMICIDAL BRAND 0

TROJAN TWISTED PLEASURE BRAND 0

TRUSTEX COLOR CONDOMS + LUBE BRAND 0

TRUSTEX LUB/RIBBED/STUDDED BRAND 0

TRUSTEX LUB/SPERMICIDE EX ST BRAND 0

TRUSTEX LUB/SPERMICIDE XL BRAND 0

TRUSTEX LUBRICATED BRAND 0

TRUSTEX LUBRICATED EX LARGE BRAND 0

TRUSTEX LUBRICATED EXTRA ST BRAND 0

TRUSTEX LUBRICATED/SPERMICIDE BRAND 0

TRUSTEX NATURAL CONDOMS + LUBE BRAND 0

TRUSTEX RIA LUB/SPERMICIDE BRAND 0

TRUSTEX RIA LUBRICATED BRAND 0

TRUSTEX-NONOXYNOL-9/RIB/STUD BRAND 0

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ketotifen fumarate (ophth) generic 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTIHISTAMINES

ALLEGRA ALLERGY CHILDRENS TAB DISP 30MG


cetirizine hcl allergy child solution 5mg/5ml

generic 1 MD 300 / 30 DAYS

cetirizine hcl cap 10 mg generic 1

cetirizine hcl chew tab 10 mg generic 1

cetirizine hcl chew tab 5 mg generic 1



cetirizine hcl tab 10 mg generic 1

childrens loratadine syrup 5 mg/5ml generic 1

CLARITIN (CAP 10 MG, CHEW TAB 5 MG) BRAND 1

CLARITIN REDITABS TAB DISP 5 MG BRAND 1

diphenhydramine hcl cap 50 mg generic 1

diphenhydramine hcl elixir 12.5 mg/5ml generic 1

fexofenadine hcl susp 30 mg/5ml (6mg/ml)

generic 1

fexofenadine hcl tab 180 mg generic 1 MD 2 per day

fexofenadine hcl tab 60 mg generic 1 MD 2 per day

loratadine allergy relief tab disp 10 mg generic 1

loratadine tab 10 mg generic 1

RESPIRATORY TRACT AGENTS, OTHER

cetirizine-pseudoephedrine generic 1 MD 2 per day

fexofenadine-pseudoephedrine tab sr 12hr60-120 mg


fexofenadine-pseudoephedrine tab sr 24hr180-240 mg


loratadine & pseudoephedrine (tab 12hr 5-120 mg, tab 24hr 10-240 mg)

generic 1

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL REPLACEMENT

ferrous sulfate soln 75 mg/ml (15 mg/mlelemental fe)

generic 0 AL Up to 1 yrs old

*prenatal vit w/ fe fumarate-fa tab 27-0.8mg***


ergocalciferol tab 400 unit generic 0 AL At least 65 yrs old

folic acid tab 1 mg generic 0 FAL Female - 12 to 55 yrsold



MULTI PRENATAL BRAND 1 MD 1 per day

PNV PRENATAL PLUS MULTIVITAMIN BRAND 1 MD 1 per day

PRE-NATAL FORMULA BRAND 1 MD 1 per day

PRENATAL LOW IRON BRAND 1 MD 1 per day

prenatal multivit-min w/fe-fa generic 1 MD 1 per day

PRENATAL ONE DAILY BRAND 1 MD 1 per day

PRENATAL TAB 27-0.8 MG BRAND 1 MD 1 per day

PRENATAL/IRON TAB BRAND 1 MD 1 per day

RIGHT STEP PRENATAL BRAND 1 MD 1 per day

THERANATAL CORE NUTRITION BRAND 1 MD 1 per day


LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

celecoxib (cap 50 mg, cap 100 mg, cap 200mg)

generic 1PAMD 2 per day

celecoxib cap 400 mg generic 1PAMD 1 per day

choline & magnesium salicylates tab 1000mg

generic 1

diclofenac potassium generic 1

diclofenac sodium (tab delayed release 25mg, tab delayed release 50 mg, tabdelayed release 75 mg, tab sr 24hr 100 mg)

generic 1

diclofenac w/ misoprostol (w/ tab 50-0.2mg, w/ tab 75-0.2 mg)

generic 1

diflunisal tab 500 mg generic 1

etodolac (cap 200 mg, cap 300 mg, tab 400mg, tab 500 mg)

generic 1

fenoprofen calcium tab 600 mg generic 1 MD 1 per day

FLECTOR BRAND 3PAMD 2 per day

flurbiprofen (tab 50 mg, tab 100 mg) generic 1

ibuprofen (susp 100 mg/5ml, tab 400 mg,tab 600 mg, tab 800 mg)

generic 1

indomethacin (cap 25 mg, cap 50 mg, capcr 75 mg)

generic 1

ketoprofen (cap 50 mg, cap 75 mg) generic 1

ketorolac tromethamine tab 10 mg generic 1 MD 20 / 30 DAYS

meclofenamate sodium (cap 50 mg, cap100 mg)

generic 1



mefenamic acid cap 250 mg generic 1

meloxicam (tab 7.5 mg, tab 15 mg) generic 1 MD 1 per day

meloxicam susp 7.5 mg/5ml generic 1

nabumetone (tab 500 mg, tab 750 mg) generic 1

naproxen (susp 125 mg/5ml, tab 250 mg,tab 375 mg, tab 500 mg, tab ec 500 mg)

generic 1

naproxen sodium tab 550 mg generic 1

oxaprozin generic 1

piroxicam (cap 10 mg, cap 20 mg) generic 1

salsalate (tab 500 mg, tab 750 mg) generic 1

sulindac (tab 150 mg, tab 200 mg) generic 1

tolmetin sodium (cap 400 mg, tab 200 mg,tab 600 mg)

generic 1

OPIOID ANALGESICS, LONG-ACTING

BUTRANS (PATCH WK 5 MCG/HR, PATCHWK 7.5 MCG/HR, PATCH WK 10 MCG/HR,PATCH WK 15 MCG/HR, PATCH WK 20MCG/HR)

BRAND 3PAMD 4 / 28 DAYS

EMBEDA (CAP ER 20-0.8 MG, CAP ER 30-1.2 MG, CAP ER 50-2 MG, CAP ER 60-2.4MG, CAP ER 80-3.2 MG, CAP ER 100-4 MG)

BRAND 3PAMD 2 per day

EXALGO TB24 DETER 32 MG BRAND 2PAMD 2 per day

fentanyl (patch 72hr 100 mcg/hr, patch72hr 12 mcg/hr, patch 72hr 25 mcg/hr,patch 72hr 50 mcg/hr, patch 72hr 75mcg/hr)


hydromorphone hcl (tab er 24hr deter 12mg, tab er 24hr deter 16 mg)


hydromorphone hcl tab er 24hr deter 32mg




hydromorphone hcl tab er 24hr deter 8 mg generic 1PAMD 1 per day

levorphanol tartrate tab 2 mg generic 1

methadone hcl conc 10 mg/ml generic 1 MD 300 / 30 DAYS

methadone hcl soln 10 mg/5ml generic 1 MD 1500 / 30 DAYS

methadone hcl soln 5 mg/5ml generic 1 MD 3000 / 30 DAYS

methadone hcl tab 10 mg generic 1 MD 10 per day

methadone hcl tab 5 mg generic 1 MD 4 per day

methadone hcl tab for oral susp 40 mg generic 3

morphine sulfate (cap 24hr 100 mg, cap24hr 20 mg, cap 24hr 30 mg, cap 24hr 50mg, cap 24hr 60 mg, cap 24hr 80 mg)


morphine sulfate er (tab 15 mg, tab 30 mg,tab 60 mg, tab 100 mg, tab 200 mg)


NUCYNTA ER (ER TAB ER 12H 100 MG, ERTAB ER 12H 150 MG, ER TAB ER 12H 200MG, ER TAB ER 12H 250 MG, ER TAB ER12H 50 MG)


OPANA ER (ER TAB ER 12H 10 MG, ER TABER 12H 20 MG, ER TAB ER 12H 30 MG, ERTAB ER 12H 5 MG)


OPANA ER TAB ER 12H 40 MG BRAND 3PAMD 4 per day

oxycodone hcl (tab er deter 10 mg, tab erdeter 20 mg, tab er deter 40 mg, tab erdeter 80 mg)


OXYCONTIN (TB12 DETER 10 MG, TB12DETER 15 MG, TB12 DETER 20 MG, TB12DETER 30 MG, TB12 DETER 40 MG, TB12DETER 60 MG, TB12 DETER 80 MG)


oxymorphone hcl (tab 5 mg, tab 7.5 mg,tab 10 mg, tab 15 mg, tab 20 mg, tab 30mg)




OXYMORPHONE HCL ER (ER TAB ER 12H 10MG, ER TAB ER 12H 15 MG, ER TAB ER 12H20 MG, ER TAB ER 12H 30 MG, ER TAB ER12H 5 MG, ER TAB ER 12H 7.5 MG)


OXYMORPHONE HCL ER TAB ER 12H 40 MG BRAND 3PAMD 4 per day

oxymorphone hcl tab sr 12hr 40 mg generic 3PAMD 4 per day

tramadol hcl (tab 24hr 100 mg, tab 24hr200 mg, tab 24hr 300 mg, tab 24hrbiphasic release 300 mg)


ZOHYDRO ER (ER CP12 DETER 10 MG, ERCP12 DETER 15 MG, ER CP12 DETER 20MG, ER CP12 DETER 30 MG, ER CP12DETER 40 MG, ER CP12 DETER 50 MG)


OPIOID ANALGESICS, SHORT-ACTING

acetaminophen w/ codeine soln 120-12mg/5ml


acetaminophen w/ codeine tab 300-15 mg generic 1 MD 13 per day



butalbital-acetaminophen-caff w/ cod cap50-325-40-30 mg


butalbital-aspirin-caffeine w/cod generic 1 MD 6 per day

butorphanol tartrate (inj 1 mg/ml, inj 2mg/ml)

generic 1

butorphanol tartrate nasal soln 10 mg/ml generic 1PA

MPL 1 / 30 days

codeine sulfate (oral soln 30 mg/5ml, tab15 mg)

generic 1



fentanyl citrate (fentnyl citrte lozengehndle 200 mcg, fentnyl citrte lozenge hndle400 mcg, fentnyl citrte lozenge hndle 600mcg, fentnyl citrte lozenge hndle 800 mcg,fentnyl citrte lozenge hndle 1200 mcg,fentnyl citrte lozenge hndle 1600 mcg)


hydrocodone-acetaminophen (tab 2.5-500mg, tab 5-500 mg, tab 7.5-500 mg, tab 10-500 mg)


hydrocodone-acetaminophen (tab 5-300mg, tab 7.5-300 mg, tab 10-300 mg)


hydrocodone-acetaminophen (tab 5-325mg, tab 7.5-325 mg, tab 10-325 mg)


hydrocodone-acetaminophen (tab 7.5-650mg, tab 10-650 mg, tab 10-660 mg)


hydrocodone-acetaminophen (tab 7.5-750mg, tab 10-750 mg)


hydrocodone-acetaminophen soln 7.5-325mg/15ml


hydrocodone-acetaminophen tab 2.5-325mg

generic 1

hydrocodone-ibuprofen tab 7.5-200 mg generic 1 MD 5 per day

hydromorphone hcl (liqd 1 mg/ml,preservative free (pf) inj 10 mg/ml)

generic 1

hydromorphone hcl (tab 2 mg, tab 4 mg,tab 8 mg)


meperidine hcl (inj 25 mg/ml, inj 50 mg/ml,inj 100 mg/ml)

generic 1

meperidine hcl (tab 50 mg, tab 100 mg) generic 1 MD 6 per day

meperidine hcl oral soln 50 mg/5ml generic 1 MD 500 / CLAIM

morphine sulfate (inj 0.5 mg/ml, inj 1mg/ml)

generic 1

morphine sulfate (tab 15 mg, tab 30 mg) generic 1 MD 6 per day



morphine sulfate oral soln 10 mg/5ml generic 1 MD 3000 / 30 DAYS

morphine sulfate oral soln 20 mg/5ml generic 1 MD 1500 / 30 DAYS

nalbuphine hcl (inj 10 mg/ml, inj 20 mg/ml) generic 1 MD 8 per day

NUCYNTA (TAB 50 MG, TAB 75 MG, TAB100 MG)


oxycodone hcl (tab 5 mg, tab 10 mg, tab 15mg, tab 20 mg)


oxycodone hcl tab 30 mg generic 1 MD 24 per day

oxycodone w/ acetaminophen (w/ tab 5-325 mg, w/ tab 7.5-325 mg, w/ tab 10-325mg)


oxycodone w/ acetaminophen tab 7.5-500mg


oxycodone-ibuprofen generic 1 MD 1 per day

oxymorphone hcl (tab 5 mg, tab 10 mg) generic 1 MD 12 per day

pentazocine w/ naloxone generic 1

TALWIN BRAND 3

tramadol hcl tab 50 mg generic 1 MD 8 per day

tramadol-acetaminophen generic 1 MD 8 per day

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl (local anesth.) (inj 0.5%, inj1%, preservative free (pf) inj 0.5%,preservative free (pf) inj 1%, preservativefree (pf) inj 2%, preservative free (pf) inj4%)

generic 1

lidocaine hcl gel 2% generic 1

lidocaine hcl laryngotracheal soln 4% generic 1

lidocaine hcl viscous soln 2% generic 1 MD 120 / 30 DAYS



lidocaine-prilocaine (cream, cream kit) generic 1

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium generic 1

disulfiram (tab 250 mg, tab 500 mg) generic 1

naltrexone hcl tab 50 mg generic 1

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) generic 1PAMD 3 per day

buprenorphine hcl inj 0.3 mg/ml (baseequiv)

generic 1

buprenorphine hcl-naloxone hcl dihydrate(sl tab 2-0.5 mg, sl tab 8-2 mg)


SUBOXONE (FILM 4-1 MG, FILM 12-3 MG) BRAND 3 PA

SUBOXONE FILM 2-0.5 MG BRAND 3PAMD 3 per day

SUBOXONE FILM 8-2 MG BRAND 3PAMD 2 per day

OPIOID REVERSAL AGENTS

naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml, inj4 mg/10ml, soln cart 0.4 mg/ml, solnprefilled syringe 2 mg/2ml)

generic 1

SMOKING CESSATION AGENTS

bupropion hcl (smoking deterrent) generic 0 MD 2 per day

CHANTIX (TAB 0.5 MG, TAB 1 MG) BRAND 0 MD 2 per day

CHANTIX CONTINUING MONTH PAK BRAND 0 MD 2 per day

CHANTIX STARTING MONTH PAK BRAND 0



NICOTROL BRAND 0 MPL 1 / claim(s)

NICOTROL NS BRAND 0

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate (inj 1 gm/4ml mg/ml), inj500 mg/2ml mg/ml))

generic 1

GENTAMICIN IN SALINE (GENTAMICSALE J0.8 MG/ML, GENTAMICSALE J 1 MG/ML,GENTAMICSALE J 1.2 MG/ML,GENTAMICSALE J 1.6 MG/ML,GENTAMICSALE SOLUTION 0.9-0.9 MG/ML-%, GENTAMICSALE SOLUTION 1.4-0.9MG/ML-%)

BRAND 1

gentamicin sulfate (inj 10 mg/ml, inj 40mg/ml, iv soln 10 mg/ml)

generic 1

gentamicin sulfate (ophth) (oint, soln) generic 1

kanamycin sulfate generic 1

neomycin sulfate generic 1

paromomycin sulfate generic 1

streptomycin sulfate for inj 1 gm generic 3

TOBRADEX OINTMENT 0.3-0.1 % BRAND 3

tobramycin (ophth) generic 1

tobramycin sulfate (for inj 1.2 gm, inj 1.2gm/30ml (40 mg/ml) (base equiv), inj 2gm/50ml (40 mg/ml) (base equiv), inj 10mg/ml (base equivalent), inj 80 mg/2ml (40mg/ml), inj 80 mg/2ml (40 mg/ml) (baseequiv))

generic 4

TOBRAMYCIN SULFATE IN SALINE(TOBRAMYCSALE SOLUTION 0.8-0.9MG/ML-%, TOBRAMYCSALE SOLUTION 1.2-0.9 MG/ML-%)

BRAND 4 PA



ANTIBACTERIALS, OTHER

acetic acid generic 1

ALTABAX OINTMENT 1 % BRAND 2

bacitracin intramuscular for soln 50000unit

generic 3

chloramphenicol sodium succinate generic 4

clindamycin hcl (cap 75 mg, cap 150 mg,cap 300 mg)

generic 1

clindamycin palmitate hydrochloride generic 1 AL Up to 12 yrs old

clindamycin phosphate (inj 300 mg/2ml, inj900 mg/6ml, iv soln 300 mg/2ml, iv soln900 mg/6ml)

generic 1

clindamycin phosphate (topical) (gel,lotion, soln)


clindamycin phosphate vaginal generic 1

CUBICIN BRAND 3

LINCOCIN BRAND 3

LINEZOLID IN SODIUM CHLORIDE BRAND 1

PAMD 600 per dayMD

S14 DAYS SUPPLY PERCLAIM(S)

linezolid iv soln 600 mg/300ml (2 mg/ml) generic 1

PAMD 600 per dayMD


linezolid tab 600 mg generic 1

PAMD 2 per dayMD


mafenide acetate generic 3

methenamine hippurate generic 1



metronidazole (tab 250 mg, tab 500 mg) generic 1

metronidazole (topical) (gel 1%, lotion0.75%)

generic 1

metronidazole cream 0.75 % generic 1

metronidazole gel 0.75 % generic 1

metronidazole vaginal generic 1

MONUROL BRAND 3

mupirocin calcium (topical) generic 1

mupirocin oint 2% generic 1

nitrofurantoin generic 1

nitrofurantoin macrocrystal (cap 50 mg,cap 100 mg)

generic 1

nitrofurantoin monohyd macro generic 1

polymyxin b sulfate for inj 500000 unit generic 1

SULFAMYLON CREAM 85 MG/GM BRAND 3

trimethoprim tab 100 mg generic 1

TYGACIL BRAND 3 PA

vancomycin hcl (cap 125 mg, cap 250 mg) generic 1

PAMD 4 per dayMD


vancomycin hcl for inj 10 gm generic 1

vancomycin hcl for inj 1000 mg generic 1 MD 14 / CLAIM

vancomycin hcl for inj 500 mg generic 1 MD 14 / 30 DAYS

VIBATIV (RECON SOLN 250 MG, RECONSOLN 750 MG)

BRAND 3

XIFAXAN (TAB 200 MG, TAB 550 MG) BRAND 3PA

AL At least 12 yrs old



BETA-LACTAM, CEPHALOSPORINS

CEDAX (RECON SUSP 90 MG/5ML, RECONSUSP 180 MG/5ML)

BRAND 3

CEDAX CAP 400 MG BRAND 1

cefaclor (cap 250 mg, cap 500 mg, for susp125 mg/5ml, for susp 250 mg/5ml, for susp375 mg/5ml)

generic 1

cefaclor monohydrate generic 1

cefadroxil (cap 500 mg, for susp 250mg/5ml, for susp 500 mg/5ml, tab 1 gm)

generic 1

cefazolin sodium (inj 1 gm, inj 10 gm, inj 20gm, inj 500 mg)

generic 1

cefdinir (susp 125 mg/5ml, susp 250mg/5ml)

generic 1

cefdinir cap 300 mg generic 1 AL At least 2 yrs old

CEFDITOREN PIVOXIL (TAB 200 MG, TAB200 MG (BASE EQUIVALENT), TAB 400 MG(BASE EQUIVALENT))

BRAND 3

cefepime hcl (inj 1 gm, inj 2 gm) generic 1

cefixime (susp 100 mg/5ml, susp 200mg/5ml)

generic 1

cefotaxime sodium (inj 1 gm, inj 2 gm, inj10 gm)

generic 1

cefotetan disodium (inj 1 gm, inj 2 gm, inj10 gm)

generic 3

cefoxitin sodium (inj 1 gm, inj 2 gm, inj 10gm, iv soln 1 gm, iv soln 2 gm)

generic 1

cefpodoxime proxetil (for susp 50 mg/5ml,for susp 100 mg/5ml, tab 100 mg, tab 200mg)

generic 1

cefprozil (for susp 125 mg/5ml, for susp250 mg/5ml, tab 250 mg, tab 500 mg)

generic 1



ceftazidime (inj 1 gm, inj 2 gm, inj 6 gm, ivsoln 1 gm, iv soln 2 gm)

generic 1

CEFTIBUTEN CAP 400 MG BRAND 1

CEFTIBUTEN RECON SUSP 180 MG/5ML BRAND 3

ceftriaxone sodium (inj 1 gm, inj 2 gm, inj250 mg, inj 500 mg, iv soln 1 gm, iv soln 2gm)

generic 1

cefuroxime axetil (for susp 125 mg/5ml,tab 250 mg, tab 500 mg)

generic 1

cefuroxime sodium (inj 1.5 gm, inj 7.5 gm,inj 750 mg, iv soln 1.5 gm)

generic 1

cephalexin (cap 250 mg, cap 500 mg, forsusp 125 mg/5ml, for susp 250 mg/5ml,tab 250 mg, tab 500 mg)

generic 1

SPECTRACEF (TAB 200 MG, TAB 400 MG) BRAND 3

SUPRAX TAB 400 MG BRAND 2

TEFLARO (RECON SOLN 400 MG, RECONSOLN 600 MG)

BRAND 3

BETA-LACTAM, OTHER

aztreonam (inj 1 gm, inj 2 gm) generic 1

DORIBAX (RECON SOLN 250 MG, RECONSOLN 500 MG)

BRAND 3

imipenem-cilastatin (soln 250 mg, soln 500mg)

generic 1

INVANZ BRAND 3

meropenem (soln 1 gm, soln 500 mg) generic 1



BETA-LACTAM, PENICILLINS

amoxicillin & pot clavulanate (chew tab200-28.5 mg, chew tab 400-57 mg, for susp200-28.5 mg/5ml, for susp 250-62.5mg/5ml, for susp 400-57 mg/5ml, for susp600-42.9 mg/5ml, tab 250-125 mg, tab500-125 mg, tab 875-125 mg, tab sr 12hr1000-62.5 mg)

generic 1

amoxicillin (cap 250 mg, cap 500 mg, chewtab 125 mg, chew tab 250 mg, for susp 125mg/5ml, for susp 200 mg/5ml, for susp 250mg/5ml, for susp 400 mg/5ml, tab 500 mg,tab 875 mg)

generic 1

ampicillin & sulbactam sodium (inj 1-0.5gm, inj 2-1 gm, inj 3 (2-1) gm, inj 10-5 gm,iv soln 1-0.5 gm, iv soln 10-5 gm)

generic 1

AMPICILLIN (CAP 250 MG, CAP 500 MG,RECON SUSP 125 MG/5ML, RECON SUSP250 MG/5ML)

BRAND 1

ampicillin sodium (inj 1 gm, inj 10 gm, ivsoln 1 gm, iv soln 10 gm)

generic 1

AMPICILLIN-SULBACTAM SODIUM RECONSOLN 1.5 (1-0.5) GM

BRAND 1

dicloxacillin sodium (cap 250 mg, cap 500mg)

generic 1

nafcillin sodium (inj 1 gm, inj 10 gm, iv soln1 gm)

generic 1

oxacillin sodium (inj 1 gm, inj 10 gm) generic 1

PENICILLIN G POT IN DEXTROSE(PENICILLSOLUTION 40000 UNIT/ML,PENICILLSOLUTION 60000 UNIT/ML)

BRAND 1

penicillin g potassium for inj 5000000 unit generic 1

PENICILLIN G PROCAINE BRAND 3

penicillin g sodium generic 3



penicillin v potassium (for soln 125mg/5ml, for soln 250 mg/5ml, tab 250 mg,tab 500 mg)

generic 1

piperacillin sodium-tazobactam sodium (nainj 3.375 gm (3-0.375, sod inj 2.25 gm (2-0.25, sod inj 4.5 gm (4-0.5, sod inj 40.5 gm(36-4.5)

generic 1

TIMENTIN RECON SOLN 3.1 GM BRAND 3

MACROLIDES

AZASITE BRAND 3

azithromycin (susp 100 mg/5ml, susp 200mg/5ml)

generic 1 MPL 1 / claim(s)

azithromycin iv for soln 500 mg generic 1

azithromycin powd pack for susp 1 gm generic 1 MD 2 / CLAIM(S)

azithromycin tab 250 mg generic 1 MD 6 / CLAIM(S)

azithromycin tab 500 mg generic 1 MD 4 / CLAIM(S)

azithromycin tab 600 mg generic 1 MD 8 / 28 DAYS

clarithromycin (for susp 125 mg/5ml, forsusp 250 mg/5ml, tab 250 mg, tab 500 mg,tab sr 24hr 500 mg)

generic 1

DIFICID BRAND 2

E.E.S. 400 BRAND 3

ERY-TAB (TAB DR 250 MG, TAB DR 333 MG,TAB DR 500 MG)

BRAND 3

ERYPED 400 BRAND 3

erythromycin (acne aid) (pads, soln) generic 1 AL At least 12 yrs old

erythromycin (ophth) generic 1

ERYTHROMYCIN BASE (TAB 250 MG, TAB500 MG)

BRAND 3

erythromycin ethylsuccinate (for susp 200mg/5ml, tab 400 mg)

generic 3



KETEK (TAB 300 MG, TAB 400 MG) BRAND 3MD 2 per dayMD


QUINOLONES

AVELOX SOLUTION 400 MG/250ML BRAND 2

BESIVANCE BRAND 3

CIPROFLOXACIN (IV SOLN 400 MG/40ML(1%), SOLUTION 400 MG/40ML)

BRAND 1

ciprofloxacin (susp 250 mg/5ml (5%) (5gm/100ml), susp 500 mg/5ml (10%) (10gm/100ml))

generic 1 AL Up to 12 yrs old

ciprofloxacin 200 mg/100ml in d5w generic 3

ciprofloxacin hcl (ophth) generic 1

ciprofloxacin hcl (otic) generic 1

ciprofloxacin hcl (tab 100 mg, tab 250 mg,tab 500 mg, tab 750 mg)

generic 1

ciprofloxacin-ciprofloxacin hcl (tab 24hr1000 mg(base, tab 24hr 500 mg (base)

generic 1

FACTIVE BRAND 3

gatifloxacin (ophth) generic 1

levofloxacin (iv soln 25 mg/ml, oral soln 25mg/ml, tab 250 mg, tab 500 mg, tab 750mg)

generic 1

levofloxacin (ophth) generic 1

levofloxacin in d5w iv soln 500 mg/100ml generic 1

moxifloxacin hcl tab 400 mg (base equiv) generic 1

NOROXIN BRAND 3

ofloxacin (ophth) generic 1

ofloxacin (otic) generic 1

ofloxacin (tab 200 mg, tab 300 mg, tab 400mg)

generic 1



SULFONAMIDES

silver sulfadiazine generic 1

sulfacetamide sodium ophth soln 10% generic 1 MPL 1 / claim(s)

sulfadiazine tab 500 mg generic 1

sulfamethoxazole-trimethoprim (iv soln400-80 mg/5ml, susp 200-40 mg/5ml, tab400-80 mg, tab 800-160 mg)

generic 1

TETRACYCLINES

demeclocycline hcl (tab 150 mg, tab 300mg)

generic 1

doxycycline (monohydrate) (cap 50 mg, cap100 mg, tab 100 mg)


doxycycline hyclate (cap 50 mg, cap 100mg, tab 20 mg, tab 100 mg)


doxycycline hyclate for inj 100 mg generic 1

minocycline hcl (cap 50 mg, cap 75 mg, cap100 mg, tab 50 mg, tab 75 mg, tab 100mg)


tetracycline hcl (cap 250 mg, cap 500 mg) generic 1 MD 8 per day

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

levetiracetam (inj 500 mg/5ml (100mg/ml), oral soln 100 mg/ml)


levetiracetam (tab 250 mg, tab 500 mg,tab 750 mg, tab sr 24hr 500 mg, tab sr24hr 750 mg)


levetiracetam tab 1000 mg generic 1 MD 3 per day

POTIGA (TAB 50 MG, TAB 200 MG, TAB 300MG, TAB 400 MG)




CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN BRAND 3

ethosuximide cap 250 mg generic 1 MD 6 per day

ethosuximide soln 250 mg/5ml generic 1 MD 900 / 30 DAYS

zonisamide (cap 25 mg, cap 50 mg, cap100 mg)


GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

DIASTAT ACUDIAL (GEL 10 MG, GEL 20 MG) BRAND 3 MD 1 / CLAIM

DIASTAT PEDIATRIC BRAND 3 MD 1 / CLAIM

diazepam (anticonvulsant) (rectal gel 2.5mg, rectal gel 10 mg, rectal gel 20 mg)

generic 3 MD 1 / CLAIM

divalproex sodium (tab delayed release 125mg, tab delayed release 250 mg, tabdelayed release 500 mg, tab sr 24 hr 250mg, tab sr 24 hr 500 mg)

generic 1

gabapentin (cap 100 mg, cap 300 mg, cap400 mg, tab 600 mg, tab 800 mg)

generic 1

gabapentin oral soln 250 mg/5ml generic 1 MD 1800 / 30 DAYS

ONFI (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND 3PAMD 2 per day

ONFI SUSPENSION 2.5 MG/ML BRAND 3PAMD 480 / 30 DAYS

phenobarbital (elixir 20 mg/5ml, tab 16.2mg, tab 30 mg, tab 32.4 mg, tab 64.8 mg,tab 97.2 mg, tab 100 mg)

generic 1

primidone (tab 50 mg, tab 250 mg) generic 1

SABRIL (PACKET 500 MG, TAB 500 MG) BRAND 4PAMD 6 per day

tiagabine hcl (tab 2 mg, tab 4 mg) generic 1



valproate sodium (inj 100 mg/ml, syrup250 mg/5ml (base equiv))

generic 1

valproic acid generic 1

GLUTAMATE REDUCING AGENTS

felbamate susp 600 mg/5ml generic 1 MD 3600 / 30 DAYS

felbamate tab 400 mg generic 1 MD 9 per day

felbamate tab 600 mg generic 1 MD 6 per day

lamotrigine (tab 25 mg, tab 100 mg, tab150 mg, tab 200 mg, tab chewabledispersible 5 mg, tab chewable dispersible25 mg)

generic 1

topiramate (sprinkle cap 25 mg, tab 200mg)


topiramate (tab 25 mg, tab 50 mg) generic 1 MD 4 per day

topiramate sprinkle cap 15 mg generic 1 MD 6 per day

topiramate tab 100 mg generic 1 MD 3 per day

SODIUM CHANNEL AGENTS

BANZEL SUSPENSION 40 MG/ML BRAND 2PAMD 2400 / 30 DAYS

BANZEL TAB 200 MG BRAND 2PAMD 2 per day

BANZEL TAB 400 MG BRAND 2PAMD 8 per day

carbamazepine (cap 200 mg, tab 200 mg) generic 1ST

MD 6 per day

carbamazepine (cap 300 mg, tab 400 mg) generic 1ST

MD 4 per day

carbamazepine (chew tab 100 mg, susp100 mg/5ml, tab 200 mg)

generic 1



carbamazepine cap sr 12hr 100 mg generic 1 ST

DILANTIN (CAP 30 MG, CAP 100 MG,SUSPENSION 125 MG/5ML)

BRAND 2

DILANTIN INFATABS BRAND 2

fosphenytoin sodium (inj 100 mg/2ml, inj500 mg/10ml)

generic 1

oxcarbazepine (tab 150 mg, tab 300 mg) generic 1 MD 3 per day

oxcarbazepine susp 300 mg/5ml (60mg/ml)

generic 1 QL 1200 / 31 day(s)

oxcarbazepine tab 600 mg generic 1 MD 4 per day

PEGANONE BRAND 3

PHENYTEK (CAP 200 MG, CAP 300 MG) BRAND 2

phenytoin (chew tab 50 mg, susp 125mg/5ml)

generic 1

phenytoin sodium extended (cap 100 mg,cap 200 mg, cap 300 mg)

generic 1

phenytoin sodium inj 50 mg/ml generic 1

TEGRETOL (CHEW TAB 100 MG,SUSPENSION 100 MG/5ML, TAB 200 MG)

BRAND 2

VIMPAT (TAB 50 MG, TAB 100 MG, TAB150 MG, TAB 200 MG)


VIMPAT SOLUTION 10 MG/ML BRAND 3PAMD 1200 / 30 DAYS

VIMPAT SOLUTION 200 MG/20ML BRAND 3 MD 1200 / 30 DAYS

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates generic 3



CHOLINESTERASE INHIBITORS

donepezil hydrochloride (orallydisintegrating tab 10 mg, tab 10 mg)


donepezil hydrochloride (orallydisintegrating tab 5 mg, tab 5 mg)


galantamine hydrobromide (cap 24hr 16mg, cap 24hr 24 mg, cap 24hr 8 mg)


galantamine hydrobromide (tab 4 mg, tab8 mg, tab 12 mg)


galantamine hydrobromide oral soln 4mg/ml


rivastigmine tartrate (cap 1.5 mg, cap 3mg, cap 4.5 mg, cap 6 mg)

generic 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl tab 10 mg generic 1 MD 2 per day

memantine hcl tab 5 mg generic 1 MD 1 per day

memantine hcl tab 5 mg (28) & 10 mg (21)titration pak

generic 1

NAMENDA SOLUTION 10 MG/5ML BRAND 2

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (tab 24hr 150 mg, tab 24hr300 mg)


bupropion hcl (tab 75 mg, tab 100 mg) generic 1 MD 3 per day

bupropion hcl er (sr) tab er 12h 100 mg generic 1 MD 2 per day

bupropion hcl er (sr) tab er 12h 150 mg generic 1 MD 2 per day

bupropion hcl tab sr 12hr 200 mg generic 1 MD 2 per day



mirtazapine (orally disintegrating tab 15mg, orally disintegrating tab 30 mg, orallydisintegrating tab 45 mg, tab 7.5 mg, tab15 mg, tab 30 mg, tab 45 mg)


perphenazine-amitriptyline (tab 2-10 mg,tab 2-25 mg, tab 4-10 mg, tab 4-25 mg, tab4-50 mg)


MONOAMINE OXIDASE INHIBITORS

EMSAM (PATCH 24HR 12 MG/24HR, PATCH24HR 6 MG/24HR, PATCH 24HR 9MG/24HR)


MARPLAN BRAND 2 MD 180 / 30 DAYS

phenelzine sulfate generic 1

tranylcypromine sulfate generic 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR

BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20MG)


citalopram hydrobromide oral soln 10mg/5ml


citalopram hydrobromide tab 10 mg (baseequiv)

generic 1 MD 1.5 per day


generic 1



escitalopram oxalate soln 5 mg/5ml (baseequiv)


escitalopram oxalate tab 10 mg (baseequiv)

generic 1

escitalopram oxalate tab 20 mg (baseequiv)




escitalopram oxalate tab 5 mg (base equiv) generic 1 MD 1.5 per day

fluoxetine hcl (cap 10 mg, tab 10 mg, tab60 mg)


fluoxetine hcl (cap 20 mg, tab 20 mg) generic 1 MD 3 per day

fluoxetine hcl (pmdd) cap 10 mg generic 1 MD 1 per day

fluoxetine hcl (pmdd) cap 20 mg generic 1 MD 3 per day

fluoxetine hcl cap 40 mg generic 1 MD 2 per day

fluoxetine hcl solution 20 mg/5ml generic 1 MD 600 / 30 DAYS

fluvoxamine maleate (tab 25 mg, tab 50mg)


fluvoxamine maleate tab 100 mg generic 1 MD 3 per day

maprotiline hcl (tab 25 mg, tab 50 mg, tab75 mg)

generic 3

nefazodone hcl (tab 50 mg, tab 100 mg,tab 150 mg, tab 200 mg, tab 250 mg)

generic 3

OLEPTRO (TAB ER 24H 150 MG, TAB ER24H 300 MG)

BRAND 3ST

MD 1 per day

paroxetine hcl (tab 10 mg, tab 20 mg, tab40 mg)


paroxetine hcl (tab 24hr 25 mg, tab 24hr37.5 mg)


paroxetine hcl oral susp 10 mg/5ml (baseequiv)

generic 3PAMD 900 / 30 DAYS

paroxetine hcl tab 30 mg generic 1 MD 2 per day

paroxetine hcl tab sr 24hr 12.5 mg generic 1PAMD 1 per day

PAXIL SUSPENSION 10 MG/5ML BRAND 3PAMD 900 / 30 DAYS

PRISTIQ TAB ER 24H 100 MG BRAND 2ST

MD 4 per day



PRISTIQ TAB ER 24H 50 MG BRAND 2ST

MD 1 per day

sertraline hcl (tab 25 mg, tab 50 mg) generic 1 MD 1.5 per day

sertraline hcl oral conc 20 mg/ml generic 1 MD 300 / 30 DAYS

sertraline hcl tab 100 mg generic 1 MD 2 per day

trazodone hcl (tab 50 mg, tab 100 mg, tab150 mg, tab 300 mg)

generic 1

venlafaxine hcl (cap 24hr 150 mg, tab 24hr150 mg)


venlafaxine hcl (cap 24hr 37.5 mg, cap24hr 75 mg, tab 24hr 37.5 mg, tab 24hr 75mg)


venlafaxine hcl (tab 25 mg, tab 37.5 mg,tab 50 mg, tab 75 mg, tab 100 mg)


VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND 1 MD 1 per day

VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40MG)


VIIBRYD KIT 10 & 20 & 40 MG BRAND 2 MPL 1 / 365 days

TRICYCLICS

amitriptyline hcl (tab 10 mg, tab 25 mg,tab 50 mg, tab 75 mg, tab 100 mg, tab 150mg)

generic 1

amoxapine (tab 25 mg, tab 50 mg, tab 100mg, tab 150 mg)

generic 3

clomipramine hcl (cap 25 mg, cap 50 mg,cap 75 mg)

generic 1

desipramine hcl (tab 10 mg, tab 25 mg, tab50 mg, tab 75 mg, tab 100 mg, tab 150mg)

generic 1

doxepin hcl (cap 10 mg, cap 25 mg, cap 50mg, cap 75 mg, cap 100 mg, cap 150 mg,conc 10 mg/ml)

generic 1



imipramine hcl (tab 10 mg, tab 25 mg, tab50 mg)

generic 1

imipramine pamoate (cap 75 mg, cap 100mg, cap 125 mg, cap 150 mg)

generic 1

nortriptyline hcl (cap 10 mg, cap 25 mg,cap 50 mg, cap 75 mg)

generic 1

protriptyline hcl (tab 5 mg, tab 10 mg) generic 1

trimipramine maleate (cap 25 mg, cap 50mg, cap 100 mg)

generic 1

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl (tab 12.5 mg, tab 25 mg) generic 1

metoclopramide hcl (tab 5 mg, tab 10 mg) generic 1MD 6 per dayMD

S84 DAYS SUPPLYWITHIN 365 DAYS

metoclopramide hcl inj 5 mg/ml generic 1

metoclopramide hcl soln 5 mg/5ml (10mg/10ml)

generic 1MD 60 per dayMD

S84 DAYS SUPPLYWITHIN 365 DAYS

perphenazine (tab 2 mg, tab 4 mg, tab 8mg, tab 16 mg)


prochlorperazine generic 1

prochlorperazine maleate (tab 5 mg, tab10 mg)

generic 1

TRANSDERM-SCOP (1.5 MG) BRAND 2

trimethobenzamide hcl cap 300 mg generic 1

EMETOGENIC THERAPY ADJUNCTS

ALOXI BRAND 3 PA

ANZEMET (TAB 50 MG, TAB 100 MG) BRAND 3PAMD 5 / 30 DAYS



ANZEMET SOLUTION 20 MG/ML BRAND 3 PA

CESAMET BRAND 3

dronabinol (cap 2.5 mg, cap 5 mg, cap 10mg)

generic 1

EMEND (CAP 40 MG, CAP 125 MG) BRAND 2PAMD 2 / 30 DAYS

EMEND CAP 80 MG BRAND 2PAMD 4 / 30 DAYS

granisetron hcl (inj 0.1 mg/ml, inj 1 mg/ml,tab 1 mg)

generic 1

ondansetron hcl (tab 4 mg, tab 8 mg) generic 1 MD 30 / 30 DAYS

ondansetron hcl inj 4 mg/2ml (2 mg/ml) generic 1

ondansetron hcl oral soln 4 mg/5ml generic 1 MD 100 / 30 DAYS

ondansetron hcl tab 24 mg generic 1 MD 4 / 28 DAYS

ondansetron orally disintegrating tab 4 mg generic 1 MD 90 / 90 DAYS



ANTIFUNGALS

ABELCET BRAND 3

AMBISOME BRAND 3

AMPHOTEC RECON SUSP 50 MG BRAND 3

amphotericin b for inj 50 mg generic 3

CANCIDAS (RECON SOLN 50 MG, RECONSOLN 70 MG)

BRAND 3

ciclopirox & vitamin e generic 1

ciclopirox (gel 0.77%, shampoo 1%,solution 8%)

generic 1

ciclopirox olamine (cream, susp) generic 1



clotrimazole (topical) (cream, soln) generic 1

clotrimazole troche 10 mg generic 1

econazole nitrate generic 1

ERAXIS (RECON SOLN 50 MG, RECON SOLN100 MG)

BRAND 3

ERTACZO BRAND 3

EXELDERM (CREAM 1 %, SOLUTION 1 %) BRAND 3

fluconazole (for susp 10 mg/ml, for susp 40mg/ml, tab 50 mg, tab 100 mg, tab 150mg, tab 200 mg)

generic 1

flucytosine (cap 250 mg, cap 500 mg) generic 1

griseofulvin microsize susp 125 mg/5ml generic 1ST


griseofulvin microsize tab 500 mg generic 1

griseofulvin ultramicrosize (tab 125 mg,tab 250 mg)

generic 1

GYNAZOLE-1 BRAND 3

itraconazole cap 100 mg generic 1PAMD 4 per day

ketoconazole (topical) (cream, shampoo) generic 1

ketoconazole tab 200 mg generic 1

MENTAX BRAND 2

MICONAZOLE 3 BRAND 3

MYCAMINE (RECON SOLN 50 MG, RECONSOLN 100 MG)

BRAND 3

NAFTIFINE HCL CREAM 1 % BRAND 3

NAFTIN (CREAM 2 %, GEL 1 %) BRAND 3

NATACYN BRAND 2

NOXAFIL SUSPENSION 40 MG/ML BRAND 3



nystatin (*nystatin oral powder*, nystatintab 500000 unit)

generic 1

nystatin (mouth-throat) generic 1

nystatin (topical) (*nystatin topicalpowder**, nystatin cream 100000 unit/gm,nystatin oint 100000 unit/gm)

generic 1

nystatin-triamcinolone (cream unit/gm-%,oint unit/gm-%)

generic 1

OXISTAT (CREAM 1 %, LOTION 1 %) BRAND 2

SPORANOX SOLUTION 10 MG/ML BRAND 3PAMD 1200 / 30 DAYS

terbinafine hcl tab 250 mg generic 1 MD 1 per day

terconazole vaginal (cream 0.4%, cream0.8%)


terconazole vaginal suppos 80 mg generic 1

voriconazole (tab 50 mg, tab 200 mg) generic 1

ANTIGOUT AGENTS

allopurinol (tab 100 mg, tab 300 mg) generic 1

COLCHICINE TAB 0.6 MG BRAND 2MFL 1 / 30 daysMD 6 / CLAIM

colchicine w/ probenecid generic 1MFL 1 / 30 daysMD 6 / CLAIM(S)

COLCRYS BRAND 2MFL 1 / 30 daysMD 6 / CLAIM

probenecid generic 1

ULORIC (TAB 40 MG, TAB 80 MG) BRAND 3PAMD 1 per day



ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

CAFERGOT BRAND 2

dihydroergotamine mesylate inj 1 mg/ml generic 1

dihydroergotamine mesylate nasal spray 4mg/ml

generic 1ST

MD 8 / 30 DAYS

ERGOMAR BRAND 3

MIGRANAL BRAND 2ST

MD 8 / 30 DAYS

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate tab 12.5 mg generic 3

ST

AL At least 12 yrs oldMD 12 / 30 DAYS

almotriptan malate tab 6.25 mg generic 3

ST


FROVA BRAND 3 MD 12 / 30 DAYS

naratriptan hcl (tab 1 mg, tab 2.5 mg) generic 1AL At least 18 yrs old

MD 9 / 30 DAYS

RELPAX (TAB 20 MG, TAB 40 MG) BRAND 3

ST


rizatriptan benzoate odt 10 mg generic 1AL At least 6 yrs old

MD 18 / 30 DAYS

rizatriptan benzoate odt 5 mg generic 1AL At least 6 yrs old

MD 12 / 30 DAYS

rizatriptan benzoate tab 10 mg (baseequivalent)

generic 1AL At least 6 yrs old

MD 18 / 30 DAYS



rizatriptan benzoate tab 5 mg (baseequivalent)


MD 12 / 30 DAYS

sumatriptan nasal spray (5 mg/act, 20mg/act)


MD 6 / 30 DAYS

sumatriptan succinate (inj 4 mg/0.5ml, inj6 mg/0.5ml, solution auto-injector 4mg/0.5ml, solution auto-injector 6mg/0.5ml, solution cartridge 6 mg/0.5ml,solution prefilled syringe 4 mg/0.5ml,solution prefilled syringe 6 mg/0.5ml)


MD 4 / 30 DAYS

sumatriptan succinate (tab 25 mg, tab 50mg, tab 100 mg)


MD 9 / 30 DAYS

sumatriptan succinate solution cartridge 4mg/0.5ml


zolmitriptan (orally disintegrating tab 2.5mg, orally disintegrating tab 5 mg, tab 2.5mg, tab 5 mg)

generic 1

ST


ZOMIG SOLUTION 5 MG BRAND 2

ST


ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine hcl generic 2

MESTINON SYRUP 60 MG/5ML BRAND 2

MYTELASE BRAND 3

pyridostigmine bromide (tab 60 mg, tab cr180 mg)

generic 1



ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (tab 25 mg, tab 100 mg) generic 3

rifabutin generic 1

ANTITUBERCULARS

CAPASTAT SULFATE BRAND 3

CYCLOSERINE BRAND 3

ethambutol hcl (tab 100 mg, tab 400 mg) generic 1

isoniazid & rifampin generic 3

isoniazid (inj 100 mg/ml, syrup 50 mg/5ml,tab 100 mg, tab 300 mg)

generic 1

PASER BRAND 3

PRIFTIN BRAND 3

pyrazinamide generic 1

RIFAMATE BRAND 3

rifampin (cap 150 mg, cap 300 mg, for inj600 mg)

generic 1

RIFATER BRAND 3

SEROMYCIN BRAND 3

TRECATOR BRAND 3

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN TAB 2 MG BRAND 2

BICNU BRAND 4

BUSULFEX BRAND 4

cyclophosphamide (cap 25 mg, cap 50 mg,for inj 1 gm, for inj 2 gm, for inj 500 mg,tab 25 mg, tab 50 mg)

generic 4



dacarbazine (inj 100 mg, inj 200 mg) generic 4

GLEOSTINE (CAP 10 MG, CAP 40 MG, CAP100 MG)

BRAND 4

HEXALEN BRAND 4

IFEX RECON SOLN 3 GM BRAND 4

ifosfamide & mesna generic 4

ifosfamide (for inj 1 gm, iv inj 1 gm/20ml(50 mg/ml), iv inj 3 gm/60ml (50 mg/ml),recon soln 3 gm)

generic 4

LEUKERAN BRAND 4

lomustine (cap 10 mg, cap 40 mg, cap 100mg)

generic 4

MATULANE BRAND 4

melphalan hcl generic 1

MUSTARGEN BRAND 4

MYLERAN BRAND 4

TEMODAR RECON SOLN 100 MG BRAND 4 PA

temozolomide (cap 5 mg, cap 20 mg, cap100 mg, cap 140 mg, cap 180 mg, cap 250mg)

generic 4 PA

TREANDA RECON SOLN 100 MG BRAND 4

TREANDA RECON SOLN 25 MG BRAND 4 PA

ZANOSAR BRAND 4

ANTIANDROGENS

bicalutamide generic 4

flutamide generic 4

NILANDRON BRAND 3 MD 2 per day

XTANDI BRAND 4 PA



ZYTIGA BRAND 4 PA

ANTIANGIOGENIC AGENTS

REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10MG, CAP 15 MG, CAP 25 MG)

BRAND 4 PA

THALOMID (CAP 50 MG, CAP 100 MG, CAP150 MG, CAP 200 MG)

BRAND 4 PA

ANTIESTROGENS/MODIFIERS

EMCYT BRAND 4

FARESTON BRAND 2

FASLODEX (125 MG/2.5ML, SOLUTION 250MG/5ML)

BRAND 4

SOLTAMOX BRAND 3 PA

tamoxifen citrate (tab 10 mg, tab 20 mg) generic 0

ANTIMETABOLITES

ALIMTA RECON SOLN 500 MG BRAND 4 PA

capecitabine (tab 150 mg, tab 500 mg) generic 4 PA

cladribine generic 4 PA

CLOLAR BRAND 4

cytarabine (for inj 1 gm, for inj 100 mg, forinj 500 mg, inj 20 mg/ml, inj pf 20 mg/ml,inj pf 100 mg/ml, solution 20 mg/ml)

generic 4 PA

DEPOCYT BRAND 4

DROXIA (CAP 200 MG, CAP 300 MG, CAP400 MG)

BRAND 4

floxuridine for inj 0.5 gm generic 4

fluorouracil (inj 1 gm/20ml mg/ml), inj 2.5gm/50ml mg/ml), inj 5 gm/100ml mg/ml),inj 500 mg/10ml mg/ml))

generic 4

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

BRAND 4



gemcitabine hcl (for inj 1 gm, for inj 2 gm,for inj 200 mg, inj 1 gm/26.3ml (38 mg/ml)(base equiv), inj 2 gm/52.6ml (38 mg/ml)(base equiv), inj 200 mg/5.26ml (38 mg/ml)(base equiv))

generic 4

hydroxyurea generic 1

mercaptopurine generic 1

NIPENT BRAND 4

pentostatin generic 4

TABLOID BRAND 4 PA

ANTINEOPLASTICS, OTHER

ABRAXANE BRAND 4 PA

ADRIAMYCIN BRAND 4

ARRANON BRAND 4

azacitidine generic 4 PA

bleomycin sulfate (inj 15, inj 30) generic 4

CAMPATH BRAND 4

CAMPTOSAR SOLUTION 300 MG/15ML BRAND 4

carboplatin (for inj 150 mg, soln 50mg/5ml, soln 150 mg/15ml, soln 450mg/45ml, soln 600 mg/60ml)

generic 4

cisplatin (inj 50 mg/50ml mg/ml), inj 100mg/100ml mg/ml), inj 200 mg/200mlmg/ml))

generic 4

COSMEGEN BRAND 4

dactinomycin generic 4

daunorubicin hcl (for inj 20 mg, inj 5 mg/ml(base equiv))

generic 4

DAUNOXOME BRAND 4

decitabine generic 4 PA



DOCEFREZ (RECON SOLN 20 MG, RECONSOLN 80 MG)

BRAND 4

DOCETAXEL (CONC 20 MG/0.5ML, CONC20 MG/ML, CONC 80 MG/2ML, CONC 80MG/4ML, CONC 140 MG/7ML, CONC 160MG/8ML, FOR INJ CONC 20 MG/0.5ML (40MG/ML), FOR INJ CONC 20 MG/ML, FORINJ CONC 80 MG/2ML (40 MG/ML), FORINJ CONC 80 MG/4ML (20 MG/ML), SOLNFOR IV INFUSION 20 MG/2ML, SOLN FORIV INFUSION 80 MG/8ML, SOLN FOR IVINFUSION 160 MG/16ML, SOLUTION 20MG/2ML, SOLUTION 80 MG/8ML,SOLUTION 160 MG/16ML)

BRAND 4

DOXIL BRAND 4

DOXORUBICIN HCL (FOR INJ 10 MG, INJ 2MG/ML, RECON SOLN 10 MG)

BRAND 4

doxorubicin hcl liposomal generic 4

ELOXATIN SOLUTION 200 MG/40ML BRAND 4

ELSPAR BRAND 4 PA

EPIRUBICIN HCL (INJ 50 MG/25ML (2MG/ML), IV SOLN 50 MG/25ML (2MG/ML), IV SOLN 200 MG/100ML (2MG/ML), RECON SOLN 50 MG)

BRAND 4 PA

ERWINAZE BRAND 4 PA

fludarabine phosphate (for inj 50 mg, inj 25mg/ml)

generic 4 PA

HALAVEN BRAND 4 PA

idarubicin hcl (inj 5 mg/5ml mg/ml), inj 10mg/10ml mg/ml), inj 20 mg/20ml mg/ml))

generic 4

irinotecan hcl (inj 40 mg/2ml mg/ml), inj100 mg/5ml mg/ml))

generic 4 PA

IRINOTECAN HCL SOLUTION 500 MG/25ML BRAND 4



ISTODAX BRAND 4 PA

IXEMPRA KIT RECON SOLN 15 MG BRAND 4 PA

JEVTANA BRAND 4 PA

leucovorin calcium (for inj 50 mg, for inj100 mg, for inj 200 mg, for inj 350 mg, forinj 500 mg, inj 10 mg/ml, tab 5 mg, tab 10mg, tab 15 mg, tab 25 mg)

generic 1

LYSODREN BRAND 4 PA

MITOMYCIN (FOR IV SOLN 5 MG, FOR IVSOLN 20 MG, FOR IV SOLN 40 MG, RECONSOLN 5 MG)

BRAND 4

mitoxantrone hcl inj conc 25 mg/12.5ml (2mg/ml)

generic 4 PA

OFORTA BRAND 4 PA

ONCASPAR BRAND 4 PA

ONTAK BRAND 4

oxaliplatin (for inj 50 mg, for inj 100 mg,soln 50 mg/10ml, soln 100 mg/20ml)

generic 4

paclitaxel (conc 30 mg/5ml mg/ml), conc100 mg/16.7ml mg/ml), conc 150 mg/25mlmg/ml), conc 300 mg/50ml mg/ml))

generic 4

PHOTOFRIN BRAND 4

PROLEUKIN BRAND 4 PA

SYLATRON (KIT 4 X 200 MCG, KIT 4 X 300MCG, KIT 4 X 600 MCG, KIT 200 MCG, KIT300 MCG, KIT 600 MCG)

BRAND 4 PA

SYNRIBO BRAND 4 PA

TAXOTERE CONC 20 MG/0.5ML BRAND 4

TENIPOSIDE BRAND 4

thiotepa generic 4



TRISENOX BRAND 4

UVADEX BRAND 4

VALSTAR BRAND 4 PA

VELCADE BRAND 4 PA

vinblastine sulfate (for inj 10 mg, inj 1mg/ml)

generic 4

vincristine sulfate generic 4

vinorelbine tartrate (inj 10 mg/ml, inj 10mg/ml (base equiv), inj 50 mg/5ml (10mg/ml) (base equiv))

generic 4

VORAXAZE BRAND 4 PA

VUMON BRAND 4

ZALTRAP SOLUTION 100 MG/4ML BRAND 4 PA

ZOLINZA BRAND 4 PA

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole tab 1 mg generic 1 PA

exemestane generic 4

letrozole tab 2.5 mg generic 1

ENZYME INHIBITORS

ETOPOPHOS BRAND 4

etoposide (cap 50 mg, inj 1 gm/50ml (20mg/ml), inj 100 mg/5ml (20 mg/ml), inj500 mg/25ml (20 mg/ml))

generic 4

HYCAMTIN (CAP 0.25 MG, CAP 1 MG) BRAND 4 PA

topotecan hcl for inj 4 mg generic 4 PA

MOLECULAR TARGET INHIBITORS

AFINITOR (TAB 2.5 MG, TAB 5 MG, TAB 7.5MG, TAB 10 MG)

BRAND 4 PA



BOSULIF (TAB 100 MG, TAB 500 MG) BRAND 4 PA

CAPRELSA (TAB 100 MG, TAB 300 MG) BRAND 4 PA

COMETRIQ (100 MG DAILY DOSE) BRAND 4 PA



ERIVEDGE BRAND 4 PA

GLEEVEC (TAB 100 MG, TAB 400 MG) BRAND 4 PA

INLYTA (TAB 1 MG, TAB 5 MG) BRAND 4 PA

JAKAFI (TAB 5 MG, TAB 10 MG, TAB 15 MG,TAB 20 MG, TAB 25 MG)

BRAND 4 PA

KYPROLIS RECON SOLN 60 MG BRAND 4 PA

NEXAVAR BRAND 4 PA

NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4MG)

BRAND 4PAMD 1 / WEEK(S)

SPRYCEL (TAB 20 MG, TAB 50 MG, TAB 70MG, TAB 80 MG, TAB 100 MG, TAB 140MG)

BRAND 4 PA

STIVARGA BRAND 4 PA

SUTENT (CAP 12.5 MG, CAP 25 MG, CAP 50MG)

BRAND 4 PA

TARCEVA (TAB 25 MG, TAB 100 MG, TAB150 MG)

BRAND 4 PA

TASIGNA (CAP 150 MG, CAP 200 MG) BRAND 4 PA

TORISEL BRAND 4

TYKERB BRAND 4 PA

VANDETANIB (TAB 100 MG, TAB 300 MG) BRAND 4 PA

VOTRIENT BRAND 4 PA

XALKORI (CAP 200 MG, CAP 250 MG) BRAND 4 PA



ZELBORAF BRAND 4 PA

MONOCLONAL ANTIBODIES

ADCETRIS BRAND 4 PA

ARZERRA CONC 100 MG/5ML BRAND 4 PA

ARZERRA CONC 1000 MG/50ML BRAND 4

AVASTIN SOLUTION 100 MG/4ML BRAND 4 PA

BEXXAR BRAND 4 PA

ERBITUX (SOLUTION 100 MG/50ML,SOLUTION 200 MG/100ML)

BRAND 4 PA

HERCEPTIN BRAND 4 PA

PERJETA BRAND 4 PA

RITUXAN (SOLUTION 100 MG/10ML,SOLUTION 500 MG/50ML)

BRAND 4 PA

VECTIBIX SOLUTION 100 MG/5ML BRAND 4 PA

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

BRAND 4 PA

RETINOIDS

bexarotene generic 4 PA

PANRETIN BRAND 3

TARGRETIN GEL 1 % BRAND 4 PA

tretinoin (chemotherapy) generic 1

ANTIPARASITICS

ANTIHELMINTHICS

ALBENZA BRAND 3

BILTRICIDE BRAND 3

ivermectin generic 1



mebendazole chew tab 100 mg generic 1

SKLICE BRAND 3

ANTIPROTOZOALS

ALINIA (RECON SUSP 100 MG/5ML, TAB500 MG)

BRAND 2

atovaquone susp 750 mg/5ml generic 1

atovaquone-proguanil hcl (tab 62.5-25 mg,tab 250-100 mg)


chloroquine phosphate (tab 250 mg, tab500 mg)

generic 1

COARTEM BRAND 2

DARAPRIM BRAND 3

hydroxychloroquine sulfate generic 1

mefloquine hcl generic 1

NEBUPENT BRAND 3

PENTAM BRAND 3

primaquine phosphate (tab 26.3 mg, tab26.3 mg (15 mg base))

generic 3

quinine sulfate cap 324 mg generic 1 MDS

84 DAYS SUPPLYWITHIN 365 DAYS

PEDICULICIDES/SCABICIDES

EURAX (CREAM 10 %, LOTION 10 %) BRAND 3

lindane (lotion, shampoo) generic 3

malathion generic 1

NATROBA BRAND 2

permethrin generic 1

SPINOSAD BRAND 2

ULESFIA BRAND 3



ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (inj 1 mg/ml, tab 0.5mg, tab 1 mg, tab 2 mg)

generic 1

trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2mg, tab 5 mg)

generic 1

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (cap 100 mg, syrup 50mg/5ml, tab 100 mg)

generic 1

carbidopa-levodopa-entacapone (tabs12.5-50-200 mg, tabs 18.75-75-200 mg,tabs 25-100-200 mg, tabs 31.25-125-200mg, tabs 37.5-150-200 mg, tabs 50-200-200 mg)

generic 1

entacapone generic 1 MD 8 per day

tolcapone generic 3

DOPAMINE AGONISTS

APOKYN BRAND 4 PA

bromocriptine mesylate (cap 5 mg, tab 2.5mg)

generic 1

NEUPRO (PATCH 24HR 1 MG/24HR, PATCH24HR 2 MG/24HR, PATCH 24HR 3MG/24HR, PATCH 24HR 4 MG/24HR,PATCH 24HR 6 MG/24HR, PATCH 24HR 8MG/24HR)

BRAND 2

pramipexole dihydrochloride (tab 0.25 mg,tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5mg)

generic 1

pramipexole dihydrochloride tab 0.125 mg generic 1 MD 4 per day

ropinirole hydrochloride (tab 0.25 mg, tab0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab4 mg, tab 5 mg)

generic 1



ropinirole hydrochloride (tab 24hr 12 mg,tab 24hr 8 mg)

generic 1ST

MD 2 per day

ropinirole hydrochloride (tab 24hr 2 mg,tab 24hr 4 mg, tab 24hr 6 mg)

generic 1ST

MD 1 per day

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa generic 1

carbidopa & levodopa odt 10-100 mg generic 1



carbidopa-levodopa (tab 10-100 mg, tab25-100 mg, tab 25-250 mg, tab cr 25-100mg, tab cr 50-200 mg)

generic 1

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT (TAB 0.5 MG, TAB 1 MG) BRAND 2PAMD 1 per day

selegiline hcl (cap 5 mg, tab 5 mg) generic 1

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (inj 25 mg/ml, inj 50mg/2ml)


chlorpromazine hcl (tab 10 mg, tab 25 mg,tab 50 mg, tab 100 mg, tab 200 mg)


fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5mg/ml, oral conc 5 mg/ml, tab 1 mg, tab2.5 mg, tab 5 mg, tab 10 mg)


haloperidol (tab 0.5 mg, tab 1 mg, tab 2mg, tab 5 mg, tab 10 mg, tab 20 mg)


haloperidol decanoate (soln 50 mg/ml, soln100 mg/ml)


MD 1 / 28 DAYS



haloperidol lactate inj 5 mg/ml generic 1 AL At least 18 yrs old

loxapine succinate (cap 5 mg, cap 10 mg,cap 25 mg, cap 50 mg)


ORAP (TAB 1 MG, TAB 2 MG) BRAND 3

thioridazine hcl (tab 10 mg, tab 25 mg, tab50 mg, tab 100 mg)


thiothixene (cap 1 mg, cap 2 mg, cap 5 mg,cap 10 mg)


trifluoperazine hcl (tab 1 mg, tab 2 mg, tab5 mg, tab 10 mg)


2ND GENERATION/ATYPICAL

ABILIFY SOLUTION 1 MG/ML BRAND 3

PA


ABILIFY SOLUTION 9.75 MG/1.3ML BRAND 3

PA


aripiprazole (tab 2 mg, tab 5 mg, tab 10mg, tab 15 mg, tab 20 mg, tab 30 mg)

generic 3

PA

AL At least 6 yrs oldMD 1 per day

FANAPT (TAB 1 MG, TAB 2 MG, TAB 4 MG,TAB 6 MG, TAB 8 MG, TAB 10 MG, TAB 12MG)

BRAND 2

PA


FANAPT TITRATION PACK BRAND 2

PA


INVEGA (TAB ER 24H 1.5 MG, TAB ER 24H 3MG, TAB ER 24H 9 MG)

BRAND 2

PA




LATUDA (TAB 20 MG, TAB 40 MG, TAB 80MG)

BRAND 3

PA


LATUDA TAB 120 MG BRAND 3PA


olanzapine (tab 15 mg, tab 20 mg) generic 1AL At least 6 yrs old

MD 2 per day

olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5mg, tab 10 mg)


MD 1 per day

olanzapine for im inj 10 mg generic 1AL At least 18 yrs old

MD 6 / 28 DAYS

quetiapine fumarate (tab 25 mg, tab 50mg, tab 100 mg, tab 200 mg, tab 300 mg,tab 400 mg)


MD 2 per day

RISPERDAL CONSTA (RECON SUSP 12.5MG, RECON SUSP 25 MG, RECON SUSP37.5 MG, RECON SUSP 50 MG)

BRAND 2

PA


risperidone (tab 0.25 mg, tab 0.5 mg, tab 1mg, tab 2 mg, tab 3 mg)


MD 2 per day

risperidone odt (tab 3 mg, tab 4 mg) generic 1

PA


risperidone orally disintegrating tab 0.25mg

generic 1

PA


risperidone orally disintegrating tab 0.5 mg generic 1

PA


risperidone orally disintegrating tab 1 mg generic 1

PA




risperidone orally disintegrating tab 2 mg generic 1

PA


risperidone soln 1 mg/ml generic 1

PA


risperidone tab 4 mg generic 1AL At least 6 yrs old

MD 4 per day

SAPHRIS (SL TAB 5 MG, SL TAB 10 MG) BRAND 2

PA


SEROQUEL XR (TAB ER 24H 150 MG, TABER 24H 200 MG, TAB ER 24H 50 MG)

BRAND 2 PA

SEROQUEL XR (TAB ER 24H 300 MG, TABER 24H 400 MG)


ziprasidone hcl (cap 20 mg, cap 40 mg, cap60 mg, cap 80 mg)


MD 2 per day

TREATMENT-RESISTANT

clozapine (tab 25 mg, tab 50 mg, tab 100mg, tab 200 mg)


ANTISPASTICITY AGENTS

baclofen (tab 10 mg, tab 20 mg) generic 1

dantrolene sodium (cap 25 mg, cap 50 mg,cap 100 mg)


tizanidine hcl (cap 2 mg (base equivalent),cap 4 mg (base equivalent), cap 6 mg (baseequivalent), tab 2 mg, tab 2 mg (baseequivalent), tab 4 mg, tab 4 mg (baseequivalent))

generic 1



ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir iv inj 75 mg/ml generic 3

FOSCARNET SODIUM (SOLUTION 24MG/ML, SOLUTION 12000 MG/500ML)

BRAND 3

FOSCAVIR BRAND 3

ganciclovir sodium generic 1

VALCYTE RECON SOLN 50 MG/ML BRAND 2PAMD 540 / 30 DAYS

valganciclovir hcl tab 450 mg (baseequivalent)


ZIRGAN BRAND 2

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil generic 4PAMD 1 per day

BARACLUDE SOLUTION 0.05 MG/ML BRAND 4PAMD 600 / 30 DAYS

entecavir (tab 0.5 mg, tab 1 mg) generic 4PAMD 1 per day

EPIVIR HBV SOLUTION 5 MG/ML BRAND 2PAMD 1800 / 30 DAYS

lamivudine (hbv) generic 1PAMD 3 per day

TYZEKA BRAND 4

PA




ANTI-HEPATITIS C (HCV) AGENTS

EPCLUSA BRAND 4PAMD 1 Per Day

HARVONI BRAND 4PAMD 1 per day

INCIVEK BRAND 4PAMD 6 per day

INFERGEN (INJECTABLE 9 MCG/0.3ML,INJECTABLE 15 MCG/0.5ML)

BRAND 4 PA

INTRON A RECON SOLN 18000000 UNIT BRAND 4 PA

PEG-INTRON (KIT 50 MCG/0.5ML, KIT 80MCG/0.5ML, KIT 120 MCG/0.5ML, KIT 150MCG/0.5ML)


PEG-INTRON REDIPEN (KIT 50 MCG/0.5ML,KIT 80 MCG/0.5ML, KIT 120 MCG/0.5ML,KIT 150 MCG/0.5ML)


PEG-INTRON REDIPEN PAK 4 (4 KIT 120MCG/0.5ML, 4 KIT 150 MCG/0.5ML, 4 KIT50 MCG/0.5ML, 4 KIT 80 MCG/0.5ML)


PEGASYS KIT 180 MCG/0.5ML BRAND 4PAMD 1 / 28 DAYS

PEGASYS PROCLICK (SOLUTION 135MCG/0.5ML, SOLUTION 180 MCG/0.5ML)


PEGASYS SOLUTION 180 MCG/0.5ML BRAND 4PAMD 2 / 28 DAYS

PEGASYS SOLUTION 180 MCG/ML BRAND 4PAMD 4 / 28 DAYS

PEGINTRON (KIT 50 MCG/0.5ML, KIT 80MCG/0.5ML, KIT 120 MCG/0.5ML, KIT 150MCG/0.5ML)


REBETOL SOLUTION 40 MG/ML BRAND 4PAMD 1050 / 30 DAYS



ribavirin (hepatitis c) (cap 200 mg, tab 200mg)


SOVALDI BRAND 4PAMD 1 per day

VICTRELIS BRAND 4PAMD 12 per day

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA BRAND 3 MD 1 Per Day

ISENTRESS (CHEW TAB 25 MG, CHEW TAB100 MG)

BRAND 2

ISENTRESS TAB 400 MG BRAND 2 MD 2 per day

TIVICAY (TAB 10 MG, TAB 25 MG, TAB 50MG)

BRAND 2

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA BRAND 3 MD 1 per day

COMPLERA BRAND 2

EDURANT BRAND 2 MD 1 per day

INTELENCE TAB 100 MG BRAND 2 MD 4 per day



nevirapine susp 50 mg/5ml generic 1 MD 1200 / 30 DAYS

nevirapine tab 200 mg generic 2 MD 2 per day

nevirapine tab sr 24hr 400 mg generic 1 MD 1 per day

ODEFSEY BRAND 3 MD 1 Per Day

RESCRIPTOR TAB 100 MG BRAND 2 MD 12 per day

RESCRIPTOR TAB 200 MG BRAND 2 MD 6 per day

SUSTIVA CAP 200 MG BRAND 2 MD 2 per day



SUSTIVA CAP 50 MG BRAND 2 MD 3 per day

SUSTIVA TAB 600 MG BRAND 2 MD 1 per day

VIRAMUNE TAB 200 MG BRAND 2 MD 2 per day

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)

abacavir sulfate generic 3 MD 2 per day

abacavir sulfate-lamivudine-zidovudine generic 1PAMD 2 per day

DESCOVY BRAND 3 MD 1 Per Day

didanosine (capsule 125 mg, capsule 200mg)


didanosine (capsule 250 mg, capsule 400mg)


EMTRIVA CAP 200 MG BRAND 2 MD 1 per day

EMTRIVA SOLUTION 10 MG/ML BRAND 2

EPIVIR TAB 150 MG BRAND 4 MD 2 per day

EPIVIR TAB 300 MG BRAND 4 MD 1 per day

EPZICOM BRAND 2PAMD 1 per day

lamivudine oral soln 10 mg/ml generic 1 MD 900 / 30 DAYS

lamivudine tab 150 mg generic 1 MD 2 per day

lamivudine tab 300 mg generic 1 MD 1 per day

lamivudine-zidovudine generic 3 MD 2 per day

RETROVIR SOLUTION 10 MG/ML BRAND 1

stavudine (cap 15 mg, cap 20 mg, cap 30mg, cap 40 mg)


stavudine for oral soln 1 mg/ml generic 1 MD 2400 / 30 DAYS



TRUVADA TAB 200-300 MG BRAND 2PAMD 1 per day

VIDEX EC (EC CAP DR 125 MG, EC CAP DR200 MG)


VIDEX EC (EC CAP DR 250 MG, EC CAP DR400 MG)


VIREAD (POWDER 40 MG/GM, TAB 150MG, TAB 200 MG, TAB 250 MG)

BRAND 2

VIREAD TAB 300 MG BRAND 2 MD 1 per day

ZIAGEN TAB 300 MG BRAND 3 MD 2 per day

zidovudine cap 100 mg generic 1 MD 6 per day

zidovudine syrup 10 mg/ml generic 1 MD 1800 / 30 DAYS

zidovudine tab 300 mg generic 1 MD 2 per day

ANTI-HIV AGENTS, OTHER

FUZEON (KIT 90 MG, RECON SOLN 90 MG) BRAND 4PAMD 1 / 30 DAYS

SELZENTRY TAB 150 MG BRAND 2 MD 2 per day

SELZENTRY TAB 300 MG BRAND 2 MD 4 per day

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS CAP 250 MG BRAND 2 MD 4 per day

APTIVUS SOLUTION 100 MG/ML BRAND 2

CRIXIVAN CAP 200 MG BRAND 2PAMD 9 per day

CRIXIVAN CAP 400 MG BRAND 2PAMD 6 per day

INVIRASE CAP 200 MG BRAND 2 MD 10 per day

INVIRASE TAB 500 MG BRAND 2 MD 4 per day



KALETRA (TAB 100-25 MG, TAB 200-50MG)


KALETRA SOLUTION 400-100 MG/5ML BRAND 2PAMD 375 / 30 DAYS

LEXIVA SUSPENSION 50 MG/ML BRAND 2PAMD 1680 / 30 DAYS

LEXIVA TAB 700 MG BRAND 2PAMD 4 per day

NORVIR (CAP 100 MG, TAB 100 MG) BRAND 2 MD 12 per day

NORVIR SOLUTION 80 MG/ML BRAND 2 MD 450 / 30 DAYS

PREZISTA (TAB 75 MG, TAB 150 MG, TAB400 MG, TAB 600 MG)


PREZISTA TAB 800 MG BRAND 2 MD 1 per day

REYATAZ (CAP 150 MG, CAP 200 MG) BRAND 2 MD 2 per day

REYATAZ CAP 100 MG BRAND 2 MD 4 per day

REYATAZ CAP 300 MG BRAND 2 MD 1 per day

VIRACEPT TAB 250 MG BRAND 2 MD 10 per day

VIRACEPT TAB 625 MG BRAND 2 MD 4 per day

ANTI-INFLUENZA AGENTS

RELENZA DISKHALER BRAND 2 MPL 1 / 30 days

rimantadine hydrochloride generic 1 MD 2 per day

TAMIFLU (CAP 45 MG, CAP 75 MG) BRAND 2 MD 10 / 30 DAYS

TAMIFLU CAP 30 MG BRAND 2 MD 20 / 30 DAYS

TAMIFLU RECON SUSP 6 MG/ML BRAND 2 MD 120 / 30 DAYS

ANTIHERPETIC AGENTS

acyclovir (cap 200 mg, tab 800 mg) generic 1 MD 50 / 30 DAYS



acyclovir susp 200 mg/5ml generic 1 MD 400 / 30 DAYS

acyclovir tab 400 mg generic 1 MD 5 per day

acyclovir topical generic 1

DENAVIR BRAND 3

famciclovir (tab 125 mg, tab 250 mg) generic 1PAMD 3 per day

famciclovir tab 500 mg generic 1PAMD 4 per day

trifluridine generic 1

valacyclovir hcl tab 1 gm generic 1 MD 4 per day

valacyclovir hcl tab 500 mg generic 1 MD 2 per day

ZOVIRAX CREAM 5 % BRAND 3

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (tab 7.5 mg, tab 10 mg, tab15 mg, tab 30 mg)

generic 1

buspirone hcl tab 5 mg generic 1 MD 1 per day

meprobamate (tab 200 mg, tab 400 mg) generic 1

BENZODIAZEPINES

alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1mg, tab 2 mg)


clonazepam (tab 0.5 mg, tab 1 mg, tab 2mg)

generic 1

diazepam (tab 2 mg, tab 5 mg, tab 10 mg) generic 1 MD 4 per day

lorazepam (tab 0.5 mg, tab 2 mg) generic 1 MD 3 per day

lorazepam tab 1 mg generic 1 MD 4 per day



BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO CAP ER 12H 100 MG BRAND 3

ST



ST



ST


lithium generic 1 AL At least 6 yrs old

lithium carbonate (cap 150 mg, cap 300mg, cap 600 mg, tab 300 mg, tab cr 300mg, tab cr 450 mg)


BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose (tab 25 mg, tab 50 mg, tab 100mg)


AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8MG)


BYETTA 10 MCG PEN BRAND 2PAMD 2.4 / 30 DAYS

BYETTA 5 MCG PEN BRAND 2PAMD 1.2 / 30 DAYS

chlorpropamide tab 100 mg generic 1 MD 3 per day

CYCLOSET BRAND 3 MD 6 per day

glimepiride (tab 1 mg, tab 2 mg) generic 1 MD 1 per day



glimepiride tab 4 mg generic 1 MD 2 per day

glipizide (tab 24hr 10 mg, tab 24hr 2.5 mg,tab 24hr 5 mg)


glipizide (tab 5 mg, tab 10 mg) generic 1 MD 4 per day

glipizide-metformin hcl (tab 2.5-250 mg,tab 2.5-500 mg)


glipizide-metformin hcl tab 5-500 mg generic 1 MD 4 per day

glyburide (tab 1.25 mg, tab 2.5 mg, tab 5mg)


glyburide micronized (tab 1.5 mg, tab 3mg, tab 6 mg)


glyburide-metformin (tab 1.25-250 mg, tab2.5-500 mg)


glyburide-metformin tab 5-500 mg generic 1 MD 4 per day

GLYSET (TAB 25 MG, TAB 50 MG, TAB 100MG)


INVOKANA (TAB 100 MG, TAB 300 MG) BRAND 3 PA

JANUVIA (TAB 25 MG, TAB 50 MG, TAB 100MG)


metformin hcl (tab 24hr 750 mg, tab 24hrosmotic 1000 mg)


metformin hcl tab 1000 mg generic 1 MD 2.5 per day

metformin hcl tab 500 mg generic 1 MD 5 per day

metformin hcl tab 850 mg generic 1 MD 3 per day

metformin hcl tab sr 24hr 500 mg generic 1 MD 4 per day

nateglinide (tab 60 mg, tab 120 mg) generic 1 MD 3 per day

ONGLYZA (TAB 2.5 MG, TAB 5 MG) BRAND 3PAMD 1 per day

pioglitazone hcl (tab 15 mg, tab 30 mg, tab45 mg)




pioglitazone hcl-metformin hcl (-metformintab 15-500 mg, -metformin tab 15-850 mg)


PRANDIMET (TAB 1-500 MG, TAB 2-500MG)


repaglinide (tab 0.5 mg, tab 1 mg, tab 2mg)


SYMLINPEN 120 BRAND 2PAMD 6 / 30 DAYS

SYMLINPEN 60 BRAND 2PAMD 10.8 / 30 DAYS

tolazamide (tab 250 mg, tab 500 mg) generic 1 MD 4 per day

tolbutamide generic 1 MD 6 per day

TRADJENTA BRAND 2PAMD 1 per day

VICTOZA BRAND 2PAMD 6 / 30 DAYS

GLYCEMIC AGENTS

GLUCAGEN DIAGNOSTIC BRAND 3 MD 12 / 365 DAYS

GLUCAGEN HYPOKIT BRAND 3 MD 12 / 365 DAYS

GLUCAGON EMERGENCY BRAND 3 MD 12 / 365 DAYS

PROGLYCEM BRAND 3

INSULINS

APIDRA BRAND 2 MD 50 / 30 DAYS

APIDRA SOLOSTAR BRAND 3 MD 50 / 30 DAYS

HUMALOG (SOLN CART 100 UNIT/ML,SOLUTION 100 UNIT/ML)

BRAND 2 MD 50 / 30 DAYS

HUMALOG KWIKPEN SOLN PEN 100UNIT/ML




HUMALOG MIX 50/50 BRAND 2 MD 50 / 30 DAYS

HUMALOG MIX 50/50 KWIKPEN BRAND 2 MD 50 / 30 DAYS

HUMALOG MIX 50/50 PEN BRAND 2 MD 50 / 30 DAYS

HUMALOG MIX 75/25 BRAND 2 MD 50 / 30 DAYS

HUMALOG MIX 75/25 KWIKPEN BRAND 2 MD 50 / 30 DAYS

HUMALOG MIX 75/25 PEN BRAND 2 MD 50 / 30 DAYS

HUMALOG PEN BRAND 2 MD 50 / 30 DAYS

HUMULIN 70/30 BRAND 2 MD 50 / 30 DAYS

HUMULIN 70/30 KWIKPEN BRAND 2 MD 50 / 30 DAYS

HUMULIN 70/30 PEN BRAND 2 MD 50 / 30 DAYS

HUMULIN N BRAND 2 MD 50 / 30 DAYS

HUMULIN N KWIKPEN BRAND 2 MD 50 / 30 DAYS

HUMULIN N PEN BRAND 2 MD 50 / 30 DAYS

HUMULIN R BRAND 2 MD 50 / 30 DAYS

HUMULIN R U-500 (CONCENTRATED) BRAND 2 MD 40 / 30 DAYS

LANTUS BRAND 2 MD 30 / 30 DAYS

LANTUS SOLOSTAR BRAND 2 MD 30 / 30 DAYS

LEVEMIR BRAND 2 MD 30 / 30 DAYS

LEVEMIR FLEXPEN BRAND 2 MD 30 / 30 DAYS

LEVEMIR FLEXTOUCH BRAND 2 MD 30 / 30 DAYS

NOVOLIN 70/30 BRAND 2 MD 50 / 30 DAYS

NOVOLIN 70/30 RELION BRAND 2 MD 50 / 30 DAYS

NOVOLIN N BRAND 2 MD 50 / 30 DAYS

NOVOLIN N RELION BRAND 2 MD 50 / 30 DAYS

NOVOLIN R BRAND 2 MD 50 / 30 DAYS



NOVOLIN R RELION BRAND 2 MD 50 / 30 DAYS

NOVOLOG BRAND 2 MD 50 / 30 DAYS

NOVOLOG FLEXPEN BRAND 2 MD 50 / 30 DAYS

NOVOLOG MIX 70/30 BRAND 2 MD 50 / 30 DAYS

NOVOLOG MIX 70/30 FLEXPEN BRAND 2 MD 50 / 30 DAYS

NOVOLOG PENFILL BRAND 2 MD 50 / 30 DAYS

RELION 70/30 BRAND 2 MD 50 / 30 DAYS

RELION N BRAND 2 MD 50 / 30 DAYS

RELION R BRAND 2 MD 50 / 30 DAYS

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN (TAB 1 MG, TAB 2 MG, TAB 2.5MG, TAB 3 MG, TAB 4 MG, TAB 5 MG, TAB6 MG, TAB 7.5 MG, TAB 10 MG)

BRAND 2

COUMADIN RECON SOLN 5 MG BRAND 3

ELIQUIS (TAB 2.5 MG, TAB 5 MG) BRAND 2 MD 74 / 30 DAYS

enoxaparin sodium (inj 100 mg/ml, inj 150mg/ml)


enoxaparin sodium (inj 80 mg/0.8ml, inj120 mg/0.8ml)


enoxaparin sodium inj 30 mg/0.3ml generic 4 MD 18 / 30 DAYS

enoxaparin sodium inj 300 mg/3ml generic 4 MD 180 / 30 DAYS





FRAGMIN (SOLUTION 2500 UNIT/0.2ML,SOLUTION 5000 UNIT/0.2ML, SOLUTION7500 UNIT/0.3ML, SOLUTION 10000UNIT/ML, SOLUTION 12500 UNIT/0.5ML,SOLUTION 15000 UNIT/0.6ML, SOLUTION18000 UNT/0.72ML, SOLUTION 25000UNIT/ML)

BRAND 4 PA

HEPARIN (PORCINE) IN NACL(HEPAR(PORCE) SOLUTION 50-0.45UNIT/ML-%, HEPAR(PORCE) SOLUTION100-0.45 UNIT/ML-%)

BRAND 1

heparin sodium (porcine) (inj 5000 unit/ml,inj 10000 unit/ml, inj 20000 unit/ml)

generic 1

heparin sodium (porcine) 40 unit/ml in d5w generic 1

PRADAXA CAP 150 MG BRAND 2 MD 2 per day

PRADAXA CAP 75 MG BRAND 2 MD 1 per day

warfarin sodium (tab 1 mg, tab 2 mg, tab2.5 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab6 mg, tab 7.5 mg, tab 10 mg)

generic 1

XARELTO (TAB 10 MG, TAB 15 MG, TAB 20MG)

BRAND 2

BLOOD FORMATION MODIFIERS

anagrelide hcl (cap 0.5 mg, cap 1 mg) generic 1

ARANESP (ALBUMIN FREE) (SOLN PRSYR150 MCG/0.3ML, SOLN PRSYR 200MCG/0.4ML, SOLN PRSYR 300 MCG/0.6ML,SOLN PRSYR 500 MCG/ML, SOLUTION 25MCG/ML, SOLUTION 40 MCG/ML,SOLUTION 60 MCG/ML, SOLUTION 100MCG/ML)

BRAND 4 PA

EPOGEN (SOLUTION 2000 UNIT/ML,SOLUTION 3000 UNIT/ML, SOLUTION 4000UNIT/ML, SOLUTION 10000 UNIT/ML,SOLUTION 20000 UNIT/ML)

BRAND 4 PA



LEUKINE (RECON SOLN 250 MCG,SOLUTION 500 MCG/ML)

BRAND 4 PA

MOZOBIL BRAND 4 PA

NEULASTA BRAND 4 PA

NEULASTA ONPRO BRAND 4

NEUPOGEN (SOLN PRSYR 300 MCG/0.5ML,SOLN PRSYR 480 MCG/0.8ML, SOLUTION300 MCG/ML, SOLUTION 480 MCG/1.6ML)

BRAND 4 PA

NPLATE (RECON SOLN 250 MCG, RECONSOLN 500 MCG)

BRAND 4 PA

OMONTYS SOLUTION 10 MG/ML BRAND 3

PROCRIT (SOLUTION 2000 UNIT/ML,SOLUTION 3000 UNIT/ML, SOLUTION 4000UNIT/ML, SOLUTION 10000 UNIT/ML,SOLUTION 20000 UNIT/ML, SOLUTION40000 UNIT/ML)

BRAND 4 PA

PROMACTA (TAB 12.5 MG, TAB 25 MG,TAB 50 MG, TAB 75 MG)

BRAND 4 PA

COAGULANTS

tranexamic acid (iv soln 1000 mg/10ml(100 mg/ml), tab 650 mg)

generic 1

PLATELET MODIFYING AGENTS

AGGRENOX BRAND 2PAMD 2 per day

aspirin-dipyridamole generic 1PAMD 2 per day

BRILINTA TAB 90 MG BRAND 2

cilostazol (tab 50 mg, tab 100 mg) generic 1

clopidogrel bisulfate tab 300 mg (baseequiv)

generic 1



clopidogrel bisulfate tab 75 mg (baseequiv)


dipyridamole (tab 25 mg, tab 50 mg, tab75 mg)

generic 1

EFFIENT TAB 10 MG BRAND 2

EFFIENT TAB 5 MG BRAND 2 MD 1 per day

REOPRO BRAND 3 PA

ticlopidine hcl generic 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab0.3 mg)


guanabenz acetate (tab 4 mg, tab 8 mg) generic 1

guanfacine hcl (tab 1 mg, tab 2 mg) generic 1

methyldopa (tab 250 mg, tab 500 mg) generic 1 MD 6 per day

methyldopate hcl generic 3

midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10mg)

generic 1

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (tab 1 mg, tab 2 mg,tab 4 mg, tab 8 mg)

generic 1

phenoxybenzamine hcl generic 3

prazosin hcl (cap 1 mg, cap 2 mg, cap 5mg)


ANGIOTENSIN II RECEPTOR ANTAGONISTS

BENICAR (TAB 5 MG, TAB 20 MG, TAB 40MG)

BRAND 2ST

MD 1 per day

candesartan cilexetil (tab 4 mg, tab 8 mg,tab 16 mg, tab 32 mg)




EDARBI (TAB 40 MG, TAB 80 MG) BRAND 3ST

MD 1 per day

eprosartan mesylate generic 1 MD 1 per day

irbesartan (tab 75 mg, tab 150 mg, tab 300mg)


losartan potassium (tab 25 mg, tab 50 mg,tab 100 mg)


telmisartan (tab 20 mg, tab 40 mg, tab 80mg)


TEVETEN TAB 400 MG BRAND 3ST

MD 2 per day

valsartan (tab 40 mg, tab 80 mg, tab 160mg, tab 320 mg)


ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (tab 5 mg, tab 10 mg, tab 20mg, tab 40 mg)

generic 1

captopril (tab 12.5 mg, tab 25 mg, tab 50mg, tab 100 mg)

generic 1

enalapril maleate (tab 2.5 mg, tab 5 mg,tab 10 mg, tab 20 mg)

generic 1

fosinopril sodium (tab 10 mg, tab 20 mg,tab 40 mg)

generic 1

lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg,tab 20 mg, tab 30 mg, tab 40 mg)

generic 1

moexipril hcl (tab 7.5 mg, tab 15 mg) generic 1

perindopril erbumine (tab 2 mg, tab 4 mg,tab 8 mg)

generic 1

quinapril hcl (tab 5 mg, tab 10 mg, tab 20mg, tab 40 mg)

generic 1

ramipril (cap 1.25 mg, cap 2.5 mg, cap 5mg, cap 10 mg)

generic 1



trandolapril (tab 1 mg, tab 2 mg, tab 4 mg) generic 1

ANTIARRHYTHMICS

amiodarone hcl (inj 150 mg/3ml (50mg/ml), tab 100 mg, tab 200 mg, tab 400mg)

generic 1

disopyramide phosphate (cap 100 mg, cap150 mg)

generic 1

flecainide acetate (tab 50 mg, tab 100 mg,tab 150 mg)

generic 1

mexiletine hcl (cap 150 mg, cap 200 mg,cap 250 mg)

generic 1

MULTAQ BRAND 3

PROCAINAMIDE HCL SOLUTION 500MG/ML

BRAND 1

propafenone hcl (cap sr 12hr 225 mg, capsr 12hr 325 mg, cap sr 12hr 425 mg, tab150 mg, tab 225 mg, tab 300 mg)

generic 1

quinidine sulfate (tab 200 mg, tab 300 mg,tab cr 300 mg)

generic 1

sotalol hcl (tab 80 mg, tab 120 mg, tab 160mg)


sotalol hcl tab 240 mg generic 1

TIKOSYN (CAP 125 MCG, CAP 250 MCG,CAP 500 MCG)

BRAND 2

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (cap 200 mg, cap 400 mg) generic 1

atenolol (tab 25 mg, tab 50 mg, tab 100mg)

generic 1

betaxolol hcl (tab 10 mg, tab 20 mg) generic 1

bisoprolol fumarate (tab 5 mg, tab 10 mg) generic 1

BYSTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10MG)




BYSTOLIC TAB 20 MG BRAND 2 MD 2 per day

carvedilol (tab 3.125 mg, tab 6.25 mg, tab12.5 mg, tab 25 mg)

generic 1

labetalol hcl (iv soln 5 mg/ml, tab 100 mg,tab 200 mg, tab 300 mg)

generic 1

LEVATOL BRAND 3

metoprolol succinate (tab 24hr 100 mg, tab24hr 100 mg (tartrate equiv), tab 24hr 200mg, tab 24hr 200 mg (tartrate equiv), tab24hr 25 mg, tab 24hr 25 mg (tartrateequiv), tab 24hr 50 mg (tartrate equiv))

generic 1

metoprolol tartrate (inj 1 mg/ml, tab 25mg, tab 50 mg, tab 100 mg)

generic 1

nadolol (tab 20 mg, tab 40 mg, tab 80 mg) generic 1

pindolol (tab 5 mg, tab 10 mg) generic 1

propranolol hcl (cap sr 24hr 120 mg, cap sr24hr 160 mg, cap sr 24hr 60 mg, cap sr24hr 80 mg, inj 1 mg/ml, oral soln 20mg/5ml, oral soln 40 mg/5ml, tab 10 mg,tab 20 mg, tab 40 mg, tab 60 mg, tab 80mg)

generic 1

timolol maleate (tab 5 mg, tab 10 mg, tab20 mg)

generic 1

CALCIUM CHANNEL BLOCKING AGENTS

amlodipine besylate (tab 2.5 mg, tab 5 mg,tab 10 mg)

generic 1

diltiazem hcl (cap sr 12hr 120 mg, cap sr12hr 60 mg, cap sr 12hr 90 mg, cap sr 24hr120 mg, cap sr 24hr 180 mg, cap sr 24hr240 mg, iv soln 50 mg/10ml (5 mg/ml),recon soln 100 mg, tab 30 mg, tab 60 mg,tab 90 mg, tab 120 mg)

generic 1



diltiazem hcl coated beads (beads cap 24hr120 mg, beads cap 24hr 180 mg, beads cap24hr 240 mg, beads cap 24hr 300 mg,beads cap 24hr 360 mg, beads tab 24hr180 mg, beads tab 24hr 240 mg, beads tab24hr 300 mg, beads tab 24hr 360 mg,beads tab 24hr 420 mg)

generic 1

diltiazem hcl extended release beads(beads cap 24hr 120 mg, beads cap 24hr180 mg, beads cap 24hr 240 mg, beads cap24hr 300 mg, beads cap 24hr 360 mg)

generic 1

felodipine (tab 24hr 10 mg, tab 24hr 2.5mg, tab 24hr 5 mg)

generic 1

isradipine (cap 2.5 mg, cap 5 mg) generic 1

nicardipine hcl (cap 20 mg, cap 30 mg, ivsoln 2.5 mg/ml)

generic 1

nifedipine (cap 10 mg, cap 20 mg, tab sr24hr 30 mg, tab sr 24hr 60 mg, tab sr 24hr90 mg, tab sr 24hr osmotic release 30 mg,tab sr 24hr osmotic release 60 mg, tab sr24hr osmotic release 90 mg)

generic 1

nimodipine generic 1

nisoldipine (tab 24hr 17 mg, tab 24hr 20mg, tab 24hr 30 mg, tab 24hr 34 mg, tab24hr 40 mg, tab 24hr 8.5 mg)

generic 1

verapamil hcl (cap sr 24hr 100 mg, cap sr24hr 120 mg, cap sr 24hr 180 mg, cap sr24hr 200 mg, cap sr 24hr 240 mg, cap sr24hr 300 mg, iv soln 2.5 mg/ml, tab 40 mg,tab 80 mg, tab 120 mg, tab cr 120 mg, tabcr 180 mg, tab cr 240 mg)

generic 1

CARDIOVASCULAR AGENTS, OTHER

amiloride & hydrochlorothiazide generic 1

amlodipine besylate-benazepril hcl (cap2.5-10 mg, cap 5-10 mg, cap 5-20 mg, cap5-40 mg, cap 10-20 mg, cap 10-40 mg)

generic 1



atenolol & chlorthalidone (tab 50-25 mg,tab 100-25 mg)

generic 1

BIDIL BRAND 2

captopril & hydrochlorothiazide (tab 25-15mg, tab 25-25 mg, tab 50-15 mg, tab 50-25mg)

generic 1

digoxin (inj 0.25 mg/ml, oral soln 0.05mg/ml, tab 125 mcg (0.125 mg), tab 250mcg (0.25 mg))

generic 1

enalapril maleate & hydrochlorothiazide(tab 5-12.5 mg, tab 10-25 mg)

generic 1

LANOXIN (SOLUTION 0.25 MG/ML, TAB62.5 MCG, TAB 125 MCG, TAB 187.5 MCG,TAB 250 MCG)

BRAND 2

LANOXIN PEDIATRIC BRAND 2

lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 20-12.5 mg, tab 20-25 mg)

generic 1

losartan potassium & hydrochlorothiazide(tab 50-12.5 mg, tab 100-12.5 mg, tab 100-25 mg)


pentoxifylline tab cr 400 mg generic 1 MD 3 per day

RANEXA TAB ER 12H 500 MG BRAND 2 MD 3 per day

spironolactone & hydrochlorothiazide generic 1

TEKTURNA TAB 150 MG BRAND 2 MD 8 per day

TEKTURNA TAB 300 MG BRAND 2 MD 1 per day

triamterene & hydrochlorothiazide (cap37.5-25 mg, tab 37.5-25 mg, tab 75-50 mg)

generic 1

valsartan-hydrochlorothiazide (tab 80-12.5mg, tab 160-12.5 mg, tab 160-25 mg, tab320-12.5 mg, tab 320-25 mg)

generic 1



DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide cap sr 12hr 500 mg generic 1 MD 2 per day

acetazolamide sodium generic 1

acetazolamide tab 125 mg generic 1 MD 8 per day

acetazolamide tab 250 mg generic 1 MD 4 per day

DIURETICS, LOOP

bumetanide (tab 0.5 mg, tab 1 mg, tab 2mg)


bumetanide inj 0.25 mg/ml generic 1

EDECRIN BRAND 3 MD 16 per day

furosemide (inj 10 mg/ml, oral soln 8mg/ml, oral soln 10 mg/ml, tab 20 mg, tab40 mg, tab 80 mg)

generic 1

torsemide (iv soln 20 mg/2ml (10 mg/ml),tab 5 mg, tab 10 mg, tab 20 mg, tab 100mg)

generic 1

DIURETICS, POTASSIUM-SPARING

amiloride hcl tab 5 mg generic 1

DYRENIUM (CAP 50 MG, CAP 100 MG) BRAND 3 MD 3 per day

eplerenone (tab 25 mg, tab 50 mg) generic 1

spironolactone (tab 25 mg, tab 50 mg, tab100 mg)

generic 1

DIURETICS, THIAZIDE

chlorothiazide (tab 250 mg, tab 500 mg) generic 1

chlorthalidone (tab 25 mg, tab 50 mg) generic 1

hydrochlorothiazide (cap 12.5 mg, tab 12.5mg, tab 25 mg, tab 50 mg)


indapamide tab 1.25 mg generic 1 MD 1 per day



indapamide tab 2.5 mg generic 1 MD 2 per day

methyclothiazide tab 5 mg generic 1

metolazone (tab 2.5 mg, tab 5 mg, tab 10mg)


DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (tab 48 mg, tab 54 mg, tab 145mg, tab 160 mg)


fenofibrate micronized (cap 67 mg, cap 134mg, cap 200 mg)


gemfibrozil tab 600 mg generic 1 MD 2 per day

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV (TAB ER 24H 20 MG, TAB ER24H 40 MG, TAB ER 24H 60 MG)

BRAND 3ST

MD 1 per day

atorvastatin calcium (tab 10 mg, tab 20mg, tab 40 mg, tab 80 mg)


CRESTOR (TAB 5 MG, TAB 10 MG, TAB 20MG, TAB 40 MG)

BRAND 2ST

MD 1 per day

fluvastatin sodium cap 20 mg generic 3 MD 1 per day

fluvastatin sodium cap 40 mg generic 3 MD 2 per day

LIVALO (TAB 1 MG, TAB 2 MG, TAB 4 MG) BRAND 3ST

MD 1 per day

lovastatin (tab 10 mg, tab 20 mg) generic 1 MD 1 per day

lovastatin tab 40 mg generic 1 MD 2 per day

pravastatin sodium (tab 10 mg, tab 20 mg,tab 40 mg, tab 80 mg)


simvastatin (tab 5 mg, tab 10 mg, tab 20mg, tab 40 mg, tab 80 mg)




DYSLIPIDEMICS, OTHER

ADVICOR (TAB ER 24H 1000-40 MG, TAB ER24H 500-20 MG, TAB ER 24H 750-20 MG)


ADVICOR TAB ER 24H 1000-20 MG BRAND 3PAMD 2 per day

cholestyramine light powder 4 gm/dose generic 1 MD 720 / 30 DAYS

cholestyramine light powder packets 4 gm generic 1 MD 6 per day

cholestyramine powder 4 gm/dose generic 1 MD 180 / 30 DAYS

cholestyramine powder packets 4 gm generic 1 MD 6 per day

colestipol hcl (granule packets 5 gm,granules 5 gm)


colestipol hcl tab 1 gm generic 1 MD 16 per day

niacin (antihyperlipidemic) (tab 500 mg,tab 750 mg, tab 1000 mg)


omega-3-acid ethyl esters generic 1ST

MD 4 per day

SIMCOR (TAB ER 24H 1000-40 MG, TAB ER24H 500-20 MG, TAB ER 24H 500-40 MG,TAB ER 24H 750-20 MG)


SIMCOR TAB ER 24H 1000-20 MG BRAND 2PAMD 2 per day

VYTORIN (TAB 10-10 MG, TAB 10-20 MG,TAB 10-40 MG, TAB 10-80 MG)

BRAND 2ST

MD 1 per day

WELCHOL PACKET 3.75 GM BRAND 2 MD 1 per day

WELCHOL TAB 625 MG BRAND 2 MD 7 per day

ZETIA BRAND 2ST

MD 1 per day



VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (inj 20 mg/ml, tab 10 mg,tab 25 mg, tab 50 mg, tab 100 mg)

generic 1

minoxidil (tab 2.5 mg, tab 10 mg) generic 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isosorbide dinitrate (tab 5 mg, tab 10 mg,tab 20 mg, tab 30 mg, tab cr 40 mg)

generic 1

isosorbide mononitrate (tab 20 mg, tab sr24hr 120 mg, tab sr 24hr 30 mg, tab sr24hr 60 mg)

generic 1

NITRO-BID BRAND 3

nitroglycerin (iv soln 5 mg/ml, td patch24hr 0.1 mg/hr, td patch 24hr 0.2 mg/hr,td patch 24hr 0.4 mg/hr, td patch 24hr 0.6mg/hr)

generic 1

NITROSTAT (SL TAB 0.3 MG, SL TAB 0.4MG, SL TAB 0.6 MG)

BRAND 2

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine-dextroamphetamine (cap24hr 10 mg, cap 24hr 15 mg, cap 24hr 5mg)

generic 1

AL 6 to 18 yrs oldMD 1 per day

C PA required for age> 18

amphetamine-dextroamphetamine (cap24hr 20 mg, cap 24hr 25 mg, cap 24hr 30mg)

generic 1



amphetamine-dextroamphetamine (tab 5mg, tab 7.5 mg, tab 10 mg, tab 12.5 mg,tab 15 mg, tab 20 mg, tab 30 mg)


MD 3 per day

dextroamphetamine sulfate (cap 24hr 10mg, cap 24hr 15 mg)

generic 1





dextroamphetamine sulfate (tab 5 mg, tab10 mg)


MD 4 per day

dextroamphetamine sulfate cap sr 24hr 5mg

generic 1



methamphetamine hcl generic 3AL At least 6 yrs old

MD 5 per day

VYVANSE (CAP 20 MG, CAP 30 MG, CAP 40MG, CAP 50 MG, CAP 60 MG, CAP 70 MG)

BRAND 2



ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

dexmethylphenidate hcl (tab 2.5 mg, tab 5mg)


dexmethylphenidate hcl tab 10 mg generic 1AL At least 6 yrs old

MD 5 per day

guanfacine hcl (adhd) (tab 24hr 1 mg, tab24hr 2 mg, tab 24hr 3 mg, tab 24hr 4 mg)

generic 1

PA


methylphenidate hcl (cap cr 10 mg (cd),cap cr 20 mg (cd), cap cr 30 mg (cd), cap cr40 mg (cd), cap cr 50 mg (cd), cap cr 60 mg(cd), tab sa osm 18 mg, tab sa osm 27 mg)

generic 1



methylphenidate hcl (cap sr 24hr 20 mg(la), tab cr 10 mg)

generic 1



methylphenidate hcl (cap sr 24hr 30 mg(la), cap sr 24hr 40 mg (la), tab sa osm 36mg, tab sa osm 54 mg)

generic 1





methylphenidate hcl (soln 5 mg/5ml, soln10 mg/5ml)


MD 900 / 30 DAYS

methylphenidate hcl (tab 24hr 27 mg, tab24hr 36 mg, tab 24hr 54 mg)

generic 1

methylphenidate hcl (tab 5 mg, tab 10 mg,tab 20 mg)


MD 3 per day

METHYLPHENIDATE HCL ER (ER TAB ER 24H27 MG, ER TAB ER 24H 36 MG, ER TAB ER24H 54 MG)

BRAND 1 AL 6 to 18 yrs old

METHYLPHENIDATE HCL ER TAB ER 24H 18MG

BRAND 1 C PA required for age> 18

methylphenidate hcl tab cr 20 mg generic 1

PA



methylphenidate hcl tab sr 24hr 18 mg generic 1 C PA required for age> 18

STRATTERA (CAP 10 MG, CAP 18 MG, CAP25 MG, CAP 40 MG)

BRAND 2

PA


STRATTERA (CAP 60 MG, CAP 80 MG, CAP100 MG)

BRAND 2

PA


CENTRAL NERVOUS SYSTEM, OTHER

butalbital-acetaminophen-caffeine (cap 50-300-40 mg, cap 50-325-40 mg, cap 50-500-40 mg, tab 50-325-40 mg, tab 50-500-40mg)

generic 1

butalbital-aspirin-caffeine cap 50-325-40mg

generic 1

DOLGIC PLUS BRAND 2



HORIZANT TAB ER 600 MG BRAND 3

NUEDEXTA BRAND 3

riluzole generic 3

tetrabenazine (tab 12.5 mg, tab 25 mg) generic 4 PA

FIBROMYALGIA AGENTS

duloxetine hcl (cap 20 mg, cap 30 mg, cap60 mg)


LYRICA (CAP 225 MG, CAP 300 MG) BRAND 2PAMD 2 per day

LYRICA (CAP 25 MG, CAP 50 MG, CAP 75MG, CAP 100 MG, CAP 150 MG, CAP 200MG)


LYRICA SOLUTION 20 MG/ML BRAND 2PAMD 900 / 30 DAYS

SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB50 MG, TAB 100 MG)


SAVELLA TITRATION PACK BRAND 2 PA

MULTIPLE SCLEROSIS AGENTS

AMPYRA BRAND 4 PA

AVONEX BRAND 4 PA

AVONEX PEN BRAND 4 PA

AVONEX PREFILLED BRAND 4 PA

BETASERON BRAND 4 PA

COPAXONE SOLN PRSYR 20 MG/ML BRAND 4 PA

EXTAVIA BRAND 4 PA

GILENYA BRAND 4 PA

glatiramer acetate generic 4 PA



REBIF (SOLN PRSYR 22 MCG/0.5ML, SOLNPRSYR 44 MCG/0.5ML)

BRAND 4 PA

REBIF REBIDOSE (SOLN A-INJ 22MCG/0.5ML, SOLN A-INJ 44 MCG/0.5ML)

BRAND 4 PA

REBIF REBIDOSE TITRATION PACK BRAND 4 PA

REBIF TITRATION PACK BRAND 4 PA

TYSABRI BRAND 4 PA

ZINBRYTA BRAND 4 PA

DENTAL AND ORAL AGENTS

ARESTIN BRAND 3 PA

cevimeline hcl generic 1

chlorhexidine gluconate (mouth-throat) generic 1

KEPIVANCE BRAND 4

pilocarpine hcl (oral) (tab 5 mg, tab 7.5 mg) generic 1

stannous fluoride conc 0.63% generic 0

DERMATOLOGICAL AGENTS

ABSORICA (CAP 10 MG, CAP 20 MG, CAP30 MG, CAP 40 MG)

BRAND 3PA


acitretin (cap 10 mg, cap 17.5 mg) generic 1 MD 1 per day

acitretin cap 25 mg generic 1 MD 2 per day

adapalene (cream, gel) generic 1

PA

ST


adapalene gel 0.3% generic 1ST


ADAPALENE LOTION 0.1 % BRAND 2ST




AMEVIVE BRAND 4 PA

AZELEX BRAND 3ST


benzoyl peroxide (foam 5.3%, foam 9.8%,gel 5%, gel 10%, liq 7%, liq 10%, lotion 6%)


benzoyl peroxide liq 4% generic 3 AL At least 12 yrs old

benzoyl peroxide-erythromycin generic 1

PA


MPL 1 / claim(s)

calcipotriene (cream, soln (50 mcg/ml)) generic 1 MPL 1 / claim

calcipotriene oint 0.005% generic 1 MPL 1 / claim(s)

calcipotriene-betamethasone dipropionate generic 1 ST

calcitriol (topical) generic 1 MPL 1 / claim(s)

clindamycin phosphate swab 1% generic 1 AL At least 12 yrs old

clindamycin phosphate-benzoyl peroxide generic 1PA


clindamycin phosphate-benzoyl peroxide(refrigerate)

generic 1PA


clotrimazole w/ betamethasone (w/ cream,w/ lotion)

generic 1

CORTISPORIN (CREAM 3.5-10000-0.5,OINTMENT 1 %)

BRAND 2

diclofenac sodium (actinic keratoses) generic 1 MPL 1 / claim

diclofenac sodium gel 1% generic 1

DIFFERIN LOTION 0.1 % BRAND 2ST


ELIDEL BRAND 2

PA


MPL 1 / 30 days



EPIDUO BRAND 3ST


FINACEA GEL 15 % BRAND 2

finasteride (alopecia) generic 1

fluorouracil (topical) (cream, soln) generic 1 MPL 1 / claim(s)

fluorouracil soln 2% generic 1 MPL 1 / claim

hydrocortisone (topical) (cream 1%, cream2.5%, lotion 2.5%, oint 1%, oint 2.5%)

generic 1

imiquimod cream 5% generic 1 MD 48 / 180 DAYS

isotretinoin (cap 10 mg, cap 20 mg, cap 30mg, cap 40 mg)

generic 3PA


lactic acid (ammonium lactate) (cream,lotion)

generic 1

LAVOCLEN-4 CREAMY WASH BRAND 3 AL At least 12 yrs old

lidocaine (oint, patch) generic 1

lidocaine hcl soln 4% generic 1

methoxsalen rapid generic 1 MD 4 per day

OXSORALEN BRAND 2

PICATO (GEL 0.015 %, GEL 0.05 %) BRAND 2

podofilox generic 1

PRUDOXIN BRAND 3

RECTIV BRAND 3

REGRANEX BRAND 3 PA

SANTYL BRAND 3

selenium sulfide generic 1 MPL 1 / claim(s)

STELARA (SOLN PRSYR 45 MG/0.5ML, SOLNPRSYR 90 MG/ML)

BRAND 4 PA

sulfacetamide sodium (acne) generic 1AL At least 12 yrs old

MPL 1 / claim(s)



sulfacetamide sodium w/ sulfur (w/ cream10-5%, w/ wash 9-4.5%)

generic 1ST


sulfacetamide sodium w/ sulfur emulsion10-5%


SYNERA BRAND 3

TACLONEX SUSPENSION 0.005-0.064 % BRAND 3 ST

tacrolimus (topical) (oint 0.03%, oint 0.1%) generic 1AL At least 2 yrs old

MPL 1 / 30 days

TAZORAC (CREAM 0.05 %, CREAM 0.1 %,GEL 0.05 %, GEL 0.1 %)

BRAND 2

tretinoin (cream 0.025%, cream 0.05%,cream 0.1%, gel 0.01%, gel 0.025%)


tretinoin microsphere gel 0.1% generic 1PA


VECTICAL BRAND 1 MPL 1 / claim(s)

VELTIN BRAND 3ST


VEREGEN BRAND 3

VOLTAREN GEL 1 % BRAND 2

ZIANA BRAND 3

ZONALON BRAND 3

ENZYME REPLACEMENT/MODIFIERS

ADAGEN BRAND 4 PA

ALDURAZYME BRAND 4 PA

BUPHENYL TAB 500 MG BRAND 3

CARBAGLU BRAND 4

CEREZYME (RECON SOLN 200, RECONSOLN 400)

BRAND 4 PA



CREON (CP DR PART 6000, CP DR PART12000, CP DR PART 24000)

BRAND 2

CYSTADANE BRAND 4 PA

ELAPRASE BRAND 4 PA

ELELYSO BRAND 4 PA

FABRAZYME RECON SOLN 35 MG BRAND 4 PA

KUVAN TAB SOL 100 MG BRAND 4 PA

LUMIZYME BRAND 4 PA

MYOZYME BRAND 4 PA

NAGLAZYME BRAND 4 PA

ORFADIN (CAP 2 MG, CAP 5 MG, CAP 10MG)

BRAND 4 PA

PANCREAZE (CP DR PART 4200, CP DRPART 10500, CP DR PART 16800, CP DRPART 21000)

BRAND 2

pancrelipase (lipase-protease-amylase) generic 1

sodium phenylbutyrate generic 3

SUCRAID BRAND 3

VPRIV BRAND 4 PA

ZAVESCA BRAND 4 PA

ZENPEP (CP DR PART 3000-10000, CP DRPART 5000, CP DR PART 10000, CP DRPART 15000, CP DR PART 20000, CP DRPART 25000)

BRAND 2

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

atropine sulfate (inj 0.1 mg/ml, solution0.05 mg/ml)

generic 1

CANTIL BRAND 3



chlordiazepoxide hcl-clidinium bromide generic 1

dicyclomine hcl (cap 10 mg, oral soln 10mg/5ml, tab 20 mg)

generic 1

glycopyrrolate (inj 4 mg/20ml (0.2 mg/ml),tab 1 mg, tab 2 mg)

generic 1

methscopolamine bromide (tab 2.5 mg, tab5 mg)

generic 1

GASTROINTESTINAL AGENTS, OTHER

CHOLBAM (CAP 50 MG, CAP 250 MG) BRAND 4 PA

diphenoxylate w/ atropine (w/ liq mg/5ml,w/ tab mg)

generic 1

ENTEREG BRAND 3 PA

loperamide hcl cap 2 mg generic 1

MOTOFEN BRAND 3

RELISTOR (KIT 12 MG/0.6ML, SOLUTION 8MG/0.4ML, SOLUTION 12 MG/0.6ML)

BRAND 2 PA

ursodiol (cap 300 mg, tab 250 mg, tab 500mg)

generic 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine (tab 200 mg, tab 300 mg, tab400 mg, tab 800 mg)

generic 1

cimetidine hcl generic 1 MD 600 / 30 DAYS

famotidine (inj 20 mg/2ml, inj 40 mg/4ml,inj 200 mg/20ml, inj 500 mg/50ml, tab 20mg, tab 40 mg)

generic 1

famotidine for susp 40 mg/5ml generic 1 MD 300 / 30 DAYS

FAMOTIDINE PREMIXED BRAND 1

nizatidine (cap 150 mg, cap 300 mg) generic 1

nizatidine oral soln 15 mg/ml generic 1 MD 600 / 30 DAYS



ranitidine hcl (cap 150 mg, cap 300 mg, inj150 mg/6ml (25 mg/ml), tab 150 mg, tab300 mg)

generic 1

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) generic 1 MD 600 / 30 DAYS

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (tab 0.5 mg, tab 1 mg) generic 1

AMITIZA (CAP 8 MCG, CAP 24 MCG) BRAND 2PAMD 2 per day

LAXATIVES

lactulose generic 1

lactulose (encephalopathy) generic 1

MOVIPREP BRAND 2

OSMOPREP BRAND 3

peg 3350-kcl-na bicarb-nacl-na sulfate forsoln 236 gm

generic 0

PREPOPIK BRAND 3

SUPREP BOWEL PREP BRAND 0

VISICOL BRAND 3 MD 40 / 180 DAYS

PROTECTANTS

misoprostol (tab 100 mcg, tab 200 mcg) generic 1 MD 4 per day

sucralfate tab 1 gm generic 1 MD 4 per day

PROTON PUMP INHIBITORS

DEXILANT (CAP DR 30 MG, CAP DR 60 MG) BRAND 3ST

MD 1 per day

esomeprazole magnesium cap delayedrelease 20 mg (base eq)

generic 3ST

MD 2 per day

esomeprazole magnesium cap delayedrelease 40 mg (base eq)

generic 3ST

MD 1 per day



lansoprazole cap delayed release 15 mg generic 1 MD 1 per day

lansoprazole cap delayed release 30 mg generic 1

NEXIUM (CAP DR 40 MG, PACKET 2.5 MG,PACKET 5 MG, PACKET 10 MG, PACKET 20MG, PACKET 40 MG)

BRAND 3ST

MD 1 per day

NEXIUM CAP DR 20 MG BRAND 3ST

MD 2 per day

omeprazole (cap 10 mg, cap 20 mg, cap 40mg)


omeprazole-sodium bicarbonate cap 20-1100 mg


pantoprazole sodium ec tab 20 mg (baseequiv)


pantoprazole sodium ec tab 40 mg (baseequiv)

generic 1

rabeprazole sodium generic 1 MD 1 per day

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

ENABLEX (TAB ER 24H 15 MG, TAB ER 24H7.5 MG)


flavoxate hcl generic 1

MYRBETRIQ (TAB ER 24H 25 MG, TAB ER24H 50 MG)

BRAND 3 PA

oxybutynin chloride (syrup 5 mg/5ml, tab 5mg, tab sr 24hr 10 mg, tab sr 24hr 15 mg,tab sr 24hr 5 mg)

generic 1

tolterodine tartrate (cap 24hr 2 mg, cap24hr 4 mg)


tolterodine tartrate (tab 1 mg, tab 2 mg) generic 1

TOVIAZ (TAB ER 24H 4 MG, TAB ER 24H 8MG)




trospium chloride cap sr 24hr 60 mg generic 1 MD 1 per day

trospium chloride tab 20 mg generic 1

VESICARE (TAB 5 MG, TAB 10 MG) BRAND 2PAMD 1 per day

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl generic 1 MD 1 per day

AVODART BRAND 2PAMD 1 per day

CIALIS TAB 5 MG BRAND 3PAMD 1 per day

finasteride tab 5 mg generic 1

RAPAFLO (CAP 4 MG, CAP 8 MG) BRAND 2

tamsulosin hcl generic 1

terazosin hcl (cap 1 mg, cap 2 mg, cap 5mg, cap 10 mg)

generic 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride (tab 5 mg, tab 10 mg,tab 25 mg, tab 50 mg)


CUPRIMINE BRAND 3

CYSTAGON (CAP 50 MG, CAP 150 MG) BRAND 3 PA

ELMIRON BRAND 2

glycine irrigation soln 1.5% generic 1

phenazopyridine hcl (tab 100 mg, tab 200mg)

generic 1

potassium citrate tab cr 10 meq (1080 mg) generic 1

RESECTISOL BRAND 1

sodium chloride (gu irrigant) generic 1

sodium citrate & citric acid generic 1



SORBITOL (SOLUTION 3 %, SOLUTION 3.3%)

BRAND 1

SORBITOL-MANNITOL BRAND 1

STENDRA (TAB 50 MG, TAB 100 MG, TAB200 MG)

BRAND 3 MD 4 / MONTH(S)

PHOSPHATE BINDERS

calcium acetate (phosphate binder) (cap667 mg (169 mg ca), tab 667 mg)

generic 1

FOSRENOL (CHEW TAB 500 MG, CHEW TAB750 MG, CHEW TAB 1000 MG)

BRAND 2

PHOSLYRA BRAND 2

RENAGEL (TAB 400 MG, TAB 800 MG) BRAND 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

A-HYDROCORT BRAND 1

alclometasone dipropionate (cream, oint) generic 1

amcinonide (lotion, oint) generic 3

amcinonide cream 0.1% generic 1

betamethasone dipropionate (topical)(cream, lotion, oint)

generic 1

betamethasone dipropionate augmented(cream, lotion, oint)

generic 1

betamethasone valerate (aerosol foam0.12%, cream 0.1%, lotion 0.1%, oint 0.1%)

generic 1

clobetasol propionate (cream, foam, gel,oint, soln)

generic 1

clobetasol propionate emollient base generic 1

clocortolone pivalate generic 3

CLODERM BRAND 3

CLODERM PUMP BRAND 3



CORDRAN (CREAM 0.05 %, LOTION 0.05 %,TAPE 4 MCG/SQCM)

BRAND 3

cortisone acetate tab 25 mg generic 1

DEPO-MEDROL SUSPENSION 20 MG/ML BRAND 3

desonide (cream, lotion, oint) generic 1

desoximetasone (cream 0.25%, gel 0.05%,oint 0.25%)

generic 1

dexamethasone (elixir 0.5 mg/5ml, soln 0.5mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1mg, tab 1.5 mg, tab 2 mg, tab 4 mg, tab 6mg)

generic 1

DEXAMETHASONE INTENSOL BRAND 1

dexamethasone sodium phosphate (inj 4mg/ml, inj 20 mg/5ml, inj 120 mg/30ml)

generic 1

diflorasone diacetate cream 0.05% generic 2

diflorasone diacetate oint 0.05% generic 1

fludrocortisone acetate tab 0.1 mg generic 1

fluocinolone acetonide (cream 0.01%,cream 0.025%, oil 0.01% (scalp oil), oint0.025%, soln 0.01%)

generic 1

fluocinonide (cream, gel, oint, soln) generic 1

fluocinonide emulsified base generic 1

fluticasone propionate (cream 0.05%, oint0.005%)

generic 1

halobetasol propionate (cream, oint) generic 1

HALOG (CREAM 0.1 %, OINTMENT 0.1 %) BRAND 3

hydrocortisone (tab 5 mg, tab 10 mg, tab20 mg)

generic 1

hydrocortisone acetate (rectal) (suppos 25mg, suppos 30 mg)

generic 1

hydrocortisone butyrate (cream, oint, soln) generic 1



hydrocortisone valerate (cream, oint) generic 1

KENALOG SUSPENSION 40 MG/ML BRAND 3

MEDROL TAB 2 MG BRAND 3

methylprednisolone (tab 4 mg, tab 4 mgdose pack, tab 8 mg, tab 16 mg, tab 32 mg,tab therapy pack 4 mg (21))

generic 1

methylprednisolone acetate (inj susp 40mg/ml, inj susp 80 mg/ml)

generic 1

methylprednisolone sod succ (inj 40 mg, inj125 mg, inj 500 mg, inj 1000 mg)

generic 1

MILLIPRED (SOLUTION 10 MG/5ML, TAB 5MG)

BRAND 3

MILLIPRED DP (TAB THPK 5 MG (21), TABTHPK 5 MG (48))

BRAND 3

MILLIPRED DP 12-DAY BRAND 3

mometasone furoate (cream, oint, solution(lotion))

generic 1

ORAPRED ODT (ODT TAB DISP 10 MG, ODTTAB DISP 15 MG, ODT TAB DISP 30 MG)

BRAND 3

prednicarbate (cream, oint) generic 1

prednisolone sodium phosphate (sodphosph oral soln 6.7 mg/5ml (5 mg/5mlbase), sod phosphate oral soln 15 mg/5ml(base equiv), sodium phosphate solution 25mg/5ml)

generic 1

prednisolone sodium phosphate (tab 10mg, tab 15 mg, tab 30 mg)

generic 3

prednisolone syrup 15 mg/5ml (uspsolution equivalent)

generic 1

prednisone (oral soln 5 mg/5ml, tab 1 mg,tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20mg, tab 50 mg)

generic 1



PSORCON BRAND 2

SOLU-CORTEF RECON SOLN 250 MG BRAND 3

SOLU-MEDROL RECON SOLN 2 GM BRAND 3

triamcinolone acetonide (mouth) generic 1

triamcinolone acetonide (topical) (cream0.025%, cream 0.1%, lotion 0.025%, lotion0.1%, oint 0.025%, oint 0.1%)

generic 1

triamcinolone acetonide cream 0.5% generic 1

triamcinolone acetonide oint 0.5% generic 2

VERIPRED 20 BRAND 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

chorionic gonadotropin for inj 10000 unit generic 4 PA

desmopressin acetate inj 4 mcg/ml generic 1 PA

desmopressin acetate spray refrigerated generic 1

desmopressin acetate tab 0.1 mg generic 1PAMD 6 per day

desmopressin acetate tab 0.2 mg generic 1PAMD 8 per day

GENOTROPIN MINIQUICK RECON SOLN 0.2MG

BRAND 4 PA

GENOTROPIN RECON SOLN 5 MG BRAND 4 PA

HUMATROPE (RECON SOLN 5 MG, RECONSOLN 6 MG, RECON SOLN 12 MG, RECONSOLN 24 MG)

BRAND 4 PA

INCRELEX BRAND 4 PA

NORDITROPIN (SOLUTION 5 MG/1.5ML,SOLUTION 15 MG/1.5ML)

BRAND 4 PA

NORDITROPIN FLEXPRO (SOLUTION 5MG/1.5ML, SOLUTION 10 MG/1.5ML,SOLUTION 15 MG/1.5ML)

BRAND 4 PA



NORDITROPIN NORDIFLEX PEN (PENSOLUTION 5 MG/1.5ML, PEN SOLUTION 10MG/1.5ML, PEN SOLUTION 15 MG/1.5ML)

BRAND 4 PA

NUTROPIN BRAND 4 PA

NUTROPIN AQ BRAND 4 PA

NUTROPIN AQ NUSPIN 10 BRAND 4 PA

NUTROPIN AQ PEN SOLUTION 10 MG/2ML BRAND 4 PA

OMNITROPE (SOLUTION 5 MG/1.5ML,SOLUTION 10 MG/1.5ML)

BRAND 4 PA

SAIZEN (RECON SOLN 5 MG, RECON SOLN8.8 MG)

BRAND 4 PA

SAIZEN CLICK.EASY BRAND 4 PA

SEROSTIM (RECON SOLN 4 MG, RECONSOLN 5 MG, RECON SOLN 6 MG)

BRAND 4 PA

STIMATE BRAND 4 PA

TEV-TROPIN BRAND 4 PA

ZOMACTON (RECON SOLN 5 MG, RECONSOLN 10 MG)

BRAND 4 PA

ZORBTIVE BRAND 4 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 BRAND 3

oxandrolone (tab 2.5 mg, tab 10 mg) generic 1

ANDROGENS

ANDRODERM (PATCH 24HR 2 MG/24HR,PATCH 24HR 4 MG/24HR)


ANDROXY BRAND 3 PA



danazol (cap 50 mg, cap 100 mg, cap 200mg)

generic 1 PA

METHITEST BRAND 3 PA

testosterone cypionate (j oil 100 mg/ml, joil 200 mg/ml)

generic 1

testosterone enanthate im inj in oil 200mg/ml

generic 1

ESTROGENS

ALORA (PATCH TW 0.025 MG/24HR,PATCH TW 0.05 MG/24HR, PATCH TW0.075 MG/24HR, PATCH TW 0.1 MG/24HR)

BRAND 3 GL Female

BEYAZ BRAND 0

CENESTIN (TAB 0.3 MG, TAB 0.45 MG, TAB0.625 MG, TAB 0.9 MG, TAB 1.25 MG)

BRAND 3 GL Female

CLIMARA PRO BRAND 3 GL Female

DEPO-ESTRADIOL BRAND 3 GL Female

desogestrel-ethinyl estradiol (triphasic) generic 0

DESOGESTREL-ETHINYL ESTRADIOL TAB0.15-0.02/0.01 MG (AZURETTE, KARIVA,PIMTREA, VIORELE, CAZIANT, CESIA,VELIVET)

BRAND 0

DESOGESTREL-ETHINYL ESTRADIOL TAB0.15-30 MG-MCG (APRI, EMOQUETTE,ENSKYCE, RECLIPSEN, SOLIA)

BRAND 0

DIVIGEL (GEL 0.25 MG/0.25GM, GEL 0.5MG/0.5GM, GEL 1 MG/GM)

BRAND 3 GL Female

drospirenone-ethinyl estradiol tab 3-0.03mg

generic 0

DROSPIRENONE-ETHINYL ESTRADIOL TAB3-0.03 MG (GIANVI, LORYNA, NIKKI,VESTURA, OCELLA, SYEDA, ZARAH)

BRAND 0

ELESTRIN BRAND 3 GL Female



ENJUVIA (TAB 0.3 MG, TAB 0.45 MG, TAB0.625 MG, TAB 0.9 MG, TAB 1.25 MG)

BRAND 3 GL Female

ESTRACE CREAM 0.1 MG/GM BRAND 3 GL Female

ESTRADERM (PATCH TW 0.05 MG/24HR,PATCH TW 0.1 MG/24HR)

BRAND 3 GL Female

estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg,td patch twice weekly 0.025 mg/24hr, tdpatch twice weekly 0.0375 mg/24hr, tdpatch twice weekly 0.05 mg/24hr, td patchtwice weekly 0.075 mg/24hr, td patchtwice weekly 0.1 mg/24hr, td patch weekly0.025 mg/24hr, td patch weekly 0.0375mg/24hr (37.5 mcg/24hr), td patch weekly0.05 mg/24hr, td patch weekly 0.06mg/24hr, td patch weekly 0.075 mg/24hr,td patch weekly 0.1 mg/24hr)

generic 1 GL Female

estradiol valerate (oil 10 mg/ml, oil 20mg/ml, oil 40 mg/ml)

generic 1 GL Female

ESTRASORB BRAND 3 GL Female

ESTROGEL BRAND 3 GL Female

estropipate (tab 0.75 mg, tab 1.5 mg, tab 3mg)

generic 1 GL Female

ETHYNODIOL DIACETATE & ETHINYLESTRADIOL TAB 1 MG-35 MCG (KELNOR,ZOVIA)

BRAND 0

EVAMIST BRAND 3 GL Female

FEMRING (RING 0.05 MG/24HR, RING 0.1MG/24HR)

BRAND 3 GL Female

LEVONORG-ETH EST TAB 0.15-0.03MG(84)& ETH EST TAB 0.01MG(7) (AMETHIA,CAMRESE, DAYSEE)

BRAND 0

LEVONORGEST-ETH ESTRAD 91-DAY TAB0.1-0.02 & 0.01 MG (AMETHIA LO,CAMRESE LO,

BRAND 0



LEVONORGEST-ETH ESTRAD 91-DAY TAB0.15-0.03 MG (INTROVALE, JOLESSA,QUASENSE)

BRAND 0

LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG (ENPRESSE,LEVONEST, MYZILRA, TRIVORA)

BRAND 0

LEVONORGESTREL-ETHINYL ESTRAD TAB0.1-20 MG (AUBRA, AVIANE, DELYLA,FALMINA, LESSINA, LUTERA, ORSYTHIA,SRONYX)

BRAND 0

LEVONORGESTREL-ETHINYL ESTRAD TAB0.15-30 MG (ALTAVERA, CHATEAL,KURVELO, LEVORA, MARLISSA, PORTIA)

BRAND 0

LEVONORGESTREL-ETHINYL ESTRADIOL(CONTINUOUS) TAB 90-20 MCG(AMETHYST)

BRAND 0

LO LOESTRIN FE BRAND 0

MENEST (TAB 0.3 MG, TAB 0.625 MG, TAB1.25 MG, TAB 2.5 MG)

BRAND 3 GL Female

MENOSTAR BRAND 3 GL Female

MINASTRIN 24 FE BRAND 0

MINIVELLE (PATCH TW 0.025 MG/24HR,PATCH TW 0.0375 MG/24HR, PATCH TW0.05 MG/24HR, PATCH TW 0.075MG/24HR, PATCH TW 0.1 MG/24HR)

BRAND 3 GL Female

NATAZIA BRAND 0

NECON 10/11 (28) BRAND 0

NORELGESTROMIN-ETHINYL ESTRADIOL TDPTWK 150-35 MCG/24HR (XULANE)

BRAND 0

NORETHINDRONE & ETHINYL ESTRADIOLTAB 0.4 MG-35 MCG (BALZIVA, BRIELLYN,GILDAGIA, PHILITH, VYFEMLA, ZENCHENT)

BRAND 0

NORETHINDRONE & ETHINYL ESTRADIOLTAB 0.5 MG-35 MCG (NECON, NORTREL,WERA)

BRAND 0



NORETHINDRONE & ETHINYL ESTRADIOLTAB 1 MG-35 MCG (ALYACEN, CYCLAFEM,DASETTA, NECON, NORTREL, PIRMELLA)

BRAND 0

NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG (WYMZYA,ZENCHENT, ZEOSA)

BRAND 0

norethindrone & ethinyl estradiol-fe chewtab 0.8 mg-25 mcg

generic 0

NORETHINDRONE AC-ETHINYL ESTRAD-FETAB 1-20/1-30/1-35 MG-MCG (TILIA, TRI-LEGEST)

BRAND 0

NORETHINDRONE ACE & ETHINYLESTRADIOL TAB 1 MG-20 MCG (GILDESS,JUNEL, LARIN, MICROGESTIN)

BRAND 0

NORETHINDRONE ACE & ETHINYLESTRADIOL TAB 1.5 MG-30 MCG (GILDESS,JUNEL, LARIN, MICROGESTIN)

BRAND 0

NORETHINDRONE ACE & ETHINYLESTRADIOL-FE TAB 1 MG-20 MCG(GILDESS, JUNEL, LARIN, MICROGESTIN)

BRAND 0

NORETHINDRONE ACE & ETHINYLESTRADIOL-FE TAB 1.5 MG-30 MCG(GILDESS, JUNEL, LARIN, MICROGESTIN)

BRAND 0

NORETHINDRONE ACE-ETHINYLESTRADIOL-FE TAB 1 MG-20 MCG(LOMEDIA)

BRAND 0

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG (ALYACEN,CYCLAFEM, DASETTA, NECON, NORTREL,PIRMELLA)

BRAND 0

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG (ARANELLE, LEENA)

BRAND 0

NORGESTIMATE & ETHINYL ESTRADIOLTAB 0.25 MG-35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA, PREVIFEM,SPRINTEC)

BRAND 0



NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG (TRI-ESTARYLLA,TRI-LINYAH, TRI-PREVIFEM, TRI-SPRINTEC,TRINESSA)

BRAND 0

NORGESTREL & ETHINYL ESTRADIOL TAB0.3 MG-30 MCG (CRYSELLE, ELINEST, LOW-OGESTREL)

BRAND 0

NUVARING BRAND 0

OGESTREL BRAND 0

ORTHO TRI-CYCLEN LO BRAND 0

PREMARIN (CREAM 0.625 MG/GM, RECONSOLN 25 MG, TAB 0.3 MG, TAB 0.45 MG,TAB 0.625 MG, TAB 0.9 MG, TAB 1.25 MG)

BRAND 2 GL Female

PREMPHASE BRAND 2 GL Female

PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5MG, TAB 0.625-2.5 MG, TAB 0.625-5 MG)

BRAND 2 GL Female

SAFYRAL BRAND 0

ZOVIA 1/50E (28) BRAND 0

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA BRAND 0

PROGESTINS

DEPO-SUBQ PROVERA 104 BRAND 0

IMPLANON BRAND 0

levonorgestrel (emergency oc) (tab 0.75mg, tab 1.5 mg)

generic 0

LILETTA (52 MG) BRAND 0

medroxyprogesterone acetate(contraceptive) (susp 150 mg/ml, suspprefilled syr 150 mg/ml)

generic 0

medroxyprogesterone acetate (tab 2.5 mg,tab 5 mg, tab 10 mg)

generic 1



megestrol acetate (appetite) generic 3

megestrol acetate (susp 40 mg/ml, tab 20mg, tab 40 mg)

generic 1

MIRENA (52 MG) BRAND 0

NEXPLANON BRAND 0

norethindrone acetate tab 5 mg generic 0

NORETHINDRONE TAB 0.35 MG (CAMILA,DEBLITANE, ERRIN, HEATHER, JENCYCLA,JOLIVETTE, LYZA, NORA-BE, NORLYROC,SHAROBEL)

BRAND 0

progesterone micronized (cap 100 mg, cap200 mg)

generic 1

SKYLA BRAND 0

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl generic 0GL FemaleMD 1 per day

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

levothyroxine sodium (for iv inj 100 mcg,for iv inj 500 mcg, tab 25 mcg, tab 50 mcg,tab 75 mcg, tab 88 mcg, tab 100 mcg, tab112 mcg, tab 125 mcg, tab 137 mcg, tab150 mcg, tab 175 mcg, tab 200 mcg, tab300 mcg)

generic 1

liothyronine sodium (iv soln 10 mcg/ml, tab5 mcg, tab 25 mcg, tab 50 mcg)

generic 1

THYROLAR-1 BRAND 3

THYROLAR-1/2 BRAND 3

THYROLAR-1/4 BRAND 3

THYROLAR-2 BRAND 3

THYROLAR-3 BRAND 3



HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR (TAB 30 MG, TAB 60 MG, TAB 90MG)

BRAND 4 PA

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline generic 1

ELIGARD (KIT 7.5 MG, KIT 22.5 MG, KIT 30MG, KIT 45 MG)

BRAND 4 PA

FIRMAGON (RECON SOLN 80 MG, RECONSOLN 120 MG)

BRAND 4 PA

leuprolide acetate inj kit 5 mg/ml generic 4 PA

LUPRON DEPOT (KIT 3.75 MG, KIT 7.5 MG,KIT 11.25 MG, KIT 22.5 MG, KIT 30 MG, KIT45 MG)

BRAND 4 PA

LUPRON DEPOT-PED (KIT 7.5 MG, KIT 11.25MG, KIT 15 MG, KIT 30 MG (PED))

BRAND 4 PA

octreotide acetate (inj 50 mcg/ml (0.05mg/ml), inj 100 mcg/ml (0.1 mg/ml), inj200 mcg/ml (0.2 mg/ml), inj 500 mcg/ml(0.5 mg/ml), inj 1000 mcg/ml (1 mg/ml))

generic 4 PA

SOMATULINE DEPOT (SOLUTION 60MG/0.2ML, SOLUTION 90 MG/0.3ML,SOLUTION 120 MG/0.5ML)

BRAND 4 PA

SOMAVERT (RECON SOLN 10 MG, RECONSOLN 15 MG, RECON SOLN 20 MG)

BRAND 4 PA

SYNAREL BRAND 4 PA

TRELSTAR (RECON SUSP 3.75 MG, RECONSUSP 11.25 MG)

BRAND 4 PA

TRELSTAR DEPOT MIXJECT BRAND 4 PA

TRELSTAR LA MIXJECT BRAND 4 PA

TRELSTAR MIXJECT (RECON SUSP 3.75 MG,RECON SUSP 11.25 MG, RECON SUSP 22.5MG)

BRAND 4 PA



ZOLADEX (IMPLANT 3.6 MG, IMPLANT 10.8MG)

BRAND 4 PA

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole (tab 5 mg, tab 10 mg) generic 1

propylthiouracil generic 1

IMMUNOLOGICAL AGENTS

IMMUNE SUPPRESSANTS

AZASAN (TAB 75 MG, TAB 100 MG) BRAND 3

azathioprine sodium generic 1

azathioprine tab 50 mg generic 1

CELLCEPT INTRAVENOUS BRAND 3

CIMZIA BRAND 4 PA

CIMZIA PREFILLED BRAND 4 PA

CIMZIA STARTER KIT BRAND 4 PA

cyclosporine (cap 25 mg, cap 100 mg, ivsoln 50 mg/ml)

generic 1

cyclosporine modified (for microemulsion)(cap 25 mg, cap 50 mg, cap 100 mg, oralsoln 100 mg/ml)

generic 1

ENBREL (RECON SOLN 25 MG, SOLN PRSYR25 MG/0.5ML, SOLN PRSYR 50 MG/ML)

BRAND 4 PA

ENBREL SURECLICK BRAND 4 PA

HUMIRA (PREF SY KT 20 MG/0.4ML, PREFSY KT 40 MG/0.8ML)

BRAND 4 PA

HUMIRA PEDIATRIC CROHNS START BRAND 4 PA

HUMIRA PEN BRAND 4 PA

HUMIRA PEN-CROHNS STARTER BRAND 4 PA



HUMIRA PEN-PSORIASIS STARTER BRAND 4 PA

KINERET BRAND 4 PA

methotrexate sodium (for inj 1 gm, inj 25mg/ml, inj 50 mg/2ml (25 mg/ml), inj 250mg/10ml (25 mg/ml), inj pf 25 mg/ml, injpf 50 mg/2ml (25 mg/ml), inj pf 100mg/4ml (25 mg/ml), inj pf 200 mg/8ml (25mg/ml), inj pf 250 mg/10ml (25 mg/ml), injpf 1000 mg/40ml (25 mg/ml))

generic 1 PA

methotrexate sodium tab 2.5 mg (baseequiv)

generic 1

mycophenolate mofetil (cap 250 mg, tab500 mg)

generic 1

mycophenolate sodium (tab dr 180 mg, tabdr 360 mg)

generic 1

NULOJIX BRAND 4 PA

ORENCIA (RECON SOLN 250 MG, SOLNPRSYR 125 MG/ML)

BRAND 4 PA

PROGRAF SOLUTION 5 MG/ML BRAND 2

RAPAMUNE SOLUTION 1 MG/ML BRAND 2

REMICADE BRAND 4 PA

RHEUMATREX BRAND 4

SIMPONI (SOLN A-INJ 50 MG/0.5ML, SOLNPRSYR 50 MG/0.5ML)

BRAND 4 PA

sirolimus (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1

tacrolimus (cap 0.5 mg, cap 1 mg, cap 5mg)

generic 1

TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10MG, TAB 15 MG)

BRAND 2

XELJANZ BRAND 4 PA

ZORTRESS (TAB 0.25 MG, TAB 0.5 MG, TAB0.75 MG)

BRAND 4



IMMUNIZING AGENTS, PASSIVE

ATGAM BRAND 4

CARIMUNE NF RECON SOLN 3 GM BRAND 4 PA

GAMMAGARD S/D (S/D RECON SOLN 2.5GM, S/D RECON SOLN 5 GM, S/D RECONSOLN 10 GM)

BRAND 4 PA

GAMMAGARD S/D LESS IGA (S/D RECONSOLN 5 GM, S/D RECON SOLN 10 GM)

BRAND 4 PA

GAMMAGARD SOLUTION 1 GM/10ML BRAND 4 PA

GAMMAKED SOLUTION 1 GM/10ML BRAND 4 PA

GAMUNEX-C SOLUTION 1 GM/10ML BRAND 4 PA

HIZENTRA SOLUTION 1 GM/5ML BRAND 4 PA

THYMOGLOBULIN BRAND 4 PA

IMMUNOMODULATORS

ACTEMRA (SOLUTION 80 MG/4ML,SOLUTION 200 MG/10ML, SOLUTION 400MG/20ML)

BRAND 4 PA

ACTIMMUNE BRAND 4 PA

ARCALYST BRAND 4 PA

leflunomide (tab 10 mg, tab 20 mg) generic 1 MD 1 per day

RIDAURA BRAND 3

SIMULECT (RECON SOLN 10 MG, RECONSOLN 20 MG)

BRAND 3

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO BRAND 2

ASACOL BRAND 2 MD 12 per day

ASACOL HD BRAND 2 MD 6 per day



balsalazide disodium generic 1

CANASA BRAND 2

DIPENTUM BRAND 2

LIALDA BRAND 2

mesalamine enema 4 gm generic 1

PENTASA (CAP ER 250 MG, CAP ER 500MG)

BRAND 2

GLUCOCORTICOIDS

budesonide delayed release particles cap 3mg

generic 1

hydrocortisone (intrarectal) generic 1

hydrocortisone rectal cream 2.5% generic 1

SULFONAMIDES

sulfasalazine (tab 500 mg, tab delayedrelease 500 mg)

generic 1

METABOLIC BONE DISEASE AGENTS

ACTONEL TAB 150 MG BRAND 2PAMD 1 / 28 DAYS

alendronate sodium (tab 35 mg, tab 70mg)


alendronate sodium (tab 5 mg, tab 10 mg) generic 1 MD 1 per day

alendronate sodium tab 40 mg generic 1

calcitonin (salmon) generic 1 MD 3.7 / 30 DAYS

calcitriol (cap 0.25 mcg, cap 0.5 mcg, inj 1mcg/ml, oral soln 1 mcg/ml)

generic 1

doxercalciferol (cap 0.5 mcg, cap 1 mcg,cap 2.5 mcg, inj 4 mcg/2ml (2 mcg/ml))

generic 1

etidronate disodium (tab 200 mg, tab 400mg)

generic 1



FORTEO BRAND 4PAMD 2.4 / 28 DAYS

FOSAMAX PLUS D (TAB 70-2800, TAB 70-5600)


HECTOROL SOLUTION 2 MCG/ML BRAND 2

ibandronate sodium iv soln 3 mg/3ml (baseequivalent)

generic 4

ibandronate sodium tab 150 mg (baseequivalent)


PAMIDRONATE DISODIUM (FOR INJ 30 MG,FOR INJ 90 MG, IV SOLN 3 MG/ML, IV SOLN9 MG/ML, SOLUTION 6 MG/ML)

BRAND 4 PA

paricalcitol (cap 1 mcg, cap 2 mcg, cap 4mcg)

generic 1

paricalcitol (soln 2 mcg/ml, soln 5 mcg/ml) generic 4

PROLIA BRAND 4 PA

risedronate sodium (tab 5 mg, tab 30 mg) generic 1PAMD 1 per day

risedronate sodium tab 150 mg generic 1PAMD 1 / 28 DAYS

risedronate sodium tab 35 mg generic 1PAMD 4 / 28 DAYS

risedronate sodium tab delayed release 35mg

generic 1 PA

SKELID BRAND 3

XGEVA BRAND 4 PA

zoledronic acid (inj conc for iv infusion 4mg/5ml, iv soln 5 mg/100ml, solution 4mg/100ml)

generic 4 PA

ZOMETA SOLUTION 4 MG/100ML BRAND 4 PA



MISCELLANEOUS THERAPEUTIC AGENTS

AEROCHAMBER MINI CHAMBER BRAND 2

AEROCHAMBER MV BRAND 2

AEROCHAMBER PLUS FLO-VU BRAND 2

AEROCHAMBER PLUS FLO-VU LARGE BRAND 2

AEROCHAMBER PLUS FLO-VU MEDIUM BRAND 2

AEROCHAMBER PLUS FLO-VU SMALL BRAND 2

AEROCHAMBER PLUS FLO-VU W/MASK BRAND 2

AEROCHAMBER PLUS FLOW VU BRAND 2

AEROCHAMBER W/FLOWSIGNAL BRAND 2

AEROCHAMBER Z-STAT PLUS BRAND 2

AEROCHAMBER Z-STAT PLUS/LARGE BRAND 2

AEROCHAMBER Z-STAT PLUS/MEDIUM BRAND 2

AEROCHAMBER Z-STAT PLUS/SMALL BRAND 2

dacarbazine powder generic 4

EASIVENT BRAND 2

FEMCAP (DEVICE 22, DEVICE 26, DEVICE30)

BRAND 0

nystatin (bulk) powder generic 1

OMNIFLEX DIAPHRAGM BRAND 0

OPTICHAMBER ADVANTAGE BRAND 2

OPTICHAMBER ADVANTAGE-LG MASK BRAND 2

OPTICHAMBER ADVANTAGE-MED MASK BRAND 2

OPTICHAMBER ADVANTAGE-SM MASK BRAND 2

OPTICHAMBER DIAMOND MISC BRAND 2

OPTICHAMBER DIAMOND-LG MASK BRAND 2

OPTICHAMBER DIAMOND-MD MASK BRAND 2



OPTICHAMBER DIAMOND-SM MASK BRAND 2

ORTHO DIAPHRAGM ALL-FLEX(DIAPHRAGM DIAPHRAGM 65,DIAPHRAGM DIAPHRAGM 70, DIAPHRAGMDIAPHRAGM 75, DIAPHRAGM DIAPHRAGM80)

BRAND 0

ORTHO DIAPHRAGM COIL (DIAPHRAGMKIT 50, DIAPHRAGM KIT 100, DIAPHRAGMKIT 105)

BRAND 0

ORTHO DIAPHRAGM FLAT (DIAPHRAGMKIT 55, DIAPHRAGM KIT 60, DIAPHRAGMKIT 65, DIAPHRAGM KIT 70, DIAPHRAGMKIT 75, DIAPHRAGM KIT 80, DIAPHRAGMKIT 85, DIAPHRAGM KIT 90, DIAPHRAGMKIT 95)

BRAND 0

PARAGARD INTRAUTERINE COPPER BRAND 0

PHISOHEX BRAND 1

PRENTIF FITTING SET BRAND 0

sodium polystyrene sulfonate (bulk) generic 1

tobramycin sulfate powder generic 4 PA

VALVED HOLDING CHAMBER BRAND 2

VISTOGARD BRAND 4

water for irrigation, sterile generic 1

WIDE-SEAL DIAPHRAGM 60 BRAND 0










OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

bacitracin (ophthalmic) generic 3

LACRISERT BRAND 3

LASTACAFT BRAND 2

neomycin-bacitracin zn-polymyxin generic 1

neomycin-polymy-dexameth (oint, susp) generic 1

neomycin-polymyxin-hc (ophth) generic 1

polymyxin b-trimethoprim generic 1

proparacaine hcl generic 1

RESTASIS BRAND 2 PA

tobramycin-dexamethasone generic 1

tropicamide (soln 0.5%, soln 1%) generic 1

VITRASERT BRAND 1

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL BRAND 3

ALOMIDE BRAND 3

azelastine hcl (ophth) generic 1 MPL 1 / claim

BEPREVE BRAND 3

cromolyn sodium (ophth) generic 1

EMADINE BRAND 3

epinastine hcl (ophth) generic 1

PATADAY BRAND 2

PATANOL BRAND 3

OPHTHALMIC ANTI-INFLAMMATORIES

ALREX BRAND 2



bromfenac sodium (ophth) (soln equiv)(once-daily), soln equivalent))

generic 1

dexamethasone sodium phosphate (ophth) generic 1

diclofenac sodium (ophth) generic 1

DUREZOL BRAND 2

fluorometholone (ophth) generic 1

flurbiprofen sodium generic 1

FML BRAND 3

FML FORTE BRAND 3

ILEVRO BRAND 3

ketorolac tromethamine (ophth) (soln0.4%, soln 0.5%)


LOTEMAX (GEL 0.5 %, OINTMENT 0.5 %,SUSPENSION 0.5 %)

BRAND 2

MAXIDEX BRAND 3

NEVANAC BRAND 3

PRED MILD BRAND 3

prednisolone acetate (ophth) generic 1

PREDNISOLONE SODIUM PHOSPHATESOLUTION 1 %

BRAND 3

VEXOL BRAND 3

OPHTHALMIC ANTIGLAUCOMA AGENTS

apraclonidine hcl generic 1

AZOPT BRAND 2 MPL 1 / claim(s)

betaxolol hcl (ophth) generic 1 MPL 1 / claim(s)

brimonidine tartrate (soln 0.15%, soln0.2%)


carteolol hcl (ophth) generic 1



COMBIGAN BRAND 2

dorzolamide hcl generic 1 MPL 1 / claim(s)

dorzolamide hcl-timolol maleate generic 1 MPL 1 / claim(s)

IOPIDINE SOLUTION 1 % BRAND 3

levobunolol hcl (soln 0.25%, soln 0.5%) generic 1 MPL 1 / claim(s)

methazolamide (tab 25 mg, tab 50 mg) generic 1 MD 6 per day

metipranolol generic 1

PHOSPHOLINE IODIDE BRAND 3

pilocarpine hcl (soln 1%, soln 2%, soln 4%) generic 1

timolol maleate (ophth) (gel forming soln0.25%, gel forming soln 0.5%, soln 0.25%,soln 0.5%)

generic 1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost ophth soln 0.03% generic 3

latanoprost ophth soln 0.005% generic 1

LUMIGAN SOLUTION 0.01 % BRAND 3 ST

LUMIGAN SOLUTION 0.03 % BRAND 3

TRAVATAN Z BRAND 2

ZIOPTAN BRAND 2

OTIC AGENTS

acetic acid (otic) generic 1

antipyrine-benzocaine otic soln 54-14mg/ml (5.4-1.4%)

generic 1

CIPRO HC BRAND 3

CIPRODEX BRAND 2

COLY-MYCIN S BRAND 3

CORTISPORIN-TC BRAND 3



fluocinolone acetonide (otic) generic 1

hydrocortisone w/acetic acid generic 1

neomycin-polymyxin-hc (otic) (soln 1%,susp 3.5 mg/ml-10000 unit/ml-1%)

generic 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO (AERO SOLN 80 MCG/ACT, AEROSOLN 160 MCG/ACT)

BRAND 3PA

MPL 1 / 30 days

ASMANEX 120 METERED DOSES BRAND 2 MD 1 / 30 DAYS


ASMANEX 30 METERED DOSES (30 AERPOW BA 110 MCG/INH, 30 AER POW BA220 MCG/INH)




budesonide (inhalation) (susp 0.25 mg/2ml,susp 0.5 mg/2ml)

generic 3PAMD 120 / 30 DAYS

budesonide (nasal) generic 1PAMD 18 / 30 DAYS

budesonide inhalation susp 1 mg/2ml generic 1PAMD 120 / 30 DAYS

FLOVENT DISKUS AER POW BA 250MCG/BLIST

BRAND 3PA

MPL 1 / 30 days

FLOVENT HFA (AEROSOL 44 MCG/ACT,AEROSOL 110 MCG/ACT, AEROSOL 220MCG/ACT)

BRAND 3PA

MPL 1 / 30 days

flunisolide (nasal) (nasal soln 25 mcg/act,nasal soln 29 mcg/act)


fluticasone propionate (nasal) generic 1 MD 16 / 30 DAYS



NASONEX BRAND 2PA

MPL 1 / 30 days

PULMICORT FLEXHALER (AER POW BA 90MCG/ACT, AER POW BA 180 MCG/ACT)


QVAR (AERO SOLN 40 MCG/ACT, AEROSOLN 80 MCG/ACT)

BRAND 2 MPL 1 / 30 days

ANTIHISTAMINES

ASTELIN BRAND 2 MPL 1 / 30 days

ASTEPRO BRAND 2

azelastine hcl nasal spray 0.1% (137mcg/spray)

generic 2 MPL 1 / 30 days

azelastine hcl nasal spray 0.15% (205.5mcg/spray)

generic 2

carbinoxamine maleate (soln 4 mg/5ml,tab 4 mg)

generic 1

cetirizine hcl allergy child solution 5mg/5ml


clemastine fumarate (syrup 0.67 mg/5ml(0.5 mg/5ml base eq), tab 2.68 mg)

generic 1

cyproheptadine hcl (syrup 2 mg/5ml, tab 4mg)

generic 1

desloratadine (tab 5 mg, tab orallydisintegrating 2.5 mg, tab orallydisintegrating 5 mg)


DEXCHLORPHENIRAMINE MALEATE BRAND 3

diphenhydramine hcl cap 50 mg generic 1

diphenhydramine hcl elixir 12.5 mg/5ml generic 1

diphenhydramine hcl inj 50 mg/ml generic 1

hydroxyzine hcl (im soln 50 mg/ml, syrup10 mg/5ml, tab 10 mg, tab 25 mg, tab 50mg)

generic 1



hydroxyzine pamoate cap 100 mg generic 1

levocetirizine dihydrochloride soln 2.5mg/5ml (0.5 mg/ml)


levocetirizine dihydrochloride tab 5 mg generic 1 MD 1 per day

olopatadine hcl (nasal) generic 1

promethazine hcl (inj 25 mg/ml, inj 50mg/ml, suppos 12.5 mg, syrup 6.25mg/5ml, tab 12.5 mg, tab 25 mg, tab 50mg)

generic 1

promethazine hcl suppos 25 mg generic 1

ANTILEUKOTRIENES

montelukast sodium (chew tab 4 mg, chewtab 5 mg, oral granules packet 4 mg, tab10 mg)


zafirlukast (tab 10 mg, tab 20 mg) generic 1 MD 2 per day

ZYFLO CR BRAND 3AL At least 12 yrs old

MD 4 per day

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA BRAND 3 MPL 1 / 30 days

INCRUSE ELLIPTA BRAND 2 MPL 1 / 30 days

ipratropium bromide inhal soln 0.02% generic 1 MD 450 / 30 DAYS

ipratropium bromide nasal soln 0.03% (21mcg/spray)


ipratropium bromide nasal soln 0.06% (42mcg/spray)

generic 1

SPIRIVA HANDIHALER BRAND 2 MPL 1 / 30 days

SPIRIVA RESPIMAT (AERO SOLN 1.25MCG/ACT, AERO SOLN 2.5 MCG/ACT)




BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML BRAND 2 C 1 kit/ 30 days

albuterol sulfate (soln nebu 0.083% (2.5mg/3ml), soln nebu 0.63 mg/3ml (baseequiv), soln nebu 1.25 mg/3ml (baseequiv))


albuterol sulfate (syrup 2 mg/5ml, tab 2mg, tab 4 mg, tab sr 12hr 4 mg, tab sr 12hr8 mg)

generic 1

albuterol sulfate soln nebu 0.5% (5 mg/ml) generic 1 MD 60 / 30 DAYS

ARCAPTA NEOHALER BRAND 2PA

MPL 1 / 30 days

AUVI-Q SOLN A-INJ 0.3 MG/0.3ML BRAND 2 C 1 kit/ 30 days

BROVANA BRAND 3PAMD 120 / 30 DAYS

epinephrine hcl (inj 1 mg/ml, soln prefilledsyringe 0.1 mg/ml)

generic 1

EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML BRAND 2 C 1 kit/ 30 days

EPIPEN BRAND 2 C 1 kit/ 30 days

EPIPEN 2-PAK BRAND 2 C 1 kit/ 30 days

EPIPEN JR BRAND 2 C 1 kit/ 30 days

EPIPEN JR 2-PAK BRAND 2 C 1 kit/ 30 days

FORADIL AEROLIZER BRAND 2PA

MPL 1 / 30 days

levalbuterol hcl (soln nebu 0.31 mg/3ml,soln nebu 0.63 mg/3ml, soln nebu 1.25mg/3ml)


levalbuterol hcl soln nebu conc 1.25mg/0.5ml (base equiv)


MAXAIR AUTOHALER BRAND 2 MPL 1 / 30 days



metaproterenol sulfate (tab 10 mg, tab 20mg)

generic 1

PROAIR HFA BRAND 2 MPL 2 / 30 days

PROVENTIL HFA BRAND 2 MPL 2 / 30 days

SEREVENT DISKUS BRAND 2 MPL 1 / 30 days

terbutaline sulfate (inj 1 mg/ml, tab 2.5mg, tab 5 mg)

generic 1

TWINJECT BRAND 2 C 1 kit/ 30 days

VENTOLIN HFA BRAND 2 MPL 2 / 30 days

XOPENEX HFA BRAND 3PA

MPL 1 / 30 days

CYSTIC FIBROSIS AGENTS

KALYDECO TAB 150 MG BRAND 4 PA

KITABIS PAK BRAND 4 PA

tobramycin nebu soln 300 mg/5ml generic 4 PA

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

aminophylline inj 25 mg/ml generic 1

ELIXOPHYLLIN BRAND 2

LUFYLLIN (TAB 200 MG, TAB 400 MG) BRAND 3

THEO-24 (CAP ER 24H 100 MG, CAP ER 24H200 MG, CAP ER 24H 300 MG, CAP ER 24H400 MG)

BRAND 2

theophylline (tab 12hr 100 mg, tab 12hr200 mg, tab 12hr 300 mg, tab 12hr 450mg, tab 24hr 400 mg, tab 24hr 600 mg)

generic 1

PULMONARY ANTIHYPERTENSIVES

ADCIRCA BRAND 4 PA

LETAIRIS (TAB 5 MG, TAB 10 MG) BRAND 4 PA



REMODULIN (SOLUTION 1 MG/ML,SOLUTION 2.5 MG/ML, SOLUTION 5MG/ML, SOLUTION 10 MG/ML)

BRAND 4 PA

sildenafil citrate (pulmonary hypertension)(iv soln 10 mg/12.5ml (base equivalent),tab 20 mg)

generic 4 PA

TRACLEER TAB 125 MG BRAND 4PAMD 2 per day

TRACLEER TAB 62.5 MG BRAND 4PAMD 1 per day

VENTAVIS (SOLUTION 10 MCG/ML,SOLUTION 20 MCG/ML)

BRAND 4 PA

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (soln 10%, soln 20%) generic 1

ADVAIR DISKUS (AER POW BA 100-50MCG/DOSE, AER POW BA 250-50MCG/DOSE, AER POW BA 500-50MCG/DOSE)

BRAND 2PA

MPL 1 / 30 days

ADVAIR HFA (AEROSOL 45-21 MCG/ACT,AEROSOL 115-21 MCG/ACT, AEROSOL 230-21 MCG/ACT)

BRAND 2PA

MPL 1 / 30 days

ARALAST BRAND 4 PA

ARALAST NP (RECON SOLN 400 MG,RECON SOLN 800 MG, RECON SOLN 1000MG)

BRAND 4 PA

benzonatate cap 100 mg generic 1MD 6 per dayMD


benzonatate cap 200 mg generic 1MD 3 per dayMD


BREO ELLIPTA (AER POW BA 100-25MCG/INH, AER POW BA 200-25 MCG/INH)




cromolyn sodium soln nebu 20 mg/2ml generic 1 MD 240 / 30 DAYS

HYPERSAL NEBU SOLN 3.5 % BRAND 2

ipratropium-albuterol generic 1 MD 540 / 30 DAYS

NEBUSAL BRAND 1

PROLASTIN RECON SUSP 1000 MG BRAND 4 PA

PROLASTIN-C BRAND 4 PA

PULMOZYME BRAND 4 PA

sodium chloride soln nebu 7% generic 1

SYMBICORT (AEROSOL 80-4.5 MCG/ACT,AEROSOL 160-4.5 MCG/ACT)

BRAND 2PA

MPL 1 / month(s)

TYZINE (SOLUTION 0.05 %, SOLUTION 0.1%)

BRAND 3

XOLAIR BRAND 4 PA

ZEMAIRA BRAND 4 PA

SKELETAL MUSCLE RELAXANTS

BOTOX (RECON SOLN 100, RECON SOLN200)

BRAND 3 PA

carisoprodol (tab 250 mg, tab 350 mg) generic 1

chlorzoxazone tab 500 mg generic 1

cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg,tab 10 mg)


DYSPORT (RECON SOLN 300, RECON SOLN500)

BRAND 3 PA

metaxalone tab 800 mg generic 1 MD 4 per day

methocarbamol (tab 500 mg, tab 750 mg) generic 1

orphenadrine citrate tab sr 12hr 100 mg generic 1 MD 2 per day

XEOMIN RECON SOLN 50 UNIT BRAND 3 PA



SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

estazolam (tab 1 mg, tab 2 mg) generic 1

eszopiclone (tab 1 mg, tab 2 mg, tab 3 mg) generic 1

ST


triazolam (tab 0.125 mg, tab 0.25 mg) generic 1

zaleplon cap 10 mg generic 1AL At least 18 yrs old

MD 2 per day

zaleplon cap 5 mg generic 1AL At least 18 yrs old

MD 1 per day

zolpidem tartrate (tab 5 mg, tab 10 mg) generic 1AL At least 18 yrs old

MD 1 per day

SLEEP DISORDERS, OTHER

modafinil tab 100 mg generic 1

PA


modafinil tab 200 mg generic 1

PA


NUVIGIL (TAB 50 MG, TAB 150 MG, TAB250 MG)

BRAND 2

PA


NUVIGIL TAB 200 MG BRAND 2PAMD 1 per day

ROZEREM BRAND 3

ST




XYREM BRAND 4PAMD 540 / 30 DAYS

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

CHEMET BRAND 3

EXJADE (TAB SOL 125 MG, TAB SOL 250MG, TAB SOL 500 MG)

BRAND 4 PA

FERRIPROX TAB 500 MG BRAND 3

JADENU (TAB 90 MG, TAB 180 MG, TAB360 MG)

BRAND 4 PA

SAMSCA (TAB 15 MG, TAB 30 MG) BRAND 4 PA

sodium polystyrene sulfonate (*sodiumpowder**, sodium oral susp 15 gm/60ml)

generic 1

SYPRINE BRAND 4

ELECTROLYTE/MINERAL REPLACEMENT

AMMONIUM CHLORIDE BRAND 3

calcium chloride inj 10% generic 1

calcium gluconate inj 10% generic 1

DELFLEX-LC/1.5% DEXTROSE BRAND 1

DELFLEX-LC/2.5% DEXTROSE BRAND 1

DEXTROSE 5%/ELECTROLYTE #48 BRAND 1

dextrose in lactated ringers generic 1

dextrose in ringers generic 1

DIANEAL LOW CALCIUM/1.5% DEX BRAND 1

DIANEAL PD-2/1.5% DEXTROSE BRAND 1





electrolyte-m in dextrose generic 1

EXTRANEAL BRAND 1

ferrous fumarate-folic acid generic 1 MD 1 per day

IONOSOL-B IN D5W BRAND 1

IONOSOL-MB IN D5W BRAND 1

irrigation solutions, physiological generic 1

ISOLYTE-H IN D5W BRAND 1

ISOLYTE-P IN D5W BRAND 1

ISOLYTE-S BRAND 1

ISOLYTE-S IN D5W BRAND 2

KCL IN DEXTROSE-NACL SOLUTION 40-5-0.9 MEQ/L-%-%

BRAND 1

KCL-LACTATED RINGERS-D5W BRAND 1

KLOR-CON M15 BRAND 1

lactated ringer's generic 1

MAGNESIUM SULFATE (INJ 50%, SOLUTION2 GM/50ML, SOLUTION 4 GM/100ML,SOLUTION 4 GM/50ML, SOLUTION 20GM/500ML, SOLUTION 40 GM/1000ML)

BRAND 1

NORMOSOL-M IN D5W BRAND 1

NORMOSOL-R PH 7.4 BRAND 1

parenteral electrolytes generic 1

peritoneal dialysis solutions (solutions 346mosm/l**, solutions 396 mosm/l**,solutions 485 mosm/l**, solutions**)

generic 1

PLASMA-LYTE 148 BRAND 1

PLASMA-LYTE A BRAND 1

PLASMA-LYTE-56 IN D5W BRAND 1

potassium acetate (inj 2 meq/ml, inj 4meq/ml)

generic 1



potassium bicarb & chloride generic 1

potassium bicarbonate effer tab 25 meq generic 1

potassium chloride (cap cr 8 meq, cap cr 10meq, inj 2 meq/ml, inj 10 meq/100ml, inj20 meq/50ml, inj 30 meq/100ml, oral soln10% (20 meq/15ml), powder packet 20meq, solution 10 meq/50ml, tab cr 8 meq(600 mg), tab cr 10 meq)

generic 1

potassium chloride in dextrose & sodiumchloride (10 meq/l (0.07) 0.4j, 20 meq/l(0.1) 0.2% j, 20 meq/l (0.1) 0.33% j, 20meq/l (0.1) 0.4j, 20 meq/l (0.1) 0.9% j, 30meq/l (0.224%) 0.4j, 40 meq/l (0.3%) 0.4j)

generic 1

potassium chloride in dextrose (20 meq/l(0.15%) 5% j, 40 meq/l (0.3%) 5% j, solution40-5 meq/l-%)

generic 1

potassium chloride in nacl (20 meq/l(0.15%) 0.45% j, 20 meq/l (0.15%) 0.9% j,40 meq/l (0.3%) 0.9% j)

generic 1

potassium chloride microencapsulatedcrystals cr (mioencapsulated ys tab 10,mioencapsulated ys tab 20)

generic 1

potassium phosphates (inj 15 mm/5ml 22meq/5ml, inj 45 mm/15ml 66 meq/15ml,inj 150 mm/50ml 220 meq/50ml)

generic 1

ringer's generic 1

ringer's irrigation generic 1

sodium acetate (inj 2 meq/ml, inj 4meq/ml)

generic 1

sodium chloride (inj 0.45%, inj 0.9%, inj 2.5meq/ml (14.6%), inj 3%, inj 4 meq/ml(23.4%), inj 5%, iv soln 0.9%)

generic 1

sodium phosphate generic 1

ULTRABAG/DIANEAL PD-2/1.5% DEX BRAND 1



ULTRABAG/DIANEAL PD-2/2.5% DEX BRAND 1

ULTRABAG/DIANEAL PD-2/4.25%DEX BRAND 1

ULTRABAG/DIANEAL/1.5% DEXTROSE BRAND 1

ULTRABAG/DIANEAL/4.25% DEX BRAND 1

AMINOSYN II IN DEXTROSE 25% BRAND 3

CAVAN PRENATAL/EC CALCIUM BRAND 1 MD 1 per day

CAVAN-FOLATE OB BRAND 1 MD 1 per day

CLINIMIX E/DEXTROSE (5/20) BRAND 3

CLINIMIX/DEXTROSE (2.75/5) BRAND 3




CLINIMIX/DEXTROSE (5/25) BRAND 3

CO-NATAL FA BRAND 1 MD 1 per day

COMPLETE-RF PRENATAL BRAND 1 MD 1 per day

COMPLETENATE BRAND 1 MD 1 per day

DRISDOL BRAND 0

ergocalciferol cap 50000 unit generic 0

folic acid tab 1 mg generic 0 FAL Female - 12 to 55 yrsold

GESTICARE BRAND 1 MD 1 per day

INATAL ADVANCE BRAND 1 MD 1 per day

INATAL GT BRAND 1 MD 1 per day

INATAL ULTRA BRAND 1 MD 1 per day

lactated ringer's (irrigation) generic 1

LACTOCAL-F BRAND 1 MD 1 per day

M-VIT BRAND 1 MD 1 per day



MARNATAL-F PLUS DUO PACK BRAND 1 MD 1 per day

MYNATAL (CAP, TAB 90-1 MG) BRAND 1 MD 1 per day

MYNATAL ADVANCE BRAND 1 MD 1 per day

MYNATAL PLUS BRAND 1 MD 1 per day

MYNATAL-Z BRAND 1 MD 1 per day

MYNATE 90 PLUS BRAND 1 MD 1 per day

NATACHEW CHEW TAB 29-1 MG BRAND 1 MD 1 per day

NATAL-V RX BRAND 1 MD 1 per day

NATALVIT BRAND 1 MD 1 per day

NIVA-PLUS BRAND 1 MD 1 per day

O-CAL FA BRAND 1 MD 1 per day

O-CAL PRENATAL BRAND 1 MD 1 per day

PNV FOLIC ACID + IRON BRAND 1 MD 1 per day

PNV PRENATAL PLUS MULTIVITAMIN BRAND 1 MD 1 per day

PNV TABS 29-1 BRAND 1 MD 1 per day

PNV-VP-U BRAND 1 MD 1 per day

PRENACARE BRAND 1 MD 1 per day

PRENAFIRST BRAND 1 MD 1 per day

PRENAPLUS BRAND 1 MD 1 per day

PRENATABS FA BRAND 1 MD 1 per day

PRENATABS RX BRAND 1 MD 1 per day

PRENATAL BRAND 1 MD 1 per day

PRENATAL 19 (19 CHEW TAB, 19 CHEWTAB 29-1 MG)


PRENATAL AD BRAND 1 MD 1 per day



PRENATAL LOW IRON BRAND 1 MD 1 per day

PRENATAL PLUS BRAND 1 MD 1 per day

PRENATAL PLUS IRON BRAND 1 MD 1 per day

PRENATAL VITAMINS PLUS BRAND 1 MD 1 per day

PRENATAL-U BRAND 1 MD 1 per day

PREPLUS BRAND 1 MD 1 per day

PRETAB BRAND 1 MD 1 per day

RE PRENATAL MULTIVITAMIN/IRON BRAND 1 MD 1 per day

RE-NATA 29 OB BRAND 1 MD 1 per day

SE-NATAL 19 CHEW TAB 29-1 MG BRAND 1 MD 1 per day

SE-NATAL 90 BRAND 1 MD 1 per day

SE-NATAL ONE BRAND 1 MD 1 per day

THRIVITE RX BRAND 1 MD 1 per day

TRIADVANCE BRAND 1 MD 1 per day

TRICARE BRAND 1 MD 1 per day

TRINATAL GT BRAND 1 MD 1 per day

TRINATAL RX 1 BRAND 1 MD 1 per day

TRINATAL ULTRA BRAND 1 MD 1 per day

TRIVEEN-U BRAND 1 MD 1 per day

VENATAL-FA BRAND 1 MD 1 per day

VINATE CALCIUM BRAND 1 MD 1 per day

VINATE GT BRAND 1 MD 1 per day

VINATE M BRAND 1 MD 1 per day

VINATE ONE BRAND 1 MD 1 per day

VINATE ULTRA BRAND 1 MD 1 per day



VIRT-ADVANCE BRAND 1 MD 1 per day

VIRT-VITE GT BRAND 1 MD 1 per day

VITAFOL-OB BRAND 1 MD 1 per day

VITAFOL-PN BRAND 1 MD 1 per day

VITASPIRE BRAND 1 MD 1 per day

VOL-PLUS BRAND 1 MD 1 per day

VOL-TAB RX BRAND 1 MD 1 per day


Index of Covered Drugs

AA-HYDROCORT 92abacavir sulfate 59abacavir sulfate-lamivudine-zidovudine 59ABELCET 36ABILIFY 53ABRAXANE 44ABSORICA 83acamprosate calcium 18acarbose 63acebutolol hcl 72acetaminophen w/ codeine 15acetazolamide 76acetazolamide sodium 76acetic acid 20acetic acid (otic) 113acetylcysteine 119acitretin 83ACTEMRA 106ACTIMMUNE 106ACTONEL 107acyclovir 61,62acyclovir topical 62ADAGEN 86adapalene 83ADAPALENE 83ADCETRIS 49ADCIRCA 118adefovir dipivoxil 56ADRENACLICK 117ADRIAMYCIN 44ADVAIR DISKUS 119ADVAIR HFA 119ADVICOR 78AEROCHAMBER MINI CHAMBER 109AEROCHAMBER MV 109AEROCHAMBER PLUS FLO-VU 109AEROCHAMBER PLUS FLO-VU LARGE 109AEROCHAMBER PLUS FLO-VU MEDIUM 109AEROCHAMBER PLUS FLO-VU SMALL 109

AEROCHAMBER PLUS FLO-VU W/MASK 109AEROCHAMBER PLUS FLOW VU 109AEROCHAMBER W/FLOWSIGNAL 109AEROCHAMBER Z-STAT PLUS 109AEROCHAMBER Z-STAT PLUS/LARGE 109AEROCHAMBER Z-STAT PLUS/MEDIUM 109AEROCHAMBER Z-STAT PLUS/SMALL 109AFINITOR 47AGGRENOX 69AIMSCO LUBRICATED 8ALBENZA 49albuterol sulfate 117alclometasone dipropionate 92ALDURAZYME 86alendronate sodium 107alfuzosin hcl 91ALIMTA 43ALINIA 50ALKERAN 41ALLEGRA ALLERGY CHILDRENS 9allopurinol 38almotriptan malate 39ALOCRIL 111ALOMIDE 111ALORA 97alosetron hcl 89ALOXI 35alprazolam 62ALREX 111ALTABAX 20ALTOPREV 77ALVESCO 114amantadine hcl 51AMBISOME 36amcinonide 92AMEVIVE 84amikacin sulfate 19amiloride & hydrochlorothiazide 74amiloride hcl 76aminophylline 118AMINOSYN II IN DEXTROSE 25% 125

amiodarone hcl 72AMITIZA 89amitriptyline hcl 34amlodipine besylate 73amlodipine besylate-benazepril hcl 74AMMONIUM CHLORIDE 122amoxapine 34amoxicillin 24amoxicillin & pot clavulanate 24amphetamine-dextroamphetamine 79AMPHOTEC 36amphotericin b 36AMPICILLIN 24ampicillin & sulbactam sodium 24ampicillin sodium 24AMPICILLIN-SULBACTAM SODIUM 24AMPYRA 82ANADROL-50 96anagrelide hcl 68anastrozole 47ANDRODERM 96ANDROXY 96antipyrine-benzocaine 113ANZEMET 35,36APIDRA 65APIDRA SOLOSTAR 65APOKYN 51apraclonidine hcl 112APRISO 106APTIVUS 60ARALAST 119ARALAST NP 119ARANESP (ALBUMIN FREE) 68ARCALYST 106ARCAPTA NEOHALER 117ARESTIN 83aripiprazole 53ARRANON 44ARZERRA 49ASACOL 106ASACOL HD 106

ASMANEX 120 METERED DOSES 114ASMANEX 14 METERED DOSES 114ASMANEX 30 METERED DOSES 114ASMANEX 60 METERED DOSES 114ASMANEX 7 METERED DOSES 114aspirin 6aspirin-dipyridamole 69ASTELIN 115ASTEPRO 115atenolol 72atenolol & chlorthalidone 75ATGAM 106atorvastatin calcium 77atovaquone 50atovaquone-proguanil hcl 50ATRIPLA 58atropine sulfate 87ATROVENT HFA 116AUVI-Q 117AVANDIA 63AVASTIN 49AVELOX 26AVODART 91AVONEX 82AVONEX PEN 82AVONEX PREFILLED 82azacitidine 44AZASAN 104AZASITE 25azathioprine 104azathioprine sodium 104azelastine hcl 115azelastine hcl (ophth) 111AZELEX 84AZILECT 52azithromycin 25AZOPT 112aztreonam 23

Bbacitracin 20

bacitracin (ophthalmic) 111baclofen 55balsalazide disodium 107BANZEL 29BARACLUDE 56benazepril hcl 71BENICAR 70benzonatate 119benzoyl peroxide 7,84benzoyl peroxide-erythromycin 84benztropine mesylate 51BEPREVE 111BESIVANCE 26betamethasone dipropionate (topical) 92betamethasone dipropionate augmented 92betamethasone valerate 92BETASERON 82betaxolol hcl 72betaxolol hcl (ophth) 112bethanechol chloride 91bexarotene 49BEXXAR 49BEYAZ 97bicalutamide 42BICNU 41BIDIL 75BILTRICIDE 49bimatoprost 113bisacodyl ec tab dr 5 mg 7bisoprolol fumarate 72bleomycin sulfate 44BOSULIF 48BOTOX 120BREO ELLIPTA 119BRILINTA 69brimonidine tartrate 112BRINTELLIX 32bromfenac sodium (ophth) 112bromocriptine mesylate 51BROVANA 117budesonide 107

budesonide (inhalation) 114budesonide (nasal) 114bumetanide 76BUPHENYL 86buprenorphine hcl 18buprenorphine hcl-naloxone hcl dihydrate 18bupropion hcl 31bupropion hcl (smoking deterrent) 18bupropion hcl er (sr) tab er 12h 100 mg 31bupropion hcl er (sr) tab er 12h 150 mg 31buspirone hcl 62BUSULFEX 41butalbital-acetaminophen-caffeine 81butalbital-acetaminophen-caffeine w/ codeine 15butalbital-aspirin-caffeine 81butalbital-aspirin-caffeine w/cod 15butorphanol tartrate 15BUTRANS 13BYETTA 10 MCG PEN 63BYETTA 5 MCG PEN 63BYSTOLIC 72,73

Ccabergoline 103CAFERGOT 39calcipotriene 84calcipotriene-betamethasone dipropionate 84calcitonin (salmon) 107calcitriol 107calcitriol (topical) 84calcium acetate (phosphate binder) 92calcium chloride (dihydrate) 122calcium gluconate 122CAMPATH 44CAMPTOSAR 44CANASA 107CANCIDAS 36candesartan cilexetil 70CANTIL 87CAPASTAT SULFATE 41capecitabine 43

CAPRELSA 48captopril 71captopril & hydrochlorothiazide 75CARBAGLU 86carbamazepine 29,30carbidopa 52carbidopa & levodopa odt 10-100 mg 52carbidopa & levodopa odt 25-100 mg 52carbidopa & levodopa odt 25-250 mg 52carbidopa-levodopa 52carbidopa-levodopa-entacapone 51carbinoxamine maleate 115carboplatin 44CARIMUNE NF 106carisoprodol 120carteolol hcl (ophth) 112carvedilol 73CAVAN PRENATAL/EC CALCIUM 125CAVAN-FOLATE OB 125CEDAX 22cefaclor 22cefaclor monohydrate 22cefadroxil 22cefazolin sodium 22cefdinir 22CEFDITOREN PIVOXIL 22cefepime hcl 22cefixime 22cefotaxime sodium 22cefotetan disodium 22cefoxitin sodium 22cefpodoxime proxetil 22cefprozil 22ceftazidime 23CEFTIBUTEN 23ceftriaxone sodium 23cefuroxime axetil 23cefuroxime sodium 23celecoxib 12CELLCEPT INTRAVENOUS 104CELONTIN 28

CENESTIN 97cephalexin 23CEREZYME 86CESAMET 36cetirizine hcl 9cetirizine hcl allergy child solution 5 mg/5ml 9,115cetirizine hcl chew tab 10 mg 9cetirizine hcl chew tab 5 mg 9cetirizine hcl tab 10 mg 10cetirizine-pseudoephedrine 10cevimeline hcl 83CHANTIX 18CHANTIX CONTINUING MONTH PAK 18CHANTIX STARTING MONTH PAK 18CHEMET 122childrens loratadine syrup 5 mg/5ml 10chloramphenicol sodium succinate 20chlordiazepoxide hcl-clidinium bromide 88chlorhexidine gluconate (mouth-throat) 83chloroquine phosphate 50chlorothiazide 76chlorpromazine hcl 52chlorpropamide 63chlorthalidone 76chlorzoxazone 120CHOLBAM 88cholestyramine 78cholestyramine light 78choline & mag salicylate 12chorionic gonadotropin 95CIALIS 91ciclopirox 36ciclopirox & vitamin e 36ciclopirox olamine 36cidofovir 56cilostazol 69cimetidine 7,88cimetidine hcl 88CIMZIA 104CIMZIA PREFILLED 104CIMZIA STARTER KIT 104

CIPRO HC 113CIPRODEX 113CIPROFLOXACIN 26ciprofloxacin 26ciprofloxacin hcl 26ciprofloxacin hcl (ophth) 26ciprofloxacin hcl (otic) 26ciprofloxacin in d5w 26ciprofloxacin-ciprofloxacin hcl 26cisplatin 44citalopram hydrobromide 32cladribine 43clarithromycin 25CLARITIN 10CLARITIN REDITABS 10clemastine fumarate 115CLIMARA PRO 97clindamycin hcl 20clindamycin palmitate hydrochloride 20clindamycin phosphate 20clindamycin phosphate (topical) 20,84clindamycin phosphate vaginal 20clindamycin phosphate-benzoyl peroxide 84clindamycin phosphate-benzoyl peroxide(refrigerate) 84CLINIMIX E/DEXTROSE (5/20) 125CLINIMIX/DEXTROSE (2.75/5) 125CLINIMIX/DEXTROSE (4.25/10) 125CLINIMIX/DEXTROSE (4.25/25) 125CLINIMIX/DEXTROSE (4.25/5) 125CLINIMIX/DEXTROSE (5/25) 125clobetasol propionate 92clobetasol propionate emollient base 92clocortolone pivalate 92CLODERM 92CLODERM PUMP 92CLOLAR 43clomipramine hcl 34clonazepam 62clonidine hcl 70clopidogrel bisulfate 69,70

clotrimazole 37clotrimazole (topical) 6,37clotrimazole vaginal 6clotrimazole w/ betamethasone 84clozapine 55CO-NATAL FA 125COARTEM 50codeine sulfate 15COLCHICINE 38colchicine w/ probenecid 38COLCRYS 38colestipol hcl 78COLY-MYCIN S 113COMBIGAN 113COMETRIQ (100 MG DAILY DOSE) 48COMETRIQ (140 MG DAILY DOSE) 48COMETRIQ (60 MG DAILY DOSE) 48COMPLERA 58COMPLETE-RF PRENATAL 125COMPLETENATE 125COPAXONE 82CORDRAN 93cortisone acetate 93CORTISPORIN 84CORTISPORIN-TC 113COSMEGEN 44COUMADIN 67CREON 87CRESTOR 77CRIXIVAN 60cromolyn sodium 120cromolyn sodium (ophth) 111CUBICIN 20CUPRIMINE 91cyclobenzaprine hcl 120cyclophosphamide 41CYCLOSERINE 41CYCLOSET 63cyclosporine 104cyclosporine modified (for microemulsion) 104cyproheptadine hcl 115

CYSTADANE 87CYSTAGON 91cytarabine 43

Ddacarbazine 42,109dactinomycin 44danazol 97dantrolene sodium 55dapsone 41DARAPRIM 50daunorubicin hcl 44DAUNOXOME 44decitabine 44DELFLEX-LC/1.5% DEXTROSE 122DELFLEX-LC/2.5% DEXTROSE 122demeclocycline hcl 27DENAVIR 62DEPO-ESTRADIOL 97DEPO-MEDROL 93DEPO-SUBQ PROVERA 104 101DEPOCYT 43DESCOVY 59desipramine hcl 34desloratadine 115desmopressin acetate 95desmopressin acetate spray refrigerated 95desogestrel-ethinyl estradiol (triphasic) 97Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01MG (Azurette, Kariva, Pimtrea, Viorele, Caziant,Cesia, Velivet) 97Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG (Apri, Emoquette, Enskyce, Reclipsen,Solia) 97desonide 93desoximetasone 93dexamethasone 93DEXAMETHASONE INTENSOL 93dexamethasone sodium phosphate 93dexamethasone sodium phosphate (ophth) 112DEXCHLORPHENIRAMINE MALEATE 115

DEXILANT 89dexmethylphenidate hcl 80dextroamphetamine sulfate 79,80DEXTROSE 5%/ELECTROLYTE #48 122dextrose in lactated ringers 122dextrose in ringers 122DIANEAL LOW CALCIUM/1.5% DEX 122DIANEAL PD-2/1.5% DEXTROSE 122DIANEAL PD-2/2.5% DEXTROSE 122DIANEAL PD-2/4.25% DEXTROSE 122DIASTAT ACUDIAL 28DIASTAT PEDIATRIC 28diazepam 62diazepam (anticonvulsant) 28diclofenac potassium 12diclofenac sodium 12diclofenac sodium (actinic keratoses) 84diclofenac sodium (ophth) 112diclofenac sodium (topical) 84diclofenac w/ misoprostol 12dicloxacillin sodium 24dicyclomine hcl 88didanosine 59DIFFERIN 84DIFICID 25diflorasone diacetate 93diflunisal 12digoxin 75dihydroergotamine mesylate 39DILANTIN 30DILANTIN INFATABS 30diltiazem hcl 73diltiazem hcl coated beads 74diltiazem hcl extended release beads 74DIPENTUM 107diphenhydramine hcl 115diphenhydramine hcl cap 50 mg 10,115diphenhydramine hcl elixir 12.5 mg/5ml 10,115diphenoxylate w/ atropine 88dipyridamole 70disopyramide phosphate 72

disulfiram 18divalproex sodium 28DIVIGEL 97DOCEFREZ 45DOCETAXEL 45docusate calcium 7docusate sodium 7docusate sodium cap 100 mg 7DOLGIC PLUS 81donepezil hydrochloride 31DORIBAX 23dorzolamide hcl 113dorzolamide hcl-timolol maleate 113doxazosin mesylate 70doxepin hcl 34doxercalciferol 107DOXIL 45DOXORUBICIN HCL 45doxorubicin hcl liposomal 45doxycycline (monohydrate) 27doxycycline hyclate 27DRISDOL 125dronabinol 36drospirenone-ethinyl estradiol 97Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG(Gianvi, Loryna, Nikki, Vestura, Ocella, Syeda,Zarah) 97DROXIA 43duloxetine hcl 82DUREZOL 112DYRENIUM 76DYSPORT 120

EE.E.S. 400 25EASIVENT 109econazole nitrate 37EDARBI 71EDECRIN 76EDURANT 58EFFIENT 70

ELAPRASE 87electrolyte-m in dextrose 123ELELYSO 87ELESTRIN 97ELEXA NATURAL FEEL 8ELEXA STIMULATING 8ELEXA ULTRA SENSITIVE 8ELIDEL 84ELIGARD 103ELIQUIS 67ELIXOPHYLLIN 118ELLA 101ELMIRON 91ELOXATIN 45ELSPAR 45EMADINE 111EMBEDA 13EMCYT 43EMEND 36EMSAM 32EMTRIVA 59ENABLEX 90enalapril maleate 71enalapril maleate & hydrochlorothiazide 75ENBREL 104ENBREL SURECLICK 104ENJUVIA 98enoxaparin sodium 67entacapone 51entecavir 56ENTEREG 88EPCLUSA 57EPIDUO 85epinastine hcl (ophth) 111EPINEPHRINE 117epinephrine hcl 117EPIPEN 117EPIPEN 2-PAK 117EPIPEN JR 117EPIPEN JR 2-PAK 117EPIRUBICIN HCL 45

EPIVIR 59EPIVIR HBV 56eplerenone 76EPOGEN 68eprosartan mesylate 71EPZICOM 59EQUETRO 63ERAXIS 37ERBITUX 49ergocalciferol 10,125ergoloid mesylates 30ERGOMAR 39ERIVEDGE 48ERTACZO 37ERWINAZE 45ERY-TAB 25ERYPED 400 25erythromycin (acne aid) 25erythromycin (ophth) 25ERYTHROMYCIN BASE 25erythromycin ethylsuccinate 25escitalopram oxalate 32,33esomeprazole magnesium 89estazolam 121ESTRACE 98ESTRADERM 98estradiol 98estradiol valerate 98ESTRASORB 98ESTROGEL 98estropipate 98eszopiclone 121ethambutol hcl 41ethosuximide 28Ethynodiol Diacetate & Ethinyl Estradiol Tab 1MG-35 MCG (Kelnor, Zovia) 98etidronate disodium 107etodolac 12ETOPOPHOS 47etoposide 47EURAX 50

EVAMIST 98EXALGO 13EXELDERM 37exemestane 47EXJADE 122EXTAVIA 82EXTRANEAL 123

FFABRAZYME 87FACTIVE 26famciclovir 62famotidine 7,88FAMOTIDINE PREMIXED 88FANAPT 53FANAPT TITRATION PACK 53FANTASY LUBRICATED 8FANTASY LUBRICATED/SPERMICIDE 8FARESTON 43FASLODEX 43FC FEMALE CONDOM 8FC2 FEMALE CONDOM 8felbamate 29felodipine 74FEMCAP 109FEMRING 98fenofibrate 77fenofibrate micronized 77fenoprofen calcium 12fentanyl 13fentanyl citrate 16FERRIPROX 122ferrous fumarate-folic acid 123ferrous sulfate 10fexofenadine hcl 10fexofenadine hcl tab 180 mg 10fexofenadine hcl tab 60 mg 10fexofenadine-pseudoephedrine 10FINACEA 85finasteride 91finasteride (alopecia) 85

FIRMAGON 103flavoxate hcl 90flecainide acetate 72FLECTOR 12FLOVENT DISKUS 114FLOVENT HFA 114floxuridine 43fluconazole 37flucytosine 37fludarabine phosphate 45fludrocortisone acetate 93flunisolide (nasal) 114fluocinolone acetonide 93fluocinolone acetonide (otic) 114fluocinonide 93fluocinonide emulsified base 93fluorometholone (ophth) 112fluorouracil 43fluorouracil (topical) 85fluoxetine hcl 33fluoxetine hcl (pmdd) 33fluphenazine hcl 52flurbiprofen 12flurbiprofen sodium 112flutamide 42fluticasone propionate 93fluticasone propionate (nasal) 114fluvastatin sodium 77fluvoxamine maleate 33FML 112FML FORTE 112folic acid 10,125FOLOTYN 43fondaparinux sodium 68FORADIL AEROLIZER 117FORTEO 108FOSAMAX PLUS D 108FOSCARNET SODIUM 56FOSCAVIR 56fosinopril sodium 71fosphenytoin sodium 30

FOSRENOL 92FRAGMIN 68FROVA 39furosemide 76FUZEON 60

Ggabapentin 28galantamine hydrobromide 31GAMMAGARD 106GAMMAGARD S/D 106GAMMAGARD S/D LESS IGA 106GAMMAKED 106GAMUNEX-C 106ganciclovir sodium 56gatifloxacin (ophth) 26gemcitabine hcl 44gemfibrozil 77GENOTROPIN 95GENOTROPIN MINIQUICK 95GENTAMICIN IN SALINE 19gentamicin sulfate 19gentamicin sulfate (ophth) 19GENVOYA 58GESTICARE 125GILENYA 82glatiramer acetate 82GLEEVEC 48GLEOSTINE 42glimepiride 63,64glipizide 64glipizide-metformin hcl 64GLUCAGEN DIAGNOSTIC 65GLUCAGEN HYPOKIT 65GLUCAGON EMERGENCY 65glyburide 64glyburide micronized 64glyburide-metformin 64glycine (gu irrigant) 91glycopyrrolate 88GLYSET 64

granisetron hcl 36griseofulvin microsize 37griseofulvin ultramicrosize 37guanabenz acetate 70guanfacine hcl 70guanfacine hcl (adhd) 80guanidine hcl 40GYNAZOLE-1 37

HHALAVEN 45halobetasol propionate 93HALOG 93haloperidol 52haloperidol decanoate 52haloperidol lactate 53HARVONI 57HECTOROL 108HEPARIN (PORCINE) IN NACL 68heparin sod (porcine) in d5w 68heparin sodium (porcine) 68HERCEPTIN 49HEXALEN 42HIZENTRA 106HORIZANT 82HUMALOG 65HUMALOG KWIKPEN 65HUMALOG MIX 50/50 66HUMALOG MIX 50/50 KWIKPEN 66HUMALOG MIX 50/50 PEN 66HUMALOG MIX 75/25 66HUMALOG MIX 75/25 KWIKPEN 66HUMALOG MIX 75/25 PEN 66HUMALOG PEN 66HUMATROPE 95HUMIRA 104HUMIRA PEDIATRIC CROHNS START 104HUMIRA PEN 104HUMIRA PEN-CROHNS STARTER 104HUMIRA PEN-PSORIASIS STARTER 105HUMULIN 70/30 66

HUMULIN 70/30 KWIKPEN 66HUMULIN 70/30 PEN 66HUMULIN N 66HUMULIN N KWIKPEN 66HUMULIN N PEN 66HUMULIN R 66HUMULIN R U-500 (CONCENTRATED) 66HYCAMTIN 47hydralazine hcl 79hydrochlorothiazide 76hydrocodone-acetaminophen 16hydrocodone-ibuprofen 16hydrocortisone 93hydrocortisone (intrarectal) 107hydrocortisone (rectal) 107hydrocortisone (topical) 7,85hydrocortisone acetate (rectal) 93hydrocortisone butyrate 93hydrocortisone valerate 94hydrocortisone w/acetic acid 114hydromorphone hcl 13,14,16hydroxychloroquine sulfate 50hydroxyurea 44hydroxyzine hcl 115hydroxyzine pamoate 116HYPERSAL 120

Iibandronate sodium 108ibuprofen 6,12idarubicin hcl 45IFEX 42ifosfamide 42ifosfamide & mesna 42ILEVRO 112imipenem-cilastatin 23imipramine hcl 35imipramine pamoate 35imiquimod 85IMPLANON 101INATAL ADVANCE 125

INATAL GT 125INATAL ULTRA 125INCIVEK 57INCRELEX 95INCRUSE ELLIPTA 116indapamide 76,77indomethacin 12INFERGEN 57INLYTA 48INTELENCE 58INTRON A 57INVANZ 23INVEGA 53,54INVIRASE 60INVOKANA 64IONOSOL-B IN D5W 123IONOSOL-MB IN D5W 123IOPIDINE 113ipratropium bromide 116ipratropium bromide (nasal) 116ipratropium-albuterol 120irbesartan 71irinotecan hcl 45IRINOTECAN HCL 45irrigation solutions, physiological 123ISENTRESS 58ISOLYTE-H IN D5W 123ISOLYTE-P IN D5W 123ISOLYTE-S 123ISOLYTE-S IN D5W 123isoniazid 41isoniazid & rifampin 41isosorbide dinitrate 79isosorbide mononitrate 79isotretinoin 85isradipine 74ISTODAX 46itraconazole 37ivermectin 49IXEMPRA KIT 46

JJADENU 122JAKAFI 48JANUVIA 64JEVTANA 46

KKALETRA 61KALYDECO 118KAMELEON LUBRICATED 8kanamycin sulfate 19KCL IN DEXTROSE-NACL 123KCL-LACTATED RINGERS-D5W 123KENALOG 94KEPIVANCE 83KETEK 26ketoconazole 37ketoconazole (topical) 37ketoprofen 12ketorolac tromethamine 12ketorolac tromethamine (ophth) 112ketotifen fumarate (ophth) 9KIMONO 8KIMONO MICRO THIN PLUS 8KIMONO PLUS 8KIMONO PS 8KIMONO PS PLUS 8KIMONO SENSATION 8KIMONO SENSATION PLUS 8KINERET 105KITABIS PAK 118KLOR-CON M15 123KUVAN 87KYPROLIS 48

Llabetalol hcl 73LACRISERT 111lactated ringer's 123lactated ringer's (irrigation) 125

lactic acid (ammonium lactate) 7,85LACTOCAL-F 125lactulose 89lactulose (encephalopathy) 89lamivudine 59lamivudine (hbv) 56lamivudine-zidovudine 59lamotrigine 29LANOXIN 75LANOXIN PEDIATRIC 75lansoprazole 7,90LANTUS 66LANTUS SOLOSTAR 66LASTACAFT 111latanoprost 113LATUDA 54LAVOCLEN-4 CREAMY WASH 85leflunomide 106LETAIRIS 118letrozole 47leucovorin calcium 46LEUKERAN 42LEUKINE 69leuprolide acetate 103levalbuterol hcl 117LEVATOL 73LEVEMIR 66LEVEMIR FLEXPEN 66LEVEMIR FLEXTOUCH 66levetiracetam 27levobunolol hcl 113levocetirizine dihydrochloride 116levofloxacin 26levofloxacin (ophth) 26levofloxacin in d5w 26Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth EstTab 0.01MG(7) (Amethia, Camrese, Daysee) 98Levonorgest-Eth Estrad 91-Day TAB 0.1-0.02 &0.01 MG (Amethia Lo, Camrese Lo, 98Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG(Introvale, Jolessa, Quasense) 99

levonorgestrel (emergency oc) 8,101Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG (Enpresse, Levonest, Myzilra,Trivora) 99Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG(Aubra, Aviane, Delyla, Falmina, Lessina, Lutera,Orsythia, Sronyx) 99Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG(Altavera, Chateal, Kurvelo, Levora, Marlissa,Portia) 99Levonorgestrel-Ethinyl Estradiol (Continuous) Tab90-20 MCG (Amethyst) 99levorphanol tartrate 14levothyroxine sodium 102LEXIVA 61LIALDA 107lidocaine 85lidocaine hcl 6,17,85lidocaine hcl (local anesth.) 17lidocaine hcl (mouth-throat) 17lidocaine-prilocaine 18LILETTA (52 MG) 101LINCOCIN 20lindane 50linezolid 20LINEZOLID IN SODIUM CHLORIDE 20liothyronine sodium 102lisinopril 71lisinopril & hydrochlorothiazide 75lithium 63lithium carbonate 63LIVALO 77LO LOESTRIN FE 99lomustine 42loperamide hcl 7,88loratadine & pseudoephedrine 10loratadine allergy relief tab disp 10 mg 10loratadine tab 10 mg 10lorazepam 62losartan potassium 71losartan potassium & hydrochlorothiazide 75

LOTEMAX 112LOTRIMIN ULTRA 6lovastatin 77loxapine succinate 53LUFYLLIN 118LUMIGAN 113LUMIZYME 87LUPRON DEPOT 103LUPRON DEPOT-PED 103LYRICA 82LYSODREN 46

MM-VIT 125mafenide acetate 20MAGNESIUM SULFATE 123malathion 50maprotiline hcl 33MARNATAL-F PLUS DUO PACK 126MARPLAN 32MATULANE 42MAXAIR AUTOHALER 117MAXIDEX 112MAXX 8MAXX PLUS 8mebendazole 50meclizine hcl 6,35meclofenamate sodium 12MEDROL 94medroxyprogesterone acetate 101medroxyprogesterone acetate (contraceptive) 101mefenamic acid 13mefloquine hcl 50megestrol acetate 102megestrol acetate (appetite) 102meloxicam 13melphalan hcl 42memantine hcl 31MENEST 99MENOSTAR 99MENTAX 37

meperidine hcl 16meprobamate 62mercaptopurine 44meropenem 23mesalamine 107MESTINON 40metaproterenol sulfate 118metaxalone 120metformin hcl 64methadone hcl 14methamphetamine hcl 80methazolamide 113methenamine hippurate 20methimazole 104METHITEST 97methocarbamol 120methotrexate sodium 105methoxsalen rapid 85methscopolamine bromide 88methyclothiazide 77methyldopa 70methyldopate hcl 70methylphenidate hcl 80,81METHYLPHENIDATE HCL ER 81methylprednisolone 94methylprednisolone acetate 94methylprednisolone sod succ 94metipranolol 113metoclopramide hcl 35metolazone 77metoprolol succinate 73metoprolol tartrate 73metronidazole 21metronidazole (topical) 21metronidazole cream 0.75 % 21metronidazole gel 0.75 % 21metronidazole vaginal 21mexiletine hcl 72MICONAZOLE 3 37midodrine hcl 70MIGRANAL 39

MILLIPRED 94MILLIPRED DP 94MILLIPRED DP 12-DAY 94MINASTRIN 24 FE 99MINIVELLE 99minocycline hcl 27minoxidil 79MIRENA (52 MG) 102mirtazapine 32misoprostol 89MITOMYCIN 46mitoxantrone hcl 46modafinil 121moexipril hcl 71mometasone furoate 94montelukast sodium 116MONUROL 21morphine sulfate 14,16,17morphine sulfate er (tab 15 mg, tab 30 mg, tab 60mg, tab 100 mg, tab 200 mg) 14MOTOFEN 88MOVIPREP 89moxifloxacin hcl 26MOZOBIL 69MULTAQ 72MULTI PRENATAL 11mupirocin 21mupirocin calcium (topical) 21MUSTARGEN 42MYCAMINE 37mycophenolate mofetil 105mycophenolate sodium 105MYLERAN 42MYNATAL 126MYNATAL ADVANCE 126MYNATAL PLUS 126MYNATAL-Z 126MYNATE 90 PLUS 126MYOZYME 87MYRBETRIQ 90MYTELASE 40

Nnabumetone 13nadolol 73nafcillin sodium 24NAFTIFINE HCL 37NAFTIN 37NAGLAZYME 87nalbuphine hcl 17naloxone hcl 18naltrexone hcl 18NAMENDA 31naproxen 13naproxen sodium 13naratriptan hcl 39NASONEX 115NATACHEW 126NATACYN 37NATAL-V RX 126NATALVIT 126NATAZIA 99nateglinide 64NATROBA 50NEBUPENT 50NEBUSAL 120NECON 10/11 (28) 99nefazodone hcl 33neomycin sulfate 19neomycin-bacitracin zn-polymyxin 111neomycin-polymy-dexameth 111neomycin-polymyxin-hc (ophth) 111neomycin-polymyxin-hc (otic) 114NEULASTA 69NEULASTA ONPRO 69NEUPOGEN 69NEUPRO 51NEVANAC 112nevirapine 58NEXAVAR 48NEXIUM 90NEXIUM 24HR 7

NEXPLANON 102niacin (antihyperlipidemic) 78nicardipine hcl 74nicotine 6nicotine polacrilex 6NICOTROL 19NICOTROL NS 19nifedipine 74NILANDRON 42nimodipine 74NINLARO 48NIPENT 44nisoldipine 74NITRO-BID 79nitrofurantoin 21nitrofurantoin macrocrystal 21nitrofurantoin monohyd macro 21nitroglycerin 79NITROSTAT 79NIVA-PLUS 126nizatidine 88NORDITROPIN 95NORDITROPIN FLEXPRO 95NORDITROPIN NORDIFLEX PEN 96Norelgestromin-Ethinyl Estradiol TD PTWK 150-35MCG/24HR (Xulane) 99Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35MCG (Balziva, Briellyn, Gildagia, Philith, Vyfemla,Zenchent) 99Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35MCG (Necon, Nortrel, Wera) 99Norethindrone & Ethinyl Estradiol Tab 1 MG-35MCG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,Pirmella) 100norethindrone & ethinyl estradiol-fe 100Norethindrone & Ethinyl Estradiol-Fe Chew Tab0.4 MG-35 MCG (Wymzya, Zenchent, Zeosa) 100Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-35 MG-MCG (Tilia, Tri-Legest) 100Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20 MCG (Gildess, Junel, Larin, Microgestin) 100

Norethindrone Ace & Ethinyl Estradiol Tab 1.5MG-30 MCG (Gildess, Junel, Larin,Microgestin) 100Norethindrone Ace & Ethinyl Estradiol-FE Tab 1MG-20 MCG (Gildess, Junel, Larin,Microgestin) 100Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5MG-30 MCG (Gildess, Junel, Larin,Microgestin) 100Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20 MCG (Lomedia) 100norethindrone acetate 102Norethindrone Tab 0.35 MG (Camila, Deblitane,Errin, Heather, Jencycla, Jolivette, Lyza, Nora-BE,Norlyroc, Sharobel) 102Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG (Alyacen, Cyclafem, Dasetta, Necon,Nortrel, Pirmella) 100Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG (Aranelle, Leena) 100Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35MCG (Estarylla, Mono-Linyah, MonoNessa,Previfem, Sprintec) 100Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-Sprintec, Trinessa) 101Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30MCG (Cryselle, Elinest, Low-Ogestrel) 101NORMOSOL-M IN D5W 123NORMOSOL-R PH 7.4 123NOROXIN 26nortriptyline hcl 35NORVIR 61NOVOLIN 70/30 66NOVOLIN 70/30 RELION 66NOVOLIN N 66NOVOLIN N RELION 66NOVOLIN R 66NOVOLIN R RELION 67NOVOLOG 67NOVOLOG FLEXPEN 67

NOVOLOG MIX 70/30 67NOVOLOG MIX 70/30 FLEXPEN 67NOVOLOG PENFILL 67NOXAFIL 37NPLATE 69NUCYNTA 17NUCYNTA ER 14NUEDEXTA 82NULOJIX 105NUTROPIN 96NUTROPIN AQ 96NUTROPIN AQ NUSPIN 10 96NUTROPIN AQ PEN 96NUVARING 101NUVIGIL 121nystatin 38nystatin (mouth-throat) 38nystatin (topical) 38,109nystatin-triamcinolone 38

OO-CAL FA 126O-CAL PRENATAL 126octreotide acetate 103ODEFSEY 58ofloxacin 26ofloxacin (ophth) 26ofloxacin (otic) 26OFORTA 46OGESTREL 101olanzapine 54OLEPTRO 33olopatadine hcl (nasal) 116omega-3-acid ethyl esters 78omeprazole 90omeprazole delayed release tab 20 mg 7omeprazole magnesium 7omeprazole-sodium bicarbonate 7,90OMNIFLEX DIAPHRAGM 109OMNITROPE 96OMONTYS 69

ONCASPAR 46ondansetron hcl 36ondansetron orally disintegrating tab 4 mg 36ondansetron orally disintegrating tab 8 mg 36ondansetron orally disintegrating tab 8 mg 36ONFI 28ONGLYZA 64ONTAK 46OPANA ER 14OPTICHAMBER ADVANTAGE 109OPTICHAMBER ADVANTAGE-LG MASK 109OPTICHAMBER ADVANTAGE-MED MASK 109OPTICHAMBER ADVANTAGE-SM MASK 109OPTICHAMBER DIAMOND 109OPTICHAMBER DIAMOND-LG MASK 109OPTICHAMBER DIAMOND-MD MASK 109OPTICHAMBER DIAMOND-SM MASK 110ORAP 53ORAPRED ODT 94ORENCIA 105ORFADIN 87orphenadrine citrate 120ORTHO DIAPHRAGM ALL-FLEX 110ORTHO DIAPHRAGM COIL 110ORTHO DIAPHRAGM FLAT 110ORTHO TRI-CYCLEN LO 101OSMOPREP 89oxacillin sodium 24oxaliplatin 46oxandrolone 96oxaprozin 13oxcarbazepine 30OXISTAT 38OXSORALEN 85oxybutynin chloride 90oxycodone hcl 14,17oxycodone w/ acetaminophen 17oxycodone-ibuprofen 17OXYCONTIN 14oxymorphone hcl 14,15,17OXYMORPHONE HCL ER 15

Ppaclitaxel 46PAMIDRONATE DISODIUM 108PANCREAZE 87pancrelipase (lipase-protease-amylase) 87PANRETIN 49pantoprazole sodium 90PARAGARD INTRAUTERINE COPPER 110parenteral electrolytes 123paricalcitol 108paromomycin sulfate 19paroxetine hcl 33PASER 41PATADAY 111PATANOL 111PAXIL 33peg 3350-kcl-sod bicarb-sod chloride-sodsulfate 89PEG-INTRON 57PEG-INTRON REDIPEN 57PEG-INTRON REDIPEN PAK 4 57PEGANONE 30PEGASYS 57PEGASYS PROCLICK 57PEGINTRON 57PENICILLIN G POT IN DEXTROSE 24penicillin g potassium 24PENICILLIN G PROCAINE 24penicillin g sodium 24penicillin v potassium 25PENTAM 50PENTASA 107pentazocine w/ naloxone 17pentostatin 44pentoxifylline 75perindopril erbumine 71peritoneal dialysis solutions 123PERJETA 49permethrin 50perphenazine 35

perphenazine-amitriptyline 32phenazopyridine hcl 91phenelzine sulfate 32phenobarbital 28phenoxybenzamine hcl 70PHENYTEK 30phenytoin 30phenytoin sodium 30phenytoin sodium extended 30PHISOHEX 110PHOSLYRA 92PHOSPHOLINE IODIDE 113PHOTOFRIN 46PICATO 85pilocarpine hcl 113pilocarpine hcl (oral) 83pindolol 73pioglitazone hcl 64pioglitazone hcl-metformin hcl 65piperacillin sodium-tazobactam sodium 25piroxicam 13PLASMA-LYTE 148 123PLASMA-LYTE A 123PLASMA-LYTE-56 IN D5W 123PNV FOLIC ACID + IRON 126PNV PRENATAL PLUS MULTIVITAMIN 11,126PNV TABS 29-1 126PNV-VP-U 126podofilox 85polymyxin b sulfate 21polymyxin b-trimethoprim 111potassium acetate 123potassium bicarb & chloride 124potassium bicarbonate 124potassium chloride 124potassium chloride in dextrose 124potassium chloride in dextrose & sodiumchloride 124potassium chloride in nacl 124potassium chloride microencapsulated crystalscr 124

potassium citrate (alkalinizer) 91potassium phosphates 124POTIGA 27PRADAXA 68pramipexole dihydrochloride 51PRANDIMET 65pravastatin sodium 77prazosin hcl 70PRE-NATAL FORMULA 11PRED MILD 112prednicarbate 94prednisolone 94prednisolone acetate (ophth) 112prednisolone sodium phosphate 94PREDNISOLONE SODIUM PHOSPHATE 112prednisone 94PREMARIN 101PREMIUM CONDOMS LUBRICATED 8PREMPHASE 101PREMPRO 101PRENACARE 126PRENAFIRST 126PRENAPLUS 126PRENATABS FA 126PRENATABS RX 126PRENATAL 11,126PRENATAL 19 126PRENATAL AD 126PRENATAL LOW IRON 11,127prenatal multivit-min w/fe-fa 11PRENATAL ONE DAILY 11PRENATAL PLUS 127PRENATAL PLUS IRON 127prenatal vit w/ ferrous fumarate-folic acid 10PRENATAL VITAMINS PLUS 127PRENATAL-U 127PRENATAL/IRON 11PRENTIF FITTING SET 110PREPLUS 127PREPOPIK 89PRETAB 127

PREZISTA 61PRIFTIN 41PRILOSEC OTC 8primaquine phosphate 50primidone 28PRISTIQ 33,34PROAIR HFA 118probenecid 38PROCAINAMIDE HCL 72prochlorperazine 35prochlorperazine maleate 35PROCRIT 69progesterone micronized 102PROGLYCEM 65PROGRAF 105PROLASTIN 120PROLASTIN-C 120PROLEUKIN 46PROLIA 108PROMACTA 69promethazine hcl 116promethazine hcl suppos 25 mg 116propafenone hcl 72proparacaine hcl 111propranolol hcl 73propylthiouracil 104protriptyline hcl 35PROVENTIL HFA 118PRUDOXIN 85PSORCON 95PULMICORT FLEXHALER 115PULMOZYME 120pyrazinamide 41pyridostigmine bromide 40

Qquetiapine fumarate 54quinapril hcl 71quinidine sulfate 72quinine sulfate 50QVAR 115

Rrabeprazole sodium 90raloxifene hcl 102ramipril 71RANEXA 75ranitidine hcl 7,89RAPAFLO 91RAPAMUNE 105RE PRENATAL MULTIVITAMIN/IRON 127RE-NATA 29 OB 127REALITY LATEX/ULTRA TEXTURED 8REALITY LATEX/ULTRA THIN 8REBETOL 57REBIF 83REBIF REBIDOSE 83REBIF REBIDOSE TITRATION PACK 83REBIF TITRATION PACK 83RECTIV 85REGRANEX 85RELENZA DISKHALER 61RELION 70/30 67RELION N 67RELION R 67RELISTOR 88RELPAX 39REMICADE 105REMODULIN 119RENAGEL 92REOPRO 70repaglinide 65RESCRIPTOR 58RESECTISOL 91RESTASIS 111RETROVIR 59REVLIMID 43REYATAZ 61RHEUMATREX 105ribavirin (hepatitis c) 58RIDAURA 106rifabutin 41

RIFAMATE 41rifampin 41RIFATER 41RIGHT STEP PRENATAL 11riluzole 82rimantadine hydrochloride 61ringer's 124ringer's irrigation 124risedronate sodium 108RISPERDAL CONSTA 54risperidone 54,55risperidone odt (tab 3 mg, tab 4 mg) 54risperidone orally disintegrating tab 0.25 mg 54risperidone orally disintegrating tab 0.5 mg 54risperidone orally disintegrating tab 1 mg 54risperidone orally disintegrating tab 2 mg 55RITUXAN 49rivastigmine tartrate 31rizatriptan benzoate 39,40rizatriptan benzoate odt 10 mg 39rizatriptan benzoate odt 5 mg 39ropinirole hydrochloride 51,52ROZEREM 121

SSABRIL 28SAFYRAL 101SAIZEN 96SAIZEN CLICK.EASY 96salsalate 13SAMSCA 122SANTYL 85SAPHRIS 55SAVELLA 82SAVELLA TITRATION PACK 82SE-NATAL 19 127SE-NATAL 90 127SE-NATAL ONE 127selegiline hcl 52selenium sulfide 85SELZENTRY 60

SENSIPAR 103SEREVENT DISKUS 118SEROMYCIN 41SEROQUEL XR 55SEROSTIM 96sertraline hcl 34sildenafil citrate (pulmonary hypertension) 119silver sulfadiazine 27SIMCOR 78SIMPONI 105SIMULECT 106simvastatin 77sirolimus 105SKELID 108SKLICE 50SKYLA 102sodium acetate 124sodium chloride 124sodium chloride (gu irrigant) 91sodium chloride (inhalant) 120sodium citrate & citric acid 91sodium phenylbutyrate 87sodium phosphate 124sodium polystyrene sulfonate 122sodium polystyrene sulfonate (bulk) 110SOLTAMOX 43SOLU-CORTEF 95SOLU-MEDROL 95SOMATULINE DEPOT 103SOMAVERT 103SORBITOL 92SORBITOL-MANNITOL 92sotalol hcl 72SOVALDI 58SPECTRACEF 23SPINOSAD 50SPIRIVA HANDIHALER 116SPIRIVA RESPIMAT 116spironolactone 76spironolactone & hydrochlorothiazide 75SPORANOX 38

SPRYCEL 48stannous fluoride 6,83stavudine 59STELARA 85STENDRA 92STIMATE 96STIVARGA 48STRATTERA 81streptomycin sulfate 19SUBOXONE 18SUCRAID 87sucralfate 89sulfacetamide sodium (acne) 85sulfacetamide sodium (ophth) 27sulfacetamide sodium w/ sulfur 86sulfadiazine 27sulfamethoxazole-trimethoprim 27SULFAMYLON 21sulfasalazine 107sulindac 13sumatriptan nasal spray (5 mg/act, 20 mg/act) 40sumatriptan succinate 40SUPRAX 23SUPREP BOWEL PREP 89SUSTIVA 58,59SUTENT 48SYLATRON 46SYMBICORT 120SYMLINPEN 120 65SYMLINPEN 60 65SYNAREL 103SYNERA 86SYNRIBO 46SYPRINE 122

TTABLOID 44TACLONEX 86tacrolimus 105tacrolimus (topical) 86TALWIN 17

TAMIFLU 61tamoxifen citrate 43tamsulosin hcl 91TARCEVA 48TARGRETIN 49TASIGNA 48TAXOTERE 46TAZORAC 86TEFLARO 23TEGRETOL 30TEKTURNA 75telmisartan 71TEMODAR 42temozolomide 42TENIPOSIDE 46terazosin hcl 91terbinafine hcl 38terbutaline sulfate 118terconazole vaginal 38testosterone cypionate 97testosterone enanthate 97tetrabenazine 82tetracycline hcl 27TEV-TROPIN 96TEVETEN 71THALOMID 43THEO-24 118theophylline 118THERANATAL CORE NUTRITION 11thioridazine hcl 53thiotepa 46thiothixene 53THRIVITE RX 127THYMOGLOBULIN 106THYROLAR-1 102THYROLAR-1/2 102THYROLAR-1/4 102THYROLAR-2 102THYROLAR-3 102tiagabine hcl 28ticlopidine hcl 70

TIKOSYN 72TIMENTIN 25timolol maleate 73timolol maleate (ophth) 113TIVICAY 58tizanidine hcl 55TOBRADEX 19tobramycin 118tobramycin (ophth) 19tobramycin sulfate 19,110TOBRAMYCIN SULFATE IN SALINE 19tobramycin-dexamethasone 111tolazamide 65tolbutamide 65tolcapone 51tolmetin sodium 13tolterodine tartrate 90topiramate 29topotecan hcl 47TORISEL 48torsemide 76TOVIAZ 90TRACLEER 119TRADJENTA 65tramadol hcl 15,17tramadol-acetaminophen 17trandolapril 72tranexamic acid 69TRANSDERM-SCOP (1.5 MG) 35tranylcypromine sulfate 32TRAVATAN Z 113trazodone hcl 34TREANDA 42TRECATOR 41TRELSTAR 103TRELSTAR DEPOT MIXJECT 103TRELSTAR LA MIXJECT 103TRELSTAR MIXJECT 103tretinoin 86tretinoin (chemotherapy) 49tretinoin microsphere 86

TREXALL 105TRIADVANCE 127triamcinolone acetonide (mouth) 95triamcinolone acetonide (topical) 95triamcinolone acetonide cream 0.5% 95triamcinolone acetonide oint 0.5% 95triamterene & hydrochlorothiazide 75triazolam 121TRICARE 127trifluoperazine hcl 53trifluridine 62trihexyphenidyl hcl 51trimethobenzamide hcl 35trimethoprim 21trimipramine maleate 35TRINATAL GT 127TRINATAL RX 1 127TRINATAL ULTRA 127TRISENOX 47TRIVEEN-U 127TROJAN MAGNUM WARM SENSATIONS 9TROJAN SUPRAS SPERMICIDAL 9TROJAN TWISTED PLEASURE 9tropicamide 111trospium chloride 91TRUSTEX COLOR CONDOMS + LUBE 9TRUSTEX LUB/RIBBED/STUDDED 9TRUSTEX LUB/SPERMICIDE EX ST 9TRUSTEX LUB/SPERMICIDE XL 9TRUSTEX LUBRICATED 9TRUSTEX LUBRICATED EX LARGE 9TRUSTEX LUBRICATED EXTRA ST 9TRUSTEX LUBRICATED/SPERMICIDE 9TRUSTEX NATURAL CONDOMS + LUBE 9TRUSTEX RIA LUB/SPERMICIDE 9TRUSTEX RIA LUBRICATED 9TRUSTEX-NONOXYNOL-9/RIB/STUD 9TRUVADA 60TWINJECT 118TYGACIL 21TYKERB 48

TYSABRI 83TYZEKA 56TYZINE 120

UULESFIA 50ULORIC 38ULTRABAG/DIANEAL PD-2/1.5% DEX 124ULTRABAG/DIANEAL PD-2/2.5% DEX 125ULTRABAG/DIANEAL PD-2/4.25%DEX 125ULTRABAG/DIANEAL/1.5% DEXTROSE 125ULTRABAG/DIANEAL/4.25% DEX 125ursodiol 88UVADEX 47

Vvalacyclovir hcl 62VALCYTE 56valganciclovir hcl 56valproate sodium 29valproic acid 29valsartan 71valsartan-hydrochlorothiazide 75VALSTAR 47VALVED HOLDING CHAMBER 110vancomycin hcl 21VANDETANIB 48VECTIBIX 49VECTICAL 86VELCADE 47VELTIN 86VENATAL-FA 127venlafaxine hcl 34VENLAFAXINE HCL ER 34VENTAVIS 119VENTOLIN HFA 118verapamil hcl 74VEREGEN 86VERIPRED 20 95VESICARE 91VEXOL 112

VIBATIV 21VICTOZA 65VICTRELIS 58VIDEX EC 60VIIBRYD 34VIMPAT 30VINATE CALCIUM 127VINATE GT 127VINATE M 127VINATE ONE 127VINATE ULTRA 127vinblastine sulfate 47vincristine sulfate 47vinorelbine tartrate 47VIRACEPT 61VIRAMUNE 59VIREAD 60VIRT-ADVANCE 128VIRT-VITE GT 128VISICOL 89VISTOGARD 110VITAFOL-OB 128VITAFOL-PN 128VITASPIRE 128VITRASERT 111VOL-PLUS 128VOL-TAB RX 128VOLTAREN 86VORAXAZE 47voriconazole 38VOTRIENT 48VPRIV 87VUMON 47VYTORIN 78VYVANSE 80

Wwarfarin sodium 68water for irrigation, sterile 110WELCHOL 78WIDE-SEAL DIAPHRAGM 60 110

WIDE-SEAL DIAPHRAGM 65 110WIDE-SEAL DIAPHRAGM 70 110WIDE-SEAL DIAPHRAGM 75 110WIDE-SEAL DIAPHRAGM 80 110WIDE-SEAL DIAPHRAGM 85 110WIDE-SEAL DIAPHRAGM 90 110WIDE-SEAL DIAPHRAGM 95 110

XXALKORI 48XARELTO 68XELJANZ 105XEOMIN 120XGEVA 108XIFAXAN 21XOLAIR 120XOPENEX HFA 118XTANDI 42XYREM 122

YYERVOY 49

Zzafirlukast 116zaleplon 121ZALTRAP 47ZANOSAR 42ZAVESCA 87ZELBORAF 49ZEMAIRA 120ZENPEP 87ZETIA 78ZIAGEN 60ZIANA 86zidovudine 60ZINBRYTA 83ZIOPTAN 113ziprasidone hcl 55ZIRGAN 56ZOHYDRO ER 15

ZOLADEX 104zoledronic acid 108ZOLINZA 47zolmitriptan 40zolpidem tartrate 121ZOMACTON 96ZOMETA 108ZOMIG 40ZONALON 86zonisamide 28ZORBTIVE 96ZORTRESS 105ZOVIA 1/50E (28) 101ZOVIRAX 62ZYFLO CR 116ZYTIGA 43ZYVOX 22

comprehensive preferred drug list - sunshine health · 2020-05-14 · page 2 last updated 12/2016...

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