formulary - epiphanyrx · 2021. 2. 17. · quantity limits (ql) - for certain drugs, the amount of...

Formulary

© EpiphanyRx, LLC. All Rights Reserved 11/30/2020

EpiphanyRx Formulary

Welcome to EpiphanyRx! We are excited to serve you and manage your prescription drug benefits. This drug list,

or formulary, contains important information about drug coverage. Our team of pharmacists, nurses, doctors,

statisticians and healthcare economists review drugs approved by the U.S. Food and Drug Administration (FDA)

to determine coverage for you and your employer. This drug list is regularly updated and subject to change at

any time.

About the list

You can use this list to find information about drug coverage and therapeutic options. You can search for a drug

name by downloading the document and clicking on Edit and then selecting Find/Search or by using the Control

and F keys on your keyboard. After typing in the drug name, click Search to find your drug. It is always an option

to bring this list with you to your next doctor’s appointment. You can use the information from this list to talk

with your doctor about potential lower-cost drug options.

On the list, each drug is identified with a tier value based on the drug’s cost to the plan. Tier 1 drugs are the lowest cost drugs to the plan and Tier 3 are the highest cost drugs to the plan. Your plan may cover specialty drugs in Tier 4. Tiers are important because the amount you pay is based on the drug tier. You can receive up to a 30-day supply of most medications on the formulary. Some drugs, like diabetes and drugs to help with heart conditions, may be covered for up to a 90-day supply. If you are interested in which drugs may qualify, please reference the Maintenance Drug list

located at https://epiphanyrx.com/resources/members/.

While this drug list is a good guide, it is good idea to check your Summary Plan Description to confirm the amount you will pay and what coverage your plan allows.

Some FDA-approved drugs may not be covered by the plan if they have over-the-counter (OTC) equivalents or provide

low-value as compared to other drugs available on the plan’s formulary. Not all FDA-approved indications or uses may

be covered for a drug if multiple uses exist. Your prescription drug benefit plan may not cover certain products or drug

categories regardless of the appearance in this document. Your Summary Plan Document is a good place to go to better

understand exclusions. You can always call us if you have questions, by dialing 844-820-3260.

Under the Affordable Care Act, certain preventative medications may be covered at a $0 copay. Please refer to the

Affordable Care Act Preventative drug list located at https://epiphanyrx.com/resources/members/for these drugs.

https://epiphanyrx.com/resources/members/

https://epiphanyrx.com/resources/members/


Legend

Prior Authorization (PA) – The Plan requires a review to determine if the drug qualifies for coverage under the

benefit. If your physician prescribes a drug that requires a prior authorization, the PBM will work with your

prescriber to complete the prior authorization review. Either you or the pharmacy can ask your doctor to call

844-820-3260 to initiate the prior authorization or appeal process.

Quantity Limits (QL) - For certain drugs, the amount of the drug that will be covered by the plan is limited based on national standards and current scientific literature. These limits ensure the quantity of units supplied for each prescription remain consistent with clinical dosing guidelines and benefit plan design.

Tier (T#)– The value that determines the copayment in which you pay for the medication. Every drug will be given a tier value. Refer to your Summary Plan Design document for the specific copayment.

Specialty Drugs – Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis. Specialty drugs must be obtained from a select pharmacy and are limited to 30-day supply.

Non-Essential Health Benefit Drugs - Your plan may cover select Non-Essential Health Benefits (Non-EHB) Drugs at the tiers outlined below. Any amount you pay for Non-Essential Health Benefits Drugs will NOT count toward your deductible and/or out of pocket maximum.


Drug Name Route Tier Specialty PA QL Non- EHB

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

Adderall XR Oral 2

Adzenys XR-ODT Oral 3

Amphetamine ER Oral 3

Amphetamine Sulfate Oral 1

Amphetamine-Dextroamphet ER Oral 1

Amphetamine-Dextroamphetamine Oral 1

Armodafinil Oral 1

Atomoxetine HCl Oral 1

Caffeine Citrate Oral 1

cloNIDine HCl ER Oral 1

Concerta Oral 2

Daytrana Transdermal 3

Dexmethylphenidate HCl Oral 1

Dexmethylphenidate HCl ER Oral 1

Dextroamphetamine Sulfate Oral 1

Dextroamphetamine Sulfate ER Oral 1

Dyanavel XR Oral 3

guanFACINE HCl ER Oral 1

Jornay PM Oral 3 Y

Metadate ER Oral 2

Methylphenidate HCl Oral 1

Methylphenidate HCl ER Oral 1

Methylphenidate HCl ER (CD) Oral 1

Methylphenidate HCl ER (LA) Oral 1

Methylphenidate HCl ER (XR) Oral 1

Methylphenidate HCl ER (XR) Oral 3

Modafinil Oral 1

Nuvigil Oral 3

Provigil Oral 3

QuilliChew ER Oral 3

Quillivant XR Oral 3

Sunosi Oral 3 Y Y

Vyvanse Oral 2 Y

Zenzedi Oral 2

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Adagen Intramuscular 3 Y Y



AMINOGLYCOSIDES

Bethkis Inhalation 3 Y Y Y

Kitabis Pak Inhalation 3 Y Y Y

Neomycin Sulfate Oral 1

Paromomycin Sulfate Oral 1

Tobi Inhalation 3 Y Y Y

Tobi Podhaler Inhalation 3 Y Y Y

Tobramycin Inhalation 1 Y Y Y

ANALGESICS - ANTI-INFLAMMATORY

Actemra Subcutaneous 2 Y Y

Actemra ACTPen Subcutaneous 2 Y Y

Arava Oral 3

Arcalyst Subcutaneous 3 Y Y

CeleBREX Oral 3

Celecoxib Oral 1

Daypro Oral 3

Diclofenac Potassium Oral 1 Y

Diclofenac Sodium ER Oral 1

Diclofenac-miSOPROStol Oral 1

Enbrel Subcutaneous 2 Y Y Y

Enbrel Mini Subcutaneous 2 Y Y

Enbrel SureClick Subcutaneous 2 Y Y Y

Etodolac Oral 1

Etodolac ER Oral 1

Feldene Oral 3

Fenoprofen Calcium Oral 1

Fenortho Oral 3

Flurbiprofen Oral 1 Y

Humira Subcutaneous 2 Y Y Y

Humira Pediatric Crohns Start Subcutaneous 2 Y Y Y

Humira Pen Subcutaneous 2 Y Y Y

Humira Pen-CD/UC/HS Starter Subcutaneous 2 Y Y Y

Humira Pen-Ps/UV/Adol HS Start Subcutaneous 2 Y Y Y

IBU Oral 1

Ibuprofen Oral 1

Ilaris Subcutaneous 2 Y Y

Indocin Oral 3



Indocin Rectal 3

Indomethacin Oral 1

Indomethacin ER Oral 1

Ketoprofen Oral 1 Y

Ketoprofen ER Oral 1 Y

Ketorolac Tromethamine Oral 1

Kevzara Subcutaneous 3 Y Y

Kineret Subcutaneous 3 Y Y Y

Leflunomide Oral 1

Lodine Oral 3

Meclofenamate Sodium Oral 1

Mefenamic Acid Oral 1

Meloxicam Oral 1 Y

Mobic Oral 3 Y

Nabumetone Oral 1

Naproxen Oral 1

Naproxen DR Oral 1

Naproxen Sodium Oral 1

Olumiant Oral 3 Y Y

Orencia Subcutaneous 3 Y Y

Orencia ClickJect Subcutaneous 3 Y Y

Otezla Oral 2 Y Y

Otezla Oral 3 Y Y

Otrexup Subcutaneous 3 Y

Oxaprozin Oral 1

Piroxicam Oral 1

Ponstel Oral 3

ProFeno Oral 3

Ridaura Oral 3

Rinvoq Oral 2 Y Y

Simponi Subcutaneous 3 Y Y Y

Sulindac Oral 1

Tolmetin Sodium Oral 1

Xeljanz Oral 2 Y Y Y

Xeljanz XR Oral 2 Y Y Y

ANALGESICS - NonNarcotic

Bupap Oral 1



Butalbital-Acetaminophen Oral 1 Y

Butalbital-APAP Oral 1 Y

Butalbital-APAP-Caffeine Oral 1 Y

Butalbital-ASA-Caffeine Oral 1

Butalbital-Aspirin-Caffeine Oral 1

Capacet Oral 1 Y

Diflunisal Oral 1

Esgic Oral 3 Y

Fioricet Oral 3 Y

Margesic Oral 1 Y

Marten-Tab Oral 1 Y

Phrenilin Forte Oral 1 Y

Salsalate Oral 1

Tencon Oral 2 Y

Vanatol S Oral 3

Vtol LQ Oral 3

Zebutal Oral 1 Y

ANALGESICS - OPIOID

Abstral Sublingual 3 Y Y

Acetaminophen-Codeine Oral 1 Y

Acetaminophen-Codeine #2 Oral 1 Y



Actiq Buccal 3 Y Y

APAP-Caff-Dihydrocodeine Oral 1 Y

Ascomp-Codeine Oral 1 Y

Aspirin-Caff-Dihydrocodeine Oral 1 Y

Bunavail Buccal 3 Y

Buprenorphine Transdermal 1 Y

Buprenorphine HCl Sublingual 1 Y

Buprenorphine HCl-Naloxone HCl Sublingual 1 Y

Butalbital-APAP-Caff-Cod Oral 1 Y

Butalbital-ASA-Caff-Codeine Oral 1 Y

Butorphanol Tartrate Nasal 1 Y

Butrans Transdermal 3 Y

Codeine Sulfate Oral 1 Y

Duragesic-12 Transdermal 3 Y






Embeda Oral 3 Y

Endocet Oral 1 Y

fentaNYL Transdermal 1 Y

fentaNYL Citrate Buccal 1 Y Y

Fentora Buccal 3 Y Y

Fioricet/Codeine Oral 3 Y

Fiorinal/Codeine #3 Oral 3 Y

HYDROcodone Bitartrate ER Oral 1 Y

HYDROcodone-Acetaminophen Oral 1 Y

HYDROcodone-Ibuprofen Oral 1 Y

HYDROmorphone HCl Oral 1 Y

HYDROmorphone HCl Rectal 1 Y

HYDROmorphone HCl ER Oral 1

Hysingla ER Oral 3 Y

Ibudone Oral 3 Y

Levorphanol Tartrate Oral 1 Y

Lorcet Oral 1 Y

Lorcet HD Oral 1 Y

Lortab Oral 1 Y

Lortab Oral 3 Y

Meperidine HCl Oral 1 Y

Methadone HCl Oral 1 Y

Methadone HCl Intensol Oral 1 Y

Methadose Oral 1 Y

Methadose Oral 3 Y

Methadose Sugar-Free Oral 3 Y

MorphaBond ER Oral 3 Y

Morphine Sulfate Oral 1 Y

Morphine Sulfate Rectal 1 Y

Morphine Sulfate (Concentrate) Oral 1 Y

Morphine Sulfate ER Oral 1 Y

Morphine Sulfate ER Beads Oral 1 Y

MS Contin Oral 3 Y

Nucynta Oral 3 Y



Nucynta ER Oral 3 Y

Opana Oral 3 Y

Opana ER Oral 3 Y

oxyCODONE HCl Oral 1 Y

oxyCODONE HCl ER Oral 1 Y

oxyCODONE-Acetaminophen Oral 1 Y

oxyCODONE-Aspirin Oral 1 Y

oxyCODONE-Ibuprofen Oral 1 Y

OxyCONTIN Oral 3 Y

oxyMORphone HCl Oral 1 Y

oxyMORphone HCl ER Oral 1 Y

Panlor Oral 3 Y

Pentazocine-Naloxone HCl Oral 1 Y

Suboxone Sublingual 2 Y

Synalgos-DC Oral 3 Y

traMADol HCl Oral 1 Y

traMADol HCl ER Oral 1 Y

traMADol HCl ER (Biphasic) Oral 1 Y

traMADol-Acetaminophen Oral 1 Y

Trezix Oral 3 Y

Tylenol with Codeine #3 Oral 3 Y

Tylenol with Codeine #4 Oral 3 Y

Vicodin HP Oral 1 Y

Xodol Oral 3 Y

Xtampza ER Oral 3 Y

Xylon Oral 1 Y

Zamicet Oral 3 Y

Zubsolv Sublingual 3 Y

ANDROGENS-ANABOLIC

Anadrol-50 Oral 3 Y

Androderm Transdermal 3 Y

AndroGel Transdermal 3 Y

AndroGel Pump Transdermal 2 Y

Android Oral 3 Y

Androxy Oral 2 Y

Axiron Transdermal 2 Y

Danazol Oral 1



Depo-Testosterone Intramuscular 3 Y

Fortesta Transdermal 3 Y

Methitest Oral 3 Y

Oxandrin Oral 3 Y

Oxandrolone Oral 1 Y

Striant Buccal 3 Y

Testim Transdermal 3 Y

Testosterone Transdermal 1 Y

Testosterone Cypionate Injection 1

Testosterone Cypionate Intramuscular 1

Testosterone Cypionate & Prop Injection 1

Testosterone Enanthate Injection 1

Testosterone Enanthate Intramuscular 1

Testosterone Propionate Injection 1

Testred Oral 3 Y

Vogelxo Transdermal 3 Y

ANORECTAL AGENTS

Vogelxo Pump Transdermal 3 Y

Analpram HC External 3

Analpram HC Singles External 3

Analpram-HC External 3

Colocort Rectal 1

Cortenema Rectal 3

Cortifoam External 2

Hydrocortisone Rectal 1

Hydrocortisone (Perianal) External 1

Hydrocortisone Ace-Pramoxine External 1

Hydrocortisone Acetate Rectal 1

Hydrocort-Pramoxine (Perianal) External 1

Proctofoam HC External 3

ANTHELMINTICS

Albendazole Oral 1

Albenza Oral 2

Benznidazole Oral 1

Biltricide Oral 2

Emverm Oral 3

Ivermectin Oral 1



Praziquantel Oral 1

Stromectol Oral 3

ANTIANGINAL AGENTS

GoNitro Sublingual 3

Isosorbide Dinitrate Oral 1

Isosorbide Dinitrate ER Oral 1

Isosorbide Mononitrate Oral 1

Isosorbide Mononitrate ER Oral 1

Minitran Transdermal 1

Nitro-Bid Transdermal 2

Nitro-Dur Transdermal 3

Nitroglycerin Sublingual 1

Nitroglycerin Transdermal 1

Nitroglycerin Translingual 1

Nitroglycerin ER Oral 1

Nitrolingual Translingual 3

NitroMist Translingual 3

Nitrostat Sublingual 3

Nitro-Time Oral 3

Ranexa Oral 3

Ranolazine ER Oral 1

ANTIANXIETY AGENTS

ALPRAZolam Oral 1

ALPRAZolam ER Oral 1

ALPRAZolam Intensol Oral 3

ALPRAZolam XR Oral 1

Ativan Injection 3

Ativan Oral 3

busPIRone HCl Oral 1

chlordiazePOXIDE HCl Oral 1

Clorazepate Dipotassium Oral 1

diazePAM Injection 1

diazePAM Oral 1

diazePAM Intensol Oral 1

hydrOXYzine HCl Oral 1

hydrOXYzine Pamoate Oral 1

LORazepam Injection 1



LORazepam Oral 1

LORazepam Intensol Oral 1

Meprobamate Oral 1

Oxazepam Oral 1

Tranxene-T Oral 3

Valium Oral 3

Vistaril Oral 3

Xanax Oral 3

Xanax XR Oral 3

ANTIARRHYTHMICS

Amiodarone HCl Oral 1

Disopyramide Phosphate Oral 1

Dofetilide Oral 1

Flecainide Acetate Oral 1

Mexiletine HCl Oral 1

Multaq Oral 2

Pacerone Oral 1

Propafenone HCl Oral 1

Propafenone HCl ER Oral 1

quiNIDine Gluconate Injection 1

quiNIDine Gluconate ER Oral 1

quiNIDine Sulfate Oral 1

Tikosyn Oral 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

Accolate Oral 3

Advair Diskus Inhalation 2

Advair HFA Inhalation 2

Aerospan Inhalation 3

AirDuo RespiClick 113/14 Inhalation 3



Albuterol Sulfate Inhalation 1

Albuterol Sulfate Oral 1

Albuterol Sulfate ER Oral 1

Albuterol Sulfate HFA Inhalation 2

Alvesco Inhalation 3

Anoro Ellipta Inhalation 2



Arcapta Neohaler Inhalation 3

ArmonAir Digihaler Inhalation 3

ArmonAir RespiClick 113 Inhalation 3



Arnuity Ellipta Inhalation 2

Asmanex (120 Metered Doses) Inhalation 2





Asmanex HFA Inhalation 2

Atrovent HFA Inhalation 3

Bevespi Aerosphere Inhalation 3

Breo Ellipta Inhalation 2

Brovana Inhalation 3

Budesonide Inhalation 1

Combivent Respimat Inhalation 3

Cromolyn Sodium Inhalation 1

Daliresp Oral 3

Dulera Inhalation 2

Elixophyllin Oral 3

Flovent Diskus Inhalation 2

Flovent HFA Inhalation 2

Fluticasone-Salmeterol Inhalation 1

Incruse Ellipta Inhalation 2

Ipratropium Bromide Inhalation 1

Ipratropium-Albuterol Inhalation 1

Levalbuterol HCl Inhalation 1

Levalbuterol Tartrate Inhalation 1

Lonhala Magnair Refill Kit Inhalation 3 Y

Lonhala Magnair Starter Kit Inhalation 3 Y

Metaproterenol Sulfate Oral 1

Montelukast Sodium Oral 1

Perforomist Inhalation 3

ProAir Digihaler Inhalation 3

ProAir HFA Inhalation 3



ProAir RespiClick Inhalation 2

Proventil HFA Inhalation 3

Pulmicort Inhalation 3

Pulmicort Flexhaler Inhalation 3

Qvar Inhalation 2

Qvar RediHaler Inhalation 2

Seebri Neohaler Inhalation 3

Serevent Diskus Inhalation 2

Singulair Oral 3

Spiriva HandiHaler Inhalation 2

Spiriva Respimat Inhalation 2

Stiolto Respimat Inhalation 2

Striverdi Respimat Inhalation 3

Symbicort Inhalation 2

Terbutaline Sulfate Oral 1

Theo-24 Oral 3

Theochron Oral 3

Theophylline Oral 1

Theophylline ER Oral 1

Trelegy Ellipta Inhalation 3

Tudorza Pressair Inhalation 3

Utibron Neohaler Inhalation 3

Ventolin HFA Inhalation 2

VoSpire ER Oral 3

Wixela Inhub Inhalation 1

Xopenex Inhalation 3

Xopenex Concentrate Inhalation 3

Xopenex HFA Inhalation 3

Zafirlukast Oral 1

Zileuton ER Oral 1

Zyflo Oral 3

Zyflo CR Oral 3

ANTICOAGULANTS

Arixtra Subcutaneous 3 Y

Bevyxxa Oral 3

Coumadin Oral 3

Eliquis Oral 2



Eliquis DVT/PE Starter Pack Oral 2

Enoxaparin Sodium Injection 1 Y

Enoxaparin Sodium Subcutaneous 1 Y

Fondaparinux Sodium Subcutaneous 1 Y

Fragmin Subcutaneous 3 Y

Heparin Sodium (Porcine) Injection 1

Heparin Sodium (Porcine) PF Injection 1

Iprivask Subcutaneous 3 Y

Jantoven Oral 1

Lovenox Injection 3 Y

Lovenox Subcutaneous 3 Y

Pradaxa Oral 3

Savaysa Oral 3

Warfarin Sodium Oral 1

Xarelto Oral 2

Xarelto Starter Pack Oral 2

ANTICONVULSANTS

Aptiom Oral 3

Banzel Oral 2 Y

Briviact Oral 3 Y

carBAMazepine Oral 1

carBAMazepine ER Oral 1

Carbatrol Oral 3

Celontin Oral 2

Cerebyx Injection 3

cloBAZam Oral 1

clonazePAM Oral 1

Depakene Oral 3

Depakote Oral 3

Depakote ER Oral 3

Depakote Sprinkles Oral 3

Diacomit Oral 3 Y Y

Diastat AcuDial Rectal 2

Diastat Pediatric Rectal 2

diazePAM Rectal 1

Dilantin Oral 2

Dilantin Infatabs Oral 3



Divalproex Sodium Oral 1

Divalproex Sodium ER Oral 1

Epidiolex Oral 3 Y

Epitol Oral 1

Ethosuximide Oral 1

Fanatrex FusePaq Oral 3 Y

Felbamate Oral 1

Felbatol Oral 3

Fycompa Oral 3 Y

Gabapentin Oral 1 Y

Gabitril Oral 3

Keppra Oral 3

Keppra XR Oral 3

KlonoPIN Oral 3

LaMICtal Oral 3

LaMICtal ODT Oral 3

LaMICtal Starter Oral 3

LaMICtal XR Oral 3

lamoTRIgine Oral 1

lamoTRIgine ER Oral 1

lamoTRIgine Starter Kit-Blue Oral 1

lamoTRIgine Starter Kit-Green Oral 1

lamoTRIgine Starter Kit-Orange Oral 1

levETIRAcetam Oral 1

levETIRAcetam ER Oral 1

Lyrica Oral 2

Mysoline Oral 3

Neurontin Oral 3 Y

Onfi Oral 3 Y

OXcarbazepine Oral 1

Oxtellar XR Oral 3 Y

Peganone Oral 3

Phenytek Oral 3

Phenytoin Oral 1

Phenytoin Infatabs Oral 1

Phenytoin Sodium Extended Oral 1

Pregabalin Oral 1



Pregabalin Oral 2

Primidone Oral 1

Qudexy XR Oral 3

Roweepra Oral 1

Roweepra XR Oral 3

Sabril Oral 2 Y Y

Subvenite Oral 1

Subvenite Starter Kit-Blue Oral 3

Subvenite Starter Kit-Green Oral 3

Subvenite Starter Kit-Orange Oral 3

Sympazan Oral 3

TEGretol Oral 3

TEGretol-XR Oral 3

tiaGABine HCl Oral 1

Topamax Oral 3

Topamax Sprinkle Oral 3

Topiramate Oral 1

Topiramate ER Oral 1

Trileptal Oral 3

Trokendi XR Oral 3 Y

Valproate Sodium Oral 1

Valproic Acid Oral 1

Vigabatrin Oral 1 Y Y

Vigadrone Oral 1 Y Y

Vimpat Oral 3 Y

Zarontin Oral 3

Zonegran Oral 3

Zonisamide Oral 1

ANTIDEPRESSANTS

Amitriptyline HCl Oral 1

Amoxapine Oral 1

Anafranil Oral 3

buPROPion HCl Oral 1

buPROPion HCl ER (SR) Oral 1

buPROPion HCl ER (XL) Oral 1

CeleXA Oral 3

Citalopram Hydrobromide Oral 1



clomiPRAMINE HCl Oral 1

Cymbalta Oral 3

Desipramine HCl Oral 1

Desvenlafaxine ER Oral 1

Desvenlafaxine Succinate ER Oral 1

Doxepin HCl Oral 1

DULoxetine HCl Oral 1

Effexor XR Oral 3

Elavil Oral 3

Emsam Transdermal 3

Escitalopram Oxalate Oral 1

Fetzima Oral 3

Fetzima Titration Oral 3

FLUoxetine HCl Oral 1

fluvoxaMINE Maleate Oral 1

fluvoxaMINE Maleate ER Oral 1

Forfivo XL Oral 3

Imipramine HCl Oral 1

Imipramine Pamoate Oral 1

Khedezla Oral 3

Lexapro Oral 3

Maprotiline HCl Oral 1

Marplan Oral 3

Mirtazapine Oral 1

Nardil Oral 3

Nefazodone HCl Oral 1

Norpramin Oral 3

Nortriptyline HCl Oral 1

Pamelor Oral 3

Parnate Oral 3

PARoxetine HCl Oral 1

PARoxetine HCl ER Oral 1

Paxil Oral 3

Paxil CR Oral 3

Pexeva Oral 3

Phenelzine Sulfate Oral 1

Pristiq Oral 3



Protriptyline HCl Oral 1

Remeron Oral 3

Remeron SolTab Oral 3

Sertraline HCl Oral 1

Surmontil Oral 3

Tofranil Oral 3

Tranylcypromine Sulfate Oral 1

traZODone HCl Oral 1

Trimipramine Maleate Oral 1

Trintellix Oral 3

Venlafaxine HCl Oral 1

Venlafaxine HCl ER Oral 1

Viibryd Oral 3

Viibryd Starter Pack Oral 3

Zoloft Oral 3

ANTIDIABETICS

Acarbose Oral 1

Actoplus Met Oral 3

Actoplus met XR Oral 3

Actos Oral 3

Adlyxin Subcutaneous 3

Adlyxin Starter Pack Subcutaneous 3

Admelog Subcutaneous 3

Admelog SoloStar Subcutaneous 3

Afrezza Inhalation 3

Alogliptin Benzoate Oral 1

Alogliptin-metFORMIN HCl Oral 1

Alogliptin-Pioglitazone Oral 1

Amaryl Oral 3

Apidra Injection 3

Apidra SoloStar Subcutaneous 3

Avandia Oral 3

Baqsimi One Pack Nasal 2 Y

Basaglar KwikPen Subcutaneous 3

Bydureon Subcutaneous 3

Bydureon BCise Subcutaneous 3

Byetta 10 MCG Pen Subcutaneous 3



Byetta 5 MCG Pen Subcutaneous 3

chlorproPAMIDE Oral 1

Cycloset Oral 3

Duetact Oral 3

Farxiga Oral 2

Fiasp Subcutaneous 2

Fiasp FlexTouch Subcutaneous 2

Fiasp PenFill Subcutaneous 2

Fiasp PenFill Subcutaneous 3

Glimepiride Oral 1

glipiZIDE Oral 1

glipiZIDE ER Oral 1

glipiZIDE XL Oral 1

glipiZIDE-metFORMIN HCl Oral 1

GlucaGen HypoKit Injection 3

Glucagon Emergency Injection 2

Glucophage Oral 3

Glucophage XR Oral 3

Glucotrol Oral 3

Glucotrol XL Oral 3

Glucovance Oral 3

glyBURIDE Oral 1

glyBURIDE Micronized Oral 1

glyBURIDE-metFORMIN Oral 1

Glynase Oral 3

Glyset Oral 3

Glyxambi Oral 2

Gvoke HypoPen 1-Pack Subcutaneous 2 Y

Gvoke HypoPen 2-Pack Subcutaneous 2 Y

Gvoke PFS Subcutaneous 2 Y

HumuLIN 70/30 Subcutaneous 3

HumuLIN 70/30 KwikPen Subcutaneous 3

HumuLIN N Subcutaneous 3

HumuLIN N KwikPen Subcutaneous 3

HumuLIN R Injection 3

HumuLIN R U-500 (CONCENTRATED) Subcutaneous 2 Y

HumuLIN R U-500 KwikPen Subcutaneous 2 Y



Insulin Lispro Subcutaneous 3

Insulin Lispro (1 Unit Dial) Subcutaneous 3

Insulin Lispro Junior KwikPen Subcutaneous 3

Insulin Lispro Prot & Lispro Subcutaneous 3

Invokamet Oral 2

Invokamet XR Oral 2

Invokana Oral 2

Janumet Oral 2

Janumet XR Oral 2

Januvia Oral 2

Jardiance Oral 2

Jentadueto Oral 3

Jentadueto XR Oral 3

Kazano Oral 3

Kombiglyze XR Oral 3

Lantus Subcutaneous 2

Lantus SoloStar Subcutaneous 2

Levemir Subcutaneous 2

Levemir FlexTouch Subcutaneous 2

metFORMIN HCl Oral 1

metFORMIN HCl Oral 3

metFORMIN HCl ER Oral 1

Miglitol Oral 1

Nateglinide Oral 1

Nesina Oral 3

NovoLIN 70/30 Subcutaneous 2

NovoLIN 70/30 FlexPen Subcutaneous 2

NovoLIN 70/30 FlexPen Relion Subcutaneous 2

NovoLIN 70/30 ReliOn Subcutaneous 2

NovoLIN N Subcutaneous 2

NovoLIN N FlexPen Subcutaneous 2

NovoLIN N FlexPen ReliOn Subcutaneous 2

NovoLIN N ReliOn Subcutaneous 2

NovoLIN R Injection 2

NovoLIN R FlexPen Injection 2 Y

NovoLIN R FlexPen ReliOn Injection 2 Y

NovoLIN R ReliOn Injection 2



NovoLOG Subcutaneous 2

NovoLOG FlexPen Subcutaneous 2

NovoLOG Mix 70/30 Subcutaneous 2

NovoLOG Mix 70/30 FlexPen Subcutaneous 2

NovoLOG PenFill Subcutaneous 2

Onglyza Oral 3

Oseni Oral 3

Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2

Ozempic (1 MG/DOSE) Subcutaneous 2

Pioglitazone HCl Oral 1

Pioglitazone HCl-Glimepiride Oral 1

Pioglitazone HCl-metFORMIN HCl Oral 1

Prandin Oral 3

Precose Oral 3

Qtern Oral 3

Repaglinide Oral 1

Repaglinide-metFORMIN HCl Oral 1

Riomet Oral 3

Riomet ER Oral 3

Segluromet Oral 3

Soliqua Subcutaneous 2

Starlix Oral 3

Steglatro Oral 3

Steglujan Oral 3

SymlinPen 120 Subcutaneous 3

SymlinPen 60 Subcutaneous 3

Synjardy Oral 2

Synjardy XR Oral 2

Tanzeum Subcutaneous 3

TOLAZamide Oral 1

TOLBUTamide Oral 1

Toujeo Max SoloStar Subcutaneous 2

Toujeo SoloStar Subcutaneous 2

Tradjenta Oral 3

Tresiba Subcutaneous 2

Tresiba FlexTouch Subcutaneous 2

Trulicity Subcutaneous 2



Victoza Subcutaneous 2

Xigduo XR Oral 2

Xultophy Subcutaneous 2

ANTIDIARRHEAL/PROBIOTIC AGENTS

Diphenoxylate-Atropine Oral 1

Lomotil Oral 3

Loperamide HCl Oral 1

ANTIDOTES AND SPECIFIC ANTAGONISTS

Cetylev Oral 3

Chemet Oral 2

Deferasirox Oral 1 Y Y

Deferiprone Oral 1 Y Y

Exjade Oral 3 Y Y

Ferriprox Oral 3 Y Y

Ferriprox Twice-A-Day Oral 3 Y Y

Jadenu Oral 3 Y Y

Jadenu Sprinkle Oral 3 Y Y

Naltrexone HCl Oral 1 Y

Narcan Nasal 2 Y

ANTIEMETICS

Akynzeo Oral 3 Y Y

Anzemet Oral 3

Aprepitant Oral 1

Cesamet Oral 3

Dronabinol Oral 1

Granisetron HCl Oral 1

Marinol Oral 3

Meclizine HCl Oral 1

Ondansetron Oral 1

Ondansetron HCl Oral 1

Sancuso Transdermal 3 Y Y

Scopolamine Transdermal 1

Tigan Intramuscular 3

Tigan Oral 3

Transderm Scop (1.5 MG) Transdermal 3

Transderm-Scop (1.5 MG) Transdermal 2

Trimethobenzamide HCl Oral 1



Varubi (180 MG Dose) Oral 3 Y Y

Zofran Oral 3

Zofran ODT Oral 3

Zuplenz Oral 3

ANTIFUNGALS

Ancobon Oral 3 Y

Cresemba Oral 3 Y

Diflucan Oral 3

Fluconazole Oral 1

Flucytosine Oral 1 Y

Griseofulvin Microsize Oral 1

Griseofulvin Ultramicrosize Oral 1

Gris-PEG Oral 3

Itraconazole Oral 1

Ketoconazole Oral 1

LamISIL Oral 3

Noxafil Oral 3 Y

Nystatin Oral 1

Posaconazole Oral 2

Sporanox Oral 3

Sporanox Pulsepak Oral 3

Terbinafine HCl Oral 1

Vfend Oral 3

Voriconazole Oral 1

ANTIHISTAMINES

Carbinoxamine Maleate Oral 1

Cetirizine HCl Oral 1

Clemastine Fumarate Oral 1

Cyproheptadine HCl Oral 1

Diphen Oral 1

diphenhydrAMINE HCl Oral 1

Levocetirizine Dihydrochloride Oral 1

Phenadoz Rectal 1

Phenergan Rectal 1

Promethazine HCl Injection 1

Promethazine HCl Oral 1

Promethazine HCl Rectal 1



Promethegan Rectal 1

RyVent Oral 3

ANTIHYPERLIPIDEMICS

Atorvastatin Calcium Oral 1

Cholestyramine Oral 1

Cholestyramine Light Oral 1

Colesevelam HCl Oral 1

Colestid Oral 3

Colestipol HCl Oral 1

Ezetimibe Oral 1

Ezetimibe-Simvastatin Oral 1

Fenofibrate Oral 1

Fenofibrate Micronized Oral 1

Fenofibric Acid Oral 1

FloLipid Oral 3

Fluvastatin Sodium ER Oral 1

Gemfibrozil Oral 1

Juxtapid Oral 3 Y Y Y

Kynamro Subcutaneous 3 Y Y

Livalo Oral 3

Lovastatin Oral 1

Niacin (Antihyperlipidemic) Oral 3

Niacin ER (Antihyperlipidemic) Oral 1

Niacor Oral 3

Niaspan Oral 3

Praluent Subcutaneous 2 Y

Pravastatin Sodium Oral 1

Prevalite Oral 1

Questran Oral 3

Questran Light Oral 3

Repatha Subcutaneous 2 Y

Repatha Pushtronex System Subcutaneous 2 Y

Repatha SureClick Subcutaneous 2 Y

Rosuvastatin Calcium Oral 1

Simvastatin Oral 1

Simvastatin Oral 3

Tricor Oral 3



Triklo Oral 1

Trilipix Oral 3

Vascepa Oral 3

Welchol Oral 2

ANTIHYPERTENSIVES

Aceon Oral 3

Aliskiren Fumarate Oral 1

amLODIPine Besy-Benazepril HCl Oral 1

amLODIPine Besylate-Valsartan Oral 1

amLODIPine-Olmesartan Oral 1

amLODIPine-Valsartan-HCTZ Oral 1

Atenolol-Chlorthalidone Oral 1

Benazepril HCl Oral 1

Benazepril-hydroCHLOROthiazide Oral 1

Bisoprolol-hydroCHLOROthiazide Oral 1

Candesartan Cilexetil Oral 1

Captopril Oral 1

Captopril-hydroCHLOROthiazide Oral 1

cloNIDine Transdermal 1

cloNIDine HCl Oral 1

Demser Oral 3

Dibenzyline Oral 3 Y

Doxazosin Mesylate Oral 1

Enalapril Maleate Oral 1

Enalapril-hydroCHLOROthiazide Oral 1

Epaned Oral 3

Eplerenone Oral 1

Eprosartan Mesylate Oral 1

Fosinopril Sodium Oral 1

Fosinopril Sodium-HCTZ Oral 1

guanFACINE HCl Oral 1

hydrALAZINE HCl Oral 1

Irbesartan Oral 1

Irbesartan-hydroCHLOROthiazide Oral 1

Lisinopril Oral 1

Lisinopril-hydroCHLOROthiazide Oral 1

Losartan Potassium Oral 1



Losartan Potassium-HCTZ Oral 1

Methyldopa Oral 1

Methyldopa-hydroCHLOROthiazide Oral 1

Metoprolol-HCTZ ER Oral 1

Metoprolol-hydroCHLOROthiazide Oral 1

metyroSINE Oral 1

Minoxidil Oral 1

Moexipril HCl Oral 1

Moexipril-hydroCHLOROthiazide Oral 1

Nadolol-Bendroflumethiazide Oral 1

Olmesartan Medoxomil Oral 1

Olmesartan Medoxomil-HCTZ Oral 1

Olmesartan-amLODIPine-HCTZ Oral 1

Perindopril Erbumine Oral 1

Phenoxybenzamine HCl Oral 1

Prazosin HCl Oral 1

Propranolol-HCTZ Oral 1

Qbrelis Oral 3

Quinapril HCl Oral 1

Quinapril-hydroCHLOROthiazide Oral 1

Ramipril Oral 1

Telmisartan Oral 1

Telmisartan-HCTZ Oral 1

Terazosin HCl Oral 1

Trandolapril Oral 1

Trandolapril-Verapamil HCl ER Oral 1

Valsartan Oral 1

Valsartan-hydroCHLOROthiazide Oral 1

Vecamyl Oral 3

ANTI-INFECTIVE AGENTS - MISC.

Aemcolo Oral 3

Alinia Oral 3 Y

Atovaquone Oral 1

Bactrim Oral 3

Bactrim DS Oral 3

Cayston Inhalation 3 Y Y Y

Cleocin Oral 3



Clindamycin HCl Oral 1

Clindamycin Palmitate HCl Oral 1

Clindamycin Phosphate Injection 1

Dapsone Oral 1

Firvanq Oral 3

Flagyl Oral 3

Furadantin Oral 3

Hiprex Oral 3

Hyophen Oral 3

Impavido Oral 3 Y

Linezolid Oral 1

Macrobid Oral 3

Macrodantin Oral 3

Mepron Oral 3

Methenamine Hippurate Oral 1

Methenamine Mandelate Oral 1

metroNIDAZOLE Oral 1

Monurol Oral 3

Nebupent Inhalation 2

Nitrofurantoin Oral 1

Nitrofurantoin Macrocrystal Oral 1

Nitrofurantoin Monohyd Macro Oral 1

Pentamidine Isethionate Inhalation 1

Pentamidine Isethionate Injection 1

Phosphasal Oral 1

Primsol Oral 3

Sivextro Oral 2 Y

Sulfamethoxazole-Trimethoprim Oral 1

Sulfatrim Pediatric Oral 1

Tindamax Oral 3

Tinidazole Oral 1

Trimethoprim Oral 1

Trimpex Oral 3

Uribel Oral 1

Ustell Oral 1

Vancocin Oral 3

Vancocin HCl Oral 3



Vancomycin HCl Oral 1

Vilamit MB Oral 1

Vilevev MB Oral 1

Xifaxan Oral 2

Zyvox Oral 3

ANTIMALARIALS

Arakoda Oral 3

Atovaquone-Proguanil HCl Oral 1

Chloroquine Phosphate Oral 1 Y

Coartem Oral 2

Hydroxychloroquine Sulfate Oral 1 Y

Krintafel Oral 3

Malarone Oral 3

Mefloquine HCl Oral 1

Plaquenil Oral 3 Y

Primaquine Phosphate Oral 1

Qualaquin Oral 3

quiNINE Sulfate Oral 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Guanidine HCl Oral 1

Mestinon Oral 3

Pyridostigmine Bromide Oral 1

Pyridostigmine Bromide Oral 3

Pyridostigmine Bromide ER Oral 1

ANTIMYCOBACTERIAL AGENTS

cycloSERINE Oral 1

Ethambutol HCl Oral 1

Isoniazid Oral 1

Myambutol Oral 3

Mycobutin Oral 3

Paser Oral 3

Priftin Oral 2

Pyrazinamide Oral 1

Rifabutin Oral 1

Rifadin Oral 3

Rifamate Oral 3

rifAMPin Oral 1



Rifater Oral 3

Sirturo Oral 3

Trecator Oral 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

Abiraterone Acetate Oral 1 Y Y Y

Actimmune Subcutaneous 2 Y Y 3

Afinitor Oral 2 Y Y Y

Afinitor Disperz Oral 2 Y Y Y

Alecensa Oral 2 Y Y Y

Alkeran Oral 3 Y Y

Alunbrig Oral 3 Y Y Y

Anastrozole Oral 1

Arimidex Oral 3

Aromasin Oral 3

Bexarotene Oral 1 Y Y Y

Bicalutamide Oral 1

Bosulif Oral 2 Y Y Y

Braftovi Oral 3 Y Y

Cabometyx Oral 3 Y Y Y

Calquence Oral 3 Y Y Y

Capecitabine Oral 1 Y Y Y

Caprelsa Oral 2 Y Y Y

Casodex Oral 3

Cometriq (100 MG Daily Dose) Oral 2 Y Y Y



Copiktra Oral 3 Y Y

Cotellic Oral 2 Y Y Y

Cyclophosphamide Oral 1

Emcyt Oral 2 Y Y

Erivedge Oral 2 Y Y Y

Erleada Oral 3 Y Y Y

Erlotinib HCl Oral 1 Y Y Y

Etoposide Oral 1 Y

Exemestane Oral 1

Fareston Oral 3 Y Y

Farydak Oral 2 Y Y Y



Femara Oral 3

Flutamide Oral 1

Gilotrif Oral 2 Y Y Y

Gleevec Oral 3 Y Y Y

Gleostine Oral 3 Y Y

Hexalen Oral 2 Y Y

Hycamtin Oral 2 Y Y

Hydrea Oral 3

Hydroxyurea Oral 1

Ibrance Oral 2 Y Y Y

Iclusig Oral 2 Y Y Y

IDHIFA Oral 3 Y Y Y

Imatinib Mesylate Oral 1 Y Y Y

Imbruvica Oral 2 Y Y Y

Inlyta Oral 2 Y Y Y

Iressa Oral 2 Y Y Y

Jakafi Oral 2 Y Y Y

Kisqali (200 MG Dose) Oral 2 Y Y



Kisqali Femara (400 MG Dose) Oral 3 Y Y

Kisqali Femara (600 MG Dose) Oral 3 Y Y

Kisqali Femara(200 MG Dose) Oral 3 Y Y

Lapatinib Ditosylate Oral 1 Y Y

Lenvima (10 MG Daily Dose) Oral 2 Y Y Y








Letrozole Oral 1

Leucovorin Calcium Oral 1

Leukeran Oral 2 Y Y

Lonsurf Oral 2 Y Y

Lynparza Oral 3 Y Y Y



Lysodren Oral 2 Y Y

Matulane Oral 2 Y Y

Megestrol Acetate Oral 1

Mekinist Oral 2 Y Y Y

Mektovi Oral 3 Y Y

Melphalan Oral 1 Y Y

Mercaptopurine Oral 1

Mesnex Oral 3 Y

Methotrexate Oral 1

Methotrexate Sodium Injection 1

Methotrexate Sodium Oral 1

Methotrexate Sodium (PF) Injection 1

Myleran Oral 2

Nerlynx Oral 3 Y Y Y

NexAVAR Oral 2 Y Y Y

Nilandron Oral 3 Y Y Y

Nilutamide Oral 1 Y Y Y

Ninlaro Oral 2 Y Y Y

Odomzo Oral 2 Y Y Y

Pomalyst Oral 2 Y Y Y

Purixan Oral 2 Y Y

Rubraca Oral 3 Y Y Y

Rydapt Oral 3 Y Y

Soltamox Oral 2

Sprycel Oral 2 Y Y Y

Stivarga Oral 2 Y Y Y

Sutent Oral 2 Y Y Y

Tabloid Oral 2 Y Y

Tafinlar Oral 2 Y Y Y

Tagrisso Oral 2 Y Y Y

Tamoxifen Citrate Oral 1

Tarceva Oral 2 Y Y Y

Targretin Oral 3 Y Y Y

Tasigna Oral 2 Y Y Y

Temodar Oral 3 Y Y Y

Temozolomide Oral 1 Y Y Y

Tibsovo Oral 3 Y Y



Toremifene Citrate Oral 1 Y Y

Tretinoin Oral 1 Y Y

Trexall Oral 3

Venclexta Oral 3 Y Y Y

Venclexta Starting Pack Oral 3 Y Y Y

Verzenio Oral 3 Y Y Y

Vizimpro Oral 3 Y Y

Votrient Oral 2 Y Y Y

Xalkori Oral 2 Y Y Y

Xatmep Oral 3

Xeloda Oral 3 Y Y

Xtandi Oral 2 Y Y Y

Yonsa Oral 3 Y Y

Zejula Oral 3 Y Y

Zelboraf Oral 2 Y Y Y

Zolinza Oral 2 Y Y Y

Zydelig Oral 2 Y Y Y

Zykadia Oral 3 Y Y Y

Everolimus (Immunosuppressant) Oral 1 Y Y Y

ANTIPARKINSON AND RELATED THERAPY AGENTS

Amantadine HCl Oral 1

Apokyn Subcutaneous 3 Y Y Y

Azilect Oral 3

Benztropine Mesylate Injection 1

Benztropine Mesylate Oral 1

Bromocriptine Mesylate Oral 1

Carbidopa Oral 1

Carbidopa-Levodopa Oral 1

Carbidopa-Levodopa ER Oral 1

Carbidopa-Levodopa-Entacapone Oral 1

Cogentin Injection 3

Comtan Oral 3

Duopa Enteral 3

Eldepryl Oral 3

Entacapone Oral 1

Inbrija Inhalation 3 Y Y

Lodosyn Oral 3



Mirapex Oral 3

Mirapex ER Oral 3

Neupro Transdermal 3 Y

Parlodel Oral 3

Pramipexole Dihydrochloride Oral 1

Pramipexole Dihydrochloride ER Oral 1

Rasagiline Mesylate Oral 1

Requip Oral 3

Requip XL Oral 3

rOPINIRole HCl Oral 1

rOPINIRole HCl ER Oral 1

Selegiline HCl Oral 1

Sinemet Oral 3

Sinemet CR Oral 3

Stalevo 100 Oral 3

Stalevo 125 Oral 3

Stalevo 150 Oral 3

Stalevo 200 Oral 3

Stalevo 50 Oral 3

Stalevo 75 Oral 3

Tasmar Oral 3

Tolcapone Oral 1

Trihexyphenidyl HCl Oral 1

Xadago Oral 3

Zelapar Oral 3

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Abilify Oral 3

Abilify Maintena Intramuscular 3

Adasuve Inhalation 3

ARIPiprazole Oral 1

Aristada Intramuscular 3

chlorproMAZINE HCl Injection 1

chlorproMAZINE HCl Injection 3

chlorproMAZINE HCl Oral 1

cloZAPine Oral 1

cloZAPine Oral 3

Clozaril Oral 3



Compro Rectal 1

Equetro Oral 3

Fanapt Oral 3 Y

Fanapt Titration Pack Oral 3

FazaClo Oral 3

fluPHENAZine Decanoate Injection 1

fluPHENAZine HCl Injection 1

fluPHENAZine HCl Oral 1

Geodon Intramuscular 3

Geodon Oral 3

Haloperidol Oral 1

Haloperidol Lactate Oral 1

Invega Oral 3 Y

Invega Sustenna Intramuscular 3

Invega Trinza Intramuscular 3 Y

Latuda Oral 3

Lithium Oral 1

Lithium Carbonate Oral 1

Lithium Carbonate ER Oral 1

Lithobid Oral 3

Loxapine Succinate Oral 1

Molindone HCl Oral 1

Nuplazid Oral 3 Y Y

OLANZapine Intramuscular 1

OLANZapine Oral 1

Paliperidone ER Oral 1

Perphenazine Oral 1

Perseris Subcutaneous 3 Y

Prochlorperazine Rectal 1

Prochlorperazine Maleate Oral 1

QUEtiapine Fumarate Oral 1

QUEtiapine Fumarate ER Oral 1

Rexulti Oral 3 Y

RisperDAL Oral 3

RisperDAL Consta Intramuscular 3

RisperDAL M-TAB Oral 3

risperiDONE Oral 1



risperiDONE M-TAB Oral 1

Saphris Sublingual 3

SEROquel Oral 3

SEROquel XR Oral 2

Thioridazine HCl Oral 1

Thiothixene Oral 1

Trifluoperazine HCl Oral 1

Vraylar Oral 3

Ziprasidone HCl Oral 1

ZyPREXA Intramuscular 3

ZyPREXA Oral 3

ZyPREXA Relprevv Intramuscular 3

ZyPREXA Zydis Oral 3

ANTIVIRALS

Abacavir Sulfate Oral 1 Y

Abacavir Sulfate-lamiVUDine Oral 1 Y

Abacavir-lamiVUDine-Zidovudine Oral 1 Y

Acyclovir Oral 1

Adefovir Dipivoxil Oral 1 Y Y Y

Aptivus Oral 3 Y

Atazanavir Sulfate Oral 1 Y

Atripla Oral 2 Y

Baraclude Oral 3 Y Y Y

Biktarvy Oral 3 Y Y

Cimduo Oral 3 Y

Combivir Oral 3 Y

Complera Oral 2 Y

Copegus Oral 3 Y Y

Crixivan Oral 3 Y

Daklinza Oral 3 Y Y Y

Delstrigo Oral 3 Y

Descovy Oral 3 Y

Didanosine Oral 1 Y

Dovato Oral 3 Y

Edurant Oral 3 Y

Efavirenz Oral 1 Y

Efavirenz-lamiVUDine-Tenofovir Oral 1 Y



Emtricitabine Oral 1

Entecavir Oral 1 Y Y Y

Epclusa Oral 2 Y Y Y

Epivir Oral 3 Y

Epivir HBV Oral 3 Y

Epzicom Oral 3 Y

Evotaz Oral 2 Y

Famciclovir Oral 1

Flumadine Oral 3

Fosamprenavir Calcium Oral 1 Y

Fuzeon Subcutaneous 3 Y

Genvoya Oral 2 Y

Harvoni Oral 2 Y Y Y

Hepsera Oral 3 Y Y Y

Intelence Oral 2 Y

Invirase Oral 3 Y

Isentress Oral 2 Y

Isentress HD Oral 2 Y

Juluca Oral 3 Y

Kaletra Oral 2 Y

Kaletra Oral 3 Y

lamiVUDine Oral 1 Y

lamiVUDine-Zidovudine Oral 1 Y

Ledipasvir-Sofosbuvir Oral 1 Y Y Y

Lexiva Oral 3 Y

Lopinavir-Ritonavir Oral 1 Y

Mavyret Oral 2 Y Y Y

Moderiba Oral 3 Y Y

Moderiba (1000 MG Pack) Oral 3 Y

Moderiba (1200 MG Pack) Oral 3 Y Y

Moderiba (600 MG Pack) Oral 3 Y

Moderiba (800 MG Pack) Oral 3 Y Y

Nevirapine Oral 1 Y

Nevirapine ER Oral 1 Y

Norvir Oral 2 Y

Norvir Oral 3 Y

Odefsey Oral 2 Y



Olysio Oral 3 Y Y Y

Oseltamivir Phosphate Oral 1 Y

Pegasys Subcutaneous 2 Y Y Y

Pegasys ProClick Subcutaneous 2 Y Y Y

PegIntron Subcutaneous 3 Y Y

Peg-Intron Redipen Subcutaneous 3 Y Y

Pifeltro Oral 3 Y

Prevymis Oral 3 Y Y

Prezcobix Oral 2 Y

Prezista Oral 2 Y

Rebetol Oral 3 Y Y

Relenza Diskhaler Inhalation 3 Y

Rescriptor Oral 3 Y

Retrovir Oral 3 Y

Reyataz Oral 2 Y

Reyataz Oral 3 Y

Ribasphere Oral 1 Y Y

Ribasphere Oral 3 Y Y

Ribasphere RibaPak (1000 Pack) Oral 3 Y

Ribasphere Ribapak (1200 Pack) Oral 3 Y



Ribavirin Inhalation 1 Y Y

Ribavirin Oral 1 Y Y

riMANTAdine HCl Oral 1

Ritonavir Oral 1 Y

Selzentry Oral 3 Y

Sofosbuvir-Velpatasvir Oral 1 Y Y Y

Sovaldi Oral 2 Y Y Y

Stavudine Oral 1 Y

Stribild Oral 2 Y

Sustiva Oral 2 Y

Symfi Oral 2 Y

Symfi Lo Oral 2 Y

Symtuza Oral 3 Y

Tamiflu Oral 3 Y

Technivie Oral 3 Y Y Y



Temixys Oral 3 Y

Tenofovir Disoproxil Fumarate Oral 1 Y

Tivicay Oral 2 Y

Triumeq Oral 2 Y

Trizivir Oral 3 Y

Truvada Oral 2 Y

Tybost Oral 3

Tyzeka Oral 3

valACYclovir HCl Oral 1

Valcyte Oral 3 Y

valGANciclovir HCl Oral 1 Y

Valtrex Oral 3

Vemlidy Oral 3 Y Y Y

Videx Oral 2 Y

Videx EC Oral 3 Y

Viekira Pak Oral 3 Y Y

Viekira XR Oral 3 Y Y

Viracept Oral 3 Y

Viramune Oral 3 Y

Viramune XR Oral 3 Y

Virazole Inhalation 3 Y Y

Viread Oral 2 Y

Vosevi Oral 2 Y Y Y

Xofluza (40 MG Dose) Oral 3 Y

Xofluza (80 MG Dose) Oral 3 Y

Zepatier Oral 3 Y Y

Zerit Oral 3 Y

Ziagen Oral 3 Y

Zidovudine Oral 1 Y

Zovirax Oral 3

BETA BLOCKERS

Acebutolol HCl Oral 1

Atenolol Oral 1

Betaxolol HCl Oral 1

Bisoprolol Fumarate Oral 1

Bystolic Oral 3

Carvedilol Oral 1



Carvedilol Phosphate ER Oral 1

Hemangeol Oral 3

Kapspargo Sprinkle Oral 3

Labetalol HCl Oral 1

Metoprolol Succinate ER Oral 1

Metoprolol Tartrate Oral 1

Nadolol Oral 1

Pindolol Oral 1

Propranolol HCl Oral 1

Propranolol HCl ER Oral 1

Sorine Oral 1

Sotalol HCl Oral 1

Sotalol HCl (AF) Oral 1

Sotylize Oral 3

Timolol Maleate Oral 1

CALCIUM CHANNEL BLOCKERS

Afeditab CR Oral 1

amLODIPine Besylate Oral 1

Cartia XT Oral 1

dilTIAZem CD Oral 1

dilTIAZem HCl Oral 1

dilTIAZem HCl ER Oral 1

dilTIAZem HCl ER Beads Oral 1

dilTIAZem HCl ER Coated Beads Oral 1

Dilt-XR Oral 1

Felodipine ER Oral 1

Isradipine Oral 1

Matzim LA Oral 1

niCARdipine HCl Oral 1

Nifedical XL Oral 1

NIFEdipine Oral 1

NIFEdipine ER Oral 1

NIFEdipine ER Osmotic Release Oral 1

niMODipine Oral 1

Nisoldipine ER Oral 1

Nymalize Oral 3

Sular Oral 3



Taztia XT Oral 1

Tiadylt ER Oral 1

Verapamil HCl Oral 1

Verapamil HCl ER Oral 1

CARDIOTONICS

Digitek Oral 1

Digox Oral 1

Digoxin Oral 1

Lanoxin Injection 3

Lanoxin Oral 3

CARDIOVASCULAR AGENTS - MISC.

Adcirca Oral 2 Y Y Y

Adempas Oral 3 Y Y Y

Alyq Oral 1 Y Y Y

Ambrisentan Oral 1 Y Y Y

amLODIPine-Atorvastatin Oral 1

BiDil Oral 3

Bosentan Oral 1 Y Y Y

Cialis Oral 3 Y

Corlanor Oral 2 Y

Entresto Oral 2

Isoxsuprine HCl Oral 1

Letairis Oral 2 Y Y Y

Levitra Oral 3 Y

Opsumit Oral 2 Y Y Y

Orenitram Oral 3 Y Y 4

Revatio Oral 3 Y Y Y

Sildenafil Citrate Oral 1 Y Y Y

Staxyn Oral 3 Y

Stendra Oral 3 Y

Tadalafil (PAH) Oral 1 Y Y Y

Tracleer Oral 2 Y Y Y

Tracleer Oral 3 Y Y

Tyvaso Inhalation 3 Y Y

Tyvaso Refill Inhalation 3 Y Y

Tyvaso Starter Inhalation 3 Y Y

Uptravi Oral 2 Y Y



Vardenafil HCl Oral 1 Y

Ventavis Inhalation 3 Y Y Y 3

Viagra Oral 3 Y

Vyndaqel Oral 2 Y Y Y

CEPHALOSPORINS

Cedax Oral 3

Cefaclor Oral 1

Cefaclor ER Oral 1

Cefadroxil Oral 1

Cefdinir Oral 1

Cefditoren Pivoxil Oral 1

Cefixime Oral 1

Cefpodoxime Proxetil Oral 1

Cefprozil Oral 1

Ceftibuten Oral 1

Ceftin Oral 3

Cefuroxime Axetil Oral 1

Cephalexin Oral 1

Daxbia Oral 3

Keflex Oral 3

Spectracef Oral 3

Suprax Oral 2

Suprax Oral 3

CONTRACEPTIVES

Afirmelle Oral 1

Altavera Oral 1

Alyacen 1/35 Oral 1

Alyacen 7/7/7 Oral 1

Amethia Oral 1

Amethia Lo Oral 1

Amethyst Oral 3

Apri Oral 1

Aranelle Oral 1

Ashlyna Oral 1

Aubra Oral 1

Aubra EQ Oral 1

Aurovela 1.5/30 Oral 1



Aurovela 1/20 Oral 1

Aurovela 24 FE Oral 1

Aurovela Fe 1.5/30 Oral 1

Aurovela FE 1/20 Oral 1

Aviane Oral 1

Ayuna Oral 1

Azurette Oral 1

Balcoltra Oral 3

Balziva Oral 1

Bekyree Oral 1

Beyaz Oral 3

Blisovi 24 Fe Oral 1

Blisovi Fe 1.5/30 Oral 1

Blisovi FE 1/20 Oral 1

Brevicon (28) Oral 3

Briellyn Oral 1

Camila Oral 1

Camrese Oral 1

Camrese Lo Oral 1

Caziant Oral 1

Charlotte 24 Fe Oral 1

Chateal Oral 1

Chateal EQ Oral 1

Cryselle-28 Oral 1

Cyclafem 1/35 Oral 1

Cyclafem 7/7/7 Oral 1

Cyclessa Oral 3

Cyred Oral 1

Cyred EQ Oral 1

Dasetta 1/35 Oral 1

Dasetta 7/7/7 Oral 1

Daysee Oral 1

Deblitane Oral 1

Delyla Oral 1

Depo-Provera Intramuscular 3 Y

Depo-SubQ Provera 104 Subcutaneous 3

Desogen Oral 3



Desogestrel-Ethinyl Estradiol Oral 1

Drospiren-Eth Estrad-Levomefol Oral 1

Drospirenone-Ethinyl Estradiol Oral 1

Elinest Oral 1

Ella Oral 2

Ella Oral 3

EluRyng Vaginal 1

Emoquette Oral 1

Enpresse-28 Oral 1

Enskyce Oral 1

Errin Oral 1

Estarylla Oral 1

Estrostep Fe Oral 3

Ethynodiol Diac-Eth Estradiol Oral 1

Etonogestrel-Ethinyl Estradiol Vaginal 1

FaLessa Oral 3

Falmina Oral 1

Fayosim Oral 1

Femynor Oral 1

Generess FE Oral 3

Gianvi Oral 1

Gildagia Oral 1

Hailey 1.5/30 Oral 1

Hailey 24 Fe Oral 1

Hailey FE 1.5/30 Oral 1

Hailey FE 1/20 Oral 1

Heather Oral 1

Incassia Oral 1

Introvale Oral 1 Y

Isibloom Oral 1

Jaimiess Oral 1 Y

Jasmiel Oral 1

Jencycla Oral 1

Jolessa Oral 1 Y

Jolivette Oral 1

Juleber Oral 1

Junel 1.5/30 Oral 1



Junel 1/20 Oral 1

Junel FE 1.5/30 Oral 1

Junel FE 1/20 Oral 1

Junel Fe 24 Oral 1

Kaitlib Fe Oral 1

Kalliga Oral 1

Kariva Oral 1

Kelnor 1/35 Oral 1

Kelnor 1/50 Oral 1

Kimidess Oral 1

Kurvelo Oral 1

Larin 1.5/30 Oral 1

Larin 1/20 Oral 1

Larin 24 FE Oral 1

Larin Fe 1.5/30 Oral 1

Larin Fe 1/20 Oral 1

Larissia Oral 1

Layolis FE Oral 1

Leena Oral 1

Lessina Oral 1

Levonest Oral 1

Levonorgest-Eth Est & Eth Est Oral 1

Levonorgest-Eth Estrad 91-Day Oral 1 Y

Levonorgestrel-Ethinyl Estrad Oral 1

Levonorg-Eth Estrad Triphasic Oral 1

Levora 0.15/30 (28) Oral 1

Lillow Oral 2

Lo Loestrin Fe Oral 3

Loestrin 1.5/30 (21) Oral 3

Loestrin 1/20 (21) Oral 3

Loestrin Fe 1.5/30 Oral 3

Loestrin Fe 1/20 Oral 3

LoJaimiess Oral 1 Y

Lomedia 24 FE Oral 1

Loryna Oral 1

LoSeasonique Oral 3

Low-Ogestrel Oral 1



Lo-Zumandimine Oral 1

Lutera Oral 1

Lyza Oral 1

Marlissa Oral 1

medroxyPROGESTERone Acetate Intramuscular 1 Y

Melodetta 24 Fe Oral 1

Mibelas 24 Fe Oral 1

Microgestin 1.5/30 Oral 1

Microgestin 1/20 Oral 1

Microgestin 24 Fe Oral 1

Microgestin FE 1.5/30 Oral 1

Microgestin FE 1/20 Oral 1

Mili Oral 1

Minastrin 24 Fe Oral 3

Mircette Oral 3

Mono-Linyah Oral 1

MonoNessa Oral 1

Myzilra Oral 1

Natazia Oral 3

Necon 0.5/35 (28) Oral 1

Necon 1/35 (28) Oral 1

Necon 1/50 (28) Oral 2

Necon 10/11 (28) Oral 2

Necon 7/7/7 Oral 1

Nexplanon Subcutaneous 3

Nikki Oral 1

Nora-BE Oral 1

Norethin Ace-Eth Estrad-FE Oral 1

Norethindrone Oral 1

Norethindrone Acet-Ethinyl Est Oral 1

Norethin-Eth Estradiol-Fe Oral 1

Norgestimate-Eth Estradiol Oral 1

Norgestim-Eth Estrad Triphasic Oral 1

Norlyda Oral 1

Norlyroc Oral 1

Nortrel 0.5/35 (28) Oral 1

Nortrel 1/35 (21) Oral 1



Nortrel 1/35 (28) Oral 1

Nortrel 7/7/7 Oral 1

NuvaRing Vaginal 2

Ocella Oral 3

Ogestrel Oral 2

Orsythia Oral 1

Ortho Micronor Oral 3

Ortho Tri-Cyclen (28) Oral 3

Ortho Tri-Cyclen Lo Oral 3

Ortho-Cyclen (28) Oral 3

Ortho-Novum 1/35 (28) Oral 3

Ortho-Novum 7/7/7 (28) Oral 3

Ovcon-35 (28) Oral 3

Philith Oral 1

Pimtrea Oral 1

Pirmella 1/35 Oral 1

Pirmella 7/7/7 Oral 1

Portia-28 Oral 1

Previfem Oral 1

Quartette Oral 3

Quasense Oral 1 Y

Rajani Oral 1

Reclipsen Oral 1

Rivelsa Oral 1

Safyral Oral 3

Seasonique Oral 3

Setlakin Oral 1 Y

Sharobel Oral 1

Simliya Oral 1

Simpesse Oral 1

Sprintec 28 Oral 1

Sronyx Oral 1

Syeda Oral 1

Tarina 24 Fe Oral 1

Tarina FE 1/20 Oral 1

Tarina FE 1/20 EQ Oral 1

Taytulla Oral 3



Tilia Fe Oral 1

Tri Femynor Oral 1

Tri-Estarylla Oral 1

Tri-Legest Fe Oral 1

Tri-Linyah Oral 1

Tri-Lo-Estarylla Oral 1

Tri-Lo-Marzia Oral 1

Tri-Lo-Mili Oral 1

Tri-Lo-Sprintec Oral 1

Tri-Mili Oral 1

TriNessa (28) Oral 1

TriNessa Lo Oral 1

Tri-Norinyl (28) Oral 3

Tri-Previfem Oral 1

Tri-Sprintec Oral 1

Trivora (28) Oral 1

Tri-VyLibra Oral 1

Tri-VyLibra Lo Oral 1

Tulana Oral 1

Tydemy Oral 3

Velivet Oral 1

Vestura Oral 1

Vienva Oral 1

Viorele Oral 1

Volnea Oral 1

Vyfemla Oral 1

VyLibra Oral 1

Wera Oral 1

Wymzya Fe Oral 1

Xulane Transdermal 2

Yasmin 28 Oral 3

YAZ Oral 3

Zarah Oral 1

Zenchent Oral 1

Zenchent FE Oral 1

Zovia 1/35E (28) Oral 1

Zovia 1/50E (28) Oral 1



Zumandimine Oral 1

CORTICOSTEROIDS

Budesonide Oral 1

Budesonide ER Oral 1

Cortef Oral 3

Cortisone Acetate Oral 1

Decadron Oral 3

Deltasone Oral 1

Dexamethasone Oral 1

Dexamethasone Intensol Oral 2

Dexamethasone Sod Phos-Bupiv Injection 3 Y

Emflaza Oral 3 Y Y

Entocort EC Oral 3

Fludrocortisone Acetate Oral 1

Hydrocortisone Oral 1

Medrol Oral 3

methylPREDNISolone Oral 1

Millipred Oral 3

Millipred DP Oral 3

Millipred DP 12-Day Oral 3

Orapred ODT Oral 3

Pediapred Oral 3

prednisoLONE Oral 1

prednisoLONE Sodium Phosphate Oral 1

predniSONE Oral 1

predniSONE Intensol Oral 3

COUGH/COLD/ALLERGY

Acetylcysteine Inhalation 1

Benzonatate Oral 1

Bromfed DM Oral 1

Hycofenix Oral 3

HYDROcodone-Homatropine Oral 1 Y

Hydromet Oral 1 Y

HyperSal Inhalation 3

Promethazine VC Plain Oral 1

Promethazine-DM Oral 1

Promethazine-Phenylephrine Oral 1



Pseudoeph-Bromphen-DM Oral 1

PulmoSal Inhalation 1

Sodium Chloride Inhalation 1

SSKI Oral 2

Tessalon Perles Oral 3

Tussigon Oral 1 Y

Vituz Oral 3 Y

DERMATOLOGICALS

Acitretin Oral 1

Acyclovir External 1

Adapalene External 1

Ala-Cort External 1

Alclometasone Dipropionate External 1

Aldara External 3

AlphaTrex External 1

Altabax External 3

Amcinonide External 1

Amnesteem Oral 1

Avita External 1

Azelaic Acid External 1

Bactroban External 3

Benzoyl Peroxide-Erythromycin External 1

Beser External 1

Betamethasone Dipropionate External 1

Betamethasone Dipropionate Aug External 1

Betamethasone Valerate External 1

Calcipotriene External 1

Calcipotriene-Betameth Diprop External 1

Calcipotriene-Betameth Diprop External 3

Calcitrene External 1

Calcitriol External 1

Capex External 3

Carac External 2 Y

Centany External 3

Cerovel External 1

Ciclodan External 1

Ciclopirox External 1



Ciclopirox Olamine External 1

Ciclopirox-Clobetasol External 1

Ciclopirox-Clobetasol-Sal Acid External 1

Ciclopirox-Salicylic Acid External 1

Claravis Oral 1

Clindamycin Phos-Benzoyl Perox External 1

Clindamycin Phosphate External 1

Clobetasol Prop Emollient Base External 1

Clobetasol Propionate External 1

Clobetasol Propionate E External 1

Clobetasol Propionate Emulsion External 1

Clobex External 3

Clocortolone Pivalate External 1

Clocortolone Pivalate Pump External 1

Clodan External 1

Cloderm External 3

Cloderm Pump External 3

Clotrimazole External 1

Clotrimazole-Betamethasone External 1

Condylox External 3

Cordran External 3

Cormax Scalp Application External 1

Cortisporin External 3

Cosentyx Subcutaneous 2 Y Y Y

Cosentyx (300 MG Dose) Subcutaneous 2 Y Y Y

Cosentyx Sensoready (300 MG) Subcutaneous 2 Y Y Y

Cosentyx Sensoready Pen Subcutaneous 2 Y Y Y

Crotan External 3

Cutivate External 3

Derma-Smoothe/FS Body External 3

Derma-Smoothe/FS Scalp External 3

Dermatop External 3

Desonate External 3

Desonide External 1

DesOwen External 3

Desoximetasone External 1

Diclofenac Epolamine External 3



Differin External 2

Differin External 3

Diprolene External 3

Diprolene AF External 3

Dovonex External 3

Drysol External 2

Dupixent Subcutaneous 3 Y Y

Econazole Nitrate External 1

Efudex External 3

Elidel External 2

Elimite External 3

Elocon External 3

Epifoam External 3

Ertaczo External 3

Erythromycin External 1

Eucrisa External 3

Eurax External 3

Flector External 3

Fluocinolone Acetonide External 1

Fluocinolone Acetonide Body External 1

Fluocinolone Acetonide Scalp External 1

Fluocinonide External 1

Fluocinonide Emulsified Base External 1

Fluoroplex External 2

Fluorouracil External 1

Fluorouracil External 2 Y

Flurandrenolide External 1

Fluticasone Propionate External 1

Gentamicin Sulfate External 1

Halcinonide External 1

Halobetasol Propionate External 1

Halog External 3

Hydrocortisone External 1

Hydrocortisone Ace-Pramoxine External 1

Hydrocortisone Butyr Lipo Base External 1

Hydrocortisone Butyrate External 1

Hydrocortisone in Absorbase External 1



Hydrocortisone Valerate External 1

Hydrocortisone-Iodoquinol External 1

Ilumya Subcutaneous 3 Y Y

Imiquimod External 1

Imiquimod Pump External 3 Y

Impoyz External 3

ISOtretinoin Oral 1

Kenalog External 3

Ketoconazole External 1

Ketodan External 1

Lidocaine External 1 Y

Lidocaine HCl Urethral/Mucosal External 1 Y

Lidoderm External 3 Y

Lindane External 1

LoKara External 1

Loprox External 3

Lotrisone External 3

Malathion External 1

Mentax External 3

Methoxsalen Rapid Oral 1

metroNIDAZOLE External 1

Mometasone Furoate External 1

Mupirocin External 1

Mupirocin Calcium External 1

Myorisan Oral 1

Naftifine HCl External 1

Naftin External 3

Natroba External 3

Neo-Synalar External 3

Nizoral External 3

Nyamyc External 1

Nyata External 1

Nystatin External 1

Nystatin-Triamcinolone External 1

Nystop External 1

Ovide External 3

Oxiconazole Nitrate External 1



Oxistat External 3

Oxsoralen Ultra Oral 3

Panretin External 3 Y

Permethrin External 1

Pimecrolimus External 1

Podofilox External 1

Pramosone External 3

Prednicarbate External 1

Protopic External 3

Rea Lo 40 External 1

Remeven External 1

Retin-A External 3

Rosadan External 1

Salicylic Acid External 1

Selenium Sulfide External 1

Siliq Subcutaneous 3 Y Y

Silvadene External 3

Silver sulfADIAZINE External 1

Sklice External 3

Skyrizi (150 MG Dose) Subcutaneous 2 Y Y

Sodium Sulfacetamide External 1

Solaraze External 3 Y Y

Soriatane Oral 3 Y

Spinosad External 1

SSD External 1

Stelara Subcutaneous 2 Y Y Y

Sulfacetamide Sodium External 1

Sulfamylon External 3

Synalar External 3

Taclonex External 3

Tacrolimus External 1

Taltz Subcutaneous 3 Y Y

Targretin External 3 Y

Tazarotene External 1

Tazorac External 2

Temovate External 3

Texacort External 3



Tolak External 3

Topicort External 3

Topicort Spray External 3

Tovet External 1

Tovet External 3

Tremfya Subcutaneous 2 Y Y Y

Tretinoin External 1

Triamcinolone Acetonide External 1

Trianex External 1

Triderm External 1

Tridesilon External 3

Ultravate External 3

Umecta Mousse External 1

Urea External 1

Urea-C40 External 1

Valchlor External 2 Y Y

Vanos External 3

Verdeso External 3

Veregen External 3 Y

Westcort External 3

Xolegel External 3

Xurea External 1

Zenatane Oral 1

Zovirax External 3

Zyclara External 3 Y

Zyclara Pump External 3 Y

DIAGNOSTIC PRODUCTS

Breeze 2 Test In Vitro 2 Y

Contour Next Test In Vitro 2 Y

Contour Test In Vitro 2 Y

DIGESTIVE AIDS

Creon Oral 2

Pancreaze Oral 3

Pertzye Oral 3

Sucraid Oral 3 Y Y

Viokace Oral 3

Zenpep Oral 2



DIURETICS

acetaZOLAMIDE Oral 1

acetaZOLAMIDE ER Oral 1

aMILoride HCl Oral 1

aMILoride-hydroCHLOROthiazide Oral 1

Bumetanide Oral 1

Chlorothiazide Oral 1

Chlorthalidone Oral 1

Diuril Oral 3

Dyazide Oral 3

Dyrenium Oral 3

Furosemide Oral 1

hydroCHLOROthiazide Oral 1

Indapamide Oral 1

Keveyis Oral 3 Y Y Y

Maxzide Oral 3

Maxzide-25 Oral 3

methazolAMIDE Oral 1

Methyclothiazide Oral 1

metOLazone Oral 1

Neptazane Oral 3

Spironolactone Oral 1

Spironolactone-HCTZ Oral 1

Torsemide Oral 1

Triamterene Oral 1

Triamterene-HCTZ Oral 1

ENDOCRINE AND METABOLIC AGENTS - MISC.

Acthar Injection 3 Y Y Y

Actonel Oral 3

Alendronate Sodium Oral 1

Atelvia Oral 3

Binosto Oral 3

Boniva Oral 3

Bravelle Injection 3 Y

Buphenyl Oral 3 Y Y

Cabergoline Oral 1

Calcitonin (Salmon) Nasal 1



Calcitriol Oral 1

Carbaglu Oral 3 Y Y

Carnitor Oral 3

Carnitor SF Oral 3

Cetrotide Subcutaneous 2 Y

Chorionic Gonadotropin Intramuscular 1 Y

Cinacalcet HCl Oral 1 Y Y

clomiPHENE Citrate Oral 1

Crysvita Subcutaneous 3 Y Y

Cystadane Oral 3 Y Y

DDAVP Nasal 3

DDAVP Oral 3

DDAVP Rhinal Tube Nasal 3

Desmopressin Ace Spray Refrig Nasal 1

Desmopressin Acetate Injection 1 Y

Desmopressin Acetate Oral 1

Desmopressin Acetate Spray Nasal 1

Doxercalciferol Oral 1

Egrifta Subcutaneous 3 Y Y Y

Etidronate Disodium Oral 1 Y

Evista Oral 3

Fensolvi (6 Month) Subcutaneous 3 Y Y

Follistim AQ Injection 2 Y

Follistim AQ Subcutaneous 2 Y

Forteo Subcutaneous 3 Y Y Y

Fosamax Oral 3

Fosamax Plus D Oral 3

Galafold Oral 3 Y Y

Ganirelix Acetate Subcutaneous 1 Y

Gonal-f Injection 2 Y

Gonal-f RFF Subcutaneous 2 Y

Gonal-f RFF Rediject Subcutaneous 2 Y

HCG Injection 3 Y

Hectorol Oral 3

Ibandronate Sodium Oral 1

Increlex Subcutaneous 2 Y Y

Jynarque Oral 3 Y Y Y



levOCARNitine Oral 1

levOCARNitine SF Oral 1

Lupaneta Pack Combination 3 Y Y

Menopur Subcutaneous 3 Y

Mifeprex Oral 3

miFEPRIStone Oral 1

Myalept Subcutaneous 3 Y Y

Nitisinone Oral 3 Y Y

Nityr Oral 3 Y Y

Nocdurna Sublingual 3

Norditropin FlexPro Subcutaneous 2 Y Y

Novarel Intramuscular 2 Y

Orfadin Oral 3 Y Y

Orilissa Oral 3 Y

Osphena Oral 3

Ovidrel Subcutaneous 2 Y

Palynziq Subcutaneous 3 Y Y

Paricalcitol Oral 1

Pregnyl Intramuscular 2 Y

Raloxifene HCl Oral 1

Ravicti Oral 3 Y Y

Risedronate Sodium Oral 1

Rocaltrol Oral 3

Samsca Oral 3 Y Y Y

Sapropterin Dihydrochloride Oral 1 Y Y

Sensipar Oral 3 Y Y

Signifor Subcutaneous 3 Y Y Y

Sodium Phenylbutyrate Oral 1 Y Y

Somatuline Depot Subcutaneous 3 Y Y

Somavert Subcutaneous 3 Y Y Y

Stimate Nasal 3

Strensiq Subcutaneous 2 Y Y 4

Supprelin LA Subcutaneous 3 Y Y

Synarel Nasal 3 Y Y

Tolvaptan Oral 1 Y Y Y

Tymlos Subcutaneous 2 Y Y

Xuriden Oral 3 Y Y



Zemplar Oral 3 Y

ESTROGENS

Activella Oral 3

Alora Transdermal 3

Amabelz Oral 1

Angeliq Oral 3

Biest/Progesterone Transdermal 3

Bijuva Oral 3

Climara Transdermal 3

Climara Pro Transdermal 2

CombiPatch Transdermal 3

Covaryx Oral 1

Covaryx HS Oral 1

Delestrogen Intramuscular 3

Depo-Estradiol Intramuscular 3

Divigel Transdermal 2

Dotti Transdermal 1

Duavee Oral 3

EEMT Oral 1

EEMT HS Oral 1

Elestrin Transdermal 3

Est Estrogens-Methyltest Oral 1

Est Estrogens-Methyltest DS Oral 1

Est Estrogens-Methyltest HS Oral 1

Estrace Oral 3

Estradiol Oral 1

Estradiol Transdermal 1

Estradiol-Norethindrone Acet Oral 1

Estrogel Transdermal 2

Estropipate Oral 1

Evamist Transdermal 3

Femhrt Low Dose Oral 3

Fyavolv Oral 1

Jevantique Lo Oral 1

Jinteli Oral 1

Lopreeza Oral 1

Menest Oral 3



Menostar Transdermal 3

Mimvey Oral 1

Mimvey Lo Oral 1

Minivelle Transdermal 3

Norethindrone-Eth Estradiol Oral 1

Prefest Oral 3

Premarin Oral 2

Premphase Oral 2

Prempro Oral 2

Vivelle-Dot Transdermal 3

FLUOROQUINOLONES

Avelox Oral 3

Baxdela Oral 3

Cipro Oral 3

Cipro XR Oral 3

Ciprofloxacin Oral 1

Ciprofloxacin HCl Oral 1

Ciprofloxacin-Ciproflox HCl ER Oral 1

Factive Oral 3

Levaquin Oral 3

levoFLOXacin Oral 1

Moxifloxacin HCl Oral 1

Ofloxacin Oral 1

GASTROINTESTINAL AGENTS - MISC.

Actigall Oral 3

Alosetron HCl Oral 1

Amitiza Oral 3

Apriso Oral 3

Asacol HD Oral 2

Auryxia Oral 3

Azulfidine Oral 3

Azulfidine EN-tabs Oral 3

Balsalazide Disodium Oral 1

Calcium Acetate Oral 1

Calcium Acetate (Phos Binder) Oral 1

Canasa Rectal 2

Chenodal Oral 2 Y Y Y



Cholbam Oral 3 Y Y

Cimzia Subcutaneous 2 Y Y Y

Cimzia Prefilled Subcutaneous 2 Y Y Y

Cimzia Starter Kit Subcutaneous 2 Y Y Y

Colazal Oral 3

Cromolyn Sodium Oral 1

Delzicol Oral 2

Dipentum Oral 3

Eliphos Oral 3

Enulose Oral 1

Fosrenol Oral 3

Gastrocrom Oral 3

Generlac Oral 1

Giazo Oral 3

Lactulose Encephalopathy Oral 1

Lanthanum Carbonate Oral 1

Lialda Oral 2

Linzess Oral 3

Lotronex Oral 3

Mesalamine Oral 1

Mesalamine Rectal 1

Mesalamine ER Oral 1

Metoclopramide HCl Oral 1

Movantik Oral 3 Y

Ocaliva Oral 3 Y Y Y

Pentasa Oral 2

Phoslyra Oral 3

Reglan Oral 3

Renagel Oral 3

Sevelamer Carbonate Oral 1

Sevelamer HCl Oral 1

SfRowasa Rectal 3

sulfaSALAzine Oral 1

Symproic Oral 2 Y

Trulance Oral 2

Trulance Oral 3

Urso 250 Oral 3



Urso Forte Oral 3

Ursodiol Oral 1

Viberzi Oral 3 Y Y

Xermelo Oral 3 Y Y

GENITOURINARY AGENTS - MISCELLANEOUS

Alfuzosin HCl ER Oral 1

Avodart Oral 3

Cardura XL Oral 3

Cystagon Oral 2 Y Y

Cytra K Crystals Oral 1

Dutasteride Oral 1

Dutasteride-Tamsulosin HCl Oral 1

Elmiron Oral 3 Y

Finasteride Oral 1

Flomax Oral 3

Jalyn Oral 3

Lithostat Oral 3

Oracit Oral 3

Phenazo Oral 1

Phenazopyridine HCl Oral 1

Pot & Sod Cit-Cit Ac Oral 1

Potassium Citrate ER Oral 1

Potassium Citrate-Citric Acid Oral 1

Proscar Oral 3

Pyridium Oral 3

Rapaflo Oral 3

Shohls Modified Oral 3

Silodosin Oral 1

Sod Citrate-Citric Acid Oral 1

Tamsulosin HCl Oral 1

Taron-Crystals Oral 1

Thiola Oral 3 Y Y

Thiola EC Oral 3 Y Y

Tricitrates Oral 1

Urocit-K 10 Oral 3

Urocit-K 15 Oral 3

Urocit-K 5 Oral 3



Uroxatral Oral 3

Virtrate-2 Oral 1

Virtrate-3 Oral 1

Virtrate-K Oral 1

GOUT AGENTS

Allopurinol Oral 1

Colchicine Oral 1

Colchicine-Probenecid Oral 1

Colcrys Oral 2

Duzallo Oral 3

Febuxostat Oral 1

Mitigare Oral 3

Probenecid Oral 1

Uloric Oral 3

Zurampic Oral 3

Zyloprim Oral 3

HEMATOLOGICAL AGENTS - MISC.

Aggrenox Oral 3

Agrylin Oral 3

Anagrelide HCl Oral 1

Aspirin-Dipyridamole ER Oral 1

Brilinta Oral 2

Cilostazol Oral 1

Clopidogrel Bisulfate Oral 1

Dipyridamole Oral 1

Effient Oral 3

Firazyr Subcutaneous 2 Y Y Y

Haegarda Subcutaneous 3 Y Y Y 1

Icatibant Acetate Subcutaneous 1 Y Y Y

Kalbitor Subcutaneous 3 Y Y Y

Pentoxifylline ER Oral 1

Plavix Oral 3

Prasugrel HCl Oral 1

Takhzyro Subcutaneous 3 Y Y 3

Tavalisse Oral 3 Y Y

Zontivity Oral 3

HEMATOPOIETIC AGENTS



Cerdelga Oral 3 Y Y Y

Doptelet Oral 3 Y Y

Droxia Oral 3 Y

Endari Oral 3 Y Y

Folic Acid Oral 1

Miglustat Oral 1 Y Y Y

Mulpleta Oral 3 Y Y

Promacta Oral 3 Y Y Y

Zavesca Oral 3 Y Y Y

HEMOSTATICS

Amicar Oral 3

Aminocaproic Acid Oral 1

Lysteda Oral 3

Tranexamic Acid Oral 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

Ambien Oral 3

Ambien CR Oral 3

Belsomra Oral 3

Butisol Sodium Oral 3

Doral Oral 3

Edluar Sublingual 3

Estazolam Oral 1

Eszopiclone Oral 1

Flurazepam HCl Oral 1

Halcion Oral 3

Hetlioz Oral 3 Y Y Y

Intermezzo Sublingual 3

Lunesta Oral 3

PHENobarbital Oral 1

Quazepam Oral 1

Ramelteon Oral 1

Restoril Oral 3

Rozerem Oral 3

Seconal Oral 3

Sonata Oral 3

Temazepam Oral 1

Triazolam Oral 1



Zaleplon Oral 1

Zolpidem Tartrate Oral 1

Zolpidem Tartrate Sublingual 1

Zolpidem Tartrate ER Oral 1

Zolpimist Oral 3

LAXATIVES

Clenpiq Oral 3

Constulose Oral 1

GaviLyte-C Oral 1

GaviLyte-G Oral 1

GaviLyte-H Oral 1

Gialax Oral 3

Golytely Oral 3

Kristalose Oral 3

Lactulose Oral 1

Lactulose Oral 3

MoviPrep Oral 3

OsmoPrep Oral 3

PCP 100 Combination 3

PEG 3350/Electrolytes Oral 1

PEG 3350-KCl-Na Bicarb-NaCl Oral 1

PEG-3350/Electrolytes Oral 1

PEG-3350/Electrolytes/Ascorbat Oral 1

PEG-KCl-NaCl-NaSulf-Na Asc-C Oral 1

PEG-Prep Oral 1

PEGyLAX Oral 1

Plenvu Oral 3

Polyethylene Glycol 3350 Oral 1

Poly-Prep Combination 3

QC Natura-LAX Oral 1

Suprep Bowel Prep Kit Oral 3

TGT Powderlax Oral 1

TriLyte Oral 1

MACROLIDES

Azithromycin Oral 1 Y

Clarithromycin Oral 1

Clarithromycin ER Oral 1



Dificid Oral 3 Y Y

E.E.S. 400 Oral 2

E.E.S. Granules Oral 3

EryPed 200 Oral 3

EryPed 400 Oral 3

Ery-Tab Oral 3

Erythrocin Stearate Oral 2

Erythromycin Oral 3

Erythromycin Base Oral 1

Erythromycin Ethylsuccinate Oral 1

PCE Oral 3

Zithromax Oral 3 Y

Zithromax Tri-Pak Oral 3 Y

Zithromax Z-Pak Oral 3 Y

Zmax Oral 3 Y

MEDICAL DEVICES AND SUPPLIES

1st Tier Unifine Pentips Miscellaneous 1 Y

1st Tier Unifine Pentips Plus Miscellaneous 1 Y

1st Tier Unilet ComforTouch Miscellaneous 1

AboutTime Pen Needle Miscellaneous 3 Y

Accu-Chek FastClix Lancets Miscellaneous 1

Accu-Chek Multiclix Lancets Miscellaneous 1

Accu-Chek Safe-T Pro Lancets Miscellaneous 1

Accu-Chek Soft Touch Lancets Miscellaneous 1

Accu-Chek Softclix Lancets Miscellaneous 1

Acti-Lance Lite Lancets 28G Miscellaneous 1

Acti-Lance Special Lancets 17G Miscellaneous 1

Acti-Lance Universal 23G Miscellaneous 1

AgaMatrix Ultra-Thin Lancets Miscellaneous 1

Aimsco Twist Lancets 32G Miscellaneous 1

Aimsco Twist Lancets 33G Miscellaneous 1

Anti-Stick Insulin Syringe Miscellaneous 1 Y

AquaLance Lancets 30G Miscellaneous 1

Assure Comfort Lancets 28G Miscellaneous 1

Assure Haemolance Plus High Miscellaneous 1

Assure Haemolance Plus Low Miscellaneous 1

Assure Haemolance Plus Micro Miscellaneous 1



Assure Haemolance Plus Normal Miscellaneous 1

Assure Haemolance Plus Ped Miscellaneous 1

Assure ID Insulin Safety Syr Miscellaneous 1 Y

Assure Lance Lancets Miscellaneous 1

Assure Lance Lancets 21G Miscellaneous 1

Assure Lance Plus Safety 25G Miscellaneous 1

Assure Lance Plus Safety 30G Miscellaneous 1

At Last Lancets Miscellaneous 1

Aurora Lancet Super Thin 30G Miscellaneous 1

Aurora Lancet Thin 23G Miscellaneous 1

Aurora Pen Needles Miscellaneous 1 Y

Aurora Unifine Pentips Miscellaneous 1 Y

Bayer Breeze 2 System Miscellaneous 3 Y

Bayer Contour Link 2.4 Miscellaneous 2 Y Y

Bayer Contour Link Monitor Miscellaneous 2 Y Y

Bayer Contour Monitor Miscellaneous 2 Y Y

Bayer Microlet Lancets Miscellaneous 1

BD AutoShield Miscellaneous 3 Y

BD AutoShield Duo Miscellaneous 3 Y

BD Insulin Syr Ultrafine II Miscellaneous 1 Y

BD Insulin Syringe Miscellaneous 1 Y

BD Insulin Syringe Half-Unit Miscellaneous 1 Y

BD Insulin Syringe MicroFine Miscellaneous 1 Y

BD Insulin Syringe U/F Miscellaneous 1 Y

BD Insulin Syringe U/F 1/2Unit Miscellaneous 1 Y

BD Insulin Syringe U-40 Miscellaneous 1 Y

BD Insulin Syringe U-500 Miscellaneous 1 Y

BD Insulin Syringe Ultrafine Miscellaneous 1 Y

BD Integra Insulin Syringe Miscellaneous 1 Y

BD Integra Syringe Miscellaneous 1 Y

BD Lancet Ultrafine 30G Miscellaneous 1

BD Lancet Ultrafine 33G Miscellaneous 1

BD Microtainer Lancets Miscellaneous 1

BD Pen Needle Mini U/F Miscellaneous 3 Y

BD Pen Needle Nano 2nd Gen Miscellaneous 3 Y

BD Pen Needle Nano U/F Miscellaneous 3 Y

BD Pen Needle Original U/F Miscellaneous 3 Y



BD Pen Needle Short U/F Miscellaneous 3 Y

BD SafetyGlide Insulin Syringe Miscellaneous 1 Y

BD Safety-Lok Insulin Syringe Miscellaneous 1 Y

BD Veo Insulin Syr U/F 1/2Unit Miscellaneous 1 Y

BD Veo Insulin Syringe U/F Miscellaneous 1 Y

CareFine Pen Needles Miscellaneous 1 Y

CareOne Insulin Syringe Miscellaneous 1 Y

CareOne Lancet Thin 23G Miscellaneous 1

CareOne Lancet Ultra Thin 28G Miscellaneous 1

CareOne Unifine Pentips Miscellaneous 1 Y

CareOne Unifine Pentips Plus Miscellaneous 1 Y

CareTouch Pen Needles Miscellaneous 1 Y

CareTouch Twist Lancets 28G Miscellaneous 1



Caya Vaginal 3

Clickfine Pen Needles Miscellaneous 3 Y

CoaguChek Lancets Miscellaneous 1

Comfort Assist Insulin Syringe Miscellaneous 1 Y

Comfort EZ Insulin Syringe Miscellaneous 1 Y

Comfort EZ Micro Pen Needles Miscellaneous 3 Y

Comfort EZ Pen Needles Miscellaneous 3 Y

Comfort EZ Short Pen Needles Miscellaneous 1 Y

Comfort Lancets Miscellaneous 1

Contour Blood Glucose System Miscellaneous 2 Y Y

Contour Monitor Miscellaneous 2 Y Y

Contour Next EZ Miscellaneous 2 Y Y

Contour Next Link Miscellaneous 2 Y Y

Contour Next Monitor Miscellaneous 2 Y Y

Contour Next One Miscellaneous 2 Y Y

Contour Next USB Monitor Miscellaneous 2 Y Y

CVS Lancets Original Miscellaneous 1

CVS Lancets Thin 26G Miscellaneous 1

CVS Ultra Thin Lancets Miscellaneous 1

Diathrive Lancet Ultra Thin 30 Miscellaneous 1

Diathrive Lancets Miscellaneous 1

Droplet Lancets Ultra Thin 30G Miscellaneous 1



Droplet Micron Miscellaneous 3 Y

Droplet Pen Needles Miscellaneous 1 Y

Drug Mart On-The-Go Lancet 30G Miscellaneous 1

Drug Mart Unifine Pentips Miscellaneous 1 Y

Drug Mart Unifine Pentips Plus Miscellaneous 1 Y

Drug Mart Unilet Lancets 28G Miscellaneous 1

Drug Mart Unilet Lancets 30G Miscellaneous 1

Easy Touch FlipLock Insulin Sy Miscellaneous 1 Y

Easy Touch Insulin Safety Syr Miscellaneous 1 Y

Easy Touch Insulin Syringe Miscellaneous 1 Y

Easy Touch Lancets 21G Miscellaneous 1




Easy Touch Lancets 28G/Twist Miscellaneous 1






Easy Touch Pen Needles Miscellaneous 1 Y

Easy Touch Pen Needles Miscellaneous 3 Y

Easy Touch Safety Lancets 21G Miscellaneous 1




Easy Touch SheathLock Syringe Miscellaneous 1 Y

EasyTest II Lancets Miscellaneous 1

EasyTest Lancets Miscellaneous 1

Elite-Thin Insulin Syringe Miscellaneous 1 Y

Exel Comfort Point Insulin Syr Miscellaneous 1 Y

Exel Comfort Point Pen Needle Miscellaneous 1 Y

FemCap Vaginal 3

Fifty50 Pen Needles Miscellaneous 3 Y

Fifty50 Safety Seal Lancets Miscellaneous 1

Fifty50 Superior Comfort Syr Miscellaneous 1 Y

Fifty50 Unilet Lancets 33G Miscellaneous 1



Fine 30 Miscellaneous 1

Fingerstix Lancets Miscellaneous 1

Freds Pharmacy Unifine Pentip+ Miscellaneous 1 Y

Freds Pharmacy Unifine Pentips Miscellaneous 1 Y

Freds Pharmacy Unilet Lanc 28G Miscellaneous 1

Freds Pharmacy Unilet Lanc 30G Miscellaneous 1

FreeStyle Unistick II Lancets Miscellaneous 1

Gentle-Let GP Lancets Miscellaneous 1

Gentle-Let Lancets Miscellaneous 1

Global Easy Glide Insulin Syr Miscellaneous 1 Y

GlucoCom Lancets 28G Miscellaneous 1



GlucoPro Insulin Syringe Miscellaneous 1 Y

Glucosource Lancets Miscellaneous 1

Gojji Sterile Lancets Miscellaneous 1

GoodSense Clickfine Pen Needle Miscellaneous 3 Y

GoodSense Pen Needle Penfine Miscellaneous 3 Y

Haemolance Miscellaneous 1

Haemolance Low Flow Lancets Miscellaneous 1

Haemolance Plus Miscellaneous 1

Haemolance Plus High Flow Miscellaneous 1

Haemolance Plus Low Flow Miscellaneous 1

Haemolance Plus Max Flow Miscellaneous 1

Haemolance Plus Pediatric Flow Miscellaneous 1

HealthWise Insulin Syr/Needle Miscellaneous 1 Y

HealthWise Micron Pen Needles Miscellaneous 1 Y

HealthWise Mini Pen Needles Miscellaneous 1 Y

HealthWise Pen Needles Miscellaneous 1 Y

HealthWise Short Pen Needles Miscellaneous 1 Y

HealthWise Unifine Pentips Miscellaneous 1 Y

Healthy Accents Unifine Pentip Miscellaneous 1 Y

Healthy Accents Unilet Lancets Miscellaneous 1

H-E-B inControl Lancets 28G Miscellaneous 1



H-E-B inControl Pen Needles Miscellaneous 1 Y



H-E-B inControl Unifine Pentip Miscellaneous 1 Y

HumaPen LUXURA HD Miscellaneous 3

InPen 100-Blue-Lilly Miscellaneous 3

InPen 100-Blue-Novo Miscellaneous 3

InPen 100-Gray-Lilly Miscellaneous 3

InPen 100-Grey-Novo Miscellaneous 3

InPen 100-Pink-Lilly Miscellaneous 3

InPen 100-Pink-Novo Miscellaneous 3

Insulin Syringe Miscellaneous 1 Y

Insulin Syringe/Needle Miscellaneous 1 Y

Insupen Pen Needles Miscellaneous 1 Y

Insupen Sensitive Miscellaneous 1 Y

Insupen Ultrafin Miscellaneous 1 Y

Kinney Lancets Miscellaneous 1

Kinney Thin Lancets Miscellaneous 1

Kinray Insulin Syringe Miscellaneous 1 Y

Kroger HealthPro Lancet 26G Miscellaneous 1

Kroger Pen Needles Miscellaneous 1 Y

Lancets Miscellaneous 1

Lancets 28G Miscellaneous 1

Lancets 30G Miscellaneous 1

Lancets Micro Thin 33G Miscellaneous 1

Lancets Thin Miscellaneous 1

Lancets Ultra Thin Miscellaneous 1

Leader Unifine Pentips Miscellaneous 1 Y

Leader Unifine Pentips Plus Miscellaneous 1 Y

Liberty Medical Lancets Miscellaneous 1

LifeScan Unistik 2 Miscellaneous 1

LifeScan Unistik II Lancets Miscellaneous 1

Litetouch Insulin Syringe Miscellaneous 1 Y

Live Better Lancet Super Thin Miscellaneous 1

Live Better Lancet Ultra Thin Miscellaneous 1

Magellan Insulin Safety Syr Miscellaneous 1 Y

Marathon Medical Pentips Miscellaneous 1 Y

Maxi-Comfort Insulin Syringe Miscellaneous 1 Y

Maxi-Comfort Safety Pen Needle Miscellaneous 3 Y

Maxicomfort syr 27G x 1/2" Miscellaneous 1 Y



Medic Insulin Syringe Miscellaneous 1 Y

MediChoice Safety Lancet Miscellaneous 1

MediChoice Safety Lancet Extra Miscellaneous 1

MediChoice Safety Lancet Norm Miscellaneous 1

Medicine Shoppe Pen Needles Miscellaneous 1 Y

MediSense Thin Lancets Miscellaneous 1

Medlance Extra 21G Miscellaneous 1

Medlance Lite 25G Miscellaneous 1

Medlance Plus Extra 21G Miscellaneous 1

Medlance Plus Lancets Miscellaneous 1

Medlance Plus Lite 25G Miscellaneous 1

Medlance Plus Special 0.8mm Miscellaneous 1

Medlance Plus SuperLite 30G Miscellaneous 1

Medlance Plus Universal 21G Miscellaneous 1

Medlance Universal 21G Miscellaneous 1

Meijer Lancets Universal 21G Miscellaneous 1

Meijer Lancets Universal 30G Miscellaneous 1

Meijer Pen Needles Miscellaneous 1 Y

Microdot Pen Needle Miscellaneous 3 Y

Microlet Lancets Miscellaneous 1

Microtainer Safety Flow Lancet Miscellaneous 1

Monoject Insulin Syringe Miscellaneous 1 Y

Monoject Ultra Comfort Syringe Miscellaneous 1 Y

Monolet Lancets Miscellaneous 1

Monolet OPD Lancets Miscellaneous 1

Monolettor Safety Lancets Miscellaneous 1

Moore Mono Insulin Syringe Miscellaneous 1 Y

NetGroup Lancets Miscellaneous 1

Nova Safety Lancets 23G Miscellaneous 1

Nova Safety Lancets 28G Miscellaneous 1

Nova Sureflex Lancets Miscellaneous 1

NovoFine Miscellaneous 3 Y

NovoFine Autocover Miscellaneous 3 Y

NovoFine Plus Miscellaneous 3 Y

NovoPen Echo Miscellaneous 3

NovoTwist Miscellaneous 3 Y

Omniflex Diaphragm Vaginal 3



On Call Lancets Miscellaneous 1

On Call Plus Lancets Miscellaneous 1

OneTouch Club Lancets Fine Pt Miscellaneous 1

OneTouch Combo Pack Miscellaneous 1

OneTouch Delica Lancets 30G Miscellaneous 1

OneTouch Delica Lancets 33G Miscellaneous 1

OneTouch Delica Plus Lancet30G Miscellaneous 1

OneTouch Delica Plus Lancet33G Miscellaneous 1

OneTouch FinePoint Lancets Miscellaneous 1

OneTouch UltraSoft Lancets Miscellaneous 1

PC Lancets Super Thin 30G Miscellaneous 1

PC Unifine Pentips Miscellaneous 1 Y

Pen Needles Miscellaneous 1 Y

Pen Needles Miscellaneous 3 Y

Pen Needles 1/2" Miscellaneous 1 Y

Pen Needles 5/16" Miscellaneous 3 Y

PenTips Miscellaneous 1 Y

Perfect Lancets 28G Miscellaneous 1

Perfect Lancets 30G Miscellaneous 1

Precision SureDose Plus Syr Miscellaneous 1 Y

Precision Sure-Dose Syringe Miscellaneous 1 Y

Precision Thin Lancets Miscellaneous 1

Precision Thins GP Lancets Miscellaneous 1

Precision Ultra Lancet Miscellaneous 1

Preferred Plus Unifine Pentips Miscellaneous 1 Y

Pressure Activat Safety Lancet Miscellaneous 1

Prevent Safety Pen Needles Miscellaneous 3 Y

Pro Comfort Pen Needles Miscellaneous 3 Y

Prodigy Insulin Syringe Miscellaneous 1 Y

Prodigy Lancets 28G Miscellaneous 1

Prodigy Safety Lancets 26G Miscellaneous 1

Prodigy Twist Top Lancets 28G Miscellaneous 1

PSS Select GP Lancets Miscellaneous 1

PSS Select Safety Lancets Miscellaneous 1

Pure Comfort Pen Needle Miscellaneous 3 Y

Push Button Safety Lancets Miscellaneous 1

PX Lancets Ultra Thin Miscellaneous 1



PX Lancets Ultra Thin 28G Miscellaneous 1

PX Mini Pen Needles Miscellaneous 1 Y

QC Lancets Super Thin 30G Miscellaneous 1

QC Lancets Ultra Thin Miscellaneous 1

QC Pen Needles Miscellaneous 1 Y

QC Unifine Pentips Miscellaneous 1 Y

QC Unilet Lancets 28G Miscellaneous 1

QC Unilet Lancets Micro Thin Miscellaneous 1

RA E-Zject Color Lancets 33G Miscellaneous 1

RA Insulin Syringe Miscellaneous 1 Y

RA Pen Needles Miscellaneous 1 Y

ReliOn Insulin Syringe Miscellaneous 1 Y

ReliOn Lancets Thin 26G Miscellaneous 1

ReliOn Mini Pen Needles Miscellaneous 1 Y

ReliOn Pen Needles Miscellaneous 1 Y

ReliOn Pen Needles Miscellaneous 3 Y

ReliOn Short Pen Needles Miscellaneous 1 Y

Rightest GL300 Lancets Miscellaneous 1

SafeSnap Insulin Syringe Miscellaneous 1 Y

Safe-T-Lance Miscellaneous 1

Safe-T-Lance Plus Miscellaneous 1

Safety Lancet 21G/Pressure Act Miscellaneous 1




Safety Lancets Miscellaneous 1

Safety Lancets 21G Miscellaneous 1

Safety Lancets 28G Miscellaneous 1

SAPS Twist Top Lancets Miscellaneous 1

SB Insulin Syringe Miscellaneous 1 Y

Schnucks Insulin Syringe Miscellaneous 1 Y

Shopko On-the-Go Lancets 30G Miscellaneous 1

Shopko Unifine Pentips Miscellaneous 1 Y

Shopko Unifine Pentips Plus Miscellaneous 1 Y

Shopko Unilet Lancets 28G Miscellaneous 1

Shopko Unilet Lancets 30G Miscellaneous 1

Side Button Safety Lancet Miscellaneous 1



Single-Let Miscellaneous 1

Smartest Lancets 28G Miscellaneous 1

Solus V2 Lancets 28G Miscellaneous 1

Solus V2 Twist Lancets 30G Miscellaneous 1

SteriLance TL Miscellaneous 1

TechLite AST Lancets Miscellaneous 1

TechLite Lancets Miscellaneous 1

TechLite Lancets 30G Miscellaneous 1

TechLite Pen Needles Miscellaneous 1 Y

Thinlets GP Lancets Miscellaneous 1

Thinlets Lancet Miscellaneous 1

Todays Health Mini Pen Needles Miscellaneous 1 Y

Todays Health Pen Needles Miscellaneous 1 Y

Todays Health Short Pen Needle Miscellaneous 1 Y

Todays Health Thin Lancets 28G Miscellaneous 1

Todays Health Thin Lancets 30G Miscellaneous 1

Topco Insulin Syringe Miscellaneous 1 Y

Travel Lancets Miscellaneous 1

TRUEplus 5-Bevel Pen Needles Miscellaneous 1 Y

TRUEplus 5-Bevel Pen Needles Miscellaneous 3 Y

TRUEplus Insulin Syringe Miscellaneous 1 Y

TRUEplus Lancets 26G Miscellaneous 1




TRUEplus Pen Needles Miscellaneous 1 Y

TRUEplus Safety Lancets 28G Miscellaneous 1

UltiCare Insulin Safety Syr Miscellaneous 1 Y

UltiCare Insulin Syringe Miscellaneous 1 Y

UltiCare Micro Pen Needles Miscellaneous 1 Y

UltiCare Mini Pen Needles Miscellaneous 1 Y

UltiCare Pen Needles Miscellaneous 1 Y

UltiCare Short Pen Needles Miscellaneous 1 Y

UltiCare Thin Lancets 30G Miscellaneous 1

UltiGuard SafePack Pen Needle Miscellaneous 1 Y

Ultilet Classic Lancets Miscellaneous 1

Ultilet Insulin Syringe Miscellaneous 1 Y



Ultilet Insulin Syringe Short Miscellaneous 1 Y

Ultilet Lancets Miscellaneous 1

Ultilet Pen Needle Miscellaneous 1 Y

Ultilet Safety Lancets Miscellaneous 1

Ultilet Safety Lancets 23G Miscellaneous 1

Ultra Flo Insulin Pen Needles Miscellaneous 3 Y

Ultra Flo Insulin Syringe Miscellaneous 1 Y

Ultra-Comfort Insulin Syringe Miscellaneous 1 Y

Ultra-Thin II Auto Lancet Miscellaneous 1

Ultra-Thin II Ins Syr Short Miscellaneous 1 Y

Ultra-Thin II Insulin Syringe Miscellaneous 1 Y

Ultra-Thin II Lancets Miscellaneous 1

Ultra-Thin II Mini Pen Needle Miscellaneous 1 Y

Ultra-Thin II Pen Needle Short Miscellaneous 1 Y

Ultra-Thin II Pen Needles Miscellaneous 1 Y

Unifine Pentips Miscellaneous 1 Y

Unifine Pentips Plus Miscellaneous 1 Y

Unifine SafeControl Pen Needle Miscellaneous 3 Y

Unilet ComforTouch Lancet Miscellaneous 1

Unilet ExceLite Miscellaneous 1

Unilet ExceLite II Miscellaneous 1

Unilet G.P. Lancet Miscellaneous 1

Unilet G.P. Superlite Lancet Miscellaneous 1

Unilet GP 28 Ultra Thin Miscellaneous 1

Unilet Lancet Miscellaneous 1

Unilet Superlite Lancet Miscellaneous 1

Unilet Super-Thin 30G Miscellaneous 1

Unilet Ultra-Thin 28G Miscellaneous 1

Unistik 3 Gentle Miscellaneous 1

Unistik Safety Lancets 28G Miscellaneous 1

Unistik Safety Lancets 30G Miscellaneous 1

Unistik Touch Safety Lanc 21G Miscellaneous 1




ValuMark Lancet Super Thin 30G Miscellaneous 1

ValuMark Lancet Ultra Thin 28G Miscellaneous 1



ValuMark Pen Needles Miscellaneous 1 Y

Vida Mia Unifine Pentips Miscellaneous 1 Y

Vida Mia Unilet Lancets 28G Miscellaneous 1

Vida Mia Unilet Lancets 30G Miscellaneous 1

V-R Mono Insulin Syringe Miscellaneous 1 Y

W&F Lancets 26G Miscellaneous 1

W&F Lancets Colored 21G Miscellaneous 1

Walgreens Adv Travel Lancets Miscellaneous 1

Wegmans Unifine Pentips Plus Miscellaneous 1 Y

Wide-Seal Diaphragm 60 Vaginal 3








MIGRAINE PRODUCTS

Aimovig Subcutaneous 2 Y

Aimovig (140 MG Dose) Subcutaneous 2 Y

Almotriptan Malate Oral 1 Y

Amerge Oral 3 Y

Axert Oral 3 Y

Cafergot Oral 3

Eletriptan Hydrobromide Oral 1 Y

Emgality Subcutaneous 2 Y

Emgality (300 MG Dose) Subcutaneous 2 Y

Ergomar Sublingual 3

Ergotamine-Caffeine Oral 1

Frova Oral 3 Y

Frovatriptan Succinate Oral 1 Y

Imitrex Nasal 3 Y

Imitrex Oral 3 Y

Imitrex Subcutaneous 3 Y

Imitrex STATdose Refill Subcutaneous 3 Y

Imitrex STATdose System Subcutaneous 3 Y

Isometheptene-Dichloral-APAP Oral 1



Maxalt Oral 3 Y

Maxalt-MLT Oral 3 Y

Migergot Rectal 3

Naratriptan HCl Oral 1 Y

Onzetra Xsail Nasal 3 Y Y

Relpax Oral 2 Y

Rizatriptan Benzoate Oral 1 Y

SUMAtriptan Nasal 1 Y

SUMAtriptan Succinate Oral 1 Y

SUMAtriptan Succinate Subcutaneous 1 Y

SUMAtriptan Succinate Refill Subcutaneous 1 Y

Sumavel DosePro Subcutaneous 3 Y Y

Zembrace SymTouch Subcutaneous 3 Y

ZOLMitriptan Oral 1 Y

Zomig Nasal 3 Y

Zomig Oral 3 Y

Zomig ZMT Oral 3 Y

MINERALS & ELECTROLYTES

Effer-K Oral 1

Effer-K Oral 3

Floriva Oral 3

Fluorabon Oral 3

Fluor-a-day Oral 1

Fluor-a-day Oral 2

Fluoritab Oral 1

Flura-Drops Oral 1

Galzin Oral 3

Karidium Oral 1

K-Effervescent Oral 1

Klor-Con Oral 1

Klor-Con 10 Oral 1

Klor-Con M10 Oral 1

Klor-Con M15 Oral 3

Klor-Con M20 Oral 1

Klor-Con Sprinkle Oral 1

Klor-Con/EF Oral 1

K-Prime Oral 1



K-Tab Oral 3

K-Vescent Oral 1

Lozi-Flur Mouth/Throat 3

Ludent Oral 1

Micro-K Oral 3

NaFrinse Oral 1

NaFrinse Drops Oral 1

Phospha 250 Neutral Oral 1

Phospho-Trin 250 Neutral Oral 1

Potassium Bicarbonate Oral 1

Potassium Chloride Oral 1

Potassium Chloride Crys ER Oral 1

Potassium Chloride ER Oral 1

Sodium Fluoride Oral 1

Virt-Phos 250 Neutral Oral 1

MISCELLANEOUS THERAPEUTIC CLASSES

Astagraf XL Oral 3

Azasan Oral 3

azaTHIOprine Oral 1

Benlysta Subcutaneous 3 Y Y Y

CellCept Oral 3

Clovique Oral 1 Y Y

Cuprimine Oral 3 Y Y

cycloSPORINE Oral 1

cycloSPORINE Modified Oral 1

Depen Titratabs Oral 2 Y Y

D-Penamine Oral 3

Envarsus XR Oral 3

Everolimus Oral 1 Y Y

Gengraf Oral 1

Imuran Oral 3

Kionex Oral 1

Lokelma Oral 3

Mycophenolate Mofetil Oral 1

Mycophenolate Sodium Oral 1

Myfortic Oral 3

Neoral Oral 3



penicillAMINE Oral 1 Y Y

Prograf Oral 3

Rapamune Oral 3

Revlimid Oral 2 Y Y Y

SandIMMUNE Oral 3

Sirolimus Oral 1

Sodium Polystyrene Sulfonate Oral 1

Sodium Polystyrene Sulfonate Rectal 1

SPS Oral 1

Syprine Oral 3 Y Y

Tacrolimus Oral 1

Thalomid Oral 2 Y Y Y

Trientine HCl Oral 1 Y Y

Veltassa Oral 3

Zortress Oral 3 Y Y

MOUTH/THROAT/DENTAL AGENTS

Cevimeline HCl Oral 1

Chlorhexidine Gluconate Mouth/Throat 1

Clotrimazole Mouth/Throat 1

Evoxac Oral 3

Lidocaine HCl Mouth/Throat 1

Lidocaine Viscous HCl Mouth/Throat 1

Nystatin Mouth/Throat 1

Oralone Mouth/Throat 1

Paroex Mouth/Throat 1

Peridex Mouth/Throat 3

Pilocarpine HCl Oral 1

Triamcinolone Acetonide Mouth/Throat 1

MUSCULOSKELETAL THERAPY AGENTS

Baclofen Oral 1 Y

Carisoprodol Oral 1

Carisoprodol-Aspirin Oral 1

Carisoprodol-Aspirin-Codeine Oral 1

Chlorzoxazone Oral 1 Y

Cyclobenzaprine HCl Oral 1

Dantrium Oral 3

Dantrolene Sodium Oral 1



Fexmid Oral 3

Metaxall Oral 1

Metaxalone Oral 1

Methocarbamol Oral 1

Orphenadrine Citrate ER Oral 1

Parafon Forte DSC Oral 3 Y

Robaxin Oral 3

Robaxin-750 Oral 3

Skelaxin Oral 3

Soma Oral 3

tiZANidine HCl Oral 1 Y

Vanadom Oral 1

Zanaflex Oral 3 Y

NASAL AGENTS - SYSTEMIC AND TOPICAL

Astepro Nasal 3

Azelastine HCl Nasal 1

Bactroban Nasal Nasal 2

Cocaine HCl Nasal 3

Dymista Nasal 3

Goprelto Nasal 3

Ipratropium Bromide Nasal 1

Numbrino Nasal 3

Patanase Nasal 3

NEUROMUSCULAR AGENTS

Rilutek Oral 3 Y

Riluzole Oral 1 Y

Tiglutik Oral 3 Y

OPHTHALMIC AGENTS

Acular Ophthalmic 3

Acular LS Ophthalmic 3

Acuvail Ophthalmic 3

AK-Poly-Bac Ophthalmic 1

Akten Ophthalmic 3

Alocril Ophthalmic 3

Alomide Ophthalmic 3

Alphagan P Ophthalmic 2

Alrex Ophthalmic 2



Altacaine Ophthalmic 1

Apraclonidine HCl Ophthalmic 1

Atropine Sulfate Ophthalmic 1

Atropine Sulfate-NaCl Ophthalmic 1

AzaSite Ophthalmic 3

Azelastine HCl Ophthalmic 1

Azopt Ophthalmic 2

Bacitracin Ophthalmic 1

Bacitracin-Polymyxin B Ophthalmic 1

Bacitra-Neomycin-Polymyxin-HC Ophthalmic 1

Bepreve Ophthalmic 3

Besivance Ophthalmic 3

Betadine Ophthalmic Prep Ophthalmic 3

Betagan Ophthalmic 3

Betaxolol HCl Ophthalmic 1

Betoptic-S Ophthalmic 3

Bimatoprost Ophthalmic 1

Bleph-10 Ophthalmic 3

Blephamide Ophthalmic 3

Blephamide S.O.P. Ophthalmic 3

Brimonidine Tartrate Ophthalmic 1

Brimonidine-Dorzolamide Ophthalmic 1

Bromfenac Sodium Ophthalmic 1

Bromfenac Sodium (Once-Daily) Ophthalmic 1

BromSite Ophthalmic 3

Carteolol HCl Ophthalmic 1

Ciloxan Ophthalmic 2

Ciprofloxacin HCl Ophthalmic 1

Combigan Ophthalmic 3

Cosopt Ophthalmic 3

Cosopt PF Ophthalmic 3

Cromolyn Sodium Ophthalmic 1

Cyclogyl Ophthalmic 3

Cyclomydril Ophthalmic 3

Cyclopentolate HCl Ophthalmic 1

cycloSPORINE in Klarity Ophthalmic 3

Cystadrops Ophthalmic 3 Y Y Y



Cystaran Ophthalmic 3 Y Y Y

Dexamethasone Sodium Phosphate Ophthalmic 1

Dexamethasone-Moxifloxacin Intraocular 1

Dexameth-Moxiflox-Ketorolac Intraocular 1

Dorzolamide HCl Ophthalmic 1

Dorzolamide HCl-Timolol Mal Ophthalmic 1

Dorzolamide HCl-Timolol Mal PF Ophthalmic 1

Double PM Ophthalmic 3

Durezol Ophthalmic 3

Elestat Ophthalmic 3

Emadine Ophthalmic 3

Epinastine HCl Ophthalmic 1

Erythromycin Ophthalmic 1

Flarex Ophthalmic 3

Fluorometholone Ophthalmic 1

Flurbiprofen Sodium Ophthalmic 1

FML Ophthalmic 3

FML Forte Ophthalmic 3

FML Liquifilm Ophthalmic 3

Gatifloxacin Ophthalmic 1

Gentak Ophthalmic 1

Gentamicin Sulfate Ophthalmic 1

Homatropaire Ophthalmic 1

Homatropine HBr Ophthalmic 1

Ilevro Ophthalmic 3

Inveltys Ophthalmic 3

Iopidine Ophthalmic 3

Isopto Atropine Ophthalmic 2

Isopto Carpine Ophthalmic 3

Istalol Ophthalmic 3

Ketorolac Tromethamine Ophthalmic 1

Klarity-A Ophthalmic 3

Lacrisert Ophthalmic 3

Lastacaft Ophthalmic 3

Latanoprost Ophthalmic 1

Latanoprost-Timolol Maleate Ophthalmic 1

Levobunolol HCl Ophthalmic 1



levoFLOXacin Ophthalmic 1

Lotemax Ophthalmic 2

Lotemax SM Ophthalmic 3

Loteprednol Etabonate Ophthalmic 1

Lumigan Ophthalmic 2

Maxidex Ophthalmic 3

Maxitrol Ophthalmic 3

Metipranolol Ophthalmic 1

Miochol-E Intraocular 3

Miostat Intraocular 3

Moxeza Ophthalmic 3

Moxifloxacin HCl Ophthalmic 1

Moxifloxacin HCl (2X Day) Ophthalmic 1

Natacyn Ophthalmic 2

Neomycin-Bacitracin Zn-Polymyx Ophthalmic 1

Neomycin-Polymyxin-Dexameth Ophthalmic 1

Neomycin-Polymyxin-Gramicidin Ophthalmic 1

Neomycin-Polymyxin-HC Ophthalmic 1

Neo-Polycin Ophthalmic 1

Neo-Polycin HC Ophthalmic 1

Neosporin Ophthalmic 3

Nevanac Ophthalmic 3

Ocufen Ophthalmic 3

Ocuflox Ophthalmic 3

Ofloxacin Ophthalmic 1

Omnipred Ophthalmic 3

Oxervate Ophthalmic 3 Y Y

Patanol Ophthalmic 3

Pazeo Ophthalmic 2

Phenylephrine HCl Ophthalmic 1

Phospholine Iodide Ophthalmic 3

Pilocarpine HCl Ophthalmic 1

Polycin Ophthalmic 1

Polymyxin B-Trimethoprim Ophthalmic 1

Polytrim Ophthalmic 3

Povidone-Iodine Ophthalmic 3

Pred Forte Ophthalmic 3



Pred Mild Ophthalmic 3

Pred-G Ophthalmic 3

Pred-G S.O.P. Ophthalmic 3

prednisoLONE Acetate Ophthalmic 1

prednisoLONE Acetate P-F Ophthalmic 3

prednisoLONE Sodium Phosphate Ophthalmic 1

prednisoLONE-Bromfenac Ophthalmic 1

prednisoLONE-Gatifloxacin Ophthalmic 1

prednisoLONE-Moxifloxacin Ophthalmic 1

Prednisolon-Gatiflox-Bromfenac Ophthalmic 1

Prednisolon-Moxiflox-Bromfenac Ophthalmic 1

Prolensa Ophthalmic 3

Proparacaine HCl Ophthalmic 1

Rescula Ophthalmic 3

Restasis Ophthalmic 3 Y

Restasis MultiDose Ophthalmic 3 Y

Rhopressa Ophthalmic 3

Simbrinza Ophthalmic 2

Sulfacetamide Sodium Ophthalmic 1

Sulfacetamide-prednisoLONE Ophthalmic 1

Tetcaine Ophthalmic 1

TetraVisc Ophthalmic 1

TetraVisc Forte Ophthalmic 1

Timolol Maleate Ophthalmic 1

Timolol-Brimon-Dorzol-Latanopr Ophthalmic 1

Timolol-Brimonidine-Dorzolamid Ophthalmic 1

Timolol-Dorzolamid-Latanoprost Ophthalmic 1

Timoptic Ophthalmic 3

Timoptic Ocudose Ophthalmic 3

Timoptic-XE Ophthalmic 3

TobraDex Ophthalmic 3

TobraDex ST Ophthalmic 3

Tobramycin Ophthalmic 1

Tobramycin-Dexamethasone Ophthalmic 1

Tobrex Ophthalmic 2

Tobrex Ophthalmic 3

Travatan Z Ophthalmic 2



Travoprost (BAK Free) Ophthalmic 1

Triamcinolone-Moxifloxacin Intraocular 1

Triesence Intraocular 3

Trifluridine Ophthalmic 1

Triple PMB Ophthalmic 3

Tropicamide Ophthalmic 1

Tropicamide-Cyclopentolate-PE Ophthalmic 1

Tropic-Proparaca-PE-Ketorolac Ophthalmic 1

Trusopt Ophthalmic 3

Vigamox Ophthalmic 2

Viroptic Ophthalmic 3

Vyzulta Ophthalmic 3

Xalatan Ophthalmic 3

Xelpros Ophthalmic 3

Xiidra Ophthalmic 3 Y

Zioptan Ophthalmic 3

Zirgan Ophthalmic 3

Zylet Ophthalmic 2

Zymaxid Ophthalmic 3

OTIC AGENTS

Acetasol HC Otic 1

Cetraxal Otic 3

Cipro HC Otic 2

Ciprodex Otic 2

Ciprofloxacin HCl Otic 1

Ciprofloxacin-Dexamethasone Otic 1

Ciprofloxacin-Fluocinolone PF Otic 3

Coly-Mycin S Otic 3

Cortane-B Otic 3

Cortane-B Aqueous Otic 3

Cortic-ND Otic 1

Cyotic Otic 1

DermOtic Otic 3

Exotic-HC Otic 1

Flac Otic 3

Floxin Otic Otic 3

Fluocinolone Acetonide Otic 1



Hydrocortisone-Acetic Acid Otic 1

Neomycin-Polymyxin-HC Otic 1

Ofloxacin Otic 1

Oticin HC NR Otic 3

Otomax-HC Otic 1

Otovel Otic 3

OXYTOCICS

Methergine Oral 2

Methylergonovine Maleate Oral 1

PENICILLINS

Amoxicillin Oral 1

Amoxicillin-Pot Clavulanate Oral 1

Amoxicillin-Pot Clavulanate ER Oral 1

Ampicillin Oral 1

Augmentin Oral 3

Augmentin ES-600 Oral 3

Augmentin XR Oral 3

Dicloxacillin Sodium Oral 1

Penicillin V Potassium Oral 1

PHARMACEUTICAL ADJUVANTS

Anhydrous Base Miscellaneous 3

ATREVIS HYDROGEL External 3

BraVura All-In-One External 3

Cream Base External 3

Durabase External 3

Durabase Advanced External 3

Emollient Base External 3

Lanolin Miscellaneous 1

Liposomal Heavy External 3

Liposomal Regular External 3

MultiBase External 3

Omnibase External 3

Oral Mix Dry Alka SF Oral 3

Oral Mix Dry Alka/Cherry Oral 3

PCCA Ellage Vaginal Miscellaneous 3

PEG Ointment Base External 3

PENcream External 3



PenSomal External 3

Performax Salt Supportive Base External 3

PLO20 Flowable External 3

Purified Water Oral 3

Salt Durable Cream External 3

Salt Stable LS Advanced External 3

Saltstable LO External 3

Skyy Derm External 3

UniSpend Anhydrous Sweetened Oral 3

Universal Water Miscellaneous 3

Vanishing External 3

White Petrolatum External 3

PROGESTINS

Aygestin Oral 3

medroxyPROGESTERone Acetate Oral 1

Megace ES Oral 3

Megestrol Acetate Oral 1

Norethindrone Acetate Oral 1

Progesterone Intramuscular 1

Progesterone Micronized Oral 1

Prometrium Oral 3

Provera Oral 3

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

Acamprosate Calcium Oral 1

Antabuse Oral 3

Aricept Oral 3

Aubagio Oral 2 Y Y Y

Austedo Oral 3 Y Y

Avonex Intramuscular 2 Y Y Y

Avonex Pen Intramuscular 2 Y Y Y

Avonex Prefilled Intramuscular 2 Y Y Y

Betaseron Subcutaneous 2 Y Y Y

buPROPion HCl ER (Smoking Det) Oral 1

Chantix Oral 2

Chantix Continuing Month Pak Oral 2

Chantix Starting Month Pak Oral 2

chlordiazePOXIDE-Amitriptyline Oral 1



Copaxone Subcutaneous 2 Y Y Y

Dalfampridine ER Oral 1 Y Y Y

Dimethyl Fumarate Oral 1 Y Y

Dimethyl Fumarate Starter Pack Oral 1 Y Y

Disulfiram Oral 1

Donepezil HCl Oral 1

Ergoloid Mesylates Oral 1

Exelon Transdermal 3

Extavia Subcutaneous 3 Y Y Y

FLUoxetine HCl (PMDD) Oral 1

Galantamine Hydrobromide Oral 1

Galantamine Hydrobromide ER Oral 1

Gilenya Oral 2 Y Y Y

Glatiramer Acetate Subcutaneous 1 Y Y Y

Glatopa Subcutaneous 1 Y Y Y

Ingrezza Oral 3 Y Y

Lyrica CR Oral 3 Y

Mavenclad (10 Tabs) Oral 2 Y Y







Mayzent Oral 2 Y Y

Mayzent Starter Pack Oral 2 Y Y

Memantine HCl Oral 1

Memantine HCl ER Oral 1

Namenda Oral 3

Namenda Titration Pak Oral 3

Namenda XR Oral 3

Namenda XR Titration Pack Oral 3

Namzaric Oral 3

Nicotrol Inhalation 2

Nicotrol NS Nasal 2

Nuedexta Oral 2 Y

OLANZapine-FLUoxetine HCl Oral 1



Orap Oral 3

Perphenazine-Amitriptyline Oral 1

Pimozide Oral 1

Plegridy Subcutaneous 2 Y Y

Plegridy Starter Pack Subcutaneous 2 Y Y

Razadyne Oral 3

Razadyne ER Oral 3

Rebif Subcutaneous 2 Y Y Y

Rebif Rebidose Subcutaneous 2 Y Y Y

Rebif Rebidose Titration Pack Subcutaneous 2 Y Y Y

Rebif Titration Pack Subcutaneous 2 Y Y Y

Rivastigmine Transdermal 1

Rivastigmine Tartrate Oral 1

Sarafem Oral 3

Savella Oral 3

Savella Titration Pack Oral 3

Symbyax Oral 3

Tetrabenazine Oral 1 Y Y Y

Xenazine Oral 3 Y Y Y

Zinbryta Subcutaneous 3 Y Y

Zyban Oral 3

RESPIRATORY AGENTS - MISC.

Esbriet Oral 3 Y Y Y

Kalydeco Oral 2 Y Y Y 3

Ofev Oral 3 Y Y Y

Orkambi Oral 3 Y Y Y 3

Pulmozyme Inhalation 2 Y Y Y

Symdeko Oral 3 Y Y Y 3

Trikafta Oral 2 Y Y 3

SULFONAMIDES

sulfADIAZINE Oral 1

TETRACYCLINES

Avidoxy Oral 1

CoreMino Oral 1

Demeclocycline HCl Oral 1

Doxycycline Hyclate Oral 1

Doxycycline Monohydrate Oral 1



Minocin Oral 3

Minocycline HCl Oral 1

Minocycline HCl ER Oral 1

Mondoxyne NL Oral 1

Monodox Oral 3

Morgidox Oral 1

Tetracycline HCl Oral 1

Vibramycin Oral 3

THYROID AGENTS

Armour Thyroid Oral 3

Cytomel Oral 3

Euthyrox Oral 1

Levo-T Oral 1

Levothyroxine Sodium Oral 1

Levoxyl Oral 1

Liothyronine Sodium Oral 1

methIMAzole Oral 1

Nature-Throid Oral 3

NP Thyroid Oral 1

Propylthiouracil Oral 1

Synthroid Oral 3

Tapazole Oral 3

Thyroid Oral 1

Thyrolar-1 Oral 3

Thyrolar-1/2 Oral 3

Thyrolar-1/4 Oral 3

Thyrolar-2 Oral 3

Thyrolar-3 Oral 3

Tirosint Oral 3

Tirosint-SOL Oral 3

Unithroid Oral 1

Unithroid Direct Oral 1

Westhroid Oral 3

WP Thyroid Oral 3

TOXOIDS

Adacel Intramuscular 3

Boostrix Intramuscular 3



TDVax Intramuscular 3

Tenivac Intramuscular 3

Tetanus-Diphtheria Toxoids Td Intramuscular 3

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

Anaspaz Oral 3

Bentyl Intramuscular 3

Bentyl Oral 3

Carafate Oral 2

chlordiazePOXIDE-Clidinium Oral 1

Cimetidine Oral 1

Cimetidine HCl Oral 1

Cuvposa Oral 3 Y

Cytotec Oral 3

Dicyclomine HCl Intramuscular 1

Dicyclomine HCl Oral 1

Ed-Spaz Oral 1

Glycopyrrolate Oral 1

Hyoscyamine Sulfate Injection 1

Hyoscyamine Sulfate Oral 1

Hyoscyamine Sulfate Sublingual 1

Hyoscyamine Sulfate ER Oral 1

Hyoscyamine Sulfate SL Sublingual 1

Hyosyne Oral 1

Levsin Injection 3

Levsin Oral 3

Levsin/SL Sublingual 3

Methscopolamine Bromide Oral 1

miSOPROStol Oral 1

Nizatidine Oral 1

NuLev Oral 1

Oscimin Oral 1

Oscimin Sublingual 1

PB-Hyoscy-Atropine-Scopolamine Oral 1

Pepcid Oral 3

PHENobarbital-Belladonna Alk Oral 1

Phenohytro Oral 1

Propantheline Bromide Oral 1



Pylera Oral 3

Robinul Oral 3

Robinul-Forte Oral 3

Sucralfate Oral 1

Symax-SL Sublingual 1

Zantac Oral 3

URINARY ANTISPASMODICS

Bethanechol Chloride Oral 1

Darifenacin Hydrobromide ER Oral 1

Detrol Oral 3

Detrol LA Oral 3

Ditropan XL Oral 3

Enablex Oral 3

flavoxATE HCl Oral 1

Gelnique Transdermal 3

Gelnique Pump Transdermal 3

Myrbetriq Oral 3

Oxybutynin Chloride Oral 1

Oxybutynin Chloride ER Oral 1

Solifenacin Succinate Oral 1

Tolterodine Tartrate Oral 1

Tolterodine Tartrate ER Oral 1

Toviaz Oral 3

Trospium Chloride Oral 1

Trospium Chloride ER Oral 1

Urecholine Oral 3

VESIcare Oral 2

VACCINES

Afluria Intramuscular 3

Afluria Preservative Free Intramuscular 3

Afluria Quadrivalent Intramuscular 3

Bexsero Intramuscular 3

Fluad Intramuscular 3

Fluad Quadrivalent Intramuscular 3

Fluarix Quadrivalent Intramuscular 3

Flublok Intramuscular 3

Flublok Quadrivalent Intramuscular 3



Flucelvax Quadrivalent Intramuscular 3

Flulaval Quadrivalent Intramuscular 3

FluMist Quadrivalent Nasal 3

Fluvirin Intramuscular 3

Fluzone High-Dose Intramuscular 3

Fluzone High-Dose Quadrivalent Intramuscular 3

Fluzone Quadrivalent Intradermal 3

Fluzone Quadrivalent Intramuscular 3

Gardasil Intramuscular 3

Gardasil 9 Intramuscular 3

Havrix Intramuscular 3

Heplisav-B Intramuscular 3

Ipol Injection 3

Menactra Intramuscular 3

MenQuadfi Intramuscular 3

Menveo Intramuscular 3

M-M-R II Injection 3

Pneumovax 23 Injection 3

Prevnar 13 Intramuscular 3

Recombivax HB Injection 3

Rotarix Oral 3

RotaTeq Oral 3

Shingrix Intramuscular 3

Trumenba Intramuscular 3

Twinrix Intramuscular 3

Varivax Subcutaneous 3

Vaxchora Oral 3

Vivotif Oral 3

Zostavax Subcutaneous 3

VAGINAL PRODUCTS

AVC Vaginal Vaginal 3

Cleocin Vaginal 2

Cleocin Vaginal 3

Clindamycin Phosphate Vaginal 1

Clindesse Vaginal 3

Crinone Vaginal 3

Endometrin Vaginal 3



Estrace Vaginal 2

Estradiol Vaginal 1

Estring Vaginal 3

Femring Vaginal 3

Gynazole-1 Vaginal 3

Imvexxy Maintenance Pack Vaginal 3

Imvexxy Starter Pack Vaginal 3

Intrarosa Vaginal 3

MetroGel-Vaginal Vaginal 3

metroNIDAZOLE Vaginal 1

Miconazole 3 Vaginal 3

Nuvessa Vaginal 3

Premarin Vaginal 3

Terazol 7 Vaginal 3

Terconazole Vaginal 1

Vagifem Vaginal 2

Vandazole Vaginal 1

Yuvafem Vaginal 1

Zazole Vaginal 1

VASOPRESSORS

Adrenalin Injection 3 Y

Adyphren Injection 3 Y

EPINEPHrine Injection 1 Y

Epinephrine Professional Injection 3 Y

EpinephrineSnap-EMS Injection 3 Y

Epinephrinesnap-v Injection 3 Y

EpiPen 2-Pak Injection 2 Y

EpiPen Jr 2-Pak Injection 2 Y

EPIsnap Injection 3 Y

Midodrine HCl Oral 1

Northera Oral 3 Y Y

VITAMINS

Phytonadione Oral 1

formulary - epiphanyrx · 2021. 2. 17. · quantity limits (ql) - for certain drugs, the amount of...

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