magellan complete care of virginia, llc (mcc of va) (hmo

Magellan Complete Care of Virginia, LLC (MCC of VA) (HMO SNP)

2020 Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 12/01/2020. For more recent information or other questions, please contact:

MCC of VA (HMO SNP)1-800-424-4495 (TTY 711)8 a.m. to 8 p.m., Monday through Friday(from October 1 – March 31, 7 days a week)www.mccofva.com/dsnp

HPMS Approved Formulary File Submission ID 20413, Version Number 18

H7559_2020_75637_ENGVAD-MEM-75637-19

http://www.mccofva.com/dsnp

This formulary was updated on 12/01/2020.For more recent information or other questions, please contact:

MCC of VA (HMO SNP)

1-800-424-4495 (TTY 711)

8 a.m. to 8 p.m., Monday through Friday

(from October 1-March 31, 7 days a week)

www.mccofva.com/dsnp


H7559_2020_75637_ENG

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Magellan Complete Care of Virginia, LLC (MCC of VA) (HMO SNP)

2020 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN


When this drug list (formulary) refers to “we,” “us”, or “our,” it means MCC of VA (HMO SNP). When it refers to “plan” or “our plan,” it means MCC of VA (HMO SNP).

This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the MCC of VA (HMO SNP) Formulary?

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

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

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• Drugs removed from the market: If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take thedrug.

• Other changes: We may make other changes that affect members currently taking a drug. Forinstance, we may add a new generic drug to replace a brand name drug currently on theformulary or add new restrictions to the brand name drug. Or we may make changes based onnew clinical guidelines. If we remove drugs from our formulary or add prior authorization,quantity limits and/or step therapy restrictions on a drug, we must notify affected members ofthe change at least 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find information inthe section below entitled “How do I request an exception to the MCC of VA (HMO SNP)Formulary?”

Changes that will not affect you if you are currently taking the drug: Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

This formulary is current as of 12/01/2020. The formulary will be updated monthly onwww.mccofva.com/dsnp. To get the most recent, updated information about the drugs covered by MCC of VA (HMO SNP), please contact Member Services. Our contact information appears on the front and back cover pages.

How do I use the Formulary?

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

Medical Condition

The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications.” If you know what your drug is used for, look for the category name in the list that begins on page 9. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the index that begins on page 124. The index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find

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your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

MCC of VA (HMO SNP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: MCC of VA (HMO SNP) requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from us before you fill yourprescriptions. If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example,we provide 60 tablets/30-day supply per prescription for Afinitor 10 mg. This may be in addition to astandard one-month or three-month supply.

• Step Therapy: In some cases, we require you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covereddrugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the MCC of VA (HMO SNP) Formulary?” on page 6 for information about how to request an exception.

What are over-the counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Please refer to your Medicaid member handbook to determine if your OTC drugs are covered under your Medicaid plan.

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What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you learn that MCC of VA (HMO SNP) does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by MCC of VA (HMO SNP).When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug thatis covered by us.

• You can ask us to make an exception and cover your drug. See below for information about how torequest an exception.

How do I request an exception to the MCC of VA (HMO SNP) Formulary?

You can ask MCC of VA (HMO SNP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask usto waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

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For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you are a current member and have a change to your level of care (for example you are discharged from a hospital to your home, or you are admitted to or discharged from a long-term care facility), the pharmacy filling your prescriptions may obtain an override for an early refill by contacting Member Services or the Magellan Rx Pharmacy Technical Help Desk at 1-888-559-2750.

For more information

For more detailed information about your MCC of VA (HMO SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about the plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048.Or you can visit http://www.medicare.gov.

MCC of VA (HMO SNP)’s Formulary

The formulary that begins on page 9 provides coverage information about the drugs covered by MCC of VA (HMO SNP). If you have trouble finding your drug in the list, turn to the index that begins on page 124.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., Afinitor ) and

generic drugs are listed in lower-case italics (e.g., simvastatin).

The information in the Requirements/Limits column tells you if MCC of VA (HMO SNP) has any special requirements for coverage of your drug.

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http://www.medicare.gov/

List of Abbreviations

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services.

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

PA – Part B vs. D Determination: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

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2020_MCC_Virginia_(H7559) (List of Covered Drugs)

DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Analgesics

Nonsteroidal Anti-inflammatory Drugscelecoxib (50 mg capsule, 100 mg capsule,200 mg capsule, 400 mg capsule)

1 QL (60 PER 30 DAYS)

diclofenac potassium 1

diclofenac sodium 1% gel 1 QL (1000 PER 30 DAYS)

diclofenac sodium (sod dr 25 mg tab, sod dr50 mg tab, sod dr 75 mg tab, sod ec 25 mgtab, sod ec 50 mg tab, sod ec 75 mg tab,sodium 3% gel)

1

diclofenac sodium er 1

diflunisal 500 mg tablet 1

ec-naproxen 1

etodolac (200 mg capsule, 300 mg capsule,400 mg tablet, 500 mg tablet)

1

fenoprofen 600 mg tablet 1

flurbiprofen (50 mg tablet, 100 mg tablet) 1

ibu 1

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

1

indomethacin (25 mg capsule, 50 mgcapsule)

1

ketoprofen (25 mg capsule, 50 mg capsule,75 mg capsule)

1

ketorolac 15.75 mg nasal spray 1 QL (5 PER 30 OVER TIME)

ketorolac tromethamine (15 mg/ml syringe, 15mg/ml vial, 30 mg/ml isecure syr, 30 mg/mlvial, 30 mg/ml syringe, 30 mg/ml carpuject, 60mg/2 ml syringe, 60 mg/2 ml carpuject, 60mg/2 ml vial)

1

ketorolac 10 mg tablet 1 QL (20 PER 30 OVER TIME)

meclofenamate sodium (50 mg capsule, 100mg capsule)

1

You can find information on what the symbols and abbreviationson this table mean by going to page 8.

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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

mefenamic acid 250 mg capsule 1

meloxicam (7.5 mg tablet, 15 mg tablet) 1

nabumetone (500 mg tablet, 750 mg tablet) 1

naproxen (125 mg/5 ml suspen, 250 mgtablet, dr 375 mg tablet, 375 mg tablet, 500mg kit, 500 mg tablet, dr 500 mg tablet)

1

naproxen sodium (275 mg tab, 550 mg tab) 1

naproxen sodium ds 1

naproxen-esomeprazole mag 1 PA, QL (60 PER 30 DAYS)

oxaprozin 1

piroxicam (10 mg capsule, 20 mg capsule) 1

SPRIX 1 QL (5 PER 30 OVER TIME)

sulindac (150 mg tablet, 200 mg tablet) 1

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

1

Opioid Analgesics, Long-actingEMBEDA 1

fentanyl 1

hydromorphone er (er 16 mg tab, er 32 mgtab)

1

INFUMORPH 1

levorphanol 3 mg tablet 1

methadone hcl (hcl 5 mg tablet, 5 mg/5 mlsolution, 10 mg/5 ml solution, hcl 10 mg/mlvial, 10 mg/ml oral conc, hcl 10 mg tablet, hcl200 mg/20 ml vl)

1

methadone intensol 1

METHADOSE 10 MG/ML ORAL CONC 1

mitigo 1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

morphine sulfate er (sulf er 15 mg tablet, sulfer 30 mg tablet, sulf er 60 mg tablet, sulf er100 mg tablet, sulf er 200 mg tablet, sulfate er10 mg cap, sulfate er 20 mg cap, sulfate er 30mg cap, sulfate er 40 mg cap, sulfate er 50mg cap, sulfate er 60 mg cap, sulfate er 80mg cap, sulfate er 100 mg cap)

1

oxymorphone hcl er 1

XTAMPZA ER 1

Opioid Analgesics, Short-actingABSTRAL 1 PA

acetaminophen-codeine (acetamin-codein300-30 mg/12.5, acetaminop-codeine 120-12mg/5, acetaminophen-cod #2 tablet,acetaminophen-cod #3 tablet,acetaminophen-cod #4 tablet)

1

butorphanol tartrate (1 mg/ml vial, 2 mg/mlvial, 4 mg/2 ml vial, 10 mg/ml spray)

1

codeine sulfate 1

DURAMORPH 1

endocet 1

fentanyl citrate (50 mcg/ml vial, 100 mcg/2 mlvial, 100 mcg/2 ml ampul, 100 mcg/2 mlsyringe, 100 mcg/2 ml carpujct, 250 mcg/5 mlampul, 250 mcg/5 ml vial, 500 mcg/10 ml vial,1,000 mcg/20 ml ampul, 1,000 mcg/20 mlvial, 2,500 mcg/50 ml vial)

1

fentanyl citrate (cit 100 mcg buccal tb, cit 200mcg buccal tb, cit 400 mcg buccal tb, cit 600mcg buccal tb, cit 800 mcg buccal tb, cit otfc1,200 mcg, cit otfc 1,600 mcg, citrate otfc 200mcg, citrate otfc 400 mcg, citrate otfc 600mcg, citrate otfc 800 mcg)

1 PA


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

hydrocodone-acetaminophen (hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin5-217/10, hydrocodone-acetamin 5-300 mg,hydrocodone-acetamin 5-325 mg,hydrocodone-acetamin 7.5-325,hydrocodone-acetamin 7.5-300,hydrocodone-acetamin 10-325 mg,hydrocodone-acetamin 10-300 mg,hydrocodone-acetamn 7.5-325/15)

1

hydromorphone hcl (0.5 mg/0.5 ml, hcl 1mg/ml amp, 1 mg/ml carpujct, 1 mg/ml vial, 1mg/ml syringe, 1 mg/ml solution, 2 mg/mlcarpujct, 2 mg/ml isecure, 2 mg tablet, 4mg/ml carpujct, hcl 4 mg/ml amp, 4 mg tablet,5 mg/5 ml soln, 8 mg tablet, 10 mg/ml vial, 10mg/ml ampule, 50 mg/5 ml vial, 50 mg/5 mlamp, 500 mg/50 ml vl)

1

LAZANDA 1 PA

lorcet 1

lorcet hd 1

lorcet plus 1

morphine sulfate (sulfate 2 mg/ml vial, 2mg/ml carpuject, 2 mg/ml syringe, 2 mg/mlisecure syr, 4 mg/ml carpuject, sulfate 4mg/ml vial, 4 mg/ml syringe, 4 mg/ml isecuresyr, 5 mg/ml vial, 5 mg/ml syringe, sulf 100mg/5 ml conc, sulfate 5 mg/ml vial, 5 mg/10ml vial, 8 mg/ml carpuject, 8 mg/ml isecuresyrng, 10 mg/ml isecure syrg, sulf 10 mg/5 mlsoln, 10 mg/ml syringe, sulf 20 mg/5 ml soln,sulfate 1 mg/ml vial, sulfate 8 mg/ml vial, 10mg/ml carpuject, sulfate 10 mg/ml vial, 10mg/10 ml vial, sulfate ir 15 mg tab, sulfate ir30 mg tab)

1

nalbuphine hcl (10 mg/ml ampul, 20 mg/mlampul, 100 mg/10 ml vial, 200 mg/10 ml vial)

1

OXAYDO 1

oxycodone hcl (5 mg/5 ml soln, 5 mg capsule,5 mg tablet, 10 mg tablet, 15 mg tablet, 20mg tablet, 30 mg tablet, 100 mg/5 ml conc)

1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

oxycodone hcl-aspirin 1

oxycodone hcl-ibuprofen 1

oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 5-325, oxycodone-acetaminophen 10-325)

1

ROXYBOND 1

tramadol hcl (50 mg tablet, 100 mg tablet) 1

tramadol hcl-acetaminophen 1

vicodin 1

vicodin es 1

vicodin hp 1

Anesthetics

Local Anestheticschloroprocaine hcl 1

glydo 1 QL (30 PER 30 DAYS)

lidocaine 5% patch 1 PA

lidocaine 5% ointment 1 PA, QL (150 PER 30 DAYS)

lidocaine hcl (0.5% vial, 1% 20 mg/2 ml vl,1% vial, 1% 50 mg/5 ml, 1% 20 mg/2 ml, 1%50 mg/5 ml vl, 1% ampul, 1% 300 mg/30 ml,1.5% ampul, 2% ampul, 2% 40 mg/2 ml, 2%100 mg/5 ml, 2% 40 mg/2 ml vl, 2% vial, 4%ampul)

1

lidocaine hcl 2% jelly 1 PA, QL (30 PER 30 DAYS)

lidocaine hcl 4% solution 1 PA, QL (250 PER 30 DAYS)

lidocaine-prilocaine 1 PA, QL (30 PER 30 DAYS)

polocaine (1% vial, 2% vial) 1

polocaine-mpf 1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium 1

disulfiram (250 mg tablet, 500 mg tablet) 1

VIVITROL 1

Opioid Dependence Treatmentsbuprenorphine hcl (2 mg tablet, 8 mg tablet) 1

buprenorphine-naloxone (buprenor-nalox 12-3 mg film, buprenorp-nalox 4-1 mg film)


buprenorphine-naloxone (bupreno-nalox 2-0.5 mg film, buprenorp-nalox 8-2 mg film,buprenorphin-naloxon 8-2 mg)


buprenorphn-naloxn 2-0.5 mg sl 1 QL (360 PER 30 DAYS)

LUCEMYRA 1 QL (480 PER 30 DAYS)

naltrexone 50 mg tablet 1

Opioid Reversal Agentsnaloxone hcl (0.4 mg/ml carpuject, 0.4 mg/mlvial, 2 mg/2 ml syringe, 4 mg/10 ml vial)

1

NARCAN 1

Smoking Cessation Agentsbupropion hcl sr 150 mg tablet 1 QL (60 PER 30 DAYS)

CHANTIX (0.5 MG TABLET, 1 MG CONTMONTH BOX, 1 MG TABLET, STARTINGMONTH BOX)

1 QL (504 PER 365 OVER TIME)

NICOTROL 1 QL (2688 PER 365 OVER TIME)

NICOTROL NS 1 QL (360 PER 365 OVER TIME)


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Anti-inflammatory Agents

Glucocorticoidsprocto-med hc 1

procto-pak 1

proctosol-hc 1

proctozone-hc 1

triamcinolone 0.147 mg/g spray 1

Antibacterials

Aminoglycosidesamikacin sulfate (sulf 1 gram/4 ml vial, sulf500 mg/2 ml vial, sulf 1,000 mg/4 ml vl,sulfate 1,000 mg/4 ml)

1

gentak 1

gentamicin sulfate (0.1% ointment, 0.1%cream, 0.3% eye drop, 3 mg/ml eye drop, ped20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 mlvial, 800 mg/20 ml vial)

1

gentamicin sulfate in ns (iso 100 mg/100 ml,isoton 60 mg/50 ml, isoton 80 mg/100 ml, 80mg/ns 50 ml pb, isoton 80 mg/50 ml, 80mg/ns 100 ml pb, 100 mg/ns 100 ml, isoton100 mg/50 ml)

1

neomycin 500 mg tablet 1

neomycin-polymyxin b (40 mg/ml amp, 40mg/ml vl)

1

paromomycin 250 mg capsule 1

streptomycin sulf 1 gm vial 1

tobramycin 0.3% eye drop 1

tobramycin sulfate (1.2 gm vial, 1.2 gram/30ml vial, 10 mg/ml vial, 40 mg/ml vial, 80 mg/2ml vial, 1,200 mg/30 ml vial)

1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TOBREX 0.3% EYE OINTMENT 1

Antibacterials, Otherbaciim 1

bacitracin (500 unit/gm ophth, 50,000 unitvial)

1

BACTROBAN NASAL 1

chloramphenicol sod succinate 1

CLEOCIN 100 MG VAGINAL OVULE 1

clindacin etz 1% pledget 1

clindacin p 1

clindamycin (pediatric) 1

clindamycin hcl (75 mg capsule, 150 mgcapsule, 300 mg capsule)

1

clindamycin pediatric 1

clindamycin phosphate (ph 1% solution, ph1% gel, 2% vaginal cream, ph 9 g/60 ml vial,ph 300 mg/2 ml vl, 300 mg/2 ml addvan, ph600 mg/4 ml vl, ph 900 mg/6 ml vl, phos 1%pledget, phosp 1% lotion, phosphate 1%foam, phosphate 1% gel, 600 mg/4 mladdvan, 900 mg/6 ml addvan)

1

clindamycin phosphate-d5w 1

clindamycin-0.9% nacl 1

colistimethate 1

daptomycin 1

IMPAVIDO 1

linezolid 100 mg/5 ml susp 1 QL (1800 PER 28 DAYS)

linezolid 600 mg tablet 1 QL (56 PER 28 DAYS)

linezolid-d5w 1

mafenide acetate 1

methenamine hippurate 1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

METRO IV 1

metronidazole (vaginal 0.75% gl, 250 mgtablet, 375 mg capsule, 500 mg/100 ml, 500mg tablet)

1

mupirocin 2% ointment 1

nitrofurantoin (25 mg/5 ml susp, mcr 25 mgcap, mcr 50 mg cap, mcr 100 mg cap)

1

nitrofurantoin mono-macro 1

polymyxin b sulfate vial 1

silver sulfadiazine 1% cream 1

SIVEXTRO (200 MG VIAL, 200 MG TABLET) 1 QL (6 PER 30 OVER TIME)

SSD 1

SYNERCID 1

tigecycline 1

trimethoprim 100 mg tablet 1

vancomycin hcl 125 mg capsule 1 QL (120 PER 30 DAYS)

vancomycin hcl 250 mg capsule 1 QL (240 PER 30 DAYS)

vancomycin hcl (1 gm vial, 1 gm add-van vial,hcl 1g/200 ml bag, hcl 1.25 gram vial, hcl 1.5gram vial, hcl 5 gm vial, hcl 10 gm vial, hcl100 gm smartpak, 250 mg/5 ml soln, hcl 250mg vial, 500 mg a-v vial, 500 mg vial, 500 mgadd-van vial, hcl 750 mg vial, 750 mg add-van vial)

1

vancomycin-d5w 500 mg/100 ml 1

VANDAZOLE 1

VIBATIV 750 MG VIAL 1

XENLETA 600 MG TABLET 1

XIFAXAN 1 PA

Beta-lactam, CephalosporinsAVYCAZ 1

cefaclor (250 mg capsule, 500 mg capsule) 1


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DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

cefaclor er 1

cefadroxil (1 gm tablet, 250 mg/5 ml susp,500 mg/5 ml susp, 500 mg capsule)

1

cefazolin sodium (1 gm add-van vial, 1 gmvial, 10 gm vial, 20 gm bulk vial, sod 100 gmbulk bag, sod 300 gm bulk bag, 500 mg vial)

1

cefazolin sodium-dextrose (1 g/50, 2 g/50, 2g/100)

1

cefdinir (125 mg/5 ml susp, 250 mg/5 mlsusp, 300 mg capsule)

1

cefepime hcl (1 gm vial, 2 gram vial) 1

cefixime (100 mg/5 ml susp, 200 mg/5 mlsusp, 400 mg capsule)

1

cefotaxime sodium 1

cefotetan 1

cefoxitin 1

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

1

cefprozil (125 mg/5 ml susp, 250 mg/5 mlsusp, 250 mg tablet, 500 mg tablet)

1

ceftazidime (1 gm vial, 2 gm vial, 6 gm vial) 1

ceftriaxone (1 gm add-vant vial, 1 gm vial, 2gm add vial, 2 gm vial, 10 gm vial, 100 grambulk bag, 250 mg vial, 500 mg vial)

1

cefuroxime 1

cefuroxime sodium 1

cephalexin (125 mg/5 ml susp, 250 mg tablet,250 mg capsule, 250 mg/5 ml susp, 500 mgtablet, 500 mg capsule, 750 mg capsule)

1

SUPRAX (100 MG TABLET CHEWABLE,200 MG TABLET CHEWABLE, 400 MGCAPSULE, 500 MG/5 ML SUSPENSION)

1

tazicef (1 gram vial, 1 gm add-vantage vial, 2gm add-vantage vial, 2 gram vial, 6 gram vial)

1


18


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TEFLARO 1

Beta-lactam, OtherAZACTAM 1

aztreonam 1

ertapenem 1

imipenem-cilastatin sodium 1

meropenem 1

meropenem-0.9% nacl 1 gram/50 1

VABOMERE 1

Beta-lactam, Penicillinsamoxicillin (125 mg tab chew, 125 mg/5 mlsusp, 200 mg/5 ml susp, 250 mg capsule,250 mg tab chew, 250 mg/5 ml susp, 400mg/5 ml susp, 500 mg tablet, 500 mgcapsule, 875 mg tablet)

1

amoxicillin-clavulanate pot er 1

amoxicillin-clavulanate potass (200-28.5 mgtab chew, 200-28.5 mg/5 ml sus, 250-62.5mg/5 ml sus, 250-125 mg tablet, 400-57 mg/5ml susp, 400-57 mg tab chew, 500-125 mgtablet, 600-42.9 mg/5 ml sus, 875-125 mgtablet)

1

ampicillin sodium (1 gm add-vantage vl, 1 gmvial, 2 gm add-vantage vl, 2 gm vial, 10 gmvial, 10 gm bottle, 125 mg vial, 250 mg vial,500 mg vial)

1

ampicillin 500 mg capsule 1

ampicillin-sulbactam (ampicillin-sulb 1.5 g addvial, ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gm vl, ampicillin-sulbactam 3gm vial, ampicillin-sulbactam 15 gm vl)

1

AUGMENTIN 125-31.25 MG/5 ML 1

BICILLIN C-R 1

BICILLIN L-A 1


19


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

dicloxacillin sodium 1

nafcillin 1

nafcillin sodium (1 gm vial, 2 gm vial, 2 gmadd-vant vial, 10 gm bulk vial)

1

penicillin g potassium 1

penicillin g sodium 1

penicillin gk-iso-osm dextrose 1

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

1

piperacillin-tazobactam (piperacil-tazo 2.25gm add vl, piperacil-tazo 3.375 gm add vl,piperacil-tazo 4.5 gm add vial, piperacil-tazobact 2.25 gm vl, piperacil-tazobact 3.375gm vl, piperacil-tazobact 4.5 gm vial,piperacil-tazobact 13.5 gm vl, piperacil-tazobact 40.5 gram)

1

ZOSYN (2.25 GM/50 ML BAG, 3.375 GM/50ML, 4.5 GM/100 ML BAG)

1

Macrolidesazithromycin (1 gm pwd packet, 100 mg/5 mlsusp, 200 mg/5 ml susp, 250 mg tablet, 500mg add-van vl, 500 mg tablet, 600 mg tablet,i.v. 500 mg vial)

1

clarithromycin (125 mg/5 ml sus, 250 mgtablet, 250 mg/5 ml sus, 500 mg tablet)

1

clarithromycin er 1

DIFICID 1

ery 1

ERY-TAB 1

ERYPED 400 1

ERYTHROCIN LACTOBIONATE (LACT 500MG VIAL, 500 MG ADDVAN VIAL)

1

ERYTHROCIN STEARATE 1


20


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

erythromycin (0.5% eye ointment, 2% gel, 2%solution, 2% pledgets, 250 mg filmtab, dr 250mg cap, dr 250 mg tablet, dr 333 mg tablet, dr500 mg tablet, 500 mg filmtab)

1

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

1

QuinolonesBAXDELA (300 MG VIAL, 450 MG TABLET) 1

BESIVANCE 1

ciprofloxacin (200 mg/20 ml vl, 250 mg/5 mlsusp, 400 mg/40 ml vl, 500 mg/5 ml susp)

1

ciprofloxacin er 1

ciprofloxacin hcl (0.2% otic soln, 0.3% eyedrop, hcl 100 mg tab, hcl 250 mg tab, hcl 500mg tab, hcl 750 mg tab)

1

ciprofloxacin-d5w 1

gatifloxacin 1

levofloxacin (0.5% eye drops, 25 mg/mlsolution, 250 mg/10 ml soln, 250 mg tablet,500 mg/20 ml vial, 500 mg tablet, 500 mg/20ml soln, 750 mg/30 ml vial, 750 mg tablet)

1

levofloxacin-d5w 1

moxifloxacin (0.5% eye drops, 400 mg/250 mlbag)

1

moxifloxacin hcl 400 mg tablet 1

ofloxacin (0.3% eye drops, 0.3% ear drops,300 mg tablet, 400 mg tablet)

1

Sulfonamidessulfacetamide sodium (drops, ointment) 1

sulfadiazine 500 mg tablet 1

sulfamethoxazole-trimethoprim (ds tablet, ivvial, ss tablet, susp)

1

SULFATRIM 1


21


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Tetracyclinesdemeclocycline hcl 1

DORYX MPC 1

doxy 100 1

doxycycline hyclate (hyc dr 50 mg tab, 50 mgtablet, hyc dr 75 mg tab, hyc dr 100 mg tab,hyc dr 150 mg tab, hyc dr 200 mg tab, hyclate20 mg tab, hyclate 50 mg cap, hyclate 75 mgtab, hyclate 100 mg tab, hyclate 100 mg vl,hyclate 100 mg cap, hyclate 150 mg tab)

1

doxycycline monohydrate (25 mg/5 ml susp,mono 50 mg cap, mono 50 mg tablet, mono75 mg tablet, mono 75 mg capsule, mono 100mg tablet, mono 100 mg cap, mono 150 mgcap, mono 150 mg tablet)

1

minocycline hcl (50 mg capsule, hcl 50 mgtablet, 75 mg capsule, hcl 75 mg tablet, 100mg capsule, hcl 100 mg tablet)

1

mondoxyne nl 1

morgidox (50 mg capsule, 100 mg capsule) 1

NUZYRA (100 MG VIAL, 150 MG TABLET-7DAY, 150 MG-7 DAY WITH LOAD, 150 MGTABLET)

1

okebo 100 mg capsule 1

SEYSARA 1

soloxide 1

tetracycline hcl (250 mg capsule, 500 mgcapsule)

1

VIBRAMYCIN 50 MG/5 ML SYRUP 1

Anticonvulsants

Anticonvulsants, OtherAPTIOM 1

BRIVIACT (10 MG TABLET, 25 MG TABLET,50 MG TABLET, 75 MG TABLET, 100 MGTABLET)

1 PA - FOR NEW STARTS ONLY


22


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

BRIVIACT (10 MG/ML ORAL SOLN, 50 MG/5ML VIAL)

1

EPIDIOLEX 1 PA - FOR NEW STARTS ONLY

FINTEPLA 1 PA - FOR NEW STARTS ONLY

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MGTABLET, 4 MG TABLET, 6 MG TABLET, 8MG TABLET, 10 MG TABLET, 12 MGTABLET)

1

levetiracetam (100 mg/ml soln, 250 mg tablet,500 mg/5 ml vial, 500 mg tablet, 500 mg/5 mlsoln, 750 mg tablet, 1,000 mg tablet)

1

levetiracetam er 1

levetiracetam-nacl 1

NAYZILAM 1

phenobarbital (20 mg/5 ml soln, 20 mg/5 mlelix)


roweepra 1

roweepra xr 1

SPRITAM 1

XCOPRI (12.5-25 MG TITRATION PK, 50MG TABLET, 50-100 MG TITRATION PAK,100 MG TABLET, 150-200 MG TITRATIONPK, 150 MG TABLET, 200 MG TABLET, 250MG DAILY DOSE PACK, 350 MG DAILYDOSE PACK)


Calcium Channel Modifying AgentsCELONTIN 1

ethosuximide (250 mg/5 ml soln, 250 mgcapsule)

1

LYRICA (25 MG CAPSULE, 50 MGCAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MGCAPSULE, 225 MG CAPSULE)


LYRICA 300 MG CAPSULE 1 QL (60 PER 30 DAYS)


23


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

LYRICA 20 MG/ML ORAL SOLUTION 1 QL (900 PER 30 DAYS)

pregabalin (25 mg capsule, 50 mg capsule,75 mg capsule, 100 mg capsule, 150 mgcapsule, 200 mg capsule, 225 mg capsule)


pregabalin 300 mg capsule 1 QL (60 PER 30 DAYS)

pregabalin 20 mg/ml solution 1 QL (900 PER 30 DAYS)

zonisamide (25 mg capsule, 50 mg capsule,100 mg capsule)

1

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam (2.5 mg/ml suspension, 10 mgtablet, 20 mg tablet)

1

clonazepam (2 mg odt, 2 mg tablet) 1 QL (300 PER 30 DAYS)

clonazepam (0.125 mg odt, 0.125 mg dis tab,0.25 mg odt, 0.5 mg dis tablet, 0.5 mg tablet,0.5 mg odt, 1 mg odt, 1 mg tablet, 1 mg distablet)


DIASTAT 1

DIASTAT ACUDIAL 1

diazepam (2.5 mg gel sys, 10 mg gel syst, 20mg gel syst)

1

divalproex sodium (dr 125 mg cap sprnk, soddr 125 mg tab, sod dr 250 mg tab, sod dr 500mg tab)

1

divalproex sodium er 1

gabapentin (100 mg capsule, 300 mgcapsule)


gabapentin 400 mg capsule 1 QL (270 PER 30 DAYS)

gabapentin (250 mg/5 ml soln, 300 mg/6 mlsoln)

1 QL (2160 PER 30 DAYS)

gabapentin 600 mg tablet 1 QL (180 PER 30 DAYS)

gabapentin 800 mg tablet 1 QL (150 PER 30 DAYS)

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



24


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

phenobarbital sodium (65 mg/ml vial, 130mg/ml vial)


primidone (50 mg tablet, 250 mg tablet) 1

SYMPAZAN 1

tiagabine hcl 1

valproate sodium 1

valproic acid (250 mg capsule, 250 mg/5 mlsoln, 500 mg/10 ml sol)

1

VALTOCO 1 QL (10 PER 30 DAYS)

vigabatrin (500 mg powder packt, 500 mgtablet)


Glutamate Reducing Agentsfelbamate (400 mg tablet, 600 mg tablet, 600mg/5 ml susp)

1

lamotrigine (5 mg disper tablet, 25 mg dispertab, 25 mg tablet, 100 mg tablet, 150 mgtablet, 200 mg tablet, tablet starter kit)

1

lamotrigine (blue) 1

lamotrigine (green) 1

lamotrigine (orange) 1

lamotrigine odt (orange) 1

subvenite 1

subvenite (blue) 1

subvenite (green) 1

subvenite (orange) 1

topiramate (15 mg sprinkle cap, 25 mgsprinkle cap, 25 mg tablet, 50 mg tablet, 100mg tablet, 200 mg tablet)

1

Sodium Channel AgentsBANZEL (40 MG/ML SUSPENSION, 200 MGTABLET, 400 MG TABLET)

1


25


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

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

1

carbamazepine er (er 100 mg cap, er 100 mgtablet, er 200 mg tablet, er 200 mg cap, er300 mg cap, er 400 mg tablet)

1

DILANTIN 30 MG CAPSULE 1

epitol 1

fosphenytoin sodium 1

oxcarbazepine (150 mg tablet, 300 mg/5 mlsusp, 300 mg tablet, 600 mg tablet)

1

PEGANONE 1

phenytoin (50 mg infatab, 50 mg tablet chew,100 mg/4 ml susp, 125 mg/5 ml susp)

1

phenytoin sodium extended 1

VIMPAT (10 MG/ML SOLUTION, 50 MGTABLET, 100 MG TABLET, 150 MGTABLET, 200 MG/20 ML VIAL, 200 MGTABLET)

1

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 1 mg tab 1

Cholinesterase Inhibitorsdonepezil hcl (5 mg tablet, 10 mg tablet) 1

donepezil hcl odt 1

galantamine er 1

galantamine hbr 1

galantamine hydrobromide 1

rivastigmine (1.5 mg capsule, 3 mg capsule,4.5 mg capsule, 4.6 mg/24hr patch, 6 mgcapsule, 9.5 mg/24hr patch, 13.3 mg/24hrptch)

1


26


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl (hcl 2 mg/ml solution, hcl 5 mgtablet, 5-10 mg titration pk, hcl 10 mg tablet)

1

memantine hcl er 1 QL (30 PER 30 DAYS)

Antidepressants

Antidepressants, Otherbupropion hcl (75 mg tablet, 100 mg tablet) 1

bupropion hcl sr (sr 100 mg tablet, sr 200 mgtablet)


bupropion hcl xl 150 mg tablet 1 QL (90 PER 30 DAYS)

bupropion hcl xl 300 mg tablet 1 QL (30 PER 30 DAYS)

mirtazapine (7.5 mg tablet, 15 mg tablet, 15mg odt, 30 mg tablet, 30 mg odt, 45 mgtablet, 45 mg odt)

1

Monoamine Oxidase InhibitorsEMSAM 1 ST, QL (30 PER 30 DAYS)

MARPLAN 1

phenelzine sulfate 15 mg tab 1

tranylcypromine sulfate 1

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin andNorepinephrine Reuptake Inhibitor

citalopram hbr (10 mg tablet, 10 mg/5 ml soln,20 mg tablet, 20 mg/10 ml sol, 40 mg tablet)

1

desvenlafaxine succinate er (er 25 mg, er 50mg)


desvenlafaxine succnt er 100mg 1 QL (120 PER 30 DAYS)

DRIZALMA SPRINKLE (DR 20 MG CAP, DR60 MG CAP)


DRIZALMA SPRINKLE (DR 30 MG CAP, DR40 MG CAP)



27


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

duloxetine hcl (dr 20 mg cap, dr 60 mg cap) 1 QL (60 PER 30 DAYS)

duloxetine hcl (dr 30 mg cap, dr 40 mg cap) 1 QL (90 PER 30 DAYS)

escitalopram oxalate (oxalate 5 mg/5 ml, 5mg tablet, 10 mg tablet, 20 mg tablet)

1

FETZIMA 20-40 MG TITRATION PAK 1 ST, QL (56 PER 365 OVER TIME)

FETZIMA (ER 20 MG CAPSULE, ER 40 MGCAPSULE, ER 80 MG CAPSULE, ER 120MG CAPSULE)

1 ST, QL (30 PER 30 DAYS)

fluoxetine dr 1 QL (4 PER 28 DAYS)

fluoxetine hcl (hcl 10 mg tablet, hcl 10 mgcapsule, hcl 20 mg tablet, hcl 20 mg capsule,20 mg/5 ml solution, hcl 40 mg capsule, hcl60 mg tablet)

1

fluvoxamine maleate 1

maprotiline hcl 1

nefazodone hcl 1

paroxetine cr 1

paroxetine er 1

paroxetine hcl 1

paroxetine mesylate 1 QL (30 PER 30 DAYS)

PAXIL 10 MG/5 ML SUSPENSION 1

sertraline hcl (20 mg/ml oral conc, hcl 25 mgtablet, hcl 50 mg tablet, hcl 100 mg tablet)

1

trazodone hcl (50 mg tablet, 100 mg tablet,150 mg tablet, 300 mg tablet)

1

TRINTELLIX 1 QL (30 PER 30 DAYS)

venlafaxine hcl 1

venlafaxine hcl er (er 37.5 mg cap, er 37.5mg tab, er 75 mg cap, er 75 mg tab, er 150mg cap, er 150 mg tab, er 225 mg tab)

1

VIIBRYD 10-20 MG STARTER PACK 1 QL (60 PER 365 OVER TIME)

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



28


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

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

1

amoxapine 1

chlordiazepoxide-amitriptyline 1 PA - FOR NEW STARTS ONLY

clomipramine hcl (25 mg capsule, 50 mgcapsule, 75 mg capsule)

1

desipramine hcl (10 mg tablet, 25 mg tablet,50 mg tablet, 75 mg tablet, 100 mg tablet,150 mg tablet)

1

doxepin hcl (10 mg/ml oral conc, 10 mgcapsule, 25 mg capsule, 50 mg capsule, 75mg capsule, 100 mg capsule, 150 mgcapsule)

1

imipramine hcl (10 mg tablet, 25 mg tablet, 50mg tablet)

1

nortriptyline hcl (hcl 10 mg cap, 10 mg/5 mlsoln, 20 mg/10 ml soln, hcl 25 mg cap, hcl 50mg cap, hcl 75 mg cap)

1

perphenazine-amitriptyline 1 PA - FOR NEW STARTS ONLY

protriptyline hcl 1

trimipramine maleate 1

Antiemetics

Antiemetics, OtherAKYNZEO 300-0.5 MG CAPSULE 1 QL (2 PER 30 OVER TIME)

compro 1

doxylamine succ-pyridoxine hcl 1 QL (120 PER 30 DAYS)

droperidol (5 mg/2 ml vial, 5 mg/2 ml ampul) 1

meclizine hcl (12.5 mg tablet, 25 mg tablet) 1

phenadoz 1 PA

prochlorperazine 1


29


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

prochlorperazine 10 mg/2 ml vl 1

prochlorperazine maleate (5 mg tablet, 10 mgtab)

1

promethazine hcl (6.25 mg/5 ml syrp, 6.25mg/5 ml soln, 12.5 mg tablet, 12.5 mgsuppos, 25 mg/ml vial, 25 mg suppository, 25mg tablet, 25 mg/ml ampul, 50 mg/ml vial, 50mg suppository, 50 mg/ml ampul, 50 mgtablet)

1 PA

promethegan 1 PA

scopolamine 1

Emetogenic Therapy AdjunctsANZEMET 1 QL (5 PER 30 OVER TIME)

aprepitant 125-80-80 mg pack 1 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

aprepitant 125 mg capsule 1 PA - Part B vs D Determination,QL (2 PER 30 OVER TIME)



CINVANTI 1

dronabinol 1 PA, QL (60 PER 30 OVER TIME)

EMEND 125 MG POWDER PACKET 1 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

granisetron hcl 1 mg tablet 1 PA - Part B vs D Determination,QL (30 PER 30 OVER TIME)

granisetron hcl (1 mg/ml vial, 4 mg/4 ml vial) 1

ondansetron hcl (hcl 4 mg/2 ml vial, hcl 4mg/2 ml syr, hcl 4 mg/2 ml amp, 4 mg/2 mlisecure, 40 mg/20 ml vial)

1

ondansetron 4 mg/5 ml solution 1 PA - Part B vs D Determination,QL (450 PER 30 DAYS)

ondansetron hcl (4 mg tablet, 8 mg tablet) 1 PA - Part B vs D Determination


30


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ondansetron hcl 24 mg tablet 1 PA - Part B vs D Determination,QL (14 PER 28 OVER TIME)

ondansetron odt 1 PA - Part B vs D Determination

palonosetron hcl (0.25 mg/5 ml vial, 0.25mg/2 ml vial)

1

SANCUSO 1 QL (2 PER 30 OVER TIME)

SYNDROS 1 PA, QL (120 PER 30 DAYS)

Antifungals

ABELCET 1 PA - Part B vs D Determination

AMBISOME 1 PA - Part B vs D Determination

amphotericin b 50 mg vial 1 PA - Part B vs D Determination

caspofungin acetate 1

ciclodan 8% solution 1 PA

ciclopirox (0.77% gel, 0.77% cream, 0.77%topical susp, 1% shampoo)

1

ciclopirox 8% solution 1 PA

clotrimazole (1% solution, 1% topical cream,10 mg troche)

1

clotrimazole-betamethasone (crm, lot) 1

CRESEMBA (186 MG CAPSULE, 372 MGVIAL)

1

econazole nitrate 1% cream 1

EXELDERM (CREAM, SOLUTION) 1

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

1

fluconazole in saline (200 mg/100 ml, 400mg/200 ml)

1

fluconazole-nacl (200 mg/100 ml, 400 mg/200ml)

1

flucytosine (250 mg capsule, 500 mg capsule) 1


31


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

griseofulvin (125 mg/5 ml susp, micro 500 mgtab)

1

griseofulvin ultramicrosize 1

itraconazole (10 mg/ml solution, 100 mgcapsule)

1 PA

JUBLIA 1

ketoconazole (2% foam, 2% shampoo, 2%cream, 200 mg tablet)

1

ketodan 2% foam 1

miconazole 3 200 mg vag supp 1

naftifine hcl (1% gel, 1% cream, 2% cream) 1

NATACYN 1

NOXAFIL (40 MG/ML SUSPENSION, DR 100MG TABLET, 300 MG/16.7 ML VIAL)

1

nyamyc 1

nystatin (100,000 unit/gm cream, 100,000unit/ml susp, 100,000 unit/gm oint, 100,000unit/gm powd, 500,000 unit oral tab, 500,000unit/5 ml sus)

1

nystatin-triamcinolone (cream, ointm) 1

nystop 1

oxiconazole nitrate 1

OXISTAT 1% LOTION 1

posaconazole dr 100 mg tablet 1

terbinafine hcl 250 mg tablet 1 QL (84 PER 180 OVER TIME)

terconazole (0.4% cream, 0.8% cream, 80 mgsuppository)

1

TOLSURA 1 PA

voriconazole (40 mg/ml susp, 50 mg tablet,200 mg tablet, 200 mg vial)

1


32


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Antigout Agents

allopurinol (100 mg tablet, 300 mg tablet) 1

allopurinol sodium 1

colchicine (0.6 mg capsule, 0.6 mg tablet) 1

febuxostat 1

GLOPERBA 1 ST

KRYSTEXXA 1 PA

probenecid 1

probenecid-colchicine 1

ULORIC 1 ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine 1 mg/ml amp 1

dihydroergotamine 4 mg/ml spry 1 QL (8 PER 30 OVER TIME)

ERGOMAR 1

ergotamine-caffeine 1

migergot suppository 1

ProphylacticAIMOVIG 140 MG/ML AUTOINJECTOR 1 PA, QL (1 PER 30 DAYS)

AIMOVIG 70 MG/ML AUTOINJECTOR 1 PA, QL (2 PER 30 DAYS)

EMGALITY PEN 1 PA, QL (1 PER 30 DAYS)

EMGALITY 120 MG/ML SYRINGE 1 PA, QL (1 PER 30 DAYS)

EMGALITY SYRINGE (100 MG/ML SYR(1OF 3), 300 MG (100 MG X3SYR))

1 PA, QL (3 PER 30 DAYS)

NURTEC ODT 1 PA, QL (8 PER 30 OVER TIME)

timolol maleate (5 mg tablet, 10 mg tablet, 20mg tablet)

1


33


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

UBRELVY 1 PA, QL (10 PER 30 OVER TIME)

Serotonin (5-HT) 1b/1d Receptor Agonistseletriptan hbr 1 QL (12 PER 30 OVER TIME)

frovatriptan succinate 1 QL (12 PER 30 OVER TIME)

naratriptan hcl 1 QL (9 PER 30 OVER TIME)

rizatriptan (5 mg tablet, 5 mg odt, 10 mg odt,10 mg tablet)


sumatriptan (5 mg spray, 20 mg spray) 1 QL (12 PER 30 OVER TIME)

sumatriptan succ-naproxen sod 1 QL (9 PER 30 OVER TIME)

sumatriptan succinate (4 mg/0.5 ml cart, 4mg/0.5 ml inject)


sumatriptan succinate (25 mg tablet, 50 mgtablet, 100 mg tablet)


sumatriptan succinate (6 mg/0.5 ml cart, 6mg/0.5 ml vial, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng)


TOSYMRA 1 QL (12 PER 30 OVER TIME)

zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL (12 PER 30 OVER TIME)

Antimyasthenic Agents

Parasympathomimeticsguanidine hcl 1

MESTINON 60 MG/5 ML SOLUTION 1

pyridostigmine bromide (br 60 mg tablet, 60mg/5 ml soln)

1

pyridostigmine bromide er 1

REGONOL 1


34


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Antimycobacterials

Antimycobacterials, Otherdapsone (25 mg tablet, 100 mg tablet) 1

rifabutin 1

AntitubercularsCAPASTAT SULFATE 1

cycloserine 250 mg capsule 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg/mlvial, 100 mg tablet, 300 mg tablet)

1

PASER 1

PRIFTIN 1

pyrazinamide 500 mg tablet 1

rifampin (150 mg capsule, 300 mg capsule, iv600 mg vial)

1

RIFATER 1

SIRTURO 100 MG TABLET 1

TRECATOR 1

Antineoplastics

Alkylating AgentsBENDEKA 1

BICNU 1

busulfan 1

carboplatin (50 mg/5 ml vial, 150 mg/15 mlvial, 450 mg/45 ml vial, 600 mg/60 ml vial)

1

carmustine 1

cisplatin (50 mg/50 ml vial, 100 mg/100 mlvial, 200 mg/200 ml vial)

1


35


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

cyclophosphamide (25 mg capsule, 50 mgcapsule)

1 PA - Part B vs D Determination

cyclophosphamide (1 gm vial, 2 gm vial, 500mg vial)

1

dacarbazine 1

EVOMELA 1

GLEOSTINE 1

HEXALEN 1

ifosfamide (1 gm/20 ml vial, 1 gm vial, 3 gmvial, 3 gm/60 ml vial)

1

KISQALI FEMARA CO-PACK 1 PA - FOR NEW STARTS ONLY

LEUKERAN 1

MATULANE 1

melphalan hcl 1

oxaliplatin (50 mg vial, 50 mg/10 ml vial, 100mg vial, 100 mg/20 ml vial)

1

TEMODAR 100 MG VIAL 1

thiotepa 15 mg vial 1

TREANDA 1

VALCHLOR 1 PA - FOR NEW STARTS ONLY

YONDELIS 1

ZANOSAR 1

Antiandrogensabiraterone acetate 1 PA - FOR NEW STARTS ONLY

bicalutamide 1

ERLEADA 1 PA - FOR NEW STARTS ONLY

flutamide 1

nilutamide 1

NUBEQA 1 PA - FOR NEW STARTS ONLY

XTANDI 1 PA - FOR NEW STARTS ONLY


36


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

YONSA 1 PA - FOR NEW STARTS ONLY

ZYTIGA 500 MG TABLET 1 PA - FOR NEW STARTS ONLY

Antiangiogenic AgentsGAVRETO 1 PA - FOR NEW STARTS ONLY

POMALYST 1 PA - FOR NEW STARTS ONLY

QINLOCK 1 PA - FOR NEW STARTS ONLY

REVLIMID 1 PA - FOR NEW STARTS ONLY

TABRECTA 150 MG TABLET 1 PA - FOR NEW STARTS ONLY

TABRECTA 200 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (120 PER 30 DAYS)

THALOMID 1 PA - FOR NEW STARTS ONLY

Antiestrogens/ModifiersEMCYT 1

FASLODEX 1

fulvestrant 1

SOLTAMOX 1

tamoxifen citrate (10 mg tablet, 20 mg tablet) 1

toremifene citrate 1

Antimetabolitesadrucil 1

ALIMTA 1

ARRANON 1

cladribine 1

clofarabine 1

cytarabine 1

DROXIA 1

floxuridine 500 mg vial 1

FLUOROPLEX 1


37


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

fluorouracil (0.5% cream, 2% topical soln, 2.5gm/50 ml btl, 2.5 gm/50 ml vial, 5% cream, 5gm/100 ml btl, 5 gm/100 ml vial, 5% topicalsoln, 500 mg/10 ml vial, 1,000 mg/20 ml vl,2,500 mg/50 ml vl, 5,000 mg/100 ml)

1

FOLOTYN 1 PA - FOR NEW STARTS ONLY

gemcitabine hcl (hcl 1 gram vial, hcl 1gram/10 ml, 1 gram/26.3 ml vl, hcl 1.5gram/15 ml, hcl 2 gram/20 ml, 2 gram/52.6 mlvl, hcl 2 gram vial, hcl 200 mg vial, hcl 200mg/2 ml vl, 200 mg/5.26 ml vl)

1

hydroxyurea 500 mg capsule 1

INFUGEM (1,200 MG/120 ML BAG, 1,300MG/130 ML BAG, 1,400 MG/140 ML BAG,1,500 MG/150 ML BAG, 1,600 MG/160 MLBAG, 1,700 MG/170 ML BAG, 1,800 MG/180ML BAG, 2,000 MG/200 ML BAG, 2,200MG/220 ML BAG)

1

LONSURF 1 PA - FOR NEW STARTS ONLY

mercaptopurine 50 mg tablet 1

NIPENT 1

PURIXAN 1

SIKLOS 1 PA

TABLOID 1

VYXEOS 1 PA - FOR NEW STARTS ONLY

Antineoplastics, OtherABRAXANE 1

adriamycin (10 mg vial, 10 mg/5 ml vial, 20mg/10 ml vial, 50 mg/25 ml vial, 50 mg vial,200 mg/100 ml vial)

1

arsenic trioxide 10 mg/10ml vl 1

azacitidine 1

BCG (TICE STRAIN) 1

BELEODAQ 1 PA - FOR NEW STARTS ONLY


38


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

bleomycin sulfate 1

bortezomib 1 PA - FOR NEW STARTS ONLY

BRAFTOVI 1 PA - FOR NEW STARTS ONLY

COPIKTRA 1 PA - FOR NEW STARTS ONLY

COTELLIC 1 PA - FOR NEW STARTS ONLY

dactinomycin 1

daunorubicin hcl (20 mg/4 ml vial, 50 mg/10ml vial)

1

DAURISMO 1 PA - FOR NEW STARTS ONLY

decitabine 1 PA - FOR NEW STARTS ONLY

dexrazoxane 1

docetaxel 1

doxorubicin hcl (10 mg/5 ml vial, 20 mg/10 mlvial, 50 mg vial, 50 mg/25 ml vial, 150 mg/75ml vial, 200 mg/100 ml vial)

1

doxorubicin hcl liposome 1

epirubicin hcl (50 mg/25 ml vial, 200 mg/100ml vial)

1

ERWINAZE 1

FARYDAK 1 PA - FOR NEW STARTS ONLY

fludarabine 50 mg vial 1

HALAVEN 1 PA - FOR NEW STARTS ONLY

IBRANCE (75 MG TABLET, 75 MGCAPSULE, 100 MG CAPSULE, 100 MGTABLET, 125 MG TABLET, 125 MGCAPSULE)


idarubicin hcl 1

INREBIC 1 PA - FOR NEW STARTS ONLY

ISTODAX 1 PA - FOR NEW STARTS ONLY

IXEMPRA (45 MG KIT, 45 MG VIAL) 1

JEVTANA 1 PA - FOR NEW STARTS ONLY


39


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

KISQALI 1 PA - FOR NEW STARTS ONLY

leucovorin calcium (cal 100 mg/10 ml vl, cal500 mg/50 ml vl, calcium 5 mg tab, calcium10 mg tab, calcium 15 mg tab, calcium 25 mgtab, calcium 50 mg vial, calcium 100 mg vial,calcium 200 mg vial, calcium 350 mg vial,calcium 500 mg vl)

1

levoleucovorin calcium (50 mg vial, 175mg/17.5 ml, 250 mg/25 ml vl)

1

LORBRENA 1 PA - FOR NEW STARTS ONLY

LYNPARZA (50 MG CAPSULE, 100 MGTABLET, 150 MG TABLET)


MARQIBO 1

MEKTOVI 1 PA - FOR NEW STARTS ONLY

mitomycin (5 mg vial, 20 mg vial, 40 mg vial) 1

mitoxantrone hcl 1 PA - FOR NEW STARTS ONLY

MUTAMYCIN 1

NERLYNX 1 PA - FOR NEW STARTS ONLY,QL (180 PER 30 DAYS)

NINLARO 1 PA - FOR NEW STARTS ONLY

ONCASPAR 1

paclitaxel 1

PEMAZYRE 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

PIQRAY 1 PA - FOR NEW STARTS ONLY

PROLEUKIN 1

RETEVMO 1 PA - FOR NEW STARTS ONLY

romidepsin (10 mg kit, 10 mg vial) 1 PA - FOR NEW STARTS ONLY

ROZLYTREK 1 PA - FOR NEW STARTS ONLY

RYDAPT 1 PA - FOR NEW STARTS ONLY

SYLATRON 1 PA - FOR NEW STARTS ONLY

SYLATRON 4-PACK 1 PA - FOR NEW STARTS ONLY


40


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

SYNRIBO 1 PA - FOR NEW STARTS ONLY

TALZENNA 1 PA - FOR NEW STARTS ONLY

TAZVERIK 1 PA - FOR NEW STARTS ONLY

TRISENOX 1

TUKYSA 1 PA - FOR NEW STARTS ONLY

valrubicin 1

VALSTAR 1

VELCADE 1 PA - FOR NEW STARTS ONLY

VERZENIO 1 PA - FOR NEW STARTS ONLY

vinblastine sulfate 1

vincasar pfs 1 mg/ml vial 1

vincristine sulfate 1

vinorelbine tartrate 1

VITRAKVI (20 MG/ML SOLUTION, 25 MGCAPSULE, 100 MG CAPSULE)


XPOVIO 1 PA - FOR NEW STARTS ONLY

ZALTRAP 1 PA - FOR NEW STARTS ONLY

ZOLINZA 1 PA - FOR NEW STARTS ONLY

ZYKADIA 150 MG TABLET 1 PA - FOR NEW STARTS ONLY

Aromatase Inhibitors, 3rd Generationanastrozole 1 mg tablet 1

exemestane 1

letrozole 2.5 mg tablet 1

Enzyme InhibitorsBALVERSA 1 PA - FOR NEW STARTS ONLY

etoposide (100 mg/5 ml vial, 500 mg/25 mlvial, 1,000 mg/50 ml vial)

1

irinotecan hcl (40 mg/2 ml vial, 100 mg/5 mlvl, 500 mg/25 ml vl)

1


41


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

KYPROLIS 1 PA - FOR NEW STARTS ONLY

ONIVYDE 1

toposar 1

topotecan hcl (4 mg/4 ml vial, 4 mg vial) 1

ZYDELIG 1 PA - FOR NEW STARTS ONLY

Molecular Target InhibitorsAFINITOR 1 PA - FOR NEW STARTS ONLY,

QL (30 PER 30 DAYS)

AFINITOR DISPERZ 1 PA - FOR NEW STARTS ONLY

ALECENSA 1 PA - FOR NEW STARTS ONLY

ALIQOPA 1 PA - FOR NEW STARTS ONLY

ALUNBRIG 90 MG-180 MG TAB PACK 1 PA - FOR NEW STARTS ONLY,QL (60 PER 365 OVER TIME)

ALUNBRIG (90 MG TABLET, 180 MGTABLET)

1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

ALUNBRIG 30 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (120 PER 30 DAYS)

AYVAKIT 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

BOSULIF 1 PA - FOR NEW STARTS ONLY

BRUKINSA 1 PA - FOR NEW STARTS ONLY

CABOMETYX 1 PA - FOR NEW STARTS ONLY

CALQUENCE 1 PA - FOR NEW STARTS ONLY

CAPRELSA 100 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

CAPRELSA 300 MG TABLET 1 PA - FOR NEW STARTS ONLY

COMETRIQ 1 PA - FOR NEW STARTS ONLY

ERIVEDGE 1 PA - FOR NEW STARTS ONLY

erlotinib hcl 1 PA - FOR NEW STARTS ONLY

everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mgtablet)

1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)


42


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

GILOTRIF 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

ICLUSIG 15 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

ICLUSIG 45 MG TABLET 1 PA - FOR NEW STARTS ONLY

IDHIFA 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

imatinib mesylate 1 PA - FOR NEW STARTS ONLY

IMBRUVICA (70 MG CAPSULE, 140 MGCAPSULE, 140 MG TABLET, 280 MGTABLET, 420 MG TABLET, 560 MGTABLET)


INLYTA 1 PA - FOR NEW STARTS ONLY

INQOVI 1 PA - FOR NEW STARTS ONLY

IRESSA 1 PA - FOR NEW STARTS ONLY

JAKAFI (5 MG TABLET, 15 MG TABLET, 20MG TABLET, 25 MG TABLET)


JAKAFI 10 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

KOSELUGO 1 PA - FOR NEW STARTS ONLY

LENVIMA 1 PA - FOR NEW STARTS ONLY

MEKINIST 1 PA - FOR NEW STARTS ONLY

NEXAVAR 1 PA - FOR NEW STARTS ONLY

ODOMZO 1 PA - FOR NEW STARTS ONLY

RUBRACA 1 PA - FOR NEW STARTS ONLY

SPRYCEL 1 PA - FOR NEW STARTS ONLY

STIVARGA 1 PA - FOR NEW STARTS ONLY

SUTENT 1 PA - FOR NEW STARTS ONLY

TAFINLAR 1 PA - FOR NEW STARTS ONLY

TAGRISSO 40 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

TAGRISSO 80 MG TABLET 1 PA - FOR NEW STARTS ONLY


43


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TASIGNA 1 PA - FOR NEW STARTS ONLY

temsirolimus 1

TIBSOVO 1 PA - FOR NEW STARTS ONLY

TORISEL 1

TURALIO 1 PA - FOR NEW STARTS ONLY

TYKERB 1 PA - FOR NEW STARTS ONLY

VENCLEXTA 1 PA - FOR NEW STARTS ONLY

VENCLEXTA STARTING PACK 1 PA - FOR NEW STARTS ONLY

VIZIMPRO 1 PA - FOR NEW STARTS ONLY

VOTRIENT 1 PA - FOR NEW STARTS ONLY

XALKORI 1 PA - FOR NEW STARTS ONLY

XOSPATA 1 PA - FOR NEW STARTS ONLY

ZEJULA 1 PA - FOR NEW STARTS ONLY

ZELBORAF 1 PA - FOR NEW STARTS ONLY

ZYKADIA 150 MG CAPSULE 1 PA - FOR NEW STARTS ONLY

Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 1

BAVENCIO 1 PA - FOR NEW STARTS ONLY

BESPONSA 1 PA - FOR NEW STARTS ONLY

BLINCYTO 35MCG VL W-STABILIZER 1 PA - FOR NEW STARTS ONLY

CYRAMZA 1 PA - FOR NEW STARTS ONLY

DARZALEX 1 PA - FOR NEW STARTS ONLY

EMPLICITI 1 PA - FOR NEW STARTS ONLY

ERBITUX 1 PA - FOR NEW STARTS ONLY

GAZYVA 1 PA - FOR NEW STARTS ONLY

HERCEPTIN 1 PA - FOR NEW STARTS ONLY

IMFINZI 1 PA - FOR NEW STARTS ONLY

KADCYLA 1 PA - FOR NEW STARTS ONLY


44


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

KEYTRUDA 1 PA - FOR NEW STARTS ONLY

LARTRUVO 1 PA - FOR NEW STARTS ONLY

MYLOTARG 1 PA - FOR NEW STARTS ONLY

OPDIVO 1 PA - FOR NEW STARTS ONLY

PERJETA 1 PA - FOR NEW STARTS ONLY

PORTRAZZA 1 PA - FOR NEW STARTS ONLY

RITUXAN 1 PA - FOR NEW STARTS ONLY

RITUXAN HYCELA 1 PA - FOR NEW STARTS ONLY

TECENTRIQ 1 PA - FOR NEW STARTS ONLY

UNITUXIN 1

VECTIBIX 1

YERVOY 1 PA - FOR NEW STARTS ONLY

ZEVALIN 1

Retinoidsbexarotene 1 PA - FOR NEW STARTS ONLY

PANRETIN 1

TARGRETIN 1% GEL 1 PA - FOR NEW STARTS ONLY

tretinoin 10 mg capsule 1

Treatment AdjunctsKHAPZORY 1

mesna 1

MESNEX 400 MG TABLET 1

Antiparasitics

Anthelminticsalbendazole 200 mg tablet 1

benznidazole 1

ivermectin 3 mg tablet 1


45


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

praziquantel 600 mg tablet 1

AntiprotozoalsALINIA (100 MG/5 ML SUSPENSION, 500MG TABLET)

1

atovaquone 1

atovaquone-proguanil hcl 1

chloroquine phosphate (250 mg tablet, 500mg tablet)

1

COARTEM 1

DARAPRIM 1 PA

hydroxychloroquine 200 mg tab 1

mefloquine hcl 1

NEBUPENT 1 PA - Part B vs D Determination

PENTAM 300 1

pentamidine 300 mg vial 1

pentamidine 300 mg inhal powdr 1 PA - Part B vs D Determination

primaquine 1

pyrimethamine 25 mg tablet 1 PA

quinine sulfate 324 mg capsule 1 PA

tinidazole (250 mg tablet, 500 mg tablet) 1

Pediculicides/Scabicidescrotan 1

EURAX (CREAM, LOTION) 1

lindane 1% shampoo 1

malathion 1

permethrin 5% cream 1


46


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Antiparkinson Agents

Anticholinergicsbenztropine mesylate (mes 0.5 mg tab, mes 1mg tablet, mes 2 mg tablet, 2 mg/2 ml vial, 2mg/2 ml ampule)

1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 mlelx, 5 mg tablet)

1

Antiparkinson Agents, Otherentacapone 1

GOCOVRI 1 PA

tolcapone 1

Dopamine AgonistsAPOKYN 1 PA, QL (90 PER 30 DAYS)

bromocriptine mesylate (2.5 mg tablet, 5 mgcapsule)

1

INBRIJA 1 PA

NEUPRO 1 ST

pramipexole dihydrochloride 1

ropinirole hcl 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 25 mg tablet 1

carbidopa-levodopa (carbidopa-levo 10-100mg odt, carbidopa-levo 25-250 mg odt,carbidopa-levo 25-100 mg odt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa 25-250 tab, carbidopa-levodopa 25-100 tab)

1

carbidopa-levodopa er 1

RYTARY 1 ST


47


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Monoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate (0.5 mg tab, 1 mg tab) 1

selegiline hcl (5 mg tablet, 5 mg capsule) 1

Antipsychotics

1st Generation/Typicalchlorpromazine hcl (10 mg tablet, 25 mg/mlampule, 25 mg tablet, 25 mg/ml amp, 50 mgtablet, 50 mg/2 ml amp, 100 mg tablet, 200mg tablet)

1

fluphenazine dec 125 mg/5 ml 1

fluphenazine hcl (1 mg tablet, 2.5 mg/ml vial,2.5 mg tablet, 2.5 mg/5 ml elix, 5 mg/ml conc,5 mg tablet, 10 mg tablet)

1

haloperidol (0.5 mg tablet, 1 mg tablet, 2 mgtablet, 5 mg tablet, 10 mg tablet, 20 mgtablet)

1

haloperidol decanoate (dec 50 mg/ml vial,dec 100 mg/ml vial, dec 100 mg/ml amp, dec250 mg/5 ml vl, dec 500 mg/5 ml vl, decan 50mg/ml amp)

1

haloperidol decanoate 100 1

haloperidol lactate (2 mg/ml conc, 5 mg/mlampul, 5 mg/ml vial, 50 mg/10 ml vl)

1

loxapine 1

molindone hcl 1

perphenazine (2 mg tablet, 4 mg tablet, 8 mgtablet, 16 mg tablet)

1

pimozide 1

thioridazine hcl 1 PA - FOR NEW STARTS ONLY

thiothixene 1

trifluoperazine hcl 1


48


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

2nd Generation/AtypicalABILIFY MAINTENA (ER 300 MG SYR, ER300 MG VL, ER 400 MG VL, ER 400 MGSYR)

1

ABILIFY MYCITE 1 ST, QL (30 PER 30 DAYS)

aripiprazole 1 mg/ml solution 1 QL (750 PER 30 DAYS)

aripiprazole (2 mg tablet, 5 mg tablet, 10 mgtablet, 15 mg tablet, 20 mg tablet, 30 mgtablet)


aripiprazole odt 1 QL (60 PER 30 DAYS)

ARISTADA 1

ARISTADA INITIO 1

CAPLYTA 1 ST, QL (30 PER 30 DAYS)

FANAPT TITRATION PACK 1 ST, QL (8 PER 180 OVER TIME)

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


GEODON 20 MG/ML VIAL 1

INVEGA SUSTENNA 1

INVEGA TRINZA 1

LATUDA (20 MG TABLET, 40 MG TABLET,60 MG TABLET, 120 MG TABLET)


LATUDA 80 MG TABLET 1 QL (60 PER 30 DAYS)

NUPLAZID (10 MG TABLET, 17 MGTABLET, 34 MG CAPSULE)


olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mgtablet, 10 mg tablet, 15 mg tablet, 20 mgtablet)


olanzapine 10 mg vial 1

olanzapine odt 1 QL (30 PER 30 DAYS)

paliperidone er (er 1.5 mg tablet, er 3 mgtablet, er 9 mg tablet)



49


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

paliperidone er 6 mg tablet 1 QL (60 PER 30 DAYS)

PERSERIS 1

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


quetiapine fumarate (300 mg tab, 400 mg tab) 1 QL (60 PER 30 DAYS)

quetiapine er 200 mg tablet 1 QL (90 PER 30 DAYS)

quetiapine fumarate er (er 50 mg tablet, er150 mg tablet, er 300 mg tablet, er 400 mgtablet)


REXULTI 1 QL (30 PER 30 DAYS)

RISPERDAL CONSTA 1

risperidone 1 mg/ml solution 1 QL (240 PER 30 DAYS)

risperidone (0.25 mg tablet, 0.5 mg tablet, 1mg tablet, 2 mg tablet, 3 mg tablet, 4 mgtablet)


risperidone odt 1 QL (60 PER 30 DAYS)

SAPHRIS 1 QL (60 PER 30 DAYS)

SECUADO 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

VRAYLAR 1.5 MG-3 MG PACK 1 ST, QL (14 PER 365 OVER TIME)

VRAYLAR (1.5 MG CAPSULE, 3 MGCAPSULE, 4.5 MG CAPSULE, 6 MGCAPSULE)


ziprasidone hcl 1 QL (60 PER 30 DAYS)

ziprasidone mesylate 1

ZYPREXA RELPREVV 1

Treatment-Resistantclozapine (25 mg tablet, 100 mg tablet) 1 QL (270 PER 30 DAYS)

clozapine 200 mg tablet 1 QL (120 PER 30 DAYS)

clozapine 50 mg tablet 1 QL (180 PER 30 DAYS)

clozapine odt (odt 25 mg tablet, odt 100 mgtablet)



50


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

clozapine odt 12.5 mg tablet 1 QL (90 PER 30 DAYS)

clozapine odt 150 mg tablet 1 QL (180 PER 30 DAYS)

clozapine odt 200 mg tablet 1 QL (120 PER 30 DAYS)

VERSACLOZ 1 QL (540 PER 30 DAYS)

Antispasticity Agents

baclofen (5 mg tablet, 10 mg tablet, 10 mg/20ml vial, 20 mg tablet, 40 mg/20 ml vial, 20,000mcg/20 ml vial)

1

BOTOX 1 PA

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

1

LIORESAL INTRATHECAL 1

tizanidine hcl (2 mg tablet, 4 mg tablet) 1

XEOMIN 200 UNIT VIAL 1 PA

Antivirals

Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 1 QL (30 PER 30 DAYS)

DELSTRIGO 1 QL (30 PER 30 DAYS)

DOVATO 1 QL (30 PER 30 DAYS)

GENVOYA 1 QL (30 PER 30 DAYS)

ISENTRESS (25 MG TABLET CHEW, 100MG POWDER PACKET, 100 MG TABLETCHEW)

1

JULUCA 1 QL (30 PER 30 DAYS)

STRIBILD 1 QL (30 PER 30 DAYS)

TIVICAY 1

TIVICAY PD 1

TRIUMEQ 1 QL (30 PER 30 DAYS)


51


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)ATRIPLA 1 QL (30 PER 30 DAYS)

COMPLERA 1 QL (30 PER 30 DAYS)

EDURANT 1

efavirenz (50 mg capsule, 200 mg capsule,600 mg tablet)

1

INTELENCE 1

nevirapine (50 mg/5 ml susp, 200 mg tablet) 1

nevirapine er 1

ODEFSEY 1 QL (30 PER 30 DAYS)

PIFELTRO 1

RESCRIPTOR 200 MG TABLET 1

SUSTIVA 600 MG TABLET 1

SYMFI 1 QL (30 PER 30 DAYS)

SYMFI LO 1 QL (30 PER 30 DAYS)

VIRAMUNE 50 MG/5 ML SUSP 1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors(NRTI)

abacavir (20 mg/ml solution, 300 mg tablet) 1

abacavir-lamivudine 1 QL (30 PER 30 DAYS)

abacavir-lamivudine-zidovudine 1 QL (60 PER 30 DAYS)

CIMDUO 1 QL (30 PER 30 DAYS)

DESCOVY 1 QL (30 PER 30 DAYS)

didanosine (dr 200 mg capsule, dr 250 mgcapsule, dr 400 mg capsule)

1

emtricitabine 1

EMTRIVA (10 MG/ML SOLUTION, 200 MGCAPSULE)

1

lamivudine (10 mg/ml oral soln, 150 mgtablet, 300 mg tablet)

1


52


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

lamivudine-zidovudine 1 QL (60 PER 30 DAYS)

RETROVIR 200 MG/20 ML VIAL 1

stavudine 1

tenofovir disoproxil fumarate 1

TRUVADA 1 QL (30 PER 30 DAYS)

VIDEX 1

VIDEX EC 125 MG CAPSULE 1

VIREAD (150 MG TABLET, 200 MGTABLET, 250 MG TABLET, POWDER)

1

ZERIT 1 MG/ML SOLUTION 1

zidovudine (50 mg/5 ml syrup, 100 mgcapsule, 300 mg tablet)

1

Anti-HIV Agents, OtherFUZEON 1 QL (60 PER 30 DAYS)

ISENTRESS 400 MG TABLET 1

ISENTRESS HD 1

RUKOBIA 1

SELZENTRY (20 MG/ML ORAL SOLN, 25MG TABLET, 75 MG TABLET, 150 MGTABLET, 300 MG TABLET)

1

SIRTURO 20 MG TABLET 1

TROGARZO 1

TYBOST 1

Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/ML SOLUTION, 250 MGCAPSULE)

1

atazanavir sulfate 1

CRIXIVAN 1

EVOTAZ 1 QL (30 PER 30 DAYS)

fosamprenavir calcium 1


53


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

INVIRASE (200 MG CAPSULE, 500 MGTABLET)

1

KALETRA (100-25 MG TABLET, 200-50 MGTABLET)

1

LEXIVA 50 MG/ML SUSPENSION 1

lopinavir-ritonavir 1

NORVIR (80 MG/ML SOLUTION, 100 MGPOWDER PACKET)

1

PREZCOBIX 1 QL (30 PER 30 DAYS)

PREZISTA (75 MG TABLET, 100 MG/MLSUSPENSION, 150 MG TABLET, 600 MGTABLET, 800 MG TABLET)

1

REYATAZ 50 MG POWDER PACKET 1

ritonavir 1

SYMTUZA 1 QL (30 PER 30 DAYS)

VIRACEPT (250 MG TABLET, 625 MGTABLET)

1

Anti-cytomegalovirus (CMV) Agentscidofovir 375 mg/5 ml vial 1

ganciclovir sodium (500 mg/10 ml vial, 500mg vial)

1

PREVYMIS (240 MG/12 ML VIAL, 240 MGTABLET, 480 MG TABLET, 480 MG/24 MLVIAL)

1

valganciclovir hcl (hcl 50 mg/ml, 450 mgtablet)

1

ZIRGAN 1

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 1

BARACLUDE 0.05 MG/ML SOLUTION 1 QL (600 PER 30 DAYS)

entecavir 1 QL (30 PER 30 DAYS)

EPIVIR HBV 25 MG/5 ML SOLN 1


54


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

INTRON A (10 MILLION UNITS VIL, 18MILLION UNIT/3 ML, 18 MILLION UNITSVIL, 25 MILLION UNIT/2.5ML, 50 MILLIONUNITS VIL)


lamivudine 100 mg tablet 1

lamivudine hbv 1

VEMLIDY 1

Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 400 MG-100 MG TABLET 1 PA, QL (84 PER 365 OVER TIME)

HARVONI 45-200 MG PELLET PACKT 1 PA, QL (336 PER 365 OVERTIME)

HARVONI (33.75-150 MG PELLET PK, 90-400 MG TABLET)

1 PA, QL (168 PER 365 OVERTIME)

ledipasvir-sofosbuvir 1 PA, QL (168 PER 365 OVERTIME)

MAVYRET 1 PA, QL (336 PER 365 OVERTIME)

sofosbuvir-velpatasvir 1 PA, QL (84 PER 365 OVER TIME)

VOSEVI 1 PA, QL (84 PER 365 OVER TIME)

Anti-hepatitis C (HCV) Agents, OtherPEGASYS (180 MCG/ML VIAL, 180 MCG/0.5ML SYRINGE)

1 PA

PEGASYS PROCLICK 180 MCG/0.5 1 PA

PEGINTRON 50 MCG KIT 1 PA

ribasphere (200 mg tablet, 200 mg capsule,400 mg tablet, 600 mg tablet)

1

RIBASPHERE RIBAPAK 1

ribavirin (200 mg capsule, 200 mg tablet) 1

Anti-influenza Agentsamantadine (50 mg/5 ml solution, 100 mgtablet, 100 mg/10 ml soln, 100 mg capsule)

1

oseltamivir phos 30 mg capsule 1 QL (168 PER 365 OVER TIME)


55


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS



oseltamivir 6 mg/ml suspension 1 QL (1080 PER 365 OVER TIME)

RELENZA 1 QL (240 PER 365 OVER TIME)

rimantadine hcl 1

XOFLUZA 20 MG TAB (40 MG DOSE) 1 QL (4 PER 365 OVER TIME)

Antiherpetic Agentsacyclovir (5% cream, 5% ointment, 200 mgcapsule, 200 mg/5 ml susp, 400 mg tablet,800 mg tablet)

1

acyclovir sodium (500 mg/10 ml vial, 1,000mg/20 ml vial)


DENAVIR 1

famciclovir 1

trifluridine 1% eye drops 1

valacyclovir 1 QL (120 PER 30 DAYS)

Anxiolytics

Anxiolytics, Otherbuspirone hcl (5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tablet, 30 mg tablet)

1

dexmedetomidine 80 mcg/20ml-ns 1

meprobamate 1

Benzodiazepinesalprazolam (0.25 mg tablet, 0.5 mg tablet, 1mg tablet)


alprazolam 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

alprazolam er (er 0.5 mg tablet, er 1 mgtablet)


alprazolam er 2 mg tablet 1 PA, QL (150 PER 30 DAYS)


56


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

alprazolam er 3 mg tablet 1 PA, QL (90 PER 30 DAYS)

alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 PA, QL (30 PER 30 DAYS)

alprazolam xr 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

alprazolam xr 3 mg tablet 1 PA, QL (90 PER 30 DAYS)

chlordiazepoxide 10 mg capsule 1 PA, QL (900 PER 30 DAYS)



clorazepate 15 mg tablet 1 QL (180 PER 30 DAYS)

clorazepate 3.75 mg tablet 1 QL (720 PER 30 DAYS)

clorazepate 7.5 mg tablet 1 QL (360 PER 30 DAYS)

diazepam (5 mg/5 ml solution, 5 mg/ml oralconc, 10 mg/2 ml carpuject, 10 mg/2 mlsyringe, 50 mg/10 ml vial)

1

diazepam 10 mg tablet 1 QL (120 PER 30 DAYS)



estazolam 1 PA, QL (30 PER 30 DAYS)

lorazepam (0.5 mg tablet, 1 mg tablet) 1 PA, QL (90 PER 30 DAYS)

lorazepam 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

lorazepam (2 mg/ml syringe, 2 mg/ml oralconcent, 2 mg/ml vial, 2 mg/ml carpuject, 4mg/ml carpuject, 4 mg/ml vial, 20 mg/10 mlvial, 40 mg/10 ml vial)

1 PA

lorazepam intensol 1 PA

midazolam hcl 2 mg/ml syrup 1

temazepam 1 PA, QL (30 PER 30 DAYS)

Bipolar Agents

Mood StabilizersEQUETRO 1


57


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

lithium 1

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

1

lithium carbonate er 1

Blood Glucose Regulators

Antidiabetic Agentsacarbose 1

CYCLOSET 1

glimepiride 1

glipizide (5 mg tablet, 10 mg tablet) 1

glipizide er 1

glipizide xl 1

glipizide-metformin 1

glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mgtablet)

1

glyburide micronized 1

glyburide-metformin hcl 1

GLYXAMBI 1 ST

INVOKAMET 1 ST

INVOKAMET XR 1 ST

INVOKANA 1 ST

JANUMET 1 ST

JANUMET XR 1 ST

JANUVIA 1 ST

JARDIANCE 1 ST

JENTADUETO 1 ST

JENTADUETO XR 1 ST

metformin hcl (500 mg/5 ml soln, 500 mgtablet, 850 mg tablet, 1,000 mg tablet)

1


58


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

metformin hcl er 1

nateglinide 1

OZEMPIC 0.25-0.5 MG DOSE PEN 1 QL (1.5 PER 28 DAYS)

OZEMPIC 1 MG DOSE PEN 1 QL (3 PER 28 DAYS)

pioglitazone hcl 1

pioglitazone-glimepiride 1

pioglitazone-metformin 1

repaglinide 1

repaglinide-metformin hcl 1

RIOMET 1

RIOMET ER 1

RYBELSUS (7 MG TABLET, 14 MGTABLET)


RYBELSUS 3 MG TABLET 1 QL (60 PER 365 OVER TIME)

SYMLINPEN 120 1 PA

SYMLINPEN 60 1 PA

SYNJARDY 1 ST

SYNJARDY XR 1 ST

tolazamide 1

tolbutamide 1

TRADJENTA 1 ST

TRIJARDY XR 1 ST

TRULICITY (0.75 MG/0.5 ML PEN, 1.5MG/0.5 ML PEN)


TRULICITY (3 MG/0.5 ML PEN, 4.5 MG/0.5ML PEN)


VICTOZA 2-PAK 1 QL (9 PER 30 DAYS)

VICTOZA 3-PAK 1 QL (9 PER 30 DAYS)


59


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Glycemic AgentsBAQSIMI 1

diazoxide 50 mg/ml oral susp 1

GLUCAGEN 1

GLUCAGON EMERGENCY KIT 1

GVOKE HYPOPEN 1-PACK 1

GVOKE HYPOPEN 2-PACK 1

GVOKE PFS 1-PACK SYRINGE 1


PROGLYCEM 1

InsulinsHUMALOG (100 UNIT/ML CARTRIDGE, 100UNIT/ML VIAL)

1

HUMALOG JUNIOR KWIKPEN 1

HUMALOG KWIKPEN U-100 1

HUMALOG KWIKPEN U-200 1

HUMALOG MIX 50-50 1

HUMALOG MIX 50-50 KWIKPEN 1

HUMALOG MIX 75-25 1

HUMALOG MIX 75-25 KWIKPEN 1

HUMULIN 70-30 1

HUMULIN 70/30 KWIKPEN 1

HUMULIN N 1

HUMULIN N KWIKPEN 1

HUMULIN R 1

HUMULIN R U-500 1

HUMULIN R U-500 KWIKPEN 1

INSULIN LISPRO 1


60


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

INSULIN LISPRO JUNIOR KWIKPEN 1

INSULIN LISPRO KWIKPEN U-100 1

INSULIN LISPRO PROTAMINE MIX 1

LANTUS 1

LANTUS SOLOSTAR 1

LEVEMIR 1

LEVEMIR FLEXTOUCH 1

TOUJEO MAX SOLOSTAR 1

TOUJEO SOLOSTAR 1

TRESIBA 1

TRESIBA FLEXTOUCH U-100 1

TRESIBA FLEXTOUCH U-200 1

Blood Products/Modifiers/Volume Expanders

Anticoagulantsargatroban 1

argatroban-0.9% nacl (50 mg/50ml-0.9%nacl,125 mg/125-0.9%nacl)

1

argatroban-sodium chloride 1

ELIQUIS DVT-PE TREAT START 5MG 1 QL (148 PER 365 OVER TIME)

ELIQUIS 2.5 MG TABLET 1 QL (60 PER 30 DAYS)

ELIQUIS 5 MG TABLET 1 QL (90 PER 30 DAYS)

enoxaparin 30 mg/0.3 ml syr 1 QL (10.5 PER 90 OVER TIME)

enoxaparin 40 mg/0.4 ml syr 1 QL (14 PER 90 OVER TIME)

enoxaparin 60 mg/0.6 ml syr 1 QL (21 PER 90 OVER TIME)

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


enoxaparin sodium (80 mg/0.8 ml syr, 120mg/0.8 ml syr)



61


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

enoxaparin 300 mg/3 ml vial 1 QL (105 PER 90 OVER TIME)

fondaparinux 10 mg/0.8 ml syr 1 QL (28 PER 90 OVER TIME)

fondaparinux 2.5 mg/0.5 ml syr 1 QL (17.5 PER 90 OVER TIME)

fondaparinux 5 mg/0.4 ml syr 1 QL (14 PER 90 OVER TIME)

fondaparinux 7.5 mg/0.6 ml syr 1 QL (21 PER 90 OVER TIME)

FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000UNIT/0.2 ML SYR)


FRAGMIN 10,000 UNIT/ML SYRINGE 1 QL (35 PER 90 OVER TIME)

FRAGMIN 12,500 UNIT/0.5 ML SYR 1 QL (17.5 PER 90 OVER TIME)

FRAGMIN 15,000 UNIT/0.6 ML SYR 1 QL (21 PER 90 OVER TIME)

FRAGMIN 18,000 UNIT/0.72 ML 1 QL (25.3 PER 90 OVER TIME)

FRAGMIN 7,500 UNIT/0.3 ML SYR 1 QL (10.5 PER 90 OVER TIME)

FRAGMIN 95,000 UNIT/3.8 ML VL 1 QL (22.8 PER 90 OVER TIME)

heparin sodium (sod 1,000 unit/ml vial, sod5,000 unit/0.5 ml, 5,000 unit/ml carpujct, sod5,000 unit/ml vial, sod 10,000 unit/ml vl,10,000 unit/10 ml vial, sod 20,000 unit/ml vl,30,000 unit/30 ml vial, 40,000 unit/4 ml vial,50,000 unit/10 ml vial, 50,000 unit/5 ml vial)

1

heparin sodium in 0.45% nacl 1

heparin sodium-0.45% nacl (heparin-12,500unit/250-1/2, heparin 25,000 unit/500-1/2,heparin 25,000 unit/250-1/2)

1

heparin sodium-0.9% nacl (1,000 unit/500,2,000 unit/1,000)

1

heparin 20,000 unit/500 ml-d5w 1

jantoven 1

PRADAXA 1 QL (60 PER 30 DAYS)

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5mg tablet, 3 mg tablet, 4 mg tablet, 5 mgtablet, 6 mg tablet, 7.5 mg tablet, 10 mgtablet)

1

XARELTO DVT-PE TREAT START 30D 1 QL (102 PER 365 OVER TIME)


62


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

XARELTO (10 MG TABLET, 20 MG TABLET) 1 QL (30 PER 30 DAYS)

XARELTO (2.5 MG TABLET, 15 MGTABLET)


Blood Formation Modifiersanagrelide hcl 1

ARANESP (10 MCG/0.4 ML SYRINGE, 25MCG/ML VIAL, 25 MCG/0.42 ML SYRING,40 MCG/ML VIAL, 40 MCG/0.4 MLSYRINGE, 60 MCG/0.3 ML SYRINGE, 60MCG/ML VIAL, 100 MCG/ML VIAL, 100MCG/0.5 ML SYRINGE, 150 MCG/0.3 MLSYRINGE, 200 MCG/0.4 ML SYRINGE, 200MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE,300 MCG/ML VIAL, 500 MCG/1 MLSYRINGE)

1 PA

FULPHILA 1 PA

GRANIX (300 MCG/ML VIAL, 480 MCG/1.6ML VIAL)

1 ST

LEUKINE 1 PA

MOZOBIL 1 PA, QL (38.4 PER 365 OVERTIME)

MULPLETA 1 PA

NEULASTA 1 PA

NEULASTA ONPRO 1 PA

NEUPOGEN (300 MCG/ML VIAL, 300MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL,480 MCG/0.8 ML SYR)

1 ST

NIVESTYM (300 MCG/ML VIAL, 300MCG/0.5 ML SYRING, 480 MCG/0.8 MLSYRING, 480 MCG/1.6 ML VIAL)

1 ST

NPLATE (250 MCG VIAL, 500 MCG VIAL) 1 PA

OXBRYTA 1 PA, QL (90 PER 30 DAYS)

PROMACTA (12.5 MG SUSPEN PACKET,12.5 MG TABLET, 25 MG TABLET, 25 MGSUSPENSION PCKT, 50 MG TABLET, 75MG TABLET)

1 PA


63


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

UDENYCA 1 PA

ZARXIO 1

ZIEXTENZO 1 PA

SOLIRIS 1 PA

ULTOMIRIS 300 MG/30 ML VIAL 1 PA

Hemostasis Agentsaminocaproic acid (5 g/20 ml vl, 500 mg tab,1,000 mg tab)

1

RETACRIT (2,000 UNIT/ML VIAL, 3,000UNIT/ML VIAL, 4,000 UNIT/ML VIAL, 10,000UNIT/ML VIAL, 40,000 UNIT/ML VIAL)

1 PA

TAVALISSE 1 PA

tranexamic acid (650 mg tablet, 1,000 mg/10ml)

1

Platelet Modifying Agentsaspirin-dipyridamole er 1

BRILINTA 1

CABLIVI (11 MG VIAL, 11 MG KIT) 1 PA, QL (30 PER 30 DAYS)

cilostazol 1

clopidogrel 1

prasugrel hcl 1

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine 1

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3mg tablet)

1

guanfacine hcl 1

methyldopa 1

methyldopa-hydrochlorothiazide 1


64


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

midodrine hcl 1

phenylephrine hcl (10 mg/ml vial, 50 mg/5 mlvial, 100 mg/10 ml vl)

1

Alpha-adrenergic Blocking Agentsphenoxybenzamine hcl 10 mg cap 1

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

1

Angiotensin II Receptor Antagonistscandesartan cilexetil 1

candesartan-hydrochlorothiazid 1

eprosartan mesylate 1

irbesartan 1

irbesartan-hydrochlorothiazide 1

losartan potassium 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil 1

olmesartan-hydrochlorothiazide 1

telmisartan 1

telmisartan-hydrochlorothiazid 1

valsartan 1

valsartan-hydrochlorothiazide 1

Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (5 mg tablet, 10 mg tablet, 20mg tablet, 40 mg tablet)

1

benazepril-hydrochlorothiazide 1

captopril (12.5 mg tablet, 25 mg tablet, 50 mgtablet, 100 mg tablet)

1

captopril-hydrochlorothiazide 1

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

1


65


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

enalapril-hydrochlorothiazide 1

EPANED 1 MG/ML ORAL SOLUTION 1

fosinopril sodium 1

fosinopril-hydrochlorothiazide 1

lisinopril (2.5 mg tablet, 5 mg tablet, 10 mgtablet, 20 mg tablet, 30 mg tablet, 40 mgtablet)

1

lisinopril-hydrochlorothiazide 1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1

quinapril-hydrochlorothiazide 1

ramipril 1

trandolapril 1

trandolapril-verapamil er 1

Antiarrhythmicsamiodarone hcl (hcl 100 mg tablet, 150 mg/3ml syringe, 150 mg/3 ml vial, hcl 200 mgtablet, hcl 400 mg tablet, 450 mg/9 ml vial,900 mg/18 ml vial)

1

disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

ibutilide fumarate 1

lidocaine hcl (1% abboject, 1% syringe, 2%syringe, 2% abboject, 2% luer-jet)

1

mexiletine hcl (150 mg capsule, 200 mgcapsule, 250 mg capsule)

1

NORPACE CR 1

pacerone (100 mg tablet, 200 mg tablet, 400mg tablet)

1


66


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

procainamide hcl (procainamid 1,000 mg/10ml syr, procainamide 1 gram/2 ml vial,procainamide 1 gram/10 ml vial,procainamide 1,000 mg/2 ml vl, procainamide1,000 mg/10 ml vl)

1

propafenone hcl 1

propafenone hcl er 1

quinidine gluconate (80 mg/ml vial, er 324 mgtab)

1

quinidine sulfate (200 mg tab, 300 mg tab) 1

sorine 1

sotalol 1

sotalol af 1

Beta-adrenergic Blocking Agentsacebutolol hcl (200 mg capsule, 400 mgcapsule)

1

atenolol (25 mg tablet, 50 mg tablet, 100 mgtablet)

1

atenolol-chlorthalidone 1

betaxolol hcl (10 mg tablet, 20 mg tablet) 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

BREVIBLOC (2,000 MG/100 ML BAG, 2,500MG/250 ML BAG)

1

BYSTOLIC 1

carvedilol 1

carvedilol er 1

esmolol hcl 100 mg/10 ml vial 1

esmolol hcl-sodium chloride 1

labetalol hcl (100 mg tablet, 200 mg tablet,300 mg tablet)

1

metoprolol succinate 1


67


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

metoprolol tartrate (25 mg tab, 50 mg tab,100 mg tab)

1

metoprolol-hydrochlorothiazide 1

nadolol (20 mg tablet, 40 mg tablet, 80 mgtablet)

1

pindolol 1

propranolol hcl (1 mg/ml vial, 10 mg tablet, 20mg/5 ml soln, 20 mg tablet, 40 mg tablet, 40mg/5 ml soln, 60 mg tablet, 80 mg tablet)

1

propranolol hcl er 1

propranolol-hydrochlorothiazid 1

Calcium Channel Blocking Agentsamlodipine besylate (2.5 mg tab, 5 mg tab, 10mg tab)

1

amlodipine besylate-benazepril 1

amlodipine-atorvastatin 1

amlodipine-valsartan 1

cartia xt 1

dilt-xr 1

diltiazem 12hr er 1

diltiazem 24hr er 1

diltiazem 24hr er (cd) 1

diltiazem 24hr er (la) 1

diltiazem 24hr er (xr) 1

diltiazem hcl (25 mg/5 ml vial, 30 mg tablet,50 mg/10 ml vial, 60 mg tablet, 90 mg tablet,100 mg add-van vial, 120 mg tablet, 125mg/25 ml vial)

1

felodipine er 1

matzim la 1

nicardipine hcl (20 mg capsule, 25 mg/10 mlampule, 25 mg/10 ml vial, 30 mg capsule)

1


68


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

nifedipine er 1

nimodipine 1

nisoldipine 1

NYMALIZE (30 MG/10 ML SOLUTION, 30MG/5 ML ORAL SYRNG, 60 MG/20 MLSOLUTION, 60 MG/10 ML ORAL SYRN)

1

taztia xt 1

tiadylt er 1

verapamil er (er 120 mg capsule, er 120 mgtablet, er 180 mg tablet, er 180 mg capsule,er 240 mg capsule, er 240 mg tablet)

1

verapamil er pm 1

verapamil hcl (5 mg/2 ml vial, 5 mg/2 mlampul, 10 mg/4 ml syringe, 10 mg/4 ml vial,40 mg tablet, 80 mg tablet, 120 mg tablet,360 mg cap pellet)

1

verapamil sr 1

Cardiovascular Agents, Otheraliskiren 1

atropine sulfate (0.4 mg/ml vial, 8 mg/20 mlvial)

1

CORLANOR 5 MG/5 ML ORAL SOLN 1 PA, QL (450 PER 30 DAYS)

CORLANOR (5 MG TABLET, 7.5 MGTABLET)


DEMSER 1

digitek 1

digox 1

digoxin (0.05 mg/ml solution, 0.125 mg tablet,0.25 mg tablet, 125 mcg tablet, 250 mcgtablet, 500 mcg/2 ml ampule)

1

dobutamine hcl 1

dobutamine hcl-d5w 1


69


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

dopamine hcl (200 mg/5 ml vial, 400 mg/10ml vial)

1

dopamine hcl in 5% dextrose 1

ENTRESTO 1 QL (60 PER 30 DAYS)

LANOXIN 62.5 MCG TABLET 1

mannitol (20% iv solution, 25% vial) 1

milrinone in 5% dextrose 1

milrinone lactate 1

norepinephrine bitartrate (4 mg/4 ml vial, 4mg/4 ml ampul)

1

NORTHERA 1 PA

OSMITROL 1

pentoxifylline er 400 mg tab 1

ranolazine er 1

REPATHA PUSHTRONEX 1 PA, QL (3.5 PER 28 DAYS)

REPATHA SURECLICK 1 PA, QL (3 PER 28 DAYS)

REPATHA SYRINGE 1 PA, QL (3 PER 28 DAYS)

TAKHZYRO 1 PA

VYNDAMAX 1 PA, QL (30 PER 30 DAYS)

VYNDAQEL 1 PA, QL (120 PER 30 DAYS)

Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide sodium 1

Diuretics, Loopbumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1mg/4 ml vial, 1 mg tablet, 2 mg tablet, 2.5mg/10 ml vial)

1

ethacrynic acid 1


70


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

furosemide (10 mg/ml solution, 20 mg tablet,20 mg/2 ml vial, 40 mg/4 ml vial, 40 mg/4 mlsyringe, 40 mg/5 ml soln, 40 mg tablet, 80 mgtablet, 100 mg/10 ml syring, 100 mg/10 mlvial)

1

torsemide 1

Diuretics, Potassium-sparingALDACTAZIDE 50-50 TABLET 1

amiloride hcl 5 mg tablet 1

amiloride-hydrochlorothiazide 1

DYRENIUM 1

eplerenone 1

spironolactone (25 mg tablet, 50 mg tablet,100 mg tablet)

1

spironolactone-hctz 1

triamterene (50 mg capsule, 100 mg capsule) 1

triamterene-hydrochlorothiazid (37.5-25 mgcp, 37.5-25 mg tb, 75-50 mg tab)

1

Diuretics, Thiazidechlorothiazide 1

chlorothiazide sodium 1

chlorthalidone 1

DIURIL 1

hydrochlorothiazide (12.5 mg tb, 12.5 mg cp,25 mg tab, 50 mg tab)

1

indapamide 1

methyclothiazide 1

metolazone 1


71


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Dyslipidemics, Fibric Acid Derivativesfenofibrate (40 mg tablet, 43 mg capsule, 48mg tablet, 54 mg tablet, 67 mg capsule, 120mg tablet, 130 mg capsule, 134 mg capsule,145 mg tablet, 160 mg tablet, 200 mgcapsule)

1

fenofibric acid (dr 45 mg cap, dr 135 mg cap) 1

gemfibrozil 600 mg tablet 1

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1

fluvastatin er 1

fluvastatin sodium 1

LIVALO 1 ST

lovastatin 1

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin (5 mg tablet, 10 mg tablet, 20 mgtablet, 40 mg tablet, 80 mg tablet)

1

Dyslipidemics, Othercholestyramine (packet, powder) 1

cholestyramine light (packet, powder) 1

colesevelam 625 mg tablet 1

colestipol hcl (hcl 1 gm tablet, hcl granules,hcl granules packet, micronized 1 gm tab)

1

ezetimibe 1

ezetimibe-simvastatin 1

JUXTAPID 1 PA, QL (30 PER 30 DAYS)

KYNAMRO 1 PA, QL (4 PER 28 DAYS)

NEXLETOL 1 PA, QL (30 PER 30 DAYS)

niacin (ra 500 mg tablet, 500 mg tablet) 1


72


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

niacin er 1

niacor 1

omega-3 acid ethyl esters 1

plain niacin 500 mg tablet 1

prevalite (packet, powder) 1

triklo 1

VASCEPA 1

Vasodilators, Direct-acting Arterialhydralazine hcl (10 mg tablet, 25 mg tablet,50 mg tablet, 100 mg tablet)

1

minoxidil (2.5 mg tablet, 10 mg tablet) 1

Vasodilators, Direct-acting Arterial/VenousDILATRATE-SR 1

ISORDIL 1

isosorbide dinitrate 1

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran 1

NITRO-BID 1

NITRO-DUR (0.3 MG/HR PATCH, 0.8MG/HR PATCH)

1

nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6mg tablet)

1

nitroglycerin in d5w (0.2 mg/ml in, 25 mg/250ml in, 100 mg/250 ml in)

1

nitroglycerin patch 1


73


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine 5 mg/5 ml 1 PA, QL (1800 PER 30 DAYS)

dextroamphetamine 10 mg tab 1 PA, QL (180 PER 30 DAYS)

dextroamphetamine 5 mg tab 1 PA, QL (90 PER 30 DAYS)

dextroamphetamine er 10 mg cap 1 PA, QL (180 PER 30 DAYS)



dextroamphetamine-amphet er 1 PA, QL (30 PER 30 DAYS)

dextroamphetamine-amphetamine 1 PA, QL (90 PER 30 DAYS)

zenzedi 10 mg tablet 1 PA, QL (180 PER 30 DAYS)

zenzedi 5 mg tablet 1 PA, QL (90 PER 30 DAYS)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine hcl (18 mg capsule, 25 mgcapsule, 40 mg capsule, 60 mg capsule, 80mg capsule, 100 mg capsule)


atomoxetine hcl 10 mg capsule 1 QL (60 PER 30 DAYS)

clonidine hcl er 1

dexmethylphenidate hcl 1 PA, QL (60 PER 30 DAYS)

dexmethylphenidate hcl er 1 PA, QL (30 PER 30 DAYS)

guanfacine hcl er 1

metadate er 1 PA, QL (90 PER 30 DAYS)

methylphenidate er (er 10 mg cap, er 15 mgcap, er 20 mg cap, er 30 mg cap)

1 PA

methylphenidate er (er 40 mg cap, er 50 mgcap, er 60 mg cap)


methylphenidate er (er 18 mg tab, er 27 mgtab, er 54 mg tab, er 72 mg tab)


methylphenidate er 36 mg tab 1 PA, QL (60 PER 30 DAYS)


74


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS



methylphenidate er (la) 1 PA, QL (30 PER 30 DAYS)

methylphenidate hcl (5 mg/5 ml soln, 10 mg/5ml sol)

1 PA

methylphenidate 10 mg chew tab 1 PA, QL (180 PER 30 DAYS)

methylphenidate hcl (2.5 mg chew tb, 5 mgtablet, 5 mg chew tab, 10 mg tablet, 20 mgtablet)


methylphenidate hcl cd 1 PA, QL (30 PER 30 DAYS)

methylphenidate hcl er (cd) 1 PA, QL (30 PER 30 DAYS)

methylphenidate la 1 PA, QL (30 PER 30 DAYS)

relexxii 1 PA, QL (30 PER 30 DAYS)

Central Nervous System, OtherAUSTEDO 1 PA, QL (120 PER 30 DAYS)

caffeine citrate (60 mg/3 ml vial, 60 mg/3 mloral)

1

clonidine hcl (1,000 mcg/10 ml vial, 5,000mcg/10 ml vial)

1

INGREZZA 40 MG CAPSULE 1 PA, QL (60 PER 30 DAYS)

INGREZZA 80 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

INGREZZA INITIATION PACK 1 PA, QL (56 PER 365 OVER TIME)

NUEDEXTA 1 PA

RADICAVA 1 PA

riluzole 1 PA

tetrabenazine 1 PA

TIGLUTIK 1 PA

Fibromyalgia AgentsSAVELLA TITRATION PACK 1 QL (110 PER 365 OVER TIME)

SAVELLA (12.5 MG TABLET, 25 MGTABLET, 50 MG TABLET, 100 MG TABLET)



75


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Multiple Sclerosis AgentsAMPYRA 1 PA, QL (60 PER 30 DAYS)

AUBAGIO 1 PA, QL (30 PER 30 DAYS)

AVONEX (30 MCG VIAL KIT, PREFILLEDSYR 30 MCG KT)


AVONEX PEN 1 PA, QL (4 PER 28 DAYS)

BAFIERTAM 1 PA, QL (120 PER 30 DAYS)

BETASERON 0.3 MG KIT 1 PA, QL (15 PER 30 DAYS)

dalfampridine er 1 PA, QL (60 PER 30 DAYS)

dimethyl fumarate (dr 120 mg cp, dr 240 mgcp)


EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) 1 PA, QL (15 PER 30 DAYS)

GILENYA 0.25 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

GILENYA 0.5 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

glatiramer 20 mg/ml syringe 1 PA, QL (30 PER 30 DAYS)

glatiramer 40 mg/ml syringe 1 PA, QL (12 PER 28 DAYS)

glatopa 20 mg/ml syringe 1 PA, QL (30 PER 30 DAYS)

glatopa 40 mg/ml syringe 1 PA, QL (12 PER 28 DAYS)

KESIMPTA PEN 1 PA

MAVENCLAD 1 PA

MAYZENT 0.25 MG TABLET 1 PA, QL (120 PER 30 DAYS)

MAYZENT 2 MG TABLET 1 PA, QL (30 PER 30 DAYS)

OCREVUS 1 PA, QL (40 PER 365 OVER TIME)

PLEGRIDY 125 MCG/0.5 ML SYRING 1 PA, QL (1 PER 28 DAYS)

PLEGRIDY SYRINGE STARTER PACK 1 PA, QL (4 PER 365 OVER TIME)

PLEGRIDY 125 MCG/0.5 ML PEN 1 PA, QL (1 PER 28 DAYS)

PLEGRIDY PEN INJ STARTER PACK 1 PA, QL (2 PER 365 OVER TIME)

REBIF (22 MCG/0.5 ML SYRINGE, 44MCG/0.5 ML SYRINGE)



76


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

REBIF TITRATION PACK 1 PA, QL (8.4 PER 365 OVERTIME)

REBIF REBIDOSE (22 MCG/0.5 ML, 44MCG/0.5 ML)


REBIF REBIDOSE TITRATION PACK 1 PA, QL (8.4 PER 365 OVERTIME)

TECFIDERA (DR 120 MG CAPSULE, DR240 MG CAPSULE)


TECFIDERA STARTER PACK 1 PA, QL (120 PER 365 OVERTIME)

TYSABRI 1 PA

VUMERITY 1 PA, QL (120 PER 30 DAYS)

ZEPOSIA (0.23-0.46 MG START PCK, 0.23-0.46-0.92 MG KIT)

1 PA

ZEPOSIA 0.92 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

Dental and Oral Agents

chlorhexidine 0.12% rinse 1

lidocaine hcl viscous 1

oralone 1

paroex 1

periogard 1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

triamcinolone 0.1% paste 1

Dermatological Agents

acitretin 1

adapalene (0.1% gel, 0.1% cream, 0.3% gelpump, 0.3% gel)

1

adapalene-benzoyl peroxide 1

ammonium lactate (cream, lotion) 1


77


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

amnesteem 1 PA

AVITA (CREAM, GEL) 1 PA

azelaic acid 15% gel 1

calcipotriene (cream, ointment) 1 QL (120 PER 30 DAYS)

calcipotriene 0.005% solution 1 QL (60 PER 30 DAYS)

calcitrene 1 QL (120 PER 30 DAYS)

claravis 1 PA

clind ph-benzoyl perox 1.2-5% 1

clindamycin phos-tretinoin 1

clindamycin-benzoyl peroxide (clinda-benzoyl1-5% pump, clindamycin-benzoyl 1-5%)

1

CONDYLOX 0.5% GEL 1

COSENTYX (2 SYRINGES) 1 PA

COSENTYX PEN 1 PA

COSENTYX PEN (2 PENS) 1 PA

COSENTYX SYRINGE 1 PA

dapsone (5% gel, 7.5% gel pump) 1

diclofenac 1.5% topical soln 1 PA

doxepin 5% cream 1 PA, QL (90 PER 30 DAYS)

doxycycline ir-dr 1

DUOBRII 1 PA

DUPIXENT PEN 1 PA, QL (8 PER 28 DAYS)

DUPIXENT 300 MG/2 ML SYRINGE 1 PA, QL (8 PER 28 DAYS)

erythromycin-benzoyl peroxide 1

EUCRISA 1

FINACEA 15% FOAM 1

hydrocort-pramoxine 1%-1% crm 1

ILUMYA 1 PA

imiquimod (3.75% cream pump, 5% creampacket)

1


78


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

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

1 PA

ivermectin 1% cream 1

klofensaid ii 1 PA

methoxsalen (10 mg softgel, 10 mg capsule) 1

metronidazole (0.75% cream, topical 0.75%gl, 0.75% lotion, top 1% gel pump, topical 1%gel)

1

MIRVASO (GEL, GEL PUMP) 1 PA

myorisan 1 PA

neuac gel 1

PICATO 1

pimecrolimus 1

podofilox 0.5% topical soln 1

RECTIV 1

rosadan (cream, gel) 1

SANTYL 1

selenium sulfide 2.5% lotion 1

SILIQ 1 PA

STELARA (45 MG/0.5 ML VIAL, 45 MG/0.5ML SYRINGE, 90 MG/ML SYRINGE, 130MG/26 ML VIAL)

1 PA

tacrolimus (0.03%, 0.1%) 1

TALTZ AUTOINJECTOR 1 PA

TALTZ AUTOINJECTOR (2 PACK) 1 PA

TALTZ AUTOINJECTOR (3 PACK) 1 PA

TALTZ SYRINGE 1 PA

TALTZ SYRINGE (2 PACK) 1 PA

tazarotene 0.1% cream 1

TREMFYA (100 MG/ML INJECTOR, 100MG/ML SYRINGE)

1 PA


79


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

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

1 PA

tretinoin microsphere (gel 0.04% tube, gel0.04% pump, gel 0.1% tube, gel 0.1% pump)

1 PA

UVADEX 1

zenatane 1 PA

ZYCLARA (2.5% CREAM PUMP, 3.75%CREAM PUMP, 3.75% CREAM)

1

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacementcalcium gluconate (gluc 1,000 mg/10 ml vl,gluc 5,000 mg/50 ml vl, gluc 10,000 mg/100ml, gluconate 10% vial)

1

CARBAGLU 1

CLINIMIX (4.25%-5% SOLUTION, 4.25%-10% SOLUTION, 5%-20% SOLUTION, 5%-15% SOLUTION)


CLINIMIX E (2.75%-5% SOLUTION, 4.25%-10% SOLUTION, 4.25%-5% SOLUTION, 5%-15% SOLUTION, 5%-20% SOLUTION)


dextrose 10%-0.2% nacl 1


dextrose 2.5%-0.45% nacl 1


dextrose 5%-0.2% nacl-kcl 1







80


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS




dextrose 5%-1/2ns-kcl 1

dextrose 5%-ns-kcl 1

dextrose 5%-potassium chloride (20 insolution, 40 in solution)

1

dextrose in lactated ringers 1

dextrose in water (5%-water 50 ml, 5%-watervial, 5%-water 100 ml, 5%-water iv soln, 10%-water iv solution, 20%-water iv soln, 25%-water syringe, 30%-water iv soln, 40%-wateriv soln, 50%-water abboject, 50%-watersyringe, 50%-water iv soln, 50%-water vial,70%-water iv soln)

1

fluoride 1

FLUORITAB (0.5 MG TABLET CHEW, 1 MGTABLET CHEW)

1

glucose in water 1

IONOSOL MB-DEXTROSE 5% 1

ISOLYTE P WITH DEXTROSE 1

ISOLYTE S IV SOLUTION-EXCEL 1

klor-con 1

KLOR-CON 10 1

KLOR-CON 8 1

klor-con m10 1

KLOR-CON M15 1

klor-con m20 1

klor-con sprinkle 1

lactated ringers injection 1

ludent fluoride 1


81


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

magnesium sulfate (sulf 2 g/50 ml bag, sulf 4g/100 ml bag, sulf 4 g/50 ml bag, sulf 20g/500 ml bag, sulf 40 g/1,000 ml, sulfate 50%vial, sulfate 50% syringe)

1

magnesium sulf 1 g/100 ml-d5w 1

NORMOSOL-M AND DEXTROSE 1

NORMOSOL-R AND DEXTROSE 1

NORMOSOL-R PH 7.4 1

PLASMA-LYTE 148 1

PLASMA-LYTE A PH 7.4 1

potassium chl-normal saline 1

potassium chloride (2 meq/ml conc, er 8 meqcapsule, er 8 meq tablet, er 10 meq tablet,10% (20 meq/15ml), 10 meq/50 ml sol, 10meq/100 ml sol, er 10 meq capsule, 10% (40meq/30ml), 10 meq/5 ml conc, 20 meqpacket, 20 meq/10 ml conc, 20 meq/50 mlsol, 20% (40 meq/15ml), er 20 meq tablet, 20meq/100 ml sol, 40 meq/20 ml conc, 40meq/100 ml sol, 60 meq/30 ml conc)

1

potassium chloride in d5lr 1

potassium chloride proamp 1

potassium chloride-nacl 1

potassium citrate er (er 5 tab, er 10 tb) 1

PROCALAMINE 1 PA - Part B vs D Determination

ringers injection 1

sodium acetate (40 meq/20 ml vl, 100 meq/50ml, 200 meq/100 ml)

1


82


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

sodium chloride (saline 0.45% soln-excel con,sodium chloride 0.45% soln, sodium chloride0.9% syringe, sodium chloride 0.9% 250 ml,sodium chloride 0.9% 50 ml, sodium chloride0.9% sol-excel, sodium chloride 0.9% vial,sodium chloride 0.9% solution, sodiumchloride 0.9% carpuject, sodium chloride0.9% soln, sodium chloride 0.9% 500 ml,sodium chloride 0.9% 1,000 ml, sodiumchloride 0.9% 100 ml, sodium chloride 3% ivsoln, sodium chloride 5% iv soln, sodiumchloride 50 meq/20 ml, sodium chloride 100meq/40 ml)

1

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1mg), 1 mg (2.2 mg))

1

sodium lactate 50 meq/10 ml vl 1

Electrolyte/Mineral/Metal Modifiersclovique 1 PA

deferasirox (90 mg tablet, 90 mg granule, 125mg tb for susp, 180 mg tablet, 180 mggranule, 250 mg tb for susp, 360 mg granule,360 mg tablet, 500 mg tb for susp)

1 PA

deferiprone 1 PA

DEPEN 1

EXJADE 1 PA

FERRIPROX (100 MG/ML SOLUTION, 500MG TABLET, 1,000 MG TABLET)

1 PA

FERRIPROX (2 TIMES A DAY) 1 PA

JADENU 1 PA

JADENU SPRINKLE 1 PA

JYNARQUE 15 MG TABLET 1 QL (60 PER 30 DAYS)

JYNARQUE 30 MG TABLET 1 QL (30 PER 30 DAYS)

JYNARQUE (15 MG TABLET, 30 MGTABLET)

1

JYNARQUE (45 MG-15 MG TABLET, 60 MG-30 MG TABLET, 90 MG-30 MG TABLET)



83


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

kionex 15 gm/60 ml suspension 1

penicillamine 250 mg tablet 1

sodium polystyrene sulfonate (sod polystyrensulf 15 g/60 ml, sodium polystyrene sulfpowder, sps 15 gm/60 ml suspension, sps 30gm/120 ml enema, sps 50 gm/200 ml enema)

1

SPS 15 GM/60 ML SUSPENSION 1

trientine hcl 1 PA

VELTASSA 1

Phosphate BindersAURYXIA 1 PA

calcium acetate (667 mg capsule, 667 mgtablet, 667 mg gelcap)

1

lanthanum carbonate 1

sevelamer carbonate (0.8 gm powder packet,2.4 gm powder packet, carbonate 800 mgtab)

1

sevelamer hcl 1

VELPHORO 1

Vitaminsprenatal vitamins 1

RAYALDEE 1

Gastrointestinal Agents

Antispasmodics, GastrointestinalCUVPOSA 1

dicyclomine hcl (10 mg capsule, 10 mg/5 mlsoln, 20 mg/2 ml vial, 20 mg/2 ml ampul, 20mg tablet)

1

GLYCATE 1

glycopyrrolate (0.2 mg/ml syrng, 0.4 mg/2 mlsyr, 1 mg tablet, 1.5 mg tablet, 2 mg tablet)

1


84


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

methscopolamine bromide (2.5 mg tb, 5 mgtab)

1

Gastrointestinal Agents, OtherCHENODAL 1

CHOLBAM 1 PA

cromolyn 100 mg/5 ml oral conc 1

diphenoxylate-atrop 2.5-0.025 1

GATTEX 1 PA

loperamide 2 mg capsule 1

metoclopramide hcl (5 mg tablet, 5 mg/5 mlsoln, 10 mg/2 ml vial, 10 mg tablet, 10 mg/2ml syr, 10 mg/10 ml sol)

1

OCALIVA 1 PA, QL (30 PER 30 DAYS)

opium tincture 1

RELISTOR (12 MG/0.6 ML SYRINGE, 12MG/0.6 ML VIAL)


RELISTOR 8 MG/0.4 ML SYRINGE 1 ST, QL (12 PER 30 DAYS)

RELISTOR 150 MG TABLET 1 ST, QL (90 PER 30 DAYS)

ursodiol (250 mg tablet, 500 mg tablet) 1

XERMELO 1 PA, QL (90 PER 30 DAYS)

Histamine2 (H2) Receptor Antagonistscimetidine (200 mg tablet, 300 mg tablet, 300mg/5 ml soln, 400 mg tablet, 800 mg tablet)

1

famotidine (20 mg tablet, 20 mg/2 ml vial, 40mg/5 ml susp, 40 mg/4 ml vial, 40 mg tablet,200 mg/20 ml vial, 500 mg/50 ml vial)

1

nizatidine (15 mg/ml solution, 150 mgcapsule, 300 mg capsule)

1


85


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 mlvial, 150 mg/10 ml syrup, hcl 150 mg/6 ml vl,150 mg tablet, 150 mg capsule, 300 mgcapsule, 300 mg tablet, 1,000 mg/40 ml vial)

1

Irritable Bowel Syndrome Agentsalosetron hcl 1 PA

AMITIZA 1 QL (60 PER 30 DAYS)

LINZESS 1 QL (30 PER 30 DAYS)

LaxativesCLENPIQ 1

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n 1

generlac 1

KRISTALOSE 1

lactulose (10 gm/15 ml solution, 10 gmpacket, 20 gm/30 ml solution)

1

peg 3350-electrolyte 1

peg-3350 and electrolytes 1

peg3350-sod sul-nacl-kcl-asb-c 1

SUPREP 1

trilyte with flavor packets 1

Protectantsmisoprostol (100 mcg tablet, 200 mcg tablet) 1

sucralfate (1 gm tablet, 1 gm/10 ml susp) 1

Proton Pump Inhibitorsesomeprazole mag dr 40 mg cap 1 QL (60 PER 30 DAYS)


86


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

esomeprazole magnesium (dr 10 mg packet,dr 20 mg packet, dr 40 mg packet, mag dr 20mg cap)


esomeprazole sodium 1

lansoprazole (dr 15 mg capsule, dr 30 mgcapsule, odt 15 mg tablet, odt 30 mg tablet)


omeprazole (dr 10 mg capsule, dr 20 mgcapsule, dr 40 mg capsule)


omeprazole-sodium bicarbonate (20-1,680pkt, 40-1,680 pkt)


pantoprazole sodium (sod dr 20 mg tab, soddr 40 mg tab, 40 mg suspension)


pantoprazole sodium 40 mg vial 1

rabeprazole sod dr 20 mg tab 1 QL (60 PER 30 DAYS)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN 1

ALDURAZYME 1 PA

CERDELGA 1 PA

CEREZYME 400 UNIT VIAL 1 PA

CREON 1

CYSTAGON 1

ELAPRASE 1 PA

EVRYSDI 1 PA, QL (240 PER 30 DAYS)

EXONDYS-51 1 PA

FABRAZYME 35 MG VIAL 1 PA

GALAFOLD 1 PA, QL (14 PER 28 DAYS)

KANUMA 1 PA

KUVAN (100 MG TABLET, 100 MGPOWDER PACKET, 500 MG POWDERPACKET)

1 PA

LUMIZYME 1 PA


87


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

miglustat 1 PA

NAGLAZYME 1 PA

nitisinone 1

NITYR 1

ONPATTRO 1 PA

ORFADIN (2 MG CAPSULE, 4 MG/MLSUSPENSION, 5 MG CAPSULE, 10 MGCAPSULE, 20 MG CAPSULE)

1

PROCYSBI (DR 25 MG CAPSULE, DR 75MG CAPSULE, DR 75 MG GRANULE PKT,DR 300 MG GRANULE PKT)

1 PA

RAVICTI 1 PA

REVCOVI 1 PA

sodium phenylbutyrate powder 1

STRENSIQ 1 PA

TEGSEDI 1 PA

VIMIZIM 1 PA

VPRIV 1 PA

XIAFLEX 1 PA

XURIDEN 1 PA, QL (120 PER 30 DAYS)

ZENPEP 1

Genitourinary Agents

Antispasmodics, Urinarydarifenacin er 1

flavoxate hcl 1

MYRBETRIQ 1

oxybutynin chloride (5 mg/5 ml syrup, 5 mgtablet)

1

oxybutynin chloride er 1


88


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

trospium chloride 1

trospium chloride er 1

Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 1

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

1

dutasteride 0.5 mg capsule 1

finasteride 5 mg tablet 1

RAPAFLO 1

silodosin 1

tamsulosin hcl 1

terazosin hcl 1

Genitourinary Agents, Otheracetic acid 0.25% irrig soln 1

bethanechol chloride (5 mg tablet, 10 mgtablet, 25 mg tablet, 50 mg tablet)

1

ELMIRON 1

THIOLA EC 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ala-cort 2.5% cream 1

alclometasone dipropionate (dipr oint, diprocrm)

1

amcinonide (cream, lotion, ointment) 1

apexicon e 1

beser 1


89


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

betamethasone diprop augmented (crm, gel,lot, oin)

1

betamethasone dipropionate (crm, lot, oint) 1

betamethasone sod phos-acetate 1

betamethasone valer 0.12% foam 1 QL (100 PER 30 DAYS)

betamethasone valerate (va cream, va lotion,valer ointm)

1

clobetasol emollient (emollient crm, emollntfoam)

1

clobetasol emulsion 1

clobetasol propionate (cream, gel, ointment,prop foam, prop spray, shampoo, solution,topical lotn)

1

clocortolone pivalate 1

clodan 0.05% shampoo 1

CORDRAN 0.025% CREAM 1

CORTIFOAM 1

cortisone 25 mg tablet 1

DELTASONE 1

DEPO-MEDROL 20 MG/ML VIAL 1

desonide (cream, gel, lotion, ointment) 1

desoximetasone (0.05% gel, 0.05% ointment,0.05% cream, 0.25% cream, 0.25% ointment,0.25% spray)

1

dexamethasone (0.5 mg tablet, 0.5 mg/5 mlelx, 0.5 mg/5 ml liq, 0.75 mg tablet, 1 mgtablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet,6 mg tablet, 6 day 1.5 mg tab, 10 day 1.5 mgtb, 13 day 1.5 mg tb)

1

dexamethasone intensol 1

dexamethasone sodium phosphate (4 mg/mlvial, 4 mg/ml syringe, 10 mg/ml vial, 20 mg/5ml vial, 100 mg/10 ml vl, 120 mg/30 ml vl)

1


90


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1 QL (60 PER 30 DAYS)

EMFLAZA (6 MG TABLET, 18 MG TABLET,22.75 MG/ML ORAL SUSP, 30 MG TABLET,36 MG TABLET)

1 PA

fludrocortisone 0.1 mg tablet 1

fluocinolone acetonide (0.01% solution,0.01% cream, 0.025% cream, 0.025%ointment)

1

fluocinonide (cream, gel, ointment, solution) 1

fluocinonide 0.1% cream 1 QL (120 PER 30 DAYS)

fluocinonide-e 1

flurandrenolide (cream, ointment) 1

fluticasone propionate (0.005% oint, 0.05%cream, 0.05% lotion)

1

halcinonide 1

halobetasol propionate (cream, foam,ointmnt)

1

HALOG 0.1% SOLUTION 1

hydrocortisone (2.5% cream, 2.5% ointment,2.5% lotion, 5 mg tablet, 10 mg tablet, 20 mgtablet)

1

hydrocortisone butyrate (buty cream, butyrlotn, butyr oint, butyr soln)

1

hydrocortisone val 0.2% cream 1 QL (60 PER 30 DAYS)

hydrocortisone val 0.2% ointmt 1

KENALOG-10 1

LEXETTE 1

methylprednisolone (4 mg tablet, 4 mgdosepk, 8 mg tab, 16 mg tab, 32 mg tab)

1

methylprednisolone acetate (40 mg/ml vl, 80mg/ml vl)

1

methylprednisolone sodium succ (1 gm vl, 40mg vl, 125 mg)

1


91


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

mifepristone 1

millipred 5 mg tablet 1

mometasone furoate (cream, oint, soln) 1

nolix 0.05% cream 1

PANDEL 1

prednicarbate (cream, ointment) 1

prednisolone (15 mg/5 ml syrup, 15 mg/5 mlsoln)

1

prednisolone sodium phosphate (5 mg/5 mlsoln, 10 mg/5 ml soln, 20 mg/5 ml soln, sodph 25 mg/5 ml)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mgtab dose pack, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab dose pack, 10 mg tablet,20 mg tablet, 50 mg tablet)

1

prednisone intensol 1

RAYOS 1

SOLU-CORTEF 1

SOLU-MEDROL 2,000 MG VIAL 1

tovet emollient 1

triamcinolone acetonide (0.025% lotion,0.025% oint, 0.025% cream, 0.05% ointment,0.05% oint, 0.1% ointment, 0.1% cream,0.1% lotion, 0.5% ointment, 0.5% cream, acet40 mg/ml vl, acet 40mg/ml vl, acet 200 mg/5ml, acet 400 mg/10ml)

1

trianex 1

triderm 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR 1 PA

CHORIONIC GONAD 10,000 UNIT VL 1 PA


92


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

desmopressin acetate (0.01% spray, 0.01%solution, ac 4 mcg/ml vial, ac 4 mcg/mlampul, acetate 0.1 mg tb, acetate 0.2 mg tb,40 mcg/10 ml vial)

1

EGRIFTA 1 PA, QL (30 PER 30 DAYS)

EGRIFTA SV 1 PA, QL (30 PER 30 DAYS)

GENOTROPIN (MINIQUICK 0.2 MG,MINIQUICK 0.4 MG, MINIQUICK 0.6 MG,MINIQUICK 0.8 MG, MINIQUICK 1 MG,MINIQUICK 1.2 MG, MINIQUICK 1.4 MG,MINIQUICK 1.6 MG, MINIQUICK 1.8 MG,MINIQUICK 2 MG, 5 MG CARTRIDGE, 12MG CARTRIDGE)

1 PA

INCRELEX 1 PA

NOVAREL 5,000 UNIT VIAL 1 PA

NUTROPIN AQ NUSPIN 1 PA

PREGNYL 1 PA

SEROSTIM 1 PA

STIMATE 1

ZORBTIVE 1 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 1 PA, QL (120 PER 30 DAYS)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 1 PA

oxandrolone 10 mg tablet 1 PA, QL (60 PER 30 DAYS)

oxandrolone 2.5 mg tablet 1 PA, QL (240 PER 30 DAYS)

AndrogensANDRODERM 1 PA

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

1


93


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

testosterone (1% (25mg/2.5g) pk, 1% (50mg/5 g) pk, 1.62% (2.5 g) pkt, 1.62%(1.25 g)pkt, 1.62% gel pump, 12.5 mg/1.25 gram, 25mg/2.5 gm pkt, 30 mg/1.5 ml pump, 50 mg/5gram gel, 50 mg/5 gram pkt)

1 PA

testosterone cypionate (testosteron 1,000mg/10 ml, testosteron 2,000 mg/10 ml,testosterone 100 mg/ml, testosterone 200mg/ml, testosterone 500 mg/5 ml,testosterone 6,000 mg/30ml)

1 PA

testosterone enanthate (testosteron 1,000mg/5 ml, testosterone 200 mg/ml)

1 PA

Estrogensaltavera 1

alyacen 1

amabelz 1

amethia 1 QL (91 PER 91 DAYS)

amethia lo 1 QL (91 PER 91 DAYS)

amethyst 1

apri 1

aranelle 1

ashlyna 1 QL (91 PER 91 DAYS)

aubra 1

aubra eq 1

aurovela 24 fe 1

aviane 1

azurette 1

balziva 1

bekyree 1

blisovi 24 fe 1

blisovi fe 1.5-30 tablet 1

briellyn 1


94


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

camrese 1 QL (91 PER 91 DAYS)

camrese lo 1 QL (91 PER 91 DAYS)

caziant 1

chateal 1

CLIMARA PRO 1

cryselle 1

cyclafem 1

cyred 1

cyred eq 1

dasetta 1

daysee 1 QL (91 PER 91 DAYS)

delyla 1

desogestr-eth estrad eth estra 1

desogestrel-ethinyl estradiol 1

dotti 1

drospirenone-eth estra-levomef 1

drospirenone-ethinyl estradiol 1

ELESTRIN 1

elinest 1

emoquette 1

enpresse 1

enskyce 1

estarylla 1

estradiol (0.01% cream, 0.5 mg tablet, 1 mgtablet, 2 mg tablet, 10 mcg vaginal insrt)

1

estradiol (once weekly) 1

estradiol (twice weekly) 1

estradiol valerate (100 mg/5 ml, 200 mg/5 ml) 1

estradiol-norethindrone acetat 1


95


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ESTRING 1 QL (1 PER 90 OVER TIME)

ethynodiol-ethinyl estradiol 1

falmina 1

fayosim 1 QL (91 PER 91 DAYS)

femynor 1

fyavolv 1

gianvi 1

hailey 24 fe 1

introvale 1 QL (91 PER 91 DAYS)

isibloom 1

jasmiel 1

jencycla 1

jinteli 1

jolessa 1 QL (91 PER 91 DAYS)

juleber 1

junel 1

junel fe 1

junel fe 24 1

kaitlib fe 1

kariva 1

kelnor 1-35 1

kelnor 1-50 1

kimidess 1

kurvelo 1

larin 1

larin 24 fe 1

larin fe 1

larissia 1


96


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

LAYOLIS FE 1

leena 1

lessina 1

levonest 1

levonorg-eth estrad eth estrad 1 QL (91 PER 91 DAYS)

levonorgestrel-eth estradiol 1

levora-28 1

LO LOESTRIN FE 1

lopreeza 1

loryna 1

low-ogestrel 1

lutera 1

marlissa 1

melodetta 24 fe 1

MENEST 1

mibelas 24 fe 1

microgestin 1

microgestin fe 1

mili 1

mimvey 1

mimvey lo 1

mono-linyah 1

mononessa 1

necon 1

nikki 1

norethin-eth estra-ferrous fum (noret-estr-fe0.4-0.035(21)-75, noreth-estrad-fe 1-0.02(21)-75, noreth-estrad-fe 1-0.02(24)-75, norethin-estra-fe 0.8-0.025 mg)

1


97


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

norethindron-ethinyl estradiol (norethin-eth 1mg-5 mcg, norethind-eth 0.5-2.5, norethind-eth 1-0.02 mg)

1

norgestimate-ethinyl estradiol 1

norlyda 1

nortrel 1

ocella 1

ogestrel 1

orsythia 1

philith 1

pimtrea 1

pirmella 1

portia 1

PREMARIN (0.3 MG TABLET, 0.45 MGTABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINALCREAM-APPL)

1

PREMPHASE 1

PREMPRO 1

previfem 1

reclipsen 1

rivelsa 1 QL (91 PER 91 DAYS)

setlakin 1 QL (91 PER 91 DAYS)

sprintec 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1

tarina fe 1-20 eq 1

tilia fe 1


98


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

tri-estarylla 1

tri-legest fe 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem 1

tri-sprintec 1

tri-vylibra 1

tri-vylibra lo 1

trivora-28 1

tydemy 1

velivet 1

vestura 1

vienva 1

viorele 1

vyfemla 1

vylibra 1

wera 1

wymzya fe 1

xulane 1

yuvafem 1

zarah 1

zovia 1-35e 1

zumandimine 1

Progesterone Agonists/AntagonistsELLA 1


99


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

MAKENA 275 MG/1.1 ML AUTOINJCT 1 PA

Progestinscamila 1

CRINONE 1 PA

deblitane 1

DEPO-PROVERA 400 MG/ML VIAL 1 QL (10 PER 28 DAYS)

DEPO-SUBQ PROVERA 104 1 QL (0.65 PER 90 OVER TIME)

errin 1

heather 1

hydroxyprogesterone 1.25 g/5ml 1 PA - FOR NEW STARTS ONLY

hydroxyprogesterone caproate (250 mg/mlvial, 1,250 mg/5 ml)

1 PA

incassia 1

jolivette 1

lyza 1

medroxyprogesterone 150 mg/ml 1 QL (1 PER 90 OVER TIME)

medroxyprogesterone acetate (2.5 mg tab, 5mg tab, 10 mg tab)

1

megestrol acetate (20 mg tablet, acet 40mg/ml susp, 40 mg tablet, acet 400 mg/10 ml,625 mg/5 ml susp)


nora-be 1

norethindrone 0.35 mg tablet 1

norethindrone ac (lupaneta) 1

norethindrone 5 mg tablet 1

norlyroc 1

progesterone (100 mg capsule, 200 mgcapsule, 500 mg/10 ml vial)

1

sharobel 1

tulana 1


100


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Selective Estrogen Receptor Modifying AgentsOSPHENA 1 PA, QL (30 PER 30 DAYS)

raloxifene hcl 1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium (25 mcg tablet, 50 mcgtablet, 75 mcg tablet, 88 mcg tablet, 100 mcgvial, 100 mcg tablet, 100 mcg/5 ml vl, 112mcg tablet, 125 mcg tablet, 137 mcg tablet,150 mcg tablet, 175 mcg tablet, 200 mcgtablet, 200 mcg/5 ml vl, 200 mcg vial, 300mcg tablet, 500 mcg/5 ml vl, 500 mcg vial)

1

LEVOXYL 1

liothyronine sodium (5 mcg tab, 10 mcg/ml vl,25 mcg tab, 50 mcg tab)

1

TIROSINT (175 MCG CAPSULE, 200 MCGCAPSULE)

1

UNITHROID 1

Hormonal Agents, Suppressant (Adrenal)

ISTURISA 1 PA

LYSODREN 1

Hormonal Agents, Suppressant (Pituitary)

BYNFEZIA 1 PA

cabergoline 1

FIRMAGON (2 X 120 MG KIT, 120 MG VIAL) 1 PA - FOR NEW STARTS ONLY,QL (4 PER 365 OVER TIME)

FIRMAGON 80 MG KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

leuprolide acetate (1 mg/0.2 ml kit, 14 mg/2.8ml vl, 14 mg/2.8 ml kt)


LUPANETA PK 11.25-5 MG 3MO KIT 1 PA, QL (1 PER 84 DAYS)


101


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

LUPANETA PK 3.75-5 MG 1MO KIT 1 PA, QL (1 PER 28 DAYS)

LUPRON DEPOT (11.25 MG 3MO KIT, 22.5MG 3MO KIT)

1 PA - FOR NEW STARTS ONLY,QL (1 PER 84 OVER TIME)

LUPRON DEPOT (3.75 MG KIT, 7.5 MG KIT) 1 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

LUPRON DEPOT 45 MG 6MO KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 168 OVER TIME)

LUPRON DEPOT-4 MONTH KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 112 OVER TIME)

LUPRON DEPO 11.25MG (LUPANETA) 1 PA - FOR NEW STARTS ONLY,QL (1 PER 84 OVER TIME)

LUPRON DEPOT 3.75MG (LUPANETA) 1 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

LUPRON DEPOT-PED (11.25 MG KIT, 15MG KIT)

1 PA, QL (1 PER 28 OVER TIME)

LUPRON DEPOT-PED 7.5 MG KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

LUPRON DEPOT-PED 11.25 MG 3MO 1 PA, PA - FOR NEW STARTSONLY, QL (1 PER 84 OVERTIME)

LUPRON DEPOT-PED 30 MG 3MO KIT 1 PA, QL (1 PER 84 OVER TIME)

MYCAPSSA 1 PA

octreotide acetate (acet 0.05 mg/ml vl, acet50 mcg/ml amp, acet 50 mcg/ml vial, acet 100mcg/ml vl, acet 100 mcg/ml amp, acet 200mcg/ml vl, acet 500 mcg/ml vl, acet 500mcg/ml amp, 1,000 mcg/5 ml vial, 1,000mcg/ml vial, 5,000 mcg/5 ml vial)

1 PA

ORIAHNN 1 PA, QL (56 PER 28 DAYS)

ORILISSA 150 MG TABLET 1 PA, QL (30 PER 30 DAYS)

ORILISSA 200 MG TABLET 1 PA, QL (60 PER 30 DAYS)

SANDOSTATIN LAR DEPOT 1 PA

SIGNIFOR 1 PA, QL (60 PER 30 DAYS)

SIGNIFOR LAR 1 PA, QL (1 PER 28 DAYS)


102


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

SOMATULINE DEPOT (60 MG/0.2 ML, 90MG/0.3 ML)

1 PA

SOMATULINE DEPOT 120 MG/0.5 ML 1 PA - FOR NEW STARTS ONLY

SOMAVERT 1 PA

SUPPRELIN LA 1 PA, QL (1 PER 365 OVER TIME)

SYNAREL 1

TRELSTAR 11.25 MG VIAL 1 PA - FOR NEW STARTS ONLY,QL (1 PER 84 OVER TIME)



TRIPTODUR 1 PA, QL (1 PER 168 OVER TIME)

ZOLADEX 3.6 MG IMPLANT SYRN 1 QL (1 PER 28 DAYS)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole (5 mg tablet, 10 mg tablet) 1

propylthiouracil 50 mg tablet 1

Immunological Agents

Angioedema AgentsBERINERT (500 UNIT VIAL, 500 UNIT KIT) 1 PA

FIRAZYR 1 PA

icatibant 1 PA

RUCONEST 1 PA

Immune SuppressantsAZASAN 1 PA - Part B vs D Determination

azathioprine 50 mg tablet 1 PA - Part B vs D Determination

azathioprine sodium 1


103


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

BENLYSTA (120 MG VIAL, 200 MG/MLSYRINGE, 200 MG/ML AUTOINJECT, 400MG VIAL)

1 PA

CIMZIA (2X200 MG/ML SYRINGE KIT,2X200 MG/ML(X3)START KT, 200 MG VIALKIT)

1 PA

cyclosporine 250 mg/5 ml ampul 1

cyclosporine (25 mg capsule, 100 mgcapsule)


cyclosporine modified (25 mg, 50 mg, 100mg, 100mg/ml)


ENBREL (25 MG/0.5 ML VIAL, 25 MG KIT,25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE)

1 PA

ENBREL MINI 1

ENBREL SURECLICK 1 PA

everolimus (0.25 mg tablet, 0.5 mg tablet,0.75 mg tablet)


gengraf (25 mg capsule, 100 mg/ml solution,100 mg capsule)


HUMIRA 1 PA

HUMIRA PEDIATRIC CROHN'S 1 PA

HUMIRA PEN 1 PA

HUMIRA PEN CROHN'S-UC-HS 1 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS 1 PA

HUMIRA(CF) 1 PA

HUMIRA(CF) PEDIATRIC CROHN'S 1 PA

HUMIRA(CF) PEN 40 MG/0.4 ML 1 PA

HUMIRA(CF) PEN CROHN'S-UC-HS 1 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS 1 PA

INFLECTRA 1 PA

KINERET 1 PA


104


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

methotrexate (1 gm vial, 2.5 mg tablet, 50mg/2 ml vial, 250 mg/10 ml vial)

1

methotrexate sodium 1

mycophenolate mofetil (200 mg/ml susp, 250mg capsule, 500 mg tablet)


mycophenolate 500 mg vial 1

mycophenolic acid 1 PA - Part B vs D Determination

NULOJIX 1 PA - FOR NEW STARTS ONLY

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5MG/0.7 ML SYRINGE, 125 MG/MLSYRINGE, 250 MG VIAL)

1 PA

ORENCIA CLICKJECT 1 PA, QL (4 PER 28 DAYS)

PROGRAF 5 MG/ML AMPULE 1

PROGRAF (0.2 MG GRANULE PACKET, 1MG GRANULE PACKET)


RASUVO 10 MG/0.2 ML AUTOINJ 1 PA, QL (0.8 PER 28 DAYS)

RASUVO 12.5 MG/0.25 ML AUTOINJ 1 PA, QL (1 PER 28 DAYS)


RASUVO 17.5 MG/0.35 ML AUTOINJ 1 PA, QL (1.4 PER 28 DAYS)



RASUVO 25 MG/0.5 ML AUTOINJ 1 PA, QL (2 PER 28 DAYS)



REMICADE 1 PA

RENFLEXIS 1 PA

SANDIMMUNE 100 MG/ML SOLN 1 PA - Part B vs D Determination

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/mlsolution, 2 mg tablet)


SKYRIZI (2 SYRINGES) KIT 1 PA

tacrolimus (0.5 mg capsule, 1 mg capsule, 5mg capsule)



105


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TREXALL 1

XATMEP 1

ZORTRESS 1 PA - Part B vs D Determination

Immunizing Agents, PassiveATGAM 1

BIVIGAM 1 PA

CARIMUNE NF NANOFILTERED 1 PA

CUTAQUIG 1 PA

CUVITRU (1 GRAM/5 ML VIAL, 2 GRAM/10ML VIAL, 4 GRAM/20 ML VIAL, 8 GRAM/ 40ML VIAL)

1 PA

FLEBOGAMMA DIF 1 PA

GAMASTAN 1 PA

GAMASTAN S-D 1 PA

GAMMAGARD LIQUID 1 PA

GAMMAGARD S-D 1 PA

GAMMAKED 1 PA

GAMMAPLEX 1 PA

GAMUNEX-C 1 PA

HEPAGAM B 1

HYPERHEP B S-D (NEONATAL SYRIN.,SYRINGE, VIAL)

1

HYPERRAB 1

HYPERRHO S-D 1

MICRHOGAM ULTRA-FILTERED PLUS 1

NABI-HB 1

OCTAGAM 1 PA

PANZYGA 1 PA

PRIVIGEN 1 PA


106


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

RHOGAM ULTRA-FILTERED PLUS 1

RHOPHYLAC 1

SYNAGIS 1 PA

ImmunomodulatorsACTEMRA (80 MG/4 ML VIAL, 200 MG/10ML VIAL, 400 MG/20 ML VIAL)

1 PA

ACTEMRA ACTPEN 1 PA

ACTIMMUNE 1 PA - FOR NEW STARTS ONLY

ARCALYST 1 PA

ENSPRYNG 1 PA

ENTYVIO 1 PA

ILARIS 1 PA, QL (2 PER 28 DAYS)

KEVZARA (150 MG/1.14 ML PEN INJ, 150MG/1.14 ML SYRINGE, 200 MG/1.14 MLPEN INJ, 200 MG/1.14 ML SYRINGE)

1 PA

leflunomide 1

LEMTRADA 1 PA

OLUMIANT 1 PA

OTEZLA 30 MG TABLET 1 PA

RIDAURA 1

RINVOQ 1 PA

SIMPONI ARIA 1 PA

SYLVANT 1 PA - FOR NEW STARTS ONLY

XELJANZ 1 PA

XELJANZ XR 1 PA

VaccinesACTHIB 1

ADACEL TDAP (SYRINGE, VIAL) 1

BCG VACCINE (TICE STRAIN) 1


107


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

BEXSERO 1

BOOSTRIX TDAP (SYRINGE, VIAL) 1

DAPTACEL DTAP 1

DIPHTHERIA-TETANUS TOXOIDS-PED 1

ENGERIX-B 20 MCG/ML SYRN 1 PA - Part B vs D Determination

ENGERIX-B PEDIATRIC-ADOLESCENT 1 PA - Part B vs D Determination

GARDASIL 9 (9 VIAL, 9 SYRINGE) 1

HAVRIX (720 UNITS/0.5 ML VIAL, 720UNIT/0.5 ML SYRINGE, 1,440 UNITS/MLVIAL, 1,440 UNITS/ML SYRINGE)

1

HIBERIX 1

IMOVAX RABIES VACCINE 1 PA - Part B vs D Determination

INFANRIX DTAP VIAL 1

IPOL 1

IXIARO 1

KINRIX (TIP-LOK SYRINGE, VIAL) 1

M-M-R II VACCINE 1

MENACTRA 1

MENQUADFI 1

MENVEO A-C-Y-W-135-DIP 1

PEDIARIX 1

PEDVAXHIB 1

PENTACEL 1

PROQUAD 1

QUADRACEL DTAP-IPV 1

RABAVERT 1 PA - Part B vs D Determination

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10MCG/ML VIAL, 10 MCG/ML SYR, 40MCG/ML VIAL)


ROTARIX 1


108


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ROTATEQ 1

SHINGRIX 1

TDVAX 1

TENIVAC SYRINGE 1

TRUMENBA 1

TWINRIX 1

TYPHIM VI (25 MCG/0.5 ML SYRNG, 25MCG/0.5 ML AL)

1

VAQTA (25 UNITS/0.5 ML SYRINGE, 25UNITS/0.5 ML VIAL, 50 UNITS/MLSYRINGE, 50 UNITS/ML VIAL)

1

VARIVAX VACCINE 1

VARIZIG 1 PA

YF-VAX 1

ZOSTAVAX 1

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 1

balsalazide disodium 1

mesalamine (dr 1.2 gm tablet, 4 gm/60 mlenema, 800 mg dr tablet, 1,000 mg supp)

1

mesalamine er 1

Glucocorticoidsbudesonide ec 1

budesonide er 1

colocort 1

hydrocortisone 100 mg/60 ml 1

ORTIKOS 1


109


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Sulfonamidessulfasalazine 500 mg tablet 1

sulfasalazine dr 1

Metabolic Bone Disease Agents

alendronate sodium (sod 70 mg/75 ml,sodium 5 mg tablet, sodium 10 mg tab,sodium 35 mg tab, sodium 40 mg tab)

1

alendronate sodium 70 mg tab 1 QL (4 PER 28 DAYS)

calcitonin-salmon 1 QL (3.7 PER 30 DAYS)

calcitriol (0.25 mcg capsule, 0.5 mcg capsule,1 mcg/ml solution, 1 mcg/ml ampul)

1

cinacalcet hcl 1

doxercalciferol (0.5 mcg cap, 1 mcg capsule,2.5 mcg cap)

1

EVENITY (2 SYRINGES) 1 PA, QL (2.34 PER 28 DAYS)

FORTEO 1 PA

ibandronate sodium 150 mg tab 1 QL (1 PER 28 DAYS)

MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2ML VIAL)

1

NATPARA 1 PA, QL (2 PER 28 DAYS)

pamidronate disodium (disod 30 mg vial, 30mg/10 ml vial, 60 mg/10 ml vial, 90 mg/10 mlvial, disod 90 mg vial)

1

paricalcitol (1 mcg capsule, 2 mcg/ml vial, 2mcg capsule, 4 mcg capsule, 5 mcg/ml vial,10 mcg/2 ml vial)

1

PROLIA 1 QL (2 PER 365 OVER TIME)

TERIPARATIDE 1 PA

TYMLOS 1 PA

XGEVA 1 PA

zoledronic acid (4 mg/5 ml vial, 4 mg/100 ml,5 mg/100 ml)

1


110


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Miscellaneous Therapeutic Agents

afirmelle 1

alcohol pads 1

AMINOSYN II 10% IV SOLUTION 1 PA - Part B vs D Determination

AMINOSYN-PF 1 PA - Part B vs D Determination

aurovela 1

aurovela fe 1-20 tablet 1

chateal eq 1

CINRYZE 1 PA

deferoxamine mesylate 1

DOJOLVI 1 PA

ENDARI 1 PA

FIRDAPSE 1 PA, QL (240 PER 30 DAYS)

FREAMINE HBC 1 PA - Part B vs D Determination

FREAMINE III 10% IV SOLN. 1

gauze pads 1

HAEGARDA 1 PA

HEPATAMINE 1 PA - Part B vs D Determination

insulin pen needles 1 QL (200 PER 30 DAYS)

insulin syringe 1 QL (200 PER 30 DAYS)

INTRALIPID 20% IV FAT EMUL 1 PA - Part B vs D Determination

KALBITOR 1 PA

KEVEYIS 1 PA, QL (120 PER 30 DAYS)

lactated ringers irrigation 1

levocarnitine (1 g/10 ml soln, 330 mg tablet) 1

lillow 1

lo-zumandimine 1


111


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

methergine 1

methylergonovine 0.2 mg tablet 1

MYALEPT 1 PA

NEPHRAMINE 1 PA - Part B vs D Determination

NUTRILIPID 1 PA - Part B vs D Determination

PHYSIOLYTE 1

PHYSIOSOL 1

PREMASOL 1 PA - Part B vs D Determination

PROSOL 1 PA - Part B vs D Determination

ringers irrigation 1

RUZURGI 1 PA, QL (300 PER 30 DAYS)

simliya 1

simpesse 1 QL (91 PER 91 DAYS)

sodium chloride (irrig., prcss sol) 1

sodium phenylacet-sod benzoate 1

SPINRAZA 1 PA

TIS-U-SOL PENTALYTE 1

TRAVASOL 1 PA - Part B vs D Determination

tri femynor 1

tri-lo-mili 1

TROPHAMINE 10% IV SOLUTION 1 PA - Part B vs D Determination

v-go 20 1

v-go 30 1

v-go 40 1

vgo 20 1

vgo 30 1

vgo 40 1

VISTOGARD 1


112


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

sterile water for irrigation 1

Ophthalmic Agents

Ophthalmic Agents, Otheratropine 1% eye drops 1

bacitracin-polymyxin 1

cyclopentolate hcl (0.5% eye drops, 1% eyedrops, 1% eye drop, hcl 2% drops)

1

CYSTARAN 1 PA, QL (60 PER 28 OVER TIME)

EYLEA 2 MG/0.05 ML VIAL 1 PA

LACRISERT 1

neo-polycin 1

neomycin-bacitracin-polymyxin 1

neomycin-polymyxin-gramicidin 1

OXERVATE 1 PA, QL (56 PER 28 DAYS)

polycin 1

polymyxin b sul-trimethoprim 1

proparacaine 0.5% eye drops 1

RESTASIS 1

RESTASIS MULTIDOSE 1

RHOPRESSA 1 ST, QL (2.5 PER 25 DAYS)

XIIDRA 1 QL (60 PER 30 DAYS)

Ophthalmic Anti-allergy Agentsazelastine hcl 0.05% drops 1

BEPREVE 1

cromolyn 4% eye drops 1

epinastine hcl 1

olopatadine hcl (0.1% drops, 0.2% drop) 1


113


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Ophthalmic Anti-inflammatoriesALREX 1

BLEPHAMIDE 1

BLEPHAMIDE S.O.P. 1

bromfenac sodium 0.09% eye drp 1

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1

DUREZOL 1

FLAREX 1

flurbiprofen sodium 1

FML FORTE 1

INVELTYS 1

ketorolac tromethamine (0.4% solution, 0.5%solution)

1

LOTEMAX 0.5% OPHTHALMIC GEL 1 QL (20 PER 365 OVER TIME)

LOTEMAX 0.5% EYE OINTMENT 1 QL (14 PER 365 OVER TIME)

LOTEMAX SM 1 QL (20 PER 365 OVER TIME)

loteprednol etabonate 1

neo-polycin hc 1

neomycin-bacitracin-poly-hc 1

neomycin-polymyxin-dexameth (neomyc-polym-dexamet ointm, neomyc-polym-dexameth drop)

1

neomycin-poly-hc eye drops 1

PRED-G (1% DROPS, S.O.P. OINTMENT) 1

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1

PROLENSA 1 QL (12 PER 365 OVER TIME)

sulfacetamide-prednisolone 1


114


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TOBRADEX EYE OINTMENT 1

TOBRADEX ST 1

tobramycin-dexamethasone 1

TRIESENCE 1

ZYLET 1

Ophthalmic Antiglaucoma Agentsacetazolamide (125 mg tablet, 250 mg tablet) 1

acetazolamide er 1

ALPHAGAN P 0.1% DROPS 1

apraclonidine hcl 1

AZOPT 1

betaxolol hcl 0.5% eye drop 1

BETIMOL 1

brimonidine tartrate (tartrate 0.15% drp, 0.2%eye drop)

1

carteolol hcl 1

dorzolamide hcl 1

dorzolamide-timolol (2%-0.5%, eye drops) 1

IOPIDINE 1% EYE DROPS 1

levobunolol hcl 1

methazolamide (25 mg tablet, 50 mg tablet) 1

PHOSPHOLINE IODIDE 1

pilocarpine hcl (1% drops, 2% drops, 4%drops)

1

ROCKLATAN 1 QL (2.5 PER 25 DAYS)

SIMBRINZA 1

timolol maleate (0.25% gfs gel-solution,0.25% gel-solution, maleate 0.25% eye drop,0.5% eye drop, 0.5% gfs gel-solution, 0.5%gel-solution, maleate 0.5% eye drops)

1


115


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost 0.03% eye drops 1 QL (5 PER 30 DAYS)

COMBIGAN 1

latanoprost 0.005% eye drops 1

LUMIGAN 0.01% EYE DROPS 1 QL (2.5 PER 25 DAYS)

VYZULTA 1 QL (5 PER 25 DAYS)

Otic Agents

acetic acid 2% ear solution 1

CIPRODEX 1

ciprofloxacin-dexamethasone 1

flac otic oil 1

fluocinolone acetonide oil 1

hydrocortisone-acetic acid 1

neomycin-polymyxin-hc ear susp 1

neomycin-polymyxin-hydrocort 1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsASMANEX (110 MCG #7, 220 MCG #14) 1 QL (1 PER 30 DAYS)

ASMANEX (TWISTHALER 110 MCG #30,TWISTHALER 220 MCG #60, TWISTHALER220 MCG #30, TWISTHALR 220 MCG #120)


ASMANEX HFA (HFA 100 MCG INHALER,HFA 200 MCG INHALER)


ASMANEX HFA 50 MCG INHALER 1 QL (13 PER 30 DAYS)

azelastine-fluticasone 1 QL (23 PER 30 DAYS)

BREO ELLIPTA 1 QL (60 PER 30 DAYS)

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 mlsusp, 1 mg/2 ml inh susp)

1 PA - Part B vs D Determination,QL (120 PER 30 DAYS)


116


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

DULERA 50 MCG-5 MCG INHALER 1 QL (13 PER 30 DAYS)

FLOVENT 250 MCG DISKUS 1 QL (240 PER 30 DAYS)

FLOVENT DISKUS (50 MCG, 100 MCG) 1 QL (60 PER 30 DAYS)

FLOVENT HFA (HFA 110 MCG INHALER,HFA 220 MCG INHALER)


FLOVENT HFA 44 MCG INHALER 1 QL (21.2 PER 30 DAYS)

flunisolide 0.025% spray 1 QL (50 PER 30 DAYS)

fluticasone prop 50 mcg spray 1

mometasone furoate 50 mcg spry 1 QL (34 PER 30 DAYS)

NUCALA 100 MG VIAL 1 PA, QL (3 PER 28 DAYS)

QVAR REDIHALER 1 QL (21.2 PER 30 DAYS)

Antihistaminesazelastine hcl (0.1% (137 mcg) spry, 0.15%nasal spray)


cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 1

cyproheptadine 4 mg tablet 1 PA

desloratadine 5 mg tablet 1

dexchlorpheniramine maleate (dexchlorphen2 mg/5 ml syrup, dexchlorpheniramine 2 mg/5ml)

1 PA

diphenhydramine hcl (50 mg/ml syrng, 50mg/ml vial, 50 mg/ml crpjt)

1

DYMISTA 1 QL (23 PER 30 DAYS)

hydroxyzine hcl (hcl 10 mg tablet, 10 mg/5 mlsyrup, 10 mg/5 ml soln, 25 mg/ml vial, hcl 25mg tablet, 50 mg/ml vial, 50 mg/25 ml syrup,hcl 50 mg tablet, 100 mg/2 ml vial, 500 mg/10ml vial)

1 PA

hydroxyzine pamoate (25 mg cap, 50 mg cap,100 mg cap)

1 PA

levocetirizine 5 mg tablet 1

olopatadine 665 mcg nasal spry 1 QL (30.5 PER 30 DAYS)


117


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

Antileukotrienesmontelukast sodium (4 mg granules, 4 mg tabchew, 5 mg tab chew, 10 mg tablet)

1

zafirlukast 1

zileuton er 1 ST

ZYFLO 1 ST

Bronchodilators, AnticholinergicATROVENT HFA 1 QL (25.8 PER 30 DAYS)

COMBIVENT RESPIMAT 1 QL (8 PER 30 DAYS)

ipratropium br 0.02% soln 1 PA - Part B vs D Determination,QL (312.5 PER 30 DAYS)

ipratropium bromide (0.03% spray, 0.06%spray)

1

ipratropium-albuterol 1 PA - Part B vs D Determination,QL (540 PER 30 DAYS)

LONHALA MAGNAIR REFILL 1 QL (60 PER 30 DAYS)

LONHALA MAGNAIR STARTER 1 QL (60 PER 30 DAYS)

SPIRIVA 1 QL (30 PER 30 DAYS)

SPIRIVA RESPIMAT 1 QL (8 PER 28 DAYS)

YUPELRI 1 PA - Part B vs D Determination,QL (90 PER 30 DAYS)

Bronchodilators, Sympathomimeticalbuterol hfa 90 mcg inhaler 1 QL (13.4 PER 30 DAYS)

albuterol hfa 90 mcg inhaler (generic forproair hfa)


albuterol sulfate (2.5 mg/0.5 ml sol, 5 mg/mlsolution, 15 mg/3 ml solution, 20 mg/4 mlsolution, 100 mg/20 ml soln)


albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate2 mg tab, sulfate 4 mg tab)

1

albuterol sul 2.5 mg/3 ml soln 1 PA - Part B vs D Determination,QL (525 PER 30 DAYS)


118


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

albuterol sulfate (0.63 mg/3 ml sol, 1.25 mg/3ml sol)


albuterol sulfate hfa 1 QL (48 PER 30 DAYS)

epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject)

1 ST

EPIPEN 2-PAK 1

EPIPEN JR 2-PAK 1

isoproterenol hcl (0.2 mg/ml ampul, 0.2 mg/mlvial, 1 mg/5 ml vial, 1 mg/5 ml ampul)

1

levalbuterol concentrate 1 PA - Part B vs D Determination,QL (90 PER 30 DAYS)

levalbuterol 1.25 mg/3 ml sol 1 PA - Part B vs D Determination,QL (270 PER 30 DAYS)

levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3ml sol)


levalbuterol tartrate hfa 1 QL (30 PER 30 DAYS)

metaproterenol sulfate (10 mg tablet, 10 mg/5ml syr, 20 mg tablet)

1

PERFOROMIST 1 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

PROAIR DIGIHALER 1 QL (2 PER 30 DAYS)

PROAIR HFA 1 QL (17 PER 30 DAYS)

PROAIR RESPICLICK 1 QL (2 PER 30 DAYS)

PROVENTIL HFA 1 QL (13.4 PER 30 DAYS)

SEREVENT DISKUS 1 QL (60 PER 30 DAYS)

terbutaline sulfate (sulf 1 mg/ml vial, sulfate2.5 mg tab, sulfate 5 mg tab)

1

VENTOLIN HFA 1 QL (48 PER 30 DAYS)

XOPENEX (0.31 MG/3 ML SOLUTION, 0.63MG/3 ML SOLUTION)


XOPENEX 1.25 MG/3 ML SOLUTION 1 PA - Part B vs D Determination,QL (270 PER 30 DAYS)

XOPENEX CONCENTRATE 1 PA - Part B vs D Determination,QL (90 PER 30 DAYS)


119


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

XOPENEX HFA 1 QL (30 PER 30 DAYS)

Cystic Fibrosis AgentsBETHKIS 1 PA - Part B vs D Determination

CAYSTON 1 PA

KALYDECO (25 MG GRANULES PACKET,50 MG GRANULES PACKET, 75 MGGRANULES PACKET, 150 MG TABLET)

1 PA

ORKAMBI (100-125 MG GRANULE PKT,150-188 MG GRANULE PKT)


ORKAMBI (100 MG TABLET, 200 MGTABLET)


PULMOZYME 1 PA

SYMDEKO 100/150 MG-150 MG TABS 1 PA, QL (56 PER 28 DAYS)

SYMDEKO 50/75 MG-75 MG TABLETS 1 PA, QL (56 PER 28 DAYS)

TOBI PODHALER 1 QL (224 PER 56 OVER TIME)

tobramycin 300 mg/5 ml ampule 1 PA - Part B vs D Determination

TRIKAFTA 1 PA, QL (84 PER 28 DAYS)

Mast Cell Stabilizerscromolyn 20 mg/2 ml neb soln 1 PA - Part B vs D Determination

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline (250 mg/10 ml vl, 500 mg/20ml vl)

1

DALIRESP 1 PA

theophylline (er 400 mg tablet, er 600 mgtablet)

1

theophylline anhydrous (er 100 mg tablet, er200 mg tablet, er 300 mg tab, er 450 mg tab)

1

theophylline 400 mg/500 ml d5w 1

Pulmonary AntihypertensivesADEMPAS 1 PA, QL (90 PER 30 DAYS)


120


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

alyq 1 PA, QL (60 PER 30 DAYS)

ambrisentan 1 PA, QL (30 PER 30 DAYS)

bosentan 1 PA, QL (60 PER 30 DAYS)

epoprostenol sodium 1 PA

LETAIRIS 1 PA, QL (30 PER 30 DAYS)

OPSUMIT 1 PA, QL (30 PER 30 DAYS)

ORENITRAM ER 1 PA

REMODULIN 1 PA

sildenafil 1 PA, QL (90 PER 30 DAYS)

sildenafil 20 mg tablet 1 PA, QL (90 PER 30 DAYS)

sildenafil citrate (10 mg/ml oral susp, 10mg/12.5 ml vial)

1 PA

tadalafil 20 mg tablet 1 PA, QL (60 PER 30 DAYS)

treprostinil 1 PA

UPTRAVI 200-800 TITRATION PACK 1 PA, QL (400 PER 365 OVERTIME)

UPTRAVI (200 MCG TABLET, 400 MCGTABLET, 600 MCG TABLET, 800 MCGTABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCGTABLET)


VELETRI 1 PA

VENTAVIS 1 PA, QL (270 PER 30 DAYS)

Pulmonary Fibrosis AgentsESBRIET (267 MG TABLET, 801 MGTABLET)

1 PA

Respiratory Tract Agents, Otheracetylcysteine (10% vial, 20% vial) 1 PA - Part B vs D Determination

ADVAIR DISKUS 1 QL (60 PER 30 DAYS)

ADVAIR HFA 1 QL (24 PER 30 DAYS)

ANORO ELLIPTA 1 QL (60 PER 30 DAYS)


121


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ARALAST NP 1 PA

DULERA (100 MCG INHALER, 200 MCGINHALER)

1 QL (17.6 PER 30 DAYS)

DUPIXENT 200 MG/1.14 ML SYRING 1 PA, QL (4.56 PER 28 DAYS)

ESBRIET 267 MG CAPSULE 1 PA

FASENRA 1 PA

FASENRA PEN 1 PA

fluticasone-salmeterol (100-50, 250-50, 500-50)


GLASSIA 1 PA

NUCALA (100 MG/ML AUTO-INJECTOR,100 MG/ML SYRINGE)


OFEV 1 PA

PROLASTIN C 1 PA

ribavirin 6 gm inhalation vial 1

STIOLTO RESPIMAT 1 QL (24 PER 30 DAYS)

SYMBICORT 160-4.5 MCG INHALER 1 QL (12 PER 30 DAYS)

SYMBICORT 80-4.5 MCG INHALER 1 QL (13.8 PER 30 DAYS)

TRELEGY ELLIPTA 100-62.5-25 1 QL (60 PER 30 DAYS)

wixela inhub 1 QL (60 PER 30 DAYS)

XOLAIR (75 MG/0.5 ML SYRINGE, 150MG/ML SYRINGE, 150 MG VIAL)

1 PA

ZEMAIRA 1 PA

Skeletal Muscle Relaxants

carisoprodol (250 mg tablet, 350 mg tablet) 1 PA

chlorzoxazone (250 mg tablet, 500 mg tablet) 1 PA

cyclobenzaprine hcl (5 mg tablet, 10 mgtablet)

1 PA

methocarbamol (500 mg tablet, 750 mgtablet)

1 PA


122


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

succinylcholine 200 mg/10 ml 1

Sleep Disorder Agents

GABA Receptor Modulatorszaleplon 10 mg capsule 1 QL (60 PER 30 DAYS)

zaleplon 5 mg capsule 1 QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1 QL (30 PER 30 DAYS)

zolpidem tartrate er 1 QL (30 PER 30 DAYS)

Sleep Disorders, OtherBELSOMRA 1 QL (30 PER 30 DAYS)

doxepin hcl (3 mg tablet, 6 mg tablet) 1 QL (30 PER 30 DAYS)

HETLIOZ 1 PA, QL (30 PER 30 DAYS)

modafinil 1 PA, QL (30 PER 30 DAYS)

pentobarbital sodium (1,000 mg/20 ml, 2,500mg/50 ml)


ramelteon 1 QL (30 PER 30 DAYS)

SILENOR 1 QL (30 PER 30 DAYS)

WAKIX 1 PA, QL (60 PER 30 DAYS)

XYREM 1 PA, QL (540 PER 30 DAYS)

Uncategorized

Unclassifiedsodium chloride 0.9% ampule 1


123

Alphabetical Listing

Aabacavir 52abacavir-lamivudine 52abacavir-lamivudine-zidovudine 52ABELCET 31ABILIFY MAINTENA 49ABILIFY MYCITE 49abiraterone acetate 36ABRAXANE 38ABSTRAL 11acamprosate calcium 14acarbose 58acebutolol hcl 67acetaminophen-codeine 11acetazolamide 115acetazolamide er 115acetazolamide sodium 70acetic acid 89,116acetylcysteine 121acitretin 77ACTEMRA 107ACTEMRA ACTPEN 107ACTHAR 92ACTHIB 107ACTIMMUNE 107acyclovir 56acyclovir sodium 56ADACEL TDAP 107ADAGEN 87adapalene 77adapalene-benzoyl peroxide 77adefovir dipivoxil 54ADEMPAS 120adriamycin 38adrucil 37ADVAIR DISKUS 121ADVAIR HFA 121AFINITOR 42AFINITOR DISPERZ 42afirmelle 111

AIMOVIG AUTOINJECTOR 33AKYNZEO 29ala-cort 89albendazole 45albuterol hfa 90 mcg inhaler 118albuterol hfa 90 mcg inhaler (generic forproair hfa) 118albuterol sulfate 118,119albuterol sulfate hfa 119alclometasone dipropionate 89alcohol pads 111ALDACTAZIDE 71ALDURAZYME 87ALECENSA 42alendronate sodium 110alfuzosin hcl er 89ALIMTA 37ALINIA 46ALIQOPA 42aliskiren 69allopurinol 33allopurinol sodium 33alosetron hcl 86ALPHAGAN P 115alprazolam 56alprazolam er 56,57alprazolam xr 57ALREX 114altavera 94ALUNBRIG 42alyacen 94alyq 121amabelz 94amantadine 55AMBISOME 31ambrisentan 121amcinonide 89amethia 94amethia lo 94amethyst 94amikacin sulfate 15

124

amiloride hcl 71amiloride-hydrochlorothiazide 71aminocaproic acid 64aminophylline 120AMINOSYN II 111AMINOSYN-PF 111amiodarone hcl 66AMITIZA 86amitriptyline hcl 29amlodipine besylate 68amlodipine besylate-benazepril 68amlodipine-atorvastatin 68amlodipine-valsartan 68ammonium lactate 77amnesteem 78amoxapine 29amoxicillin 19amoxicillin-clavulanate pot er 19amoxicillin-clavulanate potass 19amphotericin b 31ampicillin sodium 19ampicillin trihydrate 19ampicillin-sulbactam 19AMPYRA 76ANADROL-50 93anagrelide hcl 63anastrozole 41ANDRODERM 93ANORO ELLIPTA 121ANZEMET 30apexicon e 89APOKYN 47apraclonidine hcl 115aprepitant 30apri 94APRISO 109APTIOM 22APTIVUS 53ARALAST NP 122aranelle 94ARANESP 63

ARCALYST 107argatroban 61argatroban-0.9% nacl 61argatroban-sodium chloride 61aripiprazole 49aripiprazole odt 49ARISTADA 49ARISTADA INITIO 49ARRANON 37arsenic trioxide 38ashlyna 94ASMANEX 116ASMANEX HFA 116aspirin-dipyridamole er 64atazanavir sulfate 53atenolol 67atenolol-chlorthalidone 67ATGAM 106atomoxetine hcl 74atorvastatin calcium 72atovaquone 46atovaquone-proguanil hcl 46ATRIPLA 52atropine sulfate 69,113ATROVENT HFA 118AUBAGIO 76aubra 94aubra eq 94AUGMENTIN 19aurovela 111aurovela 24 fe 94aurovela fe 111AURYXIA 84AUSTEDO 75AVASTIN 44aviane 94AVITA 78AVONEX 76AVONEX PEN 76AVYCAZ 17AYVAKIT 42

125

azacitidine 38AZACTAM 19AZASAN 103azathioprine 103azathioprine sodium 103azelaic acid 78azelastine hcl 113,117azelastine-fluticasone 116azithromycin 20AZOPT 115aztreonam 19azurette 94

Bbaciim 16bacitracin 16bacitracin-polymyxin 113baclofen 51BACTROBAN NASAL 16BAFIERTAM 76balsalazide disodium 109BALVERSA 41balziva 94BANZEL 25BAQSIMI 60BARACLUDE 54BAVENCIO 44BAXDELA 21BCG (TICE STRAIN) 38BCG VACCINE (TICE STRAIN) 107bekyree 94BELEODAQ 38BELSOMRA 123benazepril hcl 65benazepril-hydrochlorothiazide 65BENDEKA 35BENLYSTA 104benznidazole 45benztropine mesylate 47BEPREVE 113BERINERT 103

beser 89BESIVANCE 21BESPONSA 44betamethasone diprop augmented 90betamethasone dipropionate 90betamethasone sod phos-acetate 90betamethasone valerate 90BETASERON 76betaxolol hcl 67,115bethanechol chloride 89BETHKIS 120BETIMOL 115bexarotene 45BEXSERO 108bicalutamide 36BICILLIN C-R 19BICILLIN L-A 19BICNU 35BIKTARVY 51bimatoprost 116bisoprolol fumarate 67bisoprolol-hydrochlorothiazide 67BIVIGAM 106bleomycin sulfate 39BLEPHAMIDE 114BLEPHAMIDE S.O.P. 114BLINCYTO 44blisovi 24 fe 94blisovi fe 94BOOSTRIX TDAP 108bortezomib 39bosentan 121BOSULIF 42BOTOX 51BRAFTOVI 39BREO ELLIPTA 116BREVIBLOC 67briellyn 94BRILINTA 64brimonidine tartrate 115BRIVIACT 22,23

126

bromfenac sodium 114bromocriptine mesylate 47BRUKINSA 42budesonide 116budesonide ec 109budesonide er 109bumetanide 70buprenorphine hcl 14buprenorphine-naloxone 14bupropion hcl 27bupropion hcl sr 14,27bupropion xl 27buspirone hcl 56busulfan 35butorphanol tartrate 11BYNFEZIA 101BYSTOLIC 67

Ccabergoline 101CABLIVI 64CABOMETYX 42caffeine citrate 75calcipotriene 78calcitonin-salmon 110calcitrene 78calcitriol 110calcium acetate 84calcium gluconate 80CALQUENCE 42camila 100camrese 95camrese lo 95candesartan cilexetil 65candesartan-hydrochlorothiazid 65CAPASTAT SULFATE 35CAPLYTA 49CAPRELSA 42captopril 65captopril-hydrochlorothiazide 65CARBAGLU 80

carbamazepine 26carbamazepine er 26carbidopa 47carbidopa-levodopa 47carbidopa-levodopa er 47carboplatin 35CARIMUNE NF NANOFILTERED 106carisoprodol 122carmustine 35carteolol hcl 115cartia xt 68carvedilol 67carvedilol er 67caspofungin acetate 31CAYSTON 120caziant 95cefaclor 17cefaclor er 18cefadroxil 18cefazolin sodium 18cefazolin sodium-dextrose 18cefdinir 18cefepime hcl 18cefixime 18cefotaxime sodium 18cefotetan 18cefoxitin 18cefpodoxime proxetil 18cefprozil 18ceftazidime 18ceftriaxone 18cefuroxime 18cefuroxime sodium 18celecoxib 9CELONTIN 23cephalexin 18CERDELGA 87CEREZYME 87cetirizine hcl 117CHANTIX 14chateal 95

127

chateal eq 111CHENODAL 85chloramphenicol sod succinate 16chlordiazepoxide hcl 57chlordiazepoxide-amitriptyline 29chlorhexidine gluconate 77chloroprocaine hcl 13chloroquine phosphate 46chlorothiazide 71chlorothiazide sodium 71chlorpromazine hcl 48chlorthalidone 71chlorzoxazone 122CHOLBAM 85cholestyramine 72cholestyramine light 72CHORIONIC GONADOTROPIN 92ciclodan 31ciclopirox 31cidofovir 54cilostazol 64CIMDUO 52cimetidine 85CIMZIA 104cinacalcet hcl 110CINRYZE 111CINVANTI 30CIPRODEX 116ciprofloxacin 21ciprofloxacin er 21ciprofloxacin hcl 21ciprofloxacin-d5w 21ciprofloxacin-dexamethasone 116cisplatin 35citalopram hbr 27cladribine 37claravis 78clarithromycin 20clarithromycin er 20CLENPIQ 86CLEOCIN 16

CLIMARA PRO 95clindacin etz 16clindacin p 16clindamycin (pediatric) 16clindamycin hcl 16clindamycin pediatric 16clindamycin phos-benzoyl perox 78clindamycin phos-tretinoin 78clindamycin phosphate 16clindamycin phosphate-d5w 16clindamycin-0.9% nacl 16clindamycin-benzoyl peroxide 78CLINIMIX 80CLINIMIX E 80clobazam 24clobetasol emollient 90clobetasol emulsion 90clobetasol propionate 90clocortolone pivalate 90clodan 90clofarabine 37clomipramine hcl 29clonazepam 24clonidine 64clonidine hcl 64,75clonidine hcl er 74clopidogrel 64clorazepate dipotassium 57clotrimazole 31clotrimazole-betamethasone 31clovique 83clozapine 50clozapine odt 50,51COARTEM 46codeine sulfate 11colchicine 33colesevelam hcl 72colestipol hcl 72colistimethate 16colocort 109COMBIGAN 116

128

COMBIVENT RESPIMAT 118COMETRIQ 42COMPLERA 52compro 29CONDYLOX 78constulose 86COPIKTRA 39CORDRAN 90CORLANOR 69CORTIFOAM 90cortisone acetate 90COSENTYX (2 SYRINGES) 78COSENTYX PEN 78COSENTYX PEN (2 PENS) 78COSENTYX SYRINGE 78COTELLIC 39CREON 87CRESEMBA 31CRINONE 100CRIXIVAN 53cromolyn sodium 85,113,120crotan 46cryselle 95CUTAQUIG 106CUVITRU 106CUVPOSA 84cyclafem 95cyclobenzaprine hcl 122cyclopentolate hcl 113cyclophosphamide 36cycloserine 35CYCLOSET 58cyclosporine 104cyclosporine modified 104cyproheptadine hcl 117CYRAMZA 44cyred 95cyred eq 95CYSTAGON 87CYSTARAN 113cytarabine 37

Ddacarbazine 36dactinomycin 39dalfampridine er 76DALIRESP 120danazol 93dantrolene sodium 51dapsone 35,78DAPTACEL DTAP 108daptomycin 16DARAPRIM 46darifenacin er 88DARZALEX 44dasetta 95daunorubicin hcl 39DAURISMO 39daysee 95deblitane 100decitabine 39deferasirox 83deferiprone 83deferoxamine mesylate 111DELSTRIGO 51DELTASONE 90delyla 95demeclocycline hcl 22DEMSER 69DENAVIR 56DEPEN 83DEPO-MEDROL 90DEPO-PROVERA 100DEPO-SUBQ PROVERA 104 100DESCOVY 52desipramine hcl 29desloratadine 117desmopressin acetate 93desogestr-eth estrad eth estra 95desogestrel-ethinyl estradiol 95desonide 90desoximetasone 90

129

desvenlafaxine succinate er 27dexamethasone 90dexamethasone intensol 90dexamethasone sodium phosphate 90,114dexchlorpheniramine maleate 117dexmedetomidine-0.9% nacl 56dexmethylphenidate hcl 74dexmethylphenidate hcl er 74dexrazoxane 39dextroamphetamine sulfate 74dextroamphetamine sulfate er 74dextroamphetamine-amphet er 74dextroamphetamine-amphetamine 74dextrose 10%-0.2% nacl 80dextrose 10%-0.45% nacl 80dextrose 2.5%-0.45% nacl 80dextrose 5%-0.2% nacl 80dextrose 5%-0.2% nacl-kcl 80dextrose 5%-0.225% nacl 80dextrose 5%-0.225% nacl-kcl 80dextrose 5%-0.3% nacl 80dextrose 5%-0.3% nacl-kcl 80dextrose 5%-0.33% nacl 80dextrose 5%-0.45% nacl 81dextrose 5%-0.45% nacl-kcl 81dextrose 5%-0.9% nacl 81dextrose 5%-1/2ns-kcl 81dextrose 5%-ns-kcl 81dextrose 5%-potassium chloride 81dextrose in lactated ringers 81dextrose in water 81DIASTAT 24DIASTAT ACUDIAL 24diazepam 24,57diazoxide 60diclofenac potassium 9diclofenac sodium 9,78,114diclofenac sodium er 9dicloxacillin sodium 20dicyclomine hcl 84didanosine 52

DIFICID 20diflorasone diacetate 91diflunisal 9digitek 69digox 69digoxin 69dihydroergotamine mesylate 33DILANTIN 26DILATRATE-SR 73dilt-xr 68diltiazem 12hr er 68diltiazem 24hr er 68diltiazem 24hr er (cd) 68diltiazem 24hr er (la) 68diltiazem 24hr er (xr) 68diltiazem hcl 68dimethyl fumarate 76diphenhydramine hcl 117diphenoxylate-atropine 85DIPHTHERIA-TETANUS TOXOIDS-PED 108disopyramide phosphate 66disulfiram 14DIURIL 71divalproex sodium 24divalproex sodium er 24dobutamine hcl 69dobutamine hcl-d5w 69docetaxel 39dofetilide 66DOJOLVI 111donepezil hcl 26donepezil hcl odt 26dopamine hcl 70dopamine hcl in 5% dextrose 70DORYX MPC 22dorzolamide hcl 115dorzolamide-timolol 115dotti 95DOVATO 51doxazosin mesylate 89doxepin hcl 29,78,123

130

doxercalciferol 110doxorubicin hcl 39doxorubicin hcl liposome 39doxy 100 22doxycycline hyclate 22doxycycline ir-dr 78doxycycline monohydrate 22doxylamine succ-pyridoxine hcl 29DRIZALMA SPRINKLE 27dronabinol 30droperidol 29drospirenone-eth estra-levomef 95drospirenone-ethinyl estradiol 95DROXIA 37DULERA 117,122duloxetine hcl 28DUOBRII 78DUPIXENT PEN 78DUPIXENT SYRINGE 78,122DURAMORPH 11DUREZOL 114dutasteride 89DYMISTA 117DYRENIUM 71

Eec-naproxen 9econazole nitrate 31EDURANT 52efavirenz 52EGRIFTA 93EGRIFTA SV 93ELAPRASE 87ELESTRIN 95eletriptan hbr 34elinest 95ELIQUIS 61ELLA 99ELMIRON 89EMBEDA 10EMCYT 37

EMEND 30EMFLAZA 91EMGALITY PEN 33EMGALITY SYRINGE 33emoquette 95EMPLICITI 44EMSAM 27emtricitabine 52EMTRIVA 52enalapril maleate 65enalapril-hydrochlorothiazide 66ENBREL 104ENBREL MINI 104ENBREL SURECLICK 104ENDARI 111endocet 11ENGERIX-B ADULT 108ENGERIX-B PEDIATRIC-ADOLESCENT 108enoxaparin sodium 61,62enpresse 95enskyce 95ENSPRYNG 107entacapone 47entecavir 54ENTRESTO 70ENTYVIO 107enulose 86EPANED 66EPCLUSA 55EPIDIOLEX 23epinastine hcl 113epinephrine 119EPIPEN 2-PAK 119EPIPEN JR 2-PAK 119epirubicin hcl 39epitol 26EPIVIR HBV 54eplerenone 71epoprostenol sodium 121eprosartan mesylate 65EQUETRO 57

131

ERBITUX 44ergoloid mesylates 26ERGOMAR 33ergotamine-caffeine 33ERIVEDGE 42ERLEADA 36erlotinib hcl 42errin 100ertapenem 19ERWINAZE 39ery 20ERY-TAB 20ERYPED 400 20ERYTHROCIN LACTOBIONATE 20ERYTHROCIN STEARATE 20erythromycin 21erythromycin ethylsuccinate 21erythromycin-benzoyl peroxide 78ESBRIET 121,122escitalopram oxalate 28esmolol hcl 67esmolol hcl-sodium chloride 67esomeprazole magnesium 86,87esomeprazole sodium 87estarylla 95estazolam 57estradiol 95estradiol (once weekly) 95estradiol (twice weekly) 95estradiol valerate 95estradiol-norethindrone acetat 95ESTRING 96ethacrynic acid 70ethambutol hcl 35ethosuximide 23ethynodiol-ethinyl estradiol 96etodolac 9etoposide 41EUCRISA 78EURAX 46EVENITY (2 SYRINGES) 110

everolimus 42,104EVOMELA 36EVOTAZ 53EVRYSDI 87EXELDERM 31exemestane 41EXJADE 83EXONDYS-51 87EXTAVIA 76EYLEA 113ezetimibe 72ezetimibe-simvastatin 72

FFABRAZYME 87falmina 96famciclovir 56famotidine 85FANAPT 49FARYDAK 39FASENRA 122FASENRA PEN 122FASLODEX 37fayosim 96febuxostat 33felbamate 25felodipine er 68femynor 96fenofibrate 72fenofibric acid 72fenoprofen calcium 9fentanyl 10fentanyl citrate 11FERRIPROX 83FERRIPROX (2 TIMES A DAY) 83FETZIMA 28FINACEA 78finasteride 89FINTEPLA 23FIRAZYR 103FIRDAPSE 111

132

FIRMAGON 101flac otic oil 116FLAREX 114flavoxate hcl 88FLEBOGAMMA DIF 106flecainide acetate 66FLOVENT DISKUS 117FLOVENT HFA 117floxuridine 37fluconazole 31fluconazole in saline 31fluconazole-nacl 31flucytosine 31fludarabine phosphate 39fludrocortisone acetate 91flunisolide 117fluocinolone acetonide 91fluocinolone acetonide oil 116fluocinonide 91fluocinonide-e 91fluoride 81FLUORITAB 81FLUOROPLEX 37fluorouracil 38fluoxetine dr 28fluoxetine hcl 28fluphenazine decanoate 48fluphenazine hcl 48flurandrenolide 91flurbiprofen 9flurbiprofen sodium 114flutamide 36fluticasone propionate 91,117fluticasone-salmeterol 122fluvastatin er 72fluvastatin sodium 72fluvoxamine maleate 28FML FORTE 114FOLOTYN 38fondaparinux sodium 62FORTEO 110

fosamprenavir calcium 53fosinopril sodium 66fosinopril-hydrochlorothiazide 66fosphenytoin sodium 26FRAGMIN 62FREAMINE HBC 111FREAMINE III 111frovatriptan succinate 34FULPHILA 63fulvestrant 37furosemide 71FUZEON 53fyavolv 96FYCOMPA 23

Ggabapentin 24GALAFOLD 87galantamine er 26galantamine hbr 26galantamine hydrobromide 26GAMASTAN 106GAMASTAN S-D 106GAMMAGARD LIQUID 106GAMMAGARD S-D 106GAMMAKED 106GAMMAPLEX 106GAMUNEX-C 106ganciclovir sodium 54GARDASIL 9 108gatifloxacin 21GATTEX 85gauze pads 111gavilyte-c 86gavilyte-g 86gavilyte-n 86GAVRETO 37GAZYVA 44gemcitabine hcl 38gemfibrozil 72generlac 86

133

gengraf 104GENOTROPIN 93gentak 15gentamicin sulfate 15gentamicin sulfate in ns 15GENVOYA 51GEODON 49gianvi 96GILENYA 76GILOTRIF 43GLASSIA 122glatiramer acetate 76glatopa 76GLEOSTINE 36glimepiride 58glipizide 58glipizide er 58glipizide xl 58glipizide-metformin 58GLOPERBA 33GLUCAGEN 60GLUCAGON EMERGENCY KIT 60glucose in water 81glyburide 58glyburide micronized 58glyburide-metformin hcl 58GLYCATE 84glycopyrrolate 84glydo 13GLYXAMBI 58GOCOVRI 47granisetron hcl 30GRANIX 63griseofulvin 32griseofulvin ultramicrosize 32guanfacine hcl 64guanfacine hcl er 74guanidine hcl 34GVOKE HYPOPEN 1-PACK 60GVOKE HYPOPEN 2-PACK 60GVOKE PFS 1-PACK SYRINGE 60


HHAEGARDA 111hailey 24 fe 96HALAVEN 39halcinonide 91halobetasol propionate 91HALOG 91haloperidol 48haloperidol decanoate 48haloperidol decanoate 100 48haloperidol lactate 48HARVONI 55HAVRIX 108heather 100HEPAGAM B 106heparin sodium 62heparin sodium in 0.45% nacl 62heparin sodium-0.45% nacl 62heparin sodium-0.9% nacl 62heparin sodium-d5w 62HEPATAMINE 111HERCEPTIN 44HETLIOZ 123HEXALEN 36HIBERIX 108HUMALOG 60HUMALOG JUNIOR KWIKPEN 60HUMALOG KWIKPEN U-100 60HUMALOG KWIKPEN U-200 60HUMALOG MIX 50-50 60HUMALOG MIX 50-50 KWIKPEN 60HUMALOG MIX 75-25 60HUMALOG MIX 75-25 KWIKPEN 60HUMIRA 104HUMIRA PEDIATRIC CROHN'S 104HUMIRA PEN 104HUMIRA PEN CROHN'S-UC-HS 104HUMIRA PEN PSOR-UVEITS-ADOL HS 104HUMIRA(CF) 104

134

HUMIRA(CF) PEDIATRIC CROHN'S 104HUMIRA(CF) PEN 104HUMIRA(CF) PEN CROHN'S-UC-HS 104HUMIRA(CF) PEN PSOR-UV-ADOL HS 104HUMULIN 70-30 60HUMULIN 70/30 KWIKPEN 60HUMULIN N 60HUMULIN N KWIKPEN 60HUMULIN R 60HUMULIN R U-500 60HUMULIN R U-500 KWIKPEN 60hydralazine hcl 73hydrochlorothiazide 71hydrocodone-acetaminophen 12hydrocortisone 91,109hydrocortisone butyrate 91hydrocortisone valerate 91hydrocortisone-acetic acid 116hydrocortisone-pramoxine 78hydromorphone er 10hydromorphone hcl 12hydroxychloroquine sulfate 46hydroxyprogesterone caproate 100hydroxyurea 38hydroxyzine hcl 117hydroxyzine pamoate 117HYPERHEP B S-D 106HYPERRAB 106HYPERRHO S-D 106

Iibandronate sodium 110IBRANCE 39ibu 9ibuprofen 9ibutilide fumarate 66icatibant 103ICLUSIG 43idarubicin hcl 39IDHIFA 43ifosfamide 36

ILARIS 107ILUMYA 78imatinib mesylate 43IMBRUVICA 43IMFINZI 44imipenem-cilastatin sodium 19imipramine hcl 29imiquimod 78IMOVAX RABIES VACCINE 108IMPAVIDO 16INBRIJA 47incassia 100INCRELEX 93indapamide 71indomethacin 9INFANRIX DTAP 108INFLECTRA 104INFUGEM 38INFUMORPH 10INGREZZA 75INGREZZA INITIATION PACK 75INLYTA 43INQOVI 43INREBIC 39INSULIN LISPRO 60INSULIN LISPRO JUNIOR KWIKPEN 61INSULIN LISPRO KWIKPEN U-100 61INSULIN LISPRO PROTAMINE MIX 61insulin pen needles 111insulin syringe 111INTELENCE 52INTRALIPID 111INTRON A 55introvale 96INVEGA SUSTENNA 49INVEGA TRINZA 49INVELTYS 114INVIRASE 54INVOKAMET 58INVOKAMET XR 58INVOKANA 58

135

IONOSOL MB-DEXTROSE 5% 81IOPIDINE 115IPOL 108ipratropium bromide 118ipratropium-albuterol 118irbesartan 65irbesartan-hydrochlorothiazide 65IRESSA 43irinotecan hcl 41ISENTRESS 51,53ISENTRESS HD 53isibloom 96ISOLYTE P WITH DEXTROSE 81ISOLYTE S 81isoniazid 35isoproterenol hcl 119ISORDIL 73isosorbide dinitrate 73isosorbide dinitrate er 73isosorbide mononitrate 73isosorbide mononitrate er 73isotretinoin 79ISTODAX 39ISTURISA 101itraconazole 32ivermectin 45,79IXEMPRA 39IXIARO 108

JJADENU 83JADENU SPRINKLE 83JAKAFI 43jantoven 62JANUMET 58JANUMET XR 58JANUVIA 58JARDIANCE 58jasmiel 96jencycla 96JENTADUETO 58

JENTADUETO XR 58JEVTANA 39jinteli 96jolessa 96jolivette 100JUBLIA 32juleber 96JULUCA 51junel 96junel fe 96junel fe 24 96JUXTAPID 72JYNARQUE 83

KKADCYLA 44kaitlib fe 96KALBITOR 111KALETRA 54KALYDECO 120KANUMA 87kariva 96kelnor 1-35 96kelnor 1-50 96KENALOG-10 91KESIMPTA PEN 76ketoconazole 32ketodan 32ketoprofen 9ketorolac tromethamine 9,114KEVEYIS 111KEVZARA 107KEYTRUDA 45KHAPZORY 45kimidess 96KINERET 104KINRIX 108kionex 84KISQALI 40KISQALI FEMARA CO-PACK 36klofensaid ii 79

136

klor-con 81KLOR-CON 10 81KLOR-CON 8 81klor-con m10 81KLOR-CON M15 81klor-con m20 81klor-con sprinkle 81KORLYM 93KOSELUGO 43KRISTALOSE 86KRYSTEXXA 33kurvelo 96KUVAN 87KYNAMRO 72KYPROLIS 42

Llabetalol hcl 67LACRISERT 113lactated ringers 81,111lactulose 86lamivudine 52,55lamivudine hbv 55lamivudine-zidovudine 53lamotrigine 25lamotrigine (blue) 25lamotrigine (green) 25lamotrigine (orange) 25lamotrigine odt (orange) 25LANOXIN 70lansoprazole 87lanthanum carbonate 84LANTUS 61LANTUS SOLOSTAR 61larin 96larin 24 fe 96larin fe 96larissia 96LARTRUVO 45latanoprost 116LATUDA 49

LAYOLIS FE 97LAZANDA 12ledipasvir-sofosbuvir 55leena 97leflunomide 107LEMTRADA 107LENVIMA 43lessina 97LETAIRIS 121letrozole 41leucovorin calcium 40LEUKERAN 36LEUKINE 63leuprolide acetate 101levalbuterol concentrate 119levalbuterol hcl 119levalbuterol tartrate hfa 119LEVEMIR 61LEVEMIR FLEXTOUCH 61levetiracetam 23levetiracetam er 23levetiracetam-nacl 23levobunolol hcl 115levocarnitine 111levocetirizine dihydrochloride 117levofloxacin 21levofloxacin-d5w 21levoleucovorin calcium 40levonest 97levonorg-eth estrad eth estrad 97levonorgestrel-eth estradiol 97levora-28 97levorphanol tartrate 10levothyroxine sodium 101LEVOXYL 101LEXETTE 91LEXIVA 54lidocaine 13lidocaine hcl 13,66lidocaine hcl viscous 77lidocaine-prilocaine 13

137

lillow 111lindane 46linezolid 16linezolid-d5w 16LINZESS 86LIORESAL INTRATHECAL 51liothyronine sodium 101lisinopril 66lisinopril-hydrochlorothiazide 66lithium 58lithium carbonate 58lithium carbonate er 58LIVALO 72LO LOESTRIN FE 97lo-zumandimine 111LONHALA MAGNAIR REFILL 118LONHALA MAGNAIR STARTER 118LONSURF 38loperamide 85lopinavir-ritonavir 54lopreeza 97lorazepam 57lorazepam intensol 57LORBRENA 40lorcet 12lorcet hd 12lorcet plus 12loryna 97losartan potassium 65losartan-hydrochlorothiazide 65LOTEMAX 114LOTEMAX SM 114loteprednol etabonate 114lovastatin 72low-ogestrel 97loxapine 48LUCEMYRA 14ludent fluoride 81LUMIGAN 116LUMIZYME 87LUPANETA PACK 101,102

LUPRON DEPOT 102LUPRON DEPOT (LUPANETA) 102LUPRON DEPOT-PED 102lutera 97LYNPARZA 40LYRICA 23,24LYSODREN 101lyza 100

MM-M-R II VACCINE 108mafenide acetate 16magnesium sulfate 82magnesium sulfate-d5w 82MAKENA 100malathion 46mannitol 70maprotiline hcl 28marlissa 97MARPLAN 27MARQIBO 40MATULANE 36matzim la 68MAVENCLAD 76MAVYRET 55MAYZENT 76meclizine hcl 29meclofenamate sodium 9medroxyprogesterone acetate 100mefenamic acid 10mefloquine hcl 46megestrol acetate 100MEKINIST 43MEKTOVI 40melodetta 24 fe 97meloxicam 10melphalan hcl 36memantine hcl 27memantine hcl er 27MENACTRA 108MENEST 97

138

MENQUADFI 108MENVEO A-C-Y-W-135-DIP 108meprobamate 56mercaptopurine 38meropenem 19meropenem-0.9% nacl 19mesalamine 109mesalamine er 109mesna 45MESNEX 45MESTINON 34metadate er 74metaproterenol sulfate 119metformin hcl 58metformin hcl er 59methadone hcl 10methadone intensol 10METHADOSE 10methazolamide 115methenamine hippurate 16methergine 112methimazole 103methocarbamol 122methotrexate 105methotrexate sodium 105methoxsalen 79methscopolamine bromide 85methyclothiazide 71methyldopa 64methyldopa-hydrochlorothiazide 64methylergonovine maleate 112methylphenidate er 74,75methylphenidate er (la) 75methylphenidate hcl 75methylphenidate hcl cd 75methylphenidate hcl er (cd) 75methylphenidate la 75methylprednisolone 91methylprednisolone acetate 91methylprednisolone sodium succ 91metoclopramide hcl 85

metolazone 71metoprolol succinate 67metoprolol tartrate 68metoprolol-hydrochlorothiazide 68METRO IV 17metronidazole 17,79mexiletine hcl 66MIACALCIN 110mibelas 24 fe 97miconazole 3 32MICRHOGAM ULTRA-FILTERED PLUS 106microgestin 97microgestin fe 97midazolam hcl 57midodrine hcl 65mifepristone 92migergot 33miglustat 88mili 97millipred 92milrinone in 5% dextrose 70milrinone lactate 70mimvey 97mimvey lo 97minitran 73minocycline hcl 22minoxidil 73mirtazapine 27MIRVASO 79misoprostol 86mitigo 10mitomycin 40mitoxantrone hcl 40modafinil 123moexipril hcl 66molindone hcl 48mometasone furoate 92,117mondoxyne nl 22mono-linyah 97mononessa 97montelukast sodium 118

139

morgidox 22morphine sulfate 12morphine sulfate er 11moxifloxacin 21moxifloxacin hcl 21MOZOBIL 63MULPLETA 63mupirocin 17MUTAMYCIN 40MYALEPT 112MYCAPSSA 102mycophenolate mofetil 105mycophenolic acid 105MYLOTARG 45myorisan 79MYRBETRIQ 88

NNABI-HB 106nabumetone 10nadolol 68nafcillin 20nafcillin sodium 20naftifine hcl 32NAGLAZYME 88nalbuphine hcl 12naloxone hcl 14naltrexone hcl 14naproxen 10naproxen sodium 10naproxen sodium ds 10naproxen-esomeprazole mag 10naratriptan hcl 34NARCAN 14NATACYN 32nateglinide 59NATPARA 110NAYZILAM 23NEBUPENT 46necon 97nefazodone hcl 28

neo-polycin 113neo-polycin hc 114neomycin sulfate 15neomycin-bacitracin-poly-hc 114neomycin-bacitracin-polymyxin 113neomycin-polymyxin b 15neomycin-polymyxin-dexameth 114neomycin-polymyxin-gramicidin 113neomycin-polymyxin-hc 114,116neomycin-polymyxin-hydrocort 116NEPHRAMINE 112NERLYNX 40neuac 79NEULASTA 63NEULASTA ONPRO 63NEUPOGEN 63NEUPRO 47nevirapine 52nevirapine er 52NEXAVAR 43NEXLETOL 72niacin 72niacin er 73niacor 73nicardipine hcl 68NICOTROL 14NICOTROL NS 14nifedipine er 69nikki 97nilutamide 36nimodipine 69NINLARO 40NIPENT 38nisoldipine 69nitisinone 88NITRO-BID 73NITRO-DUR 73nitrofurantoin 17nitrofurantoin mono-macro 17nitroglycerin 73nitroglycerin in d5w 73

140

nitroglycerin patch 73NITYR 88NIVESTYM 63nizatidine 85nolix 92nora-be 100norepinephrine bitartrate 70norethin-eth estra-ferrous fum 97norethindron-ethinyl estradiol 98norethindrone 100norethindrone ac (lupaneta) 100norethindrone acetate 100norgestimate-ethinyl estradiol 98norlyda 98norlyroc 100NORMOSOL-M AND DEXTROSE 82NORMOSOL-R AND DEXTROSE 82NORMOSOL-R PH 7.4 82NORPACE CR 66NORTHERA 70nortrel 98nortriptyline hcl 29NORVIR 54NOVAREL 93NOXAFIL 32NPLATE 63NUBEQA 36NUCALA 117,122NUEDEXTA 75NULOJIX 105NUPLAZID 49NURTEC ODT 33NUTRILIPID 112NUTROPIN AQ NUSPIN 93NUZYRA 22nyamyc 32NYMALIZE 69nystatin 32nystatin-triamcinolone 32nystop 32

OOCALIVA 85ocella 98OCREVUS 76OCTAGAM 106octreotide acetate 102ODEFSEY 52ODOMZO 43OFEV 122ofloxacin 21ogestrel 98okebo 22olanzapine 49olanzapine odt 49olmesartan medoxomil 65olmesartan-hydrochlorothiazide 65olopatadine hcl 113,117OLUMIANT 107omega-3 acid ethyl esters 73omeprazole 87omeprazole-sodium bicarbonate 87ONCASPAR 40ondansetron hcl 30,31ondansetron odt 31ONIVYDE 42ONPATTRO 88OPDIVO 45opium tincture 85OPSUMIT 121oralone 77ORENCIA 105ORENCIA CLICKJECT 105ORENITRAM ER 121ORFADIN 88ORIAHNN 102ORILISSA 102ORKAMBI 120orsythia 98ORTIKOS 109oseltamivir phosphate 55,56

141

OSMITROL 70OSPHENA 101OTEZLA 107oxaliplatin 36oxandrolone 93oxaprozin 10OXAYDO 12OXBRYTA 63oxcarbazepine 26OXERVATE 113oxiconazole nitrate 32OXISTAT 32oxybutynin chloride 88oxybutynin chloride er 88oxycodone hcl 12oxycodone hcl-aspirin 13oxycodone hcl-ibuprofen 13oxycodone-acetaminophen 13oxymorphone hcl er 11OZEMPIC 59

Ppacerone 66paclitaxel 40paliperidone er 49,50palonosetron hcl 31pamidronate disodium 110PANDEL 92PANRETIN 45pantoprazole sodium 87PANZYGA 106paricalcitol 110paroex 77paromomycin sulfate 15paroxetine cr 28paroxetine er 28paroxetine hcl 28paroxetine mesylate 28PASER 35PAXIL 28PEDIARIX 108

PEDVAXHIB 108peg 3350-electrolyte 86peg-3350 and electrolytes 86peg3350-sod sul-nacl-kcl-asb-c 86PEGANONE 26PEGASYS 55PEGASYS PROCLICK 55PEGINTRON 55PEMAZYRE 40penicillamine 84penicillin g potassium 20penicillin g sodium 20penicillin gk-iso-osm dextrose 20penicillin v potassium 20PENTACEL 108PENTAM 300 46pentamidine isethionate 46pentobarbital sodium 123pentoxifylline 70PERFOROMIST 119perindopril erbumine 66periogard 77PERJETA 45permethrin 46perphenazine 48perphenazine-amitriptyline 29PERSERIS 50phenadoz 29phenelzine sulfate 27phenobarbital 23,24phenobarbital sodium 25phenoxybenzamine hcl 65phenylephrine hcl 65phenytoin 26phenytoin sodium extended 26philith 98PHOSPHOLINE IODIDE 115PHYSIOLYTE 112PHYSIOSOL 112PICATO 79PIFELTRO 52

142

pilocarpine hcl 77,115pimecrolimus 79pimozide 48pimtrea 98pindolol 68pioglitazone hcl 59pioglitazone-glimepiride 59pioglitazone-metformin 59piperacillin-tazobactam 20PIQRAY 40pirmella 98piroxicam 10plain niacin 73PLASMA-LYTE 148 82PLASMA-LYTE A PH 7.4 82PLEGRIDY 76PLEGRIDY PEN 76podofilox 79polocaine 13polocaine-mpf 13polycin 113polymyxin b sul-trimethoprim 113polymyxin b sulfate 17POMALYST 37portia 98PORTRAZZA 45posaconazole 32potassium chl-normal saline 82potassium chloride 82potassium chloride in d5lr 82potassium chloride proamp 82potassium chloride-nacl 82potassium citrate er 82PRADAXA 62pramipexole dihydrochloride 47prasugrel hcl 64pravastatin sodium 72praziquantel 46prazosin hcl 65PRED-G 114prednicarbate 92

prednisolone 92prednisolone acetate 114prednisolone sodium phosphate 92,114prednisone 92prednisone intensol 92pregabalin 24PREGNYL 93PREMARIN 98PREMASOL 112PREMPHASE 98PREMPRO 98prenatal vitamins 84prevalite 73previfem 98PREVYMIS 54PREZCOBIX 54PREZISTA 54PRIFTIN 35primaquine 46primidone 25PRIVIGEN 106PROAIR DIGIHALER 119PROAIR HFA 119PROAIR RESPICLICK 119probenecid 33probenecid-colchicine 33procainamide hcl 67PROCALAMINE 82prochlorperazine 29prochlorperazine edisylate 30prochlorperazine maleate 30procto-med hc 15procto-pak 15proctosol-hc 15proctozone-hc 15PROCYSBI 88progesterone 100PROGLYCEM 60PROGRAF 105PROLASTIN C 122PROLENSA 114

143

PROLEUKIN 40PROLIA 110PROMACTA 63promethazine hcl 30promethegan 30propafenone hcl 67propafenone hcl er 67proparacaine hcl 113propranolol hcl 68propranolol hcl er 68propranolol-hydrochlorothiazid 68propylthiouracil 103PROQUAD 108PROSOL 112protriptyline hcl 29PROVENTIL HFA 119PULMOZYME 120PURIXAN 38pyrazinamide 35pyridostigmine bromide 34pyridostigmine bromide er 34pyrimethamine 46

QQINLOCK 37QUADRACEL DTAP-IPV 108quetiapine fumarate 50quetiapine fumarate er 50quinapril hcl 66quinapril-hydrochlorothiazide 66quinidine gluconate 67quinidine sulfate 67quinine sulfate 46QVAR REDIHALER 117

RRABAVERT 108rabeprazole sodium 87RADICAVA 75raloxifene hcl 101ramelteon 123

ramipril 66ranitidine hcl 86ranolazine er 70RAPAFLO 89rasagiline mesylate 48RASUVO 105RAVICTI 88RAYALDEE 84RAYOS 92REBIF 76,77REBIF REBIDOSE 77reclipsen 98RECOMBIVAX HB 108RECTIV 79REGONOL 34RELENZA 56relexxii 75RELISTOR 85REMICADE 105REMODULIN 121RENFLEXIS 105repaglinide 59repaglinide-metformin hcl 59REPATHA PUSHTRONEX 70REPATHA SURECLICK 70REPATHA SYRINGE 70RESCRIPTOR 52RESTASIS 113RESTASIS MULTIDOSE 113RETACRIT 64RETEVMO 40RETROVIR 53REVCOVI 88REVLIMID 37REXULTI 50REYATAZ 54RHOGAM ULTRA-FILTERED PLUS 107RHOPHYLAC 107RHOPRESSA 113ribasphere 55RIBASPHERE RIBAPAK 55

144

ribavirin 55,122RIDAURA 107rifabutin 35rifampin 35RIFATER 35riluzole 75rimantadine hcl 56ringers injection 82ringers irrigation 112RINVOQ 107RIOMET 59RIOMET ER 59RISPERDAL CONSTA 50risperidone 50risperidone odt 50ritonavir 54RITUXAN 45RITUXAN HYCELA 45rivastigmine 26rivelsa 98rizatriptan 34ROCKLATAN 115romidepsin 40ropinirole hcl 47rosadan 79rosuvastatin calcium 72ROTARIX 108ROTATEQ 109roweepra 23roweepra xr 23ROXYBOND 13ROZLYTREK 40RUBRACA 43RUCONEST 103RUKOBIA 53RUZURGI 112RYBELSUS 59RYDAPT 40RYTARY 47

SSANCUSO 31SANDIMMUNE 105SANDOSTATIN LAR DEPOT 102SANTYL 79SAPHRIS 50SAVELLA 75scopolamine 30SECUADO 50selegiline hcl 48selenium sulfide 79SELZENTRY 53SEREVENT DISKUS 119SEROSTIM 93sertraline hcl 28setlakin 98sevelamer carbonate 84sevelamer hcl 84SEYSARA 22sharobel 100SHINGRIX 109SIGNIFOR 102SIGNIFOR LAR 102SIKLOS 38sildenafil 121sildenafil citrate 121SILENOR 123SILIQ 79silodosin 89silver sulfadiazine 17SIMBRINZA 115simliya 112simpesse 112SIMPONI ARIA 107simvastatin 72sirolimus 105SIRTURO 35,53SIVEXTRO 17SKYRIZI (2 SYRINGES) KIT 105sodium acetate 82

145

sodium chloride 83,112,123sodium fluoride 83sodium lactate 83sodium phenylacet-sod benzoate 112sodium phenylbutyrate 88sodium polystyrene sulfonate 84sofosbuvir-velpatasvir 55solifenacin succinate 89SOLIRIS 64soloxide 22SOLTAMOX 37SOLU-CORTEF 92SOLU-MEDROL 92SOMATULINE DEPOT 103SOMAVERT 103sorine 67sotalol 67sotalol af 67SPINRAZA 112SPIRIVA 118SPIRIVA RESPIMAT 118spironolactone 71spironolactone-hctz 71sprintec 98SPRITAM 23SPRIX 10SPRYCEL 43SPS 84sronyx 98SSD 17stavudine 53STELARA 79STIMATE 93STIOLTO RESPIMAT 122STIVARGA 43STRENSIQ 88streptomycin sulfate 15STRIBILD 51subvenite 25subvenite (blue) 25subvenite (green) 25

subvenite (orange) 25succinylcholine chloride 123sucralfate 86sulfacetamide sodium 21sulfacetamide-prednisolone 114sulfadiazine 21sulfamethoxazole-trimethoprim 21sulfasalazine 110sulfasalazine dr 110SULFATRIM 21sulindac 10sumatriptan 34sumatriptan succ-naproxen sod 34sumatriptan succinate 34SUPPRELIN LA 103SUPRAX 18SUPREP 86SUSTIVA 52SUTENT 43syeda 98SYLATRON 40SYLATRON 4-PACK 40SYLVANT 107SYMBICORT 122SYMDEKO 120SYMFI 52SYMFI LO 52SYMLINPEN 120 59SYMLINPEN 60 59SYMPAZAN 25SYMTUZA 54SYNAGIS 107SYNAREL 103SYNDROS 31SYNERCID 17SYNJARDY 59SYNJARDY XR 59SYNRIBO 41

TTABLOID 38

146

TABRECTA 37tacrolimus 79,105tadalafil 121TAFINLAR 43TAGRISSO 43TAKHZYRO 70TALTZ AUTOINJECTOR 79TALTZ AUTOINJECTOR (2 PACK) 79TALTZ AUTOINJECTOR (3 PACK) 79TALTZ SYRINGE 79TALTZ SYRINGE (2 PACK) 79TALZENNA 41tamoxifen citrate 37tamsulosin hcl 89TARGRETIN 45tarina 24 fe 98tarina fe 98tarina fe 1-20 eq 98TASIGNA 44TAVALISSE 64tazarotene 79tazicef 18taztia xt 69TAZVERIK 41TDVAX 109TECENTRIQ 45TECFIDERA 77TEFLARO 19TEGSEDI 88telmisartan 65telmisartan-hydrochlorothiazid 65temazepam 57TEMODAR 36temsirolimus 44TENIVAC 109tenofovir disoproxil fumarate 53terazosin hcl 89terbinafine hcl 32terbutaline sulfate 119terconazole 32TERIPARATIDE 110

testosterone 94testosterone cypionate 94testosterone enanthate 94tetrabenazine 75tetracycline hcl 22THALOMID 37theophylline 120theophylline anhydrous 120theophylline in 5% dextrose 120THIOLA EC 89thioridazine hcl 48thiotepa 36thiothixene 48tiadylt er 69tiagabine hcl 25TIBSOVO 44tigecycline 17TIGLUTIK 75tilia fe 98timolol maleate 33,115tinidazole 46TIROSINT 101TIS-U-SOL PENTALYTE 112TIVICAY 51TIVICAY PD 51tizanidine hcl 51TOBI PODHALER 120TOBRADEX 115TOBRADEX ST 115tobramycin 15,120tobramycin sulfate 15tobramycin-dexamethasone 115TOBREX 16tolazamide 59tolbutamide 59tolcapone 47tolmetin sodium 10TOLSURA 32tolterodine tartrate 89tolterodine tartrate er 89topiramate 25

147

toposar 42topotecan hcl 42toremifene citrate 37TORISEL 44torsemide 71TOSYMRA 34TOUJEO MAX SOLOSTAR 61TOUJEO SOLOSTAR 61tovet emollient 92TRADJENTA 59tramadol hcl 13tramadol hcl-acetaminophen 13trandolapril 66trandolapril-verapamil er 66tranexamic acid 64tranylcypromine sulfate 27TRAVASOL 112trazodone hcl 28TREANDA 36TRECATOR 35TRELEGY ELLIPTA 122TRELSTAR 103TREMFYA 79treprostinil 121TRESIBA 61TRESIBA FLEXTOUCH U-100 61TRESIBA FLEXTOUCH U-200 61tretinoin 45,80tretinoin microsphere 80TREXALL 106tri femynor 112tri-estarylla 99tri-legest fe 99tri-linyah 99tri-lo-estarylla 99tri-lo-marzia 99tri-lo-mili 112tri-lo-sprintec 99tri-mili 99tri-previfem 99tri-sprintec 99

tri-vylibra 99tri-vylibra lo 99triamcinolone acetonide 15,77,92triamterene 71triamterene-hydrochlorothiazid 71trianex 92triderm 92trientine hcl 84TRIESENCE 115trifluoperazine hcl 48trifluridine 56trihexyphenidyl hcl 47TRIJARDY XR 59TRIKAFTA 120triklo 73trilyte with flavor packets 86trimethoprim 17trimipramine maleate 29TRINTELLIX 28TRIPTODUR 103TRISENOX 41TRIUMEQ 51trivora-28 99TROGARZO 53TROPHAMINE 112trospium chloride 89trospium chloride er 89TRULICITY 59TRUMENBA 109TRUVADA 53TUKYSA 41tulana 100TURALIO 44TWINRIX 109TYBOST 53tydemy 99TYKERB 44TYMLOS 110TYPHIM VI 109TYSABRI 77

148

UUBRELVY 34UDENYCA 64ULORIC 33ULTOMIRIS 64UNITHROID 101UNITUXIN 45UPTRAVI 121ursodiol 85UVADEX 80

Vv-go 20 112v-go 30 112v-go 40 112VABOMERE 19valacyclovir 56VALCHLOR 36valganciclovir hcl 54valproate sodium 25valproic acid 25valrubicin 41valsartan 65valsartan-hydrochlorothiazide 65VALSTAR 41VALTOCO 25vancomycin hcl 17vancomycin hcl-d5w 17VANDAZOLE 17VAQTA 109VARIVAX VACCINE 109VARIZIG 109VASCEPA 73VECTIBIX 45VELCADE 41VELETRI 121velivet 99VELPHORO 84VELTASSA 84VEMLIDY 55

VENCLEXTA 44VENCLEXTA STARTING PACK 44venlafaxine hcl 28venlafaxine hcl er 28VENTAVIS 121VENTOLIN HFA 119verapamil er 69verapamil er pm 69verapamil hcl 69verapamil sr 69VERSACLOZ 51VERZENIO 41vestura 99vgo 20 112vgo 30 112vgo 40 112VIBATIV 17VIBRAMYCIN 22vicodin 13vicodin es 13vicodin hp 13VICTOZA 2-PAK 59VICTOZA 3-PAK 59VIDEX 53VIDEX EC 53vienva 99vigabatrin 25VIIBRYD 28VIMIZIM 88VIMPAT 26vinblastine sulfate 41vincasar pfs 41vincristine sulfate 41vinorelbine tartrate 41viorele 99VIRACEPT 54VIRAMUNE 52VIREAD 53VISTOGARD 112VITRAKVI 41VIVITROL 14

149

VIZIMPRO 44voriconazole 32VOSEVI 55VOTRIENT 44VPRIV 88VRAYLAR 50VUMERITY 77vyfemla 99vylibra 99VYNDAMAX 70VYNDAQEL 70VYXEOS 38VYZULTA 116

WWAKIX 123warfarin sodium 62water 113wera 99wixela inhub 122wymzya fe 99

XXALKORI 44XARELTO 62,63XATMEP 106XCOPRI 23XELJANZ 107XELJANZ XR 107XENLETA 17XEOMIN 51XERMELO 85XGEVA 110XIAFLEX 88XIFAXAN 17XIIDRA 113XOFLUZA 56XOLAIR 122XOPENEX 119XOPENEX CONCENTRATE 119XOPENEX HFA 120

XOSPATA 44XPOVIO 41XTAMPZA ER 11XTANDI 36xulane 99XURIDEN 88XYREM 123

YYERVOY 45YF-VAX 109YONDELIS 36YONSA 37YUPELRI 118yuvafem 99

Zzafirlukast 118zaleplon 123ZALTRAP 41ZANOSAR 36zarah 99ZARXIO 64ZEJULA 44ZELBORAF 44ZEMAIRA 122zenatane 80ZENPEP 88zenzedi 74ZEPOSIA 77ZERIT 53ZEVALIN 45zidovudine 53ZIEXTENZO 64zileuton er 118ziprasidone hcl 50ziprasidone mesylate 50ZIRGAN 54ZOLADEX 103zoledronic acid 110ZOLINZA 41

150

zolmitriptan 34zolpidem tartrate 123zolpidem tartrate er 123zonisamide 24ZORBTIVE 93ZORTRESS 106ZOSTAVAX 109ZOSYN 20zovia 1-35e 99zumandimine 99ZYCLARA 80ZYDELIG 42ZYFLO 118ZYKADIA 41,44ZYLET 115ZYPREXA RELPREVV 50ZYTIGA 37

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This formulary was updated on 12/01/2020. For more recent information or other questions, please contact:

MCC of VA (HMO SNP)1-800-424-4495 (TTY 711)8 a.m. to 8 p.m., Monday through Friday(from October 1-March 31, 7 days a week) www.mccofva.com/dsnp



magellan complete care of virginia, llc (mcc of va) (hmo

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