medperform high formulary april 2017 medperform high formulary medperform formulary 2017.pdf ·...

MedPerform High Formulary April 2017

37014 MedPerform High Formulary – April 2017 i

MedPerform High Formulary April 2017

Foreword This document represents the efforts of Kroger Prescription Plan’s (KPP) Pharmacy and Therapeutics (P&T) and Formulary Committees, powered my MedImpact, to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. The ultimate goal of the formulary is to provide a process and framework to support the dynamic evolution of this document to guide prescribing decisions that reflect the most current clinical consensus associated with drug therapy decisions. This is accomplished through the auspices of the KPP P&T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. As you use this Formulary, you are encouraged to review the information and provide your input and comments to the KPP P&T and Formulary Committees. The KPP P&T and Formulary Committees use the following criteria in the evaluation of drug selection for the Portfolio Formulary:

Drug safety profile

Drug efficacy

Comparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeutic duplication where possible

Cost-effectiveness relative to comparable therapies How to Use the Formulary The Formulary is a list of medications available to KPP members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by KPP shall be considered a Non-Formulary drug. All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols:

AGE Age Edit Coverage may depend on patient age

CU Concurrent Use Edit

Coverage or lack thereof may depend upon concurrent use of another drug

MD Physician Specialty Edit

Coverage may depend on prescribing physician’s specialty or board certification

PA Prior Authorization

Requires specific physician request process

QL Quantity Limit

Coverage may be limited to specific quantities per prescription and/or time period

ST Step Therapy

Coverage may depend on previous use of another drug

Please refer to the prescribing guideline appendix within this document for details regarding specific agents. Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or KPP at (800) 482-1285. Excluded Agents As new drugs become available, they will be considered for coverage under the MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including the exclusion of any prescription drugs. Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.

EXCLUDED DRUGS

FORMULARY THERAPEUTIC ALTERNATIVES

THERAPEUTIC DRUG CLASS

VELTIN clindamycin/tretinoin,

ZIANA

ACNE AGENTS, TOPICAL

KADIAN

morphine sulfate ER tablets, oxycodone ER, NUCYNTA, NUCYNTA

ER

ANALGESICS, NARCOTICS

BELBUCA BUTRANS PATCH ANALGESICS, NARCOTICS

ABSTRAL, FENTORA, LAZANDA, ONSOLIS, SUBSYS

fentanyl citrate lozenge ANALGESICS, NARCOTICS

GRALISE immediate-release

gabapentin ANTICONVULSANTS

ACTIVE-PAC KIT,

SMARTRX GABA-V KIT, SMART RX GABA KIT

immediate-release

gabapentin & lidocaine/menthol

topical, or capsaicin/methyl

salicylate/menthol topical

ANTICONVULSANTS

HORIZANT

immediate-release gabapentin,

ropinirole, pramipexole

ANTICONVULSANTS (RESTLESS LEG

SYNDROME/POST HERPETIC NEURALGIA)

FORFIVO XL bupropion ER ANTIDEPRESSANTS

IRENKA duloxetine ANTIDEPRESSANTS

KHEDEZLA

desvenlafaxine succinate ER,

desvenlafaxine ER (Ranbaxy)

ANTIDEPRESSANTS

PEXEVA paroxetine ANTIDEPRESSANTS

ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS

NYATA nystatin topical ANTI-INFECTIVE

ZIPSOR, ZORVOLEX

diclofenac ANTI-INFLAMMATORY

NON-STEROIDAL

NAPRELAN naproxen ANTI-INFLAMMATORY

NON-STEROIDAL

VIVLODEX meloxicam ANTI-INFLAMMATORY

NON-STEROIDAL

TIVORBEX indomethacin ANTI-INFLAMMATORY

NON-STEROIDAL

VIMOVO

naproxen & esomeprazole magnesium, lansoprazole,

omeprazole, or pantoprazole

ANTI-INFLAMMATORY NON-STEROIDAL

COMBINATION AGENTS

DUEXIS famotidine & ibuprofen


COMBINATION AGENTS

RAYOS immediate-release

prednisone

ANTI-INFLAMMATORY STEROIDAL

CAPXIB

celecoxib & capsaicin/menthol

topical patch


CYCLOOXYGENASE-2 (COX-2) SELECTIVE

INHIBITOR

HYCOFENIX codeine/pseudoephedrin

e/guaifenesin sol ANTITUSSIVES

MedPerform High Formulary

37014 MedPerform High Formulary – April 2017 ii

EXCLUDED DRUGS FORMULARY

THERAPEUTIC

ALTERNATIVES


APTENSIO XR, ADZENYS XR ODT

dextroamphetamine/ amphetamine,

methylphenidate

ATTENTION DEFICIT-HYPERACTIVITY

(ADHD)/NARCOLEPSY

CIMZIA, SIMPONI 50mg, TALTZ

HUMIRA, ENBREL, COSENTYX, STELARA,

XELJANZ/XR, *SIMPONI 100mg (*for diagnosis of ulcerative

colitis only)

AUTOIMMUNE DISEASE

BINOSTO alendronate 70mg,

ibandronate

BONE RESORPTION INHIBITORS

DURLAZA aspirin (OTC),

clopidogrel CARDIOLOGY

YOSPRALA aspirin (OTC) CARDIOLOGY

GONITRO nitroglycerin CARDIOLOGY

BEAU RX KELOCOTE, RECEDO DERMATOLOGY

DERMAPAK PLUS tretinoin topical DERMATOLOGY

ACCUCAINE lidocaine topical DERMATOLOGY

PEDIPAK ciclopirox DERMATOLOGY

SYNERDERM

OTC EMOLLIENTS (EUCERIN, CETAPHIL, VASELINE,

AQUAPHOR)

DERMATOLOGY

URE-K, KERALAC, UTOPIC, UREVAZ, DERMASORB XM

urea 40%, urea 50% DERMATOLOGY

PENNSAID diclofenac sodium 1%

topical DERMATOLOGY -

ANTIINFLAMMATORY

ADLYXIN, BYDUREON,

BYETTA, TANZEUM

TRULICITY, VICTOZA DIABETES

XULTOPHY, SOLIQUA

TRULICITY, VICTOZA, LANTUS, TOUJEO

DIABETES

FARXIGA, XIGDUO XR

INVOKANA, INVOKAMET, JARDIANCE, SYNJARDY

DIABETES

GLUMETZA metformin ER DIABETES

NESINA, KAZANO, OSENI,

ONGLYZA, KOMBIGLYZE XR

JENTADUETO, JENTADUETO XR,

TRADJENTA, JANUVIA, JANUMET,

JANUMET XR

DIABETES

ALL OTHER MANUFACTURER

S OF DIABETIC TEST STRIPS AND

METERS

KROGER & ABBOTT (PRECISION AND

FREESTYLE BRAND)

DIABETIC SUPPLIES (TEST STRIPS,

METERS)

LEVITRA, STENDRA, STAXYN

VIAGRA DRUGS TO TREAT

IMPOTENCY

AUVI-Q epinephrine 0.3mg or 0.15mg auto-injector

EMERGENCY TREATMENT OF

ALLERGIC REACTIONS (TYPE 1)

GENOTROPIN, HUMATROPE,

NUTROPIN, NUTROPIN AQ, NUTROPIN AQ

NUSPIN, SAIZEN, ZOMACTON

OMNITROPE, NORDITROPIN

GROWTH HORMONES


THERAPEUTIC ALTERNATIVES


VIEKIRA PAK, DAKLINZA

HARVONI, EPCLUSA HEPATITIS C

ESTROGEL DIVIGEL HORMONAL DEFICIENCY

PRESTALIA amlodipine & benazepril hcl

HYPERTENSION

NATESTO, TESTIM,

VOGELXO, FORTESTA

ANDROGEL, AXIRON HORMONAL DEFICIENCY

H.P. ACTHAR N/A HORMONE MODIFIERS

DUTOPROL metoprolol succinate

ER-HCTZ HYPERTENSION

APIDRA, APIDRA SOLOSTAR

HUMALOG, NOVOLOG

INSULINS

BASAGLAR LANTUS, LEVEMIR, TOUJEO, TRESIBA

INSULINS

ALTOPREV, LESCOL XL

atorvastatin, lovastatin, pravastatin, simvastatin, rosuvastatin

LIPID IRREGULARITY

ANTARA fenofibrate/ micronized/

nanocrystallized LIPOTROPICS

ASACOL HD, DELZICOL, DIPENTUM

balsalazide disodium, APRISO, LIALDA,

PENTASA, sulfasalazine

LOWER GASTROINTESTINAL

DISORDERS

ONZETRA, ZEMBRACE SYMTOUCH, TREXIMET

sumatriptan MIGRAINE

EXTAVIA

REBIF, GILENYA, PLEGRIDY,

TECFIDERA, AVONEX, GLATOPA

MULTIPLE SCLEROSIS

METHAVER Individual vitamin

components MULTIVITAMIN

PREPARATIONS

armodafinil modafinil NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS

OMNARIS, ZETONNA,

BECONASE AQ, TICANASE

Nasal triamcinolone, flunisolide, fluticasone,

budesonide, mometasone, QNASL

NASAL ANTI-INFLAMMATORY

QSYMIA phentermine &

topiramate OBESITY AGENTS

ZIOPTAN

latanoprost, travoprost, LUMIGAN,

TRAVATAN Z

OPHTHALMIC GLAUCOMA

EVZIO NARCAN NASAL

SPRAY OPIOID REVERSAL

LASTACAFT, BEPREVE,

EMADINE, PAZEO

PATADAY, olopatadine OPHTHALMIC

ANTIHISTAMINES

ARESTIN N/A ORAL/PHARYNGEAL

DISORDERS

PANCREAZE, PERTZYE

lipase/protease/amylase, CREON, ZENPEP

PANCREATIC ENZYMES

ALVESCO, FLOVENT DISKUS,

FLOVENT HFA

ASMANEX HFA, ASMANEX

TWISTHALER, PULMICORT

FLEXHALER, QVAR

RESPIRATORY ASTHMA


37014 MedPerform High Formulary – April 2017 iii


THERAPEUTIC ALTERNATIVES


PROVENTIL HFA, levalbuterol HFA

PROAIR HFA, VENTOLIN HFA

RESPIRATORY ASTHMA AND COPD

TUDORZA PRESSAIR,

SEEBRI NEOHALER

SPIRIVA HANDIHALER,

SPIRIVIA RESPIMAT

RESPIRATORY COPD

UTIBRON, BEVESPI

STIOLTO RESPIRATORY COPD

NORITATE metronidazole 0.75% cream, gel or lotion

ROSACEA AGENTS, TOPICAL

EDLUAR, INTERMEZZO,

ROZEREM, ZOLPIMIST

eszopiclone, zaleplon, zolpidem

SEDATIVE-HYPNOTICS, NON-BARBITURATE

ALLZITAL butalbital/acetaminoph

en TENSION HEADACHE

AMRIX, FEXMID, FLEXEPAX

cyclobenzaprine 5mg or 10mg

SKELETAL MUSCLE RELAXANTS

TIROSINT levothyroxine THYROID HORMONES

DEXILANT

lansoprazole, omeprazole,

pantoprazole, esomeprazole

UPPER GASTROINTESTINAL

DISORDERS

Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives. Depending upon a member’s specific benefit parameters, the following topics may apply:

1. Generic Substitution When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary listing wherever an FDA approved generic drug product is available. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by KPP’s Pharmacy and Therapeutics Committee. KPP approves such multi-source drugs for addition to the MAC list based on the following criteria:

A multi-source drug product manufactured by at least one (1) nationally marketed company.

At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalency concerns by the KPP P & T Committee.

Drug product will be approved for generic substitution by the KPP P & T Committee.

This list is reviewed and updated periodically based on the clinical literature and pharmacokinetic characteristics of currently available versions of these drug products. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.

2. Three Tier Benefit The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.

3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows:

A. Formulary Agents Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per KPP P & T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

B. Non-Formulary Agents

Any drug not found in the Formulary listing, or any Formulary updates published by KPP, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:

The use of Formulary Drugs is contraindicated in the patient.

The patient has failed an appropriate trial of Formulary or related agents.

The choices available in the Formulary are not suited for the present patient care need, and the drug selected is required for patient safety.

The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care.

If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

C. Obtaining Coverage Coverage, questions or information regarding the medication request or formulary process may be obtained by:

1. Faxing a completed Medication Request Form to KPP at (858) 790-7100.

2. Contacting KPP at (800) 482-1285 and providing all necessary information requested.

KPP will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is generally not available for drugs that are specifically excluded by benefit design.

4. General Exclusions A. Over the Counter (OTC) medications or their equivalents, unless otherwise

specified in the Formulary listing. B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine

gum, nicotine inhaler). C. Drugs specifically listed as not covered. D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an experimental

manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise specified

in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States Food &

Drug Administration.

The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies.

5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P&T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task.


37014 MedPerform High Formulary – April 2017 iii

Foreword ............................................................................................................. i 1. Generic Substitution ........................................................................ iii 2. Three Tier Benefit ............................................................................ iii 3. Medication Request Process .......................................................... iii 4. General Exclusions ......................................................................... iii 5. Pharmacist and Physician Communication .................................... iii

ALLERGY ................................................................................................................. 6 Allergenic extracts .............................................................................................. 6 2nd Generation Antihistamine & Decongestant Combinations ......................... 6 Antihistamines - 1st Generation ......................................................................... 6 Antihistamines - 2nd Generation ....................................................................... 6 Nasal Anti-Inflammatory Steroids ...................................................................... 6 Nasal Antihistamine ........................................................................................... 6

ANTIEMESIS/ANTIVERTIGO .................................................................................. 6 Antiemetic/Antivertigo Agents ............................................................................ 6

ASTHMA ................................................................................................................... 6 Beta-Adrenergic Agents ..................................................................................... 6 Beta-Adrenergic & Anticholinergic Combinations .............................................. 6 Beta-Adrenergic & Glucocorticoid Combinations .............................................. 6 General Bronchodilator Agents .......................................................................... 6 Leukotriene Receptor Antagonists ..................................................................... 6 Mast Cell Stabilizers........................................................................................... 6 Oral Inhaled Corticosteroids .............................................................................. 6 Phosphodiesterase-4 (PDE4) Inhibitors ............................................................ 6 Xanthines ........................................................................................................... 6

AUTONOMIC NERVOUS SYSTEM DISORDERS .................................................. 6 Alzheimer's Therapy, NMDA Receptor Antagonists .......................................... 6 Alzheimer's Therapy, NMDA Receptor Antagonists & Cholines Inhibitors ....... 6 Cholinesterase Inhibitors ................................................................................... 6

BEHAVIORAL HEALTH - ANTIDEPRESSANTS .................................................... 6 Alpha-2 Receptor Antagonist Antidepressants .................................................. 6 MAOIs - Non-Selective & Irreversible ................................................................ 6 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ............................... 6 Selective Serotonin Reuptake Inhibitors (SSRIs) .............................................. 6 SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb ....................... 6 SSRI & 5HT1A Partial Agonist Antidepressants................................................ 6 SSRI, Serotonin Receptor Modulator Antidepressants ..................................... 6 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ........................................ 6 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) .......................................... 6 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib .......................................... 7

BEHAVIORAL HEALTH - OTHER ........................................................................... 7 Adrenergics, Aromatic, Non-Catecholamine ..................................................... 7 Anti-Alcoholic Preparations ................................................................................ 7 Anti-Anxiety Drugs ............................................................................................. 7 Anti-Mania Drugs ............................................................................................... 7 Antipsychotics, Phenothiazines ......................................................................... 7 Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed .............................. 7 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed .................................... 7 Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 7 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists .......................... 7 Antipsychotics, Dopamine Antagonists, Thioxanthenes .................................... 7 Antipsychotics, Dopamine Antagonists, Butyrophenones ................................. 7 Barbiturates ........................................................................................................ 7 Narcolepsy and Sleep Disorder Therapy Agents .............................................. 7 Narcotic Antagonists .......................................................................................... 7 Sedative-Hypnotics, Non-Barbiturate ................................................................ 7 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy .................... 7 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ....................... 7

CARDIOVASCULAR DISEASE - ARRHYTHMIA .................................................... 7 Antiarrhythmics .................................................................................................. 7

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ................................... 8 Digitalis Glycosides ............................................................................................ 8

CARDIOVASCULAR DISEASE - HYPERTENSION ............................................... 8 ACE Inhibitor/Calcium Channel Blocker Combinations ..................................... 8 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics .............................................. 8 Alpha-Adrenergic Blocking Agents .................................................................... 8 Alpha/Beta-Adrenergic Blocking Agents ............................................................ 8 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations ..................................................................................................... 8 Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ................... 8 Angiotensin II Receptor Blocker-Beta Blocker Comb. ....................................... 8 Angiotensin Receptor Antagonist & Calcium Channel Blockers ....................... 8 Antihypertensives, ACE Inhibitors ..................................................................... 8 Antihypertensives, Angiotensin Receptor Antagonist ........................................ 8 Antihypertensives, Sympatholytic ...................................................................... 8 Antihypertensives, Vasodilators ......................................................................... 8 Beta-Adrenergic Blocking Agents ...................................................................... 8 Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 8 Calcium Channel Blocking Agents ..................................................................... 8 Loop Diuretics .................................................................................................... 8 Potassium Sparing Diuretics .............................................................................. 8 Potassium Sparing Diuretics in Combination .................................................... 8 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ............... 8 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ................................... 8 Pulmonary Anti-HTN, Prostacyclin-Type ........................................................... 8 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ......................... 8 Thiazide & Related Diuretics.............................................................................. 8

CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ....................................... 8 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ................................................ 8

Antihyperlipidemic - HMG CoA Reductase Inhibitors ........................................ 9 Antihyperlipidemic - MTP Inhibitors ................................................................... 9 Antihyperlipidemic –PCSK9 Inhibitors ............................................................... 9 Bile Salt Sequestrants........................................................................................ 9 Lipotropics .......................................................................................................... 9 Niacin Preparations ............................................................................................ 9

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................. 9 Adrenergic Vasopressor Agents ........................................................................ 9 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................. 9 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ..... 9

Heart Rate Reducing, Selective I(F) Current Inhib. ................................................. 9 CARDIOVASCULAR DISEASE - VASODILATION ................................................. 9 Vasodilators, Combination ....................................................................................... 9

Vasodilators, Coronary ...................................................................................... 9 CONTRACEPTION/OXYTOCICS ............................................................................ 9

Contraceptives, Intravaginal, Systemic ............................................................. 9 Contraceptives, Oral .......................................................................................... 9 Contraceptives, Transdermal ............................................................................. 9 Oxytocics ............................................................................................................ 9

COUGH AND COLD ................................................................................................ 9 1st Generation Antihistamine & Decongestant Combinations .......................... 9 Narcotic Antitussive-1st Generation Antihistamine-Decongestants .................. 9 Narcotic Antitussive-1st Generation Antihistamines.......................................... 9 Narcotic Antitussive-Anticholinergic Comb. ....................................................... 9 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ............ 9

DERMATOLOGY - ACNE ........................................................................................ 9 Acne Agents, Systemic ...................................................................................... 9 Acne Agents, Topical ......................................................................................... 9 Keratolytic-Glucocorticoid Combinations ........................................................... 9 Keratolytics....................................................................................................... 10 Rosacea Agents, Topical ................................................................................. 10 Vitamin A Derivatives ....................................................................................... 10

DERMATOLOGY - ANTIINFECTIVE ..................................................................... 10 Topical Antibiotics ............................................................................................ 10 Topical Antifungals ........................................................................................... 10 Topical Antiparasitics ....................................................................................... 10 Topical Antivirals .............................................................................................. 10 Topical Sulfonamides....................................................................................... 10

DERMATOLOGY - ANTIINFLAMMATORY ........................................................... 10 Topical Anti-Inflammatory Steroidal ................................................................. 10 Topical Anti-Inflammatory, NSAIDs ................................................................. 10 Topical Antibiotics/Antiinflammatory, Steroidal ............................................... 10

DERMATOLOGY - MISCELLANEOUS ................................................................. 10 Antiperspirants ................................................................................................. 10 Antiseborrheic Agents ...................................................................................... 10 Topical Antineoplastic & Premalignant Lesion Agents .................................... 10 Topical Local Anesthetics ................................................................................ 10

DERMATOLOGY - PIGMENTATION DISORDERS .............................................. 10 Topical Hyperpigmentation Agents .................................................................. 10

DERMATOLOGY - PSORIASIS/ECZEMA ............................................................ 10 Antipsoriatic Agents, Systemic ........................................................................ 10 Antipsoriatics Agents ....................................................................................... 10 Topical Immunosuppressive Agents ................................................................ 10

DIABETES .............................................................................................................. 10 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ............ 10 Antihyperglycemic, Amylin Analog-Type ......................................................... 10 Antihyperglycemic, DPP-4 Inhibitors ............................................................... 10 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ..................... 10 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) ................... 11 Antihyperglycemic, Insulin-Release Stimulant Type ....................................... 11 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ............. 11 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ................................. 11 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations .................... 11 Antihyperglycemic, Insulin-Response & Release Combinations .................... 11 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ............ 11 Antihyperglycemic-Glucocorticoid Receptor Blockers ..................................... 11 Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ....................... 11 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination .................................................................................... 11 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination .......................... 11 Diabetic Supplies ............................................................................................. 11 Diabetic Ulcer Preparations, Topical ............................................................... 11 Hyperglycemics ................................................................................................ 11 Insulins ............................................................................................................. 11 Syringes & Accessories ................................................................................... 11

EAR - GENERAL DISORDERS ............................................................................. 11 Ear Preparations, Misc. Anti-Infectives ............................................................ 11 Ear Preparations, Antibiotics ........................................................................... 11 Otic Preparations, Anti-Inflammatory-Antibiotics ............................................. 11 Otic Preparations, Local anesthetics ............................................................... 11

ELECTROLYTE REGULATION ............................................................................. 11 Electrolyte Depleters ........................................................................................ 11 Potassium Replacement .................................................................................. 11

ENDOCRINE DISORDER - FERTILITY ................................................................ 11 Drugs to Treat Impotency ................................................................................ 11


37014 MedPerform High Formulary – April 2017 iv

Fertility Stimulating Preparations, Non-FSH .................................................... 11 Follicle Stimulating / Luteinizing Hormones ..................................................... 11 Pregnancy Facilitating/Maintaining Agents, Hormonal .................................... 11

ENDOCRINE DISORDER - OTHER ...................................................................... 11 Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants .................... 11 Antidiuretic & Vasopressor Hormones ............................................................. 11 Bone Formation Stim. Agents - Parathyroid Hormone .................................... 11 Bone Resorption Inhibitor & Vitamin D Combinations ..................................... 11 Bone Resorption Inhibitors ............................................................................... 12 Growth Hormone Receptor Antagonists .......................................................... 12 Growth Hormones ............................................................................................ 12 Hyperparathyroid Tx Agent, Vitamin D Analog-Type ...................................... 12 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ............................... 12 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ............................ 12 Pituitary Suppressive Agents ........................................................................... 12

ENDOCRINE DISORDER - THYROID .................................................................. 12 Antithyroid Preparations ................................................................................... 12 Iodine Containing Agents ................................................................................. 12 Thyroid Hormones............................................................................................ 12

EYE - GENERAL DISORDERS ............................................................................. 12 Eye Antibiotic-Corticoid Combinations............................................................. 12 Eye Antihistamines........................................................................................... 12 Eye Antiinflammatory Agents ........................................................................... 12 Eye Antivirals ................................................................................................... 12 Eye Sulfonamides ............................................................................................ 12

EYE - MISCELLANEOUS ...................................................................................... 12 Ophthalmic Cystine Depleting Agents ............................................................. 12 Ophthalmic Anti-Inflammatory Immunomodulator-Type .................................. 12 Ophthalmic Antibiotics ..................................................................................... 12 Ophthalmic Mast Cell Stabilizers ..................................................................... 12

EYE - GLAUCOMA ................................................................................................ 12 Carbonic Anhydrase Inhibitors ......................................................................... 12 Miotics/Other Intraocular Pressure Reducers .................................................. 12 Mydriatics ......................................................................................................... 13

GOUT AND RELATED DISEASES ....................................................................... 13 Colchicine ......................................................................................................... 13 Hyperuricemia Treatment - Purine Inhibitors ................................................... 13 Uricosuric Agents ............................................................................................. 13

HEMATOLOGICAL DISORDERS .......................................................................... 13 Anticoagulants, Coumarin Type ....................................................................... 13 Hematinics, Other ............................................................................................ 13 Hemorrheologic Agents ................................................................................... 13 Heparin & Related Preparations ...................................................................... 13 Leukocyte (WBC) Stimulants ........................................................................... 13 Platelet Aggregation Inhibitors ......................................................................... 13 Platelet Reducing Agents ................................................................................. 13 Thrombopoietin Receptor Agonists ................................................................. 13 Vitamin K Preparations .................................................................................... 13

HORMONAL DEFICIENCY .................................................................................... 13 Androgenic Agents ........................................................................................... 13 Estrogen/Androgen Combinations ................................................................... 13 Estrogenic Agents ............................................................................................ 13 Progestational Agents ...................................................................................... 13

IMMUNOSUPPRESSION/MODULATION ............................................................. 13 Immunomodulators .......................................................................................... 13 Immunosuppressives ....................................................................................... 13

INFECTIOUS DISEASE - BACTERIAL ................................................................. 13 Absorbable Sulfonamides ................................................................................ 13 Beta lactams .................................................................................................... 13 Cephalosporins - 1st Generation ..................................................................... 13 Cephalosporins - 2nd Generation .................................................................... 13 Cephalosporins - 3rd Generation ..................................................................... 13 Chemotherapeutics, Antibacterial, Miscellaneous ........................................... 13 Ketolides........................................................................................................... 13 Lincosamides ................................................................................................... 13 Macrolides ........................................................................................................ 13 Nitrofuran Derivatives ...................................................................................... 14 Oxazolidinones ................................................................................................. 14 Penicillins ......................................................................................................... 14 Quinolones ....................................................................................................... 14 Tetracyclines .................................................................................................... 14

INFECTIOUS DISEASE - FUNGAL ....................................................................... 14 Antifungal Agents ............................................................................................. 14 Antifungal Antibiotics ........................................................................................ 14

INFECTIOUS DISEASE - MISCELLANEOUS ....................................................... 14 Aminoglycosides .............................................................................................. 14 Anti-Mycobacterium Agents ............................................................................. 14 Antileprotics ...................................................................................................... 14 Antitubercular Antibiotics ................................................................................. 14 Rifamycins and Related Derivative Antibiotics ................................................ 14 Vancomycin & Derivatives ............................................................................... 14

INFECTIOUS DISEASE - PARASITIC .................................................................. 14 Amebacides ..................................................................................................... 14 Anaerobic Antiprotozoal-Antibacterial Agents ................................................. 14 Anthelmintics .................................................................................................... 14 Antimalarial Drugs ............................................................................................ 14 Antiprotozoal Drugs, Miscellaneous ................................................................ 14

INFECTIOUS DISEASE - VIRAL ........................................................................... 14

Antivirals, HIV-Spec, Non-Peptidic Protease Inhib .......................................... 14 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...................................... 14 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ..................................... 14 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. ....................................... 14 Antivirals, HIV-Specific, Fusion Inhibitors ........................................................ 14 Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................. 15 Antivirals, HIV-Specific, Nucleoside Analog, RTI ............................................ 15 Antivirals, HIV-Specific, Nucleotide Analog, RTI ............................................. 15 Antivirals, HIV-Specific, Protease Inhibitor Comb ........................................... 15 Antivirals, HIV-Specific, Protease Inhibitors .................................................... 15 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors ...................................... 15 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ........... 15 Cytochrome P450 Inhibitors ............................................................................ 15 Hepatitis B Treatment Agents .......................................................................... 15 Hepatitis C Combination Agents ...................................................................... 15 Hepatitis C Treatment Agents .......................................................................... 15

INFLAMMATORY DISEASE .................................................................................. 15 Anti-Arthritic & Chelating Agents ..................................................................... 15 Anti-Arthritic, Folate Antagonist Agents ........................................................... 15 Anti-Inflammatory Tumor Necrosis Factor Inhibitor ......................................... 15 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ......................................... 15 Bradykinin B2 Receptor Antagonists ............................................................... 15 Glucocorticoids ................................................................................................ 15 Mineralocorticoids ............................................................................................ 15 Monoclonal antibody-human interleukin .......................................................... 15 NSAIDs, Cyclooxygenase Inhibitor-Type ........................................................ 15

LOCAL ANESTHESIA ............................................................................................ 15 Local Anesthetics ............................................................................................. 15

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ................ 15 Bowel Antiinflamatory Agents .......................................................................... 15 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ......................................... 15 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...................................... 15 Hemorrhoidal Preparations .............................................................................. 15 Rectal Preparations ......................................................................................... 15 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ..................................... 16

LOWER GASTROINTESTINAL DISORDERS - OTHER ...................................... 16 Ammonia Inhibitors .......................................................................................... 16 Antidiarrheals ................................................................................................... 16 Bile Salts .......................................................................................................... 16 Laxatives & Cathartics ..................................................................................... 16 Narcotic Antagonists, Peripherally-Acting ....................................................... 16

MISCELLANEOUS AGENTS ................................................................................. 16 Anaphylaxis Therapy Agents ........................................................................... 16 Parasympathetic Agents .................................................................................. 16 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase ................................... 16

NEOPLASTIC DISEASE ........................................................................................ 16 Alkylating Agents ............................................................................................. 16 Antiandrogenic Agents ..................................................................................... 16 Antimetabolites ................................................................................................ 16 Antineoplastic - Aromatase Inhibitors .............................................................. 16 Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors ...................................... 16 Antineoplastic – Hedgehog Pathway Inhibitors ............................................... 16 Antineoplastic – Janus Kinase (JAK) Inhibitors ............................................... 16 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ....................................... 16 Antineoplastic - Topoisomerase I Inhibitors..................................................... 16 Antineoplastic - Immunomodulator Agents ...................................................... 16 Antineoplastic - Systemic Enzyme Inhibitors ................................................... 16 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ..................................... 16 Antineoplastics, Miscellaneous ........................................................................ 16 Chemotherapy Rescue/Antidote Agents ......................................................... 17 Selective Estrogen Receptor Modulators (SERM) .......................................... 17 Selective Retinoid X Receptor Agonists (RXR) ............................................... 17 Steroid Antineoplastics .................................................................................... 17

NEUROLOGICAL DISEASE - MISCELLANEOUS ................................................ 17 Agents to Treat Multiple Sclerosis ................................................................... 17 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor .............................. 17 Movement Disorders (Drug Therapy) .............................................................. 17

ORAL/PHARYNGEAL DISORDERS ..................................................................... 17 Dental Aids & Preparations .............................................................................. 17 Nose Preparations, Antibiotics ......................................................................... 17 Nose Preparations, Miscellaneous (Rx) .......................................................... 17

OTHER DRUGS ..................................................................................................... 17 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome .................. 17 General Inhalation Agents ............................................................................... 17 Metabolic disease enzyme replace, hypophosphatasia .................................. 17 Needles/Needleless Devices ........................................................................... 17 Nucleic Acid/Nucleotide Supplements ............................................................. 17 Drugs to treat hereditary tyrosinemia .............................................................. 17

OTHER RESPIRATORY DISORDERS ................................................................. 17 Antifibrotic Therapy – Pyridone Analogs ................................................................ 17

Cystic Fibrosis-Cftr Potentiator & Corrector Comb. ......................................... 17 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators ......................................................................................................................... 17 Mucolytics ........................................................................................................ 17 Pulmonary Fibrosis – Systemic Enzyme Inhibitors ......................................... 17

PAIN MANAGEMENT - ANALGESICS ................................................................. 17 Analgesic, Non-Salicylate & Barbiturate Combinations .................................. 17 Analgesic, Salicylate, Barbiturate & Xanthine Combinations .......................... 17


37014 MedPerform High Formulary – April 2017 v

Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations .................. 17 Analgesic/Antipyretics, Salicylates .................................................................. 17 Analgesics, Narcotics ....................................................................................... 17 Antimigraine Preparations ................................................................................ 17 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 18 Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ........................... 18 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ....................... 18 Narcotic Withdrawal Therapy Agents .............................................................. 18

PARKINSON’S DISEASE ...................................................................................... 18 Antiparkinsonism Drugs, Anticholinergic ......................................................... 18 Antiparkinsonism Drugs, Other ........................................................................ 18 Decarboxylase Inhibitors .................................................................................. 18

SEIZURE DISORDER ............................................................................................ 18 Anticonvulsants ................................................................................................ 18

SKELETAL MUSCLE DISORDER ......................................................................... 18 Agents To Treat Periodic Paralysis ................................................................. 18 Skeletal Muscle Relaxants ............................................................................... 18

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 18 Pancreatic Enzymes ........................................................................................ 18

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 18 Anticholinergics/Antispasmodics ..................................................................... 18 Belladonna Alkaloids ........................................................................................ 18

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ....................... 18 Anti-Ulcer Preparations .................................................................................... 18 Anti-Ulcer-H.pylori Agents ................................................................................ 18 Anticholinergics, Quaternary Ammonium ........................................................ 18 Histamine H2-Receptor Inhibitors .................................................................... 18 Intestinal Motility Stimulants............................................................................. 18 Proton-Pump Inhibitors .................................................................................... 18

URINARY TRACT - FUNCTIONAL DISORDERS ................................................. 18 Benign Prostatic Hypertrophy/Micturition Agents ............................................ 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents.......................................................................................................................... 19 Kidney Stone Agents ....................................................................................... 19 Overactive Bladder Agents, Beta-3 Adrenergic Recep ................................... 19 Urinary Tract Analgesic Agents ....................................................................... 19 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) .................................... 19 Urinary Tract Antispasmodic, M(3) Selective Antagonists .............................. 19 Urinary Tract Antispasmodic/Antiincontinence Agents .................................... 19

VAGINAL DISORDERS ......................................................................................... 19 Vaginal Antibiotics ............................................................................................ 19 Vaginal Antifungals .......................................................................................... 19 Vaginal Estrogen Preparations ........................................................................ 19 Vaginal Sulfonamides ...................................................................................... 19

VITAMIN AND/OR MINERAL DEFICIENCY ......................................................... 19 Fluoride Preparations ....................................................................................... 19 Folic Acid Preparations .................................................................................... 19 Multivitamin Preparations ................................................................................. 19 Pediatric Vitamin Preparations ........................................................................ 19 Prenatal Vitamin Preparations ......................................................................... 19 Vitamin B Preparations .................................................................................... 19 Vitamin D Preparations .................................................................................... 19

SPECIALTY INJECTABLE CROSS REFERENCE LISTING ................................ 19


37014 MedPerform High Formulary – April 2017 6

ALLERGY

Allergenic extracts

PA 5-grass pollen extract ORALAIR

PA short ragweed pollen extract RAGWITEK

PA timothy grass pollen extract GRASTEK

2nd Generation Antihistamine & Decongestant Combinations

p-ephed HCl/cetirizine HCl (OTC) ZYRTEC-D (OTC)

p-ephed sul/loratadine (OTC) CLARITIN-D 12 HOUR (OTC) CLARITIN-D 24 HOUR (OTC)

Antihistamines - 1st Generation

hydroxyzine HCl ATARAX

hydroxyzine pamoate VISTARIL

promethazine HCl PHENERGAN

Antihistamines - 2nd Generation

cetirizine HCl (OTC) ZYRTEC (OTC)

levocetirizine dihydrochloride XYZAL TABS

loratadine (OTC) CLARITIN (OTC)

Nasal Anti-Inflammatory Steroids

QL flunisolide NASAREL

QL fluticasone propionate FLONASE

QL triamcinolone acetonide NASACORT AQ

QL + ST QL + ST

betamethasone dipropionate QNASL QNASL CHILDREN

QL mometasone furoate NASONEX

Nasal Antihistamine

QL QL + ST

azelastine HCl ASTELIN ASTEPRO

ANTIEMESIS/ANTIVERTIGO

Antiemetic/Antivertigo Agents

QL + ST

dronabinol MARINOL

meclizine HCl ANTIVERT

ondansetron ZOFRAN ODT

QL ondansetron HCl (QL on solution)

ZOFRAN

prochlorperazine maleate COMPAZINE

promethazine HCl PHENERGAN

QL netupitant/palonosetron HCl AKYNZEO

QL aprepitant EMEND

prochlorperazine edisylate COMPAZINE SYRUP

ASTHMA

Beta-Adrenergic Agents

albuterol sulfate ALBUTEROL SULFATE

metaproterenol sulfate ALUPENT

terbutaline sulfate BRETHINE

albuterol sulfate PROAIR HFA PROAIR RESPICLICK VENTOLIN HFA

QL formoterol fumarate PERFOROMIST

QL olodaterol HCl STRIVERDI RESPIMAT

QL salmeterol xinafoate SEREVENT DISKUS

Beta-Adrenergic & Anticholinergic Combinations

ipratropium/albuterol sulfate DUONEB

ipratropium/albuterol sulfate COMBIVENT COMBIVENT RESPIMAT

QL tiotropium br/olodaterol HCl STIOLTO RESPIMAT

Beta-Adrenergic & Glucocorticoid Combinations

QL QL

fluticasone/salmeterol ADVAIR DISKUS ADVAIR HFA

QL fluticasone/vilanterol BREO ELLIPTA

QL QL

mometasone/formoterol budesonide/formoterol fumarate

DULERA SYMBICORT

General Bronchodilator Agents

ipratropium bromide ATROVENT

QL ipratropium bromide ATROVENT HFA

QL tiotropium bromide SPIRIVA

QL tiotropium bromide SPIRIVA RESPIMAT

Leukotriene Receptor Antagonists

montelukast sodium SINGULAIR

Mast Cell Stabilizers

cromolyn sodium INTAL

Oral Inhaled Corticosteroids

QL budesonide PULMICORT RESPULES

QL beclomethasone dipropionate QVAR

QL budesonide PULMICORT FLEXHALER

QL QL

mometasone furoate ASMANEX ASMANEX HFA

Phosphodiesterase-4 (PDE4) Inhibitors

QL + ST

roflumilast DALIRESP

Xanthines

aminophylline AMINOPHYLLIN

theophylline anhydrous UNIPHYL

theophylline anhydrous THEO-24

AUTONOMIC NERVOUS SYSTEM DISORDERS

Alzheimer's Therapy, NMDA Receptor Antagonists

QL memantine hcl NAMENDA

QL memantine hcl NAMENDA XR

Alzheimer's Therapy, NMDA Receptor Antagonists & Cholines Inhibitors

QL + ST QL + ST

memantine hcl/donepezil hcl NAMZARIC NAMZARIC TITRATION PACK

Cholinesterase Inhibitors

donepezil hcl ARICEPT ARICEPT ODT

QL QL

galantamine hydrobromide RAZADYNE RAZADYNE ER

pyridostigmine bromide MESTINON

QL rivastigmine EXELON PATCH

rivastigmine tartrate EXELON

neostigmine bromide PROSTIGMIN

BEHAVIORAL HEALTH - ANTIDEPRESSANTS

Alpha-2 Receptor Antagonist Antidepressants

mirtazapine REMERON

MAOIs - Non-Selective & Irreversible

tranylcypromine sulfate PARNATE

phenelzine sulfate NARDIL

Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs)

bupropion HCl WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram hydrobromide CELEXA

escitalopram oxalate LEXAPRO

fluoxetine HCl PROZAC

fluoxetine er PROZAC WEEKLY

paroxetine HCl PAXIL

sertraline HCl ZOLOFT

SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb

QL olanzapine/fluoxetine SYMBYAX

SSRI & 5HT1A Partial Agonist Antidepressants

QL + ST

vilazodone hcl VIIBRYD

SSRI, Serotonin Receptor Modulator Antidepressants

QL + ST

vortioxetine hydrobromide TRINTELLIX

Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)

trazodone HCl DESYREL 300MG

Serotonin-Norepinephrine Reuptake-Inhib (SNRIs)



QL + ST

desvenlafaxine ER (Ranbaxy Brand)

DESVENLAFAXINE ER (RANBAXY BRAND)

QL + ST

desvenlafaxine succinate PRISTIQ

QL duloxetine hcl CYMBALTA

QL + ST

levomilnacipran hcl FETZIMA

venlafaxine hcl EFFEXOR, EFFEXOR XR

Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib

amitriptyline HCl ELAVIL

amoxapine ASENDIN

clomipramine HCl ANAFRANIL

desipramine HCl NORPRAMIN

doxepin HCl SINEQUAN

imipramine HCl TOFRANIL

maprotiline HCl LUDIOMIL

nortriptyline HCl PAMELOR

BEHAVIORAL HEALTH - OTHER

Adrenergics, Aromatic, Non-Catecholamine

QL QL

amphet asp/amphet/d-amphet ADDERALL ADDERALL XR

QL QL QL

dextroamphetamine sulfate dextroamphetamine capsule dextroamphetamine tablet (5mg, 10mg)

DEXEDRINE DEXEDRINE SPANSULE ZENZEDI

QL + ST

dextroamphetamine tablet (2.5mg, 7.5mg)

ZENZEDI

QL dextroamphetamine tablet (15mg, 20mg, 30mg)

ZENZEDI

QL + ST

lisdexamfetamine dimesylate VYVANSE

Anti-Alcoholic Preparations

disulfiram ANTABUSE

Anti-Anxiety Drugs

alprazolam XANAX ALPRAZOLAM INTENSOL

buspirone HCl BUSPAR VANSPAR

chlordiazepoxide HCl LIBRIUM

clorazepate dipotassium TRANXENE T-TAB

diazepam VALIUM

lorazepam ATIVAN LORAZEPAM INTENSOL

meprobamate MILTOWN

oxazepam SERAX

Anti-Mania Drugs

lithium carbonate ESKALITH LITHOBID

lithium citrate CIBALITH-S

Antipsychotics, Phenothiazines

chlorpromazine HCl THORAZINE

fluphenazine HCl PROLIXIN

perphenazine TRILAFON

thioridazine HCl MELLARIL

trifluoperazine HCl STELAZINE

Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed

QL + ST

cariprazine hcl VRAYLAR

Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed

ST + QL

aripiprazole

ABILIFY SOLUTION

QL aripiprazole ABILIFY TABLET

ST + QL

Aripiprazole

ABILIFY DISCMELT

ST + QL

brexpiprazole REXULTI

Antipsychotics, Dopamine & Serotonin Antagonists

loxapine succinate LOXITANE

Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists

QL + ST QL QL + ST

asenapine maleate clozapine lurasidone hcl

SAPHRIS CLOZARIL LATUDA

QL olanzapine ZYPREXA

QL olanzapine ODT ZYPREXA ZYDIS

QL quetiapine fumarate SEROQUEL

QL quetiapine fumarate ER SEROQUEL XR

QL risperidone RISPERDAL

QL risperidone ODT RISPERDAL M-TAB

QL ziprasidone HCl GEODON

Antipsychotics, Dopamine Antagonists, Thioxanthenes

thiothixene NAVANE

Antipsychotics, Dopamine Antagonists, Butyrophenones

haloperidol HALDOL

haloperidol lactate HALDOL ORAL CONC.

Barbiturates

phenobarbital PHENOBARBITAL

Narcolepsy and Sleep Disorder Therapy Agents

PA modafinil PROVIGIL

Narcotic Antagonists

naltrexone HCl REVIA

QL naloxone HCl NARCAN NASAL

Sedative-Hypnotics, Non-Barbiturate

chloral hydrate NOCTEC

estazolam PROSOM

QL eszopiclone LUNESTA

flurazepam HCl DALMANE

temazepam RESTORIL

triazolam HALCION

QL zaleplon SONATA

QL QL + ST

zolpidem tartrate zolpidem tartrate ER

AMBIEN AMBIEN CR

Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy

QL QL+ AGE

dexmethylphenidate HCl FOCALIN FOCALIN XR

QL+ AGE QL+ AGE QL+ AGE QL QL QL+ AGE QL+ AGE

methylphenidate HCl

CONCERTA METADATE CD METADATE ER METHYLIN CHEW TAB METHYLIN SOLN RITALIN RITALIN LA RITALIN SR

QL + ST

methylphenidate ER Susp QUILLIVANT XR

Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type

QL atomoxetine HCl STRATTERA

CARDIOVASCULAR DISEASE - ARRHYTHMIA

Antiarrhythmics

amiodarone HCl CORDARONE

disopyramide phosphate NORPACE

flecainide acetate TAMBOCOR

mexiletine HCl MEXITIL

procainamide HCl PRONESTYL

propafenone HCl RYTHMOL

quinidine gluconate QUINAGLUTE



quinidine sulfate QUINIDEX

disopyramide phosphate NORPACE CR

dofetilide TIKOSYN

dronedarone HCl MULTAQ

propafenone HCl RYTHMOL SR

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS

Digitalis Glycosides

digoxin LANOXIN

DIGOXIN ORAL SOLN.

CARDIOVASCULAR DISEASE - HYPERTENSION

ACE Inhibitor/Calcium Channel Blocker Combinations

amlodipine besylate/benazepril LOTREL

ACE Inhibitor/Thiazide & Thiazide-Like Diuretics

benazepril/hydrochlorothiazide LOTENSIN HCT

captopril/hydrochlorothiazide CAPOZIDE

enalapril/hydrochlorothiazide VASERETIC

fosinopril/hydrochlorothiazide MONOPRIL HCT

lisinopril/hydrochlorothiazide PRINZIDE ZESTORETIC

moexipril/hydrochlorothiazide UNIRETIC

quinapril/hydrochlorothiazide ACCURETIC

Alpha-Adrenergic Blocking Agents

doxazosin mesylate CARDURA

phenoxybenzamine HCl DIBENZYLINE

prazosin HCl MINIPRESS

terazosin HCl HYTRIN

Alpha/Beta-Adrenergic Blocking Agents

carvedilol COREG

labetalol HCl TRANDATE

carvedilol phosphate COREG CR

Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations

ST amlodipine/valsartan/hctz EXFORGE HCT

ST olmesartan/amlodipine/hctz TRIBENZOR

Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations

irbesartan/hydrochlorothiazide AVALIDE

losartan/hydrochlorothiazide HYZAAR

valsartan/hydrochlorothiazide DIOVAN HCT

ST olmesartan/hydrochlorothiazide BENICAR HCT

Angiotensin II Receptor Blocker-Beta Blocker Comb.

nebivolol HCl/valsartan BYVALSON

Angiotensin Receptor Antagonist & Calcium Channel Blockers

ST amlodipine/valsartan EXFORGE

ST amlodipine bes/olmesartan med AZOR

Antihypertensives, ACE Inhibitors

benazepril HCl LOTENSIN

captopril CAPOTEN

enalapril maleate VASOTEC

fosinopril sodium MONOPRIL

lisinopril PRINIVIL ZESTRIL

moexipril HCl UNIVASC

quinapril HCl ACCUPRIL

ramipril ALTACE

trandolapril MAVIK

Antihypertensives, Angiotensin Receptor Antagonist

irbesartan AVAPRO

losartan potassium COZAAR

valsartan DIOVAN

ST olmesartan medoxomil BENICAR

Antihypertensives, Sympatholytic

clonidine HCl CATAPRES

guanfacine HCl TENEX

methyldopa ALDOMET

reserpine SERPASIL

Antihypertensives, Vasodilators

hydralazine HCl APRESOLINE

Beta-Adrenergic Blocking Agents

acebutolol HCl SECTRAL

atenolol TENORMIN

bisoprolol fumarate ZEBETA

metoprolol succinate TOPROL XL

metoprolol tartrate LOPRESSOR

nadolol CORGARD

pindolol VISKEN

propranolol HCl INDERAL LA

sotalol HCl BETAPACE BETAPACE AF

timolol maleate BLOCADREN

nebivolol HCl BYSTOLIC

Beta-Adrenergic Blocking Agents/Thiazide & Related

atenolol/chlorthalidone TENORETIC 100 TENORETIC 50

bisoprolol fumarate/hctz ZIAC

metoprolol/hctz LOPRESSOR HCT

propranolol/hydrochlorothiazide INDERIDE-40/25

Calcium Channel Blocking Agents

amlodipine besylate NORVASC

diltiazem HCl CARDIZEM CARDIZEM CD DILACOR XR TIAZAC

felodipine PLENDIL

isradipine IR capsules DYNACIRC

nicardipine HCl CARDENE

nifedipine ADALAT CC PROCARDIA PROCARDIA XL

nimodipine NIMOTOP

verapamil HCl CALAN VERELAN

verapamil HCl ER CALAN SR VERELAN PM

Loop Diuretics

bumetanide BUMEX

furosemide LASIX

torsemide DEMADEX

Potassium Sparing Diuretics

eplerenone INSPRA

spironolactone ALDACTONE

Potassium Sparing Diuretics in Combination

triamterene/hydrochlorothiazide DYAZIDE MAXZIDE MAXZIDE-25MG

Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors

PA sildenafil citrate REVATIO TABLET

PA tadalafil ADCIRCA

Pulmonary Anti-HTN, Endothelin Receptor Antagonists

PA ambrisentan LETAIRIS

PA bosentan TRACLEER

PA macitentan OPSUMIT

Pulmonary Anti-HTN, Prostacyclin-Type

PA selexipag UPTRAVI

Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators

PA riociguat ADEMPAS

Thiazide & Related Diuretics

chlorthalidone HYGROTON

hydrochlorothiazide MICROZIDE

indapamide LOZOL

metolazone ZAROXOLYN

chlorthalidone THALITONE

CARDIOVASCULAR DISEASE - LIPID IRREGULARITY

Antihyperlipidemic - APO B-100 Synthesis Inhibitor

PA mipomersen sodium KYNAMRO



Antihyperlipidemic - HMG CoA Reductase Inhibitors

atorvastatin calcium LIPITOR

QL

lovastatin pitavastatin

MEVACOR LIVALO

pravastatin sodium PRAVACHOL

simvastatin ZOCOR

ST simvastatin (80mg only)

QL rosuvastatin calcium CRESTOR

Antihyperlipidemic - MTP Inhibitors

PA + QL

lomitapide JUXTAPID

Antihyperlipidemic –PCSK9 Inhibitors

PA alirocumab PRALUENT

PA evolocumab REPATHA

Bile Salt Sequestrants

cholestyramine/aspartame QUESTRAN LIGHT

cholestyramine/sucrose QUESTRAN

colesevelam HCl WELCHOL WELCHOL POWDER PACKETS

colestipol COLESTID COLESTID GRANULES

Lipotropics

ST fenofibrate FENOGLIDE LOFIBRA TABS

fenofibrate, micronized LOFIBRA CAPS

fenofibrate nanocrystallized TRICOR

gemfibrozil LOPID

ST niacin NIASPAN

QL omega-3 acid ethyl esters LOVAZA

QL ezetimibe ZETIA

ST fenofibrate TRIGLIDE

QL icosapent ethyl VASCEPA

Niacin Preparations

niacin SLO-NIACIN

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS

Adrenergic Vasopressor Agents

midodrine HCl PROAMATINE

Antianginal & Anti-Ischemic Agents, Non-Hemodynamic

QL ranolazine RANEXA

Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations

QL amlodipine/atorvastatin CADUET

Heart Rate Reducing, Selective I(F) Current Inhib.

PA + QL

ivabradine HCl CORLANOR

CARDIOVASCULAR DISEASE - VASODILATION

Vasodilators, Combination

isosorb dinit/hydralazine HCl BIDIL

Vasodilators, Coronary

isosorbide dinitrate ISOCHRON ISORDIL ISORDIL TITRADOSE

isosorbide mononitrate IMDUR ISMO MONOKET

nitroglycerin transdermal patch nitroglycerin sublingual solution

NITRO-DUR NITROLINGUAL

nitroglycerin transdermal ointment nitroglycerin sublingual tablet

NITRO-BID NITROSTAT

CONTRACEPTION/OXYTOCICS

Contraceptives, Intravaginal, Systemic

QL etonogestrel/ethinyl estradiol NUVARING

Contraceptives, Oral

desog-et estra/ethin estra MIRCETTE

desogestrel-ethinyl estradiol CYCLESSA DESOGEN ORTHO-CEPT

ST ethinyl estradiol/drospirenone GIANVI

ST ST ST ST ST ST ST

LORYNA OCELLA SYEDA VESTURA YASMIN 28 YAZ ZARAH

ethynodiol d-ethinyl estradiol DEMULEN 1-50-21

levonorgestrel AFTERA PLAN B ONE-STEP TAKE ACTION

QL

levonorgestrel-eth estra NORDETTE-28 SEASONALE AVIANE-28 LESSINA LUTERA ORSYTHIA SRONYX

ST

noreth a-et estra/fe fumarate LOESTRIN FE LOESTRIN FE24

norethindrone NOR-Q-D ORTHO MICRONOR

norethindrone a-e estradiol LOESTRIN

norethindrone-ethinyl estrad NORINYL 1+35 ORTHO-NOVUM TRI-NORINYL

norethindrone-mestranol NORINYL 1+50

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN ORTHO-CYCLEN

norgestrel-ethinyl estradiol LO-OVRAL-28

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO

ST noreth a-et estra/fe fumarate LO LOESTRIN FE

Contraceptives, Transdermal

QL norelgestromin/ethin.estradiol ORTHO EVRA

Oxytocics

methylergonovine maleate METHERGINE

COUGH AND COLD

1st Generation Antihistamine & Decongestant Combinations

phenylephrine HCl/prometh HCl PHENERGAN VC

Narcotic Antitussive-1st Generation Antihistamine-Decongestants

phenylephrine HCl/cod/prometh PHENERGAN VC W/CODEINE

Narcotic Antitussive-1st Generation Antihistamines

codeine/promethazine HCl PHENERGAN W/CODEINE

hydrocodone/chlorphen p-stirex TUSSIONEX

Narcotic Antitussive-Anticholinergic Comb.

hydrocodone/homatrop me-br HYCODAN

Non-Narcotic Antitussive-1st Generation Antihistamine Combinations

d-methorphan hb/prometh HCl PHENERGAN W/ DEXTROMETHORPHAN

DERMATOLOGY - ACNE

Acne Agents, Systemic

isotretinoin AMNESTEEM CLARAVIS MYORISAN SOTRET ZENATANE

Acne Agents, Topical

AGE + ST ST

adapalene/benzoyl peroxide clindamycin phos/benzoyl peroxide clindamycin phos/benzoyl peroxide

EPIDUO, EPIDUO FORTE ONEXTON BENZACLIN

clindamycin/tretinoin sulfacetamide sodium

ZIANA KLARON

Keratolytic-Glucocorticoid Combinations

benzoyl peroxide/hydrocortisone VANOXIDE-HC



Keratolytics

benzoyl peroxide BREVOXYL-4 BREVOXYL-8 TRIAZ

podofilox CONDYLOX

Rosacea Agents, Topical

metronidazole METROCREAM METROLOTION

Vitamin A Derivatives

AGE adapalene DIFFERIN

AGE tazorotene foam FABIOR

DERMATOLOGY - ANTIINFECTIVE

Topical Antibiotics

clindamycin phosphate CLEOCIN T

erythromycin base/benz per BENZAMYCIN

erythromycin base/ethanol EMGEL ERYGEL

gentamicin sulfate GARAMYCIN

mupirocin ointment BACTROBAN CENTANY

mupirocin calcium cream BACTROBAN

clindamycin phosphate EVOCLIN

erythromycin base/benz per BENZAMYCIN PAK

Topical Antifungals

ciclopirox olamine LOPROX

ciclopirox 8% solution CICLODAN

clotrimazole/betamet diprop LOTRISONE

ketoconazole KURIC NIZORAL

naftifine HCl 1% cream NAFTIN

naftifine HCl 1% gel, 2% cream/gel

NAFTIN

nystatin MYCOSTATIN

nystatin/triamcin MYCOLOG II

sulconazole nitrate EXELDERM

terbinafine HCl LAMISIL

Topical Antiparasitics

lindane KWELL

malathion OVIDE

permethrin ELIMITE

crotamiton EURAX

Topical Antivirals

acyclovir ZOVIRAX OINTMENT

acyclovir ZOVIRAX CREAM

Topical Sulfonamides

silver sulfadiazine SILVADENE THERMAZENE

DERMATOLOGY - ANTIINFLAMMATORY

Topical Anti-Inflammatory Steroidal

alclometasone dipropionate ACLOVATE

amcinonide CYCLOCORT

betamet diprop/prop gly DIPROLENE DIPROLENE AF

betamethasone dipropionate DEL-BETA DIPROSONE

betamethasone valerate VALISONE

clobetasol propionate CLOBEX

clobetasol propionate OLUX TEMOVATE

clobetasol propionate/emoll TEMOVATE EMOLLIENT

desonide DESOWEN TRIDESILON

desoximetasone TOPICORT TOPICORT LP

diflorasone diacetate APEXICON

fluocinolone acetonide SYNALAR

fluocinonide LIDEX VANOS

fluocinonide/emollient LIDEX-E

fluticasone propionate CUTIVATE

halobetasol propionate ULTRAVATE

hydrocortisone LACTICARE-HC REDERM SCALACORT

hydrocortisone acetate/urea CARMOL HC

hydrocortisone butyrate LOCOID

hydrocortisone valerate WESTCORT

mometasone furoate ELOCON

triamcinolone acetonide KENALOG TRIDERM

diflorasone diacetate/emoll APEXICON E

flurandrenolide CORDRAN CORDRAN SP

hydrocort/sal acid/sulf/shmp#1 SCALACORT DK

hydrocortisone TEXACORT

hydrocortisone butyrate/emoll LOCOID LIPOCREAM

hydrocortisone probutate PANDEL

Topical Anti-Inflammatory, NSAIDs

diclofenac sodium VOLTAREN GEL

Topical Antibiotics/Antiinflammatory, Steroidal

neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM

neomycin/bacitra/polymyxin/hc CORTISPORIN OINT

DERMATOLOGY - MISCELLANEOUS

Antiperspirants

aluminum chloride DRYSOL

Antiseborrheic Agents

selenium sulfide SELSUN RX

sulfacetamide sodium OVACE PLUS SUSP

Topical Antineoplastic & Premalignant Lesion Agents

fluorouracil EFUDEX

PA bexarotene TARGRETIN

QL ingenol PICATO

PA mechlorethamine gel VALCHLOR

Topical Local Anesthetics

hc acetate/pramoxine HCl PRAMOSONE

DERMATOLOGY - PIGMENTATION DISORDERS

Topical Hyperpigmentation Agents

methoxsalen OXSORALEN

DERMATOLOGY - PSORIASIS/ECZEMA

Antipsoriatic Agents, Systemic

acitretin SORIATANE

methoxsalen, rapid OXSORALEN-ULTRA

methoxsalen 8-MOP

PA secukinumab COSENTYX

Antipsoriatics Agents

ST calcipotriene DOVONEX

anthralin DRITHO-SCALP

ST anthralin DRITHOCREME HP

tazarotene TAZORAC

Topical Immunosuppressive Agents

ST

tacrolimus pimecrolimus

PROTOPIC ELIDEL

DIABETES

Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea)

acarbose PRECOSE

Antihyperglycemic, Amylin Analog-Type

pramlintide acetate SYMLIN SYMLINPEN 120 SYMLINPEN 60

Antihyperglycemic, DPP-4 Inhibitors

QL linagliptin TRADJENTA

QL sitagliptin phosphate JANUVIA

Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations

QL linagliptin/metformin HCl JENTADUETO



QL sitagliptin phos/metformin HCl JANUMET

QL sitagliptin phos/metformin HCl JANUMET XR

Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists)

QL + ST

dulaglutide TRULICITY

QL + ST

liraglutide VICTOZA

Antihyperglycemic, Insulin-Release Stimulant Type

chlorpropamide DIABINESE

glimepiride AMARYL

glipizide GLUCOTROL GLUCOTROL XL

glipizide/metformin HCl METAGLIP

glyburide MICRONASE

nateglinide STARLIX

repaglinide PRANDIN

tolazamide TOLINASE

tolbutamide ORINASE

glyburide DIABETA

Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea)

pioglitazone HCl ACTOS

Antihyperglycemic, Biguanide Type (Non-Sulfonylurea)

metformin HCl GLUCOPHAGE GLUCOPHAGE XR

metformin HCl RIOMET

Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations

glyburide, micro/metformin HCl GLUCOVANCE

repaglinide/metformin HCl PRANDIMET

Antihyperglycemic, Insulin-Response & Release Combinations

ST pioglitazone/glimepiride DUETACT

Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations

ST ST

pioglitazone HCl/metformin HCl pioglitazone HCl/metformin HCl

ACTOPLUS MET ACTOPLUS MET XR

Antihyperglycemic-Glucocorticoid Receptor Blockers

PA mifepristone KORLYM

Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors

QL + ST

canagliflozin INVOKANA

QL + ST

empagliflozin JARDIANCE

Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination

QL + ST

canagliflozin/metformin HCl INVOKAMET

QL + ST

canagliflozin/metformin HCl INVOKAMET XR

QL + ST

empagliflozin/metformin HCl SYNJARDY

Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination

QL + ST

empagliflozin/linagliptin GLYXAMBI

Diabetic Supplies

blood-glucose calib. control ABBOTT CONTROL PRODUCTS (e.g., FREESTYLE, PRECISION)

blood-glucose meter ABBOTT METERS(e.g., FREESTYLE, PRECISION)

blood sugar diagnostics ABBOTT TEST STRIPS (e.g., FREESTYLE, PRECISION)

lancing device/lancets ABBOTT PRODUCTS

Diabetic Ulcer Preparations, Topical

becaplermin REGRANEX

Hyperglycemics

glucagon, human recombinant GLUCAGON EMERGENCY KIT

Insulins

QL QL

insulin glargine,hum.rec.anlog LANTUS TOUJEO

QL insulin lispro HUMALOG

QL insulin nph hum/reg insulin hm HUMULIN 70-30

QL insulin nph human isophane HUMULIN N

QL QL

insulin npl/insulin lispro HUMALOG MIX 50-50 HUMALOG MIX 75-25

QL insulin regular, human HUMULIN R

insulin regular, human HUMULIN R U-500

Syringes & Accessories

syringes & needles ALL COMMERCIALLY AVAILABLE SYRINGES AND NEEDLES

EAR - GENERAL DISORDERS

Ear Preparations, Misc. Anti-Infectives

acetic acid VOSOL

acetic acid/aluminum acetate DOMEBORO

acetic acid/hydrocortisone VOSOL HC

Ear Preparations, Antibiotics

neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC OTICIN HC

ofloxacin FLOXIN

Otic Preparations, Anti-Inflammatory-Antibiotics

ciprofloxacin HCl/dexameth CIPRODEX

Otic Preparations, Local anesthetics

antipyrine/benzocaine otic BENZOTIC

ELECTROLYTE REGULATION

Electrolyte Depleters

calcium acetate PHOSLO

sodium polystyrene sulfonate KAYEXALATE

sevelamer carbonate RENVELA

sevelamer HCl RENAGEL

Potassium Replacement

potassium chloride K-DUR K-TAB MICRO-K

ENDOCRINE DISORDER - FERTILITY

Drugs to Treat Impotency

QL sildenafil citrate VIAGRA

Fertility Stimulating Preparations, Non-FSH

clomiphene citrate CLOMID SEROPHENE

Follicle Stimulating / Luteinizing Hormones

follitropin alpha, recomb GONAL-F GONAL-F RFF

gonadotropin, chorionic, human NOVAREL PREGNYL PROFASI

hcg alpha, recombinant OVIDREL

menotropins MENOPUR REPRONEX

Pregnancy Facilitating/Maintaining Agents, Hormonal

progesterone, micronized CRINONE ENDOMETRIN PROCHIEVE

ENDOCRINE DISORDER - OTHER

Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants

PA leuprolide ELIGARD

Antidiuretic & Vasopressor Hormones

desmopressin (nonrefrigerated) DDAVP

Bone Formation Stim. Agents - Parathyroid Hormone

QL teriparatide FORTEO

Bone Resorption Inhibitor & Vitamin D Combinations

alendronate sodium/vitamin d3 FOSAMAX PLUS D



Bone Resorption Inhibitors

alendronate sodium tablet FOSAMAX

QL alendronate sodium solution FOSAMAX SOLUTION

etidronate disodium DIDRONEL

ibandronate BONIVA

QL raloxifene HCl EVISTA

Growth Hormone Receptor Antagonists

pegvisomant SOMAVERT

Growth Hormones

PA somatropin NORDITROPIN

NORDITROPIN FLEXPRO

NORDITROPIN NORDIFLEX

PA somatropin OMNITROPE

Hyperparathyroid Tx Agent, Vitamin D Analog-Type

QL calcifediol paricalcitol

RAYALDEE ZEMPLAR

LHRH (GnRH) Antagonist, Pituitary Suppressant Agents

cetrorelix acetate CETROTIDE

ganirelix acetate GANIRELIX ACETATE

Luteinizing Hormone Releasing Hormone –LHRH (GnRH)

Pituitary Suppressive Agents

cabergoline DOSTINEX

danazol DANOCRINE

ENDOCRINE DISORDER - THYROID

Antithyroid Preparations

methimazole TAPAZOLE

propylthiouracil PROPYLTHIOURACIL

Iodine Containing Agents

potassium iodide POTASSIUM IODIDE

Thyroid Hormones

levothyroxine sodium LEVOTHROID LEVOXYL SYNTHROID

liothyronine sodium CYTOMEL

thyroid, pork ARMOUR THYROID NATURE-THROID WESTHROID

EYE - GENERAL DISORDERS

Eye Antibiotic-Corticoid Combinations

neo/polymyx b sulf/dexameth MAXITROL

neomy sulf/bacitrac zn/poly/hc NEO-POLYCIN HC OPHTH OINTMENT

neomy sulf/polymyx b sulf/hc CORTISPORIN OPHTH SUSPENSION

tobramycin sulfate/dexameth TOBRADEX

tobramycin/lotepred etab ZYLET

Eye Antihistamines

azelastine HCl OPTIVAR

ketotifen fumarate (OTC) ALAWAY (OTC)

olopatadine HCl PATADAY PATANOL

Eye Antiinflammatory Agents

diclofenac sodium VOLTAREN

fluorometholone FML

flurbiprofen sodium OCUFEN

ketorolac tromethamine ACULAR ACULAR LS

prednisolone acetate OMNIPRED PRED FORTE

prednisolone sod phosphate PREDNISOL

difluprednate DUREZOL

fluorometholone FML FORTE FML S.O.P.

fluorometholone acetate FLAREX

loteprednol etabonate ALREX

LOTEMAX

nepafenac ILEVRO NEVANAC

prednisolone acetate PRED MILD

Eye Antivirals

trifluridine VIROPTIC

ganciclovir ZIRGAN

Eye Sulfonamides

na sulfacetm/prednis sp VASOCIDIN

sulfacetamide sodium SULFAC

na sulfacetm/prednisol ac BLEPHAMIDE BLEPHAMIDE S.O.P.

EYE - MISCELLANEOUS

Ophthalmic Cystine Depleting Agents

PA cysteamine CYSTARAN

Ophthalmic Anti-Inflammatory Immunomodulator-Type

QL QL QL

cyclosporine lifitegrast

RESTASIS SINGLE DOSE VIAL RESTASIS MULTIDOSE VIAL XIIDRA

Ophthalmic Antibiotics

bacitracin AK-TRACIN

bacitracin/polymyxin b sulfate POLYCIN-B

ciprofloxacin HCl CILOXAN

erythromycin base ROMYCIN

gatifloxacin ZYMAXID

gentamicin sulfate GARAMYCIN

neomycin/bacitracin/polymyxin NEOSPORIN OPHTH OINTMENT

neomycin/polymyxn b/gramicidin

NEOSPORIN OPHTH DROPS

ofloxacin OCUFLOX

polymyxin b sulfate/tmp POLYTRIM

tobramycin sulfate TOBREX

besifloxacin HCl drops susp 0.6% BESIVANCE

moxifloxacin HCl VIGAMOX

Ophthalmic Mast Cell Stabilizers

cromolyn sodium OPTICROM

lodoxamide tromethamine ALOMIDE

nedocromil sodium ALOCRIL

pemirolast potassium ALAMAST

EYE - GLAUCOMA

Carbonic Anhydrase Inhibitors

acetazolamide DIAMOX SEQUELS

methazolamide NEPTAZANE

Miotics/Other Intraocular Pressure Reducers

betaxolol HCl BETOPTIC

QL bimatoprost 0.03% LUMIGAN

brimonidine tartrate ALPHAGAN P

carteolol HCl OCUPRESS

dorzolamide HCl TRUSOPT

dorzolamide HCl/timolol maleat COSOPT

latanoprost XALATAN

levobunolol HCl BETAGAN

metipranolol OPTIPRANOLOL

pilocarpine HCl ISOPTO CARPINE

timolol maleate TIMOPTIC (Except Ocudose) TIMOPTIC-XE

QL travoprost (benzalkonium) TRAVATAN

betaxolol HCl BETOPTIC S

QL bimatoprost 0.01% LUMIGAN

brimonidine/timolol COMBIGAN

brinzolamide AZOPT

brinzolamide/brimonidine SIMBRINZA

carbachol ISOPTO CARBACHOL

timolol BETIMOL



QL travoprost TRAVATAN Z

Mydriatics

atropine sulfate ISOPTO ATROPINE

cyclopentolate HCl CYCLOGYL

homatropine hbr ISOPTO HOMATROPINE

dipivefrin HCl PROPINE

GOUT AND RELATED DISEASES

Colchicine

QL colchicine COLCRYS

colchicine/probenecid COL-BENEMID

Hyperuricemia Treatment - Purine Inhibitors

allopurinol ZYLOPRIM

QL + ST

febuxostat ULORIC

Uricosuric Agents

QL + ST

lesinurad ZURAMPIC

probenecid BENEMID

HEMATOLOGICAL DISORDERS

Anticoagulants, Coumarin Type

warfarin sodium COUMADIN

Direct Factor XA Inhibitors

QL apixaban ELIQUIS

QL rivaroxaban XARELTO

Hematinics, Other

PA epoetin alfa PROCRIT

Hemorrheologic Agents

pentoxifylline TRENTAL

Heparin & Related Preparations

QL enoxaparin sodium LOVENOX

heparin sodium, porcine HEP-LOCK HEPARIN LOCK

heparin sodium, porcine/pf HEP-LOCK

QL dalteparin sodium, porcine FRAGMIN

QL fondaparinux sodium ARIXTRA

Leukocyte (WBC) Stimulants

PA filgrastim NEUPOGEN

PA pegfilgrastim NEULASTA

PA sargramostim LEUKINE

Platelet Aggregation Inhibitors

cilostazol PLETAL

clopidogrel bisulfate PLAVIX 75MG

QL clopidogrel bisulfate 300mg PLAVIX 300MG

dipyridamole PERSANTINE

QL prasugrel HCl EFFIENT

QL ticagrelor BRILINTA

Platelet Reducing Agents

anagrelide HCl AGRYLIN

Thrombopoietin Receptor Agonists

PA + QL

eltrombopag olamine PROMACTA

Vitamin K Preparations

phytonadione MEPHYTON

HORMONAL DEFICIENCY

Androgenic Agents

QL fluoxymesterone ANDROXY

methyltestosterone ANDROID

PA testosterone 1% ANDROGEL

PA + QL

testosterone cypionate DEPO-TESTOSTERONE

PA testosterone enanthate DELATESTRYL

methyltestosterone METHITEST

PA testosterone gel 1.62% ANDROGEL

PA testosterone solution AXIRON

Estrogen/Androgen Combinations

estrogen, ester/me-testosterone ESTRATEST H.S.

Estrogenic Agents

QL

estradiol CLIMARA ESTRACE VIVELLE-DOT

estropipate OGEN

norethindrone ac-eth estradiol FEMHRT

estradiol ALORA ESTRADERM

QL estradiol/noreth ac COMBIPATCH

estrogens, conj/bazedoxifene DUAVEE

estrogen, con/m-progest acet PREMPHASE PREMPRO

estrogens, conjugated PREMARIN

estrogens, esterified MENEST

Progestational Agents

medroxyprogesterone acet PROVERA

norethindrone acetate AYGESTIN

progesterone, micronized PROMETRIUM

IMMUNOSUPPRESSION/MODULATION

Immunomodulators

PA + QL

imiquimod ALDARA

PA interferon alfa-2b, recomb. INTRON A

Immunosuppressives

azathioprine IMURAN

cyclosporine SANDIMMUNE

cyclosporine, modified NEORAL

mycophenolate mofetil CELLCEPT

sirolimus RAPAMUNE

tacrolimus anhydrous PROGRAF

everolimus ZORTRESS

INFECTIOUS DISEASE - BACTERIAL

Absorbable Sulfonamides

sulfadiazine SULFADIAZINE

sulfamethoxazole/trimethoprim BACTRIM DS SEPTRA SEPTRA DS

sulfisoxazole acetyl GANTRISIN

Beta lactams

PA aztreonam lysine CAYSTON

Cephalosporins - 1st Generation

cefadroxil hydrate DURICEF

cephalexin monohydrate KEFLEX

Cephalosporins - 2nd Generation

cefaclor CECLOR

cefprozil CEFZIL

cefuroxime axetil CEFTIN

Cephalosporins - 3rd Generation

cefdinir OMNICEF

cefpodoxime proxetil VANTIN

cefixime SUPRAX

Chemotherapeutics, Antibacterial, Miscellaneous

trimethoprim PROLOPRIM

meth/meth blue/ba/salicy/hyos PROSED-DS

mth/me blue/salicy/na phos/hyo URETRON D-S URIN D.S.

trimethoprim PRIMSOL

Ketolides

telithromycin KETEK

Lincosamides

clindamycin HCl capsules CLEOCIN HCL

clindamycin palmitate CLEOCIN PALMITATE

Macrolides

azithromycin ZITHROMAX ZITHROMAX TRI-PAK

clarithromycin BIAXIN BIAXIN XL



ery e-succ/sulfisoxazole PEDIAZOLE

erythromycin base ERYC

erythromycin ethylsuccinate ERYPED 200

erythromycin stearate ERYTHROCIN STEARATE

azithromycin ZMAX ZMAX PEDIATRIC

erythromycin base ERY-TAB PCE

erythromycin ethylsuccinate ERYPED 200 ERYPED 400

QL + ST

fidaxomicin DIFICID

Nitrofuran Derivatives

nitrofurantoin macrocrystal MACRODANTIN

nitrofurantoin/nitrofuran mac MACROBID

furazolidone FUROXONE

nitrofurantoin FURADANTIN

Oxazolidinones

PA linezolid ZYVOX

PA tedizolid phosphate tablet SIVEXTRO TABLET

Penicillins

amox tr/potassium clavulanate AUGMENTIN AUGMENTIN ES-600 AUGMENTIN XR

amoxicillin trihydrate AMOXIL

ampicillin trihydrate POLYCILLIN

dicloxacillin sodium PATHOCIL

penicillin v potassium V-CILLIN K

Quinolones

ciprofloxacin CIPRO ORAL SUSPENSION

ciprofloxacin HCl CIPRO

levofloxacin LEVAQUIN

moxifloxacin HCl AVELOX AVELOX ABC PACK

ofloxacin FLOXIN

Tetracyclines

QL QL QL

doxycycline hyclate

VIBRAMYCIN 100MG CAPSULE MORGIDOX 50MG CAPSULE MORGIDOX 100MG CAPSULE

QL doxycycline monohydrate DOXYCYCLINE MONOHYDRATE 150MG TABLET

minocycline HCl DYNACIN MINOCIN

tetracycline HCl ALA-TET

doxycycline calcium VIBRAMYCIN SYRUP

INFECTIOUS DISEASE - FUNGAL

Antifungal Agents

clotrimazole MYCELEX

fluconazole DIFLUCAN

itraconazole SPORANOX

ketoconazole NIZORAL

terbinafine HCl LAMISIL

voriconazole VFEND

terbinafine HCl LAMISIL GRANULES

Antifungal Antibiotics

griseofulvin ultramicrosize GRIS-PEG

nystatin MYCOSTATIN

griseofulvin suspension GRISEOFULVIN V

INFECTIOUS DISEASE - MISCELLANEOUS

Aminoglycosides

neomycin sulfate MYCIFRADIN

PA tobramycin in 0.225% nacl TOBI

PA tobramycin TOBI PODHALER

Anti-Mycobacterium Agents

ethambutol HCl MYAMBUTOL

isoniazid NYDRAZID

pyrazinamide PYRAZINAMIDE

Antileprotics

dapsone AVLOSULFON

PA thalidomide THALOMID

Antitubercular Antibiotics

rifampin RIFADIN

rifampin/isoniazid RIFAMATE

Rifamycins and Related Derivative Antibiotics

PA rifaximin XIFAXAN 550MG

Vancomycin & Derivatives

QL vancomycin HCl VANCOCIN HCL

INFECTIOUS DISEASE - PARASITIC

Amebacides

paromomycin sulfate HUMATIN

iodoquinol YODOXIN

Anaerobic Antiprotozoal-Antibacterial Agents

metronidazole FLAGYL

metronidazole FLAGYL ER

Anthelmintics

PA

praziquantel mebendazole

BILTRICIDE EMVERM

Antimalarial Drugs

chloroquine phosphate ARALEN PHOSPHATE

hydroxychloroquine sulfate PLAQUENIL

mefloquine HCl LARIAM

quinine sulfate QUALAQUIN

primaquine phosphate PRIMAQUINE

PA pyrimethamine DARAPRIM

Antiprotozoal Drugs, Miscellaneous

pentamidine isethionate NEBUPENT

PA miltefosine IMPAVIDO

INFECTIOUS DISEASE - VIRAL

All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit.

Antiretroviral Combination, Integrase Inhibitors

QL abacavir/dolutegravir/lamivudine TRIUMEQ

QL elvitegravir/cobicistat/emtricitabine/ tenofovir disoproxil fumarate

STRIBILD

QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide

GENVOYA

Antivirals, General

acyclovir ZOVIRAX

ganciclovir CYTOVENE

valacyclovir HCl VALTREX

QL oseltamivir phosphate TAMIFLU

ribavirin VIRAZOLE

Antivirals, HIV-Spec, Non-Peptidic Protease Inhib

QL darunavir ethanolate PREZISTA

QL darunavir/cobicistat PREZCOBIX

QL tipranavir APTIVUS CAPS

QL tipranavir/vitamin e tpgs APTIVUS SOLN

Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog

QL emtricitabine/tenofovir TRUVADA

QL emtricitabine/tenofovir alafenamide DESCOVY

Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb

QL abacavir/lamivudine/zidovudine TRIZIVIR

QL abacavir sulfate/lamivudine EPZICOM

QL lamivudine/zidovudine COMBIVIR

Antivirals, HIV-Specific, CCR5 Co-Receptor Antag.

QL maraviroc SELZENTRY

Antivirals, HIV-Specific, Fusion Inhibitors



QL enfuvirtide FUZEON

Antivirals, HIV-Specific, Non-Nucleoside, RTI

QL nevirapine VIRAMUNE

QL nevirapine ER VIRAMUNE XR

delavirdine mesylate RESCRIPTOR

efavirenz SUSTIVA

QL etravirine INTELENCE

QL rilpivirine EDURANT

Antivirals, HIV-Specific, Nucleoside Analog, RTI

QL abacavir sulfate ZIAGEN

QL didanosine VIDEX EC

QL lamivudine EPIVIR

QL stavudine ZERIT

QL zidovudine RETROVIR

QL didanosine VIDEX SOLUTION

QL emtricitabine EMTRIVA

Antivirals, HIV-Specific, Nucleotide Analog, RTI

QL tenofovir disoproxil fumarate VIREAD

Antivirals, HIV-Specific, Protease Inhibitor Comb

QL lopinavir/ritonavir KALETRA

Antivirals, HIV-Specific, Protease Inhibitors

QL atazanavir sulfate REYATAZ

QL atazanavir sulfate/cobicistat EVOTAZ

QL fosamprenavir calcium LEXIVA

indinavir sulfate CRIXIVAN

nelfinavir mesylate VIRACEPT

QL ritonavir NORVIR

QL saquinavir mesylate INVIRASE

Antivirals, HIV-1 Integrase Strand Transfer Inhibtors

QL dolutegravir TIVICAY

QL raltegravir potassium ISENTRESS

Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI

QL efavirenz/emtricitabine/tenofovir ATRIPLA

QL rilpivirine/emtricitabine/tenofovir COMPLERA

QL rilpivirine/emtricitabine/ tenofovir alafenamide

ODEFSEY

Cytochrome P450 Inhibitors

QL cobicistat TYBOST

Hepatitis B Treatment Agents

QL adefovir dipivoxil HEPSERA

QL entecavir BARACLUDE

QL lamivudine EPIVIR HBV TABLET

QL lamivudine EPIVIR HBV SOLUTION

telbivudine TYZEKA

Hepatitis C Combination Agents

PA ledipasvir/sofosbuvir HARVONI

PA sofosbuvir/velpatasvir EPCLUSA

Hepatitis C Treatment Agents

ribavirin 200mg COPEGUS REBETOL CAPSULE

PA PA

peginterferon alfa-2a peginterferon alfa-2a

PEGASYS PEGASYS PROCLICK

ribavirin REBETOL SOLUTION

PA sofosbuvir SOVALDI

INFLAMMATORY DISEASE

Anti-Arthritic & Chelating Agents

PA penicillamine DEPEN

Anti-Arthritic, Folate Antagonist Agents

methotrexate sodium RHEUMATREX

QL ST

methotrexate OTREXUP

Anti-Inflammatory Tumor Necrosis Factor Inhibitor

PA adalimumab HUMIRA

PA etanercept ENBREL

Anti-Inflammatory, Pyrimidine Synthesis Inhibitors

leflunomide ARAVA

Bradykinin B2 Receptor Antagonists

PA icatibant acetate FIRAZYR

Glucocorticoids

budesonide BUDESONIDE

cortisone acetate CORTONE ACETATE

dexamethasone tablet, elixir DECADRON

hydrocortisone CORTEF

methylprednisolone MEDROL

prednisolone MILLIPRED MILLIPRED DP

prednisolone sod phosphate ORAPRED PEDIAPRED

prednisone DELTASONE PREDNISONE INTENSOL

budesonide ENTOCORT EC

Mineralocorticoids

fludrocortisone acetate FLORINEF ACETATE

Monoclonal antibody-human interleukin

PA ustekinumab STELARA SC

NSAIDs, Cyclooxygenase Inhibitor-Type

celecoxib CELEBREX

diclofenac sodium VOLTAREN VOLTAREN-XR

etodolac LODINE

fenoprofen calcium NALFON TABLET

flurbiprofen ANSAID

ibuprofen MOTRIN

indomethacin INDOCIN INDOCIN SR

ketoprofen ORUVAIL

QL ketorolac tromethamine TORADOL

meclofenamate sodium MECLOMEN

meloxicam MOBIC

nabumetone RELAFEN

naproxen EC-NAPROSYN NAPROSYN

naproxen sodium ANAPROX ANAPROX DS

oxaprozin DAYPRO

piroxicam FELDENE

sulindac CLINORIL

tolmetin sodium TOLECTIN 600

fenoprofen calcium NALFON CAPSULE

indomethacin INDOCIN SUPPOS. INDOCIN ORAL SUSP.

LOCAL ANESTHESIA

Local Anesthetics

lidocaine HCl XYLOCAINE

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT

Bowel Antiinflamatory Agents

sulfasalazine AZULFIDINE

Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx

mesalamine SFROWASA

mesalamine w/cleansing wipes ROWASA

mesalamine CANASA

Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat

balsalazide disodium COLAZAL

mesalamine APRISO LIALDA PENTASA

Hemorrhoidal Preparations

hc acetate/pramoxine HCl ANALPRAM HC

Irritable Bowel Agents, Guanylate Cylase-C Agonists

QL linaclotide LINZESS

Rectal Preparations



hydrocortisone PROCTO-KIT PROCTOCORT CREAM PROCTOCREAM-HC

hydrocortisone acetate ANUSOL-HC PROCTOCORT SUPPOS.

hc acetate/pramoxine HCl PROCTOFOAM-HC

Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr)

hydrocortisone CORTENEMA

LOWER GASTROINTESTINAL DISORDERS - OTHER

Ammonia Inhibitors

lactulose CHRONULAC

sodium phenylbutyrate BUPHENYL POWDER

sodium phenylbutyrate BUPHENYL TABLET

Antidiarrheals

diphenoxylate HCl/atrop sulf LOMOTIL

Bile Salts

ursodiol ACTIGALL URSO URSO FORTE

Laxatives & Cathartics

peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKETS

polyethylene glycol 3350 MIRALAX

sod chloride/nahco3/kcl/peg's NULYTELY WITH FLAVOR PACKS

lactulose KRISTALOSE

peg 3350/na sulf,bicarb,cl/kcl GOLYTELY OCL

Narcotic Antagonists, Peripherally-Acting

QL naloxegol oxalate MOVANTIK

Glucagon-Like Peptide (GLP-2) Analogs

PA teduglutide [rDNA origin] GATTEX

MISCELLANEOUS AGENTS

Anaphylaxis Therapy Agents

epinephrine EPIPEN

epinephrine EPIPEN JR

Parasympathetic Agents

bethanechol chloride URECHOLINE

cevimeline HCl EVOXAC

pilocarpine HCl SALAGEN

Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase

PA sapropterin dihydrochloride KUVAN

NEOPLASTIC DISEASE

Alkylating Agents

cyclophosphamide CYTOXAN

hydroxyurea HYDREA

lomustine CEENU

PA temozolomide TEMODAR

altretamine HEXALEN

busulfan MYLERAN

chlorambucil LEUKERAN

melphalan ALKERAN

Antiandrogenic Agents

bicalutamide CASODEX

flutamide EULEXIN

PA abiraterone acetate ZYTIGA

PA enzalutamide XTANDI

QL nilutamide NILANDRON

Antimetabolites

PA capecitabine XELODA

mercaptopurine PURINETHOL

methotrexate sodium METHOTREXATE TABLET

methotrexate sodium METHOTREXATE VIAL

thioguanine THIOGUANINE

fludarabine phosphate OFORTA

ST mercaptopurine PURIXAN

methotrexate sodium TREXALL

PA trifluridine/tipiracil HCl LONSURF

Antineoplastic - Aromatase Inhibitors

anastrozole ARIMIDEX

exemestane letrozole

AROMASIN FEMARA

Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors

PA venetoclax VENCLEXTA

Antineoplastic – Hedgehog Pathway Inhibitors

PA vismodegib ERIVEDGE

PA sonidegib phosphate ODOMZO

Antineoplastic – Janus Kinase (JAK) Inhibitors

PA ruxolitinib phosphate JAKAFI

PA tofacitinib citrate XELJANZ

PA tofacitinib citrate XR XELJANZ XR

Antineoplastic - MEK1 and MEK2 Kinase Inhibitors

PA + QL

cobimetinib fumarate COTELLIC

Antineoplastic - Topoisomerase I Inhibitors

topotecan HCl HYCAMTIN

Antineoplastic - Immunomodulator Agents

PA + QL

lenalidomide REVLIMID

PA pomalidomide POMALYST

Antineoplastic - Systemic Enzyme Inhibitors

PA imatinib mesylate GLEEVEC

PA afatinib GILOTRIF

PA+ QL

alectinib hydrochloride ALECENSA

PA+QL

axitinib INLYTA

PA bosutinib BOSULIF

PA cabozantinib s-malate CABOMETYX

PA cabozanitinib COMETRIQ

PA ceritinib ZYKADIA

PA QL

crizotinib XALKORI

PA dabrafanib TAFINLAR

PA dasatinib SPRYCEL

PA+QL

erlotinib HCl TARCEVA

PA gefitinib IRESSA

PA ibrutinib IMBRUVICA

PA idelalisib ZYDELIG

PA ixazomib citrate NINLARO

PA lapatinib ditosylate TYKERB

PA lenvatinib mesylate LENVIMA

PA nilotinib hydrochloride TASIGNA

PA olaparib LYNPARZA

PA + QL

osimertinib mesylate TAGRISSO

PA pazopanib hydrochloride VOTRIENT

PA palbociclib IBRANCE

PA ponatinib ICLUSIG

PA regorafenib STIVARGA

PA sorafenib tosylate NEXAVAR

PA sunitinib malate SUTENT

PA trametinib dimethyl sulfoxide MEKINIST

PA vemurafenib ZELBORAF

Antineoplastic, Histone Deacetylase Inhibitors, HDIS

PA panobinostat lactate FARYDAK

vorinostat ZOLINZA

Antineoplastics, Miscellaneous

etoposide VEPESID

mitotane LYSODREN

procarbazine HCl MATULANE



tretinoin VESANOID

PA QL PA

everolimus everolimus

AFINITOR AFINITOR DISPERZ

Chemotherapy Rescue/Antidote Agents

QL

leucovorin calcium uridine triacetate

LEUCOVORIN CALCIUM VISTOGARD

Selective Estrogen Receptor Modulators (SERM)

tamoxifen citrate NOLVADEX

PA toremifene citrate FARESTON

Selective Retinoid X Receptor Agonists (RXR)

PA bexarotene TARGRETIN

Steroid Antineoplastics

megestrol acetate MEGACE

estramustine phosphate sodium EMCYT

NEUROLOGICAL DISEASE - MISCELLANEOUS

Agents to Treat Multiple Sclerosis

PA glatiramer acetate COPAXONE

PA dimethyl fumarate TECFIDERA

PA fingolimod HCl GILENYA

PA interferon beta-1a AVONEX

PA PA PA

interferon beta-1a/albumin

AVONEX ADMINISTRATION PACK REBIF REBIF REBIDOSE

PA PA

peginterferon beta-1a PLEGRIDY PLEGRIDY PEN

Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor

milnacipran HCl SAVELLA

Movement Disorders (Drug Therapy)

PA tetrabenazine XENAZINE

ORAL/PHARYNGEAL DISORDERS

Dental Aids & Preparations

chlorhexidine gluconate PERIDEX

triamcinolone acetonide KENALOG IN ORABASE

Nose Preparations, Antibiotics

mupirocin calcium BACTROBAN NASAL

Nose Preparations, Miscellaneous (Rx)

ipratropium bromide ATROVENT

OTHER DRUGS

Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome

megestrol acetate MEGACE MEGACE ES

General Inhalation Agents

sodium chloride for inhalation HYPER-SAL 7%

Metabolic disease enzyme replace, hypophosphatasia

PA asfotase alfa STRENSIQ

Needles/Needleless Devices

needles, insulin disp., safety PEN NEEDLE

Nucleic Acid/Nucleotide Supplements

PA uridine triacetate XURIDEN

octreotide acetate SANDOSTATIN

Drugs to treat hereditary tyrosinemia

PA nitisinone ORFADIN

OTHER RESPIRATORY DISORDERS

Antifibrotic Therapy – Pyridone Analogs

PA pirfenidone ESBRIET

Cystic Fibrosis-Cftr Potentiator & Corrector Comb.

PA lumacaftor/ivacaftor ORKAMBI

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators

PA ivacaftor KALYDECO

Mucolytics

acetylcysteine MUCOMYST-10

PA dornase alfa PULMOZYME

Pulmonary Fibrosis – Systemic Enzyme Inhibitors

PA nintedanib esylate OFEV

PAIN MANAGEMENT - ANALGESICS

Analgesic, Non-Salicylate & Barbiturate Combinations

butalbital/acetaminophen PHRENILIN

butalbital/acetaminophen PHRENILIN FORTE

Analgesic, Salicylate, Barbiturate & Xanthine Combinations

butalbital/aspirin/caffeine FIORINAL

Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations

butalb/acetaminophen/caffeine ESGIC FIORICET

Analgesic/Antipyretics, Salicylates

diflunisal DOLOBID

salsalate DISALCID

Analgesics, Narcotics

codeine phos/carisoprodol/asa SOMA COMPOUND WITH CODEINE

PA fentanyl DURAGESIC

PA fentanyl citrate lozenge ACTIQ

QL hydrocodone bit/acetaminophen (300mg)

VICODIN VICODIN ES VICODIN HP


LORCET LORCET PLUS LORTAB NORCO

QL hydrocodone bit/acetaminophen (300mg/15ml) oral solution

LORTAB ELIXIR

QL hydrocodone bit/acetaminophen oral elixir (325mg/15ml)

HYCET

QL hydrocodone bitartrate HYSINGLA ER

hydromorphone HCl DILAUDID

methadone HCl DOLOPHINE HCL

QL+ ST

methadone HCl injection solution

METHADONE HCL INJECTION SOLUTION

QL morphine sulfate AVINZA

QL morphine sulfate MS CONTIN

morphine sulfate MSIR ORAMORPH SR ROXANOL

oxycodone HCl PERCOLONE ROXICODONE ROXICODONE INTENSOL

QL oxycodone HCl/acetaminophen (325mg)

PERCOCET

QL oxycodone HCl/acetaminophen (325mg/5ml)

ROXICET

oxycodone HCl/aspirin PERCODAN

tramadol HCl ULTRAM

tramadol HCl/acetaminophen ULTRACET

QL buprenorphine BUTRANS


STAGESIC-10


XODOL 10-300

hydromorphone HCl DILAUDID-5

QL oxycodone HCl OXYCONTIN

QL tapentadol HCl NUCYNTA

QL tapentadol HCl ER NUCYNTA ER

Antimigraine Preparations

QL QL

ergotamine tartrate/caffeine CAFERGOT MIGERGOT

isomethept/acetaminop/dichlphn

MIDRIN

QL naratriptan AMERGE

QL rizatriptan benzoate MAXALT MAXALT MLT

QL sumatriptan IMITREX NASAL SPRAY

QL sumatriptan succinate IMITREX TABLET IMITREX INJECTION

QL + zolmitriptan ZOMIG



ST ZOMIG ZMT

Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations

codeine/butalbit/acetamin/caff FIORICET WITH CODEINE

Narcotic & Salicylate Analgesics, Barbiturates & Xanthines

codeine/butalbital/asa/caffein FIORINAL WITH CODEINE #3

Narcotic Analgesic & Non-Salicylate Analgesic Combinations

acetaminophen with codeine TYLENOL-CODEINE NO.3 TYLENOL-CODEINE NO.4

acetaminophen and codeine CAPITAL AND CODEINE

Narcotic Withdrawal Therapy Agents

PA + CU PA + CU PA + QL + CU

buprenorphine hcl/naloxone hcl buprenorphine hcl buprenorphine hcl/naloxone hcl

SUBOXONE SUBUTEX ZUBSOLV

PARKINSON’S DISEASE

Antiparkinsonism Drugs, Anticholinergic

benztropine mesylate COGENTIN

trihexyphenidyl HCl ARTANE

Antiparkinsonism Drugs, Other

amantadine HCl SYMMETREL

bromocriptine mesylate PARLODEL

carbidopa/levodopa PARCOPA SINEMET 25-100 SINEMET CR

carbidopa/levodopa/entacapone STALEVO

entacapone COMTAN

pramipexole di-HCl MIRAPEX

QL + ST

ropinirole HCl REQUIP REQUIP XL

selegiline HCl ELDEPRYL

QL rasagiline mesylate AZILECT

QL + ST

rotigotine NEUPRO

Decarboxylase Inhibitors

carbidopa LODOSYN

SEIZURE DISORDER

Anticonvulsants

carbamazepine CARBATROL TEGRETOL TEGRETOL XR

clonazepam KLONOPIN

QL diazepam DIASTAT

divalproex sodium DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE

QL + ST

ethosuximide ezogabine

ZARONTIN POTIGA

QL + ST QL + ST

gabapentin lacosamide lacosamide

NEURONTIN VIMPAT ORAL SOLUTION VIMPAT TABLETS

lamotrigine LAMICTAL

levetiracetam KEPPRA

oxcarbazepine TRILEPTAL

phenytoin DILANTIN-125 DILANTIN CHEW TAB

phenytoin sodium extended DILANTIN PHENYTEK

primidone MYSOLINE

QL + ST

topiramate topiramate topiramate

TOPAMAX TOPAMAX SPRINKLE TROKENDI XR

valproate sodium DEPAKENE SYRUP

valproic acid DEPAKENE CAPSULES

zonisamide ZONEGRAN

pregabalin LYRICA

SKELETAL MUSCLE DISORDER

Agents To Treat Periodic Paralysis

PA dichlorphenamide KEVEYIS

Skeletal Muscle Relaxants

baclofen LIORESAL

carisoprodol SOMA

carisoprodol/aspirin SOMA COMPOUND

chlorzoxazone PARAFON FORTE DSC

cyclobenzaprine HCl FLEXERIL

dantrolene sodium DANTRIUM

metaxalone SKELAXIN

methocarbamol ROBAXIN ROBAXIN-750

orphenadrine citrate NORFLEX

orphenadrine/aspirin/caffeine NORGESIC FORTE

tizanidine HCl ZANAFLEX

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE

Pancreatic Enzymes

amylase/lipase/protease PANCRELIPASE 5,000

amylase/lipase/protease CREON ULTRASE ULTRASE MT ZENPEP

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE

Anticholinergics/Antispasmodics

dicyclomine HCl BENTYL

Belladonna Alkaloids

belladonna alkaloids/phenobarb DONNATAL

hyoscyamine sulfate ANASPAZ LEVBID LEVSIN-SL

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE

Anti-Ulcer Preparations

misoprostol CYTOTEC

sucralfate CARAFATE

Anti-Ulcer-H.pylori Agents

lansoprazole/amox tr/clarith PREVPAC

Anticholinergics, Quaternary Ammonium

chlordiazepoxide/clidinium br LIBRAX

Histamine H2-Receptor Inhibitors

cimetidine HCl TAGAMET

famotidine PEPCID

nizatidine AXID

ranitidine HCl ZANTAC

Intestinal Motility Stimulants

metoclopramide HCl REGLAN

Proton-Pump Inhibitors

QL + ST

esomeprazole magnesium NEXIUM

lansoprazole PREVACID RX

omeprazole capsules (RX) PRILOSEC CAPSULES (RX)

omeprazole magnesium tablets (OTC)

PRILOSEC OTC TABLETS (OTC)

pantoprazole sodium PROTONIX

ST lansoprazole PREVACID SOLUTABS

ST pantoprazole sodium suspension PROTONIX SUSP

URINARY TRACT - FUNCTIONAL DISORDERS

Benign Prostatic Hypertrophy/Micturition Agents



alfuzosin UROXATRAL

ST dutasteride AVODART

finasteride PROSCAR

tamsulosin HCl FLOMAX

Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents

ST dutasteride/tamsulosin HCl JALYN

Kidney Stone Agents

PA cysteamine bitartrate PROCYSBI

Overactive Bladder Agents, Beta-3 Adrenergic Recep

ST mirabegron MYRBETRIQ

Urinary Tract Analgesic Agents

pentosan polysulfate sodium ELMIRON

Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye)

phenazopyridine HCl PYRIDIUM

Urinary Tract Antispasmodic, M(3) Selective Antagonists

ST solifenacin succinate VESICARE

Urinary Tract Antispasmodic/Antiincontinence Agents

oxybutynin chloride DITROPAN XL

ST trospium chloride SANCTURA

ST ST

tolterodine tartrate DETROL DETROL LA

ST fesoterodine fumarate TOVIAZ

VAGINAL DISORDERS

Vaginal Antibiotics

metronidazole METROGEL-VAGINAL VANDAZOLE

Vaginal Antifungals

miconazole nitrate MONISTAT 3

butoconazole nitrate GYNAZOLE-1

Vaginal Estrogen Preparations

estradiol cream estradiol tablet

ESTRACE VAGIFEM

estrogens, conjugated PREMARIN

Vaginal Sulfonamides

sulfanilamide AVC

VITAMIN AND/OR MINERAL DEFICIENCY

Fluoride Preparations

sodium fluoride FLUORITAB FLURA-DROPS FLURA-TABS LURIDE

Folic Acid Preparations

folic acid FOLIC ACID

Multivitamin Preparations

folic acid/mu-vits-min th VICON FORTE

Pediatric Vitamin Preparations

fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON

fluoride ion/multivitamins POLY-VI-FLOR

fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON

fluoride ion/vit a,c&d FLUORABON BASIC

Prenatal Vitamin Preparations

prenatal vit 15/iron cb/fa/dss TRIADVANCE

prenatal vit 16/iron cb/fa/dss VINATE GT

prenatal vit 18/iron cb/fa/dss VINATE ULTRA

prenatal vit 95/fe fum/fa PRENAVITE

Vitamin B Preparations

cyanocobalamin/fa/pyridoxine FOLGARD RX

Vitamin D Preparations

ST

calcitriol calcitriol

ROCALTROL VECTICAL

ergocalciferol DRISDOL

SPECIALTY INJECTABLE CROSS REFERENCE LISTING

The following cross reference is being provided as a guide to formulary choices within prominent “specialty” injectable drug categories. General specialty categories are cross referenced to

their corresponding formulary classification status and page number. This cross reference is not meant to be all-inclusive. Please refer to the Table of Contents or Index to determine formulary status of injectable medications not listed in this cross reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). EPO Hematinics, Other Page 7 HEPATITIS C Hepatitis C Treatment Agents Page 9 HUMAN GROWTH FACTORS Growth Hormones Page 6 LOW MOLECULAR WEIGHT HEPARINS Heparin and Related Preparations Page 7 MULTIPLE SCLEROSIS Agents to Treat Multiple Sclerosis Page 10 RHEUMATOID ARTHRITIS Anti-Inflammatory, Pyrimidine Synthesis Inhibitors

MEDICATION PRESCRIBING LIMITATIONS 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages: Concerta ≤ 18 years old

Differin

Epiduo

Epiduo Forte

≤ 25 years old ≤ 25 years old ≤ 25 years old

Fabior

Focalin XR

Metadate CD

≥ 12 years old ≤ 18 years old ≤ 18 years old

Metadate ER ≤ 18 years old

Ritalin LA 60mg ≤ 18 years old

Ritalin SR ≤ 18 years old

2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages: All carbinoxamine containing products (i.e.,

Palgic, Tussafed, etc.)

≥ 2 years old

Atralin ≤ 25 years old

Avita ≤ 25 years old

Epaned (Step Therapy applies) ≥ 12 years old

Oracea ≥ 18 years old

Refissa ≤ 25 years old

Renova ≤ 25 years old

Retin-A ≤ 25 years old

Retin-A Micro ≤ 25 years old

Retin-A Micro Pump ≤ 25 years old

Solodyn ≥ 12 years old

Tretin-X ≤ 25 years old

3. QUANTITY RESTRICTIONS (FORMULARY) Abilify

tablets solution

30 tablets per 30 days 900mL per 30 days

Abilify Discmelt 10mg

15mg

90 tablets per 30 days 60 tablets per 30 days

Adderall 60 tablets per 30 days

Adderall XR 5mg, 10mg, 15mg 20mg, 25mg, 30mg

30 capsules per 30 days 60 capsules per 30 days

Advair Diskus 60 units per 30 days

Advair HFA

Afinitor

12g (1 inhaler) per 30 days 30 tablets per 30 days

Akynzeo 1 capsule per 28 days

Aldara 24 packets per 30 days

Alecensa 240 capsules per 30 days

Alendronate solution 300mL per 28 days

Ambien / Ambien CR 30 tablets per 30 days

Amerge 18 tablets per 30 days

Androxy 120 tablets per 30 days

Anoro Ellipta 60 blister packs per 30 days



Aptivus capsule solution

120 capsules per 30 days 380mL (4 bottles) per 30 days

Arixtra 2.5mg/0.5mL 5mg/0.4mL 7.5mg/0.6mL 10mg/0.8mL

5mL (10 syringes) per 30 days 4mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 8mL (10 syringes) per 30 days

Asmanex 1 inhaler per 30 days

Asmanex HFA 13 grams per 30 days

Astelin 60mL (2 bottles) per 30 days

Astepro 60mL (2 bottles) per 30 days

Atripla 30 tablets per 30 days

Atrovent HFA 2 inhalers per 28 days

Avinza 30mg, 45mg, 60mg, 75mg, 90mg 120mg

1 capsule per day 2 capsules per day

Azilect

Baraclude 0.5mg, 1mg oral solution

30 tablets per 30 days 30 tablets per 30 days 630ml (3 bottles) per 30 days

Breo Ellipta 60 units per 30 days

Brilinta 60 tablets per 30 days

Butrans 4 patches per 28 days

Caduet 30 tablets per 30 days

Cafergot 40 tablets 28 days

Climara 4 patches per 28 days

Clozaril 90 tablets per 30 day

Colcrys 120 tablets per 30 days

Combipatch 8 patches per 30 days

Combivir

Complera


Concerta 18mg, 27mg, 54mg 36mg


Corlanor 60 tablets per 30 days

Cotellic 63 tablets per 28 days

Crestor 30 tablets per 30 days

Cymbalta 60 capsules per 30 days

Daliresp 30 tablets per 30 days

Depo-Testosterone 10mL per 30 days

Descovy 30 tablets per 30 days

Desvenlavaxine ER (Ranbaxy Brand)

30 tablets per 30 days

Dexedrine Spansule 5mg, 10mg 15mg


Diastat 1 kit per copay

Dificid 20 tablets per 30 days

Doxycycline monohydrate 150mg tablet


Dulera

13g (1 inhaler) per 30 days

Duragesic 10 patches per 30 days

Edurant 30 tablets per 30 days

Effient 30 tablets per 30 days

Eliquis 60 tablets per 30 days

Emend 40mg 80mg 125mg

1 capsules per 21 days 2 capsules per 21 days 1 capsule per 21 days

Emend Trifold Pack 1 packet per 21 days

Emtriva 10mg/mL oral solution 200mg capsules

850mL (5 bottles) per 30 days 30 capsules per 30 days

Epivir 150mg tablets 300mg tablets 10mg/mL oral solution

60 tablets per 30 days 30 tablets per 30 days 960mL (4 bottles)per 30 days

Epivir HBV 100mg oral solution

Epzicom

30 tablets per 30 days 720ml (3 bottles) per 30 days 30 tablets per 30 days

Evista 30 tablets per 30 days

Evotaz 30 tablets per 30 days

Exelon patch

Fetzima

30 patches per 30 days 30 capsules per 30 days

Flonase 16gm (1 bottle) per 30 days

Flunisolide 25mL (1 bottle) per 30 days

Focalin 60 tablets per 30 days

Focalin XR 30 capsules per 30 days

Forteo 2.4mL (1 pen) per 28 days with a max duration of 2 years per lifetime

Fragmin 2500 units/0.2mL 5000 units/0.2mL 7500 units/0.3mL 10,000 units/1mL 12,500 units/0.5mL

15,000 units/0.6mL 18,000 units/0.72mL

25,000 units/ml

2mL(10 syringes) per 30 days 2mL(10 syringes) per 30 days 3mL(10 syringes) per 30 days 10mL(10 syringes)per 30 days 5mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 7.2mL (10 syringes) per 30 days 7.6mL (2 vials) per 30 days

Fuzeon 60 vials per 30 days

Genvoya 30 tablets per 30 days

Geodon (oral) 60 capsules per 30 days

Glyxambi

Hepsera


Humulin N vial Kwikpen

40mL (4 vials) per 28 days 30mL (10 pens) per 28 days

Humulin R 100u/mL 500u/mL

40mL (4 vials) per 28 days 40mL (2 vials) per 28 days

Humulin R U-500 Kwikpen

8 pens (4 boxes of 2 pens) per 28 days

Humulin 70/30 vial Kwikpen


Humalog vial pen/cartridge

40mL (4 vials) per 28 days 30mL (10 pens/cartridges) per 28 days

Humalog Mix 50/50 / 75/25 vial Kwikpen


Hydrocodone bit/acetaminophen (maximum of 4gm of acetaminophen per day):

250mg 300mg 325mg 300mg/15ml soln 325mg/15ml elixir

16 tablets per 1 day supply 13 tablets per 1 day supply 12 tablets per 1 day supply 200ml per 1 day supply 184ml per 1 day supply

Hysingla ER 30 tablets per 30 days

Imitrex tablets (all strengths) nasal spray injection (kits and vials)

6mg/0.5ml vial 6mg/0.5ml kit/refill kit 4mg/0.5ml kit/refill kit

18 tablets per 30 days 12 units per 30 days 4 vials per 30 days 2 kits per 30 days 2 kits per 30 days

Inlyta 1mg 5mg


Intelence 25mg, 100mg 200mg


Invirase 200mg capsules 500mg tablets

300 capsules per 30 days 120 tablets per 30 days

Invokamet 60 tablets per 30 days

Invokamet XR 60 tablets per 30 days

Invokana 30 tablets per 30 days

Isentress 400 mg tablets 25mg, 100mg tablets

100mg powder

60 tablets per 30 days 180 chew tablets per 30 days 60 packets per 30 days



Janumet 60 tablets per 30 days

Janumet XR 100-1000mg

50-1000mg 50-500mg

30 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days

Januvia 30 tablets per 30 days

Jentadueto 60 tablets per 30 days

Jardiance 30 tablets per 30 days

Juxtapid 30 capsules per 30 days

Kaletra 100-25mg tablets

200-50mg tablets oral solution

60 tablets per 30 days 120 tablets per 30 days 480mL (3 bottles) per 30 days

Lantus vial Solostar


Latuda 20mg, 40mg, 60mg, 120mg 80mg

Lexiva suspension tablet

30 tablets per 30 days 60 tablets per 30 days 1800mL (8 bottles) per 30 days 120 tablets per 30 days

Linzess 30 capsules per 30 days

Livalo 30 tablets per 30 days

Lovaza 120 capsules per 30 days

Lovenox 30mg/0.3mL 40mg/0.4mL 60mg/0.6mL 80mg/0.8mL 100mg/1mL 120mg/0.8mL 150mg/1mL 300mg/3mL

6mL (20 syringes) per 30 days 8mL (20 syringes) per 30 days 12mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 30mL (10 vials) per 30 days

Lumigan 2.5ml per 30 days

Lunesta 30 tablets per 30 days

Lynparza 16 capsules per day

Marinol 60 capsules per 30 days

Maxalt/ Maxalt MLT


Metadate CD 30mg 10mg, 20mg, 40mg, 60mg


Metadate ER 90 tablets per 30 days

Methadone HCl injection solution

120mL (6 vials) per 30 days

Methylin chewable tablet 90 tablets per 30 days

Migergot 20 units per 28 days

Morgidox 50mg, 100mg

60 capsules per 30 days

Movantik 30 tablets per 30 days

MS Contin 90 tablets per 30 days

Namenda tablets titration pack solution

60 tablets per 30 days 49 tablets per 28 days 300mLper 30 days

Namenda XR capsules titration pack


Namzaric capsules titration pack


Narcan Nasal 2 boxes (4 nasal sprays per 30 days

Nasacort AQ 16.5g (1 canister) per 30 days

Nasarel 25ml (1 bottle) per 30 days

Nasonex 17g (1 canister) per 30 days

Neupro 30 patches per 30 days

Nexium capsules

packets

30 capsules per 30 days 30 packets per 30 days

Nilandron 150mg tablet 60 tablets for first 30 days, then 30 tablets per 30 days thereafter

Norvir

oral solution capsules/tablets

480mL (2 bottles) per 30 days 360 capsules/tablets per 30 days

Nucynta 180 tablets per 30 days

Nucynta ER 60 tablets per 30 days

Nuvaring 1 ring per 28 days

Odefsey 30 tablets per 30 days

Ortho Evra 3 patches per 28 days

Otrexup 1.6mL per 28 days

Oxycodone HCl/acetaminophen (maximum of 4gm acetaminophen per day):

325mg 325mg/5ml soln

12 tablets per 1 day supply 61mL per 1 day supply

Oxycontin 10mg, 15mg, 20mg, 30mg, 40mg, 60mg

80mg


Perforomist 120mL per 30 days

Picato 0.015% gel 0.05% gel

3 tubes per 56 days 2 tubes per 56 days

Plavix 300mg tablet 4 tablets per 30 days

Potiga 50mg 200mg, 300mg, 400mg

Prezcobix


Prezista oral suspension 75mg 150mg 400mg, 600mg 800mg

400mL (2 bottles) per 30 days 480 tablets per 30 days 240 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days

Pristiq 30 tablets per 30 days

Promacta 30 tablets per 30 days

Pulmicort Flexhaler 1 inhaler per 30 days

Pulmicort Respules 60mL (30 respules) per 30 days

Qnasl 8.7g (1 canister) per 30 days

Qnasl Children 4.9g (1 canister) per 30 days

Quillivant XR 60mL 120mL 150mL

180mL

60mL (1 bottle) per 30 days 240mL (2 bottles) per 30 days 300mL (2 bottles) per 30 days 360mL (2 bottles) per 30 days

QVAR 17.4g (2 inhalers) per 30 days

Ranexa 500mg

1000mg


Rayaldee

Requip XL

60 capsules per 30 days 30 tablets per 30 days

Restasis SDV

Restasis MDV

60 single use vials per 30 days 1 multidose vial per 30 days

Retrovir syrup capsules tablets

1920mL (8 bottles) per 30 days 180 capsules per 30 days 60 tablets per 30 days

Revlimid

Risperdal tablets/ODT solution

30 capsules per 30 days 60 tablets per 30 days 240mL per 30 days

Rexulti

Reyataz 150mg, 200mg 300mg 50mg

30 tablets per 30 days 60 capsules per 30 days 30 capsules per 30 days 150 packets per 30 days

Ritalin 90 tablets per 30 days

Ritalin LA 10mg, 20mg, 40mg, 60mg

30mg


Ritalin SR 90 tablets per 30 days

Saphris

Seasonale


Selzentry 75mg, 150mg 25mg, 300mg


Serevent 60 doses (1 diskus) per 30 days



Seroquel 90 tablets per 30 days

Spiriva 30 capsules per 30 days

Spiriva Respimat 1 inhaler per 30 days

Sonata 30 capsules per 30 days

Stiolto Respimat 4g (60 inhalations) per 30 days

Strattera 10mg, 18mg, 25mg, 40mg 60mg, 80mg, 100mg


Stribild 30 tablets per 30 days

Striverdi Respimat 4g (60 inhalations) per 30 days

Symbicort

Symbyax

1 inhaler per 30 days (10.2 grams) 30 capsules per 30 days

Synjardy 60 capsules per 30 days

Tagrisso 1 tablet per day

Tamiflu 30mg tablets 45mg, 75mg tablets suspension

Trintellix

Trokendi XR 25mg, 50mg, 100mg 200mg

40 tablets per 183 days 20 tablets per 183 days 360mL per 183 days 30 tablets per 30 days 30 capsules per 30 days 60 capsules per 30 days

Vibramycin 100mg 60 capsules per 30 days

Vimpat 50mg, 100mg, 150mg, 200mg

10mg/ml oral solution


Vraylar All Strengths Titration Pack

30 capsules per 30 days 7 blisters (1 dose-pack) per 28 days

NOTE: The FDA recommends a maximum of 5 days of therapy with this drug

Tarceva 30 tablets per 30 days

Tivicay 30 tablets per 30 days

Toradol 20 tablets per fill

Toujeo 13.5mL (9 prefilled pens) per 28 days

Tradjenta 30 tablets per 30 days

Travatan/Travatan Z 2.5ml per 30 days

Triumeq 30 tablets per 30 days

Trizivir 60 tablets per 30 days

Trulicity 2mL (4 pens) per 28 days

Truvada 30 tablets per 30 days

Tybost 30 tablets per 30 days

Uloric 30 tablets per 30 days

Vascepa 0.5g 1g


Vancocin Oral 125mg and 250mg

40 capsules per 30 days

Viagra 6 tablets per 30 days

Vibra-Tabs 60 tablets per 30 days

Victoza 9mL (3 pens) per 30 days

Videx 600mL (six 2g bottles or three 4g bottles) per 30 days

Videx EC 125mg, 200mg 250mg, 400mg

Viibryd

60 capsules per 30 days 30 capsules per 30 days 30 tablets per 30 days

Viramune solution tablets

1200mL (5 bottles) per 30 days 60 tablets per 30 days

Viramune XR 100mg

400mg


Viread powder tablets

Vistogard granules

240g powder per 30 days 30 tablets per 30 days 24 packets per 14 days

Vivelle Dot 8 patches per 30 days

Vyvanse

Xalkori

30 capsules/tablets per 30 days 60 capsules per 30 days

Xarelto

10mg, 20mg 15mg loading dose

30 tablets per 30 days 42 tablets per 21 days, followed by 30 tablets per 30 days

Xiidra 60 vials per 30 days

Zenzedi 2.5mg, 5mg, 7.5mg, 15mg 10mg 20mg, 30mg


Zerit oral solution capsules


Zetia 30 tablets per 30 days

Ziagen solution tablets


Zofran oral solution 4mg/5ml oral solution

50ml per 15 days

Zomig/Zomig ZMT Tablets Nasal Spray

12 tablets per 30 days 12 units per 30 days

Zubsolv 0.7mg/0.18mg 1.4/0.36mg 2.9/0.71mg 5.7/1.4mg

11.4/2.9mg 8.6/2.1mg

Zurampic

Zyprexa/Zyprexa Zydis

30 sublingual tablets per 30 days 60 sublingual tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days

4. QUANTITY RESTRICTIONS (NON FORMULARY) Aciphex 30 tablets per 30 days

Aciphex Sprinkle 30 capsules per 30 days

Acticlate 75mg, 100mg 60 tablets per 30 days

Actonel 5mg, 30mg 35mg

150mg

30 tablets per 30 days 4 tablets per 28 days 1 tablet per 28 days

Aerospan 17.8g (2 inhalers) per 30 days

Afrezza 4 unit

30-4 unit + 60-8 unit 60-4 unit + 30-8 unit

60-8 unit + 30-12 unit Titration pack

180 cartridges (2 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 180 cartridges (1 kit) per 28 days

Allegra 30mg/5ml oral susp

300ml per 30 days

Alsuma 4 units per 28 days

Amitiza

Anoro Ellipta

60 capsules per 30 days 60 blister packs per 30 days

Anzemet 50mg 100mg

8 tablets per fill 4 tablets per fill

Aplenzin 30 tablets per 30 days

Aptiom 200mg, 400mg

600mg, 800mg


Arcapta 30 capsules per 30 days

Arnuity Ellipta 30 blister packs per 30 days

Atelvia

Auryxia

4 tablets per 28 days 12 tablets per day

Avidoxy 60 tablets per 30 days

Axert 12 tablets per 30 days

Banzel 200mg 400mg 40mg/ml suspension

480 tablets per 30 days 240 tablets per 30 days 2400ml per 30 days

Belsomra 30 tablets per 30 days

Benoxyldoxy 1 kit per 30 days

Brisdelle

Briviact tablet oral solution

30 capsules per 30 days 60 tablets per 30 days 600mL per 30 days

Brovana 120mL per 30 days

Bupap 180 tablets per 30 days



Cambia 9 packets per 30 days

Caverject 1 dose per 5 days

Cesamet 180 capsules per 30 days

Chantix 56 tablets per 28 days

Cialis 2.5mg, 5mg

10mg, 20mg


Clarinex

2.5mg, 5mg reditab 5mg 5mg/10ml syrup

30 tablets per 30 days 30 tablets per 30 days 300ml per 30 days

Clarinex-D 12 hour 60 tablets per 30 days

Clarinex-D 24 hour 30 tablets per 30 days

Climara Pro 4 patches per 30 days

Clozapine ODT

Conzip

90 tablets per 30 days 30 capsules per 30 days

Cosopt PF 60 droperettes per 30 days

Daytrana 30 patches per 30 days

Demerol solution

tablets

900mL per 30 days 180 tablets per 30 days

Depo-Provera 1mL per 84 days

Depo-subQ Provera 104 0.65mL per 84 days

DermasilkRx SDS 1 kit per 30 days

Desoxyn 150 tablets per 30 days

Desvenlafaxine ER (fumarate)


D.H.E.45 30 ampules per 28 days

Diclegis

Doryx 50mg

200mg


Doryx MPC 120mg tablets

Dyanavel XRs


Dymista 23g (1 bottle) per 30 days

Edex 1 dose per 5 days

Embeda 20-0.8mg, 30-1.2mg, 50-2mg, 60-2.4mg, 80-3.2mg

100-4mg

2 capsules per day 4 capsules per day

Emsam 30 patches per 30 days

Entresto 60 tablets per 30 days

Epaned 1200mL (8 bottles) per 30 days

Ergomar SL 40 tablets per 28 days

Esomeprazole Strontium 24.65mg 49.3mg


Estring 1 ring per 90 days

Fanapt Tablets Titration Pack

60 tablets per 30 days 1 pack per 28 days

Fazaclo 90 tablets per 30 days

Felbatol 400mg 600mg 600mg/5ml solution

270 tablets per 30 days 180 tablets per 30 days 900mL per 30 days

Firmagon 80mg/vial 1 vial per 30 days

Firmagon 120mg/vial 2 vials per 365 days

Foradil 60 capsules per 30 days

Frova 18 tablets per 30 days

Fulyzaq 60 tablets per 30 days

Fycompa 2mg 4mg, 6mg 8mg, 10mg, 12mg 0.5mg/mL suspension

120 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 680mL (2 bottles) per 28 days

Gabitril 2mg, 4mg, 12mg 16mg


Granisol solution 60mL per 30 days

Hemangeol 360mL (3 bottles) per 30 days

Hydrocodone bit/ acetaminophen

(max 4gm per day)

Incruse Ellipta 30 blisters per 30 days

Intuniv 30 tablets per 30 days

Invega 1.5mg, 3mg, 9mg 6mg


Iprivask 6 syringes per 30 days

Kapvay 120 tablets per 30 days

Karbinal ER 960mL (2 bottles) per 30 days

Kytril 8 tablets per 30 days

Lamictal ODT 25mg, 50mg 100mg

200mg


Lamictal XR 25mg, 50mg 100mg 200mg, 250mg, 300mg


Lescol 60 tablets per 30 days

Liptruzet 30 tablets per 30 days

LoSeasonique 91 tablets per 84 days

Luvox CR 60 capsules per 30 days

Luzu 60g (1 tube) per 28 days

Menostar 4 patches per 30 days

Migranal 8 vials per 28 days

Mirapex ER 30 tablets per 30 days

Mitigare 60 capsules per 30 days

Moban 25mg 10mg 5mg


Mondoxyne NL 50mg, 75mg, 100mg

Monodox 50mg, 75mg, 100mg

Muse

60 capsules per 30 days 60 capsules per 30 days 1 dose per 5 days

Myalept 11.3mg vial 30 vials per 30 days

Nicotrol cartridge 1008 cartridges (6 inhalers) per 90 days

Nicotrol NS 160mL (4 packs) per 90 days

Obredon 600mL per 10 days

Oleptro ER 150mg 300mg


Onfi Tablets (5mg, 10mg, 20mg) Suspension (2.5 mg/mL)s


Opana ER 5mg,7.5mg,10mg,15mg,

20mg 30mg, 40mg

60 tablets per 30 days 120 tablets per 30 day

Oracea 30 capsules per 30 days

Osphena 30 tablets per 30 days

Oxycodone HCl/acetaminophen (maximum of 4gm acetaminophen per day):

300mg 325mg

13 tablets per 1 day supply 12 tablets per 1 day supply

Oxtellar XR 150mg, 300mg

600mg


Patanase 30.5g (1 bottle) per 30 days

Pradaxa 60 capsules per 30 days

Procentra

Qbrelis

1800mL per 30 days 1200mL (8 bottles) per 30 days

Qudexy XR 25mg, 50mg, 100mg 150mg, 200mg


Quillichew 20mg, 40mg 30mg

1 tablet per day 2 tablets per day

Rasuvo



7.5mg/0.15mL 10mg/0.2mL 12.5mg/0.25mL 15mg/0.3mL 17.5mg/0.35mL 22.5mg/0.46mL 25mg/0.5mL 27.5mg/0.55mL 30mg/0.6mL

1.6mL (4 syringes) per 28 days 0.8mL (4 syringes) per 28 days 1mL (4 syringes) per 28 days 1.2mL (4 syringes) per 28 days 1.4mL (4 syringes) per 28 days 1.8mL (4 syringes) per 28 days 2mL (4 syringes) per 28 days 2.2mL (4 syringes) per 28 days 2.4mL (4 syringes) per 28 days

Razadyne Tablets Solution

60 tablets per 30 days 200mL (2 bottles) per 30 days

Razadyne ER 30 capsules per 30 days

Relenza 2 boxes (#20 diskhalers/box) per 183 days

Relpax 12 tablets per 30 days

Rescula 10mL (2 bottles) per 30 days

Rhinocort Aqua 17.2g (2 canisters) per 30 days

Risperdal/Risperdal M-Tab 60 tablets per 30 days

Rubraca 120 tablets per 30 days

Rytary 300 capsules per 30 days

Ryzodeg 70/30 30mL (10 pens) per 28 days

Sabril 180 tablets per 30 days

Samsca 15mg tablets 30mg tablets


SanadermRX 1 kit per 30 days

Sancuso 4 patches per 28 days

Savaysa 30 tablets per 30 days

Seasonique 91 tablets per 84 days

Seroquel XR 30 tablets per 30 days

Silenor 30 tablets per 30 days

Sitavig 4 tablets per 365 days

Solodyn 30 tablets per 30 days

Sotylize 250mL 480mL

2000mL (8 bottles) per 30 days 3840mL (8 bottles) per 30 days

Spritam 250/500/750mg 1000mg


Sprix 5 bottles per 30 days

Sumavel DosePro 4 units per 28 days

Targadox

Tasmar


Timoptic Ocudose 60 droperettes per 30 days

Trezix 10 capsules per day

Trulance

Tuzistra XR


Varubi 2 tablets per 14 days

Veltassa

Vemlidy

Versacloz

1 packet per day 30 tablets per 30 days 540mL per 30 days

Vytorin 30 tablets per 30 days

Xartemis XR 360 tablets per 30 days

Xerese 10gm (2 tubes) per 365 days

Xifaxan 200mg 9 tablets per fill

Xodol 5-300mg

Xyzal solution

13 tablets per 1 day supply 300mL per 30 days

Zamicet Soln 325mg/15ml

Zecuity

184mL per 1 day supply 1 carton per 28 days

Zegerid Packets Capsules

30 packets per 30 days 30 capsules per 30 days

Zelapar 60 tablets per 30 days

Zohydro ER 60 capsules per 30 days

Zontivity 30 tablets per 30 days

Zyclara 2.5% 3.75% pump 3.75% packet

7.5 grams (1 bottle) per 28 days 7.5 grams (1 bottle) per 28 days 28 packets per 28 days

6. STEP THERAPY EDITS (FORMULARY)

Abilify Discmelt Abilify Solution

Trial of two generic SSRI’s, SNRIs or generic atypical anti-psychotics (risperidone, olanzapine, ziprasidone, quetiapine or aripiprazole tablets) within the past 365 days.

Actoplus Met Actoplus Met XR

Trial of metformin, metformin ER, sulfonylurea (e.g., glyburide, glipizide) or pioglitazone within the past 120 days

Ambien CR Trial of Ambien IR within the past 180 days

Astepro Trial of Astelin (azelastine) within the past 120 days

Avodart Trial of Proscar, alfuzosin, doxazosin, prazosin, silodosin, tamsulosin or terazosin within the past 120 days

Azor Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days

Benicar Benicar HCT

Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days

Daliresp Trial of Spiriva, Serevent, Breo Ellipta, Advair Diskus, or Dulera within the past 120 days

Desvenlafaxine ER (Ranbaxy Brand)

Trial of two of the following: paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, venlafaxine IR/ER within the past 365 days

Detrol Detrol LA

Trial of oxybutynin or oxybutynin ER within the past 120 days

Dificid Trial of vancomycin capsules within the past 120 days

Dovonex Trial of a topical corticosteroid within the past 120 days

Drithocreme HP Trial of a topical corticosteroid within the past 120 days

Duetact

Elidel

Trial of metformin, metformin ER, sulfonylurea (e.g., glyburide, glipizide) or pioglitazone within the past 120 days Trial of a topical corticosteroid within the past 120 days

Epiduo, Epiduo Forte

Trial of adapalene 0.1% gel within the past 120 days

Exforge, Exforge HCT


Fenoglide

Fetzima

Trial of gemfibrozil or generic fenofibrate within the past 120 days Trial of two of the following; paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion or venlafaxine IR/ER within the past 365 days

Gianvi Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Glyxambi Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.

Invokamet Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.

Invokamet XR Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.

Invokana Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.



Jalyn Trial of finasteride 5mg, alfuzosin, doxazosin, prazosin, tamsulosin or terazosin within the past 120 days

Jardiance Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.

Latuda

Loestrin FE

Trial of two generic atypical anti-psychotics, risperidone, olanzapine, ziprasidone, quetiapine, clozapine, or aripiprazole in the past 365 days Trial of one generic contraceptive within the past 120 days

Loestrin FE24 Trial of two generic oral contraceptives within the past 365 days

Lo Loestrin FE Trial of two generic oral contraceptives within the past 365 days

Loryna Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Marinol Trial of ondansetron, corticosteroids and Emend within the past 365 days

Methadone HCl injection solution

Trial of lower strength oral methadone tablets or solution within the past 120 days

Myrbetriq Trial of oxybutynin IR/ER within the past 120 days

Neupro Trial of pramipexole IR or ropinirole IR within the past 120 days

Nexium Nexium Suspension

Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days

Namzaric Trial of donepezil and memantine within the past 365 days

Niaspan Trial of generic/multisource statin (atorvastatin, lovastatin, pravastatin, or simvastatin), or generic/multisource gemfibrozil or fenofibrate within the past 365 days

Ocella Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Onexton

Otrexup

Trial of generic benzaclin gel required within the past 120 days Trial of methotrexate tablet or solution for injection within the past 120 days

Prevacid Solutabs Trial of lansoprazole, omeprazole or pantoprazole within the past 120 days

Pristiq Trial of two of the following: generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, or venlafaxine IR/ER within the past 365 days

Potiga

Protonix Suspension

Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or zonisamide within the past 365 days Trial of Prilosec OTC or omeprazole within the past 120 days

Purixan Trial of mercaptopurine tablet within the past 120 days

Qnasl Trial of fluticasone or flunisolide within the past 120 days

Qnasl Children Trial of fluticasone or flunisolide within the past 120 days

Quillivant XR Trial of Metadate CD or Ritalin LA within the past 120 days

Requip XL Trial of pramipexole IR or ropinirole IR within the past 120 days

Rexulti

Trial of two generic atypical antipsychotics , SSRIs or SNRIs within the past 365 days

Sanctura Trial of oxybutynin or oxybutynin ER within the past 120 days

Saphris

Syeda

Trial of two generic atypical antipsychotics within the past 365 days Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Synjardy Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.

Tribenzor

Trintellix

Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB or ARB combination within the past 120 days Trial of two of the following generic/multisource products: paroxetine, venlafaxine ER or IR, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine or bupropion within the past 365 days

Toviaz Trial of oxybutynin or oxybutynin ER within the past 120 days

Triglide

Trokendi XR

Trial of gemfibrozil or generic fenofibrate within the past 120 days Trial of topiramate IR within the past 120 days

Trulicity Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.

Uloric Trial of allopurinol within the past 120 days

Vectical Trial of a topical corticosteroid within the past 120 days

Vesicare Trial of oxybutynin or oxybutynin ER within the past 120 days

Vestura Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Vibra-Tabs

Viibryd

Trial of generic doxycycline monohydrate capsules within the past 120 days Trial of two of the following: paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, venlafaxine IR/ER within the past 365 days

Victoza

Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.

Vimpat

Vimpat oral solution

Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days

Vraylar

Vyvanse

Trial of two generic atypical antipsychotics within the past 365 days Trial of one of the following: SSRI (sertraline, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine), topiramate, generic/multisource mixed amphetamine salts (Adderall IR/XR), or methylphenidate (IR, ER, LA, CD) within the past 120 days.

Yasmin 28 Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Yaz Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Zarah Trial of two different non-drospirenone oral



contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Zenzedi (2.5mg, 7.5mg)

Trial of a multisource Dextroamphetamine sulfate tablet or dextroamphetamine solution within the past 120 days

Zocor (80mg only) Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days

Zolpidem ER Trial of zolpidem IR within the past 120 days.

Zomig Zomig ZMT

Trial of sumatriptan or rizatriptan within the past 180 days

Zurampic Trial of allopurinol or Uloric (febuxostat) within the past 120 days

7. STEP THERAPY EDITS (NON FORMULARY)

Absorica Trial of generic isotretinoin within the past 120 days

Acanya

Aciphex

Trial of generic benzaclin gel required within the past 120 days Trial of two of the following; omeprazole, lansoprazole or pantoprazole or rabeprazole within the past 365 days

Aciphex Sprinkle Trial of two of the following; omeprazole, lansoprazole, pantoprazole or rabeprazole within the past 365 days

Acticlate 75mg Trial of generic doxycycline monohydrate 75mg tablets within the past 120 days

Acticlate 150mg

Actonel

Trial of generic doxycycline monohydrate 150mg tablets within the past 120 days Trial of alendronate and ibandronate within the past 365 days

Adzenys XR-ODT Trial of Adderall XR in the past 120 days

Aerospan Trial of at least two of the following: QVAR, Asmanex or Pulmicort within the past 365 days

Amitiza

Anoro Ellipta

Trial of Linzess or Movantik within the past 120 days. Trial of Stiolto Respimat and one of the following: Spiriva, Striverdi or Serevent within the past 365 days

Anzemet Trial of ondansetron tablets or ODT within the past 120 days

Aplenzin Trial of bupropion HCl SR or XL within the past 120 days

Aptiom Trial of two of the following; carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or zonisamide within the past 365 days

Arcapta Trial of Serevent Diskus or Striverdi Respimat within the past 120 days

Arnuity Ellipta Trial of at least two of the following: Asmanex, Pulmicort, or QVAR within the past 365 days

Atelvia Trial of alendronate and ibandronate within the past 365 days

Avandia/ Avandaryl/ Avandamet

Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.

Axert Trial of sumatriptan or rizatriptan within the past 180 days

Banzel Trial of lamotrigine, valproic acid or topiramate within the past 120 days

Belsomra Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within the past 120 days

Benoxyldoxy Trial of generic doxycycline monohydrate 100mg capsules within the past 120 days

Beyaz Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days

Bravelle Trial of Gonal-F or Gonal-F-RFF required within the past 120 days

Brisdelle

Briviact

Trial of paroxetine or venlafaxine within the past 120 days Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or zonisamide within the past 365 days

Bupap Trial of generic butalbital/acetaminophen combination product required within the last 120 days

Cesamet Trial of ondansetron tablet or ODT within the past 120 days

Clarinex Reditabs/ Clarinex syrup/ Clarinex D

Trial of desloratadine or levocetirizine tablet within the past 120 days

Clindagel

Clozapine ODT

Conzip

Trial of generic clindamycin gel required within the past 120 days Trial of 2 of the following: olanzapine, quetiapine, risperidone, or ziprasidone in the past 365 days. Trial of tramadol ER (Ultram ER) within the past 120 days

Cosopt PF Trial of dorzolamide/timolol within the past 120 days

Cycloset Trial of metformin (Glucophage), metformin ER, glyburide/metformin (Glucovance), or glipizide/metformin (Metaglip) within the past 180 days

Daytrana Trial of methylphenidate CD, ER, or LA formulation or methylphenidate suspension/solution within the past 120 days

DermasilkRx SDS Trial of all three individual ingredients: triamcinolone 0.1% (RX), dimethicone 5% (OTC) and silicone tape (OTC) within the past 365 days

Desvenlafaxine ER (fumarate)

Trial of two of the following; generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, venlafaxine ER or IR, mirtazapine or bupropion within the past 365 days

Doryx 50mg tabs

Doryx 200mg tabs

Doryx MPC 120mg tablets

Trial of generic doxycycline monohydrate 50mg capsule or tablet or doxycycline hyclate 50mg capsule within the past 120 days Trial of generic doxycycline hyclate 100mg tablets/capsules or doxycycline monohydrate 100mg tablets or capsules within the past 120 days Trial of generic doxycycline hyclate 100mg tablets /capsules or doxycycline monohydrate 100mg tablets or capsules within the past 120 days

Dyanavel XR Trial of extended-release amphetamine/dextroamphetamine oral capsules within the past 120 days

Dymista Trial of fluticasone or flunisolide within the past 365 days

Edarbi Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days

Edarbyclor Trial of ACE inhibitor, ACE inhibitor



combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days

Enstilar Trial of topical corticosteroid within the past 120 days

Epaned If age ≥ 12 years, trial of enalapril tablets within the past 120 days

Esomeprazole Strontium

Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days

Eucrisa Trial of topical corticosteroid and Elidel required within the past 365 days

Fanapt Trial of two generic atypical antipsychotics within the past 365 days

Fazaclo Trial of two generic atypical antipsychotics within the past 365 days

Felbatol

Trial of lamotrigine or topiramate within the past 120 days

Follistim AQ Trial of Gonal-F or Gonal-F-RFF required within the past 120 days

Foradil Trial of Serevent Diskus or Striverdi Respimat within the past 120 days

Fortamet Trial of generic metformin ER (Glucophage XR) within the past 120 days

Frova Trial of sumatriptan or rizatriptan within the past 180 days

Fulyzaq Trial of antiretroviral therapy within the past 120 days

Fycompa tablets and suspension

Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days

Gabitril Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days

Giazo Trial of balsalazide or Apriso within the past 120 days

Hemangeol For age over 1 year, trial of generic propranolol oral solution within the past 120 days

Incruse Ellipta Trial of preferred LAMA (Spiriva) within the past 120 days

Inderal XL Trial of Inderal LA within the past 120 days

Innopran XL Trial of Inderal LA within the past 120 days

Invega Trial of two generic atypical antipsychotics within the past 365 days.

Karbinal ER Trial of generic immediate-release carbinoxamine maleate within the past 120 days

Kytril Trial of ondansetron tablets or ODT within the past 120 days

Lamictal ODT/XR Trial of lamotrigine IR within the past 120 days

Lescol/XL Trial of two of the following: atorvastatin, lovastatin, pravastatin or simvastatin within the past 365 days

Liptruzet 10/10mg 10/20mg, 10/40mg, 10/80mg

Trial of 2 of the following: atorvastatin, simvastatin, pravastatin or lovastatin within the past 365 days Trial of 40mg atorvastatin or 80mg atorvastatin within the past 120 days

Loestrin 24 Fe Trial of two generic oral contraceptives within the past 365 days

Luvox CR Trial of generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, or fluvoxamine IR within the past 120 days

Luzu Trial of ketoconazole and clotrimazole cream within the past 365 days

Mirapex ER Trial of pramipexole IR or ropinirole IR within the past 120 days

Moderiba Dosepak Trial of ribavirin 200mg capsule or tablet within the past 120 days

Natazia Trial of two generic oral contraceptives within the past 365 days

Neo-Synalar Trial of fluocinolone and bacitracin within the past 365 days

Obredon Trial of hydrocodone/homatropine methylbromide within the past 120 days

Oleptro ER Trial of immediate release trazodone within the past 120 days

Onfi Trial of lamotrigine or topiramate within the past 120 days

Oracea Trial of generic doxycycline monohydrate 50mg capsule within the past 120 days

Ovace Plus Lotion Trial of ketoconazole shampoo/cream or ciclopirox shampoo/gel within the past 120 days

Oxtellar XR Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or zonisamide within the past 365 days

Patanase Trial of Astelin (azelastine) within the past 120 days

Pradaxa Trial of Eliquis and Xarelto within the past 365 days

Qbrelis If age ≥ 12 years, trial of lisinopril tablets within the past 120 days

Qudexy XR Trial of topiramate immediate release within the past 120 days

Quillichew Trial of Ritalin LA or Metadate CD within the past 120 days

Rapaflo Trial of finasteride 5mg, alfuzosin, doxazosin, prazosin, tamsulosin or terazosin within the past 120 days

Rasuvo Trial of Otrexup and methotrexate tablet or solution for injection within the past 365 days.

Relpax Trial of sumatriptan or rizatriptan within the past 180 days

Rescula Trial of latanoprost and Lumigan or Travatan Z within the past 365 days

Retin-A Micro Pump 0.08%

Trial of generic tretinoin microspheres 0.04% AND generic tretinoin microspheres 0.10% within the past 365 days

Rhinocort Aqua Trial of fluticasone or flunisolide within the past 365 days

Ribasphere 400mg, 600mg, RibaPak

Trial of ribavirin 200mg capsule or tablet within the past 120 days

Rytary Trial of Sinemet IR or CR within the past 120 days

Ryzodeg 70/30 Trial of preferred long acting insulin and preferred pre-mixed insulin) within the past 365 days

Safyral Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Savaysa Trial of Eliquis and Xarelto within the past 365 days

SanadermRX Trial of all three individual ingredients: triamcinolone 0.1% (RX), dimethicone 5% (OTC) and silicone tape (OTC) within the past 365 days

Sernivo Trial of Kenalog (triamcinolone acetonide) 0.147mg/g spray within the past 120 days

Seroquel XR Trial of two generic atypical anti-psychotics, SSRIs, or SNRIs within the past 365 days

Sancuso Trial of ondansetron tablet or ODT within the past 120 days

Silenor Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within



the past 120 days Sitavig Trial of oral acyclovir, valacyclovir or

famciclovir within the past 120 days Solodyn Trial of generic minocycline immediate

release within the past 120 days Sorilux Trial of a topical corticosteroid within

the past 120 days Sotylize Trial of sotolol tablets within the past

120 days Spritam Trial of generic levetiracetam 100mg/mL

solution required within the last 120 days Sumavel Dose-Pro Trial of generic/multisource injectable

sumatriptan or nasal sumatriptan (Imitrex or equivalent) within the past 180 days

Taclonex Taclonex Scalp

Trial of a topical corticosteroid within the past 120 days

Targadox Trial of generic doxycycline monohydrate 50mg capsule or generic doxycycline hyclate 50mg capsule within the past 120 days

Tasmar Trial of Comtan within the past 120 days

Teveten Teveten HCT


Timoptic Ocudose Trial of timolol drops within the past 120 days

Topicort Spray

Trial of mometasone 0.1% ointment, fluocinonide 0.05% cream/ointment/ gel, desoximetasone 0.25% cream, or betamethasone dipropionate 0.05% cream within the past 120 days

Trulance

Tuzistra XR

Trial of Linzess within the past 120 days Trial of promethazine with codeine syrup within the past 120 days

Uceris rectal foam Trial of mesalamine enema within the past 120 days

Uceris tablet Trial of balsalazide within the past 120 days

Versacloz Trial of two generic atypical antipsychotics within the past 365 days.

Vytorin: 10/10mg

Trial of two of the following: atorvastatin, lovastatin, pravastatin or simvastatin within the past 365 days

10/20mg, 10/40mg Trial of atorvastatin 40mg or atorvastatin 80mg within the past 120 days

10/80mg Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days

Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days

Xyzal Solution Trial of desloratadine or levocetirizine tablet within the past 120 days

Zecuity Trial of generic/multisource sumatriptan and nasal sumatriptan within the past 365 days

Zegerid Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days

Zithranol Zithranol RR

Trial of a topical corticosteroid within the past 120 days

8. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY) Actiq Adcirca Adempas Afinitor /Afinitor Disperz Aldara Alecensa Androgel Avonex Avonex Admin Pack Axiron Bosulif

Cabometyx Cayston

Cometriq

Copaxone

Corlanor

Cosentyx

Cotellic

Cystaran

Daraprim

Delatestryl

Depen

Depo-Testosterone

Duragesic

Eligard

Emverm

Enbrel

Epclusa

Erivedge

Esbriet

Fareston Farydak Firazyr Gattex Gilenya Gilotrif Gleevec

Grastek

Harvoni

Humira Ibrance Iclusig Imbruvica

Impavido Inlyta

Intron A Iressa Jakafi

Juxtapid

Kalydeco

Keveyis Korlym

Kynamro

Lenvima

Letairis

Leukine Lonsurf Lynparza Mekinist Neulasta Neupogen Nexavar

Ninlaro Norditropin Odomzo Ofev Omnitrope Opsumit Oralair Orfadin Orkambi Pegasys Plegridy Plegridy Pen Pomalyst

Praluent Procrit Procysbi Promacta Provigil Pulmozyme

Ragwitek

Rebif

Rebif Rebidose

Repatha Revatio tablets



Revlimid Sivextro Sovaldi Sprycel Stivarga

Stelara SC

Strensiq Suboxone Subutex Sutent Tafinlar Tagrisso

Tarceva Targretin Tasigna Tecfidera Temodar capsules Thalomid Tobi Tobi Podhaler Tracleer Tykerb

Uptravi Valchlor

Venclexta Votrient Xalkori

Xeljanz

Xeljanz XR Xeloda Xenazine Xifaxan 550mg Xtandi

Xuriden Zelboraf

Zubsolv Zydelig Zykadia Zytiga Zyvox

9. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY) Abraxane* Actemra IV* Actemra SC

Adcetris*

Addyi

Afrezza

Alimta*

Ampyra

Amturnide

Anadrol-50

Androderm

Apokyn

Aranesp

Arzerra*

Aubagio

Avastin*

Beleodaq*

Belviq

Belviq XR

Berinert

Betaseron

Bethkis

Bivigam*

Blincyto*

Botox*

Bunavail

Caprelsa

Carimune NF Nanofiltered*

Cerezyme*

Cholbam

Cialis

Cinqair

Cinryze

Contrave

Cuprimine

Cuvitru

Cyramza*

Darzalex*

Duopa

Dysport*

Egrifta

Elelyso*

Elspar*

Empliciti*

Entresto

Entyvio*

Epogen

Erbitux*

Erwinase*

Euflexxa*

Evekeo

Exalgo

Exondys 51*

Eylea*

Faslodex*

Flebogamma DIF*

Flolan*

Gamastan S-D*

Gammagard Liquid

Gammagard S-D*

Gammaked

Gammaplex*

Gamunex-C

Gazyva*

Gleostine

Gel-One*

Granix*

H.P. Acthar*

Halaven*

Herceptin*

Hetlioz

Hizentra

Hyalgan*

Hymovis*

Hyqvia IG Component

Ilaris*

Imlygic*

Incivek

Increlex

Inflectra*

Iprivask

Istodax*

Ixempra*

Jublia

Kadcyla*

Kalbitor*

Kanuma*

Keytruda*

Kineret

Kitabis Pak

Kyprolis*

Lartruvo*

Lemtrada*

Lucentis*

Lumizyme*

Macugen*

Makena

Marqibo*

Mircera



Monovisc*

Mozobil*

M Myobloc*

N Natpara

N Neulasta Delivery Kit*

Northera

Novantrone*

Nucala*

Nuedexta

Nuplazid

Nutropin

Nuvigil

Nymalize

Ocaliva

Octagam*

Olysio

Opdivo*

Orencia IV*

Orencia SC

Orenitram ER

Orthovisc*

Otezla

Oxandrin

Pegintron

Pegintron Redipen

Perjeta*

Photofrin*

Portrazza*

Privigen*

Prolia*

P Provigil

Qutenza

Ravicti

Relistor

Remicade*

Remodulin

Revatio vial*

Revatio suspension

Rituxan*

Rubraca

Saxenda

Serostim

Signifor

Simponi SC

Simponi Aria IV*

Sirturo

Solaraze

Soliris*

Spinraza*

Stelara IV*

Stivarga

Striant

Sucraid

Supartz*

Suprenza ODT

Sylatron

Sylvant*

Synagis*

Synribo*

Synvisc*

Synvisc-One*

Taltz

Tecentriq*

Veltassa

Yervoy*

Yondelis*

Zaltrap*

Zarxio

Zavesca

Zepatier

Zoladex*

Zorbtive

Zyclara * = Dependent on plan benefit. If covered under pharmacy benefit, then

non-formulary with prior authorization

10. CONCURRENT USE EDITS (FORMULARY) Suboxone

Subutex

Zubsolv

11. CONCURRENT USE EDITS (NON FORMULARY) Bunavail

MedPerform High Formulary INDEX


5-grass pollen extract ........................................... 6 8-MOP ................................................................ 10 abacavir sulfate ................................................ 15 abacavir sulfate/lamivudine ............................ 14 abacavir/dolutegravir/lamivudine ....................... 14 abacavir/lamivudine/zidovudine ..................... 14 ABBOTT DIABETIC SUPPLIES......................... 11 ABILIFY DISCMELT ............................................. 7 ABILIFY SOLUTION............................................. 7 ABILIFY TABLET ................................................. 7 abiraterone acetate ............................................ 16 acarbose ............................................................ 10 ACCUPRIL ........................................................... 8 ACCURETIC......................................................... 8 acebutolol hcl ..................................................... 8 acetaminophen with codeine .......................... 18 acetazolamide ................................................... 12 acetic acid ......................................................... 11 acetic acid/aluminum acetate ......................... 11 acetic acid/hydrocortisone .............................. 11 acetylcysteine ................................................... 17 acitretin .............................................................. 10 ACLOVATE ........................................................ 10 ACTIGALL .......................................................... 16 ACTIQ ................................................................. 17 ACTOPLUS MET ............................................... 11 ACTOPLUS MET XR ......................................... 11 ACTOS ............................................................... 11 ACULAR ............................................................. 12 ACULAR LS........................................................ 12 acyclovir ...................................................... 10, 14 ADALAT CC ......................................................... 8 adalimumab ........................................................ 15 adapalene .......................................................... 10 ADCIRCA ............................................................. 8 ADDERALL........................................................... 7 ADDERALL XR .................................................... 7 ADEMPAS ............................................................ 8 ADVAIR DISKUS .................................................. 6 ADVAIR HFA ........................................................ 6 afatinib ................................................................ 16 AFINITOR ........................................................... 17 AFTERA ............................................................... 9 AGRYLIN ............................................................ 13 AK-TRACIN ........................................................ 12 AKYNZEO ............................................................ 6 ALAMAST ........................................................... 12 ALA-TET ............................................................. 14 ALAWAY OTC .................................................... 12 albuterol sulfate .................................................. 6 ALBUTEROL SULFATE ....................................... 6 alclometasone dipropionate ........................... 10 ALDACTONE ....................................................... 8 ALDARA ............................................................. 13 ALDOMET ............................................................ 8 ALECENSA ........................................................ 16 alectinib hydrochloride........................................ 16 alendronate sodium ......................................... 12 alendronate sodium solution .......................... 12 alendronate sodium/vitamin d3 .......................... 11 alfuzosin ............................................................ 19 alirocumab ............................................................ 9 ALKERAN ........................................................... 16 allopurinol ......................................................... 13

ALOCRIL ............................................................ 12 ALOMIDE ........................................................... 12 ALORA ............................................................... 13 ALPHAGAN P .................................................... 12 alprazolam ........................................................... 7 ALPRAZOLAM INTENSOL .................................. 7 ALREX ................................................................ 12 ALTACE ................................................................ 8 altretamine .......................................................... 16 aluminum chloride ........................................... 10 ALUPENT ............................................................. 6 amantadine hcl ................................................. 18 AMARYL ............................................................. 11 AMBIEN ................................................................ 7 ambrisentan .......................................................... 8 amcinonide........................................................ 10 AMERGE ............................................................ 17 AMINOPHYLLIN ................................................... 6 aminophylline ..................................................... 6 amiodarone hcl ................................................... 7

amitriptyline hcl .................................................. 7 amlodipine bes/olmesartan med ...................... 8 amlodipine besylate ........................................... 8 amlodipine besylate/benazepril ........................ 8 amlodipine/atorvast cal ..................................... 9 amlodipine/valsartan.......................................... 8 amlodipine/valsartan/hctz ................................. 8 AMNESTEEM ....................................................... 9 amox tr/potassium clavulanate ...................... 14 amoxapine ........................................................... 7 amoxicillin trihydrate ....................................... 14 AMOXIL .............................................................. 14 amphet asp/amphet/d-amphet .......................... 7 ampicillin trihydrate ......................................... 14 amylase/lipase/protease .................................. 18 ANAFRANIL ......................................................... 7 anagrelide hcl ................................................... 13 ANALPRAM HC ................................................. 15 ANAPROX .......................................................... 15 ANAPROX DS .................................................... 15 ANASPAZ ........................................................... 18 anastrozole........................................................ 16 ANDROGEL ....................................................... 13 ANDROID ........................................................... 13 ANDROXY .......................................................... 13 ANSAID .............................................................. 15 ANTABUSE .......................................................... 7 anthralin .............................................................. 10 Antipsychotics, Atypical, D3/D2 Partial

Agonist/5HT Mixed ......................................... 7 antipyrine/benzocaine otic .................................. 11 ANTIVERT ............................................................ 6 ANUSOL-HC ...................................................... 16 APEXICON ......................................................... 10 APEXICON E ..................................................... 10 apixaban ............................................................. 13 aprepitant ............................................................ 6 APRESOLINE ...................................................... 8 APRISO .............................................................. 15 APTIVUS ............................................................ 14 ARALEN PHOSPHATE ...................................... 14 ARAVA ............................................................... 15 ARICEPT .............................................................. 6 ARICEPT ODT ..................................................... 6 ARIMIDEX .......................................................... 16 aripiprazole ......................................................... 7 ARIXTRA ............................................................ 13 ARMOUR THYROID .......................................... 12 AROMASIN ........................................................ 16 ARTANE ............................................................. 18 ASACOL ............................................................. 15 ASENDIN .............................................................. 7 asfotase alfa., STRENSIQ ................................. 17 ASMANEX ............................................................ 6 ASMANEX HFA .................................................... 6 ASTELIN ............................................................... 6 ASTEPRO ............................................................ 6 ATARAX ............................................................... 6 atazanavir sulfate ............................................... 15 atazanavir sulfate/cobicistat ............................... 15 atenolol ................................................................ 8 atenolol/chlorthalidone ...................................... 8 ATIVAN ................................................................. 7 atomoxetine hcl .................................................... 7 atorvastatin calcium........................................... 9 ATRIPLA ............................................................. 15 atropine sulfate ................................................. 13 ATROVENT .................................................... 6, 17 ATROVENT HFA .................................................. 6 AUGMENTIN ...................................................... 14 AUGMENTIN ES-600 ......................................... 14 AUGMENTIN XR ................................................ 14 AVALIDE .............................................................. 8 AVAPRO ............................................................... 8 AVC .................................................................... 19 AVELOX ............................................................. 14 AVELOX ABC PACK .......................................... 14 AVIANE-28 ........................................................... 9 AVINZA ............................................................... 17 AVLOSULFON ................................................... 14 AVODART .......................................................... 19 AVONEX ............................................................. 17 AVONEX ADMINISTRATION PACK ................. 17 AXID ................................................................... 18

AXIRON .............................................................. 13 axitinib ................................................................ 16 AYGESTIN ......................................................... 13 azathioprine ...................................................... 13 azelastine hcl ................................................ 6, 12 AZILECT ............................................................. 18 azithromycin ............................................... 13, 14 AZOPT ................................................................ 12 AZOR .................................................................... 8 aztreonam lysine ................................................ 13 AZULFIDINE....................................................... 15 bacitracin........................................................... 12 bacitracin/polymyxin b sulfate........................ 12 baclofen ............................................................. 18 BACTRIM DS ..................................................... 13 BACTROBAN ..................................................... 10 BACTROBAN NASAL ........................................ 17 balsalazide disodium ....................................... 15 BARACLUDE ..................................................... 15 becaplermin ........................................................ 11 beclomethasone dipropionate .............................. 6 belladonna alkaloids/phenobarb .................... 18 benazepril hcl ..................................................... 8 benazepril/hydrochlorothiazide ........................ 8 BENEMID ........................................................... 13 BENICAR .............................................................. 8 BENICAR HCT ..................................................... 8 BENTYL .............................................................. 18 BENZACLIN ......................................................... 9 BENZAMYCIN .................................................... 10 BENZAMYCIN PAK ............................................ 10 BENZOTIC ......................................................... 11 benzoyl peroxide .............................................. 10 benzoyl peroxide/hydrocortison ........................... 9 benztropine mesylate ...................................... 18 besifloxacin hcl drops susp 0.6% ....................... 12 BESIVANCE ....................................................... 12 BETAGAN .......................................................... 12 betamet diprop/prop gly .................................. 10

betamethasone dipropionate.......................... 6, 10 betamethasone valerate .................................. 10 BETAPACE .......................................................... 8 BETAPACE AF ..................................................... 8 betaxolol hcl ..................................................... 12 bethanechol chloride ....................................... 16 BETIMOL ............................................................ 12 BETOPTIC.......................................................... 12 BETOPTIC S ...................................................... 12 bexarotene.................................................... 10, 17 BIAXIN ................................................................ 13 BIAXIN XL .......................................................... 13 bicalutamide ..................................................... 16 BIDIL ..................................................................... 9 BILTRICIDE ........................................................ 14 bimatoprost 0.01% ............................................. 12 bimatoprost 0.03% ............................................. 12 bimonidine/timolol ............................................... 12 bisoprolol fumarate ............................................ 8 bisoprolol fumarate/hctz ................................... 8 BLEPHAMIDE .................................................... 12 BLEPHAMIDE S.O.P.......................................... 12 BLOCADREN ....................................................... 8 blood sugar diagnostic ....................................... 11 blood-glucose calib. control ................................ 11 blood-glucose meter ........................................... 11 BONIVA .............................................................. 12 bosentan ............................................................... 8 BOSULIF ............................................................ 16 bosutinib ............................................................. 16 BREO ELLIPTA .................................................... 6 BRETHINE ........................................................... 6 BREVOXYL-4 ..................................................... 10 BREVOXYL-8 ..................................................... 10 BRILINTA ........................................................... 13 brimonidine tartrate ......................................... 12 brinzolamide ....................................................... 12 brinzolamide/brimonidine ................................... 12 bromocriptine mesylate ................................... 18 budesonide ................................................... 6, 15 BUDESONIDE .................................................... 15 bumetanide ......................................................... 8 BUMEX ................................................................. 8 BUPHENYL POWDER ....................................... 16 BUPHENYL TABLET ......................................... 16



buprenorphine .................................................... 17 bupropion hcl ..................................................... 6 BUSPAR ............................................................... 7 buspirone hcl ...................................................... 7 busulfan .............................................................. 16 butalb/acetaminophen/caffeine ...................... 17 butalbital/acetaminophen ................................ 17 butalbital/aspirin/caffeine ................................ 17 butoconazole nitrate ........................................... 19 BUTRANS .......................................................... 17 BYSTOLIC ............................................................ 8 BYVALSON .......................................................... 8 cabergoline ....................................................... 12 CABOMETYX ..................................................... 16 cabozanitinib ...................................................... 16 cabozantinib s-malate ........................................ 16 CADUET ............................................................... 9 CAFERGOT........................................................ 17 CALAN .................................................................. 8 CALAN SR............................................................ 8 calcipotriene ..................................................... 10 calcitriol ............................................................. 19 calcium acetate ................................................. 11 canagliflozin ........................................................ 11 canagliflozin/metformin hcl ................................. 11 CANASA ............................................................. 15 capecitabine ...................................................... 16 CAPITAL W-CODEINE ...................................... 18 CAPOTEN ............................................................ 8 CAPOZIDE ........................................................... 8 captopril .............................................................. 8 captopril/hydrochlorothiazide........................... 8 CARAFATE ........................................................ 18 carbachol ............................................................ 12 carbamazepine ................................................. 18

CARBATROL ..................................................... 18 carbidopa .......................................................... 18 carbidopa/levodopa ......................................... 18 carbidopa/levodopa/entacapone .................... 18 CARDENE ............................................................ 8 CARDIZEM ........................................................... 8 CARDIZEM CD .................................................... 8 CARDURA ............................................................ 8 carisoprodol ...................................................... 18 carisoprodol/aspirin ......................................... 18 CARMOL HC ...................................................... 10 carteolol hcl ...................................................... 12 carvedilol ............................................................. 8

carvedilol phosphate ............................................ 8 CASODEX .......................................................... 16 CATAPRES .......................................................... 8 CAYSTON .......................................................... 13 CECLOR ............................................................. 13 CEENU ............................................................... 16 cefaclor .............................................................. 13 cefadroxil hydrate ............................................ 13 cefdinir ............................................................... 13 cefixime .............................................................. 13 cefpodoxime proxetil ....................................... 13 cefprozil ............................................................. 13 CEFTIN ............................................................... 13 cefuroxime axetil .............................................. 13 CEFZIL ............................................................... 13 CELEBREX ........................................................ 15 celecoxib ........................................................... 15 CELEXA ............................................................... 6 CELLCEPT ......................................................... 13 CENTANY .......................................................... 10 cephalexin monohydrate ................................. 13 ceritinib ............................................................... 16 cetirizine hcl (OTC)............................................. 6 cetrorelix acetate ................................................ 12 CETROTIDE ....................................................... 12 cevimeline hcl ................................................... 16 chloral hydrate .................................................... 7 chlorambucil ....................................................... 16 chlordiazepoxide hcl .......................................... 7 chlordiazepoxide/clidinium br ............................. 18 chlorhexidine gluconate .................................. 17 chloroquine phosphate ................................... 14 chlorpromazine hcl ............................................ 7 chlorpropamide ................................................ 11 chlorthalidone ..................................................... 8 chlorzoxazone .................................................. 18 cholestyramine/aspartame ................................ 9 cholestyramine/sucrose .................................... 9

CHRONULAC ..................................................... 16 CIBALITH-S .......................................................... 7 CICLODAN ......................................................... 10 ciclopirox 8% solution ..................................... 10 ciclopirox olamine ............................................ 10 cilostazol ........................................................... 13 CILOXAN ............................................................ 12 cimetidine hcl ................................................... 18 CIPRO ................................................................ 14 CIPRO ORAL SUSPENSION ............................ 14 CIPRODEX ......................................................... 11 ciprofloxacin ..................................................... 14 ciprofloxacin hcl ......................................... 12, 14 ciprofloxacin hcl/dexameth ................................. 11 citalopram hydrobromide .................................. 6 CLARAVIS ............................................................ 9 clarithromycin ................................................... 13 CLARITIN (OTC) .................................................. 6 CLARITIN-D 12 HOUR......................................... 6 CLARITIN-D 24 HOUR......................................... 6 CLEOCIN HCL ................................................... 13 CLEOCIN PALMITATE ...................................... 13 CLEOCIN T ........................................................ 10 CLIMARA ............................................................ 13 clindamycin ....................................................... 13 clindamycin palmitate ...................................... 13 clindamycin phos/benzoyl perox ..................... 9 clindamycin phosphate ................................... 10 clindamycin/tretinoin ............................................. 9 CLINORIL ........................................................... 15 clobetasol propionate ...................................... 10 clobetasol propionate/emoll ........................... 10 CLOBEX ............................................................. 10 CLOMID .............................................................. 11 clomiphene citrate ............................................ 11 clomipramine hcl ................................................ 7 clonazepam ....................................................... 18 clonidine hcl ....................................................... 8 clopidogrel bisulfate ........................................ 13 clorazepate dipotassium ................................... 7 clotrimazole....................................................... 14 clotrimazole/betamet diprop ........................... 10 clozapine ............................................................. 7 CLOZARIL ............................................................ 7 cobicistat ............................................................. 15 cobimetinib fumarate .......................................... 16 codeine phos/carisoprodol/asa ...................... 17 codeine/butalbit/acetamin/caff........................ 18 codeine/butalbital/asa/caffein ......................... 18 codeine/promethazine hcl ................................. 9 COGENTIN......................................................... 18 COLAZAL ........................................................... 15 COL-BENEMID .................................................. 13 colchicine .......................................................... 13 colchicine/probenecid ..................................... 13 COLCRYS .......................................................... 13 colesevelam hcl .................................................... 9 COLESTID............................................................ 9 COLESTID GRANULES ...................................... 9 colestipol ............................................................... 9 COLYTE WITH FLAVOR PACKETS ................. 16 COMBIGAN ........................................................ 12 COMBIPATCH ................................................... 13 COMBIVENT ........................................................ 6 COMBIVENT RESPIMAT .................................... 6 COMBIVIR .......................................................... 14 COMETRIQ ........................................................ 16 COMPAZINE ........................................................ 6 COMPAZINE SYRUP........................................... 6 COMPLERA ....................................................... 15 COMTAN ............................................................ 18 CONCERTA ......................................................... 7 CONDYLOX ....................................................... 10 COPAXONE ....................................................... 17 COPEGUS.......................................................... 15 CORDARONE ...................................................... 7 CORDRAN ......................................................... 10 CORDRAN SP ................................................... 10 COREG ................................................................ 8 COREG CR .......................................................... 8 CORGARD ........................................................... 8 CORLANOR ......................................................... 9 CORTEF ............................................................. 15 CORTENEMA .................................................... 16 cortisone acetate .............................................. 15 CORTISPORIN CREAM .................................... 10

CORTISPORIN OINTMENT .............................. 10 CORTISPORIN OPHTH SUSPENSION ............ 12 CORTISPORIN OTIC ......................................... 11 CORTONE ACETATE ........................................ 15 COSENTYX ........................................................ 10 COSOPT ............................................................ 12 COTELLIC .......................................................... 16 COUMADIN ........................................................ 13 COZAAR ............................................................... 8 CREON ............................................................... 18 CRESTOR ............................................................ 9 CRINONE ........................................................... 11 CRIXIVAN........................................................... 15 crizotinib ............................................................. 16 cromolyn sodium ......................................... 6, 12 crotamiton ........................................................... 10 CUPRIMINE ....................................................... 15 CUTIVATE .......................................................... 10 cyanocobalamin/fa/pyridoxine ............................ 19 CYCLESSA .......................................................... 9 cyclobenzaprine hcl ......................................... 18 CYCLOCORT ..................................................... 10 CYCLOGYL ........................................................ 13 cyclopentolate hcl ............................................ 13 cyclophosphamide ........................................... 16

cyclosporine.................................................. 12, 13 cyclosporine, modified .................................... 13 CYMBALTA .......................................................... 7 CYSTARAN ........................................................ 12 cysteamine ......................................................... 12 cysteamine bitartrate .......................................... 19 CYTOMEL .......................................................... 12 CYTOTEC .......................................................... 18 CYTOVENE ........................................................ 14 CYTOXAN .......................................................... 16 dabrafanib........................................................... 16 DALIRESP ............................................................ 6 DALMANE ............................................................ 7 dalteparin sodium,porcine .................................. 13 danazol .............................................................. 12 DANOCRINE ...................................................... 12 DANTRIUM......................................................... 18 dantrolene sodium ........................................... 18 dapsone ............................................................. 14 DARAPRIM......................................................... 14 darunavir ethanolate........................................... 14 darunavir/cobicistat ............................................ 14 dasatinib ............................................................. 16 DAYPRO ............................................................ 15 DDAVP ............................................................... 11 DECADRON ....................................................... 15 DELATESTRYL .................................................. 13 delavirdine mesylate........................................... 15 DEL-BETA .......................................................... 10 DELTASONE ...................................................... 15 DEMADEX ............................................................ 8 DEMULEN 1-50-21 .............................................. 9 DEPAKENE CAPSULES ................................... 18 DEPAKENE SYRUP .......................................... 18 DEPAKOTE ........................................................ 18 DEPAKOTE ER .................................................. 18 DEPAKOTE SPRINKLE ..................................... 18 DEPEN ............................................................... 15 DEPO-TESTOSTERONE .................................. 13 DESCOVY .......................................................... 14 desipramine hcl .................................................. 7 desmopressin (nonrefrigerated) ..................... 11 DESOGEN............................................................ 9 desogestrel-ethinyl estradiol ............................ 9 desog-et estra/ethin estra ................................. 9 desonide ............................................................ 10 DESOWEN ......................................................... 10 desoximetasone ............................................... 10 DESVENLAFAXINE ER (RANBAXY BRAND) .... 7 desvenlafaxine ER (Ranbaxy).............................. 7 desvenlafaxine succinate .................................. 7 DESYREL 300MG ................................................ 6 DETROL ............................................................. 19 DETROL LA........................................................ 19 dexamethasone ................................................ 15 DEXEDRINE......................................................... 7 DEXEDRINE SPANSULE .................................... 7 dexmethylphenidate hcl .................................... 7 dextroamphetamine capsule............................. 7 dextroamphetamine sulfate .............................. 7 dextroamphetamine tablet ................................ 7



DIABETA ............................................................ 11 DIABINESE ........................................................ 11 DIAMOX SEQUELS ........................................... 12 DIASTAT ............................................................ 18 diazepam ....................................................... 7, 18 DIBENZYLINE ...................................................... 8 dichlorphenamide ............................................... 18 diclofenac sodium ................................ 10, 12, 15 dicloxacillin sodium ......................................... 14 dicyclomine hcl ................................................ 18 didanosine......................................................... 15 DIDRONEL ......................................................... 12 DIFFERIN ........................................................... 10 DIFICID ............................................................... 14 diflorasone diacetate ....................................... 10 diflorasone diacetate/emoll ................................ 10 DIFLUCAN.......................................................... 14 diflunisal ............................................................ 17 difluprednate ....................................................... 12 digoxin ................................................................. 8 DIGOXIN ORAL SOLN......................................... 8 DILACOR XR ....................................................... 8 DILANTIN ........................................................... 18 DILANTIN CHEW TAB ....................................... 18 DILANTIN-125 .................................................... 18 DILAUDID ........................................................... 17 DILAUDID-5........................................................ 17 diltiazem hcl ........................................................ 8 dimethyl fumarate ............................................... 17 DIOVAN ................................................................ 8 DIOVAN HCT ....................................................... 8 diphenoxylate hcl/atrop sulf ........................... 16 dipivefrin hcl........................................................ 13 DIPROLENE ....................................................... 10 DIPROLENE AF ................................................. 10 DIPROSONE ...................................................... 10 dipyridamole ..................................................... 13 DISALCID ........................................................... 17 disopyramide phosphate ............................... 7, 8 disulfiram .............................................................. 7 DITROPAN XL ................................................... 19 divalproex sodium ............................................ 18 d-methorphan hb/prometh hcl .......................... 9 dofetilide .............................................................. 8 DOLOBID ........................................................... 17 DOLOPHINE HCL .............................................. 17 dolutegravir ......................................................... 15 DOMEBORO ...................................................... 11 donepezil hcl ....................................................... 6 DONNATAL ........................................................ 18 dornase alfa ........................................................ 17 dorzolamide hcl ................................................ 12 dorzolamide hcl/timolol maleat ...................... 12 DOSTINEX ......................................................... 12 DOVONEX.......................................................... 10 doxazosin mesylate ........................................... 8 doxepin hcl.......................................................... 7 doxycycline calcium ............................................ 14 doxycycline hyclate ......................................... 14 DOXYCYCLINE MONOHYDRATE 150MG

TABLET ........................................................ 14 DRISDOL ............................................................ 19 DRITHOCREME HP........................................... 10 DRITHO-SCALP ................................................. 10 dronabinol ........................................................... 6 dronedarone hcl ................................................... 8 DRYSOL ............................................................. 10 DUAVEE ............................................................. 13 DUETACT ........................................................... 11 DULERA ............................................................... 6 duloxetine hcl ..................................................... 7 DUONEB .............................................................. 6 DURAGESIC ...................................................... 17 DUREZOL .......................................................... 12 DURICEF ............................................................ 13 dutasteride ........................................................ 19 dutasteride/tamsulosin .................................... 19 DYAZIDE .............................................................. 8 DYNACIN ........................................................... 14 DYNACIRC ........................................................... 8 EC-NAPROSYN ................................................. 15 EDURANT .......................................................... 15 efavirenz ............................................................. 15 efavirenz/emtricitab/tenofovir ............................. 15 EFFEXOR............................................................. 7 EFFEXOR XR ...................................................... 7

EFFIENT ............................................................. 13 EFUDEX ............................................................. 10 ELAVIL ................................................................. 7 ELDEPRYL ......................................................... 18 ELIDEL ............................................................... 10 ELIGARD ............................................................ 11 ELIMITE .............................................................. 10 ELIQUIS ............................................................. 13 ELMIRON ........................................................... 19 ELOCON ............................................................ 10 eltrombopag olamine .......................................... 13 elviteg/cobi/emtric/tenofo ala .............................. 14 elvitegravir .......................................................... 15 elvitegravir/cobicistat/emtricitabine/ tenofovir

disoproxil fumarate ....................................... 14 EMCYT ............................................................... 17 EMEND ................................................................. 6 EMGEL ............................................................... 10 empagliflozin....................................................... 11 empagliflozin/linagliptin ...................................... 11 empagliflozin/metformin hcl ................................ 11 emtricitabine ....................................................... 15 emtricitabine/tenofov alafenam .......................... 14 emtricitabine/tenofovir ........................................ 14 emtrictab/rilpiviri/tenof ala .................................. 15 EMTRIVA ............................................................ 15 EMVERM ............................................................ 14 enalapril maleate ................................................ 8 enalapril/hydrochlorothiazide ........................... 8 Enbrel ................................................................. 28 ENBREL ............................................................. 15 ENDOMETRIN ................................................... 11 enfuvirtide ........................................................... 15 enoxaparin sodium .......................................... 13 entacapone........................................................ 18 entecavir ............................................................ 15 ENTOCORT EC ................................................. 15 enzalutamide ...................................................... 16 EPCLUSA ........................................................... 15 EPIDUO ................................................................ 9 EPIDUO FORTE .................................................. 9 epinephrine ....................................................... 16 EPIPEN .............................................................. 16 EPIPEN JR ......................................................... 16 EPIVIR ................................................................ 15 EPIVIR HBV SOLUTION .................................... 15 EPIVIR HBV TABLET......................................... 15 eplerenone .......................................................... 8

epoetin alfa ......................................................... 13 EPZICOM ........................................................... 14 ergocalciferol .................................................... 19 ergotamine tartrate/caffeine ............................ 17 ERIVEDGE ......................................................... 16 erlotinib hcl ......................................................... 16 ery e-succ/sulfisoxazole .................................. 14 ERYC .................................................................. 14 ERYGEL ............................................................. 10 ERYPED 200 ...................................................... 14 ERYPED 400 ...................................................... 14 ERY-TAB ............................................................ 14 ERYTHROCIN STEARATE ............................... 14 erythromycin base ..................................... 12, 14 erythromycin base/benz per ........................... 10 erythromycin base/ethanol ............................. 10 erythromycin ethylsuccinate .......................... 14 erythromycin stearate ...................................... 14 ESBRIET ............................................................ 17 escitalopram oxalate .......................................... 6

ESGIC ................................................................ 17 ESKALITH ............................................................ 7 esomeprazole magnesium .............................. 18 estazolam ............................................................ 7 ESTRACE..................................................... 13, 19 ESTRADERM ..................................................... 13 estradiol ....................................................... 13, 19 estradiol/noreth ac .............................................. 13 estramustine phosphate sodium ........................ 17 ESTRATEST H.S. .............................................. 13 estrogen, con/m-progest acet ............................ 13 estrogen, ester/me-testosterone .................... 13 estrogens, conj/bazedoxifene ............................ 13 estrogens, conjugated .................................. 13, 19 estrogens, esterified ........................................... 13 estropipate ........................................................ 13 eszopiclone ......................................................... 7 etanercept........................................................... 15

ethambutol hcl .................................................. 14 ethinyl estradiol/drospirenone.......................... 9 ethosuximide ...................................................... 18 ethynodiol d-ethinyl estradiol ........................... 9 etidronate disodium ......................................... 12 etodolac ............................................................. 15 etonogestrel/ethinyl estradiol ............................... 9 etoposide........................................................... 16 etravirine ............................................................. 15 EULEXIN ............................................................ 16 EURAX ............................................................... 10 everolimus .................................................... 13, 17 EVISTA ............................................................... 12 EVOCLIN ............................................................ 10 evolocumab .......................................................... 9 EVOTAZ ............................................................. 15 EVOXAC ............................................................. 16 EXELDERM ........................................................ 10 EXELON ............................................................... 6 EXELON PATCH .................................................. 6 exemestane ....................................................... 16 EXFORGE ............................................................ 8 EXFORGE HCT ................................................... 8 ezetimibe ............................................................. 9 FABIOR .............................................................. 10 famotidine ......................................................... 18 FARESTON ........................................................ 17 FARYDAK........................................................... 16 febuxostat ........................................................... 13 FELDENE ........................................................... 15 felodipine ............................................................. 8 FEMHRT ............................................................. 13 fenofibrate ........................................................... 9 fenofibrate nanocrystallized ............................. 9 fenofibrate, micronized ...................................... 9 fenoprofen calcium .......................................... 15 fentanyl .............................................................. 17 fentanyl citrate lozenge ................................... 17 fesoterodine fumarate ........................................ 19 FETZIMA .............................................................. 7 fidaxomicin.......................................................... 14 filgrastim ............................................................. 13 finasteride ......................................................... 19 fingolimod hcl ..................................................... 17 FIORICET ........................................................... 17 FIORICET WITH CODEINE ............................... 18 FIORINAL ........................................................... 17 FIORINAL WITH CODEINE ............................... 18 FIRAZYR ............................................................ 15 FIRST-HYDROCORTISONE ............................. 10 FLAGYL .............................................................. 14 FLAGYL ER ........................................................ 14 FLAREX .............................................................. 12 flecainide acetate ............................................... 7 FLEXERIL........................................................... 18 FLOMAX ............................................................. 19 FLONASE ............................................................. 6 FLORINEF ACETATE ........................................ 15 FLOXIN ......................................................... 11, 14 fluconazole ........................................................ 14 fludarabine phosphate ........................................ 16 fludrocortisone acetate ................................... 15 flunisolide............................................................ 6 fluocinolone acetonide .................................... 10 fluocinonide ...................................................... 10 fluocinonide/emollient ..................................... 10 FLUORABON BASIC ......................................... 19 fluoride ion/iron/vit a,c&d ................................ 19 fluoride ion/multivitamins ............................... 19 fluoride ion/multivits w-fe ................................ 19 fluoride ion/vit a,c&d ........................................ 19 FLUORITAB ....................................................... 19 fluorometholone ............................................... 12 fluorometholone acetate ..................................... 12 fluorouracil ........................................................ 10 fluoxetine er ........................................................ 6 fluoxetine hcl ...................................................... 6 fluoxymesterone ............................................... 13 fluphenazine hcl ................................................. 7 FLURA-DROPS .................................................. 19 flurandrenolide ................................................. 10 FLURA-TABS ..................................................... 19 flurazepam hcl .................................................... 7 flurbiprofen ....................................................... 15 flurbiprofen sodium ......................................... 12 flutamide ............................................................ 16



fluticasone propionate ................................. 6, 10 fluticasone/salmeterol........................................... 6 fluticasone/vilanterol ............................................. 6 FML .................................................................... 12 FML FORTE ....................................................... 12 FML S.O.P. ......................................................... 12 FOCALIN .............................................................. 7 FOCALIN XR ........................................................ 7 FOLGARD RX .................................................... 19 folic acid ............................................................ 19 FOLIC ACID ....................................................... 19 folic acid/mu-vits-min th .................................. 19 follitropin alpha,recomb ...................................... 11 fondaparinux sodium .......................................... 13 formoterol fumarate .............................................. 6 FORTEO ............................................................. 11 FOSAMAX .......................................................... 12 FOSAMAX PLUS D ............................................ 11 fosamprenavir calcium ....................................... 15 fosinopril sodium ............................................... 8 fosinopril/hydrochlorothiazide ......................... 8 FRAGMIN ........................................................... 13 FURADANTIN .................................................... 14 furazolidone ........................................................ 14 furosemide .......................................................... 8

FUROXONE ....................................................... 14 FUZEON ............................................................. 15 gabapentin ........................................................ 18 galantamine hbr .................................................. 6 ganciclovir..................................................... 12, 14 ganirelix acetate ................................................. 12 GANIRELIX ACETATE....................................... 12 GANTRISIN ........................................................ 13 GARAMYCIN ................................................ 10, 12 gatifloxacin........................................................ 12

GATTEX ............................................................. 16 gefitinib ............................................................... 16 gemfibrozil .......................................................... 9 gentamicin sulfate ...................................... 10, 12 GENVOYA .......................................................... 14 GEODON .............................................................. 7 GIANVI ................................................................. 9 GILENYA ............................................................ 17 GILOTRIF ........................................................... 16 glatiramer acetate ............................................. 17 GLEEVEC........................................................... 16 glimepiride ........................................................ 11 glipizide ............................................................. 11 glipizide/metformin hcl .................................... 11 glucagon ............................................................. 11 GLUCAGON KIT ................................................ 11 GLUCOPHAGE .................................................. 11 GLUCOPHAGE XR ............................................ 11 GLUCOTROL ..................................................... 11 GLUCOTROL XL ................................................ 11 GLUCOVANCE .................................................. 11 glyburide ........................................................... 11 glyburide, micro/metformin hcl ...................... 11 GLYXAMBI ......................................................... 11 GOLYTELY......................................................... 16 gonadotropin,chorionic, human .......................... 11 GONAL-F ............................................................ 11 GONAL-F RFF ................................................... 11 GRASTEK ............................................................ 6 griseofulvin suspension ...................................... 14 griseofulvin ultramicrosize ............................. 14 GRISEOFULVIN V ............................................. 14 GRIS-PEG .......................................................... 14 guanfacine hcl .................................................... 8 GYNAZOLE-1 ..................................................... 19 HALCION .............................................................. 7 HALDOL ............................................................... 7 HALDOL ORAL CONC......................................... 7 halobetasol propionate .................................... 10 haloperidol .......................................................... 7 haloperidol lactate .............................................. 7 HARVONI ........................................................... 15 hc acetate/pramoxine hcl .................... 10, 15, 16 hcg alpha, recombinant ...................................... 11 HEPARIN LOCK ................................................. 13 heparin sodium, porcine ................................. 13 heparin sodium, porcine/pf ............................. 13 HEP-LOCK ......................................................... 13 HEPSERA .......................................................... 15 HEXALEN ........................................................... 16 homatropine hbr ............................................... 13

HUMALOG ......................................................... 11 HUMALOG MIX 50-50........................................ 11 HUMALOG MIX 75-25........................................ 11 HUMATIN ........................................................... 14 HUMIRA ............................................................. 15 HUMULIN 70-30 ................................................. 11 HUMULIN N........................................................ 11 HUMULIN R........................................................ 11 HUMULIN R U-500 ............................................. 11 HYCAMTIN ......................................................... 16 HYCET ............................................................... 17 HYCODAN............................................................ 9 hydralazine hcl ................................................... 8 HYDREA ............................................................. 16 hydrochlorothiazide ........................................... 8 hydrocodone bit/acetaminophen ................... 17 hydrocodone bit/acetaminophen oral elixir .. 17 hydrocodone bit/acetaminophen oral solution

...................................................................... 17 hydrocodone bit/homatrop me-br .................... 9 hydrocodone bitartrate ....................................... 17 hydrocodone/chlorphen p-stirex ...................... 9

hydrocort/sal acid/sulf/shmp#1........................... 10 hydrocortisone ..................................... 10, 15, 16 hydrocortisone acetate .................................... 16 hydrocortisone acetate/urea ........................... 10 hydrocortisone butyrate .................................. 10 hydrocortisone butyrate/emoll ............................ 10 hydrocortisone probutate ................................... 10 hydrocortisone valerate .................................. 10 hydromorphone hcl.......................................... 17 hydroxychloroquine sulfate ............................ 14 hydroxyurea ...................................................... 16 hydroxyzine hcl .................................................. 6 hydroxyzine pamoate ........................................ 6

HYGROTON ......................................................... 8 hyoscyamine sulfate ........................................ 18 HYPER-SAL 7% ................................................. 17 HYSINGLA ER ................................................... 17 HYTRIN ................................................................ 8 HYZAAR ............................................................... 8 ibandronate ....................................................... 12 IBRANCE ............................................................ 16 ibrutinib ............................................................... 16 ibuprofen ........................................................... 15 icatibant .............................................................. 15 ICLUSIG ............................................................. 16 icosapent ethyl ..................................................... 9 idelalisib .............................................................. 16 ILEVRO .............................................................. 12 imatinib mesylate ............................................. 16 Imbruvica ............................................................ 28 IMBRUVICA........................................................ 16 IMDUR .................................................................. 9 imipramine hcl .................................................... 7 imiquimod ......................................................... 13 IMITREX INJECTION ......................................... 17 IMITREX NASAL SPRAY ................................... 17 IMITREX TABLET .............................................. 17 IMPAVIDO .......................................................... 14 IMURAN ............................................................. 13 indapamide.......................................................... 8 INDERAL LA......................................................... 8 INDERIDE-40/25 .................................................. 8 indinavir sulfate .................................................. 15 INDOCIN ............................................................ 15 INDOCIN ORAL SUSP. ..................................... 15 INDOCIN SR ...................................................... 15 INDOCIN SUPPOS ............................................ 15 indomethacin .................................................... 15 ingenol ................................................................ 10 INLYTA ............................................................... 16 INSPRA ................................................................ 8 insulin glargine,hum.rec.anlog ........................... 11 insulin lispro ........................................................ 11 insulin nph hum/reg insulin hm........................... 11 insulin nph human isophane .............................. 11 insulin npl/insulin lispro ...................................... 11 insulin regular, human ........................................ 11 INTAL ................................................................... 6 INTELENCE ....................................................... 15 interferon alfa-2b, recomb. ................................. 13 interferon beta-1a ............................................... 17 interferon beta-1a/albumin ................................. 17 INTRON A .......................................................... 13 INVIRASE ........................................................... 15

INVOKAMET ...................................................... 11 INVOKAMET XR ................................................ 11 INVOKANA ......................................................... 11 iodoquinol ........................................................... 14 ipratropium bromide .................................... 6, 17 ipratropium/albuterol sulfate ............................ 6 irbesartan ............................................................ 8 irbesartan/hydrochlorithiazide.......................... 8 IRESSA .............................................................. 16 ISENTRESS ....................................................... 15 ISMO .................................................................... 9 ISOCHRON .......................................................... 9 isomethept/acetaminop/dichlphn ................... 17 isoniazid ............................................................ 14 ISOPTO ATROPINE .......................................... 13 ISOPTO CARBACHOL ...................................... 12 ISOPTO CARPINE ............................................. 12 ISOPTO HOMATROPINE .................................. 13 ISORDIL ............................................................... 9 ISORDIL TITRADOSE ......................................... 9 isosorb dinit/hydralazine hcl ................................. 9 isosorbide dinitrate ............................................ 9 isosorbide mononitrate ..................................... 9 isotretinoin .......................................................... 9 isradipine IR capsules ....................................... 8 itraconazole....................................................... 14 ivabradine hcl ....................................................... 9 ivacaftor .............................................................. 17 ixazomib citrate .................................................. 16 JAKAFI ............................................................... 16 JALYN ................................................................ 19 JANUMET ........................................................... 10 JANUMET XR .................................................... 10 JANUVIA ............................................................ 10 JARDIANCE ....................................................... 11 JENTADUETO ................................................... 10 JUXTAPID ............................................................ 9 KALETRA ........................................................... 15 KALYDECO ........................................................ 17 KAYEXALATE .................................................... 11 K-DUR ................................................................ 11 KEFLEX .............................................................. 13 KENALOG .......................................................... 10 KENALOG IN ORABASE ................................... 17 KEPPRA ............................................................. 18 KETEK ................................................................ 13 ketoconazole ............................................... 10, 14 ketoprofen ......................................................... 15 ketorolac tromethamine ............................ 12, 15 ketotifen fumarate (OTC) ................................. 12 KEVEYIS ............................................................ 18 KLONOPIN ......................................................... 18 KORLYM ............................................................ 11 KRISTALOSE ..................................................... 16 K-TAB ................................................................. 11 KURIC ................................................................ 10 KUVAN ............................................................... 16 KWELL ............................................................... 10 KYNAMRO ........................................................... 8 labetalol hcl ......................................................... 8 LACTICARE-HC ................................................. 10 lactulose ............................................................ 16 LAMICTAL .......................................................... 18 LAMISIL ........................................................ 10, 14 LAMISIL GRANULES ......................................... 14 lamivudine ......................................................... 15 lamivudine/zidovudine ........................................ 14 lamotrigine ........................................................ 18

lancing device/lancets ........................................ 11 LANOXIN .............................................................. 8 lansoprazole ..................................................... 18 lansoprazole/amox tr/clarith ........................... 18 LANTUS ............................................................. 11 lapatinib ditosylate .............................................. 16 LARIAM .............................................................. 14 LASIX ................................................................... 8 latanoprost .......................................................... 12 LATUDA ............................................................... 7 ledipasvir/sofosbuvir ........................................... 15 leflunomide ....................................................... 15 lenalidomide ....................................................... 16 lenvatinib mesylate ............................................. 16 LENVIMA ............................................................ 16 LESSINA .............................................................. 9 LETAIRIS .............................................................. 8 LEUKERAN ........................................................ 16



LEUKINE ............................................................ 13 leuprolide ............................................................ 11 LEVAQUIN ......................................................... 14 LEVBID ............................................................... 18 levetiracetam .................................................... 18 levobunolol hcl ................................................. 12 levocetirizine ....................................................... 6 levofloxacin ....................................................... 14 levonorgestrel ..................................................... 9 levonorgestrel-eth estra .................................... 9 LEVOTHROID .................................................... 12 levothyroxine sodium ...................................... 12 LEVOXYL ........................................................... 12 LEVSIN-SL ......................................................... 18 LEXAPRO............................................................. 6 LEXIVA ............................................................... 15 LIBRAX ............................................................... 18 LIBRIUM ............................................................... 7 LIDEX ................................................................. 10 LIDEX-E .............................................................. 10 lidocaine hcl ...................................................... 15 linaclotide ............................................................ 15 linagliptin ............................................................. 10 linagliptin/metformin hcl ...................................... 10 lindane ............................................................... 10 linezolid ............................................................. 14 LINZESS ............................................................. 15 LIORESAL .......................................................... 18 liothyronine sodium ......................................... 12 LIPITOR ................................................................ 9 liraglutide ............................................................ 11 lisdexamfetamine dimesylate ............................... 7 lisinopril ............................................................... 8 lisinopril/hydrochlorothiazide ........................... 8 lithium carbonate ............................................... 7 lithium citrate ...................................................... 7 LITHOBID ............................................................. 7 LIVALO ................................................................. 9 LO LOESTRIN FE ................................................ 9 LO MINASTRIN FE .............................................. 9 LOCOID .............................................................. 10 LOCOID LIPOCREAM ....................................... 10 LODINE .............................................................. 15 LODOSYN .......................................................... 18 lodoxamide tromethamine .................................. 12 LOESTRIN............................................................ 9 LOESTRIN FE ...................................................... 9 LOESTRIN FE24 .................................................. 9 LOFIBRA .............................................................. 9 lomitapide ............................................................. 9 LOMOTIL ............................................................ 16 lomustine........................................................... 16 LONSURF .......................................................... 16 LO-OVRAL-28 ...................................................... 9 LOPID ................................................................... 9 lopinavir/ritonavir ............................................. 15 LOPRESSOR ....................................................... 8 LOPRESSOR HCT ............................................... 8 LOPROX ............................................................. 10 loratadine (OTC) ................................................. 6 lorazepam ............................................................ 7

LORAZEPAM INTENSOL .................................... 7 LORCET ............................................................. 17 LORCET PLUS .................................................. 17 LORTAB ............................................................. 17 LORTAB ELIXIR ................................................. 17 LORYNA ............................................................... 9 losartan potassium ............................................ 8 losartan/hydrochlorothiazide ............................ 8 LOTEMAX .......................................................... 12 LOTENSIN............................................................ 8 LOTENSIN HCT ................................................... 8 loteprednol etabonate......................................... 12 LOTREL ................................................................ 8 LOTRISONE ....................................................... 10 lovastatin ............................................................. 9 LOVAZA ............................................................... 9 LOVENOX .......................................................... 13 loxapine succinate ............................................. 7 LOXITANE ............................................................ 7 LOZOL .................................................................. 8 LUDIOMIL............................................................. 7 lumacaftor/ivacaftor ............................................ 17 LUMIGAN ........................................................... 12 LUNESTA ............................................................. 7 LURIDE .............................................................. 19

LUTERA ............................................................... 9 LYNPARZA......................................................... 16 LYRICA ............................................................... 18 LYSODREN ........................................................ 16 macitentan ............................................................ 8 MACROBID ........................................................ 14 MACRODANTIN ................................................. 14 malathion........................................................... 10 maprotiline hcl .................................................... 7

maraviroc ............................................................ 14 MARINOL ............................................................. 6 MATULANE ........................................................ 16 MAVIK .................................................................. 8 MAXALT ............................................................. 17 MAXALT MLT ..................................................... 17 MAXITROL ......................................................... 12 MAXZIDE .............................................................. 8 MAXZIDE-25MG .................................................. 8 mechlorethamine ................................................ 10 meclizine hcl ....................................................... 6 meclofenamate sodium ................................... 15 MECLOMEN ....................................................... 15 MEDROL ............................................................ 15 medroxyprogesterone acet ............................. 13 mefloquine hcl .................................................. 14

MEGACE ............................................................ 17 megestrol acetate ............................................. 17 MEKINIST........................................................... 16 MELLARIL ............................................................ 7 meloxicam ......................................................... 15 melphalan ........................................................... 16 memantine hcl .................................................... 6 memantine hcl/donepezil hcl ................................ 6 MENEST ............................................................. 13 MENOPUR ......................................................... 11 menotropins ........................................................ 11 MEPHYTON ....................................................... 13 meprobamate ...................................................... 7 mercaptopurine ................................................ 16 mesalamine ....................................................... 15 mesalamine w/cleansing wipes ...................... 15 MESTINON........................................................... 6 METADATE CD .................................................... 7 METADATE ER .................................................... 7 METAGLIP ......................................................... 11 metaproterenol sulfate ...................................... 6 metaxalone ........................................................ 18 metformin hcl .................................................... 11

meth/meth blue/ba/salicy/hyos ........................... 13 methadone hcl .................................................. 17 methadone HCl injection solution .................. 17 methazolamide ................................................. 12 METHERGINE ..................................................... 9 methimazole ...................................................... 12 METHITEST ....................................................... 13 METHLYIN SOLN ................................................ 7 methocarbamol ................................................. 18 methotrexate ..................................................... 15 methotrexate sodium ................................. 15, 16 METHOTREXATE TABLET ............................... 16 METHOTREXATE VIAL ..................................... 16 methoxsalen ....................................................... 10 methoxsalen, rapid........................................... 10 methyldopa ......................................................... 8 methylergonovine maleate ................................ 9 METHYLIN CHEW TAB ....................................... 7 methylphenidate ER Susp .................................... 7 methylphenidate hcl........................................... 7 methylprednisolone ......................................... 15 methyltestosterone .......................................... 13 metipranolol ...................................................... 12 metoclopramide hcl ......................................... 18 METOCLOPRAMIDE HCL INTENSOL .............. 18 metolazone .......................................................... 8 metoprolol succinate ......................................... 8 metoprolol tartrate ............................................. 8 metoprolol/hctz ................................................... 8 METROCREAM ................................................. 10 METROGEL-VAGINAL ...................................... 19 METROLOTION ................................................. 10 metronidazole ....................................... 10, 14, 19 MEVACOR ........................................................... 9 mexiletine hcl ...................................................... 7 MEXITIL ................................................................ 7 miconazole nitrate ............................................ 19 MICRO-K ............................................................ 11

MICRONASE ...................................................... 11 MICROZIDE ......................................................... 8 midodrine hcl ...................................................... 9

MIDRIN ............................................................... 17 mifepristone ........................................................ 11 MIGERGOT ........................................................ 17 MILLIPRED......................................................... 15 MILLIPRED DP .................................................. 15 milnacipran hcl ................................................... 17 miltefosine .......................................................... 14 MILTOWN ............................................................. 7 MINIPRESS .......................................................... 8 MINOCIN ............................................................ 14 minocycline hcl ................................................ 14 mipomersen sodium ............................................. 8 mirabegron ......................................................... 19 MIRALAX ............................................................ 16 MIRAPEX ........................................................... 18 MIRCETTE ........................................................... 9 mirtazapine.......................................................... 6 misoprostol ....................................................... 18 mitotane .............................................................. 16 MOBIC ................................................................ 15 modafinil .............................................................. 7 moexipril hcl ....................................................... 8 moexipril/hydrochlorothiazide .......................... 8 mometasone furoate .................................... 6, 10 mometasone/formoterol ....................................... 6 MONISTAT 3 ...................................................... 19 MONOKET ........................................................... 9 MONOPRIL .......................................................... 8 MONOPRIL HCT .................................................. 8 montelukast sodium .......................................... 6 MORGIDOX 100MG CAPSULE......................... 14 MORGIDOX 50MG CAPSULE........................... 14 morphine sulfate .............................................. 17 MOTRIN ............................................................. 15 MOVANTIK ......................................................... 16 moxifloxacin hcl ............................................ 12, 14 MSIR ................................................................... 17 mth/me blue/salicy/na phos/hyo ......................... 13 MUCOMYST-10 ................................................. 17 MULTAQ ............................................................... 8 mupirocin .......................................................... 10 mupirocin calcium ...................................... 10, 17 MYAMBUTOL ..................................................... 14 MYCELEX .......................................................... 14 MYCIFRADIN ..................................................... 14 MYCOLOG II ...................................................... 10 mycophenolate mofetil .................................... 13 MYCOSTATIN .............................................. 10, 14 MYLERAN .......................................................... 16 MYORISAN .......................................................... 9 MYRBETRIQ ...................................................... 19 MYSOLINE ......................................................... 18 na sulfacetm/prednis sp .................................. 12 na sulfacetm/prednisol ac .................................. 12 nabumetone ...................................................... 15 nadolol ................................................................. 8 naftifine hcl ....................................................... 10 NAFTIN ............................................................... 10 NALFON CAPSULE ........................................... 15 NALFON TABLET .............................................. 15 naloxegol oxalate ............................................... 16 naltrexone hcl ..................................................... 7 NAMENDA............................................................ 6 NAMENDA XR ..................................................... 6 NAMZARIC ........................................................... 6 NAPROSYN ....................................................... 15 naproxen ........................................................... 15 naproxen sodium ............................................. 15 naratriptan ......................................................... 17 NARCAN NASAL ................................................. 7 Narcotic Withdrawal Therapy Agents ................. 18 NARDIL ................................................................ 6 NASACORT AQ ................................................... 6 NASAREL ............................................................. 6 NASONEX ............................................................ 6 nateglinide......................................................... 11 NATURE-THROID .............................................. 12 NAVANE ............................................................... 7 nebivolol hcl .......................................................... 8 NEBUPENT ........................................................ 14 nedocromil sodium ............................................. 12 needles, insulin disp., safety .............................. 17 nelfinavir mesylate .............................................. 15



neo/polymyx b sulf/dexameth ......................... 12 neomy sulf/bacitrac zn/poly/hc ....................... 12 neomy sulf/polymyx b sulf/hc ................. 10, 11, 12 neomycin sulfate .............................................. 14 neomycin/bacitra/polymyxin/hc .......................... 10 neomycin/bacitracin/polymyxin ..................... 12 neomycin/polymyxn b/gramicidin .................. 12 NEO-POLYCIN HC OPHTH OINTMENT........... 12 NEORAL ............................................................. 13 NEOSPORIN OPHTH DROPS .......................... 12 NEOSPORIN OPHTH OINTMENT .................... 12 neostigmine bromide ............................................ 6 nepafenac ........................................................... 12 NEPTAZANE ...................................................... 12 netupitant/palonosetron hcl .................................. 6 NEULASTA......................................................... 13 NEUPOGEN ....................................................... 13 NEUPRO ............................................................ 18 NEURONTIN ...................................................... 18 NEVANAC .......................................................... 12 nevirapine.......................................................... 15 nevirapine ER ................................................... 15

NEXAVAR .......................................................... 16 NEXIUM .............................................................. 18 niacin ................................................................... 9

NIASPAN .............................................................. 9 nicardipine .......................................................... 8 nifedipine ............................................................. 8 NILANDRON ...................................................... 16 nilotinib hydrochloride......................................... 16 nilutamide.......................................................... 16 nimodipine .......................................................... 8 NIMOTOP ............................................................. 8 NINLARO ............................................................ 16 nintedanib esylate .............................................. 17 NITRO-BID ........................................................... 9 NITRO-DUR ......................................................... 9 nitrofurantoin ...................................................... 14 nitrofurantoin macrocrystal ............................ 14 nitrofurantoin/nitrofuran mac ......................... 14 nitroglycerin ........................................................ 9 NITROLINGUAL ................................................... 9 NITROSTAT ......................................................... 9 nizatidine ........................................................... 18 NIZORAL ...................................................... 10, 14 NOCTEC .............................................................. 7 NOLVADEX ........................................................ 17 NORCO .............................................................. 17 NORDETTE-28 .................................................... 9 NORDITROPIN .................................................. 12 NORDITROPIN FLEXPRO ................................ 12 NORDITROPIN NORDIFLEX ............................ 12 norelgestromin/ethin.estradiol ......................... 9 noreth a-et estra/fe fumarate............................. 9 norethindrone ..................................................... 9 norethindrone acetate ..................................... 13 norethindrone ac-eth estradiol ....................... 13 norethindrone a-e estradiol ............................... 9 norethindrone-ethinyl estrad ............................ 9 norethindrone-mestranol .................................. 9 NORFLEX........................................................... 18 NORGESIC FORTE ........................................... 18 norgestimate-ethinyl estradiol .......................... 9 norgestrel-ethinyl estradiol ............................... 9 NORINYL 1+35 .................................................... 9 NORINYL 1+50 .................................................... 9 NORPACE ............................................................ 7 NORPACE CR ..................................................... 8 NORPRAMIN ....................................................... 7 NOR-Q-D .............................................................. 9 nortriptyline hcl .................................................. 7 NORVASC ............................................................ 8 NORVIR .............................................................. 15 NOVAREL .......................................................... 11 NUCYNTA .......................................................... 17 NUCYNTA ER .................................................... 17 NULYTELY WITH FLAVOR PACKS .................. 16 NUVARING........................................................... 9 NYDRAZID ......................................................... 14 nystatin ........................................................ 10, 14 nystatin/triamcin ............................................... 10 OCL .................................................................... 16 octreotide acetate ............................................. 17 OCUFEN ............................................................ 12 OCUFLOX .......................................................... 12 OCUPRESS ....................................................... 12

ODEFSEY .......................................................... 15 ODOMZO ........................................................... 16 OFEV .................................................................. 17 ofloxacin ................................................ 11, 12, 14 OFORTA ............................................................. 16 OGEN ................................................................. 13 olanzapine ........................................................... 7 olanzapine ODT .................................................. 7 olanzapine/fluoxetine ......................................... 6

olaparib ............................................................... 16 olmesartan medoxomil ...................................... 8 olmesartan/amlodipin/hcthiazid ....................... 8 olmesartan/hydrochlorothiazide ...................... 8 olodaterol hcl ........................................................ 6 olopatadine hcl ................................................. 12 OLUX .................................................................. 10 omega-3 acid ethyl esters ................................. 9 omeprazole........................................................ 18 omeprazole magnesium .................................. 18 OMNICEF ........................................................... 13 OMNIPRED ........................................................ 12 OMNITROPE ...................................................... 12 ondansetron ........................................................ 6 ondansetron hcl ................................................. 6 ONEXTON ............................................................ 9 OPSUMIT ............................................................. 8 OPTICROM ........................................................ 12 OPTIPRANOLOL ............................................... 12 OPTIVAR ............................................................ 12 ORALAIR .............................................................. 6 ORAMORPH SR ................................................ 17 ORAPRED .......................................................... 15 ORFADIN ........................................................... 17 ORINASE ........................................................... 11 ORKAMBI ........................................................... 17 orphenadrine citrate......................................... 18 orphenadrine/aspirin/caffeine ......................... 18 ORSYTHIA ........................................................... 9 ORTHO EVRA ...................................................... 9 ORTHO MICRONOR ........................................... 9 ORTHO TRI-CYCLEN .......................................... 9 ORTHO TRI-CYCLEN LO .................................... 9 ORTHO-CEPT ...................................................... 9 ORTHO-CYCLEN ................................................. 9 ORTHO-NOVUM .................................................. 9 ORUVAIL ............................................................ 15 OSCELLA ............................................................. 9 oseltamivir phosphate ..................................... 14

osimertinib mesylate........................................... 16 OTICIN HC ......................................................... 11 OTREXUP .......................................................... 15 OVACE PLUS SUSPENSION............................ 10 OVIDE ................................................................ 10 OVIDREL ............................................................ 11 oxaprozin........................................................... 15 oxazepam ............................................................ 7 oxcarbazepine .................................................. 18 OXSORALEN ..................................................... 10 OXSORALEN-ULTRA ........................................ 10 oxybutynin chloride ......................................... 19 oxycodone hcl .................................................. 17 oxycodone hcl/acetaminophen ...................... 17 oxycodone hcl/aspirin ..................................... 17 OXYCONTIN ...................................................... 17 palbociclib ........................................................... 16 PAMELOR ............................................................ 7 PANCRELIPASE 5,000 ...................................... 18 PANDEL ............................................................. 10 panobinostat lactate ........................................... 16 pantoprazole sodium ....................................... 18 PARAFON FORTE DSC .................................... 18 PARCOPA .......................................................... 18 paricalcitol......................................................... 12 PARLODEL ........................................................ 18 PARNATE............................................................. 6 paromomycin sulfate ....................................... 14 paroxetine hcl ..................................................... 6 PATADAY ........................................................... 12 PATANOL ........................................................... 12 PATHOCIL.......................................................... 14 PAXIL ................................................................... 6 pazopanib hydrochloride .................................... 16 PCE .................................................................... 14 PEDIAPRED ....................................................... 15 PEDIAZOLE ....................................................... 14 peg 3350/na sulf,bicarb,cl/kcl ......................... 16

PEGASYS .......................................................... 15 PEGASYS PROCLICK ....................................... 15 pegfilgrastim ....................................................... 13 peginterferon alfa-2a .......................................... 15 peginterferon beta-1a ......................................... 17 pegvisomant ....................................................... 12 pemirolast potassium ......................................... 12 penicillamine ....................................................... 15 penicillin v potassium ...................................... 14

pentamidine isethionate ..................................... 14 pentosan polysulfate sodium .............................. 19 pentoxifylline .................................................... 13 PEPCID .............................................................. 18 p-ephed hcl/cetirizine hcl (OTC) ....................... 6 p-ephed sul/loratadine ....................................... 6 PERCOCET........................................................ 17 PERCODAN ....................................................... 17 PERCOLONE ..................................................... 17 PERFOROMIST ................................................... 6 PERIDEX ............................................................ 17 PERISOL ............................................................ 17 permethrin ......................................................... 10 perphenazine ...................................................... 7 PERSANTINE .................................................... 13 phenazopyridine hcl......................................... 19

phenelzine sulfate ................................................ 6 PHENERGAN ....................................................... 6 PHENERGAN VC ................................................. 9 PHENERGAN VC W/CODEINE........................... 9 PHENERGAN W/CODEINE ................................. 9 PHENERGAN W/DEXTROMETHORPHAN ........ 9 phenobarbital ...................................................... 7 PHENOBARBITAL ............................................... 7 phenoxybenzamine hcl ...................................... 8 phenylephrine hcl/cod/prometh ....................... 9 phenylephrine hcl/prometh hcl ......................... 9 PHENYTEK ........................................................ 18 phenytoin .......................................................... 18 phenytoin sodium extended ........................... 18 PHOSLO ............................................................. 11 PHRENILIN ........................................................ 17 PHRENILIN FORTE ........................................... 17 phytonadione ...................................................... 13 PICATO .............................................................. 10 pilocarpine hcl ............................................ 12, 16 pindolol ................................................................ 8 pioglitazone hcl ................................................ 11 pioglitazone hcl/metformin hcl ............................ 11 pioglitazone/glimepiride .................................. 11 pirfenidone .......................................................... 17 piroxicam........................................................... 15 PLAN B ONE-STEP ............................................. 9 PLAQUENIL ....................................................... 14 PLAVIX ............................................................... 13 PLAVIX 300MG .................................................. 13 PLEGRIDY ......................................................... 17 PLEGRIDY PEN ................................................. 17 PLENDIL ............................................................... 8 PLETAL .............................................................. 13 PODHALER ........................................................ 14 podofilox ........................................................... 10

POLYCILLIN ....................................................... 14 POLYCIN-B ........................................................ 12 polyethylene glycol 3350 ................................. 16 polymyxin b sulfate/tmp .................................. 12 POLYTRIM ......................................................... 12 POLY-VI-FLOR .................................................. 19 POLY-VI-FLOR W/IRON .................................... 19 pomalidomide ..................................................... 16 POMALYST ........................................................ 16 ponatinib ............................................................. 16 potassium chloride .......................................... 11 potassium iodide .............................................. 12 POTASSIUM IODIDE ......................................... 12 POTIGA .............................................................. 18 PRALUENT .......................................................... 9 pramipexole di-hcl ............................................ 18 pramlintide acetate ............................................. 10 PRAMOSONE .................................................... 10 PRANDIMET ...................................................... 11 PRANDIN ........................................................... 11 prasugrel hcl ....................................................... 13 PRAVACHOL ....................................................... 9 pravastatin sodium ............................................ 9 praziquantel ........................................................ 14 prazosin hcl......................................................... 8



PRECOSE .......................................................... 10 PRED FORTE .................................................... 12 PRED MILD ........................................................ 12 PREDNISOL ....................................................... 12 prednisolone ..................................................... 15 prednisolone acetate ....................................... 12 prednisolone sod phosphate .................... 12, 15 prednisone ........................................................ 15 PREDNISONE INTENSOL ................................ 15 pregabalin ........................................................... 18 PREGNYL .......................................................... 11 PREMARIN................................................... 13, 19 PREMPHASE ..................................................... 13 PREMPRO ......................................................... 13 prenatal vit 15/iron cb/fa/dss........................... 19 prenatal vit 16/iron cb/fa/dss........................... 19 prenatal vit 18/iron cb/fa/dss........................... 19 prenatal vit 95/fe fum/fa ................................... 19 PRENATE GT .................................................... 19 PRENAVITE ....................................................... 19 PREVACID ......................................................... 18 PREVACID SOLUTABS ..................................... 18 PREVPAC .......................................................... 18 PREZCOBIX ....................................................... 14 PREZISTA .......................................................... 14 PRILOSEC ......................................................... 18 PRILOSEC OTC ................................................. 18 PRIMAQUINE ..................................................... 14 primaquine phosphate ........................................ 14 primidone .......................................................... 18 PRIMSOL ........................................................... 13 PRINIVIL ............................................................... 8 PRINZIDE ............................................................. 8 PRISTIQ ............................................................... 7 PROAIR HFA ....................................................... 6 PROAIR RESPICLICK ......................................... 6 PROAMATINE ...................................................... 9 probenecid ........................................................ 13 procainamide hcl ................................................ 7 procarbazine hcl ................................................. 16 PROCARDIA ........................................................ 8 PROCARDIA XL ................................................... 8 PROCHIEVE ...................................................... 11 prochlorperazine edisylate ................................... 6 prochlorperazine maleate .................................. 6 PROCRIT ........................................................... 13 PROCTOCORT .................................................. 16 PROCTOCREAM-HC......................................... 16 PROCTOFOAM-HC ........................................... 16 PROCTO-KIT ..................................................... 16 PROCYSBI ......................................................... 19 PROFASI ............................................................ 11 progesterone, micronized ............................. 11, 13 PROGRAF .......................................................... 13 PROLIXIN ............................................................. 7 PROLOPRIM ...................................................... 13 PROMACTA ....................................................... 13 promethazine hcl ................................................ 6 PROMETRIUM ................................................... 13 PRONESTYL ........................................................ 7 propafenone hcl ............................................. 7, 8

PROPINE ........................................................... 13 propranolol hcl ................................................... 8 propranolol/hydrochlorothiazid ........................ 8 propylthiouracil ................................................... 12 PROPYLTHIOURACIL ....................................... 12 PROSCAR .......................................................... 19 PROSED-DS ...................................................... 13 PROSOM .............................................................. 7 PROSTIGMIN ....................................................... 6 PROTONIX ......................................................... 18 PROTOPIC ......................................................... 10 PROVERA .......................................................... 13 PROVIGIL............................................................. 7 PROZAC ............................................................... 6 PROZAC WEEKLY .............................................. 6 PULMICORT FLEXHALER .................................. 6 PULMICORT RESPULES .................................... 6 PULMOZYME ..................................................... 17 PURINETHOL .................................................... 16 PURIXAN ............................................................ 16 pyrazinamide .................................................... 14 PYRAZINAMIDE ................................................ 14 PYRIDIUM .......................................................... 19 pyridostigmine bromide .................................... 6 pyrimethamine .................................................... 14

QNASL ................................................................. 6 QNASL CHILDREN .............................................. 6 QUALAQUIN ...................................................... 14 QUESTRAN.......................................................... 9 QUESTRAN LIGHT .............................................. 9 quetiapine fumarate ........................................... 7 QUILLIVANT XR .................................................. 7 QUINAGLUTE ...................................................... 7 quinapril hcl ........................................................ 8 quinapril/hydrochlorothiazide........................... 8 QUINIDEX ............................................................ 8 quinidine gluconate ........................................... 7 quinidine sulfate ................................................. 8 quinine sulfate .................................................. 14 QVAR ................................................................... 6 RAGWITEK .......................................................... 6 raloxifene hcl .................................................... 12 raltegravir potassium .......................................... 15 ramipril ................................................................ 8 RANEXA ............................................................... 9 ranitidine hcl ..................................................... 18 ranolazine ............................................................. 9 RAPAMUNE ....................................................... 13 rasagiline mesylate .......................................... 18 RAYALDEE ........................................................ 12 RAZADYNE .......................................................... 6 RAZADYNE ER .................................................... 6 REBETOL ........................................................... 15 REBIF ................................................................. 17 REBIF REBIDOSE ............................................. 17 REDERM ............................................................ 10 REGLAN ............................................................. 18 regorafenib ......................................................... 16 REGRANEX ....................................................... 11 RELAFEN ........................................................... 15 REMERON ........................................................... 6 RENAGEL .......................................................... 11 RENVELA ........................................................... 11 repaglinide ........................................................ 11 repaglinide/metformin hcl ............................... 11 REPATHA............................................................. 9 REPRONEX ....................................................... 11 REQUIP .............................................................. 18 REQUIP XL ........................................................ 18 RESCRIPTOR .................................................... 15 reserpine ............................................................. 8

RESTASIS .......................................................... 12 RESTASIS MULTIDOSE ................................... 12 RESTORIL............................................................ 7 RETROVIR ......................................................... 15 REVATIO TABLET ............................................... 8 REVIA ................................................................... 7 REVLIMID........................................................... 16 REXULTI .............................................................. 7 REYATAZ ........................................................... 15 RHEUMATREX .................................................. 15 ribavirin ....................................................... 14, 15 RIFADIN ............................................................. 14 RIFAMATE ......................................................... 14 rifampin ............................................................. 14 rifampin/isoniazid ............................................. 14

rifaximin .............................................................. 14 rilpivirine ............................................................. 15 rilpivirine/ emtricitabine/ tenofovir disoproxil

fumarate ....................................................... 15 riociguat ................................................................ 8 RIOMET .............................................................. 11 RISPERDAL ......................................................... 7 RISPERDAL M-TAB ............................................. 7 risperidone .......................................................... 7 risperidone ODT ................................................. 7 RITALIN ................................................................ 7 RITALIN LA .......................................................... 7 RITALIN-SR.......................................................... 7 ritonavir ............................................................... 15 rivaroxaban ......................................................... 13 rivastigmine ........................................................ 6 rivastigmine tartrate ........................................... 6 rizatriptan benzoate ......................................... 17 ROBAXIN ........................................................... 18 ROBAXIN-750 .................................................... 18 ROCALTROL ..................................................... 19 roflumilast ............................................................. 6 ROMYCIN ........................................................... 12 ropinirole hcl ..................................................... 18 rosuvastatin calcium.......................................... 9

rotigotine ............................................................. 18 ROWASA ............................................................ 15 ROXANOL .......................................................... 17 ROXICET ............................................................ 17 ROXICODONE ................................................... 17 ROXICODONE INTENSOL ................................ 17 RYTHMOL ............................................................ 7 RYTHMOL SR ...................................................... 8 SALAGEN........................................................... 16 salmeterol xinafoate ............................................. 6 salsalate ............................................................ 17 SANDIMMUNE ................................................... 13 SANDOSTATIN .................................................. 17 SAPHRIS .............................................................. 7 sapropterin dihydrochloride ................................ 16 saquinavir mesylate............................................ 15 sargramostim ...................................................... 13 SAVELLA ............................................................ 17 SCALACORT ..................................................... 10 SCALACORT DK ............................................... 10 SEASONALE ........................................................ 9 SECTRAL ............................................................. 8 secukinumab .................................................... 10 selegiline hcl ..................................................... 18 selenium sulfide ............................................... 10

selexipag .............................................................. 8 SELSUN RX ....................................................... 10 SELZENTRY ...................................................... 14 SEPTRA ............................................................. 13 SEPTRA DS ....................................................... 13 SERAX ................................................................. 7 SEREVENT DISKUS............................................ 6 SEROPHENE ..................................................... 11 SEROQUEL.......................................................... 7 SERPASIL ............................................................ 8 sertraline hcl ....................................................... 6 sevelamer carbonate .......................................... 11 sevelamer hcl ..................................................... 11 SFROWASA ....................................................... 15 short ragweed pollen extract ................................ 6 sildenafil citrate ............................................ 8, 11 SILVADENE ....................................................... 10 silver sulfadiazine ............................................ 10 SIMBRINZA ........................................................ 12 simvastatin .......................................................... 9 simvastatin (80mg only) .................................... 9

SINEMET 25-100 ............................................... 18 SINEMET CR ..................................................... 18 SINEQUAN ........................................................... 7 SINGULAIR .......................................................... 6 sirolimus ............................................................ 13 sitagliptin phos/metformin hcl ............................. 10 sitagliptin phosphate........................................... 10 SIVEXTRO ......................................................... 14 SKELAXIN .......................................................... 18 SLO-NIACIN ......................................................... 9 sod chloride/nahco3/kcl/peg's ........................ 16 sodium chloride for inhalation ............................ 17 sodium fluoride ................................................ 19 sodium phenylbutyrate .................................... 16 sodium polystyrene sulfonate ........................ 11

sofosbuvir ........................................................... 15 sofosbuvir/velpatasvir ......................................... 15 SOFTCLIX .......................................................... 11 SOMA ................................................................. 18 SOMA COMPOUND .......................................... 18 SOMA COMPOUND WITH CODEINE .............. 17 somatropin .......................................................... 12 SOMAVERT ....................................................... 12 SONATA ............................................................... 7 sonidegib phosphate .......................................... 16 sorafenib tosylate ............................................... 16 SORIATANE ....................................................... 10 sotalol hcl ............................................................ 8

SOTRET ............................................................... 9 SOVALDI ............................................................ 15 SPIRIVA ............................................................... 6 SPIRIVA RESPIMAT ............................................ 6 spironolactone .................................................... 8 SPORANOX ....................................................... 14 SPRYCEL ........................................................... 16 STAGESIC-10 .................................................... 17 STALEVO ........................................................... 18 STARLIX ............................................................. 11 stavudine ........................................................... 15 STELARA ........................................................... 15



STELAZINE .......................................................... 7 STIOLTO RESPIMAT........................................... 6 STIVARGA ......................................................... 16 STRATTERA ........................................................ 7 STRIBILD ........................................................... 14 STRIVERDI RESPIMAT ....................................... 6 sucralfate........................................................... 18 sulconazole nitrate ............................................. 10 SULFAC ............................................................. 12 sulfacetamide sodium ............................... 10, 12 sulfadiazine ....................................................... 13 SULFADIAZINE .................................................. 13 sulfamethoxazole/trimethoprim ...................... 13 sulfanilamide....................................................... 19 sulfasalazine ..................................................... 15 sulfisoxazole acetyl ............................................ 13 sulindac ............................................................. 15 sumatriptan ....................................................... 17 sumatriptan succinate ..................................... 17 sunitinib malate .................................................. 16 SUPRAX ............................................................. 13 SUSTIVA ............................................................ 15 SUTENT ............................................................. 16 SYEDA ................................................................. 9 SYMBICORT ........................................................ 6 SYMBYAX ............................................................ 6 SYMLIN .............................................................. 10 SYMLINPEN 120 ................................................ 10 SYMLINPEN 60 .................................................. 10 SYMMETREL ..................................................... 18 SYNALAR ........................................................... 10 SYNJARDY ........................................................ 11 SYNTHROID ...................................................... 12 syringes & needles ............................................. 11 tacrolimus ......................................................... 10 tacrolimus anhydrous ...................................... 13 tadalafil ................................................................. 8 TAFINLAR .......................................................... 16 TAGAMET .......................................................... 18 TAGRISSO ......................................................... 16 TAKE ACTION ..................................................... 9 TALADINE .......................................................... 18 TAMBOCOR ......................................................... 7 TAMIFLU ............................................................ 14 tamoxifen citrate ............................................... 17 tamsulosin hcl .................................................. 19

TAPAZOLE ......................................................... 12 tapentadol ........................................................... 17 tapentadol hcl ER ............................................... 17 TARCEVA........................................................... 16 TARGRETIN ................................................. 10, 17 TASIGNA ............................................................ 16 tazarotene........................................................... 10 TAZORAC .......................................................... 10 tazorotene foam ................................................. 10 TECFIDERA ....................................................... 17 tedizolid phosphate ............................................ 14 teduglutide [rDNA origin] .................................... 16 TEGRETOL ........................................................ 18 TEGRETOL XR .................................................. 18 telbivudine .......................................................... 15 telithromycin ....................................................... 13 temazepam .......................................................... 7 TEMODAR.......................................................... 16 TEMOVATE ........................................................ 10 TEMOVATE EMOLLIENT .................................. 10 temozolomide ................................................... 16 TENEX .................................................................. 8 tenofovir disoproxil fumarate .............................. 15 TENORETIC 100 .................................................. 8 TENORETIC 50 .................................................... 8 TENORMIN .......................................................... 8 terazosin hcl ....................................................... 8 terbinafine hcl ............................................... 10, 14 terbutaline sulfate .............................................. 6 teriparatide.......................................................... 11 testosterone ...................................................... 13 testosterone 1% ................................................ 13 testosterone cypionate .................................... 13 testosterone gel 1.62% ...................................... 13 testosterone solution .......................................... 13 TESTRED ........................................................... 13 tetrabenazine ...................................................... 17 tetracycline hcl ................................................. 14 TEXACORT ........................................................ 10 thalidomide ......................................................... 14

THALITONE ......................................................... 8 THALOMID ......................................................... 14 THEO-24 .............................................................. 6 theophylline anhydrous ..................................... 6 THERMAZENE ................................................... 10 thioguanine ....................................................... 16 THIOGUANINE .................................................. 16 thioridazine hcl ................................................... 7 thiothixene .......................................................... 7

THORAZINE ......................................................... 7 thyroid, pork ........................................................ 12 TIAZAC ................................................................. 8 ticagrelor ............................................................. 13 TIKOSYN .............................................................. 8 timolol ................................................................. 12 timolol maleate ............................................. 8, 12 TIMOPTIC .......................................................... 12 TIMOPTIC-XE .................................................... 12 timothy grass pollen extract ................................. 6 tiotropium br/olodaterol hcl ................................... 6 tiotropium bromide ................................................ 6 tipranavir ............................................................. 14 tipranavir/vitamin e tpgs ..................................... 14 TIVICAY .............................................................. 15 tizanidine hcl ..................................................... 18

TOBI ................................................................... 14 TOBRADEX ........................................................ 12 tobramycin for inhalation ................................ 14 tobramycin sulfate ........................................... 12 tobramycin sulfate/dexameth ......................... 12 tobramycin/lotepred etab .................................... 12 TOBREX ............................................................. 12 tofacitinib citrate ................................................. 16 tofacitinib citrate XR ........................................... 16 TOFRANIL ............................................................ 7 tolazamide ......................................................... 11 tolbutamide ....................................................... 11 TOLECTIN 600 ................................................... 15 TOLINASE .......................................................... 11 tolmetin sodium ................................................ 15 tolterodine tartrate ........................................... 19 TOPAMAX .......................................................... 18 TOPAMAX SPRINKLE ....................................... 18 TOPICORT ......................................................... 10 TOPICORT LP ................................................... 10 topiramate........................................................... 18 topotecan hcl ...................................................... 16 TOPROL XL ......................................................... 8 TORADOL .......................................................... 15 toremifene citrate ................................................ 17 torsemide ............................................................ 8 TOUJEO ............................................................. 11 TOVIAZ ............................................................... 19 TRACLEER .......................................................... 8 TRADJENTA ...................................................... 10 tramadol hcl ...................................................... 17 tramadol hcl/acetaminophen .......................... 17 trametinib dimethyl sulfoxide .............................. 16 TRANDATE .......................................................... 8 trandolapril .......................................................... 8 TRANXENE T-TAB .............................................. 7 tranylcypromine sulfate ..................................... 6 TRAVATAN ........................................................ 12 TRAVATAN Z ..................................................... 13 travoprost ............................................................ 13 travoprost (benzalkonium) .............................. 12 trazodone hcl ...................................................... 6 TRENTAL ........................................................... 13 tretinoin ............................................................... 17 TREXALL ............................................................ 16 triamcinolone acetonide ........................ 6, 10, 17 triamterene/hydrochlorothiazid ........................ 8 TRIAZ ................................................................. 10 triazolam .............................................................. 7

TRIBENZOR ......................................................... 8 TRICOR ................................................................ 9 TRIDERM ........................................................... 10 TRIDESILON ...................................................... 10 trifluoperazine hcl .............................................. 7 trifluridine .......................................................... 12 trifluridine/tipiracil hcl .......................................... 16 TRIGLIDE 160MG ................................................ 9 trihexyphenidyl hcl........................................... 18 TRILAFON ............................................................ 7 TRILEPTAL ........................................................ 18 trimethoprim ..................................................... 13

TRI-NORINYL ...................................................... 9 TRINTELLIX ......................................................... 6 TRIUMEQ ........................................................... 14 TRI-VI-FLOR W/IRON ........................................ 19 TRIZIVIR ............................................................. 14 TROKENDI XR ................................................... 18 TRUSOPT .......................................................... 12 TRUVADA .......................................................... 14 TUSSIONEX ......................................................... 9 TYBOST ............................................................. 15 TYKERB ............................................................. 16 TYLENOL-CODEINE ......................................... 18 TYZEKA .............................................................. 15 ULORIC .............................................................. 13 ULTRACET......................................................... 17 ULTRAM ............................................................. 17 ULTRASE ........................................................... 18 ULTRASE MT ..................................................... 18 ULTRAVATE ...................................................... 10 UNIPHYL .............................................................. 6 UNIRETIC ............................................................. 8 UNIVASC .............................................................. 8 UPTRAVI .............................................................. 8 URECHOLINE .................................................... 16 URETRON D-S .................................................. 13 uridine triacetate ................................................. 17 URIN D.S. ........................................................... 13 UROXATRAL ..................................................... 19 URSO ................................................................. 16 URSO FORTE .................................................... 16 ursodiol ............................................................. 16 ustekinumab ....................................................... 15 VAGIFEM ........................................................... 19 valacyclovir hcl ................................................. 14 VALCHLOR ........................................................ 10 VALISONE.......................................................... 10 VALIUM ................................................................ 7 valproate sodium .............................................. 18 valproic acid ..................................................... 18 valsartan .............................................................. 8 valsartan/hydrochlorothiazide .......................... 8 VALTREX ........................................................... 14 VANCOCIN HCL ................................................ 14 vancomycin hcl ................................................ 14 VANDAZOLE ...................................................... 19 VANOS ............................................................... 10 VANOXIDE-HC .................................................... 9 VANSPAR ............................................................ 7 VANTIN .............................................................. 13 VASCEPA............................................................. 9 VASERETIC ......................................................... 8 VASOCIDIN ........................................................ 12 VASOTEC ............................................................ 8 V-CILLIN K ......................................................... 14 VECTICAL .......................................................... 19 vemurafenib ........................................................ 16 VENCLEXTA ...................................................... 16 venetoclax .......................................................... 16 venlafaxine hcl .................................................... 7 VENTOLIN HFA ................................................... 6 VEPESID ............................................................ 16 verapamil hcl ...................................................... 8 verapamil hcl ER ................................................ 8 VERELAN ............................................................. 8 VERELAN PM ...................................................... 8 VESANOID ......................................................... 17 VESTURA............................................................. 9 VFEND ............................................................... 14 VIAGRA .............................................................. 11 VIBRAMYCIN ..................................................... 14 VIBRAMYCIN SYRUP........................................ 14 VIBRAMYCIN 100MG CAPSULE ...................... 14 VICODIN ............................................................. 17 VICODIN ES ....................................................... 17 VICODIN HP....................................................... 17 VICON FORTE ................................................... 19 VICTOZA ............................................................ 11 VIDEX ................................................................. 15 VIDEX EC ........................................................... 15 VIGAMOX ........................................................... 12 Viibryd ................................................................. 22 VIIBRYD ............................................................... 6 VIMPAT .............................................................. 18 VIRACEPT.......................................................... 15 VIRAMUNE......................................................... 15 VIRAMUNE XR .................................................. 15



VIRAZOLE .......................................................... 14 VIREAD .............................................................. 15 VIROPTIC........................................................... 12 VISKEN ................................................................ 8 vismodegib ......................................................... 16 VISTARIL .............................................................. 6 VISTOGARD ...................................................... 17 VIVELLE-DOT .................................................... 13 VOLTAREN .................................................. 12, 15 VOLTAREN GEL ................................................ 10 VOLTAREN-XR .................................................. 15 voriconazole ..................................................... 14 vorinostat ............................................................ 16 VOSOL ............................................................... 11 VOSOL HC ......................................................... 11 VOTRIENT ......................................................... 16 VRAYLAR ............................................................. 7 VYVANSE............................................................. 7 warfarin sodium ................................................ 13 WELCHOL ............................................................ 9 WELCHOL POWDER PACKETS ........................ 9 WELLBUTRIN ...................................................... 6 WELLBUTRIN SR ................................................ 6 WELLBUTRIN XL ................................................. 6 WESTCORT ....................................................... 10 WESTHROID...................................................... 12 XALATAN ........................................................... 12 XALKORI ............................................................ 16 XANAX ................................................................. 7 XARELTO ........................................................... 13 XELJANZ ............................................................ 16 XELJANZ XR ...................................................... 16 XELODA ............................................................. 16

XENAZINE.......................................................... 17 XIFAXAN 550MG ............................................... 14 XIIDRA ................................................................ 12 XODOL 10-300 ................................................... 17 XTANDI .............................................................. 16 XURIDEN ........................................................... 17 XYLOCAINE ....................................................... 15 XYZAL TABS ........................................................ 6 YASMIN 28 ........................................................... 9 YAZ ....................................................................... 9 YODOXIN ........................................................... 14 zaleplon ............................................................... 7 ZANAFLEX ......................................................... 18 ZANTAC ............................................................. 18 ZARAH ................................................................. 9 ZARONTIN ......................................................... 18 ZAROXOLYN ....................................................... 8 ZEBETA ................................................................ 8 ZELBORAF......................................................... 16 ZEMPLAR........................................................... 12 ZENATANE .......................................................... 9 ZENPEP ............................................................. 18 ZENZEDI .............................................................. 7 ZERIT ................................................................. 15 ZESTORETIC ....................................................... 8 ZESTRIL ............................................................... 8 ZETIA ................................................................... 9 ZIAC ..................................................................... 8 ZIAGEN .............................................................. 15 ZIANA ................................................................... 9 zidovudine ......................................................... 15 ziprasidone hcl ................................................... 7 ZIRGAN .............................................................. 12

ZITHROMAX ...................................................... 13 ZITHROMAX TRI-PAK ....................................... 13 ZMAX .................................................................. 14 ZMAX PEDIATRIC ............................................. 14 ZOCOR ................................................................. 9 ZOFRAN ............................................................... 6 ZOFRAN ODT ...................................................... 6 ZOLINZA ............................................................ 16 zolmitriptan ....................................................... 17

ZOLOFT ............................................................... 6 zolpidem tartrate ................................................ 7 ZOLPIDEM TARTRATE ER ................................. 7 ZOMIG ................................................................ 17 ZOMIG ZMT ....................................................... 17 ZONEGRAN ....................................................... 18 zonisamide ........................................................ 18 ZORTRESS ........................................................ 13 ZOVIRAX ............................................................ 14 ZOVIRAX CREAM .............................................. 10 ZOVIRAX OINTMENT ........................................ 10 ZUBSOLV ........................................................... 18 ZURAMPIC ......................................................... 13 ZYDELIG ............................................................ 16 ZYKADIA ............................................................ 16 ZYLET ................................................................ 12 ZYLOPRIM ......................................................... 13 ZYMAXID ............................................................ 12 ZYPREXA ............................................................. 7 ZYPREXA ZYDIS ................................................. 7 ZYRTEC (OTC) .................................................... 6 ZYRTEC-D (OTC) ................................................ 6 ZYTIGA ............................................................... 16 ZYVOX ............................................................... 14

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