missouri aca member prescription drug list...tagalog: kung ikaw, o ang iyong tinutulangan, ay may...
TRANSCRIPT
MISSOURI ACA MEMBER 2020
PRESCRIPTION DRUG LIST
HIX 2019 BCBSKC MO eff dte 01-01-2020
Please see the benefit schedule in your member certificate for member cost sharing
associated with Generic and Brand (Preferred and Non Preferred) drugs.
List of Abbreviations for Prescription Drugs Drug Category:
1 Generic Drug and Generic Specialty Drug
2 Preferred Drug and Non Preferred Generic Drug
3 Non Preferred Drug and Preferred Specialty Drug
4 Non Preferred Specialty Drug
5 Zero Cost Share Preventive Drug
6 Medical Service Drugs
ACA* Affordable Care Act is a zero cost share preventive drug.
M Maintenance drug.
MSD Medical Service Drug. This drug is only covered under the medical benefit.
OTC* Over the Counter drug.
PA Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get
approval, we may not cover the drug.
QL Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
S Specialty drug.
ST Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, we may not cover Drug B unless you try Drug A first.
*Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization.
Discrimination is Against the Law
Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex.
Blue KC:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
› Qualified sign language interpreters
› Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
› Qualified interpreters
› Information written in other languages
If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected].
If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis
of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO
Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can
file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is
available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in
your language at no cost. To talk to an interpreter, call 1-844-395-7126.
Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a
obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126.
Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫
助和訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。
Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và
có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126.
German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe
und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-844-395-7126 an.
Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-844-395-7126 로 전화하십시오.
Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć
i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126.
Arabic: فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. ، KC Blue إن كان لديك أو لدى شخص تساعده أسئلة بخصوص
للتحدث مع مترجم اتصل ب. 7126 -1-844-395.
Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете
право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком
позвоните по телефону1-844-395-7126.
French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez
le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-
844-395-7126.
Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka
na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin,
tumawag sa1-844-395-7126.
Laotian: ຖ້ າທ່ ານ, ື ຫຼ ຄົ ນ ື່ືທທ່ ານກໍ າລັ ງຊ່ ວຍເຫ ືຼ ອ, ມ ືໍືຄາຖາມກ່ ຽວກັ ບ Blue KC, ທ່ ານມ ື ືສດ ື່ືທຈະໄດ້
ຮັ ບການຊ່ ວຍເຫ ືຼ ອແລະືໍືຂ້ ມູ ນຂ່ າວສານ ື່ືທເປັ ນພາສາຂອງທ່ າືໍນ ື່ືບມ ຄ່ າໃຊ້ ຈ່ າຍ. ການໂອ້ ລົ ມກັ ບນາຍພາສາ, ໃຫ້
ໂທຫາ 1-844-395-7126.
Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht
du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me
Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe.
Persian:
داشته باشيد حق اين را داريد که کمکو اطالعات به زبان خود را به طور ، KC Blue اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد
.رايگان دريافت مناييد .1-844-395-7126متاس حاصل مناييد
Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een
afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa
bilbilaa 1-844-395-7126 tiin bilbilaa.
Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de
obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126.
For TTY services, please call 1-816-842-5607.
An Independent Licensee of the Blue Cross and Blue Shield Association
All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners. M57313-B 9/19
5
Table of Contents
Analgesics - Drugs for Pain ................................................................................................................................. 7
Analgesics - Drugs for Pain and Inflammation ................................................................................................... 11
Anesthetics ........................................................................................................................................................ 13
Anti-Addiction / Substance Abuse Treatment Agents ......................................................................................... 16
Antibacterials ..................................................................................................................................................... 16
Anticoagulants ................................................................................................................................................... 21
Anticonvulsants - Drugs for Seizures ................................................................................................................. 22
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia ................................................................ 24
Antidepressants ................................................................................................................................................. 24
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................... 26
Antifungals ......................................................................................................................................................... 27
Antigout Agents ................................................................................................................................................. 28
Anti-inflammatory Agents ................................................................................................................................... 28
Antimigraine Agents ........................................................................................................................................... 29
Antimyasthenic Agents ...................................................................................................................................... 29
Antimycobacterials ............................................................................................................................................. 29
Antineoplastics - Drugs for Cancer .................................................................................................................... 30
Antiparasitics ..................................................................................................................................................... 34
Antiparkinson Agents ......................................................................................................................................... 35
Antiplatelets ....................................................................................................................................................... 36
Antipsychotics - Drugs for Mood Disorders ........................................................................................................ 36
Antivirals ............................................................................................................................................................ 37
Anxiolytics - Drugs for Anxiety ........................................................................................................................... 39
Bipolar Agents - Drugs for Mood Disorders ........................................................................................................ 40
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders ............................................... 40
Cardiovascular Agents - Drugs for Heart and Circulation Conditions ................................................................. 41
Central Nervous System Agents - Drugs for Attention Deficit Disorder ............................................................. 49
Central Nervous System Agents - Drugs for Multiple Sclerosis .......................................................................... 50
Central Nervous System Agents - Miscellaneous .............................................................................................. 50
Dental and Oral Agents - Drugs for Mouth and Throat Conditions ..................................................................... 51
Dermatological Agents - Drugs for Skin Conditions ........................................................................................... 52
Diabetes - Antidiabetic Agents ........................................................................................................................... 58
Diabetes - Glucose Monitoring ........................................................................................................................... 60
Diabetes - Glycemic Agents ............................................................................................................................... 63
Diabetes - Insulins ............................................................................................................................................. 63
Electrolytes / Minerals / Metals / Vitamins .......................................................................................................... 64
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................................................. 72
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions .................................................. 73
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment ............................................... 75
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ........................................................ 76
Genitourinary Agents - Drugs for Prostate Conditions........................................................................................ 77
Hormonal Agents - Adrenal ................................................................................................................................ 77
Hormonal Agents - Men's Health ....................................................................................................................... 79
Hormonal Agents - Osteoporosis ....................................................................................................................... 80
Hormonal Agents - Parathyroid .......................................................................................................................... 80
Hormonal Agents - Pituitary ............................................................................................................................... 80
Hormonal Agents - Prostaglandins..................................................................................................................... 81
Hormonal Agents - Sex Hormones and Birth Control ......................................................................................... 82
Hormonal Agents - Thyroid ................................................................................................................................ 86
Immunological Agents - Drugs for Immune System Stimulation or Suppression ................................................ 87
Immunological Agents - Drugs for Vaccination ................................................................................................... 90
6
Inflammatory Bowel Disease Agents.................................................................................................................. 91
Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................................................. 91
Miscellaneous Therapeutic Agents .................................................................................................................... 92
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ...........................................................100
Ophthalmic Agents - Drugs for Glaucoma .........................................................................................................102
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions..........................................................................103
Otic Agents - Drugs for Ear Conditions .............................................................................................................104
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ........................................................105
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions ....................................106
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.....................................................................109
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension .....................................................109
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm .......................................................................109
Sleep Disorder Agents ......................................................................................................................................111
Last Updated 10/1/19
7
Drug Name Drug
Category
Limits/
Required
butalbital-apap 1
butalbital-apap-caff-cod 1
butalbital-apap-caffeine 1
butalbital-asa-caff-
codeine 1
butalbital-aspirin-
caffeine 1
butorphanol tartrate
injection 6 MSD
butorphanol tartrate
nasal 1 QL
BUTRANS 3 ST; QL
carisoprodol-aspirin-
codeine 1
codeine sulfate 1 QL
CONZIP 3 ST; QL
DEMEROL 6 MSD
DILAUDID INJECTION 6 MSD
DILAUDID ORAL 3 QL
DOLOPHINE 1 ST
DSUVIA 3
DURAGESIC-100 3 ST; QL
DURAGESIC-12 3 ST; QL
DURAGESIC-25 3 ST; QL
DURAGESIC-50 3 ST; QL
DURAGESIC-75 3 ST; QL
duramorph 6 MSD
duraxin 1
DVORAH 1 QL
EMBEDA 3 ST; QL
endocet 1 QL
esgic oral capsule 1
ESGIC ORAL TABLET 3 ST
fentanyl 1 ST; QL
fentanyl citrate (pf)
injection solution 6 PA; MSD
fentanyl citrate (pf)
injection solution
cartridge
6
MSD
Drug Name Drug
Category
Limits/
Required
Analgesics - Drugs
for Pain
7T GUMMY ES 3
ABSTRAL 3 ST; QL
acetaminophen-
codeine 1 QL
acetaminophen-
codeine #2 1 QL
acetaminophen-
codeine #3 1 QL
acetaminophen-
codeine #4 1 QL
ACTIQ 3 ST; QL
alfentanil hcl 6 MSD
ALLZITAL 3 ST
APADAZ 3 QL
apap-caff-
dihydrocodeine 1 QL
ARYMO ER 3 ST; QL
ascomp-codeine 1
BELBUCA 2 ST; QL
BENZHYDROCODON
E-ACETAMINOPHEN 3 QL
BUPAP 3 ST
BUPRENEX 6 PA; MSD
buprenorphine hcl
injection 6 PA; MSD
buprenorphine
transdermal patch
weekly 10 mcg/hr, 15
mcg/hr, 20 mcg/hr, 5
mcg/hr
1
ST; QL
BUPRENORPHINE
TRANSDERMAL
PATCH WEEKLY 7.5
MCG/HR
3
ST; QL
BUTALBITAL-
ACETAMINOPHEN
ORAL CAPSULE
1
ST
butalbital-
acetaminophen oral
tablet
1
Last Updated 10/1/19
8
Drug Name Drug
Category
Limits/
Required
FIORINAL/CODEINE
#3 3
hydrocodone-
acetaminophen 1 QL
hydrocodone-ibuprofen 1 QL
hydromorphone hcl er 1 ST; QL
HYDROMORPHONE
HCL INJECTION
SOLUTION 0.2 MG/ML
3
hydromorphone hcl
injection solution 2
mg/ml, 4 mg/ml
6
MSD
hydromorphone hcl oral 1 QL
hydromorphone hcl pf 6 MSD
hydromorphone hcl
rectal 1 QL
HYDROMORPHONE
HCL SOLUTION 1
MG/ML INJECTION
6
MSD
hydromorphone hcl
solution 1 mg/ml
injection
6
MSD
HYDROMORPHONE
HCL-NACL INJECTION 6 MSD
HYDROMORPHONE
HCL-NACL
INTRAVENOUS
SOLUTION 10-0.9
MG/50ML-%, 100-0.9
MG/100ML-%, 15-0.9
MG/30ML-%, 20-0.9
MG/100ML-%, 25-0.9
MG/50ML-%, 30-0.9
MG/30ML-%, 50-0.9
MG/50ML-%, 6-0.9
MG/30ML-%
6
MSD
Drug Name Drug
Category
Limits/
Required
fentanyl citrate buccal
lozenge on a handle 1 ST; QL
FENTANYL CITRATE
BUCCAL TABLET 3 ST; QL
FENTANYL CITRATE
INJECTION
SOLUTION
PREFILLED SYRINGE
6
MSD
FENTANYL CITRATE
INTRAVENOUS
SOLUTION 5000
MCG/100ML
6
PA; MSD
FENTANYL CITRATE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
FENTANYL CITRATE-
NACL INTRAVENOUS
SOLUTION
6
MSD
FENTANYL CITRATE-
NACL INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
550-0.9 MCG/55ML-%
6
MSD
FENTANYL CIT-
ROPIVACAINE-NACL
EPIDURAL SOLUTION
0.2-0.2-0.9 MG/100ML-
%, 0.4-0.2-0.9
MG/200ML-%
6
MSD
FENTANYL-
BUPIVACAINE-NACL
EPIDURAL SOLUTION
0.2-0.08-0.9
MG/100ML-%, 0.2-0.1-
0.9 MG/100ML-%, 0.2-
0.125-0.9 MG/100ML-
%, 0.5-0.0625-0.9
MG/250ML-%, 0.5-0.1-
0.9 MG/250ML-%, 0.5-
0.125-0.9 MG/250ML-
%
6
MSD
FENTORA 3 ST; QL
FIORICET 3 ST
FIORICET/CODEINE 3
FIORINAL 3 ST
Last Updated 10/1/19
9
Drug Name Drug
Category
Limits/
Required
MORPHABOND ER 3 ST; QL
morphine sulfate
(concentrate) oral
solution 100 mg/5ml,
20 mg/ml
1
QL
morphine sulfate (pf) 6 MSD
morphine sulfate er 1 ST; QL
morphine sulfate er
beads 1 ST; QL
MORPHINE SULFATE
INJECTION 6 MSD
morphine sulfate
intramuscular 6 MSD
MORPHINE SULFATE
INTRAVENOUS
SOLUTION 0.5 MG/ML
6
MSD
morphine sulfate
intravenous solution
150 mg/30ml, 25
mg/ml, 50 mg/ml
6
MSD
morphine sulfate oral 1 QL
morphine sulfate rectal 1 QL
MORPHINE SULFATE
SOLUTION 1 MG/ML
INTRAVENOUS
6
MSD
morphine sulfate
solution 1 mg/ml
intravenous
6
MSD
MORPHINE SULFATE-
NACL INJECTION 3
MORPHINE SULFATE-
NACL INTRAVENOUS
SOLUTION 100-0.9
MG/100ML-%, 50-0.9
MG/50ML-%, 500-0.9
MG/100ML-%
6
MSD
Drug Name Drug
Category
Limits/
Required
HYDROMORPHONE
HCL-NACL
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
0.5-0.9 MG/ML-%, 1-
0.9 MG/5ML-%, 1-0.9
MG/ML-%, 10-0.9
MG/50ML-%, 15-0.9
MG/30ML-%, 2-0.9
MG/10ML-%, 2-0.9
MG/ML-%, 5-0.9
MG/25ML-%, 50-0.9
MG/50ML-%, 55-0.9
MG/55ML-%, 6-0.9
MG/30ML-%
6
MSD
HYSINGLA ER 2 ST; QL
INFUMORPH 200 6 MSD
INFUMORPH 500 6 MSD
IONSYS 6 MSD
KADIAN 3 ST; QL
LAZANDA 3 ST; QL
levorphanol tartrate oral
tablet 2 mg 1 QL
levorphanol tartrate oral
tablet 3 mg 3
lorcet 1 QL
lorcet hd 1 QL
lorcet plus 1 QL
LORTAB 1 QL
MEDROX-RX 3
meperidine hcl injection 6 MSD
meperidine hcl oral 1 QL
methadone hcl injection 6 ST; MSD
methadone hcl intensol 1 ST
methadone hcl oral 1 ST
methadose oral
concentrate 10 mg/ml 1 ST
methadose oral tablet
soluble 1 ST
methadose sugar-free 1 ST
mitigo 6 MSD
Last Updated 10/1/19
10
Drug Name Drug
Category
Limits/
Required
PRIALT
INTRATHECAL
SOLUTION 100
MCG/ML, 500
MCG/5ML
6
MSD
PRIMLEV 3 QL
PROBUPHINE
IMPLANT KIT 6 MSD
remifentanil hcl 6 MSD
ROXICODONE 3 QL
SUBSYS 3 ST; QL
SYNAPRYN FUSEPAQ 3
tencon 1
tramadol hcl er
(biphasic) 1 ST; QL
TRAMADOL HCL ER
ORAL CAPSULE
EXTENDED RELEASE
24 HOUR 100 MG, 200
MG, 300 MG
3
ST; QL
tramadol hcl er oral
capsule extended
release 24 hour 150 mg
1
ST; QL
tramadol hcl er oral
tablet extended release
24 hour
1
ST; QL
tramadol hcl ir 1 QL
tramadol-
acetaminophen 1 QL
TREZIX 3 QL
TYLENOL WITH
CODEINE #3 3 QL
TYLENOL WITH
CODEINE #4 3 QL
ULTIVA 6 MSD
ULTRACET 3 QL
ULTRAM 3 QL
VANATOL LQ 3 ST
VANATOL S 3 ST
vicodin es 1 QL
vicodin hp 1 QL
XTAMPZA ER 3 ST; QL
Drug Name Drug
Category
Limits/
Required
MORPHINE SULFATE-
NACL INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
0.5-0.9 MG/ML-%, 2-
0.9 MG/2ML-%, 2-0.9
MG/ML-%, 30-0.9
MG/30ML-%, 4-0.9
MG/ML-%, 5-0.9
MG/5ML-%, 50-0.9
MG/50ML-%, 55-0.9
MG/55ML-%
6
MSD
MS CONTIN 3 ST; QL
nalbuphine hcl injection 6 MSD
NALOCET 3 QL
NORCO 3 ST; QL
NUCYNTA 2 QL
NUCYNTA ER 2 ST; QL
OPANA 3 QL
OXAYDO 3 QL
OXYCODONE HCL ER 3 ST; QL
oxycodone hcl oral
capsule 1 QL
oxycodone hcl oral
concentrate 100
mg/5ml
1
QL
oxycodone hcl oral
solution 1 QL
oxycodone hcl oral
tablet 1 QL
oxycodone-
acetaminophen 1 QL
oxycodone-aspirin 1 QL
oxycodone-ibuprofen 1 QL
OXYCONTIN 2 ST; QL
oxymorphone hcl 1 QL
oxymorphone hcl er 1 ST; QL
pentazocine-naloxone
hcl 1 QL
PERCOCET 3 QL
phrenilin forte 1
Last Updated 10/1/19
11
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
zebutal 1 DICLOFENAC
EPOLAMINE 3 ST; QL
ZOHYDRO ER 3 ST; QL
diclofenac potassium 1 M Analgesics - Drugs
for Pain and
Inflammation
diclofenac sodium er 1 M
diclofenac sodium oral 1 M
ACTIVE INJECTION
KET-L 3
diclofenac sodium
transdermal gel 1 % 1 QL
ACTIVE INJECTION
KETMARC-L 3
diclofenac sodium
transdermal solution 1
ACTIVE-
KETOPROFEN 3
diclofenac-misoprostol 1 M
diflunisal oral 1 M ACTIVE-PREP KIT I 3
DUAL COMPLEX
FORMULA 1 KIT 3
ACTIVE-PREP KIT II 3
ACTIVE-PREP KIT III 3
DUEXIS 3 ST; M; QL
AIF #2 DRUG
PREPARATION KIT 3
EC-NAPROSYN 3 ST; M
ec-naproxen 1 M AIF #3 DRUG
PREPARATION KIT 3
ENOVARX-
DICLOFENAC
SODIUM
3
ARTHROTEC 3 ST; M
aspirin adult 5 ACA; OTC
ENOVARX-
IBUPROFEN 3
aspirin adult low
strength oral tablet
delayed release
5
ACA; OTC ENOVARX-
NAPROXEN 3
aspirin childrens 5 ACA; OTC
etodolac 1 M
aspirin ec low dose 5 ACA; OTC
etodolac er 1 M
aspirin ec low strength 5 ACA; OTC
FBL KIT 3
aspirin low dose 5 ACA; OTC
FELDENE 3 ST; M
aspirin oral tablet 5 ACA; OTC
fenoprofen calcium oral
capsule 3 ST; M
aspirin oral tablet
delayed release 325
mg
5
ACA; OTC fenoprofen calcium oral
tablet 1 ST; M
bayer aspirin 5 ACA; OTC
fenortho 3 ST; M
bayer aspirin ec low
dose 5 ACA; OTC
FLECTOR 2 ST; QL
flurbiprofen oral 1 M
Last Updated 10/1/19
12
CAMBIA 3 ST; QL
ibu 1 M CELEBREX 3 ST; M; QL
ibuprofen lysine 6 MSD celecoxib oral 1 M; QL
ibuprofen oral
suspension 1
choline-mag
trisalicylate 1
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
1
M DAYPRO 3 ST; M
Last Updated 10/1/19
13
Drug Name Drug
Category
Limits/
Required
meloxicam oral tablet
15 mg 1 M
meloxicam oral tablet
7.5 mg 1 M; QL
MOBIC ORAL TABLET
15 MG 3 ST; M
MOBIC ORAL TABLET
7.5 MG 3 ST; M; QL
nabumetone oral 1 M
NALFON 3 ST; M
NAPRELAN 3 ST; M
NAPRO 3
NAPROSYN ORAL
SUSPENSION 3 ST; M
naproxen dr 1 M
naproxen oral 1 M
naproxen sodium er 1 M
naproxen sodium oral
tablet 275 mg, 550 mg 1 M
NEOPROFEN 6 MSD
NP #2 DRUG
PREPARATION KIT 3
oxaprozin 1 M
PENNSAID 3 QL
piroxicam oral 1 M
PRASTERA 3
qc aspirin low dose oral
tablet delayed release 5 ACA; OTC
QMIIZ ODT 3 ST; M
READYSHARP
ANESTH +
KETOROLAC
3
READYSHARP
KETOROLAC 6 MSD
RELAFEN DS 3 M
salsalate oral 1 M
SPRIX 3 ST; S; QL
st joseph low dose oral
tablet delayed release 5 ACA; OTC
sulindac oral 1 M
Drug Name Drug
Category
Limits/
Required
IC 400 3
IC 800 3
INDOCIN ORAL 3 ST; M
INDOCIN RECTAL 3 M
indomethacin er 1 M
indomethacin oral 1 M
indomethacin sodium 6 MSD
K.B.G.L IN
TERODERM 3
KETOPHENE
RAPIDPAQ 3
ketoprofen er 1 M
ketoprofen oral 1 M
KETOROCAINE-L 3
KETOROCAINE-LM 3
KETOROLAC
TROMETHAMINE
EXTERNAL
3
ketorolac tromethamine
injection 6 MSD
ketorolac tromethamine
oral 1 QL
ketorolac tromethamine
solution 60 mg/2ml
intramuscular
6
MSD
KETOROLAC
TROMETHAMINE
SOLUTION 60
MG/2ML
INTRAMUSCULAR
4
S
KETOROLAC-BUPIV-
KETAMINE 6 MSD
KETOROLAC-ROPIV-
KETAMINE 6 MSD
LIDOPROFEN 3
LODINE 3 M
meclofenamate sodium
oral 1 M
medique aspirin 5 ACA; OTC
mefenamic acid oral 1 M
Last Updated 10/1/19
14
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
TIVORBEX 3 BUPIVACAINE HCL-
NACL EPIDURAL 6 MSD
tolmetin sodium 1 M
BUPIVACAINE HCL-
NACL INJECTION
SOLUTION 0.1-0.9 %,
0.2-0.9 %
3
TORONOVA II SUIK 6 MSD
TORONOVA SUIK 6 MSD
TRIPLE COMPLEX
FORMULA 3 KIT 3
BUPIVACAINE HCL-
NACL INJECTION
SOLUTION 0.125-0.9
%
6
MSD
VIMOVO 3 ST; M; QL
VIVLODEX 3 ST; M
VOLTAREN 3 QL
BUPIVACAINE HCL-
NACL INJECTION
SOLUTION
PREFILLED SYRINGE
0.0625-0.9 % (50 ML),
0.1-0.9 % (50 ML),
0.125-0.9 % (50 ML),
0.375-0.9 %
3
VOPAC GB 3
VOPAC KT 3
VP FC KIT 3
VP GKL KIT 3
ZIPSOR 3 ST; QL
ZORVOLEX 3 M; QL
BUPIVACAINE HCL-
NACL INJECTION
SOLUTION
PREFILLED SYRINGE
0.25-0.9 % (30 ML)
6
MSD
Anesthetics
ACTIVE INJECTION
LM-2 3
bd pudendal/local
tray/1% lido 1
bupivacaine in dextrose
intrathecal 6 MSD
BUFFERED
LIDOCAINE 6 MSD
bupivacaine spinal 6 MSD
bupivacaine
fisiopharma 6 MSD
bupivacaine-
epinephrine 6 MSD
bupivacaine hcl (pf) 6 MSD
bupivacaine-
epinephrine (pf) 6 MSD
bupivacaine hcl
injection solution 0.5 % 1
CADIRAMD 6 MSD
BUPIVACAINE HCL
INJECTION
SOLUTION 312.5
MG/10ML
3
CARBOCAINE 3
CARBOCAINE
PRESERVATIVE-
FREE INJECTION
SOLUTION 1 %, 2 %
6
MSD
BUPIVACAINE HCL
INJECTION
SOLUTION
PREFILLED SYRINGE
0.125 % (50 ML), 0.5 %
(60 ML)
3
CARBOCAINE
PRESERVATIVE-
FREE INJECTION
SOLUTION 1.5 %
1
CETACAINE
EXTERNAL AEROSOL 3
BUPIVACAINE HCL
INJECTION
SOLUTION
6
MSD chloroprocaine hcl (pf) 6 MSD
Last Updated 10/1/19
15
PREFILLED SYRINGE
0.5 % (30 ML) CITANEST FORTE
DENTAL 3
Last Updated 10/1/19
16
Drug Name Drug
Category
Limits/
Required
LIDOCAINE HCL-
SODIUM CHLORIDE
INJECTION
SOLUTION
3
LIDOCAINE HCL-
SODIUM CHLORIDE
INJECTION
SOLUTION
PREFILLED SYRINGE
1-0.9 % (3 ML)
3
LIDOCAINE HCL-
SODIUM CHLORIDE
INJECTION
SOLUTION
PREFILLED SYRINGE
1-0.9 %, 1-0.9 % (1
ML)
6
MSD
lidocaine in d5w
intravenous solution 4-
5 mg/ml-%, 8-5 mg/ml-
%
6
MSD
LIDOCAINE IN
DEXTROSE 6 MSD
lidocaine-epinephrine
injection solution 0.5 %-
1:200000, 1 %-
1:100000, 1.5 %-
1:200000, 2 %-
1:100000, 2 %-
1:200000
6
MSD
lidocaine-prilocaine
external cream 1
LIDOCAINE-SODIUM
BICARBONATE 6 MSD
LIDOCAINE-
TETRACAINE 6 PA; MSD
LIDODERM 3 ST
MARCAINE
INJECTION
SOLUTION 0.25 %
3
MARCAINE
INJECTION
SOLUTION 0.75 %
6
MSD
MARCAINE
PRESERVATIVE
FREE
6
MSD
Drug Name Drug
Category
Limits/
Required
CITANEST PLAIN
DENTAL 3
CLOROTEKAL 6 MSD
cocaine hcl external 1
COCAINE HCL NASAL 6 MSD
ENOVARX-
LIDOCAINE HCL 3
ethyl chloride 1
EXPAREL 6 MSD
GEBAUERS PAIN
EASE 3
glydo external gel 2 % 1
GOPRELTO 6 MSD
L.E.T. 3
LETS 3
lido bdk 6 MSD
lidocaine external
ointment 1
lidocaine external patch 1
lidocaine hcl (pf) 6 MSD
lidocaine hcl external
solution 1
lidocaine hcl injection
solution 6 MSD
LIDOCAINE HCL
INJECTION
SOLUTION
PREFILLED SYRINGE
10 MG/ML, 100
MG/5ML, 200
MG/10ML, 400
MG/20ML
6
MSD
LIDOCAINE HCL
INJECTION
SOLUTION
PREFILLED SYRINGE
60 MG/3ML
3
LIDOCAINE HCL
INTRADERMAL 6 MSD
lidocaine hcl
urethral/mucosal
external gel
1
Last Updated 10/1/19
17
Drug Name Drug
Category
Limits/
Required
ROPIVACAINE HCL
INJECTION
SOLUTION 33.4
MG/ML
3
ROPIVACAINE HCL
INJECTION
SOLUTION
PREFILLED SYRINGE
0.5 %
6
MSD
ROPIVACAINE HCL-
NACL EPIDURAL
SOLUTION
6
MSD
ROPIVACAINE HCL-
NACL INJECTION
SOLUTION 0.2-0.9 %
6
MSD
ROPIVACAINE HCL-
NACL INJECTION
SOLUTION
PREFILLED SYRINGE
6
MSD
ROPIV-CLONIDINE-
KETOROLAC 6 MSD
sensorcaine injection
solution 0.5 % 1
sensorcaine/epinephrin
e 6 MSD
sensorcaine-mpf 6 MSD
sensorcaine-
mpf/epinephrine
injection solution 0.25%
-1:200000, 0.5% -
1:200000
6
MSD
SENSORCAINE-
MPF/EPINEPHRINE
INJECTION
SOLUTION 0.75-
1:200000 %
6
MSD
SX1 MEDICATED
POST-OPERATIVE 3
SYNERA 3
tetracaine hcl injection 1
VENIPUNCTURE PX1
PHLEBOTOMY 3
XYLOCAINE 6 MSD
xylocaine dental 6 MSD
Drug Name Drug
Category
Limits/
Required
MARCAINE SPINAL 6 MSD
MARCAINE/EPINEPH
RINE 6 MSD
MARCAINE/EPINEPH
RINE PF 6 MSD
marlido 1
MARLIDO-25 3
MARVONA SUIK 6 MSD
NAROPIN 6 MSD
NESACAINE 3
NESACAINE-MPF 6 MSD
P-CARE 100MX 3
P-CARE M 6 MSD
P-CARE MG 6 MSD
P-CARE X 6 MSD
PLIAGLIS 3 PA
POINT OF CARE LM-
2.2 3
POINT OF CARE LM-
2.5 3
polocaine injection
solution 1 % 1
polocaine injection
solution 2 % 2
polocaine-mpf injection
solution 1 %, 2 % 6 MSD
polocaine-mpf injection
solution 1.5 % 1
READYSHARP
LIDOCAINE 6 MSD
READYSHARP-A 3
RECK 6 MSD
relador pak 1
relador pak plus 1
ROPIVACAINE HCL
EPIDURAL 6 MSD
ropivacaine hcl
injection solution 10
mg/ml, 2 mg/ml, 5
mg/ml, 7.5 mg/ml
6
MSD
Last Updated 10/1/19
18
Drug Name Drug
Category
Limits/
Required
nicotine step 1 5 ACA; OTC; QL
nicotine step 2 5 ACA; OTC; QL
nicotine step 3 5 ACA; OTC; QL
NICOTROL 5 ACA; QL
NICOTROL NS 5 ACA; QL
SUBLOCADE 6 MSD
SUBOXONE 1 QL
VIVITROL 6 MSD
ZUBSOLV 1 QL
Antibacterials
ACTICLATE 3 ST
AEMCOLO 3
ALTABAX 3
amikacin sulfate
injection 6 MSD
amoxicillin 1
amoxicillin-potassium
clavulanate er 1
amoxicillin-potassium
clavulanate oral 1
ampicillin 1
ampicillin sodium 6 MSD
ampicillin-sulbactam
sodium 6 MSD
ARIKAYCE 3 PA; S
AUGMENTIN ES-600 3
AUGMENTIN ORAL
SUSPENSION
RECONSTITUTED
125-31.25 MG/5ML
2
AUGMENTIN ORAL
SUSPENSION
RECONSTITUTED
250-62.5 MG/5ML
3
AUGMENTIN ORAL
TABLET 3
AVELOX 6 MSD
avidoxy 1
AVYCAZ 6 MSD
AZACTAM 6 MSD
Drug Name Drug
Category
Limits/
Required
XYLOCAINE/EPINEPH
RINE 6 MSD
XYLOCAINE-MPF 6 MSD
XYLOCAINE-
MPF/EPINEPHRINE 6 MSD
ZINGO 6 MSD
ZTLIDO 2 ST
Anti-Addiction /
Substance Abuse
Treatment Agents
acamprosate calcium 1 M
ANTABUSE 3 M
BUNAVAIL 1 QL
buprenorphine hcl
sublingual 1 QL
buprenorphine hcl-
naloxone hcl 1 QL
bupropion hcl er
(smoking det) 5 ACA; QL
CHANTIX 5 ACA; QL
CHANTIX
CONTINUING MONTH
PAK
5
ACA; QL
CHANTIX STARTING
MONTH PAK 5 ACA; QL
disulfiram oral 1 M
EVZIO 1 ST
LUCEMYRA 3 QL
naloxone hcl injection 1
naltrexone hcl oral 1
NALTREXONE
SUBCUTANEOUS 1
NARCAN 1
NICORETTE
MOUTH/THROAT
GUM 2 MG
5
ACA; OTC; QL
nicotine polacrilex
mouth/throat gum 5 ACA; OTC; QL
nicotine polacrilex
mouth/throat lozenge 2
mg
5
ACA; OTC; QL
Last Updated 10/1/19
19
Drug Name Drug
Category
Limits/
Required
cefotetan disodium 6 MSD
cefoxitin sodium 6 MSD
cefpodoxime proxetil 1
cefprozil 1
ceftazidime and
dextrose 6 MSD
ceftriaxone sodium in
dextrose 6 MSD
ceftriaxone sodium
injection 6 MSD
ceftriaxone sodium
intravenous 6 MSD
ceftriaxone sodium-
dextrose 6 MSD
cefuroxime axetil 1
cefuroxime sodium 6 MSD
CENTANY 3
cephalexin 1
chloramphenicol sod
succinate 6 MSD
CIPRO 3
ciprofloxacin hcl oral 1
ciprofloxacin in d5w 6 MSD
ciprofloxacin oral 1
clarithromycin er 1
clarithromycin oral 1
CLEOCIN 3
CLEOCIN
PHOSPHATE 6 MSD
clindamycin hcl oral 1
clindamycin palmitate
hcl 1
clindamycin phosphate
in d5w 6 MSD
CLINDAMYCIN
PHOSPHATE IN NACL 6 MSD
clindamycin phosphate
injection 6 MSD
clindamycin phosphate
intravenous 6 MSD
Drug Name Drug
Category
Limits/
Required
azithromycin
intravenous 6 MSD
azithromycin oral 1
aztreonam 6 MSD
bacitracin intramuscular 6 MSD
BACTOCILL IN
DEXTROSE 6 MSD
BACTRIM 3
BACTRIM DS 3
BAXDELA
INTRAVENOUS 6 MSD
BAXDELA ORAL 3
benzalkonium chloride
external solution 2
BICILLIN C-R 6 MSD
BICILLIN C-R 900/300 6 MSD
BICILLIN L-A 6 MSD
cefaclor 1
cefaclor er 1
cefadroxil 1
cefazolin sodium
injection 6 MSD
CEFAZOLIN SODIUM
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
cefazolin sodium
intravenous solution
reconstituted
6
MSD
cefazolin sodium-
dextrose 6 MSD
cefdinir 1
cefditoren pivoxil 1
cefepime hcl 6 MSD
cefepime-dextrose 6 MSD
cefixime 1
CEFOTAN 6 MSD
cefotaxime sodium
injection solution
reconstituted 1 gm, 500
mg
6
MSD
Last Updated 10/1/19
20
Drug Name Drug
Category
Limits/
Required
erythromycin
ethylsuccinate oral 1
FIRST-
METRONIDAZOLE 3
FIRST-VANCOMYCIN 3
FIRVANQ 3
FLAGYL 3
FURADANTIN 3
gentamicin sulfate
external 1
gentamicin sulfate
injection solution 10
mg/ml
1
gentamicin sulfate
injection solution 40
mg/ml
6
MSD
HIPREX 3
hydrogen peroxide 2
imipenem-cilastatin 6 MSD
INVANZ 6 MSD
KEFLEX 3
LEVAQUIN ORAL
TABLET 500 MG, 750
MG
3
levofloxacin in d5w 6 MSD
levofloxacin
intravenous 6 MSD
levofloxacin oral
solution 6 MSD
levofloxacin oral tablet 1
LINCOCIN 6 MSD
lincomycin hcl injection 6 MSD
linezolid intravenous 6 MSD
linezolid oral 1 PA; QL
lugols 1
MACROBID 3
MACRODANTIN 3
mafenide acetate
external 1
MAXIPIME 6 MSD
Drug Name Drug
Category
Limits/
Required
clindamycin phosphate
vaginal 1
CLINDESSE 3
colistimethate sodium
(cba) 1
COLY-MYCIN M 3
coremino 1
CUBICIN 6 MSD
CUBICIN RF 6 MSD
DALVANCE 6 MSD
daptomycin 6 MSD
demeclocycline hcl 1
dicloxacillin sodium 1
DIFICID 3
DORYX 3 ST
DORYX MPC 3 ST
doxy 100 6 MSD
doxycycline hyclate
intravenous 6 MSD
doxycycline hyclate oral 1
doxycycline
monohydrate oral 1
e.e.s. 400 1
E.E.S. GRANULES 3
ertapenem sodium 6 MSD
ERYPED 200 3
ERYPED 400 3
ERY-TAB 1
erythrocin lactobionate
solution reconstituted
500 mg intravenous
6
MSD
ERYTHROCIN
LACTOBIONATE
SOLUTION
RECONSTITUTED 500
MG INTRAVENOUS
6
MSD
ERYTHROCIN
STEARATE 1
erythromycin base 1
Last Updated 10/1/19
21
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
meropenem 6 MSD NAFCILLIN SODIUM
IN DEXTROSE
INTRAVENOUS
SOLUTION 1
GM/50ML
6
MSD
MEROPENEM-
SODIUM CHLORIDE
INTRAVENOUS
SOLUTION
RECONSTITUTED 1
GM/50ML, 500-0.9 MG-
%
6
MSD
nafcillin sodium
injection solution
reconstituted 1 gm, 2
gm
6
MSD
MERREM 6 MSD
nafcillin sodium
intravenous solution
reconstituted 10 gm, 2
gm
6
MSD
methenamine hippurate 1
methenamine
mandelate oral 1
METRONIDAZOLE
BENZO+SYRSPEND 3
neomycin sulfate oral 1
nitrofurantoin 1 metronidazole in nacl
intravenous solution 5-
0.79 mg/ml-%, 500-
0.79 mg/100ml-%
6
MSD
nitrofurantoin
macrocrystal oral 1
nitrofurantoin
monohydrate
macrocrystals
1
METRONIDAZOLE IN
NACL INTRAVENOUS
SOLUTION 500-0.74
MG/100ML-%
6
MSD
NUTRIDOX 3 ST
NUVESSA 3
METRONIDAZOLE
INTRAVENOUS 6 MSD
NUZYRA
INTRAVENOUS 6 MSD
metronidazole oral 1
NUZYRA ORAL 3
metronidazole vaginal 1
ofloxacin oral 1
MINOCIN
INTRAVENOUS 6 ST; MSD
okebo 1
ORBACTIV 6 MSD MINOCIN ORAL
CAPSULE 50 MG 3 ST
oxacillin sodium 6 MSD
paromomycin sulfate
oral 1
minocycline hcl er 1
minocycline hcl oral 1
PENICILLIN G POT IN
DEXTROSE 6 MSD MINOLIRA 2 ST
mondoxyne nl 1
penicillin g potassium 6 MSD
MONUROL 3
penicillin g procaine 6 MSD
morgidox oral 1
penicillin g sodium 6 MSD
moxifloxacin hcl in nacl 6 MSD
penicillin v potassium 1
Last Updated 10/1/19
22
MOXIFLOXACIN HCL
INTRAVENOUS 6 MSD
PFIZERPEN
INJECTION
SOLUTION
RECONSTITUTED
20000000 UNIT
6
MSD moxifloxacin hcl oral 1
mupirocin calcium 1
mupirocin external 1
Last Updated 10/1/19
23
Drug Name Drug
Category
Limits/
Required
tazicef injection 6 MSD
TAZICEF SOLUTION
RECONSTITUTED 1
GM INTRAVENOUS
6
MSD
tazicef solution
reconstituted 1 gm
intravenous
6
MSD
TAZICEF SOLUTION
RECONSTITUTED 2
GM INTRAVENOUS
6
MSD
tazicef solution
reconstituted 2 gm
intravenous
6
MSD
TEFLARO 6 MSD
tetracycline hcl oral 1
tigecycline 6 MSD
tinidazole oral 1
tobramycin sulfate
injection 6 MSD
trimethoprim oral 1
TYGACIL 6 MSD
UNASYN INJECTION 6 MSD
VABOMERE 6 MSD
VANCOCIN HCL 3
VANCOMYCIN HCL IN
DEXTROSE
INTRAVENOUS
SOLUTION 1-5
GM/100ML-%, 1-5
GM/250ML-%, 1.25-5
GM/250ML-%, 1.5-5
GM/250ML-%, 1.5-5
GM/500ML-%, 1.75-5
GM/500ML-%
6
MSD
vancomycin hcl in
dextrose intravenous
solution 1-5 gm/200ml-
%, 500-5 mg/100ml-%,
750-5 mg/150ml-%
6
MSD
vancomycin hcl in nacl
intravenous solution 1-
0.9 gm/200ml-%, 500-
0.9 mg/100ml-%
6
MSD
Drug Name Drug
Category
Limits/
Required
pfizerpen solution
reconstituted 5000000
unit injection
6
MSD
PFIZERPEN
SOLUTION
RECONSTITUTED
5000000 UNIT
INJECTION
6
MSD
piperacillin sod-
tazobactam so 6 MSD
polymyxin b sulfate
injection 6 MSD
PRIMAXIN IV 6 MSD
PRIMSOL 3
SEYSARA 3
SILVADENE 3
silver nitrate external 1
silver sulfadiazine
external 1
SIVEXTRO
INTRAVENOUS 6 MSD; QL
SIVEXTRO ORAL 3 PA; QL
SOLODYN 2 ST
SPECTRACEF 3
ssd 1
streptomycin sulfate
intramuscular 6 MSD
sulfadiazine oral 1
sulfamethoxazole-
trimethoprim
intravenous
6
MSD
sulfamethoxazole-
trimethoprim oral 1
SULFAMYLON
EXTERNAL CREAM 2
SULFAMYLON
EXTERNAL PACKET 3
sulfatrim pediatric 1
SUPRAX 3
SYNERCID 6 MSD
TARGADOX 3 ST
Last Updated 10/1/19
24
Drug Name Drug
Category
Limits/
Required
XIFAXAN ORAL
TABLET 200 MG 2
XIFAXAN ORAL
TABLET 550 MG 2 M
XIMINO 3 ST
ZEMDRI 6 MSD
ZERBAXA 6 MSD
ZITHROMAX
INTRAVENOUS 6 MSD
ZITHROMAX ORAL 3
ZITHROMAX TRI-PAK 3
ZITHROMAX Z-PAK 3
ZOSYN
INTRAVENOUS
SOLUTION
RECONSTITUTED
6
MSD
ZYVOX
INTRAVENOUS 6 MSD
ZYVOX ORAL 3 PA; QL
Anticoagulants
acd formula a 2
acd-a noclot-50 2
ANGIOMAX 6 MSD
anticoagulant cit dext
soln a 2
anticoagulant sodium
citrate 3
argatroban 6 MSD
argatroban in sodium
chloride intravenous
solution 50 mg/50ml
6
MSD
ARIXTRA 3 QL
BEVYXXA 3 M; QL
bivalirudin
trifluoroacetate 6 MSD
BIVALIRUDIN-
SODIUM CHLORIDE 6 MSD
CATHFLO ACTIVASE 2
COUMADIN 3 M
DEFITELIO 6 MSD
ELIQUIS 2 PA; M; QL
Drug Name Drug
Category
Limits/
Required
VANCOMYCIN HCL IN
NACL INTRAVENOUS
SOLUTION 1-0.9
GM/250ML-%, 1.25-0.9
GM/250ML-%, 1.5-0.9
GM/250ML-%, 1.5-0.9
GM/300ML-%, 1.5-0.9
GM/500ML-%, 1.75-0.9
GM/250ML-%, 1.75-0.9
GM/500ML-%, 2-0.9
GM/500ML-%
6
MSD
VANCOMYCIN HCL IN
NACL SOLUTION 750-
0.9 MG/150ML-%
INTRAVENOUS
6
MSD
vancomycin hcl in nacl
solution 750-0.9
mg/150ml-%
intravenous
6
MSD
vancomycin hcl
intravenous solution
1000 mg/200ml, 1500
mg/300ml, 2000
mg/400ml
6
MSD
VANCOMYCIN HCL
INTRAVENOUS
SOLUTION 1250
MG/12.5ML, 1500
MG/15ML, 1750
MG/17.5ML, 2000
MG/20ML
6
MSD
vancomycin hcl
intravenous solution
reconstituted 1 gm,
1.25 gm, 1.5 gm, 10
gm, 100 gm, 250 mg, 5
gm, 500 mg, 750 mg
6
MSD
vancomycin hcl oral 1
VANCOMYCIN+SYRS
PEND SF 3
vandazole 1
VIBATIV 6 MSD
VIBRAMYCIN 3 ST
XEPI 3 PA
XERAVA 6 MSD
Last Updated 10/1/19
25
Drug Name Drug
Category
Limits/
Required
SODIUM CITRATE
LOCK FLUSH 6 MSD
SODIUM CITRATE-
GENTAMICIN SULF 6 MSD
THROMBATE III
INTRAVENOUS
SOLUTION
RECONSTITUTED 500
UNIT
6
MSD
TRICITRASOL 2
warfarin sodium oral 1 M
XARELTO 2 PA; M; QL
XARELTO STARTER
PACK 2 PA; QL
Anticonvulsants -
Drugs for Seizures
APTIOM 3 M
BANZEL 2 M
BRIVIACT
INTRAVENOUS 6 ST; MSD
BRIVIACT ORAL 3 ST; M
carbamazepine er 1 M
carbamazepine oral 1 M
CARBATROL 3 M
CELONTIN 2 M
CEREBYX 6 MSD
clobazam 1 M
DEPACON 6 MSD
DEPAKENE 3 ST; M
DEPAKOTE 3 ST; M
DEPAKOTE ER 3 ST; M
DEPAKOTE
SPRINKLES 3 ST; M
DIACOMIT 3 M
DIASTAT ACUDIAL 3 QL
DIASTAT PEDIATRIC 3 QL
diazepam rectal 1 QL
DILANTIN INFATABS 3 M
DILANTIN ORAL
CAPSULE 100 MG 3 M
Drug Name Drug
Category
Limits/
Required
ELIQUIS STARTER
PACK 2 PA; M; QL
enoxaparin sodium
injection 6 MSD; QL
enoxaparin sodium
subcutaneous 1 QL
fondaparinux sodium 1 QL
FRAGMIN 2 QL
heparin (porcine) in
nacl injection solution
100-0.45 unit/ml-%
6
MSD
heparin (porcine) in
nacl intravenous
solution 12500-0.45
ut/250ml-%, 25000-
0.45 ut/250ml-%,
25000-0.45 ut/500ml-%
6
MSD
HEPARIN (PORCINE)
IN NACL
INTRAVENOUS
SOLUTION 30000-0.9
UNIT/L-%, 5000-0.9
UNIT/L-%, 5000-0.9
UT/500ML-%
6
MSD
heparin sod (porcine) in
d5w 6 MSD
heparin sodium
(porcine) 1
heparin sodium
(porcine) pf 1
jantoven 1 M
LOVENOX INJECTION 6 ST; MSD; QL
LOVENOX
SUBCUTANEOUS 3 ST; QL
PRADAXA 3 PA; M; QL
RETAVASE 6 MSD
RETAVASE HALF-KIT 6 MSD
SAVAYSA 3 M; QL
SODIUM CITRATE IN
VITRO 6 MSD
SODIUM CITRATE
INTRAVENOUS 6 MSD
Last Updated 10/1/19
26
Drug Name Drug
Category
Limits/
Required
lamotrigine starter kit-
orange 1
levetiracetam er 1 M
levetiracetam in nacl 6 MSD
levetiracetam
intravenous 6 MSD
levetiracetam oral 1 M
MYSOLINE 3 M
NEMBUTAL 6 MSD
NEURONTIN 3 ST; M
ONFI 3 M
oxcarbazepine 1 M
OXTELLAR XR 3 ST; M
PEGANONE 2 M
pentobarbital sodium
injection 6 MSD
phenobarbital oral 1 M
phenobarbital sodium
injection 1
PHENYTEK 3 M
phenytoin infatabs 1 M
phenytoin oral 1 M
phenytoin sodium
extended 1 M
phenytoin sodium
injection 6 MSD
primidone oral 1 M
QUDEXY XR 2 ST; M
roweepra 1 M
roweepra xr 1 M
SABRIL 3 PA; M; S
SPRITAM 3 ST; M
subvenite 1 M
subvenite starter kit-
blue 1
subvenite starter kit-
green 1
subvenite starter kit-
orange 1
SYMPAZAN 3 M
Drug Name Drug
Category
Limits/
Required
DILANTIN ORAL
CAPSULE 30 MG 2 M
DILANTIN ORAL
SUSPENSION 3 M
divalproex sodium er 1 M
divalproex sodium oral 1 M
EPIDIOLEX 3 PA; M; S
epitol 1 M
EQUETRO 3 M
ethosuximide oral 1 M
FANATREX FUSEPAQ 3
felbamate 1 M
FELBATOL 3 M
fosphenytoin sodium 6 MSD
FYCOMPA 2 M
gabapentin oral 1 M
GABITRIL 3 M
KEPPRA
INTRAVENOUS 6 ST; MSD
KEPPRA ORAL 3 ST; M
KEPPRA XR 3 ST; M
LAMICTAL 3 ST; M
LAMICTAL ODT ORAL
KIT 3 ST
LAMICTAL ODT ORAL
TABLET
DISPERSIBLE
3
ST; M
LAMICTAL STARTER 3 ST
LAMICTAL XR ORAL
KIT 3 ST
LAMICTAL XR ORAL
TABLET EXTENDED
RELEASE 24 HOUR
3
ST; M
lamotrigine er 1 M
lamotrigine oral 1 M
lamotrigine starter kit-
blue 1
lamotrigine starter kit-
green 1
Last Updated 10/1/19
27
Drug Name Drug
Category
Limits/
Required
memantine hcl oral
tablet 10 mg, 5 mg 1 M
memantine hcl oral
tablet 28 x 5 mg & 21 x
10 mg
3
NAMENDA 3 ST; M
NAMENDA TITRATION
PAK 3 ST
NAMENDA XR 3 ST; M; QL
NAMENDA XR
TITRATION PACK 3 ST; QL
NAMZARIC ORAL
CAPSULE ER 24
HOUR THERAPY
PACK
2
ST; QL
NAMZARIC ORAL
CAPSULE EXTENDED
RELEASE 24 HOUR
2
ST; M; QL
RAZADYNE ER 3 ST; M; QL
RAZADYNE ORAL
TABLET 12 MG 3 ST; M
RAZADYNE ORAL
TABLET 4 MG, 8 MG 3 ST; M; QL
rivastigmine 1 M; QL
rivastigmine tartrate 1 M; QL
Antidepressants
amitriptyline hcl oral 1 M
amoxapine 1 M
ANAFRANIL 3 M
APLENZIN 3 ST; M; QL
BRISDELLE 3 ST; M; QL
bupropion hcl er (sr) 1 M; QL
bupropion hcl er (xl)
oral tablet extended
release 24 hour 150
mg, 300 mg
1
M; QL
BUPROPION HCL ER
(XL) ORAL TABLET
EXTENDED RELEASE
24 HOUR 450 MG
3
ST; M; QL
bupropion hcl oral 1 M
CELEXA 3 ST; M; QL
Drug Name Drug
Category
Limits/
Required
TEGRETOL 3 M
TEGRETOL-XR 3 M
tiagabine hcl 1 M
TOPAMAX 3 ST; M
TOPAMAX SPRINKLE 3 ST; M
topiramate er 3 M
topiramate oral 1 M
TRILEPTAL 3 ST; M
TROKENDI XR 3 ST; M
valproate sodium
intravenous 6 MSD
valproic acid oral 1 M
vigabatrin 1 PA; M; S
vigadrone 1 PA; M; S
VIMPAT
INTRAVENOUS 6 MSD
VIMPAT ORAL 2 M
ZARONTIN 3 M
ZONEGRAN 3 ST; M
zonisamide oral 1 M
Antidementia Agents
- Drugs for
Alzheimer's Disease
and Dementia
ARICEPT 3 ST; M
donepezil hcl 1 M
EXELON 3 ST; M; QL
galantamine
hydrobromide er 1 M; QL
galantamine
hydrobromide oral
solution
1
M; QL
galantamine
hydrobromide oral
tablet 12 mg
1
M
galantamine
hydrobromide oral
tablet 4 mg, 8 mg
1
M; QL
memantine hcl er 1 M; QL
memantine hcl oral
solution 1 M
Last Updated 10/1/19
28
Drug Name Drug
Category
Limits/
Required
fluoxetine hcl oral tablet
10 mg 1 M; QL
fluoxetine hcl oral tablet
20 mg, 60 mg 1 M
fluvoxamine maleate 1 M
fluvoxamine maleate er 1 M; QL
FORFIVO XL 3 ST; M; QL
imipramine hcl oral 1 M
imipramine pamoate 1 M
KHEDEZLA 3 ST; M; QL
LEXAPRO 3 ST; M; QL
maprotiline hcl 1 M
MARPLAN 3 M
mirtazapine oral 1 M; QL
NARDIL 3 M
nefazodone hcl 1 M
NORPRAMIN 3 M
nortriptyline hcl oral
capsule 1 M
nortriptyline hcl oral
solution 6 M; MSD
olanzapine-fluoxetine
hcl 1 M; QL
PAMELOR 3 M
PARNATE 3 M
paroxetine hcl 1 M; QL
paroxetine hcl er 1 M; QL
paroxetine mesylate 1 M; QL
PAXIL CR 3 ST; M; QL
PAXIL ORAL
SUSPENSION 3 ST; M
PAXIL ORAL TABLET 3 ST; M; QL
perphenazine-
amitriptyline 1 M
PEXEVA 3 ST; M; QL
phenelzine sulfate oral 1 M
PRISTIQ 3 ST; M; QL
protriptyline hcl 1 M
Drug Name Drug
Category
Limits/
Required
chlordiazepoxide-
amitriptyline 1 M
citalopram
hydrobromide oral
solution
1
M
citalopram
hydrobromide oral
tablet
1
M; QL
clomipramine hcl oral 1 M
CYMBALTA 3 ST; M; QL
desipramine hcl oral 1 M
DESVENLAFAXINE
ER 3 ST; M; QL
desvenlafaxine
succinate er 1 M; QL
doxepin hcl oral 1 M
duloxetine hcl oral 1 M; QL
EFFEXOR XR 3 ST; M; QL
EMSAM 3 M; QL
escitalopram oxalate
oral solution 1 M
escitalopram oxalate
oral tablet 1 M; QL
FETZIMA 2 ST; M; QL
FETZIMA TITRATION 2 ST; QL
fluoxetine hcl (pmdd)
oral capsule 10 mg 1 M; QL
fluoxetine hcl (pmdd)
oral capsule 20 mg 1 M
fluoxetine hcl (pmdd)
oral tablet 10 mg 1 M; QL
fluoxetine hcl (pmdd)
oral tablet 20 mg 1 M
fluoxetine hcl oral
capsule 10 mg, 40 mg 1 M; QL
fluoxetine hcl oral
capsule 20 mg 1 M
fluoxetine hcl oral
capsule delayed
release
1
M; QL
fluoxetine hcl oral
solution 1 M
Last Updated 10/1/19
29
Drug Name Drug
Category
Limits/
Required
ANZEMET 3 QL
aprepitant 1 QL
BONJESTA 3 QL
CINVANTI 6 MSD
compro 1
DICLEGIS 3 QL
dimenhydrinate
injection 1
doxylamine-pyridoxine 1 QL
dronabinol 1 QL
droperidol injection 1
EMEND
INTRAVENOUS 6 MSD
EMEND ORAL 3 QL
EMEND TRI-PACK 3 QL
granisetron hcl
intravenous 6 MSD
granisetron hcl oral 1 QL
MARINOL 3 QL
meclizine hcl oral tablet 1
metoclopramide hcl
injection 6 MSD
metoclopramide hcl
oral 1
ondansetron hcl
injection solution 40
mg/20ml
6
MSD
ondansetron hcl oral 1 QL
ONDANSETRON HCL
SOLUTION 4 MG/2ML
INJECTION
3
ondansetron hcl
solution 4 mg/2ml
injection
6
MSD
ondansetron odt 1 QL
palonosetron hcl 6 MSD
perphenazine oral 1 M
prochlorperazine 1
prochlorperazine
edisylate injection 6 MSD
Drug Name Drug
Category
Limits/
Required
PROZAC ORAL
CAPSULE 10 MG, 40
MG
3
ST; M; QL
PROZAC ORAL
CAPSULE 20 MG 3 ST; M
REMERON 3 M; QL
REMERON SOLTAB 3 M; QL
SARAFEM ORAL
TABLET 10 MG 3 ST; M; QL
SARAFEM ORAL
TABLET 20 MG 3 ST; M
sertraline hcl oral
concentrate 1 M
sertraline hcl oral tablet 1 M; QL
SPRAVATO (56 MG
DOSE) 4 M; S
SPRAVATO (84 MG
DOSE) 4 M; S
SYMBYAX 3 M; QL
TOFRANIL 3 M
tranylcypromine sulfate 1 M
trazodone hcl oral 1 M
trimipramine maleate
oral 1 M
TRINTELLIX 3 ST; M; QL
venlafaxine hcl 1 M; QL
venlafaxine hcl er 1 M; QL
VIIBRYD 2 ST; M; QL
VIIBRYD STARTER
PACK 2 ST; QL
WELLBUTRIN SR 3 ST; M; QL
WELLBUTRIN XL 3 ST; M; QL
ZOLOFT 3 ST; M; QL
ZULRESSO 6 MSD
Antiemetics - Drugs
for Nausea and
Vomiting
AKYNZEO
INTRAVENOUS 6 MSD
AKYNZEO ORAL 2 QL
ALOXI 6 MSD
Last Updated 10/1/19
30
Drug Name Drug
Category
Limits/
Required
clotrimazole powder 3
CLOTRIMAZOLE
POWDER 3
CRESEMBA
INTRAVENOUS 6 MSD
CRESEMBA ORAL 2
DIFLUCAN ORAL
SUSPENSION
RECONSTITUTED
3
DIFLUCAN ORAL
TABLET 100 MG, 200
MG, 50 MG
3
DIFLUCAN ORAL
TABLET 150 MG 3 QL
econazole nitrate
external 1
ECOZA 3
ERAXIS 6 MSD
ERTACZO 3
EXELDERM 3
exoderm external lotion 3
EXTINA 3
fluconazole in sodium
chloride 6 MSD
fluconazole oral
suspension
reconstituted
1
fluconazole oral tablet
100 mg, 200 mg, 50 mg 1
fluconazole oral tablet
150 mg 1 QL
flucytosine oral 1
griseofulvin microsize
oral 1
griseofulvin
ultramicrosize 1
GYNAZOLE-1 3
itraconazole oral
capsule 1 QL
itraconazole oral
solution 1
JUBLIA 3 ST; QL
Drug Name Drug
Category
Limits/
Required
prochlorperazine
maleate oral 1 M
REGLAN 3
SANCUSO 2 QL
scopolamine 1
SUSTOL 6 MSD; QL
SYNDROS 3 QL
TIGAN
INTRAMUSCULAR 6 MSD
TIGAN ORAL 3
TRANSDERM SCOP
(1.5 MG) 3
TRANSDERM-SCOP
(1.5 MG) 3
trimethobenzamide hcl
oral 1
VARUBI 2 QL
ZOFRAN 3 QL
ZUPLENZ 3 QL
Antifungals
ABELCET 6 MSD
AMBISOME 6 MSD
amphotericin b
intravenous 6 MSD
ANCOBON 3
AVC VAGINAL 3
BIO-STATIN ORAL
CAPSULE 3
bio-statin oral powder 1
CANCIDAS 6 MSD
caspofungin acetate 6 MSD
ciclodan 1
CICLODAN SOLUTION 3 ST
ciclopirox 1
ciclopirox olamine
external 1
clotrimazole crystals 3
clotrimazole external 1
clotrimazole
mouth/throat 1
Last Updated 10/1/19
31
Drug Name Drug
Category
Limits/
Required
RECURA 3
SPORANOX ORAL
CAPSULE 3 QL
SPORANOX ORAL
SOLUTION 3
SPORANOX
PULSEPAK 3 QL
terbinafine hcl oral 1 QL
terconazole 1 QL
TOLSURA 3 ST
VFEND 3
VFEND IV 6 MSD
voriconazole
intravenous 6 MSD
voriconazole oral 1
VUSION 3
XOLEGEL 3
XOLEGEL COREPAK 3
XOLEGEL DUO/HEAD
& SHOULDERS 3
XOLEGEL
DUO/XOLEX 3
Antigout Agents
allopurinol oral 1 M
allopurinol sodium 6 MSD
ALOPRIM 6 MSD
COLCHICINE ORAL 3 ST
colchicine-probenecid 1 M
COLCRYS 2 ST
febuxostat 1 ST; M
KRYSTEXXA 6 MSD
MITIGARE 2 ST
probenecid 1 M
ULORIC 2 ST; M
ZYLOPRIM 3 M
Anti-inflammatory
Agents
EMFLAZA 3 PA; S
Drug Name Drug
Category
Limits/
Required
KERYDIN 3 ST; QL
ketoconazole external 1
ketoconazole oral 1
LOPROX EXTERNAL
CREAM 3
LOPROX EXTERNAL
KIT 0.77 % (SUSP) 3
LOPROX EXTERNAL
SHAMPOO 3
LOPROX EXTERNAL
SUSPENSION 3
LULICONAZOLE 3 QL
LUZU 3 QL
MENTAX 3
miconazole 3 vaginal
suppository 1 QL
MICONAZOLE-ZINC
OXIDE-PETROLAT 3
MYCAMINE 6 MSD
naftifine hcl 1
NAFTIN 3
NIZORAL 3
NOXAFIL
INTRAVENOUS 6 M; MSD
NOXAFIL ORAL 2 M
nyamyc 6 MSD
nystatin external cream 1
nystatin external
ointment 1
nystatin external
powder 6 MSD
nystatin mouth/throat 1
nystatin oral 1
nystatin-triamcinolone 1
nystop 6 MSD
ORAVIG 3
oxiconazole nitrate 1
OXISTAT 3
PENLAC 3 ST
posaconazole 1 M
Last Updated 10/1/19
32
Drug Name Drug
Category
Limits/
Required
sumatriptan-naproxen
sodium 1 QL
TREXIMET 3 ST; QL
ZEMBRACE
SYMTOUCH 3 ST; QL
zolmitriptan oral 1 QL
ZOMIG NASAL 2 ST; QL
ZOMIG ORAL 3 ST; QL
ZOMIG ZMT 3 ST; QL
Antimyasthenic
Agents
BLOXIVERZ 6 MSD
GUANIDINE HCL 1
MESTINON ORAL
SYRUP 60 MG/5ML 2
MESTINON ORAL
TABLET 3
MESTINON ORAL
TABLET EXTENDED
RELEASE
3
neostigmine
methylsulfate
intravenous solution 10
mg/10ml, 5 mg/10ml
6
MSD
NEOSTIGMINE
METHYLSULFATE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
pyridostigmine bromide
er 1
pyridostigmine bromide
oral 1
regonol solution 10
mg/2ml intravenous 6 MSD
REGONOL SOLUTION
10 MG/2ML
INTRAVENOUS
6
MSD
Antimycobacterials
CAPASTAT SULFATE 6 MSD
cycloserine oral 3
dapsone oral 1 M
Drug Name Drug
Category
Limits/
Required
Antimigraine Agents
AIMOVIG 2 PA; M
AJOVY 2 PA; M
almotriptan malate 1 QL
AMERGE 3 ST; QL
CAFERGOT 3
D.H.E. 45 3
dihydroergotamine
mesylate injection 1
dihydroergotamine
mesylate nasal 1 QL
eletriptan hydrobromide 1 QL
EMGALITY 2 PA; M
EMGALITY (300 MG
DOSE) 2 PA; M
ERGOMAR 3
ergotamine-caffeine 1
FROVA 3 ST; QL
frovatriptan succinate 1 QL
IMITREX 3 ST; QL
IMITREX STATDOSE
REFILL 3 ST; QL
IMITREX STATDOSE
SYSTEM 3 ST; QL
MAXALT 3 ST; QL
MAXALT-MLT 3 ST; QL
MIGERGOT 1
MIGRANAL 3 QL
naratriptan hcl 1 QL
ONZETRA XSAIL 3 ST; QL
RELPAX 3 ST; QL
rizatriptan benzoate 1 QL
sumatriptan nasal 1 QL
sumatriptan succinate
oral 1 QL
sumatriptan succinate
refill 1 QL
sumatriptan succinate
subcutaneous 1 QL
Last Updated 10/1/19
33
Drug Name Drug
Category
Limits/
Required
ARRANON 6 MSD
arsenic trioxide
intravenous solution 10
mg/10ml
6
MSD
ARZERRA 6 MSD
AVASTIN 6 MSD
azacitidine 6 MSD
AZEDRA
DOSIMETRIC 6 MSD
AZEDRA
THERAPEUTIC 6 MSD
BALVERSA 3
BAVENCIO 6 PA; MSD
BELEODAQ 6 MSD
BELRAPZO 6 MSD
BENDAMUSTINE HCL 6 MSD
BENDEKA 6 MSD
BESPONSA 6 MSD
bexarotene 1 S
bicalutamide 1
BICNU 6 MSD
bleomycin sulfate 6 MSD
BLINCYTO 6 MSD
BORTEZOMIB 6 MSD
BOSULIF 3 S
BRAFTOVI 3 PA; S
busulfan 6 MSD
BUSULFEX 6 MSD
CABOMETYX 3 S; QL
CALQUENCE 3 S
CAMPATH 6 MSD
CAMPTOSAR 6 MSD
capecitabine 1 S
CAPRELSA 3 S; QL
carboplatin 6 MSD
carmustine 6 MSD
CASODEX 3
cisplatin intravenous
solution 6 MSD
Drug Name Drug
Category
Limits/
Required
ethambutol hcl oral 1
isoniazid injection 6 MSD
isoniazid oral 1 M
MYAMBUTOL 3
MYCOBUTIN 3
PASER 3
PRIFTIN 2
pyrazinamide oral 1
rifabutin 1
RIFADIN
INTRAVENOUS 6 MSD
RIFADIN ORAL 3
RIFAMATE 3
rifampin intravenous 6 MSD
rifampin oral 1
RIFAMPIN+SYRSPEN
D SF 3
RIFATER 3
SIRTURO 3 S
TRECATOR 3
Antineoplastics -
Drugs for Cancer
abiraterone acetate 1 PA; S; QL
ABRAXANE 6 MSD
ADCETRIS 6 MSD
adriamycin 6 MSD
adrucil 6 MSD
AFINITOR 3 S; QL
AFINITOR DISPERZ 3 S; QL
ALECENSA 3 S
ALIQOPA 6 MSD
ALKERAN
INTRAVENOUS 6 MSD
ALKERAN ORAL 3
ALUNBRIG 4 PA; S; QL
anastrozole oral 1 M
ARIMIDEX 3 ST; M
AROMASIN 3 M
Last Updated 10/1/19
34
Drug Name Drug
Category
Limits/
Required
ELLENCE 6 MSD
ELZONRIS 6 MSD
EMCYT 3 S
EMPLICITI 6 MSD
epirubicin hcl 6 MSD
ERBITUX 6 MSD
ERIVEDGE 3 S
ERLEADA 3 PA; S
erlotinib hcl oral tablet
100 mg, 150 mg 1
erlotinib hcl oral tablet
25 mg 1 QL
ERWINAZE 6 MSD
ETHYOL 6 MSD
ETOPOPHOS 6 MSD
etoposide intravenous 6 MSD
etoposide oral 1 S
EVOMELA 6 MSD
exemestane 1 M
FARESTON 4 M; S
FARYDAK 4 S
FASLODEX 6 MSD
FEMARA 3 M
floxuridine injection 6 MSD
fludarabine phosphate 6 MSD
fluorouracil intravenous 6 MSD
flutamide 1
FOLOTYN 6 MSD
fulvestrant 6 MSD
FUSILEV 6 MSD
GAZYVA 6 MSD
gemcitabine hcl 6 MSD
GILOTRIF 3 S; QL
GLEEVEC 4 ST; S; QL
GLEOSTINE 3 S
GLIADEL WAFER 6 MSD
HALAVEN 6 MSD
HERCEPTIN 6 PA; MSD
Drug Name Drug
Category
Limits/
Required
CISPLATIN
INTRAVENOUS
SOLUTION
RECONSTITUTED
6
MSD
cladribine 6 MSD
clofarabine 6 MSD
CLOLAR 6 MSD
COMETRIQ (100 MG
DAILY DOSE) 3 S; QL
COMETRIQ (140 MG
DAILY DOSE) 3 S; QL
COMETRIQ (60 MG
DAILY DOSE) 3 S; QL
COPIKTRA 4 PA; S
COSMEGEN 6 MSD
COTELLIC 3 S
cyclophosphamide
injection 6 MSD
cyclophosphamide oral 1
CYRAMZA 6 MSD
cytarabine 6 MSD
cytarabine (pf) 6 MSD
dacarbazine 6 MSD
DACOGEN 6 MSD
dactinomycin 6 MSD
DARZALEX 6 MSD
daunorubicin hcl 6 MSD
DAURISMO 4 S
decitabine 6 MSD
dexrazoxane hcl 6 MSD
dexrazoxane
intravenous solution
reconstituted 500 mg
6
MSD
docetaxel 6 MSD
DOXIL 6 MSD
doxorubicin hcl 6 MSD
doxorubicin hcl
liposomal 6 MSD
DROXIA 3 M; S
ELITEK 6 MSD
Last Updated 10/1/19
35
Drug Name Drug
Category
Limits/
Required
KISQALI (400 MG
DOSE) 4 PA; S
KISQALI (600 MG
DOSE) 4 PA; S
KISQALI FEMARA
(400 MG DOSE) 4 PA; S
KISQALI FEMARA
(600 MG DOSE) 4 PA; S
KISQALI FEMARA(200
MG DOSE) 4 PA; S
KYPROLIS 6 MSD
LARTRUVO 6 MSD
LENVIMA (10 MG
DAILY DOSE) 3 S
LENVIMA (12 MG
DAILY DOSE) 3 S
LENVIMA (14 MG
DAILY DOSE) 3 S
LENVIMA (18 MG
DAILY DOSE) 3 S
LENVIMA (20 MG
DAILY DOSE) 3 S
LENVIMA (24 MG
DAILY DOSE) 3 S
LENVIMA (4 MG
DAILY DOSE) 3 S
LENVIMA (8 MG
DAILY DOSE) 3 S
letrozole oral 1 M
leucovorin calcium
injection 6 MSD
leucovorin calcium oral 1
LEUKERAN 2
levoleucovorin calcium 6 MSD
levoleucovorin calcium
pf 6 MSD
LIBTAYO 6 MSD
LONSURF 3 S
LORBRENA 3 S
LUMOXITI 6 MSD
LUTATHERA 6 MSD
Drug Name Drug
Category
Limits/
Required
HERCEPTIN
HYLECTA 6 PA; MSD
HYCAMTIN
INTRAVENOUS 6 MSD
HYCAMTIN ORAL 3 S
HYDREA 3
hydroxyurea oral 1
IBRANCE 3 S
ICLUSIG ORAL
TABLET 15 MG 3 S; QL
ICLUSIG ORAL
TABLET 45 MG 3 S
IDAMYCIN PFS 6 MSD
idarubicin hcl 6 MSD
IDHIFA 3 PA; S; QL
IFEX 6 MSD
ifosfamide 6 MSD
imatinib mesylate 1 S; QL
IMBRUVICA 3 S
IMFINZI 6 MSD
IMLYGIC 6 MSD
INFUGEM 6 MSD
INLYTA 3 S; QL
IRESSA 3 S
irinotecan hcl 6 MSD
ISTODAX (OVERFILL) 6 MSD
IXEMPRA KIT 6 MSD
JAKAFI ORAL TABLET
10 MG 3 S; QL
JAKAFI ORAL TABLET
15 MG, 20 MG, 25 MG,
5 MG
3
S
JEVTANA 6 MSD
KADCYLA 6 MSD
KANJINTI 6 MSD
KEYTRUDA 6 MSD
KHAPZORY 6 MSD
KISQALI (200 MG
DOSE) 4 PA; S
Last Updated 10/1/19
36
Drug Name Drug Limits/
Category Required
PIQRAY (250 MG
DAILY DOSE)
PIQRAY (300 MG
3
3
TAGRISSO ORAL
TABLET 40 MG
TAGRISSO ORAL
TABLET 80 MG
TALZENNA
tamoxifen citrate oral
TARCEVA ORAL
TABLET 100 MG, 150
MG
TARCEVA ORAL
TABLET 25 MG
3 S; QL
3 S
3
5
PA; S
M; ACA
3 S
3 S; QL
DAILY DOSE)
POLIVY 6 MSD
POMALYST 3 S; QL
PORTRAZZA 6 MSD
POTELIGEO 6 MSD
PROLEUKIN 6 MSD
PURIXAN 3 S
QUADRAMET 6 MSD
REVLIMID 3 S
RITUXAN 6 PA; MSD
RITUXAN HYCELA 6 PA; MSD
ROMIDEPSIN 6 MSD
RUBRACA 3 PA; S
RYDAPT 3 PA; S
SIKLOS 4 ST; S
SOLTAMOX 5 M; ACA
SPRYCEL 3 S; QL
STIVARGA 3 S
SUTENT 3 S; QL
SYLATRON 3 PA; M; S; QL
SYLVANT 6 MSD
SYNRIBO 6 MSD
TABLOID 3 S
TAFINLAR 3 S
Drug Name Drug
Category
Limits/
Required
LYNPARZA 3 S
LYSODREN 3 S
MARQIBO 6 MSD
MATULANE 3 S
MEKINIST 3 S
MEKTOVI 4 PA; S
melphalan 1
melphalan hcl 6 MSD
mercaptopurine oral 1
mesna 6 MSD
MESNEX
INTRAVENOUS 6 MSD
MESNEX ORAL 2
mitomycin intravenous 6 MSD
MITOMYCIN
INTRAVESICAL 6 MSD
mitoxantrone hcl 6 MSD
mutamycin 6 MSD
MVASI 6 MSD
MYLERAN 3 S
MYLOTARG 6 MSD
NAVELBINE 6 MSD
NERLYNX 3 PA; S; QL
NEXAVAR 3 S; QL
NILANDRON 4 S
nilutamide 1 S
NINLARO 3 S
NIPENT 6 MSD
ODOMZO 4 S
ONCASPAR 6 MSD
ONIVYDE 6 MSD
OPDIVO 6 MSD
oxaliplatin 6 MSD
paclitaxel 6 MSD
PANRETIN 3
PERJETA 6 MSD
PIQRAY (200 MG
DAILY DOSE) 3
Last Updated 10/1/19
37
Drug Name Drug
Category
Limits/
Required
VIZIMPRO 3 PA; S
VORAXAZE 6 MSD
VOTRIENT 3 S; QL
VYXEOS 6 MSD
XALKORI 3 S; QL
XELODA 4 S
XOFIGO 6 MSD
XOSPATA 3 S
XTANDI 3 S; QL
YERVOY 6 MSD
YESCARTA 6 MSD
YONDELIS 6 MSD
YONSA 3 PA; S
ZALTRAP 6 MSD
ZANOSAR 6 MSD
ZEJULA 3 PA; S
ZELBORAF 3 S; QL
ZEVALIN Y-90 6 MSD
ZINECARD 6 MSD
ZOLINZA 3 S; QL
ZYDELIG 3 S
ZYKADIA ORAL
CAPSULE 3 S
ZYKADIA ORAL
TABLET 3
ZYTIGA 3 PA; S; QL
Antiparasitics
albendazole oral 1
ALBENZA 3
ALINIA 2
ARAKODA 3
atovaquone oral 1
atovaquone-proguanil
hcl 1
BENZNIDAZOLE 2
BILTRICIDE 3
chloroquine phosphate
oral 1 M
Drug Name Drug
Category
Limits/
Required
TARGRETIN
EXTERNAL 2
TARGRETIN ORAL 4 S
TASIGNA 3 S; QL
TAXOTERE 6 MSD
TECENTRIQ 6 MSD
TEMODAR
INTRAVENOUS 6 MSD
TEMODAR ORAL 4 S
temozolomide 1 S
teniposide 6 MSD
TEPADINA 6 MSD
THALOMID 3 M; S
thiotepa injection 6 MSD
TIBSOVO 3 PA; S
toposar 6 MSD
topotecan hcl 6 MSD
toremifene citrate 1 M; S
TOTECT 6 MSD
TREANDA 6 MSD
tretinoin oral 1 S
TRISENOX 6 MSD
TYKERB 3 S; QL
UNITUXIN 6 MSD
VALCHLOR 3 S
valrubicin 6 MSD
VALSTAR 6 MSD
VECTIBIX 6 MSD
VELCADE 6 MSD
VENCLEXTA 3 S
VENCLEXTA
STARTING PACK 3 S
VERZENIO 3 S
VIDAZA 6 MSD
vinblastine sulfate 6 MSD
vincristine sulfate 6 MSD
vinorelbine tartrate 6 MSD
VITRAKVI 3 S
Last Updated 10/1/19
38
Drug Name Drug
Category
Limits/
Required
benztropine mesylate
injection 6 MSD
benztropine mesylate
oral 1 M
bromocriptine mesylate
oral 1 M
carbidopa oral 1 M
carbidopa-levodopa 1 M
carbidopa-levodopa er 1 M
carbidopa-levodopa-
entacapone 1 M
COGENTIN 6 MSD
COMTAN 3 M
DUOPA 6 M; MSD
entacapone 1 M
GOCOVRI 3 PA; M; S
INBRIJA 3 M
LODOSYN 3 M
MIRAPEX 3 M
MIRAPEX ER 3 M
NEUPRO 3 M
NOURIANZ 3 M
OSMOLEX ER 3 ST; M
PARLODEL 3 M
pramipexole
dihydrochloride 1 M
pramipexole
dihydrochloride er 1 M
rasagiline mesylate oral 1 M
REQUIP XL 3 M
ropinirole hcl 1 M
ropinirole hcl er 1 M
RYTARY 3 M
selegiline hcl oral 1 M
SINEMET 3 M
SINEMET CR 3 M
STALEVO 100 3 M
STALEVO 125 3 M
STALEVO 150 3 M
Drug Name Drug
Category
Limits/
Required
COARTEM 2
crotan 1
DARAPRIM 3 PA; S
EGATEN 3
ELIMITE 3
EMVERM 2
EURAX 3
hydroxychloroquine
sulfate oral 1 M
IMPAVIDO 3 S
ivermectin oral 1
KRINTAFEL 3
lindane 1 QL
MALARONE 3
malathion 1
mefloquine hcl 1 M
MEPRON 3
NATROBA 3 QL
NEBUPENT 2 QL
OVIDE 3
PENTAM 6 MSD
pentamidine isethionate 6 MSD
permethrin external 1
PLAQUENIL 3 M
praziquantel oral 1
primaquine phosphate 2
QUALAQUIN 3
quinine sulfate oral 1
SKLICE 3
SOLOSEC 3
spinosad 1 QL
STROMECTOL 3
sulfurated lime 1
ULESFIA 3
Antiparkinson Agents
amantadine hcl oral 1 M
APOKYN 3 S; QL
AZILECT 3 M
Last Updated 10/1/19
39
Drug Name Drug
Category
Limits/
Required
ARISTADA 2 M
ARISTADA INITIO 2
chlorpromazine hcl
injection 1
chlorpromazine hcl oral 1 M
clozapine oral tablet 1 QL
clozapine oral tablet
dispersible 100 mg,
12.5 mg, 25 mg
1
QL
clozapine oral tablet
dispersible 150 mg,
200 mg
3
QL
CLOZARIL 3 QL
FANAPT 3 QL
FANAPT TITRATION
PACK 3 QL
FAZACLO 3 QL
fluphenazine
decanoate injection 6 MSD
fluphenazine hcl
injection 1
fluphenazine hcl oral 1 M
GEODON
INTRAMUSCULAR 3
GEODON ORAL 3 M; QL
HALDOL 6 MSD
HALDOL DECANOATE 3
haloperidol decanoate
intramuscular 1
haloperidol lactate
injection 6 MSD
haloperidol lactate oral 1 M
haloperidol oral 1 M
INVEGA 3 M; QL
INVEGA SUSTENNA 3
INVEGA TRINZA 3
LATUDA 2 M; QL
loxapine succinate 1 M
molindone hcl 1 M
NUPLAZID 4 M; S
Drug Name Drug
Category
Limits/
Required
STALEVO 200 3 M
STALEVO 50 3 M
STALEVO 75 3 M
TASMAR 3 M
tolcapone 1 M
trihexyphenidyl hcl oral
elixir 1 M
trihexyphenidyl hcl oral
tablet 1 M
XADAGO 3 ST; M; QL
ZELAPAR 3 M
Antiplatelets
AGGRASTAT 6 MSD
AGGRENOX 3 M
aspirin-dipyridamole er 1 M
BRILINTA 2 M
cilostazol 1 M
clopidogrel bisulfate
oral tablet 300 mg 1
clopidogrel bisulfate
oral tablet 75 mg 1 M
dipyridamole oral 1 M
DURLAZA 3 ST; M
EFFIENT 3 ST; M
eptifibatide 6 MSD
INTEGRILIN 6 MSD
KENGREAL 6 MSD
PLAVIX 3 ST; M
prasugrel hcl 1 M
REOPRO 6 MSD
ZONTIVITY 2 M
Antipsychotics -
Drugs for Mood
Disorders
ABILIFY 4 ST; M; S; QL
ABILIFY MAINTENA 2 M
ABILIFY MYCITE 3 M; S; QL
ADASUVE 3
aripiprazole 1 M; QL
Last Updated 10/1/19
40
Drug Name Drug
Category
Limits/
Required
adefovir dipivoxil 1 M
APTIVUS 3 M; QL
atazanavir sulfate 1 M
ATRIPLA 3 M; QL
BARACLUDE ORAL
SOLUTION 2 M; QL
BARACLUDE ORAL
TABLET 3 M; QL
BIKTARVY 3 M
cidofovir intravenous 6 MSD
CIMDUO 3 M
COMBIVIR 4 M; QL
COMPLERA 3 M; QL
CRIXIVAN 3 M; QL
DELSTRIGO 4 M
DENAVIR 3
DESCOVY 3 M
didanosine 1 M; QL
DOVATO 3 M
EDURANT 3 M; QL
efavirenz 1 M; QL
EMTRIVA 3 M; QL
entecavir 1 M; QL
EPCLUSA 3 PA; S; QL
EPIVIR 4 M; QL
EPIVIR HBV ORAL
SOLUTION 2 M
EPIVIR HBV ORAL
TABLET 3 M; QL
EPZICOM 4 M; QL
EVOTAZ 4 M; QL
famciclovir 1
FLUMADINE 3
fosamprenavir calcium 1 M; QL
FOSCAVIR 6 MSD
FUZEON 3 M; S; QL
GANCICLOVIR 6 MSD
ganciclovir sodium
intravenous solution 6 M; MSD
Drug Name Drug
Category
Limits/
Required
olanzapine oral 1 M; QL
paliperidone er 1 M; QL
PERSERIS 3 M
pimozide 1 M
quetiapine fumarate 1 M; QL
quetiapine fumarate er 1 M; QL
REXULTI 3 M; QL
RISPERDAL 3 M; QL
RISPERDAL CONSTA
INTRAMUSCULAR
SUSPENSION
RECONSTITUTED
12.5 MG, 25 MG, 37.5
MG, 50 MG
2
risperidone 1 M; QL
SAPHRIS 3 M; QL
SEROQUEL 3 ST; M; QL
SEROQUEL XR 3 ST; M; QL
thioridazine hcl oral 1 M
thiothixene 1 M
trifluoperazine hcl 1 M
VERSACLOZ 3 QL
VRAYLAR ORAL
CAPSULE 3 M; QL
VRAYLAR ORAL
CAPSULE THERAPY
PACK
3
QL
ziprasidone hcl 1 M; QL
ZYPREXA ORAL 3 M; QL
ZYPREXA RELPREVV 3
ZYPREXA ZYDIS 3 M; QL
Antivirals
abacavir sulfate 1 M; QL
abacavir sulfate-
lamivudine 1 M; QL
abacavir-lamivudine-
zidovudine 1 M; QL
acyclovir external 1 QL
acyclovir oral 1
acyclovir sodium 6 MSD
Last Updated 10/1/19
41
Drug Name Drug
Category
Limits/
Required
PEGINTRON 4 S; QL
PIFELTRO 4 M
PREVYMIS
INTRAVENOUS 6 MSD
PREVYMIS ORAL 2 M
PREZCOBIX 4 M
PREZISTA 3 M; QL
RELENZA DISKHALER 2 QL
RESCRIPTOR 3 M; QL
RETROVIR
INTRAVENOUS 6 MSD
RETROVIR ORAL 4 M; QL
REYATAZ ORAL
CAPSULE 4 M
REYATAZ ORAL
PACKET 3 M
ribasphere 1
ribasphere ribapak oral
tablet 400 mg, 600 mg 1
RIBASPHERE
RIBAPAK ORAL
TABLET THERAPY
PACK 200 & 400 MG,
400 & 600 MG
1
ribavirin inhalation 1 S
ribavirin oral 1
rimantadine hcl 1
ritonavir 1 M; QL
SELZENTRY ORAL
SOLUTION 3 M
SELZENTRY ORAL
TABLET 150 MG, 300
MG
3
M; QL
SELZENTRY ORAL
TABLET 25 MG, 75
MG
3
M
SITAVIG 3 QL
SOVALDI 4 PA; S; QL
stavudine 1 M; QL
STRIBILD 3 M; QL
SUSTIVA 4 M; QL
Drug Name Drug
Category
Limits/
Required
ganciclovir sodium
intravenous solution
reconstituted
6
MSD
GENVOYA 3 M
HARVONI 3 PA; S; QL
HEPSERA 3 M
INTELENCE 3 M; QL
INTRON A 3 M; S
INVIRASE 3 M; QL
ISENTRESS 3 M; QL
ISENTRESS HD 3 M
JULUCA 4 M
KALETRA ORAL
SOLUTION 4 M; QL
KALETRA ORAL
TABLET 3 M; QL
lamivudine oral solution 1 M; QL
lamivudine oral tablet
100 mg 1 M; QL
lamivudine oral tablet
150 mg, 300 mg 1 M; QL
lamivudine-zidovudine 1 M; QL
LEXIVA ORAL
SUSPENSION 3 M; QL
LEXIVA ORAL TABLET 4 M; QL
lopinavir-ritonavir 1 M; QL
MAVYRET 4 PA; S; QL
nevirapine 1 M; QL
nevirapine er 1 M; QL
NORVIR ORAL
PACKET 3 M
NORVIR ORAL
SOLUTION 3 M; QL
NORVIR ORAL
TABLET 4 M; QL
ODEFSEY 3 M
oseltamivir phosphate
oral 1 QL
PEGASYS 3 S; QL
PEGASYS PROCLICK 3 S; QL
Last Updated 10/1/19
42
Drug Name Drug
Category
Limits/
Required
ZIAGEN 4 M; QL
zidovudine 1 M; QL
ZOVIRAX EXTERNAL
CREAM 2 QL
ZOVIRAX EXTERNAL
OINTMENT 3 QL
ZOVIRAX ORAL 3
Anxiolytics - Drugs
for Anxiety
alprazolam er 1 QL
ALPRAZOLAM
INTENSOL 1 QL
alprazolam oral 1 QL
alprazolam xr 1 QL
ATIVAN INJECTION 6 MSD
ATIVAN ORAL 3 QL
buspirone hcl oral 1
chlordiazepoxide hcl 1 QL
clonazepam oral 1 QL
clorazepate
dipotassium 1 QL
diazepam intensol 1
diazepam
intramuscular 6 MSD
diazepam oral 1
diazepam solution 5
mg/ml injection 6 MSD
DIAZEPAM SOLUTION
5 MG/ML INJECTION 6 MSD
DORAL 3 QL
estazolam 1 QL
HALCION 3 QL
hydroxyzine hcl
intramuscular 6 MSD
hydroxyzine hcl oral 1
hydroxyzine pamoate
oral 1
KLONOPIN 3 QL
lorazepam injection 6 MSD
lorazepam intensol 1 QL
Drug Name Drug
Category
Limits/
Required
SYMFI 3 M
SYMFI LO 3 M
SYMTUZA 4 M
TAMIFLU 3 QL
TEMIXYS 3 M
tenofovir disoproxil
fumarate 1 M; QL
TIVICAY ORAL
TABLET 10 MG, 25
MG
3
M
TIVICAY ORAL
TABLET 50 MG 3 M; QL
TRIUMEQ 3 M; QL
TRIZIVIR 4 M; QL
TROGARZO 6 M; MSD
TRUVADA ORAL
TABLET 100-150 MG,
133-200 MG, 167-250
MG
3
M
TRUVADA ORAL
TABLET 200-300 MG 3 M; QL
TYBOST 4 M; QL
valacyclovir hcl oral 1 QL
VALCYTE 3 M
valganciclovir hcl 1 M
VALTREX 3 ST; QL
VEMLIDY 2 M
VIDEX 3 M; QL
VIDEX EC 4 M; QL
VIEKIRA PAK 4 PA; S; QL
VIRACEPT 3 M; QL
VIRAMUNE 4 M; QL
VIRAMUNE XR 4 M; QL
VIRAZOLE 4 S
VIREAD 3 M; QL
VOSEVI 3 PA; S
XERESE 3 ST; QL
XOFLUZA 2 QL
ZEPATIER 3 PA; S; QL
Last Updated 10/1/19
43
Drug Name Drug
Category
Limits/
Required
ARANESP (ALBUMIN
FREE) 6 MSD
BENEFIX 6 MSD
CEPROTIN 6 MSD
COAGADEX 6 MSD
CORIFACT 6 MSD
CYKLOKAPRON 6 MSD
DOPTELET 3 PA; S
ELOCTATE 6 MSD
EPOGEN 6 PA; MSD
FEIBA 6 MSD
FIBRYGA 6 MSD
FULPHILA 6 PA; MSD; QL
GRANIX 6 MSD
HEMLIBRA 6 M; MSD
hemofil m intravenous
solution reconstituted
1000 unit, 250 unit, 500
unit
6
MSD
HEMOFIL M
INTRAVENOUS
SOLUTION
RECONSTITUTED
1700 UNIT
6
MSD
HESPAN 6 MSD
hetastarch-nacl 6 MSD
HUMATE-P 6 MSD
IDELVION 6 MSD
IXINITY 6 MSD
JIVI 6 MSD
KCENTRA
INTRAVENOUS KIT
500 UNIT
6
MSD
KOATE 6 MSD
KOATE-DVI
INTRAVENOUS
SOLUTION
RECONSTITUTED
1000 UNIT, 500 UNIT
6
MSD
Drug Name Drug
Category
Limits/
Required
lorazepam oral 1 QL
meprobamate 1
midazolam hcl injection 6 MSD
MIDAZOLAM HCL-
SODIUM CHLORIDE 6 MSD
MIDAZOLAM-SODIUM
CHLORIDE 6 MSD
oxazepam 1 QL
quazepam 1 QL
TRANXENE-T 3 QL
triazolam 1 QL
VALIUM 3 ST
VISTARIL 3
XANAX 3 ST; QL
XANAX XR 3 ST; QL
Bipolar Agents -
Drugs for Mood
Disorders
lithium 1 M
lithium carbonate er 1 M
lithium carbonate oral 1 M
LITHOBID 3 M
Blood Products /
Modifiers / Volume
Expanders - Drugs for
Bleeding Disorders
ADVATE 6 MSD
ADYNOVATE 6 MSD
AFSTYLA 6 MSD
AGRYLIN 3 M
ALPHANATE/VWF
COMPLEX/HUMAN 6 MSD
ALPHANINE SD 6 MSD
ALPROLIX 6 MSD
AMICAR 3
aminocaproic acid
intravenous 6 MSD
aminocaproic acid oral 1
anagrelide hcl 1 M
Last Updated 10/1/19
44
Drug Name Drug
Category
Limits/
Required
protamine sulfate
intravenous 6 MSD
REBINYN 6 MSD
RECOMBINATE 6 MSD
RECOTHROM 6 MSD
RECOTHROM SPRAY
KIT 6 MSD
RETACRIT 6 MSD
RIASTAP 6 MSD
RIXUBIS 6 MSD
SOLIRIS 6 MSD
TAVALISSE 3 PA; M; S
THROMBIN-JMI 3
THROMBIN-JMI
EPISTAXIS 3
THROMBOGEN 3
tranexamic acid
intravenous 6 MSD
tranexamic acid oral 1
TRETTEN 6 MSD
UDENYCA 6 PA; MSD; QL
ULTOMIRIS 6 MSD
VOLUVEN 6 MSD
VONVENDI 6 MSD
WILATE 6 MSD
XYNTHA 6 MSD
XYNTHA SOLOFUSE 6 MSD
ZARXIO 6 MSD
Cardiovascular
Agents - Drugs for
Heart and Circulation
Conditions
ABLYSINOL 6 MSD
ACCUPRIL 3 M
ACCURETIC 3 ST; M
acebutolol hcl oral 1 M
acetazolamide oral
tablet 125 mg 1 M
acetazolamide sodium 6 MSD
Drug Name Drug
Category
Limits/
Required
koate-dvi intravenous
solution reconstituted
250 unit
6
MSD
KOGENATE FS 6 MSD
KOVALTRY 6 MSD
LEUKINE
INTRAVENOUS
SOLUTION
RECONSTITUTED 250
MCG
6
MSD
lmd in d5w solution 10-
5 % intravenous 6 MSD
LMD IN D5W
SOLUTION 10-5 %
INTRAVENOUS
6
MSD
lmd in nacl solution 10-
0.9 % intravenous 6 MSD
LMD IN NACL
SOLUTION 10-0.9 %
INTRAVENOUS
6
MSD
LYSTEDA 3
MIRCERA 6 MSD
MONONINE 6 MSD
MONSELS FERRIC
SUBSULFATE 2
MOZOBIL 6 MSD; QL
MULPLETA 3 PA; S
NEULASTA 6 PA; MSD; QL
NEULASTA ONPRO 6 PA; MSD; QL
NEUPOGEN 6 PA; MSD
NIVESTYM 6 MSD
NOVOEIGHT 6 MSD
NOVOSEVEN RT 6 MSD
NPLATE 6 MSD
NUWIQ 6 MSD
OBIZUR 6 MSD
PANHEMATIN 6 MSD
PROCRIT 6 PA; MSD
PROFILNINE 6 MSD
PROFILNINE SD 6 MSD
PROMACTA 2 PA; M
Last Updated 10/1/19
45
Drug Name Drug
Category
Limits/
Required
atorvastatin calcium
oral tablet 10 mg, 20
mg
5
M; ACA; QL
atorvastatin calcium
oral tablet 40 mg, 80
mg
1
M; QL
AVALIDE 3 ST; M
AVAPRO 3 ST; M
AZOR 3 ST; M
benazepril hcl oral 1 M
benazepril-
hydrochlorothiazide 1 M
BENICAR 3 ST; M
BENICAR HCT 3 ST; M
BETAPACE 3 ST; M
BETAPACE AF 3 ST; M
betaxolol hcl oral 1 M
BIDIL 3 M
bisoprolol fumarate 1 M
bisoprolol-
hydrochlorothiazide 1 M
BREVIBLOC IN NACL 6 ST; MSD
BREVIBLOC
PREMIXED 6 ST; MSD
BREVIBLOC
PREMIXED DS 6 ST; MSD
bumetanide injection 6 MSD
bumetanide oral 1 M
BUMEX 3 M
BYSTOLIC 2 ST; M
CADUET 3 ST; M; QL
CALAN 3 ST; M
CALAN SR 3 ST; M
candesartan cilexetil 1 M
candesartan cilexetil-
hctz 1 M
captopril oral 1 M
captopril-
hydrochlorothiazide 1 M
CARDENE IV 6 ST; MSD
Drug Name Drug
Category
Limits/
Required
ADALAT CC 3 ST; M
ADENOCARD 6 MSD
adenosine intravenous
solution 12 mg/4ml, 6
mg/2ml
6
MSD
AKOVAZ 6 MSD
ALDACTAZIDE 3 M
ALDACTONE 3 M
aliskiren fumarate 1 M
alprostadil injection 6 MSD
ALTACE 3 M
ALTOPREV 3 ST; M; QL
amiloride hcl oral 1 M
amiloride-
hydrochlorothiazide 1 M
AMIODARONE HCL IN
DEXTROSE 6 MSD
amiodarone hcl
intravenous 6 MSD
amiodarone hcl oral 1 M
AMLODIPINE
BES+SYRSPEND SF 3 ST; M
amlodipine besylate
oral 1 M
amlodipine besylate-
benazepril hcl 1 M
amlodipine besylate-
valsartan 1 M
amlodipine-atorvastatin 1 M; QL
amlodipine-olmesartan 1 M
amlodipine-valsartan-
hctz 1 M
ANTARA 3 ST; M; QL
ASCLERA 6 MSD
ATACAND 3 ST; M
ATACAND HCT 3 ST; M
atenolol oral 1 M
ATENOLOL+SYRSPE
ND SF 3 ST; M
atenolol-chlorthalidone 1 M
Last Updated 10/1/19
46
Drug Name Drug
Category
Limits/
Required
digoxin injection 6 MSD
digoxin oral 1 M
DILATRATE-SR 2 M
diltiazem hcl er beads 1 M
diltiazem hcl er coated
beads 1 M
diltiazem hcl er oral
capsule extended
release 12 hour
1
M
diltiazem hcl er oral
capsule extended
release 24 hour 180
mg, 240 mg
1
M
diltiazem hcl
intravenous 6 MSD
diltiazem hcl oral 1 M
DILTIAZEM HCL-
DEXTROSE 6 ST; MSD
DILTIAZEM HCL-
SODIUM CHLORIDE 6 ST; MSD
dilt-xr 1 M
DIOVAN 3 ST; M
DIOVAN HCT 3 ST; M
disopyramide
phosphate 1 M
DIURIL 3 M
dobutamine hcl 6 MSD
dofetilide 1 M
dopamine hcl
intravenous 6 MSD
dopamine in d5w 6 MSD
doxazosin mesylate
oral 1 M; QL
DUTOPROL 3 ST; M
DYAZIDE 3 M
DYRENIUM 3 M
EDARBI 2 ST; M
EDARBYCLOR 2 ST; M
EDECRIN 3 M
enalapril maleate oral 1 M
Drug Name Drug
Category
Limits/
Required
CARDIZEM 3 ST; M
CARDIZEM CD 3 ST; M
CARDIZEM LA 3 ST; M
CARDURA 3 ST; M; QL
CAROSPIR 3 ST; M
cartia xt 1 M
carvedilol 1 M
carvedilol phosphate er 1 M
CATAPRES 3 M
CATAPRES-TTS-1 3 M; QL
CATAPRES-TTS-2 3 M; QL
CATAPRES-TTS-3 3 M; QL
chlorothiazide 1 M
chlorothiazide sodium 6 MSD
chlorthalidone 1 M
cholestyramine light 1 M
cholestyramine oral 1 M
choline fenofibrate 1 M; QL
CLEVIPREX 6 ST; MSD
clonidine 1 M; QL
clonidine hcl oral 1 M
colesevelam hcl 1 M
COLESTID 3 ST; M
COLESTID
FLAVORED 3 ST; M
colestipol hcl 1 M
COREG 3 ST; M
COREG CR 3 ST; M
CORGARD 3 ST; M
CORLANOR ORAL
TABLET 2 M; QL
CORLOPAM 6 MSD
COZAAR 3 ST; M
CRESTOR 3 ST; M; QL
DEMSER 2
DIBENZYLINE 3
digitek 1 M
digox 1 M
Last Updated 10/1/19
47
Drug Name Drug
Category
Limits/
Required
epinephrine pf injection
solution prefilled
syringe
1
EPINEPHRINE-
DEXTROSE 6 MSD
EPINEPHRINE-NACL 6 MSD
eplerenone 1 M
eprosartan mesylate 1 M
esmolol hcl intravenous
solution 100 mg/10ml 6 MSD
ESMOLOL HCL
INTRAVENOUS
SOLUTION 2000
MG/100ML, 2500
MG/250ML
6
ST; MSD
esmolol hcl-sodium
chloride 6 MSD
ethacrynate sodium 6 MSD
ethacrynic acid 1 M
EXFORGE 3 ST; M
EXFORGE HCT 3 ST; M
EZALLOR SPRINKLE 3 ST; M
ezetimibe 1 M
ezetimibe-simvastatin 1 M; QL
felodipine er 1 M
fenofibrate micronized 1 M; QL
fenofibrate oral capsule
134 mg, 200 mg, 67 mg 1 M; QL
fenofibrate oral capsule
150 mg, 50 mg 3 M; QL
fenofibrate oral tablet 1 M; QL
fenofibric acid 1 M; QL
FENOGLIDE 3 ST; M; QL
FIBRICOR 3 ST; M; QL
FIRST -
METOPROLOL 3 ST; M
FIRST-ATENOLOL 3 ST; M
flecainide acetate 1 M
FLOLIPID 3 ST; M
fluvastatin sodium 5 M; ACA; QL
Drug Name Drug
Category
Limits/
Required
enalaprilat 6 MSD
enalapril-
hydrochlorothiazide 1 M
ENTRESTO 2 M; QL
EPANED 3 M
EPHEDRINE
SULFATE
(PRESSORS)
3
ephedrine sulfate
injection 6 MSD
ephedrine sulfate
intravenous solution 6 MSD
EPHEDRINE
SULFATE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
EPHEDRINE
SULFATE-NACL 6 MSD
EPINEPHRINE HCL-
DEXTROSE 6 MSD
EPINEPHRINE HCL-
NACL INTRAVENOUS
SOLUTION 1-0.9
MG/250ML-%, 2-0.9
MG/250ML-%, 4-0.9
MG/250ML-%, 8-0.9
MG/250ML-%
6
MSD
EPINEPHRINE HCL-
NACL INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
100-0.9 MCG/10ML-%,
1000-0.9 MCG/10ML-
%, 160-0.9 MCG/10ML-
%
6
MSD
epinephrine injection
solution 1
EPINEPHRINE
INJECTION
SOLUTION
PREFILLED SYRINGE
3
epinephrine pf injection
solution 6 MSD
Last Updated 10/1/19
48
Drug Name Drug
Category
Limits/
Required
KAPSPARGO
SPRINKLE 3 ST; M
labetalol hcl
intravenous solution 6 MSD
LABETALOL HCL
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
ST; MSD
labetalol hcl oral 1 M
LANOXIN INJECTION 6 MSD
LANOXIN ORAL 3 M
LANOXIN PEDIATRIC 6 MSD
LASIX 3 M
LESCOL XL 3 ST; M; QL
LEVOPHED 6 MSD
LIPITOR 3 ST; M; QL
LIPOFEN 2 ST; M; QL
lisinopril oral 1 M
lisinopril-
hydrochlorothiazide 1 M
LIVALO 2 ST; M; QL
LOPID 3 ST; M; QL
LOPRESSOR 3 ST; M
LOPRESSOR HCT 3 ST; M
losartan potassium 1 M
losartan potassium-hctz 1 M
LOTENSIN 3 M
LOTENSIN HCT 3 ST; M
LOTREL 3 ST; M
lovastatin 5 M; ACA; QL
LOVAZA 3 PA; M
mannitol intravenous 6 MSD
matzim la 1 M
MAXZIDE 3 M
MAXZIDE-25 3 M
methyldopa 1 M
methyldopa-
hydrochlorothiazide 1 M
metolazone 1 M
Drug Name Drug
Category
Limits/
Required
fluvastatin sodium er 5 M; ACA; QL
fosinopril sodium 1 M
fosinopril sodium-hctz 1 M
FUROSEMIDE IN
SODIUM CHLORIDE 6 MSD
furosemide injection 6 MSD
furosemide oral 1 M
gemfibrozil oral 1 M; QL
GIAPREZA 6 MSD
GONITRO 3 M
guanfacine hcl 1 M
HEMANGEOL 3 ST; M; S
hydralazine hcl
injection 6 MSD
hydralazine hcl oral 1 M
hydrochlorothiazide
oral 1 M
HYZAAR 3 ST; M
indapamide 1 M
INDERAL LA 3 ST; M
INDERAL XL 3 ST; M
INNOPRAN XL 3 ST; M
INSPRA 3 M
irbesartan 1 M
irbesartan-
hydrochlorothiazide 1 M
isoproterenol hcl
injection 6 MSD
ISORDIL TITRADOSE 3 M
isosorbide dinitrate 1 M
isosorbide dinitrate er 1 M
isosorbide mononitrate 1 M
isosorbide mononitrate
er 1 M
isoxsuprine hcl oral 1 M
isradipine 1 M
ISUPREL 6 MSD
JUXTAPID 3 PA; M; S; QL
Last Updated 10/1/19
49
Drug Name Drug
Category
Limits/
Required
nifedipine oral 1 M
nimodipine oral 1 M
NIPRIDE RTU 6 MSD
nisoldipine er 1 M
NITRO-BID 1 M
NITRO-DUR 3 M
nitroglycerin er oral
capsule extended
release 2.5 mg
1
M
nitroglycerin in d5w 6 MSD
nitroglycerin
intravenous 6 MSD
nitroglycerin sublingual 1 M
nitroglycerin
transdermal 1 M
nitroglycerin
translingual 1 M
NITROLINGUAL 3 M
NITROMIST 3 M
NITROPRESS 6 MSD
nitroprusside sodium 6 MSD
NITROSTAT 3 M
nitro-time 1 M
norepinephrine
bitartrate intravenous 6 MSD
NOREPINEPHRINE-
DEXTROSE
INTRAVENOUS
SOLUTION
6
MSD
NOREPINEPHRINE-
SODIUM CHLORIDE
INTRAVENOUS
SOLUTION 16-0.9
MG/250ML-%, 16-0.9
MG/500ML-%, 4-0.9
MG/250ML-%, 8-0.9
MG/250ML-%, 8-0.9
MG/500ML-%
6
MSD
Drug Name Drug
Category
Limits/
Required
metoprolol succinate er 1 M
metoprolol tartrate
intravenous 6 MSD
metoprolol tartrate oral 1 M
METOPROLOL-HCTZ
ER ORAL TABLET
EXTENDED RELEASE
24 HOUR 100-12.5
MG, 50-12.5 MG
3
ST; M
metoprolol-
hydrochlorothiazide 1 M
mexiletine hcl oral 1 M
MICARDIS 3 ST; M
MICARDIS HCT 3 ST; M
midodrine hcl 1
milrinone lactate 6 MSD
milrinone lactate in
dextrose 6 MSD
MINIPRESS 3 M
minitran 1 M
minoxidil oral 1 M
moexipril hcl 1 M
MULTAQ 3 M
nadolol oral 1 M
NEXTERONE 6 MSD
niacin
(antihyperlipidemic) 1
niacin er
(antihyperlipidemic) 1 M
NIACOR 3
NIASPAN 3 M
NICARDIPINE HCL IN
NACL INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
ST; MSD
nicardipine hcl
intravenous 6 MSD
nicardipine hcl oral 1 M
nifedipine er 1 M
nifedipine er osmotic
release 1 M
Last Updated 10/1/19
50
Drug Name Drug
Category
Limits/
Required
PHENYLEPHRINE
HCL-DEXTROSE
INTRAVENOUS
SOLUTION 20-5
MG/250ML-%, 8-5
MG/100ML-%
6
MSD
PHENYLEPHRINE
HCL-NACL
INTRAVENOUS
SOLUTION 100-0.9
MG/100ML-%, 20-0.9
MG/250ML-%, 25-0.9
MG/250ML-%, 30-0.9
MG/250ML-%, 40-0.9
MG/250ML-%, 50-0.9
MG/250ML-%, 80-0.9
MG/250ML-%
6
MSD
PHENYLEPHRINE
HCL-NACL
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
0.2-0.9 MG/5ML-%,
0.4-0.9 MG/10ML-%,
0.5-0.9 MG/5ML-%,
0.8-0.9 MG/10ML-%, 1-
0.9 MG/10ML-%, 20-
0.9 MG/50ML-%, 5-0.9
MG/50ML-%
6
MSD
pindolol 1 M
PRALUENT 2 PA; M; QL
PRAVACHOL ORAL
TABLET 20 MG, 40
MG
3
ST; M; QL
pravastatin sodium 5 M; ACA; QL
prazosin hcl oral 1 M
PRESTALIA 3 ST; M
prevalite 1 M
PRINIVIL 3 M
procainamide hcl
injection 6 MSD
PROCARDIA 3 ST; M
PROCARDIA XL 3 ST; M
propafenone hcl 1 M
propafenone hcl er 1 M
Drug Name Drug
Category
Limits/
Required
NOREPINEPHRINE-
SODIUM CHLORIDE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
0.16-0.9 MG/10ML-%
6
MSD
NORPACE 3 M
NORPACE CR 3 M
NORTHERA 4 PA; S
NORVASC 3 ST; M
NYMALIZE 3 ST; M
olmesartan medoxomil
oral 1 M
olmesartan medoxomil-
hctz 1 M
olmesartan-amlodipine-
hctz 1 M
OMEGA-3/D-3
WELLNESS PACK 3 M
omega-3-acid ethyl
esters 1 PA; M
osmitrol 6 MSD
pacerone 1 M
papaverine hcl injection 1
pentoxifylline er 1 M
perindopril erbumine 1 M
phenoxybenzamine hcl
oral 1
phentolamine mesylate
injection 6 MSD
phenylephrine hcl
injection solution 10
mg/ml
6
MSD
phenylephrine hcl
intravenous solution 6 MSD
PHENYLEPHRINE
HCL INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
Last Updated 10/1/19
51
Drug Name Drug
Category
Limits/
Required
SOTALOL HCL
INTRAVENOUS 6 ST; MSD
sotalol hcl oral 1 M
SOTRADECOL 6 MSD
SOTYLIZE 2 ST; M
spironolactone oral 1 M
spironolactone-hctz 1 M
SULAR 3 ST; M
SURE RESULT O3D3
SYSTEM 3 M
TARKA 3 ST; M
taztia xt 1 M
TEKTURNA 2 ST; M
TEKTURNA HCT 2 ST; M
telmisartan 1 M
telmisartan-amlodipine 1 M
telmisartan-hctz 1 M
TENORETIC 100 3 ST; M
TENORETIC 50 3 ST; M
TENORMIN 3 ST; M
TIAZAC 3 ST; M
TIKOSYN 3 ST; M
timolol maleate oral 1 M
TOPROL XL 3 ST; M
torsemide 1 M
trandolapril 1 M
trandolapril-verapamil
hcl er 1 M
triamterene oral 1 M
triamterene-hctz 1 M
TRIBENZOR 3 ST; M
TRICOR 3 ST; M; QL
TRILIPIX 3 ST; M; QL
TWYNSTA 3 ST; M
valsartan 1 M
valsartan-
hydrochlorothiazide 1 M
VARITHENA 6 MSD
Drug Name Drug
Category
Limits/
Required
propranolol hcl er 1 M
propranolol hcl
intravenous 6 MSD
propranolol hcl oral 1 M
propranolol-hctz 1 M
PROSTIN VR 3
QBRELIS 3 M
QUESTRAN 3 ST; M
QUESTRAN LIGHT 3 ST; M
quinapril hcl 1 M
quinapril-
hydrochlorothiazide 1 M
quinidine gluconate er 1 M
quinidine sulfate 1 M
ramipril 1 M
RANEXA 2 M
ranolazine er 1 M
RECTIV 2
REPATHA 3 PA; M; QL
REPATHA
PUSHTRONEX
SYSTEM
3
PA; M; QL
REPATHA
SURECLICK 3 PA; M; QL
rosuvastatin calcium
oral tablet 10 mg, 5 mg 5 M; ACA; QL
rosuvastatin calcium
oral tablet 20 mg, 40
mg
1
M; QL
RYTHMOL SR 3 M
simvastatin oral tablet
10 mg, 20 mg, 40 mg, 5
mg
5
M; ACA; QL
simvastatin oral tablet
80 mg 1 M; QL
SODIUM DIURIL 6 MSD
SODIUM EDECRIN 6 MSD
sorine 1 M
sotalol hcl (af) 1 M
Last Updated 10/1/19
52
Drug Name Drug
Category
Limits/
Required
DAYTRANA 2 ST; M; QL
DESOXYN 3 ST; M; QL
DEXEDRINE 3 ST; M; QL
dexmethylphenidate hcl 1 M; QL
dexmethylphenidate hcl
er 1 M; QL
dextroamphetamine
sulfate 1 M; QL
dextroamphetamine
sulfate er 1 M; QL
DYANAVEL XR 3 ST; M; QL
EVEKEO 3 ST; M; QL
EVEKEO ODT 3 ST; M; QL
FOCALIN 3 ST; M; QL
FOCALIN XR 3 ST; M; QL
guanfacine hcl er 1 M; QL
INTUNIV 3 ST; M; QL
JORNAY PM 3 ST; M; QL
KAPVAY 3 ST; M; QL
metadate er 1 M; QL
methamphetamine hcl 1 M; QL
METHYLIN 3 ST; M; QL
methylphenidate hcl er
(cd) 1 M; QL
methylphenidate hcl er
(la) 1 M; QL
methylphenidate hcl er
oral tablet extended
release 10 mg, 18 mg,
20 mg, 27 mg, 36 mg,
54 mg
1
M; QL
methylphenidate hcl er
oral tablet extended
release 24 hour
1
M; QL
methylphenidate hcl er
oral tablet extended
release 72 mg
3
M; QL
methylphenidate hcl
oral 1 M; QL
MYDAYIS 2 M; QL
PROCENTRA 1 ST; M; QL
Drug Name Drug
Category
Limits/
Required
VASCEPA 2 PA; M
VASERETIC 3 ST; M
VASOTEC 3 M
VAZCULEP 6 MSD
VECAMYL 3 M; S
verapamil hcl er 1 M
verapamil hcl
intravenous 6 MSD
verapamil hcl oral 1 M
VERELAN 3 ST; M
VERELAN PM 3 ST; M
VYNDAQEL 3 M; QL
VYTORIN 3 ST; M; QL
WELCHOL 3 ST; M
ZESTORETIC 3 ST; M
ZESTRIL 3 M
ZETIA 3 ST; M
ZIAC 3 ST; M
ZOCOR 3 ST; M; QL
ZYPITAMAG 3 ST; M
Central Nervous
System Agents -
Drugs for Attention
Deficit Disorder
ADDERALL 3 ST; M; QL
ADDERALL XR 3 ST; M; QL
ADHANSIA XR 3 ST; M; QL
ADZENYS ER 3 ST; M; QL
ADZENYS XR-ODT 3 ST; M; QL
amphetamine sulfate 1 PA; M; QL
amphetamine-
dextroamphetamine 1 M; QL
amphetamine-
dextroamphetamine er 1 M; QL
APTENSIO XR 3 ST; M; QL
atomoxetine hcl 1 M; QL
clonidine hcl er 1 M; QL
CONCERTA 3 ST; M; QL
COTEMPLA XR-ODT 3 ST; M; QL
Last Updated 10/1/19
53
Drug Name Drug
Category
Limits/
Required
MAVENCLAD (9
TABS) 3
MAYZENT 4 PA; M; S; QL
MAYZENT STARTER
PACK 4 PA; S; QL
OCREVUS 6 MSD; QL
PLEGRIDY 3 M; S; QL
PLEGRIDY STARTER
PACK 3 S; QL
REBIF 3 M; S; QL
REBIF REBIDOSE 3 M; S; QL
REBIF REBIDOSE
TITRATION PACK 3 M; S; QL
REBIF TITRATION
PACK 3 M; S; QL
TECFIDERA
STARTER PACK 3 S; QL
TECFIDERA ORAL
CAPSULE DELAYED
RELEASE
3
M; S; QL
TYSABRI 6 MSD; QL
Central Nervous
System Agents -
Miscellaneous
ADDYI 3 PA; M; QL
ANECTINE 6 MSD
atracurium besylate 6 MSD
AUSTEDO 3 PA; M; S; QL
CAFCIT 6 MSD
caffeine citrate
intravenous 6 MSD
caffeine citrate oral 1
CAFFEINE-SODIUM
BENZOATE 6 MSD
cisatracurium besylate
(pf) 6 MSD
cisatracurium besylate
intravenous solution 20
mg/10ml
6
MSD
GRALISE 2 ST; M; QL
GRALISE STARTER 2 ST; QL
Drug Name Drug
Category
Limits/
Required
QUILLICHEW ER 2 ST; M; QL
QUILLIVANT XR 2 ST; M; QL
relexxii 3 M; QL
RITALIN 3 ST; M; QL
RITALIN LA 3 ST; M; QL
STRATTERA 3 ST; M; QL
VYVANSE 2 M; QL
zenzedi oral tablet 10
mg, 5 mg 1 M; QL
ZENZEDI ORAL
TABLET 15 MG, 2.5
MG, 20 MG, 30 MG,
7.5 MG
3
ST; M; QL
Central Nervous
System Agents -
Drugs for Multiple
Sclerosis
AMPYRA 4 ST; M; S; QL
AUBAGIO 4 M; S; QL
AVONEX PEN 3 M; S; QL
AVONEX PREFILLED 3 M; S; QL
BETASERON 3 ST; M; S; QL
COPAXONE 3 ST; M; S; QL
dalfampridine er 1 PA; M; S; QL
EXTAVIA 4 ST; M; S; QL
GILENYA 3 M; S; QL
glatiramer acetate 1 M; S; QL
glatopa 1 M; S; QL
LEMTRADA 6 MSD
MAVENCLAD (10
TABS) 3 PA
MAVENCLAD (4
TABS) 3
MAVENCLAD (5
TABS) 3
MAVENCLAD (6
TABS) 3
MAVENCLAD (7
TABS) 3
MAVENCLAD (8
TABS) 3
Last Updated 10/1/19
54
Drug Name Drug
Category
Limits/
Required
VECURONIUM
BROMIDE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
vecuronium bromide
intravenous solution
reconstituted
6
MSD
XENAZINE 3 ST; M; S
Dental and Oral
Agents - Drugs for
Mouth and Throat
Conditions
ARESTIN 6 MSD
cavarest 1 M
cevimeline hcl 1 M
chlorhexidine gluconate
mouth/throat 1
clinpro 5000 3 M
DEBACTEROL 3
denta 5000 plus 1 M
dentagel 1 M
easygel 1
EVOXAC 3 M
FIRST-MOUTHWASH
BLM 2
fluoridex 3 M
fluoridex daily renewal 1 M
fluoridex enhanced
whitening 3 M
fluoridex sensitivity
relief 1
KEPIVANCE 6 MSD
lidocaine hcl
mouth/throat 1
lidocaine viscous
mouth/throat solution 2
%
1
NAFRINSE DAILY
ACIDULATED 3
NAFRINSE
DAILY/NEUTRAL 3 M
Drug Name Drug
Category
Limits/
Required
HORIZANT 3 ST; M; QL
INGREZZA ORAL
CAPSULE 3 PA; M; S; QL
INGREZZA ORAL
CAPSULE THERAPY
PACK
3
PA; QL
LYRICA 2 ST; M; QL
LYRICA CR 3 ST; M; QL
NIMBEX 6 MSD
NUEDEXTA 2 M
ONPATTRO 6 M; MSD
pancuronium bromide 6 MSD
pregabalin oral 1 M; QL
QUELICIN 6 MSD
RADICAVA 6 M; MSD
RILUTEK 3 M; QL
riluzole 1 M; QL
rocuronium bromide
intravenous solution 6 MSD
ROCURONIUM
BROMIDE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
100 MG/10ML, 50
MG/5ML, 75 MG/7.5ML
6
MSD
SAVELLA 2 M; QL
SAVELLA TITRATION
PACK 2 QL
succinylcholine chloride
injection solution 6 MSD
SUCCINYLCHOLINE
CHLORIDE
INJECTION
SOLUTION
PREFILLED SYRINGE
3
SUCCINYLCHOLINE
CHLORIDE
INTRAVENOUS
6
MSD
TEGSEDI 4 PA; M; S
tetrabenazine 3 PA; M; S
TIGLUTIK 3 M; QL
Last Updated 10/1/19
55
Drug Name Drug
Category
Limits/
Required
acitretin 1
ACTIVE-PREP KIT IV 3
ACTIVE-PREP KIT V 3
ACTIVE-TRAMADOL 3
ACZONE 3 ST
adapalene external
cream 1 QL
adapalene external gel 1 QL
ADAPALENE
EXTERNAL LOTION 3 ST; QL
ADAPALENE
EXTERNAL PAD 3 ST
ADAPALENE
EXTERNAL
SOLUTION
1
ST
adapalene-benzoyl
peroxide 1 QL
AKTIPAK 3 ST
ALA SCALP 3 ST
ala-cort 1
alclometasone
dipropionate 1
ALCOHOL PREP
PADS EXTERNAL 70
%
2
ALDARA 3 QL
ALTRENO 3
amcinonide 1
AMELUZ 6 MSD
ammonium lactate
external 1
amnesteem 1 QL
APEXICON E 1 ST; QL
AQUACEL AG BURN 3
arzol silver nit
applicators 1
ATRALIN 3 QL
AVAR LS CLEANSER 3 ST
AVAR-E LS 3 ST
avita external cream 1 QL
Drug Name Drug
Category
Limits/
Required
NAFRINSE WEEKLY 3 M
neutral sodium fluoride 1 M
NUMOISYN
MOUTH/THROAT
LOZENGE
3
oralone 1
paroex 1
PERIDEX 3
periogard 1
pilocarpine hcl oral 1 M
PREVIDENT 5000
BOOSTER PLUS 3 M
PREVIDENT 5000
DRY MOUTH 3 M
PREVIDENT 5000
ENAMEL PROTECT 3
PREVIDENT 5000
ORTHO DEFENSE 3 M
PREVIDENT 5000
PLUS 3 M
PREVIDENT 5000
SENSITIVE 3
PREVIDENT DENTAL 3 M
prevident mouth/throat 1 M
REMESENSE 3
SALAGEN 3 M
sf 1 M
sf 5000 plus 1 M
sodium fluoride 5000
plus 1 M
sodium fluoride dental 1 M
topex topical anesthetic 1
triamcinolone acetonide
mouth/throat 1
Dermatological
Agents - Drugs for
Skin Conditions
A.A.G.C. KIT IN
TERODERM 3
ABSORICA 2 QL
ACANYA 2 ST; QL
Last Updated 10/1/19
56
Drug Name Drug
Category
Limits/
Required
bpo 1
BRYHALI 3 ST
calcipotriene 1 QL
calcipotriene-betameth
diprop 1 QL
calcitrene 1 QL
calcitriol external 1 QL
CANTHARIDIN
EXTERNAL 3
CAPEX 3 ST; QL
CARAC 2 QL
claravis 1 QL
CLEOCIN-T 3 ST
clindacin etz external
swab 1
clindacin-p 1
CLINDAGEL 3 ST
clindamycin phosphate-
benzoyl peroxide 1 QL
clindamycin phosphate
external foam 1
clindamycin phosphate
external lotion 1
clindamycin phosphate
external solution 1
clindamycin phosphate
external swab 1
CLINDAMYCIN
PHOSPHATE GEL 1 %
EXTERNAL
3
ST
clindamycin phosphate
gel 1 % external 1
clindamycin-tretinoin 1
CLINOIN 3
clobetasol prop
emollient base 1
clobetasol propionate e 1
clobetasol propionate
emulsion 1
clobetasol propionate
external 1
Drug Name Drug
Category
Limits/
Required
avita external gel 3
azelaic acid external 1
AZELEX 3 ST; QL
balsam peru-castor oil 3
BENZAC AC WASH 3 ST
BENZACLIN 3 ST; QL
BENZACLIN WITH
PUMP 3 ST; QL
BENZAMYCIN 3 ST
benzepro external foam
5.3 % 1
benzepro foaming
cloths 1
benzepro short contact 1
BENZIQ 3 ST
BENZIQ LS 3 ST
benziq wash 3
BENZOYL PEROX-
HYDROCORTISONE 3 ST
benzoyl peroxide
external foam 9.8 % 1
BENZOYL PEROXIDE
EXTERNAL GEL 6.5
%, 8 %
3
BENZOYL PEROXIDE
FORTE- HC 3
benzoyl peroxide-
erythromycin 1
beser external lotion 1
betamethasone
dipropionate aug 1
betamethasone
dipropionate external 1
betamethasone
valerate external 1
BOTOX COSMETIC 6 MSD
bp cleansing wash 1
bp foam 1
bp wash external liquid
2.5 % 3
BPCO 3
Last Updated 10/1/19
57
Drug Name Drug
Category
Limits/
Required
diclofenac sodium
transdermal gel 3 % 1 PA; QL
DIFFERIN 3 ST; QL
diflorasone diacetate
external cream 1 QL
diflorasone diacetate
external ointment 1
DIPROLENE 3 ST
DIPROLENE AF 3 ST
DOVONEX 3 QL
doxepin hcl external 1 QL
doxycycline 3 ST
dritho-creme hp 1
DRYSOL 3
DUAC 3 ST; QL
DUOBRII 3
DUPIXENT
SUBCUTANEOUS
SOLUTION
PREFILLED SYRINGE
200 MG/1.14ML
3
PA; M; S; QL
DUPIXENT
SUBCUTANEOUS
SOLUTION
PREFILLED SYRINGE
300 MG/2ML
3
PA; S; QL
EFUDEX 3
ELIDEL 2 ST; QL
ELOCON 3 ST
ENOVARX-
TRAMADOL 3
ENSTILAR 2 QL
ENZOCLEAR 3
EPIDUO 3 ST; QL
EPIDUO FORTE 2 ST
EPIFOAM 3 ST
ery 1
ERYGEL 1
erythromycin external 1
EUCRISA 3 ST; QL
Drug Name Drug
Category
Limits/
Required
CLOBEX 3 ST
CLOBEX SPRAY 3 ST
clocortolone pivalate 3 QL
clodan external
shampoo 1
CLODERM 3 ST; QL
clotrimazole-
betamethasone 1
coal tar external 2
CONDYLOX 3
CORDRAN
EXTERNAL CREAM 3 ST
CORDRAN
EXTERNAL LOTION 3 ST
CORDRAN
EXTERNAL
OINTMENT
3
ST
CORDRAN
EXTERNAL TAPE 3 ST; QL
CORTANE-B 3
CORTISPORIN 3
curad hydrocortisone 1 OTC
CUTIVATE 3 ST
dapsone external 1
DERMA-SMOOTHE/FS
BODY 3 ST; QL
DERMA-SMOOTHE/FS
SCALP 3 ST; QL
DERMULCERA 3
DESONATE 3 ST
desonide external 1 QL
DESOWEN 3 ST; QL
desoximetasone
external cream 1 QL
desoximetasone
external gel 1 QL
desoximetasone
external liquid 1
desoximetasone
external ointment 1 QL
Last Updated 10/1/19
58
Drug Name Drug
Category
Limits/
Required
GORDOFILM 3
grafco silver nit
applicator 1
halcinonide 1
halobetasol propionate
external cream 1 QL
HALOBETASOL
PROPIONATE
EXTERNAL FOAM
3
ST
halobetasol propionate
external ointment 1 QL
HALOG 3 ST
HYALUCIL-4 3
HYDRO 35 3
HYDRO 40 3
hydrocortisone ace-
pramoxine external 1
hydrocortisone butyr
lipo base 1
hydrocortisone butyrate 1
hydrocortisone external
cream 1 %, 2.5 % 1
hydrocortisone external
lotion 2.5 % 1
hydrocortisone external
ointment 1 %, 2.5 % 1
hydrocortisone valerate 1
imiquimod external 1 QL
IMIQUIMOD PUMP 3 ST; QL
IMPOYZ 3 ST
INOVA 4/1 ACNE
CONTROL THERAPY 3 ST
INOVA EXTERNAL KIT
4 & 5 % 3 ST
isotretinoin oral 1 QL
kelo-cote external gel 6 MSD; OTC
KENALOG EXTERNAL 3 ST
KERAGEL 6 MSD
KERALYT EXTERNAL
GEL 6 % 3
Drug Name Drug
Category
Limits/
Required
EVOCLIN 3 ST
FABIOR 3 PA; QL
FINACEA EXTERNAL
FOAM 2 ST
FINACEA EXTERNAL
GEL 3 ST
fluocinolone acetonide
body 1 QL
fluocinolone acetonide
external cream 0.01 % 1
fluocinolone acetonide
external cream 0.025 % 1 QL
fluocinolone acetonide
external ointment 1 QL
fluocinolone acetonide
external solution 1 QL
fluocinolone acetonide
scalp 1 QL
fluocinonide emulsified
base 1
fluocinonide external
cream 0.05 % 1
fluocinonide external
cream 0.1 % 1 QL
fluocinonide external
gel 1
fluocinonide external
ointment 1
fluocinonide external
solution 1
FLUOROPLEX 3 QL
FLUOROURACIL
EXTERNAL CREAM
0.5 %
3
ST; QL
fluorouracil external
cream 5 % 1
fluorouracil external
solution 1 QL
flurandrenolide 1
fluticasone propionate
external 1
glycolic acid solution 2
Last Updated 10/1/19
59
Drug Name Drug
Category
Limits/
Required
ONEXTON 2 ST; QL
ORACEA 2 ST
OVACE PLUS
EXTERNAL LOTION 3 ST
OVACE PLUS
EXTERNAL
SHAMPOO
3
OVACE PLUS WASH
EXTERNAL LIQUID 3
OVACE WASH 3
OXSORALEN ULTRA 3
PANDEL 3 ST
PICATO 2 QL
pimecrolimus 1 QL
PLEXION CLEANSER 3 ST
PLEXION EXTERNAL
LOTION 3 ST
podocon 3
podofilox external 1
PRAMOSONE 3 ST
prednicarbate 1
PROTOPIC 3 ST; QL
PRUDOXIN 1 ST; QL
PSORCON 3 ST; QL
pyrogallic acid 3
QBREXZA 2 PA; QL
REGRANEX 2 QL
RETIN-A EXTERNAL
CREAM 0.025 % 3 QL
RETIN-A EXTERNAL
CREAM 0.05 %, 0.1 % 3
RETIN-A EXTERNAL
GEL 3
RETIN-A MICRO GEL
0.04 %, 0.1 % 3
RETIN-A MICRO
PUMP 3
RHOFADE 3 PA
RIAX 3
rosadan external cream 1
Drug Name Drug
Category
Limits/
Required
KERAMATRIX
REPLICINE 5CMX5CM 6 MSD
KLARON 3 ST
LAC-HYDRIN 3
lactic acid e 1
lactic acid external 1
latrix xm 1
LAVARE WOUND
WASH 3
LEVULAN KERASTICK 6 MSD
LEXETTE 3 ST
LOCOID 3 ST
LOCOID LIPOCREAM 3 ST
LOTRISONE 3
LUXIQ 3 ST
methoxsalen oral 1
methoxsalen rapid 1
methyl salicylate
external liquid 1
METROCREAM 3 ST
METROGEL 3 ST
METROLOTION 3 ST
metronidazole external 1
MICORT-HC 3 ST
MICROCYN
EXTERNAL GEL 3
MICROCYN SKIN AND
WOUND 3
MIRVASO 2 PA
mometasone furoate
external 1
myorisan 1 QL
NEO-SYNALAR
EXTERNAL CREAM 3
neuac external gel 1 QL
nolix 1
NORITATE 3 ST
OLUX 3 ST
OLUX-E 3 ST
Last Updated 10/1/19
60
Drug Name Drug
Category
Limits/
Required
sulfacetamide sodium-
sulfur external liquid
10-2 %, 9-4 %, 9.8-4.8
%
1
sulfacetamide sodium-
sulfur external lotion
10-5 %
1
sulfacetamide sodium-
sulfur external pad 1
sulfacetamide sodium-
sulfur external
suspension
1
sulfacetamide-sulfur in
urea 1
sulfacleanse 8/4 1
synalar external cream 1 QL
synalar external
ointment 3 QL
SYNALAR EXTERNAL
SOLUTION 3 ST; QL
TACLONEX
EXTERNAL
OINTMENT
3
QL
TACLONEX
EXTERNAL
SUSPENSION
2
QL
tacrolimus external 1 QL
tazarotene external 1 PA; QL
TAZORAC CREAM
0.05 % EXTERNAL 2 PA; QL
TAZORAC EXTERNAL
CREAM 0.1 % 3 PA; QL
TAZORAC EXTERNAL
GEL 2 PA; QL
TEMOVATE 3 ST
TEXACORT 3 ST
TOLAK 3 QL
TOPICORT 3 ST; QL
TOPICORT SPRAY 3 ST
tretinoin external cream
0.025 % 1 QL
Drug Name Drug
Category
Limits/
Required
rosadan external gel 1
SALEX 3
salicylic acid er 1
salicylic acid external
foam 1
salicylic acid external
gel 1
salicylic acid external
lotion 1
salicylic acid external
shampoo 1
salicylic acid-cleanser
external kit 6 % (lotion) 1
SALVAX 1
SALVAX DUO PLUS 3
SANTYL 2
selenium sulfide
external 1
SERNIVO 3 ST
sm hydrocortisone
external cream 1 % 1 OTC
sodium hyaluronate
external 1
sodium sulfacetamide 1
sodium sulfacetamide
wash liquid 10 %
external
1
SODIUM
SULFACETAMIDE
WASH LIQUID 10 %
EXTERNAL
1
SOOLANTRA 2 ST
SORIATANE 3
SORILUX 3 QL
sss 10-5 external foam 1
sulfacetamide sodium
(acne) 1
sulfacetamide sodium
external 1
sulfacetamide sodium-
sulfur external cream
10-2 %
1
Last Updated 10/1/19
61
Drug Name Drug
Category
Limits/
Required
XEROFORM OIL
EMULSION STRIP 3
XEROFORM
PETROLAT GAUZE
1"X8"
3
XEROFORM
PETROLAT GAUZE
5"X9"
3
XEROFORM
PETROLAT PATCH
2"X2"
3
XEROFORM
PETROLAT PATCH
4"X4"
3
XEROFORM
PETROLATUM ROLL
4"X9'
3
ZACARE 3 ST
zaclir cleansing 1
zenatane 1 QL
ZIANA 3 ST
ZONALON 3 ST; QL
ZYCLARA 3 ST; QL
ZYCLARA PUMP 3 ST; QL
Diabetes -
Antidiabetic Agents
acarbose oral 1 M
ACTOPLUS MET 3 ST; M; QL
ACTOS 3 M; QL
ADLYXIN 3 M; QL
ADLYXIN STARTER
PACK 3 QL
ALOGLIPTIN
BENZOATE 3 ST; M; QL
ALOGLIPTIN-
METFORMIN HCL 3 ST; M; QL
ALOGLIPTIN-
PIOGLITAZONE 3 M; QL
AMARYL 3 M
AVANDIA 3 ST; M; QL
BYDUREON 2 ST; M; QL
Drug Name Drug
Category
Limits/
Required
tretinoin external cream
0.05 %, 0.1 % 1
tretinoin external gel
0.01 %, 0.025 % 1
tretinoin external gel
0.05 % 1 QL
tretinoin microsphere 1
tretinoin microsphere
pump 1
triamcinolone acetonide
external 1
TRIANEX 1
TRI-CHLOR 1
triderm 1
TRIDESILON 3 ST; QL
turpentine external 2
ULTRAVATE 3 ST
umecta mousse 1
urea external cream 39
%, 45 % 1
urea hydrating 1
urea in zn undecyl-
lactic acid 1
urea nail 1
VANOS 3 ST; QL
VANOXIDE-HC 3 ST
vashe cleansing 6 MSD
VECTICAL 3 QL
VELTIN 3 ST
VENELEX 3
VERDESO 3 ST
VEREGEN 3
VIRASAL 3
XERAC AC 3
XERFORM OIL
EMULSION ROLL 3
XEROFORM OIL
EMULSION 2"X2" 3
XEROFORM OIL
EMULSION GAUZE 3
Last Updated 10/1/19
62
Drug Name Drug
Category
Limits/
Required
METFORMIN HCL
ORAL SOLUTION 3 ST; M; QL
metformin hcl oral
tablet 1 M
miglitol 1 M
nateglinide 1 M
NESINA 3 ST; M; QL
ONGLYZA 3 ST; M; QL
OSENI 3 M; QL
OZEMPIC 2 ST; M; QL
pioglitazone hcl 1 M; QL
pioglitazone hcl-
glimepiride 1 M; QL
pioglitazone hcl-
metformin hcl 1 M; QL
PRECOSE 3 M
QTERN 3 ST; M
repaglinide 1 M
repaglinide-metformin
hcl 1 M; QL
RIOMET 3 ST; M; QL
SEGLUROMET 2 ST; M
SOLIQUA 2 ST; M; QL
STARLIX 3 M
STEGLATRO 2 ST; M
STEGLUJAN 3 ST; M
SYMLINPEN 120 2 ST; M; QL
SYMLINPEN 60 2 ST; M; QL
SYNJARDY 2 ST; M
SYNJARDY XR 2 ST; M
tolbutamide 1 M
TRADJENTA 2 ST; M; QL
TRULICITY 2 ST; M; QL
VICTOZA 3 M; QL
XIGDUO XR ORAL
TABLET EXTENDED
RELEASE 24 HOUR
10-1000 MG, 10-500
MG, 5-1000 MG, 5-500
MG
2
ST; M; QL
Drug Name Drug
Category
Limits/
Required
BYDUREON BCISE
AUTOINJECTOR 2 ST; M; QL
BYETTA 10 MCG PEN 2 ST; M; QL
BYETTA 5 MCG PEN 2 ST; M; QL
CYCLOSET 3 M; QL
DUETACT 3 ST; M; QL
FARXIGA 2 ST; M; QL
FORTAMET 3 ST; M
glimepiride 1 M
glipizide er 1 M
glipizide ir 1 M
glipizide xl 1 M
glipizide-metformin hcl 1 M
GLUCOPHAGE 3 ST; M
GLUCOPHAGE XR 3 ST; M
GLUCOTROL 3 M
GLUCOTROL XL 3 M
GLUMETZA 3 ST; M; QL
glyburide micronized 1 M
glyburide oral 1 M
glyburide-metformin 1 M
GLYNASE 3 M
GLYSET 3 M
GLYXAMBI 2 ST; M
INVOKAMET 2 ST; M; QL
INVOKAMET XR 2 ST; M; QL
INVOKANA 2 ST; M; QL
JANUMET 2 ST; M; QL
JANUMET XR 2 ST; M; QL
JANUVIA 2 ST; M; QL
JARDIANCE 2 ST; M; QL
JENTADUETO 2 ST; M; QL
JENTADUETO XR 2 ST; M
KAZANO 3 ST; M; QL
KOMBIGLYZE XR 3 ST; M; QL
metformin hcl er 1 M
metformin hcl er (mod) 1 ST; M; QL
metformin hcl er (osm) 1 ST; M
Last Updated 10/1/19
63
Drug Name Drug
Category
Limits/
Required
ACCU-CHEK
SMARTVIEW
CONTROL
3
OTC
ACCU-CHEK
SMARTVIEW TEST
STRIPS
3
ST; OTC; QL
ACCU-CHEK
SOFTCLIX LANCET
DEVICE KIT
2
OTC
AUTOLET LANCING
DEVICE 2 OTC
BAYER CONTOUR IN
VITRO LIQUID HIGH ,
LOW , NORMAL
3
OTC
BIOTEL CARE BLOOD
GLUCOSE SYST 3 ST; OTC; QL
CARETOUCH
LANCING/EJECTOR 2 OTC
CHEMSTRIP UGK 2 OTC
CONTOUR NEXT
CONTROL 3 OTC
CONTOUR NEXT
MONITOR 3 ST; OTC; QL
CONTOUR NEXT
TEST 3 ST; OTC; QL
CONTOUR TEST 3 ST; OTC; QL
DEXCOM G4 / G5 / G6
RECEIVER,
TRANSMITTER,
SENSOR (INCLUDING
PLATINUM,
PLATINUM
PEDIATRIC)
6
MSD; QL
DEXCOM G4 / G5 / G6
RECEIVER,
TRANSMITTER,
SENSOR (INCLUDING
PLATINUM,
PLATINUM
PEDIATRIC) DEVICE
6
MSD; QL
DIATHRIVE BLOOD
GLUCOSE METER 3 ST; OTC; QL
DIATHRIVE BLOOD
GLUCOSE TEST 3 ST; OTC; QL
Drug Name Drug
Category
Limits/
Required
XIGDUO XR ORAL
TABLET EXTENDED
RELEASE 24 HOUR
2.5-1000 MG
2
ST; M
XULTOPHY 2 ST; M; QL
Diabetes - Glucose
Monitoring
ACCU-CHEK AVIVA
DEVICE 3 OTC; QL
ACCU-CHEK AVIVA
CONNECT KIT
W/DEVICE
3
ST; OTC; QL
ACCU-CHEK AVIVA IN
VITRO 3 OTC
ACCU-CHEK AVIVA
PLUS 3 ST; OTC; QL
ACCU-CHEK
COMPACT PLUS
CARE KIT
3
OTC; QL
ACCU-CHEK
COMPACT PLUS
CONTROL
3
OTC
ACCU-CHEK
COMPACT PLUS
TEST STRIPS
3
ST; OTC; QL
ACCU-CHEK
FASTCLIX LANCET
KIT
2
OTC
ACCU-CHEK GUIDE 3 ST; OTC; QL
ACCU-CHEK GUIDE
CONTROL 3 OTC
ACCU-CHEK GUIDE
ME 3 ST; OTC; QL
ACCU-CHEK GUIDE
STRIP IN VITRO 3 OTC; QL
ACCU-CHEK GUIDE
STRIP IN VITRO 3 ST; OTC; QL
ACCU-CHEK
MULTICLIX LANCET
DEVICE KIT
2
OTC
ACCU-CHEK NANO
SMARTVIEW KIT
W/DEVICE
3
ST; OTC; QL
Last Updated 10/1/19
64
Drug Name Drug
Category
Limits/
Required
FREESTYLE LIBRE
SENSOR SYSTEM 6 MSD; QL
FREESTYLE LITE
TEST 3 ST; OTC; QL
FREESTYLE
PRECISION NEO
TEST
3
ST; OTC; QL
FREESTYLE TEST 3 ST; OTC; QL
GENTEEL LANCING
KIT (BLUE) 2 OTC
GLUCOCARD 01
SENSOR PLUS 3 ST; OTC; QL
GLUCOCARD
EXPRESSION TEST 3 ST; OTC; QL
GLUCOCARD SHINE
CONNEX 3 ST; OTC; QL
GLUCOCARD SHINE
EXPRESS 3 ST; OTC; QL
GLUCOCARD SHINE
TEST 3 ST; OTC; QL
GLUCOCARD VITAL
TEST 3 ST; OTC; QL
GUARDIAN CONNECT
TRANSMITTER 6 MSD; QL
GUARDIAN LINK 3
TRANSMITTER 6 MSD; QL
GUARDIAN REAL-
TIME SYSTEM 2 QL
HW EMBRACE PRO
GLUCOSE METER 3 ST; OTC; QL
HW EMBRACE PRO
GLUCOSE TEST 3 ST; OTC; QL
HW EMBRACE TALK
BLOOD GLUCOSE 3 ST; OTC; QL
HW EMBRACE TALK
GLUCOSE TEST 3 ST; OTC; QL
KETOCARE IN VITRO
STRIP 2 OTC
KETOSTIX 2 OTC
LANCETS 2 OTC
LANCETS KIT 2 OTC
Drug Name Drug
Category
Limits/
Required
DIATHRIVE GLUCOSE
CONTROL SOLN 3 ST; OTC
DIATHRIVE GLUCOSE
TEST 3 ST; OTC; QL
DIATHRIVE LANCING
DEVICE 2 ST; OTC
EASYMAX CONTROL 3 ST; OTC
EASYPLUS BLOOD
GLUCOSE TEST 3 ST; OTC; QL
EMBRACE TALK
BLOOD GLUCOSE 3 ST; OTC; QL
EMBRACE TALK
GLUCOSE CONTROL 3 ST; OTC
EMBRACE TALK
GLUCOSE TEST 3 ST; OTC; QL
EMBRACE TALK
MONITORING
SYSTEM
3
ST; OTC; QL
ENLITE GLUCOSE
SENSOR 6 MSD; QL
EVERSENSE
SENSOR/HOLDER 6 MSD; QL
EVERSENSE SMART
TRANSMITTER 6 MSD; QL
FORA GTEL BLOOD
GLUCOSE SYSTEM 3 ST; OTC; QL
FORA GTEL BLOOD
GLUCOSE TEST 3 ST; OTC; QL
FORTISCARE
CONTROL 3 ST; OTC
FREESTYLE
FREEDOM LITE 3 ST; OTC; QL
FREESTYLE
INSULINX SYSTEM 3 ST; OTC; QL
FREESTYLE
INSULINX TEST 3 ST; OTC; QL
FREESTYLE LIBRE 14
DAY READER 6 MSD; QL
FREESTYLE LIBRE 14
DAY SENSOR 6 MSD; QL
FREESTYLE LIBRE
READER 6 MSD; QL
Last Updated 10/1/19
65
Drug Name Drug
Category
Limits/
Required
PRECISION SOF-
TACT TEST 3 ST; OTC; QL
PRECISION XTRA
BLOOD GLUCOSE 3 ST; OTC; QL
PRECISION XTRA
DEVICE 3 OTC; QL
PRECISION XTRA KIT 3 OTC; QL
PRECISION XTRA
MONITOR 3 OTC; QL
PRODIGY NO
CODING BLOOD
GLUC
3
OTC; QL
RELION BLOOD
GLUCOSE TEST 3 ST; OTC; QL
RELION PREMIER
CLASSIC 3 OTC; QL
RELION PREMIER
TEST 3 ST; OTC; QL
RELION ULTIMA TEST 3 ST; OTC; QL
SOF-SENSOR 6 MSD; QL
SURESTEP PRO
HIGH GLUCOSE 3 OTC
SURESTEP PRO LOW
GLUCOSE 3 OTC
SURESTEP PRO
NORMAL GLUCOSE 3 OTC
TRUE FOCUS BLOOD
GLUCOSE METER 3 ST; OTC; QL
TRUE METRIX BLOOD
GLUCOSE TEST 3 ST; OTC; QL
TRUE METRIX LEVEL
1 3 OTC
TRUE METRIX LEVEL
2 3 OTC
TRUE METRIX LEVEL
3 3 OTC
TRUETRACK TEST 3 ST; OTC; QL
UNISTRIP CONTROL
IN VITRO SOLUTION
LOW
3
OTC
V-GO 20 2 OTC
Drug Name Drug
Category
Limits/
Required
MICROLET NEXT
LANCING DEVICE 2 OTC
MINIMED GUARDIAN
SENSOR 3 6 MSD; QL
NOVOPEN ECHO 3
ONE DROP BLOOD
GLUCOSE MONITOR 3 ST; OTC; QL
ONE DROP TEST 3 ST; OTC; QL
ONETOUCH DELICA
LANCING DEV 2 OTC
ONETOUCH DELICA
PLUS LANCING 2 OTC
ONETOUCH ULTRA 2 2 OTC; QL
ONETOUCH ULTRA
BLUE TEST STRIPS 2 OTC; QL
ONETOUCH ULTRA
MINI 2 OTC; QL
ONE TOUCH VERIO
KIT W/DEVICE 2 OTC; QL
ONETOUCH VERIO
FLEX SYSTEM KIT
W/DEVICE
2
OTC; QL
ONETOUCH VERIO IN
VITRO SOLUTION
HIGH
2
OTC
ONETOUCH VERIO
TEST STRIPS 2 OTC; QL
ONETOUCH VERIO IQ
SYSTEM 2 OTC; QL
ONETOUCH VERIO
SYNC SYSTEM KIT
W/DEVICE
2
OTC; QL
PARADIGM REAL-
TIME STARTER 2 QL
PRECISION LINK 3 ST; OTC; QL
PRECISION PCX
PLUS TEST 3 ST; OTC; QL
PRECISION QID
MONITOR 3 OTC; QL
PRECISION QID TEST 3 ST; OTC; QL
PRECISION SOF-
TACT MONITOR 3 OTC; QL
Last Updated 10/1/19
66
Drug Name Drug
Category
Limits/
Required
BD ULTRA-FINE
INSULIN SYRINGES 2
BD ULTRA-FINE PEN
NEEDLES 2 ST; OTC
BD ULTRA-FINE PEN
NEEDLES 2 ST
FIASP 3 ST; M; QL
FIASP FLEXTOUCH 3 ST; M; QL
FIASP PENFILL 3 ST; M; QL
HUMALOG KWIKPEN 2 M; QL
HUMALOG MIX 50/50
KWIKPEN 2 M; QL
HUMALOG MIX 50/50
VIAL 2 M; QL
HUMALOG MIX 75/25
KWIKPEN 2 M; QL
HUMALOG MIX 75/25
VIAL 2 M; QL
HUMALOG U-100
JUNIOR KWIKPEN 2 M; QL
HUMALOG U-100 VIAL
AND CARTRIDGE 2 M; QL
HUMULIN 70/30
KWIKPEN 2 M; OTC; QL
HUMULIN 70/30 VIAL 2 M; OTC; QL
HUMULIN N KWIKPEN 2 M; OTC
HUMULIN N VIAL 2 M; OTC; QL
HUMULIN R U-500
KWIKPEN 2 M; QL
HUMULIN R U-500
VIAL
(CONCENTRATED)
2
M; QL
HUMULIN R VIAL 2 M; OTC; QL
INSULIN LISPRO 3 M; QL
INSULIN LISPRO
SUBCUTANEOUS
SOLUTION PEN-
INJECTOR 100
UNIT/ML
3
M; QL
Drug Name Drug
Category
Limits/
Required
VIVAGUARD INO
CONTROL SOLUTION 3 ST; OTC
VIVAGUARD INO
GLUCOSE METER 3 ST; OTC; QL
VIVAGUARD INO
TEST STRIPS 3 ST; OTC; QL
VIVAGUARD
LANCING DEVICE 2 ST; OTC
Diabetes - Glycemic
Agents
GLUCAGEN HYPOKIT 2
GLUCAGON
EMERGENCY 3
PROGLYCEM 2 M
Diabetes - Insulins
ADMELOG 3 ST; M; QL
ADMELOG
SOLOSTAR 3 ST; M; QL
AFREZZA
INHALATION
POWDER 12 UNIT, 4 &
8 & 12 UNIT, 8 UNIT,
90 X 4 UNIT & 90X8
UNIT, 90 X 8 UNIT &
90X12 UNIT
3
M
AFREZZA
INHALATION
POWDER 4 UNIT
3
M; QL
APIDRA SOLOSTAR 3 ST; M; QL
APIDRA VIAL 3 ST; M; QL
BASAGLAR KWIKPEN 2 M; QL
BD AUTOSHIELD DUO
PEN NEEDLES 2 ST; OTC
BD ULTRA-FINE
INSULIN SYRINGES
29G X 1/2" 1 ML, 30G
X 1/2" 0.3 ML, 30G X
1/2" 0.5 ML, 30G X 1/2"
1 ML, 31G X 15/64" 0.3
ML, 31G X 15/64" 0.5
ML, 31G X 15/64" 1
ML, 31G X 5/16" 0.3
ML, 31G X 5/16" 0.5
ML, 31G X 5/16" 1 ML
2
ST; OTC
Last Updated 10/1/19
67
Drug Name Drug
Category
Limits/
Required
NOVOLIN R RELION 3 ST; M; OTC;
QL
NOVOLIN R VIAL 3 ST; M; OTC;
QL
NOVOLOG FLEXPEN 3 ST; M; QL
NOVOLOG MIX 70/30
FLEXPEN 3 ST; M
NOVOLOG MIX 70/30
VIAL 3 ST; M
NOVOLOG PENFILL 3 ST; M; QL
NOVOLOG U-100 VIAL 3 ST; M
NOVOTWIST PEN
NEEDLE 2 ST; OTC
TOUJEO MAX
SOLOSTAR 2 M; QL
TOUJEO SOLOSTAR 2 M; QL
TRESIBA 2 M; QL
TRESIBA
FLEXTOUCH 2 M; QL
Electrolytes / Minerals
/ Metals / Vitamins
ACTIVE FE 3
adc/f (0.5mg/ml) 5 ACA
alcohol 6 MSD
AMINO ACID
INTRAVENOUS
SOLUTION 5 %
6
MSD
aminobenzoate
potassium 1 M
AMINOPROTECT 6 MSD
AMINOSYN II 6 MSD
AMINOSYN-PF 6 MSD
AQUASOL A 2
ARGININE HCL
INJECTION 3
ascorbic acid injection 6 MSD
AXIFOL 3
B-12 COMPLIANCE
INJECTION 6 MSD
BCAA INJECTION 3
CALCIFOL 3
Drug Name Drug
Category
Limits/
Required
INSULIN PEN
NEEDLES 29G X
12.7MM , 29G X 12MM
, 29G X 5MM , 29G X
8MM , 30G X 8 MM ,
31G X 5 MM , 31G X 6
MM , 31G X 8 MM ,
32G X 4 MM , 32G X 5
MM , 32G X 6 MM ,
33G X 4 MM , 33G X 5
MM , 33G X 6 MM
2
ST; OTC
INSULIN PEN
NEEDLES 29G X
12.7MM , 31G X 5 MM
, 31G X 6 MM , 31G X
8 MM , 32G X 4 MM
2
ST
INSULIN SYRINGES 2 ST; OTC
LANTUS SOLOSTAR 2 M; QL
LANTUS U-100 VIAL 2 M; QL
LEVEMIR U-100
FLEXTOUCH 2 M; QL
LEVEMIR U-100 VIAL 2 M; QL
MAXICOMFORT SYR
27G X 1/2" 2 ST; OTC
NOVOFINE
AUTOCOVER PEN
NEEDLE
2
ST; OTC
NOVOFINE PEN
NEEDLE 2 ST; OTC
NOVOFINE PLUS PEN
NEEDLE 2 ST; OTC
NOVOLIN 70/30
FLEXPEN 3
ST; M; OTC;
QL
NOVOLIN 70/30
FLEXPEN RELION 3
ST; M; OTC;
QL
NOVOLIN 70/30
RELION 3
ST; M; OTC;
QL
NOVOLIN 70/30 VIAL 3 ST; M; OTC;
QL
NOVOLIN N RELION 3 ST; M; OTC;
QL
NOVOLIN N VIAL 3 ST; M; OTC;
QL
Last Updated 10/1/19
68
Drug Name Drug
Category
Limits/
Required
CLINIMIX
E/DEXTROSE (5/15) 6 MSD
CLINIMIX
E/DEXTROSE (5/20) 6 MSD
CLINIMIX N14G30E 6 MSD
CLINIMIX N9G15E 6 MSD
CLINIMIX N9G20E 6 MSD
clinimix/dextrose
(4.25/10) solution 4.25
% intravenous
6
MSD
CLINIMIX/DEXTROSE
(4.25/10) SOLUTION
4.25 %
INTRAVENOUS
6
MSD
clinimix/dextrose
(4.25/25) 6 MSD
CLINIMIX/DEXTROSE
(4.25/5) 6 MSD
CLINIMIX/DEXTROSE
(5/15) 6 MSD
CLINIMIX/DEXTROSE
(5/20) 6 MSD
CLINIMIX/DEXTROSE
(5/25) 6 MSD
clinisol sf 6 MSD
COPPER CHLORIDE 6 MSD
corvita 150 1
CORVITE 150 3
CORVITE FE 3
cyanocobalamin
injection solution 1000
mcg/ml
1
CYANOCOBALAMIN
INJECTION
SOLUTION 2000
MCG/ML
2
cytra k crystals 1
deferasirox 1 M; S
dehydrated alcohol 6 MSD
delflex-lc/1.5%
dextrose 6 MSD
Drug Name Drug
Category
Limits/
Required
CALCIUM CHLORIDE
SOLUTION 10 %
INTRAVENOUS
6
MSD
calcium chloride
solution 10 %
intravenous
6
MSD
calcium gluconate 6 MSD
calcium gluconate
anhydrous 6 MSD
calcium gluconate
intravenous solution 6 MSD
CALCIUM
GLUCONATE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
CALCIUM
GLUCONATE-NACL
INTRAVENOUS
SOLUTION 1-0.675
GM/50ML-%, 1-0.9
GM/100ML-%, 2-0.675
GM/100ML-%
6
MSD
calcium-folic acid plus d 1
CALM 3
CARBAGLU 3 PA; M; S
CARDIOPLEGIC 6 MSD
CARNITOR ORAL 3 M
CARNITOR SF 3 M
CENTRATEX 3
CHEMET 2
chromic chloride
intravenous 6 MSD
CITRANATAL
MEDLEY 3
CLINIMIX
E/DEXTROSE (2.75/5) 6 MSD
CLINIMIX
E/DEXTROSE
(4.25/10)
6
MSD
CLINIMIX
E/DEXTROSE (4.25/5) 6 MSD
Last Updated 10/1/19
69
Drug Name Drug
Category
Limits/
Required
ERGOCAL 3 M
ergocalciferol oral
capsule 1 M
ESCAVITE 3
ESCAVITE D 3
ESCAVITE LQ 3
EXJADE 3 M; S
FERIVA 21/7 3
FERIVAFA 3
ferocon 1
ferotrinsic 1
FERRALET 90 3
ferraplus 90 1
FERRIPROX 3 M; S
FERRLECIT 6 MSD
ferrocite plus 1
FERRO-PLEX
HEMATINIC 3
FERROTRIN 3
FLORIVA ORAL
LIQUID 5 ACA
floriva oral tablet
chewable 0.25 mg 3
FLORIVA ORAL
TABLET CHEWABLE
0.5 MG, 1 MG
3
FLORIVA PLUS 5 ACA
FLUORABON 5 M; ACA
fluoritab oral solution 5 M; ACA
fluoritab oral tablet
chewable 0.55 (0.25 f)
mg, 1.1 (0.5 f) mg
5
M; ACA
fluoritab oral tablet
chewable 2.2 (1 f) mg 1 M
FLURA-DROPS 5 M; ACA
folic acid injection 1
folic acid oral tablet 1
mg 1 M
folic acid oral tablet 400
mcg 5 ACA; OTC
Drug Name Drug
Category
Limits/
Required
delflex-lc/2.5%
dextrose 6 MSD
delflex-lc/4.25%
dextrose solution 483
mosm/l intraperitoneal
6
MSD
DELFLEX-LC/4.25%
DEXTROSE
SOLUTION 483
MOSM/L
INTRAPERITONEAL
6
MSD
delflex-sm/1.5%
dextrose 6 MSD
DEXPANTHENOL
INJECTION 3
dextrose intravenous
solution 10 %, 20 %, 30
%, 40 %, 5 %, 70 %
6
MSD
DEXTROSE
SOLUTION 250
MG/ML
INTRAVENOUS
6
MSD
dextrose solution 250
mg/ml intravenous 6 MSD
DEXTROSE
SOLUTION 50 %
INTRAVENOUS
6
MSD
dextrose solution 50 %
intravenous 6 MSD
DIANEAL LOW
CALCIUM/1.5% DEX 6 MSD
DIANEAL LOW
CALCIUM/2.5% DEX 6 MSD
DIANEAL LOW
CALCIUM/4.25% DEX 6 MSD
DRISDOL 3 M
EFFER-K ORAL
TABLET
EFFERVESCENT 10
MEQ, 20 MEQ
3
effer-k oral tablet
effervescent 25 meq 1 M
elite-ob 3
ELLIOTTS B 6 MSD
ENBRACE HR 3
Last Updated 10/1/19
70
Drug Name Drug
Category
Limits/
Required
infuvite pediatric
solution intravenous 6 MSD
INFUVITE PEDIATRIC
SOLUTION
INTRAVENOUS
6
MSD
INJECTAFER 6 MSD
INTEGRA F 3
intralipid intravenous
emulsion 20 % 6 MSD
INTRALIPID
INTRAVENOUS
EMULSION 30 %
6
MSD
iodine strong oral 1
IONOSOL-MB IN D5W 6 MSD
IROSPAN 24/6 3
IS 24/6 3
ISOLYTE-S 6 MSD
JADENU 3 M; S
JADENU SPRINKLE 3 M; S
JYNARQUE 3 PA; S; QL
KABIVEN 6 MSD
KCL (IN NACL 0.9%)
INTRAVENOUS
SOLUTION 10
MEQ/100ML, 20
MEQ/250ML
6
MSD
KCL-LIDOCAINE-
NACL 6 MSD
kionex 1
klor-con 1 M
klor-con 10 1 M
klor-con m10 1 M
KLOR-CON M15 1 M
klor-con m20 1 M
klor-con sprinkle 1 M
klor-con/ef 1 M
K-PHOS 2 M
K-PHOS NO 2 3
K-PHOS-NEUTRAL 1 M
k-prime 1 M
Drug Name Drug
Category
Limits/
Required
folic acid oral tablet 800
mcg 5 M; ACA; OTC
FOLI-D 3
FOLITE 3
FOLIVANE-F 3
foltrin 1
FOLVITE-D 3
FREAMINE HBC 6 MSD
FREAMINE III 6 MSD
FUSION PLUS 3
FUSION SPRINKLES 3
GABA 3
GALZIN 3
GENICIN VITA-D 3
glucose intravenous 6 MSD
GLUTATHIONE
INJECTION 3
GLYCINE INJECTION 3
gnp folic acid 5 ACA; OTC
hematinic plus
vit/minerals 1
hematogen fa 1
hematogen forte 1
HEMATRON-AF 3
HEMETAB 1
HEMOCYTE PLUS 3
hemocyte-plus 1
hepatamine 6 MSD
hydroxocobalamin
acetate 1
hyperlyte-cr 6 MSD
ICAR-C PLUS 3
iferex 150 forte 1
infuvite adult injectable
intravenous 6 MSD
INFUVITE ADULT
INJECTABLE
INTRAVENOUS
6
MSD
Last Updated 10/1/19
71
Drug Name Drug
Category
Limits/
Required
magnesium sulfate
intravenous solution 2
gm/50ml, 20 gm/500ml,
4 gm/100ml, 4
gm/50ml, 40
gm/1000ml
6
MSD
MAGNESIUM
SULFATE SOLUTION
50 % INJECTION
3
magnesium sulfate
solution 50 % injection 6 MSD
MAGNESIUM
SULFATE-LACT
RINGERS
6
MSD
MAGNESIUM
SULFATE-NACL 6 MSD
MANGANESE
CHLORIDE 6 MSD
MAXFE ORAL TABLET 3
MEPHYTON 3
METHYLCOBALAMIN
INJECTION 3
M-NATAL PLUS 1
multi prenatal 5 ACA; OTC
multigen 1
multigen folic 1
multigen plus 1
multi-vit/iron/fluoride 5 ACA
multi-vitamin/fluoride 5 ACA
multivitamin/fluoride
oral solution 5 ACA
multivitamin/fluoride
oral tablet chewable
0.25 mg, 0.5 mg
5
ACA
MULTIVITAMIN/FLUO
RIDE ORAL TABLET
CHEWABLE 0.25-0.3
MG, 0.5-0.3 MG, 1-0.3
MG
3
multivitamin/fluoride
oral tablet chewable 1
mg
1
Drug Name Drug
Category
Limits/
Required
K-TAB 1 M
k-tan plus 1
lactated ringers
intravenous 6 MSD
LEVOCARNITINE
INJECTION 3
levocarnitine oral
solution 1 M
levocarnitine oral tablet 1 M
LIPO 3
LIPO-C 3
LIQUIVIDA
HYDRATION 6 MSD
LOKELMA 2 M
ludent oral tablet
chewable 0.55 (0.25 f)
mg, 1.1 (0.5 f) mg
5
M; ACA
ludent oral tablet
chewable 2.2 (1 f) mg 1 M
LYSINE HCL
INJECTION 3
M.V.I. ADULT 6 MSD
M.V.I. PEDIATRIC 6 MSD
MAGNEBIND 400 3
magnesium chloride
injection 1
magnesium sulfate in
d5w intravenous
solution 1-5 gm/100ml-
%
6
MSD
MAGNESIUM
SULFATE IN D5W
INTRAVENOUS
SOLUTION 1-5
GM/50ML-%, 2-5
GM/100ML-%, 2-5
GM/50ML-%, 3-5
GM/50ML-%, 4-5
GM/50ML-%, 50-5
GM/500ML-%, 6-5
GM/100ML-%, 6-5
GM/50ML-%
6
MSD
Last Updated 10/1/19
72
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
multivitamin/fluoride/iro
n 5 ACA
plenamine 6 MSD
pnv prenatal plus
multivit+dha 3
multi-
vitamin/fluoride/iron 5 ACA
poly-iron 150 forte 1
multivitamins/fluoride 5 ACA
polysaccharide iron
forte 1
mvc-fluoride oral tablet
chewable 0.25 mg, 0.5
mg
5
ACA POLY-VI-FLOR 3
POLY-VI-FLOR FS 3 mvc-fluoride oral tablet
chewable 1 mg 1
POLY-VI-FLOR/IRON 3
pot bicarb-pot chloride 1 M myferon 150 forte 1
POTABA 3 M na ferric gluc cplx in
sucrose 6 MSD
potassium acetate
intravenous 6 MSD
n-acetyl-l-cysteine oral 2
potassium bicarbonate
oral 1 M nafrinse 1 M
nafrinse drops 5 M; ACA
potassium chloride crys
er 1 M NASCOBAL 2 M
NEOKE ALCAR 3
potassium chloride er 1 M
NEPHRAMINE 6 MSD
potassium chloride in
nacl intravenous
solution 20-0.9 meq/l-
%, 40-0.9 meq/l-%
6
MSD
NEPHRON FA 3
NESTABS 3
NEUT 6 MSD
potassium chloride
intravenous solution 6 MSD NICOMIDE 3
NIFEREX 3
POTASSIUM
CHLORIDE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
6
MSD
NUFERA 3
nutrilipid 6 MSD
NUTRIVIT 2
OMEGAVEN 6 MSD
potassium chloride oral 1 M
ONE-A-DAY WOMENS
PRENATAL 1 5 ACA; OTC
potassium citrate er 1
potassium citrate-citric
acid 1
ORACIT 3
PERIKABIVEN 6 MSD
potassium phosphates 6 MSD
phospha 250 neutral 1 M
PREGENNA 3
phosphorous 1 M
PREMASOL 6 MSD
Last Updated 10/1/19
73
phospho-trin 250
neutral 1 M
PRENAISSANCE 3
PRENATA 3 PHYSICIANS EZ USE
B-12 6 MSD
prenatal multi +dha 5 ACA; OTC
prenatal oral tablet 27-
0.8 mg 5 ACA phytonadione injection 6 MSD
phytonadione oral 1
Last Updated 10/1/19
74
Drug Name Drug
Category
Limits/
Required
SELECT-OB ORAL
TABLET CHEWABLE
29-1 MG
3
se-tan plus 1
SMOFLIPID 6 MSD
sod citrate-citric acid 1
sodium acetate
intravenous 6 MSD
sodium bicarbonate
intravenous solution 4.2
%, 7.5 %
6
MSD
SODIUM
BICARBONATE
SOLUTION 8.4 %
INTRAVENOUS
6
MSD
sodium bicarbonate
solution 8.4 %
intravenous
6
MSD
SODIUM
BICARBONATE-
DEXTROSE
6
MSD
sodium chloride
bacteriostatic 6 MSD
sodium chloride
injection 6 MSD
sodium chloride
intravenous 6 MSD
sodium fluoride oral
solution 5 M; ACA
sodium fluoride oral
tablet 1.1 (0.5 f) mg 5 M; ACA
sodium fluoride oral
tablet 2.2 (1 f) mg 1 M
sodium fluoride oral
tablet chewable 0.55
(0.25 f) mg, 1.1 (0.5 f)
mg
5
M; ACA
sodium fluoride oral
tablet chewable 2.2 (1
f) mg
1
M
sodium lactate
intravenous 6 MSD
Drug Name Drug
Category
Limits/
Required
prenatal oral tablet 27-1
mg 3
prenatal oral tablet 28-
0.8 mg 5 ACA; OTC
prenatal plus iron 1
PRISMASOL B22GK
4/0 6 MSD
PRISMASOL BGK
0/2.5 6 MSD
PRISMASOL BGK 2/0 6 MSD
PRISMASOL BGK
2/3.5 6 MSD
PRISMASOL BGK
4/2.5 6 MSD
PRISMASOL BK
0/0/1.2 6 MSD
PROCALAMINE 6 MSD
PROSOL 6 MSD
purevit dualfe plus 1
PYRIDOXINE HCL
SOLUTION 100
MG/ML INJECTION
3
pyridoxine hcl solution
100 mg/ml injection 1
QUFLORA FE 3
QUFLORA FE
PEDIATRIC 5 ACA
QUFLORA GUMMIES 3
quflora pediatric oral
solution 5 ACA
quflora pediatric oral
tablet chewable 0.25
mg, 0.5 mg
5
ACA
quflora pediatric oral
tablet chewable 1 mg 1
RELNATE DHA 3
RENATABS WITH
IRON 3
saline bacteriostatic 6 MSD
SALINE-PHENOL 3
SAMSCA 3 PA; S; QL
Last Updated 10/1/19
75
Drug Name Drug
Category
Limits/
Required
trientine hcl 1 PA; QL
TRIFERIC
HEMODIALYSIS
PACKET
6
MSD
trigels-f forte 1
trinate 1
TRINAZ 3
TRISODIUM
CITRATE/CRRT 6 MSD
TRI-VI-FLOR 3
TRI-VI-FLORO 3
tri-vitamin/fluoride 5 ACA
tri-vite/fluoride 5 ACA
TROPHAMINE 6 MSD
tryptophan oral 1
ULTRABAG/DIANEAL/
1.5% DEXTROSE 6 MSD
ULTRABAG/DIANEAL/
2.5% DEXTROSE 6 MSD
ULTRABAG/DIANEAL/
4.25% DEX 6 MSD
UROCIT-K 10 3
UROCIT-K 15 3
UROCIT-K 5 3
VELTASSA 3 M; S
VENOFER 6 MSD
virt-phos 250 neutral 1 M
VITAFOL 3
VITAFOL-OB+DHA 3
vitamin b complex 100 6 MSD
vitamin b-complex 100 6 MSD
vitamin d
(ergocalciferol) oral
capsule 1.25 mg
(50000 ut)
1
M
vitamin k1 injection 6 MSD
vitamins acd-fluoride 5 ACA
vp-pnv-dha 3
wheat germ oil 2
ZINC TRACE METAL 6 MSD
Drug Name Drug
Category
Limits/
Required
SODIUM
PHOSPHATE-NACL
INTRAVENOUS
SOLUTION 15
MMOL/100ML, 15
MMOL/250ML, 30
MMOL/250ML
6
MSD
sodium phosphates 6 MSD
SODIUM
PHOSPHATES-
DEXTROSE
INTRAVENOUS
SOLUTION 15
MMOL/250ML
6
MSD
sodium polystyrene
sulfonate oral 1
sodium polystyrene
sulfonate rectal
suspension 30
gm/120ml
1
sodium polystyrene
sulfonate rectal
suspension 50
gm/200ml
3
sps 1
swabflush saline flush 6 MSD
SYNTHAMIN 17 6 MSD
SYPRINE 3 ST; QL
TARON FORTE 1
taron-crystals 1
TAURINE INJECTION 3
TEXAVITE LQ 3
thiamine hcl injection 1
tl icon 1
TL-FLUORIVITE 3
tpn electrolytes 6 MSD
TRAVASOL 6 MSD
TRI-AMINO 3
TRICARE PRENATAL
DHA ONE 3
tricitrates 1
tricon 1
Last Updated 10/1/19
76
Drug Name Drug
Category
Limits/
Required
NEXIUM ORAL
CAPSULE DELAYED
RELEASE 40 MG
3
ST; M; QL
NEXIUM ORAL
PACKET 2 ST; M; QL
nizatidine 1 M
omeppi 2 M; QL
omeprazole oral
capsule delayed
release
1
M; QL
omeprazole oral tablet
delayed release 1 OTC; QL
omeprazole oral tablet
delayed release
dispersible
1
OTC; QL
omeprazole-sodium
bicarbonate 2 M; QL
pantoprazole sodium
intravenous 6 MSD; QL
pantoprazole sodium
oral tablet delayed
release 20 mg
1
M; QL
pantoprazole sodium
tablet delayed release
40 mg oral
2
M; QL
pantoprazole sodium
tablet delayed release
40 mg oral
1
M; QL
PEPCID 3 M
PREVACID ORAL
CAPSULE DELAYED
RELEASE 30 MG
3
ST; M; QL
PREVACID SOLUTAB
ORAL TABLET
DISPERSIBLE 15 MG,
30 MG
3
ST; M; QL
PRILOSEC 3 ST; M; QL
PROTONIX
INTRAVENOUS 6 MSD; QL
PROTONIX ORAL 3 ST; M; QL
rabeprazole sodium
oral tablet delayed
release
1
M; QL
Drug Name Drug
Category
Limits/
Required
Gastrointestinal
Agents - Drugs for
Acid Reflux and Ulcer
ACIPHEX 3 ST; M; QL
ACIPHEX SPRINKLE 3 ST; M; QL
CARAFATE ORAL
SUSPENSION 2 M
CARAFATE ORAL
TABLET 3 M
cimetidine hcl 1 M
cimetidine oral tablet
200 mg 1
cimetidine oral tablet
300 mg, 400 mg, 800
mg
1
M
CYTOTEC 3 M
DEPRIZINE FUSEPAQ 3 M
DEXILANT 3 ST; M; QL
esomeprazole
magnesium 1 M; QL
esomeprazole sodium 6 MSD; QL
FAMOTIDINE IN NACL 6 MSD
famotidine intravenous 6 MSD
famotidine oral
suspension
reconstituted
1
M
famotidine oral tablet
20 mg, 40 mg 1 M
famotidine premixed 6 MSD
gnp lansoprazole 1 M; OTC; QL
heartburn treatment 24
hour 1 M; OTC; QL
lansoprazole oral
capsule delayed
release
1
M; QL
lansoprazole oral tablet
dispersible 15 mg, 30
mg
1
M; QL
misoprostol oral 1 M
NEXIUM I.V. 6 MSD; QL
Last Updated 10/1/19
77
Drug Name Drug
Category
Limits/
Required
citroma 5 ST; ACA; OTC
clearlax 5 ST; ACA; OTC
CLENPIQ 5 ACA
COLYTE WITH
FLAVOR PACKS 3
constulose 1 M
cromolyn sodium oral 1 M
CUVPOSA 3 M
dicyclomine hcl
intramuscular 6 MSD
dicyclomine hcl oral 1
diphenoxylate-atropine 1
DONNATAL 3
ENTEREG 3
enulose 1 M
ex-lax ultra 5 ST; ACA; OTC
GASTROCROM 3 M
GATTEX 4 M; S
gavilax oral powder 5 ST; ACA; OTC
gavilyte-c 5 ACA
gavilyte-g 5 ACA
gavilyte-h 5 ACA
gavilyte-n with flavor
pack 5 ACA
generlac 1 M
gentle laxative oral 5 ST; ACA; OTC
GIALAX 5 ACA
GLYCATE 3
glycolax 5 ST; ACA; OTC
glycopyrrolate injection
solution 6 MSD
GLYCOPYRROLATE
INJECTION
SOLUTION
PREFILLED SYRINGE
6
MSD
GLYCOPYRROLATE
INTRAVENOUS 6 MSD
glycopyrrolate oral
tablet 1 mg, 2 mg 1
Drug Name Drug
Category
Limits/
Required
ranitidine hcl injection 6 MSD
ranitidine hcl oral
capsule 1 M
ranitidine hcl oral syrup 1 M
ranitidine hcl oral tablet
150 mg, 300 mg 1 M
sm esomeprazole
magnesium 1 M; OTC; QL
sucralfate oral tablet 1 M
YOSPRALA 3 ST; M; QL
ZANTAC INJECTION 6 MSD
ZEGERID 3 ST; M; QL
Gastrointestinal
Agents - Drugs for
Bowel, Intestine and
Stomach Conditions
ACTIGALL 3 M
alosetron hcl 1 M
AMITIZA 2 M; QL
amoxicill-clarithro-
lansopraz 1 QL
ANASPAZ 1 M
ATROPEN 3
atropine sulfate
injection 6 MSD
ATROPINE SULFATE
INTRAVENOUS
SOLUTION
PREFILLED SYRINGE
0.8 MG/2ML, 1
MG/2.5ML, 2 MG/5ML
6
MSD
belladonna alkaloids-
opium 1
BENTYL 6 MSD
bisacodyl ec 5 ST; ACA; OTC
cascara sagrada oral
fluid extract 3
CHENODAL 3 PA; S
chlordiazepoxide-
clidinium 1
CHOLBAM 3 PA; M; S
Last Updated 10/1/19
78
Drug Name Drug
Category
Limits/
Required
methscopolamine
bromide oral 1
milk of magnesia oral
suspension 1200
mg/15ml, 400 mg/5ml
5
ST; ACA; OTC
mineral oil heavy oral 2
MOTEGRITY 3 M
MOTOFEN 3
MOVANTIK 2 QL
MOVIPREP 5 ACA
MYTESI 3 M; QL
NULYTELY WITH
FLAVOR PACKS 3
OMECLAMOX-PAK 3 QL
opium 1
oscimin oral tablet 1 M
oscimin sr 1 M
oscimin sublingual 1 M
OSMOPREP 5 ACA
paregoric 1
PCP 100 3
peg 3350 oral packet 5 ST; ACA; OTC
peg 3350/electrolytes 5 ACA
peg 3350-kcl-na bicarb-
nacl 5 ACA
peg-3350/electrolytes 5 ACA
peg-prep 5 ACA
phenobarbital-
belladonna alk 1
phenohytro 1
PLENVU 5 ACA
polyethylene glycol
3350 oral packet 5 ST; ACA
PREPOPIK 5 ACA
PRODIGEN 3
propantheline bromide
oral 1
PYLERA 2
RELISTOR ORAL 3 QL
Drug Name Drug
Category
Limits/
Required
GLYCOPYRROLATE
ORAL TABLET 1.5 MG 1
glycopyrrolate pf 6 MSD
GLYRX-PF 6 MSD
GOLYTELY ORAL
SOLUTION
RECONSTITUTED
227.1 GM
5
ACA
GOLYTELY ORAL
SOLUTION
RECONSTITUTED 236
GM
3
healthylax 5 ST; ACA; OTC
hyoscyamine sulfate er 1 M
hyoscyamine sulfate
oral elixir 1 M
hyoscyamine sulfate
oral solution 1 M
hyoscyamine sulfate
oral tablet 1 M
hyoscyamine sulfate sl 1 M
hyoscyamine sulfate
sublingual 1 M
hyosyne 1 M
KRISTALOSE 3 M
lactulose 1 M
lactulose
encephalopathy 1 M
LEVBID 3 M
LEVSIN INJECTION 6 MSD
LEVSIN ORAL 3 M
LEVSIN/SL 3 M
LIBRAX 3 ST
LINZESS 2 M; QL
LOMOTIL 3
loperamide hcl oral
capsule 1
LOTRONEX 3 M
magnesium citrate oral
solution 5 ST; ACA; OTC
Last Updated 10/1/19
79
Drug Name Drug
Category
Limits/
Required
ELAPRASE 6 MSD
ELELYSO 6 MSD
ENZADYNE 3
EXONDYS 51 6 MSD
FABRAZYME 6 MSD
GALAFOLD 4 PA; M; S; QL
KANUMA 6 MSD
KUVAN 3 PA; M; S
LUMIZYME 6 MSD
MEPSEVII 6 MSD
miglustat 1 M; S
MYALEPT 3 PA; M; S
NAGLAZYME 6 MSD
nitisinone 1 M
NITYR 3 M; S
OCALIVA 3 PA; M; S; QL
ORFADIN 3 M; S
PALYNZIQ 3 PA; M; S; QL
PANCREAZE 3 ST; M
PERTZYE 3 ST; M
PROCYSBI 4 ST; M; S
RAVICTI 3 M; S
REVCOVI 3 S
sod benz-sod
phenylacet 6 MSD
sodium phenylbutyrate
oral 1 M
STRENSIQ 3 M; S
SUCRAID 3 M; S
VIMIZIM 6 MSD
VIOKACE 2 M
VPRIV 6 MSD
XURIDEN 3 M; S; QL
ZAVESCA 4 M; S
ZENPEP 2 M
Drug Name Drug
Category
Limits/
Required
RELISTOR
SUBCUTANEOUS 2 QL
RESTORA RX 3
SEROSTIM 3 PA; M; S
sodium bicarbonate
oral powder 1
SUPREP BOWEL
PREP KIT 5 ACA
SYMAX DUOTAB 3 M
symax-sl 1 M
symax-sr 1 M
SYMPROIC 2 QL
trilyte 5 ACA
TRULANCE 2 M; QL
URSO 250 3 M
URSO FORTE 3 M
ursodiol oral 1 M
URSODIOL+SYRSPE
ND SF 3 M
VIBERZI 2 M; QL
VSL#3 DS 3
XERMELO 3 PA; M; S; QL
ZELAC 3
ZORBTIVE 3 PA; M; S
Genetic or Enzyme
Disorder - Drugs for
Replacement,
Modification,
Treatment
ALDURAZYME 6 MSD
AMMONUL 6 MSD
BRINEURA 6 M; MSD
BUPHENYL 3 M
CERDELGA 3 M; S
CEREZYME 6 MSD
CREON 2 M
CRYSVITA 6 M; MSD
CYSTADANE 3 M; S
CYSTAGON 3 PA; M; S
Last Updated 10/1/19
80
Drug Name Drug
Category
Limits/
Required
oxybutynin chloride er
oral tablet extended
release 24 hour 5 mg
1
M; QL
oxybutynin chloride oral 1 M
OXYTROL 3 ST; M; QL
penicillamine oral 1
phenazo oral tablet 200
mg 1
phenazopyridine hcl
oral tablet 100 mg, 200
mg
1
PHOSLYRA 2 M
phosphasal 1
PYRIDIUM 3
RENACIDIN 6 MSD
RENAGEL 3 ST; M
RENVELA 3 M
sevelamer carbonate 1 M
sevelamer hcl 1 M
solifenacin succinate 1 M
THIOLA 4 M; S
THIOLA EC 3 M
tolterodine tartrate 1 M
tolterodine tartrate er 1 M
TOVIAZ 2 ST; M
trospium chloride 1 M
trospium chloride er 1 M
URECHOLINE 3
uretron d/s 1
urimar-t 1
urin ds 1
UROGESIC-BLUE 1
uryl 1
ustell 1
uticap 1
utira-c 1
utrona-c 1
VELPHORO 2 M
VESICARE 2 ST; M
Drug Name Drug
Category
Limits/
Required
Genitourinary Agents
- Drugs for Bladder,
Genital and Kidney
Conditions
AURYXIA 3 M
bethanechol chloride
oral 1
calcium acetate (phos
binder) 1 M
CUPRIMINE 3 ST
darifenacin
hydrobromide er 1 M
DEPEN TITRATABS 2
DETROL 3 ST; M
DETROL LA 3 ST; M
DITROPAN XL ORAL
TABLET EXTENDED
RELEASE 24 HOUR
10 MG
3
ST; M
DITROPAN XL ORAL
TABLET EXTENDED
RELEASE 24 HOUR 5
MG
3
ST; M; QL
D-PENAMINE 2
ELMIRON 2
ENABLEX 3 ST; M
FEM PH 1
flavoxate hcl 1 M
FOSRENOL 3 ST; M
GELNIQUE 2 ST; M; QL
GELNIQUE PUMP 2 ST; M; QL
hyophen 1
INTRAROSA 3 M
lanthanum carbonate 1 M
LITHOSTAT 3 M
me/naphos/mb/hyo1 1
MYRBETRIQ 2 ST; M
oxybutynin chloride er
oral tablet extended
release 24 hour 10 mg,
15 mg
1
M
Last Updated 10/1/19
81
Drug Name Drug
Category
Limits/
Required
BETAMETHASONE
SOD PHOS & ACET
INJECTION
SUSPENSION 7 (4-3)
MG/ML
6
MSD
BETAMETHASONE
SOD PHOS & ACET
SUSPENSION 6 (3-3)
MG/ML INJECTION
6
MSD
betamethasone sod
phos & acet
suspension 6 (3-3)
mg/ml injection
6
MSD
BETAMETHASONE
SODIUM PHOSPHATE
INJECTION
6
MSD
BUPIVILOG 3
CELESTONE
SOLUSPAN 6 MSD
CONTRAST ALLERGY
PREMED PACK 3
CORTEF 3
cortisone acetate oral 1
DECADRON ORAL
TABLET 1
DEPO-MEDROL 6 MSD
DEXAMETHASONE
(LA) 6 MSD
DEXAMETHASONE
ACE & SOD PHOS 6 MSD
DEXAMETHASONE
INTENSOL 1
dexamethasone oral
elixir 1
dexamethasone oral
solution 1
dexamethasone oral
tablet 1
dexamethasone oral
tablet therapy pack 1 ST
DEXAMETHASONE
SOD PHOS-BUPIV 3
Drug Name Drug
Category
Limits/
Required
Genitourinary Agents
- Drugs for Prostate
Conditions
alfuzosin hcl er 1 M
AVODART 3 ST; M
CARDURA XL 3 M; QL
dutasteride oral 1 M
dutasteride-tamsulosin
hcl 1 M
finasteride oral tablet 5
mg 1 M
FLOMAX 3 ST; M
JALYN 3 ST; M
PROSCAR 3 ST; M
RAPAFLO 3 ST; M
silodosin 1 M
tamsulosin hcl 1 M
terazosin hcl 1 M; QL
UROXATRAL 3 ST; M
Hormonal Agents -
Adrenal
ACTIVE INJECTION
BLM-1 3
ACTIVE INJECTION
BM 3
ACTIVE INJECTION
DL 3
ACTIVE INJECTION
DLM 3
ACTIVE INJECTION
KIT L 3
ACTIVE INJECTION
KM 3
ACTIVE INJECTION
LM-DEP-2 3
ACTIVE INJECTION
M-1 3
BETA 1 KIT 6 MSD
BETALIDO 3
Last Updated 10/1/19
82
Drug Name Drug
Category
Limits/
Required
METHYLPREDNISOL
ONE ACETATE
INJECTION
SUSPENSION 50
MG/ML
6
MSD
METHYLPREDNISOL
ONE ACETATE
SUSPENSION 40
MG/ML INJECTION
6
MSD
methylprednisolone
acetate suspension 40
mg/ml injection
6
MSD
METHYLPREDNISOL
ONE ACETATE
SUSPENSION 80
MG/ML INJECTION
6
MSD
methylprednisolone
acetate suspension 80
mg/ml injection
6
MSD
methylprednisolone
oral 1
methylprednisolone
sodium succ 6 MSD
METHYLPREDNISOL
ONE-BUPIVACAINE 6 MSD
MILLIPRED 1
MILLIPRED DP 1
MILLIPRED DP 12-
DAY 1
MULTI-SPECIALTY 3
ORAPRED ODT 3
P-CARE D40MX 3
P-CARE D80MX 3
P-CARE K40 6 MSD
P-CARE K40G 6 MSD
P-CARE K40MX 3
P-CARE K80 6 MSD
P-CARE K80G 6 MSD
P-CARE K80MX 3
PEDIAPRED 1
POD-CARE 100K 6 MSD
POINT OF CARE KM 3
Drug Name Drug
Category
Limits/
Required
DEXAMETHASONE
SOD PHOS-NACL
INTRAVENOUS
SOLUTION 10-0.9
MG/50ML-%
6
MSD
dexamethasone sod
phosphate pf 6 MSD
dexamethasone
sodium phosphate
injection
6
MSD
DEXLIDO 3
DEXLIDO-M 3
DEXOPIN 3
DEXPAK 10 DAY 3 ST
DEXPAK 13 DAY 3 ST
DEXPAK 6 DAY 3 ST
DXEVO 11-DAY 3
DYURAL-40 3
DYURAL-80 3
DYURAL-L 3
DYURAL-LM 3
fludrocortisone acetate
oral 1 M
HIDEX 6-DAY 2 ST
hydrocortisone oral 1
KENALOG INJECTION 6 MSD
KENALOG-80 6 MSD
lidolog 1
LT INJECTION KIT 3
MARBETA-25 3
MARBETA-L 3
MARDEX-25 3
MEDROL 3
MEDROLOAN II SUIK 6 MSD
MEDROLOAN SUIK 6 MSD
METHYLPREDNISOL
ONE ACE-LIDO 3
Last Updated 10/1/19
83
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
POINT OF CARE L.2 3 triamcinolone acetonide
suspension 40 mg/ml
injection
6
MSD POINT OF CARE L.5 3
POINT OF CARE LM
DEP 2 3
TRIAMCINOLONE
DIACETATE
INJECTION
6
MSD
prednisolone oral
solution 1
TRIAMCINOLONE-
BUPIVACAINE 6 MSD prednisolone sodium
phosphate oral 1
TRILOAN II SUIK 6 MSD PREDNISONE
INTENSOL 1
TRILOAN SUIK 6 MSD
ZILRETTA 6 MSD prednisone oral 1
Hormonal Agents -
Men's Health
PRO-C-DURE 5 6 MSD
PRO-C-DURE 6 6 MSD
ANADROL-50 3 RAYOS 3 ST
ANDRODERM 2 PA; M READYSHARP
ANESTH +
BETAMETH
3
ANDROGEL PUMP 3 PA; M
ANDROGEL
TRANSDERMAL GEL
20.25 MG/1.25GM
(1.62%), 40.5
MG/2.5GM (1.62%)
3
PA; M
READYSHARP
ANESTH +
DEXAMETH
3
READYSHARP
ANESTH +
METHYLPRED
3
ANDROGEL
TRANSDERMAL GEL
25 MG/2.5GM (1%), 50
MG/5GM (1%)
3
ST; M
READYSHARP
BETAMETHASONE 6 MSD
AVEED 6 PA; MSD READYSHARP
DEXAMETHASONE 6 MSD
danazol oral 1
DEPO-
TESTOSTERONE 3 PA ROPIDEX 3
SOLU-CORTEF 6 MSD
EC-RX
TESTOSTERONE 3 M SOLU-MEDROL 6 MSD
TAPERDEX 12-DAY 3 ST
FORTESTA 3 ST; M
TAPERDEX 6-DAY 3 ST
METHITEST 2 M
TAPERDEX 7-DAY 3 ST
methyltestosterone oral 1 M
TRIAMCINOLONE
ACETONIDE
INJECTION
SUSPENSION 50
MG/ML
6
MSD
NANDROLONE
DECANOATE
INJECTION
3
NANDROLONE- 3
Last Updated 10/1/19
84
TRIAMCINOLONE
ACETONIDE
SUSPENSION 40
MG/ML INJECTION
6
MSD
TESTOSTERONE CYP
NATESTO 3 ST; M
oxandrolone oral 1 QL
STRIANT 3 PA; M
Last Updated 10/1/19
85
Drug Name Drug
Category
Limits/
Required
Hormonal Agents -
Parathyroid
cinacalcet hcl 1 M
SENSIPAR 2 M
Hormonal Agents -
Pituitary
ACTHAR 6 PA; MSD
cabergoline 1 QL
DDAVP INJECTION 6 MSD
DDAVP NASAL 3 M
DDAVP ORAL 3 M
DDAVP RHINAL TUBE 3 M
desmopressin ace
spray refrig 1 M
desmopressin acetate
injection 6 MSD
desmopressin acetate
oral 1 M
desmopressin acetate
spray 1 M
EGRIFTA 3 PA; M; S; QL
ELIGARD 3 S; QL
FIRMAGON 3 S; QL
GENOTROPIN 3 PA; M; S
GENOTROPIN
MINIQUICK 3 PA; M; S
GHRP2-GHRP6-
SERMORELIN 3
GHRP2-SERMORELIN 3
HUMATROPE 3 PA; M; S
INCRELEX 3 PA; M; S
IPAMORELIN
ACETATE 3
leuprolide acetate
injection 1 S
LEUPROLIDE
ACETATE-
BUPIVACAINE
3
LUPANETA PACK 2 QL
LUPRON DEPOT (1-
MONTH) 3 S
Drug Name Drug
Category
Limits/
Required
TESTIM 3 ST; M
TESTOPEL 3 PA
TESTOSTERONE
COMPOUNDING KIT 3 M
TESTOSTERONE
CYPIONATE & PROP 3
TESTOSTERONE
CYPIONATE
INJECTION
3
PA
testosterone cypionate
intramuscular 1 PA
TESTOSTERONE
ENANTHATE
INJECTION
1
PA
testosterone enanthate
intramuscular 1 PA
TESTOSTERONE
IMPLANT 3 PA
TESTOSTERONE
PROPIONATE
INJECTION
3
testosterone
transdermal gel 10
mg/act (2%), 12.5
mg/act (1%), 20.25
mg/1.25gm (1.62%),
20.25 mg/act (1.62%),
25 mg/2.5gm (1%),
40.5 mg/2.5gm
(1.62%), 50 mg/5gm
(1%)
1
PA; M
testosterone
transdermal solution 1 PA; M
VOGELXO 3 ST; M
VOGELXO PUMP 3 ST; M
XYOSTED 3 PA; M
Hormonal Agents -
Osteoporosis
EVISTA 3 PA; M
OSPHENA 3 M
raloxifene hcl 1 PA; M
Last Updated 10/1/19
86
Drug Name Drug
Category
Limits/
Required
OXYTOCIN-SODIUM
CHLORIDE
INTRAVENOUS
SOLUTION 20-0.9
UNT/L-%, 20-0.9
UT/500ML-%, 30-0.9
UNIT/L-%, 30-0.9
UT/500ML-%, 40-0.9
UNIT/L-%
6
MSD
PITOCIN 6 MSD
SAIZEN 3 PA; M; S
SAIZENPREP 3 PA; M; S
SANDOSTATIN 4 M; S
SANDOSTATIN LAR
DEPOT 6 MSD; QL
SIGNIFOR 6 M; MSD; QL
SIGNIFOR LAR 6 M; MSD; QL
SOMATULINE DEPOT 3 S
SOMAVERT 3 M; S
STIMATE 2 M
SUPPRELIN LA 6 MSD; QL
SYNAREL 2
TRELSTAR MIXJECT 6 MSD; QL
TRIPTODUR 6 MSD; QL
VANTAS 6 MSD; QL
VASOPRESSIN-
SODIUM CHLORIDE
INTRAVENOUS
SOLUTION 100-0.9
UT/100ML-%, 100-0.9
UT/250ML-%, 40-0.9
UT/100ML-%
6
MSD
VASOSTRICT 6 MSD
ZOLADEX 6 MSD; QL
ZOMACTON 3 PA; M; S
Hormonal Agents -
Prostaglandins
carboprost
tromethamine 6 MSD
CERVIDIL 3
HEMABATE 6 MSD
KORLYM 4 PA; M; S; QL
Drug Name Drug
Category
Limits/
Required
LUPRON DEPOT (3-
MONTH) 3 S
LUPRON DEPOT (4-
MONTH)
INTRAMUSCULAR KIT
30MG
3
S
LUPRON DEPOT (6-
MONTH)
INTRAMUSCULAR KIT
45MG
3
S
LUPRON DEPOT-PED
(1-MONTH) 3 PA; S
LUPRON DEPOT-PED
(3-MONTH) 2 PA
NOCDURNA 3 M
NOCTIVA 3 ST; M
NORDITROPIN
FLEXPRO 3 PA; M; S
NUTROPIN AQ
NUSPIN 10 4 PA; M; S
NUTROPIN AQ
NUSPIN 20 4 PA; M; S
NUTROPIN AQ
NUSPIN 5 4 PA; M; S
octreotide acetate 1 M; S
OMNITROPE
SUBCUTANEOUS
SOLUTION
4
PA; M; S
OMNITROPE
SUBCUTANEOUS
SOLUTION
RECONSTITUTED
3
PA; M; S
ORILISSA 2 PA; QL
oxytocin injection 6 MSD
OXYTOCIN-
DEXTROSE 6 MSD
OXYTOCIN-
LACTATED RINGERS 6 MSD
Last Updated 10/1/19
87
Drug Name Drug Limits/ Drug Name Drug Limits/
Category Required Category Required
Hormonal Agents - blisovi 24 fe 5 M; ACA Sex Hormones and
blisovi fe 1.5/30 5 M; ACA Birth Control
blisovi fe 1/20 5 M; ACA ACTIVELLA 3 M
briellyn 5 M; ACA afirmelle 5 M; ACA
camila 5 M; ACA ALORA 3 M; QL
camrese 5 M; ACA; QL altavera 5 M; ACA
camrese lo 5 M; ACA; QL alyacen 1/35 5 M; ACA
caziant 5 M; ACA alyacen 7/7/7 5 M; ACA
chateal 5 M; ACA amabelz 1 M
chateal eq 5 M; ACA amethia 5 M; ACA; QL
CLIMARA 3 M; QL amethia lo 5 M; ACA; QL
CLIMARA PRO 3 ST; M; QL amethyst 5 M; ACA
COMBIPATCH 2 M ANGELIQ 3 M
covaryx 1 M ANNOVERA 5 M; ACA
covaryx hs 1 M apri 5 M; ACA
CRINONE VAGINAL
GEL 4 % 2 QL aranelle 5 M; ACA
ashlyna 5 M; ACA; QL
cryselle-28 5 M; ACA
aubra 5 M; ACA
cyclafem 1/35 5 M; ACA
aubra eq 5 M; ACA
cyclafem 7/7/7 5 M; ACA
aurovela 1.5/30 5 M; ACA
cyred 5 M; ACA
aurovela 1/20 5 M; ACA
cyred eq 5 M; ACA
aurovela 24 fe 5 M; ACA
dasetta 1/35 5 M; ACA
aurovela fe 1.5/30 5 M; ACA
dasetta 7/7/7 5 M; ACA
aurovela fe 1/20 5 M; ACA
daysee 5 M; ACA; QL
aviane 5 M; ACA
deblitane 5 M; ACA
AYGESTIN 3 M
DELESTROGEN 3
ayuna 5 M; ACA
delyla 5 M; ACA
azurette 5 M; ACA
DEPO-ESTRADIOL 2
Last Updated 10/1/19
88
BALCOLTRA 5 M; ACA
DEPO-PROVERA
INTRAMUSCULAR
SUSPENSION 150
MG/ML
3
QL
balziva 5 M; ACA
bekyree 5 M; ACA
BEYAZ 3 ST; M
DEPO-PROVERA
INTRAMUSCULAR
SUSPENSION 400
6
MSD
BI-EST 80:20
PROGESTERONE 3
3 BIEST/PROGESTERO MG/ML
NE
BIJUVA 3 M
Last Updated 10/1/19
89
Drug Name Drug
Category
Limits/
Required
estradiol oral 1 M
estradiol transdermal 1 M; QL
estradiol vaginal 1 M
estradiol valerate
intramuscular 1
estradiol-norethindrone
acet 1 M
ESTRING 2 M; QL
ESTROGEL 3 ST; M; QL
ESTROSTEP FE 3 ST; M
ethynodiol diac-eth
estradiol 5 M; ACA
EVAMIST 3 M; QL
FALESSA 5 M; ACA
falmina 5 M; ACA
fayosim 5 M; ACA; QL
FEMHRT LOW DOSE 3 M
FEMRING 3 ST; M; QL
femynor 5 M; ACA
fyavolv 1 M
GENERESS FE 3 ST; M
gianvi 5 M; ACA
hailey 1.5/30 5 M; ACA
hailey 24 fe 5 M; ACA
heather 5 M; ACA
hydroxyprogesterone
caproate intramuscular 6 MSD
IMVEXXY
MAINTENANCE PACK 3 M
IMVEXXY STARTER
PACK 3 M
incassia 5 M; ACA
introvale 5 M; ACA; QL
isibloom 5 M; ACA
jasmiel 5 M; ACA
jencycla 5 M; ACA
jinteli 1 M
jolessa 5 M; ACA; QL
juleber 5 M; ACA
Drug Name Drug
Category
Limits/
Required
DEPO-PROVERA
INTRAMUSCULAR
SUSPENSION
PREFILLED SYRINGE
3
QL
DEPO-SUBQ
PROVERA 104 5 ACA; QL
desogestrel-ethinyl
estradiol 5 M; ACA
DIVIGEL
TRANSDERMAL GEL
0.25 MG/0.25GM, 0.5
MG/0.5GM, 1 MG/GM
2
M; QL
DIVIGEL
TRANSDERMAL GEL
0.75 MG/0.75GM
2
M
dotti 1 M; QL
drospiren-eth estrad-
levomefol 5 M; ACA
drospirenone-ethinyl
estradiol 5 M; ACA
DUAVEE 2 M
EC-RX ESTRADIOL 3 M
EC-RX
PROGESTERONE 3
eemt 1 M
eemt hs 1 M
ELESTRIN 3 M; QL
elinest 5 M; ACA
ELLA 5 ACA; QL
emoquette 5 M; ACA
enpresse-28 5 M; ACA
enskyce 5 M; ACA
errin 5 M; ACA
est estrogens-
methyltest 1 M
est estrogens-
methyltest ds 1 M
est estrogens-
methyltest hs 1 M
estarylla 5 M; ACA
ESTRACE 3 M
Last Updated 10/1/19
90
Drug Name Drug
Category
Limits/
Required
LOESTRIN FE 1/20 3 ST; M
lopreeza 1 M
loryna 5 M; ACA
LOSEASONIQUE 3 ST; M; QL
low-ogestrel 5 M; ACA
lo-zumandimine 5 M; ACA
lutera 5 M; ACA
lyza 5 M; ACA
MAKENA 6 MSD
marlissa 5 M; ACA
medroxyprogesterone
acetate intramuscular 5 ACA; QL
medroxyprogesterone
acetate oral 1 M
MEGACE ES 3 M
megestrol acetate oral
suspension 40 mg/ml,
400 mg/10ml
1
megestrol acetate oral
suspension 625 mg/5ml 1 M
megestrol acetate oral
tablet 1 S
melodetta 24 fe 5 M; ACA
MENEST 3 M
MENOSTAR 3 M; QL
mibelas 24 fe 5 M; ACA
microgestin 1.5/30 5 M; ACA
microgestin 1/20 5 M; ACA
microgestin fe 1.5/30 5 M; ACA
microgestin fe 1/20 5 M; ACA
mili 5 M; ACA
mimvey 1 M
mimvey lo 1 M
MINASTRIN 24 FE 3 ST; M
MINIVELLE 3 ST; M; QL
MIRCETTE 3 ST; M
MIRENA (52 MG) 6 MSD
mono-linyah 5 M; ACA
NATAZIA 5 M; ACA
Drug Name Drug
Category
Limits/
Required
junel 1.5/30 5 M; ACA
junel 1/20 5 M; ACA
junel fe 1.5/30 5 M; ACA
junel fe 1/20 5 M; ACA
junel fe 24 5 M; ACA
kaitlib fe 5 M; ACA
kalliga 5 M; ACA
kariva 5 M; ACA
kelnor 1/35 5 M; ACA
kelnor 1/50 5 M; ACA
kurvelo 5 M; ACA
KYLEENA 6 MSD
larin 1.5/30 5 M; ACA
larin 1/20 5 M; ACA
larin 24 fe 5 M; ACA
larin fe 1.5/30 5 M; ACA
larin fe 1/20 5 M; ACA
larissia 5 M; ACA
layolis fe 5 M; ACA
leena 5 M; ACA
lessina 5 M; ACA
levonest 5 M; ACA
levonorgest-eth est &
eth est 5 M; ACA; QL
levonorgest-eth estrad
91-day 5 M; ACA; QL
levonorgestrel 5 ACA; OTC; QL
levonorgestrel-ethinyl
estrad 5 M; ACA
levonorg-eth estrad
triphasic 5 M; ACA
levora 0.15/30 (28) 5 M; ACA
LILETTA (52 MG) 6 MSD
lillow 5 M; ACA
LO LOESTRIN FE 5 M; ACA
LOESTRIN 1.5/30 (21) 3 ST; M
LOESTRIN 1/20 (21) 3 ST; M
LOESTRIN FE 1.5/30 3 ST; M
Last Updated 10/1/19
91
Drug Name Drug
Category
Limits/
Required
pirmella 1/35 5 M; ACA
pirmella 7/7/7 5 M; ACA
portia-28 5 M; ACA
PREFEST 3 M
PREMARIN
INJECTION 6 MSD
PREMARIN ORAL 2 M
PREMARIN VAGINAL 2 M
PREMPHASE 2 M
PREMPRO 2 M
preventeza 5 ACA; OTC; QL
previfem 5 M; ACA
PROGESTERONE
COMPOUNDING KIT 3
progesterone
micronized oral 1 M
progesterone
micronized transdermal 1
PROMETRIUM 3 M
PROVERA 3 M
QUARTETTE 3 ST; M; QL
reclipsen 5 M; ACA
rivelsa 5 M; ACA; QL
SAFYRAL 3 ST; M
SEASONIQUE 3 ST; M; QL
setlakin 5 M; ACA; QL
sharobel 5 M; ACA
simliya 5 M; ACA
simpesse 5 M; ACA; QL
SKYLA 6 MSD
SLYND 5 M; ACA
sprintec 28 5 M; ACA
sronyx 5 M; ACA
syeda 5 M; ACA
tarina 24 fe 5 M; ACA
tarina fe 1/20 5 M; ACA
tarina fe 1/20 eq 5 M; ACA
TAYTULLA 5 M; ACA
Drug Name Drug
Category
Limits/
Required
necon 0.5/35 (28) 5 M; ACA
NEXPLANON 6 MSD
nikki 5 M; ACA
nora-be 5 M; ACA
norethin ace-eth
estrad-fe 5 M; ACA
norethindrone acetate
oral 1 M
norethindrone acet-
ethinyl est 5 M; ACA
norethindrone oral 5 M; ACA
norethindrone-eth
estradiol 1 M
norethin-eth estradiol-fe 5 M; ACA
norgestimate-eth
estradiol 5 M; ACA
norgestimate-ethinyl
estradiol triphasic 5 M; ACA
norlyda 5 M; ACA
norlyroc 5 M; ACA
nortrel 0.5/35 (28) 5 M; ACA
nortrel 1/35 (21) 5 M; ACA
nortrel 1/35 (28) 5 M; ACA
nortrel 7/7/7 5 M; ACA
NUVARING 5 M; ACA; QL
ocella 5 M; ACA
ogestrel 5 M; ACA
orsythia 5 M; ACA
ORTHO MICRONOR 3 ST; M
ORTHO TRI-CYCLEN
LO 3 ST; M
ORTHO-NOVUM 1/35
(28) 3 ST; M
ORTHO-NOVUM 7/7/7
(28) 3 ST; M
PARAGARD
INTRAUTERINE
COPPER
6
MSD
philith 5 M; ACA
pimtrea 5 M; ACA
Last Updated 10/1/19
92
Drug Name Drug
Category
Limits/
Required
levo-t 3 M
levothyroxine sodium
intravenous 6 MSD
levothyroxine sodium
oral 1 M
levothyroxine-
liothyronine oral tablet
120 mg, 15 mg, 30 mg,
60 mg, 90 mg
1
M
levoxyl 1 M
liothyronine sodium
intravenous 6 MSD
liothyronine sodium oral 1 M
methimazole oral 1 M
NATURE-THROID
ORAL TABLET 113.75
MG, 146.25 MG, 162.5
MG, 260 MG, 325 MG,
48.75 MG, 81.25 MG,
97.5 MG
1
M
nature-throid oral tablet
130 mg, 16.25 mg, 195
mg, 32.5 mg, 65 mg
1
M
np thyroid 1 M
PARSABIV 6 M; MSD
propylthiouracil oral 1 M
SYNTHROID 3 M
TAPAZOLE 3 M
TIROSINT 3 M
TIROSINT-SOL 6 M; MSD
TRIOSTAT 6 ST; MSD
unithroid 1 M
westhroid oral tablet
130 mg, 32.5 mg, 65
mg
1
M
WESTHROID ORAL
TABLET 195 MG, 97.5
MG
1
M
WP THYROID 1 M
Drug Name Drug
Category
Limits/
Required
tilia fe 5 M; ACA
tri femynor 5 M; ACA
tri-estarylla 5 M; ACA
tri-legest fe 5 M; ACA
tri-linyah 5 M; ACA
tri-lo-estarylla 5 M; ACA
tri-lo-marzia 5 M; ACA
tri-lo-mili 5 M; ACA
tri-lo-sprintec 5 M; ACA
tri-mili 5 M; ACA
tri-previfem 5 M; ACA
tri-sprintec 5 M; ACA
trivora (28) 5 M; ACA
tri-vylibra 5 M; ACA
tri-vylibra lo 5 M; ACA
tulana 5 M; ACA
tydemy 5 M; ACA
VAGIFEM 3 ST; M
velivet 5 M; ACA
vienva 5 M; ACA
viorele 5 M; ACA
VIVELLE-DOT 3 ST; M; QL
vyfemla 5 M; ACA
vylibra 5 M; ACA
wera 5 M; ACA
wymzya fe 5 M; ACA
xulane 5 M; ACA
YASMIN 28 3 ST; M
YAZ 3 ST; M
yuvafem 1 M
zarah 5 M; ACA
zovia 1/35e (28) 5 M; ACA
zumandimine 5 M; ACA
Hormonal Agents -
Thyroid
ARMOUR THYROID 1 M
CYTOMEL 3 ST; M
euthyrox 3 M
Last Updated 10/1/19
93
Drug Name Drug
Category
Limits/
Required
CIMZIA 3 PA; S
CIMZIA PREFILLED
KIT 3 PA; M; S
CIMZIA STARTER KIT 3 PA; M; S
CINRYZE 6 MSD
COSENTYX (300 MG
DOSE) 3 PA; M; S; QL
COSENTYX 150
MG/ML 3 PA; M; S; QL
COSENTYX
SENSOREADY (300
MG)
3
PA; M; S; QL
COSENTYX
SENSOREADY PEN 3 PA; M; S; QL
CUTAQUIG
SOLUTION 1 GM/6ML
SUBCUTANEOUS
3
PA
CUTAQUIG
SOLUTION 1 GM/6ML
SUBCUTANEOUS
6
PA; MSD
CUTAQUIG
SOLUTION 2
GM/12ML
SUBCUTANEOUS
3
PA
CUTAQUIG
SOLUTION 2
GM/12ML
SUBCUTANEOUS
6
PA; MSD
CUTAQUIG
SOLUTION 4
GM/24ML
SUBCUTANEOUS
3
PA
CUTAQUIG
SOLUTION 4
GM/24ML
SUBCUTANEOUS
6
PA; MSD
CUTAQUIG
SOLUTION 8
GM/48ML
SUBCUTANEOUS
3
PA
CUTAQUIG
SOLUTION 8
GM/48ML
SUBCUTANEOUS
6
PA; MSD
Drug Name Drug
Category
Limits/
Required
Immunological
Agents - Drugs for
Immune System
Stimulation or
Suppression
ACTEMRA ACTPEN 4 PA; M; S
ACTEMRA
INTRAVENOUS 6 PA; MSD
ACTEMRA
SUBCUTANEOUS 4 PA; M; S; QL
ACTIMMUNE 6 M; MSD
ALFERON N 6 MSD
ARAVA 3 M; QL
ARCALYST 4 PA; M; S
ASTAGRAF XL 3 ST; M
ATGAM 6 MSD
AZASAN 3 M
azathioprine oral 1 M
azathioprine sodium 6 MSD
BENLYSTA
INTRAVENOUS 6 MSD
BENLYSTA
SUBCUTANEOUS 3 PA; M; S
BERINERT 6 MSD
BIVIGAM 6 PA; MSD
CARIMUNE NF
SOLUTION
RECONSTITUTED 12
GM INTRAVENOUS
6
PA; MSD
carimune nf solution
reconstituted 12 gm
intravenous
6
PA; MSD
CARIMUNE NF
SOLUTION
RECONSTITUTED 6
GM INTRAVENOUS
6
PA; MSD
carimune nf solution
reconstituted 6 gm
intravenous
6
PA; MSD
CELLCEPT 3 M
CELLCEPT
INTRAVENOUS 6 MSD
Last Updated 10/1/19
94
Drug Name Drug
Category
Limits/
Required
HUMIRA PEDIATRIC
CROHNS START
SUBCUTANEOUS
PREFILLED SYRINGE
KIT 40 MG/0.8ML, 80
MG/0.8ML &
40MG/0.4ML
3
PA; M; S; QL
HUMIRA PEDIATRIC
CROHNS START
SUBCUTANEOUS
PREFILLED SYRINGE
KIT 80 MG/0.8ML
3
PA; M; S
HUMIRA PEN 3 PA; M; S; QL
HUMIRA PEN-
CD/UC/HS STARTER
SUBCUTANEOUS
PEN-INJECTOR KIT
40 MG/0.8ML
3
PA; M; S; QL
HUMIRA PEN-
CD/UC/HS STARTER
SUBCUTANEOUS
PEN-INJECTOR KIT
80 MG/0.8ML
3
PA; M; S
HUMIRA PEN-
PS/UV/ADOL HS
START
SUBCUTANEOUS
PEN-INJECTOR KIT
40 MG/0.8ML
3
PA; M; S; QL
HUMIRA PEN-
PS/UV/ADOL HS
START
SUBCUTANEOUS
PEN-INJECTOR KIT
80 MG/0.8ML &
40MG/0.4ML
3
PA; M; S
HYPERHEP B S/D 6 MSD
HYPERRAB 6 MSD
HYPERRAB S/D 6 MSD
HYPERRHO S/D 6 MSD
HYPERTET S/D 6 MSD
HYQVIA 6 PA; MSD
icatibant acetate 1 PA
ILARIS 6 PA; MSD; QL
ILUMYA 4 M; S
Drug Name Drug
Category
Limits/
Required
CUTAQUIG
SUBCUTANEOUS
SOLUTION 1.65
GM/10ML, 3.3
GM/20ML
6
PA; MSD
CUVITRU 6 PA; MSD
cyclosporine
intravenous 6 MSD
cyclosporine modified 1 M
cyclosporine oral 1 M
CYTOGAM 6 MSD
ENBREL 4 PA; M; S; QL
ENBREL MINI 4 PA; M; S; QL
ENBREL SURECLICK 4 PA; M; S; QL
ENTYVIO 6 MSD
ENVARSUS XR 3 ST; M
FIRAZYR 3 PA; S
FLEBOGAMMA DIF 6 PA; MSD
GAMASTAN 6 MSD
gamastan s/d injectable
intramuscular 6 MSD
GAMASTAN S/D
INJECTABLE
INTRAMUSCULAR
6
MSD
GAMIFANT 6 MSD
GAMMAGARD 6 PA; MSD
GAMMAGARD S/D
LESS IGA 6 PA; MSD
GAMMAKED 6 PA; MSD
GAMMAPLEX 6 PA; MSD
GAMUNEX-C 6 PA; MSD
gengraf 1 M
HAEGARDA 6 MSD
HEPAGAM B 6 MSD
HIZENTRA 6 PA; MSD
HUMIRA 3 PA; M; S; QL
Last Updated 10/1/19
95
Drug Name Drug
Category
Limits/
Required
PROGRAF
INTRAVENOUS 6 MSD
PROGRAF ORAL 3 M
PROVENGE 6 MSD
RAPAMUNE ORAL
SOLUTION 2 M
RAPAMUNE ORAL
TABLET 3 M
RASUVO 3 M; S; QL
REMICADE 6 PA; MSD
RENFLEXIS 6 PA; MSD
RHOGAM ULTRA-
FILTERED PLUS 6 MSD
RHOPHYLAC 6 MSD
RIDAURA 2 M
RUCONEST 6 MSD
SANDIMMUNE
INTRAVENOUS 6 MSD
SANDIMMUNE ORAL
CAPSULE 3 M
SANDIMMUNE ORAL
SOLUTION 2 M
SILIQ 4 PA; M; S
SIMPONI 3 PA; M; S; QL
SIMPONI ARIA 6 PA; M; MSD
SIMULECT 6 MSD
sirolimus oral 1 M
SKYRIZI (150 MG
DOSE) 3 PA; M
STELARA
INTRAVENOUS 6 PA; MSD
STELARA
SUBCUTANEOUS 3 PA; M; S
SYNAGIS 6 PA; MSD
tacrolimus oral 1 M
TALTZ 4 PA; M; S
temsirolimus 6 MSD
THYMOGLOBULIN 6 MSD
TICE BCG 6 MSD
TORISEL 6 MSD
Drug Name Drug
Category
Limits/
Required
IMOGAM RABIES-HT
INJECTION
SOLUTION 300
UNIT/2ML
6
MSD
IMURAN 3 M
INFLECTRA 6 PA; MSD
KEDRAB 6 MSD
KEVZARA 4 PA; M; S
KINERET 4 PA; M; S; QL
KYMRIAH 6 MSD
leflunomide oral 1 M; QL
methotrexate oral 1
methotrexate sodium 1
methotrexate sodium
(pf) 1
MICRHOGAM ULTRA-
FILTERED PLUS 6 MSD
mycophenolate mofetil 1 M
mycophenolate mofetil
hcl 6 MSD
mycophenolate sodium 1 M
MYFORTIC 3 M
nabi-hb 6 MSD
NEORAL 3 M
NULOJIX 6 MSD
OCTAGAM 6 PA; MSD
OLUMIANT 4 PA; M; S
ORENCIA CLICKJECT 4 PA; M; S
ORENCIA
INTRAVENOUS 6 PA; M; MSD
ORENCIA
SUBCUTANEOUS 4 PA; M; S
OTEZLA ORAL
TABLET 3 PA; M; S; QL
OTEZLA ORAL
TABLET THERAPY
PACK
3
PA; S; QL
OTREXUP 3 M; S; QL
PANZYGA 6 PA; MSD
PRIVIGEN 6 PA; MSD
Last Updated 10/1/19
96
Drug Name Drug
Category
Limits/
Required
FLUZONE
QUADRIVALENT 5 ACA
GARDASIL 9 5 ACA
HAVRIX 5 ACA
HEPLISAV-B 5 ACA
HIBERIX 5 ACA
IMOVAX RABIES 6 MSD
INFANRIX 5 ACA
IPOL 5 ACA
IXIARO 6 MSD
KINRIX 5 ACA
MENACTRA 5 ACA
MENVEO 5 ACA
M-M-R II
SUBCUTANEOUS
INJECTABLE
5
ACA
PEDIARIX 5 ACA
PEDVAX HIB 5 ACA
PENTACEL 5 ACA
pneumovax 23
injectable 25 mcg/0.5ml
injection
5
ACA
PNEUMOVAX 23
INJECTABLE 25
MCG/0.5ML
INJECTION
5
ACA
PREVNAR 13 5 ACA
PROQUAD 5 ACA
QUADRACEL 5 ACA
RABAVERT 6 MSD
RECOMBIVAX HB 5 ACA
ROTARIX 5 ACA
ROTATEQ 5 ACA
SHINGRIX 5 ACA
STAMARIL 6 MSD
TDVAX 5 ACA
TENIVAC 5 ACA
TRUMENBA 5 ACA
TWINRIX 5 ACA
Drug Name Drug
Category
Limits/
Required
TREMFYA 3 PA; M; S
TREXALL 3
VARIZIG 2
WINRHO SDF 6 MSD
XATMEP 4 PA; S
XELJANZ 3 PA; M; S; QL
XELJANZ XR 3 PA; M; S; QL
ZINPLAVA 6 PA; MSD
ZORTRESS 2 M
Immunological
Agents - Drugs for
Vaccination
ACTHIB 5 ACA
ADACEL 5 ACA
AFLURIA
QUADRIVALENT 5 ACA
BCG VACCINE 6 MSD
BEXSERO 5 ACA
BIOTHRAX 6 MSD
BOOSTRIX 5 ACA
DAPTACEL 5 ACA
DIPHTHERIA-
TETANUS TOXOIDS
DT
5
ACA
ENGERIX-B 5 ACA
EZ FLU SHOT-
FLUCELVAX QUAD 5 ACA
FLUAD 5 ACA
FLUARIX
QUADRIVALENT 5 ACA
FLUBLOK
QUADRIVALENT 5 ACA
FLUCELVAX
QUADRIVALENT 5 ACA
FLULAVAL
QUADRIVALENT 5 ACA
FLUMIST
QUADRIVALENT 5 ACA
FLUZONE HIGH-
DOSE 5 ACA
Last Updated 10/1/19
97
Drug Name Drug Limits/
Category Required
hydrocortisone acetate 1
rectal
hydrocortisone rectal 1
LIALDA 3 M
mesalamine oral
capsule delayed 1 M
release
mesalamine oral tablet
delayed release 1.2 gm 1 M
mesalamine oral tablet
delayed release 800 1
mg
mesalamine rectal 1
mesalamine-cleanser 1
PENTASA 2 M
PROCORT 3
PROCTOCORT
RECTAL CREAM 3 ST
PROCTOCORT
RECTAL 3
SUPPOSITORY
PROCTOFOAM HC 3
procto-med hc 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
ROWASA 3
SFROWASA 3
sulfasalazine oral 1 M
UCERIS ORAL 3
UCERIS RECTAL 2
Metabolic Bone
Disease Agents -
Drugs for
Osteoporosis
ACTONEL ORAL
TABLET 150 MG, 35 3 ST; M; QL
MG, 5 MG
ACTONEL ORAL
TABLET 30 MG
3
ST
Drug Name Drug
Category
Limits/
Required
TYPHIM VI 6 MSD
VAQTA 5 ACA
VARIVAX 5 ACA
VAXCHORA 6 MSD
VIVOTIF 6 MSD
yf-vax injectable
subcutaneous 6 MSD
YF-VAX INJECTABLE
SUBCUTANEOUS 6 MSD
ZOSTAVAX 5 ACA
Inflammatory Bowel
Disease Agents
ANALPRAM HC 3
ANALPRAM HC
SINGLES 3
ANALPRAM-HC 3
anucort-hc 1
ANUSOL-HC RECTAL
CREAM 3 ST
anusol-hc rectal
suppository 3
APRISO 2 M
ASACOL HD 3 ST
AZULFIDINE 3 M
AZULFIDINE EN-TABS 3 M
balsalazide disodium 1
budesonide er 1
budesonide oral 1
CANASA 3
COLAZAL 3
colocort 1
CORTENEMA 3
CORTIFOAM 3 ST
DELZICOL 3 ST; M
DIPENTUM 3 ST; M
ENTOCORT EC 3
hemmorex-hc 1
hydrocortisone ace-
pramoxine rectal 1
Last Updated 10/1/19
98
Drug Name Drug
Category
Limits/
Required
risedronate sodium oral
tablet 30 mg 1
risedronate sodium oral
tablet delayed release 1 M; QL
ROCALTROL 3 M
TYMLOS 3 PA; M; S
ZEMPLAR
INTRAVENOUS 6 MSD
ZEMPLAR ORAL 3 M
zoledronic acid
intravenous
concentrate
6
MSD
zoledronic acid
intravenous solution 6 PA; MSD
Miscellaneous
Therapeutic Agents
ACACIA
SUBCUTANEOUS 3
ACETADOTE 6 MSD
acetylcysteine
intravenous 6 MSD
ACREMONIUM 6 MSD
adenosine (diagnostic) 6 MSD
adenosine intravenous
solution 3 mg/ml 6 MSD
ALBUKED 25 6 MSD
ALBUKED 5 6 MSD
albumin human 6 MSD
ALBUMINEX 6 MSD
alburx 6 MSD
ALBUTEIN 6 MSD
alcohol prep pads pad
, 70 % 2 OTC
ALCOHOL PREP
PADS PAD 70 % 2 OTC
ALDER 3
ALPHA-LIPOIC ACID
INJECTION 3
ALTERNARIA 6 MSD
Drug Name Drug
Category
Limits/
Required
alendronate sodium
oral solution 1 M; QL
alendronate sodium
oral tablet 10 mg, 35
mg, 5 mg, 70 mg
1
M; QL
alendronate sodium
oral tablet 40 mg 1 QL
ATELVIA 3 ST; M; QL
BINOSTO 3 ST; M; QL
BONIVA
INTRAVENOUS 6 PA; MSD; QL
BONIVA ORAL 3 ST; M; QL
calcitonin (salmon) 1 M; QL
calcitriol intravenous 6 MSD
calcitriol oral 1 M
doxercalciferol
intravenous 6 MSD
doxercalciferol oral 1 M
etidronate disodium 1
EVENITY 6 MSD; QL
FORTEO 3 ST; M; S; QL
FOSAMAX 3 ST; M; QL
FOSAMAX PLUS D 3 ST; M; QL
HECTOROL 6 MSD
ibandronate sodium
intravenous 6 PA; MSD; QL
ibandronate sodium
oral 1 M; QL
MIACALCIN
INJECTION 6 MSD
NATPARA 3 PA; M; S; QL
pamidronate disodium 6 MSD
paricalcitol intravenous 6 MSD
paricalcitol oral 1 M
PROLIA 6 PA; MSD; QL
RAYALDEE 3 M
RECLAST 6 PA; MSD
risedronate sodium oral
tablet 150 mg, 35 mg, 5
mg
1
M; QL
Last Updated 10/1/19
99
Drug Name Drug
Category
Limits/
Required
bacteriostatic
water(benz alc) solution
injection
6
MSD
BAHIA 6 MSD
bal in oil 2
BALD CYPRESS 6 MSD
BANANA
(DIAGNOSTIC) 6 MSD
BAYBERRY (WAX
MYRTLE) 6 MSD
BD SYRINGE LUER-
LOK 30 ML 2
BEEF (DIAGNOSTIC) 6 MSD
BENTLEY THE BEAR
PED NEBULIZER 6 MSD
BERMUDA GRASS 6 MSD
BIOFREQUENCY
INSOLES 3
BIOGUARD ISLAND
DRESSINGS PAD
4"X10" , 4"X14"
3
BIOGUARD NON-
ADHERENT
DRESSING
3
BLACK WALNUT
POLLEN 6 MSD
BLACK WILLOW 6 MSD
BOTOX 6 PA; MSD
BOTRYTIS 6 MSD
BOX ELDER 6 MSD
BREATHERITE 6 MSD
BREATHERITE
VALVED MDI
CHAMBER
6
MSD
BREVITAL SODIUM 6 MSD
BRIDION 6 MSD
BROME 6 MSD
CALCIUM DISODIUM
VERSENATE 2
CALIFORNIA PEPPER
TREE 3
Drug Name Drug
Category
Limits/
Required
AMD FOAM
DRESSING PAD 3-
1/2"X3"
3
AMERICAN BEECH 3
AMERICAN
COCKROACH 6 MSD
AMERICAN ELM 6 MSD
AMERICAN
SYCAMORE 6 MSD
AMIDATE 6 MSD
AMINOPMRMS 3
AMPHADASE 6 MSD
ANASCORP 6 MSD
ANAVIP 6 MSD
ANDEXXA 6 MSD
ANESTHESIA S/I-40 6 MSD
ANESTHESIA S/I-40A 6 MSD
ANESTHESIA S/I-40H 6 MSD
ANESTHESIA S/I-40S 6 MSD
ANESTHESIA S/I-60 6 MSD
ANTIVENIN
LATRODECTUS
MACTANS
3
ANTIVENIN
MICRURUS FULVIUS 6 MSD
APP SLIM RMS 3
APPLE (DIAGNOSTIC) 6 MSD
ARIZONA CYPRESS 6 MSD
ARTISS 6 MSD
asilnasalrms 1
AURA PORTANEB 6 MSD
AUREOBASIDIUM 6 MSD
AUSTRALIAN PINE 6 MSD
AVOCADO
(DIAGNOSTIC) 6 MSD
AXUMIN 6 MSD
BACTERIOSTATIC
WATER(BENZ ALC)
SOLUTION
INJECTION
3
Last Updated 10/1/19
100
Drug Name Drug
Category
Limits/
Required
CYSVIEW 6 MSD
deferoxamine mesylate 6 MSD
DESFERAL 6 MSD
desflurane 6 MSD
dexmedetomidine hcl in
nacl 6 MSD
DEXMEDETOMIDINE
HCL INTRAVENOUS
SOLUTION 1000
MCG/10ML, 400
MCG/4ML
6
MSD
dexmedetomidine hcl
intravenous solution
200 mcg/2ml
6
MSD
DEXMEDETOMIDINE
HCL-DEXTROSE 6 MSD
diluent for treprostinil 6 MSD
DIPRIVAN 6 MSD
DOG EPITHELIUM 6 MSD
DOG FENNEL 3
DOTAREM
INTRAVENOUS
SOLUTION 2.5
MMOL/5ML, 5
MMOL/10ML, 50
MMOL/100ML
6
MSD
DOVER URETHRAL
CATHETER 6 MSD
DRECHSLERA 6 MSD
DUODOTE 3
DUROLANE 6 MSD
DUST MITE MIXED
ALLERGEN EXT 6 MSD
DYSPORT 6 PA; MSD
EASIVENT 6 MSD
EASTERN
COTTONWOOD 6 MSD
EASY COMFORT
ALCOHOL PADS 2 OTC
EASY GLIDE LUER
LOCK SYRINGE 3 OTC
EC-RX DHEA 3
Drug Name Drug
Category
Limits/
Required
CANDIDA ALBICANS
EXTRACT 6 MSD
CANTALOUPE
(DIAGNOSTIC) 6 MSD
CAPTAIN EAGLE PED
NEBULIZER 6 MSD
CARDIOVID PLUS 3
CASEIN
(DIAGNOSTIC) 6 MSD
CAT HAIR EXTRACT 6 MSD
CATTLE EPITHELIUM 3
CAYA 5 ACA
CEDAR ELM 6 MSD
CEFALY KIT 6 MSD
CHICKEN MEAT
(DIAGNOSTIC) 6 MSD
chlorhexidine gluconate
solution 20 % 2
CHLORHEXIDINE
GLUCONATE
SOLUTION 20 %
3
CHOLETEC 6 MSD
CLADOSPORIUM
CLADOSPORIOIDES 6 MSD
CLADOSPORIUM
SPHAEROSPERMUM 6 MSD
COCKLEBUR 3
COCOA BEAN
(DIAGNOSTIC) 6 MSD
COENZYME Q-10
INJECTION 3
CORN POLLEN 6 MSD
CORTROSYN 6 MSD
cosyntropin 6 MSD
CRAB (DIAGNOSTIC) 6 MSD
CURITY AMD
ANTIMICROBIAL
STRIP
3
CURITY IODOFORM
PACKING STRIP 3
CURVULARIA 6 MSD
Last Updated 10/1/19
101
Drug Name Drug
Category
Limits/
Required
GELFOAM-JMI
SPONGE 6 MSD
GEL-ONE 6 MSD
GELSYN-3 6 MSD
GENTLECATH
URINARY CATHETER 6 MSD; OTC
GENVISC 850 6 MSD
GERMAN
COCKROACH 3
GLUCAGON HCL
(DIAGNOSTIC) 3
glutaraldehyde external 2
GOLDENROD 6 MSD
GRASTEK 2 M; QL
HACKBERRY 3
HCU EASY 3
HISTATROL
INJECTION 6 MSD
HONEY BEE VENOM 6 MSD
HONEY BEE VENOM
PROTEIN INJECTION
SOLUTION
RECONSTITUTED
1300 MCG
3
HONEY BEE VENOM
PROTEIN INJECTION
SOLUTION
RECONSTITUTED 550
MCG
6
MSD
HORSE EPITHELIUM 6 MSD
HYALGAN 6 MSD
HYLENEX 3
HYMOVIS 6 MSD
IC GREEN 6 MSD
indigo carmine 6 MSD
indocyanine green
intravenous 6 MSD
INFED 6 MSD
infusion set 6 MSD
Drug Name Drug
Category
Limits/
Required
EGG WHITE
(DIAGNOSTIC) 6 MSD
ELCYS 6 MSD
ENDARI 3 PA; S
ENGLISH PLANTAIN 6 MSD
EPICOCCUM 6 MSD
ergoloid mesylates oral 1 M
EROS-CTD 3
etomidate intravenous 6 MSD
EUFLEXXA 6 MSD
E-Z-DISK 6 MSD
E-Z-HD 6 MSD
E-Z-PAQUE 6 MSD
E-Z-PASTE 6 MSD
FEMCAP 5 ACA
FIRDAPSE 3 S
FIRE ANT 6 MSD
FLEXBUMIN 6 MSD
flumazenil intravenous 6 MSD
FLYP NEBULIZER 6 MSD
fomepizole 6 MSD
formaldehyde external
solution 37 % 2
FUSARIUM 6 MSD
GADAVIST 6 MSD
GEL-FLOW 6 MSD
GELFOAM
COMPRESSED SIZE
100
6
MSD
GELFOAM DENTAL
PACK SIZE 4 6 MSD
GELFOAM SPONGE 6 MSD
GELFOAM SPONGE
SIZE 100 6 MSD
GELFOAM SPONGE
SIZE 200 6 MSD
GELFOAM SPONGE
SIZE 50 6 MSD
GELFOAM-JMI
POWDER 6 MSD
Last Updated 10/1/19
102
Drug Name Drug
Category
Limits/
Required
Drug Name Drug
Category
Limits/
Required
INNOSPIRE GO
PORTABLE MESH
NEB
6
MSD; OTC
MACRILEN 6 MSD
MAGNEVIST 6 MSD
MEADOW FESCUE
GRASS POLLEN 6 MSD INSPIREASE
RESERVOIR BAGS 3
MELALEUCA 3 insulin pump ir2020 3
MESQUITE 6 MSD isosulfan blue 6 MSD
methergine 1 JOHNSON GRASS 6 MSD
METHOHEXITAL
SODIUM 6 MSD J-TIP KIT W/VIAL
ADAPTERS 3
methylene blue
injection 6 MSD JUNE GRASS
POLLEN
STANDARDIZED
6
MSD
methylergonovine
maleate injection 6 MSD
KALBITOR 6 MSD
methylergonovine
maleate oral 1
KAPOK 6 MSD
kedbumin 6 MSD
MINIMED 530G
INSULIN PUMP 6 MSD
KERLIX AMD
ANTIMICROBIAL 3
MITE (D. FARINAE) 6 MSD
KERLIX AMD SUPER
SPONGES 3
MITE (D.
PTERONYSSINUS) 6 MSD
KETALAR 6 MSD
MIXED ASPERGILLUS 6 MSD
ketamine hcl injection
solution 10 mg/ml, 100
mg/ml, 50 mg/ml
6
MSD MIXED FEATHERS 6 MSD
MIXED RAGWEED 6 MSD
MIXED VESPID
VENOM PROTEIN
INJECTION
SOLUTION
RECONSTITUTED
1300-1300-1300 MCG
3
KETAMINE HCL
INJECTION
SOLUTION
PREFILLED SYRINGE
6
MSD
KETAMINE HCL
INTRAVENOUS 6 MSD
MIXED VESPID
VENOM PROTEIN
INJECTION
SOLUTION
RECONSTITUTED
550-550-550 MCG
6
MSD
KETAMINE HCL-
SODIUM CHLORIDE 6 MSD
KOCHIA 6 MSD
LAMBS QUARTERS 6 MSD
l-cysteine hcl
intravenous 6 MSD
MIXED VESPID
VENOM PROTEIN
SUBCUTANEOUS
6
MSD
LENSCALE 3
LIPIODOL 6 MSD
mlk f1 1
Last Updated 10/1/19
103
LIQUID E-Z-PAQUE 6 MSD
mlk f2 1
LIQUID POLIBAR
PLUS 6 MSD
mlk f3 1
MLK F4 3 MACI 6 MSD
Last Updated 10/1/19
104
Drug Name Drug
Category
Limits/
Required
ORTHOVISC 6 MSD
PARI ALTERA
NEBULIZER
HANDSET
6
MSD
PARI TREK S COMBO
PACK 6 MSD
PEANUT
(DIAGNOSTIC) 6 MSD
PECAN NUT
(DIAGNOSTIC) 6 MSD
PECAN POLLEN 6 MSD
PENICILLIUM
NOTATUM 6 MSD
PENTETATE
CALCIUM TRISODIUM 6 MSD
PENTETATE ZINC
TRISODIUM 6 MSD
PERENNIAL RYE
GRASS POLLEN 3
PHOMA EXIGUA 6 MSD
PHOTREXA VISCOUS 6 MSD
PHOTREXA-
PHOTREXA VISCOUS
KIT
6
MSD
PISTACHIO NUT
(DIAGNOSTIC) 6 MSD
PKU EASY 3
PKU EASY
MICROTABS 3
PLASBUMIN-25 6 MSD
PLASBUMIN-5 6 MSD
PORK (DIAGNOSTIC) 6 MSD
pralidoxime chloride
intramuscular 3
PRAXBIND 6 MSD
PRECEDEX 6 MSD
PRIVET 6 MSD
PRO COMFORT
SPACER ADULT 6 MSD; OTC
PRO COMFORT
SPACER CHILD 6 MSD; OTC
Drug Name Drug
Category
Limits/
Required
MONOVISC 6 MSD
MOUNTAIN CEDAR 6 MSD
MOUSE EPITHELIUM 6 MSD
MSUD EASY 3
MUCOR 6 MSD
MUGWORT 6 MSD
MYOBLOC 6 PA; MSD
NEOKE RA LIPOIC 3
NETSPOT 6 MSD
NEXAVIR 3
NORM-JECT LUER
SLIP SYRINGE 2
OAT GRAIN
(DIAGNOSTIC) 6 MSD
ODACTRA 2 M; QL
OLIVE TREE 6 MSD
OMNIPAQUE
INTRAVENOUS
SOLUTION 350
MG/ML
6
MSD
OMNIPOD 5 PACK 6 MSD
OMNIPOD DASH 5
PACK 6 MSD
OMNIPOD STARTER 6 MSD
OPTIONS
CONCEPTROL 5 ACA; OTC
OPTIRAY 350 6 MSD
OPTISON 6 MSD
ORAFATE 4 S
ORALAIR 4 M; S; QL
ORALAIR ADULT
SAMPLE KIT 4 M; S; QL
ORALAIR ADULT
STARTER PACK 4 M; S; QL
ORALAIR CHILDRENS
STARTER PACK 4 M; S; QL
ORANGE
(DIAGNOSTIC) 6 MSD
ORCHARD GRASS
POLLEN 6 MSD
Last Updated 10/1/19
105
Drug Name Drug
Category
Limits/
Required
RICE (DIAGNOSTIC) 6 MSD
ROUGH MARSH
ELDER 3
ROUGH PIGWEED 6 MSD
RUSSIAN THISTLE 6 MSD
RUZURGI 3 M
SACCHAROMYCES
CEREVISIAE 6 MSD
SAGEBRUSH 6 MSD
SAPS HEALTH CARE
ALCOHOL PREP 2 OTC
sash kit 6 MSD
SESAME SEED
(DIAGNOSTIC) 6 MSD
sevoflurane 6 MSD
SHAGBARK HICKORY 6 MSD
SHEEP SORREL 6 MSD
SHORT RAGWEED
POLLEN EXT 6 MSD
SHRIMP
(DIAGNOSTIC) 6 MSD
SODIUM
HYALURONATE
INTRA-ARTICULAR
6
MSD
SOLESTA 6 MSD
SORREL/DOCK MIX 6 MSD
SOYBEAN
(DIAGNOSTIC) 6 MSD
SPARKY THE DOG
PED NEBULIZER 6 MSD
SPINRAZA 6 PA; M; MSD
SPINY PIGWEED 6 MSD
STEMPHYLIUM 3
STERILE DILUENT
FLOLAN PH 12 6 MSD
STERILE DILUENT
FOR FLOLAN 6 MSD
sterile
diluent/epoprostenol 6 MSD
sterile water for
injection 6 MSD
Drug Name Drug
Category
Limits/
Required
PRO COMFORT TENS
UNIT 6 MSD
PROCARE
COMPRESSOR
NEBULIZER
6
MSD; OTC
PROCARE
SPACER/ADULT
MASK
6
MSD; OTC
PROCARE
SPACER/CHILD MASK 6 MSD; OTC
PROFESSIONAL DNA
COLLECTION 6 MSD
PROMACTIN AA PLUS
20PE 3
propofol 6 MSD
PROTHELIAL 4 S
PROVAYBLUE 6 MSD
PROVOCHOLINE 6 MSD
QUEEN PALM 3
RABBIT EPITHELIUM 6 MSD
RADIOGARDASE 6 MSD
RAGWITEK 2 M; QL
READI-CAT 2 6 MSD
RED BIRCH 6 MSD
RED CEDAR 6 MSD
RED MAPLE 6 MSD
RED MULBERRY 6 MSD
RED TOP GRASS
POLLEN 6 MSD
RESET FOR
ANDROID APP 3
RESET FOR IOS APP 3
RESET FOR IOS OR
ANDROID APP 3
RESET-O FOR
ANDROID APP 3
RESET-O FOR IOS
APP 3
RESET-O FOR IOS
OR ANDROID APP 3
RHIZOPUS 6 MSD
Last Updated 10/1/19
106
Drug Name Drug
Category
Limits/
Required
toxicology saliva
collection 6 MSD
TRICHOPHYTON 6 MSD
TRIVISC 6 MSD
TRUE COMFORT
ALCOHOL PREP
PADS
2
OTC
TYR EASY 3
ULTANE 6 MSD
ULTRAVIST
INJECTION
SOLUTION 77 %
6
MSD
VARIBAR HONEY 6 MSD
VARIBAR NECTAR 6 MSD
VARIBAR PUDDING 6 MSD
VARIBAR THIN
HONEY 6 MSD
VARIBAR THIN
LIQUID 6 MSD
vcf vaginal
contraceptive vaginal
gel
5
ACA; OTC
VENOMIL HONEY
BEE VENOM 3
VENOMIL WASP
VENOM 3
VENOMIL WHITE
FACED HORNET 3
VENOMIL YELLOW
HORNET VENOM 3
VENOMIL YELLOW
JACKET VENOM 3
V-GO 20 6 MSD
V-GO 30 6 MSD
V-GO 40 6 MSD
VIRGINIA LIVE OAK 6 MSD
VISCO-3 6 MSD
VISIPAQUE
INTRAVENOUS
SOLUTION 320
MG/ML
6
MSD
VISTOGARD 3 S
Drug Name Drug
Category
Limits/
Required
STRAWBERRY
(DIAGNOSTIC) 6 MSD
SUPARTZ FX 6 MSD
SUPRANE 6 MSD
SURGISEAL 6 MSD
SURGISEAL STYLUS 6 MSD
SURGISEAL TWIST 6 MSD
SWEET CORN
(DIAGNOSTIC) 6 MSD
SWEET GUM 3
SWEET VERNAL
GRASS POLLEN 6 MSD
SYNVISC 6 MSD
SYNVISC ONE 6 MSD
TACHOSIL 6 MSD
TAGITOL V 6 MSD
TAKHZYRO 4 PA; M; S
TALL RAGWEED 6 MSD
TECHNET TC 99M
SULFUR COLLOID 6 MSD
technetium tc 99m
mebrofenin 6 MSD
TECHNETIUM TC 99M
MEDRONATE 6 MSD
TECHNETIUM TC 99M
PYROPHOS 6 MSD
technetium tc 99m
sestamibi 6 MSD
TELFA AMD NON-
ADHERENT 3
thallous chloride tl 201
intravenous solution 1
mci/ml
6
MSD
THALLOUS
CHLORIDE TL 201
INTRAVENOUS
SOLUTION 2 MCI/ML
6
MSD
THYROGEN 6 MSD
TIMOTHY GRASS
POLLEN ALLERGEN 6 MSD
TISSEEL 6 MSD
Last Updated 10/1/19
107
Drug Name Drug
Category
Limits/
Required
XEOMIN
INTRAMUSCULAR
SOLUTION
RECONSTITUTED 200
UNIT
6
MSD
XIAFLEX 6 MSD
YELLOW DOCK 6 MSD
YELLOW HORNET
VENOM PROTEIN 6 MSD
YELLOW JACKET
VENOM PROTEIN
INJECTION
SOLUTION
RECONSTITUTED
1300 MCG
3
YELLOW JACKET
VENOM PROTEIN
INJECTION
SOLUTION
RECONSTITUTED 550
MCG
6
MSD
YELLOW JACKET
VENOM PROTEIN
SUBCUTANEOUS
6
MSD
Ophthalmic Agents -
Drugs for Eye Allergy,
Infection and
Inflammation
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ALOCRIL 3
ALOMIDE 3
ALREX 2
AZASITE 2
azelastine hcl
ophthalmic 1
bacitracin ophthalmic 1
BEPREVE 2
BESIVANCE 3
BETADINE
OPHTHALMIC PREP 3
BLEPH-10 3
Drug Name Drug
Category
Limits/
Required
VITRASE 6 MSD
VOLUMEN 6 MSD
VORTEX HOLDING
CHAMBER/MASK 6 MSD
WASP VENOM
PROTEIN INJECTION
SOLUTION
RECONSTITUTED
1300 MCG
3
WASP VENOM
PROTEIN INJECTION
SOLUTION
RECONSTITUTED 550
MCG
6
MSD
WASP VENOM
PROTEIN
SUBCUTANEOUS
6
MSD
WESTERN JUNIPER 3
WHITE ASH 6 MSD
WHITE BIRCH 6 MSD
WHITE FACED
HORNET VENOM 6 MSD
WHITE MULBERRY 6 MSD
WHITE OAK 6 MSD
WHITE PINE 6 MSD
WHITE-FACED
HORNET VENOM
INJECTION
SOLUTION
RECONSTITUTED
1300 MCG
3
WHITE-FACED
HORNET VENOM
INJECTION
SOLUTION
RECONSTITUTED 550
MCG
6
MSD
WHOLE EGG
(DIAGNOSTIC) 6 MSD
WIDE-SEAL
DIAPHRAGM 60 5 ACA
Last Updated 10/1/19
108
Drug Name Drug
Category
Limits/
Required
levofloxacin ophthalmic 1
LOTEMAX
OPHTHALMIC GEL 2 QL
LOTEMAX
OPHTHALMIC
OINTMENT
2
QL
LOTEMAX
OPHTHALMIC
SUSPENSION
2
LOTEMAX SM 2
loteprednol etabonate 1
MAXIDEX 3
MITOSOL 3
MOXEZA 2
MOXIFLOXACIN HCL
INTRAOCULAR 6 MSD
moxifloxacin hcl
ophthalmic 1
NATACYN 2
NEVANAC 3 QL
OCUFLOX 3
ofloxacin ophthalmic 1
olopatadine hcl
ophthalmic 1
OZURDEX 6 MSD
PATADAY 3 ST
PATANOL 3 ST
PAZEO 2
POVIDONE-IODINE
OPHTHALMIC 3
PRED FORTE 3
PRED MILD 3
PREDNISOL ACE-
MOXIFLOX-BROMFEN 3
prednisolone acetate
ophthalmic 1
prednisolone acetate p-
f 1
prednisolone sodium
phosphate ophthalmic 1
Drug Name Drug
Category
Limits/
Required
bromfenac sodium
(once-daily) 1 QL
BROMSITE 3 QL
CEFUROXIME
SODIUM-NACL
INTRAVITREAL
6
MSD
CILOXAN 3
ciprofloxacin hcl
ophthalmic 1
cromolyn sodium
ophthalmic 1
dexamethasone
sodium phosphate
ophthalmic
1
DEXTENZA 6 MSD
DEXYCU 6 MSD
diclofenac sodium
ophthalmic 1
DUREZOL 3
epinastine hcl 1
erythromycin
ophthalmic 1
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 3
FML FORTE 3
FML LIQUIFILM 3
gatifloxacin ophthalmic 1
gentak 1
gentamicin sulfate
ophthalmic 1
ILEVRO 2 QL
ILUVIEN 6 MSD
INVELTYS 2
ketorolac tromethamine
ophthalmic 1
KLARITY-A 2
KLARITY-B 3
KLARITY-L 3
Last Updated 10/1/19
109
Drug Name Drug
Category
Limits/
Required
COSOPT PF
OPHTHALMIC
SOLUTION 22.3-6.8
MG/ML
3
M
DORZOLAMIDE HCL
SOLUTION 2 %
OPHTHALMIC
3
M
dorzolamide hcl
solution 2 % ophthalmic 1 M
dorzolamide hcl-timolol
mal pf ophthalmic
solution 22.3-6.8 mg/ml
1
M
DORZOLAMIDE HCL-
TIMOLOL MAL
SOLUTION 22.3-6.8
MG/ML OPHTHALMIC
3
ST; M
dorzolamide hcl-timolol
mal solution 22.3-6.8
mg/ml ophthalmic
1
M
IOPIDINE 3
ISOPTO CARPINE 3 M
ISTALOL 3 M
KEVEYIS 3 PA; S; QL
LATANOPROST
SOLUTION 0.005 %
OPHTHALMIC
3
ST; M
latanoprost solution
0.005 % ophthalmic 1 M
levobunolol hcl 1 M
LUMIGAN 2 M; QL
methazolamide oral 1 M
PHOSPHOLINE
IODIDE 2 M
pilocarpine hcl
ophthalmic 1 M
RHOPRESSA 2 M
ROCKLATAN 3 M
SIMBRINZA 3 M
timolol maleate
ophthalmic 1 M
TIMOPTIC 3 M
TIMOPTIC OCUDOSE 3 M
Drug Name Drug
Category
Limits/
Required
PREDNISOLON-
MOXIFLOX-
NEPAFENAC
3
PROLENSA 2 QL
RETISERT 6 MSD
sulfacetamide sodium
ophthalmic 1
tobramycin ophthalmic 1
TOBREX 3
trifluridine 1
TRIPLE PMB 3
TRIPLE PMK 3
VIGAMOX 3
YUTIQ 6 MSD
ZIRGAN 3
ZYMAXID 3
Ophthalmic Agents -
Drugs for Glaucoma
acetazolamide er 1 M
acetazolamide oral
tablet 250 mg 1 M
ALPHAGAN P
OPHTHALMIC
SOLUTION 0.1 %
2
M
ALPHAGAN P
OPHTHALMIC
SOLUTION 0.15 %
3
M
apraclonidine hcl 1
AZOPT 3 M
betaxolol hcl
ophthalmic 1 M
BETIMOL 3 M
BETOPTIC-S 3 M
bimatoprost ophthalmic 1 M; QL
brimonidine tartrate
ophthalmic 1 M
carteolol hcl 1 M
COMBIGAN 2 M
COSOPT 3 ST; M
Last Updated 10/1/19
110
Drug Name Drug
Category
Limits/
Required
BLEPHAMIDE S.O.P. 3
CEQUA 3 PA
CYCLOGYL 3 M
CYCLOMYDRIL 3 M
cyclopentolate hcl
ophthalmic 1 M
CYSTARAN 3 PA; M; S; QL
DEXAMETHASONE-
MOXIFLOXACIN 6 MSD
DEXAMETH-
MOXIFLOX-
KETOROLAC
6
MSD
DOUBLE PM 3
EYLEA 6 MSD
GELFILM
OPHTHALMIC 3
homatropaire 1 M
homatropine hbr 1 M
HYALURONIDASE
(INTRAOCULAR) 6 MSD
ISOPTO ATROPINE 3 M
JETREA 6 MSD
LACRISERT 3
LASTACAFT 3
LIDOCAINE-
EPINEPHRINE
INTRAOCULAR
6
MSD
LIDOCAINE-
PHENYLEPHRINE 6 MSD
LIDOCAINE-
PHENYLEPHRINE-
BSS
6
MSD
LUCENTIS 6 MSD
LUXTURNA 6 MSD
MACUGEN 6 MSD
MAXITROL 3
MOXIFLOXACIN HCL-
BSS 6 MSD
MYDRIACYL 3 M
neomycin-bacitracin zn-
polymyx 1
Drug Name Drug
Category
Limits/
Required
TIMOPTIC-XE 3 M
TRAVATAN Z 2 M; QL
TRUSOPT 3 M
VYZULTA 3 M; QL
XALATAN 3 ST; M
XELPROS 3 ST; M; QL
ZIOPTAN 3 M; QL
Ophthalmic Agents -
Drugs for
Miscellaneous Eye
Conditions
ak-poly-bac 1
AKTEN 3
ALCAINE 3
altacaine 1
altafluor 6 MSD
altafluor benox 6 MSD
altafrin 1
AMVISC 6 MSD
AMVISC PLUS 6 MSD
ATROPINE SULFATE
OPHTHALMIC
EMULSION
3
M
atropine sulfate
ophthalmic ointment 1 M
atropine sulfate
ophthalmic solution 1 M
bacitracin-polymyxin b
ophthalmic 1
bacitra-neomycin-
polymyxin-hc 1
BEVACIZUMAB
INTRAOCULAR 6 MSD
BEVACIZUMAB
INTRAVITREAL
SOLUTION
PREFILLED SYRINGE
2.5 MG/0.1ML, 3.25
MG/0.13ML
6
MSD
BIOLON 6 MSD
BLEPHAMIDE 3
Last Updated 10/1/19
111
Drug Name Drug
Category
Limits/
Required
PREDNISOLON-
MOXIFLOX-
BROMFENAC
3
proparacaine hcl
ophthalmic 1
PROVISC 6 MSD
RESTASIS 2 PA; M; QL
RESTASIS
MULTIDOSE
OPHTHALMIC
EMULSION 0.05 %
2
PA; M; QL
sulfacetamide-
prednisolone
ophthalmic solution
1
tetcaine 1
tetracaine hcl solution
0.5 % ophthalmic 3
tetracaine hcl solution
0.5 % ophthalmic 1
tetravisc 3
tetravisc forte 3
TOBRADEX
OPHTHALMIC
OINTMENT
2
TOBRADEX
OPHTHALMIC
SUSPENSION
3
TOBRADEX ST 2
tobramycin-
dexamethasone 1
TRIAMCINOLONE-
MOXIFLOXACIN 6 MSD
tropicamide ophthalmic 1 M
TROPICAMIDE-
PHENYLEPHRINE 3 M
VISUDYNE 6 MSD
XIIDRA 2 M
ZYLET 2
Otic Agents - Drugs
for Ear Conditions
acetic acid otic 1
CETRAXAL 3
Drug Name Drug
Category
Limits/
Required
neomycin-polymyxin-
dexameth ophthalmic
ointment
1
neomycin-polymyxin-
dexameth ophthalmic
suspension 3.5-10000-
0.1
1
neomycin-polymyxin-
gramicidin 1
neomycin-polymyxin-hc
ophthalmic 1
neo-polycin 1
neo-polycin hc 1
OMIDRIA 6 MSD
OXERVATE 3 S; QL
phenylephrine hcl
ophthalmic 1
polycin 1
polymyxin b-
trimethoprim 1
POLYTRIM 3
PRED-G 3
PRED-G S.O.P. 3
PREDNISOLONE
ACETATE-
NEPAFENAC
3
PREDNISOLONE
ACET-MOXIFLOXACIN 3
PREDNISOLONE-
BROMFENAC
OPHTHALMIC
SOLUTION
3
PREDNISOLONE-
GATIFLOXACIN 3
PREDNISOLONE-
MOXIFLOXACIN 3
PREDNISOLON-
GATIFLOX-
BROMFENAC
OPHTHALMIC
SOLUTION
3
Last Updated 10/1/19
112
Drug Name Drug
Category
Limits/
Required
CLARINEX-D 12
HOUR 3 QL
clemastine fumarate
oral tablet 2.68 mg 1
cyproheptadine hcl oral 1
desloratadine 1 QL
dexchlorpheniramine
maleate oral 1
DICOPANOL
FUSEPAQ 3
DICOPANOL
RAPIDPAQ 3
diphenhydramine hcl
injection 6 MSD
diphenhydramine hcl
oral elixir 1
DYMISTA 2 QL
FASENRA 6 M; MSD
flunisolide nasal 1 QL
fluticasone propionate
nasal 2
GILPHEX TR 3
GILTUSS TR 3
guaiatussin ac 1 OTC; QL
guaifenesin ac 1 OTC; QL
hydrocodone polst-cpm
polst er 1 PA; QL
hydrocodone-
homatropine 1 QL
hydromet 1 QL
HYPERSAL 3
INFASURF 6 MSD
ipratropium bromide
nasal 1 M
KARBINAL ER 3
levocetirizine
dihydrochloride oral
solution
2
levocetirizine
dihydrochloride oral
tablet
2
QL
Drug Name Drug
Category
Limits/
Required
CIPRO HC 3
CIPRODEX 2
ciprofloxacin hcl otic 1
COLY-MYCIN S 3
cortic-nd 1
DERMOTIC 3
exotic-hc 1
flac 1
FLOXIN OTIC 1
fluocinolone acetonide
otic 1
hydrocortisone-acetic
acid 1
neomycin-polymyxin-hc
otic 1
ofloxacin otic 1
OTICIN HC NR 3
OTIPRIO 3
OTOVEL 2
PRAMOTIC 3
Respiratory Tract /
Pulmonary Agents -
Drugs for Allergies,
Cough, Cold
ADRENALIN NASAL 3
ASTEPRO 3 QL
azelastine hcl nasal 1 QL
BECONASE AQ 3 QL
benzonatate 1
bromfed dm 1
BROMPHENIRAMINE
MALEATE
INTRAMUSCULAR
3
brompheniramine
tannate 1
carbinoxamine maleate 1
cetirizine hcl oral
solution 2 QL
CINQAIR 6 M; MSD
CLARINEX 3 QL
Last Updated 10/1/19
113
Drug Name Drug
Category
Limits/
Required
promethegan 1
pseudoeph-chlorphen-
hydrocod 1 QL
pseudoephedrine-
bromphen-dm 1
pulmosal 1
QNASL 2 QL
QNASL CHILDRENS 2 QL
RYCLORA 3
ryvent 3
SEMPREX-D 3
SINUVA 6 MSD
sodium chloride
inhalation 1
SSKI 3
SURVANTA 6 MSD
TESSALON PERLES 3
TUSSICAPS 3 PA; QL
TUXARIN ER 3 QL
TUZISTRA XR 3 PA; QL
XHANCE 3 QL
XOLAIR
SUBCUTANEOUS
SOLUTION
PREFILLED SYRINGE
6
PA; MSD
XOLAIR
SUBCUTANEOUS
SOLUTION
RECONSTITUTED
6
PA; MSD; QL
ZETONNA 3 QL
Z-TUSS AC 3 OTC; QL
Respiratory Tract /
Pulmonary Agents -
Drugs for Asthma and
Other Lung
Conditions
ACCOLATE 3 M; QL
acetylcysteine
inhalation 1
ADRENALIN
INJECTION 6 MSD
Drug Name Drug
Category
Limits/
Required
mometasone furoate
nasal 1 QL
NASONEX 3 ST; QL
nebusal inhalation
nebulization solution 3
%
1
NEBUSAL
INHALATION
NEBULIZATION
SOLUTION 6 %
3
NEOTUSS PLUS 2
NUCALA
SUBCUTANEOUS
SOLUTION AUTO-
INJECTOR
3
M; S; QL
NUCALA
SUBCUTANEOUS
SOLUTION
PREFILLED SYRINGE
3
M; S; QL
NUCALA
SUBCUTANEOUS
SOLUTION
RECONSTITUTED
6
M; MSD; QL
olopatadine hcl nasal 1 QL
OMNARIS 3 QL
PATANASE 3 QL
phenadoz 1
PHENERGAN 6 MSD
phenylephrine-
guaifenesin oral liquid 1
promethazine hcl
injection 6 MSD
promethazine hcl oral
syrup 1
promethazine hcl oral
tablet 1
promethazine hcl rectal 1
promethazine-codeine 1 QL
promethazine-dm 1
promethazine-
phenyleph-codeine 1 QL
promethazine-
phenylephrine 1
Last Updated 10/1/19
114
Drug Name Drug
Category
Limits/
Required
BEVESPI
AEROSPHERE 2 M; QL
BREO ELLIPTA 2 M; QL
BROVANA 3 M; QL
budesonide inhalation 1 M; QL
COMBIVENT
RESPIMAT 2 M; QL
cromolyn sodium
inhalation 1 M
DALIRESP ORAL
TABLET 250 MCG 2 PA; M
DALIRESP ORAL
TABLET 500 MCG 2 PA; M; QL
difil-g forte 1
DUAKLIR PRESSAIR 3 M
DULERA 2 M; QL
ELIXOPHYLLIN 3 M
epinephrine injection
solution 0.3 mg/0.3ml 3
epinephrine injection
solution auto-injector
0.15 mg/0.15ml
3
epinephrine injection
solution auto-injector
0.15 mg/0.3ml
2
QL
epinephrine injection
solution auto-injector
0.3 mg/0.3ml
1
EPIPEN 2-PAK 3
EPIPEN JR 2-PAK 2 QL
EPISNAP 6 MSD
ESBRIET ORAL
CAPSULE 3 PA; M; S; QL
ESBRIET ORAL
TABLET 267 MG 3 PA; M; S; QL
ESBRIET ORAL
TABLET 801 MG 3 PA; M; S
FLOVENT DISKUS 2 M; QL
FLOVENT HFA 2 M; QL
Drug Name Drug
Category
Limits/
Required
ADVAIR DISKUS 3 M; QL
ADVAIR HFA 2 M; QL
AIRDUO RESPICLICK
113/14 2 M; QL
AIRDUO RESPICLICK
232/14 2 M; QL
AIRDUO RESPICLICK
55/14 2 M; QL
albuterol sulfate er 1 M
ALBUTEROL
SULFATE HFA 3 M; QL
albuterol sulfate
inhalation 1 M; QL
albuterol sulfate oral 1 M
ALVESCO 3 M; QL
aminophylline
intravenous 6 MSD
ANORO ELLIPTA 2 M; QL
ARALAST NP 6 PA; MSD
ARCAPTA NEOHALER 2 M; QL
ARNUITY ELLIPTA 2 M; QL
ASMANEX (120
METERED DOSES) 2 M; QL
ASMANEX (14
METERED DOSES) 2 M; QL
ASMANEX (30
METERED DOSES) 2 M; QL
ASMANEX (60
METERED DOSES) 2 M; QL
ASMANEX (7
METERED DOSES) 2 M; QL
ASMANEX HFA 2 M; QL
ATROVENT HFA 2 M; QL
AUVI-Q INJECTION
SOLUTION AUTO-
INJECTOR 0.1
MG/0.1ML
3
QL
AUVI-Q INJECTION
SOLUTION AUTO-
INJECTOR 0.15
MG/0.15ML, 0.3
MG/0.3ML
3
Last Updated 10/1/19
115
Drug Name Drug
Category
Limits/
Required
PROLASTIN-C
INTRAVENOUS
SOLUTION
6
MSD
PROLASTIN-C
INTRAVENOUS
SOLUTION
RECONSTITUTED
6
PA; MSD
PROVENTIL HFA 3 M; QL
PULMICORT
FLEXHALER 2 M; QL
PULMICORT
SUSPENSION 3 ST; M; QL
QVAR REDIHALER 2 M; QL
SCLEROSOL
INTRAPLEURAL 6 MSD
SEEBRI NEOHALER 3 M; QL
SEREVENT DISKUS 2 M; QL
SINGULAIR ORAL
PACKET 3 ST; M
SINGULAIR ORAL
TABLET 3 ST; M; QL
SINGULAIR ORAL
TABLET CHEWABLE 3 ST; M; QL
SPIRIVA
HANDIHALER 2 M; QL
SPIRIVA RESPIMAT 2 M; QL
STERILE TALC
POWDER 6 MSD
STERITALC 6 MSD
STIOLTO RESPIMAT 2 M; QL
STRIVERDI
RESPIMAT 2 M; QL
SYMBICORT 2 M; QL
SYMJEPI 3
terbutaline sulfate
injection 6 MSD
terbutaline sulfate oral 1 M
THEO-24 3 M
theochron 1 M
theophylline 1 M
theophylline er 1 M
Drug Name Drug
Category
Limits/
Required
fluticasone-salmeterol
inhalation aerosol
powder breath
activated 100-50
mcg/dose, 250-50
mcg/dose, 500-50
mcg/dose
1
M; QL
FLUTICASONE-
SALMETEROL
INHALATION
AEROSOL POWDER
BREATH ACTIVATED
113-14 MCG/ACT, 232-
14 MCG/ACT, 55-14
MCG/ACT
2
M; QL
GLASSIA 6 MSD
INCRUSE ELLIPTA 2 M; QL
ipratropium bromide
inhalation 1 M; QL
ipratropium-albuterol 1 M; QL
levalbuterol hcl
inhalation 1 M; QL
LEVALBUTEROL HFA
INHALATION
AEROSOL 45
MCG/ACT
3
M; QL
LONHALA MAGNAIR
REFILL KIT 3 M; QL
LONHALA MAGNAIR
STARTER KIT 3 M; QL
metaproterenol sulfate
oral 1 M
montelukast sodium
oral packet 1 M
montelukast sodium
oral tablet 1 M; QL
montelukast sodium
oral tablet chewable 1 M; QL
OFEV 3 PA; M; S; QL
PERFOROMIST 2 M; QL
PROAIR DIGIHALER 2 M; QL
PROAIR HFA 1 M; QL
PROAIR RESPICLICK 2 M; QL
Last Updated 10/1/19
116
Drug Name Drug
Category
Limits/
Required
alyq 1 PA; M; S; QL
ambrisentan 1 PA; M; QL
bosentan 1 PA; M; QL
epoprostenol sodium 6 MSD
FLOLAN 6 MSD
LETAIRIS 3 PA; M; S; QL
OPSUMIT 3 PA; M; S; QL
ORENITRAM 4 PA; M; S
REMODULIN 6 PA; MSD; QL
REVATIO
INTRAVENOUS 6 PA; MSD
REVATIO ORAL 4 PA; M; S; QL
sildenafil citrate
intravenous 6 PA; MSD
sildenafil citrate oral
suspension
reconstituted
1
PA; M; QL
sildenafil citrate oral
tablet 20 mg 1 PA; M; S; QL
tadalafil (pah) 1 PA; M; S; QL
TRACLEER 3 PA; M; S; QL
treprostinil 6 PA; MSD; QL
TYVASO 6 PA; M; MSD;
QL
TYVASO REFILL 6 PA; M; MSD;
QL
TYVASO STARTER 6 PA; M; MSD;
QL
UPTRAVI ORAL
TABLET 3 PA; M; S; QL
UPTRAVI ORAL
TABLET THERAPY
PACK
3
PA; S; QL
VELETRI 6 MSD
VENTAVIS 4 PA; M; S; QL
Skeletal Muscle
Relaxants - Drugs for
Muscle Pain and
Spasm
ACTIVE-
CYCLOBENZAPRINE 3
Drug Name Drug
Category
Limits/
Required
TRELEGY ELLIPTA 2 M; QL
TUDORZA PRESSAIR 2 M; QL
UTIBRON NEOHALER 3 M; QL
VENTOLIN HFA 2 M; QL
wixela inhub 1 M; QL
XOPENEX 3 M; QL
XOPENEX
CONCENTRATE 3 M; QL
XOPENEX HFA 3 M; QL
YUPELRI 2 M; QL
zafirlukast 1 M; QL
ZEMAIRA 6 PA; MSD
zileuton er 1 M; QL
ZYFLO 3 M
Respiratory Tract /
Pulmonary Agents -
Drugs for Cystic
Fibrosis
BETHKIS 6 M; MSD; QL
CAYSTON 3 S; QL
KALYDECO 3 PA; M; S
KITABIS PAK 2 M; QL
ORKAMBI 3 PA; M; S; QL
PULMOZYME 2 M
SYMDEKO 3 PA; M; S; QL
TOBI NEBULIZER 3 M; QL
TOBI PODHALER 2 M; QL
tobramycin nebulization
solution 300 mg/5ml
inhalation
1
M; QL
TOBRAMYCIN
NEBULIZATION
SOLUTION 300
MG/5ML INHALATION
3
M; QL
Respiratory Tract /
Pulmonary Agents -
Drugs for Pulmonary
Hypertension
ADCIRCA 4 PA; M; S; QL
ADEMPAS 3 PA; M; S; QL
Last Updated 10/1/19
117
Drug Name Drug
Category
Limits/
Required
GABLOFEN
INTRATHECAL
SOLUTION 20000
MCG/20ML
6
MSD
GABLOFEN
INTRATHECAL
SOLUTION
PREFILLED SYRINGE
6
MSD
LIORESAL
INTRATHECAL
INTRATHECAL
SOLUTION 2000
MCG/ML, 40
MG/20ML, 500
MCG/ML
6
MSD; QL
LIORESAL
INTRATHECAL
SOLUTION 0.05
MG/ML, 10 MG/20ML,
40 MG/20ML
6
MSD; QL
LORZONE 3 ST
METAXALL CP 3
metaxalone 1
methocarbamol
injection 6 MSD
methocarbamol oral 1
NORGESIC FORTE 3
orphenadrine citrate er 1
orphenadrine citrate
injection 6 MSD
orphenadrine-aspirin-
caffeine 1
ORPHENGESIC
FORTE 3
ROBAXIN 6 MSD
ROBAXIN-750 3 ST
RYANODEX 6 MSD
SKELAXIN 3 ST
SOMA 3 ST
TABRADOL FUSEPAQ 3
TABRADOL
RAPIDPAQ 3
tizanidine hcl oral 1
Drug Name Drug
Category
Limits/
Required
AMRIX 3 ST
baclofen external 1
baclofen intrathecal
solution 10 mg/20ml,
40 mg/20ml
6
MSD; QL
baclofen intrathecal
solution 20000
mcg/20ml
6
MSD
baclofen oral tablet 10
mg, 20 mg 1
baclofen oral tablet 5
mg 3
carisoprodol oral 1
carisoprodol-aspirin 1
chlorzoxazone 1 PA
cyclobenzaprine hcl er 1
cyclobenzaprine hcl
oral 1
CYCLOPHENE
RAPIDPAQ 3
DANTRIUM ORAL 3 ST
dantrolene sodium oral 1
ENOVARX-
BACLOFEN 3
enovarx-
cyclobenzaprine hcl
cream 20 mg/gm
transdermal
1
ENOVARX-
CYCLOBENZAPRINE
HCL CREAM 20
MG/GM
TRANSDERMAL
3
FEXMID 3 ST
FIRST-BACLOFEN 3
GABLOFEN
INTRATHECAL
SOLUTION 10000
MCG/20ML, 40000
MCG/20ML
6
MSD; QL
Last Updated 10/1/19
118
Drug Name Drug
Category
Limits/
Required
ZANAFLEX 3 ST
Sleep Disorder
Agents
AMBIEN 3 ST; QL
AMBIEN CR 3 ST; QL
AMYTAL SODIUM 2
armodafinil 1 PA; M; QL
BELSOMRA 3 ST; QL
BUTISOL SODIUM 3
EDLUAR 3 ST; QL
eszopiclone 1 QL
flurazepam hcl 1 QL
HETLIOZ 4 ST; M; S; QL
INTERMEZZO 3 ST; QL
LUNESTA 3 ST; QL
modafinil 1 PA; M; QL
NUVIGIL 3 PA; M; QL
PROVIGIL 3 PA; M; QL
ramelteon 1 QL
RESTORIL 3 QL
ROZEREM 2 ST; QL
SECONAL 1
SILENOR 3 ST; QL
temazepam 1 QL
WAKIX 3 M
XYREM 3 PA; S; QL
zaleplon 1 QL
zolpidem tartrate 1 QL
zolpidem tartrate er 1 QL
ZOLPIMIST 3 ST; QL
Last Updated 10/1/19
119
SMARTVIEW KIT W/DEVICE... 60
ACCU-CHEK SMARTVIEW
CONTROL ................................. 60
ACCU-CHEK SMARTVIEW
TEST STRIPS ........................... 60
ACCU-CHEK SOFTCLIX
LANCET DEVICE KIT ............... 60
ACCUPRIL ................................ 41
ACCURETIC .............................. 41
acd formula a ............................. 21
acd-a noclot-50 .......................... 21
acebutolol hcl ............................. 41
ACETADOTE ............................. 92
acetaminophen-codeine ............... 7
ACTIVE-PREP KIT II ................. 11
ACTIVE-PREP KIT III ................ 11
ACTIVE-PREP KIT IV ................ 52
ACTIVE-PREP KIT V ................. 52
ACTIVE-TRAMADOL ................. 52
ACTONEL .................................. 91
ACTOPLUS MET ....................... 58
ACTOS ...................................... 58
ACULAR .................................. 100
ACULAR LS ............................. 100
ACUVAIL ................................. 100
acyclovir ..................................... 37
acyclovir sodium ........................ 37
ACZONE .................................... 52
113
AGGRENOX ............................. 36
AGRYLIN .................................. 40
AIF #2 DRUG PREPARATION
KIT ............................................ 11
AIF #3 DRUG PREPARATION
KIT ............................................ 11
AIMOVIG................................... 29
AIRDUO RESPICLICK 113/14 107
AIRDUO RESPICLICK 232/14 107
AIRDUO RESPICLICK 55/14 107
AJOVY ...................................... 29
AKOVAZ ................................... 42
ak-poly-bac ............................. 103
AKTEN .................................... 103
Index of Drugs
7T GUMMY ES ............................ 7
A.A.G.C. KIT IN TERODERM .... 52
abacavir sulfate ......................... 37
abacavir sulfate-lamivudine ....... 37
abacavir-lamivudine-
zidovudine ................................. 37
ABELCET .................................. 27
ABILIFY ..................................... 36
ABILIFY MAINTENA .................. 36
ABILIFY MYCITE ....................... 36
abiraterone acetate .................... 30
ABLYSINOL ............................... 41
ABRAXANE ............................... 30
ABSORICA ................................ 52
ABSTRAL .................................... 7
ACACIA ..................................... 92
acamprosate calcium ................. 16
ACANYA .................................... 52
acarbose .................................... 58
ACCOLATE ............................. 106
ACCU-CHEK AVIVA
CONNECT KIT W/DEVICE ....... 60
ACCU-CHEK AVIVA DEVICE ... 60
ACCU-CHEK AVIVA PLUS ....... 60
ACCU-CHEK COMPACT
PLUS CARE KIT ....................... 60
ACCU-CHEK COMPACT
PLUS CONTROL ....................... 60
ACCU-CHEK COMPACT
PLUS TEST STRIPS ................. 60
ACCU-CHEK FASTCLIX
LANCET KIT .............................. 60
ACCU-CHEK GUIDE ................. 60
ACCU-CHEK GUIDE
CONTROL ................................. 60
ACCU-CHEK GUIDE ME .......... 60
ACCU-CHEK MULTICLIX
LANCET DEVICE KIT ............... 60
ACCU-CHEK NANO
acetaminophen-codeine #2 .......... 7
acetaminophen-codeine #3 .......... 7
acetaminophen-codeine #4 .......... 7
acetazolamide .................... 41, 102
acetazolamide er ..................... 102
acetazolamide sodium ............... 41
acetic acid ................................ 104
acetylcysteine .................... 92, 106
ACIPHEX ................................... 72
ACIPHEX SPRINKLE ................ 72
acitretin ...................................... 52
ACREMONIUM .......................... 92
ACTEMRA ................................. 87
ACTEMRA ACTPEN .................. 87
ACTHAR .................................... 80
ACTHIB...................................... 90
ACTICLATE ............................... 16
ACTIGALL ................................. 73
ACTIMMUNE ............................. 87
ACTIQ .......................................... 7
ACTIVE FE ................................ 64
ACTIVE INJECTION BLM-1 ...... 77
ACTIVE INJECTION BM ........... 77
ACTIVE INJECTION DL ............ 77
ACTIVE INJECTION DLM ......... 77
ACTIVE INJECTION KET-L ....... 11
ACTIVE INJECTION
KETMARC-L .............................. 11
ACTIVE INJECTION KIT L ........ 77
ACTIVE INJECTION KM ........... 77
ACTIVE INJECTION LM-2 ......... 13
ACTIVE INJECTION LM-DEP-
2 ................................................ 77
ACTIVE INJECTION M-1 ........... 77
ACTIVE-CYCLOBENZAPRINE
................................................ 109
ACTIVE-KETOPROFEN ............ 11
ACTIVELLA ............................... 82
ACTIVE-PREP KIT I .................. 11
ADACEL.................................... 90
ADALAT CC .............................. 42
adapalene ................................. 52
ADAPALENE ............................ 52
adapalene-benzoyl peroxide ..... 52
ADASUVE ................................. 36
adc/f (0.5mg/ml) ........................ 64
ADCETRIS ................................ 30
ADCIRCA ................................ 109
ADDERALL ............................... 49
ADDERALL XR ......................... 49
ADDYI ....................................... 50
adefovir dipivoxil........................ 37
ADEMPAS .............................. 109
ADENOCARD ........................... 42
adenosine ........................... 42, 92
adenosine (diagnostic) .............. 92
ADHANSIA XR .......................... 49
ADLYXIN ................................... 58
ADLYXIN STARTER PACK ...... 58
ADMELOG ................................ 63
ADMELOG SOLOSTAR ............ 63
ADRENALIN ................... 105, 106
adriamycin ................................. 30
adrucil ....................................... 30
ADVAIR DISKUS .................... 107
ADVAIR HFA .......................... 107
ADVATE.................................... 40
ADYNOVATE ............................ 40
ADZENYS ER ........................... 49
ADZENYS XR-ODT .................. 49
AEMCOLO ................................ 16
AFINITOR ................................. 30
AFINITOR DISPERZ ................. 30
afirmelle .................................... 82
AFLURIA QUADRIVALENT ...... 90
AFREZZA .................................. 63
AFSTYLA .................................. 40
AGGRASTAT ............................ 36
ALOGLIPTIN BENZOATE ......... 58
ALOGLIPTIN-METFORMIN
HCL ........................................... 58
ALOGLIPTIN-PIOGLITAZONE. 58
ALOMIDE ................................ 100
ALOPRIM .................................. 28
ALORA ...................................... 82
alosetron hcl .............................. 73
ALOXI ........................................ 26
ALPHAGAN P .......................... 102
ALPHA-LIPOIC ACID ................ 92
ALPHANATE/VWF
COMPLEX/HUMAN ................... 40
ALPHANINE SD ........................ 40
amethyst .................................... 82
AMICAR ..................................... 40
AMIDATE ................................... 93
amikacin sulfate ......................... 16
amiloride hcl............................... 42
amiloride-hydrochlorothiazide .... 42
AMINO ACID ............................. 64
aminobenzoate potassium ......... 64
aminocaproic acid ...................... 40
aminophylline ........................... 107
AMINOPMRMS .......................... 93
AMINOPROTECT ...................... 64
AMINOSYN II............................. 64
AMINOSYN-PF .......................... 64
ANADROL-50 ............................79
ANAFRANIL .............................. 24
anagrelide hcl ........................... 40
ANALPRAM HC .........................91
ANALPRAM HC SINGLES .........91
ANALPRAM-HC .........................91
ANASCORP ...............................93
ANASPAZ ................................. 73
anastrozole ............................... 30
ANAVIP ......................................93
ANCOBON ................................ 27
ANDEXXA ..................................93
ANDRODERM .......................... 79
ANDROGEL .............................. 79
114
AKTIPAK ................................... 52
AKYNZEO ................................. 26
ALA SCALP ............................... 52
ala-cort ...................................... 52
albendazole ............................... 34
ALBENZA .................................. 34
ALBUKED 25 ............................. 92
ALBUKED 5 ............................... 92
albumin human .......................... 92
ALBUMINEX .............................. 92
alburx ......................................... 92
ALBUTEIN ................................. 92
albuterol sulfate ....................... 107
albuterol sulfate er ................... 107
ALBUTEROL SULFATE HFA. 107
ALCAINE ................................. 103
alclometasone dipropionate ....... 52
alcohol ....................................... 64
ALCOHOL PREP PADS ...... 52, 92
alcohol prep pads ...................... 92
ALDACTAZIDE .......................... 42
ALDACTONE ............................. 42
ALDARA .................................... 52
ALDER ...................................... 92
ALDURAZYME .......................... 75
ALECENSA ............................... 30
alendronate sodium ................... 92
alfentanil hcl................................. 7
ALFERON N .............................. 87
alfuzosin hcl er .......................... 77
ALINIA ....................................... 34
ALIQOPA ................................... 30
aliskiren fumarate ...................... 42
ALKERAN .................................. 30
allopurinol .................................. 28
allopurinol sodium ...................... 28
ALLZITAL .................................... 7
almotriptan malate ..................... 29
ALOCRIL ................................. 100
alprazolam ................................. 39
alprazolam er ............................. 39
ALPRAZOLAM INTENSOL ........ 39
alprazolam xr ............................. 39
ALPROLIX ................................. 40
alprostadil .................................. 42
ALREX ..................................... 100
ALTABAX ................................... 16
altacaine .................................. 103
ALTACE ..................................... 42
altafluor .................................... 103
altafluor benox ......................... 103
altafrin ...................................... 103
altavera ...................................... 82
ALTERNARIA ............................ 92
ALTOPREV ................................ 42
ALTRENO .................................. 52
ALUNBRIG ................................ 30
ALVESCO ................................ 107
alyacen 1/35 .............................. 82
alyacen 7/7/7 ............................. 82
alyq .......................................... 109
amabelz ..................................... 82
amantadine hcl .......................... 35
AMARYL .................................... 58
AMBIEN ................................... 111
AMBIEN CR ............................. 111
AMBISOME ............................... 27
ambrisentan ............................. 109
amcinonide ................................ 52
AMD FOAM DRESSING ............ 93
AMELUZ .................................... 52
AMERGE ................................... 29
AMERICAN BEECH .................. 93
AMERICAN COCKROACH ........ 93
AMERICAN ELM ....................... 93
AMERICAN SYCAMORE .......... 93
amethia ...................................... 82
amethia lo .................................. 82
amiodarone hcl ......................... 42
AMIODARONE HCL IN
DEXTROSE .............................. 42
AMITIZA .................................... 73
amitriptyline hcl ......................... 24
AMLODIPINE
BES+SYRSPEND SF ............... 42
amlodipine besylate .................. 42
amlodipine besylate-benazepril
hcl ............................................. 42
amlodipine besylate-valsartan 42
amlodipine-atorvastatin ............. 42
amlodipine-olmesartan .............. 42
amlodipine-valsartan-hctz ......... 42
ammonium lactate ..................... 52
AMMONUL ................................ 75
amnesteem ............................... 52
amoxapine ................................ 24
amoxicill-clarithro-lansopraz ...... 73
amoxicillin ................................. 16
amoxicillin-potassium
clavulanate ................................ 16
amoxicillin-potassium
clavulanate er............................ 16
AMPHADASE ........................... 93
amphetamine sulfate ................. 49
amphetamine-
dextroamphetamine .................. 49
amphetamine-
dextroamphetamine er .............. 49
amphotericin b .......................... 27
ampicillin ................................... 16
ampicillin sodium ....................... 16
ampicillin-sulbactam sodium ..... 16
AMPYRA ................................... 50
AMRIX .................................... 110
AMVISC .................................. 103
AMVISC PLUS ........................ 103
AMYTAL SODIUM .................. 111
ANDROGEL PUMP ................... 79
ANECTINE ................................ 50
ANESTHESIA S/I-40 ................. 93
ANESTHESIA S/I-40A ............... 93
ANESTHESIA S/I-40H ............... 93
ANESTHESIA S/I-40S ............... 93
ANESTHESIA S/I-60 ................. 93
ANGELIQ ................................... 82
ANGIOMAX ............................... 21
ANNOVERA .............................. 82
ANORO ELLIPTA .................... 107
ANTABUSE ............................... 16
ANTARA .................................... 42
anticoagulant cit dext soln a ...... 21
anticoagulant sodium citrate ...... 21
ANTIVENIN LATRODECTUS
MACTANS ................................. 93
ANTIVENIN MICRURUS
FULVIUS ................................... 93
anucort-hc .................................. 91
ANUSOL-HC ............................. 91
anusol-hc ................................... 91
ANZEMET ................................. 26
APADAZ ...................................... 7
apap-caff-dihydrocodeine ............ 7
APEXICON E............................. 52
APIDRA SOLOSTAR ................. 63
APIDRA VIAL ............................ 63
APLENZIN ................................. 24
APOKYN .................................... 35
APP SLIM RMS ......................... 93
APPLE (DIAGNOSTIC) ............. 93
apraclonidine hcl ...................... 102
aprepitant ................................... 26
apri ............................................ 82
APRISO ..................................... 91
APTENSIO XR .......................... 49
APTIOM ..................................... 22
APTIVUS ................................... 37
AQUACEL AG BURN ................ 52
AQUASOL A .............................. 64
ARAKODA ................................. 34
ARALAST NP .......................... 107
aranelle ...................................... 82
ARANESP (ALBUMIN FREE) ... 40
ARAVA ...................................... 87
ARCALYST ................................ 87
ARCAPTA NEOHALER ........... 107
ARESTIN ................................... 51
argatroban ................................. 21
argatroban in sodium chloride 21
ARGININE HCL ......................... 64
ARICEPT ................................... 24
ARIKAYCE ................................. 16
ARIMIDEX ................................. 30
aripiprazole ................................ 36
ARISTADA ................................. 36
ARISTADA INITIO ..................... 36
ARIXTRA ................................... 21
ARIZONA CYPRESS ................. 93
armodafinil ............................... 111
ARMOUR THYROID .................. 86
ARNUITY ELLIPTA .................. 107
AROMASIN ................................ 30
ARRANON ................................. 30
arsenic trioxide ........................... 30
ARTHROTEC............................. 11
ARTISS ...................................... 93
ARYMO ER .................................. 7
ARZERRA .................................. 30
arzol silver nit applicators ........... 52
ASACOL HD .............................. 91
ASCLERA .................................. 42
ascomp-codeine ........................... 7
ascorbic acid .............................. 64
ashlyna ...................................... 82
asilnasalrms ............................... 93
ASMANEX (120 METERED
DOSES) ................................... 107
ASMANEX (14 METERED
DOSES) ................................... 107
ASMANEX (30 METERED
DOSES) ................................... 107
ASMANEX (60 METERED
DOSES) ................................... 107
ASMANEX (7 METERED
DOSES) ................................... 107
ASMANEX HFA ....................... 107
aspirin ........................................ 11
aspirin adult ............................... 11
aspirin adult low strength ........... 11
aspirin childrens ......................... 11
aspirin ec low dose .................... 11
aspirin ec low strength ............... 11
aspirin low dose ......................... 11
aspirin-dipyridamole er ............... 36
ASTAGRAF XL .......................... 87
ASTEPRO ................................ 105
ATACAND .................................. 42
ATACAND HCT ......................... 42
atazanavir sulfate ....................... 37
ATELVIA .................................... 92
atenolol ...................................... 42
ATENOLOL+SYRSPEND SF .... 42
atenolol-chlorthalidone ............... 42
ATGAM ...................................... 87
ATIVAN ..................................... 39
atomoxetine hcl ......................... 49
atorvastatin calcium .................. 42
atovaquone ............................... 34
atovaquone-proguanil hcl .......... 34
atracurium besylate ................... 50
ATRALIN ................................... 52
ATRIPLA ................................... 37
ATROPEN ................................. 73
atropine sulfate ................. 73, 103
ATROPINE SULFATE....... 73, 103
ATROVENT HFA .................... 107
AUBAGIO .................................. 50
aubra ......................................... 82
aubra eq .................................... 82
AUGMENTIN ............................ 16
AUGMENTIN ES-600 ............... 16
AURA PORTANEB ................... 93
AUREOBASIDIUM .................... 93
aurovela 1.5/30 ......................... 82
aurovela 1/20 ............................ 82
aurovela 24 fe ........................... 82
aurovela fe 1.5/30 ..................... 82
aurovela fe 1/20 ........................ 82
AURYXIA .................................. 76
AUSTEDO ................................. 50
AUSTRALIAN PINE .................. 93
AUTOLET LANCING DEVICE 60
AUVI-Q ................................... 107
AVALIDE ................................... 42
AVANDIA .................................. 58
AVAPRO ................................... 42
AVAR LS CLEANSER .............. 52
AVAR-E LS ............................... 52
AVASTIN ................................... 30
AVC VAGINAL .......................... 27
AVEED ...................................... 79
AVELOX.................................... 16
aviane ....................................... 82
avidoxy ...................................... 16
avita .................................... 52, 53
AVOCADO (DIAGNOSTIC) ...... 93
AVODART ................................. 77
AVONEX PEN........................... 50
AVONEX PREFILLED .............. 50
AVYCAZ.................................... 16
AXIFOL ..................................... 64
AXUMIN .................................... 93
AYGESTIN ................................ 82
ayuna ........................................ 82
azacitidine ................................. 30
AZACTAM ................................. 16
AZASAN.................................... 87
115
AZASITE .................................. 100
azathioprine ............................... 87
azathioprine sodium ................... 87
AZEDRA DOSIMETRIC ............. 30
AZEDRA THERAPEUTIC .......... 30
azelaic acid ................................ 53
azelastine hcl ................... 100, 105
AZELEX ..................................... 53
AZILECT .................................... 35
azithromycin .............................. 17
AZOPT .................................... 102
AZOR ........................................ 42
aztreonam .................................. 17
AZULFIDINE .............................. 91
AZULFIDINE EN-TABS ............. 91
azurette...................................... 82
B-12 COMPLIANCE
INJECTION ................................ 64
bacitracin ........................... 17, 100
bacitracin-polymyxin b ............. 103
bacitra-neomycin-polymyxin-hc
................................................ 103
baclofen ................................... 110
BACTERIOSTATIC
WATER(BENZ ALC) .................. 93
bacteriostatic water(benz alc) .... 93
BACTOCILL IN DEXTROSE ..... 17
BACTRIM .................................. 17
BACTRIM DS ............................ 17
BAHIA ........................................ 93
bal in oil ..................................... 93
BALCOLTRA ............................. 82
BALD CYPRESS ....................... 93
balsalazide disodium ................. 91
balsam peru-castor oil ............... 53
BALVERSA ................................ 30
balziva ....................................... 82
BANANA (DIAGNOSTIC) .......... 93
BANZEL..................................... 22
BARACLUDE ............................. 37
BASAGLAR KWIKPEN .............. 63
BAVENCIO ................................ 30
BAXDELA .................................. 17
BAYBERRY (WAX MYRTLE) .... 93
bayer aspirin .............................. 11
bayer aspirin ec low dose .......... 11
BAYER CONTOUR ................... 60
BCAA ......................................... 64
BCG VACCINE .......................... 90
BD AUTOSHIELD DUO PEN
NEEDLES .................................. 63
bd pudendal/local tray/1% lido 13
BD SYRINGE LUER-LOK .......... 93
BD ULTRA-FINE INSULIN
SYRINGES ................................ 63
BD ULTRA-FINE PEN
NEEDLES .................................. 63
BECONASE AQ ....................... 105
BEEF (DIAGNOSTIC) ................ 93
bekyree ...................................... 82
BELBUCA .................................... 7
BELEODAQ ............................... 30
belladonna alkaloids-opium ........ 73
BELRAPZO ................................ 30
BELSOMRA ............................. 111
benazepril hcl............................. 42
benazepril-hydrochlorothiazide. 42
BENDAMUSTINE HCL .............. 30
BENDEKA .................................. 30
BENEFIX ................................... 40
BENICAR ................................... 42
BENICAR HCT .......................... 42
BENLYSTA ................................ 87
BENTLEY THE BEAR PED
NEBULIZER ............................... 93
BENTYL ..................................... 73
BENZAC AC WASH .................. 53
BENZACLIN ............................... 53
BENZACLIN WITH PUMP ......... 53
benzalkonium chloride ............... 17
BENZAMYCIN ........................... 53
benzepro .................................... 53
benzepro foaming cloths ............ 53
benzepro short contact .............. 53
BENZHYDROCODONE-
ACETAMINOPHEN ...................... 7
BENZIQ ..................................... 53
BENZIQ LS ................................ 53
benziq wash ............................... 53
BENZNIDAZOLE ....................... 34
benzonatate ............................. 105
BENZOYL PEROX-
HYDROCORTISONE ................. 53
benzoyl peroxide ........................ 53
BENZOYL PEROXIDE............... 53
BENZOYL PEROXIDE
FORTE- HC ............................... 53
benzoyl peroxide-erythromycin. 53
benztropine mesylate ................. 35
BEPREVE ................................ 100
BERINERT ................................. 87
BERMUDA GRASS ................... 93
beser .......................................... 53
BESIVANCE ............................ 100
BESPONSA ............................... 30
BETA 1 KIT ................................ 77
BETADINE OPHTHALMIC
PREP ...................................... 100
BETALIDO ................................ 77
betamethasone dipropionate ..... 53
betamethasone dipropionate
aug ............................................ 53
BETAMETHASONE SOD
PHOS & ACET .......................... 77
betamethasone sod phos &
acet ........................................... 77
BETAMETHASONE SODIUM
PHOSPHATE ............................ 77
betamethasone valerate............ 53
BETAPACE ............................... 42
BETAPACE AF ......................... 42
BETASERON ............................ 50
betaxolol hcl ...................... 42, 102
bethanechol chloride ................. 76
BETHKIS ................................. 109
BETIMOL ................................ 102
BETOPTIC-S .......................... 102
BEVACIZUMAB ...................... 103
BEVESPI AEROSPHERE ....... 107
BEVYXXA ................................. 21
bexarotene ................................ 30
BEXSERO ................................. 90
BEYAZ ...................................... 82
bicalutamide .............................. 30
BICILLIN C-R ............................ 17
BICILLIN C-R 900/300 .............. 17
BICILLIN L-A ............................. 17
BICNU ....................................... 30
BIDIL ......................................... 42
BI-EST 80:20
PROGESTERONE .................... 82
BIEST/PROGESTERONE ......... 82
BIJUVA ..................................... 82
BIKTARVY ................................ 37
BILTRICIDE .............................. 34
bimatoprost ............................. 102
BINOSTO .................................. 92
BIOFREQUENCY INSOLES ..... 93
BIOGUARD ISLAND
DRESSINGS ............................. 93
BIOGUARD NON-ADHERENT
DRESSING ............................... 93
BIOLON .................................. 103
BIO-STATIN .............................. 27
bio-statin ................................... 27
BIOTEL CARE BLOOD
GLUCOSE SYST ...................... 60
BIOTHRAX ................................ 90
bisacodyl ec .............................. 73
116
bisoprolol fumarate .................... 42
bisoprolol-hydrochlorothiazide 42
bivalirudin trifluoroacetate .......... 21
BIVALIRUDIN-SODIUM
CHLORIDE ................................ 21
BIVIGAM .................................... 87
BLACK WALNUT POLLEN ....... 93
BLACK WILLOW ....................... 93
bleomycin sulfate ....................... 30
BLEPH-10 ................................ 100
BLEPHAMIDE.......................... 103
BLEPHAMIDE S.O.P. .............. 103
BLINCYTO ................................. 30
blisovi 24 fe ............................... 82
blisovi fe 1.5/30 ......................... 82
blisovi fe 1/20 ............................ 82
BLOXIVERZ .............................. 29
BONIVA ..................................... 92
BONJESTA ................................ 26
BOOSTRIX ................................ 90
BORTEZOMIB ........................... 30
bosentan .................................. 109
BOSULIF ................................... 30
BOTOX ...................................... 93
BOTOX COSMETIC .................. 53
BOTRYTIS ................................. 93
BOX ELDER .............................. 93
bp cleansing wash ..................... 53
bp foam ..................................... 53
bp wash ..................................... 53
BPCO ........................................ 53
bpo ............................................ 53
BRAFTOVI ................................. 30
BREATHERITE .......................... 93
BREATHERITE VALVED MDI
CHAMBER ................................. 93
BREO ELLIPTA ....................... 107
BREVIBLOC IN NACL ............... 42
BREVIBLOC PREMIXED .......... 42
BREVIBLOC PREMIXED DS .... 42
BREVITAL SODIUM .................. 93
BRIDION .................................... 93
briellyn ....................................... 82
BRILINTA .................................. 36
brimonidine tartrate .................. 102
BRINEURA ................................ 75
BRISDELLE ............................... 24
BRIVIACT .................................. 22
BROME ..................................... 93
bromfed dm ............................. 105
bromfenac sodium (once-daily)
................................................ 101
bromocriptine mesylate.............. 35
BROMPHENIRAMINE
MALEATE ................................ 105
brompheniramine tannate ........ 105
BROMSITE .............................. 101
BROVANA ............................... 107
BRYHALI ................................... 53
budesonide ........................ 91, 107
budesonide er ............................ 91
BUFFERED LIDOCAINE ........... 13
bumetanide ................................ 42
BUMEX ...................................... 42
BUNAVAIL ................................. 16
BUPAP ........................................ 7
BUPHENYL ............................... 75
bupivacaine fisiopharma ............ 13
bupivacaine hcl .......................... 13
BUPIVACAINE HCL .................. 13
bupivacaine hcl (pf).................... 13
BUPIVACAINE HCL-NACL ........ 13
bupivacaine in dextrose ............. 13
bupivacaine spinal ..................... 13
bupivacaine-epinephrine ............ 13
bupivacaine-epinephrine (pf) ..... 13
BUPIVILOG ............................... 77
BUPRENEX ................................. 7
buprenorphine .............................. 7
BUPRENORPHINE ...................... 7
buprenorphine hcl .................. 7, 16
buprenorphine hcl-naloxone
hcl .............................................. 16
bupropion hcl ............................. 24
bupropion hcl er (smoking det). 16
bupropion hcl er (sr) .................. 24
bupropion hcl er (xl) ................... 24
BUPROPION HCL ER (XL) ....... 24
buspirone hcl ............................. 39
busulfan ..................................... 30
BUSULFEX ................................ 30
BUTALBITAL-
ACETAMINOPHEN ...................... 7
butalbital-acetaminophen ............. 7
butalbital-apap ............................. 7
butalbital-apap-caff-cod ................ 7
butalbital-apap-caffeine ................ 7
butalbital-asa-caff-codeine ........... 7
butalbital-aspirin-caffeine ............. 7
BUTISOL SODIUM .................. 111
butorphanol tartrate ..................... 7
BUTRANS .................................... 7
BYDUREON .............................. 58
BYDUREON BCISE
AUTOINJECTOR ....................... 59
BYETTA 10 MCG PEN .............. 59
BYETTA 5 MCG PEN ............... 59
BYSTOLIC ................................ 42
cabergoline ............................... 80
CABOMETYX ........................... 30
CADIRAMD ............................... 13
CADUET ................................... 42
CAFCIT ..................................... 50
CAFERGOT .............................. 29
caffeine citrate........................... 50
CAFFEINE-SODIUM
BENZOATE ............................... 50
CALAN ...................................... 42
CALAN SR ................................ 42
CALCIFOL ................................ 64
calcipotriene .............................. 53
calcipotriene-betameth diprop ... 53
calcitonin (salmon) .................... 92
calcitrene ................................... 53
calcitriol ............................... 53, 92
calcium acetate (phos binder) ... 76
CALCIUM CHLORIDE .............. 65
calcium chloride ........................ 65
CALCIUM DISODIUM
VERSENATE ............................ 93
calcium gluconate ..................... 65
CALCIUM GLUCONATE ........... 65
calcium gluconate anhydrous ... 65
CALCIUM GLUCONATE-
NACL ........................................ 65
calcium-folic acid plus d ............ 65
CALIFORNIA PEPPER TREE 93
CALM ........................................ 65
CALQUENCE ............................ 30
CAMBIA .................................... 11
camila ....................................... 82
CAMPATH ................................ 30
CAMPTOSAR ........................... 30
camrese .................................... 82
camrese lo ................................ 82
CANASA ................................... 91
CANCIDAS ............................... 27
candesartan cilexetil ................. 42
candesartan cilexetil-hctz .......... 42
CANDIDA ALBICANS
EXTRACT ................................. 94
CANTALOUPE
(DIAGNOSTIC) ......................... 94
CANTHARIDIN .......................... 53
CAPASTAT SULFATE .............. 29
capecitabine .............................. 30
CAPEX ...................................... 53
CAPRELSA ............................... 30
117
CAPTAIN EAGLE PED
NEBULIZER .............................. 94
captopril ..................................... 42
captopril-hydrochlorothiazide ..... 42
CARAC ...................................... 53
CARAFATE ............................... 72
CARBAGLU ............................... 65
carbamazepine .......................... 22
carbamazepine er ...................... 22
CARBATROL ............................. 22
carbidopa ................................... 35
carbidopa-levodopa ................... 35
carbidopa-levodopa er ............... 35
carbidopa-levodopa-
entacapone ................................ 35
carbinoxamine maleate............ 105
CARBOCAINE ........................... 13
CARBOCAINE
PRESERVATIVE-FREE ............. 13
carboplatin ................................. 30
carboprost tromethamine ........... 81
CARDENE IV............................. 42
CARDIOPLEGIC ........................ 65
CARDIOVID PLUS .................... 94
CARDIZEM ................................ 43
CARDIZEM CD .......................... 43
CARDIZEM LA .......................... 43
CARDURA ................................. 43
CARDURA XL ........................... 77
CARETOUCH
LANCING/EJECTOR ................. 60
CARIMUNE NF .......................... 87
carimune nf ................................ 87
carisoprodol ............................. 110
carisoprodol-aspirin ................. 110
carisoprodol-aspirin-codeine ........ 7
carmustine ................................. 30
CARNITOR ................................ 65
CARNITOR SF .......................... 65
CAROSPIR ................................ 43
carteolol hcl ............................. 102
cartia xt ...................................... 43
carvedilol ................................... 43
carvedilol phosphate er ............. 43
cascara sagrada ........................ 73
CASEIN (DIAGNOSTIC) ............ 94
CASODEX ................................. 30
caspofungin acetate .................. 27
CAT HAIR EXTRACT ................ 94
CATAPRES ............................... 43
CATAPRES-TTS-1 .................... 43
CATAPRES-TTS-2 .................... 43
CATAPRES-TTS-3 .................... 43
CATHFLO ACTIVASE ............... 21
CATTLE EPITHELIUM............... 94
cavarest ..................................... 51
CAYA ......................................... 94
CAYSTON ............................... 109
caziant ....................................... 82
CEDAR ELM .............................. 94
cefaclor ...................................... 17
cefaclor er .................................. 17
cefadroxil ................................... 17
CEFALY KIT .............................. 94
cefazolin sodium ........................ 17
CEFAZOLIN SODIUM ............... 17
cefazolin sodium-dextrose ......... 17
cefdinir ....................................... 17
cefditoren pivoxil ........................ 17
cefepime hcl............................... 17
cefepime-dextrose ..................... 17
cefixime...................................... 17
CEFOTAN .................................. 17
cefotaxime sodium ..................... 17
cefotetan disodium ..................... 17
cefoxitin sodium ......................... 17
cefpodoxime proxetil .................. 17
cefprozil ..................................... 17
ceftazidime and dextrose ........... 17
ceftriaxone sodium ..................... 17
ceftriaxone sodium in dextrose. 17
ceftriaxone sodium-dextrose ...... 17
cefuroxime axetil ........................ 17
cefuroxime sodium ..................... 17
CEFUROXIME SODIUM-
NACL ....................................... 101
CELEBREX ................................ 11
celecoxib .................................... 11
CELESTONE SOLUSPAN ......... 77
CELEXA..................................... 24
CELLCEPT ................................ 87
CELLCEPT INTRAVENOUS ..... 87
CELONTIN ................................. 22
CENTANY .................................. 17
CENTRATEX ............................. 65
cephalexin .................................. 17
CEPROTIN ................................ 40
CEQUA .................................... 103
CERDELGA ............................... 75
CEREBYX .................................. 22
CEREZYME ............................... 75
CERVIDIL .................................. 81
CETACAINE .............................. 13
cetirizine hcl ............................. 105
CETRAXAL .............................. 104
cevimeline hcl ............................ 51
CHANTIX .................................. 16
CHANTIX CONTINUING
MONTH PAK............................. 16
CHANTIX STARTING MONTH
PAK ........................................... 16
chateal ...................................... 82
chateal eq ................................. 82
CHEMET ................................... 65
CHEMSTRIP UGK .................... 60
CHENODAL .............................. 73
CHICKEN MEAT
(DIAGNOSTIC) ......................... 94
chloramphenicol sod succinate. 17
chlordiazepoxide hcl ................. 39
chlordiazepoxide-amitriptyline ... 25
chlordiazepoxide-clidinium ........ 73
chlorhexidine gluconate ...... 51, 94
CHLORHEXIDINE
GLUCONATE ............................ 94
chloroprocaine hcl (pf) .............. 13
chloroquine phosphate .............. 34
chlorothiazide ............................ 43
chlorothiazide sodium ............... 43
chlorpromazine hcl .................... 36
chlorthalidone ............................ 43
chlorzoxazone ......................... 110
CHOLBAM ................................ 73
cholestyramine .......................... 43
cholestyramine light .................. 43
CHOLETEC .............................. 94
choline fenofibrate ..................... 43
choline-mag trisalicylate ............ 11
chromic chloride ........................ 65
ciclodan ..................................... 27
CICLODAN SOLUTION ............ 27
ciclopirox ................................... 27
ciclopirox olamine ..................... 27
cidofovir..................................... 37
cilostazol ................................... 36
CILOXAN ................................ 101
CIMDUO ................................... 37
cimetidine .................................. 72
cimetidine hcl ............................ 72
CIMZIA ...................................... 87
CIMZIA PREFILLED KIT ........... 87
CIMZIA STARTER KIT ............. 87
cinacalcet hcl ............................ 80
CINQAIR ................................. 105
CINRYZE .................................. 87
CINVANTI ................................. 26
CIPRO ...................................... 17
CIPRO HC .............................. 105
CIPRODEX ............................. 105
118
ciprofloxacin ............................... 17
ciprofloxacin hcl ......... 17, 101, 105
ciprofloxacin in d5w ................... 17
cisatracurium besylate ............... 50
cisatracurium besylate (pf) ........ 50
cisplatin...................................... 30
CISPLATIN ................................ 31
citalopram hydrobromide ........... 25
CITANEST FORTE DENTAL .... 13
CITANEST PLAIN DENTAL ...... 14
CITRANATAL MEDLEY ............. 65
citroma ....................................... 73
CLADOSPORIUM
CLADOSPORIOIDES ................ 94
CLADOSPORIUM
SPHAEROSPERMUM ............... 94
cladribine ................................... 31
claravis ...................................... 53
CLARINEX ............................... 105
CLARINEX-D 12 HOUR .......... 105
clarithromycin............................. 17
clarithromycin er ........................ 17
clearlax ...................................... 73
clemastine fumarate ................ 105
CLENPIQ ................................... 73
CLEOCIN ................................... 17
CLEOCIN PHOSPHATE ............ 17
CLEOCIN-T ............................... 53
CLEVIPREX .............................. 43
CLIMARA ................................... 82
CLIMARA PRO .......................... 82
clindacin etz ............................... 53
clindacin-p ................................. 53
CLINDAGEL .............................. 53
clindamycin hcl .......................... 17
clindamycin palmitate hcl ........... 17
clindamycin phosphate. 17, 18, 53
CLINDAMYCIN PHOSPHATE 53
clindamycin phosphate in d5w 17
CLINDAMYCIN PHOSPHATE
IN NACL .................................... 17
clindamycin phosphate-
benzoyl peroxide ....................... 53
clindamycin-tretinoin .................. 53
CLINDESSE .............................. 18
CLINIMIX E/DEXTROSE
(2.75/5) ...................................... 65
CLINIMIX E/DEXTROSE
(4.25/10) .................................... 65
CLINIMIX E/DEXTROSE
(4.25/5) ...................................... 65
CLINIMIX E/DEXTROSE
(5/15) ......................................... 65
CLINIMIX E/DEXTROSE
(5/20) ......................................... 65
CLINIMIX N14G30E .................. 65
CLINIMIX N9G15E .................... 65
CLINIMIX N9G20E .................... 65
clinimix/dextrose (4.25/10) ......... 65
CLINIMIX/DEXTROSE
(4.25/10) .................................... 65
clinimix/dextrose (4.25/25) ......... 65
CLINIMIX/DEXTROSE (4.25/5) 65
CLINIMIX/DEXTROSE (5/15) .... 65
CLINIMIX/DEXTROSE (5/20) .... 65
CLINIMIX/DEXTROSE (5/25) .... 65
clinisol sf .................................... 65
CLINOIN .................................... 53
clinpro 5000 ............................... 51
clobazam ................................... 22
clobetasol prop emollient base. 53
clobetasol propionate ................. 53
clobetasol propionate e .............. 53
clobetasol propionate emulsion 53
CLOBEX .................................... 54
CLOBEX SPRAY ....................... 54
clocortolone pivalate .................. 54
clodan ........................................ 54
CLODERM ................................. 54
clofarabine ................................. 31
CLOLAR .................................... 31
clomipramine hcl ........................ 25
clonazepam ............................... 39
clonidine..................................... 43
clonidine hcl ............................... 43
clonidine hcl er ........................... 49
clopidogrel bisulfate ................... 36
clorazepate dipotassium ............ 39
CLOROTEKAL ........................... 14
clotrimazole ................................ 27
CLOTRIMAZOLE ....................... 27
clotrimazole-betamethasone ...... 54
clozapine .................................... 36
CLOZARIL ................................. 36
COAGADEX .............................. 40
coal tar ....................................... 54
COARTEM ................................. 35
cocaine hcl ................................. 14
COCAINE HCL .......................... 14
COCKLEBUR ............................ 94
COCOA BEAN (DIAGNOSTIC) 94
codeine sulfate ............................. 7
COENZYME Q-10 ...................... 94
COGENTIN ................................ 35
COLAZAL .................................. 91
COLCHICINE ............................. 28
colchicine-probenecid................ 28
COLCRYS ................................. 28
colesevelam hcl ........................ 43
COLESTID ................................ 43
COLESTID FLAVORED ............ 43
colestipol hcl ............................. 43
colistimethate sodium (cba) ...... 18
colocort ..................................... 91
COLY-MYCIN M ....................... 18
COLY-MYCIN S ...................... 105
COLYTE WITH FLAVOR
PACKS ...................................... 73
COMBIGAN ............................ 102
COMBIPATCH .......................... 82
COMBIVENT RESPIMAT ....... 107
COMBIVIR ................................ 37
COMETRIQ (100 MG DAILY
DOSE) ...................................... 31
COMETRIQ (140 MG DAILY
DOSE) ...................................... 31
COMETRIQ (60 MG DAILY
DOSE) ...................................... 31
COMPLERA .............................. 37
compro ...................................... 26
COMTAN .................................. 35
CONCERTA .............................. 49
CONDYLOX .............................. 54
constulose ................................. 73
CONTOUR NEXT CONTROL ... 60
CONTOUR NEXT MONITOR ... 60
CONTOUR NEXT TEST ........... 60
CONTOUR TEST ...................... 60
CONTRAST ALLERGY
PREMED PACK ........................ 77
CONZIP ...................................... 7
COPAXONE .............................. 50
COPIKTRA ................................ 31
COPPER CHLORIDE ............... 65
CORDRAN ................................ 54
COREG ..................................... 43
COREG CR .............................. 43
coremino ................................... 18
CORGARD ................................ 43
CORIFACT ................................ 40
CORLANOR .............................. 43
CORLOPAM ............................. 43
CORN POLLEN ........................ 94
CORTANE-B ............................. 54
CORTEF ................................... 77
CORTENEMA ........................... 91
cortic-nd .................................. 105
CORTIFOAM ............................ 91
cortisone acetate ....................... 77
119
CURVULARIA ............................ 94
CUTAQUIG .......................... 87, 88
CUTIVATE ................................. 54
CUVITRU ................................... 88
CUVPOSA ................................. 73
cyanocobalamin ......................... 65
CYANOCOBALAMIN ................. 65
cyclafem 1/35............................. 82
cyclafem 7/7/7............................ 82
cyclobenzaprine hcl ................. 110
cyclobenzaprine hcl er ............. 110
CYCLOGYL ............................. 103
CYCLOMYDRIL ....................... 103
cyclopentolate hcl .................... 103
dasetta 7/7/7 .............................. 82
daunorubicin hcl ......................... 31
DAURISMO ............................... 31
DAYPRO .................................... 11
daysee ....................................... 82
DAYTRANA ............................... 49
DDAVP ...................................... 80
DDAVP RHINAL TUBE .............. 80
DEBACTEROL ........................... 51
deblitane .................................... 82
DECADRON .............................. 77
decitabine .................................. 31
deferasirox ................................. 65
deferoxamine mesylate .............. 94
desloratadine ........................... 105
desmopressin ace spray refrig 80
desmopressin acetate ................80
desmopressin acetate spray ......80
desogestrel-ethinyl estradiol.......83
DESONATE ...............................54
desonide ....................................54
DESOWEN ................................54
desoximetasone .........................54
DESOXYN .................................49
DESVENLAFAXINE ER .............25
desvenlafaxine succinate er .......25
DETROL ....................................76
DETROL LA ...............................76
120
CORTISPORIN .......................... 54
CORTROSYN ............................ 94
corvita 150 ................................. 65
CORVITE 150 ............................ 65
CORVITE FE ............................. 65
COSENTYX (300 MG DOSE) ... 87
COSENTYX 150 MG/ML ........... 87
COSENTYX SENSOREADY
(300 MG) ................................... 87
COSENTYX SENSOREADY
PEN ........................................... 87
COSMEGEN .............................. 31
COSOPT ................................. 102
COSOPT PF ............................ 102
cosyntropin ................................ 94
COTELLIC ................................. 31
COTEMPLA XR-ODT ................ 49
COUMADIN ............................... 21
covaryx ...................................... 82
covaryx hs ................................. 82
COZAAR .................................... 43
CRAB (DIAGNOSTIC) ............... 94
CREON...................................... 75
CRESEMBA .............................. 27
CRESTOR ................................. 43
CRINONE .................................. 82
CRIXIVAN .................................. 37
cromolyn sodium ....... 73, 101, 107
crotan ........................................ 35
cryselle-28 ................................. 82
CRYSVITA ................................. 75
CUBICIN .................................... 18
CUBICIN RF .............................. 18
CUPRIMINE .............................. 76
curad hydrocortisone ................. 54
CURITY AMD
ANTIMICROBIAL STRIP ........... 94
CURITY IODOFORM
PACKING STRIP ....................... 94
CYCLOPHENE RAPIDPAQ ..... 110
cyclophosphamide ..................... 31
cycloserine ................................. 29
CYCLOSET ............................... 59
cyclosporine ............................... 88
cyclosporine modified ................ 88
CYKLOKAPRON ........................ 40
CYMBALTA ............................... 25
cyproheptadine hcl ................... 105
CYRAMZA ................................. 31
cyred .......................................... 82
cyred eq ..................................... 82
CYSTADANE ............................. 75
CYSTAGON ............................... 75
CYSTARAN ............................. 103
CYSVIEW .................................. 94
cytarabine .................................. 31
cytarabine (pf) ............................ 31
CYTOGAM ................................. 88
CYTOMEL ................................. 86
CYTOTEC .................................. 72
cytra k crystals ........................... 65
D.H.E. 45 ................................... 29
dacarbazine ............................... 31
DACOGEN ................................. 31
dactinomycin .............................. 31
dalfampridine er ......................... 50
DALIRESP ............................... 107
DALVANCE ............................... 18
danazol ...................................... 79
DANTRIUM .............................. 110
dantrolene sodium ................... 110
dapsone ............................... 29, 54
DAPTACEL ................................ 90
daptomycin ................................ 18
DARAPRIM ................................ 35
darifenacin hydrobromide er ...... 76
DARZALEX ................................ 31
dasetta 1/35 ............................... 82
DEFITELIO ............................... 21
dehydrated alcohol .................... 65
DELESTROGEN ....................... 82
delflex-lc/1.5% dextrose ............ 65
delflex-lc/2.5% dextrose ............ 66
delflex-lc/4.25% dextrose .......... 66
DELFLEX-LC/4.25%
DEXTROSE .............................. 66
delflex-sm/1.5% dextrose .......... 66
DELSTRIGO ............................. 37
delyla ........................................ 82
DELZICOL ................................ 91
demeclocycline hcl .................... 18
DEMEROL .................................. 7
DEMSER ................................... 43
DENAVIR .................................. 37
denta 5000 plus ........................ 51
dentagel .................................... 51
DEPACON ................................ 22
DEPAKENE .............................. 22
DEPAKOTE .............................. 22
DEPAKOTE ER......................... 22
DEPAKOTE SPRINKLES .......... 22
DEPEN TITRATABS ................. 76
DEPO-ESTRADIOL .................. 82
DEPO-MEDROL ....................... 77
DEPO-PROVERA ............... 82, 83
DEPO-SUBQ PROVERA 104 ... 83
DEPO-TESTOSTERONE .......... 79
DEPRIZINE FUSEPAQ ............. 72
DERMA-SMOOTHE/FS BODY. 54
DERMA-SMOOTHE/FS
SCALP ...................................... 54
DERMOTIC ............................. 105
DERMULCERA ......................... 54
DESCOVY ................................ 37
DESFERAL ............................... 94
desflurane ................................. 94
desipramine hcl ......................... 25
DEXPANTHENOL ..................... 66
dexrazoxane .............................. 31
dexrazoxane hcl ........................ 31
DEXTENZA ............................. 101
dextroamphetamine sulfate ....... 49
dextroamphetamine sulfate er 49
dextrose ..................................... 66
DEXTROSE ............................... 66
DEXYCU .................................. 101
DIACOMIT ................................. 22
DIANEAL LOW
CALCIUM/1.5% DEX ................. 66
DIANEAL LOW
CALCIUM/2.5% DEX ................. 66
DILANTIN INFATABS ................ 22
DILATRATE-SR ......................... 43
DILAUDID .................................... 7
diltiazem hcl ............................... 43
diltiazem hcl er ........................... 43
diltiazem hcl er beads ................ 43
diltiazem hcl er coated beads .... 43
DILTIAZEM HCL-DEXTROSE 43
DILTIAZEM HCL-SODIUM
CHLORIDE ................................ 43
dilt-xr .......................................... 43
diluent for treprostinil .................. 94
dimenhydrinate .......................... 26
DIOVAN ..................................... 43
DOUBLE PM ............................ 103
DOVATO ....................................37
DOVER URETHRAL
CATHETER ................................94
DOVONEX .................................54
doxazosin mesylate ....................43
doxepin hcl .......................... 25, 54
doxercalciferol ............................92
DOXIL ........................................31
doxorubicin hcl ...........................31
doxorubicin hcl liposomal ...........31
doxy 100 ....................................18
doxycycline ................................54
doxycycline hyclate ....................18
121
dexamethasone ......................... 77
DEXAMETHASONE (LA) .......... 77
DEXAMETHASONE ACE &
SOD PHOS ............................... 77
DEXAMETHASONE
INTENSOL ................................. 77
DEXAMETHASONE SOD
PHOS-BUPIV............................. 77
DEXAMETHASONE SOD
PHOS-NACL .............................. 78
dexamethasone sod
phosphate pf .............................. 78
dexamethasone sodium
phosphate .......................... 78, 101
DEXAMETHASONE-
MOXIFLOXACIN ...................... 103
DEXAMETH-MOXIFLOX-
KETOROLAC........................... 103
dexchlorpheniramine maleate. 105
DEXCOM G4 / G5 / G6
RECEIVER, TRANSMITTER,
SENSOR (INCLUDING
PLATINUM, PLATINUM
PEDIATRIC) .............................. 60
DEXEDRINE .............................. 49
DEXILANT ................................. 72
DEXLIDO ................................... 78
DEXLIDO-M ............................... 78
DEXMEDETOMIDINE HCL ....... 94
dexmedetomidine hcl ................. 94
dexmedetomidine hcl in nacl ..... 94
DEXMEDETOMIDINE HCL-
DEXTROSE ............................... 94
dexmethylphenidate hcl ............. 49
dexmethylphenidate hcl er ......... 49
DEXOPIN .................................. 78
DEXPAK 10 DAY....................... 78
DEXPAK 13 DAY....................... 78
DEXPAK 6 DAY ........................ 78
DIANEAL LOW
CALCIUM/4.25% DEX ............... 66
DIASTAT ACUDIAL ................... 22
DIASTAT PEDIATRIC................ 22
DIATHRIVE BLOOD
GLUCOSE METER .................... 60
DIATHRIVE BLOOD
GLUCOSE TEST ....................... 60
DIATHRIVE GLUCOSE
CONTROL SOLN ...................... 61
DIATHRIVE GLUCOSE TEST 61
DIATHRIVE LANCING
DEVICE ..................................... 61
diazepam ............................. 22, 39
DIAZEPAM ................................ 39
diazepam intensol ...................... 39
DIBENZYLINE ........................... 43
DICLEGIS .................................. 26
DICLOFENAC EPOLAMINE ...... 11
diclofenac potassium ................. 11
diclofenac sodium ........11, 54, 101
diclofenac sodium er .................. 11
diclofenac-misoprostol ............... 11
dicloxacillin sodium .................... 18
DICOPANOL FUSEPAQ .......... 105
DICOPANOL RAPIDPAQ ........ 105
dicyclomine hcl .......................... 73
didanosine ................................. 37
DIFFERIN .................................. 54
DIFICID ...................................... 18
difil-g forte ................................ 107
diflorasone diacetate .................. 54
DIFLUCAN ................................. 27
diflunisal ..................................... 11
digitek ........................................ 43
digox .......................................... 43
digoxin ....................................... 43
dihydroergotamine mesylate ...... 29
DILANTIN ............................ 22, 23
DIOVAN HCT ............................ 43
DIPENTUM ............................... 91
diphenhydramine hcl ............... 105
diphenoxylate-atropine .............. 73
DIPHTHERIA-TETANUS
TOXOIDS DT ............................ 90
DIPRIVAN ................................. 94
DIPROLENE ............................. 54
DIPROLENE AF ........................ 54
dipyridamole .............................. 36
disopyramide phosphate ........... 43
disulfiram ................................... 16
DITROPAN XL .......................... 76
DIURIL ...................................... 43
divalproex sodium ..................... 23
divalproex sodium er ................. 23
DIVIGEL .................................... 83
dobutamine hcl .......................... 43
docetaxel ................................... 31
dofetilide.................................... 43
DOG EPITHELIUM ................... 94
DOG FENNEL........................... 94
DOLOPHINE ............................... 7
donepezil hcl ............................. 24
DONNATAL .............................. 73
dopamine hcl............................. 43
dopamine in d5w ....................... 43
DOPTELET ............................... 40
DORAL ..................................... 39
DORYX ..................................... 18
DORYX MPC ............................ 18
DORZOLAMIDE HCL ............. 102
dorzolamide hcl ....................... 102
DORZOLAMIDE HCL-
TIMOLOL MAL ........................ 102
dorzolamide hcl-timolol mal .... 102
dorzolamide hcl-timolol mal pf 102
DOTAREM ................................ 94
dotti ........................................... 83
doxycycline monohydrate .......... 18
doxylamine-pyridoxine ............... 26
D-PENAMINE ............................ 76
DRECHSLERA .......................... 94
DRISDOL ................................... 66
dritho-creme hp ......................... 54
dronabinol .................................. 26
droperidol ................................... 26
drospiren-eth estrad-levomefol. 83
drospirenone-ethinyl estradiol .... 83
DROXIA ..................................... 31
DRYSOL .................................... 54
DSUVIA ....................................... 7
DUAC ........................................ 54
DUAKLIR PRESSAIR .............. 107
DUAL COMPLEX FORMULA 1
KIT ............................................. 11
DUAVEE .................................... 83
DUETACT .................................. 59
DUEXIS ..................................... 11
DULERA .................................. 107
duloxetine hcl............................. 25
DUOBRII .................................... 54
DUODOTE ................................. 94
DUOPA ...................................... 35
DUPIXENT ................................ 54
DURAGESIC-100 ........................ 7
DURAGESIC-12 .......................... 7
DURAGESIC-25 .......................... 7
DURAGESIC-50 .......................... 7
DURAGESIC-75 .......................... 7
duramorph ................................... 7
duraxin ......................................... 7
DUREZOL ............................... 101
DURLAZA .................................. 36
DUROLANE ............................... 94
DUST MITE MIXED
ALLERGEN EXT ....................... 94
dutasteride ................................. 77
dutasteride-tamsulosin hcl ......... 77
DUTOPROL ............................... 43
DVORAH ..................................... 7
DXEVO 11-DAY ........................ 78
DYANAVEL XR ......................... 49
DYAZIDE ................................... 43
DYMISTA ................................. 105
DYRENIUM ............................... 43
DYSPORT ................................. 94
DYURAL-40 ............................... 78
DYURAL-80 ............................... 78
DYURAL-L ................................. 78
DYURAL-LM .............................. 78
e.e.s. 400 ................................... 18
E.E.S. GRANULES .................... 18
EASIVENT ................................. 94
EASTERN COTTONWOOD ...... 94
EASY COMFORT ALCOHOL
PADS ......................................... 94
EASY GLIDE LUER LOCK
SYRINGE ................................... 94
easygel ...................................... 51
EASYMAX CONTROL ............... 61
EASYPLUS BLOOD
GLUCOSE TEST ....................... 61
EC-NAPROSYN ......................... 11
ec-naproxen ............................... 11
econazole nitrate ....................... 27
ECOZA ...................................... 27
EC-RX DHEA............................. 94
EC-RX ESTRADIOL .................. 83
EC-RX PROGESTERONE ........ 83
EC-RX TESTOSTERONE ......... 79
EDARBI ..................................... 43
EDARBYCLOR .......................... 43
EDECRIN ................................... 43
EDLUAR .................................. 111
EDURANT ................................. 37
eemt ........................................... 83
eemt hs ...................................... 83
efavirenz .................................... 37
EFFER-K ................................... 66
effer-k ........................................ 66
EFFEXOR XR ............................ 25
EFFIENT .................................... 36
EFUDEX .................................... 54
EGATEN .................................... 35
EGG WHITE (DIAGNOSTIC) .... 95
EGRIFTA ................................... 80
ELAPRASE ................................ 75
ELCYS ....................................... 95
ELELYSO .................................. 75
ELESTRIN ................................. 83
eletriptan hydrobromide ............. 29
ELIDEL ...................................... 54
ELIGARD ................................... 80
ELIMITE ..................................... 35
elinest ........................................ 83
ELIQUIS..................................... 21
ELIQUIS STARTER PACK ........ 22
ELITEK ...................................... 31
elite-ob ....................................... 66
ELIXOPHYLLIN ....................... 107
ELLA .......................................... 83
ELLENCE .................................. 31
ELLIOTTS B .............................. 66
ELMIRON .................................. 76
ELOCON ................................... 54
ELOCTATE ............................... 40
ELZONRIS ................................ 31
EMBEDA ..................................... 7
EMBRACE TALK BLOOD
GLUCOSE ................................ 61
EMBRACE TALK GLUCOSE
CONTROL ................................ 61
EMBRACE TALK GLUCOSE
TEST ......................................... 61
EMBRACE TALK
MONITORING SYSTEM ........... 61
EMCYT ..................................... 31
EMEND ..................................... 26
EMEND TRI-PACK ................... 26
EMFLAZA ................................. 28
EMGALITY ................................ 29
EMGALITY (300 MG DOSE) .... 29
emoquette ................................. 83
EMPLICITI ................................ 31
EMSAM ..................................... 25
EMTRIVA .................................. 37
EMVERM .................................. 35
ENABLEX ................................. 76
enalapril maleate ....................... 43
enalaprilat ................................. 44
enalapril-hydrochlorothiazide ..... 44
ENBRACE HR .......................... 66
ENBREL.................................... 88
ENBREL MINI ........................... 88
ENBREL SURECLICK .............. 88
ENDARI .................................... 95
endocet ....................................... 7
ENGERIX-B .............................. 90
ENGLISH PLANTAIN ................ 95
ENLITE GLUCOSE SENSOR ... 61
ENOVARX-BACLOFEN .......... 110
enovarx-cyclobenzaprine hcl 110
ENOVARX-
CYCLOBENZAPRINE HCL ..... 110
ENOVARX-DICLOFENAC
SODIUM.................................... 11
ENOVARX-IBUPROFEN ........... 11
ENOVARX-LIDOCAINE HCL .... 14
ENOVARX-NAPROXEN ........... 11
ENOVARX-TRAMADOL ............ 54
enoxaparin sodium .................... 22
enpresse-28 .............................. 83
enskyce ..................................... 83
ENSTILAR ................................ 54
entacapone ............................... 35
entecavir ................................... 37
ENTEREG ................................. 73
122
ENTOCORT EC ........................ 91
ENTRESTO ............................... 44
ENTYVIO ................................... 88
enulose ...................................... 73
ENVARSUS XR ......................... 88
ENZADYNE ............................... 75
ENZOCLEAR ............................. 54
EPANED .................................... 44
EPCLUSA .................................. 37
ephedrine sulfate ....................... 44
EPHEDRINE SULFATE ............. 44
EPHEDRINE SULFATE
(PRESSORS) ............................ 44
EPHEDRINE SULFATE-NACL. 44
EPICOCCUM ............................. 95
EPIDIOLEX ................................ 23
EPIDUO ..................................... 54
EPIDUO FORTE ........................ 54
EPIFOAM .................................. 54
epinastine hcl........................... 101
epinephrine ........................ 44, 107
EPINEPHRINE .......................... 44
EPINEPHRINE HCL-
DEXTROSE ............................... 44
EPINEPHRINE HCL-NACL ....... 44
epinephrine pf ............................ 44
EPINEPHRINE-DEXTROSE ...... 44
EPINEPHRINE-NACL ................ 44
EPIPEN 2-PAK ........................ 107
EPIPEN JR 2-PAK................... 107
epirubicin hcl.............................. 31
EPISNAP ................................. 107
epitol .......................................... 23
EPIVIR ....................................... 37
EPIVIR HBV .............................. 37
eplerenone ................................. 44
EPOGEN ................................... 40
epoprostenol sodium ............... 109
eprosartan mesylate .................. 44
eptifibatide ................................. 36
EPZICOM .................................. 37
EQUETRO ................................. 23
ERAXIS ..................................... 27
ERBITUX ................................... 31
ERGOCAL ................................. 66
ergocalciferol ............................. 66
ergoloid mesylates ..................... 95
ERGOMAR ................................ 29
ergotamine-caffeine ................... 29
ERIVEDGE ................................ 31
ERLEADA .................................. 31
erlotinib hcl ................................ 31
EROS-CTD ................................ 95
errin ........................................... 83
ERTACZO .................................. 27
ertapenem sodium ..................... 18
ERWINAZE ................................ 31
ery .............................................. 54
ERYGEL .................................... 54
ERYPED 200 ............................. 18
ERYPED 400 ............................. 18
ERY-TAB ................................... 18
erythrocin lactobionate ............... 18
ERYTHROCIN
LACTOBIONATE ....................... 18
ERYTHROCIN STEARATE ....... 18
erythromycin ...................... 54, 101
erythromycin base ..................... 18
erythromycin ethylsuccinate ....... 18
ESBRIET ................................. 107
ESCAVITE ................................. 66
ESCAVITE D ............................. 66
ESCAVITE LQ ........................... 66
escitalopram oxalate .................. 25
esgic ............................................ 7
ESGIC ......................................... 7
esmolol hcl ................................. 44
ESMOLOL HCL ......................... 44
esmolol hcl-sodium chloride ...... 44
esomeprazole magnesium ......... 72
esomeprazole sodium ................ 72
est estrogens-methyltest ............ 83
est estrogens-methyltest ds ....... 83
est estrogens-methyltest hs ....... 83
estarylla ..................................... 83
estazolam .................................. 39
ESTRACE .................................. 83
estradiol ..................................... 83
estradiol valerate ....................... 83
estradiol-norethindrone acet ...... 83
ESTRING ................................... 83
ESTROGEL ............................... 83
ESTROSTEP FE ....................... 83
eszopiclone .............................. 111
ethacrynate sodium ................... 44
ethacrynic acid ........................... 44
ethambutol hcl ........................... 30
ethosuximide .............................. 23
ethyl chloride.............................. 14
ethynodiol diac-eth estradiol ...... 83
ETHYOL .................................... 31
etidronate disodium ................... 92
etodolac ..................................... 11
etodolac er ................................. 11
etomidate ................................... 95
ETOPOPHOS ............................ 31
etoposide .................................. 31
EUCRISA .................................. 54
EUFLEXXA ............................... 95
EURAX ..................................... 35
euthyrox .................................... 86
EVAMIST .................................. 83
EVEKEO ................................... 49
EVEKEO ODT........................... 49
EVENITY ................................... 92
EVERSENSE
SENSOR/HOLDER ................... 61
EVERSENSE SMART
TRANSMITTER ......................... 61
EVISTA ..................................... 80
EVOCLIN .................................. 55
EVOMELA ................................. 31
EVOTAZ.................................... 37
EVOXAC ................................... 51
EVZIO ....................................... 16
EXELDERM .............................. 27
EXELON ................................... 24
exemestane .............................. 31
EXFORGE ................................ 44
EXFORGE HCT ........................ 44
EXJADE .................................... 66
ex-lax ultra ................................ 73
exoderm .................................... 27
EXONDYS 51 ........................... 75
exotic-hc.................................. 105
EXPAREL ................................. 14
EXTAVIA ................................... 50
EXTINA ..................................... 27
EYLEA .................................... 103
EZ FLU SHOT-FLUCELVAX
QUAD ....................................... 90
EZALLOR SPRINKLE ............... 44
E-Z-DISK ................................... 95
ezetimibe ................................... 44
ezetimibe-simvastatin ................ 44
E-Z-HD ...................................... 95
E-Z-PAQUE .............................. 95
E-Z-PASTE ............................... 95
FABIOR..................................... 55
FABRAZYME ............................ 75
FALESSA .................................. 83
falmina ...................................... 83
famciclovir ................................. 37
famotidine ................................. 72
FAMOTIDINE IN NACL ............. 72
famotidine premixed .................. 72
FANAPT .................................... 36
FANAPT TITRATION PACK ..... 36
FANATREX FUSEPAQ ............. 23
123
FARESTON ............................... 31
FARXIGA ................................... 59
FARYDAK .................................. 31
FASENRA ................................ 105
FASLODEX ............................... 31
fayosim ...................................... 83
FAZACLO .................................. 36
FBL KIT ..................................... 11
febuxostat .................................. 28
FEIBA ........................................ 40
felbamate ................................... 23
FELBATOL ................................ 23
FELDENE .................................. 11
felodipine er ............................... 44
FEM PH ..................................... 76
FEMARA .................................... 31
FEMCAP .................................... 95
FEMHRT LOW DOSE ............... 83
FEMRING .................................. 83
femynor...................................... 83
fenofibrate .................................. 44
fenofibrate micronized ............... 44
fenofibric acid ............................ 44
FENOGLIDE .............................. 44
fenoprofen calcium .................... 11
fenortho ..................................... 11
fentanyl ........................................ 7
fentanyl citrate ............................. 8
FENTANYL CITRATE.................. 8
fentanyl citrate (pf) ....................... 7
FENTANYL CITRATE-NACL ....... 8
FENTANYL CIT-
ROPIVACAINE-NACL .................. 8
FENTANYL-BUPIVACAINE-
NACL ........................................... 8
FENTORA ................................... 8
FERIVA 21/7.............................. 66
FERIVAFA ................................. 66
ferocon ...................................... 66
ferotrinsic ................................... 66
FERRALET 90 ........................... 66
ferraplus 90 ............................... 66
FERRIPROX .............................. 66
FERRLECIT ............................... 66
ferrocite plus .............................. 66
FERRO-PLEX HEMATINIC ....... 66
FERROTRIN .............................. 66
FETZIMA ................................... 25
FETZIMA TITRATION ............... 25
FEXMID ................................... 110
FIASP ........................................ 63
FIASP FLEXTOUCH ................. 63
FIASP PENFILL ......................... 63
FIBRICOR .................................. 44
FIBRYGA ................................... 40
FINACEA ................................... 55
finasteride .................................. 77
FIORICET .................................... 8
FIORICET/CODEINE ................... 8
FIORINAL .................................... 8
FIORINAL/CODEINE #3 .............. 8
FIRAZYR ................................... 88
FIRDAPSE ................................. 95
FIRE ANT .................................. 95
FIRMAGON ............................... 80
FIRST - METOPROLOL ............ 44
FIRST-ATENOLOL .................... 44
FIRST-BACLOFEN .................. 110
FIRST-METRONIDAZOLE ......... 18
FIRST-MOUTHWASH BLM ....... 51
FIRST-VANCOMYCIN ............... 18
FIRVANQ ................................... 18
flac ........................................... 105
FLAGYL ..................................... 18
FLAREX ................................... 101
flavoxate hcl ............................... 76
FLEBOGAMMA DIF ................... 88
flecainide acetate ....................... 44
FLECTOR .................................. 11
FLEXBUMIN .............................. 95
FLOLAN ................................... 109
FLOLIPID ................................... 44
FLOMAX .................................... 77
FLORIVA ................................... 66
floriva ......................................... 66
FLORIVA PLUS ......................... 66
FLOVENT DISKUS .................. 107
FLOVENT HFA ........................ 107
FLOXIN OTIC .......................... 105
floxuridine .................................. 31
FLUAD ....................................... 90
FLUARIX QUADRIVALENT ....... 90
FLUBLOK QUADRIVALENT ...... 90
FLUCELVAX
QUADRIVALENT ....................... 90
fluconazole ................................. 27
fluconazole in sodium chloride 27
flucytosine .................................. 27
fludarabine phosphate ............... 31
fludrocortisone acetate .............. 78
FLULAVAL QUADRIVALENT .... 90
FLUMADINE .............................. 37
flumazenil ................................... 95
FLUMIST QUADRIVALENT ....... 90
flunisolide ................................. 105
fluocinolone acetonide ....... 55, 105
fluocinolone acetonide body ..... 55
fluocinolone acetonide scalp ..... 55
fluocinonide ............................... 55
fluocinonide emulsified base ..... 55
FLUORABON ............................ 66
fluoridex .................................... 51
fluoridex daily renewal .............. 51
fluoridex enhanced whitening ... 51
fluoridex sensitivity relief ........... 51
fluoritab ..................................... 66
fluorometholone ...................... 101
FLUOROPLEX .......................... 55
fluorouracil .......................... 31, 55
FLUOROURACIL ...................... 55
fluoxetine hcl ............................. 25
fluoxetine hcl (pmdd)................. 25
fluphenazine decanoate ............ 36
fluphenazine hcl ........................ 36
FLURA-DROPS ........................ 66
flurandrenolide .......................... 55
flurazepam hcl......................... 111
flurbiprofen ................................ 11
flurbiprofen sodium ................. 101
flutamide ................................... 31
fluticasone propionate ....... 55, 105
fluticasone-salmeterol ............. 108
FLUTICASONE-
SALMETEROL ........................ 108
fluvastatin sodium ..................... 44
fluvastatin sodium er ................. 45
fluvoxamine maleate ................. 25
fluvoxamine maleate er ............. 25
FLUZONE HIGH-DOSE ............ 90
FLUZONE QUADRIVALENT .... 90
FLYP NEBULIZER .................... 95
FML ......................................... 101
FML FORTE............................ 101
FML LIQUIFILM ...................... 101
FOCALIN .................................. 49
FOCALIN XR ............................ 49
folic acid .............................. 66, 67
FOLI-D ...................................... 67
FOLITE ..................................... 67
FOLIVANE-F ............................. 67
FOLOTYN ................................. 31
foltrin ......................................... 67
FOLVITE-D ............................... 67
fomepizole ................................. 95
fondaparinux sodium ................. 22
FORA GTEL BLOOD
GLUCOSE SYSTEM ................. 61
FORA GTEL BLOOD
GLUCOSE TEST ...................... 61
124
FORFIVO XL ............................. 25
formaldehyde ............................. 95
FORTAMET ............................... 59
FORTEO .................................... 92
FORTESTA ............................... 79
FORTISCARE CONTROL ......... 61
FOSAMAX ................................. 92
FOSAMAX PLUS D ................... 92
fosamprenavir calcium ............... 37
FOSCAVIR ................................ 37
fosinopril sodium ........................ 45
fosinopril sodium-hctz ................ 45
fosphenytoin sodium .................. 23
FOSRENOL ............................... 76
FRAGMIN .................................. 22
FREAMINE HBC ....................... 67
FREAMINE III ............................ 67
FREESTYLE FREEDOM LITE. 61
FREESTYLE INSULINX
SYSTEM .................................... 61
FREESTYLE INSULINX TEST. 61
FREESTYLE LIBRE 14 DAY
READER .................................... 61
FREESTYLE LIBRE 14 DAY
SENSOR ................................... 61
FREESTYLE LIBRE READER 61
FREESTYLE LIBRE SENSOR
SYSTEM .................................... 61
FREESTYLE LITE TEST ........... 61
FREESTYLE PRECISION
NEO TEST ................................ 61
FREESTYLE TEST ................... 61
FROVA ...................................... 29
frovatriptan succinate ................ 29
FULPHILA ................................. 40
fulvestrant .................................. 31
FURADANTIN............................ 18
furosemide ................................. 45
FUROSEMIDE IN SODIUM
CHLORIDE ................................ 45
FUSARIUM ................................ 95
FUSILEV .................................... 31
FUSION PLUS ........................... 67
FUSION SPRINKLES ................ 67
FUZEON .................................... 37
fyavolv ....................................... 83
FYCOMPA ................................. 23
GABA ........................................ 67
gabapentin ................................. 23
GABITRIL .................................. 23
GABLOFEN ............................. 110
GADAVIST ................................ 95
GALAFOLD ............................... 75
galantamine hydrobromide ........ 24
galantamine hydrobromide er .... 24
GALZIN ...................................... 67
GAMASTAN ............................... 88
gamastan s/d ............................. 88
GAMASTAN S/D ........................ 88
GAMIFANT ................................ 88
GAMMAGARD ........................... 88
GAMMAGARD S/D LESS IGA 88
GAMMAKED .............................. 88
GAMMAPLEX ............................ 88
GAMUNEX-C ............................. 88
GANCICLOVIR .......................... 37
ganciclovir sodium ............... 37, 38
GARDASIL 9.............................. 90
GASTROCROM ......................... 73
gatifloxacin ............................... 101
GATTEX .................................... 73
gavilax ....................................... 73
gavilyte-c .................................... 73
gavilyte-g ................................... 73
gavilyte-h ................................... 73
gavilyte-n with flavor pack.......... 73
GAZYVA .................................... 31
GEBAUERS PAIN EASE ........... 14
GELFILM ................................. 103
GEL-FLOW ................................ 95
GELFOAM COMPRESSED
SIZE 100 .................................... 95
GELFOAM DENTAL PACK
SIZE 4 ........................................ 95
GELFOAM SPONGE ................. 95
GELFOAM SPONGE SIZE
100 ............................................. 95
GELFOAM SPONGE SIZE
200 ............................................. 95
GELFOAM SPONGE SIZE 50 95
GELFOAM-JMI POWDER ......... 95
GELFOAM-JMI SPONGE .......... 95
GELNIQUE ................................ 76
GELNIQUE PUMP ..................... 76
GEL-ONE ................................... 95
GELSYN-3 ................................. 95
gemcitabine hcl .......................... 31
gemfibrozil ................................. 45
GENERESS FE ......................... 83
generlac ..................................... 73
gengraf ...................................... 88
GENICIN VITA-D ....................... 67
GENOTROPIN ........................... 80
GENOTROPIN MINIQUICK ....... 80
gentak ...................................... 101
gentamicin sulfate .............. 18, 101
GENTEEL LANCING KIT
(BLUE) ...................................... 61
gentle laxative ........................... 73
GENTLECATH URINARY
CATHETER ............................... 95
GENVISC 850 ........................... 95
GENVOYA ................................ 38
GEODON .................................. 36
GERMAN COCKROACH .......... 95
GHRP2-GHRP6-
SERMORELIN .......................... 80
GHRP2-SERMORELIN ............. 80
GIALAX ..................................... 73
gianvi ........................................ 83
GIAPREZA ................................ 45
GILENYA .................................. 50
GILOTRIF ................................. 31
GILPHEX TR........................... 105
GILTUSS TR ........................... 105
GLASSIA ................................. 108
glatiramer acetate ..................... 50
glatopa ...................................... 50
GLEEVEC ................................. 31
GLEOSTINE ............................. 31
GLIADEL WAFER ..................... 31
glimepiride ................................. 59
glipizide er ................................. 59
glipizide ir .................................. 59
glipizide xl ................................. 59
glipizide-metformin hcl .............. 59
GLUCAGEN HYPOKIT ............. 63
GLUCAGON EMERGENCY ..... 63
GLUCAGON HCL
(DIAGNOSTIC) ......................... 95
GLUCOCARD 01 SENSOR
PLUS ........................................ 61
GLUCOCARD EXPRESSION
TEST ......................................... 61
GLUCOCARD SHINE
CONNEX ................................... 61
GLUCOCARD SHINE
EXPRESS ................................. 61
GLUCOCARD SHINE TEST ..... 61
GLUCOCARD VITAL TEST ...... 61
GLUCOPHAGE ......................... 59
GLUCOPHAGE XR ................... 59
glucose ..................................... 67
GLUCOTROL ............................ 59
GLUCOTROL XL ...................... 59
GLUMETZA .............................. 59
glutaraldehyde........................... 95
GLUTATHIONE ......................... 67
glyburide ................................... 59
125
SYSTEM .................................... 61
GYNAZOLE-1 ............................ 27
HACKBERRY ............................ 95
HAEGARDA .............................. 88
hailey 1.5/30 .............................. 83
hailey 24 fe ................................ 83
HALAVEN .................................. 31
halcinonide ................................ 55
HALCION ................................... 39
HALDOL .................................... 36
HALDOL DECANOATE ............. 36
halobetasol propionate ............... 55
HETLIOZ .................................. 111
HIBERIX .................................... 90
HIDEX 6-DAY ............................ 78
HIPREX ..................................... 18
HISTATROL ............................... 95
HIZENTRA ................................. 88
homatropaire ............................ 103
homatropine hbr ....................... 103
HONEY BEE VENOM ................ 95
HONEY BEE VENOM
PROTEIN ................................... 95
HORIZANT ................................ 51
HORSE EPITHELIUM ................ 95
(INTRAOCULAR) ..................... 103
HYCAMTIN ............................... 32
hydralazine hcl .......................... 45
HYDREA ................................... 32
HYDRO 35 ................................ 55
HYDRO 40 ................................ 55
hydrochlorothiazide ................... 45
hydrocodone polst-cpm polst
er ............................................ 105
hydrocodone-acetaminophen ...... 8
hydrocodone-homatropine ...... 105
hydrocodone-ibuprofen ............... 8
hydrocortisone .............. 55, 78, 91
126
glyburide micronized .................. 59
glyburide-metformin ................... 59
GLYCATE .................................. 73
GLYCINE ................................... 67
glycolax...................................... 73
glycolic acid ............................... 55
glycopyrrolate ............................ 73
GLYCOPYRROLATE ........... 73, 74
glycopyrrolate pf ........................ 74
glydo .......................................... 14
GLYNASE .................................. 59
GLYRX-PF ................................. 74
GLYSET .................................... 59
GLYXAMBI ................................ 59
gnp folic acid ............................. 67
gnp lansoprazole ....................... 72
GOCOVRI .................................. 35
GOLDENROD............................ 95
GOLYTELY ................................ 74
GONITRO .................................. 45
GOPRELTO ............................... 14
GORDOFILM ............................. 55
grafco silver nit applicator .......... 55
GRALISE ................................... 50
GRALISE STARTER ................. 50
granisetron hcl ........................... 26
GRANIX ..................................... 40
GRASTEK ................................. 95
griseofulvin microsize ................ 27
griseofulvin ultramicrosize ......... 27
guaiatussin ac .......................... 105
guaifenesin ac ......................... 105
guanfacine hcl ........................... 45
guanfacine hcl er ....................... 49
GUANIDINE HCL ...................... 29
GUARDIAN CONNECT
TRANSMITTER ......................... 61
GUARDIAN LINK 3
TRANSMITTER ......................... 61
GUARDIAN REAL-TIME
HALOBETASOL
PROPIONATE ........................... 55
HALOG ...................................... 55
haloperidol ................................. 36
haloperidol decanoate ............... 36
haloperidol lactate ...................... 36
HARVONI .................................. 38
HAVRIX ..................................... 90
HCU EASY ................................ 95
healthylax ................................... 74
heartburn treatment 24 hour ...... 72
heather ...................................... 83
HECTOROL ............................... 92
HEMABATE ............................... 81
HEMANGEOL ............................ 45
hematinic plus vit/minerals ......... 67
hematogen fa ............................. 67
hematogen forte ......................... 67
HEMATRON-AF ......................... 67
HEMETAB ................................. 67
HEMLIBRA ................................ 40
hemmorex-hc ............................. 91
HEMOCYTE PLUS .................... 67
hemocyte-plus............................ 67
hemofil m ................................... 40
HEMOFIL M ............................... 40
HEPAGAM B ............................. 88
heparin (porcine) in nacl ............ 22
HEPARIN (PORCINE) IN
NACL ......................................... 22
heparin sod (porcine) in d5w ..... 22
heparin sodium (porcine) ........... 22
heparin sodium (porcine) pf ....... 22
hepatamine ................................ 67
HEPLISAV-B .............................. 90
HEPSERA .................................. 38
HERCEPTIN .............................. 31
HERCEPTIN HYLECTA............. 32
HESPAN .................................... 40
hetastarch-nacl .......................... 40
HUMALOG KWIKPEN .............. 63
HUMALOG MIX 50/50
KWIKPEN ................................. 63
HUMALOG MIX 50/50 VIAL...... 63
HUMALOG MIX 75/25
KWIKPEN ................................. 63
HUMALOG MIX 75/25 VIAL...... 63
HUMALOG U-100 JUNIOR
KWIKPEN ................................. 63
HUMALOG U-100 VIAL AND
CARTRIDGE ............................. 63
HUMATE-P ............................... 40
HUMATROPE ........................... 80
HUMIRA .................................... 88
HUMIRA PEDIATRIC
CROHNS START ...................... 88
HUMIRA PEN ........................... 88
HUMIRA PEN-CD/UC/HS
STARTER ................................. 88
HUMIRA PEN-PS/UV/ADOL
HS START ................................ 88
HUMULIN 70/30 KWIKPEN ...... 63
HUMULIN 70/30 VIAL ............... 63
HUMULIN N KWIKPEN ............ 63
HUMULIN N VIAL ..................... 63
HUMULIN R U-500 KWIKPEN 63
HUMULIN R U-500 VIAL
(CONCENTRATED) .................. 63
HUMULIN R VIAL ..................... 63
HW EMBRACE PRO
GLUCOSE METER ................... 61
HW EMBRACE PRO
GLUCOSE TEST ...................... 61
HW EMBRACE TALK BLOOD
GLUCOSE ................................ 61
HW EMBRACE TALK
GLUCOSE TEST ...................... 61
HYALGAN ................................. 95
HYALUCIL-4 ............................. 55
HYALURONIDASE
IBRANCE ................................... 32
ibu .............................................. 11
ibuprofen .................................... 11
ibuprofen lysine ......................... 11
IC 400 ........................................ 12
IC 800 ........................................ 12
IC GREEN ................................. 95
ICAR-C PLUS ............................ 67
icatibant acetate ........................ 88
ICLUSIG .................................... 32
IDAMYCIN PFS ......................... 32
idarubicin hcl .............................. 32
IDELVION .................................. 40
IDHIFA ....................................... 32
indomethacin er ......................... 12
indomethacin sodium ................. 12
INFANRIX .................................. 90
INFASURF ............................... 105
INFED ........................................ 95
INFLECTRA ............................... 89
INFUGEM .................................. 32
INFUMORPH 200 ........................ 9
INFUMORPH 500 ........................ 9
infusion set ................................. 95
infuvite adult ............................... 67
INFUVITE ADULT ...................... 67
infuvite pediatric ......................... 67
INFUVITE PEDIATRIC............... 67
IPAMORELIN ACETATE............80
IPOL ...........................................90
ipratropium bromide ........ 105, 108
ipratropium-albuterol ................ 108
irbesartan ...................................45
irbesartan-hydrochlorothiazide 45
IRESSA ......................................32
irinotecan hcl ..............................32
IROSPAN 24/6 ...........................67
IS 24/6 .......................................67
ISENTRESS ...............................38
ISENTRESS HD.........................38
isibloom ......................................83
ISOLYTE-S ................................67
127
hydrocortisone ace-pramoxine
............................................ 55, 91
hydrocortisone acetate............... 91
hydrocortisone butyr lipo base 55
hydrocortisone butyrate ............. 55
hydrocortisone valerate.............. 55
hydrocortisone-acetic acid ....... 105
hydrogen peroxide ..................... 18
hydromet .................................. 105
HYDROMORPHONE HCL ........... 8
hydromorphone hcl ...................... 8
hydromorphone hcl er .................. 8
hydromorphone hcl pf .................. 8
HYDROMORPHONE HCL-
NACL ....................................... 8, 9
hydroxocobalamin acetate ......... 67
hydroxychloroquine sulfate ........ 35
hydroxyprogesterone caproate. 83
hydroxyurea ............................... 32
hydroxyzine hcl .......................... 39
hydroxyzine pamoate ................. 39
HYLENEX .................................. 95
HYMOVIS .................................. 95
hyophen ..................................... 76
hyoscyamine sulfate .................. 74
hyoscyamine sulfate er .............. 74
hyoscyamine sulfate sl ............... 74
hyosyne ..................................... 74
HYPERHEP B S/D ..................... 88
hyperlyte-cr ................................ 67
HYPERRAB ............................... 88
HYPERRAB S/D ........................ 88
HYPERRHO S/D ....................... 88
HYPERSAL ............................. 105
HYPERTET S/D ......................... 88
HYQVIA ..................................... 88
HYSINGLA ER............................. 9
HYZAAR .................................... 45
ibandronate sodium ................... 92
iferex 150 forte ........................... 67
IFEX ........................................... 32
ifosfamide .................................. 32
ILARIS ....................................... 88
ILEVRO.................................... 101
ILUMYA ..................................... 88
ILUVIEN ................................... 101
imatinib mesylate ....................... 32
IMBRUVICA ............................... 32
IMFINZI ...................................... 32
imipenem-cilastatin .................... 18
imipramine hcl............................ 25
imipramine pamoate .................. 25
imiquimod .................................. 55
IMIQUIMOD PUMP .................... 55
IMITREX .................................... 29
IMITREX STATDOSE REFILL 29
IMITREX STATDOSE
SYSTEM .................................... 29
IMLYGIC .................................... 32
IMOGAM RABIES-HT ................ 89
IMOVAX RABIES ....................... 90
IMPAVIDO ................................. 35
IMPOYZ ..................................... 55
IMURAN..................................... 89
IMVEXXY MAINTENANCE
PACK ......................................... 83
IMVEXXY STARTER PACK ...... 83
INBRIJA ..................................... 35
incassia ...................................... 83
INCRELEX ................................. 80
INCRUSE ELLIPTA ................. 108
indapamide ................................ 45
INDERAL LA .............................. 45
INDERAL XL .............................. 45
indigo carmine ........................... 95
INDOCIN .................................... 12
indocyanine green ..................... 95
indomethacin ............................. 12
INGREZZA ................................ 51
INJECTAFER ............................ 67
INLYTA ..................................... 32
INNOPRAN XL .......................... 45
INNOSPIRE GO PORTABLE
MESH NEB ............................... 96
INOVA ....................................... 55
INOVA 4/1 ACNE CONTROL
THERAPY ................................. 55
INSPIREASE RESERVOIR
BAGS ........................................ 96
INSPRA..................................... 45
INSULIN LISPRO ...................... 63
INSULIN PEN NEEDLES .......... 64
insulin pump ir2020 ................... 96
INSULIN SYRINGES ................ 64
INTEGRA F ............................... 67
INTEGRILIN .............................. 36
INTELENCE .............................. 38
INTERMEZZO ......................... 111
intralipid..................................... 67
INTRALIPID .............................. 67
INTRAROSA ............................. 76
INTRON A ................................. 38
introvale .................................... 83
INTUNIV.................................... 49
INVANZ ..................................... 18
INVEGA .................................... 36
INVEGA SUSTENNA ................ 36
INVEGA TRINZA ...................... 36
INVELTYS ............................... 101
INVIRASE ................................. 38
INVOKAMET ............................. 59
INVOKAMET XR ....................... 59
INVOKANA ............................... 59
iodine strong ............................. 67
IONOSOL-MB IN D5W ............. 67
IONSYS ...................................... 9
IOPIDINE ................................ 102
JORNAY PM .............................. 49
J-TIP KIT W/VIAL ADAPTERS. 96
JUBLIA ...................................... 27
juleber ........................................ 83
JULUCA ..................................... 38
JUNE GRASS POLLEN
STANDARDIZED ....................... 96
junel 1.5/30 ................................ 84
junel 1/20 ................................... 84
junel fe 1.5/30 ............................ 84
junel fe 1/20 ............................... 84
junel fe 24 .................................. 84
JUXTAPID ................................. 45
SPONGES ................................. 96
KERYDIN ................................... 28
KETALAR .................................. 96
ketamine hcl ............................... 96
KETAMINE HCL ........................ 96
KETAMINE HCL-SODIUM
CHLORIDE ................................ 96
KETOCARE ............................... 61
ketoconazole .............................. 28
KETOPHENE RAPIDPAQ ......... 12
ketoprofen .................................. 12
ketoprofen er .............................. 12
KETOROCAINE-L ...................... 12
KOATE-DVI ................................40
koate-dvi ....................................41
KOCHIA .....................................96
KOGENATE FS .........................41
KOMBIGLYZE XR ......................59
KORLYM ....................................81
KOVALTRY ................................41
K-PHOS .....................................67
K-PHOS NO 2 ............................67
K-PHOS-NEUTRAL ...................67
k-prime .......................................67
KRINTAFEL ...............................35
KRISTALOSE ............................74
128
isoniazid..................................... 30
isoproterenol hcl ........................ 45
ISOPTO ATROPINE ................ 103
ISOPTO CARPINE .................. 102
ISORDIL TITRADOSE ............... 45
isosorbide dinitrate ..................... 45
isosorbide dinitrate er ................ 45
isosorbide mononitrate............... 45
isosorbide mononitrate er .......... 45
isosulfan blue ............................. 96
isotretinoin ................................. 55
isoxsuprine hcl ........................... 45
isradipine ................................... 45
ISTALOL .................................. 102
ISTODAX (OVERFILL) .............. 32
ISUPREL ................................... 45
itraconazole ............................... 27
ivermectin .................................. 35
IXEMPRA KIT ............................ 32
IXIARO ...................................... 90
IXINITY ...................................... 40
JADENU .................................... 67
JADENU SPRINKLE .................. 67
JAKAFI ...................................... 32
JALYN ....................................... 77
jantoven ..................................... 22
JANUMET .................................. 59
JANUMET XR ............................ 59
JANUVIA ................................... 59
JARDIANCE .............................. 59
jasmiel ....................................... 83
jencycla...................................... 83
JENTADUETO ........................... 59
JENTADUETO XR ..................... 59
JETREA ................................... 103
JEVTANA .................................. 32
jinteli .......................................... 83
JIVI ............................................ 40
JOHNSON GRASS .................... 96
jolessa ....................................... 83
JYNARQUE ............................... 67
K.B.G.L IN TERODERM ............ 12
KABIVEN ................................... 67
KADCYLA .................................. 32
KADIAN ....................................... 9
kaitlib fe ..................................... 84
KALBITOR ................................. 96
KALETRA .................................. 38
kalliga ........................................ 84
KALYDECO ............................. 109
KANJINTI ................................... 32
KANUMA ................................... 75
KAPOK ...................................... 96
KAPSPARGO SPRINKLE .......... 45
KAPVAY .................................... 49
KARBINAL ER ......................... 105
kariva ......................................... 84
KAZANO .................................... 59
KCENTRA .................................. 40
KCL (IN NACL 0.9%) ................. 67
KCL-LIDOCAINE-NACL ............. 67
kedbumin ................................... 96
KEDRAB .................................... 89
KEFLEX ..................................... 18
kelnor 1/35 ................................. 84
kelnor 1/50 ................................. 84
kelo-cote .................................... 55
KENALOG ........................... 55, 78
KENALOG-80 ............................ 78
KENGREAL ............................... 36
KEPIVANCE .............................. 51
KEPPRA .................................... 23
KEPPRA XR .............................. 23
KERAGEL .................................. 55
KERALYT .................................. 55
KERAMATRIX REPLICINE
5CMX5CM ................................. 56
KERLIX AMD
ANTIMICROBIAL ....................... 96
KERLIX AMD SUPER
KETOROCAINE-LM .................. 12
KETOROLAC
TROMETHAMINE ..................... 12
ketorolac tromethamine..... 12, 101
KETOROLAC-BUPIV-
KETAMINE ................................ 12
KETOROLAC-ROPIV-
KETAMINE ................................ 12
KETOSTIX ................................ 61
KEVEYIS ................................. 102
KEVZARA ................................. 89
KEYTRUDA .............................. 32
KHAPZORY .............................. 32
KHEDEZLA ............................... 25
KINERET .................................. 89
KINRIX ...................................... 90
kionex ....................................... 67
KISQALI (200 MG DOSE)......... 32
KISQALI (400 MG DOSE)......... 32
KISQALI (600 MG DOSE)......... 32
KISQALI FEMARA (400 MG
DOSE) ...................................... 32
KISQALI FEMARA (600 MG
DOSE) ...................................... 32
KISQALI FEMARA(200 MG
DOSE) ...................................... 32
KITABIS PAK .......................... 109
KLARITY-A ............................. 101
KLARITY-B ............................. 101
KLARITY-L .............................. 101
KLARON ................................... 56
KLONOPIN ............................... 39
klor-con ..................................... 67
klor-con 10 ................................ 67
klor-con m10 ............................. 67
KLOR-CON M15 ....................... 67
klor-con m20 ............................. 67
klor-con sprinkle ........................ 67
klor-con/ef ................................. 67
KOATE ...................................... 40
larin 24 fe ................................... 84
larin fe 1.5/30 ............................. 84
larin fe 1/20 ................................ 84
larissia ....................................... 84
LARTRUVO ............................... 32
LASIX ........................................ 45
LASTACAFT ............................ 103
LATANOPROST ...................... 102
latanoprost ............................... 102
latrix xm ..................................... 56
LATUDA .................................... 36
LAVARE WOUND WASH .......... 56
layolis fe ..................................... 84
LAZANDA .................................... 9
levetiracetam er ......................... 23
levetiracetam in nacl .................. 23
levobunolol hcl ......................... 102
LEVOCARNITINE ...................... 68
levocarnitine ............................... 68
levocetirizine dihydrochloride 105
levofloxacin ........................ 18, 101
levofloxacin in d5w..................... 18
levoleucovorin calcium ............... 32
levoleucovorin calcium pf ........... 32
levonest ..................................... 84
levonorgest-eth est & eth est ..... 84
levonorgest-eth estrad 91-day 84
levonorgestrel ............................ 84
LIDODERM ................................14
lidolog ........................................78
LIDOPROFEN ........................... 12
LILETTA (52 MG) .......................84
lillow ...........................................84
LINCOCIN ................................. 18
lincomycin hcl ........................... 18
lindane ...................................... 35
linezolid ......................................18
LINZESS ....................................74
LIORESAL ............................... 110
LIORESAL INTRATHECAL ...... 110
liothyronine sodium ................... 86
LIPIODOL ................................. 96
129
KRYSTEXXA ............................. 28
K-TAB ........................................ 68
k-tan plus ................................... 68
kurvelo ....................................... 84
KUVAN ...................................... 75
KYLEENA .................................. 84
KYMRIAH .................................. 89
KYPROLIS ................................. 32
L.E.T. ......................................... 14
labetalol hcl ............................... 45
LABETALOL HCL ...................... 45
LAC-HYDRIN ............................. 56
LACRISERT ............................ 103
lactated ringers .......................... 68
lactic acid ................................... 56
lactic acid e ................................ 56
lactulose .................................... 74
lactulose encephalopathy .......... 74
LAMBS QUARTERS .................. 96
LAMICTAL ................................. 23
LAMICTAL ODT ........................ 23
LAMICTAL STARTER ............... 23
LAMICTAL XR ........................... 23
lamivudine ................................. 38
lamivudine-zidovudine ............... 38
lamotrigine ................................. 23
lamotrigine er ............................. 23
lamotrigine starter kit-blue ......... 23
lamotrigine starter kit-green ....... 23
lamotrigine starter kit-orange ..... 23
LANCETS .................................. 61
LANOXIN ................................... 45
LANOXIN PEDIATRIC ............... 45
lansoprazole .............................. 72
lanthanum carbonate ................. 76
LANTUS SOLOSTAR ................ 64
LANTUS U-100 VIAL ................. 64
larin 1.5/30 ................................. 84
larin 1/20 .................................... 84
l-cysteine hcl .............................. 96
leena .......................................... 84
leflunomide ................................ 89
LEMTRADA ............................... 50
LENSCALE ................................ 96
LENVIMA (10 MG DAILY
DOSE) ....................................... 32
LENVIMA (12 MG DAILY
DOSE) ....................................... 32
LENVIMA (14 MG DAILY
DOSE) ....................................... 32
LENVIMA (18 MG DAILY
DOSE) ....................................... 32
LENVIMA (20 MG DAILY
DOSE) ....................................... 32
LENVIMA (24 MG DAILY
DOSE) ....................................... 32
LENVIMA (4 MG DAILY
DOSE) ....................................... 32
LENVIMA (8 MG DAILY
DOSE) ....................................... 32
LESCOL XL ............................... 45
lessina ....................................... 84
LETAIRIS ................................. 109
letrozole ..................................... 32
LETS .......................................... 14
leucovorin calcium ..................... 32
LEUKERAN ............................... 32
LEUKINE ................................... 41
leuprolide acetate ...................... 80
LEUPROLIDE ACETATE-
BUPIVACAINE ........................... 80
levalbuterol hcl ......................... 108
LEVALBUTEROL HFA............. 108
LEVAQUIN ................................. 18
LEVBID ...................................... 74
LEVEMIR U-100 FLEXTOUCH.64
LEVEMIR U-100 VIAL ............... 64
levetiracetam ............................. 23
levonorgestrel-ethinyl estrad ..... 84
levonorg-eth estrad triphasic ..... 84
LEVOPHED .............................. 45
levora 0.15/30 (28) .................... 84
levorphanol tartrate ..................... 9
levo-t ......................................... 86
levothyroxine sodium ................ 86
levothyroxine-liothyronine .......... 86
levoxyl ....................................... 86
LEVSIN ..................................... 74
LEVSIN/SL ................................ 74
LEVULAN KERASTICK ............ 56
LEXAPRO ................................. 25
LEXETTE .................................. 56
LEXIVA ..................................... 38
LIALDA ..................................... 91
LIBRAX ..................................... 74
LIBTAYO ................................... 32
lido bdk ..................................... 14
lidocaine .................................... 14
lidocaine hcl ........................ 14, 51
LIDOCAINE HCL ...................... 14
lidocaine hcl (pf) ........................ 14
lidocaine hcl urethral/mucosal ... 14
LIDOCAINE HCL-SODIUM
CHLORIDE ............................... 14
lidocaine in d5w ........................ 14
LIDOCAINE IN DEXTROSE ..... 14
lidocaine viscous ....................... 51
lidocaine-epinephrine ................ 14
LIDOCAINE-EPINEPHRINE .... 103
LIDOCAINE-
PHENYLEPHRINE .................. 103
LIDOCAINE-
PHENYLEPHRINE-BSS .......... 103
lidocaine-prilocaine ................... 14
LIDOCAINE-SODIUM
BICARBONATE ........................ 14
LIDOCAINE-TETRACAINE ....... 14
LIPITOR..................................... 45
LIPO .......................................... 68
LIPO-C ...................................... 68
LIPOFEN ................................... 45
LIQUID E-Z-PAQUE .................. 96
LIQUID POLIBAR PLUS ............ 96
LIQUIVIDA HYDRATION ........... 68
lisinopril...................................... 45
lisinopril-hydrochlorothiazide ...... 45
lithium ........................................ 40
lithium carbonate ....................... 40
lithium carbonate er ................... 40
LITHOBID .................................. 40
LITHOSTAT ............................... 76
LIVALO ...................................... 45
lmd in d5w ................................. 41
LMD IN D5W ............................. 41
lmd in nacl ................................. 41
LMD IN NACL ............................ 41
LO LOESTRIN FE ..................... 84
LOCOID ..................................... 56
LOCOID LIPOCREAM ............... 56
LODINE ..................................... 12
LODOSYN ................................. 35
LOESTRIN 1.5/30 (21) .............. 84
LOESTRIN 1/20 (21) ................. 84
LOESTRIN FE 1.5/30 ................ 84
LOESTRIN FE 1/20 ................... 84
LOKELMA .................................. 68
LOMOTIL ................................... 74
LONHALA MAGNAIR REFILL
KIT ........................................... 108
LONHALA MAGNAIR
STARTER KIT ......................... 108
LONSURF ................................. 32
loperamide hcl ........................... 74
LOPID ........................................ 45
lopinavir-ritonavir ....................... 38
lopreeza ..................................... 84
LOPRESSOR ............................ 45
LOPRESSOR HCT .................... 45
LOPROX .................................... 28
lorazepam ............................ 39, 40
lorazepam intensol .................... 39
LORBRENA ............................... 32
lorcet ............................................ 9
lorcet hd ....................................... 9
lorcet plus .................................... 9
LORTAB ...................................... 9
loryna ......................................... 84
LORZONE ............................... 110
losartan potassium .................... 45
losartan potassium-hctz ............. 45
LOSEASONIQUE ...................... 84
LOTEMAX ................................ 101
LOTEMAX SM ......................... 101
LOTENSIN ................................. 45
LOTENSIN HCT ........................ 45
loteprednol etabonate .............. 101
LOTREL ..................................... 45
LOTRISONE .............................. 56
LOTRONEX ............................... 74
lovastatin .................................... 45
LOVAZA..................................... 45
LOVENOX ................................. 22
low-ogestrel ............................... 84
loxapine succinate ..................... 36
lo-zumandimine .......................... 84
LT INJECTION KIT .................... 78
LUCEMYRA ............................... 16
LUCENTIS ............................... 103
ludent ......................................... 68
lugols ......................................... 18
LULICONAZOLE ........................ 28
LUMIGAN ................................ 102
LUMIZYME ................................ 75
LUMOXITI .................................. 32
LUNESTA ................................ 111
LUPANETA PACK ..................... 80
LUPRON DEPOT (1-MONTH) 80
LUPRON DEPOT (3-MONTH) 81
LUPRON DEPOT (4-MONTH)
INTRAMUSCULAR KIT 30MG 81
LUPRON DEPOT (6-MONTH)
INTRAMUSCULAR KIT 45MG 81
LUPRON DEPOT-PED (1-
MONTH) .................................... 81
LUPRON DEPOT-PED (3-
MONTH) .................................... 81
LUTATHERA ............................. 32
lutera .......................................... 84
LUXIQ ........................................ 56
LUXTURNA ............................. 103
LUZU ......................................... 28
LYNPARZA ................................ 33
LYRICA ...................................... 51
LYRICA CR ............................... 51
LYSINE HCL .............................. 68
LYSODREN ............................... 33
LYSTEDA .................................. 41
lyza ............................................ 84
M.V.I. ADULT............................. 68
M.V.I. PEDIATRIC ..................... 68
MACI .......................................... 96
MACRILEN ................................ 96
MACROBID ............................... 18
MACRODANTIN ....................... 18
MACUGEN .............................. 103
mafenide acetate ...................... 18
MAGNEBIND 400 ..................... 68
magnesium chloride .................. 68
magnesium citrate ..................... 74
magnesium sulfate .................... 68
MAGNESIUM SULFATE ........... 68
magnesium sulfate in d5w ........ 68
MAGNESIUM SULFATE IN
D5W .......................................... 68
MAGNESIUM SULFATE-LACT
RINGERS .................................. 68
MAGNESIUM SULFATE-
NACL ........................................ 68
MAGNEVIST ............................. 96
MAKENA ................................... 84
MALARONE .............................. 35
malathion .................................. 35
MANGANESE CHLORIDE ........ 68
mannitol .................................... 45
maprotiline hcl ........................... 25
MARBETA-25 ........................... 78
MARBETA-L ............................. 78
MARCAINE ............................... 14
MARCAINE PRESERVATIVE
FREE ........................................ 14
MARCAINE SPINAL ................. 15
MARCAINE/EPINEPHRINE ...... 15
MARCAINE/EPINEPHRINE
PF ............................................. 15
MARDEX-25 ............................. 78
MARINOL .................................. 26
marlido ...................................... 15
MARLIDO-25 ............................ 15
marlissa..................................... 84
MARPLAN ................................. 25
MARQIBO ................................. 33
MARVONA SUIK ...................... 15
MATULANE .............................. 33
matzim la................................... 45
MAVENCLAD (10 TABS) .......... 50
MAVENCLAD (4 TABS) ............ 50
MAVENCLAD (5 TABS) ............ 50
MAVENCLAD (6 TABS) ............ 50
MAVENCLAD (7 TABS) ............ 50
MAVENCLAD (8 TABS) ............ 50
MAVENCLAD (9 TABS) ............ 50
MAVYRET ................................. 38
MAXALT.................................... 29
MAXALT-MLT ........................... 29
MAXFE ..................................... 68
130
MAXICOMFORT SYR 27G X
1/2" ............................................ 64
MAXIDEX ................................ 101
MAXIPIME ................................. 18
MAXITROL .............................. 103
MAXZIDE ................................... 45
MAXZIDE-25 ............................. 45
MAYZENT ................................. 50
MAYZENT STARTER PACK ..... 50
me/naphos/mb/hyo1 .................. 76
MEADOW FESCUE GRASS
POLLEN .................................... 96
meclizine hcl .............................. 26
meclofenamate sodium.............. 12
medique aspirin ......................... 12
MEDROL ................................... 78
MEDROLOAN II SUIK ............... 78
MEDROLOAN SUIK .................. 78
MEDROX-RX ............................... 9
medroxyprogesterone acetate 84
mefenamic acid ......................... 12
mefloquine hcl ........................... 35
MEGACE ES ............................. 84
megestrol acetate ...................... 84
MEKINIST .................................. 33
MEKTOVI .................................. 33
MELALEUCA ............................. 96
melodetta 24 fe .......................... 84
meloxicam ................................. 12
melphalan .................................. 33
melphalan hcl ............................ 33
memantine hcl ........................... 24
memantine hcl er ....................... 24
MENACTRA .............................. 90
MENEST .................................... 84
MENOSTAR .............................. 84
MENTAX .................................... 28
MENVEO ................................... 90
meperidine hcl ............................. 9
MEPHYTON .............................. 68
meprobamate ............................ 40
MEPRON ................................... 35
MEPSEVII .................................. 75
mercaptopurine .......................... 33
meropenem ............................... 19
MEROPENEM-SODIUM
CHLORIDE ................................ 19
MERREM ................................... 19
mesalamine ............................... 91
mesalamine-cleanser ................. 91
mesna ........................................ 33
MESNEX ................................... 33
MESQUITE ................................ 96
MESTINON ................................ 29
metadate er ............................... 49
metaproterenol sulfate ............. 108
METAXALL CP ........................ 110
metaxalone .............................. 110
metformin hcl er ......................... 59
metformin hcl er (mod) .............. 59
metformin hcl er (osm) ............... 59
METFORMIN HCL IR ................ 59
metformin hcl ir .......................... 59
methadone hcl ............................. 9
methadone hcl intensol ................ 9
methadose ................................... 9
methadose sugar-free .................. 9
methamphetamine hcl ................ 49
methazolamide......................... 102
methenamine hippurate ............. 19
methenamine mandelate ........... 19
methergine ................................. 96
methimazole .............................. 86
METHITEST .............................. 79
methocarbamol ........................ 110
METHOHEXITAL SODIUM ........ 96
methotrexate .............................. 89
methotrexate sodium ................. 89
methotrexate sodium (pf) ........... 89
methoxsalen .............................. 56
methoxsalen rapid ..................... 56
methscopolamine bromide ......... 74
methyl salicylate ......................... 56
METHYLCOBALAMIN ............... 68
methyldopa ................................ 45
methyldopa-
hydrochlorothiazide .................... 45
methylene blue .......................... 96
methylergonovine maleate ......... 96
METHYLIN ................................. 49
methylphenidate hcl ................... 49
methylphenidate hcl er ............... 49
methylphenidate hcl er (cd) ....... 49
methylphenidate hcl er (la) ........ 49
methylprednisolone .................... 78
METHYLPREDNISOLONE
ACE-LIDO .................................. 78
METHYLPREDNISOLONE
ACETATE .................................. 78
methylprednisolone acetate ....... 78
methylprednisolone sodium
succ ........................................... 78
METHYLPREDNISOLONE-
BUPIVACAINE ........................... 78
methyltestosterone ..................... 79
metoclopramide hcl .................... 26
metolazone ............................... 45
metoprolol succinate er ............. 46
metoprolol tartrate ..................... 46
METOPROLOL-HCTZ ER ........ 46
metoprolol-hydrochlorothiazide. 46
METROCREAM ........................ 56
METROGEL .............................. 56
METROLOTION ........................ 56
METRONIDAZOLE ................... 19
metronidazole ..................... 19, 56
METRONIDAZOLE
BENZO+SYRSPEND ................ 19
metronidazole in nacl ................ 19
METRONIDAZOLE IN NACL .... 19
mexiletine hcl ............................ 46
MIACALCIN .............................. 92
mibelas 24 fe ............................ 84
MICARDIS ................................ 46
MICARDIS HCT ........................ 46
miconazole 3 ............................. 28
MICONAZOLE-ZINC OXIDE-
PETROLAT ............................... 28
MICORT-HC ............................. 56
MICRHOGAM ULTRA-
FILTERED PLUS ...................... 89
MICROCYN .............................. 56
MICROCYN SKIN AND
WOUND .................................... 56
microgestin 1.5/30 ..................... 84
microgestin 1/20 ........................ 84
microgestin fe 1.5/30................. 84
microgestin fe 1/20.................... 84
MICROLET NEXT LANCING
DEVICE..................................... 62
midazolam hcl ........................... 40
MIDAZOLAM HCL-SODIUM
CHLORIDE ............................... 40
MIDAZOLAM-SODIUM
CHLORIDE ............................... 40
midodrine hcl............................. 46
MIGERGOT .............................. 29
miglitol ....................................... 59
miglustat.................................... 75
MIGRANAL ............................... 29
mili ............................................ 84
milk of magnesia ....................... 74
MILLIPRED ............................... 78
MILLIPRED DP ......................... 78
MILLIPRED DP 12-DAY ........... 78
milrinone lactate ........................ 46
milrinone lactate in dextrose ..... 46
mimvey ..................................... 84
mimvey lo .................................. 84
131
MINASTRIN 24 FE .................... 84
mineral oil heavy ....................... 74
MINIMED 530G INSULIN
PUMP ........................................ 96
MINIMED GUARDIAN
SENSOR 3 ................................ 62
MINIPRESS ............................... 46
minitran ...................................... 46
MINIVELLE ................................ 84
MINOCIN ................................... 19
minocycline hcl .......................... 19
minocycline hcl er ...................... 19
MINOLIRA ................................. 19
minoxidil..................................... 46
MIRAPEX .................................. 35
MIRAPEX ER ............................ 35
MIRCERA .................................. 41
MIRCETTE ................................ 84
MIRENA (52 MG) ...................... 84
mirtazapine ................................ 25
MIRVASO .................................. 56
misoprostol ................................ 72
MITE (D. FARINAE) .................. 96
MITE (D. PTERONYSSINUS) ... 96
MITIGARE ................................. 28
mitigo ........................................... 9
mitomycin .................................. 33
MITOMYCIN .............................. 33
MITOSOL ................................ 101
mitoxantrone hcl ........................ 33
MIXED ASPERGILLUS ............. 96
MIXED FEATHERS ................... 96
MIXED RAGWEED .................... 96
MIXED VESPID VENOM
PROTEIN ................................... 96
mlk f1 ......................................... 96
mlk f2 ......................................... 96
mlk f3 ......................................... 96
MLK F4 ...................................... 96
M-M-R II .................................... 90
M-NATAL PLUS ........................ 68
MOBIC ....................................... 12
modafinil .................................. 111
moexipril hcl............................... 46
molindone hcl ............................ 36
mometasone furoate .......... 56, 106
mondoxyne nl ............................ 19
mono-linyah ............................... 84
MONONINE ............................... 41
MONOVISC ............................... 97
MONSELS FERRIC
SUBSULFATE ........................... 41
montelukast sodium ................. 108
MONUROL ................................ 19
morgidox .................................... 19
MORPHABOND ER ..................... 9
MORPHINE SULFATE ................ 9
morphine sulfate .......................... 9
morphine sulfate (concentrate) .... 9
morphine sulfate (pf) .................... 9
morphine sulfate er ...................... 9
morphine sulfate er beads ........... 9
MORPHINE SULFATE-NACL
.............................................. 9, 10
MOTEGRITY ............................. 74
MOTOFEN ................................. 74
MOUNTAIN CEDAR .................. 97
MOUSE EPITHELIUM ............... 97
MOVANTIK ................................ 74
MOVIPREP ................................ 74
MOXEZA .................................. 101
MOXIFLOXACIN HCL........ 19, 101
moxifloxacin hcl ................. 19, 101
moxifloxacin hcl in nacl .............. 19
MOXIFLOXACIN HCL-BSS ..... 103
MOZOBIL ................................... 41
MS CONTIN............................... 10
MSUD EASY.............................. 97
MUCOR ..................................... 97
MUGWORT ............................... 97
MULPLETA ................................ 41
MULTAQ .................................... 46
multi prenatal ............................. 68
multigen ..................................... 68
multigen folic .............................. 68
multigen plus.............................. 68
MULTI-SPECIALTY ................... 78
multi-vit/iron/fluoride ................... 68
multivitamin/fluoride ................... 68
MULTIVITAMIN/FLUORIDE ....... 68
multi-vitamin/fluoride .................. 68
multivitamin/fluoride/iron ............ 69
multi-vitamin/fluoride/iron ........... 69
multivitamins/fluoride.................. 69
mupirocin ................................... 19
mupirocin calcium ...................... 19
mutamycin ................................. 33
MVASI ....................................... 33
mvc-fluoride ............................... 69
MYALEPT .................................. 75
MYAMBUTOL ............................ 30
MYCAMINE ............................... 28
MYCOBUTIN ............................. 30
mycophenolate mofetil ............... 89
mycophenolate mofetil hcl ......... 89
mycophenolate sodium .............. 89
MYDAYIS .................................. 49
MYDRIACYL ........................... 103
myferon 150 forte ...................... 69
MYFORTIC ............................... 89
MYLERAN ................................. 33
MYLOTARG .............................. 33
MYOBLOC ................................ 97
myorisan ................................... 56
MYRBETRIQ ............................. 76
MYSOLINE ............................... 23
MYTESI..................................... 74
na ferric gluc cplx in sucrose .... 69
nabi-hb ...................................... 89
nabumetone .............................. 12
n-acetyl-l-cysteine ..................... 69
nadolol ...................................... 46
nafcillin sodium ......................... 19
NAFCILLIN SODIUM IN
DEXTROSE .............................. 19
nafrinse ..................................... 69
NAFRINSE DAILY
ACIDULATED ........................... 51
NAFRINSE DAILY/NEUTRAL ... 51
nafrinse drops ........................... 69
NAFRINSE WEEKLY ................ 52
naftifine hcl ................................ 28
NAFTIN ..................................... 28
NAGLAZYME ............................ 75
nalbuphine hcl ........................... 10
NALFON ................................... 12
NALOCET ................................. 10
naloxone hcl .............................. 16
NALTREXONE .......................... 16
naltrexone hcl............................ 16
NAMENDA ................................ 24
NAMENDA TITRATION PAK .... 24
NAMENDA XR .......................... 24
NAMENDA XR TITRATION
PACK ........................................ 24
NAMZARIC ............................... 24
NANDROLONE DECANOATE. 79
NANDROLONE-
TESTOSTERONE CYP ............ 79
NAPRELAN ............................... 12
NAPRO ..................................... 12
NAPROSYN .............................. 12
naproxen ................................... 12
naproxen dr ............................... 12
naproxen sodium ...................... 12
naproxen sodium er .................. 12
naratriptan hcl ........................... 29
NARCAN ................................... 16
NARDIL ..................................... 25
132
NAROPIN .................................. 15
NASCOBAL ............................... 69
NASONEX ............................... 106
NATACYN ............................... 101
NATAZIA ................................... 84
nateglinide ................................. 59
NATESTO .................................. 79
NATPARA .................................. 92
NATROBA ................................. 35
NATURE-THROID ..................... 86
nature-throid .............................. 86
NAVELBINE .............................. 33
NEBUPENT ............................... 35
nebusal .................................... 106
NEBUSAL ................................ 106
necon 0.5/35 (28) ...................... 85
nefazodone hcl .......................... 25
NEMBUTAL ............................... 23
NEOKE ALCAR ......................... 69
NEOKE RA LIPOIC ................... 97
neomycin sulfate ........................ 19
neomycin-bacitracin zn-
polymyx ................................... 103
neomycin-polymyxin-dexameth
................................................ 104
neomycin-polymyxin-
gramicidin ................................ 104
neomycin-polymyxin-hc 104, 105
neo-polycin .............................. 104
neo-polycin hc ......................... 104
NEOPROFEN ............................ 12
NEORAL .................................... 89
neostigmine methylsulfate ......... 29
NEOSTIGMINE
METHYLSULFATE .................... 29
NEO-SYNALAR ......................... 56
NEOTUSS PLUS ..................... 106
NEPHRAMINE ........................... 69
NEPHRON FA ........................... 69
NERLYNX .................................. 33
NESACAINE .............................. 15
NESACAINE-MPF ..................... 15
NESINA ..................................... 59
NESTABS .................................. 69
NETSPOT .................................. 97
neuac ......................................... 56
NEULASTA ................................ 41
NEULASTA ONPRO ................. 41
NEUPOGEN .............................. 41
NEUPRO ................................... 35
NEURONTIN ............................. 23
NEUT ......................................... 69
neutral sodium fluoride .............. 52
NEVANAC ............................... 101
nevirapine .................................. 38
nevirapine er .............................. 38
NEXAVAR .................................. 33
NEXAVIR ................................... 97
NEXIUM ..................................... 72
NEXIUM I.V. .............................. 72
NEXPLANON ............................. 85
NEXTERONE............................. 46
niacin (antihyperlipidemic) .......... 46
niacin er (antihyperlipidemic) ..... 46
NIACOR ..................................... 46
NIASPAN ................................... 46
nicardipine hcl ............................ 46
NICARDIPINE HCL IN NACL .... 46
NICOMIDE ................................. 69
NICORETTE .............................. 16
nicotine polacrilex ...................... 16
nicotine step 1 ........................... 16
nicotine step 2 ............................ 16
nicotine step 3 ............................ 16
NICOTROL ................................ 16
NICOTROL NS .......................... 16
nifedipine ................................... 46
nifedipine er ............................... 46
nifedipine er osmotic release ..... 46
NIFEREX ................................... 69
nikki ........................................... 85
NILANDRON .............................. 33
nilutamide .................................. 33
NIMBEX ..................................... 51
nimodipine ................................. 46
NINLARO ................................... 33
NIPENT...................................... 33
NIPRIDE RTU ............................ 46
nisoldipine er .............................. 46
nitisinone .................................... 75
NITRO-BID ................................ 46
NITRO-DUR ............................... 46
nitrofurantoin .............................. 19
nitrofurantoin macrocrystal ......... 19
nitrofurantoin monohydrate
macrocrystals ............................. 19
nitroglycerin ............................... 46
nitroglycerin er ........................... 46
nitroglycerin in d5w .................... 46
NITROLINGUAL ........................ 46
NITROMIST ............................... 46
NITROPRESS............................ 46
nitroprusside sodium .................. 46
NITROSTAT .............................. 46
nitro-time .................................... 46
NITYR ........................................ 75
NIVESTYM ................................ 41
nizatidine ................................... 72
NIZORAL .................................. 28
NOCDURNA ............................. 81
NOCTIVA .................................. 81
nolix .......................................... 56
nora-be ..................................... 85
NORCO..................................... 10
NORDITROPIN FLEXPRO ....... 81
norepinephrine bitartrate ........... 46
NOREPINEPHRINE-
DEXTROSE .............................. 46
NOREPINEPHRINE-SODIUM
CHLORIDE ......................... 46, 47
norethin ace-eth estrad-fe ......... 85
norethindrone ............................ 85
norethindrone acetate ............... 85
norethindrone acet-ethinyl est 85
norethindrone-eth estradiol ....... 85
norethin-eth estradiol-fe ............ 85
NORGESIC FORTE ................ 110
norgestimate-eth estradiol ......... 85
norgestimate-ethinyl estradiol
triphasic..................................... 85
NORITATE ................................ 56
norlyda ...................................... 85
norlyroc ..................................... 85
NORM-JECT LUER SLIP
SYRINGE .................................. 97
NORPACE ................................ 47
NORPACE CR .......................... 47
NORPRAMIN ............................ 25
NORTHERA .............................. 47
nortrel 0.5/35 (28) ..................... 85
nortrel 1/35 (21) ........................ 85
nortrel 1/35 (28) ........................ 85
nortrel 7/7/7 ............................... 85
nortriptyline hcl .......................... 25
NORVASC ................................ 47
NORVIR .................................... 38
NOURIANZ ............................... 35
NOVOEIGHT ............................ 41
NOVOFINE AUTOCOVER
PEN NEEDLE ........................... 64
NOVOFINE PEN NEEDLE ....... 64
NOVOFINE PLUS PEN
NEEDLE.................................... 64
NOVOLIN 70/30 FLEXPEN ...... 64
NOVOLIN 70/30 FLEXPEN
RELION..................................... 64
NOVOLIN 70/30 RELION ......... 64
NOVOLIN 70/30 VIAL ............... 64
NOVOLIN N RELION ................ 64
133
NOVOLIN N VIAL ...................... 64
NOVOLIN R RELION ................ 64
NOVOLIN R VIAL ...................... 64
NOVOLOG FLEXPEN ............... 64
NOVOLOG MIX 70/30
FLEXPEN .................................. 64
NOVOLOG MIX 70/30 VIAL ...... 64
NOVOLOG PENFILL ................. 64
NOVOLOG U-100 VIAL ............. 64
NOVOPEN ECHO ..................... 62
NOVOSEVEN RT ...................... 41
NOVOTWIST PEN NEEDLE ..... 64
NOXAFIL ................................... 28
NP #2 DRUG PREPARATION
KIT ............................................. 12
np thyroid ................................... 86
NPLATE..................................... 41
NUCALA .................................. 106
NUCYNTA ................................. 10
NUCYNTA ER ........................... 10
NUEDEXTA ............................... 51
NUFERA .................................... 69
NULOJIX ................................... 89
NULYTELY WITH FLAVOR
PACKS ...................................... 74
NUMOISYN ............................... 52
NUPLAZID ................................. 36
NUTRIDOX ................................ 19
nutrilipid ..................................... 69
NUTRIVIT .................................. 69
NUTROPIN AQ NUSPIN 10 ...... 81
NUTROPIN AQ NUSPIN 20 ...... 81
NUTROPIN AQ NUSPIN 5 ........ 81
NUVARING ................................ 85
NUVESSA ................................. 19
NUVIGIL .................................. 111
NUWIQ ...................................... 41
NUZYRA .................................... 19
nyamyc ...................................... 28
NYMALIZE ................................. 47
nystatin ...................................... 28
nystatin-triamcinolone ................ 28
nystop ........................................ 28
OAT GRAIN (DIAGNOSTIC) ..... 97
OBIZUR ..................................... 41
OCALIVA ................................... 75
ocella ......................................... 85
OCREVUS ................................. 50
OCTAGAM ................................ 89
octreotide acetate ...................... 81
OCUFLOX ............................... 101
ODACTRA ................................. 97
ODEFSEY ................................. 38
ODOMZO ................................... 33
OFEV ....................................... 108
ofloxacin.....................19, 101, 105
ogestrel ...................................... 85
okebo ......................................... 19
olanzapine ................................. 37
olanzapine-fluoxetine hcl ........... 25
OLIVE TREE .............................. 97
olmesartan medoxomil ............... 47
olmesartan medoxomil-hctz ....... 47
olmesartan-amlodipine-hctz ....... 47
olopatadine hcl .................101, 106
OLUMIANT ................................ 89
OLUX ......................................... 56
OLUX-E ..................................... 56
OMECLAMOX-PAK ................... 74
OMEGA-3/D-3 WELLNESS
PACK ......................................... 47
omega-3-acid ethyl esters ......... 47
OMEGAVEN .............................. 69
omeppi ....................................... 72
omeprazole ................................ 72
omeprazole-sodium
bicarbonate ................................ 72
OMIDRIA ................................. 104
OMNARIS ................................ 106
OMNIPAQUE ............................. 97
OMNIPOD 5 PACK .................... 97
OMNIPOD DASH 5 PACK ......... 97
OMNIPOD STARTER ................ 97
OMNITROPE ............................. 81
ONCASPAR ............................... 33
ondansetron hcl ......................... 26
ONDANSETRON HCL ............... 26
ondansetron odt ......................... 26
ONE DROP BLOOD
GLUCOSE MONITOR ............... 62
ONE DROP TEST ..................... 62
ONE TOUCH VERIO KIT
W/DEVICE ................................. 62
ONE-A-DAY WOMENS
PRENATAL 1 ............................. 69
ONETOUCH DELICA
LANCING DEV .......................... 62
ONETOUCH DELICA PLUS
LANCING ................................... 62
ONETOUCH ULTRA 2 .............. 62
ONETOUCH ULTRA BLUE
TEST STRIPS ............................ 62
ONETOUCH ULTRA MINI ......... 62
ONETOUCH VERIO FLEX
SYSTEM KIT W/DEVICE ........... 62
ONETOUCH VERIO IQ
SYSTEM ................................... 62
ONETOUCH VERIO SYNC
SYSTEM KIT W/DEVICE .......... 62
ONEXTON ................................ 56
ONFI ......................................... 23
ONGLYZA ................................. 59
ONIVYDE .................................. 33
ONPATTRO .............................. 51
ONZETRA XSAIL ...................... 29
OPANA ..................................... 10
OPDIVO .................................... 33
opium ........................................ 74
OPSUMIT ................................ 109
OPTIONS CONCEPTROL ........ 97
OPTIRAY 350 ........................... 97
OPTISON .................................. 97
ORACEA ................................... 56
ORACIT .................................... 69
ORAFATE ................................. 97
ORALAIR .................................. 97
ORALAIR ADULT SAMPLE
KIT ............................................ 97
ORALAIR ADULT STARTER
PACK ........................................ 97
ORALAIR CHILDRENS
STARTER PACK ...................... 97
oralone ...................................... 52
ORANGE (DIAGNOSTIC) ......... 97
ORAPRED ODT ........................ 78
ORAVIG .................................... 28
ORBACTIV ................................ 19
ORCHARD GRASS POLLEN ... 97
ORENCIA .................................. 89
ORENCIA CLICKJECT ............. 89
ORENITRAM .......................... 109
ORFADIN .................................. 75
ORILISSA ................................. 81
ORKAMBI ............................... 109
orphenadrine citrate ................ 110
orphenadrine citrate er ............ 110
orphenadrine-aspirin-caffeine. 110
ORPHENGESIC FORTE......... 110
orsythia ..................................... 85
ORTHO MICRONOR ................ 85
ORTHO TRI-CYCLEN LO ......... 85
ORTHO-NOVUM 1/35 (28) ....... 85
ORTHO-NOVUM 7/7/7 (28) ...... 85
ORTHOVISC ............................. 97
oscimin ...................................... 74
oscimin sr .................................. 74
oseltamivir phosphate ............... 38
OSENI ....................................... 59
134
CHLORIDE ................................ 81
OXYTROL ................................. 76
OZEMPIC .................................. 59
OZURDEX ............................... 101
pacerone .................................... 47
paclitaxel .................................... 33
paliperidone er ........................... 37
palonosetron hcl ........................ 26
PALYNZIQ ................................. 75
PAMELOR ................................. 25
pamidronate disodium................ 92
PANCREAZE ............................. 75
pancuronium bromide ................ 51
P-CARE MG .............................. 15
P-CARE X .................................. 15
PCP 100 .................................... 74
PEANUT (DIAGNOSTIC) ........... 97
PECAN NUT (DIAGNOSTIC) .... 97
PECAN POLLEN ....................... 97
PEDIAPRED .............................. 78
PEDIARIX .................................. 90
PEDVAX HIB ............................. 90
peg 3350 .................................... 74
peg 3350/electrolytes ................. 74
peg 3350-kcl-na bicarb-nacl ....... 74
peg-3350/electrolytes ................. 74
PERTZYE ..................................75
PEXEVA ................................... 25
PFIZERPEN ........................ 19, 20
pfizerpen ................................... 20
phenadoz ................................. 106
phenazo .................................... 76
phenazopyridine hcl .................. 76
phenelzine sulfate ..................... 25
PHENERGAN .......................... 106
phenobarbital ............................ 23
phenobarbital sodium ................ 23
phenobarbital-belladonna alk .... 74
phenohytro .................................74
135
osmitrol ...................................... 47
OSMOLEX ER ........................... 35
OSMOPREP .............................. 74
OSPHENA ................................. 80
OTEZLA..................................... 89
OTICIN HC NR ........................ 105
OTIPRIO .................................. 105
OTOVEL .................................. 105
OTREXUP ................................. 89
OVACE PLUS ............................ 56
OVACE PLUS WASH ................ 56
OVACE WASH .......................... 56
OVIDE ....................................... 35
oxacillin sodium ......................... 19
oxaliplatin ................................... 33
oxandrolone ............................... 79
oxaprozin ................................... 12
OXAYDO ................................... 10
oxazepam .................................. 40
oxcarbazepine ........................... 23
OXERVATE ............................. 104
oxiconazole nitrate ..................... 28
OXISTAT ................................... 28
OXSORALEN ULTRA................ 56
OXTELLAR XR .......................... 23
oxybutynin chloride .................... 76
oxybutynin chloride er ................ 76
oxycodone hcl ............................ 10
OXYCODONE HCL ER ............. 10
oxycodone-acetaminophen ........ 10
oxycodone-aspirin ...................... 10
oxycodone-ibuprofen ................. 10
OXYCONTIN ............................. 10
oxymorphone hcl ....................... 10
oxymorphone hcl er ................... 10
oxytocin ..................................... 81
OXYTOCIN-DEXTROSE ........... 81
OXYTOCIN-LACTATED
RINGERS .................................. 81
OXYTOCIN-SODIUM
PANDEL .................................... 56
PANHEMATIN ........................... 41
PANRETIN ................................. 33
pantoprazole sodium ................. 72
PANZYGA .................................. 89
papaverine hcl ........................... 47
PARADIGM REAL-TIME
STARTER .................................. 62
PARAGARD INTRAUTERINE
COPPER .................................... 85
paregoric .................................... 74
PARI ALTERA NEBULIZER
HANDSET .................................. 97
PARI TREK S COMBO PACK 97
paricalcitol .................................. 92
PARLODEL ................................ 35
PARNATE .................................. 25
paroex ........................................ 52
paromomycin sulfate .................. 19
paroxetine hcl ............................ 25
paroxetine hcl er ........................ 25
paroxetine mesylate ................... 25
PARSABIV ................................. 86
PASER ...................................... 30
PATADAY ................................ 101
PATANASE .............................. 106
PATANOL ................................ 101
PAXIL ........................................ 25
PAXIL CR .................................. 25
PAZEO .................................... 101
P-CARE 100MX ......................... 15
P-CARE D40MX ........................ 78
P-CARE D80MX ........................ 78
P-CARE K40 .............................. 78
P-CARE K40G ........................... 78
P-CARE K40MX ........................ 78
P-CARE K80 .............................. 78
P-CARE K80G ........................... 78
P-CARE K80MX ........................ 78
P-CARE M ................................. 15
PEGANONE .............................. 23
PEGASYS ................................. 38
PEGASYS PROCLICK.............. 38
PEGINTRON ............................. 38
peg-prep.................................... 74
penicillamine ............................. 76
PENICILLIN G POT IN
DEXTROSE .............................. 19
penicillin g potassium ................ 19
penicillin g procaine .................. 19
penicillin g sodium..................... 19
penicillin v potassium ................ 19
PENICILLIUM NOTATUM ......... 97
PENLAC.................................... 28
PENNSAID ................................ 12
PENTACEL ............................... 90
PENTAM ................................... 35
pentamidine isethionate ............ 35
PENTASA ................................. 91
pentazocine-naloxone hcl ......... 10
PENTETATE CALCIUM
TRISODIUM .............................. 97
PENTETATE ZINC
TRISODIUM .............................. 97
pentobarbital sodium ................. 23
pentoxifylline er ......................... 47
PEPCID..................................... 72
PERCOCET .............................. 10
PERENNIAL RYE GRASS
POLLEN .................................... 97
PERFOROMIST ...................... 108
PERIDEX .................................. 52
PERIKABIVEN .......................... 69
perindopril erbumine ................. 47
periogard ................................... 52
PERJETA .................................. 33
permethrin ................................. 35
perphenazine ............................ 26
perphenazine-amitriptyline ........ 25
PERSERIS ................................ 37
DOSE) ....................................... 33
PIQRAY (250 MG DAILY
DOSE) ....................................... 33
PIQRAY (300 MG DAILY
DOSE) ....................................... 33
pirmella 1/35 .............................. 85
pirmella 7/7/7 ............................. 85
piroxicam ................................... 12
PISTACHIO NUT
(DIAGNOSTIC) .......................... 97
PITOCIN .................................... 81
PKU EASY................................. 97
PKU EASY MICROTABS .......... 97
PLAQUENIL .............................. 35
posaconazole ............................. 28
pot bicarb-pot chloride ............... 69
POTABA .................................... 69
potassium acetate ...................... 69
potassium bicarbonate ............... 69
potassium chloride ..................... 69
POTASSIUM CHLORIDE .......... 69
potassium chloride crys er ......... 69
potassium chloride er ................. 69
potassium chloride in nacl .......... 69
potassium citrate er .................... 69
potassium citrate-citric acid ........ 69
potassium phosphates ............... 69
POTELIGEO .............................. 33
NEPAFENAC .......................... 104
PREDNISOLONE ACET-
MOXIFLOXACIN ..................... 104
prednisolone sodium
phosphate ......................... 79, 101
PREDNISOLONE-
BROMFENAC ......................... 104
PREDNISOLONE-
GATIFLOXACIN ...................... 104
PREDNISOLONE-
MOXIFLOXACIN ..................... 104
PREDNISOLON-GATIFLOX-
BROMFENAC ......................... 104
136
phenoxybenzamine hcl .............. 47
phentolamine mesylate .............. 47
phenylephrine hcl .............. 47, 104
PHENYLEPHRINE HCL ............ 47
PHENYLEPHRINE HCL-
DEXTROSE ............................... 47
PHENYLEPHRINE HCL-NACL.47
phenylephrine-guaifenesin ....... 106
PHENYTEK ............................... 23
phenytoin ................................... 23
phenytoin infatabs ..................... 23
phenytoin sodium ...................... 23
phenytoin sodium extended ....... 23
philith ......................................... 85
PHOMA EXIGUA ....................... 97
PHOSLYRA ............................... 76
phospha 250 neutral .................. 69
phosphasal ................................ 76
PHOSPHOLINE IODIDE ......... 102
phosphorous .............................. 69
phospho-trin 250 neutral ............ 69
PHOTREXA VISCOUS .............. 97
PHOTREXA-PHOTREXA
VISCOUS KIT ............................ 97
phrenilin forte ............................. 10
PHYSICIANS EZ USE B-12 ...... 69
phytonadione ............................. 69
PICATO ..................................... 56
PIFELTRO ................................. 38
pilocarpine hcl .................... 52, 102
pimecrolimus ............................. 56
pimozide .................................... 37
pimtrea ...................................... 85
pindolol ...................................... 47
pioglitazone hcl .......................... 59
pioglitazone hcl-glimepiride ....... 59
pioglitazone hcl-metformin hcl 59
piperacillin sod-tazobactam so 20
PIQRAY (200 MG DAILY
PLASBUMIN-25 ......................... 97
PLASBUMIN-5 ........................... 97
PLAVIX ...................................... 36
PLEGRIDY ................................. 50
PLEGRIDY STARTER PACK .... 50
plenamine .................................. 69
PLENVU .................................... 74
PLEXION ................................... 56
PLEXION CLEANSER ............... 56
PLIAGLIS ................................... 15
pneumovax 23 ........................... 90
PNEUMOVAX 23 ....................... 90
pnv prenatal plus multivit+dha 69
POD-CARE 100K ...................... 78
podocon ..................................... 56
podofilox .................................... 56
POINT OF CARE KM ................. 78
POINT OF CARE L.2 ................. 79
POINT OF CARE L.5 ................. 79
POINT OF CARE LM DEP 2 ..... 79
POINT OF CARE LM-2.2........... 15
POINT OF CARE LM-2.5........... 15
POLIVY ...................................... 33
polocaine ................................... 15
polocaine-mpf ............................ 15
polycin ..................................... 104
polyethylene glycol 3350 ........... 74
poly-iron 150 forte ...................... 69
polymyxin b sulfate .................... 20
polymyxin b-trimethoprim ......... 104
polysaccharide iron forte ............ 69
POLYTRIM .............................. 104
POLY-VI-FLOR .......................... 69
POLY-VI-FLOR FS .................... 69
POLY-VI-FLOR/IRON ................ 69
POMALYST ............................... 33
PORK (DIAGNOSTIC) ............... 97
portia-28..................................... 85
PORTRAZZA ............................. 33
POVIDONE-IODINE ................ 101
PRADAXA ................................. 22
pralidoxime chloride .................. 97
PRALUENT ............................... 47
pramipexole dihydrochloride ..... 35
pramipexole dihydrochloride er. 35
PRAMOSONE ........................... 56
PRAMOTIC ............................. 105
PRASTERA ............................... 12
prasugrel hcl ............................. 36
PRAVACHOL ............................ 47
pravastatin sodium .................... 47
PRAXBIND ................................ 97
praziquantel .............................. 35
prazosin hcl ............................... 47
PRECEDEX .............................. 97
PRECISION LINK ..................... 62
PRECISION PCX PLUS TEST. 62
PRECISION QID MONITOR ..... 62
PRECISION QID TEST ............. 62
PRECISION SOF-TACT
MONITOR ................................. 62
PRECISION SOF-TACT TEST. 62
PRECISION XTRA .................... 62
PRECISION XTRA BLOOD
GLUCOSE ................................ 62
PRECISION XTRA MONITOR 62
PRECOSE ................................ 59
PRED FORTE ......................... 101
PRED MILD ............................ 101
PRED-G .................................. 104
PRED-G S.O.P. ...................... 104
prednicarbate ............................ 56
PREDNISOL ACE-
MOXIFLOX-BROMFEN ........... 101
prednisolone ............................. 79
prednisolone acetate ............... 101
prednisolone acetate p-f ......... 101
PREDNISOLONE ACETATE-
PREDNISOLON-MOXIFLOX-
BROMFENAC .......................... 104
PREDNISOLON-MOXIFLOX-
NEPAFENAC ........................... 102
prednisone ................................. 79
PREDNISONE INTENSOL ........ 79
PREFEST .................................. 85
pregabalin .................................. 51
PREGENNA .............................. 69
PREMARIN ................................ 85
PREMASOL ............................... 69
PREMPHASE ............................ 85
PREMPRO ................................ 85
PRENAISSANCE ....................... 69
PRENATA .................................. 69
prenatal................................ 69, 70
prenatal multi +dha .................... 69
prenatal plus iron ....................... 70
PREPOPIK ................................ 74
PRESTALIA ............................... 47
PREVACID ................................ 72
PREVACID SOLUTAB............... 72
prevalite ..................................... 47
preventeza ................................. 85
PREVIDENT .............................. 52
prevident .................................... 52
PREVIDENT 5000 BOOSTER
PLUS ......................................... 52
PREVIDENT 5000 DRY
MOUTH ..................................... 52
PREVIDENT 5000 ENAMEL
PROTECT ................................. 52
PREVIDENT 5000 ORTHO
DEFENSE .................................. 52
PREVIDENT 5000 PLUS ........... 52
PREVIDENT 5000 SENSITIVE.52
previfem ..................................... 85
PREVNAR 13 ............................ 90
PREVYMIS ................................ 38
PREZCOBIX .............................. 38
PREZISTA ................................. 38
PRIALT ...................................... 10
PRIFTIN ..................................... 30
PRILOSEC ................................ 72
primaquine phosphate ............... 35
PRIMAXIN IV ............................. 20
primidone ................................... 23
PRIMLEV ................................... 10
PRIMSOL .................................. 20
PRINIVIL .................................... 47
PRISMASOL B22GK 4/0 ........... 70
PRISMASOL BGK 0/2.5 ............ 70
PRISMASOL BGK 2/0 ............... 70
PRISMASOL BGK 2/3.5 ............ 70
PRISMASOL BGK 4/2.5 ............ 70
PRISMASOL BK 0/0/1.2 ............ 70
PRISTIQ .................................... 25
PRIVET ...................................... 97
PRIVIGEN .................................. 89
PRO COMFORT SPACER
ADULT ....................................... 97
PRO COMFORT SPACER
CHILD ........................................ 97
PRO COMFORT TENS UNIT .... 98
PROAIR DIGIHALER ............... 108
PROAIR HFA ........................... 108
PROAIR RESPICLICK ............. 108
probenecid ................................. 28
PROBUPHINE IMPLANT KIT .... 10
procainamide hcl ........................ 47
PROCALAMINE ......................... 70
PROCARDIA ............................. 47
PROCARDIA XL ........................ 47
PROCARE COMPRESSOR
NEBULIZER ............................... 98
PROCARE SPACER/ADULT
MASK ........................................ 98
PROCARE SPACER/CHILD
MASK ........................................ 98
PRO-C-DURE 5 ......................... 79
PRO-C-DURE 6 ......................... 79
PROCENTRA ............................ 49
prochlorperazine ........................ 26
prochlorperazine edisylate ......... 26
prochlorperazine maleate ........... 27
PROCORT ................................. 91
PROCRIT ................................... 41
PROCTOCORT ......................... 91
PROCTOFOAM HC ................... 91
procto-med hc ............................ 91
procto-pak .................................. 91
proctosol hc ............................... 91
proctozone-hc ............................ 91
PROCYSBI ................................ 75
PRODIGEN ................................ 74
PRODIGY NO CODING
BLOOD GLUC ........................... 62
PROFESSIONAL DNA
COLLECTION ............................ 98
PROFILNINE ............................. 41
PROFILNINE SD ....................... 41
PROGESTERONE
COMPOUNDING KIT ................ 85
progesterone micronized ........... 85
PROGLYCEM ............................ 63
PROGRAF ................................. 89
PROLASTIN-C ........................ 108
PROLENSA ............................ 102
PROLEUKIN ............................. 33
PROLIA ..................................... 92
PROMACTA .............................. 41
PROMACTIN AA PLUS 20PE 98
promethazine hcl ..................... 106
promethazine-codeine ............. 106
promethazine-dm .................... 106
promethazine-phenyleph-
codeine ................................... 106
promethazine-phenylephrine 106
promethegan ........................... 106
PROMETRIUM .......................... 85
propafenone hcl ........................ 47
propafenone hcl er .................... 47
propantheline bromide .............. 74
proparacaine hcl...................... 104
propofol ..................................... 98
propranolol hcl .......................... 48
propranolol hcl er ...................... 48
propranolol-hctz ........................ 48
propylthiouracil .......................... 86
PROQUAD ................................ 90
PROSCAR ................................ 77
PROSOL ................................... 70
PROSTIN VR ............................ 48
protamine sulfate ....................... 41
PROTHELIAL ............................ 98
PROTONIX ............................... 72
PROTOPIC ............................... 56
protriptyline hcl .......................... 25
PROVAYBLUE .......................... 98
PROVENGE .............................. 89
PROVENTIL HFA .................... 108
PROVERA ................................ 85
PROVIGIL ............................... 111
PROVISC ................................ 104
PROVOCHOLINE ..................... 98
PROZAC ................................... 26
PRUDOXIN ............................... 56
pseudoeph-chlorphen-
hydrocod ................................. 106
pseudoephedrine-bromphen-
dm ........................................... 106
PSORCON ................................ 56
PULMICORT FLEXHALER ..... 108
PULMICORT SUSPENSION 108
pulmosal.................................. 106
PULMOZYME ......................... 109
purevit dualfe plus ..................... 70
PURIXAN .................................. 33
PYLERA .................................... 74
137
pyrazinamide ............................. 30
PYRIDIUM ................................. 76
pyridostigmine bromide.............. 29
pyridostigmine bromide er ......... 29
PYRIDOXINE HCL .................... 70
pyridoxine hcl............................. 70
pyrogallic acid ............................ 56
QBRELIS ................................... 48
QBREXZA ................................. 56
qc aspirin low dose .................... 12
QMIIZ ODT ................................ 12
QNASL .................................... 106
QNASL CHILDRENS ............... 106
QTERN ...................................... 59
QUADRACEL ............................ 90
QUADRAMET ............................ 33
QUALAQUIN ............................. 35
QUARTETTE ............................. 85
quazepam .................................. 40
QUDEXY XR ............................. 23
QUEEN PALM ........................... 98
QUELICIN .................................. 51
QUESTRAN ............................... 48
QUESTRAN LIGHT ................... 48
quetiapine fumarate ................... 37
quetiapine fumarate er ............... 37
QUFLORA FE ............................ 70
QUFLORA FE PEDIATRIC ....... 70
QUFLORA GUMMIES ............... 70
quflora pediatric ......................... 70
QUILLICHEW ER ...................... 50
QUILLIVANT XR ........................ 50
quinapril hcl ............................... 48
quinapril-hydrochlorothiazide ..... 48
quinidine gluconate er ............... 48
quinidine sulfate ......................... 48
quinine sulfate ........................... 35
QVAR REDIHALER ................. 108
RABAVERT ............................... 90
RABBIT EPITHELIUM ............... 98
rabeprazole sodium ................... 72
RADICAVA ................................ 51
RADIOGARDASE ...................... 98
RAGWITEK ............................... 98
raloxifene hcl ............................. 80
ramelteon ................................. 111
ramipril ....................................... 48
RANEXA .................................... 48
ranitidine hcl .............................. 73
ranolazine er .............................. 48
RAPAFLO .................................. 77
RAPAMUNE .............................. 89
rasagiline mesylate .................... 35
RASUVO .................................... 89
RAVICTI..................................... 75
RAYALDEE ................................ 92
RAYOS ...................................... 79
RAZADYNE ............................... 24
RAZADYNE ER ......................... 24
READI-CAT 2 ............................ 98
READYSHARP ANESTH +
BETAMETH ............................... 79
READYSHARP ANESTH +
DEXAMETH ............................... 79
READYSHARP ANESTH +
KETOROLAC ............................. 12
READYSHARP ANESTH +
METHYLPRED .......................... 79
READYSHARP
BETAMETHASONE ................... 79
READYSHARP
DEXAMETHASONE................... 79
READYSHARP KETOROLAC 12
READYSHARP LIDOCAINE ...... 15
READYSHARP-A ....................... 15
REBIF ........................................ 50
REBIF REBIDOSE ..................... 50
REBIF REBIDOSE
TITRATION PACK ..................... 50
REBIF TITRATION PACK ......... 50
REBINYN ................................... 41
RECK ......................................... 15
RECLAST .................................. 92
reclipsen .................................... 85
RECOMBINATE ......................... 41
RECOMBIVAX HB ..................... 90
RECOTHROM ........................... 41
RECOTHROM SPRAY KIT ....... 41
RECTIV...................................... 48
RECURA .................................... 28
RED BIRCH ............................... 98
RED CEDAR.............................. 98
RED MAPLE .............................. 98
RED MULBERRY ...................... 98
RED TOP GRASS POLLEN ...... 98
REGLAN .................................... 27
regonol ....................................... 29
REGONOL ................................. 29
REGRANEX ............................... 56
relador pak ................................. 15
relador pak plus ......................... 15
RELAFEN DS ............................ 12
RELENZA DISKHALER ............. 38
relexxii ....................................... 50
RELION BLOOD GLUCOSE
TEST ......................................... 62
RELION PREMIER CLASSIC... 62
RELION PREMIER TEST ......... 62
RELION ULTIMA TEST ............ 62
RELISTOR .......................... 74, 75
RELNATE DHA ......................... 70
RELPAX .................................... 29
REMERON ................................ 26
REMERON SOLTAB ................ 26
REMESENSE ........................... 52
REMICADE ............................... 89
remifentanil hcl .......................... 10
REMODULIN .......................... 109
RENACIDIN .............................. 76
RENAGEL ................................. 76
RENATABS WITH IRON .......... 70
RENFLEXIS .............................. 89
RENVELA ................................. 76
REOPRO .................................. 36
repaglinide ................................ 59
repaglinide-metformin hcl .......... 59
REPATHA ................................. 48
REPATHA PUSHTRONEX
SYSTEM ................................... 48
REPATHA SURECLICK............ 48
REQUIP XL ............................... 35
RESCRIPTOR........................... 38
RESET FOR ANDROID APP .... 98
RESET FOR IOS APP .............. 98
RESET FOR IOS OR
ANDROID APP ......................... 98
RESET-O FOR ANDROID
APP ........................................... 98
RESET-O FOR IOS APP .......... 98
RESET-O FOR IOS OR
ANDROID APP ......................... 98
RESTASIS .............................. 104
RESTASIS MULTIDOSE ........ 104
RESTORA RX........................... 75
RESTORIL .............................. 111
RETACRIT ................................ 41
RETAVASE ............................... 22
RETAVASE HALF-KIT .............. 22
RETIN-A.................................... 56
RETIN-A MICRO GEL 0.04 %,
0.1 % ......................................... 56
RETIN-A MICRO PUMP ........... 56
RETISERT .............................. 102
RETROVIR ............................... 38
REVATIO ................................ 109
REVCOVI .................................. 75
REVLIMID ................................. 33
REXULTI ................................... 37
REYATAZ ................................. 38
138
RHIZOPUS ................................ 98
RHOFADE ................................. 56
RHOGAM ULTRA-FILTERED
PLUS ......................................... 89
RHOPHYLAC ............................ 89
RHOPRESSA .......................... 102
RIASTAP ................................... 41
RIAX .......................................... 56
ribasphere .................................. 38
ribasphere ribapak ..................... 38
RIBASPHERE RIBAPAK ........... 38
ribavirin ...................................... 38
RICE (DIAGNOSTIC)................. 98
RIDAURA .................................. 89
rifabutin ...................................... 30
RIFADIN .................................... 30
RIFAMATE ................................ 30
rifampin ...................................... 30
RIFAMPIN+SYRSPEND SF ...... 30
RIFATER ................................... 30
RILUTEK ................................... 51
riluzole ....................................... 51
rimantadine hcl .......................... 38
RIOMET ..................................... 59
risedronate sodium .................... 92
RISPERDAL .............................. 37
RISPERDAL CONSTA .............. 37
risperidone ................................. 37
RITALIN ..................................... 50
RITALIN LA ............................... 50
ritonavir ...................................... 38
RITUXAN ................................... 33
RITUXAN HYCELA ................... 33
rivastigmine ............................... 24
rivastigmine tartrate ................... 24
rivelsa ........................................ 85
RIXUBIS .................................... 41
rizatriptan benzoate ................... 29
ROBAXIN ................................ 110
ROBAXIN-750 ......................... 110
ROCALTROL ............................. 92
ROCKLATAN ........................... 102
rocuronium bromide ................... 51
ROCURONIUM BROMIDE ........ 51
ROMIDEPSIN ............................ 33
ROPIDEX .................................. 79
ropinirole hcl .............................. 35
ropinirole hcl er .......................... 35
ROPIVACAINE HCL .................. 15
ropivacaine hcl ........................... 15
ROPIVACAINE HCL-NACL ....... 15
ROPIV-CLONIDINE-
KETOROLAC............................. 15
rosadan ................................ 56, 57
rosuvastatin calcium .................. 48
ROTARIX ................................... 90
ROTATEQ ................................. 90
ROUGH MARSH ELDER ........... 98
ROUGH PIGWEED .................... 98
ROWASA ................................... 91
roweepra .................................... 23
roweepra xr ................................ 23
ROXICODONE .......................... 10
ROZEREM ............................... 111
RUBRACA ................................. 33
RUCONEST ............................... 89
RUSSIAN THISTLE ................... 98
RUZURGI .................................. 98
RYANODEX ............................. 110
RYCLORA ............................... 106
RYDAPT .................................... 33
RYTARY .................................... 35
RYTHMOL SR ........................... 48
ryvent ....................................... 106
SABRIL ...................................... 23
SACCHAROMYCES
CEREVISIAE ............................. 98
SAFYRAL .................................. 85
SAGEBRUSH ............................ 98
SAIZEN ...................................... 81
SAIZENPREP ............................ 81
SALAGEN .................................. 52
SALEX ....................................... 57
salicylic acid ............................... 57
salicylic acid er ........................... 57
salicylic acid-cleanser ................ 57
saline bacteriostatic ................... 70
SALINE-PHENOL ...................... 70
salsalate..................................... 12
SALVAX ..................................... 57
SALVAX DUO PLUS ................. 57
SAMSCA .................................... 70
SANCUSO ................................. 27
SANDIMMUNE .......................... 89
SANDOSTATIN ......................... 81
SANDOSTATIN LAR DEPOT .... 81
SANTYL ..................................... 57
SAPHRIS ................................... 37
SAPS HEALTH CARE
ALCOHOL PREP ....................... 98
SARAFEM ................................. 26
sash kit ...................................... 98
SAVAYSA .................................. 22
SAVELLA ................................... 51
SAVELLA TITRATION PACK .... 51
SCLEROSOL
INTRAPLEURAL ..................... 108
scopolamine .............................. 27
SEASONIQUE .......................... 85
SECONAL ............................... 111
SEEBRI NEOHALER .............. 108
SEGLUROMET ......................... 59
SELECT-OB .............................. 70
selegiline hcl ............................. 35
selenium sulfide ........................ 57
SELZENTRY ............................. 38
SEMPREX-D ........................... 106
SENSIPAR ................................ 80
sensorcaine ............................... 15
sensorcaine/epinephrine ........... 15
sensorcaine-mpf ........................ 15
sensorcaine-mpf/epinephrine .... 15
SENSORCAINE-
MPF/EPINEPHRINE ................. 15
SEREVENT DISKUS .............. 108
SERNIVO .................................. 57
SEROQUEL .............................. 37
SEROQUEL XR ........................ 37
SEROSTIM ............................... 75
sertraline hcl.............................. 26
SESAME SEED
(DIAGNOSTIC) ......................... 98
se-tan plus ................................ 70
setlakin ...................................... 85
sevelamer carbonate ................ 76
sevelamer hcl ............................ 76
sevoflurane ............................... 98
SEYSARA ................................. 20
sf ............................................... 52
sf 5000 plus .............................. 52
SFROWASA ............................. 91
SHAGBARK HICKORY ............. 98
sharobel .................................... 85
SHEEP SORREL ...................... 98
SHINGRIX ................................. 90
SHORT RAGWEED POLLEN
EXT ........................................... 98
SHRIMP (DIAGNOSTIC) .......... 98
SIGNIFOR ................................. 81
SIGNIFOR LAR ......................... 81
SIKLOS ..................................... 33
sildenafil citrate ....................... 109
SILENOR ................................ 111
SILIQ ......................................... 89
silodosin .................................... 77
SILVADENE .............................. 20
silver nitrate ............................... 20
silver sulfadiazine ...................... 20
139
SIMBRINZA ............................. 102
simliya ....................................... 85
simpesse ................................... 85
SIMPONI ................................... 89
SIMPONI ARIA .......................... 89
SIMULECT ................................ 89
simvastatin ................................. 48
SINEMET ................................... 35
SINEMET CR ............................ 35
SINGULAIR ............................. 108
SINUVA ................................... 106
sirolimus .................................... 89
SIRTURO .................................. 30
SITAVIG .................................... 38
SIVEXTRO ................................ 20
SKELAXIN ............................... 110
SKLICE ...................................... 35
SKYLA ....................................... 85
SKYRIZI (150 MG DOSE) ......... 89
SLYND ...................................... 85
sm esomeprazole magnesium 73
sm hydrocortisone ..................... 57
SMOFLIPID ............................... 70
sod benz-sod phenylacet ........... 75
sod citrate-citric acid .................. 70
sodium acetate .......................... 70
sodium bicarbonate ............. 70, 75
SODIUM BICARBONATE .......... 70
SODIUM BICARBONATE-
DEXTROSE ............................... 70
sodium chloride ................. 70, 106
sodium chloride bacteriostatic ... 70
SODIUM CITRATE .................... 22
SODIUM CITRATE LOCK
FLUSH ....................................... 22
SODIUM CITRATE-
GENTAMICIN SULF .................. 22
SODIUM DIURIL ....................... 48
SODIUM EDECRIN ................... 48
sodium fluoride .................... 52, 70
sodium fluoride 5000 plus.......... 52
sodium hyaluronate ................... 57
SODIUM HYALURONATE ........ 98
sodium lactate ........................... 70
sodium phenylbutyrate............... 75
SODIUM PHOSPHATE-NACL 71
sodium phosphates ................... 71
SODIUM PHOSPHATES-
DEXTROSE ............................... 71
sodium polystyrene sulfonate .... 71
sodium sulfacetamide ................ 57
sodium sulfacetamide wash ...... 57
SODIUM SULFACETAMIDE
WASH ........................................ 57
SOF-SENSOR ........................... 62
SOLESTA .................................. 98
solifenacin succinate .................. 76
SOLIQUA ................................... 59
SOLIRIS..................................... 41
SOLODYN ................................. 20
SOLOSEC ................................. 35
SOLTAMOX ............................... 33
SOLU-CORTEF ......................... 79
SOLU-MEDROL ......................... 79
SOMA ...................................... 110
SOMATULINE DEPOT .............. 81
SOMAVERT ............................... 81
SOOLANTRA ............................. 57
SORIATANE .............................. 57
SORILUX ................................... 57
sorine ......................................... 48
SORREL/DOCK MIX ................. 98
SOTALOL HCL .......................... 48
sotalol hcl ................................... 48
sotalol hcl (af) ............................ 48
SOTRADECOL .......................... 48
SOTYLIZE ................................. 48
SOVALDI ................................... 38
SOYBEAN (DIAGNOSTIC) ........ 98
SPARKY THE DOG PED
NEBULIZER ............................... 98
SPECTRACEF ........................... 20
spinosad .................................... 35
SPINRAZA ................................. 98
SPINY PIGWEED ...................... 98
SPIRIVA HANDIHALER........... 108
SPIRIVA RESPIMAT ............... 108
spironolactone............................ 48
spironolactone-hctz .................... 48
SPORANOX .............................. 28
SPORANOX PULSEPAK ........... 28
SPRAVATO (56 MG DOSE) ...... 26
SPRAVATO (84 MG DOSE) ...... 26
sprintec 28 ................................. 85
SPRITAM ................................... 23
SPRIX ........................................ 12
SPRYCEL .................................. 33
sps ............................................. 71
sronyx ........................................ 85
ssd ............................................. 20
SSKI ........................................ 106
sss 10-5 ..................................... 57
st joseph low dose ..................... 12
STALEVO 100 ........................... 35
STALEVO 125 ........................... 35
STALEVO 150 .......................... 35
STALEVO 200 .......................... 36
STALEVO 50 ............................ 36
STALEVO 75 ............................ 36
STAMARIL ................................ 90
STARLIX ................................... 59
stavudine ................................... 38
STEGLATRO ............................ 59
STEGLUJAN ............................. 59
STELARA .................................. 89
STEMPHYLIUM ........................ 98
STERILE DILUENT FLOLAN
PH 12 ........................................ 98
STERILE DILUENT FOR
FLOLAN .................................... 98
sterile diluent/epoprostenol ....... 98
STERILE TALC POWDER ...... 108
sterile water for injection ........... 98
STERITALC ............................ 108
STIMATE .................................. 81
STIOLTO RESPIMAT ............. 108
STIVARGA ................................ 33
STRATTERA ............................. 50
STRAWBERRY
(DIAGNOSTIC) ......................... 99
STRENSIQ ................................ 75
streptomycin sulfate .................. 20
STRIANT ................................... 79
STRIBILD .................................. 38
STRIVERDI RESPIMAT.......... 108
STROMECTOL ......................... 35
SUBLOCADE ............................ 16
SUBOXONE .............................. 16
SUBSYS ................................... 10
subvenite ................................... 23
subvenite starter kit-blue ........... 23
subvenite starter kit-green ........ 23
subvenite starter kit-orange ...... 23
succinylcholine chloride ............ 51
SUCCINYLCHOLINE
CHLORIDE ............................... 51
SUCRAID .................................. 75
sucralfate .................................. 73
SULAR ...................................... 48
sulfacetamide sodium ....... 57, 102
sulfacetamide sodium (acne) .... 57
sulfacetamide sodium-sulfur ...... 57
sulfacetamide-prednisolone..... 104
sulfacetamide-sulfur in urea ...... 57
sulfacleanse 8/4 ........................ 57
sulfadiazine ............................... 20
sulfamethoxazole-trimethoprim. 20
SULFAMYLON .......................... 20
140
sulfasalazine .............................. 91
sulfatrim pediatric ...................... 20
sulfurated lime ........................... 35
sulindac ..................................... 12
sumatriptan ................................ 29
sumatriptan succinate ................ 29
sumatriptan succinate refill ........ 29
sumatriptan-naproxen sodium 29
SUPARTZ FX ............................ 99
SUPPRELIN LA ......................... 81
SUPRANE ................................. 99
SUPRAX .................................... 20
SUPREP BOWEL PREP KIT .... 75
SURE RESULT O3D3
SYSTEM .................................... 48
SURESTEP PRO HIGH
GLUCOSE ................................. 62
SURESTEP PRO LOW
GLUCOSE ................................. 62
SURESTEP PRO NORMAL
GLUCOSE ................................. 62
SURGISEAL .............................. 99
SURGISEAL STYLUS ............... 99
SURGISEAL TWIST .................. 99
SURVANTA ............................. 106
SUSTIVA ................................... 38
SUSTOL .................................... 27
SUTENT .................................... 33
swabflush saline flush ................ 71
SWEET CORN
(DIAGNOSTIC) .......................... 99
SWEET GUM ............................ 99
SWEET VERNAL GRASS
POLLEN .................................... 99
SX1 MEDICATED POST-
OPERATIVE .............................. 15
syeda ......................................... 85
SYLATRON ............................... 33
SYLVANT .................................. 33
SYMAX DUOTAB ...................... 75
symax-sl .................................... 75
symax-sr .................................... 75
SYMBICORT ........................... 108
SYMBYAX ................................. 26
SYMDEKO ............................... 109
SYMFI ....................................... 39
SYMFI LO .................................. 39
SYMJEPI ................................. 108
SYMLINPEN 120 ....................... 59
SYMLINPEN 60 ......................... 59
SYMPAZAN ............................... 23
SYMPROIC ............................... 75
SYMTUZA ................................. 39
SYNAGIS ................................... 89
synalar ....................................... 57
SYNALAR .................................. 57
SYNAPRYN FUSEPAQ ............. 10
SYNAREL .................................. 81
SYNDROS ................................. 27
SYNERA .................................... 15
SYNERCID ................................ 20
SYNJARDY ................................ 59
SYNJARDY XR .......................... 59
SYNRIBO ................................... 33
SYNTHAMIN 17 ......................... 71
SYNTHROID .............................. 86
SYNVISC ................................... 99
SYNVISC ONE .......................... 99
SYPRINE ................................... 71
TABLOID ................................... 33
TABRADOL FUSEPAQ............ 110
TABRADOL RAPIDPAQ .......... 110
TACHOSIL ................................. 99
TACLONEX ............................... 57
tacrolimus ............................ 57, 89
tadalafil (pah) ........................... 109
TAFINLAR ................................. 33
TAGITOL V ................................ 99
TAGRISSO ................................ 33
TAKHZYRO ............................... 99
TALL RAGWEED ....................... 99
TALTZ ........................................ 89
TALZENNA ................................ 33
TAMIFLU ................................... 39
tamoxifen citrate ......................... 33
tamsulosin hcl ............................ 77
TAPAZOLE ................................ 86
TAPERDEX 12-DAY .................. 79
TAPERDEX 6-DAY .................... 79
TAPERDEX 7-DAY .................... 79
TARCEVA .................................. 33
TARGADOX ............................... 20
TARGRETIN .............................. 34
tarina 24 fe ................................. 85
tarina fe 1/20 .............................. 85
tarina fe 1/20 eq ......................... 85
TARKA ....................................... 48
TARON FORTE ......................... 71
taron-crystals ............................. 71
TASIGNA ................................... 34
TASMAR .................................... 36
TAURINE ................................... 71
TAVALISSE ............................... 41
TAXOTERE ............................... 34
TAYTULLA ................................. 85
tazarotene .................................. 57
tazicef ....................................... 20
TAZICEF ................................... 20
TAZORAC ................................. 57
taztia xt ..................................... 48
TDVAX ...................................... 90
TECENTRIQ ............................. 34
TECFIDERA .............................. 50
TECHNET TC 99M SULFUR
COLLOID .................................. 99
technetium tc 99m mebrofenin 99
TECHNETIUM TC 99M
MEDRONATE ........................... 99
TECHNETIUM TC 99M
PYROPHOS .............................. 99
technetium tc 99m sestamibi .... 99
TEFLARO ................................. 20
TEGRETOL ............................... 24
TEGRETOL-XR ......................... 24
TEGSEDI .................................. 51
TEKTURNA ............................... 48
TEKTURNA HCT ...................... 48
TELFA AMD NON-
ADHERENT .............................. 99
telmisartan ................................ 48
telmisartan-amlodipine .............. 48
telmisartan-hctz ......................... 48
temazepam ............................. 111
TEMIXYS .................................. 39
TEMODAR ................................ 34
TEMOVATE .............................. 57
temozolomide ............................ 34
temsirolimus .............................. 89
tencon ....................................... 10
teniposide .................................. 34
TENIVAC .................................. 90
tenofovir disoproxil fumarate ..... 39
TENORETIC 100 ...................... 48
TENORETIC 50 ........................ 48
TENORMIN ............................... 48
TEPADINA ................................ 34
terazosin hcl .............................. 77
terbinafine hcl............................ 28
terbutaline sulfate .................... 108
terconazole ............................... 28
TESSALON PERLES .............. 106
TESTIM ..................................... 80
TESTOPEL ............................... 80
TESTOSTERONE ..................... 80
testosterone .............................. 80
TESTOSTERONE
COMPOUNDING KIT ................ 80
TESTOSTERONE
CYPIONATE ............................. 80
141
142
testosterone cypionate .............. 80
TESTOSTERONE
CYPIONATE & PROP ............... 80
TESTOSTERONE
ENANTHATE ............................. 80
testosterone enanthate .............. 80
TESTOSTERONE
PROPIONATE ........................... 80
tetcaine .................................... 104
tetrabenazine ............................. 51
tetracaine hcl ..................... 15, 104
tetracycline hcl ........................... 20
tetravisc ................................... 104
tetravisc forte ........................... 104
TEXACORT ............................... 57
TEXAVITE LQ ........................... 71
thallous chloride tl 201 ............... 99
THALLOUS CHLORIDE TL
201 ............................................ 99
THALOMID ................................ 34
THEO-24 ................................. 108
theochron ................................. 108
theophylline ............................. 108
theophylline er ......................... 108
thiamine hcl ............................... 71
THIOLA...................................... 76
THIOLA EC ............................... 76
thioridazine hcl ........................... 37
thiotepa ...................................... 34
thiothixene ................................. 37
THROMBATE III ........................ 22
THROMBIN-JMI ......................... 41
THROMBIN-JMI EPISTAXIS ..... 41
THROMBOGEN ......................... 41
THYMOGLOBULIN .................... 89
THYROGEN .............................. 99
tiagabine hcl .............................. 24
TIAZAC ...................................... 48
TIBSOVO ................................... 34
TICE BCG ................................. 89
TIGAN ....................................... 27
tigecycline .................................. 20
TIGLUTIK .................................. 51
TIKOSYN ................................... 48
tilia fe ......................................... 86
timolol maleate .................. 48, 102
TIMOPTIC ............................... 102
TIMOPTIC OCUDOSE ............ 102
TIMOPTIC-XE.......................... 103
TIMOTHY GRASS POLLEN
ALLERGEN ............................... 99
tinidazole ................................... 20
TIROSINT .................................. 86
TIROSINT-SOL .......................... 86
TISSEEL .................................... 99
TIVICAY ..................................... 39
TIVORBEX ................................. 13
tizanidine hcl ............................ 110
tl icon ......................................... 71
TL-FLUORIVITE ........................ 71
TOBI NEBULIZER ................... 109
TOBI PODHALER .................... 109
TOBRADEX ............................. 104
TOBRADEX ST ....................... 104
tobramycin .......................102, 109
TOBRAMYCIN ......................... 109
tobramycin sulfate ...................... 20
tobramycin-dexamethasone ..... 104
TOBREX .................................. 102
TOFRANIL ................................. 26
TOLAK ....................................... 57
tolbutamide ................................ 59
tolcapone ................................... 36
tolmetin sodium .......................... 13
TOLSURA .................................. 28
tolterodine tartrate ...................... 76
tolterodine tartrate er .................. 76
TOPAMAX ................................. 24
TOPAMAX SPRINKLE............... 24
topex topical anesthetic ............. 52
TOPICORT ................................ 57
TOPICORT SPRAY ................... 57
topiramate .................................. 24
topiramate er.............................. 24
toposar ....................................... 34
topotecan hcl ............................. 34
TOPROL XL ............................... 48
toremifene citrate ....................... 34
TORISEL ................................... 89
TORONOVA II SUIK .................. 13
TORONOVA SUIK ..................... 13
torsemide ................................... 48
TOTECT .................................... 34
TOUJEO MAX SOLOSTAR ....... 64
TOUJEO SOLOSTAR ................ 64
TOVIAZ ...................................... 76
toxicology saliva collection ......... 99
tpn electrolytes ........................... 71
TRACLEER .............................. 109
TRADJENTA .............................. 59
TRAMADOL HCL ER ................. 10
tramadol hcl er ........................... 10
tramadol hcl er (biphasic) ........... 10
tramadol hcl ir ............................ 10
tramadol-acetaminophen ........... 10
trandolapril ................................. 48
trandolapril-verapamil hcl er ...... 48
tranexamic acid ......................... 41
TRANSDERM SCOP (1.5 MG). 27
TRANSDERM-SCOP (1.5 MG).27
TRANXENE-T ........................... 40
tranylcypromine sulfate ............. 26
TRAVASOL ............................... 71
TRAVATAN Z.......................... 103
trazodone hcl ............................ 26
TREANDA ................................. 34
TRECATOR .............................. 30
TRELEGY ELLIPTA ................ 109
TRELSTAR MIXJECT ............... 81
TREMFYA ................................. 90
treprostinil ............................... 109
TRESIBA ................................... 64
TRESIBA FLEXTOUCH ............ 64
tretinoin ......................... 34, 57, 58
tretinoin microsphere ................ 58
tretinoin microsphere pump ...... 58
TRETTEN ................................. 41
TREXALL .................................. 90
TREXIMET ................................ 29
TREZIX ..................................... 10
tri femynor ................................. 86
triamcinolone acetonide 52, 58, 79
TRIAMCINOLONE
ACETONIDE ............................. 79
TRIAMCINOLONE
DIACETATE .............................. 79
TRIAMCINOLONE-
BUPIVACAINE .......................... 79
TRIAMCINOLONE-
MOXIFLOXACIN ..................... 104
TRI-AMINO ............................... 71
triamterene ................................ 48
triamterene-hctz ........................ 48
TRIANEX .................................. 58
triazolam ................................... 40
TRIBENZOR ............................. 48
TRICARE PRENATAL DHA
ONE .......................................... 71
TRI-CHLOR .............................. 58
TRICHOPHYTON ..................... 99
TRICITRASOL .......................... 22
tricitrates ................................... 71
tricon ......................................... 71
TRICOR .................................... 48
triderm ....................................... 58
TRIDESILON ............................ 58
trientine hcl ............................... 71
tri-estarylla ................................ 86
TRIFERIC ................................. 71
143
trifluoperazine hcl ...................... 37
trifluridine ................................. 102
trigels-f forte............................... 71
trihexyphenidyl hcl ..................... 36
tri-legest fe ................................. 86
TRILEPTAL ............................... 24
tri-linyah ..................................... 86
TRILIPIX .................................... 48
TRILOAN II SUIK....................... 79
TRILOAN SUIK .......................... 79
tri-lo-estarylla ............................. 86
tri-lo-marzia ................................ 86
tri-lo-mili ..................................... 86
tri-lo-sprintec .............................. 86
trilyte .......................................... 75
trimethobenzamide hcl............... 27
trimethoprim ............................... 20
tri-mili ......................................... 86
trimipramine maleate ................. 26
trinate ........................................ 71
TRINAZ...................................... 71
TRINTELLIX .............................. 26
TRIOSTAT ................................. 86
TRIPLE COMPLEX FORMULA
3 KIT .......................................... 13
TRIPLE PMB ........................... 102
TRIPLE PMK ........................... 102
tri-previfem ................................. 86
TRIPTODUR .............................. 81
TRISENOX ................................ 34
TRISODIUM CITRATE/CRRT 71
tri-sprintec .................................. 86
TRIUMEQ .................................. 39
TRI-VI-FLOR ............................. 71
TRI-VI-FLORO ........................... 71
TRIVISC .................................... 99
tri-vitamin/fluoride ...................... 71
tri-vite/fluoride ............................ 71
trivora (28) ................................. 86
tri-vylibra .................................... 86
tri-vylibra lo ................................ 86
TRIZIVIR .................................... 39
TROGARZO .............................. 39
TROKENDI XR .......................... 24
TROPHAMINE ........................... 71
tropicamide .............................. 104
TROPICAMIDE-
PHENYLEPHRINE .................. 104
trospium chloride ....................... 76
trospium chloride er ................... 76
TRUE COMFORT ALCOHOL
PREP PADS .............................. 99
TRUE FOCUS BLOOD
GLUCOSE METER .................... 62
TRUE METRIX BLOOD
GLUCOSE TEST ....................... 62
TRUE METRIX LEVEL 1 ........... 62
TRUE METRIX LEVEL 2 ........... 62
TRUE METRIX LEVEL 3 ........... 62
TRUETRACK TEST ................... 62
TRULANCE ............................... 75
TRULICITY ................................ 59
TRUMENBA ............................... 90
TRUSOPT ................................ 103
TRUVADA .................................. 39
tryptophan .................................. 71
TUDORZA PRESSAIR ............ 109
tulana ......................................... 86
turpentine ................................... 58
TUSSICAPS ............................ 106
TUXARIN ER ........................... 106
TUZISTRA XR ......................... 106
TWINRIX .................................... 90
TWYNSTA ................................. 48
TYBOST .................................... 39
tydemy ....................................... 86
TYGACIL ................................... 20
TYKERB .................................... 34
TYLENOL WITH CODEINE #3 . 10
TYLENOL WITH CODEINE #4 . 10
TYMLOS .................................... 92
TYPHIM VI ................................. 91
TYR EASY ................................. 99
TYSABRI ................................... 50
TYVASO .................................. 109
TYVASO REFILL ..................... 109
TYVASO STARTER ................ 109
UCERIS ..................................... 91
UDENYCA ................................. 41
ULESFIA .................................... 35
ULORIC ..................................... 28
ULTANE..................................... 99
ULTIVA ...................................... 10
ULTOMIRIS ............................... 41
ULTRABAG/DIANEAL/1.5%
DEXTROSE ............................... 71
ULTRABAG/DIANEAL/2.5%
DEXTROSE ............................... 71
ULTRABAG/DIANEAL/4.25%
DEX ........................................... 71
ULTRACET ................................ 10
ULTRAM .................................... 10
ULTRAVATE .............................. 58
ULTRAVIST ............................... 99
umecta mousse ......................... 58
UNASYN ................................... 20
UNISTRIP CONTROL ............... 62
unithroid .................................... 86
UNITUXIN ................................. 34
UPTRAVI ................................ 109
urea ........................................... 58
urea hydrating ........................... 58
urea in zn undecyl-lactic acid .... 58
urea nail .................................... 58
URECHOLINE........................... 76
uretron d/s ................................. 76
urimar-t ..................................... 76
urin ds ....................................... 76
UROCIT-K 10 ............................ 71
UROCIT-K 15 ............................ 71
UROCIT-K 5 .............................. 71
UROGESIC-BLUE .................... 76
UROXATRAL ............................ 77
URSO 250 ................................. 75
URSO FORTE .......................... 75
ursodiol ..................................... 75
URSODIOL+SYRSPEND SF .... 75
uryl ............................................ 76
ustell ......................................... 76
UTIBRON NEOHALER ........... 109
uticap ........................................ 76
utira-c ........................................ 76
utrona-c ..................................... 76
VABOMERE .............................. 20
VAGIFEM .................................. 86
valacyclovir hcl .......................... 39
VALCHLOR ............................... 34
VALCYTE .................................. 39
valganciclovir hcl ....................... 39
VALIUM..................................... 40
valproate sodium ....................... 24
valproic acid .............................. 24
valrubicin ................................... 34
valsartan ................................... 48
valsartan-hydrochlorothiazide .... 48
VALSTAR .................................. 34
VALTREX .................................. 39
VANATOL LQ ........................... 10
VANATOL S .............................. 10
VANCOCIN HCL ....................... 20
vancomycin hcl ......................... 21
VANCOMYCIN HCL .................. 21
VANCOMYCIN HCL IN
DEXTROSE .............................. 20
vancomycin hcl in dextrose ....... 20
vancomycin hcl in nacl ........ 20, 21
VANCOMYCIN HCL IN NACL 21
VANCOMYCIN+SYRSPEND
SF .............................................. 21
vandazole .................................. 21
VANOS ...................................... 58
VANOXIDE-HC .......................... 58
VANTAS .................................... 81
VAQTA ...................................... 91
VARIBAR HONEY ..................... 99
VARIBAR NECTAR ................... 99
VARIBAR PUDDING ................. 99
VARIBAR THIN HONEY ............ 99
VARIBAR THIN LIQUID ............ 99
VARITHENA .............................. 48
VARIVAX ................................... 91
VARIZIG .................................... 90
VARUBI ..................................... 27
VASCEPA .................................. 49
VASERETIC .............................. 49
vashe cleansing ......................... 58
VASOPRESSIN-SODIUM
CHLORIDE ................................ 81
VASOSTRICT ............................ 81
VASOTEC ................................. 49
VAXCHORA .............................. 91
VAZCULEP ................................ 49
vcf vaginal contraceptive ........... 99
VECAMYL ................................. 49
VECTIBIX .................................. 34
VECTICAL ................................. 58
VECURONIUM BROMIDE ......... 51
vecuronium bromide .................. 51
VELCADE .................................. 34
VELETRI .................................. 109
velivet ........................................ 86
VELPHORO ............................... 76
VELTASSA ................................ 71
VELTIN ...................................... 58
VEMLIDY ................................... 39
VENCLEXTA ............................. 34
VENCLEXTA STARTING
PACK ......................................... 34
VENELEX .................................. 58
VENIPUNCTURE PX1
PHLEBOTOMY .......................... 15
venlafaxine hcl ........................... 26
venlafaxine hcl er....................... 26
VENOFER ................................. 71
VENOMIL HONEY BEE
VENOM ..................................... 99
VENOMIL WASP VENOM ......... 99
VENOMIL WHITE FACED
HORNET ................................... 99
VENOMIL YELLOW HORNET
VENOM...................................... 99
VENOMIL YELLOW JACKET
VENOM...................................... 99
VENTAVIS ............................... 109
VENTOLIN HFA ....................... 109
verapamil hcl.............................. 49
verapamil hcl er ......................... 49
VERDESO ................................. 58
VEREGEN ................................. 58
VERELAN .................................. 49
VERELAN PM............................ 49
VERSACLOZ ............................. 37
VERZENIO ................................ 34
VESICARE ................................. 76
VFEND ...................................... 28
VFEND IV .................................. 28
V-GO 20 .............................. 62, 99
V-GO 30..................................... 99
V-GO 40..................................... 99
VIBATIV ..................................... 21
VIBERZI ..................................... 75
VIBRAMYCIN............................. 21
vicodin es ................................... 10
vicodin hp ................................... 10
VICTOZA ................................... 59
VIDAZA ...................................... 34
VIDEX ........................................ 39
VIDEX EC .................................. 39
VIEKIRA PAK ............................ 39
vienva ........................................ 86
vigabatrin ................................... 24
vigadrone ................................... 24
VIGAMOX ................................ 102
VIIBRYD .................................... 26
VIIBRYD STARTER PACK ........ 26
VIMIZIM ..................................... 75
VIMOVO .................................... 13
VIMPAT ..................................... 24
vinblastine sulfate ...................... 34
vincristine sulfate ....................... 34
vinorelbine tartrate ..................... 34
VIOKACE ................................... 75
viorele ........................................ 86
VIRACEPT ................................. 39
VIRAMUNE ................................ 39
VIRAMUNE XR .......................... 39
VIRASAL .................................... 58
VIRAZOLE ................................. 39
VIREAD ..................................... 39
VIRGINIA LIVE OAK .................. 99
virt-phos 250 neutral .................. 71
VISCO-3 .................................... 99
VISIPAQUE ............................... 99
VISTARIL .................................. 40
VISTOGARD ............................. 99
VISUDYNE .............................. 104
VITAFOL ................................... 71
VITAFOL-OB+DHA ................... 71
vitamin b complex 100 .............. 71
vitamin b-complex 100 .............. 71
vitamin d (ergocalciferol) ........... 71
vitamin k1 .................................. 71
vitamins acd-fluoride ................. 71
VITRAKVI .................................. 34
VITRASE ................................. 100
VIVAGUARD INO CONTROL
SOLUTION ................................ 63
VIVAGUARD INO GLUCOSE
METER ..................................... 63
VIVAGUARD INO TEST
STRIPS ..................................... 63
VIVAGUARD LANCING
DEVICE..................................... 63
VIVELLE-DOT ........................... 86
VIVITROL .................................. 16
VIVLODEX ................................ 13
VIVOTIF .................................... 91
VIZIMPRO ................................. 34
VOGELXO ................................ 80
VOGELXO PUMP ..................... 80
VOLTAREN ............................... 13
VOLUMEN .............................. 100
VOLUVEN ................................. 41
VONVENDI ............................... 41
VOPAC GB ............................... 13
VOPAC KT ................................ 13
VORAXAZE .............................. 34
voriconazole .............................. 28
VORTEX HOLDING
CHAMBER/MASK ................... 100
VOSEVI..................................... 39
VOTRIENT ................................ 34
VP FC KIT ................................. 13
VP GKL KIT .............................. 13
vp-pnv-dha ................................ 71
VPRIV ....................................... 75
VRAYLAR ................................. 37
VSL#3 DS ................................. 75
VUSION .................................... 28
vyfemla ..................................... 86
vylibra ....................................... 86
VYNDAQEL .............................. 49
VYTORIN .................................. 49
VYVANSE ................................. 50
VYXEOS ................................... 34
144
145
VYZULTA ................................ 103
WAKIX ..................................... 111
warfarin sodium ......................... 22
WASP VENOM PROTEIN ....... 100
WELCHOL ................................. 49
WELLBUTRIN SR ...................... 26
WELLBUTRIN XL ...................... 26
wera ........................................... 86
WESTERN JUNIPER .............. 100
westhroid ................................... 86
WESTHROID ............................. 86
wheat germ oil ........................... 71
WHITE ASH............................. 100
WHITE BIRCH ......................... 100
WHITE FACED HORNET
VENOM ................................... 100
WHITE MULBERRY ................ 100
WHITE OAK ............................ 100
WHITE PINE............................ 100
WHITE-FACED HORNET
VENOM ................................... 100
WHOLE EGG (DIAGNOSTIC) 100
WIDE-SEAL DIAPHRAGM 60 100
WILATE ..................................... 41
WINRHO SDF ........................... 90
wixela inhub ............................. 109
WP THYROID ............................ 86
wymzya fe ................................. 86
XADAGO ................................... 36
XALATAN ................................ 103
XALKORI ................................... 34
XANAX ...................................... 40
XANAX XR ................................ 40
XARELTO .................................. 22
XARELTO STARTER PACK ..... 22
XATMEP .................................... 90
XELJANZ ................................... 90
XELJANZ XR ............................. 90
XELODA .................................... 34
XELPROS ................................ 103
XENAZINE ................................. 51
XEOMIN .................................. 100
XEPI .......................................... 21
XERAC AC ................................ 58
XERAVA .................................... 21
XERESE .................................... 39
XERFORM OIL EMULSION
ROLL ......................................... 58
XERMELO ................................. 75
XEROFORM OIL EMULSION
2"X2" ......................................... 58
XEROFORM OIL EMULSION
GAUZE ...................................... 58
XEROFORM OIL EMULSION
STRIP ........................................ 58
XEROFORM PETROLAT
GAUZE 1"X8" ............................ 58
XEROFORM PETROLAT
GAUZE 5"X9" ............................ 58
XEROFORM PETROLAT
PATCH 2"X2" ............................. 58
XEROFORM PETROLAT
PATCH 4"X4" ............................. 58
XEROFORM PETROLATUM
ROLL 4"X9' ................................ 58
XHANCE .................................. 106
XIAFLEX .................................. 100
XIFAXAN ................................... 21
XIGDUO XR......................... 59, 60
XIIDRA ..................................... 104
XIMINO ...................................... 21
XOFIGO ..................................... 34
XOFLUZA .................................. 39
XOLAIR.................................... 106
XOLEGEL .................................. 28
XOLEGEL COREPAK................ 28
XOLEGEL DUO/HEAD &
SHOULDERS ............................ 28
XOLEGEL DUO/XOLEX ............ 28
XOPENEX ............................... 109
XOPENEX CONCENTRATE 109
XOPENEX HFA ....................... 109
XOSPATA .................................. 34
XTAMPZA ER ............................ 10
XTANDI...................................... 34
xulane ........................................ 86
XULTOPHY ............................... 60
XURIDEN ................................... 75
XYLOCAINE .............................. 15
xylocaine dental ......................... 15
XYLOCAINE/EPINEPHRINE ..... 16
XYLOCAINE-MPF ...................... 16
XYLOCAINE-
MPF/EPINEPHRINE .................. 16
XYNTHA .................................... 41
XYNTHA SOLOFUSE ................ 41
XYOSTED .................................. 80
XYREM .................................... 111
YASMIN 28 ................................ 86
YAZ ............................................ 86
YELLOW DOCK ...................... 100
YELLOW HORNET VENOM
PROTEIN ................................. 100
YELLOW JACKET VENOM
PROTEIN ................................. 100
YERVOY .................................... 34
YESCARTA ............................... 34
yf-vax ........................................ 91
YF-VAX ..................................... 91
YONDELIS ................................ 34
YONSA ..................................... 34
YOSPRALA ............................... 73
YUPELRI ................................. 109
YUTIQ ..................................... 102
yuvafem .................................... 86
ZACARE ................................... 58
zaclir cleansing ......................... 58
zafirlukast ................................ 109
zaleplon................................... 111
ZALTRAP .................................. 34
ZANAFLEX ............................. 111
ZANOSAR ................................. 34
ZANTAC.................................... 73
zarah ......................................... 86
ZARONTIN ................................ 24
ZARXIO..................................... 41
ZAVESCA ................................. 75
zebutal ...................................... 11
ZEGERID .................................. 73
ZEJULA..................................... 34
ZELAC ...................................... 75
ZELAPAR .................................. 36
ZELBORAF ............................... 34
ZEMAIRA ................................ 109
ZEMBRACE SYMTOUCH ......... 29
ZEMDRI .................................... 21
ZEMPLAR ................................. 92
zenatane ................................... 58
ZENPEP.................................... 75
zenzedi ..................................... 50
ZENZEDI ................................... 50
ZEPATIER ................................ 39
ZERBAXA ................................. 21
ZESTORETIC ........................... 49
ZESTRIL ................................... 49
ZETIA ........................................ 49
ZETONNA ............................... 106
ZEVALIN Y-90 .......................... 34
ZIAC .......................................... 49
ZIAGEN..................................... 39
ZIANA ....................................... 58
zidovudine ................................. 39
zileuton er ............................... 109
ZILRETTA ................................. 79
ZINC TRACE METAL ................ 71
ZINECARD ................................ 34
ZINGO ...................................... 16
ZINPLAVA ................................. 90
ZIOPTAN ................................ 103
146
ziprasidone hcl ........................... 37
ZIPSOR ..................................... 13
ZIRGAN ................................... 102
ZITHROMAX ............................. 21
ZITHROMAX TRI-PAK .............. 21
ZITHROMAX Z-PAK .................. 21
ZOCOR...................................... 49
ZOFRAN .................................... 27
ZOHYDRO ER ........................... 11
ZOLADEX .................................. 81
zoledronic acid ........................... 92
ZOLINZA ................................... 34
zolmitriptan ................................ 29
ZOLOFT .................................... 26
zolpidem tartrate ...................... 111
zolpidem tartrate er .................. 111
ZOLPIMIST .............................. 111
ZOMACTON .............................. 81
ZOMIG ....................................... 29
ZOMIG ZMT .............................. 29
ZONALON ................................. 58
ZONEGRAN .............................. 24
zonisamide ................................ 24
ZONTIVITY ................................ 36
ZORBTIVE ................................. 75
ZORTRESS ............................... 90
ZORVOLEX ............................... 13
ZOSTAVAX ............................... 91
ZOSYN ...................................... 21
zovia 1/35e (28) ......................... 86
ZOVIRAX ................................... 39
ZTLIDO ...................................... 16
Z-TUSS AC ............................. 106
ZUBSOLV .................................. 16
ZULRESSO ............................... 26
zumandimine ............................. 86
ZUPLENZ .................................. 27
ZYCLARA .................................. 58
ZYCLARA PUMP ....................... 58
ZYDELIG ................................... 34
ZYFLO ..................................... 109
ZYKADIA ................................... 34
ZYLET ..................................... 104
ZYLOPRIM ................................ 28
ZYMAXID ................................. 102
ZYPITAMAG .............................. 49
ZYPREXA .................................. 37
ZYPREXA RELPREVV .............. 37
ZYPREXA ZYDIS ...................... 37
ZYTIGA...................................... 34
ZYVOX ...................................... 21