[note: instructions for plans are provided within ... · formulary list of covered drugs | 2018...

formulary list of covered drugs | 2018

COMPREHENSIVE

This formulary was updated on 09/01/2018. For more recent information or other questions, please contact SelectHealth Member Services toll-free, at 855-442-9900 or, for TTY users, 711, during the following dates and times:

October 1 to February 14: Weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday 8:00 a.m. to 8:00 p.m.

February 15 to September 30:Weekdays 7:00 a.m. to 8:00 p.m., Saturday 9:00 a.m. to 2:00 p.m., closed Sunday.

Outside these hours of operation, please leave a message. Your call will be returned within one business day, or visit selecthealthadvantage.org.

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SelectHealth Advantage (HMO)

2018 Comprehensive Formulary

List of Covered Drugs

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

DRUGS WE COVER IN THIS PLAN

SelectHealth is an HMO plan sponsor with a Medicare contract. Enrollment in SelectHealth Advantage

depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply. Benefits, copayments and coinsurance may change

on January 1 of each year. The formulary may change at any time. You will receive notice when necessary.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-855-442-9900 (TTY: 711)

H1994_8601841R_Comp_Form_v25 Accepted HPMS Approved Formulary File Submission ID 18036 Version 25

Fair Treatment Notice

SelectHealth complies with Federal civil rights laws. We do not discriminate or treat you differently because of your race, color, national origin, age, disability, or sex.

We provide free:

> Aid to those with disabilities to help them communicate with us, such as sign language interpreters and written information in other formats (large print, audio, electronic formats, other).

> Language help for those whose first language is not English, such as Interpreters and member materials written in other languages.

For help, call SelectHealth Member Services at 1-800-538-5038 or SelectHealth Advantage Member Services at 1-855-442-9900 (TTY Users: 711).

If you feel you’ve been treated unfairly, call SelectHealth 504/Civil Rights Coordinator at 1-844-208-9012 (TTY Users: 711) or the Compliance Hotline at 1-800-442-4845 (TTY Users: 711). You may also call the Office for Civil Rights at 1-800-368-1019 (TTY Users: 1-800-537-7697).

Language Access Services

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 SelectHealth。

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© 2017 SelectHealth. All rights reserved. 203540 03/17

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SelectHealth: 1-800-538-5038 SelectHealth Advantage: 1-855-442-9900

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Note to existing members: This formulary has changed since last year. Please review this document to

make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means SelectHealth. When it refers to

“plan” or “our plan,” it means SelectHealth Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of September

01, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

What is the SelectHealth Advantage Formulary?

A formulary is a list of covered drugs selected by SelectHealth Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a

quality treatment program. SelectHealth Advantage will generally cover the drugs listed in our formulary

as long as the drug is medically necessary, the prescription is filled at a SelectHealth Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions,

please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except

when a new, less expensive generic drug becomes available or when new adverse information

about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It

will remain available at the same cost-sharing for those members taking it for the remainder of the

coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases

in which you can save additional money or we can ensure your safety.

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If we remove drugs from our formulary, add prior authorization, quantity limits and/or step

therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the

member requests a refill of the drug, at which time the member will receive a 60-day supply of the

drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from

our formulary and provide notice to members who take the drug. The enclosed formulary is

current as of September 01, 2018. To get updated information about the drugs covered by SelectHealth Advantage, please contact us. Our contact information appears on the front and back

cover pages.

In the event of non-maintenance changes to the formulary throughout the plan year, SelectHealth may make changes via errata sheets mailed to you. Additionally, you may visit our Website for a

link to the errata sheet.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 10. The drugs in this formulary are grouped into categories

depending on the type of medical conditions that they are used to treat. For example, drugs used to

treat a heart condition are listed under the category, Cardiovascular Drugs/Hypotensive Agents. If

you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that

begins on page 137. The Index provides an alphabetical list of all of the drugs included in this

document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage

information. Turn to the page listed in the Index and find the name of your drug in the first column

of the list.

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What are generic drugs? SelectHealth Advantage covers both brand name drugs and generic drugs. A generic drug is approved

by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost

less than brand name drugs

Are there any restrictions on my coverage?

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

limits may include:

Prior Authorization: SelectHealth Advantage requires you or your physician to get prior

authorization for certain drugs. This means that you will need to get approval from SelectHealth

Advantage before you fill your prescriptions. If you don’t get approval, SelectHealth Advantage may not cover the drug.

Quantity Limits: For certain drugs, SelectHealth Advantage limits the amount of the drug that

SelectHealth Advantage will cover. For example, SelectHealth Advantage provides 60 tablets per prescription for Valsartan. This may be in addition to a standard one-month or three-month

supply.

Step Therapy: In some cases, SelectHealth Advantage 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, SelectHealth Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SelectHealth Advantage

will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 10. You can also get more information about the restrictions applied to specific covered

drugs by visiting our website. We have posted on line documents that explain our prior authorization

and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask SelectHealth Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an

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exception to the SelectHealth Advantage formulary?” on page 5 for information about how to request

an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member

Services and ask if your drug is covered.

If you learn that SelectHealth Advantage does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by SelectHealth Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a

similar drug that is covered by SelectHealth Advantage.

You can ask SelectHealth Advantage to make an exception and cover your drug. See below for

information about how to request an exception.

How do I request an exception to the SelectHealth Advantage Formulary?

You can ask SelectHealth Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will

be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain

drugs, SelectHealth Advantage limits the amount of the drug that we will cover. If your drug has

a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, SelectHealth Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions

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would not be as effective in treating your condition and/or would cause you to have adverse medical

effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization

restriction exception. When you request a formulary, tiering or utilization restriction exception

you should submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting

statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is

granted, we must give you a decision no later than 24 hours after we get a supporting statement from

your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or

requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,

you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your

doctor to decide if you should switch to an appropriate drug that we cover or request a formulary

exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a

member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will

cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to

a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we

have provided you with a 98-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the

first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your

ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you

pursue a formulary exception.

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If you experience a change in your level of care, such as a move from a hospital to a home setting, and

you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30 days (or 31 days if you are a long-term care resident) when

you use a network pharmacy. During this period, you should use the plan's exception process if you

wish to have continued coverage of the drug after the temporary supply is finished.

For more information For more detailed information about your SelectHealth Advantage prescription drug coverage, please

review your Evidence of Coverage and other plan materials.

If you have questions about SelectHealth Advantage, please contact us. Our contact information, along

with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at

1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call

1-877-486-2048. Or, visit http://www.medicare.gov.

SelectHealth Advantage Formulary The formulary that begins on page 10 provides coverage information about the drugs covered by

SelectHealth Advantage. If you have trouble finding your drug in the list, turn to the Index that begins

on page 137.

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

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

The second column of the chart lists the Drug Tier. The Drug Tier column lets you know the type of

copayment or coinsurance you will be responsible for at the pharmacy. The third column of the chart list the Requirements/Limits and tells you if SelectHealth Advantage has any special requirements for coverage of your drug.

Please refer to your Evidence of Coverage for more information regarding how much you will pay for your

prescription drugs. The table below tells you the copayment/coinsurance amount for drugs in each tier:

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Annual Prescription Drug Deductible This is the amount you will be required to pay for your prescriptions this year before your copay or coinsurance applies. The amounts shown in the table below apply to Tier 3, Tier 4, and Tier 5 and both

retail and mail order prescription drugs. They do not apply to the Wasatch Enhanced and Treasure

Valley Enhanced benefit plans for which there is no annual prescription drug deductible.

Service Area / Plan Name

Annual

Prescription

Drug Tier 3,4,5

Deductible Wasatch Essential, Southwest and Central Utah, and Cache Valley $250.00

Treasure Valley Essential and Magic Valley $150.00

Wasatch Enhanced and Treasure Valley Enhanced $0

Initial Coverage Period Copayment/Coinsurance Levels

For Service Areas: Wasatch Essential, Southwest and Central Utah, Treasure Valley Essential, Magic Valley, and Cache Valley

Drug Tier Retail Network Pharmacy

(Up to a 30-day supply)

Mail Order

30 Day 60 Day 90 Day

Tier 1: Preferred Generic $3.00 $3.00 $6.00 $6.00

Tier 2: Generic $15.00 $15.00 $30.00 $30.00

Tier 3: Preferred Brand $45.00 after deductible $45.00 after

deductible $90.00 after deductible

$135.00

after

deductible

Tier 4: Non-Preferred Brand $95.00 after deductible $95.00 after deductible

$190.00 after

deductible

$285.00 after

deductible

Service Areas: Wasatch Essential, Southwest and Central Utah, and Cache Valley Tier 5: Specialty

28% coinsurance after deductible 28% coinsurance after deductible

Not Available

Not Available

Service Areas: Treasure Valley Essential and Magic Valley Tier 5: Specialty

30% coinsurance after deductible 30% coinsurance

after deductible

Not

Available

Not

Available

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For Service Areas: Wasatch Enhanced and Treasure Valley Enhanced

Drug Tier Retail Network Pharmacy

(Up to a 30-day supply)

Mail Order

30 Day 60 Day 90 Day

Tier 1: Preferred Generic $0.00 $0.00 $0.00 $0.00

Tier 2: Generic $10.00 $10.00 $20.00 $20.00

Tier 3: Preferred Brand $45.00 $45.00 $90.00 $135.00

Tier 4: Non-Preferred Brand $95.00 $95.00 $190.00 $285.00

Tier 5: Specialty 33% coinsurance 33% coinsurance Not

Available

Not

Available

The information in the Requirements/Limits column tells you if SelectHealth Advantage has any

special requirements for coverage of your drug. PA – We require you or your physician to get prior authorization for certain drugs before you fill

your prescriptions.

QL – We limit the amount of the drug covered in a specific time period. ST – We require you to first try certain drugs to treat your medical condition before we will cover

another drug for that condition.

LA – This drug requires special handling or has special dispensing requirements. This prescription

may be available only at certain pharmacies. For more information, consult your Provider and Pharmacy Directory or call Member Services toll-free at

855-442-9900. TTY users should call 711.

NM – This drug is not available through our mail order pharmacy. HI – This prescription drug is covered under our medical benefit. For more information, call

Member Services at 855-442-9900, Weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday 8:00

a.m. to 8:00 p.m. TTY users should call 711. BvsD – This drug may be covered under the Part B or Part D Medicare benefit.

PA – Prior Authorization QL – Quantity Limit ST – Step Therapy

LA – Limited Access NM – Non-Maintenance HI – Home Infusion BvsD – This drug may be covered under Part B or Part D.

You can find information on what the symbols and abbreviations on this table mean by going to page 9.

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Drug Tier Requirements

/Limits

ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA TABLET 200MG 3 NM

BILTRICIDE TABLET 600MG

4 NM

ivermectin tablet 3mg 2 NM

ANTIBACTERIALS amikacin sulfate solution 500 mg/2 ml

2 BvsD; HI; NM

amoxicillin capsule 250mg 2 NM

amoxicillin capsule 500mg 2 NM

amoxicillin for suspension 125 mg/5 ml

2 NM


2 NM


2 NM


2 NM

amoxicillin tablet 500mg 2 NM

amoxicillin tablet 875mg 2 NM

amoxicillin tablet chewable 125mg

2 NM

amoxicillin tablet chewable 250mg

2 NM

amoxicillin-clavulanate pot er tablet er 12hr 1,000-62.5mg

2 NM

amoxicillin-clavulanate potass for suspension 200 mg-28.5 mg/5 ml

2 NM


2 NM


/Limits

amoxicillin-clavulanate potass for suspension 400 mg-57 mg/5 ml

2 NM


2 NM

amoxicillin-clavulanate potass tablet 250-125mg

2 NM


2 NM


2 NM

amoxicillin-clavulanate potass tablet chewable 200-28.5mg

2 NM

amoxicillin-clavulanate potass tablet chewable 400-57mg

2 NM

ampicillin sodium for solution 1 gram

2 BvsD; HI; NM

ampicillin sodium for solution 10 gram

2 BvsD; HI; NM

ampicillin sodium for solution 125mg

2 BvsD; HI; NM

ampicillin trihydrate capsule 500mg

2 NM

ampicillin-sulbactam for solution 1.5 gram

2 BvsD; HI; NM

ampicillin-sulbactam for solution 15 gram

2 BvsD; HI; NM

ampicillin-sulbactam for solution 3 gram

2 BvsD; HI; NM

azithromycin for solution 500mg

2 BvsD; HI; NM

azithromycin for suspension 100 mg/5 ml

2 NM

azithromycin for suspension 200 mg/5 ml

2 NM




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/Limits

azithromycin packet 1 gram 2 NM

azithromycin tablet 250mg QL 30 each per 30 day(s)

2 QL; NM

azithromycin tablet 500mg 2 NM

azithromycin tablet 600mg 2 NM

aztreonam for solution 1 gram 2 BvsD; HI; NMBAXDELA FOR SOLUTION 300MG

QL 28 each per 14 day(s) 4 QL; PA; HI; NM

BAXDELA TABLET 450MG

QL 28 each per 14 day(s) 4 QL; PA; NM

BETHKIS 300 MG/4 ML AMPULE QL 280 milliliter(s) per 30 day(s)

5 QL; PA; NM

BICILLIN C-R SUSPENSION 1,200,000 UNIT/2 ML (600,000/600,000)

4 NM

BICILLIN C-R SUSPENSION 1,200,000 UNIT/2 ML (900,000/300,000)

4 NM

BICILLIN L-A SUSPENSION 1.2 MILLION UNIT/2 ML

4 NM

BICILLIN L-A SUSPENSION 2.4 MILLION UNIT/4 ML

4 NM

BICILLIN L-A SUSPENSION 600,000 UNIT/ML

4 NM

CAYSTON FOR SOLUTION 75 MG/ML QL 280 milliliter(s) per 30 day(s)

5 QL; PA; NM

cefaclor capsule 250mg 2 NM

cefaclor capsule 500mg 2 NM


/Limits

cefaclor er tablet er 12hr 500mg

2 NM

cefadroxil capsule 500mg 2 NMcefadroxil for suspension 250 mg/5 ml

2 NM

cefadroxil for suspension 500 mg/5 ml

2 NM

cefadroxil tablet 1 gram 2 NMcefazolin sodium for solution 1 gram

2 BvsD; HI; NM

cefazolin sodium for solution 10 gram

2 BvsD; HI; NM

cefazolin sodium for solution 500mg

2 BvsD; HI; NM

cefdinir capsule 300mg 2 NMcefdinir for suspension 125 mg/5 ml

2 NM

cefdinir for suspension 250 mg/5 ml

2 NM

cefepime hcl for solution 1 gram

2 BvsD; HI; NM

cefepime hcl for solution 2 gram

2 BvsD; HI; NM

cefixime for suspension 100 mg/5 ml

2 NM

cefixime for suspension 200 mg/5 ml

2 NM

cefotaxime sodium for solution 1 gram

2 BvsD; HI; NM

cefotaxime sodium for solution 2 gram

2 BvsD; HI; NM

cefotaxime sodium for solution 500mg

2 BvsD; HI; NM




12


/Limits

cefoxitin for solution 1 gram 2 BvsD; HI; NMcefoxitin for solution 10 gram 2 BvsD; HI; NMcefoxitin for solution 2 gram 2 BvsD; HI; NMcefpodoxime proxetil for suspension 100 mg/5 ml

2 NM

cefpodoxime proxetil for suspension 50 mg/5 ml

2 NM

cefpodoxime proxetil tablet 100mg

2 NM

cefpodoxime proxetil tablet 200mg

2 NM

cefprozil for suspension 125 mg/5 ml

2 NM

cefprozil for suspension 250 mg/5 ml

2 NM

cefprozil tablet 250mg 2 NM

cefprozil tablet 500mg 2 NM

ceftazidime for solution 1 gram

2 BvsD; HI; NM


2 BvsD; HI; NM


2 BvsD; HI; NM

ceftriaxone for solution 1 gram 2 BvsD; HI; NMceftriaxone for solution 10 gram

2 BvsD; HI; NM

ceftriaxone for solution 2 gram 2 BvsD; HI; NMceftriaxone for solution 250mg 2 BvsD; HI; NMceftriaxone for solution 500mg 2 BvsD; HI; NMcefuroxime sodium for solution 1.5 gram

2 BvsD; HI; NM

cefuroxime sodium for solution 7.5 gram

2 BvsD; HI; NM


/Limits

cefuroxime sodium for solution 750mg

2 BvsD; HI; NM

cefuroxime tablet 250mg 2 NMcefuroxime tablet 500mg 2 NMcephalexin capsule 250mg 2 NMcephalexin capsule 500mg 2 NMcephalexin for suspension 125 mg/5 ml

2 NM

cephalexin for suspension 250 mg/5 ml

2 NM

cephalexin tablet 250mg 2 NMcephalexin tablet 500mg 2 NMchloramphenicol sod succinate for solution 1 gram

2 BvsD; HI; NM

ciprofloxacin er tablet er 24hr 1,000mg

2 NM

ciprofloxacin er tablet er 24hr 500mg

2 NM

ciprofloxacin for suspension 250 mg/5 ml

2 NM

ciprofloxacin for suspension 500 mg/5 ml

2 NM

ciprofloxacin hcl tablet 100mg 2 NMciprofloxacin hcl tablet 250mg 2 NMciprofloxacin hcl tablet 500mg 2 NMciprofloxacin hcl tablet 750mg 2 NMciprofloxacin-d5w solution 200 mg/100 ml

2 BvsD; HI; NM

clarithromycin er tablet er 24hr 500mg

2 NM

clarithromycin for suspension 125 mg/5 ml

2 NM

clarithromycin for suspension 250 mg/5 ml

2 NM




13


/Limits

clarithromycin tablet 250mg 2 NM

clarithromycin tablet 500mg 2 NM

clindamycin hcl capsule 150mg

2 NM

clindamycin hcl capsule 300mg

2 NM

clindamycin hcl capsule 75mg 2 NM

clindamycin palmitate hcl for solution 75 mg/5 ml

2 NM

clindamycin phosphate solution 150 mg/ml

2 BvsD; HI; NM

clindamycin phosphate-d5w solution 300 mg/50 ml

2 BvsD; HI; NM


2 BvsD; HI; NM


2 BvsD; HI; NM

colistimethate for solution 150mg

2 BvsD; HI; NM

DALVANCE FOR SOLUTION 500MG

4 PA; HI; NM

daptomycin for solution 500mg QL 150 each per 30 day(s)

2 QL; PA; HI; NM

DARAPRIM TABLET 25MG 4 NM

dicloxacillin sodium capsule 250mg

1 NM

dicloxacillin sodium capsule 500mg

1 NM

DIFICID TABLET 200MG


doxy 100 for solution 100mg 4 BvsD; HI; NMdoxycycline hyclate capsule 100mg

2 NM

doxycycline hyclate capsule 50mg

2 NM

doxycycline hyclate tablet 100mg

2 NM


/Limits


2 NM

doxycycline hyclate tablet 20mg QL 60 each per 30 day(s)

2 QL; NM


2 NM

doxycycline hyclate tablet dr 100mg QL 60 each per 30 day(s)

2 QL; NM

doxycycline hyclate tablet dr 150mg

2 NM

doxycycline hyclate tablet dr 75mg QL 60 each per 30 day(s)

2 QL; NM

doxycycline monohydrate capsule 100mg

2 NM


2 NM


2 NM

doxycycline monohydrate for suspension 25 mg/5 ml

2 NM

doxycycline monohydrate tablet 100mg

2 NM

doxycycline monohydrate tablet 150mg QL 60 each per 30 day(s)

2 QL; NM


2 NM


2 NM

ERY-TAB TABLET DR 250MG

4 NM




14


/Limits


4 NM


4 NM

ERYPED 200 FOR SUSPENSION 200 MG/5 ML

4 NM

ERYPED 400 FOR SUSPENSION 400 MG/5 ML

4 NM

ERYTHROCIN LACTOBIONATE FOR SOLUTION 500MG

2 BvsD; HI; NM

ERYTHROCIN STEARATE TABLET 250MG

3 NM

erythromycin capsule dr part 250mg

2 NM

erythromycin ethylsuccinate for suspension 200 mg/5 ml

2 NM

erythromycin tablet 250mg 2 NM

erythromycin tablet 500mg 2 NM

gentamicin sulfate in ns solution 100 mg/100 ml

2 BvsD; HI; NM


2 BvsD; NM


2 BvsD; HI; NM


2 BvsD; HI; NM

gentamicin sulfate solution 40 mg/ml

2 BvsD; NM

imipenem-cilastatin sodium for solution 250mg

4 PA; HI; NM

imipenem-cilastatin sodium for solution 500mg

4 PA; HI; NM

INVANZ FOR SOLUTION 1 GRAM

4 BvsD; HI; NM


/Limits

lansoprazol-amoxicil-clarithro QL 122 each per 14 day(s)

2 QL; NM

levofloxacin solution 25 mg/ml 2 BvsD; HI; NMlevofloxacin tablet 250mg 2 NMlevofloxacin tablet 500mg 2 NMlevofloxacin tablet 750mg 2 NMlevofloxacin-d5w solution 500 mg/100 ml

2 BvsD; HI; NM

levofloxacin-d5w solution 750 mg/150 ml

2 BvsD; HI; NM

linezolid for suspension 100 mg/5 ml

2 NM

linezolid tablet 600mg QL 60 each per 30 day(s)

2 QL; NM

linezolid-d5w solution 600 mg/300 ml

2 BvsD; HI; NM

meropenem for solution 1 gram

2 BvsD; HI; NM

meropenem for solution 500mg

2 BvsD; HI; NM

metronidazole solution 500 mg/100 ml

2 BvsD; HI; NM

minocycline hcl capsule 100mg

2 NM

minocycline hcl capsule 50mg 2 NMminocycline hcl capsule 75mg 2 NMminocycline hcl er tablet er 24hr 135mg QL 30 each per 30 day(s)

2 QL; NM

minocycline hcl er tablet er 24hr 45mg QL 30 each per 30 day(s)

2 QL; NM

minocycline hcl er tablet er 24hr 90mg QL 30 each per 30 day(s)

2 QL; NM

moxifloxacin hcl tablet 400mg 2 NM




15


/Limits

nafcillin sodium for solution 1 gram

2 PA; HI; NM

nafcillin sodium for solution 10 gram

2 PA; HI; NM

neomycin sulfate tablet 500mg 2 NM

ofloxacin tablet 300mg 2 NM

ofloxacin tablet 400mg 2 NM

ORACEA CAPSULE DR 40MG

QL 30 each per 30 day(s) 4 QL; NM

ORBACTIV FOR SOLUTION 400MG


paromomycin sulfate capsule 250mg

2 NM

penicillin g potassium for solution 20 million unit

2 BvsD; HI; NM

penicillin g procaine suspension 1.2 million unit/2 ml

2 BvsD; NM

penicillin g sodium for solution 5 million unit

2 BvsD; HI; NM

penicillin gk-iso-osm dextrose solution 2 million unit/50 ml

2 BvsD; HI; NM

penicillin gk-iso-osm dextrose solution 3 million unit/50 ml

2 BvsD; HI; NM

penicillin v potassium for solution 125 mg/5 ml

2 NM

penicillin v potassium for solution 250 mg/5 ml

2 NM

penicillin v potassium tablet 250mg

2 NM

penicillin v potassium tablet 500mg

2 NM

PENTAM 300 FOR SOLUTION 300MG

4 BvsD; HI; NM


/Limits

piperacillin-tazobactam for solution 2.25 gram

2 BvsD; HI; NM


2 BvsD; HI; NM


2 BvsD; HI; NM


2 BvsD; HI; NM

PYLERA CAPSULE 140-125-125MG

4 NM

rifabutin capsule 150mg 2 NMrifampin capsule 150mg 2 NMrifampin capsule 300mg 2 NMrifampin for solution 600mg 2 HI; NMRIFATER TABLET 120-50-300MG

4 NM

SIVEXTRO FOR SOLUTION 200MG

QL 6 each per 30 day(s)4 QL; PA; HI; NM

SIVEXTRO TABLET 200MG

QL 6 each per 30 day(s)4 QL; PA; NM

streptomycin sulfate for solution 1 gram

2 BvsD; NM

sulfadiazine tablet 500mg 2 NMsulfamethoxazole-trimethoprim solution 80 mg-16 mg/ml

2 BvsD; HI; NM

sulfamethoxazole-trimethoprim suspension 200 mg-40 mg/5 ml

2 NM

sulfamethoxazole-trimethoprim tablet 400-80mg

2 NM

sulfamethoxazole-trimethoprim tablet 800-160mg

2 NM




16


/Limits

SUPRAX CAPSULE 400MG


SUPRAX FOR SUSPENSION 100 MG/5 ML

4 NM


4 NM


4 NM

SUPRAX TABLET CHEWABLE 100MG


SUPRAX TABLET CHEWABLE 200MG


SYNAGIS SOLUTION 100 MG/ML

4 PA

SYNAGIS SOLUTION 50 MG/0.5 ML

4 PA

SYNERCID FOR SOLUTION 500MG


TEFLARO FOR SOLUTION 400MG

4 PA; HI; NM

TEFLARO FOR SOLUTION 600MG

4 PA; HI; NM

tigecycline for solution 50mg QL 28 each per 14 day(s)

2 QL; PA; HI; NM

TOBI PODHALER CAPSULE 28MG


tobramycin 300 mg/5 ml ampule

5 PA; NM

tobramycin sulfate solution 10 mg/ml

2 BvsD; HI; NM

tobramycin sulfate solution 40 mg/ml

2 BvsD; HI; NM


/Limits

vancomycin hcl capsule 125mg QL 120 each per 30 day(s)

2 QL; NM

vancomycin hcl capsule 250mg QL 120 each per 30 day(s)

2 QL; NM

vancomycin hcl for solution 1 gram

2 BvsD; NM

vancomycin hcl for solution 10 gram

2 BvsD; HI; NM

vancomycin hcl for solution 500mg

2 BvsD; NM

XIFAXAN TABLET 200MG


XIFAXAN TABLET 550MG


ZOSYN SOLUTION 2.25 GRAM/50 ML

4 BvsD; HI; NM

ANTIFUNGAL (SYSTEMIC) AMBISOME FOR SUSPENSION 50MG

4 PA; HI; NM

amphotericin b for solution 50mg

2 PA; HI; NM

caspofungin acetate for solution 50mg

5 PA; HI; NM

caspofungin acetate for solution 70mg

5 PA; HI; NM

CRESEMBA CAPSULE 186MG


CRESEMBA FOR SOLUTION 372MG


fluconazole for suspension 10 mg/ml

2 NM




17


/Limits

fluconazole for suspension 40 mg/ml

2 NM

fluconazole tablet 100mg 1 NM




fluconazole-nacl solution 200 mg/100 ml

2 BvsD; HI; NM

fluconazole-nacl solution 400 mg/200 ml

2 BvsD; HI; NM

flucytosine capsule 250mg 2 NM

flucytosine capsule 500mg 2 NM

griseofulvin suspension 125 mg/5 ml

2 NM

griseofulvin tablet 500mg 2 NM

griseofulvin ultramicrosize tablet 125mg

2 NM

griseofulvin ultramicrosize tablet 250mg

2 NM

itraconazole capsule 100mg QL 126 each per 30 day(s)

2 QL; NM

ketoconazole tablet 200mg 2 NM

NOXAFIL SUSPENSION 200 MG/5 ML (40 MG/ML)

4 PA; NM

NOXAFIL TABLET DR 100MG


nystatin suspension 100,000 unit/ml

2 NM

nystatin tablet 500,000 unit 2 NM

SPORANOX SOLUTION 10 MG/ML

4 NM

terbinafine hcl tablet 250mg QL 90 each per 30 day(s)

1 QL; NM


/Limits

voriconazole for solution 200mg

2 PA; HI; NM

voriconazole for suspension 200 mg/5 ml (40 mg/ml) QL 450 milliliter(s) per 30 day(s)

2 QL; PA; NM

voriconazole tablet 200mg QL 90 each per 30 day(s)

2 QL; PA; NM

voriconazole tablet 50mg QL 360 each per 30 day(s)

2 QL; PA; NM

ANTIMYCOBACTERIALS CAPASTAT SULFATE FOR SOLUTION 1 GRAM

4 PA; HI; NM

dapsone tablet 100mg 2 NMdapsone tablet 25mg 2 NMethambutol hcl tablet 100mg 2 NMethambutol hcl tablet 400mg 2 NMisoniazid solution 100 mg/ml 2 NMisoniazid tablet 100mg 2 NMisoniazid tablet 300mg 2 NMPASER PACKET 4 GRAM 4 NMPRIFTIN TABLET 150MG


pyrazinamide tablet 500mg 2 NMSIRTURO TABLET 100MG


TRECATOR TABLET 250MG

4 NM

ANTIPROTOZOALSALINIA FOR SUSPENSION 100 MG/5 ML QL 240 milliliter(s) per 10 day(s)

4 QL; NM

ALINIA TABLET 500MG





18


/Limits

atovaquone suspension 750 mg/5 ml

2 NM

atovaquone-proguanil hcl tablet 250-100mg

2 NM

atovaquone-proguanil hcl tablet 62.5 mg-25 mg (pediatric)

2 NM

benznidazole tablet 100mg QL 120 each per 365 day(s)

4 QL; NM

benznidazole tablet 12.5mg QL 720 each per 365 day(s)

4 QL; NM

chloroquine phosphate tablet 250mg

2 NM

chloroquine phosphate tablet 500mg

2 NM

COARTEM TABLET 20-120MG


hydroxychloroquine sulfate tablet 200mg

1 NM

mefloquine hcl tablet 250mg QL 5 each per 30 day(s)

2 QL; NM

metronidazole capsule 375mg 2 NM

metronidazole tablet 250mg 1 NM

metronidazole tablet 500mg 1 NM

NEBUPENT FOR SOLUTION 300MG

4 BvsD; NM

primaquine tablet 26.3mg 2 NM

quinidine sulfate tablet 200mg 2 NM

quinidine sulfate tablet 300mg 2 NM

quinine sulfate capsule 324mg 2 NM

tinidazole tablet 250mg 2 NM

tinidazole tablet 500mg 2 NM

ANTIVIRALS (SYSTEMIC) abacavir solution 20 mg/ml 2 NM


/Limits

abacavir tablet 300mg QL 180 each per 30 day(s)

2 QL; NM

abacavir-lamivudine tablet 600-300mg QL 30 each per 30 day(s)

2 QL; NM

abacavir-lamivudine-zidovudine tablet 300-150-300mg QL 60 each per 30 day(s)

2 QL; NM

acyclovir capsule 200mg 1 NMacyclovir sodium solution 50 mg/ml

2 BvsD; HI; NM

acyclovir suspension 200 mg/5 ml

2 NM

acyclovir tablet 400mg 1 NMacyclovir tablet 800mg 1 NMadefovir dipivoxil tablet 10mg 2 NMamantadine capsule 100mg QL 120 each per 30 day(s)

2 QL; NM

amantadine syrup 50 mg/5 ml QL 1200 milliliter(s) per 30 day(s)

2 QL; NM

amantadine tablet 100mg QL 120 each per 30 day(s)

2 QL; NM

APTIVUS CAPSULE 250MG


APTIVUS SOLUTION 100 MG/ML QL 300 milliliter(s) per 30 day(s)

3 QL; NM

ATAZANAVIR SULFATE 150 MG CAP QL 60 per 30 day(s)

2 QL; NM


2 QL; NM




19


/Limits


2 QL; NM

ATRIPLA TABLET 600-200-300MG


BARACLUDE SOLUTION 0.05 MG/ML

4 NM

BIKTARVY TABLET 50-200-25MG


cidofovir solution 75 mg/ml 2 BvsD; HI; NMCOMPLERA TABLET 200-25-300MG

3 NM

CRIXIVAN CAPSULE 200MG


CRIXIVAN CAPSULE 400MG


DESCOVY TABLET 200-25MG


didanosine capsule dr 200mg QL 30 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM

EDURANT TABLET 25MG


EFAVIRENZ 200 MG CAPSULE QL 60 per 30 day(s)

2 QL; NM


/Limits

EFAVIRENZ 50 MG CAPSULE QL 90 per 30 day(s)

2 QL; NM

efavirenz tablet 600mg QL 60 each per 30 day(s)

2 QL; NM

EMTRIVA CAPSULE 200MG


EMTRIVA SOLUTION 10 MG/ML QL 720 milliliter(s) per 30 day(s)

3 QL; NM

entecavir tablet 0.5mg QL 30 each per 30 day(s)

2 QL; NM

entecavir tablet 1mg QL 30 each per 30 day(s)

2 QL; NM

EPCLUSA TABLET 400-100MG

QL 30 each per 30 day(s) 5 QL; PA

EPIVIR HBV SOLUTION 25 MG/5 ML (5 MG/ML) QL 1800 milliliter(s) per 30 day(s)

3 QL; NM

EVOTAZ TABLET 300-150MG


famciclovir tablet 125mg 2 NMfamciclovir tablet 250mg 2 NMfamciclovir tablet 500mg 2 NMfosamprenavir calcium tablet 700mg

2 NM

FUZEON FOR SOLUTION 90MG





20


/Limits

ganciclovir sodium for solution 500mg

2 BvsD; HI; NM

GENVOYA TABLET 150-150-200-10MG


HARVONI TABLET 90-400MG


INTELENCE TABLET 100MG

3 NM

INTELENCE TABLET 200MG

3 NM

INTELENCE TABLET 25MG 3 NM

INTRON A FOR SOLUTION 10 MILLION UNIT (1 ML) QL 60 each per 21 day(s)

5 QL; NM


5 QL


5 QL

INTRON A SOLUTION 10 MILLION UNIT/ML QL 24 milliliter(s) per 21 day(s)

5 QL

INTRON A SOLUTION 6 MILLION UNIT/ML QL 20 milliliter(s) per 14 day(s)

5 QL; NM


/Limits

INVIRASE CAPSULE 200MG


INVIRASE TABLET 500MG


ISENTRESS HD TABLET 600MG


ISENTRESS PACKET 100MG


ISENTRESS TABLET 400MG


ISENTRESS TABLET CHEWABLE 100MG


ISENTRESS TABLET CHEWABLE 25MG


JULUCA TABLET 50-25MG


KALETRA TABLET 100-25MG


KALETRA TABLET 200-50MG


lamivudine hbv tablet 100mg QL 60 each per 30 day(s)

2 QL; NM

lamivudine solution 10 mg/ml 2 NMlamivudine tablet 150mg QL 60 each per 30 day(s)

2 QL; NM




21


/Limits

lamivudine tablet 300mg QL 60 each per 30 day(s)

2 QL; NM

lamivudine-zidovudine tablet 150-300mg

2 NM

LEXIVA SUSPENSION 50 MG/ML

3 NM

lopinavir-ritonavir solution 400 mg-100 mg/5 ml QL 390 milliliter(s) per 30 day(s)

2 QL; NM

MAVYRET TABLET 100-40MG


nevirapine er tablet er 24hr 100mg

2 NM

nevirapine er tablet er 24hr 400mg QL 30 each per 30 day(s)

2 QL; NM

nevirapine tablet 200mg QL 60 each per 30 day(s)

2 QL; NM

NORVIR CAPSULE 100MG


NORVIR PACKET 100MG


NORVIR SOLUTION 80 MG/ML QL 450 milliliter(s) per 30 day(s)

3 QL; NM

ODEFSEY TABLET 200-25-25MG


oseltamivir phosphate capsule 30mg QL 84 each per 180 day(s)

2 QL; NM


/Limits


2 QL; NM


2 QL; NM

oseltamivir phosphate for suspension 6 mg/ml QL 525 milliliter(s) per 180 day(s)

2 QL; NM

PEGASYS PROCLICK SOLUTION 135 MCG/0.5 ML QL 4 milliliter(s) per 30 day(s)

5 QL; PA

PEGASYS PROCLICK SOLUTION 180 MCG/0.5 ML QL 4 milliliter(s) per 30 day(s)

5 QL; PA

PEGASYS SOLUTION 180 MCG/0.5 ML QL 4 milliliter(s) per 30 day(s)

5 QL; PA; NM

PEGASYS SOLUTION 180 MCG/ML QL 4 milliliter(s) per 28 day(s)

5 QL; PA; NM

PREVYMIS SOLUTION 240 MG/12 ML QL 2400 milliliter(s) per 365 day(s)

4 QL; PA

PREVYMIS SOLUTION 480 MG/24 ML QL 2400 milliliter(s) per 365 day(s)

4 QL; PA




22


/Limits

PREVYMIS TABLET 240MG


PREVYMIS TABLET 480MG


PREZCOBIX TABLET 800-150MG


PREZISTA SUSPENSION 100 MG/ML QL 360 milliliter(s) per 30 day(s)

3 QL; NM

PREZISTA TABLET 150MGQL 90 each per 30 day(s)

3 QL; NM


3 QL; NM

PREZISTA TABLET 75MG



3 QL; NM

PURIXAN SUSPENSION 20 MG/ML QL 300 milliliter(s) per 30 day(s)

5 QL; PA; NM

REBETOL SOLUTION 40 MG/ML

4 NM

RELENZA AERO POW BR ACT 5MG



/Limits

RESCRIPTOR TABLET 100MG


RESCRIPTOR TABLET 200MG


RETROVIR SOLUTION 10 MG/ML

3 NM

REYATAZ PACKET 50MG


ribasphere capsule 200mg QL 210 each per 30 day(s)

2 QL; NM

ribasphere tablet 200mg QL 210 each per 30 day(s)

2 QL; NM

ribavirin capsule 200mg QL 210 each per 30 day(s)

2 QL; NM

ribavirin tablet 200mg QL 210 each per 30 day(s)

2 QL; NM

ritonavir tablet 100mg QL 450 each per 30 day(s)

2 QL; NM

SELZENTRY SOLUTION 20 MG/ML QL 1800 milliliter(s) per 30 day(s)

3 QL; NM

SELZENTRY TABLET 150MG











23


/Limits

stavudine capsule 15mg QL 60 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM

STRIBILD TABLET 150-150-200-300MG


SYMFI LO TABLET 400-300-300MG


SYMFI TABLET 600-300-300MG


TENOFOVIR DISOP FUM 300 MG TB

QL 30 per 30 day(s) 2 QL; NM

TIVICAY TABLET 10MG


TIVICAY TABLET 25MG


TIVICAY TABLET 50MG


TRIUMEQ TABLET 600-50-300MG


TRUVADA TABLET 100-150MG





/Limits





TYBOST TABLET 150MG


valacyclovir tablet 1,000mg QL 30 each per 30 day(s)

2 QL; NM

valacyclovir tablet 500mg QL 60 each per 30 day(s)

2 QL; NM

VALCHLOR GEL 0.016 %

QL 120 gram(s) per 30 day(s) 5 QL; PA

valganciclovir hcl for solution 50 mg/ml

2 NM

valganciclovir hcl tablet 450mg QL 90 each per 30 day(s)

2 QL; NM

VIDEX EC CAPSULE DR 125MG

QL 30 each per 30 day(s) 3 QL

VIDEX FOR SOLUTION 10 MG/ML (FINAL CONCENTRATION)

3 NM

VIRACEPT TABLET 250MG 3 NMVIRACEPT TABLET 625MG 3 NMVIRAMUNE SUSPENSION 50 MG/5 ML QL 1200 milliliter(s) per 30 day(s)

4 QL; NM




24


/Limits

VIREAD POWDER 40 MG/SCOOP (40 MG/GRAM)

3 NM

VIREAD TABLET 150MG


VIREAD TABLET 200MG


VIREAD TABLET 250MG


VOSEVI TABLET 400-100-100MG


ZEPATIER TABLET 50-100MG


ZERIT FOR SOLUTION 1 MG/ML QL 2400 milliliter(s) per 30 day(s)

4 QL; NM

zidovudine capsule 100mg 2 NM

zidovudine syrup 10 mg/ml 2 NM

zidovudine tablet 300mg 2 NM

URINARY ANTI-INFECTIVES methenamine hippurate tablet 1 gram

2 NM

MONUROL PACKET 3 GRAM

4 NM

nitrofurantoin capsule 100mg 2 NM



nitrofurantoin mono-macro capsule 100mg

2 NM

nitrofurantoin suspension 25 mg/5 ml

2 NM

trimethoprim tablet 100mg 2 NM

ANTIHISTAMINE DRUGS


/Limits

FIRST GENERATION ANTIHISTAMINEScyproheptadine hcl syrup 2 mg/5 ml QL 4500 milliliter(s) per 30 day(s)

2 QL

cyproheptadine hcl tablet 4mg QL 450 each per 30 day(s)

2 QL

meclizine hcl tablet 12.5mg 1

meclizine hcl tablet 25mg 1

prochlorperazine edisylate solution 10 mg/2 ml (5 mg/ml)

2

prochlorperazine maleate tablet 10mg

2

prochlorperazine maleate tablet 5mg

2

prochlorperazine suppository 25mg

2

promethazine hcl solution 25 mg/ml

2 BvsD

promethazine hcl solution 50 mg/ml

2 BvsD

promethazine hcl tablet 12.5mg

2

promethazine hcl tablet 25mg 2

promethazine hcl tablet 50mg 2

SECOND GENERATION ANTIHISTAMINEScetirizine hcl solution 1 mg/ml QL 300 milliliter(s) per 30 day(s)

2 QL

CLARINEX SYRUP 2.5 MG/5 ML (0.5 MG/ML)

4

CLARINEX-D 12 HOUR TABLET ER 12HR 2.5-120MG

4




25


/Limits

desloratadine tablet 5mg QL 30 each per 30 day(s)

2 QL

desloratadine tablet disperse 2.5mg QL 30 each per 30 day(s)

2 QL

desloratadine tablet disperse 5mg QL 30 each per 30 day(s)

2 QL

levocetirizine dihydrochloride solution 2.5 mg/5 ml

2

levocetirizine dihydrochloride tablet 5mg QL 30 each per 30 day(s)

2 QL

SEMPREX-D CAPSULE 60-8MG

3

ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE FOR SUSPENSION 100MG

5 PA

AFINITOR DISPERZ TABLET SOLUBLE 2MG






AFINITOR TABLET 10MG


AFINITOR TABLET 2.5MG


AFINITOR TABLET 5MG



/Limits

AFINITOR TABLET 7.5MG


ALECENSA CAPSULE 150MG


ALIMTA FOR SOLUTION 100MG

5 PA

ALIMTA FOR SOLUTION 500MG

5 PA

ALIQOPA FOR SOLUTION 60MG

QL 3 each per 28 day(s)5 QL; PA

ALUNBRIG TAB THER PACK 90 MG (7)-180 MG (23) QL 30 each per 180 day(s)

5 QL; PA

ALUNBRIG TABLET 180MG






anastrozole tablet 1mg QL 30 each per 30 day(s)

2 QL

ARRANON SOLUTION 250 MG/50 ML

5 BvsD

AVASTIN SOLUTION 25 MG/ML

5 PA

azacitidine for suspension 100mg

5 BvsD

BAVENCIO SOLUTION 200 MG/10 ML (20 MG/ML)

5 PA




26


/Limits

BELEODAQ FOR SOLUTION 500MG

5 PA

bexarotene capsule 75mg 5 PA

bicalutamide tablet 50mg QL 30 each per 30 day(s)

2 QL

BICNU FOR SOLUTION 100MG

4 BvsD

bleomycin sulfate for solution 30 unit

2 BvsD

bortezomib for solution 3.5mg 5 PA

BOSULIF TABLET 100MG






busulfan solution 60 mg/10 ml 5 BvsDCABOMETYX TABLET 20MG


CABOMETYX TABLET 40MG


CABOMETYX TABLET 60MG


CALQUENCE CAPSULE 100MG


CAPRELSA TABLET 100MG


CAPRELSA TABLET 300MG



/Limits

carboplatin solution 10 mg/ml 2 BvsDcisplatin solution 1 mg/ml 2 BvsDcladribine solution 10 mg/10 ml

5 BvsD

clofarabine solution 20 mg/20 ml

5 BvsD

COMETRIQ KIT 100 MG/DAY (80 MG X 1-20 MG X 1/DAY)

5 PA

COMETRIQ KIT 140 MG/DAY (80 MG X 1-20 MG X 3/DAY)

5 PA

COMETRIQ KIT 60 MG/DAY (20 MG X 3/DAY)

5 PA

COTELLIC TABLET 20MG

QL 63 each per 28 day(s) 5 QL; PA; LA

cyclophosphamide capsule 25mg

2 BvsD

cyclophosphamide capsule 50mg

2 BvsD

CYRAMZA SOLUTION 100 MG/10 ML (10 MG/ML)

5 PA

CYRAMZA SOLUTION 500 MG/50 ML (10 MG/ML)

5 PA

cytarabine solution 2 gram/20 ml (100 mg/ml)

2 BvsD

cytarabine solution 20 mg/ml 2 BvsDDARZALEX SOLUTION 100 MG/5 ML (20 MG/ML)

5 PA; LA

daunorubicin hcl injectable 5 mg/ml

2 BvsD

decitabine for solution 50mg 5 BvsDdocetaxel concentrate 80 mg/4 ml (20 mg/ml)

5 BvsD

docetaxel solution 160 mg/16 ml (10 mg/ml)

5 BvsD




27


/Limits

doxorubicin hcl liposome injectable 2 mg/ml

2 BvsD

doxorubicin hcl solution 50 mg/25 ml

2 BvsD

DROXIA CAPSULE 200MG 4



ELIGARD KIT 22.5 MG (3 MONTH)

4 BvsD

ELIGARD KIT 30 MG (4 MONTH)

4 BvsD

ELIGARD KIT 7.5 MG (1 MONTH)

4 BvsD

EMCYT CAPSULE 140MG


EMPLICITI FOR SOLUTION 300MG

5 PA

EMPLICITI FOR SOLUTION 400MG

5 PA

epirubicin hcl solution 200 mg/100 ml

2 BvsD

ERBITUX SOLUTION 100 MG/50 ML

5 PA

ERIVEDGE CAPSULE 150MG


ERLEADA TABLET 60MG


ERWINAZE FOR SOLUTION 10,000 UNIT

5 PA

etoposide solution 20 mg/ml 2 BvsDexemestane tablet 25mg QL 60 each per 30 day(s)

2 QL

FARESTON TABLET 60MGQL 30 each per 30 day(s)

5 QL; PA


/Limits

FARYDAK CAPSULE 10MG






FASLODEX SOLUTION 250 MG/5 ML

5 BvsD

FIRMAGON FOR SOLUTION 120MG

5 BvsD

FIRMAGON FOR SOLUTION 80MG

4 BvsD

fludarabine phosphate for solution 50mg

2 BvsD

fluorouracil solution 2 % 2

fluorouracil solution 5 % 2

fluorouracil solution 5 gram/100 ml

2 BvsD

flutamide capsule 125mg 2

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

5 PA

GILOTRIF TABLET 20MG






GLEOSTINE CAPSULE 100MG

5 PA


4 PA


4 PA




28


/Limits

HALAVEN SOLUTION 1 MG/2 ML (0.5 MG/ML)

5 PA

HERCEPTIN FOR SOLUTION 150MG

5 BvsD

HERCEPTIN FOR SOLUTION 440MG

5 BvsD

HEXALEN CAPSULE 50MG 3

hydroxyurea capsule 500mg 2

IBRANCE CAPSULE 100MG






ICLUSIG TABLET 15MG


ICLUSIG TABLET 45MG


idarubicin hcl solution 1 mg/ml

5 BvsD

IDHIFA TABLET 100MG


IDHIFA TABLET 50MG


ifosfamide for solution 1 gram 2 BvsDimatinib mesylate tablet 100mg QL 90 each per 30 day(s)

2 QL

imatinib mesylate tablet 400mg QL 60 each per 30 day(s)

2 QL

IMBRUVICA CAPSULE 140MG



/Limits

IMBRUVICA CAPSULE 70MG


IMBRUVICA TABLET 140MG








IMFINZI SOLUTION 120 MG/2.4 ML (50 MG/ML)

5 PA

IMFINZI SOLUTION 500 MG/10 ML (50 MG/ML)

5 PA

INLYTA TABLET 1MG


INLYTA TABLET 5MG


IRESSA TABLET 250MG


irinotecan hcl solution 100 mg/5 ml

2 BvsD

ISTODAX FOR SOLUTION 10 MG/2 ML

5 PA

JAKAFI TABLET 10MG


JAKAFI TABLET 15MG


JAKAFI TABLET 20MG





29


/Limits

JAKAFI TABLET 25MG


JAKAFI TABLET 5MG


JEVTANA SOLUTION 10 MG/ML (FIRST DILUTION)

5 PA

KADCYLA FOR SOLUTION 100MG

5 PA

KADCYLA FOR SOLUTION 160MG

5 PA

KEYTRUDA SOLUTION 100 MG/4 ML (25 MG/ML) QL 16 milliliter(s) per 28 day(s)

5 QL; PA

KISQALI FEMARA CO-PACK TAB THER PACK 200 MG/DAY (200 MG X 1)-2.5 MG

QL 70 each per 28 day(s)

5 QL; PA



5 QL; PA



5 QL; PA

KISQALI TABLET 200 MG/DAY (200 MG X 1) QL 63 each per 28 day(s)

5 QL; PA


/Limits


5 QL; PA


5 QL; PA

KYPROLIS FOR SOLUTION 30MG


KYPROLIS FOR SOLUTION 60MG


LARTRUVO SOLUTION 190 MG/19 ML (10 MG/ML) QL 300 milliliter(s) per 21 day(s)

5 QL; PA

LARTRUVO SOLUTION 500 MG/50 ML (10 MG/ML) QL 300 milliliter(s) per 21 day(s)

5 QL; PA

LENVIMA CAP THER PACK 10 MG/DAY (10 MG X 1/DAY) QL 90 each per 30 day(s)

5 QL; PA

LENVIMA CAP THER PACK 14 MG/DAY (10 MG X 1 AND 4 MG X 1) QL 90 each per 30 day(s)

5 QL; PA

LENVIMA CAP THER PACK 18 MG/DAY (10 MG X 1 AND 4 MG X 2) QL 90 each per 30 day(s)

5 QL; PA

LENVIMA CAP THER PACK 20 MG/DAY (10 MG X 2) QL 90 each per 30 day(s)

5 QL; PA




30


/Limits

LENVIMA CAP THER PACK 24 MG PER DAY (10 MG X 2 AND 4 MG X 1) QL 90 each per 30 day(s)

5 QL; PA

LENVIMA CAP THER PACK 8 MG/DAY (4 MG X 2) QL 90 each per 30 day(s)

5 QL; PA

letrozole tablet 2.5mg QL 30 each per 30 day(s)

2 QL

LEUKERAN TABLET 2MG 3

leuprolide acetate kit 1 mg/0.2 ml

2

levoleucovorin calcium for solution 50mg

5 PA

levoleucovorin calcium solution 10 mg/ml

5 PA

LONSURF TABLET 15-6.14MG


LONSURF TABLET 20-8.19MG


LUPRON DEPOT KIT 11.25MG

5 BvsD

LUPRON DEPOT KIT 22.5 MG (3 MONTH)

5 BvsD

LUPRON DEPOT KIT 3.75MG

5 BvsD

LUPRON DEPOT KIT 30 MG (4 MONTH)

5 BvsD

LUPRON DEPOT KIT 45 MG (6 MONTH)

5 BvsD

LUPRON DEPOT KIT 7.5 MG (1 MONTH)

5 BvsD


/Limits

LUPRON DEPOT-PED KIT 11.25MG

5 BvsD

LUPRON DEPOT-PED KIT 15MG

5 BvsD

LUPRON DEPOT-PED KIT 30 MG (PEDIATRIC 3 MONTH)

5 BvsD

LYNPARZA CAPSULE 50MG


LYNPARZA TABLET 100MG


LYNPARZA TABLET 150MG


LYSODREN TABLET 500MG

3

MATULANE CAPSULE 50MG

3

megestrol acetate suspension 400 mg/10 ml (40 mg/ml)

2

megestrol acetate suspension 625 mg/5 ml

2

megestrol acetate tablet 20mg 2

megestrol acetate tablet 40mg 2

MEKINIST TABLET 0.5MG


MEKINIST TABLET 2MG


melphalan hcl for solution 50mg

5 BvsD

mercaptopurine tablet 50mg 2




31


/Limits

methotrexate sodium solution 25 mg/ml

2 BvsD

methotrexate solution 25 mg/ml

2 BvsD

methotrexate tablet 2.5mg 2

mitoxantrone hcl concentrate 2 mg/ml

2 BvsD

MUSTARGEN FOR SOLUTION 10MG

4 BvsD

MYLOTARG FOR SOLUTION 4.5 MG (1 MG/ML INITIAL CONCENTRATION)

5 PA

NERLYNX TABLET 40MG


NEXAVAR TABLET 200MG


nilutamide tablet 150mg 2

NINLARO CAPSULE 2.3MG


NINLARO CAPSULE 3MG


NINLARO CAPSULE 4MG


ODOMZO CAPSULE 200MG


OPDIVO SOLUTION 100 MG/10 ML QL 48 milliliter(s) per 28 day(s)

5 QL; PA

OPDIVO SOLUTION 40 MG/4 ML QL 48 milliliter(s) per 28 day(s)

5 QL; PA

oxaliplatin for solution 100mg 2 BvsD


/Limits

oxaliplatin solution 100 mg/20 ml (5 mg/ml)

2 BvsD

paclitaxel concentrate 6 mg/ml 2 BvsDPOMALYST CAPSULE 1MG


POMALYST CAPSULE 2MG






PROLEUKIN FOR SOLUTION 22 MILLION UNIT

5 PA

RASUVO SOLN AUTO-INJ 10 MG/0.2 ML QL 0.8 milliliter(s) per 28 day(s)

3 QL; ST

RASUVO SOLN AUTO-INJ 12.5 MG/0.25 ML QL 1 milliliter(s) per 28 day(s)

3 QL; ST


3 QL; ST

RASUVO SOLN AUTO-INJ 17.5 MG/0.35 ML QL 1.4 milliliter(s) per 28 day(s)

3 QL; ST


3 QL; ST


3 QL; ST




32


/Limits

RASUVO SOLN AUTO-INJ 25 MG/0.5 ML QL 2 milliliter(s) per 28 day(s)

3 QL; ST


3 QL; ST


3 QL; ST

REVLIMID CAPSULE 10MG




REVLIMID CAPSULE 2.5MG








RITUXAN SOLUTION 10 MG/ML

5 BvsD

RUBRACA TABLET 200MG





/Limits



RYDAPT CAPSULE 25MG


SOLTAMOX SOLUTION 10 MG/5 ML

4

SPRYCEL TABLET 100MG


SPRYCEL TABLET 140MG


SPRYCEL TABLET 20MG


SPRYCEL TABLET 50MG


SPRYCEL TABLET 70MG


SPRYCEL TABLET 80MG


STIVARGA TABLET 40MG


SUTENT CAPSULE 12.5MG


SUTENT CAPSULE 25MG


SUTENT CAPSULE 37.5MG


SUTENT CAPSULE 50MG


SYLATRON KIT 200 MCG 5 PASYLATRON KIT 300 MCG 5 PASYLATRON KIT 600 MCG 5 PA




33


/Limits

SYNRIBO FOR SOLUTION 3.5MG

5 PA

TABLOID TABLET 40MG 4

TAFINLAR CAPSULE 50MG


TAFINLAR CAPSULE 75MG


TAGRISSO TABLET 40MG


TAGRISSO TABLET 80MG


tamoxifen citrate tablet 10mg QL 30 each per 30 day(s)

2 QL

tamoxifen citrate tablet 20mg QL 60 each per 30 day(s)

2 QL

TARCEVA TABLET 100MGQL 30 each per 30 day(s)

5 QL; PA

TARCEVA TABLET 150MGQL 30 each per 30 day(s)

5 QL; PA

TARCEVA TABLET 25MG


TASIGNA CAPSULE 150MG






TECENTRIQ SOLUTION 1,200 MG/20 ML (60 MG/ML) QL 20 milliliter(s) per 21 day(s)

5 QL; PA


/Limits

thiotepa for solution 15mg 5 PAtoposar solution 20 mg/ml 4 BvsDtopotecan hcl for solution 4mg 5 BvsDTORISEL SOLUTION 30 MG/3 ML (10 MG/ML) (FIRST DILUTION)

5 PA

TREANDA FOR SOLUTION 100MG

5 PA

TREANDA FOR SOLUTION 25MG

5 PA

TRELSTAR FOR SUSPENSION 11.25 MG/2 ML

5 BvsD


5 BvsD


5 BvsD

tretinoin capsule 10mg QL 360 each per 30 day(s)

2 QL

TREXALL TABLET 10MG 3



TREXALL TABLET 7.5MG 3

TRISENOX SOLUTION 12 MG/6 ML (2 MG/ML)

5 BvsD

TYKERB TABLET 250MG


VECTIBIX SOLUTION 100 MG/5 ML (20 MG/ML)

5 PA

VELCADE FOR SOLUTION 3.5MG

5 PA

VENCLEXTA STARTING PACK TAB THER PACK 10 MG (14)-50 MG (7)-100 MG (21) QL 120 each per 30 day(s)

5 QL; PA




34


/Limits

VENCLEXTA TABLET 100MG






VERZENIO TABLET 100MG








vinblastine sulfate solution 1 mg/ml

2 BvsD

vincasar pfs solution 1 mg/ml 4 BvsDvincristine sulfate solution 1 mg/ml

2 BvsD

vinorelbine tartrate solution 50 mg/5 ml

2 BvsD

VOTRIENT TABLET 200MG 5 PA

VYXEOS FOR SUSPENSION 44-100MG


XALKORI CAPSULE 200MG



/Limits

XALKORI CAPSULE 250MG


XTANDI CAPSULE 40MG


YERVOY SOLUTION 50 MG/10 ML (5 MG/ML)

5 PA

YONDELIS FOR SOLUTION 1MG


YONSA TABLET 125MG


ZANOSAR FOR SOLUTION 1 GRAM

4 BvsD

ZEJULA CAPSULE 100MG


ZELBORAF TABLET 240MG


ZOLINZA CAPSULE 100MG


ZYDELIG TABLET 100MG


ZYDELIG TABLET 150MG


ZYKADIA CAPSULE 150MG


ZYTIGA TABLET 250MG


ZYTIGA TABLET 500MG





35


/Limits

AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ATROVENT HFA AEROSOL SOLN 17 MCG/ACTUATION

4

BEVESPI AEROSPHERE AEROSOL 9 MCG-4.8 MCG

QL 10.7 gram(s) per 30 day(s) 3 QL

COMBIVENT RESPIMAT AEROSOL SOLN 20 MCG-100 MCG/ACTUATION

QL 8 gram(s) per 30 day(s)

3 QL

dicyclomine hcl capsule 10mg QL 240 each per 30 day(s)

1 QL

dicyclomine hcl solution 10 mg/5 ml QL 2400 milliliter(s) per 30 day(s)

2 QL

dicyclomine hcl tablet 20mg QL 240 each per 30 day(s)

1 QL

glycopyrrolate tablet 1mg 2

glycopyrrolate tablet 2mg 2

ipratropium bromide solution 0.2 mg/ml (0.02 %)

2 BvsD

ipratropium-albuterol solution 0.5 mg-3 mg (2.5 mg base)/3 ml

2 BvsD

methscopolamine bromide tablet 2.5mg

2

methscopolamine bromide tablet 5mg

2

scopolamine patch 72hr 1 mg/3 day QL 10 each per 28 day(s)

2 QL


/Limits

SEEBRI NEOHALER CAPSULE 15.6 MCG

QL 60 each per 30 day(s) 4 QL; ST

SPIRIVA CAPSULE 18 MCG


SPIRIVA RESPIMAT AEROSOL SOLN 1.25 MCG/ACTUATION


3 QL

SPIRIVA RESPIMAT AEROSOL SOLN 2.5 MCG/ACTUATION


3 QL

STIOLTO RESPIMAT AEROSOL SOLN 2.5 MCG-2.5 MCG/ACTUATION


3 QL

TUDORZA PRESSAIR AERO POW BR ACT 400 MCG/ACTUATION


3 QL

TUDORZA PRESSAIR AERO POW BR ACT 400 MCG/ACTUATION


3 QL

UTIBRON NEOHALER CAPSULE 27.5 MCG-15.6 MCG


4 QL; ST

AUTONOMIC DRUGS, MISCELLANEOUSCHANTIX TABLET 0.5 MG (11)-1 MG (42) QL 106 each per 365 day(s)

3 QL

CHANTIX TABLET 0.5MG





36


/Limits

CHANTIX TABLET 1MG


NICOTROL INHALER 10MG


NICOTROL NS SOLUTION 10 MG/ML QL 360 milliliter(s) per 30 day(s)

4 QL

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) bethanechol chloride tablet 10mg

2

bethanechol chloride tablet 25mg

2


2


2

cevimeline hcl capsule 30mg 2

donepezil hcl odt tablet disperse 10mg

2

donepezil hcl odt tablet disperse 5mg

2

donepezil hcl tablet 10mg 1



galantamine er capsule er 24hr 16mg

2


2


2

galantamine hbr tablet 12mg 2



/Limits


galantamine hydrobromide solution 4 mg/ml

2

pilocarpine hcl tablet 5mg 2

pilocarpine hcl tablet 7.5mg 2

pyridostigmine bromide er tablet er 180mg

2

pyridostigmine bromide tablet 60mg

2

rivastigmine capsule 1.5mg 2

rivastigmine capsule 3mg 2

rivastigmine capsule 4.5mg 2

rivastigmine capsule 6mg 2

rivastigmine patch 24hr 13.3 mg/24 hour

2


2


2

SKELETAL MUSCLE RELAXANTSbaclofen tablet 10mg 1

baclofen tablet 20mg 1

baclofen tablet 5mg 1

cyclobenzaprine hcl tablet 10mg

2

cyclobenzaprine hcl tablet 5mg 2

cyclobenzaprine hcl tablet 7.5mg

2

dantrolene sodium capsule 100mg

2


2


2

tizanidine hcl capsule 2mg QL 540 each per 30 day(s)

2 QL; ST




37


/Limits


2 QL; ST


2 QL; ST

tizanidine hcl tablet 2mg QL 540 each per 30 day(s)

2 QL

tizanidine hcl tablet 4mg QL 270 each per 30 day(s)

2 QL

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS acebutolol hcl capsule 200mg QL 120 each per 30 day(s)

2 QL

acebutolol hcl capsule 400mg QL 90 each per 30 day(s)

2 QL

alfuzosin hcl er tablet er 24hr 10mg QL 30 each per 30 day(s)

2 QL

atenolol tablet 100mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL

atenolol-chlorthalidone tablet 100-25mg

2

atenolol-chlorthalidone tablet 50-25mg

2

betaxolol hcl tablet 20mg 2

bisoprolol fumarate tablet 10mg

1

bisoprolol fumarate tablet 5mg 1

bisoprolol-hydrochlorothiazide tablet 10-6.25mg

2

bisoprolol-hydrochlorothiazide tablet 2.5-6.25mg

2


/Limits

bisoprolol-hydrochlorothiazide tablet 5-6.25mg

2

BYSTOLIC TABLET 10MG


BYSTOLIC TABLET 2.5MG


BYSTOLIC TABLET 20MG


BYSTOLIC TABLET 5MG


CARDURA XL TABLET ER 24HR 4MG

4

CARDURA XL TABLET ER 24HR 8MG

4

carvedilol er capsule er 24hr 10mg

2


2


2


2

carvedilol tablet 12.5mg 1

carvedilol tablet 25mg 1



CORLANOR TABLET 5MG


CORLANOR TABLET 7.5MG


dihydroergotamine mesylate solution 0.5 mg/pump actuation (4 mg/ml)

2 PA




38


/Limits

dihydroergotamine mesylate solution 1 mg/ml QL 30 milliliter(s) per 30 day(s)

2 QL; BvsD

diphenhydramine hcl solution 50 mg/ml

2

doxazosin mesylate tablet 1mg 2




dutasteride-tamsulosin capsule 0.5-0.4mg

2

ergoloid mesylates tablet 1mg QL 90 each per 30 day(s)

2 QL

labetalol hcl tablet 100mg 2



metoprolol succinate tablet er 24hr 100mg

2


2


2


2

metoprolol tartrate tablet 100mg

1


1


1

metoprolol-hydrochlorothiazide tablet 100-25mg

2


2


/Limits


2

nadolol tablet 20mg 2



nadolol-bendroflumethiazide tablet 40-5mg

2

nadolol-bendroflumethiazide tablet 80-5mg

2

phenoxybenzamine hcl capsule 10mg QL 3600 each per 30 day(s)

5 QL; PA

pindolol tablet 10mg 2

pindolol tablet 5mg 2

prazosin hcl capsule 1mg 2



propranolol hcl er capsule er 24hr 120mg

1


1


1


1

propranolol hcl solution 20 mg/5 ml (4 mg/ml)

2

propranolol hcl solution 40 mg/5 ml (8 mg/ml)

2

propranolol hcl tablet 10mg 1







39


/Limits


propranolol-hydrochlorothiazide tablet 40 mg-25mg

2

propranolol-hydrochlorothiazide tablet 80 mg-25mg

2

RAPAFLO CAPSULE 4MG 4

RAPAFLO CAPSULE 8MG 4

sorine tablet 120mg 2




sotalol af tablet 120mg 1

sotalol tablet 160mg 1



tamsulosin hcl capsule 0.4mg 1

terazosin hcl capsule 10mg 1




timolol maleate tablet 10mg 2



SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN SOLUTION 1 MG/ML (1 ML)

2 BvsD

ADVAIR DISKUS AERO POW BR ACT 100 MCG-50 MCG/DOSE QL 60 each per 30 day(s)

4 QL; ST


4 QL; ST


/Limits


4 QL; ST

ADVAIR HFA AEROSOL 115 MCG-21 MCG/ACTUATION


4 QL; ST



4 QL; ST


QL 12 gram(s) per 30 day(s) 4 QL; ST

albuterol 5 mg/ml solution 2 BvsDalbuterol sul 0.63 mg/3 ml sol 2 BvsDalbuterol sul 1.25 mg/3 ml sol 2 BvsDalbuterol sul 2.5 mg/3 ml soln 2 BvsDalbuterol sulfate syrup 2 mg/5 ml

2

albuterol sulfate tablet 2mg 2

albuterol sulfate tablet 4mg 2

albuterol sulfate tablet er 12hr 4mg

2

albuterol sulfate tablet er 12hr 8mg

2

ANORO ELLIPTA AERO POW BR ACT 62.5 MCG-25 MCG/ACTUATION


4 QL; ST

ARCAPTA NEOHALER CAPSULE 75 MCG

4




40


/Limits

ARNUITY ELLIPTA AERO POW BR ACT 100 MCG






BREO ELLIPTA AERO POW BR ACT 100 MCG-25 MCG/DOSE QL 60 each per 30 day(s)

4 QL; ST

BREO ELLIPTA AERO POW BR ACT 200 MCG-25 MCG/DOSE QL 60 each per 30 day(s)

4 QL; ST

BROVANA 15 MCG/2 ML SOLUTION

QL 120 milliliter(s) per 30 day(s)

4 QL; BvsD

epinephrine soln auto-inj 0.15 mg/0.15 ml

2


2


2

fluticasone-salmeterol aero pow br act 113 mcg-14 mcg/actuation QL 1 each per 30 day(s)

2 QL


2 QL


/Limits


2 QL

INCRUSE ELLIPTA AERO POW BR ACT 62.5 MCG/ACTUATION


4 QL; ST

levalbuterol 0.31 mg/3 ml sol 2 BvsDlevalbuterol 0.63 mg/3 ml sol 2 BvsDlevalbuterol 1.25 mg/3 ml sol 2 BvsDlevalbuterol conc 1.25 mg/0.5 2 BvsDlevalbuterol tartrate hfa aerosol 45 mcg/actuation

2

metaproterenol sulfate syrup 10 mg/5 ml

2

metaproterenol sulfate tablet 10mg

2

metaproterenol sulfate tablet 20mg

2

midodrine hcl tablet 10mg 2

midodrine hcl tablet 2.5mg 2

midodrine hcl tablet 5mg 2

NORTHERA CAPSULE 100MG






PERFOROMIST 20 MCG/2 ML SOLN

4 BvsD




41


/Limits

PROAIR HFA AEROSOL SOLN 90 MCG


PROAIR RESPICLICK AERO POW BR ACT 90 MCG


4 QL; ST

PROVENTIL HFA AEROSOL SOLN 90 MCG

QL 13.4 gram(s) per 30 day(s) 4 QL; ST

SEREVENT DISKUS AERO POW BR ACT 50 MCG


STRIVERDI RESPIMAT AEROSOL SOLN 2.5 MCG/ACTUATION


3 QL

SYMBICORT AEROSOL 160 MCG-4.5 MCG/ACTUATION


SYMBICORT AEROSOL 80 MCG-4.5 MCG/ACTUATION


terbutaline sulfate tablet 2.5mg 2

terbutaline sulfate tablet 5mg 2

TRELEGY ELLIPTA AERO POW BR ACT 100 MCG-62.5 MCG-25 MCG/ACTUATION


4 QL; ST

VENTOLIN HFA AEROSOL SOLN 90 MCG

QL 36 gram(s) per 30 day(s) 3 QL


/Limits

BLOOD FORMATION,COAGULATION AND THROMBOSISANTITHROMBOTIC AGENTS anagrelide hcl capsule 0.5mg 2

anagrelide hcl capsule 1mg 2

aspirin-dipyridamole er capsule er 12hr 25-200mg QL 60 each per 30 day(s)

2 QL

BEVYXXA CAPSULE 40MG


BEVYXXA CAPSULE 80MG


BRILINTA TABLET 60MG


BRILINTA TABLET 90MG


cilostazol tablet 100mg 2

cilostazol tablet 50mg 2

clopidogrel tablet 75mg QL 30 each per 30 day(s)

1 QL

COUMADIN TABLET 10MG 4


COUMADIN TABLET 2.5MG

4






COUMADIN TABLET 7.5MG

4

ELIQUIS TABLET 2.5MG





42


/Limits

ELIQUIS TABLET 5 MG STARTER PACK


ELIQUIS TABLET 5MG


enoxaparin sodium solution 100 mg/ml

2

enoxaparin sodium solution 120 mg/0.8 ml

2

enoxaparin sodium solution 150 mg/ml

2


2

enoxaparin sodium solution 300 mg/3 ml

2


2


2


2

fondaparinux sodium solution 10 mg/0.8 ml QL 30 milliliter(s) per 30 day(s)

2 QL

fondaparinux sodium solution 2.5 mg/0.5 ml QL 30 milliliter(s) per 30 day(s)

2 QL

fondaparinux sodium solution 5 mg/0.4 ml QL 30 milliliter(s) per 30 day(s)

2 QL


/Limits

fondaparinux sodium solution 7.5 mg/0.6 ml QL 30 milliliter(s) per 30 day(s)

2 QL

heparin sodium solution 1,000 unit/ml

2


2


2


2

jantoven tablet 10mg 2


jantoven tablet 2.5mg 2






jantoven tablet 7.5mg 2

PRADAXA CAPSULE 110MG






prasugrel hcl tablet 10mg QL 30 each per 30 day(s)

2 QL

prasugrel hcl tablet 5mg QL 30 each per 30 day(s)

2 QL

SAVAYSA TABLET 15MG





43


/Limits

SAVAYSA TABLET 30MG


SAVAYSA TABLET 60MG


warfarin sodium tablet 10mg 1


warfarin sodium tablet 2.5mg 1






warfarin sodium tablet 7.5mg 1

XARELTO TAB THER PACK 15 MG (42)- 20 MG (9) QL 102 each per 365 day(s)

3 QL

XARELTO TABLET 10MG


XARELTO TABLET 15MG


XARELTO TABLET 20MG


ZONTIVITY TABLET 2.08MG


HEMATOPOIETIC AGENTS ARANESP SOLN PREF SYR 10 MCG/0.4 ML

3 BvsD

ARANESP SOLN PREF SYR 100 MCG/0.5 ML

5 BvsD


5 BvsD


5 BvsD


/Limits


3 BvsD


5 BvsD


3 BvsD

ARANESP SOLN PREF SYR 500 MCG/ML

5 BvsD


3 BvsD

ARANESP SOLUTION 100 MCG/ML

5 BvsD


5 BvsD


3 BvsD


5 BvsD


3 BvsD


3 BvsD

DOPTELET TABLET 20MG


DOPTELET TABLET 20MG


EPOGEN SOLUTION 2,000 UNIT/ML

4 BvsD

EPOGEN SOLUTION 20,000 UNIT/2 ML

4 BvsD


5 BvsD


4 BvsD




44


/Limits


4 BvsD

GRANIX SOLN PREF SYR 300 MCG/0.5 ML

5 BvsD

GRANIX SOLN PREF SYR 480 MCG/0.8 ML

5 BvsD

LEUKINE FOR SOLUTION 250 MCG

5 BvsD

MIRCERA SOLN PREF SYR 100 MCG/0.3 ML

4 BvsD


4 BvsD


4 BvsD

MOZOBIL SOLUTION 24 MG/1.2 ML (20 MG/ML)

5

NEULASTA SOLN PREF SYR 6 MG/0.6 ML

5 BvsD

NEUPOGEN SOLN PREF SYR 300 MCG/0.5 ML

5 BvsD

NEUPOGEN SOLN PREF SYR 480 MCG/0.8 ML

5 BvsD

NEUPOGEN SOLUTION 300 MCG/ML

5 BvsD

NEUPOGEN SOLUTION 480 MCG/1.6 ML

5 BvsD

PROMACTA TABLET 12.5MG


PROMACTA TABLET 25MG







/Limits

ZARXIO SOLN PREF SYR 300 MCG/0.5 ML

5 PA

ZARXIO SOLN PREF SYR 480 MCG/0.8 ML

5 PA

HEMORRHEOLOGIC AGENTS pentoxifylline tablet er 400mg 2

BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERSCOAGULANTStranexamic acid solution 1,000 mg/10 ml (100 mg/ml)

2 BvsD

tranexamic acid tablet 650mg QL 30 each per 30 day(s)

2 QL

CARDIOVASCULAR DRUGS ANTILIPEMIC AGENTS ALTOPREV TABLET ER 24HR 20MG


ALTOPREV TABLET ER 24HR 40MG


ALTOPREV TABLET ER 24HR 60MG


amlodipine-atorvastatin tablet 10-10mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST




45


/Limits


2 QL; ST

amlodipine-atorvastatin tablet 2.5-10mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST

atorvastatin calcium tablet 10mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL


/Limits


1 QL

cholestyramine light powder 4 gram


cholestyramine packet 4 gram


colesevelam hcl tablet 625mg QL 180 each per 30 day(s)

2 QL

colestipol hcl packet 5 gram


colestipol hcl tablet 1 gram


ezetimibe tablet 10mg QL 30 each per 30 day(s)

2 QL

ezetimibe-simvastatin tablet 10-10mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST

fenofibrate capsule 130mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL




46


/Limits


2 QL


2 QL


2 QL

fenofibrate tablet 120mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

fenofibric acid capsule dr 135mg QL 30 each per 30 day(s)

2 QL

fenofibric acid capsule dr 45mg QL 30 each per 30 day(s)

2 QL

fenofibric acid tablet 105mg QL 30 each per 30 day(s)

2 QL

fenofibric acid tablet 35mg QL 30 each per 30 day(s)

2 QL

fluvastatin er tablet er 24hr 80mg QL 30 each per 30 day(s)

2 QL

fluvastatin sodium capsule 20mg QL 120 each per 30 day(s)

1 QL


/Limits

fluvastatin sodium capsule 40mg QL 60 each per 30 day(s)

1 QL

gemfibrozil tablet 600mg QL 60 each per 30 day(s)

2 QL

JUXTAPID CAPSULE 10MG












KYNAMRO SOLN PREF SYR 200 MG/ML QL 4 milliliter(s) per 28 day(s)

5 QL; PA

LIVALO TABLET 1MG


LIVALO TABLET 2MG


LIVALO TABLET 4MG


lovastatin tablet 10mg QL 60 each per 30 day(s)

1 QL




47


/Limits


1 QL


1 QL

niacin er tablet er 1,000mg QL 120 each per 30 day(s)

2 QL

niacin er tablet er 500mg QL 120 each per 30 day(s)

2 QL

niacin er tablet er 750mg QL 120 each per 30 day(s)

2 QL

omega-3 acid ethyl esters capsule 1 gram


PRALUENT PEN SOLN PEN-INJ 150 MG/ML

5 PA

PRALUENT PEN SOLN PEN-INJ 75 MG/ML

5 PA

pravastatin sodium tablet 10mg QL 90 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

prevalite packet 4 gram


REPATHA PUSHTRONEX SOLN CARTRIDGE 420 MG/3.5 ML QL 3.5 milliliter(s) per 30 day(s)

5 QL; PA


/Limits

REPATHA SURECLICK SOLN AUTO-INJ 140 MG/ML QL 3 milliliter(s) per 30 day(s)

5 QL; PA

REPATHA SYRINGE SOLN PREF SYR 140 MG/ML QL 3 milliliter(s) per 30 day(s)

5 QL; PA

rosuvastatin calcium tablet 10mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

simvastatin tablet 10mg QL 90 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


1 QL

VASCEPA CAPSULE 0.5 GRAM


VASCEPA CAPSULE 1 GRAM





48


/Limits

WELCHOL PACKET 3.75 GRAM


WELCHOL TABLET 625MG


CARDIAC DRUGS amiodarone hcl tablet 100mg 1

amiodarone hcl tablet 200mg 1

amiodarone hcl tablet 400mg 1

digitek tablet 125 mcg 2

digitek tablet 250 mcg 2

digoxin solution 50 mcg/ml 2

digoxin tablet 125 mcg 2

digoxin tablet 250 mcg 2

dofetilide capsule 125 mcg 2



flecainide acetate tablet 100mg

2

flecainide acetate tablet 150mg

2

flecainide acetate tablet 50mg 2

mexiletine hcl capsule 150mg 2



MULTAQ TABLET 400MG 3

NORPACE CR CAPSULE ER 12HR 100MG

4

NORPACE CR CAPSULE ER 12HR 150MG

4

pacerone tablet 100mg 4



propafenone hcl er capsule er 12hr 225mg

2


/Limits


2


2

propafenone hcl tablet 150mg 2



RANEXA TABLET ER 12HR 1,000MG


RANEXA TABLET ER 12HR 500MG


HYPOTENSIVE AGENTS acetazolamide capsule er 12hr 500mg

2

acetazolamide tablet 125mg 2

acetazolamide tablet 250mg 2

afeditab cr tablet er 24hr 30mg

2

afeditab cr tablet er 24hr 60mg

2

ALDACTAZIDE TABLET 50-50MG

4

amiloride hcl tablet 5mg 2

amiloride-hydrochlorothiazide tablet 5-50mg

2

amlodipine besylate tablet 10mg

1

amlodipine besylate tablet 2.5mg

1

amlodipine besylate tablet 5mg 1

amlodipine besylate-benazepril capsule 10-20mg

2




49


/Limits


2

amlodipine besylate-benazepril capsule 2.5-10mg

2


2


2


2

amlodipine-olmesartan tablet 10-20mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

amlodipine-valsartan tablet 10-160mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


/Limits

amlodipine-valsartan-hctz tablet 10-160-12.5mg QL 60 each per 30 day(s)

2 QL

amlodipine-valsartan-hctz tablet 10-160-25mg QL 60 each per 30 day(s)

2 QL


2 QL

amlodipine-valsartan-hctz tablet 5-160-12.5mg QL 60 each per 30 day(s)

2 QL


2 QL

benazepril hcl tablet 10mg 1




benazepril-hydrochlorothiazide tablet 10-12.5mg

1


1

benazepril-hydrochlorothiazide tablet 20-25mg

1


1

betaxolol hcl tablet 10mg 2

bumetanide tablet 0.5mg 1

bumetanide tablet 1mg 1

bumetanide tablet 2mg 1

BYVALSON TABLET 5-80MG





50


/Limits

candesartan cilexetil tablet 16mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

candesartan-hydrochlorothiazid tablet 16-12.5mg QL 60 each per 30 day(s)

1 QL

candesartan-hydrochlorothiazid tablet 32-12.5mg QL 60 each per 30 day(s)

1 QL

candesartan-hydrochlorothiazid tablet 32-25mg QL 60 each per 30 day(s)

1 QL

captopril tablet 100mg 1

captopril tablet 12.5mg 1



captopril-hydrochlorothiazide tablet 25-15mg

1


1


1


1

cartia xt capsule er 24hr 120mg

2


/Limits


2


2


2

chlorothiazide tablet 250mg 2

chlorothiazide tablet 500mg 2

chlorthalidone tablet 25mg 2

chlorthalidone tablet 50mg 2

clonidine hcl er tablet er 12hr 0.1mg QL 120 each per 30 day(s)

2 QL

clonidine hcl tablet 0.1mg 1



clonidine patch weekly 0.1 mg/24 hour

2


2


2

dilt-xr capsule er 24hr 120mg 2



diltiazem 12hr er capsule er 12hr 120mg

2


2


2


2




51


/Limits


2


2


2


2


2

diltiazem hcl tablet 120mg 2




enalapril maleate tablet 10mg 1

enalapril maleate tablet 2.5mg 1



enalapril-hydrochlorothiazide tablet 10-25mg

1

enalapril-hydrochlorothiazide tablet 5-12.5mg

1

eplerenone tablet 25mg 2 ST eplerenone tablet 50mg 2 ST eprosartan mesylate tablet 600mg QL 60 each per 30 day(s)

2 QL

ethacrynic acid tablet 25mg QL 480 each per 30 day(s)

2 QL

felodipine er tablet er 24hr 10mg

2

felodipine er tablet er 24hr 2.5mg

2

felodipine er tablet er 24hr 5mg

2


/Limits

fosinopril sodium tablet 10mg 1



fosinopril-hydrochlorothiazide tablet 10-12.5mg

1

fosinopril-hydrochlorothiazide tablet 20-12.5mg

1

furosemide solution 10 mg/ml 2

furosemide solution 10 mg/ml 2 BvsDfurosemide solution 40 mg/5 ml (8 mg/ml)

2

furosemide tablet 20mg 1



hydralazine hcl tablet 100mg 1




hydrochlorothiazide capsule 12.5mg

1

hydrochlorothiazide tablet 12.5mg

1

hydrochlorothiazide tablet 25mg

1

hydrochlorothiazide tablet 50mg

1

indapamide tablet 1.25mg 1

indapamide tablet 2.5mg 1

irbesartan tablet 150mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL




52


/Limits

irbesartan-hydrochlorothiazide tablet 150-12.5mg QL 60 each per 30 day(s)

1 QL

irbesartan-hydrochlorothiazide tablet 300-12.5mg QL 60 each per 30 day(s)

1 QL

isradipine capsule 2.5mg 2

isradipine capsule 5mg 2

lisinopril tablet 10mg 1

lisinopril tablet 2.5mg 1





lisinopril-hydrochlorothiazide tablet 10-12.5mg

1

lisinopril-hydrochlorothiazide tablet 20-12.5mg

1

lisinopril-hydrochlorothiazide tablet 20-25mg

1

losartan potassium tablet 100mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL

losartan-hydrochlorothiazide tablet 100-12.5mg QL 60 each per 30 day(s)

1 QL

losartan-hydrochlorothiazide tablet 100-25mg QL 60 each per 30 day(s)

1 QL


/Limits

losartan-hydrochlorothiazide tablet 50-12.5mg QL 60 each per 30 day(s)

1 QL

matzim la tablet er 24hr 180mg

2


2


2


2


2

methyclothiazide tablet 5mg 2

metolazone tablet 10mg 2

metolazone tablet 2.5mg 2

metolazone tablet 5mg 2

minoxidil tablet 10mg 2

minoxidil tablet 2.5mg 2

moexipril hcl tablet 15mg 1

moexipril hcl tablet 7.5mg 1

moexipril-hydrochlorothiazide tablet 15-12.5mg

1

moexipril-hydrochlorothiazide tablet 15-25mg

1

moexipril-hydrochlorothiazide tablet 7.5-12.5mg

1

nicardipine hcl capsule 20mg 2

nicardipine hcl capsule 30mg 2

nifedipine er tablet er 24hr 30mg

2


2


2

nimodipine capsule 30mg 2

nisoldipine tablet er 24hr 17mg

2




53


/Limits


2

nisoldipine tablet er 24hr 25.5mg

2


2


2


2

nisoldipine tablet er 24hr 8.5mg

2

NYMALIZE SOLUTION 30 MG/10 ML (10 ML) QL 120 milliliter(s) per 30 day(s)

5 QL

olmesartan medoxomil tablet 20mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL

olmesartan-amlodipine-hctz tablet 20-5-12.5mg QL 60 each per 30 day(s)

2 QL


2 QL

olmesartan-amlodipine-hctz tablet 40-10-25mg QL 60 each per 30 day(s)

2 QL


2 QL


/Limits

olmesartan-amlodipine-hctz tablet 40-5-25mg QL 60 each per 30 day(s)

2 QL

olmesartan-hydrochlorothiazide tablet 20-12.5mg QL 60 each per 30 day(s)

2 QL

olmesartan-hydrochlorothiazide tablet 40-12.5mg QL 60 each per 30 day(s)

2 QL

olmesartan-hydrochlorothiazide tablet 40-25mg QL 60 each per 30 day(s)

2 QL

perindopril erbumine tablet 2mg

1


1


1

PROGLYCEM SUSPENSION 50 MG/ML

4

quinapril hcl tablet 10mg 1




quinapril-hydrochlorothiazide tablet 10-12.5mg

1

quinapril-hydrochlorothiazide tablet 20-12.5mg

1

quinapril-hydrochlorothiazide tablet 20-25mg

1

ramipril capsule 1.25mg 1

ramipril capsule 10mg 1

ramipril capsule 2.5mg 1




54


/Limits

ramipril capsule 5mg 1

spironolactone tablet 100mg 1



spironolactone-hctz tablet 25-25mg

2

taztia xt capsule er 24hr 120mg

2


2


2


2


2

TEKTURNA HCT TABLET 150-12.5MG

4 ST

TEKTURNA HCT TABLET 150-25MG

4 ST

TEKTURNA HCT TABLET 300-12.5MG

4 ST

TEKTURNA HCT TABLET 300-25MG

4 ST

TEKTURNA TABLET 150MG


TEKTURNA TABLET 300MG


telmisartan tablet 20mg QL 60 each per 30 day(s)

1 QL


1 QL


/Limits


1 QL

telmisartan-amlodipine tablet 40-10mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

telmisartan-hydrochlorothiazid tablet 40-12.5mg QL 60 each per 30 day(s)

1 QL

telmisartan-hydrochlorothiazid tablet 80-12.5mg QL 60 each per 30 day(s)

1 QL

telmisartan-hydrochlorothiazid tablet 80-25mg QL 60 each per 30 day(s)

1 QL

torsemide tablet 100mg 1




trandolapril tablet 1mg 1



trandolapril-verapamil er tablet er 1-240mg QL 60 each per 30 day(s)

2 QL


2 QL




55


/Limits


2 QL


2 QL

triamterene-hydrochlorothiazid capsule 37.5-25mg

1

triamterene-hydrochlorothiazid tablet 37.5-25mg

1

triamterene-hydrochlorothiazid tablet 75-50mg

1

valsartan tablet 160mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

valsartan-hydrochlorothiazide tablet 160-12.5mg QL 60 each per 30 day(s)

1 QL

valsartan-hydrochlorothiazide tablet 160-25mg QL 60 each per 30 day(s)

1 QL


1 QL

valsartan-hydrochlorothiazide tablet 320-25mg QL 60 each per 30 day(s)

1 QL


1 QL


/Limits

verapamil er capsule er 24hr 120mg

2


2


2

verapamil er pm capsule er 24hr 100mg

2


2


2

verapamil er tablet er 120mg 2



verapamil hcl capsule er 24hr 360mg

2

verapamil hcl tablet 120mg 1



VASODILATING AGENTS ADCIRCA TABLET 20MG


ADEMPAS TABLET 0.5MG




ADEMPAS TABLET 1MG




ADEMPAS TABLET 2MG





56


/Limits

isosorbide dinitrate er tablet er 40mg

2

isosorbide dinitrate tablet 10mg

1


1


1

isosorbide dinitrate tablet 5mg 1

isosorbide mononitrate er tablet er 24hr 120mg

2


2


2

isosorbide mononitrate tablet 10mg

1

isosorbide mononitrate tablet 20mg

1

LETAIRIS TABLET 10MG


LETAIRIS TABLET 5MG


minitran patch 24hr 0.1 mg/hour

2


2


2


2

NITRO-BID OINTMENT 2 % 4


/Limits

nitroglycerin patch patch 24hr 0.1 mg/hour

2


2


2


2

nitroglycerin solution 400 mcg/spray

2

nitroglycerin tab sublingual 0.3mg

2


2


2

OPSUMIT TABLET 10MG


ORENITRAM ER TABLET ER 0.125MG




ORENITRAM ER TABLET ER 1MG




ORENITRAM ER TABLET ER 5MG


REMODULIN SOLUTION 1 MG/ML

5 PA




57


/Limits


5 PA

REMODULIN SOLUTION 2.5 MG/ML

5 PA


5 PA

REVATIO FOR SUSPENSION 10 MG/ML QL 180 milliliter(s) per 30 day(s)

5 QL; PA

sildenafil tablet 20mg QL 90 each per 30 day(s)

2 QL; PA

TRACLEER TABLET 125MG


TRACLEER TABLET 62.5MG


TRACLEER TABLET SOLUBLE 32MG


UPTRAVI TAB THER PACK 200 MCG (140)-800 MCG (60) QL 60 each per 30 day(s)

5 QL; PA

UPTRAVI TABLET 1,000 MCG







/Limits



UPTRAVI TABLET 200 MCG








VENTAVIS SOLUTION 10 MCG/ML

5 PA

VENTAVIS SOLUTION 20 MCG/ML

5 PA

CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICSABSTRAL TAB SUBLINGUAL 100 MCG


ABSTRAL TAB SUBLINGUAL 200 MCG











58


/Limits



acetaminophen-codeine tablet 300-15mg QL 390 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM

ascomp with codeine capsule 30-50-325-40mg QL 180 each per 30 day(s)

2 QL; NM

buprenorphine hcl solution 0.3 mg/ml

2 BvsD; NM

buprenorphine hcl tab sublingual 2mg QL 120 each per 30 day(s)

2 QL; NM

buprenorphine hcl tab sublingual 8mg QL 120 each per 30 day(s)

2 QL; NM

buprenorphine patch weekly 10 mcg/hour QL 4 each per 28 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


/Limits

buprenorphine-naloxone tab sublingual 2-0.5mg QL 120 each per 30 day(s)

2 QL; NM

buprenorphine-naloxone tab sublingual 8-2mg QL 120 each per 30 day(s)

2 QL; NM

butalb-acetaminoph-caff-codein capsule 50-300-40-30mg QL 60 each per 30 day(s)

2 QL; NM

butalb-caff-acetaminoph-codein capsule 50-325-40-30mg QL 60 each per 30 day(s)

2 QL; NM

butalbital compound-codeine capsule 30-50-325-40mg QL 60 each per 30 day(s)

2 QL; NM

butalbital-acetaminophen-caffe capsule 50-300-40mg QL 60 each per 30 day(s)

2 QL; NM

butalbital-acetaminophen-caffe capsule 50-325-40mg QL 60 each per 30 day(s)

2 QL; NM

butalbital-acetaminophen-caffe tablet 50-325-40mg QL 60 each per 30 day(s)

2 QL; NM

butalbital-aspirin-caffeine capsule 50-325-40mg QL 60 each per 30 day(s)

2 QL; NM

butorphanol tartrate solution 10 mg/ml QL 25 milliliter(s) per 30 day(s)

2 QL; NM

BUTRANS PATCH WEEKLY 10 MCG/HOUR

QL 4 each per 28 day(s)3 QL; NM




59


/Limits







BUTRANS PATCH WEEKLY 7.5 MCG/HOUR


CAMBIA PACKET 50MG


celecoxib capsule 100mg QL 240 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

codeine sulfate tab 15 mg QL 180 per 30 day(s)

2 QL; NM

codeine sulfate tablet 30mg QL 180 each per 30 day(s)

2 QL; NM

codeine sulfate tablet 60mg QL 180 each per 30 day(s)

2 QL; NM

diclofenac potassium tablet 50mg

2

diclofenac sodium er tablet er 24hr 100mg

2

diclofenac sodium gel 1 %



/Limits

diclofenac sodium tablet dr 25mg

2


2


2

diclofenac sodium-misoprostol tablet dr 50 mg-200 mcg

2

diclofenac sodium-misoprostol tablet dr 75 mg-200 mcg

2

diflunisal tablet 500mg QL 90 each per 30 day(s)

2 QL

duramorph solution 0.5 mg/ml 2 BvsD; NMduramorph solution 1 mg/ml 2 BvsD; NMendocet tablet 10-325mg QL 360 each per 30 day(s)

2 QL; NM

endocet tablet 5-325mg QL 360 each per 30 day(s)

2 QL; NM

endocet tablet 7.5-325mg QL 360 each per 30 day(s)

2 QL; NM

etodolac capsule 200mg 2

etodolac capsule 300mg 2

etodolac er tablet er 24hr 400mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL

etodolac tablet 400mg 2

etodolac tablet 500mg 2

fenoprofen calcium capsule 400mg

2




60


/Limits

fenoprofen calcium tablet 600mg

2

fentanyl citrate loz on a handle 1,200 mcg QL 120 each per 30 day(s)

2 QL; PA; NM

fentanyl citrate loz on a handle 1,600 mcg QL 120 each per 30 day(s)

2 QL; PA; NM

fentanyl citrate loz on a handle 200 mcg QL 120 each per 30 day(s)

2 QL; PA; NM


2 QL; PA; NM


2 QL; PA; NM


2 QL; PA; NM

fentanyl patch 72hr 100 mcg/hour QL 15 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


/Limits

FENTORA TABLET 100 MCG










flurbiprofen tablet 100mg 2

flurbiprofen tablet 50mg 2

gabapentin capsule 100mg QL 960 each per 30 day(s)

1 QL


1 QL


1 QL

gabapentin solution 250 mg/5 ml QL 2160 milliliter(s) per 30 day(s)

2 QL

gabapentin tablet 600mg QL 180 each per 30 day(s)

1 QL

gabapentin tablet 800mg QL 120 each per 30 day(s)

1 QL

GRALISE 30-DAY STARTER PACK





61


/Limits

GRALISE TABLET 300MG


GRALISE TABLET 600MG


HORIZANT TABLET ER 300MG


HORIZANT TABLET ER 600MG


hydrocodone-acetaminophen tablet 10-325mg QL 120 each per 30 day(s)

1 QL; NM

hydrocodone-acetaminophen tablet 2.5-325mg QL 120 each per 30 day(s)

2 QL; NM

hydrocodone-acetaminophen tablet 5-325mg QL 120 each per 30 day(s)

1 QL; NM

hydrocodone-acetaminophen tablet 7.5-325mg QL 120 each per 30 day(s)

1 QL; NM

hydrocodone-ibuprofen tablet 7.5-200mg QL 210 each per 30 day(s)

2 QL; NM

hydromorphone er tab 24hr deter 12mg QL 30 each per 30 day(s)

2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM


/Limits


2 QL; ST; NM

hydromorphone hcl tablet 2mg QL 120 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM

ibuprofen tab 600 mg 1

ibuprofen tab 800 mg 1

ibuprofen tablet 400mg 1



ketoprofen capsule 75mg 2

ketoprofen capsule er 24hr 200mg QL 30 each per 30 day(s)

2 QL

LAZANDA SOLUTION 100 MCG/SPRAY






meclofenamate sodium capsule 100mg QL 120 each per 30 day(s)

2 QL

meclofenamate sodium capsule 50mg QL 240 each per 30 day(s)

2 QL

meloxicam tablet 15mg 1




62


/Limits

meloxicam tablet 7.5mg 1

methadone hcl solution 10 mg/5 ml QL 600 milliliter(s) per 30 day(s)

2 QL; NM

methadone hcl solution 5 mg/5 ml QL 600 milliliter(s) per 30 day(s)

2 QL; NM

methadone hcl tablet 10mg QL 120 each per 30 day(s)

2 QL; NM

methadone hcl tablet 5mg QL 120 each per 30 day(s)

2 QL; NM

morphine sulfate er capsule er 24hr 100mg QL 60 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


/Limits


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM

morphine sulfate er tablet er 100mg QL 60 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM

morphine sulfate solution 10 mg/5 ml QL 960 milliliter(s) per 30 day(s)

2 QL; NM




63


/Limits

morphine sulfate solution 10 mg/ml

2 BvsD; NM

morphine sulfate solution 100 mg/5 ml (20 mg/ml) QL 240 milliliter(s) per 30 day(s)

2 QL; NM


2 BvsD; NM

morphine sulfate solution 20 mg/5 ml (4 mg/ml) QL 960 milliliter(s) per 30 day(s)

2 QL; NM


2 BvsD; NM


2 BvsD


2 BvsD; NM

morphine sulfate tablet 15mg QL 120 each per 30 day(s)

2 QL; NM

morphine sulfate tablet 30mg QL 120 each per 30 day(s)

2 QL; NM

nabumetone tablet 500mg 2

nabumetone tablet 750mg 2

NAPRELAN TABLET ER 24HR 750MG


naproxen sodium er tablet er 24hr 375mg

2

naproxen sodium er tablet er 24hr 500mg QL 60 each per 30 day(s)

2 QL

naproxen sodium tablet 275mg 1

naproxen sodium tablet 550mg 1


/Limits

naproxen suspension 125 mg/5 ml

2

naproxen tablet 250mg 1



naproxen tablet dr 375mg QL 30 each per 30 day(s)

2 QL

naproxen tablet dr 500mg 2

oxaprozin tablet 600mg 2

oxycodone hcl capsule 5mg QL 180 each per 30 day(s)

2 QL; NM

oxycodone hcl concentrate 20 mg/ml QL 270 milliliter(s) per 30 day(s)

2 QL; NM

oxycodone hcl er tab 12hr deter 10mg QL 60 each per 30 day(s)

2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM


2 QL; ST; NM




64


/Limits

oxycodone hcl solution 5 mg/5 ml QL 240 milliliter(s) per 30 day(s)

2 QL; NM

oxycodone hcl tablet 10mg QL 180 each per 30 day(s)

2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM

oxycodone hcl-aspirin tablet 4.8355-325mg QL 360 each per 30 day(s)

2 QL; NM

oxycodone hcl-ibuprofen tablet 400-5mg QL 120 each per 30 day(s)

2 QL; NM

oxycodone-acetaminophen tablet 10-325mg QL 120 each per 30 day(s)

2 QL; NM

oxycodone-acetaminophen tablet 2.5-325mg QL 120 each per 30 day(s)

2 QL; NM

oxycodone-acetaminophen tablet 5-325mg QL 120 each per 30 day(s)

2 QL; NM

oxycodone-acetaminophen tablet 7.5-325mg QL 120 each per 30 day(s)

2 QL; NM

oxymorphone hcl er tablet er 12hr 10mg QL 60 each per 30 day(s)

2 QL; NM


/Limits


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM


2 QL; NM

oxymorphone hcl er tablet er 12hr 7.5mg QL 60 each per 30 day(s)

2 QL; NM

oxymorphone hcl tablet 10mg QL 120 each per 30 day(s)

2 QL; ST; NM

oxymorphone hcl tablet 5mg QL 120 each per 30 day(s)

2 QL; ST; NM

piroxicam capsule 10mg 2

piroxicam capsule 20mg 2

sulindac tablet 150mg 2

sulindac tablet 200mg 2

tolmetin sodium capsule 400mg

2

tolmetin sodium tablet 600mg 2

tramadol hcl er capsule er 24hr 100mg QL 30 each per 30 day(s)

2 QL


2 QL




65


/Limits


2 QL

tramadol hcl er tablet er 24hr 100mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL

tramadol hcl tablet 50mg QL 240 each per 30 day(s)

2 QL

tramadol hcl-acetaminophen tablet 37.5-325mg QL 120 each per 30 day(s)

2 QL

ZOHYDRO ER CAP 12HR DETER 10MG

QL 60 each per 30 day(s) 4 QL; ST; NM












/Limits

ZUBSOLV TAB SUBLINGUAL 1.4-0.36MG










ANOREXIGENICSRESPIR.,CEREBRAL STIMULANTarmodafinil tablet 150mg QL 30 each per 30 day(s)

2 QL; PA

armodafinil tablet 200mg QL 30 each per 30 day(s)

2 QL; PA


2 QL; PA


2 QL; PA

DAYTRANA PATCH 10 MG/9 HOUR









66


/Limits



dexmethylphenidate hcl er capsule er 24hr 10mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

dextroamphetamine sulfate er capsule er 24hr 10mg QL 120 each per 30 day(s)

2 QL


2 QL


/Limits


2 QL

dextroamphetamine-amphet er capsule er 24hr 10mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

dextroamphetamine-amphetamine tablet 10mg QL 60 each per 30 day(s)

2 QL

dextroamphetamine-amphetamine tablet 12.5mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL




67


/Limits


2 QL

dextroamphetamine-amphetamine tablet 7.5mg QL 60 each per 30 day(s)

2 QL

methylphenidate er tablet er 10mg QL 180 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

methylphenidate hcl cd capsule er 10mg QL 180 each per 30 day(s)

2 QL


2 QL


/Limits


2 QL


2 QL


2 QL


2 QL

methylphenidate hcl solution 10 mg/5 ml QL 900 milliliter(s) per 30 day(s)

2 QL

methylphenidate hcl solution 5 mg/5 ml QL 1800 milliliter(s) per 30 day(s)

2 QL

methylphenidate hcl tablet 10mg QL 90 each per 30 day(s)

2 QL


2 QL


2 QL

methylphenidate hcl tablet chewable 10mg QL 180 each per 30 day(s)

2 QL

methylphenidate hcl tablet chewable 2.5mg QL 90 each per 30 day(s)

2 QL

methylphenidate hcl tablet chewable 5mg QL 180 each per 30 day(s)

2 QL




68


/Limits

methylphenidate la capsule er 24hr 10mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL

modafinil tablet 100mg QL 30 each per 30 day(s)

2 QL; PA

modafinil tablet 200mg QL 60 each per 30 day(s)

2 QL; PA

VYVANSE CAPSULE 10MG














ANTICONVULSANTS


/Limits

APTIOM TABLET 200MG


APTIOM TABLET 400MG


APTIOM TABLET 600MG


APTIOM TABLET 800MG


BANZEL SUSPENSION 40 MG/ML QL 2400 milliliter(s) per 30 day(s)

4 QL; PA

BANZEL TABLET 200MG


BANZEL TABLET 400MG


BRIVIACT SOLUTION 10 MG/ML QL 600 milliliter(s) per 30 day(s)

4 QL

BRIVIACT SOLUTION 50 MG/5 ML QL 80 milliliter(s) per 30 day(s)

4 QL

BRIVIACT TABLET 100MG













69


/Limits

carbamazepine er capsule er 12hr 100mg QL 480 each per 30 day(s)

2 QL


2 QL


2 QL

carbamazepine er tablet er 12hr 100mg QL 480 each per 30 day(s)

2 QL


2 QL


2 QL

carbamazepine suspension 100 mg/5 ml QL 2400 milliliter(s) per 30 day(s)

2 QL

carbamazepine tablet 200mg QL 240 each per 30 day(s)

1 QL

carbamazepine tablet chewable 100mg QL 480 each per 30 day(s)

1 QL

CELONTIN CAPSULE 300MG


CEREBYX SOLUTION 500 MG PE/10 ML QL 300 milliliter(s) per 30 day(s)

4 QL; BvsD


/Limits

DILANTIN CAPSULE 100MG


DILANTIN CAPSULE 30MG


DILANTIN TABLET CHEWABLE 50MG


DILANTIN-125 SUSPENSION 125 MG/5 ML QL 750 milliliter(s) per 30 day(s)

3 QL

divalproex dr 125 mg cap sprnk QL 1080 each per 30 day(s)

2 QL

divalproex sodium er tablet er 24hr 250mg QL 510 each per 30 day(s)

2 QL

divalproex sodium er tablet er 24hr 500mg QL 270 each per 30 day(s)

2 QL

divalproex sodium tablet dr 125mg QL 600 each per 30 day(s)

2 QL


2 QL


2 QL

epitol tablet 200mg QL 240 each per 30 day(s)

1 QL

EQUETRO CAPSULE ER 12HR 100MG

4




70


/Limits


4


4

ethosuximide capsule 250mg 2

ethosuximide solution 250 mg/5 ml QL 1200 milliliter(s) per 30 day(s)

2 QL

felbamate suspension 600 mg/5 ml QL 900 milliliter(s) per 30 day(s)

2 QL

felbamate tablet 400mg QL 270 each per 30 day(s)

2 QL

felbamate tablet 600mg QL 180 each per 30 day(s)

2 QL

FYCOMPA SUSPENSION 0.5 MG/ML QL 720 milliliter(s) per 30 day(s)

4 QL

FYCOMPA TABLET 10MG


FYCOMPA TABLET 12MG


FYCOMPA TABLET 2MG


FYCOMPA TABLET 4MG


FYCOMPA TABLET 6MG


FYCOMPA TABLET 8MG



/Limits

LAMICTAL ODT TABLET DISPERSE 100MG








LAMICTAL XR (BLUE) KIT 25 MG (21)-50 MG (7) QL 56 each per 365 day(s)

4 QL

LAMICTAL XR (GREEN) KIT 50 MG (14)-100 MG (14)-200 MG (7) QL 70 each per 365 day(s)

4 QL

LAMICTAL XR (ORANGE) KIT 25 MG (14)-50 MG (14)-100 MG (7) QL 70 each per 365 day(s)

4 QL

lamotrigine (blue) kit 25 mg (35 tabs) QL 70 each per 365 day(s)

2 QL

lamotrigine (green) kit 25 mg (84)-100 mg (14) QL 196 each per 365 day(s)

2 QL

lamotrigine (orange) kit 25 mg (42)-100 mg (7) QL 98 each per 365 day(s)

2 QL

lamotrigine er tablet er 24hr 100mg QL 90 each per 30 day(s)

2 QL




71


/Limits


2 QL


2 QL


2 QL


2 QL


2 QL

lamotrigine odt tablet disperse 100mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

lamotrigine tablet 100mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


/Limits

lamotrigine tablet chewable 25mg QL 600 each per 30 day(s)

2 QL

lamotrigine tablet chewable 5mg QL 600 each per 30 day(s)

2 QL

levetiracetam er tablet er 24hr 500mg QL 120 each per 30 day(s)

2 QL

levetiracetam er tablet er 24hr 750mg QL 120 each per 30 day(s)

2 QL

levetiracetam solution 100 mg/ml QL 900 milliliter(s) per 30 day(s)

2 QL

levetiracetam solution 500 mg/5 ml

2 BvsD

levetiracetam tablet 1,000mg QL 90 each per 30 day(s)

2 QL

levetiracetam tablet 250mg QL 120 each per 30 day(s)

2 QL


2 QL


2 QL

levetiracetam-nacl solution 1,000 mg/100 ml

2 BvsD

levetiracetam-nacl solution 1,500 mg/100 ml

2 BvsD

levetiracetam-nacl solution 500 mg/100 ml

2 BvsD

LYRICA CAPSULE 100MG





72


/Limits







LYRICA CAPSULE 25MG




LYRICA CAPSULE 50MG


LYRICA CAPSULE 75MG


LYRICA SOLUTION 20 MG/ML QL 900 milliliter(s) per 30 day(s)

4 QL

oxcarbazepine suspension 300 mg/5 ml (60 mg/ml) QL 1200 milliliter(s) per 30 day(s)

2 QL

oxcarbazepine tablet 150mg QL 120 each per 30 day(s)

2 QL


2 QL


2 QL

OXTELLAR XR TABLET ER 24HR 150MG





/Limits



PEGANONE TABLET 250MG


phenytoin sodium extended capsule 100mg QL 300 each per 30 day(s)

2 QL


2 QL


2 QL

phenytoin suspension 125 mg/5 ml QL 750 milliliter(s) per 30 day(s)

2 QL

phenytoin tablet chewable 50mg QL 600 each per 30 day(s)

2 QL

SABRIL TABLET 500MG


SPRITAM 1,000 MG TABLET QL 90 each per 30 day(s)

4 QL; ST

SPRITAM 250 MG TABLET QL 90 each per 30 day(s)

4 QL; ST


4 QL; ST


4 QL; ST




73


/Limits

tiagabine hcl tablet 12mg QL 120 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

topiramate cap sprinkle 15mg QL 480 each per 30 day(s)

2 QL

topiramate cap sprinkle 25mg QL 480 each per 30 day(s)

2 QL

topiramate er cp24 sprinkle 100mg QL 30 each per 30 day(s)

2 QL; PA


2 QL; PA


2 QL; PA


2 QL; PA


2 QL; PA

topiramate tablet 100mg QL 90 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


/Limits

TROKENDI XR CAPSULE ER 24HR 100MG








valproate sodium solution 500 mg/5 ml (100 mg/ml)

2 BvsD

valproic acid capsule 250mg QL 540 each per 30 day(s)

2 QL

valproic acid solution 500 mg/10 ml (10 ml) QL 3000 milliliter(s) per 30 day(s)

2 QL

vigabatrin packet 500mg QL 9000 each per 30 day(s)

2 QL; PA

VIMPAT SOLUTION 10 MG/ML QL 1200 milliliter(s) per 30 day(s)

3 QL

VIMPAT SOLUTION 200 MG/20 ML

3 BvsD

VIMPAT TABLET 100MG


VIMPAT TABLET 150MG


VIMPAT TABLET 200MG





74


/Limits

VIMPAT TABLET 50MG


zonisamide capsule 100mg QL 180 each per 30 day(s)

2 QL


2 QL


2 QL

ANTIMANIC AGENTS lithium carbonate capsule 150mg

1

lithium carbonate capsule 300mg

1

lithium carbonate capsule 600mg

1

lithium carbonate er tablet er 300mg

1

lithium carbonate er tablet er 450mg

1

lithium carbonate tablet 300mg

1

lithium solution 8 meq/5 ml 2

ANTIMIGRAINE AGENTSfrovatriptan succinate tablet 2.5mg QL 9 each per 30 day(s)

2 QL; ST

naratriptan hcl tablet 1mg QL 9 each per 30 day(s)

2 QL

naratriptan hcl tablet 2.5mg QL 9 each per 30 day(s)

2 QL

rizatriptan tablet 10mg QL 18 each per 30 day(s)

2 QL

rizatriptan tablet 5mg QL 18 each per 30 day(s)

2 QL


/Limits

rizatriptan tablet disperse 10mg QL 18 each per 30 day(s)

2 QL

rizatriptan tablet disperse 5mg QL 18 each per 30 day(s)

2 QL

sumatriptan solution 20mg QL 12 each per 30 day(s)

2 QL

sumatriptan solution 5mg QL 12 each per 30 day(s)

2 QL

sumatriptan succinate soln auto-inj 4 mg/0.5 ml QL 4 milliliter(s) per 30 day(s)

2 QL

sumatriptan succinate soln auto-inj 6 mg/0.5 ml QL 4 milliliter(s) per 30 day(s)

2 QL

sumatriptan succinate soln cartridge 4 mg/0.5 ml QL 4 milliliter(s) per 30 day(s)

2 QL

sumatriptan succinate solution 6 mg/0.5 ml QL 4 milliliter(s) per 30 day(s)

2 QL

sumatriptan succinate tablet 100mg QL 9 each per 30 day(s)

2 QL


2 QL


2 QL




75


/Limits

zolmitriptan odt tablet disperse 2.5mg QL 9 each per 30 day(s)

2 QL

zolmitriptan odt tablet disperse 5mg QL 9 each per 30 day(s)

2 QL

zolmitriptan tablet 2.5mg QL 9 each per 30 day(s)

2 QL

zolmitriptan tablet 5mg QL 9 each per 30 day(s)

2 QL

ZOMIG SOLUTION 2.5MG


ZOMIG SOLUTION 5MG


ANTIPARKINSONIAN AGENTS (CNS)APOKYN SOLN CARTRIDGE 10 MG/ML

5 PA

benztropine mesylate solution 2 mg/2 ml

2 BvsD

benztropine mesylate tablet 0.5mg QL 90 each per 30 day(s)

2 QL

benztropine mesylate tablet 1mg QL 90 each per 30 day(s)

2 QL

benztropine mesylate tablet 2mg

2

bromocriptine mesylate capsule 5mg

2

bromocriptine mesylate tablet 2.5mg

2

cabergoline tablet 0.5mg QL 60 each per 30 day(s)

2 QL

carbidopa-levodopa er tablet er 25-100mg QL 240 each per 30 day(s)

2 QL


/Limits

carbidopa-levodopa er tablet er 50-200mg QL 240 each per 30 day(s)

2 QL

carbidopa-levodopa tablet 10-100mg QL 300 each per 30 day(s)

2 QL


2 QL


2 QL

carbidopa-levodopa tablet disperse 10-100mg QL 300 each per 30 day(s)

2 QL


2 QL


2 QL

carbidopa-levodopa-entacapone tablet 12.5-50-200mg

2


2

carbidopa-levodopa-entacapone tablet 25-100-200mg

2


2


2

carbidopa-levodopa-entacapone tablet 50-200-200mg

2




76


/Limits

entacapone tablet 200mg 2

NEUPRO PATCH 24HR 1 MG/24 HOUR












pramipexole dihydrochloride tablet 0.125mg QL 120 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


1 QL


/Limits

pramipexole dihydrochloride tablet 1mg QL 120 each per 30 day(s)

1 QL

pramipexole er tablet er 24hr 0.375mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL

pramipexole er tablet er 24hr 3mg QL 30 each per 30 day(s)

2 QL


2 QL

rasagiline mesylate tablet 0.5mg

2

rasagiline mesylate tablet 1mg 2

ropinirole er tablet er 24hr 12mg QL 90 each per 30 day(s)

2 QL


2 QL


2 QL




77


/Limits


2 QL


2 QL

ropinirole hcl tablet 0.25mg 1

ropinirole hcl tablet 0.5mg 1

ropinirole hcl tablet 1mg 1





RYTARY CAPSULE ER 23.75-95MG








tolcapone tablet 100mg 2

trihexyphenidyl hcl elixir 2 mg/5 ml

2

trihexyphenidyl hcl tablet 2mg QL 150 each per 30 day(s)

2 QL

trihexyphenidyl hcl tablet 5mg QL 150 each per 30 day(s)

2 QL

ANXIOLYTICS, SEDATIVES AND HYPNOTICS


/Limits

BELSOMRA TABLET 10MG






BELSOMRA TABLET 5MG


buspirone hcl tablet 10mg 1




buspirone hcl tablet 7.5mg 1

eszopiclone tablet 1mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST

HETLIOZ CAPSULE 20MG


hydroxyzine hcl tablet 10mg 2



ROZEREM TABLET 8MG


zaleplon capsule 10mg QL 30 each per 30 day(s)

2 QL

zaleplon capsule 5mg QL 30 each per 30 day(s)

2 QL

zolpidem tartrate er tablet er 12.5mg QL 30 each per 30 day(s)

2 QL

zolpidem tartrate er tablet er 6.25mg QL 30 each per 30 day(s)

2 QL




78


/Limits

zolpidem tartrate tablet 10mg QL 60 each per 30 day(s)

2 QL

zolpidem tartrate tablet 5mg QL 60 each per 30 day(s)

2 QL

BARBITUATES phenobarbital elixir 20 mg/5 ml (4 mg/ml)

2

phenobarbital tablet 100mg 2


phenobarbital tablet 16.2mg 2






primidone tablet 250mg QL 240 each per 30 day(s)

1 QL

primidone tablet 50mg QL 1200 each per 30 day(s)

1 QL

BENZODIAZEPINES alprazolam er tablet er 24hr 0.5mg QL 90 each per 30 day(s)

2 QL

alprazolam er tablet er 24hr 1mg QL 90 each per 30 day(s)

2 QL


2 QL


2 QL


/Limits

alprazolam intensol concentrate 1 mg/ml QL 300 milliliter(s) per 30 day(s)

2 QL

alprazolam odt tablet disperse 0.25mg QL 150 each per 30 day(s)

2 QL

alprazolam odt tablet disperse 0.5mg QL 150 each per 30 day(s)

2 QL

alprazolam odt tablet disperse 1mg QL 150 each per 30 day(s)

2 QL

alprazolam odt tablet disperse 2mg QL 150 each per 30 day(s)

2 QL

alprazolam tablet 0.25mg QL 150 each per 30 day(s)

1 QL

alprazolam tablet 0.5mg QL 150 each per 30 day(s)

1 QL

alprazolam tablet 1mg QL 150 each per 30 day(s)

1 QL

alprazolam tablet 2mg QL 150 each per 30 day(s)

1 QL

clonazepam tablet 0.5mg QL 300 each per 30 day(s)

1 QL

clonazepam tablet 1mg QL 300 each per 30 day(s)

1 QL

clonazepam tablet 2mg QL 300 each per 30 day(s)

1 QL

clonazepam tablet disperse 0.125mg QL 300 each per 30 day(s)

2 QL


2 QL




79


/Limits


2 QL

clonazepam tablet disperse 1mg QL 300 each per 30 day(s)

2 QL

clonazepam tablet disperse 2mg QL 300 each per 30 day(s)

2 QL

clorazepate dipotassium tablet 15mg QL 180 each per 30 day(s)

2 QL

clorazepate dipotassium tablet 3.75mg QL 90 each per 30 day(s)

2 QL

clorazepate dipotassium tablet 7.5mg QL 90 each per 30 day(s)

2 QL

DIASTAT ACUDIAL GEL 12.5-15-17.5-20MG

2

DIASTAT ACUDIAL GEL 5-7.5-10MG

4

DIASTAT GEL 2.5MG 4

diazepam concentrate 5 mg/ml QL 240 milliliter(s) per 30 day(s)

2 QL

diazepam solution 5 mg/5 ml (1 mg/ml) QL 1200 milliliter(s) per 30 day(s)

2 QL

diazepam tablet 10mg QL 120 each per 30 day(s)

1 QL


1 QL


1 QL


/Limits

lorazepam concentrate 2 mg/ml QL 150 milliliter(s) per 30 day(s)

2 QL

lorazepam tablet 0.5mg QL 150 each per 30 day(s)

1 QL

lorazepam tablet 1mg QL 150 each per 30 day(s)

1 QL

lorazepam tablet 2mg QL 150 each per 30 day(s)

1 QL

ONFI SUSPENSION 2.5 MG/ML QL 480 milliliter(s) per 30 day(s)

4 QL; PA

ONFI TABLET 10MG


ONFI TABLET 20MG


temazepam capsule 15mg QL 60 each per 30 day(s)

1 QL

temazepam capsule 22.5mg QL 30 each per 30 day(s)

1 QL

temazepam capsule 30mg QL 30 each per 30 day(s)

1 QL

temazepam capsule 7.5mg QL 60 each per 30 day(s)

1 QL

triazolam tablet 0.125mg QL 30 each per 30 day(s)

2 QL

triazolam tablet 0.25mg QL 30 each per 30 day(s)

2 QL

CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium tablet dr 333mg QL 180 each per 30 day(s)

2 QL




80


/Limits

atomoxetine hcl capsule 100mg QL 30 each per 30 day(s)

2 QL

atomoxetine hcl capsule 10mgQL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

carbidopa tablet 25mg 2

disulfiram tablet 250mg 2

guanfacine hcl er tablet er 24hr 1mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

INGREZZA CAPSULE 40MG


INGREZZA CAPSULE 80MG



/Limits

memantine hcl er capsule er 24hr 14mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST

memantine hcl solution 2 mg/ml

2

memantine hcl tablet 10mg QL 60 each per 30 day(s)

2 QL

memantine hcl tablet 5 mg (28)-10 mg (21) QL 49 each per 28 day(s)

2 QL

memantine hcl tablet 5mg QL 60 each per 30 day(s)

2 QL

NAMENDA XR CAPSULE ER 24HR 7 MG (7)-14 MG (7)-21 MG (7)-28 MG (7) QL 28 each per 28 day(s)

4 QL; ST

NUEDEXTA CAPSULE 20-10MG


riluzole tablet 50mg 2

tetrabenazine tablet 12.5mg QL 240 each per 30 day(s)

5 QL; PA

tetrabenazine tablet 25mg QL 120 each per 30 day(s)

5 QL; PA

XYREM SOLUTION 500 MG/ML QL 540 milliliter(s) per 30 day(s)

5 QL; PA; LA




81


/Limits

FIBROMYALGIA AGENTS SAVELLA TABLET 100MG


SAVELLA TABLET 12.5MG


SAVELLA TABLET 25MG


SAVELLA TABLET 50MG


SAVELLA TITRATION PACK


OPIATE ANTAGONISTS naloxone hcl soln cartridge 0.4 mg/ml QL 2 milliliter(s) per 30 day(s)

1 QL

naloxone hcl soln pref syr 1 mg/ml QL 40 milliliter(s) per 30 day(s)

1 QL

naloxone hcl solution 0.4 mg/ml QL 20 milliliter(s) per 30 day(s)

1 QL

naltrexone hcl tablet 50mg 2

NARCAN LIQUID 4 MG/ACTUATION


PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA FOR SUSP ER 300MG



/Limits

ABILIFY MAINTENA FOR SUSP ER 400MG

QL 2 each per 28 day(s)5 QL

ABILIFY MAINTENA PREFILLED SYR 300MG


ABILIFY MAINTENA PREFILLED SYR 400MG


amitriptyline hcl tablet 100mg 2






amoxapine tablet 100mg 2




APLENZIN TABLET ER 24HR 174MG






aripiprazole odt tablet disperse 10mg QL 60 each per 30 day(s)

2 QL; ST

aripiprazole odt tablet disperse 15mg QL 60 each per 30 day(s)

2 QL; ST




82


/Limits

aripiprazole solution 1 mg/ml QL 900 milliliter(s) per 30 day(s)

2 QL; ST

aripiprazole tablet 10mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST

ARISTADA PREFILLED SYR 1,064 MG/3.9 ML QL 3.9 milliliter(s) per 28 day(s)

5 QL; ST

ARISTADA PREFILLED SYR 441 MG/1.6 ML QL 1.6 milliliter(s) per 28 day(s)

5 QL; ST


5 QL; ST


5 QL; ST

bupropion hcl sr tablet er 12hr 100mg QL 90 each per 30 day(s)

1 QL


/Limits


1 QL


1 QL

bupropion hcl tablet 100mg QL 120 each per 30 day(s)

1 QL

bupropion hcl tablet 75mg QL 30 each per 30 day(s)

1 QL

bupropion xl tablet er 24hr 150mg QL 30 each per 30 day(s)

2 QL

bupropion xl tablet er 24hr 300mg QL 30 each per 30 day(s)

2 QL

chlorpromazine hcl solution 25 mg/ml

2 BvsD

chlorpromazine hcl tablet 100mg

2


2


2


2


2

citalopram hbr solution 10 mg/5 ml

2

citalopram hbr tablet 10mg QL 120 each per 30 day(s)

1 QL


1 QL


1 QL

clomipramine hcl capsule 25mg

2




83


/Limits


2


2

clozapine odt tablet disperse 100mg QL 270 each per 30 day(s)

2 QL

clozapine odt tablet disperse 12.5mg QL 270 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

clozapine tablet 100mg QL 180 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

compro suppository 25mg 2

desipramine hcl tablet 100mg 2






desvenlafaxine succinate er tablet er 24hr 100mg QL 30 each per 30 day(s)

2 QL; ST


/Limits


2 QL; ST


2 QL; ST

doxepin hcl capsule 100mg 2






doxepin hcl concentrate 10 mg/ml

2

duloxetine hcl capsule dr part 20mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

EMSAM PATCH 24HR 12 MG/24 HOUR









84


/Limits

escitalopram oxalate solution 5 mg/5 ml

2

escitalopram oxalate tablet 10mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL

FANAPT TABLET 1 MG (2)-2 MG (2)-4 MG (2)-6 MG (2) QL 8 each per 30 day(s)

4 QL; ST

FANAPT TABLET 10MG


FANAPT TABLET 12MG


FANAPT TABLET 1MG


FANAPT TABLET 2MG


FANAPT TABLET 4MG


FANAPT TABLET 6MG


FANAPT TABLET 8MG


FETZIMA CAPSULE ER 24HR 120MG





/Limits





FETZIMA CP24 THER PACK 20 MG (2)-40 MG (26) QL 30 each per 30 day(s)

4 QL; ST

fluoxetine dr capsule dr 90mg QL 4 each per 28 day(s)

2 QL

fluoxetine hcl capsule 10mg QL 180 each per 30 day(s)

1 QL


1 QL


1 QL

fluoxetine hcl solution 20 mg/5 ml (4 mg/ml)

2

fluoxetine hcl tablet 10mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL

fluphenazine decanoate solution 25 mg/ml

2 BvsD

fluphenazine hcl elixir 2.5 mg/5 ml

2

fluphenazine hcl solution 2.5 mg/ml

2 BvsD

fluphenazine hcl tablet 10mg 2




85


/Limits


fluphenazine hcl tablet 2.5mg 2


fluvoxamine maleate er capsule er 24hr 100mg

2

fluvoxamine maleate er capsule er 24hr 150mg

2

fluvoxamine maleate tablet 100mg

2


2


2

FORFIVO XL TABLET ER 24HR 450MG

4 ST

GEODON FOR SOLUTION 20 MG/ML (FINAL CONCENTRATION)

4

haloperidol decanoate solution 100 mg/ml

2

haloperidol decanoate solution 50 mg/ml

2

haloperidol lactate concentrate 2 mg/ml

2

haloperidol lactate solution 5 mg/ml

2

haloperidol tablet 0.5mg 2

haloperidol tablet 10mg 2





imipramine hcl tablet 10mg 2



imipramine pamoate capsule 100mg

2


/Limits


2


2


2

INVEGA SUSTENNA SUSPENSION 117 MG/0.75 ML

4

INVEGA SUSTENNA SUSPENSION 156 MG/ML

4


4


4


4

INVEGA TRINZA SUSPENSION 273 MG/0.875 ML QL 0.875 milliliter(s) per 90 day(s)

4 QL


4 QL


4 QL


4 QL




86


/Limits

KHEDEZLA TABLET ER 24HR 100MG


KHEDEZLA TABLET ER 24HR 50MG


LATUDA TABLET 120MG


LATUDA TABLET 20MG


LATUDA TABLET 40MG


LATUDA TABLET 60MG


LATUDA TABLET 80MG


loxapine capsule 10mg 2




maprotiline hcl tablet 25mg 2



MARPLAN TABLET 10MG 4

mirtazapine tablet 15mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL

mirtazapine tablet 7.5mg QL 30 each per 30 day(s)

1 QL

mirtazapine tablet disperse 15mg QL 30 each per 30 day(s)

2 QL


/Limits


2 QL


2 QL

nefazodone hcl tablet 100mg 2





nortriptyline hcl capsule 10mg 1




nortriptyline hcl solution 10 mg/5 ml

2

NUPLAZID TABLET 17MG


olanzapine for solution 10mg 2 BvsDolanzapine odt tablet disperse 10mg QL 30 each per 30 day(s)

2 QL

olanzapine odt tablet disperse 15mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL

olanzapine tablet 10mg QL 30 each per 30 day(s)

1 QL




87


/Limits


1 QL

olanzapine tablet 2.5mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL

olanzapine tablet 7.5mg QL 30 each per 30 day(s)

1 QL

olanzapine-fluoxetine hcl capsule 12-25mg

2


2


2


2


2

paliperidone er tablet er 24hr 1.5mg QL 30 each per 30 day(s)

2 QL; ST

paliperidone er tablet er 24hr 3mg QL 30 each per 30 day(s)

2 QL; ST


2 QL; ST


2 QL; ST

paroxetine er tablet er 24hr 12.5mg QL 30 each per 30 day(s)

2 QL


/Limits

paroxetine er tablet er 24hr 25mg QL 90 each per 30 day(s)

2 QL

paroxetine er tablet er 24hr 37.5mg QL 30 each per 30 day(s)

2 QL

paroxetine hcl tablet 10mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

PAXIL SUSPENSION 10 MG/5 ML

4

perphenazine tablet 16mg 2




PEXEVA TABLET 10MG 4 STPEXEVA TABLET 20MG 4 STPEXEVA TABLET 30MG 4 STPEXEVA TABLET 40MG 4 STphenelzine sulfate tablet 15mg 2

pimozide tablet 1mg QL 150 each per 30 day(s)

2 QL

pimozide tablet 2mg QL 150 each per 30 day(s)

2 QL

protriptyline hcl tablet 10mg 2

protriptyline hcl tablet 5mg 2

quetiapine fumarate er tablet er 24hr 150mg QL 30 each per 30 day(s)

2 QL




88


/Limits


2 QL


2 QL


2 QL


2 QL

quetiapine fumarate tablet 100mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


1 QL


1 QL

REXULTI TABLET 0.25MG


REXULTI TABLET 0.5MG



/Limits

REXULTI TABLET 1MG


REXULTI TABLET 2MG


REXULTI TABLET 3MG


REXULTI TABLET 4MG


RISPERDAL CONSTA FOR SUSPENSION 12.5 MG/2 ML

4

RISPERDAL CONSTA FOR SUSPENSION 25 MG/2 ML

4

RISPERDAL CONSTA FOR SUSPENSION 37.5 MG/2 ML

4

RISPERDAL CONSTA FOR SUSPENSION 50 MG/2 ML

4

risperidone odt tablet disperse 0.25mg QL 30 each per 30 day(s)

2 QL

risperidone odt tablet disperse 0.5mg QL 60 each per 30 day(s)

2 QL

risperidone odt tablet disperse 1mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL




89


/Limits


2 QL

risperidone solution 1 mg/ml QL 240 milliliter(s) per 30 day(s)

2 QL

risperidone tablet 0.25mg QL 30 each per 30 day(s)

1 QL

risperidone tablet 0.5mg QL 30 each per 30 day(s)

1 QL

risperidone tablet 1mg QL 60 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

SAPHRIS TAB SUBLINGUAL 10MG


SAPHRIS TAB SUBLINGUAL 2.5MG


SAPHRIS TAB SUBLINGUAL 5MG


selegiline hcl capsule 5mg 2

selegiline hcl tablet 5mg 2

sertraline hcl concentrate 20 mg/ml QL 300 milliliter(s) per 30 day(s)

2 QL

sertraline hcl tablet 100mg QL 60 each per 30 day(s)

1 QL


/Limits


1 QL


1 QL

thioridazine hcl tablet 100mg 2 PAthioridazine hcl tablet 10mg 2 PAthioridazine hcl tablet 25mg 2 PAthioridazine hcl tablet 50mg 2 PAthiothixene capsule 10mg 2

thiothixene capsule 1mg 2



tranylcypromine sulfate tablet 10mg

2

trazodone hcl tablet 100mg QL 120 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL

trifluoperazine hcl tablet 10mg 2




trimipramine maleate capsule 100mg

2


2


2




90


/Limits

TRINTELLIX TABLET 10MG






venlafaxine hcl er capsule er 24hr 150mg QL 60 each per 30 day(s)

2 QL

venlafaxine hcl er capsule er 24hr 37.5mg QL 30 each per 30 day(s)

2 QL

venlafaxine hcl er capsule er 24hr 75mg QL 90 each per 30 day(s)

2 QL

venlafaxine hcl tablet 100mg 2


venlafaxine hcl tablet 37.5mg 2



VERSACLOZ SUSPENSION 50 MG/ML QL 600 milliliter(s) per 30 day(s)

5 QL; PA

VIIBRYD KIT 10 MG (7)-20 MG (23) QL 30 each per 30 day(s)

4 QL; ST

VIIBRYD TABLET 10MG


VIIBRYD TABLET 20MG



/Limits

VIIBRYD TABLET 40MG


VRAYLAR CAP THER PACK 1.5 MG (1)-3 MG (6) QL 30 each per 30 day(s)

4 QL; ST

VRAYLAR CAPSULE 1.5MG


VRAYLAR CAPSULE 3MG


VRAYLAR CAPSULE 4.5MG


VRAYLAR CAPSULE 6MG


ZELAPAR TABLET DISPERSE 1.25MG

5 ST

ziprasidone hcl capsule 20mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL


2 QL

ZYPREXA RELPREVV FOR SUSPENSION 210MG

4 BvsD

DIURETICSVASOPRESSIN ANTAGONISTS JYNARQUE TAB THER PACK 45 MG (AM)/15 MG (PM) QL 60 each per 30 day(s)

5 QL; PA

JYNARQUE TAB THER PACK 60 MG (AM)/30 MG (PM) QL 60 each per 30 day(s)

5 QL; PA




91


/Limits

JYNARQUE TAB THER PACK 90 MG (AM)/30 MG (PM) QL 60 each per 30 day(s)

5 QL; PA

SAMSCA TABLET 15MG


SAMSCA TABLET 30MG


ELECTROLYTIC, CALORIC, AND WATER BALANCE

ALKALINIZING AGENTS potassium citrate er tablet er 10 meq (1,080 mg)

2

potassium citrate er tablet er 15 meq (1,620 mg)

2

potassium citrate er tablet er 5 meq (540 mg)

2

sodium lactate solution 5 meq/ml

2 BvsD; HI

AMMONIA DETOXICANTS CARBAGLU TABLET 200MG

5 PA

constulose solution 10 gram/15 ml

2

enulose solution 10 gram/15 ml

2

generlac solution 10 gram/15 ml

2

lactulose solution 10 gram/15 ml

1

sodium phenylbutyrate powder 0.94 gram/gram

2

CALORIC AGENTS *amino acid electrolyte infusion 8.5%***

2 BvsD; HI


/Limits

AMINOSYN II SOLUTION 10 %

3 BvsD; HI

AMINOSYN II SOLUTION 8.5 %

3 BvsD; HI

aminosyn ii with electrolytes solution 8.5 %

2 BvsD; HI

AMINOSYN WITH ELECTROLYTES SOLUTION 7 %

3 BvsD; HI

AMINOSYN-HBC SOLUTION 7 %

3 BvsD; HI

AMINOSYN-PF SOLUTION 10 %

3 BvsD; HI

AMINOSYN-PF SOLUTION 7 %

3 BvsD; HI

AMINOSYN-RF SOLUTION 5.2 %

3 BvsD; HI

CLINIMIX E SOLUTION 2.75 %

3 BvsD; HI

CLINIMIX E SOLUTION 4.25 %

3 BvsD; HI

CLINIMIX E SOLUTION 5 % 3 BvsD; HICLINIMIX SOLUTION 2.75 %

3 BvsD; HI

CLINIMIX SOLUTION 4.25 %

3 BvsD; HI

CLINIMIX SOLUTION 5 % 3 BvsD; HIclinisol solution 15 % 2 BvsD; HIdextrose 10%-0.2% nacl solution 10 %-0.2 %

2 BvsD; HI

dextrose 10%-0.45% nacl solution 10 %-0.45 %

2 BvsD; HI

dextrose 2.5%-0.45% nacl solution 2.5 %-0.45 %

2 BvsD




92


/Limits


2 BvsD


2 BvsD


2 BvsD


2 BvsD


2 BvsD

dextrose in water solution 10 %

2 BvsD

dextrose in water solution 5 % 2 BvsDFREAMINE HBC SOLUTION 6.9 %

3 BvsD; HI

HEPATAMINE SOLUTION 8 %

2 BvsD; HI

NEPHRAMINE SOLUTION 5.4 %

3 BvsD; HI

nutrilipid emulsion 20 % 3 BvsDplenamine solution 15 % 2 BvsD; HIPREMASOL SOLUTION 10 %

3 BvsD; HI

PREMASOL SOLUTION 6 % 2 BvsD; HIPROCALAMINE SOLUTION 3 %

3 BvsD; HI

PROSOL SOLUTION 20 % 3 BvsD; HITRAVASOL SOLUTION 10 %

3 BvsD; HI

TROPHAMINE SOLUTION 10 %

3 BvsD; HI

ION-REMOVING AGENTS


/Limits

AURYXIA TABLET 210IRONMG


calcium acetate capsule 667mg

2

FOSRENOL PACKET 1,000MG

4

FOSRENOL PACKET 750MG

4

kionex suspension 15 gram-19.3 gram/60 ml

2

lanthanum carbonate tablet chewable 1,000mg

2

lanthanum carbonate tablet chewable 500mg

2

lanthanum carbonate tablet chewable 750mg

2

RENAGEL TABLET 800MG 4

sevelamer carbonate tablet 800mg

2

sodium polystyrene sulfonate powder

2

sps suspension 15 gram-20 gram/60 ml

2

VELPHORO TABLET CHEWABLE 500IRONMG


VELTASSA PACKET 16.8 GRAM









93


/Limits

IRRIGATING SOLUTIONS physiolyte solution 140 meq-5 meq-3 meq-98 meq-27 meq-23 meq/l

2 BvsD

physiosol solution 140 meq-5 meq-3 meq-98 meq-27 meq-23 meq/l

2 BvsD

sodium chloride solution 0.9 %

2 BvsD

REPLACEMENT PREPARATIONS dextrose 5%-0.2% nacl-kcl solution 20 meq/l

2 BvsD

dextrose 5%-0.33% nacl-kcl solution 20 meq/l

2 BvsD

dextrose 5%-0.45% nacl-kcl solution 20 meq/l

2 BvsD

dextrose 5%-1/2ns-kcl solution 10 meq/l

2 BvsD; HI


2 BvsD; HI


2 BvsD; HI

dextrose 5%-ns-kcl solution 20 meq/l

2 BvsD; HI

dextrose 5%-ns-kcl solution 40 meq/l

2 BvsD; HI

dextrose 5%-potassium chloride solution 20 meq/l

2 BvsD; HI

dextrose in lactated ringers solution 5 %

2 BvsD; HI

IONOSOL MB-DEXTROSE 5% SOLUTION 5 %

3 BvsD; HI

ISOLYTE P WITH DEXTROSE SOLUTION 5 %

3 BvsD; HI

ISOLYTE S SOLUTION 3 BvsD; HIklor-con 10 tablet er 10 meq 2


/Limits

KLOR-CON M15 TABLET ER 15 MEQ

4

klor-con m20 tablet er 20 meq 2

lactated ringers solution 2 BvsD; HImagnesium sulfate solution 4 meq/ml (50 %)

2 BvsD; HI

NORMOSOL-M AND DEXTROSE SOLUTION 5 %

2 BvsD; HI

NORMOSOL-R AND DEXTROSE SOLUTION 5 %

3 BvsD; HI

NORMOSOL-R PH 7.4 SOLUTION

3 BvsD; HI

PLASMA-LYTE 148 SOLUTION

3 BvsD; HI

PLASMA-LYTE A PH 7.4 SOLUTION

3 BvsD; HI

potassium chl-normal saline solution 20 meq/l

2 BvsD; HI

potassium chl-normal saline solution 40 meq/l

2 BvsD; HI

potassium chloride capsule er 10 meq

1

potassium chloride capsule er 8 meq

1

potassium chloride in d5lr solution 20 meq/l

2 BvsD; HI

potassium chloride solution 10 meq/100 ml

2 BvsD; HI

potassium chloride solution 2 meq/ml

2 BvsD

potassium chloride solution 2 meq/ml

2 BvsD; HI


2 BvsD




94


/Limits


2


2 BvsD


2

potassium chloride tablet er 10 meq

1


1


1

potassium chloride-nacl solution 20 meq/l

2 BvsD; HI

ringers injection solution 2 BvsD; HIsodium chloride solution 0.45 %

2 BvsD

sodium chloride solution 0.9 % 2 BvsDsodium chloride solution 2.5 meq/ml

2 BvsD

sodium chloride solution 3 % 2 BvsD; HIsodium chloride solution 5 % 2 BvsD; HItpn electrolytes solution 35 meq-20 meq-5 meq-4.5 meq-35 meq-29.5 meq/20 ml

2 BvsD; HI

URICOSURIC AGENTS probenecid tablet 500mg 2

probenecid-colchicine tablet 500-0.5mg

2

ENZYMES ENZYMES ADAGEN SOLUTION 250 UNIT/ML

4

ALDURAZYME SOLUTION 2.9 MG/5 ML

5 PA


/Limits

CERDELGA CAPSULE 84MG


CEREZYME FOR SOLUTION 400 UNIT

5 PA

ELAPRASE SOLUTION 6 MG/3 ML

5 PA

ELELYSO FOR SOLUTION 200 UNIT

5 PA

ELITEK FOR SOLUTION 1.5MG

5 BvsD

ELITEK FOR SOLUTION 7.5MG

5 BvsD

FABRAZYME FOR SOLUTION 35MG

5 PA

FABRAZYME FOR SOLUTION 5MG

5 PA

KANUMA SOLUTION 20 MG/10 ML (2 MG/ML) QL 480 milliliter(s) per 28 day(s)

5 QL; PA

LUMIZYME FOR SOLUTION 50MG


NAGLAZYME SOLUTION 5 MG/5 ML

5 PA

PULMOZYME SOLUTION 1 MG/ML QL 150 milliliter(s) per 30 day(s)

5 QL; BvsD

SUCRAID SOLUTION 8,500 UNIT/ML QL 354 milliliter(s) per 30 day(s)

5 QL; PA; LA




95


/Limits

VPRIV FOR SOLUTION 400 UNIT

5 PA

EYE, EAR, NOSE AND THROAT (EENT) PREPS. ANTI-INFECTIVES (EENT) acetic acid solution 2 % 2

AZASITE SOLUTION 1 %


4 QL

bacitracin ointment 500 unit/gram

2

bacitracin-polymyxin ointment 500 unit-10,000 unit/gram

2

BACTROBAN NASAL OINTMENT 2 %

4

BESIVANCE SUSPENSION 0.6 %


4 QL

BLEPHAMIDE S.O.P. OINTMENT 10 %-0.2 %

4

BLEPHAMIDE SUSPENSION 10 %-0.2 %

4

CILOXAN OINTMENT 0.3 %


CIPRO HC SUSPENSION 0.2 %-1 %

3

CIPRODEX SUSPENSION 0.3 %-0.1 %

4

ciprofloxacin hcl solution 0.2 %

2

ciprofloxacin hcl solution 0.3 %

2


/Limits

COLY-MYCIN S SUSPENSION 3.3 MG-3 MG-10 MG-0.5 MG/ML

4 NM

erythromycin ointment 5 mg/gram (0.5 %)

2

gatifloxacin solution 0.5 %


2 QL

gentamicin sulfate solution 0.3 %

2

hydrocortisone-acetic acid solution 1 %-2 %

2

levofloxacin solution 0.5 % 2

MOXEZA SOLUTION 0.5 %


4 QL

moxifloxacin solution 0.5 %


2 QL

NATACYN SUSPENSION 5 %

4

neomycin-bacitracin-poly-hc ointment 3.5 mg-400 unit-10,000 unit/gram-1 %

2

neomycin-bacitracin-polymyxin ointment 3.5 mg-400 unit-10,000 unit/gram

2

neomycin-polymyxin-dexameth ointment 3.5 mg/gram-10,000 unit/gram-0.1 %

1

neomycin-polymyxin-dexameth suspension 3.5 mg/ml-10,000 unit/ml-0.1 %

1




96


/Limits

neomycin-polymyxin-gramicidin solution 1.75 mg-10,000 unit-0.025 mg/ml

2

neomycin-polymyxin-hc suspension 3.5 mg-10,000 unit-10 mg/ml

2

neomycin-polymyxin-hc suspension 3.5 mg/ml-10,000 unit/ml-1 %

2

neomycin-polymyxin-hydrocort solution 3.5 mg/ml-10,000 unit/ml-1 %

2

ofloxacin solution 0.3 % 2

polymyxin b sul-trimethoprim solution 10,000 unit-1 mg/ml

1

PRED-G OINTMENT 0.3 %-0.6 %

4

PRED-G SUSPENSION 0.3 %-1 %

4

sulfacetamide sodium ointment 10 %

2

sulfacetamide sodium solution 10 %

2

sulfacetamide-prednisolone solution 10 %-0.23 % (0.25 %)

2

TOBRADEX OINTMENT 0.3 %-0.1 %

4

TOBRADEX ST SUSPENSION 0.3 %-0.05 %

4

tobramycin solution 0.3 % 1

tobramycin-dexamethasone suspension 0.3 %-0.1 %

2

TOBREX OINTMENT 0.3 % 4

trifluridine solution 1 % 2

ZIRGAN GEL 0.15 % 4


/Limits

ZYLET SUSPENSION 0.3 %-0.5 %

4

ANTI-INFLAMMATORY AGENTS (EENT)ACUVAIL SOLUTION 0.45 %


ALREX SUSPENSION 0.2 %


4 QL

dexamethasone sodium phosphate solution 0.1 %

2

diclofenac sodium solution 0.1 %

2

DUREZOL EMULSION 0.05 %


4 QL

FLAREX SUSPENSION 0.1 %

4

fluocinolone acetonide oil oil 0.01 %

2

fluorometholone suspension 0.1 %

2

flurbiprofen sodium solution 0.03 %

2

FML FORTE SUSPENSION 0.25 %

4

ILEVRO SUSPENSION 0.3 %


4 QL

ketorolac tromethamine ophth soln 0.4%

2




97


/Limits

ketorolac tromethamine solution 0.5 %

2

LOTEMAX GEL 0.5 %


LOTEMAX OINTMENT 0.5 %


LOTEMAX SUSPENSION 0.5 %


4 QL

MAXIDEX SUSPENSION 0.1 %

4

NEVANAC SUSPENSION 0.1 %


4 QL

PRED MILD SUSPENSION 0.12 %


4 QL

prednisolone sodium phosphate solution 1 %

2

RESTASIS EMULSION 0.05 %


XIIDRA SOLUTION 5 %


ANTIALLERGIC AGENTS ALOMIDE SOLUTION 0.1 %


4 QL

azelastine hcl solution 0.05 % 2


/Limits

azelastine hcl solution 137 mcg (0.1 %) QL 60 milliliter(s) per 30 day(s)

2 QL

azelastine hcl solution 205.5 mcg (0.15 %) QL 60 milliliter(s) per 30 day(s)

2 QL

BEPREVE SOLUTION 1.5 %


4 QL

EMADINE SOLUTION 0.05 %

4

LASTACAFT SOLUTION 0.25 %

QL 6 milliliter(s) per 30 day(s) 4 QL

olopatadine hcl solution 0.1 %


2 QL


QL 7.5 milliliter(s) per 30 day(s)

2 QL



PAZEO SOLUTION 0.7 %


ANTIGLAUCOMA AGENTS ALPHAGAN P SOLUTION 0.1 %


3 QL




98


/Limits

AZOPT SUSPENSION 1 %


4 QL

betaxolol hcl solution 0.5 % 2

BETOPTIC S SUSPENSION 0.25 %

4

bimatoprost solution 0.03 %

QL 7.5 milliliter(s) per 30 day(s)

2 QL

brimonidine tartrate solution 0.2 %

1

COMBIGAN SOLUTION 0.2 %-0.5 %


3 QL

dorzolamide hcl solution 2 % 2

dorzolamide-timolol solution 22.3 mg-6.8 mg/ml

2

latanoprost solution 0.005 % 2

levobunolol hcl solution 0.5 % 2

LUMIGAN SOLUTION 0.01 %


methazolamide tablet 25mg 2

methazolamide tablet 50mg 2

metipranolol solution 0.3 % 2

PHOSPHOLINE IODIDE FOR SOLUTION 0.125 %

4

RHOPRESSA SOLUTION 0.02 %


4 QL; ST


/Limits

SIMBRINZA SUSPENSION 1 %-0.2 %


4 QL

timolol maleate gel form soln 0.25 %

2

timolol maleate gel form soln 0.5 %

2

timolol maleate solution 0.25 %

1

timolol maleate solution 0.5 % 1

timolol maleate solution 0.5 % 2

TIMOPTIC OCUDOSE SOLUTION 0.25 %

4

TIMOPTIC OCUDOSE SOLUTION 0.5 %

4

VYZULTA SOLUTION 0.024 %

4 ST

EENT DRUGS, MISCELLANEOUSapraclonidine hcl solution 0.5 %

2

carteolol hcl solution 1 % 2

IOPIDINE SOLUTION 1 % 4

ipratropium bromide solution 21 mcg (0.03 %)

2

ipratropium bromide solution 42 mcg (0.06 %)

2

LOCAL ANESTHETICS (EENT) lidocaine hcl gel 2 % 2

lidocaine hcl solution 40 mg/ml

2

lidocaine hcl viscous solution 2 %

2

proparacaine hcl solution 0.5 %

2




99


/Limits

GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS (GI DRUGS)APRISO CAPSULE ER 24HR 0.375 GRAM


balsalazide disodium capsule 750mg

2

budesonide er tablet er 24hr 9mg QL 30 each per 30 day(s)

2 QL; ST

DELZICOL CAPSULE DR 400MG

4 ST

DIPENTUM CAPSULE 250MG

4

mesalamine enema 4 gram/60 ml

2

mesalamine tablet dr 1.2 gram


mesalamine tablet dr 800mg 2 ST PENTASA CAPSULE ER 250MG


PENTASA CAPSULE ER 500MG


ROWASA KIT 4 GRAM/60 ML

4

sulfasalazine dr tablet dr 500mg

2 NM

sulfasalazine tablet 500mg 2 NM

UCERIS FOAM 2 MG/ACTUATION



/Limits

UCERIS TABLET ER 24HR 9MG


ANTIEMETICSaprepitant capsule 125 mg (1)-80 mg (1)-80 mg (1) QL 9 each per 30 day(s)

2 QL; BvsD

aprepitant capsule 125mg QL 3 each per 30 day(s)

2 QL; BvsD


2 QL; BvsD


2 QL; BvsD

CESAMET CAPSULE 1MG


CINVANTI EMULSION 130 MG/18 ML (7.2 MG/ML) QL 18 milliliter(s) per 21 day(s)

4 QL; BvsD

dronabinol capsule 10mg QL 60 each per 30 day(s)

2 QL; PA

dronabinol capsule 2.5mg QL 60 each per 30 day(s)

2 QL; PA

dronabinol capsule 5mg QL 60 each per 30 day(s)

2 QL; PA

granisetron hcl tablet 1mg 2 BvsDondansetron hcl solution 4 mg/2 ml

2 BvsD

ondansetron hcl solution 4 mg/5 ml

2 BvsD

ondansetron hcl tablet 24mg 2 BvsDondansetron hcl tablet 4mg QL 120 each per 30 day(s)

2 QL; BvsD

ondansetron hcl tablet 8mg QL 120 each per 30 day(s)

2 QL; BvsD




100


/Limits

ondansetron odt tablet disperse 4mg QL 120 each per 30 day(s)

2 QL; BvsD

ondansetron odt tablet disperse 8mg QL 120 each per 30 day(s)

2 QL; BvsD

promethegan suppository 25mg

2

VARUBI TABLET 90MG

QL 2 each per 14 day(s) 4 QL; BvsD

ANTIULCER AGENTS AND ACID SUPPRESSANTS CARAFATE SUSPENSION 1 GRAM/10 ML

4

cimetidine solution 300 mg/5 ml

2

cimetidine tablet 200mg 2




DEXILANT CAPSULE DR 30MG


DEXILANT CAPSULE DR 60MG


esomeprazole magnesium capsule dr 20mg QL 60 each per 30 day(s)

2 QL; ST

esomeprazole magnesium capsule dr 40mg QL 60 each per 30 day(s)

2 QL; ST

esomeprazole sodium for solution 40mg

2 BvsD

famotidine for suspension 40 mg/5 ml (8 mg/ml)

2


/Limits

famotidine solution 20 mg/2 ml 2 BvsDfamotidine solution 20 mg/50 ml

2 BvsD

famotidine tablet 20mg 1

famotidine tablet 40mg 1

lansoprazole capsule dr 15mg QL 60 each per 30 day(s)

2 QL

lansoprazole capsule dr 30mg QL 60 each per 30 day(s)

2 QL

lansoprazole tablet disperse 15mg QL 60 each per 30 day(s)

2 QL; ST

lansoprazole tablet disperse 30mg QL 60 each per 30 day(s)

2 QL; ST

misoprostol tablet 100 mcg 2

misoprostol tablet 200 mcg 2

nizatidine capsule 150mg 2

nizatidine capsule 300mg 2

nizatidine solution 150 mg/10 ml

2

omeprazole capsule dr 10mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL

pantoprazole sodium tablet dr 20mg QL 60 each per 30 day(s)

1 QL

pantoprazole sodium tablet dr 40mg QL 60 each per 30 day(s)

1 QL




101


/Limits

PROTONIX PACKET 40MG


rabeprazole sodium tablet dr 20mg QL 30 each per 30 day(s)

2 QL

ranitidine hcl capsule 150mg QL 60 each per 30 day(s)

1 QL

ranitidine hcl capsule 300mg QL 60 each per 30 day(s)

1 QL

ranitidine hcl solution 50 mg/2 ml (25 mg/ml)

2 BvsD

ranitidine hcl syrup 15 mg/ml 1

ranitidine hcl tablet 150mg QL 60 each per 30 day(s)

1 QL

ranitidine hcl tablet 300mg QL 60 each per 30 day(s)

1 QL

sucralfate tablet 1 gram 2

CATHARTICS AND LAXATIVES alosetron hcl tablet 0.5mg QL 60 each per 30 day(s)

2 QL

alosetron hcl tablet 1mg QL 60 each per 30 day(s)

2 QL

CLENPIQ SOL 4 ST GATTEX KIT 5MG 5 PA

gavilyte-c for solution 240 gram-22.72 gram-6.72 gram-5.84 gram-2.98 gram

2

gavilyte-g for solution 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram

2

gavilyte-n for solution 420 gram

2

GOLYTELY FOR SOLUTION 227.1 GRAM-21.5 GRAM-6.36 GRAM-5.53 GRAM-2.82 GRAM

4


/Limits

LINZESS CAPSULE 145 MCG






MOVANTIK TABLET 12.5MG


MOVANTIK TABLET 25MG


MOVIPREP FOR SOLUTION 100 GRAM-7.5 GRAM-2.691 GRAM-1.015 GRAM-5.9 GRAM-4.7 GRAM

4

peg 3350-electrolyte for solution 240 gram-22.72 gram-6.72 gram-5.84 gram-2.98 gram

2

peg 3350-electrolyte for solution 420 gram

2

peg-3350 and electrolytes for solution 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram

2

polyethylene glycol 3350 powder 17 gram/dose

2

RELISTOR SOLUTION 12 MG/0.6 ML QL 16.8 milliliter(s) per 28 day(s)

5 QL; PA

RELISTOR SOLUTION 8 MG/0.4 ML QL 22.4 milliliter(s) per 28 day(s)

5 QL; PA




102


/Limits

RELISTOR TABLET 150MG


SUPREP SOLUTION 17.5 GRAM-3.13 GRAM-1.6 GRAM

4

SYMPROIC TABLET 0.2MG


trilyte with flavor packets for solution 420 gram

2

TRULANCE TABLET 3MG


CHOLELITHOLYTIC AGENTS CHENODAL TABLET 250MG


CHOLBAM CAPSULE 250MG


CHOLBAM CAPSULE 50MG


OCALIVA TABLET 10MG


OCALIVA TABLET 5MG


ursodiol capsule 300mg 2

ursodiol tablet 250mg 2

ursodiol tablet 500mg 2

DIGESTANTS CREON CAPSULE DR PART 12,000 UNIT-38,000 UNIT-60,000 UNIT

3


/Limits

CREON CAPSULE DR PART 24,000 UNIT-76,000 UNIT-120,000 UNIT

3


3


3


3

PANCREAZE CAPSULE DR PART 10,500 UNIT-35,500 UNIT-61,500 UNIT

4


4


4


4


4

PERTZYE CAPSULE DR PART 16,000 UNIT-57,500 UNIT-60,500 UNIT

3


3


3




103


/Limits

VIOKACE TABLET 10,440 UNIT-39,150 UNIT-39,150 UNIT

4

VIOKACE TABLET 20,880 UNIT-78,300 UNIT-78,300 UNIT

4

ZENPEP CAPSULE DR PART 10,000 UNIT-32,000 UNIT-42,000 UNIT

3


3


3


3


3


3


3


3


3

PROKINETIC AGENTS


/Limits

diphenoxylate-atropine liquid 2.5 mg-0.025 mg/5 ml

2

diphenoxylate-atropine tablet 2.5-0.025mg

2

loperamide capsule 2mg 2

metoclopramide hcl odt tablet disperse 10mg

2

metoclopramide hcl odt tablet disperse 5mg

2

metoclopramide hcl solution 5 mg/5 ml

2

metoclopramide hcl solution 5 mg/ml

2 BvsD

metoclopramide hcl tablet 10mg

1

metoclopramide hcl tablet 5mg 1

XERMELO TABLET 250MG


GOLD COMPOUNDSGOLD COMPOUNDSRIDAURA CAPSULE 3MG 4

HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPSULE 100MG 4

DEPEN TABLET 250MG 4 PAEXJADE TABLET SOLUBLE 125MG

QL 720 each per 30 day(s) 4 QL; LA

EXJADE TABLET SOLUBLE 250MG


EXJADE TABLET SOLUBLE 500MG


FERRIPROX SOLUTION 100 MG/ML

4




104


/Limits

FERRIPROX TABLET 500MG

4

JADENU SPRINKLE PACKET 180MG






JADENU TABLET 180MG


JADENU TABLET 360MG


JADENU TABLET 90MG


trientine hcl capsule 250mg 2 PA

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS budesonide ec capsule dr part 3mg

2

cortisone acetate tablet 25mg 2

dexamethasone elixir 0.5 mg/5 ml

2

DEXAMETHASONE INTENSOL CONCENTRATE 1 MG/ML

4

dexamethasone sodium phosphate solution 10 mg/ml

2 BvsD

dexamethasone sodium phosphate solution 4 mg/ml

2 BvsD

dexamethasone tablet 0.5mg 2




/Limits

dexamethasone tablet 1mg 2




fludrocortisone acetate tablet 0.1mg

2

hydrocortisone tablet 10mg 2



INTRAROSA INSERT 6.5MG


methylprednisolone acetate suspension 40 mg/ml

2 BvsD

methylprednisolone acetate suspension 80 mg/ml

2 BvsD

methylprednisolone sodium succ for solution 1,000mg

2 BvsD

methylprednisolone sodium succ for solution 125mg

2 BvsD

methylprednisolone sodium succ for solution 40mg

2 BvsD

methylprednisolone tab ther pack 4mg

2

methylprednisolone tablet 16mg

2

methylprednisolone tablet 32mg

2

methylprednisolone tablet 4mg 2

methylprednisolone tablet 8mg 2

prednisolone acetate suspension 1 %


2 QL

prednisolone sodium phos odt tablet disperse 10mg

2




105


/Limits


2


2

prednisolone sodium phosphate solution 10 mg/5 ml

2

prednisolone sodium phosphate solution 20 mg/5 ml (4 mg/ml)

2

prednisolone sodium phosphate solution 25 mg/5 ml (5 mg/ml)

2

prednisolone sodium phosphate solution 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone solution 15 mg/5 ml

2

PREDNISONE INTENSOL CONCENTRATE 5 MG/ML

2

prednisone solution 5 mg/5 ml 2

prednisone tablet 10mg 1


prednisone tablet 2.5mg 1




VERIPRED 20 SOLUTION 20 MG/5 ML (4 MG/ML)

4

ANDROGENS ANADROL-50 TABLET 50MG


ANDRODERM PATCH 24HR 2 MG/24 HOUR



/Limits

ANDRODERM PATCH 24HR 4 MG/24 HOUR


ANDROGEL GEL 20.25 MG/1.25 GRAM (1.62 %) QL 37.5 gram(s) per 30 day(s)

4 QL

ANDROGEL GEL 20.25 MG/1.25 GRAM PER ACTUATION (1.62 %) QL 300 gram(s) per 30 day(s)

4 QL

ANDROGEL GEL 40.5 MG/2.5 GRAM (1.62 %) QL 300 gram(s) per 30 day(s)

4 QL

ANDROGEL GEL 50 MG/5 GRAM (1 %) QL 300 gram(s) per 30 day(s)

4 QL

danazol capsule 100mg 2



oxandrolone tablet 10mg 2

oxandrolone tablet 2.5mg 2

testosterone cypionate solution 100 mg/ml

2

testosterone cypionate solution 200 mg/ml

2

testosterone enanthate solution 200 mg/ml QL 10 milliliter(s) per 30 day(s)

2 QL

testosterone gel 10 mg/0.5 gram per actuation (2 %) QL 120 gram(s) per 30 day(s)

2 QL; PA

testosterone gel 12.5 mg/1.25 gram per actuation (1 %) QL 300 gram(s) per 30 day(s)

2 QL




106


/Limits

testosterone gel 25 mg/2.5 gram (1 %) QL 300 gram(s) per 30 day(s)

2 QL

testosterone gel 50 mg/5 gram (1 %) QL 300 gram(s) per 30 day(s)

2 QL

testosterone solution 30 mg/1.5 ml per actuation QL 180 milliliter(s) per 30 day(s)

2 QL; PA

ANTIDIABETIC AGENTS acarbose tablet 100mg QL 90 each per 30 day(s)

2 QL

acarbose tablet 25mg QL 90 each per 30 day(s)

2 QL

acarbose tablet 50mg QL 90 each per 30 day(s)

2 QL

ACTOPLUS MET XR TABLET ER 24HR 15-1,000MG


4 QL

ACTOPLUS MET XR TABLET ER 24HR 30-1,000MG


4 QL

alogliptin tablet 12.5mg QL 30 each per 30 day(s)

2 QL

alogliptin tablet 25mg QL 30 each per 30 day(s)

2 QL

alogliptin tablet 6.25mg QL 30 each per 30 day(s)

2 QL

alogliptin-metformin tablet 12.5-1,000mg QL 60 each per 30 day(s)

2 QL

alogliptin-metformin tablet 12.5-500mg QL 60 each per 30 day(s)

2 QL


/Limits

alogliptin-pioglitazone tablet 12.5-15mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL

alogliptin-pioglitazone tablet 25-15mg QL 30 each per 30 day(s)

2 QL


2 QL


2 QL

BASAGLAR KWIKPEN U-100 SOLN PEN-INJ 100 UNIT/ML (3 ML) QL 45 milliliter(s) per 30 day(s)

4 QL

glimepiride tablet 1mg 1



glipizide er tablet er 24hr 10mg

1

glipizide er tablet er 24hr 2.5mg

1

glipizide er tablet er 24hr 5mg 1

glipizide tablet 10mg 1




107


/Limits

glipizide tablet 5mg 1

glipizide-metformin tablet 2.5-250mg

1

glipizide-metformin tablet 2.5-500mg

1

glipizide-metformin tablet 5-500mg

1

GLYXAMBI TABLET 10-5MG


GLYXAMBI TABLET 25-5MG


INVOKAMET TABLET 150-1,000MG


INVOKAMET TABLET 150-500MG


INVOKAMET TABLET 50-1,000MG


INVOKAMET TABLET 50-500MG


INVOKAMET XR TABLET ER 24HR 150-1,000MG


INVOKAMET XR TABLET ER 24HR 150-500MG


INVOKAMET XR TABLET ER 24HR 50-1,000MG



/Limits

INVOKAMET XR TABLET ER 24HR 50-500MG


INVOKANA TABLET 100MG


INVOKANA TABLET 300MG


JARDIANCE TABLET 10MG


JARDIANCE TABLET 25MG


JENTADUETO TABLET 2.5-1,000MG


JENTADUETO TABLET 2.5-500MG


JENTADUETO TABLET 2.5-850MG


JENTADUETO XR TABLET ER 24HR 2.5-1,000MG


JENTADUETO XR TABLET ER 24HR 5-1,000MG


LANTUS SOLOSTAR SOLN PEN-INJ 100 UNIT/ML (3 ML) QL 45 milliliter(s) per 30 day(s)

3 QL




108


/Limits

LANTUS SOLUTION 100 UNIT/ML QL 30 milliliter(s) per 30 day(s)

3 QL

metformin hcl er tablet er 24hr 500mg

1

metformin hcl er tablet er 24hr 750mg

1

metformin hcl tablet 1,000mg 1

metformin hcl tablet 500mg 1

metformin hcl tablet 850mg 1

miglitol tablet 100mg 2



nateglinide tablet 120mg 1

nateglinide tablet 60mg 1

NOVOLIN 70-30 SUSPENSION 100 UNIT/ML (70-30)

3

NOVOLIN N SUSPENSION 100 UNIT/ML

3

NOVOLIN R SOLUTION 100 UNIT/ML

3

NOVOLOG FLEXPEN SOLN PEN-INJ 100 UNIT/ML

3

NOVOLOG MIX 70-30 FLEXPEN SUSP-PEN-INJ 100 UNIT/ML (70-30)

3

NOVOLOG MIX 70-30 SUSPENSION 100 UNIT/ML (70-30)

3

NOVOLOG SOLN CARTRIDGE 100 UNIT/ML

3

NOVOLOG SOLUTION 100 UNIT/ML

3


/Limits

pioglitazone hcl tablet 15mg QL 30 each per 30 day(s)

1 QL


1 QL


1 QL

pioglitazone-glimepiride tablet 30-2mg QL 30 each per 30 day(s)

2 QL

pioglitazone-glimepiride tablet 30-4mg QL 30 each per 30 day(s)

2 QL

pioglitazone-metformin tablet 15-500mg QL 90 each per 30 day(s)

2 QL

pioglitazone-metformin tablet 15-850mg QL 90 each per 30 day(s)

2 QL

repaglinide tablet 0.5mg 1

repaglinide tablet 1mg 1

repaglinide tablet 2mg 1

repaglinide-metformin hcl tablet 1-500mg

2

repaglinide-metformin hcl tablet 2-500mg

2

SEGLUROMET TABLET 2.5-1,000MG


SEGLUROMET TABLET 2.5-500MG


SEGLUROMET TABLET 7.5-1,000MG





109


/Limits

SEGLUROMET TABLET 7.5-500MG


STEGLATRO TABLET 15MG


STEGLATRO TABLET 5MG


SYMLINPEN 120 SOLN PEN-INJ 2,700 MCG/2.7 ML QL 10.8 milliliter(s) per 30 day(s)

3 QL; ST

SYMLINPEN 60 SOLN PEN-INJ 1,500 MCG/1.5 ML QL 10.8 milliliter(s) per 30 day(s)

4 QL; ST

SYNJARDY TABLET 12.5-1,000MG


SYNJARDY TABLET 12.5-500MG


SYNJARDY TABLET 5-1,000MG


SYNJARDY TABLET 5-500MG


SYNJARDY XR TABLET ER 24HR 10-1,000MG



/Limits

SYNJARDY XR TABLET ER 24HR 12.5-1,000MG






tolazamide tablet 250mg 1

tolazamide tablet 500mg 1

tolbutamide tablet 500mg 1

TOUJEO MAX SOLOSTAR SOLN PEN-INJ 300 UNIT/ML (3 ML) QL 30 milliliter(s) per 30 day(s)

3 QL

TOUJEO SOLOSTAR SOLN PEN-INJ 300 UNIT/ML (1.5 ML) QL 45 milliliter(s) per 30 day(s)

3 QL

TRADJENTA TABLET 5MG


TRULICITY SOLN PEN-INJ 0.75 MG/0.5 ML QL 4 milliliter(s) per 28 day(s)

3 QL; ST

TRULICITY SOLN PEN-INJ 1.5 MG/0.5 ML QL 4 milliliter(s) per 28 day(s)

3 QL; ST

VICTOZA 3-PAK SOLN PEN-INJ 0.6 MG/0.1 ML (18 MG/3 ML) QL 9 milliliter(s) per 30 day(s)

3 QL; ST




110


/Limits

ANTIHYPOGLYCEMIC AGENTS desmopressin acetate solution 10 mcg/spray (0.1 ml) QL 15 milliliter(s) per 30 day(s)

2 QL

desmopressin acetate solution 4 mcg/ml QL 30 milliliter(s) per 30 day(s)

2 QL; BvsD

desmopressin acetate tablet 0.1mg QL 180 each per 30 day(s)

2 QL

desmopressin acetate tablet 0.2mg QL 180 each per 30 day(s)

2 QL

H.P. ACTHAR GEL 80 UNIT/ML

5 PA

CONTRACEPTIVES amethia tablet 0.15 mg-30 mcg (84)/10 mcg (7) QL 91 each per 91 day(s)

2 QL

apri tablet 0.15-0.03mg 2

aranelle tablet 0.5 mg-35 mcg (7)/1 mg-35 mcg (9)/0.5 mg-35 mcg (5)

2

aviane tablet 0.1 mg-20 mcg 2

balziva tablet 0.4 mg-35 mcg 2

blisovi fe tablet 1.5 mg-30 mcg (21)/75 mg (7)

2

briellyn tablet 0.4 mg-35 mcg 2

camila tablet 0.35mg 2

cryselle tablet 0.3 mg-30 mcg 2

cyclafem tablet 0.5 mg-35 mcg (7)/0.75 mg-35 mcg (7)/1 mg-35 mcg (7)

2


/Limits

cyclafem tablet 1 mg-35 mcg 2

desogestr-eth estrad eth estra tablet 0.15 mg-0.02 mg (21)/0.01 mg (5)

2

desogestrel-ethinyl estradiol tablet 0.15-0.03mg

2

drospirenone-eth estra-levomef tablet 3 mg-0.02 mg-0.451 mg (24)/0.451 mg (4)

2

drospirenone-ethinyl estradiol tablet 0.03-3mg

2

emoquette tablet 0.15-0.03mg 2

errin tablet 0.35mg 2

ethynodiol-ethinyl estradiol tablet 1 mg-35 mcg

2

ethynodiol-ethinyl estradiol tablet 1 mg-50 mcg

2

introvale tablet 0.15 mg-30 mcg QL 91 each per 91 day(s)

2 QL

jolivette tablet 0.35mg 2

junel fe 24 tablet 1 mg-20 mcg (24)/75 mg (4)

2

junel fe tablet 1 mg-20 mcg (21)/75 mg (7)

2

junel fe tablet 1.5 mg-30 mcg (21)/75 mg (7)

2

junel tablet 1.5 mg-30 mcg 2

kariva tablet 0.15 mg-0.02 mg (21)/0.01 mg (5)

2

kelnor 1-35 tablet 1 mg-35 mcg

2

lessina tablet 0.1 mg-20 mcg 2

levonorg-eth estrad eth estrad tablet 0.15 mg-30 mcg (84)/10 mcg (7)

2




111


/Limits

levonorgestrel-eth estradiol tablet 0.15 mg-30 mcg QL 91 each per 91 day(s)

2 QL

levonorgestrel-eth estradiol tablet 50 mcg-30 mcg (6)/75 mcg-40 mcg (5)/125 mcg-30 mcg (10)

2

levonorgestrel-eth estradiol tablet 90 mcg-20 mcg

2

levora-28 tablet 0.15 mg-30 mcg

2

LO LOESTRIN FE TABLET 1 MG-10 MCG (24)/10 MCG (2)/75 MG (2)

4

LOESTRIN FE TABLET 1 MG-20 MCG (21)/75 MG (7)

4

LOESTRIN FE TABLET 1.5 MG-30 MCG (21)/75 MG (7)

4

LOESTRIN TABLET 1 MG-20 MCG

4

LOESTRIN TABLET 1.5 MG-30 MCG

4

lutera tablet 0.1 mg-20 mcg 2

marlissa tablet 0.15 mg-30 mcg

2

microgestin fe tablet 1 mg-20 mcg (21)/75 mg (7)

2

microgestin fe tablet 1.5 mg-30 mcg (21)/75 mg (7)

2

microgestin tablet 1 mg-20 mcg

2

microgestin tablet 1.5 mg-30 mcg

2

mononessa tablet 0.25 mg-35 mcg

2

necon tablet 0.5 mg-35 mcg 2


/Limits

necon tablet 0.5 mg-35 mcg (7)/0.75 mg-35 mcg (7)/1 mg-35 mcg (7)

2

norethin-eth estra-ferrous fum tablet 1 mg-20 mcg (24)/75 mg (4)

2

norethindron-ethinyl estradiol tablet 1 mg-20 mcg

2

norgestimate-ethinyl estradiol tablet 0.18 mg-25 mcg (7)/0.215 mg-25 mcg (7)/0.25 mg-25 mcg (7)

2

nortrel tablet 0.5 mg-35 mcg 2

nortrel tablet 0.5 mg-35 mcg (7)/0.75 mg-35 mcg (7)/1 mg-35 mcg (7)

2

nortrel tablet 1 mg-35 mcg 2

NUVARING RING 0.12 MG -0.015 MG/24 HR


OGESTREL TABLET 0.5 MG-50 MCG

4

orsythia tablet 0.1 mg-20 mcg 2

portia tablet 0.15 mg-30 mcg 2

previfem tablet 0.25 mg-35 mcg

2

quasense tablet 0.15 mg-30 mcg

2

reclipsen tablet 0.15-0.03mg 2

SAFYRAL TABLET 3 MG-0.03 MG-0.451 MG (21)/0.451 MG (7)

4

sprintec tablet 0.25 mg-35 mcg 2

sronyx tablet 0.1 mg-20 mcg 2

tri-legest fe tablet 1 mg-20 mcg (5)/1 mg-30 mcg (7)/1 mg-35 mcg (9)/75 mg (7)

2




112


/Limits

tri-lo-estarylla tablet 0.18 mg-25 mcg (7)/0.215 mg-25 mcg (7)/0.25 mg-25 mcg (7)

2

tri-lo-sprintec tablet 0.18 mg-25 mcg (7)/0.215 mg-25 mcg (7)/0.25 mg-25 mcg (7)

2

tri-previfem tablet 0.18 mg-35 mcg (7)/0.215 mg-35 mcg (7)/0.25 mg-35 mcg(7)(28)

2

tri-sprintec tablet 0.18 mg-35 mcg (7)/0.215 mg-35 mcg (7)/0.25 mg-35 mcg(7)(28)

2

trinessa tablet 0.18 mg-35 mcg (7)/0.215 mg-35 mcg (7)/0.25 mg-35 mcg(7)(28)

2

trivora-28 tablet 50 mcg-30 mcg (6)/75 mcg-40 mcg (5)/125 mcg-30 mcg (10)

2

velivet tablet 0.1 mg-25 mcg (7)/0.125 mg-25 mcg (7)/0.15 mg-25 mcg (7)

2

vienva tablet 0.1 mg-20 mcg 2

XULANE PATCH WEEKLY 150 MCG-35 MCG/24 HOUR


zovia 1-35e tablet 1 mg-35 mcg

2

ESTROGENS AND ANTIESTROGENSDEPO-ESTRADIOL OIL 5 MG/ML

4

estradiol cream 0.01 %

QL 127.5 gram(s) per 30 day(s)

2 QL

estradiol patch tw 0.025 mg/24 hour

2


/Limits


2


2


2


2

estradiol patch weekly 0.025 mg/24 hour

2


2


2


2


2


2

estradiol tablet 0.5mg QL 450 each per 30 day(s)

2 QL

estradiol tablet 10 mcg QL 30 each per 30 day(s)

2 QL

estradiol tablet 1mg QL 450 each per 30 day(s)

2 QL

estradiol tablet 2mg QL 450 each per 30 day(s)

2 QL

FEMRING RING 0.05 MG/24 HOUR


FEMRING RING 0.1 MG/24 HOUR





113


/Limits

levonest tablet 50 mcg-30 mcg (6)/75 mcg-40 mcg (5)/125 mcg-30 mcg (10)

2

loryna tablet 0.02 mg-3 mg (24)

2

norethindrone tablet 0.35mg 2

OSPHENA TABLET 60MG


PREFEST TABLET 1 MG (3)-1 MG-0.09 MG (3) QL 30 each per 30 day(s)

4 QL; PA

PREMARIN CREAM 0.625 MG/GRAM


raloxifene hcl tablet 60mg QL 30 each per 30 day(s)

2 QL

yuvafem tablet 10 mcg QL 30 each per 30 day(s)

2 QL

GONADOTROPINS chorionic gonadotropin for solution 10,000 unit

2 PA

SYNAREL SOLUTION 2 MG/ML

4

PARATHYROID

calcitonin-salmon solution 200 unit/spray

2

FORTEO SOLUTION 20 MCG/DOSE (600 MCG/2.4 ML) QL 2.4 milliliter(s) per 28 day(s)

5 QL; PA

MIACALCIN SOLUTION 200 UNIT/ML QL 15 milliliter(s) per 30 day(s)

4 QL; BvsD


/Limits

NATPARA CARTRIDGE 100 MCG/DOSE (1.61 MG/1.13 ML) QL 2 each per 28 day(s)

5 QL; PA


5 QL; PA


5 QL; PA


5 QL; PA

TYMLOS SOLN PEN-INJ 80 MCG/DOSE (3,120 MCG/1.56 ML) QL 1.56 milliliter(s) per 30 day(s)

4 QL; PA

PROGESTINSDEPO-SUBQ PROVERA 104 SUSP PREF SYR 104 MG/0.65 ML QL 1 milliliter(s) per 90 day(s)

4 QL

medroxyprogesterone acetate susp pref syr 150 mg/ml QL 1 milliliter(s) per 90 day(s)

2 QL

medroxyprogesterone acetate suspension 150 mg/ml QL 1 milliliter(s) per 90 day(s)

2 QL




114


/Limits

medroxyprogesterone acetate tablet 10mg

1

medroxyprogesterone acetate tablet 2.5mg

1

medroxyprogesterone acetate tablet 5mg

1

norethindrone acetate tablet 5mg

2

progesterone capsule 100mg 2

progesterone capsule 200mg 2

SOMATOTROPIN AGONISTS AND ANTAGONISTS INCRELEX SOLUTION 10 MG/ML

5 PA

OMNITROPE FOR SOLUTION 5.8MG

5 PA

OMNITROPE SOLUTION 10 MG/1.5 ML (6.7 MG/ML)

5 PA

OMNITROPE SOLUTION 5 MG/1.5 ML (3.3 MG/ML)

5 PA

SAIZEN FOR SOLUTION 5MG

5 PA

SAIZEN FOR SOLUTION 8.8MG

5 PA

SAIZEN-SAIZENPREP FOR SOLUTION 8.8 MG/1.51 ML (FINAL CONCENTRATION)

5 PA

SOMAVERT FOR SOLUTION 10MG



/Limits





THYROID AND ANTITHYROID AGENTSlevothyroxine sodium tablet 100 mcg QL 90 each per 30 day(s)

1 QL

levothyroxine sodium tablet 112 mcg QL 90 each per 30 day(s)

1 QL


1 QL


1 QL


1 QL


1 QL


1 QL


1 QL


1 QL


1 QL




115


/Limits


1 QL


1 QL

LEVOXYL TABLET 100 MCG



















/Limits





liothyronine sodium tablet 25 mcg

2


2


2

methimazole tablet 10mg 2

methimazole tablet 5mg 2

propylthiouracil tablet 50mg 2

SYNTHROID TABLET 100 MCG

















116


/Limits











UNITHROID TABLET 100 MCG















/Limits









MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORSdutasteride capsule 0.5mg 2

finasteride tablet 5mg 2

ALCOHOL DETERRENTS disulfiram tablet 500mg 2

ANTIDOTESacetylcysteine solution 100 mg/ml (10 %)

2 BvsD

acetylcysteine solution 200 mg/ml (20 %)

2 BvsD

leucovorin calcium for solution 100mg

2 BvsD

leucovorin calcium for solution 350mg

2 BvsD

leucovorin calcium tablet 10mg

2


2


2

leucovorin calcium tablet 5mg 2

XURIDEN PACKET 2 GRAM





117


/Limits

ANTIGOUT AGENTS allopurinol tablet 100mg 1

allopurinol tablet 300mg 1

colchicine capsule 0.6mg QL 120 each per 30 day(s)

2 QL

colchicine tablet 0.6mg QL 120 each per 30 day(s)

2 QL

ULORIC TABLET 40MG


ULORIC TABLET 80MG


BIOLOGIC RESPONSE MODIFIERS ACTIMMUNE SOLUTION 100 MCG (2 MILLION UNIT)/0.5 ML

5 PA

AUBAGIO TABLET 14MG


AUBAGIO TABLET 7MG


AVONEX KIT 30 MCG (1 ML) QL 4 each per 30 day(s)

5 QL; PA

AVONEX PEN AUTO-INJ KIT 30 MCG/0.5 ML QL 4 each per 30 day(s)

5 QL; PA

AVONEX PREFILL SYR KIT 30 MCG/0.5 ML QL 4 each per 30 day(s)

5 QL; PA

BETASERON KIT 0.3MG


EXTAVIA KIT 0.3MG


GILENYA CAPSULE 0.5MG



/Limits

glatiramer acetate soln pref syr 20 mg/ml QL 30 milliliter(s) per 30 day(s)

2 QL; PA

glatiramer acetate soln pref syr 40 mg/ml QL 30 milliliter(s) per 30 day(s)

2 QL; PA

PLEGRIDY PEN SOLN PEN-INJ 125 MCG/0.5 ML QL 2 milliliter(s) per 30 day(s)

5 QL; PA

PLEGRIDY PEN SOLN PEN-INJ 63 MCG/0.5 ML (1)-94 MCG/0.5 ML (1) QL 2 milliliter(s) per 30 day(s)

5 QL; PA

PLEGRIDY SOLN PREF SYR 125 MCG/0.5 ML QL 2 milliliter(s) per 30 day(s)

5 QL; PA

PLEGRIDY SOLN PREF SYR 63 MCG/0.5 ML (1)-94 MCG/0.5 ML (1) QL 1 milliliter(s) per 180 day(s)

5 QL; PA

REBIF REBIDOSE SOLN AUTO-INJ 22 MCG/0.5 ML QL 12 milliliter(s) per 28 day(s)

5 QL; PA

REBIF REBIDOSE SOLN AUTO-INJ 44 MCG/0.5 ML QL 12 milliliter(s) per 28 day(s)

5 QL; PA




118


/Limits

REBIF REBIDOSE SOLN AUTO-INJ 8.8 MCG/0.2 ML (6) - 22 MCG/0.5 ML (6) QL 12 milliliter(s) per 28 day(s)

5 QL; PA

REBIF SOLN PREF SYR 22 MCG/0.5 ML QL 12 milliliter(s) per 28 day(s)

5 QL; PA

REBIF SOLN PREF SYR 44 MCG/0.5 ML QL 12 milliliter(s) per 28 day(s)

5 QL; PA

REBIF SOLN PREF SYR 8.8 MCG/0.2 ML (6) - 22 MCG/0.5 ML (6) QL 12 milliliter(s) per 28 day(s)

5 QL; PA

TECFIDERA CAPSULE DR 120MG


TECFIDERA CAPSULE DR 240MG


TECFIDERA STARTER PACK


THALOMID CAPSULE 100MG









/Limits

TYSABRI CONCENTRATE 300 MG/15 ML QL 30 milliliter(s) per 30 day(s)

5 QL; PA

BONE RESORPTION INHIBITORSalendronate sodium tablet 10mg QL 30 each per 30 day(s)

1 QL

alendronate sodium tablet 35mg QL 4 each per 28 day(s)

1 QL


1 QL


1 QL


1 QL

ibandronate sodium solution 3 mg/3 ml

2 BvsD

ibandronate sodium tablet 150mg QL 1 each per 28 day(s)

2 QL

pamidronate disodium solution 30 mg/10 ml (3 mg/ml)

4 BvsD


4 BvsD


4 BvsD

PROLIA SOLUTION 60 MG/ML QL 1 milliliter(s) per 180 day(s)

4 QL; PA




119


/Limits

risedronate sodium dr tablet dr 35mg QL 4 each per 28 day(s)

2 QL; ST

risedronate sodium tablet 150mg QL 1 each per 28 day(s)

2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST


2 QL; ST

XGEVA SOLUTION 120 MG/1.7 ML (70 MG/ML)

5 PA

zoledronic acid concentrate 4 mg/5 ml

2 BvsD

zoledronic acid solution 5 mg/100 ml

2 BvsD

ZOMETA SOLUTION 4 MG/100 ML

5 BvsD

COMPLEMENT INHIBITORS CINRYZE FOR SOLUTION 500 UNIT (5 ML) QL 40 each per 28 day(s)

5 QL; PA

FIRAZYR SOLUTION 30 MG/3 ML QL 18 milliliter(s) per 30 day(s)

5 QL; PA

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS


/Limits

ACTEMRA SOLN PREF SYR 162 MG/0.9 ML QL 3.6 milliliter(s) per 28 day(s)

5 QL; PA

ACTEMRA SOLUTION 200 MG/10 ML (20 MG/ML) QL 40 milliliter(s) per 28 day(s)

5 QL; PA


5 QL; PA


5 QL; PA

CIMZIA KIT 400 MG (200 MG X 2) QL 6 each per 28 day(s)

5 QL; PA

CIMZIA KIT 400 MG/2 ML (200 MG/ML X 2) QL 6 each per 28 day(s)

5 QL; PA

ENBREL FOR SOLUTION 25 MG (1 ML) QL 8 each per 28 day(s)

5 QL; PA

ENBREL SOLN PREF SYR 25 MG/0.5 ML (0.51 ML) QL 8 milliliter(s) per 28 day(s)

5 QL; PA

ENBREL SOLN PREF SYR 50 MG/ML (0.98 ML) QL 8 milliliter(s) per 28 day(s)

5 QL; PA

ENBREL SURECLICK SOLN AUTO-INJ 50 MG/ML (0.98 ML) QL 8 milliliter(s) per 28 day(s)

5 QL; PA




120


/Limits

HUMIRA PEDIATRIC CROHN'S PREFILL SYR KIT 40 MG/0.8 ML QL 3 each per 28 day(s)

5 QL; PA


5 QL; PA


5 QL; PA

HUMIRA PEDIATRIC CROHN'S PREFILL SYR KIT 80 MG/0.8 ML-40 MG/0.4 ML QL 2 each per 28 day(s)

5 QL; PA

HUMIRA PEN CROHN-UC-HS STARTER PEN-INJ KIT 40 MG/0.8 ML QL 6 each per 28 day(s)

5 QL; PA

HUMIRA PEN PEN-INJ KIT 40 MG/0.4 ML QL 2 each per 28 day(s)

5 QL; PA

HUMIRA PEN PEN-INJ KIT 40 MG/0.8 ML QL 2 each per 28 day(s)

5 QL; PA

HUMIRA PEN PSORIASIS-UVEITIS PEN-INJ KIT 40 MG/0.8 ML QL 4 each per 28 day(s)

5 QL; PA

HUMIRA PREFILL SYR KIT 10 MG/0.1 ML QL 2 each per 28 day(s)

5 QL; PA; LA


/Limits


5 QL; PA


5 QL; PA


5 QL; PA


5 QL; PA


5 QL; PA

KEVZARA SOLN PREF SYR 150 MG/1.14 ML

5 PA

KEVZARA SOLN PREF SYR 200 MG/1.14 ML

5 PA

KINERET SOLN PREF SYR 100 MG/0.67 ML QL 20.1 milliliter(s) per 30 day(s)

5 QL; PA

leflunomide tablet 10mg 2

leflunomide tablet 20mg 2

ORENCIA CLICKJECT SOLN AUTO-INJ 125 MG/ML QL 4 milliliter(s) per 28 day(s)

5 QL; PA

ORENCIA FOR SOLUTION 250MG


ORENCIA SOLN PREF SYR 125 MG/ML QL 4 milliliter(s) per 28 day(s)

5 QL; PA




121


/Limits

ORENCIA SOLN PREF SYR 50 MG/0.4 ML QL 1.6 milliliter(s) per 28 day(s)

5 QL; PA

ORENCIA SOLN PREF SYR 87.5 MG/0.7 ML QL 2.8 milliliter(s) per 28 day(s)

5 QL; PA

OTEZLA TAB THER PACK 10 MG (4)-20 MG (4)-30 MG (47) QL 55 each per 30 day(s)

5 QL; PA

OTEZLA TABLET 30MG


REMICADE FOR SOLUTION 100MG

5 PA

RENFLEXIS FOR SOLUTION 100MG

5 PA

SIMPONI ARIA SOLUTION 50 MG/4 ML (12.5 MG/ML) QL 12 milliliter(s) per 28 day(s)

5 QL; PA

SIMPONI SOLN AUTO-INJ 100 MG/ML QL 1 milliliter(s) per 28 day(s)

5 QL; PA

SIMPONI SOLN AUTO-INJ 50 MG/0.5 ML QL 1 milliliter(s) per 28 day(s)

5 QL; PA

SIMPONI SOLN PREF SYR 100 MG/ML QL 1 milliliter(s) per 28 day(s)

5 QL; PA


/Limits

SIMPONI SOLN PREF SYR 50 MG/0.5 ML QL 1 milliliter(s) per 28 day(s)

5 QL; PA

XELJANZ TABLET 5MG


XELJANZ XR TABLET ER 24HR 11MG


IMMUNOSUPPRESSIVE AGENTSASTAGRAF XL CAPSULE ER 24HR 0.5MG

4 BvsD

ASTAGRAF XL CAPSULE ER 24HR 1MG

4 BvsD

ASTAGRAF XL CAPSULE ER 24HR 5MG

4 BvsD

ATGAM INJECTABLE 50 MG/ML

5 BvsD

azathioprine tablet 50mg 2 BvsDBENLYSTA FOR SOLUTION 120MG

5 PA

BENLYSTA FOR SOLUTION 400MG

5 PA

BENLYSTA SOLN AUTO-INJ 200 MG/ML

5 PA

BENLYSTA SOLN PREF SYR 200 MG/ML

5 PA

cyclosporine capsule 100mg 2 BvsDcyclosporine capsule 25mg 2 BvsDcyclosporine modified capsule 100mg

2 BvsD

cyclosporine modified capsule 25mg

2 BvsD




122


/Limits

cyclosporine modified capsule 50mg

2 BvsD

cyclosporine modified solution 100 mg/ml

2 BvsD

cyclosporine solution 250 mg/5 ml

2 BvsD

gengraf capsule 100mg 2 BvsDgengraf capsule 25mg 2 BvsDgengraf solution 100 mg/ml 2 BvsDmycophenolate mofetil capsule 250mg

2 BvsD

mycophenolate mofetil for suspension 200 mg/ml

2 BvsD

mycophenolate mofetil tablet 500mg

2 BvsD

mycophenolic acid tablet dr 180mg QL 240 each per 30 day(s)

2 QL; BvsD

mycophenolic acid tablet dr 360mg QL 120 each per 30 day(s)

2 QL; BvsD

NULOJIX FOR SOLUTION 250MG

5 PA

RAPAMUNE SOLUTION 1 MG/ML

3 BvsD

SANDIMMUNE SOLUTION 100 MG/ML

3 BvsD

sirolimus tablet 0.5mg 2 BvsDsirolimus tablet 1mg 2 BvsDsirolimus tablet 2mg 2 BvsDtacrolimus capsule 0.5mg 2 BvsDtacrolimus capsule 1mg 2 BvsDtacrolimus capsule 5mg 2 BvsD


/Limits

ZORTRESS TABLET 0.25MG






OTHER MISCELLANEOUS THERAPEUTIC AGENTSAMPYRA TABLET ER 12HR 10MG


ARCALYST FOR SOLUTION 220MG

5 PA

CYSTADANE POWDER 1 GRAM/1.7 ML

4

CYSTAGON CAPSULE 150MG

4

CYSTAGON CAPSULE 50MG

4

CYSTARAN SOLUTION 0.44 %


4 QL; PA

DEMSER CAPSULE 250MG 4 STELMIRON CAPSULE 100MG

3

ENDARI PACKET 5 GRAM


GLUCAGEN FOR SOLUTION 1MG

3

GLUCAGON EMERGENCY KIT KIT 1MG

3




123


/Limits

guanidine hcl tablet 125mg 2

HAEGARDA FOR SOLUTION 2,000 UNIT QL 16 each per 28 day(s)

5 QL; PA

HAEGARDA FOR SOLUTION 3,000 UNIT QL 16 each per 28 day(s)

5 QL; PA

ILARIS SOLUTION 150 MG/ML QL 2 milliliter(s) per 28 day(s)

5 QL; PA

KORLYM TABLET 300MG


KUVAN PACKET 100MG 5

KUVAN PACKET 500MG 5

KUVAN TABLET SOLUBLE 100MG

5

MIGLUSTAT 100 MG CAPSULE QL 90 per 30 day(s)

5 QL; PA

MYALEPT FOR SOLUTION 5 MG/ML (FINAL CONCENTRATION) QL 67.8 each per 30 day(s)

5 QL; PA

octreotide acetate solution 1,000 mcg/ml

5 PA

octreotide acetate solution 100 mcg/ml

2 PA


2 PA


2 PA


5 PA


/Limits

ORALAIR TAB SUBLINGUAL 300 INDEX OF REACTIVITY


4 QL; PA

ORFADIN CAPSULE 10MG


ORFADIN CAPSULE 20MG


ORFADIN CAPSULE 2MG


ORFADIN CAPSULE 5MG


ORFADIN SUSPENSION 4 MG/ML QL 1500 milliliter(s) per 30 day(s)

5 QL; PA

ORKAMBI TABLET 100-125MG


ORKAMBI TABLET 200-125MG


RAVICTI LIQUID 1.1 GRAM/ML QL 525 milliliter(s) per 30 day(s)

4 QL; PA

SENSIPAR TABLET 30MG






SIGNIFOR LAR FOR SUSP ER 20MG





124


/Limits





SIGNIFOR SOLUTION 0.3 MG/ML (1 ML) QL 60 milliliter(s) per 30 day(s)

5 QL; PA


5 QL; PA


5 QL; PA

SOMATULINE DEPOT SOLUTION 120 MG/0.5 ML

5 PA


5 PA


5 PA

STIMATE SOLUTION 150 MCG/SPRAY (0.1 ML)

5

STRENSIQ SOLUTION 40 MG/ML QL 24 milliliter(s) per 28 day(s)

5 QL; PA; LA

STRENSIQ SOLUTION 80 MG/0.8 ML QL 36.4 milliliter(s) per 28 day(s)

5 QL; PA; LA


/Limits

ZAVESCA CAPSULE 100MG


PROTECTIVE AGENTS dexrazoxane for solution 250mg

5 BvsD

MESNEX TABLET 400MG 3

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS, MISC

ENTRESTO TABLET 24-26MG






RESPIRATORY TRACT AGENTSANTI-INFLAMMATORY AGENTS (RESPIRATORY)ALOCRIL SOLUTION 2 %


4 QL

ALVESCO AEROSOL SOLN 160 MCG/ACTUATION


ALVESCO AEROSOL SOLN 80 MCG/ACTUATION


ASMANEX AERO POW BR ACT 110 MCG (30 DOSES) QL 1 each per 30 day(s)

3 QL




125


/Limits

ASMANEX AERO POW BR ACT 220 MCG (120 DOSES)QL 1 each per 30 day(s)

3 QL


3 QL


3 QL

ASMANEX HFA AEROSOL 100 MCG/ACTUATION


ASMANEX HFA AEROSOL 200 MCG/ACTUATION


BECONASE AQ SUSPENSION 42 MCG


budesonide suspension 0.25 mg/2 ml QL 240 milliliter(s) per 30 day(s)

2 QL; BvsD

budesonide suspension 0.5 mg/2 ml QL 240 milliliter(s) per 30 day(s)

2 QL; BvsD

budesonide suspension 1 mg/2 ml QL 240 milliliter(s) per 30 day(s)

2 QL; BvsD

cromolyn 20 mg/2 ml neb soln 2 BvsDcromolyn sodium solution 4 % 2


/Limits

DYMISTA SUSPENSION 137 MCG-50 MCG/SPRAY


FLOVENT DISKUS AERO POW BR ACT 100 MCG






FLOVENT HFA AEROSOL 110 MCG/ACTUATION


FLOVENT HFA AEROSOL 220 MCG


FLOVENT HFA AEROSOL 44 MCG


flunisolide solution 25 mcg (0.025 %) QL 50 milliliter(s) per 30 day(s)

2 QL

fluticasone propionate suspension 50 mcg/actuation QL 16 gram(s) per 30 day(s)

1 QL

mometasone furoate suspension 50 mcg/actuation QL 34 gram(s) per 30 day(s)

2 QL

montelukast sodium packet 4mg QL 30 each per 30 day(s)

2 QL




126


/Limits

montelukast sodium tablet 10mg QL 30 each per 30 day(s)

2 QL

montelukast sodium tablet chewable 4mg QL 30 each per 30 day(s)

2 QL

montelukast sodium tablet chewable 5mg QL 30 each per 30 day(s)

2 QL

OMNARIS SUSPENSION 50 MCG


PULMICORT FLEXHALER AERO POW BR ACT 180 MCG/ACTUATION (160 MCG DELIVERED) QL 1 each per 30 day(s)

4 QL; ST

PULMICORT FLEXHALER AERO POW BR ACT 90 MCG/ACTUATION (80 MCG DELIVERED) QL 1 each per 30 day(s)

4 QL; ST

QNASL AEROSOL SOLN 80 MCG/ACTUATION


QNASL CHILDREN AEROSOL SOLN 40 MCG/ACTUATION


4 QL

QVAR AEROSOL SOLN 80 MCG


QVAR REDIHALER AERO BREATH ACT 40 MCG/ACTUATION


4 QL; ST


/Limits

QVAR REDIHALER AERO BREATH ACT 80 MCG/ACTUATION


4 QL; ST

zafirlukast tablet 10mg QL 60 each per 30 day(s)

2 QL

zafirlukast tablet 20mg QL 60 each per 30 day(s)

2 QL

ZETONNA AEROSOL SOLN 37 MCG/ACTUATION


zileuton er tablet er 12hr 600mg QL 120 each per 30 day(s)

2 QL

PHOSPHODIESTERASE TYPE 4 INHIBITORSDALIRESP TABLET 250 MCG


DALIRESP TABLET 500 MCG


RESPIRATORY TRACT AGENTS, MISCELLANEOUSARALAST NP FOR SOLUTION 1,000MG


ESBRIET CAPSULE 267MG


FASENRA SOLN PREF SYR 30 MG/ML QL 1 milliliter(s) per 28 day(s)

5 QL; PA




127


/Limits

GLASSIA SOLUTION 1 GRAM/50 ML (2 %) QL 9000 each per 28 day(s)

5 QL; PA

KALYDECO PACKET 50MG


KALYDECO PACKET 75MG


KALYDECO TABLET 150MG

5 PA

OFEV CAPSULE 100MG


OFEV CAPSULE 150MG


PROLASTIN C FOR SOLUTION 1,000MG


SYMDEKO TAB THER PACK 100 MG-150 MG (DAY)/150 MG (NIGHT) QL 60 each per 30 day(s)

5 QL; PA

XOLAIR FOR SOLUTION 150MG

5 PA

ZEMAIRA FOR SOLUTION 1,000MG


SERUMS, TOXOIDS, AND VACCINESSERUMS BIVIGAM SOLUTION 10 % 5 PA

CARIMUNE NF NANOFILTERED FOR SOLUTION 6 GRAM

4 PA

FLEBOGAMMA DIF SOLUTION 10 %

5 PA


/Limits

GAMASTAN S-D INJECTABLE 15 %-18 % RANGE

3 PA

GAMMAGARD LIQUID SOLUTION 10 %

5 PA

GAMMAGARD S-D FOR SOLUTION 10 GRAM

5 PA

GAMMAGARD S-D FOR SOLUTION 5 GRAM

5 PA

GAMMAKED SOLUTION 1 GRAM/10 ML (10 %)

5 PA

GAMMAPLEX SOLUTION 10 %

5 PA

GAMMAPLEX SOLUTION 5 %

5 PA

GAMUNEX-C SOLUTION 1 GRAM/10 ML (10 %)

4 PA

OCTAGAM SOLUTION 10 %

5 PA

OCTAGAM SOLUTION 5 % 5 PAPRIVIGEN SOLUTION 10 % 5 PAZINPLAVA SOLUTION 1,000 MG/40 ML (25 MG/ML)

5 PA

TOXOIDSADACEL TDAP SUSPENSION 2 LF UNIT-(2.5-5-3-5 MCG)-5 LF UNIT/0.5 ML

3

BOOSTRIX TDAP SUSPENSION 2.5 LF UNIT-(2.5 MCG-8 MCG-8 MCG)-5 LF UNIT/0.5 ML

3

DAPTACEL DTAP SUSPENSION 15 LF UNIT-10 MCG-5 LF UNIT/0.5 ML

3




128


/Limits

diphtheria-tetanus toxoids-ped suspension 5 lf unit-25 lf unit/0.5 ml

2

INFANRIX DTAP SUSPENSION 25 LF UNIT-58 MCG-10 LF/0.5 ML

3

TENIVAC INJECTABLE 5 LF UNIT-2 LF UNIT/0.5 ML

3

tetanus diphtheria toxoids suspension 2 lf unit-2 lf unit/0.5 ml

2

VACCINES ACTHIB FOR SOLUTION 10 MCG/0.5 ML

3

ADACEL TDAP SUSPENSION 2 LF UNIT-(2.5-5-3-5 MCG)-5 LF UNIT/0.5 ML

3

bcg vaccine (tice strain) injectable 50mg

3

BEXSERO SUSP PREF SYR 50 MCG-50 MCG-50 MCG-25 MCG/0.5 ML

3

ENGERIX-B ADULT SUSPENSION 20 MCG/ML

3 BvsD

ENGERIX-B PEDIATRIC-ADOLESCENT SUSPENSION 10 MCG/0.5 ML

3 BvsD

GARDASIL 9 SUSP PREF SYR 0.5 ML

3

GARDASIL 9 SUSPENSION 0.5 ML

3

HAVRIX SUSPENSION 1,440 ELISA UNIT/ML

3


/Limits

HAVRIX SUSPENSION 720 ELISA UNIT/0.5 ML

3

HIBERIX FOR SOLUTION 10 MCG/0.5 ML

3

HYPERRAB S-D SOLUTION 150 UNIT/ML

3

IMOVAX RABIES VACCINE INJECTABLE 2.5 UNIT

3

IPOL INJECTABLE 40 UNIT-8 UNIT-32 UNIT/0.5 ML

3

IXIARO SUSPENSION 6 MCG/0.5 ML

3

KINRIX SUSPENSION 25 LF-(25-25-8 MCG)-10 LF-(40-8-32 D-ANTIG UNIT)/0.5 ML

3

M-M-R II VACCINE INJECTABLE 1,000-12,500-1,000 TCID50/0.5 ML

3

MENACTRA INJECTABLE 4 MCG/0.5 ML

3

MENVEO A-C-Y-W-135-DIP FOR SOLUTION 10 MCG-5 MCG/0.5 ML

3

PEDIARIX SUSPENSION 10 MCG-25 LF-(25-25-8 MCG)-10 LF-40-8-32(D-ANTG.UNIT)/0.5 ML

3

PEDVAXHIB SUSPENSION 7.5 MCG/0.5 ML

3

PROQUAD INJECTABLE 10EXP3-10EXP4.3-10EXP3-10EXP3.99 TCID50/0.5 ML

3




129


/Limits

QUADRACEL DTAP-IPV SUSPENSION 15 LF UNIT-(20-20-5-3 MCG)-5 LF UNIT-(40-8-32 UNIT)/0.5 ML

3

RABAVERT FOR SUSPENSION 2.5 UNIT

3

RECOMBIVAX HB SUSPENSION 10 MCG/ML

3 BvsD

RECOMBIVAX HB SUSPENSION 40 MCG/ML

3 BvsD

RECOMBIVAX HB SUSPENSION 5 MCG/0.5 ML

3 BvsD

ROTARIX FOR SUSPENSION 10EXP6 CCID50/ML

3

ROTATEQ SOLUTION 2 ML 3

SHINGRIX FOR SUSPENSION 50 MCG/0.5 ML

3

TRUMENBA SUSP PREF SYR 120 MCG/0.5 ML

3

TWINRIX SUSPENSION 720 ELISA UNIT-20 MCG/ML

3 BvsD

TYPHIM VI SOLUTION 25 MCG/0.5 ML

3

VAQTA SUSPENSION 25 UNIT/0.5 ML

3

VAQTA SUSPENSION 50 UNIT/ML

3

VARIVAX VACCINE INJECTABLE 1,350 UNIT/0.5 ML

3

YF-VAX INJECTABLE 10 EXP4.74 UNIT/0.5 ML

3


/Limits

ZOSTAVAX FOR SUSPENSION 19,400 UNIT/0.65 ML

3

SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)acyclovir ointment 5 % 2

chlorhexidine gluconate solution 0.12 %

2

ciclopirox cream 0.77 % 2

ciclopirox gel 0.77 % 2

ciclopirox shampoo 1 % 2

ciclopirox solution 8 % 2 NMciclopirox suspension 0.77 % 2

CLEOCIN SUPPOSITORY 100MG

3

clindamycin phosphate cream 2 %

2

clindamycin phosphate foam 1 %

2

clindamycin phosphate gel 1 %

2

clindamycin phosphate lotion 1 %

2

clindamycin phosphate solution 1 %

2

clindamycin phosphate swab 1 %

2

clindamycin-benzoyl peroxide gel 1 %-5 %

2

clotrimazole cream 1 % 2

clotrimazole lozenge 10mg 2

clotrimazole solution 1 % 2

clotrimazole-betamethasone cream 1 %-0.05 %

2

clotrimazole-betamethasone lotion 1 %-0.05 %

2




130


/Limits

CORTISPORIN CREAM 3.5 MG/GRAM-10,000 UNIT/GRAM-0.5 %

4

CORTISPORIN OINTMENT 3.5 MG-400 UNIT-5,000 UNIT-10 MG/GRAM

4

DENAVIR CREAM 1 % 4

econazole nitrate cream 1 % 2

ery pad 2 % 2

erythromycin gel 2 % 2

erythromycin solution 2 % 2

erythromycin-benzoyl peroxide gel 3 %-5 %

2

EURAX CREAM 10 % 4 ST EURAX LOTION 10 % 4 ST gentamicin sulfate cream 0.1 %

2

gentamicin sulfate ointment 0.1 %

2

ketoconazole cream 2 % 2

ketoconazole shampoo 2 % 2

lindane shampoo 1 % 2

metronidazole cream 0.75 % 2

metronidazole gel 0.75 % 2

metronidazole gel 1 %


metronidazole lotion 0.75 % 2

MICONAZOLE 3 SUPPOSITORY 200MG

4

mupirocin cream 2 % 2

mupirocin ointment 2 % 2

naftifine hcl cream 2 % 2

neomycin-polymyxin b solution 40 mg-200,000 unit/ml

2

nystatin cream 100,000 unit/gram

1


/Limits

nystatin ointment 100,000 unit/gram

2

nystatin powder 100,000 unit/gram

2

nystatin-triamcinolone cream 100,000 unit/gram-0.1 %

2

nystatin-triamcinolone ointment 100,000 unit/gram-0.1 %

2

nystop powder 100,000 unit/gram

2

oxiconazole nitrate cream 1 % 2

permethrin cream 5 % 2

silver sulfadiazine cream 1 % 2

ssd cream 1 % 2

sulfacetamide sodium lotion 10 %

2

terconazole cream 0.4 % 2

terconazole cream 0.8 % 2

terconazole suppository 80mg 2

vandazole gel 0.75 % 2

ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS)alclometasone dipropionate cream 0.05 %

2

alclometasone dipropionate ointment 0.05 %

2

amcinonide cream 0.1 % 2

amcinonide lotion 0.1 % 2

amcinonide ointment 0.1 % 2

betamethasone diprop augmented cream 0.05 %

2

betamethasone diprop augmented gel 0.05 %

2




131


/Limits

betamethasone diprop augmented lotion 0.05 %

2

betamethasone diprop augmented ointment 0.05 %

2

betamethasone dipropionate cream 0.05 %

2

betamethasone dipropionate lotion 0.05 %

2

betamethasone dipropionate ointment 0.05 %

2

betamethasone valerate cream 0.1 %

2

betamethasone valerate foam 0.12 %

2

betamethasone valerate lotion 0.1 %

2

betamethasone valerate ointment 0.1 %

2

calcipotriene-betamethasone dp ointment 0.005 %-0.064 %

2

CAPEX SHAMPOO SHAMPOO 0.01 %

4 ST

clobetasol emollient cream 0.05 %

2

clobetasol propionate foam 0.05 %

2

clobetasol propionate gel 0.05 %

2

clobetasol propionate liquid 0.05 %


2 QL

clobetasol propionate lotion 0.05 %

2


/Limits

clobetasol propionate ointment 0.05 %

2

clobetasol propionate shampoo 0.05 %

2

clobetasol propionate solution 0.05 %

2

colocort enema 100 mg/60 ml 2

CORDRAN TAPE 4 MCG/CM2

4 ST

DESONATE GEL 0.05 % 4

desonide cream 0.05 % 2

desonide lotion 0.05 % 2

desonide ointment 0.05 % 2

desoximetasone cream 0.05 % 2

desoximetasone cream 0.25 % 2

desoximetasone gel 0.05 % 2

desoximetasone ointment 0.05 %

2

desoximetasone ointment 0.25 %

2

diflorasone diacetate cream 0.05 %

2

diflorasone diacetate ointment 0.05 %

2

fluocinolone acetonide cream 0.01 %

2

fluocinolone acetonide cream 0.025 %

2

fluocinolone acetonide oil 0.01 %

2

fluocinolone acetonide ointment 0.025 %

2

fluocinolone acetonide solution 0.01 %

2

fluocinonide cream 0.1 % 2

fluocinonide gel 0.05 % 2




132


/Limits

fluocinonide ointment 0.05 % 2

fluocinonide solution 0.05 % 2

fluocinonide-e cream 0.05 % 2

flurandrenolide ointment 0.05 %

2

fluticasone propionate cream 0.05 %

2

fluticasone propionate lotion 0.05 %

2

fluticasone propionate ointment 0.005 %

2

halobetasol propionate cream 0.05 %

2

halobetasol propionate ointment 0.05 %

2

hydrocortisone butyrate cream 0.1 %

1

hydrocortisone butyrate ointment 0.1 %

1

hydrocortisone butyrate solution 0.1 %

2

hydrocortisone cream 1 % 1

hydrocortisone cream 2.5 % 2

hydrocortisone enema 100 mg/60 ml

2

hydrocortisone lotion 2.5 % 2

hydrocortisone ointment 1 % 1

hydrocortisone ointment 2.5 % 2

hydrocortisone valerate ointment 0.2 %

2

mometasone furoate cream 0.1 %

2

mometasone furoate ointment 0.1 %

2

mometasone furoate solution 0.1 %

2


/Limits

prednicarbate cream 0.1 % 2

prednicarbate ointment 0.1 % 2

procto-med hc cream 2.5 % 2

procto-pak cream 1 % 2

proctosol-hc cream 2.5 % 2

proctozone-hc cream 2.5 % 2

TACLONEX SUSPENSION 0.005 %-0.064 %

4 ST

triamcinolone acetonide aerosol soln 0.147 mg/gram

2

triamcinolone acetonide cream 0.025 %

1


1


1

triamcinolone acetonide lotion 0.025 %

1

triamcinolone acetonide lotion 0.1 %

1

triamcinolone acetonide ointment 0.025 %

1


1


1

triamcinolone acetonide paste 0.1 %

2

ANTIPRURITICS AND LOCAL ANESTHETICSdoxepin hcl cream 5 % 2

lidocaine hcl solution 10 mg/ml (1 %)

2 BvsD




133


/Limits

lidocaine ointment 5 % 2

lidocaine patch 5 % 2 PA

lidocaine-prilocaine cream 2.5 %-2.5 %

2

PRUDOXIN CREAM 5 % 4

CELL STIMULANTS AND PROLIFERANTSavita cream 0.025 % 2

avita gel 0.025 % 2

KEPIVANCE FOR SOLUTION 6.25MG

5 PA

tretinoin cream 0.025 % 2



tretinoin gel 0.01 % 2

tretinoin gel 0.025 % 2

tretinoin gel 0.05 % 2 ST tretinoin microsphere gel 0.04 %

2 ST

tretinoin microsphere gel 0.1 %

2 ST

DEPIGMENTING AND PIGMENTING AGENTSmethoxsalen capsule 10mg 5

SKIN AND MUCOUS MEMBRANE AGENTS, MISC. acitretin capsule 10mg QL 60 each per 30 day(s)

2 QL

acitretin capsule 17.5mg QL 60 each per 30 day(s)

2 QL

acitretin capsule 25mg QL 60 each per 30 day(s)

2 QL

adapalene cream 0.1 % 2

adapalene gel 0.1 % 2

adapalene gel 0.3 % 2


/Limits

adapalene-benzoyl peroxide gel 0.1 %-2.5 %

2 ST

amnesteem capsule 10mg 2



AZELEX CREAM 20 % 4 STcalcipotriene cream 0.005 % 2

calcipotriene ointment 0.005 %

2

calcipotriene solution 0.005 % 2

calcitriol ointment 3 mcg/gram 2

claravis capsule 10mg 2




COSENTYX (2 SYRINGES) SOLN PREF SYR 150 MG/ML QL 2 milliliter(s) per 28 day(s)

5 QL; PA

COSENTYX PEN (2 PENS) SOLN AUTO-INJ 150 MG/ML QL 2 milliliter(s) per 28 day(s)

5 QL; PA

dapsone gel 5 % 2 STDUPIXENT SOLN PREF SYR 300 MG/2 ML QL 4 milliliter(s) per 28 day(s)

5 QL; PA

ELIDEL CREAM 1 % 4 STENSTILAR FOAM 0.005 %-0.064 %

4

EPIDUO FORTE GEL 0.3 %-2.5 %

4 ST




134


/Limits

EUCRISA OINTMENT 2 %


FINACEA FOAM 15 % 4

FINACEA GEL 15 %


fluorouracil cream 0.5 %


fluorouracil cream 5 % 2

imiquimod cream 5 % 2

isotretinoin capsule 10mg 2




myorisan capsule 10mg 2




PANRETIN GEL 0.1 % 4 PA

PICATO GEL 0.015 %


PICATO GEL 0.05 %


podofilox solution 0.5 % 2

SANTYL OINTMENT 250 UNIT/GRAM

4

STELARA SOLN PREF SYR 45 MG/0.5 ML QL 2 milliliter(s) per 84 day(s)

5 QL; PA

STELARA SOLN PREF SYR 90 MG/ML QL 2 milliliter(s) per 84 day(s)

5 QL; PA


/Limits

STELARA SOLUTION 130 MG/26 ML QL 104 milliliter(s) per 28 day(s)

5 QL; PA

STELARA SOLUTION 45 MG/0.5 ML QL 2 milliliter(s) per 28 day(s)

5 QL; PA

tacrolimus ointment 0.03 %


tacrolimus ointment 0.1 %


TARGRETIN GEL 1 % 5 PAtazarotene cream 0.1 % 2

TAZORAC CREAM 0.05 % 4

TAZORAC GEL 0.05 % 4

TAZORAC GEL 0.1 % 4

TOLAK CREAM 4 %


zenatane capsule 10mg 2




SMOOTH MUSCLE RELAXANTSGENITOURINARY SMOOTH MUSCLE RELAXANTSdarifenacin er tablet er 24hr 15mg QL 30 each per 30 day(s)

2 QL; ST

darifenacin er tablet er 24hr 7.5mg QL 30 each per 30 day(s)

2 QL; ST

flavoxate hcl tablet 100mg 2

GELNIQUE GEL 10 % (100 MG/GRAM) QL 30 gram(s) per 30 day(s)

4 QL; ST




135


/Limits

MYRBETRIQ TABLET ER 24HR 25MG


MYRBETRIQ TABLET ER 24HR 50MG


oxybutynin chloride er tablet er 24hr 10mg QL 60 each per 30 day(s)

2 QL


2 QL


2 QL

oxybutynin chloride syrup 5 mg/5 ml QL 473 milliliter(s) per 23 day(s)

2 QL

oxybutynin chloride tablet 5mg QL 120 each per 30 day(s)

2 QL

tolterodine tartrate er capsule er 24hr 2mg QL 30 each per 30 day(s)

2 QL

tolterodine tartrate er capsule er 24hr 4mg QL 30 each per 30 day(s)

2 QL

tolterodine tartrate tablet 1mgQL 60 each per 30 day(s)

2 QL

tolterodine tartrate tablet 2mgQL 60 each per 30 day(s)

2 QL


/Limits

TOVIAZ TABLET ER 24HR 4MG


TOVIAZ TABLET ER 24HR 8MG


trospium chloride er capsule er 24hr 60mg QL 30 each per 30 day(s)

2 QL

trospium chloride tablet 20mg QL 60 each per 30 day(s)

2 QL

VESICARE TABLET 10MG


VESICARE TABLET 5MG


RESPIRATORY SMOOTH MUSCLE RELAXANTSaminophylline solution 250 mg/10 ml

2 BvsD

theophylline anhydrous tablet er 12hr 100mg

2


2


2

theophylline tablet er 24hr 400mg

2

theophylline tablet er 24hr 600mg

2

SUPPLIESSUPPLIES*alcohol swabs*** 2

gauze pads pad 2" x 2" QL 100 each per 30 day(s)

2 QL

gauze pads pad 2" x 2" QL 200 each per 30 day(s)

2 QL




136


/Limits

insulin 1 ml syringe QL 200 each per 30 day(s)

2 QL

insulin 1/2 ml syringe QL 200 each per 30 day(s)

2 QL

INSULIN SYRINGE 0.3 ML QL 200 each per 30 day(s)

2 QL

PEN NEEDLES 12MM 29G

QL 200 per 30 day(s) 2 QL

VITAMINS VITAMIN D

calcitriol capsule 0.25 mcg 2

calcitriol capsule 0.5 mcg 2

calcitriol solution 1 mcg/ml 2

doxercalciferol capsule 0.5 mcg

2

doxercalciferol capsule 1 mcg 2

doxercalciferol capsule 2.5 mcg

2

doxercalciferol solution 4 mcg/2 ml

2 BvsD

paricalcitol capsule 1 mcg 2



paricalcitol solution 2 mcg/ml QL 4 milliliter(s) per 28 day(s)

2 QL; BvsD

paricalcitol solution 5 mcg/ml QL 4 milliliter(s) per 28 day(s)

2 QL; BvsD

VITAMINS PRENATAL VITAMINS 3

sodium fluoride tab 1 mg f (from 2.2 mg naf)

2


/Limits

137

Index

*alcohol swabs*** ................. 135 *amino acid electrolyte infusion 8.5%*** .................................... 91 abacavir..................................... 18 abacavir-lamivudine ................. 18 abacavir-lamivudine-zidovudine .................................................. 18 ABILIFY MAINTENA ............ 81 ABRAXANE ............................ 25 ABSTRAL ........................... 57,58 acamprosate calcium ................ 79 acarbose .................................. 106 acebutolol hcl............................ 37 acetaminophen-codeine ............ 58 acetazolamide ........................... 48 acetic acid ................................. 95 acetylcysteine ......................... 116 acitretin ................................... 133 ACTEMRA ............................ 119 ACTHIB ................................. 128 ACTIMMUNE ....................... 117 ACTOPLUS MET XR ........... 106 ACUVAIL ................................ 96 acyclovir ............................ 18,129 acyclovir sodium ...................... 18 ADACEL TDAP ............. 127,128 ADAGEN ................................. 94 adapalene ................................ 133 adapalene-benzoyl peroxide ... 133 ADCIRCA ................................ 55 adefovir dipivoxil ..................... 18 ADEMPAS ............................... 55 ADRENALIN ........................... 39 ADVAIR DISKUS ................... 39 ADVAIR HFA ......................... 39 afeditab cr ................................. 48 AFINITOR ............................... 25 AFINITOR DISPERZ .............. 25 ALBENZA ............................... 10 albuterol 5 mg/ml solution ....... 39 albuterol sul 0.63 mg/3 ml sol .. 39

albuterol sul 1.25 mg/3 ml sol ..39albuterol sul 2.5 mg/3 ml soln ..39albuterol sulfate ........................ 39alclometasone dipropionate .... 130ALDACTAZIDE...................... 48ALDURAZYME ...................... 94ALECENSA ............................. 25alendronate sodium................. 118alfuzosin hcl er ......................... 37ALIMTA .................................. 25ALINIA .................................... 17ALIQOPA ................................ 25allopurinol .............................. 117ALOCRIL............................... 124alogliptin................................. 106alogliptin-metformin .............. 106alogliptin-pioglitazone............ 106ALOMIDE................................ 97alosetron hcl ........................... 101ALPHAGAN P......................... 97alprazolam ................................ 78alprazolam er ............................ 78alprazolam intensol................... 78alprazolam odt .......................... 78ALREX..................................... 96ALTOPREV ............................. 44ALUNBRIG ............................. 25ALVESCO.............................. 124amantadine................................ 18AMBISOME ............................ 16amcinonide ............................. 130amethia ................................... 110amikacin sulfate........................ 10amiloride hcl............................. 48amiloride-hydrochlorothiazide .48aminophylline ......................... 135AMINOSYN II......................... 91aminosyn ii with electrolytes.... 91AMINOSYN WITH ELECTROLYTES.................... 91

AMINOSYN-HBC................... 91AMINOSYN-PF ....................... 91AMINOSYN-RF ...................... 91amiodarone hcl ......................... 48amitriptyline hcl........................ 81amlodipine besylate .................. 48amlodipine besylate-benazepril............................................. 48,49amlodipine-atorvastatin ....... 44,45amlodipine-olmesartan ............. 49amlodipine-valsartan ................ 49amlodipine-valsartan-hctz ........ 49amnesteem .............................. 133amoxapine................................. 81amoxicillin ................................ 10amoxicillin-clavulanate pot er ..10amoxicillin-clavulanate potass .10amphotericin b .......................... 16ampicillin sodium ..................... 10ampicillin trihydrate ................. 10ampicillin-sulbactam ................ 10AMPYRA ............................... 122ANADROL-50 ....................... 105anagrelide hcl............................ 41anastrozole ................................ 25ANDRODERM ...................... 105ANDROGEL .......................... 105ANORO ELLIPTA................... 39APLENZIN .............................. 81APOKYN ................................. 75apraclonidine hcl ...................... 98aprepitant .................................. 99apri.......................................... 110APRISO .................................... 99APTIOM ................................... 68APTIVUS ................................. 18ARALAST NP ....................... 126aranelle ................................... 110ARANESP ................................ 43ARCALYST ........................... 122

138

ARCAPTA NEOHALER ......... 39 aripiprazole ............................... 82 aripiprazole odt ......................... 81 ARISTADA .............................. 82 armodafinil ............................... 65 ARNUITY ELLIPTA ............... 40 ARRANON .............................. 25 ascomp with codeine ................ 58 ASMANEX ..................... 124,125 ASMANEX HFA ................... 125 aspirin-dipyridamole er ............ 41 ASTAGRAF XL ..................... 121 ATAZANAVIR SULFATE 150 MG CAP ................................... 18 ATAZANAVIR SULFATE 200 MG CAP ................................... 18 ATAZANAVIR SULFATE 300 MG CAP ................................... 19 atenolol ..................................... 37 atenolol-chlorthalidone ............. 37 ATGAM ................................. 121 atomoxetine hcl ........................ 80 atorvastatin calcium .................. 45 atovaquone ................................ 18 atovaquone-proguanil hcl ......... 18 ATRIPLA ................................. 19 ATROVENT HFA.................... 35 AUBAGIO .............................. 117 AURYXIA ................................ 92 AVASTIN ................................ 25 aviane ...................................... 110 avita ........................................ 133 AVONEX ............................... 117 AVONEX PEN ....................... 117 azacitidine ................................. 25 AZASITE ................................. 95 azathioprine ............................ 121 azelastine hcl ............................ 97 AZELEX ................................ 133 azithromycin ........................ 10,11 AZOPT ..................................... 98 aztreonam ................................. 11

bacitracin .................................. 95bacitracin-polymyxin................ 95baclofen .................................... 36BACTROBAN NASAL ........... 95balsalazide disodium ................ 99balziva..................................... 110BANZEL .................................. 68BARACLUDE.......................... 19BASAGLAR KWIKPEN U-100 ................................................ 106BAVENCIO ............................. 25BAXDELA............................... 11bcg vaccine (tice strain).......... 128BECONASE AQ .................... 125BELEODAQ............................. 26BELSOMRA ............................ 77benazepril hcl............................ 49benazepril-hydrochlorothiazide 49BENLYSTA ........................... 121benznidazole ............................. 18benztropine mesylate ................ 75BEPREVE ................................ 97BESIVANCE............................ 95betamethasone diprop augmented ......................................... 130,131betamethasone dipropionate ...131betamethasone valerate........... 131BETASERON ........................ 117betaxolol hcl ................... 37,49,98bethanechol chloride................. 36BETHKIS 300 MG/4 ML AMPULE.................................. 11BETOPTIC S............................ 98BEVESPI AEROSPHERE ....... 35BEVYXXA .............................. 41bexarotene................................. 26BEXSERO.............................. 128bicalutamide ............................. 26BICILLIN C-R ......................... 11BICILLIN L-A ......................... 11BICNU...................................... 26BIKTARVY ............................. 19

BILTRICIDE ............................ 10bimatoprost ............................... 98bisoprolol fumarate................... 37bisoprolol-hydrochlorothiazide 37BIVIGAM .............................. 127bleomycin sulfate...................... 26BLEPHAMIDE ........................ 95BLEPHAMIDE S.O.P. ............. 95blisovi fe ................................. 110BOOSTRIX TDAP................. 127bortezomib ................................ 26BOSULIF ................................. 26BREO ELLIPTA ...................... 40briellyn .................................... 110BRILINTA ............................... 41brimonidine tartrate .................. 98BRIVIACT ............................... 68bromocriptine mesylate ............ 75BROVANA 15 MCG/2 ML SOLUTION .............................. 40budesonide .............................. 125budesonide ec ......................... 104budesonide er ............................ 99bumetanide ............................... 49buprenorphine ........................... 58buprenorphine hcl ..................... 58buprenorphine-naloxone........... 58bupropion hcl ............................ 82bupropion hcl sr ........................ 82bupropion xl ............................. 82buspirone hcl ............................ 77busulfan .................................... 26butalb-acetaminoph-caff-codein.................................................. 58butalb-caff-acetaminoph-codein.................................................. 58butalbital compound-codeine ...58butalbital-acetaminophen-caffe 58butalbital-aspirin-caffeine......... 58butorphanol tartrate .................. 58BUTRANS .......................... 58,59BYSTOLIC .............................. 37

139

BYVALSON ............................ 49 cabergoline ............................... 75 CABOMETYX ......................... 26 calcipotriene ........................... 133 calcipotriene-betamethasone dp ................................................ 131 calcitonin-salmon ................... 113 calcitriol ........................... 133,136 calcium acetate ......................... 92 CALQUENCE .......................... 26 CAMBIA .................................. 59 camila ..................................... 110 candesartan cilexetil ................. 50 candesartan-hydrochlorothiazid 50 CAPASTAT SULFATE ........... 17 CAPEX SHAMPOO .............. 131 CAPRELSA .............................. 26 captopril .................................... 50 captopril-hydrochlorothiazide .. 50 CARAFATE ........................... 100 CARBAGLU ............................ 91 carbamazepine .......................... 69 carbamazepine er ...................... 69 carbidopa .................................. 80 carbidopa-levodopa .................. 75 carbidopa-levodopa er .............. 75 carbidopa-levodopa-entacapone .................................................. 75 carboplatin ................................ 26 CARDURA XL ........................ 37 CARIMUNE NF NANOFILTERED .................. 127 carteolol hcl .............................. 98 cartia xt ..................................... 50 carvedilol .................................. 37 carvedilol er .............................. 37 caspofungin acetate .................. 16 CAYSTON ............................... 11 cefaclor ..................................... 11 cefaclor er ................................. 11 cefadroxil .................................. 11 cefazolin sodium ....................... 11

cefdinir...................................... 11cefepime hcl ............................. 11cefixime .................................... 11cefotaxime sodium.................... 11cefoxitin.................................... 12cefpodoxime proxetil................ 12cefprozil.................................... 12ceftazidime ............................... 12ceftriaxone ................................ 12cefuroxime................................ 12cefuroxime sodium ................... 12celecoxib................................... 59CELONTIN .............................. 69cephalexin................................. 12CERDELGA............................. 94CEREBYX ............................... 69CEREZYME ............................ 94CESAMET ............................... 99cetirizine hcl ............................. 24cevimeline hcl........................... 36CHANTIX ........................... 35,36CHEMET................................ 103CHENODAL .......................... 102chloramphenicol sod succinate.12chlorhexidine gluconate.......... 129chloroquine phosphate.............. 18chlorothiazide ........................... 50chlorpromazine hcl ................... 82chlorthalidone ........................... 50CHOLBAM ............................ 102cholestyramine.......................... 45cholestyramine light ................. 45chorionic gonadotropin........... 113ciclopirox................................ 129cidofovir ................................... 19cilostazol................................... 41CILOXAN ................................ 95cimetidine ............................... 100CIMZIA.................................. 119

CINRYZE ............................... 119CINVANTI ............................... 99CIPRO HC ................................ 95CIPRODEX .............................. 95ciprofloxacin ............................. 12ciprofloxacin er ......................... 12ciprofloxacin hcl .................. 12,95ciprofloxacin-d5w..................... 12cisplatin .................................... 26citalopram hbr ........................... 82cladribine .................................. 26claravis .................................... 133CLARINEX .............................. 24CLARINEX-D 12 HOUR ........ 24clarithromycin ..................... 12,13clarithromycin er ...................... 12CLEOCIN ............................... 129clindamycin hcl ........................ 13clindamycin palmitate hcl......... 13clindamycin phosphate ...... 13,129clindamycin phosphate-d5w..... 13clindamycin-benzoyl peroxide129CLINIMIX ................................ 91CLINIMIX E ............................ 91clinisol ...................................... 91clobetasol emollient................ 131clobetasol propionate.............. 131clofarabine ................................ 26clomipramine hcl ................. 82,83clonazepam .......................... 78,79clonidine ................................... 50clonidine hcl ............................. 50clonidine hcl er ......................... 50clopidogrel ................................ 41clorazepate dipotassium............ 79clotrimazole ............................ 129clotrimazole-betamethasone ...129clozapine ................................... 83clozapine odt ............................. 83

140

COARTEM .............................. 18 codeine sulfate .......................... 59 codeine sulfate tab 15 mg ......... 59 colchicine ................................ 117 colesevelam hcl ........................ 45 colestipol hcl ............................. 45 colistimethate ............................ 13 colocort ................................... 131 COLY-MYCIN S ..................... 95 COMBIGAN ............................ 98 COMBIVENT RESPIMAT...... 35 COMETRIQ ............................. 26 COMPLERA ............................ 19 compro ...................................... 83 constulose ................................. 91 CORDRAN ............................ 131 CORLANOR ............................ 37 cortisone acetate ..................... 104 CORTISPORIN ...................... 130 COSENTYX (2 SYRINGES). 133 COSENTYX PEN (2 PENS) .. 133 COTELLIC ............................... 26 COUMADIN ............................ 41 CREON .................................. 102 CRESEMBA ............................ 16 CRIXIVAN .............................. 19 cromolyn 20 mg/2 ml neb soln ................................................ 125 cromolyn sodium .................... 125 cryselle .................................... 110 cyclafem ................................. 110 cyclobenzaprine hcl .................. 36 cyclophosphamide .................... 26 cyclosporine ..................... 121,122 cyclosporine modified ..... 121,122 cyproheptadine hcl.................... 24 CYRAMZA .............................. 26 CYSTADANE ........................ 122 CYSTAGON .......................... 122 CYSTARAN........................... 122

cytarabine ................................. 26DALIRESP............................. 126DALVANCE ............................ 13danazol.................................... 105dantrolene sodium .................... 36dapsone.............................. 17,133DAPTACEL DTAP................ 127daptomycin ............................... 13DARAPRIM............................. 13darifenacin er .......................... 134DARZALEX............................. 26daunorubicin hcl ....................... 26DAYTRANA....................... 65,66decitabine.................................. 26DELZICOL .............................. 99DEMSER................................ 122DENAVIR .............................. 130DEPEN ................................... 103DEPO-ESTRADIOL .............. 112DEPO-SUBQ PROVERA 104 ................................................ 113DESCOVY ............................... 19desipramine hcl......................... 83desloratadine............................. 25desmopressin acetate .............. 110desogestrel-ethinyl estradiol... 110desogestr-eth estrad eth estra..110DESONATE........................... 131desonide.................................. 131desoximetasone ...................... 131desvenlafaxine succinate er ...... 83dexamethasone ....................... 104DEXAMETHASONE INTENSOL ............................ 104dexamethasone sodium phosphate ........................................... 96,104DEXILANT............................ 100dexmethylphenidate hcl er........ 66dexrazoxane............................ 124dextroamphetamine sulfate er... 66dextroamphetamine-amphet er .66dextroamphetamine-amphetamine ............................................. 66,67

dextrose 10%-0.2% nacl........... 91dextrose 10%-0.45% nacl......... 91dextrose 2.5%-0.45% nacl........ 91dextrose 5%-0.2% nacl............. 92dextrose 5%-0.2% nacl-kcl....... 93dextrose 5%-0.225% nacl......... 92dextrose 5%-0.33% nacl........... 92dextrose 5%-0.33% nacl-kcl..... 93dextrose 5%-0.45% nacl........... 92dextrose 5%-0.45% nacl-kcl..... 93dextrose 5%-0.9% nacl............. 92dextrose 5%-1/2ns-kcl .............. 93dextrose 5%-ns-kcl ................... 93dextrose 5%-potassium chloride.................................................. 93dextrose in lactated ringers....... 93dextrose in water....................... 92DIASTAT ................................. 79DIASTAT ACUDIAL.............. 79diazepam ................................... 79diclofenac potassium ................ 59diclofenac sodium................ 59,96diclofenac sodium er................. 59diclofenac sodium-misoprostol 59dicloxacillin sodium ................. 13dicyclomine hcl ........................ 35didanosine ................................. 19DIFICID ................................... 13diflorasone diacetate............... 131diflunisal ................................... 59digitek ....................................... 48digoxin ...................................... 48dihydroergotamine mesylate37,38DILANTIN ............................... 69DILANTIN-125 ........................ 69diltiazem 12hr er ....................... 50diltiazem 24hr er .................. 50,51diltiazem hcl ............................. 51dilt-xr ........................................ 50DIPENTUM ............................. 99

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diphenhydramine hcl ................ 38 diphenoxylate-atropine ........... 103 diphtheria-tetanus toxoids-ped 128 disulfiram ........................... 80,116 divalproex dr 125 mg cap sprnk 69 divalproex sodium .................... 69 divalproex sodium er ................ 69 docetaxel ................................... 26 dofetilide ................................... 48 donepezil hcl ............................. 36 donepezil hcl odt....................... 36 DOPTELET .............................. 43 dorzolamide hcl ........................ 98 dorzolamide-timolol ................. 98 doxazosin mesylate ................... 38 doxepin hcl ........................ 83,132 doxercalciferol ........................ 136 doxorubicin hcl ......................... 27 doxorubicin hcl liposome ......... 27 doxy 100 ................................... 13 doxycycline hyclate .................. 13 doxycycline monohydrate ........ 13 dronabinol ................................. 99 drospirenone-eth estra-levomef ................................................ 110 drospirenone-ethinyl estradiol 110 DROXIA .................................. 27 duloxetine hcl ........................... 83 DUPIXENT ............................ 133 duramorph ................................ 59 DUREZOL ............................... 96 dutasteride............................... 116 dutasteride-tamsulosin .............. 38 DYMISTA .............................. 125 econazole nitrate ..................... 130 EDURANT ............................... 19 efavirenz ................................... 19 EFAVIRENZ 200 MG CAPSULE ................................ 19 EFAVIRENZ 50 MG CAPSULE .................................................. 19 ELAPRASE .............................. 94

ELELYSO ................................ 94ELIDEL .................................. 133ELIGARD ................................ 27ELIQUIS ............................. 41,42ELITEK .................................... 94ELMIRON.............................. 122EMADINE................................ 97EMCYT .................................... 27emoquette ............................... 110EMPLICITI .............................. 27EMSAM ................................... 83EMTRIVA................................ 19enalapril maleate....................... 51enalapril-hydrochlorothiazide...51ENBREL ................................ 119ENBREL SURECLICK ......... 119ENDARI................................. 122endocet...................................... 59ENGERIX-B ADULT............ 128ENGERIX-B PEDIATRIC-ADOLESCENT...................... 128enoxaparin sodium.................... 42ENSTILAR............................. 133entacapone ................................ 76entecavir ................................... 19ENTRESTO............................ 124enulose...................................... 91EPCLUSA ................................ 19EPIDUO FORTE.................... 133epinephrine ............................... 40epirubicin hcl ............................ 27epitol ......................................... 69EPIVIR HBV............................ 19eplerenone................................. 51EPOGEN ............................. 43,44eprosartan mesylate .................. 51EQUETRO .......................... 69,70ERBITUX................................. 27ergoloid mesylates .................... 38ERIVEDGE .............................. 27

ERLEADA ............................... 27errin ........................................ 110ERWINAZE ............................. 27ery ........................................... 130ERYPED 200 ........................... 14ERYPED 400 ........................... 14ERY-TAB ............................ 13,14ERYTHROCIN LACTOBIONATE ................... 14ERYTHROCIN STEARATE...14erythromycin................. 14,95,130erythromycin ethylsuccinate..... 14erythromycin-benzoyl peroxide................................................ 130ESBRIET ................................ 126escitalopram oxalate ................. 84esomeprazole magnesium....... 100esomeprazole sodium ............. 100estradiol .................................. 112eszopiclone ............................... 77ethacrynic acid .......................... 51ethambutol hcl .......................... 17ethosuximide ............................ 70ethynodiol-ethinyl estradiol.... 110etodolac..................................... 59etodolac er ................................ 59etoposide ................................... 27EUCRISA ............................... 134EURAX .................................. 130EVOTAZ .................................. 19exemestane ............................... 27EXJADE ................................. 103EXTAVIA .............................. 117ezetimibe................................... 45ezetimibe-simvastatin ............... 45FABRAZYME ......................... 94famciclovir ................................ 19famotidine ............................... 100FANAPT .................................. 84FARESTON ............................. 27FARYDAK ............................... 27

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FASENRA .............................. 126 FASLODEX ............................. 27 felbamate .................................. 70 felodipine er .............................. 51 FEMRING .............................. 112 fenofibrate............................ 45,46 fenofibric acid ........................... 46 fenoprofen calcium .............. 59,60 fentanyl ..................................... 60 fentanyl citrate .......................... 60 FENTORA ................................ 60 FERRIPROX ................... 103,104 FETZIMA ................................. 84 FINACEA ............................... 134 finasteride ............................... 116 FIRAZYR ............................... 119 FIRMAGON ............................. 27 FLAREX .................................. 96 flavoxate hcl ........................... 134 FLEBOGAMMA DIF ............ 127 flecainide acetate ...................... 48 FLOVENT DISKUS .............. 125 FLOVENT HFA ..................... 125 fluconazole .......................... 16,17 fluconazole-nacl ....................... 17 flucytosine ................................ 17 fludarabine phosphate ............... 27 fludrocortisone acetate............ 104 flunisolide ............................... 125 fluocinolone acetonide............ 131 fluocinolone acetonide oil ........ 96 fluocinonide ..................... 131,132 fluocinonide-e ......................... 132 fluorometholone ....................... 96 fluorouracil ........................ 27,134 fluoxetine dr ............................. 84 fluoxetine hcl ............................ 84 fluphenazine decanoate ............ 84 fluphenazine hcl................... 84,85

flurandrenolide ....................... 132flurbiprofen............................... 60flurbiprofen sodium.................. 96flutamide................................... 27fluticasone propionate ..... 125,132fluticasone-salmeterol............... 40fluvastatin er ............................. 46fluvastatin sodium .................... 46fluvoxamine maleate ................ 85fluvoxamine maleate er ............ 85FML FORTE ............................ 96FOLOTYN ............................... 27fondaparinux sodium................ 42FORFIVO XL........................... 85FORTEO ................................ 113fosamprenavir calcium ............. 19fosinopril sodium...................... 51fosinopril-hydrochlorothiazide .51FOSRENOL ............................. 92FREAMINE HBC .................... 92frovatriptan succinate ............... 74furosemide ................................ 51FUZEON .................................. 19FYCOMPA............................... 70gabapentin................................. 60galantamine er .......................... 36galantamine hbr ........................ 36galantamine hydrobromide....... 36GAMASTAN S-D.................. 127GAMMAGARD LIQUID ...... 127GAMMAGARD S-D ............. 127GAMMAKED ........................ 127GAMMAPLEX ...................... 127GAMUNEX-C........................ 127ganciclovir sodium ................... 20GARDASIL 9......................... 128gatifloxacin ............................... 95GATTEX ................................ 101gauze pads .............................. 135

gavilyte-c ................................ 101gavilyte-g ................................ 101gavilyte-n ................................ 101GELNIQUE ............................ 134gemfibrozil ............................... 46generlac..................................... 91gengraf .................................... 122gentamicin sulfate......... 14,95,130gentamicin sulfate in ns ............ 14GENVOYA .............................. 20GEODON ................................. 85GILENYA .............................. 117GILOTRIF ................................ 27GLASSIA ............................... 127glatiramer acetate.................... 117GLEOSTINE ............................ 27glimepiride .............................. 106glipizide ........................... 106,107glipizide er .............................. 106glipizide-metformin................ 107GLUCAGEN .......................... 122GLUCAGON EMERGENCY KIT ......................................... 122glycopyrrolate ........................... 35GLYXAMBI .......................... 107GOLYTELY ........................... 101GRALISE ................................. 61GRALISE 30-DAY STARTER PACK ....................................... 60granisetron hcl .......................... 99GRANIX .................................. 44griseofulvin ............................... 17griseofulvin ultramicrosize....... 17guanfacine hcl er....................... 80guanidine hcl .......................... 123H.P. ACTHAR ....................... 110HAEGARDA .......................... 123HALAVEN ............................... 28halobetasol propionate............ 132haloperidol ................................ 85haloperidol decanoate............... 85

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haloperidol lactate .................... 85 HARVONI ................................ 20 HAVRIX ................................ 128 heparin sodium ......................... 42 HEPATAMINE ........................ 92 HERCEPTIN ............................ 28 HETLIOZ ................................. 77 HEXALEN ............................... 28 HIBERIX ................................ 128 HORIZANT .............................. 61 HUMIRA ................................ 120 HUMIRA PEDIATRIC CROHN'S ............................... 120 HUMIRA PEN ....................... 120 HUMIRA PEN CROHN-UC-HS STARTER .............................. 120 HUMIRA PEN PSORIASIS-UVEITIS ................................ 120 hydralazine hcl.......................... 51 hydrochlorothiazide .................. 51 hydrocodone-acetaminophen .... 61 hydrocodone-ibuprofen ............ 61 hydrocortisone ................. 104,132 hydrocortisone butyrate .......... 132 hydrocortisone valerate .......... 132 hydrocortisone-acetic acid ........ 95 hydromorphone er .................... 61 hydromorphone hcl ................... 61 hydroxychloroquine sulfate ...... 18 hydroxyurea .............................. 28 hydroxyzine hcl ........................ 77 HYPERRAB S-D ................... 128 ibandronate sodium ................ 118 IBRANCE ................................ 28 ibuprofen .................................. 61 ibuprofen tab 600 mg ............... 61 ibuprofen tab 800 mg ............... 61 ICLUSIG .................................. 28 idarubicin hcl ............................ 28 IDHIFA .................................... 28 ifosfamide ................................. 28 ILARIS ................................... 123

ILEVRO ................................... 96imatinib mesylate...................... 28IMBRUVICA ........................... 28IMFINZI................................... 28imipenem-cilastatin sodium ..... 14imipramine hcl.......................... 85imipramine pamoate ................. 85imiquimod .............................. 134IMOVAX RABIES VACCINE ................................................ 128INCRELEX ............................ 114INCRUSE ELLIPTA................ 40indapamide ............................... 51INFANRIX DTAP ................. 128INGREZZA .............................. 80INLYTA ................................... 28insulin 1 ml syringe ................ 136insulin 1/2 ml syringe ............. 136INSULIN SYRINGE 0.3 ML.136INTELENCE ............................ 20INTRAROSA ......................... 104INTRON A ............................... 20introvale.................................. 110INVANZ................................... 14INVEGA SUSTENNA............. 85INVEGA TRINZA ................... 85INVIRASE ............................... 20INVOKAMET........................ 107INVOKAMET XR ................. 107INVOKANA........................... 107IONOSOL MB-DEXTROSE 5% .................................................. 93IOPIDINE................................. 98IPOL ....................................... 128ipratropium bromide............ 35,98ipratropium-albuterol................ 35irbesartan .................................. 51irbesartan-hydrochlorothiazide.52IRESSA .................................... 28irinotecan hcl ............................ 28ISENTRESS ............................. 20

ISENTRESS HD ...................... 20ISOLYTE P WITH DEXTROSE.................................................. 93ISOLYTE S .............................. 93isoniazid .................................... 17isosorbide dinitrate ................... 56isosorbide dinitrate er ............... 56isosorbide mononitrate ............. 56isosorbide mononitrate er ......... 56isotretinoin .............................. 134isradipine .................................. 52ISTODAX ................................ 28itraconazole............................... 17ivermectin ................................. 10IXIARO .................................. 128JADENU ................................ 104JADENU SPRINKLE ............ 104JAKAFI ............................... 28,29jantoven .................................... 42JARDIANCE .......................... 107JENTADUETO ...................... 107JENTADUETO XR................ 107JEVTANA ................................ 29jolivette ................................... 110JULUCA ................................... 20junel ........................................ 110junel fe .................................... 110junel fe 24 ............................... 110JUXTAPID ............................... 46JYNARQUE ........................ 90,91KADCYLA .............................. 29KALETRA ............................... 20KALYDECO .......................... 127KANUMA ................................ 94kariva ...................................... 110kelnor 1-35 ............................. 110KEPIVANCE ......................... 133ketoconazole ...................... 17,130ketoprofen ................................. 61ketorolac tromethamine ............ 97

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ketorolac tromethamine ophth soln 0.4% .................................. 96 KEVZARA ............................. 120 KEYTRUDA ............................ 29 KHEDEZLA ............................. 86 KINERET ............................... 120 KINRIX .................................. 128 kionex ....................................... 92 KISQALI .................................. 29 KISQALI FEMARA CO-PACK .................................................. 29 klor-con 10 ............................... 93 KLOR-CON M15 ..................... 93 klor-con m20 ............................ 93 KORLYM ............................... 123 KUVAN .................................. 123 KYNAMRO ............................. 46 KYPROLIS .............................. 29 labetalol hcl .............................. 38 lactated ringers.......................... 93 lactulose .................................... 91 LAMICTAL ODT .................... 70 LAMICTAL XR (BLUE) ......... 70 LAMICTAL XR (GREEN) ...... 70 LAMICTAL XR (ORANGE) .. 70 lamivudine ........................... 20,21 lamivudine hbv ......................... 20 lamivudine-zidovudine ............. 21 lamotrigine ................................ 71 lamotrigine (blue) ..................... 70 lamotrigine (green) ................... 70 lamotrigine (orange) ................. 70 lamotrigine er....................... 70,71 lamotrigine odt ......................... 71 lansoprazol-amoxicil-clarithro . 14 lansoprazole ............................ 100 lanthanum carbonate ................. 92 LANTUS ................................ 108 LANTUS SOLOSTAR ........... 107 LARTRUVO ............................ 29 LASTACAFT ........................... 97

latanoprost ................................ 98LATUDA.................................. 86LAZANDA............................... 61leflunomide............................. 120LENVIMA........................... 29,30lessina ..................................... 110LETAIRIS ................................ 56letrozole .................................... 30leucovorin calcium ................. 116LEUKERAN............................. 30LEUKINE................................. 44leuprolide acetate...................... 30levalbuterol 0.31 mg/3 ml sol... 40levalbuterol 0.63 mg/3 ml sol... 40levalbuterol 1.25 mg/3 ml sol... 40levalbuterol conc 1.25 mg/0.5 ..40levalbuterol tartrate hfa............. 40levetiracetam............................. 71levetiracetam er ........................ 71levetiracetam-nacl..................... 71levobunolol hcl ......................... 98levocetirizine dihydrochloride..25levofloxacin ......................... 14,95levofloxacin-d5w...................... 14levoleucovorin calcium ............ 30levonest................................... 113levonorgestrel-eth estradiol .... 111levonorg-eth estrad eth estrad.110levora-28................................. 111levothyroxine sodium ...... 114,115LEVOXYL ............................. 115LEXIVA ................................... 21lidocaine ................................. 133lidocaine hcl ...................... 98,132lidocaine hcl viscous ................ 98lidocaine-prilocaine ................ 133lindane .................................... 130linezolid .................................... 14linezolid-d5w............................ 14

LINZESS ................................ 101liothyronine sodium................ 115lisinopril .................................... 52lisinopril-hydrochlorothiazide ..52lithium ...................................... 74lithium carbonate ...................... 74lithium carbonate er.................. 74LIVALO ................................... 46LO LOESTRIN FE................. 111LOESTRIN ............................. 111LOESTRIN FE ....................... 111LONSURF ................................ 30loperamide .............................. 103lopinavir-ritonavir..................... 21lorazepam ................................. 79loryna ...................................... 113losartan potassium .................... 52losartan-hydrochlorothiazide.... 52LOTEMAX .............................. 97lovastatin ............................. 46,47loxapine .................................... 86LUMIGAN ............................... 98LUMIZYME............................. 94LUPRON DEPOT .................... 30LUPRON DEPOT-PED ........... 30lutera ....................................... 111LYNPARZA ............................. 30LYRICA .............................. 71,72LYSODREN ............................. 30magnesium sulfate .................... 93maprotiline hcl .......................... 86marlissa ................................... 111MARPLAN .............................. 86MATULANE ............................ 30matzim la .................................. 52MAVYRET .............................. 21MAXIDEX ............................... 97meclizine hcl ............................. 24meclofenamate sodium............. 61

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medroxyprogesterone acetate ......................................... 113,114 mefloquine hcl .......................... 18 megestrol acetate ...................... 30 MEKINIST ............................... 30 meloxicam ........................... 61,62 melphalan hcl............................ 30 memantine hcl .......................... 80 memantine hcl er ...................... 80 MENACTRA .......................... 128 MENVEO A-C-Y-W-135-DIP ................................................ 128 mercaptopurine ......................... 30 meropenem ............................... 14 mesalamine ............................... 99 MESNEX ................................ 124 metaproterenol sulfate .............. 40 metformin hcl ......................... 108 metformin hcl er ..................... 108 methadone hcl ........................... 62 methazolamide .......................... 98 methenamine hippurate ............ 24 methimazole ........................... 115 methotrexate ............................. 31 methotrexate sodium ................ 31 methoxsalen ............................ 133 methscopolamine bromide ....... 35 methyclothiazide....................... 52 methylphenidate er ................... 67 methylphenidate hcl.................. 67 methylphenidate hcl cd ............. 67 methylphenidate la.................... 68 methylprednisolone ................ 104 methylprednisolone acetate .... 104 methylprednisolone sodium succ ................................................ 104 metipranolol .............................. 98 metoclopramide hcl ................ 103 metoclopramide hcl odt .......... 103 metolazone ................................ 52 metoprolol succinate ................. 38 metoprolol tartrate .................... 38

metoprolol-hydrochlorothiazide .................................................. 38metronidazole ............... 14,18,130mexiletine hcl ........................... 48MIACALCIN ......................... 113MICONAZOLE 3................... 130microgestin ............................. 111microgestin fe ......................... 111midodrine hcl............................ 40miglitol ................................... 108MIGLUSTAT 100 MG CAPSULE .............................. 123minitran .................................... 56minocycline hcl ........................ 14minocycline hcl er .................... 14minoxidil .................................. 52MIRCERA................................ 44mirtazapine ............................... 86misoprostol ............................. 100mitoxantrone hcl....................... 31M-M-R II VACCINE ............. 128modafinil .................................. 68moexipril hcl............................. 52moexipril-hydrochlorothiazide .52mometasone furoate......... 125,132mononessa .............................. 111montelukast sodium......... 125,126MONUROL.............................. 24morphine sulfate .................. 62,63morphine sulfate er ................... 62MOVANTIK .......................... 101MOVIPREP............................ 101MOXEZA................................. 95moxifloxacin............................. 95moxifloxacin hcl....................... 14MOZOBIL................................ 44MULTAQ................................. 48mupirocin................................ 130MUSTARGEN ......................... 31MYALEPT ............................. 123mycophenolate mofetil ........... 122

mycophenolic acid.................. 122MYLOTARG ........................... 31myorisan ................................. 134MYRBETRIQ ........................ 135nabumetone............................... 63nadolol ...................................... 38nadolol-bendroflumethiazide.... 38nafcillin sodium ........................ 15naftifine hcl ............................. 130NAGLAZYME ......................... 94naloxone hcl ............................. 81naltrexone hcl ........................... 81NAMENDA XR ....................... 80NAPRELAN ............................. 63naproxen ................................... 63naproxen sodium ...................... 63naproxen sodium er .................. 63naratriptan hcl ........................... 74NARCAN ................................. 81NATACYN .............................. 95nateglinide .............................. 108NATPARA ............................. 113NEBUPENT ............................. 18necon ...................................... 111nefazodone hcl .......................... 86neomycin sulfate ....................... 15neomycin-bacitracin-poly-hc.... 95neomycin-bacitracin-polymyxin.................................................. 95neomycin-polymyxin b........... 130neomycin-polymyxin-dexameth.................................................. 95neomycin-polymyxin-gramicidin.................................................. 96neomycin-polymyxin-hc........... 96neomycin-polymyxin-hydrocort.................................................. 96NEPHRAMINE ........................ 92NERLYNX ............................... 31NEULASTA ............................. 44NEUPOGEN............................. 44NEUPRO .................................. 76NEVANAC .............................. 97

146

nevirapine ................................. 21 nevirapine er ............................. 21 NEXAVAR .............................. 31 niacin er .................................... 47 nicardipine hcl .......................... 52 NICOTROL .............................. 36 NICOTROL NS ........................ 36 nifedipine er .............................. 52 nilutamide ................................. 31 nimodipine ................................ 52 NINLARO ................................ 31 nisoldipine ........................... 52,53 NITRO-BID .............................. 56 nitrofurantoin ............................ 24 nitrofurantoin mono-macro ...... 24 nitroglycerin ............................. 56 nitroglycerin patch .................... 56 nizatidine ................................ 100 norethindrone .......................... 113 norethindrone acetate.............. 114 norethindron-ethinyl estradiol 111 norethin-eth estra-ferrous fum 111 norgestimate-ethinyl estradiol 111 NORMOSOL-M AND DEXTROSE ............................. 93 NORMOSOL-R AND DEXTROSE ............................. 93 NORMOSOL-R PH 7.4 ........... 93 NORPACE CR ......................... 48 NORTHERA ............................ 40 nortrel ..................................... 111 nortriptyline hcl ........................ 86 NORVIR ................................... 21 NOVOLIN 70-30 ................... 108 NOVOLIN N .......................... 108 NOVOLIN R .......................... 108 NOVOLOG ............................ 108 NOVOLOG FLEXPEN .......... 108 NOVOLOG MIX 70-30 ......... 108 NOVOLOG MIX 70-30 FLEXPEN .............................. 108 NOXAFIL ................................ 17

NUEDEXTA ............................ 80NULOJIX ............................... 122NUPLAZID .............................. 86nutrilipid ................................... 92NUVARING........................... 111NYMALIZE ............................. 53nystatin .............................. 17,130nystatin-triamcinolone............ 130nystop ..................................... 130OCALIVA .............................. 102OCTAGAM............................ 127octreotide acetate .................... 123ODEFSEY ................................ 21ODOMZO ................................ 31OFEV...................................... 127ofloxacin .............................. 15,96OGESTREL............................ 111olanzapine............................ 86,87olanzapine odt........................... 86olanzapine-fluoxetine hcl ......... 87olmesartan medoxomil ............. 53olmesartan-amlodipine-hctz ..... 53olmesartan-hydrochlorothiazide .................................................. 53olopatadine hcl.......................... 97omega-3 acid ethyl esters ......... 47omeprazole ............................. 100OMNARIS.............................. 126OMNITROPE......................... 114ondansetron hcl......................... 99ondansetron odt ...................... 100ONFI......................................... 79OPDIVO................................... 31OPSUMIT ................................ 56ORACEA.................................. 15ORALAIR .............................. 123ORBACTIV.............................. 15ORENCIA ....................... 120,121ORENCIA CLICKJECT ........ 120ORENITRAM ER .................... 56

ORFADIN .............................. 123ORKAMBI ............................. 123orsythia ................................... 111oseltamivir phosphate............... 21OSPHENA .............................. 113OTEZLA ................................ 121oxaliplatin ................................. 31oxandrolone ............................ 105oxaprozin .................................. 63oxcarbazepine ........................... 72oxiconazole nitrate.................. 130OXTELLAR XR ...................... 72oxybutynin chloride................ 135oxybutynin chloride er............ 135oxycodone hcl ...................... 63,64oxycodone hcl er ...................... 63oxycodone hcl-aspirin .............. 64oxycodone hcl-ibuprofen.......... 64oxycodone-acetaminophen....... 64oxymorphone hcl ...................... 64oxymorphone hcl er.................. 64pacerone .................................... 48paclitaxel................................... 31paliperidone er .......................... 87pamidronate disodium ............ 118PANCREAZE......................... 102PANRETIN ............................ 134pantoprazole sodium............... 100paricalcitol .............................. 136paromomycin sulfate ................ 15paroxetine er ............................. 87paroxetine hcl ........................... 87PASER ...................................... 17PAXIL ...................................... 87PAZEO ..................................... 97PEDIARIX ............................. 128PEDVAXHIB ......................... 128peg 3350-electrolyte ............... 101peg-3350 and electrolytes....... 101

147

PEGANONE ............................ 72 PEGASYS ................................ 21 PEGASYS PROCLICK ........... 21 PEN NEEDLES 12MM 29G .. 136 penicillin g potassium ............... 15 penicillin g procaine ................. 15 penicillin g sodium ................... 15 penicillin gk-iso-osm dextrose . 15 penicillin v potassium ............... 15 PENTAM 300 ........................... 15 PENTASA ................................ 99 pentoxifylline ............................ 44 PERFOROMIST 20 MCG/2 ML SOLN ........................................ 40 perindopril erbumine ................ 53 permethrin............................... 130 perphenazine ............................. 87 PERTZYE .............................. 102 PEXEVA .................................. 87 phenelzine sulfate ..................... 87 phenobarbital ............................ 78 phenoxybenzamine hcl ............. 38 phenytoin .................................. 72 phenytoin sodium extended ...... 72 PHOSPHOLINE IODIDE ........ 98 physiolyte ................................. 93 physiosol ................................... 93 PICATO .................................. 134 pilocarpine hcl .......................... 36 pimozide ................................... 87 pindolol ..................................... 38 pioglitazone hcl ...................... 108 pioglitazone-glimepiride ........ 108 pioglitazone-metformin .......... 108 piperacillin-tazobactam ............ 15 piroxicam .................................. 64 PLASMA-LYTE 148 ............... 93 PLASMA-LYTE A PH 7.4 ...... 93 PLEGRIDY ............................ 117 PLEGRIDY PEN .................... 117

plenamine ................................. 92podofilox ................................ 134polyethylene glycol 3350 ....... 101polymyxin b sul-trimethoprim..96POMALYST ............................ 31portia....................................... 111potassium chl-normal saline ..... 93potassium chloride............... 93,94potassium chloride in d5lr ........ 93potassium chloride-nacl............ 94potassium citrate er................... 91PRADAXA............................... 42PRALUENT PEN..................... 47pramipexole dihydrochloride.... 76pramipexole er .......................... 76prasugrel hcl ............................. 42pravastatin sodium.................... 47prazosin hcl............................... 38PRED MILD............................. 97PRED-G.................................... 96prednicarbate .......................... 132prednisolone ........................... 105prednisolone acetate ............... 104prednisolone sodium phos odt ......................................... 104,105prednisolone sodium phosphate ........................................... 97,105prednisone .............................. 105PREDNISONE INTENSOL...105PREFEST ............................... 113PREMARIN ........................... 113PREMASOL............................. 92PRENATAL VITAMINS....... 136prevalite .................................... 47previfem.................................. 111PREVYMIS......................... 21,22PREZCOBIX............................ 22PREZISTA ............................... 22PRIFTIN................................... 17primaquine................................ 18primidone.................................. 78

PRIVIGEN ............................. 127PROAIR HFA .......................... 41PROAIR RESPICLICK ........... 41probenecid ................................ 94probenecid-colchicine............... 94PROCALAMINE ..................... 92prochlorperazine ....................... 24prochlorperazine edisylate........ 24prochlorperazine maleate.......... 24procto-med hc ......................... 132procto-pak ............................... 132proctosol-hc ............................ 132proctozone-hc ......................... 132progesterone ........................... 114PROGLYCEM ......................... 53PROLASTIN C ...................... 127PROLEUKIN ........................... 31PROLIA .................................. 118PROMACTA ............................ 44promethazine hcl ...................... 24promethegan ........................... 100propafenone hcl ........................ 48propafenone hcl er .................... 48proparacaine hcl........................ 98propranolol hcl..................... 38,39propranolol hcl er ..................... 38propranolol-hydrochlorothiazide.................................................. 39propylthiouracil ...................... 115PROQUAD ............................. 128PROSOL ................................... 92PROTONIX ............................ 101protriptyline hcl ........................ 87PROVENTIL HFA................... 41PRUDOXIN ........................... 133PULMICORT FLEXHALER.126PULMOZYME ......................... 94PURIXAN ................................ 22PYLERA .................................. 15pyrazinamide ............................ 17

148

pyridostigmine bromide............ 36 pyridostigmine bromide er ....... 36 QNASL ................................... 126 QNASL CHILDREN.............. 126 QUADRACEL DTAP-IPV .... 129 quasense .................................. 111 quetiapine fumarate .................. 88 quetiapine fumarate er ......... 87,88 quinapril hcl .............................. 53 quinapril-hydrochlorothiazide .. 53 quinidine sulfate ....................... 18 quinine sulfate .......................... 18 QVAR ..................................... 126 QVAR REDIHALER ............. 126 RABAVERT .......................... 129 rabeprazole sodium ................. 101 raloxifene hcl .......................... 113 ramipril ................................ 53,54 RANEXA ................................. 48 ranitidine hcl ........................... 101 RAPAFLO ................................ 39 RAPAMUNE .......................... 122 rasagiline mesylate ................... 76 RASUVO ............................. 31,32 RAVICTI ................................ 123 REBETOL ................................ 22 REBIF ..................................... 118 REBIF REBIDOSE ......... 117,118 reclipsen .................................. 111 RECOMBIVAX HB ............... 129 RELENZA ................................ 22 RELISTOR ...................... 101,102 REMICADE ........................... 121 REMODULIN ..................... 56,57 RENAGEL ............................... 92 RENFLEXIS .......................... 121 repaglinide .............................. 108 repaglinide-metformin hcl ...... 108 REPATHA PUSHTRONEX .... 47

REPATHA SURECLICK ........ 47REPATHA SYRINGE ............. 47RESCRIPTOR.......................... 22RESTASIS................................ 97RETROVIR .............................. 22REVATIO ................................ 57REVLIMID .............................. 32REXULTI ................................. 88REYATAZ ............................... 22RHOPRESSA........................... 98ribasphere ................................. 22ribavirin .................................... 22RIDAURA.............................. 103rifabutin .................................... 15rifampin .................................... 15RIFATER ................................. 15riluzole...................................... 80ringers injection........................ 94risedronate sodium.................. 119risedronate sodium dr ............. 119RISPERDAL CONSTA ........... 88risperidone ................................ 89risperidone odt ..................... 88,89ritonavir .................................... 22RITUXAN ................................ 32rivastigmine .............................. 36rizatriptan.................................. 74ropinirole er ......................... 76,77ropinirole hcl ............................ 77rosuvastatin calcium ................. 47ROTARIX .............................. 129ROTATEQ ............................. 129ROWASA................................. 99ROZEREM............................... 77RUBRACA............................... 32RYDAPT .................................. 32RYTARY.................................. 77SABRIL.................................... 72SAFYRAL.............................. 111

SAIZEN .................................. 114SAIZEN-SAIZENPREP......... 114SAMSCA .................................. 91SANDIMMUNE .................... 122SANTYL ................................ 134SAPHRIS .................................. 89SAVAYSA .......................... 42,43SAVELLA ................................ 81SAVELLA TITRATION PACK.................................................. 81scopolamine .............................. 35SEEBRI NEOHALER.............. 35SEGLUROMET .............. 108,109selegiline hcl ............................. 89SELZENTRY ........................... 22SEMPREX-D ........................... 25SENSIPAR ............................. 123SEREVENT DISKUS .............. 41sertraline hcl ............................. 89sevelamer carbonate ................. 92SHINGRIX ............................. 129SIGNIFOR .............................. 124SIGNIFOR LAR .............. 123,124sildenafil ................................... 57silver sulfadiazine ................... 130SIMBRINZA ............................ 98SIMPONI ................................ 121SIMPONI ARIA ..................... 121simvastatin ................................ 47sirolimus ................................. 122SIRTURO ................................. 17SIVEXTRO .............................. 15sodium chloride ................... 93,94sodium fluoride tab 1 mg f (from 2.2 mg naf) ............................. 136sodium lactate ........................... 91sodium phenylbutyrate ............. 91sodium polystyrene sulfonate ...92SOLTAMOX ............................ 32SOMATULINE DEPOT ........ 124SOMAVERT .......................... 114

149

sorine ........................................ 39 sotalol ....................................... 39 sotalol af ................................... 39 SPIRIVA .................................. 35 SPIRIVA RESPIMAT .............. 35 spironolactone .......................... 54 spironolactone-hctz................... 54 SPORANOX ............................ 17 sprintec ................................... 111 SPRITAM 1,000 MG TABLET .................................................. 72 SPRITAM 250 MG TABLET .. 72 SPRITAM 500 MG TABLET .. 72 SPRITAM 750 MG TABLET .. 72 SPRYCEL ................................ 32 sps ............................................. 92 sronyx ..................................... 111 ssd ........................................... 130 stavudine ................................... 23 STEGLATRO ......................... 109 STELARA .............................. 134 STIMATE ............................... 124 STIOLTO RESPIMAT ............. 35 STIVARGA .............................. 32 STRENSIQ ............................. 124 streptomycin sulfate.................. 15 STRIBILD ................................ 23 STRIVERDI RESPIMAT ........ 41 SUCRAID ................................ 94 sucralfate................................. 101 sulfacetamide sodium ........ 96,130 sulfacetamide-prednisolone ...... 96 sulfadiazine ............................... 15 sulfamethoxazole-trimethoprim 15 sulfasalazine ............................. 99 sulfasalazine dr ......................... 99 sulindac ..................................... 64 sumatriptan ............................... 74 sumatriptan succinate ............... 74 SUPRAX .................................. 16

SUPREP ................................. 102SUTENT................................... 32SYLATRON............................. 32SYMBICORT........................... 41SYMDEKO ............................ 127SYMFI...................................... 23SYMFI LO ............................... 23SYMLINPEN 120 .................. 109SYMLINPEN 60 .................... 109SYMPROIC............................ 102SYNAGIS................................. 16SYNAREL.............................. 113SYNERCID .............................. 16SYNJARDY ........................... 109SYNJARDY XR..................... 109SYNRIBO ................................ 33SYNTHROID.................. 115,116TABLOID ................................ 33TACLONEX........................... 132tacrolimus ........................ 122,134TAFINLAR .............................. 33TAGRISSO .............................. 33tamoxifen citrate....................... 33tamsulosin hcl........................... 39TARCEVA ............................... 33TARGRETIN ......................... 134TASIGNA ................................ 33tazarotene................................ 134TAZORAC ............................. 134taztia xt ..................................... 54TECENTRIQ............................ 33TECFIDERA .......................... 118TECFIDERA STARTER PACK ................................................ 118TEFLARO ................................ 16TEKTURNA............................. 54TEKTURNA HCT.................... 54telmisartan ................................ 54telmisartan-amlodipine ............. 54telmisartan-hydrochlorothiazid.54

temazepam ................................ 79TENIVAC .............................. 128TENOFOVIR DISOP FUM 300 MG TB ..................................... 23terazosin hcl .............................. 39terbinafine hcl ........................... 17terbutaline sulfate ..................... 41terconazole .............................. 130testosterone ...................... 105,106testosterone cypionate ............ 105testosterone enanthate............. 105tetanus diphtheria toxoids....... 128tetrabenazine ............................. 80THALOMID ........................... 118theophylline ............................ 135theophylline anhydrous .......... 135thioridazine hcl ......................... 89thiotepa ..................................... 33thiothixene ................................ 89tiagabine hcl ............................. 73tigecycline................................. 16timolol maleate .................... 39,98TIMOPTIC OCUDOSE ........... 98tinidazole .................................. 18TIVICAY .................................. 23tizanidine hcl ....................... 36,37TOBI PODHALER .................. 16TOBRADEX ............................ 96TOBRADEX ST ....................... 96tobramycin ................................ 96tobramycin 300 mg/5 ml ampule.................................................. 16tobramycin sulfate .................... 16tobramycin-dexamethasone...... 96TOBREX .................................. 96TOLAK .................................. 134tolazamide............................... 109tolbutamide ............................. 109tolcapone................................... 77tolmetin sodium ........................ 64tolterodine tartrate .................. 135

150

tolterodine tartrate er .............. 135 topiramate ................................. 73 topiramate er ............................. 73 toposar ...................................... 33 topotecan hcl ............................. 33 TORISEL .................................. 33 torsemide .................................. 54 TOUJEO MAX SOLOSTAR . 109 TOUJEO SOLOSTAR ........... 109 TOVIAZ ................................. 135 tpn electrolytes.......................... 94 TRACLEER ............................. 57 TRADJENTA ......................... 109 tramadol hcl .............................. 65 tramadol hcl er ..................... 64,65 tramadol hcl-acetaminophen .... 65 trandolapril ............................... 54 trandolapril-verapamil er ..... 54,55 tranexamic acid ......................... 44 tranylcypromine sulfate ............ 89 TRAVASOL ............................. 92 trazodone hcl ............................ 89 TREANDA ............................... 33 TRECATOR ............................. 17 TRELEGY ELLIPTA ............... 41 TRELSTAR .............................. 33 tretinoin ............................. 33,133 tretinoin microsphere .............. 133 TREXALL ................................ 33 triamcinolone acetonide.......... 132 triamterene-hydrochlorothiazid 55 triazolam ................................... 79 trientine hcl ............................. 104 trifluoperazine hcl ..................... 89 trifluridine ................................. 96 trihexyphenidyl hcl ................... 77 tri-legest fe .............................. 111 tri-lo-estarylla ......................... 112 tri-lo-sprintec .......................... 112

trilyte with flavor packets....... 102trimethoprim............................. 24trimipramine maleate................ 89trinessa.................................... 112TRINTELLIX........................... 90tri-previfem............................. 112TRISENOX .............................. 33tri-sprintec............................... 112TRIUMEQ................................ 23trivora-28 ................................ 112TROKENDI XR ....................... 73TROPHAMINE........................ 92trospium chloride.................... 135trospium chloride er................ 135TRULANCE........................... 102TRULICITY........................... 109TRUMENBA.......................... 129TRUVADA .............................. 23TUDORZA PRESSAIR ........... 35TWINRIX............................... 129TYBOST .................................. 23TYKERB .................................. 33TYMLOS................................ 113TYPHIM VI ........................... 129TYSABRI............................... 118UCERIS.................................... 99ULORIC ................................. 117UNITHROID.......................... 116UPTRAVI................................. 57ursodiol ................................... 102UTIBRON NEOHALER.......... 35valacyclovir .............................. 23VALCHLOR ............................ 23valganciclovir hcl ..................... 23valproate sodium ...................... 73valproic acid ............................. 73valsartan.................................... 55valsartan-hydrochlorothiazide ..55vancomycin hcl......................... 16

vandazole ................................ 130VAQTA .................................. 129VARIVAX VACCINE........... 129VARUBI ................................. 100VASCEPA ................................ 47VECTIBIX ............................... 33VELCADE ............................... 33velivet ..................................... 112VELPHORO ............................. 92VELTASSA .............................. 92VENCLEXTA .......................... 34VENCLEXTA STARTING PACK ....................................... 33venlafaxine hcl.......................... 90venlafaxine hcl er ..................... 90VENTAVIS .............................. 57VENTOLIN HFA ..................... 41verapamil er .............................. 55verapamil er pm ........................ 55verapamil hcl ............................ 55VERIPRED 20 ....................... 105VERSACLOZ .......................... 90VERZENIO .............................. 34VESICARE ............................ 135VICTOZA 3-PAK .................. 109VIDEX ...................................... 23VIDEX EC ............................... 23vienva ..................................... 112vigabatrin .................................. 73VIIBRYD ................................. 90VIMPAT .............................. 73,74vinblastine sulfate ..................... 34vincasar pfs ............................... 34vincristine sulfate...................... 34vinorelbine tartrate.................... 34VIOKACE .............................. 103VIRACEPT .............................. 23VIRAMUNE ............................ 23VIREAD ................................... 24voriconazole ............................. 17

151

VOSEVI ................................... 24 VOTRIENT .............................. 34 VPRIV ...................................... 95 VRAYLAR ............................... 90 VYVANSE ............................... 68 VYXEOS .................................. 34 VYZULTA ............................... 98 warfarin sodium ........................ 43 WELCHOL .............................. 48 XALKORI ................................ 34 XARELTO ............................... 43 XELJANZ .............................. 121 XELJANZ XR ........................ 121 XERMELO ............................. 103 XGEVA .................................. 119 XIFAXAN ................................ 16 XIIDRA .................................... 97 XOLAIR ................................. 127 XTANDI ................................... 34 XULANE ................................ 112 XURIDEN .............................. 116 XYREM .................................... 80 YERVOY ................................. 34 YF-VAX ................................. 129 YONDELIS .............................. 34 YONSA .................................... 34 yuvafem .................................. 113 zafirlukast ............................... 126 zaleplon..................................... 77 ZANOSAR ............................... 34 ZARXIO ................................... 44 ZAVESCA .............................. 124 ZEJULA ................................... 34 ZELAPAR ................................ 90 ZELBORAF ............................. 34 ZEMAIRA .............................. 127 zenatane .................................. 134 ZENPEP ................................. 103 ZEPATIER ............................... 24

ZERIT....................................... 24ZETONNA ............................. 126zidovudine ................................ 24zileuton er ............................... 126ZINPLAVA ............................ 127ziprasidone hcl.......................... 90ZIRGAN................................... 96ZOHYDRO ER ........................ 65zoledronic acid........................ 119ZOLINZA................................. 34zolmitriptan .............................. 75zolmitriptan odt ........................ 75zolpidem tartrate....................... 78zolpidem tartrate er................... 77ZOMETA ............................... 119ZOMIG..................................... 75zonisamide................................ 74ZONTIVITY............................. 43ZORTRESS ............................ 122ZOSTAVAX........................... 129ZOSYN..................................... 16zovia 1-35e ............................. 112ZUBSOLV................................ 65ZYDELIG................................. 34ZYKADIA................................ 34ZYLET ..................................... 96ZYPREXA RELPREVV.......... 90ZYTIGA ................................... 34

This formulary was updated on 09/01/2018. For more recent information or other questions, please contact SelectHealth Member Services toll-free, at 855-442-9900 or, for TTY users, 711, during the following dates and times:

October 1 to February 14: Weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday 8:00 a.m. to 8:00 p.m.

February 15 to September 30:Weekdays 7:00 a.m. to 8:00 p.m., Saturday 9:00 a.m. to 2:00 p.m., closed Sunday.

Outside these hours of operation, please leave a message. Your call will be returned within one business day, or visit selecthealthadvantage.org.

SelectHealth is an HMO plan sponsor with a Medicare contract. Enrollment in SelectHealth Advantage depends on contract renewal.

P.O. Box 30196Salt Lake City, UT 84130-0196855-442-9900 Toll-Free TTY Users: 711

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[note: instructions for plans are provided within ... · formulary list of covered drugs | 2018...

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