wv bureau for medical services v2019.1 drug quantity limits pharmacy/documents/posting 2019...

WV Bureau for Medical Services

Drug Quantity LimitsV2019.1

THERAPEUTIC CLASS ACNE AGENTS (Topical) BRAND UnitsUntil

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DaysRefills Pkg Bill Age Gender Effective Date

ACNE AGENTS,TOPICAL ADAPALENE 0.1% CREAM 45UNIT PACKAGES DIFFERIN 90 30 Y 07/01/2013ACNE AGENTS,TOPICAL ADAPALENE 0.1% GEL DIFFERIN 90 30 Y 07/01/2013ACNE AGENTS,TOPICAL ADAPALENE 0.1% LOTION 59ML DIFFERIN 59 30 Y 10/01/2013ACNE AGENTS,TOPICAL ADAPALENE 0.3% GEL PUMP 45GRAM DIFFERIN 45 30 Y 10/01/2013ACNE AGENTS,TOPICAL ADAPALENE-BENZOYL PEROXIDE 0.1-2.5% GEL 45GRAM EPIDUO 45 30 Y 10/01/2013ACNE AGENTS,TOPICAL BENZOYL PEROXIDE WASH ACNE TREATMENT PACKS GENERIC ONLY 1 Y 10/01/2018ACNE AGENTS,TOPICAL CLINDAMYCIN PHOS/BENZOYL PEROX GEL 25, 50GRAMS BENZACLIN 50 30 Y 07/01/2013TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES COLLAGENASE CLOSTRIDIUM HIST OINTMENT SANTYL 60 30 Y 10/01/2018ACNE AGENTS,TOPICAL METRONIDAZOLE/SKIN CLEANSR #23 0.75% CREAM OR GEL KIT ROSADAN 1 F 10/01/2018

THERAPEUTIC CLASS ALZHEIMER’S AGENTS BRAND UnitsUntil

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ALZHEIMER’S AGENTS DONEPEZIL HCL 5, 10 and 23MG TABLET ARICEPT / ARICEPT ODT 1 Min 45 07/01/2013ALZHEIMER’S AGENTS GALANTAMINE HBR 4, 8 and 12MG TABLET RAZADYNE 2 Min 45 07/01/2013ALZHEIMER’S AGENTS GALANTAMINE HBR 8, 16 and 24MG CAPSULE RAZADYNE ER 1 Min 45 07/01/2013ALZHEIMER’S AGENTS GALANTAMINE HBR 4MG/ML ORAL SOLUTION 100ML RAZADYNE 200 30 Min 45 10/01/2013ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL 5MG TABLET NAMENDA 1 Min 45 03/01/2014ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL 10MG TABLET NAMENDA 2 Min 45 10/01/2013ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL 7, 14, 21 and 28MG CAPSULE NAMENDA XR 1 30 Min 45 03/01/2014ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL 10MG/5ML SOLUTION NAMENDA 10 Min 45 10/01/2013ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL TITRATION PACK NAMENDA XR 28 28 0 Y Min 45 10/01/2013ALZHEIMER S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL 5-10MG TITRATION PACK 49 TABLETS NAMENDA 49 365 0 Y Min 45 10/01/2013ALZHEIMER’S AGENTS RIVASTIGMINE TARTRATE 1.5MG CAPSULE EXELON 1 Min 45 07/01/2013ALZHEIMER’S AGENTS RIVASTIGMINE TARTRATE 3, 4.5 and 6MG CAPSULE EXELON / RIVASTIGMINE 2 Min 45 07/01/2013ALZHEIMER’S AGENTS RIVASTIGMINE 4.6, 9.5 and 13.3MG/24HR PATCH EXELON 1 Y Min 45 07/01/2013

THERAPEUTIC CLASS ANALGESICS, NARCOTIC - LONG ACTING (Non-parenteral) BRAND UnitsUntil

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ANALGESICS, NARCOTICS BUPRENORPHINE PATCHES BUTRANS 4 30 10/01/2013ANALGESICS, NARCOTICS BUPRENORPHINE HCL FILMS BELBUCA 60 30 10/01/2018ANALGESICS, NARCOTICS HYDROCODONE BITARTRATE TABLETS HYSINGLA ER 60 30 2 01/01/2015ANALGESICS, NARCOTICS HYDROCODONE-CHLORPHENIRAMNE ER CAPSULES TUSSICAPS 30 10/01/2018ANALGESICS, NARCOTICS HYDROMORPHONE HCL 8, 12 and 16MG TABLET EXALGO ER 1 10/01/2013ANALGESICS, NARCOTICS MORPHINE SULFATE ER CAPSULES AVINZA 60 30 2 04/15/2014ANALGESICS, NARCOTICS MORPHABOND ER 30 2 10/01/2018ANALGESICS, NARCOTICS MORPHINE SULFATE/NALTREXONE 20-0.8MG CAPSULE EMBEDA ER 2 03/25/2015ANALGESICS, NARCOTICS MORPHINE SULFATE/NALTREXONE 30-1.2MG CAPSULE EMBEDA ER 1 03/25/2015ANALGESICS, NARCOTICS MORPHINE SULFATE/NALTREXONE 50-2MG CAPSULE EMBEDA ER 1 03/25/2015ANALGESICS, NARCOTICS MORPHINE SULFATE/NALTREXONE 60-2.4MG CAPSULE EMBEDA ER 1 03/25/2015ANALGESICS, NARCOTICS MORPHINE SULFATE/NALTREXONE 80-3.2MG CAPSULE EMBEDA ER 1 03/25/2015ANALGESICS, NARCOTICS OXYCODONE HCL ACETAMINOPHEN 7.5-325MG TABLET XARTEMIS XR 1 04/01/2014ANALGESICS, NARCOTICS OXYCODONE HCL ER and XR TABLETS OXYCONTIN 2 01/22/2015ANALGESICS, NARCOTICS OXYMORPHONE HCL 5, 7.5, 10, 15, 20, 30, and 40MG TABLETS OPANA ER 2 10/01/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG TABLET XARTEMIS XR 56 365 10/01/2018ANALGESICS, NARCOTICS OXYCODONE HCL ER 10MG TABLET OXYCONTIN 2 10/01/2018ANALGESICS, NARCOTICS OXYCODONE MYRISTATE ER CAPSULES XTAMPZA ER 30 2 10/01/2018ANALGESICS, NARCOTICS OXYMORPHONE HCL ER 5, 10, 20 and 40MG TABLET OPANA ER 2 10/01/2013ANALGESICS, NARCOTICS TAPENTADOL HCL ER 50, 100, 150, 200 and 250MG TABLET NUCYNTA ER 2 10/01/2013ANALGESICS, NARCOTICS TRAMADOL HCL 100, 150, 200 and 300MG TABLETS or CAPSULES CONZIP 1 07/01/2013

THERAPEUTIC CLASS ANALGESICS, NARCOTIC - SHORT ACTING (Non-parenteral) BRAND UnitsUntil

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NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN WITH CODEINE 120-12MG/5ML SOLUTION GENERIC ONLY 600 30 10/01/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN WITH CODEINE 300/12.5ML SOLUTION GENERIC ONLY 300 30 10/01/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN WITH CODEINE 300-15MG TABLET GENERIC ONLY 120 30 08/16/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN WITH CODEINE SUSPENSION CAPITAL W-CODEINE 1200 30 10/01/2013NARCOTIC ANALGESICNON-SALICYLATEXANTHINE ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE 325-30-16 GENERIC ONLY 120 30 10/01/2018NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN-COD #3 300MG-30MG & 60MG TABLET TYLENOL 3 120 30 08/16/2013NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB BUTALBIT/ACETAMIN/CAFF/CODEINE CAPSULES & TABLETS FIORICET WITH CODEINE 120 30 08/16/2013ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB BUTALBITAL-ACETAMINOPHN TABLETS GENERIC ONLY 30 6 10/01/2018ANALGESICS, NARCOTICS BUTORPHANOL TARTRATE 10 MG/ML SPRAY 2.5ML GENERIC ONLY 2.5 30 Y 07/01/2013ANALGESICS, NARCOTICS CODEINE SULFATE 15, 30 and 60MG TABLET GENERIC ONLY 120 30 08/16/2013NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE CODEINE/BUTALBITAL/ASA/CAFFEIN 50-325-40MG CAPSULE FIORINAL w/CODEINE 120 30 08/16/2013ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB CODEINE/BUTALBITAL/ASA/CAFFEIN 50-325-40MG CAPSULE FIORINAL 120 30 6 01/01/2019NARCOTIC ANALGESICNON-SALICYLATEXANTHINE DIHYDROCODEINE BUTALBITAL/ACETMAINPHONIE/CAFFEINE TREZIX 120 30 01/01/2015ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB DIHYDROCODEINE/ASPIRIN/CAFFEIN 16-356-30 CAPSULE SYNALGOS-DC 120 30 08/16/2013ANALGESICS, NARCOTICS FENTANYL SPRAYS ALL STRENGTHS SUBSYS 30 30 Y 09/01/2014ANALGESICS, NARCOTICS FENTANYL PATCHES ALL STRENGHTS DURAGESIC 10 30 07/01/2013ANALGESICS, NARCOTICS FENTANYL CITRATE TABLETS ALL STRENGTHS FENTORA 120 30 08/16/2013ANALGESICS, NARCOTICS FENTANYL CITRATE LOZENGES ALL STRENGTHS ACTIQ 120 30 07/01/2013ANALGESICS, NARCOTICS FENTANYL CITRATE NASAL SPRAYS ALL STRENGTHS LAZANDA 1 30 10/01/2013ANALGESICS, NARCOTICS FENTANYL CITRATE SUBLINGUAL TABLETS ALL STRENGTHS ABSTRAL 120 30 08/16/2013ANALGESICS, NARCOTICS TRAMADOL HCL/ACETAMINOPHEN 37.5-325 TABLET ULTRACET 40 30 10/01/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB HYDROCODONE-ACETAMINOPHEN 2.5-108/5ML, 5-217/5ML GENERIC ONLY 600 30 30 08/01/2014NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB HYDROCODONE/ACETAMINOPHEN 15ML SOLUTIONS HYCET/LORTAB/ZAMICET 1800 30 30 08/01/2014NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB HYDROCODONE BIT/ACETAMINOPHEN TABLETS ALL STRENGHTS VICODIN / XODOL 120 30 30 08/01/2014NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLUTIONS GENERIC ONLY 600 30 30 10/01/2018ANALGESICS, NARCOTICS HYDROCODONE BITRATE - HOMATROPINE 5 MG-1.5MG TABLET TUSSIGON 30 09/01/2014ANALGESICS, NARCOTICS HYDROCODONE BITRATE - HOMATROPINE 5-1.5 MG/5ML SOLUTION GENERIC ONLY 30 10/01/2018ANALGESICS, NARCOTICS HYDROCODONE BITRATE - HOMATROPINE 5-1.5 MG/5ML SYRUP GENERIC ONLY 600 30 30 10/01/2018ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION HYDROCODONE/IBUPROFEN TABLETS IBUDONE / REPRAXIN 120 30 30 08/01/2014ANALGESICS, NARCOTICS HYDROMORPHONE HCL 1MG/ML SOLUTION DILAUDID 1200 30 10/01/2013

ANALGESICS, NARCOTICS HYDROMORPHONE HCL 2, 4 and 8MG TABLET DILAUDID 120 30 08/16/2013ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION IBUPROFEN/OXYCODONE HCL 5-400MG TABLET GENERIC ONLY 120 30 08/16/2013ANALGESICS, NARCOTICS LEVORPHANOL TARTRATE 2MG TABLET GENERIC ONLY 120 30 08/16/2013ANALGESICS, NARCOTICS MEPERIDINE 50MG/5ML SOLUTION MEPERIDINE 600 30 10/01/2013

ANALGESICS, NARCOTICS MEPERIDINE HCL 50 and 100MG TABLET DEMEROL / MEPERITAB 120 30 08/16/2013ANALGESICS, NARCOTICS MORPHINE SULFATE 15, 30 and 60MG TABLETS ARYMO ER 120 30 10/01/2018ANALGESICS, NARCOTICS OXYCODONE HCL CAPSULES or TABLETS ALL STRENGTHS ROXICODONE 120 30 08/16/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB OXYCODONE HCL/ACETAMINOPHEN TABLETS ALL STRENGTHS PERCOCET / PERCODAN / ENDOCET 120 30 08/16/2013NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB NALOCET 120 30 8 10/01/2018NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB OXYCODONE HCL/ACETAMINOPHEN 5-325MG ORAL SOLUTION ROXICET 1800 30 07/01/2013ANALGESICS, NARCOTICS OXYMORPHONE HCL 5 and 10MG TABLET OPANA IR / OPANA 120 30 07/01/2013ANALGESICS, NARCOTICS PENTAZOCINE HCL/NALOXONE HCL 2.5-500MG TABLET GENERIC ONLY 120 30 08/16/2013ANALGESICS, NARCOTICS TAPENTADOL HCL 50, 75 and 100MG TABLET NUCYNTA 180 30 10/01/2013

ANALGESICS, NARCOTICS TRAMADOL HCL 50MG TABLET ULTRAM / RYBIX ODT 240 30 10/01/2013

THERAPEUTIC CLASS ANDROGENIC AGENTS BRAND UnitsUntil

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ANDROGENIC AGENTS TESTOSTERONE 1% & 1.62% GEL 2.5G PACKET ANDROGEL 75 30 Y M 07/01/2013ANDROGENIC AGENTS TESTOSTERONE 1% GEL 5G PACKET ANDROGEL 150 30 Y M 07/01/2013ANDROGENIC AGENTS TESTOSTERONE 1.62% GEL 1.25G PACKET ANDROGEL 37.5 30 Y M 07/01/2013ANDROGENIC AGENTS TESTOSTERONE 2, 2.5, 4 and 5MG/24HR PATCH ANDRODERM 1 60 M 08/01/2014ANDROGENIC AGENTS TESTOSTERONE 30MG SOLUTION 90ML AXIRON 90 30 Y M 10/01/2013ANDROGENIC AGENTS TESTOSTERONE 1% GEL PUMP ANDROGEL 150 30 Y M 07/01/2013ANDROGENIC AGENTS TESTOSTERONE 1% GEL TESTIM 150 30 Y 10/01/2018ANDROGENIC AGENTS TESTOSTERONE 1.62% GEL PUMP 75 ML ANDROGEL 75 30 Y M 07/01/2013ANDROGENIC AGENTS TESTOSTERONE 10MG GEL PUMP 60GRAM FORTESTA 60 30 Y M 10/01/2013ANDROGENIC AGENTS TESTOSTERONE 5.5 MG/0.122 GM NATESTO 7.32 28 10/01/2015

THERAPEUTIC CLASS ANESTHETICS, TOPICAL BRAND UnitsUntil

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HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE AC/LIDOCAINE 0.5-3% CREAM KIT 7GRAMS ANAMANTLE HC 98 10/01/2015HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE AC/LIDOCAINE 0.5-3% CREAM KIT 1 or 20 ANAMANTLE HC 1 10/01/2015HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE AC/LIDOCAINE 1-3% CREAM KIT 7GRAMS 1 or 20 ANAMANTLE HC FORTE 1 10/01/2015HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE/LIDOCAINE/ALOE 2.8-0.55% GEL 15 SINGLE USE, 100GRAM GENERIC ONLY 100 Y 10/01/2015HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3% (7GRAM) 1 or 20 EACH LIDOCORT GEL KIT 20 Y 10/01/2015HEMORRHOIDAL PREP,ANTI-INFLAM STEROID/LOCAL ANESTH HYDROCORTISONE/LIDOCAINE/ALOE 2-2% CREAM 24/7GRAM TUBES PERANEX HC 1 Y 10/01/2015

THERAPEUTIC CLASS ANGIOTENSIN MODULATORS BRAND UnitsUntil

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ANGIOTENSIN MODULATOR RENIN INHIBITOR, DIRECT ALISKIREN HEMIFUMARATE 150 and 300MG TABLET TEKTURNA 1 10/01/2013RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB ALISKIREN/HCT TABLETS ALL STRENGTHS TEKTURNA HCT 1 07/01/2013ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR AMLODIPINE BESYLATE /OLMESARTAN MED TABLETS ALL STRENGTHS AZOR 1 07/01/2013ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION AMLODIPINE BESYLATE/BENAZEPRIL CAPSULES ALL STRENGTHS LOTREL 1 07/01/2013ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR AMLODIPINE/VALSARTAN TABLETS ALL STRENGTHS EXFORGE 1 10/01/2013ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CB AMLODIPINE/VALSARTAN/HCTZ TABLETS ALL STRENGTHS EXFORGE HCT 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB AZILSARTAN MED/CHLORTHALIDONE TABLETS ALL STRENGTHS EDARBYCLOR 1 07/01/2013



ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST AZILSARTAN MEDOXOMIL 40 and 80MG TABLET EDARBI 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS BENAZEPRIL HCL 5, 10 and 20MG TABLET LOTENSIN 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS BENAZEPRIL HCL 40MG TABLET LOTENSIN 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC BENAZEPRIL/HCT TABLETS ALL STRENGTHS LOTENSIN HCT 1 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST CANDESARTAN CILEXETIL 4, 8 and 16MG TABLET ATACAND 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET ATACAND HCT 1 10/01/2018ANTIHYPERTENSIVES, ACE INHIBITORS CAPTOPRIL 12.5, 25 and 50MG TABLET GENERIC ONLY 3 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS CAPTOPRIL 100MG TABLET GENERIC ONLY 3 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC CAPTOPRIL/HCT TABLETS ALL STRENGTHS GENERIC ONLY 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS ENALAPRIL MALEATE 2.5, 5 and 10MG TABLET VASOTEC 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS ENALAPRIL MALEATE 20MG TABLET VASOTEC 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC ENALAPRIL/HCT 10-25MG TABLET VASERETIC 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC ENALAPRIL/HCT 12.5MG TABLET GENERIC ONLY 1 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST EPROSARTAN MESYLATE 600MG TABLET TEVETEN 1 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST EPROSARTAN MESYLATE 400 MG TILTAB TEVETEN 2 10/01/2018ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB EPROSARTAN/HCT 600-12.5 and 600-25MG TABLET TEVETEN HCT 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS FOSINOPRIL SODIUM 10 and 20MG TABLET GENERIC ONLY 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS FOSINOPRIL SODIUM 40MG TABLET GENERIC ONLY 2 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST IRBESARTAN 75, 150 and 300MG TABLET AVAPRO 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB IRBESARTAN/HCT 150-12.5 and 300-12.5MG TABLET AVALIDE 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS LISINOPRIL 2.5, 5, 10, 20 and 30MG TABLET PRINIVIL/ZESTRIL 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS LISINOPRIL 40MG TABLET PRINIVIL/ZESTRIL 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC LISINOPRIL/HCT 10-12.5 and 20-12.5MG TABLET PRINZIDE / ZESTORETIC 1 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC LISINOPRIL/HCT 20-25MG TABLET ZESTORETIC 2 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST LOSARTAN POTASSIUM 25 and 50MG TABLET COZAAR 2 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST LOSARTAN POTASSIUM 100MG TABLET COZAAR 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB LOSARTAN/HCT 50-12.5, 100-12.5 and 100-25MG TABLET HYZAAR 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS MOEXIPRIL HCL 7.5MG TABLET UNIVASC 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS MOEXIPRIL HCL 15MG TABLET UNIVASC 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC MOEXIPRIL/HCT 7.5-12.5, 15-12.5 and 15-25MG TABLET UNIRETIC 1 07/01/2013ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CB OLMESARTAN MED/AMLODIPINE/HCTZ TABLETS ALL STRENGTHS TRIBENZOR 1 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST OLMESARTAN MEDOXOMIL 5MG TABLET BENICAR 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB OLMESARTAN/HCT TABLETS ALL STRENGTHS BENICAR HCT 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS QUINAPRIL HCL 5, 10 and 20MG TABLET ACCUPRIL 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS QUINAPRIL HCL 40MG TABLET ACCUPRIL 2 07/01/2013ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC QUINAPRIL HCTZ 10-12.5, 20-12.5 and 20-25MG TABLET ACCURETIC 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS RAMIPRIL 1.25, 2.5 and 5MG CAPSULE or TABLET ALTACE 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS RAMIPRIL 10MG TABLET or CAPSULE ALTACE 2 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST TELMISARTAN 80MG TABLET MICARDIS 1 10/01/2013ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR TELMISARTAN/AMLODIPINE TABLET ALL STRENGTHS TWYNSTA 1 10/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG TABLET MICARDIS HCT 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS TRANDOLAPRIL 1 and 2MG TABLET MAVIK 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS TRANDOLAPRIL 4MG TABLET MAVIK 2 07/01/2013ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION TRANDOLAPRIL/VERAPAMIL HCL TABLET ALL STRENGTHS TARKA 1 07/01/2013ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST VALSARTAN 40, 80 and 160MG TABLET DIOVAN 1 07/01/2013ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB VALSARTAN/HCT TABLET ALL STRENGTHS DIOVAN HCT 1 07/01/2013

THERAPEUTIC CLASS ANTIANGINAL & ANTI-ISCHEMIC BRAND UnitsUntil

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ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC RANOLAZINE 500 and 1000MG TABLET RANEXA 2 07/01/2013

THERAPEUTIC CLASS ANTIBIOTICS, GI BRAND UnitsUntil

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ANTIBIOTICS, GI & RELATED NITAZOXANIDE 100MG/5ML SUSPENSION ALINIA 180 30 07/01/2013ANTIBIOTICS, GI & RELATED NITAZOXANIDE 500MG TABLET ALINIA 6 30 07/01/2013ANTIBIOTICS, GI & RELATED RIFAXIMIN 200MG TABLET XIFAXAN 9 30 3 07/01/2013ANTIBIOTICS, GI & RELATED RIFAXIMIN 550MG TABLET XIFAXAN 3 01/01/2016ANTIBIOTICS, GI & RELATED TINIDAZOLE 250MG TABLET TINDAMAX 24 30 5 07/01/2013ANTIBIOTICS, GI & RELATED TINIDAZOLE 500MG TABLET TINDAMAX 12 30 5 07/01/2013

THERAPEUTIC CLASS ANTIBIOTICS, INHALED BRAND UnitsUntil

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ANTIBIOTICS, INHALED AZTREONAM LYSINE 75MG/ML INHAL SOLUTION 84ML VIAL CAYSTON 3 10/01/2013AMINOGLYCOSIDES TOBRAMYCIN IN 0.225% NACL 300MG/5ML SOLUTION TOBI 10 Y 10/01/2013

THERAPEUTIC CLASS ANTIBIOTICS, TOPICAL BRAND UnitsUntil

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NOSE PREPARATIONS ANTIBIOTICS MUPIROCIN CALCIUM 2% NASAL OINTMENT BACTROBAN NASAL 10 30 Y 10/01/2018TOPICAL ANTIBIOTICS MUPIROCIN 2% OINTMENT KIT CENTANY AT 30 30 Y 10/01/2018

THERAPEUTIC CLASS ANTIBIOTICS, VAGINAL BRAND UnitsUntil

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ANTIBIOTICS, VAGINAL CLINDAMYCIN HCL CAPSULES ALL STRENGHTS GENERIC ONLY 14 1 F 10/01/2018ANTIBIOTICS, VAGINAL CLINDAMYCIN PALMITATE HCL 75MG/5ML SOLUTION GENERIC ONLY 14 1 F 10/01/2018

THERAPEUTIC CLASS ANTICOAGULANTS BRAND UnitsUntil

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ANTICOAGULANTS APIXABAN 2.5 MG TABLET ELIQUIS 2 10/01/2018ANTICOAGULANTS APIXABAN 5 MG STARTER PACK ELIQUIS 74 999 0 Y 10/01/2018ANTICOAGULANTS, LIPOGLYCOPEPTIDE ANTIBIOTICS DABIGATRAN ETEXILATE MESYLATE CAPSULES ALL STRENGTHS PRADAXA 2 07/01/2013ANTIGOAGULANTS RIVAROXABAN 10MG TABLET XARELTO 30 30 1 1 10/01/2013ANTIGOAGULANTS RIVAROXABAN 15MG TABLET XARELTO 42 30 2 10/01/2013ANTIGOAGULANTS RIVAROXABAN 20MG TABLET XARELTO 1 10/01/2013

THERAPEUTIC CLASS ANTICONVULSANTS BRAND UnitsUntil

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Dose

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ANTICONVULSANTS BRIVARACETAM TABLETS BRIVIACT 30 2 10/01/2018ANTICONVULSANTS BRIVARACETAM 10MG/ML SOLUTION BRIVIACT 30 20 10/01/2018ANTICONVULSANTS, BENZODIAZEPINES CLOBAZAM TABLETS ONFI 2 09/01/2014ANTICONVULSANTS, BENZODIAZEPINES CLONAZEPAM TABLETS AND ODT KLONOPIN 30 4 10/01/2018ANTICONVULSANT ANTI-ANXIETY DRUGS DIAZEPAM 2, 5 and 10MG TABLET VALIUM 30 4 07/01/2013ANTICONVULSANT ANTI-ANXIETY DRUGS DIAZEPAM 10MG / 2ML CARPUJECT GENERIC ONLY 30 10 Y 10/01/2018ANTICONVULSANT ANTI-ANXIETY DRUGS DIAZEPAM 50MG / 10ML VIAL GENERIC ONLY 30 4 10/01/2018ANTICONVULSANT ANTI-ANXIETY DRUGS DIAZEPAM 5MG / ML ORAL CONC GENERIC ONLY 30 4 10/01/2018ANTICONVULSANTS LACOSAMIDE 10 MG/ML SOLUTION VIMPAT 40 10/01/2018ANTICONVULSANTS LACOSAMIDE TABLETS VIMPAT 2 10/01/2018ANTICONVULSANTS LACOSAMIDE STARTER KIT VIMPAT 2 10/01/2018ANTICONVULSANT ANTI-ANXIETY DRUGS DIAZEPAM 5MG / 5ML SOLUTIONS GENERIC ONLY 30 20 10/01/2018ANTICONVULSANTS LAMOTRIGINE 25 (21)-50, 28 DOSE STARTER KIT LAMICTAL ODT START KIT BLUE) 28 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 25 (42)-100, 49 DOSE STARTER KIT LAMICTAL TB START KIT (ORANGE) 49 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 25 (84)-100, 98 DOSE STARTER KIT LAMICTAL TAB START KIT (GREEN) 98 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 25-50-100, 35 DOSE STARTER KIT LAMICTAL ODT START KIT (ORANGE) 35 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 25MG TABLET, 35 DOSE STARTER KIT LAMICTAL TAB START KIT (BLUE) 35 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 50-(42)-100, 56 DOSE STARTER KIT LAMICTAL ODT START KIT GREEN) 56 365 0 Y 12/01/2014ANTICONVULSANTS LAMOTRIGINE 50-100-200, 35 DOSE STARTER KIT LAMICTAL XR START KIT (GREEN) 35 365 0 Y 12/01/2014ANTICONVULSANTS PERAMPANEL 0.5MG/ML ORAL SUSP FYCOMPA 30 24 10/01/2018ANTICONVULSANTS PERAMPANEL TABLETS FYCOMPA 30 1 10/01/2018ANTICONVULSANTS PERAMPANEL 2MG-4MG TABLET KIT FYCOMPA KIT 14 0 Y 12/01/2014

THERAPEUTIC CLASS ANTIDEPRESSANTS, OTHER BRAND UnitsUntil

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Dose

Max


NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HBR 174, 348 and 522MG TABLET APLENZIN 1 07/01/2013NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 75MG TABLET BUDEPRION / WELLBUTRIN 6 12/01/2014NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 100MG TABLET BUDEPRION / WELLBUTRIN 3 12/01/2014NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 450MG TABLET FORFIVO XL 1 07/01/2013NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL SR 100 and 200MG TABLET WELLBUTRIN SR 2 12/01/2014NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL XL 150MG TABLET BUDEPRION / WELLBUTRIN 3 12/01/2014NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL XL 300MG TABLET BUDEPRION / WELLBUTRIN 1 12/01/2014ANTIDEPRESSANT SNRIs DESVENLAFAXINE SUCCINATE 50 and 100MG TABLET PRISTIQ ER 1 07/01/2013TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE HCL 10MG TABLET TOFRANIL 3 12/01/2014TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE HCL 25MG TABLET TOFRANIL 3 12/01/2014TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE HCL 50MG TABLET TOFRANIL 4 12/01/2014TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE PAMOATE 100MG CAPSULE TOFRANIL-PM 2 12/01/2014TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE PAMOATE 75, 125 and 150MG CAPSULE TOFRANIL-PM 1 12/01/2014MAOIS - NON-SELECTIVE & IRREVERSIBLE ISOCARBOXAZID 10MG TABLET MARPLAN 4 12/01/2014ANTIDEPRESSANT SNRIs LEVOMILNACIPRAN HCL 20-40MG TITRATION PACK FETZIMA 28 0 10/01/2018ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE 7.5, 15, 30 and 45MG TABLET & ODT TABLET REMERON 1 12/01/2014SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL 50, 100, 150, 200 and 250MG TABLET GENERIC ONLY 2 12/01/2014MAOIS - NON-SELECTIVE & IRREVERSIBLE PHENELZINE SULFATE 15MG TABLET NARDIL 6 12/01/2014ANTIDEPRESSANT, OTHER SELEGILINE 6, 9 and 12MG/24HOUR PATCH EMSAM 1 07/01/2013MAOIS - NON-SELECTIVE & IRREVERSIBLE TRANYLCYPROMINE SULFATE 10MG TABLET PARNATE 6 12/01/2014SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) TRAZODONE HCL 50 and 100MG TABLET GENERIC ONLY 3 12/01/2014SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) TRAZODONE HCL 150MG TABLET GENERIC ONLY 2 12/01/2014SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) TRAZODONE HCL 300MG TABLET GENERIC ONLY 1 12/01/2014ANTIDEPRESSANT SNRIs VENLAFAXINE HCL 25, 37.5, 50, 75 and 100MG TABLET GENERIC ONLY 3 12/01/2014



ANTIDEPRESSANT SNRIs VENLAFAXINE HCL ER 37.5, 150, 225MG TABLETS EFFEXOR XR 1 12/01/2014ANTIDEPRESSANT SNRIs VENLAFAXINE HCL XR 37.5MG CAPSULE EFFEXOR XR 1 12/01/2014ANTIDEPRESSANT SNRIs VENLAFAXINE HCL XR 150MG CAPSULE EFFEXOR XR 2 01/01/2019ANTIDEPRESSANT SNRIs VENLAFAXINE HCL ER 75MG TABLET GENERIC ONLY 3 12/01/2014ANTIDEPRESSANT SNRIs VENLAFAXINE HCL XR 75MG CAPSULE EFFEXOR XR 3 12/01/2014

THERAPEUTIC CLASS ANTIDEPRESSANTS, SSRIs BRAND UnitsUntil

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SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION GENERIC ONLY 20 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM HYDROBROMIDE 10 and 20MG TABLET CELEXA 1.5 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM HYDROBROMIDE 40MG TABLET CELEXA 1 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) ESCITALOPRAM OXALATE 5MG/5ML SOLUTION LEXAPRO 20 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) ESCITALOPRAM OXALATE 5, 10 and 20MG TABLET LEXAPRO 1 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 20MG/5ML SOLUTION PROZAC 20 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 10MG CAPSULE PROZAC 1 09/01/2014SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 20MG CAPSULE PROZAC 3 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 40MG CAPSULE PROZAC 2 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 90MG CAPSULE PROZAC WEEKLY 4 30 Y 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL 10, 20 and 60MG TABLET SARAFEM 1 09/01/2014SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUVOXAMINE MALEATE 100MG TABLET GENERIC ONLY 3 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUVOXAMINE MALEATE ER 100 and 150MG CAPSULE LUVOX CR 2 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE HCL 10MG/5ML SOLUTION PAXIL 20 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE HCL 10 20 and 40MG TABLET PAXIL 1.5 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE HCL CR 12.5 and 37.5MG TABLET PAXIL CR 1 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE HCL CR 25MG TABLET PAXIL CR 2 10/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE MESYLATE 10, 20 and 40MG TABLET PEXEVA 1 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PAROXETINE MESYLATE 30MG TABLET PEXEVA 2 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SERTRALINE HCL 20MG/ML ORAL CONC ZOLOFT 10 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SERTRALINE HCL 25 and 50MG TABLET ZOLOFT 1.5 07/01/2013SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SERTRALINE HCL 100MG TABLET ZOLOFT 2 07/01/2013SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT VILAZODONE HYDROCHLORIDE 10, 20 and 40MG TABLET VIIBRYD 1 12/01/2014SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANT VORTIOXETINE HYDROBROMIDE TABLETS BRINTELLIX 30 1 10/01/2018

THERAPEUTIC CLASS ANTIEMETICS BRAND UnitsUntil

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ANTIEMETIC/ANTIVERTIGO AGENTS APREPITANT 40, 80 and 125MG CAPSULE EMEND 3 30 10/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS APREPITANT TRIFOLD PACK - 3 CAPSULES PER PACK EMEND 3 30 Y 10/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS DOLASETRON MESYLATE 50 and 100MG TABLET ANZEMET 5 30 10/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS DRONABINOL 2.5, 5 and 10MG CAPSULE MARINOL 2 07/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS GRANISETRON 3.1MG/24HR PATCH SANCUSO 1 30 10/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS GRANISETRON HCL 1MG TABLET GENERIC ONLY 10 30 07/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS NABILONE 1MG CAPSULE CESAMET 2 07/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS ONDANSETRON 4 and 8MG SOLUBLE FILM ZUPLENZ 10 30 10/01/2013ANTIEMETIC/ANTIVERTIGO AGENTS ONDANSETRON HCL 24 MG TABLET GENERIC ONLY 1 10/01/2018

THERAPEUTIC CLASS ANTIFUNGALS (Oral) BRAND UnitsUntil

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ANTIFUNGAL AGENTS FLUCONAZOLE 50, 100, 150 and 200MG TABLET DIFLUCAN 2 30 10/01/2013ANTIFUNGAL ANTIBIOTICS GRISEOFULVIN,MICROSIZE 125MG/5ML SUSPENSION GENERIC ONLY 40 Max 6 10/01/2013ANTIFUNGAL ANTIBIOTICS GRISEOFULVIN,MICROSIZE 500MG TABLET GRIFULVIN V 2 10/01/2013ANTIFUNGAL AGENTS ITRACONAZOLE 100MG CAPSULE SPORANOX 2 10/01/2013ANTIFUNGAL AGENTS ITRACONAZOLE 200MG TABLET ONMEL 1 10/01/2013ANTIFUNGAL AGENTS MICONAZOLE 50MG BUCCAL TABLET ORAVIG 14 30 10/01/2013ANTIFUNGAL ANTIBIOTICS NYSTATIN 100K UNITS/ML SUSPENSION NILSTAT 240 30 07/14/2014ANTIFUNGAL ANTIBIOTICS NYSTATIN 500K UNITS TABLET MYCOSTATIN 4 10/01/2013ANTIFUNGAL AGENTS POSACONAZOLE 40MG/ML SUSPENSION 105ML BOTTLE NOXAFIL 105 30 10/01/2013ANTIFUNGAL AGENTS TERBINAFINE HCL 125MG GRANULES PACKET LAMISIL 2 10/01/2013ANTIFUNGAL AGENTS TERBINAFINE HCL 187.5MG GRANULES PACKET LAMISIL 1 10/01/2013ANTIFUNGAL AGENTS TERBINAFINE HCL 250MG TABLET LAMISIL 1 07/01/2013

THERAPEUTIC CLASS ANTIFUNGALS (Topical) BRAND UnitsUntil

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Dose

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TOPICAL ANTIFUNGALS CICLOPIROX 8% SOLUTION 6.6ML CICLODAN / PENLAC 6.6 30 1 Y 10/01/2013TOPICAL ANTIFUNGALS CICLOPIROX/URE/CAMPH/MENTH/EUC 8% KIT 34.6ML CICLODAN 34.6 30 1 Y 10/01/2013VAGINAL ANTIFUNGALS MICONAZOLE NITRATE KITS AND PACKS MONISTAT 3 1 30 Y 10/01/2013

THERAPEUTIC CLASS ANTIHISTAMINES, MINIMALLY SEDATING BRAND UnitsUntil

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Dose

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ANTIHISTAMINES - 2ND GENERATION CETIRIZINE HCL 5 and 10MG CHEWABLE TABLETS, LIQUID GELS or TABLETS ZYTREC 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION CETIRIZINE HCL 5MG/5ML SOLUTION GENERIC ONLY 150 30 10/01/2013ANTIHISTAMINES - 2ND GENERATION CETIRIZINE HCL/PSEUDOEPHEDRINE 5-120MG TABLET ZYRTEC-D / CETIRI-D 2 07/01/2013ANTIHISTAMINES - 2ND GENERATION DESLORATADINE 2.5MG/5ML SYRUP CLARINEX 10 07/01/2013ANTIHISTAMINES - 2ND GENERATION DESLORATADINE 2.5 and 5MG ODT or TABLETS CLARINEX 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION DESLORATADINE/PSEUDOEPHEDRINE 12HR TABLET CLARINEX-D 12 HR 2 07/01/2013ANTIHISTAMINES - 2ND GENERATION FEXOFENADINE HCL 60MG TABLET ALLEGRA 2 07/01/2013ANTIHISTAMINES - 2ND GENERATION FEXOFENADINE/PSEUDOPHEDRINE180-240 TABLET ALLEGRA - D 1 10/01/2018ANTIHISTAMINES - 2ND GENERATION FEXOFENADINE HCL 180MG TABLET ALLEGRA 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION LEVOCETIRIZINE DIHYDROCHLORIDE 2.5MG/5ML SOLUTION XYZAL 150 30 10/01/2013ANTIHISTAMINES - 2ND GENERATION LEVOCETIRIZINE DIHYDROCHLORIDE 5MG TABLET XYZAL 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION LORATADINE 10MG TABLETS CLARITIN / TAVIST ND 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION LORATADINE/PSEUDOEPHEDRINE 12HR TABLET ALAVERT / CLARITIN-D 2 07/01/2013ANTIHISTAMINES - 2ND GENERATION LORATADINE/PSEUDOEPHEDRINE 24HR TABLET CLARITIN-D 1 07/01/2013ANTIHISTAMINES - 2ND GENERATION PSEUDOEPHEDRINE HCL 30MG TABLET SUDAFED 12 30 10/01/2015

THERAPEUTIC CLASS ANTIHYPERTENSIVES, SYMPATHOLYTICS BRAND UnitsUntil

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ANTIHYPERTENSIVES, SYMPATHOLYTIC CLONIDINE 0.1MG PATCH / 1 PATCH CATAPRES-TTS 1 4 30 10/01/2018ANTIHYPERTENSIVES, SYMPATHOLYTIC CLONIDINE 0.2MG PATCH / 2 PATCH CATAPRES-TTS 2 4 30 Y 07/01/2013ANTIHYPERTENSIVES, SYMPATHOLYTIC CLONIDINE 0.3MG PATCH / 3 PATCH CATAPRES-TTS 3 4 30 Y 07/01/2013ANTIHYPERTENSIVES, SYMPATHOLYTIC CLONIDINE HCL 0.1 and 0.2 MG TABLET CATAPRES 10 07/01/2013ANTIHYPERTENSIVES, SYMPATHOLYTIC CLONIDINE HCL 0.3 MG TABLET CATAPRES 8 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS PERINDOPRIL ERBUMINE 2 and 4MG TABLET ACEON 1 07/01/2013ANTIHYPERTENSIVES, ACE INHIBITORS PERINDOPRIL ERBUMINE 8MG TABLET ACEON 2 07/01/2013

THERAPEUTIC CLASS ANTIHYPERURICEMICS BRAND UnitsUntil

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Dose

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ANTIHYPERURICEMICS COLCHICINE 0.6MG TABLET COLCRYS 20 90 10/01/2013HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS FEBUXOSTAT 40 and 80MG TABLET ULORIC 1 07/01/2013

THERAPEUTIC CLASS ANTIMIGRAINE AGENTS, OTHER BRAND UnitsUntil

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ANTIMIGRAINE PREPARATIONS DICLOFENAC POTASSIUM 50MG POWDER PACKET CAMBIA 9 30 Y 07/01/2013ANTIMIGRAINE PREPARATIONS DIHYDROERGOTAMINE MESYLATE 4MG/ML SPRAY MIGRANAL 8 30 Y 10/01/2013

THERAPEUTIC CLASS ANTIMIGRAINE AGENTS, TRIPTANS BRAND UnitsUntil

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ANTIMIGRAINE PREPARATIONS ALMOTRIPTAN MALATE 6.25 and 12.5MG TABLET AXERT 6 30 07/01/2013ANTIMIGRAINE PREPARATIONS ELETRIPTAN HBR 20 and 40MG TABLET RELPAX 6 30 07/01/2013ANTIMIGRAINE PREPARATIONS ERENUMAB-AOOE 70MG/ML AUTOINJECTOR AIMOVIG 2 30 10/01/2018ANTIMIGRAINE PREPARATIONS FROVATRIPTAN SUCCINATE 2.5MG TABLET FROVA 9 30 07/01/2013ANTIMIGRAINE PREPARATIONS NARATRIPTAN HCL 1 and 2.5MG TABLET AMERGE 9 30 07/01/2013ANTIMIGRAINE PREPARATIONS RIZATRIPTAN BENZOATE 5 and 10MG TABLET MAXALT 9 30 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN 5 and 20MG NASAL SPRAY IMITREX 6 30 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCC/NAPROXEN SOD 85-500MG TABLET TREXIMET 9 30 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 25, 50 and 100MG TABLET IMITREX 9 30 10/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 4 and 6MG/0.5ML REFILL CARTRIDGES IMITREX 2 30 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 4 and 6MG/0.5ML INJECTION ALSUMA / IMITREX 2 30 Y 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 6MG/0.5ML SYRINGE SUMAVEL DOSEPRO 2 30 10/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 6MG/0.5ML VIAL IMITREX 2.5 30 10/24/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 6.5MG/4 HOUR PATCH ZECUITY 4 30 Y 10/24/2013ANTIMIGRAINE PREPARATIONS ZOLMITRIPTAN 2.5MG TABLET ZOMIG / ZOMIG ZMT 6 30 07/01/2013ANTIMIGRAINE PREPARATIONS ZOLMITRIPTAN 5MG TABLET ZOMIG / ZOMIG ZMT 3 30 07/01/2013ANTIMIGRAINE PREPARATIONS ZOLMITRIPTAN 5MG NASAL SPRAY ZOMIG 6 30 Y 07/01/2013ANTIMIGRAINE PREPARATIONS SUMATRIPTAN SUCCINATE 11MG TABLET ONZETRA XSAIL 16 30 10/01/2018

THERAPEUTIC CLASS ANTIPARASITICS, TOPICAL BRAND UnitsUntil

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Dose

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ANTIPARASITICS, TOPICAL BENZYL ALCOHOL 5% LOTION ULESFIA 681 30 Y 10/01/2018TOPICAL ANTIPARASITICS CITRIC/CITRONELLYL/HYDROX/METH LYCELLE HEAD LICE REMOVAL KIT 1 10/01/2018ANTIPARASITICS, TOPICAL LINDANE 1% LOTION or SHAMPOO GENERIC ONLY 60 30 Y 07/01/2013ANTIPARASITICS, TOPICAL LINDANE 1% LOTION or SHAMPOO GENERIC ONLY 60 30 Y 07/01/2013ANTIPARASITICS, TOPICAL MALATHION 0.5% LOTION OVIDE 59 30 Y 07/01/2013TOPICAL ANTIPARASITICS PIP BUTOX/PYRETHRINS/PERMETH LICE KITS CVS LICE SOLUTION KIT 1 Y 10/01/2018TOPICAL ANTIPARASITICS PERMETHRIN 5% CREAM 60GRAM JAR ACTICIN 60 14 Y 04/15/2014TOPICAL ANTIPARASITICS IVERMECTIN 0.5% LOTION 117GRAMS SKLICE 234 90 Y 01/01/2019

THERAPEUTIC CLASS ANTIPARKINSON’S AGENTS (Oral) BRAND UnitsUntil

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ANTIPARKINSONISM DRUGS,OTHER RASAGILINE MESYLATE 0.5 and 1MG TABLET AZILECT 1 07/01/2013ANTIPARKINSONISM DRUGS,OTHER ROPINIROLE HCL 2, 4, 6 and 8MG TABLET REQUIP XL 1 07/01/2013



ANTIPARKINSONISM DRUGS,OTHER ROPINIROLE HCL ER 12MG TABLET REQUIP XL 2 10/01/2013ANTIPARKINSONISM DRUGS,OTHER ROTIGOTINE 24HR PATCHS ALL STRENGTHS NEUPRO 1 07/01/2013ANTIPARKINSON’S AGENTS SAFINAMIDE MESYLATE TABLETS XADAGO 1 10/01/2018ANTIPARKINSONISM DRUGS,OTHER SELEGILINE HCL 1.25MG ODT TABLET ZELAPAR 2 07/01/2013

THERAPEUTIC CLASS ANTIPSYCHOTICS, ATYPICAL BRAND UnitsUntil

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Dose

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ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARIPIPRAZOLE TABLETS ABILIFY 1 04/01/2014ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARIPIPRAZOLE DISCMELT TABLETS ABILIFY 1 04/01/2014ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARIPIPRAZOLE ER VIALS ABILIFY MAINTENA 1 30 04/01/2014ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARIPIPRAZOLE 1MG/ML SOLUTION ABILIFY 150 30 04/01/2014ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARIPIPRAZOLE LAUROXIL, SUBMICR 675 MG/2.4 ARISTADA 2.4 10/01/2018ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ARMODAFINIL 200 MG TABLET NUVIGIL 30 1 10/01/2018ANTI PSYCHOTICATYPICAL D3/D2 PARTIAL AG5HT MIXED CARIPRAZINE HCL TABLETS VRAYLAR 30 1 10/01/2018ANTI PSYCHOTICATYPICAL D3/D2 PARTIAL AG5HT MIXED CARIPRAZINE HCL 1.5MG - 3MG PACK VRAYLAR 999 0 Y 10/01/2018ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG ILOPERIDONE TABLETS FANAPT 2 11/05/2015ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG FANAPT 8 999 Y 10/01/2018ANTIPSYCHOTICS, ATYPICAL LOXAPINE 10MG INHALATION POWDER ADASUVE 1 30 Y 09/01/2014ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG PALIPERIDONE PALMITATE ALL STRENGTHS INVEGA TRINZA 90 10/01/2015SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA) PIMAVANSERIN TARTRATE 17MG TABLET NUPLAZID 30 2 10/01/2018SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA) PIMAVANSERIN TARTRATE 10MG and 34MG TABLETS NUPLAZID 30 1 10/01/2018ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG QUETIAPINE FUMARATE SAMPLE KIT SEROQUEL XR 15 0 Y 10/01/2015ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG RISPERIDONE MICROSPHERES SYRINGES RISPERDAL CONSTA 2 30 07/01/2013

THERAPEUTIC CLASS ANTIRETROVIRALS BRAND UnitsUntil

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ANTIRETROVIRAL - ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS ATAZANAVIR SULFATE 150 & 300MG CAPSULES REYATAZ 1 12/01/2014ANTIRETROVIRAL - ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS ATAZANAVIR SULFATE 200MG CAPSULES REYATAZ 2 12/01/2014ANTIRETROVIRALS DOLUTEGRAVIR SODIUM TABLETS TIVICAY 30 1 10/01/2018ANTIRETROVIRAL ELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 30 1 10/01/2018ANTIRETROVIRAL EMTRICITABINE/TENOFOVIR (TDF) TABLETS TRUVADA 30 1 10/01/2018ANTIRETROVIRAL EMTRICITABINE/TENOFOV ALAFENAM 200-25 MG TABLET DESCOVY 30 1 10/01/2018ANTIRETROVIRALS RALTEGRAVIR POTASSIUM 600MG TABLET ISENTRESS 2 10/01/2018

THERAPEUTIC CLASS ANTIVIRALS (Oral) BRAND UnitsUntil

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Dose

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ANTIVIRALS, GENERAL ACYCLOVIR 200, 400 and 800MG CAPSULES or TABLETS ZOVIRAX 5 10 10/01/2013ANTIVIRALS, GENERAL ACYCLOVIR 50MG BUCCAL TABLET SITAVIG 2 10 10/01/2013ANTIVIRALS, GENERAL FAMCICLOVIR 125, 250 and 500MG TABLET FAMVIR 3 7 10/01/2013ANTIVIRALS, GENERAL OSELTAMIVIR PHOSPHATE 6MG/ML SUSPENSION TAMIFLU 120 180 0 07/01/2013ANTIVIRALS, GENERAL OSELTAMIVIR PHOSPHATE 30MG GELCAP TAMIFLU 20 180 0 07/01/2013ANTIVIRALS, GENERAL OSELTAMIVIR PHOSPHATE 45 and 75MG GELCAP TAMIFLU 10 180 0 07/01/2013ANTIVIRALS, GENERAL VALACYCLOVIR HCL 500MG and 1GRAM CAPLET VALTREX 3 7 10/01/2013ANTIVIRALS, GENERAL ZANAMIVIR 5MG DISKHALER 5 DISKS X 4 BLISTERS RELENZA 20 180 0 07/01/2013

THERAPEUTIC CLASS BETA BLOCKERS (Oral) & MISCELLANEOUS ANTIANGINALS (Oral) BRAND UnitsUntil

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Dose

Max


BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL FUMARATE 5MG TABLET ZEBETA 1 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL FUMARATE 10MG TABLET ZEBETA 4 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL 3.125, 6.25 & 12.5MG TABLETS COREG 2 10/01/2018BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL 25MG TABLET COREG 4 10/01/2018BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE 10, 20, 40 and 80MG CAPSULE COREG CR 1 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE 25MG TABLET TOPROL XL 1 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE 50 and 100MG TABLET TOPROL XL 1.5 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE 200MG TABLET and CAPSULE TOPROL XL 2 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE 25, 50 AND 100 MG CAPSULE KAPSPARGO SPRINKLE 1 10/01/2018BETA-ADRENERGIC BLOCKING AGENTS NEBIVOLOL HCL 2.5, 5, and 10MG TABLET BYSTOLIC 1 07/01/2013BETA-ADRENERGIC BLOCKING AGENTS NEBIVOLOL HCL 20MG TABLET BYSTOLIC 2 10/01/2013BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL 60, 80, 120 and 160MG CAPSULE INDERAL LA / INNOPRAN XL 1 07/01/2013

THERAPEUTIC CLASS BLADDER RELAXANT PREPARATIONS BRAND UnitsUntil

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Dose

Max


BLADDER RELAXANT PREPARATIONS DARIFENACIN HYDROBROMIDE 7.5 and 15MG TABLET ENABLEX 1 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT FESOTERODINE FUMARATE 4 and 8MG TABLET TOVIAZ 1 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT FLAVOXATE HCL 100MG TABLET FLAVOXATE HCL 8 07/01/2013OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP MIRABEGRON 25 and 50MG TABLET MYRBETRIQ 1 07/01/2013BLADDER RELAXANTS OXYBUTYNIN 3.9MG/24HR PATCH OXYTROL 8 30 Y 07/01/2013BLADDER RELAXANTS OXYBUTYNIN CHLORIDE 10% GEL SACHET 1GRAM GELNIQUE 1 10/01/2013BLADDER RELAXANTS OXYBUTYNIN CHLORIDE 5MG/5ML SYRUP GENERIC ONLY 15 07/01/2013BLADDER RELAXANTS OXYBUTYNIN CHLORIDE 5, 10 and 15MG TABLET DITROPAN XL 1 07/01/2013BLADDER RELAXANTS OXYBUTYNIN CHLORIDE 10% GEL PUMP GELNIQUE 30 30 10/01/2018BLADDER RELAXANTS OXYBUTYNIN 5% GEL GELNIQUE 92 30 10/01/2018BLADDER RELAXANTS OXYBUTYNIN CHLORIDE 5MG IR TABLET GENERIC ONLY 3 07/01/2013BLADDER RELAXANTS SOLIFENACIN SUCCINATE 5 and 10MG TABLET VESICARE 1 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT TOLTERODINE TARTRATE 1 and 2MG TABLET DETROL 2 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT TOLTERODINE TARTRATE 2 and 4MG CAPSULE DETROL LA 1 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT TROSPIUM CHLORIDE 20MG TABLET SANCTURA 2 07/01/2013URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT TROSPIUM CHLORIDE 60MG CAPSULE SANCTURA XR 1 07/01/2013

THERAPEUTIC CLASS BONE RESORPTION SUPPRESSION AND RELATED AGENTS BRAND UnitsUntil

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Dose

Max


BONE RESORPTION SUPPRESSION AND RELATED AGENTS ALENDRONATE SODIUM 5, 10 and 40MG TABLET FOSAMAX 1 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ALENDRONATE SODIUM 35 and 70MG TABLET FOSAMAX / BINOSTO 4 30 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ALENDRONATE SODIUM 70MG/75ML SOLUTION FOSAMAX 300 30 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ALENDRONATE SODIUM/VITAMIN D3 70MG FOSAMAX+D 4 30 Y 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ALENDRONATE SODIUM/VITAMIN D3 70MG - 2800IU FOSAMAX PLUS D 4 30 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS CALCITONIN,SALMON,SYNTHETIC 200 UNITS NASAL SPRAY FORTICAL 3.7 30 Y 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ETIDRONATE DISODIUM 200MG TABLET GENERIC ONLY 3 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS ETIDRONATE DISODIUM 400MG TABLET DIDRONEL 5 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS IBANDRONATE SODIUM 150MG TABLET BONIVA 1 30 0.034 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS IBANDRONATE SODIUM 3MG/3ML SYRINGE BONIVA 3 90 90 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS RALOXIFENE HCL 60MG TABLET EVISTA 1 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS RISEDRONATE SODIUM 5 and 30MG TABLET ACTONEL 1 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS RISEDRONATE SODIUM 35MG TABLET ACTONEL 4 30 Y 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS RISEDRONATE SODIUM 150MG TABLET ACTONEL 1 30 07/01/2013BONE RESORPTION SUPPRESSION AND RELATED AGENTS TERIPARATIDE 600MCG/2.4ML PEN INJECTOR FORTEO 2.4 30 10/01/2013

THERAPEUTIC CLASS BPH AGENTS BRAND UnitsUntil

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Dose

Max


BPH TREATMENTS ALFUZOSIN HCL 10MG TABLET UROXATRAL 1 07/01/2013BPH TREATMENTS DOXAZOSIN MESYLATE 4 and 8MG TABLET CARDURA XL 1 07/01/2013BPH TREATMENTS DOXAZOSIN MESYLATE 8MG TABLET CARDURA 2 07/01/2013BPH TREATMENTS DUTASTERIDE 0.5MG SOFTGEL AVODART 1 07/01/2013BPH TREATMENTS DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4MG CAPSULE JALYN 1 07/01/2013BPH TREATMENTS FINASTERIDE 5MG TABLET PROSCAR 1 07/01/2013BPH TREATMENTS SILODOSIN 4 and 8MG CAPSULE RAPAFLO 1 07/01/2013BPH TREATMENTS TAMSULOSIN HCL 0.4MG CAPSULE FLOMAX 2 07/01/2013BPH TREATMENTS TERAZOSIN HCL 1 and 5MG CAPSULE GENERIC ONLY 1 07/01/2013BPH TREATMENTS TERAZOSIN HCL 2 and 10MG CAPSULE GENERIC ONLY 2 07/01/2013

THERAPEUTIC CLASS BRONCHODILATORS & RESPIRATORY DRUGS BRAND UnitsUntil

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Dose

Max


BRONCHODILATORS, BETA AGONIST ALBUTEROL 90 MCG INHALER & REFILL VENTOLIN 18 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL 0.83 MG/ML SOLUTION PROVENTIL 375 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL 5 MG/ML SOLUTION PROVENTIL 40 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL HFA 90 MCG INHALER PROVENTIL HFA 18 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL SUL 0.63 MG/3 ML SOL GENERIC ONLY 375 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL SUL 1.25 MG/3 ML SOL GENERIC ONLY 375 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ALBUTEROL SULFATE 2.5MG/0.5ML SOLUTION GENERIC ONLY 120 30 Y 10/01/2013BRONCHODILATORS, BETA AGONIST ALBUTEROL SULFATE INHAL POWDER PROAIR RESPICLICK 2 30 Y 10/01/2018BRONCHODILATORS, BETA AGONIST ARFORMOTEROL TARTRATE 15MCG/2ML SOLUTION BROVANA 120 30 Y 10/01/2013BRONCHODILATORS & RESPIRATORY DRUGS FORMOTEROL FUMARATE 12MCG CAPSULES FORADIL 2 Y 07/01/2013BRONCHODILATORS & RESPIRATORY DRUGS FORMOTEROL FUMARATE 20MCG/2ML SOLUTION PERFOROMIST 120 30 Y 10/01/2013BRONCHODILATORS & RESPIRATORY DRUGS INDACATEROL MALEATE 75MCG CAPSULE ARCAPTA NEOHALER 30 30 Y 10/01/2013BRONCHODILATORS & RESPIRATORY DRUGS LEVALBUTEROL HCL 0.31 and 0.63MG/3ML SOLUTION XOPENEX 30 12 Y 11/04/2013BRONCHODILATORS & RESPIRATORY DRUGS LEVALBUTEROL HCL 1.25MG/0.5ML VIALS XOPENEX CONCENTRATE 90 30 07/01/2013BRONCHODILATORS & RESPIRATORY DRUGS LEVALBUTEROL HCL 1.25MG/3ML SOLUTION XOPENEX 30 12 Y 11/04/2013BRONCHODILATORS & RESPIRATORY DRUGS LEVALBUTEROL TARTRATE 45MCG INHALER 15GRAMS XOPENEX HFA 30 30 Y 07/01/2013

THERAPEUTIC CLASS CALCIUM CHANNEL BLOCKERS BRAND UnitsUntil

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Dose

Max


CALCIUM CHANNEL BLOCKERS AMLODIPINE BESYLATE 2.5, 5 and 10MG TABLET NORVASC 1 07/01/2013CALCIUM CHANNEL BLOCKERS DILTIAZEM HCL 120, 180, 300, 360 and 420MG CAPSULE DILACOR XR 1 07/01/2013CALCIUM CHANNEL BLOCKERS DILTIAZEM HCL 240MG CAPSULE CARDIZEM CD / CARTIA XT 2 07/01/2013CALCIUM CHANNEL BLOCKERS DILTIAZEM HCL 120, 180, 240, 300, 360 and 420MG TABLET CARDIZEM LA / MATZIM LA 1 07/01/2013CALCIUM CHANNEL BLOCKERS FELODIPINE 2.5, 5 and 10MG TABLET GENERIC ONLY 1 07/01/2013CALCIUM CHANNEL BLOCKERS ISRADIPINE 5MG TABLET DYNACIRC CR 1 10/01/2018CALCIUM CHANNEL BLOCKERS NIFEDIPINE 30 and 90MG TABLET ADALAT CC / AFEDITAB CR 1 07/01/2013



CALCIUM CHANNEL BLOCKERS ISRADIPINE 10MG TABLET DYNACIRC CR 2 10/01/2018CALCIUM CHANNEL BLOCKERS NIFEDIPINE 60MG TABLET ADALAT CC / AFEDITAB CR 2 07/01/2013CALCIUM CHANNEL BLOCKERS NIMODIPINE 30MG CAPSULE GENERIC ONLY 12 10/01/2013CALCIUM CHANNEL BLOCKERS NISOLDIPINE ER 8.5, 17, 20, 25.5, 34 and 40MG TABLET SULAR 1 07/01/2013CALCIUM CHANNEL BLOCKERS NISOLDIPINE ER 30MG TABLET GENERIC ONLY 2 07/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 100 and 300MG CAPLET VERELAN PM 1 07/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 200MG CAPLET VERELAN PM 2 10/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 360MG CAPLET VERELAN 1 07/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 120, 180 and 240MG CAPSULE VERELAN 1 07/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 240MG CAPSULE VERELAN 2 10/01/2013CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL 120, 180 and 240MG TABLET CALAN SR / ISOPTIN SR 2 07/01/2013

THERAPEUTIC CLASS CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BRAND UnitsUntil

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Daily

Dose

Max


CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) AMOXICILLIN ALL STRENGTHS ALL FORMULATIONS MOXATAG ER 14 1 07/01/2013CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) AMOXICILLIN/POTASSIUM CLAVULANTE TABLETS ALL STRENGTHS AUGMENTIN XR 14 1 07/01/2013CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) AMOXICILLIN/POTASSIUM CLAVULANTE CHEWABLE TABLETS ALL STRENGTHS AMOX-TR 14 1 07/01/2013CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) AMPICILLIN TRIHYDRATE ALL STRENGTHS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFACLOR SUSPENSIONS, CAPSULE and ER TABLETS ALL STRENGHTS GENERIC ONLY 14 1 07/01/2013CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFDINIR CAPSULES and SUSPENSIONS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFADROXIL CAPSULES, SUSPENSIONS and TABLETS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFDITOREN PIVOXIL TABLETS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFIXIME SUSPENSIONS SUPRAX 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFTIBUTEN CAPSULES and SUSPENSIONS CEDAX 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFPODOXIME SUSPENSIONS and TABLETS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFPROZIL SUSPENSIONS and TABLETS GENERIC ONLY 14 1 10/01/2018CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CEFUROXIME AXETIL TABLETS ALL STRENGTHS CEFTIN 14 1 07/01/2013CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) KEFLEX 14 1 10/01/2018PENICILLIN DICLOXACILLIN SODIUM CAPSULES GENERIC ONLY 14 1 10/01/2018PENICILLIN ANTIBIOTICS PENICILLIN V POTASSIUM VK SOLUTIONS GENERIC ONLY 14 1 10/01/2018

THERAPEUTIC CLASS COPD AGENTS BRAND UnitsUntil

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Daily

Dose

Max


COPD AGENTS ACLIDINIUM BROMIDE 400MCG INHALER TUDORZA PRESSAIR 1 30 Y 07/01/2013COPD AGENTS IPRATROPIUM/ALBUTEROL SULFATE 0.5MG-3MG/3ML SOL DUONEB 540 30 Y 07/01/2013COPD AGENTS IPRATROPIUM/ALBUTEROL SULFATE INHALERS 4GRAMS COMBIVENT RESPIMAT 4 30 Y 07/01/2013COPD AGENTS IPRATROPIUM BROMIDE INHALER ATROVENT HFA 25.8 30 Y 07/01/2013COPD AGENTS IPRATROPIUM BROMIDE 0.02% SOLUTION 0.25MG/ML 2.5ML GENERIC ONLY 450 30 Y 10/01/2013COPD AGENTS IPRATROPIUM BROMIDE 0.03% SPRAY 30ML ATROVENT 30 30 Y 07/01/2013COPD AGENTS IPRATROPIUM BROMIDE 0.06% SPRAY 15ML ATROVENT 15 30 Y 07/01/2013COPD AGENTS ROFLUMILAST 500MG TABLET DALIRESP 1 07/01/2013COPD AGENTS TIOTROPIUM BROMIDE 18MCG CAP-HANDIHALER SPIRIVA 1 Y 07/01/2013

THERAPEUTIC CLASS CYTOKINE & CAM ANTAGONISTS BRAND UnitsUntil

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Daily

Dose

Max


CYTOKINE & CAM ANTAGONISTS ABATACEPT 125MG/ML SYRINGE ORENCIA 4 30 10/01/2013CYTOKINE & CAM ANTAGONISTS ABATACEPT/MALTOSE 250MG VIAL ORENCIA 4 30 10/01/2013CYTOKINE & CAM ANTAGONISTS ADALIMUMAB SYRINGES HUMIRA 2 28 Y 10/01/2018CYTOKINE & CAM ANTAGONISTS ANAKINRA 100MG/0.67ML SYPRINGE KINERET 0.67 Y 10/01/2013CYTOKINE & CAM ANTAGONISTS APREMILAST 30MG TABLET OTEZLA 2 08/01/2015CYTOKINE & CAM ANTAGONISTS APREMILAST 30MG TABLET OTEZLA Y 08/01/2015CYTOKINE & CAM ANTAGONISTS APREMILAST 30MG TABLET OTEZLA Y 08/01/2015CYTOKINE & CAM ANTAGONISTS BARICITINIB 2 MG TABLET OLUMIANT 1 10/01/2018CYTOKINE & CAM ANTAGONISTS CERTOLIZUMAB PEGOL 200MG/ML SYRINGE KIT CIMZIA 28 10/01/2013CYTOKINE & CAM ANTAGONISTS CANAKINUMAB/PF 150 MG/ML VIAL ILARIS 4 75 10/01/2018CYTOKINE & CAM ANTAGONISTS ETANERCEPT 25MG KIT AND SYRINGES ENBREL 8 28 Y 01/01/2019CYTOKINE & CAM ANTAGONISTS ETANERCEPT 250MG/0.5ML SYRINGE ENBREL 4 28 Y 01/01/2019CYTOKINE & CAM ANTAGONISTS GOLIMUMAB 50MG/0.5ML PEN INJECTOR AND SYRINGES SIMPONI 0.5 30 10/01/2013CYTOKINE & CAM ANTAGONISTS GUSELKUMAB 100 MG/ML SYRINGE TREMFYA 1 30 56 10/01/2018CYTOKINE & CAM ANTAGONISTS INFLIXIMAB 100 MG VIAL REMICADE 56 10/01/2018CYTOKINE & CAM ANTAGONISTS TOFACITINIB CITRATE TABLETS XELJANZ 2 10/01/2018CYTOKINE & CAM ANTAGONISTS USTEKINUMAB SYRINGES STELARA 84 10/01/2018

THERAPEUTIC CLASS FLUOROQUINOLONES (Oral) BRAND UnitsUntil

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Daily

Dose

Max


FLUOROQUINOLONES (Oral) CIPROFLOXACIN HCL TABLETS ALL STRENGTHS GENERIC ONLY 14 1 07/01/2013FLUOROQUINOLONES (Oral) CIPROFLOXACIN ER TABLETS CIPRO XR 14 1 10/01/2018FLUOROQUINOLONES (Oral) CIPROFLOXACIN SUSPENSIONS 14 1 10/01/2018FLUOROQUINOLONES (Oral) CIPROFLOXACIN/CIPROFLOXA HCL TABLETS ALL STRENGTHS CIPRO XR 14 1 07/01/2013FLUOROQUINOLONES (Oral) CLARITHROMYCIN SUSPENSIONS and TABLETS BIAXIN 14 1 10/01/2018FLUOROQUINOLONES (Oral) DELAFLOXACIN MEGLUMINE 450 MG TABLET BAXDELA 14 1 10/01/2018FLUOROQUINOLONES (Oral) GEMIFLOXACIN MESYLATE 320MG TABLET FACTIVE 14 1 07/01/2013FLUOROQUINOLONES (Oral) LEVOFLOXACIN SOLUTIONS AND TABLETS LEVAQUIN 14 1 07/01/2013FLUOROQUINOLONES (Oral) MOXIFLOXACIN HCL 400MG TABLET AVELOX 14 1 07/01/2013FLUOROQUINOLONES (Oral) OFLOXACIN 300, 400MG TABLETS GENERIC ONLY 14 1 10/01/2018

THERAPEUTIC CLASS GLUCOCORTICOIDS (Inhaled) BRAND UnitsUntil

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Daily

Dose

Max


GLUCOCORTICOIDS (Inhaled) BUDESONIDE 0.25, 0.5 and 1MG/2ML RESPULES PULMICORT 120 30 Y Max 8 10/01/2013GLUCOCORTICOIDS (Inhaled) BUDESONIDE 90 and 180MCG PULMICORT FLEXHALER 1 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) BUDESONIDE/FORMOTEROL FUMARATE 80-4.5 and 160-4.5MCG INHALER SYMBICORT 10.2 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) BECLOMETHASONE DIPROPIONATE 40MCG INHALER QVAR REDIHALER 10.6 30 Y 10/01/2018GLUCOCORTICOIDS (Inhaled) BECLOMETHASONE DIPROPIONATE 80MCG INHALER QVAR REDIHALER 21.2 30 Y 10/01/2018GLUCOCORTICOIDS (Inhaled) CICLESONIDE 80 and 160MCG INHALER 6.1GRAM ALVESCO 6.1 30 Y 10/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE PROPIONATE 44MCG INHALER FLOVENT HFA 10.6 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE PROPIONATE 110 and 220MCG INHALER FLOVENT HFA 12 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE PROPIONATE 50, 100 and 250MCG DISKUS FLOVENT DISKUS 60 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUNISOLIDE 0.025% SPRAY GENERIC ONLY 25 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE/SALMETEROL 45-21, 115-21 and 230-21MCG INHALER ADVAIR HFA 12 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE/SALMETEROL 100-50, 250-50 and 500-50MCG 60 UNITS ADVAIR DISKUS 60 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) FLUTICASONE/VILANTEROL 100-25 MCG INH BREO ELLIPTA 60 30 Y 10/01/2018GLUCOCORTICOIDS (Inhaled) FLUTICASONE/SALMETEROL 55-14 MCG RESPICLICK AIRDUO RESPICLICK 1 Y 10/01/2018GLUCOCORTICOIDS (Inhaled) FLUTICASONE PROPIONATE 55 MCG POWDER ARMONAIR RESPICLICK 1 10/01/2018GLUCOCORTICOIDS (Inhaled) FLUTICASONE/UMECLIDIN/VILANTER 100-62.5-25 TRELEGY ELLIPTA 60 10/01/2018GLUCOCORTICOIDS (Inhaled) MOMETASONE FUROATE 110 and 220MCG TWISTHALER ASMANEX 1 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) MOMETASONE/FORMOTEROL 100 and 200MCG/5MCG INHALER DULERA 17.6 30 Y 07/01/2013GLUCOCORTICOIDS (Inhaled) PREDNISOLONE 5 MG 6-DAY PACK MILLIPRED DP 21 Y 10/01/2018GLUCOCORTICOIDS (Inhaled) PREDNISOLONE 5 MG 12-DAY PACK MILLIPRED DP 48 Y 10/01/2018

THERAPEUTIC CLASS GLUCOCORTICOIDS (Inhaled) BRAND UnitsUntil

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Daily

Dose

Max


GLUCOCORTICOIDS BUDESONIDE EC 3MG CAPSULE ENTOCORT 3 10/01/2013GLUCOCORTICOIDS DEXAMETHASONE 13 DAY 1.5 MG TB DEXPAK 51 Y 10/01/2018GLUCOCORTICOIDS DEXAMETHASONE 10 DAY 1.5 MG TB DEXPAK 35 Y 10/01/2018GLUCOCORTICOIDS DEXAMETHASONE 6 DAY 1.5 MG TAB DEXPAK 21 Y 10/01/2018GLUCOCORTICOIDS DEXAMETHASONE 11 DAY 1.5 MG TABLET LOCORT 41 Y 10/01/2018GLUCOCORTICOIDS DEXAMETHASONE 11 DAY 1.5 MG TABLET ZONACORT 27 Y 10/01/2018GLUCOCORTICOIDS METHYLPREDNISOLONE 4 MG DOSEPK MEDROL 21 Y 10/01/2018GLUCOCORTICOIDS PREDNISONE DOSE PACKS GENERIC ONLY 48 Y 01/15/2019GLUCOCORTICOIDS PREDNISOLONE SODIUM PHOSHATE ODT TABLETS ORAPRED ODT 48 Y 10/01/2018

THERAPEUTIC CLASS H. PYLORI COMBINATION TREATMENTS BRAND UnitsUntil

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Daily

Dose

Max


H. PYLORI COMBINATION TREATMENTS BISMUTH/METRONID/TETRACYCLINE 125MG CAPSULE PYLERA 120 30 0 Y 10/01/2013H. PYLORI COMBINATION TREATMENTS LANSOPRAZOLE/AMOXICILN/CLARITH PATIENT PACK PREVPAC 112 30 Y 10/01/2013H. PYLORI COMBINATION TREATMENTS OMEPRAZOLE/CLARITH/AMOXICILLIN COMBO PACK OMECLAMOX-PAK 80 30 10/01/2013

THERAPEUTIC CLASS HEPATITIS B TREATMENTS BRAND UnitsUntil

Refill

Daily

Dose

Max


HEPATITIS B TREATMENT AGENTS ADEFOVIR DIPIVOXIL 10MG TABLET HEPSERA 1 07/01/2013HEPATITIS B TREATMENT AGENTS ENTECAVIR 0.5 and 1MG TABLET BARACLUDE 1 07/01/2013HEPATITIS B TREATMENTS HEPATITIS B VACCINE/CPG1018/PF 20MCG/0.5ML SYRINGE HEPLISAV-B 0.5 10/01/2018HEPATITIS B TREATMENTS TELBIVUDINE 600MG TABLET TYZEKA 1 07/01/2013HEPATITIS B TREATMENT AGENTS TENOFOVIR ALAFENAMID FUMARATE 25MG TABELT VEMLIDY 1 10/01/2018

THERAPEUTIC CLASS HEPATITIS C TREATMENTS BRAND UnitsUntil

Refill

Daily

Dose

Max


HEPATITIS C TREATMENTS PEGINTERFERON ALFA-2A 180MCG/ML VIAL PEGASYS 4 28 10/01/2018

THERAPEUTIC CLASS HYPERPARATHYROID AGENTS BRAND UnitsUntil

Refill

Daily

Dose

Max


HYPERPARATHYROID AGENTS CINACALCET HCL 30 and 60MG TABLET SENSIPAR 2 07/01/2013HYPERPARATHYROID AGENTS CINACALCET HCL 90MG TABLET SENSIPAR 4 07/01/2013HYPERPARATHYROID PARICALCITOL 1, 2 and 4MG CAPSULE ZEMPLAR 1 07/01/2013

THERAPEUTIC CLASS HYPOGLYCEMICS, DPP-4 INHIBITORS BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, DPP-4 INHIBITORS ALOGLIPTIN BENZOATE/METFORMIN HCL TABLETS ALL STRENGTHS KAZANO 2 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS ALOGLIPTIN BENZOATE/PIOGLITZONE TABLETS ALL STRENGTHS OSENI 1 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS ALOGLIPTIN BENZOATE 6.25, 12.5 and 25MG TABLET NESINA 1 07/01/2013



HYPOGLYCEMICS, DPP-4 INHIBITORS LINAGLIPTIN 5MG TABLET TRADJENTA 1 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS LINAGLIPTIN/METFORMIN HCL 2.5-500, 850 and 1000MG TABLET JENTADUETO 2 10/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS LINAGLIPTIN/METFORMIN HCL XR TABLETS JENTADUETO XR 30 1 10/01/2018HYPOGLYCEMICS, DPP-4 INHIBITORS SAXAGLIPTIN HCL 2.5 and 5MG TABLET ONGLYZA 1 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS SAXAGLIPTIN HCL/METFORMIN HCL 2.5-1000 MG TABLET KOMBIGLYZE XR 2 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS SAXAGLIPTIN HCL/METFORMIN HCL 5-500 and 5-1000MG TABLET KOMBIGLYZE XR 1 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS SITAGLIPTIN PHOS/METFORMIN HCL TABLETS ALL STRENGHTS JANUMET XR 1 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS SITAGLIPTIN PHOS/METFORMIN HCL TABLET ALL STRENGHTS JANUMET 2 07/01/2013HYPOGLYCEMICS, DPP-4 INHIBITORS SITAGLIPTIN PHOSPHATE 25, 50 and 100MG TABLET JANUVIA 1 07/01/2013

THERAPEUTIC CLASS HYPOGLYCEMICS, GLP-1 AGONISTS BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, GLP-1 AGONISTS EXENATIDE 5MCG DOSE PEN INJECTOR 1.2ML BYETTA 0.04 Y 07/01/2013HYPOGLYCEMICS, GLP-1 AGONISTS EXENATIDE 10MCG DOSE PEN INJECTOR 2.4ML BYETTA 0.08 Y 07/01/2013HYPOGLYCEMICS, GLP-1 AGONISTS EXENATIDE MICROSPHERES 2MG VIAL BYDUREON 4 28 10/01/2013HYPOGLYCEMICS, GLP-1 AGONISTS EXENATIDE MICROSPHERES 2 MG AUTOINJECT BYDUREON BCISE 3.4 30 10/01/2018HYPOGLYCEMICS, GLP-1 AGONISTS SEMAGLUTIDE 0.25-0.5MG DOSE PEN OZEMPIC 1.5 30 42 10/01/2018HYPOGLYCEMICS, GLP-1 AGONISTS SEMAGLUTIDE 1MG DOSE PEN OZEMPIC 3 30 10/01/2018

THERAPEUTIC CLASS HYPOGLYCEMICS, INSULINS AND RELATED AGENTS BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, INSULINS AND RELATED AGENTS HUM INSULIN NPH/REG INSULIN HM 70-30/ML PEN or VIAL HUMULIN 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN ASPART 100UNIT/ML CARTRIDGE, VIAL or SYRINGE NOVOLOG 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN DETEMIR 100UNITS/ML PEN or VIAL LEVEMIR FLEXPEN 90 30 62 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN GLARGINE, HUM.REC.ANLOG 100UNITS/ML CARTRIDGE, PEN or VIAL LANTUS 90 30 91 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN GLULISINE 100UNITS/ML PEN or VIAL APIDRA SOLOSTAR 90 30 91 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN LISPRO 100UNITS/ML CARTRIDGE, PEN or VIAL HUMALOG 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN NPL/INSULIN LISPRO 50-50/ML KWIKPEN or VIAL HUMALOG 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN REGULAR, HUMAN 100 and 500UNITS/ML VIAL HUMULIN / HUMULIN R 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULN ASP PRT/INSULIN ASPART 70-30/ML 3ML or 10ML VIAL NOVOLOG MIX VIAL 90 30 Y 09/01/2014HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN DEGLUDEC PENS AND VIALS TRESIBA 30 91 Y 10/01/2018HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN DEGLUDEC/LIRAGLUTIDE 100 UNIT-3.6MG/ML PEN XULTOPHY 91 10/01/2018HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN LISPRO 100 UNIT/ML KWIKPEN HUMALOG JR 90 30 10/01/2018HYPOGLYCEMICS, INSULINS AND RELATED AGENTS INSULIN REGULAR, HUMAN 500 UNITS/ML KWIKPEN HUMULIN R 36 30 Y 10/01/2018HYPOGLYCEMICS, INSULINS AND RELATED AGENTS NPH, HUMAN INSULIN ISOPHANE 100 UNITS/ML 3 or 10ML VIALS HUMULIN 90 30 Y 09/01/2014

THERAPEUTIC CLASS HYPOGLYCEMICS, MEGLITINIDES BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, MEGLITINIDES NATEGLINIDE 60 and 120MG TABLET STARLIX 3 07/01/2013HYPOGLYCEMICS, MEGLITINIDES REPAGLINIDE 0.5 and 1MG TABLET PRANDIN 4 07/01/2013HYPOGLYCEMICS, MEGLITINIDES REPAGLINIDE 2MG TABLET PRANDIN 8 07/01/2013HYPOGLYCEMICS, MEGLITINIDES REPAGLINIDE/METFORMIN HCL 1 and 2MG-500MG TABLET PRANDIMET 2 07/01/2013

THERAPEUTIC CLASS HYPOGLYCEMICS, MISCELLANEOUS BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, MISCELLANEOUS AGENTS PRAMLINTIDE ACETATE 1500/1.5ML SYRINGE SYMLINPEN 60 12 30 0.4 Y 07/01/2013HYPOGLYCEMICS, MISCELLANEOUS AGENTS PRAMLINTIDE ACETATE 2700/2.7ML SYRINGE SYMLINPEN 120 13.5 30 0.45 Y 07/01/2013

THERAPEUTIC CLASS HYPOGLYCEMICS, SGL-T2 BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, SGLT2 CANAGLIFLOZIN 100MG TABLET INVOKANA 2 09/01/2014HYPOGLYCEMICS, SGLT2 CANAGLIFLOZIN 300MG TABLET INVOKANA 1 09/01/2014

THERAPEUTIC CLASS HYPOGLYCEMICS, TZDS BRAND UnitsUntil

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Daily

Dose

Max


HYPOGLYCEMICS, TZD PIOGLITAZONE HCL 15, 30 and 45MG ACTOS 1 07/01/2013HYPOGLYCEMICS, TZD PIOGLITAZONE HCL/GLIMEPIRIDE 30-2 and -4MG TABLET DUETACT 1 07/01/2013HYPOGLYCEMICS, TZD PIOGLITAZONE HCL/METFORMIN HCL 15- and 30-1000MG TAB ACTOPLUS MET XR 1 07/01/2013HYPOGLYCEMICS, TZD PIOGLITAZONE HCL/METFORMIN HCL 15-5000 and -8500MG TAB ACTOPLUS MET 2 07/01/2013HYPOGLYCEMICS, TZD ROSIGLITAZONE MALEATE 2 and 4MG TABLET AVANDIA 1 07/01/2013HYPOGLYCEMICS, TZD ROSIGLITAZONE/METFORMIN HCL 2MG-500MG TABLET AVANDAMET 2 07/01/2013

THERAPEUTIC CLASS IMMUNOMODULATORS, ATOPIC DERMATITIS BRAND UnitsUntil

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Daily

Dose

Max


IMMUNOMODULATORS, ATOPIC DERMATITIS PIMECROLIMUS 1% CREAM 30GRAMS ELIDEL 60 30 Y 07/01/2013IMMUNOMODULATORS, ATOPIC DERMATITIS TACROLIMUS 0.03 and 0.1% OINTMENT 100GRAMS PROTOPIC 100 30 Y 07/01/2013

THERAPEUTIC CLASS IMMUNOMODULATORS, TOPICAL & GENITAL WARTS AGENTS BRAND UnitsUntil

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Daily

Dose

Max


IMMUNOMODULATORS, TOPICAL & GENITAL WARTS AGENTS IMIQUIMOD 2.5% and 3.75% CREAM PUMP ZYCLARA 7.5 28 14 1 Y 09/01/2014IMMUNOMODULATORS, TOPICAL & GENITAL WARTS AGENTS IMIQUIMOD 3.75% CREAM ZYCLARA 28 28 14 1 Y 09/01/2014IMMUNOMODULATORS, TOPICAL & GENITAL WARTS AGENTS IMIQUIMOD 5% CREAM 25MG PACKETS ALDARA 12 30 07/01/2013

THERAPEUTIC CLASS IMMUNOSUPPRESSIVES, ORAL BRAND UnitsUntil

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Daily

Dose

Max


MMUNOSUPPRESSIVE MYCOPHENOLATE 200 MG/ML SUSPENSION CELLCEPT 30 10/01/2018

THERAPEUTIC CLASS INTRANASAL RHINITIS AGENTS BRAND UnitsUntil

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Daily

Dose

Max


INTRANASAL RHINITIS AGENTS AZELASTINE HCL 0.1% 137MCG NASAL SPRAY 30ML GENERIC ONLY 30 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS AZELASTINE HCL 0.15% NASAL SPRAY 30ML ASTEPRO 30 30 Y 10/01/2013INTRANASAL RHINITIS AGENTS AZELASTINE/FLUTICASONE NASAL SPRAY 23GRAMS DYMISTA 23 30 Y 04/01/2014INTRANASAL RHINITIS AGENTS BECLOMETHASONE DIPROPIONATE 0.042% SPRAY BECONASE AQ 25 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS BECLOMETHASONE DIPROPIONATE 80MCG NASAL SPRAY QNASL 8.7 30 Y 10/01/2013INTRANASAL RHINITIS AGENTS BUDESONIDE NASAL SPRAY 8.6GRAMS RHINOCORT AQUA 8.6 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS CICLESONIDE 37MCG NASAL SPRAY 6.1GRAMS ZETONNA 6.1 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS CICLESONIDE 50MCG NASAL SPRAY 12.5GRAMS OMNARIS 12.5 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS FLUTICASONE FUROATE 27.5 MCG NASAL SPRAY 10GRAMS VERAMYST 10 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS FLUTICASONE PROPIONATE 0.05% NASAL SPRAY FLONASE 16 30 Y 07/01/2013INTRANASAL RHINITIS AGENTS FLUTICASONE PROPIONATE 93 MCG NASAL SPRAY XHANCE 16 Y 10/01/2018INTRANASAL RHINITIS AGENTS MOMETASONE FUROATE 50MCG NASAL SPRAY 17GM NASONEX 17 30 Y 07/01/2013

THERAPEUTIC CLASS IRRITABLE BOWEL SYNDROME/SHORT BOWEL SYNDROME/SELECTED GI AGENTS BRAND UnitsUntil

Refill

Daily

Dose

Max


IBS ELUXADOLINE TABLETS VIBERZI 30 2 10/01/2018IBS/SBS/GI AGENTS LINACLOTIDE 145 MCG CAPSULE LINZESS 1 Y 10/01/2018IBS PLECANATIDE 3 MG TABLET TRULANCE 1 10/01/2018

THERAPEUTIC CLASS LAXATIVES AND CATHARTICS BRAND UnitsUntil

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Daily

Dose

Max


LAXATIVES AND CATHARTICS PED3350/SOD SUL/NACL/KCL/ASB/C PACK MOVIPREP 1 Y 10/01/2018LAXATIVES AND CATHARTICS POLYETHYLENE GLYCOL 3350 17GRAM POWDER PACKET MIRALAX 1 10/01/2018LAXATIVES AND CATHARTICS POLYETHYLENE GLYCOL 3350 17GRAM POWDER DOSEPACK MIRALAX 36 Y 10/01/2018LAXATIVES AND CATHARTICS SODIUM CHLORIDE/NaHCO0/KCl/PEG SOLUTION PEG 3350-ELECTROLYTE SOLUTION 4000 10/01/2018

THERAPEUTIC CLASS LEUKOTRIENE MODIFIERS BRAND UnitsUntil

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Daily

Dose

Max


LEUKOTRIENE MODIFIERS MONTELUKAST SODIUM 4, 5 and 10MG GRANULES or TABLETS SINGULAIR 1 07/01/2013LEUKOTRIENE MODIFIERS ZAFIRLUKAST 10 and 20MG TABLET ACCOLATE 2 07/01/2013LEUKOTRIENE MODIFIERS ZILEUTON 600MG FILMTAB ZYFLO 4 07/01/2013

THERAPEUTIC CLASS LIPOTROPICS, OTHER (Non-statins) BRAND UnitsUntil

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Daily

Dose

Max


LIPOTROPICS, OTHER (Non-statins) EZETIMIBE 10MG TABLET ZETIA 1 07/01/2013LIPOTROPICS, OTHER (Non-statins) FENOFIBRATE 40 and 120MG TABLET FENOGLIDE 1 10/01/2013LIPOTROPICS, OTHER (Non-statins) FENOFIBRATE NANOCRYSTALLIZED TABLETS ALL STRENGTHS TRICOR 1 07/01/2013LIPOTROPICS, OTHER (Non-statins) FENOFIBRIC ACID (CHOLINE) 45 and 135MG CAPSULE TRILIPIX DR 1 10/01/2013LIPOTROPICS, OTHER (Non-statins) FENOFIBRIC ACID 35 and 105MG TABLET FIBRICOR 1 07/01/2013LIPOTROPICS, OTHER OMEGA-3 ACID ETHYL ESTERS 1MG CAPSULE LOVAZA 4 07/01/2013

THERAPEUTIC CLASS LIPOTROPICS, STATINS BRAND UnitsUntil

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Daily

Dose

Max


LIPOTROPICS, STATINS AMLOPIDINE-ATORVASTATIN TABLETS ALL STRENGTHS CADUET 1 07/01/2013LIPOTROPICS, STATINS ATORVASTATIN CALCIUM TABLETS ALL STRENGTHS LIPITOR 1 07/01/2013LIPOTROPICS, STATINS EZETIMIBE/SIMVASTATIN TABLETS ALL STRENGTHS VYTORIN 1 07/01/2013LIPOTROPICS, STATINS FLUVASTATIN SODIUM CAPSULES ALL STRENGTHS LESCOL / LESCOL XL 1 07/01/2013LIPOTROPICS, STATINS NIACIN/LOVASTATIN 500-20 MG TABLET ADVICOR 1 10/01/2018LIPOTROPICS, STATINS NIACIN/LOVASTATIN 750-20 MG TABLET ADVICOR 1 10/01/2018LIPOTROPICS, STATINS NIACIN/LOVASTATIN 1000-20 MG TABLET ADVICOR 2 10/01/2018LIPOTROPICS, STATINS NIACIN/LOVASTATIN 1000-40 MG TABLET ADVICOR 1 10/01/2018LIPOTROPICS, STATINS NIACIN/SIMVASTATIN 500-20MG, 750-20MG and 1000-20MG TABLET SIMCOR 2 07/01/2013LIPOTROPICS, STATINS NIACIN/SIMVASTATIN 500-40MG and 1000-40MG TABLET SIMCOR 1 07/01/2013LIPOTROPICS, STATINS PITAVASTATIN CALCIUM TABLETS ALL STRENGTHS LIVALO 1 10/01/2013LIPOTROPICS, STATINS PRAVASTATIN SODIUM TABLETS ALL STRENGTHS PRAVACHOL 1 07/01/2013LIPOTROPICS, STATINS ROSUVASTATIN CALCIUM TABLETS ALL STRENGTHS CRESTOR 1 07/01/2013LIPOTROPICS, STATINS SIMVASTATIN TABLETS ALL STRENGTHS ZOCOR 1 07/01/2013LIPOTROPICS, STATINS SIMVASTATIN ORAL SUSPENSION FLOLIPID 5 10/01/2018

THERAPEUTIC CLASS MACROLIDES/KETOLIDES (Oral) BRAND UnitsUntil

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Daily

Dose

Max


MACROLIDES AZITHROMYCIN SUSPENSIONS ZITHROMAX 30 14 14 1 Y 10/01/2018MACROLIDES AZITHROMYCIN 2 G/60 ML ORAL SUSPENSION ZMAX 2 14 14 1 Y 10/01/2018MACROLIDES AZITHROMYCIN 250 MG TABLET ZITHROMAX 6 14 14 1 10/01/2018MACROLIDES AZITHROMYCIN 500 MG TABLET ZITHROMAX 3 14 14 1 10/01/2018MACROLIDES AZITHROMYCIN 600 MG TABLET ZITHROMAX 14 1 10/01/2018MACROLIDES AZITHROMYCIN 1 GM PWD PACKET ZITHROMAX 14 1 10/01/2018



MACROLIDES ERYTHROMYCIN ALL STRENGHTS, ALL FORMULATIONS GENERIC ONLY 14 1 10/01/2018MACROLIDES ERYTHROMYCIN ETHYLSUCCINATE E..E.S. 400 14 1 10/01/2018MACROLIDES ERYTHROMYCIN STEARATE FILMTABS GENERIC ONLY 14 1 10/01/2018MACROLIDES ERYTHROMYCIN/SULFISOX SUSP PEDIAZOLE 14 1 10/01/2018MACROLIDES FIDAXOMICIN 200 MG TABLET DIFICID 14 1 10/01/2018VANCOMYCIN AND DERIVATIVES VANCOMYCIN HCL 125 and 250MG CAPSULE VANCOCIN HCL 14 1 07/01/2013VANCOMYCIN AND DERIVATIVES VANCOMYCIN HCL SOLUTION FIRVANQ 14 1 10/01/2018KETOLIDE ANTIBIOTICS TELITHROMYCIN TABLETS KETEK 14 1 10/01/2018

THERAPEUTIC CLASS MULTIPLE SCLEROSIS AGENTS BRAND UnitsUntil

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Daily

Dose

Max


MULTIPLE SCLEROSIS AGENTS DALFAMPRIDINE 10MG TABLET AMPYRA 2 07/01/2013MULTIPLE SCLEROSIS AGENTS FINGOLIMOD HCL 0.5MG CAPSULE GILENYA 1 07/01/2013MULTIPLE SCLEROSIS AGENTS GLATIRAMER ACETATE 40MG/ML SYRINGE COPAXONE 12 30 Y 07/01/2013MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1A 30MG/0.5ML AVONEX PEN 1 30 Y 09/01/2014MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1A PREFILLED 30MCG/0.5ML SYRINGE AVONEX 1 30 Y 10/01/2013MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1A/ALBUMIN 22 and 44MCG/0.5ML SYRINGE REBIF 6 30 Y 10/01/2013MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1A/ALBUMIN 30MCG VIAL AVONEX 4 30 Y 10/01/2013MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1A/ALBUMIN TRITATION PACKS REBIF REBIDOSE 4.2 365 Y 10/01/2013MULTIPLE SCLEROSIS AGENTS INTERFERON BETA-1B 0.3MG KIT BETASERON / EXTAVIA 15 30 Y 10/01/2013MULTIPLE SCLEROSIS AGENTS TERIFLUNOMIDE 7MG TABLET AUBAGIO 1 10/01/2013

THERAPEUTIC CLASS NEUROPATHIC PAIN BRAND UnitsUntil

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Daily

Dose

Max


NEUROPATHIC PAIN DULOXETINE HCL 30MG CAPSULE CYMBALTA 1 07/01/2013NEUROPATHIC PAIN DULOXETINE HCL 20 and 60MG CAPSULE CYMBALTA 2 07/01/2013NEUROPATHIC PAIN GABAPENTIN 100MG, 300MG CAPSULE NEURONTIN 6 10/01/2013NEUROPATHIC PAIN GABAPENTIN 300MG TABLET GRALISE ER 1 10/01/2013NEUROPATHIC PAIN GABAPENTIN 400MG CAPSULE NEURONTIN 8 10/01/2013NEUROPATHIC PAIN GABAPENTIN 600MG TABLET GRALISE ER 3 10/01/2013NEUROPATHIC PAIN GABAPENTIN 800MG TABLET NEURONTIN 4 10/01/2013NEUROPATHIC PAIN GABAPENTIN 50MG/ML SOLUTION 5 and 6ML NEURONTIN 36 10/01/2013NEUROPATHIC PAIN GABAPENTIN 30-DAY STARTER PACK 78UNITS GRALISE ER 78 365 Y 10/01/2013NEUROPATHIC PAIN LIDOCAINE 5% PATCH LIDODERM 1 01/01/2019NEUROPATHIC PAIN LIDOCAINE 5% OINTMENT GENERIC ONLY 30 Y 10/01/2018NEUROPATHIC PAIN LIDOCAINE 1.8% TOPICAL SYSTEM ZTLIDO 1 10/01/2018NEUROPATHIC PAIN MILNACIPRAN HCL 12.5, 25, 50 and 100MG TABLET SAVELLA 2 10/01/2013NEUROPATHIC PAIN MILNACIPRAN HCL TRITATION PACK (55 TABLETS) SAVELLA 55 365 0 Y 07/01/2013NEUROPATHIC PAIN PREGABALIN 25, 50, 75, 100, 150 and 200MG CAPSULE LYRICA 3 07/01/2013NEUROPATHIC PAIN PREGABALIN 225 and 300MG CAPSULE LYRICA 2 07/01/2013NEUROPATHIC PAIN PREGABALIN 20MG/ML ORAL SOLUTION LYRICA 30 07/01/2013

THERAPEUTIC CLASS NSAIDs BRAND UnitsUntil

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Daily

Dose

Max


NSAIDs CELECOXIB CAPSULES, SUSPENSIONS AND TABLETS CELEBREX 1 10/01/2018NSAIDs DICLOFENAC EPOLAMINE 1.3% PATCH FLECTOR 2 07/01/2013NSAIDs DICLOFENAC SODIUM 2% PUMP PENNSAID 224 30 Y 04/01/2014NSAIDs DICLOFENAC SODIUM 1% GEL VOLTAREN 100 30 Y 12/01/2014NSAIDs DICLOFENAC SODIUM 1.5% SOLUTION PENNSAID 150 30 07/01/2013NSAID AND HISTAMINE H2 RECEPTOR ANTAGONIST COMB IBUPROFEN/FAMOTIDINE 800-26.6 MG TABLET DUEXIS 3 10/01/2018NSAIDS MELOXICAM 7.5 MG/5 ML SUSPENSION MOBIC 10/01/2018NSAIDS MELOXICAM 7.5 AND 15 MG TABLET MOBIC 1 10/01/2018NSAIDS NAPROXEN/ESOMEPRAZOLE MAG TABLETS VIMOVO DR 2 10/01/2018NSAIDS OXAPROZIN 600 MG TABLET DAYPRO 2 10/01/2018

THERAPEUTIC CLASS OPHTHALMIC ANTIBIOTICS BRAND UnitsUntil

Refill

Daily

Dose

Max


EYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB PREDNISOLONE-GATIFLOX-NEPAFENC 1% - 0.5% - 0.1% SUSPENSION GENERIC ONLY 3.5 28 Y 10/01/2018

THERAPEUTIC CLASS OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS BRAND UnitsUntil

Refill

Daily

Dose

Max


OPHTHALMIC ALLERGIC CONJUNCTIVITIS ALCAFTADINE 0.25% EYE DROPS 3ML LASTACAFT 3 30 Y 10/01/2013OPHTHALMIC ALLERGIC CONJUNCTIVITIS AZELASTINE HCL 0.05% DROPS 6ML OPTIVAR 6 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS CROMOLYN SODIUM 4% EYE DROPS 10ML P/PACKAGE GENERIC ONLY 10 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS EMEDASTINE DIFUMARATE 0.05% EYE DROPS 5ML EMADINE 5 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS EPINASTINE HCL 0.05% EYE DROPS 5ML ELESTAT 5 30 Y 07/01/2013OPHTHALMIC ANTI-INFLAMMATORIES KETOTIFEN FUMARATE 0.025% EYE DROPS 10ML ZADITOR / ALAWAY 10 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS LODOXAMIDE TROMETHAMINE 0.1% EYE DROPS 10ML ALOMIDE 10 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS NEDOCROMIL SODIUM 2% EYE DROPS 5ML ALOCRIL 5 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS OLOPATADINE HCL 0.1% EYE DROPS 5ML PATANOL 5 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS OLOPATADINE HCL 0.2% EYE DROPS 2.5 ML PATADAY 2.5 30 Y 07/01/2013OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS OLOPATADINE HCL 0.6% 665MCG NASAL SPRAY 30.5 GRAMS PATANASE 30.5 30 Y 07/01/2013

THERAPEUTIC CLASS OPHTHALMIC ANTI-INFLAMMATORIES BRAND UnitsUntil

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Daily

Dose

Max


OPHTHALMIC ANTI-INFLAMMATORIES BROMFENAC SODIUM 0.07% EYE DROPS 1.6 or 3ML PROLENSA 3 30 Y 10/01/2013OPHTHALMIC ANTI-INFLAMMATORIES-IMUNOMODULATORS RESTASIS 60 30 Y 10/01/2018OPHTHALMIC ANTI-INFLAMMATORIES DIFLUPREDNATE 0.05% EYE DROPS 5ML DUREZOL 5 30 Y 10/01/2013OPHTHALMIC ANTI-INFLAMMATORIES KETOROLAC TROMETHAMINE 0.4% OPTH SOLUTION 5ML ACULAR LS 5 30 Y 10/01/2013OPHTHALMIC ANTI-INFLAMMATORIES KETOROLAC TROMETHAMINE/PF 0.45% OPHTHALMIC SOLUTION ACUVAIL 30 30 Y 10/01/2013OPHTHALMIC ANTI-INFLAMMATORIES KETOROLAC TROMETHAMINE 10 MG TABLET GENERIC ONLY 20 30 4 5 10/01/2018OPHTHALMIC ANTI-INFLAMMATORIES KETOROLAC TROMETHAMINE CARPUJECTS, SYRINGES AND VIALS 4 30 Y 10/01/2018OPHTHALMIC ANTI-INFLAMMATORIES PREDNISOLONE 1%-NEPAFENAC 0.1% GENERIC ONLY 3.5 28 Y 10/01/2018OPHTHALMIC ANTI-INFLAMMATORIES PREDNISOLONE 1%-GATIFLOXACIN 0.5% SUSPENSION GENERIC ONLY 3.5 28 Y 10/01/2018

THERAPEUTIC CLASS OPHTHALMICS, GLAUCOMA AGENTS BRAND UnitsUntil

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Daily

Dose

Max


OPHTHALMICS, GLAUCOMA AGENTS TAFLUPROST/PF 0.0015% EYE DROPS ZIOPTAN 30 30 Y 10/01/2013OPHTHALMICS, GLAUCOMA AGENTS LATANOPROST 0.005% EYE DROPS XALATAN 2.5 30 Y 07/01/2013OPHTHALMICS, GLAUCOMA AGENTS LATANOPROSTENE BUNOD 0.024% OPHTH SOLUTION VYZULTA 5 28 Y 10/01/2018OPHTHALMICS, GLAUCOMA AGENTS UNOPROSTONE ISOPROPYL 1.5% EYE DROPS 5ML RESCULA 5 30 07/01/2013

THERAPEUTIC CLASS OPIATE DEPENDENCE TREATMENTS BRAND UnitsUntil

Refill

Daily

Dose

Max


OPIATE DEPENDENCE TREATMENTS BUPRENORPHINE HCL/NALOXONE HCL FILM OR TABLETS - SEE WEBSITE SUBOXONE 2 10/01/2018OPIATE DEPENDENCE TREATMENTS BUPRENORPHINE HCL / NALOXONE HCL FILMS ALL STRENGTHS BUNAVAIL 2 10/01/2018OPIATE DEPENDENCE TREATMENTS BUPRENORPHINE HCL / NALOXONE HCL TABLETS ALL STRENGTHS ZUBSOLV 2 10/01/2018OPIATE DEPENDENCE TREATMENTS LOXEFIDINE HCL 0.18MG TABLET LUCEMYRA 16 14 10/01/2018OPIATE DEPENDENCE TREATMENTS NALOXONE HCL 0.4MG AUTO INJECTOR EVZIO 0.8 180 Y 09/01/2015OPIATE DEPENDENCE TREATMENTS NALOXONE HCL 1MG/ML SYRINGE 2ML GENERIC ONLY 4 Y 09/01/2015OPIATE DEPENDENCE TREATMENTS NALOXONE HCL 4MG NASAL SPRAY NARCAN 2 30 Y 10/01/2018OPIATE DEPENDENCE TREATMENTS NALOXONE HCL 2MG NASAL SPRAY NARCAN 4 30 10/01/2018

THERAPEUTIC CLASS OTIC ANTIBIOTICS BRAND UnitsUntil

Refill

Daily

Dose

Max


OTIC ANTIBIOTICS CIPROFLOXACIN HCL/DEXAMETH SUSPENSION 7.5ML CIPRODEX 7.5 30 Y 07/01/2013

THERAPEUTIC CLASS PAG AGENTS – PDE5s BRAND UnitsUntil

Refill

Daily

Dose

Max


PAH AGENTS - PDE5s SILDENAFIL CITRATE 20MG TABLET REVATIO 3 07/01/2013PAH AGENTS - PDE5s TADALAFIL 20MG TABLET ADCIRCA 2 10/01/2013

THERAPEUTIC CLASS PAG AGENTS – PROSTACYCLINS BRAND UnitsUntil

Refill

Daily

Dose

Max


PAG AGENTS – PROSTACYCLINS TREPROSTINIL 1.74MG/2.9ML SOLUTION TYVASO 2.9 10/01/2013

THERAPEUTIC CLASS PLATELET AGGREGATION INHIBITORS BRAND UnitsUntil

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Daily

Dose

Max


PLATELET AGGREGATION INHIBITORS ASPIRIN/DIPYRIDAMOLE 25MG-200MG CAPSULE AGGRENOX 2 07/01/2013PLATELET AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE 75MG TABLET PLAVIX 1 07/01/2013PLATELET AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE 300MG TABLET PLAVIX 1 30 07/01/2013PLATELET AGGREGATION INHIBITORS PRASUGREL HCL 5 and 10MG TABLET EFFIENT 1 07/01/2013PLATELET AGGREGATION INHIBITORS TICAGRELOR 60, 90MG TABLET BRILINTA 2 07/01/2013

THERAPEUTIC CLASS PROTON PUMP INHIBITORS BRAND UnitsUntil

Refill

Daily

Dose

Max


PROTON PUMP INHIBITORS DEXLANSOPRAZOLE 30 and 60MG CAPSULE DEXILANT 1 07/01/2013PROTON PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAPSULES or PACKETS ALL STRENGTHS NEXIUM 1 07/01/2013PROTON PUMP INHIBITORS ESOMEPRAZOLE MAG/GLYCERIN KIT ESOMEP-EZS 1 10/01/2018PROTON PUMP INHIBITORS LANSOPRAZOLE DR CAPSULES, SOLUTABS AND TABLETS PREVACID 1 10/01/2018PROTON PUMP INHIBITORS OMEPRAZOLE 10, 20 and 40MG CAPSULE PRILOSEC 1 10/01/2013PROTON PUMP INHIBITORS OMEPRAZOLE/SODIUM BICARBONATE CAPSULES ALL STRENGTHS ZEGERID OTC 1 07/01/2013PROTON PUMP INHIBITORS RABEPRAZOLE SODIUM 20MG TABLET ACIPHEX 1 07/01/2013PROTON PUMP INHIBITORS PANTOPRAZOLE SODIUM 20 and 40MG TABLETS or SUSPENSION PROTONIX 2 03/01/2015

THERAPEUTIC CLASS SEDATIVE HYPNOTICS BRAND UnitsUntil

Refill

Daily

Dose

Max


ANTI ANXIETY - BENZO ALPRAZOLAM TABLETS XANAX 30 3 10/01/2018ANTI ANXIETY - BENZO ALPRAZOLAM CONCENTRATES GENERIC ONLY 30 3 10/01/2018ANTI ANXIETY - BENZO ALPRAZOLAM ER TABLETS XANAX XR 30 2 10/01/2018ANTI ANXIETY - BENZO ALPRAZOLAM ODT TABLETS GENERIC ONLY 30 3 10/01/2018SEDATIVE HYPNOTICS DOXEPIN HCL 3 and 6MG TABLET SILENOR 15 30 1 01/01/2019SEDATIVE HYPNOTICS ESTAZOLAM 1 and 2MG TABLET GENERIC ONLY 15 30 1 01/01/2019SEDATIVE HYPNOTICS ESZOPICLONE 1, 2 and 3MG TABLET LUNESTA 15 30 1 01/01/2019



SEDATIVE HYPNOTICS FLURAZEPAM 15 and 30MG CAPSULE GENERIC ONLY 15 30 1 10/01/2018ANTI ANXIETY - BENZO LORAZEPAM TABLETS ATIVAN 30 3 10/01/2018ANTI ANXIETY - BENZO LORAZEPAM 2 MG/ML ORAL CONCENT ATIVAN 30 3 10/01/2018SEDATIVE-HYPNOTICS MIDAZOLAM HCL 2 MG/ML SYRUP GENERIC ONLY 30 5 10/01/2018SEDATIVE-HYPNOTICS MIDAZOLAM HCL 5 MG/2.5 ML SYRP GENERIC ONLY 30 2.5 10/01/2018SEDATIVE-HYPNOTICS MIDAZOLAM HCL 10 MG/5 ML SYRUP GENERIC ONLY 30 5 10/01/2018ANTI ANXIETY - BENZO OXAZEPAM CAPSULES GENERIC ONLY 30 3 10/01/2018SEDATIVE HYPNOTICS QUAZEPAM 15 MG TABLET DORAL 15 30 1 10/01/2018SEDATIVE HYPNOTICS RAMELTEON 8MG TABLET ROZEREM 15 30 2 01/01/2019SEDATIVE HYPNOTICS SECONAL SODIUM 100 MG CAPSULE GENERIC ONLY 15 30 1 10/01/2018SEDATIVE HYPNOTICS SUVOREXANT TABLETS BELSOMRA 15 30 1 10/01/2018SEDATIVE HYPNOTICS TASIMELTEON 20MG CAPSULE HETLIOZ 15 30 1 10/01/2018SEDATIVE HYPNOTICS TEMAZEPAM CAPSULES ALL STRENGTHS RESTORIL 15 30 1 01/01/2019SEDATIVE HYPNOTICS TRIAZOLAM 0.125 and 0.25MG TABLET HALCION 15 30 1 07/01/2013SEDATIVE HYPNOTICS ZALEPLON 5 and 10MG CAPSULE SONATA 15 30 1 01/01/2019SEDATIVE HYPNOTICS ZOLPIDEM TARTRATE SUBLINGUAL TABLETS ALL STRENGTHS INTERMEZZO 15 30 1 01/01/2019SEDATIVE HYPNOTICS ZOLPIDEM TARTRATE TABLETS ALL STRENGTHS AMBIEN 15 30 1 01/01/2019

THERAPEUTIC CLASS SKELETAL MUSCLE RELAXANTS BRAND UnitsUntil

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SKELETAL MUSCLE RELAXANTS BACLOFEN 5 MG TABLET GENERIC ONLY 3 10/01/2018SKELETAL MUSCLE RELAXANTS BACLOFEN 10 and 20MG TABLET GENERIC ONLY 4 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS CARISOPRODOL 250 and 350MG TABLET SOMA 3 Max 65 10/01/2013SKELETAL MUSCLE RELAXANTS CARISOPRODOL/ASPIRIN 200-325MG COMPOUND TABLET GENERIC ONLY 4 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS CHLORZOXAZONE 500MG TABLETS PARAFON FORTE DSC 4 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS CODEINE/CARISOPRODOL/ASPIRIN 16-200-325 TAB GENERIC ONLY 4 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS CYCLOBENZAPRINE HCL 5, 7.5, 10, 15 and 30MG TABLET FLEXERIL 3 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS DANTROLENE SODIUM 25, 50 and 100MG CAPSULE DANTRIUM 4 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS METAXALONE 800MG TABLET SKELAXIN 56 30 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS METHOCARBAMOL 500MG TABLET ROBAXIN 9 Max 65 10/01/2013SKELETAL MUSCLE RELAXANTS METHOCARBAMOL 750MG TABLET ROBAXIN 6 Max 65 10/01/2013SKELETAL MUSCLE RELAXANTS ORPHENADRINE ER 100 MG TABLET GENERIC ONLY 2 10/01/2018SKELETAL MUSCLE RELAXANTS TIZANIDINE HCL 2MG CAPSULES or TABLETS ZANAFLEX 3 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS TIZANIDINE HCL 4MG CAPSULES or TABLETS ZANAFLEX 6 Max 65 07/01/2013SKELETAL MUSCLE RELAXANTS TIZANIDINE HCL 6MG CAPSULE ZANAFLEX 4 Max 65 07/01/2013

THERAPEUTIC CLASS STEROIDS, TOPICAL BRAND UnitsUntil

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STEROIDS, TOPICAL FLUOCINOLONE/EMOL CMB#65 0.025% CREAM KIT SYNALAR 375 30 Y 10/01/2013STEROIDS, TOPICAL FLUOCINOLONE/EMOL CMB#65 0.025% OINTMENT KIT SYNALAR 375 30 Y 10/01/2013STEROIDS, TOPICAL FLURANDRENOLIDE 4MCG/SQ CM TAPE CORDRAN 1 30 07/01/2013STEROIDS, TOPICAL HYDROCORTISONE 1% CREAM GENERIC ONLY 72 10/01/2018STEROIDS, TOPICAL TRIAMCINOLONE ACETONIDE 0.025% & 0.1% LOTION KENALOG 60 30 Y 10/01/2013STEROIDS, TOPICAL TRIAMCINOLONE ACETONIDE 0.1% PASTE 5GRAM ORALONE 5 30 Y 04/01/2014STEROIDS, TOPICAL TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML GENERIC ONLY 60 30 Y 10/01/2013STEROIDS, TOPICAL TRIAMCINOLONE ACETONIDE 0.5% OINTMENT 15GRAM GENERIC ONLY 15 30 Y 10/01/2013STEROIDS, TOPICAL TRIAMCINOLONE ACETONIDE 55 MCG SPRAY 16.5GRAMS NASACORT AQ 16.5 30 Y 07/01/2013

THERAPEUTIC CLASS STIMULANTS AND RELATED AGENTS BRAND UnitsUntil

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STIMULANTS AND RELATED AGENTS AMPHETAMINE XR ODT TABLETS ADZENYS XR-ODT 30 1 10/01/2018STIMULANTS AND RELATED AGENTS - NARCOLEPSY ARMODAFINIL 50 AND 200 MG TABLETS NUVIGIL 30 1 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD ATOMOXETINE HCL 10, 18, 25, 40MG CAPSULES STRATTERA 2 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD ATOMOXETINE HCL 60, 80, 100MG CAPSULES STRATTERA 1 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD CLONIDINE HCL 0.1MG TABLET KAPVAY ER 4 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXMETHYLPHENIDATE HCL TABLETS ALL STRENGTHS FOCALIN 3 Max 18 01/01/2019STIMULANTS AND RELATED AGENTS - ADHD DEXMETHYLPHENIDATE HCL CAPSULES ALL STRENGTHS FOCALIN XR 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE TABLETS ALL STRENGTHS ADDERALL 3 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE ER CAPSULES ALL STRENGTHS DEXEDRINE 2 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE/AMPHETAMINE IR TABLETS ADDERALL 3 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE/AMPHETAMINE XR CAPSULES ALL STRENGTHS ADDERALL XR 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE SULFATE TABLETS ALL STRENGTHS ZENZEDI 4 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD DEXTROAMPHETAMINE SULFATE 5MG/5ML ORAL SOLUTION PROCENTRA 60 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD GUANFACINE HCL TABLETS INTUNIV 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD GUANFACINE HCL 1 and 2MG IR TABLET TENEX 4 12/10/2014STIMULANTS AND RELATED AGENTS - ADHD LISDEXAMFETAMINE DIMESYLATE CAPSULES AND TABLETS VYVANSE 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - ADHD LISDEXAMFETAMINE DIMESYLATE 10 MG CHEWABLE TABLET VYVANSE 1 10/01/2018STIMULANTS AND RELATED AGENTS METHAMPHETAMINE HCL 5MG TABLET DESOXYN 5 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE 8.6 MG TABLET COTEMPLA XR-ODT 1 10/01/2018STIMULANTS AND RELATED AGENTS METHYLPHENIDATE 17.3 AND 25.9 MG TABLET COTEMPLA XR-ODT 2 10/01/2018STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL ER 72 MG TAB RELEXXII 1 10/01/2018STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL TABLETS CONCERTA 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE 10MG, 15MG, 20MG or 30MG/9HR PATCH DAYTRANA 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL CD 10, 20, 30MG CAPSULE METADATE 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE CD 40, 50, 60MG CAPSULE METADATE CD 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 2.5, 5MG CHEWABLE TABLET METHYLIN 3 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 10MG CHEWABLE TABLET METHYLIN 6 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 10MG/5ML SOLUTION METHYLIN 30 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 5MG/5ML SOLUTION METHYLIN 60 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 10MG TABLET METHYLIN ER 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE 5, 10, 20MG TABLET RITALIN 3 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL LA 60 MG CAP RITALIN LA 1 10/01/2018STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 10, 20, 40MG CAPSULE RITALIN LA 1 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE HCL 30MG CAPSULE RITALIN LA 2 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS METHYLPHENIDATE ER 20MG TABLET RITALIN SR 3 Max 18 12/01/2014STIMULANTS AND RELATED AGENTS - NARCOLEPSY MODAFINIL 100, 200MG TABLET PROVIGIL 1 Max 18 12/01/2014

THERAPEUTIC CLASS TETRACYCLINES BRAND UnitsUntil

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TETRACYCLINES DOXYCYCLINE MONOHYDRATE 40 and 150MG CAPSULES or TABLETS ORACEA 1 10/01/2013TETRACYCLINES MINOCYCLINE HCL ER TABLETS ALL STRENGTHS SOLODYN 1 10/01/2013

THERAPEUTIC CLASS ULCERATIVE COLITIS AGENTS BRAND UnitsUntil

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ULCERATIVE COLITIS AGENTS BALSALAZIDE DISODIUM GIAZO 6 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE 0.375, 1.2 GRAM CAPSULE/TABLET APRISO 4 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE 250MG CAPSULE PENTASA 16 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE 400MG CAPSULES or TABLETS DELZICOL 12 01/20/2015ULCERATIVE COLITIS AGENTS MESALAMINE 500MG CAPSULE PENTASA 8 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE DR 800MG TABLET ASACOL 6 07/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE 4GM/60ML ENEMA SFROWASA 60 Y 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE W/CLEANSING WIPES ROWASA 1 28 10/01/2013ULCERATIVE COLITIS AGENTS MESALAMINE 400 MG CAPSULE DELZICOL 30 6 10/01/2018

THERAPEUTIC CLASS DIABETIC SUPPLIES BRAND UnitsUntil

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DIABETIC TESTING BLOOD SUGAR DIAGNOSTIC TEST STRIPS ACCU-CHEK SMARTVIEW STRIP 153 30 Y 09/01/2014DIABETIC SUPPLIES INSULIN NEEDLES ULITLIE PEN NEEDLES 153 30 Y 09/01/2014DIABETIC SUPPLIES LANCETS - ALL GAUGES AURORA HEALTHCARE LANCETS 153 30 Y 09/01/2014DIABETIC SUPPLIES SUB-Q INSULIN DEVICE, 20, 30 or 40 UNIT VGO 30 1 Y 09/01/2014DIABETIC SUPPLIES URINE ACETONE TEST STRIPS KETOSTIX REAGENT STRIP 100 Y 10/01/2018

THERAPEUTIC CLASS VACCINES BRAND UnitsUntil

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VACCINES TOXOID PREPARATIONS,COMBINATIONS BOOSTRIX 0.5 365 Min 19 12/10/2014VACCINES FLU VACCINE - ONE SHOT PER SEASON FLULAVAL 1 shot 365 10/01/2018VACCINES GRAM POSITIVE COCCI VACCINES PNEUMOVAX 0.5 365 Min 19 12/10/2014VACCINES PNEUMOC 13-VAL CONJ-DIP CRM/PF 999 10/01/2018VACCINES VARICELLA-ZOSTER Ge/AS01B/PF VIAL KIT SHINGRIX VIAL KIT 1 10/01/2018

THERAPEUTIC CLASS ONCOLOGY CLASS BRAND UnitsUntil

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CONTRACEPTIVES VAGINAL RING NUVARING 1 28 10/01/2018CONTRACEPTIVES LEVONORGESTREL ESTRADIOL TABLETS CHATEAL 1 91 Y 10/01/2018CONTRACEPTIVES MEDROXYPROGESTERONE ACETATE 150 MG/ML VIAL AND SYRINGE DEPO-PROVERA 1 90 90 10/01/2018CONTRACEPTIVES MEDROXYPROGESTERONE ACETATE 104 MG/0.65 ML SYRINGE DEPO-SUBQ PROVERA SYRINGE 0.65 90 90 Y 10/01/2018CONTRACEPTIVES NORELGESTROMIN/ETHIN.ESTRADIOL PATCH XULANE 3 30 10/01/2018CONTRACEPTIVES ULIPRISTAL ACETATE 30MG TABLET ELLA 1 10/01/2018


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ESTROGEN ESTRADIOL PATCH VIVELLE-DOT 8 30 Y 10/01/2018ESTROGEN ESTRADIOL 2 MG VAGINAL RING ESTRING 90 Y 10/01/2018ESTROGEN ESTRADIOL DAILY PATCH CLIMARA 4 30 Y 10/01/2018ESTROGEN ESTRADIOL ACETATE VAGINAL RINGS FEMRING 1 90 90 Y F 10/01/2018ESTROGEN ESTRADIOL LEVONORGESTREL PATCH CLIMARA PRO 4 30 Y 10/01/2018ESTROGEN ESTRADIOL 1.53 MG/SPRAY EVAMIST 56 Y 10/01/2018



CONTRACEPTIVES 91 1 91 Y 10/01/2018CONTRACEPTIVES LEVONORGEST/ETH.ESTRADIOL/IRON 0.1-0.2MG BLISTER PACK BALCOLTRA 1 10/01/2018


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THROMBOPOIETIN RECEPTOR AGONISTS AVATROMBOPAG MALEATE 20 MG TABLET DOPTELET 1 5 10/01/2018ANTIRETROVIRAL DARUNAVIR/COB/EMTRI/TENOF ALAF 800-150-200-10 MG TAB SYMTUZA 1 10/01/2018DRUGS TO TREAT MOVEMENT DISORDERS DEUTETRABENAZINE 12 MG TABLET AUSTEDO 4 10/01/2018DRUGS TO TREAT MOVEMENT DISORDERS DEUTETRABENAZINE 6 MG TABLET AUSTEDO 1 10/01/2018DRUGS TO TREAT MOVEMENT DISORDERS DEUTETRABENAZINE 9 MG TABLET AUSTEDO 3 10/01/2018AGENTS TO TX PERIODIC PARALYSIS DICHLORPHENAMIDE 50 MG TABLET KEVEYIS 4 10/01/2018ANTIPRURITICS,TOPICAL DOXEPIN 5% CREAM PRUDOXIN 30 Y 10/01/2018ANTIARRHYTHMICS DRONEDARONE HCL 400 MG TABLET MULTAQ 2 10/01/2018LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS ELAGOLIX SODIUM 150 MG TABLET ORILISSA 1 10/01/2018LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS ELAGOLIX SODIUM 200 MG TABLET ORILISSA 2 10/01/2018VITAMIN D PREP ERGOCALCIFEROL 8,000 UNITS/ML DRISDOL Y 10/01/2018SPLEEN TYROSINE KINASE INHIBITORS FOSTAMATINIB DISODIUM TABLETS TAVALISSE 2 10/01/2018INSULINS? GLUCAGON,HUMAN RECOMBINANT 1MG VIAL HYPOKIT - 2PK 2ML VIAL GLUCAGEN 2 30 Y 09/01/2014PROGESTATIONAL AGENT LEUPROLIDE/NORETHINDRONE ACETAM 11.25-5MG KIT LUPANETA PACK 3 MONTH 1 90 90 Y 10/01/2013PROGESTATIONAL AGENT LEUPROLIDE/NORETHINDRONE ACETAM 3.75-5MG KIT LUPANETA PACK 1 MONTH 1 30 Y 10/01/2013ANTHELMINTICS MEBENDAZOLE 100 MG CHEWABLE TABLET EMVERM 1 21 1 10/01/2018PINEAL HORMONE AGENTS MELATONIN 3 MG TABLET MELATIN 3 10/01/2018ANTIPROTOZOAL DRUGS,MISCELLANEOUS MILTEFOSINE 50MG CAPSULE IMPAVIDO 30 3 10/01/2018ALLERGENIC EXTRACTS, THERAPEUTICS MIXED POLLENS ALLREGAN EXTRACT 300MG SUBLINGUAL TABLET ORALAIR 30 1 01/01/2015ALLERGENIC EXTRACTS, THERAPEUTICS MIXED POLLENS ALLREGAN EXTRACT STARTER PACK ORALAIR 3 365 Y 01/01/2015AMINOGLYCOSIDES NEOMY SULF/POLYMYXIN B SULFATE 40MG/ML AMPULE or VIAL NEOSPORIN G.U. IRRIGANT 2 10/01/2013FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG OBETICHOLIC ACID TABLETS OCALIVA 30 1 10/01/2018MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR OSPEMIFENE 60MG TABLET OSPHENA 1 10/01/2018LEUKOCYTE (WBC) STIMULANTS PEGFILGRASTIM 6MG/0.6ML SYRINGE NEULASTA 1.2 30 Y 10/01/2013ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS PIRFENIDONE 267MG TABLET ESBRIET 6 10/01/2018ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS PIRFENIDONE 801MG TABLET ESBRIET 3 10/01/2018PRENATAL VITAMINS PRENATAL 48/IRON/FOLIC ACID/B6 PRENATAL COMBO PACK VINACAL B 3 10/01/2018AMMONIA INHIBITORS SODIUM PHENYLBUTYRATE POWDER BUPHENYL 20 10/01/2018ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITOR TELOTRISTAT ETIPRATE 250MG TABLET XERMELO 84 10/01/2018ANTILEPROTICS THALIDOMIDE 50 MG CAPSULE THALOMID 8 08/01/2014ANTILEPROTICS THALIDOMIDE 100MG CAPSULE THALOMID 4 08/01/2014ANTILEPROTICS THALIDOMIDE 150, 200MG CAPSULE THALOMID 2 08/01/2014ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS TOLVAPTAN TABLETS JYNARQUE 2 10/01/2018LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY TRIPTORELIN PAMOATE 22.5MG VIAL KIT TRIPTADOUR 1 10/01/2018DRUGS TO TREAT MOVEMENT DISORDERS VALBENAZINE TOSYLATE 40MG CAPSULE INGREZZA 2 10/01/2018


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ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ABEMACICLIB TABLETS VERZENIO 2 10/01/2018ANTINEOPLASTIC - ANTIANDROGENIC AGENTS ABIRATERONE ACET, SUBMICRONIZED 125MG TABLET YONSA 4 10/01/2018ANTINEOPLASTIC - ANTIANDROGENIC AGENTS ABIRATERONE ACETATE 250MG TABLET ZYTIGA 4 08/01/2014ANTINEOPLASTIC - ANTIANDROGENIC AGENTS ABIRATERONE ACETATE 500MG TABLET ZYTIGA 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ACALABRUTINIB 100MG CAPSULE CALQUENCE 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS AFATINIB DIMALEATE 20,30,40MG TABLET GILOTRIF 1 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ALECENSA 8 10/01/2018ANTINEOPLASTIC - AROMATASE INHIBITORS ARIMIDEX 1 10/01/2018ANTINEOPLASTIC - ANTIANDROGENIC AGENTS ERLEADA 4 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS AXITINIB 1 MG TABLET INLYTA 2 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS AXITINIB 5 MG TABLET INLYTA 4 08/01/2014ANTINEOPLASTIC - ANTIANDROGENIC AGENTS BICALUTAMIDE 50 MG TABLET CASODEX 3 10/01/2018ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS MEKTOVI 6 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS BOSUTINIB 100MG TABLET BOSULIF 4 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS BOSUTINIB 400 and 500MG TABLET BOSULIF 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS BRIGATINIB 30 MG TABLET ALUNBRIG 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS BRIGATINIB 90 & 180 MG TABLET and TABLET PACK ALUNBRIG 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CABOZANTINIB S-MALATE TABLETS CABOMETYX 30 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CABOZANTINIB S-MALATE 100 MG DAILY-DOSE PK COMETRIQ 14 1 Y 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CABOZANTINIB S-MALATE 140 MG DAILY DOSE PACK COMETRIQ 28 1 Y 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CABOZANTINIB S-MALATE 60 MG DAILY-DOSE PK 21 1 Y 10/01/2018ANTINEOPLASTIC - ANTIMETABOLITES CAPECITABINE 150MG TABLET XELODA 21 6 09/01/2014ANTINEOPLASTIC - ANTIMETABOLITES CAPECITABINE 500MG TABLET XELODA 21 5 09/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ZYKADIA ZYKADIA 1 10/01/2018ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS COBIMETINIB FUMARATE 20 MG TABLET COTELLIC 3 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CRIZOTINIB 200,250MG CAPSULE XALKORI 2 08/01/2014ANTINEOPLASTIC - ALKYLATING AGENTS CYCLOPHOSPHAMIDE 25 MG CAPSULE GENERIC ONLY 1 10/01/2018ANTINEOPLASTIC - BRAF KINASE INHIBITORS DABRAFENIB MESYLATE 50MG CAPSULE TAFINLAR 60 30 4 01/01/2019ANTINEOPLASTIC - BRAF KINASE INHIBITORS DABRAFENIB MESYLATE 75MG CAPSULE TAFINLAR 120 30 4 01/01/2019ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS DASATINIB 20MG TABLET SPRYCEL 2 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS DASATINIB 50,75,80,100,140MG TABLET SPRYCEL 1 08/01/2014ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INH ENASIDENIB MESYLATE TABLETS IDHIFA 1 10/01/2018ANTINEOPLASTIC - BRAF KINASE INHIBITORS ENCORAFENIB 50 MG CAPSULE BRAFTOVI 9 10/01/2018ANTINEOPLASTIC - BRAF KINASE INHIBITORS ENCORAFENIB 75 MG CAPSULE BRAFTOVI 6 10/01/2018ANTINEOPLASTIC - ANTIANDROGENIC AGENTS ENZALUTAMIDE 40MG CAPSULE XTANDI 4 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ERLOTINIB HCL 100,150MG TABLET TARCEVA 1 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ERLOTINIB HCL 25MG TABLET TARCEVA 3 08/01/2014ANTINEOPLASTIC - MTOR KINASE INHIBITORS EVEROLIMUS TABLETS and DISPERZ TABLETS AFINITOR DISPERZ 1 Y 10/01/2018ANTINEOPLASTIC - AROMATASE INHIBITORS AROMASIN 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS GEFITINIB 250 MG TABLET IRESSA 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS IBRUTINIB CAPSULES AND TABLETS IMBRUVICA 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS IDELALISIB 100, 150MG TABLET ZYDELIG 2 09/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS IMATINIB MESYLATE 100MG TABLET GLEEVEC 3 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS IMATINIB MESYLATE 400MG TABLET GLEEVEC 2 08/01/2014ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INH IVOSIDENIB 250 MG TABLET TIBSOVO 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS IXAZOMIB CITRATE 2.3 MG CAPSULE NINLARO 3 28 0.11 Y 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS LAPATINIB DITOSYLATE 250MG TABLET TYKERB 6 08/01/2014ANTINEOPLASTIC IMMUNOMODULATOR AGENTS LENALIDOMIDE 2.5, 5, 10 ,15, 20MG CAPSULES REVLIMID 1 08/01/2014ANTINEOPLASTIC IMMUNOMODULATOR AGENTS LENALIDOMIDE 25MG CAPSULE REVLIMID 25 30 1 28 09/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS LENVATINIB MESYLATE DAILY DOSE PACKS LENVIMA 30 1 03/25/2015CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM 5 MG TAB GENERIC ONLY 1 10/01/2018ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPRESSANT LEUPROLIDE ACETATE 1MG/0.2ML 2 WEEK KIT LUPRON DEPOT 1 14 Y 08/01/2014CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM 10, 15 AND 25 MG TAB GENERIC ONLY 2 10/01/2018ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPRESSANT LEUPROLIDE ACETATE 3.75MG KIT LUPRON DEPOT 1 30 Y 08/01/2014ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPRESSANT LEUPROLIDE ACETATE 3 MONTH KITS LUPRON DEPOT 1 90 90 Y 09/01/2014ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPRESSANT LEUPROLIDE ACETATE 30MG 4 MONTH KIT LUPRON DEPOT 1 120 120 Y 08/01/2014ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPRESSANT LEUPROLIDE ACETATE 45MG 6MONTH KIT LUPRON DEPOT 1 180 180 08/01/2014ANTINEOPLASTIC - ALKYLATING AGENTS LOMUSTINE CAPSULES GLEOSTINE 5 10/01/2018ANTINEOPLASTIC - STEROID ANTINEOPLASTICS MEGESTROL 20 MG TABLET GENERIC ONLY 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS MIDOSTAURIN 25MG CAPSULE RYDAPT 8 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS NERATINIB MALEATE 40MG TABLET NERLYNX 6 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS NILOTINIB HCL CAPSULES TASIGNA 4 08/01/2014ANTINEOPLASTIC - ANTIANDROGENIC AGENTS NILUTAMIDE 150 MG TABLET NILANDRON 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS NIRAPARIB TOSYLATE 100MG CAPSULE ZEJULA 3 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS OSIMERTINIB MESYLATE TABLETS TAGRISSO 30 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS PALBOCICLIB CAPSULES IBRANCE 1 03/25/2015ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS PANOBINOSTAT LACTATE CAPSULES FARYDAK 6 21 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS PAZOPANIB HCL 200MG TABLET VOTRIENT 4 08/01/2014ANTINEOPLASTIC IMMUNOMODULATOR AGENTS POMALIDOMIDE CAPSULES POMALYST 28 1 09/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS PONTANIB HCL 15MG TABLET ICLUSIG 2 03/25/2015ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS REGORAFENIB 40MG TABLET STIVARGA 28 4 28 09/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE 200MG DAILY DOSE KISQALI 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE 400MG DAILY DOSE KISQALI 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE 600MG DAILY DOSE KISQALI 3 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE/LETROZOLE 200MG CO PACK KISQALI FEMARA CO-PACK 49 30 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE/LETROZOLE 400MG CO PACK KISQALI FEMARA CO-PACK 70 30 3 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RIBOCICLIB SUCCINATE/LETROZOLE 600MG CO PACK KISQALI FEMARA CO-PACK 91 30 4 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RUCAPARIB CAMSYLATE 200 MG TABLET RUBRACA 2 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS RUCAPARIB CAMSYLATE 250 AND 300 MG TABLET RUBRACA 4 10/01/2018ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS RUXOLITINIB PHOSPHATE 10MG TABLET JAKAFI 1 08/01/2014ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS RUXOLITINIB PHOSPHATE 15, 20, 25MG TABLET JAKAFI 2 08/01/2014ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS RUXOLITINIB PHOSPHATE 5, 10MG TABLET JAKAFI 1 08/01/2014ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR SONIDEGIB PHOSPHATE 200MG CAPSULE ODOMZO 1 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS SORAFENIB TOSYLATE 200MG TABLET NEXAVAR 4 08/01/2014ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS SUNITINIB MALATE CAPSULES SUTENT 1 08/01/2014ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) TAMOXIFEN CITRATE 10MG TABLET GENERIC ONLY 1 10/01/2018



ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) TAMOXIFEN CITRATE 20 MG/10 ML SOLN SOLTAMOX 20 10/01/2018ANTINEOPLASTIC - ALKYLATING AGENTS TEMOZOLOMIDE 100, 140, 180, 250MG CAPSULE TEMODAR 2 08/01/2014ANTINEOPLASTIC - ALKYLATING AGENTS TEMOZOLOMIDE 20MG CAPSULE TEMODAR 4 08/01/2014ANTINEOPLASTIC - ALKYLATING AGENTS TEMOZOLOMIDE 250MG CAPSULE TEMODAR 1 08/01/2014ANTINEOPLASTIC - ALKYLATING AGENTS TEMOZOLOMIDE 5MG CAPSULE TEMODAR 3 08/01/2014ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS TOPOTECAN HCL CAPSULES HYCAMTIN 10 10/01/2018ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) TOREMIFENE CITRATE 60MG TABLET FARESTON 3 10/01/2018ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS TRAMETINIB DIMETHYL SULFOXIDE 0.5MG TABLET MEKINIST 30 3 01/01/2019ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS TRAMETINIB DIMETHYL SULFOXIDE 2MG TABLET MEKINIST 30 1 01/01/2019ANTINEOPLASTIC - ANTIMETABOLITES TRIFLURIDINE/TIPIRACIL HCL 15MG-6.14MG TABLET LONSURF 6 10/01/2018ANTINEOPLASTIC - ANTIMETABOLITES TRIFLURIDINE/TIPIRACIL HCL 20MG-8.19MG TABLET LONSURF 4 10/01/2018ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VANDETANIB 100, 300MG TABLET VANDETANIB 1 08/01/2014ANTINEOPLASTIC - BRAF KINASE INHIBITORS VEMURAFENIB 204MG TABLET ZELBORAF 8 08/01/2014ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS VENETOCLAX 100MG TABLET VENCLEXTA 30 4 10/01/2018ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS VENETOCLAX 10, 50 MG TABLETS VENCLEXTA 30 2 10/01/2018ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS VENETOCLAX STARTING PACK VENCLEXTA 42 999 10/01/2018ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR VISMODEGIB 150MG CAPSULE ERIVEDGE 1 08/01/2014ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS VORINOSTAT 100MG CAPSULE ZOLINZA 30 4 10/01/2018

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