yourcare health plan

Updated 08/25/17

1

YourCare Health Plan

Essential Health Plan

September 2017

Table of Contents

ANTI - INFECTIVES ........................................................................................................................................ 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ....................................................................... 8

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 12

CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 20

DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 24

DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 29

EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 31

ENDOCRINE/DIABETES .............................................................................................................................. 31

GASTROENTEROLOGY .............................................................................................................................. 37

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 41

MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 42

OBSTETRICS & GYNECOLOGY ................................................................................................................ 43

OPHTHALMOLOGY ..................................................................................................................................... 47

RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 49

UROLOGICALS .............................................................................................................................................. 52

VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 53

Index .................................................................................................................................................................. 60

2

List of Abbreviations

ACA: Affordable Care Act.

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

OTC: Over the Counter. An OTC drug is a non-prescription drug.

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

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

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

List of Tiers TIER # TIER DESCRIPTION Tier 1 Generics Tier 2 Preferred brands Tier 3 Non-preferred brands* Tier 4 Specialty (generics)

Tier 5 Specialty (preferred brands)

Tier 6 ACA/Preventative drugs (no copay required) *Tier 3 products are not listed on the formulary guidebook since these are non-preferred/non-formulary.

Updated 08/25/17

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

3

Drug Name Drug Tier

Requirements / Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

amphotericin b 1

CANCIDAS 2

clotrimazole 1

CRESEMBA 2

fluconazole in dextrose(iso-o)

1

fluconazole in nacl (iso-osm)

1

fluconazole oral suspension for reconstitution

1

fluconazole oral tablet 100 mg, 200 mg, 50 mg

1

fluconazole oral tablet 150 mg

1 QL

flucytosine 1

griseofulvin microsize

1

griseofulvin ultramicrosize

1

itraconazole 1 QL

ketoconazole 1

MYCAMINE 2

NOXAFIL 2

nystatin 1

SPORANOX 2

terbinafine hcl 1

voriconazole 1

ANTIVIRALS

Drug Name Drug Tier


abacavir 4 LA

abacavir-lamivudine 4

abacavir-lamivudine-zidovudine

4 LA

acyclovir 1

acyclovir sodium 1

adefovir 1

amantadine hcl 1

APTIVUS 5 LA

ATRIPLA 5 LA

BARACLUDE 2

cidofovir 1

COMPLERA 5 LA

CRIXIVAN 5 LA

DAKLINZA 5 PA; LA; QL

DESCOVY 5 LA

didanosine 4 LA

EDURANT 5 LA

EMTRIVA 5 LA

entecavir 1

EPCLUSA 5 PA; LA; QL

EPIVIR HBV 2

famciclovir oral tablet 125 mg, 250 mg, 500 mg

1 QL

foscarnet 1

FUZEON 5 LA

ganciclovir sodium 1

GENVOYA 5 LA

INTELENCE 5 LA


4

Drug Name Drug Tier


INVIRASE 5 LA

ISENTRESS 5 LA

KALETRA 5 LA

lamivudine oral solution

4 LA

lamivudine oral tablet 100 mg

1

lamivudine oral tablet 150 mg, 300 mg

4 LA

lamivudine-zidovudine

4 LA

LEXIVA 5 LA

lopinavir-ritonavir 4 LA

nevirapine 4 LA

NORVIR 5 LA

ODEFSEY 5 LA

OLYSIO 5 PA; LA; QL

oseltamivir oral capsule 30 mg, 45 mg, 75 mg

1 QL

PREZCOBIX 5 LA

PREZISTA 5 LA

RAPIVAB 2

RELENZA DISKHALER

2 QL

RESCRIPTOR 5 LA

RETROVIR 5 LA

REYATAZ 5 LA

ribavirin 1

rimantadine 1

SELZENTRY 5 PA; LA

stavudine 4 LA

Drug Name Drug Tier


STRIBILD 5 LA

SUSTIVA 5 LA

SYNAGIS 5 PA; LA

TAMIFLU 2 QL

TECHNIVIE 5 PA; LA; QL

TIVICAY 5 LA

TRIUMEQ 5 LA

TRUVADA 5 LA

valacyclovir 1 QL

valganciclovir 1

VEMLIDY 2

VIDEX 2 GRAM PEDIATRIC

5 LA

VIEKIRA PAK 5 PA; LA; QL

VIEKIRA XR 5 PA; LA; QL

VIRACEPT 5 LA

VIREAD 5 LA

ZEPATIER 5 PA; LA; QL

ZIAGEN 5 LA

zidovudine 4 LA

CEPHALOSPORINS

AVYCAZ 2

cefaclor 1

cefadroxil 1

cefazolin 1

cefazolin in dextrose (iso-os)

1

cefdinir 1

cefditoren pivoxil 1

cefepime 1

Updated 08/25/17


5

Drug Name Drug Tier


cefepime in dextrose,iso-osm

1

cefixime 1

cefotaxime 1

cefotetan 1

cefoxitin 1

cefoxitin in dextrose, iso-osm

1

cefpodoxime 1

cefprozil 1

ceftazidime 1

ceftibuten 1

ceftriaxone 1

ceftriaxone in dextrose,iso-os

1

cefuroxime axetil 1

cefuroxime sodium 1

cephalexin 1

ZERBAXA 2

ERYTHROMYCINS & OTHER MACROLIDES

azithromycin 1

clarithromycin 1

DIFICID 2

e.e.s. 400 1

E.E.S. GRANULES 2

ERYPED 200 2

ERYPED 400 2

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

Drug Name Drug Tier


ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate)

1

erythromycin 1

erythromycin ethylsuccinate

1

MISCELLANEOUS ANTIINFECTIVES

ALBENZA 2 QL

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

2 QL

ALINIA ORAL TABLET

2 QL

amikacin 1

atovaquone 1

atovaquone-proguanil

1

aztreonam 1

baciim 1

bacitracin 1

BILTRICIDE 2

CAYSTON 5 LA; QL

chloramphenicol sod succinate

1

chloroquine phosphate

1

cleocin 1

clindamycin hcl 1


6

Drug Name Drug Tier


clindamycin in 5 % dextrose

1

clindamycin palmitate hcl

1

clindamycin pediatric

1

clindamycin phosphate

1

COARTEM 2

colistin (colistimethate na)

1

CUBICIN RF 2

CYCLOSERINE 2

DALVANCE 2

dapsone 1

daptomycin 1

DARAPRIM 5 LA

EMVERM 2 QL

ethambutol 1

gentamicin 1

gentamicin in nacl (iso-osm)

1

gentamicin sulfate (ped) (pf)

1

gentamicin sulfate (pf)

1

hydroxychloroquine 1

imipenem-cilastatin 1

IMPAVIDO 2

isoniazid 1

ivermectin 1 QL

KITABIS PAK 5 LA; QL

lincomycin 1

Drug Name Drug Tier


linezolid intravenous 1

linezolid oral 1 PA

linezolid-0.9% sodium chloride

1

mefloquine 1

meropenem 1

MEROPENEM-0.9% SODIUM CHLORIDE

2

metro i.v. 1

metronidazole 1

metronidazole in nacl (iso-os)

1

NEBUPENT 2 QL

neomycin 1

ORBACTIV 2

paromomycin 1

PASER 2

polymyxin b sulfate 1

PRIFTIN 2

PRIMAQUINE 2

pyrazinamide 1

quinine sulfate 1

rifabutin 1

RIFAMATE 2

rifampin 1

RIFATER 2

SIRTURO 2

SIVEXTRO INTRAVENOUS

2

SIVEXTRO ORAL 2 PA

Updated 08/25/17


7

Drug Name Drug Tier


tinidazole oral tablet 250 mg

1

tinidazole oral tablet 500 mg

1 QL

tobramycin in 0.225 % nacl

4 LA; QL

tobramycin in 0.9 % nacl

1

tobramycin sulfate 1

TRECATOR 2

TYGACIL 2

XIFAXAN ORAL TABLET 200 MG, 550 MG

2 QL

ZYVOX 2

PENICILLINS

amoxicillin 1

amoxicillin-pot clavulanate

1

ampicillin 1

ampicillin sodium 1

ampicillin-sulbactam 1

AUGMENTIN 2

dicloxacillin 1

nafcillin 1

nafcillin in dextrose iso-osm

1

oxacillin 1

oxacillin in dextrose(iso-osm)

1

penicillin g potassium

1

penicillin g procaine 1

Drug Name Drug Tier


penicillin g sodium 1

penicillin v potassium

1

pfizerpen-g 1

piperacillin-tazobactam

1

QUINOLONES

AVELOX IN NACL (ISO-OSMOTIC)

2

ciprofloxacin 1

ciprofloxacin (mixture)

1

ciprofloxacin hcl 1

ciprofloxacin in 5 % dextrose

1

ciprofloxacin lactate 1

FACTIVE 2

levofloxacin 1

levofloxacin in d5w 1

moxifloxacin 1

MOXIFLOXACIN-SOD.ACE,SUL-WATER

2

ofloxacin 1

SULFA'S & RELATED AGENTS

sulfadiazine 1

sulfamethoxazole-trimethoprim

1

sulfatrim 1

TETRACYCLINES

avidoxy 1

demeclocycline 1

doxy-100 1


8

Drug Name Drug Tier


doxycycline hyclate 1

doxycycline monohydrate

1

minocycline 1

mondoxyne nl 1

morgidox 1

tetracycline 1

URINARY TRACT AGENTS

methenamine hippurate

1

methenamine mandelate

1

MONUROL 2

nitrofurantoin 1

nitrofurantoin macrocrystal

1

nitrofurantoin monohyd/m-cryst

1

trimethoprim 1

VANCOMYCIN

vancomycin 1

VANCOMYCIN IN 0.9% SODIUM CL

2

VANCOMYCIN IN DEXTROSE 5 %

2

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

amifostine crystalline

1

dexrazoxane hcl 1

ELITEK 2

Drug Name Drug Tier


KEPIVANCE 5 LA

leucovorin calcium 1

LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG

2

levoleucovorin intravenous recon soln 50 mg

1

levoleucovorin intravenous solution

1

mesna 1

MESNEX 2

VISTOGARD 5 LA

XGEVA 5 LA

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ABRAXANE 5 LA

ADCETRIS 5 LA

adriamycin 1

adrucil 1

AFINITOR 5 PA; LA

AFINITOR DISPERZ

5 PA; LA

ALECENSA 5 PA; LA; QL

ALIMTA 2

anastrozole 1

ARRANON 5 LA

ARZERRA 5 LA

AVASTIN 5 LA

azacitidine 4 LA

AZASAN 5 LA

azathioprine 4 LA

Updated 08/25/17


9

Drug Name Drug Tier


azathioprine sodium 4 LA

BAVENCIO 5 LA

BENDEKA 5 LA

bexarotene 4 LA

bicalutamide 1

BICNU 2

bleo 15k 1

bleomycin 1

BLINCYTO 5 LA

BOSULIF ORAL TABLET 100 MG, 500 MG

5 PA; LA; QL

busulfan 1

BUSULFEX 2

capecitabine 4 LA

CAPRELSA ORAL TABLET 100 MG, 300 MG

5 PA; LA; QL

carboplatin 1

CELLCEPT INTRAVENOUS

5 LA

cisplatin 1

cladribine 1

clofarabine 1

CLOLAR 2

COTELLIC 5 PA; LA; QL

cyclophosphamide intravenous

1

CYCLOPHOSPHAMIDE ORAL

2

cyclosporine 4 LA

cyclosporine modified

4 LA

Drug Name Drug Tier


CYRAMZA 5 LA

cytarabine 1

cytarabine (pf) 1

dacarbazine 1

DARZALEX 5 LA

daunorubicin 1

decitabine 4 LA

docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

1

DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML

2

doxorubicin 1

doxorubicin, peg-liposomal

1

DROXIA 2

ELIGARD 5 PA; LA

ELIGARD (3 MONTH)

5 PA; LA

ELIGARD (4 MONTH)

5 PA; LA

ELIGARD (6 MONTH)

5 PA; LA

EMCYT 2

epirubicin 1

ERBITUX 5 PA; LA


10

Drug Name Drug Tier


ERIVEDGE 5 PA; LA; QL

ETOPOPHOS 2

etoposide 1

exemestane 1

FARESTON 2

FASLODEX 2

floxuridine 1

fludarabine 1

fluorouracil 1

flutamide 1

FOLOTYN 5 LA

GAZYVA 5 LA

gemcitabine 1

gengraf 4 LA

GILOTRIF 5 PA; LA; QL

GLEOSTINE 2

HALAVEN 5 LA

HERCEPTIN 5 PA; LA

HEXALEN 2

HYCAMTIN 5 LA

hydroxyurea 1

IBRANCE 5 PA; LA; QL

ICLUSIG ORAL TABLET 15 MG, 45 MG

5 PA; LA; QL

idarubicin 1

ifosfamide 1

ifosfamide-mesna 1

imatinib oral tablet 100 mg, 400 mg

4 PA; LA; QL

IMBRUVICA 5 PA; LA; QL

Drug Name Drug Tier


INLYTA ORAL TABLET 1 MG, 5 MG

5 PA; LA; QL

IRESSA 5 LA; QL

irinotecan 1

ISTODAX 5 LA

IXEMPRA 5 LA

JAKAFI 5 PA; LA; QL

KADCYLA 5 PA; LA

KEYTRUDA 5 LA

KYPROLIS 5 LA

LARTRUVO 5 LA

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; LA

LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2)

5 ST; LA

letrozole 1

LEUKERAN 2

leuprolide 4 LA

lipodox 1

LONSURF 5 PA; LA

LUPRON DEPOT 5 PA; LA

LUPRON DEPOT (3 MONTH)

5 PA; LA

Updated 08/25/17


11

Drug Name Drug Tier


LUPRON DEPOT-PED

5 PA; LA

LUPRON DEPOT-PED (3 MONTH)

5 PA; LA

LYNPARZA 5 PA; LA

LYSODREN 2

MARQIBO 5 LA

MATULANE 5 LA

megestrol 1

MEKINIST ORAL TABLET 0.5 MG

5 ST; LA; QL

MEKINIST ORAL TABLET 2 MG

5 PA; LA; QL

melphalan 1

melphalan hcl 1

mercaptopurine 1

methotrexate sodium 1

methotrexate sodium (pf)

1

mitomycin 1

mitoxantrone 4 LA

MUSTARGEN 2

mycophenolate mofetil

4 LA

mycophenolate mofetil hcl

4 LA

mycophenolate sodium

4 LA

MYLERAN 2

NEXAVAR 5 PA; LA; QL

nilutamide 1

NINLARO 5 PA; LA; QL

NULOJIX 5 LA

Drug Name Drug Tier


octreotide acetate 4 LA

ONCASPAR 2

ONIVYDE 5 LA

OPDIVO 5 LA

oxaliplatin 1

paclitaxel 1

PERJETA 5 PA; LA

PHOTOFRIN 2

PROGRAF 5 LA

PURIXAN 5 LA

RAPAMUNE 5 LA

RITUXAN 5 PA; LA

RUBRACA ORAL TABLET 200 MG, 300 MG

5 PA; LA; QL

RUBRACA ORAL TABLET 250 MG

5 PA; LA

RYDAPT 5 PA; LA

SANDIMMUNE 5 LA

SANDOSTATIN LAR DEPOT

5 LA

SIGNIFOR 5 PA; LA

SIMULECT 5 LA

sirolimus 4 LA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

5 PA; LA; QL

STIVARGA 5 PA; LA; QL

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

5 PA; LA; QL


12

Drug Name Drug Tier


SYLVANT 5 LA

TABLOID 2

tacrolimus 4 LA

TAFINLAR 5 ST; LA; QL

TAGRISSO 5 PA; LA

tamoxifen 6 ACA

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

5 PA; LA; QL

TARGRETIN 5 LA

TASIGNA 5 PA; LA; QL

TECENTRIQ 5 LA

TEMODAR 5 LA

temozolomide 4 PA; LA

TENIPOSIDE 2

THALOMID 5 PA; LA

thiotepa 1

toposar 1

topotecan 4 LA

TORISEL 5 LA

TREANDA 5 LA

tretinoin (chemotherapy)

1

TREXALL 2

TRISENOX 2

TYKERB 5 PA; LA; QL

UNITUXIN 5 LA

VANTAS 5 LA

VECTIBIX 5 PA; LA

VELCADE 5 LA

VENCLEXTA 5 PA; LA

Drug Name Drug Tier


VENCLEXTA STARTING PACK

5 PA; LA; QL

vinblastine 1

vincasar pfs 1

vincristine 1

vinorelbine 1

VOTRIENT 5 PA; LA; QL

XALKORI 5 PA; LA; QL

XERMELO 5 PA; LA; QL

YERVOY 5 LA

YONDELIS 5 LA

ZANOSAR 2

ZEJULA 5 PA; LA; QL

ZELBORAF 5 PA; LA; QL

ZEVALIN (Y-90) 2

ZOLADEX 5 LA

ZOLINZA 5 LA

ZORTRESS 5 LA

ZYDELIG 5 PA; LA; QL

ZYKADIA 5 PA; LA; QL

ZYTIGA ORAL TABLET 250 MG, 500 MG

5 PA; LA; QL

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM 2

BANZEL 2

carbamazepine 1

CELONTIN 2

clonazepam 1

Updated 08/25/17


13

Drug Name Drug Tier


DILANTIN 2

DILANTIN EXTENDED

2

DILANTIN INFATABS

2

DILANTIN-125 2

divalproex 1

epitol 1

ethosuximide 1

felbamate 1

fosphenytoin 1

FYCOMPA 2

gabapentin 1

GABITRIL 2

lamotrigine 1

levetiracetam 1

levetiracetam in nacl (iso-os)

1

LYRICA 2 ST

ONFI 2

oxcarbazepine 1

PEGANONE 2

phenobarbital 1

phenytoin 1

phenytoin sodium 1

phenytoin sodium extended

1

primidone 1

roweepra 1

SABRIL 5 LA

tiagabine 1

Drug Name Drug Tier


topiramate 1

valproate sodium 1

valproic acid 1

valproic acid (as sodium salt)

1

VIMPAT 2

zonisamide 1

ANTIPARKINSONISM AGENTS

APOKYN 5 LA

benztropine 1

bromocriptine 1

carbidopa 1

carbidopa-levodopa 1

carbidopa-levodopa-entacapone

1

entacapone 1

pramipexole 1

rasagiline 1

ropinirole 1

selegiline hcl 1

tolcapone 1

trihexyphenidyl 1

MIGRAINE & CLUSTER HEADACHE THERAPY

almotriptan malate oral tablet 12.5 mg, 6.25 mg

1 QL

dihydroergotamine injection

1

dihydroergotamine nasal

1 QL

ERGOMAR 2


14

Drug Name Drug Tier


ergotamine-caffeine 1

frovatriptan 1 QL

isomethepten-caf-acetaminophen

1

migergot 1

naratriptan 1 QL

rizatriptan 1 QL

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

1 QL

sumatriptan succinate oral

1 QL

sumatriptan succinate subcutaneous

1 QL

zolmitriptan 1 QL

ZOMIG 2 ST; QL

MISCELLANEOUS NEUROLOGICAL THERAPY

AMPYRA 5 PA; LA; QL

donepezil oral tablet 10 mg, 5 mg

1

donepezil oral tablet 23 mg

1 ST

donepezil oral tablet,disintegrating

1

galantamine 1

memantine 1

NUEDEXTA 2 PA

RADICAVA 5 LA

rivastigmine 1

rivastigmine tartrate 1

Drug Name Drug Tier


tetrabenazine oral tablet 12.5 mg, 25 mg

4 PA; LA; QL

TYSABRI 5 PA; LA

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

baclofen 1

carisoprodol 1

chlorzoxazone 1

cyclobenzaprine 1

dantrolene 1

meprobamate 1

MESTINON 2

metaxall 1

metaxalone 1

methocarbamol 1

orphenadrine citrate 1

pyridostigmine bromide

1

regonol 1

revonto 1

tizanidine 1

NARCOTIC ANALGESICS

acetaminophen-caff-dihydrocod

1

acetaminophen-codeine

1

ascomp with codeine 1

aspirin-caffeine-dihydrocodein

1

astramorph-pf 1

buprenorphine hcl 1

Updated 08/25/17


15

Drug Name Drug Tier


butalbital compound w/codeine

1

butalbital-acetaminop-caf-cod

1

butalbital-acetaminophen

1

butalbital-acetaminophen-caff

1

butalbital-aspirin-caffeine

1

capacet 1

codeine sulfate 1

codeine-butalbital-asa-caff

1

diskets 1

duramorph (pf) 1

endocet 1

fentanyl 1

fentanyl citrate 1 PA; QL

fentanyl citrate (pf) 1

fentanyl citrate-0.9%nacl (pf)

1

hydrocodone-acetaminophen

1

hydrocodone-ibuprofen

1

hydromorphone (pf) 1

hydromorphone in 0.9 % nacl

1

hydromorphone injection

1

hydromorphone oral liquid

1

Drug Name Drug Tier


hydromorphone oral tablet

1

hydromorphone oral tablet extended release 24 hr

1 QL

hydromorphone rectal

1

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

2 ST; QL

ibuprofen-oxycodone 1

levorphanol tartrate 1

lorcet (hydrocodone) 1

lorcet hd 1

lorcet plus 1

marten-tab 1

meperidine 1

methadone 1

methadose 1

morphine (pf) 1

morphine (pf) in 0.9 % nacl

1

morphine concentrate

1

morphine injection 1

morphine intravenous

1

morphine oral capsule, er multiphase 24 hr

1 QL


16

Drug Name Drug Tier


morphine oral capsule,extend.release pellets

1 QL

morphine oral solution

1

morphine oral tablet 1

morphine oral tablet extended release

1 QL

morphine rectal 1

oxycodone 1

oxycodone-acetaminophen

1

oxycodone-aspirin 1

OXYCONTIN 2 ST; QL

oxymorphone oral tablet

1

oxymorphone oral tablet extended release 12 hr

1 QL

tencon 1

verdrocet 1

vicodin 1

vicodin es 1

vicodin hp 1

xylon 10 1

zamicet 1

zebutal 1

NON-NARCOTIC ANALGESICS

aspir-81 6 ACA; OTC

aspirin 6 ACA; OTC

aspirin low dose 6 ACA; OTC

aspir-low 6 ACA; OTC

aspir-trin 6 ACA; OTC

Drug Name Drug Tier


bayer aspirin 6 ACA; OTC

buprenorphine-naloxone

1 QL

butorphanol tartrate injection

1

butorphanol tartrate nasal

1 QL

celecoxib 1 ST

children's aspirin 6 ACA; OTC

choline,magnesium salicylate

1

diclofenac potassium 1

diclofenac sodium oral

1

diclofenac sodium topical drops

1 QL

diclofenac sodium topical gel

1 QL

diclofenac-misoprostol

1

diflunisal 1

e.c. prin 6 ACA; OTC

ecotrin 6 ACA; OTC

ecotrin low strength 6 ACA; OTC

etodolac 1

EUFLEXXA 5 LA

fenoprofen 1

flurbiprofen 1

ibuprofen 1

indomethacin 1

ketoprofen 1

ketorolac injection 1

Updated 08/25/17


17

Drug Name Drug Tier


ketorolac intramuscular

1

ketorolac oral 1 QL

lite coat aspirin 6 ACA; OTC

meclofenamate 1

mefenamic acid 1

meloxicam oral suspension

1

meloxicam oral tablet 15 mg

1

meloxicam oral tablet 7.5 mg

1 QL

nabumetone 1

nalbuphine 1

naloxone 1

naltrexone 1

naproxen 1

naproxen sodium 1

NARCAN 2 QL

NUCYNTA 2 QL

NUCYNTA ER 2 ST; QL

oxaprozin 1

piroxicam 1

salsalate 1

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

2 QL

sulindac 1

tolmetin 1

tramadol oral tablet 1 QL

Drug Name Drug Tier


tramadol oral tablet extended release 24 hr

1 QL

tramadol oral tablet, er multiphase 24 hr

1

tramadol-acetaminophen

1 QL

VIVITROL 5 LA

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

2 QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA

2

alprazolam 1

alprazolam intensol 1

amitriptyline 1

amitriptyline-chlordiazepoxide

1

amoxapine 1

aripiprazole oral solution

1

aripiprazole oral tablet

1 QL

aripiprazole oral tablet,disintegrating

1 QL

ARISTADA 2

armodafinil oral tablet 150 mg, 250 mg, 50 mg

1 ST

armodafinil oral tablet 200 mg

1 PA


18

Drug Name Drug Tier


atomoxetine 1

BELSOMRA 2 PA; QL

bupropion hcl oral tablet

1

bupropion hcl oral tablet extended release 12 hr

1 QL

bupropion hcl oral tablet extended release 24 hr

1 QL

buspirone 1

chlordiazepoxide hcl 1

chlorpromazine 1

citalopram oral solution

1

citalopram oral tablet

1 QL

clomipramine 1

clonidine hcl 1

clorazepate dipotassium

1

clozapine 1

desipramine 1

desvenlafaxine succinate

1 QL

dexedrine 1

dexmethylphenidate 1

dextroamphetamine 1

dextroamphetamine-amphetamine

1

diazepam 1

diazepam intensol 1

doxepin 1

Drug Name Drug Tier


duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg

1 QL

EMSAM 2

ergoloid 1

escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet

1 QL

estazolam 1 QL

eszopiclone 1 QL

FANAPT ORAL TABLET

2 QL

FANAPT ORAL TABLETS,DOSE PACK

2 QL

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

2 ST; QL

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

2 ST; QL

flumazenil 1

fluoxetine oral capsule 10 mg, 40 mg

1 QL

fluoxetine oral capsule 20 mg

1

fluoxetine oral capsule,delayed release(dr/ec)

1 QL

fluoxetine oral solution

1

Updated 08/25/17


19

Drug Name Drug Tier


fluoxetine oral tablet 10 mg

1 QL

fluoxetine oral tablet 20 mg

1

fluphenazine decanoate

1

fluphenazine hcl 1

flurazepam 1 QL

fluvoxamine oral capsule,extended release 24hr

1 QL

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg

1 QL

guanfacine 1

guanidine 1

haloperidol 1

haloperidol decanoate

1

haloperidol lactate 1

imipramine hcl 1

imipramine pamoate 1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

2 QL

lithium carbonate 1

lithium citrate 1

lorazepam 1

lorazepam intensol 1

loxapine succinate 1

maprotiline 1

MARPLAN 2

metadate er 1

Drug Name Drug Tier


methamphetamine 1

methylphenidate hcl 1

midazolam 1

mirtazapine 1

modafinil 1 PA

nefazodone 1

nortriptyline 1

olanzapine intramuscular

1

olanzapine oral 1 QL

olanzapine-fluoxetine

1

oxazepam 1

paliperidone 1 QL

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

1 QL

paroxetine hcl oral tablet extended release 24 hr

1 QL

perphenazine 1

perphenazine-amitriptyline

1

phenelzine 1

pimozide 1

procentra 1

protriptyline 1

quazepam 1 QL

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

1 QL


20

Drug Name Drug Tier


quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

1 QL

REXULTI 2 QL

RISPERDAL CONSTA

2

risperidone oral solution

1

risperidone oral tablet

1 QL

risperidone oral tablet,disintegrating

1 QL

ROZEREM 2 ST; QL

seconal sodium 1 QL

sertraline oral concentrate

1

sertraline oral tablet 100 mg, 25 mg, 50 mg

1 QL

temazepam 1 QL

thioridazine 1

thiothixene 1

tranylcypromine 1

trazodone 1

triazolam 1 QL

trifluoperazine 1

trimipramine 1

TRINTELLIX 2 ST; QL

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

1 QL

Drug Name Drug Tier


venlafaxine oral tablet

1 QL

venlafaxine oral tablet extended release 24hr

1 QL

VIIBRYD 2 ST; QL

VYVANSE 2 ST

XYREM 5 PA; LA

zaleplon 1 QL

zenzedi 1

ziprasidone hcl 1 QL

zolpidem 1 QL

CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone 1

disopyramide phosphate

1

dofetilide 1

flecainide 1

mexiletine 1

MULTAQ 2

pacerone 1

procainamide 1

propafenone 1

quinidine gluconate 1

quinidine sulfate 1

sotalol 1

sotalol af 1

SOTYLIZE 2

ANTIHYPERTENSIVE THERAPY

acebutolol 1

Updated 08/25/17


21

Drug Name Drug Tier


afeditab cr 1

amiloride 1

amiloride-hydrochlorothiazide

1

amlodipine 1

amlodipine-benazepril

1

amlodipine-olmesartan

1

amlodipine-valsartan

1

amlodipine-valsartan-hcthiazid

1

atenolol 1

atenolol-chlorthalidone

1

benazepril 1

benazepril-hydrochlorothiazide

1

betaxolol 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide 1

BYSTOLIC 2 ST

candesartan 1

candesartan-hydrochlorothiazid

1

captopril 1

captopril-hydrochlorothiazide

1

cartia xt 1

carvedilol 1

Drug Name Drug Tier


chlorothiazide 1

chlorothiazide sodium

1

chlorthalidone 1

clonidine 1 QL

clonidine hcl 1

clorpres 1

DEMSER 2

diltiazem 1

dilt-xr 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg

1 QL

DUTOPROL 2 ST

DYRENIUM 2

enalapril maleate 1

enalaprilat 1

enalapril-hydrochlorothiazide

1

eplerenone 1

epoprostenol (glycine)

4 LA

eprosartan 1

esmolol 1

ethacrynate sodium 1

ethacrynic acid 1

felodipine 1

fosinopril 1

fosinopril-hydrochlorothiazide

1

furosemide 1

guanfacine 1


22

Drug Name Drug Tier


hydralazine 1

hydrochlorothiazide 1

indapamide 1

irbesartan 1

irbesartan-hydrochlorothiazide

1

isradipine 1

labetalol 1

LEVATOL 2 ST

lisinopril 1

lisinopril-hydrochlorothiazide

1

losartan 1

losartan-hydrochlorothiazide

1

matzim la 1

methyclothiazide 1

methyldopa 1

methyldopa-hydrochlorothiazide

1

methyldopate 1

metolazone 1

metoprolol succinate 1

metoprolol ta-hydrochlorothiaz

1

metoprolol tartrate 1

minoxidil 1

moexipril 1

moexipril-hydrochlorothiazide

1

nadolol 1

nadolol-bendroflumethiazide

1

Drug Name Drug Tier


nicardipine 1

nifedipine 1

nimodipine 1

nisoldipine 1

olmesartan 1

olmesartan-amlodipin-hcthiazid

1

olmesartan-hydrochlorothiazide

1

papaverine 1

perindopril erbumine

1

phenoxybenzamine 1

phentolamine 1

pindolol 1

prazosin 1

propranolol 1

propranolol-hydrochlorothiazid

1

quinapril 1

quinapril-hydrochlorothiazide

1

ramipril 1

REMODULIN 5 LA

spironolactone 1

spironolacton-hydrochlorothiaz

1

taztia xt 1

telmisartan 1

telmisartan-amlodipine

1

telmisartan-hydrochlorothiazid

1

Updated 08/25/17


23

Drug Name Drug Tier


terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1 QL

timolol maleate 1

torsemide 1

trandolapril 1

trandolapril-verapamil

1

triamterene-hydrochlorothiazid

1

UPTRAVI 5 LA

valsartan 1

valsartan-hydrochlorothiazide

1

veletri 4 LA

verapamil 1

CARDIAC GLYCOSIDES

digitek 1

digox 1

digoxin 1

COAGULATION THERAPY

AMICAR 2

aminocaproic acid 1

ARGATROBAN IN NACL (ISO-OS)

2

aspirin-dipyridamole 1

bivalirudin 1

BRILINTA 2

CEPROTIN (BLUE BAR)

5 LA

CEPROTIN (GREEN BAR)

5 LA

cilostazol 1

Drug Name Drug Tier


clopidogrel 1

COAGADEX 5 LA

dipyridamole 1

EFFIENT 2

ELIQUIS 2 PA

enoxaparin 4 LA

fondaparinux 4 LA

FRAGMIN 5 LA

hep flush-10 (pf) 1

heparin (porcine) 1

heparin (porcine) in 5 % dex

1

heparin (porcine) in nacl (pf)

1

heparin flush(porcine)-0.9nacl

1

heparin lock flush 1

heparin lock flush (porcine)

1

heparin lockflush(porcine)(pf)

1

heparin(porcine) in 0.45% nacl

1

heparin, porcine (pf) 1

jantoven 1

MEPHYTON 2

NPLATE 5 PA; LA

pentoxifylline 1

PRADAXA 2 PA

PROMACTA 5 PA; LA

protamine 1


24

Drug Name Drug Tier


RIASTAP 5 LA

ticlopidine 1

tranexamic acid 1

vitamin k 1

vitamin k1 1

warfarin 1

XARELTO 2 PA

LIPID/CHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin

1 QL

atorvastatin 1 QL

cholestyramine (with sugar)

1

cholestyramine light 1

colestipol 1

ezetimibe 1

ezetimibe-simvastatin

1 QL

fenofibrate 1

fenofibrate micronized

1

fenofibrate nanocrystallized

1

fenofibric acid 1

fenofibric acid (choline)

1

fluvastatin oral capsule 20 mg, 40 mg

1 QL

fluvastatin oral tablet extended release 24 hr

1 QL

gemfibrozil 1

Drug Name Drug Tier


JUXTAPID 5 PA; LA

LIVALO 2 PA; QL

lovastatin oral tablet 10 mg, 20 mg, 40 mg

1 QL

niacin 1

omega-3 acid ethyl esters

1 PA

PRALUENT PEN 5 PA; LA; QL

pravastatin 1 QL

prevalite 1

REPATHA PUSHTRONEX

5 PA; LA; QL

REPATHA SURECLICK

5 PA; LA; QL

REPATHA SYRINGE

5 PA; LA; QL

rosuvastatin 1 QL

simvastatin 1 QL

VASCEPA 2 PA

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR 2

ENTRESTO 2 QL

NITRATES

isosorbide dinitrate 1

isosorbide mononitrate

1

nitro-bid 1

nitroglycerin 1

nitroglycerin in 5 % dextrose

1

DERMATOLOGICALS/TOPICAL THERAPY

Updated 08/25/17


25

Drug Name Drug Tier


ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 1

calcipotriene 1

calcipotriene-betamethasone

1

calcitrene 1

calcitriol 1

COAL TAR 2

COSENTYX 5 PA; LA

COSENTYX (2 SYRINGES)

5 PA; LA

COSENTYX PEN 5 PA; LA

COSENTYX PEN (2 PENS)

5 PA; LA

drithocreme hp 1

hydrocortisone-pramoxine

1

seb-prev 1

selenium sulfide 1

STELARA 5 PA; LA

sulfacetamide sodium

1

BURN THERAPY

silver sulfadiazine 1

ssd 1

thermazene 1

KERATOLYTICS

salicylic acid 1

salicylic acid er-ceramides

1

salvax 1

Drug Name Drug Tier


MISCELLANEOUS DERMATOLOGICALS

avo cream 1

bp-50% urea 1

celacyn 1

cem-urea 1

diclofenac sodium 1 PA; QL

doxepin 1 QL

DUPIXENT 5 PA; LA; QL

eletone 1

ELIDEL 2

emulsion sb 1

fluorouracil 1

hpr 1

hpr plus 1

hpr plus hydrogel 1

lactic acid 1

lactic acid e 1

luxamend 1

mb hydrogel 1

mb hydrogel (cyclomethicone)

1

methoxsalen 1

nivatopic plus 1

PANRETIN 2

PICATO 2

podofilox 1

pruclair 1

prudoxin 1 QL

prumyx 1

prutect 1


26

Drug Name Drug Tier


rea lo 39 1

rea lo 40 1

REGRANEX 2 QL

silver nitrate 1

silver nitrate applicators

1

sonafine 1

sp antipruritic 1

sp scar management 1

tacrolimus 1 QL

umecta 1

urea 1

urea nail stick 1

ure-k 1

UVADEX 2

VALCHLOR 5 LA

VEREGEN 2

THERAPY FOR ACNE

adapalene 1

amnesteem 1

avar 1

avita 1 PA

AZELEX 2 ST

benzepro 1

benzoyl peroxide 1

bp 10-1 1

bpo 1

claravis 1

cleansing wash 1

clindacin p 1

Drug Name Drug Tier



1

clindamycin-benzoyl peroxide

1

clindamycin-tretinoin

1

EPIDUO 2 ST

EPIDUO FORTE 2 ST

ery pads 1

erygel 1

erythromycin with ethanol

1

erythromycin-benzoyl peroxide

1

metronidazole 1

MIRVASO 2

neuac 1

rosadan 1

rosula cleansing cloths

1

SOOLANTRA 2 ST

ss 10-2 1

sss 10-5 1

sulfacetamide sodium-sulfur

1

sulfacetamide sod-sulfur-urea

1

sulfacetamide-sulfur-cleansr23

1

sulfacleanse 8-4 1

sulfact na-sul-avobnz-otn-ocsa

1

tazarotene 1 PA

TAZORAC 2 PA

Updated 08/25/17


27

Drug Name Drug Tier


tretinoin 1 PA

tretinoin microspheres

1 PA

VELTIN 2 PA

zenatane 1

TOPICAL ANESTHETICS

cidaleaze 1

dermacinrx prizopak 1

ethyl chloride 1

glydo 1 QL

lidocaine (pf) 1

lidocaine hcl injection

1

lidocaine hcl laryngotracheal

1

lidocaine hcl mucous membrane jelly

1 QL

lidocaine hcl mucous membrane jelly in applicator

1 QL

lidocaine hcl mucous membrane solution

1

lidocaine hcl topical 1

lidocaine hcl-hydrocortison ac

1

lidocaine topical adhesive patch,medicated

1 PA

lidocaine topical ointment

1 QL

lidocaine viscous 1

lidocaine-epinephrine

1

Drug Name Drug Tier


lidocaine-prilocaine topical cream

1 QL

lidocaine-prilocaine topical kit

1

lido-k 1

lidopin 1

lidopril 1

lta pre-attached 1

PLIAGLIS 2

relador pak 1

relador pak plus 1

TOPICAL ANTIBACTERIALS

CORTISPORIN 2

gentamicin 1

hydrocortisone-iodoquinol-aloe

1

iodoquinol-hc 1

lugols 1

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 2

sulfacetamide sodium (acne)

1

SULFAMYLON 2

TOPICAL ANTIFUNGALS

ciclodan topical cream

1 QL

ciclodan topical solution

1

ciclopirox topical cream

1 QL

ciclopirox topical gel

1 QL


28

Drug Name Drug Tier


ciclopirox topical shampoo

1 QL

ciclopirox topical solution

1

ciclopirox topical suspension

1 QL

ciclopirox-ure-camph-menth-euc

1

clotrimazole-betamethasone topical cream

1 QL

clotrimazole-betamethasone topical lotion

1 QL

econazole 1 QL

ERTACZO 2 QL

EXELDERM 2 QL

ketoconazole topical cream

1 QL

ketoconazole topical foam

1 QL

ketoconazole topical shampoo

1 QL

LUZU 2 QL

MENTAX 2 QL

naftifine 1 QL

nyamyc 1

nyata 1

nystatin topical cream

1 QL

nystatin topical ointment

1 QL

nystatin topical powder

1

Drug Name Drug Tier


nystatin-triamcinolone

1 QL

nystop 1

oxiconazole 1 QL

TRIACETIN 2

TOPICAL ANTIVIRALS

ABREVA 2 OTC

acyclovir 1 PA; QL

DENAVIR 2

ZOVIRAX 2 QL

TOPICAL CORTICOSTEROIDS

ala-cort 1

alclometasone 1

amcinonide 1

apexicon e 1

betamethasone dipropionate

1

betamethasone valerate

1

betamethasone, augmented

1

clobetasol scalp 1 QL

clobetasol topical cream

1 QL

clobetasol topical foam

1 QL

clobetasol topical gel

1 QL

clobetasol topical lotion

1 QL

clobetasol topical ointment

1 QL

clobetasol topical shampoo

1 QL

Updated 08/25/17


29

Drug Name Drug Tier


clobetasol topical spray,non-aerosol

1 QL

clobetasol-emollient topical cream

1 QL

clobetasol-emollient topical foam

1 QL

clodan 1 QL

CORDRAN 2 ST

CORDRAN TAPE LARGE ROLL

2 ST

cormax 1 QL

desonide 1

desoximetasone 1

diflorasone 1

fluocinolone 1

fluocinolone and shower cap

1

fluocinonide 1 QL

fluocinonide-e 1 QL

flurandrenolide 1

fluticasone 1

halobetasol propionate

1

HALOG 2 ST

hydrocortisone 1

hydrocortisone butyrate

1

hydrocortisone butyr-emollient

1

hydrocortisone valerate

1

hydrocortisone-min oil-wht pet

1

Drug Name Drug Tier


mometasone 1

nolix 1

prednicarbate 1

scalacort 1

triamcinolone acetonide

1

trianex 1

triderm 1

TOPICAL ENZYMES

SANTYL 2

TOPICAL SCABICIDES / PEDICULICIDES

EURAX 2

lindane 1

malathion 1

permethrin 1

spinosad 1

ULESFIA 2

DIAGNOSTICS & MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers 1

neomycin-polymyxin b gu

1

ringer's 1

tis-u-sol pentalyte 1

MISCELLANEOUS AGENTS

acamprosate 1

acetic acid 1

ADAGEN 5 LA

alendronate 1 QL


30

Drug Name Drug Tier


anagrelide 1

ARALAST NP 5 PA; LA

BUPHENYL 2

caffeine citrate 1

CARBAGLU 5 LA

cevimeline 1

CHEMET 2

curity sterile water 1 OTC; QL

disulfiram 1

etidronate disodium 1

EXJADE 5 LA

FERRIPROX 5 LA

INCRELEX 5 PA; LA

JADENU 5 LA

levocarnitine 1

levocarnitine (with sugar)

1

midodrine 1

ORFADIN 5 LA

pilocarpine hcl 1

PROLASTIN-C 5 PA; LA

RAVICTI 5 LA

riluzole 1

risedronate 1 QL

sodium benzoate-sod phenylacet

1

sodium chlor 0.9% bacteriostat

1

sodium chloride 1

sodium chloride 0.9 %

1

Drug Name Drug Tier


sodium ferric gluconat-sucrose

1

sodium phenylbutyrate

1

SOLIRIS 5 LA

water for irrigation, sterile

1 QL

XURIDEN 5 LA

ZEMAIRA 5 PA; LA

zoledronic acid-mannitol-water

4 PA; LA

SMOKING DETERRENTS

bupropion hcl (smoking deter)

6 ACA; QL

CHANTIX 6 ACA; QL

CHANTIX CONTINUING MONTH BOX

6 ACA; QL

CHANTIX STARTING MONTH BOX

6 ACA; QL

NICODERM CQ 6 ACA; OTC; QL

nicorelief 6 ACA; OTC; QL

NICORETTE BUCCAL GUM 2 MG

6 ACA; OTC; QL

nicorette buccal gum 4 mg

6 ACA; OTC; QL

NICORETTE BUCCAL LOZENGE

6 ACA; OTC; QL

NICORETTE BUCCAL MINI LOZENGE

6 ACA; OTC; QL

Updated 08/25/17


31

Drug Name Drug Tier


nicotine 6 ACA; OTC; QL

nicotine (polacrilex) 6 ACA; OTC; QL

NICOTROL 6 ACA; QL

NICOTROL NS 6 ACA; QL

nts step 1 6 ACA; OTC; QL

quit 2 buccal gum 6 ACA; OTC; QL

QUIT 2 BUCCAL LOZENGE

6 ACA; OTC; QL

quit 4 buccal gum 6 ACA; OTC; QL

QUIT 4 BUCCAL LOZENGE

6 ACA; OTC; QL

stop smoking aid 6 ACA; OTC; QL

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal aerosol,spray

1 QL

azelastine nasal spray,non-aerosol

1

BACTROBAN NASAL

2

chlorhexidine gluconate

1

DEBACTEROL 2

denta 5000 plus 1

dentagel 1

fluoride (sodium) 1

ipratropium bromide 1 QL

Drug Name Drug Tier


olopatadine 1 QL

oralone 1

paroex oral rinse 1

periogard 1

pilocarpine hcl 1

sf 1

sf 5000 plus 1


1

MISCELLANEOUS OTIC PREPARATIONS

acetic acid 1

acetic acid-aluminum acetate

1

ciprofloxacin hcl 1

floxin 1

fluocinolone acetonide oil

1

hydrocortisone-acetic acid

1

ofloxacin 1

OTIC STEROID / ANTIBIOTIC

CIPRO HC 2

CIPRODEX 2

neomycin-polymyxin-hc

1

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. 5 PA; LA

betamethasone acet,sod phos

1

cortisone 1


32

Drug Name Drug Tier


cosyntropin 1

deltasone 1

dexamethasone 1

dexamethasone intensol

1

dexamethasone sodium phos (pf)

1

dexamethasone sodium phosphate

1

fludrocortisone 1

hydrocortisone 1

methylprednisolone 1

methylprednisolone acetate

1

millipred 1

millipred dp 1

prednisolone 1

prednisolone sodium phosphate

1

prednisone 1

prednisone intensol 1


1

veripred 20 1

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES

FREESTYLE INSULINX

2 OTC; QL

FREESTYLE INSULINX TEST STRIPS

2 OTC; QL

Drug Name Drug Tier


FREESTYLE LITE STRIPS

2 OTC; QL

FREESTYLE TEST 2 OTC; QL

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT

ACE AEROSOL CLOUD ENHANCER

2 QL

AEROCHAMBER MINI

2 QL

AEROCHAMBER PLUS FLOW-VU

2 QL

AEROCHAMBER PLUS Z STAT SM MSK

2 QL

AEROTRACH PLUS

2 QL

AEROVENT PLUS 2 QL

BREATHERITE WITH MASK, SMALL

2 QL

CLEVER CHOICE CHAMBER-SM MASK

2 QL

COMPACT SPACE CHAMBER-LRG MASK

2 QL

EASIVENT HOLDING CHAMBER

2 QL

E-Z SPACER 2 QL

FLEXICHAMBER 2 QL

INSPIRACHAMBER WITH MASK-LARGE

2 QL

Updated 08/25/17


33

Drug Name Drug Tier


INSULIN SYRINGE-NEEDLE U-100

2

LITEAIRE MDI CHAMBER

2 QL

MICROCHAMBER 2 QL

MICROSPACER 2 QL

OPTICHAMBER DIAMOND LG MASK

2 QL

POCKET CHAMBER

2 QL

PRIMEAIRE 2 QL

PROCHAMBER 2 QL

RITEFLO AEROCHAMBER

2 QL

VORTEX HOLDING CHAMBER CHILD

2 QL

VORTEX VHC FROG MASK-CHILD

2 QL

VORTEX VHC LADYBUG MASK-TODDLR

2 QL

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT

2

GLUCAGON EMERGENCY KIT (HUMAN)

2

PROGLYCEM 2

INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU

Drug Name Drug Tier


AUTOJECT 2 INJECTION DEVICE

2 OTC

AUTOPEN 1 TO 21 UNITS

2 OTC

CARTRIDGE STAMPED IR 1200

2 OTC

CLEO 90 INFUSION SET 24"

2 QL

COMFORT INFUSION SET 43"

2 QL

COMFORT SHORT INSULIN PUMP 23"

2 QL

CONTACT DETACH INFUS SET 23"

2 QL

FREESTYLE CONTROL

2 OTC

FREESTYLE FLASH SYSTEM

2 OTC

FREESTYLE FREEDOM

2 OTC

FREESTYLE FREEDOM LITE

2 OTC

FREESTYLE INSULINX

2 OTC

FREESTYLE LITE METER

2 OTC

FREESTYLE SIDEKICK II

2 OTC

FREESTYLE SYSTEM KIT

2 OTC

HUMAPEN LUXURA HD

2


34

Drug Name Drug Tier


INSET 30 INFUSION SET 23"

2 QL

INSET INFUSION SET 23"

2 QL

LANCETS 2 OTC; QL

LANCING DEVICE 2 OTC

MINIMED INFUSION SET-MMT 390

2 QL

MIO INFUSION SET

2 QL

OMNIPOD INSULIN REFILL

2

PEN NEEDLE 2 OTC

QUICK-SET PARADIGM

2 QL

SAFE-CLIP BY MAIL

2 OTC

SNAP INSULIN PUMP-INFUSION SET

2

SURE-T PARADIGM

2 QL

T:30 INFUSION SET

2 QL

T:90 INFUSION SET 23"

2 QL

T:SLIM 2

T:SLIM G4 2

VGO 20 2

VGO 30 2

VGO 40 2

INSULIN THERAPY

APIDRA 2

Drug Name Drug Tier


APIDRA SOLOSTAR

2

BASAGLAR KWIKPEN

2

HUMALOG 2

HUMALOG KWIKPEN

2

HUMALOG MIX 50-50

2

HUMALOG MIX 50-50 KWIKPEN

2

HUMALOG MIX 75-25

2

HUMALOG MIX 75-25 KWIKPEN

2

HUMULIN 70/30 2

HUMULIN 70/30 KWIKPEN

2

HUMULIN N 2

HUMULIN N KWIKPEN

2

HUMULIN R U-100 2

HUMULIN R U-500 (CONC) KWIKPEN

2

HUMULIN R U-500 (CONCENTRATED)

2

LANTUS 2

LANTUS SOLOSTAR

2

LEVEMIR 2

LEVEMIR FLEXTOUCH

2

NOVOLOG 2

Updated 08/25/17


35

Drug Name Drug Tier


NOVOLOG FLEXPEN

2

NOVOLOG MIX 70-30

2

NOVOLOG MIX 70-30 FLEXPEN

2

NOVOLOG PENFILL

2

RELION NOVOLIN 70/30

2

RELION NOVOLIN N

2

RELION NOVOLIN R

2

MISCELLANEOUS HORMONES

ALDURAZYME 5 LA

ANADROL-50 2

androxy 1

BRINEURA 5 LA

cabergoline 1 QL

calcitonin (salmon) 1

calcitriol 1

CERDELGA 5 LA

danazol 1

desmopressin 1

doxercalciferol 1

ELAPRASE 5 LA

ELELYSO 5 LA

FABRAZYME 5 LA

HECTOROL 2

KANUMA 5 LA

KUVAN 5 PA; LA

Drug Name Drug Tier


LUMIZYME 5 LA

METHITEST 2

methyltestosterone 1

MYALEPT 5 PA; LA

NAGLAZYME 5 LA

NATPARA 5 PA; LA

oxandrolone 1

pamidronate 1

paricalcitol 1

SAMSCA ORAL TABLET 15 MG, 30 MG

5 PA; LA; QL

SENSIPAR 2

SOMAVERT 5 LA

STIMATE 5 LA

STRENSIQ 5 LA

SYNAREL 2

TESTOPEL 5 PA; LA

testosterone 1 PA

testosterone cypionate

1 PA

testosterone enanthate

1 PA

VIMIZIM 5 LA

VPRIV 5 LA

ZAVESCA 5 LA

zoledronic acid 4 LA

ZOMETA 5 LA

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose 1


36

Drug Name Drug Tier


ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG

2 QL

BYDUREON 2 QL

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML

2 QL

chlorpropamide 1

FARXIGA 2 ST; QL

glimepiride 1

glipizide 1

glipizide-metformin 1

glyburide 1

glyburide micronized

1

glyburide-metformin 1

GLYXAMBI 2 ST; QL

INVOKAMET 2 QL

INVOKANA 2 QL

JANUMET 2 QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG

2 QL

JANUVIA ORAL TABLET 100 MG

2 QL

Drug Name Drug Tier


JANUVIA ORAL TABLET 25 MG, 50 MG

2 ST; QL

JARDIANCE 2 ST; QL

JENTADUETO 2 QL

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG

2 ST; QL

metformin 1

miglitol 1

nateglinide 1

pioglitazone 1 QL

pioglitazone-glimepiride

1 QL

pioglitazone-metformin

1 QL

repaglinide 1

repaglinide-metformin

1 QL

SYMLINPEN 120 2 QL

SYMLINPEN 60 2 QL

SYNJARDY 2 QL

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG

2 QL

TANZEUM 2 QL

tolazamide 1

tolbutamide 1

TRADJENTA 2 QL

Updated 08/25/17


37

Drug Name Drug Tier


VICTOZA 2-PAK 2 QL

VICTOZA 3-PAK 2 QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG

2 ST; QL

THYROID HORMONES

ARMOUR THYROID

2

levothyroxine 1

levoxyl 1

liothyronine 1

nature-throid 1

np thyroid 1

SYNTHROID 2

THYROLAR-1 2

THYROLAR-1/2 2

THYROLAR-1/4 2

THYROLAR-2 2

THYROLAR-3 2

unithroid 1

westhroid 1

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz 1

atropine 1

belladonna alkaloids-opium

1

belladonna-opium 1

Drug Name Drug Tier


bismuth 1 OTC

chlordiazepoxide-clidinium

1

dicyclomine 1

diphenoxylate-atropine

1

ed-spaz 1

glycopyrrolate 1

hyoscyamine sulfate 1

hyosyne 1

loperamide 1 OTC

methscopolamine 1

MOTOFEN 2

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenohytro 1

symax fastabs 1

symax-sl 1

symax-sr 1

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO 2 QL

alophen 6 ACA; OTC

alosetron 1

ALOXI 2 QL

AMITIZA 2

aprepitant oral capsule 125 mg, 40 mg, 80 mg

1 QL


38

Drug Name Drug Tier


aprepitant oral capsule,dose pack

1 QL

APRISO 2

balsalazide 1

bisacodyl 6 ACA; OTC

bisa-lax 6 ACA; OTC

budesonide 1

calcium acetate 1

CANASA 2

CESAMET 2 QL

CHENODAL 5 PA; LA

CHOLBAM ORAL CAPSULE 250 MG

5 LA

CHOLBAM ORAL CAPSULE 50 MG

5 LA; QL

citrate of magnesia 6 ACA; OTC

citroma 6 ACA; OTC

clearlax 6 ACA; OTC

colocort 1

compro 1

constulose 1

CORTIFOAM 2

CREON 2

cromolyn 1

CYSTADANE 5 LA

dimenhydrinate 1

DIPENTUM 2

dronabinol 1

droperidol 1

ducodyl 6 ACA; OTC

eliphos 1

Drug Name Drug Tier


EMEND INTRAVENOUS

2 QL

EMEND ORAL CAPSULE

2 QL

EMEND ORAL SUSPENSION FOR RECONSTITUTION

2 QL

ENTYVIO 5 PA; LA

enulose 1

fleet laxative 6 ACA; OTC

FOSRENOL 2

gavilax 6 ACA; OTC

gavilyte-c 6 ACA

gavilyte-g 6 ACA

gavilyte-n 6 ACA

generlac 1

gentle laxative 6 ACA; OTC

gentlelax 6 ACA; OTC

glycolax 6 ACA; OTC

granisetron (pf) 1

granisetron hcl intravenous

1

granisetron hcl oral 1 QL

healthylax 6 ACA; OTC

hemmorex-hc 1

hydrocortisone 1

hydrocortisone acetate

1

hydrocortisone-pramoxine

1

INFLECTRA 5 PA; LA

kionex 1

Updated 08/25/17


39

Drug Name Drug Tier


kionex (with sorbitol)

1

lactulose 1

laxaclear 6 ACA; OTC

laxative (bisacodyl) 6 ACA; OTC

laxative feminine 6 ACA; OTC

laxative peg 3350 6 ACA; OTC

lidocaine hcl-hydrocortison ac

1

lidocaine-hydrocortisone-aloe

1

LINZESS 2

MAGNEBIND 300 2 OTC

magnesium citrate 6 ACA; OTC

mesalamine 1

mesalamine with cleansing wipe

1

metoclopramide hcl 1

milk of magnesia 6 ACA; OTC

milk of magnesia concentrated

6 ACA; OTC

miralax 6 ACA; OTC

MOVANTIK 2

MOVIPREP 6 ACA

natura-lax 6 ACA; OTC

OCALIVA 5 PA; LA; QL

ondansetron 1 QL

ondansetron hcl (pf) 1

ondansetron hcl intravenous

1

ondansetron hcl oral solution

1 QL

Drug Name Drug Tier


ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

1 QL

oral saline laxative 6 ACA; OTC

peg 3350-electrolytes

6 ACA

peg3350 6 ACA; OTC

peg-electrolyte soln 6 ACA

peg-prep 6 ACA

PENTASA 2

phosphate laxative 6 ACA; OTC

polyethylene glycol 3350

6 ACA

powderlax 6 ACA; OTC

pramcort 1

PREPOPIK 6 ACA

prochlorperazine 1

prochlorperazine edisylate

1

prochlorperazine maleate

1

procto-med hc 1

procto-pak 1

proctosol hc 1

proctozone-hc 1

purelax 6 ACA; OTC

RECTIV 2

RELISTOR 2

REMICADE 5 PA; LA

RENVELA 2

sevelamer carbonate 1

smoothlax 6 ACA; OTC


40

Drug Name Drug Tier


sodium polystyrene sulfonate

1

sps (with sorbitol) 1

SUCRAID 5 LA

sulfasalazine 1

SUPREP BOWEL PREP KIT

6 ACA

trilyte with flavor packets

6 ACA

trimethobenzamide 1

UCERIS 2

ursodiol 1

VARUBI 2 QL

VELPHORO 2

VELTASSA 2 LA

VIBERZI 2

VIOKACE 2

woman's laxative 6 ACA; OTC

women's gentle laxative(bisac)

6 ACA; OTC

women's laxative (bisacodyl)

6 ACA; OTC

ULCER THERAPY

amoxicil-clarithromy-lansopraz

1 QL

CARAFATE 2

cimetidine 1

cimetidine hcl 1

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

1 QL

Drug Name Drug Tier


esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

1

esomeprazole sodium

1

famotidine 1

famotidine (pf) 1

famotidine (pf)-nacl (iso-os)

1

lansoprazole 1

misoprostol 1

nizatidine 1

omeprazole magnesium

1 OTC

omeprazole oral capsule,delayed release(dr/ec) 10 mg

1 QL

omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg

1

omeprazole oral tablet,delayed release (dr/ec)

1 OTC

omeprazole-sodium bicarbonate oral capsule

1 ST

omeprazole-sodium bicarbonate oral packet 20-1,680 mg

1 ST; QL

omeprazole-sodium bicarbonate oral packet 40-1,680 mg

1 ST

pantoprazole intravenous

1

Updated 08/25/17


41

Drug Name Drug Tier


pantoprazole oral tablet,delayed release (dr/ec) 20 mg

1 QL

pantoprazole oral tablet,delayed release (dr/ec) 40 mg

1

rabeprazole 1

ranitidine hcl 1

sucralfate 1

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN POLYSORBATE)

5 LA

GRANIX 5 LA

LEUKINE 5 LA

MOZOBIL 5 LA

NEULASTA 5 PA; LA; QL

NEUPOGEN 5 PA; LA

PROCRIT 5 LA

ZARXIO 5 LA

GROWTH HORMONES

EGRIFTA 5 PA; LA

OMNITROPE 5 PA; LA

INTERFERONS

AVONEX (WITH ALBUMIN)

5 PA; LA; QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA; LA; QL

Drug Name Drug Tier


AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA; LA; QL

EXTAVIA 5 PA; LA; QL

GILENYA 5 PA; LA

glatopa 4 PA; LA; QL

LEMTRADA 5 LA

moderiba 4 PA; LA

moderiba dose pack 4 PA; LA

OCREVUS 5 PA; LA

PEGASYS PROCLICK

5 PA; LA; QL

PEGASYS SUBCUTANEOUS SOLUTION

5 PA; LA; QL

PEGASYS SUBCUTANEOUS SYRINGE

5 PA; LA; QL

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

5 PA; LA; QL

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

5 PA; LA; QL

POMALYST 5 LA

REBIF (WITH ALBUMIN)

5 PA; LA; QL


42

Drug Name Drug Tier


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; LA; QL

REBIF TITRATION PACK

5 PA; LA; QL

REVLIMID 5 PA; LA

ribasphere 4 PA; LA

ribasphere ribapak 4 PA; LA

ribavirin oral capsule

4 PA; LA

ribavirin oral tablet 4 ST; LA

SYLATRON 5 LA

TECFIDERA 5 PA; LA

INTERLEUKINS

ACTIMMUNE 5 LA

ALFERON N 2

ARCALYST 5 PA; LA

ILARIS (PF) 5 PA; LA

imiquimod 1

INTRON A 5 LA

KINERET 5 PA; LA

PROLEUKIN 5 LA

VACCINES & MISCELLANEOUS IMMUNOLOGICALS

BOTOX 5 PA; LA

FLUBLOK 2017-2018 (PF)

6 ACA

FLUBLOK QUAD 2017-2018 (PF)

6 ACA

PNEUMOVAX 23 6 ACA

Drug Name Drug Tier


PREVNAR 13 (PF) 6 ACA

PROVENGE 5 LA

ZOSTAVAX (PF) 6 ACA

MUSCULOSKELETAL & RHEUMATOLOGY

GOUT THERAPY

allopurinol 1

allopurinol sodium 1

aloprim 1

COLCRYS 2

KRYSTEXXA 5 PA; LA

MITIGARE 2

probenecid 1

probenecid-colchicine

1

ULORIC 2 ST

OSTEOPOROSIS THERAPY

alendronate oral solution

1 QL

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1 QL

FORTEO 5 PA; LA; QL

FOSAMAX PLUS D

2 ST; QL

ibandronate intravenous

4 PA; LA

ibandronate oral 1 QL

raloxifene 6 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg

1 QL

Updated 08/25/17


43

Drug Name Drug Tier


risedronate oral tablet,delayed release (dr/ec)

1 QL

TYMLOS 5 PA; LA; QL

OTHER RHEUMATOLOGICALS

ACTEMRA INTRAVENOUS

5 PA; LA

ACTEMRA SUBCUTANEOUS

5 ST; LA

BENLYSTA 5 LA

DEPEN TITRATABS

2

ENBREL SUBCUTANEOUS RECON SOLN

5 PA; LA; QL

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

5 PA; LA; QL

ENBREL SURECLICK

5 ST; LA; QL

HUMIRA 5 PA; LA; QL

HUMIRA PEDIATRIC CROHN'S START

5 ST; LA; QL

HUMIRA PEN CROHN'S-UC-HS START

5 ST; LA; QL

HUMIRA PEN PSORIASIS-UVEITIS

5 ST; LA; QL

leflunomide 1 QL

ORENCIA 5 PA; LA

OTEZLA 5 PA; LA

Drug Name Drug Tier


OTEZLA STARTER

5 PA; LA

RIDAURA 2

SAVELLA ORAL TABLET

2 ST; QL

SAVELLA ORAL TABLETS,DOSE PACK

2 ST; QL

SIMPONI 5 PA; LA

OBSTETRICS & GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED

6 ACA

FC2 FEMALE CONDOM

6 ACA; OTC; QL

FEMCAP 6 ACA

MIRENA 6 ACA; LA

PARAGARD T 380A

6 ACA; LA

WIDE-SEAL DIAPHRAGM

6 ACA

ESTROGENS & PROGESTINS

amabelz 1

camila 6 ACA

CRINONE 2

deblitane 6 ACA

DEPO-PROVERA 2

DUAVEE 2

errin 6 ACA

ESTRACE 2

estradiol oral 1


44

Drug Name Drug Tier


estradiol transdermal patch semiweekly

1 QL

estradiol transdermal patch weekly

1 QL

estradiol valerate 1

estradiol-norethindrone acet

1

estropipate 1

fyavolv 1

heather 6 ACA

hydroxyprogesterone caproate

1

jencycla 6 ACA

jevantique lo 1

jinteli 1

jolivette 6 ACA

lopreeza 1

lyza 6 ACA

MAKENA 5 PA; LA

medroxyprogesterone intramuscular

6 ACA; QL

medroxyprogesterone oral

1

MENEST 2

mimvey 1

mimvey lo 1

nora-be 6 ACA

norethindrone (contraceptive)

6 ACA

norethindrone acetate

1

Drug Name Drug Tier


norethindrone ac-eth estradiol

1

norlyda 6 ACA

norlyroc 6 ACA

progesterone micronized

1

sharobel 6 ACA

yuvafem 1

MISCELLANEOUS OB/GYN


1

fem ph 1

GYNAZOLE-1 2

gynol ii 6 ACA; OTC

isoxsuprine 1

metronidazole 1

miconazole-3 1

NEXPLANON 6 ACA; LA

NUVARING 6 ACA

OSPHENA 2

terconazole 1

tranexamic acid 1

vaginal contraceptive foam

6 ACA; OTC

vandazole 1

xulane 6 ACA

ORAL CONTRACEPTIVES & RELATED AGENTS

altavera (28) 6 ACA

alyacen 1/35 (28) 6 ACA

alyacen 7/7/7 (28) 6 ACA

amethia 6 ACA

Updated 08/25/17


45

Drug Name Drug Tier


amethia lo 6 ACA

amethyst 6 ACA

apri 6 ACA

aranelle (28) 6 ACA

ashlyna 6 ACA

aubra 6 ACA

aviane 6 ACA

azurette (28) 6 ACA

balziva (28) 6 ACA

bekyree (28) 6 ACA

blisovi 24 fe 6 ACA

blisovi fe 1.5/30 (28) 6 ACA

blisovi fe 1/20 (28) 6 ACA

briellyn 6 ACA

camrese 6 ACA

camrese lo 6 ACA

caziant (28) 6 ACA

chateal 6 ACA

cryselle (28) 6 ACA

cyclafem 1/35 (28) 6 ACA

cyclafem 7/7/7 (28) 6 ACA

cyred 6 ACA

dasetta 1/35 (28) 6 ACA

dasetta 7/7/7 (28) 6 ACA

daysee 6 ACA

delyla (28) 6 ACA

desog-e.estradiol/e.estradiol

6 ACA

desogestrel-ethinyl estradiol

6 ACA

Drug Name Drug Tier


drospirenone-e.estradiol-lm.fa

6 ACA

drospirenone-ethinyl estradiol

6 ACA

econtra ez 6 ACA; OTC; QL

elinest 6 ACA

ELLA 6 ACA; QL

emoquette 6 ACA

enpresse 6 ACA

enskyce 6 ACA

estarylla 6 ACA

ethynodiol diac-eth estradiol

6 ACA

fallback solo 6 ACA; OTC; QL

falmina (28) 6 ACA

fayosim 6 ACA

femynor 6 ACA

gianvi (28) 6 ACA

gildagia 6 ACA

introvale 6 ACA

isibloom 6 ACA

jolessa 6 ACA

juleber 6 ACA

junel 1.5/30 (21) 6 ACA

junel 1/20 (21) 6 ACA

junel fe 1.5/30 (28) 6 ACA

junel fe 1/20 (28) 6 ACA

junel fe 24 6 ACA

kaitlib fe 6 ACA

kariva (28) 6 ACA


46

Drug Name Drug Tier


kelnor 1/35 (28) 6 ACA

kimidess (28) 6 ACA

kurvelo 6 ACA

l norgest/e.estradiol-e.estrad

6 ACA

larin 1.5/30 (21) 6 ACA

larin 1/20 (21) 6 ACA

larin 24 fe 6 ACA

larin fe 1.5/30 (28) 6 ACA

larin fe 1/20 (28) 6 ACA

larissia 6 ACA

layolis fe 6 ACA

leena 28 6 ACA

lessina 6 ACA

levonest (28) 6 ACA

levonorgestrel-ethinyl estrad

6 ACA

levonorg-eth estrad triphasic

6 ACA

levora-28 6 ACA

lomedia 24 fe 6 ACA

loryna (28) 6 ACA

low-ogestrel (28) 6 ACA

lutera (28) 6 ACA

marlissa 6 ACA

mibelas 24 fe 6 ACA

microgestin 1.5/30 (21)

6 ACA

microgestin 1/20 (21)

6 ACA

microgestin fe 1.5/30 (28)

6 ACA

Drug Name Drug Tier


microgestin fe 1/20 (28)

6 ACA

mono-linyah 6 ACA

mononessa (28) 6 ACA

my way 6 ACA; OTC; QL

myzilra 6 ACA

necon 0.5/35 (28) 6 ACA

necon 1/50 (28) 6 ACA

necon 7/7/7 (28) 6 ACA

next choice one dose 6 ACA; OTC; QL

nikki (28) 6 ACA

noreth-ethinyl estradiol-iron

6 ACA

norethindrone ac-eth estradiol

6 ACA

norethindrone-e.estradiol-iron

6 ACA

norgestimate-ethinyl estradiol

6 ACA

nortrel 0.5/35 (28) 6 ACA

nortrel 1/35 (21) 6 ACA

nortrel 1/35 (28) 6 ACA

nortrel 7/7/7 (28) 6 ACA

ocella 6 ACA

ogestrel (28) 6 ACA

opcicon one-step 6 ACA; OTC; QL

option-2 6 ACA; OTC; QL

orsythia 6 ACA

philith 6 ACA

Updated 08/25/17


47

Drug Name Drug Tier


pimtrea (28) 6 ACA

pirmella 6 ACA

PLAN B ONE-STEP 6 ACA; OTC; QL

portia 6 ACA

previfem 6 ACA

quasense 6 ACA

rajani 6 ACA

reclipsen (28) 6 ACA

rivelsa 6 ACA

setlakin 6 ACA

sprintec (28) 6 ACA

sronyx 6 ACA

syeda 6 ACA

tarina fe 1/20 (28) 6 ACA

tilia fe 6 ACA

tri femynor 6 ACA

tri-estarylla 6 ACA

tri-legest fe 6 ACA

tri-linyah 6 ACA

tri-lo-estarylla 6 ACA

tri-lo-marzia 6 ACA

tri-lo-sprintec 6 ACA

trinessa (28) 6 ACA

trinessa lo 6 ACA

tri-previfem (28) 6 ACA

tri-sprintec (28) 6 ACA

trivora (28) 6 ACA

velivet triphasic regimen (28)

6 ACA

vestura (28) 6 ACA

Drug Name Drug Tier


vienva 6 ACA

viorele (28) 6 ACA

vyfemla (28) 6 ACA

wera (28) 6 ACA

wymzya fe 6 ACA

zarah 6 ACA

zenchent (28) 6 ACA

zenchent fe 6 ACA

zovia 1/35e (28) 6 ACA

zovia 1/50e (28) 6 ACA

OXYTOCICS

methergine 1

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE 2

bacitracin 1

bacitracin-polymyxin b

1

BESIVANCE 2

ciprofloxacin hcl 1

erythromycin 1

gatifloxacin 1

gentak 1

gentamicin 1

levofloxacin 1

MOXEZA 2

moxifloxacin 1

NATACYN 2

neomycin-bacitracin-polymyxin

1


48

Drug Name Drug Tier


neomycin-polymyxin-gramicidin

1

neo-polycin 1

ofloxacin 1

polycin 1

polymyxin b sulf-trimethoprim

1

tobramycin 1

ANTIVIRALS

trifluridine 1

ZIRGAN 2

BETA-BLOCKERS

betaxolol 1

carteolol 1

levobunolol 1

metipranolol 1

timolol maleate 1

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE

2

CYCLOPLEGIC MYDRIATICS

atropine 1

cyclopentolate 1

homatropaire 1

homatropine hbr 1

tropicamide 1

DIRECT ACTING MIOTICS

pilocarpine hcl 1

MISCELLANEOUS OPHTHALMOLOGICS

Drug Name Drug Tier


acuicyn 1

ALOCRIL 2

ALOMIDE 2

altacaine 1

altafluor 1

azelastine 1

BEPREVE 2 ST

cromolyn 1

CYSTARAN 5 LA

EMADINE 2 ST

epinastine 1

EYLEA 5 PA; LA

flucaine 1

fluorescein-proparacaine

1

flurox 1

JETREA (PF) 5 LA

LASTACAFT 2 ST

LUCENTIS 5 PA; LA

olopatadine 1

proparacaine 1

RESTASIS 2 PA; QL

RESTASIS MULTIDOSE

2 PA; QL

tetcaine 1

tetracaine hcl 1

tetracaine hcl (pf) 1

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac 1

diclofenac sodium 1

Updated 08/25/17


49

Drug Name Drug Tier


flurbiprofen sodium 1

ILEVRO 2

ketorolac 1

NEVANAC 2

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1

acetazolamide sodium

1

methazolamide 1

OTHER GLAUCOMA DRUGS

AZOPT 2

bimatoprost 1

COMBIGAN 2

dorzolamide 1

dorzolamide-timolol 1

latanoprost 1

miostat 1

SIMBRINZA 2

TRAVATAN Z 2 ST

ZIOPTAN (PF) 2 ST

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc

1

neomycin-polymyxin b-dexameth

1

neomycin-polymyxin-hc

1

neo-polycin hc 1

tobramycin-dexamethasone

1

STEROIDS

Drug Name Drug Tier


dexamethasone sodium phosphate

1

DUREZOL 2

fluorometholone 1

LOTEMAX 2

OZURDEX 5 LA

PRED MILD 2

prednisolone acetate 1

prednisolone sodium phosphate

1

STEROID-SULFONAMIDE COMBINATIONS

sulfacetamide-prednisolone

1

SULFONAMIDES

sulfacetamide sodium

1

SYMPATHOMIMETICS

ALPHAGAN P 2

apraclonidine 1

brimonidine 1

VASOCONSTRICTOR DECONGESTANTS

phenylephrine hcl 1

RESPIRATORY, ALLERGY, COUGH & COLD

ANTIHISTAMINE & ANTIALLERGENIC AGENTS

adrenalin 1

carbinoxamine maleate

1

clemastine 1


50

Drug Name Drug Tier


cyproheptadine 1

desloratadine oral tablet

1 QL

desloratadine oral tablet,disintegrating

1 QL

diphenhydramine hcl 1

EPINEPHRINE INJECTION AUTO-INJECTOR

2 QL

epinephrine injection solution

1

epinephrine injection syringe

1

hydroxyzine hcl 1

hydroxyzine pamoate

1

phenadoz 1

phenergan 1

promethazine 1

promethegan 1

COUGH & COLD THERAPY

benzonatate 1

brompheniramine-pseudoeph-dm

1

centergy 1

cheratussin ac 1

codeine-guaifenesin 1

g tussin ac 1

guaiatussin ac 1

guaifenesin ac 1

guaifenesin dac 1

hydrocodone-chlorpheniramine

1

Drug Name Drug Tier


hydrocodone-cpm-pseudoephed

1

hydrocodone-homatropine

1

hydromet 1

lortuss ex 1

m-clear wc 1

promethazine vc-codeine

1

promethazine-codeine

1

promethazine-dm 1

promethazine-phenyleph-codeine

1

promethazine-phenylephrine

1

relcof c 1

rydex 1

tusnel c 1

tussigon 1

virtussin ac 1

virtussin dac 1

ZODRYL AC 40 2

ZODRYL DEC 30 2

PULMONARY AGENTS

acetylcysteine 1

ADCIRCA 5 PA; LA; QL

ADEMPAS 5 PA; LA

ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

albuterol sulfate 1

Updated 08/25/17


51

Drug Name Drug Tier


ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION

2 QL

ANORO ELLIPTA 2 QL

ARCAPTA NEOHALER

2 QL

ASMANEX HFA 2 QL

ASMANEX TWISTHALER

2 QL

ATROVENT HFA 2 QL

BEVESPI AEROSPHERE

2 QL

BREO ELLIPTA 2 QL

BROVANA 2 QL

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

1 QL

budesonide nasal 1 QL

CINRYZE 5 PA; LA

COMBIVENT RESPIMAT

2 QL

cromolyn 1

DALIRESP 2

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION

2 QL

Drug Name Drug Tier


ESBRIET ORAL CAPSULE

5 PA; LA; QL

ESBRIET ORAL TABLET

5 PA; LA

FIRAZYR 5 PA; LA

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

2 QL

flunisolide 1 QL

fluticasone 1 QL

FLUTICASONE-SALMETEROL

2 QL

INCRUSE ELLIPTA

2 QL

ipratropium bromide 1

ipratropium-albuterol

1 QL

KALBITOR 5 PA; LA

KALYDECO ORAL GRANULES IN PACKET

5 PA; LA; QL

KALYDECO ORAL TABLET

5 PA; LA; QL

levalbuterol hcl 1

metaproterenol 1

mometasone 1 QL

montelukast 1

nebusal 1

NUCALA 5 PA; LA


52

Drug Name Drug Tier


OFEV 5 PA; LA; QL

OPSUMIT 5 PA; LA

ORKAMBI 5 PA; LA; QL

PERFOROMIST 2 QL

PROAIR HFA 2 QL

PROAIR RESPICLICK

2 QL

pulmosal 1

PULMOZYME 5 LA

QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

2 QL

sildenafil intravenous

4 PA; LA

sildenafil oral 4 PA; LA; QL

sodium chloride 1

SPIRIVA WITH HANDIHALER

2 QL

STRIVERDI RESPIMAT

2 QL

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

2 QL

terbutaline 1

theochron 1

theophylline 1

TRACLEER 5 PA; LA

TUDORZA PRESSAIR

2 QL

Drug Name Drug Tier


TYVASO 5 PA; LA

TYVASO REFILL KIT

5 PA; LA

TYVASO STARTER KIT

5 PA; LA

VENTAVIS 5 PA; LA

VENTOLIN HFA 2 QL

XOLAIR 5 PA; LA; QL

zafirlukast 1

zileuton 1

ZYFLO 2 ST

UROLOGICALS

ANTICHOLINERGICS & ANTISPASMODICS

darifenacin 1

flavoxate 1

MYRBETRIQ 2

oxybutynin chloride 1

tolterodine 1

TOVIAZ 2

trospium 1

VESICARE 2

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

alfuzosin 1

CIALIS ORAL TABLET 2.5 MG, 5 MG

2 QL

dutasteride 1 ST

dutasteride-tamsulosin

1 ST

finasteride 1

Updated 08/25/17


53

Drug Name Drug Tier


RAPAFLO 2 ST

tamsulosin 1

CHOLINERGIC STIMULANTS

bethanechol chloride 1

MISCELLANEOUS UROLOGICALS

alprostadil 1

azuphen mb 1

CAVERJECT 2 PA; QL

CAVERJECT IMPULSE

2 PA; QL

CIALIS 2 QL

CYSTAGON 5 LA

cytra k crystals 1

cytra-2 1

cytra-3 1

cytra-k 1

ELMIRON 2

hyolev mb 1

hyophen 1

K-PHOS NO 2 2

K-PHOS ORIGINAL

2

methen-sod phos-meth blue-hyos

1

MUSE 2 PA; QL

phosphasal 1

pot,sodium citrate-citric acid

1

potassium citrate 1

potassium citrate-citric acid

1

RENACIDIN 2

Drug Name Drug Tier


sodium citrate-citric acid

1

tricitrates 1

ur n-c 1

uramit mb 1

uretron d-s 1

urimar-t 1

urin ds 1

uro-458 1

urogesic-blue 1

uro-mp 1

urophen mb 1

uryl 1

ustell 1

utira-c 1

VIAGRA 2 QL

virtrate-2 1

virtrate-3 1

virtrate-k 1

URINARY ANESTHETICS

phenazopyridine 1

VITAMINS, HEMATINICS & ELECTROLYTES

ELECTROLYTES

calcium 500 + d 6 ACA; OTC

calcium 500 with d 6 ACA; OTC

calcium 600 + d(3) 6 ACA; OTC

calcium 600 with vitamin d3

6 ACA; OTC

calcium carbonate-vitamin d3

6 ACA; OTC


54

Drug Name Drug Tier


calcium citrate + d 6 ACA; OTC

calcium citrate-vitamin d3

6 ACA; OTC

citrus calcium 6 ACA; OTC

effer-k 1

hi-cal plus vit d 6 ACA; OTC

k-effervescent 1

klor-con 1

klor-con 10 1

klor-con 8 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con sprinkle 1

klor-con/ef 1

k-phos-neutral 1

k-tab 1

lugols 1

oysco 500/d 6 ACA; OTC

oyster shell + d3 6 ACA; OTC

oyster shell calcium-vit d3

6 ACA; OTC

oystercal-d 6 ACA; OTC

phospha 250 neutral 1

potassium acetate 1

potassium bicarb and chloride

1

potassium bicarb-citric acid

1

potassium chlorid-d5-0.45%nacl

1

potassium chloride 1

Drug Name Drug Tier


potassium chloride in 0.9%nacl

1

potassium chloride in 5 % dex

1

potassium chloride in lr-d5

1

potassium chloride-0.45 % nacl

1

potassium chloride-d5-0.2%nacl

1


1


1

potassium phosphate m-/d-basic

1

sodium chloride 1

sodium chloride 0.45 %

1

sodium chloride 3 % 1

sodium chloride 5 % 1

sodium phosphate 1

strong iodine 1

virt-phos 250 neutral 1

VITAMINS & HEMATINICS

AQUADEKS PEDIATRIC

2 OTC

b complex 100 1

b complex-vitamin b12

6 ACA; OTC

balanced b-100 1 OTC

balanced b-50 6 ACA; OTC

bal-care dha 1

Updated 08/25/17


55

Drug Name Drug Tier


b-complex with vitamin c

6 ACA; OTC

calcium pnv 1

calcium-folic acid-vitamin d

1

centratex 1

child vitamin with minerals

1 OTC

children's iron 6 ACA; OTC

child's chewable vitamins/iron

1 OTC

cholecalciferol (vitamin d3)

6 ACA; OTC

ciferex 1

c-nate dha 1

complete multivitamin

1 OTC

complete natal dha 1

completenate 1

complex b-100 6 ACA; OTC

corvita 1

corvita 150 1

cyanocobalamin (vitamin b-12)

1

daily multivitamin with iron

1 OTC

delta d3 6 ACA; OTC

dialyvite 1

dothelle dha 1

d-vi-sol 6 ACA; OTC

elite-ob 1

Drug Name Drug Tier


ergocalciferol (vitamin d2) oral capsule

1

ergocalciferol (vitamin d2) oral tablet

6 ACA; OTC

ferocon 1

ferosul 6 ACA; OTC

ferraplus 90 1

ferrex 150 forte 1

ferrex 150 forte plus 1

ferrex 150 plus 1 OTC

ferrex 28 1

ferrocite plus 1

ferrous fumarate 1 OTC

ferrous gluconate 1 OTC

ferrous sulfate oral drops

6 ACA; OTC

ferrous sulfate oral elixir

6 ACA; OTC

ferrous sulfate oral liquid

1 OTC

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg

6 ACA

fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg

1

fluoride (sodium) oral drops

6 ACA


56

Drug Name Drug Tier


fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

6 ACA

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

6 ACA

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

focalgin 90 dha 1

focalgin ca 1

focalgin dss 1

folbecal 1

folbee 1

folbee ar 1

folbee plus 1

folbic 1

folic acid injection 1

folic acid oral tablet 1 mg

1

folic acid oral tablet 400 mcg, 800 mcg

6 ACA; OTC

folic acid-vit b6-vit b12

1

folivane-f 1

folivane-ob 1

folivane-plus 1

Drug Name Drug Tier


folplex 2.2 1

hematinic plus vit/minerals

1

hematinic/folic acid 1

hematogen 1

hematogen fa 1

hematogen forte 1

hemenatal ob 1

hemenatal ob + dha 1

hemetab 1

hydroxocobalamin 1

ICAPS MV 2 OTC

iferex 150 forte 1

infed 1

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

6 ACA

ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

m.v.i. adult 1

multigen folic 1

multigen plus 1

multi-vit with fluoride-iron

6 ACA

multi-vitamin hp/minerals

1 OTC

multi-vitamin with fluoride oral drops

6 ACA

Updated 08/25/17


57

Drug Name Drug Tier


multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

6 ACA

multi-vitamin with fluoride oral tablet,chewable 1 mg

1

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

6 ACA

multivitamins with fluoride oral tablet,chewable 1 mg

1

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

6 ACA

mvc-fluoride oral tablet,chewable 1 mg

1

myferon 150 forte 1

mynatal 1

mynatal advance 1

mynatal plus 1

mynatal-z 1

mynate 90 plus 1

mynephrocaps 1

mynephron 1

nephplex rx 1

nephro-vite rx 1

newgen 1

obstetrix dha 1

one daily women's health

1 OTC

Drug Name Drug Tier


ortho d 1

pnv 29-1 1

pnv ob+dha 1

pnv-dha 1

pnv-dha + docusate 1

pnv-ferrous fumarate-docu-fa

1

pnv-omega 1

pnv-select 1

pnv-vp-u 1

poly-iron 1 OTC

poly-iron 150 forte 1

pr natal 400 1

pr natal 400 ec 1

pr natal 430 1

pr natal 430 ec 1

prena1 chew 1

prena1 pearl 1

prena1 true 1

prenaissance 1

prenaissance plus 1

prenatabs fa 1

prenatabs rx 1

prenatal 6 ACA; OTC

prenatal formula 6 ACA; OTC

prenatal plus 1

prenatal plus (calcium carb)

1

prenatal vitamin plus low iron

1


58

Drug Name Drug Tier


prenatal vits96-iron fum-folic

6 ACA; OTC

prenatal-u 1

preplus 1

pretab 1

PROFERRIN-FORTE

2

prosight 1 OTC

purevit dualfe plus 1

relnate dha 1

renal caps 1

rena-vite rx 1

reno caps 1

se-natal 19 1

se-natal 19 (with docusate)

1

se-tan plus 1

stress b with zinc 1 OTC

stress formula 6 ACA; OTC

stress formula with iron

6 ACA; OTC

super b complex-vitamin c

6 ACA; OTC

super b-50 complex plus

6 ACA; OTC

super quints b-50 6 ACA; OTC

superplex-t 6 ACA; OTC

taron forte 1

taron-c dha 1

taron-prex prenatal-dha

1

thrivite-19 1

tl gard rx 1

Drug Name Drug Tier


tl g-fol os 1

tl icon 1

tl-hem 150 1

total b/c 6 ACA; OTC

tricon 1

trigels-f forte 1

trinatal gt 1

trinatal rx 1 1

trinate 1

triphrocaps 1

tri-tabs dha 1

triveen-duo dha 1

tri-vit with fluoride and iron

6 ACA

tri-vitamin with fluoride

6 ACA

trust natal dha 1

ultimatecare one 1

ultimatecare one nf 1

ultra b-100 complex 6 ACA; OTC

v-c forte 1

vemavite-prx-2 1

VENOFER 2

vic-forte 1

vinate care 1

vinate dha 1

vinate ii 1

vinate m 1

vinate one 1

vinate ultra 1

virt-advance 1

Updated 08/25/17


59

Drug Name Drug Tier


virt-c dha 1

virt-gard 1

virt-nate 1

virt-nate dha 1

virt-pn 1

virt-pn dha 1

virt-pn plus 1

virt-select 1

virt-vite 1

virt-vite forte 1

virt-vite gt 1

vit 3 1

VITAFOL-OB 2

vitajoy daily d 6 ACA; OTC

vitamin b complex 6 ACA; OTC

vitamin d3 6 ACA; OTC

Drug Name Drug Tier


vitamins a,c,d and fluoride

6 ACA

vol-care rx 1

vol-nate 1

vol-plus 1

vol-tab rx 1

vp-ch plus 1

vp-ch-pnv 1

vp-ggr-b6 1

vp-heme ob 1

vp-heme one 1

vp-vite rx 1

zatean-ch 1

zatean-pn dha 1

zatean-pn plus 1

zavara 1

zingiber 1


60

Index A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-

zidovudine .......................... 3 ABILIFY MAINTENA ........ 17 ABRAXANE .......................... 8 ABREVA ............................. 28 acamprosate .......................... 29 acarbose ................................ 35 ACE AEROSOL CLOUD

ENHANCER .................... 32 acebutolol ............................. 20 acetaminophen-caff-

dihydrocod ........................ 14 acetaminophen-codeine ........ 14 acetazolamide ....................... 49 acetazolamide sodium .......... 49 acetic acid ....................... 29, 31 acetic acid-aluminum acetate 31 acetylcysteine ....................... 50 acitretin ................................. 25 ACTEMRA .......................... 43 ACTHAR H.P. ..................... 31 ACTIMMUNE ..................... 42 ACTOPLUS MET XR ......... 36 acuicyn ................................. 48 acyclovir ........................... 3, 28 acyclovir sodium .................... 3 ADAGEN ............................. 29 adapalene .............................. 26 ADCETRIS ............................ 8 ADCIRCA ............................ 50 adefovir................................... 3 ADEMPAS ........................... 50 adrenalin ............................... 49 adriamycin .............................. 8 adrucil ..................................... 8 ADVAIR DISKUS ............... 50 ADVAIR HFA ..................... 50 AEROCHAMBER MINI ..... 32 AEROCHAMBER PLUS

FLOW-VU ....................... 32 AEROCHAMBER PLUS Z

STAT SM MSK ............... 32 AEROTRACH PLUS ........... 32

AEROVENT PLUS .............. 32 afeditab cr ............................. 21 AFINITOR ............................. 8 AFINITOR DISPERZ ............ 8 AKYNZEO ........................... 37 ala-cort .................................. 28 ALBENZA ............................. 5 albuterol sulfate .................... 50 alclometasone ....................... 28 ALDURAZYME .................. 35 ALECENSA ........................... 8 alendronate ..................... 29, 42 ALFERON N ........................ 42 alfuzosin ............................... 52 ALIMTA ................................ 8 ALINIA .................................. 5 allopurinol ............................ 42 allopurinol sodium ................ 42 almotriptan malate ................ 13 ALOCRIL ............................. 48 ALOMIDE............................ 48 alophen ................................. 37 aloprim.................................. 42 alosetron ............................... 37 ALOXI.................................. 37 ALPHAGAN P ..................... 49 alprazolam ............................ 17 alprazolam intensol............... 17 alprostadil ............................. 53 altacaine ................................ 48 altafluor ................................ 48 altavera (28) .......................... 44 ALVESCO............................ 51 alyacen 1/35 (28) .................. 44 alyacen 7/7/7 (28) ................. 44 amabelz ................................. 43 amantadine hcl ........................ 3 amcinonide ........................... 28 amethia ................................. 44 amethia lo ............................. 45 amethyst................................ 45 AMICAR .............................. 23 amifostine crystalline ............. 8 amikacin ................................. 5 amiloride ............................... 21

amiloride-hydrochlorothiazide .......................................... 21

aminocaproic acid ................. 23 amiodarone ........................... 20 AMITIZA ............................. 37 amitriptyline ......................... 17 amitriptyline-chlordiazepoxide

.......................................... 17 amlodipine ............................ 21 amlodipine-atorvastatin ........ 24 amlodipine-benazepril .......... 21 amlodipine-olmesartan ......... 21 amlodipine-valsartan ............ 21 amlodipine-valsartan-hcthiazid

.......................................... 21 amnesteem ............................ 26 amoxapine ............................. 17 amoxicil-clarithromy-lansopraz

.......................................... 40 amoxicillin .............................. 7 amoxicillin-pot clavulanate .... 7 amphotericin b ........................ 3 ampicillin ................................ 7 ampicillin sodium ................... 7 ampicillin-sulbactam .............. 7 AMPYRA ............................. 14 ANADROL-50 ..................... 35 anagrelide ............................. 30 anaspaz ................................. 37 anastrozole .............................. 8 androxy ................................. 35 ANORO ELLIPTA ............... 51 apexicon e ............................. 28 APIDRA ............................... 34 APIDRA SOLOSTAR .......... 34 APOKYN ............................. 13 apraclonidine ........................ 49 aprepitant ........................ 37, 38 apri ........................................ 45 APRISO ................................ 38 APTIOM ............................... 12 APTIVUS ............................... 3 AQUADEKS PEDIATRIC .. 54 ARALAST NP ...................... 30 aranelle (28) .......................... 45

Updated 08/25/17


61

ARANESP (IN POLYSORBATE) ............ 41

ARCALYST ......................... 42 ARCAPTA NEOHALER ..... 51 ARGATROBAN IN NACL

(ISO-OS) .......................... 23 aripiprazole ........................... 17 ARISTADA .......................... 17 armodafinil ........................... 17 ARMOUR THYROID ......... 37 ARRANON ............................ 8 ARZERRA ............................. 8 ascomp with codeine ............ 14 ashlyna .................................. 45 ASMANEX HFA ................. 51 ASMANEX TWISTHALER 51 aspir-81 ................................. 16 aspirin ................................... 16 aspirin low dose .................... 16 aspirin-caffeine-dihydrocodein

.......................................... 14 aspirin-dipyridamole ............ 23 aspir-low ............................... 16 aspir-trin ............................... 16 astramorph-pf ....................... 14 atenolol ................................. 21 atenolol-chlorthalidone......... 21 atomoxetine .......................... 18 atorvastatin ........................... 24 atovaquone ............................. 5 atovaquone-proguanil ............. 5 ATRIPLA ............................... 3 atropine ........................... 37, 48 ATROVENT HFA ............... 51 aubra ..................................... 45 AUGMENTIN ........................ 7 AUTOJECT 2 INJECTION

DEVICE ........................... 33 AUTOPEN 1 TO 21 UNITS 33 avar ....................................... 26 AVASTIN .............................. 8 AVELOX IN NACL (ISO-

OSMOTIC) ........................ 7 aviane ................................... 45 avidoxy ................................... 7 avita ...................................... 26 avo cream ............................. 25

AVONEX ............................. 41 AVONEX (WITH ALBUMIN)

.......................................... 41 AVYCAZ ............................... 4 azacitidine ............................... 8 AZASAN ................................ 8 AZASITE ............................. 47 azathioprine ............................ 8 azathioprine sodium ............... 9 azelastine ........................ 31, 48 AZELEX .............................. 26 azithromycin ........................... 5 AZOPT ................................. 49 aztreonam ............................... 5 azuphen mb........................... 53 azurette (28) .......................... 45 B b complex 100 ...................... 54 b complex-vitamin b12 ......... 54 baciim ..................................... 5 bacitracin .......................... 5, 47 bacitracin-polymyxin b......... 47 baclofen ................................ 14 BACTROBAN NASAL ....... 31 balanced b-100 ..................... 54 balanced b-50 ....................... 54 bal-care dha .......................... 54 balsalazide ............................ 38 balziva (28) ........................... 45 BANZEL .............................. 12 BARACLUDE ....................... 3 BASAGLAR KWIKPEN ..... 34 BAVENCIO ........................... 9 bayer aspirin ......................... 16 b-complex with vitamin c ..... 55 bekyree (28) .......................... 45 belladonna alkaloids-opium . 37 belladonna-opium ................. 37 BELSOMRA ........................ 18 benazepril ............................. 21 benazepril-hydrochlorothiazide

.......................................... 21 BENDEKA ............................. 9 BENLYSTA ......................... 43 benzepro ............................... 26 benzonatate ........................... 50 benzoyl peroxide .................. 26

benztropine ........................... 13 BEPREVE ............................ 48 BESIVANCE ........................ 47 betamethasone acet,sod phos 31 betamethasone dipropionate . 28 betamethasone valerate ......... 28 betamethasone, augmented ... 28 betaxolol ......................... 21, 48 bethanechol chloride ............. 53 BEVESPI AEROSPHERE ... 51 bexarotene ............................... 9 bicalutamide ........................... 9 BICNU .................................... 9 BILTRICIDE .......................... 5 bimatoprost ........................... 49 bisacodyl ............................... 38 bisa-lax ................................. 38 bismuth ................................. 37 bisoprolol fumarate ............... 21 bisoprolol-hydrochlorothiazide

.......................................... 21 bivalirudin ............................. 23 bleo 15k .................................. 9 bleomycin ............................... 9 BLINCYTO ............................ 9 blisovi 24 fe .......................... 45 blisovi fe 1.5/30 (28) ............ 45 blisovi fe 1/20 (28) ............... 45 BOSULIF ............................... 9 BOTOX ................................ 42 bp 10-1 .................................. 26 bp-50% urea .......................... 25 bpo ........................................ 26 BREATHERITE WITH

MASK, SMALL ............... 32 BREO ELLIPTA .................. 51 briellyn .................................. 45 BRILINTA ........................... 23 brimonidine ........................... 49 BRINEURA .......................... 35 bromfenac ............................. 48 bromocriptine ....................... 13 brompheniramine-pseudoeph-

dm ..................................... 50 BROVANA .......................... 51 budesonide ...................... 38, 51 bumetanide ........................... 21


62

BUPHENYL......................... 30 buprenorphine hcl ................. 14 buprenorphine-naloxone....... 16 bupropion hcl........................ 18 bupropion hcl (smoking deter)

.......................................... 30 buspirone .............................. 18 busulfan .................................. 9 BUSULFEX ........................... 9 butalbital compound w/codeine

.......................................... 15 butalbital-acetaminop-caf-cod

.......................................... 15 butalbital-acetaminophen ..... 15 butalbital-acetaminophen-caff

.......................................... 15 butalbital-aspirin-caffeine .... 15 butorphanol tartrate .............. 16 BYDUREON ........................ 36 BYETTA .............................. 36 BYSTOLIC .......................... 21 C cabergoline ........................... 35 caffeine citrate ...................... 30 calcipotriene ......................... 25 calcipotriene-betamethasone 25 calcitonin (salmon) ............... 35 calcitrene .............................. 25 calcitriol .......................... 25, 35 calcium 500 + d .................... 53 calcium 500 with d ............... 53 calcium 600 + d(3) ............... 53 calcium 600 with vitamin d3 53 calcium acetate ..................... 38 calcium carbonate-vitamin d3

.......................................... 53 calcium citrate + d ................ 54 calcium citrate-vitamin d3 .... 54 calcium pnv .......................... 55 calcium-folic acid-vitamin d 55 camila ................................... 43 camrese ................................. 45 camrese lo ............................. 45 CANASA ............................. 38 CANCIDAS ........................... 3 candesartan ........................... 21

candesartan-hydrochlorothiazid .......................................... 21

capacet .................................. 15 capecitabine ............................ 9 CAPRELSA............................ 9 captopril ................................ 21 captopril-hydrochlorothiazide

.......................................... 21 CARAFATE ......................... 40 CARBAGLU ........................ 30 carbamazepine ...................... 12 carbidopa .............................. 13 carbidopa-levodopa .............. 13 carbidopa-levodopa-

entacapone ........................ 13 carbinoxamine maleate ......... 49 carboplatin .............................. 9 carisoprodol .......................... 14 carteolol ................................ 48 cartia xt ................................. 21 CARTRIDGE STAMPED IR

1200 .................................. 33 carvedilol .............................. 21 CAVERJECT ....................... 53 CAVERJECT IMPULSE ..... 53 CAYA CONTOURED ......... 43 CAYSTON ............................. 5 caziant (28) ........................... 45 cefaclor ................................... 4 cefadroxil ................................ 4 cefazolin ................................. 4 cefazolin in dextrose (iso-os) . 4 cefdinir.................................... 4 cefditoren pivoxil ................... 4 cefepime ................................. 4 cefepime in dextrose,iso-osm . 5 cefixime .................................. 5 cefotaxime .............................. 5 cefotetan ................................. 5 cefoxitin .................................. 5 cefoxitin in dextrose, iso-osm 5 cefpodoxime ........................... 5 cefprozil .................................. 5 ceftazidime ............................. 5 ceftibuten ................................ 5 ceftriaxone .............................. 5 ceftriaxone in dextrose,iso-os . 5

cefuroxime axetil .................... 5 cefuroxime sodium ................. 5 celacyn .................................. 25 celecoxib ............................... 16 CELLCEPT INTRAVENOUS

............................................ 9 CELONTIN .......................... 12 cem-urea ............................... 25 centergy ................................ 50 centratex ............................... 55 cephalexin ............................... 5 CEPROTIN (BLUE BAR) ... 23 CEPROTIN (GREEN BAR) 23 CERDELGA ......................... 35 CESAMET ........................... 38 cevimeline ............................. 30 CHANTIX ............................ 30 CHANTIX CONTINUING

MONTH BOX .................. 30 CHANTIX STARTING

MONTH BOX .................. 30 chateal ................................... 45 CHEMET .............................. 30 CHENODAL ........................ 38 cheratussin ac ........................ 50 child vitamin with minerals .. 55 children's aspirin ................... 16 children's iron ....................... 55 child's chewable vitamins/iron

.......................................... 55 chloramphenicol sod succinate

............................................ 5 chlordiazepoxide hcl ............. 18 chlordiazepoxide-clidinium .. 37 chlorhexidine gluconate ........ 31 chloroquine phosphate ............ 5 chlorothiazide ....................... 21 chlorothiazide sodium .......... 21 chlorpromazine ..................... 18 chlorpropamide ..................... 36 chlorthalidone ....................... 21 chlorzoxazone ....................... 14 CHOLBAM .......................... 38 cholecalciferol (vitamin d3) . 55 cholestyramine (with sugar) . 24 cholestyramine light ............. 24

Updated 08/25/17


63

choline,magnesium salicylate .......................................... 16

CIALIS ........................... 52, 53 ciclodan ................................ 27 ciclopirox ........................ 27, 28 ciclopirox-ure-camph-menth-

euc .................................... 28 cidaleaze ............................... 27 cidofovir ................................. 3 ciferex ................................... 55 cilostazol............................... 23 cimetidine ............................. 40 cimetidine hcl ....................... 40 CINRYZE ............................ 51 CIPRO HC ........................... 31 CIPRODEX .......................... 31 ciprofloxacin........................... 7 ciprofloxacin (mixture) .......... 7 ciprofloxacin hcl ......... 7, 31, 47 ciprofloxacin in 5 % dextrose. 7 ciprofloxacin lactate ............... 7 cisplatin .................................. 9 citalopram ............................. 18 citrate of magnesia ............... 38 citroma .................................. 38 citrus calcium ....................... 54 cladribine ................................ 9 claravis ................................. 26 clarithromycin ........................ 5 cleansing wash ..................... 26 clearlax ................................. 38 clemastine ............................. 49 CLEO 90 INFUSION SET 24

.......................................... 33 cleocin .................................... 5 CLEVER CHOICE

CHAMBER-SM MASK .. 32 clindacin p ............................ 26 clindamycin hcl ...................... 5 clindamycin in 5 % dextrose .. 6 clindamycin palmitate hcl ...... 6 clindamycin pediatric ............. 6 clindamycin phosphate .... 6, 26,

44 clindamycin-benzoyl peroxide

.......................................... 26 clindamycin-tretinoin ........... 26

clobetasol ........................ 28, 29 clobetasol-emollient ............. 29 clodan ................................... 29 clofarabine .............................. 9 CLOLAR ................................ 9 clomipramine ........................ 18 clonazepam ........................... 12 clonidine ............................... 21 clonidine hcl ................... 18, 21 clopidogrel ............................ 23 clorazepate dipotassium ....... 18 clorpres ................................. 21 clotrimazole ............................ 3 clotrimazole-betamethasone . 28 clozapine ............................... 18 c-nate dha ............................. 55 COAGADEX........................ 23 COAL TAR .......................... 25 COARTEM ............................ 6 codeine sulfate ...................... 15 codeine-butalbital-asa-caff ... 15 codeine-guaifenesin .............. 50 COLCRYS............................ 42 colestipol .............................. 24 colistin (colistimethate na) ..... 6 colocort ................................. 38 COMBIGAN ........................ 49 COMBIVENT RESPIMAT . 51 COMFORT INFUSION SET

43 ...................................... 33 COMFORT SHORT INSULIN

PUMP 23 .......................... 33 COMPACT SPACE

CHAMBER-LRG MASK 32 COMPLERA .......................... 3 complete multivitamin .......... 55 complete natal dha ................ 55 completenate ......................... 55 complex b-100 ...................... 55 compro .................................. 38 constulose ............................. 38 CONTACT DETACH INFUS

SET 23 .............................. 33 CORDRAN .......................... 29 CORDRAN TAPE LARGE

ROLL................................ 29 CORLANOR ........................ 24

cormax .................................. 29 CORTIFOAM ....................... 38 cortisone ............................... 31 CORTISPORIN .................... 27 corvita ................................... 55 corvita 150 ............................ 55 COSENTYX ......................... 25 COSENTYX (2 SYRINGES)

.......................................... 25 COSENTYX PEN ................ 25 COSENTYX PEN (2 PENS) 25 cosyntropin ........................... 32 COTELLIC ............................. 9 CREON ................................. 38 CRESEMBA ........................... 3 CRINONE ............................ 43 CRIXIVAN ............................. 3 cromolyn ................... 38, 48, 51 cryselle (28) .......................... 45 CUBICIN RF .......................... 6 curity sterile water ................ 30 cyanocobalamin (vitamin b-12)

.......................................... 55 cyclafem 1/35 (28) ................ 45 cyclafem 7/7/7 (28) ............... 45 cyclobenzaprine .................... 14 cyclopentolate ....................... 48 cyclophosphamide .................. 9 CYCLOPHOSPHAMIDE ...... 9 CYCLOSERINE ..................... 6 cyclosporine ............................ 9 cyclosporine modified ............ 9 cyproheptadine ..................... 50 CYRAMZA ............................ 9 cyred ..................................... 45 CYSTADANE ...................... 38 CYSTAGON ........................ 53 CYSTARAN ......................... 48 cytarabine ............................... 9 cytarabine (pf) ........................ 9 cytra k crystals ...................... 53 cytra-2 ................................... 53 cytra-3 ................................... 53 cytra-k ................................... 53 D dacarbazine ............................. 9 daily multivitamin with iron . 55


64

DAKLINZA ........................... 3 DALIRESP ........................... 51 DALVANCE .......................... 6 danazol ................................. 35 dantrolene ............................. 14 dapsone ................................... 6 daptomycin ............................. 6 DARAPRIM ........................... 6 darifenacin ............................ 52 DARZALEX .......................... 9 dasetta 1/35 (28) ................... 45 dasetta 7/7/7 (28) .................. 45 daunorubicin ........................... 9 daysee ................................... 45 DEBACTEROL ................... 31 deblitane ............................... 43 decitabine ............................... 9 delta d3 ................................. 55 deltasone ............................... 32 delyla (28) ............................ 45 demeclocycline ....................... 7 DEMSER .............................. 21 DENAVIR ............................ 28 denta 5000 plus..................... 31 dentagel ................................ 31 DEPEN TITRATABS .......... 43 DEPO-PROVERA ............... 43 dermacinrx prizopak ............. 27 DESCOVY ............................. 3 desipramine .......................... 18 desloratadine......................... 50 desmopressin ........................ 35 desog-e.estradiol/e.estradiol . 45 desogestrel-ethinyl estradiol . 45 desonide ................................ 29 desoximetasone .................... 29 desvenlafaxine succinate ...... 18 dexamethasone ..................... 32 dexamethasone intensol........ 32 dexamethasone sodium phos

(pf) .................................... 32 dexamethasone sodium

phosphate .................... 32, 49 dexedrine .............................. 18 dexmethylphenidate ............. 18 dexrazoxane hcl ...................... 8 dextroamphetamine .............. 18

dextroamphetamine-amphetamine .................... 18

dialyvite ................................ 55 diazepam ............................... 18 diazepam intensol ................. 18 diclofenac potassium ............ 16 diclofenac sodium..... 16, 25, 48 diclofenac-misoprostol ......... 16 dicloxacillin ............................ 7 dicyclomine .......................... 37 didanosine ............................... 3 DIFICID ................................. 5 diflorasone ............................ 29 diflunisal ............................... 16 digitek ................................... 23 digox ..................................... 23 digoxin .................................. 23 dihydroergotamine................ 13 DILANTIN ........................... 13 DILANTIN EXTENDED ..... 13 DILANTIN INFATABS ...... 13 DILANTIN-125.................... 13 diltiazem ............................... 21 dilt-xr .................................... 21 dimenhydrinate ..................... 38 DIPENTUM ......................... 38 diphenhydramine hcl ............ 50 diphenoxylate-atropine ......... 37 dipyridamole ......................... 23 diskets ................................... 15 disopyramide phosphate ....... 20 disulfiram.............................. 30 divalproex ............................. 13 docetaxel ................................. 9 DOCETAXEL ........................ 9 dofetilide ............................... 20 donepezil .............................. 14 dorzolamide .......................... 49 dorzolamide-timolol ............. 49 dothelle dha .......................... 55 doxazosin .............................. 21 doxepin ........................... 18, 25 doxercalciferol ...................... 35 doxorubicin ............................. 9 doxorubicin, peg-liposomal .... 9 doxy-100 ................................. 7 doxycycline hyclate ................ 8

doxycycline monohydrate ...... 8 drithocreme hp ...................... 25 dronabinol ............................. 38 droperidol ............................. 38 drospirenone-e.estradiol-lm.fa

.......................................... 45 drospirenone-ethinyl estradiol

.......................................... 45 DROXIA ................................. 9 DUAVEE .............................. 43 ducodyl ................................. 38 DULERA .............................. 51 duloxetine ............................. 18 DUPIXENT .......................... 25 duramorph (pf) ...................... 15 DUREZOL ........................... 49 dutasteride ............................. 52 dutasteride-tamsulosin .......... 52 DUTOPROL ......................... 21 d-vi-sol .................................. 55 DYRENIUM ......................... 21 E e.c. prin ................................. 16 e.e.s. 400 ................................. 5 E.E.S. GRANULES ................ 5 EASIVENT HOLDING

CHAMBER ...................... 32 econazole .............................. 28 econtra ez .............................. 45 ecotrin ................................... 16 ecotrin low strength .............. 16 ed-spaz .................................. 37 EDURANT ............................. 3 effer-k ................................... 54 EFFIENT .............................. 23 EGRIFTA ............................. 41 ELAPRASE .......................... 35 ELELYSO ............................ 35 eletone ................................... 25 ELIDEL ................................ 25 ELIGARD ............................... 9 ELIGARD (3 MONTH) ......... 9 ELIGARD (4 MONTH) ......... 9 ELIGARD (6 MONTH) ......... 9 elinest .................................... 45 eliphos ................................... 38 ELIQUIS ............................... 23

Updated 08/25/17


65

ELITEK .................................. 8 elite-ob .................................. 55 ELLA .................................... 45 ELMIRON ............................ 53 EMADINE ........................... 48 EMCYT .................................. 9 EMEND ................................ 38 emoquette ............................. 45 EMSAM ............................... 18 EMTRIVA .............................. 3 emulsion sb ........................... 25 EMVERM .............................. 6 enalapril maleate .................. 21 enalaprilat ............................. 21 enalapril-hydrochlorothiazide

.......................................... 21 ENBREL .............................. 43 ENBREL SURECLICK ....... 43 endocet ................................. 15 enoxaparin ............................ 23 enpresse ................................ 45 enskyce ................................. 45 entacapone ............................ 13 entecavir ................................. 3 ENTRESTO ......................... 24 ENTYVIO ............................ 38 enulose .................................. 38 EPCLUSA .............................. 3 EPIDUO ............................... 26 EPIDUO FORTE.................. 26 epinastine .............................. 48 epinephrine ........................... 50 EPINEPHRINE .................... 50 epirubicin ................................ 9 epitol ..................................... 13 EPIVIR HBV.......................... 3 eplerenone ............................ 21 epoprostenol (glycine) .......... 21 eprosartan ............................. 21 ERBITUX .............................. 9 ergocalciferol (vitamin d2) ... 55 ergoloid................................. 18 ERGOMAR .......................... 13 ergotamine-caffeine .............. 14 ERIVEDGE .......................... 10 errin ...................................... 43 ERTACZO ........................... 28

ery pads................................. 26 erygel .................................... 26 ERYPED 200 ......................... 5 ERYPED 400 ......................... 5 ery-tab ..................................... 5 ERY-TAB ............................... 5 erythrocin (as stearate) ........... 5 erythromycin .................... 5, 47 erythromycin ethylsuccinate ... 5 erythromycin with ethanol.... 26 erythromycin-benzoyl peroxide

.......................................... 26 ESBRIET .............................. 51 escitalopram oxalate ............. 18 esmolol ................................. 21 esomeprazole magnesium..... 40 esomeprazole sodium ........... 40 estarylla ................................ 45 estazolam .............................. 18 ESTRACE ............................ 43 estradiol .......................... 43, 44 estradiol valerate ................... 44 estradiol-norethindrone acet . 44 estropipate ............................ 44 eszopiclone ........................... 18 ethacrynate sodium ............... 21 ethacrynic acid ...................... 21 ethambutol .............................. 6 ethosuximide ........................ 13 ethyl chloride ........................ 27 ethynodiol diac-eth estradiol 45 etidronate disodium .............. 30 etodolac ................................ 16 ETOPOPHOS ....................... 10 etoposide ............................... 10 EUFLEXXA ......................... 16 EURAX ................................ 29 EXELDERM ........................ 28 exemestane ........................... 10 EXJADE ............................... 30 EXTAVIA ............................ 41 EYLEA ................................. 48 E-Z SPACER ........................ 32 ezetimibe .............................. 24 ezetimibe-simvastatin ........... 24 F FABRAZYME ..................... 35

FACTIVE ............................... 7 fallback solo .......................... 45 falmina (28) .......................... 45 famciclovir .............................. 3 famotidine ............................. 40 famotidine (pf) ...................... 40 famotidine (pf)-nacl (iso-os) 40 FANAPT ............................... 18 FARESTON ......................... 10 FARXIGA ............................ 36 FASLODEX ......................... 10 fayosim ................................. 45 FC2 FEMALE CONDOM ... 43 felbamate .............................. 13 felodipine .............................. 21 fem ph ................................... 44 FEMCAP .............................. 43 femynor ................................. 45 fenofibrate ............................. 24 fenofibrate micronized .......... 24 fenofibrate nanocrystallized . 24 fenofibric acid ....................... 24 fenofibric acid (choline) ....... 24 fenoprofen ............................. 16 fentanyl ................................. 15 fentanyl citrate ...................... 15 fentanyl citrate (pf) ............... 15 fentanyl citrate-0.9%nacl (pf)

.......................................... 15 ferocon .................................. 55 ferosul ................................... 55 ferraplus 90 ........................... 55 ferrex 150 forte ..................... 55 ferrex 150 forte plus ............. 55 ferrex 150 plus ...................... 55 ferrex 28 ................................ 55 FERRIPROX ........................ 30 ferrocite plus ......................... 55 ferrous fumarate .................... 55 ferrous gluconate .................. 55 ferrous sulfate ....................... 55 FETZIMA ............................. 18 finasteride ............................. 52 FIRAZYR ............................. 51 flavoxate ............................... 52 flecainide .............................. 20 fleet laxative ......................... 38


66

FLEXICHAMBER ............... 32 FLOVENT HFA ................... 51 floxin .................................... 31 floxuridine ............................ 10 FLUBLOK 2017-2018 (PF) . 42 FLUBLOK QUAD 2017-2018

(PF) ................................... 42 flucaine ................................. 48 fluconazole ............................. 3 fluconazole in dextrose(iso-o) 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 10 fludrocortisone ..................... 32 flumazenil ............................. 18 flunisolide ............................. 51 fluocinolone .......................... 29 fluocinolone acetonide oil .... 31 fluocinolone and shower cap 29 fluocinonide .......................... 29 fluocinonide-e....................... 29 fluor-a-day (with xylitol) ...... 55 fluorescein-proparacaine ...... 48 fluoride (sodium) ...... 31, 55, 56 fluoritab ................................ 56 fluorometholone ................... 49 fluorouracil ..................... 10, 25 fluoxetine ........................ 18, 19 fluphenazine decanoate ........ 19 fluphenazine hcl ................... 19 flurandrenolide ..................... 29 flurazepam ............................ 19 flurbiprofen........................... 16 flurbiprofen sodium .............. 49 flurox .................................... 48 flutamide............................... 10 fluticasone ...................... 29, 51 FLUTICASONE-

SALMETEROL ............... 51 fluvastatin ............................. 24 fluvoxamine .......................... 19 focalgin 90 dha ..................... 56 focalgin ca ............................ 56 focalgin dss ........................... 56 folbecal ................................. 56 folbee .................................... 56 folbee ar ................................ 56

folbee plus ............................ 56 folbic ..................................... 56 folic acid ............................... 56 folic acid-vit b6-vit b12 ........ 56 folivane-f .............................. 56 folivane-ob............................ 56 folivane-plus ......................... 56 FOLOTYN ........................... 10 folplex 2.2 ............................. 56 fondaparinux ......................... 23 FORTEO .............................. 42 FOSAMAX PLUS D ............ 42 foscarnet ................................. 3 fosinopril .............................. 21 fosinopril-hydrochlorothiazide

.......................................... 21 fosphenytoin ......................... 13 FOSRENOL ......................... 38 FRAGMIN............................ 23 FREESTYLE CONTROL .... 33 FREESTYLE FLASH

SYSTEM .......................... 33 FREESTYLE FREEDOM .... 33 FREESTYLE FREEDOM

LITE ................................. 33 FREESTYLE INSULINX ... 32,

33 FREESTYLE INSULINX

TEST STRIPS .................. 32 FREESTYLE LITE METER 33 FREESTYLE LITE STRIPS 32 FREESTYLE SIDEKICK II 33 FREESTYLE SYSTEM KIT 33 FREESTYLE TEST ............. 32 frovatriptan ........................... 14 furosemide ............................ 21 FUZEON ................................ 3 fyavolv .................................. 44 FYCOMPA ........................... 13 G g tussin ac ............................. 50 gabapentin ............................ 13 GABITRIL ........................... 13 galantamine .......................... 14 ganciclovir sodium ................. 3 gatifloxacin ........................... 47 gavilax .................................. 38

gavilyte-c .............................. 38 gavilyte-g .............................. 38 gavilyte-n .............................. 38 GAZYVA ............................. 10 gemcitabine ........................... 10 gemfibrozil ........................... 24 generlac ................................. 38 gengraf .................................. 10 gentak ................................... 47 gentamicin .................. 6, 27, 47 gentamicin in nacl (iso-osm) .. 6 gentamicin sulfate (ped) (pf) .. 6 gentamicin sulfate (pf) ............ 6 gentle laxative ....................... 38 gentlelax ............................... 38 GENVOYA ............................ 3 gianvi (28) ............................ 45 gildagia ................................. 45 GILENYA ............................ 41 GILOTRIF ............................ 10 glatopa .................................. 41 GLEOSTINE ........................ 10 glimepiride ............................ 36 glipizide ................................ 36 glipizide-metformin .............. 36 GLUCAGEN HYPOKIT ...... 33 GLUCAGON EMERGENCY

KIT (HUMAN) ................. 33 glyburide ............................... 36 glyburide micronized ............ 36 glyburide-metformin ............. 36 glycolax ................................ 38 glycopyrrolate ....................... 37 glydo ..................................... 27 GLYXAMBI ......................... 36 granisetron (pf) ..................... 38 granisetron hcl ...................... 38 GRANIX ............................... 41 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guaiatussin ac ........................ 50 guaifenesin ac ....................... 50 guaifenesin dac ..................... 50 guanfacine ....................... 19, 21 guanidine .............................. 19 GYNAZOLE-1 ..................... 44 gynol ii .................................. 44

Updated 08/25/17


67

H HALAVEN........................... 10 halobetasol propionate.......... 29 HALOG ................................ 29 haloperidol ............................ 19 haloperidol decanoate ........... 19 haloperidol lactate ................ 19 healthylax ............................. 38 heather .................................. 44 HECTOROL......................... 35 hematinic plus vit/minerals .. 56 hematinic/folic acid .............. 56 hematogen ............................ 56 hematogen fa ........................ 56 hematogen forte .................... 56 hemenatal ob ........................ 56 hemenatal ob + dha .............. 56 hemetab ................................ 56 hemmorex-hc ........................ 38 hep flush-10 (pf) ................... 23 heparin (porcine) .................. 23 heparin (porcine) in 5 % dex 23 heparin (porcine) in nacl (pf) 23 heparin flush(porcine)-0.9nacl

.......................................... 23 heparin lock flush ................. 23 heparin lock flush (porcine) . 23 heparin lockflush(porcine)(pf)

.......................................... 23 heparin(porcine) in 0.45% nacl

.......................................... 23 heparin, porcine (pf) ............. 23 HERCEPTIN ........................ 10 HEXALEN ........................... 10 hi-cal plus vit d ..................... 54 homatropaire......................... 48 homatropine hbr ................... 48 hpr ........................................ 25 hpr plus ................................. 25 hpr plus hydrogel .................. 25 HUMALOG ......................... 34 HUMALOG KWIKPEN ...... 34 HUMALOG MIX 50-50 ...... 34 HUMALOG MIX 50-50

KWIKPEN ....................... 34 HUMALOG MIX 75-25 ...... 34

HUMALOG MIX 75-25 KWIKPEN........................ 34

HUMAPEN LUXURA HD .. 33 HUMIRA .............................. 43 HUMIRA PEDIATRIC

CROHN'S START ........... 43 HUMIRA PEN CROHN'S-

UC-HS START ................ 43 HUMIRA PEN PSORIASIS-

UVEITIS .......................... 43 HUMULIN 70/30 ................. 34 HUMULIN 70/30 KWIKPEN

.......................................... 34 HUMULIN N ....................... 34 HUMULIN N KWIKPEN .... 34 HUMULIN R U-100 ............ 34 HUMULIN R U-500 (CONC)

KWIKPEN........................ 34 HUMULIN R U-500

(CONCENTRATED) ....... 34 HYCAMTIN ........................ 10 hydralazine ........................... 22 hydrochlorothiazide .............. 22 hydrocodone-acetaminophen 15 hydrocodone-chlorpheniramine

.......................................... 50 hydrocodone-cpm-

pseudoephed ..................... 50 hydrocodone-homatropine .... 50 hydrocodone-ibuprofen ........ 15 hydrocortisone .......... 29, 32, 38 hydrocortisone acetate .......... 38 hydrocortisone butyrate ........ 29 hydrocortisone butyr-emollient

.......................................... 29 hydrocortisone valerate ........ 29 hydrocortisone-acetic acid .... 31 hydrocortisone-iodoquinol-aloe

.......................................... 27 hydrocortisone-min oil-wht pet

.......................................... 29 hydrocortisone-pramoxine... 25,

38 hydromet ............................... 50 hydromorphone .................... 15 hydromorphone (pf) ............. 15

hydromorphone in 0.9 % nacl .......................................... 15

hydroxocobalamin ................ 56 hydroxychloroquine ................ 6 hydroxyprogesterone caproate

.......................................... 44 hydroxyurea .......................... 10 hydroxyzine hcl .................... 50 hydroxyzine pamoate ............ 50 hyolev mb ............................. 53 hyophen ................................ 53 hyoscyamine sulfate ............. 37 hyosyne ................................. 37 HYSINGLA ER .................... 15 I ibandronate ........................... 42 IBRANCE ............................. 10 ibuprofen ............................... 16 ibuprofen-oxycodone ............ 15 ICAPS MV ........................... 56 ICLUSIG .............................. 10 idarubicin .............................. 10 iferex 150 forte ..................... 56 ifosfamide ............................. 10 ifosfamide-mesna ................. 10 ILARIS (PF) ......................... 42 ILEVRO ............................... 49 imatinib ................................. 10 IMBRUVICA ....................... 10 imipenem-cilastatin ................ 6 imipramine hcl ...................... 19 imipramine pamoate ............. 19 imiquimod ............................. 42 IMPAVIDO ............................ 6 INCRELEX .......................... 30 INCRUSE ELLIPTA ............ 51 indapamide ........................... 22 indomethacin ........................ 16 infed ...................................... 56 INFLECTRA ........................ 38 INLYTA ............................... 10 INSET 30 INFUSION SET 23

.......................................... 34 INSET INFUSION SET 23 .. 34 INSPIRACHAMBER WITH

MASK-LARGE ................ 32


68

INSULIN SYRINGE-NEEDLE U-100 ............... 33

INTELENCE .......................... 3 INTRON A ........................... 42 introvale ................................ 45 INVIRASE ............................. 4 INVOKAMET ...................... 36 INVOKANA ........................ 36 iodoquinol-hc ....................... 27 ipratropium bromide ....... 31, 51 ipratropium-albuterol ........... 51 irbesartan .............................. 22 irbesartan-hydrochlorothiazide

.......................................... 22 IRESSA ................................ 10 irinotecan .............................. 10 ISENTRESS ........................... 4 isibloom ................................ 45 isomethepten-caf-

acetaminophen .................. 14 isoniazid ................................. 6 isosorbide dinitrate ............... 24 isosorbide mononitrate ......... 24 isoxsuprine ........................... 44 isradipine .............................. 22 ISTODAX ............................ 10 itraconazole ............................ 3 ivermectin ............................... 6 IXEMPRA ............................ 10 J JADENU .............................. 30 JAKAFI ................................ 10 jantoven ................................ 23 JANUMET ........................... 36 JANUMET XR ..................... 36 JANUVIA ............................ 36 JARDIANCE ........................ 36 jencycla................................. 44 JENTADUETO .................... 36 JENTADUETO XR.............. 36 JETREA (PF) ....................... 48 jevantique lo ......................... 44 jinteli .................................... 44 jolessa ................................... 45 jolivette ................................. 44 juleber ................................... 45 junel 1.5/30 (21) ................... 45

junel 1/20 (21) ...................... 45 junel fe 1.5/30 (28) ............... 45 junel fe 1/20 (28) .................. 45 junel fe 24 ............................. 45 JUXTAPID ........................... 24 K KADCYLA .......................... 10 kaitlib fe ................................ 45 KALBITOR .......................... 51 KALETRA ............................. 4 KALYDECO ........................ 51 KANUMA ............................ 35 kariva (28) ............................ 45 k-effervescent ....................... 54 kelnor 1/35 (28) .................... 46 KEPIVANCE ......................... 8 ketoconazole ..................... 3, 28 ketoprofen ............................. 16 ketorolac ................... 16, 17, 49 KEYTRUDA ........................ 10 kimidess (28) ........................ 46 KINERET ............................. 42 kionex ................................... 38 kionex (with sorbitol) ........... 39 KITABIS PAK ....................... 6 klor-con ................................ 54 klor-con 10 ........................... 54 klor-con 8 ............................. 54 klor-con m10 ........................ 54 klor-con m15 ........................ 54 klor-con m20 ........................ 54 klor-con sprinkle................... 54 klor-con/ef ............................ 54 K-PHOS NO 2 ...................... 53 K-PHOS ORIGINAL ........... 53 k-phos-neutral ....................... 54 KRYSTEXXA ...................... 42 k-tab ...................................... 54 kurvelo .................................. 46 KUVAN................................ 35 KYPROLIS .......................... 10 L l norgest/e.estradiol-e.estrad . 46 labetalol ................................ 22 lactated ringers ..................... 29 lactic acid .............................. 25 lactic acid e ........................... 25

lactulose ................................ 39 lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine ............................ 13 LANCETS ............................ 34 LANCING DEVICE ............ 34 lansoprazole .......................... 40 LANTUS .............................. 34 LANTUS SOLOSTAR ......... 34 larin 1.5/30 (21) .................... 46 larin 1/20 (21) ....................... 46 larin 24 fe .............................. 46 larin fe 1.5/30 (28) ................ 46 larin fe 1/20 (28) ................... 46 larissia ................................... 46 LARTRUVO ........................ 10 LASTACAFT ....................... 48 latanoprost ............................ 49 LATUDA .............................. 19 laxaclear ................................ 39 laxative (bisacodyl) .............. 39 laxative feminine .................. 39 laxative peg 3350 .................. 39 layolis fe ............................... 46 leena 28 ................................. 46 leflunomide ........................... 43 LEMTRADA ........................ 41 LENVIMA ............................ 10 lessina ................................... 46 letrozole ................................ 10 leucovorin calcium ................. 8 LEUKERAN ......................... 10 LEUKINE ............................. 41 leuprolide .............................. 10 levalbuterol hcl ..................... 51 LEVATOL ............................ 22 LEVEMIR ............................ 34 LEVEMIR FLEXTOUCH .... 34 levetiracetam ......................... 13 levetiracetam in nacl (iso-os) 13 levobunolol ........................... 48 levocarnitine ......................... 30 levocarnitine (with sugar) ..... 30 levofloxacin ...................... 7, 47 levofloxacin in d5w ................ 7 levoleucovorin ........................ 8 LEVOLEUCOVORIN ........... 8

Updated 08/25/17


69

levonest (28) ......................... 46 levonorgestrel-ethinyl estrad 46 levonorg-eth estrad triphasic 46 levora-28............................... 46 levorphanol tartrate .............. 15 levothyroxine ........................ 37 levoxyl .................................. 37 LEXIVA ................................. 4 lidocaine ............................... 27 lidocaine (pf) ........................ 27 lidocaine hcl ......................... 27 lidocaine hcl-hydrocortison ac

.................................... 27, 39 lidocaine viscous .................. 27 lidocaine-epinephrine ........... 27 lidocaine-hydrocortisone-aloe

.......................................... 39 lidocaine-prilocaine .............. 27 lido-k .................................... 27 lidopin .................................. 27 lidopril .................................. 27 lincomycin .............................. 6 lindane .................................. 29 linezolid .................................. 6 linezolid-0.9% sodium chloride

............................................ 6 LINZESS .............................. 39 liothyronine .......................... 37 lipodox .................................. 10 lisinopril ............................... 22 lisinopril-hydrochlorothiazide

.......................................... 22 lite coat aspirin ..................... 17 LITEAIRE MDI CHAMBER

.......................................... 33 lithium carbonate .................. 19 lithium citrate ....................... 19 LIVALO ............................... 24 lomedia 24 fe ........................ 46 LONSURF ............................ 10 loperamide ............................ 37 lopinavir-ritonavir .................. 4 lopreeza ................................ 44 lorazepam ............................. 19 lorazepam intensol................ 19 lorcet (hydrocodone) ............ 15 lorcet hd ................................ 15

lorcet plus ............................. 15 lortuss ex............................... 50 loryna (28) ............................ 46 losartan ................................. 22 losartan-hydrochlorothiazide 22 LOTEMAX .......................... 49 lovastatin .............................. 24 low-ogestrel (28) .................. 46 loxapine succinate ................ 19 lta pre-attached ..................... 27 LUCENTIS ........................... 48 ludent fluoride ...................... 56 lugols .............................. 27, 54 LUMIZYME ........................ 35 LUPRON DEPOT ................ 10 LUPRON DEPOT (3

MONTH) .......................... 10 LUPRON DEPOT-PED ....... 11 LUPRON DEPOT-PED (3

MONTH) .......................... 11 lutera (28) ............................. 46 luxamend .............................. 25 LUZU ................................... 28 LYNPARZA ......................... 11 LYRICA ............................... 13 LYSODREN ......................... 11 lyza ....................................... 44 M m.v.i. adult ............................ 56 MAGNEBIND 300............... 39 magnesium citrate................. 39 MAKENA ............................ 44 malathion .............................. 29 maprotiline............................ 19 marlissa ................................. 46 MARPLAN .......................... 19 MARQIBO ........................... 11 marten-tab ............................. 15 MATULANE........................ 11 matzim la .............................. 22 mb hydrogel .......................... 25 mb hydrogel (cyclomethicone)

.......................................... 25 m-clear wc ............................ 50 meclofenamate ...................... 17 medroxyprogesterone ........... 44 mefenamic acid ..................... 17

mefloquine .............................. 6 megestrol .............................. 11 MEKINIST ........................... 11 meloxicam ............................ 17 melphalan ............................. 11 melphalan hcl ........................ 11 memantine ............................ 14 MENEST .............................. 44 MENTAX ............................. 28 meperidine ............................ 15 MEPHYTON ........................ 23 meprobamate ........................ 14 mercaptopurine ..................... 11 meropenem ............................. 6 MEROPENEM-0.9%

SODIUM CHLORIDE ....... 6 mesalamine ........................... 39 mesalamine with cleansing

wipe .................................. 39 mesna ...................................... 8 MESNEX ................................ 8 MESTINON ......................... 14 metadate er ............................ 19 metaproterenol ...................... 51 metaxall ................................ 14 metaxalone ............................ 14 metformin ............................. 36 methadone ............................. 15 methadose ............................. 15 methamphetamine ................. 19 methazolamide ...................... 49 methenamine hippurate .......... 8 methenamine mandelate ......... 8 methen-sod phos-meth blue-

hyos ................................... 53 methergine ............................ 47 methimazole ......................... 32 METHITEST ........................ 35 methocarbamol ..................... 14 methotrexate sodium ............ 11 methotrexate sodium (pf) ..... 11 methoxsalen .......................... 25 methscopolamine .................. 37 methyclothiazide ................... 22 methyldopa ........................... 22 methyldopa-

hydrochlorothiazide .......... 22


70

methyldopate ........................ 22 methylphenidate hcl ............. 19 methylprednisolone .............. 32 methylprednisolone acetate .. 32 methyltestosterone ................ 35 metipranolol ......................... 48 metoclopramide hcl .............. 39 metolazone ........................... 22 metoprolol succinate ............ 22 metoprolol ta-hydrochlorothiaz

.......................................... 22 metoprolol tartrate ................ 22 metro i.v. ................................ 6 metronidazole ............. 6, 26, 44 metronidazole in nacl (iso-os) 6 mexiletine ............................. 20 mibelas 24 fe ........................ 46 miconazole-3 ........................ 44 MICROCHAMBER ............. 33 microgestin 1.5/30 (21) ........ 46 microgestin 1/20 (21) ........... 46 microgestin fe 1.5/30 (28) .... 46 microgestin fe 1/20 (28) ....... 46 MICROSPACER .................. 33 midazolam ............................ 19 midodrine ............................. 30 migergot ............................... 14 miglitol ................................. 36 milk of magnesia .................. 39 milk of magnesia concentrated

.......................................... 39 millipred ............................... 32 millipred dp .......................... 32 mimvey ................................. 44 mimvey lo ............................. 44 MINIMED INFUSION SET-

MMT 390 ......................... 34 minocycline ............................ 8 minoxidil .............................. 22 MIO INFUSION SET .......... 34 miostat .................................. 49 miralax .................................. 39 MIRENA .............................. 43 mirtazapine ........................... 19 MIRVASO ........................... 26 misoprostol ........................... 40 MITIGARE .......................... 42

mitomycin ............................. 11 mitoxantrone ......................... 11 modafinil .............................. 19 moderiba ............................... 41 moderiba dose pack .............. 41 moexipril .............................. 22 moexipril-hydrochlorothiazide

.......................................... 22 mometasone .................... 29, 51 mondoxyne nl ......................... 8 mono-linyah.......................... 46 mononessa (28)..................... 46 montelukast .......................... 51 MONUROL ............................ 8 morgidox ................................ 8 morphine ......................... 15, 16 morphine (pf) ........................ 15 morphine (pf) in 0.9 % nacl .. 15 morphine concentrate ........... 15 MOTOFEN ........................... 37 MOVANTIK ........................ 39 MOVIPREP .......................... 39 MOXEZA ............................. 47 moxifloxacin ..................... 7, 47 MOXIFLOXACIN-

SOD.ACE,SUL-WATER ... 7 MOZOBIL ............................ 41 MULTAQ ............................. 20 multigen folic ....................... 56 multigen plus ........................ 56 multi-vit with fluoride-iron .. 56 multi-vitamin hp/minerals .... 56 multi-vitamin with fluoride . 56,

57 multivitamins with fluoride .. 57 mupirocin.............................. 27 mupirocin calcium ................ 27 MUSE ................................... 53 MUSTARGEN ..................... 11 mvc-fluoride ......................... 57 my way ................................. 46 MYALEPT ........................... 35 MYCAMINE .......................... 3 mycophenolate mofetil ......... 11 mycophenolate mofetil hcl ... 11 mycophenolate sodium ......... 11 myferon 150 forte ................. 57

MYLERAN .......................... 11 mynatal ................................. 57 mynatal advance ................... 57 mynatal plus .......................... 57 mynatal-z .............................. 57 mynate 90 plus ...................... 57 mynephrocaps ....................... 57 mynephron ............................ 57 MYRBETRIQ ....................... 52 myzilra .................................. 46 N nabumetone ........................... 17 nadolol .................................. 22 nadolol-bendroflumethiazide 22 nafcillin ................................... 7 nafcillin in dextrose iso-osm .. 7 naftifine ................................. 28 NAGLAZYME ..................... 35 nalbuphine ............................ 17 naloxone ............................... 17 naltrexone ............................. 17 naproxen ............................... 17 naproxen sodium .................. 17 naratriptan ............................. 14 NARCAN ............................. 17 NATACYN ........................... 47 nateglinide ............................ 36 NATPARA ........................... 35 natura-lax .............................. 39 nature-throid ......................... 37 NEBUPENT ........................... 6 nebusal .................................. 51 necon 0.5/35 (28) .................. 46 necon 1/50 (28) ..................... 46 necon 7/7/7 (28) .................... 46 nefazodone ............................ 19 neomycin ................................ 6 neomycin-bacitracin-poly-hc 49 neomycin-bacitracin-

polymyxin ......................... 47 neomycin-polymyxin b gu .... 29 neomycin-polymyxin b-

dexameth ........................... 49 neomycin-polymyxin-

gramicidin ......................... 48 neomycin-polymyxin-hc . 31, 49 neo-polycin ........................... 48

Updated 08/25/17


71

neo-polycin hc ...................... 49 NEO-SYNALAR ................. 27 nephplex rx ........................... 57 nephro-vite rx ....................... 57 neuac..................................... 26 NEULASTA ......................... 41 NEUPOGEN ........................ 41 NEVANAC .......................... 49 nevirapine ............................... 4 newgen ................................. 57 NEXAVAR .......................... 11 NEXPLANON ..................... 44 next choice one dose ............ 46 niacin .................................... 24 nicardipine ............................ 22 NICODERM CQ .................. 30 nicorelief............................... 30 nicorette ................................ 30 NICORETTE ........................ 30 nicotine ................................. 31 nicotine (polacrilex) ............. 31 NICOTROL .......................... 31 NICOTROL NS ................... 31 nifedipine .............................. 22 nikki (28) .............................. 46 nilutamide ............................. 11 nimodipine ............................ 22 NINLARO ............................ 11 nisoldipine ............................ 22 nitro-bid ................................ 24 nitrofurantoin .......................... 8 nitrofurantoin macrocrystal .... 8 nitrofurantoin monohyd/m-

cryst .................................... 8 nitroglycerin ......................... 24 nitroglycerin in 5 % dextrose 24 nivatopic plus ....................... 25 nizatidine .............................. 40 nolix ...................................... 29 nora-be .................................. 44 noreth-ethinyl estradiol-iron . 46 norethindrone (contraceptive)

.......................................... 44 norethindrone acetate ........... 44 norethindrone ac-eth estradiol

.................................... 44, 46

norethindrone-e.estradiol-iron .......................................... 46

norgestimate-ethinyl estradiol .......................................... 46

norlyda .................................. 44 norlyroc ................................ 44 nortrel 0.5/35 (28)................. 46 nortrel 1/35 (21).................... 46 nortrel 1/35 (28).................... 46 nortrel 7/7/7 (28) .................. 46 nortriptyline .......................... 19 NORVIR ................................. 4 NOVOLOG .......................... 34 NOVOLOG FLEXPEN ........ 35 NOVOLOG MIX 70-30 ....... 35 NOVOLOG MIX 70-30

FLEXPEN ........................ 35 NOVOLOG PENFILL ......... 35 NOXAFIL .............................. 3 np thyroid ............................. 37 NPLATE ............................... 23 nts step 1 ............................... 31 NUCALA ............................. 51 NUCYNTA .......................... 17 NUCYNTA ER .................... 17 NUEDEXTA ........................ 14 NULOJIX ............................. 11 NUVARING ......................... 44 nyamyc ................................. 28 nyata ..................................... 28 nystatin ............................. 3, 28 nystatin-triamcinolone .......... 28 nystop ................................... 28 O obstetrix dha ......................... 57 OCALIVA ............................ 39 ocella .................................... 46 OCREVUS ........................... 41 octreotide acetate .................. 11 ODEFSEY .............................. 4 OFEV.................................... 52 ofloxacin ..................... 7, 31, 48 ogestrel (28) .......................... 46 olanzapine ............................. 19 olanzapine-fluoxetine ........... 19 olmesartan ............................ 22

olmesartan-amlodipin-hcthiazid ........................... 22

olmesartan-hydrochlorothiazide .......... 22

olopatadine ..................... 31, 48 OLYSIO ................................. 4 omega-3 acid ethyl esters ..... 24 omeprazole ........................... 40 omeprazole magnesium ........ 40 omeprazole-sodium

bicarbonate ....................... 40 OMNIPOD INSULIN REFILL

.......................................... 34 OMNITROPE ....................... 41 ONCASPAR ......................... 11 ondansetron ........................... 39 ondansetron hcl ..................... 39 ondansetron hcl (pf) .............. 39 one daily women's health ..... 57 ONFI ..................................... 13 ONIVYDE ............................ 11 opcicon one-step ................... 46 OPDIVO ............................... 11 opium tincture ....................... 37 OPSUMIT ............................. 52 OPTICHAMBER DIAMOND

LG MASK ........................ 33 option-2 ................................. 46 oral saline laxative ................ 39 oralone .................................. 31 ORBACTIV ............................ 6 ORENCIA ............................ 43 ORFADIN ............................ 30 ORKAMBI ........................... 52 orphenadrine citrate .............. 14 orsythia ................................. 46 ortho d ................................... 57 oscimin ................................. 37 oscimin sl .............................. 37 oscimin sr .............................. 37 oseltamivir .............................. 4 OSPHENA ............................ 44 OTEZLA ............................... 43 OTEZLA STARTER ............ 43 oxacillin .................................. 7 oxacillin in dextrose(iso-osm) 7 oxaliplatin ............................. 11


72

oxandrolone .......................... 35 oxaprozin .............................. 17 oxazepam .............................. 19 oxcarbazepine ....................... 13 oxiconazole........................... 28 oxybutynin chloride.............. 52 oxycodone ............................ 16 oxycodone-acetaminophen ... 16 oxycodone-aspirin ................ 16 OXYCONTIN ...................... 16 oxymorphone ........................ 16 oysco 500/d .......................... 54 oyster shell + d3 ................... 54 oyster shell calcium-vit d3 ... 54 oystercal-d ............................ 54 OZURDEX ........................... 49 P pacerone ............................... 20 paclitaxel .............................. 11 paliperidone .......................... 19 pamidronate .......................... 35 PANRETIN .......................... 25 pantoprazole ................... 40, 41 papaverine ............................ 22 PARAGARD T 380A .......... 43 paregoric ............................... 37 paricalcitol ............................ 35 paroex oral rinse ................... 31 paromomycin .......................... 6 paroxetine hcl ....................... 19 PASER ................................... 6 peg 3350-electrolytes ........... 39 peg3350 ................................ 39 PEGANONE ........................ 13 PEGASYS ............................ 41 PEGASYS PROCLICK ....... 41 peg-electrolyte soln .............. 39 peg-prep ................................ 39 PEN NEEDLE ...................... 34 penicillin g potassium............. 7 penicillin g procaine ............... 7 penicillin g sodium ................. 7 penicillin v potassium............. 7 PENTASA ............................ 39 pentoxifylline ....................... 23 PERFOROMIST .................. 52 perindopril erbumine ............ 22

periogard ............................... 31 PERJETA ............................. 11 permethrin ............................ 29 perphenazine ......................... 19 perphenazine-amitriptyline ... 19 pfizerpen-g.............................. 7 phenadoz ............................... 50 phenazopyridine ................... 53 phenelzine ............................. 19 phenergan ............................. 50 phenobarbital ........................ 13 phenohytro ............................ 37 phenoxybenzamine ............... 22 phentolamine ........................ 22 phenylephrine hcl ................. 49 phenytoin .............................. 13 phenytoin sodium ................. 13 phenytoin sodium extended .. 13 philith.................................... 46 phospha 250 neutral.............. 54 phosphasal ............................ 53 phosphate laxative ................ 39 PHOSPHOLINE IODIDE .... 48 PHOTOFRIN........................ 11 PICATO................................ 25 pilocarpine hcl .......... 30, 31, 48 pimozide ............................... 19 pimtrea (28) .......................... 47 pindolol ................................. 22 pioglitazone .......................... 36 pioglitazone-glimepiride ...... 36 pioglitazone-metformin ........ 36 piperacillin-tazobactam .......... 7 pirmella ................................. 47 piroxicam .............................. 17 PLAN B ONE-STEP ............ 47 PLEGRIDY .......................... 41 PLIAGLIS ............................ 27 PNEUMOVAX 23 ............... 42 pnv 29-1 ................................ 57 pnv ob+dha ........................... 57 pnv-dha ................................. 57 pnv-dha + docusate ............... 57 pnv-ferrous fumarate-docu-fa

.......................................... 57 pnv-omega ............................ 57 pnv-select.............................. 57

pnv-vp-u ............................... 57 POCKET CHAMBER .......... 33 podofilox ............................... 25 polycin .................................. 48 polyethylene glycol 3350 ..... 39 poly-iron ............................... 57 poly-iron 150 forte ................ 57 polymyxin b sulfate ................ 6 polymyxin b sulf-trimethoprim

.......................................... 48 POMALYST ......................... 41 portia ..................................... 47 pot,sodium citrate-citric acid 53 potassium acetate .................. 54 potassium bicarb and chloride

.......................................... 54 potassium bicarb-citric acid .. 54 potassium chlorid-d5-

0.45%nacl ......................... 54 potassium chloride ................ 54 potassium chloride in 0.9%nacl

.......................................... 54 potassium chloride in 5 % dex

.......................................... 54 potassium chloride in lr-d5 ... 54 potassium chloride-0.45 % nacl

.......................................... 54 potassium chloride-d5-

0.2%nacl ........................... 54 potassium chloride-d5-

0.3%nacl ........................... 54 potassium chloride-d5-

0.9%nacl ........................... 54 potassium citrate ................... 53 potassium citrate-citric acid .. 53 potassium phosphate m-/d-

basic .................................. 54 powderlax ............................. 39 pr natal 400 ........................... 57 pr natal 400 ec ...................... 57 pr natal 430 ........................... 57 pr natal 430 ec ...................... 57 PRADAXA ........................... 23 PRALUENT PEN ................. 24 pramcort ................................ 39 pramipexole .......................... 13 pravastatin ............................. 24

Updated 08/25/17


73

prazosin ................................ 22 PRED MILD ........................ 49 prednicarbate ........................ 29 prednisolone ......................... 32 prednisolone acetate ............. 49 prednisolone sodium phosphate

.................................... 32, 49 prednisone ............................ 32 prednisone intensol ............... 32 prena1 chew.......................... 57 prena1 pearl .......................... 57 prena1 true ............................ 57 prenaissance ......................... 57 prenaissance plus .................. 57 prenatabs fa .......................... 57 prenatabs rx .......................... 57 prenatal ................................. 57 prenatal formula ................... 57 prenatal plus ......................... 57 prenatal plus (calcium carb) . 57 prenatal vitamin plus low iron

.......................................... 57 prenatal vits96-iron fum-folic

.......................................... 58 prenatal-u .............................. 58 preplus .................................. 58 PREPOPIK ........................... 39 pretab .................................... 58 prevalite ................................ 24 previfem ............................... 47 PREVNAR 13 (PF) .............. 42 PREZCOBIX .......................... 4 PREZISTA ............................. 4 PRIFTIN ................................. 6 PRIMAQUINE ....................... 6 PRIMEAIRE ........................ 33 primidone ............................. 13 PROAIR HFA ...................... 52 PROAIR RESPICLICK ....... 52 probenecid ............................ 42 probenecid-colchicine .......... 42 procainamide ........................ 20 procentra ............................... 19 PROCHAMBER .................. 33 prochlorperazine ................... 39 prochlorperazine edisylate.... 39 prochlorperazine maleate ..... 39

PROCRIT ............................. 41 procto-med hc ....................... 39 procto-pak ............................. 39 proctosol hc .......................... 39 proctozone-hc ....................... 39 PROFERRIN-FORTE .......... 58 progesterone micronized ...... 44 PROGLYCEM ..................... 33 PROGRAF ........................... 11 PROLASTIN-C .................... 30 PROLEUKIN ....................... 42 PROMACTA ........................ 23 promethazine ........................ 50 promethazine vc-codeine ...... 50 promethazine-codeine .......... 50 promethazine-dm .................. 50 promethazine-phenyleph-

codeine.............................. 50 promethazine-phenylephrine 50 promethegan ......................... 50 propafenone .......................... 20 proparacaine ......................... 48 propranolol ........................... 22 propranolol-hydrochlorothiazid

.......................................... 22 propylthiouracil .................... 32 prosight ................................. 58 protamine .............................. 23 protriptyline .......................... 19 PROVENGE ......................... 42 pruclair.................................. 25 prudoxin................................ 25 prumyx.................................. 25 prutect ................................... 25 pulmosal ............................... 52 PULMOZYME ..................... 52 purelax .................................. 39 purevit dualfe plus ................ 58 PURIXAN ............................ 11 pyrazinamide .......................... 6 pyridostigmine bromide ....... 14 Q quasense................................ 47 quazepam .............................. 19 quetiapine ....................... 19, 20 QUICK-SET PARADIGM... 34 quinapril................................ 22

quinapril-hydrochlorothiazide .......................................... 22

quinidine gluconate .............. 20 quinidine sulfate ................... 20 quinine sulfate ........................ 6 quit 2 ..................................... 31 QUIT 2 .................................. 31 quit 4 ..................................... 31 QUIT 4 .................................. 31 QVAR ................................... 52 R rabeprazole ........................... 41 RADICAVA ......................... 14 rajani ..................................... 47 raloxifene .............................. 42 ramipril ................................. 22 ranitidine hcl ......................... 41 RAPAFLO ............................ 53 RAPAMUNE ........................ 11 RAPIVAB ............................... 4 rasagiline ............................... 13 RAVICTI .............................. 30 rea lo 39 ................................ 26 rea lo 40 ................................ 26 REBIF (WITH ALBUMIN) . 41 REBIF REBIDOSE .............. 42 REBIF TITRATION PACK . 42 reclipsen (28) ........................ 47 RECTIV ................................ 39 regonol .................................. 14 REGRANEX ........................ 26 relador pak ............................ 27 relador pak plus .................... 27 relcof c .................................. 50 RELENZA DISKHALER ...... 4 RELION NOVOLIN 70/30 .. 35 RELION NOVOLIN N ........ 35 RELION NOVOLIN R ......... 35 RELISTOR ........................... 39 relnate dha ............................ 58 REMICADE ......................... 39 REMODULIN ...................... 22 RENACIDIN ........................ 53 renal caps .............................. 58 rena-vite rx ............................ 58 reno caps ............................... 58 RENVELA ........................... 39


74

repaglinide ............................ 36 repaglinide-metformin .......... 36 REPATHA PUSHTRONEX 24 REPATHA SURECLICK .... 24 REPATHA SYRINGE ......... 24 RESCRIPTOR ........................ 4 RESTASIS ........................... 48 RESTASIS MULTIDOSE ... 48 RETROVIR ............................ 4 REVLIMID .......................... 42 revonto .................................. 14 REXULTI ............................. 20 REYATAZ ............................. 4 RIASTAP ............................. 24 ribasphere ............................. 42 ribasphere ribapak ................ 42 ribavirin ............................ 4, 42 RIDAURA ............................ 43 rifabutin .................................. 6 RIFAMATE ........................... 6 rifampin .................................. 6 RIFATER ............................... 6 riluzole .................................. 30 rimantadine ............................. 4 ringer's .................................. 29 risedronate ................ 30, 42, 43 RISPERDAL CONSTA ....... 20 risperidone ............................ 20 RITEFLO AEROCHAMBER

.......................................... 33 RITUXAN ............................ 11 rivastigmine .......................... 14 rivastigmine tartrate.............. 14 rivelsa ................................... 47 rizatriptan ............................. 14 ropinirole .............................. 13 rosadan ................................. 26 rosula cleansing cloths ......... 26 rosuvastatin........................... 24 roweepra ............................... 13 ROZEREM ........................... 20 RUBRACA .......................... 11 RYDAPT .............................. 11 rydex ..................................... 50 S SABRIL ................................ 13 SAFE-CLIP BY MAIL ........ 34

salicylic acid ......................... 25 salicylic acid er-ceramides ... 25 salsalate ................................ 17 salvax .................................... 25 SAMSCA ............................. 35 SANDIMMUNE .................. 11 SANDOSTATIN LAR

DEPOT ............................. 11 SANTYL .............................. 29 SAVELLA ............................ 43 scalacort ................................ 29 seb-prev ................................ 25 seconal sodium ..................... 20 selegiline hcl ......................... 13 selenium sulfide .................... 25 SELZENTRY ......................... 4 se-natal 19............................. 58 se-natal 19 (with docusate) ... 58 SENSIPAR ........................... 35 sertraline ............................... 20 se-tan plus ............................. 58 setlakin.................................. 47 sevelamer carbonate ............. 39 sf 31 sf 5000 plus .......................... 31 sharobel ................................ 44 SIGNIFOR............................ 11 sildenafil ............................... 52 silver nitrate .......................... 26 silver nitrate applicators ....... 26 silver sulfadiazine ................. 25 SIMBRINZA ........................ 49 SIMPONI.............................. 43 SIMULECT .......................... 11 simvastatin ............................ 24 sirolimus ............................... 11 SIRTURO ............................... 6 SIVEXTRO ............................ 6 smoothlax ............................. 39 SNAP INSULIN PUMP-

INFUSION SET ............... 34 sodium benzoate-sod

phenylacet ......................... 30 sodium chlor 0.9% bacteriostat

.......................................... 30 sodium chloride ........ 30, 52, 54 sodium chloride 0.45 % ........ 54

sodium chloride 0.9 % .......... 30 sodium chloride 3 % ............. 54 sodium chloride 5 % ............. 54 sodium citrate-citric acid ...... 53 sodium ferric gluconat-sucrose

.......................................... 30 sodium phenylbutyrate ......... 30 sodium phosphate ................. 54 sodium polystyrene sulfonate

.......................................... 40 SOLIRIS ............................... 30 SOMAVERT ........................ 35 sonafine ................................. 26 SOOLANTRA ...................... 26 sotalol ................................... 20 sotalol af ............................... 20 SOTYLIZE ........................... 20 sp antipruritic ........................ 26 sp scar management .............. 26 spinosad ................................ 29 SPIRIVA WITH

HANDIHALER ................ 52 spironolactone ....................... 22 spironolacton-hydrochlorothiaz

.......................................... 22 SPORANOX ........................... 3 sprintec (28) .......................... 47 SPRYCEL ............................. 11 sps (with sorbitol) ................. 40 sronyx ................................... 47 ss 10-2 ................................... 26 ssd ......................................... 25 sss 10-5 ................................. 26 stavudine ................................. 4 STELARA ............................ 25 STIMATE ............................. 35 STIVARGA .......................... 11 stop smoking aid ................... 31 STRENSIQ ........................... 35 stress b with zinc .................. 58 stress formula ........................ 58 stress formula with iron ........ 58 STRIBILD .............................. 4 STRIVERDI RESPIMAT .... 52 strong iodine ......................... 54 SUBOXONE ........................ 17 SUCRAID ............................. 40

Updated 08/25/17


75

sucralfate .............................. 41 sulfacetamide sodium ..... 25, 49 sulfacetamide sodium (acne) 27 sulfacetamide sodium-sulfur 26 sulfacetamide sod-sulfur-urea

.......................................... 26 sulfacetamide-prednisolone .. 49 sulfacetamide-sulfur-cleansr23

.......................................... 26 sulfacleanse 8-4 .................... 26 sulfact na-sul-avobnz-otn-ocsa

.......................................... 26 sulfadiazine............................. 7 sulfamethoxazole-trimethoprim

............................................ 7 SULFAMYLON .................. 27 sulfasalazine ......................... 40 sulfatrim ................................. 7 sulindac................................. 17 sumatriptan ........................... 14 sumatriptan succinate ........... 14 super b complex-vitamin c ... 58 super b-50 complex plus ...... 58 super quints b-50 .................. 58 superplex-t ............................ 58 SUPREP BOWEL PREP KIT

.......................................... 40 SURE-T PARADIGM ......... 34 SUSTIVA ............................... 4 SUTENT .............................. 11 syeda ..................................... 47 SYLATRON......................... 42 SYLVANT ........................... 12 symax fastabs ....................... 37 symax-sl ............................... 37 symax-sr ............................... 37 SYMBICORT ...................... 52 SYMLINPEN 120 ................ 36 SYMLINPEN 60 .................. 36 SYNAGIS .............................. 4 SYNAREL ........................... 35 SYNJARDY ......................... 36 SYNJARDY XR .................. 36 SYNTHROID ....................... 37 T T

30 INFUSION SET .......... 34

90 INFUSION SET 23 ..... 34 SLIM ................................ 34 SLIM G4........................... 34

TABLOID ............................ 12 tacrolimus ....................... 12, 26 TAFINLAR .......................... 12 TAGRISSO .......................... 12 TAMIFLU .............................. 4 tamoxifen .............................. 12 tamsulosin ............................. 53 TANZEUM .......................... 36 TARCEVA ........................... 12 TARGRETIN ....................... 12 tarina fe 1/20 (28) ................. 47 taron forte ............................. 58 taron-c dha ............................ 58 taron-prex prenatal-dha ........ 58 TASIGNA ............................ 12 tazarotene.............................. 26 TAZORAC ........................... 26 taztia xt ................................. 22 TECENTRIQ ........................ 12 TECFIDERA ........................ 42 TECHNIVIE ........................... 4 telmisartan ............................ 22 telmisartan-amlodipine ......... 22 telmisartan-hydrochlorothiazid

.......................................... 22 temazepam ............................ 20 TEMODAR .......................... 12 temozolomide ....................... 12 tencon ................................... 16 TENIPOSIDE ....................... 12 terazosin................................ 23 terbinafine hcl ......................... 3 terbutaline ............................. 52 terconazole............................ 44 TESTOPEL .......................... 35 testosterone ........................... 35 testosterone cypionate .......... 35 testosterone enanthate ........... 35 tetcaine.................................. 48 tetrabenazine ......................... 14 tetracaine hcl......................... 48 tetracaine hcl (pf) .................. 48 tetracycline ............................. 8 THALOMID ......................... 12

theochron .............................. 52 theophylline .......................... 52 thermazene ............................ 25 thioridazine ........................... 20 thiotepa ................................. 12 thiothixene ............................ 20 thrivite-19 ............................. 58 THYROLAR-1 ..................... 37 THYROLAR-1/2 .................. 37 THYROLAR-1/4 .................. 37 THYROLAR-2 ..................... 37 THYROLAR-3 ..................... 37 tiagabine ............................... 13 ticlopidine ............................. 24 tilia fe .................................... 47 timolol maleate ............... 23, 48 tinidazole ................................ 7 tis-u-sol pentalyte ................. 29 TIVICAY ................................ 4 tizanidine .............................. 14 tl gard rx ............................... 58 tl g-fol os ............................... 58 tl icon .................................... 58 tl-hem 150 ............................. 58 tobramycin ............................ 48 tobramycin in 0.225 % nacl .... 7 tobramycin in 0.9 % nacl ........ 7 tobramycin sulfate .................. 7 tobramycin-dexamethasone .. 49 tolazamide ............................. 36 tolbutamide ........................... 36 tolcapone ............................... 13 tolmetin ................................. 17 tolterodine ............................. 52 topiramate ............................. 13 toposar .................................. 12 topotecan ............................... 12 TORISEL .............................. 12 torsemide .............................. 23 total b/c ................................. 58 TOVIAZ ............................... 52 TRACLEER ......................... 52 TRADJENTA ....................... 36 tramadol ................................ 17 tramadol-acetaminophen ...... 17 trandolapril ........................... 23 trandolapril-verapamil .......... 23


76

tranexamic acid .............. 24, 44 tranylcypromine ................... 20 TRAVATAN Z .................... 49 trazodone .............................. 20 TREANDA ........................... 12 TRECATOR ........................... 7 tretinoin ................................ 27 tretinoin (chemotherapy) ...... 12 tretinoin microspheres .......... 27 TREXALL ............................ 12 tri femynor ............................ 47 TRIACETIN ......................... 28 triamcinolone acetonide 29, 31,

32 triamterene-hydrochlorothiazid

.......................................... 23 trianex ................................... 29 triazolam ............................... 20 tricitrates ............................... 53 tricon..................................... 58 triderm .................................. 29 tri-estarylla ........................... 47 trifluoperazine ...................... 20 trifluridine............................. 48 trigels-f forte ......................... 58 trihexyphenidyl .................... 13 tri-legest fe............................ 47 tri-linyah ............................... 47 tri-lo-estarylla ....................... 47 tri-lo-marzia .......................... 47 tri-lo-sprintec ........................ 47 trilyte with flavor packets ..... 40 trimethobenzamide ............... 40 trimethoprim ........................... 8 trimipramine ......................... 20 trinatal gt .............................. 58 trinatal rx 1 ........................... 58 trinate .................................... 58 trinessa (28) .......................... 47 trinessa lo.............................. 47 TRINTELLIX....................... 20 triphrocaps ............................ 58 tri-previfem (28) ................... 47 TRISENOX .......................... 12 tri-sprintec (28) ..................... 47 tri-tabs dha ............................ 58 TRIUMEQ .............................. 4

triveen-duo dha ..................... 58 tri-vit with fluoride and iron . 58 tri-vitamin with fluoride ....... 58 trivora (28) ............................ 47 tropicamide ........................... 48 trospium ................................ 52 trust natal dha ....................... 58 TRUVADA ............................ 4 TUDORZA PRESSAIR ....... 52 tusnel c .................................. 50 tussigon ................................. 50 TYGACIL .............................. 7 TYKERB .............................. 12 TYMLOS.............................. 43 TYSABRI ............................. 14 TYVASO .............................. 52 TYVASO REFILL KIT........ 52 TYVASO STARTER KIT ... 52 U UCERIS ................................ 40 ULESFIA.............................. 29 ULORIC ............................... 42 ultimatecare one ................... 58 ultimatecare one nf ............... 58 ultra b-100 complex.............. 58 umecta .................................. 26 unithroid ............................... 37 UNITUXIN .......................... 12 UPTRAVI ............................. 23 ur n-c..................................... 53 uramit mb ............................. 53 urea ....................................... 26 urea nail stick........................ 26 ure-k...................................... 26 uretron d-s............................. 53 urimar-t ................................. 53 urin ds ................................... 53 uro-458 ................................. 53 urogesic-blue ........................ 53 uro-mp .................................. 53 urophen mb ........................... 53 ursodiol ................................. 40 uryl........................................ 53 ustell ..................................... 53 utira-c.................................... 53 UVADEX ............................. 26

V vaginal contraceptive foam ... 44 valacyclovir ............................ 4 VALCHLOR ........................ 26 valganciclovir ......................... 4 valproate sodium .................. 13 valproic acid ......................... 13 valproic acid (as sodium salt)

.......................................... 13 valsartan ................................ 23 valsartan-hydrochlorothiazide

.......................................... 23 vancomycin ............................. 8 VANCOMYCIN IN 0.9%

SODIUM CL ...................... 8 VANCOMYCIN IN

DEXTROSE 5 % ................ 8 vandazole .............................. 44 VANTAS .............................. 12 VARUBI ............................... 40 VASCEPA ............................ 24 v-c forte ................................ 58 VECTIBIX ........................... 12 VELCADE ........................... 12 veletri .................................... 23 velivet triphasic regimen (28)

.......................................... 47 VELPHORO ......................... 40 VELTASSA .......................... 40 VELTIN ................................ 27 vemavite-prx-2 ..................... 58 VEMLIDY .............................. 4 VENCLEXTA ...................... 12 VENCLEXTA STARTING

PACK ............................... 12 venlafaxine ........................... 20 VENOFER ............................ 58 VENTAVIS .......................... 52 VENTOLIN HFA ................. 52 verapamil .............................. 23 verdrocet ............................... 16 VEREGEN ........................... 26 veripred 20 ............................ 32 VESICARE ........................... 52 vestura (28) ........................... 47 VGO 20 ................................ 34 VGO 30 ................................ 34

Updated 08/25/17


77

VGO 40 ................................ 34 VIAGRA .............................. 53 VIBERZI .............................. 40 vic-forte ................................ 58 vicodin .................................. 16 vicodin es.............................. 16 vicodin hp ............................. 16 VICTOZA 2-PAK ................ 37 VICTOZA 3-PAK ................ 37 VIDEX 2 GRAM PEDIATRIC

............................................ 4 VIEKIRA PAK ...................... 4 VIEKIRA XR ......................... 4 vienva ................................... 47 VIIBRYD ............................. 20 VIMIZIM ............................. 35 VIMPAT .............................. 13 vinate care ............................ 58 vinate dha ............................. 58 vinate ii ................................. 58 vinate m ................................ 58 vinate one ............................. 58 vinate ultra ............................ 58 vinblastine ............................ 12 vincasar pfs ........................... 12 vincristine ............................. 12 vinorelbine ............................ 12 VIOKACE ............................ 40 viorele (28) ........................... 47 VIRACEPT ............................ 4 VIREAD ................................. 4 virt-advance .......................... 58 virt-c dha .............................. 59 virt-gard ................................ 59 virt-nate ................................ 59 virt-nate dha.......................... 59 virt-phos 250 neutral ............ 54 virt-pn ................................... 59 virt-pn dha ............................ 59 virt-pn plus ........................... 59 virtrate-2 ............................... 53 virtrate-3 ............................... 53 virtrate-k ............................... 53 virt-select .............................. 59 virtussin ac............................ 50 virtussin dac.......................... 50 virt-vite ................................. 59

virt-vite forte......................... 59 virt-vite gt ............................. 59 VISTOGARD ......................... 8 vit 3 ....................................... 59 VITAFOL-OB ...................... 59 vitajoy daily d ....................... 59 vitamin b complex ................ 59 vitamin d3 ............................. 59 vitamin k ............................... 24 vitamin k1 ............................. 24 vitamins a,c,d and fluoride ... 59 VIVITROL ........................... 17 vol-care rx............................. 59 vol-nate ................................. 59 vol-plus ................................. 59 vol-tab rx .............................. 59 voriconazole ........................... 3 VORTEX HOLDING

CHAMBER CHILD ......... 33 VORTEX VHC FROG

MASK-CHILD ................. 33 VORTEX VHC LADYBUG

MASK-TODDLR ............. 33 VOTRIENT .......................... 12 vp-ch plus ............................. 59 vp-ch-pnv.............................. 59 vp-ggr-b6 .............................. 59 vp-heme ob ........................... 59 vp-heme one ......................... 59 VPRIV .................................. 35 vp-vite rx .............................. 59 vyfemla (28) ......................... 47 VYVANSE ........................... 20 W warfarin ................................ 24 water for irrigation, sterile .... 30 wera (28)............................... 47 westhroid .............................. 37 WIDE-SEAL DIAPHRAGM

.......................................... 43 woman's laxative .................. 40 women's gentle laxative(bisac)

.......................................... 40 women's laxative (bisacodyl)40 wymzya fe ............................ 47 X XALKORI ............................ 12

XARELTO ........................... 24 XERMELO ........................... 12 XGEVA .................................. 8 XIFAXAN .............................. 7 XIGDUO XR ........................ 37 XOLAIR ............................... 52 xulane ................................... 44 XURIDEN ............................ 30 xylon 10 ................................ 16 XYREM ................................ 20 Y YERVOY ............................. 12 YONDELIS .......................... 12 yuvafem ................................ 44 Z zafirlukast ............................. 52 zaleplon ................................. 20 zamicet .................................. 16 ZANOSAR ........................... 12 zarah ..................................... 47 ZARXIO ............................... 41 zatean-ch ............................... 59 zatean-pn dha ........................ 59 zatean-pn plus ....................... 59 zavara .................................... 59 ZAVESCA ............................ 35 zebutal ................................... 16 ZEJULA ............................... 12 ZELBORAF ......................... 12 ZEMAIRA ............................ 30 zenatane ................................ 27 zenchent (28) ........................ 47 zenchent fe ............................ 47 zenzedi .................................. 20 ZEPATIER ............................. 4 ZERBAXA ............................. 5 ZEVALIN (Y-90) ................. 12 ZIAGEN ................................. 4 zidovudine .............................. 4 zileuton ................................. 52 zingiber ................................. 59 ZIOPTAN (PF) ..................... 49 ziprasidone hcl ...................... 20 ZIRGAN ............................... 48 ZODRYL AC 40 .................. 50 ZODRYL DEC 30 ................ 50 ZOLADEX ........................... 12


78

zoledronic acid ..................... 35 zoledronic acid-mannitol-water

.......................................... 30 ZOLINZA............................. 12 zolmitriptan .......................... 14 zolpidem ............................... 20 ZOMETA ............................. 35

ZOMIG ................................. 14 zonisamide ............................ 13 ZORTRESS .......................... 12 ZOSTAVAX (PF) ................ 42 zovia 1/35e (28) .................... 47 zovia 1/50e (28) .................... 47 ZOVIRAX ............................ 28

ZUBSOLV ............................ 17 ZYDELIG ............................. 12 ZYFLO ................................. 52 ZYKADIA ............................ 12 ZYTIGA ............................... 12 ZYVOX .................................. 7

yourcare health plan

Documents