2019 medicare part d drug formulary - emblemhealth...2019 medicare part d drug formulary national...

2019 Medicare Part D Drug FormularyNational Drug Plan (PDP) Abridged Medication List

This abridged formulary was updated on 12 . This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact EmblemHealth Medicare at 800-585-5786 or, for TTY users, 800-899-2114, 24 hours a day, 7 days a week. Or visit emblemhealth.com/medicare.

i

EmblemHealth National Drug Plan (PDP) Formulary 2019 Abridged Formulary(Partial List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

9Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Health Plan of New York (HIP)/EmblemHealth and Group Health Incorporated (GHI)/EmblemHealth. When it refers to “plan” or “our plan,” it means EmblemHealth National Drug Plan (PDP) plan.

This document includes a partial list of the drugs (formulary) for our plan, which is current as of 12/1 . For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

The formulary and pharmacy network may change at any time. You will receive notice when necessary.

ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call 1-877-344-7364 (TTY: 711) ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al, 877-344-7364 (TTY: 711).

Group Health Incorporated (GHI) is a standalone PDP with a Medicare contract. Enrollment in GHI depends on contract renewal. GHI is an EmblemHealth company.

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EmblemHealth National Drug Plan (PDP)

What is the EmblemHealth National Drug Plan (PDP) Abridged Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

This document is a partial formulary and includes only some of the drugs covered by our plan. For a complete listing of all prescription drugs covered by, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

Can the formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:

• New generic drugs. We may immediately remove a brand-name drug on our druglist if we are replacing it with a new generic drug that will appear on the same orlower cost-sharing tier and with the same or fewer restrictions. Also, when addingthe new generic drug, we may decide to keep the brand-name drug on our drug list,but immediately move it to a different cost-sharing tier or add new restrictions. If youare currently taking that brand-name drug, we may not tell you in advance before wemake that change, but we will later provide you with information about the specificchange(s) we have made.– I

• Drugs removed from the market. If the Food and Drug Administration (FDA) deemsa drug on our formulary to be unsafe or the drug’s manufacturer removes the drugfrom the market, we will immediately remove the drug from our formulary andprovide notice to members who take the drug.


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• Other chang es. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to market to replace abrand-name drug currently on the formulary, or add new restrictions to the brand-name drug or move it to a different cost-sharing tier. Or we may make changes basedon new clinical guidelines. If we remove drugs from our formulary, add priorauthorization, quantity limits, and/or step therapy restrictions on a drug or move adrug to a higher cost-sharing tier, we must notify affected members of the change atleast 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 30-day supply ofthe drug.

The enclosed formulary is current as of 12 . To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

Note: In the event of a mid-year, non-maintenance formulary change, the change is added to a comprehensive list of changes that have been made since the formulary was printed. The list of changes is included with the formulary booklet that is mailed to new members with their welcome kit. Existing members can view the updated formulary by visiting us on the web at www.emblemhealth.com/medicare. The formulary that is posted on our website is updated.

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

Medical ConditionThe formulary begins on page 2. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Hypertensive/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 2. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 131. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

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Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Our plan requires your physician to get prior authorization forcertain drugs. This means that you will need to get approval from our plan before youfill your prescriptions. If you don’t get approval, our plan may not cover the drug.

• Quantity Limits: For certain drugs, our plan limit the amount of the drug that we willcover. For example, our plan provides 30 tablets per prescription for JANUVIA®. Thismay be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, our plan requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, our plan may notcover Drug B unless you try Drug A first. If Drug A does not work for you, our plan willthen cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to EmblemHealth National Drug Plan (PDP) Formulary?” on page iv for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so our plan may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you learn that our plan does not cover your drug, you have two options:

• Y ou can ask Customer Services for a list of similar drugs that are covered by our plan.When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by our plan.

• Y ou can ask our plan to make an exception and cover your drug. See below forinformation about how to request an exception.


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How do I request an exception to the EmblemHealth National Drug Plan (PDP) Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• Y ou can ask us to cover a drug even if it is not on our formulary. If approved, this drugwill be covered at a pre-determined cost-sharing level, and you would not be able toask us to provide the drug at a lower cost-sharing level.

• Y ou can ask us to cover a formulary drug at a lower cost-sharing level if this drug isnot on the specialty tier. If approved, this would lower the amount you must pay foryour drug.

• Y ou can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, our plan limit the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you are a current member in our plan and you experience a change in the level of care, such as an admission or discharge from the long-term care facility, you will be allowed an “early” refill of your medications, as needed, to assist with your transition to your new level of care for more information.

For more informationFor more detailed information about your EmblemHealth Medicare HMO prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/seven days a week. TTY users should call 877-486-2048. Or, visit medicare.gov.

EmblemHealth National Drug Plan (PDP) Formulary The abridged formulary that begins on page 2 provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 131.

Remember: This is only a partial list of drugs covered by our plan. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SYNTHROID and generic drugs are listed in lower-case italics (e.g., levothyroxine).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug.


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List of AbbreviationsB/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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

MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

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.

Please refer to your plan Benefit Summary about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in listed in Benefit Summary about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Customer Service at the numbers listed on the back cover and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).

Please Note: Employer Group Waiver Plan (EGWP) please refer to your Cost Sharing Guide or contact Customer Service for benefit details and cost sharing amounts.

(Continued)

Y0026_126476 Accepted 8/29/16Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are

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Notice of Nondiscrimination Policy EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

EmblemHealth: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages

If you need these services, contact 1-877-411-3625.

If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call 1-877- 411-3625. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services).

Complaint forms are available at hhs.gov/ocr/office/file/index.html.

Y0026_126477 NM

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Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column

that tells you if there are any special requirements for coverage of your drug.

List of Abbreviations

B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the

circumstances. Information may need to be submitted describing the use and setting of the drug to make the

determination.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more

information, please call Customer Service.

MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through

our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such

as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term

prescriptions (such as antibiotics).

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.

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

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Drug Name Drug Tier Requirements/Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET INTRAVENOUS SUSPENSION 4 B/D PA; MO

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

4 B/D PA; MO

amphotericin b injection recon soln 3 B/D PA; MO

ANCOBON ORAL CAPSULE 4 MO

CANCIDAS INTRAVENOUS RECON SOLN 4 B/D PA; MO

caspofungin intravenous recon soln 4 B/D PA

clotrimazole mucous membrane troche 1 MO

CRESEMBA ORAL CAPSULE 4 MO

DIFLUCAN ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

DIFLUCAN ORAL TABLET 3 MO

ERAXIS(WATER DILUENT) INTRAVENOUS

RECON SOLN 100 MG

4 MO

ERAXIS(WATER DILUENT) INTRAVENOUS

RECON SOLN 50 MG

3 MO

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml

1 MO

fluconazole in nacl (iso-osm) intravenous


1

fluconazole oral suspension for reconstitution 1 MO

fluconazole oral tablet 1 MO

flucytosine oral capsule 4 MO

griseofulvin microsize oral suspension 1 MO

griseofulvin microsize oral tablet 1 MO

griseofulvin ultramicrosize oral tablet 1 MO

itraconazole oral capsule 1 MO

itraconazole oral solution 1 MO

ketoconazole oral tablet 1 MO

MYCAMINE INTRAVENOUS RECON SOLN 4 MO

NOXAFIL ORAL SUSPENSION 4 MO

NOXAFIL ORAL TABLET,DELAYED

RELEASE (DR/EC)

4 MO

nystatin oral suspension 1 MO


3


nystatin oral tablet 1 MO

ORAVIG MUCO-ADHESIVE BUCCAL

TABLET

3 MO

posaconazole oral tablet,delayed release (dr/ec) 4 MO

SPORANOX ORAL CAPSULE 3 MO

SPORANOX ORAL SOLUTION 2 MO

terbinafine hcl oral tablet 1 MO

TOLSURA ORAL CAPSULE, SOLID

DISPERSION

4 MO

VFEND IV INTRAVENOUS RECON SOLN 3 MO

VFEND ORAL SUSPENSION FOR

RECONSTITUTION

4 MO

VFEND ORAL TABLET 4 MO

voriconazole intravenous recon soln 1 MO

voriconazole oral suspension for reconstitution 4 MO

voriconazole oral tablet 4 MO

ANTIVIRALS

abacavir oral solution 1 MO

abacavir oral tablet 1 MO

abacavir-lamivudine oral tablet 4 MO

abacavir-lamivudine-zidovudine oral tablet 4 MO

acyclovir oral capsule 1 MO

acyclovir oral suspension 200 mg/5 ml 1 MO

acyclovir oral tablet 1 MO

acyclovir sodium intravenous solution 3 B/D PA; MO

adefovir oral tablet 4 MO

amantadine hcl oral capsule 1 MO

amantadine hcl oral solution 1 MO

amantadine hcl oral tablet 1 MO

APTIVUS ORAL CAPSULE 4 MO

APTIVUS ORAL SOLUTION 4

atazanavir oral capsule 150 mg, 200 mg 1 MO

atazanavir oral capsule 300 mg 4 MO

ATRIPLA ORAL TABLET 4 MO

BARACLUDE ORAL SOLUTION 4 MO


4


BARACLUDE ORAL TABLET 4 MO

BIKTARVY ORAL TABLET 4 MO

CIMDUO ORAL TABLET 4 MO

COMBIVIR ORAL TABLET 4 MO

COMPLERA ORAL TABLET 4 MO

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 MO

DELSTRIGO ORAL TABLET 4 MO

DESCOVY ORAL TABLET 4 MO

didanosine oral capsule,delayed release(dr/ec)

200 mg

1

didanosine oral capsule,delayed release(dr/ec)

250 mg, 400 mg

1 MO

DOVATO ORAL TABLET 4 MO

EDURANT ORAL TABLET 4 MO

efavirenz oral capsule 200 mg 4 MO

efavirenz oral capsule 50 mg 1 MO

efavirenz oral tablet 4 MO

EMTRIVA ORAL CAPSULE 2 MO

EMTRIVA ORAL SOLUTION 2 MO

entecavir oral tablet 4 MO

EPCLUSA ORAL TABLET 4 PA; MO; QL (28 per 28 days)

EPIVIR HBV ORAL SOLUTION 2 MO

EPIVIR HBV ORAL TABLET 3 MO

EPIVIR ORAL SOLUTION 3 MO

EPIVIR ORAL TABLET 3 MO

EPZICOM ORAL TABLET 4 MO

EVOTAZ ORAL TABLET 4 MO

famciclovir oral tablet 1 MO

FLUMADINE ORAL TABLET 3 MO

fosamprenavir oral tablet 4 MO

FUZEON SUBCUTANEOUS RECON SOLN 4 MO

GENVOYA ORAL TABLET 4 MO

HARVONI ORAL TABLET 90-400 MG 4 PA; MO; QL (28 per 28 days)

HEPSERA ORAL TABLET 4 MO

INTELENCE ORAL TABLET 100 MG, 200 MG 4 MO


5


INTELENCE ORAL TABLET 25 MG 2 MO

INVIRASE ORAL TABLET 4 MO

ISENTRESS HD ORAL TABLET 4 MO

ISENTRESS ORAL POWDER IN PACKET 4 MO

ISENTRESS ORAL TABLET 4 MO

ISENTRESS ORAL TABLET,CHEWABLE 100

MG

4 MO

ISENTRESS ORAL TABLET,CHEWABLE 25

MG

2 MO

JULUCA ORAL TABLET 4 MO

KALETRA ORAL SOLUTION 4 MO

KALETRA ORAL TABLET 100-25 MG 2 MO

KALETRA ORAL TABLET 200-50 MG 4 MO

lamivudine oral solution 1 MO

lamivudine oral tablet 1 MO

lamivudine-zidovudine oral tablet 1 MO

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 4 PA; MO; QL (28 per 28 days)

LEXIVA ORAL SUSPENSION 2 MO

LEXIVA ORAL TABLET 4 MO

lopinavir-ritonavir oral solution 1 MO

MAVYRET ORAL TABLET 4 PA; MO; QL (84 per 28 days)

nevirapine oral suspension 1

nevirapine oral tablet 1 MO

nevirapine oral tablet extended release 24 hr 1 MO

NORVIR ORAL POWDER IN PACKET 2 MO

NORVIR ORAL SOLUTION 2 MO

NORVIR ORAL TABLET 3 MO

ODEFSEY ORAL TABLET 4 MO

oseltamivir oral capsule 1 MO

oseltamivir oral suspension for reconstitution 1 MO

PIFELTRO ORAL TABLET 4 MO

PREVYMIS ORAL TABLET 4 MO; QL (30 per 30 days)

PREZCOBIX ORAL TABLET 4 MO

PREZISTA ORAL SUSPENSION 4 MO

PREZISTA ORAL TABLET 150 MG, 75 MG 2 MO


6


PREZISTA ORAL TABLET 600 MG, 800 MG 4 MO

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE

2 MO

RESCRIPTOR ORAL TABLET 2 MO

RETROVIR ORAL CAPSULE 3 MO

RETROVIR ORAL SYRUP 3 MO

REYATAZ ORAL CAPSULE 150 MG, 200 MG,

300 MG

4 MO

REYATAZ ORAL POWDER IN PACKET 4 MO

ribavirin oral capsule 1 MO

ribavirin oral tablet 200 mg 1 MO

rimantadine oral tablet 1 MO

ritonavir oral tablet 1 MO

SELZENTRY ORAL SOLUTION 2 MO

SELZENTRY ORAL TABLET 2 MO

SITAVIG MUCO-ADHESIVE BUCCAL

TABLET

3 MO

SOFOSBUVIR-VELPATASVIR ORAL TABLET 4 PA; MO; QL (28 per 28 days)

SOVALDI ORAL TABLET 400 MG 4 PA; MO; QL (28 per 28 days)

stavudine oral capsule 1 MO

STRIBILD ORAL TABLET 4 MO

SUSTIVA ORAL CAPSULE 200 MG 4 MO

SUSTIVA ORAL CAPSULE 50 MG 3 MO

SUSTIVA ORAL TABLET 4 MO

SYMFI LO ORAL TABLET 4 MO

SYMFI ORAL TABLET 4 MO

SYMTUZA ORAL TABLET 4 MO

TAMIFLU ORAL CAPSULE 3 MO

TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

TEMIXYS ORAL TABLET 4 MO

tenofovir disoproxil fumarate oral tablet 4 MO

TIVICAY ORAL TABLET 10 MG 2 MO

TIVICAY ORAL TABLET 25 MG, 50 MG 4 MO

TRIUMEQ ORAL TABLET 4 MO

TRIZIVIR ORAL TABLET 4 MO


7


TRUVADA ORAL TABLET 4 MO

TYBOST ORAL TABLET 3 MO

valacyclovir oral tablet 1 gram 1 MO; QL (120 per 30 days)

valacyclovir oral tablet 500 mg 1 MO; QL (60 per 30 days)

VALCYTE ORAL RECON SOLN 4 MO

VALCYTE ORAL TABLET 4 MO

valganciclovir oral recon soln 4 MO

valganciclovir oral tablet 4 MO

VALTREX ORAL TABLET 1 GRAM 3 MO; QL (120 per 30 days)

VALTREX ORAL TABLET 500 MG 3 MO; QL (60 per 30 days)

VEMLIDY ORAL TABLET 4 MO

VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN

2 MO

VIDEX EC ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

3 MO

VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; MO; QL (112 per 28 days)

VIRACEPT ORAL TABLET 4 MO

VIRAMUNE ORAL SUSPENSION 3 MO

VIRAMUNE ORAL TABLET 3 MO

VIRAMUNE XR ORAL TABLET EXTENDED

RELEASE 24 HR 400 MG

3 MO

VIREAD ORAL POWDER 4 MO

VIREAD ORAL TABLET 4 MO

VOSEVI ORAL TABLET 4 PA; MO; QL (28 per 28 days)

XOFLUZA ORAL TABLET 2 MO

ZEPATIER ORAL TABLET 4 PA; MO; QL (28 per 28 days)

ZIAGEN ORAL SOLUTION 3 MO

ZIAGEN ORAL TABLET 3 MO

zidovudine oral capsule 1 MO

zidovudine oral syrup 1 MO

zidovudine oral tablet 1 MO

ZOVIRAX ORAL CAPSULE 3 MO

ZOVIRAX ORAL SUSPENSION 3 MO

ZOVIRAX ORAL TABLET 800 MG 3 MO

CEPHALOSPORINS


8


AVYCAZ INTRAVENOUS RECON SOLN 4 MO

cefaclor oral capsule 1 MO

cefaclor oral suspension for reconstitution 125

mg/5 ml

1 MO

cefaclor oral suspension for reconstitution 250

mg/5 ml, 375 mg/5 ml

1

cefaclor oral tablet extended release 12 hr 1 MO

cefadroxil oral capsule 1 MO

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1 MO

cefadroxil oral tablet 1 MO

cefazolin injection recon soln 1 gram, 500 mg 1 MO

cefazolin injection recon soln 10 gram 1

cefdinir oral capsule 1 MO

cefdinir oral suspension for reconstitution 1 MO

cefepime injection recon soln 1 MO

cefixime oral capsule 1 MO

cefixime oral suspension for reconstitution 1 MO

cefotaxime injection recon soln 1 gram, 500 mg 1

cefotetan injection recon soln 1

cefoxitin intravenous recon soln 1 gram, 2 gram 1 MO

cefoxitin intravenous recon soln 10 gram 1

cefpodoxime oral suspension for reconstitution 1 MO

cefpodoxime oral tablet 1 MO

cefprozil oral suspension for reconstitution 1 MO

cefprozil oral tablet 1 MO

ceftazidime injection recon soln 1 gram, 2 gram 1 MO

ceftazidime injection recon soln 6 gram 1

ceftriaxone injection recon soln 1 gram, 2 gram,

250 mg, 500 mg

1 MO

ceftriaxone injection recon soln 10 gram 1

cefuroxime axetil oral tablet 1 MO

cefuroxime sodium injection recon soln 750 mg 1 MO

cefuroxime sodium intravenous recon soln 1.5

gram

1 MO


9


cefuroxime sodium intravenous recon soln 7.5

gram

1

cephalexin oral capsule 1 MO

cephalexin oral suspension for reconstitution 1 MO

cephalexin oral tablet 1 MO

MAXIPIME INJECTION RECON SOLN 3 MO

SUPRAX ORAL CAPSULE 3 MO

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML, 200 MG/5

ML

3 MO

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5 ML

3

SUPRAX ORAL TABLET,CHEWABLE 3 MO

tazicef injection recon soln 1 gram 1

tazicef injection recon soln 2 gram, 6 gram 1 MO

TEFLARO INTRAVENOUS RECON SOLN 4 MO

ZERBAXA INTRAVENOUS RECON SOLN 4

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous recon soln 1 MO

azithromycin oral packet 1 MO

azithromycin oral suspension for reconstitution 1 MO

azithromycin oral tablet 250 mg, 250 mg (6 pack),

500 mg, 600 mg

1 MO

azithromycin oral tablet 500 mg (3 pack) 1

clarithromycin oral suspension for reconstitution 1 MO

clarithromycin oral tablet 1 MO

clarithromycin oral tablet extended release 24 hr 1 MO

DIFICID ORAL TABLET 4 MO

e.e.s. 400 oral tablet 1 MO

E.E.S. GRANULES ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

ERYPED 200 ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

ERYPED 400 ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

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

333 mg

1 MO


10


ERY-TAB ORAL TABLET,DELAYED

RELEASE (DR/EC) 500 MG

2 MO

erythrocin (as stearate) oral tablet 250 mg 1 MO

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

2 MO

erythromycin ethylsuccinate oral suspension for

reconstitution

1 MO

erythromycin ethylsuccinate oral tablet 1 MO

erythromycin oral capsule,delayed release(dr/ec) 1 MO

erythromycin oral tablet 1 MO

erythromycin oral tablet,delayed release (dr/ec) 1 MO

ZITHROMAX INTRAVENOUS RECON SOLN 3 MO

ZITHROMAX ORAL PACKET 3 MO

ZITHROMAX ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

ZITHROMAX ORAL TABLET 250 MG, 500

MG

3 MO

ZITHROMAX TRI-PAK ORAL TABLET 3 MO

ZITHROMAX Z-PAK ORAL TABLET 3 MO

MISCELLANEOUS ANTIINFECTIVES

albendazole oral tablet 4 MO

ALBENZA ORAL TABLET 4 MO

ALINIA ORAL SUSPENSION FOR

RECONSTITUTION

2 MO

ALINIA ORAL TABLET 4 MO

amikacin injection solution 500 mg/2 ml 1 MO

ARIKAYCE INHALATION SUSPENSION FOR

NEBULIZATION

4 PA; MO; LA

atovaquone oral suspension 4 MO

atovaquone-proguanil oral tablet 1 MO

AZACTAM INJECTION RECON SOLN 3 MO

aztreonam injection recon soln 1 gram 1 MO

BENZNIDAZOLE ORAL TABLET 2

BETHKIS INHALATION SOLUTION FOR

NEBULIZATION

4 B/D PA; MO; QL (224 per 28 days)

BILTRICIDE ORAL TABLET 4 MO


11


CAYSTON INHALATION SOLUTION FOR

NEBULIZATION

4 MO; LA; QL (84 per 28 days)

chloroquine phosphate oral tablet 1 MO

CLEOCIN HCL ORAL CAPSULE 3 MO

CLEOCIN IN 5 % DEXTROSE INTRAVENOUS

PIGGYBACK 300 MG/50 ML, 900 MG/50 ML

3

CLEOCIN IN 5 % DEXTROSE INTRAVENOUS

PIGGYBACK 600 MG/50 ML

3 MO

CLEOCIN INJECTION SOLUTION 3 MO

CLEOCIN PEDIATRIC ORAL RECON SOLN 3 MO

clindamycin hcl oral capsule 1 MO

clindamycin in 5 % dextrose intravenous

piggyback

1 MO

clindamycin palmitate hcl oral recon soln 1 MO

clindamycin phosphate injection solution 1 MO

clindamycin phosphate intravenous solution 600

mg/4 ml

1 MO

COARTEM ORAL TABLET 2 MO

colistin (colistimethate na) injection recon soln 1 MO

CUBICIN INTRAVENOUS RECON SOLN 4 MO

DALVANCE INTRAVENOUS SOLUTION 3 MO

dapsone oral tablet 1 MO

DAPTOMYCIN INTRAVENOUS RECON

SOLN 350 MG

2 MO

daptomycin intravenous recon soln 500 mg 4 MO

DARAPRIM ORAL TABLET 4 PA

EMVERM ORAL TABLET,CHEWABLE 4 MO

ertapenem injection recon soln 1 MO

ethambutol oral tablet 1 MO

FIRVANQ ORAL RECON SOLN 3 MO

FLAGYL ORAL CAPSULE 3 MO

FLAGYL ORAL TABLET 3 MO

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50

ml

1 MO

gentamicin in nacl (iso-osm) intravenous


1


12


gentamicin injection solution 40 mg/ml 1 MO

hydroxychloroquine oral tablet 1 MO

imipenem-cilastatin intravenous recon soln 1 MO

INVANZ INJECTION RECON SOLN 3 MO

isoniazid oral solution 1 MO

isoniazid oral tablet 1 MO

ivermectin oral tablet 1 MO

KITABIS PAK INHALATION SOLUTION FOR

NEBULIZATION

4 MO

KRINTAFEL ORAL TABLET 3 MO

linezolid in dextrose 5% intravenous piggyback 4

linezolid oral suspension for reconstitution 4 MO

linezolid oral tablet 4 MO

MALARONE ORAL TABLET 3 MO

MALARONE PEDIATRIC ORAL TABLET 3 MO

mefloquine oral tablet 1 MO

MEPRON ORAL SUSPENSION 4 MO

meropenem intravenous recon soln 1 MO

MERREM INTRAVENOUS RECON SOLN 500

MG

3

metronidazole in nacl (iso-osm) intravenous

piggyback

1 MO

metronidazole oral capsule 1 MO

metronidazole oral tablet 1 MO

MYAMBUTOL ORAL TABLET 400 MG 3 MO

MYCOBUTIN ORAL CAPSULE 3 MO

NEBUPENT INHALATION RECON SOLN 2 B/D PA; MO; QL (1 per 28 days)

neomycin oral tablet 1 MO

paromomycin oral capsule 3 MO

PASER ORAL GRANULES DR FOR SUSP IN

PACKET

2 MO

PENTAM INJECTION RECON SOLN 3 MO

PLAQUENIL ORAL TABLET 3 MO

polymyxin b sulfate injection recon soln 1 MO

praziquantel oral tablet 1 MO

PRIFTIN ORAL TABLET 2 MO


13


PRIMAQUINE ORAL TABLET 2 MO

PRIMAXIN IV INTRAVENOUS RECON SOLN

500 MG

3 MO

pyrazinamide oral tablet 1 MO

QUALAQUIN ORAL CAPSULE 3 MO

quinine sulfate oral capsule 1 MO

rifabutin oral capsule 1 MO

RIFADIN ORAL CAPSULE 150 MG 3 MO

RIFAMATE ORAL CAPSULE 3 MO

rifampin intravenous recon soln 1 MO

rifampin oral capsule 1 MO

RIFATER ORAL TABLET 3 MO

SIRTURO ORAL TABLET 4 MO; LA

SIVEXTRO INTRAVENOUS RECON SOLN 4

SIVEXTRO ORAL TABLET 4 MO

SOLOSEC ORAL GRANULES DEL RELEASE

IN PACKET

3 MO

STREPTOMYCIN INTRAMUSCULAR RECON

SOLN

2 MO

STROMECTOL ORAL TABLET 3 MO

tigecycline intravenous recon soln 4

tinidazole oral tablet 1 MO

TOBI INHALATION SOLUTION FOR

NEBULIZATION


TOBI PODHALER INHALATION CAPSULE,

W/INHALATION DEVICE

4 MO; QL (224 per 28 days)

tobramycin in 0.225 % nacl inhalation solution for

nebulization


tobramycin sulfate injection solution 1 MO

TRECATOR ORAL TABLET 2 MO

TYGACIL INTRAVENOUS RECON SOLN 4 MO

VABOMERE INTRAVENOUS RECON SOLN 3

VANCOCIN ORAL CAPSULE 4 MO

vancomycin intravenous recon soln 1,000 mg, 10

gram, 500 mg, 750 mg

1 MO

VANCOMYCIN INTRAVENOUS RECON

SOLN 250 MG

3


14


vancomycin oral capsule 125 mg 1 MO

vancomycin oral capsule 250 mg 4 MO

vancomycin oral recon soln 1

XENLETA ORAL TABLET 4

XIFAXAN ORAL TABLET 200 MG 4 MO; QL (9 per 30 days)

XIFAXAN ORAL TABLET 550 MG 4 MO; QL (90 per 30 days)

ZYVOX INTRAVENOUS PIGGYBACK 600

MG/300 ML

4 MO

ZYVOX ORAL SUSPENSION FOR

RECONSTITUTION

4 MO

ZYVOX ORAL TABLET 4 MO

PENICILLINS

amoxicillin oral capsule 1 MO

amoxicillin oral suspension for reconstitution 1 MO

amoxicillin oral tablet 1 MO

amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO

amoxicillin-pot clavulanate oral suspension for

reconstitution

1 MO

amoxicillin-pot clavulanate oral tablet 1 MO

amoxicillin-pot clavulanate oral tablet extended

release 12 hr

1 MO

amoxicillin-pot clavulanate oral tablet,chewable 1 MO

ampicillin oral capsule 500 mg 1 MO

ampicillin sodium injection recon soln 1 gram, 10

gram, 125 mg

1 MO

ampicillin-sulbactam injection recon soln 1.5

gram, 3 gram

1 MO

ampicillin-sulbactam injection recon soln 15 gram 1

AUGMENTIN ORAL SUSPENSION FOR

RECONSTITUTION 125-31.25 MG/5 ML

2 MO

BICILLIN C-R INTRAMUSCULAR SYRINGE 2 MO

BICILLIN L-A INTRAMUSCULAR SYRINGE 2 MO

dicloxacillin oral capsule 1 MO

nafcillin injection recon soln 1 gram, 2 gram 1 MO

nafcillin injection recon soln 10 gram 4 MO

oxacillin in dextrose (iso-osm) intravenous

piggyback 1 gram/50 ml

1


15


oxacillin in dextrose (iso-osm) intravenous

piggyback 2 gram/50 ml

1 MO

oxacillin injection recon soln 1 gram 1

oxacillin injection recon soln 10 gram 4

oxacillin injection recon soln 2 gram 1 MO

PENICILLIN G POT IN DEXTROSE

INTRAVENOUS PIGGYBACK 2 MILLION

UNIT/50 ML

2

PENICILLIN G POT IN DEXTROSE

INTRAVENOUS PIGGYBACK 3 MILLION

UNIT/50 ML

2 MO

penicillin g potassium injection recon soln 20

million unit

1 MO

penicillin g procaine intramuscular syringe 1.2

million unit/2 ml

1 MO

penicillin g sodium injection recon soln 1 MO

penicillin v potassium oral recon soln 1 MO

penicillin v potassium oral tablet 1 MO

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1 MO

UNASYN INJECTION RECON SOLN 15

GRAM

3

UNASYN INJECTION RECON SOLN 3 GRAM 3 MO

ZOSYN IN DEXTROSE (ISO-OSM)

INTRAVENOUS PIGGYBACK 2.25 GRAM/50

ML

3

ZOSYN IN DEXTROSE (ISO-OSM)

INTRAVENOUS PIGGYBACK 3.375 GRAM/50

ML

3 MO

ZOSYN INTRAVENOUS RECON SOLN 40.5

GRAM

3 MO

QUINOLONES

BAXDELA INTRAVENOUS RECON SOLN 4

BAXDELA ORAL TABLET 4 MO

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

3 MO

CIPRO ORAL TABLET 250 MG, 500 MG 3 MO

ciprofloxacin hcl oral tablet 1 MO


16


ciprofloxacin in 5 % dextrose intravenous


1 MO

ciprofloxacin oral suspension,microcapsule recon

500 mg/5 ml

1

LEVAQUIN ORAL TABLET 500 MG, 750 MG 3 MO

levofloxacin in d5w intravenous piggyback 500

mg/100 ml, 750 mg/150 ml

1 MO

levofloxacin intravenous solution 1 MO

levofloxacin oral solution 1 MO

levofloxacin oral tablet 1 MO

moxifloxacin oral tablet 1 MO

moxifloxacin-sod.chloride(iso) intravenous

piggyback

1

ofloxacin oral tablet 300 mg 1

ofloxacin oral tablet 400 mg 1 MO

SULFA'S / RELATED AGENTS

BACTRIM DS ORAL TABLET 3 MO

BACTRIM ORAL TABLET 3 MO

sulfadiazine oral tablet 3 MO

sulfamethoxazole-trimethoprim oral suspension 1 MO

sulfamethoxazole-trimethoprim oral tablet 1 MO

TETRACYCLINES

demeclocycline oral tablet 3 MO

DORYX MPC ORAL TABLET,DELAYED

RELEASE (DR/EC)

3 ST; MO

DORYX ORAL TABLET,DELAYED RELEASE

(DR/EC) 200 MG, 50 MG

3 ST; MO

doxy-100 intravenous recon soln 1 MO

doxycycline hyclate oral capsule 1 MO

doxycycline hyclate oral tablet 100 mg, 150 mg, 20

mg, 75 mg

1 MO

doxycycline hyclate oral tablet,delayed release

(dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

1 MO

doxycycline monohydrate oral capsule 1 MO

doxycycline monohydrate oral suspension for

reconstitution

1 MO

doxycycline monohydrate oral tablet 1 MO


17


MINOCIN ORAL CAPSULE 50 MG 3 ST; MO

minocycline oral capsule 1 MO

minocycline oral tablet 1 MO

minocycline oral tablet extended release 24 hr 105

mg, 80 mg

4 MO

minocycline oral tablet extended release 24 hr 115

mg, 135 mg, 45 mg, 65 mg, 90 mg

1 MO

MINOCYCLINE ORAL TABLET EXTENDED

RELEASE 24 HR 55 MG

4 ST; MO

MINOLIRA ER ORAL TABLET, IR - ER,

BIPHASIC 24HR

3 ST; MO

mondoxyne nl oral capsule 100 mg, 75 mg 1 MO

morgidox oral capsule 50 mg 1 MO

NUZYRA (7 DAY WITH LOAD DOSE) ORAL

TABLET

4 ST

NUZYRA (7 DAY) ORAL TABLET 4 ST

NUZYRA INTRAVENOUS RECON SOLN 4

NUZYRA ORAL TABLET 4 ST; MO

ORACEA ORAL CAPSULE, IR - DELAYED

RELEASE, BIPHASE

3 ST; MO

SOLODYN ORAL TABLET EXTENDED

RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65

MG, 80 MG

4 ST; MO

TARGADOX ORAL TABLET 3 ST; MO

tetracycline oral capsule 1 MO

VIBRAMYCIN ORAL CAPSULE 100 MG 3 ST; MO

VIBRAMYCIN ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

VIBRAMYCIN ORAL SYRUP 2 MO

XIMINO ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 ST; MO

URINARY TRACT AGENTS

FURADANTIN ORAL SUSPENSION 3

HIPREX ORAL TABLET 3 MO

MACROBID ORAL CAPSULE 3 MO

MACRODANTIN ORAL CAPSULE 3 MO

methenamine hippurate oral tablet 1 MO


18


MONUROL ORAL PACKET 3 MO

nitrofurantoin macrocrystal oral capsule 1 MO

nitrofurantoin monohyd/m-cryst oral capsule 1 MO

nitrofurantoin oral suspension 1 MO

trimethoprim oral tablet 1 MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium oral tablet 1 MO

MESNEX ORAL TABLET 4 MO

XGEVA SUBCUTANEOUS SOLUTION 4 B/D PA; MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone oral tablet 4 PA; MO; QL (120 per 30 days)

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION

4 PA; MO

AFINITOR ORAL TABLET 4 PA; MO; QL (30 per 30 days)

ALECENSA ORAL CAPSULE 4 PA; MO; QL (240 per 30 days)

ALUNBRIG ORAL TABLET 180 MG, 90 MG 4 PA; MO; QL (30 per 30 days)

ALUNBRIG ORAL TABLET 30 MG 4 PA; MO; QL (60 per 30 days)

ALUNBRIG ORAL TABLETS,DOSE PACK 4 PA; MO; QL (30 per 30 days)

anastrozole oral tablet 1 MO

ARIMIDEX ORAL TABLET 3 MO

AROMASIN ORAL TABLET 3 MO

ASTAGRAF XL ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 B/D PA; MO

AZASAN ORAL TABLET 3 B/D PA; MO

azathioprine oral tablet 1 B/D PA; MO

BALVERSA ORAL TABLET 4 PA; MO; LA

bexarotene oral capsule 4 PA; MO

bicalutamide oral tablet 1 MO

BOSULIF ORAL TABLET 100 MG 4 PA; MO; QL (90 per 30 days)

BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA; MO; QL (30 per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG 4 PA; MO; LA; QL (180 per 30 days)

CABOMETYX ORAL TABLET 4 PA; MO; LA

CALQUENCE ORAL CAPSULE 4 PA; MO; LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 100 MG 4 PA; LA; QL (60 per 30 days)


19


CAPRELSA ORAL TABLET 300 MG 4 PA; MO; LA; QL (30 per 30 days)

CASODEX ORAL TABLET 3 MO

CELLCEPT ORAL CAPSULE 3 B/D PA; MO

CELLCEPT ORAL SUSPENSION FOR

RECONSTITUTION

4 B/D PA; MO

CELLCEPT ORAL TABLET 4 B/D PA; MO

COMETRIQ ORAL CAPSULE 4 PA; MO

COPIKTRA ORAL CAPSULE 4 PA; MO; LA

COTELLIC ORAL TABLET 4 PA; MO; LA; QL (63 per 28 days)

cyclophosphamide oral capsule 1 B/D PA; MO

cyclosporine modified oral capsule 1 B/D PA; MO

cyclosporine modified oral solution 1 B/D PA; MO

cyclosporine oral capsule 1 B/D PA; MO

DAURISMO ORAL TABLET 4 PA; MO

DROXIA ORAL CAPSULE 2 MO

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE

3 PA; MO


SYRINGE

3 PA; MO


SYRINGE

3 PA; MO

ELIGARD SUBCUTANEOUS SYRINGE 3 PA; MO

EMCYT ORAL CAPSULE 4 MO

ENVARSUS XR ORAL TABLET EXTENDED

RELEASE 24 HR

3 B/D PA; MO

ERIVEDGE ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)

ERLEADA ORAL TABLET 4 PA; MO

erlotinib oral tablet 100 mg, 150 mg 4 PA; MO; QL (30 per 30 days)

erlotinib oral tablet 25 mg 4 PA; MO; QL (60 per 30 days)

exemestane oral tablet 1 MO

FARESTON ORAL TABLET 4 MO

FARYDAK ORAL CAPSULE 10 MG 4 PA; MO; QL (12 per 21 days)

FARYDAK ORAL CAPSULE 15 MG, 20 MG 4 PA; MO; QL (6 per 21 days)

FEMARA ORAL TABLET 3 MO

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 120 MG

4 B/D PA; MO


20


FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 80 MG

2 B/D PA; MO

flutamide oral capsule 1 MO

gengraf oral capsule 100 mg, 25 mg 1 B/D PA; MO

gengraf oral solution 1 B/D PA; MO

GILOTRIF ORAL TABLET 4 PA; MO; QL (30 per 30 days)

GLEEVEC ORAL TABLET 100 MG 4 PA; MO; QL (180 per 30 days)

GLEEVEC ORAL TABLET 400 MG 4 PA; MO; QL (60 per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,

40 MG

2 MO

HYDREA ORAL CAPSULE 3 MO

hydroxyurea oral capsule 1 MO

IBRANCE ORAL CAPSULE 4 PA; MO; QL (21 per 28 days)

ICLUSIG ORAL TABLET 15 MG 4 PA; MO; QL (60 per 30 days)

ICLUSIG ORAL TABLET 45 MG 4 PA; MO; QL (30 per 30 days)

IDHIFA ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)

imatinib oral tablet 100 mg 4 PA; MO; QL (180 per 30 days)

imatinib oral tablet 400 mg 4 PA; MO; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 4 PA; MO; QL (120 per 30 days)

IMBRUVICA ORAL CAPSULE 70 MG 4 PA; MO; QL (30 per 30 days)

IMBRUVICA ORAL TABLET 4 PA; MO; QL (30 per 30 days)

IMURAN ORAL TABLET 3 B/D PA; MO

INLYTA ORAL TABLET 1 MG 4 PA; MO; QL (180 per 30 days)

INLYTA ORAL TABLET 5 MG 4 PA; MO; QL (120 per 30 days)

INREBIC ORAL CAPSULE 4 PA; MO; LA; QL (120 per 30 days)

IRESSA ORAL TABLET 4 PA; MO; QL (30 per 30 days)

JAKAFI ORAL TABLET 4 PA; MO; QL (60 per 30 days)

KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; MO

KISQALI ORAL TABLET 4 PA; MO

LENVIMA ORAL CAPSULE 4 PA; MO

letrozole oral tablet 1 MO

LEUKERAN ORAL TABLET 2 MO

leuprolide subcutaneous kit 4 MO

LONSURF ORAL TABLET 4 PA; MO

LORBRENA ORAL TABLET 4 PA; MO


21


LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT

4 PA; MO



4 PA; MO



4 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT

4 PA; MO

LYNPARZA ORAL TABLET 4 PA; MO; QL (120 per 30 days)

LYSODREN ORAL TABLET 2 MO

MATULANE ORAL CAPSULE 4 MO

megestrol oral suspension 400 mg/10 ml (40

mg/ml), 625 mg/5 ml

1 PA; MO

megestrol oral tablet 1 PA; MO

MEKINIST ORAL TABLET 0.5 MG 4 PA; MO; QL (90 per 30 days)

MEKINIST ORAL TABLET 2 MG 4 PA; MO; QL (30 per 30 days)

MEKTOVI ORAL TABLET 4 PA; MO; LA; QL (180 per 30 days)

mercaptopurine oral tablet 1 MO

methotrexate sodium (pf) injection solution 1 B/D PA; MO

methotrexate sodium injection solution 1 B/D PA; MO

methotrexate sodium oral tablet 1 B/D PA; MO

mycophenolate mofetil oral capsule 1 B/D PA; MO

mycophenolate mofetil oral suspension for

reconstitution

4 B/D PA; MO

mycophenolate mofetil oral tablet 1 B/D PA; MO

mycophenolate sodium oral tablet,delayed release

(dr/ec)

1 B/D PA; MO

MYFORTIC ORAL TABLET,DELAYED

RELEASE (DR/EC)

3 B/D PA; MO

NEORAL ORAL CAPSULE 3 B/D PA; MO

NEORAL ORAL SOLUTION 3 B/D PA; MO

NERLYNX ORAL TABLET 4 PA; MO; LA

NEXAVAR ORAL TABLET 4 PA; MO; LA; QL (120 per 30 days)

NILANDRON ORAL TABLET 4 MO

nilutamide oral tablet 4 MO

NINLARO ORAL CAPSULE 2.3 MG 4 PA; MO; QL (6 per 28 days)

NINLARO ORAL CAPSULE 3 MG 4 PA; MO; QL (4 per 28 days)


22


NINLARO ORAL CAPSULE 4 MG 4 PA; MO; QL (3 per 28 days)

NUBEQA ORAL TABLET 4 PA; MO; LA

octreotide acetate injection solution 1,000 mcg/ml,

500 mcg/ml

4 MO

octreotide acetate injection solution 100 mcg/ml,

200 mcg/ml, 50 mcg/ml

1 MO

ODOMZO ORAL CAPSULE 4 PA; MO; LA; QL (30 per 30 days)

PIQRAY ORAL TABLET 4 PA; MO

POMALYST ORAL CAPSULE 4 PA; MO; LA

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG 3 B/D PA; MO

PROGRAF ORAL CAPSULE 5 MG 4 B/D PA; MO

PROGRAF ORAL GRANULES IN PACKET 2 B/D PA; MO

PURIXAN ORAL SUSPENSION 4

RAPAMUNE ORAL SOLUTION 4 B/D PA; MO

RAPAMUNE ORAL TABLET 0.5 MG 3 B/D PA; MO

RAPAMUNE ORAL TABLET 1 MG, 2 MG 4 B/D PA; MO

REVLIMID ORAL CAPSULE 4 PA; MO; LA; QL (28 per 28 days)

ROZLYTREK ORAL CAPSULE 4 PA; MO

RUBRACA ORAL TABLET 4 PA; MO; LA; QL (120 per 30 days)

RYDAPT ORAL CAPSULE 4 PA; MO

SANDIMMUNE ORAL CAPSULE 3 B/D PA; MO

SANDIMMUNE ORAL SOLUTION 2 B/D PA; MO

SANDOSTATIN INJECTION SOLUTION 100

MCG/ML

4 MO

SANDOSTATIN INJECTION SOLUTION 50

MCG/ML, 500 MCG/ML

3 MO

SIGNIFOR SUBCUTANEOUS SOLUTION 4 MO

SIKLOS ORAL TABLET 4 MO

sirolimus oral solution 4 B/D PA; MO

sirolimus oral tablet 0.5 mg, 1 mg 1 B/D PA; MO

sirolimus oral tablet 2 mg 4 B/D PA; MO

SOLTAMOX ORAL SOLUTION 2 MO

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE

4 MO

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50

MG, 80 MG

4 PA; MO; QL (30 per 30 days)


23


SPRYCEL ORAL TABLET 20 MG 4 PA; MO; QL (90 per 30 days)

SPRYCEL ORAL TABLET 70 MG 4 PA; MO; QL (60 per 30 days)

STIVARGA ORAL TABLET 4 PA; MO; QL (84 per 28 days)

SUTENT ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)

SYNRIBO SUBCUTANEOUS RECON SOLN 4 B/D PA; MO

TABLOID ORAL TABLET 2 MO

tacrolimus oral capsule 1 B/D PA; MO

TAFINLAR ORAL CAPSULE 4 PA; MO; QL (120 per 30 days)

TAGRISSO ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)

TALZENNA ORAL CAPSULE 4 PA; MO

tamoxifen oral tablet 1 MO

TARCEVA ORAL TABLET 100 MG, 150 MG 4 PA; MO; QL (30 per 30 days)

TARCEVA ORAL TABLET 25 MG 4 PA; MO; QL (60 per 30 days)

TARGRETIN ORAL CAPSULE 4 PA; MO

TARGRETIN TOPICAL GEL 4 PA; MO

TASIGNA ORAL CAPSULE 150 MG, 200 MG 4 PA; MO; QL (112 per 28 days)

TASIGNA ORAL CAPSULE 50 MG 4 PA; MO; QL (120 per 30 days)

THALOMID ORAL CAPSULE 4 PA; MO

TIBSOVO ORAL TABLET 4 PA; MO

toremifene oral tablet 4 MO

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION

4 B/D PA; MO

tretinoin (chemotherapy) oral capsule 4 MO

TREXALL ORAL TABLET 3 B/D PA; MO

TURALIO ORAL CAPSULE 4 PA; MO; LA

TYKERB ORAL TABLET 4 PA; MO; LA; QL (180 per 30 days)

VENCLEXTA ORAL TABLET 10 MG, 50 MG 2 PA; MO; LA

VENCLEXTA ORAL TABLET 100 MG 4 PA; MO; LA

VENCLEXTA STARTING PACK ORAL

TABLETS,DOSE PACK

4 PA; MO; LA; QL (42 per 180 days)

VERZENIO ORAL TABLET 4 PA; MO; LA; QL (60 per 30 days)

VITRAKVI ORAL CAPSULE 4 PA; MO; LA

VITRAKVI ORAL SOLUTION 4 PA; MO; LA

VIZIMPRO ORAL TABLET 4 PA; MO; QL (30 per 30 days)

VOTRIENT ORAL TABLET 4 PA; MO; QL (120 per 30 days)


24


XALKORI ORAL CAPSULE 4 PA; MO; QL (60 per 30 days)

XATMEP ORAL SOLUTION 4 B/D PA; MO

XERMELO ORAL TABLET 4 PA; MO; LA; QL (90 per 30 days)

XOSPATA ORAL TABLET 4 PA; MO; LA

XPOVIO ORAL TABLET 4 PA; MO; LA

XTANDI ORAL CAPSULE 4 PA; MO; QL (120 per 30 days)

YONSA ORAL TABLET 4 PA; MO; QL (120 per 30 days)

ZEJULA ORAL CAPSULE 4 PA; MO; LA; QL (90 per 30 days)

ZELBORAF ORAL TABLET 4 PA; MO; QL (240 per 30 days)

ZOLINZA ORAL CAPSULE 4 MO

ZORTRESS ORAL TABLET 4 B/D PA; MO

ZYDELIG ORAL TABLET 4 PA; MO; QL (60 per 30 days)

ZYKADIA ORAL CAPSULE 4 PA; MO; QL (150 per 30 days)

ZYKADIA ORAL TABLET 4 PA; MO; QL (150 per 30 days)

ZYTIGA ORAL TABLET 250 MG 4 PA; MO; QL (120 per 30 days)

ZYTIGA ORAL TABLET 500 MG 4 PA; MO; QL (60 per 30 days)

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET 200 MG, 400 MG, 800

MG

3 MO

APTIOM ORAL TABLET 600 MG 4 MO

BANZEL ORAL SUSPENSION 4 MO

BANZEL ORAL TABLET 4 MO

BRIVIACT INTRAVENOUS SOLUTION 3

BRIVIACT ORAL SOLUTION 4 MO

BRIVIACT ORAL TABLET 4 MO

carbamazepine oral capsule, er multiphase 12 hr 1 MO

carbamazepine oral suspension 100 mg/5 ml 1 MO

carbamazepine oral tablet 1 MO

carbamazepine oral tablet extended release 12 hr 1 MO

carbamazepine oral tablet,chewable 1 MO

CARBATROL ORAL CAPSULE, ER

MULTIPHASE 12 HR

3 MO

CELONTIN ORAL CAPSULE 300 MG 2 MO

clobazam oral suspension 1 PA; MO; QL (480 per 30 days)


25


clobazam oral tablet 1 PA; MO; QL (60 per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 per 30 days)

clonazepam oral tablet 2 mg 1 PA; MO; QL (300 per 30 days)

clonazepam oral tablet,disintegrating 0.125 mg,

0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet,disintegrating 2 mg 1 PA; MO; QL (300 per 30 days)

DEPAKOTE ER ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

DEPAKOTE ORAL TABLET,DELAYED

RELEASE (DR/EC)

3 MO

DEPAKOTE SPRINKLES ORAL CAPSULE,

DELAYED REL SPRINKLE

3 MO

DIASTAT ACUDIAL RECTAL KIT 3 MO

DIASTAT RECTAL KIT 3 MO

DILANTIN 30 MG ORAL CAPSULE 2 MO

DILANTIN EXTENDED 100 MG ORAL

CAPSULE

3 MO

DILANTIN INFATABS 50 MG ORAL

TABLET,CHEWABLE

3 MO

DILANTIN-125 125 MG/5 ML ORAL

SUSPENSION

3 MO

divalproex oral capsule, delayed release sprinkle 1 MO

divalproex oral tablet extended release 24 hr 1 MO

divalproex oral tablet,delayed release (dr/ec) 1 MO

EPIDIOLEX ORAL SOLUTION 4 PA; MO; LA

epitol oral tablet 1 MO

EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR

3 MO

ethosuximide oral capsule 1 MO

ethosuximide oral solution 1 MO

felbamate oral suspension 4 MO

felbamate oral tablet 1 MO

FELBATOL ORAL SUSPENSION 4 MO

FELBATOL ORAL TABLET 4 MO

FYCOMPA ORAL SUSPENSION 4 MO

FYCOMPA ORAL TABLET 2 MO

gabapentin oral capsule 100 mg 1 PA; MO; QL (1080 per 30 days)


26




gabapentin oral solution 250 mg/5 ml 1 PA; MO; QL (2160 per 30 days)

gabapentin oral tablet 600 mg 1 PA; MO; QL (180 per 30 days)

gabapentin oral tablet 800 mg 1 PA; MO; QL (120 per 30 days)

GABITRIL ORAL TABLET 3 MO

GRALISE 30-DAY STARTER PACK ORAL

TABLET EXTENDED RELEASE 24 HR

2 PA; QL (78 per 180 days)

GRALISE ORAL TABLET EXTENDED



GRALISE ORAL TABLET EXTENDED



KEPPRA ORAL SOLUTION 3 MO

KEPPRA ORAL TABLET 3 MO

KEPPRA XR ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

KLONOPIN ORAL TABLET 0.5 MG, 1 MG 3 PA; MO; QL (90 per 30 days)

KLONOPIN ORAL TABLET 2 MG 3 PA; MO; QL (300 per 30 days)

LAMICTAL ODT ORAL

TABLET,DISINTEGRATING

3 MO

LAMICTAL ORAL TABLET 3 MO

LAMICTAL ORAL TABLET, CHEWABLE

DISPERSIBLE 25 MG, 5 MG

3 MO

LAMICTAL STARTER (BLUE) KIT ORAL

TABLETS,DOSE PACK

3 MO

LAMICTAL STARTER (GREEN) KIT ORAL

TABLETS,DOSE PACK

3 MO

LAMICTAL STARTER (ORANGE) KIT ORAL

TABLETS,DOSE PACK

3 MO

LAMICTAL XR ORAL TABLET EXTENDED

RELEASE 24HR

3 MO

LAMICTAL XR STARTER (BLUE) ORAL

TABLET EXTENDED REL,DOSE PACK

3 MO

LAMICTAL XR STARTER (GREEN) ORAL


3 MO

LAMICTAL XR STARTER (ORANGE) ORAL


3 MO

lamotrigine oral tablet 1 MO


27


lamotrigine oral tablet extended release 24hr 3 MO

lamotrigine oral tablet, chewable dispersible 1 MO

lamotrigine oral tablet,disintegrating 3 MO

lamotrigine oral tablets,dose pack 1 MO

levetiracetam oral solution 100 mg/ml 1 MO

levetiracetam oral tablet 1 MO

levetiracetam oral tablet extended release 24 hr 1 MO

LYRICA CR ORAL TABLET EXTENDED

RELEASE 24 HR 165 MG, 82.5 MG


LYRICA CR ORAL TABLET EXTENDED



LYRICA ORAL CAPSULE 100 MG, 150 MG,

200 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 225 MG, 300 MG 2 PA; MO; QL (60 per 30 days)

LYRICA ORAL SOLUTION 2 PA; MO; QL (900 per 30 days)

MYSOLINE ORAL TABLET 4 MO

NEURONTIN ORAL CAPSULE 100 MG 3 PA; MO; QL (1080 per 30 days)



NEURONTIN ORAL SOLUTION 3 PA; MO; QL (2160 per 30 days)

NEURONTIN ORAL TABLET 600 MG 3 PA; MO; QL (180 per 30 days)

NEURONTIN ORAL TABLET 800 MG 3 PA; MO; QL (120 per 30 days)

ONFI ORAL SUSPENSION 4 PA; MO; QL (480 per 30 days)

ONFI ORAL TABLET 10 MG, 20 MG 4 PA; MO; QL (60 per 30 days)

oxcarbazepine oral suspension 1 MO

oxcarbazepine oral tablet 1 MO

OXTELLAR XR ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

PEGANONE ORAL TABLET 2 MO

phenobarbital oral elixir 1 PA; MO

phenobarbital oral tablet 1 PA; MO

PHENYTEK ORAL CAPSULE 3 MO

phenytoin oral suspension 125 mg/5 ml 1 MO

phenytoin oral tablet,chewable 1 MO

phenytoin sodium extended release oral capsule 1 MO


28


pregabalin oral capsule 100 mg, 150 mg, 200 mg,

25 mg, 50 mg, 75 mg


pregabalin oral capsule 225 mg, 300 mg 1 PA; MO; QL (60 per 30 days)

pregabalin oral solution 1 PA; MO; QL (900 per 30 days)

primidone oral tablet 1 MO

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER

24HR

3 PA; MO

roweepra oral tablet 1 MO

roweepra xr oral tablet extended release 24 hr 1 MO

SABRIL ORAL POWDER IN PACKET 4 MO; LA

SABRIL ORAL TABLET 4 MO; LA

SPRITAM ORAL TABLET FOR SUSPENSION 3 MO

SYMPAZAN ORAL FILM 10 MG, 20 MG 4 PA; MO; QL (60 per 30 days)

SYMPAZAN ORAL FILM 5 MG 3 PA; MO; QL (60 per 30 days)

TEGRETOL ORAL SUSPENSION 3 MO

TEGRETOL ORAL TABLET 3 MO

TEGRETOL XR ORAL TABLET EXTENDED

RELEASE 12 HR

3 MO

tiagabine oral tablet 3 MO

TOPAMAX ORAL CAPSULE, SPRINKLE 3 PA; MO

TOPAMAX ORAL TABLET 3 PA; MO

topiramate oral capsule, sprinkle 1 PA; MO

TOPIRAMATE ORAL

CAPSULE,SPRINKLE,ER 24HR

3 PA; MO

topiramate oral tablet 1 PA; MO

TRILEPTAL ORAL SUSPENSION 3 MO

TRILEPTAL ORAL TABLET 3 MO

TROKENDI XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 100 MG, 25 MG, 50 MG

3 PA; MO

TROKENDI XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 200 MG

4 PA; MO

valproic acid (as sodium salt) oral solution 250

mg/5 ml

1 MO

valproic acid oral capsule 1 MO

vigabatrin oral powder in packet 4 MO; LA

vigabatrin oral tablet 4 MO; LA

vigadrone oral powder in packet 4 MO; LA


29


VIMPAT ORAL SOLUTION 2 MO

VIMPAT ORAL TABLET 2 MO

ZARONTIN ORAL CAPSULE 3 MO

ZARONTIN ORAL SOLUTION 3 MO

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG 3 PA; MO

zonisamide oral capsule 1 PA; MO

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE 4 MO; LA

AZILECT ORAL TABLET 3 MO

benztropine oral tablet 1 PA; MO

bromocriptine oral capsule 3 MO

bromocriptine oral tablet 3 MO

carbidopa oral tablet 1 MO

carbidopa-levodopa oral tablet 1 MO

carbidopa-levodopa oral tablet extended release 1 MO

carbidopa-levodopa oral tablet,disintegrating 1 MO

carbidopa-levodopa-entacapone oral tablet 3 MO

COMTAN ORAL TABLET 3 MO

DUOPA J-TUBE INTESTINAL PUMP

SUSPENSION

3 B/D PA; MO

entacapone oral tablet 1 MO

GOCOVRI ORAL CAPSULE,EXTENDED

RELEASE 24HR 137 MG


GOCOVRI ORAL CAPSULE,EXTENDED

RELEASE 24HR 68.5 MG


INBRIJA INHALATION CAPSULE,

W/INHALATION DEVICE

4 PA; MO

LODOSYN ORAL TABLET 3 MO

MIRAPEX ER ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

MIRAPEX ORAL TABLET 3 MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 2 MO

NOURIANZ ORAL TABLET 4 MO; LA

OSMOLEX ER ORAL TABLET, IR - ER,

BIPHASIC 24HR

3 PA; MO

PARLODEL ORAL CAPSULE 3 MO


30


PARLODEL ORAL TABLET 3 MO

pramipexole oral tablet 1 MO

pramipexole oral tablet extended release 24 hr 1 MO

rasagiline oral tablet 1 MO

REQUIP XL ORAL TABLET EXTENDED

RELEASE 24 HR 12 MG, 4 MG, 6 MG, 8 MG

3 MO

ropinirole oral tablet 1 MO

ropinirole oral tablet extended release 24 hr 1 MO

RYTARY ORAL CAPSULE, EXTENDED

RELEASE

3 MO

selegiline hcl oral capsule 1 MO

selegiline hcl oral tablet 1 MO

SINEMET CR ORAL TABLET EXTENDED

RELEASE

3 MO

SINEMET ORAL TABLET 3 MO

STALEVO 100 ORAL TABLET 3 MO






TASMAR ORAL TABLET 100 MG 4 MO

tolcapone oral tablet 4 MO

ZELAPAR ORAL TABLET,DISINTEGRATING 3 MO

MIGRAINE / CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR 140 MG/ML


AIMOVIG AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR 70 MG/ML


AJOVY SUBCUTANEOUS SYRINGE 3 PA; MO; QL (1.5 per 30 days)

almotriptan malate oral tablet 12.5 mg 1 MO; QL (24 per 28 days)

almotriptan malate oral tablet 6.25 mg 1 MO; QL (18 per 28 days)

AMERGE ORAL TABLET 3 MO; QL (18 per 28 days)

CAFERGOT ORAL TABLET 3 MO

dihydroergotamine nasal spray,non-aerosol 1 MO; QL (8 per 28 days)

eletriptan oral tablet 1 MO; QL (18 per 28 days)


31


EMGALITY SUBCUTANEOUS PEN

INJECTOR


EMGALITY SUBCUTANEOUS SYRINGE 120

MG/ML


EMGALITY SUBCUTANEOUS SYRINGE 300

MG/3 ML (100 MG/ML X 3)


ergotamine-caffeine oral tablet 1 MO

FROVA ORAL TABLET 3 MO; QL (27 per 28 days)

frovatriptan oral tablet 1 MO; QL (27 per 28 days)

IMITREX NASAL SPRAY,NON-AEROSOL 20

MG/ACTUATION


IMITREX NASAL SPRAY,NON-AEROSOL 5

MG/ACTUATION


IMITREX ORAL TABLET 3 MO; QL (18 per 28 days)

IMITREX STATDOSE SUBCUTANEOUS PEN

INJECTOR 4 MG/0.5 ML


IMITREX STATDOSE REFILL

SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML


IMITREX SUBCUTANEOUS SOLUTION 3 MO; QL (8 per 28 days)

MAXALT ORAL TABLET 10 MG 3 MO; QL (36 per 28 days)

MAXALT-MLT ORAL

TABLET,DISINTEGRATING 10 MG


migergot rectal suppository 1 MO

MIGRANAL NASAL SPRAY,NON-AEROSOL 3 MO; QL (8 per 28 days)

naratriptan oral tablet 1 MO; QL (18 per 28 days)

ONZETRA XSAIL NASAL AEROSOL POWDR

BREATH ACTIVATED


RELPAX ORAL TABLET 3 MO; QL (18 per 28 days)

rizatriptan oral tablet 1 MO; QL (36 per 28 days)

rizatriptan oral tablet,disintegrating 1 MO; QL (36 per 28 days)

sumatriptan nasal spray,non-aerosol 20

mg/actuation


sumatriptan nasal spray,non-aerosol 5

mg/actuation


sumatriptan succinate oral tablet 1 MO; QL (18 per 28 days)

sumatriptan succinate subcutaneous cartridge 1 MO; QL (8 per 28 days)

sumatriptan succinate subcutaneous pen injector 1 MO; QL (8 per 28 days)

sumatriptan succinate subcutaneous solution 1 MO; QL (8 per 28 days)


32


sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml


sumatriptan-naproxen oral tablet 1 MO; QL (18 per 28 days)

TOSYMRA NASAL SPRAY,NON-AEROSOL 3

TREXIMET ORAL TABLET 85-500 MG 3 MO; QL (18 per 28 days)

ZEMBRACE SYMTOUCH SUBCUTANEOUS

PEN INJECTOR


zolmitriptan oral tablet 1 MO; QL (18 per 28 days)

zolmitriptan oral tablet,disintegrating 1 MO; QL (18 per 28 days)

ZOMIG NASAL SPRAY,NON-AEROSOL 3 MO; QL (18 per 28 days)

ZOMIG ORAL TABLET 3 MO; QL (18 per 28 days)

ZOMIG ZMT ORAL



MISCELLANEOUS NEUROLOGICAL THERAPY

AMPYRA ORAL TABLET EXTENDED

RELEASE 12 HR

4 PA; MO; LA

ARICEPT ORAL TABLET 3 MO

AUBAGIO ORAL TABLET 4 PA; MO

AUSTEDO ORAL TABLET 12 MG, 9 MG 4 PA; MO; LA; QL (120 per 30 days)

AUSTEDO ORAL TABLET 6 MG 4 PA; MO; LA; QL (60 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 20

MG/ML


COPAXONE SUBCUTANEOUS SYRINGE 40

MG/ML


dalfampridine oral tablet extended release 12 hr 4 PA; MO

donepezil oral tablet 10 mg, 5 mg 1 MO

donepezil oral tablet 23 mg 3 MO

donepezil oral tablet,disintegrating 1 MO

EXELON TRANSDERMAL PATCH 24 HOUR 3 MO

FIRDAPSE ORAL TABLET 4 PA; MO; LA

galantamine oral capsule, extended release pellets

24 hr

1 MO

galantamine oral solution 1 MO

galantamine oral tablet 1 MO

GILENYA ORAL CAPSULE 0.5 MG 4 PA; MO

glatiramer subcutaneous syringe 20 mg/ml 4 PA; MO; QL (30 per 30 days)


33


glatiramer subcutaneous syringe 40 mg/ml 4 PA; MO; QL (12 per 28 days)

glatopa subcutaneous syringe 20 mg/ml 4 PA; MO; QL (30 per 30 days)

glatopa subcutaneous syringe 40 mg/ml 4 PA; MO; QL (12 per 28 days)

HORIZANT ORAL TABLET EXTENDED

RELEASE 300 MG


HORIZANT ORAL TABLET EXTENDED

RELEASE 600 MG


INGREZZA INITIATION PACK ORAL

CAPSULE,DOSE PACK


INGREZZA ORAL CAPSULE 4 PA; MO; LA; QL (30 per 30 days)

KEVEYIS ORAL TABLET 4 PA; MO

MAVENCLAD (10 TABLET PACK) ORAL

TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA


TABLET

4 PA; MO; LA

MAYZENT ORAL TABLET 4 PA; MO

memantine oral capsule,sprinkle,er 24hr 1 PA; MO

memantine oral solution 1 PA; MO

memantine oral tablet 1 PA; MO

MEMANTINE ORAL TABLETS,DOSE PACK 3 PA; MO

NAMENDA ORAL TABLET 3 PA; MO

NAMENDA TITRATION PAK ORAL

TABLETS,DOSE PACK

3 PA; MO

NAMENDA XR ORAL CAP,SPRINKLE,ER

24HR DOSE PACK

3 PA; MO

NAMENDA XR ORAL


3 PA; MO

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR

DOSE PACK

2 PA; MO


34


NAMZARIC ORAL CAPSULE,SPRINKLE,ER

24HR

2 PA; MO

NUEDEXTA ORAL CAPSULE 2 PA; MO

RAZADYNE ER ORAL CAPSULE,EXT REL.

PELLETS 24 HR

3 MO

RAZADYNE ORAL TABLET 3 MO

rivastigmine tartrate oral capsule 1 MO

rivastigmine transdermal patch 24 hour 1 MO

RUZURGI ORAL TABLET 4 PA; MO

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

4 PA; MO; LA

TEGSEDI SUBCUTANEOUS SYRINGE 4 PA; MO; LA

tetrabenazine oral tablet 12.5 mg 4 PA; MO; QL (240 per 30 days)

tetrabenazine oral tablet 25 mg 4 PA; MO; QL (120 per 30 days)

XENAZINE ORAL TABLET 12.5 MG 4 PA; MO; LA; QL (240 per 30 days)

XENAZINE ORAL TABLET 25 MG 4 PA; MO; LA; QL (120 per 30 days)

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral tablet 10 mg, 20 mg 1 MO

BACLOFEN ORAL TABLET 5 MG 3 MO

cyclobenzaprine oral tablet 3 PA; MO

DANTRIUM ORAL CAPSULE 25 MG, 50 MG 3 MO

dantrolene oral capsule 1 MO

FEXMID ORAL TABLET 3 PA

MESTINON ORAL SYRUP 4 MO

MESTINON ORAL TABLET 4 MO

MESTINON TIMESPAN ORAL TABLET

EXTENDED RELEASE

4 MO

pyridostigmine bromide oral syrup 4 MO

PYRIDOSTIGMINE BROMIDE ORAL TABLET

30 MG

4 MO

pyridostigmine bromide oral tablet 60 mg 1 MO

pyridostigmine bromide oral tablet extended

release

1 MO

tizanidine oral capsule 1 MO

tizanidine oral tablet 1 MO

ZANAFLEX ORAL CAPSULE 3 MO


35


ZANAFLEX ORAL TABLET 3 MO

NARCOTIC ANALGESICS

ABSTRAL SUBLINGUAL TABLET 4 PA; MO; QL (120 per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5

ml


acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg


acetaminophen-codeine oral tablet 300-60 mg 1 MO; QL (180 per 30 days)

ACTIQ BUCCAL LOZENGE ON A HANDLE 4 PA; MO; QL (120 per 30 days)

ARYMO ER ORAL TABLET,ORAL

ONLY,EXTND RELEASE


BELBUCA BUCCAL FILM 3 PA; MO; QL (60 per 30 days)

buprenorphine hcl sublingual tablet 1 MO

buprenorphine transdermal patch weekly 10

mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour


BUPRENORPHINE TRANSDERMAL PATCH

WEEKLY 7.5 MCG/HOUR


BUTRANS TRANSDERMAL PATCH WEEKLY 3 PA; MO; QL (4 per 28 days)

codeine sulfate oral tablet 30 mg, 60 mg 1 MO; QL (180 per 30 days)

DILAUDID ORAL LIQUID 3 MO; QL (2400 per 30 days)

DILAUDID ORAL TABLET 3 MO; QL (180 per 30 days)

DOLOPHINE ORAL TABLET 10 MG 3 PA; MO; QL (120 per 30 days)

DOLOPHINE ORAL TABLET 5 MG 3 PA; MO; QL (240 per 30 days)

DURAGESIC TRANSDERMAL PATCH 72

HOUR 100 MCG/HR, 75 MCG/HR


DURAGESIC TRANSDERMAL PATCH 72

HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR


duramorph (pf) injection solution 0.5 mg/ml 1 MO; QL (4000 per 30 days)

duramorph (pf) injection solution 1 mg/ml 1 QL (2000 per 30 days)

dvorah oral tablet 1 QL (300 per 30 days)

EMBEDA ORAL CAPSULE,ORAL

ONLY,EXT.REL PELL 100-4 MG, 60-2.4 MG,

80-3.2 MG


EMBEDA ORAL CAPSULE,ORAL

ONLY,EXT.REL PELL 20-0.8 MG, 30-1.2 MG,

50-2 MG


endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325

mg



36


fentanyl citrate buccal lozenge on a handle 4 PA; MO; QL (120 per 30 days)

FENTANYL CITRATE BUCCAL TABLET,

EFFERVESCENT


fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,

62.5 mcg/hour, 75 mcg/hr


fentanyl transdermal patch 72 hour 87.5 mcg/hour 4 PA; MO; QL (10 per 30 days)

FENTORA BUCCAL TABLET,

EFFERVESCENT


hydrocodone-acetaminophen oral solution 7.5-325

mg/15 ml


hydrocodone-acetaminophen oral tablet 10-300

mg, 5-300 mg, 7.5-300 mg


hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg, 7.5-200 mg


hydromorphone (pf) injection solution 10 (mg/ml)

(5 ml), 10 mg/ml


hydromorphone injection syringe 2 mg/ml 1 QL (1200 per 30 days)

hydromorphone oral liquid 1 MO; QL (2400 per 30 days)

hydromorphone oral tablet 1 MO; QL (180 per 30 days)

hydromorphone oral tablet extended release 24 hr

12 mg, 8 mg


hydromorphone oral tablet extended release 24 hr

16 mg, 32 mg


HYSINGLA ER ORAL TABLET,ORAL

ONLY,EXT.REL.24 HR 100 MG, 120 MG, 80

MG


HYSINGLA ER ORAL TABLET,ORAL

ONLY,EXT.REL.24 HR 20 MG, 30 MG, 40 MG,

60 MG


ibuprofen-oxycodone oral tablet 1 MO; QL (28 per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 40

MG, 50 MG, 60 MG, 80 MG


KADIAN ORAL CAPSULE, EXTENDED

RELEASE PELLETS 200 MG


LAZANDA NASAL SPRAY,NON-AEROSOL

100 MCG/SPRAY



37



300 MCG/SPRAY



400 MCG/SPRAY


levorphanol tartrate oral tablet 2 mg 1 MO; QL (120 per 30 days)

LEVORPHANOL TARTRATE ORAL TABLET

3 MG


lorcet (hydrocodone) oral tablet 1 MO; QL (360 per 30 days)

lorcet hd oral tablet 1 MO; QL (360 per 30 days)

lorcet plus oral tablet 7.5-325 mg 1 MO; QL (360 per 30 days)

methadone oral solution 10 mg/5 ml 1 PA; MO; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 1 PA; MO; QL (1200 per 30 days)

methadone oral tablet 10 mg 1 PA; MO; QL (120 per 30 days)

methadone oral tablet 5 mg 1 PA; MO; QL (240 per 30 days)

MORPHABOND ER ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 100 MG, 60 MG


MORPHABOND ER ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 15 MG, 30 MG


morphine concentrate oral solution 1 MO; QL (900 per 30 days)

morphine oral capsule, er multiphase 24 hr 1 PA; MO; QL (60 per 30 days)

morphine oral capsule, extended release pellets 1 PA; MO; QL (90 per 30 days)

morphine oral solution 1 MO; QL (900 per 30 days)

morphine oral tablet 1 MO; QL (180 per 30 days)

morphine oral tablet extended release 1 PA; MO; QL (120 per 30 days)

MS CONTIN ORAL TABLET EXTENDED

RELEASE 100 MG, 200 MG, 60 MG


MS CONTIN ORAL TABLET EXTENDED

RELEASE 15 MG, 30 MG


NORCO ORAL TABLET 3 MO; QL (360 per 30 days)

OPANA ORAL TABLET 10 MG 3 MO; QL (360 per 30 days)

OPANA ORAL TABLET 5 MG 3 MO; QL (180 per 30 days)

OXAYDO ORAL TABLET, ORAL ONLY 4 MO; QL (360 per 30 days)

oxycodone oral capsule 1 MO; QL (360 per 30 days)

oxycodone oral concentrate 1 MO; QL (180 per 30 days)

oxycodone oral solution 1 MO; QL (1200 per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 MO; QL (180 per 30 days)

oxycodone oral tablet 5 mg 1 MO; QL (360 per 30 days)


38


OXYCODONE ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG



ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG



ONLY,EXT.REL.12 HR 80 MG


oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 1 MO; QL (360 per 30 days)

OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG,

30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET, EXTENDED

RELEASE 12 HR 80 MG


oxymorphone oral tablet 10 mg 1 MO; QL (360 per 30 days)

oxymorphone oral tablet 5 mg 1 MO; QL (180 per 30 days)

oxymorphone oral tablet extended release 12 hr 1 PA; MO; QL (90 per 30 days)

PERCOCET ORAL TABLET 10-325 MG, 2.5-

325 MG, 5-325 MG, 7.5-325 MG


PRIMLEV ORAL TABLET 3 MO; QL (390 per 30 days)

ROXICODONE ORAL TABLET 15 MG, 30 MG 3 MO; QL (180 per 30 days)

ROXICODONE ORAL TABLET 5 MG 3 QL (360 per 30 days)

SUBSYS SUBLINGUAL SPRAY,NON-

AEROSOL


TREZIX ORAL CAPSULE 320.5-30-16 MG 3 MO; QL (300 per 30 days)

TYLENOL-CODEINE #3 ORAL TABLET 3 MO; QL (360 per 30 days)

TYLENOL-CODEINE #4 ORAL TABLET 3 MO; QL (180 per 30 days)

vicodin es oral tablet 1 MO; QL (390 per 30 days)

vicodin hp oral tablet 1 MO; QL (390 per 30 days)

XTAMPZA ER ORAL

CAP,SPRINKL,ER12HR(DONT CRUSH)


ZOHYDRO ER CAPSULE, ORAL ONLY, ER

12HR


NON-NARCOTIC ANALGESICS

ARTHROTEC 50 ORAL

TABLET,IR,DELAYED REL,BIPHASIC

3 ST; MO

ARTHROTEC 75 ORAL

TABLET,IR,DELAYED REL,BIPHASIC

3 ST; MO


39


BUNAVAIL BUCCAL FILM 2.1-0.3 MG 3 MO; QL (30 per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1

MG


buprenorphine-naloxone sublingual film 12-3 mg 1 MO; QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg 1 MO; QL (360 per 30 days)

buprenorphine-naloxone sublingual film 4-1 mg,

8-2 mg


buprenorphine-naloxone sublingual tablet 2-0.5

mg


buprenorphine-naloxone sublingual tablet 8-2 mg 1 MO; QL (90 per 30 days)

butorphanol tartrate nasal spray,non-aerosol 1 MO; QL (10 per 28 days)

CAMBIA ORAL POWDER IN PACKET 3 ST; MO; QL (9 per 30 days)

CELEBREX ORAL CAPSULE 3 MO

celecoxib oral capsule 1 MO

CONZIP ORAL CAPSULE,ER BIPHASE 24 HR

17-83


CONZIP ORAL CAPSULE,ER BIPHASE 24 HR

25-75


DAYPRO ORAL TABLET 3 ST; MO

DICLOFENAC EPOLAMINE TRANSDERMAL

PATCH 12 HOUR


diclofenac potassium oral tablet 1 MO

diclofenac sodium oral tablet extended release 24

hr

1 MO

diclofenac sodium oral tablet,delayed release

(dr/ec)

1 MO

diclofenac sodium topical drops 1 MO; QL (300 per 28 days)

diclofenac sodium topical gel 1 % 1 MO; QL (1000 per 28 days)

diclofenac-misoprostol oral tablet, ir, delayed

release, biphasic

1 MO

diflunisal oral tablet 1 MO

DUEXIS ORAL TABLET 3 ST; MO

etodolac oral capsule 1 MO

etodolac oral tablet 1 MO

etodolac oral tablet extended release 24 hr 1 MO

EVZIO INJECTION AUTO-INJECTOR 2

MG/0.4 ML

3 MO; QL (0.8 per 30 days)


40


FELDENE ORAL CAPSULE 3 ST; MO

FENOPROFEN ORAL CAPSULE 400 MG 3 ST; MO

fenoprofen oral tablet 1 MO

FLECTOR TRANSDERMAL PATCH 12 HOUR 3 PA; MO; QL (60 per 30 days)

flurbiprofen oral tablet 1 MO

ibu oral tablet 600 mg, 800 mg 1 MO

ibuprofen oral suspension 1 MO

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO

INDOCIN RECTAL SUPPOSITORY 3 MO

ketoprofen oral capsule 25 mg 1 MO

ketoprofen oral capsule, extended release pellets

24 hr 200 mg

1 MO

LODINE ORAL TABLET 3 ST

LUCEMYRA ORAL TABLET 4 MO

meclofenamate oral capsule 1 MO

mefenamic acid oral capsule 1 MO

meloxicam oral tablet 15 mg 1 MO

meloxicam oral tablet 7.5 mg 1 MO; QL (30 per 30 days)

MOBIC ORAL TABLET 15 MG 3 ST; MO

MOBIC ORAL TABLET 7.5 MG 3 ST; MO; QL (30 per 30 days)

nabumetone oral tablet 1 MO

NALFON ORAL TABLET 3 ST

naloxone injection solution 1 MO

naloxone injection syringe 1 MO

naltrexone oral tablet 1 MO

NAPRELAN CR ORAL TABLET, ER

MULTIPHASE 24 HR

3 ST; MO

naproxen oral suspension 1 MO

naproxen oral tablet 1 MO

naproxen oral tablet,delayed release (dr/ec) 1 MO

naproxen sodium oral tablet 275 mg, 550 mg 1 MO

naproxen sodium oral tablet, er multiphase 24 hr 1 MO

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION

2 MO

NUCYNTA ER ORAL TABLET EXTENDED

RELEASE 12 HR



41


NUCYNTA ORAL TABLET 100 MG 3 MO; QL (181 per 30 days)



oxaprozin oral tablet 1 MO

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP

4 ST; MO; QL (224 per 28 days)

piroxicam oral capsule 1 MO

QMIIZ ODT ORAL

TABLET,DISINTEGRATING 15 MG

3 ST; MO

QMIIZ ODT ORAL

TABLET,DISINTEGRATING 7.5 MG


SPRIX NASAL SPRAY,NON-AEROSOL 3 ST

SUBOXONE SUBLINGUAL FILM 12-3 MG 2 MO; QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG 2 MO; QL (360 per 30 days)

SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2

MG


sulindac oral tablet 1 MO

TIVORBEX ORAL CAPSULE 3 ST; MO; QL (90 per 30 days)

tolmetin oral capsule 1 MO

tolmetin oral tablet 600 mg 1 MO

TRAMADOL ORAL CAPSULE,ER BIPHASE

24 HR 17-83


TRAMADOL ORAL CAPSULE,ER BIPHASE

24 HR 25-75 100 MG, 200 MG


tramadol oral tablet 1 MO; QL (240 per 30 days)

tramadol oral tablet extended release 24 hr 1 PA; MO; QL (30 per 30 days)

tramadol oral tablet, er multiphase 24 hr 1 PA; MO; QL (30 per 30 days)

tramadol-acetaminophen oral tablet 1 MO; QL (240 per 30 days)

ULTRACET ORAL TABLET 3 MO; QL (240 per 30 days)

ULTRAM ORAL TABLET 3 MO; QL (240 per 30 days)

VIMOVO ORAL TABLET,IR,DELAYED

REL,BIPHASIC

4 ST; MO

VIVITROL INTRAMUSCULAR SUSPENSION,

EXTENDED RELEASE RECON

4 MO

VIVLODEX ORAL CAPSULE 10 MG 3 ST; MO

VIVLODEX ORAL CAPSULE 5 MG 3 ST; MO; QL (30 per 30 days)

VOLTAREN TOPICAL GEL 3 ST; MO; QL (1000 per 28 days)


42


ZIPSOR ORAL CAPSULE 3 ST; MO

ZORVOLEX ORAL CAPSULE 3 ST; MO

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


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG 2 MO; QL (60 per 30 days)

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION, EXTENDED RELEASE RECON

4 MO

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION, EXTENDED RELEASE

SYRINGE

4 MO

ABILIFY MYCITE ORAL TABLET WITH

SENSOR AND PATCH


ABILIFY ORAL TABLET 4 MO; QL (30 per 30 days)

ADDERALL ORAL TABLET 20 MG, 5 MG, 7.5

MG

3 MO

ADDERALL XR ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO

ADZENYS ER ORAL SUSPEN, IR - ER,

BIPHASIC 24HR

3 MO

ADZENYS XR-ODT ORAL

TABLET,DISINTEG ER BIPHASE 24H

3 MO

AMBIEN CR ORAL TABLET,EXT RELEASE

MULTIPHASE


AMBIEN ORAL TABLET 3 ST; MO; QL (30 per 30 days)

amitriptyline oral tablet 1 PA; MO

amoxapine oral tablet 1 PA; MO

amphetamine sulfate oral tablet 1 PA; MO

ANAFRANIL ORAL CAPSULE 3 PA; MO

APLENZIN ORAL TABLET EXTENDED

RELEASE 24 HR


APTENSIO XR ORAL CAP,ER

SPRINKLE,BIPHASIC 40-60

3 MO

aripiprazole oral solution 4 MO

aripiprazole oral tablet 1 MO; QL (30 per 30 days)

aripiprazole oral tablet,disintegrating 4 MO; QL (60 per 30 days)

ARISTADA INITIO INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING

4 MO


43


ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED RELEASE SYRINGE

4 MO

armodafinil oral tablet 3 PA; MO

ATIVAN ORAL TABLET 0.5 MG, 1 MG 3 PA; MO; QL (90 per 30 days)

ATIVAN ORAL TABLET 2 MG 3 PA; MO; QL (150 per 30 days)

atomoxetine oral capsule 1 MO

BELSOMRA ORAL TABLET 3 ST; MO; QL (30 per 30 days)

BRISDELLE ORAL CAPSULE 3 MO; QL (30 per 30 days)

bupropion hcl oral tablet 1 MO

bupropion hcl oral tablet extended release 24 hr

150 mg


bupropion hcl oral tablet extended release 24 hr

300 mg


BUPROPION HCL ORAL TABLET

EXTENDED RELEASE 24 HR 450 MG


bupropion hcl oral tablet sustained-release 12 hr 1 MO; QL (60 per 30 days)

buspirone oral tablet 1 MO

CELEXA ORAL TABLET 3 MO; QL (30 per 30 days)

chlorpromazine oral tablet 1 MO

citalopram oral solution 1 MO

citalopram oral tablet 1 MO; QL (30 per 30 days)

clomipramine oral capsule 3 PA; MO

clonidine hcl oral tablet extended release 12 hr 1 MO

clorazepate dipotassium oral tablet 15 mg 1 PA; MO; QL (180 per 30 days)

clorazepate dipotassium oral tablet 3.75 mg 1 PA; MO; QL (90 per 30 days)

clorazepate dipotassium oral tablet 7.5 mg 1 PA; MO; QL (360 per 30 days)

clozapine oral tablet 1 MO

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 25 mg

1

CLOZAPINE ORAL

TABLET,DISINTEGRATING 150 MG, 200 MG

3

CLOZARIL ORAL TABLET 3

CONCERTA ORAL TABLET EXTENDED

RELEASE 24HR

3 MO

COTEMPLA XR-ODT ORAL

TABLET,DISINTEG ER BIPHASE 24H

3 MO


44


CYMBALTA ORAL CAPSULE,DELAYED

RELEASE(DR/EC)


DAYTRANA TRANSDERMAL PATCH 24

HOUR

3 MO

desipramine oral tablet 1 PA; MO

DESOXYN ORAL TABLET 3 PA; MO

DESVENLAFAXINE ORAL TABLET



DESVENLAFAXINE ORAL TABLET



desvenlafaxine succinate oral tablet extended

release 24 hr


DEXEDRINE SPANSULE ORAL CAPSULE,

EXTENDED RELEASE

3 MO

dexmethylphenidate oral capsule,er biphasic 50-

50

1 MO

dexmethylphenidate oral tablet 1 MO

dextroamphetamine oral capsule, extended release 1 MO

dextroamphetamine oral tablet 1 MO

dextroamphetamine-amphetamine oral

capsule,extended release 24hr

1 MO

dextroamphetamine-amphetamine oral tablet 1 MO

diazepam intensol oral concentrate 1 PA; MO; QL (240 per 30 days)

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA; MO; QL (1200 per 30 days)

diazepam oral tablet 1 PA; MO; QL (120 per 30 days)

doxepin oral capsule 3 PA; MO

doxepin oral concentrate 3 PA; MO

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 30 mg, 60 mg


duloxetine oral capsule,delayed release(dr/ec) 40

mg


DYANAVEL XR ORAL SUSPEN, IR - ER,

BIPHASIC 24HR

3 MO

EFFEXOR XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 150 MG, 37.5 MG


EFFEXOR XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 75 MG


EMSAM TRANSDERMAL PATCH 24 HOUR 4 MO


45


ergoloid oral tablet 3 MO

escitalopram oxalate oral solution 1 MO

escitalopram oxalate oral tablet 1 MO; QL (30 per 30 days)

eszopiclone oral tablet 3 ST; MO; QL (30 per 30 days)

EVEKEO ODT ORAL


3 PA; MO

EVEKEO ORAL TABLET 3 PA; MO

FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 3 MO; QL (60 per 30 days)

FANAPT ORAL TABLET 10 MG, 12 MG, 6

MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK 3 MO; QL (8 per 28 days)

FAZACLO ORAL TABLET,DISINTEGRATING

100 MG

4

FAZACLO ORAL TABLET,DISINTEGRATING

12.5 MG, 150 MG, 200 MG, 25 MG

3

FETZIMA ORAL CAPSULE, EXTENDED

RELEASE 24HR DOSE PACK


FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR


fluoxetine oral capsule 10 mg 1 MO; QL (30 per 30 days)

fluoxetine oral capsule 20 mg 1 MO

fluoxetine oral capsule 40 mg 1 MO; QL (60 per 30 days)

fluoxetine oral capsule,delayed release(dr/ec) 1 MO; QL (4 per 28 days)

fluoxetine oral solution 1 MO

fluoxetine oral tablet 10 mg 1 MO; QL (30 per 30 days)

fluoxetine oral tablet 20 mg, 60 mg 1 MO

fluphenazine decanoate injection solution 1 MO

fluphenazine hcl injection solution 1 MO

fluphenazine hcl oral concentrate 1 MO

fluphenazine hcl oral elixir 1 MO

fluphenazine hcl oral tablet 1 MO

fluvoxamine oral capsule,extended release 24hr 3 MO; QL (60 per 30 days)

fluvoxamine oral tablet 100 mg 1 MO; QL (90 per 30 days)



FOCALIN ORAL TABLET 3 MO


46


FOCALIN XR ORAL CAPSULE,ER BIPHASIC

50-50

3 MO

FORFIVO XL ORAL TABLET EXTENDED

RELEASE 24 HR


GEODON INTRAMUSCULAR RECON SOLN 3 MO

GEODON ORAL CAPSULE 4 MO; QL (60 per 30 days)

guanidine oral tablet 1 MO

HALDOL DECANOATE INTRAMUSCULAR

SOLUTION

3 MO

HALDOL INJECTION SOLUTION 3 MO

haloperidol decanoate intramuscular solution 1 MO

haloperidol lactate injection solution 1 MO

haloperidol lactate intramuscular syringe 1

haloperidol lactate oral concentrate 1 MO

haloperidol oral tablet 1 MO

HETLIOZ ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)

imipramine hcl oral tablet 3 PA; MO

imipramine pamoate oral capsule 3 PA; MO

INVEGA ORAL TABLET EXTENDED

RELEASE 24HR 1.5 MG, 3 MG, 9 MG


INVEGA ORAL TABLET EXTENDED

RELEASE 24HR 6 MG


INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234

MG/1.5 ML, 78 MG/0.5 ML

4 MO

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 39 MG/0.25 ML

3 MO

INVEGA TRINZA INTRAMUSCULAR

SYRINGE

4 MO

KAPVAY ORAL TABLET EXTENDED

RELEASE 12 HR

3 MO

KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24HR 100 MG


KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24HR 50 MG


LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG


LATUDA ORAL TABLET 80 MG 4 MO; QL (60 per 30 days)


47


LEXAPRO ORAL TABLET 3 MO; QL (30 per 30 days)

lithium carbonate oral capsule 1 MO

lithium carbonate oral tablet 1 MO

lithium carbonate oral tablet extended release 1 MO

lithium citrate oral solution 8 meq/5 ml 1 MO

LITHOBID ORAL TABLET EXTENDED

RELEASE

3 MO

lorazepam oral concentrate 1 PA; MO; QL (150 per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 per 30 days)

lorazepam oral tablet 2 mg 1 PA; MO; QL (150 per 30 days)

loxapine succinate oral capsule 1 MO

LUNESTA ORAL TABLET 3 ST; MO; QL (30 per 30 days)

maprotiline oral tablet 1 MO

MARPLAN ORAL TABLET 2 MO

metadate oral tablet extended release 1 MO

methamphetamine oral tablet 1 PA; MO

METHYLIN ORAL SOLUTION 3 MO

methylphenidate hcl oral capsule, er biphasic 30-

70

1 MO

methylphenidate hcl oral capsule,er biphasic 50-

50

1 MO

methylphenidate hcl oral solution 1 MO

methylphenidate hcl oral tablet 1 MO

methylphenidate hcl oral tablet extended release 1 MO

methylphenidate hcl oral tablet extended release

24hr 18 mg, 27 mg, 36 mg, 54 mg

1 MO

METHYLPHENIDATE HCL ORAL TABLET

EXTENDED RELEASE 24HR 72 MG

3 MO

methylphenidate hcl oral tablet,chewable 1 MO

mirtazapine oral tablet 1 MO

mirtazapine oral tablet,disintegrating 1 MO

modafinil oral tablet 1 PA; MO

molindone oral tablet 1 MO

MYDAYIS ORAL CAPSULE, ER TRIPHASIC

24 HR

3 MO

NARDIL ORAL TABLET 3 MO


48


nefazodone oral tablet 1 MO

NORPRAMIN ORAL TABLET 10 MG, 25 MG 3 PA; MO

nortriptyline oral capsule 1 PA; MO

nortriptyline oral solution 1 PA; MO

NUPLAZID ORAL CAPSULE 4 PA; MO

NUPLAZID ORAL TABLET 10 MG 4 PA; MO

NUVIGIL ORAL TABLET 3 PA; MO

olanzapine intramuscular recon soln 1 MO

olanzapine oral tablet 1 MO; QL (30 per 30 days)

olanzapine oral tablet,disintegrating 1 MO; QL (30 per 30 days)

olanzapine-fluoxetine oral capsule 1 MO

paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg


paliperidone oral tablet extended release 24hr 6

mg


paliperidone oral tablet extended release 24hr 9

mg


PAMELOR ORAL CAPSULE 3 PA; MO

PARNATE ORAL TABLET 3 MO

paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg 1 MO; QL (30 per 30 days)

paroxetine hcl oral tablet 30 mg 1 MO; QL (60 per 30 days)

paroxetine hcl oral tablet extended release 24 hr 1 MO; QL (60 per 30 days)

paroxetine mesylate(menop.sym) oral capsule 1 MO; QL (30 per 30 days)

PAXIL CR ORAL TABLET EXTENDED

RELEASE 24 HR


PAXIL ORAL SUSPENSION 3 MO

PAXIL ORAL TABLET 10 MG, 20 MG, 40 MG 3 MO; QL (30 per 30 days)

PAXIL ORAL TABLET 30 MG 3 MO; QL (60 per 30 days)

perphenazine oral tablet 1 MO

PERSERIS ABDOMINAL SUBCUTANEOUS

SUSPENSION,EXTEND REL SYR KIT

4 MO

PEXEVA ORAL TABLET 10 MG, 20 MG, 40

MG


PEXEVA ORAL TABLET 30 MG 3 MO; QL (60 per 30 days)

phenelzine oral tablet 1 MO

pimozide oral tablet 1 MO


49


PRISTIQ ORAL TABLET EXTENDED

RELEASE 24 HR


procentra oral solution 1 MO

protriptyline oral tablet 1 MO

PROVIGIL ORAL TABLET 4 PA; MO

PROZAC ORAL CAPSULE 10 MG 3 MO; QL (30 per 30 days)

PROZAC ORAL CAPSULE 20 MG 3 MO

PROZAC ORAL CAPSULE 40 MG 3 MO; QL (60 per 30 days)

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

mg


quetiapine oral tablet 300 mg, 400 mg 1 MO; QL (60 per 30 days)

quetiapine oral tablet extended release 24 hr 150

mg, 200 mg


quetiapine oral tablet extended release 24 hr 300

mg, 400 mg, 50 mg


QUILLICHEW ER ORAL TABLET,CHEW,IR-

ER.BIPHASIC24HR

3 MO

QUILLIVANT XR ORAL SUSPENSION,EXT

REL 24HR,RECON

3 MO

ramelteon oral tablet 1 MO; QL (30 per 30 days)

RELEXXII ORAL TABLET EXTENDED

RELEASE 24HR

3

REMERON ORAL TABLET 15 MG, 30 MG 3 MO

REMERON SOLTAB ORAL


3 MO

REXULTI ORAL TABLET 4 MO; QL (30 per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 12.5 MG/2 ML, 25 MG/2 ML

2 MO

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 37.5 MG/2 ML, 50 MG/2 ML

4 MO

RISPERDAL ORAL SOLUTION 3 MO

RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2

MG, 3 MG


RISPERDAL ORAL TABLET 4 MG 3 MO; QL (120 per 30 days)

risperidone oral solution 1 MO

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg


risperidone oral tablet 4 mg 1 MO; QL (120 per 30 days)


50


risperidone oral tablet,disintegrating 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet,disintegrating 4 mg 1 MO; QL (120 per 30 days)

RITALIN LA ORAL CAPSULE,ER BIPHASIC

50-50 10 MG, 20 MG, 30 MG, 40 MG

3 MO

RITALIN ORAL TABLET 3 MO

ROZEREM ORAL TABLET 2 MO; QL (30 per 30 days)

SAPHRIS SUBLINGUAL TABLET 2 MO; QL (60 per 30 days)

SARAFEM ORAL TABLET 10 MG, 20 MG 3 MO

SEROQUEL ORAL TABLET 100 MG, 200 MG,

25 MG, 50 MG


SEROQUEL ORAL TABLET 300 MG, 400 MG 3 MO; QL (60 per 30 days)

SEROQUEL XR ORAL TABLET EXTENDED

RELEASE 24 HR 150 MG, 200 MG


SEROQUEL XR ORAL TABLET EXTENDED

RELEASE 24 HR 300 MG, 400 MG, 50 MG


sertraline oral concentrate 1 MO

sertraline oral tablet 100 mg, 50 mg 1 MO; QL (60 per 30 days)

sertraline oral tablet 25 mg 1 MO; QL (30 per 30 days)

SILENOR ORAL TABLET 3 MO; QL (30 per 30 days)

STRATTERA ORAL CAPSULE 3 MO

SUNOSI ORAL TABLET 3 PA; MO

SYMBYAX ORAL CAPSULE 12-50 MG, 3-25

MG, 6-25 MG, 6-50 MG

3 MO

thioridazine oral tablet 3 MO

thiothixene oral capsule 1 MO

TOFRANIL ORAL TABLET 3 PA; MO

TRANXENE T-TAB ORAL TABLET 7.5 MG 3 PA; MO; QL (360 per 30 days)

tranylcypromine oral tablet 3 MO

trazodone oral tablet 1 MO

trifluoperazine oral tablet 1 MO

trimipramine oral capsule 3 PA; MO

TRINTELLIX ORAL TABLET 2 MO; QL (30 per 30 days)

VALIUM ORAL TABLET 3 PA; MO; QL (120 per 30 days)

venlafaxine oral capsule,extended release 24hr

150 mg, 37.5 mg



51


venlafaxine oral capsule,extended release 24hr 75

mg


venlafaxine oral tablet 1 MO; QL (90 per 30 days)

VENLAFAXINE ORAL TABLET EXTENDED

RELEASE 24HR


VERSACLOZ ORAL SUSPENSION 4

VIIBRYD ORAL TABLET 2 MO; QL (30 per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)


VRAYLAR ORAL CAPSULE 4 MO; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK 3 MO; QL (7 per 30 days)

VYVANSE ORAL CAPSULE 3 MO

VYVANSE ORAL TABLET,CHEWABLE 3 MO

WELLBUTRIN SR ORAL TABLET

SUSTAINED-RELEASE 12 HR


WELLBUTRIN XL ORAL TABLET



WELLBUTRIN XL ORAL TABLET



XYREM ORAL SOLUTION 4 PA; MO; LA

zaleplon oral capsule 10 mg 3 ST; MO; QL (60 per 30 days)

zaleplon oral capsule 5 mg 3 ST; MO; QL (30 per 30 days)

zenzedi oral tablet 10 mg, 5 mg 1 MO

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20

MG, 30 MG, 7.5 MG

3 MO

ziprasidone hcl oral capsule 1 MO; QL (60 per 30 days)

ZOLOFT ORAL TABLET 100 MG, 50 MG 3 MO; QL (60 per 30 days)

ZOLOFT ORAL TABLET 25 MG 3 MO; QL (30 per 30 days)

zolpidem oral tablet 1 ST; MO; QL (30 per 30 days)

zolpidem oral tablet, extended release multiphase 1 ST; MO; QL (30 per 30 days)

ZYPREXA INTRAMUSCULAR RECON SOLN 3 MO

ZYPREXA ORAL TABLET 10 MG, 2.5 MG, 5

MG, 7.5 MG


ZYPREXA ORAL TABLET 15 MG, 20 MG 4 MO; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 210

MG

2 MO


52


ZYPREXA ZYDIS ORAL



ZYPREXA ZYDIS ORAL



CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral tablet 1 MO

BETAPACE AF ORAL TABLET 3 MO

dofetilide oral capsule 1 MO

flecainide oral tablet 1 MO

mexiletine oral capsule 1 MO

MULTAQ ORAL TABLET 3 MO

pacerone oral tablet 100 mg, 200 mg, 400 mg 1 MO

propafenone oral capsule,extended release 12 hr 1 MO

propafenone oral tablet 1 MO

quinidine gluconate oral tablet extended release 1 MO

quinidine sulfate oral tablet 1 MO

RYTHMOL SR ORAL CAPSULE,EXTENDED

RELEASE 12 HR

3 MO

sorine oral tablet 120 mg, 160 mg, 80 mg 1 MO

sorine oral tablet 240 mg 1

sotalol af oral tablet 120 mg 1 MO

sotalol oral tablet 1 MO

SOTYLIZE ORAL SOLUTION 2 MO

TIKOSYN ORAL CAPSULE 3 MO

ANTIHYPERTENSIVE THERAPY

ACCUPRIL ORAL TABLET 3 MO

ACCURETIC ORAL TABLET 3 MO

acebutolol oral capsule 1 MO

ADALAT CC ORAL TABLET EXTENDED

RELEASE

3 MO

ALDACTAZIDE ORAL TABLET 3 MO

ALDACTONE ORAL TABLET 3 MO

aliskiren oral tablet 1 MO

ALTACE ORAL CAPSULE 3 MO


53


amiloride oral tablet 1 MO

amiloride-hydrochlorothiazide oral tablet 1 MO

amlodipine oral tablet 1 MO

amlodipine-benazepril oral capsule 1 MO

amlodipine-olmesartan oral tablet 1 MO

amlodipine-valsartan oral tablet 1 MO

amlodipine-valsartan-hydrochlorothiazide oral

tablet

1 MO

ATACAND HCT ORAL TABLET 3 ST; MO

ATACAND ORAL TABLET 3 ST; MO

atenolol oral tablet 1 MO

atenolol-chlorthalidone oral tablet 1 MO

AVALIDE ORAL TABLET 3 ST; MO

AVAPRO ORAL TABLET 3 ST; MO

AZOR ORAL TABLET 3 ST; MO

benazepril oral tablet 1 MO

benazepril-hydrochlorothiazide oral tablet 1 MO

BENICAR HCT ORAL TABLET 3 ST; MO

BENICAR ORAL TABLET 3 ST; MO

betaxolol oral tablet 1 MO

BIDIL ORAL TABLET 2 MO

bisoprolol fumarate oral tablet 1 MO

bisoprolol-hydrochlorothiazide oral tablet 1 MO

bumetanide injection solution 1 MO

bumetanide oral tablet 1 MO

BYSTOLIC ORAL TABLET 2 MO

CALAN ORAL TABLET 120 MG 3 MO

CALAN SR ORAL TABLET EXTENDED

RELEASE 120 MG, 240 MG

3 MO

candesartan oral tablet 1 MO

candesartan-hydrochlorothiazide oral tablet 1 MO

captopril oral tablet 1 MO

captopril-hydrochlorothiazide oral tablet 1 MO

CARDIZEM CD ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO


54


CARDIZEM LA ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

CARDIZEM ORAL TABLET 120 MG, 30 MG,

60 MG

3 MO

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG 3 ST; MO; QL (30 per 30 days)

CARDURA ORAL TABLET 8 MG 3 ST; MO; QL (60 per 30 days)

CARDURA XL ORAL TABLET EXTENDED

RELEASE 24HR


CAROSPIR ORAL SUSPENSION 3 MO

cartia xt oral capsule,extended release 24hr 1 MO

carvedilol oral tablet 1 MO

carvedilol phosphate oral capsule, er multiphase

24 hr

1 MO

CATAPRES ORAL TABLET 3 MO

CATAPRES-TTS-1 TRANSDERMAL PATCH

WEEKLY



WEEKLY



WEEKLY


chlorothiazide oral tablet 1 MO

chlorthalidone oral tablet 25 mg, 50 mg 1 MO

clonidine hcl oral tablet 1 MO

clonidine transdermal patch weekly 3 MO; QL (4 per 28 days)

COREG CR ORAL CAPSULE, ER

MULTIPHASE 24 HR

3 MO

COREG ORAL TABLET 3 MO

CORGARD ORAL TABLET 3 MO

COZAAR ORAL TABLET 3 ST; MO

DEMSER ORAL CAPSULE 4 PA; MO

DIBENZYLINE ORAL CAPSULE 4 PA; MO

diltiazem hcl oral capsule,extended release 12 hr 1 MO

diltiazem hcl oral capsule,extended release 24 hr

360 mg, 420 mg

1 MO

diltiazem hcl oral capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg

1 MO

diltiazem hcl oral tablet 1 MO


55


dilt-xr oral capsule, extended release 24h

degradable

1 MO

DIOVAN HCT ORAL TABLET 3 ST; MO

DIOVAN ORAL TABLET 3 ST; MO

DIURIL ORAL SUSPENSION 3 MO

doxazosin oral tablet 1 mg, 2 mg, 4 mg 1 MO; QL (30 per 30 days)

doxazosin oral tablet 8 mg 1 MO; QL (60 per 30 days)

DUTOPROL ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

DYAZIDE ORAL CAPSULE 3 MO

DYRENIUM ORAL CAPSULE 3 MO

EDARBI ORAL TABLET 2 MO

EDARBYCLOR ORAL TABLET 2 MO

EDECRIN ORAL TABLET 4 MO

enalapril maleate oral tablet 1 MO

enalapril-hydrochlorothiazide oral tablet 1 MO

eplerenone oral tablet 1 MO

eprosartan oral tablet 1 MO

ethacrynic acid oral tablet 4 MO

EXFORGE HCT ORAL TABLET 3 ST; MO

EXFORGE ORAL TABLET 3 ST; MO

felodipine oral tablet extended release 24 hr 1 MO

fosinopril oral tablet 1 MO

fosinopril-hydrochlorothiazide oral tablet 1 MO

furosemide injection solution 1 MO

furosemide injection syringe 1 MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1 MO

furosemide oral tablet 1 MO

hydralazine oral tablet 1 MO

hydrochlorothiazide oral capsule 1 MO

hydrochlorothiazide oral tablet 1 MO

HYZAAR ORAL TABLET 3 ST; MO

indapamide oral tablet 1 MO

INDERAL LA ORAL CAPSULE,EXTENDED

RELEASE 24 HR

3 MO


56


INNOPRAN XL ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO

INSPRA ORAL TABLET 3 MO

irbesartan oral tablet 1 MO

irbesartan-hydrochlorothiazide oral tablet 1 MO

isradipine oral capsule 1 MO

KAPSPARGO SPRINKLE ORAL


3 MO

labetalol oral tablet 1 MO

LASIX ORAL TABLET 3 MO

lisinopril oral tablet 1 MO

lisinopril-hydrochlorothiazide oral tablet 1 MO

LOPRESSOR HCT ORAL TABLET 3

LOPRESSOR ORAL TABLET 100 MG 3 MO

losartan oral tablet 1 MO

losartan-hydrochlorothiazide oral tablet 1 MO

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40

MG

3 MO

LOTREL ORAL CAPSULE 10-20 MG, 10-40

MG, 5-10 MG, 5-20 MG

3 MO

matzim la oral tablet extended release 24 hr 1 MO

MAXZIDE ORAL TABLET 3 MO

MAXZIDE-25MG ORAL TABLET 3 MO

methyldopa oral tablet 1 MO

metolazone oral tablet 1 MO

metoprolol succinate oral tablet extended release

24 hr

1 MO

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

1 MO

metoprolol tartrate-hydrochlorothiazide oral

tablet

1 MO

MICARDIS HCT ORAL TABLET 3 ST; MO

MICARDIS ORAL TABLET 3 ST; MO

MINIPRESS ORAL CAPSULE 3 MO

minoxidil oral tablet 1 MO

moexipril oral tablet 1 MO

nadolol oral tablet 1 MO


57


nadolol-bendroflumethiazide oral tablet 40-5 mg 1

nicardipine oral capsule 1 MO

nifedipine oral tablet extended release 1 MO

nifedipine oral tablet extended release 24hr 1 MO

nimodipine oral capsule 1 MO

nisoldipine oral tablet extended release 24 hr 1 MO

NORVASC ORAL TABLET 3 MO

NYMALIZE ORAL SOLUTION 30 MG/10 ML 4

olmesartan oral tablet 1 MO

olmesartan-amlodipine-hydrochlorothiazide oral

tablet

1 MO

olmesartan-hydrochlorothiazide oral tablet 1 MO

ORENITRAM ORAL TABLET EXTENDED

RELEASE 0.125 MG

3 PA; MO

ORENITRAM ORAL TABLET EXTENDED

RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG

4 PA; MO

perindopril erbumine oral tablet 1 MO

phenoxybenzamine oral capsule 4 PA; MO

pindolol oral tablet 1 MO

prazosin oral capsule 1 MO

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5

MG

3 MO

PROCARDIA XL ORAL TABLET EXTENDED

RELEASE 24HR

3 MO

propranolol oral capsule,extended release 24 hr 1 MO

propranolol oral solution 1 MO

propranolol oral tablet 1 MO

propranolol-hydrochlorothiazide oral tablet 1 MO

QBRELIS ORAL SOLUTION 3 MO

quinapril oral tablet 1 MO

quinapril-hydrochlorothiazide oral tablet 1 MO

ramipril oral capsule 1 MO

spironolactone oral tablet 1 MO

spironolactone-hydrochlorothiazide oral tablet 1 MO

SULAR ORAL TABLET EXTENDED

RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

3 MO


58


TARKA ORAL TABLET, IR - ER, BIPHASIC

24HR 2-180 MG, 2-240 MG, 4-240 MG

3 MO

taztia xt oral capsule,extended release 24 hr 1 MO

TEKTURNA HCT ORAL TABLET 2 MO

TEKTURNA ORAL TABLET 2 MO

telmisartan oral tablet 1 MO

telmisartan-amlodipine oral tablet 1 MO

telmisartan-hydrochlorothiazide oral tablet 1 MO

TENORETIC 100 ORAL TABLET 3 MO

TENORETIC 50 ORAL TABLET 3 MO

TENORMIN ORAL TABLET 3 MO

terazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO; QL (30 per 30 days)

terazosin oral capsule 10 mg 1 MO; QL (60 per 30 days)

TIAZAC ORAL CAPSULE,EXTENDED

RELEASE 24 HR

3 MO

timolol maleate oral tablet 1 MO

TOPROL XL ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

torsemide oral tablet 1 MO

trandolapril oral tablet 1 MO

trandolapril-verapamil oral tablet, ir - er, biphasic

24hr

1 MO

triamterene oral capsule 1 MO

triamterene-hydrochlorothiazide oral capsule

37.5-25 mg

1 MO

triamterene-hydrochlorothiazide oral tablet 1 MO

TRIBENZOR ORAL TABLET 3 ST; MO

TWYNSTA ORAL TABLET 40-10 MG, 40-5

MG, 80-5 MG

3 ST; MO

UPTRAVI ORAL TABLET 4 PA; MO; LA

UPTRAVI ORAL TABLETS,DOSE PACK 4 PA; MO; LA

valsartan oral tablet 1 MO

valsartan-hydrochlorothiazide oral tablet 1 MO

VASERETIC ORAL TABLET 3 MO

VASOTEC ORAL TABLET 3 MO

verapamil oral capsule, 24 hr er pellet ct 1 MO


59


verapamil oral capsule,ext rel. pellets 24 hr 120

mg, 180 mg, 240 mg

1 MO

verapamil oral capsule,ext rel. pellets 24 hr 360

mg

1 MO

verapamil oral tablet 1 MO

verapamil oral tablet extended release 1 MO

VERELAN ORAL CAPSULE,EXT REL.

PELLETS 24 HR

3 MO

VERELAN PM ORAL CAPSULE, 24 HR ER

PELLET CT

3 MO

ZESTORETIC ORAL TABLET 3 MO

ZESTRIL ORAL TABLET 3 MO

ZIAC ORAL TABLET 3 MO

COAGULATION THERAPY

AGGRENOX ORAL CAPSULE, ER

MULTIPHASE 12 HR

3 MO

ARIXTRA SUBCUTANEOUS SYRINGE 10

MG/0.8 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML

4 MO

ARIXTRA SUBCUTANEOUS SYRINGE 2.5

MG/0.5 ML

3 MO

aspirin-dipyridamole oral capsule, er multiphase

12 hr

1 MO

BEVYXXA ORAL CAPSULE 3 MO

BRILINTA ORAL TABLET 2 MO

CABLIVI INJECTION KIT 4 PA; MO; LA

cilostazol oral tablet 1 MO

clopidogrel oral tablet 75 mg 1 MO

COUMADIN ORAL TABLET 3 MO

dipyridamole oral tablet 1 MO

DOPTELET (10 TAB PACK) ORAL TABLET 4 PA; MO; LA



EFFIENT ORAL TABLET 3 MO

ELIQUIS ORAL TABLET 2 MO

ELIQUIS ORAL TABLETS,DOSE PACK 2 MO

enoxaparin subcutaneous syringe 1 MO


60


fondaparinux subcutaneous syringe 10 mg/0.8 ml,

5 mg/0.4 ml, 7.5 mg/0.6 ml

4 MO

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 1 MO

FRAGMIN SUBCUTANEOUS SOLUTION 4 MO

FRAGMIN SUBCUTANEOUS SYRINGE 10,000

ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5

ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000

ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA

UNIT/0.3 ML

4 MO

FRAGMIN SUBCUTANEOUS SYRINGE 2,500

ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA

UNIT/0.2 ML

3 MO

heparin (porcine) injection solution 1 MO

jantoven oral tablet 1 MO

LOVENOX SUBCUTANEOUS SYRINGE 3 MO

MULPLETA ORAL TABLET 4 PA; MO

pentoxifylline oral tablet extended release 1 MO

PLAVIX ORAL TABLET 75 MG 3 MO

PRADAXA ORAL CAPSULE 3 MO

prasugrel oral tablet 1 MO

PROMACTA ORAL POWDER IN PACKET 4 PA; MO; LA

PROMACTA ORAL TABLET 4 PA; MO; LA

SAVAYSA ORAL TABLET 3 MO

TAVALISSE ORAL TABLET 4 PA; MO; LA; QL (60 per 30 days)

warfarin oral tablet 1 MO

XARELTO ORAL TABLET 2 MO

XARELTO ORAL TABLETS,DOSE PACK 2 MO

YOSPRALA ORAL TABLET,IR,DELAYED

REL,BIPHASIC

3 MO

ZONTIVITY ORAL TABLET 2 MO

LIPID/CHOLESTEROL LOWERING AGENTS

ALTOPREV ORAL TABLET EXTENDED

RELEASE 24 HR


amlodipine-atorvastatin oral tablet 1 MO; QL (30 per 30 days)

ANTARA ORAL CAPSULE 30 MG, 90 MG 3 MO

atorvastatin oral tablet 1 MO; QL (30 per 30 days)


61


CADUET ORAL TABLET 10-10 MG, 10-20 MG,

10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40

MG, 5-80 MG


cholestyramine (with sugar) oral powder in packet 1 MO

cholestyramine light oral powder 1 MO

colesevelam oral powder in packet 1 MO

colesevelam oral tablet 1 MO

COLESTID ORAL PACKET 3 MO

COLESTID ORAL TABLET 3 MO

colestipol oral packet 1 MO

colestipol oral tablet 1 MO

CRESTOR ORAL TABLET 3 ST; MO; QL (30 per 30 days)

EZALLOR SPRINKLE ORAL CAPSULE 3 ST; MO; QL (30 per 30 days)

ezetimibe oral tablet 1 MO

ezetimibe-simvastatin oral tablet 1 MO; QL (30 per 30 days)

fenofibrate micronized oral capsule 1 MO

fenofibrate nanocrystallized oral tablet 145 mg, 48

mg

1 MO

FENOFIBRATE ORAL CAPSULE 3 MO

fenofibrate oral tablet 1 MO

fenofibric acid (choline) oral capsule,delayed

release(dr/ec)

1 MO

fenofibric acid oral tablet 1 MO

FENOGLIDE ORAL TABLET 3 MO

FIBRICOR ORAL TABLET 3 MO

FLOLIPID ORAL SUSPENSION 3 ST; MO; QL (300 per 30 days)

fluvastatin oral capsule 20 mg 1 MO; QL (30 per 30 days)

fluvastatin oral capsule 40 mg 1 MO; QL (60 per 30 days)

fluvastatin oral tablet extended release 24 hr 1 MO; QL (30 per 30 days)

gemfibrozil oral tablet 1 MO

JUXTAPID ORAL CAPSULE 4 PA; MO; LA

LESCOL XL ORAL TABLET EXTENDED

RELEASE 24 HR


LIPITOR ORAL TABLET 3 ST; MO; QL (30 per 30 days)

LIPOFEN ORAL CAPSULE 3 MO

LIVALO ORAL TABLET 2 MO; QL (30 per 30 days)


62


LOPID ORAL TABLET 3 MO

lovastatin oral tablet 10 mg 1 MO; QL (30 per 30 days)

lovastatin oral tablet 20 mg, 40 mg 1 MO; QL (60 per 30 days)

LOVAZA ORAL CAPSULE 3 ST; MO

niacin oral tablet extended release 24 hr 1 MO

NIACOR ORAL TABLET 3 MO

NIASPAN EXTENDED-RELEASE ORAL

TABLET EXTENDED RELEASE 24 HR

3 MO

omega-3 acid ethyl esters oral capsule 3 ST; MO

PRALUENT SUBCUTANEOUS PEN

INJECTOR 150 MG/ML


PRALUENT SUBCUTANEOUS PEN

INJECTOR 75 MG/ML


PRAVACHOL ORAL TABLET 20 MG, 40 MG,

80 MG


pravastatin oral tablet 1 MO; QL (30 per 30 days)

prevalite oral powder in packet 1 MO

QUESTRAN LIGHT ORAL POWDER 3 MO

QUESTRAN ORAL POWDER IN PACKET 3 MO

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR

4 PA; MO; QL (3.5 per 28 days)

REPATHA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (3 per 28 days)

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR


rosuvastatin oral tablet 1 MO; QL (30 per 30 days)

simvastatin oral tablet 1 MO; QL (30 per 30 days)

TRICOR ORAL TABLET 3 MO

TRIGLIDE ORAL TABLET 160 MG 3 MO

TRILIPIX ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

3 MO

VASCEPA ORAL CAPSULE 2 MO

VYTORIN 10-10 ORAL TABLET 3 ST; MO; QL (30 per 30 days)




WELCHOL ORAL POWDER IN PACKET 3 MO

WELCHOL ORAL TABLET 3 MO


63


ZETIA ORAL TABLET 3 MO

ZOCOR ORAL TABLET 10 MG, 20 MG, 40

MG, 80 MG


ZYPITAMAG ORAL TABLET 3 ST; MO; QL (30 per 30 days)

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL SOLUTION 2 PA

CORLANOR ORAL TABLET 2 PA; MO

digitek oral tablet 1 MO

digox oral tablet 1 MO

digoxin oral solution 50 mcg/ml (0.05 mg/ml) 1 MO

digoxin oral tablet 1 MO

ENTRESTO ORAL TABLET 2 MO; QL (60 per 30 days)

LANOXIN ORAL TABLET 125 MCG (0.125

MG), 250 MCG (0.25 MG)

3 MO

LANOXIN ORAL TABLET 62.5 MCG (0.0625

MG)

2 MO

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR

2 MO

ranolazine oral tablet extended release 12 hr 1 MO

VECAMYL ORAL TABLET 4

VYNDAQEL ORAL CAPSULE 4 PA; MO

NITRATES

ISORDIL ORAL TABLET 3 MO

ISORDIL TITRADOSE ORAL TABLET 5 MG 3 MO

isosorbide dinitrate oral tablet 1 MO

isosorbide dinitrate oral tablet extended release 1

isosorbide mononitrate oral tablet 1 MO

isosorbide mononitrate oral tablet extended

release 24 hr

1 MO

MINITRAN TRANSDERMAL PATCH 24

HOUR

3 MO

nitro-bid transdermal ointment 1 MO

NITRO-DUR TRANSDERMAL PATCH 24

HOUR

3 MO

nitroglycerin sublingual tablet 1 MO

nitroglycerin transdermal patch 24 hour 1 MO


64


nitroglycerin translingual spray,non-aerosol 1 MO

NITROSTAT SUBLINGUAL TABLET 3 MO

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin oral capsule 10 mg 1 MO

acitretin oral capsule 17.5 mg, 25 mg 4 MO

calcipotriene scalp solution 1 MO; QL (120 per 30 days)

calcipotriene topical cream 3 MO; QL (120 per 30 days)

calcipotriene topical ointment 1 MO; QL (120 per 30 days)

calcipotriene-betamethasone topical ointment 1 MO; QL (400 per 30 days)

calcitriol topical ointment 3 MO

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE

4 PA; MO

COSENTYX (2 PENS) SUBCUTANEOUS PEN

INJECTOR

4 PA; MO

DOVONEX TOPICAL CREAM 3 MO; QL (120 per 30 days)

ENSTILAR TOPICAL FOAM 4 MO; QL (400 per 30 days)

ILUMYA SUBCUTANEOUS SYRINGE 4 PA; MO

selenium sulfide topical lotion 1 MO

SILIQ SUBCUTANEOUS SYRINGE 4 PA; MO

SKYRIZI SUBCUTANEOUS SYRINGE KIT 4 PA; MO; QL (1 per 28 days)

SORIATANE ORAL CAPSULE 10 MG, 25 MG 4 MO

SORILUX TOPICAL FOAM 3 MO; QL (120 per 30 days)

STELARA INTRAVENOUS SOLUTION 4 PA; MO

STELARA SUBCUTANEOUS SOLUTION 4 PA; MO

STELARA SUBCUTANEOUS SYRINGE 4 PA; MO

TACLONEX TOPICAL OINTMENT 3 MO; QL (400 per 30 days)

TACLONEX TOPICAL SUSPENSION 3 MO; QL (400 per 30 days)

TALTZ AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR

4 PA; MO

TALTZ SUBCUTANEOUS SYRINGE 4 PA; MO

TREMFYA SUBCUTANEOUS AUTO-

INJECTOR

4 PA; MO

TREMFYA SUBCUTANEOUS SYRINGE 4 PA; MO

VECTICAL TOPICAL OINTMENT 3 MO


65


MISCELLANEOUS DERMATOLOGICALS

ALDARA TOPICAL CREAM IN PACKET 3 ST; MO

ammonium lactate topical cream 1 MO

ammonium lactate topical lotion 1 MO

CARAC TOPICAL CREAM 4 MO

CONDYLOX TOPICAL GEL 2 MO

diclofenac sodium topical gel 3 % 4 PA; MO; QL (100 per 28 days)

doxepin topical cream 4 MO; QL (45 per 30 days)

DUPIXENT SUBCUTANEOUS SYRINGE 4 PA; MO

EFUDEX TOPICAL CREAM 3 ST; MO

ELIDEL TOPICAL CREAM 3 PA; MO; QL (100 per 30 days)

EUCRISA TOPICAL OINTMENT 3 PA; MO; QL (120 per 30 days)

FLUOROURACIL TOPICAL CREAM 0.5 % 4 ST; MO

fluorouracil topical cream 5 % 1 MO

fluorouracil topical solution 1 MO

IMIQUIMOD TOPICAL CREAM IN

METERED-DOSE PUMP

4 ST; MO

imiquimod topical cream in packet 1 MO

lidocaine hcl mucous membrane jelly 1 MO; QL (60 per 30 days)

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

1 MO

lidocaine topical adhesive patch,medicated 1 PA; MO; QL (90 per 30 days)

lidocaine topical ointment 3 MO; QL (36 per 30 days)

lidocaine viscous mucous membrane solution 1 MO

lidocaine-prilocaine topical cream 1 MO; QL (30 per 30 days)

LIDODERM TOPICAL ADHESIVE

PATCH,MEDICATED


methoxsalen oral capsule, liquid-filled, rapid

release

4 MO

OXSORALEN ULTRA ORAL CAPSULE,LIQD-

FILLED,RAPID REL

4 MO

PANRETIN TOPICAL GEL 4 MO

PICATO TOPICAL GEL 4 MO

pimecrolimus topical cream 1 PA; MO; QL (100 per 30 days)

PLIAGLIS TOPICAL CREAM 3 MO

podofilox topical solution 1 MO


66


PROTOPIC TOPICAL OINTMENT 3 PA; MO; QL (100 per 30 days)

prudoxin topical cream 1 MO; QL (45 per 30 days)

QBREXZA TOPICAL TOWELETTE 3 MO

REGRANEX TOPICAL GEL 4 MO

SANTYL TOPICAL OINTMENT 2 MO

SILVADENE TOPICAL CREAM 3 MO

silver sulfadiazine topical cream 1 MO

ssd topical cream 1 MO

tacrolimus topical ointment 1 PA; MO; QL (100 per 30 days)

TOLAK TOPICAL CREAM 3 MO

VALCHLOR TOPICAL GEL 4 MO

VEREGEN TOPICAL OINTMENT 3 MO

ZONALON TOPICAL CREAM 3 MO; QL (45 per 30 days)

ZTLIDO TOPICAL ADHESIVE

PATCH,MEDICATED


ZYCLARA TOPICAL CREAM IN METERED-

DOSE PUMP

4 ST; MO

ZYCLARA TOPICAL CREAM IN PACKET 4 ST; MO

THERAPY FOR ACNE

ABSORICA ORAL CAPSULE 4 MO

ACANYA TOPICAL GEL WITH PUMP 3 MO

ACZONE TOPICAL GEL 3 MO

adapalene topical cream 1 PA; MO

adapalene topical gel 1 PA; MO

adapalene topical solution 1 PA

adapalene topical swab 1 PA

adapalene-benzoyl peroxide topical gel with pump 1 PA; MO

AKTIPAK TOPICAL GEL 3 MO

ALTRENO TOPICAL LOTION 3 PA; MO

amnesteem oral capsule 1 MO

ATRALIN TOPICAL GEL 3 PA; MO

avita topical cream 1 PA; MO

AVITA TOPICAL GEL 3 PA; MO

azelaic acid topical gel 1 MO

AZELEX TOPICAL CREAM 3 MO


67


BENZACLIN TOPICAL GEL WITH PUMP 3 MO

BENZAMYCIN TOPICAL GEL 3 MO

claravis oral capsule 3 MO

CLEOCIN T TOPICAL GEL 3 MO

CLEOCIN T TOPICAL LOTION 3 MO

CLEOCIN T TOPICAL SWAB 3 MO

clindacin p topical swab 1 MO

CLINDAGEL TOPICAL GEL, ONCE DAILY 3 MO

clindamycin phosphate topical foam 1 MO

clindamycin phosphate topical gel 1 MO

clindamycin phosphate topical lotion 1 MO

clindamycin phosphate topical solution 1 MO

clindamycin phosphate topical swab 1 MO

clindamycin-benzoyl peroxide topical gel 1 MO

clindamycin-benzoyl peroxide topical gel with

pump 1.2-2.5 %

1 MO

clindamycin-tretinoin topical gel 1 PA; MO

dapsone topical gel 1 MO

DIFFERIN TOPICAL CREAM 3 PA; MO

DIFFERIN TOPICAL GEL 0.1 % 3 PA; MO

DIFFERIN TOPICAL GEL WITH PUMP 3 PA; MO

DIFFERIN TOPICAL LOTION 3 PA; MO

DUAC TOPICAL GEL 3 MO

EPIDUO FORTE TOPICAL GEL WITH PUMP 3 PA; MO

EPIDUO TOPICAL GEL WITH PUMP 3 PA; MO

ery pads topical swab 1 MO

erygel topical gel 1 MO

erythromycin with ethanol topical gel 1 MO

erythromycin with ethanol topical solution 1 MO

erythromycin-benzoyl peroxide topical gel 1 MO

EVOCLIN TOPICAL FOAM 3 MO

FABIOR TOPICAL FOAM 3 MO

FINACEA TOPICAL FOAM 3 ST; MO

FINACEA TOPICAL GEL 3 ST; MO

isotretinoin oral capsule 1 MO


68


METROCREAM TOPICAL CREAM 3 ST; MO

METROGEL TOPICAL GEL 1 % 3 ST; MO

METROLOTION TOPICAL LOTION 3 ST; MO

metronidazole topical cream 1 MO

metronidazole topical gel 1 MO

metronidazole topical lotion 1 MO

MIRVASO TOPICAL GEL WITH PUMP 3 PA; MO

myorisan oral capsule 1 MO

neuac topical gel 1 MO

NORITATE TOPICAL CREAM 4 ST; MO

ONEXTON TOPICAL GEL WITH PUMP 3 MO

RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1 % 3 PA; MO

RETIN-A MICRO TOPICAL GEL WITH PUMP

0.06 %, 0.08 %

3 PA; MO

RETIN-A TOPICAL CREAM 3 PA; MO

RETIN-A TOPICAL GEL 3 PA; MO

RHOFADE TOPICAL CREAM 3 PA; MO

SOOLANTRA TOPICAL CREAM 3 ST; MO

tazarotene topical cream 1 PA; MO

TAZORAC TOPICAL CREAM 0.05 % 2 PA; MO

TAZORAC TOPICAL CREAM 0.1 % 3 PA; MO

TAZORAC TOPICAL GEL 2 PA; MO

tretinoin microspheres topical gel 1 PA; MO

tretinoin topical cream 1 PA; MO

tretinoin topical gel 1 PA; MO

zenatane oral capsule 3 MO

ZIANA TOPICAL GEL 3 PA; MO

TOPICAL ANTIBACTERIALS

CORTISPORIN TOPICAL CREAM 3 MO

CORTISPORIN TOPICAL OINTMENT 3 MO

gentamicin topical cream 1 MO

gentamicin topical ointment 1 MO

KLARON TOPICAL SUSPENSION 3 MO

mafenide acetate topical packet 1 MO

mupirocin calcium topical cream 1 MO


69


mupirocin topical ointment 1 MO

NEO-SYNALAR TOPICAL CREAM 3 MO

sulfacetamide sodium (acne) topical suspension 1 MO

SULFAMYLON TOPICAL CREAM 2 MO

SULFAMYLON TOPICAL PACKET 4 MO

XEPI TOPICAL CREAM 3 MO

TOPICAL ANTIFUNGALS

ciclopirox topical cream 1 MO; QL (90 per 28 days)

ciclopirox topical gel 1 MO; QL (45 per 28 days)

ciclopirox topical shampoo 1 MO; QL (120 per 28 days)

ciclopirox topical solution 1 MO

ciclopirox topical suspension 1 MO; QL (60 per 28 days)

clotrimazole topical cream 1 MO; QL (45 per 28 days)

clotrimazole topical solution 1 MO; QL (30 per 28 days)

clotrimazole-betamethasone topical cream 1 MO; QL (45 per 28 days)

clotrimazole-betamethasone topical lotion 1 MO; QL (60 per 28 days)

econazole topical cream 1 MO; QL (85 per 28 days)

ERTACZO TOPICAL CREAM 3 MO; QL (60 per 28 days)

EXELDERM TOPICAL CREAM 3 MO

EXELDERM TOPICAL SOLUTION 3 MO

EXTINA TOPICAL FOAM 3 MO; QL (100 per 28 days)

JUBLIA TOPICAL SOLUTION WITH

APPLICATOR

3 MO

KERYDIN TOPICAL SOLUTION WITH

APPLICATOR

3 MO

ketoconazole topical cream 1 MO; QL (60 per 28 days)

ketoconazole topical foam 1 MO; QL (100 per 28 days)

ketoconazole topical shampoo 1 MO; QL (120 per 28 days)

LOPROX (AS OLAMINE) TOPICAL CREAM 3 MO; QL (90 per 28 days)

LOPROX TOPICAL SHAMPOO 3 MO; QL (120 per 28 days)

LOTRISONE TOPICAL CREAM 3 MO; QL (45 per 28 days)

LULICONAZOLE TOPICAL CREAM 3 MO; QL (60 per 28 days)

LUZU TOPICAL CREAM 3 MO; QL (60 per 28 days)

MENTAX TOPICAL CREAM 3 MO

naftifine topical cream 1 MO; QL (60 per 28 days)


70


NAFTIN TOPICAL CREAM 2 % 3 MO; QL (60 per 28 days)

NAFTIN TOPICAL GEL 2 MO; QL (60 per 28 days)

NIZORAL TOPICAL SHAMPOO 3 MO; QL (120 per 28 days)

nyamyc topical powder 1 MO

nystatin topical cream 1 MO; QL (30 per 28 days)

nystatin topical ointment 1 MO; QL (30 per 28 days)

nystatin topical powder 1 MO

nystatin-triamcinolone topical cream 1 MO; QL (60 per 28 days)

nystatin-triamcinolone topical ointment 1 MO; QL (60 per 28 days)

nystop topical powder 1 MO

oxiconazole topical cream 1 MO

OXISTAT TOPICAL CREAM 3 MO

OXISTAT TOPICAL LOTION 3 MO

TOPICAL ANTIVIRALS

acyclovir topical cream 1 PA; MO; QL (5 per 30 days)

acyclovir topical ointment 3 PA; MO; QL (30 per 30 days)

DENAVIR TOPICAL CREAM 2 MO

XERESE TOPICAL CREAM 3 MO

ZOVIRAX TOPICAL CREAM 4 PA; MO; QL (5 per 30 days)

ZOVIRAX TOPICAL OINTMENT 4 PA; MO; QL (30 per 30 days)

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 MO

ALA-SCALP TOPICAL LOTION 3 MO

alclometasone topical cream 1 MO

alclometasone topical ointment 1 MO

amcinonide topical cream 1 MO

amcinonide topical lotion 1 MO

amcinonide topical ointment 1

apexicon e topical cream 1 MO

beser topical lotion 1

betamethasone dipropionate topical cream 1 MO

betamethasone dipropionate topical lotion 1 MO

betamethasone dipropionate topical ointment 1 MO

betamethasone valerate topical cream 1 MO


71


betamethasone valerate topical foam 1 MO

betamethasone valerate topical lotion 1 MO

betamethasone valerate topical ointment 1 MO

betamethasone, augmented topical cream 1 MO

betamethasone, augmented topical gel 1 MO

betamethasone, augmented topical lotion 1 MO

betamethasone, augmented topical ointment 1 MO

BRYHALI TOPICAL LOTION 3 MO

CAPEX TOPICAL SHAMPOO 2 MO

clobetasol scalp solution 1 MO; QL (100 per 28 days)

clobetasol topical cream 1 MO; QL (120 per 28 days)

clobetasol topical foam 1 MO; QL (100 per 28 days)

clobetasol topical gel 1 MO; QL (120 per 28 days)

clobetasol topical lotion 1 MO; QL (118 per 28 days)

clobetasol topical ointment 1 MO; QL (120 per 28 days)

clobetasol topical shampoo 1 MO; QL (236 per 28 days)

clobetasol topical spray,non-aerosol 1 MO; QL (125 per 28 days)

clobetasol-emollient topical cream 1 MO; QL (120 per 28 days)

clobetasol-emollient topical foam 1 MO; QL (100 per 28 days)

CLOBEX TOPICAL LOTION 3 MO; QL (118 per 28 days)

CLOBEX TOPICAL SHAMPOO 3 MO; QL (236 per 28 days)

CLOBEX TOPICAL SPRAY,NON-AEROSOL 3 MO; QL (125 per 28 days)

CLOCORTOLONE PIVALATE TOPICAL

CREAM

3 MO

clodan topical shampoo 1 MO; QL (236 per 28 days)

CLODERM TOPICAL CREAM 3 MO

CORDRAN LARGE ROLL TOPICAL TAPE 3 MO

CUTIVATE TOPICAL LOTION 3 MO

DESONATE TOPICAL GEL 3 MO

desonide topical cream 3 MO

desonide topical lotion 3 MO

desonide topical ointment 3 MO

DESOWEN TOPICAL CREAM 3 MO

DESOWEN TOPICAL LOTION 3 MO

desoximetasone topical cream 1 MO


72


desoximetasone topical gel 1 MO

desoximetasone topical ointment 1 MO

desoximetasone topical spray,non-aerosol 1 MO

diflorasone topical cream 1 MO

diflorasone topical ointment 1 MO

DIPROLENE TOPICAL OINTMENT 3 MO

DUOBRII TOPICAL LOTION 4 MO

ELOCON TOPICAL CREAM 3 MO

fluocinolone and shower cap scalp oil 1 MO

fluocinolone topical cream 1 MO

fluocinolone topical ointment 1 MO

fluocinolone topical solution 1 MO

fluocinonide topical cream 0.1 % 1 MO; QL (120 per 30 days)

fluocinonide topical gel 1 MO; QL (120 per 30 days)

fluocinonide topical ointment 1 MO; QL (120 per 30 days)

fluocinonide topical solution 1 MO; QL (120 per 30 days)

fluocinonide-e topical cream 1 MO; QL (120 per 30 days)

flurandrenolide topical cream 1 MO

flurandrenolide topical lotion 1 MO

flurandrenolide topical ointment 1 MO

fluticasone propionate topical cream 1 MO

fluticasone propionate topical lotion 1 MO

fluticasone propionate topical ointment 1 MO

halcinonide topical cream 1 MO

halobetasol propionate topical cream 1 MO

HALOBETASOL PROPIONATE TOPICAL

FOAM

3 MO

halobetasol propionate topical ointment 1 MO

HALOG TOPICAL CREAM 3 MO

HALOG TOPICAL OINTMENT 3 MO

hydrocortisone butyrate topical cream 1 MO

hydrocortisone butyrate topical lotion 1 MO

hydrocortisone butyrate topical ointment 1 MO

hydrocortisone butyrate topical solution 1 MO

hydrocortisone topical cream 1 %, 2.5 % 1 MO


73


hydrocortisone topical lotion 2.5 % 1 MO

hydrocortisone topical ointment 1 %, 2.5 % 1 MO

hydrocortisone valerate topical cream 1 MO

hydrocortisone valerate topical ointment 1 MO

IMPOYZ TOPICAL CREAM 3 MO; QL (120 per 28 days)

KENALOG TOPICAL AEROSOL 3 MO

LEXETTE TOPICAL FOAM 3 MO

LOCOID LIPOCREAM TOPICAL CREAM 3 MO

LOCOID TOPICAL LOTION 3 MO

LOCOID TOPICAL SOLUTION 3 MO

LUXIQ TOPICAL FOAM 3 MO

mometasone topical cream 1 MO

mometasone topical ointment 1 MO

mometasone topical solution 1 MO

nolix topical cream 1

nolix topical lotion 1 MO

OLUX TOPICAL FOAM 3 MO; QL (100 per 28 days)

OLUX-E TOPICAL FOAM 3 MO; QL (100 per 28 days)

PANDEL TOPICAL CREAM 3 MO

prednicarbate topical cream 1 MO

prednicarbate topical ointment 1 MO

PSORCON TOPICAL CREAM 3

SERNIVO TOPICAL SPRAY WITH PUMP 4 MO

SYNALAR TOPICAL CREAM 3 MO

TEXACORT TOPICAL SOLUTION 3 MO

TOPICORT TOPICAL CREAM 3 MO

TOPICORT TOPICAL GEL 3 MO

TOPICORT TOPICAL OINTMENT 3 MO

TOPICORT TOPICAL SPRAY,NON-AEROSOL 3 MO

triamcinolone acetonide topical aerosol 1 MO

triamcinolone acetonide topical cream 1 MO

triamcinolone acetonide topical lotion 1 MO

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

1 MO

trianex topical ointment 1 MO


74


triderm topical cream 0.1 % 1 MO

TRIDESILON TOPICAL CREAM 3 MO

ULTRAVATE TOPICAL LOTION 4 MO

ULTRAVATE TOPICAL OINTMENT 3 MO

VANOS TOPICAL CREAM 4 MO; QL (120 per 30 days)

TOPICAL SCABICIDES / PEDICULICIDES

ELIMITE TOPICAL CREAM 3

EURAX TOPICAL CREAM 3 MO

EURAX TOPICAL LOTION 3 MO

lindane topical shampoo 1 MO

malathion topical lotion 1 MO

NATROBA TOPICAL SUSPENSION 3 MO

OVIDE TOPICAL LOTION 3 MO

permethrin topical cream 1 MO

SKLICE TOPICAL LOTION 2 MO

DIAGNOSTICS / MISCELLANEOUS AGENTS

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec) 3 MO

AGRYLIN ORAL CAPSULE 3 MO

alendronate oral tablet 40 mg 1 MO; QL (30 per 30 days)

anagrelide oral capsule 1 MO

ANTABUSE ORAL TABLET 3 MO

ARALAST NP INTRAVENOUS RECON SOLN

1,000 MG

4 MO; LA

AURYXIA ORAL TABLET 4 PA; MO

BUPHENYL ORAL POWDER 4 MO

BUPHENYL ORAL TABLET 4 MO

CARBAGLU ORAL TABLET, DISPERSIBLE 4 MO; LA

CARNITOR ORAL SOLUTION 3 MO

CARNITOR ORAL TABLET 3 MO

cevimeline oral capsule 1 MO

CHEMET ORAL CAPSULE 2 PA; MO

CLINIMIX 4.25%/D5W SULFITE FREE

INTRAVENOUS PARENTERAL SOLUTION

2 B/D PA


75


CLINIMIX E 2.75%/D5W SULFITE FREE


3 B/D PA

d10 %-0.45 % sodium chloride intravenous

parenteral solution

1

d2.5 %-0.45 % sodium chloride intravenous

parenteral solution

1

d5 % and 0.9 % sodium chloride intravenous

parenteral solution

1 MO

d5 %-0.45 % sodium chloride intravenous

parenteral solution

1 MO

deferasirox oral tablet, dispersible 4 PA; MO

dextrose 10 % and 0.2 % nacl intravenous

parenteral solution

1

dextrose 10 % in water (d10w) intravenous

parenteral solution

1 MO

dextrose 5 % in water (d5w) intravenous

parenteral solution

1 MO

dextrose 5%-0.2 % sod chloride intravenous

parenteral solution

1

dextrose 5%-0.3 % sod.chloride intravenous

parenteral solution

1

dextrose with sodium chloride intravenous

parenteral solution

1

disulfiram oral tablet 1 MO

ENDARI ORAL POWDER IN PACKET 4 PA; MO

etidronate disodium oral tablet 1 MO

EVOXAC ORAL CAPSULE 3 MO

EXJADE ORAL TABLET, DISPERSIBLE 4 PA; MO; LA

FERRIPROX ORAL SOLUTION 4 PA; MO

ferriprox oral tablet 1,000 mg 4 PA; MO

FERRIPROX ORAL TABLET 500 MG 4 PA; MO

FOSRENOL ORAL POWDER IN PACKET 3 MO

FOSRENOL ORAL TABLET,CHEWABLE 3 MO

GLASSIA INTRAVENOUS SOLUTION 4 MO; LA

INCRELEX SUBCUTANEOUS SOLUTION 4 MO; LA

JADENU ORAL TABLET 4 PA; MO

JADENU SPRINKLE ORAL GRANULES IN

PACKET

4 PA; MO


76


kionex (with sorbitol) oral suspension 1 MO

lanthanum oral tablet,chewable 1 MO

levocarnitine (with sugar) oral solution 1 MO

levocarnitine oral tablet 1 MO

LITHOSTAT ORAL TABLET 3 MO

LOKELMA ORAL POWDER IN PACKET 2 MO

midodrine oral tablet 1 MO

NITYR ORAL TABLET 3 MO; LA

NORTHERA ORAL CAPSULE 4 PA; MO

ORFADIN ORAL CAPSULE 4 MO; LA

ORFADIN ORAL SUSPENSION 4 MO; LA

pilocarpine hcl oral tablet 1 MO

PROLASTIN-C INTRAVENOUS RECON SOLN 4 LA

PROLASTIN-C INTRAVENOUS SOLUTION 4 MO; LA

RAVICTI ORAL LIQUID 4 MO

RENAGEL ORAL TABLET 800 MG 3 MO

RENVELA ORAL POWDER IN PACKET 4 MO

RENVELA ORAL TABLET 4 MO

RILUTEK ORAL TABLET 4 MO

riluzole oral tablet 1 MO

risedronate oral tablet 30 mg 1 MO; QL (30 per 30 days)

SALAGEN (PILOCARPINE) ORAL TABLET 3 MO

sevelamer carbonate oral powder in packet 4 MO

sevelamer carbonate oral tablet 1 MO

sevelamer hcl oral tablet 1 MO

sodium chloride 0.9 % intravenous parenteral

solution

1 MO

sodium chloride irrigation solution 1 MO

sodium phenylbutyrate oral powder 4 MO

sodium phenylbutyrate oral tablet 4 MO

sodium polystyrene sulfonate oral powder 1 MO

sps (with sorbitol) oral suspension 1 MO

SYPRINE ORAL CAPSULE 4 PA; MO

THIOLA EC ORAL TABLET,DELAYED

RELEASE (DR/EC)

4 MO


77


THIOLA ORAL TABLET 4 MO

TIGLUTIK ORAL SUSPENSION 4 MO

trientine oral capsule 4 PA; MO

VELPHORO ORAL TABLET,CHEWABLE 4 MO

VELTASSA ORAL POWDER IN PACKET 2 MO

XURIDEN ORAL GRANULES IN PACKET 4 MO

ZEMAIRA INTRAVENOUS RECON SOLN 4 MO; LA

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended

release 12 hr

1 MO

CHANTIX CONTINUING MONTH BOX ORAL

TABLET

2 MO

CHANTIX ORAL TABLET 2 MO

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK

2 MO

NICOTROL INHALATION CARTRIDGE 3 MO

NICOTROL NS NASAL SPRAY,NON-

AEROSOL

3 MO

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

ASTEPRO NASAL SPRAY,NON-AEROSOL 3 MO; QL (60 per 30 days)

azelastine nasal spray, aerosol 1 MO; QL (60 per 30 days)

azelastine nasal spray,non-aerosol 1 MO; QL (60 per 30 days)

chlorhexidine gluconate mucous membrane

mouthwash

1 MO

ipratropium bromide nasal spray,non-aerosol 1 MO; QL (30 per 30 days)

olopatadine nasal spray,non-aerosol 1 MO; QL (30.5 per 30 days)

PATANASE NASAL SPRAY,NON-AEROSOL 3 MO; QL (30.5 per 30 days)

triamcinolone acetonide dental paste 1 MO

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution 1 MO

CETRAXAL OTIC (EAR) DROPPERETTE 3 MO

ciprofloxacin hcl otic (ear) dropperette 1 MO

flac oil otic (ear) drops 1

fluocinolone acetonide oil otic (ear) drops 1 MO

hydrocortisone-acetic acid otic (ear) drops 1 MO


78


ofloxacin otic (ear) drops 1 MO

OTIC STEROID / ANTIBIOTIC

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 3 MO

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2 MO

COLY-MYCIN S OTIC (EAR)

DROPS,SUSPENSION

3 MO

neomycin-polymyxin-hc otic (ear)

drops,suspension

1 MO

neomycin-polymyxin-hc otic (ear) solution 1 MO

OTOVEL OTIC (EAR) SOLUTION 2 MO

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR INJECTION GEL 4 PA; MO

CORTEF ORAL TABLET 3 MO

cortisone oral tablet 1 MO

dexamethasone intensol oral drops 1 MO

dexamethasone oral elixir 1 MO

dexamethasone oral tablet 1 MO

dexamethasone oral tablets,dose pack 1 MO

DEXPAK 13 DAY ORAL TABLETS,DOSE

PACK

3 MO

EMFLAZA ORAL SUSPENSION 4 PA; MO; LA

EMFLAZA ORAL TABLET 4 PA; MO; LA

fludrocortisone oral tablet 1 MO

hydrocortisone oral tablet 1 MO

MEDROL (PAK) ORAL TABLETS,DOSE

PACK

3 MO

MEDROL ORAL TABLET 3 B/D PA; MO

methylprednisolone oral tablet 1 B/D PA; MO

methylprednisolone oral tablets,dose pack 1 MO

millipred oral tablet 3 B/D PA; MO

ORAPRED ODT ORAL


3 B/D PA; MO

prednisolone oral solution 15 mg/5 ml 1 MO


79


prednisolone sodium phosphate oral solution 10

mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5

mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1 MO

prednisolone sodium phosphate oral

tablet,disintegrating

1 B/D PA; MO

prednisone intensol oral concentrate 1 B/D PA; MO

prednisone oral solution 1 MO

prednisone oral tablet 1 B/D PA; MO

prednisone oral tablets,dose pack 1 MO

RAYOS ORAL TABLET,DELAYED RELEASE

(DR/EC)

4 B/D PA; MO

TAPERDEX ORAL TABLETS,DOSE PACK 1.5

MG (21 TABS)

3 MO

TAPERDEX ORAL TABLETS,DOSE PACK 1.5

MG (27 TABS), 1.5 MG (49 TABS)

3

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1 MO

propylthiouracil oral tablet 1 MO

TAPAZOLE ORAL TABLET 3 MO

DIABETES THERAPY

acarbose oral tablet 100 mg 1 MO; QL (90 per 30 days)



ACTOPLUS MET ORAL TABLET 3 MO; QL (90 per 30 days)

ACTOS ORAL TABLET 3 MO; QL (30 per 30 days)

ADLYXIN SUBCUTANEOUS PEN INJECTOR

10 MCG/0.2 ML- 20 MCG/0.2 ML


ADLYXIN SUBCUTANEOUS PEN INJECTOR

20 MCG/0.2 ML


ADMELOG SOLOSTAR U-100 INSULIN

SUBCUTANEOUS PEN

3 ST; MO

ADMELOG U-100 INSULIN LISPRO

SUBCUTANEOUS SOLUTION

3 ST; MO

AFREZZA INHALATION CARTRIDGE WITH

INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8

UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8

UNIT, 8 UNIT (90)/ 12 UNIT (90)

3 MO


80


ALCOHOL PADS TOPICAL PADS,

MEDICATED

2 MO

ALOGLIPTIN ORAL TABLET 3 ST; MO; QL (30 per 30 days)

ALOGLIPTIN-METFORMIN ORAL TABLET 3 ST; MO; QL (60 per 30 days)

ALOGLIPTIN-PIOGLITAZONE ORAL

TABLET


AMARYL ORAL TABLET 1 MG 3 MO; QL (240 per 30 days)



APIDRA SOLOSTAR U-100 INSULIN

SUBCUTANEOUS PEN

3 ST; MO

APIDRA U-100 INSULIN SUBCUTANEOUS

SOLUTION

3 ST; MO

AVANDIA ORAL TABLET 2 MG, 4 MG 3 MO; QL (60 per 30 days)

BAQSIMI NASAL SPRAY,NON-AEROSOL 2 MO

BASAGLAR KWIKPEN U-100 INSULIN

SUBCUTANEOUS PEN

3 ST; MO

BYDUREON BCISE SUBCUTANEOUS AUTO-

INJECTOR


BYDUREON SUBCUTANEOUS PEN

INJECTOR


BYETTA SUBCUTANEOUS PEN INJECTOR

10 MCG/DOSE(250 MCG/ML) 2.4 ML


BYETTA SUBCUTANEOUS PEN INJECTOR 5

MCG/DOSE (250 MCG/ML) 1.2 ML


CYCLOSET ORAL TABLET 3 MO; QL (180 per 30 days)

DUETACT ORAL TABLET 3 MO; QL (30 per 30 days)

FARXIGA ORAL TABLET 10 MG 2 MO; QL (30 per 30 days)

FARXIGA ORAL TABLET 5 MG 2 MO; QL (60 per 30 days)

FIASP FLEXTOUCH U-100 INSULIN

SUBCUTANEOUS PEN

3 ST; MO

FIASP U-100 INSULIN SUBCUTANEOUS

SOLUTION

3 ST; MO

FORTAMET ORAL TABLET EXTENDED

RELEASE 24HR 1,000 MG


FORTAMET ORAL TABLET EXTENDED

RELEASE 24HR 500 MG


GAUZE PADS 2 X 2 2 MO


81


glimepiride oral tablet 1 mg 1 MO; QL (240 per 30 days)



glipizide oral tablet 10 mg 1 MO; QL (120 per 30 days)

glipizide oral tablet 5 mg 1 MO; QL (240 per 30 days)

glipizide oral tablet extended release 24hr 10 mg 1 MO; QL (60 per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg 1 MO; QL (240 per 30 days)

glipizide oral tablet extended release 24hr 5 mg 1 MO; QL (120 per 30 days)

glipizide-metformin oral tablet 2.5-250 mg 1 MO; QL (240 per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg


GLUCAGEN HYPOKIT INJECTION RECON

SOLN

2 MO

GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION RECON SOLN

2 MO

GLUCOPHAGE ORAL TABLET 1,000 MG 3 MO; QL (75 per 30 days)

GLUCOPHAGE ORAL TABLET 500 MG 3 MO; QL (150 per 30 days)

GLUCOPHAGE ORAL TABLET 850 MG 3 MO; QL (90 per 30 days)

GLUCOPHAGE XR ORAL TABLET



GLUCOPHAGE XR ORAL TABLET



GLUCOTROL ORAL TABLET 10 MG 3 MO; QL (120 per 30 days)

GLUCOTROL ORAL TABLET 5 MG 3 MO; QL (240 per 30 days)

GLUCOTROL XL ORAL TABLET EXTENDED

RELEASE 24HR 10 MG



RELEASE 24HR 2.5 MG



RELEASE 24HR 5 MG


GLUMETZA ORAL TABLET,ER

GAST.RETENTION 24 HR 1,000 MG


GLUMETZA ORAL TABLET,ER

GAST.RETENTION 24 HR 500 MG


GLYSET ORAL TABLET 100 MG 3 MO; QL (90 per 30 days)




82


GLYXAMBI ORAL TABLET 2 MO; QL (30 per 30 days)

GVOKE SUBCUTANEOUS SYRINGE 3 MO

HUMALOG JUNIOR KWIKPEN U-100

SUBCUTANEOUS INSULIN PEN, HALF-UNIT

2 MO

HUMALOG KWIKPEN INSULIN

SUBCUTANEOUS PEN

2 MO

HUMALOG MIX 50-50 INSULN U-100

SUBCUTANEOUS SUSPENSION

2 MO

HUMALOG MIX 50-50 KWIKPEN

SUBCUTANEOUS INSULIN PEN

2 MO

HUMALOG MIX 75-25 KWIKPEN


2 MO

HUMALOG MIX 75-25(U-100)INSULN


2 MO

HUMALOG U-100 INSULIN SUBCUTANEOUS

CARTRIDGE

2 MO

HUMALOG U-100 INSULIN SUBCUTANEOUS

SOLUTION

2 MO

HUMULIN 70/30 U-100 INSULIN


2 MO

HUMULIN 70/30 U-100 KWIKPEN


2 MO

HUMULIN N NPH INSULIN KWIKPEN

SUBCUTANEOUS PEN

2 MO

HUMULIN N NPH U-100 INSULIN


2 MO

HUMULIN R REGULAR U-100 INSULN

INJECTION SOLUTION

2 MO

HUMULIN R U-500 (CONC) INSULIN


2 MO

HUMULIN R U-500 (CONC) KWIKPEN


2 MO

INSULIN LISPRO SUBCUTANEOUS PEN 3 ST; MO

INSULIN LISPRO SUBCUTANEOUS

SOLUTION

3 ST; MO

INSULIN PEN NEEDLE 2 MO

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1

ML, 1/2 ML

2 MO

INVOKAMET ORAL TABLET 150-1,000 MG,

150-500 MG, 50-1,000 MG



83


INVOKAMET ORAL TABLET 50-500 MG 2 MO; QL (120 per 30 days)

INVOKAMET XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 150-1,000 MG, 150-500 MG,

50-1,000 MG


INVOKAMET XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 50-500 MG


INVOKANA ORAL TABLET 100 MG 2 MO; QL (90 per 30 days)

INVOKANA ORAL TABLET 300 MG 2 MO; QL (30 per 30 days)

JANUMET ORAL TABLET 2 MO; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA ORAL TABLET 2 MO; QL (30 per 30 days)

JARDIANCE ORAL TABLET 2 MO; QL (30 per 30 days)

JENTADUETO ORAL TABLET 3 ST; MO; QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG


KAZANO ORAL TABLET 3 ST; MO; QL (60 per 30 days)

KOMBIGLYZE XR ORAL TABLET, ER

MULTIPHASE 24 HR 2.5-1,000 MG


KOMBIGLYZE XR ORAL TABLET, ER

MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG


LANTUS SOLOSTAR U-100 INSULIN

SUBCUTANEOUS PEN

2 MO

LANTUS U-100 INSULIN SUBCUTANEOUS

SOLUTION

2 MO

LEVEMIR FLEXTOUCH U-100 INSULN


3 ST; MO

LEVEMIR U-100 INSULIN SUBCUTANEOUS

SOLUTION

3 ST; MO

metformin oral tablet 1,000 mg 1 MO; QL (75 per 30 days)

metformin oral tablet 500 mg 1 MO; QL (150 per 30 days)

metformin oral tablet 850 mg 1 MO; QL (90 per 30 days)

metformin oral tablet extended release 24 hr 500

mg



84


metformin oral tablet extended release 24 hr 750

mg


metformin oral tablet extended release (osm) 24 hr

1,000 mg


metformin oral tablet extended release (osm) 24 hr

500 mg


metformin oral tablet,er gast.retention 24 hr 1,000

mg


metformin oral tablet,er gast.retention 24 hr 500

mg


miglitol oral tablet 100 mg 1 MO; QL (90 per 30 days)



nateglinide oral tablet 120 mg 1 MO; QL (90 per 30 days)

nateglinide oral tablet 60 mg 1 MO; QL (180 per 30 days)

NEEDLES, INSULIN DISP., SAFETY 2 MO

NESINA ORAL TABLET 3 ST; MO; QL (30 per 30 days)

NOVOFINE 32 NEEDLE 2 MO

NOVOLIN 70/30 U-100 INSULIN


3 ST; MO

NOVOLIN N NPH U-100 INSULIN


3 ST; MO

NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION

3 ST; MO

NOVOLOG FLEXPEN U-100 INSULIN

SUBCUTANEOUS PEN

3 ST; MO

NOVOLOG MIX 70-30 U-100 INSULN


3 ST; MO

NOVOLOG MIX 70-30FLEXPEN U-100


3 ST; MO

NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE

3 ST; MO

NOVOLOG U-100 INSULIN ASPART


3 ST; MO

OMNIPOD DASH INSULIN POD


2 MO

OMNIPOD INSULIN MANAGEMENT 2 MO

OMNIPOD INSULIN REFILL


2 MO


85


ONGLYZA ORAL TABLET 2 MO; QL (30 per 30 days)

OSENI ORAL TABLET 3 MO; QL (30 per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG(2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1

MG/DOSE (2 MG/1.5 ML)


pioglitazone oral tablet 1 MO; QL (30 per 30 days)

pioglitazone-glimepiride oral tablet 1 MO; QL (30 per 30 days)

pioglitazone-metformin oral tablet 1 MO; QL (90 per 30 days)

PRANDIN ORAL TABLET 1 MG 3 MO; QL (480 per 30 days)

PRANDIN ORAL TABLET 2 MG 3 MO; QL (240 per 30 days)

PRECOSE ORAL TABLET 100 MG 3 MO; QL (90 per 30 days)



PROGLYCEM ORAL SUSPENSION 2 MO

QTERN ORAL TABLET 10-5 MG 3 MO; QL (30 per 30 days)

QTERN ORAL TABLET 5-5 MG 3

repaglinide oral tablet 0.5 mg 1 MO; QL (960 per 30 days)

repaglinide oral tablet 1 mg 1 MO; QL (480 per 30 days)

repaglinide oral tablet 2 mg 1 MO; QL (240 per 30 days)

repaglinide-metformin oral tablet 1 MO; QL (150 per 30 days)

RIOMET ORAL SOLUTION 2 MO; QL (765 per 30 days)

SEGLUROMET ORAL TABLET 2.5-1,000 MG,

7.5-1,000 MG, 7.5-500 MG


SEGLUROMET ORAL TABLET 2.5-500 MG 2 MO; QL (120 per 30 days)

SOLIQUA 100/33 SUBCUTANEOUS INSULIN

PEN

2 MO

STARLIX ORAL TABLET 120 MG 3 MO; QL (90 per 30 days)

STARLIX ORAL TABLET 60 MG 3 MO; QL (180 per 30 days)

STEGLATRO ORAL TABLET 2 MO; QL (30 per 30 days)

STEGLUJAN ORAL TABLET 3 MO; QL (30 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR


SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR


SYNJARDY ORAL TABLET 12.5-1,000 MG,

12.5-500 MG, 5-1,000 MG



86


SYNJARDY ORAL TABLET 5-500 MG 2 MO; QL (120 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,

5-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER,



TECHLITE INSULIN SYR HALF UNIT

SYRINGE

2

TECHLITE INSULIN SYRINGE 2

tolbutamide oral tablet 1 MO; QL (180 per 30 days)

TOUJEO MAX U-300 SOLOSTAR


2 MO

TOUJEO SOLOSTAR U-300 INSULIN

SUBCUTANEOUS PEN

2 MO

TRADJENTA ORAL TABLET 3 ST; MO; QL (30 per 30 days)

TRESIBA FLEXTOUCH U-100


3 ST; MO

TRESIBA FLEXTOUCH U-200


3 ST; MO

TRESIBA U-100 INSULIN SUBCUTANEOUS

SOLUTION

3 ST; MO

TRULICITY SUBCUTANEOUS PEN

INJECTOR


V-GO 20 DEVICE 2 MO

V-GO 30 DEVICE 2 MO

V-GO 40 DEVICE 2 MO

VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR


XIGDUO XR ORAL TABLET, IR - ER,



XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-500 MG, 2.5-1,000 MG, 5-

1,000 MG, 5-500 MG


XULTOPHY 100/3.6 SUBCUTANEOUS

INSULIN PEN


MISCELLANEOUS HORMONES

ANADROL-50 ORAL TABLET 4 PA; MO

ANDRODERM TRANSDERMAL PATCH 24

HOUR



87


ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25 GRAM

(1.62 %)



PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5

GRAM)



PACKET 1.62 % (20.25 MG/1.25 GRAM)



PACKET 1.62 % (40.5 MG/2.5 GRAM)


AVEED INTRAMUSCULAR SOLUTION 3 PA; MO; LA

cabergoline oral tablet 1 MO

calcitonin (salmon) nasal spray,non-aerosol 1 MO

calcitriol oral capsule 1 MO

calcitriol oral solution 1 MO

CERDELGA ORAL CAPSULE 4 MO

cinacalcet oral tablet 30 mg 1 MO

cinacalcet oral tablet 60 mg, 90 mg 4 MO

danazol oral capsule 3 MO

DDAVP NASAL SOLUTION 2 MO

DDAVP NASAL SPRAY WITH PUMP 3 MO

DDAVP ORAL TABLET 3 MO

DEPO-TESTOSTERONE INTRAMUSCULAR

OIL

3 PA; MO

desmopressin nasal spray,non-aerosol 1 MO

desmopressin oral tablet 1 MO

doxercalciferol oral capsule 1 MO

FORTESTA TRANSDERMAL GEL IN

METERED-DOSE PUMP


GALAFOLD ORAL CAPSULE 4 PA; MO; LA; QL (15 per 30 days)

JYNARQUE ORAL TABLET 4 PA; LA

JYNARQUE ORAL TABLETS, SEQUENTIAL 4 PA; MO; LA

KORLYM ORAL TABLET 4 PA; MO

KUVAN ORAL POWDER IN PACKET 4 PA; MO

KUVAN ORAL TABLET,SOLUBLE 4 PA; MO

METHITEST ORAL TABLET 3 MO

methyltestosterone oral capsule 4 MO


88


miglustat oral capsule 4 MO; LA

MYALEPT SUBCUTANEOUS RECON SOLN 4 PA; MO; LA

NATPARA SUBCUTANEOUS CARTRIDGE 4 PA; MO; LA

NOCDURNA (MEN) SUBLINGUAL



NOCDURNA (WOMEN) SUBLINGUAL



NOCTIVA NASAL SPRAY,NON-AEROSOL 3 PA; MO; QL (3.8 per 30 days)

ORILISSA ORAL TABLET 4 MO

oxandrolone oral tablet 10 mg 4 PA; MO

oxandrolone oral tablet 2.5 mg 1 PA; MO

PALYNZIQ SUBCUTANEOUS SYRINGE 10

MG/0.5 ML


PALYNZIQ SUBCUTANEOUS SYRINGE 2.5

MG/0.5 ML


PALYNZIQ SUBCUTANEOUS SYRINGE 20

MG/ML


paricalcitol oral capsule 3 MO

RAYALDEE ORAL CAPSULE,EXTENDED

RELEASE 24 HR

4 MO

ROCALTROL ORAL CAPSULE 3 MO

ROCALTROL ORAL SOLUTION 3 MO

SAMSCA ORAL TABLET 4 PA; MO

SENSIPAR ORAL TABLET 30 MG 2 MO

SENSIPAR ORAL TABLET 60 MG, 90 MG 4 MO

SOMAVERT SUBCUTANEOUS RECON SOLN 4 MO

STIMATE NASAL SPRAY,NON-AEROSOL 2 MO

STRIANT BUCCAL MUCOADHESIVE

SYSTEM ER 12 HR


SYNAREL NASAL SPRAY,NON-AEROSOL 4 MO

TESTIM TRANSDERMAL GEL 3 PA; MO; QL (300 per 30 days)

testosterone cypionate intramuscular oil 1 PA; MO

testosterone enanthate intramuscular oil 1 PA; MO

testosterone transdermal gel in metered-dose

pump 10 mg/0.5 gram /actuation



pump 12.5 mg/ 1.25 gram (1 %)



89



pump 20.25 mg/1.25 gram (1.62 %)


testosterone transdermal gel in packet 1 % (25

mg/2.5gram), 1 % (50 mg/5 gram)


testosterone transdermal gel in packet 1.62 %

(20.25 mg/1.25 gram)


testosterone transdermal gel in packet 1.62 %

(40.5 mg/2.5 gram)


testosterone transdermal solution in metered pump

w/app


VOGELXO TRANSDERMAL GEL IN

METERED-DOSE PUMP


VOGELXO TRANSDERMAL GEL IN PACKET 3 PA; MO; QL (300 per 30 days)

XYOSTED SUBCUTANEOUS AUTO-

INJECTOR

3 PA; MO

ZAVESCA ORAL CAPSULE 4 MO; LA

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG 3 MO

THYROID HORMONES

CYTOMEL ORAL TABLET 3 MO

LEVO-T ORAL TABLET 3

levothyroxine oral tablet 1 MO

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

1 MO

liothyronine oral tablet 1 MO

SYNTHROID ORAL TABLET 3 MO

TIROSINT ORAL CAPSULE 3 MO

TIROSINT-SOL ORAL SOLUTION 3 MO

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

1 MO

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

CUVPOSA ORAL SOLUTION 3 MO

dicyclomine oral capsule 1 MO

dicyclomine oral solution 1 MO

dicyclomine oral tablet 1 MO


90


diphenoxylate-atropine oral liquid 1 MO

diphenoxylate-atropine oral tablet 1 MO

glycopyrrolate oral tablet 1 mg, 2 mg 1 MO

LOMOTIL ORAL TABLET 3 MO

loperamide oral capsule 1 MO

methscopolamine oral tablet 1 MO

MYTESI ORAL TABLET,DELAYED RELEASE

(DR/EC)

3 MO

MISCELLANEOUS GASTROINTESTINAL AGENTS

ACTIGALL ORAL CAPSULE 3 MO

AKYNZEO (FOSNETUPITANT)

INTRAVENOUS RECON SOLN

3 MO

alosetron oral tablet 4 MO

AMITIZA ORAL CAPSULE 2 MO

ANUSOL-HC TOPICAL CREAM WITH

PERINEAL APPLICATOR

3 MO

aprepitant oral capsule 1 B/D PA; MO

aprepitant oral capsule,dose pack 1 B/D PA; MO

APRISO ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO

ASACOL HD ORAL TABLET,DELAYED

RELEASE (DR/EC)

2 MO

AZULFIDINE EN-TABS ORAL

TABLET,DELAYED RELEASE (DR/EC)

3 MO

AZULFIDINE ORAL TABLET 3 MO

balsalazide oral capsule 1 MO

BONJESTA ORAL TABLET,IR,DELAYED

REL,BIPHASIC

3 MO

budesonide oral capsule, delayed, extended

release

4 MO

budesonide oral tablet,delayed and ext.release 4 MO

CANASA RECTAL SUPPOSITORY 3 MO

CESAMET ORAL CAPSULE 4 B/D PA; MO

CHENODAL ORAL TABLET 4 PA; MO; LA

CHOLBAM ORAL CAPSULE 250 MG 4 PA; MO

CHOLBAM ORAL CAPSULE 50 MG 4 PA; MO; QL (120 per 30 days)


91


CIMZIA POWDER FOR RECONST

SUBCUTANEOUS KIT

4 PA; MO

CIMZIA SUBCUTANEOUS SYRINGE KIT 4 PA; MO

CLENPIQ ORAL SOLUTION 3 ST; MO

COLAZAL ORAL CAPSULE 4 MO

colocort rectal enema 1 MO

COLYTE WITH FLAVOR PACKS ORAL

RECON SOLN 240-22.72-6.72 -5.84 GRAM

3 ST; MO

compro rectal suppository 1 MO

constulose oral solution 1 MO

CORTIFOAM RECTAL FOAM 2 MO

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

2 MO

cromolyn oral concentrate 1 MO

CYSTADANE ORAL POWDER 4 MO

DELZICOL ORAL CAPSULE (WITH

DELAYED RELEASE TABLETS)

2 MO

DICLEGIS ORAL TABLET,DELAYED

RELEASE (DR/EC)

3 MO

DIPENTUM ORAL CAPSULE 4 MO

doxylamine-pyridoxine (vit b6) oral tablet,delayed

release (dr/ec)

1 MO

dronabinol oral capsule 10 mg 4 B/D PA; MO

dronabinol oral capsule 2.5 mg, 5 mg 3 B/D PA; MO

EMEND ORAL CAPSULE 3 B/D PA; MO

EMEND ORAL CAPSULE,DOSE PACK 3 B/D PA; MO

EMEND ORAL SUSPENSION FOR

RECONSTITUTION

2 B/D PA; MO

ENTOCORT EC ORAL

CAPSULE,DELAYED,EXTEND.RELEASE

4 MO

enulose oral solution 1 MO

GASTROCROM ORAL CONCENTRATE 3 MO

GATTEX 30-VIAL SUBCUTANEOUS KIT 4 PA; MO

gavilyte-c oral recon soln 1 MO

gavilyte-g oral recon soln 1 MO

gavilyte-n oral recon soln 1 MO

generlac oral solution 1 MO


92


GOLYTELY ORAL POWDER IN PACKET 3 ST; MO

GOLYTELY ORAL RECON SOLN 3 ST; MO

granisetron hcl oral tablet 1 B/D PA; MO

hydrocortisone rectal enema 1 MO

hydrocortisone-pramoxine rectal cream 1-1 % 1 MO

INFLECTRA INTRAVENOUS RECON SOLN 4 PA; MO

KRISTALOSE ORAL PACKET 3 MO

lactulose oral packet 1

lactulose oral solution 10 gram/15 ml 1 MO

LIALDA ORAL TABLET,DELAYED RELEASE

(DR/EC)

3 MO

LINZESS ORAL CAPSULE 2 MO

LOTRONEX ORAL TABLET 4 MO

MARINOL ORAL CAPSULE 10 MG, 5 MG 4 B/D PA; MO

MARINOL ORAL CAPSULE 2.5 MG 3 B/D PA; MO

meclizine oral tablet 12.5 mg, 25 mg 1 MO

mesalamine oral capsule (with del rel tablets) 1 MO

mesalamine oral tablet,delayed release (dr/ec) 1 MO

mesalamine rectal enema 1 MO

mesalamine rectal suppository 1 MO

metoclopramide hcl oral solution 1 MO

metoclopramide hcl oral tablet 1 MO

metoclopramide hcl oral tablet,disintegrating 1 MO

MICORT-HC TOPICAL CREAM WITH

PERINEAL APPLICATOR 2.5 %

3 MO

MOTEGRITY ORAL TABLET 3 MO

MOVANTIK ORAL TABLET 2 MO

MOVIPREP ORAL POWDER IN PACKET 3 MO

NULYTELY WITH FLAVOR PACKS ORAL

RECON SOLN

3 ST; MO

OCALIVA ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)

ondansetron hcl oral solution 1 B/D PA; MO

ondansetron hcl oral tablet 24 mg 1 B/D PA

ondansetron hcl oral tablet 4 mg, 8 mg 1 B/D PA; MO

ondansetron oral tablet,disintegrating 1 B/D PA; MO


93


OSMOPREP ORAL TABLET 3 MO

PANCREAZE ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT,

16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850

UNIT, 21,000-54,700- 83,900 UNIT, 4,200-

14,200- 24,600 UNIT

3 ST; MO

peg 3350-electrolytes oral recon soln 236-22.74-

6.74 -5.86 gram

1 MO

peg 3350-electrolytes oral recon soln 240-22.72-

6.72 -5.84 gram

1

peg-electrolyte oral recon soln 1

PENTASA ORAL CAPSULE, EXTENDED

RELEASE 250 MG

2 MO

PENTASA ORAL CAPSULE, EXTENDED

RELEASE 500 MG

4 MO

PERTZYE ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT

4 ST; MO

PERTZYE ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 4,000-14,375- 15,125 UNIT,

8,000-28,750- 30,250 UNIT

3 ST; MO

PLENVU ORAL POWDER IN PACKET,

SEQUENTIAL

3 ST; MO

PREPOPIK ORAL POWDER IN PACKET 3 ST; MO

prochlorperazine maleate oral tablet 1 MO

prochlorperazine rectal suppository 1 MO

procto-med hc topical cream with perineal

applicator

1 MO

procto-pak topical cream with perineal applicator 1 MO

proctosol hc topical cream with perineal

applicator

1 MO

proctozone-hc topical cream with perineal

applicator

1 MO

RECTIV RECTAL OINTMENT 2 MO

REGLAN ORAL TABLET 3 MO

RELISTOR ORAL TABLET 4 MO

RELISTOR SUBCUTANEOUS SOLUTION 4 MO

RELISTOR SUBCUTANEOUS SYRINGE 4 MO

REMICADE INTRAVENOUS RECON SOLN 4 PA; MO

ROWASA RECTAL ENEMA KIT 3 MO


94


SANCUSO TRANSDERMAL PATCH WEEKLY 4 MO

scopolamine base transdermal patch 3 day 1 MO

SUCRAID ORAL SOLUTION 4 MO

sulfasalazine oral tablet 1 MO

sulfasalazine oral tablet,delayed release (dr/ec) 1 MO

SUPREP BOWEL PREP KIT ORAL RECON

SOLN

2 MO

SYMPROIC ORAL TABLET 2 MO

SYNDROS ORAL SOLUTION 4 B/D PA; MO

TRANSDERM-SCOP TRANSDERMAL PATCH

3 DAY

3 MO

trilyte with flavor packets oral recon soln 1 MO

TRULANCE ORAL TABLET 3 MO

UCERIS ORAL TABLET, DELAYED AND

EXTENDED RELEASE

4 MO

UCERIS RECTAL FOAM 3 MO

URSO 250 ORAL TABLET 3 MO

URSO FORTE ORAL TABLET 3 MO

ursodiol oral capsule 1 MO

ursodiol oral tablet 1 MO

VARUBI INTRAVENOUS EMULSION 2

VARUBI ORAL TABLET 2 B/D PA; MO

VIBERZI ORAL TABLET 4 MO

VIOKACE ORAL TABLET 2 MO

ZELNORM ORAL TABLET 3 MO

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT, 20,000-63,000-

84,000 UNIT, 25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT, 40,000-126,000-

168,000 UNIT, 5,000-17,000- 24,000 UNIT

2 MO

ZOFRAN ORAL TABLET 8 MG 3 B/D PA; MO

ZUPLENZ ORAL FILM 3 B/D PA; MO

ULCER THERAPY

ACIPHEX ORAL TABLET,DELAYED

RELEASE (DR/EC)

3 MO


95


amoxicillin-clarithromycin-lansoprazole oral

combo pack


CARAFATE ORAL SUSPENSION 3 MO

CARAFATE ORAL TABLET 3 MO

cimetidine hcl oral solution 1 MO

cimetidine oral tablet 1 MO

CYTOTEC ORAL TABLET 3 MO

DEXILANT ORAL CAPSULE, BIPHASE

DELAYED RELEASE 30 MG


DEXILANT ORAL CAPSULE, BIPHASE

DELAYED RELEASE 60 MG

3 MO

esomeprazole magnesium oral capsule,delayed

release(dr/ec) 20 mg


esomeprazole magnesium oral capsule,delayed

release(dr/ec) 40 mg

1 MO

ESOMEPRAZOLE STRONTIUM ORAL

CAPSULE,DELAYED RELEASE(DR/EC) 49.3

MG

3 MO

famotidine oral suspension 1 MO

famotidine oral tablet 20 mg, 40 mg 1 MO

lansoprazole oral capsule,delayed release(dr/ec)

15 mg


lansoprazole oral capsule,delayed release(dr/ec)

30 mg

1 MO

lansoprazole oral tablet,disintegrat, delay rel 15

mg


lansoprazole oral tablet,disintegrat, delay rel 30

mg

1 MO

misoprostol oral tablet 1 MO

NEXIUM ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 20 MG


NEXIUM ORAL CAPSULE,DELAYED


3 MO

NEXIUM ORAL GRANULES DR FOR SUSP IN

PACKET 10 MG, 2.5 MG, 20 MG, 5 MG


NEXIUM ORAL GRANULES DR FOR SUSP IN

PACKET 40 MG

2 MO

nizatidine oral capsule 1 MO

nizatidine oral solution 1 MO


96


OMECLAMOX-PAK ORAL COMBO PACK 3 MO; QL (80 per 28 days)

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

mg, 20 mg


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

mg

1 MO

omeprazole-sodium bicarbonate oral capsule 20-

1.1 mg-gram


omeprazole-sodium bicarbonate oral capsule 40-

1.1 mg-gram

4 MO

omeprazole-sodium bicarbonate oral packet 20-

1,680 mg


omeprazole-sodium bicarbonate oral packet 40-

1,680 mg

4 MO

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

mg


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

mg

1 MO

PEPCID ORAL TABLET 3 MO

PREVACID ORAL CAPSULE,DELAYED



PREVACID ORAL CAPSULE,DELAYED


3 MO

PREVACID SOLUTAB ORAL

TABLET,DISINTEGRAT, DELAY REL 15 MG


PREVACID SOLUTAB ORAL

TABLET,DISINTEGRAT, DELAY REL 30 MG

3 MO

PRILOSEC ORAL SUSP,DELAYED RELEASE

FOR RECON

3 MO

PROTONIX ORAL GRANULES DR FOR SUSP

IN PACKET

3 MO

PROTONIX ORAL TABLET,DELAYED



PROTONIX ORAL TABLET,DELAYED


3 MO

PYLERA ORAL CAPSULE 2 MO

rabeprazole oral tablet,delayed release (dr/ec) 1 MO

ranitidine hcl oral capsule 1 MO

ranitidine hcl oral syrup 1 MO

ranitidine hcl oral tablet 150 mg, 300 mg 1 MO


97


sucralfate oral tablet 1 MO

ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM 4 MO; QL (30 per 30 days)

ZEGERID ORAL CAPSULE 40-1.1 MG-GRAM 4 MO

ZEGERID ORAL PACKET 20-1,680 MG 4 MO; QL (30 per 30 days)

ZEGERID ORAL PACKET 40-1,680 MG 4 MO

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE SUBCUTANEOUS SOLUTION 4 B/D PA; MO

ARANESP (IN POLYSORBATE) INJECTION

SOLUTION 100 MCG/ML, 200 MCG/ML, 300

MCG/ML, 60 MCG/ML

4 PA; MO


SOLUTION 150 MCG/0.75 ML

4 PA


SOLUTION 25 MCG/ML, 40 MCG/ML

3 PA; MO


SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML,

40 MCG/0.4 ML

3 PA; MO


SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML,

200 MCG/0.4 ML, 300 MCG/0.6 ML, 500

MCG/ML, 60 MCG/0.3 ML

4 PA; MO

ARCALYST SUBCUTANEOUS RECON SOLN 4 PA; MO

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT


AVONEX INTRAMUSCULAR PEN INJECTOR

KIT


AVONEX INTRAMUSCULAR SYRINGE KIT 4 PA; MO; QL (4 per 28 days)

BETASERON SUBCUTANEOUS KIT 4 PA; MO; QL (15 per 28 days)

EGRIFTA SUBCUTANEOUS RECON SOLN 1

MG

4 PA; MO

EPOGEN INJECTION SOLUTION 2,000

UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML,

4,000 UNIT/ML

3 PA; MO

EPOGEN INJECTION SOLUTION 20,000

UNIT/ML

4 PA; MO

EXTAVIA SUBCUTANEOUS KIT 4 PA; MO; QL (15 per 28 days)

FULPHILA SUBCUTANEOUS SYRINGE 4 PA; MO


98


GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.2 MG/0.25 ML

3 PA; MO

GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML,

0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25

ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8

MG/0.25 ML, 2 MG/0.25 ML

4 PA; MO

GENOTROPIN SUBCUTANEOUS

CARTRIDGE

4 PA; MO

GRANIX SUBCUTANEOUS SOLUTION 4 PA; MO

GRANIX SUBCUTANEOUS SYRINGE 4 PA; MO

HUMATROPE INJECTION CARTRIDGE 4 PA; MO

HUMATROPE INJECTION RECON SOLN 4 PA; MO

INTRON A INJECTION RECON SOLN 4 B/D PA; MO

INTRON A INJECTION SOLUTION 10

MILLION UNIT/ML

2 B/D PA; MO

INTRON A INJECTION SOLUTION 6

MILLION UNIT/ML

4 B/D PA; MO

LEUKINE INJECTION RECON SOLN 4 MO

NEULASTA SUBCUTANEOUS SYRINGE 4 PA; MO

NEUPOGEN INJECTION SOLUTION 4 PA; MO

NEUPOGEN INJECTION SYRINGE 4 PA; MO

NIVESTYM INJECTION SOLUTION 4 PA; MO

NIVESTYM SUBCUTANEOUS SYRINGE 4 PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR

4 PA; MO

NUTROPIN AQ NUSPIN SUBCUTANEOUS

PEN INJECTOR

4 PA; MO

OMNITROPE SUBCUTANEOUS CARTRIDGE 4 PA; MO

OMNITROPE SUBCUTANEOUS RECON

SOLN

4 PA; MO

PEGASYS PROCLICK SUBCUTANEOUS PEN

INJECTOR 180 MCG/0.5 ML


PEGASYS SUBCUTANEOUS SOLUTION 4 MO; QL (4 per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE 4 MO; QL (2 per 28 days)

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

125 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR

63 MCG/0.5 ML- 94 MCG/0.5 ML



99


PLEGRIDY SUBCUTANEOUS SYRINGE 125

MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63

MCG/0.5 ML- 94 MCG/0.5 ML


PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML

2 PA; MO

PROCRIT INJECTION SOLUTION 20,000

UNIT/ML, 40,000 UNIT/ML

4 PA; MO

REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE


REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE


RETACRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML

2 PA; MO

RETACRIT INJECTION SOLUTION 40,000

UNIT/ML

4 PA; MO

SAIZEN SAIZENPREP SUBCUTANEOUS

CARTRIDGE

4 PA; MO

SAIZEN SUBCUTANEOUS RECON SOLN 4 PA; MO

SEROSTIM SUBCUTANEOUS RECON SOLN 4

MG, 5 MG, 6 MG

4 PA; MO

SYLATRON SUBCUTANEOUS KIT 4 MO

UDENYCA SUBCUTANEOUS SYRINGE 4 PA; MO

ZARXIO INJECTION SYRINGE 4 PA; MO

ZOMACTON SUBCUTANEOUS RECON SOLN

10 MG

4 PA; MO

ZOMACTON SUBCUTANEOUS RECON SOLN

5 MG

3 PA; MO

ZORBTIVE SUBCUTANEOUS RECON SOLN 4 PA; MO

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN

2 MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION

2 MO


100


ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE

2 MO

BCG VACCINE, LIVE (PF) PERCUTANEOUS

SUSPENSION FOR RECONSTITUTION

2 MO

BEXSERO INTRAMUSCULAR SYRINGE 2 MO

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION

2 MO

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE

2 MO

DAPTACEL (DTAP PEDIATRIC) (PF)


2 MO

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

2 B/D PA; MO

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE

2 B/D PA; MO

FLEBOGAMMA DIF INTRAVENOUS

SOLUTION 10 %

4 PA; MO

GAMMAGARD LIQUID INJECTION

SOLUTION

4 PA; MO

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN

4 PA; MO

GAMMAKED INJECTION SOLUTION 1

GRAM/10 ML (10 %)

4 PA; MO

GAMMAPLEX (WITH SORBITOL)

INTRAVENOUS SOLUTION

4 PA; MO

GAMMAPLEX INTRAVENOUS SOLUTION 4 PA; MO

GAMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %)

4 PA; MO

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION

2 MO

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE

2 MO

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION

2 MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML

2 MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT/0.5 ML

2

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN

2 MO


101


IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN

2 MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION

2 MO

IPOL INJECTION SUSPENSION 2 MO

IXIARO (PF) INTRAMUSCULAR SYRINGE 2 MO

KINRIX (PF) INTRAMUSCULAR

SUSPENSION

2

KINRIX (PF) INTRAMUSCULAR SYRINGE 2 MO

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

2 MO

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT

2 MO

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN

2 MO

OCTAGAM INTRAVENOUS SOLUTION 4 PA; MO

ORALAIR SUBLINGUAL TABLET 300 INDX

REACTIVITY

3 PA; MO

PANZYGA INTRAVENOUS SOLUTION 10 % 4 PA; MO

PANZYGA INTRAVENOUS SOLUTION 10 %

(100 ML), 10 % (200 ML), 10 % (25 ML), 10 %

(300 ML), 10 % (50 ML)

4 PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 2 MO

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION

2 MO

PRIVIGEN INTRAVENOUS SOLUTION 4 PA; MO

PROQUAD (PF) SUBCUTANEOUS


2 MO

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION

2 MO

RABAVERT (PF) INTRAMUSCULAR


2 MO

RAGWITEK SUBLINGUAL TABLET 2 MO

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML

2 B/D PA; MO


SYRINGE 10 MCG/ML

2 B/D PA; MO


SYRINGE 5 MCG/0.5 ML

2 B/D PA


102


ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION

2

ROTATEQ VACCINE ORAL SOLUTION 2 MO

SHINGRIX (PF) INTRAMUSCULAR


2 MO

TDVAX INTRAMUSCULAR SUSPENSION 2 MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE 2 MO

TETANUS,DIPHTHERIA TOX PED(PF)


2 MO

TRUMENBA INTRAMUSCULAR SYRINGE 2 MO

TWINRIX (PF) INTRAMUSCULAR SYRINGE 2 MO

TYPHIM VI INTRAMUSCULAR SOLUTION 2

TYPHIM VI INTRAMUSCULAR SYRINGE 2 MO

VAQTA (PF) INTRAMUSCULAR

SUSPENSION

2 MO

VAQTA (PF) INTRAMUSCULAR SYRINGE 2 MO

VARIVAX (PF) SUBCUTANEOUS


2 MO

VARIZIG INTRAMUSCULAR SOLUTION 2 MO

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION

2 MO

ZOSTAVAX (PF) SUBCUTANEOUS


2 MO

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 1 MO

COLCHICINE ORAL CAPSULE 3 ST; MO

COLCHICINE ORAL TABLET 3 ST; MO

COLCRYS ORAL TABLET 2 MO

DUZALLO ORAL TABLET 200-200 MG 3 MO

febuxostat oral tablet 1 MO

MITIGARE ORAL CAPSULE 2 MO

probenecid oral tablet 1 MO

probenecid-colchicine oral tablet 1 MO

ULORIC ORAL TABLET 2 MO

ZYLOPRIM ORAL TABLET 3 MO


103


OSTEOPOROSIS THERAPY

ACTONEL ORAL TABLET 150 MG 3 ST; MO; QL (1 per 30 days)



alendronate oral solution 1 MO; QL (1286 per 30 days)

alendronate oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg 1 MO; QL (4 per 28 days)

ATELVIA ORAL TABLET,DELAYED

RELEASE (DR/EC)


BINOSTO ORAL TABLET, EFFERVESCENT 3 ST; MO; QL (4 per 28 days)

BONIVA ORAL TABLET 3 ST; MO; QL (1 per 30 days)

EVENITY SUBCUTANEOUS SYRINGE

210MG/2.34ML ( 105MG/1.17MLX2)


EVISTA ORAL TABLET 3 MO

FORTEO SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (2.4 per 28 days)

FOSAMAX ORAL TABLET 70 MG 3 ST; MO; QL (4 per 28 days)

FOSAMAX PLUS D ORAL TABLET 3 ST; MO; QL (4 per 28 days)

ibandronate oral tablet 1 MO; QL (1 per 30 days)

PROLIA SUBCUTANEOUS SYRINGE 2 PA; MO

raloxifene oral tablet 1 MO


risedronate oral tablet 35 mg, 35 mg (12 pack), 35

mg (4 pack)



risedronate oral tablet,delayed release (dr/ec) 1 MO; QL (4 per 28 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (1.56 per 30 days)

OTHER RHEUMATOLOGICALS

ACTEMRA ACTPEN SUBCUTANEOUS PEN

INJECTOR


ACTEMRA INTRAVENOUS SOLUTION 4 PA; MO

ACTEMRA SUBCUTANEOUS SYRINGE 4 PA; MO

ARAVA ORAL TABLET 4 MO; QL (30 per 30 days)

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR

4 PA; MO

BENLYSTA SUBCUTANEOUS SYRINGE 4 PA; MO

CUPRIMINE ORAL CAPSULE 4 MO


104


DEPEN TITRATABS ORAL TABLET 4 MO

ENBREL MINI SUBCUTANEOUS

CARTRIDGE


ENBREL SUBCUTANEOUS RECON SOLN 4 PA; MO; QL (16 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 4 PA; MO; QL (8 per 28 days)

ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR


HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML


HUMIRA PEDIATRIC CROHNS START


ML (6 PACK)


HUMIRA PEN CROHNS-UC-HS START

SUBCUTANEOUS INJECTOR KIT


HUMIRA PEN PSOR-UVEITS-ADOL HS



HUMIRA PEN SUBCUTANEOUS INJECTOR

KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT 10

MG/0.2 ML, 20 MG/0.4 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 40

MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER


ML


HUMIRA(CF) PEDI CROHNS STARTER


ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS



HUMIRA(CF) PEN PSOR-UV-ADOL HS



HUMIRA(CF) SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE

KIT 10 MG/0.1 ML, 20 MG/0.2 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML


KEVZARA SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (2.28 per 28 days)


105


KEVZARA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (2.28 per 28 days)

KINERET SUBCUTANEOUS SYRINGE 4 PA; MO

leflunomide oral tablet 1 MO; QL (30 per 30 days)

OLUMIANT ORAL TABLET 4 PA; MO; QL (30 per 30 days)

ORENCIA (WITH MALTOSE) INTRAVENOUS

RECON SOLN

4 PA; MO

ORENCIA CLICKJECT SUBCUTANEOUS

AUTO-INJECTOR

4 PA; MO

ORENCIA SUBCUTANEOUS SYRINGE 4 PA; MO

OTEZLA ORAL TABLET 4 PA; MO

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47)

4 PA; MO

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG(19)

4 PA

OTREXUP (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15

MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML,

22.5 MG/0.4 ML, 25 MG/0.4 ML

3 MO

penicillamine oral capsule 4 MO

RASUVO (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15

MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML,

22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6

ML, 7.5 MG/0.15 ML

2 MO

RIDAURA ORAL CAPSULE 4 MO

RINVOQ ER ORAL TABLET EXTENDED

RELEASE 24 HR


SAVELLA ORAL TABLET 2 MO; QL (60 per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK 2 MO; QL (55 per 30 days)

SIMPONI SUBCUTANEOUS PEN INJECTOR 4 PA; MO

SIMPONI SUBCUTANEOUS SYRINGE 4 PA; MO

XELJANZ ORAL TABLET 4 PA; MO

XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HR

4 PA; MO

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

ACTIVELLA ORAL TABLET 1-0.5 MG 3 PA; MO


106


ALORA TRANSDERMAL PATCH

SEMIWEEKLY


amabelz oral tablet 1 PA; MO

ANGELIQ ORAL TABLET 3 PA; MO

AYGESTIN ORAL TABLET 3 MO

BIJUVA ORAL CAPSULE 3 PA; MO

camila oral tablet 1 MO

CLIMARA PRO TRANSDERMAL PATCH

WEEKLY

3 PA; MO

CLIMARA TRANSDERMAL PATCH WEEKLY 3 PA; MO; QL (4 per 28 days)

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY

3 PA; MO

CRINONE VAGINAL GEL 4 % 3 MO

CRINONE VAGINAL GEL 8 % 3 PA; MO

deblitane oral tablet 1 MO

DELESTROGEN INTRAMUSCULAR OIL 3 MO

DEPO-ESTRADIOL INTRAMUSCULAR OIL 3 MO

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 150 MG/ML

3 MO

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML

2 MO

DEPO-SUBQ PROVERA 104

SUBCUTANEOUS SYRINGE

3 MO

DIVIGEL TRANSDERMAL GEL IN PACKET 1

MG/GRAM (0.1 %)


dotti transdermal patch semiweekly 1 PA; MO; QL (8 per 28 days)

DUAVEE ORAL TABLET 2 MO

ELESTRIN TRANSDERMAL GEL IN

METERED-DOSE PUMP

3 PA; MO

errin oral tablet 1 MO

ESTRACE ORAL TABLET 3 PA; MO

ESTRACE VAGINAL CREAM 3 MO

estradiol oral tablet 3 PA; MO

estradiol transdermal patch semiweekly 1 PA; MO; QL (8 per 28 days)

estradiol transdermal patch weekly 1 PA; MO; QL (4 per 28 days)

estradiol vaginal cream 1 MO

estradiol vaginal tablet 1 MO


107


estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

1 MO

estradiol-norethindrone acet oral tablet 1 PA; MO

ESTRING VAGINAL RING 2 MO

EVAMIST TRANSDERMAL SPRAY,NON-

AEROSOL


FEMHRT LOW DOSE ORAL TABLET 3 PA; MO

FEMRING VAGINAL RING 3 MO

fyavolv oral tablet 1 PA; MO

IMVEXXY MAINTENANCE PACK VAGINAL

INSERT

3 MO

IMVEXXY STARTER PACK VAGINAL

INSERT, DOSE PACK

3 MO

incassia oral tablet 1 MO

jinteli oral tablet 1 PA; MO

lopreeza oral tablet 1-0.5 mg 1 PA; MO

lyza oral tablet 1 MO

medroxyprogesterone intramuscular suspension 1 MO

medroxyprogesterone intramuscular syringe 1 MO

medroxyprogesterone oral tablet 1 MO

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG

2 PA; MO

MENOSTAR TRANSDERMAL PATCH

WEEKLY


mimvey lo oral tablet 1 PA; MO

mimvey oral tablet 1 PA; MO

MINIVELLE TRANSDERMAL PATCH

SEMIWEEKLY


nora-be oral tablet 1 MO

norethindrone (contraceptive) oral tablet 1 MO

norethindrone acetate oral tablet 1 MO

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg

3 PA; MO

norlyroc oral tablet 1

ORTHO MICRONOR ORAL TABLET 3 MO

PREFEST ORAL TABLET 3 PA; MO

PREMARIN ORAL TABLET 2 MO


108


PREMARIN VAGINAL CREAM 2 MO

PREMPHASE ORAL TABLET 3 PA; MO

PREMPRO ORAL TABLET 3 PA; MO

progesterone micronized oral capsule 1 MO

PROMETRIUM ORAL CAPSULE 3 MO

PROVERA ORAL TABLET 3 MO

sharobel oral tablet 1 MO

VAGIFEM VAGINAL TABLET 3 MO

VIVELLE-DOT TRANSDERMAL PATCH

SEMIWEEKLY


yuvafem vaginal tablet 1 MO

MISCELLANEOUS OB/GYN

AVC VAGINAL CREAM 3 MO

CLEOCIN VAGINAL CREAM 3 MO

CLEOCIN VAGINAL SUPPOSITORY 2 MO

clindamycin phosphate vaginal cream 1 MO

CLINDESSE VAGINAL CREAM,EXTENDED

RELEASE

3 MO

GYNAZOLE-1 VAGINAL CREAM 3 MO

INTRAROSA VAGINAL INSERT 3 MO

LUPANETA PACK (1 MONTH) KIT. SYRINGE

AND TABLET

4 MO

LUPANETA PACK (3 MONTH) KIT. SYRINGE

AND TABLET

4 MO

LYSTEDA ORAL TABLET 3 MO

metronidazole vaginal gel 1 MO

miconazole-3 vaginal suppository 1 MO

NUVARING VAGINAL RING 3 MO

OSPHENA ORAL TABLET 3 MO

terconazole vaginal cream 1 MO

terconazole vaginal suppository 1 MO

tranexamic acid oral tablet 1 MO

vandazole vaginal gel 1 MO

xulane transdermal patch weekly 1 MO

ORAL CONTRACEPTIVES / RELATED AGENTS

altavera (28) oral tablet 1 MO


109


alyacen 1/35 (28) oral tablet 1 MO

amethia lo oral tablets,dose pack,3 month 1 MO

amethia oral tablets,dose pack,3 month 1 MO

apri oral tablet 1 MO

aranelle (28) oral tablet 1 MO

ashlyna oral tablets,dose pack,3 month 1 MO

aubra oral tablet 1 MO

aviane oral tablet 1 MO

BALCOLTRA ORAL TABLET 3 MO

balziva (28) oral tablet 1 MO

BEYAZ ORAL TABLET 3 MO

blisovi 24 fe oral tablet 1 MO

blisovi fe 1.5/30 (28) oral tablet 1 MO

briellyn oral tablet 1 MO

camrese lo oral tablets,dose pack,3 month 1 MO

caziant (28) oral tablet 1 MO

cryselle (28) oral tablet 1 MO

cyclafem 1/35 (28) oral tablet 1 MO

cyclafem 7/7/7 (28) oral tablet 1 MO

cyred eq oral tablet 1 MO

delyla (28) oral tablet 1

desog-e.estradiol/e.estradiol oral tablet 1 MO

desogestrel-ethinyl estradiol oral tablet 1 MO

drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-

0.451 mg (24) (4)

1 MO

drospirenone-ethinyl estradiol oral tablet 1 MO

emoquette oral tablet 1 MO

enpresse oral tablet 1 MO

enskyce oral tablet 1 MO

estarylla oral tablet 1 MO

ethynodiol diac-eth estradiol oral tablet 1

falmina (28) oral tablet 1 MO

fayosim oral tablets,dose pack,3 month 1 MO

femynor oral tablet 1 MO

GENERESS FE ORAL TABLET,CHEWABLE 3 MO


110


gianvi (28) oral tablet 1 MO

hailey 24 fe oral tablet 1 MO

introvale oral tablets,dose pack,3 month 1 MO

isibloom oral tablet 1 MO

jasmiel (28) oral tablet 1 MO

juleber oral tablet 1 MO

junel 1.5/30 (21) oral tablet 1 MO

junel 1/20 (21) oral tablet 1 MO

junel fe 1.5/30 (28) oral tablet 1 MO

junel fe 1/20 (28) oral tablet 1 MO

junel fe 24 oral tablet 1 MO

kaitlib fe oral tablet,chewable 1 MO

kariva (28) oral tablet 1 MO

kelnor 1/35 (28) oral tablet 1 MO

kelnor 1-50 oral tablet 1 MO

kurvelo (28) oral tablet 1 MO

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month

1 MO

larin 1.5/30 (21) oral tablet 1 MO

larin 1/20 (21) oral tablet 1 MO

larin fe 1.5/30 (28) oral tablet 1 MO

larin fe 1/20 (28) oral tablet 1 MO

larissia oral tablet 1 MO

layolis fe oral tablet,chewable 1 MO

leena 28 oral tablet 1 MO

lessina oral tablet 1 MO

levonest (28) oral tablet 1 MO

levonorgestrel-ethinyl estrad oral tablet 1 MO

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

1 MO

levonorg-eth estrad triphasic oral tablet 1 MO

levora-28 oral tablet 1 MO

LO LOESTRIN FE ORAL TABLET 3 MO

LOESTRIN 1.5/30 (21) ORAL TABLET 3 MO

LOESTRIN 1/20 (21) ORAL TABLET 3 MO


111


LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET 3 MO

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET 3 MO

loryna (28) oral tablet 1 MO

LOSEASONIQUE ORAL TABLETS,DOSE

PACK,3 MONTH

3 MO

low-ogestrel (28) oral tablet 1 MO

lutera (28) oral tablet 1 MO

marlissa (28) oral tablet 1 MO

melodetta 24 fe oral tablet,chewable 1 MO

mibelas 24 fe oral tablet,chewable 1 MO

microgestin 1.5/30 (21) oral tablet 1 MO

microgestin 1/20 (21) oral tablet 1 MO

microgestin fe 1.5/30 (28) oral tablet 1 MO

microgestin fe 1/20 (28) oral tablet 1 MO

mili oral tablet 1 MO

MINASTRIN 24 FE ORAL

TABLET,CHEWABLE

3 MO

NATAZIA ORAL TABLET 3 MO

necon 0.5/35 (28) oral tablet 1 MO

nikki (28) oral tablet 1 MO

noreth-ethinyl estradiol-iron oral tablet,chewable 1 MO

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg

1 MO

norethindrone-e.estradiol-iron oral tablet 1 mg-20

mcg (24)/75 mg (4)

1 MO

norethindrone-e.estradiol-iron oral

tablet,chewable

1 MO

norgestimate-ethinyl estradiol oral tablet 1 MO

nortrel 0.5/35 (28) oral tablet 1 MO

nortrel 1/35 (21) oral tablet 1 MO

nortrel 1/35 (28) oral tablet 1 MO

nortrel 7/7/7 (28) oral tablet 1 MO

ocella oral tablet 1 MO

ogestrel (28) oral tablet 1 MO

orsythia oral tablet 1 MO

ORTHO TRI-CYCLEN LO (28) ORAL TABLET 3 MO


112


ORTHO-NOVUM 1/35 (28) ORAL TABLET 3 MO

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 3 MO

pimtrea (28) oral tablet 1 MO

pirmella oral tablet 1-35 mg-mcg 1 MO

portia 28 oral tablet 1 MO

previfem oral tablet 1 MO

QUARTETTE ORAL TABLETS,DOSE PACK,3

MONTH

3 MO

reclipsen (28) oral tablet 1 MO

rivelsa oral tablets,dose pack,3 month 1 MO

SAFYRAL ORAL TABLET 3 MO

SEASONIQUE ORAL TABLETS,DOSE PACK,3

MONTH

3 MO

setlakin oral tablets,dose pack,3 month 1 MO

SLYND ORAL TABLET 3 MO

sprintec (28) oral tablet 1 MO

sronyx oral tablet 1 MO

syeda oral tablet 1 MO

tarina 24 fe oral tablet 1

tarina fe 1/20 (28) oral tablet 1 MO

tri-estarylla oral tablet 1 MO

tri-legest fe oral tablet 1 MO

tri-lo-estarylla oral tablet 1 MO

tri-lo-sprintec oral tablet 1 MO

tri-mili oral tablet 1 MO

tri-previfem (28) oral tablet 1 MO

tri-sprintec (28) oral tablet 1 MO

trivora (28) oral tablet 1 MO

tri-vylibra lo oral tablet 1 MO

tri-vylibra oral tablet 1 MO

tydemy oral tablet 1 MO

velivet triphasic regimen (28) oral tablet 1 MO

vienva oral tablet 1 MO

vyfemla (28) oral tablet 1 MO

vylibra oral tablet 1 MO


113


wymzya fe oral tablet,chewable 1 MO

YASMIN (28) ORAL TABLET 3 MO

YAZ (28) ORAL TABLET 3 MO

zarah oral tablet 1 MO

zovia 1/35e (28) oral tablet 1 MO

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE OPHTHALMIC (EYE) DROPS 2 MO

bacitracin ophthalmic (eye) ointment 1 MO

bacitracin-polymyxin b ophthalmic (eye) ointment 1 MO

BESIVANCE OPHTHALMIC (EYE)

DROPS,SUSPENSION

2 MO

CILOXAN OPHTHALMIC (EYE) DROPS 3 MO

CILOXAN OPHTHALMIC (EYE) OINTMENT 3 MO

ciprofloxacin hcl ophthalmic (eye) drops 1 MO

erythromycin ophthalmic (eye) ointment 1 MO

gatifloxacin ophthalmic (eye) drops 1 MO

gentak ophthalmic (eye) ointment 1 MO

gentamicin ophthalmic (eye) drops 1 MO

levofloxacin ophthalmic (eye) drops 1 MO

MOXEZA OPHTHALMIC (EYE) DROPS,

VISCOUS

3 MO

moxifloxacin ophthalmic (eye) drops 1 MO

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION

2 MO

neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops

1 MO

OCUFLOX OPHTHALMIC (EYE) DROPS 3 MO

ofloxacin ophthalmic (eye) drops 1 MO

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops

1 MO

POLYTRIM OPHTHALMIC (EYE) DROPS 3 MO

tobramycin ophthalmic (eye) drops 1 MO

TOBREX OPHTHALMIC (EYE) DROPS 3 MO


114


TOBREX OPHTHALMIC (EYE) OINTMENT 3 MO

VIGAMOX OPHTHALMIC (EYE) DROPS 3 MO

ZYMAXID OPHTHALMIC (EYE) DROPS 3 MO

ANTIVIRALS

trifluridine ophthalmic (eye) drops 1 MO

ZIRGAN OPHTHALMIC (EYE) GEL 3 MO

BETA-BLOCKERS

betaxolol ophthalmic (eye) drops 1 MO

BETIMOL OPHTHALMIC (EYE) DROPS 3 MO

BETOPTIC S OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

carteolol ophthalmic (eye) drops 1 MO

ISTALOL OPHTHALMIC (EYE) DROPS,

ONCE DAILY

3 MO

levobunolol ophthalmic (eye) drops 0.5 % 1 MO

timolol maleate ophthalmic (eye) drops 1 MO

timolol maleate ophthalmic (eye) drops, once daily 1 MO

timolol maleate ophthalmic (eye) gel forming

solution

1 MO

TIMOPTIC OCUDOSE (PF) OPHTHALMIC

(EYE) DROPPERETTE

3 MO

TIMOPTIC-XE OPHTHALMIC (EYE) GEL

FORMING SOLUTION

3 MO

MISCELLANEOUS OPHTHALMOLOGICS

ALOCRIL OPHTHALMIC (EYE) DROPS 3 MO

ALOMIDE OPHTHALMIC (EYE) DROPS 3 MO

atropine ophthalmic (eye) drops 1 MO

azelastine ophthalmic (eye) drops 1 MO

BEPREVE OPHTHALMIC (EYE) DROPS 3 MO

BLEPH-10 OPHTHALMIC (EYE) DROPS 3 MO

BLEPHAMIDE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)

OINTMENT

3 MO

CEQUA OPHTHALMIC (EYE) DROPPERETTE 3 MO; QL (60 per 30 days)

cromolyn ophthalmic (eye) drops 1 MO


115


CYSTARAN OPHTHALMIC (EYE) DROPS 4 MO

epinastine ophthalmic (eye) drops 1 MO

ISOPTO CARPINE OPHTHALMIC (EYE)

DROPS

3 MO

LACRISERT OPHTHALMIC (EYE) INSERT 3 MO

LASTACAFT OPHTHALMIC (EYE) DROPS 3 MO

olopatadine ophthalmic (eye) drops 1 MO

OXERVATE OPHTHALMIC (EYE) DROPS 4 PA; MO

PATADAY OPHTHALMIC (EYE) DROPS 3 MO

PATANOL OPHTHALMIC (EYE) DROPS 3 MO

PAZEO OPHTHALMIC (EYE) DROPS 2 MO

PHOSPHOLINE IODIDE OPHTHALMIC (EYE)

DROPS

2 MO

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

1 MO

RESTASIS MULTIDOSE OPHTHALMIC (EYE)

DROPS


RESTASIS OPHTHALMIC (EYE)

DROPPERETTE


sulfacetamide sodium ophthalmic (eye) drops 1 MO

sulfacetamide sodium ophthalmic (eye) ointment 1 MO

sulfacetamide-prednisolone ophthalmic (eye)

drops

1 MO

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 3 MO; QL (60 per 30 days)

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACULAR LS OPHTHALMIC (EYE) DROPS 3 MO

ACULAR OPHTHALMIC (EYE) DROPS 3 MO

ACUVAIL (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 MO

bromfenac ophthalmic (eye) drops 1 MO

BROMSITE OPHTHALMIC (EYE) DROPS 2 MO

diclofenac sodium ophthalmic (eye) drops 1 MO

flurbiprofen sodium ophthalmic (eye) drops 1 MO

ILEVRO OPHTHALMIC (EYE)

DROPS,SUSPENSION

2 MO

ketorolac ophthalmic (eye) drops 1 MO


116


NEVANAC OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

PROLENSA OPHTHALMIC (EYE) DROPS 2 MO

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule, extended release 1 MO

acetazolamide oral tablet 1 MO

methazolamide oral tablet 1 MO

OTHER GLAUCOMA DRUGS

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

bimatoprost ophthalmic (eye) drops 1 MO

COMBIGAN OPHTHALMIC (EYE) DROPS 2 MO

COSOPT (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 MO

COSOPT OPHTHALMIC (EYE) DROPS 3 MO

dorzolamide ophthalmic (eye) drops 1 MO

dorzolamide-timolol (pf) ophthalmic (eye)

dropperette

1 MO

dorzolamide-timolol ophthalmic (eye) drops 1 MO

latanoprost ophthalmic (eye) drops 1 MO

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%

2 MO

RHOPRESSA OPHTHALMIC (EYE) DROPS 2 MO

ROCKLATAN OPHTHALMIC (EYE) DROPS 2 MO

SIMBRINZA OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

TRAVATAN Z OPHTHALMIC (EYE) DROPS 2 MO

TRUSOPT OPHTHALMIC (EYE) DROPS 3 MO

VYZULTA OPHTHALMIC (EYE) DROPS 3 MO

XALATAN OPHTHALMIC (EYE) DROPS 3 ST; MO

XELPROS OPHTHALMIC (EYE) DROPS,

EMULSION

3 ST; MO

ZIOPTAN (PF) OPHTHALMIC (EYE)

DROPPERETTE

3 ST; MO

STEROID-ANTIBIOTIC COMBINATIONS

MAXITROL OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO


117


MAXITROL OPHTHALMIC (EYE) OINTMENT 3 MO

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension

1 MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

drops,suspension

1 MO

PRED-G OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

PRED-G S.O.P. OPHTHALMIC (EYE)

OINTMENT

3 MO

TOBRADEX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

TOBRADEX OPHTHALMIC (EYE)

OINTMENT

3 MO

TOBRADEX ST OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

tobramycin-dexamethasone ophthalmic (eye)

drops,suspension

1 MO

ZYLET OPHTHALMIC (EYE)

DROPS,SUSPENSION

2 MO

STEROIDS

ALREX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

dexamethasone sodium phosphate ophthalmic

(eye) drops

1 MO

DUREZOL OPHTHALMIC (EYE) DROPS 3 MO

FLAREX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

fluorometholone ophthalmic (eye)

drops,suspension

1 MO

FML FORTE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

FML LIQUIFILM OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 3 MO

INVELTYS OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO


118


LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 2 MO

LOTEMAX OPHTHALMIC (EYE)

DROPS,SUSPENSION

2 MO

LOTEMAX OPHTHALMIC (EYE) OINTMENT 2 MO

LOTEMAX SM OPHTHALMIC (EYE)

DROPS,GEL

2 MO

loteprednol etabonate ophthalmic (eye)

drops,suspension

1 MO

MAXIDEX OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

PRED FORTE OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

PRED MILD OPHTHALMIC (EYE)

DROPS,SUSPENSION

3 MO

prednisolone acetate ophthalmic (eye)

drops,suspension

1 MO

prednisolone sodium phosphate ophthalmic (eye)

drops

1 MO

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

2 MO

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.15 %

3 MO

apraclonidine ophthalmic (eye) drops 1 MO

brimonidine ophthalmic (eye) drops 1 MO

IOPIDINE OPHTHALMIC (EYE)

DROPPERETTE

3 MO

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

AUVI-Q INJECTION AUTO-INJECTOR 4 ST; MO; QL (4 per 30 days)

cetirizine oral solution 1 mg/ml 1 MO

CLARINEX ORAL SYRUP 3

CLARINEX ORAL TABLET 3 MO; QL (30 per 30 days)

CLARINEX-D 12 HOUR ORAL TABLET, ER

MULTIPHASE 12 HR


desloratadine oral tablet 1 MO; QL (30 per 30 days)

desloratadine oral tablet,disintegrating 1 MO; QL (30 per 30 days)


119


EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.15 ML, 0.3 MG/0.3 ML NOT MADE

BY MYLAN


epinephrine injection auto-injector 0.15 mg/0.3 ml,

0.3 mg/0.3 ml (manufactured by mylan specialty)


EPIPEN 2-PAK INJECTION AUTO-INJECTOR 2 MO; QL (4 per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-

INJECTOR


hydroxyzine hcl oral tablet 1 PA; MO

levocetirizine oral solution 1 MO

levocetirizine oral tablet 1 MO; QL (30 per 30 days)

promethazine oral syrup 3 PA; MO

promethazine oral tablet 3 PA; MO

SEMPREX-D ORAL CAPSULE 3 MO

SYMJEPI INJECTION SYRINGE 3 MO

PULMONARY AGENTS

ACCOLATE ORAL TABLET 3 MO

acetylcysteine solution 1 B/D PA; MO

ADCIRCA ORAL TABLET 4 PA; MO; QL (60 per 30 days)

ADEMPAS ORAL TABLET 4 PA; MO; LA

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE


ADVAIR HFA AEROSOL INHALER 2 MO; QL (12 per 30 days)

AIRDUO RESPICLICK INHALATION

AEROSOL POWDR BREATH ACTIVATED


ALBUTEROL SULFATE INHALATION HFA

AEROSOL INHALER 90 MCG/ACTUATION




(NDA020503)

3 ST; MO; QL (13.4 per 30 days)



(NDA020983)


albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3

ml (0.083 %), 5 mg/ml

1 B/D PA; MO

albuterol sulfate oral syrup 1 MO

albuterol sulfate oral tablet 3 MO


120


albuterol sulfate oral tablet extended release 12 hr 3 MO

ALVESCO INHALATION HFA AEROSOL

INHALER 160 MCG/ACTUATION


ALVESCO INHALATION HFA AEROSOL

INHALER 80 MCG/ACTUATION


alyq oral tablet 4 PA; MO; QL (60 per 30 days)

ambrisentan oral tablet 4 PA; MO; LA

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE


ARCAPTA NEOHALER INHALATION

CAPSULE, W/INHALATION DEVICE


ARMONAIR RESPICLICK INHALATION

AEROSOL POWDR BREATH ACTIVATED 232

MCG/ACTUATION, 55 MCG/ACTUATION

3 QL (60 per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE


ASMANEX HFA AEROSOL INHALER 2 MO; QL (13 per 30 days)

ASMANEX TWISTHALER INHALATION


MCG/ ACTUATION (30), 220 MCG/

ACTUATION (30), 220 MCG/ ACTUATION

(60)


ASMANEX TWISTHALER INHALATION


MCG/ ACTUATION (120)


ATROVENT HFA AEROSOL INHALER 2 MO; QL (25.8 per 30 days)

BECONASE AQ NASAL SPRAY,NON-

AEROSOL


BERINERT INTRAVENOUS KIT 4 PA; MO

BEVESPI AEROSPHERE HFA AEROSOL

INHALER


bosentan oral tablet 4 PA; MO; LA

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE


BROVANA INHALATION SOLUTION FOR

NEBULIZATION

3 B/D PA; MO

budesonide inhalation suspension for nebulization 1 B/D PA; MO

CINRYZE INTRAVENOUS RECON SOLN 4 PA; MO

COMBIVENT RESPIMAT INHALATION MIST 2 MO; QL (8 per 30 days)


121


cromolyn inhalation solution for nebulization 1 B/D PA; MO

DALIRESP ORAL TABLET 3 PA; MO

DULERA INHALATION HFA AEROSOL

INHALER


DYMISTA NASAL SPRAY,NON-AEROSOL 2 MO; QL (23 per 30 days)

ESBRIET ORAL CAPSULE 4 PA; MO; QL (270 per 30 days)

ESBRIET ORAL TABLET 267 MG 4 PA; MO; QL (270 per 30 days)

ESBRIET ORAL TABLET 801 MG 4 PA; MO; QL (90 per 30 days)

FASENRA SUBCUTANEOUS SYRINGE 4 PA; MO

FIRAZYR SUBCUTANEOUS SYRINGE 4 PA; MO

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 50

MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA AEROSOL INHALER 110

MCG/ACTUATION



MCG/ACTUATION



MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)


fluticasone propionate nasal spray,suspension 1 MO; QL (16 per 30 days)

FLUTICASONE PROPION-SALMETEROL

INHALATION AEROSOL POWDR BREATH

ACTIVATED


FLUTICASONE PROPION-SALMETEROL

INHALATION BLISTER WITH DEVICE


HAEGARDA SUBCUTANEOUS RECON SOLN 4 PA; MO; LA

icatibant subcutaneous syringe 4 PA; MO

INCRUSE ELLIPTA INHALATION BLISTER

WITH DEVICE


ipratropium bromide inhalation solution 1 B/D PA; MO

ipratropium-albuterol inhalation solution for

nebulization

1 B/D PA; MO

KALBITOR SUBCUTANEOUS SOLUTION 4 MO

KALYDECO ORAL GRANULES IN PACKET

25 MG

4 PA; MO


122


KALYDECO ORAL GRANULES IN PACKET

50 MG, 75 MG


KALYDECO ORAL TABLET 4 PA; MO; QL (60 per 30 days)

LETAIRIS ORAL TABLET 4 PA; MO; LA

levalbuterol hcl inhalation solution for

nebulization

1 B/D PA; MO

LEVALBUTEROL TARTRATE INHALATION

HFA AEROSOL INHALER


LONHALA MAGNAIR REFILL INHALATION

SOLUTION FOR NEBULIZATION


LONHALA MAGNAIR STARTER

INHALATION SOLUTION FOR

NEBULIZATION


metaproterenol oral syrup 1 MO

mometasone nasal spray,non-aerosol 1 MO; QL (34 per 30 days)

montelukast oral granules in packet 1 MO

montelukast oral tablet 1 MO

montelukast oral tablet,chewable 1 MO

NASONEX NASAL SPRAY,NON-AEROSOL 3 MO; QL (34 per 30 days)

NUCALA SUBCUTANEOUS AUTO-INJECTOR 4 PA; MO; LA; QL (3 per 28 days)

NUCALA SUBCUTANEOUS RECON SOLN 4 PA; MO; LA; QL (3 per 28 days)

NUCALA SUBCUTANEOUS SYRINGE 4 PA; MO; LA; QL (3 per 28 days)

OFEV ORAL CAPSULE 4 PA; MO; QL (60 per 30 days)

OMNARIS NASAL SPRAY,NON-AEROSOL 3 MO; QL (12.5 per 30 days)

OPSUMIT ORAL TABLET 4 PA; MO; LA

ORKAMBI ORAL GRANULES IN PACKET 4 PA; MO; QL (56 per 28 days)

ORKAMBI ORAL TABLET 4 PA; MO; QL (112 per 28 days)

PERFOROMIST INHALATION SOLUTION

FOR NEBULIZATION

2 B/D PA; MO

PROAIR HFA AEROSOL INHALER 3 ST; MO; QL (17 per 30 days)

PROAIR RESPICLICK INHALATION



PROVENTIL HFA INHALATION AEROSOL

INHALER

3 ST; MO; QL (13.4 per 30 days)

PULMICORT FLEXHALER INHALATION


MCG/ACTUATION



123


PULMICORT FLEXHALER INHALATION


MCG/ACTUATION


PULMICORT INHALATION SUSPENSION

FOR NEBULIZATION

3 B/D PA; MO

PULMOZYME INHALATION SOLUTION 4 B/D PA; MO

QNASL NASAL HFA AEROSOL INHALER 40

MCG/ACTUATION


QNASL NASAL HFA AEROSOL INHALER 80

MCG/ACTUATION


QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40

MCG/ACTUATION


QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 80

MCG/ACTUATION


REVATIO ORAL SUSPENSION FOR

RECONSTITUTION


REVATIO ORAL TABLET 4 PA; MO; QL (90 per 30 days)

RUCONEST INTRAVENOUS RECON SOLN 4 PA; MO

SEEBRI NEOHALER INHALATION CAPSULE,

W/INHALATION DEVICE


SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE


sildenafil (pulmonary arterial hypertension) oral

suspension for reconstitution 10 mg/ml


sildenafil (pulmonary arterial hypertension) oral

tablet 20 mg


SINGULAIR ORAL GRANULES IN PACKET 3 MO

SINGULAIR ORAL TABLET 3 MO

SINGULAIR ORAL TABLET,CHEWABLE 3 MO

SPIRIVA RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)

SPIRIVA WITH HANDIHALER INHALATION



STIOLTO RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)

STRIVERDI RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)

SYMBICORT HFA AEROSOL INHALER 2 MO; QL (10.2 per 30 days)

SYMDEKO ORAL TABLETS, SEQUENTIAL 4 PA; MO; QL (56 per 28 days)


124


tadalafil (pulmonary arterial hypertension) oral

tablet 20 mg


TAKHZYRO SUBCUTANEOUS SOLUTION 4 PA; MO; LA

terbutaline oral tablet 1 MO

THEO-24 ORAL CAPSULE,EXTENDED

RELEASE 24HR

2 MO

theophylline oral solution 1 MO

theophylline oral tablet extended release 12 hr 300

mg

1 MO

theophylline oral tablet extended release 24 hr 1 MO

TRACLEER ORAL TABLET 4 PA; MO; LA

TRACLEER ORAL TABLET FOR

SUSPENSION

4 PA; MO; LA

TRELEGY ELLIPTA INHALATION BLISTER

WITH DEVICE


TUDORZA PRESSAIR INHALATION



UTIBRON NEOHALER INHALATION



VENTAVIS INHALATION SOLUTION FOR

NEBULIZATION

4 B/D PA; MO

VENTOLIN HFA AEROSOL INHALER 2 MO; QL (36 per 30 days)

WIXELA INHUB INHALATION BLISTER

WITH DEVICE


XHANCE NASAL AEROSOL BREATH

ACTIVATED


XOLAIR SUBCUTANEOUS RECON SOLN 4 PA; MO; LA; QL (6 per 28 days)

XOLAIR SUBCUTANEOUS SYRINGE 150

MG/ML


XOLAIR SUBCUTANEOUS SYRINGE 75

MG/0.5 ML


XOPENEX CONCENTRATE INHALATION

SOLUTION FOR NEBULIZATION

3 B/D PA; MO

XOPENEX HFA INHALATION AEROSOL

INHALER


XOPENEX INHALATION SOLUTION FOR

NEBULIZATION

3 B/D PA; MO

YUPELRI INHALATION SOLUTION FOR

NEBULIZATION

4 B/D PA; MO


125


zafirlukast oral tablet 1 MO

ZETONNA NASAL HFA AEROSOL INHALER 3 MO; QL (6.1 per 30 days)

zileuton oral tablet, er multiphase 12 hr 4 MO

ZYFLO ORAL TABLET 4 MO

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

darifenacin oral tablet extended release 24 hr 1 MO

DETROL LA ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO

DETROL ORAL TABLET 3 MO

DITROPAN XL ORAL TABLET EXTENDED

RELEASE 24HR 10 MG, 5 MG

3 MO

ENABLEX ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

flavoxate oral tablet 1 MO

GELNIQUE TRANSDERMAL GEL IN

METERED-DOSE PUMP 100 MG/GRAM (10

%)


MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HR

2 MO

oxybutynin chloride oral syrup 1 MO

oxybutynin chloride oral tablet 1 MO

oxybutynin chloride oral tablet extended release

24hr

1 MO

OXYTROL TRANSDERMAL PATCH

SEMIWEEKLY


solifenacin oral tablet 1 MO

tolterodine oral capsule,extended release 24hr 1 MO

tolterodine oral tablet 1 MO

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HR

2 MO

trospium oral capsule,extended release 24hr 1 MO

trospium oral tablet 1 MO

VESICARE ORAL TABLET 2 MO

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin oral tablet extended release 24 hr 1 MO

AVODART ORAL CAPSULE 3 MO


126


dutasteride oral capsule 1 MO

dutasteride-tamsulosin oral capsule, er multiphase

24 hr

1 MO

finasteride oral tablet 5 mg 1 MO

FLOMAX ORAL CAPSULE 3 ST; MO

JALYN ORAL CAPSULE, ER MULTIPHASE 24

HR

3 MO

PROSCAR ORAL TABLET 3 MO

RAPAFLO ORAL CAPSULE 2 ST; MO

silodosin oral capsule 1 MO

tamsulosin oral capsule 1 MO

UROXATRAL ORAL TABLET EXTENDED

RELEASE 24 HR

3 ST; MO

MISCELLANEOUS UROLOGICALS

bethanechol chloride oral tablet 1 MO

CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; MO; QL (30 per 30 days)

CYSTAGON ORAL CAPSULE 2 MO; LA

ELMIRON ORAL CAPSULE 2 MO

potassium citrate oral tablet extended release 1 MO

tadalafil oral tablet 2.5 mg, 5 mg 1 PA; MO; QL (30 per 30 days)

URECHOLINE ORAL TABLET 3 MO

UROCIT-K 10 ORAL TABLET EXTENDED

RELEASE

3 MO


RELEASE

3 MO


RELEASE

3 MO

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate oral capsule 1 MO

calcium acetate oral tablet 667 mg 1 MO

klor-con 10 oral tablet extended release 1 MO

klor-con 8 oral tablet extended release 1 MO

klor-con m10 oral tablet,er particles/crystals 1 MO




127


klor-con oral packet 1 MO

klor-con sprinkle oral capsule, extended release 8

meq

1 MO

K-TAB ORAL TABLET EXTENDED RELEASE

10 MEQ, 20 MEQ

3 MO

k-tab oral tablet extended release 8 meq 1 MO

magnesium sulfate injection solution 1 MO

magnesium sulfate injection syringe 1

NORMOSOL-R IN 5 % DEXTROSE


2

PHOSLYRA ORAL SOLUTION 3 MO

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

1

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 20 meq/l

1 MO

potassium chloride in 0.9%nacl intravenous

parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in 5 % dex intravenous

parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in lr-d5 intravenous parenteral

solution 20 meq/l

1 MO

potassium chloride in water intravenous

piggyback 10 meq/100 ml

1 MO

potassium chloride in water intravenous

piggyback 20 meq/100 ml, 40 meq/100 ml

1

potassium chloride intravenous solution 1 MO

potassium chloride oral capsule, extended release 1 MO

potassium chloride oral liquid 1 MO

potassium chloride oral packet 1 MO

potassium chloride oral tablet extended release 1 MO

potassium chloride oral tablet,er particles/crystals 1 MO

potassium chloride-0.45 % nacl intravenous

parenteral solution

1

potassium chloride-d5-0.2%nacl intravenous


1 MO



1



1 MO


128




1

sodium chloride 0.45 % intravenous parenteral

solution

1 MO

sodium chloride 3 % intravenous parenteral

solution

1 MO

sodium chloride 5 % intravenous parenteral

solution

1 MO

sodium lactate intravenous solution 1

TPN ELECTROLYTES INTRAVENOUS

SOLUTION

3

MISCELLANEOUS NUTRITION PRODUCTS

AMINOSYN II 10 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

AMINOSYN II 15 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

AMINOSYN-PF 10 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

AMINOSYN-PF 7 % SULFITE FREE


2 B/D PA

CLINIMIX 5%/D15W SULFITE FREE


2 B/D PA

CLINIMIX 5%/D25W SULFITE FREE


2 B/D PA

CLINIMIX 4.25%/D10W SULFITE FREE


2 B/D PA

CLINIMIX 4.25%-D25W SULFITE FREE


2 B/D PA

CLINIMIX 5%-D20W SULFITE FREE


2 B/D PA



3 B/D PA



3 B/D PA

CLINIMIX E 5%/D15W SULFITE FREE


3 B/D PA

CLINIMIX E 5%/D20W SULFITE FREE


3 B/D PA

CLINISOL SF 15 % INTRAVENOUS

PARENTERAL SOLUTION

3 B/D PA; MO


129


FREAMINE HBC 6.9 % INTRAVENOUS

PARENTERAL SOLUTION

3 B/D PA

HEPATAMINE 8% INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

intralipid intravenous emulsion 20 % 1 B/D PA

INTRALIPID INTRAVENOUS EMULSION 30

%

3 B/D PA

IONOSOL-MB IN D5W INTRAVENOUS

PARENTERAL SOLUTION

2

ISOLYTE-P IN 5 % DEXTROSE


2

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

2

NEPHRAMINE 5.4 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

NORMOSOL-M IN 5 % DEXTROSE


3

NORMOSOL-R PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION

2

NUTRILIPID INTRAVENOUS EMULSION 3 B/D PA

PLASMA-LYTE 148 INTRAVENOUS

PARENTERAL SOLUTION

2

PLASMA-LYTE A INTRAVENOUS

PARENTERAL SOLUTION

2

plenamine intravenous parenteral solution 1 B/D PA

premasol 10 % intravenous parenteral solution 1 B/D PA; MO

PREMASOL 6 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

PROCALAMINE 3% INTRAVENOUS

PARENTERAL SOLUTION

3 B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL

SOLUTION

3 B/D PA; MO

travasol 10 % intravenous parenteral solution 3 B/D PA; MO

TROPHAMINE 10 % INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA; MO

TROPHAMINE 6% INTRAVENOUS

PARENTERAL SOLUTION

2 B/D PA

VITAMINS / HEMATINICS

fluoride (sodium) oral tablet 1 MO


130


prenatal vitamin oral tablet 1 MO


131

Index

A abacavir .................................. 3

abacavir-lamivudine ............... 3

abacavir-lamivudine-

zidovudine .......................... 3

ABELCET .............................. 2

ABILIFY .............................. 42

ABILIFY MAINTENA ........ 42

ABILIFY MYCITE .............. 42

abiraterone ............................ 18

ABSORICA .......................... 66

ABSTRAL ............................ 35

acamprosate .......................... 74

ACANYA ............................. 66

acarbose ................................ 79

ACCOLATE....................... 119

ACCUPRIL .......................... 52

ACCURETIC ....................... 52

acebutolol ............................. 52

acetaminophen-codeine ........ 35

acetazolamide ..................... 116

acetic acid ............................. 77

acetylcysteine ..................... 119

ACIPHEX............................. 94

acitretin ................................. 64

ACTEMRA ........................ 103

ACTEMRA ACTPEN ........ 103

ACTHAR ............................. 78

ACTHIB (PF) ....................... 99

ACTIGALL .......................... 90

ACTIMMUNE ..................... 97

ACTIQ .................................. 35

ACTIVELLA ..................... 105

ACTONEL ......................... 103

ACTOPLUS MET ................ 79

ACTOS ................................. 79

ACULAR ........................... 115

ACULAR LS ...................... 115

ACUVAIL (PF) .................. 115

acyclovir ........................... 3, 70

acyclovir sodium .................... 3

ACZONE .............................. 66

ADACEL(TDAP

ADOLESN/ADULT)(PF)99,

100

ADALAT CC ....................... 52

adapalene .............................. 66

adapalene-benzoyl peroxide . 66

ADCIRCA .......................... 119

ADDERALL ........................ 42

ADDERALL XR .................. 42

adefovir ................................... 3

ADEMPAS ......................... 119

ADLYXIN ............................ 79

ADMELOG SOLOSTAR U-

100 INSULIN ................... 79

ADMELOG U-100 INSULIN

LISPRO ............................ 79

ADVAIR DISKUS ............. 119

ADVAIR HFA ................... 119

ADZENYS ER ..................... 42

ADZENYS XR-ODT ........... 42

AFINITOR ........................... 18

AFINITOR DISPERZ .......... 18

AFREZZA ............................ 79

AGGRENOX........................ 59

AGRYLIN ............................ 74

AIMOVIG AUTOINJECTOR

.......................................... 30

AIRDUO RESPICLICK..... 119

AJOVY ................................. 30

AKTIPAK ............................ 66

AKYNZEO

(FOSNETUPITANT) ....... 90

ala-cort .................................. 70

ALA-SCALP ........................ 70

albendazole ........................... 10

ALBENZA ........................... 10

albuterol sulfate .......... 119, 120

ALBUTEROL SULFATE .. 119

alclometasone ....................... 70

ALCOHOL PADS ................ 80

ALDACTAZIDE .................. 52

ALDACTONE...................... 52

ALDARA ............................. 65

ALECENSA ......................... 18

alendronate ................... 74, 103

alfuzosin ............................. 125

ALINIA ................................ 10

aliskiren ................................ 52

allopurinol .......................... 102

almotriptan malate ................ 30

ALOCRIL ........................... 114

ALOGLIPTIN ...................... 80

ALOGLIPTIN-METFORMIN

.......................................... 80

ALOGLIPTIN-

PIOGLITAZONE ............. 80

ALOMIDE .......................... 114

ALORA .............................. 106

alosetron ............................... 90

ALPHAGAN P ................... 118

ALREX ............................... 117

ALTACE .............................. 52

altavera (28) ........................ 108

ALTOPREV ......................... 60

ALTRENO ........................... 66

ALUNBRIG ......................... 18

ALVESCO .......................... 120

alyacen 1/35 (28) ................ 109

alyq ..................................... 120

amabelz ............................... 106

amantadine hcl ........................ 3

AMARYL ............................. 80

AMBIEN .............................. 42

AMBIEN CR ........................ 42

AMBISOME ........................... 2

ambrisentan ......................... 120

amcinonide ........................... 70

AMERGE ............................. 30

amethia ............................... 109

amethia lo ........................... 109

amikacin ............................... 10

amiloride ............................... 53

amiloride-hydrochlorothiazide

.......................................... 53

AMINOSYN II 10 % .......... 128

AMINOSYN II 15 % .......... 128

AMINOSYN-PF 10 % ....... 128

AMINOSYN-PF 7 %

SULFITE FREE ............. 128

amiodarone ........................... 52

AMITIZA ............................. 90

amitriptyline ......................... 42

amlodipine ............................ 53

amlodipine-atorvastatin ........ 60

amlodipine-benazepril .......... 53

amlodipine-olmesartan ......... 53

amlodipine-valsartan ............ 53

amlodipine-valsartan-

hydrochlorothiazide .......... 53

ammonium lactate ................ 65

amnesteem ............................ 66

amoxapine ............................. 42


132

amoxicil-clarithromy-lansopraz

.......................................... 95

amoxicillin ............................ 14

amoxicillin-pot clavulanate .. 14

amphetamine sulfate ............. 42

amphotericin b ........................ 2

ampicillin .............................. 14

ampicillin sodium ................. 14

ampicillin-sulbactam ............ 14

AMPYRA ............................. 32

ANADROL-50 ..................... 86

ANAFRANIL ....................... 42

anagrelide ............................. 74

anastrozole ............................ 18

ANCOBON ............................ 2

ANDRODERM .................... 86

ANDROGEL ........................ 87

ANGELIQ .......................... 106

ANORO ELLIPTA ............ 120

ANTABUSE......................... 74

ANTARA ............................. 60

ANUSOL-HC ....................... 90

apexicon e ............................. 70

APIDRA SOLOSTAR U-100

INSULIN .......................... 80

APIDRA U-100 INSULIN ... 80

APLENZIN .......................... 42

APOKYN ............................. 29

apraclonidine ...................... 118

aprepitant .............................. 90

apri ...................................... 109

APRISO ................................ 90

APTENSIO XR .................... 42

APTIOM............................... 24

APTIVUS ............................... 3

ARALAST NP ..................... 74

aranelle (28)........................ 109

ARANESP (IN

POLYSORBATE) ............ 97

ARAVA .............................. 103

ARCALYST ......................... 97

ARCAPTA NEOHALER ... 120

ARICEPT ............................. 32

ARIKAYCE ......................... 10

ARIMIDEX .......................... 18

aripiprazole ........................... 42

ARISTADA .......................... 43

ARISTADA INITIO ............ 42

ARIXTRA ............................ 59

armodafinil ........................... 43

ARMONAIR RESPICLICK

........................................ 120

ARNUITY ELLIPTA ......... 120

AROMASIN ......................... 18

ARTHROTEC 50 ................. 38

ARTHROTEC 75 ................. 38

ARYMO ER ......................... 35

ASACOL HD ....................... 90

ashlyna ................................ 109

ASMANEX HFA ............... 120

ASMANEX TWISTHALER

........................................ 120

aspirin-dipyridamole ............ 59

ASTAGRAF XL................... 18

ASTEPRO ............................ 77

ATACAND .......................... 53

ATACAND HCT ................. 53

atazanavir................................ 3

ATELVIA ........................... 103

atenolol ................................. 53

atenolol-chlorthalidone ......... 53

ATIVAN ............................... 43

atomoxetine .......................... 43

atorvastatin ........................... 60

atovaquone............................ 10

atovaquone-proguanil ........... 10

ATRALIN ............................ 66

ATRIPLA ............................... 3

atropine ............................... 114

ATROVENT HFA ............. 120

AUBAGIO............................ 32

aubra ................................... 109

AUGMENTIN ...................... 14

AURYXIA............................ 74

AUSTEDO ........................... 32

AUVI-Q .............................. 118

AVALIDE ............................ 53

AVANDIA ........................... 80

AVAPRO.............................. 53

AVC.................................... 108

AVEED ................................ 87

aviane.................................. 109

avita ...................................... 66

AVITA.................................. 66

AVODART ........................ 125

AVONEX ............................. 97

AVONEX (WITH ALBUMIN)

.......................................... 97

AVYCAZ ............................... 8

AYGESTIN ........................ 106

AZACTAM .......................... 10

AZASAN .............................. 18

AZASITE ........................... 113

azathioprine .......................... 18

azelaic acid ........................... 66

azelastine ...................... 77, 114

AZELEX ............................... 66

AZILECT ............................. 29

azithromycin ........................... 9

AZOPT ............................... 116

AZOR ................................... 53

aztreonam ............................. 10

AZULFIDINE ...................... 90

AZULFIDINE EN-TABS .... 90

B bacitracin ............................ 113

bacitracin-polymyxin b ....... 113

baclofen ................................ 34

BACLOFEN ......................... 34

BACTRIM ............................ 16

BACTRIM DS ...................... 16

BALCOLTRA .................... 109

balsalazide ............................ 90

BALVERSA ......................... 18

balziva (28) ......................... 109

BANZEL .............................. 24

BAQSIMI ............................. 80

BARACLUDE .................... 3, 4

BASAGLAR KWIKPEN U-

100 INSULIN ................... 80

BAXDELA ........................... 15

BCG VACCINE, LIVE (PF)

........................................ 100

BECONASE AQ ................ 120

BELBUCA ........................... 35

BELSOMRA ........................ 43

benazepril ............................. 53

benazepril-hydrochlorothiazide

.......................................... 53

BENICAR ............................. 53

BENICAR HCT .................... 53

BENLYSTA ....................... 103

BENZACLIN PUMP ............ 67

BENZAMYCIN ................... 67

BENZNIDAZOLE ............... 10

benztropine ........................... 29

BEPREVE .......................... 114

BERINERT ......................... 120

beser ...................................... 70

BESIVANCE ...................... 113

betamethasone dipropionate . 70

betamethasone valerate ... 70, 71


133

betamethasone, augmented... 71

BETAPACE AF ................... 52

BETASERON ...................... 97

betaxolol ....................... 53, 114

bethanechol chloride .......... 126

BETHKIS ............................. 10

BETIMOL .......................... 114

BETOPTIC S...................... 114

BEVESPI AEROSPHERE . 120

BEVYXXA .......................... 59

bexarotene ............................ 18

BEXSERO .......................... 100

BEYAZ............................... 109

bicalutamide ......................... 18

BICILLIN C-R ..................... 14

BICILLIN L-A ..................... 14

BIDIL ................................... 53

BIJUVA .............................. 106

BIKTARVY ........................... 4

BILTRICIDE ........................ 10

bimatoprost ......................... 116

BINOSTO........................... 103

bisoprolol fumarate .............. 53

bisoprolol-hydrochlorothiazide

.......................................... 53

BLEPH-10 .......................... 114

BLEPHAMIDE .................. 114

BLEPHAMIDE S.O.P. ....... 114

blisovi 24 fe ........................ 109

blisovi fe 1.5/30 (28) .......... 109

BONIVA ............................ 103

BONJESTA .......................... 90

BOOSTRIX TDAP ............ 100

bosentan .............................. 120

BOSULIF ............................. 18

BRAFTOVI .......................... 18

BREO ELLIPTA ................ 120

briellyn ............................... 109

BRILINTA ........................... 59

brimonidine ........................ 118

BRISDELLE ........................ 43

BRIVIACT ........................... 24

bromfenac ........................... 115

bromocriptine ....................... 29

BROMSITE ........................ 115

BROVANA ........................ 120

BRYHALI ............................ 71

budesonide .................... 90, 120

bumetanide ........................... 53

BUNAVAIL ......................... 39

BUPHENYL......................... 74

buprenorphine ....................... 35

BUPRENORPHINE ............. 35

buprenorphine hcl ................. 35

buprenorphine-naloxone ....... 39

bupropion hcl ........................ 43

BUPROPION HCL .............. 43

bupropion hcl (smoking deter)

.......................................... 77

buspirone .............................. 43

butorphanol tartrate .............. 39

BUTRANS ........................... 35

BYDUREON ........................ 80

BYDUREON BCISE ........... 80

BYETTA .............................. 80

BYSTOLIC .......................... 53

C cabergoline ........................... 87

CABLIVI .............................. 59

CABOMETYX ..................... 18

CADUET .............................. 61

CAFERGOT ......................... 30

CALAN ................................ 53

CALAN SR .......................... 53

calcipotriene ......................... 64

calcipotriene-betamethasone 64

calcitonin (salmon) ............... 87

calcitriol .......................... 64, 87

calcium acetate ................... 126

CALQUENCE ...................... 18

CAMBIA .............................. 39

camila ................................. 106

camrese lo ........................... 109

CANASA.............................. 90

CANCIDAS............................ 2

candesartan ........................... 53

candesartan-


CAPEX ................................. 71

CAPRELSA.................... 18, 19

captopril ................................ 53

captopril-hydrochlorothiazide

.......................................... 53

CARAC ................................ 65

CARAFATE ......................... 95

CARBAGLU ........................ 74

carbamazepine ...................... 24

CARBATROL ...................... 24

carbidopa .............................. 29

carbidopa-levodopa .............. 29

carbidopa-levodopa-

entacapone ........................ 29

CARDIZEM ......................... 54

CARDIZEM CD ................... 53

CARDIZEM LA ................... 54

CARDURA ........................... 54

CARDURA XL .................... 54

CARNITOR .......................... 74

CAROSPIR ........................... 54

carteolol .............................. 114

cartia xt ................................. 54

carvedilol .............................. 54

carvedilol phosphate ............. 54

CASODEX ........................... 19

caspofungin ............................. 2

CATAPRES .......................... 54

CATAPRES-TTS-1 .............. 54

CATAPRES-TTS-2 .............. 54

CATAPRES-TTS-3 .............. 54

CAYSTON ........................... 11

caziant (28) ......................... 109

cefaclor ................................... 8

cefadroxil ................................ 8

cefazolin ................................. 8

cefdinir .................................... 8

cefepime ................................. 8

cefixime .................................. 8

cefotaxime .............................. 8

cefotetan ................................. 8

cefoxitin .................................. 8

cefpodoxime ........................... 8

cefprozil .................................. 8

ceftazidime ............................. 8

ceftriaxone .............................. 8

cefuroxime axetil .................... 8

cefuroxime sodium ............. 8, 9

CELEBREX ......................... 39

celecoxib ............................... 39

CELEXA .............................. 43

CELLCEPT .......................... 19

CELONTIN .......................... 24

cephalexin ............................... 9

CEQUA .............................. 114

CERDELGA ......................... 87

CESAMET ........................... 90

cetirizine ............................. 118

CETRAXAL ......................... 77

cevimeline ............................. 74

CHANTIX ............................ 77

CHANTIX CONTINUING

MONTH BOX .................. 77

CHANTIX STARTING

MONTH BOX .................. 77


134

CHEMET ............................. 74

CHENODAL ........................ 90

chlorhexidine gluconate ....... 77

chloroquine phosphate.......... 11

chlorothiazide ....................... 54

chlorpromazine ..................... 43

chlorthalidone ....................... 54

CHOLBAM .......................... 90

cholestyramine (with sugar) . 61

cholestyramine light ............. 61

CIALIS ............................... 126

ciclopirox .............................. 69

cilostazol............................... 59

CILOXAN .......................... 113

CIMDUO ................................ 4

cimetidine ............................. 95

cimetidine hcl ....................... 95

CIMZIA ................................ 91

CIMZIA POWDER FOR

RECONST ........................ 91

cinacalcet .............................. 87

CINRYZE........................... 120

CIPRO .................................. 15

CIPRO HC............................ 78

CIPRODEX .......................... 78

ciprofloxacin......................... 16

ciprofloxacin hcl ..... 15, 77, 113

ciprofloxacin in 5 % dextrose

.......................................... 16

citalopram ............................. 43

claravis ................................. 67

CLARINEX ........................ 118

CLARINEX-D 12 HOUR .. 118

clarithromycin ........................ 9

CLENPIQ ............................. 91

CLEOCIN..................... 11, 108

CLEOCIN HCL.................... 11

CLEOCIN IN 5 %

DEXTROSE ..................... 11

CLEOCIN PEDIATRIC ....... 11

CLEOCIN T ......................... 67

CLIMARA ......................... 106

CLIMARA PRO ................. 106

clindacin p ............................ 67

CLINDAGEL ....................... 67

clindamycin hcl .................... 11

clindamycin in 5 % dextrose 11

clindamycin palmitate hcl .... 11

clindamycin phosphate .. 11, 67,

108

clindamycin-benzoyl peroxide

.......................................... 67

clindamycin-tretinoin ........... 67

CLINDESSE ...................... 108

CLINIMIX 5%/D15W

SULFITE FREE ............. 128

CLINIMIX 5%/D25W

SULFITE FREE ............. 128

CLINIMIX 4.25%/D10W

SULFITE FREE ............. 128

CLINIMIX 4.25%/D5W

SULFITE FREE ............... 74

CLINIMIX 4.25%-D25W

SULFITE FREE ............. 128

CLINIMIX 5%-D20W

SULFITE FREE ............. 128

CLINIMIX E 2.75%/D5W

SULFITE FREE ............... 75


SULFITE FREE ............. 128


SULFITE FREE ............. 128

CLINIMIX E 5%/D15W

SULFITE FREE ............. 128

CLINIMIX E 5%/D20W

SULFITE FREE ............. 128

CLINISOL SF 15 % ........... 128

clobazam ......................... 24, 25

clobetasol .............................. 71

clobetasol-emollient ............. 71

CLOBEX .............................. 71

CLOCORTOLONE

PIVALATE ...................... 71

clodan ................................... 71

CLODERM .......................... 71

clomipramine ........................ 43

clonazepam ........................... 25

clonidine ............................... 54

clonidine hcl ................... 43, 54

clopidogrel ............................ 59

clorazepate dipotassium ....... 43

clotrimazole ...................... 2, 69

clotrimazole-betamethasone . 69

clozapine ............................... 43

CLOZAPINE ........................ 43

CLOZARIL .......................... 43

COARTEM .......................... 11

codeine sulfate ...................... 35

COLAZAL ........................... 91

COLCHICINE .................... 102

COLCRYS.......................... 102

colesevelam .......................... 61

COLESTID ........................... 61

colestipol ............................... 61

colistin (colistimethate na) ... 11

colocort ................................. 91

COLY-MYCIN S ................. 78

COLYTE WITH FLAVOR

PACKS ............................. 91

COMBIGAN ...................... 116

COMBIPATCH .................. 106

COMBIVENT RESPIMAT 120

COMBIVIR ............................ 4

COMETRIQ ......................... 19

COMPLERA .......................... 4

compro .................................. 91

COMTAN ............................. 29

CONCERTA ......................... 43

CONDYLOX ........................ 65

constulose ............................. 91

CONZIP ................................ 39

COPAXONE ........................ 32

COPIKTRA .......................... 19

CORDRAN TAPE LARGE

ROLL ................................ 71

COREG ................................. 54

COREG CR .......................... 54

CORGARD ........................... 54

CORLANOR ........................ 63

CORTEF ............................... 78

CORTIFOAM ....................... 91

cortisone ............................... 78

CORTISPORIN .................... 68

COSENTYX (2 SYRINGES)

.......................................... 64

COSENTYX PEN (2 PENS) 64

COSOPT ............................. 116

COSOPT (PF) ..................... 116

COTELLIC ........................... 19

COTEMPLA XR-ODT ........ 43

COUMADIN ........................ 59

COZAAR .............................. 54

CREON ................................. 91

CRESEMBA ........................... 2

CRESTOR ............................ 61

CRINONE .......................... 106

CRIXIVAN ............................. 4

cromolyn ............... 91, 114, 121

cryselle (28) ........................ 109

CUBICIN .............................. 11

CUPRIMINE ...................... 103

CUTIVATE .......................... 71


135

CUVPOSA ........................... 89

cyclafem 1/35 (28) ............. 109

cyclafem 7/7/7 (28) ............ 109

cyclobenzaprine .................... 34

cyclophosphamide ................ 19

CYCLOSET ......................... 80

cyclosporine ......................... 19

cyclosporine modified .......... 19

CYMBALTA ....................... 44

cyred eq .............................. 109

CYSTADANE ...................... 91

CYSTAGON ...................... 126

CYSTARAN ...................... 115

CYTOMEL........................... 89

CYTOTEC ........................... 95

D d10 %-0.45 % sodium chloride

.......................................... 75

d2.5 %-0.45 % sodium

chloride ............................. 75

d5 % and 0.9 % sodium

chloride ............................. 75

d5 %-0.45 % sodium chloride

.......................................... 75

dalfampridine ....................... 32

DALIRESP ......................... 121

DALVANCE ........................ 11

danazol ................................. 87

DANTRIUM ........................ 34

dantrolene ............................. 34

dapsone ........................... 11, 67

DAPTACEL (DTAP

PEDIATRIC) (PF).......... 100

daptomycin ........................... 11

DAPTOMYCIN ................... 11

DARAPRIM ......................... 11

darifenacin .......................... 125

DAURISMO......................... 19

DAYPRO ............................. 39

DAYTRANA ....................... 44

DDAVP ................................ 87

deblitane ............................. 106

deferasirox ............................ 75

DELESTROGEN ............... 106

DELSTRIGO .......................... 4

delyla (28) .......................... 109

DELZICOL .......................... 91

demeclocycline ..................... 16

DEMSER .............................. 54

DENAVIR ............................ 70

DEPAKOTE ......................... 25

DEPAKOTE ER ................... 25

DEPAKOTE SPRINKLES .. 25

DEPEN TITRATABS ........ 104

DEPO-ESTRADIOL .......... 106

DEPO-PROVERA.............. 106

DEPO-SUBQ PROVERA 104

........................................ 106

DEPO-TESTOSTERONE .... 87

DESCOVY ............................. 4

desipramine .......................... 44

desloratadine ....................... 118

desmopressin ........................ 87

desog-e.estradiol/e.estradiol

........................................ 109

desogestrel-ethinyl estradiol

........................................ 109

DESONATE ......................... 71

desonide ................................ 71

DESOWEN .......................... 71

desoximetasone .............. 71, 72

DESOXYN ........................... 44

DESVENLAFAXINE .......... 44

desvenlafaxine succinate ...... 44

DETROL ............................ 125

DETROL LA ...................... 125

dexamethasone ..................... 78

dexamethasone intensol ........ 78

dexamethasone sodium

phosphate ........................ 117

DEXEDRINE SPANSULE .. 44

DEXILANT .......................... 95

dexmethylphenidate.............. 44

DEXPAK 13 DAY ............... 78

dextroamphetamine .............. 44

dextroamphetamine-

amphetamine .................... 44

dextrose 10 % and 0.2 % nacl

.......................................... 75

dextrose 10 % in water (d10w)

.......................................... 75

dextrose 5 % in water (d5w). 75

dextrose 5%-0.2 % sod

chloride ............................. 75

dextrose 5%-0.3 %

sod.chloride ...................... 75

dextrose with sodium chloride

.......................................... 75

DIASTAT ............................. 25

DIASTAT ACUDIAL .......... 25

diazepam ............................... 44

diazepam intensol ................. 44

DIBENZYLINE ................... 54

DICLEGIS ............................ 91

DICLOFENAC EPOLAMINE

.......................................... 39

diclofenac potassium ............ 39

diclofenac sodium ... 39, 65, 115

diclofenac-misoprostol ......... 39

dicloxacillin .......................... 14

dicyclomine .......................... 89

didanosine ............................... 4

DIFFERIN ............................ 67

DIFICID ................................. 9

diflorasone ............................ 72

DIFLUCAN ............................ 2

diflunisal ............................... 39

digitek ................................... 63

digox ..................................... 63

digoxin .................................. 63

dihydroergotamine ................ 30

DILANTIN 30 MG ............... 25

DILANTIN EXTENDED 100

MG .................................... 25

DILANTIN INFATABS 50

MG .................................... 25

DILANTIN-125 125 MG/5

ML .................................... 25

DILAUDID ........................... 35

diltiazem hcl ......................... 54

dilt-xr .................................... 55

DIOVAN .............................. 55

DIOVAN HCT ..................... 55

DIPENTUM ......................... 91

diphenoxylate-atropine ......... 90

DIPROLENE ........................ 72

dipyridamole ......................... 59

disulfiram .............................. 75

DITROPAN XL .................. 125

DIURIL ................................. 55

divalproex ............................. 25

DIVIGEL ............................ 106

dofetilide ............................... 52

DOLOPHINE ....................... 35

donepezil ............................... 32

DOPTELET (10 TAB PACK)

.......................................... 59


.......................................... 59


.......................................... 59

DORYX ................................ 16

DORYX MPC ...................... 16


136

dorzolamide ........................ 116

dorzolamide-timolol ........... 116

dorzolamide-timolol (pf) .... 116

dotti..................................... 106

DOVATO ............................... 4

DOVONEX .......................... 64

doxazosin .............................. 55

doxepin ........................... 44, 65

doxercalciferol ...................... 87

doxy-100............................... 16

doxycycline hyclate .............. 16

doxycycline monohydrate .... 16

doxylamine-pyridoxine (vit b6)

.......................................... 91

dronabinol............................. 91

drospirenone-e.estradiol-lm.fa

........................................ 109

drospirenone-ethinyl estradiol

........................................ 109

DROXIA .............................. 19

DUAC................................... 67

DUAVEE ........................... 106

DUETACT ........................... 80

DUEXIS ............................... 39

DULERA ............................ 121

duloxetine ............................. 44

DUOBRII ............................. 72

DUOPA ................................ 29

DUPIXENT .......................... 65

DURAGESIC ....................... 35

duramorph (pf) ..................... 35

DUREZOL ......................... 117

dutasteride .......................... 126

dutasteride-tamsulosin ........ 126

DUTOPROL......................... 55

DUZALLO ......................... 102

dvorah ................................... 35

DYANAVEL XR ................. 44

DYAZIDE ............................ 55

DYMISTA .......................... 121

DYRENIUM ........................ 55

E e.e.s. 400 ................................. 9

E.E.S. GRANULES ............... 9

econazole .............................. 69

EDARBI ............................... 55

EDARBYCLOR ................... 55

EDECRIN............................. 55

EDURANT ............................. 4

efavirenz ................................. 4

EFFEXOR XR...................... 44

EFFIENT .............................. 59

EFUDEX .............................. 65

EGRIFTA ............................. 97

ELESTRIN ......................... 106

eletriptan ............................... 30

ELIDEL ................................ 65

ELIGARD ............................ 19

ELIGARD (3 MONTH) ....... 19



ELIMITE .............................. 74

ELIQUIS .............................. 59

ELMIRON .......................... 126

ELOCON .............................. 72

EMBEDA ............................. 35

EMCYT ................................ 19

EMEND ................................ 91

EMFLAZA ........................... 78

EMGALITY PEN................. 31

EMGALITY SYRINGE ....... 31

emoquette ........................... 109

EMSAM ............................... 44

EMTRIVA .............................. 4

EMVERM ............................ 11

ENABLEX ......................... 125

enalapril maleate................... 55

enalapril-hydrochlorothiazide

.......................................... 55

ENBREL ............................ 104

ENBREL MINI .................. 104

ENBREL SURECLICK ..... 104

ENDARI ............................... 75

endocet.................................. 35

ENGERIX-B (PF) .............. 100

ENGERIX-B PEDIATRIC

(PF) ................................. 100

enoxaparin ............................ 59

enpresse .............................. 109

enskyce ............................... 109

ENSTILAR ........................... 64

entacapone ............................ 29

entecavir ................................. 4

ENTOCORT EC................... 91

ENTRESTO.......................... 63

enulose .................................. 91

ENVARSUS XR .................. 19

EPCLUSA .............................. 4

EPIDIOLEX ......................... 25

EPIDUO ............................... 67

EPIDUO FORTE .................. 67

epinastine ............................ 115

epinephrine ......................... 119

EPINEPHRINE .................. 119

EPIPEN 2-PAK .................. 119

EPIPEN JR 2-PAK ............. 119

epitol ..................................... 25

EPIVIR ................................... 4

EPIVIR HBV .......................... 4

eplerenone ............................. 55

EPOGEN .............................. 97

eprosartan ............................. 55

EPZICOM ............................... 4

EQUETRO ........................... 25

ERAXIS(WATER DILUENT)

............................................ 2

ergoloid ................................. 45

ergotamine-caffeine .............. 31

ERIVEDGE .......................... 19

ERLEADA ........................... 19

erlotinib ................................. 19

errin ..................................... 106

ERTACZO ............................ 69

ertapenem ............................. 11

ery pads ................................. 67

erygel .................................... 67

ERYPED 200 .......................... 9

ERYPED 400 .......................... 9

ery-tab ..................................... 9

ERY-TAB ............................. 10

ERYTHROCIN .................... 10

erythrocin (as stearate) ......... 10

erythromycin ................. 10, 113

erythromycin ethylsuccinate . 10

erythromycin with ethanol .... 67

erythromycin-benzoyl peroxide

.......................................... 67

ESBRIET ............................ 121

escitalopram oxalate ............. 45

esomeprazole magnesium ..... 95

ESOMEPRAZOLE

STRONTIUM ................... 95

estarylla ............................... 109

ESTRACE .......................... 106

estradiol .............................. 106

estradiol valerate ................. 107

estradiol-norethindrone acet

........................................ 107

ESTRING ........................... 107

eszopiclone ........................... 45

ethacrynic acid ...................... 55

ethambutol ............................ 11

ethosuximide ......................... 25


137

ethynodiol diac-eth estradiol

........................................ 109

etidronate disodium .............. 75

etodolac ................................ 39

EUCRISA ............................. 65

EURAX ................................ 74

EVAMIST .......................... 107

EVEKEO .............................. 45

EVEKEO ODT ..................... 45

EVENITY........................... 103

EVISTA .............................. 103

EVOCLIN ............................ 67

EVOTAZ ................................ 4

EVOXAC ............................. 75

EVZIO .................................. 39

EXELDERM ........................ 69

EXELON .............................. 32

exemestane ........................... 19

EXFORGE ........................... 55

EXFORGE HCT .................. 55

EXJADE ............................... 75

EXTAVIA ............................ 97

EXTINA ............................... 69

EZALLOR SPRINKLE........ 61

ezetimibe .............................. 61

ezetimibe-simvastatin ........... 61

F FABIOR ............................... 67

falmina (28) ........................ 109

famciclovir ............................. 4

famotidine............................. 95

FANAPT .............................. 45

FARESTON ......................... 19

FARXIGA ............................ 80

FARYDAK........................... 19

FASENRA .......................... 121

fayosim ............................... 109

FAZACLO ........................... 45

febuxostat ........................... 102

felbamate .............................. 25

FELBATOL ......................... 25

FELDENE ............................ 40

felodipine .............................. 55

FEMARA ............................. 19

FEMHRT LOW DOSE ...... 107

FEMRING .......................... 107

femynor .............................. 109

fenofibrate ............................ 61

FENOFIBRATE ................... 61

fenofibrate micronized ......... 61

fenofibrate nanocrystallized . 61

fenofibric acid....................... 61

fenofibric acid (choline) ....... 61

FENOGLIDE........................ 61

fenoprofen ............................ 40

FENOPROFEN .................... 40

fentanyl ................................. 36

fentanyl citrate ...................... 36

FENTANYL CITRATE ....... 36

FENTORA............................ 36

ferriprox ................................ 75

FERRIPROX ........................ 75

FETZIMA ............................. 45

FEXMID ............................... 34

FIASP FLEXTOUCH U-100

INSULIN .......................... 80

FIASP U-100 INSULIN ....... 80

FIBRICOR............................ 61

FINACEA ............................. 67

finasteride ........................... 126

FIRAZYR ........................... 121

FIRDAPSE ........................... 32

FIRMAGON KIT W

DILUENT SYRINGE 19, 20

FIRVANQ ............................ 11

flac otic oil ............................ 77

FLAGYL .............................. 11

FLAREX ............................ 117

flavoxate ............................. 125

FLEBOGAMMA DIF ........ 100

flecainide .............................. 52

FLECTOR ............................ 40

FLOLIPID ............................ 61

FLOMAX ........................... 126

FLOVENT DISKUS .......... 121

FLOVENT HFA ................. 121

fluconazole ............................. 2

fluconazole in nacl (iso-osm) . 2

flucytosine .............................. 2

fludrocortisone...................... 78

FLUMADINE ........................ 4

flunisolide ........................... 121

fluocinolone .......................... 72

fluocinolone acetonide oil .... 77

fluocinolone and shower cap 72

fluocinonide .......................... 72

fluocinonide-e ....................... 72

fluoride (sodium) ................ 129

fluorometholone ................. 117

fluorouracil ........................... 65

FLUOROURACIL ............... 65

fluoxetine .............................. 45

fluphenazine decanoate ........ 45

fluphenazine hcl .................... 45

flurandrenolide ..................... 72

flurbiprofen ........................... 40

flurbiprofen sodium ............ 115

flutamide ............................... 20

fluticasone propionate .. 72, 121

FLUTICASONE PROPION-

SALMETEROL .............. 121

fluvastatin ............................. 61

fluvoxamine .......................... 45

FML FORTE ...................... 117

FML LIQUIFILM .............. 117

FML S.O.P. ......................... 117

FOCALIN ............................. 45

FOCALIN XR ...................... 46

fondaparinux ......................... 60

FORFIVO XL ....................... 46

FORTAMET ......................... 80

FORTEO ............................. 103

FORTESTA .......................... 87

FOSAMAX ......................... 103

FOSAMAX PLUS D .......... 103

fosamprenavir ......................... 4

fosinopril ............................... 55

fosinopril-hydrochlorothiazide

.......................................... 55

FOSRENOL ......................... 75

FRAGMIN ............................ 60

FREAMINE HBC 6.9 % .... 129

FROVA ................................. 31

frovatriptan ........................... 31

FULPHILA ........................... 97

FURADANTIN .................... 17

furosemide ............................ 55

FUZEON ................................ 4

fyavolv ................................ 107

FYCOMPA ........................... 25

G gabapentin ....................... 25, 26

GABITRIL ........................... 26

GALAFOLD ......................... 87

galantamine ........................... 32

GAMMAGARD LIQUID .. 100

GAMMAGARD S-D (IGA < 1

MCG/ML) ....................... 100

GAMMAKED .................... 100

GAMMAPLEX .................. 100

GAMMAPLEX (WITH

SORBITOL) ................... 100

GAMUNEX-C .................... 100


138

GARDASIL 9 (PF)............. 100

GASTROCROM .................. 91

gatifloxacin ......................... 113

GATTEX 30-VIAL .............. 91

GAUZE PAD ....................... 80

gavilyte-c .............................. 91

gavilyte-g .............................. 91

gavilyte-n .............................. 91

GELNIQUE ........................ 125

gemfibrozil ........................... 61

GENERESS FE .................. 109

generlac ................................ 91

gengraf .................................. 20

GENOTROPIN .................... 98

GENOTROPIN MINIQUICK

.......................................... 98

gentak ................................. 113

gentamicin .............. 12, 68, 113

gentamicin in nacl (iso-osm) 11

GENVOYA ............................ 4

GEODON ............................. 46

gianvi (28) .......................... 110

GILENYA ............................ 32

GILOTRIF ............................ 20

GLASSIA ............................. 75

glatiramer ....................... 32, 33

glatopa .................................. 33

GLEEVEC ............................ 20

GLEOSTINE ........................ 20

glimepiride ........................... 81

glipizide ................................ 81

glipizide-metformin .............. 81

GLUCAGEN HYPOKIT ..... 81

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 81

GLUCOPHAGE ................... 81

GLUCOPHAGE XR ............ 81

GLUCOTROL ...................... 81

GLUCOTROL XL ............... 81

GLUMETZA ........................ 81

glycopyrrolate....................... 90

GLYSET............................... 81

GLYXAMBI ........................ 82

GOCOVRI ............................ 29

GOLYTELY......................... 92

GRALISE ............................. 26

GRALISE 30-DAY STARTER

PACK ............................... 26

granisetron hcl ...................... 92

GRANIX .............................. 98

griseofulvin microsize ............ 2

griseofulvin ultramicrosize ..... 2

guanidine .............................. 46

GVOKE SYRINGE .............. 82

GYNAZOLE-1 ................... 108

H HAEGARDA...................... 121

hailey 24 fe ......................... 110

halcinonide ........................... 72

HALDOL.............................. 46

HALDOL DECANOATE .... 46

halobetasol propionate .......... 72

HALOBETASOL

PROPIONATE ................. 72

HALOG ................................ 72

haloperidol ............................ 46

haloperidol decanoate ........... 46

haloperidol lactate ................ 46

HARVONI.............................. 4

HAVRIX (PF) .................... 100

heparin (porcine) .................. 60

HEPATAMINE 8% ............ 129

HEPSERA .............................. 4

HETLIOZ ............................. 46

HIBERIX (PF) .................... 100

HIPREX................................ 17

HORIZANT.......................... 33

HUMALOG JUNIOR

KWIKPEN U-100 ............ 82

HUMALOG KWIKPEN

INSULIN .......................... 82

HUMALOG MIX 50-50

INSULN U-100 ................ 82

HUMALOG MIX 50-50

KWIKPEN........................ 82

HUMALOG MIX 75-25

KWIKPEN........................ 82

HUMALOG MIX 75-25(U-

100)INSULN .................... 82

HUMALOG U-100 INSULIN

.......................................... 82

HUMATROPE ..................... 98

HUMIRA ............................ 104

HUMIRA PEDIATRIC

CROHNS START .......... 104

HUMIRA PEN ................... 104

HUMIRA PEN CROHNS-UC-

HS START ..................... 104

HUMIRA PEN PSOR-

UVEITS-ADOL HS ....... 104

HUMIRA(CF) .................... 104

HUMIRA(CF) PEDI

CROHNS STARTER ..... 104

HUMIRA(CF) PEN ............ 104

HUMIRA(CF) PEN

CROHNS-UC-HS ........... 104

HUMIRA(CF) PEN PSOR-

UV-ADOL HS ................ 104

HUMULIN 70/30 U-100

INSULIN .......................... 82

HUMULIN 70/30 U-100

KWIKPEN ........................ 82

HUMULIN N NPH INSULIN

KWIKPEN ........................ 82

HUMULIN N NPH U-100

INSULIN .......................... 82

HUMULIN R REGULAR U-

100 INSULN .................... 82

HUMULIN R U-500 (CONC)

INSULIN .......................... 82

HUMULIN R U-500 (CONC)

KWIKPEN ........................ 82

hydralazine ........................... 55

HYDREA ............................. 20

hydrochlorothiazide .............. 55

hydrocodone-acetaminophen 36

hydrocodone-ibuprofen ........ 36

hydrocortisone .... 72, 73, 78, 92

hydrocortisone butyrate ........ 72

hydrocortisone valerate ........ 73

hydrocortisone-acetic acid .... 77

hydrocortisone-pramoxine .... 92

hydromorphone ..................... 36

hydromorphone (pf) .............. 36

hydroxychloroquine .............. 12

hydroxyurea .......................... 20

hydroxyzine hcl .................. 119

HYSINGLA ER .................... 36

HYZAAR ............................. 55

I ibandronate ......................... 103

IBRANCE ............................. 20

ibu ......................................... 40

ibuprofen ............................... 40

ibuprofen-oxycodone ............ 36

icatibant .............................. 121

ICLUSIG .............................. 20

IDHIFA ................................. 20

ILEVRO ............................. 115

ILUMYA .............................. 64

imatinib ................................. 20

IMBRUVICA ....................... 20


139

imipenem-cilastatin .............. 12

imipramine hcl...................... 46

imipramine pamoate ............. 46

imiquimod ............................ 65

IMIQUIMOD ....................... 65

IMITREX ............................. 31

IMITREX STATDOSE PEN 31

IMITREX STATDOSE

REFILL ............................ 31

IMOVAX RABIES VACCINE

(PF) ................................. 101

IMPOYZ............................... 73

IMURAN .............................. 20

IMVEXXY MAINTENANCE

PACK ............................. 107

IMVEXXY STARTER PACK

........................................ 107

INBRIJA............................... 29

incassia ............................... 107

INCRELEX .......................... 75

INCRUSE ELLIPTA.......... 121

indapamide ........................... 55

INDERAL LA ...................... 55

INDOCIN ............................. 40

INFANRIX (DTAP) (PF)... 101

INFLECTRA ........................ 92

INGREZZA .......................... 33

INGREZZA INITIATION

PACK ............................... 33

INLYTA ............................... 20

INNOPRAN XL ................... 56

INREBIC .............................. 20

INSPRA ................................ 56

INSULIN LISPRO ............... 82

INSULIN PEN NEEDLE ..... 82

INSULIN SYRINGE (DISP)

U-100 ................................ 82

INTELENCE ...................... 4, 5

intralipid ............................. 129

INTRALIPID ..................... 129

INTRAROSA ..................... 108

INTRON A ........................... 98

introvale .............................. 110

INVANZ............................... 12

INVEGA............................... 46

INVEGA SUSTENNA ......... 46

INVEGA TRINZA ............... 46

INVELTYS ........................ 117

INVIRASE ............................. 5

INVOKAMET ................ 82, 83

INVOKAMET XR ............... 83

INVOKANA ........................ 83

IONOSOL-MB IN D5W .... 129

IOPIDINE ........................... 118

IPOL ................................... 101

ipratropium bromide ..... 77, 121

ipratropium-albuterol.......... 121

irbesartan .............................. 56

irbesartan-hydrochlorothiazide

.......................................... 56

IRESSA ................................ 20

ISENTRESS ........................... 5

ISENTRESS HD .................... 5

isibloom .............................. 110

ISOLYTE-P IN 5 %

DEXTROSE ................... 129

ISOLYTE-S ........................ 129

isoniazid................................ 12

ISOPTO CARPINE ............ 115

ISORDIL .............................. 63

ISORDIL TITRADOSE ....... 63

isosorbide dinitrate ............... 63

isosorbide mononitrate ......... 63

isotretinoin ............................ 67

isradipine .............................. 56

ISTALOL ........................... 114

itraconazole ............................ 2

ivermectin ............................. 12

IXIARO (PF) ...................... 101

J JADENU .............................. 75

JADENU SPRINKLE .......... 75

JAKAFI ................................ 20

JALYN ............................... 126

jantoven ................................ 60

JANUMET ........................... 83

JANUMET XR ..................... 83

JANUVIA ............................. 83

JARDIANCE ........................ 83

jasmiel (28) ......................... 110

JENTADUETO .................... 83

JENTADUETO XR .............. 83

jinteli ................................... 107

JUBLIA ................................ 69

juleber ................................. 110

JULUCA ................................. 5

junel 1.5/30 (21) ................. 110

junel 1/20 (21) .................... 110

junel fe 1.5/30 (28) ............. 110

junel fe 1/20 (28) ................ 110

junel fe 24 ........................... 110

JUXTAPID ........................... 61

JYNARQUE ......................... 87

K KADIAN .............................. 36

kaitlib fe .............................. 110

KALBITOR ........................ 121

KALETRA ............................. 5

KALYDECO .............. 121, 122

KAPSPARGO SPRINKLE .. 56

KAPVAY ............................. 46

kariva (28) .......................... 110

KAZANO ............................. 83

kelnor 1/35 (28) .................. 110

kelnor 1-50 .......................... 110

KENALOG ........................... 73

KEPPRA ............................... 26

KEPPRA XR ........................ 26

KERYDIN ............................ 69

ketoconazole ..................... 2, 69

ketoprofen ............................. 40

ketorolac ............................. 115

KEVEYIS ............................. 33

KEVZARA ................. 104, 105

KHEDEZLA ......................... 46

KINERET ........................... 105

KINRIX (PF) ...................... 101

kionex (with sorbitol) ........... 76

KISQALI .............................. 20

KISQALI FEMARA CO-

PACK ............................... 20

KITABIS PAK ..................... 12

KLARON ............................. 68

KLONOPIN .......................... 26

klor-con ............................... 127

klor-con 10 .......................... 126

klor-con 8 ............................ 126

klor-con m10 ...................... 126

klor-con m15 ...................... 126

klor-con m20 ...................... 126

klor-con sprinkle ................. 127

KOMBIGLYZE XR ............. 83

KORLYM ............................. 87

KRINTAFEL ........................ 12

KRISTALOSE ...................... 92

k-tab .................................... 127

K-TAB ................................ 127

kurvelo (28) ........................ 110

KUVAN ................................ 87

L l norgest/e.estradiol-e.estrad

........................................ 110

labetalol ................................ 56


140

LACRISERT ...................... 115

lactulose ................................ 92

LAMICTAL ......................... 26

LAMICTAL ODT ................ 26

LAMICTAL STARTER

(BLUE) KIT ..................... 26

LAMICTAL STARTER

(GREEN) KIT .................. 26

LAMICTAL STARTER

(ORANGE) KIT ............... 26

LAMICTAL XR ................... 26

LAMICTAL XR STARTER

(BLUE) ............................. 26

LAMICTAL XR STARTER

(GREEN) .......................... 26

LAMICTAL XR STARTER

(ORANGE)....................... 26

lamivudine .............................. 5

lamivudine-zidovudine ........... 5

lamotrigine ..................... 26, 27

LANOXIN ............................ 63

lansoprazole .......................... 95

lanthanum ............................. 76

LANTUS SOLOSTAR U-100

INSULIN .......................... 83

LANTUS U-100 INSULIN .. 83

larin 1.5/30 (21) .................. 110

larin 1/20 (21) ..................... 110

larin fe 1.5/30 (28) .............. 110

larin fe 1/20 (28) ................. 110

larissia................................. 110

LASIX .................................. 56

LASTACAFT ..................... 115

latanoprost .......................... 116

LATUDA ............................. 46

layolis fe ............................. 110

LAZANDA..................... 36, 37

LEDIPASVIR-SOFOSBUVIR

............................................ 5

leena 28 .............................. 110

leflunomide......................... 105

LENVIMA ........................... 20

LESCOL XL ........................ 61

lessina ................................. 110

LETAIRIS .......................... 122

letrozole ................................ 20

leucovorin calcium ............... 18

LEUKERAN ........................ 20

LEUKINE............................. 98

leuprolide .............................. 20

levalbuterol hcl ................... 122

LEVALBUTEROL

TARTRATE ................... 122

LEVAQUIN ......................... 16

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 83

LEVEMIR U-100 INSULIN 83

levetiracetam ........................ 27

levobunolol ......................... 114

levocarnitine ......................... 76

levocarnitine (with sugar) ..... 76

levocetirizine ...................... 119

levofloxacin .................. 16, 113

levofloxacin in d5w .............. 16

levonest (28) ....................... 110

levonorgestrel-ethinyl estrad

........................................ 110

levonorg-eth estrad triphasic

........................................ 110

levora-28 ............................. 110

levorphanol tartrate............... 37

LEVORPHANOL

TARTRATE ..................... 37

LEVO-T................................ 89

levothyroxine ........................ 89

levoxyl .................................. 89

LEXAPRO............................ 47

LEXETTE ............................ 73

LEXIVA ................................. 5

LIALDA ............................... 92

lidocaine ............................... 65

lidocaine hcl ......................... 65

lidocaine viscous .................. 65

lidocaine-prilocaine .............. 65

LIDODERM ......................... 65

lindane .................................. 74

linezolid ................................ 12

linezolid in dextrose 5% ....... 12

LINZESS .............................. 92

liothyronine .......................... 89

LIPITOR ............................... 61

LIPOFEN.............................. 61

lisinopril................................ 56

lisinopril-hydrochlorothiazide

.......................................... 56

lithium carbonate .................. 47

lithium citrate ....................... 47

LITHOBID ........................... 47

LITHOSTAT ........................ 76

LIVALO ............................... 61

LO LOESTRIN FE ............. 110

LOCOID ............................... 73

LOCOID LIPOCREAM ....... 73

LODINE ............................... 40

LODOSYN ........................... 29

LOESTRIN 1.5/30 (21) ...... 110

LOESTRIN 1/20 (21) ......... 110

LOESTRIN FE 1.5/30 (28-

DAY) .............................. 111

LOESTRIN FE 1/20 (28-DAY)

........................................ 111

LOKELMA ........................... 76

LOMOTIL ............................ 90

LONHALA MAGNAIR

REFILL ........................... 122

LONHALA MAGNAIR

STARTER ...................... 122

LONSURF ............................ 20

loperamide ............................ 90

LOPID .................................. 62

lopinavir-ritonavir ................... 5

lopreeza ............................... 107

LOPRESSOR ....................... 56

LOPRESSOR HCT .............. 56

LOPROX .............................. 69

LOPROX (AS OLAMINE) .. 69

lorazepam ............................. 47

LORBRENA ......................... 20

lorcet (hydrocodone) ............ 37

lorcet hd ................................ 37

lorcet plus ............................. 37

loryna (28) .......................... 111

losartan ................................. 56

losartan-hydrochlorothiazide 56

LOSEASONIQUE .............. 111

LOTEMAX ......................... 118

LOTEMAX SM .................. 118

LOTENSIN ........................... 56

loteprednol etabonate .......... 118

LOTREL ............................... 56

LOTRISONE ........................ 69

LOTRONEX ......................... 92

lovastatin ............................... 62

LOVAZA .............................. 62

LOVENOX ........................... 60

low-ogestrel (28) ................ 111

loxapine succinate ................ 47

LUCEMYRA ........................ 40

LULICONAZOLE ............... 69

LUMIGAN ......................... 116

LUNESTA ............................ 47

LUPANETA PACK (1

MONTH) ........................ 108


141

LUPANETA PACK (3

MONTH) ........................ 108

LUPRON DEPOT ................ 21

LUPRON DEPOT (3

MONTH) .......................... 21

LUPRON DEPOT (4

MONTH) .......................... 21

LUPRON DEPOT (6

MONTH) .......................... 21

lutera (28) ........................... 111

LUXIQ ................................. 73

LUZU ................................... 69

LYNPARZA......................... 21

LYRICA ............................... 27

LYRICA CR ......................... 27

LYSODREN......................... 21

LYSTEDA .......................... 108

lyza ..................................... 107

M MACROBID ........................ 17

MACRODANTIN ................ 17

mafenide acetate ................... 68

magnesium sulfate .............. 127

MALARONE ....................... 12

MALARONE PEDIATRIC . 12

malathion .............................. 74

maprotiline ........................... 47

MARINOL ........................... 92

marlissa (28) ....................... 111

MARPLAN .......................... 47

MATULANE ....................... 21

matzim la .............................. 56

MAVENCLAD (10 TABLET

PACK) .............................. 33

MAVENCLAD (4 TABLET

PACK) .............................. 33

MAVENCLAD (5 TABLET

PACK) .............................. 33

MAVENCLAD (6 TABLET

PACK) .............................. 33

MAVENCLAD (7 TABLET

PACK) .............................. 33

MAVENCLAD (8 TABLET

PACK) .............................. 33

MAVENCLAD (9 TABLET

PACK) .............................. 33

MAVYRET ............................ 5

MAXALT ............................. 31

MAXALT-MLT ................... 31

MAXIDEX ......................... 118

MAXIPIME ............................ 9

MAXITROL ............... 116, 117

MAXZIDE............................ 56

MAXZIDE-25MG ................ 56

MAYZENT .......................... 33

meclizine .............................. 92

meclofenamate...................... 40

MEDROL ............................. 78

MEDROL (PAK) ................. 78

medroxyprogesterone ......... 107

mefenamic acid..................... 40

mefloquine ............................ 12

megestrol .............................. 21

MEKINIST ........................... 21

MEKTOVI............................ 21

melodetta 24 fe ................... 111

meloxicam ............................ 40

memantine ............................ 33

MEMANTINE...................... 33

MENACTRA (PF) ............. 101

MENEST ............................ 107

MENOSTAR ...................... 107

MENTAX ............................. 69

MENVEO A-C-Y-W-135-DIP

(PF) ................................. 101

MEPRON ............................. 12

mercaptopurine ..................... 21

meropenem ........................... 12

MERREM ............................. 12

mesalamine ........................... 92

MESNEX.............................. 18

MESTINON ......................... 34

MESTINON TIMESPAN .... 34

metadate er ........................... 47

metaproterenol .................... 122

metformin ....................... 83, 84

methadone ............................ 37

methamphetamine ................ 47

methazolamide.................... 116

methenamine hippurate ........ 17

methimazole ......................... 79

METHITEST ........................ 87

methotrexate sodium ............ 21

methotrexate sodium (pf) ..... 21

methoxsalen .......................... 65

methscopolamine .................. 90

methyldopa ........................... 56

METHYLIN ......................... 47

methylphenidate hcl ............. 47

METHYLPHENIDATE HCL

.......................................... 47

methylprednisolone .............. 78

methyltestosterone ................ 87

metoclopramide hcl .............. 92

metolazone ............................ 56

metoprolol succinate ............. 56

metoprolol tartrate ................ 56

metoprolol tartrate-


METROCREAM .................. 68

METROGEL ........................ 68

METROLOTION ................. 68

metronidazole ......... 12, 68, 108

metronidazole in nacl (iso-

osm) .................................. 12

mexiletine ............................. 52

mibelas 24 fe ....................... 111

MICARDIS ........................... 56

MICARDIS HCT .................. 56

miconazole-3 ...................... 108

MICORT-HC ........................ 92

microgestin 1.5/30 (21) ...... 111

microgestin 1/20 (21) ......... 111

microgestin fe 1.5/30 (28) .. 111

microgestin fe 1/20 (28) ..... 111

midodrine .............................. 76

migergot ................................ 31

miglitol ................................. 84

miglustat ............................... 88

MIGRANAL ......................... 31

mili ...................................... 111

millipred ............................... 78

mimvey ............................... 107

mimvey lo ........................... 107

MINASTRIN 24 FE ........... 111

MINIPRESS ......................... 56

MINITRAN .......................... 63

MINIVELLE ...................... 107

MINOCIN ............................. 17

minocycline .......................... 17

MINOCYCLINE .................. 17

MINOLIRA ER .................... 17

minoxidil ............................... 56

MIRAPEX ............................ 29

MIRAPEX ER ...................... 29

mirtazapine ........................... 47

MIRVASO ............................ 68

misoprostol ........................... 95

MITIGARE ......................... 102

M-M-R II (PF) .................... 101

MOBIC ................................. 40

modafinil ............................... 47

moexipril ............................... 56


142

molindone ............................. 47

mometasone .................. 73, 122

mondoxyne nl ....................... 17

montelukast ........................ 122

MONUROL .......................... 18

morgidox .............................. 17

MORPHABOND ER ........... 37

morphine............................... 37

morphine concentrate ........... 37

MOTEGRITY ...................... 92

MOVANTIK ........................ 92

MOVIPREP .......................... 92

MOXEZA ........................... 113

moxifloxacin................. 16, 113

moxifloxacin-sod.chloride(iso)

.......................................... 16

MS CONTIN ........................ 37

MULPLETA......................... 60

MULTAQ ............................. 52

mupirocin ............................. 69

mupirocin calcium ................ 68

MYALEPT ........................... 88

MYAMBUTOL .................... 12

MYCAMINE .......................... 2

MYCOBUTIN ...................... 12

mycophenolate mofetil ......... 21

mycophenolate sodium ......... 21

MYDAYIS ........................... 47

MYFORTIC ......................... 21

myorisan ............................... 68

MYRBETRIQ .................... 125

MYSOLINE ......................... 27

MYTESI ............................... 90

N nabumetone .......................... 40

nadolol .................................. 56

nadolol-bendroflumethiazide 57

nafcillin................................. 14

naftifine ................................ 69

NAFTIN ............................... 70

NALFON .............................. 40

naloxone ............................... 40

naltrexone ............................. 40

NAMENDA ......................... 33

NAMENDA TITRATION

PAK .................................. 33

NAMENDA XR ................... 33

NAMZARIC................... 33, 34

NAPRELAN CR .................. 40

naproxen ............................... 40

naproxen sodium .................. 40

naratriptan ............................. 31

NARCAN ............................. 40

NARDIL ............................... 47

NASONEX ......................... 122

NATACYN ........................ 113

NATAZIA .......................... 111

nateglinide ............................ 84

NATPARA ........................... 88

NATROBA ........................... 74

NEBUPENT ......................... 12

necon 0.5/35 (28) ................ 111

NEEDLES, INSULIN

DISP.,SAFETY ................ 84

nefazodone............................ 48

neomycin .............................. 12

neomycin-bacitracin-poly-hc

........................................ 117

neomycin-bacitracin-

polymyxin ....................... 113

neomycin-polymyxin b-

dexameth ........................ 117

neomycin-polymyxin-

gramicidin ....................... 113

neomycin-polymyxin-hc ..... 78,

117

NEORAL .............................. 21

NEO-SYNALAR.................. 69

NEPHRAMINE 5.4 % ....... 129

NERLYNX ........................... 21

NESINA ............................... 84

neuac ..................................... 68

NEULASTA ......................... 98

NEUPOGEN ........................ 98

NEUPRO .............................. 29

NEURONTIN ....................... 27

NEVANAC ........................ 116

nevirapine ............................... 5

NEXAVAR .......................... 21

NEXIUM .............................. 95

NEXIUM PACKET ............. 95

niacin .................................... 62

NIACOR ............................... 62

NIASPAN EXTENDED-

RELEASE ........................ 62

nicardipine ............................ 57

NICOTROL .......................... 77

NICOTROL NS .................... 77

nifedipine .............................. 57

nikki (28) ............................ 111

NILANDRON ...................... 21

nilutamide ............................. 21

nimodipine ............................ 57

NINLARO ...................... 21, 22

nisoldipine ............................ 57

nitro-bid ................................ 63

NITRO-DUR ........................ 63

nitrofurantoin ........................ 18

nitrofurantoin macrocrystal .. 18

nitrofurantoin monohyd/m-

cryst .................................. 18

nitroglycerin ................... 63, 64

NITROSTAT ........................ 64

NITYR .................................. 76

NIVESTYM ......................... 98

nizatidine .............................. 95

NIZORAL ............................. 70

NOCDURNA (MEN) ........... 88

NOCDURNA (WOMEN) .... 88

NOCTIVA ............................ 88

nolix ...................................... 73

nora-be ................................ 107

NORCO ................................ 37

NORDITROPIN FLEXPRO 98

noreth-ethinyl estradiol-iron

........................................ 111

norethindrone (contraceptive)

........................................ 107

norethindrone acetate .......... 107

norethindrone ac-eth estradiol

................................ 107, 111

norethindrone-e.estradiol-iron

........................................ 111

norgestimate-ethinyl estradiol

........................................ 111

NORITATE .......................... 68

norlyroc ............................... 107

NORMOSOL-M IN 5 %

DEXTROSE ................... 129

NORMOSOL-R IN 5 %

DEXTROSE ................... 127

NORMOSOL-R PH 7.4 ...... 129

NORPRAMIN ...................... 48

NORTHERA ........................ 76

nortrel 0.5/35 (28) ............... 111

nortrel 1/35 (21) .................. 111

nortrel 1/35 (28) .................. 111

nortrel 7/7/7 (28) ................. 111

nortriptyline .......................... 48

NORVASC ........................... 57

NORVIR ................................. 5

NOURIANZ ......................... 29

NOVOFINE 32 ..................... 84


143

NOVOLIN 70/30 U-100

INSULIN .......................... 84

NOVOLIN N NPH U-100

INSULIN .......................... 84

NOVOLIN R REGULAR U-

100 INSULN .................... 84

NOVOLOG FLEXPEN U-100

INSULIN .......................... 84

NOVOLOG MIX 70-30 U-100

INSULN ........................... 84

NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 84

NOVOLOG PENFILL U-100

INSULIN .......................... 84

NOVOLOG U-100 INSULIN

ASPART........................... 84

NOXAFIL .............................. 2

NUBEQA ............................. 22

NUCALA ........................... 122

NUCYNTA .......................... 41

NUCYNTA ER .................... 40

NUEDEXTA ........................ 34

NULYTELY WITH FLAVOR

PACKS ............................. 92

NUPLAZID .......................... 48

NUTRILIPID ..................... 129

NUTROPIN AQ NUSPIN ... 98

NUVARING....................... 108

NUVIGIL ............................. 48

NUZYRA ............................. 17

NUZYRA (7 DAY WITH

LOAD DOSE) .................. 17

NUZYRA (7 DAY) .............. 17

nyamyc ................................. 70

NYMALIZE ......................... 57

nystatin ......................... 2, 3, 70

nystatin-triamcinolone .......... 70

nystop ................................... 70

O OCALIVA ............................ 92

ocella .................................. 111

OCTAGAM ........................ 101

octreotide acetate .................. 22

OCUFLOX ......................... 113

ODEFSEY .............................. 5

ODOMZO ............................ 22

OFEV ................................. 122

ofloxacin ................. 16, 78, 113

ogestrel (28)........................ 111

olanzapine............................. 48

olanzapine-fluoxetine ........... 48

olmesartan ............................ 57

olmesartan-amlodipine-


olmesartan-


olopatadine ................... 77, 115

OLUMIANT ....................... 105

OLUX ................................... 73

OLUX-E ............................... 73

OMECLAMOX-PAK .......... 96

omega-3 acid ethyl esters ..... 62

omeprazole ........................... 96

omeprazole-sodium

bicarbonate ....................... 96

OMNARIS.......................... 122

OMNIPOD DASH INSULIN

POD .................................. 84

OMNIPOD INSULIN

MANAGEMENT ............. 84

OMNIPOD INSULIN REFILL

.......................................... 84

OMNITROPE ....................... 98

ondansetron .......................... 92

ondansetron hcl..................... 92

ONEXTON ........................... 68

ONFI ..................................... 27

ONGLYZA ........................... 85

ONZETRA XSAIL............... 31

OPANA ................................ 37

OPSUMIT .......................... 122

ORACEA.............................. 17

ORALAIR .......................... 101

ORAPRED ODT .................. 78

ORAVIG ................................ 3

ORENCIA .......................... 105

ORENCIA (WITH

MALTOSE) .................... 105

ORENCIA CLICKJECT .... 105

ORENITRAM ...................... 57

ORFADIN ............................ 76

ORILISSA ............................ 88

ORKAMBI ......................... 122

orsythia ............................... 111

ORTHO MICRONOR ........ 107

ORTHO TRI-CYCLEN LO

(28) ................................. 111

ORTHO-NOVUM 1/35 (28)

........................................ 112

ORTHO-NOVUM 7/7/7 (28)

........................................ 112

oseltamivir .............................. 5

OSENI .................................. 85

OSMOLEX ER ..................... 29

OSMOPREP ......................... 93

OSPHENA .......................... 108

OTEZLA ............................. 105

OTEZLA STARTER .......... 105

OTOVEL .............................. 78

OTREXUP (PF) .................. 105

OVIDE .................................. 74

oxacillin ................................ 15

oxacillin in dextrose(iso-osm)

.................................... 14, 15

oxandrolone .......................... 88

oxaprozin .............................. 41

OXAYDO ............................. 37

oxcarbazepine ....................... 27

OXERVATE ....................... 115

oxiconazole ........................... 70

OXISTAT ............................. 70

OXSORALEN ULTRA ........ 65

OXTELLAR XR .................. 27

oxybutynin chloride ............ 125

oxycodone ............................. 37

OXYCODONE ..................... 38

oxycodone-acetaminophen ... 38

oxycodone-aspirin ................ 38

OXYCONTIN ...................... 38

oxymorphone ........................ 38

OXYTROL ......................... 125

OZEMPIC ............................. 85

P pacerone ................................ 52

paliperidone .......................... 48

PALYNZIQ .......................... 88

PAMELOR ........................... 48

PANCREAZE ....................... 93

PANDEL .............................. 73

PANRETIN .......................... 65

pantoprazole ......................... 96

PANZYGA ......................... 101

paricalcitol ............................ 88

PARLODEL ................... 29, 30

PARNATE ............................ 48

paromomycin ........................ 12

paroxetine hcl ....................... 48

paroxetine

mesylate(menop.sym) ....... 48

PASER .................................. 12

PATADAY ......................... 115

PATANASE ......................... 77

PATANOL ......................... 115


144

PAXIL .................................. 48

PAXIL CR ............................ 48

PAZEO ............................... 115

PEDIARIX (PF) ................. 101

PEDVAX HIB (PF) ............ 101

peg 3350-electrolytes ........... 93

PEGANONE ........................ 27

PEGASYS ............................ 98

PEGASYS PROCLICK ....... 98

peg-electrolyte ...................... 93

penicillamine ...................... 105

PENICILLIN G POT IN

DEXTROSE ..................... 15

penicillin g potassium........... 15

penicillin g procaine ............. 15

penicillin g sodium ............... 15

penicillin v potassium........... 15

PENNSAID .......................... 41

PENTAM ............................. 12

PENTASA ............................ 93

pentoxifylline ....................... 60

PEPCID ................................ 96

PERCOCET ......................... 38

PERFOROMIST ................ 122

perindopril erbumine ............ 57

permethrin ............................ 74

perphenazine......................... 48

PERSERIS ............................ 48

PERTZYE ............................ 93

PEXEVA .............................. 48

phenelzine............................. 48

phenobarbital ........................ 27

phenoxybenzamine ............... 57

PHENYTEK ......................... 27

phenytoin .............................. 27

phenytoin sodium extended .. 27

PHOSLYRA ....................... 127

PHOSPHOLINE IODIDE .. 115

PICATO ............................... 65

PIFELTRO ............................. 5

pilocarpine hcl .............. 76, 115

pimecrolimus ........................ 65

pimozide ............................... 48

pimtrea (28) ........................ 112

pindolol................................. 57

pioglitazone .......................... 85

pioglitazone-glimepiride ...... 85

pioglitazone-metformin ........ 85

piperacillin-tazobactam ........ 15

PIQRAY ............................... 22

pirmella............................... 112

piroxicam .............................. 41

PLAQUENIL........................ 12

PLASMA-LYTE 148 ......... 129

PLASMA-LYTE A ............ 129

PLAVIX ............................... 60

PLEGRIDY .................... 98, 99

plenamine ........................... 129

PLENVU .............................. 93

PLIAGLIS ............................ 65

podofilox .............................. 65

polymyxin b sulfate .............. 12

polymyxin b sulf-trimethoprim

........................................ 113

POLYTRIM........................ 113

POMALYST ........................ 22

portia 28 .............................. 112

posaconazole .......................... 3

potassium chlorid-d5-

0.45%nacl ....................... 127

potassium chloride .............. 127

potassium chloride in 0.9%nacl

........................................ 127

potassium chloride in 5 % dex

........................................ 127

potassium chloride in lr-d5 . 127

potassium chloride in water 127

potassium chloride-0.45 % nacl

........................................ 127

potassium chloride-d5-

0.2%nacl ......................... 127


0.3%nacl ......................... 127


0.9%nacl ................. 127, 128

potassium citrate ................. 126

PRADAXA ........................... 60

PRALUENT PEN................. 62

pramipexole .......................... 30

PRANDIN ............................ 85

prasugrel ............................... 60

PRAVACHOL...................... 62

pravastatin ............................ 62

praziquantel .......................... 12

prazosin ................................ 57

PRECOSE ............................ 85

PRED FORTE .................... 118

PRED MILD....................... 118

PRED-G.............................. 117

PRED-G S.O.P. .................. 117

prednicarbate ........................ 73

prednisolone ......................... 78

prednisolone acetate ........... 118

prednisolone sodium phosphate

.................................. 79, 118

prednisone ............................. 79

prednisone intensol ............... 79

PREFEST ........................... 107

pregabalin ............................. 28

PREMARIN ............... 107, 108

premasol 10 % .................... 129

PREMASOL 6 % ............... 129

PREMPHASE ..................... 108

PREMPRO ......................... 108

prenatal vitamin oral tablet . 130

PREPOPIK ........................... 93

PREVACID .......................... 96

PREVACID SOLUTAB ....... 96

prevalite ................................ 62

previfem .............................. 112

PREVYMIS ............................ 5

PREZCOBIX .......................... 5

PREZISTA ......................... 5, 6

PRIFTIN ............................... 12

PRILOSEC ........................... 96

PRIMAQUINE ..................... 13

PRIMAXIN IV ..................... 13

primidone .............................. 28

PRIMLEV ............................. 38

PRINIVIL ............................. 57

PRISTIQ ............................... 49

PRIVIGEN ......................... 101

PROAIR HFA .................... 122

PROAIR RESPICLICK ...... 122

probenecid .......................... 102

probenecid-colchicine ......... 102

PROCALAMINE 3% ......... 129

PROCARDIA XL ................. 57

procentra ............................... 49

prochlorperazine ................... 93

prochlorperazine maleate oral

.......................................... 93

PROCRIT ............................. 99

procto-med hc ....................... 93

procto-pak ............................. 93

proctosol hc .......................... 93

proctozone-hc ....................... 93

progesterone micronized .... 108

PROGLYCEM ..................... 85

PROGRAF ............................ 22

PROLASTIN-C .................... 76

PROLENSA ....................... 116

PROLIA .............................. 103


145

PROMACTA ........................ 60

promethazine ...................... 119

PROMETRIUM ................. 108

propafenone .......................... 52

propranolol ........................... 57

propranolol-


propylthiouracil .................... 79

PROQUAD (PF) ................ 101

PROSCAR .......................... 126

PROSOL 20 % ................... 129

PROTONIX .......................... 96

PROTOPIC........................... 66

protriptyline .......................... 49

PROVENTIL HFA ............. 122

PROVERA ......................... 108

PROVIGIL ........................... 49

PROZAC .............................. 49

prudoxin ............................... 66

PSORCON ........................... 73

PULMICORT ..................... 123

PULMICORT FLEXHALER

................................ 122, 123

PULMOZYME................... 123

PURIXAN ............................ 22

PYLERA .............................. 96

pyrazinamide ........................ 13

pyridostigmine bromide ....... 34

PYRIDOSTIGMINE

BROMIDE ....................... 34

Q QBRELIS ............................. 57

QBREXZA ........................... 66

QMIIZ ODT ......................... 41

QNASL............................... 123

QTERN................................. 85

QUADRACEL (PF) ........... 101

QUALAQUIN ...................... 13

QUARTETTE .................... 112

QUDEXY XR ...................... 28

QUESTRAN......................... 62

QUESTRAN LIGHT............ 62

quetiapine ............................. 49

QUILLICHEW ER ............... 49

QUILLIVANT XR ............... 49

quinapril ............................... 57

quinapril-hydrochlorothiazide

.......................................... 57

quinidine gluconate .............. 52

quinidine sulfate ................... 52

quinine sulfate ...................... 13

QVAR REDIHALER ......... 123

R RABAVERT (PF) .............. 101

rabeprazole ........................... 96

RAGWITEK ....................... 101

raloxifene ............................ 103

ramelteon .............................. 49

ramipril ................................. 57

RANEXA ............................. 63

ranitidine hcl ......................... 96

ranolazine ............................. 63

RAPAFLO .......................... 126

RAPAMUNE........................ 22

rasagiline .............................. 30

RASUVO (PF) ................... 105

RAVICTI .............................. 76

RAYALDEE ........................ 88

RAYOS ................................ 79

RAZADYNE ........................ 34

RAZADYNE ER .................. 34

REBIF (WITH ALBUMIN) . 99

REBIF REBIDOSE .............. 99

REBIF TITRATION PACK . 99

reclipsen (28) ...................... 112

RECOMBIVAX HB (PF) .. 101

RECTIV................................ 93

REGLAN .............................. 93

REGRANEX ........................ 66

RELENZA DISKHALER ...... 6

RELEXXII............................ 49

RELISTOR ........................... 93

RELPAX .............................. 31

REMERON .......................... 49

REMERON SOLTAB .......... 49

REMICADE ......................... 93

RENAGEL ........................... 76

RENVELA ........................... 76

repaglinide ............................ 85

repaglinide-metformin .......... 85

REPATHA............................ 62

REPATHA PUSHTRONEX 62

REPATHA SURECLICK .... 62

REQUIP XL ......................... 30

RESCRIPTOR ........................ 6

RESTASIS.......................... 115

RESTASIS MULTIDOSE . 115

RETACRIT .......................... 99

RETIN-A .............................. 68

RETIN-A MICRO ................ 68

RETROVIR ............................ 6

REVATIO .......................... 123

REVLIMID ........................... 22

REXULTI ............................. 49

REYATAZ ............................. 6

RHOFADE ........................... 68

RHOPRESSA ..................... 116

ribavirin .................................. 6

RIDAURA .......................... 105

rifabutin ................................ 13

RIFADIN .............................. 13

RIFAMATE .......................... 13

rifampin ................................ 13

RIFATER ............................. 13

RILUTEK ............................. 76

riluzole .................................. 76

rimantadine ............................. 6

RINVOQ ER ...................... 105

RIOMET ............................... 85

risedronate .................... 76, 103

RISPERDAL ........................ 49

RISPERDAL CONSTA ....... 49

risperidone ...................... 49, 50

RITALIN .............................. 50

RITALIN LA ........................ 50

ritonavir .................................. 6

rivastigmine .......................... 34

rivastigmine tartrate .............. 34

rivelsa ................................. 112

rizatriptan .............................. 31

ROCALTROL ...................... 88

ROCKLATAN ................... 116

ropinirole .............................. 30

rosuvastatin ........................... 62

ROTARIX .......................... 102

ROTATEQ VACCINE ....... 102

ROWASA ............................. 93

roweepra ............................... 28

roweepra xr ........................... 28

ROXICODONE .................... 38

ROZEREM ........................... 50

ROZLYTREK ...................... 22

RUBRACA ........................... 22

RUCONEST ....................... 123

RUZURGI ............................ 34

RYDAPT .............................. 22

RYTARY .............................. 30

RYTHMOL SR .................... 52

S SABRIL ................................ 28

SAFYRAL .......................... 112

SAIZEN ................................ 99

SAIZEN SAIZENPREP ....... 99


146

SALAGEN (PILOCARPINE)

.......................................... 76

SAMSCA ............................. 88

SANCUSO ........................... 94

SANDIMMUNE .................. 22

SANDOSTATIN .................. 22

SANTYL .............................. 66

SAPHRIS ............................. 50

SARAFEM ........................... 50

SAVAYSA ........................... 60

SAVELLA .......................... 105

scopolamine base.................. 94

SEASONIQUE ................... 112

SEEBRI NEOHALER........ 123

SEGLUROMET ................... 85

selegiline hcl ......................... 30

selenium sulfide.................... 64

SELZENTRY ......................... 6

SEMPREX-D ..................... 119

SENSIPAR ........................... 88

SEREVENT DISKUS ........ 123

SERNIVO............................. 73

SEROQUEL ......................... 50

SEROQUEL XR .................. 50

SEROSTIM .......................... 99

sertraline ............................... 50

setlakin ............................... 112

sevelamer carbonate ............. 76

sevelamer hcl ........................ 76

sharobel .............................. 108

SHINGRIX (PF) ................. 102

SIGNIFOR ........................... 22

SIKLOS ................................ 22

sildenafil (pulmonary arterial

hypertension) .................. 123

SILENOR ............................. 50

SILIQ .................................... 64

silodosin ............................. 126

SILVADENE ....................... 66

silver sulfadiazine ................. 66

SIMBRINZA ...................... 116

SIMPONI ........................... 105

simvastatin ............................ 62

SINEMET............................. 30

SINEMET CR ...................... 30

SINGULAIR ...................... 123

sirolimus ............................... 22

SIRTURO ............................. 13

SITAVIG ................................ 6

SIVEXTRO .......................... 13

SKLICE ................................ 74

SKYRIZI .............................. 64

SLYND ............................... 112

sodium chloride .................... 76

sodium chloride 0.45 % ...... 128

sodium chloride 0.9 % .......... 76

sodium chloride 3 % ........... 128

sodium chloride 5 % ........... 128

sodium lactate intravenous . 128

sodium phenylbutyrate ......... 76

sodium polystyrene sulfonate

.......................................... 76

SOFOSBUVIR-

VELPATASVIR ................. 6

solifenacin .......................... 125

SOLIQUA 100/33 ................ 85

SOLODYN ........................... 17

SOLOSEC ............................ 13

SOLTAMOX ........................ 22

SOMATULINE DEPOT ...... 22

SOMAVERT ........................ 88

SOOLANTRA ...................... 68

SORIATANE ....................... 64

SORILUX ............................. 64

sorine .................................... 52

sotalol ................................... 52

sotalol af ............................... 52

SOTYLIZE ........................... 52

SOVALDI .............................. 6

SPIRIVA RESPIMAT ........ 123

SPIRIVA WITH

HANDIHALER .............. 123

spironolactone ...................... 57

spironolactone-


SPORANOX .......................... 3

sprintec (28) ........................ 112

SPRITAM ............................. 28

SPRIX ................................... 41

SPRYCEL ...................... 22, 23

sps (with sorbitol) ................. 76

sronyx ................................. 112

ssd ......................................... 66

STALEVO 100 ..................... 30

STALEVO 125 ..................... 30

STALEVO 150 ..................... 30

STALEVO 200 ..................... 30

STALEVO 50 ....................... 30

STALEVO 75 ....................... 30

STARLIX ............................. 85

stavudine ................................. 6

STEGLATRO ....................... 85

STEGLUJAN ....................... 85

STELARA ............................ 64

STIMATE ............................. 88

STIOLTO RESPIMAT ....... 123

STIVARGA .......................... 23

STRATTERA ....................... 50

STREPTOMYCIN ............... 13

STRIANT ............................. 88

STRIBILD .............................. 6

STRIVERDI RESPIMAT .. 123

STROMECTOL ................... 13

SUBOXONE ........................ 41

SUBSYS ............................... 38

SUCRAID ............................. 94

sucralfate ............................... 97

SULAR ................................. 57

sulfacetamide sodium ......... 115

sulfacetamide sodium (acne) 69

sulfacetamide-prednisolone 115

sulfadiazine ........................... 16

sulfamethoxazole-trimethoprim

.......................................... 16

SULFAMYLON ................... 69

sulfasalazine ......................... 94

sulindac ................................. 41

sumatriptan ........................... 31

sumatriptan succinate ..... 31, 32

sumatriptan-naproxen ........... 32

SUNOSI ................................ 50

SUPRAX ................................ 9

SUPREP BOWEL PREP KIT

.......................................... 94

SUSTIVA ............................... 6

SUTENT ............................... 23

syeda ................................... 112

SYLATRON ......................... 99

SYMBICORT ..................... 123

SYMBYAX .......................... 50

SYMDEKO ........................ 123

SYMFI .................................... 6

SYMFI LO .............................. 6

SYMJEPI ............................ 119

SYMLINPEN 120 ................ 85

SYMLINPEN 60 .................. 85

SYMPAZAN ........................ 28

SYMPROIC .......................... 94

SYMTUZA ............................. 6

SYNALAR ........................... 73

SYNAREL ............................ 88

SYNDROS ........................... 94

SYNJARDY ................... 85, 86


147

SYNJARDY XR .................. 86

SYNRIBO ............................ 23

SYNTHROID ....................... 89

SYPRINE ............................. 76

T TABLOID ............................ 23

TACLONEX ........................ 64

tacrolimus ....................... 23, 66

tadalafil ............................... 126

tadalafil (pulm. hypertension)

........................................ 124

TAFINLAR .......................... 23

TAGRISSO .......................... 23

TAKHZYRO ...................... 124

TALTZ AUTOINJECTOR .. 64

TALTZ SYRINGE ............... 64

TALZENNA......................... 23

TAMIFLU .............................. 6

tamoxifen .............................. 23

tamsulosin........................... 126

TAPAZOLE ......................... 79

TAPERDEX ......................... 79

TARCEVA ........................... 23

TARGADOX ....................... 17

TARGRETIN ....................... 23

tarina 24 fe .......................... 112

tarina fe 1/20 (28) ............... 112

TARKA ................................ 58

TASIGNA ............................ 23

TASMAR ............................. 30

TAVALISSE ........................ 60

tazarotene ............................. 68

tazicef ..................................... 9

TAZORAC ........................... 68

taztia xt ................................. 58

TDVAX .............................. 102

TECFIDERA ........................ 34

TECHLITE INSULIN SYR

HALF UNIT ..................... 86

TECHLITE INSULIN

SYRINGE......................... 86

TEFLARO .............................. 9

TEGRETOL ......................... 28

TEGRETOL XR ................... 28

TEGSEDI ............................. 34

TEKTURNA ........................ 58

TEKTURNA HCT ............... 58

telmisartan ............................ 58

telmisartan-amlodipine ......... 58

telmisartan-


TEMIXYS .............................. 6

TENIVAC (PF) .................. 102

tenofovir disoproxil fumarate . 6

TENORETIC 100 ................. 58

TENORETIC 50 ................... 58

TENORMIN ......................... 58

terazosin................................ 58

terbinafine hcl ......................... 3

terbutaline ........................... 124

terconazole.......................... 108

TESTIM................................ 88

testosterone ..................... 88, 89

testosterone cypionate .......... 88

testosterone enanthate........... 88

TETANUS,DIPHTHERIA

TOX PED(PF) ................ 102

tetrabenazine ......................... 34

tetracycline ........................... 17

TEXACORT ......................... 73

THALOMID ......................... 23

THEO-24 ............................ 124

theophylline ........................ 124

THIOLA ............................... 77

THIOLA EC ......................... 76

thioridazine ........................... 50

thiothixene ............................ 50

tiagabine ............................... 28

TIAZAC ............................... 58

TIBSOVO ............................. 23

tigecycline ............................ 13

TIGLUTIK ........................... 77

TIKOSYN ............................ 52

timolol maleate ............. 58, 114

TIMOPTIC OCUDOSE (PF)

........................................ 114

TIMOPTIC-XE .................. 114

tinidazole .............................. 13

TIROSINT ............................ 89

TIROSINT-SOL ................... 89

TIVICAY................................ 6

TIVORBEX .......................... 41

tizanidine .............................. 34

TOBI ..................................... 13

TOBI PODHALER .............. 13

TOBRADEX ...................... 117

TOBRADEX ST................. 117

tobramycin .......................... 113

tobramycin in 0.225 % nacl .. 13

tobramycin sulfate ................ 13

tobramycin-dexamethasone 117

TOBREX .................... 113, 114

TOFRANIL .......................... 50

TOLAK ................................. 66

tolbutamide ........................... 86

tolcapone ............................... 30

tolmetin ................................. 41

TOLSURA .............................. 3

tolterodine ........................... 125

TOPAMAX .......................... 28

TOPICORT ........................... 73

topiramate ............................. 28

TOPIRAMATE .................... 28

TOPROL XL ........................ 58

toremifene ............................. 23

torsemide .............................. 58

TOSYMRA ........................... 32

TOUJEO MAX U-300

SOLOSTAR ..................... 86

TOUJEO SOLOSTAR U-300

INSULIN .......................... 86

TOVIAZ ............................. 125

TPN ELECTROLYTES ..... 128

TRACLEER ....................... 124

TRADJENTA ....................... 86

tramadol ................................ 41

TRAMADOL ....................... 41

tramadol-acetaminophen ...... 41

trandolapril ........................... 58

trandolapril-verapamil .......... 58

tranexamic acid ................... 108

TRANSDERM-SCOP .......... 94

TRANXENE T-TAB ............ 50

tranylcypromine .................... 50

travasol 10 % ...................... 129

TRAVATAN Z ................... 116

trazodone .............................. 50

TRECATOR ......................... 13

TRELEGY ELLIPTA ......... 124

TRELSTAR .......................... 23

TREMFYA ........................... 64

TRESIBA FLEXTOUCH U-

100 .................................... 86

TRESIBA FLEXTOUCH U-

200 .................................... 86

TRESIBA U-100 INSULIN . 86

tretinoin (chemotherapy) ...... 23

tretinoin microspheres .......... 68

tretinoin topical ..................... 68

TREXALL ............................ 23

TREXIMET .......................... 32

TREZIX ................................ 38

triamcinolone acetonide .. 73, 77


148

triamterene ............................ 58

triamterene-


trianex ................................... 73

TRIBENZOR ....................... 58

TRICOR ............................... 62

triderm .................................. 74

TRIDESILON ...................... 74

trientine................................. 77

tri-estarylla ......................... 112

trifluoperazine ...................... 50

trifluridine........................... 114

TRIGLIDE ........................... 62

tri-legest fe.......................... 112

TRILEPTAL......................... 28

TRILIPIX ............................. 62

tri-lo-estarylla ..................... 112

tri-lo-sprintec ...................... 112

trilyte with flavor packets ..... 94

trimethoprim ......................... 18

tri-mili................................. 112

trimipramine ......................... 50

TRINTELLIX....................... 50

tri-previfem (28) ................. 112

tri-sprintec (28) ................... 112

TRIUMEQ .............................. 6

trivora (28).......................... 112

tri-vylibra ............................ 112

tri-vylibra lo........................ 112

TRIZIVIR ............................... 6

TROKENDI XR ................... 28

TROPHAMINE 10 % ........ 129

TROPHAMINE 6% ........... 129

trospium .............................. 125

TRULANCE......................... 94

TRULICITY ......................... 86

TRUMENBA ..................... 102

TRUSOPT .......................... 116

TRUVADA ............................ 7

TUDORZA PRESSAIR ..... 124

TURALIO ............................ 23

TWINRIX (PF) .................. 102

TWYNSTA .......................... 58

TYBOST ................................ 7

tydemy ................................ 112

TYGACIL ............................ 13

TYKERB .............................. 23

TYLENOL-CODEINE #3.... 38

TYLENOL-CODEINE #4.... 38

TYMLOS ........................... 103

TYPHIM VI ....................... 102

U UCERIS ................................ 94

UDENYCA .......................... 99

ULORIC ............................. 102

ULTRACET ......................... 41

ULTRAM ............................. 41

ULTRAVATE ...................... 74

UNASYN ............................. 15

unithroid ............................... 89

UPTRAVI ............................. 58

URECHOLINE .................. 126

UROCIT-K 10 .................... 126

UROCIT-K 15 .................... 126

UROCIT-K 5 ...................... 126

UROXATRAL ................... 126

URSO 250 ............................ 94

URSO FORTE ...................... 94

ursodiol ................................. 94

UTIBRON NEOHALER .... 124

V VABOMERE........................ 13

VAGIFEM .......................... 108

valacyclovir ............................ 7

VALCHLOR ........................ 66

VALCYTE ............................. 7

valganciclovir ......................... 7

VALIUM .............................. 50

valproic acid ......................... 28

valproic acid (as sodium salt)

.......................................... 28

valsartan................................ 58

valsartan-hydrochlorothiazide

.......................................... 58

VALTREX ............................. 7

VANCOCIN ......................... 13

vancomycin .................... 13, 14

VANCOMYCIN .................. 13

vandazole ............................ 108

VANOS ................................ 74

VAQTA (PF) ...................... 102

VARIVAX (PF) ................. 102

VARIZIG............................ 102

VARUBI ............................... 94

VASCEPA ............................ 62

VASERETIC ........................ 58

VASOTEC............................ 58

VECAMYL .......................... 63

VECTICAL .......................... 64

velivet triphasic regimen (28)

........................................ 112

VELPHORO ......................... 77

VELTASSA .......................... 77

VEMLIDY .............................. 7

VENCLEXTA ...................... 23

VENCLEXTA STARTING

PACK ............................... 23

venlafaxine ..................... 50, 51

VENLAFAXINE .................. 51

VENTAVIS ........................ 124

VENTOLIN HFA ............... 124

verapamil ........................ 58, 59

VEREGEN ........................... 66

VERELAN ........................... 59

VERELAN PM ..................... 59

VERSACLOZ ....................... 51

VERZENIO .......................... 23

VESICARE ......................... 125

VFEND ................................... 3

VFEND IV .............................. 3

V-GO 20 ............................... 86

V-GO 30 ............................... 86

V-GO 40 ............................... 86

VIBERZI .............................. 94

VIBRAMYCIN .................... 17

vicodin es .............................. 38

vicodin hp ............................. 38

VICTOZA 3-PAK ................ 86

VIDEX 2 GRAM PEDIATRIC

............................................ 7

VIDEX EC .............................. 7

VIEKIRA PAK ....................... 7

vienva ................................. 112

vigabatrin .............................. 28

vigadrone .............................. 28

VIGAMOX ......................... 114

VIIBRYD ............................. 51

VIMOVO .............................. 41

VIMPAT ............................... 29

VIOKACE ............................ 94

VIRACEPT ............................. 7

VIRAMUNE ........................... 7

VIRAMUNE XR .................... 7

VIREAD ................................. 7

VITRAKVI ........................... 23

VIVELLE-DOT .................. 108

VIVITROL ........................... 41

VIVLODEX ......................... 41

VIZIMPRO ........................... 23

VOGELXO ........................... 89

VOLTAREN ......................... 41

voriconazole ........................... 3

VOSEVI ................................. 7


149

VOTRIENT .......................... 23

VRAYLAR........................... 51

vyfemla (28) ....................... 112

vylibra................................. 112

VYNDAQEL ........................ 63

VYTORIN 10-10.................. 62

VYTORIN 10-20.................. 62

VYTORIN 10-40.................. 62

VYTORIN 10-80.................. 62

VYVANSE ........................... 51

VYZULTA ......................... 116

W warfarin ................................ 60

WELCHOL .......................... 62

WELLBUTRIN SR .............. 51

WELLBUTRIN XL.............. 51

WIXELA INHUB .............. 124

wymzya fe .......................... 113

X XALATAN......................... 116

XALKORI ............................ 24

XARELTO ........................... 60

XATMEP ............................. 24

XELJANZ .......................... 105

XELJANZ XR .................... 105

XELPROS .......................... 116

XENAZINE .......................... 34

XENLETA ........................... 14

XEPI ..................................... 69

XERESE ............................... 70

XERMELO........................... 24

XGEVA ................................ 18

XHANCE ........................... 124

XIFAXAN ............................ 14

XIGDUO XR........................ 86

XIIDRA .............................. 115

XIMINO ............................... 17

XOFLUZA ............................. 7

XOLAIR ............................. 124

XOPENEX ......................... 124

XOPENEX CONCENTRATE

........................................ 124

XOPENEX HFA ................ 124

XOSPATA ........................... 24

XPOVIO ............................... 24

XTAMPZA ER .................... 38

XTANDI ............................... 24

xulane ................................. 108

XULTOPHY 100/3.6 ........... 86

XURIDEN ............................ 77

XYOSTED ........................... 89

XYREM................................ 51

Y YASMIN (28)..................... 113

YAZ (28) ............................ 113

YF-VAX (PF) ..................... 102

YONSA ................................ 24

YOSPRALA ......................... 60

YUPELRI ........................... 124

yuvafem .............................. 108

Z zafirlukast ........................... 125

zaleplon ................................ 51

ZANAFLEX ................... 34, 35

zarah ................................... 113

ZARONTIN.......................... 29

ZARXIO ............................... 99

ZAVESCA............................ 89

ZEGERID ............................. 97

ZEJULA ............................... 24

ZELAPAR ............................ 30

ZELBORAF ......................... 24

ZELNORM ........................... 94

ZEMAIRA ............................ 77

ZEMBRACE SYMTOUCH . 32

ZEMPLAR ........................... 89

zenatane ................................ 68

ZENPEP ............................... 94

zenzedi .................................. 51

ZENZEDI ............................. 51

ZEPATIER ............................. 7

ZERBAXA ............................. 9

ZESTORETIC ...................... 59

ZESTRIL .............................. 59

ZETIA .................................. 63

ZETONNA ......................... 125

ZIAC ..................................... 59

ZIAGEN ................................. 7

ZIANA.................................. 68

zidovudine .............................. 7

zileuton ............................... 125

ZIOPTAN (PF) ................... 116

ziprasidone hcl ...................... 51

ZIPSOR ................................ 42

ZIRGAN ............................. 114

ZITHROMAX ...................... 10

ZITHROMAX TRI-PAK ..... 10

ZITHROMAX Z-PAK ......... 10

ZOCOR ................................. 63

ZOFRAN .............................. 94

ZOHYDRO ER .................... 38

ZOLINZA ............................. 24

zolmitriptan ........................... 32

ZOLOFT ............................... 51

zolpidem ............................... 51

ZOMACTON ....................... 99

ZOMIG ................................. 32

ZOMIG ZMT ........................ 32

ZONALON ........................... 66

ZONEGRAN ........................ 29

zonisamide ............................ 29

ZONTIVITY ......................... 60

ZORBTIVE .......................... 99

ZORTRESS .......................... 24

ZORVOLEX ......................... 42

ZOSTAVAX (PF) .............. 102

ZOSYN ................................. 15

ZOSYN IN DEXTROSE (ISO-

OSM) ................................ 15

zovia 1/35e (28) .................. 113

ZOVIRAX ........................ 7, 70

ZTLIDO ................................ 66

ZUBSOLV ............................ 42

ZUPLENZ ............................ 94

ZYCLARA ........................... 66

ZYDELIG ............................. 24

ZYFLO ............................... 125

ZYKADIA ............................ 24

ZYLET ............................... 117

ZYLOPRIM ........................ 102

ZYMAXID ......................... 114

ZYPITAMAG ....................... 63

ZYPREXA ............................ 51

ZYPREXA RELPREVV ...... 51

ZYPREXA ZYDIS ............... 52

ZYTIGA ............................... 24

ZYVOX ................................ 14

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