2018 comprehensive formulary

Pennsylvania Public School Employees’ Retirement System (PSERS)

Health Options Program

Comprehensive Prescription Drug Formulary (List of Covered Drugs)

2018FOR THE ENHANCED, BASIC AND VALUE MEDICARE Rx OPTIONSPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS.

This formulary is effective as of July 1, 2018. For more recent information or other questions, please contact OptumRx at 1-888-239-1301, 24 hours a day, 7 days a week. TTY users should call 1-800-498-5428. You can also visit www.HOPbenefits.com.

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means the Health Options Program, which is sponsored by the Pennsylvania Public School Employees’ Retirement System. When it refers to “plan” or “our plan,” it means the Enhanced, Basic or Value Medicare Rx Option.

This document includes a list of the drugs (formulary) for our plans which is current as of July 1, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

What is the Formulary?A formulary is a list of drugs selected for the Enhanced, Basic and Value Medicare Rx Options 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. The Enhanced, Basic and Value Medicare Rx Options will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, and other Plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Please note that this formulary covers the Enhanced, Basic and Value Medicare Rx Options only. If you have coverage through a Medicare Advantage plan through the Health Options Program, you will have to contact the Medicare Advantage plan directly for a copy of the formulary for your prescription drug plan.

CMS CONTRACT NUMBER: E3014

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Can the formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of July 1, 2018. To get updated information about the drugs covered by the Enhanced, Basic and Value Medicare Rx Options, please contact us. Our contact information appears on the front and back cover pages. In the event of midyear formulary changes, a revised Comprehensive Formulary will be posted to www.HOPbenefits.com.

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

• Medical Condition The formulary begins on page 1. 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 Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

• Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 80. 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? The Enhanced, Basic and Value Medicare Rx Options cover both brand-name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

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

• Prior Authorization (PA): The Enhanced, Basic and Value Medicare Rx Options require you (or your physician) to get prior authorization for certain drugs. This means

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that you will need to get approval from the Enhanced, Basic or Value Medicare Rx Option before you fill your prescriptions. If you don’t get approval, the Enhanced, Basic or Value Medicare Rx Option may not cover the drug.

• Quantity Limits (QL): For certain drugs, the Enhanced, Basic and Value Medicare Rx Options limit the amount of the drug that will be covered. For example, the Enhanced, Basic and Value Medicare Rx Options cover 30 pills per 30 days for Crestor. If your prescription is for more, OptumRx will contact your doctor to determine whether more than one per day will be covered.

• Step Therapy (ST): In some cases, the Enhanced, Basic and Value Medicare Rx Options require 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, the Enhanced, Basic and Value Medicare Rx Options may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask the Enhanced, Basic or Value Medicare Option 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 the Enhanced, Basic and Value Medicare Rx Options formulary?” to the right 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 OptumRx and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you learn that the Enhanced, Basic and Value Medicare Rx Options do not cover your drug, you have two options:

• You can ask OptumRx for a list of similar drugs that are covered by the Enhanced, Basic and Value Medicare Rx Options. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan.

• You can ask your plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Enhanced, Basic and Value Medicare Rx Options formulary?You can ask your plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the Enhanced, Basic and Value Medicare Rx Options limit the amount of drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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Generally, the Enhanced, Basic or Value Medicare Rx Option 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 for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or prescribing physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’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 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

For those members who were in the plan last year, we will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a 31-day supply or less if your prescription is written for fewer days.

This transition policy applies to drugs that are covered under the Enhanced, Basic or Value Medicare Rx Option and filled at a network pharmacy.

For More InformationFor more detailed information about the Enhanced, Basic and Value Medicare Rx Options, please review your Evidence of Coverage and other plan materials. If you have questions about the Enhanced, Basic and Value Medicare Rx Options, please contact us. Our contact information, along with the date we last updated the

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formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or visit https://www.medicare.gov.

Medicare-Excluded Drugs Covered under the Enhanced Medicare Rx Option OnlyCertain Medicare-excluded drugs are covered under the Enhanced Medicare Rx Option, but not the Basic or Value Medicare Rx Options. A list of these drugs can be found beginning on page 110.

How to Read the FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by the Enhanced, Basic and Value Medicare Rx Options.

If you have trouble finding your drug in the list, turn to the Index that begins on page 80.

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

The information in the Requirements/Limits column tells you if the Enhanced, Basic and Value Medicare Options have any special requirements for coverage of your drug.

WHAT THE ABBREVIATIONS MEAN

B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This 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.

NDS: Non-Extended Day Supply. This prescription drug is not available for an extended day supply under the Enhanced, Basic or Value Medicare Rx Option.

PA: Prior Authorization. You or your physician need to get approval from the Enhanced, Basic or Value Medicare Rx Option before you fill this prescription. If you don’t get approval, the Enhanced, Basic or Value Medicare Rx Option may not cover the drug. See page ii for more information.

QL: Quantity Limit. The Enhanced, Basic and Value Medicare Rx Options limit the amount of this drug that will be covered. See page iii for more information.

ST: Step Therapy. The Enhanced, Basic and Value Medicare Rx Options require you to first try another drug to treat your medical condition before we will cover this one for that condition. See page iii for more information.

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2018 Comprehensive Prescription Drug Formulary

DEDUCTIBLE• You must pay Medicare’s annual deductible of

$405 before the Value Medicare Rx Option pays any portion of your prescription drug costs.

• The Enhanced and Basic Medicare Rx Options pay Medicare’s annual deductible for you.

GENERIC DRUGS (TIER 1)• In Initial Coverage, if you are enrolled in the

Enhanced Medicare Rx Option, you’ll pay a maximum of $7 for up to a 30-day supply (and $21 for a 31- to 90-day supply).

• In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you’ll pay a maximum of $8 for up to a 30-day supply (and $24 for a 31- to 90-day supply).

• In Initial Coverage, if you are enrolled in the Value Medicare Rx Option, you’ll pay 25% of the cost after you satisfy Medicare’s annual deductible.

• In the Coverage Gap, if you are enrolled in the Enhanced Medicare Rx Option, you’ll pay 25% of the cost.

• In the Coverage Gap, if you are enrolled in the Basic Medicare Rx Option, you’ll pay 44% of the cost.

• In the Coverage Gap, if you are enrolled in the Value Medicare Rx Option, you’ll pay 44% of the cost.

PREFERRED BRAND-NAME DRUGS (TIER 2)• In Initial Coverage, if you are enrolled in the

Enhanced Medicare Rx Option, you’ll pay 25% to a maximum of $75 for up to a 30-day supply and $150 ($140 if you use mail order) for a 31- to 90-day supply.

• In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you’ll pay 30% of the cost to a maximum of $100 for up to a 30-day supply and $250 ($225 if you use mail order) for a 31- to 90-day supply.


• In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, you’ll pay 35% of the cost.

NON-PREFERRED BRAND-NAME DRUGS (TIER 3)• In Initial Coverage, if you are enrolled in the

Enhanced Medicare Rx Option, you’ll pay 35% of the cost to a maximum of $100 for up to a 30-day supply and $200 ($190 if you use mail order) for a 31- to 90-day supply.

• In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you’ll pay 40% of the cost.


• In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, you’ll pay 35% of the cost.

SPECIALTY DRUGS (TIER 4)• In Initial Coverage, if you are enrolled in the

Enhanced or Basic Medicare Rx Option, you pay 33% of the cost.


• In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, your cost for a Specialty generic drug is the same as your cost for any other generic drug, and your cost for a Specialty brand-name drug is the same as your cost for any other brand-name drug.

• Specialty drugs are limited to a 30-day supply.

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Drug Name

Drug

Tier Requirements/Limits

Analgesics

Nonsteroidal Anti-inflammatory Drugs

ARTHROTEC 50 3 ST

ARTHROTEC 75 TBEC 3 ST

CAMBIA 2

CELEBREX 3 QL (60 EA per 30 days)

celecoxib caps 1 QL (60 EA per 30 days)

DAYPRO 3 ST

diclofenac potassium 1

diclofenac sodium dr 1

diclofenac sodium er 1

diclofenac sodium/misoprostol 1

diclofenac sodium gel 3% 1

diflunisal tabs 500mg 1

DUEXIS 4 QL (90 EA per 30 days) ST NDS

EC-NAPROSYN TBEC 375MG 3

etodolac er 1

etodolac caps, tabs 1

FELDENE 3 ST

fenoprofen calcium caps 400mg 1

fenoprofen calcium tabs 1

FLECTOR 2 QL (60 EA per 30 days) PA

flurbiprofen tabs 1

ibuprofen susp 1

ibuprofen tabs 400mg, 600mg, 800mg 1

ibu tabs 600mg, 800mg 1

INDOCIN SUSP 2

indomethacin er 1

indomethacin caps 1

ketoprofen er cp24 200mg 1

ketoprofen caps 50mg, 75mg 1

ketorolac tromethamine inj 15mg/ml, 30mg/ml 1 PA

ketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PA

LODINE TABS 400MG 4 ST NDS

meclofenamate sodium caps 1

mefenamic acid caps 1

meloxicam tabs 1

MOBIC TABS 3 ST

nabumetone tabs 1

NAPRELAN TB24 750MG 2 ST

NAPRELAN TB24 375MG, 500MG 4 ST NDS

naproxen dr 1

naproxen sodium er tb24 375mg 1

naproxen sodium tb24 1

naproxen sodium tabs 275mg, 550mg 1

naproxen susp, tabs 1

oxaprozin 1

piroxicam caps 1

profeno 1

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Drug Name

Drug


SOLARAZE 4 NDS

sulindac tabs 1

TIVORBEX 2

tolmetin sodium caps 1

tolmetin sodium tabs 600mg 1

VIMOVO 4 QL (60 EA per 30 days) PA NDS

VIVLODEX 2

ZIPSOR 4 ST NDS

ZORVOLEX 2 ST

Opioid Analgesics, Long-acting

BELBUCA 2

BUPRENEX 4 NDS

buprenorphine hcl inj 0.3mg/ml 1

BUPRENORPHINE PTWK 10MCG/HR, 15MCG/HR,

20MCG/HR, 5MCG/HR

2 QL (4 EA per 28 days)

BUTRANS 2 QL (4 EA per 28 days)

DOLOPHINE TABS 3

DURAGESIC PT72 12MCG/HR, 25MCG/HR 3

DURAGESIC PT72 100MCG/HR, 50MCG/HR, 75MCG/HR 4 NDS

EMBEDA CPCR 20MG; 0.8MG, 30MG; 1.2MG, 50MG;

2MG, 60MG; 2.4MG

2

EMBEDA CPCR 100MG; 4MG, 80MG; 3.2MG 4 NDS

EXALGO T24A 12MG, 8MG 3

EXALGO T24A 16MG, 32MG 4 NDS

fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 37.5mcg/hr,

50mcg/hr, 62.5mcg/hr, 75mcg/hr

1

fentanyl pt72 87.5mcg/hr 4 NDS

hydromorphone hcl er t24a 12mg, 16mg, 8mg 1

hydromorphone hydrochloride er 4 NDS

HYSINGLA ER T24A 20MG, 30MG, 40MG, 60MG 2 PA

HYSINGLA ER T24A 100MG, 120MG, 80MG 4 PA NDS

KADIAN CP24 40MG 2 ST

KADIAN CP24 10MG, 20MG, 30MG 3 ST

KADIAN CP24 100MG, 200MG, 50MG, 60MG, 80MG 4 ST NDS

levorphanol tartrate tabs 4 NDS

methadone hcl inj, oral soln, tabs 1

morphine sulfate er cp24 10mg, 120mg, 20mg, 30mg, 45mg,

50mg, 60mg, 75mg, 80mg, 90mg

1

morphine sulfate er cp24 100mg 4 NDS

morphine sulfate er tbcr 1

MS CONTIN TBCR 15MG, 30MG 3

MS CONTIN TBCR 100MG, 200MG, 60MG 4 NDS

NUCYNTA ER TB12 100MG, 150MG, 50MG 2

NUCYNTA ER TB12 200MG, 250MG 4 NDS

OXYCODONE HCL ER T12A 10MG, 15MG, 20MG, 30MG,

40MG

2 ST

OXYCODONE HCL ER T12A 60MG, 80MG 4 ST NDS

OXYCONTIN T12A 10MG, 15MG, 20MG, 30MG, 40MG 2 ST

OXYCONTIN T12A 60MG, 80MG 4 ST NDS

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Drug Name

Drug


oxymorphone hydrochloride er 1

tramadol hcl er tb24 1

XTAMPZA ER 2 ST

ZOHYDRO ER C12A 2 PA

Opioid Analgesics, Short-acting

ABSTRAL 4 PA NDS

acetaminophen/codeine 1

ACTIQ 4 PA NDS

ascomp/codeine 1

butalbital/acetaminophen/caffeine/codeine 1

butalbital/aspirin/caffeine/codeine 1

butorphanol tartrate 1

carisoprodol/aspirin/codeine 1 PA

codeine sulfate tabs 1

DEMEROL INJ 25MG/ML, 50MG/ML 3 PA

DEMEROL TABS 100MG 3 PA

DILAUDID LIQD 3

DILAUDID TABS 2MG, 4MG, 8MG 3

duramorph 1

endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg 1 PA

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg,

600mcg, 800mcg

4 PA NDS

FENTORA TABS 100MCG, 200MCG, 400MCG, 600MCG,

800MCG

4 PA NDS

FIORICET/CODEINE CAPS 300MG; 50MG; 40MG; 30MG 3

FIORINAL/CODEINE #3 4 NDS

HYCET 3

hydrocodone bitartrate/acetaminophen soln 325mg/15ml;

7.5mg/15ml

1

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,

300mg; 5mg, 300mg; 7.5mg, 325mg; 2.5mg

1

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg,

325mg; 7.5mg

1

hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg,

7.5mg; 200mg

1

hydromorphone hcl liqd, tabs 1

hydromorphone hcl inj 10mg/ml, 2mg/ml, 50mg/5ml 1

ibudone tabs 10mg; 200mg 1

LAZANDA 4 PA NDS

lorcet 1

lorcet hd 1

lorcet plus tabs 325mg; 7.5mg 1

meperidine hcl oral soln, tabs 1 PA

meperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml 1 PA

morphine sulfate oral soln, tabs 1

morphine sulfate inj 5mg/ml 1

morphine sulfate inj 10mg/ml, 2mg/ml, 4mg/ml, 8mg/ml 1 B/D

nalbuphine hcl inj 10mg/ml, 20mg/ml 1

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Drug Name

Drug


NORCO 3

NUCYNTA 3

OPANA TABS 5MG 3

OPANA TABS 10MG 4 NDS

oxycodone hcl caps, conc, soln, tabs 1

oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg,

325mg; 5mg, 325mg; 7.5mg

1

oxycodone/aspirin tabs 325mg; 4.835mg 1

oxycodone/ibuprofen 1

oxymorphone hydrochloride 1

panlor tabs 1

pentazocine/naloxone hcl 1

PERCOCET TABS 325MG; 2.5MG 3

PERCOCET TABS 325MG; 10MG, 325MG; 5MG, 325MG;

7.5MG

4 NDS

PRIMLEV TABS 300MG; 5MG, 300MG; 7.5MG 2

PRIMLEV TABS 300MG; 10MG 4 NDS

ROXICODONE TABS 15MG, 5MG 3

ROXICODONE TABS 30MG 4 NDS

SUBSYS LIQD 100MCG, 200MCG, 400MCG, 600MCG,

800MCG

4 PA NDS

tramadol hcl tabs 1

tramadol hydrochloride/acetaminophen 1

trezix caps 320.5mg; 30mg; 16mg 1 QL (300 EA per 30 days)

TYLENOL/CODEINE #3 3


ULTRACET 3

ULTRAM 3 ST

vicodin es tabs 300mg; 7.5mg 1

vicodin hp tabs 300mg; 10mg 1

vicodin tabs 300mg; 5mg 1

Anesthetics

Local Anesthetics

lidocaine hcl jelly 1

lidocaine hcl external soln 1

lidocaine hcl inj 0.5%, 1%, 2% 1

lidocaine viscous 1

lidocaine/prilocaine crea 1 QL (30 GM per 30 days)

lidocaine oint 1

lidocaine ptch 1 PA

LIDODERM 3 PA

PLIAGLIS 2

XYLOCAINE EXTERNAL SOLN 3

XYLOCAINE INJ 2% 3

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium dr 1

ANTABUSE 3

disulfiram tabs 1

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Drug Name

Drug


VIVITROL 4 NDS

Opioid Dependence Treatments

BUNAVAIL FILM 2.1MG; 0.3MG 2 QL (180 EA per 30 days)

BUNAVAIL FILM 6.3MG; 1MG 2 QL (60 EA per 30 days)

BUNAVAIL FILM 4.2MG; 0.7MG 2 QL (90 EA per 30 days)

buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 QL (360 EA per 30 days)

buprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 QL (90 EA per 30 days)

buprenorphine hcl subl 2mg, 8mg 1

naltrexone hcl tabs 1

SUBOXONE FILM 4MG; 1MG 2 QL (180 EA per 30 days)

SUBOXONE FILM 2MG; 0.5MG 2 QL (360 EA per 30 days)



ZUBSOLV SUBL 2.9MG; 0.71MG 2 QL (180 EA per 30 days)





Opioid Reversal Agents

EVZIO INJ 2MG/0.4ML 4 ST NDS

naloxone hcl inj 0.4mg/ml, 2mg/2ml 1

NARCAN LIQD 2

Smoking Cessation Agents

bupropion hcl sr tb12 150mg 1 QL (60 EA per 30 days)

CHANTIX CONTINUING MONTH PAK 2 QL (504 EA per 365 days)

CHANTIX STARTING MONTH PAK 2 QL (504 EA per 365 days)

CHANTIX TABS 0.5MG, 1MG 2 QL (504 EA per 365 days)

NICOTROL INHALER 2 QL (2688 EA per 365 days)

NICOTROL NS 2 QL (360 ML per 365 days)

ZYBAN 3 QL (60 EA per 30 days)

Antibacterials

Aminoglycosides

amikacin sulfate inj 500mg/2ml 1

gentak oint 1

gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%,

1.6mg/ml; 0.9%, 1mg/ml; 0.9%

1

gentamicin sulfate crea, oint, ophthalmic soln 1

gentamicin sulfate inj 40mg/ml 1

isotonic gentamicin inj 0.8mg/ml; 0.9% 1

neomycin sulfate 1

neomycin/polymyxin b sulfates 1

paromomycin sulfate 1

STREPTOMYCIN SULFATE INJ 1GM 2

tobramycin sulfate ophthalmic soln 1

tobramycin sulfate inj 10mg/ml, 80mg/2ml 1

TOBREX OINT 2

TOBREX SOLN 3

Antibacterials, Other

baciim 1

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Drug Name

Drug


bacitracin inj, oint 1

BACTROBAN NASAL 2

BACTROBAN CREA 3

chloramphenicol sodium succinate 1

CLEOCIN IN D5W 3

CLEOCIN PEDIATRIC GRANULES 3

CLEOCIN PHOSPHATE INJ 900MG/6ML 3

CLEOCIN-T 3

CLEOCIN SUPP 2

CLEOCIN CAPS, CREA 3

CLINDAGEL 2

clindamycin hcl caps 1

clindamycin palmitate hcl 1

clindamycin phosphate in d5w 1

clindamycin phosphate crea, foam, gel, lotn, external soln,

swab

1

clindamycin phosphate inj 300mg/2ml, 600mg/4ml,

900mg/6ml

1

CLINDESSE 2

colistimethate sodium 1

CORTISPORIN CREA, OINT 2

CUBICIN 4 NDS

DALVANCE 4 NDS

daptomycin 4 NDS

EVOCLIN 3

FLAGYL 3

FURADANTIN 4 QL (7200 ML per 365 days) NDS

HIPREX 3

LINCOCIN INJ 3

lincomycin hcl inj 1

linezolid susr 4 QL (1800 ML per 28 days) NDS

linezolid tabs 4 QL (56 EA per 28 days) NDS

linezolid inj 600mg/300ml 1

MACROBID 3 QL (180 EA per 365 days)

MACRODANTIN CAPS 25MG 3 QL (1440 EA per 365 days)



methenamine hippurate 1

METROCREAM 3

METROGEL-VAGINAL 3

METROGEL GEL 1% 3

METROLOTION 4 NDS

metronidazole in nacl 0.79% 1

metronidazole vaginal 1

metronidazole caps, crea, gel, lotn, tabs 1

MONUROL 2

mupirocin crea, oint 1

NEO-SYNALAR 2

neomycin/polymyxin/bacitracin/hydrocortisone 1

7

Drug Name

Drug


neomycin/polymyxin/hydrocortisone ophthalmic susp 1%;

3.5mg/ml; 10000unit/ml

1

nitrofurantoin macrocrystals caps 25mg 1 QL (1440 EA per 365 days)



nitrofurantoin monohydrate/macrocrystals 1 QL (180 EA per 365 days)

nitrofurantoin susp 1 QL (7200 ML per 365 days)

NORITATE 4 NDS

ORBACTIV 4 NDS

polymyxin b sulfate inj 1

SILVADENE 3

silver sulfadiazine crea 1

SIVEXTRO 4 QL (6 EA per 30 days) NDS

ssd 1

SULFAMYLON CREA 2

SULFAMYLON PACK 4 NDS

SYNERCID INJ 350MG; 150MG 4 NDS

TIGECYCLINE 4 NDS

trimethoprim tabs 1

TYGACIL 4 NDS

VANCOCIN HCL CAPS 4 NDS

vancomycin hcl caps 1

vancomycin hcl inj 1000mg, 10gm, 500mg 1

vandazole 1

XIFAXAN 4 PA NDS

ZYVOX SUSR 4 QL (1800 ML per 28 days) NDS

ZYVOX TABS 4 QL (56 EA per 28 days) NDS

ZYVOX INJ 600MG/300ML 4 NDS

Beta-lactam, Cephalosporins

AVYCAZ 4 NDS

CEFACLOR ER TB12 500MG 1

CEFACLOR CAPS 250MG 1

cefaclor caps 500mg 1

CEFACLOR SUSR 125MG/5ML, 375MG/5ML 2

cefaclor susr 250mg/5ml 1

cefadroxil caps, tabs 1

CEFADROXIL SUSR 500MG/5ML 1

cefadroxil susr 250mg/5ml 1

CEFAZOLIN SODIUM INJ 1GM 1

cefazolin sodium inj 10gm, 500mg 1

cefdinir 1

cefepime inj 1gm, 2gm 1

cefixime 1

cefotaxime sodium inj 1gm, 2gm, 500mg 1

cefotetan inj 1gm, 2gm 1

cefoxitin sodium inj 10gm, 1gm, 2gm 1

cefpodoxime proxetil 1

cefprozil 1

ceftazidime inj 1gm, 2gm, 6gm 1

8

Drug Name

Drug


CEFTIN SUSR 2

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg 1

cefuroxime axetil tabs 1

cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1

CEPHALEXIN CAPS 250MG 1

cephalexin caps 500mg, 750mg 1

cephalexin tabs 1

CEPHALEXIN SUSR 125MG/5ML 1

cephalexin susr 250mg/5ml 1

MAXIPIME INJ 1GM, 2GM 3

SUPRAX CAPS, CHEW 2

SUPRAX SUSR 100MG/5ML, 200MG/5ML 3

SUPRAX SUSR 500MG/5ML 4 NDS

tazicef inj 1gm, 2gm, 6gm 1

TEFLARO 4 NDS

ZERBAXA 4 NDS

Beta-lactam, Other

AZACTAM INJ 1GM, 2GM 2

aztreonam inj 1gm 1

DORIPENEM INJ 500MG 2

imipenem/cilastatin 1

INVANZ 2

meropenem 1

MERREM INJ 500MG 3

PRIMAXIN IV INJ 500MG; 500MG 3

VABOMERE 4 NDS

Beta-lactam, Penicillins

amoxicillin/clavulanate potassium 1

amoxicillin/clavulanate potassium er 1

amoxicillin chew 125mg, 250mg 1

amoxicillin caps, susr, tabs 1

ampicillin sodium inj 10gm, 125mg, 1gm 1

ampicillin-sulbactam 1

ampicillin caps 500mg 1

AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML 4 NDS

BACTOCILL IN DEXTROSE 2

BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML,

900000UNIT/2ML; 300000UNIT/2ML

2

BICILLIN L-A INJ 1200000UNIT/2ML,

2400000UNIT/4ML, 600000UNIT/ML

2

dicloxacillin sodium 1

nafcillin sodium inj 1gm 1

nafcillin sodium inj 10gm 4 NDS

oxacillin sodium inj 10gm, 2gm 1

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE INJ 0; 40000UNIT/ML, 0; 60000UNIT/ML

2

penicillin g potassium inj 20000000unit 1

penicillin g procaine 1

penicillin g sodium 4 NDS

9

Drug Name

Drug


penicillin v potassium 1

piperacillin sodium/ tazobactam sodium 1

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1

piperacillin/tazobactam inj 2gm; 0.25gm, 4gm; 0.5gm 1

UNASYN BULK PACK 3

UNASYN INJ 2GM; 1GM 3

ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%;

3GM/50ML; 0.375GM/50ML

2

ZOSYN INJ 36GM; 4.5GM 3

Macrolides

AZASITE 2

azithromycin pack, susr, tabs 1

azithromycin inj 500mg 1

clarithromycin er 1

clarithromycin susr, tabs 1

DIFICID 4 NDS

E.E.S. 400 TABS 3

E.E.S. GRANULES 2

ery 1

ERY-TAB 2

ERYGEL 3

ERYPED 200 2

ERYPED 400 4 NDS

ERYTHROCIN LACTOBIONATE INJ 500MG 2

ERYTHROCIN STEARATE TABS 250MG 2

erythromycin base 1

erythromycin ethylsuccinate susr, tabs 1

erythromycin cpep, gel, oint 1

erythromycin soln 2% 1

PCE 2

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZITHROMAX INJ, PACK, SUSR, TABS 3

Quinolones

AVELOX INJ 2

AVELOX TABS 3

BAXDELA 4 NDS

BESIVANCE 2

CETRAXAL 3 ST

CILOXAN OINT 2

CILOXAN SOLN 3

CIPRO I.V.-IN D5W INJ 400MG/200ML; 5% 3

CIPRO SUSR 2

ciprofloxacin er 1

ciprofloxacin hcl soln, tabs 1

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1

ciprofloxacin susr 1

ciprofloxacin inj 400mg/40ml 1

CIPRO TABS 250MG, 500MG 3

10

Drug Name

Drug


FLOXIN OTIC 3

gatifloxacin 1

LEVAQUIN TABS 500MG, 750MG 3

levofloxacin 1

levofloxacin in d5w inj 5%; 500mg/100ml, 5%; 750mg/150ml 1

MOXEZA 2

MOXIFLOXACIN HCL INJ 2

moxifloxacin hcl ophthalmic soln, tabs 1

OCUFLOX 3

ofloxacin ophthalmic soln, otic soln 1

ofloxacin tabs 300mg, 400mg 1

VIGAMOX 3

ZYMAXID 3

Sulfonamides

AVC CREA 2

BACTRIM DS 3

BACTRIM TABS 3

BLEPH-10 SOLN 3

KLARON 3

sodium sulfacetamide soln 1

sulfacetamide sodium lotn, oint 1

sulfadiazine tabs 1

sulfamethoxazole/trimethoprim 1

sulfamethoxazole/trimethoprim ds 1

Tetracyclines

demeclocycline hcl tabs 1

DORYX MPC 2

DORYX TBEC 50MG 3

DORYX TBEC 200MG 4 NDS

doxy 100 1

doxycycline hyclate dr 1

doxycycline hyclate caps 1

doxycycline hyclate tabs 100mg, 150mg, 20mg, 75mg 1

doxycycline monohydrate caps, tabs 1

doxycycline susr 1

MINOCIN INJ 4 NDS

MINOCIN CAPS 100MG, 50MG 4 NDS

minocycline hcl er 1

minocycline hcl caps, tabs 1

minocycline hydrochlorideer 4 NDS

morgidox 1x50mg 1

SOLODYN TB24 105MG, 115MG, 55MG, 65MG, 80MG 4 NDS

TARGADOX 2

tetracycline hydrochloride 1

VIBRAMYCIN SYRP 2

VIBRAMYCIN SUSR 3

VIBRAMYCIN CAPS 100MG 3

XIMINO 2

Anticonvulsants

11

Drug Name

Drug


Anticonvulsants, Other

APTIOM 4 NDS

BRIVIACT INJ 2

BRIVIACT ORAL SOLN, TABS 4 NDS

FYCOMPA SUSP 2

FYCOMPA TABS 2MG, 8MG 2

FYCOMPA TABS 10MG, 12MG, 4MG, 6MG 4 NDS

KEPPRA XR 4 NDS

KEPPRA SOLN 4 NDS

KEPPRA TABS 250MG 3

KEPPRA TABS 1000MG, 500MG, 750MG 4 NDS

levetiracetam er 1

levetiracetam inj, oral soln, tabs 1

roweepra 1

roweepra xr 1

SPRITAM 2

Calcium Channel Modifying Agents

CELONTIN CAPS 300MG 2

ethosuximide 1

LYRICA SOLN 2 QL (900 ML per 30 days)

LYRICA CAPS 300MG 2 QL (60 EA per 30 days)

LYRICA CAPS 100MG, 150MG, 200MG, 225MG, 25MG,

50MG, 75MG


ZARONTIN 3

ZONEGRAN CAPS 100MG, 25MG 4 NDS

zonisamide 1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam odt tbdp 2mg 1 QL (300 EA per 30 days)

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg 1 QL (90 EA per 30 days)

clonazepam tabs 1

DEPACON 3

DEPAKENE CAPS 3

DEPAKENE SOLN 4 NDS

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC GEL 2.5MG 3

divalproex sodium dr 1

divalproex sodium er 1

divalproex sodium csdr 1

gabapentin caps, soln 1

gabapentin tabs 600mg, 800mg 1

GABITRIL TABS 12MG, 16MG 2

GABITRIL TABS 2MG 3

GABITRIL TABS 4MG 4 NDS

KLONOPIN 3

MYSOLINE TABS 4 NDS

NEURONTIN CAPS, SOLN 3

12

Drug Name

Drug


NEURONTIN TABS 4 NDS

ONFI SUSP 4 NDS

ONFI TABS 10MG, 20MG 4 NDS

phenobarbital elix 1

phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg,

60mg, 64.8mg, 97.2mg

1

primidone tabs 1

SABRIL 4 PA NDS

tiagabine hydrochloride 1

valproate sodium inj 1

valproic acid caps, soln 1

vigabatrin 4 PA NDS

Glutamate Reducing Agents

felbamate tabs 1

felbamate susp 4 NDS

FELBATOL 4 NDS

LAMICTAL CHEWABLE DISPERSIBLE CHEW 5MG 3

LAMICTAL CHEWABLE DISPERSIBLE CHEW 25MG 4 NDS

LAMICTAL ODT TBDP 3

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 2

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT

TAKING VALPROATE

4 NDS

LAMICTAL STARTER/TAKING VALPROATE 2

LAMICTAL XR KIT 2

LAMICTAL XR TB24 4 NDS

LAMICTAL TABS 4 NDS

lamotrigine er 1

lamotrigine odt 1

lamotrigine starter kit/blue 1

lamotrigine starter kit/green 4 NDS

lamotrigine starter kit/orange 1

lamotrigine chew, tabs 1

QUDEXY XR CS24 100MG, 200MG, 25MG, 50MG 3 ST

QUDEXY XR CS24 150MG 4 ST NDS

TOPAMAX SPRINKLE CPSP 15MG 3

TOPAMAX SPRINKLE CPSP 25MG 4 NDS

TOPAMAX TABS 25MG 3

TOPAMAX TABS 100MG, 200MG, 50MG 4 NDS

topiramate er 1

topiramate cpsp, tabs 1

TROKENDI XR CP24 100MG, 25MG, 50MG 2

TROKENDI XR CP24 200MG 4 NDS

Sodium Channel Agents

BANZEL 4 NDS

carbamazepine er 1

carbamazepine chew, susp, tabs 1

CARBATROL 3

CEREBYX INJ 500MG PE/10ML 3

DILANTIN INFATABS 3

13

Drug Name

Drug


DILANTIN-125 3

DILANTIN CAPS 30MG 2

DILANTIN CAPS 100MG 3

epitol 1

fosphenytoin sodium inj 100mg pe/2ml 1

oxcarbazepine 1

OXTELLAR XR TB24 150MG, 300MG 2

OXTELLAR XR TB24 600MG 4 NDS

PEGANONE TABS 250MG 2

PHENYTEK 3

phenytoin sodium extended 1

phenytoin sodium inj 1

phenytoin chew, susp 1

TEGRETOL-XR 3

TEGRETOL SUSP, TABS 3

TRILEPTAL SUSP 4 NDS

TRILEPTAL TABS 150MG, 300MG 3

TRILEPTAL TABS 600MG 4 NDS

VIMPAT 2

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates tabs 1 PA

NAMZARIC CP24 10MG; 14MG, 10MG; 21MG, 10MG;

28MG, 10MG; 7MG


Cholinesterase Inhibitors

ARICEPT 3 ST

donepezil hcl 1

EXELON PT24 3 ST

galantamine hydrobromide er 1

galantamine hydrobromide soln, tabs 1

RAZADYNE ER 3 ST

RAZADYNE TABS 3 ST

rivastigmine tartrate 1

rivastigmine transdermal system 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl 1

memantine hcl titration pak 1

memantine hydrochloride er 1 QL (30 EA per 30 days)

memantine hydrochloride soln 1

NAMENDA TITRATION PAK 3

NAMENDA XR 2 QL (30 EA per 30 days)

NAMENDA XR TITRATION PACK 2 QL (56 EA per 365 days)

NAMENDA TABS 3

Antidepressants

Antidepressants, Other

APLENZIN 4 QL (30 EA per 30 days) ST NDS

bupropion hcl sr tb12 100mg, 150mg, 200mg 1 QL (90 EA per 30 days)

bupropion hcl xl tb24 300mg 1 QL (30 EA per 30 days)

bupropion hcl xl tb24 150mg 1 QL (90 EA per 30 days)

14

Drug Name

Drug


bupropion hcl tabs 1

FORFIVO XL 2 QL (30 EA per 30 days) ST

mirtazapine odt 1

mirtazapine tabs 1

REMERON 3 ST

REMERON SOLTAB 3 ST

WELLBUTRIN SR 3 QL (90 EA per 30 days) ST

WELLBUTRIN XL TB24 300MG 4 QL (30 EA per 30 days) ST NDS

WELLBUTRIN XL TB24 150MG 4 QL (90 EA per 30 days) ST NDS

Monoamine Oxidase Inhibitors

EMSAM 4 QL (30 EA per 30 days) ST NDS

MARPLAN 2 ST

NARDIL 3 ST

PARNATE 4 ST NDS

phenelzine sulfate 1

tranylcypromine sulfate 1

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin

and Norepinephrine Reuptake Inhibitor

BRISDELLE 3 QL (30 EA per 30 days) ST

CELEXA TABS 3 ST

citalopram hydrobromide 1

CYMBALTA CPEP 20MG, 60MG 3 QL (60 EA per 30 days) ST

CYMBALTA CPEP 30MG 3 QL (90 EA per 30 days) ST

DESVENLAFAXINE ER TB24 100MG 2 QL (120 EA per 30 days) ST

DESVENLAFAXINE ER TB24 50MG 2 QL (30 EA per 30 days) ST

desvenlafaxine er tb24 100mg 1 QL (120 EA per 30 days)

desvenlafaxine er tb24 25mg, 50mg 1 QL (30 EA per 30 days)

DULOXETINE HCL CPEP 40MG 2 QL (90 EA per 30 days) ST

duloxetine hcl cpep 20mg, 60mg 1 QL (60 EA per 30 days)

duloxetine hcl cpep 30mg 1 QL (90 EA per 30 days)

EFFEXOR XR 3 ST

escitalopram oxalate 1

FETZIMA 2 QL (30 EA per 30 days) ST

FETZIMA TITRATION PACK 2 QL (56 EA per 365 days) ST

fluoxetine dr 1 QL (4 EA per 28 days)

fluoxetine hcl caps, soln, tabs 1

fluvoxamine maleate 1

fluvoxamine maleate er 1 QL (60 EA per 30 days)

KHEDEZLA TB24 100MG 2 QL (120 EA per 30 days) ST

KHEDEZLA TB24 50MG 2 QL (30 EA per 30 days) ST

LEXAPRO TABS 3 ST

maprotiline hcl 1

nefazodone hcl 1

olanzapine/fluoxetine caps 25mg; 12mg, 50mg; 12mg, 50mg;

6mg


olanzapine/fluoxetine caps 25mg; 3mg, 25mg; 6mg 1 QL (90 EA per 30 days)

paroxetine 1 QL (30 EA per 30 days)

paroxetine hcl 1

paroxetine hcl er 1

15

Drug Name

Drug


PAXIL CR 3 ST

PAXIL SUSP 2 ST

PAXIL TABS 3 ST

PEXEVA TABS 10MG, 20MG, 40MG 2 QL (30 EA per 30 days) ST

PEXEVA TABS 30MG 2 QL (60 EA per 30 days) ST

PRISTIQ TB24 100MG 3 QL (120 EA per 30 days) ST

PRISTIQ TB24 25MG, 50MG 3 QL (30 EA per 30 days) ST

PROZAC CAPS 10MG, 20MG 3 ST

PROZAC CAPS 40MG 4 ST NDS

SARAFEM TABS 3 ST

sertraline hcl conc, tabs 1

SYMBYAX CAPS 25MG; 12MG, 50MG; 12MG, 50MG;

6MG

3 QL (30 EA per 30 days) ST

SYMBYAX CAPS 25MG; 3MG, 25MG; 6MG 3 QL (90 EA per 30 days) ST

trazodone hcl tabs 1

TRINTELLIX 2 QL (30 EA per 30 days) ST

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD STARTER PACK 2 QL (60 EA per 365 days) ST

VIIBRYD TABS 2 QL (30 EA per 30 days) ST

ZOLOFT TABS 3 ST

Tricyclics

amitriptyline hcl tabs 1

amoxapine 1

ANAFRANIL 4 NDS

chlordiazepoxide/amitriptyline 1

clomipramine hcl caps 1

desipramine hcl tabs 1

doxepin hcl caps, conc 1

imipramine hcl tabs 1

imipramine pamoate 1

NORPRAMIN TABS 10MG, 25MG 3 ST

nortriptyline hcl caps, soln 1

PAMELOR CAPS 4 ST NDS

perphenazine/amitriptyline 1

protriptyline hcl 1

SURMONTIL 3

TOFRANIL TABS 10MG 3

TOFRANIL TABS 25MG, 50MG 4 NDS

trimipramine maleate caps 1

Antiemetics

Antiemetics, Other

BONJESTA 2

compro 1

meclizine hcl tabs 1

phenadoz supp 12.5mg 1

PHENERGAN INJ 3

phenergan supp 1

prochlorperazine edisylate inj 1

16

Drug Name

Drug


prochlorperazine maleate tabs 1

prochlorperazine supp 25mg 1

promethazine hcl plain 1

promethazine hcl inj, supp 1

promethazine hcl tabs 50mg 1

promethazine hcl tabs 12.5mg, 25mg 1 B/D

promethegan supp 25mg, 50mg 1

scopolamine 1

TIGAN INJ 2

TIGAN CAPS 300MG 3 B/D

TRANSDERM-SCOP 3 ST

trimethobenzamide hcl caps 300mg 1 B/D

Emetogenic Therapy Adjuncts

ALOXI INJ 0.25MG/5ML 2 ST

ANZEMET TABS 50MG 2 QL (5 EA per 30 days) ST B/D

ANZEMET TABS 100MG 4 QL (5 EA per 30 days) ST B/D NDS

aprepitant caps 40mg 1 QL (1 EA per 30 days) B/D


aprepitant caps 0 1 QL (6 EA per 30 days) B/D


CESAMET 4 QL (60 EA per 30 days) PA NDS

CINVANTI 2

dronabinol 1 QL (60 EA per 30 days) PA

EMEND TRIPACK 3 QL (6 EA per 30 days) ST B/D

EMEND SUSR 2 QL (6 EA per 30 days) ST B/D

EMEND INJ 2 ST

EMEND CAPS 40MG 3 QL (1 EA per 30 days) ST B/D



granisetron hcl inj 1

granisetron hcl tabs 1 QL (30 EA per 30 days) B/D

MARINOL CAPS 2.5MG 3 QL (60 EA per 30 days) PA

MARINOL CAPS 10MG, 5MG 4 QL (60 EA per 30 days) PA NDS

ondansetron hcl oral soln 1 QL (450 ML per 30 days) B/D

ondansetron hcl inj 4mg/2ml 1 QL (240 ML per 30 days)

ondansetron hcl tabs 4mg, 8mg 1 B/D

ondansetron hcl tabs 24mg 1 QL (14 EA per 28 days) B/D

ondansetron odt 1 B/D

palonosetron hydrochlori de 1

palonosetron hydrochloride 1

SANCUSO 4 QL (2 EA per 30 days) ST NDS

SYNDROS 4 QL (120 ML per 30 days) PA NDS

VARUBI TABS 2 QL (4 EA per 30 days) B/D

ZOFRAN ODT 4 ST B/D NDS

ZOFRAN SOLN 4 QL (450 ML per 30 days) ST B/D

NDS

ZOFRAN TABS 4MG, 8MG 4 ST B/D NDS

ZUPLENZ FILM 4MG 2 ST B/D

ZUPLENZ FILM 8MG 4 ST B/D NDS

17

Drug Name

Drug


Antifungals

Antifungals

ABELCET 4 B/D NDS

AMBISOME 2 B/D

amphotericin b inj 1 B/D

ANCOBON 4 NDS

CANCIDAS 4 NDS

caspofungin acetate 4 NDS

ciclopirox nail lacquer 1 PA

ciclopirox olamine crea 1

ciclopirox gel, sham, susp 1

clotrimazole crea, lozg, soln 1

CRESEMBA 4 NDS

DIFLUCAN SUSR 3

DIFLUCAN TABS 100MG, 150MG, 50MG 3

DIFLUCAN TABS 200MG 4 NDS

econazole nitrate crea 1

ERAXIS INJ 100MG 2

ERAXIS INJ 50MG 4 NDS

ERTACZO 4 NDS

EXELDERM 2

EXTINA 4 NDS

fluconazole in nacl inj 200mg/100ml; 0.9%, 400mg/200ml;

0.9%

1

fluconazole susr, tabs 1

flucytosine caps 4 NDS

GRIS-PEG 3

griseofulvin microsize 1

griseofulvin ultramicrosize tabs 125mg, 250mg 1

GYNAZOLE-1 2

itraconazole caps 1 PA

JUBLIA 2

KERYDIN 4 PA NDS

ketoconazole crea, foam, sham, tabs 1

LAMISIL TABS 4 QL (84 EA per 180 days) NDS

LOPROX SHAMPOO 4 NDS

LOPROX CREA 3

LUZU 2

MENTAX 2

miconazole 3 supp 1

MYCAMINE 4 NDS

naftifine hcl 1

naftifine hydrochloride 1

NAFTIN GEL 2

NAFTIN CREA 2% 3

NATACYN 2

NIZORAL SHAM 3

NOXAFIL SUSP, TBEC 4 NDS

nyamyc 1

18

Drug Name

Drug


nystatin/triamcinolone 1

nystatin crea, oint, powd, susp, tabs 1

nystop 1

ORAVIG 2

oxiconazole nitrate 1

OXISTAT LOTN 2

OXISTAT CREA 3

SPORANOX CAPS, SOLN 4 PA NDS

terbinafine hcl tabs 1 QL (84 EA per 180 days)

terconazole 1

VFEND 4 NDS

VFEND IV 3

voriconazole inj, tabs 1

voriconazole susr 4 NDS

Antigout Agents

Antigout Agents

allopurinol sodium 1

allopurinol tabs 1

ALOPRIM 3

COLCHICINE CAPS 2

COLCHICINE TABS 0.6MG 2

COLCRYS 2

DUZALLO TABS 300MG; 200MG 2 ST

MITIGARE 2

probenecid/colchicine 1

probenecid tabs 1

ULORIC 2

ZURAMPIC 2 ST

ZYLOPRIM 3

Antimigraine Agents

Ergot Alkaloids

CAFERGOT TABS 3

dihydroergotamine mesylate inj 4 NDS

dihydroergotamine mesylate nasal soln 4 QL (8 ML per 30 days) NDS

ergotamine tartrate/caffeine 1

MIGERGOT 4 NDS

MIGRANAL 4 QL (8 ML per 30 days) NDS

Serotonin (5-HT) 1b/1d Receptor Agonists

almotriptan 1 QL (12 EA per 30 days)

AMERGE 3 QL (9 EA per 30 days)

AXERT TABS 12.5MG 3 QL (12 EA per 30 days)

eletriptan hydrobromide 1 QL (12 EA per 30 days)

FROVA 3 QL (12 EA per 30 days)

frovatriptan succinate 1 QL (12 EA per 30 days)

IMITREX STATDOSE REFILL INJ 6MG/0.5ML 4 QL (5 ML per 30 days) NDS

IMITREX STATDOSE SYSTEM INJ 4MG/0.5ML 3 QL (8 ML per 30 days)

IMITREX NASAL SOLN 3 QL (12 EA per 30 days)

IMITREX TABS 3 QL (9 EA per 30 days)

IMITREX INJ 4 QL (5 ML per 30 days) NDS

19

Drug Name

Drug


MAXALT 3 QL (18 EA per 30 days)

MAXALT-MLT 3 QL (18 EA per 30 days)

naratriptan hcl 1 QL (9 EA per 30 days)

ONZETRA XSAIL 2 QL (8 EA per 30 days)

RELPAX 3 QL (12 EA per 30 days)

rizatriptan benzoate 1 QL (18 EA per 30 days)

rizatriptan benzoate odt 1 QL (18 EA per 30 days)

sumatriptan succinate refill inj 4mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate tabs 1 QL (9 EA per 30 days)

sumatriptan succinate inj 6mg/0.5ml 1 QL (5 ML per 30 days)

sumatriptan succinate inj 4mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan/naproxen sodium 4 QL (9 EA per 30 days) NDS

sumatriptan soln 1 QL (12 EA per 30 days)

SUMAVEL DOSEPRO INJ 6MG/0.5ML 4 QL (6 ML per 30 days) NDS

TREXIMET TABS 60MG; 10MG 2 QL (9 EA per 30 days)

TREXIMET TABS 500MG; 85MG 4 QL (9 EA per 30 days) NDS

ZEMBRACE SYMTOUCH 4 QL (8 ML per 30 days) NDS

zolmitriptan odt tbdp 2.5mg 1 QL (12 EA per 30 days)

zolmitriptan odt tbdp 5mg 1 QL (9 EA per 30 days)

zolmitriptan tabs 1 QL (12 EA per 30 days)

ZOMIG ZMT TBDP 2.5MG 4 QL (12 EA per 30 days) NDS

ZOMIG ZMT TBDP 5MG 4 QL (9 EA per 30 days) NDS

ZOMIG TABS 4 QL (12 EA per 30 days) NDS

ZOMIG SOLN 5MG 2 QL (12 EA per 30 days)

ZOMIG SOLN 2.5MG 2 QL (18 EA per 30 days)

Antimyasthenic Agents

Parasympathomimetics

GUANIDINE HCL 2

MESTINON TIMESPAN 4 NDS

MESTINON SYRP, TABS 4 NDS

pyridostigmine bromide er 1

pyridostigmine bromide tabs 1

Antimycobacterials

Antimycobacterials, Other

dapsone tabs 100mg, 25mg 1

MYCOBUTIN 4 NDS

rifabutin 1

Antituberculars

CAPASTAT SULFATE 2

ethambutol hcl tabs 1

isoniazid inj, syrp, tabs 1

MYAMBUTOL TABS 400MG 3

PASER 2

PRIFTIN 2

pyrazinamide tabs 1

RIFADIN CAPS 150MG 3

RIFAMATE 3

rifampin caps, inj 1

RIFATER 2

20

Drug Name

Drug


SIRTURO 4 NDS

TRECATOR 2

Antineoplastics

Alkylating Agents

ALKERAN INJ 3

BICNU 4 NDS

busulfan 4 NDS

BUSULFEX 4 NDS

carboplatin inj 150mg/15ml 1

cisplatin inj 50mg/50ml 1

CYCLOPHOSPHAMIDE CAPS 2 B/D

dacarbazine inj 200mg 1

GLEOSTINE 2

HEXALEN 4 NDS

IFEX INJ 1GM 3

ifosfamide inj 1gm 1

KISQALI FEMARA 200 DOSE 4 QL (91 EA per 28 days) PA NDS



LEUKERAN 4 NDS

MATULANE 4 NDS

melphalan hydrochloride 4 NDS

MUSTARGEN 4 NDS

oxaliplatin inj 100mg 1

oxaliplatin inj 100mg/20ml 1 B/D

thiotepa inj 15mg 4 NDS

TREANDA INJ 100MG, 25MG 4 NDS

VALCHLOR 4 PA NDS

YONDELIS 4 NDS

ZANOSAR 4 NDS

Antiandrogens

bicalutamide 1

CASODEX 3

ERLEADA 4 QL (120 EA per 30 days) PA NDS

flutamide 1

NILANDRON TABS 150MG 4 NDS

nilutamide 4 NDS

XTANDI 4 PA NDS

ZYTIGA 4 PA NDS

Antiangiogenic Agents

POMALYST 4 PA NDS

REVLIMID 4 PA NDS

THALOMID 4 PA NDS

Antiestrogens/Modifiers

EMCYT 4 NDS

FARESTON 4 NDS

FASLODEX INJ 250MG/5ML 4 NDS

SOLTAMOX 2

tamoxifen citrate tabs 1

21

Drug Name

Drug


Antimetabolites

adrucil inj 500mg/10ml 1 B/D

ALIMTA 4 NDS

ARRANON 4 NDS

cladribine 4 B/D NDS

clofarabine 4 NDS

CLOLAR 4 NDS

cytarabine aqueous 1 B/D

DROXIA 2

fluorouracil inj 5gm/100ml 1 B/D

FOLOTYN INJ 40MG/2ML 4 PA NDS

gemcitabine hcl inj 1gm 1

GEMZAR INJ 1GM 4 NDS

HYDREA 3

hydroxyurea caps 1

LONSURF TABS 6.14MG; 15MG 4 QL (100 EA per 28 days) PA NDS

LONSURF TABS 8.19MG; 20MG 4 QL (80 EA per 28 days) PA NDS

mercaptopurine tabs 1

NIPENT 4 NDS

PURIXAN 4 NDS

TABLOID 2

VYXEOS 4 PA NDS

Antineoplastics, Other

ABRAXANE 4 NDS

adriamycin inj 2mg/ml 1 B/D

azacitidine 4 NDS

BELEODAQ 4 PA NDS

bleomycin sulfate inj 30unit 1 B/D

BORTEZOMIB 4 PA NDS

CAMPTOSAR INJ 100MG/5ML 3 B/D

COSMEGEN 4 NDS

COTELLIC 4 QL (90 EA per 30 days) PA NDS

DACOGEN 4 PA NDS

dactinomycin 4 NDS

daunorubicin hcl inj 5mg/ml 1

decitabine 4 PA NDS

dexrazoxane inj 250mg 4 NDS

docetaxel inj 160mg/16ml, 80mg/4ml 4 NDS

DOXIL 4 B/D NDS

doxorubicin hcl liposome 4 B/D NDS

doxorubicin hcl inj 2mg/ml 1 B/D

ELLENCE INJ 200MG/100ML 4 NDS

epirubicin hcl inj 200mg/100ml 1

ERWINAZE 4 NDS

FARYDAK 4 PA NDS

fludarabine phosphate inj 50mg 1

FUSILEV 4 NDS

HALAVEN 4 PA NDS

IBRANCE 4 PA NDS

22

Drug Name

Drug


IDAMYCIN PFS INJ 20MG/20ML 4 NDS

idarubicin hcl inj 10mg/10ml 4 NDS

irinotecan inj 100mg/5ml 1 B/D

ISTODAX (OVERFILL) 4 PA NDS

JEVTANA 4 PA NDS

KISQALI 4 QL (63 EA per 28 days) PA NDS

leucovorin calcium tabs 1

leucovorin calcium inj 100mg, 350mg 1

levoleucovorin inj 175mg/17.5ml, 50mg 4 NDS

LYNPARZA 4 PA NDS

mitomycin inj 20mg, 40mg, 5mg 4 NDS

mitoxantrone hcl inj 2mg/ml 1 PA

NINLARO 4 PA NDS

paclitaxel inj 100mg/16.7ml 1

PROLEUKIN 4 NDS

RUBRACA 4 QL (120 EA per 30 days) PA NDS

RYDAPT 4 QL (240 EA per 30 days) PA NDS

SYLATRON 4 PA NDS

SYNRIBO 4 PA NDS

TAXOTERE INJ 80MG/4ML 4 NDS

TRISENOX INJ 12MG/6ML 4 NDS

VELCADE 4 PA NDS

VERZENIO 4 QL (60 EA per 30 days) PA NDS

VIDAZA 4 NDS

vinblastine sulfate inj 1mg/ml 1 B/D

vincasar pfs 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate inj 50mg/5ml 1

ZALTRAP INJ 100MG/4ML 4 PA NDS

ZEJULA 4 QL (90 EA per 30 days) PA NDS

ZINECARD INJ 250MG 4 NDS

ZOLINZA 4 PA NDS

Aromatase Inhibitors, 3rd Generation

anastrozole tabs 1

ARIMIDEX 3

AROMASIN 4 NDS

exemestane 1

FEMARA 3

letrozole 1

Enzyme Inhibitors

ETOPOPHOS 2

etoposide inj 100mg/5ml 1

HYCAMTIN INJ 4 NDS

KYPROLIS 4 PA NDS

toposar inj 1gm/50ml 1

topotecan hcl inj 4mg 4 NDS

ZYDELIG 4 PA NDS

Molecular Target Inhibitors

AFINITOR 4 QL (30 EA per 30 days) PA NDS

23

Drug Name

Drug


AFINITOR DISPERZ 4 PA NDS

ALECENSA 4 QL (240 EA per 30 days) PA NDS

ALIQOPA 4 PA NDS

ALUNBRIG TBPK 4 QL (60 EA per 365 days) PA NDS

ALUNBRIG TABS 30MG 4 QL (180 EA per 30 days) PA NDS

ALUNBRIG TABS 180MG, 90MG 4 QL (30 EA per 30 days) PA NDS

BOSULIF 4 PA NDS

CABOMETYX 4 PA NDS

CALQUENCE 4 QL (60 EA per 30 days) PA NDS

CAPRELSA TABS 300MG 4 PA NDS

CAPRELSA TABS 100MG 4 QL (60 EA per 30 days) PA NDS

COMETRIQ 4 PA NDS

ERIVEDGE 4 PA NDS

GILOTRIF 4 QL (30 EA per 30 days) PA NDS

GLEEVEC TABS 4 PA NDS

ICLUSIG TABS 45MG 4 PA NDS

ICLUSIG TABS 15MG 4 QL (60 EA per 30 days) PA NDS

IDHIFA 4 QL (30 EA per 30 days) PA NDS

imatinib mesylate 4 PA NDS

IMBRUVICA 4 PA NDS

INLYTA 4 PA NDS

IRESSA 4 PA NDS

JAKAFI 4 QL (60 EA per 30 days) PA NDS

LENVIMA 10 MG DAILY DOSE 4 PA NDS






MEKINIST 4 PA NDS

NERLYNX 4 QL (180 EA per 30 days) PA NDS

NEXAVAR 4 PA NDS

ODOMZO 4 PA NDS

SPRYCEL 4 PA NDS

STIVARGA 4 PA NDS

SUTENT 4 PA NDS

TAFINLAR 4 PA NDS

TAGRISSO 4 QL (30 EA per 30 days) PA NDS

TARCEVA TABS 100MG, 150MG 4 QL (30 EA per 30 days) PA NDS

TARCEVA TABS 25MG 4 QL (90 EA per 30 days) PA NDS

TASIGNA 4 PA NDS

TORISEL 4 NDS

TYKERB 4 PA NDS

VENCLEXTA STARTING PACK 4 PA NDS

VENCLEXTA TABS 10MG, 50MG 2 PA

VENCLEXTA TABS 100MG 4 PA NDS

VOTRIENT 4 PA NDS

XALKORI 4 PA NDS

ZELBORAF 4 PA NDS

24

Drug Name

Drug


ZYKADIA 4 PA NDS

Monoclonal Antibody/Antibody-Drug Conjugate

AVASTIN 4 NDS

BAVENCIO 4 PA NDS

CYRAMZA 4 PA NDS

DARZALEX INJ 100MG/5ML 4 PA NDS

EMPLICITI 4 PA NDS

ERBITUX INJ 100MG/50ML 4 PA NDS

HERCEPTIN 4 PA NDS

IMFINZI 4 PA NDS

KADCYLA 4 PA NDS

KEYTRUDA INJ 100MG/4ML 4 PA NDS

LARTRUVO 4 PA NDS

MYLOTARG 4 PA NDS

OPDIVO INJ 100MG/10ML, 40MG/4ML 4 PA NDS

PERJETA 4 PA NDS

RITUXAN 4 PA NDS

TECENTRIQ 4 PA NDS

VECTIBIX INJ 100MG/5ML 4 B/D NDS

YERVOY INJ 50MG/10ML 4 PA NDS

Retinoids

bexarotene 4 PA NDS

PANRETIN 4 NDS

TARGRETIN 4 PA NDS

tretinoin caps 10mg 4 NDS

Treatment Adjuncts

ELITEK 4 NDS

mesna 1

MESNEX INJ 3

MESNEX TABS 4 NDS

Antiparasitics

Anthelmintics

ALBENZA 4 NDS

BILTRICIDE 2

EMVERM 4 NDS

ivermectin tabs 1

STROMECTOL TABS 3MG 3

Antiprotozoals

ALINIA 4 NDS

atovaquone 4 NDS

atovaquone/proguanil hcl 1

BENZNIDAZOLE 2

chloroquine phosphate tabs 1

COARTEM 2

DARAPRIM 4 PA NDS

hydroxychloroquine sulfate tabs 1

MALARONE 3

mefloquine hcl 1

MEPRON SUSP 4 NDS

25

Drug Name

Drug


NEBUPENT 2 B/D

PENTAM 300 3

PLAQUENIL 3

primaquine phosphate tabs 1

QUALAQUIN 3 PA

quinine sulfate caps 324mg 1 PA

TINDAMAX TABS 500MG 3

tinidazole tabs 1

Pediculicides/Scabicides

ELIMITE 3

EURAX 2

lindane sham 1

malathion 1

NATROBA 3

OVIDE 3

permethrin crea 1

SKLICE 2

Antiparkinson Agents

Anticholinergics

benztropine mesylate inj, tabs 1

COGENTIN INJ 4 ST NDS

trihexyphenidyl hcl 1

Antiparkinson Agents, Other

COMTAN 4 ST NDS

entacapone 1

GOCOVRI 4 PA NDS

TASMAR TABS 100MG 4 ST NDS

tolcapone 4 NDS

Dopamine Agonists

APOKYN INJ 30MG/3ML 4 QL (90 ML per 30 days) PA NDS

bromocriptine mesylate caps, tabs 1

MIRAPEX 3 ST

MIRAPEX ER 3 ST

NEUPRO 2 ST

PARLODEL 3 ST

pramipexole dihydrochloride 1

pramipexole dihydrochloride er 1

REQUIP XL TB24 2MG, 4MG, 6MG, 8MG 3 ST

REQUIP XL TB24 12MG 4 ST NDS

REQUIP TABS 3 ST

ropinirole er 1

ropinirole hcl 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa 1

carbidopa/levodopa er 1

carbidopa/levodopa odt 1

carbidopa/levodopa/entacapone 1

carbidopa tabs 4 NDS

DUOPA 4 PA NDS

26

Drug Name

Drug


LODOSYN 4 ST NDS

RYTARY 2 ST

SINEMET 3 ST

SINEMET CR 3 ST

STALEVO 100 4 ST NDS




STALEVO 50 3 ST

STALEVO 75 3 ST

Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT 3 ST

ELDEPRYL CAPS 3 ST

rasagiline mesylate tabs 1

selegiline hcl caps, tabs 1

ZELAPAR 4 ST NDS

Antipsychotics

1st Generation/Typical

chlorpromazine hcl tabs 1

chlorpromazine hcl inj 50mg/2ml 1

fluphenazine decanoate inj 1

fluphenazine hcl conc, elix, inj, tabs 1

HALDOL DECANOATE 100 3


HALDOL INJ 3

haloperidol decanoate inj 1

haloperidol lactate 1

haloperidol conc, tabs 1

loxapine succinate caps 1

ORAP TABS 1MG 3

perphenazine tabs 1

pimozide 1

thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg 1

thiothixene caps 10mg, 1mg, 2mg, 5mg 1

trifluoperazine hcl tabs 1

2nd Generation/Atypical

ABILIFY MAINTENA 4 NDS

ABILIFY TABS 10MG, 15MG, 20MG, 30MG 4 QL (30 EA per 30 days) NDS

ABILIFY TABS 2MG, 5MG 4 QL (60 EA per 30 days) NDS

aripiprazole odt 4 QL (60 EA per 30 days) NDS

aripiprazole soln 1 QL (750 ML per 30 days)

aripiprazole tabs 10mg, 15mg, 20mg, 30mg 1 QL (30 EA per 30 days)

aripiprazole tabs 2mg, 5mg 1 QL (60 EA per 30 days)

ARISTADA 4 NDS

FANAPT TITRATION PACK 2 QL (8 EA per 180 days) ST

FANAPT TABS 1MG, 2MG, 4MG 2 QL (60 EA per 30 days) ST

FANAPT TABS 10MG, 12MG, 6MG, 8MG 4 QL (60 EA per 30 days) ST NDS

GEODON INJ 2 QL (60 EA per 30 days)

GEODON CAPS 4 QL (60 EA per 30 days) ST NDS

27

Drug Name

Drug


INVEGA SUSTENNA INJ 39MG/0.25ML 2

INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML,

234MG/1.5ML, 78MG/0.5ML

4 NDS

INVEGA TRINZA 4 ST NDS

INVEGA TB24 1.5MG, 3MG, 9MG 4 QL (30 EA per 30 days) ST NDS

INVEGA TB24 6MG 4 QL (60 EA per 30 days) ST NDS

LATUDA TABS 120MG, 20MG, 40MG, 60MG 4 QL (30 EA per 30 days) NDS

LATUDA TABS 80MG 4 QL (60 EA per 30 days) NDS

NUPLAZID 4 QL (60 EA per 30 days) PA NDS

olanzapine odt 1 QL (30 EA per 30 days)

olanzapine inj 1

olanzapine tabs 1 QL (30 EA per 30 days)

paliperidone er tb24 1.5mg, 3mg 1 QL (30 EA per 30 days)

paliperidone er tb24 6mg 1 QL (60 EA per 30 days)

paliperidone er tb24 9mg 4 QL (30 EA per 30 days) NDS

quetiapine fumarate er tb24 150mg, 300mg, 400mg, 50mg 1 QL (60 EA per 30 days)

quetiapine fumarate er tb24 200mg 1 QL (90 EA per 30 days)

quetiapine fumarate tabs 300mg, 400mg 1 QL (60 EA per 30 days)

quetiapine fumarate tabs 100mg, 200mg, 25mg, 50mg 1 QL (90 EA per 30 days)

REXULTI 4 QL (30 EA per 30 days) NDS

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG 2

RISPERDAL CONSTA INJ 50MG 4 NDS

RISPERDAL SOLN 3 QL (240 ML per 30 days)

RISPERDAL TABS 0.25MG, 0.5MG, 1MG 3 QL (60 EA per 30 days)

RISPERDAL TABS 2MG, 3MG, 4MG 4 QL (60 EA per 30 days) NDS

risperidone odt 1 QL (60 EA per 30 days)

risperidone soln 1 QL (240 ML per 30 days)

risperidone tabs 1 QL (60 EA per 30 days)

SAPHRIS SUBL 2.5MG, 5MG 2 QL (60 EA per 30 days)

SAPHRIS SUBL 10MG 4 QL (60 EA per 30 days) NDS

SEROQUEL XR TB24 150MG, 300MG, 50MG 3 QL (60 EA per 30 days)

SEROQUEL XR TB24 200MG 3 QL (90 EA per 30 days)

SEROQUEL XR TB24 400MG 4 QL (60 EA per 30 days) NDS

SEROQUEL TABS 100MG, 200MG, 25MG, 50MG 3 QL (90 EA per 30 days)

SEROQUEL TABS 300MG, 400MG 4 QL (60 EA per 30 days) NDS

VRAYLAR CPPK 2 QL (14 EA per 365 days) ST

VRAYLAR CAPS 4 QL (30 EA per 30 days) ST NDS

ziprasidone hcl 1 QL (60 EA per 30 days)

ZYPREXA RELPREVV INJ 210MG 2

ZYPREXA ZYDIS TBDP 10MG, 5MG 3 QL (30 EA per 30 days)

ZYPREXA ZYDIS TBDP 15MG, 20MG 4 QL (30 EA per 30 days) NDS

ZYPREXA INJ 3

ZYPREXA TABS 10MG, 2.5MG, 5MG, 7.5MG 3 QL (30 EA per 30 days)

ZYPREXA TABS 15MG, 20MG 4 QL (30 EA per 30 days) NDS

Treatment-Resistant

clozapine odt tbdp 150mg 1 QL (180 EA per 30 days)

clozapine odt tbdp 100mg, 25mg 1 QL (270 EA per 30 days)

clozapine odt tbdp 12.5mg 1 QL (90 EA per 30 days)

clozapine odt tbdp 200mg 4 QL (120 EA per 30 days) NDS

28

Drug Name

Drug


clozapine tabs 200mg 1 QL (120 EA per 30 days)

clozapine tabs 50mg 1 QL (180 EA per 30 days)

clozapine tabs 100mg, 25mg 1 QL (270 EA per 30 days)

CLOZARIL TABS 25MG 3 QL (270 EA per 30 days)

CLOZARIL TABS 100MG 4 QL (270 EA per 30 days) NDS

FAZACLO TBDP 25MG 3 QL (270 EA per 30 days)

FAZACLO TBDP 12.5MG 3 QL (90 EA per 30 days)

FAZACLO TBDP 200MG 4 QL (120 EA per 30 days) NDS



VERSACLOZ 4 QL (540 ML per 30 days) NDS

Antispasticity Agents

Antispasticity Agents

baclofen tabs 10mg, 20mg 1

BOTOX 2 PA

DANTRIUM CAPS 25MG, 50MG 3 ST

dantrolene sodium caps 1

DYSPORT 2 PA

GABLOFEN INJ 40000MCG/20ML 4 B/D NDS

LIORESAL INTRATHECAL INJ 500MCG/ML 2 B/D

LIORESAL INTRATHECAL INJ 2000MCG/ML 4 B/D NDS

tizanidine hcl caps, tabs 1

XEOMIN INJ 50UNIT 2 PA

ZANAFLEX CAPS 3 ST

ZANAFLEX TABS 4MG 3 ST

Antivirals

Anti-cytomegalovirus (CMV) Agents

cidofovir 4 NDS

CYTOVENE INJ 3 B/D

ganciclovir inj 500mg 1 B/D

PREVYMIS 4 NDS

VALCYTE 4 NDS

valganciclovir 4 NDS

valganciclovir hydrochlorde 4 NDS

ZIRGAN 2

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 4 NDS

BARACLUDE SOLN 2 QL (600 ML per 30 days)

BARACLUDE TABS 4 QL (30 EA per 30 days) NDS

entecavir tabs 0.5mg 1 QL (30 EA per 30 days)

entecavir tabs 1mg 4 QL (30 EA per 30 days) NDS

EPIVIR HBV SOLN 2

EPIVIR HBV TABS 3

HEPSERA 4 NDS

INTRON A 4 PA NDS

lamivudine tabs 100mg 1

VEMLIDY 4 NDS

Anti-hepatitis C (HCV) Agents, Direct Acting Agents

DAKLINZA 4 QL (168 EA per 365 days) PA NDS

29

Drug Name

Drug


EPCLUSA 4 QL (84 EA per 365 days) PA NDS

HARVONI 4 QL (168 EA per 365 days) PA NDS

MAVYRET 4 QL (336 EA per 365 days) PA NDS

OLYSIO 4 QL (168 EA per 365 days) PA NDS

SOVALDI 4 QL (336 EA per 365 days) PA NDS

TECHNIVIE 4 QL (168 EA per 365 days) PA NDS

VIEKIRA PAK 4 QL (672 EA per 365 days) PA NDS

VIEKIRA XR 4 QL (504 EA per 365 days) PA NDS

VOSEVI 4 PA

ZEPATIER 4 QL (112 EA per 365 days) PA NDS

Anti-hepatitis C (HCV) Agents, Other

moderiba 1200 dose pack 4 NDS

moderiba 800 dose pack 1

moderiba tabs 1

PEGASYS 4 PA NDS

PEGASYS PROCLICK 4 PA NDS

REBETOL SOLN 2

ribasphere ribapak tabs 400mg 1

ribasphere ribapak tabs 600mg 4 NDS

ribasphere ribapak tbpk 0 1

ribasphere ribapak tbpk 0 4 NDS

ribasphere caps 1

ribasphere tabs 200mg, 400mg 1

ribasphere tabs 600mg 4 NDS

ribavirin caps 1

ribavirin tabs 200mg 1

Anti-HIV Agents, Integrase Inhibitors (INSTI)

BIKTARVY 4 QL (30 EA per 30 days) NDS

GENVOYA 4 QL (30 EA per 30 days) NDS

ISENTRESS HD 4 NDS

ISENTRESS PACK 2

ISENTRESS TABS 4 NDS

ISENTRESS CHEW 25MG 2

ISENTRESS CHEW 100MG 4 NDS

JULUCA 4 QL (30 EA per 30 days) NDS

STRIBILD 4 QL (30 EA per 30 days) NDS

TIVICAY TABS 10MG 2

TIVICAY TABS 25MG, 50MG 4 NDS

TRIUMEQ 4 QL (30 EA per 30 days) NDS

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

ATRIPLA 4 QL (30 EA per 30 days) NDS

COMPLERA 4 QL (30 EA per 30 days) NDS

EDURANT 4 NDS

efavirenz caps 50mg 1

efavirenz caps 200mg 4 NDS

efavirenz tabs 4 NDS

INTELENCE TABS 25MG 2

INTELENCE TABS 100MG, 200MG 4 NDS

30

Drug Name

Drug


nevirapine er 1

nevirapine tabs 1

ODEFSEY 4 QL (30 EA per 30 days) NDS

RESCRIPTOR 2

SUSTIVA TABS 4 NDS

SUSTIVA CAPS 50MG 2

SUSTIVA CAPS 200MG 4 NDS

SYMFI LO 4 QL (30 EA per 30 days) NDS

VIRAMUNE 4 NDS

VIRAMUNE XR 3

Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors (NRTI)

abacavir 1

abacavir sulfate/lamivudine/zidovudine 4 QL (60 EA per 30 days) NDS

abacavir/lamivudine 4 QL (30 EA per 30 days) NDS

COMBIVIR 4 QL (60 EA per 30 days) NDS

DESCOVY 4 QL (30 EA per 30 days) NDS

didanosine cpdr 200mg, 250mg, 400mg 1

EMTRIVA 2

EPIVIR 3

EPZICOM 4 QL (30 EA per 30 days) NDS

lamivudine/zidovudine 1 QL (60 EA per 30 days)

lamivudine soln 10mg/ml 1

lamivudine tabs 150mg, 300mg 1

RETROVIR IV INFUSION 2

RETROVIR CAPS, SYRP 3

stavudine caps 1

tenofovir disoproxil fumarate 4 NDS

TRIZIVIR 4 QL (60 EA per 30 days) NDS

TRUVADA 4 QL (30 EA per 30 days) NDS

VIDEX EC CPDR 125MG 2

VIDEX EC CPDR 200MG, 250MG, 400MG 3

VIDEX PEDIATRIC SOLR 4GM 2

VIREAD 4 NDS

ZERIT 3

ZIAGEN SOLN 2

ZIAGEN TABS 3

zidovudine 1

Anti-HIV Agents, Other

FUZEON 4 QL (60 EA per 30 days) NDS

SELZENTRY SOLN 4 NDS

SELZENTRY TABS 25MG, 75MG 2

SELZENTRY TABS 150MG, 300MG 4 NDS

TYBOST 2

Anti-HIV Agents, Protease Inhibitors

APTIVUS 4 NDS

atazanavir sulfate 4 NDS

CRIXIVAN CAPS 200MG, 400MG 2

EVOTAZ 4 QL (30 EA per 30 days) NDS

31

Drug Name

Drug


fosamprenavir calcium 4 NDS

INVIRASE 4 NDS

KALETRA SOLN 3

KALETRA TABS 100MG; 25MG 2

KALETRA TABS 200MG; 50MG 4 NDS

LEXIVA SUSP 2

LEXIVA TABS 4 NDS

lopinavir/ritonavir 1

NORVIR CAPS, SOLN, TABS 2

PREZCOBIX 4 QL (30 EA per 30 days) NDS

PREZISTA SUSP 4 NDS

PREZISTA TABS 150MG, 75MG 2

PREZISTA TABS 600MG, 800MG 4 NDS

REYATAZ 4 NDS

ritonavir 1

VIRACEPT 4 NDS

Anti-influenza Agents

amantadine hcl caps, syrp, tabs 1

FLUMADINE TABS 3

oseltamivir phosphate caps 75mg 1 QL (110 EA per 365 days)



oseltamivir phosphate susr 1 QL (720 ML per 365 days)

RELENZA DISKHALER 2 QL (240 EA per 365 days)

rimantadine hcl 1

TAMIFLU CAPS 75MG 3 QL (110 EA per 365 days)



TAMIFLU SUSR 6MG/ML 2 QL (720 ML per 365 days)

Antiherpetic Agents

acyclovir sodium inj 50mg/ml 1 B/D

acyclovir caps, oint, susp, tabs 1

DENAVIR 4 NDS

famciclovir tabs 1

trifluridine 1

valacyclovir hcl 1 QL (120 EA per 30 days)

VALTREX 3 QL (120 EA per 30 days)

VIROPTIC 3

XERESE 4 NDS

ZOVIRAX CAPS, SUSP 3

ZOVIRAX CREA, OINT 4 NDS

ZOVIRAX TABS 800MG 4 NDS

Anxiolytics

Anxiolytics, Other

buspirone hcl tabs 1

meprobamate 1

Benzodiazepines

alprazolam er tb24 2mg 1 QL (150 EA per 30 days)

alprazolam er tb24 0.5mg, 1mg 1 QL (30 EA per 30 days)

32

Drug Name

Drug


alprazolam er tb24 3mg 1 QL (90 EA per 30 days)

alprazolam intensol 1

alprazolam odt tbdp 0.25mg, 0.5mg, 1mg 1 QL (120 EA per 30 days)

alprazolam odt tbdp 2mg 1 QL (150 EA per 30 days)

alprazolam tabs 0.25mg, 0.5mg, 1mg 1 QL (120 EA per 30 days)

alprazolam tabs 2mg 1 QL (150 EA per 30 days)

ATIVAN TABS 2MG 4 QL (150 EA per 30 days) NDS

ATIVAN TABS 0.5MG, 1MG 4 QL (90 EA per 30 days) NDS

chlordiazepoxide hcl caps 5mg 1 QL (120 EA per 30 days)



clorazepate dipotassium tabs 15mg 1 QL (180 EA per 30 days)

clorazepate dipotassium tabs 7.5mg 1 QL (360 EA per 30 days)

clorazepate dipotassium tabs 3.75mg 1 QL (720 EA per 30 days)

diazepam intensol 1

diazepam soln, tabs 1

estazolam 1 QL (30 EA per 30 days)

HALCION TABS 0.25MG 3 QL (60 EA per 30 days)

lorazepam conc 1

lorazepam tabs 2mg 1 QL (150 EA per 30 days)

lorazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days)

oxazepam 1 QL (120 EA per 30 days)

RESTORIL 3 QL (30 EA per 30 days)

temazepam 1 QL (30 EA per 30 days)

TRANXENE T TABS 7.5MG 3 QL (360 EA per 30 days)

triazolam 1 QL (60 EA per 30 days)

VALIUM TABS 3

XANAX XR TB24 0.5MG, 1MG 3 QL (30 EA per 30 days)

XANAX XR TB24 3MG 3 QL (90 EA per 30 days)

XANAX XR TB24 2MG 4 QL (150 EA per 30 days) NDS

XANAX TABS 0.25MG, 0.5MG, 1MG 3 QL (120 EA per 30 days)

XANAX TABS 2MG 3 QL (150 EA per 30 days)

Bipolar Agents

Mood Stabilizers

EQUETRO 2

lithium 1

lithium carbonate er 1

lithium carbonate caps, tabs 1

LITHOBID 3

Blood Glucose Regulators

Antidiabetic Agents

acarbose 1

ACTOPLUS MET 3 QL (90 EA per 30 days) ST

ACTOPLUS MET XR TB24 1000MG; 30MG 2 QL (30 EA per 30 days) ST

ACTOPLUS MET XR TB24 1000MG; 15MG 2 QL (60 EA per 30 days) ST

ACTOS TABS 45MG 3 QL (30 EA per 30 days) ST



ADLYXIN 2 QL (6 ML per 28 days) ST

33

Drug Name

Drug


ADLYXIN STARTER PACK 2 QL (12 ML per 365 days) ST

ALOGLIPTIN 2 ST

ALOGLIPTIN/METFORMIN HCL 2 QL (60 EA per 30 days) ST

ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG; 30MG,

12.5MG; 45MG, 25MG; 15MG, 25MG; 30MG, 25MG;

45MG


ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG; 15MG 2 QL (60 EA per 30 days) ST

AMARYL TABS 2MG 3 QL (120 EA per 30 days)



AVANDIA TABS 2MG 2 QL (120 EA per 30 days) ST

AVANDIA TABS 4MG 2 QL (60 EA per 30 days) ST

BYDUREON 2 QL (4 EA per 28 days) ST

BYDUREON BCISE 2 QL (3.4 ML per 28 days) ST

BYDUREON PEN 2 QL (4 EA per 28 days) ST

BYETTA INJ 10MCG/0.04ML 2 QL (2.4 ML per 28 days) ST

BYETTA INJ 5MCG/0.02ML 2 QL (4.8 ML per 28 days) ST

chlorpropamide tabs 100mg 1 QL (210 EA per 30 days) PA

chlorpropamide tabs 250mg 1 QL (90 EA per 30 days) PA

CYCLOSET 2

DUETACT 3 QL (45 EA per 30 days) ST

FARXIGA TABS 10MG 2 QL (30 EA per 30 days) ST

FARXIGA TABS 5MG 2 QL (60 EA per 30 days) ST

FORTAMET TB24 500MG 4 QL (120 EA per 30 days) NDS

FORTAMET TB24 1000MG 4 QL (60 EA per 30 days) NDS

glimepiride tabs 2mg 1 QL (120 EA per 30 days)



glipizide er tb24 5mg 1 QL (120 EA per 30 days)

glipizide er tb24 2.5mg 1 QL (240 EA per 30 days)

glipizide er tb24 10mg 1 QL (60 EA per 30 days)

glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg 1 QL (120 EA per 30 days)

glipizide/metformin hcl tabs 2.5mg; 250mg 1 QL (240 EA per 30 days)

glipizide tabs 10mg 1 QL (120 EA per 30 days)

glipizide tabs 5mg 1 QL (240 EA per 30 days)

GLUCOPHAGE XR TB24 500MG 3 QL (120 EA per 30 days)

GLUCOPHAGE XR TB24 750MG 3 QL (60 EA per 30 days)

GLUCOPHAGE TABS 500MG 3 QL (150 EA per 30 days)



GLUCOTROL XL TB24 5MG 3 QL (120 EA per 30 days)

GLUCOTROL XL TB24 2.5MG 3 QL (240 EA per 30 days)

GLUCOTROL XL TB24 10MG 3 QL (60 EA per 30 days)

GLUCOTROL TABS 10MG 3 QL (120 EA per 30 days)

GLUCOTROL TABS 5MG 3 QL (240 EA per 30 days)

GLUCOVANCE TABS 2.5MG; 500MG, 5MG; 500MG 3 QL (120 EA per 30 days)

GLUMETZA TB24 500MG 4 QL (120 EA per 30 days) NDS

GLUMETZA TB24 1000MG 4 QL (60 EA per 30 days) NDS

glyburide micronized tabs 3mg 1 QL (120 EA per 30 days)

34

Drug Name

Drug


glyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days)

glyburide micronized tabs 6mg 1 QL (60 EA per 30 days)

glyburide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg 1 QL (120 EA per 30 days)

glyburide/metformin hcl tabs 1.25mg; 250mg 1 QL (240 EA per 30 days)

glyburide tabs 5mg 1 QL (120 EA per 30 days)

glyburide tabs 2.5mg 1 QL (240 EA per 30 days)

glyburide tabs 1.25mg 1 QL (480 EA per 30 days)

GLYNASE TABS 3MG 3 QL (120 EA per 30 days)

GLYNASE TABS 1.5MG 3 QL (240 EA per 30 days)

GLYNASE TABS 6MG 3 QL (60 EA per 30 days)

GLYSET 3 ST

GLYXAMBI 2 QL (30 EA per 30 days)

INVOKAMET XR 2 QL (60 EA per 30 days) ST

INVOKAMET TABS 50MG; 500MG 2 QL (120 EA per 30 days) ST

INVOKAMET TABS 150MG; 1000MG, 150MG; 500MG,

50MG; 1000MG


INVOKANA TABS 300MG 2 QL (30 EA per 30 days) ST

INVOKANA TABS 100MG 2 QL (90 EA per 30 days) ST

JANUMET 2 QL (60 EA per 30 days) ST

JANUMET XR TB24 1000MG; 100MG 2 QL (30 EA per 30 days) ST

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG 2 QL (60 EA per 30 days) ST

JANUVIA 2 ST

JARDIANCE TABS 25MG 2 QL (30 EA per 30 days) ST

JARDIANCE TABS 10MG 2 QL (60 EA per 30 days) ST

JENTADUETO 2 QL (60 EA per 30 days) ST

JENTADUETO XR TB24 5MG; 1000MG 2 QL (30 EA per 30 days) ST

JENTADUETO XR TB24 2.5MG; 1000MG 2 QL (60 EA per 30 days) ST

KAZANO 3 QL (60 EA per 30 days) ST

KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG; 5MG 2 QL (30 EA per 30 days) ST

KOMBIGLYZE XR TB24 1000MG; 2.5MG 2 QL (60 EA per 30 days) ST

metformin hcl er tb24 500mg 1 QL (120 EA per 30 days)

metformin hcl er tb24 1000mg, 750mg 1 QL (60 EA per 30 days)

metformin hcl er tb24 500mg 4 QL (120 EA per 30 days) NDS

metformin hcl er tb24 1000mg 4 QL (60 EA per 30 days) NDS

metformin hcl tabs 500mg 1 QL (150 EA per 30 days)



miglitol 1

nateglinide 1

NESINA 3 ST

ONGLYZA 2 ST

OSENI TABS 12.5MG; 30MG, 12.5MG; 45MG, 25MG;

15MG, 25MG; 30MG, 25MG; 45MG


OSENI TABS 12.5MG; 15MG 3 QL (60 EA per 30 days) ST

OZEMPIC INJ 2MG/1.5ML 2 QL (1.5 ML per 28 days) ST

OZEMPIC INJ 2MG/1.5ML 2 QL (3 ML per 28 days) ST

pioglitazone hcl-glimepiride 1 QL (45 EA per 30 days)

pioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days)

pioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days)

35

Drug Name

Drug




PRANDIN TABS 1MG 3 ST

PRANDIN TABS 2MG 4 ST NDS

PRECOSE 3 ST

QTERN 2 QL (30 EA per 30 days) ST

repaglinide 1

repaglinide/metformin hydrochloride 1 QL (150 EA per 30 days)

RIOMET 2 QL (765 ML per 30 days)

SEGLUROMET TABS 2.5MG; 500MG 2 QL (120 EA per 30 days) ST

SEGLUROMET TABS 2.5MG; 1000MG, 7.5MG; 1000MG,

7.5MG; 500MG


STARLIX 3 ST

STEGLATRO TABS 15MG 2 QL (30 EA per 30 days) ST

STEGLATRO TABS 5MG 2 QL (60 EA per 30 days) ST

STEGLUJAN 2 ST

SYMLINPEN 120 4 PA NDS

SYMLINPEN 60 4 PA NDS

SYNJARDY TABS 12.5MG; 500MG, 5MG; 500MG 2 QL (120 EA per 30 days) ST

SYNJARDY TABS 12.5MG; 1000MG, 5MG; 1000MG 2 QL (60 EA per 30 days) ST

TANZEUM 2 QL (4 EA per 28 days) ST

tolazamide tabs 500mg 1 QL (120 EA per 30 days)

tolazamide tabs 250mg 1 QL (240 EA per 30 days)

tolbutamide 1 QL (180 EA per 30 days)

TRADJENTA 2 ST

TRULICITY 2 QL (2 ML per 28 days) ST

VICTOZA 2 QL (9 ML per 30 days) ST

XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG 2 QL (30 EA per 30 days) ST

XIGDUO XR TB24 2.5MG; 1000MG, 5MG; 1000MG, 5MG;

500MG


Glycemic Agents

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT 2

PROGLYCEM 4 NDS

Insulins

ADMELOG 3 ST

ADMELOG SOLOSTAR 3 ST

AFREZZA 2 PA

APIDRA 2

APIDRA SOLOSTAR 2

BASAGLAR KWIKPEN 2 ST

FIASP 2

FIASP FLEXTOUCH 2

HUMALOG 2

HUMALOG JUNIOR KWIKPEN 2

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 2

HUMALOG MIX 50/50 KWIKPEN 2

HUMALOG MIX 75/25 2

36

Drug Name

Drug



HUMULIN 70/30 2

HUMULIN 70/30 KWIKPEN 2

HUMULIN N 2

HUMULIN N KWIKPEN 2

HUMULIN R 2

HUMULIN R U-500 (CONCENTRATED) 4 NDS

HUMULIN R U-500 KWIKPEN 4 NDS

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN N 2

NOVOLIN R 2

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2

NOVOLOG PENFILL 2

SOLIQUA 100/33 2 QL (18 ML per 30 days) ST

TOUJEO MAX SOLOSTAR 2

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

XULTOPHY 100/3.6 2 QL (15 ML per 30 days) ST

Blood Products/Modifiers/Volume Expanders

Anticoagulants

argatroban inj 125mg/125ml; 0.9%, 250mg/2.5ml 4 NDS

ARIXTRA INJ 5MG/0.4ML 4 QL (14 ML per 90 days) NDS

ARIXTRA INJ 2.5MG/0.5ML 4 QL (17.5 ML per 90 days) NDS

ARIXTRA INJ 7.5MG/0.6ML 4 QL (21 ML per 90 days) NDS

ARIXTRA INJ 10MG/0.8ML 4 QL (28 ML per 90 days) NDS

BEVYXXA 3 QL (43 EA per 180 days)

COUMADIN TABS 3

ELIQUIS STARTER PACK 2 QL (148 EA per 365 days)

ELIQUIS TABS 2.5MG 2 QL (60 EA per 30 days)

ELIQUIS TABS 5MG 2 QL (90 EA per 30 days)

enoxaparin sodium inj 30mg/0.3ml 1 QL (10.5 ML per 90 days)

enoxaparin sodium inj 300mg/3ml 1 QL (105 ML per 90 days)

enoxaparin sodium inj 40mg/0.4ml 1 QL (14 ML per 90 days)

enoxaparin sodium inj 60mg/0.6ml 1 QL (21 ML per 90 days)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml 1 QL (28 ML per 90 days)

enoxaparin sodium inj 100mg/ml, 150mg/ml 1 QL (35 ML per 90 days)

fondaparinux sodium inj 2.5mg/0.5ml 1 QL (17.5 ML per 90 days)

fondaparinux sodium inj 5mg/0.4ml 4 QL (14 ML per 90 days) NDS

fondaparinux sodium inj 7.5mg/0.6ml 4 QL (21 ML per 90 days) NDS

fondaparinux sodium inj 10mg/0.8ml 4 QL (28 ML per 90 days) NDS

FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML 2 QL (7 ML per 90 days)

FRAGMIN INJ 7500UNIT/0.3ML 4 QL (10.5 ML per 90 days) NDS

37

Drug Name

Drug



FRAGMIN INJ 15000UNIT/0.6ML 4 QL (21 ML per 90 days) NDS


FRAGMIN INJ 18000UNT/0.72ML 4 QL (25.3 ML per 90 days) NDS

FRAGMIN INJ 10000UNIT/ML 4 QL (35 ML per 90 days) NDS

heparin sodium/d5w 1

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml,

5000unit/ml

1

jantoven 1

LOVENOX INJ 30MG/0.3ML 3 QL (10.5 ML per 90 days)

LOVENOX INJ 40MG/0.4ML 3 QL (14 ML per 90 days)

LOVENOX INJ 300MG/3ML 4 QL (105 ML per 90 days) NDS

LOVENOX INJ 60MG/0.6ML 4 QL (21 ML per 90 days) NDS

LOVENOX INJ 120MG/0.8ML, 80MG/0.8ML 4 QL (28 ML per 90 days) NDS

LOVENOX INJ 100MG/ML, 150MG/ML 4 QL (35 ML per 90 days) NDS

PRADAXA 3 QL (60 EA per 30 days)

SAVAYSA 3 QL (30 EA per 30 days)

warfarin sodium tabs 1

XARELTO STARTER PACK 2 QL (102 EA per 365 days)

XARELTO TABS 10MG, 20MG 2 QL (30 EA per 30 days)

XARELTO TABS 15MG 2 QL (60 EA per 30 days)

Blood Formation Modifiers

AGRYLIN CAPS 0.5MG 3

anagrelide hydrochloride 1

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML,

25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML,

60MCG/0.3ML, 60MCG/ML

2 PA

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML,

100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML,

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

4 PA NDS

EPOGEN INJ 10000UNIT/ML, 2000UNIT/ML,

3000UNIT/ML, 4000UNIT/ML

2 PA

EPOGEN INJ 20000UNIT/ML 4 PA NDS

GRANIX 4 ST NDS

LEUKINE INJ 250MCG 4 PA NDS

MIRCERA INJ 100MCG/0.3ML, 50MCG/0.3ML,

75MCG/0.3ML

2 PA

MOZOBIL 4 QL (38.4 ML per 365 days) PA NDS

NEULASTA 4 PA NDS

NEUPOGEN 4 ST NDS

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,

3000UNIT/ML, 4000UNIT/ML

2 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML 4 PA NDS

PROMACTA 4 PA NDS

ZARXIO 4 NDS

Hemostasis Agents

CYKLOKAPRON INJ 1000MG/10ML 3

LYSTEDA 4 NDS

tranexamic acid inj, tabs 1

38

Drug Name

Drug


Platelet Modifying Agents

AGGRENOX 3

aspirin/dipyridamole 1

BRILINTA 2

cilostazol 1

clopidogrel tabs 75mg 1

dipyridamole tabs 1

EFFIENT 3

PLAVIX TABS 75MG 3

prasugrel 1

YOSPRALA 2 QL (30 EA per 30 days)

ZONTIVITY 2

Cardiovascular Agents

Alpha-adrenergic Agonists

CATAPRES 3

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

clonidine hcl ptwk, tabs 1

guanfacine hcl 1

methyldopa/hydrochlorothiazide 1

methyldopa tabs 250mg, 500mg 1

methyldopate hcl 1

midodrine hcl 1

Alpha-adrenergic Blocking Agents

DIBENZYLINE 4 NDS

MINIPRESS 3

phenoxybenzamine hydrochloride 4 NDS

prazosin hcl caps 1

Angiotensin II Receptor Antagonists

ATACAND 3 ST

ATACAND HCT 3 ST

AVALIDE 3 ST

AVAPRO 3 ST

BENICAR 3 ST

BENICAR HCT 3 ST

candesartan cilexetil 1

candesartan cilexetil/hydrochlorothiazide 1

COZAAR 3 ST

DIOVAN HCT 3 ST

DIOVAN TABS 3 ST

EDARBI 2 ST

EDARBYCLOR 2 ST

eprosartan mesylate 1

HYZAAR 3 ST

irbesartan 1

irbesartan/hydrochlorothiazide 1

losartan potassium 1

losartan potassium/hydrochlorothiazide 1

39

Drug Name

Drug


MICARDIS 3 ST

MICARDIS HCT 3 ST

olmesartan medoxomil/hydrochlorothiazide 1

olmesartan medoxomil tabs 1

telmisartan 1

telmisartan/hydrochlorothiazide 1

valsartan 1

valsartan/hydrochlorothiazide 1

Angiotensin-converting Enzyme (ACE) Inhibitors

ACCUPRIL 3

ACCURETIC 3

ALTACE CAPS 3

benazepril hcl/hydrochlorothiazide 1

benazepril hcl tabs 1

captopril/hydrochlorothiazide 1

captopril tabs 1

enalapril maleate/hydrochlorothiazide 1

enalapril maleate tabs 1

fosinopril sodium 1

fosinopril sodium/hydrochlorothiazide 1

lisinopril/hydrochlorothiazide 1

lisinopril tabs 1

LOTENSIN TABS 20MG, 40MG 3

moexipril hcl 1

moexipril/hydrochlorothiazide 1

perindopril erbumine 1

PRINIVIL TABS 10MG, 20MG, 5MG 3

QBRELIS 3 ST

quinapril hcl 1

quinapril/hydrochlorothiazide 1

ramipril 1

TARKA TBCR 2MG; 180MG, 2MG; 240MG, 4MG; 240MG 3

trandolapril 1

trandolapril/verapamil hcl er 1

VASERETIC TABS 10MG; 25MG 3

VASOTEC TABS 2.5MG, 5MG 3

VASOTEC TABS 10MG, 20MG 4 NDS

ZESTORETIC 3

ZESTRIL 3

Antiarrhythmics

amiodarone hcl tabs 1

amiodarone hcl inj 50mg/ml 1

BETAPACE AF TABS 80MG 3

BETAPACE AF TABS 120MG, 160MG 4 NDS

disopyramide phosphate caps 1

dofetilide 1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2

40

Drug Name

Drug


NEXTERONE INJ 150MG/100ML; 42.1MG/ML 2

NEXTERONE INJ 360MG/200ML; 41.4MG/ML 4 NDS

NORPACE 3

NORPACE CR 2

PACERONE TABS 100MG, 400MG 3

pacerone tabs 200mg 1

procainamide hcl inj 1

propafenone hcl 1

propafenone hcl er 1

quinidine gluconate cr 1

QUINIDINE GLUCONATE INJ 2

quinidine sulfate tabs 1

RYTHMOL SR CP12 225MG 3

RYTHMOL SR CP12 325MG, 425MG 4 NDS

sorine 1

sotalol hcl (af) tabs 120mg 1

sotalol hcl tabs 160mg, 240mg, 80mg 1

TIKOSYN 3

Beta-adrenergic Blocking Agents

acebutolol hcl caps 1

atenolol/chlorthalidone 1

atenolol tabs 1

betaxolol hcl tabs 10mg, 20mg 1

bisoprolol fumarate 1

bisoprolol fumarate/hydrochlorothiazide 1

BYSTOLIC 2

BYVALSON 2 ST

carvedilol 1

carvedilol phosphate 1

COREG 3 ST

COREG CR CP24 10MG, 20MG, 40MG 2 ST

COREG CR CP24 80MG 3 ST

CORGARD TABS 20MG, 40MG, 80MG 3

CORZIDE 3

DUTOPROL 2

INDERAL LA CP24 60MG, 80MG 3

INDERAL LA CP24 120MG, 160MG 4 NDS

INNOPRAN XL 2

labetalol hcl inj, tabs 1

LOPRESSOR HCT TABS 25MG; 50MG 3

LOPRESSOR TABS 100MG 3

metoprolol succinate er 1

metoprolol tartrate inj 1

metoprolol tartrate tabs 100mg, 25mg, 50mg 1

metoprolol/hydrochlorothiazide 1

nadolol/bendroflumethiazide 1

nadolol tabs 20mg, 40mg, 80mg 1

pindolol tabs 1

propranolol hcl er 1

41

Drug Name

Drug


propranolol hcl inj, oral soln 1

propranolol hcl tabs 10mg, 20mg, 40mg, 80mg 1

propranolol hydrochloride tabs 60mg 1

propranolol/hydrochlorothiazide 1

SOTYLIZE 2

TENORETIC 100 3

TENORETIC 50 3

TENORMIN TABS 3

timolol maleate tabs 10mg, 20mg, 5mg 1

TOPROL XL 3

ZIAC TABS 2.5MG; 6.25MG 3

Calcium Channel Blocking Agents

ADALAT CC 3

afeditab cr 1

amlodipine besylate/atorvastatin calcium 1

amlodipine besylate/benazepril hydrochloride 1

amlodipine besylate/valsartan 1

amlodipine besylate tabs 1

amlodipine/olmesartan medoxomil 1

amlodipine/valsartan/hctz 1

AZOR 3 ST

CADUET TABS 10MG; 10MG, 10MG; 20MG, 10MG;

40MG, 10MG; 80MG, 5MG; 10MG, 5MG; 20MG, 5MG;

40MG, 5MG; 80MG

3

CALAN SR TBCR 120MG, 240MG 3

CALAN TABS 120MG, 80MG 3

CARDENE IV INJ 20MG/200ML; 0.86%, 40MG/200ML;

0.83%

2

CARDIZEM CD CP24 180MG 3

CARDIZEM CD CP24 120MG, 240MG, 360MG 4 NDS

CARDIZEM LA TB24 120MG 2

CARDIZEM LA TB24 180MG, 240MG, 300MG, 360MG,

420MG

3

CARDIZEM TABS 120MG, 30MG, 60MG 4 NDS

cartia xt 1

dilt-xr 1

diltiazem hcl er cp12, cp24 1

diltiazem hcl tabs 1

diltiazem hcl inj 100mg, 50mg/10ml 1

EXFORGE 3 ST

EXFORGE HCT 3 ST

felodipine er 1

isradipine 1

LOTREL CAPS 10MG; 20MG, 10MG; 40MG, 5MG; 10MG,

5MG; 20MG

3

matzim la 1

nicardipine hcl caps, inj 1

nifedipine er 1

nifedipine caps 1

42

Drug Name

Drug


nimodipine caps 0; 30mg 4 NDS

nisoldipine er 1

NORVASC 3

NYMALIZE SOLN 30MG/10ML 4 NDS

olmesartan medoxomil/amlodipine/hydrochlorothiazide 1

PROCARDIA XL 3

PROCARDIA CAPS 10MG 3

SULAR TB24 17MG, 34MG, 8.5MG 3

taztia xt 1

telmisartan/amlodipine 1

TIAZAC 3

TRIBENZOR 3 ST

TWYNSTA 3 ST

verapamil hcl er 1

verapamil hcl sr cp24 360mg 1

verapamil hcl inj, tabs 1

VERELAN 3

VERELAN PM 3

Cardiovascular Agents, Other

ADRENALIN INJ 1MG/ML 2

atropine sulfate inj 0.25mg/5ml 1

CORLANOR 2 QL (60 EA per 30 days) PA

DEMSER 4 NDS

digitek tabs 0.25mg 1

digitek tabs 0.125mg 1 QL (30 EA per 30 days)

digoxin oral soln 1

digoxin inj 0.25mg/ml 1

digoxin tabs 250mcg 1

digoxin tabs 125mcg 1 QL (30 EA per 30 days)

digox tabs 250mcg 1

digox tabs 125mcg 1 QL (30 EA per 30 days)

ENTRESTO 2 QL (60 EA per 30 days) PA

LANOXIN INJ 3

LANOXIN TABS 187.5MCG 2 QL (30 EA per 30 days)

LANOXIN TABS 62.5MCG 2 QL (60 EA per 30 days)

LANOXIN TABS 250MCG 3

LANOXIN TABS 125MCG 3 QL (30 EA per 30 days)

NORTHERA 4 PA NDS

pentoxifylline er 1

PRALUENT 4 QL (2 ML per 28 days) PA NDS

RANEXA 2

REPATHA 4 QL (3 ML per 28 days) PA NDS

REPATHA PUSHTRONEX SYSTEM 4 QL (3.5 ML per 28 days) PA NDS

REPATHA SURECLICK 4 QL (3 ML per 28 days) PA NDS

TEKTURNA 2 ST

TEKTURNA HCT 2 ST

VECAMYL 4 NDS

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide 1

43

Drug Name

Drug


acetazolamide er 1

acetazolamide sodium 4 NDS

Diuretics, Loop

bumetanide inj, tabs 1

DEMADEX TABS 10MG, 20MG 3

EDECRIN TABS 25MG 4 NDS

ethacrynate sodium 4 NDS

ethacrynic acid tabs 4 NDS

furosemide inj, oral soln, tabs 1

LASIX TABS 3

torsemide tabs 1

Diuretics, Potassium-sparing

ALDACTAZIDE TABS 50MG; 50MG 2

ALDACTAZIDE TABS 25MG; 25MG 3

ALDACTONE 3

amiloride hcl tabs 1

amiloride/hydrochlorothiazide 1

CAROSPIR 4 NDS

DYAZIDE 3

DYRENIUM 2

eplerenone 1

INSPRA 3

MAXZIDE 3

MAXZIDE-25 3

spironolactone/hydrochlorothiazide 1

spironolactone tabs 1

triamterene/hydrochlorothiazide 1

Diuretics, Thiazide

chlorothiazide 1

chlorothiazide sodium 1

chlorthalidone tabs 25mg, 50mg 1

DIURIL SUSP 2

hydrochlorothiazide caps, tabs 1

indapamide tabs 1

methyclothiazide tabs 1

metolazone 1

MICROZIDE 3

SODIUM DIURIL 3

Dyslipidemics, Fibric Acid Derivatives

ANTARA CAPS 30MG, 90MG 2 ST

fenofibrate micronized 1

fenofibrate caps 130mg, 150mg, 43mg, 50mg 1

fenofibrate tabs 1

fenofibric acid 1

fenofibric acid dr 1

FENOGLIDE 3 ST

FIBRICOR 3 ST

gemfibrozil tabs 1

LIPOFEN 2 ST

44

Drug Name

Drug


LOPID TABS 3 ST

TRICOR TABS 145MG, 48MG 3 ST

TRIGLIDE TABS 160MG 2 ST

TRILIPIX 3 ST

Dyslipidemics, HMG CoA Reductase Inhibitors

ALTOPREV TB24 20MG, 40MG, 60MG 2 ST

atorvastatin calcium 1

CRESTOR 3

FLOLIPID 2 ST

fluvastatin 1

fluvastatin sodium er 1

LESCOL XL 3 ST

LIPITOR 3 ST

LIVALO 2 ST

lovastatin 1

PRAVACHOL TABS 20MG, 40MG, 80MG 3

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin tabs 10mg, 20mg, 40mg, 5mg 1

simvastatin tabs 80mg 1 PA

ZOCOR TABS 10MG, 20MG, 40MG, 5MG 3

ZOCOR TABS 80MG 3 PA

Dyslipidemics, Other

cholestyramine light powd 1

cholestyramine pack 1

COLESTID PACK, TABS 3

colestipol hcl pack, tabs 1

ezetimibe 1

ezetimibe/simvastatin tabs 10mg; 10mg, 10mg; 20mg, 10mg;

40mg

1

ezetimibe/simvastatin tabs 10mg; 80mg 1 PA

JUXTAPID 4 QL (30 EA per 30 days) PA NDS

KYNAMRO 4 QL (4 ML per 28 days) PA NDS

LOVAZA 3

niacin er 1

niacor 1

NIASPAN TBCR 1000MG, 500MG, 750MG 3

omega-3-acid ethyl esters 1

prevalite pack 1

QUESTRAN LIGHT POWD 3

QUESTRAN PACK 3

VASCEPA 2

VYTORIN TABS 10MG; 80MG 3 PA

VYTORIN TABS 10MG; 10MG, 10MG; 20MG, 10MG;

40MG

3 ST

WELCHOL 3

ZETIA 3

Vasodilators, Direct-acting Arterial/Venous

BIDIL 2

45

Drug Name

Drug


GONITRO 2

ISORDIL TITRADOSE TABS 5MG 3

ISORDIL TITRADOSE TABS 40MG 4 NDS

isosorbide dinitrate er 1

isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran 1

NITRO-BID 2

NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR 2

NITRO-DUR PT24 0.1MG/HR, 0.2MG/HR, 0.4MG/HR,

0.6MG/HR

3

nitroglycerin lingual soln 1

nitroglycerin transdermal 1

nitroglycerin inj 5mg/ml 1

nitroglycerin subl 0.3mg, 0.4mg, 0.6mg 1

NITROSTAT SUBL 3

Vasodilators, Direct-acting Arterial

hydralazine hcl inj, tabs 1

minoxidil tabs 1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADDERALL XR 3 QL (30 EA per 30 days) ST

ADDERALL TABS 1.25MG; 1.25MG; 1.25MG; 1.25MG,

1.875MG; 1.875MG; 1.875MG; 1.875MG, 5MG; 5MG;

5MG; 5MG


ADZENYS ER 2 QL (450 ML per 30 days) ST

ADZENYS XR-ODT 2 QL (30 EA per 30 days) ST

amphetamine/dextroamphetamine cp24 1 QL (30 EA per 30 days)

amphetamine/dextroamphetamine tabs 1 QL (90 EA per 30 days)

DESOXYN 4 QL (150 EA per 30 days) PA NDS

DEXEDRINE CP24 5MG 3 QL (60 EA per 30 days) ST

DEXEDRINE CP24 15MG 4 QL (120 EA per 30 days) ST NDS

DEXEDRINE CP24 10MG 4 QL (180 EA per 30 days) ST NDS

dextroamphetamine sulfate er cp24 15mg 1 QL (120 EA per 30 days)



dextroamphetamine sulfate tabs 10mg 1 QL (180 EA per 30 days)

dextroamphetamine sulfate tabs 5mg 1 QL (90 EA per 30 days)

DYANAVEL XR 2 QL (464 ML per 58 days) ST

methamphetamine hcl 4 QL (150 EA per 30 days) PA NDS

MYDAYIS 2 QL (30 EA per 30 days)

PROCENTRA 3 QL (1800 ML per 30 days) ST

VYVANSE 2 QL (30 EA per 30 days) PA

ZENZEDI TABS 30MG 2 QL (60 EA per 30 days) ST

ZENZEDI TABS 15MG, 2.5MG, 20MG 2 QL (90 EA per 30 days) ST



ZENZEDI TABS 7.5MG 4 QL (90 EA per 30 days) ST NDS

46

Drug Name

Drug


Attention Deficit Hyperactivity Disorder Agents, Non-

amphetamines

APTENSIO XR 2 QL (30 EA per 30 days) ST

atomoxetine caps 100mg, 18mg, 25mg, 40mg, 60mg, 80mg 1 QL (30 EA per 30 days)

atomoxetine caps 10mg 1 QL (60 EA per 30 days)

clonidine hcl er 1

CONCERTA TBCR 18MG, 27MG, 54MG 3 QL (30 EA per 30 days) ST

CONCERTA TBCR 36MG 3 QL (60 EA per 30 days) ST

DAYTRANA 2 QL (30 EA per 30 days) ST

dexmethylphenidate hcl 1 QL (60 EA per 30 days)

dexmethylphenidate hcl er 1 QL (30 EA per 30 days)

FOCALIN 3 QL (60 EA per 30 days) ST

FOCALIN XR 3 QL (30 EA per 30 days) ST

guanfacine er 1

INTUNIV 3

KAPVAY 3

metadate er tbcr 20mg 1 QL (90 EA per 30 days)

METHYLIN SOLN 3 ST

methylphenidate hcl cd 1 QL (30 EA per 30 days)

methylphenidate hcl er (la) 1 QL (30 EA per 30 days)

methylphenidate hcl er cp24 1 QL (30 EA per 30 days)

methylphenidate hcl er tbcr 10mg 1 QL (180 EA per 30 days)

methylphenidate hcl er tbcr 18mg, 27mg, 54mg 1 QL (30 EA per 30 days)



methylphenidate hcl chew 10mg 1 QL (180 EA per 30 days)

methylphenidate hcl chew 2.5mg, 5mg 1 QL (90 EA per 30 days)

methylphenidate hcl tabs 1 QL (90 EA per 30 days)

methylphenidate hydrochloride er cp24 1 QL (30 EA per 30 days)

methylphenidate hydrochloride er tbcr 72mg 1 QL (30 EA per 30 days)

methylphenidate hydrochloride soln 1

QUILLICHEW ER CHER 20MG, 40MG 2 QL (30 EA per 30 days) ST

QUILLICHEW ER CHER 30MG 2 QL (60 EA per 30 days) ST

QUILLIVANT XR 2 QL (360 ML per 30 days) ST

RITALIN 3 QL (90 EA per 30 days) ST

RITALIN LA CP24 10MG 2 QL (30 EA per 30 days) ST

RITALIN LA CP24 20MG, 30MG, 40MG 3 QL (30 EA per 30 days) ST

STRATTERA CAPS 100MG, 18MG, 25MG, 40MG, 60MG,

80MG


STRATTERA CAPS 10MG 2 QL (60 EA per 30 days) ST

Central Nervous System, Other

ALLZITAL 4 NDS

AUSTEDO 4 QL (120 EA per 30 days) PA NDS

BUPAP 3

butalbital/acetaminophen/caffeine caps 300mg; 50mg; 40mg 1

butalbital/acetaminophen/caffeine caps 325mg; 50mg; 40mg 1 QL (360 EA per 30 days)

butalbital/acetaminophen/caffeine tabs 1

butalbital/acetaminophen tabs 300mg; 50mg 1

butalbital/acetaminophen tabs 325mg; 50mg 1 QL (360 EA per 30 days)

47

Drug Name

Drug


butalbital/aspirin/caffeine caps 1

ESGIC TABS 3

FIORICET 3

FIORINAL 3

GRALISE STARTER 2 QL (156 EA per 365 days) ST

GRALISE TABS 300MG 2 QL (180 EA per 30 days) ST

GRALISE TABS 600MG 2 QL (90 EA per 30 days) ST

HORIZANT 2 QL (60 EA per 30 days) PA

INGREZZA CAPS 80MG 4 QL (30 EA per 30 days) PA NDS

INGREZZA CAPS 40MG 4 QL (60 EA per 30 days) PA NDS

NAMZARIC C4PK 10MG; 0 2 QL (56 EA per 365 days)

NUEDEXTA 2

phrenilin forte 1

RADICAVA 4 PA NDS

RILUTEK 4 PA NDS

riluzole 1 PA

tencon 1 QL (360 EA per 30 days)

tetrabenazine 4 PA NDS

vanatol lq 4 NDS

XENAZINE 4 PA NDS

zebutal caps 325mg; 50mg; 40mg 1 QL (360 EA per 30 days)

Fibromyalgia Agents

LYRICA CR TB24 330MG 2 QL (60 EA per 30 days)

LYRICA CR TB24 165MG, 82.5MG 2 QL (90 EA per 30 days)

SAVELLA 2 QL (60 EA per 30 days)

SAVELLA TITRATION PACK 2 QL (110 EA per 365 days)

Multiple Sclerosis Agents

AMPYRA 4 QL (60 EA per 30 days) PA NDS

AUBAGIO 4 QL (30 EA per 30 days) PA NDS

AVONEX 4 QL (4 EA per 28 days) PA NDS

AVONEX PEN 4 QL (4 EA per 28 days) PA NDS

BETASERON 4 QL (15 EA per 30 days) PA NDS

COPAXONE INJ 40MG/ML 4 QL (12 ML per 28 days) PA NDS

COPAXONE INJ 20MG/ML 4 QL (30 ML per 30 days) PA NDS

EXTAVIA 4 QL (15 EA per 30 days) PA NDS

GILENYA CAPS 0.5MG 4 QL (30 EA per 30 days) PA NDS

glatiramer acetate inj 40mg/ml 4 QL (12 ML per 28 days) PA NDS

glatiramer acetate inj 20mg/ml 4 QL (30 ML per 30 days) PA NDS

glatopa inj 40mg/ml 4 QL (12 ML per 28 days) PA NDS

glatopa inj 20mg/ml 4 QL (30 ML per 30 days) PA NDS

PLEGRIDY 4 QL (1 ML per 28 days) PA NDS

PLEGRIDY STARTER PACK 4 QL (2 ML per 365 days) PA NDS

REBIF 4 QL (6 ML per 28 days) PA NDS

REBIF REBIDOSE 4 QL (6 ML per 28 days) PA NDS

REBIF REBIDOSE TITRATION PACK 4 QL (8.4 ML per 365 days) PA NDS

REBIF TITRATION PACK 4 QL (8.4 ML per 365 days) PA NDS

TECFIDERA 4 QL (60 EA per 30 days) PA NDS

TECFIDERA STARTER PACK 4 QL (120 EA per 365 days) PA NDS

TYSABRI 4 PA NDS

48

Drug Name

Drug


Dental and Oral Agents

Dental and Oral Agents

cevimeline hcl 1

chlorhexidine gluconate soln 1

EVOXAC 3

KEPIVANCE 4 NDS

periogard 1

pilocarpine hcl tabs 7.5mg 1

pilocarpine hydrochloride 1

SALAGEN 3

triamcinolone acetonide dental paste 1

Dermatological Agents

Dermatological Agents

ABSORICA 4 PA NDS

ACANYA 2

acitretin caps 10mg, 25mg 1

acitretin caps 17.5mg 4 NDS

ACZONE GEL 5% 3

adapalene and benzoyl peroxide 1

adapalene crea, gel 1

AKTIPAK 2

ALDARA 4 NDS

ammonium lactate crea, lotn 1

amnesteem 1 PA

ATRALIN 3 PA

avita 1 PA

AZELEX 2

BENZACLIN WITH PUMP 3

BENZAMYCIN 3

calcipotriene 1

calcipotriene/betamethasone dipropionate 1 QL (400 GM per 30 days)

calcitriol oint 3mcg/gm 1

CARAC 4 NDS

claravis 1 PA

clindacin-p 2

clindamycin phosphate/tretinoin 1

clindamycin/benzoyl peroxide 1

clotrimazole/betamethasone dipropionate 1

CONDYLOX GEL 2

COSENTYX 4 PA NDS

COSENTYX SENSOREADY PEN 4 PA NDS

dapsone gel 5% 1

diclofenac sodium gel 1% 1 QL (1000 GM per 30 days)

diclofenac sodium transdermal soln 1.5% 1 PA

DIFFERIN LOTN 2

DIFFERIN CREA, GEL 3

DOVONEX CREA 4 NDS

doxepin hydrochloride 1

DUAC 3

49

Drug Name

Drug


DUPIXENT 4 QL (8 ML per 28 days) PA NDS

EFUDEX CREA 3

ELIDEL 2 ST

ENSTILAR 4 QL (420 GM per 28 days) NDS

EPIDUO 3

EPIDUO FORTE 2

erythromycin/benzoyl peroxide 1

EUCRISA 2 PA

FABIOR 4 NDS

FINACEA 2

FLUOROURACIL CREA 0.5% 4 NDS

fluorouracil crea 5% 1

fluorouracil external soln 2%, 5% 1

hydrocortisone acetate/pramoxine crea 1%; 1% 1

imiquimod crea 1

IMPOYZ 2

isotretinoin caps 1 PA

LOTRISONE 3

methoxsalen caps 4 NDS

MIRVASO 2 PA

myorisan 1 PA

neuac 1

ONEXTON 2

ORACEA 3

OXSORALEN ULTRA 4 NDS

PENNSAID SOLN 2% 4 PA NDS

PICATO 4 NDS

podofilox soln 1

PROTOPIC 3

prudoxin 1

RECTIV 2

REGRANEX 4 PA NDS

RETIN-A MICRO PUMP GEL 0.08% 4 PA NDS

RETIN-A MICRO GEL 0.04%, 0.1% 3 PA

RETIN-A MICRO GEL 0.06% 4 PA NDS

RETIN-A CREA, GEL 3 PA

SANTYL 2

selenium sulfide lotn 1

SILIQ 4 PA NDS

SOOLANTRA 2

SORIATANE CAPS 10MG, 17.5MG, 25MG 4 NDS

SORILUX 4 NDS

STELARA 4 PA NDS

SYNALAR CREA 2

TACLONEX 4 QL (400 GM per 30 days) NDS

tacrolimus oint 0.03%, 0.1% 1

TALTZ 4 PA NDS

tazarotene crea 1

TAZORAC 2

50

Drug Name

Drug


TOLAK 2

tretinoin microsphere 1 PA

tretinoin crea 0.025%, 0.05%, 0.1% 1 PA

tretinoin gel 0.01%, 0.025%, 0.05% 1 PA

VECTICAL 4 NDS

VEREGEN 4 NDS

VOLTAREN 3 QL (1000 GM per 30 days)

zenatane 1 PA

ZIANA 4 NDS

ZONALON 3

ZYCLARA PUMP 4 NDS

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

AMINOSYN 7%/ELECTROLYTES 2 B/D

aminosyn 8.5%/electrolytes 1 B/D

aminosyn ii 8.5%/electrolytes 1 B/D

CARBAGLU 4 NDS

CLINIMIX 2.75%/DEXTROSE 5% 2 B/D





CLINIMIX 5%/DEXTROSE 15% 2 B/D



CLINIMIX E 2.75%/DEXTROSE 10% 2 B/D





CLINIMIX E 5%/DEXTROSE 15% 2 B/D



dextrose 10%/nacl 0.45% 1

dextrose 10% 1


dextrose 2.5%/nacl 0.45% 1

dextrose 5% 1

dextrose 5%/lactated ringers 1






IONOSOL-MB/DEXTROSE 5% 2

ISOLYTE-P/DEXTROSE 5% 2

ISOLYTE-S 2

K-TAB 3

kcl 0.075%/d5w/nacl 0.45% 1

51

Drug Name

Drug


kcl 0.15%/d5w/nacl 0.2% 1

kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% 1

kcl 0.15%/d5w/nacl 0.9% 1

kcl 0.3%/d5w/nacl 0.45% 1

kcl 0.3%/d5w/nacl 0.9% 1

klor-con 1

klor-con 10 1

klor-con 8 1

klor-con m10 1

KLOR-CON M15 2

klor-con m20 1

klor-con sprinkle 1

lactated ringers viaflex 1

magnesium sulfate inj 50% 1

NORMOSOL-M IN D5W 2

NORMOSOL-R 2

NORMOSOL-R IN D5W 2

PLASMA-LYTE A 2

PLASMA-LYTE-148 2

potassium chloride cr tbcr 10meq 1

potassium chloride er cpcr 1

potassium chloride er tbcr 10meq, 20meq, 8meq 1

potassium chloride/dextrose 1

potassium chloride/dextrose/lactated ringers inj 3meq/l;

149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

1

potassium chloride/dextrose/sodium chloride 1

potassium chloride/sodium chloride inj 20meq/l; 0.45%,

20meq/l; 0.9%, 40meq/l; 0.9%

1

potassium chloride oral soln 1

potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml,

40meq/100ml

1

potassium citrate er 1

PROCALAMINE 2 B/D

ringers injection 1

sodium chloride 0.45% inj 1

sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% 1

sodium fluoride tabs 1mg 1

sodium lactate inj 5meq/ml 1

tpn electrolytes 1

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

Electrolyte/Mineral/Metal Modifiers

CHEMET 4 NDS

CUPRIMINE 4 NDS

DEPEN TITRATABS 4 NDS

EXJADE 4 PA NDS

FERRIPROX 4 PA NDS

JADENU 4 PA NDS

52

Drug Name

Drug


JADENU SPRINKLE 4 PA NDS

kionex susp 1

SAMSCA TABS 15MG 4 QL (30 EA per 60 days) NDS

SAMSCA TABS 30MG 4 QL (60 EA per 30 days) NDS

sodium polystyrene sulfonate powd 1

sps 1

SYPRINE 4 NDS

trientine hydrochloride 4 NDS

VELTASSA 2

Phosphate Binders

AURYXIA 4 NDS

calcium acetate caps 1

calcium acetate tabs 667mg 1

FOSRENOL PACK 4 NDS

FOSRENOL CHEW 1000MG, 500MG, 750MG 4 NDS

lanthanum carbonate 4 NDS

PHOSLYRA 2

RENAGEL TABS 400MG 2

RENAGEL TABS 800MG 4 NDS

RENVELA 4 NDS

sevelamer carbonate 4 NDS

VELPHORO 4 NDS

Vitamins

RAYALDEE 4 NDS

VP-PNV-DHA 2

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

BENTYL INJ 3

CUVPOSA 2

dicyclomine hcl 1

glycopyrrolate inj 4mg/20ml 1

glycopyrrolate tabs 1mg, 2mg 1

methscopolamine bromide tabs 1

propantheline bromide tabs 1

ROBINUL FORTE 3

ROBINUL TABS 3

Gastrointestinal Agents, Other

ACTIGALL 4 NDS

CHENODAL 4 NDS

CHOLBAM 4 PA NDS

cromolyn sodium conc 100mg/5ml 1

diphenoxylate/atropine 1

GASTROCROM CONC 4 NDS

GATTEX 4 PA NDS

lansoprazole/amoxicillin/clarithromycin 1

LOMOTIL TABS 3

loperamide hcl caps 1

metoclopramide hcl inj, oral soln, tabs 1

metoclopramide odt 1

53

Drug Name

Drug


MOVANTIK 2 QL (30 EA per 30 days)

MYTESI 2 QL (60 EA per 30 days)

OCALIVA 4 QL (30 EA per 30 days) PA NDS

OMECLAMOX-PAK 2

PREVPAC 4 NDS

PYLERA 4 NDS

REGLAN TABS 3

RELISTOR TABS 4 QL (90 EA per 30 days) PA NDS

RELISTOR INJ 8MG/0.4ML 4 QL (12 ML per 30 days) PA NDS

RELISTOR INJ 12MG/0.6ML 4 QL (18 ML per 30 days) PA NDS

SYMPROIC 2 QL (30 EA per 30 days) ST

TRULANCE 2 QL (90 EA per 30 days) ST

URSO 250 3

URSO FORTE 3

ursodiol caps, tabs 1

XERMELO 4 QL (90 EA per 30 days) PA NDS

Histamine2 (H2) Receptor Antagonists

cimetidine hcl soln 1

cimetidine tabs 1

famotidine premixed 1

famotidine susr 1

famotidine inj 20mg/2ml 1

famotidine tabs 20mg, 40mg 1

nizatidine 1

PEPCID SUSR 3

PEPCID TABS 20MG 3

PEPCID TABS 40MG 4 NDS

ranitidine hcl caps, syrp 1

ranitidine hcl inj 50mg/2ml 1

ranitidine hcl tabs 150mg, 300mg 1

ZANTAC INJ 25MG/ML 2

ZANTAC TABS 300MG 3

Irritable Bowel Syndrome Agents

alosetron hydrochloride 4 PA NDS

AMITIZA 2 QL (60 EA per 30 days)

LINZESS 2 QL (30 EA per 30 days)

LOTRONEX 4 PA NDS

VIBERZI 4 QL (60 EA per 30 days) PA NDS

Laxatives

CLENPIQ 2

COLYTE-FLAVOR PACKS SOLR 240GM; 2.98GM;

6.72GM; 5.84GM; 22.72GM

3

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n/flavor pack 1

generlac 1

54

Drug Name

Drug


GOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM; 5.53GM;

21.5GM

2

GOLYTELY SOLR 236GM; 2.97GM; 6.74GM; 5.86GM;

22.74GM

3

KRISTALOSE 2 ST

lactulose soln 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 2

peg 3350/electrolytes 1

peg-3350/electrolytes 1

peg-3350/nacl/na bicarbonate/kcl 1

polyethylene glycol 3350 powd 1

PREPOPIK 2

SUPREP BOWEL PREP KIT 2

trilyte 1

Protectants

CARAFATE SUSP 2

CARAFATE TABS 3

CYTOTEC 3

misoprostol 1

sucralfate tabs 1

Proton Pump Inhibitors

ACIPHEX 3 QL (60 EA per 30 days) ST

ACIPHEX SPRINKLE CPSP 10MG 2 QL (120 EA per 30 days) ST

ACIPHEX SPRINKLE CPSP 5MG 2 QL (240 EA per 30 days) ST

DEXILANT CPDR 60MG 2 QL (30 EA per 30 days) ST

DEXILANT CPDR 30MG 2 QL (60 EA per 30 days) ST

esomeprazole magnesium cpdr 20mg 1 QL (120 EA per 30 days)

esomeprazole magnesium cpdr 40mg 1 QL (60 EA per 30 days)

esomeprazole sodium 1

ESOMEPRAZOLE STRONTIUM CPDR 49.3MG 2 QL (30 EA per 30 days) ST

lansoprazole cpdr 15mg 1 QL (180 EA per 30 days)

lansoprazole cpdr 30mg 1 QL (90 EA per 30 days)

lansoprazole tbdp 15mg 1 QL (180 EA per 30 days)

lansoprazole tbdp 30mg 1 QL (90 EA per 30 days)

NEXIUM I.V. INJ 40MG 3 ST

NEXIUM CPDR 20MG 3 QL (120 EA per 30 days) ST

NEXIUM CPDR 40MG 3 QL (60 EA per 30 days) ST

NEXIUM PACK 20MG 2 QL (120 EA per 30 days) ST




NEXIUM PACK 2.5MG 2 QL (960 EA per 30 days) ST

omeprazole/sodium bicarbonate caps 4 QL (30 EA per 30 days) NDS

omeprazole/sodium bicarbonate pack 4 QL (60 EA per 30 days) NDS

omeprazole cpdr 10mg 1 QL (120 EA per 30 days)



55

Drug Name

Drug


pantoprazole sodium inj 1

pantoprazole sodium tbec 20mg 1 QL (120 EA per 30 days)

pantoprazole sodium tbec 40mg 1 QL (60 EA per 30 days)

PREVACID SOLUTAB TBDP 15MG 2 QL (180 EA per 30 days) ST

PREVACID SOLUTAB TBDP 30MG 2 QL (90 EA per 30 days) ST

PREVACID CPDR 15MG 3 QL (180 EA per 30 days) ST

PREVACID CPDR 30MG 3 QL (90 EA per 30 days) ST

PRILOSEC PACK 2 ST

PROTONIX PACK 2 QL (60 EA per 30 days) ST

PROTONIX INJ 3 ST

PROTONIX TBEC 20MG 3 QL (120 EA per 30 days) ST

PROTONIX TBEC 40MG 3 QL (60 EA per 30 days) ST

rabeprazole sodium 1 QL (60 EA per 30 days)

ZEGERID CAPS 4 QL (30 EA per 30 days) ST NDS

ZEGERID PACK 40MG; 1680MG 4 QL (60 EA per 30 days) NDS

ZEGERID PACK 20MG; 1680MG 4 QL (60 EA per 30 days) ST NDS

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN 4 PA NDS

ALDURAZYME 4 PA NDS

BUPHENYL 4 NDS

CERDELGA 4 PA NDS

CEREZYME 4 PA NDS

CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT,

15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT;

36000UNIT; 114000UNIT, 30000UNIT; 6000UNIT;

19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT

2

CYSTADANE 4 NDS

CYSTAGON 2

ELAPRASE 4 PA NDS

ELELYSO 4 PA NDS

EXONDYS 51 4 PA NDS

FABRAZYME 4 PA NDS

KANUMA 4 PA NDS

KUVAN 4 PA NDS

LUMIZYME 4 PA NDS

NAGLAZYME 4 PA NDS

ORFADIN 4 NDS

PANCREAZE CPEP 10850UNIT; 2600UNIT; 6200UNIT,



56800UNIT

2 ST

PANCREAZE CPEP 83900UNIT; 21000UNIT; 54700UNIT 4 ST NDS

PERTZYE CPEP 15125UNIT; 4000UNIT; 14375UNIT,

30250UNIT; 8000UNIT; 28750UNIT

2 ST

PERTZYE CPEP 60500UNIT; 16000UNIT; 57500UNIT 4 ST NDS

RAVICTI 4 PA NDS

sodium phenylbutyrate powd, tabs 4 NDS

STRENSIQ INJ 40MG/ML, 80MG/0.8ML 4 PA NDS

56

Drug Name

Drug


SUCRAID 4 NDS

VIOKACE TABS 39150UNIT; 10440UNIT; 39150UNIT 2 ST

VIOKACE TABS 78300UNIT; 20880UNIT; 78300UNIT 4 ST NDS

VPRIV 4 PA NDS

XURIDEN 4 QL (120 EA per 30 days) PA NDS

ZAVESCA 4 PA NDS

ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT,



17000UNIT, 42000UNIT; 10000UNIT; 32000UNIT,


20000UNIT; 63000UNIT

2

Genitourinary Agents

Antispasmodics, Urinary

darifenacin hydrobromide er 1

DETROL 3 ST

DETROL LA 3 ST

DITROPAN XL 3 ST

ENABLEX 3 ST

flavoxate hcl 1

GELNIQUE GEL 10% 2 ST

MYRBETRIQ 2 ST

oxybutynin chloride er 1

oxybutynin chloride syrp, tabs 1

OXYTROL 2 QL (8 EA per 28 days) ST

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 2

trospium chloride 1

trospium chloride er 1

VESICARE 2

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er 1

AVODART 3 ST

CARDURA 3 ST

CARDURA XL 2 ST

CIALIS TABS 2.5MG, 5MG 2 QL (30 EA per 30 days) PA

doxazosin mesylate tabs 1mg, 2mg, 8mg 1

doxazosin tabs 4mg 1

dutasteride/tamsulosin hydrochloride 1

dutasteride caps 1

finasteride tabs 5mg 1

FLOMAX 3 ST

JALYN 3 ST

PROSCAR 3 ST

RAPAFLO 2

tamsulosin hcl 1

terazosin hcl caps 1

UROXATRAL 3 ST

57

Drug Name

Drug


Genitourinary Agents, Other

bethanechol chloride tabs 1

ELMIRON 2

LITHOSTAT 4 NDS

THIOLA 4 NDS

URECHOLINE TABS 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ALA SCALP 3

ala-cort 1

alclometasone dipropionate 1

amcinonide 1

ANUSOL-HC CREA 3

APEXICON E 4 NDS

augmented betamethasone dipropionate 1

betamethasone dipropionate crea, lotn, oint 1

betamethasone valerate crea, foam, lotn, oint 1

CAPEX 2

clobetasol propionate e 1

clobetasol propionate foam, gel, liqd, lotn, oint, sham, soln 1

CLOBEX LOTN 3

CLOBEX LIQD, SHAM 4 NDS

clodan 1

CLODERM 3

colocort 1

CORDRAN TAPE 2

CORTEF TABS 3

cortisone acetate tabs 25mg 1

CUTIVATE LOTN 4 NDS

DEPO-MEDROL INJ 20MG/ML 2

DEPO-MEDROL INJ 40MG/ML, 80MG/ML 3

DESONATE 2

desonide crea, lotn, oint 1

DESOWEN CREA, LOTN 3

desoximetasone crea, gel, oint 1

dexamethasone intensol 1

dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml 1

dexamethasone elix 1

dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg,

6mg

1

DEXPAK 13 DAY TBPK 2

diflorasone diacetate 1

DIPROLENE OINT 3

ELOCON CREA, OINT 3

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA NDS

fludrocortisone acetate tabs 1

fluocinolone acetonide scalp 1

fluocinolone acetonide crea 0.01%, 0.025% 1

58

Drug Name

Drug


fluocinolone acetonide oint 0.025% 1

fluocinolone acetonide soln 0.01% 1

fluocinonide emulsified base 1

fluocinonide crea 0.1% 4 NDS

fluocinonide gel, oint, soln 1

flurandrenolide 1

fluticasone propionate crea 0.05% 1

fluticasone propionate lotn 0.05% 1

fluticasone propionate oint 0.005% 1

halobetasol propionate 1

HALOG OINT 2

HALOG CREA 0.1% 4 NDS

hydrocortisone butyrate crea, oint, soln 1

hydrocortisone valerate 1

hydrocortisone crea 1%, 2.5% 1

hydrocortisone enem, tabs 1

hydrocortisone lotn 2.5% 1

hydrocortisone oint 1%, 2.5% 1

INTRAROSA 2 QL (28 EA per 28 days) PA

KENALOG-10 2

KENALOG-40 2

KENALOG AERS 3

LOCOID LIPOCREAM 3

LOCOID LOTN 2

LOCOID SOLN 3

MEDROL DOSEPAK 3

MEDROL TABS 2MG 2

MEDROL TABS 16MG, 32MG, 4MG, 8MG 3

methylprednisolone acetate inj 40mg/ml, 80mg/ml 1

methylprednisolone dose pack tbpk 1

methylprednisolone sodiumsuccinate inj 1000mg, 125mg,

40mg

1

methylprednisolone tabs 1

MICORT-HC 2

MILLIPRED 2

mometasone furoate crea 0.1% 1

mometasone furoate oint 0.1% 1

mometasone furoate soln 0.1% 1

nolix 1

OLUX 4 NDS

ORAPRED ODT 3

PANDEL 4 NDS

prednicarbate 1

prednisolone sodium phosphate odt 1

prednisolone sodium phosphate oral soln 10mg/5ml,

20mg/5ml, 25mg/5ml, 5mg/5ml

1

prednisolone soln 1

prednisone intensol 1

prednisone soln, tbpk 1

59

Drug Name

Drug


prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg 1

procto-med hc 1

procto-pak 1

proctosol hc 1

proctozone-hc 1

psorcon crea 1

RAYOS 4 NDS

SOLU-CORTEF INJ 100MG, 250MG 2

SOLU-MEDROL INJ 2GM, 500MG 2

SOLU-MEDROL INJ 1000MG, 125MG, 40MG 3

TAPERDEX 12-DAY 2

TAPERDEX 6-DAY 2

TOPICORT LIQD 2

TOPICORT CREA, GEL, OINT 3

triamcinolone acetonide aers 0.147mg/gm 1

triamcinolone acetonide crea 0.025%, 0.1%, 0.5% 1

triamcinolone acetonide inj 40mg/ml 1

triamcinolone acetonide lotn 0.025%, 0.1% 1

triamcinolone acetonide oint 0.025%, 0.1%, 0.5% 1

TRIANEX 4 NDS

triderm crea 0.1% 1

tridesilon crea 1

UCERIS FOAM 2MG/ACT 2

ULTRAVATE CREA, OINT 3

ULTRAVATE LOTN 4 NDS

VANOS 4 NDS

VERIPRED 20 2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

chorionic gonadotropin 1 PA

DDAVP NASAL SOLN 4 NDS

DDAVP INJ 4MCG/ML 4 NDS

DDAVP TABS 0.1MG 3

DDAVP TABS 0.2MG 4 NDS

desmopressin acetate inj, nasal soln, tabs 1

EGRIFTA INJ 1MG 4 QL (60 EA per 30 days) PA NDS

GENOTROPIN 4 PA NDS

GENOTROPIN MINIQUICK INJ 0.2MG 2 PA

GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG,

1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

4 PA NDS

H.P. ACTHAR 4 PA NDS

HUMATROPE COMBO PACK 4 PA NDS

HUMATROPE INJ 12MG, 24MG, 6MG 4 PA NDS

INCRELEX 4 PA NDS

NOCTIVA 2

NORDITROPIN FLEXPRO 4 PA NDS

NOVAREL INJ 5000UNIT 2

novarel inj 10000unit 1 PA

NUTROPIN AQ NUSPIN 10 4 PA NDS

60

Drug Name

Drug




OMNITROPE INJ 5.8MG 2 PA

OMNITROPE INJ 10MG/1.5ML, 5MG/1.5ML 4 PA NDS

pregnyl w/diluent benzyl alcohol/nacl 1 PA

SAIZEN 4 PA NDS

SAIZEN CLICK.EASY 4 PA NDS

SEROSTIM INJ 4MG, 5MG, 6MG 4 PA NDS

STIMATE SOLN 4 NDS

ZOMACTON INJ 5MG 2 PA

ZOMACTON INJ 10MG 4 PA NDS

ZORBTIVE 4 PA NDS

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

KORLYM 4 QL (120 EA per 30 days) PA NDS

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers)

Anabolic Steroids

ANADROL-50 4 PA NDS

oxandrolone tabs 2.5mg 1 QL (240 EA per 30 days) PA

oxandrolone tabs 10mg 1 QL (60 EA per 30 days) PA

Androgens

ANDRODERM PT24 2MG/24HR, 4MG/24HR 2 PA

ANDROGEL PUMP GEL 1.62% 2 PA

ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM 2 PA

ANDROGEL GEL 25MG/2.5GM, 50MG/5GM 3 PA

AVEED 2 PA

danazol caps 1

DEPO-TESTOSTERONE INJ 100MG/ML, 200MG/ML 3 PA

FORTESTA 2 PA

METHITEST 2 PA

methyltestosterone caps 4 PA NDS

STRIANT 2 PA

TESTIM 3 PA

testosterone cypionate inj 1 PA

testosterone enanthate inj 1 PA

testosterone pump 1 PA

TESTOSTERONE GEL 10MG/ACT 2 PA

testosterone gel 25mg/2.5gm, 50mg/5gm 1 PA

testosterone soln 1 PA

VOGELXO 3 PA

VOGELXO PUMP 3 PA

Estrogens

ACTIVELLA 3

ALORA 2

altavera 1

alyacen 1/35 1

61

Drug Name

Drug


amabelz 1

amethia 1 QL (91 EA per 91 days)

amethia lo 1 QL (91 EA per 91 days)

ANGELIQ 2

apri 1

aranelle 1

ashlyna 1 QL (91 EA per 91 days)

aubra 1

aviane 1

balziva 1

bekyree 1

BEYAZ 3

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camrese lo 1 QL (91 EA per 91 days)

caziant 1

CLIMARA 3

CLIMARA PRO 2

COMBIPATCH 2

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

DELESTROGEN INJ 10MG/ML 2

DELESTROGEN INJ 20MG/ML, 40MG/ML 3

delyla 1

DEPO-ESTRADIOL INJ 5MG/ML 2

desogestrel/ethinyl estradiol 1

DIVIGEL GEL 1MG/GM 2

drospirenone/ethinyl estradiol 1

drospirenone/ethinyl estradiol/levomefolate calcium tabs 3mg;

0.02mg; 0.451mg

1

DUAVEE 2

ELESTRIN 2

emoquette 1

enpresse-28 1

enskyce 1

ESTRACE CREA 2

ESTRACE TABS 3

estradiol valerate inj 20mg/ml, 40mg/ml 1

estradiol/norethindrone acetate 1

estradiol crea, pttw, ptwk, oral tabs, vaginal tabs 1

ESTRING 2 QL (1 EA per 90 days)

estropipate tabs 1

ethynodiol diacetate/ethinyl estradiol 1

EVAMIST 2

falmina 1

fayosim 1 QL (91 EA per 91 days)

62

Drug Name

Drug


FEMHRT LOW DOSE 3

FEMRING 2 QL (1 EA per 90 days)

femynor 1

fyavolv 1

GENERESS FE 3

gianvi 1

introvale 1 QL (91 EA per 91 days)

isibloom 1

jinteli 1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kaitlib fe 1

kariva 1

kelnor 1/35 1

kelnor 1/50 1

kimidess 1

kurvelo 1

larin 1.5/30 1

larin 1/20 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 1

leena 1

lessina 1

levonest 1

levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 1

levonorgestrel and ethinyl estradiol tabs 0; 0 1 QL (91 EA per 91 days)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0,

20mcg; 0.1mg

1

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 1 QL (91 EA per 91 days)

levora 0.15/30-28 1

LO LOESTRIN FE 2

LOESTRIN 1.5/30-21 3

LOESTRIN 1/20-21 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

loryna 1

LOSEASONIQUE 3 QL (91 EA per 91 days)

low-ogestrel 1

lutera 1

marlissa 1

melodetta 24 fe 1

MENEST TABS 0.3MG, 0.625MG, 1.25MG 2

MENOSTAR 2

63

Drug Name

Drug


mibelas 24 fe 1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1

microgestin fe 1.5/30 1

mimvey 1

mimvey lo 1

MINASTRIN 24 FE 2

MINIVELLE 2

mononessa 1

NATAZIA 2

necon 0.5/35-28 1

necon 7/7/7 1

nikki 1

norethindrone & ethinyl estradiol ferrous fumarate 1

norethindrone acetate/ethinyl estradiol/ferrous fumarate 1

norethindrone acetate/ethinyl estradiol tabs 1

norethindrone/ethinyl estradiol/ferrous fumarate 1

norgestimate/ethinyl estradiol 1

nortrel 0.5/35 (28) 1

nortrel 1/35 1

nortrel 7/7/7 1

NUVARING 2

ocella 1

ogestrel 1

orsythia 1

ORTHO TRI-CYCLEN 3

ORTHO TRI-CYCLEN LO 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

pimtrea 1

pirmella 1/35 1

portia-28 1

PREFEST 2

PREMARIN CREA, INJ 2

PREMARIN TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG,

1.25MG

2

PREMPHASE 2

PREMPRO 2

previfem 1

QUARTETTE 3 QL (91 EA per 91 days)

quasense 1 QL (91 EA per 91 days)

reclipsen 1

rivelsa 1 QL (91 EA per 91 days)

SAFYRAL 2

SEASONIQUE 3 QL (91 EA per 91 days)

setlakin 1 QL (91 EA per 91 days)

sprintec 28 1

64

Drug Name

Drug


sronyx 1

syeda 1

tarina fe 1/20 1

tri-legest fe 1

tri-lo-estarylla 1

tri-lo-sprintec 1

TRI-NORINYL 28 3

tri-previfem 1

tri-sprintec 1

tri-vylibra 1

trinessa 1

trivora-28 1

tydemy 1

VAGIFEM TABS 10MCG 3

velivet 1

vestura 1

vienva 1

VIVELLE-DOT 3

vyfemla 1

vylibra 1

wymzya fe 1

xulane 1

YASMIN 28 3

YAZ 3

yuvafem 1

zarah 1

zenchent 1

zovia 1/35e 1

zovia 1/50e 1

Progesterone Agonists/Antagonists

MAKENA INJ 275MG/1.1ML 4 PA NDS

Progestins

AYGESTIN 3

camila 1

CRINONE 2 PA

deblitane 1

DEPO-PROVERA CONTRACEPTIVE 3 QL (1 ML per 90 days)

DEPO-PROVERA INJ 400MG/ML 2 QL (10 ML per 28 days)

DEPO-SUBQ PROVERA 104 2 QL (0.65 ML per 90 days)

errin 1

hydroxyprogesterone caproate inj 1.25gm/5ml 4 PA NDS

jolivette 1

lyza 1

MAKENA INJ 250MG/ML 4 PA NDS

medroxyprogesterone acetate tabs 1

medroxyprogesterone acetate inj 1 QL (1 ML per 90 days)

MEGACE ES 4 PA NDS

megestrol acetate susp, tabs 1 PA

nora-be 1

65

Drug Name

Drug


norethindrone acetate tabs 1

norethindrone tabs 1

norlyroc 1

ORTHO MICRONOR 3

progesterone caps 1

PROMETRIUM 3

PROVERA 3

sharobel 1

Selective Estrogen Receptor Modifying Agents

EVISTA 3

OSPHENA 2 QL (30 EA per 30 days) PA

raloxifene hydrochloride 1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

CYTOMEL 3

levo-t 1

levothyroxine sodium tabs 1

levothyroxine sodium inj 100mcg 1

levoxyl tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,

175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg

1

liothyronine sodium inj, tabs 1

SYNTHROID TABS 3

THYROLAR-1 2

THYROLAR-1/2 2

THYROLAR-1/4 2

THYROLAR-2 2

THYROLAR-3 2

TIROSINT 2

TRIOSTAT 4 NDS

TYMLOS 4 PA NDS

unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,

200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 4 NDS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

cabergoline 1

ELIGARD INJ 30MG 2 QL (1 EA per 112 days) PA

ELIGARD INJ 45MG 2 QL (1 EA per 168 days) PA

ELIGARD INJ 7.5MG 2 QL (1 EA per 28 days) PA

ELIGARD INJ 22.5MG 2 QL (1 EA per 84 days) PA

FIRMAGON INJ 80MG 2 QL (1 EA per 28 days) PA

FIRMAGON INJ 120MG 4 QL (4 EA per 365 days) PA NDS

leuprolide acetate inj 4 PA NDS

LUPANETA PACK KIT 3.75MG; 5MG 4 QL (1 EA per 28 days) PA NDS

LUPANETA PACK KIT 11.25MG; 5MG 4 QL (1 EA per 84 days) PA NDS

LUPRON DEPOT (1-MONTH) 4 QL (1 EA per 28 days) PA NDS


66

Drug Name

Drug




LUPRON DEPOT-PED (1-MONTH) INJ 11.25MG, 15MG 4 QL (1 EA per 28 days) PA NDS

LUPRON DEPOT-PED (3-MONTH) INJ 30MG 4 QL (1 EA per 84 days) PA

octreotide acetate 1 PA

SANDOSTATIN LAR DEPOT 4 PA NDS

SANDOSTATIN INJ 50MCG/ML 3 PA

SANDOSTATIN INJ 100MCG/ML, 500MCG/ML 4 PA NDS

SIGNIFOR 4 QL (60 ML per 30 days) PA NDS

SIGNIFOR LAR 4 QL (1 EA per 28 days) PA NDS

SOMATULINE DEPOT 4 PA NDS

SOMAVERT 4 PA NDS

SYNAREL 4 NDS

TRELSTAR MIXJECT INJ 22.5MG 4 QL (1 EA per 168 days) PA NDS



Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole tabs 10mg, 5mg 1

propylthiouracil tabs 1

TAPAZOLE 3

Immunological Agents

Angioedema (HAE) Agents

HAEGARDA 4 PA NDS

Angioedema Agents

BERINERT 4 PA NDS

CINRYZE 4 PA NDS

FIRAZYR 4 PA NDS

RUCONEST 4 PA NDS

Immune Suppressants

ASTAGRAF XL 2 B/D

AZASAN 2 B/D

azathioprine inj, tabs 1 B/D

BENLYSTA 4 PA NDS

CELLCEPT 4 B/D NDS

CELLCEPT INTRAVENOUS 3 B/D

CIMZIA 4 PA NDS

cyclosporine modified 1 B/D

cyclosporine caps, inj 1 B/D

ENBREL 4 PA NDS

ENBREL SURECLICK 4 PA NDS

ENVARSUS XR TB24 0.75MG, 1MG 2 B/D

ENVARSUS XR TB24 4MG 4 B/D NDS

gengraf caps 100mg, 25mg 1 B/D

gengraf soln 1 B/D

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK

4 PA NDS

HUMIRA PEN 4 PA NDS

HUMIRA PEN-CROHNS DISEASESTARTER 4 PA NDS

67

Drug Name

Drug


HUMIRA PEN-PSORIASIS STARTER 4 PA NDS

HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.4ML,

40MG/0.4ML, 40MG/0.8ML

4 PA NDS

IMURAN TABS 3 B/D

INFLECTRA 4 PA NDS

KINERET 4 PA NDS

methotrexate sodium inj 1gm, 250mg/10ml, 50mg/2ml 1

methotrexate tabs 1

mycophenolate mofetil caps, inj, tabs 1 B/D

mycophenolate mofetil susr 4 B/D NDS

mycophenolic acid dr 1 B/D

MYFORTIC TBEC 180MG 3 B/D

MYFORTIC TBEC 360MG 4 B/D NDS

NEORAL 3 B/D

NULOJIX 4 PA NDS

ORENCIA 4 PA NDS

ORENCIA CLICKJECT 4 QL (4 ML per 28 days) PA NDS

OTREXUP INJ 10MG/0.4ML, 12.5MG/0.4ML,

15MG/0.4ML, 17.5MG/0.4ML, 20MG/0.4ML,

22.5MG/0.4ML, 25MG/0.4ML

2 QL (1.6 ML per 28 days) PA

PROGRAF INJ 2 B/D

PROGRAF CAPS 0.5MG, 1MG 3 B/D

PROGRAF CAPS 5MG 4 B/D NDS

RAPAMUNE SOLN 4 B/D NDS

RAPAMUNE TABS 0.5MG 3 B/D

RAPAMUNE TABS 1MG, 2MG 4 B/D NDS

RASUVO INJ 7.5MG/0.15ML 2 QL (0.6 ML per 28 days) PA

RASUVO INJ 10MG/0.2ML 2 QL (0.8 ML per 28 days) PA

RASUVO INJ 12.5MG/0.25ML 2 QL (1 ML per 28 days) PA





RASUVO INJ 25MG/0.5ML 2 QL (2 ML per 28 days) PA


REMICADE 4 PA NDS

RENFLEXIS 4 PA NDS

SANDIMMUNE ORAL SOLN 2 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE CAPS 25MG 3 B/D

SANDIMMUNE CAPS 100MG 4 B/D NDS

SIMPONI 4 PA NDS

SIMPONI ARIA 4 PA NDS

sirolimus tabs 1 B/D

tacrolimus caps 0.5mg, 1mg, 5mg 1 B/D

TREMFYA 4 PA NDS

TREXALL 2

XATMEP 2

ZORTRESS 4 PA NDS

68

Drug Name

Drug


Immunizing Agents, Passive

ATGAM 4 B/D NDS

BIVIGAM INJ 10GM/100ML 4 PA NDS

CARIMUNE NANOFILTERED INJ 6GM 4 PA NDS

FLEBOGAMMA DIF INJ 10% 4 PA NDS

GAMASTAN S/D 2 PA

GAMMAGARD LIQUID INJ 2.5GM/25ML 4 PA NDS

GAMMAGARD S/D IGA LESS THAN 1MCG/ML 4 PA NDS

GAMMAKED INJ 1GM/10ML 4 PA NDS

GAMMAPLEX INJ 10GM/100ML; 0, 10GM/200ML,

20GM/200ML, 5GM/50ML

4 PA NDS

GAMUNEX-C INJ 1GM/10ML 4 PA NDS

HYPERRAB S/D INJ 1500UNIT/10ML, 300UNIT/2ML 4 B/D NDS

IMOGAM RABIES-HT INJ 300UNIT/2ML 4 B/D NDS

OCTAGAM INJ 1GM/20ML, 2GM/20ML 4 PA NDS

PRIVIGEN INJ 20GM/200ML 4 PA NDS

SYNAGIS INJ 100MG/ML, 50MG/0.5ML 4 PA NDS

THYMOGLOBULIN 4 B/D NDS

Immunomodulators

ACTEMRA INJ 80MG/4ML 2 PA

ACTEMRA INJ 200MG/10ML, 400MG/20ML 4 PA NDS

ACTEMRA INJ 162MG/0.9ML 4 QL (3.6 ML per 28 days) PA NDS

ACTIMMUNE 4 PA NDS

ARAVA TABS 10MG, 20MG 4 NDS

ARCALYST 4 PA NDS

ILARIS INJ 150MG/ML 4 QL (2 ML per 28 days) PA NDS

KEVZARA 4 PA NDS

leflunomide tabs 1

OTEZLA 4 PA NDS

RIDAURA 4 NDS

SIMULECT INJ 20MG 4 B/D NDS

SYLVANT 4 PA NDS

XELJANZ 4 PA NDS

XELJANZ XR 4 PA NDS

ZINPLAVA 4 NDS

Vaccines

ACTHIB INJ 0 2

ADACEL 2

BCG VACCINE 2

BEXSERO 2

BOOSTRIX 2

DAPTACEL INJ 23MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 2

diphtheria/tetanus toxoids adsorbed pediatric 1

ENGERIX-B 2 B/D

GARDASIL 9 2

HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML 2

HIBERIX 2

IMOVAX RABIES (H.D.C.V.) 2 B/D

INFANRIX 2

69

Drug Name

Drug


IPOL INACTIVATED IPV 2

IXIARO 2

KINRIX 2

M-M-R II 2

MENACTRA 2

MENVEO 2

PEDIARIX 2

PEDVAX HIB INJ 7.5MCG/0.5ML 2

PROQUAD 2

QUADRACEL 2

RABAVERT 2 B/D

RECOMBIVAX HB 2 B/D

ROTARIX 2

ROTATEQ SOLN 2

SHINGRIX 2

TENIVAC 2

tetanus/diphtheria toxoids-adsorbed 1

TRUMENBA 2

TWINRIX 2

TYPHIM VI 2

VAQTA 2

VARIVAX 2

VARIZIG 4 PA NDS

YF-VAX 2

ZOSTAVAX 2

Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO 2

ASACOL HD 2 ST

balsalazide disodium 1

CANASA SUPP 1000MG 4 NDS

COLAZAL 4 NDS

DELZICOL 2 ST

DIPENTUM 4 NDS

GIAZO 4 NDS

LIALDA 3

MESALAMINE DR TBEC 800MG 2 ST

mesalamine dr tbec 1.2gm 1

mesalamine enem 1

PENTASA CPCR 250MG 2

PENTASA CPCR 500MG 4 NDS

ROWASA KIT 4 NDS

Glucocorticoids

budesonide cpep 3mg 1

ENTOCORT EC 4 NDS

UCERIS TB24 9MG 4 ST NDS

Sulfonamides

AZULFIDINE EN-TABS 3

AZULFIDINE TABS 3

70

Drug Name

Drug


sulfasalazine tabs, tbec 1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

ACTONEL TABS 150MG 3 QL (1 EA per 28 days) ST

ACTONEL TABS 35MG 3 QL (4 EA per 28 days) ST

ACTONEL TABS 30MG, 5MG 3 ST

alendronate sodium soln 1

alendronate sodium tabs 10mg, 35mg, 40mg, 5mg 1

alendronate sodium tabs 70mg 1 QL (4 EA per 28 days)

ATELVIA 3 QL (4 EA per 28 days) ST

BINOSTO 2 QL (4 EA per 28 days)

BONIVA INJ 3 ST

BONIVA TABS 150MG 3 QL (1 EA per 28 days) ST

calcitonin-salmon soln 1 QL (3.7 ML per 30 days)

calcitriol caps 0.25mcg, 0.5mcg 1

calcitriol inj 1mcg/ml 1

calcitriol oral soln 1mcg/ml 1

doxercalciferol 1

etidronate disodium 1

FORTEO INJ 600MCG/2.4ML 4 PA NDS

FOSAMAX PLUS D 2 QL (4 EA per 28 days) ST

FOSAMAX TABS 70MG 3 QL (4 EA per 28 days) ST

HECTOROL CAPS 0.5MCG, 1MCG 3

HECTOROL CAPS 2.5MCG 4 NDS

HECTOROL INJ 4MCG/2ML 3

ibandronate sodium inj 1

ibandronate sodium tabs 1 QL (1 EA per 28 days)

MIACALCIN INJ 4 NDS

NATPARA 4 QL (2 EA per 28 days) PA NDS

pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml 1

paricalcitol 1

PROLIA 2 QL (2 ML per 365 days)

RECLAST 3

risedronate sodium dr 1 QL (4 EA per 28 days)

risedronate sodium tabs 30mg, 5mg 1

risedronate sodium tabs 150mg 1 QL (1 EA per 28 days)

risedronate sodium tabs 35mg 1 QL (4 EA per 28 days)

ROCALTROL 3

SENSIPAR 4 B/D NDS

XGEVA 4 PA NDS

ZEMPLAR CAPS 1MCG 3

ZEMPLAR CAPS 2MCG 4 NDS

ZEMPLAR INJ 2MCG/ML 3

ZEMPLAR INJ 5MCG/ML 4 NDS

zoledronic acid inj 4mg/5ml, 5mg/100ml 1

ZOMETA INJ 4MG/100ML, 4MG/5ML 4 NDS

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS 1

71

Drug Name

Drug


AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML;

865MG/100ML; 595MG/100ML; 627MG/100ML;

425MG/100ML; 255MG/100ML; 561MG/100ML;

850MG/100ML; 893MG/100ML; 146MG/100ML;

253MG/100ML; 614MG/100ML; 450MG/100ML;

33.3MEQ/L; 340MG/100ML; 170MG/100ML;

230MG/100ML; 425MG/100ML, 71.8MEQ/L;

993MG/100ML; 1018MG/100ML; 700MG/100ML;

738MG/100ML; 500MG/100ML; 300MG/100ML;

660MG/100ML; 1000MG/100ML; 1050MG/100ML;

172MG/100ML; 298MG/100ML; 722MG/100ML;

530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML;

270MG/100ML; 500MG/100ML

2 B/D

AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML;

1527MG/100ML; 1050MG/100ML; 1107MG/100ML;

750MG/100ML; 450MG/100ML; 990MG/100ML;

1500MG/100ML; 1575MG/100ML; 258MG/100ML;

447MG/100ML; 1083MG/100ML; 795MG/100ML;

50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML;

750MG/100ML

3 B/D

AMINOSYN-HBC 2 B/D

AMINOSYN-PF 7% 2 B/D

AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;

1227MG/100ML; 527MG/100ML; 820MG/100ML;

385MG/100ML; 312MG/100ML; 760MG/100ML;

1200MG/100ML; 677MG/100ML; 180MG/100ML;

427MG/100ML; 812MG/100ML; 495MG/100ML;

3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;

44MG/100ML; 673MG/100ML

2 B/D

AMINOSYN-RF 2 B/D

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 1 QL (200 EA per 30 days)

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 1 QL (200 EA per 30 days)

CARNITOR 3

CLINISOL SF 15% 3 B/D

CURITY GAUZE PADS 2"X2" 1

ENDARI 4 PA NDS

fomepizole 4 NDS

FREAMINE HBC 6.9% 2 B/D

hepatamine 1 B/D

INTRALIPID INJ 30GM/100ML 2 B/D

intralipid inj 20gm/100ml 1 B/D

KEVEYIS 4 QL (120 EA per 30 days) PA NDS

lactated ringers irrigation 1

levocarnitine soln, tabs 1

MYALEPT 4 PA NDS

NEPHRAMINE 2 B/D

72

Drug Name

Drug


NUTRESTORE 2

nutrilipid 1 B/D

ORALAIR 2 QL (30 EA per 30 days) PA

PHYSIOLYTE 2

PHYSIOSOL IRRIGATION 2

plenamine 1 B/D

PREMASOL INJ 52MEQ/L; 1760MG/100ML;

880MG/100ML; 34MEQ/L; 1760MG/100ML;

372MG/100ML; 406MG/100ML; 526MG/100ML;

492MG/100ML; 492MG/100ML; 526MG/100ML;

356MG/100ML; 356MG/100ML; 390MG/100ML;

34MG/100ML; 152MG/100ML

2 B/D

premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;

190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;

220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;

490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;

230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;

120mg/100ml; 140mg/100ml; 470mg/100ml

1 B/D

PROSOL 2 B/D

ringers irrigation 1

sodium chloride 0.9% 1

sterile water irrigation plastic bottle 1

TRAVASOL INJ 52MEQ/L; 1760MG/100ML;

880MG/100ML; 34MEQ/L; 1760MG/100ML;

372MG/100ML; 406MG/100ML; 526MG/100ML;

492MG/100ML; 492MG/100ML; 526MG/100ML;

356MG/100ML; 356MG/100ML; 390MG/100ML;

34MG/100ML; 152MG/100ML

2 B/D

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML;

1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML;

0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML;

1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML;

0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML;

5MEQ/L; 0.025GM/100ML; 0.42GM/100ML;

0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

2 B/D

TROPHAMINE INJ 0; 0.32GM/100ML; 0.73GM/100ML;

0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML;

0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML;

0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML;

0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML;

0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML;

0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML

3 B/D

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost 1 QL (5 ML per 30 days)

COMBIGAN 2

latanoprost soln 1 QL (2.5 ML per 25 days)

LUMIGAN 2 QL (2.5 ML per 25 days)

TRAVATAN Z 2 QL (2.5 ML per 25 days)

73

Drug Name

Drug


VYZULTA 3 QL (5 ML per 25 days) ST

XALATAN 3 QL (2.5 ML per 25 days)

ZIOPTAN 3 QL (30 EA per 30 days) ST

Ophthalmic Agents, Other

atropine sulfate soln 1% 1

bacitracin/polymyxin b 1

CYSTARAN 4 QL (60 ML per 28 days) PA NDS

LACRISERT 2

neomycin/bacitracin/polymyxin 1

neomycin/polymyxin/gramicidin 1

polymyxin b sulfate/trimethoprim sulfate 1

POLYTRIM 3

PROCYSBI 4 PA NDS

proparacaine hcl 1

RESTASIS 2

RHOPRESSA 2 QL (2.5 ML per 25 days) ST

XIIDRA 2 QL (60 EA per 30 days) PA

Ophthalmic Anti-allergy Agents

ALOCRIL 2

azelastine hcl ophthalmic soln 0.05% 1

BEPREVE 2

cromolyn sodium soln 4% 1

ELESTAT 3

EMADINE 2

epinastine hcl 1

LASTACAFT 2

olopatadine hcl ophthalmic soln 0.1% 1

olopatadine hydrochloride 1

PATADAY 2

PATANOL 3

PAZEO 2

Ophthalmic Anti-inflammatories

ACULAR 3

ACULAR LS 3

ACUVAIL 2

ALOMIDE 2

ALREX 2

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

dexamethasone sodium phosphate ophthalmic soln 0.1% 1

diclofenac sodium ophthalmic soln 0.1% 1

DUREZOL 2

FLAREX 2

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

FML LIQUIFILM 3

ILEVRO 2 QL (6 ML per 30 days)

74

Drug Name

Drug


ketorolac tromethamine ophthalmic soln 0.4%, 0.5% 1

LOTEMAX SUSP 2

LOTEMAX OINT 2 QL (14 GM per 365 days)

LOTEMAX GEL 2 QL (20 GM per 365 days)

MAXIDEX SUSP 2

MAXITROL 3

neomycin/polymyxin/dexamethasone 1

NEVANAC 2 QL (6 ML per 30 days)

OMNIPRED 3

PRED FORTE 3

PRED MILD 2

PRED-G 2

PRED-G S.O.P. 2

prednisolone acetate 1

prednisolone sodium phosphate ophthalmic soln 1% 1

PROLENSA 2 QL (12 ML per 365 days)

sulfacetamide sodium/prednisolone sodium phosphate 1

TOBRADEX ST 2

TOBRADEX OINT 2

TOBRADEX SUSP 3

tobramycin/dexamethasone 1

ZYLET 2

Ophthalmic Antiglaucoma Agents

ALPHAGAN P SOLN 0.1% 2

ALPHAGAN P SOLN 0.15% 3

apraclonidine 1

AZOPT 2

BETAGAN SOLN 0.5% 3

betaxolol hcl soln 0.5% 1

BETIMOL 2

BETOPTIC-S 2

brimonidine tartrate 1

carteolol hcl 1

COSOPT 3

COSOPT PF 2

dorzolamide hcl 1

dorzolamide hcl/timolol maleate 1

IOPIDINE SOLN 1% 2

IOPIDINE SOLN 0.5% 3

ISOPTO CARPINE SOLN 1%, 2%, 4% 3

ISTALOL 3

levobunolol hcl soln 0.5% 1

methazolamide tabs 1

metipranolol 1

PHOSPHOLINE IODIDE SOLR 0.125% 2

pilocarpine hcl soln 1%, 2%, 4% 1

SIMBRINZA 2

timolol maleate ophthalmic gel forming 1

timolol maleate soln 0.25%, 0.5% 1

75

Drug Name

Drug


TIMOPTIC OCUDOSE 2

TIMOPTIC-XE SOLG 0.25% 3

TRUSOPT 3

Otic Agents

Otic Agents

acetic acid 1

CIPRO HC 2

CIPRODEX 2

COLY-MYCIN S 2

fluocinolone acetonide oil 0.01% 1

hydrocortisone/acetic acid 1

neomycin/polymyxin/hc 1

neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml;

10000unit/ml

1

OTOVEL 2 ST

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled Corticosteroids

AEROSPAN 2 QL (17.8 GM per 30 days) ST

AIRDUO RESPICLICK 113/14 3 QL (1 EA per 30 days) ST



ALVESCO 2 QL (12.2 GM per 30 days) ST

ARMONAIR RESPICLICK 113 2 QL (1 EA per 30 days) ST



ARNUITY ELLIPTA AEPB 100MCG/ACT, 200MCG/ACT 2 QL (30 EA per 30 days)

ASMANEX HFA 2 QL (26 GM per 30 days)

ASMANEX TWISTHALER 120 METERED DOSES 2 QL (1 EA per 30 days)



BECONASE AQ SUSP 2 QL (50 GM per 25 days)

BREO ELLIPTA 2 QL (60 EA per 30 days)

budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml 1 QL (120 ML per 30 days) B/D

FLOVENT DISKUS AEPB 250MCG/BLIST 2 QL (240 EA per 30 days)

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST 2 QL (60 EA per 30 days)

FLOVENT HFA AERO 44MCG/ACT 2 QL (21.2 GM per 30 days)

FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT 2 QL (24 GM per 30 days)

flunisolide soln 0.025% 1 QL (50 ML per 30 days)

fluticasone propionate/salmeterol 1 QL (1 EA per 30 days)

fluticasone propionate susp 50mcg/act 1

mometasone furoate susp 50mcg/act 1 QL (34 GM per 30 days)

NASONEX 3 QL (34 GM per 30 days)

NUCALA 4 QL (3 EA per 28 days) PA NDS

OMNARIS 2 QL (12.5 GM per 30 days) ST

PULMICORT 3 QL (120 ML per 30 days) B/D

PULMICORT FLEXHALER 2 QL (2 EA per 30 days) ST

QNASL 2 QL (8.7 GM per 30 days)

QNASL CHILDRENS 2 QL (4.9 GM per 30 days)

QVAR REDIHALER 2 QL (21.2 GM per 30 days)

76

Drug Name

Drug


QVAR AERS 40MCG/ACT 2 QL (17.4 GM per 30 days)

QVAR AERS 80MCG/ACT 2 QL (26.1 GM per 30 days)

triamcinolone acetonide aero 55mcg/act 1

XHANCE 2

ZETONNA 2 QL (6.1 GM per 30 days) ST

Antihistamines

ASTEPRO SOLN 0.15% 3 QL (60 ML per 30 days)

azelastine hcl nasal soln 0.1%, 0.15% 1 QL (60 ML per 30 days)

carbinoxamine maleate soln 1

carbinoxamine maleate tabs 4mg 1

cetirizine hcl soln 1mg/ml 1

CLARINEX-D 12 HOUR 2

CLARINEX SYRP 2

CLARINEX TABS 3

clemastine fumarate tabs 2.68mg 1

cyproheptadine hcl syrp, tabs 1

desloratadine 1

desloratadine odt 1

diphenhydramine hcl inj 50mg/ml 1

DYMISTA 2 QL (23 GM per 30 days)

hydroxyzine hcl inj, syrp, tabs 1

hydroxyzine pamoate caps 1

KARBINAL ER 2

levocetirizine dihydrochloride soln, tabs 1

olopatadine hcl nasal soln 0.6% 1 QL (30.5 GM per 30 days)

PATANASE 3 QL (30.5 GM per 30 days)

ryvent 1

SEMPREX-D 2

VISTARIL CAPS 25MG, 50MG 3

XYZAL SOLN 3

Antileukotrienes

ACCOLATE 3

montelukast sodium chew, pack, tabs 1

SINGULAIR 3

zafirlukast 1

zileuton er 4 NDS

ZYFLO 4 ST NDS

ZYFLO CR 4 ST NDS

Bronchodilators, Anticholinergic

ATROVENT HFA 2 QL (25.8 GM per 30 days)

COMBIVENT RESPIMAT 2 QL (8 GM per 30 days)

INCRUSE ELLIPTA 2 QL (30 EA per 30 days) ST

ipratropium bromide/albuterol sulfate 1 QL (540 ML per 30 days) B/D

ipratropium bromide nasal soln 1

ipratropium bromide inhalation soln 1 QL (312.5 ML per 30 days) B/D

LONHALA MAGNAIR STARTER KIT 4 QL (60 ML per 30 days) NDS

SEEBRI NEOHALER 2 ST

SPIRIVA HANDIHALER 2 QL (30 EA per 30 days)

SPIRIVA RESPIMAT 2 QL (4 GM per 30 days)

77

Drug Name

Drug


TUDORZA PRESSAIR 2 QL (60 EA per 30 days) ST

Bronchodilators, Sympathomimetic

albuterol sulfate er 1

albuterol sulfate syrp, tabs 1

albuterol sulfate nebu 0.5% 1 QL (100 ML per 30 days) B/D

albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml 1 QL (375 ML per 30 days) B/D

albuterol sulfate nebu 0.083% 1 QL (525 ML per 30 days) B/D

ARCAPTA NEOHALER 2 QL (30 EA per 30 days) ST

AUVI-Q INJ 0.3MG/0.3ML 2 ST

AUVI-Q INJ 0.1MG/0.1ML 4 PA NDS

AUVI-Q INJ 0.15MG/0.15ML 4 ST NDS

BEVESPI AEROSPHERE 2 QL (10.7 GM per 30 days) ST

BROVANA 2 QL (120 ML per 30 days) B/D

epinephrine inj 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

levalbuterol hcl nebu 1.25mg/3ml 1 QL (270 ML per 30 days) B/D

levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml 1 QL (540 ML per 30 days) B/D

LEVALBUTEROL TARTRATE HFA 2 QL (30 GM per 30 days) ST

levalbuterol nebu 1 QL (90 EA per 30 days) B/D

metaproterenol sulfate syrp, tabs 1

PERFOROMIST 4 QL (120 ML per 30 days) B/D NDS

PROAIR HFA 2 QL (17 GM per 30 days)

PROAIR RESPICLICK 2 QL (2 EA per 30 days)

PROVENTIL HFA 2 QL (13.4 GM per 30 days) ST

SEREVENT DISKUS 2 QL (60 EA per 30 days)

STRIVERDI RESPIMAT 2 QL (4 GM per 30 days)

terbutaline sulfate tabs 1

terbutaline sulfate inj 4 NDS

UTIBRON NEOHALER 2 ST

VENTOLIN HFA 2 QL (48 GM per 30 days)

XOPENEX CONCENTRATE 3 QL (90 EA per 30 days) B/D

XOPENEX HFA 2 QL (30 GM per 30 days) ST

XOPENEX NEBU 1.25MG/3ML 3 QL (270 ML per 30 days) B/D

XOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML 3 QL (540 ML per 30 days) B/D

Cystic Fibrosis Agents

BETHKIS 4 B/D NDS

CAYSTON 4 PA NDS

KALYDECO 4 PA NDS

ORKAMBI 4 QL (112 EA per 28 days) PA NDS

PULMOZYME 4 PA NDS

SYMDEKO 4 QL (56 EA per 28 days) PA NDS

TOBI 4 B/D NDS

TOBI PODHALER 4 QL (224 EA per 56 days) NDS

tobramycin 4 B/D NDS

Mast Cell Stabilizers

cromolyn sodium nebu 20mg/2ml 1 B/D

Phosphodiesterase Inhibitors, Airways Disease

aminophylline inj 1

78

Drug Name

Drug


DALIRESP 2 PA

THEO-24 2

theophylline cr tb12 100mg, 200mg 1

theophylline er tb24 1

theophylline er tb12 300mg 1

theophylline soln 1

Pulmonary Antihypertensives

ADCIRCA 4 QL (60 EA per 30 days) PA NDS

ADEMPAS 4 QL (90 EA per 30 days) PA NDS

LETAIRIS 4 QL (30 EA per 30 days) PA NDS

OPSUMIT 4 QL (30 EA per 30 days) PA NDS

ORENITRAM TBCR 0.125MG 2 PA

ORENITRAM TBCR 0.25MG, 1MG, 2.5MG, 5MG 4 PA NDS

REMODULIN 4 PA NDS

REVATIO INJ, SUSR 4 PA NDS

REVATIO TABS 4 QL (90 EA per 30 days) PA NDS

sildenafil tabs 1 QL (90 EA per 30 days) PA

sildenafil inj 4 PA NDS

TRACLEER TBSO 4 QL (112 EA per 28 days) PA NDS

TRACLEER TABS 4 QL (60 EA per 30 days) PA NDS

UPTRAVI TBPK 4 QL (400 EA per 365 days) PA NDS

UPTRAVI TABS 4 QL (60 EA per 30 days) PA NDS

VENTAVIS 4 QL (270 ML per 30 days) PA NDS

Pulmonary Fibrosis Agents

ESBRIET 4 PA NDS

OFEV 4 PA NDS

Respiratory Tract Agents, Other

acetylcysteine soln 1 B/D

ADVAIR DISKUS 2 QL (60 EA per 30 days)

ADVAIR HFA 2 QL (24 GM per 30 days)

ANORO ELLIPTA 2 QL (60 EA per 30 days)

ARALAST NP INJ 1000MG 4 PA NDS

DULERA 2 QL (17.6 GM per 30 days)

FASENRA 4 PA NDS

GLASSIA 4 PA NDS

PROLASTIN-C INJ 1000MG 4 PA NDS

promethazine vc plain 1

STIOLTO RESPIMAT 2 QL (4 GM per 30 days)

SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 2 QL (12 GM per 30 days)

SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 2 QL (13.8 GM per 30 days)

TRELEGY ELLIPTA 2 QL (60 EA per 30 days) ST

XOLAIR 4 PA NDS

ZEMAIRA 4 PA NDS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

AMRIX 4 NDS

carisoprodol/aspirin 1 PA

carisoprodol tabs 1 PA

chlorzoxazone tabs 500mg 1

79

Drug Name

Drug


cyclobenzaprine hcl tabs 1

FEXMID 3

LORZONE 2

metaxall 1

metaxalone 1

methocarbamol tabs 1 PA

methocarbamol inj 1000mg/10ml 1 PA

orphenadrine citrate er 1

orphenadrine citrate inj 1

ROBAXIN INJ 1000MG/10ML 3 PA

SKELAXIN TABS 800MG 3

SOMA TABS 250MG 3

SOMA TABS 350MG 4 NDS

Sleep Disorder Agents

GABA Receptor Modulators

AMBIEN 3 QL (30 EA per 30 days)

AMBIEN CR 3 QL (30 EA per 30 days)

EDLUAR 2 QL (30 EA per 30 days)

eszopiclone 1 QL (30 EA per 30 days)

flurazepam hcl 1 QL (30 EA per 30 days)

INTERMEZZO 3 QL (30 EA per 30 days)

LUNESTA 3 QL (30 EA per 30 days)

SONATA CAPS 5MG 3 QL (30 EA per 30 days)

SONATA CAPS 10MG 3 QL (60 EA per 30 days)

zaleplon caps 5mg 1 QL (30 EA per 30 days)

zaleplon caps 10mg 1 QL (60 EA per 30 days)

zolpidem tartrate 1 QL (30 EA per 30 days)

zolpidem tartrate er 1 QL (30 EA per 30 days)

Sleep Disorders, Other

armodafinil tabs 150mg, 200mg, 250mg 1 QL (30 EA per 30 days) PA

armodafinil tabs 50mg 1 QL (60 EA per 30 days) PA

BELSOMRA 2 QL (30 EA per 30 days)

BUTISOL SODIUM TABS 30MG 2 PA

HETLIOZ 4 QL (30 EA per 30 days) PA NDS

modafinil 1 QL (30 EA per 30 days) PA

NUVIGIL TABS 150MG, 200MG, 250MG 3 QL (30 EA per 30 days) PA

NUVIGIL TABS 50MG 3 QL (60 EA per 30 days) PA

PROVIGIL 4 QL (30 EA per 30 days) PA NDS

ROZEREM 2 QL (30 EA per 30 days)

SILENOR 2 QL (30 EA per 30 days)

XYREM 4 QL (540 ML per 30 days) PA NDS

80

Index Drug Name Page #

abacavir 30

abacavir sulfate/lamivudine/zidovudine 30

abacavir/lamivudine 30

ABELCET 17

ABILIFY 26

ABILIFY MAINTENA 26

ABRAXANE 21

ABSORICA 48

ABSTRAL 3

acamprosate calcium dr 4

ACANYA 48

acarbose 32

ACCOLATE 76

ACCUPRIL 39

ACCURETIC 39

acebutolol hcl 40

acetaminophen/codeine 3

acetazolamide 42

acetazolamide er 43

acetazolamide sodium 43

acetic acid 75

acetylcysteine 78

ACIPHEX 54

ACIPHEX SPRINKLE 54

acitretin 48

ACTEMRA 68

ACTHIB 68

ACTIGALL 52

ACTIMMUNE 68

ACTIQ 3

ACTIVELLA 60

ACTONEL 70

ACTOPLUS MET 32

ACTOPLUS MET XR 32

ACTOS 32

ACULAR 73

ACULAR LS 73

ACUVAIL 73

acyclovir 31

acyclovir sodium 31

ACZONE 48

ADACEL 68

ADAGEN 55

ADALAT CC 41

adapalene 48

adapalene and benzoyl peroxide 48

Drug Name Page #

ADCIRCA 78

ADDERALL 45

ADDERALL XR 45

adefovir dipivoxil 28

ADEMPAS 78

ADLYXIN 32

ADLYXIN STARTER PACK 33

ADMELOG 35

ADMELOG SOLOSTAR 35

ADRENALIN 42

adriamycin 21

adrucil 21

ADVAIR DISKUS 78

ADVAIR HFA 78

ADZENYS ER 45

ADZENYS XR-ODT 45

AEROSPAN 75

afeditab cr 41

AFINITOR 22

AFINITOR DISPERZ 23

AFREZZA 35

AGGRENOX 38

AGRYLIN 37

AIRDUO RESPICLICK 113/14 75



AKTIPAK 48

ALA SCALP 57

ala-cort 57

ALBENZA 24

albuterol sulfate 77

albuterol sulfate er 77

alclometasone dipropionate 57

ALCOHOL PREP PADS 70

ALDACTAZIDE 43

ALDACTONE 43

ALDARA 48

ALDURAZYME 55

ALECENSA 23

alendronate sodium 70

alfuzosin hcl er 56

ALIMTA 21

ALINIA 24

ALIQOPA 23

ALKERAN 20

allopurinol 18

allopurinol sodium 18

ALLZITAL 46

almotriptan 18

ALOCRIL 73

81

Drug Name Page #

ALOGLIPTIN 33

ALOGLIPTIN/METFORMIN HCL 33

ALOGLIPTIN/PIOGLITAZONE 33

ALOMIDE 73

ALOPRIM 18

ALORA 60

alosetron hydrochloride 53

ALOXI 16

ALPHAGAN P 74

alprazolam 32

alprazolam er 31

alprazolam intensol 32

alprazolam odt 32

ALREX 73

ALTACE 39

altavera 60

ALTOPREV 44

ALUNBRIG 23

ALVESCO 75

alyacen 1/35 60

amabelz 61

amantadine hcl 31

AMARYL 33

AMBIEN 79

AMBIEN CR 79

AMBISOME 17

amcinonide 57

AMERGE 18

amethia 61

amethia lo 61

amikacin sulfate 5

amiloride hcl 43

amiloride/hydrochlorothiazide 43

aminophylline 77

AMINOSYN 7%/ELECTROLYTES 50

aminosyn 8.5%/electrolytes 50

AMINOSYN II 71

aminosyn ii 8.5%/electrolytes 50

AMINOSYN-HBC 71

AMINOSYN-PF 71

AMINOSYN-PF 7% 71

AMINOSYN-RF 71

amiodarone hcl 39

AMITIZA 53

amitriptyline hcl 15

amlodipine besylate 41

amlodipine besylate/atorvastatin calcium 41

amlodipine besylate/benazepril

hydrochloride

41

amlodipine besylate/valsartan 41

Drug Name Page #

amlodipine/olmesartan medoxomil 41

amlodipine/valsartan/hctz 41

ammonium lactate 48

amnesteem 48

amoxapine 15

amoxicillin 8

amoxicillin/clavulanate potassium 8

amoxicillin/clavulanate potassium er 8

amphetamine/dextroamphetamine 45

amphotericin b 17

ampicillin 8

ampicillin sodium 8

ampicillin-sulbactam 8

AMPYRA 47

AMRIX 78

ANADROL-50 60

ANAFRANIL 15

anagrelide hydrochloride 37

anastrozole 22

ANCOBON 17

ANDRODERM 60

ANDROGEL 60

ANDROGEL PUMP 60

ANGELIQ 61

ANORO ELLIPTA 78

ANTABUSE 4

ANTARA 43

ANUSOL-HC 57

ANZEMET 16

APEXICON E 57

APIDRA 35

APIDRA SOLOSTAR 35

APLENZIN 13

APOKYN 25

apraclonidine 74

aprepitant 16

apri 61

APRISO 69

APTENSIO XR 46

APTIOM 11

APTIVUS 30

ARALAST NP 78

aranelle 61

ARANESP ALBUMIN FREE 37

ARAVA 68

ARCALYST 68

ARCAPTA NEOHALER 77

argatroban 36

ARICEPT 13

ARIMIDEX 22

82

Drug Name Page #

aripiprazole 26

aripiprazole odt 26

ARISTADA 26

ARIXTRA 36

armodafinil 79

ARMONAIR RESPICLICK 113 75



ARNUITY ELLIPTA 75

AROMASIN 22

ARRANON 21

ARTHROTEC 50 1

ARTHROTEC 75 1

ASACOL HD 69

ascomp/codeine 3

ashlyna 61

ASMANEX HFA 75

ASMANEX TWISTHALER 120

METERED DOSES

75

ASMANEX TWISTHALER 30 METERED

DOSES

75

ASMANEX TWISTHALER 60 METERED

DOSES

75

aspirin/dipyridamole 38

ASTAGRAF XL 66

ASTEPRO 76

ATACAND 38

ATACAND HCT 38

atazanavir sulfate 30

ATELVIA 70

atenolol 40

atenolol/chlorthalidone 40

ATGAM 68

ATIVAN 32

atomoxetine 46

atorvastatin calcium 44

atovaquone 24

atovaquone/proguanil hcl 24

ATRALIN 48

ATRIPLA 29

atropine sulfate 42

atropine sulfate 73

ATROVENT HFA 76

AUBAGIO 47

aubra 61

augmented betamethasone dipropionate 57

AUGMENTIN 8

AURYXIA 52

AUSTEDO 46

AUVI-Q 77

Drug Name Page #

AVALIDE 38

AVANDIA 33

AVAPRO 38

AVASTIN 24

AVC 10

AVEED 60

AVELOX 9

aviane 61

avita 48

AVODART 56

AVONEX 47

AVONEX PEN 47

AVYCAZ 7

AXERT 18

AYGESTIN 64

azacitidine 21

AZACTAM 8

AZASAN 66

AZASITE 9

azathioprine 66

azelastine hcl 73

azelastine hcl 76

AZELEX 48

AZILECT 26

azithromycin 9

AZOPT 74

AZOR 41

aztreonam 8

AZULFIDINE 69

AZULFIDINE EN-TABS 69

baciim 5

bacitracin 6

bacitracin/polymyxin b 73

baclofen 28

BACTOCILL IN DEXTROSE 8

BACTRIM 10

BACTRIM DS 10

BACTROBAN 6

BACTROBAN NASAL 6

balsalazide disodium 69

balziva 61

BANZEL 12

BARACLUDE 28

BASAGLAR KWIKPEN 35

BAVENCIO 24

BAXDELA 9

BCG VACCINE 68

BD INSULIN SYRINGE

SAFETYGLIDE/1ML/29G X 1/2"

71

83

Drug Name Page #

BD INSULIN SYRINGE

ULTRAFINE/0.3ML/31G X 5/16"

71

BD INSULIN SYRINGE

ULTRAFINE/0.5ML/30G X 1/2"

71

BD INSULIN SYRINGE

ULTRAFINE/1ML/31G X 5/16"

71

BD PEN NEEDLE/ULTRAFINE/29G X

12.7MM

71

BECONASE AQ 75

bekyree 61

BELBUCA 2

BELEODAQ 21

BELSOMRA 79

benazepril hcl 39

benazepril hcl/hydrochlorothiazide 39

BENICAR 38

BENICAR HCT 38

BENLYSTA 66

BENTYL 52

BENZACLIN WITH PUMP 48

BENZAMYCIN 48

BENZNIDAZOLE 24

benztropine mesylate 25

BEPREVE 73

BERINERT 66

BESIVANCE 9

BETAGAN 74

betamethasone dipropionate 57

betamethasone valerate 57

BETAPACE AF 39

BETASERON 47

betaxolol hcl 40

betaxolol hcl 74

bethanechol chloride 57

BETHKIS 77

BETIMOL 74

BETOPTIC-S 74

BEVESPI AEROSPHERE 77

BEVYXXA 36

bexarotene 24

BEXSERO 68

BEYAZ 61

bicalutamide 20

BICILLIN C-R 8

BICILLIN L-A 8

BICNU 20

BIDIL 44

BIKTARVY 29

BILTRICIDE 24

bimatoprost 72

Drug Name Page #

BINOSTO 70

bisoprolol fumarate 40

bisoprolol fumarate/hydrochlorothiazide 40

BIVIGAM 68

bleomycin sulfate 21

BLEPH-10 10

BLEPHAMIDE 73

BLEPHAMIDE S.O.P. 73

blisovi 24 fe 61

blisovi fe 1.5/30 61

blisovi fe 1/20 61

BONIVA 70

BONJESTA 15

BOOSTRIX 68

BORTEZOMIB 21

BOSULIF 23

BOTOX 28

BREO ELLIPTA 75

briellyn 61

BRILINTA 38

brimonidine tartrate 74

BRISDELLE 14

BRIVIACT 11

bromocriptine mesylate 25

BROVANA 77

budesonide 69

budesonide 75

bumetanide 43

BUNAVAIL 5

BUPAP 46

BUPHENYL 55

BUPRENEX 2

BUPRENORPHINE 2

buprenorphine hcl 2

buprenorphine hcl 5

buprenorphine hcl/naloxone hcl 5

bupropion hcl 14

bupropion hcl sr 5

bupropion hcl sr 13

bupropion hcl xl 13

buspirone hcl 31

busulfan 20

BUSULFEX 20

butalbital/acetaminophen 46

butalbital/acetaminophen/caffeine 46

butalbital/acetaminophen/caffeine/codeine 3

butalbital/aspirin/caffeine 47

butalbital/aspirin/caffeine/codeine 3

BUTISOL SODIUM 79

butorphanol tartrate 3

84

Drug Name Page #

BUTRANS 2

BYDUREON 33

BYDUREON BCISE 33

BYDUREON PEN 33

BYETTA 33

BYSTOLIC 40

BYVALSON 40

cabergoline 65

CABOMETYX 23

CADUET 41

CAFERGOT 18

CALAN 41

CALAN SR 41

calcipotriene 48

calcipotriene/betamethasone dipropionate 48

calcitonin-salmon 70

calcitriol 48

calcitriol 70

calcium acetate 52

CALQUENCE 23

CAMBIA 1

camila 64

CAMPTOSAR 21

camrese lo 61

CANASA 69

CANCIDAS 17

candesartan cilexetil 38

candesartan cilexetil/hydrochlorothiazide 38

CAPASTAT SULFATE 19

CAPEX 57

CAPRELSA 23

captopril 39

captopril/hydrochlorothiazide 39

CARAC 48

CARAFATE 54

CARBAGLU 50

carbamazepine 12

carbamazepine er 12

CARBATROL 12

carbidopa 25

carbidopa/levodopa 25

carbidopa/levodopa er 25

carbidopa/levodopa odt 25

carbidopa/levodopa/entacapone 25

carbinoxamine maleate 76

carboplatin 20

CARDENE IV 41

CARDIZEM 41

CARDIZEM CD 41

CARDIZEM LA 41

Drug Name Page #

CARDURA 56

CARDURA XL 56

CARIMUNE NANOFILTERED 68

carisoprodol 78

carisoprodol/aspirin 78

carisoprodol/aspirin/codeine 3

CARNITOR 71

CAROSPIR 43

carteolol hcl 74

cartia xt 41

carvedilol 40

carvedilol phosphate 40

CASODEX 20

caspofungin acetate 17

CATAPRES 38

CATAPRES-TTS-1 38

CATAPRES-TTS-2 38

CATAPRES-TTS-3 38

CAYSTON 77

caziant 61

CEFACLOR 7

CEFACLOR ER 7

cefadroxil 7

CEFAZOLIN SODIUM 7

cefdinir 7

cefepime 7

cefixime 7

cefotaxime sodium 7

cefotetan 7

cefoxitin sodium 7

cefpodoxime proxetil 7

cefprozil 7

ceftazidime 7

CEFTIN 8

ceftriaxone sodium 8

cefuroxime axetil 8

cefuroxime sodium 8

CELEBREX 1

celecoxib 1

CELEXA 14

CELLCEPT 66

CELLCEPT INTRAVENOUS 66

CELONTIN 11

CEPHALEXIN 8

CERDELGA 55

CEREBYX 12

CEREZYME 55

CESAMET 16

cetirizine hcl 76

CETRAXAL 9

85

Drug Name Page #

cevimeline hcl 48

CHANTIX 5

CHANTIX CONTINUING MONTH PAK 5

CHANTIX STARTING MONTH PAK 5

CHEMET 51

CHENODAL 52

chloramphenicol sodium succinate 6

chlordiazepoxide hcl 32

chlordiazepoxide/amitriptyline 15

chlorhexidine gluconate 48

chloroquine phosphate 24

chlorothiazide 43

chlorothiazide sodium 43

chlorpromazine hcl 26

chlorpropamide 33

chlorthalidone 43

chlorzoxazone 78

CHOLBAM 52

cholestyramine 44

cholestyramine light 44

chorionic gonadotropin 59

CIALIS 56

ciclopirox 17

ciclopirox nail lacquer 17

ciclopirox olamine 17

cidofovir 28

cilostazol 38

CILOXAN 9

cimetidine 53

cimetidine hcl 53

CIMZIA 66

CINRYZE 66

CINVANTI 16

CIPRO 9

CIPRO HC 75

CIPRO I.V.-IN D5W 9

CIPRODEX 75

ciprofloxacin 9

ciprofloxacin er 9

ciprofloxacin hcl 9

ciprofloxacin i.v.-in d5w 9

cisplatin 20

citalopram hydrobromide 14

cladribine 21

claravis 48

CLARINEX 76

CLARINEX-D 12 HOUR 76

clarithromycin 9

clarithromycin er 9

clemastine fumarate 76

Drug Name Page #

CLENPIQ 53

CLEOCIN 6

CLEOCIN IN D5W 6

CLEOCIN PEDIATRIC GRANULES 6

CLEOCIN PHOSPHATE 6

CLEOCIN-T 6

CLIMARA 61

CLIMARA PRO 61

clindacin-p 48

CLINDAGEL 6

clindamycin hcl 6

clindamycin palmitate hcl 6

clindamycin phosphate 6

clindamycin phosphate in d5w 6

clindamycin phosphate/tretinoin 48

clindamycin/benzoyl peroxide 48

CLINDESSE 6

CLINIMIX 2.75%/DEXTROSE 5% 50





CLINIMIX 5%/DEXTROSE 15% 50



CLINIMIX E 2.75%/DEXTROSE 10% 50





CLINIMIX E 5%/DEXTROSE 15% 50



CLINISOL SF 15% 71

clobetasol propionate 57

clobetasol propionate e 57

CLOBEX 57

clodan 57

CLODERM 57

clofarabine 21

CLOLAR 21

clomipramine hcl 15

clonazepam 11

clonazepam odt 11

clonidine hcl 38

clonidine hcl er 46

clopidogrel 38

clorazepate dipotassium 32

clotrimazole 17

clotrimazole/betamethasone dipropionate 48

86

Drug Name Page #

clozapine 28

clozapine odt 27

CLOZARIL 28

COARTEM 24

codeine sulfate 3

COGENTIN 25

COLAZAL 69

COLCHICINE 18

COLCRYS 18

COLESTID 44

colestipol hcl 44

colistimethate sodium 6

colocort 57

COLY-MYCIN S 75

COLYTE-FLAVOR PACKS 53

COMBIGAN 72

COMBIPATCH 61

COMBIVENT RESPIMAT 76

COMBIVIR 30

COMETRIQ 23

COMPLERA 29

compro 15

COMTAN 25

CONCERTA 46

CONDYLOX 48

constulose 53

COPAXONE 47

CORDRAN 57

COREG 40

COREG CR 40

CORGARD 40

CORLANOR 42

CORTEF 57

cortisone acetate 57

CORTISPORIN 6

CORZIDE 40

COSENTYX 48

COSENTYX SENSOREADY PEN 48

COSMEGEN 21

COSOPT 74

COSOPT PF 74

COTELLIC 21

COUMADIN 36

COZAAR 38

CREON 55

CRESEMBA 17

CRESTOR 44

CRINONE 64

CRIXIVAN 30

cromolyn sodium 52

Drug Name Page #

cromolyn sodium 73

cromolyn sodium 77

cryselle-28 61

CUBICIN 6

CUPRIMINE 51

CURITY GAUZE PADS 2"X2" 71

CUTIVATE 57

CUVPOSA 52

cyclafem 1/35 61

cyclafem 7/7/7 61

cyclobenzaprine hcl 79

CYCLOPHOSPHAMIDE 20

CYCLOSET 33

cyclosporine 66

cyclosporine modified 66

CYKLOKAPRON 37

CYMBALTA 14

cyproheptadine hcl 76

CYRAMZA 24

CYSTADANE 55

CYSTAGON 55

CYSTARAN 73

cytarabine aqueous 21

CYTOMEL 65

CYTOTEC 54

CYTOVENE 28

dacarbazine 20

DACOGEN 21

dactinomycin 21

DAKLINZA 28

DALIRESP 78

DALVANCE 6

danazol 60

DANTRIUM 28

dantrolene sodium 28

dapsone 19

dapsone 48

DAPTACEL 68

daptomycin 6

DARAPRIM 24

darifenacin hydrobromide er 56

DARZALEX 24

daunorubicin hcl 21

DAYPRO 1

DAYTRANA 46

DDAVP 59

deblitane 64

decitabine 21

DELESTROGEN 61

delyla 61

87

Drug Name Page #

DELZICOL 69

DEMADEX 43

demeclocycline hcl 10

DEMEROL 3

DEMSER 42

DENAVIR 31

DEPACON 11

DEPAKENE 11

DEPAKOTE 11

DEPAKOTE ER 11

DEPAKOTE SPRINKLES 11

DEPEN TITRATABS 51

DEPO-ESTRADIOL 61

DEPO-MEDROL 57

DEPO-PROVERA 64

DEPO-PROVERA CONTRACEPTIVE 64

DEPO-SUBQ PROVERA 104 64

DEPO-TESTOSTERONE 60

DESCOVY 30

desipramine hcl 15

desloratadine 76

desloratadine odt 76

desmopressin acetate 59

desogestrel/ethinyl estradiol 61

DESONATE 57

desonide 57

DESOWEN 57

desoximetasone 57

DESOXYN 45

DESVENLAFAXINE ER 14

DETROL 56

DETROL LA 56

dexamethasone 57

dexamethasone intensol 57

dexamethasone sodium phosphate 57

dexamethasone sodium phosphate 73

DEXEDRINE 45

DEXILANT 54

dexmethylphenidate hcl 46

dexmethylphenidate hcl er 46

DEXPAK 13 DAY 57

dexrazoxane 21

dextroamphetamine sulfate 45

dextroamphetamine sulfate er 45


dextrose 10% 50


dextrose 2.5%/nacl 0.45% 50

dextrose 5% 50

dextrose 5%/lactated ringers 50

Drug Name Page #






DIASTAT ACUDIAL 11

DIASTAT PEDIATRIC 11

diazepam 32

diazepam intensol 32

DIBENZYLINE 38

diclofenac potassium 1

diclofenac sodium 1

diclofenac sodium 48

diclofenac sodium 73

diclofenac sodium dr 1

diclofenac sodium er 1

diclofenac sodium/misoprostol 1

dicloxacillin sodium 8

dicyclomine hcl 52

didanosine 30

DIFFERIN 48

DIFICID 9

diflorasone diacetate 57

DIFLUCAN 17

diflunisal 1

digitek 42

digox 42

digoxin 42

dihydroergotamine mesylate 18

DILANTIN 13

DILANTIN INFATABS 12

DILANTIN-125 13

DILAUDID 3

diltiazem hcl 41

diltiazem hcl er 41

dilt-xr 41

DIOVAN 38

DIOVAN HCT 38

DIPENTUM 69

diphenhydramine hcl 76

diphenoxylate/atropine 52

diphtheria/tetanus toxoids adsorbed

pediatric

68

DIPROLENE 57

dipyridamole 38

disopyramide phosphate 39

disulfiram 4

DITROPAN XL 56

DIURIL 43

divalproex sodium 11

88

Drug Name Page #

divalproex sodium dr 11

divalproex sodium er 11

DIVIGEL 61

docetaxel 21

dofetilide 39

DOLOPHINE 2

donepezil hcl 13

DORIPENEM 8

DORYX 10

DORYX MPC 10

dorzolamide hcl 74

dorzolamide hcl/timolol maleate 74

DOVONEX 48

doxazosin 56

doxazosin mesylate 56

doxepin hcl 15

doxepin hydrochloride 48

doxercalciferol 70

DOXIL 21

doxorubicin hcl 21

doxorubicin hcl liposome 21

doxy 100 10

doxycycline 10

doxycycline hyclate 10

doxycycline hyclate dr 10

doxycycline monohydrate 10

dronabinol 16

drospirenone/ethinyl estradiol 61

drospirenone/ethinyl estradiol/levomefolate

calcium

61

DROXIA 21

DUAC 48

DUAVEE 61

DUETACT 33

DUEXIS 1

DULERA 78

DULOXETINE HCL 14

DUOPA 25

DUPIXENT 49

DURAGESIC 2

duramorph 3

DUREZOL 73

dutasteride 56

dutasteride/tamsulosin hydrochloride 56

DUTOPROL 40

DUZALLO 18

DYANAVEL XR 45

DYAZIDE 43

DYMISTA 76

DYRENIUM 43

Drug Name Page #

DYSPORT 28

E.E.S. 400 9

E.E.S. GRANULES 9

EC-NAPROSYN 1

econazole nitrate 17

EDARBI 38

EDARBYCLOR 38

EDECRIN 43

EDLUAR 79

EDURANT 29

efavirenz 29

EFFEXOR XR 14

EFFIENT 38

EFUDEX 49

EGRIFTA 59

ELAPRASE 55

ELDEPRYL 26

ELELYSO 55

ELESTAT 73

ELESTRIN 61

eletriptan hydrobromide 18

ELIDEL 49

ELIGARD 65

ELIMITE 25

ELIQUIS 36

ELIQUIS STARTER PACK 36

ELITEK 24

ELLENCE 21

ELMIRON 57

ELOCON 57

EMADINE 73

EMBEDA 2

EMCYT 20

EMEND 16

EMEND TRIPACK 16

EMFLAZA 57

emoquette 61

EMPLICITI 24

EMSAM 14

EMTRIVA 30

EMVERM 24

ENABLEX 56

enalapril maleate 39

enalapril maleate/hydrochlorothiazide 39

ENBREL 66

ENBREL SURECLICK 66

ENDARI 71

endocet 3

ENGERIX-B 68

enoxaparin sodium 36

89

Drug Name Page #

enpresse-28 61

enskyce 61

ENSTILAR 49

entacapone 25

entecavir 28

ENTOCORT EC 69

ENTRESTO 42

enulose 53

ENVARSUS XR 66

EPCLUSA 29

EPIDUO 49

EPIDUO FORTE 49

epinastine hcl 73

epinephrine 77

EPIPEN 2-PAK 77

EPIPEN-JR 2-PAK 77

epirubicin hcl 21

epitol 13

EPIVIR 30

EPIVIR HBV 28

eplerenone 43

EPOGEN 37

eprosartan mesylate 38

EPZICOM 30

EQUETRO 32

ERAXIS 17

ERBITUX 24

ergoloid mesylates 13

ergotamine tartrate/caffeine 18

ERIVEDGE 23

ERLEADA 20

errin 64

ERTACZO 17

ERWINAZE 21

ery 9

ERYGEL 9

ERYPED 200 9

ERYPED 400 9

ERY-TAB 9

ERYTHROCIN LACTOBIONATE 9

ERYTHROCIN STEARATE 9

erythromycin 9

erythromycin base 9

erythromycin ethylsuccinate 9

erythromycin/benzoyl peroxide 49

ESBRIET 78

escitalopram oxalate 14

ESGIC 47

esomeprazole magnesium 54

esomeprazole sodium 54

Drug Name Page #

ESOMEPRAZOLE STRONTIUM 54

estazolam 32

ESTRACE 61

estradiol 61

estradiol valerate 61

estradiol/norethindrone acetate 61

ESTRING 61

estropipate 61

eszopiclone 79

ethacrynate sodium 43

ethacrynic acid 43

ethambutol hcl 19

ethosuximide 11

ethynodiol diacetate/ethinyl estradiol 61

etidronate disodium 70

etodolac 1

etodolac er 1

ETOPOPHOS 22

etoposide 22

EUCRISA 49

EURAX 25

EVAMIST 61

EVISTA 65

EVOCLIN 6

EVOTAZ 30

EVOXAC 48

EVZIO 5

EXALGO 2

EXELDERM 17

EXELON 13

exemestane 22

EXFORGE 41

EXFORGE HCT 41

EXJADE 51

EXONDYS 51 55

EXTAVIA 47

EXTINA 17

ezetimibe 44

ezetimibe/simvastatin 44

FABIOR 49

FABRAZYME 55

falmina 61

famciclovir 31

famotidine 53

famotidine premixed 53

FANAPT 26

FANAPT TITRATION PACK 26

FARESTON 20

FARXIGA 33

FARYDAK 21

90

Drug Name Page #

FASENRA 78

FASLODEX 20

fayosim 61

FAZACLO 28

felbamate 12

FELBATOL 12

FELDENE 1

felodipine er 41

FEMARA 22

FEMHRT LOW DOSE 62

FEMRING 62

femynor 62

fenofibrate 43

fenofibrate micronized 43

fenofibric acid 43

fenofibric acid dr 43

FENOGLIDE 43

fenoprofen calcium 1

fentanyl 2

fentanyl citrate oral transmucosal 3

FENTORA 3

FERRIPROX 51

FETZIMA 14

FETZIMA TITRATION PACK 14

FEXMID 79

FIASP 35

FIASP FLEXTOUCH 35

FIBRICOR 43

FINACEA 49

finasteride 56

FIORICET 47

FIORICET/CODEINE 3

FIORINAL 47

FIORINAL/CODEINE #3 3

FIRAZYR 66

FIRMAGON 65

FLAGYL 6

FLAREX 73

flavoxate hcl 56

FLEBOGAMMA DIF 68

flecainide acetate 39

FLECTOR 1

FLOLIPID 44

FLOMAX 56

FLOVENT DISKUS 75

FLOVENT HFA 75

FLOXIN OTIC 10

fluconazole 17

fluconazole in nacl 17

flucytosine 17

Drug Name Page #

fludarabine phosphate 21

fludrocortisone acetate 57

FLUMADINE 31

flunisolide 75

fluocinolone acetonide 57

fluocinolone acetonide 75

fluocinolone acetonide scalp 57

fluocinonide 58

fluocinonide emulsified base 58

fluorometholone 73

fluorouracil 21

FLUOROURACIL 49

fluoxetine dr 14

fluoxetine hcl 14

fluphenazine decanoate 26

fluphenazine hcl 26

flurandrenolide 58

flurazepam hcl 79

flurbiprofen 1

flurbiprofen sodium 73

flutamide 20

fluticasone propionate 58

fluticasone propionate 75

fluticasone propionate/salmeterol 75

fluvastatin 44

fluvastatin sodium er 44

fluvoxamine maleate 14

fluvoxamine maleate er 14

FML 73

FML FORTE 73

FML LIQUIFILM 73

FOCALIN 46

FOCALIN XR 46

FOLOTYN 21

fomepizole 71

fondaparinux sodium 36

FORFIVO XL 14

FORTAMET 33

FORTEO 70

FORTESTA 60

FOSAMAX 70

FOSAMAX PLUS D 70

fosamprenavir calcium 31

fosinopril sodium 39

fosinopril sodium/hydrochlorothiazide 39

fosphenytoin sodium 13

FOSRENOL 52

FRAGMIN 36

FREAMINE HBC 6.9% 71

FROVA 18

91

Drug Name Page #

frovatriptan succinate 18

FURADANTIN 6

furosemide 43

FUSILEV 21

FUZEON 30

fyavolv 62

FYCOMPA 11

gabapentin 11

GABITRIL 11

GABLOFEN 28

galantamine hydrobromide 13

galantamine hydrobromide er 13

GAMASTAN S/D 68

GAMMAGARD LIQUID 68

GAMMAGARD S/D IGA LESS THAN

1MCG/ML

68

GAMMAKED 68

GAMMAPLEX 68

GAMUNEX-C 68

ganciclovir 28

GARDASIL 9 68

GASTROCROM 52

gatifloxacin 10

GATTEX 52

gavilyte-c 53

gavilyte-g 53

gavilyte-n/flavor pack 53

GELNIQUE 56

gemcitabine hcl 21

gemfibrozil 43

GEMZAR 21

GENERESS FE 62

generlac 53

gengraf 66

GENOTROPIN 59

GENOTROPIN MINIQUICK 59

gentak 5

gentamicin sulfate 5

gentamicin sulfate/0.9% sodium chloride 5

GENVOYA 29

GEODON 26

gianvi 62

GIAZO 69

GILENYA 47

GILOTRIF 23

GLASSIA 78

glatiramer acetate 47

glatopa 47

GLEEVEC 23

GLEOSTINE 20

Drug Name Page #

glimepiride 33

glipizide 33

glipizide er 33

glipizide/metformin hcl 33

GLUCAGEN HYPOKIT 35

GLUCAGON EMERGENCY KIT 35

GLUCOPHAGE 33

GLUCOPHAGE XR 33

GLUCOTROL 33

GLUCOTROL XL 33

GLUCOVANCE 33

GLUMETZA 33

glyburide 34

glyburide micronized 33

glyburide/metformin hcl 34

glycopyrrolate 52

GLYNASE 34

GLYSET 34

GLYXAMBI 34

GOCOVRI 25

GOLYTELY 54

GONITRO 45

GRALISE 47

GRALISE STARTER 47

granisetron hcl 16

GRANIX 37

griseofulvin microsize 17

griseofulvin ultramicrosize 17

GRIS-PEG 17

guanfacine er 46

guanfacine hcl 38

GUANIDINE HCL 19

GYNAZOLE-1 17

H.P. ACTHAR 59

HAEGARDA 66

HALAVEN 21

HALCION 32

HALDOL 26



halobetasol propionate 58

HALOG 58

haloperidol 26

haloperidol decanoate 26

haloperidol lactate 26

HARVONI 29

HAVRIX 68

HECTOROL 70

heparin sodium 37

heparin sodium/d5w 37

92

Drug Name Page #

hepatamine 71

HEPSERA 28

HERCEPTIN 24

HETLIOZ 79

HEXALEN 20

HIBERIX 68

HIPREX 6

HORIZANT 47

HUMALOG 35

HUMALOG JUNIOR KWIKPEN 35

HUMALOG KWIKPEN 35

HUMALOG MIX 50/50 35


HUMALOG MIX 75/25 35


HUMATROPE 59

HUMATROPE COMBO PACK 59

HUMIRA 67

HUMIRA PEDIATRIC CROHNS

DISEASE STARTER PACK

66

HUMIRA PEN 66

HUMIRA PEN-CROHNS

DISEASESTARTER

66

HUMIRA PEN-PSORIASIS STARTER 67

HUMULIN 70/30 36

HUMULIN 70/30 KWIKPEN 36

HUMULIN N 36

HUMULIN N KWIKPEN 36

HUMULIN R 36

HUMULIN R U-500 (CONCENTRATED) 36

HUMULIN R U-500 KWIKPEN 36

HYCAMTIN 22

HYCET 3

hydralazine hcl 45

HYDREA 21

hydrochlorothiazide 43

hydrocodone bitartrate/acetaminophen 3

hydrocodone/acetaminophen 3

hydrocodone/ibuprofen 3

hydrocortisone 58

hydrocortisone acetate/pramoxine 49

hydrocortisone butyrate 58

hydrocortisone valerate 58

hydrocortisone/acetic acid 75

hydromorphone hcl 3

hydromorphone hcl er 2

hydromorphone hydrochloride er 2

hydroxychloroquine sulfate 24

hydroxyprogesterone caproate 64

hydroxyurea 21

Drug Name Page #

hydroxyzine hcl 76

hydroxyzine pamoate 76

HYPERRAB S/D 68

HYSINGLA ER 2

HYZAAR 38

ibandronate sodium 70

IBRANCE 21

ibu 1

ibudone 3

ibuprofen 1

ICLUSIG 23

IDAMYCIN PFS 22

idarubicin hcl 22

IDHIFA 23

IFEX 20

ifosfamide 20

ILARIS 68

ILEVRO 73

imatinib mesylate 23

IMBRUVICA 23

IMFINZI 24

imipenem/cilastatin 8

imipramine hcl 15

imipramine pamoate 15

imiquimod 49

IMITREX 18

IMITREX STATDOSE REFILL 18

IMITREX STATDOSE SYSTEM 18

IMOGAM RABIES-HT 68

IMOVAX RABIES (H.D.C.V.) 68

IMPOYZ 49

IMURAN 67

INCRELEX 59

INCRUSE ELLIPTA 76

indapamide 43

INDERAL LA 40

INDOCIN 1

indomethacin 1

indomethacin er 1

INFANRIX 68

INFLECTRA 67

INGREZZA 47

INLYTA 23

INNOPRAN XL 40

INSPRA 43

INTELENCE 29

INTERMEZZO 79

INTRALIPID 71

INTRAROSA 58

INTRON A 28

93

Drug Name Page #

introvale 62

INTUNIV 46

INVANZ 8

INVEGA 27

INVEGA SUSTENNA 27

INVEGA TRINZA 27

INVIRASE 31

INVOKAMET 34

INVOKAMET XR 34

INVOKANA 34

IONOSOL-MB/DEXTROSE 5% 50

IOPIDINE 74

IPOL INACTIVATED IPV 69

ipratropium bromide 76

ipratropium bromide/albuterol sulfate 76

irbesartan 38

irbesartan/hydrochlorothiazide 38

IRESSA 23

irinotecan 22

ISENTRESS 29

ISENTRESS HD 29

isibloom 62

ISOLYTE-P/DEXTROSE 5% 50

ISOLYTE-S 50

isoniazid 19

ISOPTO CARPINE 74

ISORDIL TITRADOSE 45

isosorbide dinitrate 45

isosorbide dinitrate er 45

isosorbide mononitrate 45

isosorbide mononitrate er 45

isotonic gentamicin 5

isotretinoin 49

isradipine 41

ISTALOL 74

ISTODAX (OVERFILL) 22

itraconazole 17

ivermectin 24

IXIARO 69

JADENU 51

JADENU SPRINKLE 52

JAKAFI 23

JALYN 56

jantoven 37

JANUMET 34

JANUMET XR 34

JANUVIA 34

JARDIANCE 34

JENTADUETO 34

JENTADUETO XR 34

Drug Name Page #

JEVTANA 22

jinteli 62

jolivette 64

JUBLIA 17

juleber 62

JULUCA 29

junel 1.5/30 62

junel 1/20 62

junel fe 1.5/30 62

junel fe 1/20 62

junel fe 24 62

JUXTAPID 44

KADCYLA 24

KADIAN 2

kaitlib fe 62

KALETRA 31

KALYDECO 77

KANUMA 55

KAPVAY 46

KARBINAL ER 76

kariva 62

KAZANO 34

kcl 0.075%/d5w/nacl 0.45% 50

kcl 0.15%/d5w/nacl 0.2% 51

kcl 0.15%/d5w/nacl 0.45% 51

kcl 0.15%/d5w/nacl 0.9% 51

kcl 0.3%/d5w/nacl 0.45% 51

kcl 0.3%/d5w/nacl 0.9% 51

kelnor 1/35 62

kelnor 1/50 62

KENALOG 58

KENALOG-10 58

KENALOG-40 58

KEPIVANCE 48

KEPPRA 11

KEPPRA XR 11

KERYDIN 17

ketoconazole 17

ketoprofen 1

ketoprofen er 1

ketorolac tromethamine 1

ketorolac tromethamine 74

KEVEYIS 71

KEVZARA 68

KEYTRUDA 24

KHEDEZLA 14

kimidess 62

KINERET 67

KINRIX 69

kionex 52

94

Drug Name Page #

KISQALI 22

KISQALI FEMARA 200 DOSE 20



KLARON 10

KLONOPIN 11

klor-con 51

klor-con 10 51

klor-con 8 51

klor-con m10 51

KLOR-CON M15 51

klor-con m20 51

klor-con sprinkle 51

KOMBIGLYZE XR 34

KORLYM 60

KRISTALOSE 54

K-TAB 50

kurvelo 62

KUVAN 55

KYNAMRO 44

KYPROLIS 22

labetalol hcl 40

LACRISERT 73

lactated ringers irrigation 71

lactated ringers viaflex 51

lactulose 54

LAMICTAL 12

LAMICTAL CHEWABLE DISPERSIBLE 12

LAMICTAL ODT 12

LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE

12

LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING

VALPROATE

12

LAMICTAL STARTER/TAKING

VALPROATE

12

LAMICTAL XR 12

LAMISIL 17

lamivudine 28

lamivudine 30

lamivudine/zidovudine 30

lamotrigine 12

lamotrigine er 12

lamotrigine odt 12

lamotrigine starter kit/blue 12

lamotrigine starter kit/green 12

lamotrigine starter kit/orange 12

LANOXIN 42

lansoprazole 54

lansoprazole/amoxicillin/clarithromycin 52

Drug Name Page #

lanthanum carbonate 52

LANTUS 36

LANTUS SOLOSTAR 36

larin 1.5/30 62

larin 1/20 62

larin fe 1.5/30 62

larin fe 1/20 62

larissia 62

LARTRUVO 24

LASIX 43

LASTACAFT 73

latanoprost 72

LATUDA 27

layolis fe 62

LAZANDA 3

leena 62

leflunomide 68

LENVIMA 10 MG DAILY DOSE 23






LESCOL XL 44

lessina 62

LETAIRIS 78

letrozole 22

leucovorin calcium 22

LEUKERAN 20

LEUKINE 37

leuprolide acetate 65

levalbuterol 77

levalbuterol hcl 77

LEVALBUTEROL TARTRATE HFA 77

LEVAQUIN 10

LEVEMIR 36

LEVEMIR FLEXTOUCH 36

levetiracetam 11

levetiracetam er 11

levobunolol hcl 74

levocarnitine 71

levocetirizine dihydrochloride 76

levofloxacin 10

levofloxacin in d5w 10

levoleucovorin 22

levonest 62

levonorgestrel and ethinyl estradiol 62

levonorgestrel/ethinyl estradiol 62

levora 0.15/30-28 62

levorphanol tartrate 2

95

Drug Name Page #

levo-t 65

levothyroxine sodium 65

levoxyl 65

LEXAPRO 14

LEXIVA 31

LIALDA 69

lidocaine 4

lidocaine hcl 4

lidocaine hcl jelly 4

lidocaine viscous 4

lidocaine/prilocaine 4

LIDODERM 4

LINCOCIN 6

lincomycin hcl 6

lindane 25

linezolid 6

LINZESS 53

LIORESAL INTRATHECAL 28

liothyronine sodium 65

LIPITOR 44

LIPOFEN 43

lisinopril 39

lisinopril/hydrochlorothiazide 39

lithium 32

lithium carbonate 32

lithium carbonate er 32

LITHOBID 32

LITHOSTAT 57

LIVALO 44

LO LOESTRIN FE 62

LOCOID 58

LOCOID LIPOCREAM 58

LODINE 1

LODOSYN 26

LOESTRIN 1.5/30-21 62

LOESTRIN 1/20-21 62

LOESTRIN FE 1.5/30 62

LOESTRIN FE 1/20 62

LOMOTIL 52

LONHALA MAGNAIR STARTER KIT 76

LONSURF 21

loperamide hcl 52

LOPID 44

lopinavir/ritonavir 31

LOPRESSOR 40

LOPRESSOR HCT 40

LOPROX 17

LOPROX SHAMPOO 17

lorazepam 32

lorcet 3

Drug Name Page #

lorcet hd 3

lorcet plus 3

loryna 62

LORZONE 79

losartan potassium 38

losartan potassium/hydrochlorothiazide 38

LOSEASONIQUE 62

LOTEMAX 74

LOTENSIN 39

LOTREL 41

LOTRISONE 49

LOTRONEX 53

lovastatin 44

LOVAZA 44

LOVENOX 37

low-ogestrel 62

loxapine succinate 26

LUMIGAN 72

LUMIZYME 55

LUNESTA 79

LUPANETA PACK 65

LUPRON DEPOT (1-MONTH) 65




LUPRON DEPOT-PED (1-MONTH) 66

LUPRON DEPOT-PED (3-MONTH) 66

lutera 62

LUZU 17

LYNPARZA 22

LYRICA 11

LYRICA CR 47

LYSODREN 65

LYSTEDA 37

lyza 64

MACROBID 6

MACRODANTIN 6

magnesium sulfate 51

MAKENA 64

MAKENA 64

MALARONE 24

malathion 25

maprotiline hcl 14

MARINOL 16

marlissa 62

MARPLAN 14

MATULANE 20

matzim la 41

MAVYRET 29

MAXALT 19

96

Drug Name Page #

MAXALT-MLT 19

MAXIDEX 74

MAXIPIME 8

MAXITROL 74

MAXZIDE 43

MAXZIDE-25 43

meclizine hcl 15

meclofenamate sodium 1

MEDROL 58

MEDROL DOSEPAK 58

medroxyprogesterone acetate 64

mefenamic acid 1

mefloquine hcl 24

MEGACE ES 64

megestrol acetate 64

MEKINIST 23

melodetta 24 fe 62

meloxicam 1

melphalan hydrochloride 20

memantine hcl 13

memantine hcl titration pak 13

memantine hydrochloride 13

memantine hydrochloride er 13

MENACTRA 69

MENEST 62

MENOSTAR 62

MENTAX 17

MENVEO 69

meperidine hcl 3

meprobamate 31

MEPRON 24

mercaptopurine 21

meropenem 8

MERREM 8

mesalamine 69

MESALAMINE DR 69

mesna 24

MESNEX 24

MESTINON 19

MESTINON TIMESPAN 19

metadate er 46

metaproterenol sulfate 77

metaxall 79

metaxalone 79

metformin hcl 34

metformin hcl er 34

methadone hcl 2

methamphetamine hcl 45

methazolamide 74

methenamine hippurate 6

Drug Name Page #

methimazole 66

METHITEST 60

methocarbamol 79

methotrexate 67

methotrexate sodium 67

methoxsalen 49

methscopolamine bromide 52

methyclothiazide 43

methyldopa 38

methyldopa/hydrochlorothiazide 38

methyldopate hcl 38

METHYLIN 46

methylphenidate hcl 46

methylphenidate hcl cd 46

methylphenidate hcl er 46

methylphenidate hcl er (la) 46

methylphenidate hydrochloride 46

methylphenidate hydrochloride er 46

methylprednisolone 58

methylprednisolone acetate 58

methylprednisolone dose pack 58

methylprednisolone sodiumsuccinate 58

methyltestosterone 60

metipranolol 74

metoclopramide hcl 52

metoclopramide odt 52

metolazone 43

metoprolol succinate er 40

metoprolol tartrate 40

metoprolol/hydrochlorothiazide 40

METROCREAM 6

METROGEL 6

METROGEL-VAGINAL 6

METROLOTION 6

metronidazole 6

metronidazole in nacl 0.79% 6

metronidazole vaginal 6

mexiletine hcl 39

MIACALCIN 70

mibelas 24 fe 63

MICARDIS 39

MICARDIS HCT 39

miconazole 3 17

MICORT-HC 58

microgestin 1.5/30 63

microgestin 1/20 63

microgestin fe 63

microgestin fe 1.5/30 63

MICROZIDE 43

midodrine hcl 38

97

Drug Name Page #

MIGERGOT 18

miglitol 34

MIGRANAL 18

MILLIPRED 58

mimvey 63

mimvey lo 63

MINASTRIN 24 FE 63

MINIPRESS 38

minitran 45

MINIVELLE 63

MINOCIN 10

minocycline hcl 10

minocycline hcl er 10

minocycline hydrochlorideer 10

minoxidil 45

MIRAPEX 25

MIRAPEX ER 25

MIRCERA 37

mirtazapine 14

mirtazapine odt 14

MIRVASO 49

misoprostol 54

MITIGARE 18

mitomycin 22

mitoxantrone hcl 22

M-M-R II 69

MOBIC 1

modafinil 79

moderiba 29



moexipril hcl 39

moexipril/hydrochlorothiazide 39

mometasone furoate 58

mometasone furoate 75

mononessa 63

montelukast sodium 76

MONUROL 6

morgidox 1x50mg 10

morphine sulfate 3

morphine sulfate er 2

MOVANTIK 53

MOVIPREP 54

MOXEZA 10

MOXIFLOXACIN HCL 10

MOZOBIL 37

MS CONTIN 2

MULTAQ 39

mupirocin 6

MUSTARGEN 20

Drug Name Page #

MYALEPT 71

MYAMBUTOL 19

MYCAMINE 17

MYCOBUTIN 19

mycophenolate mofetil 67

mycophenolic acid dr 67

MYDAYIS 45

MYFORTIC 67

MYLOTARG 24

myorisan 49

MYRBETRIQ 56

MYSOLINE 11

MYTESI 53

nabumetone 1

nadolol 40

nadolol/bendroflumethiazide 40

nafcillin sodium 8

naftifine hcl 17

naftifine hydrochloride 17

NAFTIN 17

NAGLAZYME 55

nalbuphine hcl 3

naloxone hcl 5

naltrexone hcl 5

NAMENDA 13

NAMENDA TITRATION PAK 13

NAMENDA XR 13

NAMENDA XR TITRATION PACK 13

NAMZARIC 13

NAMZARIC 47

NAPRELAN 1

naproxen 1

naproxen dr 1

naproxen sodium 1

naproxen sodium er 1

naratriptan hcl 19

NARCAN 5

NARDIL 14

NASONEX 75

NATACYN 17

NATAZIA 63

nateglinide 34

NATPARA 70

NATROBA 25

NEBUPENT 25

necon 0.5/35-28 63

necon 7/7/7 63

nefazodone hcl 14

neomycin sulfate 5

neomycin/bacitracin/polymyxin 73

98

Drug Name Page #

neomycin/polymyxin b sulfates 5

neomycin/polymyxin/bacitracin/hydrocortis

one

6

neomycin/polymyxin/dexamethasone 74

neomycin/polymyxin/gramicidin 73

neomycin/polymyxin/hc 75

neomycin/polymyxin/hydrocortisone 7

neomycin/polymyxin/hydrocortisone 75

NEORAL 67

NEO-SYNALAR 6

NEPHRAMINE 71

NERLYNX 23

NESINA 34

neuac 49

NEULASTA 37

NEUPOGEN 37

NEUPRO 25

NEURONTIN 11

NEVANAC 74

nevirapine 30

nevirapine er 30

NEXAVAR 23

NEXIUM 54

NEXIUM I.V. 54

NEXTERONE 40

niacin er 44

niacor 44

NIASPAN 44

nicardipine hcl 41

NICOTROL INHALER 5

NICOTROL NS 5

nifedipine 41

nifedipine er 41

nikki 63

NILANDRON 20

nilutamide 20

nimodipine 42

NINLARO 22

NIPENT 21

nisoldipine er 42

NITRO-BID 45

NITRO-DUR 45

nitrofurantoin 7

nitrofurantoin macrocrystals 7

nitrofurantoin monohydrate/macrocrystals 7

nitroglycerin 45

nitroglycerin lingual 45

nitroglycerin transdermal 45

NITROSTAT 45

nizatidine 53

Drug Name Page #

NIZORAL 17

NOCTIVA 59

nolix 58

nora-be 64

NORCO 4

NORDITROPIN FLEXPRO 59

norethindrone 65

norethindrone & ethinyl estradiol ferrous

fumarate

63

norethindrone acetate 65

norethindrone acetate/ethinyl estradiol 63

norethindrone acetate/ethinyl

estradiol/ferrous fumarate

63

norethindrone/ethinyl estradiol/ferrous

fumarate

63

norgestimate/ethinyl estradiol 63

NORITATE 7

norlyroc 65

NORMOSOL-M IN D5W 51

NORMOSOL-R 51

NORMOSOL-R IN D5W 51

NORPACE 40

NORPACE CR 40

NORPRAMIN 15

NORTHERA 42

nortrel 0.5/35 (28) 63

nortrel 1/35 63

nortrel 7/7/7 63

nortriptyline hcl 15

NORVASC 42

NORVIR 31

NOVAREL 59

NOVOLIN 70/30 36

NOVOLIN N 36

NOVOLIN R 36

NOVOLOG 36

NOVOLOG FLEXPEN 36

NOVOLOG MIX 70/30 36

NOVOLOG MIX 70/30 PREFILLED

FLEXPEN

36

NOVOLOG PENFILL 36

NOXAFIL 17

NUCALA 75

NUCYNTA 4

NUCYNTA ER 2

NUEDEXTA 47

NULOJIX 67

NULYTELY/FLAVOR PACKS 54

NUPLAZID 27

NUTRESTORE 72

99

Drug Name Page #

nutrilipid 72

NUTROPIN AQ NUSPIN 10 59



NUVARING 63

NUVIGIL 79

nyamyc 17

NYMALIZE 42

nystatin 18

nystatin/triamcinolone 18

nystop 18

OCALIVA 53

ocella 63

OCTAGAM 68

octreotide acetate 66

OCUFLOX 10

ODEFSEY 30

ODOMZO 23

OFEV 78

ofloxacin 10

ogestrel 63

olanzapine 27

olanzapine odt 27

olanzapine/fluoxetine 14

olmesartan medoxomil 39

olmesartan

medoxomil/amlodipine/hydrochlorothiazide

42

olmesartan medoxomil/hydrochlorothiazide 39

olopatadine hcl 73

olopatadine hcl 76

olopatadine hydrochloride 73

OLUX 58

OLYSIO 29

OMECLAMOX-PAK 53

omega-3-acid ethyl esters 44

omeprazole 54

omeprazole/sodium bicarbonate 54

OMNARIS 75

OMNIPRED 74

OMNITROPE 60

ondansetron hcl 16

ondansetron odt 16

ONEXTON 49

ONFI 12

ONGLYZA 34

ONZETRA XSAIL 19

OPANA 4

OPDIVO 24

OPSUMIT 78

ORACEA 49

Drug Name Page #

ORALAIR 72

ORAP 26

ORAPRED ODT 58

ORAVIG 18

ORBACTIV 7

ORENCIA 67

ORENCIA CLICKJECT 67

ORENITRAM 78

ORFADIN 55

ORKAMBI 77

orphenadrine citrate 79

orphenadrine citrate er 79

orsythia 63

ORTHO MICRONOR 65

ORTHO TRI-CYCLEN 63

ORTHO TRI-CYCLEN LO 63

ORTHO-CYCLEN 63

ORTHO-NOVUM 1/35 63

ORTHO-NOVUM 7/7/7 63

oseltamivir phosphate 31

OSENI 34

OSMOPREP 54

OSPHENA 65

OTEZLA 68

OTOVEL 75

OTREXUP 67

OVIDE 25

oxacillin sodium 8

oxaliplatin 20

oxandrolone 60

oxaprozin 1

oxazepam 32

oxcarbazepine 13

oxiconazole nitrate 18

OXISTAT 18

OXSORALEN ULTRA 49

OXTELLAR XR 13

oxybutynin chloride 56

oxybutynin chloride er 56

oxycodone hcl 4

OXYCODONE HCL ER 2

oxycodone/acetaminophen 4

oxycodone/aspirin 4

oxycodone/ibuprofen 4

OXYCONTIN 2

oxymorphone hydrochloride 4

oxymorphone hydrochloride er 3

OXYTROL 56

OZEMPIC 34

PACERONE 40

100

Drug Name Page #

paclitaxel 22

paliperidone er 27

palonosetron hydrochlori de 16

palonosetron hydrochloride 16

PAMELOR 15

pamidronate disodium 70

PANCREAZE 55

PANDEL 58

panlor 4

PANRETIN 24

pantoprazole sodium 55

paricalcitol 70

PARLODEL 25

PARNATE 14

paromomycin sulfate 5

paroxetine 14

paroxetine hcl 14

paroxetine hcl er 14

PASER 19

PATADAY 73

PATANASE 76

PATANOL 73

PAXIL 15

PAXIL CR 15

PAZEO 73

PCE 9

PEDIARIX 69

PEDVAX HIB 69

peg 3350/electrolytes 54

peg-3350/electrolytes 54

peg-3350/nacl/na bicarbonate/kcl 54

PEGANONE 13

PEGASYS 29

PEGASYS PROCLICK 29

penicillin g potassium 8

PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE

8

penicillin g procaine 8

penicillin g sodium 8

penicillin v potassium 9

PENNSAID 49

PENTAM 300 25

PENTASA 69

pentazocine/naloxone hcl 4

pentoxifylline er 42

PEPCID 53

PERCOCET 4

PERFOROMIST 77

perindopril erbumine 39

periogard 48

Drug Name Page #

PERJETA 24

permethrin 25

perphenazine 26

perphenazine/amitriptyline 15

PERTZYE 55

PEXEVA 15

phenadoz 15

phenelzine sulfate 14

PHENERGAN 15

phenobarbital 12

phenoxybenzamine hydrochloride 38

PHENYTEK 13

phenytoin 13

phenytoin sodium 13

phenytoin sodium extended 13

PHOSLYRA 52

PHOSPHOLINE IODIDE 74

phrenilin forte 47

PHYSIOLYTE 72

PHYSIOSOL IRRIGATION 72

PICATO 49

pilocarpine hcl 48

pilocarpine hcl 74

pilocarpine hydrochloride 48

pimozide 26

pimtrea 63

pindolol 40

pioglitazone hcl 34

pioglitazone hcl/metformin hcl 34

pioglitazone hcl-glimepiride 34

piperacillin sodium/ tazobactam sodium 9

piperacillin sodium/tazobactam sodium 9

piperacillin/tazobactam 9

pirmella 1/35 63

piroxicam 1

PLAQUENIL 25

PLASMA-LYTE A 51

PLASMA-LYTE-148 51

PLAVIX 38

PLEGRIDY 47

PLEGRIDY STARTER PACK 47

plenamine 72

PLIAGLIS 4

podofilox 49

polyethylene glycol 3350 54

polymyxin b sulfate 7

polymyxin b sulfate/trimethoprim sulfate 73

POLYTRIM 73

POMALYST 20

portia-28 63

101

Drug Name Page #

potassium chloride 51

potassium chloride cr 51

potassium chloride er 51

potassium chloride/dextrose 51

potassium chloride/dextrose/lactated

ringers

51

potassium chloride/dextrose/sodium

chloride

51

potassium chloride/sodium chloride 51

potassium citrate er 51

PRADAXA 37

PRALUENT 42

pramipexole dihydrochloride 25

pramipexole dihydrochloride er 25

PRANDIN 35

prasugrel 38

PRAVACHOL 44

pravastatin sodium 44

prazosin hcl 38

PRECOSE 35

PRED FORTE 74

PRED MILD 74

PRED-G 74

PRED-G S.O.P. 74

prednicarbate 58

prednisolone 58

prednisolone acetate 74

prednisolone sodium phosphate 58

prednisolone sodium phosphate 74

prednisolone sodium phosphate odt 58

prednisone 58

prednisone intensol 58

PREFEST 63

pregnyl w/diluent benzyl alcohol/nacl 60

PREMARIN 63

PREMASOL 72

PREMPHASE 63

PREMPRO 63

PREPOPIK 54

PREVACID 55

PREVACID SOLUTAB 55

prevalite 44

previfem 63

PREVPAC 53

PREVYMIS 28

PREZCOBIX 31

PREZISTA 31

PRIFTIN 19

PRILOSEC 55

primaquine phosphate 25

Drug Name Page #

PRIMAXIN IV 8

primidone 12

PRIMLEV 4

PRINIVIL 39

PRISTIQ 15

PRIVIGEN 68

PROAIR HFA 77

PROAIR RESPICLICK 77

probenecid 18

probenecid/colchicine 18

procainamide hcl 40

PROCALAMINE 51

PROCARDIA 42

PROCARDIA XL 42

PROCENTRA 45

prochlorperazine 16

prochlorperazine edisylate 15

prochlorperazine maleate 16

PROCRIT 37

procto-med hc 59

procto-pak 59

proctosol hc 59

proctozone-hc 59

PROCYSBI 73

profeno 1

progesterone 65

PROGLYCEM 35

PROGRAF 67

PROLASTIN-C 78

PROLENSA 74

PROLEUKIN 22

PROLIA 70

PROMACTA 37

promethazine hcl 16

promethazine hcl plain 16

promethazine vc plain 78

promethegan 16

PROMETRIUM 65

propafenone hcl 40

propafenone hcl er 40

propantheline bromide 52

proparacaine hcl 73

propranolol hcl 41

propranolol hcl er 40

propranolol hydrochloride 41

propranolol/hydrochlorothiazide 41

propylthiouracil 66

PROQUAD 69

PROSCAR 56

PROSOL 72

102

Drug Name Page #

PROTONIX 55

PROTOPIC 49

protriptyline hcl 15

PROVENTIL HFA 77

PROVERA 65

PROVIGIL 79

PROZAC 15

prudoxin 49

psorcon 59

PULMICORT 75

PULMICORT FLEXHALER 75

PULMOZYME 77

PURIXAN 21

PYLERA 53

pyrazinamide 19

pyridostigmine bromide 19

pyridostigmine bromide er 19

QBRELIS 39

QNASL 75

QNASL CHILDRENS 75

QTERN 35

QUADRACEL 69

QUALAQUIN 25

QUARTETTE 63

quasense 63

QUDEXY XR 12

QUESTRAN 44

QUESTRAN LIGHT 44

quetiapine fumarate 27

quetiapine fumarate er 27

QUILLICHEW ER 46

QUILLIVANT XR 46

quinapril hcl 39

quinapril/hydrochlorothiazide 39

QUINIDINE GLUCONATE 40

quinidine gluconate cr 40

quinidine sulfate 40

quinine sulfate 25

QVAR 76

QVAR REDIHALER 75

RABAVERT 69

rabeprazole sodium 55

RADICAVA 47

raloxifene hydrochloride 65

ramipril 39

RANEXA 42

ranitidine hcl 53

RAPAFLO 56

RAPAMUNE 67

rasagiline mesylate 26

Drug Name Page #

RASUVO 67

RAVICTI 55

RAYALDEE 52

RAYOS 59

RAZADYNE 13

RAZADYNE ER 13

REBETOL 29

REBIF 47

REBIF REBIDOSE 47

REBIF REBIDOSE TITRATION PACK 47

REBIF TITRATION PACK 47

RECLAST 70

reclipsen 63

RECOMBIVAX HB 69

RECTIV 49

REGLAN 53

REGRANEX 49

RELENZA DISKHALER 31

RELISTOR 53

RELPAX 19

REMERON 14

REMERON SOLTAB 14

REMICADE 67

REMODULIN 78

RENAGEL 52

RENFLEXIS 67

RENVELA 52

repaglinide 35

repaglinide/metformin hydrochloride 35

REPATHA 42

REPATHA PUSHTRONEX SYSTEM 42

REPATHA SURECLICK 42

REQUIP 25

REQUIP XL 25

RESCRIPTOR 30

RESTASIS 73

RESTORIL 32

RETIN-A 49

RETIN-A MICRO 49

RETIN-A MICRO PUMP 49

RETROVIR 30

RETROVIR IV INFUSION 30

REVATIO 78

REVLIMID 20

REXULTI 27

REYATAZ 31

RHOPRESSA 73

ribasphere 29

ribasphere ribapak 29

ribavirin 29

103

Drug Name Page #

RIDAURA 68

rifabutin 19

RIFADIN 19

RIFAMATE 19

rifampin 19

RIFATER 19

RILUTEK 47

riluzole 47

rimantadine hcl 31

ringers injection 51

ringers irrigation 72

RIOMET 35

risedronate sodium 70

risedronate sodium dr 70

RISPERDAL 27

RISPERDAL CONSTA 27

risperidone 27

risperidone odt 27

RITALIN 46

RITALIN LA 46

ritonavir 31

RITUXAN 24

rivastigmine tartrate 13

rivastigmine transdermal system 13

rivelsa 63

rizatriptan benzoate 19

rizatriptan benzoate odt 19

ROBAXIN 79

ROBINUL 52

ROBINUL FORTE 52

ROCALTROL 70

ropinirole er 25

ropinirole hcl 25

rosuvastatin calcium 44

ROTARIX 69

ROTATEQ 69

ROWASA 69

roweepra 11

roweepra xr 11

ROXICODONE 4

ROZEREM 79

RUBRACA 22

RUCONEST 66

RYDAPT 22

RYTARY 26

RYTHMOL SR 40

ryvent 76

SABRIL 12

SAFYRAL 63

SAIZEN 60

Drug Name Page #

SAIZEN CLICK.EASY 60

SALAGEN 48

SAMSCA 52

SANCUSO 16

SANDIMMUNE 67

SANDOSTATIN 66

SANDOSTATIN LAR DEPOT 66

SANTYL 49

SAPHRIS 27

SARAFEM 15

SAVAYSA 37

SAVELLA 47

SAVELLA TITRATION PACK 47

scopolamine 16

SEASONIQUE 63

SEEBRI NEOHALER 76

SEGLUROMET 35

selegiline hcl 26

selenium sulfide 49

SELZENTRY 30

SEMPREX-D 76

SENSIPAR 70

SEREVENT DISKUS 77

SEROQUEL 27

SEROQUEL XR 27

SEROSTIM 60

sertraline hcl 15

setlakin 63

sevelamer carbonate 52

sharobel 65

SHINGRIX 69

SIGNIFOR 66

SIGNIFOR LAR 66

sildenafil 78

SILENOR 79

SILIQ 49

SILVADENE 7

silver sulfadiazine 7

SIMBRINZA 74

SIMPONI 67

SIMPONI ARIA 67

SIMULECT 68

simvastatin 44

SINEMET 26

SINEMET CR 26

SINGULAIR 76

sirolimus 67

SIRTURO 20

SIVEXTRO 7

SKELAXIN 79

104

Drug Name Page #

SKLICE 25

sodium chloride 51



SODIUM DIURIL 43

sodium fluoride 51

sodium lactate 51

sodium phenylbutyrate 55

sodium polystyrene sulfonate 52

sodium sulfacetamide 10

SOLARAZE 2

SOLIQUA 100/33 36

SOLODYN 10

SOLTAMOX 20

SOLU-CORTEF 59

SOLU-MEDROL 59

SOMA 79

SOMATULINE DEPOT 66

SOMAVERT 66

SONATA 79

SOOLANTRA 49

SORIATANE 49

SORILUX 49

sorine 40

sotalol hcl 40

sotalol hcl (af) 40

SOTYLIZE 41

SOVALDI 29

SPIRIVA HANDIHALER 76

SPIRIVA RESPIMAT 76

spironolactone 43

spironolactone/hydrochlorothiazide 43

SPORANOX 18

sprintec 28 63

SPRITAM 11

SPRYCEL 23

sps 52

sronyx 64

ssd 7

STALEVO 100 26

STALEVO 125 26

STALEVO 150 26

STALEVO 200 26

STALEVO 50 26

STALEVO 75 26

STARLIX 35

stavudine 30

STEGLATRO 35

STEGLUJAN 35

STELARA 49

Drug Name Page #

sterile water irrigation plastic bottle 72

STIMATE 60

STIOLTO RESPIMAT 78

STIVARGA 23

STRATTERA 46

STRENSIQ 55

STREPTOMYCIN SULFATE 5

STRIANT 60

STRIBILD 29

STRIVERDI RESPIMAT 77

STROMECTOL 24

SUBOXONE 5

SUBSYS 4

SUCRAID 56

sucralfate 54

SULAR 42

sulfacetamide sodium 10

sulfacetamide sodium/prednisolone sodium

phosphate

74

sulfadiazine 10

sulfamethoxazole/trimethoprim 10

sulfamethoxazole/trimethoprim ds 10

SULFAMYLON 7

sulfasalazine 70

sulindac 2

sumatriptan 19

sumatriptan succinate 19

sumatriptan succinate refill 19

sumatriptan/naproxen sodium 19

SUMAVEL DOSEPRO 19

SUPRAX 8

SUPREP BOWEL PREP KIT 54

SURMONTIL 15

SUSTIVA 30

SUTENT 23

syeda 64

SYLATRON 22

SYLVANT 68

SYMBICORT 78

SYMBYAX 15

SYMDEKO 77

SYMFI LO 30

SYMLINPEN 120 35

SYMLINPEN 60 35

SYMPROIC 53

SYNAGIS 68

SYNALAR 49

SYNAREL 66

SYNDROS 16

SYNERCID 7

105

Drug Name Page #

SYNJARDY 35

SYNRIBO 22

SYNTHROID 65

SYPRINE 52

TABLOID 21

TACLONEX 49

tacrolimus 49

tacrolimus 67

TAFINLAR 23

TAGRISSO 23

TALTZ 49

TAMIFLU 31

tamoxifen citrate 20

tamsulosin hcl 56

TANZEUM 35

TAPAZOLE 66

TAPERDEX 12-DAY 59

TAPERDEX 6-DAY 59

TARCEVA 23

TARGADOX 10

TARGRETIN 24

tarina fe 1/20 64

TARKA 39

TASIGNA 23

TASMAR 25

TAXOTERE 22

tazarotene 49

tazicef 8

TAZORAC 49

taztia xt 42

TECENTRIQ 24

TECFIDERA 47

TECFIDERA STARTER PACK 47

TECHNIVIE 29

TEFLARO 8

TEGRETOL 13

TEGRETOL-XR 13

TEKTURNA 42

TEKTURNA HCT 42

telmisartan 39

telmisartan/amlodipine 42

telmisartan/hydrochlorothiazide 39

temazepam 32

tencon 47

TENIVAC 69

tenofovir disoproxil fumarate 30

TENORETIC 100 41

TENORETIC 50 41

TENORMIN 41

terazosin hcl 56

Drug Name Page #

terbinafine hcl 18

terbutaline sulfate 77

terconazole 18

TESTIM 60

TESTOSTERONE 60

testosterone cypionate 60

testosterone enanthate 60

testosterone pump 60

tetanus/diphtheria toxoids-adsorbed 69

tetrabenazine 47

tetracycline hydrochloride 10

THALOMID 20

THEO-24 78

theophylline 78

theophylline cr 78

theophylline er 78

THIOLA 57

thioridazine hcl 26

thiotepa 20

thiothixene 26

THYMOGLOBULIN 68

THYROLAR-1 65

THYROLAR-1/2 65

THYROLAR-1/4 65

THYROLAR-2 65

THYROLAR-3 65

tiagabine hydrochloride 12

TIAZAC 42

TIGAN 16

TIGECYCLINE 7

TIKOSYN 40

timolol maleate 41

timolol maleate 74

timolol maleate ophthalmic gel forming 74

TIMOPTIC OCUDOSE 75

TIMOPTIC-XE 75

TINDAMAX 25

tinidazole 25

TIROSINT 65

TIVICAY 29

TIVORBEX 2

tizanidine hcl 28

TOBI 77

TOBI PODHALER 77

TOBRADEX 74

TOBRADEX ST 74

tobramycin 77

tobramycin sulfate 5

tobramycin/dexamethasone 74

TOBREX 5

106

Drug Name Page #

TOFRANIL 15

TOLAK 50

tolazamide 35

tolbutamide 35

tolcapone 25

tolmetin sodium 2

tolterodine tartrate 56

tolterodine tartrate er 56

TOPAMAX 12

TOPAMAX SPRINKLE 12

TOPICORT 59

topiramate 12

topiramate er 12

toposar 22

topotecan hcl 22

TOPROL XL 41

TORISEL 23

torsemide 43

TOUJEO MAX SOLOSTAR 36

TOUJEO SOLOSTAR 36

TOVIAZ 56

tpn electrolytes 51

TRACLEER 78

TRADJENTA 35

tramadol hcl 4

tramadol hcl er 3

tramadol hydrochloride/acetaminophen 4

trandolapril 39

trandolapril/verapamil hcl er 39

tranexamic acid 37

TRANSDERM-SCOP 16

TRANXENE T 32

tranylcypromine sulfate 14

TRAVASOL 72

TRAVATAN Z 72

trazodone hcl 15

TREANDA 20

TRECATOR 20

TRELEGY ELLIPTA 78

TRELSTAR MIXJECT 66

TREMFYA 67

TRESIBA FLEXTOUCH 36

tretinoin 24

tretinoin 50

tretinoin microsphere 50

TREXALL 67

TREXIMET 19

trezix 4

triamcinolone acetonide 59

triamcinolone acetonide 76

Drug Name Page #

triamcinolone acetonide dental paste 48

triamterene/hydrochlorothiazide 43

TRIANEX 59

triazolam 32

TRIBENZOR 42

TRICOR 44

triderm 59

tridesilon 59

trientine hydrochloride 52

trifluoperazine hcl 26

trifluridine 31

TRIGLIDE 44

trihexyphenidyl hcl 25

tri-legest fe 64

TRILEPTAL 13

TRILIPIX 44

tri-lo-estarylla 64

tri-lo-sprintec 64

trilyte 54

trimethobenzamide hcl 16

trimethoprim 7

trimipramine maleate 15

trinessa 64

TRI-NORINYL 28 64

TRINTELLIX 15

TRIOSTAT 65

tri-previfem 64

TRISENOX 22

tri-sprintec 64

TRIUMEQ 29

trivora-28 64

tri-vylibra 64

TRIZIVIR 30

TROKENDI XR 12

TROPHAMINE 72

trospium chloride 56

trospium chloride er 56

TRULANCE 53

TRULICITY 35

TRUMENBA 69

TRUSOPT 75

TRUVADA 30

TUDORZA PRESSAIR 77

TWINRIX 69

TWYNSTA 42

TYBOST 30

tydemy 64

TYGACIL 7

TYKERB 23


107

Drug Name Page #


TYMLOS 65

TYPHIM VI 69

TYSABRI 47

UCERIS 59

UCERIS 69

ULORIC 18

ULTRACET 4

ULTRAM 4

ULTRAVATE 59

UNASYN 9

UNASYN BULK PACK 9

unithroid 65

UPTRAVI 78

URECHOLINE 57

UROCIT-K 10 51

UROCIT-K 15 51

UROCIT-K 5 51

UROXATRAL 56

URSO 250 53

URSO FORTE 53

ursodiol 53

UTIBRON NEOHALER 77

VABOMERE 8

VAGIFEM 64

valacyclovir hcl 31

VALCHLOR 20

VALCYTE 28

valganciclovir 28

valganciclovir hydrochlorde 28

VALIUM 32

valproate sodium 12

valproic acid 12

valsartan 39

valsartan/hydrochlorothiazide 39

VALTREX 31

vanatol lq 47

VANCOCIN HCL 7

vancomycin hcl 7

vandazole 7

VANOS 59

VAQTA 69

VARIVAX 69

VARIZIG 69

VARUBI 16

VASCEPA 44

VASERETIC 39

VASOTEC 39

VECAMYL 42

VECTIBIX 24

Drug Name Page #

VECTICAL 50

VELCADE 22

velivet 64

VELPHORO 52

VELTASSA 52

VEMLIDY 28

VENCLEXTA 23

VENCLEXTA STARTING PACK 23

venlafaxine hcl 15

venlafaxine hcl er 15

VENTAVIS 78

VENTOLIN HFA 77

verapamil hcl 42

verapamil hcl er 42

verapamil hcl sr 42

VEREGEN 50

VERELAN 42

VERELAN PM 42

VERIPRED 20 59

VERSACLOZ 28

VERZENIO 22

VESICARE 56

vestura 64

VFEND 18

VFEND IV 18

VIBERZI 53

VIBRAMYCIN 10

vicodin 4

vicodin es 4

vicodin hp 4

VICTOZA 35

VIDAZA 22

VIDEX EC 30

VIDEX PEDIATRIC 30

VIEKIRA PAK 29

VIEKIRA XR 29

vienva 64

vigabatrin 12

VIGAMOX 10

VIIBRYD 15

VIIBRYD STARTER PACK 15

VIMOVO 2

VIMPAT 13

vinblastine sulfate 22

vincasar pfs 22

vincristine sulfate 22

vinorelbine tartrate 22

VIOKACE 56

VIRACEPT 31

VIRAMUNE 30

108

Drug Name Page #

VIRAMUNE XR 30

VIREAD 30

VIROPTIC 31

VISTARIL 76

VIVELLE-DOT 64

VIVITROL 5

VIVLODEX 2

VOGELXO 60

VOGELXO PUMP 60

VOLTAREN 50

voriconazole 18

VOSEVI 29

VOTRIENT 23

VP-PNV-DHA 52

VPRIV 56

VRAYLAR 27

vyfemla 64

vylibra 64

VYTORIN 44

VYVANSE 45

VYXEOS 21

VYZULTA 73

warfarin sodium 37

WELCHOL 44

WELLBUTRIN SR 14

WELLBUTRIN XL 14

wymzya fe 64

XALATAN 73

XALKORI 23

XANAX 32

XANAX XR 32

XARELTO 37

XARELTO STARTER PACK 37

XATMEP 67

XELJANZ 68

XELJANZ XR 68

XENAZINE 47

XEOMIN 28

XERESE 31

XERMELO 53

XGEVA 70

XHANCE 76

XIFAXAN 7

XIGDUO XR 35

XIIDRA 73

XIMINO 10

XOLAIR 78

XOPENEX 77

XOPENEX CONCENTRATE 77

XOPENEX HFA 77

Drug Name Page #

XTAMPZA ER 3

XTANDI 20

xulane 64

XULTOPHY 100/3.6 36

XURIDEN 56

XYLOCAINE 4

XYREM 79

XYZAL 76

YASMIN 28 64

YAZ 64

YERVOY 24

YF-VAX 69

YONDELIS 20

YOSPRALA 38

yuvafem 64

zafirlukast 76

zaleplon 79

ZALTRAP 22

ZANAFLEX 28

ZANOSAR 20

ZANTAC 53

zarah 64

ZARONTIN 11

ZARXIO 37

ZAVESCA 56

zebutal 47

ZEGERID 55

ZEJULA 22

ZELAPAR 26

ZELBORAF 23

ZEMAIRA 78

ZEMBRACE SYMTOUCH 19

ZEMPLAR 70

zenatane 50

zenchent 64

ZENPEP 56

ZENZEDI 45

ZEPATIER 29

ZERBAXA 8

ZERIT 30

ZESTORETIC 39

ZESTRIL 39

ZETIA 44

ZETONNA 76

ZIAC 41

ZIAGEN 30

ZIANA 50

zidovudine 30

zileuton er 76

ZINECARD 22

109

Drug Name Page #

ZINPLAVA 68

ZIOPTAN 73

ziprasidone hcl 27

ZIPSOR 2

ZIRGAN 28

ZITHROMAX 9

ZITHROMAX TRI-PAK 9

ZITHROMAX Z-PAK 9

ZOCOR 44

ZOFRAN 16

ZOFRAN ODT 16

ZOHYDRO ER 3

zoledronic acid 70

ZOLINZA 22

zolmitriptan 19

zolmitriptan odt 19

ZOLOFT 15

zolpidem tartrate 79

zolpidem tartrate er 79

ZOMACTON 60

ZOMETA 70

ZOMIG 19

ZOMIG ZMT 19

ZONALON 50

ZONEGRAN 11

zonisamide 11

ZONTIVITY 38

ZORBTIVE 60

ZORTRESS 67

ZORVOLEX 2

ZOSTAVAX 69

ZOSYN 9

zovia 1/35e 64

zovia 1/50e 64

ZOVIRAX 31

ZUBSOLV 5

ZUPLENZ 16

ZURAMPIC 18

ZYBAN 5

ZYCLARA PUMP 50

ZYDELIG 22

ZYFLO 76

ZYFLO CR 76

ZYKADIA 24

ZYLET 74

ZYLOPRIM 18

ZYMAXID 10

ZYPREXA 27

ZYPREXA RELPREVV 27

ZYPREXA ZYDIS 27

Drug Name Page #

ZYTIGA 20

ZYVOX 7

110

Medicare-Excluded Drugs Covered under the Enhanced Medicare Rx Option Only

DRUG DRUG NAME TIER

COUGH AND COLDbenzonatate cap 100mg 1benzonatate cap 150mg 1benzonatate cap 200mg 1biotuss liq 1biotuss liq pediatrc 1brom/pse/dm syp 1bromfed dm syp 1CARBAPHEN 12 LIQ 2CARBAPHEN 12 SUS PED 2DECON-G DRO 2-1-40MG 2difil-g fort liq 100-100 1FLOWTUSS SOL 2.5-200 2guaifenesin tab 600mg sr 1guaifenex la tab 600mg 1hyd pol/cpm sus 10-8/5ml 1hydr/cpm/pse liq 5-4-60mg 1hydro/chlor/ liq 5-4-60mg 1hydroc/homat tab 5-1.5mg 1hydrocod/hom syp 5-1.5/5 1hydromet syp 5-1.5/5 1MEPER/PROMET CAP 50-25MG 2nortuss-de dro 1nortuss-ex liq 200-20/5 1OBREDON SOL 2.5-200 2pe/guaifenes dro 1.5-20mg 1prometh vc/ syp codeine 1prometh/cod syp 6.25-10 1prometh/pe/ syp codeine 1promethazine syp dm 1q-bid-la tab 600mg 1RELHIST CHW 2REZIRA SOL 60-5/5ML 2TESSALON PER CAP 100MG 3

DRUG DRUG NAME TIERtgq 15dm/5pe syp h/2cpm 1tgq 30/ syp 150/15 1tgq 30/pse/3 syp brm/15dm 1TUSSICAPS CAP 10-8MG 2TUSSICAPS CAP 5-4MG 2tussigon tab 5-1.5mg 1TUSSIONEX SUS 10-8/5ML 3VITUZ SOL 5-4MG 2ZUTRIPRO LIQ 60-4-5MG 3

ERECTILE DYSFUNCTIONCIALIS TAB 2.5MG (Limit: 6 per 30 days)

2

CIALIS TAB 5MG (Limit: 6 per 30 days)

2


2


2

LEVITRA TAB 2.5MG (Limit: 6 per 30 days)

2

LEVITRA TAB 5MG (Limit: 6 per 30 days)

2


2


2

VIAGRA TAB 25MG (Limit: 6 per 30 days)

2


2


2

FEMALE SEXUAL DYSFUNCTIONADDYI TAB 100MG 2

111

DRUG DRUG NAME TIER

VITAMINSABANEU-SL SUB 2active fe tab 75-1.25 1adc/fluoride dro 0.25mg 1ADVANCED MIS AM/PM 2airavite tab 1aminobez pot pow 1ANIMI-3 CAP 2ANIMI-3 CAP VIT D 2AP-ZEL TAB 2AQUASOL A INJ 50000/ML 2ascorbic acd inj 500mg/ml 1AVAILNEX CHW 750MG 2av-phos 250 tab neutral 1av-vite fb tab 2.5-25-1 1av-vite fb tab 2.5-25-2 1AXONA POW 2b3/azel/turm tab fa/b6/zn 1b6 folic acd cap 1BACMIN TAB 2b-complex inj 100 1BIFERARX TAB 2biocel tab 1bp vit 3 cap 1b-plex tab 1b-plex plus tab 1CALCIFOL WAF 2calcium-fa waf plus d 1CARDIOTEK-RX TAB 2CENFOL TAB 2CENTRATEX CAP 2CEREFOLIN TAB 3CEREFOLIN TAB NAC 3CEREFOLIN TAB NAC 2chromagen cap 1CIFEREX CAP 2CIFRAZOL CAP 1-3775 2corvita tab 1corvita 150 tab 1CORVITE TAB 3

DRUG DRUG NAME TIERCORVITE 150 TAB 2CORVITE 150 TAB 3corvite fe tab 1corvite free tab 1cyanocobalam inj 1000mcg 1DEPLIN 15 CAP 2DEPLIN 7.5 CAP 2DIABETIC CAP VITAMIN 2dialyvite tab 1DIALYVITE TAB 3000 2DIALYVITE TAB 5000 2DIALYVITE TAB SUPREM D 2DIALYVITE/ TAB ZINC 2DIVISTA CAP 2DRISDOL CAP 50000UNT 3DURACHOL CAP 1-3775IU 2ELFOLATE TAB 7.5MG 2ELIGEN B12 TAB 1000-100 2ENLYTE CAP 2ergocalcifer cap 50000unt 1ESCAVITE CHW 2ESCAVITE D CHW 2ESCAVITE LQ DRO 0.25-6MG 2fa-b6-b12 tab 1fabb tab 2.2-25-1 1FERAHEME INJ 510/17ML 2FERIVA CAP 75-1MG 2FERIVA TAB 21/7 2FERIVAFA CAP 110-1MG 2ferocon cap 1ferotrinsic cap 1FERRALET 90 TAB 2ferraplus 90 tab 1ferric gluco inj 12.5/ml 1ferric gluco inj 12.5mg/m 1FERRLECIT INJ 12.5MG/M 3ferrocite tab plus 1FERRO-PLEX TAB 2FERROTRIN CAP 2FLORIVA CHW 0.5MG 2FLORIVA CHW 1MG 2

112

DRUG DRUG NAME TIERFOCALGIN DSS TAB 90-1MG 2folbee tab 1folbee plus tab 1folbee plus tab cz 1folbic tab 1FOLBIC RF TAB 2FOLGARD OS TAB 2FOLGARD RX TAB 3folic acid inj 5mg/ml 1folic acid tab 1000mcg 1folic acid tab 1mg 1FOLIVANE-F CAP 2FOLIVANE-PLS CAP 2folplex 2.2 tab 1foltanx tab 1FOLTANX RF CAP 2FOLTRATE TAB 2foltrin cap 1FOLTX TAB 2FORTAVIT CAP 2FOSTEUM PLUS CAP 2FOVEX CAP 2FUSION PLUS CAP 2GABADONE CAP 2hematinic pl tab vit/min 1hematinic/fa tab 1hematogen cap 1hematogen cap forte 1HEMATOGEN FA CAP 2HEMATRON-AF TAB 3HEMETAB TAB 2hemocyte tab -plus 1HEMOCYTE PLS CAP 2HEMOCYTE-F ELX 2hemocyte-f tab 1HYDROXOCOBAL INJ 1000MCG 2HYPERTENSA CAP 2ICAR-C PLUS TAB 3iferex 150 cap forte 1INFUVITE INJ 2INFUVITE INJ ADULT 2

DRUG DRUG NAME TIERINFUVITE INJ PEDIATRI 2INJECTAFER INJ 750/15ML 2INTEGRA F CAP 2INTEGRA PLUS CAP 2IROSPAN 24/6 MIS 2IS 24/6 MIS 2K-PHOS TAB NEUTRAL 3k-tan plus cap 1LIPICHOL 540 CAP 2LISTER-V CAP 2l-methyl- tab b6-b12 1l-methylfola cap form 15 1l-methylfola cap form 7.5 1L-METHYLFOLA CAP FORTE 2l-methylfola cap forte 15 1l-methylfola tab 15mg 1l-methylfola tab 7.5mg 1l-methyl-mc tab 1l-methyl-mc tab nac 1lmthf/b6/b12 tab 1lysiplex tab plus 1M.V.I PEDIAT INJ 2M.V.I. ADULT INJ 2M.V.I-12 W/O INJ VIT K 2MACUZIN CAP 2MAGNEBIND TAB 400 2MAXFE TAB 2mega-c/a plu inj 500mg/ml 1MEPHYTON TAB 5MG 2metafolbic tab 1metafolbic tab plus 1metafolbic tab plus rf 1METANX CAP 2METHAVER CAP 2METHAZEL CAP 2methylfol/ca tab me-cbl 1methylfol/me cap cbl/p5p 1mult vit-bet chw fl0.25mg 1multi vit/fl chw 0.25mg 1multi vit/fl chw 1mg 1multi vit/fl dro 0.5mg/ml 1

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DRUG DRUG NAME TIERMULTIGEN TAB 2MULTIGEN TAB FOLIC 2MULTIGEN PLS TAB 2multi-vit/fe dro /fl 0.25 1MULTIVIT/FL CHW 0.25MG 2multivit/fl chw 0.25mg 1MULTIVIT/FL CHW 0.5MG 2multivit/fl chw 0.5mg 1MULTIVIT/FL CHW 1MG 2multivit/fl chw 1mg 1multivit/fl dro 0.25mg 1multi-vit/fl dro /fe 0.25 1multi-vit/fl dro 0.25mg 1multi-vit/fl dro 0.5mg/ml 1mult-vit/fl chw 0.5mg 1mvc-fluoride chw 0.25mg 1mvc-fluoride chw 0.5mg 1mvc-fluoride chw 1mg 1myferon 150 cap forte 1MYKIDZ IRON SUS FL 2mynephrocaps cap 1mynephron cap 1NASCOBAL SPR 500MCG 2NEPHPLEX RX TAB 2NEPHROCAPS CAP 3NEPHRON FA TAB 2nephronex tab 1mg 1NEPHRO-VITE TAB RX 3NEUREPA CAP 2NEURIN-SL SUB 2NICADAN TAB 2NICADAN ZX TAB 2NICAZEL TAB 2NICAZEL TAB FORTE 2NICOMIDE TAB 2NIFEREX TAB 2

niva-fol tab 1NOXIFOL-D TAB 2NUFERA TAB 2nufol tab 1

DRUG DRUG NAME TIERNUTRICAP TAB 2nutrifac zx tab 1NUTRIVIT LIQ 800-15-1 2OCUVEL CAP 0.5MG 2ORTHO D CAP 1-3775IU 2ortho-cs 250 inj 250mg/ml 1PERCURA CAP 2phospha 250 tab neutral 1phospho-trin tab 250 neut 1phytonadione inj 1mg/0.5 1PODIAPN CAP 2poly-iron cap 150 fort 1polysacchari cap iron 1POLY-VI-FLOR MIS FS 2POLY-VI-FLOR MIS FS 0.25 2POLY-VI-FLOR MIS FS 0.5MG 2poly-vit/fl chw 0.5mg 1poly-vit/fl dro 0.25mg 1poly-vit/fl dro 0.5mg 1PRE-FOLIC TAB 1-100MG 2PROFERRIN- TAB FORTE 2PROTECT PLUS CAP 2PROTECTIRON TAB 2PULMONA CAP 2purefe cap plus 1purevit dual cap fe plus 1pyridoxine inj 100mg/ml 1QUFLORA FE DRO 0.25-9.5 2QUFLORA PED CHW 0.25MG 2QUFLORA PED CHW 0.5MG 2QUFLORA PED CHW 1MG 2QUFLORA PED DRO 0.25MG 3QUFLORA PED DRO 0.5MG/ML 3renal cap softgel 1RENATABS MIS IRON 2RENATABS TAB 2rena-vite rx tab 1reno cap 1REQ 49+ TAB 2REVESTA CAP 1MG-5750 2

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DRUG DRUG NAME TIERRHEUMATE CAP 2RIBOZEL CAP 2SENTRA AM CAP 2SENTRA PM CAP 2se-tan plus cap 1SIDEROL TAB 2SOD POLYSULT CAP /FA 2STROVITE FOR SYP 2STROVITE FOR TAB 2STROVITE ONE TAB 2SULFZIX CAP 2SUPERVITE LIQ 2support liq 1SUPPORT-500 CAP 2SYNAGEX CAP 1.25MG 2SYNATEK CAP 2TANDEM F CAP 3TANDEM PLUS CAP 3TARON FORTE CAP 2THERAMINE CAP 2THERAMINE POW PLUS 2thiamine hcl inj 100mg/ml 1tl gard rx tab 1TL G-FOL OS TAB 2tl icon cap 1TL-FLUORIVIT CHW 2tl-hem 150 tab 1TL-ICARE CAP 2TREPADONE CAP 2tricon cap 1TRIFERIC POW 272MG 2trigels-f cap forte 1

triphrocaps cap 1tri-vit/fe dro /fl 0.25 1tri-vit/fl dro 0.25mg 1tri-vit/fl dro 0.5mg 1tri-vit/fluo dro 0.25mg 1tri-vit/fluo dro 0.5mg 1T-SUPPORT CAP MAX 2

DRUG DRUG NAME TIERUDAMIN SP TAB 2urosex tab 1v-c forte cap 1vicap forte cap 1vic-forte cap 1virt-caps cap 1virt-gard tab 2.2-25-1 1virt-phos tab 250 neut 1virt-vite tab 1virt-vite tab forte 1virt-vite tab plus 1VISBIOME PAK 2vit a/c/d/fl dro 0.25mg 1vita s forte tab 1vitacel tab 1vitaject inj 1VITAL-D RX TAB 2VITAMAX PED DRO 2vita-min cap 1vitamin c inj 222mg/ml 1vitamin d cap 50000unt 1vitamin k1 inj 10mg/ml 1vitamin k1 inj 1mg/0.5 1VITAROCA PLU TAB 2vol-care rx tab 1vp-vite rx tab 1VP-ZEL TAB 2ZAVARA CAP 1MG-5750 2ZOLATE CAP 2

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Pennsylvania Public School Employees’ Retirement System (PSERS) Notice of Nondiscrimination

The Pennsylvania Public School Employees’ Retirement System (PSERS) Health Options Program complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Pennsylvania Public School Employees’ Retirement System (PSERS) Health Options Program does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The PSERS Health Options Program:

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

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact Joseph E. Wasiak Jr., Assistant Executive Director.

If you believe that the PSERS Health Options Program 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:

Joseph E. Wasiak Jr., Assistant Executive Director Public School Employees’ Retirement System 5 N 5th Street Harrisburg, PA 17101-1905 Phone: (888) 773-7748; Fax: (717) 772-5372; Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Joseph Wasiak is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-868-1019, 800-537-7697 (TDD).

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

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Attention: Free Language Assistance

This chart displays, in various languages, the phone number to call for free language assistance services for individuals with limited English proficiency.

Language Message About Language AssistanceSpanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al 1-800-773-7725.Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-800-773-7725 。French ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont

proposés gratuitement. Appelez le 1-800-773-7725.Italian ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero 1-800-773-7725.German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-773-7725.Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.

Gọi số 1-800-773-7725.Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng

tulong sa wika nang walang bayad. Tumawag sa 1-800-773-7725.Arabic ملحوظة: إذا كنت تتحدث العربية اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

.1-800-773-7725Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수

있습니다. 1-800-773-7725 번으로 전화해 주십시오.

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-773-7725.

Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-773-7725.

Serbo-Croatian

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-773-7725.

Gujarati સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-773-7725.

Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-773-7725.

Cambodian ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្ម្ររ, ស្រវាជំនួយផ្ន្រកភាសា ដ្រយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-800-773-7725។

French Creole (Haitian)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-773-7725.

Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-773-7725.

Greek ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-773-7725.

Pennsylvania Dutch

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-773-7725.

This formulary is effective as of July 1, 2018. For more recent

information or other questions, please contact OptumRx at 1-888-239-1301,

24 hours a day, 7 days a week. TTY users should call 1-800-498-5428. You can

also visit www.HOPbenefits.com.

THE ENHANCED, BASIC OR VALUE MEDICARE Rx OPTION (EMPLOYER PDP) IS A STANDALONE PRESCRIPTION DRUG PLAN WITH A MEDICARE CONTRACT. ENROLLMENT IN THE ENHANCED,

BASIC OR VALUE MEDICARE Rx OPTION (PDP) DEPENDS ON CONTRACT RENEWAL. CMS CONTRACT NUMBER: E3014

2018 comprehensive formulary

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