2019 list of covered drugs (formulary) · 2019 list of covered drugs (formulary) ucare’s msho and...

2019 List of Covered Drugs (Formulary)

UCare’s MSHO and UCare Connect + Medicare

If you have questions, please call either UCare’s MSHO Customer Services at 612‑676‑6868/ 1‑866‑280‑7202, or call UCare Connect + Medicare Customer Services at 612‑676‑3310/ 1‑855‑260‑9707, TTY 612‑676‑6810/1‑800‑688‑2534, 8 am to 8 pm, seven days a week. The call is free. For more information, visit ucare.org.

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IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over‑the‑counter (OTC) drugs are covered by UCare’s MSHO and UCare Connect + Medicare. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UCare's MSHO and UCare Connect + Medicare. Key terms and their definitions appear in the last chapter of the Member Handbook.

H5937_083018_C DHS Approved (09052018) H2456_11192019 DHS/CMS Approved (11192019) CMS Non‑Marketing 19439, Version 18

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older, this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your health plan Primary Care Provider prior to the referral.

A. Disclaimers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

B. Frequently Asked Questions (FAQ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) . . . . . . . . . . . . . . . . . iB2. Does the Drug List ever change?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iB3. What happens when there is a change to the Drug List? . . . . . . . . . . . . . . . . . iiB4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?. . . . . . . . . . . . . . . . . . . . . . iiiB5. How will you know if the drug you want has limitations or if there are any actions required to get the drug? . . . . . . . . . . . . . . . . . . . . . . iiiB6. What happens if we change our rules about how we cover some drugs (for example, prior authorization, quantity limits, and/or step therapy restrictions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiB7. How can you find a drug on the Drug List? . . . . . . . . . . . . . . . . . . . . . . . . . . iiiB8. What if the drug you want to take is not on the Drug List? . . . . . . . . . . . . . . . ivB9. What if you are a new UCare’s MSHO or UCare Connect + Medicare member and can’t find your drug on the Drug List or have a problem getting your drug?. . . ivB10. Can you ask for an exception to cover your drug? . . . . . . . . . . . . . . . . . . . . ivB11. How can you ask for an exception? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vB12. How long does it take to get an exception?. . . . . . . . . . . . . . . . . . . . . . . . . .vB13. What are generic drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vB14. What are over‑the‑counter (OTC) drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . .vB15. Does UCare’s MSHO or UCare Connect + Medicare cover non‑drug OTC products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vB16. Can I get my drugs through Mail‑Order? . . . . . . . . . . . . . . . . . . . . . . . . . . .vB17. What is your copay? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

C. Overview of the List of Covered Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

C1. List of Drugs by Drug Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

D. Index of Covered Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Table of Contents

2019 UCare’s MSHO and UCare Connect + Medicare Formulary i

If you have questions, please call either UCare’s MSHO Customer Services at 612‑676‑6868/1‑866‑280‑7202, or call UCare Connect + Medicare Customer Services at 612‑676‑3310/1‑855‑260‑9707, TTY 612‑676‑6810/1‑800‑688‑2534, 8 am to 8 pm, seven days a week. The call is free. For more information, visit ucare.org.

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A. DisclaimersThis is a list of drugs that members can get in UCare’s MSHO and UCare Connect + Medicare.

• UCare’s MSHO and UCare Connect + Medicare are health plans that contract with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in UCare’s MSHO and UCare Connect + Medicare depends on contract renewal.

• The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year.

• Benefits and/or copays may change on January 1 of each year.

• You can always check UCare’s up‑to‑date List of Covered Drugs online at ucare.org or call Customer Services at the number listed at the bottom of this page.

• You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Services at the number listed at the bottom of this page.

• To make a standing request to always get your UCare materials in a language other than English or in an alternate format such as large print, please contact Customer Services at the number listed below.

B. Frequently Asked Questions (FAQ)Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs?

(We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the Drug List that starts on page 1 are the drugs covered by UCare’s MSHO and UCare Connect + Medicare. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• UCare’s MSHO and UCare Connect + Medicare will cover all medically necessary drugs on the Drug List if:

‑ your doctor or other prescriber says you need them to get better or stay healthy, and

‑ you fill the prescription at a UCare’s MSHO and UCare Connect + Medicare network pharmacy.

• UCare’s MSHO and UCare Connect + Medicare may have additional steps to access certain drugs (see question B4 below).

You can also see an up‑to‑date list of drugs that we cover on our website at ucare.org or call Customer Services at the number listed at the bottom of this page.

B2. Does the Drug List ever change?Yes. UCare’s MSHO and UCare Connect + Medicare may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior authorization for a drug. (Prior authorization is permission from UCare’s MSHO or UCare’s Connect + Medicare before you can get a drug.)

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• Add or change the amount of a drug you can get (called quantity limits).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that is covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe, or

• a drug is removed from the market.

Questions B3 and B6 have more information on what happens when the Drug List changes.

• You can always check UCare’s MSHO and UCare Connect + Medicare’s current Drug List online at ucare.org.

• You can also call Customer Services at the number listed at the bottom of this page to check the current Drug List.

B3. What happens when there is a change to the Drug List?

Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.

‑ We may not tell you before we make this change, but we will send you information about the specific change or changes we made.

‑ You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10‑B12 for more information on exceptions.

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Members should also contact their doctor or pharmacy for further information.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is not new to the market and

• Replace a brand name drug currently on the Drug List or

• Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

• Get a 30‑day supply of the drug before the change to the Drug List is made, or

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• Ask for an exception from these changes. Please see questions B10‑B12 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you, your doctor, or other prescriber must do something before you can get the drug. For example:

• Prior Authorization: For some drugs, you, your doctor, or other prescriber must get authorization from UCare’s MSHO or UCare Connect + Medicare before you fill your prescription. Prior authorization means an approval from UCare’s MSHO or UCare Connect + Medicare to seek services outside of our network or to get services not routinely covered by our network before you get the services. Prior authorization is different from a referral. UCare’s MSHO and UCare Connect + Medicare may not cover the drug if you do not get authorization.

• Quantity Limits: Sometimes UCare’s MSHO and UCare UCare Connect + Medicare limits the amount of a drug you can get.

• Step Therapy: Sometimes UCare’s MSHO and UCare Connect + Medicare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1–102. You can also get more information by visiting our website at ucare.org. We have posted online documents

that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an “exception” to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10‑B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug?

The Drug List on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about how we cover some drugs (for example, prior authorization, quantity limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior authorization, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List?

There are two ways to find a drug: • You can search alphabetically (if you know

how to spell the drug), or• You can search by drug type.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 103. The Index of Covered Drugs is an

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alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the Index.

To search by drug type, find the section labeled “List of drugs by drug type” on page 1. The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

B8. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Customer Services at the number listed at the bottom of this page and ask about it. If you learn that UCare’s MSHO and UCare Connect + Medicare will not cover the drug, you can do one of these things:

• Ask Customer Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. See questions B10‑B12 for more information about exceptions.

B9. What if you are a new UCare’s MSHO or UCare Connect + Medicare member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30‑day supply of your drug during the first 90 days you are a member of UCare’s MSHO or UCare Connect + Medicare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication.

We will cover a 30‑day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior authorization by UCare’s MSHO or UCare Connect + Medicare, or

• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long‑term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long‑term care facility, and need a supply right away:

• We will cover one 31 day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UCare’s MSHO or UCare Connect + Medicare member.

• This is in addition to the temporary supply during the first 90 days you are a member of UCare’s MSHO or UCare Connect + Medicare.

If your level of care changes (e.g. home to nursing home), we will authorize a one‑time (31‑day) transition supply.

B10. Can you ask for an exception to cover your drug?

Yes. You can ask UCare’s MSHO or UCare Connect + Medicare to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

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• For example, UCare’s MSHO or UCare Connect + Medicare may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements.

B11. How can you ask for an exception?To ask for an exception, call UCare’s MSHO Customer Services at 612‑676‑6868/ 1‑866‑280‑7202, or call UCare Connect + Medicare Customer Services at 612‑676‑3310/ 1‑855‑260‑9707, TTY 612‑676‑6810/ 1‑800‑688‑2534, 8 am to 8 pm, seven days a week. A Customer Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception?

First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs?Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well‑known names. Generic drugs are approved by the Food and Drug Administration (FDA).

UCare’s MSHO and UCare Connect + Medicare covers both brand name drugs and generic drugs.

B14. What are over-the-counter (OTC) drugs?

OTC stands for “over‑the‑counter.” UCare’s MSHO and UCare Connect + Medicare offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List, starting on page 115.

B15. Does UCare’s MSHO and UCare Connect + Medicare cover non-drug OTC products?

UCare’s MSHO and UCare Connect + Medicare covers some non‑drug OTC products through Medical Assistance (Medicaid). These non‑drug OTC products are listed in this Drug List. Examples of OTC non‑drug products include gauze pads and bandages.

B16. Can I get my drugs through Mail-Order?

• We offer a mail‑order program that allows you to get up to a 90‑day supply of your prescription drugs sent directly to your home. A 90‑day supply has the same copay as a one‑month supply.

For more information about getting drugs through mail‑order, please call Customer Services at the number listed at the bottom of this page.

B17. What is your copay?You can read the UCare’s MSHO and UCare Connect + Medicare Drug List to learn about the copay for each drug.

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A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $0 to $8.50 for a prescription drug.

UCare’s MSHO and UCare Connect + Medicare members living in nursing homes or other long‑term care facilities will have no copays. Some members getting long‑term care in the community will also have no copays.

The Drug List includes copay listed by tiers.

• Tier 1 Generic drugs have the lowest copay. The copay will be from $0 to $3.40,

depending on your income and level of Medical Assistance (Medicaid) eligibility.

• Tier 1 Brand drugs have a higher copay. The copay will be from $0 to $8.50, depending on your income and level of Medical Assistance (Medicaid) eligibility.

• OTCs have a $0 copay.

If you have questions, call Customer Services at the number at the bottom of this page. We can help you understand what your copays will be.

C. Overview of the List of Covered DrugsThe List of Covered Drugs gives you information about the drugs covered by UCare’s MSHO and UCare Connect + Medicare. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 103. The index alphabetically lists all drugs covered by UCare’s MSHO and UCare Connect + Medicare.

The first column of the table lists the name of the drug. Generic drugs are listed in lower‑case italics (e.g., azathioprine), brand name drugs are capitalized (e.g., AZASAN), and over‑the‑counter (OTC) drugs are listed separately after the Index of Covered Drugs at the end of the document. The information in the “Necessary actions, restrictions, or limits on use” column tells you if UCare’s MSHO or UCare Connect + Medicare has any rules for covering your drug.

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

PA – Prior authorization: You must have approval from the plan before you can get this drug.

ST – Step therapy: You must try another drug before you can get this one.

BvsD – Drugs requiring prior authorization to determine coverage under Part B or Part D.

QLL – Quantity limit.

LA – Limited Distribution drugs (drugs that may be available only at certain pharmacies).

Part B Covered – Covered under Part B benefit.

C1. List of Drugs by Drug TypeThe drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

UCare's Minnesota Senior Health Options (MSHO) and UCare Connect + Medicare Formulary

Name of Drug What the Drug will Cost You (Tier

Level)

Necessary Actions, Restrictions or Limits on Use

ANALGESICSacetaminophen-codeine oral solution 120-12 mg/5 ml 1 QLL (4500 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg 1 QLL (360 EA per 30 days)

acetaminophen-codeine oral tablet 300-60 mg 1 QLL (180 EA per 30 days)

buprenorphine hcl sublingual tablet 2 mg, 8 mg 1

buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour

1 PA; QLL (4 EA per 28 days)

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml 1 QLL (10 ML per 28 days)

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 1

diclofenac potassium oral tablet 50 mg 1diclofenac sodium oral tablet extended release 24 hr 100 mg 1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg 1

diclofenac sodium topical drops 1.5 % 1 QLL (300 ML per 28 days)diclofenac sodium topical gel 3 % 1 PA; QLL (100 GM per 28 days)diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

1

diflunisal oral tablet 500 mg 1DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML 1 QLL (4000 ML per 30 days)

DURAMORPH (PF) INJECTION SOLUTION 1 MG/ML 1 QLL (2000 ML per 30 days)

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG 1 QLL (360 EA per 30 days)

etodolac oral capsule 200 mg, 300 mg 1etodolac oral tablet 400 mg, 500 mg 1etodolac oral tablet extended release 24 hr400 mg, 500 mg, 600 mg 1

You can find information on what the symbols and abbreviations on this table mean by going to page vi.Effective: December 1, 2019

1


Level)


fenoprofen oral tablet 600 mg 1fentanyl citrate buccal lozenge on a handle1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


flurbiprofen oral tablet 100 mg, 50 mg 1hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml 1 QLL (5550 ML per 30 days)

hydrocodone-acetaminophen oral tablet10-300 mg, 5-300 mg, 7.5-300 mg 1 QLL (390 EA per 30 days)

hydrocodone-acetaminophen oral tablet10-325 mg, 5-325 mg, 7.5-325 mg 1 QLL (360 EA per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 1 QLL (50 EA per 30 days)

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml 1 QLL (240 ML per 30 days)

hydromorphone injection syringe 2 mg/ml 1 QLL (1200 ML per 30 days)hydromorphone oral liquid 1 mg/ml 1 QLL (2400 ML per 30 days)hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QLL (180 EA per 30 days)

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg 1 PA; QLL (60 EA per 30 days)

IBU ORAL TABLET 600 MG, 800 MG 1ibuprofen oral suspension 100 mg/5 ml 1ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

ibuprofen-oxycodone oral tablet 400-5 mg 1 QLL (28 EA per 30 days)ketoprofen oral capsule 25 mg 1ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 1

levorphanol tartrate oral tablet 2 mg 1 QLL (120 EA per 30 days)LORCET (HYDROCODONE) ORAL TABLET 5-325 MG 1 QLL (360 EA per 30 days)

LORCET HD ORAL TABLET 10-325 MG 1 QLL (360 EA per 30 days)LORCET PLUS ORAL TABLET 7.5-325 MG 1 QLL (360 EA per 30 days)meclofenamate oral capsule 100 mg, 50 mg 1



Level)


mefenamic acid oral capsule 250 mg 1meloxicam oral tablet 15 mg 1meloxicam oral tablet 7.5 mg 1 QLL (30 EA per 30 days)methadone oral solution 10 mg/5 ml 1 PA; QLL (600 ML per 30 days)

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

methadone oral tablet 10 mg 1 PA; QLL (120 EA per 30 days)methadone oral tablet 5 mg 1 PA; QLL (240 EA per 30 days)morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) 1 QLL (900 ML per 30 days)

morphine oral capsule, er multiphase 24 hr120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg


morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) 1 QLL (900 ML per 30 days)

morphine oral tablet 15 mg, 30 mg 1 QLL (180 EA per 30 days)morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg 1 PA; QLL (120 EA per 30 days)

nabumetone oral tablet 500 mg, 750 mg 1naproxen oral suspension 125 mg/5 ml 1naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg 1

naproxen sodium oral tablet 275 mg, 550 mg 1

oxaprozin oral tablet 600 mg 1oxycodone oral capsule 5 mg 1 QLL (360 EA per 30 days)oxycodone oral concentrate 20 mg/ml 1 QLL (180 ML per 30 days)oxycodone oral solution 5 mg/5 ml 1 QLL (1200 ML per 30 days)oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 QLL (180 EA per 30 days)

oxycodone oral tablet 5 mg 1 QLL (360 EA per 30 days)oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QLL (360 EA per 30 days)


3


Level)


oxycodone-aspirin oral tablet 4.8355-325 mg 1 QLL (360 EA per 30 days)

piroxicam oral capsule 10 mg, 20 mg 1sulindac oral tablet 150 mg, 200 mg 1tolmetin oral capsule 400 mg 1tolmetin oral tablet 600 mg 1tramadol oral tablet 50 mg 1 QLL (240 EA per 30 days)tramadol-acetaminophen oral tablet 37.5-325 mg 1 QLL (240 EA per 30 days)

VICODIN ES ORAL TABLET 7.5-300 MG 1 QLL (390 EA per 30 days)VICODIN HP ORAL TABLET 10-300 MG 1 QLL (390 EA per 30 days)ANESTHETICSlidocaine hcl mucous membrane jelly 2 % 1 QLL (60 ML per 30 days)lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 1

lidocaine topical adhesive patch,medicated5 % 1 PA; QLL (90 EA per 30 days)

lidocaine topical ointment 5 % 1 QLL (36 GM per 30 days)LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % 1

lidocaine-prilocaine topical cream 2.5-2.5 % 1 QLL (30 GM per 30 days)

ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTSacamprosate oral tablet,delayed release (dr/ec) 333 mg 1

buprenorphine hcl sublingual tablet 2 mg, 8 mg 1

buprenorphine-naloxone sublingual film12-3 mg 1 QLL (60 EA per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg 1 QLL (360 EA per 30 days)

buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg 1 QLL (90 EA per 30 days)

buprenorphine-naloxone sublingual tablet2-0.5 mg 1 QLL (360 EA per 30 days)

buprenorphine-naloxone sublingual tablet8-2 mg 1 QLL (90 EA per 30 days)



Level)


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg 1

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG 1

CHANTIX ORAL TABLET 0.5 MG, 1 MG 1CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

1

disulfiram oral tablet 250 mg, 500 mg 1naloxone injection solution 0.4 mg/ml 1naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1

naltrexone oral tablet 50 mg 1NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 1

NICOTROL INHALATION CARTRIDGE 10 MG 1

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML 1

SUBOXONE SUBLINGUAL FILM 12-3 MG 1 QLL (60 EA per 30 days)SUBOXONE SUBLINGUAL FILM 2-0.5 MG 1 QLL (360 EA per 30 days)SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG 1 QLL (90 EA per 30 days)

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG

1

ANTIBACTERIALSacetic acid otic (ear) solution 2 % 1ALCOHOL PADS TOPICAL PADS, MEDICATED 1

amikacin injection solution 500 mg/2 ml 1amoxicillin oral capsule 250 mg, 500 mg 1amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1amoxicillin oral tablet,chewable 125 mg, 250 mg 1


5


Level)


amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg 1

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg 1

ampicillin oral capsule 500 mg 1ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg 1

ampicillin-sulbactam injection recon soln1.5 gram, 15 gram, 3 gram 1

ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML 1 PA; LA

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML 1

azithromycin intravenous recon soln 500 mg 1

azithromycin oral packet 1 gram 1azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml 1

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg

1

aztreonam injection recon soln 1 gram 1bacitracin ophthalmic (eye) ointment 500 unit/gram 1

BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML 1 B vs D; QLL (224 ML per 28

days)BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K)

1

BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML

1

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 1 LA; QLL (84 ML per 28 days)

cefaclor oral capsule 250 mg, 500 mg 1



Level)


cefaclor oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 1

cefaclor oral tablet extended release 12 hr500 mg 1

cefadroxil oral capsule 500 mg 1cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1

cefadroxil oral tablet 1 gram 1cefazolin injection recon soln 1 gram, 10 gram, 500 mg 1

cefdinir oral capsule 300 mg 1cefdinir oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml 1

cefepime injection recon soln 1 gram, 2 gram 1

cefixime oral capsule 400 mg 1cefixime oral suspension for reconstitution100 mg/5 ml, 200 mg/5 ml 1

cefotaxime injection recon soln 1 gram, 500 mg 1

cefotetan injection recon soln 1 gram, 2 gram 1

cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram 1

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml 1

cefpodoxime oral tablet 100 mg, 200 mg 1cefprozil oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml 1

cefprozil oral tablet 250 mg, 500 mg 1ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 1

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg 1

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection recon soln 750 mg 1

cefuroxime sodium intravenous recon soln1.5 gram, 7.5 gram 1


7


Level)


cephalexin oral capsule 250 mg, 500 mg 1cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1

cephalexin oral tablet 250 mg, 500 mg 1ciprofloxacin hcl ophthalmic (eye) drops0.3 % 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1

ciprofloxacin hcl otic (ear) dropperette 0.2 % 1

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml 1

ciprofloxacin oral suspension,microcapsule recon 500 mg/5 ml 1

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1

clarithromycin oral tablet 250 mg, 500 mg 1clarithromycin oral tablet extended release 24 hr 500 mg 1

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1

clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml

1

clindamycin palmitate hcl oral recon soln75 mg/5 ml 1

clindamycin phosphate injection solution150 (mg/ml) (6 ml), 150 mg/ml 1

clindamycin phosphate intravenous solution 600 mg/4 ml 1

clindamycin phosphate topical gel 1 % 1clindamycin phosphate topical lotion 1 % 1clindamycin phosphate topical solution 1 % 1clindamycin phosphate vaginal cream 2 % 1colistin (colistimethate na) injection recon soln 150 mg 1

daptomycin intravenous recon soln 350 mg, 500 mg 1

demeclocycline oral tablet 150 mg, 300 mg 1



Level)


dicloxacillin oral capsule 250 mg, 500 mg 1DOXY-100 INTRAVENOUS RECON SOLN 100 MG 1

doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg 1

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg 1

doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml 1

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1

E.E.S. 400 ORAL TABLET 400 MG 1ertapenem injection recon soln 1 gram 1ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG 1

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG 1

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 1

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml, 400 mg/5 ml

1

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) 1

erythromycin oral capsule,delayed release(dr/ec) 250 mg 1

erythromycin oral tablet 250 mg, 500 mg 1erythromycin oral tablet,delayed release (dr/ec) 250 mg, 333 mg, 500 mg 1

erythromycin with ethanol topical solution2 % 1

gatifloxacin ophthalmic (eye) drops 0.5 % 1GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) 1


9


Level)


gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

1

gentamicin injection solution 40 mg/ml 1gentamicin ophthalmic (eye) drops 0.3 % 1gentamicin topical cream 0.1 % 1gentamicin topical ointment 0.1 % 1imipenem-cilastatin intravenous recon soln250 mg, 500 mg 1

INVANZ INJECTION RECON SOLN 1 GRAM 1levofloxacin in d5w intravenous piggyback500 mg/100 ml, 750 mg/150 ml 1

levofloxacin intravenous solution 25 mg/ml 1levofloxacin ophthalmic (eye) drops 0.5 % 1levofloxacin oral solution 250 mg/10 ml 1levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml 1

linezolid oral suspension for reconstitution100 mg/5 ml 1

linezolid oral tablet 600 mg 1meropenem intravenous recon soln 1 gram, 500 mg 1

methenamine hippurate oral tablet 1 gram 1metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml 1

metronidazole oral capsule 375 mg 1metronidazole oral tablet 250 mg, 500 mg 1metronidazole topical cream 0.75 % 1metronidazole topical gel 0.75 %, 1 % 1metronidazole topical lotion 0.75 % 1metronidazole vaginal gel 0.75 % 1minocycline oral capsule 100 mg, 50 mg, 75 mg 1

minocycline oral tablet 100 mg, 50 mg, 75 mg 1



Level)


MONDOXYNE NL ORAL CAPSULE 100 MG, 75 MG 1

MORGIDOX ORAL CAPSULE 50 MG 1moxifloxacin ophthalmic (eye) drops 0.5 % 1moxifloxacin oral tablet 400 mg 1moxifloxacin-sod.chloride(iso) intravenous piggyback 400 mg/250 ml 1

mupirocin calcium topical cream 2 % 1mupirocin topical ointment 2 % 1nafcillin injection recon soln 1 gram, 10 gram, 2 gram 1

neomycin oral tablet 500 mg 1nitrofurantoin macrocrystal oral capsule100 mg, 25 mg, 50 mg 1

nitrofurantoin monohyd/m-cryst oral capsule 100 mg 1

nitrofurantoin oral suspension 25 mg/5 ml 1ofloxacin ophthalmic (eye) drops 0.3 % 1ofloxacin oral tablet 400 mg 1ofloxacin otic (ear) drops 0.3 % 1oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1

oxacillin injection recon soln 1 gram, 10 gram, 2 gram 1

paromomycin oral capsule 250 mg 1penicillin g potassium injection recon soln20 million unit 1

penicillin g procaine intramuscular syringe1.2 million unit/2 ml 1

penicillin g sodium injection recon soln 5 million unit 1

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml 1

penicillin v potassium oral tablet 250 mg, 500 mg 1

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1


11


Level)


polymyxin b sulfate injection recon soln500,000 unit 1

silver sulfadiazine topical cream 1 % 1SSD TOPICAL CREAM 1 % 1streptomycin intramuscular recon soln 1 gram 1

sulfacetamide sodium (acne) topical suspension 10 % 1

sulfacetamide sodium ophthalmic (eye) drops 10 % 1

sulfacetamide sodium ophthalmic (eye) ointment 10 % 1

sulfadiazine oral tablet 500 mg 1sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml 1

sulfamethoxazole-trimethoprim oral tablet400-80 mg, 800-160 mg 1

SULFAMYLON TOPICAL CREAM 85 MG/G 1SULFAMYLON TOPICAL PACKET 50 GRAM 1SUPRAX ORAL CAPSULE 400 MG 1SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML 1

SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG 1

TAZICEF INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM 1

TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 1

tetracycline oral capsule 250 mg, 500 mg 1tigecycline intravenous recon soln 50 mg 1tinidazole oral tablet 250 mg, 500 mg 1tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml 1 B vs D; QLL (280 ML per 28

days)tobramycin ophthalmic (eye) drops 0.3 % 1tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml 1

trimethoprim oral tablet 100 mg 1TYGACIL INTRAVENOUS RECON SOLN 50 MG 1



Level)


vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg 1

vancomycin oral capsule 125 mg, 250 mg 1VANDAZOLE VAGINAL GEL 0.75 % 1XIFAXAN ORAL TABLET 200 MG 1 QLL (9 EA per 30 days)XIFAXAN ORAL TABLET 550 MG 1 QLL (90 EA per 30 days)ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 1

BANZEL ORAL SUSPENSION 40 MG/ML 1BANZEL ORAL TABLET 200 MG, 400 MG 1BRIVIACT ORAL SOLUTION 10 MG/ML 1BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG 1

carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 200 mg 1carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg 1

carbamazepine oral tablet,chewable 100 mg 1

CELONTIN ORAL CAPSULE 300 MG 1clobazam oral suspension 2.5 mg/ml 1 PA; QLL (480 ML per 30 days)clobazam oral tablet 10 mg, 20 mg 1 PA; QLL (60 EA per 30 days)clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 PAclonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 PA

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 PA

DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG 1

DIASTAT RECTAL KIT 2.5 MG 1DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 1 PA

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA

diazepam oral tablet 10 mg, 2 mg, 5 mg 1 PADILANTIN ORAL CAPSULE 30 MG 1


13


Level)


divalproex oral capsule, delayed rel sprinkle 125 mg 1

divalproex oral tablet extended release 24 hr 250 mg, 500 mg 1

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg 1

EPIDIOLEX ORAL SOLUTION 100 MG/ML 1 PA; LAEPITOL ORAL TABLET 200 MG 1ethosuximide oral capsule 250 mg 1ethosuximide oral solution 250 mg/5 ml 1felbamate oral suspension 600 mg/5 ml 1felbamate oral tablet 400 mg, 600 mg 1FYCOMPA ORAL SUSPENSION 0.5 MG/ML 1FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG 1

gabapentin oral capsule 100 mg 1 QLL (1080 EA per 30 days)gabapentin oral capsule 300 mg 1 QLL (360 EA per 30 days)gabapentin oral capsule 400 mg 1 QLL (270 EA per 30 days)gabapentin oral solution 250 mg/5 ml 1 QLL (2160 ML per 30 days)gabapentin oral tablet 600 mg 1 QLL (180 EA per 30 days)gabapentin oral tablet 800 mg 1 QLL (120 EA per 30 days)GABITRIL ORAL TABLET 12 MG, 16 MG 1lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 1

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg 1

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14)

1

levetiracetam oral solution 100 mg/ml 1levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg 1

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg 1



Level)


lorazepam oral concentrate 2 mg/ml 1 PAlorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 PALYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 1 PA; QLL (90 EA per 30 days)

LYRICA ORAL CAPSULE 225 MG, 300 MG 1 PA; QLL (60 EA per 30 days)LYRICA ORAL SOLUTION 20 MG/ML 1 PA; QLL (900 ML per 30 days)ONFI ORAL SUSPENSION 2.5 MG/ML 1 PAONFI ORAL TABLET 10 MG, 20 MG 1 PAoxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1

PEGANONE ORAL TABLET 250 MG 1phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 1 PA

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1 PA

phenytoin oral suspension 125 mg/5 ml 1phenytoin oral tablet,chewable 50 mg 1phenytoin sodium extended oral capsule100 mg, 200 mg, 300 mg 1

primidone oral tablet 250 mg, 50 mg 1ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG 1

ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG 1

SABRIL ORAL TABLET 500 MG 1 LASPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG 1

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG 1 PA; QLL (60 EA per 30 days)

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1

topiramate oral capsule, sprinkle 15 mg, 25 mg 1 PA

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 PA


15


Level)


valproic acid (as sodium salt) oral solution250 mg/5 ml 1

valproic acid oral capsule 250 mg 1vigabatrin oral powder in packet 500 mg 1 LAvigabatrin oral tablet 500 mg 1 LAVIGADRONE ORAL POWDER IN PACKET 500 MG 1 LA

VIMPAT ORAL SOLUTION 10 MG/ML 1VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 1

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 PA

ANTIDEMENTIA AGENTSdonepezil oral tablet 10 mg, 23 mg, 5 mg 1donepezil oral tablet,disintegrating 10 mg, 5 mg 1

ergoloid oral tablet 1 mg 1galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg 1

galantamine oral solution 4 mg/ml 1galantamine oral tablet 12 mg, 4 mg, 8 mg 1memantine oral capsule,sprinkle,er 24hr14 mg, 21 mg, 28 mg, 7 mg 1 PA

memantine oral solution 2 mg/ml 1 PAmemantine oral tablet 10 mg, 5 mg 1 PANAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG 1 PA

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

1 PA

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1

rivastigmine transdermal patch 24 hour13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

1

ANTIDEPRESSANTSABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

1



Level)


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

1

amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1

aripiprazole oral solution 1 mg/ml 1aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 1 QLL (30 EA per 30 days)

aripiprazole oral tablet,disintegrating 10 mg, 15 mg 1 QLL (60 EA per 30 days)

bupropion hcl oral tablet 100 mg, 75 mg 1bupropion hcl oral tablet extended release 24 hr 150 mg 1 QLL (90 EA per 30 days)

bupropion hcl oral tablet extended release 24 hr 300 mg, 450 mg 1 QLL (30 EA per 30 days)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg 1 QLL (60 EA per 30 days)

citalopram oral solution 10 mg/5 ml 1citalopram oral tablet 10 mg, 40 mg 1 QLL (30 EA per 30 days)citalopram oral tablet 20 mg 1 QLL (60 EA per 30 days)clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 PA

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg


doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA

doxepin oral concentrate 10 mg/ml 1 PAduloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg 1 QLL (60 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 40 mg 1 QLL (90 EA per 30 days)

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR 1

escitalopram oxalate oral solution 5 mg/5 ml 1


17


Level)


escitalopram oxalate oral tablet 10 mg 1 QLL (60 EA per 30 days)escitalopram oxalate oral tablet 20 mg, 5 mg 1 QLL (30 EA per 30 days)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) 1 QLL (28 EA per 28 days)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG


fluoxetine oral capsule 10 mg 1 QLL (30 EA per 30 days)fluoxetine oral capsule 20 mg 1fluoxetine oral capsule 40 mg 1 QLL (60 EA per 30 days)fluoxetine oral capsule,delayed release(dr/ec) 90 mg 1 QLL (4 EA per 28 days)

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1

fluoxetine oral tablet 10 mg 1 QLL (30 EA per 30 days)fluoxetine oral tablet 20 mg, 60 mg 1fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg 1 QLL (60 EA per 30 days)

fluvoxamine oral tablet 100 mg 1 QLL (90 EA per 30 days)fluvoxamine oral tablet 25 mg 1 QLL (30 EA per 30 days)fluvoxamine oral tablet 50 mg 1 QLL (60 EA per 30 days)imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg 1 PA

maprotiline oral tablet 25 mg, 50 mg, 75 mg 1

MARPLAN ORAL TABLET 10 MG 1mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg 1

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 1

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1

nortriptyline oral solution 10 mg/5 ml 1



Level)


olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

1

paroxetine hcl oral tablet 10 mg, 40 mg 1 QLL (30 EA per 30 days)paroxetine hcl oral tablet 20 mg, 30 mg 1 QLL (60 EA per 30 days)paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg 1 QLL (60 EA per 30 days)

paroxetine mesylate(menop.sym) oral capsule 7.5 mg 1 QLL (30 EA per 30 days)

PAXIL ORAL SUSPENSION 10 MG/5 ML 1phenelzine oral tablet 15 mg 1protriptyline oral tablet 10 mg, 5 mg 1PRUDOXIN TOPICAL CREAM 5 % 1 QLL (45 GM per 30 days)quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 QLL (90 EA per 30 days)

quetiapine oral tablet 300 mg, 400 mg 1 QLL (60 EA per 30 days)quetiapine oral tablet extended release 24 hr 150 mg, 200 mg 1 QLL (30 EA per 30 days)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg 1 QLL (60 EA per 30 days)

sertraline oral concentrate 20 mg/ml 1sertraline oral tablet 100 mg, 50 mg 1 QLL (60 EA per 30 days)sertraline oral tablet 25 mg 1 QLL (30 EA per 30 days)tranylcypromine oral tablet 10 mg 1trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1

trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 PA

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 1 QLL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg 1 QLL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr 75 mg 1 QLL (90 EA per 30 days)

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 QLL (90 EA per 30 days)

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 1 QLL (30 EA per 30 days)


19


Level)


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 1 QLL (30 EA per 180 days)

ANTIEMETICSaprepitant oral capsule 125 mg, 40 mg, 80 mg 1 B vs D

aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) 1 B vs D

chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg 1

COMPRO RECTAL SUPPOSITORY 25 MG 1doxylamine-pyridoxine (vit b6) oral tablet,delayed release (dr/ec) 10-10 mg 1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 B vs D

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)

1 B vs D

granisetron hcl oral tablet 1 mg 1 B vs Dhydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA

meclizine oral tablet 12.5 mg, 25 mg 1metoclopramide hcl oral solution 5 mg/5 ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg 1

ondansetron hcl oral solution 4 mg/5 ml 1 B vs Dondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 B vs D

ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 B vs D

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 1promethazine oral syrup 6.25 mg/5 ml 1 PApromethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA



Level)


scopolamine base transdermal patch 3 day1 mg over 3 days 1

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS 1

VARUBI ORAL TABLET 90 MG 1 B vs DANTIFUNGALSABELCET INTRAVENOUS SUSPENSION 5 MG/ML 1 B vs D

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 1 B vs D

amphotericin b injection recon soln 50 mg 1 B vs DCANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG 1 B vs D

caspofungin intravenous recon soln 50 mg 1 B vs Dciclopirox topical cream 0.77 % 1 QLL (90 GM per 28 days)ciclopirox topical gel 0.77 % 1 QLL (45 GM per 28 days)ciclopirox topical shampoo 1 % 1 QLL (120 ML per 28 days)ciclopirox topical solution 8 % 1ciclopirox topical suspension 0.77 % 1 QLL (60 ML per 28 days)clotrimazole mucous membrane troche 10 mg 1

clotrimazole topical cream 1 % 1 QLL (45 GM per 28 days)clotrimazole topical solution 1 % 1 QLL (30 ML per 28 days)CRESEMBA ORAL CAPSULE 186 MG 1econazole topical cream 1 % 1 QLL (85 GM per 28 days)fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml 1

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml 1

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1

flucytosine oral capsule 250 mg, 500 mg 1griseofulvin microsize oral suspension 125 mg/5 ml 1

griseofulvin microsize oral tablet 500 mg 1griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1

itraconazole oral capsule 100 mg 1


21


Level)


itraconazole oral solution 10 mg/ml 1ketoconazole oral tablet 200 mg 1ketoconazole topical cream 2 % 1 QLL (60 GM per 28 days)ketoconazole topical foam 2 % 1 QLL (100 GM per 28 days)ketoconazole topical shampoo 2 % 1 QLL (120 ML per 28 days)MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG 1

MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG 1

naftifine topical cream 1 %, 2 % 1 QLL (60 GM per 28 days)NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % 1

NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) 1

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG 1

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM 1

nystatin oral suspension 100,000 unit/ml 1nystatin oral tablet 500,000 unit 1nystatin topical cream 100,000 unit/gram 1 QLL (30 GM per 28 days)nystatin topical ointment 100,000 unit/gram 1 QLL (30 GM per 28 days)

nystatin topical powder 100,000 unit/gram 1NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM 1

posaconazole oral tablet,delayed release (dr/ec) 100 mg 1

SPORANOX ORAL SOLUTION 10 MG/ML 1terbinafine hcl oral tablet 250 mg 1terconazole vaginal cream 0.4 %, 0.8 % 1terconazole vaginal suppository 80 mg 1voriconazole intravenous recon soln 200 mg 1

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) 1

voriconazole oral tablet 200 mg, 50 mg 1ZOLINZA ORAL CAPSULE 100 MG 1



Level)


ANTIGOUT AGENTSallopurinol oral tablet 100 mg, 300 mg 1colchicine oral tablet 0.6 mg 1COLCRYS ORAL TABLET 0.6 MG 1 STfebuxostat oral tablet 40 mg, 80 mg 1MITIGARE ORAL CAPSULE 0.6 MG 1probenecid oral tablet 500 mg 1probenecid-colchicine oral tablet 500-0.5 mg 1

ULORIC ORAL TABLET 40 MG, 80 MG 1ANTI-INFLAMMATORY AGENTSbetamethasone dipropionate topical cream0.05 % 1

betamethasone dipropionate topical lotion0.05 % 1

betamethasone dipropionate topical ointment 0.05 % 1

betamethasone valerate topical cream 0.1 % 1

betamethasone valerate topical foam 0.12 % 1

betamethasone valerate topical lotion 0.1 % 1

betamethasone valerate topical ointment0.1 % 1

betamethasone, augmented topical cream0.05 % 1

betamethasone, augmented topical gel0.05 % 1

betamethasone, augmented topical lotion0.05 % 1

betamethasone, augmented topical ointment 0.05 % 1

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 % 1

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 % 1

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 1


23


Level)


cortisone oral tablet 25 mg 1DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML 1

dexamethasone oral elixir 0.5 mg/5 ml 1dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1

dexamethasone oral tablets,dose pack 1.5 mg (21 tabs), 1.5 mg (35 tabs), 1.5 mg (51 tabs)

1

diclofenac potassium oral tablet 50 mg 1diclofenac sodium oral tablet extended release 24 hr 100 mg 1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg 1

diflunisal oral tablet 500 mg 1etodolac oral capsule 200 mg 1etodolac oral tablet 400 mg, 500 mg 1etodolac oral tablet extended release 24 hr400 mg, 500 mg, 600 mg 1

fenoprofen oral tablet 600 mg 1flurbiprofen oral tablet 100 mg, 50 mg 1hydrocortisone oral tablet 20 mg, 5 mg 1hydrocortisone-pramoxine rectal cream 1-1 % 1

IBU ORAL TABLET 600 MG, 800 MG 1ibuprofen oral suspension 100 mg/5 ml 1ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

ibuprofen-oxycodone oral tablet 400-5 mg 1 QLL (28 EA per 30 days)ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 1

meclofenamate oral capsule 100 mg, 50 mg 1

mefenamic acid oral capsule 250 mg 1meloxicam oral tablet 15 mg 1meloxicam oral tablet 7.5 mg 1 QLL (30 EA per 30 days)methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 B vs D



Level)


MILLIPRED ORAL TABLET 5 MG 1 B vs Dnabumetone oral tablet 500 mg, 750 mg 1naproxen oral suspension 125 mg/5 ml 1naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg 1

naproxen sodium oral tablet 275 mg, 550 mg 1

oxaprozin oral tablet 600 mg 1piroxicam oral capsule 10 mg, 20 mg 1prednisolone acetate ophthalmic (eye) drops,suspension 1 % 1

prednisolone oral solution 15 mg/5 ml 1prednisolone sodium phosphate ophthalmic (eye) drops 1 % 1

prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML 1 B vs D

prednisone oral solution 5 mg/5 ml 1prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 1 B vs D

prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) 1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) 1

sulindac oral tablet 150 mg, 200 mg 1tolmetin oral capsule 400 mg 1tolmetin oral tablet 600 mg 1triamcinolone acetonide topical aerosol0.147 mg/gram 1

ANTIMIGRAINE AGENTSAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML 1 PA; QLL (2 ML per 30 days)

AJOVY SUBCUTANEOUS SYRINGE 225 MG/1.5 ML 1 PA; QLL (1.5 ML per 30 days)


25


Level)


dihydroergotamine nasal spray,non-aerosol0.5 mg/pump act. (4 mg/ml) 1 QLL (8 ML per 28 days)




eletriptan oral tablet 20 mg, 40 mg 1 QLL (18 EA per 28 days)EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML 1 PA; QLL (2 ML per 30 days)

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML 1 PA; QLL (2 ML per 30 days)

ergotamine-caffeine oral tablet 1-100 mg 1MIGERGOT RECTAL SUPPOSITORY 2-100 MG 1

naratriptan oral tablet 1 mg, 2.5 mg 1 QLL (18 EA per 28 days)rizatriptan oral tablet 10 mg, 5 mg 1 QLL (36 EA per 28 days)rizatriptan oral tablet,disintegrating 10 mg, 5 mg 1 QLL (36 EA per 28 days)

sumatriptan nasal spray,non-aerosol 20 mg/actuation 1 QLL (18 EA per 28 days)

sumatriptan nasal spray,non-aerosol 5 mg/actuation 1 QLL (36 EA per 28 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 QLL (18 EA per 28 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml 1 QLL (8 ML per 28 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml 1 QLL (8 ML per 28 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml 1 QLL (8 ML per 28 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 1 QLL (8 ML per 28 days)

sumatriptan-naproxen oral tablet 85-500 mg 1 QLL (18 EA per 28 days)

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

topiramate oral capsule, sprinkle 15 mg, 25 mg 1 PA



Level)


topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 PA


valproic acid oral capsule 250 mg 1zolmitriptan oral tablet 2.5 mg, 5 mg 1 QLL (18 EA per 28 days)zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg 1 QLL (18 EA per 28 days)

ANTIMYASTHENIC AGENTSguanidine oral tablet 125 mg 1MESTINON ORAL SYRUP 60 MG/5 ML 1pyridostigmine bromide oral syrup 60 mg/5 ml 1

pyridostigmine bromide oral tablet 60 mg 1pyridostigmine bromide oral tablet extended release 180 mg 1

ANTIMYCOBACTERIALSdapsone oral tablet 100 mg, 25 mg 1ethambutol oral tablet 100 mg, 400 mg 1isoniazid oral solution 50 mg/5 ml 1isoniazid oral tablet 100 mg, 300 mg 1PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM 1

PRIFTIN ORAL TABLET 150 MG 1pyrazinamide oral tablet 500 mg 1rifabutin oral capsule 150 mg 1rifampin intravenous recon soln 600 mg 1rifampin oral capsule 150 mg, 300 mg 1SIRTURO ORAL TABLET 100 MG 1 LATRECATOR ORAL TABLET 250 MG 1ANTINEOPLASTICSabiraterone oral tablet 250 mg 1 PA; QLL (120 EA per 30 days)AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 1 PA; QLL (30 EA per 30 days)

ALECENSA ORAL CAPSULE 150 MG 1 PA; QLL (240 EA per 30 days)ALUNBRIG ORAL TABLET 180 MG, 90 MG 1 PA; QLL (30 EA per 30 days)ALUNBRIG ORAL TABLET 30 MG 1 PA; QLL (60 EA per 30 days)


27


Level)


ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) 1 PA; QLL (30 EA per 30 days)

anastrozole oral tablet 1 mg 1BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG 1 PA; LA

bexarotene oral capsule 75 mg 1 PAbicalutamide oral tablet 50 mg 1BOSULIF ORAL TABLET 100 MG 1 PA; QLL (90 EA per 30 days)BOSULIF ORAL TABLET 400 MG, 500 MG 1 PA; QLL (30 EA per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG 1 PA; LA; QLL (180 EA per 30 days)

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 1 PA; LA

CALQUENCE ORAL CAPSULE 100 MG 1 PA; LA; QLL (60 EA per 30 days)

CAPRELSA ORAL TABLET 100 MG 1 PA; LA; QLL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG 1 PA; LA; QLL (30 EA per 30 days)

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

1 PA

COPIKTRA ORAL CAPSULE 15 MG, 25 MG 1 PA; LA

COTELLIC ORAL TABLET 20 MG 1 PA; LA; QLL (63 EA per 28 days)

cyclophosphamide oral capsule 25 mg, 50 mg 1 B vs D

DAURISMO ORAL TABLET 100 MG, 25 MG 1 PADROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 1

EMCYT ORAL CAPSULE 140 MG 1ERIVEDGE ORAL CAPSULE 150 MG 1 PA; QLL (30 EA per 30 days)ERLEADA ORAL TABLET 60 MG 1 PAerlotinib oral tablet 100 mg, 150 mg 1 PA; QLL (30 EA per 30 days)erlotinib oral tablet 25 mg 1 PA; QLL (60 EA per 30 days)exemestane oral tablet 25 mg 1FARESTON ORAL TABLET 60 MG 1FARYDAK ORAL CAPSULE 10 MG 1 PA; QLL (12 EA per 21 days)You can find information on what the symbols and abbreviations on this table mean by going to page vi.Effective: December 1, 201928


Level)


FARYDAK ORAL CAPSULE 15 MG, 20 MG 1 PA; QLL (6 EA per 21 days)flutamide oral capsule 125 mg 1GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 1 PA; QLL (30 EA per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 1

hydroxyurea oral capsule 500 mg 1IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 1 PA; QLL (21 EA per 28 days)

ICLUSIG ORAL TABLET 15 MG 1 PA; QLL (60 EA per 30 days)ICLUSIG ORAL TABLET 45 MG 1 PA; QLL (30 EA per 30 days)

IDHIFA ORAL TABLET 100 MG, 50 MG 1 PA; LA; QLL (30 EA per 30 days)

imatinib oral tablet 100 mg 1 PA; QLL (180 EA per 30 days)imatinib oral tablet 400 mg 1 PA; QLL (60 EA per 30 days)IMBRUVICA ORAL CAPSULE 140 MG 1 PA; QLL (120 EA per 30 days)IMBRUVICA ORAL CAPSULE 70 MG 1 PA; QLL (30 EA per 30 days)IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG 1 PA; QLL (30 EA per 30 days)

INLYTA ORAL TABLET 1 MG 1 PA; QLL (180 EA per 30 days)INLYTA ORAL TABLET 5 MG 1 PA; QLL (120 EA per 30 days)

INREBIC ORAL CAPSULE 100 MG 1 PA; LA; QLL (120 EA per 30 days)

IRESSA ORAL TABLET 250 MG 1 PA; QLL (30 EA per 30 days)JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 1 PA; QLL (60 EA per 30 days)

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

1 PA

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)

1 PA

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)

1 PA

letrozole oral tablet 2.5 mg 1You can find information on what the symbols and abbreviations on this table mean by going to page vi.Effective: December 1, 2019

29


Level)


leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1

LEUKERAN ORAL TABLET 2 MG 1LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 1 PA

LORBRENA ORAL TABLET 100 MG, 25 MG 1 PALYNPARZA ORAL TABLET 100 MG, 150 MG 1 PA; QLL (120 EA per 30 days)MATULANE ORAL CAPSULE 50 MG 1MEKINIST ORAL TABLET 0.5 MG 1 PA; QLL (90 EA per 30 days)MEKINIST ORAL TABLET 2 MG 1 PA; QLL (30 EA per 30 days)

MEKTOVI ORAL TABLET 15 MG 1 PA; LA; QLL (180 EA per 30 days)

MESNEX ORAL TABLET 400 MG 1NERLYNX ORAL TABLET 40 MG 1 PA; LA

NEXAVAR ORAL TABLET 200 MG 1 PA; LA; QLL (120 EA per 30 days)

nilutamide oral tablet 150 mg 1NINLARO ORAL CAPSULE 2.3 MG 1 PA; QLL (6 EA per 28 days)NINLARO ORAL CAPSULE 3 MG 1 PA; QLL (4 EA per 28 days)NINLARO ORAL CAPSULE 4 MG 1 PA; QLL (3 EA per 28 days)NUBEQA ORAL TABLET 300 MG 1 PA; LA

ODOMZO ORAL CAPSULE 200 MG 1 PA; LA; QLL (30 EA per 30 days)

OFEV ORAL CAPSULE 100 MG, 150 MG 1 PA; QLL (60 EA per 30 days)PANRETIN TOPICAL GEL 0.1 % 1PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

1 PA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 1 PA; LA

PURIXAN ORAL SUSPENSION 20 MG/ML 1REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG 1 PA; LA

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG 1 PA; LA

RUBRACA ORAL TABLET 200 MG, 300 MG 1 PA; LA; QLL (120 EA per 30 days)



Level)


RUBRACA ORAL TABLET 250 MG 1 PA; LA; QLL (150 EA per 30 days)

RYDAPT ORAL CAPSULE 25 MG 1 PASOLTAMOX ORAL SOLUTION 10 MG/5 ML 1SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG 1 PA; QLL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG 1 PA; QLL (90 EA per 30 days)SPRYCEL ORAL TABLET 70 MG 1 PA; QLL (60 EA per 30 days)STIVARGA ORAL TABLET 40 MG 1 PA; QLL (84 EA per 28 days)SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG 1 PA; QLL (30 EA per 30 days)

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG 1

SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 1 B vs D

TABLOID ORAL TABLET 40 MG 1TAFINLAR ORAL CAPSULE 50 MG, 75 MG 1 PA; QLL (120 EA per 30 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG 1 PA; LA; QLL (30 EA per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG 1 PAtamoxifen oral tablet 10 mg, 20 mg 1TARCEVA ORAL TABLET 100 MG, 150 MG 1 PA; QLL (30 EA per 30 days)TARCEVA ORAL TABLET 25 MG 1 PA; QLL (60 EA per 30 days)TARGRETIN TOPICAL GEL 1 % 1 PATASIGNA ORAL CAPSULE 150 MG, 200 MG 1 PA; QLL (112 EA per 28 days)TASIGNA ORAL CAPSULE 50 MG 1 PA; QLL (120 EA per 30 days)THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG 1 PA

TIBSOVO ORAL TABLET 250 MG 1 PAtoremifene oral tablet 60 mg 1tretinoin (chemotherapy) oral capsule 10 mg 1

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1 PA

tretinoin topical gel 0.01 %, 0.025 % 1 PATURALIO ORAL CAPSULE 200 MG 1 PA; LA

TYKERB ORAL TABLET 250 MG 1 PA; LA; QLL (180 EA per 30 days)


31


Level)


VALCHLOR TOPICAL GEL 0.016 % 1VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 1 PA; LA

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

1 PA; LA; QLL (42 EA per 180 days)

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 1 PA; LA; QLL (60 EA per 30

days)VITRAKVI ORAL CAPSULE 100 MG, 25 MG 1 PA; LAVITRAKVI ORAL SOLUTION 20 MG/ML 1 PA; LAVIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG 1 PA; QLL (30 EA per 30 days)

VOTRIENT ORAL TABLET 200 MG 1 PA; QLL (120 EA per 30 days)XALKORI ORAL CAPSULE 200 MG, 250 MG 1 PA; QLL (60 EA per 30 days)XOSPATA ORAL TABLET 40 MG 1 PA; LAXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 160 MG/WEEK (20 MG X 8), 60 MG/WEEK (20 MG X 3), 80 MG/WEEK (20 MG X 4)

1 PA; LA

XTANDI ORAL CAPSULE 40 MG 1 PA; QLL (120 EA per 30 days)YONSA ORAL TABLET 125 MG 1 PA; QLL (120 EA per 30 days)

ZEJULA ORAL CAPSULE 100 MG 1 PA; LA; QLL (90 EA per 30 days)

ZELBORAF ORAL TABLET 240 MG 1 PA; QLL (240 EA per 30 days)ZOLINZA ORAL CAPSULE 100 MG 1ZYDELIG ORAL TABLET 100 MG, 150 MG 1 PA; QLL (60 EA per 30 days)ZYKADIA ORAL CAPSULE 150 MG 1 PA; QLL (150 EA per 30 days)ZYKADIA ORAL TABLET 150 MG 1 PA; QLL (150 EA per 30 days)ZYTIGA ORAL TABLET 250 MG 1 PA; QLL (120 EA per 30 days)ZYTIGA ORAL TABLET 500 MG 1 PA; QLL (60 EA per 30 days)ANTIPARASITICSalbendazole oral tablet 200 mg 1ALBENZA ORAL TABLET 200 MG 1 QLL (120 EA per 30 days)ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 1 QLL (360 ML per 30 days)

ALINIA ORAL TABLET 500 MG 1 QLL (14 EA per 30 days)atovaquone oral suspension 750 mg/5 ml 1



Level)


atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg 1

BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG 1

BILTRICIDE ORAL TABLET 600 MG 1chloroquine phosphate oral tablet 250 mg, 500 mg 1

COARTEM ORAL TABLET 20-120 MG 1 QLL (24 EA per 30 days)DARAPRIM ORAL TABLET 25 MG 1 PAEMVERM ORAL TABLET,CHEWABLE 100 MG 1hydroxychloroquine oral tablet 200 mg 1ivermectin oral tablet 3 mg 1lindane topical shampoo 1 % 1malathion topical lotion 0.5 % 1mefloquine oral tablet 250 mg 1NEBUPENT INHALATION RECON SOLN 300 MG 1 B vs D; QLL (1 EA per 28

days)PENTAM INJECTION RECON SOLN 300 MG 1permethrin topical cream 5 % 1praziquantel oral tablet 600 mg 1primaquine oral tablet 26.3 mg 1quinine sulfate oral capsule 324 mg 1 QLL (42 EA per 30 days)ANTIPARKINSON AGENTSamantadine hcl oral capsule 100 mg 1amantadine hcl oral solution 50 mg/5 ml 1amantadine hcl oral tablet 100 mg 1APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML 1 LA

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PAbromocriptine oral capsule 5 mg 1bromocriptine oral tablet 2.5 mg 1carbidopa oral tablet 25 mg 1carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg 1

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg 1


33


Level)


carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa-entacapone oral tablet12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

1

entacapone oral tablet 200 mg 1NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

1

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

1

rasagiline oral tablet 0.5 mg, 1 mg 1ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg 1

selegiline hcl oral capsule 5 mg 1selegiline hcl oral tablet 5 mg 1tolcapone oral tablet 100 mg 1trihexyphenidyl oral elixir 0.4 mg/ml 1ANTIPSYCHOTICSABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

1

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

1

aripiprazole oral solution 1 mg/ml 1aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 1 QLL (30 EA per 30 days)

aripiprazole oral tablet,disintegrating 10 mg, 15 mg 1 QLL (60 EA per 30 days)

ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML

1



Level)


ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

1

chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg 1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg 1

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG 1 QLL (60 EA per 30 days)

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) 1 QLL (8 EA per 28 days)

FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG 1

fluphenazine decanoate injection solution25 mg/ml 1

fluphenazine hcl injection solution 2.5 mg/ml 1

fluphenazine hcl oral concentrate 5 mg/ml 1fluphenazine hcl oral elixir 2.5 mg/5 ml 1fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1

GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) 1

haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml (1 ml), 50 mg/ml

1

haloperidol lactate injection solution 5 mg/ml 1

haloperidol lactate intramuscular syringe 5 mg/ml 1

haloperidol lactate oral concentrate 2 mg/ml 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

1


35


Level)


INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML

1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG 1 QLL (30 EA per 30 days)

LATUDA ORAL TABLET 80 MG 1 QLL (60 EA per 30 days)loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1

molindone oral tablet 10 mg, 25 mg, 5 mg 1NUPLAZID ORAL CAPSULE 34 MG 1 PANUPLAZID ORAL TABLET 10 MG 1 PAolanzapine intramuscular recon soln 10 mg 1olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 QLL (30 EA per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg 1 QLL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg 1 QLL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr 6 mg 1 QLL (60 EA per 30 days)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 120 MG, 90 MG

1

pimozide oral tablet 1 mg, 2 mg 1prochlorperazine maleate oral tablet 10 mg, 5 mg 1

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 QLL (90 EA per 30 days)



REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG 1 QLL (30 EA per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

1



Level)


risperidone oral solution 1 mg/ml 1risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QLL (60 EA per 30 days)

risperidone oral tablet 4 mg 1 QLL (120 EA per 30 days)risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QLL (60 EA per 30 days)

risperidone oral tablet,disintegrating 4 mg 1 QLL (120 EA per 30 days)SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG 1 QLL (60 EA per 30 days)

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

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

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1

VERSACLOZ ORAL SUSPENSION 50 MG/ML 1VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 1 QLL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) 1 QLL (7 EA per 30 days)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 QLL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

1

ANTISPASTICITY AGENTSbaclofen oral tablet 10 mg, 20 mg 1dantrolene oral capsule 100 mg, 25 mg, 50 mg 1

tizanidine oral capsule 2 mg, 4 mg, 6 mg 1tizanidine oral tablet 2 mg, 4 mg 1ANTIVIRALSabacavir oral solution 20 mg/ml 1abacavir oral tablet 300 mg 1abacavir-lamivudine oral tablet 600-300 mg 1

abacavir-lamivudine-zidovudine oral tablet300-150-300 mg 1

acyclovir oral capsule 200 mg 1


37


Level)


acyclovir oral suspension 200 mg/5 ml 1acyclovir oral tablet 400 mg, 800 mg 1acyclovir sodium intravenous solution 50 mg/ml 1 B vs D

acyclovir topical cream 5 % 1 PA; QLL (5 GM per 30 days)acyclovir topical ointment 5 % 1 PA; QLL (30 GM per 30 days)adefovir oral tablet 10 mg 1amantadine hcl oral capsule 100 mg 1amantadine hcl oral solution 50 mg/5 ml 1amantadine hcl oral tablet 100 mg 1APTIVUS ORAL CAPSULE 250 MG 1APTIVUS ORAL SOLUTION 100 MG/ML 1atazanavir oral capsule 150 mg, 200 mg, 300 mg 1

ATRIPLA ORAL TABLET 600-200-300 MG 1BARACLUDE ORAL SOLUTION 0.05 MG/ML 1BIKTARVY ORAL TABLET 50-200-25 MG 1CIMDUO ORAL TABLET 300-300 MG 1COMPLERA ORAL TABLET 200-25-300 MG 1CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 1DELSTRIGO ORAL TABLET 100-300-300 MG 1

DENAVIR TOPICAL CREAM 1 % 1DESCOVY ORAL TABLET 200-25 MG 1didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg 1

DOVATO ORAL TABLET 50-300 MG 1EDURANT ORAL TABLET 25 MG 1efavirenz oral capsule 200 mg, 50 mg 1efavirenz oral tablet 600 mg 1EMTRIVA ORAL CAPSULE 200 MG 1EMTRIVA ORAL SOLUTION 10 MG/ML 1entecavir oral tablet 0.5 mg, 1 mg 1EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) 1

EVOTAZ ORAL TABLET 300-150 MG 1



Level)


famciclovir oral tablet 125 mg, 250 mg, 500 mg 1

fosamprenavir oral tablet 700 mg 1FUZEON SUBCUTANEOUS RECON SOLN 90 MG 1

GENVOYA ORAL TABLET 150-150-200-10 MG 1

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG 1

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

1 B vs D

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML 1

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 1 B vs D

INVIRASE ORAL TABLET 500 MG 1ISENTRESS HD ORAL TABLET 600 MG 1ISENTRESS ORAL POWDER IN PACKET 100 MG 1

ISENTRESS ORAL TABLET 400 MG 1ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 1

JULUCA ORAL TABLET 50-25 MG 1KALETRA ORAL TABLET 100-25 MG, 200-50 MG 1

lamivudine oral solution 10 mg/ml 1lamivudine oral tablet 100 mg, 150 mg, 300 mg 1

lamivudine-zidovudine oral tablet 150-300 mg 1

ledipasvir-sofosbuvir oral tablet 90-400 mg 1 PALEXIVA ORAL SUSPENSION 50 MG/ML 1lopinavir-ritonavir oral solution 400-100 mg/5 ml 1

MAVYRET ORAL TABLET 100-40 MG 1 PA; QLL (84 EA per 28 days)nevirapine oral suspension 50 mg/5 ml 1nevirapine oral tablet 200 mg 1


39


Level)


nevirapine oral tablet extended release 24 hr 100 mg, 400 mg 1

NORVIR ORAL POWDER IN PACKET 100 MG 1NORVIR ORAL SOLUTION 80 MG/ML 1NORVIR ORAL TABLET 100 MG 1ODEFSEY ORAL TABLET 200-25-25 MG 1oseltamivir oral capsule 30 mg, 45 mg, 75 mg 1

oseltamivir oral suspension for reconstitution 6 mg/ml 1

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML 1 QLL (2 ML per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML 1 QLL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML 1 QLL (2 ML per 28 days)

PIFELTRO ORAL TABLET 100 MG 1PREVYMIS ORAL TABLET 240 MG, 480 MG 1 QLL (30 EA per 30 days)PREZCOBIX ORAL TABLET 800-150 MG-MG 1PREZISTA ORAL SUSPENSION 100 MG/ML 1PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 1

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION 1

RESCRIPTOR ORAL TABLET 200 MG 1REYATAZ ORAL POWDER IN PACKET 50 MG 1ribavirin oral capsule 200 mg 1ribavirin oral tablet 200 mg 1rimantadine oral tablet 100 mg 1ritonavir oral tablet 100 mg 1SELZENTRY ORAL SOLUTION 20 MG/ML 1SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 1

sofosbuvir-velpatasvir oral tablet 400-100 mg 1 PA

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1



Level)


STRIBILD ORAL TABLET 150-150-200-300 MG 1

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG 1

SYMFI LO ORAL TABLET 400-300-300 MG 1SYMFI ORAL TABLET 600-300-300 MG 1SYMTUZA ORAL TABLET 800-150-200-10 MG 1

tenofovir disoproxil fumarate oral tablet300 mg 1

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG 1

trifluridine ophthalmic (eye) drops 1 % 1TRIUMEQ ORAL TABLET 600-50-300 MG 1TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG 1

valacyclovir oral tablet 1 gram 1 QLL (120 EA per 30 days)valacyclovir oral tablet 500 mg 1 QLL (60 EA per 30 days)valganciclovir oral recon soln 50 mg/ml 1valganciclovir oral tablet 450 mg 1VEMLIDY ORAL TABLET 25 MG 1VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) 1

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG 1

VIRACEPT ORAL TABLET 250 MG, 625 MG 1VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 1

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) 1

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 1

VOSEVI ORAL TABLET 400-100-100 MG 1 PA; QLL (28 EA per 28 days)XOFLUZA ORAL TABLET 20 MG, 40 MG 1zidovudine oral capsule 100 mg 1zidovudine oral syrup 10 mg/ml 1zidovudine oral tablet 300 mg 1ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 1


41


Level)


ZOVIRAX TOPICAL CREAM 5 % 1 PA; QLL (5 GM per 30 days)ANXIOLYTICSalprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 PA

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 PAclonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 PA

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 PA

DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG 1

DIASTAT RECTAL KIT 2.5 MG 1DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 1 PA

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA

diazepam oral tablet 10 mg, 2 mg, 5 mg 1 PAdoxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA

doxepin oral concentrate 10 mg/ml 1 PAduloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg 1 QLL (60 EA per 30 days)


escitalopram oxalate oral solution 5 mg/5 ml 1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 QLL (30 EA per 30 days)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA

lorazepam oral concentrate 2 mg/ml 1 PAlorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 PAoxazepam oral capsule 10 mg, 15 mg, 30 mg 1 PA

paroxetine hcl oral tablet 10 mg, 40 mg 1 QLL (30 EA per 30 days)paroxetine hcl oral tablet 20 mg, 30 mg 1 QLL (60 EA per 30 days)



Level)


paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg 1 QLL (60 EA per 30 days)

PAXIL ORAL SUSPENSION 10 MG/5 ML 1sertraline oral concentrate 20 mg/ml 1sertraline oral tablet 100 mg, 50 mg 1 QLL (60 EA per 30 days)sertraline oral tablet 25 mg 1 QLL (30 EA per 30 days)venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg 1 QLL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr 75 mg 1 QLL (90 EA per 30 days)

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 QLL (90 EA per 30 days)

BIPOLAR AGENTScarbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg 1

carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 200 mg 1carbamazepine oral tablet extended release 12 hr 100 mg 1

carbamazepine oral tablet,chewable 100 mg 1




EPITOL ORAL TABLET 200 MG 1GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) 1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet extended release 24hr 50 mg 1

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 1

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg 1


43


Level)


lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14)

1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1

lithium carbonate oral tablet 300 mg 1lithium carbonate oral tablet extended release 300 mg, 450 mg 1

lithium citrate oral solution 8 meq/5 ml 1olanzapine intramuscular recon soln 10 mg 1olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 QLL (30 EA per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg 1 QLL (30 EA per 30 days)

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 QLL (90 EA per 30 days)



RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

1

risperidone oral solution 1 mg/ml 1risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QLL (60 EA per 30 days)

risperidone oral tablet 4 mg 1 QLL (120 EA per 30 days)risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 1 QLL (60 EA per 30 days)

risperidone oral tablet,disintegrating 4 mg 1 QLL (120 EA per 30 days)SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG 1 QLL (60 EA per 30 days)


valproic acid oral capsule 250 mg 1VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 1 QLL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) 1 QLL (7 EA per 30 days)



Level)


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 QLL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

1

BLOOD GLUCOSE REGULATORSacarbose oral tablet 100 mg 1 QLL (90 EA per 30 days)acarbose oral tablet 25 mg 1 QLL (360 EA per 30 days)acarbose oral tablet 50 mg 1 QLL (180 EA per 30 days)ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" 1

BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION 1

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML 1 PA; QLL (4 ML per 28 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML 1 PA; QLL (4 EA per 28 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML 1 PA; QLL (2.4 ML per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 1 PA; QLL (1.2 ML per 30 days)

CYCLOSET ORAL TABLET 0.8 MG 1 QLL (180 EA per 30 days)GAUZE PAD TOPICAL BANDAGE 2 X 2 " 1glimepiride oral tablet 1 mg 1 QLL (240 EA per 30 days)glimepiride oral tablet 2 mg 1 QLL (120 EA per 30 days)glimepiride oral tablet 4 mg 1 QLL (60 EA per 30 days)glipizide oral tablet 10 mg 1 QLL (120 EA per 30 days)glipizide oral tablet 5 mg 1 QLL (240 EA per 30 days)glipizide oral tablet extended release 24hr10 mg 1 QLL (60 EA per 30 days)

glipizide oral tablet extended release 24hr2.5 mg 1 QLL (240 EA per 30 days)

glipizide oral tablet extended release 24hr5 mg 1 QLL (120 EA per 30 days)

glipizide-metformin oral tablet 2.5-250 mg 1 QLL (240 EA per 30 days)glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 QLL (120 EA per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG 1


45


Level)


GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG 1

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

1

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

1

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

1

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

1

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML 1

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML 1

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

1

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge

1

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG 1 QLL (60 EA per 30 days)

INVOKAMET ORAL TABLET 50-500 MG 1 QLL (120 EA per 30 days)INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG


INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 50-500 MG 1 QLL (120 EA per 30 days)

INVOKANA ORAL TABLET 100 MG 1 QLL (90 EA per 30 days)INVOKANA ORAL TABLET 300 MG 1 QLL (30 EA per 30 days)JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG 1 QLL (60 EA per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG 1 QLL (30 EA per 30 days)

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




Level)


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 1 QLL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG 1 QLL (30 EA per 30 days)JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG 1 QLL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG 1 QLL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG 1 QLL (30 EA per 30 days)

KORLYM ORAL TABLET 300 MG 1 PALANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

1

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML 1

metformin oral tablet 1,000 mg 1 QLL (75 EA per 30 days)metformin oral tablet 500 mg 1 QLL (150 EA per 30 days)metformin oral tablet 850 mg 1 QLL (90 EA per 30 days)metformin oral tablet extended release 24 hr 500 mg 1 QLL (120 EA per 30 days)

metformin oral tablet extended release 24 hr 750 mg 1 QLL (75 EA per 30 days)

miglitol oral tablet 100 mg 1 QLL (90 EA per 30 days)miglitol oral tablet 25 mg 1 QLL (360 EA per 30 days)miglitol oral tablet 50 mg 1 QLL (180 EA per 30 days)nateglinide oral tablet 120 mg 1 QLL (90 EA per 30 days)nateglinide oral tablet 60 mg 1 QLL (180 EA per 30 days)NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

1

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

1

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML 1

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

1


47


Level)


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

1

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

1

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 1

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML 1

OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) 1 PA; QLL (1.5 ML per 28 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML) 1 PA; QLL (3 ML per 28 days)

pen needle, diabetic needle 29 gauge x 1/2" 1

pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 QLL (30 EA per 30 days)

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg 1 QLL (30 EA per 30 days)

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg 1 QLL (90 EA per 30 days)

PROGLYCEM ORAL SUSPENSION 50 MG/ML 1repaglinide oral tablet 0.5 mg 1 QLL (960 EA per 30 days)repaglinide oral tablet 1 mg 1 QLL (480 EA per 30 days)repaglinide oral tablet 2 mg 1 QLL (240 EA per 30 days)repaglinide-metformin oral tablet 1-500 mg, 2-500 mg 1 QLL (150 EA per 30 days)

RIOMET ORAL SOLUTION 500 MG/5 ML 1 QLL (765 ML per 30 days)SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML 1

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML 1 PA; QLL (10.8 ML per 30

days)SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML 1 PA; QLL (6 ML per 30 days)

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG 1 QLL (60 EA per 30 days)

SYNJARDY ORAL TABLET 5-500 MG 1 QLL (120 EA per 30 days)



Level)


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


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG 1 QLL (30 EA per 30 days)

tolbutamide oral tablet 500 mg 1 QLL (180 EA per 30 days)TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)

1

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)

1

TRADJENTA ORAL TABLET 5 MG 1 QLL (30 EA per 30 days)VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) 1 PA; QLL (9 ML per 30 days)

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERSanagrelide oral capsule 0.5 mg, 1 mg 1aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg 1

BRILINTA ORAL TABLET 60 MG, 90 MG 1CABLIVI INJECTION KIT 11 MG 1 PA; LAcilostazol oral tablet 100 mg, 50 mg 1clopidogrel oral tablet 75 mg 1dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

DOPTELET (10 TAB PACK) ORAL TABLET 20 MG 1 PA

DOPTELET (15 TAB PACK) ORAL TABLET 20 MG 1 PA

DOPTELET (30 TAB PACK) ORAL TABLET 20 MG 1 PA; LA

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 1ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) 1

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

1


49


Level)


fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

1

FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML 1 PA

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 1 PA

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 1 PA

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

1

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

LEUKINE INJECTION RECON SOLN 250 MCG 1

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML 1 PA

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 1 PA

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 1 PA

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 1 PA

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 1

prasugrel oral tablet 10 mg, 5 mg 1PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

1 PA

PROMACTA ORAL POWDER IN PACKET 12.5 MG 1 PA; LA

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 1 PA; LA

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

1 PA

tranexamic acid oral tablet 650 mg 1



Level)


warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG 1

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) 1

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 1 PA

CARDIOVASCULAR AGENTSacebutolol oral capsule 200 mg, 400 mg 1acetazolamide oral capsule, extended release 500 mg 1

acetazolamide oral tablet 125 mg, 250 mg 1aliskiren oral tablet 150 mg, 300 mg 1amiloride oral tablet 5 mg 1amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

amiodarone oral tablet 100 mg, 200 mg, 400 mg 1

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg


amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg 1

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg 1

amlodipine-valsartan-hcthiazid oral tablet10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

1

atenolol oral tablet 100 mg, 25 mg, 50 mg 1atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 QLL (30 EA per 30 days)


51


Level)


benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

benazepril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1

betaxolol oral tablet 10 mg, 20 mg 1bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg 1

bumetanide injection solution 0.25 mg/ml 1bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1

candesartan-hydrochlorothiazid oral tablet16-12.5 mg, 32-12.5 mg, 32-25 mg 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

captopril-hydrochlorothiazide oral tablet25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg 1

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG

1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg

1

chlorothiazide oral tablet 250 mg, 500 mg 1chlorthalidone oral tablet 25 mg, 50 mg 1cholestyramine (with sugar) oral powder in packet 4 gram 1

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM 1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr 1 QLL (4 EA per 28 days)

colesevelam oral powder in packet 3.75 gram 1



Level)


colesevelam oral tablet 625 mg 1colestipol oral packet 5 gram 1colestipol oral tablet 1 gram 1CORLANOR ORAL SOLUTION 5 MG/5 ML 1 PACORLANOR ORAL TABLET 5 MG, 7.5 MG 1 PADEMSER ORAL CAPSULE 250 MG 1 PADIGITEK ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG) 1

DIGOX ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG) 1

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

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) 1

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg 1

diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg 1

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg 1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG 1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg 1 QLL (30 EA per 30 days)doxazosin oral tablet 8 mg 1 QLL (60 EA per 30 days)enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1

enalapril-hydrochlorothiazide oral tablet10-25 mg, 5-12.5 mg 1

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 1 QLL (60 EA per 30 days)

eplerenone oral tablet 25 mg, 50 mg 1eprosartan oral tablet 600 mg 1ethacrynic acid oral tablet 25 mg 1ezetimibe oral tablet 10 mg 1


53


Level)


ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg 1 QLL (30 EA per 30 days)

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg 1

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 1

fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg 1

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

1

fenofibric acid oral tablet 105 mg, 35 mg 1flecainide oral tablet 100 mg, 150 mg, 50 mg 1

fluvastatin oral capsule 20 mg 1 QLL (30 EA per 30 days)fluvastatin oral capsule 40 mg 1 QLL (60 EA per 30 days)fluvastatin oral tablet extended release 24 hr 80 mg 1 QLL (30 EA per 30 days)

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1fosinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg 1

furosemide injection solution 10 mg/ml 1furosemide injection syringe 10 mg/ml 1furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

gemfibrozil oral tablet 600 mg 1hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

hydrochlorothiazide oral capsule 12.5 mg 1hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 1irbesartan oral tablet 150 mg, 300 mg, 75 mg 1



Level)


irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg 1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1

isosorbide dinitrate oral tablet extended release 40 mg 1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

1

isradipine oral capsule 2.5 mg, 5 mg 1JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG 1 PA; LA

labetalol oral tablet 100 mg, 200 mg, 300 mg 1

LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG) 1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1

lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 1

losartan oral tablet 100 mg, 25 mg, 50 mg 1losartan-hydrochlorothiazide oral tablet100-12.5 mg, 100-25 mg, 50-12.5 mg 1

lovastatin oral tablet 10 mg 1 QLL (30 EA per 30 days)lovastatin oral tablet 20 mg, 40 mg 1 QLL (60 EA per 30 days)MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

1

methazolamide oral tablet 25 mg, 50 mg 1methyldopa oral tablet 250 mg, 500 mg 1metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet100-25 mg, 100-50 mg, 50-25 mg 1


55


Level)


metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

mexiletine oral capsule 150 mg, 200 mg, 250 mg 1

midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1minoxidil oral tablet 10 mg, 2.5 mg 1moexipril oral tablet 15 mg, 7.5 mg 1nadolol oral tablet 20 mg, 40 mg, 80 mg 1nadolol-bendroflumethiazide oral tablet 40-5 mg 1

niacin oral tablet extended release 24 hr1,000 mg, 500 mg, 750 mg 1

nicardipine oral capsule 20 mg, 30 mg 1nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg 1

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg 1

nimodipine oral capsule 30 mg 1nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

1

NITRO-BID TRANSDERMAL OINTMENT 2 % 1nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg 1

nitroglycerin transdermal patch 24 hour0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

nitroglycerin translingual spray,non-aerosol400 mcg/spray 1

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 1 PA

olmesartan oral tablet 20 mg, 40 mg, 5 mg 1olmesartan-amlodipin-hcthiazid oral tablet20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

1

olmesartan-hydrochlorothiazide oral tablet20-12.5 mg, 40-12.5 mg, 40-25 mg 1

omega-3 acid ethyl esters oral capsule 1 gram 1



Level)


PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG 1

pentoxifylline oral tablet extended release400 mg 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

phenoxybenzamine oral capsule 10 mg 1 PApindolol oral tablet 10 mg, 5 mg 1PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML 1 PA; QLL (2 ML per 28 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML 1 PA; QLL (4 ML per 28 days)

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 QLL (30 EA per 30 days)

prazosin oral capsule 1 mg, 2 mg, 5 mg 1PREVALITE ORAL POWDER IN PACKET 4 GRAM 1

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg 1

propafenone oral tablet 150 mg, 225 mg, 300 mg 1

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg 1

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) 1

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1

propranolol-hydrochlorothiazid oral tablet40-25 mg, 80-25 mg 1

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 1

quinidine gluconate oral tablet extended release 324 mg 1

quinidine sulfate oral tablet 200 mg, 300 mg 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1


57


Level)


RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG 1

ranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg 1

RECTIV RECTAL OINTMENT 0.4 % (W/W) 1REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML 1 PA; QLL (3.5 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML 1 PA; QLL (3 ML per 28 days)

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML 1 PA; QLL (3 ML per 28 days)

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 QLL (30 EA per 30 days)

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 1 QLL (30 EA per 30 days)

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG 1

SOTALOL AF ORAL TABLET 120 MG 1sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1

SOTYLIZE ORAL SOLUTION 5 MG/ML 1spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolacton-hydrochlorothiaz oral tablet25-25 mg 1

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

1

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG 1

TEKTURNA ORAL TABLET 150 MG, 300 MG 1telmisartan oral tablet 20 mg, 40 mg, 80 mg 1

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg 1

telmisartan-hydrochlorothiazid oral tablet40-12.5 mg, 80-12.5 mg, 80-25 mg 1

terazosin oral capsule 1 mg, 2 mg, 5 mg 1 QLL (30 EA per 30 days)terazosin oral capsule 10 mg 1 QLL (60 EA per 30 days)



Level)


timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

1

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg 1

triamterene-hydrochlorothiazid oral tablet37.5-25 mg, 75-50 mg 1

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

1 PA; LA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) 1 PA; LA

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM 1

verapamil oral capsule, 24 hr er pellet ct100 mg, 200 mg, 300 mg 1

verapamil oral capsule,ext rel. pellets 24 hr120 mg, 180 mg, 240 mg, 360 mg 1

verapamil oral tablet 120 mg, 40 mg, 80 mg 1

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg 1

CENTRAL NERVOUS SYSTEM AGENTSAMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG 1 PA; LA

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg 1

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG 1 PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML 1 PA; QLL (4 EA per 28 days)


59


Level)


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML 1 PA; QLL (4 EA per 28 days)

BETASERON SUBCUTANEOUS KIT 0.3 MG 1 PA; QLL (15 EA per 28 days)clonidine hcl oral tablet extended release 12 hr 0.1 mg 1

dalfampridine oral tablet extended release 12 hr 10 mg 1 PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

1

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg 1 QLL (60 EA per 30 days)


FIRDAPSE ORAL TABLET 10 MG 1 PA; LAGILENYA ORAL CAPSULE 0.5 MG 1 PAglatiramer subcutaneous syringe 20 mg/ml 1 PA; QLL (30 ML per 30 days)glatiramer subcutaneous syringe 40 mg/ml 1 PA; QLL (12 ML per 28 days)GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML 1 PA; QLL (30 ML per 30 days)

GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML 1 PA; QLL (12 ML per 28 days)

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 1 PA; QLL (90 EA per 30 days)

LYRICA ORAL CAPSULE 225 MG, 300 MG 1 PA; QLL (60 EA per 30 days)LYRICA ORAL SOLUTION 20 MG/ML 1 PA; QLL (900 ML per 30 days)MAYZENT ORAL TABLET 0.25 MG, 2 MG 1 PAMETADATE ER ORAL TABLET EXTENDED RELEASE 20 MG 1

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

1

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml 1

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1



Level)


methylphenidate hcl oral tablet extended release 10 mg, 20 mg 1

methylphenidate hcl oral tablet,chewable10 mg, 2.5 mg, 5 mg 1

NUEDEXTA ORAL CAPSULE 20-10 MG 1 PAPLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML 1 PA; QLL (1 ML per 28 days)

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML 1 PA; QLL (1 ML per 180 days)

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML 1 PA; QLL (1 ML per 28 days)

PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML 1 PA; QLL (1 ML per 180 days)

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg 1 PA; QLL (90 EA per 30 days)

pregabalin oral capsule 225 mg, 300 mg 1 PA; QLL (60 EA per 30 days)pregabalin oral solution 20 mg/ml 1 PA; QLL (900 ML per 30 days)PROCENTRA ORAL SOLUTION 5 MG/5 ML 1REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML 1 PA; QLL (6 ML per 28 days)

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML 1 PA; QLL (6 ML per 28 days)

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

1 PA; QLL (4.2 ML per 180 days)

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

1 PA; QLL (4.2 ML per 180 days)

riluzole oral tablet 50 mg 1TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

1 PA; LA

tetrabenazine oral tablet 12.5 mg 1 PA; QLL (240 EA per 30 days)tetrabenazine oral tablet 25 mg 1 PA; QLL (120 EA per 30 days)VECAMYL ORAL TABLET 2.5 MG 1DENTAL AND ORAL AGENTScevimeline oral capsule 30 mg 1chlorhexidine gluconate mucous membrane mouthwash 0.12 % 1


61


Level)


doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg 1

doxycycline monohydrate oral tablet 150 mg, 75 mg 1

minocycline oral capsule 100 mg, 50 mg, 75 mg 1

minocycline oral tablet 100 mg, 50 mg, 75 mg 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1triamcinolone acetonide dental paste 0.1 % 1DERMATOLOGICAL AGENTSacitretin oral capsule 10 mg, 17.5 mg, 25 mg 1

ammonium lactate topical cream 12 % 1ammonium lactate topical lotion 12 % 1AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG 1

azelaic acid topical gel 15 % 1betamethasone dipropionate topical lotion0.05 % 1

calcipotriene scalp solution 0.005 % 1 QLL (120 ML per 30 days)calcipotriene topical cream 0.005 % 1 QLL (120 GM per 30 days)calcipotriene topical ointment 0.005 % 1 QLL (120 GM per 30 days)calcipotriene-betamethasone topical ointment 0.005-0.064 % 1 QLL (400 GM per 30 days)

calcitriol topical ointment 3 mcg/gram 1CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 1

clobetasol topical spray,non-aerosol 0.05 % 1 QLL (125 ML per 28 days)

clotrimazole-betamethasone topical cream1-0.05 % 1 QLL (45 GM per 28 days)

clotrimazole-betamethasone topical lotion1-0.05 % 1 QLL (60 ML per 28 days)

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML 1 PA



Level)


COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML 1 PA

dapsone topical gel 5 % 1diclofenac sodium topical gel 1 % 1 QLL (1000 GM per 28 days)diclofenac sodium topical gel 3 % 1 PA; QLL (100 GM per 28 days)doxepin topical cream 5 % 1 QLL (45 GM per 30 days)doxycycline hyclate oral capsule 50 mg 1doxycycline monohydrate oral capsule 100 mg, 50 mg 1

doxycycline monohydrate oral tablet 100 mg, 50 mg 1

DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML, 300 MG/2 ML 1 PA

fluocinonide topical cream 0.1 % 1 QLL (120 GM per 30 days)fluorouracil topical cream 5 % 1fluorouracil topical solution 2 %, 5 % 1hydrocortisone butyrate topical lotion 0.1 % 1

imiquimod topical cream in packet 5 % 1isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1

mafenide acetate topical packet 50 gram 1methoxsalen oral capsule,liqd-filled,rapid rel 10 mg 1

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 1

NOLIX TOPICAL CREAM 0.05 % 1nystatin-triamcinolone topical cream100,000-0.1 unit/g-% 1 QLL (60 GM per 28 days)

nystatin-triamcinolone topical ointment100,000-0.1 unit/gram-% 1 QLL (60 GM per 28 days)

oxiconazole topical cream 1 % 1pimecrolimus topical cream 1 % 1 PA; QLL (100 GM per 30 days)podofilox topical solution 0.5 % 1prednicarbate topical cream 0.1 % 1PRUDOXIN TOPICAL CREAM 5 % 1 QLL (45 GM per 30 days)REGRANEX TOPICAL GEL 0.01 % 1


63


Level)


SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 1

selenium sulfide topical lotion 2.5 % 1SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2) 1 PA; QLL (1 EA per 28 days)

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML 1 PA

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML 1 PA

tacrolimus topical ointment 0.03 %, 0.1 % 1 PA; QLL (100 GM per 30 days)tazarotene topical cream 0.1 % 1 PATAZORAC TOPICAL CREAM 0.05 % 1 PATAZORAC TOPICAL GEL 0.05 %, 0.1 % 1 PAtretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1 PA

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

TRIANEX TOPICAL OINTMENT 0.05 % 1VALCHLOR TOPICAL GEL 0.016 % 1ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 1

ELECTROLYTES/MINERALS/METALS/VITAMINSAMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 1 B vs D

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % 1 B vs D

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 1 B vs D

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 %

1 B vs D

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG 1 LA

CHEMET ORAL CAPSULE 100 MG 1 PACLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

1 B vs D



Level)


CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

1 B vs D

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

1 B vs D

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

1 B vs D

CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

1 B vs D

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %

1 B vs D

d10 %-0.45 % sodium chloride intravenous parenteral solution 1

d2.5 %-0.45 % sodium chloride intravenous parenteral solution 1

d5 % and 0.9 % sodium chloride intravenous parenteral solution 1

d5 %-0.45 % sodium chloride intravenous parenteral solution 1

deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg 1 PA

DEPEN TITRATABS ORAL TABLET 250 MG 1dextrose 10 % and 0.2 % nacl intravenous parenteral solution 1

dextrose 10 % in water (d10w) intravenous parenteral solution 10 % 1

dextrose 5 % in water (d5w) intravenous parenteral solution 1

dextrose 5%-0.2 % sod chloride intravenous parenteral solution 1

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution 1

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1

EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG 1 PA; LA

FERRIPROX ORAL SOLUTION 100 MG/ML 1 PA


65


Level)


FERRIPROX ORAL TABLET 1,000 MG, 500 MG 1 PA

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

HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % 1 B vs D

INTRALIPID INTRAVENOUS EMULSION 20 % 1 B vs D

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % 1

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

1

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION 1

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML 1

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 1

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ 1

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ 1



KLOR-CON ORAL PACKET 20 MEQ 1KLOR-CON SPRINKLE ORAL CAPSULE, EXTENDED RELEASE 8 MEQ 1

K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ 1

levocarnitine (with sugar) oral solution 100 mg/ml 1

levocarnitine oral tablet 330 mg 1magnesium sulfate injection solution 4 meq/ml (50 %) 1

magnesium sulfate injection syringe 4 meq/ml 1



Level)


NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % 1 B vs D

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

1

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION 1

penicillamine oral capsule 250 mg 1PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION 1

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION 1

PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % 1 B vs D

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

1

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l 1

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l 1

potassium chloride in water intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml

1

potassium chloride intravenous solution 2 meq/ml, 2 meq/ml (20 ml) 1

potassium chloride oral capsule, extended release 10 meq, 8 meq 1

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml 1

potassium chloride oral packet 20 meq 1potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq 1

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq 1

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l 1


67


Level)


potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l 1

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l 1

potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

1

PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 1 B vs D

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % 1 B vs D

PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG 1

SAMSCA ORAL TABLET 15 MG, 30 MG 1 PAsodium chloride 0.45 % intravenous parenteral solution 0.45 % 1

sodium chloride 0.9 % intravenous parenteral solution 1

sodium chloride 3 % intravenous parenteral solution 3 % 1

sodium chloride 5 % intravenous parenteral solution 5 % 1

sodium chloride irrigation solution 0.9 % 1sodium lactate intravenous solution 5 meq/ml 1

sodium polystyrene sulfonate oral powder 1SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML 1

TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 1 B vs D

trientine oral capsule 250 mg 1 PATROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 1 B vs D

TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % 1 B vs D

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM 1

GASTROINTESTINAL AGENTSalosetron oral tablet 0.5 mg, 1 mg 1



Level)


amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg 1 QLL (112 EA per 30 days)

budesonide oral capsule,delayed,extend.release 3 mg 1

budesonide oral tablet,delayed and ext.release 9 mg 1

CHENODAL ORAL TABLET 250 MG 1 PA; LACHOLBAM ORAL CAPSULE 250 MG 1 PACHOLBAM ORAL CAPSULE 50 MG 1 PA; QLL (120 EA per 30 days)cimetidine hcl oral solution 300 mg/5 ml 1cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1

CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML 1

dicyclomine oral capsule 10 mg 1dicyclomine oral solution 10 mg/5 ml 1dicyclomine oral tablet 20 mg 1diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

ENULOSE ORAL SOLUTION 10 GRAM/15 ML 1esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg 1 QLL (30 EA per 30 days)

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg 1

famotidine oral suspension 40 mg/5 ml (8 mg/ml) 1

famotidine oral tablet 20 mg, 40 mg 1GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG 1 PA

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM 1

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM 1

GAVILYTE-N ORAL RECON SOLN 420 GRAM 1GENERLAC ORAL SOLUTION 10 GRAM/15 ML 1

glycopyrrolate oral tablet 1 mg, 2 mg 1


69


Level)


lactulose oral solution 10 gram/15 ml 1lansoprazole oral capsule,delayed release(dr/ec) 15 mg 1 QLL (30 EA per 30 days)

lansoprazole oral capsule,delayed release(dr/ec) 30 mg 1

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG 1

loperamide oral capsule 2 mg 1metoclopramide hcl oral solution 5 mg/5 ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg 1

misoprostol oral tablet 100 mcg, 200 mcg 1MOVANTIK ORAL TABLET 12.5 MG, 25 MG 1 PA; QLL (30 EA per 30 days)nizatidine oral capsule 150 mg, 300 mg 1nizatidine oral solution 150 mg/10 ml 1

OCALIVA ORAL TABLET 10 MG, 5 MG 1 PA; LA; QLL (30 EA per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 10 mg 1 QLL (30 EA per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 20 mg 1 QLL (60 EA per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 40 mg 1

pantoprazole oral tablet,delayed release (dr/ec) 20 mg 1 QLL (30 EA per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg 1

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram

1

peg-electrolyte soln oral recon soln 420 gram 1

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

ranitidine hcl oral capsule 150 mg, 300 mg 1ranitidine hcl oral syrup 15 mg/ml 1



Level)


ranitidine hcl oral tablet 150 mg, 300 mg 1RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML 1

RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML 1

scopolamine base transdermal patch 3 day1 mg over 3 days 1

sucralfate oral tablet 1 gram 1TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM 1

ursodiol oral capsule 300 mg 1ursodiol oral tablet 250 mg, 500 mg 1VIBERZI ORAL TABLET 100 MG, 75 MG 1

XERMELO ORAL TABLET 250 MG 1 PA; LA; QLL (90 EA per 30 days)

XIFAXAN ORAL TABLET 200 MG 1 QLL (9 EA per 30 days)GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENTCERDELGA ORAL CAPSULE 84 MG 1CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

1

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML 1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 1 LAKUVAN ORAL POWDER IN PACKET 100 MG, 500 MG 1 PA

KUVAN ORAL TABLET,SOLUBLE 100 MG 1 PAmiglustat oral capsule 100 mg 1 LAORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG 1 LA

ORFADIN ORAL SUSPENSION 4 MG/ML 1 LARAVICTI ORAL LIQUID 1.1 GRAM/ML 1RUZURGI ORAL TABLET 10 MG 1 PAsodium phenylbutyrate oral tablet 500 mg 1


71


Level)


SUCRAID ORAL SOLUTION 8,500 UNIT/ML 1VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT 1

XURIDEN ORAL GRANULES IN PACKET 2 GRAM 1

GENITOURINARY AGENTSalfuzosin oral tablet extended release 24 hr10 mg 1

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1

calcium acetate oral capsule 667 mg 1calcium acetate oral tablet 667 mg 1CUPRIMINE ORAL CAPSULE 250 MG 1DEPEN TITRATABS ORAL TABLET 250 MG 1doxazosin oral tablet 1 mg, 2 mg, 4 mg 1 QLL (30 EA per 30 days)doxazosin oral tablet 8 mg 1 QLL (60 EA per 30 days)dutasteride oral capsule 0.5 mg 1dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg 1

ELMIRON ORAL CAPSULE 100 MG 1finasteride oral tablet 5 mg 1flavoxate oral tablet 100 mg 1lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG 1

oxybutynin chloride oral syrup 5 mg/5 ml 1oxybutynin chloride oral tablet 5 mg 1oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg 1

phenoxybenzamine oral capsule 10 mg 1 PApotassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)

1

prazosin oral capsule 1 mg, 2 mg, 5 mg 1sevelamer carbonate oral powder in packet0.8 gram, 2.4 gram 1

sevelamer carbonate oral tablet 800 mg 1



Level)


sevelamer hcl oral tablet 400 mg, 800 mg 1silodosin oral capsule 4 mg, 8 mg 1sodium phenylbutyrate oral powder 0.94 gram/gram 1

solifenacin oral tablet 10 mg, 5 mg 1tadalafil oral tablet 2.5 mg, 5 mg 1 PA; QLL (30 EA per 30 days)tamsulosin oral capsule 0.4 mg 1terazosin oral capsule 1 mg, 2 mg, 5 mg 1 QLL (30 EA per 30 days)terazosin oral capsule 10 mg 1 QLL (60 EA per 30 days)THIOLA ORAL TABLET 100 MG 1tolterodine oral capsule,extended release 24hr 2 mg, 4 mg 1

tolterodine oral tablet 1 mg, 2 mg 1trospium oral capsule,extended release 24hr 60 mg 1

trospium oral tablet 20 mg 1HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)ALA-CORT TOPICAL CREAM 1 %, 2.5 % 1alclometasone topical cream 0.05 % 1alclometasone topical ointment 0.05 % 1betamethasone dipropionate topical cream0.05 % 1

betamethasone dipropionate topical ointment 0.05 % 1

betamethasone valerate topical cream 0.1 % 1

betamethasone valerate topical foam 0.12 % 1

betamethasone valerate topical lotion 0.1 % 1

betamethasone valerate topical ointment0.1 % 1

betamethasone, augmented topical cream0.05 % 1

betamethasone, augmented topical gel0.05 % 1


73


Level)


betamethasone, augmented topical lotion0.05 % 1

betamethasone, augmented topical ointment 0.05 % 1

clobetasol scalp solution 0.05 % 1 QLL (100 ML per 28 days)clobetasol topical cream 0.05 % 1 QLL (120 GM per 28 days)clobetasol topical foam 0.05 % 1 QLL (100 GM per 28 days)clobetasol topical gel 0.05 % 1 QLL (120 GM per 28 days)clobetasol topical lotion 0.05 % 1 QLL (118 ML per 28 days)clobetasol topical ointment 0.05 % 1 QLL (120 GM per 28 days)clobetasol topical shampoo 0.05 % 1 QLL (236 ML per 28 days)clobetasol-emollient topical cream 0.05 % 1 QLL (120 GM per 28 days)clobetasol-emollient topical foam 0.05 % 1 QLL (100 GM per 28 days)cortisone oral tablet 25 mg 1desonide topical cream 0.05 % 1desonide topical lotion 0.05 % 1desonide topical ointment 0.05 % 1DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML 1



1

fludrocortisone oral tablet 0.1 mg 1fluocinolone acetonide oil otic (ear) drops0.01 % 1

fluocinolone and shower cap scalp oil 0.01 % 1

fluocinolone topical cream 0.01 %, 0.025 % 1

fluocinolone topical ointment 0.025 % 1fluocinolone topical solution 0.01 % 1fluocinonide topical cream 0.1 % 1 QLL (120 GM per 30 days)fluocinonide topical gel 0.05 % 1 QLL (120 GM per 30 days)fluocinonide topical ointment 0.05 % 1 QLL (120 GM per 30 days)fluocinonide topical solution 0.05 % 1 QLL (120 ML per 30 days)You can find information on what the symbols and abbreviations on this table mean by going to page vi.Effective: December 1, 201974


Level)


FLUOCINONIDE-E TOPICAL CREAM 0.05 % 1 QLL (120 GM per 30 days)halobetasol propionate topical cream 0.05 % 1

halobetasol propionate topical ointment0.05 % 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

hydrocortisone topical cream 1 %, 2.5 % 1hydrocortisone topical lotion 2.5 % 1hydrocortisone topical ointment 1 %, 2.5 % 1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 B vs D

methylprednisolone oral tablets,dose pack4 mg 1

MILLIPRED ORAL TABLET 5 MG 1 B vs Dmometasone topical cream 0.1 % 1mometasone topical ointment 0.1 % 1mometasone topical solution 0.1 % 1prednicarbate topical ointment 0.1 % 1prednisolone oral solution 15 mg/5 ml 1prednisolone sodium phosphate oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg, 30 mg 1 B vs D



prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) 1

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 1

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1


75


Level)


triamcinolone acetonide topical aerosol0.147 mg/gram 1

triamcinolone acetonide topical cream0.025 %, 0.1 %, 0.5 % 1

triamcinolone acetonide topical lotion0.025 %, 0.1 % 1

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 % 1

TRIDERM TOPICAL CREAM 0.1 % 1HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE) 1

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) 1

desmopressin oral tablet 0.1 mg, 0.2 mg 1INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 1 LA

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) 1 PA; LA

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

1 PA

OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG 1 PA

ORILISSA ORAL TABLET 150 MG, 200 MG 1 PASTIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) 1

VYNDAQEL ORAL CAPSULE 20 MG 1 PAHORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PROSTAGLANDINS)misoprostol oral tablet 200 mcg 1HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)ALTAVERA (28) ORAL TABLET 0.15-0.03 MG 1



Level)


ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG 1

AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) 1

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) 1

ANADROL-50 ORAL TABLET 50 MG 1 PAANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

1 PA; QLL (150 GM per 30 days)

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) 1 PA; QLL (37.5 GM per 30

days)ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) 1 PA; QLL (150 GM per 30 days)

APRI ORAL TABLET 0.15-0.03 MG 1ARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG 1

ASHLYNA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) 1

AUBRA ORAL TABLET 0.1-20 MG-MCG 1AVIANE ORAL TABLET 0.1-20 MG-MCG 1BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG 1

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

BRIELLYN ORAL TABLET 0.4-35 MG-MCG 1budesonide oral capsule,delayed,extend.release 3 mg 1

CAMILA ORAL TABLET 0.35 MG 1CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) 1

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG 1

CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG 1

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG 1


77


Level)


CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG 1

CYRED EQ ORAL TABLET 0.15-0.03 MG 1danazol oral capsule 100 mg, 200 mg, 50 mg 1

DEBLITANE ORAL TABLET 0.35 MG 1DELYLA (28) ORAL TABLET 0.1-20 MG-MCG 1

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML 1

desog-e.estradiol/e.estradiol oral tablet0.15-0.02 mgx21 /0.01 mg x 5 1

desogestrel-ethinyl estradiol oral tablet0.15-0.03 mg 1

DOTTI TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


drospirenone-e.estradiol-lm.fa oral tablet3-0.02-0.451 mg (24) (4) 1

drospirenone-ethinyl estradiol oral tablet3-0.02 mg, 3-0.03 mg 1

EMOQUETTE ORAL TABLET 0.15-0.03 MG 1ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) 1

ENSKYCE ORAL TABLET 0.15-0.03 MG 1ERRIN ORAL TABLET 0.35 MG 1ESTARYLLA ORAL TABLET 0.25-35 MG-MCG 1

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PAestradiol transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr


estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr


estradiol vaginal cream 0.01 % (0.1 mg/gram) 1

estradiol vaginal tablet 10 mcg 1



Level)


estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1

estradiol-norethindrone acet oral tablet0.5-0.1 mg, 1-0.5 mg 1 PA

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg 1

FALMINA (28) ORAL TABLET 0.1-20 MG-MCG 1

FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

1

FEMYNOR ORAL TABLET 0.25-35 MG-MCG 1GIANVI (28) ORAL TABLET 3-0.02 MG 1INCASSIA ORAL TABLET 0.35 MG 1INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) 1

ISIBLOOM ORAL TABLET 0.15-0.03 MG 1JASMIEL (28) ORAL TABLET 3-0.02 MG 1JULEBER ORAL TABLET 0.15-0.03 MG 1JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 1

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG 1

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) 1

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 1

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG 1

KELNOR 1-50 ORAL TABLET 1-50 MG-MCG 1KURVELO (28) ORAL TABLET 0.15-0.03 MG 1


79


Level)


l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7)

1

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 1

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 1

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

LARISSIA ORAL TABLET 0.1-20 MG-MCG 1LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) 1

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG 1

LESSINA ORAL TABLET 0.1-20 MG-MCG 1LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) 1

levonorgestrel-ethinyl estrad oral tablet0.1-20 mg-mcg, 0.15-0.03 mg, 90-20 mcg (28)

1

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

1

levonorg-eth estrad triphasic oral tablet50-30 (6)/75-40 (5)/125-30(10) 1

LEVORA-28 ORAL TABLET 0.15-0.03 MG 1LORYNA (28) ORAL TABLET 3-0.02 MG 1LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG 1

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG 1

LYZA ORAL TABLET 0.35 MG 1MARLISSA (28) ORAL TABLET 0.15-0.03 MG 1

medroxyprogesterone intramuscular suspension 150 mg/ml 1



Level)


medroxyprogesterone intramuscular syringe 150 mg/ml 1

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg 1

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 1 PA

megestrol oral tablet 20 mg, 40 mg 1 PAMELODETTA 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 1 PA

methyltestosterone oral capsule 10 mg 1MIBELAS 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4) 1

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 1

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 1

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

MILI ORAL TABLET 0.25-35 MG-MCG 1NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG 1

NIKKI (28) ORAL TABLET 3-0.02 MG 1NORA-BE ORAL TABLET 0.35 MG 1noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4)

1

norethindrone (contraceptive) oral tablet0.35 mg 1

norethindrone acetate oral tablet 5 mg 1norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg, 1-5 mg-mcg 1 PA

norethindrone ac-eth estradiol oral tablet1-20 mg-mcg 1

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) 1


81


Level)


norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

1

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1

NORLYROC ORAL TABLET 0.35 MG 1NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG 1

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21) 1

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG 1

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG 1

OCELLA ORAL TABLET 3-0.03 MG 1OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG 1

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 1OSPHENA ORAL TABLET 60 MG 1oxandrolone oral tablet 10 mg, 2.5 mg 1 PAPIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 1

PIRMELLA ORAL TABLET 1-35 MG-MCG 1PORTIA 28 ORAL TABLET 0.15-0.03 MG 1PREVIFEM ORAL TABLET 0.25-35 MG-MCG 1progesterone micronized oral capsule 100 mg, 200 mg 1

raloxifene oral tablet 60 mg 1RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG 1

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

1

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) 1

SHAROBEL ORAL TABLET 0.35 MG 1SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG 1



Level)


SRONYX ORAL TABLET 0.1-20 MG-MCG 1SYEDA ORAL TABLET 3-0.03 MG 1TARINA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

TARINA FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml 1 PA

testosterone enanthate intramuscular oil200 mg/ml 1 PA

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation 1 PA; QLL (120 GM per 30 days)

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) 1 PA; QLL (300 GM per 30 days)

testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %) 1 PA; QLL (150 GM per 30 days)

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) 1 PA; QLL (300 GM per 30 days)

testosterone transdermal gel in packet1.62 % (20.25 mg/1.25 gram) 1 PA; QLL (37.5 GM per 30

days)testosterone transdermal gel in packet1.62 % (40.5 mg/2.5 gram) 1 PA; QLL (150 GM per 30 days)

testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml)

1 PA; QLL (180 ML per 30 days)

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) 1

TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 1

TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 1

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1


83


Level)


TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) 1

TYDEMY ORAL TABLET 3-0.03-0.451 MG (21) (7) 1

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG 1

VIENVA ORAL TABLET 0.1-20 MG-MCG 1VYFEMLA (28) ORAL TABLET 0.4-35 MG-MCG 1

WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) 1

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR 1

YUVAFEM VAGINAL TABLET 10 MCG 1ZARAH ORAL TABLET 3-0.03 MG 1ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG 1

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)LYSODREN ORAL TABLET 500 MG 1



Level)


HORMONAL AGENTS, SUPPRESSANT (PITUITARY)bromocriptine oral capsule 5 mg 1bromocriptine oral tablet 2.5 mg 1cabergoline oral tablet 0.5 mg 1FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG

1 B vs D

leuprolide subcutaneous kit 1 mg/0.2 ml 1LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

1 PA

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG 1 PA

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG 1 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG 1 PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

1

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML

1

SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG 1

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML 1

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG

1 B vs D

HORMONAL AGENTS, SUPPRESSANT (THYROID)methimazole oral tablet 10 mg, 5 mg 1propylthiouracil oral tablet 50 mg 1


85


Level)


IMMUNOLOGICAL AGENTSACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML 1

ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML 1 B vs D

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

1

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

1

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG 1 PA

AFINITOR ORAL TABLET 2.5 MG 1 PA; QLL (30 EA per 30 days)ARCALYST SUBCUTANEOUS RECON SOLN 220 MG 1 PA

azathioprine oral tablet 50 mg 1 B vs Dbcg vaccine, live (pf) percutaneous suspension for reconstitution 50 mg 1

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML 1 PA

BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML 1 PA

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML 1

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML 1

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML 1

CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) 1 PA

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 B vs D

cyclosporine modified oral solution 100 mg/ml 1 B vs D

cyclosporine oral capsule 100 mg, 25 mg 1 B vs DDAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

1

DEPEN TITRATABS ORAL TABLET 250 MG 1



Level)


ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) 1 PA; QLL (8 ML per 28 days)

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) 1 PA; QLL (16 EA per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) 1 PA; QLL (8 ML per 28 days)

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) 1 PA; QLL (8 ML per 28 days)

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML 1 B vs D

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML 1 B vs D

FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML 1 PA

GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %) 1 PA

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) 1 PA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML 1

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML 1

GENGRAF ORAL CAPSULE 100 MG, 25 MG 1 B vs DGENGRAF ORAL SOLUTION 100 MG/ML 1 B vs DHAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT 1 PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

1

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

1

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML 1

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK)



87


Level)


HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML 1 PA; QLL (4 EA per 28 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML 1 PA; QLL (2 EA per 28 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 1 PA; QLL (4 EA per 28 days)

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML 1 PA; QLL (3 EA per 180 days)

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 40 MG/0.4 ML 1 PA; QLL (4 EA per 28 days)

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 20 MG/0.2 ML 1 PA; QLL (2 EA per 28 days)

icatibant subcutaneous syringe 30 mg/3 ml 1 PAIMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT 1

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML 1

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML 1

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML 1

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML 1



Level)


KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML 1

leflunomide oral tablet 10 mg, 20 mg 1 QLL (30 EA per 30 days)MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML 1

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML 1

mercaptopurine oral tablet 50 mg 1methotrexate sodium (pf) injection solution25 mg/ml 1 B vs D

methotrexate sodium injection solution 25 mg/ml 1 B vs D

methotrexate sodium oral tablet 2.5 mg 1 B vs DM-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML 1

mycophenolate mofetil oral capsule 250 mg 1 B vs D

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml 1 B vs D

mycophenolate mofetil oral tablet 500 mg 1 B vs Dmycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg 1 B vs D

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML 1 PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML 1 PA

OTEZLA ORAL TABLET 30 MG 1 PAOTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 1 PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML 1

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML 1

PRIVIGEN INTRAVENOUS SOLUTION 10 % 1 PAPROGRAF ORAL GRANULES IN PACKET 0.2 MG, 1 MG 1 B vs D

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

1


89


Level)


QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

1

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

1

RAPAMUNE ORAL SOLUTION 1 MG/ML 1 B vs DRECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML 1 B vs D

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML 1 B vs D

RIDAURA ORAL CAPSULE 3 MG 1RINVOQ ER ORAL TABLET EXTENDED RELEASE 24 HR 15 MG 1 PA; QLL (30 EA per 30 days)

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML 1

ROTATEQ VACCINE ORAL SOLUTION 2 ML 1SANDIMMUNE ORAL SOLUTION 100 MG/ML 1 B vs DSHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

1

sirolimus oral solution 1 mg/ml 1 B vs Dsirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 B vs Dtacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 B vs D

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML) 1 PA; LA

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML 1

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML 1

tetanus,diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml

1

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML 1

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML 1

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML 1



Level)


TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML 1

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML 1

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML 1

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

1

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2 ML 1

XATMEP ORAL SOLUTION 2.5 MG/ML 1 B vs DXELJANZ ORAL TABLET 10 MG, 5 MG 1 PAXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 1 PA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

1

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG 1 B vs D

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

1

INFLAMMATORY BOWEL DISEASE AGENTSbalsalazide oral capsule 750 mg 1budesonide oral capsule,delayed,extend.release 3 mg 1

COLOCORT RECTAL ENEMA 100 MG/60 ML 1cortisone oral tablet 25 mg 1DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML 1



1

DIPENTUM ORAL CAPSULE 250 MG 1


91


Level)


hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

hydrocortisone rectal enema 100 mg/60 ml 1mesalamine oral capsule (with del rel tablets) 400 mg 1

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mg 1

mesalamine rectal enema 4 gram/60 ml 1mesalamine rectal suppository 1,000 mg 1methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 B vs D

methylprednisolone oral tablets,dose pack4 mg 1

MILLIPRED ORAL TABLET 5 MG 1 B vs DPENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG 1

prednisolone acetate ophthalmic (eye) drops,suspension 1 % 1

prednisolone oral solution 15 mg/5 ml 1prednisolone sodium phosphate oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg, 30 mg 1 B vs D



PROCTO-MED HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

sulfasalazine oral tablet 500 mg 1sulfasalazine oral tablet,delayed release (dr/ec) 500 mg 1

METABOLIC BONE DISEASE AGENTSalendronate oral solution 70 mg/75 ml 1 QLL (1286 ML per 30 days)



Level)


alendronate oral tablet 10 mg, 40 mg, 5 mg 1 QLL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg 1 QLL (4 EA per 28 days)calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation 1

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1calcitriol oral solution 1 mcg/ml 1cinacalcet oral tablet 30 mg, 60 mg, 90 mg 1doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1

etidronate disodium oral tablet 200 mg, 400 mg 1

ibandronate oral tablet 150 mg 1 QLL (1 EA per 30 days)NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

1 PA; LA

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML 1 PA

risedronate oral tablet 150 mg 1 QLL (1 EA per 30 days)risedronate oral tablet 30 mg, 5 mg 1 QLL (30 EA per 30 days)risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) 1 QLL (4 EA per 28 days)

risedronate oral tablet,delayed release (dr/ec) 35 mg 1 QLL (4 EA per 28 days)

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG 1

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) 1 PA; QLL (1.56 ML per 30

days)XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML) 1 B vs D

NON-FRFAIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML

1 PA; QLL (2 ML per 30 days)

DEXCOM G4 RECEIVER Part B CoveredDEXCOM G4 RECEIVER-SHARE KIT Part B CoveredDEXCOM G4 TRANSMITTER DEVICE Part B Covered


93


Level)


DEXCOM G5 RECEIVER Part B CoveredDEXCOM G5 TRANSMITTER DEVICE Part B CoveredDEXCOM G5-G4 SENSOR DEVICE Part B CoveredDEXCOM G6 RECEIVER Part B CoveredDEXCOM G6 SENSOR DEVICE Part B CoveredDEXCOM G6 TRANSMITTER DEVICE Part B CoveredDEXCOM RECEIVER Part B CoveredFREESTYLE LIBRE 10 DAY READER Part B CoveredFREESTYLE LIBRE 10 DAY SENSOR KIT Part B CoveredFREESTYLE LIBRE 14 DAY READER Part B CoveredFREESTYLE LIBRE 14 DAY SENSOR KIT Part B CoveredONETOUCH ULTRA BLUE TEST STRIP STRIP Part B CoveredONETOUCH ULTRA2 METER KIT Part B CoveredONETOUCH ULTRAMINI KIT Part B CoveredONETOUCH VERIO FLEX Part B CoveredONETOUCH VERIO FLEX START KIT Part B CoveredONETOUCH VERIO IQ METER Part B CoveredONETOUCH VERIO IQ METER KIT Part B CoveredONETOUCH VERIO STRIP Part B CoveredONETOUCH VERIO SYSTEM Part B Coveredtetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml 1

OPHTHALMIC AGENTSacetazolamide oral tablet 125 mg, 250 mg 1ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % 1

apraclonidine ophthalmic (eye) drops 0.5 % 1

atropine ophthalmic (eye) drops 1 % 1azelastine ophthalmic (eye) drops 0.05 % 1bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram 1

betaxolol ophthalmic (eye) drops 0.5 % 1bimatoprost ophthalmic (eye) drops 0.03 % 1

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 % 1



Level)


BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 % 1

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 1

bromfenac ophthalmic (eye) drops 0.09 % 1carteolol ophthalmic (eye) drops 1 % 1cromolyn ophthalmic (eye) drops 4 % 1CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % 1

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % 1

diclofenac sodium ophthalmic (eye) drops0.1 % 1

dorzolamide ophthalmic (eye) drops 2 % 1dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 % 1

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml 1

epinastine ophthalmic (eye) drops 0.05 % 1fluorometholone ophthalmic (eye) drops,suspension 0.1 % 1

flurbiprofen sodium ophthalmic (eye) drops0.03 % 1

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 1

latanoprost ophthalmic (eye) drops 0.005 % 1

levobunolol ophthalmic (eye) drops 0.5 % 1loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 % 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % 1

methazolamide oral tablet 25 mg, 50 mg 1neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

1


95


Level)


neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension3.5mg/ml-10,000 unit/ml-0.1 %

1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

1

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

1

olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % 1

OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % 1 PA

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % 1

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml 1

prednisolone acetate ophthalmic (eye) drops,suspension 1 % 1

prednisolone sodium phosphate ophthalmic (eye) drops 1 % 1

sulfacetamide sodium ophthalmic (eye) ointment 10 % 1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) 1

timolol maleate ophthalmic (eye) drops0.25 %, 0.5 % 1

timolol maleate ophthalmic (eye) drops, once daily 0.5 % 1

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % 1

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % 1



Level)


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % 1 QLL (60 EA per 30 days)

OTIC AGENTSCIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % 1

hydrocortisone-acetic acid otic (ear) drops1-2 % 1

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1

neomycin-polymyxin-hc otic (ear) solution3.5-10,000-1 mg/ml-unit/ml-% 1

ofloxacin oral tablet 300 mg 1RESPIRATORY TRACT/ PULMONARY AGENTSacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 1 B vs D

ADCIRCA ORAL TABLET 20 MG 1 PA; QLL (60 EA per 30 days)ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG 1 PA; LA

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

1 QLL (12 GM per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

1 B vs D

albuterol sulfate oral syrup 2 mg/5 ml 1albuterol sulfate oral tablet 2 mg, 4 mg 1albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 1

ALYQ ORAL TABLET 20 MG 1 PA; QLL (60 EA per 30 days)ambrisentan oral tablet 10 mg, 5 mg 1 PA; LAANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION 1 QLL (60 EA per 30 days)

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG 1 LA


97


Level)


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (120)


ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION 1 QLL (25.8 GM per 30 days)

azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 QLL (60 ML per 30 days)

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) 1 QLL (60 ML per 30 days)

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG 1 QLL (10.7 GM per 30 days)

bosentan oral tablet 125 mg, 62.5 mg 1 PA; LABREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE


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

1 B vs D

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 1 LA; QLL (84 ML per 28 days)

cetirizine oral solution 1 mg/ml 1COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION 1 QLL (8 GM per 30 days)

cromolyn inhalation solution for nebulization 20 mg/2 ml 1 B vs D

cromolyn oral concentrate 100 mg/5 ml 1DALIRESP ORAL TABLET 250 MCG, 500 MCG 1 PA

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


epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml 1 QLL (4 EA per 30 days)



Level)


EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML 1 QLL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML 1 QLL (4 EA per 30 days)

esbriet oral capsule 267 mg 1 PA; QLL (270 EA per 30 days)ESBRIET ORAL CAPSULE 267 MG 1 PA; QLL (270 EA per 30 days)esbriet oral tablet 267 mg 1 PA; QLL (270 EA per 30 days)ESBRIET ORAL TABLET 267 MG 1 PA; QLL (270 EA per 30 days)esbriet oral tablet 801 mg 1 PA; QLL (90 EA per 30 days)ESBRIET ORAL TABLET 801 MG 1 PA; QLL (90 EA per 30 days)FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML 1 PA

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 1 QLL (50 ML per 30 days)

fluticasone propionate nasal spray,suspension 50 mcg/actuation 1 QLL (16 GM per 30 days)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION 1 QLL (30 EA per 30 days)

ipratropium bromide inhalation solution0.02 % 1 B vs D

ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) 1 QLL (30 ML per 30 days)

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

1 B vs D

KALYDECO ORAL GRANULES IN PACKET 25 MG 1 PA

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG 1 PA; QLL (56 EA per 28 days)

KALYDECO ORAL TABLET 150 MG 1 PA; QLL (60 EA per 30 days)LETAIRIS ORAL TABLET 10 MG, 5 MG 1 PA; LAlevalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

1 B vs D

levocetirizine oral solution 2.5 mg/5 ml 1levocetirizine oral tablet 5 mg 1 QLL (30 EA per 30 days)


99


Level)


LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML 1 ST; QLL (60 ML per 30 days)

metaproterenol oral syrup 10 mg/5 ml 1mometasone nasal spray,non-aerosol 50 mcg/actuation 1 QLL (34 GM per 30 days)

montelukast oral granules in packet 4 mg 1montelukast oral tablet 10 mg 1montelukast oral tablet,chewable 4 mg, 5 mg 1

ofev oral capsule 100 mg, 150 mg 1 PA; QLL (60 EA per 30 days)OFEV ORAL CAPSULE 100 MG, 150 MG 1 PA; QLL (60 EA per 30 days)olopatadine nasal spray,non-aerosol 0.6 % 1 QLL (30.5 GM per 30 days)OPSUMIT ORAL TABLET 10 MG 1 PA; LAORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG 1 PA; QLL (56 EA per 28 days)

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 1 PA; QLL (112 EA per 28 days)

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML 1 B vs D

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 1 QLL (17 GM per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION


PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG 1 LA

promethazine oral syrup 6.25 mg/5 ml 1 PApromethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA

PULMOZYME INHALATION SOLUTION 1 MG/ML 1 B vs D

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION

1 QLL (10.6 GM per 30 days)

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE 1 QLL (60 EA per 30 days)



Level)


sildenafil (antihypertensive) oral suspension for reconstitution 10 mg/ml 1 PA; QLL (224 ML per 30 days)

sildenafil (antihypertensive) oral tablet 20 mg 1 PA; QLL (90 EA per 30 days)

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 1 QLL (90 EA per 90 days)

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION 1 QLL (4 GM per 30 days)

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION 1 QLL (4 GM per 30 days)

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


SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)


SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 MG/0.3 ML 1

tadalafil (antihypertensive) oral tablet 20 mg 1 PA; QLL (60 EA per 30 days)

terbutaline oral tablet 2.5 mg, 5 mg 1THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG

1

theophylline oral solution 80 mg/15 ml 1theophylline oral tablet extended release 12 hr 300 mg 1

theophylline oral tablet extended release 24 hr 400 mg, 600 mg 1

TRACLEER ORAL TABLET 125 MG, 62.5 MG 1 PA; LATRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG 1 QLL (60 EA per 30 days)

WIXELA INHUB INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 1 PA; LA; QLL (6 EA per 28

days)


101


Level)


XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML 1 PA; LA; QLL (6 ML per 28

days)XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML 1 PA; LA; QLL (5 ML per 28

days)zafirlukast oral tablet 10 mg, 20 mg 1SKELETAL MUSCLE RELAXANTSchlorzoxazone oral tablet 500 mg 1 PAcyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg 1 PA

tizanidine oral capsule 2 mg, 4 mg, 6 mg 1tizanidine oral tablet 2 mg, 4 mg 1SLEEP DISORDER AGENTSarmodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 1 PA

doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg 1 PA

doxepin oral concentrate 10 mg/ml 1 PAeszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 ST; QLL (30 EA per 30 days)HETLIOZ ORAL CAPSULE 20 MG 1 PA; QLL (30 EA per 30 days)modafinil oral tablet 100 mg, 200 mg 1 PAramelteon oral tablet 8 mg 1 ST; QLL (30 EA per 30 days)ROZEREM ORAL TABLET 8 MG 1 QLL (30 EA per 30 days)temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 PA

XYREM ORAL SOLUTION 500 MG/ML 1 PA; LAzaleplon oral capsule 10 mg 1 ST; QLL (60 EA per 30 days)zaleplon oral capsule 5 mg 1 ST; QLL (30 EA per 30 days)zolpidem oral tablet 10 mg, 5 mg 1 ST; QLL (30 EA per 30 days)zolpidem oral tablet,ext release multiphase12.5 mg, 6.25 mg 1 ST; QLL (30 EA per 30 days)


2019 UCare’s MSHO and UCare Connect + Medicare Formulary vii


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D. Index of Covered DrugsIn this section, you can find a drug by searching by its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.

viii 2019 UCare’s MSHO and UCare Connect + Medicare Formulary


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Indexabacavir...........................37abacavir-lamivudine.......... 37abacavir-lamivudine-zidovudine........................37ABELCET.......................... 21ABILIFY MAINTENA.16, 17, 34abiraterone.......................27acamprosate...................... 4acarbose.......................... 45acebutolol........................ 51acetaminophen-codeine....... 1acetazolamide............. 51, 94acetic acid..........................5acetylcysteine...................97acitretin........................... 62ACTHIB (PF)..................... 86ACTIMMUNE..................... 86acyclovir.....................37, 38acyclovir sodium............... 38ADACEL(TDAP ADOLESN/ADULT)(PF)........86ADCIRCA..........................97adefovir........................... 38ADEMPAS......................... 97ADVAIR DISKUS................97ADVAIR HFA..................... 97AFINITOR................... 27, 86AFINITOR DISPERZ........... 86AIMOVIG AUTOINJECTOR... 25AIMOVIG AUTOINJECTOR (2 PACK)..........................93AJOVY..............................25ALA-CORT........................ 73albendazole...................... 32ALBENZA..........................32albuterol sulfate................ 97alclometasone...................73ALCOHOL PADS.................. 5ALECENSA........................27alendronate................ 92, 93alfuzosin.......................... 72ALINIA.............................32aliskiren...........................51allopurinol........................ 23alosetron..........................68ALPHAGAN P.....................94alprazolam....................... 42ALTAVERA (28)................. 76ALUNBRIG.................. 27, 28ALYACEN 1/35 (28)........... 77

ALYQ............................... 97amantadine hcl............33, 38AMBISOME....................... 21ambrisentan..................... 97AMETHIA..........................77AMETHIA LO..................... 77amikacin............................5amiloride..........................51amiloride-hydrochlorothiazide........... 51AMINOSYN II 10 %............64AMINOSYN II 15 %............64AMINOSYN-PF 10 %.......... 64AMINOSYN-PF 7 % (SULFITE-FREE)................ 64amiodarone...................... 51amitriptyline..................... 17amlodipine....................... 51amlodipine-atorvastatin..... 51amlodipine-benazepril........51amlodipine-olmesartan.......51amlodipine-valsartan......... 51amlodipine-valsartan-hcthiazid.......................... 51ammonium lactate.............62AMNESTEEM..................... 62amoxapine....................... 17amoxicil-clarithromy-lansopraz......................... 69amoxicillin..........................5amoxicillin-pot clavulanate... 6amphotericin b..................21ampicillin........................... 6ampicillin sodium................ 6ampicillin-sulbactam............6AMPYRA........................... 59ANADROL-50.................... 77anagrelide........................ 49anastrozole...................... 28ANDROGEL.......................77ANORO ELLIPTA................ 97APOKYN........................... 33apraclonidine.................... 94aprepitant........................ 20APRI................................77APTIOM............................13APTIVUS.......................... 38ARALAST NP..................... 97ARANELLE (28)................. 77ARCALYST........................ 86

ARIKAYCE.......................... 6aripiprazole.................17, 34ARISTADA........................ 35ARISTADA INITIO..............34armodafinil..................... 102ASHLYNA......................... 77ASMANEX HFA.................. 98ASMANEX TWISTHALER......98aspirin-dipyridamole.......... 49ASSURE ID INSULIN SAFETY............................ 45atazanavir........................ 38atenolol........................... 51atenolol-chlorthalidone.......51atomoxetine..................... 59atorvastatin......................51atovaquone...................... 32atovaquone-proguanil........ 33ATRIPLA...........................38atropine........................... 94ATROVENT HFA.................98AUBRA.............................77AUGMENTIN....................... 6AUSTEDO.........................59AVIANE............................77AVONEX..................... 59, 60azathioprine..................... 86azelaic acid.......................62azelastine................... 94, 98azithromycin...................... 6aztreonam......................... 6bacitracin...........................6bacitracin-polymyxin b.......94baclofen...........................37balsalazide....................... 91BALVERSA........................28BALZIVA (28)................... 77BANZEL........................... 13BAQSIMI.......................... 45BARACLUDE......................38bcg vaccine, live (pf)......... 86benazepril........................ 52benazepril-hydrochlorothiazide........... 52BENLYSTA........................ 86BENZNIDAZOLE................ 33benztropine...................... 33betamethasone dipropionate.......... 23, 62, 73betamethasone valerate23, 73


103

betamethasone, augmented............23, 73, 74BETASERON..................... 60betaxolol.................... 52, 94bethanechol chloride..........72BETHKIS............................6BEVESPI AEROSPHERE.......98bexarotene.......................28BEXSERO......................... 86bicalutamide.....................28BICILLIN C-R......................6BICILLIN L-A...................... 6BIKTARVY........................ 38BILTRICIDE...................... 33bimatoprost......................94bisoprolol fumarate............52bisoprolol-hydrochlorothiazide........... 52BLEPHAMIDE...............23, 94BLEPHAMIDE S.O.P...... 23, 95BLISOVI 24 FE.................. 77BLISOVI FE 1.5/30 (28)..... 77BOOSTRIX TDAP............... 86bosentan..........................98BOSULIF.......................... 28BRAFTOVI........................ 28BREO ELLIPTA...................98BRIELLYN.........................77BRILINTA......................... 49brimonidine...................... 95BRIVIACT.........................13bromfenac........................95bromocriptine..............33, 85budesonide...... 69, 77, 91, 98bumetanide...................... 52buprenorphine.................... 1buprenorphine hcl........... 1, 4buprenorphine-naloxone...... 4bupropion hcl....................17bupropion hcl (smoking deter)................................5buspirone.........................42butorphanol tartrate............ 1BYDUREON.......................45BYDUREON BCISE............. 45BYETTA............................45cabergoline.......................85CABLIVI........................... 49CABOMETYX..................... 28calcipotriene..................... 62

calcipotriene-betamethasone................. 62calcitonin (salmon)............ 93calcitriol..................... 62, 93calcium acetate.................72CALQUENCE..................... 28CAMILA............................77CAMRESE LO.................... 77CANCIDAS........................21candesartan..................... 52candesartan-hydrochlorothiazid.............52CAPRELSA........................ 28captopril.......................... 52captopril-hydrochlorothiazide........... 52CARBAGLU....................... 64carbamazepine............ 13, 43carbidopa......................... 33carbidopa-levodopa......33, 34carbidopa-levodopa-entacapone...................... 34carteolol...........................95CARTIA XT....................... 52carvedilol......................... 52carvedilol phosphate..........52caspofungin......................21CAYSTON..................... 6, 98CAZIANT (28)................... 77cefaclor..........................6, 7cefadroxil...........................7cefazolin............................ 7cefdinir.............................. 7cefepime............................7cefixime.............................7cefotaxime......................... 7cefotetan........................... 7cefoxitin............................ 7cefpodoxime.......................7cefprozil.............................7ceftazidime........................ 7ceftriaxone.........................7cefuroxime axetil................ 7cefuroxime sodium..............7celecoxib...................... 1, 23CELONTIN........................ 13cephalexin......................... 8CERDELGA....................... 71cetirizine.......................... 98cevimeline........................61CHANTIX........................... 5

CHANTIX CONTINUING MONTH BOX....................... 5CHANTIX STARTING MONTH BOX....................... 5CHEMET........................... 64CHENODAL....................... 69chlorhexidine gluconate......61chloroquine phosphate....... 33chlorothiazide................... 52chlorpromazine............20, 35chlorthalidone...................52chlorzoxazone................. 102CHOLBAM.........................69cholestyramine (with sugar)............................. 52CHOLESTYRAMINE LIGHT... 52ciclopirox......................... 21cilostazol..........................49CIMDUO...........................38cimetidine........................ 69cimetidine hcl................... 69cinacalcet.........................93CINRYZE.......................... 86CIPRODEX........................97ciprofloxacin.......................8ciprofloxacin hcl..................8ciprofloxacin in 5 % dextrose............................ 8citalopram........................17CLARAVIS........................ 62clarithromycin.................... 8clindamycin hcl................... 8clindamycin in 5 % dextrose............................ 8clindamycin palmitate hcl..... 8clindamycin phosphate.........8CLINIMIX 5%/D15W SULFITE FREE...................64CLINIMIX 5%/D25W SULFITE-FREE...................65CLINIMIX 4.25%/D10W SULF FREE....................... 65CLINIMIX 4.25%/D5W SULFIT FREE.....................65CLINIMIX 4.25%-D25W SULF-FREE....................... 65CLINIMIX 5%-D20W(SULFITE-FREE)........65clobazam......................... 13clobetasol................... 62, 74clobetasol-emollient...........74


clomipramine....................17clonazepam.................13, 42clonidine.......................... 52clonidine hcl................52, 60clopidogrel....................... 49clorazepate dipotassium13, 42clotrimazole......................21clotrimazole-betamethasone................. 62clozapine..........................35COARTEM.........................33colchicine......................... 23COLCRYS......................... 23colesevelam................ 52, 53colestipol......................... 53colistin (colistimethate na)... 8COLOCORT....................... 91COMBIVENT RESPIMAT...... 98COMETRIQ....................... 28COMPLERA....................... 38COMPRO.......................... 20CONSTULOSE................... 69COPIKTRA........................ 28CORLANOR.......................53cortisone...............24, 74, 91COSENTYX (2 SYRINGES)...62COSENTYX PEN (2 PENS)... 63COTELLIC.........................28CREON.............................71CRESEMBA....................... 21CRIXIVAN.........................38cromolyn.................... 95, 98CRYSELLE (28)................. 77CUPRIMINE...................... 72CYCLAFEM 1/35 (28)......... 77CYCLAFEM 7/7/7 (28)........ 78cyclobenzaprine...............102cyclophosphamide............. 28CYCLOSET........................45cyclosporine..................... 86cyclosporine modified.........86CYRED EQ........................ 78CYSTADANE......................71CYSTAGON....................... 71CYSTARAN....................... 95d10 %-0.45 % sodium chloride............................65d2.5 %-0.45 % sodium chloride............................65d5 % and 0.9 % sodium chloride............................65

d5 %-0.45 % sodium chloride............................65dalfampridine................... 60DALIRESP.........................98danazol............................78dantrolene........................37dapsone..................... 27, 63DAPTACEL (DTAP PEDIATRIC) (PF)............... 86daptomycin........................ 8DARAPRIM........................33DAURISMO....................... 28DDAVP.............................76DEBLITANE.......................78deferasirox....................... 65DELSTRIGO...................... 38DELYLA (28)..................... 78demeclocycline................... 8DEMSER...........................53DENAVIR..........................38DEPEN TITRATABS..65, 72, 86DEPO-PROVERA................ 78DESCOVY......................... 38desipramine......................17desmopressin................... 76desog-e.estradiol/e.estradiol........ 78desogestrel-ethinyl estradiol...........................78desonide.......................... 74desvenlafaxine succinate.... 17dexamethasone......24, 74, 91DEXAMETHASONE INTENSOL............. 24, 74, 91dexamethasone sodium phosphate........................ 95DEXCOM G4 RECEIVER...... 93DEXCOM G4 RECEIVER-SHARE KIT....................... 93DEXCOM G4 TRANSMITTER.93DEXCOM G5 RECEIVER...... 94DEXCOM G5 TRANSMITTER.94DEXCOM G5-G4 SENSOR....94DEXCOM G6 RECEIVER...... 94DEXCOM G6 SENSOR.........94DEXCOM G6 TRANSMITTER.94DEXCOM RECEIVER........... 94dextroamphetamine-amphetamine................... 60dextrose 10 % and 0.2 % nacl.................................65

dextrose 10 % in water (d10w)............................ 65dextrose 5 % in water (d5w).............................. 65dextrose 5%-0.2 % sod chloride............................65dextrose 5%-0.3 % sod.chloride......................65DIASTAT.....................13, 42DIASTAT ACUDIAL....... 13, 42diazepam....................13, 42DIAZEPAM INTENSOL... 13, 42diclofenac potassium......1, 24diclofenac sodium........................ 1, 24, 63, 95diclofenac-misoprostol......... 1dicloxacillin........................ 9dicyclomine...................... 69didanosine........................38diflunisal...................... 1, 24DIGITEK.......................... 53DIGOX............................. 53digoxin............................ 53dihydroergotamine............ 26DILANTIN.........................13diltiazem hcl..................... 53DILT-XR...........................53DIPENTUM........................91diphenoxylate-atropine...... 69dipyridamole.....................49disulfiram...........................5divalproex............. 14, 26, 43dofetilide..........................53donepezil......................... 16DOPTELET (10 TAB PACK).. 49DOPTELET (15 TAB PACK).. 49DOPTELET (30 TAB PACK).. 49dorzolamide......................95dorzolamide-timolol........... 95dorzolamide-timolol (pf).....95DOTTI..............................78DOVATO.......................... 38doxazosin................... 53, 72doxepin......... 17, 42, 63, 102doxercalciferol.............65, 93DOXY-100..........................9doxycycline hyclate.. 9, 62, 63doxycycline monohydrate............................. 9, 62, 63doxylamine-pyridoxine (vit b6)..................................20


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dronabinol........................20drospirenone-e.estradiol-lm.fa............................... 78drospirenone-ethinyl estradiol...........................78DROXIA........................... 28DULERA........................... 98duloxetine............. 17, 42, 60DUPIXENT........................ 63DURAMORPH (PF)............... 1dutasteride.......................72dutasteride-tamsulosin.......72E.E.S. 400..........................9econazole.........................21EDURANT......................... 38efavirenz..........................38eletriptan......................... 26ELIQUIS...........................49ELMIRON..........................72EMCYT............................. 28EMEND............................ 20EMGALITY PEN..................26EMGALITY SYRINGE...........26EMOQUETTE..................... 78EMSAM............................ 17EMTRIVA..........................38EMVERM.......................... 33enalapril maleate...............53enalapril-hydrochlorothiazide........... 53ENBREL............................87ENBREL MINI....................87ENBREL SURECLICK...........87ENDOCET...........................1ENGERIX-B (PF)................ 87ENGERIX-B PEDIATRIC (PF).................................87enoxaparin....................... 49ENPRESSE........................78ENSKYCE......................... 78entacapone...................... 34entecavir..........................38ENTRESTO........................53ENULOSE......................... 69EPIDIOLEX....................... 14epinastine........................ 95epinephrine...................... 98EPIPEN 2-PAK................... 99EPIPEN JR 2-PAK...............99EPITOL....................... 14, 43EPIVIR HBV...................... 38

eplerenone....................... 53eprosartan....................... 53ergoloid........................... 16ergotamine-caffeine...........26ERIVEDGE........................ 28ERLEADA..........................28erlotinib........................... 28ERRIN..............................78ertapenem......................... 9ERY-TAB............................ 9ERYTHROCIN......................9ERYTHROCIN (AS STEARATE)........................ 9erythromycin......................9erythromycin ethylsuccinate.................... 9erythromycin with ethanol....9esbriet............................. 99ESBRIET.......................... 99escitalopram oxalate............................17, 18, 42esomeprazole magnesium.. 69ESTARYLLA.......................78estradiol...........................78estradiol valerate.............. 79estradiol-norethindrone acet.................................79eszopiclone.....................102ethacrynic acid..................53ethambutol.......................27ethosuximide.................... 14ethynodiol diac-eth estradiol...........................79etidronate disodium...........93etodolac....................... 1, 24EVOTAZ........................... 38exemestane......................28EXJADE............................65ezetimibe......................... 53ezetimibe-simvastatin........ 54FALMINA (28)................... 79famciclovir........................39famotidine........................69FANAPT............................35FARESTON....................... 28FARYDAK.................... 28, 29FASENRA......................... 99FAYOSIM..........................79FAZACLO..........................35febuxostat........................23felbamate.........................14

felodipine......................... 54FEMYNOR......................... 79fenofibrate....................... 54fenofibrate micronized....... 54fenofibrate nanocrystallized 54fenofibric acid................... 54fenofibric acid (choline)......54fenoprofen....................2, 24fentanyl............................. 2fentanyl citrate................... 2FERRIPROX................. 65, 66FETZIMA.......................... 18finasteride........................72FIRAZYR.......................... 87FIRDAPSE........................ 60FIRMAGON KIT W DILUENT SYRINGE..........................85flavoxate..........................72flecainide......................... 54fluconazole....................... 21fluconazole in nacl (iso-osm)............................... 21flucytosine........................21fludrocortisone..................74flunisolide........................ 99fluocinolone......................74fluocinolone acetonide oil... 74fluocinolone and shower cap..................................74fluocinonide................ 63, 74FLUOCINONIDE-E..............75fluoride (sodium)...............66fluorometholone................95fluorouracil.......................63fluoxetine.........................18fluphenazine decanoate......35fluphenazine hcl................ 35flurbiprofen...................2, 24flurbiprofen sodium........... 95flutamide......................... 29fluticasone propionate........99fluvastatin........................54fluvoxamine......................18fondaparinux.................... 50fosamprenavir...................39fosinopril..........................54fosinopril-hydrochlorothiazide........... 54FREESTYLE LIBRE 10 DAY READER........................... 94


FREESTYLE LIBRE 10 DAY SENSOR...........................94FREESTYLE LIBRE 14 DAY READER........................... 94FREESTYLE LIBRE 14 DAY SENSOR...........................94FULPHILA......................... 50furosemide....................... 54FUZEON........................... 39FYCOMPA......................... 14gabapentin....................... 14GABITRIL......................... 14galantamine..................... 16GAMMAKED...................... 87GAMUNEX-C..................... 87GARDASIL 9 (PF).............. 87gatifloxacin........................ 9GATTEX 30-VIAL............... 69GAUZE PAD...................... 45GAVILYTE-C......................69GAVILYTE-G..................... 69GAVILYTE-N..................... 69gemfibrozil....................... 54GENERLAC....................... 69GENGRAF......................... 87GENTAK.............................9gentamicin....................... 10gentamicin in nacl (iso-osm)............................... 10GENVOYA.........................39GEODON.....................35, 43GIANVI (28)..................... 79GILENYA.......................... 60GILOTRIF......................... 29glatiramer........................ 60GLATOPA......................... 60GLEOSTINE...................... 29glimepiride....................... 45glipizide........................... 45glipizide-metformin............45GLUCAGEN HYPOKIT..........45GLUCAGON EMERGENCY KIT (HUMAN)....................46glycopyrrolate...................69granisetron hcl..................20GRANIX........................... 50griseofulvin microsize.........21griseofulvin ultramicrosize.. 21guanidine......................... 27HAEGARDA.......................87halobetasol propionate.......75

haloperidol....................... 35haloperidol decanoate........ 35haloperidol lactate.............35HAVRIX (PF).....................87heparin (porcine).............. 50HEPATAMINE 8%...............66HETLIOZ........................ 102HIBERIX (PF)....................87HUMIRA........................... 88HUMIRA PEDIATRIC CROHNS START................ 87HUMIRA PEN.....................88HUMIRA PEN CROHNS-UC-HS START........................ 88HUMIRA PEN PSOR-UVEITS-ADOL HS.............. 88HUMIRA(CF)..................... 88HUMIRA(CF) PEDI CROHNS STARTER..........................88HUMIRA(CF) PEN...............88HUMIRA(CF) PEN CROHNS-UC-HS............................. 88HUMIRA(CF) PEN PSOR-UV-ADOL HS.....................88HUMULIN 70/30 U-100 INSULIN...........................46HUMULIN 70/30 U-100 KWIKPEN......................... 46HUMULIN N NPH INSULIN KWIKPEN......................... 46HUMULIN N NPH U-100 INSULIN...........................46HUMULIN R REGULAR U-100 INSULN..................... 46HUMULIN R U-500 (CONC) INSULIN...........................46HUMULIN R U-500 (CONC) KWIKPEN......................... 46hydralazine.......................54hydrochlorothiazide........... 54hydrocodone-acetaminophen................... 2hydrocodone-ibuprofen........ 2hydrocortisone....... 24, 75, 92hydrocortisone butyrate..... 63hydrocortisone-acetic acid.. 97hydrocortisone-pramoxine.. 24hydromorphone.................. 2hydromorphone (pf)............ 2hydroxychloroquine........... 33hydroxyurea..................... 29

hydroxyzine hcl......20, 42, 99ibandronate......................93IBRANCE..........................29IBU..............................2, 24ibuprofen......................2, 24ibuprofen-oxycodone......2, 24icatibant...........................88ICLUSIG...........................29IDHIFA............................ 29imatinib........................... 29IMBRUVICA...................... 29imipenem-cilastatin........... 10imipramine hcl.................. 18imipramine pamoate..........18imiquimod........................ 63IMOVAX RABIES VACCINE (PF).................................88INCASSIA.........................79INCRELEX........................ 76INCRUSE ELLIPTA..............99indapamide...................... 54INFANRIX (DTAP) (PF)....... 88INLYTA............................ 29INREBIC...........................29insulin syringe-needle u-100................................. 46INTELENCE.......................39INTRALIPID...................... 66INTRON A.........................39INTROVALE...................... 79INVANZ........................... 10INVEGA SUSTENNA........... 35INVEGA TRINZA................ 36INVIRASE.........................39INVOKAMET......................46INVOKAMET XR.................46INVOKANA....................... 46IONOSOL-MB IN D5W........ 66IPOL................................88ipratropium bromide.......... 99ipratropium-albuterol.........99irbesartan........................ 54irbesartan-hydrochlorothiazide........... 55IRESSA............................ 29ISENTRESS...................... 39ISENTRESS HD................. 39ISIBLOOM........................ 79ISOLYTE-P IN 5 % DEXTROSE....................... 66ISOLYTE-S....................... 66


107

isoniazid.......................... 27isosorbide dinitrate............55isosorbide mononitrate.......55isotretinoin.......................63isradipine......................... 55itraconazole................ 21, 22ivermectin........................33IXIARO (PF)......................88JAKAFI.............................29JANTOVEN........................50JANUMET......................... 46JANUMET XR.....................46JANUVIA.......................... 47JARDIANCE...................... 47JASMIEL (28)....................79JENTADUETO.................... 47JENTADUETO XR............... 47JULEBER.......................... 79JULUCA............................39JUNEL 1.5/30 (21).............79JUNEL 1/20 (21)............... 79JUNEL FE 1.5/30 (28)........ 79JUNEL FE 1/20 (28)........... 79JUNEL FE 24..................... 79JUXTAPID.........................55KAITLIB FE.......................79KALETRA..........................39KALYDECO....................... 99KARIVA (28).....................79KELNOR 1/35 (28).............79KELNOR 1-50....................79ketoconazole.................... 22ketoprofen....................2, 24ketorolac..........................95KINRIX (PF)................ 88, 89KIONEX (WITH SORBITOL). 66KISQALI...........................29KISQALI FEMARA CO-PACK.29KLOR-CON....................... 66KLOR-CON 10................... 66KLOR-CON 8.....................66KLOR-CON M10.................66KLOR-CON M15.................66KLOR-CON M20.................66KLOR-CON SPRINKLE.........66KORLYM...........................47K-TAB..............................66KURVELO (28).................. 79KUVAN.............................71l norgest/e.estradiol-e.estrad........................... 80

labetalol...........................55lactulose.......................... 70lamivudine....................... 39lamivudine-zidovudine....... 39lamotrigine............14, 43, 44LANOXIN..........................55lansoprazole..................... 70lanthanum........................72LANTUS SOLOSTAR U-100 INSULIN...........................47LANTUS U-100 INSULIN..... 47LARIN 1.5/30 (21).............80LARIN 1/20 (21)............... 80LARIN FE 1.5/30 (28)........ 80LARIN FE 1/20 (28)........... 80LARISSIA......................... 80latanoprost.......................95LATUDA........................... 36LAYOLIS FE...................... 80ledipasvir-sofosbuvir..........39LEENA 28......................... 80leflunomide...................... 89LENVIMA..........................29LESSINA.......................... 80LETAIRIS......................... 99letrozole...........................29leucovorin calcium.............30LEUKERAN........................30LEUKINE.......................... 50leuprolide.........................85levalbuterol hcl................. 99levetiracetam....................14levobunolol.......................95levocarnitine.....................66levocarnitine (with sugar)...66levocetirizine.................... 99levofloxacin...................... 10levofloxacin in d5w............ 10LEVONEST (28).................80levonorgestrel-ethinyl estrad..............................80levonorg-eth estrad triphasic...........................80LEVORA-28.......................80levorphanol tartrate.............2levothyroxine....................84LEVOXYL.......................... 84LEXIVA............................ 39lidocaine............................ 4lidocaine hcl....................... 4LIDOCAINE VISCOUS...........4

lidocaine-prilocaine..............4lindane............................ 33linezolid........................... 10linezolid in dextrose 5%..... 10LINZESS.......................... 70liothyronine...................... 84lisinopril...........................55lisinopril-hydrochlorothiazide........... 55lithium carbonate.............. 44lithium citrate................... 44LONHALA MAGNAIR STARTER........................ 100LONSURF......................... 30loperamide....................... 70lopinavir-ritonavir..............39lorazepam...................15, 42LORBRENA....................... 30LORCET (HYDROCODONE)....2LORCET HD........................ 2LORCET PLUS..................... 2LORYNA (28).................... 80losartan........................... 55losartan-hydrochlorothiazide........... 55loteprednol etabonate........ 95lovastatin......................... 55LOW-OGESTREL (28)......... 80loxapine succinate............. 36LUMIGAN......................... 95LUPRON DEPOT.................85LUPRON DEPOT (3 MONTH) 85LUPRON DEPOT (4 MONTH) 85LUPRON DEPOT (6 MONTH) 85LUTERA (28).....................80LYNPARZA........................30LYRICA.......................15, 60LYSODREN....................... 84LYZA............................... 80mafenide acetate.............. 63magnesium sulfate............ 66malathion.........................33maprotiline.......................18MARLISSA (28)................. 80MARPLAN......................... 18MATULANE....................... 30MATZIM LA.......................55MAVYRET......................... 39MAYZENT......................... 60meclizine..........................20meclofenamate............. 2, 24


medroxyprogesterone...80, 81mefenamic acid............. 3, 24mefloquine....................... 33megestrol.........................81MEKINIST........................ 30MEKTOVI..........................30MELODETTA 24 FE.............81meloxicam....................3, 24memantine.......................16MENACTRA (PF)................ 89MENEST........................... 81MENVEO A-C-Y-W-135-DIP (PF).................................89mercaptopurine.................89meropenem......................10mesalamine......................92MESNEX...........................30MESTINON....................... 27METADATE ER...................60metaproterenol............... 100metformin........................ 47methadone.........................3methazolamide............55, 95methenamine hippurate..... 10methimazole.....................85methotrexate sodium.........89methotrexate sodium (pf)...89methoxsalen.....................63methyldopa...................... 55methylphenidate hcl.....60, 61methylprednisolone 24, 75, 92methyltestosterone............81metoclopramide hcl......20, 70metolazone...................... 55metoprolol succinate..........55metoprolol ta-hydrochlorothiaz............... 55metoprolol tartrate............ 56metronidazole...................10metronidazole in nacl (iso-os).................................. 10mexiletine........................ 56MIBELAS 24 FE................. 81MICONAZOLE-3.................22MICROGESTIN 1.5/30 (21). 81MICROGESTIN 1/20 (21)....81MICROGESTIN FE 1.5/30 (28)................................ 81MICROGESTIN FE 1/20 (28)................................ 81midodrine.........................56

MIGERGOT....................... 26miglitol............................ 47miglustat..........................71MILI................................ 81MILLIPRED............ 25, 75, 92minocycline.................10, 62minoxidil.......................... 56mirtazapine...................... 18misoprostol.................70, 76MITIGARE........................ 23M-M-R II (PF)................... 89modafinil........................ 102moexipril..........................56molindone........................ 36mometasone............. 75, 100MONDOXYNE NL................11montelukast....................100MORGIDOX.......................11morphine........................... 3morphine concentrate..........3MOVANTIK....................... 70moxifloxacin..................... 11moxifloxacin-sod.chloride(iso)............... 11mupirocin.........................11mupirocin calcium............. 11MYALEPT..........................76MYCAMINE....................... 22mycophenolate mofetil.......89mycophenolate sodium...... 89MYORISAN....................... 63MYRBETRIQ...................... 72nabumetone................. 3, 25nadolol............................ 56nadolol-bendroflumethiazide.......... 56nafcillin............................11naftifine........................... 22naloxone............................5naltrexone......................... 5NAMZARIC....................... 16naproxen......................3, 25naproxen sodium...........3, 25naratriptan....................... 26NARCAN............................ 5NATACYN......................... 22nateglinide....................... 47NATPARA......................... 93NEBUPENT........................33NECON 0.5/35 (28)........... 81nefazodone.......................18

neomycin......................... 11neomycin-bacitracin-poly-hc................................... 95neomycin-bacitracin-polymyxin........................ 95neomycin-polymyxin b-dexameth.........................96neomycin-polymyxin-gramicidin........................ 96neomycin-polymyxin-hc 96, 97NEPHRAMINE 5.4 %.......... 67NERLYNX..........................30NEULASTA........................50NEUPOGEN.......................50NEUPRO...........................34nevirapine.................. 39, 40NEXAVAR......................... 30niacin.............................. 56nicardipine....................... 56NICOTROL..........................5NICOTROL NS.....................5nifedipine......................... 56NIKKI (28)....................... 81nilutamide........................30nimodipine....................... 56NINLARO..........................30nisoldipine........................56NITRO-BID....................... 56nitrofurantoin................... 11nitrofurantoin macrocrystal.11nitrofurantoin monohyd/m-cryst................................11nitroglycerin..................... 56NIVESTYM........................ 50nizatidine......................... 70NOLIX..............................63NORA-BE..........................81noreth-ethinyl estradiol-iron................................. 81norethindrone (contraceptive)................. 81norethindrone acetate........81norethindrone ac-eth estradiol...........................81norethindrone-e.estradiol-iron............................81, 82norgestimate-ethinyl estradiol...........................82NORLYROC....................... 82NORMOSOL-R IN 5 % DEXTROSE....................... 67


109

NORMOSOL-R PH 7.4.........67NORTHERA....................... 56NORTREL 0.5/35 (28)........ 82NORTREL 1/35 (21)........... 82NORTREL 1/35 (28)........... 82NORTREL 7/7/7 (28)..........82nortriptyline..................... 18NORVIR........................... 40NOVOLIN 70/30 U-100 INSULIN...........................47NOVOLIN N NPH U-100 INSULIN...........................47NOVOLIN R REGULAR U-100 INSULN..................... 47NOVOLOG FLEXPEN U-100 INSULIN...........................47NOVOLOG MIX 70-30 U-100 INSULN..................... 48NOVOLOG MIX 70-30FLEXPEN U-100............. 48NOVOLOG PENFILL U-100 INSULIN...........................48NOVOLOG U-100 INSULIN ASPART........................... 48NOXAFIL.......................... 22NUBEQA...........................30NUEDEXTA....................... 61NUPLAZID........................ 36NYAMYC...........................22nystatin........................... 22nystatin-triamcinolone....... 63NYSTOP........................... 22OCALIVA.......................... 70OCELLA............................82octreotide acetate............. 85ODEFSEY......................... 40ODOMZO..........................30OFEV........................30, 100ofev...............................100ofloxacin.....................11, 97OGESTREL (28).................82olanzapine.................. 36, 44olanzapine-fluoxetine.........19olmesartan....................... 56olmesartan-amlodipin-hcthiazid.......................... 56olmesartan-hydrochlorothiazide........... 56olopatadine............... 96, 100omega-3 acid ethyl esters.. 56omeprazole...................... 70

OMNITROPE......................76ondansetron..................... 20ondansetron hcl................ 20ONETOUCH ULTRA BLUE TEST STRIP...................... 94ONETOUCH ULTRA2 METER 94ONETOUCH ULTRAMINI......94ONETOUCH VERIO.............94ONETOUCH VERIO FLEX..... 94ONETOUCH VERIO FLEX START............................. 94ONETOUCH VERIO IQ METER............................. 94ONETOUCH VERIO SYSTEM.94ONFI............................... 15OPSUMIT........................100ORENCIA..........................89ORENCIA CLICKJECT..........89ORFADIN..........................71ORILISSA.........................76ORKAMBI....................... 100ORSYTHIA........................ 82oseltamivir....................... 40OSPHENA......................... 82OTEZLA........................... 89OTEZLA STARTER..............89oxacillin........................... 11oxacillin in dextrose(iso-osm)............................... 11oxandrolone..................... 82oxaprozin..................... 3, 25oxazepam........................ 42oxcarbazepine...................15OXERVATE........................96oxiconazole...................... 63oxybutynin chloride........... 72oxycodone......................... 3oxycodone-acetaminophen... 3oxycodone-aspirin...............4OZEMPIC..........................48PACERONE....................... 57paliperidone..................... 36PANRETIN........................ 30pantoprazole.................... 70paricalcitol........................93paromomycin....................11paroxetine hcl........19, 42, 43paroxetine mesylate(menop.sym)....... 19PASER............................. 27PAXIL.........................19, 43

PEDIARIX (PF).................. 89PEDVAX HIB (PF).............. 89peg 3350-electrolytes........ 70PEGANONE....................... 15PEGASYS..........................40PEGASYS PROCLICK.......... 40peg-electrolyte soln........... 70pen needle, diabetic...........48penicillamine.................... 67penicillin g potassium.........11penicillin g procaine........... 11penicillin g sodium.............11penicillin v potassium.........11PENTAM........................... 33PENTASA..........................92pentoxifylline.................... 57PERFOROMIST................ 100perindopril erbumine..........57permethrin....................... 33perphenazine.............. 20, 36PERSERIS.........................36phenelzine........................19phenobarbital................... 15phenoxybenzamine...... 57, 72phenytoin.........................15phenytoin sodium extended..........................15PHOSPHOLINE IODIDE.......96PIFELTRO......................... 40pilocarpine hcl............. 62, 96pimecrolimus.................... 63pimozide.......................... 36PIMTREA (28)................... 82pindolol............................57pioglitazone......................48pioglitazone-glimepiride..... 48pioglitazone-metformin...... 48piperacillin-tazobactam...... 11PIQRAY............................ 30PIRMELLA.........................82piroxicam..................... 4, 25PLASMA-LYTE 148............. 67PLASMA-LYTE A................ 67PLEGRIDY........................ 61PLENAMINE...................... 67podofilox..........................63polymyxin b sulfate........... 12polymyxin b sulf-trimethoprim.................... 96POMALYST........................30PORTIA 28....................... 82


posaconazole.................... 22potassium chlorid-d5-0.45%nacl........................67potassium chloride............ 67potassium chloride in 0.9%nacl......................... 67potassium chloride in 5 % dex................................. 67potassium chloride in lr-d5. 67potassium chloride in water 67potassium chloride-0.45 % nacl.................................67potassium chloride-d5-0.2%nacl......................... 68potassium chloride-d5-0.3%nacl......................... 68potassium chloride-d5-0.9%nacl......................... 68potassium citrate.............. 72PRADAXA......................... 50PRALUENT PEN................. 57pramipexole..................... 34prasugrel......................... 50pravastatin.......................57praziquantel..................... 33prazosin..................... 57, 72prednicarbate..............63, 75prednisolone..........25, 75, 92prednisolone acetate............................25, 92, 96prednisolone sodium phosphate........25, 75, 92, 96prednisone............ 25, 75, 92PREDNISONE INTENSOL............................25, 75, 92pregabalin........................61PREMASOL 10 %............... 68PREMASOL 6 %.................68PRENATAL VITAMIN PLUS LOW IRON........................68PREVALITE....................... 57PREVIFEM........................ 82PREVYMIS........................ 40PREZCOBIX...................... 40PREZISTA.........................40PRIFTIN........................... 27primaquine.......................33primidone.........................15PRIVIGEN.........................89PROAIR HFA................... 100PROAIR RESPICLICK........ 100

probenecid....................... 23probenecid-colchicine.........23PROCENTRA..................... 61prochlorperazine............... 20prochlorperazine maleate................................. 20, 36PROCRIT.......................... 50PROCTO-MED HC...............92PROCTO-PAK.................... 75PROCTOSOL HC................ 92PROCTOZONE-HC........ 70, 75progesterone micronized.... 82PROGLYCEM..................... 48PROGRAF......................... 89PROLASTIN-C..................100PROLIA............................ 93PROMACTA....................... 50promethazine............ 20, 100propafenone..................... 57propranolol.......................57propranolol-hydrochlorothiazid.............57propylthiouracil................. 85PROQUAD (PF)..................89protriptyline......................19PRUDOXIN.................. 19, 63PULMOZYME................... 100PURIXAN..........................30pyrazinamide....................27pyridostigmine bromide......27QUADRACEL (PF)...............90quetiapine............. 19, 36, 44quinapril.......................... 57quinapril-hydrochlorothiazide........... 57quinidine gluconate........... 57quinidine sulfate................57quinine sulfate.................. 33QVAR REDIHALER............100RABAVERT (PF).................90raloxifene.........................82ramelteon.......................102ramipril............................57RANEXA........................... 58ranitidine hcl............... 70, 71ranolazine........................ 58RAPAMUNE....................... 90rasagiline......................... 34RAVICTI...........................71REBIF (WITH ALBUMIN)..... 61REBIF REBIDOSE...............61

REBIF TITRATION PACK..... 61RECLIPSEN (28)................82RECOMBIVAX HB (PF)........ 90RECTIV............................ 58REGRANEX....................... 63RELENZA DISKHALER.........40RELISTOR........................ 71repaglinide....................... 48repaglinide-metformin........48REPATHA PUSHTRONEX......58REPATHA SURECLICK.........58REPATHA SYRINGE............ 58RESCRIPTOR.................... 40RETACRIT........................ 50REVLIMID.........................30REXULTI.......................... 36REYATAZ..........................40ribavirin........................... 40RIDAURA..........................90rifabutin...........................27rifampin........................... 27riluzole............................ 61rimantadine......................40RINVOQ ER...................... 90RIOMET........................... 48risedronate.......................93RISPERDAL CONSTA.....36, 44risperidone..................37, 44ritonavir...........................40rivastigmine..................... 16rivastigmine tartrate..........16RIVELSA.......................... 82rizatriptan........................ 26ropinirole......................... 34rosuvastatin..................... 58ROTARIX..........................90ROTATEQ VACCINE............90ROWEEPRA.......................15ROWEEPRA XR.................. 15ROZEREM....................... 102ROZLYTREK...................... 30RUBRACA....................30, 31RUZURGI......................... 71RYDAPT........................... 31SABRIL............................ 15SAMSCA...........................68SANDIMMUNE...................90SANTYL............................64SAPHRIS.................... 37, 44scopolamine base........ 21, 71selegiline hcl.....................34


111

selenium sulfide................ 64SELZENTRY...................... 40SENSIPAR........................ 93SEREVENT DISKUS.......... 100sertraline....................19, 43SETLAKIN.........................82sevelamer carbonate......... 72sevelamer hcl................... 73SHAROBEL....................... 82SHINGRIX (PF)................. 90SIGNIFOR........................ 85sildenafil (antihypertensive)........... 101silodosin.......................... 73silver sulfadiazine..............12simvastatin.......................58sirolimus.......................... 90SIRTURO..........................27SKYRIZI...........................64sodium chloride.................68sodium chloride 0.45 %..... 68sodium chloride 0.9 %....... 68sodium chloride 3 %.......... 68sodium chloride 5 %.......... 68sodium lactate.................. 68sodium phenylbutyrate. 71, 73sodium polystyrene sulfonate..........................68sofosbuvir-velpatasvir........40solifenacin........................73SOLIQUA 100/33...............48SOLTAMOX.......................31SOMATULINE DEPOT..........85SOMAVERT....................... 85SORINE........................... 58sotalol............................. 58SOTALOL AF..................... 58SOTYLIZE.........................58SPIRIVA RESPIMAT.......... 101SPIRIVA WITH HANDIHALER.................. 101spironolactone.................. 58spironolacton-hydrochlorothiaz............... 58SPORANOX.......................22SPRINTEC (28)................. 82SPRITAM..........................15SPRYCEL.......................... 31SPS (WITH SORBITOL).......68SRONYX...........................83SSD.................................12

stavudine......................... 40STELARA..........................64STIMATE.......................... 76STIOLTO RESPIMAT......... 101STIVARGA........................ 31streptomycin.................... 12STRIBILD......................... 41STRIVERDI RESPIMAT...... 101SUBOXONE........................ 5SUCRAID..........................72sucralfate.........................71sulfacetamide sodium...12, 96sulfacetamide sodium (acne)............................. 12sulfacetamide-prednisolone................................. 25, 96sulfadiazine...................... 12sulfamethoxazole-trimethoprim.................... 12SULFAMYLON....................12sulfasalazine.....................92sulindac....................... 4, 25sumatriptan......................26sumatriptan succinate........26sumatriptan-naproxen....... 26SUPRAX........................... 12SUTENT........................... 31SYEDA............................. 83SYLATRON.................. 31, 41SYMBICORT.................... 101SYMDEKO.......................101SYMFI..............................41SYMFI LO......................... 41SYMJEPI......................... 101SYMLINPEN 120................ 48SYMLINPEN 60..................48SYMPAZAN....................... 15SYMTUZA......................... 41SYNAREL..........................85SYNJARDY........................48SYNJARDY XR................... 49SYNRIBO..........................31SYNTHROID......................84TABLOID.......................... 31tacrolimus...................64, 90tadalafil........................... 73tadalafil (antihypertensive).....................................101TAFINLAR.........................31TAGRISSO........................31TAKHZYRO....................... 90

TALZENNA........................31tamoxifen.........................31tamsulosin....................... 73TARCEVA......................... 31TARGRETIN...................... 31TARINA 24 FE................... 83TARINA FE 1/20 (28)......... 83TASIGNA..........................31tazarotene........................64TAZICEF...........................12TAZORAC......................... 64TAZTIA XT........................58TDVAX............................. 90TECFIDERA.......................61TEFLARO..........................12TEKTURNA....................... 58TEKTURNA HCT.................58telmisartan.......................58telmisartan-amlodipine...... 58telmisartan-hydrochlorothiazid.............58temazepam.................... 102TENIVAC (PF)................... 90tenofovir disoproxil fumarate..........................41terazosin.................... 58, 73terbinafine hcl...................22terbutaline......................101terconazole...................... 22testosterone..................... 83testosterone cypionate.......83testosterone enanthate...... 83tetanus,diphtheria tox ped(pf)............................ 90tetanus-diphtheria toxoids-td....................................94tetrabenazine................... 61tetracycline...................... 12THALOMID....................... 31THEO-24........................ 101theophylline....................101THIOLA............................73thioridazine...................... 37thiothixene....................... 37tiagabine..........................15TIBSOVO..........................31tigecycline........................12timolol maleate...... 26, 59, 96tinidazole......................... 12TIVICAY........................... 41tizanidine..................37, 102


tobramycin.......................12tobramycin in 0.225 % nacl.................................12tobramycin sulfate.............12tobramycin-dexamethasone................ 96tolbutamide...................... 49tolcapone......................... 34tolmetin....................... 4, 25tolterodine....................... 73topiramate............ 15, 26, 27toremifene....................... 31torsemide.........................59TOUJEO MAX U-300 SOLOSTAR....................... 49TOUJEO SOLOSTAR U-300 INSULIN...........................49TRACLEER...................... 101TRADJENTA...................... 49tramadol............................4tramadol-acetaminophen..... 4trandolapril.......................59trandolapril-verapamil........59tranexamic acid................ 50TRANSDERM-SCOP............ 21tranylcypromine................ 19TRAVASOL 10 %............... 68TRAVATAN Z.....................96trazodone.........................19TRECATOR....................... 27TRELEGY ELLIPTA............ 101TRELSTAR........................ 85tretinoin..................... 31, 64tretinoin (chemotherapy)....31triamcinolone acetonide............................25, 62, 76triamterene-hydrochlorothiazid.............59TRIANEX.......................... 64TRIDERM..........................76trientine...........................68TRI-ESTARYLLA.................83trifluoperazine.................. 37trifluridine........................ 41trihexyphenidyl................. 34TRI-LEGEST FE................. 83TRI-LO-ESTARYLLA............83TRI-LO-SPRINTEC............. 83TRILYTE WITH FLAVOR PACKETS..........................71trimethoprim.................... 12

TRI-MILI.......................... 83trimipramine.....................19TRINTELLIX...................... 19TRI-PREVIFEM (28)........... 83TRI-SPRINTEC (28)........... 83TRIUMEQ......................... 41TRIVORA (28)...................84TROPHAMINE 10 %........... 68TROPHAMINE 6%.............. 68trospium.......................... 73TRUMENBA.......................90TRUVADA......................... 41TURALIO.......................... 31TWINRIX (PF)................... 90TYDEMY........................... 84TYGACIL.......................... 12TYKERB............................31TYMLOS........................... 93TYPHIM VI.................. 90, 91ULORIC............................23UNITHROID...................... 84UPTRAVI.......................... 59ursodiol........................... 71valacyclovir...................... 41VALCHLOR.................. 32, 64valganciclovir....................41valproic acid.......... 16, 27, 44valproic acid (as sodium salt)..................... 16, 27, 44valsartan..........................59valsartan-hydrochlorothiazide........... 59vancomycin...................... 13VANDAZOLE..................... 13VAQTA (PF)...................... 91VARIVAX (PF)................... 91VARIZIG.......................... 91VARUBI............................21VASCEPA..........................59VECAMYL......................... 61VELIVET TRIPHASIC REGIMEN (28).................. 84VELTASSA........................ 68VEMLIDY.......................... 41VENCLEXTA...................... 32VENCLEXTA STARTING PACK............................... 32venlafaxine................. 19, 43verapamil.........................59VERSACLOZ......................37VERZENIO........................32

VIBERZI...........................71VICODIN ES....................... 4VICODIN HP....................... 4VICTOZA 3-PAK................ 49VIDEX 2 GRAM PEDIATRIC..41VIDEX EC......................... 41VIENVA............................84vigabatrin.........................16VIGADRONE..................... 16VIIBRYD..................... 19, 20VIMPAT............................16VIOKACE..........................72VIRACEPT.........................41VIRAMUNE....................... 41VIREAD............................41VITRAKVI......................... 32VIVITROL...........................5VIZIMPRO........................ 32voriconazole..................... 22VOSEVI............................41VOTRIENT........................ 32VRAYLAR.................... 37, 44VYFEMLA (28)...................84VYNDAQEL....................... 76warfarin........................... 51WIXELA INHUB................101WYMZYA FE...................... 84XALKORI.......................... 32XARELTO..........................51XATMEP........................... 91XELJANZ.......................... 91XELJANZ XR..................... 91XERMELO......................... 71XGEVA.............................93XIFAXAN.....................13, 71XIIDRA............................ 97XOFLUZA......................... 41XOLAIR...................101, 102XOSPATA......................... 32XPOVIO........................... 32XTANDI............................32XULANE........................... 84XURIDEN..........................72XYREM........................... 102YF-VAX (PF)......................91YONSA.............................32YUVAFEM......................... 84zafirlukast...................... 102zaleplon......................... 102ZARAH.............................84ZARXIO............................51


113

ZEJULA............................ 32ZELBORAF........................32ZENATANE....................... 64zidovudine........................41ziprasidone hcl............ 37, 45ZIRGAN........................... 41ZOLINZA.................... 22, 32zolmitriptan......................27zolpidem........................ 102zonisamide....................... 16ZORTRESS....................... 91ZOSTAVAX (PF).................91ZOVIA 1/35E (28)............. 84ZOVIRAX..........................42ZYDELIG.......................... 32ZYKADIA..........................32ZYPREXA RELPREVV..... 37, 45ZYTIGA............................ 32


UCare’s MSHO and UCare Connect + Medicare 2019 OTC List

The following list of over-the-counter (OTC) medications are covered for UCare’s

MSHO and UCare Connect + Medicare members. This drug list only includes the

generic version of products. Some brand products are listed in parentheses for

reference purposes only. This list is subject to change.

If you have questions, please call either UCare’s MSHO Customer Services at

612-676-6868/1-866-280-7202, or call UCare Connect + Medicare Customer Services at 612-676-3310/1-855-260-9707, TTY 612-676-6810/

1-800-688-2534, 8 a.m. to 8 p.m., seven days a week.

ANALGESICS AND ANTI-INFLAMMATORY DRUGS

acetaminophen (TYLENOL)

aspirin (BAYER)

aspirin / acetaminophen/ caffeine (EXCEDRIN)

aspirin / buffers (BUFFERIN)

aspirin / sodium bicarb / citric acid (ALKA-SELTZER)

ibuprofen (MOTRIN)

naproxen (ALEVE)

COUGH AND COLD MEDICATIONS

ANTIHISTAMINES

cetirizine (ZYRTEC)

clemastine fumurate

diphenhydramine (BENADRYL)

loratadine (CLARITIN)

DECONGESTANTS

phenylephrine (SUDAFED PE)

pseudoephedrine (SUDAFED)

ANTIHISTAMINE / DECONGESTANT COMBINATIONS

cetirizine / pseudoephedrine (ZYRTEC – D)

loratadine / pseudoephedrine (CLARITIN – D)

phenylephrine / acetaminophen

phenylephrine / guaifenesin

pseudoephedrine / ibuprofen

psueodoephedrine / acetaminophen

ANTITUSSIVES AND EXPECTORANT DRUGS

dextromethorphan (ROBITUSSIN)

dextromethorphan / phenylephrine

dextromethorphan / phenylephrine / acetaminophen

dextromethorphan / pseudoephedrine

dextromethorphan / pseudoephedrine / acetaminophen

guaifenesin (MUCINEX)

(8/18) U6245


guaifenesin / dextromethorphan (MUCINEX DM)

guaifenesin / dextromethorphan / phenylephrine

guaifenesin / dextromethorphan / pseudoephedrine

guaifenesin / dextromethorphan / pseudoephedrine / acetaminophen

guaifenesin / phenylephrine

guaifenesin / pseudoephedrine

DERMATOLOGICAL DRUGS

ANTIACNE DRUGS

benzoyl peroxide

benzoyl peroxide / aloe vera

KEROLYTIC DRUGS

salicylic acid

salicylic acid / acetic acid (COMPOUND W)

SCABICIDES

permethrin (NIX)

piperonyl / pyrethrins (RID)

TOPICAL ANESTHETICS

pramoxine (PROCTO-FOAM)

TOPICAL ANTIBACTERIAL DRUGS

bacitracin

bacitracin zinc

bacitracin / polymyxin b (POLYSPORIN)

chlorhexidine

neomycin / bacitracin / polymixin (NEOSPORIN)

neomycin / bacitracin / polymixin / pramoxine (NEOSPORIN PLUS)

TOPICAL ANTIFUNGALS

clotrimazole (LOTRIMIN)

miconazole (MICATIN)

terbinafine (LAMISIL)

tolnaftate (TINACTIN)

TOPICAL CORTICOSTEROIDS

hydrocortisone / aloe vera

hydrocortisone

OTHER TOPICAL DERMATOLOGICAL DRUGS

ammonium lactate (AMLACTIN)

calamine

calamine / zinc oxide

capsaicin (ZOSTRIX)

chloroxylenol

coal tar

diphenhydramine

diphenhydramine / calamine

diphenhydramine / zinc


dimethicone

glyceryl / dimethicone / petrolatum (CETAPHIL)

hydrogen peroxide

methyl salicylate / menthol / camphor (BENGAY)

mineral oil / petrolatum (AQUAPHOR, EUCERIN)

petrolatum (VASELINE)

povidone-iodine (BETADINE)

pramoxine / calamine

salonpas

trolamine salicylate (MYOFLEX)

urea (CARMOL)

zinc oxide (DESITIN)

EAR / NOSE / THROAT MEDICATIONS

DRUGS AFFECTING THE EAR

carbamide peroxide (DEBROX)

DRUGS AFFECTING THE NOSE

cromolyn (NASALCROM)

Nasacort AQ 24hr

oxymetazoline (AFRIN)

phenylephrine (NEO-SYNEPHRINE)

sodium chloride

DRUGS AFFECTING THE THROAT

zinc

GASTROINTESTINAL DRUGS

ANTACIDS

aluminum hydroxide (ALTERNAGEL)

calcium carbonate (TUMS)

calcium carbonate / magnesium hydroxide (MYLANTA SUPREME)

magnesium carbonate / aluminum hydroxide (GAVISCON)

magnesium hydroxide / aluminum hydroxide / simethicone (MYLANTA)

magnesium hydroxide / aluminum hydroxide (MAALOX)

magnesium oxide (URO-MAG)

sodium bicarbonate

ANTIDIARRHEAL DRUGS

bismuth subsalicylate (PEPTO-BISMOL)

loperamide (IMMODIUM)

ANTIULCER DRUGS

famotidine (PEPCID)

lansoprazole (PREVACID)

ranitidine (ZANTAC)

omeprazole (PRILOSEC)

LAXATIVES AND CATHARTICS

activated charcoal


bisacodyl (DULCOLAX)

calcium polycarbophil

cellulose

charcoal / sorbitol

docusate calcium (SURFAK)

docusate sodium (COLACE)

glycerin

magnesium citrate (CITROMA)

magnesium hydroxide (PHILLIPS’ MOM)

methylcellulose (CITRUCEL)

mineral oil polycarbophil

polyethylene glycol 3350 (MIRALAX)

psyllium (METAMUCIL)

senna / docusate sodium (PERI-COLACE)

sennosides / calcium (EX-LAX)

OTHER GI DRUGS

hamamelis leaf / glycerin (TUCKS)

lactase (LACTAID)

phenylephrine

phenylephrine / shark liver / petrolatum (PREPARATION H)

simethicone (MYLICON)

sorbitol

witch hazel

MISCELLANEOUS (OTHER) Drugs

dimenhydrinate (DRAMAMINE)

levonorgestrel (PLAN B)

meclizine

phenazopyridine (AZO)

OPHTHALMIC DRUGS

carboxymethylcellulose drops

dextran 70/he-cell drops (TEARS NATURALE-II)

eyelid cleanser combinations

glycerin / propylene glycol drops

hydroxypropylmethylcellulose drops (GENTEAL)

hypromellose drops (GENTEAL MILD)

ketotifen drops (ZADITOR)

lanolin/mineral oil / petrolatum ointment

mineral oil / petrolatum ointment (LACRI-LUBE S.O.P.)

naphazoline /pheniramine drops (NAPHCON-A)

polyvinyl alcohol / povidone drops (REFRESH)

polyvinyl alcohol drops (HYPOTEARS)

propylene glycol (SYSTANE)

propylene glycol / PEGs (SYSTANE ULTRA)


sodium chloride

sodium chloride / petrolatum / mineral oil (REFRESH PM)

tetrahydrazoline drops (VISINE)

SMOKING CESSATION PRODUCTS

nicotine (NICODERM)

nicotine gum

nicotine polacrilex (COMMIT)

VAGINAL ANTIFUNGALS

clotrimazole (GYNE-LOTRIMIN)

miconazole (MONISTAT)

tioconazole (VAGISTAT)

VITAMINS AND RELATED PRODUCTS

MINERALS / ELECTROLYTES

calcium carbonate

calcium citrate

calcium glubionate

calcium gluconate

calcium lactate

calcium / magnesium

calcium / magnesium / zinc

chromium

electrolyte solution (pediatric)

ferrous gluconate

ferrous sulfate

_agnesium chloride

magnesium gluconate

magnesium oxide

potassium chloride

potassium gluconate

selenium

sodium chloride

zinc gluconate

zinc sulfate

MISCELLANEOUS NUTRIENTS

beta-carotene

biotin

glucose

glucosamine sulfate

glucosamine / chondroitin

omega-3 fatty acids

protein replacement preparations

VITAMINS

cyanocobalmin (vitamin B12)


folic acid

niacin

niacinamide

pantothenic acid

pyridoxine (vitamin B6)

riboflavin (vitamin B2)

thiamine (vitamin B1)

vitamin A

vitamin C

vitamin D

vitamin E

VITAMIN COMBINATION PRODUCTS

beta carotene / vitamin C / vitamin E / minerals

calcium carbonate / vitamin D

calcium carbonate / vitamin D / minerals

folic acid / vitamin B complex / vitamin C

multivitamins

multivitamins / iron

multivitamins / minerals

multivitamins / minerals / iron

prenatal vitamin

vitamin A / vitamin D

vitamin A / vitamin C / vitamin D

vitamin B complex

vitamin B complex / folic acid

vitamin B complex / minerals

vitamin B complex / vitamin C

vitamin B complex / vitamin C / vitamin E / zinc

vitamin C / vitamin E

UCare’s MSHO (HMO SNP) is a health plan that contracts with both Medicare and

the Minnesota Medical Assistance (Medicaid) program to provide benefits of both

programs to enrollees. Enrollment in UCare’s MSHO depends on contract

renewal.

UCare’s Connect + Medicare (HMO SNP) is a health plan that contracts with both

Medicare and the Minnesota Medical Assistance (Medicaid) program to provide

benefits of both programs to enrollees. Enrollment in UCare Connect + Medicare

depends on contract renewal.

U1549 (11/2019)

P.O. Box 52 Minneapolis, MN 55440‑0052

UCare’s MSHO 612‑676‑6868

1‑866‑280‑7202 toll free

UCare Connect + Medicare 612‑676‑3310

1‑855‑260‑9707 toll free

TTY/Hearing impaired 612‑676‑6810

1‑800‑688‑2534 toll free

8 am to 8 pm, seven days a week

ucare.org

This formulary was updated on 11/19/2019

For more recent information or other questions, contact us at UCare’s MSHO Customer Service at 612‑676‑6868/1‑866‑280‑7202, UCare Connect + Medicare Customer Service at 612‑676‑3310/1‑855‑260‑9707. TTY 612‑676‑6810/1‑800‑688‑2534. 8 am – 8 pm, seven days a week. The call is free. Or visit us at ucare.org

2019 list of covered drugs (formulary) · 2019 list of covered drugs (formulary) ucare’s msho and...

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