2021 long-term care formulary

For the most current list of covered medications or if you have questions:

• Call the number on your member ID card.

• Visit your plan’s website on your member ID card to:

– Find a participating retail pharmacy by ZIP code.

– Look up possible lower-cost medication alternatives.

– Compare medication pricing and options.

LTC Select Standard

2021 Long-Term Care FormularyEffective July 1, 2021

2

Understanding your formulary

What is a formulary?A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

To create the list, we are guided by the Pharmacy and Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

About this formulary When differences between this formulary and your benefit plan exist, the benefit plan documents rule. This formulary may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.

How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor.

When does the formulary change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equal becomes available.

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 ofeach year.

If a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or is similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card.

3

Medication tips

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. In some situations, brand-name medications could be lower in cost.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a lower-cost option could be right for you.

Over-the-counter medications (OTC)Talk to your doctor about OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

What if I am taking a specialty medication?Specialty medications are used to treat complex conditions and are generally higher in cost. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services.

4

Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).

Tier informationUsing lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost generics and some brand name

Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2 $$ Mid-range cost preferred brand name

Use Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket costs.

Tier 3 $$$ Highest-cost brand name and some generics

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

SP Specialty Medication – Medication is designated as specialty.

3P Tier 3 preferred

Table of Contents

Analgesics - Drugs for Pain.................................................................................................................................6Analgesics - Drugs for Pain and Inflammation.................................................................................................... 6Anesthetics..........................................................................................................................................................6Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 7Antibacterials.......................................................................................................................................................7Anticoagulants.....................................................................................................................................................7Anticonvulsants - Drugs for Seizures.................................................................................................................. 8Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................................ 8Antidepressants...................................................................................................................................................8Antiemetics - Drugs for Nausea and Vomiting.................................................................................................... 9Antifungals...........................................................................................................................................................9Antigout Agents................................................................................................................................................... 9Antimigraine Agents............................................................................................................................................ 9Antineoplastics - Drugs for Cancer......................................................................................................................9Antiparasitics..................................................................................................................................................... 10Antiparkinson Agents........................................................................................................................................ 10Antiplatelets.......................................................................................................................................................10Antipsychotics - Drugs for Mood Disorders....................................................................................................... 10Antivirals............................................................................................................................................................11Anxiolytics - Drugs for Anxiety...........................................................................................................................11Bipolar Agents - Drugs for Mood Disorders.......................................................................................................11Blood Products and Modifiers - Drugs for Blood Disorders...............................................................................11Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 12Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 13Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 14Central Nervous System Agents - Miscellaneous............................................................................................. 14Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................14Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 14Diabetes - Antidiabetic Agents.......................................................................................................................... 15Diabetes - Glucose Monitoring.......................................................................................................................... 16Diabetes - Glycemic Agents.............................................................................................................................. 17Diabetes - Insulins.............................................................................................................................................17Electrolytes / Minerals / Metals / Vitamins.........................................................................................................18Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................18Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................18Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 19Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................19Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 19Hormonal Agents - Adrenal............................................................................................................................... 19Hormonal Agents - Men's Health.......................................................................................................................20Hormonal Agents - Osteoporosis...................................................................................................................... 20Hormonal Agents - Pituitary.............................................................................................................................. 20Hormonal Agents - Sex Hormones and Birth Control........................................................................................20Hormonal Agents - Thyroid............................................................................................................................... 22Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 22Inflammatory Bowel Disease Agents.................................................................................................................23Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 23Metabolic Bone Disease Agents - Other........................................................................................................... 23Miscellaneous Therapeutic Agents................................................................................................................... 23Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................23Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................24

4

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 24Otic Agents - Drugs for Ear Conditions............................................................................................................. 24Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................24Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 25Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 26Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 26Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 26Sleep Disorder Agents...................................................................................................................................... 26

5

Drug Name Drug Tier Notes

Analgesics - Drugs

for Pain

acetaminophen-codeine #2

1


1


1

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

1

apap-caff-dihydrocodeine oral capsule

1

BELBUCA 2

butalbital-apap-caffeine 1

fentanyl 1

hydrocodone-acetaminophen oral tablet

1

hydromorphone hcl oral tablet

1

HYSINGLA ER 2

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1

morphine sulfate er oral tablet extended release

1

morphine sulfate oral solution

1

NUCYNTA 3

oxycodone hcl oral tablet

1

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG

3


oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

OXYCONTIN 2

tramadol hcl oral tablet 50 mg

1

TREZIX 3

XTAMPZA ER 2

Analgesics - Drugs

for Pain and

Inflammation

celecoxib oral 1

diclofenac sodium external gel 1 %

1

diclofenac sodium oral 1

etodolac oral tablet 1

ibuprofen oral tablet 1

INDOMETHACIN ORAL CAPSULE 20 MG

3

indomethacin oral capsule 25 mg, 50 mg

1

ketorolac tromethamine oral

1

meloxicam oral tablet 1

nabumetone oral 1

NAPRELAN 3

naproxen oral tablet 1

naproxen sodium oral tablet

1

Anesthetics

lidocaine external patch 1

lidocaine-prilocaine external cream

1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

6


Anti-Addiction /

Substance Abuse

Treatment Agents

BUNAVAIL 3

buprenorphine hcl sublingual

1

buprenorphine hcl-naloxone hcl

1

CHANTIX STARTING MONTH PAK

3

naltrexone hcl oral 1

NARCAN 2

ZUBSOLV 2

Antibacterials

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin-potassium clavulanate oral suspension reconstituted

1

amoxicillin-potassium clavulanate oral tablet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 1

cefdinir 1

cefuroxime axetil 1

cephalexin oral capsule 1

cephalexin oral suspension reconstituted

1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

1

clarithromycin oral tablet

1


clindamycin hcl oral 1

CLINDESSE 3

DIFICID ORAL TABLET

3

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet

1

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral tablet

1

levofloxacin oral tablet 1

metronidazole oral tablet

1

metronidazole vaginal 1

minocycline hcl oral capsule

1

mupirocin external 1

nitrofurantoin macrocrystal

1

nitrofurantoin monohydrate macrocrystals

1

NUZYRA ORAL 3

penicillin v potassium oral tablet

1

SEYSARA 3

SOLOSEC 3

sulfamethoxazole-trimethoprim oral tablet

1

XENLETA 3

XEPI 3

XIMINO 3

Anticoagulants

ELIQUIS 2


7


ELIQUIS DVT/PE STARTER PACK

2

enoxaparin sodium 1 SP

PRADAXA 2

warfarin sodium oral 1

XARELTO 2

XARELTO STARTER PACK

2

Anticonvulsants -

Drugs for Seizures

BRIVIACT 3

carbamazepine oral tablet

1

divalproex sodium er 1

divalproex sodium oral tablet delayed release

1

EPIDIOLEX 3 SP

FYCOMPA 3

gabapentin oral capsule

1

gabapentin oral tablet 1

lamotrigine er 1

lamotrigine oral tablet 1

levetiracetam oral tablet

1

NAYZILAM 3

oxcarbazepine oral tablet

1

SYMPAZAN 3

topiramate oral tablet 1

TROKENDI XR 3

VALTOCO 3

VIMPAT 3

XCOPRI 3

zonisamide oral 1


Antidementia Agents

- Drugs for

Alzheimer's Disease

and Dementia

donepezil hcl oral tablet 10 mg, 23 mg

1

memantine hcl oral tablet 10 mg, 5 mg

1

NAMZARIC 2

Antidepressants

amitriptyline hcl oral 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

BUPROPION HCL ER (XL) ORAL TABLETEXTENDED RELEASE24 HOUR 450 MG

3

bupropion hcl oral 1

citalopram hydrobromide oral tablet

1

desvenlafaxine succinate er

1

doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

1

duloxetine hcl oral 1

escitalopram oxalate oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

FORFIVO XL 3

mirtazapine oral tablet 1


8


nortriptyline hcl oral capsule

1

paroxetine hcl 1

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD 3

VIIBRYD STARTER PACK

3

Antiemetics - Drugs

for Nausea and

Vomiting

meclizine hcl oral tablet 1

metoclopramide hcl oral tablet 10 mg

1

ondansetron hcl oral tablet 4 mg, 8 mg

1

ondansetron odt 1

prochlorperazine maleate oral

1

scopolamine 1

VARUBI (180 MG DOSE)

3

Antifungals

ciclopirox external solution

1

clotrimazole external cream

1

clotrimazole-betamethasone external cream

1

CRESEMBA ORAL 3

fluconazole oral tablet 1

GYNAZOLE-1 3

KERYDIN 3


ketoconazole external cream

1

ketoconazole external shampoo

1

nystatin external cream 1

nystatin mouth/throat 1

terbinafine hcl oral 1

terconazole vaginal cream

1

Antigout Agents

allopurinol oral 1

colchicine oral tablet 1

febuxostat 1

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

2

eletriptan hydrobromide 1

EMGALITY 2

EMGALITY (300 MG DOSE)

2

NURTEC 2

rizatriptan benzoate 1

sumatriptan succinate oral

1

UBRELVY 2

Antineoplastics -

Drugs for Cancer

ALECENSA 2 SP

ALUNBRIG 2 SP

anastrozole oral 1

CABOMETYX 2 SP

CALQUENCE 3 SP

capecitabine 1 SP

IBRANCE ORAL TABLET

3 SP


9


IDHIFA 3 SP

KANJINTI 2 SP

KEYTRUDA 3 SP

letrozole oral 1

LYNPARZA 2 SP

MVASI 2 SP

NUBEQA 3 SP

PHESGO 2 SP

REVLIMID 2 SP

ROZLYTREK 3 SP

RUBRACA 2 SP

RUXIENCE 2 SP

SPRYCEL 2 SP

TAGRISSO 3 SP

tamoxifen citrate oral 1

TARGRETIN EXTERNAL

3 SP

TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 420 MG

2 SP

VELCADE 2 SP

VITRAKVI 3 SP

XTANDI ORAL CAPSULE

3 SP

ZEJULA 2 SP

ZIRABEV 2 SP

Antiparasitics

ARAKODA 3

EMVERM 2

hydroxychloroquine sulfate oral

1

Antiparkinson Agents

benztropine mesylate oral

1


carbidopa-levodopa oral tablet

1

INBRIJA 3 SP

KYNMOBI 3 SP

KYNMOBI TITRATION KIT

3 SP

NOURIANZ 3

ONGENTYS 3

pramipexole dihydrochloride

1

ropinirole hcl 1

RYTARY 3

Antiplatelets

BRILINTA 2

clopidogrel bisulfate oral

1

prasugrel hcl 1

Antipsychotics -

Drugs for Mood

Disorders

ABILIFY MAINTENA 3

aripiprazole oral tablet 1

ARISTADA 3

ARISTADA INITIO 3

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3

olanzapine oral tablet 1

PERSERIS 3

quetiapine fumarate 1

quetiapine fumarate er 1

REXULTI 3

risperidone oral tablet 1

VRAYLAR 3

ziprasidone hcl 1


10


Antivirals

acyclovir oral tablet 1

BIKTARVY 3

CIMDUO 2

DESCOVY 3

DOVATO 2

entecavir 1 SP

EPCLUSA 2 SP

GENVOYA 3

HARVONI 2 SP

JULUCA 2

MAVYRET 2 SP

ODEFSEY 3

PREZCOBIX 2

RUKOBIA 3

SYMFI 2

SYMFI LO 2

TIVICAY 2

TRIUMEQ 2

TRUVADA 3

valacyclovir hcl oral 1

VEMLIDY 3 SP

VOSEVI 2 SP

XOFLUZA (40 MG DOSE)

3

XOFLUZA (80 MG DOSE)

3

Anxiolytics - Drugs

for Anxiety

alprazolam oral tablet 1

buspirone hcl oral 1

clonazepam oral tablet 1

diazepam oral tablet 1

hydroxyzine hcl oral tablet

1


hydroxyzine pamoate oral

1

lorazepam oral tablet 1

triazolam 1

Bipolar Agents -

Drugs for Mood

Disorders

lithium carbonate er 1

lithium carbonate oral capsule

1

Blood Products and

Modifiers - Drugs for

Blood Disorders

ADVATE 2 SP

ADYNOVATE 3 SP

AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3 SP

ARANESP (ALBUMIN FREE)

2 SP

ELOCTATE 3 SP

JIVI 3 SP

KOATE 2 SP

MULPLETA 2 SP

NEULASTA 3 SP

NEULASTA ONPRO 3 SP

NIVESTYM 2 SP

NOVOEIGHT 2 SP

NPLATE 3 SP

NUWIQ 2 SP

RECOMBINATE 2 SP

RETACRIT 2 SP

SOLIRIS 3 SP

ULTOMIRIS 3 SP

WILATE 2 SP

XYNTHA 2 SP


11


XYNTHA SOLOFUSE 2 SP

ZARXIO 2 SP

ZIEXTENZO 3 SP

Cardiovascular

Agents - Drugs for

Heart and Circulation

Conditions

amiodarone hcl oral 1

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-olmesartan 1

ANTARA 3

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

benazepril hcl oral 1

bisoprolol fumarate oral 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BYSTOLIC 2

candesartan cilexetil 1

cartia xt 1

carvedilol 1

chlorthalidone 1

clonidine hcl oral 1

CORLANOR 3

digoxin oral tablet 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1


doxazosin mesylate oral

1

EDARBI 3

EDARBYCLOR 3

enalapril maleate oral 1

ENTRESTO 2

ezetimibe 1

ezetimibe-simvastatin 1

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral tablet 1

fenofibric acid oral capsule delayed release

1

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

irbesartan 1

irbesartan-hydrochlorothiazide

1

isosorbide mononitrate er

1

labetalol hcl oral 1

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3

losartan potassium oral 1

losartan potassium-hctz 1

lovastatin oral 1

metoprolol succinate er 1


12


metoprolol tartrate oral 1

MULTAQ 3

nadolol oral 1

NEXLETOL 2

NEXLIZET 2

nifedipine er 1

nifedipine er osmotic release

1

nitroglycerin sublingual 1

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

omega-3-acid ethyl esters

1

PRALUENT 2

pravastatin sodium 1

prazosin hcl oral 1

propranolol hcl er 1

propranolol hcl oral tablet

1

ramipril 1

ranolazine er 1

REPATHA 2

REPATHA PUSHTRONEX SYSTEM

2

REPATHA SURECLICK

2

rosuvastatin calcium 1

simvastatin oral 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 2

TEKTURNA HCT 2


telmisartan 1

telmisartan-hctz 1

torsemide 1

triamterene-hctz 1

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2

verapamil hcl er oral tablet extended release

1

Central Nervous

System Agents -

Drugs for Attention

Deficit Disorder

ADDERALL XR 3

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1

atomoxetine hcl 1

dexmethylphenidate hcl er

1

dexmethylphenidate hcl oral tablet 10 mg, 5 mg

1

guanfacine hcl er 1

JORNAY PM 3

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg

1

methylphenidate hcl er (xr)

1

methylphenidate hcl er oral tablet extended release

1

methylphenidate hcl oral tablet

1

VYVANSE 2


13


Central Nervous

System Agents -

Drugs for Multiple

Sclerosis

AMPYRA 3 SP

AUBAGIO 3 SP

AVONEX PEN 2 SP

AVONEX PREFILLED 2 SP

BAFIERTAM 2 SP

BETASERON 2 SP

COPAXONE 2 SP

GILENYA 3 SP

KESIMPTA 2 SP

MAVENCLAD 3 SP

MAYZENT 3 SP

REBIF 3 SP

REBIF REBIDOSE 3 SP

REBIF REBIDOSE TITRATION PACK

3 SP

REBIF TITRATION PACK

3 SP

TECFIDERA ORAL CAPSULE DELAYED RELEASE

3 SP

VUMERITY 2 SP

ZEPOSIA 3 SP

ZEPOSIA 7-DAY STARTER PACK

3 SP

ZEPOSIA STARTER KIT

3 SP

Central Nervous

System Agents -

Miscellaneous

ADDYI 3

AUSTEDO 3 SP

GRALISE ORAL TABLET

3

HORIZANT 3


INGREZZA 3 SP

phentermine hcl oral tablet

1

pregabalin oral capsule 1

QSYMIA 3

SAXENDA 3

TEGSEDI 3 SP

TIGLUTIK 3 SP

VYLEESI 3

Dental and Oral

Agents - Drugs for

Mouth and Throat

Conditions

chlorhexidine gluconate mouth/throat

1

lidocaine viscous hcl 1

Dermatological

Agents - Drugs for

Skin Conditions

ABSORICA 3

ABSORICA LD 3

ACZONE EXTERNAL GEL 7.5 %

2

adapalene external gel 1

AMZEEQ 3

betamethasone dipropionate external cream

1

BRYHALI 3

claravis 1

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1


14


clindamycin phosphate gel 1 % external

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

3

clobetasol propionate external cream

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

DUPIXENT 2 SP

ENSTILAR 3

EPIDUO FORTE 3

EUCRISA 2

FINACEA 3

fluocinonide external cream

1

fluocinonide external solution

1

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

hydrocortisone external cream

1

hydrocortisone external ointment 1 %, 2.5 %

1

imiquimod external cream 5 %

1

metronidazole external cream

1

metronidazole external gel

1

MIRVASO 3

mometasone furoate external cream

1


ONEXTON 3

pimecrolimus 1

QBREXZA 3

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

2

RHOFADE 3

SERNIVO 3

SOOLANTRA 3

TACLONEX 3

tacrolimus external ointment

1

tretinoin external cream 1

triamcinolone acetonide external cream

1

triamcinolone acetonide external ointment

1

ZILXI 3

Diabetes -

Antidiabetic Agents

BYDUREON BCISE AUTOINJECTOR

2

BYETTA 10 MCG PEN 2

BYETTA 5 MCG PEN 2

FARXIGA 2

glimepiride 1

glipizide er 1

glipizide ir 1

glyburide oral 1

GLYXAMBI 2

INVOKANA 3

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2


15


metformin hcl er 1

metformin hcl er (mod) 1

metformin hcl er (osm) 1

metformin hcl oral tablet

1

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

2

pioglitazone hcl 1

RYBELSUS 2

SOLIQUA 2

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 2

SYNJARDY XR 2

TRADJENTA 2

TRIJARDY XR 2

TRULICITY 2

VICTOZA 2

XIGDUO XR 2

Diabetes - Glucose

Monitoring

ACCU-CHEK FASTCLIX LANCET KIT

2

ACCU-CHEK GUIDE TEST STRIPS

3

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

2

CONTOUR CONTROL SOLUTION

2

CONTOUR MONITOR DEVICE

2

CONTOUR MONITOR KIT W/DEVICE

2


CONTOUR NEXT CONTROL SOLUTION

2

CONTOUR NEXT EZ KIT W/DEVICE

2

CONTOUR NEXT MONITOR KIT W/DEVICE

2

CONTOUR NEXT ONE KIT

2

CONTOUR NEXT TEST STRIPS

2

CONTOUR TEST STRIPS

2

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

2

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

2

FREESTYLE LIBRE 14 DAY READER

2

FREESTYLE LIBRE 14 DAY SENSOR

2

FREESTYLE LIBRE 2 READER

2

FREESTYLE LIBRE 2 SENSOR

2

FREESTYLE LIBRE READER

2

FREESTYLE LIBRE SENSOR SYSTEM

2

V-GO 20 2

V-GO 30 2


16


V-GO 40 2

Diabetes - Glycemic

Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

glucagon emergency kit 1 mg injection 1 mg

1

GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG

3 Made by Lilly

GLUCAGON EMERGENCY KIT

2Made by Fresenius

GVOKE HYPOPEN 1-PACK

2

GVOKE HYPOPEN 2-PACK

2

GVOKE PFS 2

Diabetes - Insulins

BD AUTOSHIELD DUO PEN NEEDLES

2

BD ULTRA-FINE INSULIN SYRINGES

2

BD ULTRA-FINE PEN NEEDLES

2

BD VEO INSULIN SYR U/F 1/2UNIT

2

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 KWIKPEN

2

HUMALOG MIX 50/50 VIAL

2

HUMALOG MIX 75/25 KWIKPEN

2

HUMALOG MIX 75/25 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2


HUMULIN 70/30 KWIKPEN

2

HUMULIN 70/30 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL

2

HUMULIN R VIAL 2

LANTUS SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

2

LEVEMIR U-100 VIAL 2

LYUMJEV KWIKPEN 2

LYUMJEV VIAL 2

NOVOFINE AUTOCOVER PEN NEEDLE

2

NOVOFINE PEN NEEDLE

2

NOVOFINE PLUS PEN NEEDLE

2

NOVOLIN 70/30 FLEXPEN

2

NOVOLIN 70/30 VIAL 2

NOVOLIN N FLEXPEN 2

NOVOLIN N VIAL 2

NOVOLIN R FLEXPEN 2

NOVOLIN R VIAL 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 FLEXPEN

2

NOVOLOG MIX 70/30 VIAL

2

NOVOLOG PENFILL 2

NOVOLOG U-100 VIAL 2


17


NOVOTWIST PEN NEEDLE

2

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA 2

TRESIBA FLEXTOUCH

2

Electrolytes / Minerals

/ Metals / Vitamins

cyanocobalamin injection solution 1000 mcg/ml

1

ergocalciferol oral capsule

1

folic acid oral tablet 1 mg

1

klor-con m20 1

LOKELMA 3

NASCOBAL 3

potassium chloride crys er

1

potassium chloride er 1

potassium citrate er 1

sodium fluoride oral tablet chewable

1

VELTASSA 3

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

Gastrointestinal

Agents - Drugs for

Acid Reflux and Ulcer

DEXILANT 2

esomeprazole magnesium oral capsule delayed release

1


famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule delayed release

1

misoprostol oral 1

omeprazole oral capsule delayed release

1

pantoprazole sodium oral tablet delayed release

1

rabeprazole sodium oral tablet delayed release

1

sucralfate oral tablet 1

Gastrointestinal

Agents - Drugs for

Bowel, Intestine and

Stomach Conditions

CLENPIQ 3

dicyclomine hcl oral capsule

1

dicyclomine hcl oral tablet

1

diphenoxylate-atropine oral tablet

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GLYCOPYRROLATE ORAL TABLET 1.5 MG

3

hyoscyamine sulfate sl 1

hyoscyamine sulfate sublingual

1

lactulose oral solution 1

LINZESS 2

MOTEGRITY 3


18


MOVANTIK 2

OMECLAMOX-PAK 2

peg 3350-kcl-na bicarb-nacl

1

PYLERA 2

SUPREP BOWEL PREP KIT

3

SYMPROIC 2

TRULANCE 3

VIBERZI 3

ZELNORM 3

Genetic or Enzyme

Disorder - Drugs for

Replacement,

Modification,

Treatment

CERDELGA 3 SP

CREON 2

NITYR 3 SP

ORFADIN 3 SP

STRENSIQ SUBCUTANEOUS SOLUTION 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

2 SP

ZENPEP 2

ZOLGENSMA 3 SP

Genitourinary Agents

- Drugs for Bladder,

Genital and Kidney

Conditions

AURYXIA 3

DEPEN TITRATABS 2 SP

MYRBETRIQ 2

oxybutynin chloride er 1

oxybutynin chloride oral tablet

1


phenazopyridine hcl oral tablet 100 mg, 200 mg

1

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1

solifenacin succinate 1

STENDRA 3

tadalafil oral 1

tolterodine tartrate er 1

TOVIAZ 3

VELPHORO 3

Genitourinary Agents

- Drugs for Prostate

Conditions

alfuzosin hcl er 1

dutasteride oral 1

finasteride oral tablet 5 mg

1

tamsulosin hcl 1

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

1

Hormonal Agents -

Adrenal

dexamethasone oral tablet

1

hydrocortisone oral 1

methylprednisolone oral tablet therapy pack

1

prednisolone sodium phosphate oral solution

1

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY 3

TAPERDEX 7-DAY 3


19


Hormonal Agents -

Men's Health

ANDRODERM 2

testosterone cypionate intramuscular

1

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1

XYOSTED 3

Hormonal Agents -

Osteoporosis

OSPHENA 3

Hormonal Agents -

Pituitary

ACTHAR 2 SP

cabergoline 1

clomiphene citrate oral 1

FENSOLVI (6 MONTH) 3 SP

FOLLISTIM AQ 2 SP

ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous

1 SP

ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous

1Made by Organon; SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

2 SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

2 SP


LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 SP

NOCDURNA 3

NORDITROPIN FLEXPRO

2 SP

NUTROPIN AQ NUSPIN 10

2 SP


2 SP


2 SP

ORILISSA 2

SOMATULINE DEPOT 3 SP

SUPPRELIN LA 2 SP

TRIPTODUR 3 SP

Hormonal Agents -

Sex Hormones and

Birth Control

apri 1

aurovela fe 1/20 1

aviane 1

BIJUVA 3

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

CLIMARA PRO 2

cryselle-28 1

DIVIGEL 3

dotti 1

drospirenone-ethinyl estradiol

1

DUAVEE 2


20


ELESTRIN 3

eluryng 1

ENDOMETRIN 2

enskyce 1

estarylla 1

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

estradiol-norethindrone acet

1

ESTROGEL 3

etonogestrel-ethinyl estradiol

1

EVAMIST 3

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

isibloom 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kurvelo 1

larin fe 1/20 1

larissia 1

lessina 1

levonorgest-eth est & eth est

1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg, 0.15-0.03 mg

1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1


LO LOESTRIN FE 3

loryna 1

MAKENA 2 SP

medroxyprogesterone acetate intramuscular

1

medroxyprogesterone acetate oral

1

MIRENA (52 MG) 3

mono-linyah 1

NATAZIA 2

nikki 1

norethin ace-eth estrad-fe oral tablet

1

norethindrone acetate oral

1

norethindrone acet-ethinyl est

1

norethindrone oral 1

norgestimate-ethinyl estradiol triphasic

1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

ORIAHNN 2

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral

1

sprintec 28 1

syeda 1

tri femynor 1

tri-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-sprintec 1


21


vienva 1

xulane 1

Hormonal Agents -

Thyroid

ARMOUR THYROID 3

euthyrox 1

levothyroxine sodium oral tablet

1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

np thyroid oral tablet 30 mg, 60 mg

1

SYNTHROID 3

TIROSINT 3

TIROSINT-SOL 3

Immunological

Agents - Drugs for

Immune System

Stimulation or

Suppression

ACTEMRA ACTPEN 3 3P; SP

ACTEMRA SUBCUTANEOUS

3 3P; SP

AVSOLA 2 SP

azathioprine oral 1

CIMZIA 2 SP

CIMZIA PREFILLED KIT

2 SP

CIMZIA STARTER KIT 2 SP

COSENTYX SENSOREADY (300 MG)

3 SP

COSENTYX SENSOREADY PEN

3 SP

cyclosporine modified oral capsule

1 SP

ENBREL MINI 3 SP


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 SP

ENBREL SURECLICK 3 SP

FIRAZYR 3 SP

GAMMAGARD 3 SP

HAEGARDA 3 SP

HUMIRA 2 SP

HUMIRA PEDIATRIC CROHNS START

2 SP

HUMIRA PEN 2 SP

HUMIRA PEN-CD/UC/HS STARTER

2 SP

HUMIRA PEN-PS/UV/ADOL HS START

2 SP

HUMIRA PEN-PSOR/UVEIT STARTER

2 SP

INFLECTRA 2 SP

leflunomide oral 1

methotrexate oral 1

methotrexate sodium oral

1

mycophenolate mofetil oral capsule

1 SP

mycophenolate mofetil oral tablet

1 SP

mycophenolate sodium 1 SP

ORENCIA CLICKJECT 3 3P; SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML

3 3P; SP

OTEZLA 2 SP

RASUVO 2

RINVOQ 2 SP


22


RUCONEST 3 SP

SIMPONI 2 SP

SIMPONI ARIA 2 SP

SKYRIZI (150 MG DOSE)

2 SP

STELARA 2 SP

tacrolimus oral 1 SP

TAKHZYRO 3 SP

TALTZ 3 3P; SP

TREMFYA 2 SP

XELJANZ 2 SP

XELJANZ XR 2 SP

XEMBIFY 3 SP

Inflammatory Bowel

Disease Agents

APRISO 2

DIPENTUM 3

hydrocortisone (perianal)

1

mesalamine oral tablet delayed release

1

PENTASA 3

PROCTOFOAM HC 2

sulfasalazine oral tablet 1

UCERIS RECTAL 3

Metabolic Bone

Disease Agents -

Drugs for

Osteoporosis

alendronate sodium oral tablet

1

BINOSTO 3

FORTEO 3 SP

ibandronate sodium oral

1

PROLIA 2 SP

RAYALDEE 3


TERIPARATIDE (RECOMBINANT)

2 SP

TYMLOS 2 SP

XGEVA 2 SP

Metabolic Bone

Disease Agents -

Other

calcitriol oral capsule 1

Miscellaneous

Therapeutic Agents

BOTOX 2Non-Cosmetic; SP

DUROLANE 2 SP

ENDARI 3

EUFLEXXA 2 SP

GELSYN-3 2 SP

Ophthalmic Agents -

Drugs for Eye Allergy,

Infection and

Inflammation

AZASITE 3

BESIVANCE 3

ciprofloxacin hcl ophthalmic

1

erythromycin ophthalmic

1

FLAREX 3

INVELTYS 3

ketorolac tromethamine ophthalmic

1

LOTEMAX OPHTHALMIC GEL

3

LOTEMAX OPHTHALMIC OINTMENT

3

LOTEMAX SM 3

MOXEZA 2


23


MOXIFLOXACIN HCL INTRAOCULAR SOLUTION

3

moxifloxacin hcl ophthalmic solution

1

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic

1

prednisolone acetate ophthalmic

1

PROLENSA 2

Ophthalmic Agents -

Drugs for Glaucoma

ALPHAGAN P 2

AZOPT 2

BETIMOL 3

brimonidine tartrate ophthalmic

1

COMBIGAN 2

dorzolamide hcl-timolol mal

1

latanoprost ophthalmic 1

LUMIGAN 2

RHOPRESSA 3

ROCKLATAN 3

SIMBRINZA 2

timolol maleate ophthalmic solution

1

timolol maleate pf 1

ZIOPTAN 3

Ophthalmic Agents -

Drugs for

Miscellaneous Eye

Conditions

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1


polymyxin b-trimethoprim

1

RESTASIS 2

RESTASIS MULTIDOSE

2

TOBRADEX ST 3

tobramycin-dexamethasone

1

XIIDRA 2

Otic Agents - Drugs

for Ear Conditions

CIPRODEX 3

ciprofloxacin-dexamethasone

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTOVEL 3

Respiratory Tract /

Pulmonary Agents -

Drugs for Allergies,

Cough, Cold

allergy relief oral tablet 5 mg

1

azelastine hcl nasal 1

azelastine-fluticasone 1

benzonatate 1

cetirizine hcl oral solution

1

cyproheptadine hcl oral tablet

1

DYMISTA 2

FASENRA 2 SP

FASENRA PEN 2 SP

fluticasone propionate nasal

1

ipratropium bromide nasal

1


24


levocetirizine dihydrochloride oral tablet

1

mometasone furoate nasal

1

NUCALA 2 SP

OMNARIS 3

promethazine hcl oral tablet

1

promethazine-dm 1

pseudoephedrine-bromphen-dm

1

QNASL 3

QNASL CHILDRENS 3

XOLAIR 2 SP

ZETONNA 3

Respiratory Tract /

Pulmonary Agents -

Drugs for Asthma and

Other Lung

Conditions

ADVAIR DISKUS 2

ADVAIR HFA 2

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

3

albuterol sulfate inhalation

1

ALVESCO 3

ANORO ELLIPTA 2

ARNUITY ELLIPTA 2

ATROVENT HFA 3


BREO ELLIPTA 2

BREZTRI AEROSPHERE

2

budesonide inhalation 1

BUDESONIDE-FORMOTEROL FUMARATE

3

COMBIVENT RESPIMAT

2

epinephrine injection solution auto-injector

1

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

FLOVENT DISKUS 2

FLOVENT HFA 2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

ipratropium-albuterol 1

LONHALA MAGNAIR REFILL KIT

3

LONHALA MAGNAIR STARTER KIT

3

montelukast sodium oral tablet

1

montelukast sodium oral tablet chewable

1

PERFOROMIST 3

PROAIR HFA 2

PROAIR RESPICLICK 2

PULMICORT FLEXHALER

2

QVAR REDIHALER 2

SEREVENT DISKUS 2


25


SPIRIVA HANDIHALER

2

SPIRIVA RESPIMAT 2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT

2

SYMBICORT 2

SYMJEPI 3

TRELEGY ELLIPTA 2

VENTOLIN HFA 2

wixela inhub 1

YUPELRI 3

Respiratory Tract /

Pulmonary Agents -

Drugs for Cystic

Fibrosis

PULMOZYME 2 SP

TOBI PODHALER 3 SP

TRIKAFTA 3 SP

Respiratory Tract /

Pulmonary Agents -

Drugs for Pulmonary

Hypertension

ADEMPAS 2 SP

OPSUMIT 2 SP

ORENITRAM 3 SP

sildenafil citrate oral tablet 20 mg

1 SP

Skeletal Muscle

Relaxants - Drugs for

Muscle Pain and

Spasm

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral

1

LORZONE 3

metaxalone 1


methocarbamol oral 1

tizanidine hcl oral tablet 1

Sleep Disorder

Agents

armodafinil 1

BELSOMRA 3

DAYVIGO 3

eszopiclone 1

modafinil 1

SILENOR 3

SUNOSI 2

temazepam 1

WAKIX 3 SP

XYREM 3 SP

zolpidem tartrate er 1

zolpidem tartrate oral 1


26

Index of Drugs

ABILIFY MAINTENA................. 10ABSORICA............................... 14ABSORICA LD..........................14ACCU-CHEK FASTCLIX LANCET KIT............................. 16ACCU-CHEK GUIDE TEST STRIPS..................................... 16ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...............16acetaminophen-codeine..............6acetaminophen-codeine #2.........6acetaminophen-codeine #3.........6acetaminophen-codeine #4.........6ACTEMRA................................ 22ACTEMRA ACTPEN.................22ACTHAR................................... 20acyclovir.................................... 11ACZONE................................... 14adapalene................................. 14ADDERALL XR......................... 13ADDYI....................................... 14ADEMPAS................................ 26ADVAIR DISKUS...................... 25ADVAIR HFA............................ 25ADVATE....................................11ADYNOVATE............................11AFSTYLA.................................. 11AIMOVIG.....................................9albuterol sulfate.........................25albuterol sulfate hfa...................25ALBUTEROL SULFATE HFA... 25ALECENSA.................................9alendronate sodium.................. 23alfuzosin hcl er.......................... 19allergy relief...............................24allopurinol....................................9ALPHAGAN P........................... 24alprazolam................................ 11ALUNBRIG..................................9ALVESCO................................. 25amiodarone hcl......................... 12amitriptyline hcl........................... 8amlodipine besylate.................. 12amlodipine besylate-benazepril hcl............................................. 12amlodipine besylate-valsartan.. 12amlodipine-olmesartan..............12amoxicillin................................... 7amoxicillin-potassium clavulanate..................................7amphetamine-dextroamphetamine.................. 13

amphetamine-dextroamphetamine er.............. 13AMPYRA...................................14AMZEEQ...................................14anastrozole................................. 9ANDRODERM.......................... 20ANORO ELLIPTA..................... 25ANTARA................................... 12apap-caff-dihydrocodeine........... 6apri............................................ 20APRISO.................................... 23ARAKODA................................ 10ARANESP (ALBUMIN FREE)...11aripiprazole............................... 10ARISTADA................................ 10ARISTADA INITIO.................... 10armodafinil ................................ 26ARMOUR THYROID.................22ARNUITY ELLIPTA...................25atenolol..................................... 12atenolol-chlorthalidone..............12atomoxetine hcl.........................13atorvastatin calcium.................. 12ATROVENT HFA...................... 25AUBAGIO..................................14aurovela fe 1/20........................ 20AURYXIA.................................. 19AUSTEDO.................................14aviane....................................... 20AVONEX PEN...........................14AVONEX PREFILLED.............. 14AVSOLA....................................22AZASITE................................... 23azathioprine.............................. 22azelastine hcl............................ 24azelastine-fluticasone............... 24azithromycin................................7AZOPT...................................... 24baclofen.................................... 26BAFIERTAM............................. 14BAQSIMI ONE PACK............... 17BAQSIMI TWO PACK...............17BD AUTOSHIELD DUO PEN NEEDLES................................. 17BD ULTRA-FINE INSULIN SYRINGES............................... 17BD ULTRA-FINE PEN NEEDLES................................. 17BD VEO INSULIN SYR U/F 1/2UNIT.....................................17BELBUCA................................... 6BELSOMRA.............................. 26benazepril hcl............................12

benzonatate.............................. 24benztropine mesylate................10BESIVANCE............................. 23betamethasone dipropionate.... 14BETASERON............................14BETIMOL.................................. 24BIJUVA..................................... 20BIKTARVY................................ 11BINOSTO..................................23bisoprolol fumarate................... 12bisoprolol-hydrochlorothiazide.. 12blisovi 24 fe............................... 20blisovi fe 1.5/30......................... 20blisovi fe 1/20............................ 20BOTOX..................................... 23BREO ELLIPTA........................ 25BREZTRI AEROSPHERE.........25BRILINTA..................................10brimonidine tartrate................... 24BRIVIACT................................... 8BRYHALI...................................14budesonide............................... 25BUDESONIDE-FORMOTEROL FUMARATE....25bumetanide............................... 12BUNAVAIL.................................. 7buprenorphine hcl....................... 7buprenorphine hcl-naloxone hcl............................................... 7bupropion hcl.............................. 8bupropion hcl er (sr)....................8bupropion hcl er (xl).................... 8BUPROPION HCL ER (XL)........ 8buspirone hcl.............................11butalbital-apap-caffeine...............6BYDUREON BCISE AUTOINJECTOR...................... 15BYETTA 10 MCG PEN............. 15BYETTA 5 MCG PEN............... 15BYSTOLIC................................ 12cabergoline............................... 20CABOMETYX............................. 9calcitriol..................................... 23CALQUENCE..............................9candesartan cilexetil ................. 12capecitabine................................9carbamazepine........................... 8carbidopa-levodopa.................. 10carisoprodol.............................. 26cartia xt..................................... 12carvedilol...................................12cefdinir........................................ 7cefuroxime axetil ......................... 7

27

celecoxib..................................... 6cephalexin...................................7CERDELGA.............................. 19cetirizine hcl.............................. 24CHANTIX STARTING MONTH PAK.............................................7chlorhexidine gluconate............ 14chlorthalidone............................12ciclopirox..................................... 9CIMDUO................................... 11CIMZIA......................................22CIMZIA PREFILLED KIT...........22CIMZIA STARTER KIT............. 22CIPRODEX............................... 24ciprofloxacin hcl.................... 7, 23ciprofloxacin-dexamethasone... 24citalopram hydrobromide............ 8claravis......................................14clarithromycin..............................7CLENPIQ.................................. 18CLIMARA PRO......................... 20clindamycin hcl............................7clindamycin phosphate....... 14, 15CLINDAMYCIN PHOSPHATE.. 15clindamycin phosphate-benzoyl peroxide.......................14CLINDESSE................................7clobetasol propionate................15clomiphene citrate.....................20clonazepam...............................11clonidine hcl.............................. 12clopidogrel bisulfate.................. 10clotrimazole.................................9clotrimazole-betamethasone.......9colchicine.................................... 9COMBIGAN.............................. 24COMBIVENT RESPIMAT......... 25CONTOUR CONTROL SOLUTION................................16CONTOUR MONITOR DEVICE.....................................16CONTOUR MONITOR KIT W/DEVICE................................ 16CONTOUR NEXT CONTROL SOLUTION................................16CONTOUR NEXT EZ KIT W/DEVICE................................ 16CONTOUR NEXT MONITOR KIT W/DEVICE..........................16CONTOUR NEXT ONE KIT......16CONTOUR NEXT TEST STRIPS..................................... 16CONTOUR TEST STRIPS........16

COPAXONE..............................14CORLANOR..............................12COSENTYX SENSOREADY (300 MG)...................................22COSENTYX SENSOREADY PEN...........................................22CREON..................................... 19CRESEMBA................................9cryselle-28.................................20cyanocobalamin........................ 18cyclobenzaprine hcl.................. 26cyclosporine modified............... 22cyproheptadine hcl....................24DAYVIGO..................................26DEPEN TITRATABS.................19DESCOVY................................ 11desvenlafaxine succinate er........8dexamethasone........................ 19DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)..............................16DEXILANT................................ 18dexmethylphenidate hcl............ 13dexmethylphenidate hcl er........ 13diazepam.................................. 11diclofenac sodium....................... 6dicyclomine hcl..........................18DIFICID....................................... 7digoxin.......................................12diltiazem hcl er coated beads... 12DIPENTUM............................... 23diphenoxylate-atropine..............18divalproex sodium....................... 8divalproex sodium er...................8DIVIGEL....................................20donepezil hcl............................... 8dorzolamide hcl-timolol mal...... 24dotti ........................................... 20DOVATO...................................11doxazosin mesylate.................. 12doxepin hcl..................................8doxycycline hyclate..................... 7doxycycline monohydrate........... 7drospirenone-ethinyl estradiol...20DUAVEE................................... 20duloxetine hcl.............................. 8DUPIXENT................................15DUROLANE.............................. 23dutasteride................................ 19DYMISTA.................................. 24EDARBI.....................................12

EDARBYCLOR......................... 12ELESTRIN................................ 21eletriptan hydrobromide.............. 9ELIQUIS......................................7ELIQUIS DVT/PE STARTER PACK.......................................... 8ELOCTATE............................... 11eluryng...................................... 21EMGALITY..................................9EMGALITY (300 MG DOSE)...... 9EMVERM.................................. 10enalapril maleate.......................12ENBREL....................................22ENBREL MINI........................... 22ENBREL SURECLICK.............. 22ENDARI.................................... 23ENDOMETRIN..........................21enoxaparin sodium......................8enskyce.....................................21ENSTILAR................................ 15entecavir................................... 11ENTRESTO.............................. 12EPCLUSA................................. 11EPIDIOLEX................................. 8EPIDUO FORTE....................... 15epinephrine............................... 25EPIPEN 2-PAK......................... 25EPIPEN JR 2-PAK.................... 25ergocalciferol.............................18erythromycin............................. 23escitalopram oxalate................... 8esomeprazole magnesium........18estarylla.....................................21estradiol.................................... 21estradiol-norethindrone acet..... 21ESTROGEL.............................. 21eszopiclone............................... 26etodolac...................................... 6etonogestrel-ethinyl estradiol.... 21EUCRISA.................................. 15EUFLEXXA............................... 23euthyrox.................................... 22EVAMIST.................................. 21ezetimibe...................................12ezetimibe-simvastatin............... 12famotidine................................. 18FARXIGA.................................. 15FASENRA................................. 24FASENRA PEN.........................24febuxostat................................... 9fenofibrate................................. 12fenofibrate micronized...............12fenofibric acid............................12

28

FENSOLVI (6 MONTH).............20fentanyl....................................... 6FINACEA.................................. 15finasteride................................. 19FIRAZYR...................................22FLAREX.................................... 23flecainide acetate...................... 12FLOVENT DISKUS................... 25FLOVENT HFA......................... 25fluconazole..................................9fluocinonide...............................15FLUOROPLEX..........................15FLUOROURACIL......................15fluorouracil ................................ 15fluoxetine hcl............................... 8fluticasone propionate...............24fluticasone-salmeterol............... 25fluvoxamine maleate................... 8folic acid.................................... 18FOLLISTIM AQ......................... 20FORFIVO XL...............................8FORTEO................................... 23FREESTYLE LIBRE 14 DAY READER................................... 16FREESTYLE LIBRE 14 DAY SENSOR...................................16FREESTYLE LIBRE 2 READER................................... 16FREESTYLE LIBRE 2 SENSOR...................................16FREESTYLE LIBRE READER..16FREESTYLE LIBRE SENSOR SYSTEM................................... 16furosemide................................ 12FYCOMPA.................................. 8gabapentin.................................. 8GAMMAGARD.......................... 22ganirelix acetate........................20GELSYN-3................................ 23gemfibrozil .................................12GENVOYA................................ 11GILENYA.................................. 14glimepiride.................................15glipizide er.................................15glipizide ir.................................. 15glucagon emergency kit ............ 17GLUCAGON EMERGENCY KIT............................................ 17glyburide................................... 15glycopyrrolate............................18GLYCOPYRROLATE................18GLYXAMBI................................15GRALISE.................................. 14

guanfacine hcl...........................12guanfacine hcl er.......................13GVOKE HYPOPEN 1-PACK.....17GVOKE HYPOPEN 2-PACK.....17GVOKE PFS............................. 17GYNAZOLE-1............................. 9HAEGARDA..............................22HARVONI..................................11HEMANGEOL........................... 12HORIZANT................................14HUMALOG KWIKPEN.............. 17HUMALOG MIX 50/50 KWIKPEN................................. 17HUMALOG MIX 50/50 VIAL......17HUMALOG MIX 75/25 KWIKPEN................................. 17HUMALOG MIX 75/25 VIAL......17HUMALOG U-100 JUNIOR KWIKPEN................................. 17HUMALOG VIAL....................... 17HUMIRA....................................22HUMIRA PEDIATRIC CROHNS START......................22HUMIRA PEN........................... 22HUMIRA PEN-CD/UC/HS STARTER................................. 22HUMIRA PEN-PS/UV/ADOL HS START................................ 22HUMIRA PEN-PSOR/UVEIT STARTER................................. 22HUMULIN 70/30 KWIKPEN...... 17HUMULIN 70/30 VIAL...............17HUMULIN N KWIKPEN............ 17HUMULIN N VIAL..................... 17HUMULIN R U-500 KWIKPEN..17HUMULIN R U-500 VIAL.......... 17HUMULIN R VIAL..................... 17hydralazine hcl.......................... 12hydrochlorothiazide...................12hydrocodone-acetaminophen..... 6hydrocortisone.................... 15, 19hydrocortisone (perianal).......... 23hydromorphone hcl..................... 6hydroxychloroquine sulfate....... 10hydroxyzine hcl......................... 11hydroxyzine pamoate................11hyoscyamine sulfate................. 18hyoscyamine sulfate sl..............18HYSINGLA ER............................6ibandronate sodium.................. 23IBRANCE.................................... 9ibuprofen..................................... 6IDHIFA...................................... 10

imiquimod..................................15IMVEXXY MAINTENANCE PACK........................................ 21IMVEXXY STARTER PACK..... 21INBRIJA.................................... 10INDOMETHACIN........................ 6indomethacin...............................6INFLECTRA.............................. 22INGREZZA................................14INVEGA SUSTENNA................10INVEGA TRINZA...................... 10INVELTYS.................................23INVOKANA............................... 15ipratropium bromide.................. 24ipratropium-albuterol................. 25irbesartan.................................. 12irbesartan-hydrochlorothiazide..12isibloom.....................................21isosorbide mononitrate er......... 12JANUMET................................. 15JANUMET XR........................... 15JANUVIA...................................15JARDIANCE..............................15JENTADUETO.......................... 15JENTADUETO XR.................... 15JIVI............................................11JORNAY PM............................. 13JULUCA.................................... 11junel 1.5/30............................... 21junel 1/20.................................. 21junel fe 1.5/30........................... 21junel fe 1/20.............................. 21junel fe 24................................. 21KANJINTI.................................. 10KERYDIN.................................... 9KESIMPTA................................14ketoconazole...............................9ketorolac tromethamine........ 6, 23KEYTRUDA.............................. 10klor-con m20............................. 18KOATE......................................11kurvelo...................................... 21KYNMOBI................................. 10KYNMOBI TITRATION KIT.......10labetalol hcl............................... 12lactulose....................................18lamotrigine.................................. 8lamotrigine er.............................. 8lansoprazole..............................18LANTUS SOLOSTAR............... 17LANTUS U-100 VIAL................ 17larin fe 1/20............................... 21larissia.......................................21

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latanoprost................................ 24LATUDA....................................10leflunomide................................22lessina.......................................21letrozole.................................... 10LEVEMIR U-100 FLEXTOUCH.17LEVEMIR U-100 VIAL...............17levetiracetam...............................8levocetirizine dihydrochloride....25levofloxacin................................. 7levonorgest-eth est & eth est.... 21levonorgest-eth estrad 91-day.. 21levonorgestrel-ethinyl estrad.....21levothyroxine sodium................ 22levoxyl....................................... 22lidocaine......................................6lidocaine viscous hcl................. 14lidocaine-prilocaine..................... 6LINZESS................................... 18liothyronine sodium................... 22lisinopril ..................................... 12lisinopril-hydrochlorothiazide.....12lithium carbonate.......................11lithium carbonate er.................. 11LIVALO..................................... 12LO LOESTRIN FE.....................21LOKELMA................................. 18LONHALA MAGNAIR REFILL KIT............................................ 25LONHALA MAGNAIR STARTER KIT...........................25lorazepam................................. 11loryna........................................ 21LORZONE.................................26losartan potassium....................12losartan potassium-hctz............ 12LOTEMAX.................................23LOTEMAX SM.......................... 23lovastatin...................................12LUMIGAN..................................24LUPRON DEPOT (1-MONTH)..20LUPRON DEPOT (3-MONTH)..20LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..20LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..20LYNPARZA............................... 10LYUMJEV KWIKPEN................17LYUMJEV VIAL.........................17MAKENA...................................21MAVENCLAD............................14MAVYRET.................................11MAYZENT.................................14

meclizine hcl............................... 9medroxyprogesterone acetate.. 21meloxicam...................................6memantine hcl.............................8mesalamine...............................23metaxalone............................... 26metformin hcl er........................ 16metformin hcl er (mod)..............16metformin hcl er (osm).............. 16metformin hcl ir ......................... 16methimazole..............................22methocarbamol......................... 26methotrexate............................. 22methotrexate sodium................ 22methylphenidate hcl.................. 13methylphenidate hcl er..............13methylphenidate hcl er (la)........13methylphenidate hcl er (xr)....... 13methylprednisolone...................19metoclopramide hcl.....................9metoprolol succinate er.............12metoprolol tartrate.....................13metronidazole....................... 7, 15minocycline hcl............................7MIRENA (52 MG)......................21mirtazapine................................. 8MIRVASO................................. 15misoprostol................................18modafinil ....................................26mometasone furoate........... 15, 25mono-linyah.............................. 21montelukast sodium.................. 25morphine sulfate......................... 6morphine sulfate (concentrate)... 6morphine sulfate er..................... 6MOTEGRITY.............................18MOVANTIK............................... 19MOXEZA...................................23MOXIFLOXACIN HCL...............24moxifloxacin hcl.........................24MULPLETA............................... 11MULTAQ................................... 13mupirocin.................................... 7MVASI.......................................10mycophenolate mofetil .............. 22mycophenolate sodium............. 22MYRBETRIQ.............................19nabumetone................................ 6nadolol...................................... 13naltrexone hcl..............................7NAMZARIC................................. 8NAPRELAN.................................6naproxen..................................... 6

naproxen sodium........................ 6NARCAN.....................................7NASCOBAL.............................. 18NATAZIA...................................21NAYZILAM.................................. 8neomycin-polymyxin-dexameth 24neomycin-polymyxin-hc............ 24NEULASTA............................... 11NEULASTA ONPRO.................11NEXLETOL............................... 13NEXLIZET.................................13nifedipine er.............................. 13nifedipine er osmotic release.... 13nikki...........................................21nitrofurantoin macrocrystal..........7nitrofurantoin monohydrate macrocrystals..............................7nitroglycerin...............................13NITYR....................................... 19NIVESTYM................................11NOCDURNA............................. 20NORDITROPIN FLEXPRO....... 20norethin ace-eth estrad-fe.........21norethindrone............................21norethindrone acetate............... 21norethindrone acet-ethinyl est...21norgestimate-ethinyl estradiol triphasic.....................................21nortrel 1/35 (21)........................ 21nortrel 1/35 (28)........................ 21nortriptyline hcl............................9NOURIANZ............................... 10NOVOEIGHT............................ 11NOVOFINE AUTOCOVER PEN NEEDLE........................... 17NOVOFINE PEN NEEDLE....... 17NOVOFINE PLUS PEN NEEDLE....................................17NOVOLIN 70/30 FLEXPEN...... 17NOVOLIN 70/30 VIAL............... 17NOVOLIN N FLEXPEN.............17NOVOLIN N VIAL..................... 17NOVOLIN R FLEXPEN.............17NOVOLIN R VIAL..................... 17NOVOLOG FLEXPEN.............. 17NOVOLOG MIX 70/30 FLEXPEN..................................17NOVOLOG MIX 70/30 VIAL......17NOVOLOG PENFILL................ 17NOVOLOG U-100 VIAL............ 17NOVOTWIST PEN NEEDLE.... 18np thyroid.................................. 22NPLATE.................................... 11

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NUBEQA...................................10NUCALA................................... 25NUCYNTA...................................6NURTEC..................................... 9NUTROPIN AQ NUSPIN 10..... 20NUTROPIN AQ NUSPIN 20..... 20NUTROPIN AQ NUSPIN 5....... 20NUWIQ......................................11NUZYRA..................................... 7nystatin........................................9ODEFSEY.................................11ofloxacin....................................24olanzapine.................................10olmesartan medoxomil..............13olmesartan medoxomil-hctz...... 13olmesartan-amlodipine-hctz......13olopatadine hcl..........................24OMECLAMOX-PAK.................. 19omega-3-acid ethyl esters.........13omeprazole............................... 18OMNARIS................................. 25ondansetron hcl.......................... 9ondansetron odt.......................... 9ONEXTON................................ 15ONGENTYS..............................10OPSUMIT..................................26ORENCIA..................................22ORENCIA CLICKJECT............. 22ORENITRAM............................ 26ORFADIN..................................19ORIAHNN................................. 21ORILISSA................................. 20OSPHENA................................ 20OTEZLA.................................... 22OTOVEL................................... 24oxcarbazepine.............................8oxybutynin chloride................... 19oxybutynin chloride er............... 19oxycodone hcl............................. 6OXYCODONE-ACETAMINOPHEN.....................6oxycodone-acetaminophen.........6OXYCONTIN...............................6OZEMPIC..................................16pantoprazole sodium.................18paroxetine hcl..............................9peg 3350-kcl-na bicarb-nacl......19penicillin v potassium.................. 7PENTASA................................. 23PERFOROMIST........................25PERSERIS................................10phenazopyridine hcl.................. 19phentermine hcl........................ 14

PHESGO...................................10pimecrolimus.............................15pioglitazone hcl......................... 16polymyxin b-trimethoprim..........24potassium chloride crys er........ 18potassium chloride er................18potassium citrate er...................18PRADAXA...................................8PRALUENT...............................13pramipexole dihydrochloride..... 10prasugrel hcl............................. 10pravastatin sodium....................13prazosin hcl...............................13prednisolone acetate.................24prednisolone sodium phosphate................................. 19prednisone................................ 19pregabalin................................. 14PREMARIN............................... 21PREMPHASE........................... 21PREMPRO................................21PREZCOBIX............................. 11PROAIR HFA............................ 25PROAIR RESPICLICK..............25prochlorperazine maleate........... 9PROCTOFOAM HC.................. 23progesterone micronized.......... 21PROLENSA.............................. 24PROLIA.....................................23promethazine hcl.......................25promethazine-dm...................... 25propranolol hcl.......................... 13propranolol hcl er...................... 13pseudoephedrine-bromphen-dm............................................. 25PULMICORT FLEXHALER.......25PULMOZYME........................... 26PYLERA....................................19QBREXZA.................................15QNASL......................................25QNASL CHILDRENS................ 25QSYMIA.................................... 14quetiapine fumarate.................. 10quetiapine fumarate er.............. 10QVAR REDIHALER.................. 25rabeprazole sodium.................. 18ramipril ...................................... 13ranolazine er............................. 13RASUVO...................................22RAYALDEE...............................23REBIF....................................... 14REBIF REBIDOSE....................14

REBIF REBIDOSE TITRATION PACK.................... 14REBIF TITRATION PACK.........14RECOMBINATE........................11REPATHA................................. 13REPATHA PUSHTRONEX SYSTEM................................... 13REPATHA SURECLICK........... 13RESTASIS................................ 24RESTASIS MULTIDOSE.......... 24RETACRIT................................ 11RETIN-A MICRO PUMP........... 15REVLIMID................................. 10REXULTI...................................10RHOFADE................................ 15RHOPRESSA........................... 24RINVOQ....................................22risperidone................................ 10rizatriptan benzoate.................... 9ROCKLATAN............................ 24ropinirole hcl..............................10rosuvastatin calcium................. 13ROZLYTREK............................ 10RUBRACA................................ 10RUCONEST..............................23RUKOBIA..................................11RUXIENCE............................... 10RYBELSUS...............................16RYTARY................................... 10SAXENDA.................................14scopolamine................................9SEREVENT DISKUS................ 25SERNIVO..................................15sertraline hcl................................9SEYSARA................................... 7sildenafil citrate................... 19, 26SILENOR.................................. 26SIMBRINZA.............................. 24SIMPONI...................................23SIMPONI ARIA......................... 23simvastatin................................ 13SKYRIZI (150 MG DOSE).........23sodium fluoride..........................18solifenacin succinate.................19SOLIQUA.................................. 16SOLIRIS....................................11SOLOSEC...................................7SOMATULINE DEPOT............. 20SOOLANTRA............................15sotalol hcl.................................. 13SPIRIVA HANDIHALER............26SPIRIVA RESPIMAT................ 26spironolactone...........................13

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sprintec 28................................ 21SPRYCEL................................. 10STELARA..................................23STENDRA.................................19STIOLTO RESPIMAT............... 26STRENSIQ................................19STRIVERDI RESPIMAT........... 26sucralfate.................................. 18sulfamethoxazole-trimethoprim...7sulfasalazine............................. 23sumatriptan succinate................. 9SUNOSI.................................... 26SUPPRELIN LA........................ 20SUPREP BOWEL PREP KIT....19syeda........................................ 21SYMBICORT.............................26SYMFI....................................... 11SYMFI LO................................. 11SYMJEPI...................................26SYMLINPEN 120...................... 16SYMLINPEN 60........................ 16SYMPAZAN................................ 8SYMPROIC...............................19SYNJARDY...............................16SYNJARDY XR.........................16SYNTHROID.............................22TACLONEX...............................15tacrolimus............................15, 23tadalafil ......................................19TAGRISSO............................... 10TAKHZYRO.............................. 23TALTZ....................................... 23tamoxifen citrate........................10tamsulosin hcl........................... 19TAPERDEX 12-DAY................. 19TAPERDEX 6-DAY................... 19TAPERDEX 7-DAY................... 19TARGRETIN............................. 10TECFIDERA..............................14TEGSEDI.................................. 14TEKTURNA...............................13TEKTURNA HCT...................... 13telmisartan................................ 13telmisartan-hctz.........................13temazepam............................... 26terazosin hcl..............................19terbinafine hcl..............................9terconazole................................. 9TERIPARATIDE (RECOMBINANT)..................... 23testosterone.............................. 20testosterone cypionate..............20TIGLUTIK..................................14

timolol maleate..........................24timolol maleate pf......................24TIROSINT................................. 22TIROSINT-SOL.........................22TIVICAY.................................... 11tizanidine hcl............................. 26TOBI PODHALER.....................26TOBRADEX ST.........................24tobramycin-dexamethasone......24tolterodine tartrate er.................19topiramate................................... 8torsemide.................................. 13TOUJEO MAX SOLOSTAR...... 18TOUJEO SOLOSTAR...............18TOVIAZ..................................... 19TRADJENTA.............................16tramadol hcl ir ............................. 6TRAZIMERA............................. 10trazodone hcl.............................. 9TRELEGY ELLIPTA..................26TREMFYA.................................23TRESIBA...................................18TRESIBA FLEXTOUCH............18tretinoin..................................... 15TREZIX....................................... 6tri femynor................................. 21triamcinolone acetonide............ 15triamterene-hctz........................ 13triazolam................................... 11tri-estarylla................................ 21TRIJARDY XR.......................... 16TRIKAFTA.................................26tri-lo-marzia............................... 21tri-lo-mili .................................... 21tri-lo-sprintec............................. 21TRINTELLIX................................9TRIPTODUR............................. 20tri-sprintec................................. 21TRIUMEQ................................. 11TROKENDI XR........................... 8TRULANCE...............................19TRULICITY............................... 16TRUVADA.................................11TYMLOS................................... 23UBRELVY................................... 9UCERIS.................................... 23ULTOMIRIS.............................. 11valacyclovir hcl..........................11valsartan................................... 13valsartan-hydrochlorothiazide... 13VALTOCO...................................8VARUBI (180 MG DOSE)........... 9VASCEPA................................. 13

VELCADE................................. 10VELPHORO.............................. 19VELTASSA............................... 18VEMLIDY.................................. 11venlafaxine hcl............................ 9venlafaxine hcl er........................ 9VENTOLIN HFA........................26verapamil hcl er.........................13V-GO 20....................................16V-GO 30....................................16V-GO 40....................................17VIBERZI.................................... 19VICTOZA.................................. 16vienva........................................22VIIBRYD......................................9VIIBRYD STARTER PACK......... 9VIMPAT.......................................8vitamin d (ergocalciferol)...........18VITRAKVI..................................10VOSEVI.....................................11VRAYLAR................................. 10VUMERITY............................... 14VYLEESI................................... 14VYVANSE................................. 13WAKIX...................................... 26warfarin sodium...........................8WILATE.....................................11wixela inhub.............................. 26XARELTO................................... 8XARELTO STARTER PACK.......8XCOPRI...................................... 8XELJANZ.................................. 23XELJANZ XR............................ 23XEMBIFY.................................. 23XENLETA....................................7XEPI............................................7XGEVA......................................23XIGDUO XR..............................16XIIDRA...................................... 24XIMINO....................................... 7XOFLUZA (40 MG DOSE)........ 11XOFLUZA (80 MG DOSE)........ 11XOLAIR.....................................25XTAMPZA ER............................. 6XTANDI.....................................10xulane....................................... 22XYNTHA................................... 11XYNTHA SOLOFUSE...............12XYOSTED.................................20XYREM..................................... 26YUPELRI...................................26ZARXIO.....................................12ZEJULA.....................................10

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ZELNORM................................ 19ZENPEP....................................19ZEPOSIA.................................. 14ZEPOSIA 7-DAY STARTER PACK........................................ 14ZEPOSIA STARTER KIT.......... 14ZETONNA.................................25ZIEXTENZO..............................12ZILXI......................................... 15ZIOPTAN.................................. 24ziprasidone hcl.......................... 10ZIRABEV...................................10ZOLGENSMA........................... 19zolpidem tartrate....................... 26zolpidem tartrate er................... 26zonisamide..................................8ZUBSOLV................................... 7

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WL1312773_LTC Select Standard_noUM Booklet_070121 LTC Select Standard

2021 long-term care formulary

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