2022 premium standard formulary - benefits.hshs.org

2022 Premium Standard FormularyEffective January 1, 2022

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 or log on to the OptumRx app to:

• Find a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

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, OptumRx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors 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.

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 of each 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.

About this formulary

Where differences exist between this list and your benefit plan, the benefit plan documents rule. This is not a complete list of your covered medications. Please review your benefit plan documents for full details. Not all formulary alternatives listed in this document may be appropriate for your specific condition. Please talk to your doctor.

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. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients.

What if my doctor writes a brand-name prescription?

If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication?

Specialty medications are used to treat complex conditions. These high-cost medications may be injected, infused or taken by mouth. 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.

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.

3

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 information

Using 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 $$$ Higher-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.

Tier E Excluded May not be covered or need prior authorization. Lower-cost options are available and covered.

Drug list information

In 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.

M Authorized generic or cobranded product

PA Prior authorization – Your doctor is required to give OptumRx more information to determine coverage.

QL Quantity limit – Medication may be limited to a certain quantity.

SP Specialty medication – Medication is designated as specialty.

ST Step therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered

3P Tier 3 preferred

++ Benefit design options – Coverage is determined by your prescription medication benefit plan.

Hospital Sisters

Table of Contents

Analgesics - Drugs for Pain.................................................................................................................................6Analgesics - Drugs for Pain and Inflammation.................................................................................................... 7Anesthetics..........................................................................................................................................................7Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 7Antibacterials.......................................................................................................................................................7Anticoagulants.....................................................................................................................................................8Anticonvulsants - Drugs for Seizures.................................................................................................................. 8Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................................ 9Antidepressants...................................................................................................................................................9Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 10Antifungals.........................................................................................................................................................10Antigout Agents................................................................................................................................................. 10Antimigraine Agents.......................................................................................................................................... 10Antineoplastics - Drugs for Cancer....................................................................................................................11Antiparasitics..................................................................................................................................................... 12Antiparkinson Agents........................................................................................................................................ 12Antiplatelets.......................................................................................................................................................12Antipsychotics - Drugs for Mood Disorders....................................................................................................... 12Antivirals............................................................................................................................................................12Anxiolytics - Drugs for Anxiety...........................................................................................................................13Bipolar Agents - Drugs for Mood Disorders.......................................................................................................13Blood Products and Modifiers - Drugs for Blood Disorders...............................................................................13Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 14Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 16Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 16Central Nervous System Agents - Miscellaneous............................................................................................. 17Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................17Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 17Diabetes - Antidiabetic Agents.......................................................................................................................... 19Diabetes - Glucose Monitoring.......................................................................................................................... 20Diabetes - Glycemic Agents.............................................................................................................................. 23Diabetes - Insulins.............................................................................................................................................23Electrolytes / Minerals / Metals / Vitamins.........................................................................................................24Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................26Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................26Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 27Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................27Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 28Hormonal Agents - Adrenal............................................................................................................................... 28Hormonal Agents - Men's Health.......................................................................................................................28Hormonal Agents - Pituitary.............................................................................................................................. 28Hormonal Agents - Selective Estrogen Receptor Modifying Agents................................................................. 29Hormonal Agents - Sex Hormones and Birth Control........................................................................................29Hormonal Agents - Thyroid............................................................................................................................... 30Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 30Inflammatory Bowel Disease Agents.................................................................................................................31Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 31Metabolic Bone Disease Agents - Other........................................................................................................... 31Miscellaneous Therapeutic Agents................................................................................................................... 31Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................32

4

Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................32Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 33Otic Agents - Drugs for Ear Conditions............................................................................................................. 33Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................33Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 34Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 35Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 35Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 35Sleep Disorder Agents...................................................................................................................................... 36

5

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

acetaminophen-codeine #2

1 QL


1 QL


1 QL

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

1 QL

APADAZ E

apap-caff-dihydrocodeine oral capsule

1 QL

BELBUCA 2 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

E

butalbital-apap-caffeine 1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR

E

CONZIP E

DILAUDID ORAL E

fentanyl 1 PA; QL

FENTANYL CITRATE BUCCAL TABLET

E

FENTORA E

FIORICET E

FIORICET/CODEINE E

hydrocodone-acetaminophen oral tablet

1 QL

hydromorphone hcl oral tablet

1 QL

HYSINGLA ER 2 PA; QL

LAZANDA E


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

1 QL

morphine sulfate (pf) 1

morphine sulfate er oral tablet extended release

1 PA; QL

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

3

morphine sulfate injection solution 2 mg/ml, 4 mg/ml

1

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

3

MORPHINE SULFATE INTRAVENOUS SOLUTION 1 MG/ML

3

morphine sulfate oral solution

1 QL

MS CONTIN E

NUCYNTA E

NUCYNTA ER E

OXYCODONE HCL ER E

oxycodone hcl oral tablet

1 QL

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

1 QL

OXYCONTIN 2 PA; QL

PERCOCET E

QDOLO E

ROXICODONE E

SUBSYS E

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

E

tramadol hcl oral tablet 50 mg

1 QL

TREZIX 3 QL

Effective Date: 01/01/2022

6


ULTRACET E

ULTRAM E

XTAMPZA ER 2 PA; QL

Analgesics - Drugs for Pain and Inflammation

ARTHROTEC E

CAMBIA E

CELEBREX E

celecoxib oral 1 QL

DICLOFENAC CAP 35MG

E

DICLOFENAC PATCH 1.3%

E

diclofenac sodium external gel 1 %

1 QL

diclofenac sodium oral 1

DUEXIS E

etodolac oral tablet 1

FLECTOR E

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

ibuprofen-famotidine E

indomethacin oral capsule 25 mg, 50 mg

1

KETOROLAC TROMETHAMINE NASAL

E

ketorolac tromethamine oral

1 QL

LICART E

meloxicam oral tablet 1

MOBIC E

nabumetone oral 1

NALFON E

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

3

naproxen oral tablet 1


naproxen sodium oral tablet 275 mg, 550 mg

1

PENNSAID E

RELAFEN E

RELAFEN DS E

SPRIX E

VIMOVO E

ZIPSOR E

ZORVOLEX E

Anesthetics

lidocaine external patch 5 %

1

lidocaine-prilocaine external cream

1

LIDODERM E

ZTLIDO E

Anti-Addiction / Substance Abuse Treatment Agents

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

LIFEMS NALOXONE E

naltrexone hcl oral 1

NARCAN 2

SUBOXONE E

ZUBSOLV 2 QL

Antibacterials

ACTICLATE E

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


7


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, 750 mg

1

clarithromycin oral tablet

1

CLEOCIN VAGINAL E

clindamycin hcl oral 1

CLINDESSE 3

DIFICID 3

DORYX E

DORYX MPC E

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet

1

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

E

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

MINOLIRA E

mupirocin external 1


nitrofurantoin macrocrystal

1

nitrofurantoin monohydrate macrocrystals

1

NUVESSA E

NUZYRA ORAL 3

penicillin v potassium oral tablet

1

SEYSARA 3 ST

SILVADENE E

SOLODYN E

SOLOSEC 3

sulfamethoxazole-trimethoprim oral tablet

1

TARGADOX E

XENLETA 3

XEPI 3

XIMINO 3

Anticoagulants

ELIQUIS 2 QL

ELIQUIS DVT/PE STARTER PACK

2 QL

enoxaparin sodium 1 SP; QL

PRADAXA 2 QL

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

Anticonvulsants - Drugs for Seizures

APTIOM 3

BRIVIACT 3

carbamazepine oral tablet

1

CARBATROL E

DEPAKOTE E

DEPAKOTE ER E

DEPAKOTE SPRINKLES

E

DILANTIN INFATABS E


8


DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL SUSPENSION

E

divalproex sodium er 1

divalproex sodium oral tablet delayed release

1

ELEPSIA XR E

EPIDIOLEX 3 PA; SP

FYCOMPA 3

gabapentin oral capsule

1

gabapentin oral tablet 1

KEPPRA ORAL E

KEPPRA XR E

LAMICTAL E

LAMICTAL ODT E

LAMICTAL STARTER E

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR

E

lamotrigine er 1

lamotrigine oral tablet 1

levetiracetam oral tablet

1

NAYZILAM 3

NEURONTIN E

ONFI E

oxcarbazepine oral tablet

1

OXTELLAR XR E

QUDEXY XR E

SABRIL E

SYMPAZAN 3

TEGRETOL E

TEGRETOL-XR E

TOPAMAX E

TOPAMAX SPRINKLE E

topiramate oral tablet 1

TRILEPTAL E


TROKENDI XR 3

VALTOCO 3

VIMPAT 3

XCOPRI 3

ZONEGRAN E

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

BRISDELLE E

bupropion hcl er (sr) 1 QL

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

1 QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

E

bupropion hcl oral 1

CELEXA E

citalopram hydrobromide oral tablet

1

CYMBALTA E

desvenlafaxine succinate er

1 QL

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

1

duloxetine hcl oral 1 QL

EFFEXOR XR E

escitalopram oxalate oral tablet

1


9


fluoxetine hcl oral capsule

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

FORFIVO XL E

LEXAPRO E

mirtazapine oral tablet 1

nortriptyline hcl oral capsule

1

paroxetine hcl oral tablet

1

PAXIL CR E

PAXIL ORAL TABLET E

PRISTIQ E

PROZAC E

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3 QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD 3 QL

VIIBRYD STARTER PACK

3 QL

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

Antiemetics - Drugs for Nausea and Vomiting

GIMOTI E

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

SANCUSO E

scopolamine 1


VARUBI (180 MG DOSE)

3 QL

Antifungals

ciclopirox external solution

1

clotrimazole external cream

1

clotrimazole-betamethasone external cream

1

CRESEMBA ORAL 3 PA

fluconazole oral tablet 1

GYNAZOLE-1 3

JUBLIA E

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external shampoo

1

nystatin external cream 1

nystatin mouth/throat 1

terbinafine hcl oral 1

terconazole vaginal cream

1

TOLSURA E

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

E

colchicine oral tablet 1

COLCRYS E

febuxostat 1 ST

GLOPERBA E

MITIGARE E

Antimigraine Agents

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

2 PA; QL

AJOVY E


10


eletriptan hydrobromide 1 QL

EMGALITY 2 PA; QL

EMGALITY (300 MG DOSE)

2 PA; QL

IMITREX E

IMITREX STATDOSE REFILL

E

IMITREX STATDOSE SYSTEM

E

MAXALT E

MAXALT-MLT E

NURTEC 2 PA; QL

ONZETRA XSAIL E

RELPAX E

REYVOW E

rizatriptan benzoate 1 QL

sumatriptan succinate oral

1 QL

TOSYMRA E

TREXIMET E

UBRELVY 2 PA; QL

ZEMBRACE SYMTOUCH

E

ZOMIG ORAL E

Antineoplastics - Drugs for Cancer

AFINITOR E

ALECENSA 2 PA; SP

ALUNBRIG 2 PA; SP; QL

anastrozole oral 1

ARIMIDEX E

BELRAPZO E

CABOMETYX 2 PA; SP

CALQUENCE 3 PA; SP

capecitabine 1 PA; SP

COSELA E

DARZALEX FASPRO E

ERIVEDGE 3 PA; SP

ERLEADA E

FOTIVDA E


GAVRETO E

GLEEVEC E

HERZUMA E

IBRANCE ORAL TABLET

3 PA; SP

IDHIFA 3 PA; SP; QL

INQOVI E

KANJINTI 2 PA; SP

KEYTRUDA 3 PA; SP

KISQALI FEMARA 3 PA; SP

KISQALI ORAL TABLET THERAPY PACK 200 MG

3 PA; SP

letrozole oral 1

LYNPARZA 2 PA; SP

MVASI 2 PA; SP

NUBEQA 3 PA; SP

ODOMZO 3 PA; SP

OGIVRI E

ONTRUZANT E

ORGOVYX 3 PA; SP

PHESGO 2 PA; SP

RETEVMO 3 PA; SP

REVLIMID 2 PA; SP

RIABNI E

ROZLYTREK 3 PA; SP

RUBRACA 2 PA; SP

RUXIENCE 2 PA; SP

SPRYCEL 2 PA; SP

TABRECTA 3 PA; SP

TAGRISSO ORAL TABLET 40 MG

3 PA; SP; QL

TAGRISSO ORAL TABLET 80 MG

3 PA; SP

tamoxifen citrate oral 1

TARGRETIN EXTERNAL

3 PA; SP

TARGRETIN ORAL E

TAZVERIK E

TEPMETKO E


11


TRAZIMERA 2 PA; SP

TREANDA E

TRUXIMA E

UKONIQ 3 PA; SP

VELCADE 2 PA; SP

VITRAKVI 3 PA; SP

XTANDI 3 PA; SP

YONSA E

ZEJULA 2 PA; SP

ZIRABEV 2 PA; SP

ZYTIGA E

Antiparasitics

ARAKODA 3

EMVERM 2

hydroxychloroquine sulfate oral tablet 200 mg

1

NATROBA E

PLAQUENIL E

Antiparkinson Agents

benztropine mesylate oral

1

carbidopa-levodopa oral tablet

1

GOCOVRI E

INBRIJA 3 PA; SP

KYNMOBI 3 PA; SP; QL

KYNMOBI TITRATION KIT

3 PA; SP; QL

NEUPRO 3

NOURIANZ 3 PA

ONGENTYS 3

OSMOLEX ER E

pramipexole dihydrochloride

1

ropinirole hcl 1

RYTARY 3

Antiplatelets

ASPIRIN-OMEPRAZOLE

E


BRILINTA 2

clopidogrel bisulfate oral

1

PLAVIX E

prasugrel hcl 1

YOSPRALA E

Antipsychotics - Drugs for Mood Disorders

ABILIFY E

ABILIFY MAINTENA 3

aripiprazole oral tablet 1 QL

ARISTADA 3

ARISTADA INITIO 3

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3 QL

olanzapine oral tablet 1 QL

PERSERIS 3

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 QL

RISPERDAL E

risperidone oral tablet 1 QL

SAPHRIS E

SECUADO E

SEROQUEL E

SEROQUEL XR E

VRAYLAR 3 QL

ziprasidone hcl 1 QL

ZYPREXA E

Antivirals

acyclovir oral tablet 1

ATRIPLA E

BARACLUDE ORAL TABLET

E

BIKTARVY 3

CABENUVA E

CIMDUO 2


12


DESCOVY E

DOVATO 2

entecavir 1 SP; QL

EPCLUSA ORAL TABLET

2 PA; SP; QL

GENVOYA 3

HARVONI 2 PA; SP; QL

JULUCA 2

LEDIPASVIR-SOFOSBUVIR

E

MAVYRET ORAL TABLET

2 PA; SP; QL

ODEFSEY 3

PREZCOBIX 2

RUKOBIA 2

SOFOSBUVIR-VELPATASVIR

E

SYMFI 2

SYMFI LO 2

TAMIFLU E

TEMIXYS E

TIVICAY 2

TRIUMEQ 2

TRUVADA E

valacyclovir hcl oral 1 QL

VALTREX E

VEMLIDY 3 SP

VOCABRIA E

VOSEVI 2 PA; SP; QL

XOFLUZA (40 MG DOSE)

3 QL

XOFLUZA (80 MG DOSE)

3 QL

ZOVIRAX E

Anxiolytics - Drugs for Anxiety

alprazolam oral tablet 1

ATIVAN ORAL E

buspirone hcl oral 1

clonazepam oral tablet 1


diazepam oral tablet 1

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

KLONOPIN E

lorazepam oral tablet 1

triazolam 1 QL

VALIUM E

XANAX E

XANAX XR E

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 3 SP

ARANESP (ALBUMIN FREE)

2 PA; SP

ELOCTATE 3 SP

EPOGEN E

ESPEROCT E

FULPHILA E

GRANIX E

JIVI 3 SP

KOATE 2 SP

MULPLETA 2 PA; SP

NEULASTA 3 PA; SP

NEULASTA ONPRO 3 PA; SP

NEUPOGEN E

NIVESTYM 2 PA; SP

NOVOEIGHT 2 SP

NPLATE 3 PA; SP

NUWIQ 2 SP


13


NYVEPRIA E

PROCRIT E

RECOMBINATE 2 SP

RETACRIT 2 PA; SP

SEVENFACT E

SOLIRIS 3 PA; SP

UDENYCA E

ULTOMIRIS 3 PA; SP

WILATE 2 SP

XYNTHA 2 SP

XYNTHA SOLOFUSE 2 SP

ZARXIO 2 PA; SP

ZIEXTENZO 3 PA; SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ALTACE E

amiodarone hcl oral 1

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-olmesartan 1

ATACAND E

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

AVAPRO E

AZOR E

benazepril hcl oral 1

BENICAR E

BENICAR HCT E

BIDIL 3

bisoprolol fumarate oral 1

bisoprolol-hydrochlorothiazide

1


bumetanide oral 1

BYSTOLIC E

candesartan cilexetil 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

E

cartia xt 1

carvedilol 1

CATAPRES-TTS-1 E

CATAPRES-TTS-2 E

CATAPRES-TTS-3 E

chlorthalidone 1

clonidine hcl oral 1

COLESTID E

COLESTID FLAVORED

E

CONJUPRI E

CONSENSI E

COREG E

COREG CR E

CORLANOR 3 PA; QL

COZAAR E

CRESTOR E

digoxin oral tablet 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

DIOVAN E

DIOVAN HCT E

doxazosin mesylate oral

1

EDARBI 3

EDARBYCLOR 3

enalapril maleate oral tablet

1

ENTRESTO 2 QL

EXFORGE E

EXFORGE HCT E


14


ezetimibe 1

EZETIMIBE-ROSUVASTATIN

E

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

HYZAAR E

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

irbesartan 1

irbesartan-hydrochlorothiazide

1

isosorbide mononitrate er

1

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral 1

LASIX E

LESCOL XL E

LIPITOR E

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO E

losartan potassium oral 1

losartan potassium-hctz 1


LOTREL E

lovastatin oral 1

LOVAZA E

metoprolol succinate er 1

metoprolol tartrate oral 1

MICARDIS E

MICARDIS HCT E

MULTAQ 3

nadolol oral 1

NEXLETOL 2 PA; QL

NEXLIZET 2 PA; QL

NIASPAN E

nifedipine er 1

nifedipine er osmotic release

1

nitroglycerin sublingual 1

NITROSTAT E

NORVASC E

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

omega-3-acid ethyl esters

1

PRALUENT E

pravastatin sodium 1

prazosin hcl oral 1

PRINIVIL E

propranolol hcl er 1

propranolol hcl oral tablet

1

QUESTRAN E

QUESTRAN LIGHT E

ramipril 1

RANEXA E

ranolazine er 1

REPATHA 2 PA; SP; QL


15


REPATHA PUSHTRONEX SYSTEM

2 PA; SP; QL

REPATHA SURECLICK

2 PA; SP; QL

rosuvastatin calcium 1

ROSZET E

simvastatin oral 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 2

TEKTURNA HCT 2

telmisartan 1

telmisartan-hctz 1

TENORMIN E

TIKOSYN E

TOPROL XL E

torsemide 1

triamterene-hctz 1

TRIBENZOR E

TRICOR E

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2

verapamil hcl er oral tablet extended release

1

VERQUVO 3 PA; QL

VYTORIN E

WELCHOL E

ZESTRIL E

ZETIA E

ZOCOR E

ZYPITAMAG E

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL E

ADDERALL XR E


ADHANSIA XR E

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1

atomoxetine hcl 1

CONCERTA E

dexmethylphenidate hcl er

1

dexmethylphenidate hcl oral tablet 10 mg, 5 mg

1

EVEKEO E

FOCALIN E

FOCALIN XR E

guanfacine hcl er 1

INTUNIV E

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

QELBREE E

RITALIN E

RITALIN LA E

STRATTERA E

VYVANSE 2

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA; SP; QL

AUBAGIO 3 PA; SP; QL

AVONEX PEN 2 PA; SP; QL

AVONEX PREFILLED 2 PA; SP; QL


16


BAFIERTAM 2 PA; SP; QL

BETASERON 2 PA; SP; QL

COPAXONE 2 PA; SP; QL

EXTAVIA E

GILENYA 3 PA; SP; QL

KESIMPTA 2 PA; SP; QL

MAVENCLAD 3 PA; SP

MAYZENT 3 PA; SP; QL

PLEGRIDY E

PLEGRIDY STARTER PACK

E

PONVORY E

PONVORY STARTER PACK

E

REBIF E

REBIF REBIDOSE E

REBIF REBIDOSE TITRATION PACK

E

REBIF TITRATION PACK

E

TECFIDERA E

VUMERITY 2 PA; SP; QL

ZEPOSIA 3 PA; SP; QL

ZEPOSIA 7-DAY STARTER PACK

3 PA; SP; QL

ZEPOSIA STARTER KIT

3 PA; SP; QL

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA; QL

ADIPEX-P E

AUSTEDO 3 PA; SP; QL

CONTRAVE E

EXSERVAN E

GRALISE 3

HORIZANT 3

IMCIVREE E

INGREZZA 3 PA; SP; QL

LYRICA E


LYRICA CR E

pregabalin oral capsule 1

TEGSEDI 3 PA; SP

TIGLUTIK 3

VYLEESI 3 PA; QL

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 E

ABSORICA LD 3

ACANYA E

ACZONE EXTERNAL GEL 5 %

E

ACZONE EXTERNAL GEL 7.5 %

2

adapalene external gel 1 PA

AKLIEF E

ALA SCALP E

AMZEEQ 3

APEXICON E E

ARAZLO E

AVITA E

BENZACLIN E

BENZACLIN WITH PUMP

E

BENZAMYCIN E

betamethasone dipropionate external cream

1

CALCIPOTRIENE EXTERNAL FOAM

E

CAPEX E

claravis 1

CLINDAGEL E


17


clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external gel

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

clobetasol propionate external cream

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

CLOBEX E

CLOBEX SPRAY E

CLODERM E

CORDRAN EXTERNAL TAPE

E

DAPSONE EXTERNAL GEL 7.5 %

E

DESONATE E

DIFFERIN EXTERNAL CREAM

E

DIFFERIN EXTERNAL GEL 0.3 %

E

DIFFERIN EXTERNAL LOTION

E

DUOBRII E

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML

2 PA; SP; QL

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA; SP; QL

ELIDEL E

EPIDUO E


EPIDUO FORTE 3

EUCRISA 2

FABIOR E

FINACEA 3

fluocinonide external cream

1

fluocinonide external solution

1

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

E

HALOG EXTERNAL CREAM

E

HALOG EXTERNAL OINTMENT

E

hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

imiquimod external 1

IMIQUIMOD PUMP E

IMPEKLO E

IMPOYZ E

KENALOG EXTERNAL E

KLISYRI 3 ST

LEXETTE E

METROGEL E

metronidazole external cream

1

metronidazole external gel

1

MIRVASO 3

mometasone furoate external cream

1

NORITATE E

ONEXTON 3


18


ORACEA E

PANDEL E

pimecrolimus 1

PROPECIA E

PSORCON E

QBREXZA 3

RETIN-A E

RETIN-A MICRO GEL 0.04 %, 0.1 %

E

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

E

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

2 PA

RHOFADE 3

SERNIVO 3

SOOLANTRA 3

SORILUX E

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3

tacrolimus external 1

TAZAROTENE EXTERNAL FOAM

E

TAZORAC E

TOPICORT SPRAY E

tretinoin external cream 1 PA

triamcinolone acetonide external cream

1

triamcinolone acetonide external ointment

1

TRIANEX E

ULTRAVATE E

VECTICAL E

VELTIN E

VERDESO E

WINLEVI E


WYNZORA E

ZIANA E

ZILXI 3

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

ADLYXIN E

ADLYXIN STARTER PACK

E

ALOGLIPTIN BENZOATE

E

ALOGLIPTIN-METFORMIN HCL

E

ALOGLIPTIN-PIOGLITAZONE

E

BYDUREON BCISE AUTOINJECTOR

2 QL

BYETTA 10 MCG PEN 2 QL

BYETTA 5 MCG PEN 2 QL

FARXIGA 2

glimepiride 1

glipizide er 1

glipizide ir 1

GLUMETZA E

glyburide oral 1

GLYXAMBI 2

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E


19


metformin hcl er (osm) E

metformin hcl oral tablet

1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC 2 QL

pioglitazone hcl 1

QTERN E

RYBELSUS 2 QL

SEGLUROMET E

SOLIQUA 2 QL

STEGLATRO E

STEGLUJAN E

SYMLINPEN 120 3 PA

SYMLINPEN 60 3 PA

SYNJARDY 2

SYNJARDY XR 2

TRADJENTA 2

TRIJARDY XR 2

TRULICITY 2 QL

VICTOZA 2 QL

XIGDUO XR 2

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA DEVICE

E

ACCU-CHEK AVIVA PLUS KIT W/DEVICE

E

ACCU-CHEK COMPACT PLUS CONTROL

E

ACCU-CHEK COMPACT PLUS TEST STRIPS

E

ACCU-CHEK FASTCLIX LANCET KIT

2

ACCU-CHEK GUIDE TEST STRIPS

E


ACCU-CHEK GUIDE CONTROL

E

ACCU-CHEK GUIDE KIT W/DEVICE

E

ACCU-CHEK SMARTVIEW CONTROL

E

ACCU-CHEK SMARTVIEW TEST STRIPS

E

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

2

AGAMATRIX CONTROL LEVEL 2

E

AGAMATRIX CONTROL LEVEL 4

E

AGAMATRIX PRESTO TEST

E

ASSURE PLATINUM E

BIOTEL CARE BLOOD GLUCOSE

E

BIOTEL CARE BLOOD GLUCOSE SYST

E

BLOOD GLUCOSE TEST

E

BLULINK CONTROL HIGH & LOW

E

BLULINK GLUCOSE MONITORING SYS

E

BLULINK GLUCOSE TEST

E

CARETOUCH CONTROL SOL LEVEL 2

E

CARETOUCH TEST E

CONTOUR MONITOR KIT W/DEVICE

$0

CONTOUR NEXT EZ KIT W/DEVICE

$0

CONTOUR NEXT LINK KIT W/DEVICE

$0


20


CONTOUR NEXT MONITOR KIT W/DEVICE

$0

CONTOUR NEXT ONE KIT

$0

CONTOUR NEXT TEST STRIPS

$0

CONTOUR TEST STRIPS

$0

DEXCOM G5 MOBILE RECEIVER

2

DEXCOM G5 MOBILE TRANSMITTER

2

DEXCOM G5 RECEIVER KIT

2

DEXCOM G6 RECEIVER

2

DEXCOM G6 SENSOR 2

DEXCOM G6 TRANSMITTER

2

DIATHRIVE BLOOD GLUCOSE METER

E

DIATHRIVE BLOOD GLUCOSE TEST

E

DIATHRIVE GLUCOSE CONTROL SOLN

E

DIATHRIVE GLUCOSE TEST

E

DIATHRIVE+ GLUCOSE MONITOR

E

DIATHRIVE+ GLUCOSE TEST

E

EASY TALK PLUS II TEST STRIPS

E

EASY TOUCH HEALTHPRO GLUCOSE

E

EASY TRAK II BLOOD GLUCOSE SYS

E

EASY TRAK II CONTROL

E

EASY TRAK II GLUCOSE TEST

E


EASYMAX 15 LEVEL 2-3 CONTROL

E

EASYMAX CONTROL E

GLUCOSE CONTROL SOLUTIONS

E

EMBRACE EVO GLUCOSE MONITOR

E

EMBRACE TALK BLOOD GLUCOSE

E

EMBRACE TALK GLUCOSE CONTROL

E

EMBRACE TALK GLUCOSE TEST

E

EMBRACE TALK MONITORING SYSTEM

E

FORA 6 CONNECT E

FORA GTEL BLOOD GLUCOSE SYSTEM

E

FORA GTEL BLOOD GLUCOSE TEST

E

FORA TN'G ADVANCE PRO IN VITRO

E

FORTISCARE CONTROL

E

FORTISCARE G1 TEST STRIP

E

FORTISCARE T1 GLUCOSE SYSTEM

E

FREESTYLE FREEDOM LITE

E

FREESTYLE INSULINX SYSTEM

E

FREESTYLE INSULINX TEST

E

FREESTYLE LIBRE 14 DAY READER

E

FREESTYLE LIBRE 14 DAY SENSOR

E

FREESTYLE LIBRE 2 READER

E

FREESTYLE LIBRE 2 SENSOR

E


21


FREESTYLE LIBRE READER

E

FREESTYLE LITE TEST

E

FREESTYLE PRECISION NEO TEST

E

FREESTYLE TEST E

GHT BLOOD GLUCOSE MONITOR

E

GLUCOCARD 01 SENSOR PLUS

E

GLUCOCARD EXPRESSION TEST

E

GLUCOCARD SHINE CONNEX

E

GLUCOCARD SHINE EXPRESS

E

GLUCOCARD SHINE TEST

E

GLUCOCARD VITAL TEST

E

GOJJI BLOOD GLUCOSE TEST

E

GOJJI CONTROL E

GUARDIAN CONNECT TRANSMITTER

3

GUARDIAN LINK 3 TRANSMITTER

3

GUARDIAN SENSOR (3)

3

HW EMBRACE PRO GLUCOSE METER

E

HW EMBRACE PRO GLUCOSE TEST

E

HW EMBRACE TALK BLOOD GLUCOSE

E

HW EMBRACE TALK GLUCOSE TEST

E

INFINITY BLOOD GLUCOSE TEST

E

KROGER HEALTHPRO GLUCOSE TEST

E


LANCETS IN VITRO STRIP

E

MICRODOT TEST E

ONE DROP BLOOD GLUCOSE MONITOR

E

ONE DROP TEST E

ONETOUCH ULTRA TEST STRIPS

E

ONETOUCH ULTRA 2 KIT W/DEVICE

E

ONETOUCH ULTRA MINI KIT W/DEVICE

E

ONETOUCH VERIO KIT W/DEVICE

E

ONETOUCH VERIO FLEX SYSTEM

E

ONETOUCH VERIO IN VITRO SOLUTION HIGH

E

ONETOUCH VERIO TEST STRIPS

E

ONETOUCH VERIO IQ SYSTEM

E

ONETOUCH VERIO REFLECT

E

ONETOUCH VERIO SYNC SYSTEM

E

POGO AUTOMATIC BLOOD GLUCOSE

E

POGO AUTOMATIC TEST CARTRIDGES

E

PRECISION LINK E

PRECISION PCX PLUS TEST

E

PRECISION QID MONITOR

E

PRECISION QID TEST E

PRECISION SOF-TACT MONITOR

E

PRECISION SOF-TACT TEST

E

PRECISION XTRA BLOOD GLUCOSE

E


22


PRECISION XTRA DEVICE

E

PRECISION XTRA KIT E

PRECISION XTRA MONITOR

E

PRODIGY NO CODING BLOOD GLUC

E

RELION BLOOD GLUCOSE TEST

E

RELION PREMIER CLASSIC

E

RELION PREMIER TEST

E

RIGHTEST GT333 BLOOD GLUCOSE

E

SURESTEP PRO HIGH GLUCOSE

E

SURESTEP PRO LOW GLUCOSE

E

SURESTEP PRO NORMAL GLUCOSE

E

TRUE FOCUS BLOOD GLUCOSE METER

E

TRUE METRIX BLOOD GLUCOSE TEST

E

TRUE METRIX LEVEL 1

E

TRUE METRIX LEVEL 2

E

TRUE METRIX LEVEL 3

E

TRUE METRIX METER KIT

E

TRUE METRIX PRO BLOOD GLUCOSE

E

TRUETRACK TEST E

UNISTRIP CONTROL IN VITRO SOLUTION LOW

E

VIVAGUARD INO CONTROL SOLUTION

E

VIVAGUARD INO GLUCOSE METER

E


VIVAGUARD INO TEST STRIPS

E

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED

2

GVOKE HYPOPEN 1-PACK

2

GVOKE HYPOPEN 2-PACK

2

GVOKE PFS 2

Diabetes - Insulins

ADMELOG E

ADMELOG SOLOSTAR

E

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

BD AUTOSHIELD DUO PEN NEEDLES

$0

BD ULTRA-FINE INSULIN SYRINGES

$0

BD ULTRA-FINE PEN NEEDLES

$0

FIASP E

FIASP FLEXTOUCH E

FIASP PENFILL E

HUMALOG 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


23


HUMALOG U-100 JUNIOR KWIKPEN

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

INSULIN ASP PROT & ASP FLEXPEN

E

INSULIN ASPART E

INSULIN ASPART FLEXPEN

E

INSULIN ASPART PENFILL

E

INSULIN ASPART PROT & ASPART

E

INSULIN GLARGINE-YFGN

E

INSULIN LISPRO E

INSULIN LISPRO (1 UNIT DIAL)

E

INSULIN LISPRO JUNIOR KWIKPEN

E

INSULIN LISPRO PROT & LISPRO

E

LANTUS SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

LYUMJEV KWIKPEN 2

LYUMJEV VIAL 2

NOVOLIN 70/30 FLEXPEN

E

NOVOLIN 70/30 FLEXPEN RELION

E


NOVOLIN 70/30 RELION

E

NOVOLIN 70/30 VIAL E

NOVOLIN N FLEXPEN E

NOVOLIN N FLEXPEN RELION

E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R FLEXPEN E

NOVOLIN R FLEXPEN RELION

E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG 70/30 FLEXPEN RELION

E

NOVOLOG FLEXPEN E

NOVOLOG FLEXPEN RELION

E

NOVOLOG MIX 70/30 FLEXPEN

E

NOVOLOG MIX 70/30 RELION

E

NOVOLOG MIX 70/30 VIAL

E

NOVOLOG PENFILL E

NOVOLOG RELION E

NOVOLOG U-100 VIAL E

SEMGLEE E

SEMGLEE (YFGN) E

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA E

TRESIBA FLEXTOUCH

E

Electrolytes / Minerals / Metals / Vitamins

ACCRUFER E

AZESCO E

BIOPAR DELTA-FORTE

E


24


CARNITOR ORAL E

CARNITOR SF E

CITRANATAL BLOOM E

CITRANATAL ESSENCE

E

cyanocobalamin injection solution 1000 mcg/ml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

3

DAYAVITE E

DERMACINRX PRETRATE

E

DERMACINRX RIBOTIN-E

E

DERMACINRX ZINTREXYL-C

E

DEXIFOL E

ENBRACE HR E

ergocalciferol oral capsule

1

FEONYX E

folic acid oral tablet 1 mg

1

FOLIC-K E

FOLITIN-Z E

FOLTREXYL E

GENICIN VITA-Q E

GENICIN VITA-S E

HYLAVITE E

HYLAZINC E

JENLIVA PRENATAL/POSTNATAL

E

klor-con m20 1

K-TAB E

LOKELMA 3

LORID E

MULTIPRO E


NASCOBAL 3

NEONATAL + DHA E

NEONATAL COMPLETE ORAL TABLET 29-1 MG

E

NEONATAL FE E

NESTABS ONE E

NICADAN E

NICAZEL E

NICAZEL FORTE E

NICOMIDE E

PNV TABS 20-1 E

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1

potassium chloride er 1

potassium citrate er 1

PREGEN DHA E

PREGENNA E

PRENARA E

PRENATE E

PRENATE DHA E

PRENATE ELITE E

PRENATE ENHANCE E

PRENATE ESSENTIAL E

PRENATE MINI E

PRENATE PIXIE E

PRENATE RESTORE E

PRENATRIX E

PRENATRYL E

PRENATVITE COMPLETE

E

PRIMACARE E

PROFOLA E

QUFLORA FE E

REMEDIENT E

sodium fluoride oral tablet chewable

1

TRINAZ E


25


TRISTART DHA E

TRISTART FREE E

TRISTART ONE E

TRONVITE E

VELTASSA 3

VENEXA E

VENEXA FE E

VENTRIXYL E

VENTRIXYL FE E

VITAFOL FE+ E

VITAFOL-NANO E

VITAFOL-OB+DHA E

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

1

VITASURE E

VITATHELY WITH GINGER

E

VITRAMYN E

VITRANOL FE E

VITREXATE E

VITREXATE FE E

VITREXYL E

VITREXYL + IRON E

WESTGEL DHA E

XVITE E

ZALVIT E

ZYVANA E

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX E

CARAFATE ORAL TABLET

E

DEXILANT 2 QL

esomeprazole magnesium oral capsule delayed release

1 QL


famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule delayed release

1 QL

misoprostol oral 1

NEXIUM ORAL CAPSULE DELAYED RELEASE

E

omeprazole oral capsule delayed release

1 QL

omeprazole-sodium bicarbonate

E

pantoprazole sodium oral tablet delayed release

1 QL

PREVACID E

PREVACID SOLUTAB E

PROTONIX ORAL TABLET DELAYED RELEASE

E

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E

rabeprazole sodium oral tablet delayed release

1 QL

sucralfate oral tablet 1

ZEGERID E

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

AMITIZA E

CLENPIQ 3

dicyclomine hcl oral capsule

1

dicyclomine hcl oral tablet

1


26


diphenoxylate-atropine oral tablet

1

glycopyrrolate oral 1

GOLYTELY E

hyoscyamine sulfate sl 1

hyoscyamine sulfate sublingual

1

lactulose oral solution 1

LINZESS 2

LUBIPROSTONE E

MOTEGRITY 3

MOTOFEN E

MOVANTIK E

MOVIPREP E

NULYTELY LEMON-LIME

E

OMECLAMOX-PAK 2

OSMOPREP E

peg 3350-kcl-na bicarb-nacl

1

PLENVU E

PYLERA 2

RELISTOR E

RELTONE E

SUPREP BOWEL PREP KIT

3

SUTAB 3

SYMPROIC 2

TALICIA 3

TRULANCE E

URSODIOL ORAL CAPSULE 200 MG, 400 MG

E

VIBERZI 3

ZELNORM 3

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

AMONDYS 45 E


CERDELGA 3 PA; SP

CREON 2

EXONDYS 51 E

KUVAN E

NITYR 3 PA; SP

ORFADIN 3 PA; SP

PANCREAZE E

PERTZYE E

STRENSIQ 2 PA; SP

VIOKACE E

VYONDYS 53 E

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA 3

CIALIS E

CUPRIMINE E

DEPEN TITRATABS 2 SP

ELMIRON E

GEMTESA E

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER

E

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR

2

oxybutynin chloride er 1

oxybutynin chloride oral tablet

1

penicillamine oral capsule

E

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

RENAGEL E

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

1 QL

solifenacin succinate 1


27


STENDRA E

tadalafil oral 1 QL

tolterodine tartrate er 1

TOVIAZ 3

VELPHORO 3

VESICARE E

VESICARE LS E

VIAGRA E

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART E

dutasteride oral 1

finasteride oral tablet 5 mg

1

FLOMAX E

tamsulosin hcl 1

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

1

Hormonal Agents - Adrenal

ALKINDI SPRINKLE E

CORTEF E

dexamethasone oral tablet

1

HEMADY E

hydrocortisone oral 1

KENALOG INJECTION SUSPENSION 40 MG/ML

E

methylprednisolone oral tablet therapy pack

1

prednisolone sodium phosphate oral solution

1

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

RAYOS E


Hormonal Agents - Men's Health

ANDRODERM 2 PA

ANDROGEL E

ANDROGEL PUMP E

AVEED E

DEPO-TESTOSTERONE

E

FORTESTA E

JATENZO E

NATESTO E

TESTIM E

TESTOPEL E

testosterone cypionate intramuscular

1 PA

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 PA

VOGELXO E

VOGELXO PUMP E

XYOSTED 3 PA

Hormonal Agents - Pituitary

ACTHAR 2 PA; SP

cabergoline 1

CETROTIDE E

FENSOLVI (6 MONTH) 3 PA; SP; QL

GENOTROPIN E

GENOTROPIN MINIQUICK

E

GONAL-F E

GONAL-F RFF E

GONAL-F RFF REDIJECT

E

HUMATROPE E

ISTURISA E


28


LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

2 PA; SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

2 PA; SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA; SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA; SP

MYCAPSSA E

NOCDURNA 3

NORDITROPIN FLEXPRO

2 PA; SP

NUTROPIN AQ NUSPIN 10

2 PA; SP


2 PA; SP


2 PA; SP

OMNITROPE E

ORILISSA 2

SAIZEN E

SAIZENPREP E

SANDOSTATIN E

SIGNIFOR E

SOMATULINE DEPOT 3 PA; SP

SUPPRELIN LA 2 PA; SP; QL

TRIPTODUR 3 PA; SP; QL

ZOMACTON E

ZOMACTON (FOR ZOMA-JET 10)

E

Hormonal Agents - Selective Estrogen Receptor Modifying Agents

OSPHENA 3


Hormonal Agents - Sex Hormones and Birth Control

BIJUVA 3

CLIMARA E

CLIMARA PRO 2

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

E

DIVIGEL 3

dotti 1

DUAVEE 2

ELESTRIN 3

ENDOMETRIN 2

ESTRACE E

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

estradiol-norethindrone acet

1

ESTROGEL 3

EVAMIST 3

IMVEXXY MAINTENANCE PACK

2

IMVEXXY STARTER PACK

2

MAKENA 2 PA; SP

medroxyprogesterone acetate oral

1

norethindrone acetate oral

1

ORIAHNN 2

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

PROMETRIUM E

VAGIFEM E

VIVELLE-DOT E


29


Hormonal Agents - Thyroid

ARMOUR THYROID 3

CYTOMEL E

euthyrox 1

LEVOTHYROXINE SODIUM ORAL CAPSULE

E

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

THYQUIDITY E

TIROSINT E

TIROSINT-SOL E

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 3 PA; SP

ACTEMRA SUBCUTANEOUS

3 PA; SP

ASCENIV E

AVSOLA 2 PA; SP

azathioprine oral tablet 50 mg

1

CIMZIA 2 PA; SP

CIMZIA PREFILLED KIT

2 PA; SP

CIMZIA STARTER KIT 2 PA; SP

COSENTYX (300 MG DOSE)

E

COSENTYX 150 MG/ML

E

COSENTYX SENSOREADY (300 MG)

E


COSENTYX SENSOREADY PEN

E

CUTAQUIG E

cyclosporine modified oral capsule

1

ENBREL MINI 3 PA; SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ENBREL SURECLICK 3 PA; SP

FIRAZYR E

GAMMAGARD 3 PA; SP

HAEGARDA 3 PA; SP

HUMIRA 2 PA; SP

HUMIRA PEDIATRIC CROHNS START

2 PA; SP

HUMIRA PEN 2 PA; SP

HUMIRA PEN-CD/UC/HS STARTER

2 PA; SP

HUMIRA PEN-PEDIATRIC UC START

2 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START

2 PA; SP

HUMIRA PEN-PSOR/UVEIT STARTER

2 PA; SP

INFLECTRA 2 PA; SP

leflunomide oral 1

LUPKYNIS E

methotrexate oral 1

methotrexate sodium oral

1

mycophenolate mofetil oral capsule

1

mycophenolate mofetil oral tablet

1

mycophenolate sodium 1

OLUMIANT E

ORENCIA 3 PA; SP


30


ORENCIA CLICKJECT 3 PA; SP

ORLADEYO 3 PA; SP; QL

OTEZLA 2 PA; SP

OTREXUP E

PANZYGA E

RASUVO 2

REDITREX E

REMICADE E

RENFLEXIS E

RINVOQ 2 PA; SP

RUCONEST 3 PA; SP; QL

SIMPONI 2 PA; SP

SIMPONI ARIA 2 PA; SP

SKYRIZI 2 PA; SP; QL

SKYRIZI (150 MG DOSE)

2 PA; SP; QL

SKYRIZI PEN 2 PA; SP; QL

STELARA INTRAVENOUS

2 PA; SP

STELARA SUBCUTANEOUS

2 PA; SP; QL

tacrolimus oral 1

TAKHZYRO 3 PA; SP

TALTZ 3 PA; SP

TREMFYA 2 PA; SP

TREXALL 3

XELJANZ 2 PA; SP

XELJANZ XR 2 PA; SP

XEMBIFY 3 PA; SP

Inflammatory Bowel Disease Agents

APRISO 2

ASACOL HD E

CANASA E

CORTIFOAM 3

DELZICOL E

DIPENTUM E

hydrocortisone (perianal)

1


LIALDA E

mesalamine er oral capsule 0.375 gm

1

mesalamine oral tablet delayed release

1

ORTIKOS E

PENTASA 3

PROCTOFOAM HC 2

sulfasalazine oral tablet 1

UCERIS ORAL E

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium oral tablet 10 mg, 5 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1 QL

FORTEO E

ibandronate sodium oral

1 QL

PROLIA 2 PA; SP; QL

RAYALDEE 3

TERIPARATIDE (RECOMBINANT)

2 PA; SP

TYMLOS 2 PA; SP

XGEVA 2 PA; SP

Metabolic Bone Disease Agents - Other

calcitriol oral capsule 1

SENSIPAR E

Miscellaneous Therapeutic Agents

BOTOX 2 PA; SP

DOJOLVI E

DUROLANE 2 PA; SP

ENDARI 3 PA

EUFLEXXA 2 PA; SP


31


FIRDAPSE E

GEL-ONE E

GELSYN-3 2 PA; SP

GENVISC 850 E

HYALGAN E

HYMOVIS E

MONOVISC E

ORTHOVISC E

OXBRYTA E

PALFORZIA E

PHEXXI E

SUPARTZ FX E

SYNVISC E

SYNVISC ONE E

TRILURON E

TRIVISC E

VILTEPSO E

VISCO-3 E

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

AZASITE 3

BEPREVE E

BESIVANCE 3

BROMSITE E

ciprofloxacin hcl ophthalmic

1

erythromycin ophthalmic

1

EYSUVIS 3 PA

FLAREX 3

ILEVRO E

INVELTYS 3

ketorolac tromethamine ophthalmic

1

LOTEMAX OPHTHALMIC SUSPENSION

E

LOTEMAX SM 3


MOXEZA 2

moxifloxacin hcl (2x day)

1

moxifloxacin hcl ophthalmic solution

1

NEVANAC E

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic

1

PRED FORTE E

prednisolone acetate ophthalmic

1

PROLENSA 2

VIGAMOX E

ZERVIATE E

Ophthalmic Agents - Drugs for Glaucoma

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

E

AZOPT E

BETIMOL 3

brimonidine tartrate ophthalmic

1

COMBIGAN 2

COSOPT E

COSOPT PF E

dorzolamide hcl-timolol mal

1

latanoprost ophthalmic 1

LUMIGAN 2 QL

RHOPRESSA 3 QL

ROCKLATAN 3 QL

SIMBRINZA 2

timolol maleate ophthalmic solution

1

timolol maleate pf 1

TIMOPTIC E


32


TIMOPTIC OCUDOSE E

TIMOPTIC-XE E

TRAVATAN Z E

VYZULTA E

XALATAN E

ZIOPTAN E

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

BEOVU E

CEQUA E

LASTACAFT E

LATISSE E

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

1

polymyxin b-trimethoprim

1

RESTASIS 2 PA

RESTASIS MULTIDOSE

2 PA

TOBRADEX OPHTHALMIC SUSPENSION

E

TOBRADEX ST 3

tobramycin-dexamethasone

1

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

CIPRODEX E

ciprofloxacin-dexamethasone

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1


Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal 1 QL

azelastine-fluticasone 1 QL

benzonatate 1

cetirizine hcl oral solution

1

CLARINEX E

CLARINEX-D 12 HOUR

E

cyproheptadine hcl oral tablet

1

DYMISTA 2 QL

FASENRA 2 PA; SP

FASENRA PEN 2 PA; SP

fluticasone propionate nasal

1

ipratropium bromide nasal

1

levocetirizine dihydrochloride oral tablet

1

mometasone furoate nasal

1 QL

NASONEX E

NUCALA 2 PA; SP; QL

OMNARIS 3 QL

promethazine hcl oral tablet

1

promethazine-dm 1

pseudoephedrine-bromphen-dm

1

QNASL 3 QL

QNASL CHILDRENS 3 QL

XHANCE E

XOLAIR 2 PA; SP

ZETONNA 3 QL


33


Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

AIRDUO DIGIHALER E

AIRDUO RESPICLICK 113/14

E


E


E

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

1 QL

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

E

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml

1 QL

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml

1

ALVESCO E

ANORO ELLIPTA 2 QL

ARMONAIR DIGIHALER

E

ARNUITY ELLIPTA 2 QL

ASMANEX (120 METERED DOSES)

E


E


E



E


E

ASMANEX HFA E

ATROVENT HFA 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML

E

BEVESPI AEROSPHERE

E

BREO ELLIPTA 2 QL

BREZTRI AEROSPHERE

2 QL

budesonide inhalation 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E

COMBIVENT RESPIMAT

2 QL

DUAKLIR PRESSAIR E

DULERA E

epinephrine injection solution auto-injector

1

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK E

ESBRIET 3 PA; SP

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

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

1 QL

INCRUSE ELLIPTA E

ipratropium-albuterol 1 QL


34


LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

E

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral tablet

1

montelukast sodium oral tablet chewable

1

OFEV 3 PA; SP

PERFOROMIST 3 QL

PROAIR DIGIHALER E

PROAIR HFA E

PROAIR RESPICLICK E

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

PULMICORT SUSPENSION

E

QVAR REDIHALER E

SEREVENT DISKUS 2 QL

SINGULAIR E

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

STRIVERDI RESPIMAT

2 QL

SYMBICORT 2 QL

SYMJEPI 3

TRELEGY ELLIPTA 2 QL

TUDORZA PRESSAIR E

VENTOLIN HFA E

wixela inhub 1 QL

XOPENEX HFA E

YUPELRI 3 QL


Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS E

BRONCHITOL E

BRONCHITOL TOLERANCE TEST

E

CAYSTON E

KITABIS PAK E

TOBI NEBULIZER E

TOBI PODHALER 3 SP; QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

E

TRIKAFTA 3 PA; SP; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA E

ADEMPAS 2 PA; SP; QL

LETAIRIS E

OPSUMIT 2 PA; SP; QL

ORENITRAM 3 PA; SP

REMODULIN E

sildenafil citrate oral tablet 20 mg

1 PA; SP; QL

TRACLEER 62.5 MG, 125 MG

E

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral

1

LORZONE 3

metaxalone 1


35


methocarbamol oral 1

NORGESIC FORTE E

ORPHENGESIC FORTE

E

OZOBAX E

SKELAXIN E

SOMA E

tizanidine hcl oral tablet 1

VANADOM E

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

armodafinil 1 PA; QL

BELSOMRA 3 QL

DAYVIGO 3 QL

eszopiclone 1 QL

HETLIOZ LQ E

LUNESTA E

modafinil 1 PA; QL

NUVIGIL E

PROVIGIL E

RESTORIL E

SILENOR 3 QL

SUNOSI 2 PA; QL

temazepam 1 QL

WAKIX 3 PA; SP; QL

XYREM 3 PA; SP; QL

XYWAV 3 PA; SP; QL

zolpidem tartrate er 1 QL

zolpidem tartrate oral 1 QL


36

Index of Drugs

ABILIFY.....................................12ABILIFY MAINTENA................. 12ABSORICA............................... 17ABSORICA LD..........................17ACANYA................................... 17ACCRUFER.............................. 24ACCU-CHEK AVIVA DEVICE...20ACCU-CHEK AVIVA PLUS KIT W/DEVICE..........................20ACCU-CHEK COMPACT PLUS CONTROL...................... 20ACCU-CHEK COMPACT PLUS TEST STRIPS................ 20ACCU-CHEK FASTCLIX LANCET KIT............................. 20ACCU-CHEK GUIDE CONTROL................................ 20ACCU-CHEK GUIDE KIT W/DEVICE................................ 20ACCU-CHEK GUIDE TEST STRIPS..................................... 20ACCU-CHEK SMARTVIEW CONTROL................................ 20ACCU-CHEK SMARTVIEW TEST STRIPS...........................20ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...............20acetaminophen-codeine..............6acetaminophen-codeine #2.........6acetaminophen-codeine #3.........6acetaminophen-codeine #4.........6ACIPHEX.................................. 26ACTEMRA................................ 30ACTEMRA ACTPEN.................30ACTHAR................................... 28ACTICLATE................................ 7acyclovir.................................... 12ACZONE................................... 17adapalene................................. 17ADCIRCA..................................35ADDERALL............................... 16ADDERALL XR......................... 16ADDYI....................................... 17ADEMPAS................................ 35ADHANSIA XR..........................16ADIPEX-P................................. 17ADLYXIN...................................19ADLYXIN STARTER PACK...... 19ADMELOG................................ 23ADMELOG SOLOSTAR........... 23ADVAIR DISKUS...................... 34ADVAIR HFA............................ 34ADVATE....................................13

ADYNOVATE............................13AFINITOR................................. 11AFSTYLA.................................. 13AGAMATRIX CONTROL LEVEL 2....................................20AGAMATRIX CONTROL LEVEL 4....................................20AGAMATRIX PRESTO TEST...20AIMOVIG...................................10AIRDUO DIGIHALER................34AIRDUO RESPICLICK 113/14..34AIRDUO RESPICLICK 232/14..34AIRDUO RESPICLICK 55/14....34AJOVY...................................... 10AKLIEF......................................17ALA SCALP.............................. 17albuterol sulfate.........................34albuterol sulfate hfa...................34ALBUTEROL SULFATE HFA... 34ALECENSA...............................11alendronate sodium.................. 31alfuzosin hcl er.......................... 28ALKINDI SPRINKLE................. 28allopurinol..................................10ALOGLIPTIN BENZOATE........ 19ALOGLIPTIN-METFORMIN HCL...........................................19ALOGLIPTIN-PIOGLITAZONE. 19ALPHAGAN P........................... 32alprazolam................................ 13ALTACE.................................... 14ALUNBRIG................................11ALVESCO................................. 34AMBIEN.................................... 36AMBIEN CR.............................. 36amiodarone hcl......................... 14AMITIZA....................................26amitriptyline hcl........................... 9amlodipine besylate.................. 14amlodipine besylate-benazepril hcl............................................. 14amlodipine besylate-valsartan.. 14amlodipine-olmesartan..............14AMONDYS 45...........................27amoxicillin................................... 7amoxicillin-potassium clavulanate..................................7amphetamine-dextroamphetamine.................. 16amphetamine-dextroamphetamine er.............. 16AMPYRA...................................16AMRIX.......................................35

AMZEEQ...................................17anastrozole............................... 11ANDRODERM.......................... 28ANDROGEL..............................28ANDROGEL PUMP.................. 28ANORO ELLIPTA..................... 34APADAZ......................................6apap-caff-dihydrocodeine........... 6APEXICON E............................ 17APIDRA SOLOSTAR................ 23APIDRA VIAL............................23APRISO.................................... 31APTIOM...................................... 8ARAKODA................................ 12ARANESP (ALBUMIN FREE)...13ARAZLO....................................17ARIMIDEX.................................11aripiprazole............................... 12ARISTADA................................ 12ARISTADA INITIO.................... 12armodafinil ................................ 36ARMONAIR DIGIHALER.......... 34ARMOUR THYROID.................30ARNUITY ELLIPTA...................34ARTHROTEC..............................7ASACOL HD............................. 31ASCENIV.................................. 30ASMANEX (120 METERED DOSES).................................... 34ASMANEX (14 METERED DOSES).................................... 34ASMANEX (30 METERED DOSES).................................... 34ASMANEX (60 METERED DOSES).................................... 34ASMANEX (7 METERED DOSES).................................... 34ASMANEX HFA........................ 34ASPIRIN-OMEPRAZOLE......... 12ASSURE PLATINUM................ 20ATACAND.................................14atenolol..................................... 14atenolol-chlorthalidone..............14ATIVAN..................................... 13atomoxetine hcl.........................16atorvastatin calcium.................. 14ATRIPLA................................... 12ATROVENT HFA...................... 34AUBAGIO..................................16AURYXIA.................................. 27AUSTEDO.................................17AUVI-Q......................................34AVAPRO................................... 14

37

AVEED......................................28AVITA........................................17AVODART.................................28AVONEX PEN...........................16AVONEX PREFILLED.............. 16AVSOLA....................................30AZASITE................................... 32azathioprine.............................. 30azelastine hcl............................ 33azelastine-fluticasone............... 33AZESCO................................... 24azithromycin................................8AZOPT...................................... 32AZOR........................................ 14baclofen.................................... 35BAFIERTAM............................. 17BAQSIMI ONE PACK............... 23BAQSIMI TWO PACK...............23BARACLUDE............................ 12BASAGLAR KWIKPEN............. 23BD AUTOSHIELD DUO PEN NEEDLES................................. 23BD ULTRA-FINE INSULIN SYRINGES............................... 23BD ULTRA-FINE PEN NEEDLES................................. 23BELBUCA................................... 6BELRAPZO...............................11BELSOMRA.............................. 36benazepril hcl............................14BENICAR.................................. 14BENICAR HCT..........................14BENZACLIN..............................17BENZACLIN WITH PUMP........ 17BENZAMYCIN.......................... 17BENZHYDROCODONE-ACETAMINOPHEN.....................6benzonatate.............................. 33benztropine mesylate................12BEOVU..................................... 33BEPREVE................................. 32BESIVANCE............................. 32betamethasone dipropionate.... 17BETASERON............................17BETHKIS...................................35BETIMOL.................................. 32BEVESPI AEROSPHERE.........34BIDIL......................................... 14BIJUVA..................................... 29BIKTARVY................................ 12BIOPAR DELTA-FORTE.......... 24BIOTEL CARE BLOOD GLUCOSE................................ 20

BIOTEL CARE BLOOD GLUCOSE SYST...................... 20bisoprolol fumarate................... 14bisoprolol-hydrochlorothiazide.. 14BLOOD GLUCOSE TEST.........20BLULINK CONTROL HIGH & LOW..........................................20BLULINK GLUCOSE MONITORING SYS.................. 20BLULINK GLUCOSE TEST...... 20BOTOX..................................... 31BREO ELLIPTA........................ 34BREZTRI AEROSPHERE.........34BRILINTA..................................12brimonidine tartrate................... 32BRISDELLE................................ 9BRIVIACT................................... 8BROMSITE............................... 32BRONCHITOL.......................... 35BRONCHITOL TOLERANCE TEST.........................................35budesonide............................... 34BUDESONIDE-FORMOTEROL FUMARATE....34bumetanide............................... 14buprenorphine hcl....................... 7buprenorphine hcl-naloxone hcl............................................... 7bupropion hcl.............................. 9bupropion hcl er (sr)....................9bupropion hcl er (xl).................... 9BUPROPION HCL ER (XL)........ 9buspirone hcl.............................13butalbital-apap-caffeine...............6BUTRANS...................................6BYDUREON BCISE AUTOINJECTOR...................... 19BYETTA 10 MCG PEN............. 19BYETTA 5 MCG PEN............... 19BYSTOLIC................................ 14CABENUVA.............................. 12cabergoline............................... 28CABOMETYX........................... 11CALCIPOTRIENE..................... 17calcitriol ..................................... 31CALQUENCE............................11CAMBIA...................................... 7CANASA................................... 31candesartan cilexetil ................. 14capecitabine..............................11CAPEX......................................17CARAFATE...............................26carbamazepine........................... 8

CARBATROL.............................. 8carbidopa-levodopa.................. 12CARDIZEM LA..........................14CARETOUCH CONTROL SOL LEVEL 2....................................20CARETOUCH TEST................. 20carisoprodol.............................. 35CARNITOR............................... 25CARNITOR SF..........................25cartia xt..................................... 14carvedilol...................................14CATAPRES-TTS-1................... 14CATAPRES-TTS-2................... 14CATAPRES-TTS-3................... 14CAYSTON.................................35cefdinir........................................ 8cefuroxime axetil ......................... 8CELEBREX.................................7celecoxib..................................... 7CELEXA......................................9cephalexin...................................8CEQUA..................................... 33CERDELGA.............................. 27cetirizine hcl.............................. 33CETROTIDE............................. 28chlorhexidine gluconate............ 17chlorthalidone............................14CIALIS.......................................27ciclopirox................................... 10CIMDUO................................... 12CIMZIA......................................30CIMZIA PREFILLED KIT...........30CIMZIA STARTER KIT............. 30CIPRODEX............................... 33ciprofloxacin hcl.................... 8, 32ciprofloxacin-dexamethasone... 33citalopram hydrobromide............ 9CITRANATAL BLOOM..............25CITRANATAL ESSENCE......... 25claravis......................................17CLARINEX................................ 33CLARINEX-D 12 HOUR............33clarithromycin..............................8CLENPIQ.................................. 26CLEOCIN.................................... 8CLIMARA.................................. 29CLIMARA PRO......................... 29CLINDAGEL..............................17clindamycin hcl............................8clindamycin phosphate............. 18clindamycin phosphate-benzoyl peroxide.......................18CLINDESSE................................8

38

clobetasol propionate................18CLOBEX................................... 18CLOBEX SPRAY...................... 18CLODERM................................ 18clonazepam...............................13clonidine hcl.............................. 14clopidogrel bisulfate.................. 12clotrimazole...............................10clotrimazole-betamethasone.....10COLCHICINE............................10colchicine.................................. 10COLCRYS.................................10COLESTID................................ 14COLESTID FLAVORED............14COMBIGAN.............................. 32COMBIVENT RESPIMAT......... 34CONCERTA..............................16CONJUPRI................................14CONSENSI............................... 14CONTOUR MONITOR KIT W/DEVICE................................ 20CONTOUR NEXT EZ KIT W/DEVICE................................ 20CONTOUR NEXT LINK KIT W/DEVICE................................ 20CONTOUR NEXT MONITOR KIT W/DEVICE..........................21CONTOUR NEXT ONE KIT......21CONTOUR NEXT TEST STRIPS..................................... 21CONTOUR TEST STRIPS........21CONTRAVE.............................. 17CONZIP...................................... 6COPAXONE..............................17CORDRAN................................18COREG.....................................14COREG CR...............................14CORLANOR..............................14CORTEF................................... 28CORTIFOAM............................ 31COSELA................................... 11COSENTYX (300 MG DOSE)...30COSENTYX 150 MG/ML.......... 30COSENTYX SENSOREADY (300 MG)...................................30COSENTYX SENSOREADY PEN...........................................30COSOPT...................................32COSOPT PF............................. 32COZAAR................................... 14CREON..................................... 27CRESEMBA..............................10CRESTOR................................ 14

CUPRIMINE..............................27CUTAQUIG............................... 30cyanocobalamin........................ 25CYANOCOBALAMIN................ 25cyclobenzaprine hcl.................. 35cyclosporine modified............... 30CYMBALTA.................................9cyproheptadine hcl....................33CYTOMEL.................................30DAPSONE................................ 18DARZALEX FASPRO............... 11DAYAVITE................................ 25DAYVIGO..................................36DELESTROGEN.......................29DELZICOL................................ 31DEPAKOTE................................ 8DEPAKOTE ER.......................... 8DEPAKOTE SPRINKLES........... 8DEPEN TITRATABS.................27DEPO-TESTOSTERONE......... 28DERMACINRX PRETRATE......25DERMACINRX RIBOTIN-E.......25DERMACINRX ZINTREXYL-C. 25DESCOVY................................ 13DESONATE.............................. 18desvenlafaxine succinate er........9dexamethasone........................ 28DEXCOM G5 MOBILE RECEIVER................................21DEXCOM G5 MOBILE TRANSMITTER........................ 21DEXCOM G5 RECEIVER KIT.. 21DEXCOM G6 RECEIVER......... 21DEXCOM G6 SENSOR............ 21DEXCOM G6 TRANSMITTER..21DEXIFOL...................................25DEXILANT................................ 26dexmethylphenidate hcl............ 16dexmethylphenidate hcl er........ 16DIATHRIVE BLOOD GLUCOSE METER...................21DIATHRIVE BLOOD GLUCOSE TEST...................... 21DIATHRIVE GLUCOSE CONTROL SOLN......................21DIATHRIVE GLUCOSE TEST.. 21DIATHRIVE+ GLUCOSE MONITOR................................. 21DIATHRIVE+ GLUCOSE TEST.........................................21diazepam.................................. 13DICLOFENAC CAP 35MG..........7DICLOFENAC PATCH 1.3%...... 7

diclofenac sodium....................... 7dicyclomine hcl..........................26DIFFERIN................................. 18DIFICID....................................... 8digoxin.......................................14DILANTIN....................................9DILANTIN INFATABS................. 8DILAUDID................................... 6diltiazem hcl er coated beads... 14DIOVAN.................................... 14DIOVAN HCT............................14DIPENTUM............................... 31diphenoxylate-atropine..............27divalproex sodium....................... 9divalproex sodium er...................9DIVIGEL....................................29DOJOLVI...................................31donepezil hcl............................... 9DORYX....................................... 8DORYX MPC.............................. 8dorzolamide hcl-timolol mal...... 32dotti ........................................... 29DOVATO...................................13doxazosin mesylate.................. 14doxepin hcl..................................9doxycycline hyclate..................... 8DOXYCYCLINE HYCLATE.........8doxycycline monohydrate........... 8DUAKLIR PRESSAIR............... 34DUAVEE................................... 29DUEXIS.......................................7DULERA................................... 34duloxetine hcl.............................. 9DUOBRII................................... 18DUPIXENT................................18DUROLANE.............................. 31dutasteride................................ 28DYMISTA.................................. 33EASY TALK PLUS II TEST STRIPS..................................... 21EASY TOUCH HEALTHPRO GLUCOSE................................ 21EASY TRAK II BLOOD GLUCOSE SYS........................ 21EASY TRAK II CONTROL........ 21EASY TRAK II GLUCOSE TEST.........................................21EASYMAX 15 LEVEL 2-3 CONTROL................................ 21EASYMAX CONTROL.............. 21EDARBI.....................................14EDARBYCLOR......................... 14EFFEXOR XR............................. 9

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ELEPSIA XR............................... 9ELESTRIN................................ 29eletriptan hydrobromide............ 11ELIDEL......................................18ELIQUIS......................................8ELIQUIS DVT/PE STARTER PACK.......................................... 8ELMIRON..................................27ELOCTATE............................... 13EMBRACE EVO GLUCOSE MONITOR................................. 21EMBRACE TALK BLOOD GLUCOSE................................ 21EMBRACE TALK GLUCOSE CONTROL................................ 21EMBRACE TALK GLUCOSE TEST.........................................21EMBRACE TALK MONITORING SYSTEM...........21EMGALITY................................11EMGALITY (300 MG DOSE).... 11EMVERM.................................. 12enalapril maleate.......................14ENBRACE HR.......................... 25ENBREL....................................30ENBREL MINI........................... 30ENBREL SURECLICK.............. 30ENDARI.................................... 31ENDOMETRIN..........................29enoxaparin sodium......................8entecavir................................... 13ENTRESTO.............................. 14EPCLUSA................................. 13EPIDIOLEX................................. 9EPIDUO.................................... 18EPIDUO FORTE....................... 18epinephrine............................... 34EPIPEN 2-PAK......................... 34EPIPEN JR 2-PAK.................... 34EPOGEN...................................13ergocalciferol.............................25ERIVEDGE............................... 11ERLEADA................................. 11erythromycin............................. 32ESBRIET...................................34escitalopram oxalate................... 9esomeprazole magnesium........26ESPEROCT.............................. 13ESTRACE................................. 29estradiol.................................... 29estradiol-norethindrone acet..... 29ESTROGEL.............................. 29eszopiclone............................... 36

etodolac...................................... 7EUCRISA.................................. 18EUFLEXXA............................... 31euthyrox.................................... 30EVAMIST.................................. 29EVEKEO................................... 16EXFORGE................................ 14EXFORGE HCT........................ 14EXONDYS 51........................... 27EXSERVAN.............................. 17EXTAVIA...................................17EYSUVIS.................................. 32ezetimibe...................................15EZETIMIBE-ROSUVASTATIN..15ezetimibe-simvastatin............... 15FABIOR.....................................18famotidine................................. 26FARXIGA.................................. 19FASENRA................................. 33FASENRA PEN.........................33febuxostat................................. 10fenofibrate................................. 15fenofibrate micronized...............15fenofibric acid............................15FENSOLVI (6 MONTH).............28fentanyl....................................... 6FENTANYL CITRATE.................6FENTORA...................................6FEONYX................................... 25FIASP........................................23FIASP FLEXTOUCH.................23FIASP PENFILL........................ 23FINACEA.................................. 18finasteride................................. 28FIORICET................................... 6FIORICET/CODEINE..................6FIRAZYR...................................30FIRDAPSE................................ 32FLAREX.................................... 32flecainide acetate...................... 15FLECTOR................................... 7FLOMAX................................... 28FLOVENT DISKUS................... 34FLOVENT HFA......................... 34fluconazole................................10fluocinonide...............................18FLUOROPLEX..........................18FLUOROURACIL......................18fluorouracil ................................ 18fluoxetine hcl............................. 10fluticasone propionate...............33fluticasone-salmeterol............... 34fluvoxamine maleate................. 10

FOCALIN.................................. 16FOCALIN XR............................ 16folic acid.................................... 25FOLIC-K....................................25FOLITIN-Z.................................25FOLTREXYL............................. 25FORA 6 CONNECT.................. 21FORA GTEL BLOOD GLUCOSE SYSTEM.................21FORA GTEL BLOOD GLUCOSE TEST...................... 21FORA TN'G ADVANCE PRO....21FORFIVO XL.............................10FORTEO................................... 31FORTESTA...............................28FORTISCARE CONTROL........ 21FORTISCARE G1 TEST STRIP....................................... 21FORTISCARE T1 GLUCOSE SYSTEM................................... 21FOTIVDA.................................. 11FREESTYLE FREEDOM LITE. 21FREESTYLE INSULINX SYSTEM................................... 21FREESTYLE INSULINX TEST. 21FREESTYLE LIBRE 14 DAY READER................................... 21FREESTYLE LIBRE 14 DAY SENSOR...................................21FREESTYLE LIBRE 2 READER................................... 21FREESTYLE LIBRE 2 SENSOR...................................21FREESTYLE LIBRE READER..22FREESTYLE LITE TEST.......... 22FREESTYLE PRECISION NEO TEST................................ 22FREESTYLE TEST...................22FULPHILA.................................13furosemide................................ 15FYCOMPA.................................. 9gabapentin.................................. 9GAMMAGARD.......................... 30GAVRETO................................ 11GEL-ONE..................................32GELSYN-3................................ 32gemfibrozil .................................15GEMTESA................................ 27GENICIN VITA-Q...................... 25GENICIN VITA-S...................... 25GENOTROPIN..........................28GENOTROPIN MINIQUICK......28GENVISC 850...........................32

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GENVOYA................................ 13GHT BLOOD GLUCOSE MONITOR................................. 22GILENYA.................................. 17GIMOTI..................................... 10GLEEVEC................................. 11glimepiride.................................19glipizide er.................................19glipizide ir.................................. 19GLOPERBA.............................. 10GLUCAGON EMERGENCY KIT............................................ 23GLUCOCARD 01 SENSOR PLUS.........................................22GLUCOCARD EXPRESSION TEST.........................................22GLUCOCARD SHINE CONNEX...................................22GLUCOCARD SHINE EXPRESS................................. 22GLUCOCARD SHINE TEST.....22GLUCOCARD VITAL TEST......22GLUCOSE CONTROL SOLUTIONS............................. 21GLUMETZA.............................. 19glyburide................................... 19glycopyrrolate............................27GLYXAMBI................................19GOCOVRI................................. 12GOJJI BLOOD GLUCOSE TEST.........................................22GOJJI CONTROL..................... 22GOLYTELY............................... 27GONAL-F.................................. 28GONAL-F RFF.......................... 28GONAL-F RFF REDIJECT....... 28GRALISE.................................. 17GRANIX.................................... 13guanfacine hcl...........................15guanfacine hcl er.......................16GUARDIAN CONNECT TRANSMITTER........................ 22GUARDIAN LINK 3 TRANSMITTER........................ 22GUARDIAN SENSOR (3)......... 22GVOKE HYPOPEN 1-PACK.....23GVOKE HYPOPEN 2-PACK.....23GVOKE PFS............................. 23GYNAZOLE-1........................... 10HAEGARDA..............................30HALOBETASOL PROPIONATE.......................... 18HALOG..................................... 18

HARVONI..................................13HEMADY...................................28HEMANGEOL........................... 15HERZUMA................................ 11HETLIOZ LQ............................. 36HORIZANT................................17HUMALOG................................23HUMALOG KWIKPEN.............. 23HUMALOG MIX 50/50 KWIKPEN................................. 23HUMALOG MIX 50/50 VIAL......23HUMALOG MIX 75/25 KWIKPEN................................. 23HUMALOG MIX 75/25 VIAL......23HUMALOG U-100 JUNIOR KWIKPEN................................. 24HUMATROPE........................... 28HUMIRA....................................30HUMIRA PEDIATRIC CROHNS START......................30HUMIRA PEN........................... 30HUMIRA PEN-CD/UC/HS STARTER................................. 30HUMIRA PEN-PEDIATRIC UC START...................................... 30HUMIRA PEN-PS/UV/ADOL HS START................................ 30HUMIRA PEN-PSOR/UVEIT STARTER................................. 30HUMULIN 70/30 KWIKPEN...... 24HUMULIN 70/30 VIAL...............24HUMULIN N KWIKPEN............ 24HUMULIN N VIAL..................... 24HUMULIN R U-500 KWIKPEN..24HUMULIN R U-500 VIAL.......... 24HUMULIN R VIAL..................... 24HW EMBRACE PRO GLUCOSE METER...................22HW EMBRACE PRO GLUCOSE TEST...................... 22HW EMBRACE TALK BLOOD GLUCOSE................................ 22HW EMBRACE TALK GLUCOSE TEST...................... 22HYALGAN.................................32hydralazine hcl.......................... 15hydrochlorothiazide...................15hydrocodone-acetaminophen..... 6hydrocortisone.................... 18, 28hydrocortisone (perianal).......... 31hydromorphone hcl..................... 6hydroxychloroquine sulfate....... 12hydroxyzine hcl......................... 13

hydroxyzine pamoate................13HYLAVITE.................................25HYLAZINC................................ 25HYMOVIS................................. 32hyoscyamine sulfate................. 27hyoscyamine sulfate sl..............27HYSINGLA ER............................6HYZAAR................................... 15ibandronate sodium.................. 31IBRANCE.................................. 11ibuprofen..................................... 7ibuprofen-famotidine................... 7IDHIFA...................................... 11ILEVRO.....................................32IMCIVREE.................................17imiquimod..................................18IMIQUIMOD PUMP...................18IMITREX................................... 11IMITREX STATDOSE REFILL..11IMITREX STATDOSE SYSTEM................................... 11IMPEKLO.................................. 18IMPOYZ.................................... 18IMVEXXY MAINTENANCE PACK........................................ 29IMVEXXY STARTER PACK..... 29INBRIJA.................................... 12INCRUSE ELLIPTA.................. 34INDERAL LA............................. 15INDERAL XL............................. 15indomethacin...............................7INFINITY BLOOD GLUCOSE TEST.........................................22INFLECTRA.............................. 30INGREZZA................................17INNOPRAN XL..........................15INQOVI..................................... 11INSULIN ASP PROT & ASP FLEXPEN..................................24INSULIN ASPART.................... 24INSULIN ASPART FLEXPEN... 24INSULIN ASPART PENFILL.....24INSULIN ASPART PROT & ASPART....................................24INSULIN GLARGINE-YFGN..... 24INSULIN LISPRO......................24INSULIN LISPRO (1 UNIT DIAL).........................................24INSULIN LISPRO JUNIOR KWIKPEN................................. 24INSULIN LISPRO PROT & LISPRO.....................................24INTUNIV....................................16

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INVEGA SUSTENNA................12INVEGA TRINZA...................... 12INVELTYS.................................32INVOKAMET.............................19INVOKAMET XR.......................19INVOKANA............................... 19ipratropium bromide.................. 33ipratropium-albuterol................. 34irbesartan.................................. 15irbesartan-hydrochlorothiazide..15isosorbide mononitrate er......... 15ISTURISA................................. 28JANUMET................................. 19JANUMET XR........................... 19JANUVIA...................................19JARDIANCE..............................19JATENZO..................................28JENLIVA PRENATAL/POSTNATAL.........25JENTADUETO.......................... 19JENTADUETO XR.................... 19JIVI............................................13JORNAY PM............................. 16JUBLIA......................................10JULUCA.................................... 13KANJINTI.................................. 11KAPSPARGO SPRINKLE.........15KATERZIA................................ 15KAZANO................................... 19KENALOG...........................18, 28KEPPRA..................................... 9KEPPRA XR............................... 9KERYDIN.................................. 10KESIMPTA................................17ketoconazole.............................10KETOROLAC TROMETHAMINE.......................7ketorolac tromethamine........ 7, 32KEYTRUDA.............................. 11KISQALI.................................... 11KISQALI FEMARA.................... 11KITABIS PAK............................ 35KLISYRI.................................... 18KLONOPIN............................... 13klor-con m20............................. 25KOATE......................................13KOMBIGLYZE XR.....................19KROGER HEALTHPRO GLUCOSE TEST...................... 22K-TAB....................................... 25KUVAN......................................27KYNMOBI................................. 12KYNMOBI TITRATION KIT.......12

labetalol hcl............................... 15lactulose....................................27LAMICTAL.................................. 9LAMICTAL ODT..........................9LAMICTAL STARTER.................9LAMICTAL XR............................ 9lamotrigine.................................. 9lamotrigine er.............................. 9LANCETS................................. 22lansoprazole..............................26LANTUS SOLOSTAR............... 24LANTUS U-100 VIAL................ 24LASIX........................................15LASTACAFT............................. 33latanoprost................................ 32LATISSE................................... 33LATUDA....................................12LAZANDA................................... 6LEDIPASVIR-SOFOSBUVIR.... 13leflunomide................................30LESCOL XL.............................. 15LETAIRIS.................................. 35letrozole.................................... 11LEVALBUTEROL HFA..............35LEVEMIR U-100 FLEXTOUCH.24LEVEMIR U-100 VIAL...............24levetiracetam...............................9levocetirizine dihydrochloride....33levofloxacin................................. 8LEVOTHYROXINE SODIUM.... 30levothyroxine sodium................ 30levoxyl....................................... 30LEXAPRO................................. 10LEXETTE.................................. 18LIALDA......................................31LICART....................................... 7lidocaine......................................7lidocaine viscous hcl................. 17lidocaine-prilocaine..................... 7LIDODERM................................. 7LIFEMS NALOXONE.................. 7LINZESS................................... 27liothyronine sodium................... 30LIPITOR.................................... 15lisinopril ..................................... 15lisinopril-hydrochlorothiazide.....15lithium carbonate.......................13lithium carbonate er.................. 13LIVALO..................................... 15LOKELMA................................. 25LONHALA MAGNAIR REFILL KIT............................................ 35

LONHALA MAGNAIR STARTER KIT...........................35lorazepam................................. 13LORID....................................... 25LORZONE.................................35losartan potassium....................15losartan potassium-hctz............ 15LOTEMAX.................................32LOTEMAX SM.......................... 32LOTREL.................................... 15lovastatin...................................15LOVAZA....................................15LUBIPROSTONE......................27LUMIGAN..................................32LUNESTA................................. 36LUPKYNIS................................ 30LUPRON DEPOT (1-MONTH)..29LUPRON DEPOT (3-MONTH)..29LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..29LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..29LYNPARZA............................... 11LYRICA..................................... 17LYRICA CR...............................17LYUMJEV KWIKPEN................24LYUMJEV VIAL.........................24MAKENA...................................29MAVENCLAD............................17MAVYRET.................................13MAXALT....................................11MAXALT-MLT........................... 11MAYZENT.................................17meclizine hcl............................. 10medroxyprogesterone acetate.. 29meloxicam...................................7memantine hcl.............................9mesalamine...............................31mesalamine er oral capsule 0.375 gm................................... 31metaxalone............................... 35metformin hcl er........................ 19metformin hcl er (mod)..............19metformin hcl er (osm).............. 20metformin hcl ir ......................... 20methimazole..............................30methocarbamol......................... 36methotrexate............................. 30methotrexate sodium................ 30methylphenidate hcl.................. 16methylphenidate hcl er..............16methylphenidate hcl er (la)........16methylphenidate hcl er (xr)....... 16

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methylprednisolone...................28metoclopramide hcl...................10metoprolol succinate er.............15metoprolol tartrate.....................15METROGEL..............................18metronidazole....................... 8, 18MICARDIS................................ 15MICARDIS HCT........................ 15MICRODOT TEST.................... 22minocycline hcl............................8MINOLIRA...................................8mirtazapine............................... 10MIRVASO................................. 18misoprostol................................26MITIGARE.................................10MOBIC........................................ 7modafinil ....................................36mometasone furoate........... 18, 33MONOVISC.............................. 32montelukast sodium.................. 35MORPHINE SULFATE............... 6morphine sulfate......................... 6morphine sulfate (concentrate)... 6morphine sulfate (pf)................... 6morphine sulfate er..................... 6MOTEGRITY.............................27MOTOFEN................................ 27MOVANTIK............................... 27MOVIPREP............................... 27MOXEZA...................................32moxifloxacin hcl.........................32moxifloxacin hcl (2x day)...........32MS CONTIN................................6MULPLETA............................... 13MULTAQ................................... 15MULTIPRO............................... 25mupirocin.................................... 8MVASI.......................................11MYCAPSSA.............................. 29mycophenolate mofetil .............. 30mycophenolate sodium............. 30MYRBETRIQ.............................27nabumetone................................ 7nadolol...................................... 15NALFON..................................... 7naltrexone hcl..............................7NAMZARIC................................. 9NAPRELAN.................................7naproxen..................................... 7naproxen sodium........................ 7NARCAN.....................................7NASCOBAL.............................. 25NASONEX................................ 33

NATESTO................................. 28NATROBA.................................12NAYZILAM.................................. 9neomycin-polymyxin-dexameth 33neomycin-polymyxin-hc............ 33NEONATAL + DHA...................25NEONATAL COMPLETE..........25NEONATAL FE......................... 25NESINA.....................................20NESTABS ONE........................ 25NEULASTA............................... 13NEULASTA ONPRO.................13NEUPOGEN............................. 13NEUPRO...................................12NEURONTIN...............................9NEVANAC.................................32NEXIUM.................................... 26NEXLETOL............................... 15NEXLIZET.................................15NIASPAN.................................. 15NICADAN..................................25NICAZEL...................................25NICAZEL FORTE......................25NICOMIDE................................ 25nifedipine er.............................. 15nifedipine er osmotic release.... 15nitrofurantoin macrocrystal..........8nitrofurantoin monohydrate macrocrystals..............................8nitroglycerin...............................15NITROSTAT..............................15NITYR....................................... 27NIVESTYM................................13NOCDURNA............................. 29NORDITROPIN FLEXPRO....... 29norethindrone acetate............... 29NORGESIC FORTE..................36NORITATE................................18nortriptyline hcl..........................10NORVASC................................ 15NOURIANZ............................... 12NOVOEIGHT............................ 13NOVOLIN 70/30 FLEXPEN...... 24NOVOLIN 70/30 FLEXPEN RELION.....................................24NOVOLIN 70/30 RELION......... 24NOVOLIN 70/30 VIAL............... 24NOVOLIN N FLEXPEN.............24NOVOLIN N FLEXPEN RELION.....................................24NOVOLIN N RELION................24NOVOLIN N VIAL..................... 24NOVOLIN R FLEXPEN.............24

NOVOLIN R FLEXPEN RELION.....................................24NOVOLIN R RELION................24NOVOLIN R VIAL..................... 24NOVOLOG 70/30 FLEXPEN RELION.....................................24NOVOLOG FLEXPEN.............. 24NOVOLOG FLEXPEN RELION.....................................24NOVOLOG MIX 70/30 FLEXPEN..................................24NOVOLOG MIX 70/30 RELION.....................................24NOVOLOG MIX 70/30 VIAL......24NOVOLOG PENFILL................ 24NOVOLOG RELION................. 24NOVOLOG U-100 VIAL............ 24np thyroid.................................. 30NPLATE.................................... 13NUBEQA...................................11NUCALA................................... 33NUCYNTA...................................6NUCYNTA ER.............................6NULYTELY LEMON-LIME........ 27NURTEC................................... 11NUTROPIN AQ NUSPIN 10..... 29NUTROPIN AQ NUSPIN 20..... 29NUTROPIN AQ NUSPIN 5....... 29NUVESSA...................................8NUVIGIL....................................36NUWIQ......................................13NUZYRA..................................... 8nystatin......................................10NYVEPRIA................................14ODEFSEY.................................13ODOMZO..................................11OFEV........................................ 35ofloxacin..............................32, 33OGIVRI..................................... 11olanzapine.................................12olmesartan medoxomil..............15olmesartan medoxomil-hctz...... 15olmesartan-amlodipine-hctz......15olopatadine hcl..........................32OLUMIANT............................... 30OMECLAMOX-PAK.................. 27omega-3-acid ethyl esters.........15omeprazole............................... 26omeprazole-sodium bicarbonate............................... 26OMNARIS................................. 33OMNITROPE............................ 29ondansetron hcl........................ 10

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ondansetron odt........................ 10ONE DROP BLOOD GLUCOSE MONITOR.............. 22ONE DROP TEST.....................22ONETOUCH ULTRA 2 KIT W/DEVICE................................ 22ONETOUCH ULTRA MINI KIT W/DEVICE................................ 22ONETOUCH ULTRA TEST STRIPS..................................... 22ONETOUCH VERIO FLEX SYSTEM................................... 22ONETOUCH VERIO IQ SYSTEM................................... 22ONETOUCH VERIO KIT W/DEVICE................................ 22ONETOUCH VERIO REFLECT..................................22ONETOUCH VERIO SYNC SYSTEM................................... 22ONEXTON................................ 18ONFI........................................... 9ONGENTYS..............................12ONGLYZA.................................20ONTRUZANT............................11ONZETRA XSAIL......................11OPSUMIT..................................35ORACEA...................................19ORENCIA..................................30ORENCIA CLICKJECT............. 31ORENITRAM............................ 35ORFADIN..................................27ORGOVYX................................11ORIAHNN................................. 29ORILISSA................................. 29ORLADEYO.............................. 31ORPHENGESIC FORTE.......... 36ORTHOVISC.............................32ORTIKOS..................................31OSENI.......................................20OSMOLEX ER.......................... 12OSMOPREP............................. 27OSPHENA................................ 29OTEZLA.................................... 31OTREXUP.................................31OXBRYTA.................................32oxcarbazepine.............................9OXTELLAR XR........................... 9oxybutynin chloride................... 27oxybutynin chloride er............... 27oxycodone hcl............................. 6OXYCODONE HCL ER.............. 6oxycodone-acetaminophen.........6

OXYCONTIN...............................6OZEMPIC..................................20OZOBAX................................... 36PALFORZIA.............................. 32PANCREAZE............................ 27PANDEL....................................19pantoprazole sodium.................26PANZYGA.................................31paroxetine hcl............................10PAXIL........................................10PAXIL CR..................................10peg 3350-kcl-na bicarb-nacl......27penicillamine............................. 27penicillin v potassium.................. 8PENNSAID..................................7PENTASA................................. 31PERCOCET................................ 6PERFOROMIST........................35PERSERIS................................12PERTZYE................................. 27phenazopyridine hcl.................. 27PHESGO...................................11PHEXXI.....................................32pimecrolimus.............................19pioglitazone hcl......................... 20PLAQUENIL..............................12PLAVIX..................................... 12PLEGRIDY................................17PLEGRIDY STARTER PACK... 17PLENVU....................................27PNV TABS 20-1........................ 25POGO AUTOMATIC BLOOD GLUCOSE................................ 22POGO AUTOMATIC TEST CARTRIDGES.......................... 22polymyxin b-trimethoprim..........33PONVORY................................ 17PONVORY STARTER PACK... 17potassium chloride crys er........ 25potassium chloride er................25potassium citrate er...................25PRADAXA...................................8PRALUENT...............................15pramipexole dihydrochloride..... 12prasugrel hcl............................. 12pravastatin sodium....................15prazosin hcl...............................15PRECISION LINK..................... 22PRECISION PCX PLUS TEST. 22PRECISION QID MONITOR.....22PRECISION QID TEST.............22PRECISION SOF-TACT MONITOR................................. 22

PRECISION SOF-TACT TEST. 22PRECISION XTRA....................23PRECISION XTRA BLOOD GLUCOSE................................ 22PRECISION XTRA MONITOR..23PRED FORTE...........................32prednisolone acetate.................32prednisolone sodium phosphate................................. 28prednisone................................ 28pregabalin................................. 17PREGEN DHA.......................... 25PREGENNA..............................25PREMARIN............................... 29PREMPHASE........................... 29PREMPRO................................29PRENARA.................................25PRENATE................................. 25PRENATE DHA........................ 25PRENATE ELITE...................... 25PRENATE ENHANCE.............. 25PRENATE ESSENTIAL............ 25PRENATE MINI........................ 25PRENATE PIXIE.......................25PRENATE RESTORE...............25PRENATRIX............................. 25PRENATRYL............................ 25PRENATVITE COMPLETE.......25PREVACID................................26PREVACID SOLUTAB..............26PREZCOBIX............................. 13PRIMACARE.............................25PRINIVIL................................... 15PRISTIQ....................................10PROAIR DIGIHALER................35PROAIR HFA............................ 35PROAIR RESPICLICK..............35prochlorperazine maleate......... 10PROCRIT..................................14PROCTOFOAM HC.................. 31PRODIGY NO CODING BLOOD GLUC.......................... 23PROFOLA.................................25PROLENSA.............................. 32PROLIA.....................................31promethazine hcl.......................33promethazine-dm...................... 33PROMETRIUM......................... 29PROPECIA............................... 19propranolol hcl.......................... 15propranolol hcl er...................... 15PROTONIX............................... 26PROVENTIL HFA..................... 35

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PROVIGIL................................. 36PROZAC................................... 10pseudoephedrine-bromphen-dm............................................. 33PSORCON................................19PULMICORT FLEXHALER.......35PULMICORT SUSPENSION.... 35PYLERA....................................27QBREXZA.................................19QDOLO....................................... 6QELBREE................................. 16QNASL......................................33QNASL CHILDRENS................ 33QTERN..................................... 20QUDEXY XR...............................9QUESTRAN.............................. 15QUESTRAN LIGHT.................. 15quetiapine fumarate.................. 12quetiapine fumarate er.............. 12QUFLORA FE........................... 25QVAR REDIHALER.................. 35RABEPRAZOLE SODIUM........ 26rabeprazole sodium.................. 26ramipril ...................................... 15RANEXA................................... 15ranolazine er............................. 15RASUVO...................................31RAYALDEE...............................31RAYOS..................................... 28REBIF....................................... 17REBIF REBIDOSE....................17REBIF REBIDOSE TITRATION PACK.................... 17REBIF TITRATION PACK.........17RECOMBINATE........................14REDITREX................................31RELAFEN................................... 7RELAFEN DS............................. 7RELION BLOOD GLUCOSE TEST.........................................23RELION PREMIER CLASSIC...23RELION PREMIER TEST......... 23RELISTOR................................ 27RELPAX....................................11RELTONE................................. 27REMEDIENT.............................25REMICADE............................... 31REMODULIN............................ 35RENAGEL.................................27RENFLEXIS.............................. 31REPATHA................................. 15REPATHA PUSHTRONEX SYSTEM................................... 16

REPATHA SURECLICK........... 16RESTASIS................................ 33RESTASIS MULTIDOSE.......... 33RESTORIL................................ 36RETACRIT................................ 14RETEVMO................................ 11RETIN-A....................................19RETIN-A MICRO GEL 0.04 %, 0.1 %.........................................19RETIN-A MICRO PUMP........... 19REVLIMID................................. 11REXULTI...................................12REYVOW.................................. 11RHOFADE................................ 19RHOPRESSA........................... 32RIABNI...................................... 11RIGHTEST GT333 BLOOD GLUCOSE................................ 23RINVOQ....................................31RISPERDAL..............................12risperidone................................ 12RITALIN.................................... 16RITALIN LA...............................16rizatriptan benzoate.................. 11ROCKLATAN............................ 32ropinirole hcl..............................12rosuvastatin calcium................. 16ROSZET................................... 16ROXICODONE........................... 6ROZLYTREK............................ 11RUBRACA................................ 11RUCONEST..............................31RUKOBIA..................................13RUXIENCE............................... 11RYBELSUS...............................20RYTARY................................... 12SABRIL....................................... 9SAIZEN..................................... 29SAIZENPREP........................... 29SANCUSO................................ 10SANDOSTATIN........................ 29SAPHRIS.................................. 12scopolamine..............................10SECUADO................................ 12SEGLUROMET.........................20SEMGLEE.................................24SEMGLEE (YFGN)................... 24SENSIPAR................................31SEREVENT DISKUS................ 35SERNIVO..................................19SEROQUEL.............................. 12SEROQUEL XR........................ 12sertraline hcl..............................10

SEVENFACT............................ 14SEYSARA................................... 8SIGNIFOR.................................29sildenafil citrate................... 27, 35SILENOR.................................. 36SILVADENE................................8SIMBRINZA.............................. 32SIMPONI...................................31SIMPONI ARIA......................... 31simvastatin................................ 16SINGULAIR...............................35SKELAXIN................................ 36SKYRIZI.................................... 31SKYRIZI (150 MG DOSE).........31SKYRIZI PEN............................31sodium fluoride..........................25SOFOSBUVIR-VELPATASVIR.13solifenacin succinate.................27SOLIQUA.................................. 20SOLIRIS....................................14SOLODYN.................................. 8SOLOSEC...................................8SOMA....................................... 36SOMATULINE DEPOT............. 29SOOLANTRA............................19SORILUX.................................. 19sotalol hcl.................................. 16SPIRIVA HANDIHALER............35SPIRIVA RESPIMAT................ 35spironolactone...........................16SPRIX......................................... 7SPRYCEL................................. 11STEGLATRO............................ 20STEGLUJAN.............................20STELARA..................................31STENDRA.................................28STIOLTO RESPIMAT............... 35STRATTERA.............................16STRENSIQ................................27STRIVERDI RESPIMAT........... 35SUBOXONE................................7SUBSYS..................................... 6sucralfate.................................. 26sulfamethoxazole-trimethoprim...8sulfasalazine............................. 31sumatriptan succinate............... 11SUNOSI.................................... 36SUPARTZ FX............................32SUPPRELIN LA........................ 29SUPREP BOWEL PREP KIT....27SURESTEP PRO HIGH GLUCOSE................................ 23

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SURESTEP PRO LOW GLUCOSE................................ 23SURESTEP PRO NORMAL GLUCOSE................................ 23SUTAB...................................... 27SYMBICORT.............................35SYMFI....................................... 13SYMFI LO................................. 13SYMJEPI...................................35SYMLINPEN 120...................... 20SYMLINPEN 60........................ 20SYMPAZAN................................ 9SYMPROIC...............................27SYNJARDY...............................20SYNJARDY XR.........................20SYNTHROID.............................30SYNVISC.................................. 32SYNVISC ONE......................... 32TABRECTA...............................11TACLONEX...............................19tacrolimus............................19, 31tadalafil ......................................28TAGRISSO............................... 11TAKHZYRO.............................. 31TALICIA.................................... 27TALTZ....................................... 31TAMIFLU...................................13tamoxifen citrate........................11tamsulosin hcl........................... 28TARGADOX................................8TARGRETIN............................. 11TAZAROTENE..........................19TAZORAC.................................19TAZVERIK................................ 11TECFIDERA..............................17TEGRETOL.................................9TEGRETOL-XR.......................... 9TEGSEDI.................................. 17TEKTURNA...............................16TEKTURNA HCT...................... 16telmisartan................................ 16telmisartan-hctz.........................16temazepam............................... 36TEMIXYS.................................. 13TENORMIN...............................16TEPMETKO.............................. 11terazosin hcl..............................28terbinafine hcl............................10terconazole............................... 10TERIPARATIDE (RECOMBINANT)..................... 31TESTIM.....................................28TESTOPEL............................... 28

testosterone.............................. 28testosterone cypionate..............28THYQUIDITY............................ 30TIGLUTIK..................................17TIKOSYN.................................. 16timolol maleate..........................32timolol maleate pf......................32TIMOPTIC.................................32TIMOPTIC OCUDOSE..............33TIMOPTIC-XE...........................33TIROSINT................................. 30TIROSINT-SOL.........................30TIVICAY.................................... 13tizanidine hcl............................. 36TOBI NEBULIZER.................... 35TOBI PODHALER.....................35TOBRADEX.............................. 33TOBRADEX ST.........................33TOBRAMYCIN.......................... 35tobramycin-dexamethasone......33TOLSURA................................. 10tolterodine tartrate er.................28TOPAMAX.................................. 9TOPAMAX SPRINKLE................9TOPICORT SPRAY.................. 19topiramate................................... 9TOPROL XL..............................16torsemide.................................. 16TOSYMRA................................ 11TOUJEO MAX SOLOSTAR...... 24TOUJEO SOLOSTAR...............24TOVIAZ..................................... 28TRACLEER...............................35TRADJENTA.............................20TRAMADOL HCL ER..................6tramadol hcl ir ............................. 6TRAVATAN Z............................33TRAZIMERA............................. 12trazodone hcl............................ 10TREANDA.................................12TRELEGY ELLIPTA..................35TREMFYA.................................31TRESIBA...................................24TRESIBA FLEXTOUCH............24tretinoin..................................... 19TREXALL.................................. 31TREXIMET................................11TREZIX....................................... 6triamcinolone acetonide............ 19triamterene-hctz........................ 16TRIANEX.................................. 19triazolam................................... 13TRIBENZOR............................. 16

TRICOR.................................... 16TRIJARDY XR.......................... 20TRIKAFTA.................................35TRILEPTAL.................................9TRILURON................................32TRINAZ..................................... 25TRINTELLIX..............................10TRIPTODUR............................. 29TRISTART DHA........................26TRISTART FREE......................26TRISTART ONE........................26TRIUMEQ................................. 13TRIVISC....................................32TROKENDI XR........................... 9TRONVITE................................26TRUE FOCUS BLOOD GLUCOSE METER...................23TRUE METRIX BLOOD GLUCOSE TEST...................... 23TRUE METRIX LEVEL 1.......... 23TRUE METRIX LEVEL 2.......... 23TRUE METRIX LEVEL 3.......... 23TRUE METRIX METER............ 23TRUE METRIX PRO BLOOD GLUCOSE................................ 23TRUETRACK TEST..................23TRULANCE...............................27TRULICITY............................... 20TRUVADA.................................13TRUXIMA..................................12TUDORZA PRESSAIR............. 35TYMLOS................................... 31UBRELVY................................. 11UCERIS.................................... 31UDENYCA................................ 14UKONIQ....................................12ULTOMIRIS.............................. 14ULTRACET................................. 7ULTRAM..................................... 7ULTRAVATE.............................19UNISTRIP CONTROL...............23URSODIOL............................... 27VAGIFEM..................................29valacyclovir hcl..........................13VALIUM.....................................13valsartan................................... 16valsartan-hydrochlorothiazide... 16VALTOCO...................................9VALTREX..................................13VANADOM................................36VARUBI (180 MG DOSE)......... 10VASCEPA................................. 16VECTICAL................................ 19

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VELCADE................................. 12VELPHORO.............................. 28VELTASSA............................... 26VELTIN..................................... 19VEMLIDY.................................. 13VENEXA................................... 26VENEXA FE..............................26venlafaxine hcl.......................... 10venlafaxine hcl er...................... 10VENTOLIN HFA........................35VENTRIXYL.............................. 26VENTRIXYL FE........................ 26verapamil hcl er.........................16VERDESO................................ 19VERQUVO................................ 16VESICARE................................28VESICARE LS.......................... 28VIAGRA.................................... 28VIBERZI.................................... 27VICTOZA.................................. 20VIGAMOX................................. 32VIIBRYD....................................10VIIBRYD STARTER PACK....... 10VILTEPSO................................ 32VIMOVO......................................7VIMPAT.......................................9VIOKACE.................................. 27VISCO-3....................................32VITAFOL FE+........................... 26VITAFOL-NANO....................... 26VITAFOL-OB+DHA...................26vitamin d (ergocalciferol)...........26VITASURE................................ 26VITATHELY WITH GINGER..... 26VITRAKVI..................................12VITRAMYN............................... 26VITRANOL FE.......................... 26VITREXATE.............................. 26VITREXATE FE........................ 26VITREXYL.................................26VITREXYL + IRON....................26VIVAGUARD INO CONTROL SOLUTION................................23VIVAGUARD INO GLUCOSE METER..................................... 23VIVAGUARD INO TEST STRIPS..................................... 23VIVELLE-DOT...........................29VOCABRIA............................... 13VOGELXO................................ 28VOGELXO PUMP..................... 28VOSEVI.....................................13VRAYLAR................................. 12

VUMERITY............................... 17VYLEESI................................... 17VYONDYS 53........................... 27VYTORIN.................................. 16VYVANSE................................. 16VYZULTA..................................33WAKIX...................................... 36warfarin sodium...........................8WELCHOL................................ 16WELLBUTRIN SR.....................10WELLBUTRIN XL..................... 10WESTGEL DHA........................26WILATE.....................................14WINLEVI................................... 19wixela inhub.............................. 35WYNZORA................................19XALATAN..................................33XANAX......................................13XANAX XR................................13XARELTO................................... 8XARELTO STARTER PACK.......8XCOPRI...................................... 9XELJANZ.................................. 31XELJANZ XR............................ 31XEMBIFY.................................. 31XENLETA....................................8XEPI............................................8XGEVA......................................31XHANCE................................... 33XIGDUO XR..............................20XIIDRA...................................... 33XIMINO....................................... 8XOFLUZA (40 MG DOSE)........ 13XOFLUZA (80 MG DOSE)........ 13XOLAIR.....................................33XOPENEX HFA........................ 35XTAMPZA ER............................. 7XTANDI.....................................12XVITE........................................26XYNTHA................................... 14XYNTHA SOLOFUSE...............14XYOSTED.................................28XYREM..................................... 36XYWAV..................................... 36YONSA..................................... 12YOSPRALA...............................12YUPELRI...................................35ZALVIT......................................26ZANAFLEX............................... 36ZARXIO.....................................14ZEGERID.................................. 26ZEJULA.....................................12ZELNORM................................ 27

ZEMBRACE SYMTOUCH........ 11ZENPEP....................................27ZEPOSIA.................................. 17ZEPOSIA 7-DAY STARTER PACK........................................ 17ZEPOSIA STARTER KIT.......... 17ZERVIATE................................ 32ZESTRIL................................... 16ZETIA........................................16ZETONNA.................................33ZIANA....................................... 19ZIEXTENZO..............................14ZILXI......................................... 19ZIOPTAN.................................. 33ziprasidone hcl.......................... 12ZIPSOR.......................................7ZIRABEV...................................12ZOCOR..................................... 16ZOLOFT....................................10zolpidem tartrate....................... 36zolpidem tartrate er................... 36ZOMACTON............................. 29ZOMACTON (FOR ZOMA-JET 10).............................................29ZOMIG...................................... 11ZONEGRAN................................9zonisamide..................................9ZORVOLEX................................ 7ZOVIRAX.................................. 13ZTLIDO....................................... 7ZUBSOLV................................... 7ZYCLARA................................. 19ZYCLARA PUMP...................... 19ZYLET.......................................33ZYPITAMAG............................. 16ZYPREXA................................. 12ZYTIGA..................................... 12ZYVANA....................................26

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