8 commercial drug formulary - apex health solutions · prescription drug benefits the following is...

2018 Commercial Drug Formulary

Effective 8/1/18

PRESCRIPTION DRUG BENEFITS

The following is a comprehensive listing by drug class of formulary

medications approved under the Apex Prescription Drug Benefit.

Brand name drugs are capitalized and generic drugs are listed in

lower case. Apex tiered prescription drug benefits are generic-

based. Prescription drug benefits vary, but in most cases, brand

name medications that have a generic equivalent require the

patient to pay a Tier 3 copay or the difference in cost between the

brand and generic medication. Some benefits may exclude certain

drugs on this list. Refer to your Prescription Drug Benefit Rider or

plan documents for more coverage information.

ABOUT TIERS

Apex members pay a Tier 1 copay for most generic drugs and

selected over-the-counter drugs. Members pay a Tier 2 copay for

higher cost generic drugs and preferred brand name drugs.

Members pay a Tier 3 copay for non-preferred brand name drugs.

Note: Some benefits may require a deductible be met before copays

apply and/or have a Tier 4 copay level. Refer to your plan

documents for further information.

OVER-THE-COUNTER (OTC) DRUG COVERAGE

Apex’s Prescription Drug Formulary includes selected OTC drugs

that are covered when they are presented to a pharmacy with a

written prescription.

USING YOUR APEX ID CARD

It is important to show your Apex ID card when filling prescriptions.

By showing your Apex ID card, safety checks are performed such

as drug-drug interactions, therapeutic duplications and dose

checks, even if you use multiple pharmacies including mail order.

MEDIMPACT

MedImpact is Apex’s Pharmacy Benefit Manager and is responsible

for processing pharmacy claims for Apex members. MedImpact also

handles pharmacy benefit customer service and utilization

management requests on Apex’s behalf. To reach MedImpact,

members should call the Apex customer service number on the

back of their ID card.

PHARMACY UTILIZATION PROGRAMS

Apex’s Prescription Drug Benefit incorporates utilization

management programs (prior authorization, step therapy and

quantity limits). Drugs requiring utilization management are

indicated in the “Requirements/Limits” column of the formulary

document and will be indicated with PA, QL or ST. If you are

prescribed one of these drugs, the prescriber may need to contact

MedImpact to provide supporting medical information.

PriorAuthorization = PA

Prior authorization requirements are placed on medications when

they have limited conditions for which they are prescribed, special

monitoring or dispensing requirement or an extremely high cost.

Guidelines for approving coverage for prior authorization drugs

are developed and approved by a panel of practicing physicians

and pharmacists.

Step Therapy = ST

Step Therapy is the practice of initiating drug therapy for a

medical condition with the most cost-effective and safest drug and

progressing to other more costly or risky therapy, only if

necessary (i.e., you must try drug “A” before you can get drug

“B”). The goal is to control costs and minimize risks. Step therapy

is an automated process. If you present a prescription for a “step

therapy” drug (i.e., “B”) to a pharmacy, an automated check of

your prescription history will occur. If the system finds that you

have received the qualifying drug(s) (i.e., “A”), your prescription

will be processed. If the system does not find that you received a

qualifying drug (i.e., “A”) in recent history, a prior authorization will

be necessary.

Quantity Limits= QL

When a drug has a Quantity Limit, the amount of medication per

prescription is limited to a specified amount per 30 days. These

limitations are usually in place due to safety issues or because the

use of a dose higher than what is recommended has been shown

to result in minimal additional benefit to the patient.

Specialty Drugs

Specialty drugs are designated as such because they may require

special handling, are expensive and/or special monitoring of the

patient receiving the drug may be appropriate. Distribution is often

restricted to a Specialty pharmacy. Some benefits may cover

these drugs at a higher copay level. Refer to your plan documents

for more information. These drugs are indicated by *May have

Specialty Costshare.

Employers and Members needing further information regarding the

Apex prescription drug benefit please refer to the number on the

back of your Member ID card or call Group Customer Service at

800-996-8701. Providers, please call Provider Services at

800-996-8401. TTY/TDD users should call 800-750-0750.

TO VIEW THE MOST RECENT FORMULARY, PLEASE VISIT WWW.APEX-HEALTHSOLUTIONS.COM.

Revised 09/17

8 D

http://www.summacare.com/

http://www.summacare.com/

Table of Contents

Analgesics.....................................................................................................................................................3Anesthetics................................................................................................................................................. 15Anti-Addiction/Substance Abuse Treatment Agents.................................................................................. 16Antianxiety Agents..................................................................................................................................... 17Antibacterials............................................................................................................................................. 19Anticancer Agents...................................................................................................................................... 29Anticholinergic Agents............................................................................................................................... 37Anticonvulsants..........................................................................................................................................38Antidementia Agents.................................................................................................................................. 45Antidepressants.......................................................................................................................................... 46Antidiabetic Agents.................................................................................................................................... 51Antifungals.................................................................................................................................................60Antigout Agents......................................................................................................................................... 63Antihistamines............................................................................................................................................63Anti-Infectives (Skin And Mucous Membrane)..........................................................................................67Antimigraine Agents...................................................................................................................................68Antimycobacterials.....................................................................................................................................70Antinausea Agents......................................................................................................................................70Antiparasite Agents.................................................................................................................................... 72Antiparkinsonian Agents............................................................................................................................74Antipsychotic Agents..................................................................................................................................76Antivirals (Systemic)...................................................................................................................................79Blood Products/Modifiers/Volume Expanders........................................................................................... 90Cardiovascular Agents............................................................................................................................... 94Central Nervous System Agents............................................................................................................... 113Contraceptives.......................................................................................................................................... 120Cough And Cold Products........................................................................................................................130Dental And Oral Agents........................................................................................................................... 131Dermatological Agents............................................................................................................................. 132Devices..................................................................................................................................................... 151Enzyme Replacement/Modifiers............................................................................................................... 151Eye, Ear, Nose, Throat Agents................................................................................................................. 153Gastrointestinal Agents............................................................................................................................ 162Genitourinary Agents............................................................................................................................... 170Heavy Metal Antagonists......................................................................................................................... 172Hormonal Agents, Stimulant/Replacement/Modifying.............................................................................173

1

Immunological Agents..............................................................................................................................184Inflammatory Bowel Disease Agents........................................................................................................ 192Metabolic Bone Disease Agents................................................................................................................193Miscellaneous Therapeutic Agents............................................................................................................195Ophthalmic Agents................................................................................................................................... 196Replacement Preparations........................................................................................................................ 199Respiratory Tract Agents......................................................................................................................... 201Skeletal Muscle Relaxants........................................................................................................................ 208Sleep Disorder Agents.............................................................................................................................. 209Vasodilating Agents..................................................................................................................................210Vitamins And Minerals.............................................................................................................................211

2

Drug Name Drug Tier Requirements/Limits

AnalgesicsAnalgesics, MiscellaneousABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA; QL (120 per 30 days)

acetaminophen-caff-dihydrocod oral capsule 320.5-30-16 mg

(Trezix) 2 QL (300 per 30 days)

acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg

(Panlor(acetam-caff-dihydrocod))

2 QL (300 per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5 ml

1 QL (2700 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg



(Tylenol-Codeine #3) 1 QL (360 per 30 days)


(Tylenol-Codeine #4) 1 QL (180 per 30 days)

ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


alagesic lq oral solution 50-325-40 mg/15 ml

1

ALLZITAL ORAL TABLET 25-325 MG


ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG, 30 MG, 60 MG

3

aspirin-caffeine-dihydrocodein oral capsule 356.4-30-16 mg


AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 120 MG, 30 MG, 45 MG, 60 MG, 75 MG, 90 MG


BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

3 ST; QL (60 per 30 days)

belladonna alkaloids-opium rectal suppository 16.2-60 mg

2

belladonna-opium rectal suppository16.2-30 mg

2

BUPAP ORAL TABLET 50-300 MG 3 QL (180 per 30 days)

3


buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour

(Butrans) 2 QL (4 per 28 days)

butalbital compound w/codeine oral capsule 30-50-325-40 mg

1

butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

1

butalbital-acetaminophen oral tablet 50-300 mg

(Bupap) 1 QL (180 per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg

(Tencon) 1

butalbital-acetaminophen-caff oral capsule 50-300-40 mg

(Fioricet) 2

butalbital-acetaminophen-caff oral capsule 50-325-40 mg

(Capacet) 2

butalbital-acetaminophen-caff oral tablet50-325-40 mg

(Esgic) 1

butalbital-aspirin-caffeine oral capsule50-325-40 mg

(Fiorinal) 1

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

1

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml

1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR


capacet oral capsule 50-325-40 mg 2

CAPITAL WITH CODEINE ORAL SUSPENSION 120-12 MG/5 ML

3 QL (2700 per 30 days)

codeine sulfate oral solution 15 mg/2.5 ml (2.5 ml)

3

CODEINE SULFATE ORAL SOLUTION 30 MG/5 ML

3

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

1

CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 17-83 300 MG


CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 25-75 100 MG, 200 MG


4


DEMEROL (PF) INJECTION SOLUTION 100 MG/ML

3

DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 25 MG/ML, 50 MG/ML

3

DEMEROL INJECTION SOLUTION 100 MG/ML

3

DEMEROL ORAL TABLET 100 MG, 50 MG


DILAUDID ORAL LIQUID 1 MG/ML

3

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG

3

DISKETS ORAL TABLET,SOLUBLE 40 MG


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

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

DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR


EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG


EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG


endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


endodan oral tablet 4.8355-325 mg 1 QL (360 per 30 days)

ESGIC ORAL CAPSULE 50-325-40 MG

3

ESGIC ORAL TABLET 50-325-40 MG 3

EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG, 32 MG, 8 MG


fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

(Actiq) 1 PA; QL (120 per 30 days)

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

(Duragesic) 1 QL (10 per 30 days)

5


fentanyl transdermal patch 72 hour 25 mcg/hr

(Duragesic) 2 QL (10 per 30 days)

fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour


FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


fioricet oral capsule 50-300-40 mg 3

FIORICET WITH CODEINE ORAL CAPSULE 50-300-40-30 MG

3

FIORINAL ORAL CAPSULE 50-325-40 MG

3

FIORINAL-CODEINE #3 ORAL CAPSULE 30-50-325-40 MG

3

HYCET ORAL SOLUTION 7.5-325 MG/15 ML

3 QL (2700 per 30 days)

hydrocodone-acetaminophen oral solution2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)

1 QL (2700 per 30 days)

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml

(Hycet) 1 QL (2700 per 30 days)

hydrocodone-acetaminophen oral tablet10-300 mg

(Vicodin HP) 2 QL (390 per 30 days)


(Lorcet HD) 1 QL (360 per 30 days)

hydrocodone-acetaminophen oral tablet2.5-325 mg

(Verdrocet) 1 QL (360 per 30 days)


(Vicodin) 2 QL (390 per 30 days)


(Lorcet (hydrocodone)) 1 QL (360 per 30 days)


(Vicodin ES) 2 QL (390 per 30 days)


(Lorcet Plus) 1 QL (360 per 30 days)

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

(Ibudone) 2

hydrocodone-ibuprofen oral tablet 2.5-200 mg

2

hydrocodone-ibuprofen oral tablet 7.5-200 mg

1

hydromorphone oral liquid 1 mg/ml (Dilaudid) 1

6


hydromorphone oral tablet 2 mg, 4 mg, 8 mg

(Dilaudid) 1

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg

(Exalgo ER) 2 QL (30 per 30 days)

hydromorphone oral tablet extended release 24 hr 32 mg

(Exalgo ER) 2 QL (60 per 30 days)

hydromorphone rectal suppository 3 mg 1

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


IBUDONE ORAL TABLET 10-200 MG, 5-200 MG

3

ibuprofen-oxycodone oral tablet 400-5 mg

1

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG


LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY


levorphanol tartrate oral tablet 2 mg 1

lorcet (hydrocodone) oral tablet 5-325 mg


lorcet hd oral tablet 10-325 mg 2 QL (360 per 30 days)

lorcet plus oral tablet 7.5-325 mg 2 QL (360 per 30 days)

LORTAB 10-325 ORAL TABLET 10-325 MG


LORTAB 5-325 ORAL TABLET 5-325 MG


LORTAB 7.5-325 ORAL TABLET 7.5-325 MG


LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML

3 QL (2025 per 30 days)

margesic oral capsule 50-325-40 mg 2

marten-tab oral tablet 50-325 mg 1

meperidine (pf) injection solution 100 mg/ml, 50 mg/ml

(Demerol (PF)) 1

meperidine injection cartridge 10 mg/ml 1

meperidine oral solution 50 mg/5 ml 1 QL (900 per 30 days)

7


meperidine oral tablet 100 mg (Demerol) 1 QL (180 per 30 days)

meperidine oral tablet 50 mg 1 QL (180 per 30 days)

methadone oral concentrate 10 mg/ml (Methadone Intensol) 1 QL (120 per 30 days)

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

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

methadone oral tablet 10 mg (Dolophine) 1 QL (120 per 30 days)

methadone oral tablet 5 mg (Dolophine) 1 QL (240 per 30 days)

methadone oral tablet,soluble 40 mg (Diskets) 1 QL (30 per 30 days)

METHADOSE ORAL CONCENTRATE 10 MG/ML


methadose oral tablet,soluble 40 mg 1 QL (30 per 30 days)

MORPHABOND ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 100 MG, 15 MG, 30 MG, 60 MG


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

1

morphine intravenous cartridge 15 mg/ml 1

morphine oral capsule, er multiphase 24 hr 120 mg, 45 mg, 75 mg, 90 mg


morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg


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

(Kadian) 2 QL (60 per 30 days)

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

1

MORPHINE ORAL TABLET 15 MG, 30 MG

2

morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

(MS Contin) 1 QL (90 per 30 days)

morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

1

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG


nalocet oral tablet 2.5-300 mg 1 QL (360 per 30 days)

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG


8


NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG


OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG


OPANA ORAL TABLET 10 MG, 5 MG


OXAYDO ORAL TABLET, ORAL ONLY 5 MG, 7.5 MG

3

OXECTA ORAL TABLET, ORAL ONLY 5 MG, 7.5 MG

2

oxycodone oral capsule 5 mg 1

oxycodone oral concentrate 20 mg/ml 2

oxycodone oral solution 5 mg/5 ml 1

oxycodone oral tablet 10 mg, 20 mg 1

oxycodone oral tablet 15 mg, 30 mg, 5 mg

(Roxicodone) 1

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg

(OxyContin) 2 QL (60 per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg

(OxyContin) 2 QL (120 per 30 days)

oxycodone-acetaminophen oral solution5-325 mg/5 ml

1 QL (1800 per 30 days)

oxycodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

(Primlev) 1 QL (360 per 30 days)

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

(Endocet) 1 QL (360 per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


oxymorphone oral tablet 10 mg, 5 mg (Opana) 1 QL (120 per 30 days)

9


oxymorphone oral tablet extended release 12 hr 10 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg


oxymorphone oral tablet extended release 12 hr 15 mg


panlor(acetam-caff-dihydrocod) oral tablet 325-30-16 mg


pentazocine-naloxone oral tablet 50-0.5 mg

1

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG


PERCODAN ORAL TABLET 4.8355-325 MG


phrenilin forte(with caffeine) oral capsule 50-300-40 mg

2

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG


reprexain oral tablet 10-200 mg, 2.5-200 mg, 5-200 mg

2

roxicet oral solution 5-325 mg/5 ml 1 QL (1800 per 30 days)

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG

3

ROXYBOND ORAL TABLET, ORAL ONLY 15 MG, 30 MG, 5 MG

3

SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML

3

SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 1,600 MCG (800 MCG/SPRAY X 2), 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY


SYNALGOS-DC ORAL CAPSULE 356.4-30-16 MG


tencon oral tablet 50-325 mg 1

tramadol oral capsule,er biphase 24 hr 17-83 300 mg

(ConZip) 2 ST; QL (30 per 30 days)

10


tramadol oral capsule,er biphase 24 hr 25-75 100 mg, 200 mg

(ConZip) 2 ST; QL (30 per 30 days)

tramadol oral capsule,er biphase 24 hr 25-75 150 mg


tramadol oral tablet 50 mg (Ultram) 1

tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg

2

tramadol oral tablet, er multiphase 24 hr100 mg, 200 mg, 300 mg

2

tramadol-acetaminophen oral tablet 37.5-325 mg

(Ultracet) 1

TREZIX ORAL CAPSULE 320.5-30-16 MG


TYLENOL-CODEINE #3 ORAL TABLET 300-30 MG


TYLENOL-CODEINE #4 ORAL TABLET 300-60 MG


ULTRACET ORAL TABLET 37.5-325 MG

3

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 300 MG

3

ULTRAM ORAL TABLET 50 MG 3

VANATOL LQ ORAL SOLUTION 50-325-40 MG/15 ML

3

VERDROCET ORAL TABLET 2.5-325 MG


vicodin es oral tablet 7.5-300 mg 2 QL (390 per 30 days)

vicodin hp oral tablet 10-300 mg 2 QL (390 per 30 days)

vicodin oral tablet 5-300 mg 2 QL (390 per 30 days)

VICOPROFEN ORAL TABLET 7.5-200 MG

3

XARTEMIS XR ORAL TAB,ORAL ONLY,IR - ER, BIPHASE 7.5-325 MG


XODOL 10/300 ORAL TABLET 10-300 MG


XODOL 5/300 ORAL TABLET 5-300 MG


XODOL 7.5/300 ORAL TABLET 7.5-300 MG


11


XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG


XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG


XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG


xylon 10 oral tablet 10-200 mg 2

ZAMICET ORAL SOLUTION 10-325 MG/15 ML

3 QL (2700 per 30 days)

zebutal oral capsule 50-325-40 mg 2

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG


Nonsteroidal Anti-Inflammatory AgentsANAPROX DS ORAL TABLET 550 MG

3

ANAPROX ORAL TABLET 275 MG 3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC 50-200 MG-MCG

3

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC 75-200 MG-MCG

3

aspirin oral tablet,delayed release (dr/ec)650 mg

1

CAMBIA ORAL POWDER IN PACKET 50 MG


CATAFLAM ORAL TABLET 50 MG 3

CELEBREX ORAL CAPSULE 100 MG, 50 MG


CELEBREX ORAL CAPSULE 200 MG, 400 MG


celecoxib oral capsule 100 mg, 50 mg (Celebrex) 2 PA; QL (60 per 30 days)

celecoxib oral capsule 200 mg, 400 mg (Celebrex) 2 PA; QL (30 per 30 days)

choline,magnesium salicylate oral liquid500 mg/5 ml

1

DAYPRO ORAL TABLET 600 MG 3

12


diclofenac potassium oral tablet 50 mg 1

diclofenac sodium oral tablet extended release 24 hr 100 mg

(Voltaren-XR) 1

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

1

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg

(Arthrotec 50) 2

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 75-200 mg-mcg

(Arthrotec 75) 2

diflunisal oral tablet 500 mg 2

DISALCID ORAL TABLET 500 MG, 750 MG

3

DUEXIS ORAL TABLET 800-26.6 MG


DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR 162.5 MG


EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG

3

etodolac oral capsule 200 mg, 300 mg 2

etodolac oral tablet 400 mg (Lodine) 2

etodolac oral tablet 500 mg 2

etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

2

FELDENE ORAL CAPSULE 10 MG, 20 MG

3

fenoprofen oral capsule 200 mg (Fenortho) 1

fenoprofen oral capsule 400 mg (Nalfon) 2

fenoprofen oral tablet 600 mg (ProFeno) 2

flurbiprofen oral tablet 100 mg, 50 mg 1

ibu oral tablet 400 mg, 600 mg, 800 mg 1

ibuprofen oral suspension 100 mg/5 ml (Child Ibuprofen) 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

(IBU) 1

INDOCIN ORAL SUSPENSION 25 MG/5 ML

3

INDOCIN RECTAL SUPPOSITORY 50 MG

3

indomethacin oral capsule 25 mg, 50 mg 1

13


indomethacin oral capsule, extended release 75 mg

2

ketoprofen oral capsule 25 mg, 50 mg, 75 mg

1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

2

ketorolac oral tablet 10 mg 1

LODINE ORAL TABLET 400 MG 3

meclofenamate oral capsule 100 mg, 50 mg

2

mefenamic acid oral capsule 250 mg 2

meloxicam oral suspension 7.5 mg/5 ml 1

meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 1

MOBIC ORAL SUSPENSION 7.5 MG/5 ML

3

MOBIC ORAL TABLET 15 MG, 7.5 MG

3

nabumetone oral tablet 500 mg, 750 mg 1

NALFON ORAL CAPSULE 400 MG 3

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 375 MG, 500 MG, 750 MG

3

NAPROSYN ORAL SUSPENSION 125 MG/5 ML

3

NAPROSYN ORAL TABLET 250 MG, 375 MG, 500 MG

3

naproxen oral suspension 125 mg/5 ml (Naprosyn) 1

naproxen oral tablet 250 mg, 375 mg 1

naproxen oral tablet 500 mg (Naprosyn) 1

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

(EC-Naprosyn) 1

naproxen sodium oral tablet 275 mg 1

naproxen sodium oral tablet 550 mg (Anaprox DS) 1

naproxen sodium oral tablet, er multiphase 24 hr 375 mg, 500 mg

(Naprelan CR) 2

oxaprozin oral tablet 600 mg (Daypro) 2

piroxicam oral capsule 10 mg, 20 mg (Feldene) 2

PONSTEL ORAL CAPSULE 250 MG 3

PROFENO ORAL TABLET 600 MG 3

salsalate oral tablet 500 mg, 750 mg (Disalcid) 1

14


SPRIX NASAL SPRAY,NON-AEROSOL 15.75 MG/SPRAY


sulindac oral tablet 150 mg, 200 mg 1

TIVORBEX ORAL CAPSULE 20 MG, 40 MG


tolmetin oral capsule 400 mg 2

tolmetin oral tablet 200 mg 1

tolmetin oral tablet 600 mg 2

VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG


VIVLODEX ORAL CAPSULE 10 MG, 5 MG


VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

3

ZIPSOR ORAL CAPSULE 25 MG 3 ST; QL (120 per 30 days)

ZORVOLEX ORAL CAPSULE 18 MG, 35 MG


AnestheticsLocal Anestheticsana-lex kit rectal kit 2-2 % 3

ASTERO TOPICAL GEL WITH PUMP 4 %

3

CIDALEAZE TOPICAL CREAM 3 % 1

EMLA TOPICAL CREAM 2.5-2.5 % 3

glydo mucous membrane jelly in applicator 2 %

2

lidocaine hcl mucous membrane jelly 2 % 1

lidocaine hcl mucous membrane solution4 % (40 mg/ml)

1

lidocaine hcl topical cream 3 % (Lidopin) 1

lidocaine hcl-hydrocortison ac rectal kit3-1 % (7 gram)

2

lidocaine hcl-hydrocortison ac topical cream 3-0.5 %

1

lidocaine topical adhesive patch,medicated 5 %

(Lidoderm) 2

lidocaine topical ointment 5 % 2

15


lidocaine viscous mucous membrane solution 2 %

1

lidocaine-hydrocortisone-aloe rectal kit2-2 %

(Ana-Lex Kit) 1

lidocaine-hydrocortisone-aloe rectal kit3-2.5 % (7 gram)

2

lidocaine-prilocaine topical cream 2.5-2.5 %

1

lidocaine-prilocaine topical kit 2.5-2.5 % (AgonEaze) 1

lidocaine-tetracaine topical cream 7-7 % (Pliaglis) 2

LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED 5 %

3

LIDO-K TOPICAL LOTION 3 % 2

LIDOPIN TOPICAL CREAM 3.25 % 3

LIDORX TOPICAL GEL WITH PUMP 3 %

3

PLIAGLIS TOPICAL CREAM 7-7 % 3

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING 70-70 MG

3

Anti-Addiction/Substance Abuse Treatment AgentsAnti-Addiction/Substance Abuse Treatment Agentsacamprosate oral tablet,delayed release (dr/ec) 333 mg

2

ANTABUSE ORAL TABLET 250 MG, 500 MG

3

BUNAVAIL BUCCAL FILM 2.1-0.3 MG


BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG


buprenorphine hcl sublingual tablet 2 mg, 8 mg


buprenorphine-naloxone sublingual film8-2 mg

(Suboxone) 2 PA; QL (60 per 30 days)

buprenorphine-naloxone sublingual tablet2-0.5 mg, 8-2 mg


buproban oral tablet extended release 12 hr 150 mg


16


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

(Zyban) 1 QL (60 per 30 days)

CAMPRAL ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG

3

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

0 QL (336 per 365 days)

CHANTIX ORAL TABLET 0.5 MG 0 QL (672 per 365 days)

CHANTIX ORAL TABLET 1 MG 0 QL (336 per 365 days)

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

0 QL (106 per 365 days)

disulfiram oral tablet 250 mg, 500 mg (Antabuse) 1

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML, 2 MG/0.4 ML

3 QL (0.8 per 365 days)

naloxone injection solution 0.4 mg/ml 2

naloxone injection syringe 1 mg/ml 2

naltrexone oral tablet 50 mg 1

NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION


REVIA ORAL TABLET 50 MG 3

SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG


SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG


ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG


ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR 150 MG


Antianxiety AgentsBenzodiazepinesALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

2

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

(Xanax) 1

17


alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

(Xanax XR) 2

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg

2

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

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

1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

(Klonopin) 1

clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

2

clorazepate dipotassium oral tablet 15 mg, 3.75 mg

1

clorazepate dipotassium oral tablet 7.5 mg

(Tranxene T-Tab) 1

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

3 QL (1 per 1 day)

DIASTAT RECTAL KIT 2.5 MG 3 QL (1 per 1 day)

diazepam intensol oral concentrate 5 mg/ml

1

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

1

diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) 1

diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg

(Diastat AcuDial) 1 QL (1 per 1 day)

diazepam rectal kit 2.5 mg (Diastat) 1 QL (1 per 1 day)

DORAL ORAL TABLET 15 MG 3

estazolam oral tablet 1 mg, 2 mg 1

flurazepam oral capsule 15 mg, 30 mg 1

HALCION ORAL TABLET 0.25 MG 3

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

lorazepam oral concentrate 2 mg/ml (Lorazepam Intensol) 1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan) 1

meprobamate oral tablet 200 mg, 400 mg 2

midazolam oral syrup 2 mg/ml 1

ONFI ORAL SUSPENSION 2.5 MG/ML


18


ONFI ORAL TABLET 10 MG, 20 MG 3 PA; QL (60 per 30 days)

oxazepam oral capsule 10 mg, 15 mg, 30 mg

1

quazepam oral tablet 15 mg (Doral) 2

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG

3

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

(Restoril) 1

TRANXENE T-TAB ORAL TABLET 15 MG, 3.75 MG, 7.5 MG

3

triazolam oral tablet 0.125 mg 1

triazolam oral tablet 0.25 mg (Halcion) 1

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG

3

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

3

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 0.5 MG, 1 MG, 2 MG, 3 MG

3

AntibacterialsAminoglycosidesBETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML

3 *May have Specialty Costshare

neomycin oral tablet 500 mg 1

TOBI INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML


TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG


tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

(Tobi) 2 *May have Specialty Costshare

Antibacterials, MiscellaneousCLEOCIN HCL ORAL CAPSULE 150 MG, 300 MG, 75 MG

3

CLEOCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML

3

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

(Cleocin HCl) 1

clindamycin palmitate hcl oral recon soln75 mg/5 ml

(Cleocin Pediatric) 1

19


FLAGYL ER ORAL TABLET EXTENDED RELEASE 750 MG

3

FLAGYL ORAL CAPSULE 375 MG 3

FLAGYL ORAL TABLET 250 MG, 500 MG

3

FURADANTIN ORAL SUSPENSION 25 MG/5 ML

3

HIPREX ORAL TABLET 1 GRAM 3

hyolev mb oral tablet 81-10.8-40.8 mg 2

linezolid oral suspension for reconstitution 100 mg/5 ml

(Zyvox) 2 PA

linezolid oral tablet 600 mg (Zyvox) 2 PA

MACROBID ORAL CAPSULE 100 MG

3

MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG

3

methenamine hippurate oral tablet 1 gram

(Hiprex) 1

methenamine mandelate oral tablet 0.5 g, 1 gram

1

methen-sod phos-meth blue-hyos oral tablet 81.6-40.8-0.12 mg

(Urogesic-Blue) 3

metronidazole oral capsule 375 mg (Flagyl) 1

metronidazole oral tablet 250 mg, 500 mg (Flagyl) 1

MONUROL ORAL PACKET 3 GRAM

3

nitrofurantoin macrocrystal oral capsule100 mg, 25 mg, 50 mg

(Macrodantin) 1

nitrofurantoin monohyd/m-cryst oral capsule 100 mg

(Macrobid) 1

nitrofurantoin oral suspension 25 mg/5 ml (Furadantin) 2

PHOSPHASAL ORAL TABLET 81.6-10.8-40.8 MG

2

PRIMSOL ORAL SOLUTION 50 MG/5 ML

3

SIVEXTRO ORAL TABLET 200 MG 3 *May have Specialty Costshare

SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET 2 GRAM

3

trimethoprim oral tablet 100 mg 1

TRIMPEX ORAL SOLUTION 50 MG/5 ML

3

20


ur n-c oral tablet 81.6-10.8-40.8 mg 2

URELLE ORAL TABLET 81-10.8-40.8 MG

3

uretron d-s oral tablet 120-0.12-10.8 mg 2

URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG

3

urimar-t oral tablet 120-0.12-10.8 mg 2

URIN DS ORAL TABLET 81.6-10.8-40.8 MG

3

uro-458 oral tablet 81-10.8-40.8 mg 2

uro-blue oral tablet 81.6-40.8-0.12 mg 2

urogesic-blue oral tablet 81.6-40.8-0.12 mg

2

urolet mb oral tablet 81.6-40.8-0.12 mg 2

UROQID-ACID NO.2 ORAL TABLET 500-500 MG

2

UTIRA-C ORAL TABLET 81.6-10.8-40.8 MG

3

VANCOCIN ORAL CAPSULE 125 MG


VANCOCIN ORAL CAPSULE 250 MG


vancomycin oral capsule 125 mg (Vancocin) 2 QL (56 per 30 days)

vancomycin oral capsule 250 mg (Vancocin) 2 QL (112 per 30 days)

XIFAXAN ORAL TABLET 200 MG 3 QL (63 per 21 days)

XIFAXAN ORAL TABLET 550 MG 3 PA

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

3 PA

ZYVOX ORAL TABLET 600 MG 3 PACephalosporinsCEDAX ORAL CAPSULE 400 MG 3

CEDAX ORAL SUSPENSION FOR RECONSTITUTION 180 MG/5 ML

3

cefaclor oral capsule 250 mg, 500 mg 1

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

1

cefaclor oral tablet extended release 12 hr 500 mg

1

cefadroxil oral capsule 500 mg 1

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

1

21


cefadroxil oral tablet 1 gram 1

cefdinir oral capsule 300 mg 1

cefdinir oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml

1

cefditoren pivoxil oral tablet 200 mg 1

cefditoren pivoxil oral tablet 400 mg (Spectracef) 1

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

(Suprax) 1

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

1

cefpodoxime oral tablet 100 mg, 200 mg 1

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1

cefprozil oral tablet 250 mg, 500 mg 1

ceftibuten oral capsule 400 mg 2

ceftibuten oral suspension for reconstitution 180 mg/5 ml

2

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML

2

CEFTIN ORAL TABLET 250 MG, 500 MG

3

cefuroxime axetil oral tablet 250 mg, 500 mg

1

cephalexin oral capsule 250 mg, 500 mg, 750 mg

(Keflex) 1

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

1

cephalexin oral tablet 250 mg, 500 mg 1

DAXBIA ORAL CAPSULE 333 MG 3

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG

3

SPECTRACEF ORAL TABLET 400 MG

3

SUPRAX ORAL CAPSULE 400 MG 2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML

3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

2

22


SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG

2

Macrolidesazithromycin oral packet 1 gram (Zithromax) 1

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

(Zithromax) 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

(Zithromax) 1

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML

3

BIAXIN ORAL TABLET 250 MG, 500 MG

3

BIAXIN XL ORAL TABLET EXTENDED RELEASE 24 HR 500 MG

3

BIAXIN XL PAK ORAL TABLET EXTENDED RELEASE 24 HR 500 MG

3

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

1

clarithromycin oral tablet 250 mg, 500 mg

1

clarithromycin oral tablet extended release 24 hr 500 mg

2

DIFICID ORAL TABLET 200 MG 3 ST; QL (20 per 10 days)

e.e.s. 400 oral tablet 400 mg 1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML

1

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML

3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML

2

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

1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG

3

23


ery-tab oral tablet,delayed release (dr/ec) 500 mg

2

erythrocin (as stearate) oral tablet 250 mg

1

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

(E.E.S. Granules) 1

erythromycin ethylsuccinate oral tablet400 mg

(E.E.S. 400) 1

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

1

erythromycin oral tablet 250 mg, 500 mg 1

KETEK ORAL TABLET 300 MG, 400 MG

3

PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG

3

ZITHROMAX ORAL PACKET 1 GRAM

3

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML

3

ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG

3

ZITHROMAX TRI-PAK ORAL TABLET 500 MG

3

ZITHROMAX Z-PAK ORAL TABLET 250 MG

3

ZMAX ORAL SUSPENSION,EXTENDED REL RECON 2 GRAM/60 ML

2

Miscellaneous B-Lactam AntibioticsCAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

3 PA; *May have Specialty Costshare; QL (84 per 56 days)

Penicillinsamoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet, er multiphase 24 hr 775 mg

(Moxatag) 1

24


amoxicillin oral tablet,chewable 125 mg, 250 mg

1

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

1

amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml

(Augmentin) 1

amoxicillin-pot clavulanate oral suspension for reconstitution 600-42.9 mg/5 ml

(Augmentin ES-600) 1

amoxicillin-pot clavulanate oral tablet250-125 mg

1

amoxicillin-pot clavulanate oral tablet500-125 mg, 875-125 mg

(Augmentin) 1

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

(Augmentin XR) 2

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

1

ampicillin oral capsule 250 mg, 500 mg 1

ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION 600-42.9 MG/5 ML

3

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

2

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

3

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

3

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR 1,000-62.5 MG

3

dicloxacillin oral capsule 250 mg, 500 mg 1

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR 775 MG

3

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

1

25


penicillin v potassium oral tablet 250 mg, 500 mg

1

QuinolonesAVELOX ABC PACK ORAL TABLET 400 MG

3

AVELOX ORAL TABLET 400 MG 3

BAXDELA ORAL TABLET 450 MG 2

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML

3

CIPRO ORAL TABLET 250 MG, 500 MG

3

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 MG, 500 MG

3

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg

(Cipro XR) 1

ciprofloxacin hcl oral tablet 100 mg, 750 mg

1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

(Cipro) 1

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

(Cipro) 2

FACTIVE ORAL TABLET 320 MG 3

LEVAQUIN ORAL SOLUTION 250 MG/10 ML

3

LEVAQUIN ORAL TABLET 250 MG, 500 MG, 750 MG

3

levofloxacin oral solution 250 mg/10 ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

(Levaquin) 1

moxifloxacin oral tablet 400 mg (Avelox) 2

NOROXIN ORAL TABLET 400 MG 3

ofloxacin oral tablet 300 mg, 400 mg 1SulfonamidesBACTRIM DS ORAL TABLET 800-160 MG

3

BACTRIM ORAL TABLET 400-80 MG

3

sulfadiazine oral tablet 500 mg 1

26


sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

(Sulfatrim) 1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) 1

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

(Bactrim DS) 1

sulfatrim oral suspension 200-40 mg/5 ml 2TetracyclinesACTICLATE ORAL TABLET 150 MG, 75 MG

3

ADOXA ORAL CAPSULE 150 MG 3 PA

AVIDOXY ORAL TABLET 100 MG 3 PA

BENZODOX 30 KIT, CLEANSER ER AND TABLET 100-4.4 MG-%

3

BENZODOX 60 KIT, CLEANSER ER AND TABLET 100-4.4 MG-%

3

demeclocycline oral tablet 150 mg, 300 mg

1

DORYX MPC ORAL TABLET,DELAYED RELEASE (DR/EC) 120 MG

3 PA

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 150 MG, 200 MG, 50 MG

3 PA

doxycycline hyclate oral capsule 100 mg, 50 mg

(Morgidox) 1

doxycycline hyclate oral tablet 100 mg, 20 mg

1

doxycycline hyclate oral tablet 150 mg, 75 mg

(Acticlate) 1

doxycycline hyclate oral tablet 50 mg (Targadox) 1

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 75 mg

1

doxycycline hyclate oral tablet,delayed release (dr/ec) 150 mg

(Soloxide) 1

doxycycline hyclate oral tablet,delayed release (dr/ec) 200 mg, 50 mg

(Doryx) 2 PA

doxycycline monohydrate oral capsule100 mg, 50 mg

(Mondoxyne NL) 1

doxycycline monohydrate oral capsule150 mg

1

27


doxycycline monohydrate oral capsule,ir - delay rel,biphase 40 mg

(Oracea) 2

doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml

(Vibramycin) 1

doxycycline monohydrate oral tablet 100 mg

(Avidoxy) 1

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

1

MINOCIN KIT WITH WIPES COMBO PACK 100 MG, 50 MG

3

MINOCIN ORAL CAPSULE 100 MG, 50 MG, 75 MG

3

minocycline oral capsule 100 mg, 50 mg (Minocin) 1

minocycline oral capsule 75 mg 1

minocycline oral tablet 100 mg, 50 mg, 75 mg

2

minocycline oral tablet extended release 24 hr 115 mg, 65 mg

(Solodyn) 2 PA

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

(CoreMino) 2 PA

mondoxyne nl oral capsule 100 mg, 50 mg, 75 mg

3 PA

MONODOX ORAL CAPSULE 100 MG, 50 MG, 75 MG

3 PA

MORGIDOX ORAL CAPSULE 100 MG, 50 MG

3

okebo oral capsule 100 mg 1

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE 40 MG

3 PA

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

3 PA

soloxide oral tablet,delayed release (dr/ec) 150 mg

1

TARGADOX ORAL TABLET 50 MG 3 PA; QL (120 per 30 days)

tetracycline oral capsule 250 mg, 500 mg 1

VIBRAMYCIN ORAL CAPSULE 100 MG

3

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 25 MG/5 ML

3

28


VIBRAMYCIN ORAL SYRUP 50 MG/5 ML

2

XIMINO ORAL CAPSULE,EXTENDED RELEASE 24HR 135 MG, 45 MG, 90 MG

3 PA

Anticancer AgentsAnticancer AgentsAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG


AFINITOR ORAL TABLET 10 MG, 7.5 MG


AFINITOR ORAL TABLET 2.5 MG, 5 MG


ALECENSA ORAL CAPSULE 150 MG


ALKERAN ORAL TABLET 2 MG 3

ALUNBRIG ORAL TABLET 180 MG, 90 MG


ALUNBRIG ORAL TABLET 30 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)


anastrozole oral tablet 1 mg (Arimidex) 1

ARIMIDEX ORAL TABLET 1 MG 3

AROMASIN ORAL TABLET 25 MG 3 ST

bexarotene oral capsule 75 mg (Targretin) 2 PA NSO; *May have Specialty Costshare; QL (420 per 30 days)

bicalutamide oral tablet 50 mg (Casodex) 1

BOSULIF ORAL TABLET 100 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

BOSULIF ORAL TABLET 400 MG, 500 MG


29


CABOMETYX ORAL TABLET 20 MG, 60 MG


CABOMETYX ORAL TABLET 40 MG


CALQUENCE ORAL CAPSULE 100 MG


capecitabine oral tablet 150 mg, 500 mg (Xeloda) 2 *May have Specialty Costshare

CAPRELSA ORAL TABLET 100 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

CASODEX ORAL TABLET 50 MG 3

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


COTELLIC ORAL TABLET 20 MG 3 PA; *May have Specialty Costshare; QL (63 per 28 days)

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG


DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

2

EMCYT ORAL CAPSULE 140 MG 2 *May have Specialty Costshare

ERIVEDGE ORAL CAPSULE 150 MG


ERLEADA ORAL TABLET 60 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

etoposide oral capsule 50 mg 1

exemestane oral tablet 25 mg (Aromasin) 1 ST

FARESTON ORAL TABLET 60 MG 2 *May have Specialty Costshare

30


FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG


FEMARA ORAL TABLET 2.5 MG 3

flutamide oral capsule 125 mg 1

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG


GLEEVEC ORAL TABLET 100 MG 2 PA; *May have Specialty Costshare; QL (60 per 30 days)

GLEEVEC ORAL TABLET 400 MG 2 PA; *May have Specialty Costshare; QL (30 per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG


HEXALEN ORAL CAPSULE 50 MG 3 *May have Specialty Costshare

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG


HYDREA ORAL CAPSULE 500 MG 3

hydroxyurea oral capsule 500 mg (Hydrea) 1

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


ICLUSIG ORAL TABLET 15 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

ICLUSIG ORAL TABLET 45 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

IDHIFA ORAL TABLET 100 MG, 50 MG


imatinib oral tablet 100 mg (Gleevec) 2 PA; *May have Specialty Costshare; QL (60 per 30 days)

imatinib oral tablet 400 mg (Gleevec) 2 PA; *May have Specialty Costshare; QL (30 per 30 days)

31


IMBRUVICA ORAL CAPSULE 140 MG


IMBRUVICA ORAL CAPSULE 70 MG


IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG


INLYTA ORAL TABLET 1 MG 3 PA; *May have Specialty Costshare; QL (180 per 30 days)

INLYTA ORAL TABLET 5 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

IRESSA ORAL TABLET 250 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG






KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)






LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY)


32


LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)


LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)


letrozole oral tablet 2.5 mg (Femara) 1

LEUKERAN ORAL TABLET 2 MG 2 *May have Specialty Costshare

leuprolide subcutaneous kit 1 mg/0.2 ml 2 PA; *May have Specialty Costshare

lomustine oral capsule 10 mg, 100 mg, 40 mg

(Gleostine) 2 *May have Specialty Costshare

LONSURF ORAL TABLET 15-6.14 MG


LONSURF ORAL TABLET 20-8.19 MG


LYNPARZA ORAL CAPSULE 50 MG


LYNPARZA ORAL TABLET 100 MG, 150 MG


LYSODREN ORAL TABLET 500 MG 2 *May have Specialty Costshare

MATULANE ORAL CAPSULE 50 MG


megestrol oral tablet 20 mg, 40 mg 1

MEKINIST ORAL TABLET 0.5 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

MEKINIST ORAL TABLET 2 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

melphalan oral tablet 2 mg (Alkeran) 1

mercaptopurine oral tablet 50 mg 1

methotrexate sodium (pf) injection recon soln 1 gram

1

33


methotrexate sodium (pf) injection solution 25 mg/ml

1

methotrexate sodium injection solution 25 mg/ml

1

methotrexate sodium oral tablet 2.5 mg 1

MYLERAN ORAL TABLET 2 MG 2 *May have Specialty Costshare

NERLYNX ORAL TABLET 40 MG 3 PA; *May have Specialty Costshare; QL (180 per 30 days)

NEXAVAR ORAL TABLET 200 MG 2 PA; *May have Specialty Costshare; QL (120 per 30 days)

NILANDRON ORAL TABLET 150 MG

3 *May have Specialty Costshare; QL (150 per 30 days)

nilutamide oral tablet 150 mg (Nilandron) 2 *May have Specialty Costshare; QL (150 per 30 days)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG


ODOMZO ORAL CAPSULE 200 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG


PURINETHOL ORAL TABLET 50 MG

3

PURIXAN ORAL SUSPENSION 20 MG/ML

3

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG


RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG

3

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG


34


RYDAPT ORAL CAPSULE 25 MG 3 PA; *May have Specialty Costshare; QL (224 per 28 days)

SIKLOS ORAL TABLET 100 MG 3

SOLTAMOX ORAL SOLUTION 10 MG/5 ML

3

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG


SPRYCEL ORAL TABLET 20 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

STIVARGA ORAL TABLET 40 MG 3 PA; *May have Specialty Costshare; QL (84 per 28 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG


TABLOID ORAL TABLET 40 MG 3 *May have Specialty Costshare

TAFINLAR ORAL CAPSULE 50 MG, 75 MG


TAGRISSO ORAL TABLET 40 MG, 80 MG


tamoxifen oral tablet 10 mg, 20 mg 0

TARCEVA ORAL TABLET 100 MG, 25 MG


TARCEVA ORAL TABLET 150 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

TARGRETIN ORAL CAPSULE 75 MG

3 PA NSO; *May have Specialty Costshare; QL (420 per 30 days)

TARGRETIN TOPICAL GEL 1 % 3 PA NSO; *May have Specialty Costshare; QL (60 per 30 days)

35


TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG


TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG


temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

(Temodar) 2 *May have Specialty Costshare

tretinoin (chemotherapy) oral capsule 10 mg


TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

2

TYKERB ORAL TABLET 250 MG 3 PA; *May have Specialty Costshare; QL (180 per 30 days)

VENCLEXTA ORAL TABLET 10 MG






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


VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


VOTRIENT ORAL TABLET 200 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

XALKORI ORAL CAPSULE 200 MG, 250 MG


XATMEP ORAL SOLUTION 2.5 MG/ML


XELODA ORAL TABLET 150 MG, 500 MG


36


XTANDI ORAL CAPSULE 40 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

ZEJULA ORAL CAPSULE 100 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

ZELBORAF ORAL TABLET 240 MG 3 PA; *May have Specialty Costshare; QL (240 per 30 days)

ZOLINZA ORAL CAPSULE 100 MG 3 *May have Specialty Costshare

ZYDELIG ORAL TABLET 100 MG, 150 MG


ZYKADIA ORAL CAPSULE 150 MG 3 PA; *May have Specialty Costshare; QL (140 per 28 days)

ZYTIGA ORAL TABLET 250 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

ZYTIGA ORAL TABLET 500 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

Anticholinergic AgentsAntimuscarinics/AntispasmodicsB-DONNA ORAL TABLET 16.2-0.1037 -0.0194 MG

3

chlordiazepoxide-clidinium oral capsule5-2.5 mg

(Librax (with clidinium))

1

DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

3

DONNATAL ORAL TABLET 16.2-0.1037 -0.0194 MG

3

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE 5-2.5 MG

3

ME-PB-HYOS ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

1

me-pb-hyos oral tablet 16.2-0.1037 -0.0194 mg

1

PHENOBARB-HYOSCY-ATROPINE-SCOP ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

(Donnatal) 1

37


phenobarb-hyoscy-atropine-scop oral tablet 16.2-0.1037 -0.0194 mg

(Donnatal) 1

PHENOHYTRO ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

3

PHENOHYTRO ORAL TABLET 16.2-0.1037 -0.0194 MG

3

propantheline oral tablet 15 mg 1

AnticonvulsantsAnticonvulsantsAPTIOM ORAL TABLET 200 MG, 400 MG, 800 MG


APTIOM ORAL TABLET 600 MG 3 ST; QL (60 per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML

2

BANZEL ORAL TABLET 200 MG, 400 MG

2

BRIVIACT ORAL SOLUTION 10 MG/ML

3 ST; *May have Specialty Costshare; QL (600 per 30 days)

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG


carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

(Carbatrol) 1

carbamazepine oral suspension 100 mg/5 ml

(Tegretol) 1

carbamazepine oral tablet 200 mg (Epitol) 1

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

(Tegretol XR) 1

carbamazepine oral tablet,chewable 100 mg

1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

3

CELONTIN ORAL CAPSULE 300 MG

2

DEPAKENE ORAL CAPSULE 250 MG

3

DEPAKENE ORAL SOLUTION 250 MG/5 ML

3

38


DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG

2

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 500 MG

3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG

2

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG

3

DILANTIN EXTENDED ORAL CAPSULE 100 MG

2

DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG

2

DILANTIN ORAL CAPSULE 30 MG 2

DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML

2

divalproex oral capsule, delayed rel sprinkle 125 mg

(Depakote Sprinkles) 1

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

(Depakote ER) 1

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

(Depakote) 1

epitol oral tablet 200 mg 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

3

ethosuximide oral capsule 250 mg (Zarontin) 1

ethosuximide oral solution 250 mg/5 ml (Zarontin) 1

felbamate oral suspension 600 mg/5 ml (Felbatol) 1

felbamate oral tablet 400 mg, 600 mg (Felbatol) 1

FELBATOL ORAL SUSPENSION 600 MG/5 ML

3

FELBATOL ORAL TABLET 400 MG, 600 MG

3

FYCOMPA ORAL SUSPENSION 0.5 MG/ML


FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG


39


FYCOMPA ORAL TABLET 2 MG 3 ST; QL (120 per 30 days)

FYCOMPA ORAL TABLET 4 MG, 6 MG


gabapentin oral capsule 100 mg, 300 mg, 400 mg

(Neurontin) 1

gabapentin oral solution 250 mg/5 ml (Neurontin) 1

gabapentin oral tablet 600 mg, 800 mg (Neurontin) 1

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG

3

GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69)


GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG


HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG


HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG


KEPPRA ORAL SOLUTION 100 MG/ML

3

KEPPRA ORAL TABLET 1,000 MG, 250 MG, 500 MG, 750 MG

3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG

3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG

3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG (21) -50 MG (7)

3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (42) -100 MG (14)

3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG(14)-50 MG (14)-100 MG (7)

3

40


LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG, 25 MG, 5 MG

3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)

3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)

3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)

3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7)

3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)

3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7)

3

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

(Lamictal) 1

lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7)

(Lamictal ODT Starter (Blue))

2

lamotrigine oral tablet disintegrating, dose pk 25 mg(14)-50 mg (14)-100 mg (7)

(Lamictal ODT Starter (Orange))

2

lamotrigine oral tablet disintegrating, dose pk 50 mg (42) -100 mg (14)

(Lamictal ODT Starter (Green))

2

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

(Lamictal XR) 2

41


lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

(Lamictal) 1

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

(Lamictal ODT) 2

lamotrigine oral tablets,dose pack 25 mg (35)

(Lamictal Starter (Blue) Kit)

1

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

(Lamictal Starter (Orange) Kit)

1

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

(Lamictal Starter (Green) Kit)

1

levetiracetam oral solution 100 mg/ml (Keppra) 1

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

(Keppra) 1

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

(Keppra XR) 1

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

2

LYRICA ORAL SOLUTION 20 MG/ML

2

MYSOLINE ORAL TABLET 250 MG, 50 MG

3

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

3

NEURONTIN ORAL SOLUTION 250 MG/5 ML

3

NEURONTIN ORAL TABLET 600 MG, 800 MG

3

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

(Trileptal) 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

(Trileptal) 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG


PEGANONE ORAL TABLET 250 MG

2

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml)

1

42


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

1

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

2

phenytoin oral suspension 125 mg/5 ml (Dilantin-125) 1

phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) 1

phenytoin sodium extended oral capsule100 mg

(Dilantin Extended) 1

phenytoin sodium extended oral capsule200 mg, 300 mg

(Phenytek) 1

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG


POTIGA ORAL TABLET 50 MG 3 ST; QL (270 per 30 days)

primidone oral tablet 250 mg, 50 mg (Mysoline) 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 25 MG, 50 MG


QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 150 MG, 200 MG


ROWEEPRA ORAL TABLET 1,000 MG, 750 MG

3

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

3

SABRIL ORAL POWDER IN PACKET 500 MG


SABRIL ORAL TABLET 500 MG 3 QL (180 per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG


SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG


STAVZOR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG, 250 MG, 500 MG

3

subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

43


subvenite starter (blue) kit oral tablets,dose pack 25 mg (35)

1

subvenite starter (green) kit oral tablets,dose pack 25 mg (84) -100 mg (14)

1

subvenite starter (orange) kit oral tablets,dose pack 25 mg (42) -100 mg (7)

1

TEGRETOL ORAL SUSPENSION 100 MG/5 ML

3

TEGRETOL ORAL TABLET 200 MG 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG

3

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

(Gabitril) 2

TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG

3

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

3

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

1

topiramate oral capsule, sprinkle 15 mg, 25 mg

(Topamax) 1

topiramate oral capsule,sprinkle,er 24hr100 mg, 150 mg, 200 mg, 25 mg, 50 mg

(Qudexy XR) 2

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

(Topamax) 1

TRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 MG/ML)

3

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG


TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG


valproic acid (as sodium salt) oral solution 250 mg/5 ml

(Depakene) 1

valproic acid oral capsule 250 mg (Depakene) 1

vigabatrin oral powder in packet 500 mg (Sabril) 2 QL (180 per 30 days)

44


vigadrone oral powder in packet 500 mg 2 QL (180 per 30 days)

VIMPAT ORAL SOLUTION 10 MG/ML

2

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

2

ZARONTIN ORAL CAPSULE 250 MG

3

ZARONTIN ORAL SOLUTION 250 MG/5 ML

3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

3

zonisamide oral capsule 100 mg, 25 mg (Zonegran) 1

zonisamide oral capsule 50 mg 1

Antidementia AgentsAntidementia AgentsARICEPT ODT ORAL TABLET,DISINTEGRATING 10 MG

3

ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG

3

donepezil oral tablet 10 mg, 5 mg (Aricept) 1

donepezil oral tablet 23 mg (Aricept) 2

donepezil oral tablet,disintegrating 10 mg, 5 mg

1

EXELON ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

3

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5 MG/24 HR


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

(Razadyne ER) 1

galantamine oral solution 4 mg/ml 1

galantamine oral tablet 12 mg, 4 mg, 8 mg

(Razadyne) 1

memantine oral capsule,sprinkle,er 24hr14 mg, 21 mg, 28 mg, 7 mg

(Namenda XR) 2 QL (30 per 30 days)

memantine oral solution 2 mg/ml 1

memantine oral tablet 10 mg, 5 mg (Namenda) 1

memantine oral tablets,dose pack 5-10 mg

(Namenda Titration Pak)

1

NAMENDA ORAL SOLUTION 2 MG/ML

3

45


NAMENDA ORAL TABLET 10 MG, 5 MG

3

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 5-10 MG

3

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG

3

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG


NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG


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


RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR 16 MG, 24 MG, 8 MG

3

RAZADYNE ORAL SOLUTION 4 MG/ML

3

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG

3

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

1

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

(Exelon) 2 QL (30 per 30 days)

AntidepressantsAntidepressantsamitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

amitriptyline-chlordiazepoxide oral tablet12.5-5 mg, 25-10 mg

1

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

1

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

3

46


APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG


BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG


BRISDELLE ORAL CAPSULE 7.5 MG


bupropion hcl oral tablet 100 mg, 75 mg 1

bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 mg

(Wellbutrin SR) 1

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

(Wellbutrin XL) 1

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

3

citalopram oral solution 10 mg/5 ml 1

citalopram oral tablet 10 mg, 20 mg, 40 mg

(Celexa) 1

clomipramine oral capsule 25 mg, 50 mg, 75 mg

(Anafranil) 2

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG


desipramine oral tablet 10 mg, 25 mg (Norpramin) 2

desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg

2

DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG


DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG


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

(Pristiq) 2 ST; QL (30 per 30 days)

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

1

doxepin oral concentrate 10 mg/ml 1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

(Cymbalta) 2 QL (60 per 30 days)

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


47


EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG

3

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


escitalopram oxalate oral solution 5 mg/5 ml

1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

(Lexapro) 1

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)


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


fluoxetine oral capsule 10 mg, 20 mg, 40 mg

(Prozac) 1

fluoxetine oral capsule,delayed release(dr/ec) 90 mg

2

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

1

fluoxetine oral tablet 10 mg, 20 mg (Sarafem) 1

FLUOXETINE ORAL TABLET 60 MG

1

fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg


fluvoxamine oral tablet 100 mg, 25 mg, 50 mg

1

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG


imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

(Tofranil) 2

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

2

IRENKA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 40 MG


KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG


48


LEXAPRO ORAL SOLUTION 5 MG/5 ML

3

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG

3

LUVOX CR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 150 MG


maprotiline oral tablet 25 mg, 50 mg, 75 mg

1

MARPLAN ORAL TABLET 10 MG 3

mirtazapine oral tablet 15 mg, 30 mg (Remeron) 1

mirtazapine oral tablet 45 mg, 7.5 mg 1

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

(Remeron SolTab) 1

NARDIL ORAL TABLET 15 MG 3

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

2

NORPRAMIN ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG

3

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

(Pamelor) 1

nortriptyline oral solution 10 mg/5 ml 1

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

(Symbyax) 2 QL (30 per 30 days)

OLEPTRO ER ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG

3

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

3

PARNATE ORAL TABLET 10 MG 3

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

(Paxil) 1

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

(Paxil CR) 2

paroxetine mesylate(menop.sym) oral capsule 7.5 mg

(Brisdelle) 2

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG

3

49


PAXIL ORAL SUSPENSION 10 MG/5 ML

3

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

3

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG


phenelzine oral tablet 15 mg (Nardil) 1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG


protriptyline oral tablet 10 mg, 5 mg 2

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG

3

PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 90 MG

3

REMERON ORAL TABLET 15 MG, 30 MG, 45 MG

3

REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG

3

SARAFEM ORAL TABLET 10 MG, 20 MG

3

sertraline oral concentrate 20 mg/ml (Zoloft) 1

sertraline oral tablet 100 mg, 25 mg, 50 mg

(Zoloft) 1

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

3

SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG


TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG

3

TOFRANIL-PM ORAL CAPSULE 100 MG, 125 MG, 150 MG, 75 MG

3

tranylcypromine oral tablet 10 mg (Parnate) 2

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

50


trimipramine oral capsule 100 mg, 25 mg, 50 mg

(Surmontil) 1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG


venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

(Effexor XR) 1

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg

2

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16)


VIVACTIL ORAL TABLET 10 MG, 5 MG

3

WELLBUTRIN ORAL TABLET 100 MG, 75 MG

3

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG

3

ZOLOFT ORAL CONCENTRATE 20 MG/ML

3

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

3

Antidiabetic AgentsAntidiabetic Agents, Miscellaneousacarbose oral tablet 100 mg, 25 mg, 50 mg

(Precose) 1

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG

3

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG

3

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

3

51


ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML


alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg

(Nesina) 3 ST; QL (30 per 30 days)

alogliptin-metformin oral tablet 12.5-1,000 mg, 12.5-500 mg

(Kazano) 3 ST; QL (60 per 30 days)

alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg

(Oseni) 3 ST; QL (30 per 30 days)

AVANDAMET ORAL TABLET 2-1,000 MG, 2-500 MG, 4-500 MG

3 ST

AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4 MG, 8-4 MG

3 ST

AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG

3 ST

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML

3 ST; QL (3.4 per 28 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML


BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG


BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML


BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML


CYCLOSET ORAL TABLET 0.8 MG 3

DUETACT ORAL TABLET 30-2 MG, 30-4 MG

3

FARXIGA ORAL TABLET 10 MG, 5 MG


FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 MG, 500 MG

3

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG

2

52


GLUCOPHAGE ORAL TABLET 1,000 MG, 500 MG, 850 MG

3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG

3

GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG, 500 MG


GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

3

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG


INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG


JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG


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


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


JARDIANCE ORAL TABLET 10 MG, 25 MG


JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG


KAZANO ORAL TABLET 12.5-1,000 MG, 12.5-500 MG


53


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG


KORLYM ORAL TABLET 300 MG 3 PA NSO; *May have Specialty Costshare; QL (120 per 30 days)

metformin oral tablet 1,000 mg, 500 mg, 850 mg

(Glucophage) 1

metformin oral tablet extended release 24 hr 500 mg, 750 mg

(Glucophage XR) 1

metformin oral tablet extended release 24hr 1,000 mg, 500 mg

(Fortamet) 1

metformin oral tablet,er gast.retention 24 hr 1,000 mg, 500 mg

(Glumetza) 2 ST; QL (60 per 30 days)

miglitol oral tablet 100 mg, 25 mg, 50 mg (Glyset) 2

nateglinide oral tablet 120 mg, 60 mg (Starlix) 1

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


ONGLYZA ORAL TABLET 2.5 MG, 5 MG


OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/0.75 ML (2 MG/1.5 ML)


pioglitazone oral tablet 15 mg, 30 mg, 45 mg

(Actos) 1

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg

(DUETACT) 2

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg

(Actoplus MET) 1

PRANDIMET ORAL TABLET 1-500 MG, 2-500 MG

3

PRANDIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

54


PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG

3

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

repaglinide oral tablet 0.5 mg 2

repaglinide oral tablet 1 mg, 2 mg (Prandin) 2

repaglinide-metformin oral tablet 1-500 mg, 2-500 mg

2

RIOMET ORAL SOLUTION 500 MG/5 ML

3

SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG


STARLIX ORAL TABLET 120 MG, 60 MG

3

STEGLATRO ORAL TABLET 15 MG, 5 MG


STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG


SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML

3 PA; QL (10.8 per 28 days)

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML


SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG


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


TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML


TRADJENTA ORAL TABLET 5 MG 3 QL (30 per 30 days)

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


55


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 MG


InsulinsADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

2

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT


AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30), 8 UNIT (60)/ 12 UNIT (30)


APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

2

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

3 ST

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

3

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

3

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML

2

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)

2

56


HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)

2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)

2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

2

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

2

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

2

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

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

2

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

2

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

2

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

2

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

2

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

2

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

2

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

2

57


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

2

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

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

2

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

2

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

2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

2

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

2

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

2

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

2

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

2

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML


TOUJEO MAX SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)

2

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

2

58


TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

3

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)

3

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML)


SulfonylureasAMARYL ORAL TABLET 1 MG, 2 MG, 4 MG

3

chlorpropamide oral tablet 100 mg, 250 mg

1

DIABETA ORAL TABLET 1.25 MG, 2.5 MG, 5 MG

3

glimepiride oral tablet 1 mg, 2 mg, 4 mg (Amaryl) 1

glipizide oral tablet 10 mg, 5 mg (Glucotrol) 1

glipizide oral tablet extended release 24hr10 mg, 2.5 mg, 5 mg

(Glucotrol XL) 1

glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

1

GLUCOTROL ORAL TABLET 10 MG, 5 MG

3

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 2.5 MG, 5 MG

3

GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG

3

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

(Glynase) 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

1

glyburide-metformin oral tablet 1.25-250 mg

1

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

(Glucovance) 1

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG

3

tolazamide oral tablet 250 mg, 500 mg 1

tolbutamide oral tablet 500 mg 1

59


AntifungalsAntifungalsANCOBON ORAL CAPSULE 250 MG, 500 MG

3

CICLODAN KIT TOPICAL COMBO PACK 0.77 %

3

CICLODAN KIT TOPICAL SOLUTION 8 %

3

CICLODAN TOPICAL CREAM 0.77 %

3

CICLODAN TOPICAL SOLUTION 8 %

3

ciclopirox topical cream 0.77 % (Ciclodan) 1

ciclopirox topical gel 0.77 % 2

ciclopirox topical shampoo 1 % (Loprox) 2

ciclopirox topical solution 8 % (Ciclodan) 1

ciclopirox topical suspension 0.77 % (Loprox (as olamine)) 1

ciclopirox-ure-camph-menth-euc topical solution 8 %

(Ciclodan Kit) 2

clotrimazole mucous membrane troche 10 mg

1

clotrimazole topical cream 1 % (Antifungal (clotrimazole))

1

clotrimazole topical solution 1 % 1

clotrimazole-betamethasone topical cream 1-0.05 %

(Lotrisone) 1

clotrimazole-betamethasone topical lotion 1-0.05 %

1

CNL 8 NAIL TOPICAL KIT 8 % 3

CRESEMBA ORAL CAPSULE 186 MG


DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML, 40 MG/ML

3

DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3

econazole topical cream 1 % 2

ECOZA TOPICAL FOAM 1 % 3

ERTACZO TOPICAL CREAM 2 % 3

EXELDERM TOPICAL CREAM 1 % 3

60


EXELDERM TOPICAL SOLUTION 1 %

3

EXTINA TOPICAL FOAM 2 % 3

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

(Diflucan) 1

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

(Diflucan) 1

flucytosine oral capsule 250 mg, 500 mg (Ancobon) 1

GRIFULVIN V ORAL TABLET 500 MG

3

griseofulvin microsize oral suspension 125 mg/5 ml

1

griseofulvin microsize oral tablet 500 mg 2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

2

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 125 MG, 250 MG

3

itraconazole oral capsule 100 mg (Sporanox) 1

JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 %


KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 %


ketoconazole oral tablet 200 mg 1

ketoconazole topical cream 2 % 1

ketoconazole topical foam 2 % (Extina) 1

ketoconazole topical shampoo 2 % (Nizoral) 1

KETODAN KIT TOPICAL COMBO PACK 2 %

3

ketodan topical foam 2 % 3

LAMISIL ORAL GRANULES IN PACKET 125 MG, 187.5 MG

3

LAMISIL ORAL TABLET 250 MG 3

LOPROX (AS OLAMINE) TOPICAL CREAM 0.77 %

3

LOPROX (AS OLAMINE) TOPICAL SUSPENSION 0.77 %

3

LOPROX TOPICAL SHAMPOO 1 % 3

LOTRISONE TOPICAL CREAM 1-0.05 %

3

LUZU TOPICAL CREAM 1 % 3 ST; QL (60 per 28 days)

MENTAX TOPICAL CREAM 1 % 3

61


miconazole-3 vaginal suppository 200 mg 1

naftifine topical cream 1 % 2

naftifine topical cream 2 % (Naftin) 2

NAFTIN TOPICAL CREAM 1 %, 2 % 3

NAFTIN TOPICAL GEL 1 %, 2 % 3

NIZORAL TOPICAL SHAMPOO 2 % 3

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

2 PA

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

3 PA

nyamyc topical powder 100,000 unit/gram

1

nyata topical powder 100,000 unit/gram 1

nystatin oral powder 150 million unit 1

nystatin oral suspension 100,000 unit/ml 1

nystatin oral tablet 500,000 unit 1

nystatin topical cream 100,000 unit/gram 1

nystatin topical ointment 100,000 unit/gram

1

nystatin topical powder 100,000 unit/gram

(Nyamyc) 1

nystatin-triamcinolone topical cream100,000-0.1 unit/g-%

2

nystatin-triamcinolone topical ointment100,000-0.1 unit/gram-%

2

nystop topical powder 100,000 unit/gram 1

ONMEL ORAL TABLET 200 MG 3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG

3

oxiconazole topical cream 1 % (Oxistat) 2

OXISTAT TOPICAL CREAM 1 % 3

OXISTAT TOPICAL LOTION 1 % 3

pedi-dri topical powder 100,000 unit/gram

1

PENLAC TOPICAL SOLUTION 8 % 3

SPORANOX ORAL CAPSULE 100 MG

3

SPORANOX ORAL SOLUTION 10 MG/ML

3

62


terbinafine hcl oral tablet 250 mg 1

VFEND ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML (40 MG/ML)

3

VFEND ORAL TABLET 200 MG, 50 MG

3

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

(Vfend) 2

voriconazole oral tablet 200 mg, 50 mg (Vfend) 2

VUSION TOPICAL OINTMENT 0.25-15-81.35 %

3

XOLEGEL TOPICAL GEL 2 % 3

Antigout AgentsAntigout Agents, Otherallopurinol oral tablet 100 mg, 300 mg (Zyloprim) 1

colchicine oral capsule 0.6 mg (Mitigare) 3 QL (60 per 30 days)

colchicine oral tablet 0.6 mg (Colcrys) 2

COLCRYS ORAL TABLET 0.6 MG 3

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG


MITIGARE ORAL CAPSULE 0.6 MG


probenecid oral tablet 500 mg 1

probenecid-colchicine oral tablet 500-0.5 mg

1

ULORIC ORAL TABLET 40 MG, 80 MG


ZURAMPIC ORAL TABLET 200 MG 3 ST; QL (30 per 30 days)

ZYLOPRIM ORAL TABLET 100 MG, 300 MG

3

AntihistaminesAntihistaminesalavert d-12 allergy-sinus oral tablet extended release 12 hr 5-120 mg

1

alavert oral tablet,disintegrating 10 mg 1

ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG

1

ALLEGRA-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR 60-120 MG

1

63


ALLEGRA-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR 180-240 MG

1

allerclear d-12hr oral tablet extended release 12 hr 5-120 mg

1

allerclear d-24hr oral tablet extended release 24 hr 10-240 mg

1

allergy relief (cetirizine) oral capsule 10 mg

1

allergy relief (loratadine) oral tablet,disintegrating 10 mg

1

allergy relief d12 oral tablet extended release 12 hr 5-120 mg

1

aller-tec d oral tablet extended release 12 hr 5-120 mg

1

carbinoxamine maleate oral liquid 4 mg/5 ml

1

carbinoxamine maleate oral tablet 4 mg 1

carbinoxamine maleate oral tablet 6 mg (RyVent) 1

cetiri-d oral tablet extended release 12 hr5-120 mg

1

cetirizine oral solution 1 mg/ml (All Day Allergy (cetirizine))

1

cetirizine oral tablet 10 mg (24Hour Allergy) 1

cetirizine oral tablet 5 mg 1

cetirizine oral tablet,chewable 10 mg, 5 mg

(Children's Cetirizine) 1

cetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg

(All Day Allergy-D) 1

child allergy relf(cetirizine) oral tablet,chewable 10 mg

1

children's allegra allergy oral suspension30 mg/5 ml

1

children's allegra allergy oral tablet,disintegrating 30 mg

1

children's allergy relief(fex) oral suspension 30 mg/5 ml

1

children's allergy relief(lor) oral tablet,chewable 5 mg

1

children's aller-tec oral solution 1 mg/ml 1

children's cetirizine oral tablet,chewable10 mg

1

64


CHILDREN'S CLARITIN ORAL SOLUTION 5 MG/5 ML

1

CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE 5 MG

1

children's wal-fex oral suspension 30 mg/5 ml

1

children's wal-zyr oral solution 1 mg/ml 1

children's wal-zyr oral tablet,chewable 10 mg

1

CHILDREN'S ZYRTEC ALLERGY ORAL SOLUTION 1 MG/ML

1

CHILDREN'S ZYRTEC ALLERGY ORAL TABLET,DISINTEGRATING 10 MG

1

CLARINEX ORAL SYRUP 2.5 MG/5 ML (0.5 MG/ML)


CLARINEX ORAL TABLET 5 MG 3 ST; QL (30 per 30 days)

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG


CLARITIN LIQUI-GEL ORAL CAPSULE 10 MG

1

CLARITIN ORAL TABLET 10 MG 1

CLARITIN REDITABS ORAL TABLET,DISINTEGRATING 10 MG, 5 MG

1

CLARITIN-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG

1

CLARITIN-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

1

clemastine oral syrup 0.67 mg/5 ml 1

clemastine oral tablet 2.68 mg 1

cyproheptadine oral syrup 2 mg/5 ml 1

cyproheptadine oral tablet 4 mg 1

desloratadine oral tablet 5 mg (Clarinex) 2 ST; QL (30 per 30 days)

desloratadine oral tablet,disintegrating2.5 mg, 5 mg


fexofenadine oral tablet 180 mg, 60 mg (Allegra Allergy) 1

fexofenadine-pseudoephedrine oral tablet extended release 12 hr 60-120 mg

(Allegra-D 12 Hour) 1

65


hydroxyzine hcl oral solution 10 mg/5 ml 1

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

1

KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 HR 4 MG/5 ML


levocetirizine oral solution 2.5 mg/5 ml (Xyzal) 1 ST; QL (300 per 30 days)

levocetirizine oral tablet 5 mg (24HR Allergy Relief) 1 ST; QL (30 per 30 days)

lorata-d oral tablet extended release 24 hr 10-240 mg

1

loratadine oral capsule 10 mg (Claritin Liqui-Gel) 1

loratadine oral solution 5 mg/5 ml (Allergy Relief (loratadine))

1

loratadine oral tablet 10 mg (Allerclear) 1

loratadine-d oral tablet extended release 24 hr 10-240 mg

1

mucinex allergy oral tablet 180 mg 1

promethazine oral syrup 6.25 mg/5 ml 1

promethazine vc oral syrup 6.25-5 mg/5 ml

1

respa-ar oral tablet extended release 12 hr 8-90-0.24 mg

2

RYVENT ORAL TABLET 6 MG 3

SEMPREX-D ORAL CAPSULE 8-60 MG

3

wal-fex allergy oral tablet 180 mg, 60 mg 1

wal-fex d 12 hour oral tablet extended release 12 hr 60-120 mg

1

wal-fex d 24 hour oral tablet extended release 24 hr 180-240 mg

1

wal-itin d 12 hour oral tablet extended release 12 hr 5-120 mg

1

wal-itin d oral tablet extended release 24 hr 10-240 mg

1

wal-itin oral solution 5 mg/5 ml 1

wal-itin oral tablet 10 mg 1

wal-itin oral tablet,disintegrating 10 mg 1

wal-zyr (cetirizine) oral tablet 10 mg 1

wal-zyr d oral tablet extended release 12 hr 5-120 mg

1

66


XYZAL ORAL SOLUTION 2.5 MG/5 ML


XYZAL ORAL TABLET 5 MG 3 ST; QL (30 per 30 days)

ZYRTEC ORAL CAPSULE 10 MG 1

ZYRTEC ORAL TABLET 10 MG 1

ZYRTEC ORAL TABLET,DISINTEGRATING 10 MG

1

ZYRTEC-D ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG

1

Anti-Infectives (Skin And Mucous Membrane)Anti-Infectives (Skin And Mucous Membrane)AVC VAGINAL VAGINAL CREAM 15 %

2

CLEOCIN VAGINAL CREAM 2 % 3

CLEOCIN VAGINAL SUPPOSITORY 100 MG

2

clindamycin phosphate vaginal cream 2 % (Cleocin) 1

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE 2 %

3

FEM PH VAGINAL GEL 0.9-0.025 % 3

GYNAZOLE-1 VAGINAL CREAM 2 %

2

METROGEL VAGINAL VAGINAL GEL 0.75 %

3

metronidazole vaginal gel 0.75 % (Metrogel Vaginal) 1

NUVESSA VAGINAL GEL 1.3 % 3

RELAGARD VAGINAL GEL 0.9-0.025 %

3

TERAZOL 3 VAGINAL CREAM 0.8 %

3

TERAZOL 7 VAGINAL CREAM 0.4 %

3

terconazole vaginal cream 0.4 %, 0.8 % 1

terconazole vaginal suppository 80 mg 1

VANDAZOLE VAGINAL GEL 0.75 %

2

67


Antimigraine AgentsAntimigraine AgentsAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML


almotriptan malate oral tablet 12.5 mg (Axert) 2 ST; QL (12 per 30 days)

almotriptan malate oral tablet 6.25 mg 2 ST; QL (12 per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG


AXERT ORAL TABLET 12.5 MG, 6.25 MG


CAFERGOT ORAL TABLET 1-100 MG

3

D.H.E.45 INJECTION SOLUTION 1 MG/ML


dihydroergotamine injection solution 1 mg/ml

(D.H.E.45) 2 ST; QL (15 per 14 days)

dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

(Migranal) 2 QL (8 per 28 days)

eletriptan oral tablet 20 mg, 40 mg (Relpax) 2 ST; QL (12 per 30 days)

ERGOMAR SUBLINGUAL TABLET 2 MG

3

ergotamine-caffeine oral tablet 1-100 mg (Cafergot) 1

FROVA ORAL TABLET 2.5 MG 3 ST; QL (18 per 30 days)

frovatriptan oral tablet 2.5 mg (Frova) 2 ST; QL (18 per 30 days)

IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION


IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG


IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML, 6 MG/0.5 ML


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5 ML


isometh-dichloral-acetaminophn oral capsule 65-100-325 mg

1

MAXALT ORAL TABLET 10 MG, 5 MG


MAXALT-MLT ORAL TABLET,DISINTEGRATING 10 MG, 5 MG


68


MIGERGOT RECTAL SUPPOSITORY 2-100 MG

1

MIGRANAL NASAL SPRAY,NON-AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML)


naratriptan oral tablet 1 mg, 2.5 mg (Amerge) 2 QL (18 per 30 days)

nodolor oral capsule 65-100-325 mg 2

ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG


RELPAX ORAL TABLET 20 MG, 40 MG


rizatriptan oral tablet 10 mg (Maxalt) 1 QL (12 per 30 days)

rizatriptan oral tablet 5 mg 1 QL (12 per 30 days)

rizatriptan oral tablet,disintegrating 10 mg, 5 mg

(Maxalt-MLT) 1 QL (12 per 30 days)

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

(Imitrex) 1 QL (12 per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Kit Refill)


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Pen)


sumatriptan succinate subcutaneous solution 6 mg/0.5 ml


sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


sumatriptan-naproxen oral tablet 85-500 mg

(Treximet) 2 ST; QL (9 per 30 days)

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML, 6 MG/0.5 ML


TREXIMET ORAL TABLET 10-60 MG, 85-500 MG


ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN INJECTOR 3 MG/0.5 ML


zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) 2 QL (12 per 30 days)

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg

(Zomig ZMT) 2 QL (12 per 30 days)

69


ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG


ZOMIG ORAL TABLET 2.5 MG, 5 MG


ZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5 MG, 5 MG


AntimycobacterialsAntimycobacterialscycloserine oral capsule 250 mg 2 *May have Specialty

Costshare

dapsone oral tablet 100 mg, 25 mg 1

ethambutol oral tablet 100 mg 1

ethambutol oral tablet 400 mg (Myambutol) 1

isoniazid oral solution 50 mg/5 ml 1

isoniazid oral tablet 100 mg, 300 mg 1

MYAMBUTOL ORAL TABLET 400 MG

3

MYCOBUTIN ORAL CAPSULE 150 MG

3

PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

3

PRIFTIN ORAL TABLET 150 MG 2

pyrazinamide oral tablet 500 mg 1

rifabutin oral capsule 150 mg (Mycobutin) 2

RIFADIN ORAL CAPSULE 150 MG, 300 MG

3

RIFAMATE ORAL CAPSULE 300-150 MG

3

rifampin oral capsule 150 mg, 300 mg (Rifadin) 1

RIFATER ORAL TABLET 50-120-300 MG

3

SIRTURO ORAL TABLET 100 MG 3 PA; *May have Specialty Costshare; QL (188 per 168 days)

TRECATOR ORAL TABLET 250 MG 3

Antinausea AgentsAntinausea AgentsAKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG


70


ANZEMET ORAL TABLET 100 MG, 50 MG


aprepitant oral capsule 125 mg (Emend) 2 QL (1 per 1 day)



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

(Emend) 2 QL (3 per 1 day)

BONJESTA ORAL TABLET,IR,DELAYED REL,BIPHASIC 20-20 MG


CESAMET ORAL CAPSULE 1 MG 3 PA; QL (20 per 1 day)

COMPAZINE ORAL TABLET 10 MG, 5 MG

3

COMPAZINE RECTAL SUPPOSITORY 25 MG

3

compro rectal suppository 25 mg 1

DICLEGIS ORAL TABLET,DELAYED RELEASE (DR/EC) 10-10 MG


dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

(Marinol) 2 QL (60 per 30 days)

EMEND ORAL CAPSULE 125 MG 3 QL (1 per 1 day)



EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2)

3 QL (3 per 1 day)

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

3 QL (3 per 3 days)

granisetron hcl oral tablet 1 mg 2 QL (8 per 28 days)

granisol oral solution 1 mg/5 ml 1 QL (60 per 30 days)

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG


meclizine oral tablet 12.5 mg 1

meclizine oral tablet 25 mg (Dramamine Less Drowsy)

1

ondansetron hcl oral solution 4 mg/5 ml (Zofran) 1 QL (50 per 15 days)

ondansetron hcl oral tablet 24 mg 1

ondansetron hcl oral tablet 4 mg, 8 mg (Zofran) 1

ondansetron oral tablet,disintegrating 4 mg, 8 mg

(Zofran ODT) 1

71


phenadoz rectal suppository 12.5 mg, 25 mg

1

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG

3

prochlorperazine maleate oral tablet 10 mg, 5 mg

(Compazine) 1

prochlorperazine rectal suppository 25 mg

(Compazine) 1

promethazine oral tablet 12.5 mg, 25 mg, 50 mg

1

promethazine rectal suppository 12.5 mg, 25 mg

(Phenadoz) 1

promethazine rectal suppository 50 mg (Phenergan) 1

promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

1

SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR


scopolamine base transdermal patch 3 day 1 mg over 3 days

(Transderm-Scop) 2

SYNDROS ORAL SOLUTION 5 MG/ML


TIGAN ORAL CAPSULE 300 MG 3

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

3

trimethobenzamide oral capsule 300 mg (Tigan) 2

VARUBI ORAL TABLET 90 MG 3 QL (4 per 28 days)

ZOFRAN ODT ORAL TABLET,DISINTEGRATING 4 MG, 8 MG

3

ZOFRAN ORAL SOLUTION 4 MG/5 ML


ZOFRAN ORAL TABLET 4 MG, 8 MG

3

ZUPLENZ ORAL FILM 4 MG 3 ST; QL (12 per 30 days)

ZUPLENZ ORAL FILM 8 MG 3 ST; QL (8 per 30 days)

Antiparasite AgentsAntiparasite AgentsALBENZA ORAL TABLET 200 MG 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

2

72


ALINIA ORAL TABLET 500 MG 2

atovaquone oral suspension 750 mg/5 ml (Mepron) 2

atovaquone-proguanil oral tablet 250-100 mg

(Malarone) 1

atovaquone-proguanil oral tablet 62.5-25 mg

(Malarone Pediatric) 1

benznidazole oral tablet 100 mg, 12.5 mg 1

BILTRICIDE ORAL TABLET 600 MG

3

chloroquine phosphate oral tablet 250 mg, 500 mg

1

COARTEM ORAL TABLET 20-120 MG

3

DARAPRIM ORAL TABLET 25 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

EMVERM ORAL TABLET,CHEWABLE 100 MG

3

hydroxychloroquine oral tablet 200 mg (Plaquenil) 1

IMPAVIDO ORAL CAPSULE 50 MG 3 PA; *May have Specialty Costshare

ivermectin oral tablet 3 mg (Stromectol) 2

MALARONE ORAL TABLET 250-100 MG

3

MALARONE PEDIATRIC ORAL TABLET 62.5-25 MG

3

mefloquine oral tablet 250 mg 1

MEPRON ORAL SUSPENSION 750 MG/5 ML

3

paromomycin oral capsule 250 mg 1

PLAQUENIL ORAL TABLET 200 MG

3

praziquantel oral tablet 600 mg (Biltricide) 2

PRIMAQUINE ORAL TABLET 26.3 MG

3

QUALAQUIN ORAL CAPSULE 324 MG

3

quinine sulfate oral capsule 324 mg (Qualaquin) 2

STROMECTOL ORAL TABLET 3 MG

3

TINDAMAX ORAL TABLET 250 MG, 500 MG

3

73


tinidazole oral tablet 250 mg 2

tinidazole oral tablet 500 mg (Tindamax) 2

YODOXIN ORAL TABLET 210 MG, 650 MG

3

Antiparkinsonian AgentsAntiparkinsonian Agentsamantadine hcl oral capsule 100 mg 1

amantadine hcl oral solution 50 mg/5 ml 1

amantadine hcl oral tablet 100 mg 1

APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML


AZILECT ORAL TABLET 0.5 MG, 1 MG


benztropine oral tablet 0.5 mg, 1 mg, 2 mg

1

bromocriptine oral capsule 5 mg (Parlodel) 2

bromocriptine oral tablet 2.5 mg (Parlodel) 2

cabergoline oral tablet 0.5 mg 1

carbidopa oral tablet 25 mg (Lodosyn) 2

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

(Sinemet) 1

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

(Sinemet CR) 1

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

1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

(Stalevo 50) 1


(Stalevo 75) 1

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

(Stalevo 100) 1


(Stalevo 125) 1


(Stalevo 150) 1

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg

(Stalevo 200) 1

COMTAN ORAL TABLET 200 MG 3

ELDEPRYL ORAL CAPSULE 5 MG 3

74


entacapone oral tablet 200 mg (Comtan) 1

GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG


GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 68.5 MG


LODOSYN ORAL TABLET 25 MG 3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG


MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

3

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR


PARLODEL ORAL CAPSULE 5 MG 3

PARLODEL ORAL TABLET 2.5 MG 3

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

(Mirapex) 1

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

(Mirapex ER) 2 QL (30 per 30 days)

rasagiline oral tablet 0.5 mg, 1 mg (Azilect) 1 QL (30 per 30 days)

REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG

3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


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

(Requip) 1

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

(Requip XL) 2 QL (30 per 30 days)

RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG


75


selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG

3

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG

3

STALEVO 100 ORAL TABLET 25-100-200 MG

3

STALEVO 125 ORAL TABLET 31.25-125-200 MG

3


3

STALEVO 200 ORAL TABLET 50-200-200 MG

3


3


3

TASMAR ORAL TABLET 100 MG 3

tolcapone oral tablet 100 mg (Tasmar) 1

trihexyphenidyl oral elixir 0.4 mg/ml 1

trihexyphenidyl oral tablet 2 mg, 5 mg 1

XADAGO ORAL TABLET 100 MG, 50 MG


ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG


Antipsychotic AgentsAntipsychotic AgentsABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG


ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 15 MG


ABILIFY ORAL SOLUTION 1 MG/ML


ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG


aripiprazole oral solution 1 mg/ml 2 QL (900 per 30 days)

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

(Abilify) 2 QL (30 per 30 days)

76


aripiprazole oral tablet,disintegrating 10 mg


aripiprazole oral tablet,disintegrating 15 mg


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

1

clozapine oral tablet 100 mg, 25 mg (Clozaril) 1

clozapine oral tablet 200 mg, 50 mg 1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

(FazaClo) 2

CLOZARIL ORAL TABLET 100 MG, 25 MG

3

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)


FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG


fluphenazine hcl oral concentrate 5 mg/ml 1

fluphenazine hcl oral elixir 2.5 mg/5 ml 1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

2

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

3

haloperidol lactate oral concentrate 2 mg/ml

1

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

1

INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG


INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG


LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

3 PA NSO; QL (30 per 30 days)

LATUDA ORAL TABLET 80 MG 3 PA NSO; QL (60 per 30 days)

77


loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1

LOXITANE ORAL CAPSULE 5 MG 3

molindone oral tablet 10 mg 2 QL (240 per 30 days)

molindone oral tablet 25 mg 2 QL (270 per 30 days)

molindone oral tablet 5 mg 2

NUPLAZID ORAL TABLET 17 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

(Zyprexa) 1

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

(Zyprexa Zydis) 2

ORAP ORAL TABLET 1 MG, 2 MG 3

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

(Invega) 2 ST; QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg

(Invega) 2 ST; QL (60 per 30 days)

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

1

pimozide oral tablet 1 mg, 2 mg (Orap) 1

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

(Seroquel) 1 QL (90 per 30 days)

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

(Seroquel XR) 2 QL (30 per 30 days)

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3

RISPERDAL ORAL SOLUTION 1 MG/ML

3

RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3

risperidone oral solution 1 mg/ml (Risperdal) 1

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

(Risperdal) 1

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2

78


SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG


SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG


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

1

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

1

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

1

VERSACLOZ ORAL SUSPENSION 50 MG/ML


VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG


VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

(Geodon) 1

ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG

3

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG

3

Antivirals (Systemic)Antiretroviralsabacavir oral solution 20 mg/ml (Ziagen) 2 *May have Specialty

Costshare; QL (960 per 30 days)

abacavir oral tablet 300 mg (Ziagen) 2 *May have Specialty Costshare; QL (60 per 30 days)

79


abacavir-lamivudine oral tablet 600-300 mg

(Epzicom) 3 *May have Specialty Costshare; QL (30 per 30 days)

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) 3 *May have Specialty Costshare; QL (60 per 30 days)

APTIVUS ORAL CAPSULE 250 MG 2 *May have Specialty Costshare; QL (120 per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML


atazanavir oral capsule 150 mg, 200 mg (Reyataz) 2 *May have Specialty Costshare; QL (60 per 30 days)

atazanavir oral capsule 300 mg (Reyataz) 2 *May have Specialty Costshare; QL (30 per 30 days)

ATRIPLA ORAL TABLET 600-200-300 MG


BIKTARVY ORAL TABLET 50-200-25 MG


CIMDUO ORAL TABLET 300-300 MG


COMBIVIR ORAL TABLET 150-300 MG


COMPLERA ORAL TABLET 200-25-300 MG


CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2

DESCOVY ORAL TABLET 200-25 MG


didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg

(Videx EC) 1 QL (60 per 30 days)

didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg

(Videx EC) 1 QL (30 per 30 days)

80


EDURANT ORAL TABLET 25 MG 3 *May have Specialty Costshare; QL (30 per 30 days)

efavirenz oral capsule 200 mg, 50 mg (Sustiva) 2 *May have Specialty Costshare

efavirenz oral tablet 600 mg (Sustiva) 2 *May have Specialty Costshare

EMTRIVA ORAL CAPSULE 200 MG 2 QL (30 per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML


EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)


EPIVIR HBV ORAL TABLET 100 MG


EPIVIR ORAL SOLUTION 10 MG/ML


EPIVIR ORAL TABLET 150 MG 3 QL (60 per 30 days)

EPIVIR ORAL TABLET 300 MG 3 QL (30 per 30 days)

EPZICOM ORAL TABLET 600-300 MG


EVOTAZ ORAL TABLET 300-150 MG


fosamprenavir oral tablet 700 mg (Lexiva) 2 *May have Specialty Costshare; QL (120 per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN 90 MG


GENVOYA ORAL TABLET 150-150-200-10 MG


INTELENCE ORAL TABLET 100 MG, 25 MG


INTELENCE ORAL TABLET 200 MG


INVIRASE ORAL CAPSULE 200 MG 2 *May have Specialty Costshare; QL (300 per 30 days)

81


INVIRASE ORAL TABLET 500 MG 2 *May have Specialty Costshare; QL (120 per 30 days)

ISENTRESS HD ORAL TABLET 600 MG


ISENTRESS ORAL POWDER IN PACKET 100 MG


ISENTRESS ORAL TABLET 400 MG 2 *May have Specialty Costshare; QL (60 per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG


JULUCA ORAL TABLET 50-25 MG 2 *May have Specialty Costshare

KALETRA ORAL SOLUTION 400-100 MG/5 ML


KALETRA ORAL TABLET 100-25 MG


KALETRA ORAL TABLET 200-50 MG


lamivudine oral solution 10 mg/ml (Epivir) 2 QL (960 per 30 days)

lamivudine oral tablet 100 mg (Epivir HBV) 1 QL (30 per 30 days)

lamivudine oral tablet 150 mg (Epivir) 1 QL (60 per 30 days)

lamivudine oral tablet 300 mg (Epivir) 1 QL (30 per 30 days)

lamivudine-zidovudine oral tablet 150-300 mg

(Combivir) 2 *May have Specialty Costshare; QL (60 per 30 days)

LEXIVA ORAL SUSPENSION 50 MG/ML


LEXIVA ORAL TABLET 700 MG 2 *May have Specialty Costshare; QL (120 per 30 days)

lopinavir-ritonavir oral solution 400-100 mg/5 ml

(Kaletra) 2 *May have Specialty Costshare; QL (480 per 30 days)

nevirapine oral suspension 50 mg/5 ml (Viramune) 1 QL (1200 per 30 days)

82


nevirapine oral tablet 200 mg (Viramune) 1 QL (60 per 30 days)

nevirapine oral tablet extended release 24 hr 100 mg

(Viramune XR) 2 QL (90 per 30 days)

nevirapine oral tablet extended release 24 hr 400 mg

(Viramune XR) 2 QL (30 per 30 days)

NORVIR ORAL CAPSULE 100 MG 3 *May have Specialty Costshare; QL (360 per 30 days)

NORVIR ORAL POWDER IN PACKET 100 MG


NORVIR ORAL SOLUTION 80 MG/ML


NORVIR ORAL TABLET 100 MG 3 *May have Specialty Costshare; QL (360 per 30 days)

ODEFSEY ORAL TABLET 200-25-25 MG


PREZCOBIX ORAL TABLET 800-150 MG-MG


PREZISTA ORAL SUSPENSION 100 MG/ML


PREZISTA ORAL TABLET 150 MG 2 *May have Specialty Costshare; QL (240 per 30 days)

PREZISTA ORAL TABLET 400 MG, 600 MG




RESCRIPTOR ORAL TABLET 200 MG

2

RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG

2

83


RETROVIR ORAL CAPSULE 100 MG


RETROVIR ORAL SYRUP 10 MG/ML

3 QL (1920 per 30 days)

REYATAZ ORAL CAPSULE 150 MG, 200 MG


REYATAZ ORAL CAPSULE 300 MG 3 *May have Specialty Costshare; QL (30 per 30 days)

REYATAZ ORAL POWDER IN PACKET 50 MG


ritonavir oral tablet 100 mg (Norvir) 3 *May have Specialty Costshare; QL (360 per 30 days)

SELZENTRY ORAL SOLUTION 20 MG/ML


SELZENTRY ORAL TABLET 150 MG, 75 MG


SELZENTRY ORAL TABLET 25 MG, 300 MG


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

(Zerit) 1 QL (60 per 30 days)

stavudine oral recon soln 1 mg/ml (Zerit) 1 QL (2400 per 30 days)

STRIBILD ORAL TABLET 150-150-200-300 MG


SUSTIVA ORAL CAPSULE 200 MG, 50 MG


SUSTIVA ORAL TABLET 600 MG 3 *May have Specialty Costshare

SYMFI LO ORAL TABLET 400-300-300 MG


SYMFI ORAL TABLET 600-300-300 MG


tenofovir disoproxil fumarate oral tablet300 mg

(Viread) 2 *May have Specialty Costshare; QL (30 per 30 days)

84


TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


TRIUMEQ ORAL TABLET 600-50-300 MG


TRIZIVIR ORAL TABLET 300-150-300 MG


TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG


VEMLIDY ORAL TABLET 25 MG 3 *May have Specialty Costshare; QL (30 per 30 days)

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)


VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG, 200 MG


VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 250 MG, 400 MG


VIRACEPT ORAL TABLET 250 MG, 625 MG


VIRAMUNE ORAL SUSPENSION 50 MG/5 ML

3 QL (1200 per 30 days)

VIRAMUNE ORAL TABLET 200 MG


VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG


VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG


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


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG


85


VITEKTA ORAL TABLET 150 MG, 85 MG


ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG


ZERIT ORAL RECON SOLN 1 MG/ML

3 QL (2400 per 30 days)

ZIAGEN ORAL SOLUTION 20 MG/ML


ZIAGEN ORAL TABLET 300 MG 3 *May have Specialty Costshare; QL (60 per 30 days)

zidovudine oral capsule 100 mg (Retrovir) 1 QL (180 per 30 days)

zidovudine oral syrup 10 mg/ml (Retrovir) 1 QL (1920 per 30 days)

zidovudine oral tablet 300 mg 1 QL (60 per 30 days)Antivirals, MiscellaneousFLUMADINE ORAL TABLET 100 MG

3

oseltamivir oral capsule 30 mg (Tamiflu) 2 QL (20 per 180 days)

oseltamivir oral capsule 45 mg, 75 mg (Tamiflu) 2 QL (10 per 180 days)

oseltamivir oral suspension for reconstitution 6 mg/ml

(Tamiflu) 2 QL (180 per 180 days)

PREVYMIS ORAL TABLET 240 MG, 480 MG


RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION


rimantadine oral tablet 100 mg (Flumadine) 1

TAMIFLU ORAL CAPSULE 30 MG 3 QL (20 per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG


TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML

3 QL (180 per 180 days)

Hcv AntiviralsDAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG


EPCLUSA ORAL TABLET 400-100 MG


86


HARVONI ORAL TABLET 90-400 MG


MAVYRET ORAL TABLET 100-40 MG


OLYSIO ORAL CAPSULE 150 MG 3 PA; *May have Specialty Costshare; QL (28 per 28 days)

SOVALDI ORAL TABLET 400 MG 3 PA; *May have Specialty Costshare; QL (28 per 28 days)

TECHNIVIE ORAL TABLET 12.5-75-50 MG


VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG


VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG-50 MG- 33.33 MG-200 MG


VOSEVI ORAL TABLET 400-100-100 MG


ZEPATIER ORAL TABLET 50-100 MG


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

3 PA; *May have Specialty Costshare

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML


PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML


PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML


87


PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML


PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML


PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML


PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML


SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


Nucleosides And Nucleotidesacyclovir oral capsule 200 mg (Zovirax) 1

acyclovir oral suspension 200 mg/5 ml (Zovirax) 1

acyclovir oral tablet 400 mg, 800 mg (Zovirax) 1

adefovir oral tablet 10 mg (Hepsera) 2 *May have Specialty Costshare; QL (30 per 30 days)

BARACLUDE ORAL SOLUTION 0.05 MG/ML


BARACLUDE ORAL TABLET 0.5 MG, 1 MG


COPEGUS ORAL TABLET 200 MG 3

entecavir oral tablet 0.5 mg, 1 mg (Baraclude) 3 *May have Specialty Costshare; QL (30 per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg

2

FAMVIR ORAL TABLET 125 MG, 250 MG, 500 MG

3

HEPSERA ORAL TABLET 10 MG 3 *May have Specialty Costshare; QL (30 per 30 days)

88


MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (7)- 400 MG (7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7)

3

MODERIBA ORAL TABLET 200 MG 3

REBETOL ORAL CAPSULE 200 MG 3

REBETOL ORAL SOLUTION 40 MG/ML

3

ribasphere oral capsule 200 mg 2

ribasphere oral tablet 200 mg, 400 mg, 600 mg

2

ribasphere ribapak oral tablets,dose pack200 mg (7)- 400 mg (7), 400-400 mg (28)-mg (28), 600-400 mg (28)-mg (28), 600-600 mg (28)-mg (28)

2

RIBATAB DOSE PACK ORAL TABLETS,DOSE PACK 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28)

3

ribavirin oral capsule 200 mg (Ribasphere) 1

ribavirin oral tablet 200 mg (Moderiba) 2

SITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG


TYZEKA ORAL TABLET 600 MG 3 ST; *May have Specialty Costshare; QL (30 per 30 days)

valacyclovir oral tablet 1 gram, 500 mg (Valtrex) 1

VALCYTE ORAL RECON SOLN 50 MG/ML

3

VALCYTE ORAL TABLET 450 MG 3

valganciclovir oral recon soln 50 mg/ml (Valcyte) 1

valganciclovir oral tablet 450 mg (Valcyte) 1

VALTREX ORAL TABLET 1 GRAM, 500 MG

3

ZOVIRAX ORAL CAPSULE 200 MG 3

ZOVIRAX ORAL SUSPENSION 200 MG/5 ML

3

ZOVIRAX ORAL TABLET 400 MG, 800 MG

3

89


Blood Products/Modifiers/Volume ExpandersAnticoagulantsARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML

3

BEVYXXA ORAL CAPSULE 40 MG, 80 MG


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

2

ELIQUIS ORAL TABLET 2.5 MG, 5 MG


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


enoxaparin subcutaneous solution 300 mg/3 ml

(Lovenox) 2

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

(Lovenox) 2

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

(Arixtra) 2

FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML

3

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

3

heparin (porcine) injection cartridge5,000 unit/ml (1 ml)

1

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

1

heparin (porcine) injection syringe 5,000 unit/ml

1

90


heparin, porcine (pf) injection syringe5,000 unit/0.5 ml

1

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

1

LOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML

3

LOVENOX SUBCUTANEOUS SYRINGE 100 MG/ML, 120 MG/0.8 ML, 150 MG/ML, 30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6 ML, 80 MG/0.8 ML

3

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG


SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG


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

(Coumadin) 1

XARELTO ORAL TABLET 10 MG, 20 MG


XARELTO ORAL TABLET 15 MG 2 QL (42 per 21 days)

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


Blood Formation ModifiersARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML


ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML

3 PA; *May have Specialty Costshare; QL (1.6 per 28 days)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML


ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML




91




ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML


DOPTELET ORAL TABLET 20 MG 3 PA; *May have Specialty Costshare

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML


FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML


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


HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT


LEUKINE INJECTION RECON SOLN 250 MCG


MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML


NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML


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


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


PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML


PROCRIT INJECTION SOLUTION 40,000 UNIT/ML


PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG


92


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


Hematologic Agents, MiscellaneousAGRYLIN ORAL CAPSULE 0.5 MG 3 *May have Specialty

Costshare

AMICAR ORAL SOLUTION 250 MG/ML (25 %)

3

AMICAR ORAL TABLET 1,000 MG, 500 MG

3

aminocaproic acid oral solution 250 mg/ml (25 %)

(Amicar) 1

aminocaproic acid oral tablet 1,000 mg, 500 mg

(Amicar) 1

anagrelide oral capsule 0.5 mg (Agrylin) 2 *May have Specialty Costshare

anagrelide oral capsule 1 mg 2 *May have Specialty Costshare

LYSTEDA ORAL TABLET 650 MG 3

tranexamic acid oral tablet 650 mg (Lysteda) 2Platelet-Aggregation InhibitorsAGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR 25-200 MG

3

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

(Aggrenox) 2

BRILINTA ORAL TABLET 60 MG, 90 MG


cilostazol oral tablet 100 mg, 50 mg 1

clopidogrel oral tablet 300 mg, 75 mg (Plavix) 1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

1

EFFIENT ORAL TABLET 10 MG, 5 MG


pentoxifylline oral tablet extended release 400 mg

1

PERSANTINE ORAL TABLET 25 MG, 50 MG, 75 MG

3

PLAVIX ORAL TABLET 300 MG, 75 MG

3

PLETAL ORAL TABLET 100 MG, 50 MG

3

prasugrel oral tablet 10 mg, 5 mg (Effient) 2 QL (30 per 30 days)

ticlopidine oral tablet 250 mg 1

93


ZONTIVITY ORAL TABLET 2.08 MG


Cardiovascular AgentsAlpha-Adrenergic AgentsCARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG

3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG

3

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG

3

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24 HR

3


3


3

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

(Catapres) 1

clonidine transdermal patch weekly 0.1 mg/24 hr

(Catapres-TTS-1) 1


(Catapres-TTS-2) 1


(Catapres-TTS-3) 1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg

2

DIBENZYLINE ORAL CAPSULE 10 MG


doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg

(Cardura) 1

guanfacine oral tablet 1 mg, 2 mg 1

methyldopa oral tablet 250 mg, 500 mg 1

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

1

midodrine oral tablet 10 mg, 2.5 mg, 5 mg

1

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG

3

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG


94


phenoxybenzamine oral capsule 10 mg (Dibenzyline) 2 *May have Specialty Costshare

prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) 1

TENEX ORAL TABLET 1 MG, 2 MG 3Angiotensin Ii Receptor AntagonistsATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG

3 ST

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3 ST

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG

3 ST

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG

3 ST

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG

3 ST

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

3 ST

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg

(Atacand) 2 ST

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

(Atacand HCT) 2 ST

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG

3 ST

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

3 ST

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

3 ST

EDARBI ORAL TABLET 40 MG, 80 MG

3 ST

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

3 ST

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG


eprosartan oral tablet 600 mg 2 ST

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

3 ST

irbesartan oral tablet 150 mg, 300 mg, 75 mg

(Avapro) 1

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

(Avalide) 1

95


losartan oral tablet 100 mg, 25 mg, 50 mg

(Cozaar) 1

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

(Hyzaar) 1

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

3 ST

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG

3 ST

olmesartan oral tablet 20 mg, 40 mg, 5 mg

(Benicar) 2

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

(Tribenzor) 2

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

(Benicar HCT) 2

telmisartan oral tablet 20 mg, 40 mg, 80 mg

(Micardis) 2 ST

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

(Twynsta) 2 ST

telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

(Micardis HCT) 2 ST

TEVETEN HCT ORAL TABLET 600-12.5 MG, 600-25 MG

3 ST

TEVETEN ORAL TABLET 600 MG 3 ST

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

3 ST

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG

3 ST

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

(Diovan) 1

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

(Diovan HCT) 1

Angiotensin-Converting Enzyme InhibitorsACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3

ACEON ORAL TABLET 4 MG, 8 MG 3

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG

3

96


benazepril oral tablet 10 mg, 20 mg, 40 mg

(Lotensin) 1

benazepril oral tablet 5 mg 1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

(Lotensin HCT) 1

benazepril-hydrochlorothiazide oral tablet 5-6.25 mg

1

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

1

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

1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

(Vasotec) 1

enalapril-hydrochlorothiazide oral tablet10-25 mg

(Vaseretic) 1

enalapril-hydrochlorothiazide oral tablet5-12.5 mg

1

EPANED ORAL SOLUTION 1 MG/ML

3 QL (1200 per 30 days)

fosinopril oral tablet 10 mg, 20 mg, 40 mg

1

fosinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg

1

lisinopril oral tablet 10 mg, 20 mg, 5 mg (Prinivil) 1

lisinopril oral tablet 2.5 mg, 30 mg, 40 mg

(Zestril) 1

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

(Zestoretic) 1

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG

3

MAVIK ORAL TABLET 1 MG, 2 MG, 4 MG

3

moexipril oral tablet 15 mg, 7.5 mg 1

moexipril-hydrochlorothiazide oral tablet15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1

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

1

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG

3

97


QBRELIS ORAL SOLUTION 1 MG/ML

3 QL (1200 per 30 days)

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

(Accupril) 1

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

(Accuretic) 1

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

(Altace) 1

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 1-240 MG, 2-180 MG, 2-240 MG, 4-240 MG

3

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg

2

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

(Tarka) 2

UNIRETIC ORAL TABLET 15-12.5 MG

3

UNIVASC ORAL TABLET 15 MG, 7.5 MG

3

VASERETIC ORAL TABLET 10-25 MG

3

VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

3

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

3

Antiarrhythmic Agentsamiodarone oral tablet 100 mg, 200 mg, 400 mg

(Pacerone) 1

CORDARONE ORAL TABLET 200 MG

3

disopyramide phosphate oral capsule 100 mg, 150 mg

(Norpace) 1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

(Tikosyn) 2

flecainide oral tablet 100 mg, 150 mg, 50 mg

1

mexiletine oral capsule 150 mg, 200 mg, 250 mg

1

98


MULTAQ ORAL TABLET 400 MG 2

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG

3

NORPACE ORAL CAPSULE 100 MG, 150 MG

3

pacerone oral tablet 100 mg, 200 mg, 400 mg

1

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

(Rythmol SR) 1

propafenone oral tablet 150 mg, 225 mg, 300 mg

1

quinidine gluconate oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg

1

quinidine sulfate oral tablet extended release 300 mg

1

RYTHMOL ORAL TABLET 150 MG, 225 MG

3

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR 225 MG, 325 MG, 425 MG

3

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3

Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg, 400 mg 1

atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) 1

atenolol-chlorthalidone oral tablet 100-25 mg

(Tenoretic 100) 1

atenolol-chlorthalidone oral tablet 50-25 mg

(Tenoretic 50) 1

BETAPACE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

3

betaxolol oral tablet 10 mg, 20 mg 1

bisoprolol fumarate oral tablet 10 mg, 5 mg

1

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

(Ziac) 1

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

2

99


BYVALSON ORAL TABLET 5-80 MG

2

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

(Coreg) 1

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

(Coreg CR) 1

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG

3

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG

3

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG

3

CORZIDE ORAL TABLET 40-5 MG, 80-5 MG

3

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR 100-12.5 MG


DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR 25-12.5 MG, 50-12.5 MG


HEMANGEOL ORAL SOLUTION 4.28 MG/ML


INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 160 MG, 60 MG, 80 MG

3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG

3

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG

3

labetalol oral tablet 100 mg, 200 mg, 300 mg

1

LEVATOL ORAL TABLET 20 MG 3

LOPRESSOR HCT ORAL TABLET 50-25 MG

3

LOPRESSOR ORAL TABLET 100 MG, 50 MG

3

100


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

(Toprol XL) 1

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg

(Lopressor HCT) 1

metoprolol tartrate oral tablet 100 mg, 50 mg

(Lopressor) 1

metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg

1

nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) 1

nadolol-bendroflumethiazide oral tablet40-5 mg, 80-5 mg

(Corzide) 1

pindolol oral tablet 10 mg, 5 mg 1

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

(Inderal LA) 1

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

1

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

1

propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg

1

SECTRAL ORAL CAPSULE 200 MG, 400 MG

3

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

(Betapace) 1

SOTYLIZE ORAL SOLUTION 5 MG/ML

3

TENORETIC 100 ORAL TABLET 100-25 MG

3

TENORETIC 50 ORAL TABLET 50-25 MG

3

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG

3

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

1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG

3

101


TRANDATE ORAL TABLET 100 MG, 200 MG, 300 MG

3

ZEBETA ORAL TABLET 10 MG, 5 MG

3

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG

3

Calcium-Channel Blocking AgentsCALAN ORAL TABLET 120 MG, 80 MG

3

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG

3

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

3

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

1

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

1

diltiazem hcl oral capsule,extended release 24 hr 360 mg

(Taztia XT) 1

diltiazem hcl oral capsule,extended release 24 hr 420 mg

(Tiazac) 1

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

(Cardizem CD) 1

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

(Cardizem) 1

diltiazem hcl oral tablet 90 mg 1

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

(Cardizem LA) 1

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg

1

102


matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3

verapamil oral capsule, 24 hr er pellet ct100 mg, 200 mg, 300 mg

(Verelan PM) 1

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg

(Verelan) 1

verapamil oral tablet 120 mg, 80 mg (Calan) 1

verapamil oral tablet 40 mg 1

verapamil oral tablet extended release120 mg, 180 mg, 240 mg

(Calan SR) 1

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 120 MG, 180 MG, 240 MG, 360 MG

3

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG, 200 MG, 300 MG

3

Cardiovascular Agents, MiscellaneousADRENACLICK INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML

3 QL (4 per 1 day)

AUVI-Q INJECTION AUTO-INJECTOR 0.1 MG/0.1 ML, 0.15 MG/0.15 ML, 0.3 MG/0.3 ML


CORLANOR ORAL TABLET 5 MG, 7.5 MG


DEMSER ORAL CAPSULE 250 MG 3

digitek oral tablet 125 mcg, 250 mcg 1

digox oral tablet 125 mcg, 250 mcg 1

DIGOXIN ORAL SOLUTION 50 MCG/ML

2

digoxin oral tablet 125 mcg, 250 mcg (Digitek) 1

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml

(Auvi-Q) 1 QL (4 per 1 day)

103


epinephrine injection auto-injector 0.15 mg/0.3 ml

(EpiPen Jr) 1 QL (4 per 1 day)

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

3 QL (4 per 1 day)

EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

3 QL (4 per 1 day)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML

3 QL (4 per 1 day)

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

isoxsuprine oral tablet 10 mg, 20 mg 1

LANOXIN ORAL TABLET 125 MCG, 187.5 MCG, 250 MCG, 62.5 MCG

3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG


RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 500 MG


reserpine oral tablet 0.1 mg, 0.25 mg 1

VECAMYL ORAL TABLET 2.5 MG 3 PA; *May have Specialty Costshare

YOSPRALA ORAL TABLET,IR,DELAYED REL,BIPHASIC 325-40 MG, 81-40 MG


DihydropyridinesADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG, 90 MG

3

afeditab cr oral tablet extended release30 mg, 60 mg

1

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg

(Norvasc) 1

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

(Lotrel) 1

amlodipine-benazepril oral capsule 2.5-10 mg

1

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

(Azor) 2

104


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

(Exforge) 2

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

(Exforge HCT) 2

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG

3 ST

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

3 ST

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG

3 ST

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

1

isradipine oral capsule 2.5 mg, 5 mg 1

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 2.5-10 MG, 5-10 MG, 5-20 MG, 5-40 MG

3

nicardipine oral capsule 20 mg, 30 mg 1

nifedical xl oral tablet extended release 24hr 30 mg, 60 mg

1

nifedipine oral capsule 10 mg (Procardia) 1

nifedipine oral capsule 20 mg 1

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

(Procardia XL) 1

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

(Adalat CC) 1

nimodipine oral capsule 30 mg 1

nisoldipine oral tablet extended release 24 hr 17 mg, 34 mg, 8.5 mg

(Sular) 1

nisoldipine oral tablet extended release 24 hr 20 mg, 25.5 mg, 30 mg, 40 mg

1

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

3

NYMALIZE ORAL SOLUTION 60 MG/20 ML


PROCARDIA ORAL CAPSULE 10 MG

3

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG, 90 MG

3

105


SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

3

DiureticsALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG

3

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG

3

amiloride oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet5-50 mg

1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg

1

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

DEMADEX ORAL TABLET 10 MG, 100 MG, 20 MG, 5 MG

3

DIURIL ORAL SUSPENSION 250 MG/5 ML

3

DYAZIDE ORAL CAPSULE 37.5-25 MG

3

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

3

EDECRIN ORAL TABLET 25 MG 3

ethacrynic acid oral tablet 25 mg (Edecrin) 2

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

1

furosemide oral tablet 20 mg, 40 mg, 80 mg

(Lasix) 1

hydrochlorothiazide oral capsule 12.5 mg (Microzide) 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

indapamide oral tablet 1.25 mg, 2.5 mg 1

JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)


LASIX ORAL TABLET 20 MG, 40 MG, 80 MG

3

MAXZIDE ORAL TABLET 75-50 MG

3

106


MAXZIDE-25MG ORAL TABLET 37.5-25 MG

3

methyclothiazide oral tablet 5 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

1

MICROZIDE ORAL CAPSULE 12.5 MG

3

SAMSCA ORAL TABLET 15 MG 3 PA; *May have Specialty Costshare; QL (30 per 365 days)

SAMSCA ORAL TABLET 30 MG 3 PA; *May have Specialty Costshare; QL (60 per 365 days)

spironolactone oral tablet 100 mg, 25 mg, 50 mg

(Aldactone) 1

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

(Aldactazide) 1

torsemide oral tablet 10 mg, 20 mg (Demadex) 1

torsemide oral tablet 100 mg, 5 mg 1

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

(Dyazide) 1

triamterene-hydrochlorothiazid oral capsule 50-25 mg

1

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg

(Maxzide-25mg) 1

triamterene-hydrochlorothiazid oral tablet 75-50 mg

(Maxzide) 1

ZAROXOLYN ORAL TABLET 2.5 MG, 5 MG

3

DyslipidemicsADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20 MG, 750-20 MG


ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40 MG, 500-20 MG


ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG


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

(Caduet) 2 QL (30 per 30 days)

107


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


ANTARA ORAL CAPSULE 30 MG, 90 MG

3

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

(Lipitor) 0 QL (30 per 30 days)

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 2.5-10 MG, 2.5-20 MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG


cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) 1

cholestyramine light oral powder in packet 4 gram

1

colesevelam oral tablet 625 mg (WelChol) 2

COLESTID FLAVORED ORAL PACKET 7.5 GRAM

3

COLESTID ORAL TABLET 1 GRAM 3

colestipol oral packet 5 gram (Colestid) 1

colestipol oral tablet 1 gram (Colestid) 1

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG


ezetimibe oral tablet 10 mg (Zetia) 1 QL (30 per 30 days)

ezetimibe-simvastatin oral tablet 10-10 mg

(Vytorin 10-10) 2 QL (30 per 30 days)






(Vytorin 10-80) 2 PA NSO; QL (30 per 30 days)

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg

2

fenofibrate micronized oral capsule 43 mg, 67 mg

1

fenofibrate nanocrystallized oral tablet145 mg, 48 mg

(Tricor) 1

fenofibrate oral capsule 150 mg, 50 mg (Lipofen) 2

fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) 2

fenofibrate oral tablet 160 mg, 54 mg 1

108


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

(Trilipix) 2

fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) 1

FENOGLIDE ORAL TABLET 120 MG, 40 MG

3

FIBRICOR ORAL TABLET 105 MG, 35 MG

3

FLOLIPID ORAL SUSPENSION 20 MG/5 ML (4 MG/ML), 40 MG/5 ML (8 MG/ML)


fluvastatin oral capsule 20 mg, 40 mg (Lescol) 2 QL (30 per 30 days)

fluvastatin oral tablet extended release 24 hr 80 mg

(Lescol XL) 2 QL (30 per 30 days)

gemfibrozil oral tablet 600 mg (Lopid) 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 60 MG


JUXTAPID ORAL CAPSULE 5 MG 3 PA; *May have Specialty Costshare; QL (45 per 30 days)

KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML


LESCOL ORAL CAPSULE 20 MG, 40 MG


LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR 80 MG


LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG


LIPOFEN ORAL CAPSULE 150 MG, 50 MG

3

LIPTRUZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG


LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG


LOFIBRA ORAL CAPSULE 134 MG, 200 MG, 67 MG

3

LOFIBRA ORAL TABLET 160 MG, 54 MG

3

LOPID ORAL TABLET 600 MG 3

109


lovastatin oral tablet 10 mg, 20 mg, 40 mg


LOVAZA ORAL CAPSULE 1 GRAM 3 QL (120 per 30 days)

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

(Niaspan Extended-Release)

2

niacor oral tablet 500 mg 1

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 500 MG, 750 MG

3

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza) 2 QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML


PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML


PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG


pravastatin oral tablet 10 mg 0 QL (30 per 30 days)

pravastatin oral tablet 20 mg, 40 mg, 80 mg

(Pravachol) 0 QL (30 per 30 days)

prevalite oral powder in packet 4 gram 1

QUESTRAN LIGHT ORAL POWDER 4 GRAM

3

QUESTRAN ORAL POWDER IN PACKET 4 GRAM

3

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML


rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

(Crestor) 1 QL (30 per 30 days)

SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20 MG, 750-20 MG


110


SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40 MG, 500-20 MG, 500-40 MG


simvastatin oral tablet 10 mg, 20 mg, 40 mg

(Zocor) 0 QL (30 per 30 days)

simvastatin oral tablet 5 mg 0 QL (30 per 30 days)

simvastatin oral tablet 80 mg (Zocor) 0 PA NSO; QL (30 per 30 days)

TRICOR ORAL TABLET 145 MG, 48 MG

3

TRIGLIDE ORAL TABLET 160 MG 3

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC) 135 MG, 45 MG

3

VASCEPA ORAL CAPSULE 0.5 GRAM


VASCEPA ORAL CAPSULE 1 GRAM


VYTORIN 10-10 ORAL TABLET 10-10 MG








WELCHOL ORAL POWDER IN PACKET 3.75 GRAM

3

WELCHOL ORAL TABLET 625 MG 3

ZETIA ORAL TABLET 10 MG 3 QL (30 per 30 days)

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG


ZOCOR ORAL TABLET 80 MG 3 PA NSO; QL (30 per 30 days)

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG


Renin-Angiotensin-Aldosterone System InhibitorsAMTURNIDE ORAL TABLET 150-5-12.5 MG, 300-10-12.5 MG, 300-10-25 MG, 300-5-12.5 MG, 300-5-25 MG


111


CAROSPIR ORAL SUSPENSION 25 MG/5 ML

2 ST

eplerenone oral tablet 25 mg, 50 mg (Inspra) 1 ST

INSPRA ORAL TABLET 25 MG, 50 MG

3 ST

TEKAMLO ORAL TABLET 150-10 MG, 150-5 MG, 300-10 MG, 300-5 MG


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


TEKTURNA ORAL TABLET 150 MG, 300 MG


VasodilatorsBIDIL ORAL TABLET 20-37.5 MG 3

DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG

2

GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG

3

IMDUR ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 30 MG, 60 MG

3

ISOCHRON ORAL TABLET EXTENDED RELEASE 40 MG

3

ISORDIL ORAL TABLET 40 MG 2

ISORDIL TITRADOSE ORAL TABLET 5 MG

3

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

1

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 1

isosorbide dinitrate oral tablet extended release 40 mg

(ISOCHRON) 1

isosorbide mononitrate oral tablet 10 mg, 20 mg

1

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

1

minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

minoxidil oral tablet 10 mg, 2.5 mg 1

NITRO-BID TRANSDERMAL OINTMENT 2 %

2

112


NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR

3

nitroglycerin oral capsule, extended release 2.5 mg, 6.5 mg, 9 mg

(Nitro-Time) 1

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

(Nitrostat) 1

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

(Minitran) 1

nitroglycerin translingual spray,non-aerosol 400 mcg/spray

(Nitrolingual) 2

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL 400 MCG/SPRAY

3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 MCG/SPRAY

3

NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG

3

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG


Central Nervous System AgentsCentral Nervous System AgentsADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG


ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG


ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 20 MG, 25 MG, 30 MG


ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR 1.25 MG/ML


ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG


AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG


113


APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

(Strattera) 2 PA NSO; QL (60 per 30 days)

AUBAGIO ORAL TABLET 14 MG, 7 MG


AUSTEDO ORAL TABLET 12 MG, 9 MG


AUSTEDO ORAL TABLET 6 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG


AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML


BETASERON SUBCUTANEOUS KIT 0.3 MG


CAFCIT ORAL SOLUTION 60 MG/3 ML (20 MG/ML)

3

caffeine citrate oral solution 60 mg/3 ml (20 mg/ml)

1

clonidine hcl oral tablet extended release 12 hr 0.1 mg

(Kapvay) 2 QL (120 per 30 days)

CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 54 MG


CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 36 MG


COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML


114


COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML


COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 8.6 MG


COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 25.9 MG


DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR


DESOXYN ORAL TABLET 5 MG 3 PA NSO; QL (150 per 30 days)

DEXEDRINE ORAL TABLET 10 MG


DEXEDRINE ORAL TABLET 5 MG 3 PA NSO; QL (90 per 30 days)

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 5 MG


DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG


dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

(Focalin XR) 2 QL (30 per 30 days)

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

(Focalin) 1 QL (60 per 30 days)

dextroamphetamine oral capsule, extended release 10 mg, 5 mg

(Dexedrine Spansule) 2 QL (60 per 30 days)

dextroamphetamine oral capsule, extended release 15 mg

(Dexedrine Spansule) 2 QL (120 per 30 days)

dextroamphetamine oral solution 5 mg/5 ml

(ProCentra) 2 QL (1800 per 30 days)

dextroamphetamine oral tablet 10 mg (Zenzedi) 1 QL (180 per 30 days)

dextroamphetamine oral tablet 5 mg (Zenzedi) 1 QL (90 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg

(Adderall XR) 2 QL (30 per 30 days)

115


dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg

(Adderall XR) 2 QL (60 per 30 days)

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

(Adderall) 1 QL (60 per 30 days)

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML


EVEKEO ORAL TABLET 10 MG, 5 MG


EXTAVIA SUBCUTANEOUS KIT 0.3 MG


FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG


FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG


GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG


glatiramer subcutaneous syringe 20 mg/ml

(Copaxone) 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

glatiramer subcutaneous syringe 40 mg/ml

(Copaxone) 3 PA; *May have Specialty Costshare; QL (12 per 28 days)

glatopa subcutaneous syringe 20 mg/ml 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

glatopa subcutaneous syringe 40 mg/ml 3 PA; *May have Specialty Costshare; QL (12 per 28 days)

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

(Intuniv ER) 2 QL (30 per 30 days)

INGREZZA ORAL CAPSULE 40 MG, 80 MG


INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG


116


KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR 0.1 MG


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

1

lithium carbonate oral tablet 300 mg 1

lithium carbonate oral tablet extended release 300 mg

(Lithobid) 1

lithium carbonate oral tablet extended release 450 mg

1

lithium citrate oral solution 8 meq/5 ml 1

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

3

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 330 MG, 82.5 MG


METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 10 MG, 20 MG, 40 MG, 50 MG, 60 MG


METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 30 MG


metadate er oral tablet extended release20 mg


methamphetamine oral tablet 5 mg (Desoxyn) 2 PA; QL (150 per 30 days)

METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML


METHYLIN ORAL TABLET,CHEWABLE 10 MG, 2.5 MG, 5 MG


methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl oral capsule, er biphasic 30-70 30 mg


methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 40 mg

(Ritalin LA) 2 QL (30 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 30 mg

(Ritalin LA) 2 QL (60 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 60 mg


117


methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml

(Methylin) 1

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

(Ritalin) 1 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 10 mg


methylphenidate hcl oral tablet extended release 20 mg

(Metadate ER) 2 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 54 mg

(Concerta) 2 QL (30 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 36 mg

(Concerta) 2 QL (60 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 72 mg

(Relexxii) 2 QL (30 per 30 days)

methylphenidate hcl oral tablet,chewable10 mg, 2.5 mg, 5 mg


MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG


NUEDEXTA ORAL CAPSULE 20-10 MG


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML


PROCENTRA ORAL SOLUTION 5 MG/5 ML


QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 40 MG


QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 30 MG


QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML


118


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)


RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG


RILUTEK ORAL TABLET 50 MG 3 PA; *May have Specialty Costshare

riluzole oral tablet 50 mg (Rilutek) 3 PA; *May have Specialty Costshare

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 40 MG, 60 MG


RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 30 MG


RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG


RITALIN SR ORAL TABLET EXTENDED RELEASE 20 MG


SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG


SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)


STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG


119


tetrabenazine oral tablet 12.5 mg (Xenazine) 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

tetrabenazine oral tablet 25 mg (Xenazine) 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


XENAZINE ORAL TABLET 12.5 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

XENAZINE ORAL TABLET 25 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

zenzedi oral tablet 10 mg 2 QL (180 per 30 days)

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 7.5 MG


ZENZEDI ORAL TABLET 20 MG, 30 MG


zenzedi oral tablet 5 mg 2 QL (90 per 30 days)

ContraceptivesContraceptivesaftera oral tablet 1.5 mg 0

altavera (28) oral tablet 0.15-0.03 mg 0

alyacen 1/35 (28) oral tablet 1-35 mg-mcg

0

alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

0

amethia lo oral tablets,dose pack,3 month0.10 mg-20 mcg (84)/10 mcg (7)

0

amethia oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

0

amethyst oral tablet 90-20 mcg 3

apri oral tablet 0.15-0.03 mg 0

aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg

0

ashlyna oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

0

120


aubra oral tablet 0.1-20 mg-mcg 0

aviane oral tablet 0.1-20 mg-mcg 0

azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

BALCOLTRA ORAL TABLET 0.1 MG-0.02 MG (21)/36.5 MG(7)

2

balziva (28) oral tablet 0.4-35 mg-mcg 0

bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

BEYAZ ORAL TABLET 3-0.02-0.451 MG (24) (4)

3

blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

0

blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

brevicon (28) oral tablet 0.5-35 mg-mcg 0

briellyn oral tablet 0.4-35 mg-mcg 0

camila oral tablet 0.35 mg 0

camrese lo oral tablets,dose pack,3 month0.10 mg-20 mcg (84)/10 mcg (7)

0

camrese oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

0

caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg

0

chateal oral tablet 0.15-0.03 mg 0

cryselle (28) oral tablet 0.3-30 mg-mcg 0

cyclafem 1/35 (28) oral tablet 1-35 mg-mcg

0

cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

0

CYCLESSA (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

3

cyred oral tablet 0.15-0.03 mg 0

dasetta 1/35 (28) oral tablet 1-35 mg-mcg

0

dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

0

daysee oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

0

121


deblitane oral tablet 0.35 mg 0

delyla (28) oral tablet 0.1-20 mg-mcg 0

DEMULEN 1/50 (21) ORAL TABLET 1-50 MG-MCG

3

desog-e.estradiol/e.estradiol oral tablet0.15-0.02 mgx21 /0.01 mg x 5

(Azurette (28)) 0

DESOGEN ORAL TABLET 0.15-0.03 MG

3

desogestrel-ethinyl estradiol oral tablet0.15-0.03 mg

(Apri) 0

drospirenone-e.estradiol-lm.fa oral tablet3-0.02-0.451 mg (24) (4)

(Beyaz) 0

drospirenone-e.estradiol-lm.fa oral tablet3-0.03-0.451 mg (21) (7)

(Safyral) 0

drospirenone-ethinyl estradiol oral tablet3-0.02 mg

(Gianvi (28)) 0

drospirenone-ethinyl estradiol oral tablet3-0.03 mg

(Ocella) 0

econtra ez oral tablet 1.5 mg 0

elinest oral tablet 0.3-30 mg-mcg 0

ELLA ORAL TABLET 30 MG 2

emoquette oral tablet 0.15-0.03 mg 0

enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10)

0

enskyce oral tablet 0.15-0.03 mg 0

errin oral tablet 0.35 mg 0

estarylla oral tablet 0.25-35 mg-mcg 0

ESTROSTEP FE-28 ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

3

ethynodiol diac-eth estradiol oral tablet1-35 mg-mcg

(Kelnor 1/35 (28)) 0

ethynodiol diac-eth estradiol oral tablet1-50 mg-mcg

(Kelnor 1-50) 0

fallback solo oral tablet 1.5 mg 0

falmina (28) oral tablet 0.1-20 mg-mcg 0

fayosim oral tablets,dose pack,3 month0.15 mg-20 mcg/ 0.15 mg-25 mcg

0

FEMCON FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

3

femynor oral tablet 0.25-35 mg-mcg 0

122


GENERESS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

3

gianvi (28) oral tablet 3-0.02 mg 0

gildagia oral tablet 0.4-35 mg-mcg 0

gildess 1.5/30 (21) oral tablet 1.5-30 mg-mcg

0

gildess 1/20 (21) oral tablet 1-20 mg-mcg 0

gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

0

gildess fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

heather oral tablet 0.35 mg 0

introvale oral tablets,dose pack,3 month0.15 mg-30 mcg

0

isibloom oral tablet 0.15-0.03 mg 0

jencycla oral tablet 0.35 mg 0

jolessa oral tablets,dose pack,3 month0.15 mg-30 mcg

0

jolivette oral tablet 0.35 mg 0

juleber oral tablet 0.15-0.03 mg 0

junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg

0

junel 1/20 (21) oral tablet 1-20 mg-mcg 0

junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

0

junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

0

kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

kelnor 1/35 (28) oral tablet 1-35 mg-mcg 0

kelnor 1-50 oral tablet 1-50 mg-mcg 0

kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

kurvelo oral tablet 0.15-0.03 mg 0

123


l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

(Amethia Lo) 0

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

(Fayosim) 0

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

(Amethia) 0

larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg

0

larin 1/20 (21) oral tablet 1-20 mg-mcg 0

larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

0

larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

larissia oral tablet 0.1-20 mg-mcg 0

layolis fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

0

leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 0

lessina oral tablet 0.1-20 mg-mcg 0

levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)

0

levonorgestrel oral tablet 0.75 mg 0

levonorgestrel oral tablet 1.5 mg (Aftera) 0

levonorgestrel-ethinyl estrad oral tablet0.1-20 mg-mcg

(Aubra) 0

levonorgestrel-ethinyl estrad oral tablet0.15-0.03 mg

(Altavera (28)) 0

levonorgestrel-ethinyl estrad oral tablet90-20 mcg

(Amethyst) 0

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg

(Introvale) 0

levonorg-eth estrad triphasic oral tablet50-30 (6)/75-40 (5)/125-30(10)

(Enpresse) 0

levora-28 oral tablet 0.15-0.03 mg 0

lillow oral tablet 0.15-0.03 mg 0

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2)

2

124


LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

3

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

3

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

3

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

3

lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

loryna (28) oral tablet 3-0.02 mg 0

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)

3

low-ogestrel (28) oral tablet 0.3-30 mg-mcg

0

lutera (28) oral tablet 0.1-20 mg-mcg 0

lyza oral tablet 0.35 mg 0

marlissa oral tablet 0.15-0.03 mg 0

melodetta 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

0

mibelas 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

0

microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg

0

microgestin 1/20 (21) oral tablet 1-20 mg-mcg

0

microgestin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4)

0

microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

0

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

mili oral tablet 0.25-35 mg-mcg 0

MINASTRIN 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

3

MIRCETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

3

125


MODICON (28) ORAL TABLET 0.5-35 MG-MCG

3

mono-linyah oral tablet 0.25-35 mg-mcg 0

mononessa (28) oral tablet 0.25-35 mg-mcg

0

my choice oral tablet 1.5 mg 0

my way oral tablet 1.5 mg 0

myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10)

0

NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG

2

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg

0

necon 1/35 (28) oral tablet 1-35 mg-mcg 0

necon 1/50 (28) oral tablet 1-50 mg-mcg 0

necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg

0

necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

0

next choice one dose oral tablet 1.5 mg 0

nikki (28) oral tablet 3-0.02 mg 0

nora-be oral tablet 0.35 mg 0

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

(Wymzya Fe) 0

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

(Generess Fe) 0

norethindrone (contraceptive) oral tablet0.35 mg

(Camila) 0

norethindrone ac-eth estradiol oral tablet1-20 mg-mcg

(Junel 1/20 (21)) 0

norethindrone-e.estradiol-iron oral tablet1 mg-20 mcg (21)/75 mg (7)

(Blisovi Fe 1/20 (28)) 0

norethindrone-e.estradiol-iron oral tablet1 mg-20 mcg (24)/75 mg (4)

(Blisovi 24 Fe) 0

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

(Melodetta 24 Fe) 0

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg

(Ortho Tri-Cyclen LO (28))

0

126


norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-35 mcg (28)

(Ortho Tri-Cyclen (28)) 0

norgestimate-ethinyl estradiol oral tablet0.25-35 mg-mcg

(Estarylla) 0

norinyl 1/35 (28) oral tablet 1-35 mg-mcg

0

NORINYL 1+50 (28) ORAL TABLET 1-50 MG-MCG

3

norlyda oral tablet 0.35 mg 0

norlyroc oral tablet 0.35 mg 0

NOR-QD ORAL TABLET 0.35 MG 3

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg

0

nortrel 1/35 (21) oral tablet 1-35 mg-mcg

0

nortrel 1/35 (28) oral tablet 1-35 mg-mcg

0

nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

0

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR

2

ocella oral tablet 3-0.03 mg 0

ogestrel (28) oral tablet 0.5-50 mg-mcg 0

opcicon one-step oral tablet 1.5 mg 0

option-2 oral tablet 1.5 mg 0

orsythia oral tablet 0.1-20 mg-mcg 0

ORTHO EVRA TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR

3

ORTHO MICRONOR ORAL TABLET 0.35 MG

3

ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

3

ORTHO TRI-CYCLEN LO (28) ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

3

ORTHO-CEPT (28) ORAL TABLET 0.15-0.03 MG

3

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG

3

127


ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG

3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

3

OVCON-35 (28) ORAL TABLET 0.4-35 MG-MCG

3

philith oral tablet 0.4-35 mg-mcg 0

pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg

0

PLAN B ONE-STEP ORAL TABLET 1.5 MG

3

portia oral tablet 0.15-0.03 mg 0

previfem oral tablet 0.25-35 mg-mcg 0

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

3

quasense oral tablets,dose pack,3 month0.15 mg-30 mcg

0

rajani oral tablet 3-0.02-0.451 mg (24) (4)

0

react oral tablet 1.5 mg 0

reclipsen (28) oral tablet 0.15-0.03 mg 0

rivelsa oral tablets,dose pack,3 month0.15 mg-20 mcg/ 0.15 mg-25 mcg

0

SAFYRAL ORAL TABLET 3-0.03-0.451 MG (21) (7)

3

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

3

setlakin oral tablets,dose pack,3 month0.15 mg-30 mcg

0

sharobel oral tablet 0.35 mg 0

sprintec (28) oral tablet 0.25-35 mg-mcg 0

sronyx oral tablet 0.1-20 mg-mcg 0

syeda oral tablet 3-0.03 mg 0

TAKE ACTION ORAL TABLET 1.5 MG

0

tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

0

128


TAYTULLA ORAL CAPSULE 1 MG-20 MCG (24)/75 MG (4)

2

tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)

0

tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)

0

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

0

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg

0

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

0

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

0

TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

3

tri-previfem (28) oral tablet0.18/0.215/0.25 mg-35 mcg (28)

0

tri-sprintec (28) oral tablet0.18/0.215/0.25 mg-35 mcg (28)

0

trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)

0

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

tulana oral tablet 0.35 mg 0

tydemy oral tablet 3-0.03-0.451 mg (21) (7)

0

velivet triphasic regimen (28) oral tablet0.1/.125/.15-25 mg-mcg

0

vestura (28) oral tablet 3-0.02 mg 0

vienva oral tablet 0.1-20 mg-mcg 0

129


viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

0

vyfemla (28) oral tablet 0.4-35 mg-mcg 0

vylibra oral tablet 0.25-35 mg-mcg 0

wera (28) oral tablet 0.5-35 mg-mcg 0

wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

0

xulane transdermal patch weekly 150-35 mcg/24 hr

0

YASMIN (28) ORAL TABLET 3-0.03 MG

3

YAZ (28) ORAL TABLET 3-0.02 MG 3

zarah oral tablet 3-0.03 mg 0

zenchent (28) oral tablet 0.4-35 mg-mcg 0

zenchent fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

0

zeosa oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

0

zovia 1/35e (28) oral tablet 1-35 mg-mcg 0

zovia 1/50e (28) oral tablet 1-50 mg-mcg 0

Cough And Cold ProductsCough And Cold Productsbenzonatate oral capsule 100 mg (Tessalon Perles) 1

benzonatate oral capsule 150 mg 2

benzonatate oral capsule 200 mg 1

bromfed dm oral syrup 2-30-10 mg/5 ml 2

brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg/5 ml

(Bromfed DM) 2

centergy dm oral drops 1-2-3 mg/ml 1

cheratussin ac oral liquid 10-100 mg/5 ml 1 AGE (Min 18 Years)

codeine-guaifenesin oral liquid 10-100 mg/5 ml

(Cheratussin AC) 1 AGE (Min 18 Years)

HYCOFENIX ORAL SOLUTION 2.5-30-200 MG/5 ML

3 QL (473 per 30 days); AGE (Min 18 Years)

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr 10-8 mg/5 ml

(Tussionex Pennkinetic ER)

1 AGE (Min 18 Years)

hydrocodone-cpm-pseudoephed oral solution 5-4-60 mg/5 ml


hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

(Hydrocodone Compound)


130


hydrocodone-homatropine oral tablet 5-1.5 mg

(Tussigon) 1 AGE (Min 18 Years)

hydromet oral syrup 5-1.5 mg/5 ml 1 AGE (Min 18 Years)

promethazine vc-codeine oral syrup 6.25-5-10 mg/5 ml


promethazine-codeine oral syrup 6.25-10 mg/5 ml


promethazine-dm oral syrup 6.25-15 mg/5 ml

1

REZIRA ORAL SOLUTION 60-5 MG/5 ML


TESSALON PERLES ORAL CAPSULE 100 MG

3

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR 10-8 MG, 5-4 MG


TUSSIGON ORAL TABLET 5-1.5 MG


TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDED REL 12 HR 10-8 MG/5 ML


TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR 14.7-2.8 MG/5 ML


VITUZ ORAL SOLUTION 5-4 MG/5 ML


ZONATUSS ORAL CAPSULE 150 MG

3

ZUTRIPRO ORAL SOLUTION 5-4-60 MG/5 ML


Dental And Oral AgentsDental And Oral AgentsCAPHOSOL MUCOUS MEMBRANE SOLUTION

3

cevimeline oral capsule 30 mg (Evoxac) 2

chlorhexidine gluconate mucous membrane mouthwash 0.12 %

(Paroex Oral Rinse) 1

CLINPRO 5000 DENTAL PASTE 1.1 %

3

denta 5000 plus dental cream 1.1 % 1

dentagel dental gel 1.1 % 1

EVOXAC ORAL CAPSULE 30 MG 3

131


fluoride (sodium) dental solution 0.2 % (PreviDent) 1

FLUORIDEX DAILY DEFENSE DENTAL PASTE 1.1 %

3

fluoridex sensitivity relief dental gel 1.1-5 %

1

oralone dental paste 0.1 % 1

paroex oral rinse mucous membrane mouthwash 0.12 %

1

PERIDEX MUCOUS MEMBRANE MOUTHWASH 0.12 %

3

periogard mucous membrane mouthwash0.12 %

1

pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

3

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

3

PREVIDENT DENTAL SOLUTION 0.2 %

3

SALAGEN (PILOCARPINE) ORAL TABLET 5 MG, 7.5 MG

3

sf 5000 plus dental cream 1.1 % 1

stannous fluoride dental solution 0.63 % (Perio Med) 1

triamcinolone acetonide dental paste 0.1 %

(Oralone) 1

Dermatological AgentsDermatological Agents, Other8-MOP ORAL CAPSULE 10 MG 3

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

3 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

(Soriatane) 3 *May have Specialty Costshare

acyclovir topical ointment 5 % (Zovirax) 2

ACZONE TOPICAL GEL 5 % 3

ACZONE TOPICAL GEL WITH PUMP 7.5 %

3

ALDARA TOPICAL CREAM IN PACKET 5 %

3

ALUVEA TOPICAL CREAM 39 % 3

ammonium lactate topical cream 12 % (Geri-Hydrolac) 1

132


ammonium lactate topical lotion 12 % (AmLactin) 1

amnesteem oral capsule 10 mg, 20 mg, 40 mg

2 PA

ANACAINE TOPICAL OINTMENT 10 %

2

AVAR LS TOPICAL CLEANSER 10-2 %

3

AVAR LS TOPICAL FOAM 10-2 % 3

AVAR LS TOPICAL PADS, MEDICATED 10-2 %

3

AVAR TOPICAL CLEANSER 10-5 % (W/W)

3

AVAR TOPICAL FOAM 9.5-5 % 3

AVAR TOPICAL PADS, MEDICATED 9.5-5 %

3

AVAR-E LS TOPICAL CREAM 10-2 %

3

AVAR-E TOPICAL CREAM 10-5 % (W/W)

3

AZELEX TOPICAL CREAM 20 % 3

BENSAL HP TOPICAL OINTMENT 3 %

3

BENZAC AC TOPICAL GEL 5 % 3

BENZAC AC WASH TOPICAL CLEANSER 10 %

3

BENZEFOAM TOPICAL FOAM 5.3 %

3

BENZEFOAM ULTRA TOPICAL FOAM 9.8 %

3

benzepro (microspheres) topical cleanser7 %

2

benzepro topical towelette 6 % 2

benzoyl peroxide topical cleanser 7 % (BP Wash) 2

benzoyl peroxide topical foam 5.3 % (BenzEFoam) 2

benzoyl peroxide topical foam 9.8 % (BenzEFoam Ultra) 1

benzoyl peroxide topical gel 10 % (Acne Medication) 1

bp 10-1 topical cleanser 10-1 % 2

bpo topical gel 4 %, 8 % 2

bpo topical towelette 6 % 2

bpo topical towelette 9 % 1

calcipotriene scalp solution 0.005 % 1

133


calcipotriene topical cream 0.005 % (Dovonex) 1

calcipotriene topical ointment 0.005 % (Calcitrene) 1

calcipotriene-betamethasone topical ointment 0.005-0.064 %

(Taclonex) 2

calcitrene topical ointment 0.005 % 1

calcitriol topical ointment 3 mcg/gram (Vectical) 2

CARAC TOPICAL CREAM 0.5 % 3

cem-urea topical gel 45 % 1

CETACAINE ANESTHETIC TOPICAL LIQUID 2-2-14 %

3

CETACAINE TOPICAL AEROSOL,SPRAY 2 %-2 %-14 % (200 MG/SEC)

3

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2 PA

CLARIS CLARIFYING WASH TOPICAL CLEANSER 10-4-10 %

3

cleansing wash topical cleanser 10-4-10 %

2

CONDYLOX TOPICAL GEL 0.5 % 3

CONDYLOX TOPICAL SOLUTION 0.5 %

3

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML


COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML


dapsone topical gel 5 % (Aczone) 2

DENAVIR TOPICAL CREAM 1 % 2

diclofenac sodium topical drops 1.5 % 2 ST

diclofenac sodium topical gel 1 % (Voltaren) 2

diclofenac sodium topical gel 3 % (Solaraze) 2 QL (105 per 1 day)

DOVONEX TOPICAL CREAM 0.005 %

3

doxepin topical cream 5 % (Prudoxin) 2

DRITHOCREME HP TOPICAL CREAM 1 %

3 ST

DRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 %

3

134


DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML


EFUDEX TOPICAL CREAM 5 % 3

ENSTILAR TOPICAL FOAM 0.005-0.064 %

3

exoderm topical lotion 25-1 % 1

FINACEA TOPICAL FOAM 15 % 3

FINACEA TOPICAL GEL 15 % 3

FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 %

3

FLUOROPLEX TOPICAL CREAM 1 %

3

fluorouracil topical cream 0.5 % (Carac) 1

fluorouracil topical cream 5 % (Efudex) 1

fluorouracil topical solution 2 %, 5 % 1

GORDONS UREA TOPICAL OINTMENT 22 %, 40 %

3

HYDRO 35 TOPICAL FOAM 35 % 3

hypercare topical solution 20 % 1

imiquimod topical cream in packet 5 % (Aldara) 1

INOVA 4-1 TOPICAL COMBO PACK 1-4-5 %

3

INOVA 8-2 TOPICAL COMBO PACK 2-8-5 %

3

IODOSORB TOPICAL GEL 0.9 % 3

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

(Absorica) 2 PA NSO

KERAFOAM TOPICAL FOAM 30 %, 42 %

3

KERALYT RX TOPICAL GEL 6 % 3

KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO AND GEL 6-6 %

3

LAC-HYDRIN TOPICAL CREAM 12 %

3

LAC-HYDRIN TOPICAL LOTION 12 %

3

latrix topical suspension 50 % 1

latrix xm topical emulsion in metered-dose pump 45 %

1

135


lidocaine-hydrocortisone-aloe rectal gel2.8-0.55 %

1

mafenide acetate topical packet 50 gram (Sulfamylon) 2

methoxsalen oral capsule,liqd-filled,rapid rel 10 mg

(Oxsoralen Ultra) 2

MIRVASO TOPICAL GEL WITH PUMP 0.33 %

3

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2 PA

OVACE PLUS TOPICAL FOAM 9.8 %

3

OXSORALEN ULTRA ORAL CAPSULE,LIQD-FILLED,RAPID REL 10 MG

3

PACNEX HP TOPICAL PADS, MEDICATED 7 %

3

PACNEX LP TOPICAL PADS, MEDICATED 4.25 %

3

PACNEX MX TOPICAL CLEANSER 4.25 %

3

PACNEX TOPICAL CLEANSER 7 % 3

PANRETIN TOPICAL GEL 0.1 % 3 *May have Specialty Costshare

PENNSAID TOPICAL DROPS 1.5 % 3 ST

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %)

3 ST

PICATO TOPICAL GEL 0.015 %, 0.05 %

3

PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED 9.8-4.8 %

3

PLEXION TOPICAL CLEANSER 9.8-4.8 %

3

PLEXION TOPICAL CREAM 9.8-4.8 %

3

PLEXION TOPICAL LOTION 9.8-4.8 %

3

podocon topical liquid 25 % 1

podofilox topical solution 0.5 % 1

PRUDOXIN TOPICAL CREAM 5 % 3

RADIAPLEXRX TOPICAL GEL 3

136


REGRANEX TOPICAL GEL 0.01 % 3

remeven topical cream 50 % 1

RHOFADE TOPICAL CREAM 1 % 3

ROSANIL TOPICAL CLEANSER 10-5 % (W/W)

3

rosula cleansing cloths topical pads, medicated 10-5 %

3

ROSULA TOPICAL CLEANSER 10-4.5 %

3

SALACYN TOPICAL CREAM 6 % 3

salacyn topical lotion 6 % 1

SALEX TOPICAL COMBO PACK 6 %

3

SALEX TOPICAL KIT,CLEANSER AND CREAM ER 6 %

3

SALEX TOPICAL SHAMPOO 6 % 3

salicylic acid er-ceramides topical kit,cleanser and cream er 6 %

(Salex) 1

salicylic acid topical film forming liquid w/appl 27.5 %

(Virasal) 2

salicylic acid topical foam 6 % (Salvax) 2

salicylic acid topical gel 6 % (Keralyt Rx) 1

salicylic acid topical liquid 26 % 1

salicylic acid topical lotion 6 % 1

salicylic acid topical shampoo 6 % (Salex) 1

SALKERA TOPICAL FOAM 6 % 3

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM


seb-prev topical cleanser 10 % 1

SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML


SOLARAZE TOPICAL GEL 3 % 3 QL (105 per 1 day)

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG


SORILUX TOPICAL FOAM 0.005 % 3

sss 10-5 topical foam 10-5 % 1

sulfacetamide sodium topical cleanser 10 %

(Ovace) 1

sulfacetamide sodium topical shampoo 10 %

(Ovace Plus Shampoo) 2

137


sulfacetamide sodium-sulfur topical cleanser 10-2 %

(Avar LS) 2

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

(Avar) 1

sulfacetamide sodium-sulfur topical cleanser 9.8-4.8 %

(Plexion) 2

sulfacetamide sodium-sulfur topical cleanser 9-4 %

(Sumaxin) 2

sulfacetamide sodium-sulfur topical cleanser 9-4.5 %

(Sumadan) 1

sulfacetamide sodium-sulfur topical cream 10-2 %

(Avar-E LS) 2

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w)

(Avar-E) 1

sulfacetamide sodium-sulfur topical cream 9.8-4.8 %

(Plexion) 2

sulfacetamide sodium-sulfur topical lotion10-5 % (w/w)

2

sulfacetamide sodium-sulfur topical lotion9.8-4.8 %

(Plexion) 2

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

(Sumaxin) 2

sulfacetamide sodium-sulfur topical pads, medicated 10-5 %

(Rosula cleansing cloths)

1

sulfacetamide sodium-sulfur topical suspension 8-4 %

(SulfaCleanse 8-4) 2

SULFAMYLON TOPICAL CREAM 85 MG/G

3

SULFAMYLON TOPICAL PACKET 50 GRAM

3

SUMADAN TOPICAL CLEANSER 9-4.5 %

3

SUMAXIN TOPICAL CLEANSER 9-4 %

3

SUMAXIN TOPICAL PADS, MEDICATED 10-4 %

3

SUMAXIN TS TOPICAL SUSPENSION 8-4 %

3

TACLONEX TOPICAL OINTMENT 0.005-0.064 %

3

TACLONEX TOPICAL SUSPENSION 0.005-0.064 %

3

138


TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML


TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML


TOLAK TOPICAL CREAM 4 % 3

TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML


UMECTA PD TOPICAL EMULSION, ADHESIVE 40 %

3

UMECTA TOPICAL EMULSION 40 %

3

umecta topical foam 40 % 3

UMECTA TOPICAL SUSPENSION 40 %

3

URAMAXIN TOPICAL CREAM 45 %

3

URAMAXIN TOPICAL FOAM 20 % 3

URAMAXIN TOPICAL GEL 45 % 3

URAMAXIN TOPICAL LOTION 45 %

3

urea nail stick topical solution 50 % 1

urea topical cream 39 % (Uredeb) 2

urea topical cream 40 % 1

urea topical cream 45 % (Uramaxin) 1

urea topical cream 47 % (Keralac) 1

urea topical foam 35 % (Hydro 35) 1

urea topical gel 40 % 1

urea topical gel 45 % (CEM-Urea) 1

urea topical lotion 40 % 1

urea topical lotion 45 % (Uramaxin) 1

UREDEB TOPICAL CREAM 39 % 3

VALCHLOR TOPICAL GEL 0.016 % 3 *May have Specialty Costshare

VANOXIDE-HC TOPICAL SUSPENSION 5-0.5 %

3

vasolex topical ointment 90-87-788 unit-mg-mg/gram

1

139


VECTICAL TOPICAL OINTMENT 3 MCG/GRAM

3

VENELEX TOPICAL OINTMENT 87-788 MG/GRAM

3

VEREGEN TOPICAL OINTMENT 15 %

3

VIRASAL TOPICAL FILM FORMING LIQUID W/APPL 27.5 %

3

VOLTAREN TOPICAL GEL 1 % 3

XERESE TOPICAL CREAM 5-1 % 3

x-viate topical cream 40 % 1

X-VIATE TOPICAL GEL 40 % 3

x-viate topical lotion 40 % 1

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2 PA NSO

ZENCIA TOPICAL CLEANSER 9-4 %

3

ZITHRANOL TOPICAL SHAMPOO 1 %

3 ST

ZITHRANOL-RR TOPICAL CREAM, RAPID RELEASE 1.2 %

3 ST

ZONALON TOPICAL CREAM 5 % 3

ZOVIRAX TOPICAL CREAM 5 % 3

ZOVIRAX TOPICAL OINTMENT 5 %

3

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 %, 3.75 %

3

Dermatological AntibacterialsACANYA TOPICAL GEL WITH PUMP 1.2-2.5 %

3

AKNE-MYCIN TOPICAL OINTMENT 2 %

3

AKTIPAK TOPICAL GEL 3-5 % 3

ALTABAX TOPICAL OINTMENT 1 %

3

BACTROBAN NASAL NASAL OINTMENT 2 %

3

BACTROBAN TOPICAL CREAM 2 %

3

BACTROBAN TOPICAL OINTMENT 2 %

3

140


BENZACLIN PUMP TOPICAL GEL WITH PUMP 1-5 %

3

BENZAMYCIN TOPICAL GEL 3-5 % 3

CENTANY AT TOPICAL OINTMENT KIT 2 %

3

CENTANY TOPICAL OINTMENT 2 %

3

CLEOCIN T TOPICAL GEL 1 % 3

CLEOCIN T TOPICAL LOTION 1 % 3

CLEOCIN T TOPICAL SOLUTION 1 %

3

CLEOCIN T TOPICAL SWAB 1 % 3

CLINDACIN ETZ TOPICAL SWAB 1 %

3

CLINDAGEL TOPICAL GEL, ONCE DAILY 1 %

3

clindamycin phosphate topical foam 1 % (Evoclin) 2

clindamycin phosphate topical gel 1 % (Cleocin T) 1

clindamycin phosphate topical lotion 1 % (Cleocin T) 1

clindamycin phosphate topical solution 1 %

(Cleocin T) 1

clindamycin phosphate topical swab 1 % (Cleocin T) 1

clindamycin-benzoyl peroxide topical gel1.2 %(1 % base) -5 %

(Duac) 1

clindamycin-benzoyl peroxide topical gel1-5 %

(Benzaclin) 2

clindamycin-tretinoin topical gel 1.2-0.025 %

(Veltin) 2 AGE (Max 25 Years)

CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 MG/G-UNIT/G-%

3

CORTISPORIN TOPICAL OINTMENT 1 %

3

DUAC TOPICAL GEL 1.2 %(1 % BASE) -5 %

3

ery pads topical swab 2 % 1

ERYGEL TOPICAL GEL 2 % 3

erythromycin with ethanol topical gel 2 % (Erygel) 2

erythromycin with ethanol topical solution 2 %

1

erythromycin with ethanol topical swab 2 %

(Ery Pads) 1

141


erythromycin-benzoyl peroxide topical gel 3-5 %

(Aktipak) 2

EVOCLIN TOPICAL FOAM 1 % 3

gentamicin topical cream 0.1 % 1

gentamicin topical ointment 0.1 % 1

KLARON TOPICAL SUSPENSION 10 %

3

METROCREAM TOPICAL CREAM 0.75 %

3

METROGEL TOPICAL GEL 1 % 3

METROLOTION TOPICAL LOTION 0.75 %

3

metronidazole topical cream 0.75 % (MetroCream) 1

metronidazole topical gel 0.75 % (Rosadan) 1

metronidazole topical gel 1 % (Metrogel) 2

metronidazole topical lotion 0.75 % (MetroLotion) 1

mupirocin calcium topical cream 2 % (Bactroban) 2

mupirocin topical ointment 2 % (Centany) 1

NEO-SYNALAR TOPICAL CREAM 0.5 % (0.35 % BASE)-0.025 %

3 ST

neuac topical gel 1.2 %(1 % base) -5 % 2

NORITATE TOPICAL CREAM 1 % 2

ONEXTON TOPICAL GEL WITH PUMP 1.2 %(1 % BASE) -3.75 %

3

OVACE PLUS TOPICAL LOTION 9.8 %

3

rosadan topical cream 0.75 % 1

ROSADAN TOPICAL GEL 0.75 % 3

selenium sulfide topical lotion 2.5 % 1

selenium sulfide topical shampoo 2.25 % 2

SILVADENE TOPICAL CREAM 1 % 3

silver nitrate applicators topical stick 75-25 %

2

silver nitrate topical ointment 10 % 1

silver sulfadiazine topical cream 1 % (Silvadene) 1

ssd topical cream 1 % 1

sulfacetamide sodium (acne) topical suspension 10 %

(Klaron) 2

TERSI FOAM TOPICAL FOAM 2.25 %

3

142


THERMAZENE TOPICAL CREAM 1 %

3

VELTIN TOPICAL GEL 1.2-0.025 % 3 AGE (Max 25 Years)

ZIANA TOPICAL GEL 1.2-0.025 % 3 AGE (Max 25 Years)Dermatological Anti-Inflammatory Agentsala-cort topical cream 1 %, 2.5 % 1

ala-scalp topical lotion 2 % 2

alclometasone topical cream 0.05 % 2

alclometasone topical ointment 0.05 % 2

amcinonide topical cream 0.1 % 2

amcinonide topical lotion 0.1 % 2

amcinonide topical ointment 0.1 % 2

ANALPRAM ADVANCED KIT 2.5 %-1 %/ 630 MG/1 %-1 %

3

ANALPRAM E RECTAL KIT,CREAM AND TOWELETTE 2.5 %-1 % (4 GRAM)-1 %, 2.5-1-1 %

3

ANALPRAM-HC RECTAL CREAM 1-1 %, 2.5-1 %

3

ANALPRAM-HC TOPICAL LOTION 2.5-1 %

3

anucort-hc rectal suppository 25 mg 1

ANUSOL-HC RECTAL SUPPOSITORY 25 MG

3

ANUSOL-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

3

APEXICON E TOPICAL CREAM 0.05 %

3

betamethasone dipropionate topical cream 0.05 %

2

betamethasone dipropionate topical lotion 0.05 %

2

betamethasone dipropionate topical ointment 0.05 %

2

betamethasone valerate topical cream 0.1 %

1

betamethasone valerate topical foam 0.12 %

(Luxiq) 2

betamethasone valerate topical lotion 0.1 %

1

143


betamethasone valerate topical ointment0.1 %

2

betamethasone, augmented topical cream0.05 %

2

betamethasone, augmented topical gel0.05 %

1

betamethasone, augmented topical lotion0.05 %

2

betamethasone, augmented topical ointment 0.05 %

(Diprolene) 2

CAPEX TOPICAL SHAMPOO 0.01 % 3

clobetasol scalp solution 0.05 % (Cormax) 2

clobetasol topical cream 0.05 % (Temovate) 2

clobetasol topical foam 0.05 % (Olux) 2

clobetasol topical gel 0.05 % 2

clobetasol topical lotion 0.05 % (Clobex) 2

clobetasol topical ointment 0.05 % (Temovate) 2

clobetasol topical shampoo 0.05 % (Clobex) 2

clobetasol topical spray,non-aerosol 0.05 %

(Clobex) 2

clobetasol-emollient topical cream 0.05 % 2

clobetasol-emollient topical foam 0.05 % (Olux-E) 2

CLOBEX TOPICAL LOTION 0.05 % 3

CLOBEX TOPICAL SHAMPOO 0.05 %

3

CLOBEX TOPICAL SPRAY,NON-AEROSOL 0.05 %

3

clocortolone pivalate topical cream 0.1 % (Cloderm) 2

CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER 0.05 %

3

CLODAN TOPICAL SHAMPOO 0.05 %

3

CLODERM TOPICAL CREAM 0.1 % 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2

3

CORDRAN TOPICAL CREAM 0.05 %

3

CORDRAN TOPICAL LOTION 0.05 %

3

144


CORDRAN TOPICAL OINTMENT 0.05 %

3

cormax scalp solution 0.05 % 2

CORTIFOAM RECTAL FOAM 10 % (80 MG)

3

CUTIVATE TOPICAL CREAM 0.05 %

3

CUTIVATE TOPICAL LOTION 0.05 %

3

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL 0.01 %

3

DERMATOP TOPICAL CREAM 0.1 %

3

DERMATOP TOPICAL OINTMENT 0.1 %

3

dermazene topical cream 1-1 % 1

DESONATE TOPICAL GEL 0.05 % 3

desonide topical cream 0.05 % (DesOwen) 2

desonide topical lotion 0.05 % (DesOwen) 2

desonide topical ointment 0.05 % 2

desoximetasone topical cream 0.05 %, 0.25 %

(Topicort) 2

desoximetasone topical gel 0.05 % (Topicort) 2

desoximetasone topical ointment 0.05 %, 0.25 %

(Topicort) 2

diflorasone topical cream 0.05 % (Psorcon) 2

diflorasone topical ointment 0.05 % 2

DIPROLENE AF TOPICAL CREAM 0.05 %

3

DIPROLENE TOPICAL LOTION 0.05 %

3

DIPROLENE TOPICAL OINTMENT 0.05 %

3

ELIDEL TOPICAL CREAM 1 % 3

ELOCON TOPICAL CREAM 0.1 % 3

ELOCON TOPICAL OINTMENT 0.1 %

3

ELOCON TOPICAL SOLUTION 0.1 %

3

EPIFOAM TOPICAL FOAM 1-1 % 3

145


EUCRISA TOPICAL OINTMENT 2 %

3 ST; AGE (Min 2 Years)

fluocinolone topical cream 0.01 % 1

fluocinolone topical cream 0.025 % (Synalar) 1

fluocinolone topical oil 0.01 % (Derma-Smoothe/FS Body Oil)

1

fluocinolone topical ointment 0.025 % (Synalar) 1

fluocinolone topical solution 0.01 % (Synalar) 2

fluocinonide topical cream 0.05 % 2

fluocinonide topical cream 0.1 % (Vanos) 2

fluocinonide topical gel 0.05 % 2

fluocinonide topical ointment 0.05 % 2

fluocinonide topical solution 0.05 % 2

fluocinonide-e topical cream 0.05 % 2

flurandrenolide topical cream 0.05 % (Cordran) 2

flurandrenolide topical lotion 0.05 % (Cordran) 2

flurandrenolide topical ointment 0.05 % (Cordran) 2

fluticasone topical cream 0.05 % (Cutivate) 1

fluticasone topical lotion 0.05 % (Cutivate) 2

fluticasone topical ointment 0.005 % 1

halobetasol propionate topical cream 0.05 %

(Ultravate) 2

halobetasol propionate topical ointment0.05 %

(Ultravate) 2

HALOG TOPICAL CREAM 0.1 % 3

HALOG TOPICAL OINTMENT 0.1 %

3

HEMMOREX-HC RECTAL SUPPOSITORY 25 MG, 30 MG

3

hydrocortisone acet-aloe vera topical gel2 %

1

hydrocortisone acetate rectal suppository25 mg

(Anucort-HC) 1

hydrocortisone acetate rectal suppository30 mg

(Hemmorex-HC) 1

hydrocortisone butyrate topical cream 0.1 %

(Locoid) 2

hydrocortisone butyrate topical lotion 0.1 %

(Locoid) 2

hydrocortisone butyrate topical ointment0.1 %

2

146


hydrocortisone butyrate topical solution0.1 %

(Locoid) 2

hydrocortisone topical cream 1 %, 2.5 % (Ala-Cort) 1

hydrocortisone topical cream with perineal applicator 2.5 %

(Anusol-HC) 1

hydrocortisone topical lotion 1 % (Anti-Itch (HC)) 1

hydrocortisone topical lotion 2.5 % 1

hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 1

hydrocortisone topical ointment 2.5 % 1

hydrocortisone valerate topical cream 0.2 %

2

hydrocortisone valerate topical ointment0.2 %

2

hydrocortisone-pramox-e-pram#1 rectal kit,cream and towelette 2.5-1-1 %

1

hydrocortisone-pramoxine rectal cream1-1 %, 2.5-1 %

(Analpram-HC) 1

hydrocortisone-pramoxine topical cream2.5-1 %

(Pramosone) 1

IMPOYZ TOPICAL CREAM 0.025 % 3

iodoquinol-hc topical cream 1-1 % 1

KENALOG TOPICAL AEROSOL 0.147 MG/GRAM

3

LOCOID TOPICAL CREAM 0.1 % 3

LOCOID TOPICAL LOTION 0.1 % 3

LOCOID TOPICAL OINTMENT 0.1 %

3

LOCOID TOPICAL SOLUTION 0.1 %

3

LUXIQ TOPICAL FOAM 0.12 % 3

MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

3

mometasone topical cream 0.1 % (Elocon) 1

mometasone topical ointment 0.1 % (Elocon) 1

mometasone topical solution 0.1 % 1

NOLIX TOPICAL CREAM 0.05 % 3

NOLIX TOPICAL LOTION 0.05 % 3

NUCORT TOPICAL LOTION 2 % 3

OLUX TOPICAL FOAM 0.05 % 3

OLUX-E TOPICAL FOAM 0.05 % 3

147


PANDEL TOPICAL CREAM 0.1 % 3

PEDIADERM HC TOPICAL KIT,LOTION AND CREAM,EMOLLIENT 2 %

3

PRAMCORT RECTAL CREAM 1-1 %

3

PRAMOSONE E TOPICAL CREAM 2.5-1 %

3

PRAMOSONE TOPICAL CREAM 1-1 %, 2.5-1 %

3

PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1 %

3

PRAMOSONE TOPICAL OINTMENT 1-1 %, 2.5-1 %

3

prednicarbate topical cream 0.1 % 2

prednicarbate topical ointment 0.1 % (Dermatop) 2

PROCORT RECTAL CREAM 1.85-1.15 %

3

PROCTOCORT RECTAL SUPPOSITORY 30 MG

3

PROCTOCORT TOPICAL CREAM 1 %

3

PROCTOFOAM HC RECTAL FOAM 1-1 %

3

procto-med hc topical cream with perineal applicator 2.5 %

1

procto-pak topical cream with perineal applicator 1 %

1

proctosol hc topical cream with perineal applicator 2.5 %

1

proctozone-hc topical cream with perineal applicator 2.5 %

1

PROTOPIC TOPICAL OINTMENT 0.03 %, 0.1 %

3

PSORCON TOPICAL CREAM 0.05 % 3

RECTACORT-HC RECTAL SUPPOSITORY 25 MG

3

SCALACORT DK TOPICAL COMBO PACK 2-2-2 %

3

SCALACORT TOPICAL LOTION 2 %

3

148


SERNIVO TOPICAL SPRAY WITH PUMP 0.05 %

3 ST; *May have Specialty Costshare

SYNALAR TOPICAL CREAM 0.025 %

3

SYNALAR TOPICAL OINTMENT 0.025 %

3

SYNALAR TOPICAL SOLUTION 0.01 %

3

SYNALAR TS TOPICAL KIT 0.01 % 3

tacrolimus topical ointment 0.03 %, 0.1 %

(Protopic) 2

TEMOVATE TOPICAL CREAM 0.05 %

3

TEMOVATE TOPICAL OINTMENT 0.05 %

3

TOPICORT TOPICAL CREAM 0.05 %, 0.25 %

3

TOPICORT TOPICAL GEL 0.05 % 3

TOPICORT TOPICAL OINTMENT 0.05 %, 0.25 %

3

TOPICORT TOPICAL SPRAY,NON-AEROSOL 0.25 %

3

triamcinolone acetonide topical aerosol0.147 mg/gram

(Kenalog) 2

triamcinolone acetonide topical cream0.025 %

1

triamcinolone acetonide topical cream 0.1 %, 0.5 %

(Triderm) 1

triamcinolone acetonide topical lotion0.025 %, 0.1 %

1

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %

1

trianex topical ointment 0.05 % 2

triderm topical cream 0.1 %, 0.5 % 1

tridesilon topical cream 0.05 % 2

u-cort topical cream 1-10 % 1

ULTRAVATE TOPICAL CREAM 0.05 %

3

ULTRAVATE TOPICAL LOTION 0.05 %

3

ULTRAVATE TOPICAL OINTMENT 0.05 %

3

149


VANOS TOPICAL CREAM 0.1 % 3

VERDESO TOPICAL FOAM 0.05 % 3

ZYPRAM RECTAL KIT,CREAM AND TOWELETTE 2.35-1 %

3

Dermatological Retinoidsadapalene topical cream 0.1 % (Differin) 1 AGE (Max 25 Years)

adapalene topical gel 0.1 %, 0.3 % (Differin) 1 AGE (Max 25 Years)

adapalene topical lotion 0.1 % (Differin) 1 AGE (Max 25 Years)

adapalene-benzoyl peroxide topical gel with pump 0.1-2.5 %

(Epiduo) 2 AGE (Max 25 Years)

ATRALIN TOPICAL GEL 0.05 % 3 AGE (Max 25 Years)

avita topical cream 0.025 % 1 AGE (Max 25 Years)

avita topical gel 0.025 % 1 AGE (Max 25 Years)

DIFFERIN TOPICAL CREAM 0.1 % 3 AGE (Max 25 Years)

DIFFERIN TOPICAL GEL 0.1 % 3 AGE (Max 25 Years)

DIFFERIN TOPICAL GEL WITH PUMP 0.3 %

3 AGE (Max 25 Years)

DIFFERIN TOPICAL LOTION 0.1 % 3 AGE (Max 25 Years)

EPIDUO FORTE TOPICAL GEL WITH PUMP 0.3-2.5 %


EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5 %


FABIOR TOPICAL FOAM 0.1 % 3 AGE (Max 25 Years)

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.06 %, 0.08 %


RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1 %


RETIN-A TOPICAL CREAM 0.025 %, 0.05 %, 0.1 %


RETIN-A TOPICAL GEL 0.01 %, 0.025 %


tazarotene topical cream 0.1 % (Avage) 2

TAZORAC TOPICAL CREAM 0.05 %, 0.1 %


TAZORAC TOPICAL GEL 0.05 %, 0.1 %


tretinoin microspheres topical gel 0.04 %, 0.1 %

(Retin-A Micro) 2 AGE (Max 25 Years)

tretinoin topical cream 0.025 % (Avita) 1 AGE (Max 25 Years)

tretinoin topical cream 0.05 %, 0.1 % (Retin-A) 2 AGE (Max 25 Years)

tretinoin topical gel 0.01 % (Retin-A) 2 AGE (Max 25 Years)

150


tretinoin topical gel 0.025 % (Avita) 2 AGE (Max 25 Years)

tretinoin topical gel 0.05 % (Atralin) 2 AGE (Max 25 Years)

TRETIN-X CREAM KIT TOPICAL COMBO PACK 0.025 %, 0.05 %, 0.1 %


TRETIN-X TOPICAL CREAM 0.0375 %, 0.075 %


Scabicides And PediculicidesEURAX TOPICAL CREAM 10 % 3

EURAX TOPICAL LOTION 10 % 3

lindane topical lotion 1 % 1

lindane topical shampoo 1 % 1

malathion topical lotion 0.5 % (Ovide) 2

NATROBA TOPICAL SUSPENSION 0.9 %

3

OVIDE TOPICAL LOTION 0.5 % 3

permethrin topical cream 5 % (Elimite) 1

SKLICE TOPICAL LOTION 0.5 % 3 QL (117 per 30 days)

SOOLANTRA TOPICAL CREAM 1 %

3

spinosad topical suspension 0.9 % (Natroba) 2

DevicesDevicesBD LUER-LOK SYRINGE SYRINGE 1 ML 20 GAUGE X 1"

2

BD ULTRA-FINE NANO PEN NEEDLE NEEDLE 32 GAUGE X 5/32"

2

BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 15/64"

2

BD VEO INSULIN SYRINGE UF SYRINGE 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64"

2

LANCING DEVICE WITH LANCETS KIT

(Accu-Chek FastClix Lancing Dev)

2

VGO 40 DEVICE 2

Enzyme Replacement/ModifiersEnzyme Replacement/ModifiersCERDELGA ORAL CAPSULE 84 MG


151


CHENODAL ORAL TABLET 250 MG

3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

2

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

3

KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG


KUVAN ORAL TABLET,SOLUBLE 100 MG


miglustat oral capsule 100 mg (Zavesca) 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG


ORFADIN ORAL SUSPENSION 4 MG/ML


PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

3

pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000 -27,000 unit

1

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT, 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT

3

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG


PULMOZYME INHALATION SOLUTION 1 MG/ML


152


STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML


SUCRAID ORAL SOLUTION 8,500 UNIT/ML


ULTRESA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 13,800-27,600 UNIT, 20,700-41,400 UNIT, 23,000-46,000 UNIT

3

VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT

3

ZAVESCA ORAL CAPSULE 100 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000-47,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 40,000-136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

2

Eye, Ear, Nose, Throat AgentsEye, Ear, Nose, Throat Agents, MiscellaneousAKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 %

3

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 %

3

apraclonidine ophthalmic (eye) drops 0.5 %

(Iopidine) 1

ASTEPRO NASAL SPRAY,NON-AEROSOL 0.15 % (205.5 MCG)


atropine in 0.9 % sod chloride ophthalmic (eye) drops 0.01 %

1

atropine ophthalmic (eye) drops 1 % 1

153


atropine ophthalmic (eye) ointment 1 % 1

atropine-care ophthalmic (eye) drops 1 %

1

ATROVENT NASAL SPRAY,NON-AEROSOL 0.03 %, 42 MCG (0.06 %)

3

azelastine nasal aerosol,spray 137 mcg (0.1 %)


azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg)

(Astepro) 2 QL (60 per 30 days)

azelastine ophthalmic (eye) drops 0.05 % 1

BEPREVE OPHTHALMIC (EYE) DROPS 1.5 %


cromolyn ophthalmic (eye) drops 4 % 1

CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 %


DYMISTA NASAL SPRAY,NON-AEROSOL 137-50 MCG/SPRAY


ELESTAT OPHTHALMIC (EYE) DROPS 0.05 %

3

EMADINE OPHTHALMIC (EYE) DROPS 0.05 %


epinastine ophthalmic (eye) drops 0.05 % (Elestat) 2

GELFILM OPHTHALMIC (EYE) FILM

3

homatropaire ophthalmic (eye) drops 5 %

1

homatropine hbr ophthalmic (eye) drops5 %

(Homatropaire) 2

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 %

3

IOPIDINE OPHTHALMIC (EYE) DROPS 0.5 %

3

ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %)

1

ISOPTO ATROPINE OPHTHALMIC (EYE) DROPS 1 %

3

ISOPTO HYOSCINE OPHTHALMIC (EYE) DROPS 0.25 %

2

LACRISERT OPHTHALMIC (EYE) INSERT 5 MG

3

154


LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 %


naphazoline ophthalmic (eye) drops 0.1 %

1

olopatadine nasal spray,non-aerosol 0.6 %

(Patanase) 2 QL (30.5 per 30 days)

olopatadine ophthalmic (eye) drops 0.1 %

(Patanol) 2

olopatadine ophthalmic (eye) drops 0.2 %

(Pataday) 2 QL (3 per 30 days)

OPTIVAR OPHTHALMIC (EYE) DROPS 0.05 %

3

OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % (0.25 ML)

2

PATADAY OPHTHALMIC (EYE) DROPS 0.2 %


PATANASE NASAL SPRAY,NON-AEROSOL 0.6 %

3 QL (30.5 per 30 days)

PATANOL OPHTHALMIC (EYE) DROPS 0.1 %

3

PAZEO OPHTHALMIC (EYE) DROPS 0.7 %

3 QL (2.5 per 30 days)

phenylephrine hcl ophthalmic (eye) drops10 %, 2.5 %

1

proparacaine ophthalmic (eye) drops 0.5 %

1

TYZINE NASAL DROPS 0.1 % 3

TYZINE NASAL SPRAY,NON-AEROSOL 0.1 %

3

ZADITOR OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)

1

Eye, Ear, Nose, Throat Anti-Infectives Agentsacetasol hc otic (ear) drops 1-2 % 2

acetic acid otic (ear) solution 2 % 1

antipyrine-benzocaine otic (ear) drops5.4-1.4 %

1

aurodex otic (ear) drops 5.4-1.4 % 1

auroguard otic (ear) drops 5.4-1.4 % 1

AZASITE OPHTHALMIC (EYE) DROPS 1 %

3

155


bacitracin ophthalmic (eye) ointment 500 unit/gram

1

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

(AK-Poly-Bac) 1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 %

2

bleph-10 ophthalmic (eye) drops 10 % 2

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

2

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

2

CETRAXAL OTIC (EAR) DROPPERETTE 0.2 %

3

CILOXAN OPHTHALMIC (EYE) DROPS 0.3 %

3

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 %

3

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %

3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

2

ciprofloxacin hcl ophthalmic (eye) drops0.3 %

(Ciloxan) 1

ciprofloxacin hcl otic (ear) dropperette0.2 %

(Cetraxal) 2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML

2

CORTISPORIN-TC OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML

3

cresylate otic (ear) drops 25 % 1

erythromycin ophthalmic (eye) ointment5 mg/gram (0.5 %)

1

FLOXIN OTIC (EAR) DROPS 0.3 % 3

GARAMYCIN OPHTHALMIC (EYE) DROPS 0.3 %

3

GARAMYCIN OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM)

3

156


gatifloxacin ophthalmic (eye) drops 0.5 %

(Zymaxid) 2

gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram)

1

gentamicin ophthalmic (eye) drops 0.3 % 1

gentamicin ophthalmic (eye) ointment0.3 % (3 mg/gram)

(Gentak) 1

hydrocortisone-acetic acid otic (ear) drops 1-2 %

2

ILOTYCIN OPHTHALMIC (EYE) OINTMENT 5 MG/GRAM (0.5 %)

3

levofloxacin ophthalmic (eye) drops 0.5 %

1

MAXITROL OPHTHALMIC (EYE) DROPS,SUSPENSION 3.5MG/ML-10,000 UNIT/ML-0.1 %

3

MAXITROL OPHTHALMIC (EYE) OINTMENT 3.5 MG/G-10,000 UNIT/G-0.1 %

3

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 %

3

moxifloxacin ophthalmic (eye) drops 0.5 %

(Vigamox) 1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 %

3

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

(Neo-Polycin HC) 1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

(Neo-Polycin) 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension3.5mg/ml-10,000 unit/ml-0.1 %

(Maxitrol) 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

(Maxitrol) 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

1

157


neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

1

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

1

neo-polycin hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

1

neo-polycin ophthalmic (eye) ointment3.5-400-10,000 mg-unit-unit/g

3

NEOSPORIN (NEO-POLYM-GRAMICID) OPHTHALMIC (EYE) DROPS 1.75 MG-10,000 UNIT-0.025MG/ML

3

OCUFLOX OPHTHALMIC (EYE) DROPS 0.3 %

3

ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) 1

ofloxacin otic (ear) drops 0.3 % 1

OTIC CARE (ANTIPYRINE) OTIC (EAR) DROPS 5.4-1.4 %

1

polycin ophthalmic (eye) ointment 500-10,000 unit/gram

1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

(Polytrim) 1

POLYTRIM OPHTHALMIC (EYE) DROPS 10,000 UNIT- 1 MG/ML

3

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-1 %

2

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT 0.3-0.6 %

2

sulfacetamide sodium ophthalmic (eye) drops 10 %

(Bleph-10) 1

sulfacetamide sodium ophthalmic (eye) ointment 10 %

1

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

1

TOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.1 %

3

158


TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %

3

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.05 %

3

tobramycin ophthalmic (eye) drops 0.3 %

(Tobrex) 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

(TobraDex) 1

TOBREX OPHTHALMIC (EYE) DROPS 0.3 %

3

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 %

3

trifluridine ophthalmic (eye) drops 1 % (Viroptic) 1

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 %

3

VIROPTIC OPHTHALMIC (EYE) DROPS 1 %

3

VOSOL-HC OTIC (EAR) DROPS 1-2 %

3

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 %

2

ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 %

3

ZYMAXID OPHTHALMIC (EYE) DROPS 0.5 %

3

Eye, Ear, Nose, Throat Anti-Inflammatory AgentsACULAR LS OPHTHALMIC (EYE) DROPS 0.4 %

3

ACULAR OPHTHALMIC (EYE) DROPS 0.5 %

3

ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 %

3

AERO OTIC HC OTIC (EAR) DROPS 10-10-1 MG/ML

1

ALOCRIL OPHTHALMIC (EYE) DROPS 2 %

3

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 %

2

159


BECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG (0.042 %)


bromfenac ophthalmic (eye) drops 0.09 %

2

BROMSITE OPHTHALMIC (EYE) DROPS 0.075 %

3

budesonide nasal spray,non-aerosol 32 mcg/actuation

(Rhinocort Allergy) 2 ST; QL (17.2 per 30 days)

cortane-b otic (ear) drops 10-10-1 mg/ml 1

DERMOTIC OIL OTIC (EAR) DROPS 0.01 %

3

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %

1

diclofenac sodium ophthalmic (eye) drops 0.1 %

1

DUREZOL OPHTHALMIC (EYE) DROPS 0.05 %

3

exotic-hc otic (ear) drops 10-10-1 mg/ml 1

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

2

FLONASE ALLERGY RELIEF NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


FLONASE NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


fluocinolone acetonide oil otic (ear) drops 0.01 %

(DermOtic Oil) 1

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

(FML Liquifilm) 1

flurbiprofen sodium ophthalmic (eye) drops 0.03 %

1

fluticasone nasal spray,suspension 50 mcg/actuation

(24 Hour Allergy Relief)


FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

2

FML LIQUIFILM OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

3

160


FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 %

2

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 %

3

ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) 1

ketorolac ophthalmic (eye) drops 0.5 % (Acular) 1

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 %

2

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 %

2

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 %

2

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

2

mometasone nasal spray,non-aerosol 50 mcg/actuation

(Nasonex) 2 QL (17 per 30 days)

NASACORT NASAL AEROSOL,SPRAY 55 MCG

3 QL (16.5 per 30 days)

NASONEX NASAL SPRAY,NON-AEROSOL 50 MCG/ACTUATION


NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

2

OCUFEN OPHTHALMIC (EYE) DROPS 0.03 %

3

OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG


OMNIPRED OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

3

oto-end 10 otic (ear) drops 10-10-1 mg/ml

1

otomax-hc otic (ear) drops 10-10-1 mg/ml

1

PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

3

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

2

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

(Omnipred) 1

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

1

PROLENSA OPHTHALMIC (EYE) DROPS 0.07 %

3

161


QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION


QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION


RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %


RHINOCORT AQUA NASAL SPRAY,NON-AEROSOL 32 MCG/ACTUATION


triamcinolone acetonide nasal aerosol,spray 55 mcg

(24 Hour Nasal Allergy)

1 QL (16.5 per 30 days)

VERAMYST NASAL SPRAY,SUSPENSION 27.5 MCG/ACTUATION


VEXOL OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

3

XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 %


ZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION


Gastrointestinal AgentsAntiulcer Agents And Acid SuppressantsACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG


ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 10 MG, 5 MG


amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg


CARAFATE ORAL SUSPENSION 100 MG/ML

3

CARAFATE ORAL TABLET 1 GRAM

3

cimetidine hcl oral solution 300 mg/5 ml 1

cimetidine oral tablet 200 mg (Acid Reducer (cimetidine))

1

cimetidine oral tablet 300 mg, 400 mg, 800 mg

1

162


CYTOTEC ORAL TABLET 100 MCG, 200 MCG

3

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG


esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg

(Nexium) 2 ST; QL (30 per 30 days)

esomeprazole strontium oral capsule,delayed release(dr/ec) 24.65 mg, 49.3 mg


famotidine oral suspension 40 mg/5 ml (8 mg/ml)

(Pepcid) 2

famotidine oral tablet 20 mg (Acid Controller) 1

famotidine oral tablet 40 mg (Pepcid) 1

lansoprazole oral capsule,delayed release(dr/ec) 15 mg

(Heartburn Treatment 24 Hour)


lansoprazole oral capsule,delayed release(dr/ec) 30 mg

(Prevacid) 1 ST; QL (30 per 30 days)

lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg

(Prevacid SoluTab) 2 ST; QL (30 per 30 days)

misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) 1

NEXIUM 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG


NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 40 MG


NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG


nizatidine oral capsule 150 mg, 300 mg 2

nizatidine oral solution 150 mg/10 ml 2

OMECLAMOX-PAK ORAL COMBO PACK 20 MG-500 MG- 500 MG (40)

3 QL (240 per 365 days)

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg


omeprazole oral tablet,delayed release (dr/ec) 20 mg

1

omeprazole oral tablet,disintegrat, delay rel 20 mg

1

163


omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram, 40-1.1 mg-gram

(OmePPi) 2 ST; QL (30 per 30 days)

omeprazole-sodium bicarbonate oral packet 20-1,680 mg, 40-1,680 mg

(Zegerid) 2 ST; QL (30 per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg

(Protonix) 1 QL (30 per 30 days)

PEPCID ORAL SUSPENSION 40 MG/5 ML (8 MG/ML)

3

PEPCID ORAL TABLET 20 MG, 40 MG

3

PREVACID ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG, 30 MG


PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL 15 MG, 30 MG


PREVPAC ORAL COMBO PACK 500-500-30 MG


PRILOSEC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG, 20 MG, 40 MG


PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 10 MG, 2.5 MG


PRILOSEC OTC ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG

1

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET 40 MG


PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG, 40 MG


rabeprazole oral tablet,delayed release (dr/ec) 20 mg

(Aciphex) 2 ST; QL (30 per 30 days)

ranitidine hcl oral capsule 150 mg, 300 mg

2

ranitidine hcl oral syrup 15 mg/ml 1

ranitidine hcl oral tablet 150 mg (Acid Control (ranitidine))

1

ranitidine hcl oral tablet 300 mg (Zantac) 1

sucralfate oral suspension 100 mg/ml (Carafate) 1

164


sucralfate oral tablet 1 gram (Carafate) 1

ZANTAC ORAL TABLET 150 MG, 300 MG

3

ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM, 40-1.1 MG-GRAM


ZEGERID ORAL PACKET 20-1,680 MG, 40-1,680 MG


ZEGERID OTC ORAL CAPSULE 20-1.1 MG-GRAM


Gastrointestinal Agents, OtherACTIGALL ORAL CAPSULE 300 MG

3

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG


ANASPAZ ORAL TABLET,DISINTEGRATING 0.125 MG

3

BENTYL ORAL CAPSULE 10 MG 3

BENTYL ORAL TABLET 20 MG 3

BUPHENYL ORAL POWDER 0.94 GRAM/GRAM


BUPHENYL ORAL TABLET 500 MG 3 *May have Specialty Costshare

CANTIL ORAL TABLET 25 MG 3

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG


CHOLBAM ORAL CAPSULE 250 MG, 50 MG


constulose oral solution 10 gram/15 ml 1

cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) 1

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML)

2

dicyclomine oral capsule 10 mg 1

dicyclomine oral solution 10 mg/5 ml 1

dicyclomine oral tablet 20 mg 1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

(Lomotil) 1

ed-spaz oral tablet,disintegrating 0.125 mg

1

165


enulose oral solution 10 gram/15 ml 1

FULYZAQ ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG

3 PA

GASTROCROM ORAL CONCENTRATE 100 MG/5 ML

3

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG


generlac oral solution 10 gram/15 ml 1

GLYCATE ORAL TABLET 1.5 MG 3

glycopyrrolate oral tablet 1 mg (Robinul) 1

glycopyrrolate oral tablet 1.5 mg (Glycate) 1

glycopyrrolate oral tablet 2 mg (Robinul Forte) 1

hyoscyamine sulfate oral elixir 0.125 mg/5 ml

(Hyosyne) 1

hyoscyamine sulfate oral tablet 0.125 mg (Levsin) 1

hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg

(Levbid) 1

hyoscyamine sulfate oral tablet,disintegrating 0.125 mg

(Anaspaz) 1

hyoscyamine sulfate sublingual tablet0.125 mg

(Levsin/SL) 1

hyosyne oral drops 0.125 mg/ml 1

KAYEXALATE ORAL POWDER 3

kionex (with sorbitol) oral suspension15-19.3 gram/60 ml

1

KRISTALOSE ORAL PACKET 10 GRAM, 20 GRAM

2

lactulose oral solution 10 gram/15 ml (Constulose) 1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR 0.375 MG

3

LEVSIN ORAL TABLET 0.125 MG 3

LEVSIN/SL SUBLINGUAL TABLET 0.125 MG

3

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG


LOMOTIL ORAL TABLET 2.5-0.025 MG

3

loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))

1

166


methscopolamine oral tablet 2.5 mg, 5 mg 1

metoclopramide hcl oral solution 5 mg/5 ml

1

metoclopramide hcl oral tablet 10 mg, 5 mg

(Reglan) 1

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg


METOZOLV ODT ORAL TABLET,DISINTEGRATING 5 MG


MOTOFEN ORAL TABLET 1-0.025 MG

3

MOVANTIK ORAL TABLET 12.5 MG, 25 MG


MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG

3 PA

NULEV ORAL TABLET,DISINTEGRATING 0.125 MG

3

OCALIVA ORAL TABLET 10 MG, 5 MG


opium tincture oral tincture 10 mg/ml (morphine)

2

oscimin oral tablet 0.125 mg 1

oscimin oral tablet,disintegrating 0.125 mg

1

oscimin sl sublingual tablet 0.125 mg 1

oscimin sr oral tablet extended release 12 hr 0.375 mg

1

PAMINE ORAL TABLET 2.5 MG 3

paregoric oral liquid 2 mg/5 ml 1

PYLERA ORAL CAPSULE 140-125-125 MG

2

RAVICTI ORAL LIQUID 1.1 GRAM/ML


REGLAN ORAL TABLET 10 MG, 5 MG

3

RELISTOR ORAL TABLET 150 MG 3 PA; QL (90 per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML


167


RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML


RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML


ROBINUL FORTE ORAL TABLET 2 MG

3

ROBINUL ORAL TABLET 1 MG 3

sodium phenylbutyrate oral powder 0.94 gram/gram

(Buphenyl) 3 *May have Specialty Costshare

sodium phenylbutyrate oral tablet 500 mg (Buphenyl) 2 *May have Specialty Costshare

sodium polystyrene (sorb free) oral suspension 15 gram/60 ml

1

sps (with sorbitol) oral suspension 15-20 gram/60 ml

1

SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG)

3

SYMAX FASTABS ORAL TABLET,DISINTEGRATING 0.125 MG

3

SYMAX-SL SUBLINGUAL TABLET 0.125 MG

3

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HR 0.375 MG

3

SYMPROIC ORAL TABLET 0.2 MG 3 QL (30 per 30 days)

TRULANCE ORAL TABLET 3 MG 3 ST; QL (30 per 30 days)

URSO 250 ORAL TABLET 250 MG 3

URSO FORTE ORAL TABLET 500 MG

3

ursodiol oral capsule 300 mg (Actigall) 2

ursodiol oral tablet 250 mg (URSO 250) 2

ursodiol oral tablet 500 mg (URSO Forte) 2

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM


VIBERZI ORAL TABLET 100 MG, 75 MG


168


XERMELO ORAL TABLET 250 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

LaxativesCLENPIQ ORAL SOLUTION 10 MG-3.5 GRAM -12 GRAM/160 ML

3

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

2

gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram

1

gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram

1

gavilyte-h and bisacodyl oral kit 5-210 mg-gram

1

gavilyte-n oral recon soln 420 gram 1

GIALAX ORAL KIT 17 GRAM/ SCOOP

2

GOLYTELY ORAL POWDER IN PACKET 227.1-21.5-6.36 GRAM

2

GOLYTELY ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM

3

MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM

2

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN 420 GRAM

3

OSMOPREP ORAL TABLET 1.5 GRAM

3

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

(GaviLyte-G) 1

peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram

(Colyte with Flavor Packs)

1

peg-electrolyte soln oral recon soln 420 gram

(GaviLyte-N) 1

peg-prep oral kit 5-210 mg-gram 3

polyethylene glycol 3350 oral powder 17 gram/dose

(ClearLax) 1

PREPOPIK ORAL POWDER IN PACKET 10 MG-3.5 GRAM-12 GRAM

3

169


SUCLEAR ORAL SOLN AND SOLN RECON,SEQUENTIAL 210-17.5-3.13 GRAM

3

SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5-3.13-1.6 GRAM

2

trilyte with flavor packets oral recon soln420 gram

1

Phosphate BindersAURYXIA ORAL TABLET 210 MG IRON


calcium acetate oral capsule 667 mg 1

calcium acetate oral tablet 667 mg (Calphron) 1

eliphos oral tablet 667 mg 1

FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG

3

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG

3

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

(Fosrenol) 2

PHOSLO ORAL CAPSULE 667 MG 3

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML

2

RENAGEL ORAL TABLET 400 MG, 800 MG

3

RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM

3

RENVELA ORAL TABLET 800 MG 3

sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram

(Renvela) 2

sevelamer carbonate oral tablet 800 mg (Renvela) 2

VELPHORO ORAL TABLET,CHEWABLE 500 MG

3

Genitourinary AgentsAntispasmodics, Urinarybethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

(Urecholine) 1

darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg

(Enablex) 2 ST; QL (30 per 30 days)

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 2 MG, 4 MG


170


DETROL ORAL TABLET 1 MG, 2 MG


DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG

3

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG


flavoxate oral tablet 100 mg 1

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 28 MG/0.92 GRAM (3 %)

3 ST

GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 MG/GRAM)

3 ST

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG


oxybutynin chloride oral syrup 5 mg/5 ml 1

oxybutynin chloride oral tablet 5 mg 1

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg

(Ditropan XL) 1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 MG/24 HR

3 ST

SANCTURA ORAL TABLET 20 MG 3

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

(Detrol LA) 2 QL (30 per 30 days)

tolterodine oral tablet 1 mg, 2 mg (Detrol) 2 ST; QL (60 per 30 days)

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG


trospium oral capsule,extended release 24hr 60 mg

2

trospium oral tablet 20 mg 1

URECHOLINE ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG

3

VESICARE ORAL TABLET 10 MG, 5 MG

2

Genitourinary Agents, Miscellaneousalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) 1

AVODART ORAL CAPSULE 0.5 MG 3

171


azuphen mb oral capsule 120-0.12 mg 2

dutasteride oral capsule 0.5 mg (Avodart) 2

dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg

(Jalyn) 2

finasteride oral tablet 5 mg (Proscar) 1

FLOMAX ORAL CAPSULE 0.4 MG 3

hyophen oral tablet 81.6-0.12-10.8 mg 2

indiomin mb oral capsule 120-40.8-10 mg 2

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG

3

phenazopyridine oral tablet 100 mg, 200 mg

(Pyridium) 1

PROSCAR ORAL TABLET 5 MG 3

PYRIDIUM ORAL TABLET 100 MG, 200 MG

3

RAPAFLO ORAL CAPSULE 4 MG, 8 MG


tamsulosin oral capsule 0.4 mg (Flomax) 1

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

1

uramit mb oral capsule 118-10-40.8-36 mg

2

URIBEL ORAL CAPSULE 118-10-40.8-36 MG

3

uro-mp oral capsule 118-10-40.8-36 mg 2

urophen mb oral tablet 81.6-0.12-10.8 mg 2

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR 10 MG

3

ustell oral capsule 120-0.12 mg 2

UTA (WITH PHENYL SALICYLATE) ORAL CAPSULE 120-0.12 MG

3

UTA ORAL CAPSULE 120-40.8-10 MG

3

Heavy Metal AntagonistsHeavy Metal AntagonistsCHEMET ORAL CAPSULE 100 MG 2

CUPRIMINE ORAL CAPSULE 250 MG


172


DEPEN TITRATABS ORAL TABLET 250 MG


EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG


JADENU ORAL TABLET 180 MG, 360 MG, 90 MG


JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG


SYPRINE ORAL CAPSULE 250 MG 3 *May have Specialty Costshare

trientine oral capsule 250 mg (Syprine) 3 *May have Specialty Costshare

Hormonal Agents, Stimulant/Replacement/ModifyingAndrogensANADROL-50 ORAL TABLET 50 MG

3

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR


ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %)


ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)


ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1.62 % (40.5 MG/2.5 GRAM)


ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)


ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)

3 PA NSO; QL (37.5 per 30 days)

ANDROID ORAL CAPSULE 10 MG 3 PA NSO; QL (150 per 30 days)

androxy oral tablet 10 mg 2 QL (120 per 30 days)

173


AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 30 MG/ACTUATION (1.5 ML)


covaryx h.s. oral tablet 0.625-1.25 mg 1

covaryx oral tablet 1.25-2.5 mg 1

danazol oral capsule 100 mg, 200 mg, 50 mg

1

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML, 200 MG/ML


estrogens-methyltestosterone oral tablet0.625-1.25 mg

(Covaryx H.S.) 1

estrogens-methyltestosterone oral tablet1.25-2.5 mg

(Covaryx) 1

FORTESTA TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION


METHITEST ORAL TABLET 10 MG 3 PA NSO; QL (20 per 10 days)

methyltestosterone oral capsule 10 mg (Android) 2 PA NSO; QL (150 per 30 days)

NATESTO NASAL GEL IN METERED-DOSE PUMP 5.5 MG/0.122 GRAM/ACTUATION

3 PA NSO; QL (21.96 per 30 days)

OXANDRIN ORAL TABLET 10 MG, 2.5 MG

3

oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) 1

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR 30 MG


TESTIM TRANSDERMAL GEL 50 MG/5 GRAM (1 %)


testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml

(Depo-Testosterone) 1 PA NSO; QL (10 per 30 days)

testosterone enanthate intramuscular oil200 mg/ml


testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation

(Fortesta) 2 PA NSO; QL (120 per 30 days)

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

(Vogelxo) 2 PA NSO; QL (300 per 30 days)

174


testosterone transdermal gel in packet 1 % (25 mg/2.5gram)

(AndroGel) 2 PA NSO; QL (150 per 30 days)

testosterone transdermal gel in packet 1 % (50 mg/5 gram)

(AndroGel) 2 PA NSO; QL (300 per 30 days)

testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml)

(Axiron) 2 PA NSO; QL (180 per 30 days)

TESTRED ORAL CAPSULE 10 MG 3 PA NSO; QL (150 per 30 days)

VOGELXO TRANSDERMAL GEL 50 MG/5 GRAM (1 %)


VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %)


Estrogens And AntiestrogensACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

3

ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

2

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

3

CENESTIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

3

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/24 HR

2

CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.06 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

3

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR

3

DIVIGEL TRANSDERMAL GEL IN PACKET 1 MG/GRAM (0.1 %)

2

DUAVEE ORAL TABLET 0.45-20 MG

3

175


ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION

3

ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

3

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM)

3

estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) 1

estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Alora) 2

estradiol transdermal patch semiweekly0.0375 mg/24 hr

(Minivelle) 2

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Climara) 1

estradiol vaginal cream 0.01 % (0.1 mg/gram)

(Estrace) 1

estradiol vaginal tablet 10 mcg (Vagifem) 1

estradiol-norethindrone acet oral tablet0.5-0.1 mg, 1-0.5 mg

(Activella) 1

ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR)

3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ACTUATION

2

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg

1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%)

3 QL (16.2 per 30 days)

EVISTA ORAL TABLET 60 MG 3 PA

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG

3

FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR

3

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

176


IMVEXXY VAGINAL INSERT 10 MCG, 4 MCG

3

INTRAROSA VAGINAL INSERT 6.5 MG

2

JEVANTIQUE LO ORAL TABLET 0.5-2.5 MG-MCG

3

jinteli oral tablet 1-5 mg-mcg 1

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg 1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG

3

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24 HR

2

mimvey lo oral tablet 0.5-0.1 mg 1

mimvey oral tablet 1-0.5 mg 1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

3

norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg

(Femhrt Low Dose) 1

norethindrone ac-eth estradiol oral tablet1-5 mg-mcg

(Fyavolv) 1

PREFEST ORAL TABLET 1 MG (15)/1 MG- 0.09 MG (15)

2

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

2

PREMARIN VAGINAL CREAM 0.625 MG/GRAM

2

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)

2

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

2

raloxifene oral tablet 60 mg (Evista) 2 PA

VAGIFEM VAGINAL TABLET 10 MCG

3

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

3

yuvafem vaginal tablet 10 mcg 1

177


Glucocorticoids/MineralocorticoidsCORTEF ORAL TABLET 10 MG, 20 MG, 5 MG

3

cortisone oral tablet 25 mg 1

decadron oral elixir 0.5 mg/5 ml 3

decadron oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg

3

deltasone oral tablet 20 mg 1

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

2

dexamethasone oral elixir 0.5 mg/5 ml (Decadron) 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg

(Decadron) 1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg

1

dexpak 10 day oral tablets,dose pack 1.5 mg (35 tabs)

3


3


3

EMFLAZA ORAL SUSPENSION 22.75 MG/ML


EMFLAZA ORAL TABLET 18 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG


FLO-PRED ORAL SUSPENSION 15 MG/5 ML

3

fludrocortisone oral tablet 0.1 mg 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

(Cortef) 1

locort oral tablets,dose pack 1.5 mg (27 tabs), 1.5 mg (41 tabs)

3

MEDROL (PAK) ORAL TABLETS,DOSE PACK 4 MG

3

MEDROL ORAL TABLET 16 MG, 2 MG, 32 MG, 4 MG, 8 MG

3

178


methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

(Medrol) 1

methylprednisolone oral tablets,dose pack4 mg

(Medrol (Pak)) 1

MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS), 5 MG (48 TABS)

3

MILLIPRED ORAL SOLUTION 10 MG/5 ML

3

MILLIPRED ORAL TABLET 5 MG 3

ORAPRED ODT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 30 MG

3

PEDIAPRED ORAL SOLUTION 5 MG BASE/5 ML (6.7 MG/5 ML)

3

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

prednisolone sodium phosphate oral solution 20 mg/5 ml (4 mg/ml)

(Veripred 20) 1

prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg, 30 mg

(Orapred ODT) 2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

2

prednisone oral solution 5 mg/5 ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg, 50 mg

1

prednisone oral tablet 20 mg (Deltasone) 1

prednisone oral tablets,dose pack 10 mg, 5 mg

1

prelone oral solution 15 mg/5 ml 1

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, 2 MG, 5 MG

3 ST

taperdex oral tablets,dose pack 1.5 mg (21 tabs), 1.5 mg (49 tabs)

3

VERIPRED 20 ORAL SOLUTION 20 MG/5 ML (4 MG/ML)

3

zodex oral tablets,dose pack 1.5 mg (21 tabs), 1.5 mg (49 tabs)

3

179


zonacort oral tablets,dose pack 1.5 mg (27 tabs), 1.5 mg (41 tabs)

3

PituitaryDDAVP INJECTION SOLUTION 4 MCG/ML

3

DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE)

3

DDAVP NASAL SPRAY WITH PUMP 10 MCG/SPRAY (0.1 ML)

3

DDAVP ORAL TABLET 0.1 MG, 0.2 MG

3

desmopressin injection solution 4 mcg/ml (DDAVP) 2

desmopressin nasal solution 0.1 mg/ml (refrigerate)

(DDAVP) 1

desmopressin nasal spray with pump 10 mcg/spray (0.1 ml)

(DDAVP) 1

desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) 1

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML


GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)


HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)


HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG


NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY (0.1 ML)

3

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)


180


NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)


NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML)


octreotide acetate injection solution 1,000 mcg/ml, 200 mcg/ml


octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml

(Sandostatin) 2 PA; *May have Specialty Costshare

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)


OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)


OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG


SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.)


SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG


SANDOSTATIN INJECTION SOLUTION 1,000 MCG/ML, 100 MCG/ML, 200 MCG/ML, 500 MCG/ML


SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG


SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)


SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG


STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)

3

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML


181


ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG


ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG


ProgestinsAYGESTIN ORAL TABLET 5 MG 3

CRINONE VAGINAL GEL 4 % 3 QL (6 per 1 day)

CRINONE VAGINAL GEL 8 % 3 PA; QL (6 per 1 day)

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML, 400 MG/ML

3

DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MG/ML

3

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

3

ENDOMETRIN VAGINAL INSERT 100 MG


medroxyprogesterone intramuscular suspension 150 mg/ml

(Depo-Provera) 0

medroxyprogesterone intramuscular syringe 150 mg/ml

(Depo-Provera) 0

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

(Provera) 1

MEGACE ES ORAL SUSPENSION 625 MG/5 ML

3

MEGACE ORAL SUSPENSION 400 MG/10 ML (40 MG/ML)

3

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

1

megestrol oral suspension 625 mg/5 ml (Megace ES) 1

norethindrone acetate oral tablet 5 mg (Aygestin) 1

progesterone micronized oral capsule 100 mg, 200 mg

(Prometrium) 1

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG

3

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG

3

182


Thyroid And Antithyroid AgentsARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

2

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

3

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

(Levo-T) 1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg

(Cytomel) 1

methimazole oral tablet 10 mg, 5 mg (Tapazole) 1

nature-throid oral tablet 113.75 mg, 130 mg, 146.25 mg, 16.25 mg, 162.5 mg, 195 mg, 260 mg, 32.5 mg, 325 mg, 48.75 mg, 65 mg, 81.25 mg, 97.5 mg

2

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

2

propylthiouracil oral tablet 50 mg 1

sski oral solution 1 gram/ml 2

strong iodine oral solution 5 % 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

2

TAPAZOLE ORAL TABLET 10 MG, 5 MG

3

thyroid (pork) oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

(Armour Thyroid) 2

THYROLAR-1 ORAL TABLET 12.5-50 MCG

3

183


THYROLAR-1/2 ORAL TABLET 6.25-25 MCG

3

THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG

3

THYROLAR-2 ORAL TABLET 25-100 MCG

3

THYROLAR-3 ORAL TABLET 37.5-150 MCG

3

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

2

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

1

wp thyroid oral tablet 113.75 mg, 130 mg, 16.25 mg, 32.5 mg, 48.75 mg, 65 mg, 81.25 mg, 97.5 mg

2

Immunological AgentsImmunological AgentsACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML


ARAVA ORAL TABLET 10 MG, 20 MG

3 ST

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG


ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG

3 ST; *May have Specialty Costshare

AZASAN ORAL TABLET 100 MG, 75 MG

3

azathioprine oral tablet 50 mg (Imuran) 1

CELLCEPT ORAL CAPSULE 250 MG

3

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML

3

184


CELLCEPT ORAL TABLET 500 MG 3

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)


CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)


CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %)


cyclosporine modified oral capsule 100 mg, 25 mg

(Gengraf) 1

cyclosporine modified oral capsule 50 mg 1

cyclosporine modified oral solution 100 mg/ml

(Gengraf) 1

cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) 1

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)


ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)


ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)


ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG


gengraf oral capsule 100 mg, 25 mg, 50 mg

1

gengraf oral solution 100 mg/ml 1

HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG


HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)


HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML


185


HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML


HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %)


HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)


IMURAN ORAL TABLET 50 MG 3

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG/1.14 ML, 200 MG/1.14 ML


KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML


KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML


leflunomide oral tablet 10 mg, 20 mg (Arava) 1 ST

mycophenolate mofetil oral capsule 250 mg

(CellCept) 1

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

(CellCept) 2

mycophenolate mofetil oral tablet 500 mg (CellCept) 1

186


mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

(Myfortic) 2

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 180 MG, 360 MG


NEORAL ORAL CAPSULE 100 MG, 25 MG

3

NEORAL ORAL SOLUTION 100 MG/ML

3

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML

3 PA NSO; *May have Specialty Costshare; QL (1.6 per 28 days)

ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML

3 PA NSO; *May have Specialty Costshare; QL (2.8 per 28 days)

OTEZLA ORAL TABLET 30 MG 3 PA; *May have Specialty Costshare; QL (60 per 30 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)


OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)


OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML

3 *May have Specialty Costshare; QL (1.6 per 28 days)

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG


RAPAMUNE ORAL SOLUTION 1 MG/ML


RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG


187


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML

3 ST; *May have Specialty Costshare; QL (0.8 per 28 days)

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 12.5 MG/0.25 ML


















RIDAURA ORAL CAPSULE 3 MG 3 *May have Specialty Costshare

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

3

SANDIMMUNE ORAL SOLUTION 100 MG/ML

3

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML


SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML


188


SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML


SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML


sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune) 3 *May have Specialty Costshare

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML


STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML


STELARA SUBCUTANEOUS SYRINGE 90 MG/ML


tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

(Prograf) 2 *May have Specialty Costshare

XELJANZ ORAL TABLET 10 MG, 5 MG


XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG


ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG


VaccinesADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

0 QL (0.5 per 365 days); AGE (Min 7 Years)

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML


BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML

0 QL (1 per 365 days); AGE (Min 10 Years and Max 25 Years)

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML


189


BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML


CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML

0 QL (1.5 per 365 days); AGE (Min 9 Years and Max 26 Years)

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML


ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML


GARDASIL (PF) INTRAMUSCULAR SUSPENSION 20-40-40-20 MCG/0.5 ML


GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 MCG/0.5 ML


GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML


GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML


HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML


HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML


HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5 ML


MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML


MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

0 QL (1 per 365 days); AGE (Min 11 Years and Max 23 Years)

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML


PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML

0 QL (0.5 per 365 days)

190


PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML

0 QL (0.5 per 365 days)

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

0 QL (0.5 per 365 days)

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5


RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML


RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML


SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML


TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML


TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML


TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML


TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML


TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT- 20 MCG/ML


TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML


VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML


VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML


191


VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML


ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML


Inflammatory Bowel Disease AgentsInflammatory Bowel Disease Agentsalosetron oral tablet 0.5 mg, 1 mg (Lotronex) 2

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM

2

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG

3 ST

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

3

AZULFIDINE ORAL TABLET 500 MG

3

balsalazide oral capsule 750 mg (Colazal) 1

budesonide oral capsule,delayed,extend.release 3 mg

(Entocort EC) 2

budesonide oral tablet,delayed and ext.release 9 mg

(Uceris) 3 *May have Specialty Costshare

CANASA RECTAL SUPPOSITORY 1,000 MG

2

COLAZAL ORAL CAPSULE 750 MG 3

colocort rectal enema 100 mg/60 ml 1

CORTENEMA RECTAL ENEMA 100 MG/60 ML

3

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG

3 ST

DIPENTUM ORAL CAPSULE 250 MG

3 ST

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE 3 MG

3

GIAZO ORAL TABLET 1.1 GRAM 3 PA; ST; *May have Specialty Costshare

192


hydrocortisone rectal enema 100 mg/60 ml

(Colocort) 1

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM

2

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

3

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

(Lialda) 2

mesalamine oral tablet,delayed release (dr/ec) 800 mg

(Asacol HD) 2 ST

mesalamine rectal enema 4 gram/60 ml (Rowasa) 1

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

3

ROWASA RECTAL ENEMA KIT 4 GRAM/60 ML

3

sulfasalazine oral tablet 500 mg (Azulfidine) 1

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

(Azulfidine EN-tabs) 1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG


UCERIS RECTAL FOAM 2 MG/ACTUATION

3

Metabolic Bone Disease AgentsMetabolic Bone Disease AgentsACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG

3

alendronate oral solution 70 mg/75 ml 1

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg

1

alendronate oral tablet 70 mg (Fosamax) 1

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC) 35 MG

3

BINOSTO ORAL TABLET, EFFERVESCENT 70 MG

3

BONIVA ORAL TABLET 150 MG 3

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

1

calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) 1

calcitriol oral solution 1 mcg/ml (Rocaltrol) 1

193


doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

2

etidronate disodium oral tablet 200 mg, 400 mg

2

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML


FORTICAL NASAL SPRAY,NON-AEROSOL 200 UNIT/ACTUATION

2

FOSAMAX ORAL TABLET 70 MG 3

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT

3

HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 MCG

3

ibandronate oral tablet 150 mg (Boniva) 1

MIACALCIN NASAL SPRAY,NON-AEROSOL 200 UNIT/ACTUATION

3

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE


paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) 2

paricalcitol oral capsule 4 mcg 2

RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG

3

risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg

(Actonel) 2

risedronate oral tablet,delayed release (dr/ec) 35 mg

(Atelvia) 2

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG

3

ROCALTROL ORAL SOLUTION 1 MCG/ML

3

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG


TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)


ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG

3

194


Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTHAR H.P. INJECTION GEL 80 UNIT/ML


ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML


BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML


BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML


CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML

3

CARNITOR ORAL TABLET 330 MG 3

CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG

3

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML


ELMIRON ORAL CAPSULE 100 MG 3

ergoloid oral tablet 1 mg 1

GRASTEK SUBLINGUAL TABLET 2,800 BAU

3

guanidine oral tablet 125 mg 1

hydroxyzine pamoate oral capsule 100 mg

1

hydroxyzine pamoate oral capsule 25 mg, 50 mg

(Vistaril) 1

KEVEYIS ORAL TABLET 50 MG 3 PA; *May have Specialty Costshare; QL (120 per 30 days)

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

1

levocarnitine (with sugar) oral solution100 mg/ml

(Carnitor) 1

levocarnitine oral tablet 330 mg (Carnitor) 1

LITHOSTAT ORAL TABLET 250 MG

3

MESNEX ORAL TABLET 400 MG 3

195


MESTINON ORAL SYRUP 60 MG/5 ML

2

MESTINON ORAL TABLET 60 MG 3

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG

3

methylergonovine oral tablet 0.2 mg (Methergine) 1

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)

3 PA; *May have Specialty Costshare; QL (1 per 1 day)

ORALAIR SUBLINGUAL TABLET 100 INDX REACTIVITY, 100 IR (3) /300 IR (6), 300 INDX REACTIVITY

3

PROGLYCEM ORAL SUSPENSION 50 MG/ML

3

pyridostigmine bromide oral tablet 60 mg (Mestinon) 1

pyridostigmine bromide oral tablet extended release 180 mg

(Mestinon Timespan) 1

RADIOGARDASE ORAL CAPSULE 0.5 GRAM

3

RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT

3

RECTIV RECTAL OINTMENT 0.4 % (W/W)

2

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG


THIOLA ORAL TABLET 100 MG 3 *May have Specialty Costshare

TYBOST ORAL TABLET 150 MG 3 QL (30 per 30 days)

VISTARIL ORAL CAPSULE 25 MG, 50 MG

3

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


XCLAIR TOPICAL CREAM 3

Ophthalmic AgentsAntiglaucoma Agentsacetazolamide oral capsule, extended release 500 mg

1

acetazolamide oral tablet 125 mg, 250 mg 1

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %, 0.15 %

3

196


AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

3

BETAGAN OPHTHALMIC (EYE) DROPS 0.5 %

3

betaxolol ophthalmic (eye) drops 0.5 % 1

BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 %

3

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

3

bimatoprost ophthalmic (eye) drops 0.03 %


brimonidine ophthalmic (eye) drops 0.15 %

(Alphagan P) 1

brimonidine ophthalmic (eye) drops 0.2 %

1

carteolol ophthalmic (eye) drops 1 % 1

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 %

3

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE 2-0.5 %


COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML

3

DIAMOX SEQUELS ORAL CAPSULE, EXTENDED RELEASE 500 MG

3

dorzolamide ophthalmic (eye) drops 2 % (Trusopt) 1

dorzolamide-timolol (pf) ophthalmic (eye) drops 2-0.5 %

1

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

(Cosopt) 1

ISOPTO CARPINE OPHTHALMIC (EYE) DROPS 1 %, 2 %, 4 %

3

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 %

3

latanoprost ophthalmic (eye) drops 0.005 %

(Xalatan) 1

levobunolol ophthalmic (eye) drops 0.5 %

(Betagan) 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %


methazolamide oral tablet 25 mg (Neptazane) 2

methazolamide oral tablet 50 mg 2

197


metipranolol ophthalmic (eye) drops 0.3 %

1

NEPTAZANE ORAL TABLET 25 MG, 50 MG

3

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 %

2

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

(Isopto Carpine) 1

RESCULA OPHTHALMIC (EYE) DROPS 0.15 %

3

RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 %


SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 %

3

timolol maleate ophthalmic (eye) drops0.25 %, 0.5 %

(Timoptic) 1

timolol maleate ophthalmic (eye) drops, once daily 0.5 %

(Istalol) 1

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

(Timoptic-XE) 2

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.25 %, 0.5 %

3

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.5 %

3

TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION 0.25 %, 0.5 %

3

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 %

2

TRUSOPT OPHTHALMIC (EYE) DROPS 2 %

3

VYZULTA OPHTHALMIC (EYE) DROPS 0.024 %

3

XALATAN OPHTHALMIC (EYE) DROPS 0.005 %

3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 0.0015 %

3

198


Replacement PreparationsReplacement Preparationscytra k crystals oral packet 3,300-1,002 mg

1

cytra-2 oral solution 500-334 mg/5 ml 1

cytra-3 oral solution 550-500-334 mg/5 ml

1

cytra-k oral solution 1,100-334 mg/5 ml 1

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

2

effer-k oral tablet, effervescent 25 meq 1

k-effervescent oral tablet, effervescent 25 meq

1

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

1

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ

2

klor-con m10 oral tablet,er particles/crystals 10 meq

1


1


1

KLOR-CON ORAL PACKET 20 MEQ

2

klor-con sprinkle oral capsule, extended release 10 meq, 8 meq

1

KLOR-CON/25 ORAL PACKET 25 MEQ

2

KLOR-CON/EF ORAL TABLET, EFFERVESCENT 25 MEQ

2

K-PHOS NO 2 ORAL TABLET 305-700 MG

2

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 500 MG

2

K-PHOS-NEUTRAL ORAL TABLET 250 MG

3

K-SOL ORAL LIQUID 40 MEQ/15 ML

1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

3

199


ORACIT ORAL SOLUTION 490-640 MG/5 ML

2

phospha 250 neutral oral tablet 250 mg 1

pot,sodium citrate-citric acid oral solution 550-500-334 mg/5 ml

(Cytra-3) 1

potassium bicarb and chloride oral tablet, effervescent 25 meq

1

potassium bicarb-citric acid oral tablet, effervescent 25 meq

(Effer-K) 1

potassium chloride oral capsule, extended release 10 meq, 8 meq

(Klor-Con Sprinkle) 1

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

1

potassium chloride oral packet 20 meq (Klor-Con) 1

potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq

(K-Tab) 1

potassium chloride oral tablet,er particles/crystals 10 meq

(Klor-Con M10) 1

potassium chloride oral tablet,er particles/crystals 20 meq

(Klor-Con M20) 1

potassium citrate oral tablet extended release 10 meq (1,080 mg)

(Urocit-K 10) 1

potassium citrate oral tablet extended release 15 meq

(Urocit-K 15) 2

potassium citrate oral tablet extended release 5 meq (540 mg)

(Urocit-K 5) 1

potassium citrate-citric acid oral packet3,300-1,002 mg

(Cytra K Crystals) 2

potassium citrate-citric acid oral solution1,100-334 mg/5 ml

(Cytra-K) 1

SHOHL'S MODIFIED ORAL SOLUTION 500-300 MG/5 ML

2

sodium citrate-citric acid oral solution500-334 mg/5 ml

(Cytra-2) 1

tricitrates oral solution 550-500-334 mg/5 ml

1

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1,080 MG)

3

UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ

3

200


UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ (540 MG)

3

virt-phos 250 neutral oral tablet 250 mg 1

Respiratory Tract AgentsAnti-Inflammatories, Inhaled CorticosteroidsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION


AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION

3 QL (17.8 per 30 days)

AIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION


ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION


ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 55 MCG/ACTUATION


ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION


201


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 110 MCG (7 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE


budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

(Pulmicort) 2 QL (120 per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml

(Pulmicort) 2 QL (60 per 30 days)

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION





2 QL (21.2 per 28 days)

fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

(AirDuo RespiClick) 3 ST; QL (1 per 30 days)

202


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION


PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML


PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML


QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

2 QL (17.4 per 25 days)

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION

2 QL (21.2 per 25 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

3 QL (10.2 per 30 days)

AntileukotrienesACCOLATE ORAL TABLET 10 MG, 20 MG

3

montelukast oral granules in packet 4 mg (Singulair) 1

montelukast oral tablet 10 mg (Singulair) 1

montelukast oral tablet,chewable 4 mg, 5 mg

(Singulair) 1

SINGULAIR ORAL GRANULES IN PACKET 4 MG

3

SINGULAIR ORAL TABLET 10 MG 3

SINGULAIR ORAL TABLET,CHEWABLE 4 MG, 5 MG

3

zafirlukast oral tablet 10 mg, 20 mg (Accolate) 2

zileuton oral tablet, er multiphase 12 hr600 mg

(Zyflo CR) 2

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG

3

ZYFLO ORAL TABLET 600 MG 3

203


Bronchodilatorsalbuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

1

albuterol sulfate oral syrup 2 mg/5 ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION


ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG


ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

2 QL (25.8 per 30 days)

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG


BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION


FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 12 MCG


INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION


ipratropium bromide inhalation solution0.02 %

1

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

1

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml

(Xopenex) 2

levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml

(Xopenex Concentrate) 2

204


levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation

(Xopenex HFA) 2 QL (30 per 30 days)

LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML

3

LUFYLLIN ORAL TABLET 200 MG, 400 MG

3

metaproterenol oral syrup 10 mg/5 ml 1

metaproterenol oral tablet 10 mg, 20 mg 1

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML


PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION


PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION


PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

3 QL (13.4 per 25 days)

SEEBRI NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 15.6 MCG


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE


SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG


STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION


STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION


terbutaline oral tablet 2.5 mg, 5 mg 1

205


THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG

2

theochron oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg

1

theophylline oral solution 80 mg/15 ml 1

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg

(Theochron) 1

theophylline oral tablet extended release 12 hr 450 mg

1

theophylline oral tablet extended release 24 hr 400 mg, 600 mg

1

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION


UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 27.5-15.6 MCG


VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION


VOSPIRE ER ORAL TABLET EXTENDED RELEASE 12 HR 4 MG, 8 MG

3

XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION 1.25 MG/0.5 ML

3

XOPENEX HFA INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION


XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.31 MG/3 ML, 0.63 MG/3 ML, 1.25 MG/3 ML

3

Respiratory Tract Agents, Othercromolyn inhalation solution for nebulization 20 mg/2 ml

1

206


cromolyn nasal spray,non-aerosol 5.2 mg/spray (4 %)

(Nasal Allergy Symptom Control)

1

DALIRESP ORAL TABLET 250 MCG, 500 MCG


ESBRIET ORAL CAPSULE 267 MG 3 PA; *May have Specialty Costshare; QL (270 per 30 days)

ESBRIET ORAL TABLET 267 MG 3 PA; *May have Specialty Costshare; QL (270 per 30 days)

ESBRIET ORAL TABLET 801 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION 3.5 %

2

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG


KALYDECO ORAL TABLET 150 MG


nebusal inhalation solution for nebulization 3 %

1

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 6 %

2

OFEV ORAL CAPSULE 100 MG, 150 MG


ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG


sodium chloride inhalation solution for nebulization 0.9 %

2

sodium chloride inhalation solution for nebulization 3 %

(NebuSal) 1

sodium chloride inhalation solution for nebulization 7 %

(Hyper-Sal) 1

SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N)


207


Skeletal Muscle RelaxantsSkeletal Muscle RelaxantsAMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR 15 MG, 30 MG

3 ST

baclofen oral tablet 10 mg, 20 mg, 5 mg 1

carisoprodol oral tablet 250 mg, 350 mg (Soma) 2

carisoprodol-asa-codeine oral tablet 200-325-16 mg

2

carisoprodol-aspirin oral tablet 200-325 mg

2

chlorzoxazone oral tablet 250 mg, 500 mg

1

cyclobenzaprine oral tablet 10 mg, 5 mg 1

cyclobenzaprine oral tablet 7.5 mg (Fexmid) 2

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

3

dantrolene oral capsule 100 mg 1

dantrolene oral capsule 25 mg, 50 mg (Dantrium) 1

FEXMID ORAL TABLET 7.5 MG 3

LORZONE ORAL TABLET 375 MG, 750 MG

3

metaxall oral tablet 800 mg 2

metaxalone oral tablet 400 mg 2

metaxalone oral tablet 800 mg (Metaxall) 2

methocarbamol oral tablet 500 mg (Robaxin) 1

methocarbamol oral tablet 750 mg (Robaxin-750) 1

orphenadrine citrate oral tablet extended release 100 mg

1

orphenadrine compound-ds oral tablet 50-770-60 mg

1

ROBAXIN ORAL TABLET 500 MG 3

ROBAXIN-750 ORAL TABLET 750 MG

3

SKELAXIN ORAL TABLET 800 MG 3

SOMA ORAL TABLET 250 MG, 350 MG

3

tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) 2

tizanidine oral tablet 2 mg 1

tizanidine oral tablet 4 mg (Zanaflex) 1

208


ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG

3

ZANAFLEX ORAL TABLET 4 MG 3

Sleep Disorder AgentsSleep Disorder AgentsAMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG


AMBIEN ORAL TABLET 10 MG, 5 MG


armodafinil oral tablet 150 mg, 200 mg, 250 mg

(Nuvigil) 2 PA; QL (30 per 30 days)

armodafinil oral tablet 50 mg (Nuvigil) 2 PA; QL (90 per 30 days)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG


BUTISOL ORAL ELIXIR 30 MG/5 ML

3

BUTISOL ORAL TABLET 30 MG, 50 MG

3

EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG


eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) 2 ST; QL (30 per 30 days)

HETLIOZ ORAL CAPSULE 20 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

INTERMEZZO SUBLINGUAL TABLET 1.75 MG, 3.5 MG


LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG


modafinil oral tablet 100 mg, 200 mg (Provigil) 2 PA; QL (60 per 30 days)

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG


NUVIGIL ORAL TABLET 50 MG 3 PA; QL (90 per 30 days)

PROVIGIL ORAL TABLET 100 MG, 200 MG


ROZEREM ORAL TABLET 8 MG 3 QL (30 per 30 days)

SECONAL SODIUM ORAL CAPSULE 100 MG

3

209


SILENOR ORAL TABLET 3 MG, 6 MG


SONATA ORAL CAPSULE 10 MG, 5 MG


XYREM ORAL SOLUTION 500 MG/ML


zaleplon oral capsule 10 mg, 5 mg (Sonata) 1 QL (30 per 30 days)

zolpidem oral tablet 10 mg, 5 mg (Ambien) 1 QL (30 per 30 days)

zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg

(Ambien CR) 2 ST; QL (30 per 30 days)

zolpidem sublingual tablet 1.75 mg, 3.5 mg

(Intermezzo) 2 QL (30 per 30 days)

ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)


Vasodilating AgentsVasodilating AgentsADCIRCA ORAL TABLET 20 MG 2 PA; *May have

Specialty Costshare; QL (60 per 30 days)

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


CIALIS ORAL TABLET 2.5 MG, 5 MG

3 PA

LETAIRIS ORAL TABLET 10 MG, 5 MG


OPSUMIT ORAL TABLET 10 MG 3 PA; *May have Specialty Costshare; QL (30 per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG


REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML


REVATIO ORAL TABLET 20 MG 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

210


sildenafil (antihypertensive) oral tablet20 mg

(Revatio) 3 PA; *May have Specialty Costshare; QL (90 per 30 days)

STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG

3

TRACLEER ORAL TABLET 125 MG, 62.5 MG


TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)


TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)


TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML


UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG


UPTRAVI ORAL TABLET 200 MCG 3 PA; *May have Specialty Costshare; QL (240 per 30 days)

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)


VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML


Vitamins And MineralsVitamins And MineralsACTIVE FE ORAL TABLET 75 MG IRON- 1,250 MCG

3

CORVITE FE ORAL TABLET 125 MG IRON-25 MG IRON-1 MG

3

folic acid oral tablet 1 mg 1

FUSION PLUS ORAL CAPSULE 130 MG IRON -1,250 MCG

3

211

INDEX

Index

8-MOP.................................. 132abacavir ...................................79abacavir-lamivudine ................. 80abacavir-lamivudine-zidovudine 80ABILIFY................................76ABILIFY DISCMELT...........76ABSORICA.......................... 132ABSTRAL................................3acamprosate ............................ 16ACANYA.............................140acarbose .................................. 51ACCOLATE.........................203ACCUPRIL............................96ACCURETIC.........................96acebutolol ................................ 99ACEON.................................. 96acetaminophen-caff-dihydrocod . 3acetaminophen-codeine .............. 3acetasol hc ............................. 155acetazolamide ........................ 196acetic acid ..............................155ACIPHEX............................ 162ACIPHEX SPRINKLE........ 162acitretin ................................. 132ACTEMRA.......................... 184ACTHAR H.P...................... 195ACTICLATE..........................27ACTIGALL..........................165ACTIMMUNE.....................195ACTIQ..................................... 3ACTIVE FE..........................211ACTIVELLA........................175ACTONEL........................... 193ACTOPLUS MET..................51ACTOPLUS MET XR........... 51ACTOS................................... 51ACULAR............................. 159ACULAR LS........................159

Index

ACUVAIL (PF).................... 159acyclovir ...........................88, 132ACZONE..............................132ADACEL(TDAP ADOLESN/ADULT)(PF).... 189ADALAT CC....................... 104adapalene ...............................150adapalene-benzoyl peroxide ....150ADCIRCA............................210ADDERALL........................ 113ADDERALL XR................. 113adefovir ................................... 88ADEMPAS...........................210ADLYXIN............................. 52ADMELOG SOLOSTAR U-100 INSULIN.........................56ADMELOG U-100 INSULIN LISPRO.................................. 56ADOXA................................. 27ADRENACLICK.................103ADVAIR DISKUS...............201ADVAIR HFA..................... 201ADVICOR............................107ADZENYS ER..................... 113ADZENYS XR-ODT........... 113AERO OTIC HC.................. 159AEROSPAN.........................201afeditab cr ..............................104AFINITOR............................ 29AFINITOR DISPERZ........... 29AFREZZA............................. 56aftera .....................................120AGGRENOX.........................93AGRYLIN............................. 93AIMOVIG AUTOINJECTOR................. 68AIRDUO RESPICLICK......201AKNE-MYCIN....................140

Index

AKTEN (PF)........................ 153AKTIPAK............................ 140AKYNZEO (NETUPITANT)70ala-cort ..................................143alagesic lq ..................................3ala-scalp ................................ 143alavert ..................................... 63alavert d-12 allergy-sinus ......... 63ALBENZA............................. 72albuterol sulfate ..................... 204alclometasone ........................ 143ALDACTAZIDE................. 106ALDACTONE..................... 106ALDARA............................. 132ALECENSA........................... 29alendronate ............................ 193alfuzosin ................................ 171ALINIA............................ 72, 73ALKERAN............................ 29ALLEGRA ALLERGY......... 63ALLEGRA-D 12 HOUR....... 63ALLEGRA-D 24 HOUR....... 64allerclear d-12hr ...................... 64allerclear d-24hr ...................... 64allergy relief (cetirizine) ..........64allergy relief (loratadine) ........ 64allergy relief d12 ...................... 64aller-tec d ................................ 64allopurinol ............................... 63ALLZITAL.............................. 3almotriptan malate ...................68ALOCRIL............................ 159alogliptin ................................. 52alogliptin-metformin ................ 52alogliptin-pioglitazone ..............52ALOMIDE........................... 153ALORA................................ 175alosetron ................................192

I-1

Index

ALPHAGAN P.................... 196alprazolam ......................... 17, 18ALPRAZOLAM INTENSOL17ALREX................................ 159ALTABAX........................... 140ALTACE................................ 96altavera (28) ......................... 120ALTOPREV......................... 107ALUNBRIG...........................29ALUVEA..............................132ALVESCO............................ 201alyacen 1/35 (28) ...................120alyacen 7/7/7 (28) ................. 120amabelz ................................. 175amantadine hcl .........................74AMARYL.............................. 59AMBIEN.............................. 209AMBIEN CR........................209amcinonide .............................143AMERGE.............................. 68amethia ..................................120amethia lo .............................. 120amethyst ................................ 120AMICAR................................93amiloride ................................106amiloride-hydrochlorothiazide 106aminocaproic acid .................... 93amiodarone ..............................98AMITIZA.............................165amitriptyline ............................ 46amitriptyline-chlordiazepoxide . 46amlodipine ............................. 104amlodipine-atorvastatin .. 107, 108amlodipine-benazepril ............ 104amlodipine-olmesartan ........... 104amlodipine-valsartan .............. 105amlodipine-valsartan-hcthiazid.............................................. 105ammonium lactate .......... 132, 133amnesteem ............................. 133

Index

amoxapine ............................... 46amoxicil-clarithromy-lansopraz.............................................. 162amoxicillin ......................... 24, 25amoxicillin-pot clavulanate ...... 25ampicillin .................................25AMPYRA.............................113AMRIX................................ 208AMTURNIDE..................... 111ANACAINE.........................133ANADROL-50..................... 173ANAFRANIL........................ 46anagrelide ................................93ana-lex kit ............................... 15ANALPRAM ADVANCED 143ANALPRAM E....................143ANALPRAM-HC................ 143ANAPROX............................ 12ANAPROX DS...................... 12ANASPAZ............................165anastrozole .............................. 29ANCOBON............................ 60ANDRODERM................... 173ANDROGEL....................... 173ANDROID...........................173androxy ................................. 173ANGELIQ............................175ANORO ELLIPTA.............. 204ANTABUSE...........................16ANTARA............................. 108antipyrine-benzocaine .............155anucort-hc ..............................143ANUSOL-HC.......................143ANZEMET............................ 71APEXICON E...................... 143APIDRA SOLOSTAR U-100 INSULIN............................... 56APIDRA U-100 INSULIN.... 56APLENZIN............................47APOKYN............................... 74

Index

apraclonidine ......................... 153aprepitant ................................ 71apri ........................................120APRISO................................192APTENSIO XR.................... 114APTIOM................................ 38APTIVUS............................... 80aranelle (28) ......................... 120ARANESP (IN POLYSORBATE).............91, 92ARAVA................................184ARCALYST......................... 184ARCAPTA NEOHALER.... 204ARICEPT...............................45ARICEPT ODT......................45ARIMIDEX........................... 29aripiprazole ........................76, 77ARIXTRA..............................90armodafinil ............................ 209ARMONAIR RESPICLICK201ARMOUR THYROID........ 183ARNUITY ELLIPTA.......... 201AROMASIN.......................... 29ARTHROTEC 50...................12ARTHROTEC 75...................12ARYMO ER............................ 3ASACOL HD....................... 192ashlyna .................................. 120ASMANEX HFA................. 202ASMANEX TWISTHALER202aspirin ..................................... 12aspirin-caffeine-dihydrocodein ... 3aspirin-dipyridamole ................ 93ASTAGRAF XL.................. 184ASTEPRO............................ 153ASTERO................................ 15ATACAND............................ 95ATACAND HCT................... 95atazanavir ................................80ATELVIA.............................193

I-2

Index

atenolol ....................................99atenolol-chlorthalidone .............99ATIVAN.................................18atomoxetine ........................... 114atorvastatin ............................108atovaquone .............................. 73atovaquone-proguanil ...............73ATRALIN............................ 150ATRIPLA...............................80atropine ..........................153, 154atropine in 0.9 % sod chloride .153atropine-care ..........................154ATROVENT........................ 154ATROVENT HFA............... 204AUBAGIO........................... 114aubra ..................................... 121AUGMENTIN.......................25AUGMENTIN ES-600...........25AUGMENTIN XR................ 25aurodex ................................. 155auroguard .............................. 155AURYXIA........................... 170AUSTEDO........................... 114AUVI-Q................................103AVALIDE.............................. 95AVANDAMET...................... 52AVANDARYL...................... 52AVANDIA............................. 52AVAPRO................................95AVAR...................................133AVAR LS............................. 133AVAR-E............................... 133AVAR-E LS..........................133AVC VAGINAL.................... 67AVELOX................................26AVELOX ABC PACK........... 26aviane .................................... 121AVIDOXY............................. 27AVINZA.................................. 3avita ...................................... 150

Index

AVODART.......................... 171AVONEX............................. 114AVONEX (WITH ALBUMIN)..........................114AXERT.................................. 68AXIRON.............................. 174AYGESTIN..........................182AZASAN..............................184AZASITE............................. 155azathioprine ........................... 184azelastine ...............................154AZELEX.............................. 133AZILECT............................... 74azithromycin ............................23AZOPT................................. 197AZOR................................... 105AZULFIDINE..................... 192AZULFIDINE EN-TABS....192azuphen mb ............................172azurette (28) ......................... 121bacitracin ...............................156bacitracin-polymyxin b ...........156baclofen ................................. 208BACTRIM............................. 26BACTRIM DS....................... 26BACTROBAN..................... 140BACTROBAN NASAL....... 140BALCOLTRA...................... 121balsalazide ............................. 192balziva (28) ...........................121BANZEL................................ 38BARACLUDE....................... 88BASAGLAR KWIKPEN U-100 INSULIN.........................56BAXDELA.............................26BD LUER-LOK SYRINGE.151BD ULTRA-FINE NANO PEN NEEDLE..................... 151BD VEO INSULIN SYR HALF UNIT........................ 151

Index

BD VEO INSULIN SYRINGE UF......................151B-DONNA............................. 37BECONASE AQ...................160bekyree (28) ..........................121BELBUCA............................... 3belladonna alkaloids-opium ........3belladonna-opium ...................... 3BELSOMRA........................ 209benazepril ................................ 97benazepril-hydrochlorothiazide .97BENICAR.............................. 95BENICAR HCT..................... 95BENLYSTA......................... 195BENSAL HP........................ 133BENTYL.............................. 165BENZAC AC........................133BENZAC AC WASH........... 133BENZACLIN PUMP........... 141BENZAMYCIN................... 141BENZEFOAM..................... 133BENZEFOAM ULTRA.......133benzepro ................................ 133benzepro (microspheres) ........133benznidazole ............................ 73BENZODOX 30..................... 27BENZODOX 60..................... 27benzonatate ............................130benzoyl peroxide .................... 133benztropine .............................. 74BEPREVE............................ 154BESIVANCE........................156BETAGAN...........................197betamethasone dipropionate ... 143betamethasone valerate ...143, 144betamethasone, augmented .....144BETAPACE........................... 99BETASERON...................... 114betaxolol .......................... 99, 197bethanechol chloride ...............170

I-3

Index

BETHKIS...............................19BETIMOL............................ 197BETOPTIC S........................ 197BEVESPI AEROSPHERE... 204BEVYXXA.............................90bexarotene ...............................29BEXSERO............................ 189BEYAZ.................................121BIAXIN..................................23BIAXIN XL............................23BIAXIN XL PAK.................. 23bicalutamide ............................ 29BIDIL................................... 112BIKTARVY........................... 80BILTRICIDE......................... 73bimatoprost ............................197BINOSTO.............................193bisoprolol fumarate ..................99bisoprolol-hydrochlorothiazide . 99bleph-10 .................................156BLEPHAMIDE....................156BLEPHAMIDE S.O.P..........156blisovi 24 fe ............................121blisovi fe 1.5/30 (28) ..............121blisovi fe 1/20 (28) .................121BONIVA...............................193BONJESTA............................ 71BOOSTRIX TDAP....... 189, 190BOSULIF............................... 29bp 10-1 ...................................133bpo ........................................ 133BREO ELLIPTA.................. 202brevicon (28) .........................121briellyn .................................. 121BRILINTA.............................93brimonidine ............................197BRINTELLIX........................47BRISDELLE.......................... 47BRIVIACT............................. 38bromfed dm ............................130

Index

bromfenac ..............................160bromocriptine .......................... 74brompheniramine-pseudoeph-dm ......................................... 130BROMSITE..........................160BROVANA.......................... 204budesonide .............. 160, 192, 202bumetanide ............................ 106BUNAVAIL........................... 16BUPAP.....................................3BUPHENYL........................ 165buprenorphine ............................4buprenorphine hcl .....................16buprenorphine-naloxone ...........16buproban ................................. 16bupropion hcl ........................... 47bupropion hcl (smoking deter) . 17buspirone ................................. 18butalbital compound w/codeine ...4butalbital-acetaminop-caf-cod ....4butalbital-acetaminophen ...........4butalbital-acetaminophen-caff ....4butalbital-aspirin-caffeine .......... 4BUTISOL............................. 209butorphanol tartrate .................. 4BUTRANS...............................4BYDUREON......................... 52BYDUREON BCISE............. 52BYETTA................................ 52BYSTOLIC.............................99BYVALSON.........................100cabergoline .............................. 74CABOMETYX.......................30CADUET............................. 108CAFCIT............................... 114CAFERGOT.......................... 68caffeine citrate ....................... 114CALAN................................ 102CALAN SR.......................... 102calcipotriene ................... 133, 134

Index

calcipotriene-betamethasone ...134calcitonin (salmon) ................193calcitrene ............................... 134calcitriol .........................134, 193calcium acetate ...................... 170CALQUENCE....................... 30CAMBIA................................12camila ....................................121CAMPRAL............................ 17camrese ..................................121camrese lo ..............................121CANASA..............................192candesartan ............................. 95candesartan-hydrochlorothiazid95CANTIL............................... 165capacet ...................................... 4capecitabine .............................30CAPEX.................................144CAPHOSOL......................... 131CAPITAL WITH CODEINE.. 4CAPRELSA........................... 30captopril .................................. 97captopril-hydrochlorothiazide ...97CARAC................................ 134CARAFATE.........................162CARBAGLU........................165carbamazepine ......................... 38CARBATROL........................38carbidopa .................................74carbidopa-levodopa .................. 74carbidopa-levodopa-entacapone74carbinoxamine maleate ............ 64CARDIZEM.........................102CARDIZEM CD.................. 102CARDIZEM LA.................. 102CARDURA............................94CARDURA XL..................... 94carisoprodol ........................... 208carisoprodol-asa-codeine ........ 208carisoprodol-aspirin ............... 208

I-4

Index

CARNITOR......................... 195CARNITOR (SUGAR-FREE).................................. 195CAROSPIR.......................... 112carteolol .................................197cartia xt .................................102carvedilol ............................... 100carvedilol phosphate ...............100CASODEX............................. 30CATAFLAM..........................12CATAPRES........................... 94CATAPRES-TTS-1................ 94CATAPRES-TTS-2................ 94CATAPRES-TTS-3................ 94CAYSTON............................. 24caziant (28) ...........................121CEDAX.................................. 21cefaclor ....................................21cefadroxil ...........................21, 22cefdinir .................................... 22cefditoren pivoxil ..................... 22cefixime ...................................22cefpodoxime ............................ 22cefprozil ...................................22ceftibuten .................................22CEFTIN................................. 22cefuroxime axetil ..................... 22CELEBREX........................... 12celecoxib ..................................12CELEXA................................ 47CELLCEPT...................184, 185CELONTIN........................... 38cem-urea ................................134CENESTIN.......................... 175CENTANY...........................141CENTANY AT.................... 141centergy dm ........................... 130cephalexin ................................22CERDELGA........................ 151

Index

CERVARIX VACCINE (PF).............................................. 190CESAMET............................. 71CETACAINE....................... 134CETACAINE ANESTHETIC..................... 134cetiri-d .....................................64cetirizine ..................................64cetirizine-pseudoephedrine ........64CETRAXAL.........................156CETYLEV............................ 195cevimeline .............................. 131CHANTIX............................. 17CHANTIX CONTINUING MONTH BOX........................17CHANTIX STARTING MONTH BOX........................17chateal ................................... 121CHEMET............................. 172CHENODAL........................152cheratussin ac ........................ 130child allergy relf(cetirizine) ..... 64children's allegra allergy ...........64children's allergy relief(fex) .....64children's allergy relief(lor) ..... 64children's aller-tec .................... 64children's cetirizine ...................64CHILDREN'S CLARITIN.... 65children's wal-fex ..................... 65children's wal-zyr ..................... 65CHILDREN'S ZYRTEC ALLERGY.............................65chlordiazepoxide hcl .................18chlordiazepoxide-clidinium .......37chlorhexidine gluconate ..........131chloroquine phosphate ..............73chlorothiazide ........................ 106chlorpromazine ........................ 77chlorpropamide ........................ 59chlorthalidone ........................ 106

Index

chlorzoxazone ........................ 208CHOLBAM.......................... 165cholestyramine (with sugar) .. 108cholestyramine light ............... 108choline,magnesium salicylate ....12CIALIS................................. 210CICLODAN...........................60CICLODAN KIT................... 60ciclopirox .................................60ciclopirox-ure-camph-menth-euc ...........................................60CIDALEAZE......................... 15cilostazol ................................. 93CILOXAN............................156CIMDUO............................... 80cimetidine .............................. 162cimetidine hcl ......................... 162CIMZIA............................... 185CIMZIA POWDER FOR RECONST............................185CIPRO....................................26CIPRO HC........................... 156CIPRO XR............................. 26CIPRODEX..........................156ciprofloxacin ............................26ciprofloxacin (mixture) ........... 26ciprofloxacin hcl ...............26, 156citalopram ............................... 47claravis .................................. 134CLARINEX........................... 65CLARINEX-D 12 HOUR......65CLARIS CLARIFYING WASH.................................. 134clarithromycin ......................... 23CLARITIN.............................65CLARITIN LIQUI-GEL....... 65CLARITIN REDITABS........ 65CLARITIN-D 12 HOUR....... 65CLARITIN-D 24 HOUR....... 65cleansing wash ....................... 134

I-5

Index

clemastine ................................65CLENPIQ.............................169CLEOCIN.............................. 67CLEOCIN HCL..................... 19CLEOCIN PEDIATRIC........ 19CLEOCIN T......................... 141CLIMARA........................... 175CLIMARA PRO.................. 175CLINDACIN ETZ............... 141CLINDAGEL.......................141clindamycin hcl ........................ 19clindamycin palmitate hcl .........19clindamycin phosphate ......67, 141clindamycin-benzoyl peroxide .141clindamycin-tretinoin ............. 141CLINDESSE.......................... 67CLINPRO 5000.................... 131clobetasol ...............................144clobetasol-emollient ............... 144CLOBEX.............................. 144clocortolone pivalate .............. 144CLODAN............................. 144CLODAN KIT..................... 144CLODERM.......................... 144clomipramine ........................... 47clonazepam ..............................18clonidine .................................. 94clonidine hcl ..................... 94, 114clopidogrel ...............................93clorazepate dipotassium ........... 18clorpres ....................................94clotrimazole .............................60clotrimazole-betamethasone ..... 60clozapine ..................................77CLOZARIL............................77CNL 8 NAIL.......................... 60COARTEM............................ 73codeine sulfate ........................... 4CODEINE SULFATE............. 4codeine-guaifenesin ................ 130

Index

COLAZAL........................... 192colchicine .................................63COLCRYS............................. 63colesevelam ............................108COLESTID...........................108COLESTID FLAVORED.... 108colestipol ................................108colocort ..................................192COLY-MYCIN S................. 156COLYTE WITH FLAVOR PACKS................................. 169COMBIGAN........................ 197COMBIPATCH....................175COMBIVENT RESPIMAT. 204COMBIVIR............................80COMETRIQ...........................30COMPAZINE........................ 71COMPLERA..........................80compro .................................... 71COMTAN.............................. 74CONCERTA........................ 114CONDYLOX....................... 134constulose .............................. 165CONZIP................................... 4COPAXONE.................114, 115COPEGUS............................. 88CORDARONE...................... 98CORDRAN.................. 144, 145CORDRAN TAPE LARGE ROLL................................... 144COREG................................ 100COREG CR..........................100CORGARD..........................100CORLANOR........................103cormax .................................. 145cortane-b ............................... 160CORTEF.............................. 178CORTENEMA.....................192CORTIFOAM......................145cortisone ................................ 178

Index

CORTISPORIN................... 141CORTISPORIN-TC............. 156CORVITE FE.......................211CORZIDE............................ 100COSENTYX (2 SYRINGES).............................................. 134COSENTYX PEN (2 PENS) 134COSOPT...............................197COSOPT (PF).......................197COTELLIC............................ 30COTEMPLA XR-ODT........ 115COUMADIN......................... 90covaryx ..................................174covaryx h.s. ............................174COZAAR............................... 95CREON................................ 152CRESEMBA.......................... 60CRESTOR............................108cresylate ................................ 156CRINONE............................182CRIXIVAN............................ 80cromolyn ......... 154, 165, 206, 207cryselle (28) .......................... 121CUPRIMINE....................... 172CUTIVATE.......................... 145CUVITRU............................185CUVPOSA............................165cyclafem 1/35 (28) .................121cyclafem 7/7/7 (28) ............... 121CYCLESSA (28)...................121cyclobenzaprine ......................208CYCLOPHOSPHAMIDE..... 30cycloserine ............................... 70CYCLOSET........................... 52cyclosporine ........................... 185cyclosporine modified .............185CYMBALTA..........................47cyproheptadine .........................65cyred ......................................121CYSTADANE......................195

I-6

Index

CYSTAGON........................ 152CYSTARAN........................ 154CYTOMEL...........................183CYTOTEC............................163cytra k crystals ...................... 199cytra-2 ...................................199cytra-3 ...................................199cytra-k ...................................199D.H.E.45.................................68DAKLINZA...........................86DALIRESP...........................207danazol .................................. 174DANTRIUM........................208dantrolene ..............................208dapsone ............................ 70, 134DARAPRIM.......................... 73darifenacin .............................170dasetta 1/35 (28) ................... 121dasetta 7/7/7 (28) .................. 121DAXBIA................................ 22DAYPRO............................... 12daysee ....................................121DAYTRANA....................... 115DDAVP................................ 180deblitane ................................ 122decadron ................................ 178deltasone ................................178delyla (28) ............................ 122DELZICOL.......................... 192DEMADEX..........................106demeclocycline .........................27DEMEROL..............................5DEMEROL (PF)......................5DEMSER............................. 103DEMULEN 1/50 (21)........... 122DENAVIR............................134denta 5000 plus ...................... 131dentagel ................................. 131DEPAKENE.......................... 38DEPAKOTE.......................... 39

Index

DEPAKOTE ER.................... 39DEPAKOTE SPRINKLES....39DEPEN TITRATABS.......... 173DEPO-PROVERA............... 182DEPO-SUBQ PROVERA 104.............................................. 182DEPO-TESTOSTERONE....174DERMA-SMOOTHE/FS SCALP OIL.......................... 145DERMATOP........................145dermazene ..............................145DERMOTIC OIL.................160DESCOVY............................. 80desipramine ............................. 47desloratadine ........................... 65desmopressin ..........................180desog-e.estradiol/e.estradiol ... 122DESOGEN........................... 122desogestrel-ethinyl estradiol ... 122DESONATE.........................145desonide .................................145desoximetasone ......................145DESOXYN...........................115DESVENLAFAXINE............47DESVENLAFAXINE FUMARATE......................... 47desvenlafaxine succinate .......... 47DETROL..............................171DETROL LA........................170dexamethasone ...................... 178DEXAMETHASONE INTENSOL.......................... 178dexamethasone sodium phosphate ...............................160DEXEDRINE...................... 115DEXEDRINE SPANSULE. 115DEXILANT......................... 163dexmethylphenidate ............... 115dexpak 10 day ........................178dexpak 13 day ........................178

Index

dexpak 6 day ..........................178dextroamphetamine ................115dextroamphetamine-amphetamine .................. 115, 116DIABETA.............................. 59DIAMOX SEQUELS........... 197DIASTAT...............................18DIASTAT ACUDIAL........... 18diazepam ................................. 18diazepam intensol .....................18DIBENZYLINE.....................94DICLEGIS............................. 71diclofenac potassium ................ 13diclofenac sodium ......13, 134, 160diclofenac-misoprostol ............. 13dicloxacillin ............................. 25dicyclomine ............................165didanosine ................................80DIFFERIN...........................150DIFICID................................ 23diflorasone ............................. 145DIFLUCAN...........................60diflunisal ..................................13digitek ................................... 103digox ..................................... 103DIGOXIN............................ 103digoxin ...................................103dihydroergotamine ................... 68DILANTIN............................ 39DILANTIN EXTENDED..... 39DILANTIN INFATABS........39DILANTIN-125..................... 39DILATRATE-SR................. 112DILAUDID............................. 5diltiazem hcl ...........................102dilt-xr .................................... 102DIOVAN................................ 95DIOVAN HCT.......................95DIPENTUM.........................192diphenoxylate-atropine ...........165

I-7

Index

DIPROLENE....................... 145DIPROLENE AF.................145dipyridamole ............................93DISALCID.............................13DISKETS................................. 5disopyramide phosphate ........... 98disulfiram ................................ 17DITROPAN XL................... 171DIURIL................................106divalproex ................................39DIVIGEL............................. 175dofetilide ..................................98DOLOPHINE.......................... 5donepezil ..................................45DONNATAL......................... 37DOPTELET........................... 92DORAL..................................18DORYX................................. 27DORYX MPC........................27dorzolamide ........................... 197dorzolamide-timolol ............... 197dorzolamide-timolol (pf) ........197DOVONEX.......................... 134doxazosin ................................ 94doxepin ............................ 47, 134doxercalciferol ....................... 194doxycycline hyclate ..................27doxycycline monohydrate ... 27, 28DRITHOCREME HP.......... 134dronabinol ............................... 71drospirenone-e.estradiol-lm.fa 122drospirenone-ethinyl estradiol .122DROXIA................................ 30DRYSOL DAB-O-MATIC.. 134DUAC.................................. 141DUAVEE............................. 175DUETACT.............................52DUEXIS................................. 13DULERA............................. 202duloxetine ................................47

Index

DUPIXENT......................... 135DURAGESIC.......................... 5DUREZOL...........................160DURLAZA............................ 13dutasteride ............................. 172dutasteride-tamsulosin ........... 172DUTOPROL........................ 100DUZALLO.............................63DYANAVEL XR................. 116DYAZIDE............................106DYMISTA............................154DYRENIUM........................106e.e.s. 400 ..................................23E.E.S. GRANULES............... 23EC-NAPROSYN....................13econazole ................................. 60econtra ez .............................. 122ECOZA...................................60EDARBI.................................95EDARBYCLOR.................... 95EDECRIN............................ 106EDLUAR............................. 209ed-spaz ...................................165EDURANT............................ 81efavirenz .................................. 81EFFER-K............................. 199effer-k ....................................199EFFEXOR XR.......................48EFFIENT............................... 93EFUDEX..............................135ELDEPRYL........................... 74ELESTAT.............................154ELESTRIN...........................176eletriptan ................................. 68ELIDEL................................145elinest .................................... 122eliphos ................................... 170ELIQUIS................................ 90ELLA....................................122ELMIRON........................... 195

Index

ELOCON..............................145EMADINE........................... 154EMBEDA.................................5EMCYT..................................30EMEND................................. 71EMFLAZA...........................178EMLA.................................... 15emoquette .............................. 122EMSAM................................. 48EMTRIVA............................. 81EMVERM.............................. 73ENABLEX........................... 171enalapril maleate ..................... 97enalapril-hydrochlorothiazide ...97ENBREL.............................. 185ENBREL SURECLICK.......185endocet ...................................... 5endodan ..................................... 5ENDOMETRIN...................182ENGERIX-B (PF)................ 190ENJUVIA.............................176enoxaparin ...............................90enpresse ................................. 122enskyce .................................. 122ENSTILAR.......................... 135entacapone ...............................75entecavir .................................. 88ENTOCORT EC.................. 192ENTRESTO........................... 95enulose ...................................166ENVARSUS XR.................. 185EPANED................................97EPCLUSA.............................. 86EPIDUO...............................150EPIDUO FORTE.................150EPIFOAM............................ 145epinastine ...............................154epinephrine ..................... 103, 104EPIPEN................................ 104EPIPEN 2-PAK.................... 104

I-8

Index

EPIPEN JR 2-PAK...............104epitol ....................................... 39EPIVIR...................................81EPIVIR HBV..........................81eplerenone ..............................112EPOGEN................................92eprosartan ............................... 95EPZICOM.............................. 81EQUETRO.............................39ergoloid ..................................195ERGOMAR........................... 68ergotamine-caffeine ................. 68ERIVEDGE........................... 30ERLEADA.............................30errin .......................................122ERTACZO............................. 60ery pads ................................. 141ERYGEL..............................141ERYPED 200......................... 23ERYPED 400......................... 23ery-tab ............................... 23, 24ERY-TAB...............................23erythrocin (as stearate) ........... 24erythromycin .................... 24, 156erythromycin ethylsuccinate .....24erythromycin with ethanol ...... 141erythromycin-benzoyl peroxide.............................................. 142ESBRIET..............................207escitalopram oxalate ................48ESGIC...................................... 5esomeprazole magnesium ....... 163esomeprazole strontium ..........163estarylla .................................122estazolam .................................18ESTRACE............................ 176estradiol .................................176estradiol-norethindrone acet ... 176ESTRING.............................176ESTROGEL......................... 176

Index

estrogens-methyltestosterone ..174estropipate ............................. 176ESTROSTEP FE-28............. 122eszopiclone .............................209ethacrynic acid .......................106ethambutol ...............................70ethosuximide ............................39ethynodiol diac-eth estradiol ...122etidronate disodium ................194etodolac ................................... 13etoposide ..................................30EUCRISA.............................146EURAX................................151EVAMIST............................ 176EVEKEO.............................. 116EVISTA................................ 176EVOCLIN............................ 142EVOTAZ................................ 81EVOXAC..............................131EVZIO.................................... 17EXALGO ER...........................5EXELDERM.................... 60, 61EXELON................................45exemestane .............................. 30EXFORGE........................... 105EXFORGE HCT..................105EXJADE...............................173exoderm .................................135exotic-hc ................................160EXTAVIA............................ 116EXTINA.................................61ezetimibe ................................108ezetimibe-simvastatin ............. 108FABIOR............................... 150FACTIVE...............................26fallback solo ...........................122falmina (28) .......................... 122famciclovir ...............................88famotidine ..............................163FAMVIR................................88

Index

FANAPT................................77FARESTON...........................30FARXIGA............................. 52FARYDAK............................31fayosim ..................................122FAZACLO............................. 77felbamate .................................39FELBATOL........................... 39FELDENE............................. 13felodipine ............................... 105FEM PH................................. 67FEMARA...............................31FEMCON FE....................... 122FEMHRT LOW DOSE........176FEMRING........................... 176femynor ................................. 122fenofibrate ............................. 108fenofibrate micronized ............108fenofibrate nanocrystallized ... 108fenofibric acid ........................ 109fenofibric acid (choline) .........109FENOGLIDE.......................109fenoprofen ............................... 13fentanyl ................................. 5, 6fentanyl citrate .......................... 5FENTORA...............................6FETZIMA.............................. 48FEXMID.............................. 208fexofenadine ............................ 65fexofenadine-pseudoephedrine ..65FIASP FLEXTOUCH U-100 INSULIN............................... 56FIASP U-100 INSULIN.........56FIBRICOR........................... 109FINACEA............................ 135finasteride ..............................172fioricet .......................................6FIORICET WITH CODEINE................................6FIORINAL.............................. 6

I-9

Index

FIORINAL-CODEINE #3......6FLAGYL................................20FLAGYL ER......................... 20FLAREX.............................. 160flavoxate ................................171flecainide ................................. 98FLECTOR............................135FLOLIPID............................109FLOMAX.............................172FLONASE............................160FLONASE ALLERGY RELIEF................................160FLO-PRED.......................... 178FLOVENT DISKUS............ 202FLOVENT HFA.................. 202FLOXIN...............................156fluconazole .............................. 61flucytosine ............................... 61fludrocortisone .......................178FLUMADINE....................... 86flunisolide .............................. 160fluocinolone ........................... 146fluocinolone acetonide oil ....... 160fluocinonide ........................... 146fluocinonide-e .........................146fluoride (sodium) ...................132FLUORIDEX DAILY DEFENSE............................ 132fluoridex sensitivity relief ....... 132fluorometholone ..................... 160FLUOROPLEX................... 135fluorouracil ............................ 135fluoxetine .................................48FLUOXETINE...................... 48fluphenazine hcl ....................... 77flurandrenolide .......................146flurazepam ...............................18flurbiprofen ..............................13flurbiprofen sodium ................ 160flutamide ................................. 31

Index

fluticasone ...................... 146, 160fluticasone-salmeterol ............ 202fluvastatin ..............................109fluvoxamine ............................. 48FML FORTE....................... 160FML LIQUIFILM............... 160FML S.O.P........................... 161FOCALIN............................ 116FOCALIN XR......................116folic acid ................................ 211fondaparinux ........................... 90FORADIL AEROLIZER.... 204FORFIVO XL........................ 48FORTAMET..........................52FORTEO.............................. 194FORTESTA..........................174FORTICAL.......................... 194FOSAMAX.......................... 194FOSAMAX PLUS D............194fosamprenavir .......................... 81fosinopril ................................. 97fosinopril-hydrochlorothiazide ..97FOSRENOL......................... 170FRAGMIN............................ 90FROVA.................................. 68frovatriptan ............................. 68FULPHILA............................92FULYZAQ........................... 166FURADANTIN.....................20furosemide ............................. 106FUSION PLUS.................... 211FUZEON............................... 81fyavolv ................................... 176FYCOMPA.......................39, 40gabapentin ............................... 40GABITRIL.............................40galantamine ............................. 45GARAMYCIN.....................156GARDASIL (PF)................. 190GARDASIL 9 (PF)...............190

Index

GASTROCROM..................166gatifloxacin ............................157GATTEX 30-VIAL...............166gavilyte-c ............................... 169gavilyte-g ...............................169gavilyte-h and bisacodyl ......... 169gavilyte-n ...............................169GELFILM............................ 154GELNIQUE......................... 171gemfibrozil .............................109GENERESS FE....................123generlac ................................. 166gengraf .................................. 185GENOTROPIN....................180GENOTROPIN MINIQUICK....................... 180gentak ....................................157gentamicin ......................142, 157GENVOYA............................ 81GEODON...............................77GIALAX.............................. 169gianvi (28) ............................ 123GIAZO................................. 192gildagia ..................................123gildess 1.5/30 (21) ................. 123gildess 1/20 (21) .................... 123gildess 24 fe ........................... 123gildess fe 1.5/30 (28) ............. 123gildess fe 1/20 (28) ................ 123GILENYA............................116GILOTRIF.............................31glatiramer ..............................116glatopa .................................. 116GLEEVEC..............................31GLEOSTINE..........................31glimepiride ...............................59glipizide ................................... 59glipizide-metformin ..................59GLUCAGEN HYPOKIT...... 52

I-10

Index

GLUCAGON EMERGENCY KIT (HUMAN)..............................52GLUCOPHAGE.................... 53GLUCOPHAGE XR..............53GLUCOTROL....................... 59GLUCOTROL XL.................59GLUCOVANCE.................... 59GLUMETZA......................... 53glyburide ..................................59glyburide micronized ................ 59glyburide-metformin ................ 59GLYCATE........................... 166glycopyrrolate ........................166glydo ....................................... 15GLYNASE............................. 59GLYSET................................ 53GLYXAMBI.......................... 53GOCOVRI............................. 75GOLYTELY.........................169GONITRO........................... 112GORDONS UREA.............. 135GRALISE...............................40GRALISE 30-DAY STARTER PACK.................. 40granisetron hcl ......................... 71granisol ....................................71GRANIX................................92GRASTEK........................... 195GRIFULVIN V......................61griseofulvin microsize ...............61griseofulvin ultramicrosize ....... 61GRIS-PEG (ULTRAMICROSIZE)..........61guanfacine ........................94, 116guanidine ............................... 195GYNAZOLE-1.......................67HAEGARDA.........................92HALCION............................. 18halobetasol propionate ........... 146

Index

HALOG................................146haloperidol ...............................77haloperidol lactate ................... 77HARVONI............................. 87HAVRIX (PF)...................... 190heather ...................................123HECORIA............................185HECTOROL........................ 194HEMANGEOL.................... 100HEMMOREX-HC............... 146heparin (porcine) .....................90heparin, porcine (pf) ................91HEPLISAV-B....................... 190HEPSERA..............................88HETLIOZ.............................209HEXALEN.............................31HIPREX................................. 20HIZENTRA......................... 185homatropaire ......................... 154homatropine hbr .....................154HORIZANT...........................40HUMALOG JUNIOR KWIKPEN U-100.................. 56HUMALOG KWIKPEN INSULIN............................... 56HUMALOG MIX 50-50 INSULN U-100...................... 57HUMALOG MIX 50-50 KWIKPEN.............................57HUMALOG MIX 75-25 KWIKPEN.............................57HUMALOG MIX 75-25(U-100)INSULN.......................... 57HUMALOG U-100 INSULIN............................... 57HUMATROPE.....................180HUMIRA............................. 186HUMIRA PEDIATRIC CROHN'S START............... 185HUMIRA PEN.................... 186

Index

HUMIRA PEN CROHN'S-UC-HS START.................... 186HUMIRA PEN PSORIASIS-UVEITIS.............................. 186HUMULIN 70/30 U-100 INSULIN............................... 57HUMULIN 70/30 U-100 KWIKPEN.............................57HUMULIN N NPH INSULIN KWIKPEN............57HUMULIN N NPH U-100 INSULIN............................... 57HUMULIN R REGULAR U-100 INSULN...................... 57HUMULIN R U-500 (CONC) INSULIN.................57HUMULIN R U-500 (CONC) KWIKPEN.............. 57HYCAMTIN..........................31HYCET.................................... 6HYCOFENIX...................... 130hydralazine ............................ 104HYDREA...............................31HYDRO 35...........................135hydrochlorothiazide ................106hydrocodone-acetaminophen ...... 6hydrocodone-chlorpheniramine.............................................. 130hydrocodone-cpm-pseudoephed.............................................. 130hydrocodone-homatropine.......................................130, 131hydrocodone-ibuprofen .............. 6hydrocortisone ........ 147, 178, 193hydrocortisone acet-aloe vera . 146hydrocortisone acetate ........... 146hydrocortisone butyrate .. 146, 147hydrocortisone valerate .......... 147hydrocortisone-acetic acid ......157

I-11

Index

hydrocortisone-pramox-e-pram#1 ..................................147hydrocortisone-pramoxine ......147hydromet ............................... 131hydromorphone ...................... 6, 7hydroxychloroquine ................. 73hydroxyurea ............................ 31hydroxyzine hcl ........................66hydroxyzine pamoate ............. 195hyolev mb ................................ 20hyophen ................................. 172hyoscyamine sulfate ............... 166hyosyne ..................................166hypercare ...............................135HYPER-SAL........................ 207HYQVIA.............................. 186HYQVIA IG COMPONENT.............................................. 186HYSINGLA ER.......................7HYZAAR...............................95ibandronate ............................194IBRANCE.............................. 31ibu ........................................... 13IBUDONE............................... 7ibuprofen ................................. 13ibuprofen-oxycodone ..................7ICLUSIG................................31IDHIFA..................................31ILEVRO............................... 161ILOTYCIN...........................157imatinib ................................... 31IMBRUVICA.........................32IMDUR................................ 112imipramine hcl ......................... 48imipramine pamoate .................48imiquimod ..............................135IMITREX...............................68IMITREX STATDOSE PEN.68IMPAVIDO............................73IMPOYZ.............................. 147

Index

IMURAN............................. 186IMVEXXY........................... 177INCRUSE ELLIPTA........... 204indapamide ............................ 106INDERAL LA......................100INDERAL XL......................100indiomin mb ........................... 172INDOCIN.............................. 13indomethacin ......................13, 14INGREZZA......................... 116INLYTA.................................32INNOPRAN XL.................. 100INOVA 4-1........................... 135INOVA 8-2........................... 135INSPRA................................112INTELENCE......................... 81INTERMEZZO....................209INTRAROSA.......................177INTRON A............................ 87introvale .................................123INTUNIV ER.......................116INVEGA................................ 77INVIRASE....................... 81, 82INVOKAMET....................... 53INVOKAMET XR.................53INVOKANA.......................... 53iodoquinol-hc ......................... 147IODOSORB..........................135IOPIDINE............................ 154ipratropium bromide ....... 154, 204ipratropium-albuterol .............204irbesartan ................................ 95irbesartan-hydrochlorothiazide .95IRENKA................................ 48IRESSA.................................. 32ISENTRESS........................... 82ISENTRESS HD.................... 82isibloom ................................. 123ISOCHRON......................... 112

Index

isometh-dichloral-acetaminophn ...........................68isoniazid .................................. 70ISOPTO ATROPINE........... 154ISOPTO CARPINE..............197ISOPTO HYOSCINE...........154ISORDIL..............................112ISORDIL TITRADOSE.......112isosorbide dinitrate .................112isosorbide mononitrate ........... 112isotretinoin .............................135isoxsuprine .............................104isradipine ............................... 105ISTALOL............................. 197itraconazole ............................. 61ivermectin ................................ 73JADENU..............................173JADENU SPRINKLE......... 173JAKAFI..................................32JALYN................................. 172jantoven ................................... 91JANUMET.............................53JANUMET XR...................... 53JANUVIA.............................. 53JARDIANCE......................... 53jencycla ..................................123JENTADUETO......................53JENTADUETO XR...............53JEVANTIQUE LO...............177jinteli ..................................... 177jolessa ....................................123jolivette ..................................123JUBLIA.................................. 61juleber ....................................123JULUCA................................ 82junel 1.5/30 (21) .................... 123junel 1/20 (21) .......................123junel fe 1.5/30 (28) ................ 123junel fe 1/20 (28) ................... 123junel fe 24 .............................. 123

I-12

Index

JUXTAPID.......................... 109JYNARQUE........................ 106KADIAN................................. 7kaitlib fe ................................ 123KALETRA.............................82KALYDECO........................207KAPVAY............................. 117KARBINAL ER.....................66kariva (28) ............................ 123KAYEXALATE...................166KAZANO...............................53k-effervescent .........................199KEFLEX................................ 22kelnor 1/35 (28) .................... 123kelnor 1-50 .............................123KENALOG.......................... 147KEPPRA................................ 40KEPPRA XR..........................40KERAFOAM....................... 135KERALYT RX.................... 135KERALYT SCALP COMPLETE.........................135KERYDIN............................. 61KETEK.................................. 24ketoconazole ............................61ketodan ....................................61KETODAN KIT.................... 61ketoprofen ............................... 14ketorolac .......................... 14, 161KEVEYIS............................. 195KEVZARA...........................186KHEDEZLA.......................... 48kimidess (28) .........................123KINERET............................ 186kionex (with sorbitol) ............ 166KISQALI................................32KISQALI FEMARA CO-PACK..................................... 32KLARON.............................142KLONOPIN...........................18

Index

KLOR-CON......................... 199KLOR-CON 10.................... 199KLOR-CON 8...................... 199klor-con m10 ..........................199klor-con m15 ..........................199klor-con m20 ..........................199klor-con sprinkle .................... 199KLOR-CON/25.................... 199KLOR-CON/EF................... 199KOMBIGLYZE XR.............. 54KORLYM.............................. 54K-PHOS NO 2...................... 199K-PHOS ORIGINAL...........199K-PHOS-NEUTRAL........... 199KRISTALOSE..................... 166K-SOL.................................. 199K-TAB..................................199kurvelo ...................................123KUVAN............................... 152KYNAMRO.........................109l norgest/e.estradiol-e.estrad ...124labetalol .................................100LAC-HYDRIN.....................135LACRISERT........................154lactulose .................................166LAMICTAL........................... 41LAMICTAL ODT..................40LAMICTAL ODT STARTER (BLUE)................ 40LAMICTAL ODT STARTER (GREEN).............40LAMICTAL ODT STARTER (ORANGE)......... 40LAMICTAL STARTER (BLUE) KIT........................... 41LAMICTAL STARTER (GREEN) KIT........................41LAMICTAL STARTER (ORANGE) KIT.................... 41LAMICTAL XR.................... 41

Index

LAMICTAL XR STARTER (BLUE)...................................41LAMICTAL XR STARTER (GREEN)............................... 41LAMICTAL XR STARTER (ORANGE)............................ 41LAMISIL............................... 61lamivudine ............................... 82lamivudine-zidovudine .............. 82lamotrigine .........................41, 42LANCING DEVICE WITH LANCETS............................ 151LANOXIN........................... 104lansoprazole ...........................163lanthanum ..............................170LANTUS SOLOSTAR U-100 INSULIN............................... 57LANTUS U-100 INSULIN....58larin 1.5/30 (21) .................... 124larin 1/20 (21) ....................... 124larin 24 fe .............................. 124larin fe 1.5/30 (28) ................ 124larin fe 1/20 (28) ................... 124larissia ................................... 124LASIX.................................. 106LASTACAFT.......................155latanoprost .............................197latrix ..................................... 135latrix xm ................................135LATUDA............................... 77layolis fe ................................ 124LAZANDA.............................. 7leena 28 ................................. 124leflunomide ............................ 186LENVIMA........................32, 33LESCOL............................... 109LESCOL XL.........................109lessina ....................................124LETAIRIS............................ 210letrozole ...................................33

I-13

Index

leucovorin calcium ..................195LEUKERAN..........................33LEUKINE..............................92leuprolide .................................33levalbuterol hcl .......................204levalbuterol tartrate ............... 205LEVAQUIN........................... 26LEVATOL............................100LEVBID............................... 166LEVEMIR FLEXTOUCH U-100 INSULN.......................... 58LEVEMIR U-100 INSULIN..58levetiracetam ........................... 42levobunolol .............................197levocarnitine .......................... 195levocarnitine (with sugar) ...... 195levocetirizine ............................66levofloxacin ......................26, 157levonest (28) ......................... 124levonorgestrel .........................124levonorgestrel-ethinyl estrad ...124levonorg-eth estrad triphasic ...124levora-28 ................................124levorphanol tartrate ................... 7LEVO-T................................183levothyroxine ......................... 183LEVOXYL........................... 183LEVSIN................................166LEVSIN/SL.......................... 166LEXAPRO............................. 49LEXIVA................................. 82LIALDA...............................193LIBRAX (WITH CLIDINIUM)........................ 37lidocaine .................................. 15lidocaine hcl .............................15lidocaine hcl-hydrocortison ac .. 15lidocaine viscous ...................... 16lidocaine-hydrocortisone-aloe.........................................16, 136

Index

lidocaine-prilocaine ..................16lidocaine-tetracaine ..................16LIDODERM.......................... 16LIDO-K..................................16LIDOPIN............................... 16LIDORX................................ 16lillow ......................................124lindane ................................... 151linezolid ................................... 20LINZESS.............................. 166liothyronine ............................183LIPITOR.............................. 109LIPOFEN............................. 109LIPTRUZET........................ 109lisinopril .................................. 97lisinopril-hydrochlorothiazide ...97lithium carbonate ................... 117lithium citrate ........................ 117LITHOBID...........................117LITHOSTAT........................195LIVALO............................... 109LO LOESTRIN FE.............. 124LOCOID...............................147locort ..................................... 178LODINE.................................14LODOSYN.............................75LOESTRIN 1.5/30 (21)......... 125LOESTRIN 1/20 (21)............125LOESTRIN FE 1.5/30 (28-DAY).................................... 125LOESTRIN FE 1/20 (28-DAY).................................... 125LOFIBRA.............................109lomedia 24 fe ..........................125LOMOTIL............................166lomustine ................................. 33LONHALA MAGNAIR STARTER............................ 205LONSURF............................. 33loperamide ............................. 166

Index

LOPID.................................. 109lopinavir-ritonavir ....................82lopreeza ................................. 177LOPRESSOR....................... 100LOPRESSOR HCT.............. 100LOPROX................................61LOPROX (AS OLAMINE)....61lorata-d ....................................66loratadine ................................ 66loratadine-d ............................. 66lorazepam ................................18lorcet (hydrocodone) .................7lorcet hd .................................... 7lorcet plus ..................................7LORTAB 10-325...................... 7LORTAB 5-325........................ 7LORTAB 7.5-325..................... 7LORTAB ELIXIR................... 7loryna (28) ............................125LORZONE........................... 208losartan ................................... 96losartan-hydrochlorothiazide ....96LOSEASONIQUE................125LOTEMAX.......................... 161LOTENSIN............................ 97LOTENSIN HCT................... 97LOTREL.............................. 105LOTRISONE......................... 61LOTRONEX........................ 193lovastatin ............................... 110LOVAZA..............................110LOVENOX.............................91low-ogestrel (28) ................... 125loxapine succinate ....................78LOXITANE........................... 78LUFYLLIN..........................205LUMIGAN.......................... 197LUNESTA............................209lutera (28) .............................125LUVOX CR............................49

I-14

Index

LUXIQ................................. 147LUZU.....................................61LYNPARZA.......................... 33LYRICA.................................42LYRICA CR........................ 117LYSODREN.......................... 33LYSTEDA..............................93lyza ........................................125MACROBID.......................... 20MACRODANTIN................. 20mafenide acetate .................... 136MALARONE.........................73MALARONE PEDIATRIC.. 73malathion ...............................151maprotiline .............................. 49margesic .................................... 7MARINOL.............................71marlissa ................................. 125MARPLAN............................49marten-tab .................................7MATULANE......................... 33matzim la ...............................103MAVIK.................................. 97MAVYRET............................ 87MAXALT...............................68MAXALT-MLT.....................68MAXIDEX...........................161MAXITROL.........................157MAXZIDE........................... 106MAXZIDE-25MG................107meclizine ..................................71meclofenamate .........................14MEDROL.............................178MEDROL (PAK)................. 178medroxyprogesterone .............182mefenamic acid ........................ 14mefloquine ............................... 73MEGACE.............................182MEGACE ES....................... 182megestrol ......................... 33, 182

Index

MEKINIST............................ 33melodetta 24 fe ...................... 125meloxicam ............................... 14melphalan ................................ 33memantine ............................... 45MENACTRA (PF)............... 190MENEST..............................177MENOSTAR........................177MENTAX.............................. 61MENVEO A-C-Y-W-135-DIP (PF).......................................190ME-PB-HYOS........................37me-pb-hyos .............................. 37meperidine ............................. 7, 8meperidine (pf) ......................... 7meprobamate ........................... 18MEPRON...............................73mercaptopurine ........................ 33mesalamine ............................ 193MESNEX............................. 195MESTINON......................... 196MESTINON TIMESPAN....196METADATE CD................. 117metadate er ............................117metaproterenol .......................205metaxall .................................208metaxalone ............................ 208metformin ................................54methadone ................................. 8METHADOSE.........................8methadose ..................................8methamphetamine .................. 117methazolamide ....................... 197methenamine hippurate ............ 20methenamine mandelate ........... 20methen-sod phos-meth blue-hyos .........................................20methimazole ...........................183METHITEST....................... 174methocarbamol ...................... 208

Index

methotrexate sodium ................34methotrexate sodium (pf) .. 33, 34methoxsalen ...........................136methscopolamine ....................167methyclothiazide .................... 107methyldopa .............................. 94methyldopa-hydrochlorothiazide ................. 94methylergonovine ................... 196METHYLIN.........................117methylphenidate hcl ........ 117, 118methylprednisolone ................ 179methyltestosterone ................. 174metipranolol ...........................198metoclopramide hcl ................ 167metolazone .............................107metoprolol succinate .............. 101metoprolol ta-hydrochlorothiaz.............................................. 101metoprolol tartrate .................101METOZOLV ODT...............167METROCREAM................. 142METROGEL........................142METROGEL VAGINAL...... 67METROLOTION.................142metronidazole ............. 20, 67, 142mexiletine ................................ 98MIACALCIN....................... 194mibelas 24 fe .......................... 125MICARDIS............................96MICARDIS HCT...................96miconazole-3 ............................62MICORT-HC....................... 147microgestin 1.5/30 (21) ..........125microgestin 1/20 (21) ............ 125microgestin 24 fe ....................125microgestin fe 1.5/30 (28) ......125microgestin fe 1/20 (28) .........125MICROZIDE....................... 107midazolam ............................... 18

I-15

Index

midodrine .................................94MIGERGOT.......................... 69miglitol .................................... 54miglustat ................................152MIGRANAL..........................69mili ........................................ 125MILLIPRED........................ 179MILLIPRED DP..................179mimvey .................................. 177mimvey lo .............................. 177MINASTRIN 24 FE.............125MINIPRESS...........................94minitran .................................112MINIVELLE........................177MINOCIN..............................28MINOCIN KIT WITH WIPES.................................... 28minocycline ..............................28minoxidil ................................112MIRAPEX............................. 75MIRAPEX ER....................... 75MIRCERA............................. 92MIRCETTE (28).................. 125mirtazapine ..............................49MIRVASO............................136misoprostol ............................ 163MITIGARE............................63M-M-R II (PF)..................... 190MOBIC...................................14modafinil ............................... 209MODERIBA.......................... 89MODERIBA DOSE PACK... 89MODICON (28)................... 126moexipril ................................. 97moexipril-hydrochlorothiazide ..97molindone ................................ 78mometasone ....................147, 161mondoxyne nl .......................... 28MONODOX...........................28mono-linyah ........................... 126

Index

mononessa (28) ..................... 126montelukast ........................... 203MONUROL........................... 20MORGIDOX......................... 28MORPHABOND ER...............8morphine ................................... 8MORPHINE............................ 8morphine concentrate .................8MOTOFEN.......................... 167MOVANTIK........................ 167MOVIPREP..........................169MOXATAG........................... 25MOXEZA.............................157moxifloxacin .................... 26, 157MS CONTIN............................8mucinex allergy ....................... 66MULTAQ.............................. 99mupirocin ...............................142mupirocin calcium .................. 142my choice ...............................126my way .................................. 126MYALEPT........................... 196MYAMBUTOL......................70MYCOBUTIN....................... 70mycophenolate mofetil ........... 186mycophenolate sodium ........... 187MYDAYIS........................... 118MYFORTIC.........................187MYLERAN............................34myorisan ................................136MYRBETRIQ...................... 171MYSOLINE........................... 42MYTESI............................... 167myzilra .................................. 126nabumetone ............................. 14nadolol ...................................101nadolol-bendroflumethiazide ...101naftifine ................................... 62NAFTIN.................................62NALFON............................... 14

Index

nalocet .......................................8naloxone ..................................17naltrexone ............................... 17NAMENDA..................... 45, 46NAMENDA TITRATION PAK........................................46NAMENDA XR.................... 46NAMZARIC.......................... 46naphazoline ............................155NAPRELAN CR....................14NAPROSYN.......................... 14naproxen ................................. 14naproxen sodium ......................14naratriptan .............................. 69NARCAN...............................17NARDIL................................ 49NASACORT........................ 161NASONEX...........................161NATACYN.......................... 157NATAZIA............................ 126nateglinide ............................... 54NATESTO............................174NATPARA...........................194NATROBA...........................151nature-throid ..........................183nebusal ...................................207NEBUSAL............................207necon 0.5/35 (28) ...................126necon 1/35 (28) ..................... 126necon 1/50 (28) ..................... 126necon 10/11 (28) ....................126necon 7/7/7 (28) .................... 126nefazodone ...............................49neomycin ................................. 19neomycin-bacitracin-poly-hc ...157neomycin-bacitracin-polymyxin.............................................. 157neomycin-polymyxin b-dexameth ............................... 157

I-16

Index

neomycin-polymyxin-gramicidin ..............................157neomycin-polymyxin-hc ......... 158neo-polycin ............................ 158neo-polycin hc ........................ 158NEORAL............................. 187NEOSPORIN (NEO-POLYM-GRAMICID).........158NEO-SYNALAR................. 142NEPTAZANE...................... 198NERLYNX............................ 34NESINA................................. 54neuac ..................................... 142NEULASTA...........................92NEUPOGEN..........................92NEUPRO............................... 75NEURONTIN........................42NEVANAC.......................... 161nevirapine ...........................82, 83NEXAVAR............................ 34NEXIUM............................. 163NEXIUM 24HR................... 163NEXIUM PACKET.............163next choice one dose ...............126niacin .....................................110niacor .................................... 110NIASPAN EXTENDED-RELEASE............................ 110nicardipine ............................. 105nifedical xl ............................. 105nifedipine ............................... 105nikki (28) ..............................126NILANDRON....................... 34nilutamide ................................34nimodipine ............................. 105NINLARO............................. 34nisoldipine ..............................105NITRO-BID......................... 112NITRO-DUR....................... 113nitrofurantoin .......................... 20

Index

nitrofurantoin macrocrystal ..... 20nitrofurantoin monohyd/m-cryst ........................................ 20nitroglycerin .......................... 113NITROLINGUAL............... 113NITROMIST........................113NITROSTAT........................113nizatidine ............................... 163NIZORAL..............................62NOCTIVA............................ 180nodolor .................................... 69NOLIX................................. 147nora-be .................................. 126NORCO................................... 8NORDITROPIN FLEXPRO.............................................. 180noreth-ethinyl estradiol-iron ... 126norethindrone (contraceptive) 126norethindrone acetate .............182norethindrone ac-eth estradiol.......................................126, 177norethindrone-e.estradiol-iron 126norgestimate-ethinyl estradiol.......................................126, 127norinyl 1/35 (28) ................... 127NORINYL 1+50 (28)........... 127NORITATE..........................142norlyda .................................. 127norlyroc ................................. 127NOROXIN.............................26NORPACE.............................99NORPACE CR...................... 99NORPRAMIN....................... 49NOR-QD.............................. 127NORTHERA......................... 94nortrel 0.5/35 (28) .................127nortrel 1/35 (21) ....................127nortrel 1/35 (28) ....................127nortrel 7/7/7 (28) ...................127nortriptyline .............................49

Index

NORVASC........................... 105NORVIR................................ 83NOVOLIN 70/30 U-100 INSULIN............................... 58NOVOLIN N NPH U-100 INSULIN............................... 58NOVOLIN R REGULAR U-100 INSULN.......................... 58NOVOLOG FLEXPEN U-100 INSULIN.........................58NOVOLOG MIX 70-30 U-100 INSULN.......................... 58NOVOLOG MIX 70-30FLEXPEN U-100............... 58NOVOLOG PENFILL U-100 INSULIN............................... 58NOVOLOG U-100 INSULIN ASPART.................................58NOXAFIL..............................62np thyroid .............................. 183NUCORT............................. 147NUCYNTA..............................9NUCYNTA ER....................... 8NUEDEXTA........................118NULEV................................ 167NULYTELY WITH FLAVOR PACKS................ 169NUPLAZID........................... 78NUTROPIN AQ.................. 181NUTROPIN AQ NUSPIN...181NUVARING........................ 127NUVESSA..............................67NUVIGIL.............................209nyamyc .................................... 62nyata ....................................... 62NYMALIZE.........................105nystatin ....................................62nystatin-triamcinolone ............. 62nystop ......................................62OCALIVA............................ 167

I-17

Index

ocella ..................................... 127octreotide acetate ...................181OCUFEN............................. 161OCUFLOX...........................158ODEFSEY..............................83ODOMZO.............................. 34OFEV....................................207ofloxacin .......................... 26, 158ogestrel (28) ..........................127okebo .......................................28olanzapine ............................... 78olanzapine-fluoxetine ............... 49OLEPTRO ER....................... 49olmesartan ...............................96olmesartan-amlodipin-hcthiazid96olmesartan-hydrochlorothiazide96olopatadine ............................ 155OLUX...................................147OLUX-E............................... 147OLYSIO................................. 87OMECLAMOX-PAK.......... 163omega-3 acid ethyl esters ........110omeprazole ............................ 163omeprazole-sodium bicarbonate.............................................. 164OMNARIS........................... 161OMNIPRED........................ 161OMNITROPE...................... 181ondansetron ............................. 71ondansetron hcl ........................71ONEXTON.......................... 142ONFI................................ 18, 19ONGLYZA............................ 54ONMEL................................. 62ONZETRA XSAIL................ 69OPANA....................................9OPANA ER..............................9opcicon one-step .....................127opium tincture ........................167OPSUMIT............................ 210

Index

option-2 ................................. 127OPTIVAR.............................155ORACEA............................... 28ORACIT...............................200ORALAIR............................196oralone ...................................132ORAP..................................... 78ORAPRED ODT..................179ORAVIG................................ 62ORENCIA............................187ORENCIA CLICKJECT..... 187ORENITRAM......................210ORFADIN........................... 152ORKAMBI...........................207orphenadrine citrate ............... 208orphenadrine compound-ds ..... 208orsythia ................................. 127ORTHO EVRA.................... 127ORTHO MICRONOR.........127ORTHO TRI-CYCLEN (28) 127ORTHO TRI-CYCLEN LO (28)........................................127ORTHO-CEPT (28)..............127ORTHO-CYCLEN (28)....... 127ORTHO-NOVUM 1/35 (28).128ORTHO-NOVUM 7/7/7 (28) 128oscimin .................................. 167oscimin sl ............................... 167oscimin sr ...............................167oseltamivir ............................... 86OSENI.................................... 54OSMOPREP.........................169OTEZLA.............................. 187OTEZLA STARTER............187OTIC CARE (ANTIPYRINE)...................158oto-end 10 ..............................161otomax-hc ..............................161OTOVEL.............................. 155OTREXUP (PF)................... 187

Index

OVACE PLUS.............. 136, 142OVCON-35 (28)....................128OVIDE..................................151OXANDRIN........................ 174oxandrolone ........................... 174oxaprozin ................................ 14OXAYDO................................ 9oxazepam ................................ 19oxcarbazepine ..........................42OXECTA..................................9oxiconazole ..............................62OXISTAT...............................62OXSORALEN ULTRA....... 136OXTELLAR XR.................... 42oxybutynin chloride ................171oxycodone ................................. 9oxycodone-acetaminophen ......... 9oxycodone-aspirin ......................9OXYCONTIN..........................9oxymorphone ....................... 9, 10OXYTROL...........................171OZEMPIC.............................. 54pacerone .................................. 99PACNEX..............................136PACNEX HP........................136PACNEX LP........................ 136PACNEX MX...................... 136paliperidone ............................. 78PAMELOR............................ 49PAMINE.............................. 167PANCREAZE...................... 152pancrelipase 5000 ...................152PANDEL..............................148panlor(acetam-caff-dihydrocod) ............................. 10PANRETIN..........................136pantoprazole .......................... 164paregoric ............................... 167paricalcitol .............................194PARLODEL...........................75

I-18

Index

PARNATE............................. 49paroex oral rinse .................... 132paromomycin ........................... 73paroxetine hcl .......................... 49paroxetine mesylate(menop.sym) ..............49PASER................................... 70PATADAY...........................155PATANASE......................... 155PATANOL........................... 155PAXIL.................................... 50PAXIL CR..............................49PAZEO................................. 155PCE........................................ 24PEDIADERM HC............... 148PEDIAPRED....................... 179pedi-dri .................................... 62peg 3350-electrolytes ..............169PEGANONE..........................42PEGASYS.............................. 88PEGASYS CONVENIENCE PACK..................................... 87PEGASYS PROCLICK......... 87peg-electrolyte soln ................ 169PEGINTRON........................ 88PEGINTRON REDIPEN...... 88peg-prep .................................169penicillin v potassium ..........25, 26PENLAC................................ 62PENNSAID..........................136PENTASA............................ 193pentazocine-naloxone ...............10pentoxifylline ...........................93PEPCID................................164PERCOCET........................... 10PERCODAN..........................10PERFOROMIST..................205PERIDEX.............................132perindopril erbumine ................ 97periogard ............................... 132

Index

permethrin ............................. 151perphenazine ............................78perphenazine-amitriptyline .......50PERSANTINE....................... 93PERTZYE............................ 152PEXEVA................................ 50phenadoz ................................. 72phenazopyridine ..................... 172phenelzine ................................ 50PHENERGAN.......................72PHENOBARB-HYOSCY-ATROPINE-SCOP.................37phenobarb-hyoscy-atropine-scop ......................................... 38phenobarbital ..................... 42, 43PHENOHYTRO.................... 38phenoxybenzamine ...................95phenylephrine hcl ................... 155PHENYTEK.......................... 43phenytoin .................................43phenytoin sodium extended .......43philith .................................... 128PHOSLO.............................. 170PHOSLYRA.........................170phospha 250 neutral ............... 200PHOSPHASAL...................... 20PHOSPHOLINE IODIDE... 198phrenilin forte(with caffeine) ... 10PICATO............................... 136pilocarpine hcl ................ 132, 198pimozide .................................. 78pimtrea (28) ..........................128pindolol ..................................101pioglitazone ............................. 54pioglitazone-glimepiride ........... 54pioglitazone-metformin ............ 54pirmella ................................. 128piroxicam ................................ 14PLAN B ONE-STEP............ 128PLAQUENIL......................... 73

Index

PLAVIX................................. 93PLEGRIDY..........................118PLETAL.................................93PLEXION.............................136PLEXION CLEANSING CLOTHS.............................. 136PLIAGLIS..............................16PNEUMOVAX 23........ 190, 191podocon ................................. 136podofilox ............................... 136polycin ................................... 158polyethylene glycol 3350 ........ 169polymyxin b sulf-trimethoprim158POLYTRIM......................... 158POMALYST.......................... 34PONSTEL.............................. 14portia .....................................128pot,sodium citrate-citric acid .. 200potassium bicarb and chloride .200potassium bicarb-citric acid ....200potassium chloride ..................200potassium citrate ....................200potassium citrate-citric acid ... 200POTIGA................................. 43PRADAXA............................ 91PRALUENT PEN................110PRALUENT SYRINGE...... 110PRAMCORT........................148pramipexole .............................75PRAMOSONE..................... 148PRAMOSONE E..................148PRANDIMET........................54PRANDIN............................. 54prasugrel ..................................93PRAVACHOL......................110pravastatin .............................110praziquantel .............................73prazosin ................................... 95PRECOSE.............................. 55PRED FORTE..................... 161

I-19

Index

PRED MILD........................161PRED-G............................... 158PRED-G S.O.P..................... 158prednicarbate ......................... 148prednisolone acetate ...............161prednisolone sodium phosphate.......................................161, 179prednisone ..............................179PREDNISONE INTENSOL 179PREFEST............................. 177prelone ...................................179PREMARIN.........................177PREMPHASE...................... 177PREMPRO...........................177PREPOPIK...........................169PRESTALIA........................ 113PREVACID..........................164PREVACID SOLUTAB.......164prevalite .................................110PREVIDENT....................... 132PREVIDENT 5000 BOOSTER PLUS................. 132PREVIDENT 5000 SENSITIVE.......................... 132previfem .................................128PREVNAR 13 (PF).............. 191PREVPAC............................ 164PREVYMIS............................86PREZCOBIX..........................83PREZISTA............................. 83PRIFTIN................................70PRILOSEC........................... 164PRILOSEC OTC.................. 164PRIMAQUINE...................... 73primidone .................................43PRIMLEV.............................. 10PRIMSOL.............................. 20PRINIVIL.............................. 97PRISTIQ.................................50PROAIR HFA......................205

Index

PROAIR RESPICLICK.......205probenecid ............................... 63probenecid-colchicine ............... 63PROCARDIA...................... 105PROCARDIA XL................ 105PROCENTRA......................118prochlorperazine ...................... 72prochlorperazine maleate ......... 72PROCORT........................... 148PROCRIT.............................. 92PROCTOCORT................... 148PROCTOFOAM HC............148procto-med hc ........................ 148procto-pak ............................. 148proctosol hc ........................... 148proctozone-hc .........................148PROCYSBI...........................152PROFENO............................. 14progesterone micronized .........182PROGLYCEM.....................196PROGRAF...........................187PROLENSA......................... 161PROMACTA......................... 92promethazine ......................66, 72promethazine vc ....................... 66promethazine vc-codeine .........131promethazine-codeine .............131promethazine-dm ................... 131promethegan ............................ 72PROMETRIUM.................. 182propafenone ............................. 99propantheline ........................... 38proparacaine .......................... 155propranolol ............................ 101propranolol-hydrochlorothiazid.............................................. 101propylthiouracil ..................... 183PROQUAD (PF).................. 191PROSCAR............................172PROTONIX......................... 164

Index

PROTOPIC.......................... 148protriptyline .............................50PROVENTIL HFA.............. 205PROVERA........................... 182PROVIGIL........................... 209PROZAC................................50PROZAC WEEKLY.............. 50PRUDOXIN.........................136PSORCON........................... 148PULMICORT...................... 203PULMICORT FLEXHALER.............................................. 203PULMOZYME.................... 152PURINETHOL...................... 34PURIXAN..............................34PYLERA.............................. 167pyrazinamide ........................... 70PYRIDIUM......................... 172pyridostigmine bromide .......... 196QBRELIS............................... 98QNASL.................................162QTERN.................................. 55QUALAQUIN....................... 73QUARTETTE...................... 128quasense ................................ 128quazepam ................................ 19QUDEXY XR........................ 43QUESTRAN........................ 110QUESTRAN LIGHT........... 110quetiapine ................................ 78QUILLICHEW ER.............. 118QUILLIVANT XR...............118quinapril .................................. 98quinapril-hydrochlorothiazide ...98quinidine gluconate .................. 99quinidine sulfate .......................99quinine sulfate ..........................73QVAR...................................203QVAR REDIHALER.......... 203rabeprazole ............................ 164

I-20

Index

RADIAPLEXRX................. 136RADIOGARDASE..............196RAGWITEK........................ 196rajani ..................................... 128raloxifene .............................. 177ramipril ................................... 98RANEXA............................. 104ranitidine hcl ..........................164RAPAFLO........................... 172RAPAMUNE....................... 187rasagiline ................................. 75RASUVO (PF)......................188RAVICTI..............................167RAYALDEE........................ 194RAYOS.................................179RAZADYNE......................... 46RAZADYNE ER................... 46react ...................................... 128REBETOL..............................89REBIF (WITH ALBUMIN).......................................118, 119REBIF REBIDOSE..............119REBIF TITRATION PACK 119reclipsen (28) ........................ 128RECOMBIVAX HB (PF).....191RECTACORT-HC............... 148RECTIV............................... 196REGLAN............................. 167REGRANEX........................137RELAGARD......................... 67RELENZA DISKHALER..... 86RELEXXII........................... 119RELISTOR................... 167, 168RELPAX................................ 69REMERON............................50REMERON SOLTAB............50remeven ................................. 137RENAGEL...........................170RENVELA........................... 170repaglinide ...............................55

Index

repaglinide-metformin ..............55REPATHA PUSHTRONEX110REPATHA SURECLICK....110REPATHA SYRINGE.........110reprexain ................................. 10REQUIP................................. 75REQUIP XL...........................75RESCRIPTOR....................... 83RESCULA............................198reserpine ................................ 104respa-ar ................................... 66RESTASIS............................162RESTORIL............................ 19RETIN-A..............................150RETIN-A MICRO............... 150RETIN-A MICRO PUMP... 150RETROVIR........................... 84REVATIO............................ 210REVIA....................................17REVLIMID............................34REXULTI.............................. 78REYATAZ............................. 84REZIRA............................... 131RHEUMATREX................... 34RHINOCORT AQUA......... 162RHOFADE.......................... 137RHOPRESSA.......................198ribasphere ................................89ribasphere ribapak ................... 89RIBATAB DOSE PACK....... 89ribavirin ...................................89RIDAURA........................... 188rifabutin ...................................70RIFADIN...............................70RIFAMATE...........................70rifampin ...................................70RIFATER.............................. 70RILUTEK............................ 119riluzole ...................................119rimantadine ............................. 86

Index

RIOMET................................ 55risedronate .............................194RISPERDAL..........................78RISPERDAL M-TAB............ 78risperidone ...............................78RITALIN............................. 119RITALIN LA....................... 119RITALIN SR........................119ritonavir ...................................84rivastigmine ............................. 46rivastigmine tartrate ................ 46rivelsa .................................... 128rizatriptan ............................... 69ROBAXIN............................208ROBAXIN-750.....................208ROBINUL............................168ROBINUL FORTE..............168ROCALTROL......................194ropinirole ................................. 75rosadan ..................................142ROSADAN.......................... 142ROSANIL............................ 137ROSULA..............................137rosula cleansing cloths ............137rosuvastatin ........................... 110ROWASA.............................193ROWEEPRA..........................43ROWEEPRA XR................... 43roxicet ..................................... 10ROXICODONE..................... 10ROXYBOND......................... 10ROZEREM.......................... 209RUBRACA............................ 34RYDAPT................................35RYTARY............................... 75RYTHMOL............................99RYTHMOL SR......................99RYVENT............................... 66SABRIL..................................43SAFYRAL............................128

I-21

Index

SAIZEN................................181SAIZEN SAIZENPREP.......181SALACYN........................... 137salacyn ...................................137SALAGEN (PILOCARPINE).............................................. 132SALEX................................. 137salicylic acid .......................... 137salicylic acid er-ceramides ...... 137SALKERA........................... 137salsalate ...................................14SAMSCA..............................107SANCTURA........................ 171SANCUSO............................. 72SANDIMMUNE..................188SANDOSTATIN..................181SANTYL.............................. 137SAPHRIS (BLACK CHERRY)..............................79SARAFEM.............................50SAVAYSA..............................91SAVELLA............................ 119SCALACORT...................... 148SCALACORT DK............... 148scopolamine base ..................... 72SEASONIQUE.....................128seb-prev ................................. 137SECONAL SODIUM...........209SECTRAL............................ 101SEEBRI NEOHALER......... 205SEGLUROMET.................... 55selegiline hcl ............................ 76selenium sulfide ......................142SELZENTRY.........................84SEMPREX-D......................... 66SENSIPAR........................... 194SEREVENT DISKUS.......... 205SERNIVO.............................149SEROQUEL...........................79SEROQUEL XR.................... 79

Index

SEROSTIM.......................... 181sertraline ................................. 50setlakin .................................. 128sevelamer carbonate ...............170sf 5000 plus ............................ 132sharobel ................................. 128SHINGRIX (PF).................. 191SHOHL'S MODIFIED.........200SIGNIFOR...........................181SIKLOS.................................. 35sildenafil (antihypertensive) ...211SILENOR.............................210SILIQ....................................137SILVADENE........................142silver nitrate ...........................142silver nitrate applicators .........142silver sulfadiazine ...................142SIMBRINZA........................198SIMCOR....................... 110, 111SIMPONI......................188, 189simvastatin .............................111SINEMET.............................. 76SINEMET CR........................76SINGULAIR........................203sirolimus ................................ 189SIRTURO.............................. 70SITAVIG................................89SIVEXTRO............................ 20SKELAXIN..........................208SKLICE................................151sodium chloride ...................... 207sodium citrate-citric acid ........200sodium phenylbutyrate ........... 168sodium polystyrene (sorb free).............................................. 168SOLARAZE......................... 137SOLIQUA 100/33................... 58SOLODYN.............................28SOLOSEC.............................. 20soloxide ................................... 28

Index

SOLTAMOX..........................35SOMA...................................208SOMAVERT........................ 181SONATA..............................210SOOLANTRA......................151SORIATANE....................... 137SORILUX............................ 137sorine .....................................101sotalol ....................................101SOTYLIZE........................... 101SOVALDI.............................. 87SPECTRACEF.......................22spinosad .................................151SPIRIVA RESPIMAT..........205SPIRIVA WITH HANDIHALER...................205spironolactone ........................107spironolacton-hydrochlorothiaz.............................................. 107SPORANOX.......................... 62sprintec (28) ..........................128SPRITAM.............................. 43SPRIX.................................... 15SPRYCEL.............................. 35sps (with sorbitol) ..................168sronyx ....................................128ssd ......................................... 142sski ........................................ 183sss 10-5 .................................. 137STALEVO 100........................76STALEVO 125........................76STALEVO 150........................76STALEVO 200........................76STALEVO 50......................... 76STALEVO 75......................... 76stannous fluoride ....................132STARLIX...............................55stavudine ..................................84STAVZOR..............................43STEGLATRO........................ 55

I-22

Index

STEGLUJAN.........................55STELARA............................ 189STENDRA........................... 211STIMATE.............................181STIOLTO RESPIMAT.........205STIVARGA............................35STRATTERA.......................119STRENSIQ...........................153STRIANT.............................174STRIBILD..............................84STRIVERDI RESPIMAT....205STROMECTOL..................... 73strong iodine .......................... 183SUBLOCADE........................ 10SUBOXONE.......................... 17SUBSYS................................. 10subvenite ..................................43subvenite starter (blue) kit .......44subvenite starter (green) kit .....44subvenite starter (orange) kit ...44SUCLEAR............................170SUCRAID............................ 153sucralfate ....................... 164, 165SULAR.................................106sulfacetamide sodium ......137, 158sulfacetamide sodium (acne) ..142sulfacetamide sodium-sulfur ... 138sulfacetamide-prednisolone .....158sulfadiazine ..............................26sulfamethoxazole-trimethoprim 27SULFAMYLON.................. 138sulfasalazine .......................... 193sulfatrim .................................. 27sulindac ................................... 15SUMADAN......................... 138sumatriptan ............................. 69sumatriptan succinate .............. 69sumatriptan-naproxen ..............69SUMAVEL DOSEPRO......... 69SUMAXIN........................... 138

Index

SUMAXIN TS......................138SUPRAX.......................... 22, 23SUPREP BOWEL PREP KIT.............................................. 170SURMONTIL........................ 50SUSTIVA............................... 84SUTENT................................ 35syeda ..................................... 128SYLATRON.......................... 88SYMAX DUOTAB.............. 168SYMAX FASTABS..............168SYMAX-SL.......................... 168SYMAX-SR..........................168SYMBICORT.......................203SYMBYAX............................ 50SYMDEKO.......................... 207SYMFI................................... 84SYMFI LO............................. 84SYMLINPEN 120.................. 55SYMLINPEN 60.................... 55SYMPROIC......................... 168SYNALAR........................... 149SYNALAR TS......................149SYNALGOS-DC....................10SYNAREL........................... 181SYNDROS............................. 72SYNERA................................16SYNJARDY...........................55SYNJARDY XR.................... 55SYNRIBO.............................. 35SYNTHROID...................... 183SYPRINE............................. 173TABLOID.............................. 35TACLONEX........................ 138tacrolimus ...................... 149, 189TAFINLAR........................... 35TAGRISSO............................ 35TAKE ACTION................... 128TALTZ AUTOINJECTOR..139TALTZ SYRINGE...............139

Index

TAMIFLU............................. 86tamoxifen ................................ 35tamsulosin ..............................172TANZEUM............................55TAPAZOLE......................... 183taperdex ................................ 179TARCEVA............................. 35TARGADOX......................... 28TARGRETIN........................ 35tarina fe 1/20 (28) ................. 128TARKA..................................98TASIGNA.............................. 36TASMAR............................... 76TAYTULLA.........................129tazarotene ..............................150TAZORAC........................... 150taztia xt ................................. 103TECFIDERA....................... 119TECHNIVIE.......................... 87TEGRETOL...........................44TEGRETOL XR.................... 44TEKAMLO.......................... 112TEKTURNA........................112TEKTURNA HCT...............112telmisartan .............................. 96telmisartan-amlodipine .............96telmisartan-hydrochlorothiazid .96temazepam .............................. 19TEMODAR............................36TEMOVATE........................ 149temozolomide ...........................36tencon ......................................10TENEX...................................95TENIVAC (PF).................... 191tenofovir disoproxil fumarate ... 84TENORETIC 100.................101TENORETIC 50...................101TENORMIN........................ 101TERAZOL 3...........................67TERAZOL 7...........................67

I-23

Index

terazosin ................................ 172terbinafine hcl ..........................63terbutaline ............................. 205terconazole .............................. 67TERSI FOAM...................... 142TESSALON PERLES.......... 131TESTIM............................... 174testosterone .................... 174, 175testosterone cypionate ............ 174testosterone enanthate ............174TESTRED............................ 175TETANUS-DIPHTHERIA TOXOIDS-TD......................191tetrabenazine ......................... 120tetracycline ..............................28TEVETEN..............................96TEVETEN HCT.....................96THALOMID........................ 196THEO-24.............................. 206theochron ...............................206theophylline ........................... 206THERMAZENE.................. 143THIOLA...............................196thioridazine ..............................79thiothixene ...............................79thyroid (pork) ....................... 183THYROLAR-1.....................183THYROLAR-1/2..................184THYROLAR-1/4..................184THYROLAR-2.....................184THYROLAR-3.....................184tiagabine ..................................44TIAZAC............................... 103ticlopidine ................................ 93TIGAN................................... 72TIKOSYN.............................. 99tilia fe .................................... 129timolol maleate ...............101, 198TIMOPTIC...........................198

Index

TIMOPTIC OCUDOSE (PF).............................................. 198TIMOPTIC-XE.................... 198TINDAMAX..........................73tinidazole ................................. 74TIROSINT........................... 184TIVICAY............................... 85TIVORBEX............................15tizanidine ............................... 208TOBI.......................................19TOBI PODHALER................19TOBRADEX.................158, 159TOBRADEX ST...................159tobramycin .............................159tobramycin in 0.225 % nacl ...... 19tobramycin-dexamethasone ....159TOBREX.............................. 159TOFRANIL........................... 50TOFRANIL-PM.................... 50TOLAK................................ 139tolazamide ............................... 59tolbutamide ..............................59tolcapone ................................. 76tolmetin ................................... 15tolterodine ............................. 171TOPAMAX............................ 44TOPICORT.......................... 149topiragen ................................. 44topiramate ............................... 44TOPROL XL........................ 101torsemide ............................... 107TOUJEO MAX SOLOSTAR.58TOUJEO SOLOSTAR U-300 INSULIN............................... 58TOVIAZ............................... 171TRACLEER.........................211TRADJENTA........................ 55tramadol ............................ 10, 11tramadol-acetaminophen ..........11TRANDATE........................ 102

Index

trandolapril ..............................98trandolapril-verapamil ............. 98tranexamic acid ....................... 93TRANSDERM-SCOP............72TRANXENE T-TAB............. 19tranylcypromine .......................50TRAVATAN Z.....................198trazodone .................................50TRECATOR.......................... 70TRELEGY ELLIPTA.......... 206TREMFYA.......................... 139TRESIBA FLEXTOUCH U-100.......................................... 59TRESIBA FLEXTOUCH U-200.......................................... 59tretinoin ......................... 150, 151tretinoin (chemotherapy) .........36tretinoin microspheres ............ 150TRETIN-X........................... 151TRETIN-X CREAM KIT.... 151TREXALL............................. 36TREXIMET........................... 69TREZIX................................. 11tri femynor .............................129triamcinolone acetonide............................... 132, 149, 162triamterene-hydrochlorothiazid.............................................. 107trianex ................................... 149triazolam ................................. 19TRIBENZOR......................... 96tricitrates ...............................200TRICOR...............................111triderm ...................................149tridesilon ................................149trientine ................................. 173tri-estarylla ............................129trifluoperazine ......................... 79trifluridine ............................. 159TRIGLIDE...........................111

I-24

Index

trihexyphenidyl ........................ 76tri-legest fe .............................129TRILEPTAL.......................... 44tri-linyah ................................129TRILIPIX.............................111tri-lo-estarylla ........................129tri-lo-marzia .......................... 129tri-lo-sprintec ......................... 129trilyte with flavor packets .......170trimethobenzamide ...................72trimethoprim ............................20tri-mili ................................... 129trimipramine ............................51TRIMPEX..............................20trinessa (28) ..........................129trinessa lo .............................. 129TRI-NORINYL (28)............ 129TRINTELLIX........................51tri-previfem (28) ....................129tri-sprintec (28) .....................129TRIUMEQ............................. 85trivora (28) ........................... 129tri-vylibra .............................. 129TRIZIVIR.............................. 85TROKENDI XR.................... 44trospium ................................ 171TRULANCE........................ 168TRULICITY.......................... 55TRUMENBA....................... 191TRUSOPT............................ 198TRUVADA............................ 85TUDORZA PRESSAIR.......206tulana .................................... 129TUSSICAPS......................... 131TUSSIGON.......................... 131TUSSIONEX PENNKINETIC ER............ 131TUZISTRA XR....................131TWINRIX (PF).................... 191TWYNSTA............................ 96

Index

TYBOST...............................196tydemy ...................................129TYKERB................................36TYLENOL-CODEINE #3.....11TYLENOL-CODEINE #4.....11TYMLOS..............................194TYVASO.............................. 211TYVASO REFILL KIT....... 211TYVASO STARTER KIT....211TYZEKA................................89TYZINE............................... 155UCERIS............................... 193u-cort .....................................149ULORIC.................................63ULTRACET...........................11ULTRAM.............................. 11ULTRAM ER........................ 11ULTRAVATE......................149ULTRESA............................153UMECTA.............................139umecta ................................... 139UMECTA PD.......................139UNIRETIC............................ 98UNITHROID.......................184UNIVASC.............................. 98UPTRAVI............................ 211ur n-c .......................................21URAMAXIN....................... 139uramit mb .............................. 172urea ....................................... 139urea nail stick ........................ 139URECHOLINE....................171UREDEB..............................139URELLE................................ 21uretron d-s ............................... 21URETRON D-S..................... 21URIBEL............................... 172urimar-t ................................... 21URIN DS............................... 21uro-458 ....................................21

Index

uro-blue ................................... 21UROCIT-K 10......................200UROCIT-K 15......................200UROCIT-K 5........................201urogesic-blue ............................21urolet mb ................................. 21uro-mp ...................................172urophen mb ............................ 172UROQID-ACID NO.2...........21UROXATRAL.....................172URSO 250.............................168URSO FORTE..................... 168ursodiol ..................................168ustell ......................................172UTA......................................172UTA (WITH PHENYL SALICYLATE).................... 172UTIBRON NEOHALER.....206UTIRA-C............................... 21VAGIFEM........................... 177valacyclovir ..............................89VALCHLOR........................ 139VALCYTE............................. 89valganciclovir ...........................89VALIUM................................19valproic acid ............................ 44valproic acid (as sodium salt) .. 44valsartan ..................................96valsartan-hydrochlorothiazide .. 96VALTREX............................. 89VANATOL LQ...................... 11VANCOCIN...........................21vancomycin ..............................21VANDAZOLE....................... 67VANOS.................................150VANOXIDE-HC..................139VAQTA (PF)........................ 191VARIVAX (PF)....................192VARUBI.................................72VASCEPA............................ 111

I-25

Index

VASERETIC.......................... 98vasolex ...................................139VASOTEC..............................98VECAMYL.......................... 104VECTICAL.......................... 140velivet triphasic regimen (28) .129VELPHORO.........................170VELTASSA.......................... 168VELTIN............................... 143VEMLIDY............................. 85VENCLEXTA........................36VENCLEXTA STARTING PACK..................................... 36VENELEX............................140venlafaxine .............................. 51VENTAVIS.......................... 211VENTOLIN HFA................ 206VERAMYST........................ 162verapamil ...............................103VERDESO............................150VERDROCET........................11VEREGEN........................... 140VERELAN........................... 103VERELAN PM.................... 103VERIPRED 20..................... 179VERSACLOZ.........................79VERZENIO............................36VESICARE...........................171vestura (28) ...........................129VEXOL.................................162VFEND.................................. 63VGO 40.................................151VIBERZI.............................. 168VIBRAMYCIN................ 28, 29vicodin ..................................... 11vicodin es ................................. 11vicodin hp ................................ 11VICOPROFEN...................... 11VICTOZA.............................. 55

Index

VIDEX 2 GRAM PEDIATRIC.......................... 85VIDEX EC............................. 85VIEKIRA PAK...................... 87VIEKIRA XR........................ 87vienva .................................... 129vigabatrin ................................ 44vigadrone .................................45VIGAMOX...........................159VIIBRYD............................... 51VIMOVO................................15VIMPAT.................................45VIOKACE............................ 153viorele (28) ............................130VIRACEPT............................ 85VIRAMUNE..........................85VIRAMUNE XR................... 85VIRASAL.............................140VIREAD.................................85VIROPTIC........................... 159virt-phos 250 neutral .............. 201VISTARIL............................196VISTOGARD.......................196VITEKTA.............................. 86VITUZ..................................131VIVACTIL............................. 51VIVELLE-DOT....................177VIVLODEX........................... 15VOGELXO...........................175VOLTAREN........................ 140VOLTAREN-XR................... 15voriconazole .............................63VOSEVI..................................87VOSOL-HC.......................... 159VOSPIRE ER....................... 206VOTRIENT............................36VRAYLAR............................ 79VUSION.................................63vyfemla (28) ..........................130vylibra ................................... 130

Index

VYTORIN 10-10.................. 111VYTORIN 10-20.................. 111VYTORIN 10-40.................. 111VYTORIN 10-80.................. 111VYVANSE........................... 120VYZULTA........................... 198wal-fex allergy .........................66wal-fex d 12 hour ..................... 66wal-fex d 24 hour ..................... 66wal-itin .................................... 66wal-itin d ................................. 66wal-itin d 12 hour .....................66wal-zyr (cetirizine) ..................66wal-zyr d ..................................66warfarin ...................................91WELCHOL.......................... 111WELLBUTRIN..................... 51WELLBUTRIN SR................51WELLBUTRIN XL............... 51wera (28) .............................. 130westhroid ............................... 184wp thyroid ..............................184wymzya fe ..............................130XADAGO.............................. 76XALATAN...........................198XALKORI............................. 36XANAX................................. 19XANAX XR...........................19XARELTO............................. 91XARTEMIS XR.....................11XATMEP............................... 36XCLAIR...............................196XELJANZ............................ 189XELJANZ XR......................189XELODA............................... 36XENAZINE......................... 120XERESE...............................140XERMELO.......................... 169XHANCE............................. 162XIFAXAN............................. 21

I-26

Index

XIGDUO XR......................... 56XIIDRA................................162XIMINO.................................29XODOL 10/300.......................11XODOL 5/300........................ 11XODOL 7.5/300......................11XOLEGEL............................. 63XOPENEX........................... 206XOPENEX CONCENTRATE................ 206XOPENEX HFA.................. 206XTAMPZA ER...................... 12XTANDI................................ 37xulane ....................................130XULTOPHY 100/3.6..............59x-viate ................................... 140X-VIATE.............................. 140xylon 10 ...................................12XYREM............................... 210XYZAL.................................. 67YASMIN (28)....................... 130YAZ (28)...............................130YODOXIN.............................74YOSPRALA......................... 104yuvafem ................................. 177ZADITOR............................ 155zafirlukast ..............................203zaleplon ................................. 210ZAMICET..............................12ZANAFLEX.........................209ZANTAC..............................165zarah ..................................... 130ZARONTIN...........................45ZAROXOLYN.....................107ZARXIO.................................93ZAVESCA............................ 153ZEBETA...............................102zebutal .....................................12ZEGERID............................ 165ZEGERID OTC................... 165

Index

ZEJULA.................................37ZELAPAR..............................76ZELBORAF........................... 37ZEMBRACE SYMTOUCH.. 69ZEMPLAR........................... 194zenatane ................................ 140zenchent (28) ........................ 130zenchent fe ............................. 130ZENCIA............................... 140ZENPEP............................... 153zenzedi ...................................120ZENZEDI.............................120zeosa ......................................130ZEPATIER.............................87ZERIT.................................... 86ZESTORETIC........................98ZESTRIL................................98ZETIA.................................. 111ZETONNA...........................162ZIAC.....................................102ZIAGEN.................................86ZIANA................................. 143zidovudine ................................86zileuton .................................. 203ZIOPTAN (PF).....................198ziprasidone hcl ......................... 79ZIPSOR.................................. 15ZIRGAN.............................. 159ZITHRANOL.......................140ZITHRANOL-RR................140ZITHROMAX....................... 24ZITHROMAX TRI-PAK...... 24ZITHROMAX Z-PAK...........24ZMAX.................................... 24ZOCOR................................ 111zodex ..................................... 179ZOFRAN............................... 72ZOFRAN ODT...................... 72ZOHYDRO ER......................12ZOLINZA.............................. 37

Index

zolmitriptan ............................. 69ZOLOFT................................ 51zolpidem ................................ 210ZOLPIMIST......................... 210ZOMACTON....................... 182ZOMIG.................................. 70ZOMIG ZMT.........................70zonacort .................................180ZONALON.......................... 140ZONATUSS......................... 131ZONEGRAN......................... 45zonisamide ...............................45ZONTIVITY.......................... 94ZORBTIVE.......................... 182ZORTRESS.......................... 189ZORVOLEX.......................... 15ZOSTAVAX (PF).................192zovia 1/35e (28) .....................130zovia 1/50e (28) .....................130ZOVIRAX...................... 89, 140ZUBSOLV..............................17ZUPLENZ..............................72ZURAMPIC...........................63ZUTRIPRO..........................131ZYBAN.................................. 17ZYCLARA........................... 140ZYDELIG.............................. 37ZYFLO.................................203ZYFLO CR.......................... 203ZYKADIA............................. 37ZYLET................................. 159ZYLOPRIM........................... 63ZYMAXID...........................159ZYPITAMAG...................... 111ZYPRAM............................. 150ZYPREXA............................. 79ZYPREXA ZYDIS.................79ZYRTEC................................ 67ZYRTEC-D............................67ZYTIGA.................................37

I-27

Index

ZYVOX.................................. 21

I-28

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