ohp drug list (formulary) -...

OHP Drug List (Formulary)

2018

For members of Columbia Pacific, Health Share/CareOregon and Jackson Care Connect

If you want a copy of this book, need this book in another language, large print, Braille, CD, or other format,

please call the Customer Service number of your CCO listed below. TTY/TDD users can call 7‐1‐1.

You can always view the most recent version of this drug list on your CCO’s website.

Columbia Pacific CCO Customer Service: toll‐free, 1‐855‐722‐8206; online: www.colpachealth.org Health Share/CareOregon Customer Service: 503‐416‐4100 or toll‐free, 1‐800‐224‐4840; online: www.careoregon.org/healthshare Jackson Care Connect Customer Service: toll‐free, 1‐855‐722‐8208; online: www.jacksoncareconnect.org

Si desea una copia de este documento, necesita este documento en otro idioma, letra grande, Braille, CD u

otro formato, llame al número de servicio al cliente de su CCO que se encuentra más adelante. Los usuarios de

TTY/TDD pueden llamar al 7‐1‐1. Puede consultar en cualquier momento la versión más reciente de esta lista

de medicamentos en el sitio web de su CCO.

Columbia Pacific CCO Servicio al cliente: llame gratis al 1‐855‐722‐8206; en línea: www.colpachealth.org Health Share/CareOregon Servicio al cliente: 503‐416‐4100 o llame gratis al 1‐800‐224‐4840; en línea: www.careoregon.org/healthshare Jackson Care Connect Servicio al cliente: llame gratis al 1‐855‐722‐8208; en línea: www.jacksoncareconnect.org

Haddii aad doonayso nuqulka buugan, u baahan tahay buugan oo ku qoran luqad kale, far waaweyn, farta

dadka indhaha aan qabin wax ku akhriyaan ee Braille, CD, ama qaab kale, fadlan wac lambarka Adeega

Macmiilka ee CCO‐gaaga ee hoos ku qoran. Dadka isticmaala TTY/TDD waxay wici karaan 7‐1‐1.

Waxaad markasta liiskii u dambeeyay ee daawadan ka fiirin kartaa website‐kaaga CCO.

Columbia Pacific CCO Adeega Macmiilka: khadka bilaashka ah, 1‐855‐722‐8206; internet‐ka: www.colpachealth.org Health Share/CareOregon Adeega Macmiilka: 503‐416‐4100 ama khadka bilaashka ah, 1‐800‐224‐4840; internet‐ka: www.careoregon.org/healthshare Jackson Care Connect Adeega Macmiilka: khadka bilaashka ah, 1‐855‐722‐8208; internet‐ka: www.jacksoncareconnect.org

Если вы желаете получить копию данного материала или вам необходимо, чтобы данный материал был переведен на другой язык, напечатан крупным шрифтом, шрифтом Брайля, записан на компакт‐диск или был доступен в каком‐либо другом формате, пожалуйста, позвоните в отдел обслуживания клиентов вашей организации координированного обслуживания (CCO) по телефону, указанному ниже. Пользователи системы телетайп (TTY/TDD) могут звонить на номер 7‐1‐1. Самую последнюю версию данного перечня лекарственных препаратов всегда можно увидеть на веб‐сайте вашей организации COO.

Отдел обслуживания клиентов организации Columbia Pacific CCO: бесплатный номер, 1‐855‐722‐8206; в Интернете: www.colpachealth.org Отдел обслуживания клиентов организации Health Share/CareOregon: 503‐416‐4100 или бесплатный номер, 1‐800‐224‐4840; в Интернете: www.careoregon.org/healthshare Отдел обслуживания клиентов организации Jackson Care Connect: бесплатный номер, 1‐855‐722‐8208; в Интернете: www.jacksoncareconnect.org

如果您想獲得一份本手冊、需要本手冊的其他語言版本、大字版、盲文版、CD 或其他格式，請致電下

列您 CCO 的客戶服務部電話號碼。聽語障專線使用者可致電 7-1-1。您可隨時在您 CCO 的網站上檢視本藥物清單的最新版本。

Columbia Pacific CCO 客戶服務部：免費電話 1-855-722-8206；網站：www.colpachealth.org Health Share/CareOregon 客戶服務部：503-416-4100 或免費電話 1-800-224-4840；網站：www.careoregon.org/healthshare Jackson Care Connect 客戶服務部：免費電話 1-855-722-8208；網站：www.jacksoncareconnect.org

Nếu quý vị muốn có một bản sao của cuốn sách này, cần cuốn sách này trên ngôn ngữ khác, bản in khổ lớn,

chữ nổi Braille, CD, hoặc hình thức khác, xin vui lòng gọi số điện thoại dịch vụ khách hàng của Tổ chức Săn sóc

Phối hợp (Coordinated Care Organization/CCO) của quý vị được liệt kê dưới đây. Những ai sử dụng điện thoại

dành cho người khiếm thính/điếc (TTY/TDD) có thể gọi số 7‐1‐1.

Quý vị luôn có thể xem phiên bản mới nhất của danh mục thuốc này trên trang web của CCO của quý vị.

Dịch vụ Khách hang của Columbia Pacific CCO: số miễn phí, 1‐855‐722‐8206; trực tuyến: www.colpachealth.org Dịch vụ Khách hang của Health Share/CareOregon: 503‐416‐4100 hoặc số miễn phí, 1‐800‐224‐4840; trực tuyến: www.careoregon.org/healthshare Dịch vụ Khách hàng của Jackson Care Connect: số miễn phí, 1‐855‐722‐8208; trực tuyến: www.jacksoncareconnect.org

2018 OHP Drug List (Formulary) Administered by

INTRODUCTION Pharmacy benefitAs a member of your CCO, you have Medicaid prescription drug coverage under the Oregon

Health Plan (OHP). This booklet is your list of the drugs that are covered. We call it a drug

“formulary.” A group of pharmacists and doctors decide which drugs should be in the

formulary. Their goal is to create a formulary with medications that are safe and effective.

This formulary is administered by CareOregon, a partner in your CCO.

This booklet was last updated on April 1, 2018. Usually, we will update this formulary every two

months. To get up‐to‐date information about drugs covered by us, call your CCO’s Customer

Service department. They are available Monday‐Friday, from 8 a.m. to 5 p.m.

Columbia Pacific CCO Customer Service: toll‐free, 855‐722‐8206

Health Share/CareOregon Customer Service: 503‐416‐4100 or toll‐free, 800‐224‐4840

Jackson Care Connect Customer Service: toll‐free, 855‐722‐8208

Getting startedFor some drugs, your provider will need to check with us before we will cover the prescription. This will save you time, help you avoid any hassles and get you started on your medication as soon as possible. Important things for you to know are:

1. Before you leave your provider’s office, ask if your CCO covers the drug. 2. If we don’t cover it, ask if there is a covered drug that would work for you. 3. If your provider does not prescribe a different drug for you, ask your provider’s office

staff to mail or fax a Prior Authorization or Formulary Exception Request Form to us. A copy of this form can be found on your CCO’s website in the “Provider Forms and Policies” section.

Be sure to follow your provider’s and pharmacist’s directions for taking your medication(s).

i

How to fill your prescriptionsYou must fill your prescriptions at a participating network pharmacy. A list of pharmacies can be found using the online Provider Directory on your CCO’s web site.

Columbia Pacific CCO: colpachealth.org/providerdirectory

Health Share/CareOregon: careoregon.org/providerdirectory.aspx

Jackson Care Connect: jacksoncareconnect.org/providerdirectory

Show your CCO ID card every time you fill a prescription.

The drugs listed in the formulary do not have copays. If a pharmacy asks you to pay for a prescription, call Customer Service before you pay.

IMPORTANT: As a member, it is your responsibility to contact Customer Service before paying out‐of‐pocket for prescriptions. In situations where contacting us is not possible due to emergency, we may pay you back on prescriptions you paid for on your own. This depends on your benefit coverage and the limitations and exclusions of the plan. A form with instructions for getting paid back can be found in the “Member Forms” section on your CCO’s website.

If your PCP’s clinic is closed and you think you need a prescription filled immediately, call your PCP’s after‐hours telephone number. There will usually be someone there that can answer your questions.

How to search the formularyYou can search for a drug in the formulary in two ways:

1. By medical condition The drugs are organized into categories that match the type of medical conditions each drug treats. For example, drugs to treat heart conditions are listed under the category “Cardiovascular Agents.” If you know what a drug is used for, start by looking for its category in the table of contents. Then check the category for the name of your drug.

2. Alphabetically If you’re not sure which category a drug is in, look for the drug in the index that begins on page 93. The number next to the drug shows which page has information on the drug. Turn to that page and find the name of your drug in the first column. Note: If the formulary includes only generic versions of a drug, this means that we do not cover the brand‐name drug.

ii

Non-covered drugsTo help members have the best possible health outcomes, your CCO may add or remove drugs from the formulary or change coverage rules on drugs. If we remove a drug from the formulary or change the rules for a drug that you take, we will tell you at least 30 days before we do it. The following items are not covered:

Drugs not listed in the formulary (see section titled “Drugs Not Listed in the Formulary” for more information)

Drugs used to treat conditions that are not covered by the Oregon Health Plan, such as fibromyalgia, allergic rhinitis, acne and chronic back pain

Drugs used for cosmetic purposes

Drugs used for non‐medically accepted indications

Investigational drugs and/or drugs used in an investigational manner

Mental health drugs, such as antidepressants, anxiolytics and antipsychotics, are covered through the state’s Medical Assistance Programs (MAP). These drugs are not listed in this formulary. Your pharmacist sends the bill directly to MAP. Your CCO covers some over‐the‐counter drugs that are listed in the formulary. These drugs are covered if you have a prescription for the drug from your provider.

Non-formulary or restricted drugs for a chronic (constant)medical condition New members or members who move to a different level of care may be using a non‐formulary or restricted drug. If a provider asks for this drug to be covered, we may provide a transition supply.

A transition supply gives you time to try a different formulary drug to see if it meets your needs. Meanwhile, your provider may send a Prior Authorization or Formulary Exception Request Form to us, with reasons why this drug should be covered. A copy of this form can be found on your CCO’s website in the “Provider Forms and Policies” section.

Generic drugsA generic drug is a copy of a brand‐name drug. It has the same active ingredients as the brand‐name drug. Generic drugs are approved by the U.S. Food and Drug Administration after being tested for effectiveness and safety. They usually cost less than brand‐name drugs and become available after the patent for a brand‐ name drug expires.

If your PCP decides that you have a medical need for a brand‐name drug that does not have a generic equivalent, they must send a Prior Authorization or Formulary Exception Request Form to us.

iii

Restrictions on the formulary drugsSome covered drugs may have special rules related to their use. These rules may include:

Prior Authorization (PA): If providers want to prescribe a drug marked “PA” in the formulary, they must send a Prior Authorization or Formulary Exception Request Form to us. We cannot pay for the prescription unless we approve the request in advance. Usually, we only approve prior authorization requests if the drug treats conditions covered by the Oregon Health Plan. Also, the prescription must meet drug use rules set by our Pharmacy & Therapeutics Committee. Each Prior Authorization or Formulary Exception Request Form must have only one medication request. All fields on the form must be complete and legible.

Quantity Limits (QL): For drugs marked “QL,” we limit the amount of the drug we’ll pay for. Your provider must send a Prior Authorization or Formulary Exception Request Form to us if they want to prescribe an amount of the drug that is over our quantity limits. Our decisions for prior authorization and formulary exception requests are based only on appropriate care and coverage. Our staff are not rewarded for denying requests. We do not use financial incentives to reward underutilization.

Step Therapy (ST): Sometimes we ask you to try other drugs before we cover a drug marked “ST.” Suppose Drug A and Drug B both treat your medical condition. We may not cover Drug B before you try Drug A. If Drug A has harmful side effects or doesn’t work for you, we’ll cover Drug B.

Age Restriction (AR): For some drugs, we require you to be younger than or older than a specific age. For example, a drug may be restricted to people under age 6 or over age 16.

Over‐the‐Counter (OTC): Some over‐the‐counter (OTC) drugs are in the formulary. We can cover an OTC drug if you get a prescription from your provider and give it to a network pharmacist.

ExceptionsYou may get up to a 90‐day supply of the following drugs:

Generic oral contraceptives (birth control pills) Pediatric multivitamins with fluoride, prenatal vitamins, folic acid, sodium fluoride Digoxin, furosemide, hydrochlorothiazide, atenolol, metoprolol, captopril, enalapril,

lisinopril Levothyroxine Albuterol HFA inhalers and nebulizer solutions

Note: Your CCO may approve an additional refill in the following situations:

Your prescription is lost, stolen, or spilled.

You need extra medication because you will be out of town.

You need extra medication because your dosage was increased.

You need a supply of a certain medication for work or school.

For more information call your CCO’s Customer Service department.

iv

Drugs not listed in the formulary Drugs usually are not covered unless they are in the formulary. However, if your provider believes a drug outside of our formulary is the best drug for you, the provider can ask us to cover it. This is called “making a formulary exception request.” Your provider will need to submit a Prior Authorization or Formulary Exception Request Form to us. Usually, we’ll approve formulary exception requests only if other formulary drugs would be less effective in treating your condition, or would cause side effects that could hurt you.

Urgent needs for non-formulary or restricted drugsYou, or your provider or a pharmacist may ask for a five‐day emergency supply of a non‐formulary or restricted drug. This gives you, or your provider time to send a Prior Authorization or Formulary Exception Request Form to us. To ask for an emergency supply, call your CCO’s Customer Service.

Formulary updates As mentioned above, the formulary is updated about every two months. Generally, drugs on the formulary will not change during the year unless:

The same medication becomes available in generic form.

The FDA deems a drug to be unsafe.

The drug’s manufacturer removes the drug from the market.

For more information For the most up‐to‐date information about medications covered by your pharmacy benefit, visit your CCO’s website, or call the Customer Service department. Customer service hours are 8 a.m.‐5 p.m., Monday through Friday.

Columbia Pacific CCO Customer Service: toll‐free, 855‐722‐8206

Health Share/CareOregon Customer Service: 503‐416‐4100 or toll‐free, 800‐224‐4840

Jackson Care Connect Customer Service: toll‐free, 855‐722‐8208

Other prescription drug resources To keep track of your prescription history, search for network pharmacies or check on the status of a prior authorization request, you can create an account with OptumRx. Simply go to your CCO’s website at one of the links below and click on the big yellow button at the bottom of the page.

Columbia Pacific CCO: colpachealth.org/druglist

Health Share/CareOregon: careoregon.org/druglist.aspx

Jackson Care Connect: jacksoncareconnect.org/druglist

v

TABLE OF CONTENTS ANTI‐INFECTIVES .......................................................................................................... 1

PENICILLINS........................................................................................................................................................ 1

CEPHALOSPORINS.............................................................................................................................................. 1

MACROLIDES...................................................................................................................................................... 2

TETRACYCLINES.................................................................................................................................................. 3

FLUOROQUINOLONES....................................................................................................................................... 3

AMEBICIDES....................................................................................................................................................... 3

AMINOGLYCOSIDES........................................................................................................................................... 3

ANTITUBERCULOSIS AGENTS ............................................................................................................................ 4

ANTIFUNGALS.................................................................................................................................................... 4

ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) ............................................................................................................ 5

ANTIVIRALS ........................................................................................................................................................ 5

HEPATITIS AGENTS ............................................................................................................................................. 6

HIV...................................................................................................................................................................... 6

INFLUENZA AGENTS ........................................................................................................................................... 9

ANTIMALARIALS ................................................................................................................................................ 9

ANTHELMINTICS ................................................................................................................................................ 9

ANTI‐INFECTIVE AGENTS:MISC ................................................................................................................................ 9

HEPATIC ENCEPHALOPATHY ........................................................................................................................... 10

MONOBACTAMS ............................................................................................................................................. 11

BIOLOGICALS (VACCINES) ........................................................................................... 11

VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN.................................................................... 11

ANTI‐NEOPLASTICS ..................................................................................................... 12

ANTIDOTES....................................................................................................................................................... 12

ANTIMETABOLITES ..................................................................................................... 12

ANTINEOPLASTIC AGENTS ............................................................................................................................... 12

PROGESTINS..................................................................................................................................................... 16

ENDOCRINE AND METABOLIC DRUGS ......................................................................... 17

ADRENALS........................................................................................................................................................ 17

ANDROGENS .................................................................................................................................................... 18

ESTROGENS...................................................................................................................................................... 18

CONTRACEPTIVES............................................................................................................................................ 19

ALPHA‐GLUCOSIDASE INHIBITORS .................................................................................................................. 23

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS ........................................................................................... 23

BIGUANIDES..................................................................................................................................................... 24 vi

COMBO ANTI‐DIABETIC ......................................................................................................................................... 24

GLUCAGON.......................................................................................................................................................... 24

INCRETIN MIMETICS ........................................................................................................................................ 24

INSULINS .......................................................................................................................................................... 24

DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS.............................................................................................................. 25

SULFONYLUREAS ............................................................................................................................................. 25

THIAZOLIDINEDIONES ..................................................................................................................................... 26

ANTITHYROID AGENTS .................................................................................................................................... 26

THYROID AGENTS ............................................................................................................................................ 26

OXYTOCICS....................................................................................................................................................... 28

ERGOT‐DERIV. DOPAMINE RECEPTOR AGONISTS .......................................................................................... 28

ESTROGEN AGONIST‐ANTAGONISTS .............................................................................................................. 28

OSTEOPOROSIS................................................................................................................................................ 28

OTHER MISCELLANEOUS THERAPEUTIC AGENTS ........................................................................................... 28

PITUITARY ........................................................................................................................................................ 29

SOMATOTROPIN AGONISTS ............................................................................................................................ 29

SOMATOTROPIN ANTAGONISTS ..................................................................................................................... 30

VITAMIN D ........................................................................................................................................................ 30

CARDIOVASCULAR AGENTS ........................................................................................ 31

CARDIOTONIC AGENTS .................................................................................................................................... 31

CARDIAC DRUGS, MISCELLANEOUS ................................................................................................................ 31

NITRATES AND NITRITES .................................................................................................................................. 31

BETA‐ADRENERGIC BLOCKING AGENTS .......................................................................................................... 32

CALCIUM‐CHANNEL BLOCKING AGENTS ........................................................................................................ 33

ANTIARRHYTHMICS................................................................................................................................................ 35

ANGIOTENSIN II RECEPTOR ANTAGONISTS .................................................................................................... 36

ANGIOTENSIN‐CONVERTINGENZYME INHIBITORS ....................................................................................... 36

CENTRAL ALPHA‐AGONISTS ............................................................................................................................ 37

COMBO HYPERTENSION MEDS ....................................................................................................................... 37

DIRECT VASODILATORS ................................................................................................................................... 38

CARBONIC ANHYDRASE INHIBITORS (EENT) ................................................................................................... 38

LOOP DIURETICS .............................................................................................................................................. 38

POTASSIUM‐SPARING DIURETICS ................................................................................................................... 39

THIAZIDE AND THIAZIDE‐LIKE DIURETICS ........................................................................................................ 39

ALPHA‐ADRENERGIC AGONISTS ...................................................................................................................... 39

EPINEPHRINE ................................................................................................................................................... 39

ANTILIPEMIC AGENTS, MISCELLANEOUS ........................................................................................................ 39

BILE ACID SEQUESTRANTS ............................................................................................................................... 40

CHOLESTEROL ABSORPTION INHIBITORS ....................................................................................................... 40

FIBRIC ACID DERIVATIVES ................................................................................................................................ 40

vii

PCSK9 INHIBITORS ........................................................................................................................................... 40

STATINS............................................................................................................................................................ 40

PULMONARY HYPERTENSION ......................................................................................................................... 41

RESPIRATORY AGENTS ................................................................................................ 41

ANTI‐HISTAMINES............................................................................................................................................ 41

NASAL STEROIDS .............................................................................................................................................. 42

COUGH ............................................................................................................................................................. 42

CYSTIC FIBROSIS ............................................................................................................................................... 42

INHALED ANTICHOLINERGICS ......................................................................................................................... 42

INHALED BETA‐AGONISTS ............................................................................................................................... 42

INHALED COMBO ANTICHOLINERGICS/BETA‐AGONISTS .............................................................................. 43

INHALED COMBO BETA‐AGONISTS/ANTICHOLINERGICS .............................................................................. 43

INHALED COMBO STEROID/BETA‐AGONISTS ................................................................................................. 43

INHALED STEROIDS .......................................................................................................................................... 43

LEUKOTRIENE MODIFIERS ............................................................................................................................... 44

MAST‐CELL STABILIZERS .................................................................................................................................. 44

OTHER ASTHMA/COPD .................................................................................................................................... 44

GASTROINTESTINAL AGENTS ...................................................................................... 44

CATHARTICS AND LAXATIVES .......................................................................................................................... 44

ANTACIDS AND ADSORBENTS ......................................................................................................................... 45

ANTIMUSCARINICS/ANTISPASMODICS .......................................................................................................... 45

HISTAMINE H2‐ANTAGONISTS ........................................................................................................................ 46

PROSTAGLANDINS........................................................................................................................................... 47

PROTECTANTS.................................................................................................................................................. 47

PROTON‐PUMP INHIBITORS ............................................................................................................................ 47

ANTI‐NAUSEA................................................................................................................................................... 47

DIGESTANTS..................................................................................................................................................... 49

CHOLELITHOLYTICAGENTS ............................................................................................................................. 49

INFLAMMATORY BOWEL AGENTS .................................................................................................................. 49

PHOSPHATE‐REMOVING AGENTS ................................................................................................................... 50

PROKINETIC AGENTS ....................................................................................................................................... 50

GENITOURINARY PRODUCTS ...................................................................................... 50

INCONTINENCE/URINARY FREQUENCY .......................................................................................................... 50

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) ...................................................................................... 51

CONTRACEPTIVES (E.G. FOAMS, DEVICES) ..................................................................................................... 51

VAGINAL ANTI‐INFECTIVES .............................................................................................................................. 52

ALKALINIZING AGENTS .................................................................................................................................... 52

IRRIGATING SOLUTIONS .................................................................................................................................. 52

MISCL URINARY AGENTS ................................................................................................................................. 52 viii

SELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT .......................................................................................... 52

CENTRAL NERVOUS SYSTEM DRUGS ........................................................................... 52

ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. .............................................................................................. 52

BENZODIAZEPINES ................................................................................................................................................. 53

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) ............................................................................................... 53

ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANT AGENTS ............................... 54

AMPHETAMINES.............................................................................................................................................. 54

METHYLPHENIDATES....................................................................................................................................... 54

RESPIRATORY AND CNS STIMULANTS ............................................................................................................. 55

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC ...................................... 55

ALCOHOL DETERRENTS ................................................................................................................................... 55

ANTIDEMENTIA AGENTS ................................................................................................................................. 55

MULTIPLE SCLEROSIS ....................................................................................................................................... 55

SMOKING DETERRENTS ................................................................................................................................... 56

ANALGESICS AND ANESTHETICS ................................................................................. 57

ANALGESICS AND ANTIPYRETICS, MISC. ......................................................................................................... 57

SALICYLATES..................................................................................................................................................... 57

OPIATE PARTIAL AGONISTS ............................................................................................................................. 57

OPIATES............................................................................................................................................................ 57

ANTI‐TNF INHIBITORS ...................................................................................................................................... 60

DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ........................................................................................... 60

MISCL BIOLOGIC ............................................................................................................................................... 60

NONSTEROIDALANTI‐INFLAMMATORY (NSAID) ........................................................................................... 60

MIGRAINE PRODUCTS ..................................................................................................................................... 61

TRIPTANS.......................................................................................................................................................... 61

ANTIGOUT AGENTS ......................................................................................................................................... 62

URICOSURIC AGENTS ....................................................................................................................................... 62

NEUROMUSCULAR DRUGS ......................................................................................... 64

ANTICHOLINERGIC AGENTS (CNS) ................................................................................................................... 64

ANTIPARKINSON.............................................................................................................................................. 64

DOPAMINERGICS............................................................................................................................................. 64

CENTRAL NERVOUS SYSTEM AGENTS, MISC. .................................................................................................. 65

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT .......................................................................................... 65

DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS ............................................................................................ 65

NUTRITIONAL PRODUCTS ........................................................................................... 65

VITAMIN B COMPLEX ....................................................................................................................................... 65

ix

MULTIVITAMINPREPARATIONS ..................................................................................................................... 66

FLUORIDE ............................................................................................................................................................ 74

REPLACEMENTPREPARATIONS ...................................................................................................................... 75

CALORIC AGENTS ............................................................................................................................................. 78

HEMATOLOGICAL AGENTS .......................................................................................... 78

HEMATOPOIETIC AGENTS ............................................................................................................................... 78

IRON PREPARATIONS ....................................................................................................................................... 79

ANTICOAGULANTS .......................................................................................................................................... 80

HEMOSTATICS.................................................................................................................................................. 82

HEMORRHEOLOGIC AGENTS ........................................................................................................................... 82

PLATELET‐ACTINGAGENTS ............................................................................................................................. 82

TOPICAL PRODUCTS.................................................................................................... 82

ALPHA‐ADRENERGIC AGONISTS (EENT) .......................................................................................................... 82

ANTIBACTERIALS (EENT) .................................................................................................................................. 82

ANTIVIRALS (EENT) .......................................................................................................................................... 83

BETA‐ADRENERGIC BLOCKING AGENTS (EENT) .............................................................................................. 83

CORTICOSTEROIDS (EENT) ............................................................................................................................... 83

EENT DRUGS, MISCELLANEOUS ...................................................................................................................... 84

EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS ............................................................................................... 84

MIOTICS ........................................................................................................................................................... 84

MYDRIATICS..................................................................................................................................................... 84

PROSTAGLANDIN ANALOGS ............................................................................................................................ 85

LOCAL ANESTHETICS (EENT) ............................................................................................................................ 85

EENT ANTI‐INFECTIVES, MISCELLANEOUS ...................................................................................................... 85

ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) .......................................................................................... 85

ANTIPRURITICS AND LOCAL ANESTHETICS ..................................................................................................... 85

LOCAL ANTI‐INFECTIVES, MISCELLANEOUS .................................................................................................... 85

SCABICIDES AND PEDICULICIDES ..................................................................................................................... 86

SKINANDMUCOUSMEMBRANEAGENTS,MISC. .......................................................................................... 86

TOPICAL CORTICOSTEROIDS ............................................................................................................................ 87

MISCELLANEOUS PRODUCTS ...................................................................................... 88

COMPLEMENT INHIBITORS ............................................................................................................................. 88

EMETICS ........................................................................................................................................................... 88

OPIATE ANTAGONISTS ..................................................................................................................................... 89

ADRENOCORTICAL INSUFFICIENCY ................................................................................................................. 89

MISCL OTHER ................................................................................................................................................... 89

DEVICES............................................................................................................................................................ 90

IMMUNOSUPPRESSIVE AGENTS ..................................................................................................................... 92

POTASSIUM‐REMOVING AGENTS ................................................................................................................... 92 x

Drug Name Dosage Form/Strength Drug Type Requirements

ANTI‐INFECTIVES PENICILLINS AMOXICILLIN/CLAVULANATE POTASSIUM TAB 250MG Generic

AMOXICILLIN/CLAVULANATE POTASSIUM TAB 500MG Generic

AMOXICILLIN/CLAVULANATE POTASSIUM TAB 875MG Generic

AMOXICILLIN/CLAVULANATE POTASSIUM CHW 200MG Generic

AMOXICILLIN/CLAVULANATE POTASSIUM CHW 400MG Generic

AMOXICILLIN/CLAVULANATE POTASSIUM SUS 200/5ML Generic




AMOXICILLIN TAB 875MG Generic

AMOXICILLIN CAP 250MG Generic

AMOXICILLIN CAP 500MG Generic

AMOXICILLIN CHW 250MG Generic

AMOXICILLIN SUS 125/5ML Generic




AMOXICILLIN/CLAVULANATE POTASSIUM TAB ER Generic

AMPICILLIN CAP 250MG Generic

AMPICILLIN CAP 500MG Generic

AMP‐SULBACTA INJ 1.5GM Generic

AMP‐SULBACTA INJ 1‐0.5GM Generic

AMP‐SULBACTA INJ 1.5GM Generic

AMP‐SULBACTA INJ 3GM Generic

AMP‐SULBACTA INJ 2‐1GM Generic

AMP‐SULBACTA INJ 10‐5GM Generic

AMP‐SULBACTA INJ 15GM Generic

DICLOXACILLIN SODIUM CAP 250MG Generic

DICLOXACILLIN SODIUM CAP 500MG Generic

PENICILLIN G POTASSIUM INJ 5000000 Generic

PENICILLN VK TAB 250MG Generic

PENICILLN VK TAB 500MG Generic

PENICILLN VK SOL 125/5ML Generic

PENICILLN VK SOL 250/5ML Generic

CEPHALOSPORINS CEFACLOR CAP 250MG Generic

CEFACLOR CAP 500MG Generic

CEFADROXIL CAP 500MG Generic

CEFADROXIL TAB 1GM Generic

QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

1


CEFADROXIL SUS 250/5ML Generic

CEFADROXIL SUS 500/5ML Generic

CEFAZOLIN INJ 500MG Generic

CEFAZOLIN INJ 1GM Generic





CEFAZOLIN INJ 1GM/50ML Generic

CEFAZOLIN/DEXTROSE SOL 1GM Generic

CEFAZOLIN/DEXTROSE SOL 2GM Generic

CEFDINIR CAP 300MG Generic

CEFDINIR SUS 125/5ML Generic

CEFDINIR SUS 250/5ML Generic

CEFIXIME SUS 100/5ML Generic

CEFIXIME SUS 200/5ML Generic

CEFPODOXIME TAB 100MG Generic

CEFPODOXIME TAB 200MG Generic

CEFPROZIL TAB 250MG Generic

CEFPROZIL TAB 500MG Generic

CEFPROZIL SUS 125/5ML Generic

CEFPROZIL SUS 250/5ML Generic

CEFTRIAXONE INJ 250MG Generic

CEFTRIAXONE INJ 500MG Generic

CEFTRIAXONE INJ 1GM Generic




CEFTRIAXONE INJ DEX 1GM Generic

CEFTRIAXONE INJ DEX 2GM Generic

CEFUROXIME TAB 250MG Generic

CEFUROXIME TAB 500MG Generic

CEPHALEXIN CAP 250MG Generic

CEPHALEXIN CAP 500MG Generic

CEPHALEXIN SUS 125/5ML Generic

CEPHALEXIN SUS 250/5ML Generic

SUPRAX SUS 500/5ML Brand

MACROLIDES AZITHROMYCIN TAB 250MG Generic

AZITHROMYCIN TAB 500MG Generic

AZITHROMYCIN TAB 600MG Generic

AZITHROMYCIN SUS 100/5ML Generic


2


AZITHROMYCIN SUS 200/5ML Generic

AZITHROMYCIN POW 1GM PAK Generic

CLARITHROMYCIN TAB 250MG Generic

CLARITHROMYCIN TAB 500MG Generic

CLARITHROMYCIN SUS 125/5ML Generic

CLARITHROMYCIN SUS 250/5ML Generic

CLARITHROMYCIN TAB 500MG ER Generic

ZITHROMAX POW 1GM PAK Brand

TETRACYCLINES

DOXYCYCLINE MONOHYDRATE CAP 50MG Generic QL 14 day supply per 60

days

DOXYCYCLINE MONOHYDRATE CAP 100MG Generic QL 14 day supply per 60

days

MONDOXYNE NL CAP 50MG Generic QL 14 day supply per 60

days

MONDOXYNE NL CAP 100MG Generic QL 14 day supply per 60

days

VIBRAMYCIN SYP 50MG/5ML Brand AR PA required > 6

FLUOROQUINOLONES CIPROFLOXACIN SUS 250MG/5 Generic

CIPROFLOXACIN SUS 500MG/5 Generic

CIPROFLOXACIN TAB 100MG Generic




CIPROFLOXACIN INJ 200MG Generic

CIPROFLOXACIN INJ 400MG Generic

LEVOFLOXACIN TAB 250MG Generic



LEVOFLOXACIN SOL 25MG/ML Generic

MOXIFLOXACIN TAB 400MG Generic

AMEBICIDES PAROMOMYCIN CAP 250MG Generic

YODOXIN TAB 210MG Brand

YODOXIN TAB 650MG Brand

AMINOGLYCOSIDES BETHKIS NEB 300/4ML Brand

NEOMYCIN TAB 500MG Generic

TOBRAMYCIN NEB 300/5ML Generic QL 280ml per 60 days

TOBRAMYCIN INJ 80MG/2ML Generic

TOBRAMYCIN INJ 40MG/ML Generic


3


ANTITUBERCULOSIS AGENTS ETHAMBUTOL TAB 100MG Generic

ETHAMBUTOL TAB 400MG Generic

ISONIAZID TAB 100MG Generic

ISONIAZID TAB 300MG Generic

PYRAZINAMIDE TAB 500MG Generic

RIFABUTIN CAP 150MG Generic

RIFAMPIN CAP 150MG Generic

RIFAMPIN CAP 300MG Generic

ANTIFUNGALS AMPHOTERICIN INJ 50MG Generic PA

BIO‐STATIN POW Generic PA

FLUCONAZOLE TAB 50MG Generic




FLUCONAZOLE SUS 10MG/ML Generic

FLUCONAZOLE SUS 40MG/ML Generic

FLUCYTOSINE CAP 250MG Generic

FLUCYTOSINE CAP 500MG Generic

GRISEOFULVIN SUS 125/5ML Generic PA required > 6

ITRACONAZOLE CAP 100MG Generic PA

KETOCONAZOLE TAB 200MG Generic

NOXAFIL TAB 100 MG DR Brand PA

NOXAFIL SUSP 40MG/ML Brand PA

NYSTATIN TAB 500000 Generic

NYSTATIN POW Generic PA

NYSTATIN SUS 100000 Generic

NYSTATIN POW 10BU Generic PA

NYSTATIN POW 50MU Generic PA






NYSTATIN CRE 100000 Generic

NYSTATIN OIN 100000 Generic

SPORANOX SOL 10MG/ML Brand PA

TERBINAFINE TAB 250MG Generic

VORICONAZOLE TAB 50MG Generic PA

VORICONAZOLE TAB 200MG Generic PA

VORICONAZOLE SUS 40MG/ML Generic PA


4


VORICONAZOLE INJ 200MG Generic PA

ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) 3 DAY VAGINAL CRE 2% Generic

3 DAY VAGINAL CRE 4% Generic

ATHLETE FOOT CRE 1% Generic

CLOTRIMAZOLE CRE 1% Generic

CLOTRIMAZOLE CRE 1% VAG Generic

CLOTRIMAZOLE CRE 2% Generic

CLOTRIMAZOLE CRE 3 DAY Generic

CLOTRIMAZOLE TRO 10MG Generic

CLOTRIMAZOLE LOZ 10MG Generic

CLOTRIMAZOLE CRE GRX 1% Generic

DESENEX CRE 1% Generic

JOCK ITCH CRE 1% Generic

MICADERM CRE 2% Generic

MICONAZOLE 3 KIT COMBO PK Generic

MICONAZOLE SUP 100MG Generic

MICONAZOLE CRE 2% CRE 2% Generic

MICONAZOLE POW POW Generic PA

MICONAZOLE 3 CRE 4% Generic

MICONAZOLE 7 CRE TUBE/KIT Generic

MICONAZOLE 7 CRE 2% Generic

MICONAZOLE 7 SUP 100MG Generic

MICRO GUARD CRE 2% Generic

NEOSPORIN AF CRE 2% JOCK Generic

PODACTIN CRE 2% Generic

RINGWORM CRE 1% Generic

SM ANTIFUNGL CRE 1% Generic

SOOTHE&COOL CRE INZO 2% Generic

TINEACIDE CRE Generic

VAGISTAT‐3 KIT COMBO PK Generic

ANTIVIRALS AMANTADINE TAB 100MG Generic

AMANTADINE CAP 100MG Generic

AMANTADINE SYP 50MG/5ML Generic

RIMANTADINE TAB 100MG Generic

ACYCLOVIR CAP 200MG Generic

ACYCLOVIR TAB 400MG Generic

ACYCLOVIR TAB 800MG Generic

ACYCLOVIR SUS 200/5ML Generic

FAMCICLOVIR TAB 125MG Generic PA



5



VALACYCLOVIR TAB 500MG Generic

VALACYCLOVIR TAB 1GM Generic

VALGANCICLOVIR SOL 50MG/ML Generic PA required > 6

VALGANCICLOVIR TAB 450MG Generic

HEPATITIS AGENTS ADEFOVIR DIPIVOXIL TAB 10MG Generic PA QL 1 per day

BARACLUDE SOL .05MG/ML Brand QL 20 per day

CIDOFOVIR INJ 75MG/ML Generic

DAKLINZA TAB 30MG Brand PA QL 1 per day; 84 tabs per life

DAKLINZA TAB 60MG Brand PA QL 1 per day; 84 tabs per life

ENTECAVIR TAB 0.5MG Generic QL 1 per day

ENTECAVIR TAB 1MG Generic QL 1 per day

EPCLUSA TAB 400‐100 Brand PA QL 1 per day; 84 tabs

per life

INFERGEN INJ 9MCG Brand PA

INFERGEN INJ 15MCG Brand PA

MAVYRET TAB 100‐40MG Brand PA QL 3 tabs per day; max 112 day supply per life

MODERIBA TAB 200MG Generic PA

RIBASPHERE CAP 200MG Generic PA

RIBASPHERE TAB 200MG Generic PA

RIBAVIRIN CAP 200MG Generic PA

RIBAVIRIN TAB 200MG Generic PA

SOVALDI TAB 400MG Brand PA QL 1 per day; 84 tabs per life

TYZEKA TAB 600MG Brand PA QL 1 per day

VOSEVI TAB 400‐100‐100MG Brand PA QL 1 per day; max 84 day

supply per life

ZEPATIER TAB 50‐100MG Brand PA QL 1 per day; 84 tabs per life

HIV ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE

TAB 300MG‐150MG‐300MG Generic

ABACAVIR/LAMIVUDINE TAB 600MG‐300MG Generic

ABACAVIR TAB 300MG Generic

APTIVUS CAP 250MG Brand

APTIVUS SOL Brand

ATAZANAVIR CAP 150MG Generic




6


ATRIPLA TAB Brand

BIKTARVY TAB Brand QL 1 per day

COMPLERA TAB 200MG‐25MG‐

300MG Brand

CRIXIVAN CAP 200MG Brand

CRIXIVAN CAP 400MG Brand

DESCOVY TAB 200/25MG Brand QL 1 per day

DIDANOSINE CAP 125MG Generic




EDURANT TAB 25MG Brand

EFAVIRENZ CAP 50MG Generic

EFAVIRENZ CAP 200MG Generic

EFAVIRENZ TAB 600MG Generic

EMTRIVA CAP 200MG Brand

EMTRIVA SOL 10MG/ML Brand

EPIVIR HBV SOL 5MG/ML Brand

EVOTAZ TAB 300‐150 Brand QL 1 per day

FOSAMPRENAVIR TAB 700MG Generic

FUZEON INJ 90MG Brand

GENVOYA TAB 150‐150‐200‐10 MG Brand QL 1 per day

INTELENCE TAB 100MG Brand



INVIRASE CAP 200MG Brand

INVIRASE TAB 500MG Brand

ISENTRESS CHEW 100MG Brand

ISENTRESS CHEW 25MG Brand

ISENTRESS POW 100MG Brand

ISENTRESS TAB 400MG Brand

ISENTRESS HD TAB 600 MG Brand QL 2 per day

JULUCA TAB 50‐25MG Brand QL 1 per day

KALETRA TAB 100‐25MG Brand

KALETRA TAB 200‐50MG Brand

KALETRA SOL Brand

LAMIVUDINE/ZIDOVUDINE TAB 150‐300 Generic

LAMIVUDINE TAB 150MG Generic

LAMIVUDINE TAB 300MG Generic QL 1 per day

LAMIVUDINE SOL 10MG/ML Generic

LAMIVUDINE TAB 100MG Generic

LEXIVA SUS 50MG/ML Brand


7


NEVIRAPINE SUS 50MG/5ML Generic

NEVIRAPINE TAB 200MG Generic

NEVIRAPINE TAB 400MG ER Generic

NORVIR CAP 100MG Brand

NORVIR TAB 100MG Brand

NORVIR SOL 80MG/ML Brand

ODEFSY TAB 200‐25‐25MG Brand QL 1 per day

PREZCOBIX TAB 800‐150 Brand QL 1 per day

PREZISTA TAB 75MG Brand





PREZISTA SUS 100MG/ML Brand

RESCRIPTOR TAB 100 MG Brand

RESCRIPTOR TAB 200MG Brand

RETROVIR INJ 10MG/ML Brand

REYATAZ POW 50MG Brand

SELZENTRY TAB 25MG Brand QL 4 tabs per day

SELZENTRY TAB 75MG Brand QL 2 tabs per day

SELZENTRY TAB 150MG Brand

SELZENTRY TAB 300MG Brand

SELZENTRY SOLN 20MG/ML Brand AR Covered for patients <6

STAVUDINE CAP 15MG Generic




STAVUDINE SOL 1MG/ML Generic

STRIBILD TAB Brand

TENOFOVIR TAB 300MG Generic

TIVICAY TAB 10MG Brand QL 1 per day

TIVICAY TAB 25MG Brand QL 1 per day

TIVICAY TAB 50MG Brand

TRIUMEQ TAB Brand QL 1 per day

TRUVADA TAB 100‐150 Brand QL 1 per day



TRUVADA TAB 200‐300 Brand

TYBOST TAB 150MG Brand QL 1 per day

VIDEX SOL 2GM Brand

VIDEX SOL 4GM Brand

VIRACEPT TAB 250MG Brand


8


VIRACEPT TAB 625MG Brand

VIRAMUNE SUS 50MG/5ML Brand

VIRAMUNE XR TAB 100MG Brand AR PA required > 18

VIREAD TAB 150MG Brand QL 1 per day

VIREAD TAB 200MG Brand

VIREAD TAB 250MG Brand

VIREAD POW 40MG/GM Brand AR PA required > 6

VITEKTA TAB 150MG Brand QL 1 per day

VITEKTA TAB 85MG Brand QL 1 per day

ZIAGEN SOL 20MG/ML Brand

ZIDOVUDINE CAP 100MG Generic

ZIDOVUDINE TAB 300MG Generic

ZIDOVUDINE SYP 50MG/5ML Generic

INFLUENZA AGENTS OSELTAMIVIR CAP 30MG Generic QL 40 per 365 days

OSELTAMIVIR CAP 45MG Generic QL 20 per 365 days

OSELTAMIVIR CAP 75MG Generic QL 20 per 365 days

OSELTAMIVIR SUS 6MG/ML Generic AR PA required > 8; QL 240mls per 365 days

RELENZA MIS DISKHALE Brand QL 20 per 30 days

ANTIMALARIALS CHLOROQUINE TAB 250MG Generic

CHLOROQUINE TAB 500MG Generic

COARTEM TAB 20‐120MG Brand

DARAPRIM TAB 25MG Brand

HYDROXYCHLOR TAB 200MG Generic

MEFLOQUINE TAB 250MG Generic

ANTHELMINTICS ALBENZA TAB 200MG Brand PA

BILTRICIDE TAB 600MG Brand

IVERMECTIN TAB 3MG Generic

PINWORM TAB MEDICINE Generic

PIN‐X SUS 50MG/ML Generic

REESES MED SUS PINWORM Generic

ANTI‐INFECTIVE AGENTS: MISC ATOVAQUONE SUS 750/5ML Generic PA; QL 10mls per day

BENZNIDAZOLE TAB 12.5MG Brand PA

BENZNIDAZOLE TAB 100MG Brand PA

CLINDAMYCIN CAP 75MG Generic



CLINDAMYCIN SOL 75MG/5ML Generic AR PA required > 6 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

9


IMPAVIDO CAP 50MG Brand PA; QL 3 per day

LINEZOLID TAB 600MG Generic QL 14 day supply per fill

LINEZOLID INJ 2MG/ML Generic QL 14 day supply per fill

METRONIDAZOLE CAP 375MG Generic

METRONIDAZOLE TAB 250MG Generic

METRONIDAZOLE TAB 500MG Generic

NEBUPENT INH 300MG Brand

NEUTREXIN INJ 25MG Brand

NITROFURANTOIN MACROCRYSTALS CAP 25MG Generic AR PA required > 64



NITROFURANTOIN SUS 25MG/5ML Generic

NITROFURANTOIN CAP 100MG Generic AR PA required > 64

PENTAM 300 INJ 300MG Brand

SMZ/TMP DS TAB 800‐160 Generic

SMZ‐TMP TAB 400‐80MG Generic

SMZ‐TMP SUS 200‐40/5 Generic

SULFATRIM PD SUS 200‐40/5 Generic

SYNAGIS INJ 50MG Brand PA QL 5 fills per 6 months

SYNAGIS INJ 100MG/ML Brand PA QL 5 fills per 6 months

TRIMETHOPRIM TAB 100MG Generic

VANCOMYCIN CAP 125MG Generic

VANCOMYCIN CAP 250MG Generic

VANCOMYCIN INJ 500MG Generic


VANCOMYCIN INJ 1 GM Generic


VANCOMYCIN INJ 5GM Generic

VANCOMYCIN INJ 10GM Generic

VANCOMYCIN (compound kit) SOL 25MG/ML Brand

VANCOMYCIN (compound kit) SOL 50MG/ML Brand

VANCOMYCIN/DEXTROSE INJ 500MG/100ML Generic

VANCOMYCIN/DEXTROSE INJ 750MG/150ML Generic

VANCOMYCIN/DEXTROSE INJ 1GM/200ML Generic

HEPATIC ENCEPHALOPATHY CONSTULOSE SOL 10GM/15 Generic

ENULOSE SOL 10GM/15 Generic

GENERLAC SOL 10GM/15 Generic

LACTULOSE SOL 10GM/15 Generic

LACTULOSE SOL 20GM/30 Generic

XIFAXAN TAB 550MG Brand PA


10


MONOBACTAMS CAYSTON INH 75MG Brand PA 84mls per 60 days

BIOLOGICALS (VACCINES) VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN ADACEL INJ Brand AR <19 covered by VFC

AFLURIA INJ 2017‐2018 Brand AR <19 covered by VFC

AFLURIA QUAD INJ 2017‐2018 Brand AR <19 covered by VFC

BEXSERO INJ Brand AR covered for ages 19‐25

BOOSTRIX INJ Brand AR <19 covered by VFC

DAPTACEL INJ Brand AR <19 covered by VFC

ENGERIX‐B INJ 10/0.5ML Brand AR <19 covered by VFC

ENGERIX‐B INJ 20MCG/ML Brand AR <19 covered by VFC

FLUAD INJ 2017‐2018 Brand AR covered ages >64

FLUBLOK QUAD INJ 2017‐2018 Brand AR <19 covered by VFC

FLUCELVAX QUAD INJ 2016‐17 Brand AR <19 covered by VFC

FLULAVAL QUAD INJ 2017‐2018 Brand AR <19 covered by VFC

FLUVIRIN INJ 2017‐2018 Brand AR <19 covered by VFC

FLUZONE INJ INTRADRM Brand AR <19 covered by VFC

FLUZONE HD INJ PF 2017‐2018 Brand AR < 65 not covered

FLUZONE QUAD INJ 2017‐2018 Brand AR <19 covered by VFC

GARDASIL 9 INJ Brand AR Covered for ages 19‐26

HAVRIX INJ 720UNIT Brand AR <19 covered by VFC

HAVRIX INJ 1440UNIT Brand AR <19 covered by VFC

INFANRIX INJ Brand AR <19 covered by VFC

MENACTRA INJ Brand AR <19 covered by VFC

MENOMUNE INJ A/C/Y/W Brand AR <19 covered by VFC

MENVEO INJ Brand AR Covered for ages 19‐55

M‐M‐R II INJ Brand AR <19 covered by VFC

PNEUMOVAX 23 INJ 25/0.5 Generic AR <19 covered by VFC;

QL 0.5ml per day

PREVNAR 13 INJ Brand AR <19 covered by VFC

RECOMBIVA HB INJ 5MCG/0.5 Brand AR <19 covered by VFC

RECOMBIVA HB INJ 10MCG/ML Brand AR <19 covered by VFC

RECOMBIVA HB INJ 40MCG/ML Brand AR <19 covered by VFC

SHINGRIX INJ 50MCG Brand AR Covered ages > 50; QL

2 inj per lifetime

TRUMENBA INJ Brand AR Covered ages 19‐25

TWINRIX INJ Brand AR <19 Covered by VFC

VAQTA INJ 25/0.5ML Brand AR <19 covered by VFC

VAQTA INJ 50UNT/ML Brand AR <19 covered by VFC

VARIVAX INJ Brand AR <19 covered by VFC


11


ANTI‐NEOPLASTICS ANTIDOTES LEUCOVOR CA TAB 5MG Generic

LEUCOVOR CA TAB 10MG Generic



ANTIMETABOLITES MERCAPTOPURINE TAB 50MG Generic

METHOTREXATE INJ 100/4ML Generic

METHOTREXATE INJ 1GM Generic

METHOTREXATE INJ 1GM/40ML Generic



METHOTREXATE INJ 25MG/ML Generic

METHOTREXATE INJ 50MG/2ML Generic

METHOTREXATE TAB 2.5MG Generic

ANTINEOPLASTIC AGENTS ACTIMMUNE INJ 2MU/0.5 Brand PA

AFINITOR TAB 10MG Brand PA QL 1 per day

AFINITOR TAB 2.5MG Brand PA QL 1 per day

AFINITOR TAB 5MG Brand PA QL 2 per day

AFINITOR TAB 7.5MG Brand PA QL 1 per day

AFINITOR DIS TAB 2MG Brand PA




ALECENSA CAP 150MG Brand PA QL 8 per day

ALFERON N INJ 5MU/ML Brand PA

ALKERAN TAB 2MG Brand

ALUNBRIG STARTER PAK Brand PA QL 30 tabs per 180

days

ALUNBRIG 30MG Brand PA QL 2 per day



ANASTROZOLE TAB 1MG Generic

BICALUTAMIDE TAB 50MG Generic

BOSULIF TAB 100MG Brand PA QL 3 per day



CABOMETYX TAB 20MG Brand PA QL 1 per day



12



CALQUENCE CAP 100MG Brand PA QL 2 per day

CAPECITABINE TAB 150MG Generic

CAPECITABINE TAB 500MG Generic

CAPRELSA TAB 100MG Brand PA QL 2 per day

CAPRELSA TAB 300MG Brand PA QL 1 per day

COMETRIQ KIT 60MG Brand PA QL 3 per day



COTELLIC TAB 20MG Brand PA

CYCLOPHOSPH CAP 25MG Generic

CYCLOPHOSPH CAP 50MG Generic

DROXIA CAP 200MG Brand



ELIGARD INJ 22.5MG Brand PA

ELIGARD INJ 7.5MG Brand PA

EMCYT CAP 140MG Brand

ERIVEDGE TAB 150MG Brand PA QL 1 per day

ETOPOSIDE CAP 50MG Generic

EXEMESTANE TAB 25MG Generic

FARESTON TAB 60MG Brand

FARYDAK CAP 10MG Brand PA



FLUTAMIDE CAP 125MG Generic

GILOTRIF TAB 20MG Brand PA QL 1 per day

GILOTRIF TAB 30MG Brand PA QL 1 per day

GILOTRIF TAB 40mg Brand PA QL 1 per day

GLEOSTINE CAP 5MG Brand PA




HEXALEN CAP 50MG Brand

HYCAMTIN CAP 0.25MG Brand

HYCAMTIN CAP 1MG Brand

HYDROXYUREA CAP 500MG Generic

IBRANCE CAP 100MG Brand PA QL 0.75/day



ICLUSIG TAB 15MG Brand PA

ICLUSIG TAB 45MG Brand PA


13


IDHIFA TAB 50MG Brand PA QL 1 per day

IDHIFA TAB 100MG Brand PA QL 1 per day

IMATINIB MESYLATE TAB 100MG Generic PA QL 1 per day

IMATINIB MESYLATE TAB 400MG Generic PA QL 1 per day

IMBRUVICA CAP 140MG Brand PA

INLYTA TAB 1MG Brand PA QL 8 per day

INLYTA TAB 5MG Brand PA QL 4 per day

INTRON A INJ 10MU Brand PA




IRESSA TAB 250MG Brand PA QL 1 per day

KISQALI TAB 200 DOSE Brand PA QL 2.25 per day



LENVIMA CAP 8MG Brand PA QL 2 per day


LENVIMA CAP 14 MG Brand PA QL 2 per day


LENVIMA CAP 20 MG Brand PA QL 2 per day


LETROZOLE TAB 2.5MG Generic

LEUKERAN TAB 2MG Brand

LEUPROLIDE INJ 1MG/0.2 Generic PA

LOMUSTINE CAP 100MG Generic



LONSURF TAB 15‐6.14MG Brand PA

LONSURF TAB 20‐8.19MG Brand PA

LUPANETA KIT 11.25‐5 Brand PA

LUPANETA KIT 3.75‐5 Brand PA

LUPR DEP‐PED INJ 11.25MG Brand PA

LUPR DEP‐PED INJ 15MG Brand PA

LUPR DEP‐PED INJ 30MG Brand PA QL 1 per day

LUPR DEP‐PED INJ 7.5MG Brand PA

LUPRON DEPOT INJ 11.25MG Brand PA QL 1 per 90 days

LUPRON DEPOT INJ 22.5MG Brand PA QL 1 per 90 days

LUPRON DEPOT INJ 3.75MG Brand PA

LUPRON DEPOT INJ 30MG Brand PA

LUPRON DEPOT INJ 45MG Brand PA

LUPRON DEPOT INJ 7.5MG Brand PA

LYNPARZA CAP 50MG Brand PA QL 8 per day


14


LYNPARZA TAB 100MG Brand PA QL 4 per day

LYNPARZA TAB 150MG Brand PA QL 4 per day

LYSODREN TAB 500MG Brand

MATULANE CAP 50MG Brand

MEGESTROL AC SUS 400MG/10 Generic AR PA required >64

MEGESTROL AC SUS 40MG/ML Generic AR PA required >64

MEGESTROL AC TAB 20MG Generic AR PA required >64

MEGESTROL AC TAB 40MG Generic AR PA required >64

MEKINIST TAB 0.5MG Brand PA QL 3 per day

MEKINIST TAB 2MG Brand PA QL 1 per day

MYLERAN TAB 2MG Brand

NERLYNX TAB 40MG Brand PA QL 6 per day

NEXAVAR TAB 200MG Brand PA QL 4 per day

NINLARO CAP 2.3MG Brand PA QL 1 per day

NINLARO CAP 3MG Brand PA QL 1 per day

NINLARO CAP 4MG Brand PA QL 1 per day

ODOMZO CAP 200MG Brand PA QL 1 per day

POMALYST CAP 1MG Brand PA




REVLIMID CAP 2.5 MG Brand PA QL 1 per day

REVLIMID CAP 5 MG Brand PA QL 1 per day




RUBRACA TAB 200MG Brand PA QL 4 per day

RUBRACA TAB 300MG Brand PA QL 4 per day

RYDAPT CAP 25MG Brand PA QL 8 per day

SPRYCEL TAB 100MG Brand PA






STIVARGA TAB 40 MG Brand PA QL 4 per day

SUTENT CAP 12.5MG Brand PA QL 1 per day

SUTENT CAP 25MG Brand PA QL 1 per day

SUTENT CAP 37.5MG Brand PA QL 1 per day

SUTENT CAP 50MG Brand PA QL 1 per day

TABLOID TAB 40MG Brand

TAFINLAR CAP 50MG Brand PA QL 4 per day


15


TAFINLAR CAP 75MG Brand PA QL 4 per day

TAGRISSO TAB 40MG Brand PA QL 1 per day

TAGRISSO TAB 80MG Brand PA QL 1 per day

TAMOXIFEN TAB 10MG Generic

TAMOXIFEN TAB 20MG Generic

TARCEVA TAB 100MG Brand PA QL 1 per day



TASIGNA CAP 200MG Brand PA

TEMOZOLOMIDE CAP 100MG Generic PA






TRETINOIN CAP 10MG Generic

TYKERB TAB 250MG Brand PA QL 5 per day

VENCLEXTA TAB 10MG Brand PA QL 4 per day



VENCLEXTA TAB STARTER PACK Brand PA QL 1 fill per 180 days

VERZENIO TAB 50MG Brand PA QL 2 tabs per day



VOTRIENT TAB 200MG Brand PA QL 4 per day

XALKORI CAP 200MG Brand PA

XTANDI TAB 40MG Brand PA

ZEJULA CAP 100MG Brand PA QL 3 cap per day

ZELBORAF TAB 240MG Brand PA QL 8 per day

ZOLINZA CAP 100MG Brand PA

ZYDELIG TAB 100MG Brand PA QL 2 per day

ZYDELIG TAB 150MG Brand PA QL 2 per day

ZYKADIA CAP 150MG Brand PA QL 5 per day

ZYTIGA TAB 250MG Brand PA QL 4 per day

ZYTIGA TAB 500MG Brand PA QL 2 per day

PROGESTINS DEPO‐PROVERA INJ 400/ML Brand

HYDROXYPROG POW CAPROATE Generic

MEDROXYPR AC INJ 150MG/ML Generic QL 1 injection per 90 days

MEDROXYPR AC TAB 2.5MG Generic

MEDROXYPR AC TAB 5MG Generic

MEDROXYPR AC TAB 10MG Generic


16


NORETHIN ACE TAB 5MG Generic

PROGESTERONE CAP 100MG Generic

PROGESTERONE CAP 200MG Generic

ENDOCRINE AND METABOLIC DRUGS ADRENALS BAYCADRON ELX 0.5/5ML Generic

DELTASONE TAB 20MG Generic

DEXAMETHASONE ELX 0.5/5ML Generic

DEXAMETHASONE TAB 0.5MG Generic


DEXAMETHASONE TAB 1MG Generic





DEXAMETHASONE ELX 0.5/5ML Generic

DEXAMETHASONE CON 1MG/ML Brand

DEXAMETHASONE SOL 0.5/5ML Generic

FLUDROCORTISONE TAB 0.1MG Generic

HYDROCORTISONE TAB 10MG Generic



METHYLPREDNISOLONE TAB 4MG Generic




METHYLPREDNISOLONE PAK 4MG Generic

PREDNISOLONE SODIUM PHOSPHATE SOL 5MG/5ML Generic

PREDNISOLONE SODIUM PHOSPHATE SOL 5MG/5ML Generic

PREDNISOLONE SOL 15MG/5ML Generic

PREDNISOLONE SYP 15MG/5ML Generic

PREDNISONE TAB 1MG Generic

PREDNISONE TAB 2.5MG Generic





PREDNISONE SOL 5MG/5ML Generic

PREDNISONE PAK 5MG Generic

PREDNISONE PAK 10MG Generic


17


ANDROGENS ANDRODERM DIS 4MG/24HR Brand PA

ANDRODERM DIS 2MG/24HR Brand PA

DANAZOL CAP 50MG Generic



FIRST‐TESTOSTERONE OIN 2% Brand PA

METHITEST TAB 10MG Brand PA

OXANDROLONE TAB 2.5MG Generic PA

TESTIM GEL 1%(50MG) Brand PA

TESTOSTERONE CYPIONATE INJ 100MG/ML Generic QL 91 day supply available

TESTOSTERONE CYPIONATE INJ 200MG/ML Generic QL 91 day supply

available

TESTOSTERONE ENATHATE INJ 200MG/ML Generic QL 91 day supply

available

TESTOSTERONE GEL 1%(25MG) Generic PA

TESTOSTERONE GEL 1%(50MG) Generic PA

TESTOSTERONE GEL PUMP 1% Generic PA

TESTOSTERONE INJ 250MG/ML Generic PA

VOGELXO GEL 1%(50MG) Brand PA

VOGELXO GEL PUMP 1% Brand PA

ESTROGENS COMBIPATCH DIS .05/.14 Brand

COMBIPATCH DIS .05/.25 Brand

ESTRADIOL CRE 0.1MG/GM Generic

ESTRADIOL TAB 0.5MG Generic AR PA required >64

ESTRADIOL TAB 1MG Generic AR PA required >64

ESTRADIOL TAB 2MG Generic AR PA required >64

ESTRADIOL (Generic Climara) PATCH WKLY 0.025MG Generic QL 4 per month AR PA

required >64

ESTRADIOL (Generic Climara) PATCH WKLY 0.0375MG Generic

QL 4 per month AR PA required >64


required >64


required >64


required >64


required >64

ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.025MG Generic QL 8 per month; AR PA

required >64


18



required >64


required >64


required >64


required >64

ESTRADIOL VALERATE INJ 10MG/ML Generic AR PA required >64

ESTRADIOL VALERATE INJ 200MG/5 Generic AR PA required >64



DEPO‐ESTRADIOL INJ 5MG/ML Brand AR PA required >64

ESTRING MIS 2MG Brand AR PA required >64

ESTROPIPATE TAB 0.75MG Generic AR PA required >64

ESTROPIPATE TAB 1.5MG Generic AR PA required >64

ESTROPIPATE TAB 3MG Generic AR PA required >64

MENEST TAB 0.3MG Brand AR PA required >64




ORTHO‐EST TAB 0.625 Generic AR PA required >64

ORTHO‐EST TAB 1.25 Generic AR PA required >64

PREMARIN VAG CRE 0.625MG Brand QL 1 per day

YUVAFEM TAB 10MCG Generic

CONTRACEPTIVES *unless otherwise stated: generics QL max 91 day supply first fill;

future fills up to 12 month supply. Brands QL max 91 day supply all fills

AFTERA TAB 1.5MG Generic *QL

ALTAVERA TAB Generic *QL

ALYACEN TAB 1/35 Generic *QL

ALYACEN TAB 7/7/7 Generic *QL

AMETHIA TAB Generic *QL

AMETHIA LO TAB Generic *QL

AMETHYST TAB 90‐20MCG Generic *QL

APRI TAB Generic *QL

ARANELLE TAB Generic *QL


19


ASHLYNA TAB Generic *QL

AUBRA TAB 0.1‐0.02 Generic *QL

AVIANE TAB Generic *QL

AZURETTE TAB 28 DAY Generic *QL

BALZIVA TAB Generic *QL

BRIELLYN TAB Generic *QL

CAMILA TAB 0.35MG Generic *QL

CAMRESE TAB Generic *QL

CAMRESE LO TAB Generic *QL

CAZIANT PAK Generic *QL

CESIA PAK Generic *QL

CHATEAL TAB 0.15/30 Generic *QL

CRYSELLE‐28 TAB 28 TABS Generic *QL

CYCLAFEM TAB 1/35 Generic *QL

CYCLAFEM TAB 7/7/7 Generic *QL

CYRED TAB Generic *QL

DASETTA TAB 1/35 Generic *QL

DASETTA TAB 7/7/7 Generic *QL

DAYSEE TAB Generic *QL

DEBLITANE TAB 0.35MG Generic *QL

DELYLA TAB 0.1‐0.02 Generic *QL

DESO/ETHINYL TAB ESTRADIO Generic *QL

DROSPIR/ETHI TAB 3‐0.03MG Generic *QL

DROSPIRE/ETH TAB ESTR/LEV TAB Generic *QL

DROSPIRENONE TAB ETHY EST Generic *QL

ECONTRA EZ TAB 1.5MG Generic *QL

ELINEST TAB Generic *QL

ELLA TAB 30MG Brand QL 3 tabs per 31 days

EMOQUETTE TAB Generic *QL

ENPRESSE‐28 TAB Generic *QL

ENSKYCE TAB Generic *QL

ERRIN TAB 0.35MG Generic *QL

ESTARYLLA TAB 0.25‐35 Generic *QL

FALLBACK TAB 1.5MG Generic *QL

FALMINA TAB Generic *QL

FAYOSIM TAB Generic *QL

GIANVI TAB 3‐0.02MG Generic *QL

GILDAGIA TAB 0.4‐35 Generic *QL

GILDESS TAB 1/20 Generic *QL

GILDESS TAB 1.5/30 Generic *QL

GILDESS 24 TAB FE 1/20 Generic *QL

GILDESS FE TAB 1/20 Generic *QL


20


GILDESS FE TAB 1.5/30 Generic *QL

HEATHER TAB 0.35MG Generic *QL

IMPLANON IMP 68MG Brand

INTROVALE TAB Generic *QL

JENCYCLA TAB 0.35MG Generic *QL

JOLESSA TAB Generic *QL

JOLIVETTE TAB 0.35MG Generic *QL

JULEBER TAB Generic *QL

JUNEL 1.5/30 TAB Generic *QL

JUNEL 1/20 TAB Generic *QL

JUNEL FE TAB 1/20 Generic *QL

JUNEL FE TAB 1.5/30 Generic *QL

JUNEL FE 24 TAB 1/20 Generic *QL

KARIVA TAB 28 DAY Generic *QL

KELNOR TAB 1/35 Generic *QL

KIMIDESS TAB Generic *QL

KURVELO TAB 0.15/30 Generic *QL

LARIN TAB 1/20 Generic *QL

LARIN TAB 1.5/30 Generic *QL

LARIN 24 TAB FE 1/20 Generic *QL

LARIN FE TAB 1/20 Generic *QL

LARIN FE TAB 1.5/30 Generic *QL

LAYOLIS FE CHW Generic *QL

LEENA TAB Generic *QL

LESSINA TAB Generic *QL

LEVO‐ETH EST TAB 90‐20MCG Generic *QL

LEVONEST TAB Generic *QL

LEVONOR/ETHI TAB 0.1‐0.02 Generic *QL

LEVONOR/ETHI TAB ESTRADIO Generic *QL

LEVONORGESTR TAB 0.75MG Generic *QL

LEVONORGESTR TAB 1.5MG Generic *QL

LEVORA‐28 TAB 0.15/30 Generic *QL

LO LOESTRIN TAB Brand *QL

LO MINASTRIN PAK FE Brand *QL

LOMEDIA 24 TAB FE Generic *QL

LORYNA TAB 3‐0.02MG Generic *QL

LOW‐OGESTREL TAB Generic *QL

LUTERA TAB Generic *QL

LYZA TAB 0.35MG Generic *QL

MARLISSA TAB 0.15/30 Generic *QL

MIBELAS 24 CHW FE Generic *QL

MICROGESTIN TAB 1/20 Generic *QL


21


MICROGESTIN TAB 1.5/30 Generic *QL

MICROGESTIN TAB FE 1/20 Generic *QL

MICROGESTIN TAB FE1.5/30 Generic *QL

MONO‐LINYAH TAB 0.25‐35 Generic *QL

MONONESSA TAB Generic *QL

MY WAY TAB 1.5MG Generic *QL

MYZILRA TAB Generic *QL

NECON TAB 0.5/35 Generic *QL

NECON TAB 1/35 Generic *QL

NECON TAB 1/50‐28 Generic *QL

NECON TAB 10/11‐28 Generic *QL

NECON TAB 7/7/7 Generic *QL

NEXT CHOICE TAB 1.5MG Generic *QL

NIKKI TAB 3‐0.02MG Generic *QL

NORA‐BE TAB 0.35MG Generic *QL

NORETH/ETHIN TAB 1/20 Generic *QL

NORETH/ETHIN CHW FE Generic *QL

NORETH/ETHIN TAB FE 1/20 Generic *QL

NORETHINDRON TAB 0.35MG Generic *QL

NORGEST/ETHI TAB 0.25/35 Generic *QL

NORGEST/ETHI TAB ESTRADIO Generic *QL

NORINYL TAB 1+50‐28 Generic *QL

NORLYROC TAB 0.35MG Generic *QL

NORTREL TAB 0.5/35 Generic *QL

NORTREL TAB 1/35 Generic *QL

NORTREL TAB 7/7/7 Generic *QL

NUVARING MIS Brand *QL

OCELLA TAB 3‐0.03MG Generic *QL

OGESTREL TAB Generic *QL

OPCICON TAB 1.5MG Generic *QL

ORSYTHIA TAB Generic *QL

ORTHO TRI‐CYCLN LO TAB Generic *QL

PHILITH TAB 0.4‐35 Generic *QL

PIMTREA TAB Generic *QL

PIRMELLA TAB 1/35 Generic *QL

PIRMELLA TAB 7/7/7 Generic *QL

PLAN B TAB 0.75MG Brand QL 6 tabs per 31 days

PLAN B TAB 1.5MG Brand QL 3 tabs per 31 days

PORTIA‐28 TAB Generic *QL

PREVIFEM TAB Generic *QL

QUASENSE TAB Generic *QL

RAJANI TAB Generic *QL


22


RECLIPSEN TAB Generic *QL

RIVELSA TAB Generic *QL

SAFYRAL TAB Brand *QL

SETLAKIN TAB Generic *QL

SHAROBEL TAB 0.35MG Generic *QL

SOLIA TAB Generic *QL

SPRINTEC 28 TAB 28 DAY Generic *QL

SRONYX TAB Generic *QL

SYEDA TAB 3‐0.03MG Generic *QL

TAKE ACTION TAB 1.5MG Generic *QL

TARINA FE TAB 1/20 Generic *QL

TILIA FE TAB Generic *QL

TRI‐ESTARYLL TAB Generic *QL

TRI‐LEGEST TAB FE Generic *QL

TRI‐LINYAH TAB Generic *QL

TRINESSA TAB Generic *QL

TRI‐PREVIFEM TAB Generic *QL

TRI‐SPRINTEC TAB Generic *QL

TRIVORA‐28 TAB Generic *QL

VELIVET PAK Generic *QL

VESTURA TAB 3‐0.02MG Generic *QL

VIORELE TAB Generic *QL

VYFEMLA TAB 0.4‐35 Generic *QL

WERA TAB 0.5/35 Generic *QL

WYMZYA FE CHW 0.4MG‐35 Generic *QL

XULANE DIS 150‐35 Generic *QL

ZARAH TAB 3‐0.03MG Generic *QL

ZENCHENT TAB Generic *QL

ZENCHENT FE CHW 0.4MG‐35 Generic *QL

ZOVIA TAB 1/35E Generic *QL

ZOVIA TAB 1/50E Generic *QL

ALPHA‐GLUCOSIDASE INHIBITORS ACARBOSE TAB 50MG Generic QL 3 per day

ACARBOSE TAB 100MG Generic QL 3 per day

ACARBOSE TAB 25MG Generic QL 3 per day

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS DEX4 CHW 1GM Brand

DEX4 GLUCOSE CHW QK DISLV Brand

GLUCOSE CHW 4GM various

flavors Generic

GLUCOSE BITS CHW 1GM Brand

GLUTOSE 15 GEL 40% Generic


23


GLUTOSE 45 GEL 40% Generic

INSTA‐GLUCOS GEL 77.4% Brand

PROGLYCEM SUS 50MG/ML Brand

BIGUANIDES METFORMIN TAB 500MG Generic

METFORMIN TAB 850MG Generic

METFORMIN TAB 1000MG Generic

METFORMIN TAB 500MG ER Generic

METFORMIN TAB 750MG ER Generic

COMBO ANTI‐DIABETIC GLIPIZIDE/METFORMIN TAB 2.5‐250M Generic

GLIPIZIDE/METFORMIN TAB 2.5‐500M Generic

GLIPIZIDE/METFORMIN TAB 5‐500MG Generic

GLYBURIDE/METFORMIN TAB 1.25‐250 Generic AR PA required > 64

GLYBURIDE/METFORMIN TAB 2.5‐500 Generic AR PA required > 64

GLYBURIDE/METFORMIN TAB 5‐500MG Generic AR PA required > 64

PIOGLITAZONE/METFORMIN TAB 15‐500MG Generic QL 3 per day

PIOGLITAZONE/METFORMIN TAB 15‐850MG Generic QL 3 per day

GLUCAGON GLUCAGEN INJ HYPOKIT Brand

GLUCAGON KIT 1MG Brand

INCRETIN MIMETICS ADLYXIN INJ 20MCG Brand PA QL 0.215mls per day

ADLYXIN INJ 10/20MCG Brand PA QL 6 per 180 days

BYDUREON INJ Brand PA QL 0.143mls per day

BYETTA INJ 10MCG Brand PA QL 2.4mls per month

BYETTA INJ 5MCG Brand PA QL 1.2mls per month

TANZEUM INJ 30MG Brand PA QL 0.143mls per day

TANZEUM INJ 50MG Brand PA QL 0.143mls per day

VICTOZA INJ 18MG/3ML Brand PA QL 0.3mls per day

INSULINS ADMELOG INJ 100U/ML Brand

ADMELOG SOLO INJ 100U/ML Brand PA

BASAGLAR INJ 100U Brand

HUMALOG MIX INJ 50/50 Brand

HUMALOG MIX INJ 50/50KWP Brand PA

HUMALOG MIX INJ 75/25KWP Brand PA

HUMALOG MIX SUS 75/25 Brand

HUMULIN INJ 70/30 Brand

HUMULIN INJ 70/30KWP Brand PA

HUMULIN N INJ U‐100 Brand


24


HUMULIN N INJ U‐100KWP Brand PA

HUMULIN N PN INJ U‐100 Brand PA

HUMULIN PEN INJ 70/30 Brand PA

HUMULIN R INJ U‐100 Brand

HUMULIN R INJ 5‐500 (pens) Brand PA

NOVOLIN INJ 70/30 Brand

NOVOLIN N INJ RELION Brand

NOVOLIN N INJ U‐100 Brand

NOVOLIN R INJ RELION Brand

NOVOLIN R INJ U‐100 Brand

NOVOLIN 70/30 INJ RELION Brand

NOVOLOG MIX INJ 70/30 Brand

NOVOLOG MIX INJ FLEXPEN Brand PA

RELION R INJ 100/ML Brand

SOLIQUA INJ 10/33 Brand PA

TOUJEO SOLO INJ 300IU/ML Brand PA

DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS ALOGLIPTAN TAB 6.25MG Brand PA

ALOGLIPTAN TAB 12.5MG Brand PA

ALOGLIPTAN TAB 25MG Brand PA

SULFONYLUREAS GLIMEPIRIDE TAB 1MG Generic QL 2 per day

GLIMEPIRIDE TAB 2MG Generic QL 2 per day

GLIMEPIRIDE TAB 4MG Generic QL 2 per day

GLIPIZIDE TAB 5MG Generic

GLIPIZIDE TAB 10MG Generic

GLIPIZIDE ER TAB 2.5MG Generic

GLIPIZIDE ER TAB 5MG Generic

GLIPIZIDE ER TAB 10MG Generic

GLIPIZIDE XL TAB 2.5MG Generic

GLIPIZIDE XL TAB 5MG Generic

GLIPIZIDE XL TAB 10MG Generic

GLYBURID MCR TAB 1.5MG Generic AR PA required > 64

GLYBURID MCR TAB 3MG Generic AR PA required > 64

GLYBURID MCR TAB 6MG Generic AR PA required > 64

GLYBURIDE TAB 1.25MG Generic AR PA required > 64

GLYBURIDE TAB 2.5MG Generic AR PA required > 64

GLYBURIDE TAB 5MG Generic AR PA required > 64

TOLAZAMIDE TAB 250MG Generic


25


THIAZOLIDINEDIONES PIOGLITAZONE TAB 15MG Generic QL 1 per day

PIOGLITAZONE TAB 30MG Generic QL 1 per day

PIOGLITAZONE TAB 45MG Generic QL 1 per day

ANTITHYROID AGENTS METHIMAZOLE TAB 5MG Generic

METHIMAZOLE TAB 10MG Generic

PROPYLTHIOUR TAB 50MG Generic

SSKI SOL 1GM/ML Brand

THYROID AGENTS ARMOUR THYROID TAB 15MG Brand AR PA required > 64

ARMOUR THYROID TAB 30MG Brand AR PA required > 64







LEVOTHYROXINE TAB 25MCG Generic QL 90 day fill available












LEVOTHYROXINE INJ 100MCG Generic

LEVOTHYROXINE INJ 200MCG Generic

LEVOTHYROXINE INJ 500MCG Generic QL 90 day fill available

LEVOXYL TAB 25MCG Generic QL 90 day fill available








LEVOXYL TAB 150MCG Generic QL 90 day fill available QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

26




LIOTHYRONINE TAB 5MCG Generic



NP THYROID TAB 30MG Generic AR PA required > 64



SYNTHROID TAB 25MCG Brand QL 90 day fill available












THYROLAR‐1 TAB 60MG Brand

THYROLAR‐1/2 TAB 30MG Brand

THYROLAR‐1/4 TAB 15MG Brand



UNITHROID DIRECT TAB 25MCG Generic QL 90 day fill available











UNITHROID TAB 25MCG Generic QL 90 day fill available







27








OXYTOCICS METHYLERGON TAB 0.2MG Generic

ERGOT‐DERIV. DOPAMINE RECEPTOR AGONISTS CABERGOLINE TAB 0.5MG Generic QL 20 per month

ESTROGEN AGONIST‐ANTAGONISTS RALOXIFENE TAB 60MG Generic

OSTEOPOROSIS ALENDRONATE TAB 5MG Generic QL 1 per day

ALENDRONATE TAB 10MG Generic QL 1 per day

ALENDRONATE TAB 35MG Generic QL 4 per 30 days

ALENDRONATE TAB 40MG Generic QL 1 per day

ALENDRONATE TAB 70MG Generic QL 4 per 30 days

CALCITONIN SPR 200/ACT Generic QL 3.7mls per 30 days

ETIDRONATE DISODIUM TAB 200MG Generic

ETIDRONATE DISODIUM TAB 400MG Generic

IBANDRONATE TAB 150MG Generic QL 1 per 30 day

RISEDRONATE TAB 5MG Generic ST (Alendronate) QL 1 per day

RISEDRONATE TAB 30MG Generic ST (Alendronate) QL 1 per day

RISEDRONATE TAB 35MG Generic ST (Alendronate) QL 4 per 30 days

RISEDRONATE TAB 150MG Generic ST (Alendronate) QL 4 per 30 days

TYMLOS INJ Brand PA QL 0.052ml per day

OTHER MISCELLANEOUS THERAPEUTIC AGENTS FISH OIL CAP 1000MG Generic

FISH OIL CAP 1200MG Generic




FISH OIL CAP 900MG Brand

KUVAN POW 100MG Brand PA

KUVAN POW 500MG Brand PA

KUVAN TAB 100MG Brand PA

LEVOCARNITINE TAB 330MG Generic


28


LEVOCARNITINE SOL 1GM/10ML Generic

OMEGA III CAP EPA+DHA Generic

SAM‐E.P.A. CAP 500MG Generic

SENSIPAR TAB 30MG Brand



SUPER DHA CAP GEMS Generic

SUPER OMEGA CAP 500MG Generic

SUPER OMEGA CAP ‐3 Generic

SUPER OMEGA CAP‐EPA Generic

PITUITARY DESMOPRESSIN TAB 0.1MG Generic PA

DESMOPRESSIN TAB 0.2MG Generic PA

DESMOPRESSIN INJ 4MCG/ML Generic PA

DESMOPRESSIN SOL 0.01% Generic PA

DESMOPRESSIN SPR 0.01% Generic PA

SOMATOTROPIN AGONISTS GENOTROPIN INJ 5MG Brand PA

GENOTROPIN INJ 12MG Brand PA

GENOTROPIN INJ 0.2MG Brand PA










HUMATROPE INJ 5MG Brand PA




INCRELEX INJ 40MG/4ML Brand PA

NORDITROPIN INJ 5/1.5ML Brand PA



NORDITROPIN INJ 30/3ML Brand PA

NUTROPIN INJ 10MG Brand PA

NUTROPIN AQ INJ NUSPIN 5 Brand PA

NUTROPIN AQ INJ 10MG/2ML Brand PA

OCTREOTIDE INJ 100MCG Generic PA


29


OCTREOTIDE INJ 1000MCG Generic PA

OMNITROPE INJ 5/1.5ML Brand PA

OMNITROPE INJ 10/1.5ML Brand PA

OMNITROPE INJ 5.8MG Brand PA

SIGNIFOR INJ 0.3MG/ML Brand PA



TEV‐TROPIN INJ 5MG Brand PA

ZOMACTON INJ 5MG Brand PA

ZOMACTON INJ 10MG Brand PA

SOMATOTROPIN ANTAGONISTS SOMAVERT INJ 10MG Brand PA

SOMAVERT INJ 15MG Brand PA




VITAMIN D CALCITRIOL CAP 0.25MCG Generic

CALCITRIOL CAP 0.5MCG Generic

CALCITRIOL SOL 1MCG/ML Generic

CHILD VIT D CHW 400UNIT Generic

D 400 CHW 400UNIT Generic

D‐3 GUMMY CHW 400UNIT Generic

D3 KIDS CHW 400UNIT Generic

D‐VI‐SOL LIQ 400UNIT Brand

D‐VITA LIQ 400UNIT Generic

ERGOCALCIFER DRO 8000/ML Generic

ERGOCALCIFER SOL 8000/ML Generic

JUST D LIQ 400UNIT Generic

MEPHYTON TAB 5MG Brand QL 5 tabs per fill; ST

(warfarin)

PARICALCITOL CAP 1 MCG Generic PA QL 15 per 31 days



THERA‐D TAB 4000UNIT Brand

VITAJOY DALY CHW D 1000IU Generic

VITAMIN D CHW 400UNIT Generic

VITAMIN D TAB 5000IU Generic

VITAMIN D3 TAB 1000UNIT Generic





30



VITAMIN D3 TAB 50000UNIT Brand

VITAMIN D3 CAP 400UNIT Generic


VITAMIN D3 CAP 10000UNT Generic


VITAMIN D3 CHW 1000UNIT Generic

VITAMIN D3 CHW 400UNIT Generic

VITAMIN D3 DRO 400UNIT Generic

VIT D GUMMIE CHW 400UNIT Generic

CARDIOVASCULAR AGENTS CARDIOTONIC AGENTS DIGITEK TAB 0.125MG Generic QL 90 day fill available

DIGITEK TAB 0.25MG Generic QL 90 day fill available; PA

required > 64

DIGOX TAB 0.125MG Generic QL 90 day fill available

DIGOX TAB 0.25MG Generic QL 90 day fill available; PA

required > 64

DIGOXIN TAB 0.125MG Generic QL 90 day fill available

DIGOXIN TAB 0.25MG Generic QL 90 day fill available; PA

required > 64

DIGOXIN SOL 50MCG/ML Generic QL 90 day fill available

CARDIAC DRUGS, MISCELLANEOUS CORLANOR TAB 5MG Brand QL 2 per day

CORLANOR TAB 7.5MG Brand QL 2 per day

ENTRESTO TAB 24‐26MG Brand PA QL 2 per day



RANEXA TAB 500MG Brand

RANEXA TAB 1000MG Brand

NITRATES AND NITRITES DILATRATE SR CAP 40MG Brand

ISORDIL TAB 40MG Brand

ISOSORBIDE DINITRATE TAB 5MG Generic




ISOSORBIDE DINITRATE TAB 40MG ER Generic

ISOSORBIDE MONONITRATE TAB 10MG Generic

ISOSORBIDE MONONITRATE TAB 20MG Generic

ISOSORBIDE MONONITRATE TAB 30MG ER Generic


31




MINITRAN DIS 0.1MG/HR Generic




NITRO‐BID OIN 2% Brand

NITRO‐DUR DIS 0.3MG/HR Brand

NITRO‐DUR DIS 0.8MG/HR Brand

NITROGLYCERIN INJ 5MG/ML Generic

NITROGLYCERIN DIS 0.1MG/HR Generic




NITROGLYCERIN SPR 0.4MG Generic

NITROGLYCERIN SPR LINGUAL Generic

NITROGLYCERIN SUB 0.3MG Generic



BETA‐ADRENERGIC BLOCKING AGENTS ACEBUTOLOL CAP 200MG Generic

ACEBUTOLOL CAP 400MG Generic

ATENOLOL TAB 25MG Generic QL 90 day supply available



CARVEDILOL TAB 3.125MG Generic



CARVEDILOL TAB 25MG Generic

LABETALOL TAB 100MG Generic



METOPROLOL TARTRATE TAB 25MG Generic QL 90 day supply available



METOPROLOL TAB 25MG ER Generic QL 90 day supply available




NADOLOL TAB 20MG Generic




32


PINDOLOL TAB 10MG Generic

PINDOLOL TAB 5MG Generic

PROPRANOLOL CAP 60MG ER Generic




PROPRANOLOL TAB 10MG Generic





PROPRANOLOL SOL 20MG/5ML Generic AR PA required >6

PROPRANOLOL SOL 40MG/5ML Generic AR PA required >6

SORINE TAB 80MG Generic




SOTALOL AF TAB 80MG Generic



SOTALOL HCL TAB 80MG Generic




CALCIUM‐CHANNEL BLOCKING AGENTS AFEDITAB TAB 30MG CR Generic

AFEDITAB TAB 60MG CR Generic

AMLODIPINE TAB 2.5MG Generic

AMLODIPINE TAB 5MG Generic

AMLODIPINE TAB 10MG Generic

CARTIA XT CAP 120/24HR Generic




DILT‐CD CAP 120MG Generic




DILTIAZEM TAB 30MG Generic





33


DILTIAZEM CAP 60MG ER Generic





DILTIAZEM CAP 120MG/24 Generic







DILTIAZEM CAP 120MG CD Generic






DILT‐XR CAP 120MG Generic



DILTZAC CAP 120MG/24 Generic





NIFEDIAC CC TAB 30MG ER Generic

NIFEDIAC CC TAB 60MG ER Generic

NIFEDICAL XL TAB 30MG Generic

NIFEDICAL XL TAB 60MG Generic

NIFEDIPINE CAP 10MG Generic AR PA required > 64

NIFEDIPINE CAP 20MG Generic AR PA required > 64

NIFEDIPINE TAB 30MG ER Generic



TAZTIA XT CAP 120MG/24 Generic





VERAPAMIL TAB 40MG Generic



34



VERAPAMIL TAB 120MG ER Generic



VERAPAMIL INJ 2.5MG/ML Generic

VERAPAMIL CAP 100MG ER Generic


VERAPAMIL CAP 120MG SR Generic








ANTIARRHYTHMICS ADENOSINE INJ 6MG/2ML Generic

ADENOSINE INJ 12MG/4ML Generic

AMIODARONE TAB 200MG Generic QL 90 day fill available

AMIODARONE INJ 50MG/ML Generic

AMIODARONE INJ 150MG/3M Generic

DISOPYRAMIDE CAP 100MG Generic AR PA required > 64

DISOPYRAMIDE CAP 150MG Generic AR PA required > 64

DOFETILIDE CAP 125MCG Generic



FLECAINIDE TAB 50MG Generic



LIDOCAINE INJ 20MG/ML Generic

MEXILETINE CAP 150MG Generic



MULTAQ TAB 400MG Brand PA QL 2 per day

NORPACE CAP 100MG CR Brand

NORPACE CAP 150MG CR Brand

PACERONE TAB 200MG Generic QL 90 day fill available

PROCAINAMIDE INJ 100MG/ML Generic

PROCAINAMIDE INJ 500MG/ML Generic

PROPAFENONE TAB 150MG Generic




35


QUINIDINE GLUCONATE TAB 324MG CR Generic

QUINIDINE GLUCONATE TAB 324MG ER Generic

QUINIDINE SULFATE TAB 200MG Generic

QUINIDINE SULFATE TAB 300MG Generic

ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN TAB 4MG Generic PA

CANDESARTAN TAB 8MG Generic PA



CANDESARTAN/HCTZ TAB 16‐12.5MG Generic PA

CANDESARTAN/HCTZ TAB 32‐12.5MG Generic PA

CANDESARTAN/HCTZ TAB 32‐25MG Generic PA

IRBESARTAN TAB 75MG Generic



LOSARTAN POTASSIUM TAB 25MG Generic



VALSARTAN TAB 40MG Generic PA




VALSARTAN/HCTZ TAB 80‐12.5MG Generic PA


VALSARTAN/HCTZ TAB 160‐25MG Generic PA


VALSARTAN/HCTZ TAB 320‐25MG Generic PA

ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS BENAZEPRIL TAB 5MG Generic

BENAZEPRIL TAB 10MG Generic



CAPTOPRIL TAB 12.5MG Generic QL 90 day supply available

CAPTOPRIL TAB 25MG Generic QL 90 day supply available



ENALAPRIL TAB 2.5MG Generic QL 90 day supply available

ENALAPRIL TAB 5MG Generic QL 90 day supply available



FOSINOPRIL TAB 10MG Generic



36



LISINOPRIL TAB 2.5MG Generic QL 90 day supply available

LISINOPRIL TAB 5MG Generic QL 90 day supply available





QUINAPRIL TAB 5MG Generic





RAMIPRIL CAP 10MG Generic

RAMIPRIL CAP 1.25MG Generic

RAMIPRIL CAP 2.5MG Generic

RAMIPRIL CAP 5MG Generic

CENTRAL ALPHA‐AGONISTS CLONIDINE TAB 0.1MG Generic

CLONIDINE TAB 0.2MG Generic

CLONIDINE TAB 0.3MG Generic

GUANFACINE TAB 1MG Generic AR PA required > 64

GUANFACINE TAB 2MG Generic AR PA required > 64

METHYLDOPA TAB 250MG Generic AR PA required > 64

METHYLDOPA TAB 500MG Generic AR PA required > 64

COMBO HYPERTENSION MEDS ATENOLOL/CHLORTHALIDONE TAB 50‐25MG Generic QL 90 day supply available

ATENOLOL/CHLORTHALIDONE TAB 100‐25MG Generic QL 90 day supply available

BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 5‐6.25 Generic



BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 20‐25MG Generic

BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 2.5/6.25 Generic BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 5‐6.25MG Generic BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 10/6.25 Generic

CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 25‐15MG Generic QL 90 day supply available



ENALAPRIL/HYDROCHLOROTHIAZIDE TAB 5‐12.5MG Generic QL 90 day supply available

ENALAPRIL/HYDROCHLOROTHIAZIDE TAB 10‐25MG Generic QL 90 day supply available


37


IRBESARTAN/HYDROCHLOROTHIAZIDE TAB 300‐12.5 Generic

IRBESARTAN/HYDROCHLOROTHIAZIDE TAB 150‐12.5 Generic

LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 10‐12.5 Generic QL 90 day supply available

LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 20‐12.5 Generic QL 90 day supply available

LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 20‐25MG Generic QL 90 day supply available

LOSARTAN/HYDROCHLOROTHIAZIDE TAB 50‐12.5 Generic

LOSARTAN/HYDROCHLOROTHIAZIDE TAB 100‐12.5 Generic

LOSARTAN/HYDROCHLOROTHIAZIDE TAB 100‐25 Generic

METOPROLOL/HYDROCHLOROTHIAZIDE TAB 50‐25MG Generic



SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TAB 25/25 Generic

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 37.5‐25 Generic

TRIAMTERENE/HYDROCHLOROTHIAZIDE TAB 37.5‐25 Generic

TRIAMTERENE/HYDROCHLOROTHIAZIDE TAB 75‐50MG Generic

DIRECT VASODILATORS HYDRALAZINE TAB 10MG Generic

HYDRALAZINE TAB 25MG Generic



MINOXIDIL TAB 2.5MG Generic

MINOXIDIL TAB 10MG Generic

CARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMIDE TAB 125MG Generic

ACETAZOLAMIDE TAB 250MG Generic

ACETAZOLAMIDE CAP 500MG ER Generic

AZOPT SUS 1% OP Brand

DORZOLAMIDE/TIMOLOL MALEATE SOL 22.3‐6.8 Generic

DORZOLAMIDE SOL 2% OP Generic

METHAZOLAMIDE TAB 25MG Generic

METHAZOLAMIDE TAB 50MG Generic

LOOP DIURETICS BUMETANIDE TAB 0.5MG Generic

BUMETANIDE TAB 1MG Generic

BUMETANIDE TAB 2MG Generic

BUMETANIDE INJ 0.25/ML Generic

FUROSEMIDE TAB 20MG Generic QL 90 day fill available



FUROSEMIDE INJ 10MG/ML Generic QL 90 day fill available

FUROSEMIDE INJ 20MG/2ML Generic QL 90 day fill available

FUROSEMIDE INJ 40MG/4ML Generic QL 90 day fill available QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

38


FUROSEMIDE INJ 100/10ML Generic QL 90 day fill available

FUROSEMIDE SOL 8MG/ML Generic QL 90 day fill available

FUROSEMIDE SOL 10MG/ML Generic QL 90 day fill available

TORSEMIDE TAB 5MG Generic




POTASSIUM‐SPARING DIURETICS AMILORIDE/HYDROCHLOROTHIAZIDE TAB 5‐50 Generic

AMILORIDE TAB 5MG Generic

DYRENIUM CAP 50MG Brand

DYRENIUM CAP 100MG Brand

SPIRONOLACTONE TAB 25MG Generic



THIAZIDE AND THIAZIDE‐LIKE DIURETICS CHLORTHALIDONE TAB 25MG Generic

CHLORTHALIDONE TAB 50MG Generic

CHLORTHALIDONE TAB 100MG Generic

HYDROCHLOROTHIAZIDE CAP 12.5MG Generic QL 90 day fill available

HYDROCHLOROTHIAZIDE TAB 25MG Generic QL 90 day fill available

HYDROCHLOROTHIAZIDE TAB 50MG Generic QL 90 day fill available

INDAPAMIDE TAB 1.25MG Generic

INDAPAMIDE TAB 2.5MG Generic

METOLAZONE TAB 2.5MG Generic

METOLAZONE TAB 5MG Generic

METOLAZONE TAB 10MG Generic

ALPHA‐ADRENERGIC AGONISTS MIDODRINE TAB 2.5MG Generic

MIDODRINE TAB 5MG Generic

MIDODRINE TAB 10MG Generic

EPINEPHRINE EPINEPHRINE AUTO‐INJECTOR INJ 0.15MG Generic

EPINEPHRINE AUTO‐INJECTOR INJ 0.3MG Generic

ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB 500MG ER Generic

NIACIN ER TAB 500MG Generic




39


BILE ACID SEQUESTRANTS CHOLESTYRAM POW 4GM Generic

CHOLESTYRAM POW 4GM LITE Generic

COLESTIPOL TAB 1GM Generic

COLESTIPOL GRA 5GM Generic

PREVALITE POW 4GM Generic

PREVALITE POW 4GM PK Generic

CHOLESTEROL ABSORPTION INHIBITORS EZETIMIBE TAB 10MG Brand PA

FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 48MG Generic

FENOFIBRATE TAB 54MG Generic

FENOFIBRATE TAB 160MG Generic

FENOFIBRATE CAP 43MG Generic



FENOFIBRIC CAP 45MG DR Generic

GEMFIBROZIL TAB 600MG Generic

PCSK9 INHIBITORS REPATHA PUSH INJ 420/3.5 Brand PA; QL 1 device per month

REPATHA SURE INJ 140MG/ML Brand PA; QL 2 pens per month

REPATHA INJ 140MG/ML Brand PA; QL 2 pens per month

STATINS ATORVASTATIN TAB 10MG Generic

ATORVASTATIN TAB 20MG Generic



LOVASTATIN TAB 10MG Generic QL 90 day supply available



PRAVASTATIN TAB 10MG Generic




SIMVASTATIN TAB 5MG Generic






40


PULMONARY HYPERTENSION ADCIRCA TAB 20MG Brand PA QL 2 per day

ADEMPAS TAB 0.5MG Brand PA

ADEMPAS TAB 1MG Brand PA


ADEMPAS TAB 2MG Brand PA


EPOPROSTENOL INJ 0.5MG Generic PA

EPOPROSTENOL INJ 1.5MG Generic PA

REMODULIN INJ 1MG/ML Brand PA

REMODULIN INJ 2.5MG/ML Brand PA



SILDENAFIL TAB 20MG Generic PA QL 3 per day

TRACLEER TAB 32MG Brand PA QL 4 per day

TRACLEER TAB 62.5MG Brand PA

TRACLEER TAB 125MG Brand PA

VELETRI INJ 0.5MG Brand PA

VELETRI INJ 1.5MG Generic PA

VENTAVIS SOL 10MCG/ML Brand PA

VENTAVIS SOL 20MCG/ML Brand PA

RESPIRATORY AGENTS ANTI‐HISTAMINES ALA‐HIST IR TAB 2MG Brand

ALAVERT TAB 10MG Generic QL 1 per day

ALER‐DRYL TAB 50MG Generic AR PA required > 64

CHLORPHENIRAMINE MALEATE TAB 4MG Generic AR PA required > 64

DIPHENHYDRAMINE CAP 25MG Generic AR PA required > 64

DIPHENHYDRAMINE TAB 25MG Generic AR PA required > 64

DIPHENHYDRAMINE LIQ 12.5/5ML Generic AR PA required > 64

CHLORPHENIRAMINE MALEATE TAB 12MG CR Generic AR PA required > 64

DIPHENHYDRAMINE TAB DYE‐FREE Generic AR PA required > 64

DIPHENHYDRAMINE LIQ 12.5/5ML Generic AR PA required > 64

DIPHENHYDRAMINE CHW 12.5MG Generic AR PA required > 64

DIPHENHYDRAMINE ELX 12.5/5ML Generic AR PA required > 64

DIPHENHYDRAMINE LIQ 50/20ML Generic AR PA required > 64

CETIRIZINE TAB 5MG Generic QL 1 per day

CETIRIZINE TAB 10MG Generic QL 1 per day

CETIRIZINE SYP 5MG/5ML Generic

CETIRIZINE SYP 1MG/ML Generic

CETIRIZINE SOL 1MG/ML Generic


41


CETIRIZINE SOL 5MG/5ML Generic

CYPROHEPTADINE TAB 4MG Generic AR PA required > 64

CYPROHEPTADINE SYP 2MG/5ML Generic AR PA required > 64

DIABET TUSS SYP ALLERGY Generic

DIPHENHYDRAMINE INJ 50MG/ML Generic

LORATADINE TAB 10MG Generic QL 1 per day

LORATADINE SOL 5MG/5ML Generic

LORATADINE SYP 5MG/5ML Generic

NASAL STEROIDS FLUNISOLIDE SPR 0.025% Generic PA QL 25mls per 30 days

FLUTICASONE SPR 50MCG Generic QL 16mls per 30 days

TRIAMCINOLONE NASAL SPR 55MCG/AC Generic ST (fluticasone)

COUGH BENZONATATE CAP 100MG Generic

BENZONATATE CAP 200MG Generic

CYSTIC FIBROSIS KALYDECO TAB 150MG Brand PA QL 2 per day

KALYDECO PAK 50MG Brand PA QL 2 per day

KALYDECO PAK 75MG Brand PA QL 2 per day

NEBUSAL NEB 3% Generic

ORKAMBI TAB 200‐125 Brand PA QL 4 tabs per day

PULMOSAL NEB 7% Generic

PULMOZYME SOL 1MG/ML Brand QL 150mls per 31 days

SODIUM CHLORIDE NEB 0.9% Generic

SODIUM CHLORIDE NEB 3% Generic

SODIUM CHLORIDE NEB 7% Generic

INHALED ANTICHOLINERGICS ATROVENT HFA AER 17MCG Brand

SPIRIVA CAP HANDIHLR Brand QL 1 per day

SPIRIVA SPR RESPIMAT Brand QL 2 puffs per day

INHALED BETA‐AGONISTS ALBUTEROL NEB 0.083% Generic QL 90 day fill available

ALBUTEROL NEB 0.5% Generic QL 90 day fill available

ALBUTEROL NEB 0.63MG/3 Generic QL 90 day fill available

ALBUTEROL NEB 1.25MG/3 Generic QL 90 day fill available

PROAIR HFA AER Brand QL 90 day fill available

PROVENTIL AER HFA Brand QL 90 day fill available

SEREVENT DISKUS AER 50MCG Brand

VENTOLIN HFA AER Brand QL 90 day fill available

XOPENEX HFA AER Brand QL 60 day supply per fill


42


INHALED COMBO ANTICHOLINERGICS/BETA‐AGONISTS ANORO ELLIPTA AER 62.5‐25 Brand PA QL 2 per day

STIOLTO AER RESPIMAT Brand PA QL 0.134 per day

INHALED COMBO BETA‐AGONISTS/ANTICHOLINERGICS COMBIVENT AER Brand

COMBIVENT AER RESPIMAT Brand

IPRATROPIUM/ SOL ALBUTER Generic

IPRATROPIUM/ SOL SULFATE Generic

INHALED COMBO STEROID/BETA‐AGONISTS ADVAIR DISKUS AER 100/50 Brand PA Required; QL 2 per day

ADVAIR DISKUS AER 250/50 Brand PA Required; QL 2 per day

ADVAIR DISKUS AER 500/50 Brand PA Required; QL 2 per day

ADVAIR HFA AER 45/21 Brand PA Required



FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 55/14 Generic

FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 113‐14 Generic

FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 232‐14 Generic

SYMBICORT AER 80‐4.5 Brand PA Required

SYMBICORT AER 160‐4.5 Brand PA Required

TRELEGY AER ELLIPTA Brand PA QL 2 blister strips per

day

INHALED STEROIDS ARMONAIR AER 55/ACT Brand QL 1 inhaler per month

ARMONAIR AER 113/ACT Brand QL 1 inhaler per month

ARMONAIR AER 232/ACT Brand QL 1 inhaler per month

BUDESONIDE SUS 0.25MG/2 Generic AR PA > 6 years of age

BUDESONIDE SUS 0.5MG/2 Generic AR PA > 6 years of age

BUDESONIDE SUS 1MG/2ML Generic AR PA > 6 years of age

FLOVENT HFA AER 110MCG Brand QL 60 days per fill



FLOVENT DISK AER 100MCG Brand QL 60 days per fill

FLOVENT DISK AER 50MCG Brand

FLOVENT DISK AER 250MCG Brand QL 60 days per fill

QVAR AER 40MCG Brand QL 50 days per fill

QVAR AER 80MCG Brand QL 50 days per fill

QVAR REDIHALER AER 40MCG Brand QL 2 puffs per day; 60 day

supply per fill


43


QVAR REDIHALER AER 80MCG Brand QL up to 60 day supply per

fill

LEUKOTRIENE MODIFIERS MONTELUKAST TAB 10MG Generic

MONTELUKAST CHW 4MG Generic

MONTELUKAST CHW 5MG Generic

MONTELUKAST GRA 4MG Generic

ZAFIRLUKAST TAB 10MG Generic

ZAFIRLUKAST TAB 20MG Generic

MAST‐CELL STABILIZERS CROMOLYN SOD NEB 20MG/2ML Generic

OTHER ASTHMA/COPD ALBUTEROL TAB 4MG ER Generic

ALBUTEROL TAB 2MG Generic

ALBUTEROL TAB 4MG Generic

ALBUTEROL SYP 2MG/5ML Generic

ARALAST NP INJ 400MG Brand PA




ELIXOPHYLLIN ELX 80/15ML Brand

METAPROTEREN SYP 10MG/5ML Generic

TERBUTALINE TAB 2.5MG Generic

TERBUTALINE TAB 5MG Generic

THEO‐24 CAP 200MG CR Brand

THEOCHRON TAB 100MG CR Generic



THEOPHYLLINE TAB 100MG ER Generic

THEOPHYLLINE TAB 100MG CR Generic


THEOPHYLLINE TAB 200MG CR Generic





ZEMAIRA INJ 1000MG Brand PA

GASTROINTESTINAL AGENTS CATHARTICS AND LAXATIVES (List not all encompassing. Representative products listed only)

BISACODYL SUPP, TAB, TAB EC, Generic


44


CASCARA SAGRADA CAP 450MG Generic

DOCUSATE SODIUM CAP, SOFTGEL, SOL,

SYRUP, TAB Generic

ENEMA Generic

GLYCERIN SUPP Generic

KONSYL CAP Generic

MAGNESIUM CITRATE SOLN Generic

METAMUCIL PACKET, WAFER Generic

MILK OF MAGNESIUM SUSP Generic

MINERAL OIL ENEMA, LAXATIVE Generic

SALINE LAXATIVE Generic

POLYETHYLENE GLYCOL POWDER, PACKET Generic

PSYLLIUM FIBER TAB, POWDER Generic

SENNA TAB, LAXATIVE Generic

SENNA‐DOCUSATE SODIUM TAB Generic

GAVILYTE‐C SOLN Generic

GAVILYTE‐G SOLN Generic

GAVILYTE‐N SOLN Generic

PEDIA‐LAX LIQ 50MG Brand

TRILYTE SOL Generic

ANTACIDS AND ADSORBENTS (List not all encompassing. Representative products listed only)

ALCALAK CHW 420MG Generic

ALMACONE SUS CHW 1000MG Generic

ANTACID TAB, GELCAP, CHEW

TAB, SUSP Generic

CALC ANTACID CHW 1000MG Generic



CALCIUM CARB CHW 500MG Generic

CALCIUM CARB TAB 648MG Generic

CHILD SOOTHE CHW 400MG Generic

CHILDRENS CHW PEPTO Generic

COMFORT GEL SUS Generic

MAALOX LIQ, CHEW Generic

MAG OXIDE TAB 400MG Generic

SODIUM BICAR TAB 10GR Generic

SODIUM BICAR TAB 650MG Generic

STOMACH RLF CHW 400MG Generic

ANTIMUSCARINICS/ANTISPASMODICS BELLA/OPIUM SUP 16.2‐30 Generic QL 1 per 180 days

BELLA/OPIUM SUP 16.2‐60 Generic QL 1 per 180 days


45


DAPSONE TAB 100MG Generic

DAPSONE TAB 25MG Generic

DICYCLOMINE CAP 10MG Generic AR PA required > 64

DICYCLOMINE SOL 10MG/5ML Generic AR PA required > 64

DICYCLOMINE TAB 20MG Generic AR PA required > 64

ED‐SPAZ TAB 0.125MG Generic AR PA required > 64

HYOMAX‐SL SUB 0.125MG Generic AR PA required > 64

HYOSCYAMINE DRO 0.125/ML Generic AR PA required > 64

HYOSCYAMINE ELX 0.125/5 Generic AR PA required > 64

HYOSCYAMINE SUB 0.125MG Generic AR PA required > 64

HYOSCYAMINE TAB 0.375 ER Generic AR PA required > 64

HYOSCYAMINE TAB 0.375 SR Generic AR PA required > 64

HYOSYNE DRO 0.125/ML Generic AR PA required > 64

HYOSYNE ELX 0.125/5 Generic AR PA required > 64

IPRATROPIUM SOL 0.02%INH Generic

NULEV TAB 0.125MG Generic AR PA required > 64

OSCIMIN TAB 0.125MG Generic AR PA required > 64

OSCIMIN SUB 0.125MG Generic AR PA required > 64

OSCIMIN SR TAB 0.375MG Generic AR PA required > 64

PROPANTHELIN TAB 15MG Generic AR PA required > 64

SYMAX FASTAB TAB 0.125MG Generic AR PA required > 64

SYMAX‐SL SUB 0.125MG Generic AR PA required > 64

SYMAX‐SR TAB 0.375MG Generic AR PA required > 64

HISTAMINE H2‐ANTAGONISTS ACID CONTROL TAB 10MG Generic

ACID CONTROL TAB 150MG Generic



ACID REDUCER TAB 10MG Generic





ACID RELIEF TAB 200MG Generic

CIMETIDINE SOL 300/5ML Generic

CIMETIDINE TAB 200MG Generic




EQL HEARTBRN TAB 10MG Generic

FAMOTIDINE TAB 10MG Generic



46



HEARTBRN REL TAB 200MG Generic

HEARTBRN REL TAB 75MG Generic

HEARTBURN TAB 150MG Generic

HEARTBURN TAB 20MG Generic

NIZATIDINE SOL 15MG/ML Generic AR PA required > 6

PEPCID AC TAB 20MG Generic

RANITIDINE CAP 150MG Generic

RANITIDINE CAP 300MG Generic

RANITIDINE SYP 150/10ML Generic

RANITIDINE SYP 15MG/ML Generic

RANITIDINE SYP 75MG/5ML Generic

RANITIDINE TAB 150MG Generic



SM ACID REDU TAB 200MG Generic

WAL‐ZAN TAB 150MG Generic

WAL‐ZAN TAB 75MG Generic

WAL‐ZAN 75 TAB Generic

PROSTAGLANDINS MISOPROSTOL TAB 100MCG Generic

MISOPROSTOL TAB 200MCG Generic

PROTECTANTS CARAFATE SUS 1GM/10ML Brand

SUCRALFATE TAB 1GM Generic

PROTON‐PUMP INHIBITORS FIRST‐OMEPRA SUS 2MG/ML Brand AR PA > 6

LANSOPRAZOLE SUS 3MG/ML Brand PA

LANSOPRAZOLE CAP 15MG DR Generic PA QL 1 per day

LANSOPRAZOLE CAP 30MG DR Generic PA QL 1 per day

OMEPRAZOLE CAP 10MG Generic



OMEPRAZOLE + SUS SYRSPEND Brand AR PA Required > 6

PANTOPRAZOLE TAB 20MG Generic QL 1 per day

PANTOPRAZOLE TAB 40MG Generic

RABEPRAZOLE TAB 20MG Generic PA

ANTI‐NAUSEA AMBIZINE TAB 25MG Generic

COMPAZINE SUP 25MG Generic

APREPITANT CAP 40MG Generic PA


47




APREPITANT PAK 80 & 125 Generic PA

COMPRO SUP 25MG Generic

DIMENHYDRIN TAB 50MG Generic

DRAMAMINE TAB 25MG Generic

DRIMINATE TAB 50MG Generic

DRONABINOL CAP 2.5MG Generic PA QL 4 per day

DRONABINOL CAP 5MG Generic PA QL 4 per day

DRONABINOL CAP 10MG Generic PA QL 4 per day

EMEND SUSP 125 MG Brand PA GRANISETRON INJ 0.1MG/ML Generic PA

GRANISETRON INJ 4MG/4ML Generic PA

GRANISETRON INJ 1MG/ML Generic PA

GRANISOL SOL 2MG/10ML Brand PA

MECLIZINE CHW 25MG Generic

MECLIZINE TAB 12.5MG Generic

MECLIZINE TAB 25MG Generic

MEDI‐MECLIZI TAB 25MG Generic

MOTION RELF CHW 25MG Generic

MOTION SICK TAB 50MG Generic

MOTION‐TIME CHW 25MG Generic

ONDANSETRON SOL 4MG/5ML Generic QL 6 per day

ONDANSETRON TAB 4MG ODT Generic QL 3 per day

ONDANSETRON TAB 8MG ODT Generic QL 3 per day

ONDANSETRON TAB 4MG Generic QL 3 per day



PHENADOZ SUP 12.5MG Generic AR PA required < 2

PHENADOZ SUP 25MG Generic AR PA required < 2

PHENERGAN SUP 12.5MG Generic AR PA required < 2

PHENERGAN SUP 25MG Generic AR PA required < 2

PHENERGAN SUP 50MG Generic AR PA required < 2

PROCHLORPER SUP 25MG Generic

PROCHLORPER TAB 5MG Generic

PROCHLORPER TAB 10MG Generic

PROMETHAZINE TAB 12.5MG Generic AR PA required < 2 or > 64

PROMETHAZINE TAB 25MG Generic AR PA required < 2 or > 64

PROMETHAZINE TAB 50MG Generic AR PA required < 2 or > 64

PROMETHAZINE SYP 6.25/5ML Generic AR PA required < 2 or > 64

PROMETHAZINE SOL 6.25/5ML Generic AR PA required < 2 or > 64

PROMETHAZINE INJ 25MG/ML Generic AR PA required < 2


48


PROMETHAZINE INJ 50MG/ML Generic AR PA required < 2

PROMETHAZINE SUP 12.5MG Generic AR PA required < 2

PROMETHAZINE SUP 25MG Generic AR PA required < 2

PROMETHAZINE SUP 50MG Generic AR PA required < 2

PROMETHEGAN SUP 12.5MG Generic AR PA required < 2

PROMETHEGAN SUP 25MG Generic AR PA required < 2

PROMETHEGAN SUP 50MG Generic AR PA required < 2

TRAVEL SICK CHW 25MG Generic

TRAVEL SICK TAB 50MG Generic

TRAV‐TABS TAB 50MG Generic

TRIPTONE TAB 50MG Generic

WAL‐DRAM TAB 50MG Generic

WAL‐DRAM II TAB 25MG Generic

DIGESTANTS CREON CAP 3000UNIT Brand PA

CREON CAP 6000UNIT Brand PA

CREON CAP 12000UNT Brand PA



PANCREAZE CAP 4200UNIT Brand PA

PANCREAZE CAP 10500UNT Brand PA



ZENPEP CAP 3000UNIT Brand PA

ZENPEP CAP 5000UNIT Brand PA

ZENPEP CAP 10000UNT Brand PA





CHOLELITHOLYTIC AGENTS URSODIOL CAP 300MG Generic

URSODIOL TAB 250MG Generic

URSODIOL TAB 500MG Generic

INFLAMMATORY BOWEL AGENTS

APRISO CAP 0.375GM Brand ST (sulfasalazine,

balsalazide)

BALSALAZIDE CAP 750MG Generic

CANASA SUP 1000MG Brand QL 42 per fill

DELZICOL CAP 400MG Brand ST (sulfasalazine,

balsalazide)

MESALAMINE ENE 4GM Generic


49


MESALAMINE (generic Asacol HD) TAB 800MG DR Generic ST (sulfasalazine,

balsalazide); QL 6 per day

MESALAMINE (generic Lialda) TAB 1.2GM Generic ST (sulfasalazine,

balsalazide)

PENTASA CAP 250MG CR Brand ST (sulfasalazine,

balsalazide)

PENTASA CAP 500MG CR Brand ST (sulfasalazine,

balsalazide)

SULFADIAZINE TAB 500MG Generic

SULFASALAZIN TAB 500MG Generic

SULFASALAZIN TAB 500MG DR Generic

SULFAZINE TAB 500MG Generic

SULFAZINE EC TAB 500MG Generic

PHOSPHATE‐REMOVING AGENTS CALCIUM ACETATE CAP 667MG Generic

CALCIUM ACETATE TAB 667MG Generic

FOSRENOL POW 750MG Brand

FOSRENOL POW 1000MG Brand

LANTHANUM CHW 500MG Generic



RENAGEL TAB 400MG Brand

RENAGEL TAB 800MG Brand

SEVELAMER TAB 800MG Generic

SEVELAMER PAK 2.4 GM Generic

SEVELAMER PAK 0.8GM Generic

PROKINETIC AGENTS METOCLOPRAMIDE TAB 5MG Generic

METOCLOPRAMIDE TAB 10MG Generic

METOCLOPRAMIDE INJ 5MG/ML Generic

METOCLOPRAMIDE INJ 10MG/2ML Generic

METOCLOPRAMIDE SOL 5MG/5ML Generic

METOCLOPRAMIDE SOL 10/10ML Generic

GENITOURINARY PRODUCTS INCONTINENCE/URINARY FREQUENCY OXYBUTYNIN TAB 5MG Generic

OXYBUTYNIN SYP 5MG/5ML Generic

OXYBUTYNIN TAB 5MG ER Generic



OXYTROL/WOMN DIS 3.9MG/24 Brand ST

TOLTERODINE TAB 1MG Generic PA


50


TOLTERODINE TAB 2MG Generic PA

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) BETHANECHOL TAB 5MG Generic

BETHANECHOL TAB 10MG Generic



PILOCARPINE TAB 5MG Generic

PYRIDOSTIGMINE BROMIDE TAB 60MG Generic

PYRIDOSTIGMINE BROMIDE TAB 180MG Generic

REGONOL INJ 5MG/ML Brand

CONTRACEPTIVES (E.G. FOAMS, DEVICES) CERVICAL CAP Various Brand QL 1 per 180 days

FEMALE CONDOMS Various Various

MALE CONDOMS Various Various

ORTHO COIL DPR KIT 50 Brand QL 1 per 180 days



ORTHO FLAT DPR KIT 55 Brand QL 1 per 180 days









ORTHO FLEX DPR 65MM Brand QL 1 per 180 days




SPONGE VAGINAL SPONGE Brand

VCF VAGINAL AER CONTRACP Generic

WIDE‐SEAL DPR KIT 60 Brand QL 1 per 180 days








51


VAGINAL ANTI‐INFECTIVES CLEOCIN SUP 100MG Generic

CLINDAMYCIN CRE 2% VAG Generic

METRONIDAZOLE GEL 0.75%VAG Generic

VANDAZOLE GEL 0.75% Generic

ALKALINIZING AGENTS CITRIC ACID/SODIUM CITRATE SOL Generic

CYTRA K CRYSTALS PACK Generic

CYTRA‐2 SOL Generic

CYTRA‐3 SYP Generic

CYTRA‐K SOL Generic

POTASSIUM CITRATE/CITRIC ACID SOL Generic

NEUT INJ 4% Brand

POTASSIUM CITRATE TAB 540MG ER Generic

POTASSIUM CITRATE TAB 1080MG Generic

POTASSIUM CITRATE TAB 1620MG Generic

POTASSIUM CITRATE/CITRIC ACID PACK Generic

SOD BICARB INJ 8.4% Generic



VIRTRATE‐2 SOL 500‐334 Generic

VIRTRATE‐2 SOL Generic

VIRTRATE‐K SOL 1100‐334 Generic

VIRTRATE‐K SOL Generic

IRRIGATING SOLUTIONS ARGYL SALINE SOL 0.9% Generic

ARGYL SALINE SOL 100ML Generic

CURITY SALIN SOL 0.9% IRR Generic

SODIUM CHLOR SOL 0.9% IRR Generic

STERIL WATER SOL IRRIG Generic

MISCL URINARY AGENTS ELMIRON CAP 100MG Brand PA

PHENAZO TAB 200MG Generic

PHENAZOPYRID TAB 100MG Generic

PHENAZOPYRID TAB 200MG Generic

SELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT TAMSULOSIN CAP 0.4MG Generic

CENTRAL NERVOUS SYSTEM DRUGS ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. COMPOZ TAB 50MG Generic AR PA required > 64


52


DIPHENHYDRAM TAB 50MG Generic AR PA required > 64

HYDROXYZINE HCL TAB 10MG Generic AR PA required > 64



HYDROXYZINE HCL SYP 10MG/5ML Generic AR PA required > 64

HYDROXYZINE HCL SOL 10MG/5ML Generic AR PA required > 64

HYDROXYZINE PAMOATE CAP 25MG Generic AR PA required > 64



IBUPROFEN PM TAB 200‐38MG Generic AR PA required > 64

MOTRIN PM TAB 200‐38MG Generic AR PA required > 64

SLEEP AID CAP 50MG Generic AR PA required > 64

SLEEP AID TAB 25MG Generic AR PA required > 64

ZOLPIDEM TAB 5MG Generic PA required > 64 QL 15

per 30 days

ZOLPIDEM TAB 10MG Generic PA required > 64 QL 15

per 30 days

BENZODIAZEPINES CLONAZEPAM TAB 0.5MG Generic PA

CLONAZEPAM TAB 1MG Generic PA

CLONAZEPAM TAB 2MG Generic PA

DIASTAT ACDL GEL 5‐10MG Brand

DIASTAT ACDL GEL 12.5‐20 Brand

DIASTAT PED GEL 2.5M GEL Brand

DIAZEPAM GEL 2.5MG Generic

DIAZEPAM GEL 10MG Generic

DIAZEPAM GEL 20MG Generic

LORAZEPAM INJ 2MG/ML Generic

LORAZEPAM INJ 4MG/ML Generic

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PHENOBARB TAB 15MG Generic AR PA required > 64

PHENOBARB TAB 16.2MG Generic AR PA required > 64

PHENOBARB TAB 30MG Generic AR PA required > 64






PHENOBARB ELX 20MG/5ML Generic AR PA required > 64

PHENOBARB SOL 20MG/5ML Generic AR PA required > 64


53


ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANT AGENTS AMPHETAMINES AMPHETAMINE (Generic Adderall IR) TAB 30MG Generic QL 3 per day

AMPHETAMINE (Generic Adderall XR) CAP 15MG ER Generic Age > 18 not covered QL

1 per day


1 per day

AMPHETAMINE (Generic Adderall IR) TAB 5MG Generic QL 3 per day

AMPHETAMINE (Generic Adderall IR) TAB 7.5MG Generic QL 3 per day


AMPHETAMINE (Generic Adderall IR) TAB 12.5MG Generic QL 3 per day




1 per day


1 per day


1 per day


1 per day


1 per day

DEXTROAMPHETAMINE (Dexedrine IR) TAB 5MG Generic

DEXTROAMPHETAMINE (Dexedrine IR) TAB 10MG Generic

METHYLPHENIDATES DEXMETHYLPHENIDATE TAB 2.5MG Generic

DEXMETHYLPHENIDATE TAB 5MG Generic

DEXMETHYLPHENIDATE TAB 10MG Generic

METHYLPHENIDATE (generic Metadate CD) CAP 10MG Generic AR PA >18






METHYLPHENIDATE TAB 5MG Generic AR PA>64



METHYLPHENIDATE (generic Concerta) TAB 18MG ER Generic AR PA >18; QL 1 per day



METHYLPHENIDATE (generic Concerta) TAB 54MG ER Generic AR PA >18; QL 1 per day QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

54


METHYLPHENIDATE SOL 5MG/5ML Generic AR PA>6

METHYLPHENIDATE SOL 10MG/5ML Generic AR PA>6

METHLPHENIDATE (generic Ritalin LA) CAP 10MG ER Generic AR PA >18; QL 1 per day

METHYLPHENIDATE (generic Ritalin LA) CAP 20MG ER Generic AR PA > 18; QL 1 per day



RESPIRATORY AND CNS STIMULANTS CAFFEINE CIT INJ 60MG/3ML Generic AR PA >1

CAFFEINE CIT SOL 20MG/ML Generic AR PA >1

CAFFEINE CIT SOL 60MG/3ML Generic AR PA >1

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC ALCOHOL DETERRENTS ACAMPRO CAL TAB 333MG Generic PA QL 6 per day

DISULFIRAM TAB 250MG Generic

DISULFIRAM TAB 500MG Generic

ANTIDEMENTIA AGENTS DONEPEZIL TAB 5MG Generic QL 1 per day

DONEPEZIL TAB 10MG Generic QL 1 per day

DONEPEZIL TAB 5MG ODT Generic QL 1 per day

DONEPEZIL TAB 10MG ODT Generic QL 1 per day

GALANTAMINE TAB 4MG Generic



GALANTAMINE CAP 8MG ER Generic



MEMANTINE TAB HCL 5MG Generic PA

MEMANTINE TAB HCL 10MG Generic PA

MEMANTINE HC SOL 2MG/ML Generic PA

NAMENDA XR CAP 7MG Brand PA




NAMENDA XR CAP TITRATIO Brand PA

RIVASTIGMINE CAP 1.5MG Generic

RIVASTIGMINE CAP 3MG Generic

RIVASTIGMINE CAP 4.5MG Generic

RIVASTIGMINE CAP 6MG Generic

MULTIPLE SCLEROSIS AUBAGIO TAB 7MG Brand PA

AUBAGIO TAB 14MG Brand PA


55


AVONEX KIT 30MCG Brand QL 4 per month

AVONEX PEN KIT 30MCG Brand QL 1 per 30 days

AVONEX PREFL KIT 30MCG Brand QL 1 per 30 days

EXTAVIA INJ 0.3MG Brand QL 14 per month

GLATOPA (Generic Copaxone 20 mg) INJ 20MG/ML Generic QL 30 syringes per 30 days

GLATIRAMER (Generic Copaxone 40mg) INJ 40MG/ML Generic QL 12 syringes per 28 days

PLEGRIDY INJ PEN Brand QL 0.036mls per day

PLEGRIDY INJ Brand QL 0.036mls per day

PLEGRIDY INJ STARTER Brand QL 1 per 180 days

PLEGRIDY PEN INJ STARTER Brand QL 1 per 180 days

REBIF INJ 22/0.5 Brand QL 6ml per 30 days

REBIF INJ 44/0.5 Brand QL 6ml per 30 days

REBIF REBIDO INJ 22/0.5 Brand QL 6ml per 30 days

REBIF REBIDO INJ 44/0.5 Brand QL 6ml per 30 days

REBIF REBIDO INJ TITRATN Brand

REBIF TITRTN INJ PACK Brand

TECFIDERA MIS STARTER Brand PA

TECFIDERA CAP 120MG Brand PA

TECFIDERA CAP 240MG Brand PA

ZINBRYTA INJ 150MG/ML Brand PA QL 0.034mls per day

SMOKING DETERRENTS

BUPROBAN TAB 150MG Generic QL 2 per day;180 days per

365 days

CHANTIX PAK 1MG Brand QL 2 per day; max benefit 90 days per 365 days

CHANTIX PAK 0.5& 1MG Brand QL 2 per day; max benefit 90 days per 365 days

CHANTIX TAB 0.5MG Brand QL 2 per day; max benefit 90 days per 365 days

CHANTIX TAB 1MG Brand QL 2 per day; max benefit 90 days per 365 days

NICOTINE GUM 2MG Generic QL 24 pieces per day max 180 days per 365 days

NICOTINE GUM 4MG Generic QL 24 pieces per day; 180

days per 365 days

NICOTINE PATCH 7MG/24HR Generic QL 1 patch per day; 180

days per 365 days

NICOTINE LOZENGE 2MG Generic QL 20 lozenges per day; 180 days per 365 days

NICOTINE LOZENGE 4MG Generic QL 20 lozenges per day; 180 days per 365 days

NICOTINE PATCH 21MG/24H Generic QL 1 patch per day;

180 days per 365 days


56


NICOTINE PATCH 14MG/24H Generic QL 1 patch per day;

180 days per 365 days

NICOTINE SYS KIT TRANSDER Generic

QL 1 patch per day; 180 days per 365 days; 56

day supply per fill

NICOTROL NASAL SPRAY 10MG/ML Brand

PA QL 4mls per day (80 sprays) 180 day supply per

365 days

NICOTROL INHALER 10MG Brand PA QL

16 cartridges per day

ANALGESICS AND ANESTHETICS ANALGESICS AND ANTIPYRETICS, MISC. (List not all encompassing. Representative products listed only)

ACETAMINOPHEN

CAP, CHEW, DROPS, ELIX, GELCAP, SOLN, SUPP,SUSP, TAB Generic

ACETAMINOPHEN/CAFF/PYRILAMINE TAB Generic

SALICYLATES (List not all encompassing. Representative products listed only)

ASPIRIN TAB, CHEW, TAB EC,

SUP Generic

CHILD ASPIRIN CHW 81MG Generic

CHOLINE MAG TRISALICYLATE TAB, LIQ Generic

SALSALATE TAB 500MG Generic

SALSALATE TAB 750MG Generic

OPIATE PARTIAL AGONISTS BUPRENORPHINE/NALOXONE SUB 2‐0.5MG Generic QL 3 per day

BUPRENORPHINE/NALOXONE SUB 8‐2MG Generic QL 3 per day

BUPRENORPHINE SUB 2MG Generic QL 3 per day

BUPRENORPHINE SUB 8MG Generic QL 3 per day

OPIATES APAP/CODEINE TAB 300‐15MG Generic QL 13 per day

APAP/CODEINE TAB 300‐30MG Generic QL 13 per day

APAP/CODEINE TAB 300‐60MG Generic QL 13 per day

APAP/CODEINE SOL 120‐12/5 Generic QL 166mls per day

CODEINE SULF TAB 30MG Generic QL 26 tabs per day

CODEINE SULF TAB 60MG Generic QL 13 tabs per day

DILAUDID‐HP INJ 250MG Brand

ENDOCET TAB 5‐325MG Generic QL 12 per day

ENDOCET TAB 7.5‐325 Generic QL 12 per day

ENDOCET TAB 7.5‐500M Generic QL 8 per day




57


ENDODAN TAB 4.8355‐325MG Generic QL 12 per day

FENTANYL DIS 12MCG/HR Generic PA QL 11 per month


FENTANYL DIS 37.5MCG Generic PA QL 11 per month





FENTANYL DIS 100MCG/H Generic PA QL 11 per month

HYDROCODONE/APAP TAB 10‐325MG Generic QL 12 per day

HYDROCODONE/APAP TAB 2.5‐500 Generic QL 8 per day









HYDROCODONE/APAP SOL 7.5‐325 Generic QL 184mls per day

HYDROCODONE/APAP SOL 5‐217/10 Generic

HYDROCODONE/APAP SOL 7.5‐500 Generic

HYDROCODONE/IBUPROFEN TAB 7.5‐200 Generic QL 16 tabs per day

HYDROMORPHONE INJ 1MG/ML Generic QL 30mls per day




HYDROMORPHONE INJ 50MG/5ML Generic QL 3mls per day

HYDROMORPHONE INJ 500/50ML Generic QL 3mls per day

LORCET TAB 5‐325MG Generic QL 12 per day

LORCET HD TAB 10‐325MG Generic QL 12 per day

LORCET PLUS TAB 7.5‐325 Generic QL 12 per day

LORTAB TAB 10‐325MG Generic QL 12 per day

LORTAB TAB 5‐325MG Generic QL 12 per day

LORTAB TAB 7.5‐325 Generic QL 12 per day

MORPHINE SULFATE TAB 15MG Generic QL 8 tabs per day

MORPHINE SULFATE TAB 30MG Generic QL 4 tabs per day

MORPHINE SULFATE TAB 15MG ER Generic PA QL 3 per day






58


MORPHINE SULFATE INJ 1MG/ML Generic QL 120mls per day




MORPHINE SULFATE INJ 150/30ML Generic QL 24mls per day



MORPHINE SULFATE SOL 10MG/5ML Generic QL 60mls per day

MORPHINE SULFATE SOL 20MG/5ML Generic QL 30mls per day

MORPHINE SULFATE SOL 100/5ML Generic QL 6mls per day

MORPHINE SULFATE SUP 5MG Generic 24 per day




OXYCODONE/APAP CAP 5‐500MG Generic QL 8 per day

OXYCODONE/APAP TAB 5‐325MG Generic QL 12 per day

OXYCODONE/APAP SOLN 5‐325MG/5ML Generic QL 61mls per day

OXYCODONE/APAP TAB 7.5‐325 Generic QL 10 per day

OXYCODONE/APAP TAB 7.5‐500 Generic QL 8 per day



OXYCODONE/ASA TAB Generic QL 12 per day

OXYCODONE TAB 5MG Generic QL 16 per day





OXYCODONE CON 100/5ML Generic QL 4mls per day

OXYCODONE CON 20MG/ML Generic QL 4mls per day

OXYCODONE SOL 5MG/5ML Generic QL 80mls per day

OXYCODONE TAB 10MG ER Generic PA QL 3 per day




OXYCONTIN TAB 10MG CR Brand PA QL 3 per day







ROXICET TAB 5‐325MG Generic QL 12 per day


59


TRAMADL/APAP TAB 37.5‐325 Generic QL 10 per day

TRAMADOL HCL TAB 50MG Generic QL 8 per day

ANTI‐TNF INHIBITORS ENBREL INJ 25MG Brand PA QL 8mls per month

ENBREL INJ 25/0.5ML Brand PA QL 2mls per 31 days

ENBREL INJ 50MG/ML Brand PA QL 4mls per 31 days

ENBREL SRCLK INJ 50MG/ML Brand PA QL 4mls per 31 days

HUMIRA INJ 10MG/0.2 Brand PA QL 2 per 31 days

HUMIRA KIT 20MG/0.4 Brand PA QL 2.4 per 31 days

HUMIRA KIT 40MG/0.8 Brand PA QL 2 per 31 days

HUMIRA PEDIA INJ CROHNS STARTER

PACK Brand PA QL 3 per 180 days

HUMIRA PEN INJ 40MG/0.8 Brand PA QL 2 syringes per

month

HUMIRA PEN INJ CROHNS Brand PA QL 6 syringes per 180

days

HUMIRA PEN INJ PSORIASI Brand PA QL 4 syringes per 180

days

DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS LEFLUNOMIDE TAB 10MG Generic

LEFLUNOMIDE TAB 20MG Generic

OTEZLA TAB 30MG Brand PA QL 2 tabs per day

OTEZLA TAB 10/20/30 Brand PA QL 1 per 180 days

MISCL BIOLOGIC ACTEMRA INJ 162/0.9 Brand PA QL 3.6mls per 31 days

COSENTYX INJ 150MG/ML Brand PA QL 1 per month

COSENTYX PEN INJ 150MG/ML Brand PA QL 1 per month

TALTZ INJ 80MG/ML Brand PA QL 0.036mls per day

NONSTEROIDAL ANTI‐INFLAMMATORY (NSAID) (List not all encompassing. Representative products listed only)

CELECOXIB CAP 100MG Generic PA QL 1 per day

CELECOXIB CAP 200MG Generic PA QL 2 per day

DICLOFEN POTASSIUM TAB 50MG Generic

DICLOFENAC TAB 25MG DR Generic



DICLOFENAC TAB 100MG ER Generic

FLURBIPROFEN TAB 50MG Generic

ETODOLAC CAP 200MG Generic ST (meloxicam)

ETODOLAC CAP 300MG Generic ST (meloxicam)

ETODOLAC TAB 400MG Generic ST (meloxicam)

ETODOLAC TAB 500MG Generic ST (meloxicam)


60


FLURBIPROFEN TAB 100MG Generic

GENPRIL TAB 200MG Generic

IBU‐DROPS DRO 40MG/ML Generic

IBUPROFEN CAP 200MG Generic

IBUPROFEN TAB 200MG Generic




IBUPROFEN DRO 50/1.25 Generic

IBUPROFEN SUS 100/5ML Generic

IBUPROFEN IB TAB 200MG Generic

IBUPROFEN JR CHW 100MG Generic

INDOCIN SUS 25MG/5ML Brand

INDOMETHACIN CAP 25MG Generic AR PA required > 64

INDOMETHACIN CAP 50MG Generic AR PA required > 64

INDOMETHACIN CAP 75MG ER Generic AR PA required > 64

KETOPROFEN CAP 50MG Generic

KETOPROFEN CAP 75MG Generic

MEDI‐PROFEN CAP 200MG Generic

MEDI‐PROFEN TAB 200MG Generic

MEDI‐PROFEN SUS 40MG/ML Generic

MEDI‐PROFEN SUS 100/5ML Generic

MELOXICAM TAB 7.5MG Generic QL 2 per day

MELOXICAM TAB 15MG Generic

MIDOL CAP 200MG Generic

NABUMETONE TAB 500MG Generic

NABUMETONE TAB 750MG Generic

NAPROXEN TAB 250MG Generic



NAPROXEN SUS 125/5ML Generic

PROVIL TAB 200MG Generic

SULINDAC TAB 150MG Generic

SULINDAC TAB 200MG Generic

MIGRAINE PRODUCTS DIHYDROERGOT INJ 1MG/ML Generic

DIHYDROERGOT SPR 4MG/ML Generic QL 24mls per 30 days

ERGOMAR SUB 2MG Brand

TRIPTANS NARATRIPTAN TAB 1MG Generic QL 9 per 30 days

NARATRIPTAN TAB 2.5MG Generic QL 9 per 30 days

RIZATRIPTAN TAB 5MG Generic QL 12 per 30 days


61


RIZATRIPTAN TAB 10MG Generic QL 12 per 30 days

SUMATRIPTAN SPR 5MG/ACT Generic QL 6 per 30 days

SUMATRIPTAN SPR 20MG/ACT Generic QL 6 per 30 days

SUMATRIPTAN TAB 25MG Generic QL 9 per 30 days



SUMATRIPTAN INJ 4MG/0.5 Generic

SUMATRIPTAN INJ 6MG/0.5 Generic QL 3mls per 30 days

ZOLMITRIPTAN TAB 2.5MG Generic QL 12 per 30 days

ZOLMITRIPTAN TAB 5MG Generic QL 12 per 30 days

ANTIGOUT AGENTS ALLOPURINOL TAB 100MG Generic

ALLOPURINOL TAB 300MG Generic

COLCHICINE TAB 0.6MG Generic

COLCRYS TAB 0.6MG Brand

URICOSURIC AGENTS PROBEN/COLCH TAB 500‐0.5 Generic

PROBENECID TAB 500MG Generic

CARBAMAZEPINE TAB 200MG Generic

CARBAMAZEPINE CHW 100MG Generic

CARBAMAZEPINE SUS 100/5ML Generic

CARBAMAZEPINE CAP 100MG ER Generic



CARBAMAZEPINE TAB 100MG ER Generic



CELONTIN CAP 300MG Brand

DILANTIN CHW 50MG Brand

DILANTIN CAP 30MG Brand

DILANTIN CAP 100MG Brand

DILANTIN‐125 SUS 125/5ML Brand

EPITOL TAB 200MG Generic

ETHOSUXIMIDE CAP 250MG Generic

ETHOSUXIMIDE SOL 250/5ML Generic

FELBAMATE TAB 400MG Generic

FELBAMATE TAB 600MG Generic

FELBAMATE SUS 600/5ML Generic

FOSPHENYTOIN INJ 100/2ML Generic

FOSPHENYTOIN INJ 500/10ML Generic

GABAPENTIN CAP 100MG Generic



62



GABAPENTIN TAB 600MG Generic

GABAPENTIN TAB 800MG Generic

GABAPENTIN SOL 250/5ML Generic

GABITRIL TAB 12MG Brand

GABITRIL TAB 16MG Brand

LEVETIRACETA SOL 100MG/ML Generic

LEVETIRACETA TAB 500MG Generic



LEVETIRACETA SOL 100MG/ML Generic

LEVETIRACETA SOL 500/5ML Generic

LEVETIRACETA TAB 500MG ER Generic

LEVETIRACETA TAB 750MG ER Generic

LYRICA CAP 150MG Brand PA QL 3 per day








LYRICA SOL 20MG/ML Brand PA

OXCARBAZEPIN TAB 150MG Generic



OXCARBAZEPIN SUS 300MG/5M Generic AR PA > 6 years of age

OXCARBAZEPIN SUS 300MG/5M Generic AR PA > 6 years of age

PEGANONE TAB 250MG Brand

PHENYTOIN CHW 50MG Generic

PHENYTOIN SUS 125/5ML Generic

PHENYTOIN INJ 50MG/ML Generic

PHENYTOIN EX CAP 100MG Generic



PRIMIDONE TAB 50MG Generic

PRIMIDONE TAB 250MG Generic

SABRIL TAB 500MG Brand PA

SABRIL POW 500MG Brand PA

TIAGABINE TAB 2MG Generic

TIAGABINE TAB 4MG Generic

TOPIRAGEN TAB 25MG Generic


63





TOPIRAMATE TAB 25MG Generic




TOPIRAMATE CAP 15MG Generic

TOPIRAMATE CAP 25MG Generic

TRILEPTAL SUS 300MG/5M Brand AR PA > 6 years of age

VIMPAT TAB 100MG Brand PA; QL 2 tabs per day

VIMPAT TAB 150MG Brand PA



VIMPAT INJ 200MG/20 Brand PA

VIMPAT SOL 10MG/ML Generic PA

ZONISAMIDE CAP 25MG Generic



NEUROMUSCULAR DRUGS ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE TAB 0.5MG Generic AR PA required >64

BENZTROPINE TAB 1MG Generic AR PA required >64

BENZTROPINE TAB 2MG Generic AR PA required >64

BENZTROPINE INJ 1MG/ML Generic

TRIHEXYPHEN TAB 2MG Generic AR PA required >64

TRIHEXYPHEN TAB 5MG Generic AR PA required >64

TRIHEXYPHEN ELX 0.4MG/ML Generic AR PA required >64

ANTIPARKINSON ENTACAPONE TAB 200MG Generic

SELEGILINE CAP 5MG Generic

SELEGILINE TAB 5MG Generic

TOLCAPONE TAB 100MG Generic

DOPAMINERGICS BROMOCRIPTIN CAP 5MG Generic

BROMOCRIPTIN TAB 2.5MG Generic

CARBIDOPA/LEVODOPA TAB 10‐100MG Generic



CARBIDOPA/LEVODOPA ER TAB 25‐100MG Generic

CARBIDOPA/LEVODOPA ER TAB 50‐200MG Generic


64


PRAMIPEXOLE TAB 0.125MG Generic QL 3 per day




PRAMIPEXOLE TAB 1MG Generic QL 3 per day


ROPINIROLE TAB 0.25MG Generic

ROPINIROLE TAB 0.5MG Generic

ROPINIROLE TAB 1MG Generic





CENTRAL NERVOUS SYSTEM AGENTS, MISC. RILUZOLE TAB 50MG Generic

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT BACLOFEN TAB 10MG Generic

BACLOFEN TAB 20MG Generic

CHLORZOXAZONE TAB 500MG Generic AR PA required >64

CYCLOBENZAPRINE TAB 5MG Generic AR PA required >64

CYCLOBENZAPRINE TAB 10MG Generic AR PA required >64

METHOCARBAMOL TAB 500MG Generic AR PA required >64

METHOCARBAMOL TAB 750MG Generic AR PA required >64

TIZANIDINE TAB 2MG Generic

TIZANIDINE TAB 4MG Generic

DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS DANTROLENE CAP 25MG Generic

DANTROLENE CAP 50MG Generic

DANTROLENE CAP 100MG Generic

NUTRITIONAL PRODUCTS VITAMIN B COMPLEX B1 NATURAL TAB 250MG Brand

CYANOCOBALAM INJ 1000MCG Generic

ENDUR‐ACIN TAB 250MG SR Generic

ENDUR‐ACIN TAB 500MG SR Generic

EQL B‐12 TAB 1000MCG Generic

FOLIC ACID TAB 400MCG Generic 90 day supply available


FOLIC ACID TAB 1MG Generic 90 day supply available


FOLIC ACID INJ 5MG/ML Generic 90 day supply available


65


FOLIC ACID TAB XTRA Brand 90 day supply available

NIACIN CAP 250MG TR Generic

NIACIN CAP 250MG TD Generic

NIACIN CAP 250MG ER Generic

NIACIN CAP 250MG SR Generic

NIACIN CAP 500MG TR Generic

NIACIN CAP 500MG SR Generic

NIACIN TAB 50MG Generic




NIACIN TAB 250MG SR Generic

NIACIN TAB 500MG CR Generic

NIACIN TAB 500MG ER Generic

NIACIN TAB 500MG PR Generic

NIACIN TAB 750MG TR Generic

NIACIN ER CAP 250MG Generic

NIACIN ER CAP 500MG Generic

NIACIN TR TAB 1000MG Generic

NIACINAMIDE TAB 100MG Generic

NIACINAMIDE TAB 500MG Generic

PYRIDOXINE TAB 25MG Generic



SLO‐NIACIN TAB 250MG CR Generic

THIAMINE HCL TAB 100MG Generic

VITAMIN B‐1 TAB 50MG Generic

VITAMIN B‐1 TAB 100MG Generic

VITAMIN B‐12 TAB 50MCG Generic






VITAMIN B‐12 TAB 1000 CR Generic

VITAMIN B‐12 TAB 1000 TR Generic

VITAMIN B‐12 SUB 500MCG Generic

VITAMIN B‐12 SUB 1000MCG Generic

MULTIVITAMIN PREPARATIONS ACD/FLUORIDE DRO 0.25MG Generic AR PA required > 2

B COMPLEX WITH VITAMIN C TAB Generic

B COMPLEX W/C & FOLIC ACID TAB Generic


66


BIOTIN FORTE TAB Brand

BPROTECTED SOL TRI‐VITE Generic AR PA required > 2

CALCIUM SOFT CHEW Generic

CALNA TAB Brand AR PA required >50;

covered for females only

CAVAN‐EC SOD MIS DHA Generic AR PA required >50;


CENTRUM SPEC PAK PRENATAL Brand AR PA required >50;


CHEW CALCIUM CHW Generic

CITRANATAL PAK DHA Brand AR PA required >50;


CITRANATAL PAK ASSURE Brand AR PA required >50;


CL PRENATAL TAB 28‐0.8MG Generic AR PA required >50;


COMP PRNATAL MIS DHA Generic AR PA required >50;


COMPL PRENAT MIS +DHA Brand AR PA required >50;


COMPLETENATE CHW Generic AR PA required >50;


CO‐NATAL FA TAB 29‐1MG Generic AR PA required >50;


CONCEPT OB CAP Brand AR PA required >50;


CVS PRENATAL TAB 28‐0.8MG Brand AR PA required >50;


CVS PRENATAL TAB Generic AR PA required >50;


CVS STRESS TAB FORMULA Generic

CVS SUPER B TAB COMPLX/C Generic

DIALYVITE TAB 800 Generic

DIALYVITE TAB Generic

DIALYVITE/ TAB ZINC Brand

ELITE‐OB TAB Generic AR PA required >50;


ENFAMIL MIS EXPECTA Brand AR PA required >50;


EQL PRENATAL TAB FORMULA Generic AR PA required >50;


FOCALGIN CA MIS Brand AR PA required >50;



67


FOLCAPS CAP OMEGA 3 Brand AR PA required >50;


FOLIVANE‐OB CAP Brand AR PA required >50;


FOLIVANE‐PRX CAP DHA NF Brand AR PA required >50;


FULL SPECT TAB B/ VIT C Generic

GESTICARE PAK DHA Brand AR PA required >50;


GNP PRENATAL TAB 28‐0.8MG Generic AR PA required >50;


GOODSENSE TAB 28‐0.8MG Brand AR PA required >50;


HM B COMPLEX TAB WITH C Generic

HM PRENATAL TAB Brand AR PA required >50;


INATAL ADV TAB Generic AR PA required >50;


INATAL GT TAB Generic AR PA required >50;


INATAL ULTRA TAB Generic AR PA required >50;


KP B COMPLEX TAB /C Generic

KP PRENATAL TAB MULTIVIT Brand AR PA required >50;


KPN PRENATAL TAB Brand AR PA required >50;


MISSION PREN TAB Brand AR PA required >50;


MISSION PREN TAB HP Generic AR PA required >50;


MULTI PRENAT TAB Generic AR PA required >50;


MULTI‐VIT/FE DRO /FL 0.25 Generic AR PA required > 2

MULTI‐VIT/FL DRO 0.25MG Generic AR PA required > 2

MULTI‐VIT/FL DRO 0.5MG/ML Generic AR PA required > 2

MULTI‐VIT/FL DRO /FE 0.25 Generic AR PA required > 2

M‐VIT TAB 27‐1MG Generic AR PA required >50;


MYNATAL CAP Brand AR PA required >50;


MYNATAL TAB Generic AR PA required >50;



68


MYNATAL TAB ADVANCE Generic AR PA required >50;


MYNATAL PLUS TAB Generic AR PA required >50;


MYNATAL‐Z TAB Generic AR PA required >50;


MYNEPHROCAPS CAP Generic

NATAL‐V RX TAB 29‐1MG Brand AR PA required >50;


NATALVIRT CA PAK Brand AR PA required >50;


NATALVIT TAB 75‐1MG Brand AR PA required >50;


NEPHPLEX RX TAB Brand

NEPHRONEX TAB 1MG Generic

NEPHRO‐VITE TAB Brand

NIVA‐PLUS TAB Brand AR PA required >50;


NOVAFERRUM DRO 10MG/ML Generic AR PA required > 2

OB COMPLETE TAB Brand AR PA required >50;


OB‐NATAL ONE CAP 27‐1MG Generic AR PA required >50;


O‐CAL TAB PRENATAL Brand AR PA required >50;


O‐CAL FA TAB Brand AR PA required >50;


PNV FE FUM TAB DOC/FA Brand AR PA required >50;


PNV FOLIC AC TAB + IRON Brand AR PA required >50;


PNV OB+DHA PAK Brand AR PA required >50;


PNV PRENATAL TAB PLUS Brand AR PA required >50;


PNV TABS TAB 29‐1MG Brand AR PA required >50;


PNV‐DHA CAP Generic AR PA required >50;


PNV‐SELECT TAB Brand AR PA required >50;


PNV‐VP‐U CAP 106.5‐1 Brand AR PA required >50;



69


POLY‐VI‐SOL DRO Brand AR PA required > 2

POLY‐VI‐SOL DRO/IRON Brand AR PA required > 2

POLY‐VITA DRO Generic AR PA required > 2

POLY‐VITA DRO/IRON Generic AR PA required > 2

POLYVITAMIN DRO Generic AR PA required > 2

POLYVITAMIN DRO/IRON Generic AR PA required > 2

POLY‐VITE DRO Generic AR PA required > 2

POLY‐VITE SOL/IRON Generic AR PA required > 2

PRENAISSANCE PAK DHA Brand AR PA required >50;


PRENAISSANCE PAK PROMISE Brand AR PA required >50;


PRENAPLUS TAB Generic AR PA required >50;


PRENAT PLUS TAB 27‐1MG Brand AR PA required >50;


PRENATABS FA TAB Generic AR PA required >50;


PRENATABS RX TAB Generic AR PA required >50;


PRENATAL TAB Generic AR PA required >50;


PRENATAL TAB FORTE Generic AR PA required >50;


PRENATAL TAB VITAMINS Generic AR PA required >50;


PRENATAL TAB PLUS FE Brand AR PA required >50;


PRENATAL TAB COMPLETE Brand AR PA required >50;


PRENATAL TAB 27‐0.8MG Generic AR PA required >50;


PRENATAL TAB LOW IRON Generic AR PA required >50;


PRENATAL TAB 27‐1MG Brand AR PA required >50;


PRENATAL TAB PLUS Brand AR PA required >50;


PRENATAL TAB 28‐0.8MG Generic AR PA required >50;


PRENATAL TAB FORMULA Generic AR PA required >50;



70


PRENATAL TAB PLUS DHA Brand AR PA required >50;


PRENATAL 1 CAP Brand AR PA required >50;


PRENATAL 19 CHW 29‐1MG Brand AR PA required >50;


PRENATAL 19 CHW TAB Generic AR PA required >50;


PRENATAL 19 TAB 29‐1MG Brand AR PA required >50;


PRENATAL AD TAB Generic AR PA required >50;


PRENATAL FRM TAB A‐FREE Brand AR PA required >50;


PRENATAL MV MIS + DHA Brand AR PA required >50;


PRENATAL VIT TAB 28‐0.8MG Generic AR PA required >50;


PRENATAL/FE TAB Generic AR PA required >50;


PRENATAL+DHA MIS Brand AR PA required >50;


PRENATAL+DHA MIS WOMENS Brand AR PA required >50;


PRENATAL+FE TAB 29‐1MG Brand AR PA required >50;


PRENATAL‐U CAP 106.5‐1 Generic AR PA required >50;


PRENATL MULT CAP + DHA Brand AR PA required >50;


PREPLUS TAB 27‐1MG Brand AR PA required >50;


PRETAB TAB 29‐1MG Brand AR PA required >50;


PX PRENATAL TAB MULTIVIT Generic AR PA required >50;


QC PRENATAL TAB 28‐0.8MG Brand AR PA required >50;


QUFLORA PED DRO 0.25MG Generic AR PA required > 2

QUFLORA PED DRO 0.5MG/ML Generic AR PA required > 2

RA CALCIUM CHW CARAMEL Generic

RA CALCIUM CHW MLK CHOC Generic


71


RA PRENATAL TAB FORMULA Brand AR PA required >50;


RA PRENATAL TAB 28‐0.8MG Generic AR PA required >50;


RENAL CAP SOFTGEL Generic

RENAL TAB MULTIVIT Generic

RENALPREN CAP Generic

RENA‐VITE TAB Generic

RENA‐VITE RX TAB Generic

RENO CAP Generic

RULAVITE DHA CAP Brand AR PA required >50;


SE‐NATAL 19 CHW Generic AR PA required >50;


SE‐TAN DHA CAP Generic AR PA required >50;


SIMILAC PREN PAK EARLY SH Brand AR PA required >50;


SM CALCIUM CHW Generic

SM PRENATAL TAB VITAMINS Generic AR PA required >50;


STRESS 500 TAB B‐COMPLE Generic

STRESS FORM TAB Generic

STUART PREN TAB Brand AR PA required >50;


SUPER B‐COMP TAB VIT C/FA Generic

SUPER B‐COMP TAB /VIT C Generic

SUPERPLEX‐T TAB Generic

TH PRENATAL TAB VITAMINS Brand AR PA required >50;


THERANATAL MIS COMPLETE Brand AR PA required >50;


THERANATAL MIS PLUS Brand AR PA required >50;


THRIVITE 19 TAB Brand AR PA required >50;


THRIVITE RX TAB 29‐1MG Brand AR PA required >50;


TOTAL B/C TAB Generic

TRIADVANCE TAB Generic AR PA required >50;


TRICARE TAB PRENATAL Generic AR PA required >50;



72


TRINATAL TAB ULTRA Brand AR PA required >50;


TRINATAL GT TAB Brand AR PA required >50;


TRINATAL RX TAB 1 Generic AR PA required >50;


TRINATE TAB Generic AR PA required >50;


TRIPHROCAPS CAP Generic

TRI‐VI‐SOL SOL Brand

TRI‐VIT/FL DRO 0.25MG Generic AR PA required > 2

TRI‐VIT/FL DRO 0.5MG Generic AR PA required > 2

TRI‐VIT/FLUO DRO 0.25MG Generic AR PA required > 2

TRI‐VIT/FLUO DRO 0.5MG Generic AR PA required > 2

TRI‐VITA SOL Generic AR PA required > 2

TRI‐VITA/FL DRO 0.25MG Generic AR PA required > 2

TRI‐VITAMIN DRO Generic AR PA required > 2

ULTIMATECARE CAP ONE Generic AR PA required >50;


ULTRA TABS TAB Generic AR PA required >50;


VENATAL‐FA TAB Brand AR PA required >50;


VINATE AZ EX TAB Brand AR PA required >50;


VINATE CAL TAB Brand AR PA required >50;


VINATE GT TAB Generic AR PA required >50;


VINATE IC CAP Generic AR PA required >50;


VINATE II TAB Generic AR PA required >50;


VINATE ONE TAB Generic AR PA required >50;


VINATE ULTRA TAB Generic AR PA required >50;


VIRT NATE TAB Brand AR PA required >50;


VIRT NATE TAB 28‐1MG Brand AR PA required >50;


VIRT‐ADVANCE TAB 90‐1MG Brand AR PA required >50;



73


VIRT‐CAPS CAP Generic

VIRT‐CARE CAP ONE Brand AR PA required >50;


VIRT‐PN TAB Brand AR PA required >50;


VIRT‐PN DHA CAP Brand AR PA required >50;


VIRT‐VITE GT TAB 90‐1MG Brand AR PA required >50;


VITA‐BEE/C TAB Generic

VITAFOL‐OB TAB 65‐1MG Generic AR PA required >50;


VITAFOL‐PN TAB Brand AR PA required >50;


VOL‐CARE RX TAB Generic

VOL‐NATE TAB Brand AR PA required >50;


VOL‐PLUS TAB Brand AR PA required >50;


VOL‐TAB RX TAB Brand AR PA required >50;


VP‐ERA OB PAK PLUS Brand AR PA required >50;


VP‐VITE RX TAB Generic

ZATEAN‐PN TAB Brand AR PA required >50;


ZATEAN‐PN CAP DHA Brand AR PA required >50;


FLUORIDE CAVAREST GEL 1.1% Generic AR > 18 not covered

CONTROLRX CRE 1.1% Generic AR > 18 not covered

DENTA 5000 CRE PLUS Generic AR > 18 not covered

DENTA 5000 CRE PLUS 2PK Generic AR > 18 not covered

DENTAGEL GEL 1.1% Generic AR > 18 not covered

FLUORABON DRO Brand AR > 18 not covered

FLUOR‐A‐DAY DRO 0.125MG Generic AR > 18 not covered

FLUOR‐A‐DAY CHW 0.25MG F Brand AR > 18 not covered

FLUOR‐A‐DAY CHW 0.5MG F Brand AR > 18 not covered

FLUOR‐A‐DAY CHW 1MG F Brand AR > 18 not covered

FLUORIDE CHW 0.25MG F Generic AR > 18 not covered

FLUORIDE CHW 0.5MG F Generic AR > 18 not covered

FLUORIDE CHW 1MG F Generic AR > 18 not covered


74


FLUORIDEX GEL 1.1% Generic AR > 18 not covered

FLUORIDEX GEL WHITENIN Generic AR > 18 not covered

FLUORITAB CHW 0.25MG F Generic AR > 18 not covered

FLUORITAB CHW 0.5MG F Generic AR > 18 not covered

FLUORITAB CHW 1MG F Generic AR > 18 not covered

FLUORITAB CHW 2.2MG Generic AR > 18 not covered

FLUORITAB DRO 0.125MG Generic AR > 18 not covered

FLURA‐DROPS DRO 0.125MG Generic AR > 18 not covered

FLURA‐DROPS DRO 0.25MG F Generic AR > 18 not covered

KARIDIUM DRO 0.125MG Generic AR > 18 not covered

KARIGEL GEL 0.5% Generic AR > 18 not covered

KARIGEL‐N GEL 1.1% Generic AR > 18 not covered

LUDENT CHW 0.25MG F Generic AR > 18 not covered

LUDENT CHW 0.5MG F Generic AR > 18 not covered

LUDENT CHW 1MG F Generic AR > 18 not covered

NAFRINSE CHW 1MG F Generic AR > 18 not covered

NAFRINSE DRO 0.125MG Generic AR > 18 not covered

NEUTRAGARD GEL 1.1% Generic AR > 18 not covered

PHOS‐FLUR GEL 1.1% Generic AR > 18 not covered

SF GEL 1.1% Generic AR > 18 not covered

SF 5000 PLUS CRE 1.1% Generic AR > 18 not covered

SOD FLUORIDE CHW 0.25MG F Generic AR > 18 not covered

SOD FLUORIDE CHW 0.5MG F Generic AR > 18 not covered

SOD FLUORIDE CHW 1.1MG Generic AR > 18 not covered

SOD FLUORIDE CHW 1MG F Generic AR > 18 not covered

SOD FLUORIDE CHW 2.2MG Generic AR > 18 not covered

SOD FLUORIDE DRO 0.5MG/ML Generic AR > 18 not covered

REPLACEMENT PREPARATIONS CALCIUM CARBONATE CHW 500MG Generic

CALCIUM CARBONATE CHW 600‐400 Generic

CALCIUM W/VIT D & POTASSIUM CHEW TAB 500MG‐100 Generic

CALCIUM/PLUS D TAB Generic

CALCIUM CITRATE TAB Generic

CALCIUM W/VIT D TAB 600MG‐200 Generic

CALCIUM CITRATE PLUS VIT D TAB Generic

CALCIUM PLUS D/ MINERALS TAB Generic

CALCIUM PLUS D3 TAB Generic

CALCIUM CARBONATE CHEW TAB Generic

CALCIUM CARBONATE 1250/5ML SUSP Generic

CALCIUM CARBONATE TAB Generic

CALCIUM CITRATE PLUS VITAMIN D TAB Generic

CALCIUM GLUCONATE TAB Generic


75


CALCIUM LACTATE TAB Generic

CERALYTE 70 LIQ Brand

CERASPORT SOL Brand

CERASPORT SOL EX1 Brand

CIT CALC/D TAB 200‐250 Generic

CIT CALC/D TAB 315‐250 Generic

D5W/NACL INJ 0.45% Generic

D5W/NACL INJ 0.9% Generic

EFFER‐K TAB 25MEQ EF Generic

ENFALYTE SOL Brand

ENFAMIL SOL ENFALYTE Brand

FLUSH SYRING INJ 0.9% Generic

GERBER SOL REPLENSH Generic

GNP CALCIUM TAB 500/D Generic

K‐EFFERVESCE TAB 25MEQ EF Generic

KLOR‐CON 10 TAB 10MEQ ER Generic

KLOR‐CON 8 TAB 8MEQ ER Generic

KLOR‐CON M10 TAB 10MEQ ER Generic

KLOR‐CON M20 TAB 20MEQ ER Generic

KLOR‐CON SPR CAP 8MEQ Generic

KLOR‐CON SPR CAP 10MEQ Generic

KLOR‐CON/EF TAB 25MEQ EF Generic

KLOR‐CON/EF TAB 25MEQ FR Generic

KP CALCIUM TAB 600+D Generic

K‐PHOS TAB Brand

K‐PRIME TAB 25MEQ EF Generic

K‐SOL SOL 10% Generic

K‐SOL SOL 20% Generic

K‐VESCENT TAB 25MEQ EF Generic

K‐VESCENT POW 20MEQ Generic

LIQ CA/VIT D CAP 600MG Generic

MAG OXIDE TAB 400MG Generic

NATURALYTE SOL Generic

NORML SALINE INJ IV FLUSH Generic

ORAL ELECTRO SOL H‐E‐B Generic

ORALYTE SOL Generic

OS‐CAL CHW 500‐600 Generic

OS‐CAL 500 CHW Generic

OSCAL TAB 500/200 D‐3 Generic

OYS SHELL CA TAB 500MG Generic

OYS SHELL+D TAB 250‐125 Generic

OYS SHELL+D CHW 500‐400 Generic


76


OYSCO 500 + D CHW Generic

OYST CAL/D TAB 250MG Generic

OYST CAL/D TAB 500MG Generic

OYST SHELL/D TAB 250MG Generic


OYST SHELL/D TAB 500‐200 Generic




PEDIALYTE SOL Brand

PHOSPHA 250 TAB NEUTRAL Generic

POT ACETATE INJ 2MEQ/ML Generic

POT ACETATE INJ 4MEQ/ML Generic

POT CHLORIDE CAP 8MEQ ER Generic

POT CHLORIDE CAP 10MEQ ER Generic

POT CHLORIDE TAB 8MEQ ER Generic

POT CHLORIDE TAB 8MEQ SR Generic


POT CHLORIDE TAB 10MEQ CR Generic


POT CHLORIDE INJ 2MEQ/ML Generic

POT CHLORIDE INJ 10MEQ Generic



POT CHLORIDE SOL 10% SF Generic

POT CHLORIDE SOL 10% Generic

POT CHLORIDE SOL 20% SF Generic

POT CHLORIDE SOL 20% Generic

POT CHLORIDE TAB 25MEQ EF Generic

POT CL MICRO TAB 10MEQ ER Generic

POT CL MICRO TAB 10MEQ CR Generic

POT CL MICRO TAB 20MEQ ER Generic

POT GLUCONAT TAB 2MEQ Generic

POT GLUCONAT TAB 550MG Generic

POT GLUCONAT TAB 2.5MEQ Generic



POTASSIUM TAB 99MG Generic

SALINE FLUSH INJ 0.9% Generic

SALINE FLUSH INJ ZR 0.9% Generic

SOD CHLORIDE INJ 0.45% Generic



77


SOD CHLORIDE INJ 3% Generic

SOD CHLORIDE INJ 5% Generic


SOD CHLORIDE INJ 4MEQ/ML Generic

SOD CHLORIDE INJ 2.5/ML Generic

TH CALCIUM/D TAB 600‐400 Generic

VIRT‐PHOS TAB 250 NEUT Generic

CALORIC AGENTS (most nutritional supplements covered with prior authorization required; not all products listed)

BOOST PA

ENSURE PA

GLUCERNA PA

PEDIASURE PA

DEXTROSE INJ 5% Generic

DEXTROSE INJ 5% PGBK Generic








HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ARANESP INJ 25MCG Brand PA

ARANESP INJ 40MCG Brand PA








EPOGEN INJ 2000/ML Brand PA





NEULASTA INJ 6MG/0.6M Brand PA QL 0.6mls per 31 days

NEULASTA KIT 6MG/0.6M Brand PA QL 0.6mls per 31 days


78


PROCRIT INJ 2000/ML Brand PA






PROMACTA TAB 12.5MG Brand PA

PROMACTA TAB 25MG Brand PA



ZARXIO (NEUPOGEN BIOSIMILAR) INJ 300 MCG/0.5ML Brand PA

ZARXIO (NEUPOGEN BIOSIMILAR) INJ 480 MCG/0.8ML Brand PA

IRON PREPARATIONS FE GLUCONATE TAB 325MG Generic

FE TABS TAB 325MG EC Generic

FEOSOL TAB 65MG Generic

FERATE TAB 27MG Generic

FERATE TAB 28MG Generic

FERGON TAB 27MG Generic

FER‐IRON DRO 15MG/ML Generic

FEROSUL ELX 220/5ML Generic

FERREX 150 CAP 150MG Generic

FERRIC X‐150 CAP 150MG Generic

FERRO‐BOB TAB 325MG Generic

FERROTABS TAB Generic

FERROUS DRO 15MG/ML Generic

FERROUS GLUCONATE TAB 240MG Generic




FERROUS SULFATE LIQ 220/5ML Generic

FERROUS SULFATE TAB 325MG Generic

FERROUS SULFATE TAB 325MG FC Generic

FERROUS SULFATE TAB 5GR Generic

FERROUS SULFATE TAB 324MG EC Generic

FERROUS SULFATE TAB 325MG EC Generic

FERROUS SULFATE ELX 220/5ML Generic

FERROUS SULFATE SYP 300/5ML Generic

FERROUS SULFATE DRO 15MG/ML Generic

FERUS CAP 150MG Generic

IFEREX 150 CAP Generic

IRON TAB 65MG Generic


79





IRON SUPPLEM TAB THERAPY Generic

IRON SUPPLMT DRO 15MG/ML Generic

IRON THERAPY TAB 200MG Generic

MYFERON 150 CAP 150MG Generic

NEPHRON FA TAB Brand

NU‐IRON 150 CAP 150MG Generic

PEDIA IRON DRO 15MG/ML Generic

POLY‐IRON CAP 150MG Generic

SLOW IRON TAB 160MG CR Generic

SLOW REL FE TAB 143MG CR Brand

SLOW REL FE TAB 160MG CR Generic

SLOW RELEASE TAB 143MG Generic

SLOW RELEASE TAB 47.5MG Generic

SM IRON TAB 325MG Generic

SM IRON SLOW TAB 160MG CR Generic

TH IRON TAB 65MG Generic

ANTICOAGULANTS COUMADIN TAB 1MG Brand

COUMADIN TAB 2MG Brand

COUMADIN TAB 2.5MG Brand





COUMADIN TAB 7.5MG Brand


COUMADIN INJ 5 MG Brand

ELIQUIS TAB 2.5MG Brand QL 2 per day

ELIQUIS TAB 5MG Brand QL 2 per day

ENOXAPARIN INJ 30/0.3ML Generic QL 0.6mls per day; 14 day

supply per fill


supply per fill


supply per fill


supply per fill

ENOXAPARIN INJ 100MG/ML Generic QL 2mls per day; 14 day

supply per fill


80


ENOXAPARIN INJ 120/0.8 Generic QL 1.6mls per day; 14 day

supply per fill

ENOXAPARIN INJ 150MG/ML Generic QL 2mls per day; 14 day

supply per fill

ENOXAPARIN INJ 300/3ML Generic 14 day supply per fill

FONDAPARINUX INJ 2.5/0.5 Generic QL 0.5mls per day

FONDAPARINUX INJ 5/0.4ML Generic QL 0.4mls per day

FONDAPARINUX INJ 7.5/0.6 Generic QL 0.6mls per day

FONDAPARINUX INJ 10/0.8ML Generic QL 0.8mls per day

FRAGMIN INJ 10000/ML Brand QL 10mls per 30 days

FRAGMIN INJ 2500/0.2 Brand QL 2mls per 30 days



FRAGMIN INJ 12500UNT Brand QL 5mls per 30 days

FRAGMIN INJ 15000UNT Brand QL 6mls per 30 days

FRAGMIN INJ 18000UNT Brand QL 7.2mls per 30 days

FRAGMIN INJ 25000/ML Brand QL 10mls per 30 days

FRAGMIN INJ 95000UNT Brand

HEPARIN SOD INJ 1000/ML Generic


HEPARIN SOD INJ 5000/0.5 Generic



JANTOVEN TAB 1MG Generic


JANTOVEN TAB 2.5MG Generic





JANTOVEN TAB 7.5MG Generic


PRADAXA CAP 75MG Brand QL 2 per day

PRADAXA CAP 110MG Brand QL 2 per day;

#70 per 180 days

PRADAXA CAP 150MG Brand QL 2 per day

WARFARIN TAB 1MG Generic


WARFARIN TAB 2.5MG Generic






81


WARFARIN TAB 7.5MG Generic

WARFARIN SOD TAB 10MG Generic


XARELTO TAB 10MG Brand QL 1 per day

XARELTO TAB 20MG Brand

XARELTO TAB 15MG Brand

XARELTO STAR TAB 15/20MG Brand QL 1 per 365 days

HEMOSTATICS

AMINOCAPROIC ACID SYRUP 25% Generic

TRANEXAMIC ACID TAB 650MG Generic PA Required

HEMORRHEOLOGIC AGENTS PENTOXIFYLLI TAB 400MG ER Generic

PLATELET‐ACTING AGENTS AGGRENOX CAP 25‐200MG Brand

ANAGRELIDE CAP 0.5MG Generic

ANAGRELIDE CAP 1MG Generic

ASA/DIPYRIDA CAP 25‐200MG Generic

CILOSTAZOL TAB 50MG Generic

CILOSTAZOL TAB 100MG Generic

CLOPIDOGREL TAB 75MG Generic

TICLOPIDINE TAB 250MG Generic AR PA required >64

TOPICAL PRODUCTS ALPHA‐ADRENERGIC AGONISTS (EENT) BRIMONIDINE SOL 0.2% OP Generic

BRIMONIDINE SOL 0.15% Generic

DOXAZOSIN TAB 8MG Generic




PRAZOSIN HCL CAP 1MG Generic



TERAZOSIN CAP 10MG Generic




ANTIBACTERIALS (EENT) AK‐POLY‐BAC OIN OP Generic

BACIT/POLYMY OIN OP Generic

BACITRACIN OIN OP Generic


82


CILOXAN OIN 0.3% OP Brand

CIPROFLOXACIN SOL 0.3% OP Generic

ERYTHROMYCIN OIN 5MG/GM Generic

ERYTHROMYCIN OIN OP Generic

GARAMYCIN OIN 0.3% OP Generic

GATIFLOXACIN SOL 0.5% Generic

GENTAK OIN 0.3% OP Generic

GENTAMICIN SOL 0.3% OP Generic

GENTAMICIN OIN 0.3% OP Generic

ILOTYCIN OIN OP Generic

ILOTYCIN OIN OP Generic

NEO/BAC/POLY OIN OP Generic

NEO/POLY/GRA SOL OP Generic

NEO‐POLYCIN OIN OP Generic

OFLOXACIN DRO 0.3% OP Generic

OFLOXACIN DRO 0.3%OTIC Generic

POLYCIN OIN OP Generic

POLYCIN OIN OP Generic

POLYCIN B OIN OP Generic

POLYMYXIN B/SOL TRIMETHOPRIM SULFATE SOL Generic

ROMYCIN Generic

SULFACET SOD SOL 10% OP Generic

TOBRAMYCIN SOL 0.3% OP Generic

TRIMETHOPRIM SOL POLYMYXN SOL Generic

ANTIVIRALS (EENT) TRIFLURIDINE SOL 1% OP Generic

ZIRGAN GEL 0.15% Brand

BETA‐ADRENERGIC BLOCKING AGENTS (EENT) BETOPTIC‐S SUS 0.25% OP Brand

LEVOBUNOLOL SOL 0.25% OP Generic

LEVOBUNOLOL SOL 0.5% OP Generic

METIPRANOLOL SOL 0.3% OPH Generic

TIMOLOL GEL SOL 0.25% OP Generic

TIMOLOL GEL SOL 0.5% OP Generic

TIMOLOL MAL SOL 0.25% OP Generic

TIMOLOL MAL SOL 0.5% OP Generic

CORTICOSTEROIDS (EENT) ACETASOL HC SOL OTIC Generic

BLEPHAMIDE SUS OP Brand

BLEPHAMIDE OIN S.O.P. Brand

CIPRODEX SUS 0.3‐0.1% Brand PA

DEXAMETH PHO SOL 0.1% OP Generic QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

83


FLUOROMETHOL SUS 0.1% OP Generic

FML OIN 0.1% OP Brand

FML FORTE SUS 0.25% OP Brand

HC/ACET ACID SOL OTIC Generic

NEO/POLY/BAC OIN /HC 1%OP Generic

NEO/POLY/DEX SUS 0.1% OP Generic

NEO/POLY/DEX OIN 0.1% OP Generic

NEO/POLY/HC SUS OP Generic

NEO/POLY/HC SUS 1% OTIC Generic

NEO/POLY/HC SOL 1% OTIC Generic

NEO‐POLYCIN OIN HC 1%OP Generic

POLY‐DEX OIN 0.1% OP Generic

PRED MILD SUS 0.12% OP Brand

PRED SOD PHO SOL 1% OP Generic

PREDNISOLONE SUS 1% OP Generic

SULF/PRED NA SOL OP Generic

TOBRA/DEXAME SUS 0.3‐0.1% Generic

TOBRADEX OIN 0.3‐0.1% Brand

EENT DRUGS, MISCELLANEOUS ACETIC ACID SOL 2% OTIC Generic

APRACLONIDIN SOL 0.5% OP Generic

EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS DICLOFENAC SOL 0.1% OP Generic

FLURBIPROFEN SOL 0.03% OP Generic

KETOROLAC SOL 0.4% Generic

KETOROLAC SOL 0.5% Generic

MIOTICS PHOSPHOLINE SOL 0.125%OP Brand

PILOCARPINE SOL 1% OP Generic



MYDRIATICS ATROPIN‐CARE SOL 1% OP Generic

ATROPINE SUL SOL 1% OP Generic

CYCLOMYDRIL SOL OP Brand

CYCLOPENTOL SOL 1% OP Generic

CYCLOPENTOL SOL 2% OP Generic

CYCLOPENTOLATE SOL 0.5% OP Generic

HOMATROPAIRE SOL 5% OP Generic

HOMATROPINE SOL 5% OP Generic

MYDRAL SOL 0.5% OP Generic


84


MYDRAL SOL 1% OP Generic

TROPICAMIDE SOL 0.5% OP Generic

TROPICAMIDE SOL 1% OP Generic

PROSTAGLANDIN ANALOGS LATANOPROST SOL 0.005% Generic

TRAVOPROST DRO 0.004% Generic

LOCAL ANESTHETICS (EENT) ANTIPY/BENZO SOL OTIC Generic

AURODEX SOL OTIC Generic

LIDOCAINE SOL 2% VISC Generic

EENT ANTI‐INFECTIVES, MISCELLANEOUS CHLORHEX GLU SOL 0.12% Generic

PAROEX SOL 0.12% Generic

PERIOGARD SOL 0.12% Generic

ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) ANTIBIOTIC OIN Generic

ANTIBIOTIC OIN PAIN RLF Brand

BAC/NEO/POLY OIN Generic

BACITR ZINC OIN 500/GM Generic

GENTAMICIN CRE 0.1% Generic

GENTAMICIN OIN 0.1% Generic

LANABIOTIC OIN Generic

MUPIROCIN OIN 2% Generic

NEOPORACIN OIN Generic

NEOSPORIN+PN OIN RELF MAX Generic

SM FIRST AID OIN 500/GM Generic

ANTIPRURITICS AND LOCAL ANESTHETICS GLYDO GEL 2% Generic

LIDO/PRILOCN CRE 2.5‐2.5% Generic QL 2 grams per day

LIDOCAINE GEL 2% JELLY Generic

LIDOCAINE SOL 4% Generic

LOCAL ANTI‐INFECTIVES, MISCELLANEOUS ALCOHOL MIS WIPES Generic

ALCOHOL WIPE MIS 70% Generic

AVC CRE 15% Brand

RA ALCOHOL MIS WIPES Brand

SILVER SULFA CRE 1% Generic

SSD CRE 1% Generic

THERMAZENE CRE 1% Generic


85


SCABICIDES AND PEDICULICIDES ACTICIN CRE 5% Generic

LICE KILLING SHA 0.33‐4% Generic

LICE TREATMENT LOT 1% Generic

LICE TRTMNT LIQ 1% Generic

LICE TRTMNT LIQ CRM RNSE Generic

LICIDE LIQ MAX ST Generic

LICIDE SHA 0.33‐4% Generic

LINDANE LOT 1% Generic

LINDANE SHA 1% Generic

PERMETHRIN CRE 5% Generic

PERMETHRIN LOT 1% Generic

PRONTO PLUS LIQ MOUSSE Generic

SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ACITRETIN CAP 10MG Generic PA, QL 2 caps per day

ACITRETIN CAP 17.5MG Generic PA, QL 2 caps per day

ACITRETIN CAP 25MG Generic PA QL 2 caps per day

CALCIPOTRIEN SOL 0.005% Generic PA

CALCIPOTRIEN CRE 0.005% Generic PA

CAPREX + CRE 0.075% Generic

CAPSAICIN CRE 0.025% Generic

CAPSAICIN CRE 0.1% Generic

CAPZASIN‐P CRE 0.035% Brand

CONDYLOX GEL 0.5% Brand

FLUOROURACIL DRO 5% Generic PA

FLUOROURACIL SOL 5% Generic PA

FLUOROURACIL CRE 5% Generic PA

IMIQUIMOD CRE 5% Generic PA

PODOFILOX SOL 0.5% Generic

PSORIASIN LIQ 3% Generic

RA ARTH PAIN CRE 0.075% Generic

REGRANEX GEL 0.01% Brand PA QL 2

SCALPICIN LIQ 3% Generic

SILIQ INJ 210/1.5 Brand PA QL .108mls per fill

STELARA INJ 45MG/0.5 Brand PA 0.006mls per day

Max 84 day supply per fill

STELARA INJ 90MG/ML Brand PA 0.012mls per day

Max 84 day supply per fill

THERAGEN HP CRE 0.075% Generic

TREMFYA INJ 100MG/ML Brand PA QL 0.018ml per day; max 56 day supply per fill

TRIXAICIN HP CRE 0.075% Generic

VEREGEN OIN 15% Brand QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter

86


TOPICAL CORTICOSTEROIDS ANTI‐ITCH LOT 1% Generic

ANTI‐ITCH CRE 1% Generic

AUGMENTED BETAMETHASONE CRE 0.05% Generic

BETAMETH DIP LOT 0.05% Generic

BETAMETHASONE CRE 0.1% Generic

COLOCORT ENE 100MG Generic QL 60mls per day

CORT INTENSE CRE 1% Generic

CORTAID CRE 1% Generic

CORTAID SPR 1% Generic

CORTAID ADV CRE 1% 12 HR Generic

CORTIFOAM AER 90MG Brand

CORTISONE CRE 1% Generic

CORTISONE LOT 1% Generic

CORTISONE OIN 1%MAX ST Generic

CORTIZONE‐10 OIN 1% Generic

CORTIZONE‐10 CRE /ALOE 1% Generic

CORTIZONE‐10 CRE HEALING Generic

CORTIZONE‐10 CRE PLUS Generic

CORTIZONE‐10 LOT ECZEMA Generic

CORTIZONE‐10 LOT HYDRATEN Generic

DESOXIMETAS CRE 0.25% Generic

FLUTICASONE CRE 0.05% Generic

FLUTICASONE OIN 0.005% Generic

GYNECORT 10 CRE 1% Generic

HYDROSKIN LOT 1% Generic

HYDROCORTISONE OIN 0.5% Generic

HYDROCORTISONE CRE 0.5% Generic

HYDROCORTISONE CRE 1% Generic

HYDROCORTISONE CRE 2.5% Generic

HYDROCORTISONE ENE 100MG Generic QL 60mls per day

HYDROCORTISONE LOT 1% Generic

HYDROCORTISONE LOT 2.5% Generic

HYDROCORTISONE OIN 1% Generic

HYDROCORTISONE OIN 2.5% Generic

HYDROCORT AC CRE 1% Generic

HYDROCORT/AB OIN 1% Generic

HYDROCREAM CRE 1% Generic

HYDRO‐LOTION LOT 1% Generic

HYDROSKIN CRE 1% Generic

INSTACORT 5 CRE 0.5% Generic

KERICORT 10 CRE 1% Generic


87


K HYDROCORTISON CRE PLS 1% Generic

LANACORT 10 CRE 1% Generic

MED‐DERM HC CRE 1% Generic

MED‐DERM HC CRE 0.5% Generic

MEDI‐CORT CRE 1% Generic

MOMETASONE CRE 1% Generic

MOMETASONE OIN 0.1% Generic

MOMETASONE SOL 0.1% Generic

NEOSPORIN CRE ECZEMA Generic

NOBLE FORMUL CRE HC 1% Generic

NOBLE FORMUL SPR 1% Generic

NYSTAT/TRIAM CRE Generic PA

NYSTAT/TRIAM OIN Generic PA

PREP H HC CRE 1% Generic

PROCTO‐PAK CRE 1% Generic

PROCTOSOL HC CRE 2.5% Generic

PROCTOZONE CRE ‐HC 2.5% Generic

QC HYDROCORT CRE 1% Generic

RECORT PLUS CRE 1% Generic

REDERM LOT 1% Generic

SARNOL‐HC LOT 1% Generic

SB HYDROCORT CRE 1% Generic

SCALP RELIEF SOL 1% Generic

SCALPICIN SOL 1% Generic

TRIAMCINOLON OIN 0.1% Generic

TRIAMCINOLON CRE 0.025% Generic



TRIAMCINOLON LOT 0.025% Generic

TRIDERM CRE 0.1% Generic

MISCELLANEOUS PRODUCTS COMPLEMENT INHIBITORS HAEGARDA INJ 2000 UNIT Brand PA

HAEGARDA INJ 4000 UNIT Brand PA

EMETICS IPECAC SYP Generic

SM IPECAC SYP Generic


88


OPIATE ANTAGONISTS

NALOXONE INJ 0.4MG/ML Generic QL 2 per fill; max 1 fill per 180 days

NALOXONE INJ 1MG/ML Generic QL 4 MLs per fill;

max 1 fill per 180 days

NALTREXONE TAB 50MG Generic

NARCAN SPRAY 4MG/0.1ML Brand QL 2 per fill;

max 1 fill per 180 days

ADRENOCORTICAL INSUFFICIENCY COSYNTROPIN INJ 0.25MG Generic

MISCL OTHER BUBBLE GUM SYP Generic

CHERRY SYP Generic

CHERRY SYP CONCENTR Generic

COTTONSEED OIL Generic

FLAVOR BLEND SUS Brand

FLAVOR PLUS LIQ Brand

FLAVOR SWEET SYP Brand

FLAVOR SWEET LIQ S/F Brand

GRAPE SYP Generic

ORA‐BLEND SUS Brand

ORA‐BLEND SF SUS Brand

ORAL MIX LIQ SUSPENDI Brand

ORAL MIX SF LIQ Brand

ORAL SUSPEND LIQ Generic

ORAL SYRUP LIQ FLAVORED Generic

ORAL SYRUP LIQ SF Generic

ORA‐PLUS LIQ Brand

ORA‐SWEET SYP Brand

ORA‐SWEET SF SYP Brand

PCCA SWEET SYP ‐SF Brand

PCCA SYRUP SYP VEHICLE Brand

PCCA‐PLUS SUS Brand

SIMPLE SYP Generic

STERIL WATER INJ Generic

SUSPENSION SUS VEHICLE Generic

SYRPALTA SYP Brand

SYRSPEND SF LIQ Brand

SYRUP SYP VEHICLE Generic

SYRUP SF SYP VEHICLE Generic

VERSAFREE SYP Brand

VERSAPLUS SYP Brand


89


DEVICES AERCHMBR PLS MIS SM MASK Brand QL 2 per 365 days

AERCHMBR PLS MIS FLOW‐VU Brand QL 2 per 365 days

AERCHMBR PLS MIS LRG MASK Brand QL 2 per 365 days

AERCHMBR Z‐ MIS STAT PLS Brand QL 2 per 365 days

AEROCHAMBER MIS PLUS Brand QL 2 per 365 days

AEROCHAMBER MIS FLOSIGNA Brand QL 2 per 365 days

AEROCHAMBER MIS PLUS Brand QL 2 per 365 days

AEROCHAMBER MIS MV Brand QL 2 per 365 days

AEROCHAMBER MIS CHAMBER Brand QL 2 per 365 days

AEROCHAMBER KIT ACTION Brand

AIRZONE PEAK MIS FLOW MTR Brand QL 2 per 365 days

ALCOHOL PREP PAD Generic

ALCOHOL PREP SWAB PAD Generic

ALCOHOL SWAB PAD Generic

ALCOHOL WIPE PAD Generic

ARIAL MIS CHAMBER Brand QL 2 per 365 days

ASSESS METER MIS FULL RNG Brand QL 2 per 365 days

ASSESS METER MIS LOW RANG Brand QL 2 per 365 days

ASSESS METER MIS FULL Brand QL 2 per 365 days

ASSESS METER MIS LOW Brand QL 2 per 365 days

ASTHMA CHECK MIS SYSTEM Brand QL 2 per 365 days

ASTHMAMENTOR MIS Brand QL 2 per 365 days

BAND‐AID PAD 2"X2" Brand

BD SWAB BFLY PAD SNGL USE Brand

BD SWAB REG PAD SNGL USE Brand

BREATHERITE MIS Brand QL 2 per 365 days

BREATHERITE MIS W/MASK Brand QL 2 per 365 days

BREATHERITE MIS LG MASK Brand QL 2 per 365 days

BREATHERITE MIS MED MASK Brand QL 2 per 365 days

BREATHERITE MIS SM MASK Brand QL 2 per 365 days

BREATHERITE MIS SPACER Brand QL 2 per 365 days

DERMACEA PAD 2"X2" Brand

EASIVENT MIS Brand QL 2 per 365 days

EASIVENT MIS MASK SM Brand QL 2 per 365 days

EASIVENT MIS MASK MED Brand QL 2 per 365 days

EASIVENT MIS MASK LG Brand QL 2 per 365 days

EQL GAUZE PAD 2"X2" Brand

E‐Z SPACER MIS Brand QL 2 per 365 days

E‐Z SPACER MIS BODY GRD Brand QL 2 per 365 days

INSPIREASE MIS DD SYST Brand QL 2 per 365 days

LITEAIRE MIS Brand QL 2 per 365 days


90


MASK VORTEX/ MIS BABY DUC Brand QL 2 per 365 days

MASK VORTEX/ MIS DUCK Brand QL 2 per 365 days

MASK VORTEX/ MIS LADY BUG Brand QL 2 per 365 days

MASK VORTEX/ MIS FROG Brand QL 2 per 365 days

MICROCHAMBER MIS Brand QL 2 per 365 days

MICROLIFE MIS PEAK FLO Brand QL 2 per 365 days

MICROSPACER MIS Brand QL 2 per 365 days

MINI WRIGHT MIS PFM Brand QL 2 per 365 days

MINI WRIGHT MIS PFM LOW Brand QL 2 per 365 days

MIRASORB MIS 2" X 2" Brand

NESSI SPACER MIS MOUTHPC Brand QL 2 per 365 days

NESSI SPACER MIS SM/MED Brand QL 2 per 365 days

NESSI SPACER MIS LARGE Brand QL 2 per 365 days

OPTICHAMBER MIS ADVANTAG Brand QL 2 per 365 days

OPTICHAMBER MIS ADV SM Brand QL 2 per 365 days

OPTICHAMBER MIS ADV MED Brand QL 2 per 365 days

OPTICHAMBER MIS ADV LRG Brand QL 2 per 365 days

OPTICHAMBER MIS FACE MAS Brand QL 2 per 365 days

OPTICHAMBER MIS DIAMOND Brand QL 2 per 365 days

OPTICHAMBER MIS DIA SM Brand QL 2 per 365 days

OPTICHAMBER MIS DIA MD Brand QL 2 per 365 days

OPTICHAMBER MIS DIA LG Brand QL 2 per 365 days

PANDA MASK MIS PEDIATRI Brand QL 2 per 365 days

PANDA MASK MIS SMALL Brand QL 2 per 365 days

PANDA MASK MIS MEDIUM Brand QL 2 per 365 days

PANDA MASK MIS LARGE Brand QL 2 per 365 days

PEAK AIR FLO MIS ADLT/PED Brand QL 2 per 365 days

PEAK FLOW MIS METER Generic QL 2 per 365 days

PEAK FLW MTR MIS UNIVERSL Generic QL 2 per 365 days

PERSONAL BES MIS FULL RNG Brand QL 2 per 365 days

PERSONAL BES MIS LOW RANG Brand QL 2 per 365 days

PIKO 1 MIS ELECTRON Brand QL 2 per 365 days

POCKET PEAK MIS METER Generic QL 2 per 365 days

POCKETPEAK MIS UNIVERSA Brand QL 2 per 365 days

POCKETPEAK MIS MTR LOW Brand QL 2 per 365 days

PRIMEAIRE MIS CHAMBER Brand

TABLET CUTTER Brand QL 1 per 365 days

RITEFLO MIS Brand QL 2 per 365 days

TRUZONE PEAK MIS FLOW MTR Brand QL 2 per 365 days

VALVD HOLDNG MIS CHAMBER Brand QL 2 per 365 days

VORTEX VALVE MIS CHAMBER Brand QL 2 per 365 days

VORTEX/MASK MIS TODDLER Brand


91


VORTEX/MASK MIS CHILDS Brand

WATCHHALER MIS Brand QL 2 per 365 days

IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50MG Generic

BENLYSTA INJ 200 MG/ML Brand PA QL 4 syringes per 28

days

CYCLOSPORINE CAP 25MG Generic

CYCLOSPORINE CAP 100MG Generic

CYCLOSPORINE CAP 25MG MOD Generic

CYCLOSPORINE CAP 50MG MOD Generic

CYCLOSPORINE CAP 100MG MD Generic

CYCLOSPORINE SOL MODIFIED Generic

GENGRAF CAP 25MG Generic

GENGRAF CAP 100MG Generic

GENGRAF SOL 100MG/ML Generic

HECORIA CAP 0.5MG Generic

HECORIA CAP 1MG Generic

HECORIA CAP 5MG Generic

MYCOPHENOLAT CAP 250MG Generic

MYCOPHENOLAT TAB 500MG Generic

MYCOPHENOLAT SUS 200MG/ML Generic

RAPAMUNE SOL 1MG/ML Brand QL 2mls per day

SIROLIMUS TAB 0.5MG Generic QL 2 per day

SIROLIMUS TAB 1MG Generic QL 2 per day

SIROLIMUS TAB 2MG Generic QL 2 per day

TACROLIMUS CAP 0.5MG Generic

TACROLIMUS CAP 1MG Generic

TACROLIMUS CAP 5MG Generic

ZORTRESS TAB 0.25MG Brand



POTASSIUM‐REMOVING AGENTS KIONEX SUS 15GM/60 Generic

KIONEX POW Generic

SOD POLY SUL SUS 15GM/60 Generic

SOD POLY SUL SUS 30/120ML Generic

SOD POLY SUL SUS 50/200ML Generic

SOD POLY SUL POW Generic

SPS SUS 15GM/60 Generic

VELTASSA POW 8.4GM Brand PA QL 1 packet per day




92

INDEX OF DRUGS

3

3 DAY VAGINAL ............................................................... 5

A

ABACAVIR........................................................................ 6

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ............6

ABACAVIR/LAMIVUDINE ................................................. 6

ACAMPRO CAL .............................................................. 55

ACARBOSE ..................................................................... 23

ACD/FLUORIDE .............................................................. 66

ACEBUTOLOL................................................................. 32

ACETAMINOPHEN ......................................................... 57

ACETAMINOPHEN/CAFF/PYRILAMINE..........................57

ACETASOL HC ................................................................ 83

ACETAZOLAMIDE ........................................................... 38

ACETIC ACID .................................................................. 84

ACID CONTROL .............................................................. 46

ACID REDUCER .............................................................. 46

ACID RELIEF ................................................................... 46

ACITRETIN ..................................................................... 86

ACTEMRA ...................................................................... 60

ACTICIN ......................................................................... 86

ACTIMMUNE ................................................................. 12

ACYCLOVIR ...................................................................... 5

ADACEL.......................................................................... 11

ADCIRCA ........................................................................ 41

ADEFOVIR DIPIVOXIL....................................................... 6

ADEMPAS ...................................................................... 41

ADENOSINE ................................................................... 35

ADLYXIN ........................................................................ 24

ADMELOG ...................................................................... 24

ADMELOG SOLO............................................................ 24

ADVAIR DISKUS ............................................................. 43

ADVAIR HFA .................................................................. 43

AERCHMBR PLS ............................................................. 90

AERCHMBR Z‐ ................................................................ 90

AEROCHAMBER ............................................................. 90

AFEDITAB....................................................................... 33

AFINITOR ....................................................................... 12

AFINITOR DIS ................................................................ 12

AFLURIA ........................................................................ 11

AFLURIA QUAD ............................................................. 11

AFTERA.......................................................................... 19

AGGRENOX ................................................................... 82

AIRZONE PEAK .............................................................. 90

AK‐POLY‐BAC ................................................................ 82

ALA‐HIST IR ................................................................... 41

ALAVERT........................................................................ 41

ALBENZA ......................................................................... 9

ALBUTEROL ............................................................. 42, 44

ALCALAK........................................................................ 45

ALCOHOL....................................................................... 85

ALCOHOL PREP ............................................................. 90

ALCOHOL PREP SWAB................................................... 90

ALCOHOL SWAB ............................................................ 90

ALCOHOL WIPE ....................................................... 85, 90

ALECENSA ..................................................................... 12

ALENDRONATE .............................................................. 28

ALER‐DRYL..................................................................... 41

ALFERON N.................................................................... 12

ALKERAN ....................................................................... 12

ALLOPURINOL ............................................................... 62

ALMACONE SUS ........................................................ 45

ALOGLIPTAN ................................................................. 25

ALTAVERA ..................................................................... 19

ALUNBRIG ..................................................................... 12

ALYACEN ....................................................................... 19

AMANTADINE ................................................................. 5

AMBIZINE...................................................................... 47

AMETHIA....................................................................... 19

AMETHIA LO.................................................................. 19

AMETHYST .................................................................... 19

AMILORIDE .................................................................... 39

AMILORIDE/HYDROCHLOROTHIAZIDE .......................... 39

AMINOCAPROIC ACID ................................................... 82

AMIODARONE............................................................... 35

AMLODIPINE ................................................................. 33

AMOXICILLIN................................................................... 1

AMOXICILLIN/CLAVULANATE POTASSIUM ..................... 1

93

AMPHETAMINE (Generic Adderall IR) ..........................54

AMPHETAMINE (Generic Adderall XR) .........................54

AMPHOTERICIN............................................................... 4

AMPICILLIN...................................................................... 1

AMP‐SULBACTA ............................................................... 1

ANAGRELIDE.................................................................. 82

ANASTROZOLE ............................................................... 12

ANDRODERM ................................................................ 18

ANORO ELLIPTA ............................................................. 43

ANTACID........................................................................ 45

ANTIBIOTIC.................................................................... 85

ANTI‐ITCH...................................................................... 87

ANTIPY/BENZO.............................................................. 85

APAP/CODEINE.............................................................. 57

APRACLONIDIN.............................................................. 84

APREPITANT ............................................................ 47, 48

APRI ............................................................................... 19

APRISO .......................................................................... 49

APTIVUS........................................................................... 6

ARALAST NP .................................................................. 44

ARANELLE ...................................................................... 19

ARANESP ....................................................................... 78

ARGYL SALINE................................................................ 52

ARIAL ............................................................................. 90

ARMONAIR.................................................................... 43

ARMOUR THYROID........................................................ 26

ASA/DIPYRIDA ............................................................... 82

ASHLYNA ....................................................................... 20

ASPIRIN.......................................................................... 57

ASSESS METER ............................................................... 90

ASTHMA CHECK ............................................................. 90

ASTHMAMENTOR .......................................................... 90

ATAZANAVIR ................................................................... 6

ATENOLOL ..................................................................... 32

ATENOLOL/CHLORTHALIDONE .....................................37

ATHLETE FOOT ................................................................ 5

ATORVASTATIN ............................................................. 40

ATOVAQUONE................................................................. 9

ATRIPLA ........................................................................... 7

ATROPIN‐CARE .............................................................. 84

ATROPINE SUL ............................................................... 84

ATROVENT..................................................................... 42

AUBAGIO....................................................................... 55

AUBRA........................................................................... 20

AUGMENTED BETAMETHASONE .................................. 87

AURODEX ...................................................................... 85

AVC ............................................................................... 85

AVIANE.......................................................................... 20

AVONEX ........................................................................ 56

AVONEX PEN................................................................. 56

AVONEX PREFL .............................................................. 56

AZATHIOPRINE .............................................................. 92

AZITHROMYCIN........................................................... 2, 3

AZOPT ........................................................................... 38

AZURETTE ..................................................................... 20

B

B COMPLEX W/C & FOLIC ACID .................................... 66

B COMPLEX WITH VITAMIN C....................................... 66

B1 NATURAL.................................................................. 65

BAC/NEO/POLY ............................................................. 85

BACIT/POLYMY ............................................................. 82

BACITR ZINC .................................................................. 85

BACITRACIN .................................................................. 82

BACLOFEN..................................................................... 65

BALSALAZIDE ................................................................. 49

BALZIVA......................................................................... 20

BAND‐AID...................................................................... 90

BARACLUDE .................................................................... 6

BASAGLAR..................................................................... 24

BAYCADRON ................................................................. 17

BD SWAB BFLY .............................................................. 90

BD SWAB REG ............................................................... 90

BELLA/OPIUM ............................................................... 45

BENAZEPRIL .................................................................. 36

BENAZEPRIL/HYDROCHLOROTHIAZIDE ........................ 37

BENLYSTA...................................................................... 92

BENZNIDAZOLE ............................................................... 9

BENZONATATE .............................................................. 42

BENZTROPINE ............................................................... 64

BETAMETH DIP .............................................................. 87

BETAMETHASONE ......................................................... 87

BETHANECHOL .............................................................. 51

BETHKIS........................................................................... 3

BETOPTIC‐S ................................................................... 83

BEXSERO ....................................................................... 11

BICALUTAMIDE ............................................................. 12

BIKTARVY ........................................................................ 7

94

BILTRICIDE ....................................................................... 9

BIO‐STATIN...................................................................... 4

BIOTIN FORTE................................................................ 67

BISACODYL .................................................................... 44

BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE .....37

BLEPHAMIDE ................................................................. 83

BOOST ........................................................................... 78

BOOSTRIX ...................................................................... 11

BOSULIF......................................................................... 12

BPROTECTED ................................................................. 67

BREATHERITE ................................................................ 90

BRIELLYN ....................................................................... 20

BRIMONIDINE ................................................................ 82

BROMOCRIPTIN............................................................. 64

BUBBLE GUM ................................................................ 89

BUDESONIDE ................................................................. 43

BUMETANIDE ................................................................ 38

BUPRENORPHINE .......................................................... 57

BUPRENORPHINE/NALOXONE ......................................57

BUPROBAN.................................................................... 56

BYDUREON .................................................................... 24

BYETTA .......................................................................... 24

C

CABERGOLINE ............................................................... 28

CABOMETYX............................................................ 12, 13

CAFFEINE CIT ................................................................. 55

CALC ANTACID............................................................... 45

CALCIPOTRIEN ............................................................... 86

CALCITONIN................................................................... 28

CALCITRIOL.................................................................... 30

CALCIUM ....................................................................... 67

CALCIUM ACETATE ........................................................ 50

CALCIUM CARB.............................................................. 45

CALCIUM CARBONATE .................................................. 75

CALCIUM CITRATE ......................................................... 75

CALCIUM CITRATE PLUS VIT D ...................................... 75

CALCIUM CITRATE PLUS VITAMIN D .............................75

CALCIUM GLUCONATE .................................................. 75

CALCIUM LACTATE ........................................................ 76

CALCIUM PLUS D/ MINERALS ........................................ 75

CALCIUM PLUS D3......................................................... 75

CALCIUM W/VIT D......................................................... 75

CALCIUM W/VIT D & POTASSIUM .................................75

CALCIUM/D................................................................... 78

CALCIUM/PLUS D.......................................................... 75

CALNA ........................................................................... 67

CALQUENCE .................................................................. 13

CAMILA ......................................................................... 20

CAMRESE ...................................................................... 20

CAMRESE LO ................................................................. 20

CANASA......................................................................... 49

CANDESARTAN .............................................................. 36

CANDESARTAN/HCTZ .................................................... 36

CAPECITABINE............................................................... 13

CAPRELSA...................................................................... 13

CAPREX +....................................................................... 86

CAPSAICIN..................................................................... 86

CAPTOPRIL .................................................................... 36

CAPTOPRIL/HYDROCHLOROTHIAZIDE .......................... 37

CAPZASIN‐P................................................................... 86

CARAFATE ..................................................................... 47

CARBAMAZEPINE .......................................................... 62

CARBIDOPA/LEVODOPA ............................................... 64

CARTIA XT ..................................................................... 33

CARVEDILOL.................................................................. 32

CASCARA SAGRADA ...................................................... 45

CAVAN‐EC SOD ............................................................. 67

CAVAREST ..................................................................... 74

CAYSTON....................................................................... 11

CAZIANT ........................................................................ 20

CEFACLOR ....................................................................... 1

CEFADROXIL ................................................................ 1, 2

CEFAZOLIN ...................................................................... 2

CEFAZOLIN/DEXTROSE.................................................... 2

CEFDINIR ......................................................................... 2

CEFIXIME ......................................................................... 2

CEFPODOXIME ................................................................ 2

CEFPROZIL....................................................................... 2

CEFTRIAXONE .................................................................. 2

CEFUROXIME .................................................................. 2

CELECOXIB .................................................................... 60

CELONTIN...................................................................... 62

CENTRUM SPEC............................................................. 67

CEPHALEXIN.................................................................... 2

CERALYTE 70 ................................................................. 76

CERASPORT................................................................... 76

CERVICAL CAP ............................................................... 51

95

CESIA ............................................................................. 20

CETIRIZINE............................................................... 41, 42

CHANTIX ........................................................................ 56

CHATEAL........................................................................ 20

CHERRY.......................................................................... 89

CHEW CALCIUM ............................................................ 67

CHILD ASPIRIN ............................................................... 57

CHILD SOOTHE .............................................................. 45

CHILD VIT D ................................................................... 30

CHILDRENS .................................................................... 45

CHLORHEX GLU ............................................................. 85

CHLOROQUINE ................................................................ 9

CHLORPHENIRAMINE MALEATE ...................................41

CHLORTHALIDONE ........................................................ 39

CHLORZOXAZONE ......................................................... 65

CHOLESTYRAM.............................................................. 40

CHOLINE MAG TRISALICYLATE ...................................... 57

CIDOFOVIR ...................................................................... 6

CILOSTAZOL................................................................... 82

CILOXAN ........................................................................ 83

CIMETIDINE ................................................................... 46

CIPRODEX ...................................................................... 83

CIPROFLOXACIN ........................................................ 3, 83

CIT CALC/D .................................................................... 76

CITRANATAL .................................................................. 67

CITRIC ACID/SODIUM CITRATE ...................................... 52

CL PRENATAL................................................................. 67

CLARITHROMYCIN........................................................... 3

CLEOCIN ........................................................................ 52

CLINDAMYCIN ........................................................... 9, 52

CLONAZEPAM................................................................ 53

CLONIDINE .................................................................... 37

CLOPIDOGREL ................................................................ 82

CLOTRIMAZOLE ............................................................... 5

COARTEM ........................................................................ 9

CODEINE SULF ............................................................... 57

COLCHICINE................................................................... 62

COLCRYS ........................................................................ 62

COLESTIPOL................................................................... 40

COLOCORT..................................................................... 87

COMBIPATCH ................................................................ 18

COMBIVENT .................................................................. 43

COMETRIQ..................................................................... 13

COMFORT GEL ............................................................... 45

COMP PRNATAL ............................................................ 67

COMPAZINE .................................................................. 47

COMPL PRENAT ............................................................ 67

COMPLERA...................................................................... 7

COMPLETENATE ............................................................ 67

COMPOZ ....................................................................... 52

COMPRO ....................................................................... 48

CO‐NATAL FA ................................................................ 67

CONCEPT OB ................................................................. 67

CONDYLOX .................................................................... 86

CONSTULOSE ................................................................ 10

CONTROLRX .................................................................. 74

CORLANOR .................................................................... 31

CORT INTENSE............................................................... 87

CORTAID ....................................................................... 87

CORTAID ADV ................................................................ 87

CORTIFOAM .................................................................. 87

CORTISONE ................................................................... 87

CORTIZONE‐10 .............................................................. 87

COSENTYX ..................................................................... 60

COSENTYX PEN .............................................................. 60

COSYNTROPIN ............................................................... 89

COTELLIC ....................................................................... 13

COTTONSEED ................................................................ 89

COUMADIN ................................................................... 80

CREON........................................................................... 49

CRIXIVAN......................................................................... 7

CROMOLYN................................................................... 44

CRYSELLE‐28.................................................................. 20

CURITY SALIN ................................................................ 52

CVS PRENATAL .............................................................. 67

CVS STRESS ................................................................... 67

CVS SUPER B ................................................................. 67

CYANOCOBALAM .......................................................... 65

CYCLAFEM..................................................................... 20

CYCLOBENZAPRINE ....................................................... 65

CYCLOMYDRIL ............................................................... 84

CYCLOPENTOL ............................................................... 84

CYCLOPENTOLATE ......................................................... 84

CYCLOPHOSPH .............................................................. 13

CYCLOSPORINE ............................................................. 92

CYPROHEPTADINE ........................................................ 42

CYRED ........................................................................... 20

CYTRA K CRYSTALS ........................................................ 52

96

CYTRA‐2......................................................................... 52

CYTRA‐3......................................................................... 52

CYTRA‐K......................................................................... 52

D

D 400 ............................................................................. 30

D‐3 GUMMY .................................................................. 30

D3 KIDS.......................................................................... 30

D5W/NACL .................................................................... 76

DAKLINZA ........................................................................ 6

DANAZOL....................................................................... 18

DANTROLENE ................................................................ 65

DAPSONE....................................................................... 46

DAPTACEL...................................................................... 11

DARAPRIM....................................................................... 9

DASETTA........................................................................ 20

DAYSEE .......................................................................... 20

DEBLITANE .................................................................... 20

DELTASONE ................................................................... 17

DELYLA .......................................................................... 20

DELZICOL ....................................................................... 49

DENTA 5000 .................................................................. 74

DENTAGEL ..................................................................... 74

DEPO‐ESTRADIOL .......................................................... 19

DEPO‐PROVERA............................................................. 16

DERMACEA.................................................................... 90

DESCOVY ......................................................................... 7

DESENEX.......................................................................... 5

DESMOPRESSIN............................................................. 29

DESO/ETHINYL............................................................... 20

DESOXIMETAS ............................................................... 87

DEX4 .............................................................................. 23

DEXAMETH PHO............................................................ 83

DEXAMETHASONE ......................................................... 17

DEXMETHYLPHENIDATE................................................ 54

DEXTROAMPHETAMINE ................................................ 54

DEXTROSE ..................................................................... 78

DIABET TUSS.................................................................. 42

DIALYVITE ...................................................................... 67

DIALYVITE/ .................................................................... 67

DIASTAT ACDL ............................................................... 53

DIASTAT PED ................................................................. 53

DIAZEPAM ..................................................................... 53

DICLOFEN POTASSIUM .................................................. 60

DICLOFENAC ........................................................... 60, 84

DICLOXACILLIN SODIUM ................................................. 1

DICYCLOMINE ............................................................... 46

DIDANOSINE ................................................................... 7

DIGITEK ......................................................................... 31

DIGOX ........................................................................... 31

DIGOXIN........................................................................ 31

DIHYDROERGOT............................................................ 61

DILANTIN....................................................................... 62

DILANTIN‐125 ............................................................... 62

DILATRATE SR ............................................................... 31

DILAUDID‐HP ................................................................ 57

DILT‐CD ......................................................................... 33

DILTIAZEM............................................................... 33, 34

DILT‐XR.......................................................................... 34

DILTZAC......................................................................... 34

DIMENHYDRIN .............................................................. 48

DIPHENHYDRAM ........................................................... 53

DIPHENHYDRAMINE ............................................... 41, 42

DISOPYRAMIDE ............................................................. 35

DISULFIRAM.................................................................. 55

DOCUSATE SODIUM ...................................................... 45

DOFETILIDE ................................................................... 35

DONEPEZIL .................................................................... 55

DORZOLAMIDE .............................................................. 38

DORZOLAMIDE/TIMOLOL MALEATE ............................. 38

DOXAZOSIN................................................................... 82

DOXYCYCLINE MONOHYDRATE ...................................... 3

DRAMAMINE ................................................................. 48

DRIMINATE ................................................................... 48

DRONABINOL................................................................ 48

DROSPIR/ETHI............................................................... 20

DROSPIRENONE ............................................................ 20

DROXIA ......................................................................... 13

D‐VI‐SOL........................................................................ 30

D‐VITA........................................................................... 30

DYRENIUM .................................................................... 39

E

EASIVENT ...................................................................... 90

ECONTRA EZ.................................................................. 20

ED‐SPAZ ........................................................................ 46

EDURANT ........................................................................ 7

EFFER‐K ......................................................................... 76

97

ELIGARD ........................................................................ 13

ELINEST.......................................................................... 20

ELIQUIS.......................................................................... 80

ELITE‐OB........................................................................ 67

ELIXOPHYLLIN ................................................................ 44

ELLA............................................................................... 20

ELMIRON ....................................................................... 52

EMCYT ........................................................................... 13

EMEND .......................................................................... 48

EMOQUETTE ................................................................. 20

EMTRIVA ......................................................................... 7

ENALAPRIL..................................................................... 36

ENALAPRIL/HYDROCHLOROTHIAZIDE ...........................37

ENBREL .......................................................................... 60

ENBREL SRCLK ............................................................... 60

ENDOCET....................................................................... 57

ENDODAN...................................................................... 58

ENDUR‐ACIN.................................................................. 65

ENEMA .......................................................................... 45

ENFALYTE ...................................................................... 76

ENFAMIL.................................................................. 67, 76

ENGERIX‐B..................................................................... 11

ENOXAPARIN........................................................... 80, 81

ENPRESSE‐28................................................................. 20

ENSKYCE ........................................................................ 20

ENSURE ......................................................................... 78

ENTACAPONE ................................................................ 64

ENTECAVIR ...................................................................... 6

ENTRESTO ..................................................................... 31

ENULOSE ....................................................................... 10

EPCLUSA .......................................................................... 6

EPINEPHRINE AUTO‐INJECTOR .....................................39

EPITOL ........................................................................... 62

EPIVIR HBV ...................................................................... 7

EPOGEN......................................................................... 78

EPOPROSTENOL ............................................................ 41

EQL B‐12........................................................................ 65

EQL GAUZE .................................................................... 90

EQL HEARTBRN.............................................................. 46

EQL PRENATAL .............................................................. 67

ERGOCALCIFER .............................................................. 30

ERGOMAR ..................................................................... 61

ERIVEDGE ...................................................................... 13

ERRIN............................................................................. 20

ERYTHROMYCIN ............................................................ 83

ESTARYLLA .................................................................... 20

ESTRADIOL .................................................................... 18

ESTRADIOL (Generic Climara) ....................................... 18

ESTRADIOL (Generic Vivelle Dot) ............................ 18, 19

ESTRADIOL VALERATE ................................................... 19

ESTRING ........................................................................ 19

ESTROPIPATE ................................................................ 19

ETHAMBUTOL ................................................................. 4

ETHOSUXIMIDE ............................................................. 62

ETIDRONATE DISODIUM ............................................... 28

ETODOLAC .................................................................... 60

ETOPOSIDE .................................................................... 13

EVOTAZ ........................................................................... 7

EXEMESTANE ................................................................ 13

EXTAVIA ........................................................................ 56

E‐Z SPACER .................................................................... 90

EZETIMIBE ..................................................................... 40

F

FALLBACK ...................................................................... 20

FALMINA ....................................................................... 20

FAMCICLOVIR .............................................................. 5, 6

FAMOTIDINE ........................................................... 46, 47

FARESTON..................................................................... 13

FARYDAK ....................................................................... 13

FAYOSIM ....................................................................... 20

FE GLUCONATE ............................................................. 79

FE TABS ......................................................................... 79

FELBAMATE ................................................................... 62

FEMALE CONDOMS ...................................................... 51

FENOFIBRATE ................................................................ 40

FENOFIBRIC................................................................... 40

FENTANYL ..................................................................... 58

FEOSOL.......................................................................... 79

FERATE .......................................................................... 79

FERGON ........................................................................ 79

FER‐IRON....................................................................... 79

FEROSUL ....................................................................... 79

FERREX 150 ................................................................... 79

FERRIC X‐150................................................................. 79

FERRO‐BOB ................................................................... 79

FERROTABS ................................................................... 79

FERROUS ....................................................................... 79

98

FERROUS GLUCONATE .................................................. 79

FERROUS SULFATE ........................................................ 79

FERUS ............................................................................ 79

FIRST‐OMEPRA .............................................................. 47

FIRST‐TESTOSTERONE ................................................... 18

FISH OIL ......................................................................... 28

FLAVOR BLEND.............................................................. 89

FLAVOR PLUS................................................................. 89

FLAVOR SWEET ............................................................. 89

FLECAINIDE.................................................................... 35

FLOVENT........................................................................ 43

FLOVENT DISK ............................................................... 43

FLUAD............................................................................ 11

FLUBLOK QUAD ............................................................. 11

FLUCELVAX QUAD ......................................................... 11

FLUCONAZOLE ................................................................. 4

FLUCYTOSINE .................................................................. 4

FLUDROCORTISONE ...................................................... 17

FLULAVAL QUAD ........................................................... 11

FLUNISOLIDE ................................................................. 42

FLUORABON.................................................................. 74

FLUOR‐A‐DAY ................................................................ 74

FLUORIDE ...................................................................... 74

FLUORIDEX .................................................................... 75

FLUORITAB .................................................................... 75

FLUOROMETHOL........................................................... 84

FLUOROURACIL ............................................................. 86

FLURA‐DROPS ................................................................ 75

FLURBIPROFEN ..................................................60, 61, 84

FLUSH SYRING ............................................................... 76

FLUTAMIDE ................................................................... 13

FLUTICASONE .......................................................... 42, 87

FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) ...43

FLUVIRIN ....................................................................... 11

FLUZONE ....................................................................... 11

FLUZONE HD .................................................................. 11

FLUZONE QUAD ............................................................ 11

FML................................................................................ 84

FML FORTE .................................................................... 84

FOCALGIN CA ................................................................ 67

FOLCAPS ........................................................................ 68

FOLIC ACID .............................................................. 65, 66

FOLIVANE‐OB ................................................................ 68

FOLIVANE‐PRX ............................................................... 68

FONDAPARINUX............................................................ 81

FOSAMPRENAVIR ............................................................ 7

FOSINOPRIL............................................................. 36, 37

FOSPHENYTOIN............................................................. 62

FOSRENOL..................................................................... 50

FRAGMIN ...................................................................... 81

FULL SPECT.................................................................... 68

FUROSEMIDE .......................................................... 38, 39

FUZEON........................................................................... 7

G

GABAPENTIN........................................................... 62, 63

GABITRIL ....................................................................... 63

GALANTAMINE .............................................................. 55

GARAMYCIN.................................................................. 83

GARDASIL 9 ................................................................... 11

GATIFLOXACIN .............................................................. 83

GAVILYTE‐C ................................................................... 45

GAVILYTE‐G................................................................... 45

GAVILYTE‐N................................................................... 45

GEMFIBROZIL ................................................................ 40

GENERLAC..................................................................... 10

GENGRAF ...................................................................... 92

GENOTROPIN ................................................................ 29

GENPRIL ........................................................................ 61

GENTAK......................................................................... 83

GENTAMICIN........................................................... 83, 85

GENVOYA........................................................................ 7

GERBER ......................................................................... 76

GESTICARE .................................................................... 68

GIANVI .......................................................................... 20

GILDAGIA ...................................................................... 20

GILDESS......................................................................... 20

GILDESS 24 .................................................................... 20

GILDESS FE .............................................................. 20, 21

GILOTRIF ....................................................................... 13

GLATIRAMER (Generic Copaxone 40mg)...................... 56

GLATOPA (Generic Copaxone 20 mg) ........................... 56

GLEOSTINE .................................................................... 13

GLIMEPIRIDE ................................................................. 25

GLIPIZIDE....................................................................... 25

GLIPIZIDE ER .................................................................. 25

GLIPIZIDE XL .................................................................. 25

GLIPIZIDE/METFORMIN ................................................ 24

99

GLUCAGEN .................................................................... 24

GLUCAGON.................................................................... 24

GLUCERNA..................................................................... 78

GLUCOSE ....................................................................... 23

GLUCOSE BITS ............................................................... 23

GLUTOSE 15 .................................................................. 23

GLUTOSE 45 .................................................................. 24

GLYBURID MCR ............................................................. 25

GLYBURIDE .............................................................. 24, 25

GLYBURIDE/METFORMIN.............................................. 24

GLYCERIN....................................................................... 45

GLYDO ........................................................................... 85

GNP CALCIUM ............................................................... 76

GNP PRENATAL ............................................................. 68

GOODSENSE .................................................................. 68

GRANISETRON ............................................................... 48

GRANISOL...................................................................... 48

GRAPE ........................................................................... 89

GRISEOFULVIN ................................................................ 4

GUANFACINE................................................................. 37

GYNECORT 10 ................................................................ 87

H

HAEGARDA .................................................................... 88

HAVRIX .......................................................................... 11

HC/ACET ACID ............................................................... 84

HEARTBRN REL .............................................................. 47

HEARTBURN .................................................................. 47

HEATHER ....................................................................... 21

HECORIA........................................................................ 92

HEPARIN SOD ................................................................ 81

HEXALEN ....................................................................... 13

HM B COMPLEX............................................................. 68

HM PRENATAL ............................................................... 68

HOMATROPAIRE ........................................................... 84

HOMATROPINE ............................................................. 84

HUMALOG ..................................................................... 24

HUMATROPE ................................................................. 29

HUMIRA......................................................................... 60

HUMIRA PEDIA .............................................................. 60

HUMIRA PEN ................................................................. 60

HUMULIN ................................................................ 24, 25

HYCAMTIN..................................................................... 13

HYDRALAZINE ................................................................ 38

HYDROCHLOROTHIAZIDE .............................................. 39

HYDROCODONE/APAP .................................................. 58

HYDROCODONE/IBUPROFEN........................................ 58

HYDROCORT.................................................................. 88

HYDROCORT AC ............................................................ 87

HYDROCORT/AB ............................................................ 87

HYDROCORTISONE .................................................. 17, 87

HYDROCREAM .............................................................. 87

HYDRO‐LOTION............................................................. 87

HYDROMORPHONE ....................................................... 58

HYDROSKIN ................................................................... 87

HYDROXYCHLOR ............................................................. 9

HYDROXYPROG ............................................................. 16

HYDROXYUREA ............................................................. 13

HYDROXYZINE HCL........................................................ 53

HYDROXYZINE PAMOATE .............................................. 53

HYOMAX‐SL................................................................... 46

HYOSCYAMINE .............................................................. 46

HYOSYNE ....................................................................... 46

I

IBANDRONATE .............................................................. 28

IBRANCE........................................................................ 13

IBU‐DROPS .................................................................... 61

IBUPROFEN ............................................................. 53, 61

IBUPROFEN IB ............................................................... 61

IBUPROFEN JR ............................................................... 61

IBUPROFEN PM ............................................................. 53

ICLUSIG ......................................................................... 13

IDHIFA ........................................................................... 14

IFEREX 150 .................................................................... 79

ILOTYCIN ....................................................................... 83

IMATINIB MESYLATE ..................................................... 14

IMBRUVICA ................................................................... 14

IMIQUIMOD.................................................................. 86

IMPAVIDO..................................................................... 10

IMPLANON.................................................................... 21

INATAL ADV .................................................................. 68

INATAL GT ..................................................................... 68

INATAL ULTRA ............................................................... 68

INCRELEX....................................................................... 29

INDAPAMIDE................................................................. 39

INDOCIN........................................................................ 61

INDOMETHACIN ............................................................ 61

100

INFANRIX ....................................................................... 11

INFERGEN........................................................................ 6

INLYTA ........................................................................... 14

INSPIREASE.................................................................... 90

INSTACORT 5 ................................................................. 87

INSTA‐GLUCOS .............................................................. 24

INTELENCE ....................................................................... 7

INTRON A ...................................................................... 14

INTROVALE .................................................................... 21

INVIRASE ......................................................................... 7

IPECAC........................................................................... 88

IPRATROPIUM ............................................................... 46

IPRATROPIUM/.............................................................. 43

IRBESARTAN .................................................................. 36

IRBESARTAN/HYDROCHLOROTHIAZIDE ........................38

IRESSA ........................................................................... 14

IRON ........................................................................ 79, 80

IRON SUPPLEM .............................................................. 80

IRON SUPPLMT.............................................................. 80

IRON THERAPY .............................................................. 80

ISENTRESS ....................................................................... 7

ISENTRESS HD.................................................................. 7

ISONIAZID........................................................................ 4

ISORDIL.......................................................................... 31

ISOSORBIDE DINITRATE ................................................. 31

ISOSORBIDE MONONITRATE ................................... 31, 32

ITRACONAZOLE ............................................................... 4

IVERMECTIN .................................................................... 9

J

JANTOVEN..................................................................... 81

JENCYCLA....................................................................... 21

JOCK ITCH........................................................................ 5

JOLESSA ......................................................................... 21

JOLIVETTE ...................................................................... 21

JULEBER ......................................................................... 21

JUNEL 1.5/30 ................................................................. 21

JUNEL 1/20 .................................................................... 21

JUNEL FE ........................................................................ 21

JUNEL FE 24 ................................................................... 21

JUST D............................................................................ 30

K

K HYDROCORTISON....................................................... 88

KALETRA.......................................................................... 7

KALYDECO..................................................................... 42

KARIDIUM ..................................................................... 75

KARIGEL ........................................................................ 75

KARIGEL‐N..................................................................... 75

KARIVA .......................................................................... 21

K‐EFFERVESCE ............................................................... 76

KELNOR ......................................................................... 21

KERICORT 10 ................................................................. 87

KETOCONAZOLE .............................................................. 4

KETOPROFEN ................................................................ 61

KETOROLAC ................................................................... 84

KIMIDESS....................................................................... 21

KIONEX.......................................................................... 92

KISQALI.......................................................................... 14

KLOR‐CON 10 ................................................................ 76

KLOR‐CON 8 .................................................................. 76

KLOR‐CON M10 ............................................................. 76

KLOR‐CON M20 ............................................................. 76

KLOR‐CON SPR .............................................................. 76

KLOR‐CON/EF ................................................................ 76

KONSYL ......................................................................... 45

KP B COMPLEX .............................................................. 68

KP CALCIUM .................................................................. 76

KP PRENATAL ................................................................ 68

K‐PHOS.......................................................................... 76

KPN PRENATAL .............................................................. 68

K‐PRIME ........................................................................ 76

K‐SOL............................................................................. 76

KURVELO....................................................................... 21

KUVAN .......................................................................... 28

K‐VESCENT .................................................................... 76

L

LABETALOL.................................................................... 32

LACTULOSE ................................................................... 10

LAMIVUDINE................................................................... 7

LAMIVUDINE/ZIDOVUDINE............................................. 7

LANABIOTIC .................................................................. 85

LANACORT 10 ............................................................... 88

LANSOPRAZOLE ............................................................ 47

LARIN ............................................................................ 21

LARIN 24 ....................................................................... 21

LARIN FE ........................................................................ 21

101

LATANOPROST .............................................................. 85

LAYOLIS FE..................................................................... 21

LEENA ............................................................................ 21

LEFLUNOMIDE ............................................................... 60

LENVIMA ....................................................................... 14

LESSINA ......................................................................... 21

LETROZOLE .................................................................... 14

LEUCOVOR CA ............................................................... 12

LEUKERAN ..................................................................... 14

LEUPROLIDE .................................................................. 14

LEVETIRACETA............................................................... 63

LEVOBUNOLOL .............................................................. 83

LEVOCARNITINE ...................................................... 28, 29

LEVO‐ETH EST................................................................ 21

LEVOFLOXACIN................................................................ 3

LEVONEST...................................................................... 21

LEVONOR/ETHI .............................................................. 21

LEVONORGESTR ............................................................ 21

LEVORA‐28 .................................................................... 21

LEVOTHYROXINE ........................................................... 26

LEVOXYL .................................................................. 26, 27

LEXIVA ............................................................................. 7

LICE KILLING .................................................................. 86

LICE TREATMENT........................................................... 86

LICE TRTMNT................................................................. 86

LICIDE ............................................................................ 86

LIDO/PRILOCN............................................................... 85

LIDOCAINE............................................................... 35, 85

LINDANE........................................................................ 86

LINEZOLID ...................................................................... 10

LIOTHYRONINE .............................................................. 27

LIQ CA/VIT D .................................................................. 76

LISINOPRIL..................................................................... 37

LISINOPRIL/HYDROCHLOROTHIAZIDE...........................38

LITEAIRE ........................................................................ 90

LO LOESTRIN ................................................................. 21

LO MINASTRIN .............................................................. 21

LOMEDIA 24 .................................................................. 21

LOMUSTINE ................................................................... 14

LONSURF ....................................................................... 14

LORATADINE ................................................................. 42

LORAZEPAM .................................................................. 53

LORCET .......................................................................... 58

LORCET HD .................................................................... 58

LORCET PLUS................................................................. 58

LORTAB ......................................................................... 58

LORYNA......................................................................... 21

LOSARTAN POTASSIUM ................................................ 36

LOSARTAN/HYDROCHLOROTHIAZIDE........................... 38

LOVASTATIN.................................................................. 40

LOW‐OGESTREL ............................................................ 21

LUDENT ......................................................................... 75

LUPANETA..................................................................... 14

LUPR DEP‐PED ............................................................... 14

LUPRON DEPOT............................................................. 14

LUTERA.......................................................................... 21

LYNPARZA ............................................................... 14, 15

LYRICA........................................................................... 63

LYSODREN..................................................................... 15

LYZA .............................................................................. 21

M

MAALOX........................................................................ 45

MAG OXIDE ............................................................. 45, 76

MAGNESIUM CITRATE .................................................. 45

MALE CONDOMS .......................................................... 51

MARLISSA...................................................................... 21

MASK VORTEX/ ............................................................. 91

MATULANE ................................................................... 15

MAVYRET ........................................................................ 6

MECLIZINE ..................................................................... 48

MED‐DERM HC .............................................................. 88

MEDI‐CORT ................................................................... 88

MEDI‐MECLIZI ............................................................... 48

MEDI‐PROFEN ............................................................... 61

MEDROXYPR AC ............................................................ 16

MEFLOQUINE.................................................................. 9

MEGESTROL AC ............................................................. 15

MEKINIST ...................................................................... 15

MELOXICAM .................................................................. 61

MEMANTINE ................................................................. 55

MEMANTINE HC............................................................ 55

MENACTRA ................................................................... 11

MENEST ........................................................................ 19

MENOMUNE ................................................................. 11

MENVEO ....................................................................... 11

MEPHYTON ................................................................... 30

MERCAPTOPURINE ....................................................... 12

102

MESALAMINE ................................................................ 49

MESALAMINE (generic Asacol HD) ................................50

MESALAMINE (generic Lialda)....................................... 50

METAMUCIL .................................................................. 45

METAPROTEREN ........................................................... 44

METFORMIN.................................................................. 24

METHAZOLAMIDE ......................................................... 38

METHIMAZOLE .............................................................. 26

METHITEST .................................................................... 18

METHLPHENIDATE (generic Ritalin LA) .........................55

METHOCARBAMOL ....................................................... 65

METHOTREXATE ............................................................ 12

METHYLDOPA................................................................ 37

METHYLERGON ............................................................. 28

METHYLPHENIDATE ................................................ 54, 55

METHYLPHENIDATE (generic Concerta)........................54

METHYLPHENIDATE (generic Metadate CD) .................54

METHYLPHENIDATE (generic Ritalin LA) .......................55

METHYLPREDNISOLONE ................................................ 17

METIPRANOLOL ............................................................ 83

METOCLOPRAMIDE....................................................... 50

METOLAZONE................................................................ 39

METOPROLOL................................................................ 32

METOPROLOL TARTRATE .............................................. 32

METOPROLOL/HYDROCHLOROTHIAZIDE......................38

METRONIDAZOLE .................................................... 10, 52

MEXILETINE ................................................................... 35

MIBELAS 24 ................................................................... 21

MICADERM...................................................................... 5

MICONAZOLE .................................................................. 5

MICONAZOLE CRE 2%.................................................... 5

MICONAZOLE POW ........................................................ 5

MICONAZOLE 3 ............................................................... 5

MICONAZOLE 7 ............................................................... 5

MICRO GUARD ................................................................ 5

MICROCHAMBER........................................................... 91

MICROGESTIN ......................................................... 21, 22

MICROLIFE ..................................................................... 91

MICROSPACER ............................................................... 91

MIDODRINE................................................................... 39

MIDOL ........................................................................... 61

MILK OF MAGNESIUM .................................................. 45

MINERAL OIL ................................................................. 45

MINI WRIGHT ................................................................ 91

MINITRAN ..................................................................... 32

MINOXIDIL .................................................................... 38

MIRASORB .................................................................... 91

MISOPROSTOL .............................................................. 47

MISSION PREN .............................................................. 68

M‐M‐R II........................................................................ 11

MODERIBA ...................................................................... 6

MOMETASONE ............................................................. 88

MONDOXYNE NL............................................................. 3

MONO‐LINYAH .............................................................. 22

MONONESSA ................................................................ 22

MONTELUKAST ............................................................. 44

MORPHINE SULFATE............................................... 58, 59

MOTION RELF ............................................................... 48

MOTION SICK ................................................................ 48

MOTION‐TIME .............................................................. 48

MOTRIN PM .................................................................. 53

MOXIFLOXACIN............................................................... 3

MULTAQ........................................................................ 35

MULTI PRENAT .............................................................. 68

MULTI‐VIT/FE................................................................ 68

MULTI‐VIT/FL ................................................................ 68

MUPIROCIN................................................................... 85

M‐VIT ............................................................................ 68

MY WAY ........................................................................ 22

MYCOPHENOLAT .......................................................... 92

MYDRAL .................................................................. 84, 85

MYFERON 150 ............................................................... 80

MYLERAN ...................................................................... 15

MYNATAL ................................................................ 68, 69

MYNATAL PLUS ............................................................. 69

MYNATAL‐Z................................................................... 69

MYNEPHROCAPS ........................................................... 69

MYZILRA........................................................................ 22

N

NABUMETONE .............................................................. 61

NADOLOL ...................................................................... 32

NAFRINSE ...................................................................... 75

NALOXONE .................................................................... 89

NALTREXONE ................................................................ 89

NAMENDA XR ............................................................... 55

NAPROXEN.................................................................... 61

NARATRIPTAN ............................................................... 61

103

NARCAN ........................................................................ 89

NATAL‐V RX ................................................................... 69

NATALVIRT CA ............................................................... 69

NATALVIT ...................................................................... 69

NATURALYTE ................................................................. 76

NEBUPENT..................................................................... 10

NEBUSAL ....................................................................... 42

NECON........................................................................... 22

NEO/BAC/POLY ............................................................. 83

NEO/POLY/BAC ............................................................. 84

NEO/POLY/DEX ............................................................. 84

NEO/POLY/GRA............................................................. 83

NEO/POLY/HC ............................................................... 84

NEOMYCIN ...................................................................... 3

NEO‐POLYCIN .......................................................... 83, 84

NEOPORACIN ................................................................ 85

NEOSPORIN ................................................................... 88

NEOSPORIN AF ................................................................ 5

NEOSPORIN+PN ............................................................ 85

NEPHPLEX RX................................................................. 69

NEPHRON FA ................................................................. 80

NEPHRONEX .................................................................. 69

NEPHRO‐VITE ................................................................ 69

NERLYNX........................................................................ 15

NESSI SPACER ................................................................ 91

NEULASTA ..................................................................... 78

NEUT ............................................................................. 52

NEUTRAGARD ................................................................ 75

NEUTREXIN.................................................................... 10

NEVIRAPINE ..................................................................... 8

NEXAVAR ....................................................................... 15

NEXT CHOICE ................................................................. 22

NIACIN..................................................................... 39, 66

NIACIN ER................................................................ 39, 66

NIACIN TR...................................................................... 66

NIACINAMIDE ................................................................ 66

NICOTINE ................................................................. 56, 57

NICOTINE SYS ................................................................ 57

NICOTROL...................................................................... 57

NIFEDIAC CC .................................................................. 34

NIFEDICAL XL................................................................. 34

NIFEDIPINE .................................................................... 34

NIKKI.............................................................................. 22

NINLARO........................................................................ 15

NITRO‐BID ..................................................................... 32

NITRO‐DUR ................................................................... 32

NITROFURANTOIN ........................................................ 10

NITROFURANTOIN MACROCRYSTALS........................... 10

NITROGLYCERIN............................................................ 32

NIVA‐PLUS..................................................................... 69

NIZATIDINE ................................................................... 47

NOBLE FORMUL............................................................ 88

NORA‐BE ....................................................................... 22

NORDITROPIN ............................................................... 29

NORETH/ETHIN............................................................. 22

NORETHIN ACE .............................................................. 17

NORETHINDRON........................................................... 22

NORGEST/ETHI .............................................................. 22

NORINYL........................................................................ 22

NORLYROC .................................................................... 22

NORPACE ...................................................................... 35

NORTREL ....................................................................... 22

NORVIR ........................................................................... 8

NOVAFERRUM .............................................................. 69

NOVOLIN....................................................................... 25

NOVOLOG ..................................................................... 25

NOXAFIL .......................................................................... 4

NP THYROID .................................................................. 27

NU‐IRON 150 ................................................................ 80

NULEV ........................................................................... 46

NUTROPIN..................................................................... 29

NUTROPIN AQ ............................................................... 29

NUVARING .................................................................... 22

NYSTAT/TRIAM ............................................................. 88

NYSTATIN ........................................................................ 4

O

OB COMPLETE ............................................................... 69

OB‐NATAL ONE ............................................................. 69

O‐CAL ............................................................................ 69

O‐CAL FA ....................................................................... 69

OCELLA.......................................................................... 22

OCTREOTIDE ........................................................... 29, 30

ODEFSY ........................................................................... 8

ODOMZO ...................................................................... 15

OFLOXACIN ................................................................... 83

OGESTREL ..................................................................... 22

OMEGA III ..................................................................... 29

104

OMEPRAZOLE................................................................ 47

OMEPRAZOLE + ............................................................. 47

OMNITROPE .................................................................. 30

ONDANSETRON............................................................. 48

OPCICON ....................................................................... 22

OPTICHAMBER .............................................................. 91

ORA‐BLEND ................................................................... 89

ORA‐BLEND SF............................................................... 89

ORAL ELECTRO .............................................................. 76

ORAL MIX ...................................................................... 89

ORAL MIX SF.................................................................. 89

ORAL SUSPEND .............................................................. 89

ORAL SYRUP .................................................................. 89

ORALYTE ........................................................................ 76

ORA‐PLUS ...................................................................... 89

ORA‐SWEET................................................................... 89

ORA‐SWEET SF .............................................................. 89

ORKAMBI....................................................................... 42

ORSYTHIA ...................................................................... 22

ORTHO COIL .................................................................. 51

ORTHO FLAT .................................................................. 51

ORTHO FLEX .................................................................. 51

ORTHO TRI‐CYCLN LO.................................................... 22

ORTHO‐EST.................................................................... 19

OSCAL............................................................................ 76

OS‐CAL........................................................................... 76

OSCIMIN........................................................................ 46

OSCIMIN SR ................................................................... 46

OSELTAMIVIR .................................................................. 9

OTEZLA .......................................................................... 60

OXANDROLONE ............................................................. 18

OXCARBAZEPIN ............................................................. 63

OXYBUTYNIN ................................................................. 50

OXYCODONE ................................................................. 59

OXYCODONE/APAP ....................................................... 59

OXYCODONE/ASA ......................................................... 59

OXYCONTIN ................................................................... 59

OXYTROL/WOMN.......................................................... 50

OYS SHELL CA ................................................................ 76

OYS SHELL+D ................................................................. 76

OYSCO 500+D ................................................................ 77

OYST CAL/D ................................................................... 77

OYST SHELL/D ................................................................ 77

P

PACERONE .................................................................... 35

PANCREAZE................................................................... 49

PANDA MASK................................................................ 91

PANTOPRAZOLE ............................................................ 47

PARICALCITOL ............................................................... 30

PAROEX......................................................................... 85

PAROMOMYCIN .............................................................. 3

PCCA SWEET ................................................................. 89

PCCA SYRUP .................................................................. 89

PCCA‐PLUS .................................................................... 89

PEAK AIR FLO ................................................................ 91

PEAK FLOW ................................................................... 91

PEAK FLW MTR ............................................................. 91

PEDIA IRON ................................................................... 80

PEDIA‐LAX ..................................................................... 45

PEDIALYTE ..................................................................... 77

PEDIASURE.................................................................... 78

PEGANONE.................................................................... 63

PENICILLIN G POTASSIUM ............................................... 1

PENTAM 300................................................................. 10

PENTASA ....................................................................... 50

PENTOXIFYLLI................................................................ 82

PEPCID AC ..................................................................... 47

PERIOGARD ................................................................... 85

PERMETHRIN ................................................................ 86

PERSONAL BES .............................................................. 91

PHENADOZ.................................................................... 48

PHENAZO ...................................................................... 52

PHENAZOPYRID ............................................................. 52

PHENERGAN.................................................................. 48

PHENOBARB.................................................................. 53

PHENYTOIN ................................................................... 63

PHENYTOIN EX .............................................................. 63

PHILITH ......................................................................... 22

PHOS‐FLUR .................................................................... 75

PHOSPHA 250 ............................................................... 77

PHOSPHOLINE ............................................................... 84

PIKO 1 ........................................................................... 91

PILOCARPINE ........................................................... 51, 84

PIMTREA ....................................................................... 22

PINDOLOL ..................................................................... 33

PINWORM....................................................................... 9

PIN‐X ............................................................................... 9

105

PIOGLITAZONE ........................................................ 24, 26

PIOGLITAZONE/METFORMIN........................................24

PIRMELLA ...................................................................... 22

PLAN B........................................................................... 22

PLEGRIDY....................................................................... 56

PLEGRIDY PEN ............................................................... 56

PNEUMOVAX 23 ............................................................ 11

PNV FE FUM .................................................................. 69

PNV FOLIC AC ................................................................ 69

PNV OB+DHA................................................................. 69

PNV PRENATAL .............................................................. 69

PNV TABS ...................................................................... 69

PNV‐DHA ....................................................................... 69

PNV‐SELECT................................................................... 69

PNV‐VP‐U ...................................................................... 69

POCKET PEAK ................................................................ 91

POCKETPEAK ................................................................. 91

PODACTIN ....................................................................... 5

PODOFILOX ................................................................... 86

POLYCIN ........................................................................ 83

POLYCIN B ..................................................................... 83

POLY‐DEX ...................................................................... 84

POLYETHYLENE GLYCOL ................................................ 45

POLY‐IRON..................................................................... 80

POLYMYXIN B/SOL TRIMETHOPRIM SULFATE ..............83

POLY‐VI‐SOL .................................................................. 70

POLY‐VITA ..................................................................... 70

POLYVITAMIN ................................................................ 70

POLY‐VITE ...................................................................... 70

POMALYST..................................................................... 15

PORTIA‐28 ..................................................................... 22

POT ACETATE ................................................................ 77

POT CHLORIDE .............................................................. 77

POT CL MICRO............................................................... 77

POT GLUCONAT ............................................................. 77

POTASSIUM ................................................................... 77

POTASSIUM CITRATE..................................................... 52

POTASSIUM CITRATE/CITRIC ACID ................................52

PRADAXA....................................................................... 81

PRAMIPEXOLE ............................................................... 65

PRAVASTATIN ................................................................ 40

PRAZOSIN ...................................................................... 82

PRED MILD .................................................................... 84

PRED SOD PHO.............................................................. 84

PREDNISOLONE ....................................................... 17, 84

PREDNISOLONE SODIUM PHOSPHATE ......................... 17

PREDNISONE................................................................. 17

PREMARIN VAG............................................................. 19

PRENAISSANCE ............................................................. 70

PRENAPLUS ................................................................... 70

PRENAT PLUS ................................................................ 70

PRENATABS FA.............................................................. 70

PRENATABS RX.............................................................. 70

PRENATAL ................................................... 69, 70, 71, 72

PRENATAL 1 .................................................................. 71

PRENATAL 19 ................................................................ 71

PRENATAL AD ............................................................... 71

PRENATAL FRM ............................................................. 71

PRENATAL MV ............................................................... 71

PRENATAL VIT ............................................................... 71

PRENATAL/FE ................................................................ 71

PRENATAL+DHA ............................................................ 71

PRENATAL+FE ............................................................... 71

PRENATAL‐U ................................................................. 71

PRENATL MULT ............................................................. 71

PREP H HC ..................................................................... 88

PREPLUS........................................................................ 71

PRETAB.......................................................................... 71

PREVALITE ..................................................................... 40

PREVIFEM...................................................................... 22

PREVNAR 13.................................................................. 11

PREZCOBIX ...................................................................... 8

PREZISTA ......................................................................... 8

PRIMEAIRE .................................................................... 91

PRIMIDONE ................................................................... 63

PROAIR HFA .................................................................. 42

PROBEN/COLCH ............................................................ 62

PROBENECID ................................................................. 62

PROCAINAMIDE ............................................................ 35

PROCHLORPER .............................................................. 48

PROCRIT ........................................................................ 79

PROCTO‐PAK................................................................. 88

PROCTOSOL HC ............................................................. 88

PROCTOZONE................................................................ 88

PROGESTERONE ............................................................ 17

PROGLYCEM .................................................................. 24

PROMACTA ................................................................... 79

PROMETHAZINE ...................................................... 48, 49

106

PROMETHEGAN ............................................................ 49

PRONTO PLUS ............................................................... 86

PROPAFENONE .............................................................. 35

PROPANTHELIN ............................................................. 46

PROPRANOLOL .............................................................. 33

PROPYLTHIOUR ............................................................. 26

PROVENTIL .................................................................... 42

PROVIL........................................................................... 61

PSORIASIN ..................................................................... 86

PSYLLIUM FIBER ............................................................ 45

PULMOSAL .................................................................... 42

PULMOZYME ................................................................. 42

PX PRENATAL ................................................................ 71

PYRAZINAMIDE ............................................................... 4

PYRIDOSTIGMINE BROMIDE ......................................... 51

PYRIDOXINE ................................................................... 66

Q

QC PRENATAL ................................................................ 71

QUASENSE..................................................................... 22

QUFLORA PED ............................................................... 71

QUINAPRIL .................................................................... 37

QUINIDINE GLUCONATE ............................................... 36

QUINIDINE SULFATE ...................................................... 36

QVAR ............................................................................. 43

QVAR REDIHALER .................................................... 43, 44

R

RA ALCOHOL.................................................................. 85

RA ARTH PAIN ............................................................... 86

RA CALCIUM .................................................................. 71

RA PRENATAL ................................................................ 72

RABEPRAZOLE ............................................................... 47

RAJANI........................................................................... 22

RALOXIFENE .................................................................. 28

RAMIPRIL....................................................................... 37

RANEXA ......................................................................... 31

RANITIDINE ................................................................... 47

RAPAMUNE ................................................................... 92

REBIF ............................................................................. 56

REBIF REBIDO ................................................................ 56

REBIF TITRTN................................................................. 56

RECLIPSEN ..................................................................... 23

RECOMBIVA HB ............................................................. 11

RECORT PLUS ................................................................ 88

REDERM ........................................................................ 88

REESES MED.................................................................... 9

REGONOL ...................................................................... 51

REGRANEX .................................................................... 86

RELENZA.......................................................................... 9

RELION .......................................................................... 25

REMODULIN.................................................................. 41

RENAGEL ....................................................................... 50

RENAL ........................................................................... 72

RENALPREN................................................................... 72

RENA‐VITE ..................................................................... 72

RENA‐VITE RX ................................................................ 72

RENO............................................................................. 72

REPATHA....................................................................... 40

RESCRIPTOR .................................................................... 8

RETROVIR ........................................................................ 8

REVLIMID ...................................................................... 15

REYATAZ.......................................................................... 8

RIBASPHERE .................................................................... 6

RIBAVIRIN ....................................................................... 6

RIFABUTIN....................................................................... 4

RIFAMPIN........................................................................ 4

RILUZOLE ....................................................................... 65

RIMANTADINE ................................................................ 5

RINGWORM .................................................................... 5

RISEDRONATE ............................................................... 28

RITEFLO......................................................................... 91

RIVASTIGMINE .............................................................. 55

RIVELSA......................................................................... 23

RIZATRIPTAN........................................................... 61, 62

ROMYCIN ...................................................................... 83

ROPINIROLE .................................................................. 65

ROXICET ........................................................................ 59

RUBRACA ...................................................................... 15

RULAVITE DHA .............................................................. 72

RYDAPT ......................................................................... 15

S

SABRIL ........................................................................... 63

SAFYRAL ........................................................................ 23

SALINE........................................................................... 45

SALINE FLUSH................................................................ 77

SALSALATE .................................................................... 57

107

SAM‐E.P.A. .................................................................... 29

SARNOL‐HC ................................................................... 88

SB HYDROCORT ............................................................. 88

SCALP RELIEF ................................................................. 88

SCALPICIN................................................................ 86, 88

SELEGILINE .................................................................... 64

SELZENTRY....................................................................... 8

SE‐NATAL 19.................................................................. 72

SENNA ........................................................................... 45

SENNA‐DOCUSATE SODIUM .........................................45

SENSIPAR ....................................................................... 29

SEREVENT DISKUS ......................................................... 42

SE‐TAN DHA................................................................... 72

SETLAKIN ....................................................................... 23

SEVELAMER ................................................................... 50

SF75

SF 5000 PLUS................................................................. 75

SHAROBEL ..................................................................... 23

SHINGRIX....................................................................... 11

SIGNIFOR....................................................................... 30

SILDENAFIL .................................................................... 41

SILIQ .............................................................................. 86

SILVER SULFA ................................................................ 85

SIMILAC PREN ............................................................... 72

SIMPLE........................................................................... 89

SIMVASTATIN ................................................................ 40

SIROLIMUS .................................................................... 92

SLEEP AID ...................................................................... 53

SLO‐NIACIN.................................................................... 66

SLOW IRON ................................................................... 80

SLOW REL FE ................................................................. 80

SLOW RELEASE .............................................................. 80

SM ACID REDU .............................................................. 47

SM ANTIFUNGL ............................................................... 5

SM CALCIUM ................................................................. 72

SM FIRST AID ................................................................. 85

SM IPECAC..................................................................... 88

SM IRON........................................................................ 80

SM IRON SLOW ............................................................. 80

SMZ/TMP DS ................................................................. 10

SMZ‐TMP....................................................................... 10

SOD BICARB................................................................... 52

SOD CHLORIDE ........................................................ 77, 78

SOD FLUORIDE .............................................................. 75

SOD POLY ...................................................................... 92

SODIUM BICAR .............................................................. 45

SODIUM CHLOR ............................................................ 52

SODIUM CHLORIDE ....................................................... 42

SOLIA............................................................................. 23

SOLIQUA ....................................................................... 25

SOMAVERT.................................................................... 30

SOOTHE&COOL ............................................................... 5

SORINE .......................................................................... 33

SOTALOL AF .................................................................. 33

SOTALOL HCL ................................................................ 33

SOVALDI .......................................................................... 6

SPIRIVA ......................................................................... 42

SPIRONOLACTONE .................................................. 38, 39

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE .............. 38

SPONGE ......................................................................... 51

SPORANOX...................................................................... 4

SPRINTEC 28.................................................................. 23

SPRYCEL ........................................................................ 15

SPS ................................................................................ 92

SRONYX......................................................................... 23

SSD ................................................................................ 85

SSKI ............................................................................... 26

STAVUDINE ..................................................................... 8

STELARA........................................................................ 86

STERIL WATER ......................................................... 52, 89

STIOLTO ........................................................................ 43

STIVARGA...................................................................... 15

STOMACH RLF ............................................................... 45

STRESS 500.................................................................... 72

STRESS FORM ................................................................ 72

STRIBILD.......................................................................... 8

STUART PREN ................................................................ 72

SUCRALFATE ................................................................. 47

SULF/PRED NA .............................................................. 84

SULFACET SOD .............................................................. 83

SULFADIAZINE............................................................... 50

SULFASALAZIN .............................................................. 50

SULFATRIM PD .............................................................. 10

SULFAZINE ..................................................................... 50

SULFAZINE EC ................................................................ 50

SULINDAC...................................................................... 61

SUMATRIPTAN .............................................................. 62

SUPER B‐COMP ............................................................. 72

108

SUPER DHA.................................................................... 29

SUPER OMEGA .............................................................. 29

SUPERPLEX‐T ................................................................. 72

SUPRAX ........................................................................... 2

SUSPENSION.................................................................. 89

SUTENT.......................................................................... 15

SYEDA ............................................................................ 23

SYMAX FASTAB .............................................................. 46

SYMAX‐SL ...................................................................... 46

SYMAX‐SR ...................................................................... 46

SYMBICORT ................................................................... 43

SYNAGIS ........................................................................ 10

SYNTHROID ................................................................... 27

SYRPALTA ...................................................................... 89

SYRSPEND SF ................................................................. 89

SYRUP............................................................................ 89

SYRUP SF ....................................................................... 89

T

TABLET .......................................................................... 91

TABLOID ........................................................................ 15

TACROLIMUS................................................................. 92

TAFINLAR................................................................. 15, 16

TAGRISSO ...................................................................... 16

TAKE ACTION................................................................. 23

TALTZ............................................................................. 60

TAMOXIFEN................................................................... 16

TAMSULOSIN................................................................. 52

TANZEUM...................................................................... 24

TARCEVA ....................................................................... 16

TARINA FE ..................................................................... 23

TASIGNA ........................................................................ 16

TAZTIA XT ...................................................................... 34

TECFIDERA..................................................................... 56

TEMOZOLOMIDE ........................................................... 16

TENOFOVIR ..................................................................... 8

TERAZOSIN .................................................................... 82

TERBINAFINE ................................................................... 4

TERBUTALINE ................................................................ 44

TESTIM .......................................................................... 18

TESTOSTERONE ............................................................. 18

TESTOSTERONE CYPIONATE.......................................... 18

TESTOSTERONE ENATHATE ........................................... 18

TEV‐TROPIN................................................................... 30

TH IRON ........................................................................ 80

TH PRENATAL ................................................................ 72

THEO‐24 ........................................................................ 44

THEOCHRON ................................................................. 44

THEOPHYLLINE .............................................................. 44

THERA‐D........................................................................ 30

THERAGEN HP ............................................................... 86

THERANATAL ................................................................ 72

THERMAZENE................................................................ 85

THIAMINE HCL .............................................................. 66

THRIVITE 19 .................................................................. 72

THRIVITE RX .................................................................. 72

THYROLAR‐1.................................................................. 27

THYROLAR‐1/2 .............................................................. 27

THYROLAR‐1/4 .............................................................. 27

THYROLAR‐2.................................................................. 27

THYROLAR‐3.................................................................. 27

TIAGABINE .................................................................... 63

TICLOPIDINE .................................................................. 82

TILIA FE.......................................................................... 23

TIMOLOL GEL ................................................................ 83

TIMOLOL MAL ............................................................... 83

TINEACIDE ....................................................................... 5

TIVICAY............................................................................ 8

TIZANIDINE ................................................................... 65

TOBRA/DEXAME ........................................................... 84

TOBRADEX .................................................................... 84

TOBRAMYCIN............................................................ 3, 83

TOLAZAMIDE ................................................................. 25

TOLCAPONE .................................................................. 64

TOLTERODINE ......................................................... 50, 51

TOPIRAGEN ............................................................. 63, 64

TOPIRAMATE ................................................................ 64

TORSEMIDE ................................................................... 39

TOTAL B/C ..................................................................... 72

TOUJEO ......................................................................... 25

TRACLEER...................................................................... 41

TRAMADL/APAP ............................................................ 60

TRAMADOL HCL ............................................................ 60

TRANEXAMIC ACID ....................................................... 82

TRAVEL SICK.................................................................. 49

TRAVOPROST ................................................................ 85

TRAV‐TABS .................................................................... 49

TRELEGY ........................................................................ 43

109

TREMFYA....................................................................... 86

TRETINOIN..................................................................... 16

TRIADVANCE ................................................................. 72

TRIAMCINOLON ............................................................ 88

TRIAMCINOLONE NASAL............................................... 42

TRIAMTERENE/HYDROCHLOROTHIAZIDE .....................38

TRICARE......................................................................... 72

TRIDERM ....................................................................... 88

TRI‐ESTARYLL................................................................. 23

TRIFLURIDINE ................................................................ 83

TRIHEXYPHEN ................................................................ 64

TRI‐LEGEST .................................................................... 23

TRILEPTAL...................................................................... 64

TRI‐LINYAH .................................................................... 23

TRILYTE .......................................................................... 45

TRIMETHOPRIM ............................................................ 10

TRIMETHOPRIM SOL POLYMYXN ..................................83

TRINATAL....................................................................... 73

TRINATAL GT ................................................................. 73

TRINATAL RX ................................................................. 73

TRINATE ......................................................................... 73

TRINESSA....................................................................... 23

TRIPHROCAPS ................................................................ 73

TRI‐PREVIFEM................................................................ 23

TRIPTONE ...................................................................... 49

TRI‐SPRINTEC ................................................................ 23

TRIUMEQ......................................................................... 8

TRI‐VI‐SOL...................................................................... 73

TRI‐VIT/FL...................................................................... 73

TRI‐VIT/FLUO................................................................. 73

TRI‐VITA......................................................................... 73

TRI‐VITA/FL.................................................................... 73

TRI‐VITAMIN.................................................................. 73

TRIVORA‐28................................................................... 23

TRIXAICIN HP................................................................. 86

TROPICAMIDE ............................................................... 85

TRUMENBA ................................................................... 11

TRUVADA ........................................................................ 8

TRUZONE PEAK.............................................................. 91

TWINRIX ........................................................................ 11

TYBOST ............................................................................ 8

TYKERB .......................................................................... 16

TYMLOS ......................................................................... 28

TYZEKA ............................................................................ 6

U

ULTIMATECARE ............................................................. 73

ULTRA TABS .................................................................. 73

UNITHROID ............................................................. 27, 28

UNITHROID DIRECT....................................................... 27

URSODIOL ..................................................................... 49

V

VAGISTAT‐3..................................................................... 5

VALACYCLOVIR ................................................................ 6

VALGANCICLOVIR ........................................................... 6

VALSARTAN................................................................... 36

VALSARTAN/HCTZ ......................................................... 36

VALVD HOLDNG ............................................................ 91

VANCOMYCIN ............................................................... 10

VANCOMYCIN (compound kit) ..................................... 10

VANCOMYCIN/DEXTROSE ............................................. 10

VANDAZOLE .................................................................. 52

VAQTA........................................................................... 11

VARIVAX........................................................................ 11

VCF VAGINAL ................................................................ 51

VELETRI ......................................................................... 41

VELIVET ......................................................................... 23

VELTASSA ...................................................................... 92

VENATAL‐FA.................................................................. 73

VENCLEXTA ................................................................... 16

VENTAVIS ...................................................................... 41

VENTOLIN HFA .............................................................. 42

VERAPAMIL ............................................................. 34, 35

VEREGEN....................................................................... 86

VERSAFREE .................................................................... 89

VERSAPLUS ................................................................... 89

VERZENIO...................................................................... 16

VESTURA ....................................................................... 23

VIBRAMYCIN ................................................................... 3

VICTOZA ........................................................................ 24

VIDEX .............................................................................. 8

VIMPAT ......................................................................... 64

VINATE AZ EX ................................................................ 73

VINATE CAL ................................................................... 73

VINATE GT..................................................................... 73

VINATE IC ...................................................................... 73

VINATE II ....................................................................... 73

110

VINATE ONE .................................................................. 73

VINATE ULTRA............................................................... 73

VIORELE......................................................................... 23

VIRACEPT..................................................................... 8, 9

VIRAMUNE ...................................................................... 9

VIREAD ............................................................................ 9

VIRT NATE ..................................................................... 73

VIRT‐ADVANCE .............................................................. 73

VIRT‐CAPS...................................................................... 74

VIRT‐CARE ..................................................................... 74

VIRT‐PHOS..................................................................... 78

VIRT‐PN ......................................................................... 74

VIRT‐PN DHA ................................................................. 74

VIRTRATE‐2 ................................................................... 52

VIRTRATE‐K ................................................................... 52

VIRT‐VITE GT ................................................................. 74

VIT D GUMMIE .............................................................. 31

VITA‐BEE/C .................................................................... 74

VITAFOL‐OB................................................................... 74

VITAFOL‐PN................................................................... 74

VITAJOY DALY................................................................ 30

VITAMIN B‐1.................................................................. 66

VITAMIN B‐12................................................................ 66

VITAMIN D..................................................................... 30

VITAMIN D3............................................................. 30, 31

VITEKTA ........................................................................... 9

VOGELXO....................................................................... 18

VOL‐CARE RX ................................................................. 74

VOL‐NATE...................................................................... 74

VOL‐PLUS....................................................................... 74

VOL‐TAB RX ................................................................... 74

VORICONAZOLE ........................................................... 4, 5

VORTEX VALVE .............................................................. 91

VORTEX/MASK ........................................................ 91, 92

VOSEVI............................................................................. 6

VOTRIENT ...................................................................... 16

VP‐ERA OB..................................................................... 74

VP‐VITE RX..................................................................... 74

VYFEMLA ....................................................................... 23

W

WAL‐DRAM ................................................................... 49

WAL‐DRAM II ................................................................ 49

WAL‐ZAN....................................................................... 47

WAL‐ZAN 75.................................................................. 47

WARFARIN .............................................................. 81, 82

WATCHHALER ............................................................... 92

WERA ............................................................................ 23

WIDE‐SEAL .................................................................... 51

WYMZYA FE .................................................................. 23

X

XALKORI ........................................................................ 16

XARELTO ....................................................................... 82

XARELTO STAR .............................................................. 82

XIFAXAN........................................................................ 10

XOPENEX HFA ............................................................... 42

XTANDI.......................................................................... 16

XULANE ......................................................................... 23

Y

YODOXIN......................................................................... 3

YUVAFEM ...................................................................... 19

Z

ZAFIRLUKAST................................................................. 44

ZARAH ........................................................................... 23

ZARXIO (NEUPOGEN BIOSIMILAR) ................................ 79

ZATEAN‐PN ................................................................... 74

ZEJULA .......................................................................... 16

ZELBORAF...................................................................... 16

ZEMAIRA ....................................................................... 44

ZENCHENT..................................................................... 23

ZENCHENT FE ................................................................ 23

ZENPEP.......................................................................... 49

ZEPATIER......................................................................... 6

ZIAGEN............................................................................ 9

ZIDOVUDINE ................................................................... 9

ZINBRYTA ...................................................................... 56

ZIRGAN.......................................................................... 83

ZITHROMAX .................................................................... 3

ZOLINZA ........................................................................ 16

ZOLMITRIPTAN.............................................................. 62

ZOLPIDEM ..................................................................... 53

ZOMACTON................................................................... 30

ZONISAMIDE ................................................................. 64

ZORTRESS...................................................................... 92

111

ZOVIA ............................................................................ 23 ZYKADIA ........................................................................ 16

ZYDELIG ......................................................................... 16 ZYTIGA........................................................................... 16

112

ohp drug list (formulary) -...

Documents